UWorld Notes: Step 2 CK
of inferiority with a desire for friends, but intense ----------------------------------------------------------------
 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  maternal infection may be asymptomatic
fear of embarrassment or rejection; low self-esteem  ceftriaxone should be avoided in infants with
---------------------------------------------------------------- hyperbilirubinemia  displacement of bilirubin
 prolonged hypotension from any cause can lead from albumin-binding sites,  risk of kernicterus
to acute tubular necrosis  oral erythromycin: Rx chlamydial conjunctivitis
o U/A: muddy brown granular casts consist of & pneumonia
renal tubular epithelial cells o risk of infantile hypertrophic pyloric stenosis
o serum BUN:Cr ratio < 20:1  topical erythromycin: prophylaxis for neonatal
o urine osmolality 300 - 350 mOsm/L gonococcal conjunctivitis; regardless of screening
o urine Na+ > 20 mEq/L, FENa > 2%  topical silver nitrate: prophylaxis against
---------------------------------------------------------------- penicillinase-producing strains of N. gonorrhea
 broad casts: a/w chronic renal failure (not available in the US)
o arise in dilated tubules of enlarged nephrons  nasolacrimal duct obstruction (dacryostenosis):
that undergone compensatory hypertrophy in unilateral chronic tearing & minimal conjunctival
response to the reduced renal mass injection; Rx massage nasolacrimal ducts
 waxy casts: chronic renal disease ----------------------------------------------------------------
o shiny & translucent  neonatal gonococcal conjunctivitis: acquired
 RBC casts: glomerulonephritis or vasculitis; through infected genital secretions
o Wegener’s, SLE, Henoch-Schonlein  prophylaxis: erythromycin ophthalmic ointment
 WBC casts: interstitial nephritis & pyelonephritis  Rx: IV or IM ceftriaxone or cefotaxime
o WBCs that originate in kidneys  complications: corneal ulcers, scarring, blindness
 fatty casts: nephrotic syndrome ----------------------------------------------------------------
 hyaline casts: asymptomatics & prerenal azotemia  meniscal & ligamentous tears can both be a/w a
o proteins that pass unchanged along urinary tract popping sensation following precipitating injury
----------------------------------------------------------------  meniscal injury: gradual joint swelling, 12 – 24 hr
Neonatal conjunctivitis etiologies  ligamentous injury (ACL): rapid joint swelling
onset features Rx & effusion due to hemarthrosis (ligaments have
Chemical ˂ 24 mild conjunctival eye lubricant greater vascular supply than menisci, which rely
hrs irritation/injection on diffusion for nourishment)
& tearing after  definitive Dx: MRI
silver nitrate ----------------------------------------------------------------
ophthalmic  Ulcerative colitis: MC in females, Ashkenazi Jew,
prophylaxis peak @ age 15 - 25
Gonococcal 2 - 5 eyelid swelling, IV or IM  MC site: rectum, confined to mucosal layer
days purulent exudate, ceftriaxone or  bloody diarrhea, tenesmus, pseudopolyps
corneal ulceration cefotaxime  severe disease: weight loss, fever, or anemia
Chlamydia 5 - 14 eyelid swelling; oral  +p-ANCA
l days chemosis; watery erythromycin  confirm Dx: friable mucosa on colonoscopy &
or mucopurulent biopsy with mucosal inflammation
discharge  extraintestinal: erythema nodosum, uveitis,
sclerosing cholangitis, spondyloarthropathy
 best way to prevent neonatal chlamydial &  complications: toxic megacolon & colorectal ca
gonococcal conjunctivitis: screen, Dx, Rx pregos  surveillance: annual colonoscopies beginning at
 screen for chlamydia @ 1st & 3rd prenatal visit 8 - 10 yrs after Dx for colon cancer detection
 o colonic dysplasia is a/w progression to
adenocarcinoma; Rx: total colectomy
----------------------------------------------------------------
 young patient, aphthous ulcer, chronic diarrhea,
abdominal pain, weight loss: Crohn’s
 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 intercourse
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
≥ 65
prior screens & not high-risk
no screening if no Hx of
Hysterectomy
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
o 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
(anti-CCP)
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
----------------------------------------------------------------
 Paget’s 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
features chemical burn or liquefaction necrosis
results in:
 laryngeal damage: hoarseness,
stridor, orofacial inflammation
 esophageal damage: dysphagia,
odynophagia
 gastric damage: epigastric pain,
GI bleeding
management  ABCs
 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
 cancer
 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
 body’s 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
ADPKD
symptoms most are asymptomatic
hematuria
flank pain (due to renal calculi, cyst
rupture, hemorrhage, or upper UTI)
clinical signs early onset HTN
B/L upper abdominal masses
mild proteinuria, CKD
extra-renal cerebral aneurysm
manifestation hepatic/pancreatic cysts
cardiac valves (MVP, AR)
diverticulosis
ventral/inguinal hernias
diagnosis abdominal USS
management monitor BP, renal Fx, & potassium
control cardiovascular risk factors
ACE-inhibitors for HTN
ESRD: dialysis, renal transplant
DDx
 central obesity, facial plethora, proximal weakness,
abdominal striae, ecchymosis: Cushing’s
 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 Bell’s 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
causes 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  Dressler’s 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
@ LLSB (VSD), CHF
----------------------------------------------------------------
 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
time artery features echo
RV failure Acute RCA hypotension, hypokinetic
clear lungs, RV
Kussmal sign
papillary Acute, RCA acute, severe severe MR
muscle 3-5 pulmonary with flail
rupture days edema; new leaflet
holosystolic  strabismus after age 4 months is abnormal &
murmur requires Rx to prevent amblyopia (vision loss
IV septum Acute, LAD shock & left-to-right from disuse of deviated eye)
rupture 3-5 = chest pain, shunt VSD  intermittent strabismus can be expected in
days apical holosystolic infants < 4 months due to immaturity of
RCA murmur, extraocular muscles; reassurance & observation
= biventricular  new onset strabismus can be a sign of
basal failure retinoblastoma if accompanied by white reflex
free wall 5 days LAD shock & pericardial  acute onset strabismus can result from
rupture of - 2 wks chest pain, effusion intracranial hemorrhage, brain abscess, or
ventricle JVD, distant with encephalitis
heart sounds, tamponade ----------------------------------------------------------------
PEA  first 5 years of life are critical to development of
 large pericardial effusion presenting as cardiac visual acuity, a time of visual cortex maturity
tamponade post-MI: LV free wall rupture  esotropia beyond infancy must be treated to
o dyspnea, hypotension, pulsus paradoxus, JVD prevent amblyopia
o EKG: low voltage QRS, electrical alternans  deviated eye can be strengthened by patching the
---------------------------------------------------------------- normal eye (occlusion therapy) or blurring the
 Sarcoidosis: no definitive diagnostic test normal eye with cycloplegic drops (penalization)
 CXR: hilar adenopathy, reticulonodular infiltrates ----------------------------------------------------------------
 Bx: noncaseating granulomas; serum ACE  Rx for SLE, malaria prophylaxis, acute malaria,
 erythema nodosum, acute polyarthritis, cough, rheumatoid arthritis: hydroxychloroquine
anterior uveitis, dyspnea  Rx for Crohn’s, ankylosing spondylitis, RA,
 asymptomatics Rx: followed without treatment psoriasis: infliximab (TNF-α-blocker)
due to high rate of spontaneous remission  Rx for histoplasmosis: itraconazole
 symptomatic Rx: systemic glucocorticoid  Rx SLE with renal involvement: cyclophosphamide
---------------------------------------------------------------- ----------------------------------------------------------------
 sudden onset abdominal pain a/w vaginal bleed,  encephalopathy, ocular dysfunction, gait ataxia:
fetal distress, loss of fetal station in active labor: Wernicke encephalopathy
uterine rupture  giving IV fluids containing glucose prior to
o risk factors: pre-existing uterine scar, thiamine can precipitate or worsen WE
abdominal trauma, macrosomia  thiamine is given along with or before glucose
o prior low transverse c-section: < 1% risk ----------------------------------------------------------------
o prior vertical c-section: as high as 9%  acute onset back pain after physical exertion,
 HTN & cocaine use: risk for placental abruption paravertebral tenderness, absence of radiation,
 sinusoidal fetal HR tracing: vasa previa negative straight leg raise test, normal neuro
 fever, tender uterus, foul-smelling lochia, exam: lumbosacral strain
progression to sepsis: endometritis o Rx: NSAIDs, early mobilization
o polymicrobial infection ----------------------------------------------------------------
o Rx: IV clindamycin & gentamicin  acute back pain, local spinal tenderness, &
 clindamycin for Gram+ & anaerobes decreased spinal mobility after minimal trauma,
 gentamicin for Gram-negatives coughing, lifting: vertebral compression fracture
----------------------------------------------------------------  worse with standing, walking, laying on back
 point tenderness, but normal neuro exam
 risk factors: postmenopausal or senile osteoporosis
 o also: steroid Rx, osteomalacia, osteomyelitis,
trauma, bone mets, hyper-PTH, Paget’s
 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)
Dx CSF features…
 high opening pressure
 low glucose, high protein
 WBC ˂ 50/μL
(mononuclear predominance)
 cryptococcal antigen positive
 transparent capsule on India ink
 culture on Sabouraud agar
Rx 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
----------------------------------------------------------------
 sulfadiazine–pyrimethamine: 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
appearance
----------------------------------------------------------------
 +HIV, bloody diarrhea, normal stool: CMV colitis
 typically CD4 < 50 cells/μL
 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
 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
Meniere’s 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
mmHg mic shock ic shock shock
RA 4   nrml
pressure or 
(preload)
PCWP 9   nrml
(preload) or 
Cardiac 2-4    (exaggerated decrease (> 10 mmHg) in systemic
index L/min/
(pump m2
function)
SVR   
(afterload)
Mixed   
venous
O2
saturation
 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,
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: Horner’s, 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
hospitalized) symptoms not severe
marked impairment in enough to cause marked
social or occupational impairment or necessitate
functioning, hospitalization,
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
C/I  chronic kidney disease
 cardiovascular disease
 hyponatremia or diuretic use
Baseline  BUN/creatinine, U/A  Entamoeba histolytica causes amebiasis,
studies  Ca++ resulting in abdo pain & bloody diarrhea
 Thyroid function ----------------------------------------------------------------
 EKG if coronary risk factors  constrictive pericarditis is a complication of
A/E Acute mediastinal irradiation (Hodgkin lymphoma), TB,
 tremor, ataxia, weakness & cause of right heart failure (hepatomegaly,
 polyuria, polydipsia progressive peripheral edema, JVD, ascites)
 vomiting, diarrhea, weight gain  can present 10 – 20 yrs after irradiation or
 cognitive impairment anthracycline therapy
 scarring & inelastic pericardium results in
Chronic
diastolic dysfunction
 nephrogenic DI
 CXR: pericardial calcifications
 thyroid dysfunction
 confirm Dx: echo show pericardial thickening,
 hyperPTH with hyperCa++
abnormal septal motion, bi-atrial enlargement
 Rx: diuretics for temporary relief;
 Lithium has a narrow therapeutic window, thus
pericardiectomy for refractory symptoms
monitor every 6 – 12 months or 5 – 7 days after
dose changes or drug interactions (diuretics, SSRIs,
Constrictive pericarditis
NSAIDs, ACE-I, phenytoin, carbamazepine)
Etiology idiopathic or viral, cardiac surgery,
 pregnancy: Ebstein’s anomaly, polyhydramnios,
radiation therapy (Hodgkin’s),
nephrogenic DI, floppy infant syndrome
TB (developing countries)
 no effect on liver function, lipids, or glucose
Features fatigue, dyspnea on exertion,
---------------------------------------------------------------- right heart failure (peripheral edema,
 complications following rhinoplasty: ascites, JVD, Kussmaul sign )
dissatisfaction, nasal obstruction, epistaxis hepatojugular reflux
 nasal septum has poor blood supply & pericardial knock (mid-diastolic sound)
regenerating capacity, thus trauma or surgery pulsus paradoxus
may result in septal perforation complication: cardiac cirrhosis
 presents as a whistling during respiration due to Dx EKG: a-fib, or low voltage QRS
a septal hematoma following rhinoplasty pericardial calcifications & thickening
---------------------------------------------------------------- prominent x & y descents
 > 2 weeks of persistent, high-volume, non-bloody Rx NSAIDs, diuretics, pericardiectomy
watery diarrhea after recent travel; no fever, ----------------------------------------------------------------
tenesmus or vomiting: Cryptosporidium parvum  spontaneous esophageal rupture after severe
 travel-associated diarrhea > 2 weeks; parasitic retching/vomiting: Boerhaave’s
o cryptosporidium cystoisospora,  CXR: left-sided pleural effusion with/without
microsporidia, Giardia pneumothorax, subcutaneous emphysema, &
 diarrhea < 1 week: viral or bacterial widened mediastinum
o rotavirus/norovirus: vomiting  exudative pleural fluid: low pH, high amylase
o ETEC/EPEC: contaminated food/water (>2500 IU)
o Campylobacter: abdo pain, bloody diarrhea,  Dx: CT or contrast esophagogram w/ Gastrografin
“pseudoappendicitis” (water-soluble contrast)
o Salmonella: frequent fever Mallory-Weiss Boerhaave
o Shigella: fever, bloody diarrhea, abd pain etiology mucosal tear transmural tear 2/2
2/2 forceful retching;
 forceful retching; o pleural fluid shows elevated WBCs, protein,  a/w children with endocrinopathies
submucosal esophageal perforation & LDH, but not amylase (hypothyroidism, growth hormone deficiency)
arterial or venule with air/fluid leakage ---------------------------------------------------------------- have B/L disease & present at an earlier age
plexus bleeding  RA, moderate anemia, low serum iron, low TIBC,  Dx: XR in frog-leg lateral view
features vomiting, vomiting, retching,  transferrin: anemia of chronic disease  Rx: surgical screw fixation at current slippage
retching retrosternal pain,  WBC  a/w chronic inflammatory diseases (RA)  complication: avascular necrosis
epigastric pain odynophagia, fever,  iron trapping within macrophages, leads to poor ----------------------------------------------------------------
hematemesis dyspnea, or septic shock iron availability for Hb synthesis  Legg-Calve-Perthes: idiopathic avascular necrosis
subcutaneous emphysema  low reticulocyte count of femoral capital epiphysis
Dx EGD endoscopy CT or contrast  Rx underlying cause can improve anemia  MC in boys, age 5 – 7 yrs
esophagography with ----------------------------------------------------------------  insidious hip, groin, or knee pain & antalgic gait
Gastrografin  stress fractures: MC in anterior middle third of the (indication of pain with weight bearing)
CXR: tibia in jumping sports & posteromedial distal third  limited internal rotation & hip abduction
pneumomediastinum & of the tibia in runners  Dx: high suspicion; early XR may be negative
exudative pleural effusion  microfractures within cortical bone that coalesce  Rx: observation & bracing; surgery if severe
(low pH, high amylase)
 risk factor: “female athlete triad” ( caloric intake,  DDx: SCFE, transient synovitis
Rx self-limited; cervical perforations:
oligo-/amenorrhea, osteoporosis) ----------------------------------------------------------------
endoscopic Rx conservative measures
 MC site: 2nd metatarsal  MCC of hip pain in children: transient synovitis
as needed thoracic perforations:
(clipping or surgery  XR is normal initially, 6 wks  boys age 3 – 10 yrs; after viral infection or trauma
coagulation)  Dx: MRI or bone scan  well-appearing, able to bear weight
----------------------------------------------------------------  Rx: rest & analgesia  affected hip is flexed, slightly abducted &
 allergic rhinitis: rhinorrhea, nasal pruritus, cough;  Rx: surgery for displaced fx or 5th metatarsal fx externally rotated which maximizes joint space
nasal mucosa is edematous & pale; polyps? ----------------------------------------------------------------  Dx: XR to exclude bone lesions, fx, Legg-Calve
 nasal furunculosis: 2/2 staphylococcal folliculitis  child with severe headache of gradual onset a/w  Rx: ibuprofen & rest, F/U in 1 wk
due to nose-picking or hair plucking N/V, photophobia, visual aura: migraine o recovery within 1 – 4 wks; no complications
o pain, tenderness, erythema in nasal vestibule  most common form of headache < age 20 ----------------------------------------------------------------
o life-threatening if spreads to cavernous sinus  migraines in children are often bifrontal &  amenorrhea > 3 months, hypoestrogenism,  FSH,
---------------------------------------------------------------- shorter duration than adult migraines age < 40: premature ovarian failure
 fetal distress (repetitive late decelerations) is an  Rx in < age 12: supportive (dark, quiet room, &  may be secondary to accelerated follicle atresia
indication for emergent c-section cool cloth on forehead), acetaminophen or or low number of primordial follicles
---------------------------------------------------------------- NSAID (ibuprofen)  MC is idiopathic; or a/w mumps, oophoritis,
 chronic ankylosing spondylitis (> 20 yrs) are at   alternative Rx: triptans irradiation, chemotherapy, autoimmunity
risk for vertebral fractures with minimal trauma ---------------------------------------------------------------- (Hashimoto’s, Addison’s, DM Type I, pernicious
 DDx: spinal root compression, bone mets  indications for neuroimaging in a child with anemia)
---------------------------------------------------------------- headache: Hx of coordination difficulties, tingling,  Dx:  FSH/LH, hypoestrogen
 acute pancreatitis can cause unilateral, left-sided numbness, focal neurologic signs; headache that o do not wait for 1 yr of amenorrhea for Dx
pleural effusion with high amylase concentration, awakens from sleep,  headache frequency  early Dx prevents osteoporosis
but not widened mediastinum ----------------------------------------------------------------  Rx: in vitro fertilization with donor oocytes
 cocaine use predisposes to aortic dissection with  obese boy with a limp, knee pain, decreased ROM, ----------------------------------------------------------------
wide mediastinum & unilateral pleural effusion, pain with hip internal rotation: slipped capital  pulsatile GnRH agonists: induces ovulation
but not high amylase content femoral epiphysis (SCFE)  progesterone: corrects luteal phase defect (failure
 aspiration pneumonia is MC in right lower lobe  MC in obese boys, age 10 – 16 yrs of corpus luteum to produce progesterone to
& unilateral pleural effusion due to  insidious onset dull hip or referred knee pain, maintain the endometrium for implantation)
parapneumonic effusion or empyema altered gait with no preceding trauma ----------------------------------------------------------------
 affected hip is held in passive external rotation
 exertional dyspnea, fatigue, pale conjunctiva
 iron deficiency is MCC of microcytic anemia
 iron studies confirm Dx
Microcytic/Hypochromic anemias
Iron-def anemia  ferritin,  TIBC
Thalassemias normal/ serum iron & ferritin
Anemia of  ferritin & transferrin,
chronic disease  TIBC
Sideroblastic normal/ iron & ferritin,
anemia  TIBC
 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
hemolysis
 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 OSA
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
Skeletal arachnodactyly
 upper:lower body segment ratio
 arm:height ratio
pectus deformity, scoliosis/kyphosis
joint hypermobility
Ocular ectopia lentis (lens subluxation)
Cardio aortic dilation, regurgitation, dissection
MVP
Pulmonar spontaneous pneumothorax due to
y apical blebs
----------------------------------------------------------------
 aortic dissection risk factors
o HTN (most significant)
o Marfan
o cocaine use
----------------------------------------------------------------
 office-based anoscopy/proctoscopy is the initial  DDx: HSV-1 (vesicular eruption), HPV mass on valve rheumatoid factor,
procedure for age < 50 with minimal bright red (verrucous papules), Staph (furuncles, carbuncles) Osler nodes, Roth spots
blood per rectum & no colon cancer risk factors ---------------------------------------------------------------- Dx : 2 Major, 0 Minor predisposing heart condition
o blood intermixed with stool is not included  Staph aureus is MCC of healthcare-associated Dx : 1 Major, 3 Minor or IVDA
 MCC: hemorrhoids, anal fissure, polyps, infective endocarditis (S. epidermidis) Dx : 0 Major, 5 Minor fever: > 38.0° C (100.4°)
proctitis, rectal ulcers, cancer o prosthetic valves, indwelling catheters, IVDA, ----------------------------------------------------------------
 anoscopy has higher sensitivity for hemorrhoids implanted devices (pacemakers, defibrillators) Acute rheumatic fever
than flexible endoscopy  Streptococci is MCC of community-acquired IE epidemiology MC in females, age 5 – 15 yrs
 colonoscopy/sigmoidoscopy for age > 50 or o viridans strep: S. sanguinis, S. mutans MCC: group A Strep pharyngitis
other risk factors for colon cancer o after dental procedures or procedures precedes onset of ARF by 2 – 4 wks
---------------------------------------------------------------- involving incision/biopsy of respiratory tract Major o Joints (migratory arthritis)
 DNA testing for RET proto-oncogene germline  Enterococci: E. faecalis: a/w nosocomial UTIs criteria o ♥ (carditis, mitral stenosis)
mutation is screening test for suspected MEN 2  Strep bovis: S. gallolyticus (“J♥NES”) o Nodules (subcutaneous)
o no further monitoring for a negative result o colon cancer & inflammatory bowel disease o Erythema marginatum
o total thyroidectomy for a positive test result; ---------------------------------------------------------------- o Sydenham chorea
risk of invasive MTC is 100% Endocarditis overview Minor fever, arthralgias, elevated ESR/CRP
risk poor dentition, congenital heart disease, criteria prolonged PR interval
Multiple endocrine neoplasia classification factors valve abnormalities (MVP, MR), IVDA, late features mitral regurgitation/stenosis
Type I o Pituitary tumors intravascular catheters prevention PCN (regardless of +/- pharyngitis)
o Primary hyperPTH (90%) features subungal hemorrhages, petechiae,
o Pancreatic/GI tumors (gastrinoma) Janeway lesions, Osler’s nodes,  Dx: 2 major, or 1 major + 2 minor criteria
Type 2A o Medullary thyroid cancer (MTC) Roth spots, splenomegaly,  supportive findings: ASO titer, Strep antigen test
(Sipple’s) o Pheochromocytoma mitral valve disease (MVP, MR)  DDx: SLE, Henoch-Schonlein, Juvenile arthritis
o Parathyroid hyperplasia labs positive blood cultures,  WBCs,
Type 2B o MTC glomerulonephritis, septic emboli  Hx of rheumatic fever increases risk of recurrence
o Pheochromocytoma Rx vancomycin (initially), based on cultures & progression of rheumatic heart disease
o Mucosal neuromas  Janeway lesions: macular, erythematous,  Dx: continuous ABX prophylaxis to prevent
o marfanoid habitus nontender lesions of palms/soles recurrent group A Strep pharyngitis
 Osler’s nodes: painful, violaceous nodules on
 MEN1 pancreatic tumors: gastrinoma, insulinoma, fingertips/toes ABX prophylaxis for rheumatic fever (RF)
 Roth spots: edematous, hemorrhagic retinal lesions  IM benzathine PCN G every 4 wks
glucagonoma, VIPoma
o gastrinoma causes recurrent peptic ulcers ---------------------------------------------------------------- RF without carditis 5 yrs or until age 21
 blood cultures from 2 separate venipuncture sites RF with carditis, but no 10 yrs or until age 21
----------------------------------------------------------------
 firm, flesh-colored, umbilicated, dome-shape plaques for suspected IE prior to initiating ABX heart or valvular disease
on trunk, limbs, anogenital areas; spares palms/soles: RF with carditis & 10 yrs or until age 40
Duke Criteria for Infective Endocarditis persistent ♥ or valve dz
molluscum contagiosum (poxvirus)
 MCC due to sexual contact MC occur on genitalia, Major Criteria Minor Criteria ----------------------------------------------------------------
lower abdomen, inner thighs 2 positive blood culture Vascular phenomena:  sore throat, skin infection, generalized edema,
 transmitted: skin-skin or fomites for typical IE organisms systemic arterial emboli, dark urine, HTN: post-strep glomerulonephritis
(strep viridans or bovis, pulmonary infarcts, mycotic  recurrent high fevers, rash, arthritis: Adult Still’s
 self-limited, localized infection
S. aureus, enterococcus aneurysms, Janeway o maculopapular, non-pruritic rash on the
 linear pattern due to spread 2/2 scratching HACEK) lesions, conjunctival
 MC a/w cellular immunodeficiency (HIV), trunk & extremities during febrile episodes
hemorrhages  hypotension, hyperpigmentation, hyponatremia:
corticosteroid use, chemotherapy Echocardiogram with Immunologic phenomena: adrenal insufficiency (Addison’s)
oscillating intracardiac glomerulonephritis, ----------------------------------------------------------------
 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
 café-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,
thrombocytopenia
----------------------------------------------------------------
 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, café-au-lait spots, pancytopenia,
congenital abnormalities, hyperpigmentation on
trunk, neck & intertriginous areas, hypogonadism,
renal malformations: Fanconi’s 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/μL): 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
----------------------------------------------------------------
Dermatomyositis
features proximal, symmetric extensor
muscle weakness; UE = LE
Grotton’s papules, heliotrope rash
extramuscular interstitial lung disease,
findings dysphagia, myocarditis
Dx  CPK, aldolase, LDH
anti-RNP, anti-Jo-1, anti-Mi2
equivocal: EMG, muscle biopsy
Rx 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, Raynaud’s, 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
 Rx…
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-Barré,
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,
s visuospatial & language deficits,
word finding difficulty
late: personality changes, hallucinations,
dyspraxia, urinary incontinence
Vascular stepwise decline, cerebral infarction,
dementia early executive dysfunction (ADLs),
focal neuro deficits (+pronator drift,
+Romberg, unsteady gait)
Pick’s 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
NPH dementia, gait ataxia, urinary incontinence
MRI: enlarged ventricles
CJD rapidly progressive behavior changes,
myoclonus, akinetic mutism
Huntington choreoathetosis, behavioral disturbances,
dementia
chronic insidious decrease in consciousness,
subdural headache, cognitive & memory deficits,
hematoma aphasia, or motor deficits
pernicious dementia with megaloblastic anemia,
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: Parkinson’s (motor symptoms present early),
Alzheimer’s (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 O-
blood 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)
----------------------------------------------------------------
 β-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 Myer’s 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 (Meckel’s), 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 μL, 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 μL, no bleeding = observe
 Rx: PLT ˂ 30,000 μL, OR bleeding = IV Ig or
glucocorticoids
----------------------------------------------------------------
 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
thrombocytopenia
----------------------------------------------------------------
 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
 Munchausen’s: 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: Cushing’s,
renal artery stenosis, renin-secreting tumor
o  aldosterone,  renin, &  bicarbonate
----------------------------------------------------------------
 Cushing’s 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 (Cushing’s 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 β-thalassemia major or HbH
----------------------------------------------------------------
 splenectomy  risk of sepsis by encapsulated spp
(S. pneumo, N. meningitides, H. influenza)
o impaired Ab-mediated phagocytosis by
opsonization
  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-Barré: 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
WBC Glucose Protein
Normal 0–5 40 -70
bacterial meningitis   
TB meningitis  
viral meningitis  normal
Guillain-Barré normal normal
 Guillain-Barré: 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,
& LVEDV
 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
----------------------------------------------------------------
Hemodynamics
Cardia Systemic LVED
c index vascular volum
resistanc e  light flashes, floaters, or “curtain coming across
e visual field” from the periphery: detached retina
   Distributive shock
   Intravascular
volume loss
   LV systolic dysFx
----------------------------------------------------------------
 epigastric pain, weight loss, jaundice, distended GB:
pancreatic cancer
< 40
 nontender but palpable gallbladder in a jaundiced
patient is unlikely gallstones (Courvoisier’s sign)

  bilirubin & ALP suggest bile duct obstruction,
normal
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)
----------------------------------------------------------------
 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
skin flushing (cherry-red)
CNS headache, altered mental status,
hyperreflexia, seizure, coma
CVS arrhythmias
respirator tachypnea followed by respiratory
y depression, pulmonary edema
GI abdominal pain, N/V
renal metabolic acidosis 2/2 lactic acidosis,
renal failure
----------------------------------------------------------------
 delusion: fixed, false beliefs not consistent with
cultural norms; grandiose, paranoid, or somatic
 magical thinking: one’s 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 LE’s 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; Coomb’s 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
amoxicillin
----------------------------------------------------------------
 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
 osteoporosis**
  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
manifestations…
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 &
malnutrition
----------------------------------------------------------------
 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,
sympathomimetics)
 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
o 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 (Eisenmenger’s)
----------------------------------------------------------------
 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
----------------------------------------------------------------
MS
 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): Huntington’s
----------------------------------------------------------------
 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:
histoplasmosis
 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 α-subunits
of dimeric hormones (LH, FSH)
 symptoms 2/2 mass effect with disruption of
dopaminergic pathways that normally suppress
prolactin
 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
|------specificity------||--sensitivity--|
----------------------------------------------------------------
 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
 Dx: MRI
 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
relapse
 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 β-blocker, CCB, nitrates
continue 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 (Addison’s) 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
DDx of vaginitis
Bacterial Trichomoniasis Candida
Vaginosis vaginitis vaginitis
thin, off-white thin, frothy, thick, cottage
discharge, fishy green-yellow, cheese-like;
malodorous;
NO inflammation inflammation inflammatio
n defect; covered by peritoneum
pH > 4.5 ph > 4.5 normal pH
clue cells, +Whiff motile, pear-shape pseudohyphae
(amine odor in trichomonads,
KOH) strawberry cervix
oral metronidazole metronidazole; fluconazole
(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,
prematurity
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
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
 HELLP
 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 μL
 abnormal placentation triggers systemic
inflammation, with activation of coagulation &
PLT consumption
 hepatocellular necrosis cause elevated LFTs,
liver swelling, & distension of Glisson’s 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
----------------------------------------------------------------
 Dressler’s: 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 Raynaud’s: 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 PE’s 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 ˃ 38.5°C (101.3°F) or ˂ 35°C (95°F)
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:
Rx TTP
----------------------------------------------------------------
 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  XR: reduced bone density, thinning cortex, ----------------------------------------------------------------
with rapid ventricular response, LV systolic dysFx: symmetric pseudofratures (Looser zones)  altered mental status, volume depletion, polyuria:
tachycardia-mediated cardiomyopathy ---------------------------------------------------------------- hyperosmolar hyperglycemic state (HHS)
 develops in patients with persistent or recurrent  2 major treatment issues for all new-onset a-fib  hyponatremia in HHS is due to osmotic shift of
tachyarrhythmias with prolonged periods of 1. rate or rhythm control strategy H2O into extracellular space & Na+ renal loss
rapid ventricular rate (a-fib, a-flutter, AVNRT) 2. risk assessment of systemic embolization from osmotic diuresis
 Rx: aggressive rate or rhythm control using  CHA2-DS2-VASc score: assesses long-term
AV nodal blocking agents, antiarrhythmics, or stroke risk in patients with non-valvular a-fib DKA HHS
catheter ablation o score 0: low risk, no therapy Type I diabetics Type II diabetics
---------------------------------------------------------------- o score 1: intermediate risk, no therapy or younger age older age
 infants with hydrocephalus may present with ASA or oral anticoagulation rapid onset of symptoms gradual symptoms onset
the following findings: o score ≥ 2: high risk, oral anticoagulation hyperventilation altered mental status
 warfarin reduces risk of embolization in groups abdominal pain neurologic symptoms
symptoms physical findings at moderate- to high-risk of thromboembolism glucose 250 – 500 mg/dL glucose > 600 mg/dL
poor feeding tense & bulging fontanelle bicarbonate < 18 mEq/L bicarbonate > 18 mEq/L
irritability prominent scalp veins CHA2-DS2-VASc score anion gap metab. acidosis normal anion gap
decreased activity widely spaced cranial sutures C CHF 1 ketonemia negative ketones
vomiting rapidly increasing circumference H HTN 1 serum Osm < 320 serum Osm > 320
A2 Age ≥ 75 2 total body K+ deficit due to osmotic diuresis
 Dx: brain CT scan D DM 1
o USS requires a widely open anterior fontanelle; S2 Stroke/TIA 2  Thiazides can precipitate HHS by reducing
infants < age 6 months V vascular disease (prior-MI, 1 intravascular volume, thus  GFR, leads to
 lumbar puncture for suspected meningitis PAD, aortic plaque) decreased renal glucose excretion
 skull radiograph to evaluate abnormal head shape A Age 65 – 74 1   osmolality leads to altered mentation, lethargy, &
---------------------------------------------------------------- Sc Sex 1 weakness
Serum Serum Serum Max score 9  Dx: serum glucose, plasma Osm, absent ketonemia
Ca++ phosphate PTH ---------------------------------------------------------------- ----------------------------------------------------------------
   10 hyper-PTH  DM Type 2 a/w physiologic stressor (infection)  best markers for resolution of DKA
   hypoparathyroidism are prone to nonketotic hyperosmolar syndrome o serum anion gap
/nrml   osteomalacia (NKHS) o beta-hydroxybutyrate assay (ketones)
normal normal normal osteoporosis/Paget’s  risk factors: URI, MI, stroke, trauma, burns  measure serum glucose every hour
----------------------------------------------------------------  stress causes  catecholamines & cortisol, both  measure electrolytes & anion gap every 2 – 4 hr
 osteomalacia due to vitamin D deficiency: insulin counterregulatory hormones
o mildly low serum Ca++  severe hyperglycemia (> 600 mg/dL), with Management of DKA & HHS
o marked hypophosphatemia resultant osmotic diuresis, causes dehydration IV fluids high-flow 0.9% NS; change to D5% in
o  PTH &  alkaline phosphatase & serum hyperosmolarity (> 320 mOsm/L) 0.45% @ serum glucose < 200 mg/dL
o low plasma 25-OH vitamin D  altered consciousness (confusion) & acute onset IV initial continuous IV infusion;
o decreased urinary Ca++ of blurred vision are common regular switch to SC when patient is able to eat,
 secondary hypo-PTH brings serum Ca++ to  #1 Rx: IV fluids can reduce hyperglycemia insulin glucose < 200, anion gap < 12, or
normal/near-normal by increasing bone & renal o if hypovolemic: NS until euvolemic, then HCO3 > 15
Ca++ reabsorption &  urinary phosphate replace with 0.45% saline IV K+ if < 5.2 mEq/L
excretion  #2 Rx: insulin HCO3- only if pH < 6.9
 bone pain, muscle weakness, cramps  #3 Rx: K+ supplementation once K+ reaches phosphate if phosphate < 1.0, cardiac dysFx, or
 causes: malabsorption (Crohn’s, Celiac), GI normal levels respiratory depression,
bypass surgery, chronic liver/kidney disease  DDx: cataracts, diabetic retinopathy, uveitis monitor serum Ca++
----------------------------------------------------------------
 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
vasodilation)
----------------------------------------------------------------
 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
compression
 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
----------------------------------------------------------------
 Beck’s 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
(immunosuppressants)
 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: Cushing’s, 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
features fatigue & pruritus, or asymptomatic
a/w comorbid ulcerative colitis
labs, imaging cholestatic pattern:  LFTs,  ALP
+p-ANCA
liver Bx fibrous obliteration of small bile ducts,
 concentric replacement by connective
tissue = “onion skin” pattern
Dx cholangiogram: periductal portal tract
fibrosis; segmental stenosis of
extrahepatic & intrahepatic bile ducts
Rx: 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 Parkinson’s, 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)
 Asymmetry
 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,
s alopecia with residual black dot,
lymphadenopathy,
transmission: human-human or fomite
Dx clinical; KOH of hair shaft: spores
Rx oral griseofulvin,
household contacts: selenium sulfide or
ketoconazole shampoo
----------------------------------------------------------------
 flank pain, N/V, fever ˃ 38°C (100.4°F), 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
----------------------------------------------------------------
 Whipple’s 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: Celiac’s, Crohn’s, 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: Meckel’s, 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 Meckel’s 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
 DDx
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
hypertriglyceridemia
 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
contusion
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
microhematuria
 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
Auscultation TVF Percussn Mdstinum
Consolid  dull none
ation bronchial breath sounds ( expiratory)
(lobar) crackles, egophony ( sound transmission),
bronchophony, whisper pectoriloquy
Pleural  breath  dull away
effusion sounds from
effusion
(large)
COPD  breath  hyperres none
sounds onant
PnmTX  breath  hyperres away
sounds onant (tension)
 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  β-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
Listeria early-onset sepsis during outbreaks
Enterococcus preterm infants
Coagulase- indwelling umbilical venous catheters
negative Staph in neonatal ICU
(S. epidermidis)
other Gram- (Klebsiella, Enterobacter, Pseudomonas)
negatives 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 GBS UTI
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 goat’s 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 &
specificity
 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
----------------------------------------------------------------
 Bruton’s (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 Bruton’s, 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.
aureus)
 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,
Hirschsprung
----------------------------------------------------------------
DDx of delayed passage of meconium
(within 48 hrs) level of meconium
obstruction consistency
Hirschsprung rectosigmoid normal
meconium ileus ileum inspissated
 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
dilation
 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)
----------------------------------------------------------------
 β-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: “Hampton’s 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, Alzheimer’s,
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:
colchicine
----------------------------------------------------------------
 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: Turner’s
 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:
Huntington’s
 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
Marijuana  appetite, dry mouth,
conjunctival injection,
tachycardia, slow reaction time,
euphoria/dysphoria/paranoia,
psychomotor impairment (days)
gynecomastia (chronic use)
phencyclidin violent behavior, impulsivity,
e hallucinations, amnesia,
P dissociation, vertical
C nystagmus,
P mydriasis, ataxia
LSD visual hallucinations,
mydriasis,
euphoria/dysphoria/panic,
perceptual intensification,
tachycardia/palpitations/HTN,
Cocaine euphoria, agitation,
formication (“cocaine bugs”)
chest pain, stroke, MI, seizures
tachycardia, HTN, mydriasis
Meth violent behavior, tooth decay
diaphoresis, tachycardia, HTN,
choreiform movements,
psychosis
Heroin euphoria, miosis,
(opioid) respiratory depression,
depressed mental state,
constipation, hypotension,
hypothermia, & bradycardia
amphetamin agitation, paranoia, delirium,
e palpitations, tachycardia, HTN,
diaphoresis, mydriasis,
seizures, hyperthermia,
intracerebral hemorrhage
Alcohol slurred speech, unsteady gait,
disinhibition, nystagmus
 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
----------------------------------------------------------------
 esophageal perforation MC occurs following
instrumentation of the esophagus
o less commonly due to Boerhaave’s
 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 (Addison’s)
 hyponatremia, hyperkalemia
 hyponatremia is due to volume contraction
(aldosterone deficiency) & increased vasopressin
(lack of cortisol suppression)
 mild hyperchloremic acidosis
----------------------------------------------------------------
 hypernatremia, hypokalemia: Cushing’s
----------------------------------------------------------------
 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, β-blocker, CCB,
digoxin) can  accessory pathway conduction,
thus worsen WPW
----------------------------------------------------------------
 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
----------------------------------------------------------------
 Todd’s paralysis: focal neurologic deficit
following a seizure
----------------------------------------------------------------
 muscle weakness & dry mouth: Lambert-Eaton
 a/w lung small cell carcinoma & Hodgkin’s
 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
AChE-inhibitor)
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:
polymyositis
 multicentric CNS inflammation & demyelination:
MS
----------------------------------------------------------------
 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
one’s 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 (Pompe’s): 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
CTS in RA
----------------------------------------------------------------
 severe hypovolemic hypernatremia Rx: isotonic
normal saline or lactated Ringer’s
 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,
disorder return to full function
Schizophreniform > 1 month, < 6 months;
functional decline not required
Schizophrenia at least 6 months;
functional decline required
Schizoaffective at least 2 week Hx of psychotic
symptoms w/o mood symptoms
delusional ≥ 1 delusion, at least > 1 month,
disorder 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: β-
blocker (propranolol) + endoscopic band ligation 1-
2 wk later
o Rx small, non-bleeding varices
o β-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
release
 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 Turner’s
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: β-hCG for pregnancy
 next: prolactin, TSH, FSH
o  prolactin  brain MRI
o  TSH  hypothyroidism  5-α-reductase deficiency: 46, XY
o  FSH  premature ovarian failure o male gonads
 if Hx of uterine procedure or infection, may have o female/undermasculinized/ambiguous
scarring of uterine cavity (Asherman syndrome) external genitalia at birth
o hormone therapy to test for ability to grow a o often raised as girl, but male identity
uterine lining o masculinization at puberty;  phallus size,
o hysteroscopy to visualize uterine adhesions muscle growth, but lack breasts
---------------------------------------------------------------- o infertility; risk of cryptorchidism
boobs organs axillary, ----------------------------------------------------------------
pubic hair  Lyme arthritis is the MC late manifestation of
Complete 46, Yes absent uterus minimal untreated Lyme disease (months/years)
androgen XY & upper or absent  migratory arthralgias progress into
insensitivit vagina monoarticular arthritis of the knee; travel history
y  Dx: synovial fluid show inflammatory profile
Mullerian 46, Yes absent or normal  confirm Dx: ELISA & Western blot
agenesis XX rudimentary  Rx: doxycycline or amoxicillin
uterus &  DDx: reactive arthritis (1 – 4 wks after urethritis
upper vagina or diarrheal infection), acute osteomyelitis, gout
Transverse 46, Yes abnormal normal ----------------------------------------------------------------
vaginal XX vagina,   17-hydroxyprogesterone = nonclassic CAH
septum normal uterus
due to 21-hydroxylase deficiency
Turner’s 45, streak ovaries normal  hyperandrogenism in late childhood
X normal uterus
 male pattern hair distribution, severe acne
----------------------------------------------------------------
 non-classical CAH presents similar to PCOS
Androgen insensitivity syndrome (46, XY)
 end-organ resistance to androgens ----------------------------------------------------------------
 DDx of stridor: croup, foreign body aspiration,
 testicular descent is an androgen-dependent process
epiglottitis, laryngomalacia, vascular rings,
 cryptorchid testes secretes testosterone which is
retropharyngeal abscess
aromatized to estrogen  breast development  laryngomalacia is MCC of chronic stridor
 external female genitalia
----------------------------------------------------------------
 no axillary or pubic hair  high-grade fever, sore throat with odynophagia,
 primary amenorrhea; no uterus or upper vagina muffled voice, drooling, stridor: epiglottitis
due to anti-Mullerian hormone from testes  “tripoding” with inspiratory stridor
o Wolffian ducts degenerate  neck hyperextension provides relief
 cryptorchid gonads  risk of dysgerminoma or  MCC in adults: Hib & Strep pyogenes
gonadoblastoma after puberty o especially unvaccinated immigrants
 Rx: gonadectomy after puberty + estrogen
 CXR: enlarged epiglottis “thumbprint”
----------------------------------------------------------------
 Dx: clinical, high suspicion
 Mullerian agenesis (Mayer-Rokitansky-Kuster-
 Rx: emergency intubation in the OR
Hauser syndrome): hypoplastic/absent mullerian
ductal system; normal ovaries  DDx: peritonsilar abscess (uvular deviation),
angioedema, vascular ring, croup, foreign body
 genotypic & phenotypic female
 no menstruation due to absent/underdeveloped ----------------------------------------------------------------
 inspiratory stridor that worsens when supine &
uterus, cervix, & upper 2/3 vagina
---------------------------------------------------------------- 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 person’s
attitude into one’s 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, Complete abortion
lacrimation, cramps: opioid withdrawal  whole conceptus expelled before 20 wks gestation
 mydriasis, piloerection, hyperactive bowel sounds  “solid white mass covered with blood”
 within 6 – 12 hr, peaks @ 24 – 48 hr  abdo pain & contractions subsides
 Rx: methadone  β-hCG still positive; undetectable after 4 -6 wks
----------------------------------------------------------------  risk factors: smoking, advanced maternal age,
 Streptokinase is a fibrinolytic for STEMI only previous spontaneous abortion
 Cilostazol: anticoagulant for chronic claudication,
not acute limb ischemia Management of spontaneous abortion
---------------------------------------------------------------- Threatene expectant management until…
 GnRH stimulation test: precocious puberty d symptom resolution OR progression to
---------------------------------------------------------------- inevitable, incomplete, or missed
 anovulation & amenorrhea in lactating mothers abortion
is due to  prolactin, which suppresses GnRH, Missed, hemodynamically unstable, heavy bleed:
thus  LH/FSH Inevitable, surgical evacuation (D&C)
o not a reliable method of birth control Incomplet hemodynamically stable, mild bleeding:
---------------------------------------------------------------- e expectant O/P management, misoprostol,
 human placental lactogen (hPL): insulin antagonist or surgical evacuation
 causes maternal lipolysis & insulin resistance, thus Septic blood & endometrial cultures,
 delivery of fatty acids & glucose to the fetus broad-spectrum ABX,
---------------------------------------------------------------- surgical evacuation (D&C)
 significant blood loss from MVA, receives Ectopic MTX
several units of pRBCs (inhibits actively proliferating fetal cells)
 whole blood is mixed with citrate coagulant ----------------------------------------------------------------
 pRBCs derived from whole blood contains citrate  IV oxytocin: augment labor, Rx postpartum
 infused citrate chelates Ca++ & Mg++, thus hemorrhage, expel a retained fetus or POC
----------------------------------------------------------------
reducing serum levels  paresthesia 2/2 hypoCa++
 progesterone: prevention of preterm labor of a
 Rx: Ca++ gluconate
singleton pregnancy in patients with a Hx of
----------------------------------------------------------------
spontaneous preterm delivery
 spontaneous abortion: < 20 wks gestation
----------------------------------------------------------------
 advanced maternal age is a significant risk factor Congenital diaphragmatic hernia
 absent fetal movement on USS is the most  pulmonary hypoplasia, pulmonary HTN,
significant indicator of fetal loss polyhydramnios from esophageal compression,
right heart deviation, gasless abdomen
Types of miscarriages  worsened with positive-pressure ventilation as
bleeding cervix products of air into GIT compresses the lungs
conception  Rx: intubation, then gastric tube to prevent
Threatened yes closed +fetal heart tones bowel distension against the lungs
Missed none closed no cardiac activity, ----------------------------------------------------------------
or empty sac  pulmonary cavitation in HIV patients DDX: TB,
Inevitable yes dilated no cardiac activity, atypical mycobacteria, Nocardia, G-negative rods,
collapsed sac anaerobes
Incomplete yes dilated partial expulsion  Nocardia: aerobic, G-positive, weakly acid-fast,
Complete maybe closed conceptus expelled beaded, branching, filamentous rod
 o CXR: pulmonary nodules
o Rx: TMP-SMX
----------------------------------------------------------------
 persistent culture-negative monoarthritis that
fails to respond to ABX: TB arthritis
----------------------------------------------------------------
 pain, pulselessness, paresthesia, poikilothermia
(coldness), pallor (5 “P’s”): 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
cytotoxicity
 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
present
 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 Grave’s 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
 Ebstein’s 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 β-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 Cushing’s (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,
angiodysplasia
----------------------------------------------------------------
 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
o 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 β2 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,
meningitis
----------------------------------------------------------------
DDx of menorrhagia
endometriosis chronic pelvic pain, endometrioma,
pain peaks 1-2 days before menses,
dyspareunia, infertility,
endometrial glands outside uterus
fibroids heavy menses with clots,
firm, irregular, enlarged uterus,
constipation & urinary frequency
due to extrinsic compression
adenomyosis dysmenorrhea, menorrhagia,
chronic pelvic pain,
bulky, globular, tender uterus
endometrial Hx chronic anovulation, obesity,
hyperplasia/c nulliparity (estrogen excess),
a irregular, intermenstrual,
postmenopausal bleeding,
small, nontender uterus
endometritis 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
----------------------------------------------------------------
Phenylketonuria
 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, Fanconi’s
 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 Crohn’s 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,
AIN, ATN
----------------------------------------------------------------
 dysuria, urinary frequency, WBC’s 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
(Broca’s) 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 (Meyer’s 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: Alzheimer’s
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: Pick’s
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 &
acetylcysteine
 prednisone minimizes hypersensitivity reactions
to contrast media & dye allergies
 withhold NSAIDS; causes renal vasoconstriction
----------------------------------------------------------------
 painless hematochezia in a toddler: Meckel’s
 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, Horner’s (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
 Horner’s 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 β-blockers, due to unopposed alpha activity
 avoid fibrinolytics due to ICH risk
 avoid thrombolytics for suspected aortic dissection
Acute cocaine intoxication
features 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 vasoconstrict’n)
 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
corticosteroids
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: Meckel’s,
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
o A/E: EPS, NMS
----------------------------------------------------------------
 relative risk (RR): probability of an outcome of
interest occurring in the exposed group compared
to the non-exposed group; a/w cohort studies
o 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
interval interval
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
Goodpasture’s or Wegener’s; 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: Wernicke’s
----------------------------------------------------------------
 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:
hypocalcemia
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
risk maternal HTN, pre-eclampsia/eclampsia,
factors abdominal trauma, prior placental abruption
cocaine use or tobacco use
feature acute onset vaginal bleeding,
s hyperactive, hypertonic & tender uterus,
high-frequency, low-intensity contractions,
constant abdominal pain, late decelerations
Dx clinical presentation primarily;
USS used only to r/o placenta previa
Rx 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
----------------------------------------------------------------
PPD Patients to treat (positive PPD)
≥ 5 mm HIV-positive
recent contact with TB
previously healed TB on CXR
organ transplant recipients
immunosuppressed patients
≥ 10 mm recent TB-endemic immigrants (< 5 yrs)
IVDA
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
o 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
sensitization
 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: ≥ 39°C (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
 Dx: MRI
 Rx: prophylaxis with factor concentrates
----------------------------------------------------------------
 clenched fist injury, human bite, dog bite
 Rx: amoxicillin-clavulanate (augmentin)
----------------------------------------------------------------
 erythromycin: Rx Legionnaire’s & 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
surfaces
----------------------------------------------------------------
 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
 PTX Rx:
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
basal C/L hemiparesis & hemisensory loss
ganglia homonymous hemianopsia
(putamen) gaze palsy AWAY from lesion**
cerebellum no hemiparesis, occipital headache,
neck stiffness, gait ataxia, nystagmus
thalamus C/L hemiparesis, hemisensory loss
(“toward”) nonreactive pinpoint pupil
upward gaze palsy
eyes deviate TOWARD hemiparesis**
cerebral frontal: C/L hemiparesis
lobe parietal: C/L hemisensory loss
(rare) occipital: homonymous hemianopsia
eyes deviate AWAY from hemiparesis
pons 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
 β-blockers & ergotamine: a/w Raynaud’s
 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 center’s
temporary upregulation of body temp by the
hypothalamus
----------------------------------------------------------------
 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
glucocorticoids
----------------------------------------------------------------
 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 tonic-
clonic seizure that is self-limited: Todd paralysis
----------------------------------------------------------------
Infantile hypertrophic pyloric stenosis
risk first-born male, age 3 – 5 wks
factors erythromycin use, formula feeding
features projectile non-bilious emesis
poor weight gain, good appetite,
dehydration, sunken fontanelles
tachypnea, olive-shaped mass
Lads hypochloremic, hypokalemic metabolic
alkalosis with compensatory respiratory
acidosis
Dx abdominal USS
Rx IV hydration
pyloromyotomy
 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
Pertussis
H. influenza Type B
Pneumococcal
Meningococcal
HPV
influenza (injection)
live attenuated rotavirus
MMR
varicella
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
puberty
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
 o 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: Klinefelter’s
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
o 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: Goodpasture’s
 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, hematology iron deficiency anemia recipient IgE & mast cell
oral atovaquone, or clindamycin-primaquine neuro peripheral neuropathy, headache activation
---------------------------------------------------------------- endocrine autoimmune thyroiditis, Type I DM transfusion-related respiratory distress, non-
 male adolescent with epistaxis, visible nasal mass, psych depression, psychosis acute lung injury cardiogenic pulmonary edema
bony erosion in back of nose: angiofribroma ---------------------------------------------------------------- (within 6 hrs) donor anti-leukocyte Ab’s
 benign, but can erode & invade locally  lidocaine: class IB anti-arrhythmic delayed hemolytic mild fever & hemolytic anemia
----------------------------------------------------------------   frequency of PVCs &  risk of v-fib (within 2 – 10 days) direct Coombs test positive
 reactive nasal polyps do not cause bony erosions  do not use prophylactically to prevent v-fib in anamnestic Ab response to
 a/w chronic infections or allergies patients with acute MI RBC antigen
----------------------------------------------------------------   risk of asystole
 giant cell tumor of bone: locally aggressive ----------------------------------------------------------------  leukocytes release cytokines during blood storage
skeletal neoplasm, benign; MC in adolescents Pain management for terminal cancer that cause transient fever, chills, & flank pain;
 knee pain, swelling, decreased joint ROM  initially Rx: short-acting morphine; subsequent causes febrile non-hemolytic reaction
 distal femur or proximal tibia doses titrated to achieve complete pain control o prevented by using leuko-reduced blood
 XR: osteolytic bone lesion, “soap-bubble” in the  once established, switch to long-acting narcotics  IgA-deficient individuals are at risk for
epiphyseal region of long bones (patches), with short-acting morphine PRN for anaphylactic transfusion reactions
 Rx: surgery break-through pain o Rx: IM epinephrine, vasopressors, histamine
---------------------------------------------------------------- ---------------------------------------------------------------- blockers, glucocorticoids
 loss to follow-up in prospective studies has  vesiculoureteral reflux (VUR) is a risk factor o future transfusions: IgA-deficient plasma &
potential for attrition bias (selection bias) for recurrent UTIs, leading to renal scarring washed RBC products
 can over- or under-estimate the association  all children age 2 – 24 months, first febrile UTI ----------------------------------------------------------------
between exposure & disease should undergo renal USS  altered mental status, acute renal failure, fever,
----------------------------------------------------------------  Dx recurrent UTIs: voiding cystourethrogram hemolytic anemia, thrombocytopenia: TTP
Celiac’s screening: o not routine for first UTI  reticulocytosis,  indirect bilirubin, schistocytes
 IgA anti-tissue transglutaminase Ab assay  not a/w bladder cancer, RCC, abscess, or calculi  Dx: clinical; ADAMTS13 not used for diagnosis
o IgA anti-endomysial antibodies ----------------------------------------------------------------  Rx: plasma exchange
 may be absent with selective IgA deficiency Immunologic blood transfusion reactions
 Dx: if suspicion is high, measure total IgA anaphylactic rapid onset shock, hypotension, Indications for specialized RBC treatments
 confirm Dx: upper GI endoscopy with biopsy (seconds – minutes) angioedema/urticaria, Irradiated BM transplant recipients,
respiratory distress/failure cellular immunodeficiency,
Features of malabsorption in celiac disease recipient anti-IgA IgG blood donated by 10 or 20 relative
Nutrient Symptoms primary transient hypotension, Leukoreduced chronic transfusions,
fat bulky, foul-smelling, floating stools hypotension patients on ACE-I, caused by CMV at-risk patients (AIDS),
protein loss of subcutaneous fat & muscle mass reaction (minutes) bradykinin in blood products Hx of febrile non-hemolytic rxn,
iron pallor, fatigue, iron deficiency anemia normally degraded by ACE potential transplant recipient,
Ca++, vit osteoporosis, osteomalacia acute hemolytic fever, flank pain, hemolysis, Washed IgA deficiency,
D (within 1 hr) hemoglobinuria, DIC complement-dependent autoimmune
medical emergency! direct Coombs test positive** hemolytic anemia,
Vit K easy bruising
ABO incompatibility urticaria despite antihistamines
Vit A hyperkeratosis
febrile fever & chills (most common) ----------------------------------------------------------------
nonhemolytic cytokine accumulation during  Cat-scratch disease: Bartonella henselae
Extraintestinal symptoms of Celiac’s
(within 1 – 6 hrs) blood storage (from leukocytes)  local skin lesion evolves through vesicular,
general fatigue, weight loss
urticarial/allergic urticarial, flushing, pruritus, erythematous, papular phases
skin dermatitis herpetiformis, vitiligo
(within 2 – 3 hr) angioedema  tender, localized, regional lymphadenopathy
MSK osteopenia/osteoporosis
  Rx: azithromycin (5 days) to reduce symptoms,  Alveolar-arterial gradient: estimates the degree deposits humps with C3
but mainly self-limited of alveolar oxygen transfer to blood Px benign, children: good
---------------------------------------------------------------- o normal: < 15 ( with age); > 30 is elevated if RPGN or nephrotic adults: CKD
 membranous glomerulonephritis is a/w Hep B  patients with Hx of CAD & sudden onset dyspnea syndrome (worse Px)
 focal segmental glomerulosclerosis are MC a/w after IV fluids is likely pulmonary edema ----------------------------------------------------------------
HIV, blacks, HTN, obesity, IVDA, sickle cell o pulmonary edema  the A-a gradient due to  B/L sensorineural hearing loss, recurrent hematuria,
o segmental sclerosis & hyalinosis V/Q mismatch; excess fluid reduces lung ocular abnormalities, renal insufficiency: Alport’s
---------------------------------------------------------------- compliance by preventing alveolar expansion  X-linked defect in collagen IV formation
 collagenous colitis: chronic watery diarrhea o Rx: supplemental O2  normal complement levels
 colonoscopy: normal mucosa  extensive ARDS results in a poorly aerated lung  EM: thin & thick capillary loops, GBM splitting,
 biopsy: mucosal subepithelial collagen deposits that is stiff & less compliant tram-track appearance
----------------------------------------------------------------  left-to-right shunts (VSD) lowers lung compliance ----------------------------------------------------------------
 anorexia, fatigue, weight loss, cognitive impairment, by  pulmonary blood flow, causing fluid leakage  necrotizing fasciitis: erythema & swelling,
Hx of IVDA: HIV testing into the interstitium severe pain out of proportion to physical exam
 HIV patients are at risk of depression & dementia ----------------------------------------------------------------  involves subcutaneous tissue & deep fascia
 DDx: MDD, chronic primary adrenal insufficiency,  Hx of travel to endemic area (Mexico), dysentery,  systemic symptoms: fever, hypotension
iron deficiency anemia RUQ pain, single cyst in right lobe of liver:  signs of tissue necrosis: crepitus, purulent drainage,
---------------------------------------------------------------- amebic liver abscess (E. histolytica) radiographic evidence of gas in deep tissues
 phenytoin & carbamazepine: block voltage-gated  primary infection in the colon  bloody diarrhea  rapidly progresses to discoloration, bullae, necrosis
Na+ channels   ALP  MCC: Group A Strep
 Rx primary generalized tonic-clonic seizures  Dx: trophozoites in stool, serology, or imaging to  Rx: surgical debridement & ABX
with/without secondary generalization r/o pyogenic abscess  DDx: abscesses, cellulitis, deep muscle hematoma,
 A/E for both: SJS/TEN, fetal hydantoin syndrome  Rx: empiric metronidazole thrombophlebitis
 phenytoin A/E: gingival hypertrophy o also paromomycin (luminal agent to ----------------------------------------------------------------
---------------------------------------------------------------- eradicate intestinal colonization)  anti-ischemic & anti-anginal effects of nitrates
 phenobarbital: acts at GABA receptors by o do not drain the abscess are due to systemic vasodilation
extending GABA-mediated Ca++ channels open  DDx: pyogenic liver abscess (2/2 surgery, GI o concomitant use of β-blockers prevents
 A/E: sedation infection, acute pancreatitis), hepatic adenoma reflex tachycardia caused by nitrates
---------------------------------------------------------------- (solid lesion), hydatid cyst (Echinococcus) ----------------------------------------------------------------
A-a PaCO2 corrects ----------------------------------------------------------------  recurrent epistaxis, ruby-colored papules on the
gradient with O2?  gross hematuria a/w URI, HTN, proteinuria, lips that blanch, widespread AVMs: hereditary
reduced inspired O2 normal normal yes RBC casts, AKI: glomerulonephritis telangiectasia (Osler-Weber-Rendu syndrome)
tension (high altitude)  AVMs occur in mucous membranes, skin, GIT
hypoventilation normal  yes IgA nephropathy Post-infectious GN  diffuse telangiectasias, digital clubbing
(CNS depression) features within 5 days of URI 10 – 21 days after URI  pulmonary AVMs can cause R-to-L cardiac shunt,
diffusion limitation  normal yes (synpharyngitic) (post-pharyngitic) resulting in hypoxemia & reactive polycythemia; &
(interstitial lung dz) men, age 20 – 30 yrs, age 6 – 10 or adults massive hemoptysis
intracardiac shunt,  normal NO gross hematuria ----------------------------------------------------------------
extensive ARDS recurrent gross adults: asymptomatic  Henoch-Schonlein Purpura: systemic form of IgA
V/Q mismatch  normal yes hematuria or acute nephritic involvement of glomeruli, skin, joints, intestines
(obstructive disease, or  syndrome ----------------------------------------------------------------
pulmonary edema, Dx normal C3 low C3** Causes of postoperative fever (> 380C)
atelectasis, pneumonia) elevated ASO &/or Wind PE, pneumonia, aspiration
anti-DNase B Wound SSI
Bx: mesangial IgA Bx: subepithelial Water UTI
 Walk DVT
Wonder drug fever, IV lines
drugs 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
outpatient healthy: doxycycline or macrolide
comorbidities: fluoroquinolone,
OR beta-lactam + macrolide
inpatient fluoroquinolone, OR
(non-ICU) beta-lactam + macrolid
inpatient beta-lactam + macrolide (IV), OR
(ICU) beta-lactam + fluoroquinolone
 ICU patient ABX to cover: S. aureus, Legionella,
Pseudomonas
----------------------------------------------------------------
 copious white/yellow vaginal discharge, non-
malodorous, absence of other findings on vaginal
exam: physiologic leukorrhea
----------------------------------------------------------------
 stillbirth: ≥ 20 wks gestation
 risk factors: HTN, DM, adv maternal age, smoking
Stillbirth delivery options
2nd trimester D&C (up to 24 wks)
induction
spontaneous delivery
3rd trimester induction with oxytocin (preferred)
(after 28 wks) spontaneous delivery
c-section
 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:
herpangina
 MCC: Coxsackie A
 gray vesicles/ulcers on posterior oropharynx
 lesion on palms & soles = hand-foot-mouth disease
 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)
cystitis TMP-SMX (3 days)
fosfomycin (single dose)
complicated **requires urine culture prior to Rx
cystitis fluoroquinolones (5 – 14 days), but
not for pregos
pyelonephritis **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
conditions
----------------------------------------------------------------
 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 ----------------------------------------------------------------  #1 Rx major depression: SSRI
tumor that produce excess estrogen  ethylene glycol poisoning (anti-freeze) is a/w  Dx: must have depressed mood or anhedonia
 bimodal age distribution hypocalcemia & calcium oxalate deposition with at least 4 symptoms of SIGECAPS
o presents as isosexual precocious puberty or  flank pain, hematuria, oliguria, AKI, profound  for patients with advanced cancer, also consider
postmenopausal bleeding & uterine anion gap metabolic acidosis (HCO3 < 8) adjustment disorder w/ depressive features
myohyperplasia  U/A: rectangular, enveloped-shaped crystals is o symptoms must occur within 3 months
 Rx: tumor removal results in symptom regression a/w Ca++ oxalate ----------------------------------------------------------------
----------------------------------------------------------------  Rx: fomepizole or ethanol to inhibit alcohol Antipsychotic extrapyramidal effects
 dysgerminoma: malignant ovarian tumor dehydrogenase; sodium bicarbonate to relieve (related to degree of D2 blockade)
 women age < 20 yr acidosis, & hemodialysis for severe acidosis a/w high-potency typical antipsychotic, acute dystonic
 unilateral; can undergo torsion &/or end-organ damage onset after 4 hours to 4 days, reaction
 undifferentiated gonadal germinal cells ---------------------------------------------------------------- sudden, sustained contraction of neck,
 neutral; does not secrete sex hormones  methanol poisoning: vision loss & coma mouth, tongue, EOM, opisthotonus
 testes equivalent = seminoma  within 24 hr: headache, N/V, epigastric pain Rx: benztropine (anticholinergic) or
----------------------------------------------------------------  optic disc hyperemia diphenhydramine (antihistamine)
 sertoli-leydig cell tumor: produce androgens, ---------------------------------------------------------------- subjective restlessness, akathisia
causes defeminization, then masculinization in Toxicity Features Labs onset can occur at anytime
child-bearing age women alcohol slurred speech, high osmolar gap, Rx: benzodiazepine (lorazepam) or
 serous cystadenomas: MC benign cystic ovarian ketoacidosis unsteady gait, anion gap beta-blocker (propranolol)
neoplasm; no estrogen or androgens altered mentation metabolic acidosis onset within 4 days to 4 months; drug-induced
o ovarian mass & abdominal pain due to ketosis tremor, rigidity, bradykinesia Parkinsonism
---------------------------------------------------------------- methanol visual burning, high osmolar gap, Rx: benztropine or amantadine
Constipation in children (EYES) central scotoma, anion gap onset within 1 – 6 months; Tardive
afferent pupil defect, metabolic acidosis dyskinesia of mouth/face, extremities; dyskinesia
risk factors transition to solid foods & cow’s milk,
altered mentation, lip smacking, puckering, biting,
toilet training, & school entry
acute pancreatitis grunting, tongue protrusion
complications anal fissures, hemorrhoids, vomiting, ethylene flank pain, oliguria, high osmolar gap, no effective treatment
encopresis, enuresis, recurrent cystitis glycol hematuria, tetany, anion gap ----------------------------------------------------------------
Rx dietary fiber, limit cow’s milk < 24 oz (KIDNEYS) CN palsy metabolic acidosis,  atypical antipsychotic most likely to cause EPS:
oral laxative (polyethylene glycol, Ca-oxalate risperidone
mineral oil) crystals  Rx: replace with clozapine; least likely for EPS
isopropyl CNS depression, high osmolar gap, o CBC before starting clozapine
 recurrent cystitis in toddlers 2/2 constipation can alcohol disconjugate gaze, NO anion gap, ----------------------------------------------------------------
cause rectal distension  compresses the bladder absent ciliary reflex NO metabolic  amiodarone: Rx conversion & maintenance of
 resulting in urinary stasis acidosis sinus rhythm for patients with a-fib
---------------------------------------------------------------- ----------------------------------------------------------------  does not prevent thrombus formation
 musculoskeletal infections (osteomyelitis, abscess)  NPV: probability of being disease-free if test ----------------------------------------------------------------
results from hematogenous spread from other result is negative Running injuries of the foot &ankle
sites such as the skin (furuncles)  NPV varies with the pretest probability of disease a/w sudden  in activity, Stress
 MCC S. aureus o high probability of disease = low NPV insidious, localized pain in navicular fracture
---------------------------------------------------------------- o low probability of disease = high NPV or metatarsals; microfractures that
 if anion gap is markedly elevated with absence of  prevalence is directly related to pretest probability coalesce within cortical bone,
frank uremia, calculate osmolar gap to assess for o sensitivity & specificity to not vary with burning pain, worse when initiating Plantar
ethanol, methanol, or ethylene glycol intoxication pretest probability first steps of the day, fasciitis
o high osmolar gap & severe metabolic acidosis ---------------------------------------------------------------- pain decreases with activity, but
worsens with prolong weight-bearing
burning pain or stiffness 2 to 4 cm Achilles
above posterior calcaneus tendinopathy
numbness/pain between 3rd & 4th toe, Morton
clicking sensation when palpating neuroma
plantar space between 3rd & 4th toes
while squeezing metatarsal joints
compression of tibial nerve at ankle Tarsal tunnel
burning, numbness, aching of distal syndrome
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)
 DDx: UTI
----------------------------------------------------------------
 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
 infertility
----------------------------------------------------------------
 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: Ewing’s 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
smoking
 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
pulmonary chronic bronchitis, PE,
bronchiectasis, Mallory-Weiss,
lung cancer  DDx: acute cholecystitis, acute pancreatitis,
cardiac MS/acute pulmonary edema PUD, Crohn’s, SMA syndrome
infectious TB, lung abscess ----------------------------------------------------------------
hematologic coagulopathy  prodromal fever, irritability, skin tenderness,
vascular AVMs, severe thrombocytopenia followed by generalized erythema & superficial
systemic Wegener’s, Goodpasture’s, flaccid blisters; + Nikolsky sign: Staphylococcal
SLE, vasculitis scalded skin syndrome
----------------------------------------------------------------  scaling & desquamation (5 days), then resolution
Diabetic autonomic neuropathy within 1 – 2 wks
cardiac tachycardia, postural hypotension,  children age < 10 yrs
impaired exercise tolerance  superficial flaccid blisters with flexural accentuation,
peripheral dry skin, pruritus, retinopathy, perioral crusting, & facial edema
nerves foot ulcers, poor would healing ----------------------------------------------------------------
Charcot arthropathy ( fx risk)  erythema multiforme: targetoid papule or plaque,
GI gastroparesis, delayed gastric emptying acrofacial distribution, involves palms & soles
esophageal dysmotility, dyspepsia  a/w HSV, coccidiomycosis, Mycoplasma
GU erectile dysfunction, decreased libido ----------------------------------------------------------------
neurogenic bladder, urinary retention,  use dependence: enhanced pharmacologic effects
overflow incontinence, high PVR, during faster HR (Class IC & IV antiarrhythmics)
nephropathy  flecainide (class IC): Rx a-fib for maintenance
---------------------------------------------------------------- of sinus rhythm with structurally normal hearts
 foot ulcers are graded from 0 - 5 o slowest rate of drug binding & dissociation
Management of diabetic foot ulcers from Na+ channel receptors
o off-loading o normally does not prolong QRS or QT
o debridement o faster HR causes progressive  impulse
o wound dressing conduction, leading to wide QRS
o ABX  Rx: supraventricular arrhythmia
o revascularization ----------------------------------------------------------------
o amputation  non-dihydropyridine CCB (verapamil, diltiazem)
----------------------------------------------------------------  displays use dependence by prolonging AV node
 Hx of cyanotic congenital heart disease & refractory period, thus  PR interval
recurrent sinusitis predisposes to brain abscess ----------------------------------------------------------------
o direct spread from sinuses to frontal lobe  Digoxin: inhibits ATPase-dependent Na+/K+
 cyanotic heart disease  hematogenous spread pump, thus  intracellular Na+
 fever, headache, focal neurologic deficits, seizure o results in decreased Na+/Ca++ exchanger,
 indolent process thus  intracellular Ca++
----------------------------------------------------------------  enhances vagal tone & slows AV node conduction
 urinary diverticulum: outpouchings of the  Rx: systolic dysfunction (+inotrope)
bladder or urethra into adjacent tissue ----------------------------------------------------------------
 MC in women  excisional biopsy with narrow margins & depth
 post-void dribbling, dysuria, dyspareunia through SC fat is preferred for Dx of melanoma
 urinary stasis leads to recurrent cystitis/UTI  tumors > 1 mm in depth should have a sentinel
---------------------------------------------------------------- lymph node study
 post-op adhesions cause mechanical SBO  depth is the most important prognostic factor
 congenital adhesions: Ladd’s bands ----------------------------------------------------------------
  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
Croup age 6 mo – 6 yrs
(laryngotracheo parainfluenza virus
-bronchitis) “barky” cough, inspiratory stridor
fever, rhinorrhea, congestion
Rx: nebulized racemic epinephrine
Epiglottitis stridor, dysphagia, excess drooling,
high fever, tachypnea, tachycardia
muffled “hot potato” voice
lateral XR: thick aryepiglottic folds
Laryngomalaci age 4 – 8 months
a stridor worsens when supine,
improves when prone
foreign body age 6 mo – 4 yr
aspiration 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 β-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
  ALP & GGT
 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: Waldenstrom’s
 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,
Waldenstrom’s, 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: Bruton’s
 XR defect in B-cell tyrosine kinase
 all serum Ig’s & B-cells levels decreased
 recurrent pyogenic infections (S. pnemo, H. infl)
 maternal IgG maintained for first 6 months
----------------------------------------------------------------
 CVID: serum Ig’s decreased; similar to Bruton’s
 less severe symptoms & later onset (age 15 – 35 yrs)
 normal circulating B cells
----------------------------------------------------------------
 neonate with hypocalcemic seizures: DiGeorge
----------------------------------------------------------------
 mortality benefits in CHF: ACE-I, β-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,  endometrial ablation is contraindicated with  acute Hep B markers: HBsAg & IgM anti-HBc
hammer toes endometrial hyperplasia; prevents future o both are elevated during “window period”
 MCC death: cardiomyopathy evaluation of the endometrium by biopsy  HBsAg: first to appear 4 -8 wk after infection
---------------------------------------------------------------- ----------------------------------------------------------------  HBcAg is not detectable
Causes of AUB in premenopausal women  peripheral artery aneurysm: pulsatile mass that ----------------------------------------------------------------
o structural: fibroids, adenomyosis, compresses adjacent structures, results in  fever, lethargy, signs of heart failure after a viral
endometrial polyp, malignancy thrombosis & ischemia prodrome in a child: viral myocarditis
o non-structural: coagulopathy, infection  anterior thigh pain 2/2 femoral nerve compression  MCC: Coxackie B, Adenovirus
o ovulatory dysFx: prolactinoma, PCOS,  popliteal & femoral artery aneurysm are a/w AAA  myocyte necrosis impairs systolic/diastolic function
thyroid disorder, eating disorder, weight loss ----------------------------------------------------------------  heart failure signs: dyspnea, syncope, N/V,
 #1 Dx: exclude pregnancy Cervicitis tachycardia, hepatomegaly
 Dx: endometrial Bx  #1 MCC: C. trachomatis  CXR: cardiomegaly, pulmonary edema
----------------------------------------------------------------  #2 MCC: N. gonorrhea (urethritis & PID)  echo: diffuse hypokinesis
 postmenopausal women with AUB are at high risk o 50% asymptomatic  Dx: myocardial biopsy shows inflammatory
for endometrial cancer o friable cervix with easy bleeding, infiltrate of myocardium with myocyte necrosis
 Dx: transvaginal USS, then endometrial Bx mucopurulent discharge  Rx: diuretics, inotropes, ICU
 Rx uncomplicated gonococcal cervicitis/urethritis: ----------------------------------------------------------------
endometrial biopsy is indicated for evaluating ceftriaxone + azithromycin or doxycycline,  Paget’s disease of bone is typically asymptomatic,
abnormal uterine bleeding for…. which covers resistant gonococci & simultaneous with incidentally  ALP
 all women ≥ 45 & all postmenopausal bleeding Rx C. trachomatis o normal Ca++, phosphorous, & GGT
 women < 45 with persistent symptoms or risk  do not delay empiric Rx to confirm Dx  symptomatics present with pain a/w long bone fx
factors for endometrial cancer  Dx: nucleic acid amplification testing resulting in secondary arthritis of hip or knee
 unopposed estrogen exposure (obesity, PCOS) ----------------------------------------------------------------  defective osteoid formation at sites of high bone
 prolonged amenorrhea with anovulation  amiodarone causes pulmonary toxicity turnover; abnormal bone remodeling
----------------------------------------------------------------  related to cumulative dose  Dx: elevated ALP; also nuclear bone scan to
Risk factors  avoid in patients with pre-existing lung disease determine extent of skeletal involvement
Endometrial carcinoma Breast cancer 2/2 decreased pulmonary reserve  Rx: bisphosphonates only if symptomatic
 advancing age  family Hx ----------------------------------------------------------------  highest risk for hearing loss & osteosarcoma
 unopposed estrogen  BRCA1/BRCA2  IM epinephrine can prevent/reverse progression  DDx: prostate ca with bone mets, MM, statins,
 chronic tamoxifen  early menarche of anaphylaxis to anaphylactic shock biliary obstruction, osteoporosis
 obesity  late menopause  β2-agonist effect: bronchodilation &  systemic ----------------------------------------------------------------
 nulliparity  prolonged HRT release of inflammatory mediators Indications for treating Paget’s disease of bone
 chronic anovulation  nulliparity  α1-agonist effect: vasoconstriction raises BP &   symptomatic bone & joint pain
(PCOS) upper airway edema  hypercalcemia of immobilization
 HNPCC  bee stings: refer for venom immunotherapy  neuro-compressive symptoms
---------------------------------------------------------------- ----------------------------------------------------------------  high-output cardiac failure
Endometrial biopsy for AUB  ASA/salicylate intoxication leads to
 involvement of weight-bearing bones
 hyperplasia without atypia (< 3% cancer risk) respiratory alkalosis by stimulating respiratory
 symptomatic pseudofractures
 Rx: progestin therapy to oppose estrogen center, & anion gap metabolic acidosis by
----------------------------------------------------------------
uncoupling oxidative phosphorylation, leads to
 F/U in 3 months to assess response  sudden worsening of asthma & nasal congestion
anaerobic metabolism
 hyperplasia with atypia (30% cancer risk) 30 min – 3 hr after NSAIDs ingestion
 triad: fever, tinnitus, tachypnea
 if considering pregnancy  progestin
 ABG: low PaCO2, low HCO3, normal pH
 if no pregnancy plans  hysterectomy
 mixed respiratory alkalosis & metabolic acidosis
  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
HSV multiple, grouped shallow ulcers
(genital herpes) with erythematous base,
(PAINFUL) tender lymph nodes,
recurrence is common
H. ducreyi single/multiple deep ulcers with
(chancroid) irregular/ragged border, friable base,
gray/yellow exudate,
(PAINFUL) matted & tender lymph nodes
T. pallidum single, indurated, well-circumscribed
(10 syphilis) papule/chancre that ulcerates
punched-out, clean base,
(PAINLESS) painless inguinal lymphadenopathy
C. trachomatis painless, small shallow ulcers,
(LGV) large & painful “buboes”
(PAINLESS)
Donovanosis ulcers with red, beefy base
(granuloma no lymphadenopathy
inguinale) does not resolve with ABX  also volume depletion, altered mental status,
hypotension, electrolyte abnormalities
 vulvar pain, malaise, dysuria, painful labial ulcers  XR: dilated right or transverse colon (> 6 cm)
a/w inguinal lymphadenopathy: genital herpes  Dx: XR, +anemia, fever > 380C, pulse > 120,
due to HSV WBC > 10,000
 non-tender pedunculated lesions (genital warts)  medical emergency!!
due to HPV; can progress to SCC if untreated  Rx: IV fluids, ABX, bowel rest
 primary syphilis Dx: dark field microscopy o IV steroids if IBD-induced
o high rate of false negatives with RPR, FTA-ABS ----------------------------------------------------------------
serologic testing  right-sided colon cancer presents with anemia
----------------------------------------------------------------  left-sided colon cancer presents with obstruction
 familial colonic polyposis (FAP): 100% cancer risk  both are a/w change in bowel habits
 AD inheritance, APC gene mutation ----------------------------------------------------------------
 Rx: elective proctocolectomy  intestinal lymphoma: diffuse infiltrate by
---------------------------------------------------------------- atypical lymphocytes
 EEG: symmetrical 3 Hz spike-and-wave activity  occult blood in stool, abdo pain, weight loss, N/V
on a normal background; provoked/simulated by ----------------------------------------------------------------
hyperventilation: absence seizure (petit mal)  clinical evidence of PE should be anticoagulated
 MCC: age 4 – 8 yrs before undergoing diagnostic evaluation
 daydreaming episodes, no post-ictal state  Rx:
 Rx: valproate or ethosuximide  presence of DVT features should have Dx
---------------------------------------------------------------- confirmed before starting anticoagulation
 complex partial seizures: brief episodes of impaired Wells criteria for
consciousness, postictal confusion, staring spells, pretest probability of PE
failure to respond to stimuli, automatisms +3 points
(swallowing, lip smacking, hand picking movements) o clinical signs of DVT
 EEG: normal or brief discharges; hyperventilation o alternate Dx less likely than PE
cannot simulate complex partial seizures +1.5 points
---------------------------------------------------------------- o previous PE or DVT
 Lennox-Gastaut syndrome: childhood seizures
o HR > 100
of multiple types, mental retardation, age < 7 yrs o recent surgery or immobilization
 EEG: slow spike-and-wave
+1 point
---------------------------------------------------------------- o hemoptysis
 H. pylori with MALT lymphoma w/o metastasis o cancer
 Rx: omeprazole + clarithromycin + amoxicillin Total score
o Rx: CHOP chemotherapy if ABX fails < 2  low risk
(cyclophosphamide, adriamycin, vincristine, 2 – 6  moderate risk
prednisone) > 7  high risk
----------------------------------------------------------------
 Toxic megacolon is a complication of UC  evaluation of DVT: assess pretest probability
 UC: multiple bloody BMs, fever, weight loss using Modified Wells Criteria
 megacolon: total or segmental nonobstructive o if DVT not likely  D-dimer testing
colonic dilation, severe bloody diarrhea, fever,  low D-dimer  DVT unlikely
tachycardia, leukocytosis  high D-dimer  compression USS
 o 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, Cushing’s,
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 Rh-
 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
obstruction
 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: β-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/E’s
----------------------------------------------------------------
 β-thalassemia major: impaired β-globin
production, leads to excess α-globin chains
 chronic hemolysis, transfusion-dependent anemia
 β-thalassemia minor: one normal β-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
----------------------------------------------------------------
----------------------------------------------------------------
iron α- β-
 deficiency thalassemia thalassemia  #2 Rx: CBT pelvic USS: enlarged, edematous
anemia ---------------------------------------------------------------- ovary with  blood flow
MCV     somatic symptom disorder: ≥1 persistent physical ruptured sudden onset U/L abdominal pain
RDW  normal normal symptom; excessive anxiety, concern & energy ovarian cyst after strenuous or sexual activity,
RBC low high devoted to symptoms; persists ≥ 6 months pelvic USS: free fluid near cyst
count  physiologic symptoms: pain, heartburn, fatigue PID fever/chills, new vaginal discharge,
PBS microcytic, target cells target cells  Rx: regularly scheduled appointments focusing dysuria, cervical motion tenderness,
hypochromi on psychological distress; emphasize reassurance transvaginal USS: r/o tubo-ovarian
c ---------------------------------------------------------------- abscess
iron  ferritin, normal/ iron normal/ iron  depression with comorbid medical conditions,  uncomplicated ovarian cyst rupture: no fever,
studies  TIBC & ferritin & ferritin including terminal illness hypotension, tachycardia, or hemoperitoneum
response  Hb does not does not  short life expectancy Rx: rapid psychostimulants o Rx: analgesics as outpatient
to iron improve improve (methylphenidate, modafinil) ----------------------------------------------------------------
Hb normal normal  Hb A2  long life expectancy Rx: SSRI (takes longer to  situational syncope: 2/2 autonomic dysregulation
electro reach therapeutic effect) (LOC after urination or during coughing fits)
 thalassemia trait: often found incidentally on ---------------------------------------------------------------- ----------------------------------------------------------------
universal screening for anemia at age 1 yr  preterm labor: uterine contractions @ < 37 wks  postexposure HIV prophylaxis: immediately start
 low MCV,  total RBC count, normal RDW gestation; cervical dilation &/or effacement with 3-drug antiviral therapy for 4 weeks following
o rarely require Rx, but Dx for genetic counseling  preterm labor @ < 34 wks should receive… high-risk occupational exposure to blood or body
o iron Rx can cause hemochromatosis o tocolytic (CCB, β-blockers, NSAIDs) fluids from HIV-infected individuals
 iron deficiency:  RDW,  total RBC count o Mg-sulfate for neuroprotection  Rx: tenofovir, emtricitabine, + raltegravir
---------------------------------------------------------------- o corticosteroids for lung maturity  HIV testing immediately to establish baseline
 folic acid supplementation: megaloblastic anemia, ---------------------------------------------------------------- status; repeat @ 6 weeks, 3 months, & 6 months
hereditary spherocytosis, PND, sickle cell disease,  crampy lower abdominal & back pain during ----------------------------------------------------------------
β-thalassemia major, on MTX menses, normal exam: primary dysmenorrhea  Strep pneumoniae: MCC of community-acquired
---------------------------------------------------------------- o Rx: NSAIDs & OCPs pneumonia & nursing homes
 prednisone: Rx autoimmune hemolytic anemia  pain 1 to 2 days before menstruation, dyspareunia, ----------------------------------------------------------------
---------------------------------------------------------------- dysmenorrhea, infertility: endometriosis  pivoting/twisting injury or knee struck from
 TNF-α inhibitors: anti-cytokine  heavy menses with clots, constipation, urinary lateral side with foot planted: MCL tear
o infliximab, etanercept frequency, pelvic pain; irregular/enlarged uterus:  immediate swelling of knee joint 2/2 effusion
 Rx: chronic RA fibroids  Rx: bracing & early ambulation
 A/E: neutropenia, latent TB reactivation, CHF,  dysmenorrhea, menorrhagia, pelvic pain; bulky, o surgery is rarely needed
demyelination, risk of malignancy globular & tender uterus: adenomyosis ----------------------------------------------------------------
----------------------------------------------------------------  dull & ill-defined pelvic pain that worsens with  high index of suspicion for physical/sexual abuse
 renal vein thrombosis is a/w nephrotic syndrome standing & relieved with menses, dyspareunia: in children with sudden behavioral problems,
 membranous glomerulopathy pelvic congestion unstable economic backgrounds, or parents with a
 due to loss of anti-thrombin III in urine ---------------------------------------------------------------- Hx of drug/alcohol abuse
---------------------------------------------------------------- DDx of acute pelvic pain ----------------------------------------------------------------
 conversion disorder: sudden onset of neurologic Mittelschmer recurrent mild, unilateral mid-cycle  vertigo, ear fullness, tinnitus, & hearing loss:
symptoms incompatible with neuro exam z pain 2/2 normal follicular enlargement Meniere’s disease
 unexplained weakness, non-epileptic seizures, prior to ovulation  endolymph accumulation in inner ear
paralysis, ataxia, aphonia, blindness, or paresthesia ectopic crampy abdominal pain, amenorrhea,  horizontal nystagmus during acute attacks
 triggered by stress or emotions pregnancy vaginal bleed, +β-hCG  #1 Rx: environmental & dietary modifications
 not feigned or intentional; “la belle indifference” ovarian acute onset unilateral abdominal pain,  low-salt diet; avoid caffeine, nicotine, alcohol
 #1 Rx: education, encouragement, support torsion N/V, tender adnexal mass, ----------------------------------------------------------------
  inflammation of pericolic fat, thickened bowel wall, (18 – 20 wks) position soft markers o edrophonium: short-acting anticholinesterase;
soft tissue mass (phlegmons), pericolic fluid Dx only
suggesting abscess: diverticulitis  pregos age ≥ 35 at increased risk of aneuploidy ----------------------------------------------------------------
 Dx: abdominal CT should be offered cell-free fetal DNA  atropine: Rx to prevent muscarinic side effects
---------------------------------------------------------------- o abnormal cffDNA should be confirmed by of AChE inhibitor with myasthenia gravis
 calcium oxalate crystals are a frequent finding fetal karyotyping with CVS (1st trimester) or ----------------------------------------------------------------
in urinary sediment, not clinically significant amniocentesis (2nd trimester)  incentive spirometry is the most effective at
unless symptoms suggest acute nephrolithiasis  low risk of aneuploidy: 1st trimester combined test preventing post-op pulmonary complications
---------------------------------------------------------------- o PAPP, β-hCG, USS nuchal translucency ----------------------------------------------------------------
 persistent PTX & significant air leak following  2nd trimester (18 – 20 wks) Quad screen  PAPP-A is produced by trophoblast
chest tube placement in a patient with sustained o maternal AFP, β-hCG, estriol, inhibin A  1st trimester screen with PAPP-A + β-hCG along
blunt chest trauma: tracheobronchial rupture o  AFP & estriol, with  β-hCG & inhibin A is with USS nuchal translucency to detect Down’s
 pneumomediastinum & subcut. emphysema a/w Down’s o Down’s produces less PAPP-A
 confirm Dx: high-resolution CT, bronchoscopy,  next: transabdominal USS to evaluate fetal ----------------------------------------------------------------
or surgical exploration anatomy & growth; abnormal markers  risk  well-appearing infant with intermittent cyanosis
---------------------------------------------------------------- o next: amniocentesis to confirm abnormal & distress during feeing, relieved by crying:
 painless blisters on back of hand, hypertrichosis, quad screen choanal atresia
hyperpigmentation: porphyria cutanea tarda ----------------------------------------------------------------  Dx: head CT
 uroporphyrinogen decarboxylase deficiency  aminoglycosides cause ototoxicity (hearing loss) ----------------------------------------------------------------
 a/w Hep C by damaging cochlear cells  CHARGE syndrome: Coloboma, Heart defects,
 triggers: alcohol, estrogens  gentamicin causes selective vestibular injury Atresia of choanae, Renal anomalies, Growth
 Dx: elevated urine porphyrin (vestibulopathy) without significant ototocity impairment, Ear abnormalities
 Rx: phlebotomy, hydroxychloroquine,  oscillopsia: sensation of objects moving around ----------------------------------------------------------------
interferon-alpha in the visual field when looking in any direction;  dermatitis herpetiformis is a/w Celiac’s
---------------------------------------------------------------- leads to gait disturbance  intensely pruritic papules, vesicles over elbows,
Prenatal testing for fetal aneuploidy  Dx: head thrust test (inability to maintain eyes knees, buttocks, posterior neck, scalp
advantages disadvantages on a target)  IF: granular IgA deposits along dermal papillae
cff DNA high sensitivity & ----------------------------------------------------------------  +anti-endomysial antibodies
(≥ 10 wks) specificity for not diagnostic  myasthenia gravis: diplopia, jaw fatigue after  Rx: dapsone (heals within hours)
aneuploidy prolonged chewing, dysarthria with talking ----------------------------------------------------------------
1st trimester  normal reflexes  benign paroxysmal positional vertigo (BPPV):
combined noninvasive not diagnostic  hallmark: resolution of weakness with rest Ca++ crystals in semicircular canals (canaliths)
test  Dx: EMG & ACh Rc antibody test  MCC of vertigo
(9 – 13 wks)  also chest CT to screen/exclude for thymoma  brief, recurrent episodes of “room spinning” with
2nd trimester ---------------------------------------------------------------- head movements or position change
quad screen noninvasive not diagnostic  Rx options for myasthenia gravis  no neurologic or auditory symptoms
(15 – 20 wks) o pyridostigmine: symptomatic relief only  Dx: Dix-Hallpike maneuver cause nystagmus
CVS early definitive pain, vaginal (A/E: cramps, fasciculations, weakness)  Rx: Epley maneuver
(10 – 13 wks) karyotypic Dx spotting, risk of o atropine: anticholinergic; prevents ----------------------------------------------------------------
pregnancy loss  lateral cerebellar infarction: dizziness, ataxia,
muscarinic A/E of anticholinesterases
amniocentesi definitive pain, risk of bleed weakness, swaying TOWARD the lesion side
o immunosuppressives: induce remission
s karyotypic Dx & amniotic fluid ----------------------------------------------------------------
(prednisone, azathioprine, cyclosporine)
(15 – 20 wks) leak  hypercalcemia, renal insufficiency, metabolic
o thymectomy: induces remission
2nd trimester fetal growth, cannot identify all alkalosis: milk-alkali syndrome
o plasmapheresis: Rx myasthenia crisis
USS anatomy, placenta abnormalities;  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 Parkinson’s,
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;
MCC is COPD
 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
o meningocele, enteric cysts, lymphoma,
esophageal tumors, diaphragmatic hernias,
aortic aneurysms
----------------------------------------------------------------
 seminomas:  β-hCG only
 non-seminomatous germ cell tumors
o yolk sac tumors, choriocarcinoma,
embryonal carcinoma
o  AFP,  β-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  headache, vomiting, abdo pain, phosphorus skin,  elderly, memory impairment, social withdrawal,
B/L renal artery stenosis bitter almond odor: cyanide toxicity depressed mood: pseudodementia
---------------------------------------------------------------- o Rx: sodium thiosulfate  poor effort with cognitive testing
 child with nocturnal headaches, morning vomiting,  tinnitus, N/V, fever, acid-base abnormalities:  distressed by impaired memory
with coexisting otitis & mastoiditis: temporal salicylate intoxication (Alzheimer’s are indifferent & confabulate)
brain abscess o Rx: sodium bicarbonate to alkalinize urine  Rx: SSRI improves depression & cognition
 intracranial pressure increases in supine position  HTN, hyperthermia, tachycardia, diaphoresis, ----------------------------------------------------------------
& stimulates medullary vomiting center mydriasis, hyperreflexia: serotonin syndrome  crescent formation on light microscopy: RPGN
 Dx: solitary ring-enhancing lesion on CT with o Rx: benzo (lorazepam)  hyalinosis of afferent & efferent arterioles:
contrast or MRI  horizontal nystagmus, cerebellar ataxia, confusion: diabetic nephropathy
 Rx: high-dose corticosteroids phenytoin toxicity  linear deposits & anti-IgM: Goodpasture’s
----------------------------------------------------------------  tremor, hyperreflexia, ataxia, seizure: lithium tox.  granular deposits: immune complex GN
 3 phases of viral hepatitis: prodromal, enteric, o Rx: hemodialysis (postinfectious GN, lupus nephritis, IgA neph)
convalescent ---------------------------------------------------------------- ----------------------------------------------------------------
Hep A Hep B Hep C  undiagnosed pleural effusion is best evaluated  unexplained chronic & severe abdo pain, weight
incubation 30 days 1–3 40 – 50 with thoracocentesis loss, food aversion: chronic mesenteric ischemia
period months days  Dx: diagnostic thoracocentesis  chronic occlusion of visceral arteries leads to
transmssn contaminated sexual, parenteral o if clear evidence of CHF  trial of diuretic worsening postprandial pain & food avoidance
food or water, parenteral,  transudate or exudate?  evidence of atherosclerotic disease (HTN,
fecal-oral vertical  transudative effusion rules out malignancy CAD, DM type II, hypercholesterolemia, PVD)
risk factors recent travel IVDA  lung carcinoma, breast carcinoma, & lymphoma:  nonspecific physical exam, XR, CT scan
prognosis self-limited cirrhosis,  Dx: angiography or Doppler USS
MCC malignant exudative pleural effusion
HCC ----------------------------------------------------------------
----------------------------------------------------------------
 artificial heart valves or severely calcified valves  acute aortic dissection can cause hemopericardium,
 acute onset malaise, anorexia, N/V, mild abdo pain, progress to cardiac tamponade & cardiogenic shock
cause microangiopathic hemolytic anemia
aversion to smoking: Hep A   LDH,  haptoglobin,  indirect bilirubin,  Dx: TEE (hemodynamically stable)
 hepatosplenomegaly, AST/ALT spike  Rx: IV labetalol
reticulocytosis, schistocytes
 Rx: supportive; close contacts: Hep A Ig  chronic hemolysis leads to iron loss &  Rx: pericardiocentesis (hemodynamically unstable)
---------------------------------------------------------------- microcytic anemia ----------------------------------------------------------------
 dysphagia, salivation, mouth burns, severe pain, ----------------------------------------------------------------  sharp, pleuritic chest pain, pericardial friction rub,
white tongue: caustic poisoning  autoimmune hemolysis: +direct Coombs, uremia (BUN > 60): uremic pericarditis
 does not cause altered mental status +spherocytes  do not have classic EKG changes
 complications: peritonitis, mediastinitis ----------------------------------------------------------------  Rx: hemodialysis
----------------------------------------------------------------  AL amyloidosis (primary): MM, Waldenstrom ----------------------------------------------------------------
 hyperthermia, mydriasis, delirium, dry, mouth,  AA amyloidosis (secondary to chronic inflmmation):  brain infarct: hypodense on CT scan
urinary retention, decreased bowel sounds: RA, TB, Crohn’s, lymphoma, vasculitis  IC hemorrhage: hyperdense on CT scan
anticholinergic toxicity ---------------------------------------------------------------- o Rx: stop warfarin & ASA, give FFP & Vit K
o Rx: physostigmine  rheumatoid arthritis predisposes to AA amyloidosis ----------------------------------------------------------------
 CNS depression, arrhythmias, hypotension,  causes nephrotic syndrome  after blunt chest trauma, hemorrhagic shock a/w
anticholinergic signs: TCA poisoning  enlarged kidneys, hepatomegaly decreased breath sounds & dullness to percussion
o Rx: sodium bicarbonate  renal Bx: amyloid deposits stain with Congo red over one hemithorax & C/L tracheal deviation:
 anticholinergic symptoms, drowsiness, confusion: & apple-green birefringence massive hemothorax
diphenhydramine toxicity ----------------------------------------------------------------  MCC: traumatic laceration of lung parenchyma or
o Rx: physostigmine 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
 observational
 better ability to prove causation than case control
& cross-sectional studies
----------------------------------------------------------------
 cross-sectional study: current risk factor
exposures  compare disease prevalence
 observational
 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, CT-
guided aspiration & culture
 Rx: ABX, surgical decompression & drainage
 complications: cord compression, cauda equina
----------------------------------------------------------------
Common skin infections
fiery red, tender, painful plaque Erysipelas
with demarcated edges; limited to (S. pyogenes)
epidermis & superficial dermis
folliculitis: purulence in hair follicle Cellulitis
in areas of heavy friction/sweating (purulent)
furuncles: folliculitis extending into S. aureus
dermis, leads to abscess
carbuncle: severe infection due to
aggregation of multiple furuncles
erythema, edema, tenderness Cellulitis
flat subcut. lesions, less demarcated (non-purulent)
regional lymphadenopathy Group A Strep
 risk factors: venous insufficiency, skin disruption,
obesity
 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
 MDD
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)
ophthalmicus
 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
 thrombocytopenia
----------------------------------------------------------------
 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: β-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
 Gilbert’s: 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, +Coomb’s
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
thrombolytics
 Rx: labetalol or nicardipine
----------------------------------------------------------------
 intravascular hemolysis: RBC structural damage
(PNH, DIC)
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, +Coomb’s
o HS: +family Hx, negative Coomb’s
o G6PD deficiency: Heinz bodies, neg Coomb’s
----------------------------------------------------------------
 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
pattern
adults: PLUS arthralgias/arthritis ----------------------------------------------------------------
transmit mild disease 2 – 3 wks after inhalation of  Viridans group Streptococci (S. mutans) causing
respiratory droplets native-valve IE are susceptible to PCN
Dx PCR, anti-rubella IgM & IgG  IV ABX is preferred for initial Rx
Rx supportive, acetaminophen  empiric Rx: IV vancomycin
prevent live attenuated rubella vaccine (MMR)  Rx: IV aqueous PCN G or IV ceftriaxone
 first trimester infection results in spontaneous  PCN-allergic: vancomycin
abortion & congenital rubella; teratogenic ----------------------------------------------------------------
----------------------------------------------------------------  ALL: lymphoblasts lack peroxidase positive
Measles (rubeola) granules but contain cytoplasmic aggregates of
transmission respiratory droplets (hours) PAS positive material
manifest 1 – 3 wks after exposure  positive TdT: expressed only by pre-B & pre-T
features prodrome fever, malaise, anorexia; lymphoblasts
cough, coryza, conjunctivitis, &  recurrent infection, lymphadenopathy, splenomegaly
Koplik spots, followed by…  Dx: > 25% lymphoblasts
blanching, red-brown maculopapular rash with ----------------------------------------------------------------
cephalocaudal/centrifugal spread; spares palms/soles  myeloblasts contain peroxidase positive material
Dx PCR, anti-measles IgM & IgG ----------------------------------------------------------------
prevention live, attenuated vaccine  mass involving mandible or abdominal viscera,
Rx supportive, anti-pyretics, hydration high mitotic index, “starry sky” appearance:
Vitamin A ( morbidity/mortality) Burkitt lymphoma
complications otitis media, pneumonia,  Rx: high-dose chemotherapy
gastroenteritis, encephalitis ----------------------------------------------------------------
(subacute sclerosing panencephalitis)  abdominal pain, constipation, polydipsia
 a single elevated Ca++ must be confirmed with a
 known/suspected cases: immediate isolation with second serum Ca++ to confirm hypercalcemia
negative air pressure, N95 mask  next: measure PTH levels
 Koplik spots: tiny, white lesions in conjunctiva  elevated PTH  measure urinary Ca++
& buccal mucosa o high urine Ca++  10 & 30 hyperPTH
---------------------------------------------------------------- o low urine Ca++  familial hypercalcemic
 complication of untreated Strep pharyngitis: hypocalciuria
Scarlet fever  suppressed PTH  measure PTHrP, 25(OH)D,
 preceding Group A Strep infection (tonsillitis, & 1,25(OH)D
pharyngitis) with tonsillar gray/white exudates o  PTHrP  malignant tumor
 produces erythrogenic exotoxins o  25(OH)D  Vit D toxicity
 incubation: 1 – 7 days o  1,25(OH)D  CXR for lymphoma, sarcoid
 prodromal fever, headache, vomiting, sore throat, o all normal  hyperthyroidism, MM,
acromegaly, milk-alkali syndrome
circumoral pallor, then 12 – 48 hr later…
----------------------------------------------------------------
 fine pink blanching papules on neck, axilla, groin;
 antipsychotics cause hyperprolactinemia by
sandpaper-like texture; spares palms/soles
blocking DA activity of tuberoinfundibular path,
 Dx: throat culture
projects from hypothalamus to pituitary
 Rx: rapid response to PCN V; or amoxicillin o amenorrhea, galactorrhea, gynecomastia,
 complications: rheumatic fever sexual dysfunction
 DDx: Kawasaki’s (B/L conjunctival injection)
 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
 Ab’s 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 Edward’s (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:
glucagonoma
 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)
(maternal antiphospholipid Ab syndrome
factors) autoimmune disease (SLE)
cyanotic cardiac disease
substance abuse (tobacco, alcohol, cocaine)
symmetric genetics (aneuploidy)
(fetal congenital heart disease
factors) 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)  #1 Rx: discontinue drug, ICU, aggressive cooling,  papillary necrosis & tubulointerstitial nephritis
o microangiopathy 2/2 advanced glycation end antipyretics, fluids & electrolytes, alkaline diuresis with focal glomerulosclerosis
(AGE) products  Rx: dantrolene (muscle relaxant) or bromocriptine  results in CKD & ESRD
o mesangial expansion, glomerular sclerosis, (DA agonist) or amantadine (DA properties)  severe cases: nephrotic range proteinuria
glomerular BM thickening,  complication: rhabdomyolysis  CT: small kidneys, B/L papillary calcifications
microalbuminuria, arteriolar hyalinosis, HTN ---------------------------------------------------------------- ----------------------------------------------------------------
 overt DN (15+ yrs)  management of placenta previa depends on  simple renal cyst: thin wall, no solid component,
o mesangial nodules (Kimmelstiel-Wilson), gestational age & bleeding severity no contrast enhancement on CT, no septae
tubulointerstitial fibrosis, nephrotic syndrome,  active, uncontrolled antepartum hemorrhage with o incidental finding; no Rx, no follow-up
 GFR; CKD unstable vital signs & non-reassuring fetal HR,  malignant cystic mass: irregular septae walls,
---------------------------------------------------------------- regardless of gestational age  c-section multilocular, heterogeneous (solid & cystic),
 air in the biliary tract: gallstone ileus o induction of labor will aggravate bleeding contrast enhancement on CT
---------------------------------------------------------------- by triggering uterine contractions ----------------------------------------------------------------
 porcelain gallbladder results from deposition of  prior c-section increases risk for placenta accreta  HTN, low plasma renin, hypokalemia,: primary
Ca++ salts 2/2 chronic cholecystitis ---------------------------------------------------------------- hyperaldosteronism
 incidental finding, a/w risk of GB carcinoma  Fibromuscular dysplasia: causes arterial stenosis, ----------------------------------------------------------------
 definitive Rx: cholecystectomy aneurysm, or dissection; MCC of secondary HTN  COPD exacerbation with cor pulmonale
---------------------------------------------------------------- o renal artery involvement  resistant HTN (peripheral edema, hepatomegaly, clear lungs,
 ASD, VSD, PDA, & dextrocardia are acyanotic o cerebrovascular arteries  TIA, stroke, JVD, pulmonary HTN)
congenital heart diseases amaurosis fugax, Horner’s  #1 Rx: bronchodilators, glucocorticoids
---------------------------------------------------------------- o non-specific: headache, dizziness, tinnitus  Rx: furosemide is used to lower RV filling &
Congenital cyanotic heart diseases ---------------------------------------------------------------- reduce peripheral edema
MCC in the neonatal period, Transposition  increased intragastric pressure during vomiting o caution: C.O. reduction & prerenal azotemia
cyanosis within 24 hr, single S2 of great causing tears in submucosal arteries of distal ----------------------------------------------------------------
CXR: narrow mediastinum vessels esophagus & proximal stomach: Mallory-Weiss Medication side effects
“egg-on-a-string”  rupture of dilated submucosal veins at GE junction: levodopa/carbidopa early: hallucination, agitation,
Rx: prostaglandins keep PDA open esophageal varices (DA precursor dizziness, headache, confusion
MCC after the neonatal period, ToF ---------------------------------------------------------------- late: dyskinesia, dystonia
harsh pulmonary stenosis murmur,  complication of IE: cerebral septic emboli trihexyphenidyl dry mouth, blurry vision,
VSD murmur, single S2,  DDx: carotid thrombosis, drug-induced vascular (anticholinergic) constipation, urinary retention
CXR: RVH, “boot-shaped” heart spasm, migraine, lacunar stroke amantadine livedo reticularis, ankle edema
single S2, minimal pulmonary flow Tricuspid ---------------------------------------------------------------- bromocriptine, somnolence, hypotension,
VSD murmur, hypoplastic RV atresia  post-ictal lactic acidosis occurs following a ropinirole confusion, hallucination
newborn with left-axis deviation tonic-clonic seizure (DA agonist)
single S2, systolic ejection murmur, Truncus  transient anion gap metabolic acidosis entacapone dyskinesia, hallucinations,
increased pulmonary flow, edema arteriosus resolves without Rx within 60 – 90 min (COMT inhibitor) confusion, orthostatic
severe cyanosis, pulmonary edema, Total following resolution of seizure activity hypotension
respiratory distress anomalous  Rx: repeat labs after 2 hrs selegiline insomnia, confusion
RA & RV enlargement pulmonary ---------------------------------------------------------------- (MAO-B inhibitor)
CXR: “snowman” sign venous return  painless hematuria, sterile pyuria, WBC casts: ----------------------------------------------------------------
---------------------------------------------------------------- analgesic nephropathy  trihexyphenidyl: anti-muscarinic used for
 fever, muscle rigidity, autonomic instability,  females chronically using combined analgesics Parkinson’s & drug-induced EPS
diaphoresis, confusion, elevated CPK: NMS  asymptomatic; incidental increase in Cr  “red as a beet, dry as a bone, hot as a hare,
 MCC: haloperidol; occurs within 2 weeks blind as a bat, mad as a hatter, full as a flask”
 painless hematuria due to papillary ischemia from
analgesia-induced vasoconstriction of vas recta
  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:
hypothyroidism
 fatigue, myalgia, proximal muscle weakness,
sluggish ankle reflexes, normal ESR
 Dx: TSH, T4
 DDx: polymyositis (normal DTRs,  ESR)
----------------------------------------------------------------
Major stroke types
local artery obstruction, ischemic
symptoms fluctuate, stuttering progress (thrombotic)
Hx of a-fib, endocarditis, carotid bruit, ischemic
abrupt onset, (embolic)
maximal symptoms at the start
focal neurologic deficits early,
progress over minutes to hours, then intracerebral
features of increased ICP (vomiting, hemorrhage
headache, bradycardia)
ruptured berry aneurysm or AVM,
severe headache at onset, subarachnoid
meningeal irritation, hemorrhage
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,  causes of  BUN/Cr: prerenal azotemia
hemisensory disturbances), then ICH symptoms (dehydration), GI bleeding, systemic steroids
(vomiting, headache, bradycardia) o GI bleeding results in bacterial breakdown of
 Dx: brain CT Hb in the GIT with resultant urea absorption
---------------------------------------------------------------- ----------------------------------------------------------------
 lacunar stroke: occluded single penetrating branch  Kallmann syndrome: XR disordered migration
of a large cerebral artery; MC basal ganglia of fetal GnRH & olfactory neurons
 unilateral pure motor impairment  hypogonadotropic hypogonadism & anosmia
 no cortical signs (aphasia, hemianopsia)  normal genotype & internal reproductive organs
 main cause: HTN, which induces microatheroma  primary amenorrhea, low FSH & LH
& lipohyalinotic thickening  absent breast development, small phallus
o small vessel hyalinosis  no body hair, short stature
 MC site: posterior limb of internal capsule  Rx: hormone replacement
 symptoms over a short period, slow progression ----------------------------------------------------------------
over 24 – 36 hr; limited neurologic deficits  bilious vomiting, abdominal distension, gassless
 pure motor, pure sensory, or ataxic hemiparesis; colon, “triple bubble” sign: jejunal atresia
or dysarthria-clumsy hand syndrome  risk factors: prenatal cocaine or tobacco exposure
 pure sensory stroke (VPL nucleus of thalamus)  DDx: necrotizing enterocolitis, pyloric stenosis,
---------------------------------------------------------------- duodenal atresia, Hirschsprung’s
Brain lesions ----------------------------------------------------------------
pure motor hemiparesis, posterior limb Antepartum fetal surveillance
pure sensory stroke, clumsy-hand, of int. capsule o NST: Nonstress test; #1 test
no visual field abnormalities (lacunar infarct) o BPP: Biophysical profile; #2 test
C/L somatosensory & motor deficit o CST: Contraction Stress test; #2 test
@ face & upper limbs, o umbilical artery Doppler velocimetry
conjugate eye deviate toward infarct, MCA occlusion ----------------------------------------------------------------
homonymous hemianopia,  NST is performed when there is loss of perception
aphasia (dominant hemisphere), of fetal movements or in high-risk pregnancies at
hemineglect (non-dominant parietal) 32-34 wks gestation; fetal heart tones by Doppler
C/L somatosensory & motor deficit  “reactive”: within 20 min, ≥ 2 accelerations at
in lower extremities, ACA occlusion least 15 beats/min > baseline, lasting ≥ 15 seconds
abulia (lack of will or initiative),  high negative predictive value
dyspraxia, urinary incontinence  abnormal result yields a low PPV
homonymous hemianopia,
 MCC of non-reactive NST: fetal sleep cycle (20 min)
alexia without agraphia (dominant), PCA occlusion
o Rx: vibroacoustic stimulation
visual hallucinations,
3rd nerve palsy, C/L motor deficits  weekly NST for 3rd trimester pregos requiring
alternate syndrome: vertebrobasilar ongoing antenatal surveillance
C/L hemiplegia, system lesion  non-reactive NST requires  BPP or CST
I/L cranial nerve deficits (brainstem) ----------------------------------------------------------------
 anterior vasculature: internal carotid artery,  Biophysical profile (BPP): assess fetal well-being
ACA & MCA o NST
 posterior circulation: paired vertebral arteries o amniotic fluid volume
form the basilar artery, then divide into PCAs o fetal movement
---------------------------------------------------------------- o fetal tone
 o fetal breathing movements o rare: stroke, MI erythematous macules, toxicum in 2 wks
 if abnormal NST  amniotic fluid volume & fetal  women who smoke, with uncontrolled HTN, papules, or pustules neonatorum
activity are assessed with real-time USS, 30 min end-organ damage, or age > 35 should consider vesicular clusters on skin,
 score 8 – 10 = normal contraception without estrogen eyes, mucous membranes, neonatal acyclovir
 score 6 = equivocal ---------------------------------------------------------------- CNS infection (seizures), HSV
 score ≤ 4 = delivery! Emergency contraception multi-organ disease
---------------------------------------------------------------- method mechanism time frame efficacy fever, ranges from neonatal
 contraction stress test (CST): infusion of oxytocin copper inflammatory rxn is 0 – 120 hr vesicular clusters to varicella acyclovir
sufficient to result in 3 contractions every 10 min IUD toxic to sperm, (5 days) 99% disseminated disease
 normal CST suggests a low likelihood of stillbirth impairs implantation fever, irritability, diffuse (SSSS)Staph oxacillin,
within 1 wk of the test; F/U testing in 1 wk ulipristal anti-progestin, 0 – 120 hr ≥ 85% erythema; blistering & scalded skin nafcillin,
 late decelerations is an indication for delivery pill delays ovulation (5 days) exfoliation, +Nikolsky syndrome vanco
---------------------------------------------------------------- levonorg progestin, 0 – 72 hr ----------------------------------------------------------------
 umbilical artery Doppler velocimetry: estrel delays ovulation (3 days) 85%  hoarseness, barking cough, respiratory distress:
evaluation of IUGR only (Plan B) croup (laryngotracheitis)
---------------------------------------------------------------- OCPs progestin 0 – 72 hr) 75% o age < 3 yrs; due to Parainfluenza
 Dx of intrauterine fetal demise: real-time USS delays ovulation o lateral XR: subglottic narrowing
 occurs @ >20 wks, before onset of labor ----------------------------------------------------------------
 fetal heart tone not heard by Doppler  copper IUD & OCPs are also precoital methods  exertional dyspnea, heart pounding sensation,
 autopsy of fetus & placenta should be performed  copper IUD is the most effective emergency widened pulse pressure: aortic regurgitation
contraceptive method, regardless of parity or age  MMC in developing countries: rheumatic fever
in the first episode of intrauterine fetal demise
 also perform maternal coagulation profile o C/I: acute cervicitis & PID  MCC in developed countries: aortic root dilation
---------------------------------------------------------------- ---------------------------------------------------------------- or congenital bicuspid valve
 ovulation occurs on day 14  DPMA & etonogestrel subdermal implants are ----------------------------------------------------------------
systemic progestin-based precoital contraceptives Features of TCA overdose
 fertilization is possible 24 hr after ovulation
that inhibit GnRH secretion, thus FSH/LH CNS drowsiness, delirium, coma,
 pregnancy = embryo implants @ 6 – 12 days
---------------------------------------------------------------- seizure, respiratory depression
after fertilization; β-hCG produced by blastocyst  newborns with suspected DiGeorge must be cardio sinus bradycardia, hypotension,
can be detected on a pregnancy test
assessed for life-threatening hypocalcemia (MCC death) prolonged PR/QRS/QT,
----------------------------------------------------------------
(tetany, seizures, arrhythmias) ventricular tachycardia, v-fib
Combined estrogen/progestin OCPs
o Conotruncal defects (truncus arteriosus) anticholinergi dry mouth, blurred vision,
 early A/E: nausea, bloating, breast tenderness;
o Abnormal facies c mydriasis, flushing, hyperthermia,
improves with use; does not cause weight gain
o Thymic aplasia/hypoplasia urinary retention
 MC A/E: breakthrough bleeding due to lower
o Cleft palate  TCAs inhibit fast Na+ channels, thus  conduction
estrogen dose
o Hypocalcemia velocity,  duration of repolarization, & prolongs
 benefits
 T-cell lymphopenia  risk for bacterial, viral, & absolute refractory period
  endometrial & ovarian cancer risk ----------------------------------------------------------------
o  risk of iron deficiency anemia fungal infections
----------------------------------------------------------------  TCA overdose decreases myocardial conduction
 risks velocity, leading to QRS prolongation & risk of
 appendicitis begins as vague periumbilical visceral
 HTN ventricular arrhythmia or seizure
pain caused by stretching of the appendiceal wall
o venous thromboembolism  QRS complex duration is the best
 peritoneum becomes inflamed & localize to RLQ
o hepatic adenoma (chronic OCP use) prognostic indicator of TCA overdose
----------------------------------------------------------------
o amenorrhea  supportive Rx: supplemental O2, IV fluids,
Neonatal rashes
  risk of cervical cancer activated charcoal if within 2 hrs of ingestion
Features Dx Rx
  triglycerides asymptomatic, blanching Erythema resolves
  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-α
 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
endophthalmitis
 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,
β-agonist use ≤ 2x/wk
normal baseline FEV1 & FEV1/FVC
no limitations of daily activities
Rx: short-acting β-agonist (albuterol) PRN
mild symptoms ˃ 2x/wk, but not daily,
persistent nighttime awakenings 3 – 4x/month,
normal PFTs, minor limitations
Rx: add low-dose inhaled corticosteroid
moderate daily symptoms, weekly nighttime
persistent awakenings, FEV1 60 – 80% of predicted
Rx: add long-acting inhaled β2-agonist
severe symptoms throughout, frequent nighttime
persistent 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 β-agonists (SABA)
 if no response: oral systemic corticosteroids
 moderate/severe asthma exacerbation ----------------------------------------------------------------
o O2, until saturation ≥ 90% Features of crystal-induced AKI
o inhaled high-dose SABA etiologie IV acyclovir, sulfonamides, MTX,
 PLUS ipratropium nebulizer s ethylene glycol, protease inhibitors
o oral systemic corticosteroids features  creatinine within 24 – 48 hr,
 impending or actual respiratory arrest intratubular obstruction & direct toxicity
o mechanical ventilation with intubation on U/A: hematuria, pyuria, crystals
100% O2; admit to ICU  risk with volume depletion or CKD
o nebulized SABA + ipratropium Rx discontinue drug & volume repletion,
 IV corticosteroids concurrent volume repletion with drug can
prevent kidney injury
o if no improvement: Mg++-sulfate
 adding ipratropium to SABA causes greater
 AIN occurs 7 – 10 days after drug exposure
bronchodilation than either alone
o skin rash, eosinophilia, eosinophiluria, pyuria
 systemic corticosteroids take several hours to
----------------------------------------------------------------
exert its effects
 MC renal malignancy in childhood: Wilms tumor
----------------------------------------------------------------
(aka nephroblastoma); asymptomatic
 asthmatic child with altered mental status,
----------------------------------------------------------------
unresponsive to Rx, poor air entry on exam,
 excess tearing, burning, mild pain, conjunctival &
hypoxemia & CO2 retention: acute asthma
exacerbation eyelid edema, vision is not affected: conjunctivitis
 elevated or normal pCO2 suggest decreased  blurry vision, moderate pain, conjunctival injection,
respiratory drive due to respiratory muscle fatigue miosis: uveitis
& impending respiratory failure  significant pain, photophobia, miosis, vision loss:
 Rx: intubation & mechanical ventilation anterior uveitis (iritis)
o inhaled SABA + inhaled ipratropium, &  proptosis, ophthalmoplegia, chemosis, vision loss:
cavernous sinus thrombosis
systemic corticosteroids; admit to ICU
 pain with eye movement, proptosis, diplopia,
----------------------------------------------------------------
 prevalence is directly related to pre-test probability impaired EOM: orbital cellulitis
 corneal vesicles, opacification, dendritic ulcers:
 if a test result is negative, probability of
viral keratitis (HSV or varicella)
having the disease = 1 – NPV
----------------------------------------------------------------
 false positive ratio = 1 – specificity
Differentiation of conjunctivitis
 false negative ratio = 1 – sensitivity
Viral Bacterial Allergic
unilateral unilateral bilateral
“stuck shut” “stuck shut” “stuck shut” N. ampicillin, & ----------------------------------------------------------------
watery, scant purulent, thick, watery, scant meningitidis, 3rd gen  diabetic, severe ear pain, granulation tissue in ear
stringy mucus white/yellow stringy mucus Listeria cephalosporin canal, otorrhea,: malignant otitis externa MCC
burning, sandy, unremitting intense itching, immunocomp. pneumococcus, vancomycin, is P. aeruginosa
gritty feeling discharge Hx of allergy N. ampicillin, &  MC in elderly with poorly controlled diabetes
follicular or non-follicular conjunctival meningitidis, cefepime  aggravated by chewing, difficulty eating
“bumpy” edema (chemosis) Listeria, G- rod  worsens despite topical ABX
self-limited self-limited, 24 hr  Dx: CT or MRI
 alternative to ampicillin: TMP-SMX for Listeria  Rx: systemic anti-pseudomonals (ciprofloxacin)
 intense itching, hyperemia, tearing, edema of ----------------------------------------------------------------  risk factor: immunosuppressed conditions
conjunctiva & eyelids, subsides in 24 hr: allergic  empiric Rx for bacterial meningitis for  complications: osteomyelitis of skull base & CN
 viral “pink eye” presents similar to allergic, but immunocompromised: vancomycin, ampicillin, damage (facial drooping)
lasts several days; a/w URI, MCC adenovirus + cefepime with dexamethasone ----------------------------------------------------------------
o adding corticosteroids prevent complications  anxiety restricted to social & performance, also
Conjunctivitis Rx of meningitis due to S. pneumoniae fear of scrutiny & embarrassment: social phobia
 if there is delay in performing LP, empiric Rx  DDx: specific phobia, panic disorder, GAD
topical erythromycin ointment, bacterial
fluoroquinolone drops (contact lens) must be given after obtaining blood cultures ----------------------------------------------------------------
cool, moist compress viral ---------------------------------------------------------------- Specific phobia
 Rx dehydration: IV Na+-containing crystalloid  marked anxiety > 6 months
OTC antihistamine/decongestant drops allergic
---------------------------------------------------------------- (0.9% NS)  no fear of scrutiny by others
 hyperestrogenism in cirrhosis: gynecomastia,  can unmask subclinical heart failure in elderly  #1 Rx: behavior therapy
testicular atrophy,  body hair, spider angiomas, ----------------------------------------------------------------  #2 Rx: short-acting benzo (limited role)
palmar erythema  colloid solutions contain albumin
----------------------------------------------------------------
----------------------------------------------------------------  Rx: burns, hypoproteinemia  anemia, bone disease, & HTN persist with dialysis,
liver functions ---------------------------------------------------------------- but controlled with renal transplantation
 synthesis of clotting factors, cholesterols, protein  post-op cholestasis is a benign condition after  transplant patients have return or normal
 metabolism of drugs & steroids, detoxification prolonged surgery characterized by endocrine, sexual, & reproductive functions
 excretion of bile hypotension, extensive blood loss into tissues, & ----------------------------------------------------------------
---------------------------------------------------------------- massive blood replacement  bupropion inhibits re-uptake of NE, DA, 5-HT
 portal HTN leads to esophageal varices, ----------------------------------------------------------------
 C/I to use of bupropion: Hx of anorexia/bulimia
 liver has dual blood supply: hepatic arteries &
hemorrhoids, & caput medusae since development of electrolyte abnormalities
---------------------------------------------------------------- portal veins
can precipitate seizures
 asterixis is a neurologic sign a/w poor hepatic ----------------------------------------------------------------
----------------------------------------------------------------
 raising the cut-off point of a test…
function & hyperammonemia  acute pancreatitis can cause an acute abdomen
 a/w CO2 retention, hepatic encephalopathy, & o  specificity &  sensitivity
 Rx: analgesics, IV fluids, NPO
uremic encephalopathy ----------------------------------------------------------------
 Px: self-limited, subsides in 4 – 7 days
 uremic encephalopathy Rx: urgent hemodialysis  CKD causes decreased renal production of Vit D,
----------------------------------------------------------------
 hepatic encephalopathy Rx: lactulose leading to hypocalcemia, hyperphosphatemia, &
 medial meniscus is injured during forceful torsion
secondary hyperPTH
---------------------------------------------------------------- of the knee with foot planted
 circulating PTH increases with declining GFR,
Bacterial meningitis  delayed evidence of effusion
correlates with severity of renal failure
risk group MCC empiric ABX  swelling & pain within 24 hrs
 hyperphosphatemia directly stimulates parathyroids
age 2 – 50 yrs N. vanco & 3rd gen  limited ROM, popping, catching, locking
to synthesize & release PTH
meningitidis, S. cephalosporin (inability to extend the knee)
 DDx: Vit D deficiency (low/normal phosphate,
pneumoniae  joint line tenderness
normal serum Ca++)
age > 50 yrs S. pneumo, vancomycin,
 evaluation: positive McMurray’s & Apley’s
 Dx: MRI
----------------------------------------------------------------
 ACL tear from forceful hyperextension
 swelling & effusion immediately
 Dx: positive Lachman’s
----------------------------------------------------------------
 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
 CSF: EBV DNA
----------------------------------------------------------------
 multiple, ring-enhancing lesions in basal ganglia:
Toxoplasmosis
o @ cortical grey-white matter interface
 multiple, non-enhancing lesions, no mass effect:
PML
 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
cardiac sinus bradycardia, heart block
QT prolongation, TdP
pulmonary chronic interstitial pneumonitis,  infants losing > 7%: formula supplementation
pulmonary fibrosis ----------------------------------------------------------------
endocrine hypothyroid (MC), hyperthyroid  # of wet diapers = age in days for 1st wk
GI/hepatic  transaminases, hepatitis  ≥ 6 diapers/day after the 1st wk is normal
ocular optic neuropathy,  “pink stains” or “brick dust” in neonatal diapers
corneal deposits = uric acid crystals, common in first few weeks
skin blue-gray discoloration (face) ----------------------------------------------------------------
neuro peripheral neuropathy  dysthymia (persistent depressive disorder)
----------------------------------------------------------------  depressed mood ≥ 2 yrs (1 yr in childhood)
 Dofetilide A/E: risk of TdP o MDE symptoms may occur concurrently or
 Procainamide A/E: drug-induced lupus, intermittently
agranulocytosis, QT prolongation ----------------------------------------------------------------
----------------------------------------------------------------  hairy cell leukemia: bone marrow is fibrotic,
 quinidine A/E: diarrhea, tinnitus, QT prolongation, leading to dry taps of aspirates
TdP, hemolytic anemia & thrombocytopenia  pancytopenia & splenomegaly
 hydralazine A/E: peripheral edema, salt & fluid  +tartrate resistant acid phosphatase (TRAP)
retention, palpitations, orthostatic hypotension,  Rx: cladibine (2-CdA)
drug-induced lupus ----------------------------------------------------------------
 metoprolol A/E: worsening of heart failure,  Hep B vaccination decreases HCC incidence,
bradyarrhythmia, bronchoconstriction, fatigue, especially if from Asia & Africa; MCC due to
depression, weight gain, sexual dysfunction vertical transmission
---------------------------------------------------------------- ----------------------------------------------------------------
Antihypertensive in pregnancy  hemodynamically unstable with penetrating
first-line contraindicated abdominal trauma  exploratory laparotomy
**labetalol ACE-I/ARBs  any penetrating wound below the 4th IC space is
**methyldopa (slow) spironolactone considered to involve the abdomen
hydralazine direct renin inhibitor ----------------------------------------------------------------
nifedipine furosemide  detrusor instability, bladder irritation from neoplasm,
second-line interstitial cystitis results in urge incontinence
thiazides o sudden, infrequent loss of moderate to large
clonidine amounts of urine, nocturia & frequency
---------------------------------------------------------------- ----------------------------------------------------------------
 labetalol & hydralazine: Rx pre-eclamptic  diabetic neuropathy causes overflow incontinence
hypertensive emergencies (BP ≥ 160/110)  loss of small amounts of urine from overdistended
o not methyldopa (slow onset) bladder;  residual volume
---------------------------------------------------------------- ----------------------------------------------------------------
 severe antepartum hemorrhage first requires  cerebellar astrocytoma: #1 MC posterior fossa
hemodynamic resuscitation, then emergency USS tumor, MC site is lateral hemispheres
o vaginal exam is C/I for risk of aggravating  medulloblastomas MC arise from the vermis
possible placenta previa bleeding o #2 MC posterior fossa tumor; infratentorial
----------------------------------------------------------------  posterior vermis syndrome: truncal dystaxia
 healthy infants can lose up to 7% of birth weight
o highly radiosensitive
in the first 5 days of life
----------------------------------------------------------------
 no Rx required; continue exclusive breastfeeding
 idiopathic thrombocytopenic purpura (ITP) is
 F/U @ age 10 – 14 days for weight gain
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
children no bleeding: observe
bleeding: IV Ig or glucocorticoids
adults PLT > 30,000, no bleeding: observe
PLT < 30,000 or bleeding: IV Ig or
glucocorticoids
 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, Raynaud’s,
esophageal dysmotility, sclerodactyly, telangiectasias
 calcinosis cutis: localized dystrophic Ca++ skin
depositions; subcutaneous pink/white nodules
on upper extremities
 Raynaud’s: 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
respiratory bronchiectasis, recurrent pneumonia,
chronic rhinosinusitis, nasal polyps
GI meconium ileus, steatorrhea,
fat-soluble vitamin malabsorption
(night blindness, rickets, neuropathy,
coagulopathy),
exocrine pancreatic insufficiency
microcolon
reproductive infertility ( 95% males)
MSK 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, Hartnup’s
 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  no previous imaging  chest CT  age > 50 with B/L pain & stiffness >1 month,
 right heart strain  ventricular dysFx   C.O., o benign features  serial CT scans morning stiffness > 1 hr, constitutional symptoms,
bradycardia, & cardiogenic shock o intermediate suspicion  Bx or PET  ESR, normal CK
 Dx: CT angiography o high suspicion  surgical excision   active ROM of shoulder, neck, & hip
 Rx: fibrinolysis (relative C/I: surgery within  ≥ 2 cm, low density, speculated/irregular,  no focal tenderness or weakness
preceding 10 days) eccentric calcification favors carcinoma  Rx: low-dose prednisone (rapid, thorough relief)
----------------------------------------------------------------  high risk: age > 60, current smoker, weight loss,  a/w giant cell arteritis
 pancreatic pseudocyst: fibrous capsule containing previous malignancy o Dx: temporal artery Bx if suspected
enzyme-rich fluid, tissue, & debris accumulates  Bx central lesions: bronchoscopy o Rx: high-dose prednisone
within the pancreas  elevated amylase  Bx peripheral lesions: CT-guided percutaneous Bx ----------------------------------------------------------------
 palpable epigastric mass a/w chronic pancreatitis ----------------------------------------------------------------  euvolemic hyponatremia due to renal Na+ losses
 Dx: USS  uncomplicated proximal LE DVT  when normal saline bolus is given,  urine Na+
 Rx: resolves spontaneously Management of SIADH excretion, while serum Na+ is unaffected
---------------------------------------------------------------- asymptomatic/mild fluid restriction (< 800 mL/day), SIADH findings
 diffuse infection of necrotic pancreatic tissue, (forgetfulness, oral Na+ tablets, o serum osmolality < 290
MC 1 – 2 wks after acute pancreatitis episode: unstable gait) furosemide if urine Osm > 2x  urine osmolality > 300 (concentrated urine)
infected pancreatic necrosis serum Osm  urine Na+ > 40 mEq/L
 Rx: surgical debridement moderate hypertonic saline (3 – 4 hrs) to  o absence of hypovolemia (euvolemic)
---------------------------------------------------------------- (confusion, lethargy) Na+ > 120 mEq/L o normal Cr, K+, acid-base
DDx of flaccid paralysis severe hypertonic saline bolus until o normal renal, adrenal, & thyroid function
infant botulism foodborne Guillain-Barre (mental status symptoms resolve,  asymptomatic or mild symptoms of SIADH
botulism change, seizure, +/- conivaptan (ADH Rc respond to fluid restriction &/or Na+ tablets
C. botulinum C. botulinum autoimmune &/or coma) antagonist; cause water diuresis)  severe, symptomatic hyponatremia requires
spore ingestion preformed peripheral nerve  Rx: anticoagulation (unfractionated or LMWH) hypertonic saline
from environmt toxin demyelination  anticoagulation C/I: recent surgery, active bleed,   serum Na+ correction: 0.5 – 1 mEq/L/hr or 10
dust/soil Hx of HIT, hemorrhagic stroke, bleeding diathesis mEq/24 hr to prevent osmotic demyelination
descending descending ascending flaccid  Rx: IVC filter ----------------------------------------------------------------
flaccid paralysis flaccid paralysis paralysis  proximal DVT with hemodynamically unstable PE  demeclocycline:  responsiveness to ADH
CA, PA, UT prodrome N/V, absent DTRx or massive proximal DVT with severe swelling or  Rx SIADH by inhibiting ADH-mediated aquaporin
diarrhea limb-threatening ischemia insertion
Rx: botulism Ig Rx: anti-toxin IV Ig or plsmphrss  Rx: thrombolytics  A/E: nephrotoxic
 previously healthy infant with B/L bulbar palsies o if C/I: iliac stenting, mechanical or ----------------------------------------------------------------
(ptosis, sluggish pupillary response, poor suck or surgical thrombectomy  effective management of SIADH required the
gag reflexes), symmetric hypotonia, constipation, ---------------------------------------------------------------- infused fluid to have a higher electrolyte
drooling  middle-aged woman, widespread pain, fatigue, concentration than urine & plasma
 Rx: empiric IV botulism Ig cognitive/mood disturbance: fibromyalgia  NS (0.9%) is only slightly higher than serum
----------------------------------------------------------------  normal lab findings, normal ESR osmolality & leads to NaCl excretion
 mucopurulent vaginal discharge, friable cervix:  symptoms > 3 months  excessive ADH causes more water retention,
cervicitis  Dx: widespread pain index/symptom severity scale thus concentrates the urine, dilutes the serum, &
 #1 MCC: C. trachomatis; #2: N. gonorrhea  #1 Rx: education, exercise, & sleep hygiene worsens hyponatremia
 Dx: nucleic acid amplification  #2 Rx: amitriptyline (TCAs) ----------------------------------------------------------------
----------------------------------------------------------------  alt Rx: pregabalin, duloxetine, milnacepran  ACE-I are recommended for patients with
 solitary pulmonary nodule on CXR: compare ---------------------------------------------------------------- proteinuria, heart failure, or CKD with HTN
with previous CXR Polymyalgia rheumatica  C/I in B/L renal artery stenosis
 stable lesion, 2 – 3 yrs  no further testing
----------------------------------------------------------------
 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 ----------------------------------------------------------------
----------------------------------------------------------------  chronic Rx with supra-physiologic doses of
Histoplasmosis glucocorticoids (Rx giant cell arteritis) is a/w
 immunocompetent: asymptomatic or mild hyperglycemia, bone loss, chronic myopathy
pulmonary disease  glucocorticoid-induced myopathy progresses
 immunocompromised: pneumonia, pancytopenia, over weeks to month after Rx initiation
adenopathy, hepatosplenomegaly, mucocutaneous  painless proximal weakness, no tenderness
lesions  normal CK & ESR, no inflammation
 Dx: urine or serum antigen  DDx: MS, Myasthenia, polymyalgia rheumatica
 Rx (mild): oral itraconazole ----------------------------------------------------------------
 Rx: (severe): amphotericin B, then oral itraconazole DDx of myopathy
---------------------------------------------------------------- features ESR CK
 short-acting benzos (alprazolam) is a/w seizures glucocorticoid progressive proximal nrml nrml
& confusion following abrupt discontinuation -induced weakness, mainly LE,
 dose-dependent A/E of bupropion use: seizures no pain or tenderness
---------------------------------------------------------------- statin-induced pain & tenderness, nrml 
 AAA screening: 1x abdominal USS for male w/without weakness,
active or former smokers ager 65 – 75 rhabdomyolysis
 selective screening for male never smokers hypothyroid pain, cramps, weakness nrml 
 women age 65 - 75 who have ever smoked myopathy of proximal muscles,
o insufficient evidence delayed DTRs,
 surgical Rx AAA ≥ 5.5 cm hypothyroid features
---------------------------------------------------------------- polymyalgia pain & stiffness  nrml
 acute onset back pain & profound hypotension: rheumatica decreased ROM at hip
& shoulders
evaluate for presumptive ruptured AAA
rapid response to
 Rx: emergent surgical AAA repair
glucocorticoids
 complication: AAA can rupture into retroperitoneum,
inflammatory proximal weakness,  
creating an aortocaval fistula with the IVC  venous
myopathies pain & tenderness,
congestion in the bladder  fragile, distended veins rash, arthritis
can rupture  gross hematuria
----------------------------------------------------------------
 DDx: renal colic, mesenteric ischemia,
 Management of blunt abdominal trauma in
pancreatitis, diverticulitis, biliary disease
hemodynamically unstable: FAST exam
----------------------------------------------------------------
o positive  laparotomy
 symptoms of impending eclampsia: persistent
o negative  abdominal CT
frontal/occipital headache, visual disturbance,
o inconclusive  DPL
altered mental status, RUQ or epigastric pain, SOB
 tonic-clonic (grand mal) seizures last 3 – 4 min ----------------------------------------------------------------
 hearing tests for children with behavioral concerns,
& self-limited
 fetal bradycardia is common during seizures; poor language & social skills, “inattentive”
 MCC: conductive hearing loss due to recurrent
resolves once patient is stabilized
 Rx: Mg++ sulfate prevents seizure recurrence; ear infections
----------------------------------------------------------------
continued through labor & postpartum period
 SGA infant: weight < 10th percentile
 Rx: labor induction/augmentation if no evidence
 complications: hypoxia, polycythemia,
of fetal distress
o c-section reserved for typical OC reasons hypoglycemia, hypothermia, hypocalcemia
 Anti-diabetic medications
o polycythemia is 2/2 hypoxia  A1c features o biliary dilatation: extrahepatic cholestasis
---------------------------------------------------------------- Metformin 1 – 2% initial therapeutic agent ----------------------------------------------------------------
 preseptal cellulitis: anterior to orbital septum weight neutral  polyuria, polydipsia, mild hypernatremia (> 145)
 orbital cellulitis: posterior to orbital septum low risk of hypoglycemia & serum hypertonicity: diabetes insipidus
presepta orbital A/E: lactic acidosis  nephrogenic DI: intact thirst mechanism
l celluliti C/I: renal insufficiency o serum Na+ ~ 145
cellulitis s Sulfonylurea 1 – 2% added for metformin failure  central DI: no intact thirst mechanism
eyelid edema & erythema + + weight gain, hypoglycemia o serum Na+ > 150
fever, leukocytosis +/- +/- Pioglitazone 1 - 1.5% 2nd line to metformin/sulfon. o desmopressin: #1 Rx for central DI
ophthalmoplegia, diplopia - + (TZDs) low risk of hypoglycemia ----------------------------------------------------------------
pain with eye movement - + can use in renal insufficiency 10 polydipsia central DI nephrogenic DI
proptosis - + A/E: weight gain, edema,  H2O intake  ADH release ADH resistance
decreased visual acuity - + CHF, bone fx, bladder cancer
anxious idiopathic, trauma chronic lithium,
 Dx: orbital CT scan Insulin 1 - 3.5% basal insulin added in middle-age pituitary surgery, hyperCa++,
 Rx preseptal: outpatient, oral ABX metformin failure, A1c >8.5% female on ischemic hereditary
weight gain, hypoglycemia
 Rx orbital: inpatient, IV ABX antipsychotics encephalopathy
Sitagliptin .5 - .8% weight neutral
 complication: cavernous sinus thrombosis polyuria, low urine osmolality (dilute urine)
(DPP-IV low risk of hypoglycemia
---------------------------------------------------------------- Na+ < 137 Na+ > 150, Na+ 142 – 150,
inhibitors) can use in renal insufficiency
 circumferential full-thickness burns of extremity thirst impairment intact thirst mech
Exenatide 0.5 - 1% 2nd agent to metformin
o Rx: IV fluids, analgesia, topical ABX, & ----------------------------------------------------------------
(GLP-1 Rc weight loss**
wound dressing  diuretic: hypoK+, hyperglycemia, hyperuricemia
agonist) low hypoglycemia risk
 eschar: firm necrotic tissue on exposed tissue o stimulates ADH  concentrated urine
A/E: acute pancreatitis
following burn wounds ----------------------------------------------------------------
----------------------------------------------------------------
o compromises blood & lymph circulation  demeclocycline: Rx SIADH by inhibiting the
 secondary dysmenorrhea: age 20s – 30s,
 compartment syndrome: deep pain out of ADH-mediated aquaporin insertion
previous Hx of non-painful menses
proportion to injury, pulselessness, paresthesia ----------------------------------------------------------------
 MCC: endometriosis, adenomyosis, fibroids,
 Dx: Doppler USS to document peripheral pulses  tolvaptan: V2 vasopressin Rc antagonist, causes
pelvic infection
& tissue compartment pressure selective free water loss
----------------------------------------------------------------
 Rx: escharotomy for edema & constriction of  Rx severe hypervolemic/euvolemic hyponatremia
 chronic corticosteroids & chronic alcohol are
vascular supply or  peripheral pulses ----------------------------------------------------------------
a/w avascular necrosis
o evaluate for signs of adequate perfusion  hypersensitivity pneumonitis: inflammation of
 progressive hip pain, normal ROM; normal XR
 fasciotomy: Rx compartment syndrome lung parenchyma due to antigen exposure
 Dx: MRI
----------------------------------------------------------------  cough, dyspnea, fever, malaise within 4 – 6 hr
----------------------------------------------------------------
 decreased appetite, behavioral changes, erythema  chronic: weight loss, clubbing, honeycomb lung
 hemodynamic compromise 3 – 7 days post-MI:
of turbinates in nasal septum: cocaine abuse  CXR: ground-glass opacity, “haziness”
MR due to papillary rupture, LV free wall rupture,
----------------------------------------------------------------  Rx: avoidance of antigen
or interventricular septum rupture
 primary dysmenorrhea: lower abdo cramping ----------------------------------------------------------------  complications: pulmonary fibrosis
with menses, in absence of other pathology  young patient with a fleshy, immobile mass on ----------------------------------------------------------------
o MC onset during adolescence the midline hard palate: torus platinus  SSRIs take 4 – 6 wks for benefits
 cramping in 1st few days of menses, due to o benign, congenital lesion o should be continued if no significant A/E
release of prostaglandins from sloughing ----------------------------------------------------------------  initial change:  dosage
endometrium causes uterine contractions  elevated ALP indicates cholestasis  next: prescribe another SSRI
 normal physical exam  Dx: RUQ USS; intrahepatic or extrahepatic ----------------------------------------------------------------
 Rx: NSAIDs & OCPs cause of biliary obstruction  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:
presbycusis
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 (Crohn’s), impaired intestinal surface
epithelium (Celiac’s), or Whipple’s
 MCC of chronic pancreatitis: alcohol abuse
----------------------------------------------------------------
Seizures
 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 & β-blockers can trigger bronchoconstriction
in asthmatics (acute dyspnea, prolonged expiration)
o especially with chronic rhinitis & nasal polyps
 cardioselective β-blockers (metoprolol, atenolol)
act on β-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 & α-blockers: Rx overflow incont.
----------------------------------------------------------------
 most predictive sign of opioid intoxication:
bradypnea (respiratory depression)
o 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
risk fetal macrosomia, shoulder dystocia,
factors instrumentation delivery
features crying with passive motion, crepitus,
asymmetric Moro reflex
Dx XR
Rx 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, &
hemochromatosis
----------------------------------------------------------------
 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
 Rx: CBT
 DDx: alopecia acreta, body dysmorphic disorder,
GAD, SLE, OCD
----------------------------------------------------------------
 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
hypocalcemia
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
syndrome syndrome
LMN signs UMN & LMN signs
B/L radicular pain sudden severe back pain
saddle anesthesia perianal anesthesia
asymmetric motor weak symmetric motor weak
hypo-/arefflexia hyperreflexia
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)
Toxoplasma CD4 < 100 TMP-SMX (10)
MAC CD4 < 50 azithromycin (10)
Histoplasma CD4 < 150 Itraconazole
 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
Bruton /absent B-cells
agammaglobulinemi  all Ig
a
CVID normal B-cells
 all Ig
IgA deficiency normal B-cells
 IgA only
Hyper-IgM normal B-cells
syndrome  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,  ABG: hypoxemia, hypocapnia, resp. alkalosis  itchy, painful, erosive purple lesions on the vulva:
motor weakness, gait/balance disturbance: MS  Rx: pain control, breathing exercises, directed vulvar lichen planus
 relapsing-remitting pattern coughing, early mobilization, incentive spirometry  MC in middle-aged women
 optic neuritis, internuclear ophthalmoplegia ---------------------------------------------------------------- ----------------------------------------------------------------
 MRI: multiple, B/L, asymmetric hyperintense Preventing post-op pulmonary complications Down syndrome comorbidities
lesions in periventricular white matter  pre-operative cardiac AV septal defect, VSD, ASD
 acute exacerbation Rx: high-dose IV  smoking cessation at least 8 wks prior GI duodenal atresia, Hirschsprung
methylprednisolone o COPD symptom control neuro intellectual disability
o plasma exchange if no response o Rx respiratory infections early-onset Alzheimer’s
---------------------------------------------------------------- o education on lung expansion maneuvers hematologi acute leukemia
 M. tuberculosis occurs when droplets of bacilli  post-operative c
reach the alveolar space & replicate; accumulation o incentive spirometry, deep breathing exercises endocrine hypothyroidism, Type I DM
of macrophage & neutrophils, with bacilli o CPAP, chest PT MSK atlanto-axial instability
proliferation form a tubercle ---------------------------------------------------------------- ----------------------------------------------------------------
 tubercle + lymphadenopathy = Gohn complex Rome criteria for irritable bowel syndrome  Small intestinal bacterial overgrowth:  native
 cell-mediated immune response forms a  recurrent abdo pain/discomfort, ≥ 3 days/month & non-native bacteria causing excess
granuloma, resulting in latent TB for the last 3 months + ≥ 2… fermentation, inflammation, & malabsorption
---------------------------------------------------------------- o improves with bowel movement  causes: anatomic or dysmotility disorders
 initial menstrual cycles at menarche are anovulatory o change in stool frequency (strictures, fistulas, systemic sclerosis, diabetes,
 2/2 immature hypothalamic-pituitary-ovarian axis o change in stool form immunodeficiency, chronic pancreatitis, cirrhosis)
 causes irregular cycles &/or menorrhagia  diarrhea- or constipation-predominant, or mixed  bloating, flatulence, abdominal pain, diarrhea,
 some cyclic bleeding due to breakthrough  no extensive workup if no alarm features, & no weight loss, malabsorption
----------------------------------------------------------------  Dx: endoscopy with jejunal aspirate
family Hx or IBD or CRC
 acute low back pain  colonoscopy: normal colonic mucosa  Rx: ABX, trial of metoclopramide, diet changes
o no red flags, sciatica or cord compression ----------------------------------------------------------------  DDx: IBD, IBS, lactose intolerance, SBO
 Rx: conservative therapy 4 – 6 wks  severe vulvar itching with numerous excoriations, ----------------------------------------------------------------
 back XR & ESR if no improvement & skin is thin, dry, & white; post-menopause:  post-op DVT prophylaxis: LMWH
o red flags or sciatica: back XR & ESR lichen sclerosis ----------------------------------------------------------------
 MRI if results abnormal  porcelain-white polygonal macules & papules Breastfeeding failure Breast milk jaundice
 cord compression signs/symptoms: MRI with atrophic, “cigarette paper” quality jaundice
 premalignant lesion  SCC 1st week of life 3 -5 days, peak @ 2 wks
 red flags: age > 50, nighttime pain, constitutional
 Dx: vulvar punch biopsy (r/o vulvar SCC) lactation failure,  β-glucuronidase in
symptoms (fever, weight loss), unrelieved by rest,
 Rx: high-potency topical corticosteroids  unconjugated breast milk deconjugate
not exacerbated with movement or palpation,
hyperbilirubinemia, intestinal bilirubin, & 
neurologic symptoms, Hx of malignancy, IVDA ----------------------------------------------------------------
 bilirubin elimination, & enterohepatic circulation
 cord compression signs: back pain, paralysis,  clusters of small teardrop-shaped growths at
 enterohepatic circulation
hyperreflexia, urinary & fecal incontinence vestibule of the vulva: HPV genital warts
sub-optimal feeding, adequate breastfeeding
---------------------------------------------------------------- (condyloma acuminata)
dehydration signs, normal exam,
 atelectasis: common post-op complication  clusters of smooth, pink/skin-colored lesions
inadequate stooling no dehydration
 peak severity: 2nd post-op day  Rx: trichloroacetic acid (complete resolution) or
Rx: feeding 15 minutes per
 MC due to airway obstruction from retained airway podophyllin side every 2 -3 hrs
secretion,  lung compliance, post-operative pain,  DDx: condyloma lata (20 syphilis; flat & velvety),
& medications interfering with deep breathing vulva ca (single, fleshy lesion), lichen sclerosis,  causes of lactation failure: inadequate milk supply,
 results from shallow breathing & weak cough vulvar lichen planus
infrequent feedings, cracked/clogged nipples,
 V/Q mismatch evident ----------------------------------------------------------------
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
features jaundice, acholic stool, dark urine,
conjugated hyperbilirubinemia &
hepatomegaly in first 2 months of life
Dx 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
Rx 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)
etiology MC childhood cancer
peak age: 2 – 5 yrs; M > F
features bone pain, pallor (anemia),
petechiae
(thrombocytopenia)
nontender lymphadenopathy,
hepatosplenomegaly
confirm bone marrow Bx
Dx shows > 25% lymphoblasts
Rx chemotherapy
----------------------------------------------------------------
 aphthous ulcers, granulomatous inflammation,
weight loss, vague abdominal pain: Crohn’s
----------------------------------------------------------------
 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-to-
measure 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: investigator’s 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
β-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, &
aldosterone
----------------------------------------------------------------
Causes of Vit K deficiency
 fat malabsorption, fat-soluble vitamin deficiency
 ABX
 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
feature septic arthritis without skin lesions
s OR
triad: tenosynovitis, dermatitis,
migratory asymmetric polyarthritis
without purulent arthritis
Dx synovial fluid: > 50,000 (septic),
urethral, cervical, or rectal cultures,
HIV & syphilis screen
Rx 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 Paget’s, thiamine deficiency
----------------------------------------------------------------
Bacterial meningitis in children age > 1 month
MCC S. pneumoniae & N. meningitidis
features fever, vomiting/poor feeding,
lethargy, irritability, seizures,
bulging anterior fontanelle
nuchal rigidity, +Kernig, +Brudzinski
Dx CBC, electrolytes, blood cultures, LP
Rx 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:
MCC is HCC
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 Raynaud’s & migraines
 precipitated by emotional stress, hyperventilation,
exercise, cold, cocaine use
 greatest risk factor: smoking
 Rx: CCB or nitrates
o non-selective β-blockers (β2) & ASA
promote vasoconstriction
----------------------------------------------------------------
 protease inhibitors (indinavir) commonly cause
crystal-induced nephropathy
o periodic monitoring of U/A & serum Cr
 NRTI: a/w lactic acidosis
 NNRTI: a/w SJS
 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:
narcolepsy
 #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,
hypothyroidism
 monitor CBC weekly: clozapine
o a/w agranulocytosis, lowers seizure threshold
 1st gen anti-psychotics & risperidone are a/w
hyperprolactinemia
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
aspiration
 Rx: rigid bronchoscopy
----------------------------------------------------------------
 situs inversus, recurrent sinusitis, bronchiectasis:
Kartagener’s
 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  fever, localized back pain, neurologic deficits ----------------------------------------------------------------
 otosclerosis causes conductive hearing loss in (motor weakness, paresthesia, bowel/bladder):  sarcoidosis causes hypercalcemia by extra-renal
females age 20s – 30s; autoimmune process spinal epidural abscess conversion of 25(OH) VitD to 1,25(OH) VitD in
 radicular pain below the knee, +straight leg test, granulomatous tissue
Interpretation of Rinne & Weber tests pain improves with rest: herniated disk   intestinal Ca++ absorption
Rinne result Weber result  chronic back pain, fatigue, weight loss, anemia, ----------------------------------------------------------------
normal air > bone midline hypercalcemia, elevated Cr: MM Approach to hypercalcemia
conduction B/L  low back pain radiates to buttocks & thighs,  first: confirm by repeat testing
Conductive BC > AC affected lateralizes neuro deficits, worse with walking or standing:  next: measure PTH
hearing loss AC > BC unaffected toward lumbar spinal stenosis o high/normal PTH (PTH-dependent): 10 or 30
affected ear  low back pain, claudication of hip muscles, hyperPTH, familial hypercalcemic
Sensorineura AC > BC both ears lateralize to impotence: iliac artery thrombosis hypocalciuria, Lithium, teriparatide
l hearing loss (diminished AC & unaffected ear,  age > 50, pain worse at night, point tenderness, o suppressed PTH (PTH-independent)
BC in both) away from cauda equina syndrome, Hx of malignancy:  measure PTHrP, 25(OH)D, 1,25(OH)D
affected ear cancer mets to bone  malignancy, Vit D toxicity, sarcoidosis
 local tenderness to palpation after minor trauma, ----------------------------------------------------------------
 sensorineural hearing loss: involves inner ear, in elderly with Hx of osteoporosis: vertebral  fatigue, anxiety, depression, tetany
cochlea, or auditory nerve compression fracture Approach to hypocalcemia
o MCC ototoxic ABX, Meniere’s  chronic progressive pain, local point tenderness,  always confirm with repeat Ca++ measurement
 conductive hearing loss: decreased movement low-grade fever,  ESR/CRP, soft tissue infection:  correct serum albumin or measure ionized Ca++
of small ear bones, otitis media, otosclerosis vertebral osteomyelitis  evaluate Mg++, medications (Ca++ chelators,
---------------------------------------------------------------- ---------------------------------------------------------------- bisphosphonates, phenytoin), recent transfusion
Manifestations of sarcoidosis  tenderness to gentle percussion over spinous o correct underlying cause
 non-caseating granulomatous inflammation processes of involved vertebrae, not relieved  next: measure serum PTH…
pulmonary B/L hilar adenopathy, with rest,  ESR: vertebral osteomyelitis
interstitial infiltrates  MCC: S. aureus normal/low PTH high PTH
ophthalmic anterior uveitis  MC in IVDA or recent distant infection (UTI) radical neck surgery, Vit D deficiency, CKD
reticuloendothelia peripheral lymphadenopathy,  initial tests: CBC, blood cultures, ESR/CRP, parathyroidectomy,
l hepatosplenomegaly spine XR thyroidectomy
MSK acute polyarthritis (ankles)  Dx: spinal MRI autoimmune pancreatitis, sepsis
chronic arthritis  confirm Dx: CT-guided aspiration & Bx Wilson’s, tumor lysis syndrome
CNS central DI, hypercalcemia  Rx: long-term IV ABX +/- surgery hemochromatosis
Lofgren o erythema nodosum  complications: epidural abscess, paralysis genetic: PTH gene, Ca+ PTH resistance
syndrome (painful shin lesions) ---------------------------------------------------------------- +- sensing Rc gene (pseudo-hypoPTH)
o hilar adenopathy  hyperplastic polyp: MC non-neoplastic polyp in
o migratory polyarthralgia the colon; no CRC risk; no further work-up  hypoMg++ causes hypoCa++ in alcoholics; due
o fever  hamartomatous polyp: juvenile & Peutz-Jegher to decreased PTH release & PTH resistance
polyps; non-malignant  not a/w hyperphosphatemia
 mostly asymptomatic  adenomatous polyp: premalignant potential ----------------------------------------------------------------
 cough, dyspnea, fever, malaise, weight loss  sessile villous adenoma, > 2.5 cm  total serum Ca++ varies with albumin levels
 elevated ACE & hypercalcemia ---------------------------------------------------------------- o 50% of Ca++ is albumin bound
 Dx: mediastinoscopy/bronchoscopy tissue Bx  fevers, chills, malaise, cough, dyspnea, tachypnea ----------------------------------------------------------------
 Rx: systemic corticosteroids if symptomatic & diffuse fine crackles; diffuse reticular or  hypophosphatemia coexists with hypoMg++ in
---------------------------------------------------------------- ground-glass opacities on CXR: hypersensitivity alcoholics
reaction or pneumonitis   GI absorption &  renal loss of phosphate
----------------------------------------------------------------
Prolactinoma
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
 Dx: BNP, PCWP
 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)
systemic fatigue, arthralgia
skin telangiectasia, sclerodactyly,
digital ulcers, calcinosis cutis
vascular Raynaud’s
cardiac myocarditis, pericarditis
pericardial effusion
pulmonary pulmonary fibrosis, pulmonary HTN
GI 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:
ACTH, GH, FSH, LH, TSH
 posterior pituitary (ADH, oxytocin) is unaffected
 no effective Rx to restore lactation
----------------------------------------------------------------
 non-pitting edema seen in Turner’s 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 β-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
 Rx: IV ABX
 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
sedation decrease metabolic demand &
control HTN
IV mannitol osmotic diuresis (free water)
hyperventilatio cerebral vasoconstriction
n (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,
Turner’s, 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
----------------------------------------------------------------
Light’s 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…
 uncomplicated
 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
cholecystectomy
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
general weight loss, weakness, polydipsia,
polyuria, decreased libido, ED
skin hyperpigmentation (bronze diabetes)
MSK arthralgia, arthropathy,
chondrocalcinosis (pseudogout)
GI elevated LFTs, hepatomegaly,
cirrhosis, risk of HCC
endocrine DM, secondary hypogonadism
 hypothyroidism
cardiac dilated cardiomyopathy, systolic dysFx,
conduction defect (sick sinus syndrome)
infection 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):
Nocardia
 aerobic, Gram+ weakly acid fast, filamentous rod
 subacute pneumonia that mimics TB
 Rx: TMP-SMX
----------------------------------------------------------------
 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
osteoporosis
 a/w xanthomas & xanthelasmas
 a/w Sjogren’s, Raynaud’s, scleroderma, Celiac’s
 Dx: anti-mitochondrial antibodies in serum
 Rx: ursodeoxycholic acid relieves symptoms &  hyperpigmentation due to increased ACTH &
slows disease progression melanocyte-stimulating hormone
o definitive Rx: liver transplant  ketoconazole can precipitate adrenal insufficiency
---------------------------------------------------------------- by inhibiting adrenal steroid synthesis
 post-partum adrenal insufficiency can be  a/w other autoimmune disorders
primary (adrenal) or secondary (pituitary)  Rx: hydrocortisone
 hyperpigmentation & signs of mineralocorticoid ----------------------------------------------------------------
deficiency suggests an adrenal cause Secondary (central) adrenal insufficiency
 weakness, fatigue, abdominal pain, anorexia,  loss of only glucocorticoid & adrenal androgen
mild hyponatremia, postural hypotension, secretion; preserved mineralocorticoid production
hyperkalemia  aldosterone is regulated by RAA system
----------------------------------------------------------------  no hypotension, hyperK+, or hyperCl- acidosis
Adrenal insufficiency  MCC: lymphocytic hypophysitis & Sheehan
10 (adrenal) 20 (pituitary) ----------------------------------------------------------------
MCC autoimmune chronic  screen for Cushing’s: 24-hr urine free cortisol &
glucocorticoid Rx low-dose dexamethasone suppression test
ACTH   ----------------------------------------------------------------
cortisol    ursodeoxycholic acid: Rx primary biliary cirrhosis
aldosteron  normal & primary sclerosing cholangitis
e ----------------------------------------------------------------
features severe symptoms less severe
hyperpigmenttn no hyperpigment,
hyperkalemia no hyperkalemia,
hyponatremia possible
hypotension hyponatremia
 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.  recurrent oral & genital ulcers, anterior uveitis,
 chronic central AI develop adrenal gland atrophy, erythema nodosum: Behcet syndrome
thus a suboptimal response to cosyntropin  MC in Turkish, Asian, Middle Eastern
----------------------------------------------------------------  immune-mediated small-vessel systemic vasculitis
 weakness, fatigue, weight loss, anorexia,  Dx: triple-symptom complex: recurrent aphthous
depression, hypotension, hyperpigmentation, ulcers, genital ulcers, anterior uveitis
eosinophilia, hyponatremia, hyperkalemia o also erythema nodosum
Primary adrenal insufficiency (Addison’s)  Rx: high dose corticosteroids
 MCC: autoimmune adrenalitis  humoral &  complications: aneurysm, dementia, & blindness
cell-mediated destruction of adrenal cortex ----------------------------------------------------------------
 loss of glucocorticoid, mineralocorticoid, & Tamoxifen: SERM
adrenal androgens 2/2 adrenal cortex destruction  antagonist on breast
 hyperchloremic acidosis o Rx breast cancer & prevention in other breast
  agonist on endometrium  soltalol causes prolonged QT & TdP o  tearing, hyperacusis, loss of taste over
  endometrial cancer risk ---------------------------------------------------------------- anterior 2/3 of tongue
o  uterine sarcoma risk  adenosine: Rx PSVT  forehead muscle sparing suggests intracranial
 agonist on osteoclasts (inhibits turnover)  amiodarone: Rx hemodynamically stable atrial & lesion  brain imaging for ischemia or tumor
o  risk of osteoporosis ventricular wide-complex tachycardia; also a-fib o lesion above facial nucleus
  venous thrombosis risk  atropine: symptomatic sinus brady, AV block o C/L hemiparesis, hemianesthesia, dysarthria
----------------------------------------------------------------  sodium bicarbonate: TCA overdose, hyperK+, ----------------------------------------------------------------
Raloxifene: SERM ASA overdose  Vit K deficiency in newborns result from poor
 antagonist on breast & endometrium ---------------------------------------------------------------- placental transfer, absent gut flora, immature
o  breast cancer risk  small, rubbery lymph nodes < 1 cm are commonly liver function, inadequate levels in breast milk
 does not increase risk of endometrial cancer benign in children & young adults  bruising, bloody stools, intracranial hemorrhage
 agonist in bone o asymptomatic, soft lymph nodes can be  initially prolonged PT, followed by aPTT
o #1 Rx prevents osteoporosis observed for growth or symptoms  Rx: Vit K replenishes in 8 – 10 hrs
 A/E:  risk of VTE; C/I if Hx of DVT  cancerous nodes are firm & immobile, > 2 cm  FFP for acute hemorrhage
----------------------------------------------------------------  hard cervical nodes in adults or smokers suggest ----------------------------------------------------------------
 early decelerations: due to fetal head compression metastatic cancer or oropharyngeal neoplasia  ACTH does not affect aldosterone production,
leading to a vagal response ---------------------------------------------------------------- which is regulated by RAA system
o does not indicate fetal distress Peripheral facial palsy Central facial palsy ----------------------------------------------------------------
o normal finding of active labor (Bell’s palsy) Muscular dystrophy
 variable & late decelerations indicate risk for loss of forehead & brow preservation of forehead Duchenne Becker Myotonic
fetal hypoxemia & acidosis movement & brow movement XR deletion of dystrophin, Xp21 AD inheritance,
o variable: cord compression or prolapse, inability to close eye & C/L lower face weakness CTG repeats,
drooping eyelids DMPK gene
oligohydramnios; abrupt drop in fetal HR
o late: uteroplacental insufficiency loss of nasolabial folds, drooping lower lip onset: age 2 – 3 age 5 – 15 age 12 - 30
---------------------------------------------------------------- progressive mild weakness facial weakness,
Alcohol withdrawal syndrome weakness, Gower, (*decreased hand grip
pseudohypertroph dystrophin*) myotonia,
features last drink
y dysphagia (asp.
mild anxiety, tremulousness, 6 hrs
pneumonia),
withdrawal sweating, palpitations
foot drop
withdrawal single or multiple in short 12 – 48 hr
scoliosis, cardiomyopath arrhythmias,
seizures period of time
cardiomyopathy; y cataracts, bald,
alcohol auditory, visual, tactile 12 – 24 hr
wheelchair-bound testicular
hallucinosis hallucination; normal vitals resolves
by adolescence atrophy/infertilit
& intact sensorium in 24 – 48
y
hr
death by 20 – 30; death by 40 - respiratory or
delirium fever, HTN, tachycardia,
respiratory or 50 heart failure
tremens diaphoresis, hallucinations, 48 – 96 hr
heart failure heart failure
disorientation
----------------------------------------------------------------
 DMD: absent dystrophin on immuno staining
 polymorphic ventricular tachycardia in the setting
 CPK & aldolase are elevated before manifestations
of congenital or acquired prolonged QT interval:
----------------------------------------------------------------
Torsades de Pointes (TdP)
 medullary thyroid cancer: calcitonin secretion
 can resolve spontaneously or degenerate to V-fib
 follicular & papillary cancers: a/w Hurthle cells
 Rx hemodynamically unstable: defibrillation  Bell’s: CN VII neuropathy, lesion below the pons
----------------------------------------------------------------
 Rx hemodynamically stable: Mg++ sulfate
 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
cyclophosphamide
----------------------------------------------------------------
 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  aldosterone adrenal adenoma
before empiric IV ABX (vancomycin) B/L adrenal hyperplasia
o ABX can interfere with cultures Dx: adrenal CT
 Rx: synovial fluid aspiration & drainage Secondary
prevents long-term disability & joint destruction  renin, diuretics, cirrhosis, CHF,
 DDx: transient synovitis, acute rheumatic fever,  aldosterone renovascular HTN,
osteomyelitis (ratio > 20) renin-secreting tumor,
---------------------------------------------------------------- malignant HTN,
 malaria causes cyclical fever, nonspecific GI & coarctation of aorta
constitutional symptom, anemia & thrombocytopenia Other
 cyclical fever coincides with RBC lysis  renin, CAH, Cushing’s,
 up to 2 wks after mosquito bite  aldosterone glucocorticoid resistance,
 Dx: thin & thick peripheral blood smears exogenous mineralocorticoids
 protective: hemaglobinopathies (HbS, HbC,
thalassemia, sickle cell trait, Hx of malaria)  easily induced hypokalemia after starting a
---------------------------------------------------------------- thiazide suggests primary hyperaldosteronism
 Dengue fever: leukopenia is common  metabolic alkalosis (loss of H+)
----------------------------------------------------------------  mild hypernatremia only (aldosterone escape)
 cholestyramine: bile acid sequestrant ----------------------------------------------------------------
o  fecal loss of bile salts & cholesterol  recurrent episodes of flash pulmonary edema
 Rx: hypercholesterolemia, pruritus a/w liver failure,  screen for renovascular HTN: abdominal CT
bile acid diarrhea, absorb C. difficile toxins A & B angiography
----------------------------------------------------------------  MCC: renal artery stenosis, fibromuscular dysplasia
 fever, jaundice, hepatomegaly, dark urine, ----------------------------------------------------------------
pruritus, acholic stools: Hep A  acute, painless vision loss, fundoscopy: optic disk
 incubation: 30 days swelling, retinal hemorrhages, dilated & tortuous
---------------------------------------------------------------- veins, & cotton wool spots: central vein occlusion
 headache, abdominal pain, vomiting, diarrhea,  “blood & thunder” appearance
salmon rose spots, bradycardia: typhoid fever  monocular loss of vision caused by thrombosis
----------------------------------------------------------------  Dx: fluorescein angiography
 inhaled albuterol & systemic steroids Rx acute  Rx: conservative, observation
asthma attacks  DDx: angle closure glaucoma, anterior uveitis,
 high-dose β2-agonists can cause hypokalemia, amaurosis fugax, optic neuritis
resulting in weakness, arrhythmias, EKG changes ----------------------------------------------------------------
 check serum electrolytes  acute, severe eye pain, blurred vision, N/V,
---------------------------------------------------------------- steamy cornea with non-reactive, dilated pupils:
 muscle cramps, weakness, palpitations, HTN after acute angle-closure glaucoma
initiating a thiazide  acute, severe eye pain, unilateral vision loss,
 HTN & hypokalemia: suspect hyperaldosteronism afferent pupillary defect: optic neuritis
 test: plasma renin & aldosterone ----------------------------------------------------------------
 fever > 390C (102.20F) in any child age < 3 should
Causes of HTN & hypokalemia prompt evaluation for UTI
 renin, Primary 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: Acute Chronic
native valve endocarditis with cardioembolic stroke feature fever, chills, malaise, no fever, dysuria,
 high risk of TIA or stroke due to septic emboli s myalgia, perineal pain, frequency,
 ischemic stroke: Rx underlying cause cloudy urine recurrent UTI
 Rx: IV ABX reduces risk of septic cardioemboli Dx **mid-stream urine sample**
in native valve IE pyuria, tender prostate, pyuria,
 Rx: aortic valve surgery for severe cases +urine culture (E. coli) +urine culture
 IV heparin is a/w risk of intracranial hemorrhage Rx empiric TMP-SMX for fluoroquinolones
---------------------------------------------------------------- 4 – 6 wks
 evidence of acute pericarditis & renal failure:  complication: prostatic abscess (CT scan)
uriemic pericarditis ----------------------------------------------------------------
 inflammation of visceral & parietal membranes  all present with irritative voiding symptoms
of pericardial sac; BUN > 60 (frequency, urgency, suprapubic or perineal pain)
 no evidence of pericarditis on EKG  acute bacterial prostatitis: very tender prostate
 definitive Rx: hemodialysis
---------------------------------------------------------------- Prostatitis
 acute viral or idiopathic pericarditis Rx: NSAIDs feve U/A prostatic secretions
& colchicine r leukocyte bacteria
---------------------------------------------------------------- acute bacterial + +  +
hypertensive BP ≥ 180/120 mmHg chronic bacterial - nrml  +
urgency without symptoms or end-organ damage chronic _ nrml  _
hypertensive headache, dyspnea, blurred vision, inflammatory
emergency + acute, end-organ complications… chronic _ nrml nrml _
(BP > 220/120)  malignant HTN: exudates, non-inflammatory
retinal hemorrhage, papilledema ----------------------------------------------------------------
Rx:  hypertensive encephalopathy: Glasgow Coma Scale
nitroprusside: cerebral edema, neuro symptoms,  eye opening (4), verbal (5), motor (6)
SAH or ICH  not used to Dx coma
---------------------------------------------------------------- o Dx coma: impaired brainstem activity, motor
 most intussusceptions before age 2 following dysfunction, impaired LOC
viral illness have no identifiable lead point ----------------------------------------------------------------
o gastroenteritis  hypertrophied Peyer patches  hypoglycemic episodes can occur with pre-meal
 pathological lead point should be suspected in insulin administration in diabetic gastroparesis
older children with recurrent intussusception  metoclopramide: Rx N/V & gastroparesis
o MCC: Meckel’s o DA receptor antagonist; prokinetic & antiemetic
 other risk factors: Henoch-Schonlein, rotavirus  monitor for drug-induced EPS, dystonic reaction
vaccination  rarely, NMS may occur
----------------------------------------------------------------  Rx: discontinue; benztropine or diphenhydramine
 ventilator-associated pneumonia occurs 48 hr  alt Rx: erythromycin (prokinetic)
after intubation ----------------------------------------------------------------
 MCC: P. aeruginosa, E. coli, Klebsiella, MRSA  fibrocystic disease of the breast: B/L tenderness
 Dx: CXR, lower respiratory tract culture & palpable mass during luteal phase
 Rx: empiric ABX (after obtaining sample) ----------------------------------------------------------------
----------------------------------------------------------------
Prostatitis overview
 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 Grave’s, 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
----------------------------------------------------------------  large head, prominent forehead & jaw, protruding
 PVCs are common post-MI; a/w worse prognosis ears, joint laxity, macroorchidism: Fragile X
 no Rx unless symptomatic (β-blockers)  hyperactivity, short attention, autism
----------------------------------------------------------------  FMR1 gene with CGG repeats
 initial Rx of acute & chronic anal fissures: diet, ----------------------------------------------------------------
stool softener, local anesthetic Breastfeeding
 chronic or refractory cases: lateral sphincterotomy Benefits Contraindications
---------------------------------------------------------------- Maternal
MCC of esophagitis in HIV  breast & ovarian ca active untreated TB
Candida white plaques, oral thrush risk (not endometrial) (resume feeds after 2 wks
Rx: empiric fluconazole, of anti-TB therapy)
endoscopy if no improvement rapid uterine involution, maternal HIV infection
HSV small, round/ovoid ulcers  post-partum bleeding, herpetic breast lesions
Rx: acyclovir rapid return to pre-partum varicella infection (< 5
CMV large, linear ulcers in distal esophagus weight, days prior or 2 days after
Rx: IV ganciclovir delivery)
improved child spacing, chemotherapy/radiation
 MC when CD4 < 100 maternal-infant bonding drug or alcohol abuse
 odynophagia without dysphagia: MCC is viral Infant
 Dx: esophagoscopy immunity, GI function,
 acyclovir is not effective Rc for CMV due to its prevention…otitis media,
lack of thymidine kinase to convert to active form respiratory/GI illness, UTI galactosemia
----------------------------------------------------------------  risk of childhood ca,
Type I DM, NEC
 dysphagia, heartburn, refractory to GERD Rx:
eosinophilic esophagitis
 comorbid asthma, seasonal allergies  exclusively breastfed infants require Vit D suppl
until age 6 months
 manometry shows hypercontractility
----------------------------------------------------------------  mastitis & Hep B or C are not C/I to breastfeeding
----------------------------------------------------------------
 acute odynophagia, retrosternal chest pain,
epigastric burning: pill esophagitis Indications for cytoscopy
 gross hematuria with no glomerular disease
 direct mucosal injury due to prolonged contact
result in discrete ulcers on endoscopy  microscopic hematuria without evidence of
glomerular disease, but risk for malignancy
 MCC: KCl, tetracycline, aldendronate, NSAIDS,
 recurrent UTIs
quinidine, iron
 obstructive symptoms (strictures, stones)
----------------------------------------------------------------
 irritative symptoms without infection
 alcoholic with altered mental status, gait instability,
 abnormal bladder imaging or urine cytology
nystagmus, conjugated gaze palsy: Wernicke’s
----------------------------------------------------------------
 no labs or radiological studies necessary
 risk of bladder cancer: smoking, chronic cystitis,
 can be induced iatrogenically by giving glucose
cyclophosphamide, pelvic radiation, occupational
without thiamine
 screening is not recommended, even those at risk
----------------------------------------------------------------
----------------------------------------------------------------
 apathy, irreversible amnesia, confabulation,:
 severe ear pain especially at night, exacerbated
Korsakoff’s
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
 Rx: TMP-SMX
 DDx: TB
----------------------------------------------------------------
 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 Barrett’s, 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; Beck’s 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
DVT & PE
 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
 hypotension
 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
(Cushing’s 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 &
hematochezia
 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
pathogenesis dysregulation of imprinted gene
expression
features fetal macrosomia, rapid growth,
omphalocele or umbilical hernia,
macroglossia, hemihyperplasia
complication Wilms nephroblastoma,
s heptapoblastoma
surveillance 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, Hutchinson’s 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:
Huntington’s
----------------------------------------------------------------
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,
factors sepsis, excessive diuretics, SBP
 glomerular pressure & GFR: NSAIDs
(constricts afferents)
Dx renal hypoperfusion: FeNa < 1%
prerenal azotemia
absence of tubular injury
(no RBC, protein, or granular casts)
does not respond to fluid resuscitation
Rx 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 β-hCG
Thyroid hormones during pregnancy
Total T4  β-hCG stimulates TH production
1.5x & estrogen stimulates  TBG
Free T4  slight increase
TSH  suppressed
----------------------------------------------------------------
 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
risk obese women of child-bearing age, OCPs,
factors tetracycline, isotretinoin, excess Vit. A
symptom o headache (holocranial, pulsatile)
s worse at night, awakens from sleep
o transient vision loss, diplopia
o pulsatile tinnitus (“whooshing”)
exam papilledema, peripheral vision defect,
CN VI palsy (lateral rectus)
Dx MRI: normal (may see empty sella)
LP: normal CSF analysis
 opening pressure > 250 mmHg
(communicating hydrocephalus)
Rx stop offending medication, weight loss,
acetazolamide (if weight reduction fails)
definitive Rx: surgery
complication: blindness
DDx: migraine, cluster headache, viral encephalitis,
MS, NPH
 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
----------------------------------------------------------------
 Parkinson’s 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
----------------------------------------------------------------
 Hashimoto’s: lymphocytic infiltration of thyroid
 anti-TPO Ab’s, elevated TSH, low T4
 enlarged, rubbery goiter
 can cause transient hyperthyroidism 2/2 initial
inflammatory destruction of thyroid follicles
----------------------------------------------------------------
 thyroid lymphomas: MC a/w Hashimoto’s
 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 Preconception counseling
tubule @ high doses  initial screening of hemaglobinopathies for
 serial K+ monitoring required non-African American: CBC of the female only
 also competitively inhibits tubular Cr secretion, o further testing if anemic & reduced MCV
results in artificial increase of serum Cr  African Americans: CBC & Hb electrophoresis
without affecting GFR ----------------------------------------------------------------
----------------------------------------------------------------  iron level, TIBC, & ferritin are normal in
 glomerular hyperfiltration is the earliest renal thalassemia; abnormal with iron deficiency
abnormality in diabetic nephropathy ----------------------------------------------------------------
o detectable several days after DM Dx  ceftriaxone use is a/w cholestasis
o creates intraglomerular HTN & progressive  C/I in newborns at high risk of cholestasis
glomerular damage ----------------------------------------------------------------
 Rx: ACE-I reduces intraglomerular HTN Skin conditions & associated diseases
 first quantified change: glomerular BM thickening, acanthosis nigricans insulin resistance
followed by mesangial expansion, nodular sclerosis (PCOS, obesity, DM),
---------------------------------------------------------------- GI malignancy
 rapid onset respiratory failure, severe hypotension, multiple skin tags insulin resistance,
& DIC during labor or immediately post-partum: pregnancy,
amniotic fluid embolism Crohn’s (perianal)
 cardiogenic shock, seizures, or coma porphyria cutanea tarda &
 risk factors: adv maternal age, high gravida palpable purpura 2/2 Hep C
 Dx: clinical cryoglobulinemia
 Rx: respiratory & hemodynamic support dermatitis herpetiformis Celiac’s
 DDx: eclampsia, peripartum cardiomyopathy, PE sudden onset psoriasis,
recurrent herpes zoster, HIV
----------------------------------------------------------------
 severe aortic stenosis can cause anginal chest pain molluscum contagiosum
severe seborrheic dermatitis HIV,
due to  myocardial O2 demand
 accompanying prolonged myocardial contraction Parkinson
explosive, itchy seborrheic GI malignancy
& impaired diastole  coronary blood flow
dermatitis
----------------------------------------------------------------
 HCM: murmur @ LLSB; dual upstroke carotids pyoderma gangrenosum Crohn’s
erythema nodosum sarcoidosis, UC, TB,
 aortic stenosis: murmur located in 2nd IC space
coccidiomycosis,
with radiation to carotids
histoplasmosis, Bechet
----------------------------------------------------------------
 myocardium meets increased O2 demand by
 DDx of hyperpigmentation: Addison’s, pellagra,
inducing dilation of coronary vessels
hemochromatosis
o unable to increase O2 extraction
----------------------------------------------------------------
----------------------------------------------------------------
 pyoderma gangrenosum: neutrophilic ulcerative
 anti-tissue transglutaminase Ab: Dx Celiac’s
skin disease; purulent base, violaceous borders
----------------------------------------------------------------
 a/w underlying systemic disorder (IBD, RA, AML)
 heparin inactivates antitrhombin III, which
 Dx: skin biopsy
inactivates thrombin, factor IXa & Xa
 Rx: local or systemic corticosteroids
----------------------------------------------------------------
 mean values are extremely sensitive to outliers ----------------------------------------------------------------
 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,
Cushing’s
----------------------------------------------------------------
 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, Murphy’s 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 Paget’s
 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
 Rx: CBT
----------------------------------------------------------------
 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. o moon facies, bruises o emphysema COPD:  DLCO due to alveolar
pyogenes, S. pneumo, H. influenza)  GI hamartomatous polyps, mucocutaneous destruction
 underweight, dermatitis, lymphadenopathy, pigmentation: Peutz-Jeghers ----------------------------------------------------------------
hypergammaglobulinemia, hepatic abscesses,  sporadic phakomatosis, mental retardation,  DLCO = function of alveolar-capillary membrane
hepatosplenomegaly, anemia of chronic disease seizures, visual impairment: Sturge-Weber DDx based on DLCO
 Dx: nitroblue tetrazolium test ---------------------------------------------------------------- obstructive restrictive normal
 Rx: daily TMP-SMX, gamma-INF 3x/wk  MCC of secondary digital clubbing: CF, pattern pattern spirometry
---------------------------------------------------------------- lung malignancies, right-to-left shunts  DLCO emphysema interstitial anemia, PE,
 lethargy, bradycardia, AV block, hypotension,  2/2 trapping of megakaryocytes in distal (COPD) lung disease, pulmonary
diffuse wheezing: β-blocker overdose fingertips, releasing PDGF & VEGF sarcoidosis, HTN
 wheezing is hallmark  hypertrophic osteoarthropathy: clubbing & asbestosis,
 hypoglycemia, bronchospasm, delirium, seizures painful joint enlargement, synovial effusions, heart failure
 initial Rx: isotonic fluid bolus, IV atropine periostosis of long bones; a/w lung cancer normal chronic MSK
 Rx: IV glucagon ( intracellular cAMP) for ---------------------------------------------------------------- DLCO bronchitis deformity,
refractory hypotension  MC complication of PUD: hemorrhage (COPD), neuromuscula
---------------------------------------------------------------- ---------------------------------------------------------------- asthma r disease
 prematurity & LBW infants are risk factor for Obstructive Restrictive  DLCO severe morbid pulmonary
intraventricular hemorrhage lung disease lung disease asthma obesity hemorrhage,
 Dx: transfontanelle USS of all newborns with FEV1 < 80% < 80% polycythemi
FEV1/FVC < 70% () > 70% a
predisposing risk factors
(normal) Causes of  DLCO (look at FEV pattern)
----------------------------------------------------------------
FVC normal or  < 80%  restrictive pattern: interstitial fibrosis, bleomycin,
 Parinaud syndrome: due to pineal gland tumor
idiopathic pulmonary fibrosis
(pineal produces melatonin)
 obstructive pattern: emphysema COPD
 MCC: germ cell tumors
 normal spirometry: PE, anemia, pulmonary HTN
 central precocious puberty:  β-hCG
Causes of  DLCO
 pressure on pretectal midbrain region near
 due to  pulmonary blood volume
superior colliculus & CN II
 limited upward gaze (“sun-setting” sign), ptosis,  exercise, supine position, pulmonary hemorrhage,
B/L eyelid retraction (Collier’s sign) severe asthma, smoking, polycythemia
 pseudo-Argyll-Robertson (minimally reactive) ----------------------------------------------------------------
  DLCO in emphysema due to "adjoining
 obstructive hydrocephalus: headache, vomiting,
capillary beds" (decreased surface area)
papilledema
  DLCO in asthma due to "increased pulmonary
 Dx: MRI, AFP & β-hCG
blood volumes"
----------------------------------------------------------------
----------------------------------------------------------------
 ecchymosis on areas exposed to repeated minor
 chronic bronchitis: COPD subtype a/w smoking
trauma (extensors) in elderly: senile purpura
 productive cough ≥ 3 months in 2 successive yrs
 age-related loss of elastic fibers in perivascular
 hypersecretion of mucus & structural changes to
connective tissue  positive bronchodilator response (> 12%  FEV1),
  incidence & severity a/w anticoagulants, tracheobronchial tree; normal DLCO
normal DLCO, dyspnea, wheezing, cough: asthma  CXR: prominent bronchovascular markings
NSAIDs, & corticosteroids  COPD & asthma both show airflow obstruction
 normal labs; no further evaluation ----------------------------------------------------------------
 only asthma shows complete reversible Evaluation of hyperthyroidism
---------------------------------------------------------------- airway obstruction with bronchodilators  Dx: measure TSH & free T4
 precocious puberty, pigmentation, polyostotic o asthma: normal or  DLCO (if severe) o  TSH,  free T4  20 hyperthyroidism
fibrous dysplasia (3 P’s): McCune Albright
o Dx: MRI  pituitary adenoma
o café au lait spots, multiple bone defects
 o  TSH,  free T4  10 hyperthyroidism ---------------------------------------------------------------- aldosterone/renin > 20:1
o goiter, ophthalmopathy  Graves’  fatigue, malaise, fever, night sweats, anorexia, pheochromo- headache, palpitations, diaphoresis
o Dx: radioactive iodine uptake (RIU) weight loss, pallor, abdominal pain: CML cytoma paroxysmal elevated BP
  RIU = de novo hormone synth  leukocytosis with left shift, basophilia, anemia, adrenal incidentaloma
  RIU = preformed or exogenous thrombocytosis, splenomegaly Cushing’s central obesity, facial plethora,
 high RIU: diffuse  Graves’   myelocytes > metamyelocytes proximal weakness, striae,
 high RIU: nodular  adenoma, multi-nodular goiter  reciprocal t(9, 22) form Philadelphia Xome amenorrhea/erectile dysfunction
 low RIU  thyroglobulin low  exogenous TH containing the BCR/ABL fusion gene causes hypothyroidis fatigue, dry skin, cold intolerance,
 low RIU  thyroglobulin high  thyroiditis dysregulated tyrosine kinase activity m constipation, weight gain
  LAP score (leukocyte alkaline phosphatase) primary hypercalcemia, renal stones
----------------------------------------------------------------
 Rx: tyrosine kinase inhibitors (imatinib) hyperPTH polyuria, polydipsia
 thyroglobulin: produced by follicular cells of
inhibit BCR/ABL tyrosine kinase activation confusion, depression, psychosis
the thyroid; used only within the thyroid gland
---------------------------------------------------------------- aortic differential HTN, headache,
----------------------------------------------------------------
  leukocyte alkaline phosphatase (LAP) score: coarctation epistaxis, blurred vision,, LVH
 fever, neck pain, tender thyroid, elevated ESR:
leukemoid reaction, polycythemia vera brachial-femoral delay, rib notching
subacute thyroiditis (de Quervain) continuous “to-&-fro” machine-like
 self-limited < 8 wks due to depletion of   LAP score: CML (Dx: Philadelphia Xome)
---------------------------------------------------------------- murmur (posterior chest) due to
preformed thyroid hormone large collateral circulation
----------------------------------------------------------------  acute promyelocytic leukemia (APL) is a/w
 upper GI bleed Rx: supplemental O2, IV fluids, retinoic acid receptor
 +Auer rods, +myeloblasts  hypercalcemia: “bones, stones, moans, groans”
NPO, monitor CBC & vitals for ongoing bleeding  hyperPTH can cause HTN, arrhythmias, ventricular
----------------------------------------------------------------  no fever, no splenomegaly
 Rx: all-trans retinoic acid (ATRA) hypertrophy, vascular & valvular calcifications
Manifestations of SLE  significant HTN & 10 hyperPTH; MEN syndrome
feature constitutional: fever, fatigue, weight loss ----------------------------------------------------------------
 MC thyroid malignancy: papillary carcinoma ----------------------------------------------------------------
s non-deforming migratory arthritis
Acute decompensated heart failure
butterfly rash & photosensitivity  best prognosis
feature acute dyspnea, orthopnea, PND, HTN,
serositis: pleurisy, pericarditis, peritonitis  MC mets to local lymph nodes
s accessory muscle use, tachycardia,
thromboembolic events (antiphospholipid)  risk factors: childhood head/neck irradiation,
tachypnea, bibasilar crackles, JVD, S3,
cognitive dysfunction & seizures family Hx of thyroid ca peripheral edema
labs hemolytic anemia, thrombocytopenia, ---------------------------------------------------------------- Rx stable: supplemental O2,
leukopenia  follicular thyroid carcinoma: hematogenous IV furosemide, IV vasodilator (nitro)
proteinuria, elevated Cr  anaplastic thyroid ca: rapidly enlarging mass;
hypocomplementemia (C3, C4) hypotension or shock: supplemental O2,
worst prognosis (months) IV furosemide, IV vasopressor (NE)
ANA, anti-dsDNA, anti-Smith ----------------------------------------------------------------
false-positive RPR test for syphilis  resistant HTN: despite ≥ 3 anti-hypertensives
 acute decompensated HF can present with acute
Secondary causes of HTN
 SLE joint Rx: NSAIDs, low-dose glucocorticoids, pulmonary edema
renal  serum Cr, proteinuria, RBC casts
hydroxychloroquine ----------------------------------------------------------------
parenchymal
---------------------------------------------------------------- disease Tetanus prophylaxis
 cough & wheezing with ASA-exacerbated renovascular continuous abdominal bruit, wound clean, minor dirty, severe
respiratory disease is preceded by refractory disease severe HTN (≥ 180/120), ≥ 3 tetanus tetanus toxoid if tetanus toxoid if
chronic rhinosinusitis a/w nasal polyposis (MCC) diffuse atherosclerosis (PAD, PVD) toxoid doses last dose was last dose was
---------------------------------------------------------------- recurrent flash pulmonary edema ≥ 10 yrs ago ≥ 5 yrs ago
 child with morning headaches, seizures, irritable,  serum Cr (after starting ACE-I) no TIg no TIg
decorticate posturing, space-occupying lesion primary HTN, mild hyponatremia, unimmunized, tetanus toxoid tetanus toxoid
 infratentorial, benign astrocytomas: MC in kids aldosteronism easily provoked hypokalemia uncertain, or vaccine only, vaccine + TIg
< 3 tetanus doses no TIg  5-HT is synthesized in carcinoid cells from Nephrotic histopathology
---------------------------------------------------------------- tryptophan, also used for niacin  crescent formation: focal segmental GN
 diastolic dysfunction = heart failure with o  5-HT production  pellagra  thick BM & subepithelial “spikes”: membranous
preserved LV ejection fraction (contractility)  DDx: right-sided IE (fever, malaise, arthralgias)  mesangial hypercellularity: membranoproliferative
 elevated diastolic pressure  reduced C.O. ---------------------------------------------------------------- ----------------------------------------------------------------
----------------------------------------------------------------  folic acid depletion: 4 – 5 months  parents are not allowed to refuse life-saving Rx
Drugs/supplements that affect  elderly on a tea & toast diet for a child, including religious reasons
warfarin metabolism  Vit B12 stores: 3 – 4 yrs  obtain court order to proceed with intervention
p450 acetaminophen* NSAIDs ---------------------------------------------------------------- ----------------------------------------------------------------
inhibitors ABX/antifungals thyroid hormone  perifollicular hemorrhage, poor wound healing,  adolescents can receive confidential care w/o consent
(metronidazole) SSRI swollen gums: Vit C deficiency for contraception, pregnancy, & STDs
 warfarin amiodarone cranberry juice  RBC fragility, hyporeflexia, muscle weakness, ----------------------------------------------------------------
( bleed risk) cimetidine Gingko biloba blindness: Vit E deficiency  presbyopia: age-related  lens elasticity
omeprazole Vit E ----------------------------------------------------------------  prohibits accommodation, thus loss of near vision
p450 inducers carbamazepine phenobarbital  unilateral pulsatile headache, vomiting,  peaks at age 40, Hx of eye problems
ginseng rifampin photophobia, 4 – 72 hrs duration: migraine ----------------------------------------------------------------
 warfarin spinach (greens) St. John’s wort  Rx acute attacks: IV anti-emetics (chlorpromazine,  weakness, postprandial epigastric pain, +FOBT:
effects/efficacy OCPs prochlorperazine, metoclopramide), esp. w/ N/V gastric cancer
---------------------------------------------------------------- o monotherapy or adjunct to NSAIDs & triptans  Dx: endoscopy/Bx positive for adenocarcinoma
 lupus anticoagulant: causes artificially  migraine prophylaxis: amitriptyline, propranolol Staging gastric adenocarcinoma
prolonged aPTT by binding phospholipids ----------------------------------------------------------------  initial staging: abdomen & pelvis CT
  risk of thrombosis  most effective in reducing UTI risk a/w  limited stage  surgical resection
---------------------------------------------------------------- neurogenic bladder: intermittent catheterization  advanced stage  chemotherapy +/- laparotomy
 episodic flushing, secretory diarrhea, wheezing,  indwelling catheters can acquire a biofilm ----------------------------------------------------------------
tricuspid regurgitation ----------------------------------------------------------------  nocturnal wheezing & cough: GERD
Nephritic syndrome Nephrotic syndrome ----------------------------------------------------------------
Carcinoid syndrome
HTN, oliguria, edema, hypoalbuminemia, Esophageal perforation
feature episodic flushing, telangiectasias, periorbital edema hyperlipidemia, VTE etiology Boerhaave’s, endoscopy, esophagitis
s cyanosis, secretory diarrhea, cramping, hematuria, RBC casts no hematuria, fatty casts (infectious/pill/caustic), ulcer
bronchospasm, tricuspid regurgitation, proteinuria < 3.5 g/day proteinuria > 3.5 g/day features chest/abdo pain, fever,
niacin deficiency (pellagra)
pediatric etiologies subcutaneous emphysema, crepitus
Dx  24 hr urine 5-HIAA
post-strep GN, HUS minimal change disease Dx CXR: wide mediastinum, pneumoTx,
CT/MRI abdomen/pelvis localizes tumor
adult etiologies pneumomediastinum
OctreoScan (detect mets), echo
IgA nephropathy, focal segmental GN, CT: esophageal wall thickening,
Rx octreotide only if symptomatic & prior to
crescentic GN membranous nephropathy, mediastinal air-fluid level
surgery for liver mets
(rapidly progressive GN) membranoproliferative, water soluble contrast esophagogram
lupus nephritis, amyloidosis, Rx ABX, parenteral nutrition, supportive care
 carcinoid tumors can secrete histamine, 5-HT,
Alport’s diabetic glomerularnepho surgical repair
VIP that are metabolized in the liver
----------------------------------------------------------------
o liver mets results in hormone release into Hep B is a risk factor for membranous nephropathy
  β-blockers can exacerbate severe reactive airway
systemic circulation o immunofluorescence: granular disease, but safe with mild/moderate COPD/asthma
 hallmark: plaque-like deposits of fibrous tissue
 membranoproliferative glomerulonephritis is o Rx: use cardioselective β-blockers
on endocardium  tricuspid regurgitation & right
a/w Hep C infection ----------------------------------------------------------------
heart failure
o can cause nephritic or nephrotic syndrome
----------------------------------------------------------------
 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,
somatization
----------------------------------------------------------------
 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
lithium aripiprazole risperidone
lamotrigine olanzapine ziprasadone
valproate quetiapine
 haloperidol can Rx acute mania, not maintenance
 valproate A/E: weight gain & acute pancreatitis
 lamotrigine: Rx of bipolar depressive episodes;
A/E: SJS
----------------------------------------------------------------
 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 β-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,  β-hCG,  AFP: features asymptomatic, firm abdominal mass,
non-seminomtous germ cell tumor does not cross midline
 young males, locally invasive Dx USS, then contrast-enhanced CT
 most are primary tumors Rx excision or nephrectomy,
 Dx: testicular USS (r/o primary tumor) chemotherapy +/- radiation
 DDx: seminoma ( β-hCG only), benign teratoma, prognosis 5 yr survival with Rx: 90%
bronchogenic cyst, Hodgkin’s MC site of mets: lungs
----------------------------------------------------------------
 choriocarcinoma:  β-hCG  DDx: neuroblastoma
 seminoma:  β-hCG only o arises from neuro crest cells (precursor of
 non-seminomtous tumor:  β-hCG,  AFP sympathetic chain & adrenal medulla)
 benign teratoma: no markers o can arise anywhere in sympathetic NS, but
 HCC:  AFP typically the adrenals
----------------------------------------------------------------  firm, nodular mass that crosses midline
#1 testicular sex cord stromal tumor: leydig cell tumor o metastatic sites: long bones, bone marrow,
 gynecomastia, precocious puberty skull, liver, lymph nodes, skin
  estrogen due to  aromatase expression with o  urine HVA, VMA catecholamines
secondary inhibition of LH & FSH o XR: calcifications & hemorrhages
 undetectable β-hCG & AFP ----------------------------------------------------------------
----------------------------------------------------------------  relative risk can be calculated from cohort studies
 subacute combined degeneration: neurologic by comparing incidence
complication of Vit B12 deficiency  odds ratio measures association in case-control
 progressive symmetric polyneuropathy (legs) studies; compares the odds of exposure
 degeneration of dorsal spinal column, gait ataxia o if outcome/disease is uncommon, odds ratio
 corticospinal disease (UMN signs) is a close approximation of relative risk
 peripheral neuropathy, memory loss, dementia (“rare disease assumption”)
 if low incidence  OR approximates RR
 Dx: elevated methylmalonic acid
----------------------------------------------------------------
----------------------------------------------------------------
Thoracic aortic aneurysm
 Toxoplasmosis Rx: empiric sulfadiazine &
 ascending aortic aneurysm: cystic medial necrosis
pyrimethamine
(aging) or connective tissue disorders (Marfan)
 prophylaxis: TMP-SMX
 descending aortic aneurysm: atherosclerosis
----------------------------------------------------------------
o HTN, hypercholesterolemia, smoking
 large sample size: decreases p-value & narrows CI
 CXR: wide mediastinum, increased aortic knob,
----------------------------------------------------------------
tracheal deviation
Wilms tumor (nephroblastoma)
 Dx: contrast-enhanced CT
epidemiolog arise from metanephros
y (precursor of renal parenchyma) ----------------------------------------------------------------
MC renal malignancy of childhood  De Quervain tenosynovitis: inflammation of
peak @ age 2 – 5 yrs; sporadic, abductor pollicis longus & extensor pollicis brevis
associated syndromes…  MC in new mothers holding infants
o WAGR (Wilms, Aniridia, GU  Finkelstein test (grasps thumb & ulnar deviate
anomalies, mental Retardation) the wrist)
o Beckwith-Wiedemann ----------------------------------------------------------------
o Denys-Drash  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,  Vit B12 supplements for exclusively breastfed etiology COPD, interstitial lung disease,
then remission for up to 1 yr infants born to strict vegetarian mothers pulmonary vascular disease, OSA
 redness, I/L tearing, rhinorrhea, I/L Horner’s ---------------------------------------------------------------- symptom dyspnea on exertion, fatigue, lethargy,
 acute Rx: 100% O2, subcutaneous sumatripan  acute confusion, fluctuating LOC, inability to s exertional syncope, exertional angina
 prophylaxis Rx: verapamil, lithium, ergotamine sustain attention: delirium exam peripheral edema, loud S2,
---------------------------------------------------------------- ---------------------------------------------------------------- JVD + prominent ‘a’ wave, RV heave,
Iron deficiency anemia in age < 2 yr  epinephrine (Rx asthma, croup) tricuspid regurgitation
risk factors prematurity**  α-agonist effect: reduces bronchial secretions & imaging EKG: partial/complete RBBB, RAD,
lead exposure mucosal edema RVH, RA enlargement
infants who consume…  β-agonist effect: smooth muscle relaxation echo: pulmonary HTN, dilated RV,
o low-iron formula ---------------------------------------------------------------- tricuspid regurgitation
 cow, soy, or goat milk  fibromuscular dysplasia: non-inflammatory, right heart catheterization (gold std Dx):
introduced before age 1 yr non-atherosclerotic condition; women age < 50 RV dysfunction, pulmonary HTN,
o exclusive breastfeeding after  abnormal development of arterial wall absence of left heart disease
age 6 months  primarily affect renal arteries  HTN ----------------------------------------------------------------
toddlers who consume…  involvement of carotid or vertebral arteries cause  constrictive pericarditis is an important cause
o 24 oz/day milk (> 3 glasses) TIA, amaurosis fugax, stroke, headache, dizziness of right heart failure
o < 3 servings/day iron-rich food  secondary hyperaldosteronism 2/2 decreased ----------------------------------------------------------------
 adrenal vein sampling: Dx adrenal hyperplasia
universal CBC in all age 9 – 12 months perfusion to kidneys (aldosterone: renin ratio < 20)
screening  Dx: abdominal CT angiography or duplex USS vs. adenoma (primary hyperaldosteronism)
 aldosterone > 15; aldosterone:renin ratio > 20
Rx empiric iron supplementation,  Rx: angioplasty with stent placement
recheck Hb in 4 wks, ----------------------------------------------------------------
o Rx: ACE-I if poor surgical candidate
 start cow milk @ age 1 yr  symptoms of CAD can be unmasked or worsened
 ACE-I is C/I in B/L renal artery stenosis
with thyrotoxicosis
----------------------------------------------------------------
 term infants have adequate iron stores for 6 months Cardiovascular effects of thyrotoxicosis
 painful non-itchy pustules & honey-crust lesions
 excess cow milk is low in iron & causes occult rhythm sinus tachycardia, PACs, PVCs
on mouth, nose, & neck: non-bullous impetigo
a-fib
intestinal blood loss  MCC: S. aureus, group A Strep (S. pyogenes)
hemodynamics systolic HTN,  pulse pressure,
 goat milk is folate deficient  risk factors: eczema, abrasion, insect bites  contractility & C.O.,  SVR,
----------------------------------------------------------------  no fever, no systemic symptoms  myocardial O2 demand
 all pregos without C/I: influenza vaccination  Rx: topical mupirocin heart failure high-output failure
o @ any trimester  complications: post-strep GN angina coronary vasospasm,
----------------------------------------------------------------  DDx: HSV (orolabial region), VZV, erysipelas anginal symptoms in pre-existing
 cough, erythema nodosum, anterior uveitis, arthritis: ---------------------------------------------------------------- coronary atherosclerosis
sarcoidosis  3+ proteinuria, hematuria, dense intramembranous
 most are asymptomatic, incidental CXR findings deposits staining for C3: membranoproliferative  systolic HTN in thyrotoxicosis is due to
 DDx: acute HIV, TB, histoplasmosis, Hodgkin’s glomerulonephritis hyperdynamic circulation from  contractility
----------------------------------------------------------------  caused by IgG against C3 convertase of  hypothyroidism causes HTN due to  SVR
 primary CNS lymphoma Rx: irradiation alternative complement pathway, leads to ----------------------------------------------------------------
 suspected if no response to ABX persistent complement activation  thiazide A/E: hyperglycemia,  LDL & TGs,
---------------------------------------------------------------- ---------------------------------------------------------------- hyponatremia, hypokalemia, hypercalcemia,
 all exclusively breastfed infants should start on  cor pulmonale: RV failure from pulmonary HTN uric acid retention (risk of acute gout)
VitD daily within 1st month of life due to COPD, PVD, or OSA ----------------------------------------------------------------
 solid foods @ < 6 months  risk of GI infections
Findings of cor pulmonale
 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
1 latent 0 – 6 cm dilated
active 6 – 10 cm dilated (complete)
2 10 cm dilated  delivery
3 delivery  placenta expulsion
----------------------------------------------------------------
 bloody/purulent nasal discharge, oral ulcers,
sinusitis, dyspnea, hemoptysis, renal insufficiency,
microscopic hematuria, RBC casts: Wegener’s
 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: Paget’s
----------------------------------------------------------------
 scleroderma renal crisis: acute onset renal failure
(w/o previous kidney disease) & malignant HTN
(headache, blurry vision, nausea)
 microangiopathic hemolytic anemia with
schistocytes & thrombocytopenia
 Rx: ACE-I
----------------------------------------------------------------  Rx for a single episode of major depression:
Antiphospholipid antibody syndrome continue for 6 months following patient response
clinical arterial/venous thrombosis (VTE, PE)  multiple episodes Rx: maintenance therapy
pregnancy… ----------------------------------------------------------------
o ≥ 3 consecutive unexplained fetal loss Asbestosis
before 10th wk  occupational (shipyard, construction, mining, pipes)
o ≥ 1 unexplained fetal loss after 10th  latency period: > 20 yrs
wk  progressive dyspnea (months), clubbing,
o ≥ 1 premature birth of normal neonate bibasilar end-expiratory crackles
before 34th wk due to preeclampsia, (no cough, sputum, or wheezing)
eclampsia or placental insufficiency  risk for lung cancer & malignant mesothelioma
labs  lupus anticoagulant  CXR: benign pleural plaques, interstitial fibrosis
 anti-cardiolipin antibody   DLCO, PFT: restrictive pattern
 anti-β2-glycoprotein 1 antibody  complication: cor pulmonale (RV heave)
Dx 1 clinical & 1 lab criterion ----------------------------------------------------------------
Enzyme deficiencies
 lupus anticoagulant: prolongs PTT in vitro 21-hydroxylase (CAH)
----------------------------------------------------------------  cortisol & aldosterone ambiguous genitalia (girls)
 young female, decreased visual acuity in one eye,  testosterone salt waste ( Na+,  K+)
pain on eye movement, change in color perception: 17-OH-progesterone hypotension
optic neuritis 11β- hydroxylase
 afferent pupil defect & central scotoma  cortisol & aldosterone ambiguous genitalia (girls)
 DDx: orbital cellulitis, anterior uveitis  testosterone fluid & Na+ retention,
----------------------------------------------------------------  11-deoxycorticosterone HTN
 anterior uveitis: unilateral eye is painful & red (weak mineralocorticoid)
 blurred vision, perilimbal injection 17α-hydroxylase
 keratic precipitates & corneal stromal edema  cortisol & testosterone all phenotypic female
----------------------------------------------------------------  mineralocorticoids fluid & Na+ retention,
 splenomegaly, pruritus with hot baths due to  corticosterone HTN
histamine release: polycythemia vera (weak glucocorticoid) hypogonadism @ puberty
 myeloproliferative disorders are common causes
of uric acid overproduction;  purine catabolism  classic CAH Dx:  17-OH-progesterone
o gouty arthritis is a common manifestation  partial deficiency of 21-hydroxylase present in
---------------------------------------------------------------- childhood: non-classic CAH
Vasovagal syncope o precocious puberty, hirsutism/virilism,
inciting age < 60: emotional stress, orthostatic stress medication-resistant acne, accelerated growth
events (prolonged standing, venipuncture) o Dx: cosyntropin stimulation test (gold std)
age > 60: micturition, cough, defecation  licorice is known to inhibit 11β- hydroxylase;
feature prodrome pallor, dizziness, nausea, sweating chronic consumption can result in
s short duration of syncope (minutes) pseudohyperaldosteronism
symptoms improve in supine position ----------------------------------------------------------------
Dx mainly clinical  post-operative pneumonia deteriorating into
upright tilt table test if uncertain septic shock with lactic acidosis 2/2 tissue hypoxia
Rx self-limited; avoid triggers  Rx: IV normal saline, ABX
---------------------------------------------------------------- ----------------------------------------------------------------
  external validity: how generalizable are results  monosymptomatic (isolated) enuresis: urinary   CPK is a/w acute tubular necrosis due to
to other populations? incontinence > 2x/wk in age ≥ 5 yrs myoglobinuria
 internal validity: are results in this specific  workup: U/A; imaging for +daytime symptoms  U/A: +blood, but no RBCs on microscopy
cohort valid? (design, method, analysis) or recurrent UTIs  Rx: hydration, mannitol, urine alkalinization
----------------------------------------------------------------  #1 Rx: behavior modification, enuresis alarm o avoid β-blockers: unopposed α activation
Vaccines for adults with HIV  #2 Rx: (short-term) desmopressin; alt Rx: TCAs worsens HTN & causes coronary vasospasm
HAV chronic liver disease (HBV, HCV) ---------------------------------------------------------------- ----------------------------------------------------------------
men/men sex, IVDA  acute onset severe liver injury with encephalopathy  aseptic meningitis MCC: Coxsackie or Echovirus
HBV all unimmunized to HBV & INR > 1.5, without cirrhosis or underlying liver ----------------------------------------------------------------
HPV all age 9 – 26 disease: fulminant hepatitis Management of acute STEMI
influenza all annually (IM inactivated)  acute liver failure: MCC are acute viral hepatitis, o supplemental O2 (if O2 Sat < 90%)
all age 11 – 18 acetaminophen toxicity, ischemic hepatopathy o chewed ASA
meningococcu large groups in close quarters, (“shock liver”), Wilson’s o clopidogrel
s asplenia or complement deficiency o concurrent alcohol use increases propensity o sublingual nitrate (not for RV infarct,
pneumococcus PCV13 once, then… of hepatotoxicity from acetaminophen hypotensive, severe aortic stenosis)
PPSV23, 8 wks later & every 5 yrs  RUQ pain, pruritus, jaundice, encephalopathy o metoprolol (not for hypotensive, bradycardia,
Td, Tdap Tdap once, then Td every 10 yrs  acute  AST & ALT (1000s),  PTT,  bilirubin decompensated CHF, heart block)
Tdap for each pregnancy  decreasing aminotransferases & worsening PT/INR, o high-dose statin
indicates progressive liver failure o LMWH or unfractionated heparin
 live vaccines (MMR, varicella, intranasal influenza,  PT is the most important prognostic indicator  persistent pain, HTN, or heart failure: IV nitro
zoster) are C/I for CD4 < 200 ---------------------------------------------------------------- (not for hypotension, RV infarct, severe AS)
 MMR should be given if CD4 > 200 & no evidence Intrapartum fetal HR monitoring  persistent severe pain: IV morphine
of immunity Early fetal head compression (anxiolytic & preload reduction)
o HIV+ are at increased risk for measles can be normal  unstable sinus bradycardia: IV atropine
---------------------------------------------------------------- Late uteroplacental insufficiency  acute pulmonary edema: IV furosemide
 vaccinate ≥ 14 days before or after splenectomy Variable cord compression, cord prolapse, (not for hypotensive or hypovolemic)
Vaccines for asplenic adults oligohydramnios  reperfusion: PCI within 90 min; thrombolysis if
pneumococcus sequential PCV13, then PPSV23; PCI not available within 120 min
PPSV23 again in 5 yrs & age 65  intermittent variable decelerations (< 50%) are ----------------------------------------------------------------
H. influenza 1x Hib vaccine well tolerated by the fetus; does not require a Guidelines for primary PCI of acute STEMI
meningococcu quadrivalent vaccine every 5 yrs change in management  within 12 hr of symptom onset, AND
s  recurrent variable decelerations (> 50%) are  within 90 min of first medical contact to device
influenza IM inactivated vaccine annually concerning for fetal academia; prompt intervention time at PCI-capable facility, OR
others HAV, HBC, Tdap 1x, Td every 10 yr o #1 Rx: O2 & change maternal position o within 120 min at non-PCI-capable facility
 S. pneumo is MCC of sepsis post-splenectomy o discontinue uterotonic drugs ----------------------------------------------------------------
---------------------------------------------------------------- o #2 Rx: artificial ROM & amnioinfusion  fibrinolytics is a/w  recurrent MI, ICH, mortality
 late-term pregnancies (41 – 42 wks)  risk for o #3 Rx: c-section compared to PCI
uteroplacental insufficiency ---------------------------------------------------------------- ----------------------------------------------------------------
 antenatal fetal surveillance begin @ 41 wks: BPP  terbutaline: β2-agonist tocolytic  headaches worse at night, N/V,  LOC, cognitive
 diffuse placental calcifications on USS are  Rx tachysystole (> 5 contractions in 10 min) dysFx, vision changes, worse with maneuvers that
common in late-term; indicates a mature placenta ----------------------------------------------------------------  ICP (leaning forward, Valsalva, coughing):
---------------------------------------------------------------- Rhabdomyolysis intracranial HTN
 D-dimer: product of cross-linked fibrin degradation  MCC: cocaine overdose, tonic-clonic seizures  Cushing reflex: HTN, bradycardia, resp depressn;
----------------------------------------------------------------  rhabdomyolysis releases K+, CPK, & myoglobin suggests brainstem compression
 DDx: sinusitis (purulent nasal discharge), acute  rapidly progressive GN o nephrosclerosis = hypertrophy & intimal
angle closure glaucoma, temporal arteritis  thin BM disease medial fibrosis of renal arterioles
----------------------------------------------------------------  lupus nephritis (low complement) o glomerulosclerosis = progressive loss of
 oliguria, azotemia & BUN/Cr > 20:1 in post-op:  post-streptococcal GN (low complement) glomerular capillary surface area with
acute prerenal failure from hypovolemia  membranoproliferative GN (low complement) glomerular & peritubular fibrosis
 #1: rule out urinary catheter obstruction  mixed cryoglobulinemia (low complement) ----------------------------------------------------------------
 Dx: IV fluid challenge ----------------------------------------------------------------  diabetic nephropathy: #1 cause of ESRD
----------------------------------------------------------------  atypical presentations of ACS: N/V, dyspnea,  1st year:  GFR, glomerular hyerperfusion, renal
 low-dose dopamine infusion can dilate renal epigastric pain; MC in women, elderly, diabetics hypertrophy
arterioles   GFR & urine output (temporary)  initial evaluation: EKG  extracellular matrix, BM thickening, mesangial
----------------------------------------------------------------  DDx: acute cholecystitis, pancreatitis, PUD expansion, & fibrosis
Chronic Hep C strongly a/w… ----------------------------------------------------------------  5 – 10 yrs: microalbuminuria, overt nephropathy
 porphyria cutanea tarda (photosensitivity,  hilar mass, mediastinal adenopathy, cough, ----------------------------------------------------------------
vesicles/erosions on dorsum hand) dyspnea, weight loss: small cell lung cancer  hypoparathyroidism (PTH deficiency): hypoCa++,
 essential mixed cryoglobulinemia (circulating hyperphosphatemia, normal renal function
immune complexes deposit in small/med vessels) Paraneoplastic syndromes a/w lung cancer  hypoCa++: perioral tingling/numbness, tetany,
o IgM complexes with anti-hepatitis C IgG endocrine SIADH** cramps, carpopedal spasm, seizures
o vasculitis of skin, kidney, nerves, joints PTHrP (hypercalcemia)  causes: post-surgical, autoimmune, DiGeorge,
 membranoproliferative GN ACTH (Cushing’s)** defective Ca++-sensing receptors, irradiation
---------------------------------------------------------------- hematologic hypercoagulability (Trousseau’s) ----------------------------------------------------------------
Chronic Hep C features neurologic Lambert-Eaton**  phenytoin, carbamazepine, rifampin can cause
 fatigue, arthralgia, Raynaud’s ataxia, autonomic/sensory neuropathy Vit D deficiency by inducing p450
 low complement MSK hypertrophic osteoarthropathy  resulting in secondary hyperparathyroidism:
 intermittent elevations of AST/ALT,  RF (a/w adenocarcinoma) hypoCa++, hypophosphatemia
 Dx: viral hepatitis serology dermatomyositis & polymyositis ----------------------------------------------------------------
 confirm Dx: kidney/skin Bx **a/w small cell lung cancer  CKD impairs 1-α-hydroxylase, which converts
 Rx: plasmapheresis (cryoglobulins), 25-OH Vit D to 1,25-OH Vit D  Vit D deficiency
glucocorticoids & cyclophosphamide  Trousseau's: spontaneous recurrent or migratory  resulting in secondary hyperparathyroidism:
 complications: cirrhosis & HCC venous thromboses, arterial emboli caused by hypoCa++, hyperphosphatemia
---------------------------------------------------------------- non-bacterial thrombotic endocarditis ----------------------------------------------------------------
MCC of nephrotic syndrome ----------------------------------------------------------------  inadequate Ca++ intake  20 hyperparathyroidism
focal segmental African-Am & Hispanics,  shoulder pain & weakness with arm lifting:   bone resorption   Ca++
glomerulosclerosis obesity, HIV, heroin use rotator cuff pathology (tendonitis or tear)   25-OH Vit D to 1,25-OH Vit D, which
membranous adenocarcinoma (breast,  limited mid-arc abduction & external rotation stimulates gut Ca++ absorption
nephropathy lung), NSAIDs, Hep B, SLE  Dx: lidocaine injection  renal phosphate loss  hypophosphatemia
membranoproliferativ Hep B & C o improvement = tendonitis/impingement ----------------------------------------------------------------
e glomerulonephritis o no improvement = tear  weight loss, anorexia, constipation, easy fatigue,
minimal change adults: NSAIDs, lymphoma  Dx rotator cuff tear: drop arm test, shoulder MRI dry mucous membranes, confusion, polyuria
disease (Hodgkin’s) o MCC: fall on outstretched hands  hypercalcemia induces urinary Na+ wasting,
IgA nephropathy upper URI ---------------------------------------------------------------- resulting in volume depletion, further impairing
 nephrosclerosis 2/2 HTN renal clearance of Ca++
 secondary: diabetes & primary amyloidosis (MM)  atherosclerotic lesions of afferent & efferent
---------------------------------------------------------------- arterioles & glomerular capillary tufts Management of hypercalcemia
MCC of nephritic syndrome  nephrosclerosis  glomerulosclerosis severe short-term: aggressive hydration;
 IgA nephropathy (Ca++ > 14) normal saline & calcitonin
or symptomatic long-term:  shifting the cutoff point to the left: &  FP will ----------------------------------------------------------------
bisphosphonate (zoledronate) decrease PPV (PPV = TP/ (TP + FP))  excess androgens in PCOS suppress ovulation by
moderate no immediate Rx unless ---------------------------------------------------------------- suppressing GnRH & FSH by feedback inhibition
(12 – 14) symptomatic (same as above)  selective survival bias occurs in case-control ----------------------------------------------------------------
mild (< 12) or no immediate Rx studies; cases are selected from the entire disease  inhibin B: use to determine ovulatory reserve;
asymptomatic avoid thiazides, lithium, volume population instead of newly diagnosed (cancer)  with declining reserves
depletion & prolonged bed rest ---------------------------------------------------------------- ----------------------------------------------------------------
 saline hydration restores intravascular volume &  strongest predictor of AAA expansion & rupture:  MCC of acute pancreatitis: alcohol, gallstones
promotes urinary Ca++ excretion active smoking  others: hypertriglyceridemia, hypercalcemia,
 loop diuretics only if volume overloaded  other risks: large diameter & rate of expansion recent ERCP, trauma, viral infection, medications
o avoid diuretics if volume-depleted o HTN has a weak association  eruptive xanthomas  Dx: fasting lipid profile
----------------------------------------------------------------  indications for AAA repair… o triglycerides > 1000 causes pancreatitis
 hyperthyroidism-related tachysystolic a-fib o > 5.5 cm ----------------------------------------------------------------
 Rx: propranolol o expansion rate > 1 cm/yr  club foot Rx: stretching, manipulation, serial casts
---------------------------------------------------------------- o symptomatic (regardless of size)  surgery if conservative management fails
 atypical community-acquired pneumonia with ---------------------------------------------------------------- ----------------------------------------------------------------
CNS & GI features: Legionnaires’  MC complication of AAA repair: bowel ischemia  acute urticaria (< 6 wks)
 fever with relative bradycardia  due to inadequate colonic collateral perfusion to  well-circumscribed, raised erythematous plaques
 intracellular G-negative rod left colon & sigmoid 2/2 loss of IMA perfusion with central pallor; intense pruritus
 CXR: unilateral patchy infiltrates  presents with abdominal pain & bloody diarrhea  worsen over minutes – hrs; resolve within 24 hr
 Dx: urine antigen testing & culture  Rx: check sigmoid perfusion after graft placement  mast cell activation in superficial dermis, which
 Rx: fluoroquinolone or macrolide ----------------------------------------------------------------  histamine release  pruritus & swelling
 morphine contributes to post-op ileus by  angioedema can occur in deep dermal & SC tissues
Suspicion of Legionella pneumonia decreasing GI motility  MCC: IgE mediated, direct mast cell activation,
exposure recent travel within previous 2 wks o post-op ileus: hypoactive/absent bowel sounds NSAIDs, infection, idiopathic
(cruise ships, hotel)  mechanical obstruction: hyperactive BS ----------------------------------------------------------------
nosocomial (hospital, nursing home) ----------------------------------------------------------------  atopic dermatitis (eczema): pruritic erythematous,
features fever > 39 (102.20 F) with bradycardia,  child with meningeal signs & erythematous scaly patches on extensor surfaces
confusion (CNS), watery diarrhea (GI), petechial/purpuric rash: N. meningitides  epidermal dysfunction of stratum corneum synthesis
unilateral lung diffuse crackles (meningococcal meningitis)  MC in infancy; cheeks, scalp, extensor limbs
labs hyponatremia, mild hepatitis,  rash appears within 24 hr of infection  MC site (adults): flexural areas, face, wrist, forearm
hematuria, proteinuria ---------------------------------------------------------------- o lichenified plaques on flexural creases
CXR: unilateral interstitial infiltrates  HSV causes temporal lobe encephalitis in  risk factors: low humidity, stress, overheating,
Gram stain: neutrophils, no organisms neonates & infants; presents with seizures excessive bathing, irritants
Dx urine antigen testing & culture ----------------------------------------------------------------  complication: eczema herpeticum, cellulitis/abscess
Rx: fluoroquinolones  causes of anatomic defects in the uterus or ----------------------------------------------------------------
 Legionella stains poorly; intracellular fallopian tubes: Hx of PID, in utero DES,  eczema herpeticum: HSV superinfection in areas
 DDx: influenza, mycoplasma, PCP, TB endometriosis, congenital malformations of severe atopic dermatitis (eczema)
----------------------------------------------------------------  Dx: hysterosalpingogram o numerous umbilicated vesicles over
 amoxicillin/clavulanate: Rx sinusitis, otitis media ---------------------------------------------------------------- erythematous skin
 ceftriaxone: Rx pneumococcus, H. influenza  elevated serum prolactin suppresses ovulation by o a/w fever & adenopathy
 clindamycin: Rx aspiration pneumonia inhibiting GnRH release  amenorrhea o Rx: acyclovir
 vancomycin: Rx nosocomial pneumonia (MRSA) ----------------------------------------------------------------  erysipelas: red, indurated, tense, shiny plaque
----------------------------------------------------------------  mid-luteal serum progesterone tests for ovulation with raised, sharply demarcated margin
 PPV & NPV depend of prevalence of a disease  ovulation  corpus luteum produces progesterone
 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 Fanconi’s
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
thermoregulation
 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
nephropathy
----------------------------------------------------------------
 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: β-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)
epidemiolog women, a/w psychiatric disorders
y (anxiety) & fibromyalgia
features pain with filling, relief with voiding
chronic pelvic pain
 frequency, urgency, dyspareunia
Dx bladder pain, no other cause ≥ 6 wks
normal U/A
Rx not curative; focus on quality of life,
behavior modification, avoid triggers,
amitriptyline
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
arteriogram
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: bull’s 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
 surgery
 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 Down’s
 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
 Rx: ABX
----------------------------------------------------------------
 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 Well’s (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
infection
----------------------------------------------------------------
 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
Dx stool toxin via PCR
Rx 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
 iatrogenic
----------------------------------------------------------------
 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
Potassium”
----------------------------------------------------------------
 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
 #1 Rx: CBT & SSRI/SNRI
 #2 Rx: benzos, buspirone
o benzos: adjunct for acute anxiety
o buspirone: monotherapy or with SSRIs
----------------------------------------------------------------
 systemic vasculitis, upper & lower airway
granulomatous inflammation, glomerulonephritis:
Wegener’s (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 mild Rx: topical retinoid + benzoyl
(urinary incontinence), & palpable “step-offs” in peroxide
lumbosacral area: spondylolisthesis moderate Rx: add topical ABX
 forward slippage of vertebrae (L5 over S1) (erythromycin, clindamycin)
 DDx: lumbosacral strain, herniated disk, severe Rx: add oral ABX
ankylosing spondylitis, epidural abscess, tumor nodular large (> 5 cm) nodules, may form
---------------------------------------------------------------- (cystic) acne sinus tracts & scarring
 daily alcohol intake (≥ 3 men, ≥ 2 women) can severe Rx: add oral ABX
raise BP, causing refractory HTN unresponsive: oral Isotretinoin
---------------------------------------------------------------- (diminishes sebum excretion)
 exogenous testosterone use: gynecomastia,
erythrocytosis, hepatotoxicity,  LDL,  HDL  benzoyl peroxide: Rx inflammatory features
 DDx: autologous blood transfusion & EPO do  isotretinoin A/E: teratogenic, hyper-TG-emia
not cause gynecomastia ----------------------------------------------------------------
----------------------------------------------------------------  diabetic retinopathy: microaneurysms,
 diarrhea in HIV+ patients requires stool culture, exudates, hemorrhages, macular edema
exam for ova & parasites, & test for C. difficile  non-proliferative: cotton-wool spots
for Dx prior to ABX  proliferative: neovascularization
----------------------------------------------------------------  Rx: laser photocoagulation
 follicular conjunctivitis, corneal neovascularization ----------------------------------------------------------------
with concurrent nasopharynx infection & discharge  sudden, unilateral visual impairment noted upon
 trachoma: major cause of blindness worldwide waking, disc swelling, venous dilation &
 Chlamydia trachomatis serotypes A – C tortuosity, retinal hemorrhages, cotton-wool spots:
 Dx: Giemsa stain of conjunctival scrapings central retinal vein occlusion
 Rx: topical tetracycline or oral azithromycin ----------------------------------------------------------------
 complication: corneal scarring  smoking increases risk of macular degeneration
----------------------------------------------------------------  primary risk factor: age
 eye pain, photophobia, decreased vision,  grid test: straight lines appear wavy
dendritic ulcer: herpes simplex keratitis  atrophic form: multiple sores in macular region
 abrupt fever, proptosis, swollen eyelids,  exudative form: new blood vessels may leak,
restricted EOM movements: orbital cellulitis bleed, & scar the retina
---------------------------------------------------------------- ----------------------------------------------------------------
 female athletes have  GnRH & LH, resulting in  myasthenia gravis: normal reflexes, sensory, &
estrogen deficiency coordination
o secondary amenorrhea, infertility,  symptoms seen on exertion, resolves with rest
osteopenia, vaginal & breast atrophy  nasal speech, difficulty chewing or swallowing
---------------------------------------------------------------- ----------------------------------------------------------------
Treatment of acne vulgaris  vegans are at risk for low Vit D & bone loss
comedonal closed/open comedones on face; ----------------------------------------------------------------
acne minimal inflammation Vaginal cancer
Rx: topical retinoid; or add Squamous cell Clear cell
salicylic, azelaic, or glycolic acid adenocarcinoma
inflammatory inflamed papules (< 5 mm), onset age > 60 age < 20
acne pustules, erythema risk HPV 16 or 18, in utero exposure
factors cervical dysplasia Hx, to DES
smoking
locatio upper 1/3 wall of upper 1/3 wall of
n posterior vagina anterior vaginal
features malodorous vaginal discharge,
postmenopausal or post-coital bleeding,
irregular vaginal mass, plaque, or ulcer
Dx lesion biopsy
 risk factors for SCC are similar to cervical cancer:
smoking & HPV 16 or 18
----------------------------------------------------------------
 neutrophilic crypttis is seen in UC & Crohn’s
 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 Alzheimer’s
----------------------------------------------------------------
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 Hodgkin’s 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
punctum
 Rx: resolves spontaneously, but can recur
 Rx: excision for cosmetic reasons
----------------------------------------------------------------
 benign, painless subcutaneous mass with
overlying epidermis; soft/rubbery & irregular:
lipoma
----------------------------------------------------------------
 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
----------------------------------------------------------------
 café-au-lait spots, microcephaly, microphthalmia,
short stature, horseshoe kidney, absent thumbs,
progressive pancytopenia & macrocytosis in a
child: Fanconi’s 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:
Sturge-Weber
 hemianopia, hemiparesis, hemisensory loss,
ipsilateral glaucoma
 skull XR: tramline intracranial calcifications
 DDx: tuberous sclerosis (adenoma sebaceum)
----------------------------------------------------------------
Indications for urgent dialysis (AEIOU)
Acidosis metabolic acidosis (pH < 7.1)
Electrolytes symptomatic hyper-K+,
severe hyper-K+ (> 6.5)
Ingestion methanol, ethylene glycol,
salicylate, lithium,, carbamazepine
Overload volume overload refractory to diuretics
Uremia 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
cardiotoxicity
 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  hyperplasia of squamous epithelium
 Rx: epinephrine, systemic corticosteroids,  reactive precancerous lesion for SCC
antihistamines  resolves with cessation of tobacco
----------------------------------------------------------------  development of induration or ulceration  Bx
 asthma causes  airflow during effort-independent ----------------------------------------------------------------
phase of exhalation, causing the flow-volume loop  white plaques on oral mucosa, oropharynx, or
to have a “scooped out” exhalation pattern, smaller, tongue with underlying erythema; can scrape off:
& shifted to the left (obstructive pattern) oral candidiasis
 flow-volume look remains normal in panic attacks  localized, shallow, painful oral ulcers on gray base:
 pneumoTx & pulmonary edema causes reduced aphthous stomatitis
lung compliance; increased expiratory flow rates,  multiple vesicular lesions with erythematous border
smaller, shifted to the right (restrictive pattern) within oral cavity & perioral area: gingivostomatitis
(HSV-1)
 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
---------------------------------------------------------------- ----------------------------------------------------------------
 microangiopathic hemolytic anemia (DIC, HUS,  weakness, fatigue, muscle cramps: hypokalemia
TTP) & artificial mechanical valves  schistocytes:  EKG: broad, flat T-waves, U-waves, ST depression,
 serum haptoglobin,  LDH,  indirect bilirubin, &
& PVCs
 urinary urobilinogen  MCC: HCTZ, diarrhea, anorexia, hyperaldosteronism
urine urine
----------------------------------------------------------------
bilirubin urobilinogen
 most accurate estimate of gestational age:
normal none low
crown-rump length via 1st trimester USS
hemolytic negative increased
 pregnancy dating by LMP assumes a normal
disease
28-day cycle with fertilization on day 14
hepatic + or - increased
----------------------------------------------------------------
disease
 karyotyping of fetal tissue is not indicated after
biliary positive low
one spontaneous abortion, but after recurrent
obstruction
pregnancy loss, or loss in 2nd trimester
----------------------------------------------------------------
----------------------------------------------------------------
 white granular patch/plaque over the buccal mucosa
 abdominal pain after traumatic injury with
that cannot be scraped off, Hx of alcohol & tobacco:
vertebral fracture & retroperitoneal hemorrhage:
oral leukoplakia
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
aphthous recurrent ulcers on anterior oral
stomatitis mucosa
(“canker sore”) no fever or systemic symptoms
herpangina vesicles & ulcers on posterior
oropharynx & hard palate,
MCC: fever, pharyngitis
Coxackie A Rx: supportive; self-limited in 1 wk
gingivostomatitis vesicles & ulcers on anterior oral
mucosa & perioral area, fever,
MCC: HSV-1 pharyngitis, erythematous gingiva
Rx: oral acyclovir
Group A Strep tonsillar exudates, fever,
pharyngitis 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
primary all adolescents age 11 – 12;
vaccine optional at age 19 – 21 for high risk
& 1st year college students
booster age 16 – 21 (if primary vaccine given
vaccine before age 16)
age > 21 considered if @ high risk
----------------------------------------------------------------
Live-attenuated vaccines
 oral polio  intranasal
 MMR influenza
 rotavirus  yellow fever
 varicella
 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
hemorrhage
 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:
Lesch-Nyhan
 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
“SAD PERSONS”
Sex, Age, Depression,
Previous attempt, EtOH use, Rational thought
loss (psychosis), Social support (lack of),
Organized plan, No spouse or significant other,
Sickness/injury
----------------------------------------------------------------
 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 mother’s 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
----------------------------------------------------------------  Rx: prenatal counseling for subsequent pregnancy
Acute HIV infection ----------------------------------------------------------------
 presents 2 – 4 wks after exposure Pertussis in infants & children
 mononucleosis-like syndrome (fever, night sweats, Catarrhal phase mild cough, rhinitis
diarrhea, weight loss, lymphadenopathy, arthralgia) (1 – 2 wks)
 generalized macular rash Paroxysmal phase coughing paroxysms with
 painful mucocutaneous ulcerations (2 – 6 wks) inspiratory “whoop”,
 GI: diarrhea, abdominal distension, flatulence posttussive emesis,
 Dx: low threshold for HIV testing;  viral load; apnea & cyanosis (infants)
negative HIV Ab, normal CD4 Convalescent symptom resolution
 Rx: combination anti-retrovirals phase
 DDx: IBD, connective tissue disease, lymphoma, (wks – months)
Whipple’s, hyperthyroidism, Celiac’s
----------------------------------------------------------------  total duration if untreated: 3 months
Rx chronic stable angina  lymphocyte predominant leukocytosis
antianginals β-blocker (#1; improves survival)  Dx: Pertussis PCR or culture of nasopharyngeal
CCB (peripheral & coronary vasodilation) secretions
nitrates (long-acting)  Rx on clinical suspicion: empiric macrolides
prevention ASA, statin (azithromycin, erythromycin, clarithromycin)
smoking cessation, exercise, weight loss, o respiratory isolation at home for 1st 5 days
BP & diabetes control  prevention: acellular pertussis vaccine
o 5 doses of DTaP between age 2 months – 6 yrs
 avoid β-blockers if hypotensive or bradycardic o Tdap booster once at age 11 – 18 & pregos
---------------------------------------------------------------- o does not provide lifelong immunity
 reddish nodule that later ulcerates @ site of injury,  complications: pneumonia, weight loss,
spreads along lymphatics forming subcutaneous pneumoTx, subconjunctival hemorrhages,
nodules & ulcers: sporotrichosis respiratory failure, death (infants)
----------------------------------------------------------------
 leprosy: chronic granulomatous disease that Pertussis Rx & post-exposure prophylaxis
affects peripheral nerves & skin; MC in Asians age < 1 azithromycin x5 days
 MCC: Mycobacterium leprae month
 early: insensate, hypopigmented plaque age ≥ 1 azithromycin x5 days, or
 peripheral nerve damage & muscle atrophy with month clarithromycin x7 days, or
crippling deformities erythromycin x14 days
 face, ears, wrists, buttocks, knees, eyebrows  ABX prophylaxis for all close contacts
 Dx: skin biopsy (acid-fast bacilli) regardless of vaccination status
---------------------------------------------------------------- ----------------------------------------------------------------
 child with unsteady wide-based gait & weakness Indications for renal & bladder USS
of lower limbs, decreased vibratory & position  age < 2 yrs with a first febrile UTI to evaluate
sense, absent B/L ankle jerks, high plantar arches: for anatomic abnormalities
Friedreich Ataxia  any age child with recurrent febrile UTI
 AR inheritance, excess trinucleotide repeats  UTI in a child of any age with family Hx of
 a/w necrosis & degeneration of cardiac muscle renal or urologic disease, HTN, or poor growth
fibers  myocarditis, fibrosis, cardiomyopathy  child does not respond to appropriate ABX
 MCC of death: arrhythmia & CHF
  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)
HIV 15 – 65 HIV antibody 1x
Hyperlipidemi men 35+ lipid panel every 5 yrs
a  DDx of T-wave inversion: MI, old pericarditis,
HTN 18+ BP every 2 yrs
Osteoporosis 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
----------------------------------------------------------------
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 β-blocker, CCB, or nitrates
o not for initial therapy
----------------------------------------------------------------
 Klumpke palsy: excessive traction of C8 & T1
during delivery; intact Moro & biceps reflexes
 “Claw hand”, Horner’s (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: Celiac’s)
 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 G-
o 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,
fluoroquinolones
----------------------------------------------------------------
 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  octreotide: Rx active variceal bleeding by
is MC type of diabetic neuropathy causing splanchnic vasoconstriction & reduced
 “stocking glove” sensory loss portal blood flow by inhibiting glucagon release
 neuropathic pain is present at rest, worse at night ----------------------------------------------------------------
 Rx: TCAs (amitriptyline), gabapentin, NSAIDs  molar pregnancy: abnormal trophoblastic
o TCAs may worsen urinary symptoms & proliferation following abnormal fertilization
orthostatic hypotension; Rx: gabapentin o Rx: D&C
o NSAIDs: C/I in renal dysfunction o F/U: serial β-hCG post-evacuation
---------------------------------------------------------------- o complication: gestational trophoblastic neoplasia
 pronator drift  assess UMN damage  complete mole: 2 sperm + 1 empty ovum
o seen in some stroke patients o no fetal tissue (“completely empty”)
 Romberg’s assess proprioception o symptomatic: theca lutein ovarian cysts,
----------------------------------------------------------------  β-hCG, hyperemesis graviarum
 any patient with an acute, severe illness can have  partial mole: 2 sperm + 1 haploid ovum (triploid)
abnormal thyroid function tests: euthyroid sick o abnormal placenta + fetal tissue
syndrome (aka low T3 syndrome) ----------------------------------------------------------------
  total & free T3, normal T4 & TSH Manifestations of hyperthyroidism
 thyroid function tests are not recommended in symptom o anxiety, insomnia
acutely ill patients; unreliable s o palpitations
 DDx: subclinical hypothyroidism ( TSH, o heat intolerance
normal T4) o  perspiration
---------------------------------------------------------------- o weight loss
Non-allergic rhinitis Allergic rhinitis o goiter
 nasal congestion,  watery rhinorrhea, findings o HTN, tachycardia
rhinorrhea, postnasal sneezing, eye itching o tremors of fingers/hands
drainage (dry cough)  early age of onset o hyprreflexia
 late age onset (> 20)  allergen or seasonal o proximal muscle weakness
 no allergic triggers  pale/blue nasal o lid lag
 perennial symptoms mucosa o a-fib
 erythematous nasal  a/w asthma, eczema  chronic thyrotoxic myopathy: inability to comb
mucosa hair, difficulty holding arms up, muscle atrophy
mild Rx: intranasal Rx: intranasal ----------------------------------------------------------------
antihistamine spray or glucocorticoids or Suspected hyperthyroidism…
intranasal glucocorticoids antihistamines  initial Dx test: plasma TSH
mod/severe Rx: combo  if plasma TSH is low  measure free T4
---------------------------------------------------------------- o elevated free T4  clinical hyperthyroidism
 all cirrhotic patients require diagnostic endoscopy
 24-hr RIU scan to differentiate Graves’ from
to asses risk for variceal hemorrhage
toxic adenoma
 small, non-bleeding varices Rx: propranolol
 next test: EKG to r/o arrhythmia
as primary prophylaxis, results in unopposed
 initial Rx: propranolol for symptomatic relief
alpha-mediated vasoconstriction
 endoscopic band ligation is an alternative Rx  definitive Rx: radioactive iodine
 complications if untreated: rapid bone loss 2/2
 endoscopic sclerotherapy is for active bleeding
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
risk HG in a prior pregnancy,
factors multifetal gestation,
gestational trophoblastic disease (molar)
features severe, persistent N/V in 1st trimester,
enlarged uterus than expected,
abnormally elevated β-hCG,
> 5% loss of pre-pregnancy weight,
ketonuria, metabolic alkalosis
workup pelvic USS, thyroid function,
electrolytes, U/A, BUN, Cr,
Rx 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
 DDx: TB, CMV
----------------------------------------------------------------
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 β-blocker or CCB
(diltiazem)
 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:
PSVT
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
----------------------------------------------------------------
Niemann-Pick Tay-Sachs
Sphingomyelinase def. β-hexosaminidase A def.
AR inheritance; MC in Ashkenazi Jews
 onset: age 2 – 6 months
 loss of motor  loss of motor
milestones milestones
 hypotonia  hypotonia
 feeding difficulties  feeding difficulties
 “cherry red” macula  “cherry red” macula
 hepatosplenomegal  hyperreflexia
y  microcytic anemia, basophilic stippling
 hypo-/areflexia
----------------------------------------------------------------
 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
regurgitation
 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
o 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
----------------------------------------------------------------
 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
amiodarone
 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,
painful)
 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, β-lactams, TMP-SMX),
Type III hypersensitivity reaction
features fever, urticarial rash, polyarthralgia
(1 – 2 wks after first exposure);
headache, edema, lymphadenopathy,
splenomegaly (less common)
labs hypocomplementemia,  ESR & CRP
Rx 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,
splenomegaly
 MCC: Staph, Strep, Salmonella
 MC risk factors: infective endocarditis with
hematogenous spread
 Rx: ABX + splenectomy
 percutaneous drainage for poor surgical candidate
 DDx: malaria, Hodgkin’s, 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
----------------------------------------------------------------
VIPoma
feature watery diarrhea, weight loss, lethargy,
s facial flushing, N/V, muscle weakness
labs hypokalemia ( intestinal K+ secretion),
acholrhydria (  gastric acid secretion),
hypercalcemia ( bone resorption),
hyperglycemia ( glycogenolysis),
secretory diarrhea:  Na+,  osmolal gap
Dx watery diarrhea, VIP > 75 pg/mL
abdominal CT (usually pancreatic tail)
Rx 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
mastocystosis
o pruritus, facial flushing, urticaria
----------------------------------------------------------------
 striatal neuro-degeneration: Huntington’s
 spongiform encephalopathy: CJD
 loss of nigrostriatal DA neurons: Parkinson’s
 selective loss of cholinergic neurons: Alzheimer’s
 neurodegeneration of frontal/temporal lobes: Pick’s
----------------------------------------------------------------
 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:
PND
 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
Dx  TSH,  free T4, via newborn screening
Rx levothyroxine
----------------------------------------------------------------
 maternal Graves’: transplacental passage of
TSH receptor antibodies  congenital Grave’s:
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
special Hep A & B (high risk)
circumstances Pneumococcus (2nd & 3rd trimester
if high risk),
H. influenza (if asplenic),
Meningococcus (if high risk),
Anti-D Ig (if Rh-negative mother)
not HPV, MMR, Varicella, smallpox,
recommended 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,
 ESR: MM
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
----------------------------------------------------------------
Impetigo
Non-bullous Bullous-type
MCC S. aureus or S. aureus
Group A Strep
feature localized painful, rapidly enlarging
s non-itchy pustules flaccid bullae with
& honey-crusted yellow fluid,
lesions; “collarette” of scale @
lymphadenopathy periphery of lesion
Rx topical mupirocin oral ABX (cephalexin,
dicloxacillin, clinda)
 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
primary painless chancre
Dx: spirochetes on darkfield microscopy
Rx: IM benzathine PCN G 1x
PCN-allergic: oral doxycycline x14 days
secondar diffuse rash (+ palms/soles), hepatitis,
y condyloma lata, lymphadenopathy
Rx: IM PCN G 1x
PCN-allergic: oral doxycycline x 14 days
latent asymptomatic
Rx: IM PCN G 3x doses
PCN-allergic: doxycycline x 28 days
tertiary Tabes dorsalis, Argyll-Robertson pupil,
dementia, aortic insufficiency, gummas
Rx: IV PCN G x14 days
PCN-allergic: ceftriaxone x 14 days
pregos intrapartum transmission
Rx: PCN G
PCN-allergic: desensitize to PCN
 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)
risk cardiac catheterization or angiography;
factors with comorbid hypercholesterolemia,
DM Type II, HTN
feature livedo reticularis, blue toe syndrome,
s acute kidney injury, amaurosis fugax,
Hollenhorst plaques, intestinal ischemia
Dx  Cr, eosinophilia, hypocomplementemia,
eosinophiluria
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 β-blockers,
repeat EGD annually**
o ascites: dietary Na+ restriction, diuretics,
paracentesis, abstain from alcohol
 o 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
syndrome
 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 Cushing’s
 #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
dietar fluids (produce > 2 L urine/day)
y reduce Na+, reduce protein, reduce oxalate,
normal Ca++ intake, increase citrate
Rx 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: Wilson’s (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 Fanconi’s, 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:
hemochromatosis
----------------------------------------------------------------
 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
Stress loss of urethral support, intraabdominal
pressure exceeds urethral sphincter
leaking with cough, sneeze, laugh, lifting
Urge 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 Crohn’s, 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 (Gilbert’s)
 predominant conjugated hyperbilirubinemia
o hepatocellular injury
o  bilirubin excretion in bile canaliculi
(Dubin-Johnson)
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
features sudden onset unilateral pelvic pain,
tender adnexal mass, N/V,
 vaginal bleeding is uncommon
Dx β-hCG to exclude ectopic pregnancy,
USS with color Doppler
Rx 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
(surgery)
 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:
osteoporosis
 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:
rickets
----------------------------------------------------------------
Rickets
risk  skin pigmentation,
factors exclusive breastfeeding,
inadequate sun exposure,
maternal Vit D deficiency
feature craniotabes (“ping-pong ball” skull),
s delayed fontanelle closure, frontal bossing,
costochondral hypertrophy (rachitic rosary)
genu varum
XR metaphyseal cupping & fraying,
epiphyseal widening, osteopenia
labs  Ca++ & phosphorus,  ALP & PTH
Rx Vit D fortified baby food or formula; or
supplementation
----------------------------------------------------------------
 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: Paget’s, 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
Asperger’s 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 β- 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 α-1 agonist vasoconstriction results in
ischemia & necrosis of distal fingers & toes
----------------------------------------------------------------
 Raynaud’s 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
maneuver
----------------------------------------------------------------
 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, Crohn’s, 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)
euvolemic SIADH (drugs, malignancy),
hyponatremia psychogenic polydipsia,
secondary adrenal insufficiency,
hypothyroidism
hypervolemi CHF, cirrhosis,
c CKD, nephrotic syndrome
hyponatremia
 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 (nursemaid’s 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: Fanconi’s
 short stature, microcephaly, abnormal thumbs,
hypogonadism, café-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
hypogonadism
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
Severe pancreatitis
risk factors age > 75, obesity, alcoholism,
CXR: infiltrates or pleural effusion
features 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
Dx CT or MRCP to look for…
pancreatic necrosis & extrapancreatic
inflammation
Rx supportive, IV fluids to replace lost
intravascular volume
complications 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 H’s 5 T’s
hypovolemia tension pneumoTx
hypoxia tamponade
H+ ions (acidosis) toxins (narcotics,benzos)
hypo- or hyperK+ thrombosis
hypothermia trauma
 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)
Spirometry
 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
(asbestosis)
----------------------------------------------------------------
 long-term Rx asthma: inhaled corticosteroids
 long-term Rx COPD: inhaled long-acting
anticholinergic
----------------------------------------------------------------
 Ebstein’s 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 β-blocker or amiodarone
 hemodynamic unstable a-fib with rapid ventricular
response Rx: synchronized cardioversion
 Rx a-fib > 24 hr after CABG: anticoagulation or
cardioversion
----------------------------------------------------------------
 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
 Rx ASA
----------------------------------------------------------------
 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)
features poor feeding, vomiting, blood stools,
abdominal distension
CXR pneumatosis intestinalis,
portal venous gas, pneumoperitoneum
Rx 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, ASA
no prior anti-platelet Rx
recurrent stroke, already on ASA ASA +
 clopidogrel
stroke, with a-fib (CHADS2) warfarin
 ASA reduces risk of early recurrence of ischemic
stroke; continue indefinitely to prevent future strokes
 clopidogrel: not for ASA-naïve 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
----------------------------------------------------------------
 Turner’s is prone to osteoporosis 2/2 low estrogen
due to gonadal dysgenesis
 Rx: HRT
----------------------------------------------------------------
 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  fever, progress to abdominal pain & salmon-colored
 Dx: suspected PCP pneumonia rash, then hepatosplenomegaly with intestinal bleed:
o non-productive cough, progressive dyspnea, typhoid fever
weight loss, tachypnea ----------------------------------------------------------------
o CXR: B/L interstitial alveolar infiltrates  gout begins with asymptomatic hyperuricemia &
o Dx sputum induction with hypertonic saline progression to monoarticular arthritis
o Dx: bronchoalveolar lavage if sputum is o swelling & pain in great toe due to
not diagnostic deposition of monosodium urate = podagra
----------------------------------------------------------------  uric acid in renal tubules = nephrolithiasis
 proximal deep veins (iliac femoral, popliteal) of  chronic urate deposits in soft tissues = tophi
LE are the MC sources of symptomatic PE  risk factors: HCTZ enhance uric acid reabsorption
---------------------------------------------------------------- ----------------------------------------------------------------
 adolescent female with hirsutism, irregular menses, Dx panic disorder
acne,  17-hydroxyprogesterone: CAH 2/2 partial  ≥ 1 unexpected full-symptom panic attack
deficiency of 21-hydroxylase  Dx: clinical; drug screen, monitor vital signs,
 precocious puberty in boys EKG, & cardiac enzymes
 concomitant aldosterone deficiency results in Rx panic disorder
salt wasting  immediate: benzo, then tapered
 androgen excess impairs hypothalamic sensitivity  long-term: SSRI/SNRI &/or CBT
to progesterone, resulting in  GnRH secretion,  ----------------------------------------------------------------
LH/FSH   gonadal steroids Water-soluble vitamin deficiencies
 DDx: classic CAH 2/2 21-hydroxylase deficiency Wernicke-Korsakoff, B1 (thiamine)
(infant virilization & salt wasting), Cushing’s peripheral neuropathy (dry),
(hypercortisolism), PCOS (amenorrhea) dilated cardiomyopathy (wet)
---------------------------------------------------------------- angular cheilosis, stomatitis, B2 (riboflavin)
 diastolic rumble at the apex may be heard in a glossitis, seborrheic dermatitis,
large VSD due to  flow across mitral valve normocytic anemia
 Dx: echo to determine location & size of defect pellagra (dermatitis, diarrhea, B3 (niacin)
 complications: pulmonary HTN & Eisenmenger’s dementia, death) glossitis
---------------------------------------------------------------- cheilosis, stomatitis, glossitis, B6 (pyridoxine)
 infant with meningitis, nuchal rigidity, lethargy, irritability, confusion, depression
large purpuric lesions, hypotensive: adrenal megaloblastic anemia, NTDs B9 (folate)
hemorrhage 2/2 meningococcemia megaloblastic anemia, B12 (cobalamin)
(Waterhouse-Frederickson syndrome) confusion, paresthesia, ataxia
 sudden vasomotor collapse & purpuric skin rash scurvy (punctate hemorrhage, C (ascorbic acid)
 MCC of death: adrenal gland failure gingivitis, corkscrew hair),
---------------------------------------------------------------- ecchymosis, petechiae
Features of hypopituitarism
 central hypothyroidism  angular cheilosis: fissures at corners of lips
 amenorrhea, infertility, loss of libido, small testes  glossitis: hyperemic tongue
 ACTH/cortisol deficiency (20 adrenal insufficiency):  stomatitis: hyperemic/edematous oropharyngeal
pale skin, fatigue, hyponatremia, hypoglycemia, mucous membranes, sore throat
eosinophilia ----------------------------------------------------------------
 normal aldosterone, normal serum K+
----------------------------------------------------------------
 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
 PCOS
 non-classic CAH
 ovarian/adrenal tumors
 hyperprolactinemia
 Cushing’s syndrome
 acromegaly
----------------------------------------------------------------
 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:
craniopharyngioma
 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
----------------------------------------------------------------
 Ludwig’s 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 infant’s TSH receptors
 can occur despite maternal Rx for Graves’
 Dx: maternal anti-TSH Rc antibodies
 self-limited in 3 months
o Rx: methimazole + β-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,
gynecomastia
 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,
s hematemesis, melena, hypotensive shock
within 2 days: hepatic necrosis
within 2 – 8 wks: pyloric stenosis 2/2
gastric scarring
Dx anion gap metabolic acidosis, serum iron,
XR: radiopaque tablets
Rx 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: β-blocker
 avoid precipitating factors: alcohol, tobacco, stress
----------------------------------------------------------------
 post-MI secondary prevention; mortality benefits
o ASA, β-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
location associations
adenocarcinom peripheral, clubbing,
a solitary hypertrophic
(non-smokers) osteoarthropathy
SCC central,
(squ-Ca++mous) necrosis & hypercalcemia
cavitation
small cell central Cushing’s, SIADH,
carcinoma Lambert-Eaton
large cell peripheral gynecomastia,
carcinoma galactorrhea
 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:
Parkinson’s
 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 &
nystagmus
 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 Parkinson’s
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
diaphragm
 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
menopause
 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, it’s 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
blockage AV node below AV node
EKG progressive PR PR & R-R
prolongation remain constant
leads to a unpredictable
nonconducted nonconducted
P-wave P-wave
QRS narrow narrow or wide  inadequate alveolar clearance at birth results in
exercise or improves worsens mild pulmonary edema
atropine AV block AV block  CXR: B/L perihilar linear streaking
vagal maneuvers worsens improves  resolves by day 2; no long-term sequelae
risk of complete low risk, high risk; ----------------------------------------------------------------
heart block benign pacemaker  persistent pulmonary HTN of the newborn
 AV node blockers: digoxin, β-blockers, CCB should be suspected in all term & post-term
---------------------------------------------------------------- neonates with cyanosis
 unexplained syncope evaluation: EKG  high pulmonary vascular resistance result in
 prolonged PR & QRS suggests intermittent right-to-left shunting of deoxygenated blood
bradyarrhythmia or high-grade AV block through foramen ovale & ductus arteriosus
 isolated PVCs with normal EF is not a/w syncope  tachypnea & severe cyanosis
----------------------------------------------------------------  CXR: clear lungs,  vascularity
Rx symptomatic ureteral stone < 1 cm ----------------------------------------------------------------
 hydration  dry cough, weight loss, right arm pain, smoking Hx:
 pain control superior sulcus tumor
 α-blocker (tamsulosin) facilitate stone passage  compressive symptoms: Horner’s, hoarse voice,
---------------------------------------------------------------- SVC syndrome, Pancoast syndrome (brachial
 bethanechol: cholinergic agonist; Rx urinary plexus invasion @ C8, T1)
retention, atonic bladder  shoulder pain radiating in ulnar distribution
 oxybutynin: anticholinergic; Rx overactive bladder ----------------------------------------------------------------
(detrusor instability)  swelling of head, neck, & arms upon waking;
 imipramine: TCA with anticholinergic activity; plethoric face, engorged chest veins, smoking Hx:
Rx childhood enuresis superior vena cava syndrome
----------------------------------------------------------------  MCC: small cell lung cancer, non-Hodgkin’s
 Mg++-sulfate toxicity: depression of DTRs &  Dx: CXR with F/U CT & histology
respiratory depression ----------------------------------------------------------------
o Mg++ blocks neuromuscular transmission &  painful, red corneal opacification & ulceration
cause CNS depression a/w contact lens use: contact lens keratitis
 Rx: Ca++ gluconate, stop Mg++-sulfate, o medical emergency!!
monitor DTRs  MCC: Pseudomonas
----------------------------------------------------------------  Rx: topical ABX
Neonatal respiratory distress syndrome  DDx: anterior uveitis, viral conjunctivitis, episcleritis
 tachypnea (RR > 60/min), grunting, nasal flaring, ----------------------------------------------------------------
intercostal retractions, cyanosis  MC benign primary intracardiac tumor in LA:
 surfactant deficiency results in alveolar cardiac myxoma
collapse & diffuse atelectasis  fever, weight loss, Raynaud’s
 risk factors: prematurity, very low birth weight  mimics mitral valve disease; obstruction of blood
 CXR: diffuse, reticulogranular (ground-glass) flow across mitral valve, early diastolic rumble
opacities, bronchograms  complication: systemic embolization (stroke, TIA)
 Rx: continuous PAP ventilation  Dx: TEE
----------------------------------------------------------------  Rx: surgical resection
 MCC of respiratory distress in full-term infants: ----------------------------------------------------------------
transient tachypnea of the newborn
 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
pregnancy
 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
----------------------------------------------------------------
 Crohn’s 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 Crohn’s
 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 Burkitt’s, ALL
  Ca++,  phosphate,  K+,  uric acid
o K+ & phosphate are intracellular ions
o released phosphate binds Ca++
 Rx: allopurinol reduces acute urate nephropathy
----------------------------------------------------------------

 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
conjunctiva)
----------------------------------------------------------------
 sore throat, cheilitis, hyperemic & edematous
oropharyngeal mucous membranes, stomatitis,
glossitis, photophobia, normocytic anemia,
seborrheic dermatitis: riboflavin (B2) deficiency
----------------------------------------------------------------
 ecchymosis, petechiae, hyperkeratosis, Sjogren’s,
arthralgias, depression, neuropathy, coiled hair:
Vit C deficiency
----------------------------------------------------------------
 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 β-hCG < 6,500
 transvaginal USS can visualize an intrauterine
gestational sac when β-hCG @ 1500+
o #1 Dx: r/o ectopic pregnancy
o failure to detect intrauterine or adnexal sac,
serial β-hCG is required in 48 hrs
 normal pregos, β-hCG doubles every 48-72 hrs
until 10,000 - 20,000 IU/mL
 ectopic pregnancies, β-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 β-HCG levels
 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 β-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:
Cushing’s 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,
Crohn’s), Gottron’s 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
 Rx: NSAIDs
 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 (Beck’s 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
 #1 Rx: DMARDs ASAP  MTX
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-α 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
labs amylase/lipase can be normal,
dilated ducts, enlarged pancreas
Dx CT scan show calcifications
Rx 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
Fetal Maternal
 oligohydramnios  cesarean delivery
 meconium aspiration  infection
 macrosomia  postpartum
 convulsions hemorrhage
 stillbirth  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, Horner’s: 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
 Dx: MRI
 Rx: IV thrombolytics (tPA)
Wallenberg syndrome
(lateral medullary syndrome)
vestibulo- vertigo, falling TOWARD the lesion,
cerebellar difficulty sitting upright,
nystagmus (horizontal & vertical),
sensory abnormal facial sensation/pain,
pain/temp loss on I/L face & C/L body
bulbar dysphagia, aspiration, dysarthria,
hoarseness, diminished gag reflex
autonomic I/L Horner’s (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
vessel EKG
anterior LAD lead V1 – V6
inferior RCA or ST elevation in II, III, aVF
LCX
posterior LCX or ST depression in V1 – V3
RCA ST elevation in I & aVL (LCX)
ST depression in I & aVL (RCA)
lateral LCX, ST elevation in I, aVL, V5 & V6
diagonl ST depression in II, III, aVF
RV RCA ST elevation in V4R – V6R
 RCA occlusion a/w inferior wall MI can lead to
hypotension, AV block, & sinus bradycardia
----------------------------------------------------------------
 Rx pheochromocytoma: always α-blocker first,
then β-blocker
 β-blockers first lead to unopposed stimulation of
vascular α-receptors by catecholamines, results
in rapid, catastrophic  BP
o α-blockers decrease BP
o β-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, &
clindamycin/gentamicin
 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
  ALP & WBC
 Dx: USS
 #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)
 Klinefelter’s (testicular fibrosis)
 mumps (orchitis)
 myotonic dystrophy (testicular atrophy)
 CF (B/L absence of vas deferens)
 5-α-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
pathophysiolog microvesicular fatty infiltration &
y on liver Bx hepatic mitochondrial dysfunction
etiology pediatric ASA use for influenza or
VZV infection
features o hepatomegaly
o acute liver failure
o encephalopathy
labs o  transaminitis
o  PT/INR, PTT
o  hyperammonemia
----------------------------------------------------------------
 macrovascular fatty infiltration: alcoholic hepatitis
& nonalcoholic fatty liver disease (NAFLD)
 asymptomatic
----------------------------------------------------------------
 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 β-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)
----------------------------------------------------------------
ADHD
 ≥ 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,  Hx of painful, itchy, red streaks on chest, then o moderate: active external rewarming (warm
restricted interests, insistence on routine, arms; Hx smoking: superficial migratory blankets, heating pads, warm bath)
delayed language: autism spectrum disorder thrombophlebitis 2/2 Trousseau’s syndrome o severe: active internal rewarming (warmed
 can occur without language impairment  Trousseau’s: hypercoagulable disorder with pleural or peritoneal irrigation, warmed
---------------------------------------------------------------- recurrent, migratory superficial venous thrombosis humidified oxygen)
 risk factors for cholesterol gallstones: Caucasian, at unusual sites (arms, chest); Dx prior to or during ----------------------------------------------------------------
obesity, female, rapid weight loss, OCPs, GB occult visceral malignancy; MC pancreas  TBI of any severity can lead to post-concussive
hypomobility (fasting, prolonged TPN, pregnancy)  evaluate: abdominal CT r/o pancreatic carcinoma syndrome
 protective factors: low-CHO diet, exercise, ----------------------------------------------------------------  headache, confusion, amnesia, mood alteration,
caffeinated coffee, ASA or NSAID use  oliguria s/p renal transplant, HTN,  BUN & Cr, difficulty concentrating, vertigo, sleep disturbance
---------------------------------------------------------------- renal Bx: lymphocytic infiltration & vascular  resolves with symptomatic treatment within
 female with joint pain, fatigue, ankle edema, involvement with intima swelling: acute rejection weeks to months following TBI
facial rash, proteinuria, & decreased C3: SLE  Rx: IV steroids  DDx: delayed subdural hematoma (neuro deficits)
2/2 immune complex-mediated kidney damage, ---------------------------------------------------------------- ----------------------------------------------------------------
resulting in complement activation ( C3) Late presentation of aortic coarctation  hypochromic, microcytic anemia unresponsive to
 DDx: cytotoxic antibodies (Goodpasture’s) features asymptomatic HTN, chest pain, iron supplementation: thalassemia
---------------------------------------------------------------- claudication, headache, epistaxis,  2/2 reduced Hb synthesis
 thalamic stroke involving VPL nucleus, which heart failure ----------------------------------------------------------------
transmits sensory info from C/L body exam brachial-femoral delay,  acute bleeding with liver failure Rx: FFP to
 C/L hemianesthesia with transient hemiparesis, continuous cardiac murmur from large replace clotting factors
athetosis, or ballistic movements collaterals o liver failure hepatocytes cannot utilize Vit K
 dysesthesia in areas affected by sensory loss: studies EKG: LVH ----------------------------------------------------------------
“thalamic pain phenomenon” CXR: rib-notching, “3” sign Aspiration syndromes
 DDx: internal capsule strokes (motor symptoms) confirm Dx: echo pneumonia pneumonitis
---------------------------------------------------------------- Rx balloon angioplasty +/- stent pathophy lung parenchyma lung parenchyma
Causes of urinary incontinence in elderly associatio bicuspid aortic valve, VSD, Turner’s s infection, inflammation,
GU  detrusor contractility, n aspiration of oral aspiration of
detrusor overactivity, ---------------------------------------------------------------- cavity anaerobes gastric contents
bladder/urethra obstruction (tumor, BPH) Hypothermia with acid injury
urogenital fistula  mild: tachycardia, tachypnea, ataxia, dysarthria, onset days after aspiration hours after
neurologic dementia (Alzheimer’s, Parkinson, NPH),  shivering aspiration
MS, SCI, disk herniation  moderate: bradycardia, lethargy, hypoventilation, features fever, cough, sputum range from
potentially “DIAPPERS”  shivering asymptomatic to
reversible Delirium  severe: coma, CV collapse, v-fib, acidosis non-prod cough,
Infection (UTI) ---------------------------------------------------------------- hypoxemia,
Atrophic urethritis/vaginitis  bradycardia a/w hypothermia is refractory to Rx resp distress
Pharma (α-blockers, anticholinergics) with atropine & cardiac pacing, but improves CXR infiltrate in dependent infiltrates in one
Psych (depression) with correction of hypothermia lung (RLL) or both lower
Excess urine output (diuretics, DM, CHF) Rx hypothermia lobes; resolves
Restricted mobility (post-op)  warmed crystalloid IV fluids for hypotension without ABX
Stool impaction  intubation if comatose Rx ABX: clindamycin, supportive,
 Dx: U/A with culture  rewarming techniques to improve or β-lactams & no ABX
---------------------------------------------------------------- hemodynamic status β-lactams inhibitors
o mild cases: passive external rewarming
(cover with blankets)
 aspiration pneumonitis: acute lung injury 2/2  aspiration pneumonia: infection by ----------------------------------------------------------------
chemical burn from gastric contents oropharyngeal secretions 2/2 impaired
consciousness (overdose, seizure, anesthetics)