STEP 2 GUIDE

• Cardiovascular 2-8
• Pulmonary 9 - 12
• Gastrointestinal 13 - 17
• Hepatobiliary/pancreatic 18 - 20
• Genitourinary 21 - 25
• Endocrine 26 - 29
• Hematology/oncology 30 - 34
• Acute care 35 - 38
• Neurology 39 - 44
• HEENT 45 - 46
• Musculoskeletal 47 - 52
• Dermatology 53 - 55
• Obstetrics 56 - 60
• Gynecology 61 - 66
• Pediatrics 67 - 71
• Infectious disease 72 - 77
• Psychiatry 78 - 84
• Health maintenance 85
• Ethics 86
• Biostatistics 87

Young Kim
kim2yg@email.uc.edu
 STEP 2 × CV

ISCHEMIC HEART DZ S3: volume overload (e.g. CHF)

S4: stiff ventricles (e.g. MI)

Dz Presentation Management Other

Stable angina
Acute coronary syndrome (ACS)
Prinzmetal (variant) angina
Congestive heart failure (CHF)
Cocaine-induced MI
substernal “gripping” chest
pain or pressure on exertion,
relieved w/ rest or NTG
(NTG can relieve sx of GERD and
DES so don’t rely on as dx tool)
unstable angina
↓ +biomarkers
NSTEMI
↓ +EKG change
STEMI
Unstable angina: ruptured
atherosclerotic plaque →
increasing pain or pain at rest
NSTEMI/STEMI: ruptured
atherosclerotic plaque →
typical MI-pattern chest pain;
can be asx in elderly, diabetics,
women, s/p heart txp
transient coronary vasospasm
→ episodic angina at rest
Left-sided CHF: pulmonary
edema → dyspnea, orthopnea,
PND
Right-sided CHF: systemic
edema → pitting edema,
hepatic congestion, JVD, ascites
Severe CHF: extreme water
retention → hyponatremia
NYHA class I: sx only w/
vigorous activity (e.g. sports)
NYHA class II: sx w/ moderate
activity (e.g. stairs)
NYHA class III: sx w/ ADLs
NYHA class IV: sx at rest
acute MI sx + stigmata in a
young pt (e.g. pupillary dilation,
nosebleeds, track marks)
• Dx EKG → if normal, then exercise stress test
• (pharmacological if unable to exercise)
• mild (1 vx) → Tx NTG
• moderate (2 vx) → Tx NTG + PTCA/CABG
• severe (3 vx) → Tx NTG + PTCA/CABG
• Dx EKG + serial cardiac enzymes (may be false
• negative within first 6 hrs), +Levine sign
• Tx MONABASH – Morphine (pain)
O2
NTG (pain)
*ASA ± Plavix (coag)
*β-blockers
*ACE inhibitor (remodeling)
Statins (anti-inflam)
Heparin/LMWH (coag)
• (*only these will ↓mortality)
• STEMI → Tx PTCA/CABG
• LV infarct (left-sided CHF sx) → d/c β-blocker +
give Lasix
• RV infarct (right-sided CHF sx) → d/c NTG +
give NS bolus
• Dx EKG (ST-elevation during episodes)
• Tx CCB or NTG (will ↓vasospasms)
• Dx ↑BNP + echo (best test, estimates EF)
• Dx CXR (cardiomegaly, Kerley B-lines)
• class I → Tx Lasix + ACE inhibitor
• class II-III → add β-blocker
• class IV → add digoxin
• acute CHF exacerbation → hold β-blocker +
• Tx LMNOP – Lasix, morphine, NTG, O2, position
• Tx IV diazepam
Pharmacological stress test:
dobutamine (β1-ag) can stress
the heart in place of exercise
Coronary steal: dipyridamole
causes redistribution of coronary
blood flow to nondiseased
segments during perfusion scan
Troponin I: lasts 1-2 weeks, most
specific test
CK-MB: lasts only 1-2 days, good
to check for repeat MI
EKG changes: peaked T waves,
ST-elevation, ST-depression, Q
waves, T wave inversion
• Lateral: I/aVL = clot in LCX
• Inferior: II/III/aVF = clot in RCA
• Anterior: V1-V4 = clot in LAD
• Posterior: V1-V2 = clot in PD
Sudden death s/p MI: Vfib
(sudden), ventricular wall
rupture (3-7 days out)
Chest pain s/p MI: recurrent MI
(Dx ↑CK-MB), acute pericarditis
(Tx NSAIDs), Dressler syndrome
(2-4 wks out, Tx NSAIDs)
Embolic sx s/p MI: embolized
mural thrombus (Dx echo)
Frank-Starling curve: normal
heart has ↑contractility with
↑preload, but impaired in CHF
Etiology: post-MI (MCC systolic),
LVH due to chronic HTN (MCC
diastolic)
Right-sided CHF vs. hepatic
congestion: only right heart
failure has hepatojugular reflex
and JVD

CARDIAC DRUGS ACEI toxicity: dry cough (↑bradykinin), angioedema, ↑K (↓aldosterone); c/i in bilateral renal artery stenosis
Amiodarone toxicity: check LFTs, PFTs, TFTs; c/i in restrictive lung dz pts
ASA toxicity: tinnitus, fever, hyperventilation → respiratory alkalosis (early), metabolic acidosis (late); triad asthma (Tx LT-blockers)
BB toxicity: bradycardia, AV block, asthma exacerbation, impotence; relative c/i in asthma pts
CCB toxicity: peripheral vasodilation → pitting edema, constipation (verapamil only)
Digoxin toxicity: nausea/vomiting, visual changes (“yellow-green halos”), atrial tachycardia w/ AV block; exacerbated by hypo-K
HCTZ toxicity: hyperGLUC – hyperGlycemia, hyperLipidemia, hyperUricemia, hyperCalcemia
Niacin toxicity: facial flushing (↑prostaglandins); Tx ASA
NTG toxicity: headache, orthostatic hypotension → syncope, tolerance
Lasix toxicity: ototoxic (c/i with aminoglycosides), ↓K/↓Mg → Vtach
Lidocaine toxicity: during acute MI, can ↓Vfib but ↑asystole
Pressor toxicity: ↓blood flow to fingers (digital ischemia), intestines (NOMI), kidneys (ARF)
Statin toxicity: myopathy (↓CoQ10 synthesis), hepatotoxic
 STEP 2 × CV

ARRHYTHMIAS Arrhythmia EKG tracing Management/Other

Premature atrial contractions
(PAC)
Premature ventricular
contractions (PVC)
Atrial fibrillations (Afib)
early P wave that looks differently than other P waves • asx → Tx reassurance
• sx → Tx β-blockers
wide QRS without preceding P wave • asx → Tx reassurance
• sx → Tx β-blockers
• acute → anticoagulate + rate
• control w/ BB or CCB, then
• get echo to r/o thrombus, then
• cardioversion
“irregularly irregular” rhythm
• unstable → DC cardioversion
• chronic → anticoagulate +
• rate control w/ BB or CCB

Afib anticoagulation: ASA if no

risk factors, coumadin otherwise
Atrial flutter (Aflutter) • (same as Afib)

saw-tooth baseline w/ HR >150

Multifocal atrial tachycardia looks like Afib but the P waves are variable, need 3 different P waves for dx • Tx 100% O2 (since MAT is due to
(MAT) • end-stage COPD)
Paroxysmal supraventricular • stable → Tx IV adenosine
tachycardia (PSVT) • unstable → DC cardioversion

HR >200 → “light-headedness” that improves w/ vagal maneuvers (e.g. cold water

to face)
Wolff-Parkinson-White (WPW) • Tx procainamide, amiodarone,
syndrome • or cath ablation

“delta wave” reflects accessory conduction pathway from atria to ventricles

Ventricular tachycardia (Vtach) • sustained → Tx IV amiodarone
• nonsustained → reassurance
• torsades → Tx IV mag sulfate

Sustained Vtach: lasts >30 sec

Nonsustained Vtach: lasts <30 sec, usually asx
Torsades de pointes: sine-wave Vtach due to QT prolongation
Ventricular fibrillations (Vfib) • Tx immediate defib + CPR, then
• continue IV amiodarone

Pulseless electrical activity: EKG

shows activity but no pulses felt;
Tx CPR (do not shock them)
Sinus bradycardia HR <60 • asx → Tx reassurance
• sx → Tx atropine (block vagus)
Sick sinus syndrome persistent sinus bradycardia → dizziness, syncope, fatigue • Tx pacemaker
1° AV block • Tx reassurance

PR interval >0.2 sec (>1 block)

2° AV block (Mobitz type 1) • Tx reassurance

dz in AV node → progressive PR prolongation until QRS drops

2° AV block (Mobitz type 2) • Tx pacemaker (can convert to
• 3° if left alone)

dz in bundle of His → random QRS drop

3° AV block (complete) • Tx pacemaker

AV block × Bell palsy: Lyme dz

AV block × atrial tachycardia:
P waves and QRS complexes function independently digoxin toxicity

Congenital long QT syndrome: AR ΔK-channel → deafness + ↑risk of torsades → syncope, sudden death; Tx β-blockers

Class I: Na-blockers will prolong depolarization + stabilize membranes, may prolong QRS-complex
Class II: β-blockers (-olol) will ↓sympathetics
Class III: K-blockers (amiodarone) will prolong repolarization, may prolong QT-interval
Class IV: Ca-blocker (verapamil, diltiazem) will ↓contractility and ↓BP
Class V: Na/K-blockers (digoxin) will ↑contractility and ↓HR

MYOCARDIAL DZ Dz Presentation
Dilated cardiomyopathy (DCM) ↓contractility → systolic CHF sx
Chagas dz: Trypanosoma cruzi
infx in S. America → DCM +
achalasia + megacolon
Hypertrophic-obstructive exertional dyspnea, angina,
cardiomyopathy (HOCM) syncope, “sudden death in a
young athlete”
Restrictive cardiomyopathy infiltration of myocardium →
(RCM) ↓compliance → diastolic CHF sx
Myocarditis usually asx; can present w/
fever, chest pain, pericarditis
PERICARDIAL DZ Dz Presentation
Acute pericarditis pleuritic positional chest pain
(relieved by leaning forward),
pericardial friction rub; can lead
to effusion and tamponade
Constrictive pericarditis fibrous pericardial scarring →
diastolic CHF sx + JVD,
pericardial knock, Kussmaul
sign
Pericardial effusion muffled heart sounds, soft PMI,
pulsus paradoxus (sBP drops
>10 w/ inspiration)
Cardiac tamponade pulsus paradoxus + Beck’s triad
(hypOtension, JVD, muffled
heart sounds)
VALVULAR DZ Murmur maneuvers: squatting → ↑preload
Murmur maneuvers: Valsalva → ↓preload
Murmur maneuvers: handgrip → ↑afterload
Left vs. right murmurs: expiration → ↑left-sided (aortic, mitral)
inspiration → ↑right-sided (pulmonary, tricuspid)
Dz Presentation
Mitral stenosis (MS) loud S1, opening snap w/ late
diastolic rumble, ±Afib on EKG,
can present during pregnancy
Mitral regurgitation (MR) holosystolic blowing murmur
Aortic stenosis (AS) systolic crescendo-decrescendo
murmur following opening
snap, “parvus et tardus”; triad
of angina, syncope, dyspnea
Aortic regurgitation (AR) high-pitched blowing diastolic
murmur, wide pulse pressures,
head bobbing, pulsating uvula,
pistol-shot over femoral arteries
Tricuspid regurgitation (TR) holosystolic blowing murmur +
“pulsatile liver”
Mitral valve prolapse (MVP) midsystolic click, late systolic
crescendo murmur; associated
w/ “panic attacks”
Management
• Dx echo + CXR (“globular heart”)
• Tx for CHF, heart txp (MC indication)
• alcoholic DCM → Tx total abstinence
• Dx auscultation (murmur louder w/ ↓preload,
• softer w/ ↑preload), confirm w/ echo + CXR
• Tx avoid exercise + β-blockers, partial septal
• myomectomy vs. pacemaker if severe
• Dx endomyocardial bx
• Tx for CHF
• hemochromatosis RCM → Tx phlebotomy
• Dx ↑cardiac enzymes, ↑ESR
• Tx supportive care
Management
• Dx EKG (diffuse ST elevation + PR dePRession)
• Tx NSAIDs
• uremic pericarditis → Tx hemodialysis
• Dx EKG (Afib), catheter (“square root sign”)
• Tx pericardiectomy
• Dx echo (gold standard), CXR (“water bottle”
• silhouette)
• small/asx → repeat echo in 1-2 wks
• large → Tx pericardiocentesis
• Dx echo (gold standard), EKG (electrical
• alternans)
• small/asx → close monitoring
• large → Tx emergent pericardiocentesis
• hemorrhagic → ER thoracotomy
Management
• asx → observation
• sx → Tx balloon valvuloplasty
• asx → medical management
• sx → Tx valve replacement
• asx → observation
• sx → Tx valve replacement
• Tx CCB or ACE-inhibitor to ↓afterload
• acute-onset → emergent valve replacement
• asx → medical management
• sx → Tx valve replacement
• Dx auscultation (murmur louder w/ ↓preload,
• softer w/ ↑preload)
• observation
STEP 2 × CV
Other
Etiology: MI (MCC), viral infx,
alcohol, cocaine, doxorubicin
(Adriamycin)
Etiology: autosomal dominant
(“family hx of sudden death”)
HOCM vs. MVP: handgrip
(↑afterload) intensifies MVP,
diminishes HOCM
Etiology: ASHES – amyloidosis,
sarcoidosis, hemochromatosis,
endocardial fibroelastosis (peds),
scleroderma
Etiology: coxsackie B virus
(MCC), doxorubicin (Adriamycin)
Other
Etiology: coxsackie B virus (MCC)
Dressler syndrome: pericarditis
2-4 wks s/p MI, “feels like a
second heart attack”; Tx NSAIDs
Etiology: radiation (MCC US),
viral infx, TB (MCC 3rd world)
Etiology: acute pericarditis
(MCC), neoplastic or TB (if
effusions are exudative)
Postpericardiotomy syndrome:
reactive pericarditis w/ effusion
1-6 wks s/p heart surgery
Etiology: trauma, pericarditis,
post-MI w/ free wall rupture
Pulsus paradoxus ddx: cardiac
tamponade, tension PTX, severe
asthma
Other
Etiology: rheumatic heart
disease (MCC)
Etiology: MVP (MCC), papillary
muscle rupture, LV dilation,
rheumatic fever
Etiology: calcified tricuspid valve
(old), congenital bicuspid aortic
valve (young)
Etiology: congenital bicuspid
aortic valve, syphilitic aortitis,
rheumatic fever
Etiology: tricuspid endocarditis
(IVDA), RV dilation
Etiology: connective tissue d/o
(e.g. Marfan)
HOCM vs. MVP: handgrip
(↑afterload) intensifies MVP,
diminishes HOCM

ENDOCARDITIS Dz
Rheumatic fever
Rheumatic heart disease
Infx endocarditis
Marantic (thrombotic)
endocarditis
Libman-Sacks endocarditis
PEDS CV Fetal circulation: ductus venosus shunts away from liver, foramen ovale and ductus arteriosus shunt away from lungs
Eisenmenger syndrome: L-to-R shunts → pulmonary HTN → reversal of shunting → late-onset cyanosis
Pediatric murmurs: if systolic, I-II/VI, and asymptomatic → reassurance
Pediatric murmurs: if diastolic/continuous, >III/VI, or symptomatic → Dx echo
Dz
Henoch-Schonlein purpura
Kawasaki disease
Atrial septal defect (ASD)
Ventricular septal defect (VSD)
Patent ductus arteriosus (PDA)
Aortic coarctation
Transposition of the great
vessels (TGV)
Endocardial cushion defect
(AVSD)
Tetralogy of Fallot
Presentation
strep throat (GAS) → anti-M ab
→ type 2 hypersensitivity →
FEVERSS – fever, erythema
marginatum, valvular damage,
↑ESR, red-hot joints (migratory
polyarthritis), subcutaneous
nodules, Sydenham chorea
multiple episodes of rheumatic
fever → scarring of mitral valve
spiking fever, night sweats,
new-onset murmur, Osler
nodes (tender nodules on
finger/toe pads), Janeway
lesions (peripheral petechiae),
splinter hemorrhages, Roth
spots (retinal hemorrhages)
metastatic cancer → hyper-
coagulable state → clots form
on valves → can embolize
SLE → wart-like vegetations on
both sides of mitral valve →
mitral regurg > mitral stenosis
Presentation
IgA-mediated small vessel
vasculitis → “palpable purpura”
on buttocks and legs, IgA
glomerulonephritis, ileocecal
edema → colicky abdominal
pain + ↑risk for intussusception
CRASH & BURN – Conjunctivitis,
Rash, Adenopathy, Strawberry
tongue, Hand/feet swelling,
fever >5 days
low-grade diastolic rumble
murmur w/ fixed split S2
pansystolic murmur at LLSB;
can present w/ failure to thrive,
easy fatigability, CHF sx
continuous “machinery-like”
murmur (accentuated during
systole and diastole)
HTN in upper extremities,
hypotension in lower
extremities, “delayed femoral
pulse”, midsystolic murmur
heard over back
life-threatening cyanosis in a
newborn + single loud S2
without murmur (no valves
being clogged here)
failure to thrive, ↑risk w/ Down
syndrome
PROVe – Pulmonic stenosis
(defines Px), RVH, Overriding
aorta, VSD; presents as cyanotic
“tet spells” and clubbing in a
kid who squats for relief
STEP 2 × CV
Management Other
• Dx ↑ASO titers MC murmur: mitral regurgitation
• rheumatic fever → Tx NSAIDs or steroids
• strep throat → Tx amoxicillin
• Tx balloon valvuloplasty MC murmur: mitral stenosis
• Dx echo or blood cx ×3 Rapid-onset: Staph aureus
• Tx long-term IV abx Dental procedures: viridans-
group strep (Strep mutans)
GI/GU procedures: enterococcus
Colon cancer: Strep bovis,
Clostridium septicum
IVDA: S. aureus on tricuspid valve
Prosthetic valves: S. epidermidis
Cx-negative: HACEK group
(Haemophilus, Actinobacillus,
Cardiobacterium, Eikenella,
Kingella)
• Tx heparin (controversial)
• Dx screen w/ ANA; confirm w/ anti-dsDNA,
• anti-Smith, or ↓C3-C5
• Tx underlying SLE + anticoagulate
Management Other
• Tx steroids vs. symptomatic relief (will self-
• resolve)
• Dx echo to r/o coronary artery aneurysms Strawberry tongue ddx:
• Tx IVIG + high-dose aspirin Kawasaki disease, scarlet fever,
• PPx flu vaccination (prevent Reye syndrome) toxic shock syndrome
• Dx echo Paradoxical emboli: venous clots
• asx → reassurance can travel through PFO and
• sx → Tx surgical repair cause stroke instead of PE
Complications: more susceptible
to desatting w/ high altitudes
and the bends w/ deep sea diving
• Dx echo
• asx → reassurance
• sx → Tx surgical repair
• Dx echo PDA + deafness/cataracts:
• infants → Tx indomethacin congenital rubella syndrome
• adults → Tx surgical ligation
• adults w/ Eisenmenger → surgery is •
• contraindicated
• Dx CXR (rib notching + “figure 3” aorta) Aortic coarctation + short
• Tx surgical decompression stature: Turner syndrome
• Dx echo, CXR (“egg on a string” w/ RVH)
• Tx emergent PGE1 then cath lab for atrial
• septostomy
• Dx echo
• Tx surgical correction
• Dx echo, CXR (“boot-shaped heart”)
• Tx surgical correction

ARTERIAL DZ Dz
Hypertensive urgency
Hypertensive emergency
Aortic dissection
Abdominal aortic aneurysm
(AAA)
Ruptured AAA
Peripheral vascular dz (PVD)
Acute arterial occlusion
Cholesterol embolization
syndrome
Mycotic aneurysm
Luetic heart
Traumatic aortic injury
VENOUS DZ Virchow triad: ↑risk of blood clots w/ stasis, hypercoagulability, endothelial damage
Dz
Superficial venous thrombosis
(SVT)
Deep venous thrombosis (DVT)
Pulmonary embolism (PE)
Phlegmasia cerulea dolens
(PCD)
Chronic venous insufficiency
(post-thrombotic syndrome)
Arteriovenous malformation
(AVM)
Varicose veins
Presentation
BP >200/120
BP >200/120 + end-organ
damage (e.g. headache, renal
failure, pulmonary edema)
severe “tearing” chest pain
(type A) or interscapular back
pain (type B), asymmetric BP, pt
usually in severe distress
pulsatile mass on abd exam
(but not in obese pts)
triad of tearing abdominal or
back pain, severe hypotension,
pulsatile mass
peripheral atherosclerosis →
cold, shiny legs w/ atrophied
calf muscles, intermittent
claducation (mild), rest pain and
ischemic ulcers (severe)
emboli → arterial occlusion →
6 Ps – pain, pallor, paralysis,
parasthesias, poikilothermia,
pulselessness
surgical or radiographic
procedure → disruption of
atherosclerotic plaque →
cholesterol emboli → small
areas of tissue ischemia (e.g.
black/blue spots on toes), renal
impairment (slight ↑BUN)
bacterial (Salmonella) infx of
tunica intima → aneurysm
3° syphilis → aortic aneurysm +
aortic regurg + coronary artery
stenosis
blunt chest trauma (e.g. MVC)
→ aorta tears at ligamentum
arteriosum → instant death
Presentation
painful, palpable venous cord
w/ local erythema and edema
acute-onset dull leg pain,
unilateral swelling, Homans’
sign (not a reliable test)
acute-onset pleuritic chest pain,
dyspnea, hyperventilation,
hemoptysis, right-sided heart
failure → death
venous outflow obstruction →
acute onset leg edema with
pain and cyanosis
damaged venous valves →
chronic venous HTN → ranges
from mild varicosities to severe
leg edema w/ ankle ulcers
abnormal arterial-venous
communication → warm,
palpable, pulsating masses
incompetent venous valves →
distended, tortuous LE veins
Management
• lower BP gradually over 24 hrs w/ PO meds
• lower BP by 25% in 1-2 hrs w/ IV nitroprusside
• severe HA → Dx head CT (r/o ICH)
• first step is to control HTN before any dx tests
• Dx screen w/ CXR (widened mediastinum),
• confirm w/ TEE or CT scan (intimal flap)
• type A → Tx surgery
• type B → Tx β-blockers
• all smoking men >65 y/o → screen w/ abd U/S
• Dx abdominal U/S
• <5 cm → close f/u vs. elective repair
• >5 cm or sx → Tx synthetic graft
• Tx emergency laparotomy (don’t waste time
• on dx tests)
• Dx ABI (normal ≥1.0, mild <0.7, severe <0.4;
• calcified arteries give false readings)
• mild → lifestyle changes
• moderate → Tx ASA + cilostazol (antiplatelets)
• severe → bypass graft vs. angioplasty
• Dx arteriogram
• Tx heparin gtt + surgical embolectomy (<6 hrs)
• vs. amputation (>6 hrs)
• PPx fasciotomy for compartment syndrome
• Tx supportive care
• severe → Tx amputation
• Tx IV abx + surgical debridement
• Tx IV PCN G + surgical repair
• Dx CXR (widened mediastinum + hemothorax)
• Tx surgical repair (if still alive)
Management
• Tx aspirin + warm compresses
• septic → Tx IV abx + excise vein
• Dx duplex U/S
• Tx heparin + warfarin
• PPx compression boots + early ambulation ±
• SQ heparin/LMWH
• high-suspicion → start heparin before dx tests
• Dx D-dimer to r/o, CTPA or V/Q to confirm
• Tx heparin + warfarin
• recurrent PE or anti-coag contraindicated
• (recent surgery, hemorrhagic stroke, active
• bleed, bleeding d/o) → Tx IVC filter
• Dx duplex U/S or pelvic CT scan
• Tx heparin + venous thrombectomy
• Tx compression stockings + leg elevation
• ulcers → Tx wet-to-dry TID
• asx → Tx reassurance
• sx or located in brain/bowel → Tx surgical
• removal vs. sclerosis
• Tx compression stockings + leg elevation;
• elective surgical removal vs. sclerosis (except
• GSV since it’s used for bypass grafting)
STEP 2 × CV
Other
Nitroprusside toxicity: cyanide
poisoning (Tx hydroxocobalamin
+ nitrites + thiosulfate)
Etiology: HTN (MCC), connective
tissue diseases
Stanford classification: type A
involves Ascending aorta, type B
involves descending aorta
Aortoenteric fistula: small herald
bleed followed by massive UGIB
s/p aortic graft placement
Spinal cord ischemia: clamping
of aorta → ↓bloodflow through
artery of Adamkiewicz to T9-T12
→ spinal cord ischemia → flaccid
paralysis of bilateral legs
Leriche syndrome: PVD of distal
aorta → bilateral claudication +
impotence + ↓femoral pulses
PVD vs. spinal stenosis: both
have leg pain w/ exertion but
spinal stenosis has normal ABI
Etiology: Afib (MCC)
Volkmann ischemic contracture:
ischemia → fibrous replacement
of dead muscle
Other
Trousseau phenomenon:
pancreatic cancer → mucins →
migratory SVT
Effort thrombosis: upper
extremity DVT in young healthy
pts following physical activity
PE on EKG: sinus tachycardia is
more common than S1Q3T3
Fat embolism: PE sx + petechiae
in a pt w/ long bone fx
Amniotic fluid embolism: PE sx
s/p amniocentesis
Sturge-Weber syndrome: facial
port-wine stain + brain AVM
Heyde syndrome: aortic stenosis
+ colon AVM
Osler-Weber-Rendu syndrome:
widespread AVM + epistaxis
 STEP 2 × CV

SHOCK Shock: inadequate tissue perfusion

Types of shock: cardiogenic (JVD, PCWP >18)
hypovolemic
septic (warm skin)
neurogenic (warm skin)
anaphylactic (warm skin)
Initial shock management: ABCs → 2 large-bore IVs + 2L IVF (except cardiogenic)

Dz Presentation Management Other

Cardiogenic shock heart can’t pump blood →
typical shock sx + JVD
Hypovolemic shock Class I: <15% + asx
Class II: 15-30% + ↑HR
Class III: 30-40% + ↓BP
Class IV: >40% + ∆MS, anuria
Septic shock SIRS: 2+ of the following – ↑/↓T,
↑RR, ↑HR, ↑/↓WBC
Sepsis: SIRS + positive blood cx
Septic shock: sepsis + ↓BP
Neurogenic shock sympathetic denervation →
loss of vascular tone → typical
shock sx + warm skin
Anaphylactic shock allergen exposure → systemic
type I hypersensitivity rxn
• (initial shock management) but give pressors Cardiogenic shock vs. ARDS:
• (dobutamine) not IV fluids cardiogenic shock has PCWP ≥18,
• Dx EKG + echo to find underlying cause ARDS has PCWP <18 (normal)
• Tx underlying cause
• (initial shock management)
• hemorrhagic → find and stop source of bleed
• f/u UOP q shift
• (initial shock management) Complications: septic shock is
• Dx blood cx ×3 MCC of ARDS + ICU death
• Tx IV abx + IV fluids + pressors
• (initial shock management)
• Tx IV fluids + pressors
• (initial shock management)
• Tx epinephrine, antihistamines

CARDIAC NEOPLASMS Dz Presentation Management Other

Cardiac metastases --- • Dx CT scan more common than primary
• Tx surgical excision tumors (75%)
Atrial myxoma pedunculated, benign mass that
presents like intermittent mitral
stenosis (located in left atrium),
systemic sx (fever, weight loss),
embolic sx (stroke)
Cardiac rhabdomyoma MC heart tumor in kids,
associated w/ tuberous
sclerosis

VASCULITIS Small vessel vasculitis: type 3 HS, “palpable purpura”

Muscular artery vasculitis: claudication/infarction
Elastic artery vasculitis: granulomatous dz, pulselessness

Dz Presentation Management Other

Temporal arteritis (giant cell
arteritis)
Takayasu arteritis
Polyarteritis nodosa
Buerger disease
(thromboangiitis obliterans)
Behçet syndrome
Churg-Strauss syndrome
Wegener granulomatosis
Hypersensitivity vasculitis
elderly pt w/ unilateral
headache, jaw claudication,
visual changes
young Asian woman w/ absent
pulses and asymmetrical BP
vasculitis of renal and visceral
vx → abd pain (bowel angina),
fatigue, joint pain, renal failure
smokers w/ gangrene →
autoamputation of fingers/toes
recurrent oral and genital
ulcers, arthritis, uveitis, CNS sx
triad of asthma + eosinophilia +
granulomatous vasculitis
triad of necrotizing vasculitis,
necrotizing granulomas in lungs
and upper respiratory tract
(“saddle nose”), and
necrotizing glomerulonephritis
→ hematuria + hemoptysis
drug-induced type 3 HS →
palpable purpura
• Dx screen w/ ↑ESR Temporal arteritis × myalgia:
• Tx emergent high-dose steroids (can become check ESR; ↑ESR = polymyalgia
• blind if you wait too long) + low-dose ASA rheumatica, normal ESR =
• f/u temporal artery bx (granulomas) steroid-induced myopathy
• Dx arteriogram
• Tx steroids, angioplasty for stenosed vx
• Dx tissue bx, ↑P-ANCA Risk factors: young, male, HBV+
• Tx steroids
• Tx d/c smoking
• Dx tissue bx
• Tx steroids
• Dx tissue bx (eosinophilic granulomas),
• ↑P-ANCA
• Tx steroids
• Dx tissue bx (necrotizing granulomas), Saddle nose ddx: congenital
• ↑C-ANCA syphilis, cocaine abuse, leprosy,
• Tx cyclophosphamide Wegener granulomatosis
• Dx tissue bx
• Tx steroids, d/c meds

OUTPATIENT CV Dz Presentation
Hypertension (HTN) asx, but can present w/ end-
organ complications...
Heart: LVH, MI, CHF
Eyes: retinopathy, papilledema
Kidney: CKD
Brain: stroke, TIA
Arteries: PVD, aortic dissection
Hyperlipidemia (HLD) asx, but can present w/ end-
organ complications…
Atherosclerosis: MI, CAD,
stroke, PVD, AAA
↑↑LDL: xanthelasma (eyelids),
xanthoma (Achilles tendon)
↑↑TG: acute pancreatitis
STEP 2 × CV
Management Other
Dx measure BP Pre-HTN: 120-139/80-89
Stage 1 HTN: ≥140/90
lifestyle modifications Stage 2 HTN: ≥160/100
(weight loss (#1), DASH diet (#2), Malignant HTN: ≥200/120 +
aerobic exercise (#3), ↓EtOH) papilledema (due to fibrinoid
necrosis of arterioles)
not at goal BP
(<140/90, <130/80 if CKD or DM) Isolated systolic HTN: ↑sBP w/
normal dBP in elderly pts, due to
stage 1 stage 2 compelling arterial wall stiffness
indications
1° (essential) HTN: 95%, no
Tx HCTZ Tx HCTZ + Tx specific drug underlying cause
ACEI/ARB/BB/CCB 2° HTN: 5%, due to renovascular
dz (MCC), OCPs (MCC young
not at goal BP women), stimulants, hyper-PTH
optimize dose or add drug
• diabetic, stroke → Tx ACE inhibitor
• CAD, CHF → Tx β-blocker
• pregnant → Tx hydralazine, nifedipine,
• labetalol, methyldopa
• malignant HTN → Tx IV nitroprusside
• OCP-related HTN → d/c OCPs
• Dx fasting lipid panel CHD risk factors:
1. smoking (#1)
• CHD or equivalent → Tx lifestyle if LDL ≥100, 2. HTN
• statins if LDL ≥130 3. DM
• 2+ risk factors → Tx lifestyle if LDL ≥130, 4. HDL <40 (>60 is protective)
• statins if LDL ≥160 5. FHx
• 0-1 risk factors → Tx lifestyle if LDL ≥160, 6. age (male >45, female >55)
• statins if LDL ≥190
LDL: total chol – HDL – TG/5
• TG >500 → Tx niacin

OBSTRUCTIVE LUNG DZ Lung volumes:
Obstructive lung dz: ↑TLC, ↓FEV1/FVC (<70%), ↑compliance, ↓elasticity
Restrictive lung dz: ↓TLC, ↑FEV1/FVC (>110%), ↓compliance, ↑elasticity
DLCO: diffusing capacity of lungs, ability to transfer gases from alveoli to pulmonary capillaries
COPD: emphysema + chronic bronchitis
COPD + new-onset clubbing: lung cancer until proven otherwise
Dz Presentation
Emphysema destruction of alveolar walls →
permanent alveolar dilation →
“pink puffers”, thin w/ barrel
chest, expiration w/ pursed lips
Chronic bronchitis chronic productive cough of 3
months/year for 2 years →
“blue bloaters”, overweight
and cyanotic, may have signs of
cor pulmonale
Asthma Asthma attack: airway
inflammation → reversible
airflow obstruction →
wheezing, shortness of breath,
cough, chest tightness
Status asthmaticus: sustained
asthmatic state, not responsive
to meds
Poor px factors: silent lungs,
normal CO2, pulsus paradoxus
Bronchiectasis destruction of bronchial walls
→ permanent bronchiolar
dilation → chronic cough w/
“cupfuls” of purulent sputum,
dyspnea, hemoptysis, recurrent
Pseudomonas pneumonia
Management
• Dx screen w/ PFTs (FEV1/FVC <70%)
• emphysema → Dx CXR (hyperinflated lungs,
• increased AP diameter)
• chronic bronchitis → Dx clinical criteria
• <50 y/o → Dx A1AT levels
• first step is d/c smoking*
• stage I (FEV1 ≥80%) → Tx short-acting
• bronchodilators (albuterol, ipratropium)
• stage II (FEV1 50-80%) → add long-acting
• bronchodilators (salmeterol, tiotropium)
• stage III (FEV1 30-50%) → add inhaled steroids
• (fluticasone, triamcinolone)
• stage IV (FEV1 <30% or hypoxic) → home O2*
• (* only these will ↓mortality)
• COPD exacerbation → Tx bronchodilators +
• abx + systemic steroids + O2 therapy
• Dx PFTs (reversible FEV1/FVC <70%)
• 1-2 atk/wk → prn SABA (albuterol)
• 2+ atk/wk or 3-4 nighttime sx/month → add
• low-dose inhaled steroids
• daily atk → add LABA (salmeterol)
• continuous → add high-dose inhaled steroids
• status asthmaticus → Tx bronchodilators +
• systemic steroids + O2 therapy
• normal CO2 → emergent intubation
• Dx high-res CT scan (“signet rings”)
• Tx bronchodilators + abx for acute
• exacerbations
STEP 2 × PULMONARY
Other
Etiology: smoking causes centri-
acinar emphysema in upper
lungs; A1AT deficiency causes
panacinar emphysema in lower
lungs in pts <50 y/o
Etiology: smoking (MCC)
Emphysema vs. bronchitis:
chronic bronchitis has normal
DLCO, emphysema has ↓DLCO
Atopy: asthma + allergic rhinitis +
atopic dermatitis (eczema)
Triad asthma: asthma + aspirin
sensitivity (↑LT) + nasal polyps
ABPA: asthma + pulmonary
infiltrates + Aspergillus allergy
Churg-Strauss syndrome:
asthma + eosinophilia +
granulomatous vasculitis
Albuterol toxicity: hypokalemia
(weakness, tremors, arrhythmia)
Inhaled steroid toxicity: thrush
Theophylline toxicity: caffeine-
like sx (n/v, HA, arrhythmias)
Etiology: cystic fibrosis (MCC),
Kartagener syndrome (∆dynein)

LUNG NEOPLASMS Anterior mediastinal masses: 4 Ts – Thymoma (myasthenia gravis), Teratoma, Thyroid neoplasm, Terrible lymphoma
Middle mediastinal masses: bronchogenic cysts, pericardial cysts
Posterior mediastinal masses: neurogenic tumors (e.g. neurilemmoma)
Dz Presentation
Lung cancer cough, hemoptysis, dyspnea,
wheezing, recurrent PNA in
same lobe
Pancoast tumor: superior sulcus
tumor at the apex of the lung;
presents as Horner syndrome –
ipsilateral ptosis, miosis,
anhidrosis, flushing due to loss
of sympathetic tone (invades
superior cervical ganglia)
Adenocarcinoma: MC cancer in
women and nonsmokers
Solitary pulmonary nodule solitary pulmonary nodule
(“coin lesion”) found incidentally on a CXR
(40% are malignant)
Laryngeal cancer worsening hoarseness w/
subacute onset, dysphagia,
hemopytsis
PLEURAL DZ Dz Presentation
Pleural effusion fluid build-up in pleural space;
two types – transudative (thin)
and exudative (thick)
Empyema collection of Staph aureus pus in
pleural cavity → nonproductive
cough, fever, chest pain
Pneumothorax (PTX) air pocket in pleural space →
chest pain, cough, dyspnea
Tension PTX PTX + building pressure →
mediastinal shift, hypOtension,
JVD, absent breath sounds,
hyperresonance to percussion
Malignant mesothelioma cancer of mesothelial lining →
dyspnea, cough, weight loss
Management
• Dx CXR → if suspicious, sputum cytology and
• CT scan → if still suspicious, bronchoscopy and
• mediastinoscopy w/ biopsy (“tissue is the
• issue”)
• adenocarcinoma → Dx thoracentesis
• (↑hyaluroindase ), Tx lobectomy is curative
• NSCLC → Tx surgical resection (local) or
• chemoradiation (invasive or mets)
• SCLC → Tx chemoradiation
• Pancoast tumor → radiation for 6 weeks to
• shrink tumor, then surgical resection
• SVC syndrome → Tx steroids + endovascular
• stent
• solitary brain met → Tx surgical resection
• multiple brain mets → Tx brain radiation
• first step is get prior CXR for comparison, if
• changed from before then Dx CT scan
• Benign coin lesions (calcification = granuloma,
• bulls-eye shape, popcorn shape = hamartoma,
• air-crescent or halo sign = aspergilloma,
• Southwest region = coccidioido, Ohio river
• valley = histo) → f/u CXR in 3-6 mo
• Indeterminate coin lesions → cut it out
• Malignant coin lesions (spiculations or 20+
• pack-year smoking = primary lung cancer,
• multiple lesions = mets) → cut it out
• Dx laryngoscopy w/ bx
• Tx surgical resection (local) or chemoradiation
• (invasive or mets)
Management
• Dx CXR (blunting of costophrenic angle),
• confirm w/ thoracentesis/pleural fluid analysis
• transudative → Tx diuretics + Na+ restriction
• exudative → Tx underlying disease
• parapneumonic → abx ± chest tube drainage
• Dx CXR (unilateral “white out”) or CT scan
• Tx abx + insert chest tube, evacuate pus
• collection, then re-expand the lung
• Dx CXR (visceral pleura line or “deep sulcus
• sign”)
• small (<15%) → observation
• large (>15%) → Tx chest tube
• recurrent → Tx pleurodesis (scraping vs. talc)
• get CXR after chest tube, thoracentesis, or
• central line to r/o iatrogenic PTX
• Dx clinical judgment (do not wait for a CXR)
• Tx emergent needle thoracostomy (2nd •
• intercostal space) + insert chest tube
• Dx CT scan (thick pleural walls)
• Tx extrapleural pneumonectomy (high rate of
• morbidity/mortality)
STEP 2 × PULMONARY
Other
Complications: SPHERE – SVC
syndrome, Pancoast tumor →
Horner syndrome, Endocrine
(paraneoplastic), Recurrent
laryngeal nerve (hoarseness),
Effusions (pleural or pericardial)
Lambert-Eaton myasthenic
syndrome (LEMS): SCLC → anti-
VGCC antibodies → myasthenia
gravis-like presentation
Paraneoplastic syndromes:
squamous cell makes PTH-rP,
SCLC makes ADH and ACTH
Risk factors: EtOH and smoking
are synergistic
Other
Light criteria: pleural fluid is
exudative if any of the following
– p/s protein >0.5, p/s LDH >0.6,
p LDH >2/3 upper limit of normal
Pleural fluid analysis:
• ↑amylase = Boerhaave (saliva),
• pancreatitis, cancer
• milky fluid = chylothorax
• purulent fluid = empyema
• bloody fluid = cancer
• ↑lymphocytes = TB
• pH <7.2 = empyema or
• parapneumonic effusion
• glucose <60 = being used up by
• WBCs, consider RA
1° spontaneous PTX: rupture of
apical blebs in thin, tall, healthy
young men
2° spontaneous PTX: due to
underlying lung dz (MCC COPD)
Iatrogenic PTX: s/p chest tube,
thoracentesis, or central line
Etiology: asbestos exposure
(especially shipyards, rooftops),
synergistic w/ smoking
 STEP 2 × PULMONARY

INTERSTITIAL LUNG DZ ILD presentation: dyspnea, nonproductive cough, fatigue

ILD management: Dx screen w/ PFTs (↓TLC, ↑FEV1/FVC), confirm w/ CXR + tissue bx

“Honeycomb lung”: scarred, shrunken lung w/ dilated air spaces; indicates end-stage ILD

Dz Presentation Management Other

Idiopathic pulmonary fibrosis (classic ILD sx) → death in 5 yrs
(IPF)
Sarcoidosis young black female w/
respiratory sx, erythema
nodosum, and blurry vision
(anterior uveitis)
Asbestosis exposure to shipyards, naval
bases, rooftops → inhalation of
asbestos → fibrosis of lower
lungs + pleural plaques
Silicosis exposure to mining, glass
manufacturing, sandblasting →
inhalation of silicon → fibrosis
of upper lungs
Coal worker disease exposure to coal mining →
inhalation of coal dust →
(classic ILD sx)
Berylliosis exposure to electronics →
inhalation of beryllium →
(classic ILD sx)
Wegener granulomatosis triad of necrotizing vasculitis,
necrotizing granulomas in lungs
and upper respiratory tract
(“saddle nose”), and
necrotizing glomerulonephritis
→ hematuria + hemoptysis
Goodpasture syndrome anti-GBM antibodies attack
alveolar and glomerular
basement membrane (type II)
→ hematuria + hemoptysis
Radiation pneumonitis pulmonary fibrosis s/p radiation
for lung or breast cancer; ↑risk
of late-onset secondary cancer
Drug-induced pulmonary pulmonary fibrosis s/p
fibrosis amiodarone, busulfan,
bleomycin, MTX, nitrofurantoin
• Dx CXR (honeycomb lungs w/ “temporal
• heterogeneity”)
• Tx steroids (temporary), lung txp (definitive)
• Dx CXR (bilateral hilar LAD) Complications: GRAINeD – ↑IgG,
• Dx tissue bx (noncaseating granulomas) rheumatoid arthritis, ↑ACE, ILD,
• Tx steroids noncaseating granulomas, ↑1α-
hydroxylase → ↑vitamin D
• Dx CXR (lower lung fibrosis + pleural plaques) Complications: bronchogenic
• Dx tissue bx (ferruginous bodies) carcinoma >> mesothelioma
• Dx CXR (upper lung fibrosis + “egg shell” Complications: ↑risk of TB infx
• calcifications)
--- Caplan syndrome: rheumatoid
nodules + pneumoconiosis
• Dx beryllium lymphocyte proliferation test
• Tx chronic steroids
• Dx ↑c-ANCA
• Dx tissue bx (necrotizing granulomas)
• Tx cyclophosphamide
• Dx anti-GBM antibodies
• Dx tissue bx (“linear staining”)
• Tx steroids + plasmapheresis
• Dx CT scan shows diffuse infiltrates (CXR is
• usually normal)
• Tx steroids
• PPx not useful
• Tx d/c meds

RESPIRATORY FAILURE Dz Presentation Management Other

Acute respiratory failure
hypoxemia (PaO2 <60) or
hypercapnia (PCO2 >50) →
dyspnea, tachypnea, cough,
respiratory distress, etc.
• Dx ABG analysis
• ↑A-a, corrects w/ O2 → V/Q mismatch
• ↑A-a, doesn’t correct w/ O2 → shunting
• nl A-a, ↑CO2 → hypoventilation
• nl A-a, nl CO2 → ↓inspired O2

• Tx underlying cause + supplemental O2,

Acute respiratory distress
syndrome (ARDS)
diffuse inflammatory response
→ neutrophil activation →
interstitial damage and alveolar
collapse → massive shunting →
dyspnea + respiratory distress
• have low threshold for intubation
• Dx CXR (bilateral “white-out” of lungs),
• ABG anaylsis (↑A-a, doesn’t correct w/ O2),
• PaO2:FiO2 ratio <200 (normally 300-500)
• Tx ventilation w/ ↓FiO2 (prevent O2 toxicity) +
• ↑PEEP (keep alveoli open)
Etiology: septic shock (MCC),
aspiration pneumonia, trauma
ARDS vs. cardiogenic shock:
cardiogenic shock has PCWP ≥18,
ARDS has PCWP <18 (normal)

VENTILATION Key parameters: RR and VT control CO2

FiO2 and PEEP control O2

Tracheomalacia: softening of tracheal cartilage w/ prolonged ventilation; PPx tracheostomy if ventilator-dependent for >3 wks
↑PEEP complications: tension PTX, alveolar barotrauma
↑FiO2 complications: oxygen toxicity
Succinylcholine toxicity: used for sedation prior to intubation; can cause ↑K (c/i in hyper-K pts)

PULMONARY VX DZ Dz Presentation
Pulmonary hypertension (PH) PA pressure >25 (rest) or >30
(exercise) → presents as
exertional dyspnea, fatigue
1° pulmonary hypertension ∆BMPR2 → uninhibited smooth
(PPH) muscle growth → ↑pulmonary
resistance → PH w/o underlying
cause (dx of exclusion)
Pulmonary embolism (PE) acute-onset pleuritic chest pain,
dyspnea, hyperventilation,
hemoptysis, right-sided heart
failure → death
OTHER LUNG DZ Dz Presentation
Aspiration pneumonitis either acute-onset respiratory
distress, or delayed-onset of
respiratory sx (cough, SOB,
fever, tachypnea, dypsnea, etc.)
Obstructive sleep apnea (OSA) intermittent airflow obstruction
→ episodic apenic periods →
snoring + fragmented sleep →
daytime sleepiness, brain
damage, HTN/pulmonary HTN
Atelectasis localized alveolar collapse →
fever POD#1 s/p surgery
Massive hemoptysis coughing >100 mL blood/24 hrs
Pulmonary contusions blunt chest trauma (e.g. MVC)
→ delayed-onset pulmonary
edema + respiratory distress sx,
exacerbated by IV fluids
PEDS PULMONARY Dz Presentation
Croup parainfluenza infx of larynx →
“barking” cough, low-grade
fever, inspiratory stridor
Epiglottitis H. flu infx of epiglottis → sore
throat, fever, inspiratory
stridor, drooling, “sitting on a
table leaning forward”
Bronchiolitis RSV infx during wintertime →
bronchiolar inflammation →
wheezing, URI sx, respiratory
distress
Pertussis Bordetella pertussis via
respiratory droplets →
“whooping cough” (short
paroxysms of cough followed
by loud inspiratory sound)
Neonatal RDS (hyaline prematurity (<34 wks) or infant
membrane disease) of diabetic mother (↑insulin
blocks cortisol) → lack of
surfactant → respiratory
distress in a newborn
Meconium aspiration syndrome suspect w/ meconium staining,
low Apgar scores, respiratory
distress in a newborn
Cystic fibrosis (CF) AR ΔCFTR (ΔF508) → thick
mucus → recurrent
Pseudomonas pneumonia,
bronchiectasis, infertility,
chronic pancreatitis →
malabsorption/steatorrhea +
type 1 DM, meconium ileus (rare
but pathognomonic), focal
biliary cirrhosis, nasal polyps
Vascular rings congenital abnormalities of
aortic arch/branches → rings
around airway can compromise
ventilation → inspiratory
stridor relieved w/ opisthotonic
position (crowing respiration)
Management
• Dx auscultation (loud S2 + subtle sternal lift)
• Tx underlying cause ± bosentan
• Dx auscultation (loud S2 + subtle sternal lift)
• Tx pulmonary vasodilators (CCB) + lung txp
• high-suspicion → start heparin before dx tests
• Dx D-dimer to r/o, CTPA or V/Q to confirm
• Tx heparin + warfarin
• recurrent PE or anti-coag contraindicated
• (recent surgery, hemorrhagic stroke, active
• bleed, bleeding d/o) → Tx IVC filter
Management
• Dx CXR (right lower lobe infiltrate)
• Tx ABCs, O2 mask, supportive care
• aspiration PNA → Tx clinda (for anaerobes)
• obstruction → Tx rigid bronchoscopy
• Dx polysomnography
• mild/moderate → Tx weight loss
• severe → Tx CPAP
• refractory → Tx surgery
• Tx incentive spirometry, early ambulation
• first step is to intubate (protect airway)
• Tx bronchoscopy (visualize and stabilize
• bleeding site)
• Dx CXR (bilateral patchy infiltrates)
• Tx close monitoring, intubation if severe
Management
• Dx AP neck X-ray (“steeple sign”)
• Tx inhaled steroids + O2 therapy > racemic
• epinephrine > intubation
• Dx lateral neck X-ray (“thumbprint sign”)
• hypoxic → skip the X-ray
• Tx emergent intubation + IV ceftriaxone
• Dx CXR (lung hyperinflation, patchy infiltrates)
• Tx supportive care w/ monitoring of O2 and
• hydration status
• Dx CBC (↑lymphocytes), confirm w/
• nasopharyngeal swab if necessary
• Tx azithromycin for pt + all close contacts
• (regardless of immunization status)
• Dx L:SM ratio <2 or ↓phosphatidylglycerol in
• amniotic fluid
• Tx surfactant + O2 therapy + CPAP
• PPx tocolytics + betamethasone for 48 hrs in
• deliveries <34 wks
• Tx tracheal suction + O2 mask, intubation if
• severe distress
• Dx sweat chloride test x2 (>60)
• Tx pancreatic enzymes + vitamins ADEK +
• chest physiotherapy + mucolytics (DNAse,
• N-acetylcysteine)
• Tx surgical repair
STEP 2 × PULMONARY
Other
Cor pulmonale: PH + RVH
PE on EKG: sinus tachycardia is
more common than S1Q3T3
Fat embolism: PE sx + petechiae
in a pt w/ long bone fx
Amniotic fluid embolism: PE sx
s/p amniocentesis
Other
Etiology: gastric aspirates (can
lead to ARDS), oral flora (can
lead to abscess), foreign bodies
Risk factors: ∆MS, alcoholics,
instrumentation, esophageal d/o
Pickwickian syndrome: morbid
obesity → severe OSA → chronic
↓O2/↑CO2 respiratory failure,
reactive polycythemia, PH, cor
pulmonale
Complications: pneumonia on
POD#3 if atelectasis unresolved
Other
Complications: ↑risk of
developing asthma
Pertussis vs. CML: both can have
WBC >50, but pertussis has ↑LAP
score and CML has ↓LAP score
Complications: ↑risk of
developing asthma
Complications: ↑risk of
developing asthma
Meconium ileus: impacted
meconium in GI tract → bowel
obstruction → feculent vomiting

ORAL/ESOPHAGEAL DZ Dz
Salivary obstruction
Dysphagia
Esophageal cancer
Achalasia
Diffuse esophageal spasm (DES)
Hiatal hernia
Mallory-Weiss syndrome
Boerhaave syndrome
Plummer-Vinson syndrome
Schatzki ring
Esophageal divertula
Gastroesophageal reflux
disease (GERD)
Presentation
obstruction due to stone,
inflammation, or cancer →
enlarged painful glands, worse
w/ eating
“food stuck in throat”, solids
only = mechanical cause, solids
and liquids = neuromuscular
dysphagia of solids > liquids +
weight loss ± odynophagia (if
severe)
SCC: found in upper 2/3, due to
smoking and EtOH abuse
Adenocarcinoma: found in
lower 1/3, due to GERD/Barrett
hypertonic and nonrelaxing LES
w/ poorly relaxing esophagus
→ dysphagia of liquids > solids
uncoordinated esophageal
peristalsis → dysphagia +
angina-like chest pain
Type 1 HH: sliding hernia, can
present as GERD or reflux
esophagitis
Type 2 HH: paraesophageal
hernia, high risk of incarceration
and strangulation
retching → laceration of lower
esophagus → UGIB
retching → perforation of lower
esophagus → epigastric pain,
fever, pneumomediastinum
(Hamman crunch)
iron deficiency → microcytic
anemia, upper esophageal webs
(dysphagia), koilonychia
ingestion of acids, alkali, bleach,
detergents → lower esophageal
webs (dysphagia)
Zenker diverticulum: lack of
cricopharyngeal relaxation →
diverticuli at upper esophagus
→ food gets stuck → halitosis +
dysphagia
Traction diverticulum: TB or
cancer → LAD cause traction →
diverticuli at mid esophagus
Epiphrenic diverticulum:
esophageal motility d/o →
diverticuli at lower esophagus
↓LES tone → retrograde flow of
stomach contents into
esophagus → heartburn,
regurgitation, waterbrash,
nocturnal cough
Barrett esophagus: intestinal
metaplasia of esophageal lining
STEP 2 × GI
Management Other
• Tx warm compresses, gentle massage; Surgical complications: facial
• surgery if cancer paralysis (damage to CN VII)
• Dx barium swallow then EGD (risk of perf)
• Tx underlying cause
• Dx EGD w/ bx, then staging via endoscopic U/S
• or CT scan
• upper 1/3 → Tx chemoradiation
• middle 1/3 → Tx chemoradiation then
• esophagectomy
• lower 1/3 → Tx esophagectomy + proximal
• gastrectomy
• Dx screen w/ barium swallow (“bird beak”), Chagas dz: Trypanosoma cruzi
• confirm w/ manometry (↑LES pressure) infx in S. America → DCM +
• Tx botox vs. Heller myotomy achalasia + megacolon
Achalasia vs. scleroderma:
• high-risk pts → Dx EGD to r/o pseudoachalasia achalasia has ↑LES tone,
• (achalasia-like sx 2/2 esophageal cancer) scleroderma has ↓LES tone
• first step is EKG + cardiac enzymes (r/o MI) DES vs. angina: NTG is unreliable
• Dx screen w/ barium swallow (“corkscrew”), since it can relieve pain of both
• confirm w/ manometry (uncoordinated)
• Tx nifedipine, NTG
• Dx barium swallow
• Tx PPIs vs. lap Nissen
• Dx barium swallow
• Tx surgical repair
• Dx EGD Etiology: alcoholics (MCC),
• Tx observation (bleeding stops on its own) hyperemesis gravidarum, etc.
• Dx barium swallow Etiology: alcoholics (MCC),
• Tx emergent surgical repair hyperemesis gravidarum, etc.
• Tx esophageal dilatation + PO FeSO4
• dysphagia → Tx esophageal dilatation Complications: esophageal
• full-thickness necrosis → Tx esophagectomy stricture or cancer
• Dx barium swallow
• Tx cricopharyngeal myotomy
• Dx barium swallow
• Tx underlying cause
• Dx barium swallow
• Tx esophagomyotomy
• Dx 24hr pH monitoring (gold standard) Complications: erosive
• Tx dietary changes (↓chocolate, caffeine, esophagitis, peptic strictures,
• EtOH, soda, etc.) esophageal ulcers, Barrett
• refractory → Tx PPIs, lap Nissen if severe esophagus, recurrent PNA w/
lipid-laden macrophages
• BE + no dysplasia → Tx PPIs
• BE + low-grade dysplasia → Tx lap Nissen +
• annual surveillance
• BE + hi-grade dysplasia → Tx esophagectomy

STOMACH DZ H. pylori: GNB responsible for PUD, gastric adenocarcinoma, gastric lymphoma; Dx serology > stool ag > urease breath test, Tx triple therapy
Dz Presentation
Peptic ulcer disease (PUD) burning or gnawing epigastric
pain, either relieved (DU) or
exacerbated (GU) by eating
Perforated ulcer: anterior
ulcers → severe abd pain,
hemodynamic instability
Gastric outlet obstruction: early
satiety, nausea/vomiting
Bleeding ulcer: posterior ulcers
erode into GDA → iron-
deficiency anemia (chronic) or
hemorrhagic shock (acute)
Gastritis inflammation of gastric mucosa
→ burning or gnawing
epigastric pain
Acute gastritis: erosive, due to
chronic ASA or NSAID use
Chronic gastritis: nonerosive,
due to H. pylori or pernicious
anemia
Gastric adenocarcinoma presents as epigastric abd pain,
weight loss, early satiety, etc.
Linitis plastica: “leather bottle”
stomach due to full thickness
infiltration and fibrosis, poor px
Gastric lymphoma presents as epigastric abd pain,
weight loss, early satiety, etc.
SI DZ Dz Presentation
Celiac sprue gluten hypersensitivity → villi
atrophy w/ dietary wheat →
malabsorption (steatorrhea,
weight loss, bloating, etc.)
Tropical sprue malabsorption + megaloblastic
anemia in a pt from the tropics
Lactose intolerance lactase deficiency in SI lining →
osmotic diarrhea after dairy
consumption
Whipple disease Tropheryma whippelii infx →
malabsorption + migratory
arthritis, general LAD, CNS sx
Small bowel obstruction (SBO) colicky abd pain, bilious
vomiting, constipation;
obstipation (no flatus) =
complete SBO
Irritable bowel syndrome (IBS) altered bowel habits (diarrhea,
constipation, or both) + chronic
abdominal pain that improves
w/ defecation
APPENDIX DZ Dz Presentation
Acute appendicitis lymphoid hyperplasia or fecalith
in appendix → ischemia → infx
and necrosis → perforation
Nonruptured sx: umbilical abd
pain that migrates to RLQ
Ruptured sx: severe abd pain w/
guarding in all 4 quadrants
Carcinoid tumor neuroendocrine tumor that
secretes 5-HT, most commonly
found in appendix (no systemic
effects b/c liver metabolism)
Carcinoid syndrome: metastasis
of carcinoid tumor to liver →
systemic 5-HT effects → flush +
diarrhea + wheezing + TIPS
(tricuspid insufficiency,
pulmonary stenosis)
Management
• Dx EGD + H. pylori serology
• Tx PPIs
• H. pylori → Tx triple therapy (PPI + 2 abx)
• refractory → Dx gastrin (r/o Zollinger-Ellison)
• Dx CXR (pneumoperitoneum)
• Tx emergent surgical repair
• Dx barium swallow
• Tx NPO/IVF/NG tube, then surgical repair
• Dx EGD
• chronic → Tx PPI drip
• acute → Tx PPI drip + surgical repair
• Dx EGD + H. pylori serology
• Tx PPIs
• acute gastritis → d/c NSAIDs
• chronic gastritis → Tx triple therapy (H. pylori)
• or B12 replacement (pernicious anemia)
• Dx EGD w/ bx, then CT scan for staging
• proximal 2/3 → Tx total gastrectomy + chemo
• distal 1/3 → Tx subtotal gastrectomy + chemo
• f/u CEA tumor marker
• Dx EGD w/ bx
• Tx triple therapy for H. pylori
Management
• Dx anti-gliadin or anti-endomysial ab
• Tx dietary restriction
• refractory diarrhea → Dx CT scan to r/o
• intestinal lymphoma
• r/o celiac sprue
• Tx tetracycline + folate supplements
• Dx hydrogen breath test
• Tx dietary restriction
• Dx SI bx (PAS+ material)
• Tx Bactrim or ceftriaxone
• Dx KUB (dilated loops w/ air-fluid levels)
• partial → Tx NPO/IVF/NG tube, observation
• complete or strangulated → Tx laparotomy
• adhesions → Tx LOA + resect dead gut
• hernias → Tx herniorrhaphy + resect dead gut
• r/o organic causes w/ CBC, FOBT
• constipation → Tx high-fiber diet
• diarrhea → Tx loperamide
Management
• Dx CT scan + CBC (↑WBC) + β-HCG (r/o ectopic
• in females)
• high suspicion → no need for imaging
• Tx appendectomy
• perforated appendicitis → cool off w/ abx
• then schedule elective appy
• Dx CT scan
• <2 cm → Tx appendectomy
• >2 cm → Tx right hemicolectomy
• Dx ↑urinary 5-HIAA
• Tx surgical resection
• nonsurgical candidate → Tx octreotide
STEP 2 × GI
Other
Dumping syndrome: high-carb
meal after gastrectomy → insulin
overload → hypoglycemia →
epinephrine → sympathetic sx;
Tx acarbose
Afferent loop syndrome: abd
pain after gastrectomy, relieved
by bilious vomiting; Tx surgery
vs. sucralfate
Bacterial overgrowth syndrome:
malabsorption after gastrectomy
w/ “succusion splash” from fluid-
filled loops of bowel; Tx PO abx
Krukenberg tumor: ovarian mets
(bx shows “signet ring” cells)
SMJ node: periumbilical LN mets
Virchow node: left supra-
clavicular LN mets
Risk factors: type A blood ,
Japanese (smoked food), EtOH,
smoking, vit C deficiency
Other
Dermatitis herpetiformis: skin
lesions found in celiac sprue, Tx
Dapsone
Risk factors: adhesions from
prior abdominal surgery (MCC),
strangulated hernias (#2)
SBO vs. paralytic ileus: SBO has
bowel sounds, paralytic ileus
doesn’t
Risk factors: depression, anxiety,
women w/ axis II diagnoses
Other
Pellagra: use up tryptophan
stores making 5-HT → niacin
deficiency → 3 Ds – diarrhea,
dermatitis, dementia

COLON DZ Dz Presentation
Colorectal cancer (CRC) “left-side obstructs, right-side
bleeds”
Proximal colon: bleeding →
melena, iron-deficiency anemia,
fatigue, dull abd pain
Distal colon: obstruction →
colicky abd pain, “pencil-thin
poop”
Rectal cancer: hematochezia,
rectal mass, tenesmus
Metastatic: portal drainage to
liver → jaundice, ↑LFTs
Polyps asx
Diverticulosis low-fiber diet → need more
strain to poop → outpouching
of sigmoid colon → erosion →
painless LGIB
Diverticulitis fecalith impacts in diverticuli →
necrosis → infx → “left-sided
appendicitis”
Angiodysplasia (vascular AV malformation in submucosa
ectasia) of colon wall → erosion →
painless LGIB
Mesenteric ischemia compromised blood supply to
mesenteric circulation →
ischemia → diffuse abd pain
“out of proportion to exam” w/
“food fear”
Arterial embolism: MC type,
from Afib, most sudden/severe
Arterial thrombosis: athero-
sclerotic, gradual onset
Nonocclusive ischemia (NOMI):
due to ↓CO, seen in critically ill
pts on multiple pressors
Venous thrombosis: rare, due
to hypercoagulable states
Volvulus twisting of redundant bowel →
acute-onset colicky pain,
obstipation, nausea/vomiting
Ogilvie syndrome colonic pseudoobstruction w/o
mechanical cause → bloating,
obstipation, nausea/vomiting
RECTAL DZ Dz Presentation
Hemorrhoids Internal hemorrhoids: dilated
superior rectal veins → BRBPR,
can prolapse, painless
External hemorrhoids: dilated
inferior rectal veins → BRBPR,
can thrombose, painful
Anal fissures strained defecation or buttsex
→ painful, bleeding tears in
posterior wall of anus
Perirectal abscess (“butt pus”) throbbing rectal pain
Rectal fistula fistula formation 2/2 perirectal
abscess or IBD → mild pain,
“dirty underwear”
Pilonidal cysts infected hair follicle in superior
midline gluteal cleft → abscess
formation
STEP 2 × GI
Management Other
• >50 y/o → colonoscopy screen q 10 yrs Risk factors: old age (>50),
• Dx screen w/ FOBT, confirm w/ barium enema villous adenomas, IBD, family hx,
• (“apple core”) or colonoscopy low-fiber diet, major polyposis
syndromes
FAP: AD ∆APC → thousands of
polyps → 100% become CRC
Gardner syndrome: FAP +
osteomas, soft tissue tumors
Turcot syndrome: FAP + CNS
tumors
Peutz-Jeghers syndrome:
• multiple nonmalignant
hamartomas throughout GI tract
• Duke stage A/B → Tx surgery w/ perioral pigmented spots
• Duke stage C/D → Tx surgery + chemotherapy HNPCC/Lynch syndrome: colon
• FAP → Tx prophylactic colectomy cancer + endometrial cancer
• f/u CEA tumor marker
• Dx colonoscopy Hyperplastic polyps: MC type,
• Tx polypectomy leave alone, no malig potential
Adenomatous polyps: high risk
of malig potential, worst types
are large villous polyps
• Dx barium enema Complications: iron-deficiency
• Tx stool softeners (high-fiber diet, psyllium) anemia, hypovolemic shock,
diverticulitis
• Dx CT scan Complications: abscess, bowel
• first episode → Tx IVF, NPO, IV abx obstruction, colovesical fistulas,
• complicated or recurrent →Tx sigmoid perforation
• colectomy (“two and out”)
• Dx colonoscopy Heyde syndrome: angiodysplasia
• Tx observation (90% stop spontaneously), + aortic stenosis
• colonoscopy w/ coagulation (2nd line)
• Dx ↑LDH, CT scan (pneumatosis, bowel wall
• thickening, “thumbprint sign”)
• Tx IVF, NPO, IV abx; intra-arterial papaverine if
• arterial, heparin if venous
• dead gut → Tx surgical resection
• Dx KUB (Omega loop sign = sigmoid volvulus,
• coffee bean sign = cecal volvulus)
• sigmoid volvulus → Tx colonoscopic
• decompression ± elective surgery
• cecal volvulus → Tx emergent surgery
• Dx KUB Risk factors: surgery or trauma,
• Tx underlying cause + supportive care elderly, serious medical illnesses,
• refractory → Tx decompressive colonoscopy > drugs (e.g. opiates)
• neostigmine
• cecum >10 cm → Tx emergent decompression
Management Other
• Tx stool softeners, sitz baths, steroid
• suppository
• severe → Tx surgery or rubber band ligation
• Tx stool softeners, topical NTG (for spasms)
• Tx I+D
• Tx fistulotomy
• Tx I+D

GI BLEEDING Dz Presentation
Upper GI bleed (UGIB) GI bleed proximal to Ligament
of Treitz → hematemesis,
melena, hematochezia (if rapid)
Lower GI bleed (LGIB) GI bleed distal to Ligament of
Treitz → hematochezia, melena
(if slow)
IBD IBD: Crohn disease and ulcerative colitis
HLA-B27: PAIR – psoriatic arthritis, ankylosing spondylitis, IBD, Reiter syndrome
Dz Presentation
Crohn disease flare-and-remission pattern of
crampy abd pain, watery
diarrhea, recent weight loss
Ulcerative colitis flare-and-remission pattern of
crampy abd pain, bloody
diarrhea, recent weight loss
Toxic megacolon: huge flare
paralyzes the colon → fever,
bloody diarrhea, abd distention
Management
• Dx NG tube aspirate/lavage
• +blood/±bile = UGIB → Dx/Tx EGD
• –blood/+bile = LGIB → Dx colonoscopy
• minimal BRBPR → Dx anoscopy (likely rectal)
• unable to localize → Dx tagged RBC scan
• Tx underlying cause
Management
• Dx ↑ASCA
• Dx barium enema (terminal ileal “string sign”),
• colonoscopy w/ bx (transmural, noncaseating
• granulomas, creeping fat)
• Tx steroids + 5-ASA (sulfsalazine)
• Dx ↑p-ANCA
• Dx barium enema (“lead pipe sign”),
• colonoscopy w/ bx (mucosa only, crypt
• abscesses, pseudopolyps)
• Tx steroids + 5-ASA (sulfsalazine)
• refractory → Tx total colectomy
• f/u annual colonoscopy
• Dx KUB (dilated colon)
• Tx NPO/IVF/NG tube, IV steroids
STEP 2 × GI
Other
Etiology: PUD (#1), NSAIDs (#2),
esophageal varices (#3)
UGIB in ICU pt: stress ulcer
UGIB in alcoholics: esophageal
varices, Mallory-Weiss tear
UGIB s/p aortic graft: aorto-
enteric fistula (small herald bleed
followed by massive UGIB)
Etiology: diverticulosis (#1), AVM
(#2), colon cancer (#3)
LGIB in kids: Meckel diverticulum
(Dx technetium scan)
Other
Location: “mouth to anus” w/
skip lesions, terminal ileum is MC
site
Complications: erythema
nodosum, SBO, fissures/fistulas
Location: colorectal only,
continuous lesions
Complications: colon cancer,
pyoderma gangrenosum, PSC →
cholangiocarcinoma, toxic
megacolon
 STEP 2 × GI

PEDS GI Dz Presentation Management Other

Esophageal atresia/TE fistula
Duodenal atresia
Intestinal atresia
Pyloric stenosis
Necrotizing enterocolitis (NEC)
Hirschsprung disease
Intussusception
Meckel diverticulum
Neonatal jaundice
Failure to thrive (FTT)
Infantile GERD
Omphalocele
Gastroschisis
Reye syndrome
Neonatal volvulus
drooling/choking on first feed
neonate w/ bilious vomiting +
polyhydramnios (can’t swallow
amniotic fluid); ↑risk w/ Down
syndrome
aka “apple peel” atresia;
vascular accidents in utero →
duodenal atresia-like sx
non-bilious projectile vomiting
in 1-month-old firstborn boys w/
“palpable epigastric olive”
abdominal distention, vomiting,
GI bleed, decreased bowel
sounds; ↑risk w/ prematurity
lack of nerves in distal colon →
chronic constipation since birth;
↑risk w/ Down syndrome
colicky abdominal pain +
bloody/mucoid “currant jelly”
stools; ↑risk w/ Henoch-
Schonlein purpura
remnant of vitelline duct →
MCC painless LGIB in a child
hyperbili due to breastmilk,
breastfeeding failure, neonatal
sepsis, hypothyroidism, or other
congenital abnormalities
Breastmilk jaundice: breastmilk
contains glucuronidase and
indirect bili → indirect hyperbili
>1 wk old
Breastfeeding failure jaundice:
failure to feed correctly →
↑enterohepatic circulation →
indirect hyperbili <1 wk old
Biliary atresia: lack of CBD →
progressive direct hyperbili
Choledochal cyst: cyst in CBD
→ biliary tree obstruction →
progressive direct hyperbili
growth <5th percentile in 2+ of
the following – height, weight,
head circumference; most
commonly due to nonorganic
causes
frequent vomiting (nonbloody,
nonbilious) in kids <1 y/o,
normal weight gain
intestines protrude into
umbilical cord w/ peritoneal
covering, ↑risk of associated
cardiac defects
intestines tear through abd wall
w/o peritoneal covering
viral infx + ASA = fatty liver/liver
failure, vomiting, AMS, 40%
mortality rate (due to cerebral
edema → herniation)
twisting of redundant bowel →
abdominal distention, bilious
vomiting, bloody stools
• Dx CXR (coiled NG tube)
• Tx surgical repair
• Dx KUB (“double bubble” appearance)
• Tx surgical repair
• Dx KUB (“triple bubble” appearance)
• Tx surgical repair
• Dx abdominal U/S Electrolyte imbalance:
• replete electrolytes before surgery hypochloremic, hypokalemic
• Tx pyloromyotomy metabolic alkalosis
• Dx KUB (pneumatosis intestinalis)
• unperforated → Tx NPO/IVF/abx
• perforated → Tx surgical resection
• Dx rectal bx (no ganglia) Blast sign: blast of stool w/ rectal
• Tx surgical pull-through exam
• Dx palpable RUQ “sausage-like mass”
• Dx/Tx barium/air contrast enema
• Dx technetium scan (ectopic gastric mucosa)
• asx → reassurance
• sx → Tx surgical resection
• Dx LFTs (T-bili >15, D-bili >2, or jaundice within Kernicterus: bili >20 → deposit in
• 24 hrs indicates pathologic cause) basal ganglia → brain damage
• physiologic → Tx phototherapy Jaundice w/o scleral icterus:
• pathologic → Tx underlying cause hypercarotenemia (kid eats too
• Tx temporary stop feeds many carrots), benign
• Tx feed baby correctly
• Dx abdominal U/S, confirm w/ HIDA scan
• Tx hepatoenterostomy (Kasai procedure)
• Dx abdominal U/S, confirm w/ HIDA scan
• Tx surgical excision
• Dx bone age (left wrist X-ray) Constitutional growth delay:
• Tx underlying cause bone age < real age, tracks along
low percentile on growth chart,
good prognosis
Familial short stature: bone age
= real age, usually have short
parents, poor prognosis
• Tx thickened feeds + upright positioning
• first step is sterile wrapping
• Tx closure if small, silo if large
• get echo to r/o cardiac defects
• first step is sterile wrapping
• Tx closure if small, silo if large
• don’t give ASA to kids
• if you have to give ASA (e.g. Kawasaki dz),
• make sure vaccinations are up to date
• Dx KUB
• Tx surgical correction
 STEP 2 × HEPATOBILIARY/PANCREATIC

LIVER DZ Dz Presentation Management Other

Cirrhosis
Wilson disease
(hepatolenticular degeneration)
Hemochromatosis (bronze
diabetes)
Hepatic adenoma
Cavernous hemangioma
Focal nodular hyperplasia (FNH)
Hepatocellular carcinoma (HCC)
Nonalcoholic steatohepatitis
(NASH)
Congenital hyperbilirubinemia
syndromes
Hemobilia
Liver cysts
Liver abscess
Budd-Chiari syndrome
Autoimmune hepatitis
fibrosis → disruption of liver
architecture → portal HTN +
impaired biosynthetic function
→ multiple complications
Varices: portal HTN → dilated
veins in butt (hemorrhoids), gut
(esophageal varices), and caput
(caput medusae)
Ascites: portal HTN + hypo-
albuminemia → fluid
accumulation in abd cavity
Hepatic encephalopathy: ↑NH4
→ neurotransmitter imbalance
→ ∆MS, asterixis (“liver flap”),
hyperreflexia, fetor hepaticus
Hepatorenal syndrome: ESRD
2/2 cirrhosis despite otherwise
normal kidneys
Spontaneous bacterial
peritonitis (SBP): infx of ascitic
fluid → abd pain, fever, n/v,
rebound tenderness
Hyperestrinism: ↑estrogen →
spider angiomas, palmar
erythema, gynecomastia,
testicular atrophy
Coagulopathy: ↓clotting factor
synthesis → ↑risk of bleeding
AR ∆copper ATPase → copper
accumulation in liver (cirrhosis),
corneas (Kayser-Fleischer rings),
brain (movement d/o), RBCs
(schistocytes)
↑iron → accumulation in liver
(cirrhosis), heart (RCM + AV
block), joints (arthritis), skin
(bronze suntan), pancreas (DM)
usually asx, can present as
hypovolemic shock and
distended abdomen if ruptured
usually asx, MC benign liver
tumor
usually asx
vague RUQ pain and mass +
s/sx of chronic liver dz (portal
HTN, ascites, jaundice)
fatty liver in an obese,
nonalcoholic pt
Gilbert syndrome: AD ∆UDP-
glucuronyltransferase → mild
indirect hyperbili
Crigler-Najjar syndrome: severe
indirect hyperbili
Dubin-Johnson syndrome: mild
direct hyperbili + “black liver”
Rotor syndrome: mild direct
hyperbili + normal liver
injury to liver or biliary tract →
blood drains into duodenum via
CBD → UGIB, jaundice, RUQ
pain
Polycystic liver: ADPKD →
simple cysts in kidneys and liver
Hydatid cysts: Echinococcus
granulosus (dog tapeworm) →
multilocular cyst w/ calcified
walls
RUQ pain, fever
hepatic vein thrombosis →
hepatic congestion + portal
HTN → hepatomegaly, RUQ
pain, ascites, jaundice
autoimmune attack on liver →
RUQ pain, jaundice, etc.
• Dx U/S or liver bx Etiology: alcohol (MCC), HBV and
• screen all pts for esophageal varices via EGD HCV (2nd), other causes
• Tx liver txp (must be sober for 6 mo)
Child classification: stratifies risk
• PPx β-blockers of surgery in pts w/ liver failure;
• bleeding esophageal varices → Tx band the measure albumin, bilirubin, INR,
• varices + give FFP for ↑INR encephalopathy, ascites
• Dx PE (shifting dullness, fluid wave) + SAAG: [serum albumin – ascites
• paracentesis (to determine cause) albumin], >1.1 indicates ascites is
• Tx SALT – salt restriction > Aldactone > Lasix > due to portal HTN
• therapeutic paracentesis
• Tx lactulose (nonabsorbable disaccharide Refractory pleural effusions 2/2
• prevents NH4 absorption) + neomycin (kills GI cirrhosis: Tx TIPS
• flora that make NH4) + low protein diet
• Tx octreotide (temporary), liver txp
• Dx paracentesis (↑WBC)
• Tx IV abx + repeat paracentesis in 2-3 days
---
• Dx ↑INR
• Tx FFP (vit K won’t work)
• Dx ↓ceruloplasmin, ↑AST/ALT, liver bx
• Tx penicillamine (chelates) + zinc (blocks
• absorption)
• Dx ↑ferritin, ↓TIBC, liver bx Hemochromatosis × infx: ↑risk of
• Tx repeated phlebotomies Listeria, Vibrio vulnificus, Yersinia
enterocolitica infx (iron-loving
bacteria)
• Dx CT scan Risk factors: OCP and anabolic
• d/c OCP, if it persists → Tx resection due to steroid use
• possibility of rupture
• Dx CT scan Risk factors: VAT – vinyl chloride,
• Tx reassurance aflatoxin, thorotrast
• Dx CT scan (central stellate scar or sunburst
• pattern)
• Tx reassurance
• Dx screen w/ ↑αFP, confirm w/ CT scan Risk factors: cirrhosis (MCC),
• Tx resection w/ negative margins (as long as A1AT deficiency, Wilson dz,
• there’s no mets) hemochromatosis, smoking,
chemical carcinogens
• Dx mild ↑ALT/AST
• Tx controversial
• Tx reassurance
• Dx arteriogram (gold std); EGD shows Risk factors: trauma (MCC),
• bleeding from ampulla of Vater surgery (ERCP), tumors, infx
• Tx supportive care, stop bleeding if severe
• Tx reassurance
• Tx inject hypertonic saline inside cyst and
• carefully excise it + post-op mebendazole
• multiple, small abscesses → Tx IV abx
• single, large abscess → Tx perc drain
• amebic abscess (in Mexicans) → Tx Flagyl
• Tx TIPS as a “bridge to liver txp” Risk factors: polycythemia vera
(MCC), OCPs (#2)
• Dx ↑anti-smooth muscle ab
• Tx steroids

LFTS ↑AST/ALT (ALT>AST): chronic viral hepatitis (virALT)
↑AST/ALT (AST>ALT): acute alcoholic hepatitis (toAST)
↑↑AST/ALT: acute viral hepatitis, medication-induced liver damage (Tylenol), shock liver
↑↑↑AST/ALT: severe hepatic necrosis
↑AΦ + GGT nl: pregnancy or bone dz (e.g. Paget’s)
↑AΦ + ↑GGT: biliary obstruction
↑bilirubin (direct <20%): hemolytic jaundice
↑bilirubin (direct 20-50%): hepatocellular jaundice (viral or alcoholic hepatitis)
↑bilirubin (direct >50%): obstructive jaundice (cancer, choledocholithiasis)
↓albumin: chronic liver dz, nephrotic syndrome, malnutrition, inflammatory states
BILIARY DZ Post-operative cholestasis: jaundice POD#2-3 s/p major surgery w/ hypotension, massive blood transfusion
Intrahepatic cholestasis of pregnancy: idiopathic biliary stasis → ↑LFTS + ↑bile salts → intense pruritus
Dz Presentation
Gallstone disease
cholelithiasis
fatty meal
passes biliary colic
into CBD lodge/infx
acute cholecystitis
choledocholithiasis
lodge/infx
acute cholangitis lodge
gallstone pancreatitis
Asx cholelithiasis: presence of
stones in GB, usually asx
Sx cholelithiasis: biliary colic
(RUQ pain after fatty meals)
Acute cholecystitis: impacted
stone in cystic duct → infx →
RUQ pain, n/v, Murphy sign
Choledocholithiasis: presence
of stones in CBD
Gallstone pancreatitis:
impacted stone in pancreatic
duct → reflux of pancreatic
enzymes → midepigastric pain
Acute cholangitis: impacted
stone in CBD → infx → Charcot
triad → Reynold pentad
Acalculous cholecystitis acute cholecystitis (RUQ pain,
n/v, Murphy sign) w/o stones,
usually found in ICU pts
Gallbladder adenocarcinoma presents as a mass in GB fossa
1° sclerosing cholangitis (PSC) idiopathic thickening of bile
ducts → narrowed lumens →
gradual jaundice and pruritus
1° biliary cirrhosis (PBC) autoimmune destruction of
intrahepatic bile ducts →
gradual jaundice and pruritus
Cholangiocarcinoma tumor of bile ducts → s/sx of
obstructive jaundice (dark
urine, clay stools, pruritus)
Choledochal cysts cystic dilation of biliary tree →
s/sx of obstructive jaundice
(dark urine, clay stools,
pruritus)
Biliary stricture iatrogenic injury → s/sx of
obstructive jaundice (dark
urine, clay stools, pruritus)
Biliary dyskinesia motor dysfxn of sphincter of
Oddi → recurrent biliary colic
w/o stones
STEP 2 × HEPATOBILIARY/PANCREATIC
AΦ AST
T-bili/D-bili
albumin ALT
Management Other
• Dx RUQ U/S (HIDA scan if inconclusive) + get Boas sign: referred right scapular
• ERCP for choledocholithiasis/acute cholangitis pain of biliary colic
Charcot triad: RUQ pain, fever,
jaundice
Reynold pentad: Charcot triad +
∆MS, hypotension (septic shock)
Gallstone ileus: gallstone enters
bowel through cholecystenteric
fistula → gets stuck at TI → SBO
Emphysematous cholecystitis:
acute cholecystitis w/ gas-
• Tx reassurance forming bacteria in old diabetics
• Tx elective lap chole Post-chole RUQ pain: functional
pain (MCC, Tx analgesics),
• Tx lap chole within 72 hrs sphincter of Oddi dysfxn (Tx
ERCP), CBD stone (Tx ERCP)
• Tx ERCP to remove stone
• if lipase returns to normal → Tx lap chole
• if lipase elevated → Tx ERCP to remove stone,
• then elective lap chole
• Tx ERCP to decompress CBD, then lap chole
• Tx lap chole within 72 hrs
• nonsurgical candidate → Tx perc drain
• Dx CT scan Porcelain GB: dystrophic
• Tx radical cholecystectomy (GB + hilar LN + calcification of GB has 10-30% risk
• liver resection w/ negative margins) of adenocarcinoma, take it out
• Dx ERCP (beading of bile ducts) Risk factors: ulcerative colitis
• Tx cholestyramine (helps w/ pruritus), liver txp
• (definitive)
• Dx screen w/ AMA (anti-mitochondrial ab), PBC × skin lesions: ↑↑TG →
• confirm w/ liver bx xanthoma, xanthelasma
• Tx ursodeoxycholic acid
• Dx ERCP Risk factors: PSC (MCC US),
• Tx Whipple if resectable Chlonorchis sinensis (MCC China)
Klatskin tumor: tumor of
proximal 1/3 of CBD, poor px
since it’s not resectable
• Dx ERCP
• Tx resection
• Dx ERCP
• Tx endoscopic stent
• Dx HIDA scan (fill up GB w/ contrast and give Risk factors: irritable bowel
• CCK to determine ejection fraction) syndrome
• Tx lap chole

PANCREATIC DZ (pancreatic endocrine tumors in endocrine section)
Dz Presentation
Acute pancreatitis sharp, “stabbing” epigastric
pain radiating to the mid-back
Hemorrhagic pancreatitis:
presents as MSOF, ARDS, hemo-
dynamic instability, signs of
ecchymoses (Grey-Turner, Fox,
Cullen signs)
Pancreatic abscess: presents as
abd pain and early satiety 2 wks
s/p acute pancreatitis
Pseudocyst: presents as abd
pain and early satiety 5 wks s/p
acute pancreatitis
Chronic pancreatitis chronic epigastric pain,
steatorrhea, type I DM
Pancreatic cancer dull abd pain + s/sx of
obstructive jaundice (dark
urine, clay stools, pruritus),
“painless jaundice”
Management
• suspect gallstones → Dx RUQ U/S
• Dx screen w/ ↑lipase, confirm w/ CT scan
• Tx NPO/IVF/pain meds (meperidine)
• Dx CT scan
• Tx admit to ICU for close monitoring
• Dx CT scan
• Tx perc drain + IV abx
• Dx CT scan
• <5 cm → Tx observation
• >5 cm or lasts >6 wks → Tx perc drain
• Dx ↓fecal elastase, KUB (calcifications)
• Tx insulin + pancreatic enzyme replacement,
• IVF/NPO/pain meds for acute attacks
• Dx CT scan
• cancer in head → Tx Whipple
• cancer in body or tail → Tx distal
• pancreatectomy
• mets or invasion → palliative care, stents
• f/u tumor markers CA 19-9, CEA
STEP 2 × HEPATOBILIARY/PANCREATIC
Other
Risk factors: GET SMASHED –
gallstones (#1), EtOH (#2),
trauma, steroids, mumps,
autoimmune, scorpion sting,
hypertriglyceridemia (#3),
hypercalcemia, ERCP, drugs
Grey-Turner sign: flank
ecchymoses
Cullen sign: periumbilical
ecchymoses
Fox sign: ecchymoses of inguinal
ligament
Risk factors: alcoholism (MCC
adults), cystic fibrosis (MCC kids)
Risk factors: smoking (#1),
chronic pancreatitis, not EtOH
(counterintuitive)
Trousseau phenomenon:
migratory SVT (10%)
Courvoisier sign: palpable,
nontender GB (30%)
 STEP 2 × GU

URINALYSIS ↑protein: proteinuria >150 mg/day, nephrotic syndrome >3.5 g/day

↑albumin: microalbuminuria is earliest sign of diabetic nephropathy
↑glucose: diabetes
↑RBC: microscopic hematuria >3 RBC/HPF, gross hematuria visible to naked eye
↑ketones: DKA or starvation
↑nitrites: indicates bacteria in urine
↑LE: indicates WBC in urine
↑eosinophils: acute interstitial nephritis
↑squamous cells: contaminated sample

RBC casts: glomerulonephritis, ischemia, or malignant HTN Hexagonal crystals: cystine

WBC casts: pyelonephritis, tubulointerstitial dz, or txp rejection
Granular casts: acute tubular necrosis (ATN)
Broad waxy casts: CRF w/ dilated ducts
Fatty casts: nephrotic syndrome
Hyaline casts: nonspecific
Envelope-shaped crystals: calcium oxalate
Needle-shaped crystals: uric acid
Coffin-shaped crystals: struvite (Proteus mirabilis)

RENAL DZ Dz Presentation Management Other

Nephrolithiasis (kidney stones)
Urinary tract obstruction
Acute interstitial nephritis (AIN)
Renal tubular acidosis (RTA)
Adult polycystic kidney disease
(ADPKD)
Renal artery stenosis
(renovascular HTN)
Kidney txp rejection
colicky flank pain ± radiation to
groin, hematuria, n/v
Calcium stones: most common
type, 2/2 hypercalciuria or
hyperoxaluria
Uric acid stones: radiolUcent
(rest are all radioopaque), 2/2
gout or tumor lysis syndrome
Struvite stones: 2/2 urease+
bugs (P. mirabilis), can form
large staghorn caliculi
Cystine stones: 2/2 cystinuria
colicky flank pain ± radiation to
groin (if acute), asx (if chronic),
anuria (if bilateral)
drug allergy → autoimmune
damage to renal parenchyma →
acute renal failure, rash, fever
Type 1 (distal) RTA: collecting
duct can’t excrete H+ →
metabolic acidosis, hypo-K,
nephrolithiasis, alkaline urine
Type 2 (proximal) RTA:
proximal tubule can’t reabsorb
HCO3- → metabolic acidosis,
hypo-K, hypophosphatemic
rickets, alkaline urine
Type 4 (hyper-K) RTA: either
hypoaldosteronism or lack of
response to aldosterone →
metabolic acidosis, hyper-K,
acidic urine
AD ∆APKD1/2 → multiple, large
bilateral cysts that can destroy
renal parenchyma → renal
failure, HTN, berry aneurysms,
liver cysts
RA stenosis → ↓renal blood
flow → kidney thinks you’re
hypotensive → RAA system →
HTN, abdominal bruits, ↓renal
function
Hyperacute rejection:
preformed ab’s against donor
organ → black/blue within min
Acute rejection: s/sx of acute
renal failure, months s/p txp
Chronic rejection: progressive
deterioration of fxn over years
GVHD: donor T-cells attack host
skin (rash), GI (abdominal pain,
diarrhea), and liver (↑LFTs)
• Dx CT scan
• pregnant → Dx renal U/S
• <0.5 cm → Tx analgesics + fluids
• 0.5 – 2 cm → Tx shockwave lithotripsy
• ≥2 cm → Tx percutaneous nephrolithotomy
• recurrent calcium stones → PPx HCTZ
• uric acid stones → PPx allopurinol, Tx
• potassium citrate (alkalinizes urine)
• cystine stones → Dx urinary sodium nitro-
• prusside test, Tx acetazolamide
• Dx renal U/S (hydronephrosis), then IV pyelo
• Tx underlying cause
• anuria → first step is Foley cath, if still anuric
• then next step is NS bolus
• Dx UA (eosinophiluria)
• Tx d/c meds
• Tx IV HCO3-
• Tx underlying cause
• Tx fludrocortisone
• Dx physical exam (bilateral nontender upper
• abd masses), renal U/S (multiple large cysts)
• Tx supportive care
• Dx renal arteriogram (if pt is in renal failure,
• use MRA instead since dye is nephrotoxic)
• Tx angioplasty
• Tx take it back out
• Dx kidney bx (lymphocytic infiltrate)
• Tx steroids > cytotoxic drugs
• Tx supportive care
• Tx steroids > cytotoxic drugs
Kidney stones × malabsorption
syndromes: ↑oxalate absorption
→ calcium oxalate stones
Kidney stones × vitamin toxicity:
↑vit C = uric acid stones, ↑vit D =
calcium oxalate stones
Kidney stone diet: high fluids
(#1), low sodium, low protein,
high calcium (counterintuitive),
low oxalate
MC location: ureteropelvic
junction
Etiology: gentamicin (MCC),
cadmium, lead, hemoglobin,
myoglobin (crush injury)
Complications: berry aneurysms
→ rupture → subarachnoid
hemorrhage (“worst headache
of my life”)
ARPKD: polycystic kidney dz in
kids, fatal w/o renal txp
Etiology: fibromuscular dysplasia
(young women), atherosclerosis
(old men)
Cyclosporine toxicity: hirsutism,
gum hypertrophy, nephrotoxic
Tacrolimus toxicity: nephrotoxic
Mycophenolate toxicity: bone
Marrow suppression
Azathioprine toxicity: diarrhea,
leukopenia, hepatotoxic
Ideal donor: living HLA-matched,
ABO-compatible relative
 STEP 2 × GU

GLOMERULAR DZ Nephritic syndrome NephrOtic syndrome Nephritic syndrome × chronic pain: analgesic nephropathy
Etiology glomerular loss of GBM negative Nephritic syndrome × hemoptysis: Goodpasture, Wegener
inflammation charge Nephritic syndrome × strep throat or cellulitis: post-strep GN
Sx - hematuria - proteinuria (>3.5 g) Nephritic syndrome × deaf/blind: Alport syndrome
- oliguria - edema
- HTN (renin) - hypoalbuminemia NephrOtic syndrome × Af-Americans: FSGS
- azotemia - hyperlipidemia NephrOtic syndrome × kids: minimal change dz
- proteinuria (<3.5 g) - hypercoagulability NephrOtic syndrome × HBV: MGN
(pee out ATIII) NephrOtic syndrome × HCV: MPGN
Glomeruli hypercellular (WBC) normo-/hypocellular NephrOtic syndrome × HIV: FSGS
Casts RBC casts fatty casts NephrOtic syndrome × Hodgkin lymphoma: minimal change dz
NephrOtic syndrome × renal vein thrombosis: MGN

Dz Presentation Management Other

Poststreptococcal glomerulo- “coke-colored” urine and
nephritis (PSGN) periorbital edema in a kid w/
strep throat or cellulitis
IgA nephropathy (Berger nephritic syndrome associated
disease) w/ Henoch-Schonlein purpura
Goodpasture syndrome anti-GBM attacks glomerular +
alveolar basement membranes
→ hematuria + hemoptysis
Alport syndrome XR ∆type 4 collagen → split
GBM (hematuria), deafness,
cataracts
Lupus nephropathy ag-ab deposits → type III HS →
nephritic syndrome in SLE pts
Minimal change disease nephrOtic syndrome in kids
following a viral infx
Focal segmental glomerulo- nephrOtic syndrome in adults
sclerosis (FSGS) and HIV+ pts, steroid-resistant
Membranous glomerulo- nephrOtic syndrome in HBV+
nephritis (MGN) pts; ↑risk of RV thrombosis
Membranoproliferative nephrOtic syndrome in HCV+
glomerulonephritis (MPGN) pts
Diabetic nephropathy nonenzymatic glycosylation of
GBM → loses its charge →
nephrOtic syndrome in DM pts
• Dx ↑ASO titers, LM (“lumpy-bumpy”)
• Tx reassurance
• Dx ↑serum IgA, LM (mesangial deposits)
• Dx ↑anti-GBM, IF (linear staining)
• Tx steroids, plasmapheresis
• Dx family hx, EM (“split GBM”)
• Dx ANA, anti-dsDNA, anti-Smith, ↓C3-C5
• Dx LM (“wire loops”), IF (“full house”)
• Tx underlying SLE
• Dx EM (foot process effacement)
• Tx steroids
• Dx LM (sclerosis)
• Dx EM (“spike and dome” appearance)
• Dx EM (double-layer “train tracks”) MPGN type 2: C3 nephritic factor
→ persistent activation of
alternative complement pathway
→ nephrOtic syndrome
• Dx microalbuminuria, LM (Kimmelsteil-Wilson
• nodules)
• Tx ACE inhibitors

RENAL FAILURE BUN: normally reabsorbed, can’t be reabsorbed if kidney is damaged

Cr: freely filtered and not reabsorbed, measure of GFR

Acute renal failure: rapid decline in renal fxn → ↑BUN + ↑Cr

Prerenal ARF Intrinsic ARF Postrenal ARF
Etiology ↓renal blood flow → damage to renal bilateral urinary tract
↓GFR (hypotension, parenchyma (ATN, obstruction (stones,
CHF, etc.) toxins, glomerulo- BPH, cancer, etc.)
nephritis, etc.)
Urine osm >500 (reabsorb H2o) <350 <350
Urine Na+ <10 (reabsorb Na) >20 >40
FENa <1% (reabsorb Na) >2% >4%
BUN/Cr >20 (reabsorb BUN) <15 >15

Ischemic ATN: ↓renal blood flow → proximal/distal tubules don’t enough O2 for Na/K pump → cell death → ARF
Nephrotoxic ATN: toxin-mediated damage to proximal tubules → cell death → ARF (e.g. IV dye, gentamicin, Hb/Mb)

Chronic renal failure: irreversible, progressive reduction in GFR

Etiology: DM (#1), HTN (#2), chronic glomerulonephritis (#3)

ARF/CRF complications: ↓GFR → electrolyte retention (↑Na, ↑K, ↑H) → HTN, CHF
uremia → n/v, pericarditis, asterixis, encephalopathy, platelet dysfxn
↓EPO → normocytic anemia
↓vit D → renal osteodystrophy, 2° HPTH, calciphylaxis

Dialysis indications: Acidosis (metabolic, pH <7.2)

Electrolyes (severe ↑K)
Intoxication
Overload (fluid)
Uremia (BUN >150 or pericarditis)

Acyclovir toxicity: crystalline nephropathy → ARF; Tx aggressive IV hydration

EPO toxicity: worsening of HTN (expands intravascular volume)
IV contrast toxicity: nephropathy if Cr >1.5 → ARF; Tx IV fluids + use nonionic contrast instead
Metformin toxicity: lactic acidosis in renal failure pts
NSAID toxicity: chronic analgesic abuse → papillary necrosis + tubulointerstitial nephritis → CRF
Amyloidosis: deposits in heart (RCM), liver (hepatomegaly), kidneys (enlarged kidneys w/ renal failure)
Multiple myeloma: CRAB – hyperCalcemia, Renal failure, Anemia, Bone pain
 STEP 2 × GU

ACID-BASE Acid-base algorithm: pH <7.4 pH >7.4

CO2 <40 met acidosis* resp alkalosis
CO2 >40 resp acidosis met alkalosis
*if met acidosis, calculate anion gap (Na+ – (Cl- + HCO3-)), nl 8-12

Causes Management
Respiratory acidosis hypoventilation Tx ventilation
Respiratory alkalosis hyperventilation 2/2 pain, fever, Tx underlying cause
sepsis, or early ARDS
Anion-gap metabolic acidosis MUDPILES – Methanol, Uremia, Tx underlying cause
DKA, Paraldehyde, Iron, INH,
Lactic acidosis, Ethylene glycol,
Salicylates
Non anion-gap metabolic acidosis diarrhea, glue sniffing, RTA, Tx underlying cause
hyperchloremia
Metabolic alkalosis vomiting, diuretics, antacids, Tx KCl replacement
hyperaldosteronism

Post-ictal AGMA: will resolve on its own in 60-90 minutes, recheck labs then
Aspirin overdose: tinnitus, fever, hyperventilation → respiratory alkalosis (early), metabolic acidosis (late)
Iron overdose: AGMA, shock, abdominal pain, UGIB
Respiratory alkalosis during pregnancy: progesterone stimulates medullary respiratory center → hyperventilation

ELECTROLYTES ADH: water reabsorption (V2, aquaporins) and vasoconstriction (V1)

Aldosterone: ↑Na, ↓K, ↓H
PTH: ↑Ca, ↓P, ↑vit D
Calcitonin: ↓Ca, ↓P
Vit D: ↑Ca, ↑P

Imbalance Etiology Presentation Management

Hypernatremia 6 Ds – Dehydration, Diuretics, thirst and signs of volume depletion • Tx PO fluids > IV fluids (correct gradually due
Diabetes insipidus, Docs (slow) or ∆MS (rapid) • to risk of cerebral edema)
(iatrogenic), Diarrhea, Diseases
Hyponatremia SIADH (MCC) confusion, coma, convulsions • Tx water restriction (correct gradually due to
• risk of central pontine myelinolysis)

• emergent → Tx 3% hypertonic saline

Hyperkalemia renal failure, K-sparing diuretics,
release from dead tissue (crush
injury, ischemic bowel, etc.)
nausea/vomiting, intestinal colic,
weakness
• first step is to confirm w/ repeat blood draw
• Dx EKG (peaked T waves, “sine waves”)
• Tx C BIG K DIE – calcium gluconate, bicarb-
• insulin-glucose, kayexalate, dialysis (if severe)

• emergent → Tx IV calcium gluconate (stabilize

Hypokalemia diarrhea, vomiting, diuretics
Hypercalcemia hyperparathyroidism (MCC
outpt), cancer (MCC inpt)
Hypocalcemia hypoparathyroidism (MCC)
weakness, muscle cramps, ileus,
digoxin toxicity (K and dig compete for
same Na/K receptors on heart)
“stones, bones, groans, psychiatric
overtones”
Familial hypocalciuric hypercalcemia:
genetic d/o of renal Ca-receptors →
↑serum Ca + ↓urine Ca
neuromuscular irritability (tingling,
tetany), arrhythmias, Chvostek and
Trousseau signs
• membranes) + insulin-glucose (put K into cells)
• Dx EKG (scooped or broad/flat T waves)
• Tx KCl (<10 mEq/hr)
• refractory hypo-K → Tx correct hypo-mag
• Dx EKG (short QT)
• mild → Tx bisphosphonates
• severe → Tx “flush and drain” (NS + Lasix),
• Ca >15 → cancer until proven otherwise, do
• full workup for cancer (parathyroid, lung, etc.)
• first step is to confirm w/ corrected Ca =
• [measured Ca + 0.8 x (4 – albumin)]
• Dx EKG (prolonged QT)
• Tx vit D + calcium replacement

GU NEOPLASMS Dz Presentation
Renal cell carcinoma (RCC) abdominal mass, flank pain,
hematuria, can have left-sided
varicocele if invading renal vein
Bladder cancer painless hematuria
Prostate cancer usually asx, “elderly man w/ low
back pain” if invasive
Testicular cancer firm, painless testicular mass
Leydig cell tumor: secretes
testosterone → precocious
puberty, gynecomastia
MALE GU DZ Dz Presentation
Benign prostatic hyperplasia prostatic enlargement at central
(BPH) zone in men >40 y/o → urinary
hesitancy, weak stream,
dribbling, nocturia
Testicular torsion twisting of spermatic cord →
severe testicular pain + “high
riding testicle w/ horizontal lie”
Epididymitis presents like testicular torsion,
but w/ fever, pyuria, and cord is
also tender
Male infertility inability to achieve pregnancy
w/ >1 yr unprotected sex
Erectile dysfunction (ED) can’t get it up
Priapism can’t get it down
URINARY INCONTINENCE Urinary incontinence + dementia/gait apraxia: normal pressure hydrocephalus
Dz Presentation
Stress incontinence urine leakage w/ exertion or
straining
Urge incontinence urine leakage d/t involuntary
bladder contractions (detrusor
hyperactivity)
Overflow incontinence urine leakage d/t urinary
retention → overdistention
Bypass incontinence urine leakage d/t fistula after
pelvic surgery or radiation
Functional incontinence urine leakage d/t physical or
psych issues; common in
nursing home or gero pts
Management
• Dx CT scan (renal mass)
• Tx radical nephrectomy
• Dx cystoscopy w/ bx
• Tx resection + close f/u for high recurrence
• Dx screen w/ PSA (≥10) or DRE (firm nodule);
• confirm w/ U/S-guided needle bx
• local → Tx radical prostatectomy
• invasive → Tx external beam radiation
• Dx transillumination (doesn’t light up),
• testicular U/S (solid mass)
• Tx radical orchiectomy, then CT scan for
• staging, then radiation (if seminoma),
• retroperitoneal LN-ectomy (if nonseminoma)
Management
• Dx DRE → if positive, then next step is UA + Cr
• (r/o hematuria, infx, obstruction) → if abnl,
• then next step is U/S (r/o hydronephrosis)
• Tx terazosin (α1-blocker relaxes prostate) +
• finasteride (5-αR-blocker shrinks prostate)
• <6 hrs → Tx emergent surgical detorsion, then
• orchipexy (don’t waste time on dx tests)
• >6 hrs → Tx orchiectomy
• Dx U/S to r/o torsion
• Tx abx
• Dx semen analysis + hormone levels (FSH)
• Tx underlying cause
• Tx sildenafil (Viagra)
• Tx pseudoephedrine
• sickle cell → Tx exchange transfusion
Management
• Tx surgery to stabilize hypermobile urethra
• (best), Kegel exercises, pessaries
• Tx anticholinergics (oxybutinin), TCAs
• (imipramine)
• Tx intermittent self-cath
• Dx methylene blue or indigo carmine dye
• Tx fistulotomy
• Tx underlying cause
STEP 2 × GU
Other
Risk factors: smoking (#1),
asbestos, cadmium
Paraneoplastic syndromes:
PAPER – PTH-rP, ACTH, prolactin,
EPO (polycythemia), renin (HTN)
Bilateral RCC: von Hippel-Lindau
Risk factors: Pee SAC – painkiller
abuse, smoking (#1), aniline dyes,
cyclophosphamide
Bladder SCC: Schistosoma
haematobium
Painless hematuria ddx: bladder
cancer, sickle cell trait,
cyclophosphamide toxicity
Cancers that rarely metastasize:
prostate, esophageal, skin
(nonmelanoma), oropharyngeal
Tumor markers: seminoma has
↑βHCG only, nonseminomas have
both ↑αFP/↑βHCG
Other
Cremasteric reflex: stroking of
inner thigh causes elevation of
testicle; absent w/ torsion
Etiology: STDs in young men,
E. coli in kids and elderly
Male infertility × frequent infx:
cystic fibrosis (Dx sweat test)
Etiology: atherosclerosis (MCC),
meds (β-blockers), EtOH, etc.
Physiologic vs. psychogenic ED:
psychogenic ED can get it up at
other times (e.g. morning wood)
Sildenafil toxicity: hypotension
with nitrites (absolute c/i) and α1-
blockers (need 4 hr interval)
Etiology: sickle cell, perineal or
genital trauma, neuropathy, or
meds (prazosin, trazodone)
Other

PEDS GU Dz Presentation
Wilms tumor renal cancer in kids <4 y/o
Epispadias/hypospadias Hypospadias: urethral opening
on ventral penis, ↑risk of UTIs
Epispadias: urethral opening on
dorsal penis, associated w/
bladder exstrophy
Enuresis involuntary urination >5 y/o
Cryptorchidism undescended testis → ↑risk of
testicular torsion, seminoma,
infertility
Posterior urethral valve oliguria + lower abdominal mass
(distended bladder) in neonate
Vesicoureteral reflux (VUR) ureters implanted into wrong
site on bladder → no
mechanism for preventing
retrograde urine reflux →
recurrent UTIs at young age
Hydrocele accumulation of fluid in tunica
vaginalis → dilated, fluid-filled
sac around testicle
Varicocele incompetent venous valves →
dilation of pampiniform plexus
→ “bag of worms” appearance
when standing up but
disappears lying down
STEP 2 × GU
Management Other
• Dx CT scan WAGR syndrome: ∆WT1 on
• Tx nephrectomy + chemoradiation chromosome 11 → Wilms tumor,
Aniridia, GU anomalies, mental
Retardation, hemihypertrophy
Beckwith-Wiedemann
syndrome: neonatal overgrowth
syndrome w/ large tongue,
omphalocele, Wilms tumor
• do not circumcise (need foreskin for surgery)
• Tx surgical correction
• Dx UA to r/o UTI
• Tx bed-wetting alarm > desmopressin >
• imipramine
• Dx U/S of inguinal canal
• Tx orchipexy if undescended by 1 y/o (to avoid
• sterility and cancer)
• first step is Foley cath to empty bladder
• Dx VCUG
• Tx surgical resection
• Dx VCUG
• low-grade → Tx long-term abx until pt “grows
• out of it”
• high-grade → Tx surgical correction
• screening VCUG indicated for all males w/ UTI,
• all girls <5 w/ UTI, or girls >5 w/ 2+ UTIs
• Dx transillumination (shines through)
• <1 y/o → Tx reassurance
• >1 y/o → Tx surgery (↑risk of hernia)
• Dx transillumination (doesn’t shine through) Left-sided varicocele × flank
• kids → Tx reassurance mass: renal cell carcinoma
• adults → Tx surgery (↑risk of infertility)

GLUCOSE DZ Dz
Impaired glucose tolerance
Type 1 diabetes mellitus (T1DM)
Type 2 diabetes mellitus (T2DM)
DM complications
Diabetic ketoacidosis (DKA)
Hyperosmolar hyperglycemic
non-ketotic syndrome (HHNS)
Hypoglycemia
Presentation
asx
autoimmune destruction of β-
cells → lack of insulin → pt
usually presents in acute DKA
obesity → ↑FFA release →
↑insulin resistance → ↑glucose
→ classic sx (polyuria, poly-
dipsia, polyphagia) + blurry
vision, weight loss, recurrent
vaginal yeast infx, etc.
Macrovascular complications:
nonenzymatic glycosylation
(NEG) → atherosclerosis →
CAD, MI, PVD, stroke/TIA, etc.
Diabetic nephropathy: NEG of
GBM → loss of negative charge
→ microalbuminuria (first sign),
proteinuria, CKD, ESRD
Diabetic retinopathy: NEG of
retinal vx → either background
or proliferative retinopathy →
progressive loss of vision
Diabetic neuropathy: NEG of
peripheral nerves → “stocking
and glove” burning pain,
numbness, parasthseias,
CN III palsy (“down and out”)
Diabetic foot ulcers: peripheral
neuropathy + PVD (ischemia) →
repetitive injuries → ulcers and
nonhealing
T1DM exacerbation → total lack
of insulin → hyperglycemia +
conversion of TG into ketones
→ osmotic diuresis,
dehydration, “fruity breath”,
Kussmaul respiration, etc.
T2DM exacerbation → ↓insulin
→ hyperglycemia → hyper-
osmolarity, osmotic diuresis,
severe dehydration
↓glc → ↑glucagon/↑epinephrine
(sympathetic sx) + CNS sx
(weakness, HA, dizziness,
coma)
STEP 2 × ENDOCRINE
Management Other
• Dx fasting glc 110-126
• Tx lifestyle changes
• Tx insulin regimen T1DM × bronze skin:
hemochromatosis
• Dx fasting glc >126 ×2, random glc >200 w/ sx, Ideal levels: HbA1c <7%, fasting
• glc >200 w/ 75g oral load, or HbA1C >6.5% glc <130, postprandial glc <180,
BP <130/80, LDL <100
T2DM
T2DM × sinusitis: mucormycosis
fasting glc <240 fasting glc >240 T2DM × anovulation: PCOS
lifestyle changes Metformin toxicity: lactic
(still high) acidosis in renal failure pts
Tx metformin or Tx insulin Sulfonylurea toxicity:
sulfonylurea hypoglycemia
(still high) (still high)
add another PO drug
Outpatient mgmt: q day – glucose
q visit – BP, foot chk
q 3 mo – HbA1c
q 6 mo – neuropathy chk
q yr – microalbuminuria,
BUN/Cr, lipids, eye chk
• PPx reduction of risk factors (BP, lipids,
• smoking, diet, exercise)
• Tx low-dose ASA
• Dx random urine collection (microalbuminuria)
• Tx ACE inhibitors
• Dx fundoscope (microaneurysms, dot-
• blot hemorrhages, neovascularization)
• Tx laser photocoagulation
• PPx annual ophtho referral
• neuropathy → Tx amitriptyline (1st line),
• gabapentin or duloxetine (2nd line)
• gastroparesis → Tx metoclopramide
• PPx regular foot checks
• Tx wound care + debridement, amputation
• (last resort)
• Dx ↑glc, ↑ketones (metabolic acidosis)
• Tx insulin + IVF (NS) + potassium (counter-
• intuitive, serum may be hyper-K but cells have
• depleted their stores)
• Dx ↑glc, no acidosis/ketosis
• Tx insulin + IVF (NS)
• Dx ↓glc Somogyi effect: nocturnal hypo-
• Dx C-peptide, insulin levels, anti-insulin ab, and glycemia → reflex ↑epinephrine
• sulfonylurea levels (look for underlying cause) + ↑glucagon → hyperglycemia in
• Tx underlying cause + glc replacement the morning

THYROID DZ Hypothyroid sx: cold intolerance, fatigue, weight gain, depression, bradycardia, myopathy (Dx ↑CPK)
Hyperthyroid sx: heat intolerance, anxiety, weight loss, palpitations, Afib in elderly, accelerated bone loss
TFTs during pregnancy: ↑E2 stimulates ↑TBG → ↑total T4 (bound to TBG) but normal free T4, normal TSH
Dz Presentation
Thyroglossal duct cyst remnant of thyroglossal duct →
mobile midline neck mass
Hyperthyroidism Graves disease: TSI (anti-TSH
antibodies) → hyperthyroid sx +
exophthalmos, thyroid bruits,
pretibial myxedema
Toxic multinodular goiter:
multiple hyperfunctioning areas
in thyroid → hyperthyroid sx
Toxic adenoma: single hyper-
functioning nodule → hyper-
thyroid sx
Factitious thyrotoxicosis: girl
trying to lose weight takes
exogenous Synthroid → hyper-
thyroid sx
Thyroid storm precipitating factor (stress,
infx) → hyperthyroidism
exacerbation → marked fever,
tachycardia, agitation, GI sx
Hypothyroidism Hashimoto thyroiditis:
autoimmune dz w/ lymphocytic
infiltrates → hypothyroid sx
De Quervain thyroiditis: painful
granulomatous inflammation
s/p viral URI → hypothyroid sx
Acute thyroiditis: painful,
swollen mass 2/2 Staph or Strep
infx → hypothyroid sx
Riedel thyroiditis: painless
fibrotic scarring of thyroid
gland → hypothyroid sx
Myxedema coma precipitating factor (stress,
infx) → hypothyroidism
exacerbation → marked
hypothermia, ∆MS, respiratory
depression
Thyroid nodules thyroid nodule found on
physical exam
Thyroid cancer thyroid nodule or mass found
on physical exam; 80% papillary,
15% follicular, 4% medullary, 1%
anaplastic
Papillary cancer: lymphatic
spread, “Psamomma bodies w/
Orphan Annie nuclei”, best px
Follicular cancer: hemato-
genous spread, endemic to
iodine-deficient areas
Medullary cancer: lymphatic
and hematogenous spread,
amyloid deposits
Anaplastic cancer: worst px
Sick euthyroid syndrome ↑stress (trauma, starvation,
etc.) → ↑cortisol blocks TSH
and stimulates deiodinase 3 →
nl TSH, ↓T3, ↑reverse T3
(incidental finding in sick pts)
STEP 2 × ENDOCRINE
Management Other
• Tx Sistrunk operation (take out cyst, trunk, and
• medial portion of hyoid bone)
• Dx ↓TSH/↑fT4 + thyroid scan (diffuse uptake) Radioiodine toxicity: ↑risk of
• Tx radioiodine > PTU/MMI becoming hypothyroid, can kill
• refractory → Tx subtotal thyroidectomy infant’s thyroid gland too
PTU/MMI toxicity: agranulo-
• Dx ↓TSH/↑fT4 + thyroid scan (patchy uptake) cytosis (d/c meds if pt presents
• <2 cm → Tx radioiodine w/ sore throat or fever), MMI is
• >2 cm → Tx surgical resection teratogenic
• Dx ↓TSH/↑fT4 + thyroid scan (hot nodule)
• <2 cm → Tx radioiodine Struma ovarii: ovarian teratoma
• >2 cm → Tx surgical resection that secretes thyroid hormone
• Dx ↓TSH/↑fT4 + thyroid scan (no uptake)
• Tx d/c Synthroid
• Dx ↑↑↑fT4
• Tx β-blockers + antithyroid drugs
• Dx ↑TSH/↓fT4 Hashimoto abs: anti-thyroid
• Tx Synthroid peroxidase (anti-TPO) is MC ab;
anti-TSH, anti-microsomal, anti-
• Dx ↑TSH/↓fT4 thyroglobulin
• Tx NSAIDs + observation (will self-resolve) Hashimoto × thyroid cancer:
thyroid lymphoma
• Dx ↑TSH/↓fT4
• Tx I+D
• Dx ↑TSH/↓fT4
• Tx Synthroid vs. surgery
• Dx ↓↓↓fT4
• Tx IV thyroxine + hydrocortisone + supportive
• care
Dx TSH levels MC type: benign colloid nodule
Malignant nodules: solid
↑TSH nl TSH ↓TSH nodules, cold nodules (lack of
radioiodine uptake), size >1.5 cm
work-up for work-up for
hypothyroid hyperthyroid
Dx FNA
benign indeterminate malignant
Dx thyroid scan
hot cold
observation Tx surgery
• Dx FNA (for all types except follicular, must Risk factors: Post-radiation
• see capsular invasion for adenoma/carcinoma) (Papillary), MEN2 syndrome
(Medullary)
• Tx total thyroidectomy w/ central LN excision Px: MACIS system – Metastasis,
• → modified radical neck dissection if +LN Age (<45), Completeness of
• f/u thyroglobulin levels resection, Invasion, Size (>2 cm)
• Tx hemilobectomy + frozen bx → total
• thyroidectomy if bx shows carcinoma Surgical complications:
• f/u thyroglobulin levels recurrent laryngeal nerve
• Tx total thyroidectomy w/ central LN excision (hoarseness or dyspnea),
• → modified radical neck dissection if +LN superior laryngeal nerve (soft,
• f/u calcitonin levels deep voice), parathyroid glands
(hypocalcemia)
• ret+ pts → prophylactic thyroidectomy
• Tx palliative care
• Dx nl TSH, ↓T3, ↑reverse T3
• Tx underlying cause
 STEP 2 × ENDOCRINE

PARATHYROID DZ Hypocalcemia sx: neuromuscular irritability (tingling, tetany), arrhythmias, Chvostek and Trousseau signs
Hypercalcemia sx: stones (kidney)
bones (bone pain, osteitis fibrosa cystica)
groans (peptic ulcers, pancreatitis)
psychiatric overtones (depression, anxiety, ∆MS)

Dz Presentation Management Other

Hypoparathyroidism
Pseudohypoparathyroidism
1° hyperparathyroidism
head/neck surgery → accidental
PTH-ectomy → hypocalcemia sx
end-organ resistance to PTH →
hypocalcemia sx + “knuckle-
knuckle-dimple-knuckle” sign
90% adenoma, 9% hyperplasia,
1% carcinoma → hypercalcemia
sx
• Dx ↓PTH, ↓Ca, ↑P Chvostek sign: tapping on Cheek
• Tx vit D + calcium replacement causes muscle contractions
Trousseau sign: inflating BP cuff
causes carpal muscle spasms
DiGeorge syndrome: thyroid +
parathyroid hypoplasia
• Dx ↑PTH, ↓Ca, ↑P
• Tx vit D + calcium replacement
• Dx ↑PTH, ↑Ca, ↓P HPTH × arthritis: pseudogout
• get Sestamibi scan only if surgery is indicated
• (criteria = symptomatic, age <50, Ca >11.5,
• osteoporotic, or ↓renal function)

• adenoma → Tx cut it out

2° hyperparathyroidism
3° hyperparathyroidism
Hypercalcemic crisis
renal failure → ↓1α-hydroxylase
→ ↓active vit D → ↓Ca →
compensatory ↑PTH
2° HPTH pts get renal txp but
parathyroid glands still
hypersecretory despite ↑Ca
Ca >15 → ΔMS, constipation,
polyuria/polydipsia, etc.
• hyperplasia → Tx 3½ gland removal
• carcinoma → Tx en bloc resection of
• parathyroid + ipsilateral thyroid lobe
• Dx ↑↑PTH, ↓Ca, ↑P
• Tx vit D + calcium replacement, low P diet
• Dx ↑PTH, ↑Ca, ↓P
• Tx observation for 1 year, then 3½ gland
• excision if still problematic
• Tx “flush and drain” (NS then Lasix)
• perform full workup for cancer after pt is
• stabilized (parathyroid, lung, etc.)

PITUITARY DZ Polyuria/polydipsia ddx: T1DM/T2DM, DI, diuretic use, primary polydipsia (Ψ d/o)

Dz Presentation Management Other

Pituitary adenoma tumor of anterior pituitary
gland → bitemporal hemi-
anopsia (◐◑) + hyperpituitary
or hypopituitary sx
Prolactinoma: ↑PRL →
galactorrhea and amenorrhea
(women), ↓libido, gyno (men)
Acromegaly: ↑GH →
overgrowth of brow, jaw,
hands, and feet; MCC death is
CV disease
Pituitary Cushing: ↑ACTH →
truncal obesity, abd striae,
buffalo hump, hyperglycemia,
osteoporosis, HTN, immuno-
suppression
Hypopituitarism: ↓FLAT PEG
(FSH/LH, ACTH, TSH, PRL, GH)
Craniopharyngioma embryological remnant of
Rathke pouch → bitemporal
hemianopsia (◐◑), headache,
papilledema, ∆MS
Diabetes insipidus (DI) polyuria, polydipsia,
dehydration → hypernatremia
Central DI: ↓ADH secretion from
posterior pituitary
Nephrogenic DI: normal ADH
but kidneys don’t respond
SIADH ↑ADH → water overload →
hyponatremia (coma/sz/death if
acute, asx if chronic)
• Dx MRI Sheehan syndrome: postpartum
necrosis of pituitary gland →
hypopituitary sx (“sudden
cessation of lactation”) in a new
• Dx ↑PRL + β-HCG/TSH (r/o 2° causes) mother s/p hemorrhagic shock
• <1 cm → Tx cabergoline > bromocriptine
• ≥1 cm → Tx transsphenoid hypophysectomy
• first step is compare w/ old photographs
• Dx oral glucose test (↑GH following glc load)
• Tx transsphenoid hypophysectomy +
• octreotide (suppress GH)
• Dx ↑ACTH + dexamethasone suppression test
• (pituitary Cushing is suppressable)
• Tx transsphenoid hypophysectomy
• Dx ↓serum hormone levels
• Tx hormone replacement
• Dx MRI (supracellar calcified cysts)
• Tx transsphenoid hypophysectomy
• Dx water deprivation test (normal pts increase DI × bipolar pts: lithium toxicity
• urine osm >280, central DI <280 but normalize
• w/ ADH, nephrogenic DI <280 and don’t
• normalize w/ ADH)
• Tx DDAVP
• Tx HCTZ
• Dx Na <135, plasma osm <270 SIADH × lung cancer: small cell
• Tx water restriction lung cancer
Central pontine myelinolysis:
• emergent → Tx 3% hypertonic saline rapid correction of hyponatremia
will cause demyelination and
locked-in syndrome, so replace
Na at a max of 0.5/hr

ADRENAL DZ Dz Presentation
Cushing syndrome ↑cortisol → truncal obesity, abd
striae, buffalo hump,
hyperglycemia, osteoporosis,
HTN, immunosuppression
Pituitary Cushing: ↑ACTH
secretion from pituitary gland
Adrenal Cushing: ↑cortisol
secretion from adrenal gland
Ectopic Cushing: ↑ACTH
secretion from cancers
(paraneoplastic syndrome)
Iatrogenic Cushing: MCC
0verall, d/t exogenous steroids
Pheochromocytoma episodic catecholamine excess
→ 5 Ps – Pressure (BP), Pain
(HA), Perspiration, Palpitations,
Pallor
Conn syndrome (1° 85% adenoma, 15% hyperplasia
hyperaldosteronism) → ↑aldosterone → ↑Na (HTN),
↓K, ↓H (metabolic alkalosis)
Adrenal insufficiency ↓cortisol/↓aldosterone →
hypoglycemia, HTN, fatigue,
hyperpigmentation (↑MSH),
weight loss, abd pain
Addison disease (1° adrenal
insufficiency): autoimmune
(MC US), TB (MC 3rd world)
2° adrenal insufficiency: due to
abrupt cessation of steroid use
Congenital adrenal hyperplasia Δ21α-hydroxylase → ↓cortisol,
(CAH) ↓aldosterone (↓Na/↑K/↑H),
↑androgens (virilization)
Incidentaloma adrenal tumor found
incidentally on CT scan
PANCREATIC DZ Dz Presentation
Insulinoma ↑insulin → Whipple’s triad
(hypoglycemia, worse w/
fasting, better w/ glucose)
Gastrinoma (Zollinger-Ellison ↑gastrin → ↑gastric acid
syndrome) secretion → ulcers
Glucagonoma ↑glucagon → refractory DM +
necrolytic migratory erythema
VIPoma ↑VIP → “rice water” diarrhea
MEN SYNDROME Dz Presentation
MEN 1 (Wermer syndrome) AD Δmenin → parathyroid
hyperplasia + pituitary adenoma
+ pancreatic endocrine cancer
(MC gastrinoma)
MEN 2A (Sipple syndrome) AD Δret → parathyroid
hyperplasia + thyroid medullary
cancer + pheochromocytoma
MEN 2B AD Δret → thyroid medullary
cancer + pheochromocytoma +
mucosal neuromas + Marfanoid
habitus
PEDS ENDOCRINE Dz Presentation
Cretinism prolonged neonatal jaundice,
thick tongue, umbilical hernia
STEP 2 × ENDOCRINE
Management Other
Cushing syndrome Cushing × lung cancer: small cell
lung cancer
Dx ACTH + high-dose Cushing × renal cancer: renal cell
dexamethasone suppression test carcinoma
Cushing × painless limp:
↑ACTH ↓ACTH avascular necrosis of hip
Cushing × electrolyte imbalance:
adrenal Cushing cortisol binds weakly to
(Dx CT scan) aldosterone receptors → ↑Na,
↓K, ↓H
>50% suppression <50% suppression
pituitary Cushing ectopic Cushing
(Dx head MRI) (Dx CT scan)
• Tx transsphenoid hypophysectomy
• Tx adrenalectomy
• Tx underlying cause
• Tx taper steroids slowly
• Dx 24 hr urinary metanephrines Rule of 10’s: 10% malignant, 10%
• Tx α-blockers (phenoxybenzamine) then bilateral, 10% extraadrenal, 10%
• β-blockers then adrenalectomy calcify, 10% kids, 10% familial
(MEN2A/2B)
• Dx screen w/ aldosterone:renin ratio (>30), Spironolactone toxicity: anti-
• confirm w/ CT scan androgen effects (testicular
• adenoma → Tx adrenalectomy atrophy, gynecomastia, etc.)
• hyperplasia → Tx spironolactone
• Dx cosyntropin stimulation test… Waterhouse-Friderichsen
• ↓cortisol + ↑ACTH = primary syndrome: bilateral adrenal
• ↓cortisol + ↓ACTH = secondary hemorrhage due to Neisseria
meningitidis infx (meningitis +
• Tx glucocorticoid (prednisone) + dynamic petechiae)
• mineralocorticoid (fludrocortisone)
• Tx glucocorticoid (prednisone) only
• Dx ↑17-OHP
• Tx glucocorticoid (prednisone) +
• mineralocorticoid (fludrocortisone)
• <5 cm → leave alone
• >5 cm → Tx resection + check other organs
• since adrenals are common site for mets
Management Other
• Dx 24 hr monitored fasting Insulinoma vs. factitious
• Tx resection hypoglycemia: true insulinomas
have ↑C-peptide levels
• Dx gastrin levels (<200 absent, >500 present); Gastrinoma triangle: neck of
• if 200-500, get secretin stimulation test pancreas, cystic duct, junction
• Tx resection b/t 2nd and 3rd part of duodenum
• Dx ↑serum glucagon
• Tx resection
• Dx ↑serum VIP
• Tx resection
Management Other
• Dx genetic testing
• Tx excise parathyroid first (hypercalcemia can
• cause ↑gastrin)
• Dx genetic testing
• Tx excise pheo first (life-threatening)
• Dx genetic testing
• Tx excise pheo first (life-threatening)
Management Other
• Dx ↑TSH, ↓/nl fT4
• Tx Synthroid
 STEP 2 × HEM/ONC

RBC PANEL MCV: RBC size, normally 80-100

Ferritin: iron levels in blood
TIBC: total iron binding capacity; ferritin has a negative feedback on TIBC
RDW: variability in RBC size; characteristic ↓RDW in thalassemias
RI: measure of immature RBCs; <2% indicates impaired bone marrow function

LDH: enzyme of anaerobyic glycolysis; ↑LDH = intravascular hemolysis or tissue hypoxia

Haptoglobin: enzyme in blood that binds free Hb; ↓haptoglobin = intravascular hemolysis
Schistocytes/helmet cells: RBC fragments, indicates hemolytic anemia
Target cells: RBCs w/ ↑surface area-to-volume ratio; indicates thalassema or liver dz
Howell-Jolly bodies: DNA remnants in RBCs; indicates asplenia
Heinz bodies: oxygen radicals → denatured Hb in RBCs; indicates G6PD deficiency

ANEMIA Anemia algorithm: Anemia

(Hb <14 males, <12 females, <11 kids)

microcytic normocytic macrocytic

(MCV <80) (MCV 80-100) (MCV >100)

• IDA (↑TIBC) • folate deficiency

• ACD (↓TIBC) • B12 deficiency
• thalassemias (↓RDW) • reticulocytosis
• sideroblastic anemia

calculate reticulocyte index

(retic count × hct/45)

impaired erythropoiesis normal erythropoiesis

(RI <2%) (RI >2%)

• acute hemorrhage intrinsic RBC defects extrinsic RBC defects

• acute IDA or ACD
• aplastic anemia • membrane defects (PNH, spherocytosis) • AIHA
• anemia of CRF (↓EPO) • abnormal hemoglobin (sickle cell) • prosthetic valves
• deficient enzymes (G6PD, PK) • MAHA
• chronic hemorrhage
Pseudoanemia: ↓WBC/↓Hb/↓Hct/↓plt secondary to dilution (e.g. fluid overload)

Dz Presentation Management Other

Iron-deficiency anemia (IDA)
Anemia of chronic disease
(ACD)
Sideroblastic anemia
Aplastic anemia
Folate deficiency
anemia sx ± koilonychia,
esophageal webs (Plummer-
Vinson syndrome), pica
chronic inflammatory state →
↑hepcidin → blocks iron usage
→ anemia sx
biochemical abnormalities →
iron gets stuck in mitochondria
→ can’t make Hb → anemia sx
+ peripheral neuropathy
bone marrow failure →
pancytopenia (anemia, neutro-
penia, thrombocytopenia) →
anemia sx + ↑infx + petechiae
↓folate → ↓methionine (RBC)
→ anemia sx + glossitis
• Dx RBC panel (MCV <80, ↓Fe, ↑TIBC, ↑RDW) IDA × kids: Meckel diverticulum
• Tx underlying cause + PO FeSO4 IDA × women: menorrhagia
IDA × men: peptic ulcer dz
• IDA in elderly → Dx colonoscopy IDA × elderly: colon cancer
• Dx RBC panel (MCV <80, ↑Fe, ↓TIBC, ↑RDW),
• Tx underlying cause
• Dx blood smear (ringed sideroblasts, Etiology: lead poisoning, vit B6
• basophilic stippling if lead poisoning) deficiency, INH or EtOH use
• Tx underlying cause, vit B6 supplements
• lead poisoning → Tx EDTA, succimer,
• dimercaprol
• Dx screen w/ CBC (↓Hb/Hct, ↓WBC, ↓plt);
• confirm w/ bone marrow bx (hypocellularity)
• Tx transfusions, bone marrow txp
• Dx RBC panel (MCV >100), hypersegmented Folate source: leafy vegetables
• neutrophils, ↓folate Etiology: “tea and toast” diet,
• Tx underlying cause, folate supplements alcoholics, phenytoin or MTX use

• reproductive-age females → all require folate

Vit B12 deficiency ↓vit B12 → ↓methionine (RBC) +
impaired FA synthesis (myelin)
→ anemia sx + glossitis,
peripheral neuropathy
α-thalassemia α -thal minor: 1-2 α-chain
deletion → generally asx
HbH disease: 3 α-chain deletion
→ severe anemia sx
Barts disease: 4 α-chain
deletion → fetal hydrops
β-thalassemia β-thal minor: heterozygous
∆β-chain → mild anemia sx
β-thal major: homozygous
∆β-chain → severe anemia sx
• supplements to prevent neural tube defects
• Dx RBC panel (MCV >100), hypersegmented Vit B12 source: meats
• neutrophils, ↓vit B12 Etiology: pernicious anemia (lack
• get Schilling test to find underlying cause of IF), s/p gastrectomy, strict
• Tx underlying cause, vit B12 injections vegans, terminal ileal dz (Crohn),
• Diphyllobothrium latum → Tx praziquantel D. latum fish tapeworm
---
• Dx RBC panel (MCV <80, ↓RDW); confirm w/
• Hb electrophoresis (↑HbH)
• Tx frequent transfusions
• Dx post-mortem autopsy
• Dx RBC panel (MCV <80, ↓RDW); confirm w/
• Hb electrophoresis
• Tx reassurance
• Dx RBC panel (MCV <80, ↓RDW); confirm w/
• Hb electrophoresis (↑HbF)
• Tx frequent transfusions + deferoxamine
• (prevents secondary hemochromatosis)
 STEP 2 × HEM/ONC

HEMOLYTIC ANEMIA Hemolytic anemia labs: ↑LDH, ↑indirect bili, ↓haptoglobin, schistocytes, helmet cells

Intravascular hemolysis: hemolysis within blood stream → acute-onset fever/chills, flank pain; ↑risk of hypovolemic shock, DIC, renal failure
Extravascular hemolysis: RBC opsonization within spleen → mild fever, indirect jaundice

MCC transfusion errors: clerical error

Hypocalcemia s/p transfusion: citrate chelates calcium → hypocalcemia sx
Anaphylactic shock s/p transfusion: IgA deficiency
“Oozing around IV site” s/p transfusion: ABO mismatch
Fever/chills s/p transfusion: due to antibodies against donor WBC, prevent w/ cell washing

Dz Presentation Management Other

Sickle cell disease (SCD)
AR ∆Hb-E6V (β-chain) → sickling
of RBCs during hypoxia → small
vessel occlusion →
extravascular hemolysis, painful
vasoocclusive crises, priapism,
autosplenic infarction
• Dx blood smear (sickled RBCs, ↑retics, Howell- SCD × sepsis: Strep pneumo
• Jolly bodies), confirm w/ Hb electrophoresis• SCD × osteomyelitis: Salmonella
• (100% HbS)
• Tx hydroxyurea (↑HbF) + vaccination against
• encapsulated bacteria (Strep pneumo, H. flu,
• Neisseria meningitidis)

Acute chest syndrome: • acute crises → Tx IV fluids + O2 + analgesics

Sickle cell trait
Hereditary spherocytosis
G6PD deficiency
Autoimmune hemolytic anemia
(AIHA)
Paroxysmal nocturnal
hemoglobinuria (PNH)
pulmonary infarction
Splenic sequestration crisis:
sudden, rapid pooling of blood
into spleen → splenomegaly,
hypovolemic shock, death
Hyposthenuria: inability of
kidney to concentrate urine →
frequent nocturia in SCD pts
painless hematuria
AD ∆spectrin → spherical RBCs
get stuck in spleen →
extravascular hemolysis; ↑risk
of pigmented gallstones →
acute cholecystitis
XR ∆G6PD → ↓glutathione for
handling oxidant stressors
(sulfa drugs, antimalarials, infx,
fava beans) → hemolysis,
hemoglobinuria, flank pain
Warm AIHA: IgG against RBC →
chronic extravascular hemolysis
Cold AIHA: IgM against RBC →
acute intravascular hemolysis
triggered by cold
acquired ∆DAF → lack of
complement inactivation on
RBCs → hemolytic anemia +
hepatic vein thromboses
• stroke → Tx exchange transfusion (anti-coag
• drugs won’t help since it’s the RBCs clotting)
• priapism → Tx exchange transfusion
• Dx Hb electrophoresis (40% HbS)
• Tx reassurance
• Dx osmotic fragility test Aplastic crisis: spherocytosis +
• Tx splenectomy parvovirus B19 infx, prevent w/
folic acid supplements
Spherocytes × positive Coombs:
autoimmune hemolytic anemia
(not hereditary spherocytosis)
• Dx blood smear (Heinz bodies, bite cells),
• G6PD levels can be falsely normal after attack
• Tx avoid precipitants
• Dx Coombs test (coating w/ IgG is warm, Essential cryoglobulinemia:
• complement is cold) ag-ab deposits in skin (palpable
• warm AIHA → Tx steroids purpura), kidney (GN), joints
• cold AIHA → Tx avoid cold exposure (arthritis), and liver (HSM) in a
HCV+ pt
• Dx sugar water test, ↑urine hemosiderin
• Tx steroids, bone marrow txp

PLATELET DZ Dz Presentation Management Other

Thrombocytopenia petechiae (initial sx), purpura,
ecchymoses, ↑risk of bleeding
Heparin-induced HIT type 1: heparin directly
thrombocytopenia (HIT) causes platelet aggregation,
occurs in 0-2 days
HIT type 2: heparin induces
auto-antibodies against platelet
factor 4 → paradoxical clotting,
occurs in 4-10 days
Idiopathic thrombocytopenic auto-antibodies against
purpura (ITP) gpIIb/IIIa → platelet clearance in
spleen → thrombocytopenia sx
Hemolytic-uremic syndrome, HUS: tons of clots form in small
thrombotic thrombocytopenic vx → hemolytic anemia +
purpura (HUS-TTP) thrombocytopenia + renal
failure (uremia)
TTP: HUS + fever + ∆MS
HELLP syndrome Hemolysis, Elevated LFTs, Low
Platelets in preeclamptic pts
• Dx plt (<150), ↑bleeding time Thrombocytopenia sx but w/
• Tx underlying cause, plt transfusion (severe) normal plt count: consider ASA,
Plavix, or uremia
• first step is d/c heparin
• Dx HIT panel
• Tx argatroban or lepirudin
• Dx plt (<50), ↑megakaryocytes
• plt >30 → Tx observation
• plt <30 → Tx steroids
• refractory → Tx splenectomy
• Dx CBC (↓plt, ↓RBC) + BUN (>60) HUS × diarrhea: EHEC (O157:H7)
• Tx emergent plasmapheresis
• Dx CBC (↓plt, ↓RBC) + ↑LFTs
• Tx anti-HTN + steroids (if <34 wks) + induction
 STEP 2 × HEM/ONC

COAG PANEL PTT: measures intrinsic pathway, follows heparin

PT/INR: measures extrinsic pathway, follows warfarin
Anti-Xa: follows LMWH PT PTT
Thrombin time: measures fibrinogen levels INR
Bleeding time: measures platelet function
Therapeutic INR: 2-3 normally, 2.5-3.5 for prosthetic valves

ANTICOAGULATION Heparin: potentiates AT-III to inhibit factors 2/10 → ↑PTT

Heparin toxicity: bleeding, HIT, osteoporosis, ineffective w/ AT-III deficiency (give argatroban instead)
Heparin reversal: protamine sulfate

Warfarin: blocks vitamin K from activating factors 2/7/9/10/C/S → ↑PT/INR

Warfarin toxicity: bleeding, skin necroses (blocks protein C/S first), teratogen
Warfarin reversal: vit K if mild, FFP if severe

tPA: activates plasmin to break down existing clots

tPA toxicity: severe bleeding (c/i in active bleeding, recent surgery, prior ICH)
tPA reversal: aminocaproid acid

COAGULATION DZ Dz Presentation Management Other

von Willebrand disease (vWD) vWD type 1: AD ↓vWF → can’t
carry around factor 8 in blood
→ bleeding diathesis
vWD type 2: AD ∆vWF →
bleeding diathesis
vWD type 3: AD lack of vWF →
severe bleeding diathesis
Hemophilia A XR ∆factor 8 → hemarthroses,
hematomas, and ICH in men
Hemophilia B XR ∆factor 9 → hemarthroses,
hematomas, and ICH in men
Disseminated intravascular abnl activation of clotting
coagulation (DIC) factors → microthrombi all over
blood stream → run out of
factors → bleed out → die
Vit K deficiency ↓vit K → can’t γ-carboxylate
factors 2/7/9/10/C/S → bleeding
diathesis
Factor V leiden (activated protein C can’t block factor 5 →
protein C resistance) hypercoagulability
AT-III deficiency can’t break down factors 2-12 →
hypercoagulability that doesn’t
respond to heparin
Senile purpura perivascular connective tissue
atrophy → ecchymoses on
dorsal hands and arms (not a
coagulation/platelet disorder)
• Dx ↑PTT, ↑bleeding time, ↓ristocetin cofactor
• activity
• type 1 → Tx DDAVP
• type 2/3 → Tx factor 8 concentrate
• Dx ↑PTT, ↓factor 8 Hemophilia A vs. factor 8
• Tx factor 8 concentrate inhibitor: mix plasma w/ normal
• acute hemarthroses → Tx analgesia + RICE plasma; if PTT fails to normalize,
then it’s factor 8 inhibitor
• Dx ↑PTT, ↓factor 9
• Tx factor 9 concentrate
• acute hemarthroses → Tx analgesia + RICE
• Dx ↑PT/↑PTT, ↑D-dimer, ↓fibrinogen, ↓plt, Risk factors: septic shock (MCC),
• blood smear (schistocytes) severe trauma, obstetric
• Tx underlying cause complications, massive burns,
rattlesnake bites
• Dx ↑PT/↑PTT, everything else is nl Vit K source: leafy vegetables,
• Tx vit K supplements, FFP if severe intestinal flora
↓vit K × neonates: bleeding in
home-delivery neonates who
don’t get their vitamin K shot
↓vit K × ICU pts: NPO and broad-
spectrum abx kills off intestinal
flora that make vitamin K
• Dx ↓PT/↓PTT
• Tx heparin + warfarin
• Dx ↓PT/↓PTT
• Tx argatroban
• Tx reassurance

CHEMORADIATION Neoadjuvant therapy: given before standard treatment

Adjuvant therapy: given in addition to standard treatment
Induction therapy: initial dose of radiation to rapidly kill tumor cells
Consolidation therapy: given after induction to further reduce tumor burden
Maintenance therapy: given after induction/consolidation to keep pt in remission
Salvage therapy: used when standard treatment fails

Chemo-induced nausea: Tx ondansetron (5-HT3 blocker)

Chemo-induced anorexia: Tx Megace (progesterone derivative) or Marinol (marijuana derivative)
 STEP 2 × HEM/ONC

HEMATOLOGIC Dz Presentation Management Other

NEOPLASMS Polycythemia vera bone marrow cells become
hyperactive → ↑RBC, ↑WBC,
↑platelets → splenomegaly,
burning pain in hands/feet,
intense pruritus w/ showers
(↑mast cells release histamine)
Multiple myeloma monoclonal plasma cell
proliferation → makes lots of
monoclonal IgG and eats up
bone marrow space → CRAB –
hyperCalcemia, Renal failure,
Anemia, Bone lesions/fx
Waldenstrom monoclonal IgM plasma cell
macroglobulinemia proliferation → ↑IgM →
hyperviscosity (IgM is big),
anemia, splenomegaly, LAD
Leukemia ALL: pre-B cell proliferation →
bone pain, ↑infx, easy bruising,
HSM in kids <15 y/o; ↑risk w/
Down syndrome
AML: myeloblast proliferation
→ ↑infx, easy bruising, HSM, no
bone pain
• Dx screen w/ CBC (↑RBC, ↑WBC, ↑plt), ↓EPO;
• confirm w/ bone marrow bx (hypercellular)
• Tx serial phelobotomy, Benadryl for pruritus,
• ASA for ↑risk of clots
• Dx SPEP (monoclonal spike), urinalysis (Bence
• Jones protein), X-ray (“punched out” bone
• lesions), blood smear (rouleaux formation)
• Tx chemoradiation only if symptomatic
• Dx SPEP (monoclonal spike), urinalysis (Bence
• Jones protein), ↑IgM, no bone lesions
• Tx supportive care
• Dx bone marrow bx (↑↑blasts)
• Tx chemotherapy, bone marrow txp
• Dx blood smear (Auer rods), confirm w/ bone
• marrow bx (myeloperoxidase+ blasts)
• Tx chemotherapy, bone marrow txp
Monocolonal gammopathy of
undetermined significance
(MGUS): asymptomatic
precursor of multiple myeloma,
<20% convert in 10-15 yrs
LAP score: indicates functional
WBCs, ↓LAP in CML but ↑LAP in
leukemoid reactions
CMV pneumonitis: pneumonitis
(dry cough) + colitis (diarrhea),
2 months s/p bone marrow txp

Acute monocytic leukemia:

gum infiltration
Acute promyelocytic leukemia:
↑risk of DIC, Tx retinoic acid
CLL: mature B-cell proliferation
→ MCC painless generalized
LAD in elderly pts >60 y/o;
thrombocytopenia = poor px
CML: mature myeloid cell
proliferation → usually asx until
“blast crisis” (fatigue, weight
loss, night sweats, etc.)
Hairy-cell leukemia: mature B-
cell proliferation → usually asx
except massive splenomegaly
Lymphoma Hodgkin lymphoma: B-cell
proliferation → painless cervical
LAD + “B sx” (fever, weight
loss, night sweats) in 20-40 y/o
or >60 y/o (bimodal distro)
Non-Hodgkin lymphoma: B-cell
proliferation → painless
generalized LAD + “B sx” in <65
y/o
Tumor lysis syndrome (TLS) lysis of cancer cells (usually w/
leukemia tx) → release of
intracellular contents into blood
→ ↑uric acid → renal failure
• Dx blood smear (“smudge cells”)
• Tx chemoradiation
• CLL + hemolytic anemia (warm) → Tx steroids
• Dx CBC (WBC >100), ↓LAP score, confirm w/
• chromosome analysis (t(9;22) or Philadelphia
• chromosome)
• Tx imatinib (blocks bcr-abl tyrosine kinase)
• Dx blood smear (positive TRAP stain)
• Tx cladribine (purine nucleoside)
• Dx LN bx (Reed-Sternberg “owl eyes” cells = Burkitt lymphoma: due to EBV
• Hodgkin, cleaved cells = non-Hodgkin, “starry Thyroid lymphoma: due to
• sky appearance” = Burkitt) Hashimoto thyroiditis
• Tx chemoradiation Gastric lymphoma: due to H.
pylori infx (Tx triple therapy)
Parotid lymphoma: due to
Sjogren syndrome
• Dx renal panel (↓Ca, ↑P, ↑K) + ↑uric acid
• Tx rasburicase (wash out uric acid) +
• allopurinol (prevent uric acid synthesis)

PEDS HEM-ONC Dz Presentation
Rh hemolytic disease Rh- mom w/ 2nd Rh+ baby
(erythroblastosis fetalis) develops anti-D IgG → crosses
placenta and attacks fetal RBCs
→ causes fetal hydrops
Fanconi anemia AR ∆DNA repair genes →
aplastic anemia + short stature,
hypopigmented areas, eye/ear
deformities
Diamond-Blackfan anemia pure RBC aplasia + short
stature, webbed neck, cleft lip,
shield chest, triphalangeal
thumbs
Neuroblastoma N-myc amplification →
proliferation of neural crest
cells in adrenal gland →
abdominal mass/pain ± bone
mets (pancytopenia)
Opsoclonus-myoclonus
syndrome: muscle jerks + eyelid
twitches in neuroblastoma pts
Rhabdomyosarcoma striated muscle tumor →
painful soft tissue mass w/
swelling, associated w/
tuberous sclerosis
STEP 2 × HEM/ONC
Management Other
• Dx Coombs test
• Tx intrauterine blood transfusions
• PPx RhoGAM
• Dx karyotype (chromosomal breaks)
• Tx androgens + hematopoietic drugs (EPO,
• neupogen, etc.), bone marrow txp
• Dx CBC (↓RBC, ↓reticulocytes)
• Tx frequent transfusions, bone marrow txp
• Dx urinary ↑HVA/↑VMA, confirm w/ CT scan Neuroblastoma vs. Wilms tumor:
• Tx surgical resection Wilms can present w/ hematuria
since it’s from the kidney,
neuroblastoma doesn’t since it’s
from the adrenal
• Dx muscle bx
• Tx surgical resection

EMERGENCY MED Tetanus ppx: open wound
clean dirty
last Td last Td last Td last Td
<10 yrs ≥10 yrs <5 yrs 5-10 yrs
nothing Td only nothing Td only
Dz Presentation
Burns First-degree: epidermis only
Second-degree: extends into
dermis, causes blistering
Third-degree: full-thickness,
painless
Drowning fluid aspiration → pulmonary
damage → cerebral hypoxia →
death
Foreign body aspiration sudden-onset respiratory
distress + focal wheezing, can
have recurrent PNA in same
lobe (usually right lower lobe)
Heat stroke T>105 after playing in the sun,
↑risk of rhabdomyolysis → ARF
Hypothermia T<95, lethargy, weakness,
uncoordination, bradycardia
Severe hypothermia: pt stops
shivering and will undergo fatal
increase in blood viscosity
Bites and stings Human bite: pain/swelling at
wound site, can also occur w/
punching someone’s teeth out
Dog/cat bite: pain/swelling at
wound site
Black widow bite: neurotoxin
→ severe abdominal cramps,
acute abdomen, vomiting
Brown recluse bite: necrotoxin
→ local skin ulceration
Scorpion sting: pain/swelling at
wound site, ↑risk of acute
pancreatitis if you’re in Trinidad
Snake bite: pain/swelling at
wound site, progressive
dyspnea, ↑risk of DIC
STEP 2 × ACUTE CARE
last Td
≥10 yrs
Td + TIG
Management Other
• first step is ABCs, then remove all clothing to Rule of nines: estimates %BSA;
• estimate degree/%BSA using “rule of nines” head and arms are 9% each;
anterior trunk, posterior trunk,
• 1st degree → Tx outpatient wound care and legs are 18% each; and
• 2nd/3rd degree → Tx admit, IV fluids (Parkland perineum is the last 1%
• formula), wound care, topical abx, pain meds
Parkland formula: give [4mL/kg
• airway burns → emergent intubation (↑risk of × %BSA] of LR; ½ over first 8 hrs
• laryngeal edema) and ½ over next 16 hrs
• chemical burns → Tx massive tap water
• irrigation, do not try acid-base neutralization
• circumferential burns → Tx escharotomy
• (↑risk of compartment syndrome)
• electrical burns → Tx mannitol (need high
• UOP due to ↑risk of rhabdomyolysis → ARF)
• scalding burns in kids → call CPS
• Tx supportive care, admit if hypoxic
• first step is Heimlich or finger sweep
• can’t remove object → Tx rigid bronchoscopy
• Tx IV fluids + evaporation cooling
• Dx EKG (J waves) Hypothermia × schizophrenics:
fluphenazine toxicity (inhibits
shivering mechanism)
•
• Tx gradual rewarming
• Tx saline irrigation, wound debridement, Human bite × cellulitis: Eikenella
• Augmentin for Eikenella ppx Animal bite × cellulitis: Pasturella
Spider bite × cellulitis: MRSA
• Tx saline irrigation, wound debridement,
• Augmentin for Pasturella ppx
• make sure tetanus/rabies is up to date
• Tx IV calcium gluconate + muscle relaxants
• Tx dapsone + wound debridement
• Tx antivenin
• Tx antivenin

TOXICOLOGY Substance Presentation
Acetaminophen nausea, malaise, liver damage
(↑LFTs)
Anticholinergics dry mouth, urinary retention,
dilated pupils; ↑risk in elderly
Benzodiazepines sedation, mild respiratory
depression
Barbiturates sedation, mild respiratory
depression
β-blockers bradycardia, hypotension,
hypoglycemia
Calcium channel blockers bradycardia, hypotension
Carbon monoxide car fumes, burns, paint thinner
exposure → CO has 200×
affinity for Hb → prevents O2
delivery to tissues → headache,
ΔMS, “pinkish skin hue”
Caustic ingestion esophageal erosion, possible
perforation
Cocaine euphoria, ↑self-esteem,
↑sympathetic activity, tactile
hallucinations, paranoia, nasal
erythema; ↑risk of MI, stroke,
epistaxis
Cyanide headaches, ΔMS, seizures,
metabolic acidosis
Digoxin nausea/vomiting, visual changes
(“yellow-green halos”), atrial
tachycardia w/ AV block;
exacerbated by hypo-K
Ethylene glycol (antifreeze) ΔMS and AGMA after drinking
“homemade alcohol” + renal
failure (calcium oxalate crystals)
Heparin hemorrhagic diathesis
Isoniazid (INH) peripheral neuropathy (wrist
drop, foot drop), hepatotoxicity
Iron upper GI bleed, abd pain,
metabolic acidosis, shock
Isopropyl alcohol ΔMS, nausea, abdominal pain
Lead sideroblastic anemia, abdominal
pain, peripheral neuropathy
(wrist drop, foot drop)
Mercury ΔMS, renal failure, tremors
Methanol (wood alcohol) ΔMS and AGMA after drinking
“homemade alcohol” + optic
neuritis (blindness)
Opioids sedation, severe respiratory
depression, “pinpoint pupils”
(not always present)
Organophosphates “pt playing in garden shed
found salivating/unconscious”,
blocks ACh-esterase →
muscarinic sx (LUSHPADS BBB)
Salicylates tinnitus, fever, hyperventilation
→ respiratory alkalosis (early) +
metabolic acidosis (late)
Sulfonylureas hypoglycemia
Tricyclic antidepressants (TCA) ΔMS, widened QRS → ↑risk of
Vfib, anticholinergic effects
(dilated pupils, etc.)
Warfarin hemorrhagic diathesis
STEP 2 × ACUTE CARE
Management Other
• wait 4 hrs then get acet levels, determine
• need for N-acetylcysteine at that time (no
• harm in waiting 8 hrs before giving antidote)
• Tx physostigmine
• Tx flumazenil
• Tx IV bicarb
• Tx glucagon
• Tx glucagon + calcium
• Dx ABGs (↑COHb), pulse ox is falsely normal
• Tx 100% O2
• Dx endoscopy to determine extent of damage
• Tx controversial (call poison control)
• Tx IV diazepam
• severe agitation → Tx Haldol
• Tx nitrites + hydroxocobalamin + thiosulfate
• Tx digoxin Fab antibody fragments
• Dx urinalysis (envelope-shaped crystals)
• Tx EtOH vs. fomipezole (4-MP)
• Dx ↑PT/↑↑PTT
• Tx protamine sulfate
• Tx vit B6
• Dx iron levels
• Tx deferoxamine
• Tx supportive care
• Dx screen w/ finger stick, confirm w/ serum
• lead (>10 μg/dL)
• Tx EDTA, succimer, dimercaprol
• Tx dimercaprol
• Tx EtOH vs. fomipezole (4-MP)
• Tx naloxone
• first step is remove clothing + wash body
• (prevents further transdermal absorption)
• Tx atropine + pralidoxime (2-PAM)
• Tx IV bicarb
• triad asthma → Tx LT-blockers (montelukast,
• zafirlukast, zileuton)
• Tx glucose replacement
• Tx sodium bicarb (sodium competes w/ TCA
• for cardiac Na-channels)
• Dx ↑↑PT/↑PTT
• Tx vitamin K + FFP if severe

TRAUMA Dz Presentation
Head trauma EDH: LOC w/ “lucid interval” or
ipsilateral fixed/dilated pupil
SDH: LOC or ΔMS w/ ↑risk for
brain herniation
Basal skull fx: “raccoon eyes”,
hemotympanum, otorrhea,
rhinorrhea, ecchymosis behind
the ear (Battle’s sign)
Spinal cord trauma Hemisection (Brown-Sequard)
syndrome: stab wound to
posterior neck → ipsi DCML +
motor loss, contra ALS loss
Anterior cord syndrome:
vertebral burst fractures →
injures vertebral artery →
bilateral ALS/motor loss
Central cord syndrome:
whiplash (e.g. rear end
collisions) → UE burning pain
and paralysis, but LE intact
Neck trauma dysphagia = esophagus injury,
hoarseness = larynx or
recurrent laryngeal nerve injury,
hemiparesis = internal carotid
artery injury
Chest trauma Aortic injury: blunt chest
trauma → aorta tears at
ligamentum arteriosum
Flail chest: blunt chest trauma
→ multiple rib fx → paradoxical
chest wall motion during
breathing
Pulmonary contusions: blunt
chest trauma → delayed-onset
pulmonary edema + respiratory
distress sx, exacerbated by IV
fluids
Cardiac tamponade: pulsus
paradoxus + Beck’s triad
(hypOtension, JVD, muffled
heart sounds)
Tension PTX: PTX + building
pressure → mediastinal shift,
hypOtension, JVD, absent
breath sounds, hyperresonance
to percussion
Abdominal trauma abdominal pain; acute abdomen
(rigidity, rebound) indicates
intraperitoneal bleeding
Splenic laceration: bleeding
into abdomen → hypotensive
shock, left shoulder pain (Kehr
sign), can have delayed onset
Abdominal compartment
syndrome: ↑intra-abdominal
pressure compresses ureters
and diaphragm → anuria +
respiratory distress
Pelvic trauma Urethral injury: blood on
meatus, scrotal hematoma,
distended bladder, “high-
riding” prostate
Bladder injury: associated w/
low-seatbelt trauma in adults
Renal injury: associated w/
blunt trauma to back and rib fx
Penis fx: penis pain and “snap”
sound after rough cowgirl sex
Limb trauma limb pain ± deformity
STEP 2 × ACUTE CARE
Management Other
• Dx head CT (r/o ICH) Cushing triad: ↑intracranial
• Dx C-spine X-ray (r/o cervical fx and spinal cord pressure → ↑BP, ↓HR, irregular
• injury before any head movement) respirations
Glasgow coma scale (GCS):
• C-spine fx → Tx neck collar estimates level of consciousness;
• ↑intracranial pressure → Tx mannitol + head measures eye opening + verbal
• elevation + sedation + hyperventilation response + motor response
• EDH → Dx head CT (convex lens hematoma),
• Tx emergent craniotomy
• SDH → Dx head CT (crescent hematoma),
• Tx for elevated ICP
• Dx screen w/ neuro exam, confirm w/ MRI
• Tx high-dose steroids (↓inflammatory damage)
• then c/s neuro or ortho
• penetrating trauma → surgery for zone 2,
• observation for zones 1/3 if stable
• expanding hematoma, hemoptysis,
• hemodynamic instability, subcutaneous
• emphysema → emergent surgery
• Dx CXR (widened mediastinum + hemothorax)
• Tx surgical repair (if still alive)
• Tx bilateral chest tubes + serial ABGs
• Dx CXR (bilateral patchy infiltrates)
• Tx close monitoring, intubation if severe
• Tx emergent pericardiocentesis (mild), ER
• thoracotomy (severe)
• Dx clinical judgment (do not wait for a CXR)
• Tx immediate needle decompression (2nd •
• intercostal space) + chest tube
• any penetrating trauma below the nipples, Kid hitting abdomen on bicycle
• acute abdomen, or hemodynamic instability → handlebars: associated w/
• Tx emergent laparotomy pancreatic transection and
duodenal hematoma → SBO sx
• stable → Dx screen for bleed w/ FAST or DPL, Severe back pain s/p femoral
• confirm w/ CT scan access: consider iatrogenic
• intraperitoneal bleed → Tx laparotomy retroperitoneal hematoma
• high retroperitoneal bleed → Tx laparotomy
• low retroperitoneal bleed → Tx embolization
• (bleeding is being tamponaded)
• Dx retrograde urethrogram
• Tx surgical repair
• do not insert Foley for distended bladder (may
• compound injury), go suprapubic instead
• Dx retrograde cystogram + post-void films
• Tx surgical repair
• Dx CT scan
• Tx manage non-op if possible
• Dx retrograde urethrogram
• Tx surgical repair
• first step is distal neurovascular exam Limb trauma × acute respiratory
• Dx X-ray distress: consider fat embolism
• bone injury only → Tx stabilization/fixation
• bone/vessel/nerve injury → order of repair is
• bone > vessels > nerves
 STEP 2 × ACUTE CARE

ABUSE Dz Presentation Management Other

Child abuse suspect w/ retinal hemorrhages, • first step is r/o medical causes, then do a
subdural hematoma, multiple • complete physical exam, then get whole-body
healed fx, posterior rib fx, • X-rays, then call CPS (in that order)
metaphyseal corner (“bucket
handle”) fx, long-bone spiral fx
(except distal tibia), cigarette
burns, stocking-and-glove
scalding water injury, or genital
trauma/STDs

Neglect: failure to provide for

needs of child, MC abuse type
Sexual assault noncensensual sexual activity ±
intercourse
• first step is call social worker, then get detailed
• hx and complete physical exam
• Dx oral/genital/anal swabs for STD testing +
• HIV test + β-HCG levels + start STD ppx

SURGERY Pre-op risk factors: age >70 → manage non-op if possible

COMPLICATIONS MI within 30 days → c/s cards
smoking → d/c 8 wks before
cirrhosis → manage non-op if possible
DM → put on sliding-scale
warfarin → d/c 3-4 days before + check pre-op INR (ideal <1.5)
ASA/Plavix → d/c 1 wk before

Dz Presentation Management Other

Post-op fever 5 Ws – wind (atelectasis POD #1 • any post-op fever → Dx CXR + CBC + UA/UCx +
or PNA POD #3), water (UTI • BCx + bronch/BAL if ventilated
POD #3), walking (DVT POD #5),
wound infx (POD #7+), wonder
drug (drug-induced fever)
Atelectasis: localized alveolar • Tx incentive spirometry, early ambulation
collapse → fever (mechanism
unknown)
PNA: fever + productive cough, • Dx CXR (lobar consolidations), sputum cx
pleuritic chest pain • Tx azithromycin + either ceftriaxone or
• respiratory fluoroquinolone
UTI: fever + dysuria, • Dx UA/UCx (≥105 CFU w/o squamous cells)
±hematuria, frequency/urgency, • Tx Bactrim or Cipro
suprapubic tenderness
DVT: fever + acute-onset dull • Dx duplex U/S
leg pain, unilateral swelling, • Tx heparin + warfarin
Homans’ sign (not a reliable • PPx compression boots + early ambulation ±
test) • SQ heparin/LMWH
Wound infx: fever + wound • Tx IV antibiotics
erythema, drainage • abscess → Tx I+D
Medication-induced fever: • Tx d/c meds
fever on any POD, MCC abx
Intraoperative fever Malignant hyperthermia: T>104 • Tx dantrolene + O2 + cooling blankets
and rigidity after anesthesia,
↑risk of rhabdomyolysis → ARF
Bacteremia: T>104 and chills • Dx blood cx ×3
within 1 hour of an invasive • Tx empiric IV abx
procedure
Alcohol withdrawal anxiety, insomnia, gross • Dx CIWA scale
tremors, delirium tremens, • Tx chlordiazepoxide (Librium)
tactile hallucinations (“bugs
crawling on my skin”) on POD
#2-3
Opioid withdrawal nausea, abdominal pain, • Dx COWS scale
diarrhea, arthralgias, myalgias, • Tx methadone
diaphoresis on POD #2-3
Acute adrenal insufficiency hypotensive shock, severe • Tx IVF + steroid replacement
abdominal pain, n/v
immediately post-op in a
steroid-dependent pt

STROKE Dz
Subclavian steal syndrome
Transient ischemic attack (TIA)
Ischemic stroke
Hemorrhagic stroke
Epidural hematoma (EDH)
Subdural hematoma (SDH)
STEP 2 × NEURO
Presentation Management Other
asx at rest, but arm claudication • Dx arteriogram
and CNS sx with exercise due to • Tx bypass surgery
stenotic subclavian artery (can
present like a TIA)
focal neuro sx <24 hrs (most are • Dx noncontrast head CT (r/o stroke), carotid
<2 hrs and recurrent) • duplex (check for carotid artery stenosis)
• Tx ASA + statins
Drop attacks: brief paralytic
spells resulting in pt dropping
to knees w/o LOC
Transient global amnesia: TIA in
temporal lobes or thalamus →
rapid retrograde memory loss +
confusion but preservation of
self-identity
focal neuro sx >24 hours • Dx noncontrast head CT (dark areas) Risk factors: HTN (#1), old age
• Tx TPA <3 hrs, aspirin ≥3 hrs or TPA c/i + (#2), CAD, CHF, acute MI, Afib,
ACA stroke: contralateral leg • start ASA/Plavix within 48 hrs diabetes, male sex, Black race,
hemiparesis, incontinence smoking, alcohol, OCPs
MCA stroke: contralateral • Afib-related stroke → Tx heparin/warfarin
face/arm hemiparesis • lacunar strokes → Tx control HTN
PCA stroke: homonymous • ischemic strokes → Dx carotid duplex,
hemianopia • Tx CEA if ≥70% stenosis
Vertebrobasilar stroke:
ipsilateral CN palsy,
contralateral hemiplegia
Cerebellar stroke: headache,
nausea, vertigo, nystagmus
Thalamic stroke: hemisensory
loss + severe dysesthesia
Hemineglect syndrome:
nondominant parietal lobe
Lacunar strokes: hyaline
arteriolosclerosis in lacunar vx
→ pure motor stroke, pure
sensory stroke, ataxia-
hemiparesis syndrome, clumsy
hand-dysarthria syndrome
ICH: bleeding into brain • Dx noncontrast head CT (white circle) Risk factors: HTN (#1)
parenchyma → focal neuro sx + • Tx control ↑ICP w/ mannitol + head elevation +
sudden headache + vomiting • sedation + hyperventilation
• keep BP high (maintains cerebral perfusion)
SAH: rupture of berry aneurysm • Dx noncontrast head CT (white star), Risk factors: polycystic kidney dz
→ bleeding into subarachnoid • LP if unsure (blood, xanthrochromia) Xanthrochromia vs. traumatic
space → “worst headache of • Tx nifedipine for vasospasm ppx + neurosurg LP: declining RBC over successive
my life” • c/s to clip aneurysm tubes indicates traumatic LP
SAH × electrolyte imbalance:
↑ADH → hyponatremia
temporal bone fx → tear in • Dx noncontrast head CT (convex lens)
middle meningeal artery → • Tx emergent craniotomy
bleeding into epidural space →
LOC w/ lucid interval
tear in bridging veins → venous • Dx noncontrast head CT (crescent moon) Risk factors: shrunken brain
bleed into subdural space → • acute → Tx craniotomy states (alcoholics, elderly)
slowly progressive headache • chronic → Tx reassurance
and ∆MS • kids → call CPS
 STEP 2 × NEURO

HEADACHE Sudden-onset headaches: first step is noncontrast head CT to r/o intracranial bleed

Dz Presentation Management Other

Tension headache
Cluster headache
Migraine headache
Rebound-analgesic headache
Trigeminal neuralgia (tic
douloureux)
Pseudotumor cerebri
Cavernous sinus thrombosis
tight band-like pain encircling
entire head + tightness in
posterior neck muscles
unilateral, episodic “burning,
searing, or stabbing pain”
behind eye + ipsilateral Horner
syndrome in men
stress → ↓5-HT → vasospasm →
unilateral, throbbing HA ± n/v,
phono-/photophobia in women
“migraine” after discontinuing
long-term analgesic use
severe, recurrent pain attacks in
trigeminal distribution
fat girl w/ pulsatile headache
and tinnitus, ↑risk of blindness
infx spreads to cavernous sinus
→ thrombosis → headache,
low-grade fever, periorbital
edema, CN III-VI palsies
• mild/moderate → Tx analgesics
• severe → Tx sumatriptan
• acute attacks → Tx 100% O2
• PPx TCA, β-blocker, CCB
• acute attacks → Tx IV antiemetics > Sumatriptan toxicity:
• sumatriptan teratogenic, requires β-HCG
• PPx TCA, β-blocker, CCB testing in repro-age females
• Tx wean pt from analgesics (do not give pt
• more narcotics)
• Tx carbamazepine
• first step is head CT (r/o mass lesion), then do Risk factors: vitamin A toxicity
• LP w/ opening pressure (r/o infx causes) (e.g. isotretinoin use)
• Tx acetazolamide
• Dx CT scan
• Tx broad-spectrum IV abx

LOSS OF CONSCIOUSNESS Syncope vs. seizures: prolonged LOC, postictal confusion, biting tongue, and bowel/bladder incontinence indicate seizures

Dz Presentation Management Other

Seizures Simple partial sz: transient
automatisms w/o LOC
Complex partial sz: transient
automatisms w/ LOC →
postictal confusion
Grand-mal sz: sudden LOC →
rigidity (tonic phase) →
musculature jerking (clonic
phase) → postictal confusion
Absence sz: “staring into
space” for a few seconds
Status epilepticus: brain is stuck
in persistent seizure >10 min
Syncope Cardiac syncope: sudden LOC
w/o prodromal sx; d/t massive
MI, arrhythmias, or obstruction
(e.g. aortic stenosis)
Vasovagal syncope: excessive
vagal tone during intense
emotion → syncope preceded
by pallor, sweating, nausea
Orthostatic hypotension: delay
in peripheral venoconstriction
→ LOC w/ sudden or prolonged
standing
Brain death irreversible absence of brain
function, no brainstem reflexes
(spinal cord reflexes intact)
• first time → Dx labs (renal panel, glucose) + Pseudoseizure: sz-like but no EEG
• EEG + MRI (r/o mass lesions) changes, will not have self-harm
• epileptic → check anticonvulsant levels or bowel/bladder incontinence
Todd paralysis: focal weakness
• partial sz → Tx phenytoin or valproic acid for 1-2 days following grand-mal
• grand-mal sz → Tx phenytoin or valproic acid seizure, will self-resolve
• absence sz → Dx EEG (3 Hz spike-and-wave), Secondary generalization:
• Tx ethosuximide > valproic acid partial sz → generalized sz
• status epilepticus → Tx benzodiazepines to
• end sz, then phenytoin afterwards Phenytoin toxicity: folate
deficiency, gingival hyperplasia
• alcohol-withdrawal sz → Tx chlordiazepoxide (Tx good dental hygiene),
• eclampsia sz → Tx IV mag sulfate teratogenicity
• first step is to r/o cardiac causes
• cardiac syncope → Tx underlying cause
• vasovagal syncope → Dx tilt-table testing,
• Tx β-blockers + disopyramide
• orthostatic hypotension → Dx orthostatics,
• Tx fluid/sodium intake
• Dx EEG (no activity)
• call another MD to confirm brain death, then
• d/c life support

MOVEMENT D/O Movement d/o in young pt: consider Wilson disease
LMN lesions: flaccid paralysis, ↓DTRs, fasciculations/fibrillations, –Babinski sign
UMN lesions: spastic paralysis, ↑DTRs, +Babinski sign, +pronator drift
LMN and UMN lesions: amyotrophic lateral sclerosis
Dz Presentation
Parkinson disease (PD) loss of dopaminergic neurons in
basal ganglia → TRAP – pill-
rolling Tremor, cogwheel
Rigidity, Akinesia, Postural
instability
Shy-Drager syndrome
(multiple system atrophy): PD +
widespread autonomic dysfxn
Lewy-body dementia: PD +
dementia + visual hallucinations
Huntington chorea AD CAG trinucleotide repeats on
chromosome 4 → ↓GABA →
chorea, apathy, depression,
dementia w/ onset at 35-50 y/o;
↑risk of suicide
Essential tremor AD tremor w/ intentional
activity but not at rest,
improved w/ EtOH use
Ataxia gait instability, loss of balance,
impaired limb coordination
Tourette syndrome most severe tic disorder w/
multiple daily motor/vocal tics,
onset before 18 y/o; associated
w/ OCD and ADHD
Amyotrophic lateral sclerosis upper and lower motor neuron
(Lou Gehrig disease) lesions → progressive spastic
and flaccid paralysis (sensation
intact) → death in 5-10 yrs
Restless leg syndrome uncontrollable desire to move
legs at night → wake up the gf
CNS NEOPLASMS Dz Presentation
Primary brain cancer all types have headache,
seizures, ↑ICP, focal neuro sx
GBM: can cross corpus callosum
(“butterfly glioma”)
Acoustic neuroma: CN VII (facial
paralysis) + CN VIII (deafness)
1° CNS lymphoma: ↑risk w/ AIDS
Medulloblastoma: childhood
obstructive hydrocephalus
Craniopharyngioma:
bitemporal hemianopia
Pinealoma: vertical gaze
paralysis (Parinaud syndrome) +
eyelid retraction (Collier sign)
Brain metastases headache, ↑ICP, focal neuro sx
Neurofibromatosis type I AD ∆NF1 → café-au-lait spots,
(von Recklinghausen disease) Lisch nodules (iris hamartomas),
optic gliomas, axillary freckling,
CNS tumors, pheos
Neurofibromatosis type II AD ∆NF2 → bilateral acoustic
neuromas, juvenile cataracts
Management
• Dx physical exam
• early PD → Tx Sinemet (carbidopa + levodopa)
• late PD → Tx subthalamic nucleus deep brain
• stimulation
• tremor only → Tx trihexylphenidyl
• Dx MRI (caudate atrophy), DNA testing
• Tx supportive care
• Tx propranolol > primidone
• Tx underlying cause
• Tx haloperidol or pimozide
• Dx EMG (fasciculations + fibrillations), nerve
• conduction studies (↓conduction velocity)
• Tx supportive care + riluzole (glutamate-
• antagonist that delays death by 3-5 months)
• Tx dopaminergics (pramipexole, ropinirole)
Management
• Dx MRI
• Tx surgical resection + radiation
• lymphoma → Tx steroids + chemoradiation
• Dx MRI (multiple ring-enhancing lesions)
• solitary brain met → Tx surgical resection
• multiple brain mets → Tx brain radiation
• Dx genetic testing
• NF pt w/ HTN → Dx urinary metanephrines
• Dx genetic testing
STEP 2 × NEURO
Other
PD brain: substantia nigra
depigmentation
PD in young pt: due to illicit
meperidine (opiate) toxicity
Sinemet toxicity: hallucinations
(acute), involuntary movements
(over years)
Trihexylphenidyl toxicity:
anticholinergic sx
Anticipation: longer CAG repeats
correlates w/ earlier age of onset
Essential tremor vs. PD tremor:
essential tremor is worse w/
intention and better at rest, PD
tremor is better w/ intention and
worse at rest
Primidone toxicity: acute
intermittent porphyria (Dx
↑urine porphobilinogen)
Friedreich ataxia: ataxia w/
staggering gait, nystagmus, pes
cavus and hammer toes
Coprolalia: involuntary swearing,
rare but pathognomonic for
Tourette syndrome
Other
Bilateral acoustic neuromas:
neurofibromatosis II
Bleeding brain mets: melanoma
 STEP 2 × NEURO

DEMENTIA Dementia vs. normal aging: no impairment of daily functioning w/ normal aging
Dementia vs. delirium: Delirium Dementia
Definition waxing-and- impairment in
waning change in memory and
pt’s level of other cognitive
consciousness functions
Onset acute chronic
Duration days – wks months – yrs
Px reversible irreversible
Amnesia immediate and recent and
recent memory remote memory
Alert no yes
Oriented no sometimes
Dx abnormal EEG abnormal MRI

Dz Presentation Management Other

Pseudodementia
Secondary dementia
Alzheimer disease (AD)
Vascular dementia
Lewy body dementia
Pick disease (frontotemporal
dementia)
Normal pressure hydrocephalus
(NPH)
Creutzfeldt-Jakob disease
(spongiform encephalopathy)
Wernicke-Korsakoff syndrome
severe depression that can • Tx SSRIs
present like dementia in elderly
dementia 2/2 hypothyroidism, • Tx underlying cause
B12/folate deficiency, thiamine
deficiency, neurosyphilis, or
medication use
↓ACh → gradual progressive • Dx head CT (diffuse atrophy w/ enlarged Amyloid cascade hypothesis:
decline in memory and other • ventricles, flat sulci) + r/o secondary causes high risk genes (presenilin I,
cognitive functions • mild/moderate AD → Tx AChE-inhibitors presenilin II, APP, apoE4) can
• (tacrine, donepezil, rivastigmine, galantamine) predispose to Aβ-amyloidosis
• severe AD → Tx memantine Alzheimer × Down syndrome:
trisomy 21 → triple apoE4
expression → inevitable by 40
y/o
accumulation of multiple small • Dx head CT (multiple small lacunar infarcts)
infarcts → stepwise loss of • Tx supportive care
function + focal neurological sx
Lewy body accumulations in the • Dx clinical judgment
basal ganglia → dementia + • manage like Alzheimer disease
visual hallucinations, PD,
sensitivity to antipsychotics
profound changes in • Dx head CT (frontal/temporal lobe atrophy)
personality and social conduct, • no tx available
disinhibition, hyperorality,
hypersexuality; good memory
and language though
↓CSF resorption → 3 Ws – Wet • Dx head CT (ventriculomegaly)
(urinary incontinence), Wobbly • Tx VP shunt
(gait apraxia), Wacky
(dementia)
abnormal prion accumulation • Dx EEG (generalized sharp waves), confirm w/
→ rapidly progressive • postmortem brain bx (spongiform change)
dementia, myoclonus (muscle • Tx supportive care
spasms), personality changes
Wernicke encephalopathy: • Dx ↑LFTs (AST:ALT >2, ↑GGT, ↑CDT), ↑MCV
acute thiamine deficiency → • Tx thiamine supplements
reversible confusion, ataxia,
ophthalmoplegia (CN VI palsy)
Korsakoff psychosis: chronic
thiamine deficiency → amnesia,
confabulations
 STEP 2 × NEURO

OTHER NEURO DZ Spinal cord tracts:

Dz Presentation Management Other

Multiple sclerosis (MS)
Guillain-Barré syndrome (GBS)
Myasthenia gravis
Lambert-Eaton myasthenic
syndrome (LEMS)
Syringomyelia
Bell palsy
young women w/ selective CNS
demyelination → optic neuritis
(“colors look washed out”),
intranuclear ophthalmoplegia
(lesion in medial longitudinal
fasciculus), constellation of sx
that don’t fit any pattern
rapid PNS demyelination →
ascending weakness/paralysis,
possible respiratory arrest;
often preceded by
Campylobacter jejuni
anti-nAChR → gradually
progressive muscle weakness
(initial sx is ptosis, diplopia,
blurry vision) that get worse w/
repetitive muscle use and
better w/ rest
SCLC → anti-VGCC → gradually
progressive muscle weakness
that get better w/ repetitive
muscle use
central cavitation of cervical
cord after whiplash accident →
bilateral “cape-like” loss of ALS
(“accidentally burned my
hands”) + unilateral motor
weakness or paralysis of facial
muscles innervated by CN VII
• Dx MRI (multiple periventricular white
• plaques), CSF (oligoclonal bands, unreliable)
• Tx IFN-β or glatiramer acetate
• acute flares → Tx high-dose steroids
• Dx CSF (albumino-cytologic dissociation =
• ↑protein but nl cell count), EMG (↓conduction)
• Tx IVIG vs. plasmapheresis
• low vital capacity → emergent ventilation
• Dx ↑anti-nAChR (best), edrophonium test,
• EMG (↓response w/ repetitive stimulation)
• next step is chest CT to look for thymoma
• Tx pyridostigmine
• myasthenic crisis → emergent ventilation
• Dx ↑anti-VGCC, EMG (↑response w/ repetitive
• stimulation)
• Tx underlying lung cancer
• Dx MRI
• Tx syringosubarachnoid shunt
• <10 days → observation (usually self-resolves)
• ≥10 days → Tx steroids
MS vs. somatization disorder:
consider somatization disorder
w/ normal work-up despite
multiple sx
GBS vs. ALS: intact sensation
indicates ALS
GBS vs. tick-borne paralysis: if
CSF study is normal, look for tick
LEMS vs. dermatomyositis: both
can present w/ muscle weakness
and lung cancer, but dermato-
myositis has a skin rash
Bilateral Bell: Lyme disease or
Guillain-Barre syndrome

Central vs. peripheral CN VII

lesions: central lesions will
preserve forehead movement,
but peripheral lesions won’t
Aphasia Wernicke aphasia: dominant • Tx supportive care
superior temporal gyrus lesion
→ fluent w/ impaired
comprehension (“word salad”)
Broca aphasia: dominant
inferior frontal gyrus lesion →
nonfluent w/ intact
comprehension
Complex regional pain abnormal pain fiber rewiring • Tx nerve block, TENS, pain control
syndrome (CRPS) after trauma → severe pain,
hyperesthesia at injury site

PEDS NEURO Dz Presentation
Febrile seizures brief seizure in febrile child
usually 2/2 infx, #1 risk factor is
rate of temp change
Childhood hydrocephalus enlarged ventricles →
increasing head growth, bulging
fontanelles, neuro sx
Nonobstructing: due to
dysfunction of arachnoid villi
Obstructing: blockage of CSF
circulation in 4th ventricle
Tay-Sachs disease ∆hexosaminidase A → MR,
“cherry-red macula” w/o HSM,
exaggerated startle response
(hyperacusis), coarse facial
features, joint contractures,
HSM in an Ashkenazi Jewish pt
Neural tube defects (NTDs) Spina bifida occulta: lumbar
“tuft of hair”
Meningocele: herniation of
meningeal sac
Myelomeningocele: herniation
of meningeal sac + spinal cord
→ neurologic deficits
Anencephaly: no brain
Cerebral palsy (CP) cerebral anoxia in utero → brain
damage → non-progressive
impairment of motor function
(either spastic or dyskinetic)
Management
• Dx clinical judgment
• <1 y/o or suspect meningitis → Dx LP
• Tx APAP + underlying infx
• Dx head CT or MTI (ventriculomegaly)
• Tx underlying cause ± surgical shunt
• Dx DNA testing
• Tx supportive care
• Dx screen w/ ↑αFP, then confirm w/ fetal U/S
• (could be gestational age error)
• Tx surgical repair
• PPx folate supplements before 4th week of
• gestation (0.4 mg/day; 4 mg/day if prior NTD
• or taking an anticonvulsant)
• Dx clinical judgment
• Tx supportive care
STEP 2 × NEURO
Other
Intraventricular hemorrhage:
progressive hemorrhagic
hydrocephalus in a premie
Congenital toxoplasmosis:
chorioretinitis + hydrocephalus +
intracranial calcifications
Dandy-Walker syndrome:
hydrocephalus + agenesis of
cerebellar vermis
Cherry-red macula ddx: Tay-
Sachs dz if no HSM (∆hexA),
Niemann-Pick dz if HSM present
(∆sphingomyelinase)
AFP: ↑αFP w/ neural tube
defects, abdominal wall defects
(gastroschisis, omphalocele),
and hepatocellular carcinoma;
↓αFP w/ Down syndrome

OPHTHO Dz Presentation
Cataracts opacification of lens → gradual
loss of visual acuity
Glaucoma Open-angle: gradual ↑IOP over
years → optic nerve damage →
loss of peripheral vision
Closed-angle: blocked canal of
Schlemm → sudden ↑IOP →
painful loss of vision w/ fixed
dilated pupil, tearing, n/v, “halos
around lights”
Macular degeneration (ARMD) degeneration of macula →
retinal fibrosis + loss of central
vision
Retinal detachment retina detaches from epithelium
→ painless acute loss of vision,
“curtain pulled over my eye” +
numerous floaters
Central retinal artery occlusion emboli in retinal artery →
(CRAO) painless acute loss of vision
Central retinal vein occlusion clot in retinal vein → painless
(CRVO) subacute loss of vision
Amaurosis fugax cholesterol emboli to retinal
artery → temporary painless
acute loss of vision, also
“curtain pulled over my eye”
Conjunctivitis (red eye) Allergic conjunctivitis: bilateral
red eye w/ itching, tearing, other
upper respiratory sx
Viral conjunctivitis: adenovirus
infx → swollen, red eye w/
watery discharge
Bacterial conjunctivitis: Strep
pneumo infx → rapid-onset red
eye w/ mucopurulent discharge
Hyperacute conjunctivitis: N.
gonorrhoeae infx → rapid-onset
red eye w/ copious
mucopurulent discharge
Uveitis inflammation of iris → corneal
injection, eye pain, blurry vision
Presbyopia age-related ↓lens elasticity →
gradual loss of near vision
HSV keratitis conjunctivitis sx w/ corneal
vesicles and dendritic ulcers
Vitreous hemorrhage diabetic retinopathy → bleed
from neovascularization →
painless acute loss of vision
Orbital cellulitis cellulitis w/ proptosis, limited
extraocular movements, painful
movement, loss of vision
Chalazion sebaceous gland obstruction →
rubbery nodule in eyelid w/
painful swelling
Dacryocystitis infx of medial canthus of eye
Subconjunctival hematoma blood vx rupture → blotchy red
spot in eye
Trachoma Chlamydia trachomatis A-C
serotypes infect the eyeball →
blindness (MCC in 3rd world
countries)
STEP 2 × HEENT
Management Other
• Dx ophthalmoscope Juvenile cataracts: galactosemia,
• Tx lens replacement surgery congenital rubella syndrome, or
neurofibromatosis II
Postoperative endophthalmitis:
vitreous body infx s/p cataract
surgery → fever, swollen eyelids,
conjunctivitis, anterior chamber
exudates
• Dx tonometry (↑IOP)
• Tx topical β-blockers, α-agonists, pilocarpine,
• acetazolamide, prostaglandins
• f/u regular ophtho exams
• Dx tonometry (↑IOP)
• Tx pilocarpine drops + emergent iridotomy
• Dx ophthalmoscope (drusen)
• dry ARMD → Tx vitamin ACE + zinc
• wet ARMD → Tx anti-VEGF drugs (pegaptinib,
• ranibizumab)
• Dx ophthalmoscope (retinal detachment) Central serous chorio-
• Tx surgical reattachment retinopathy: temporary fluid
buildup under macula → retinal
detachment in a highly stressed
type A male
• Dx ophthalmoscope (pale edematous retina
• w/ cherry-red spot)
• Tx hyperventilate into bag and continue
• tapping on eye to make embolus go distal
• Dx ophthalmoscope (“blood and thunder” =
• optic disc swelling, retinal hemorrhages,
• dilated veins, cotton wool spots)
• Tx supportive care
• Dx ophthalmoscope (pale edematous retina,
• rarely Hollenhorst plaque)
• Tx underlying cause
• Tx antihistamine drops
• Tx cold compress
• Tx cipro drops
• Tx topical + PO ceftriaxone
• first step is perform fluorescein dye test to r/o Uveitis × diarrhea: Crohn dz
• corneal ulcers Uveitis × kids: juvenile RA
• infectious → Tx cipro drops Uveitis × black female:
• noninfectious → Tx steroid drops sarcoidosis
Sympathetic ophthalmia:
penetrating trauma to eye →
exposure of hidden antigens →
immune attack on other eye →
uveitis
• Tx reading glasses
• Dx fluorescein stain (dendritic ulcer) VZV ophthalmicus vs. HSV
• Tx acyclovir drops keratitis: VZV also has overlying
shingles in CN V1 distribution
• Dx ophthalmoscope (loss of fundus, floating
• debris, dark red glow)
• Tx ophtho c/s
• Dx head CT (check for abscess) Preseptal cellulitis: cellulitis w/
• Tx admit + IV abx eyelid discoloration only, not a
medical emergency
• Tx warm compress
• recurrent → Tx excisional bx (could indicate
• sebaceous carcinoma)
• Tx PO abx
• Tx reassurance
• Dx ocular exam (follicular conjunctivitis,
• corneal neovascularization)
• Tx tetracycline drops + PO azithromycin
 STEP 2 × HEENT

PEDS OPHTHO Dz Presentation Management Other

Retinoblastoma AD ∆Rb on chromosome 13 → • Dx CT scan (intraocular calcifications)
retinoblastoma (MCC leukocoria • small → Tx cryotherapy or photocoagulation
in kids), ↑risk of osteosarcoma • large → Tx enucleation
later in life • bilateral or metastatic → Tx chemoradiation
Neonatal conjunctivitis Chemical conjunctivitis: • Tx reassurance Erythromycin toxicity: ↑risk of
presents on day 0-1 developing pyloric stenosis
Gonococcal conjunctivitis: • Tx topical erythromycin + IV ceftriaxone
presents on day 2-5, ↑risk of
corneal ulceration
Chlamydia conjunctivitis: • Tx PO erythromycin
presents on day 5-14, ↑risk of
chlamydial pneumonia
(“staccato cough”, eosinophilia)
Strabismus extraocular muscle weakness → • Tx patch the good eye
cross-eyes, can lead to future
ambylopia if uncorrected

ENT Dz Presentation Management Other

Otitis media Strep pneumo > H. flu > • Dx otoscope (bulging TM w/ poor mobility) Serous OM: middle ear effusion
Moraxella catarrhalis infx of • Tx amoxicillin w/o underlying infx
middle ear → ear pain,
decreased hearing, “pulling on • recurrent OM → Tx ear tubes
ears” in an infant
Otitis externa Staph infx → painful, swollen • Dx otoscope (red/swollen ear canal)
ear w/ discharge • Tx cipro drops
Malignant OE: Pseudomonas OE • Dx otoscope (red/swollen ear canal +
in poorly controlled diabetics • granulation tissue)
• Tx IV cipro
Benign paroxysmal positional otolith inside inner ear canal • Dx Dix-Hallpike maneuver
vertigo (BPPV) disrupts flow → brief, episodic • Tx physical maneuvers to free otolith
vertigo w/ nystagmus
Ménière disease ↑lymphatic fluid in inner ear • Tx low-salt diet + meclizine
canal → triad of vertigo +
hearing loss + tinnitus
Acoustic schwannoma benign tumor of CN VIII • Dx MRI Bilateral schwannoma:
schwann cells → mass effect → • Tx surgical excision neurofibromatosis II
vertigo, tinnitus, deafness
Deafness Conductive hearing loss: lesion • Dx whisper test, audiogram, Weber/Rinne test Presbycusis: sensorineural
in external or middle ear → • suspect CNS lesion → Dx MRI hearing loss w/ old age, can’t
decreased perception of low- hear in loud environments
volume sounds • cerumen impaction → Tx Debrox eardrops Otosclerosis: bony overgrowth
Sensorineural hearing loss: • conductive → Tx underlying cause of stapes → conductive hearing
lesion in CN VIII or CNS → • sensorineural → Tx underlying cause, consider loss in young adults
decreased perception of low- • cochlear implants
and high-volume sounds
Peritonsillar abscess (PTA) Staph/Strep or oral anaerobe • Tx emergent I+D (can penetrate into jugular
infx → fever, sore throat, “hot • vein and embolize)
potato voice”, deviated uvula
Retropharyngeal abscess (RPA) Staph/Strep or oral anaerobe • Dx lateral neck X-ray (bulging mass)
infx of posterior pharyngeal wall • Tx emergent I+D (can drain into mediastinum)
→ fever, sore throat, “muffled
voice”, drooling
Ludwig angina infected tooth → infx spreads • Tx IV abx + tooth-ectomy
to submandibular/sublingual
glands → fever, dysphagia,
odynophagia, drooling, crepitus;
MCC death is asphyxiation
Nasal angiofibroma epistaxis, visible mass in nose, • Dx nasal endoscopy (bony erosion)
bony erosion in back of nasal • Tx surgical removal
cavity
Nasopharyngeal carcinoma Asian pt w/ EBV infx has mass in • Dx nasal endoscopy (fleshy mass)
posterior nasal cavity causing • Tx surgical removal
recurrent episodes of epistaxis +
bacterial sinusitis
Torus palatinus benign bony overgrowth on • Tx reassurance
midline hard palate
TMJ dysfunction abnormal TMJ → referred pain • Tx nocturnal bite guard
to ear worse w/ chewing,
associated w/ nocturnal teeth
grinding
Cholesteatoma small whitish debris-containing • Tx surgical removal
sac on TM, ↑risk w/ recurrent
otitis media in kids
Leukoplakia whitish plaque in a smoker’s • Dx tissue bx (r/o SCC)
mouth that doesn’t scrape off
(unlike thrush), ↑risk of SCC

ORTHO/UPPER BODY First step in management of fractures: neurovascular exam distal to fx site
ORIF indications: open fx, intraarticular fx, failed closed reduction, vascular compromise, multiple traumas, need for quick recovery
Dz
Carpal tunnel syndrome (CTS)
Shoulder dislocation
Scaphoid fx
Colles fx (distal radius)
th
Boxer fx (5 metacarpal)
Humerus fx
Monteggia fx (ulnar diaphysis)
Galeazzi fx (radial diaphysis)
Rib fx
Rotator cuff tear
Rotator cuff tendonitis
Subacromial bursitis
Adhesive capsulitis (frozen
shoulder)
Lateral epicondylitis (tennis
elbow)
Medial epicondylitis (golfer
elbow)
De Quervain tenosynovitis
Presentation
median nerve compression →
pain, numbness, tingling over
median nerve distribution; long-
term = thenar muscle atrophy
Tinel sign: tapping median
nerve causes tingling
Phalen sign: prolonged wrist
flexion causes tingling
posterior force on abducted
humerus drives humeral head
forward (e.g. getting rebound)
Posterior dislocation: due to
seizures or shock
FOOSH → localized anatomical
snuffbox tenderness
FOOSH in osteoporotic lady →
distal radius fx ± distal ulna fx
punching w/ bad form → 5th
metacarpal neck fx
blunt trauma to humerus →
severe pain and swelling
using forearm to defend
baseball bats, nightsticks, etc.
→ ulnar diaphyseal fx
blunt trauma to forearm →
radial diaphyseal fx
blunt chest trauma → severe
pain worse w/ inspiration
Flail chest: blunt chest trauma
(e.g. MVC) → multiple rib fx →
paradoxical chest wall motion
during breathing
shoulder injury → pain and
weakness w/ positive “drop arm
sign” (can’t hold arm up <90°)
repetitive overhead motions →
inflammation of rotator cuff
tendons → shoulder pain w/
movement but normal ROM
repetitive overhead motions →
inflammation of bursa between
acromion and supraspinatus
tendon → shoulder pain w/
passive internal rotation/flexion
fibrosis of shoulder capsule →
pain w/ motion + inability to lift
arm over head
pain at lateral elbow w/ wrist
extension
pain at medial elbow w/ wrist
flexion
pain at radial wrist w/ thumb
gripping motions; commonly in
moms holding babies
STEP 2 × MSK
Management Other
• Dx EMG (↓conduction) CTS × hypothyroidism: ↑matrix
• Tx wrist splints > steroid injections accumulation in carpal tunnel
• refractory → Tx surgical release CTS × pregnancy: ↑fluid
accumulation in carpal tunnel
• Tx emergent closed reduction + sling
• anterior → check axillary nerve damage
• (deltoid weakness or shoulder numbness)
• Dx X-ray
• displaced → Tx thumb spica cast
• nondisplaced → Tx ORIF (↑risk of avascular
• necrosis)
• indeterminate → Tx thumb spica cast +
• repeat X-ray in 1 wk
• Dx X-ray
• Tx closed reduction + splint
• Dx X-ray “Fight bite”: Eikenella cellulitis
• Tx closed reduction + splint from punching someone’s mouth
• Dx X-ray
• Tx closed reduction + splint
• humeral neck → check axillary nerve damage
• (deltoid weakness or shoulder numbness)
• humeral diaphysis → check radial nerve
• damage (wrist drop)
• supracondylar fx (kids) → check radial pulse
• since brachial artery can be injured
• Dx X-ray
• Tx surgical repair
• Dx X-ray
• Tx surgical repair
• Dx X-ray
• Tx adequate pain control (prevent atelectasis)
• Tx bilateral chest tubes + serial ABGs
• Dx MRI
• Tx symptomatic relief ± surgical repair
• Dx physical exam
• Tx rest + NSAIDs
• Dx physical exam
• Tx rest + NSAIDs
• Dx physical exam
• Tx physical therapy
• Dx physical exam
• Tx forearm splint
• Dx physical exam
• Tx forearm splint
• Dx physical exam (+Finkelstein test)
• Tx thumb spica cast

NERVE PALSIES
Radial nerve palsy
Ulnar nerve palsy
Median nerve palsy
Axillary nerve palsy
Peroneal nerve palsy
Erb-Duchenne palsy
Klumpke palsy
ORTHO/LOWER BODY Dz
Hip fx (femoral head/neck)
Femur fx (femoral diaphysis)
Pelvic fx
Tibia fx
Ankle fx
Metatarsal stress fx
Ankle sprain
Meniscal tear
Ligament tears
Compartment syndrome
Hip dislocation
Morton neuroma
Anserine bursitis
Presentation
wrist drop
ulnar claw hand
parasthesias/pain in fingers 1-3,
possible thenar muscle atrophy
deltoid weakness w/ possible atrophy,
shoulder numbness
foot drop (slapping gait)
waiter’s tip
total claw hand + ipsilateral Horner
syndrome
Presentation
fall, MVC, or other blunt trauma
to hip → femoral head/neck fx
→ shortened and externally
rotated leg; ↑risk of avascular
necrosis
blunt trauma to femur →
femoral diaphyseal fx; ↑risk of
fat embolization
blunt trauma to pelvis → pelvis
fx usually in two places since it’s
a bony ring; ↑risk of urethral
injury and hypotensive shock
blunt trauma to tibia → tibia
diaphyseal fx; ↑risk of
compartment syndrome
excessive twisting or blunt
trauma to ankle → fx at medial,
lateral, or posterior malleoli
overuse injury in military and
athletes → swelling and point
tenderness over metatarsals
point tenderness directly over
injured ligament
forceful twisting of knee w/
fixed foot → severe pain,
“popping” sensation, delayed-
onset swelling
ACL tear: forceful hyper-
extension of knee → ACL tear
→ severe pain, “popping”
sensation, rapid-onset swelling
PCL tear: posteriorly directed
force on a flexed hip (e.g.
dashboard injury) → PCL tear
oxygen radical toxicity w/
revascularization → swelling of
forearm or leg muscles →
nerve/vein/artery compression
→ 6 Ps – pain, pallor, paralysis,
parasthesias, poikilothermia,
pulselessness
posteriorly directed force on a
flexed hip (e.g. dashboard
injury) → posterior dislocation
mechanically-induced
degenerative neuropathy →
pain between 3rd and 4th toes,
reproducible w/ palpation,
common in runners
sharp, well-localized pain over
anteromedial part of tibial
plateau not exacerbated by
valgus test (vs. MCL strain)
STEP 2 × MSK
Scenarios
humeral diaphyseal fx
elbow dislocation, banging funny
bone too hard
carpal tunnel syndrome
humeral neck fx, anterior shoulder
dislocation
knee dislocation
shoulder dystocia in neonates
shoulder dystocia in neonates, arm
hyperabduction
Management Other
• Dx X-ray
• Tx surgical repair + fondaparinux for AVN ppx
• Dx X-ray
• Tx surgical repair
• first step is ABCs, then pelvic binder, then
• FAST exam to assess intraperitoneal bleed
• Tx surgical repair
• Dx X-ray
• Tx cast ± surgical repair
• compartment syndrome → Tx fasciotomy
• Dx X-ray
• Tx cast ± surgical repair
• Dx X-ray (hairline fx)
• Tx RICE
• Dx ankle X-ray only if Ottawa rules are met
• (can’t walk 4 steps, tenderness over either
• malleolus, navicular, or base of 5th metatarsal)
• Tx RICE
• Dx physical exam (+McMurray sign), confirm Popping knee ddx: meniscal tear
• w/ MRI has delayed swelling (poor blood
• Tx RICE ± arthroscopic repair supply), ACL tear has rapid
swelling (hemarthrosis)
• Dx physical exam (+anterior drawer sign), Unhappy triad: medially directed
• confirm w/ MRI blunt trauma to lateral knee →
• Tx RICE ± arthroscopic repair ACL + MCL + medial meniscus
• Dx physical exam (+posterior drawer sign),
• confirm w/ MRI
• Tx RICE ± arthroscopic repair
• Dx physical exam (pain w/ passive stretching)
• Tx fasciotomy
• Dx X-ray + angiogram (r/o vascular lesion)
• Tx closed reduction + bracing
• Dx physical exam (“clicking” sound when
• squeezing metatarsal joints)
• Tx bilateral shoe inserts
• Dx physical exam
• Tx rest + NSAIDs

ORTHO/SPINE Dz Presentation
Low back pain Lumbar strain: dull LBP after
physical activity
Herniated disc: sciatic-type LBP
radiating to butt/thigh, worse
w/ sitting or leaning forward
Vertebral osteomyelitis: LBP +
fever, localized tenderness
Malignancy: LBP + night pain,
h/o cancer, weight loss, failure
to improve
Spinal stenosis: LBP worse w/
activity, better w/ flexion
Ankylosing spondylitis: LBP
worse w/ rest, better w/ activity
Compression fx: well-localized
LBP in osteoporotic lady
Spondylolisthesis: LBP worse
w/ extension, better w/ flexion,
“step off” on physical exam
Degenerative disc disease degenerative changes to
intervertebral disc → herniation
→ nerve impingement →
shooting LBP worse w/ Valsalva
Spinal stenosis spinal arthritic changes →
gradual narrowing of spinal
canal → shooting LBP worse w/
activity, better w/ flexion
Cauda equina syndrome acute compression of spinal
cord → motor/sensory loss in
bilateral LE, absent rectal tone,
“saddle anesthesia”, urinary
incontinence
ARTHRITIS Dz Presentation
Osteoarthritis (degenerative wear-and-tear of joints →
joint disease) degeneration of cartilage →
deep, dull joint pain, bony
crepitus, worse w/ activity and
improved w/ rest
Joints involved: weight-bearing
joints (hips, knees, spine),
PIP+DIP (Heberden, Bouchard)
Rheumatoid arthritis (RA) type 3 HS → symmetric
polyarthritis w/ severe morning
stiffness (>1 hr), rheumatoid
nodules; ↑risk of osteoporosis
Joints: wrists (ulnar deviation),
MCP+PIP (Boutonniere, swan
neck, Z-thumb deformities),
cervical spine
Viral arthritis RA-like presentation (i.e.
symmetric small joint arthritis
involving MCP and PIP) but fully
resolves in <2 months
Gout cold, stress, EtOH, red meat →
hyperuricemia → MSU deposits
in joints → sudden-onset
monoarthritis (e.g. podagra),
chronic tophi
Pseudogout (CPPD) calcium pyrophosphate
deposits in joints → sudden-
onset monoarthritis
STEP 2 × MSK
Management Other
LBP
no red flags red flags
(night pain, pain at rest,
Tx rest + NSAIDs fever, neuro sx, trauma,
bowel/bladder sx, IVDA)
focused work-up
• suspect compression fx, tumor mets, or
• osteomyelitis → Dx X-ray
• Dx physical exam (+straight leg raise test),
• confirm w/ MRI
• Tx rest + NSAIDs
• refractory → Tx surgical discectomy
• Dx physical exam (+straight leg raise test),
• confirm w/ CT scan
• Tx rest + NSAIDs
• refractory → Tx surgical laminectomy
• Dx MRI
• Tx emergent high-dose steroids + ortho c/s
• for surgical decompression
Management Other
• Dx X-ray (joint space narrowing, osteophytes
• aka bone spurs, sclerosis, subchondral cysts)
• Tx weight loss + physical therapy + NSAIDs
• severe → Tx steroid injections
• refractory → Tx joint replacement
• Dx ↑RF, ↑anti-CCP, X-ray (joint space Felty syndrome: RA +
• narrowing, bony erosions) neutropenia + splenomegaly
• Tx MTX > hydroxychloroquine, anti-TNFα Caplan syndrome: rheumatoid
nodules + pneumoconioses
MTX toxicity: hepatotoxic
(↑LFTs), megaloblastic anemia,
stomatitis (mouth ulcers); Tx
folic acid (“leucovorin rescue”)
Hydroxychloroquine toxicity:
retinopathy (requires ophtho
visits q 6 mo)
Anti-TNFα toxicity: ↑↑risk of TB
• Dx ESR is normal (RA has ↑ESR), RF and ANA
• may be false positive
• work w/ kids → Dx ↑anti-B19 IgM (parvo B19)
• Tx NSAIDs
• Dx arthrocentesis (needle-shaped, negatively Etiology: ↓uric acid excretion
• birefringent yellow crystals) (90%), ↑uric acid production (10%)
• Tx dietary modifications (↓EtOH, ↓purines) Lesch-Nyhan syndrome: AR
∆HGPRT → gout, self-mutilation,
• gouty flare → Tx indomethacin > colchicine yellow sand in diapers
• chronic ppx → Tx probenecid or allopurinol Gout × generalized pruritus:
• (do not give these during acute attacks) polycythemia vera
• Dx arthrocentesis (rhomboid-shaped, weakly
• positively birefringent blue crystals)
• acute flare → Tx indomethacin > colchicine
 STEP 2 × MSK

OTHER BONE DZ Dz Presentation Management Other

Osteoporosis ↑osteoclasts (women) or
↓osteoblasts (men) → ↓bone
mass → asx, but can cause
compression fx → kyphosis,
Colles fx, hip fx
Osteopenia: T-score -1 to -2.5
Paget disease of bone (osteitis abnormal bone remodeling →
deformans) ↑hat size, deafness
Osteogenesis imperfecta AD ∆type 1 collagen → abnl
bone matrix (multiple fx) + blue
sclera + abnormal dentition +
hearing loss
Osteopetrosis (marble bone ↓osteoclast activity → ↑bone
disease) density → ↑risk of fx + mass
effect (deafness, blindness,
other neuro sx)
• screen women ≥65 w/ DEXA scan q 2 yrs
• Dx DEXA scan (T-score < -2.5 std dev)
• Tx calcium + vitamin D + weight-bearing
• exercise (not swimming)
• refractory → Tx bisphosphonates
• Dx ↑urine hydroxyproline, ↑AΦ only (Ca/P wnl)
• Tx bisphosphonates (only if symptomatic)
• r/o child abuse
• Tx activity restriction to ↓risk of fx
• Dx X-ray (↑bone density, “Erlenmeyer flask”
• bones), AΦ/Ca/P wnl
• Tx bone marrow txp (for osteoclasts) +
• activity restriction to ↓risk of fx
Risk factors: postmenopause,
old age, chronic steroid or
heparin use; obesity is protective
Bisphosphonate toxicity:
esophagitis, osteonecrosis of jaw
Paget dz of breast: nipple
eczema indicates underlying
adenocarcinoma
Erlenmeyer-flask bone ddx:
Gaucher dz, osteopetrosis,
rickets

MSK NEOPLASMS Dz Presentation Management Other

Osteosarcoma localized pain and swelling in
knees or proximal humerus;
↑risk w/ retinoblastoma
Ewing sarcoma localized pain and swelling in
long bone diaphyses
Bone metastases deep bone pain, localized
tenderness, pathologic fx
• Dx X-ray (Codman’s triangle, “sunburst”
• appearance)
• Tx radical surgical excision
• Dx X-ray (“onion skin” appearance)
• Tx radical surgical excision
• Dx bone scan Mets types: Lung is Lytic,
• Tx chemoradiation ± bisphosphonates (help prostaTIC is blasTIC, Breast is
• slow bone loss) Both

RHEUM BUZZWORDS HLA-A3: hA3mochromatosis

HLA-B8: Graves dz
HLA-B27: PAIR – psoriatic arthritis, ankylosing spondylitis, IBD, Reiter syndrome
HLA-DR2: SLE
HLA-DR3: SLE, T1DM
HLA-DR4: Rheumatoid 4rthritis, T1DM
HLA-DR5: perniciou5 anemia

ASCA: Crohn dz
C-ANCA: Wegener granulomatosis
P-ANCA: Churg-Strauss syndrome, microscopic polyangiitis, ulcerative colitis

Anti-basement membrane: Goodpasture syndrome

Anti-CCP: rheumatoid arthritis
Anti-centromere: CREST syndrome
Anti-desmosome: pemphigus vulgaris
Anti-dsDNA: SLE
Anti-endomysial: celiac sprue
Anti-Fc IgG (RF): SLE, RA, many others
Anti-gliadin: celiac sprue
Anti-hemidesmosome: bullous pemphigoid
Anti-histone: drug-induced lupus
Anti-Jo-1: polymyositis/dermatomyositis
Anti-microsomal: Hashimoto thyroiditis
Anti-mitochondrial (AMA): primary biliary cirrhosis
Anti-nAChR: myasthenia gravis
Anti-nuclear (ANA): SLE, RA, many others
Anti-Scl-70 (anti-topoisomerase): scleroderma (diffuse)
Anti-Smith: SLE
Anti-smooth muscle: autoimmune hepatitis
Anti-SSA/SSB (anti-Ro/La): Sjögren syndrome
Anti-thyroid peroxidase (TPO): Hashimoto thyroiditis
Anti-TSH (TSI): Graves disease
Anti-U1-RNP: mixed CT disease
Anti-VGCC: Lambert-Eaton myasthenic syndrome

RHEUMATOLOGY Seronegative spondyloarthropathy: PAIR (Psoriatic arthritis, Ankylosing spondylitis, IBD, Reiter syndrome) are all +HLA-B27 and –RF
-myositis: weakness, may have pain
-myalgia: pain, no weakness
Dz Presentation
Systemic lupus erythematosus type 3 HS → flare-and-remission
(SLE) pattern of I’M DAMN SHARP in
an African-American woman…
↑IgG
Malar rash
Discoid rash
ANA
Mucositis (throat ulcers)
Neurologic d/o
Serositis (pleuritis, pericarditis)
Hematologic d/o
Arthritis (not deforming)
Renal d/o (“wire loops”)
Photosensitivity
Drug-induced lupus HIPP (Hydralazine, INH,
erythematosus (DILE) Procainamide, Phenytoin) can
all cause SLE-like sx but no
kidney or CNS involvement
Neonatal lupus maternal ag-ab cross placenta
→ lupus sx; anti-SSA attacks
fetal heart → 3° AV block
Antiphospholipid syndrome hypercoagulability in SLE or
other collagen-vascular dz →
high-risk for venous (DVT, PE)
and arterial clots (stroke, MI),
recurrent miscarriage
Polymyositis proximal muscle weakness ±
pain
Dermatomyositis proximal muscle weakness ±
pain, skin rashes (heliotrope
rash, Gottron papules, V sign,
shawl sign)
Inclusion body myositis symmetrical proximal and distal
muscle weakness
Polymyalgia rheumatica (PMR) proximal muscle pain w/o
weakness, profound morning
stiffness
Fibromyalgia widespread muscle pain and
stiffness associated w/ trigger
points
Ankylosing spondylitis bilateral sacroiliitis + gradual-
onset upward fusion of spine +
enthesitis (pain at tendon
attachment sites); joint pain is
better w/ activity, worse w/ rest
Reiter syndrome (reactive triad of anterior uveitis,
arthritis) urethritis, arthritis (“can’t see,
can’t pee, can’t climb a tree”)
following a bacterial GI infx
(Salmonella, Shigella, Campy,
Chlamydia, Yersinia)
Psoriatic arthritis asymmetric polyarthritis in 10%
of psoriasis pts, usually fingers
Scleroderma severe, widespread fibrosis of
skin (sclerodactyly) and viscera
CREST syndrome Calcinosis of fingers, Raynaud
phenomenon, Esophageal
dysmotility, Sclerodactyly (face
and fingers), Telangiectasias
(over fingers)
Raynaud disease digital vasospasm → fingertips
go from blue-to-white-to-red
Mixed connective tissue disease “overlap syndrome” of SLE,
(MCTD) RA, scleroderma, polymyositis
Sjögren syndrome autoimmune attack of salivary
and lacrimal glands → dry eyes,
dry mouth, arthritis; ↑risk of
parotid gland lymphomas and
fetal 3° AV block
STEP 2 × MSK
Management Other
• Dx screen w/ ANA; confirm w/ anti-dsDNA, SLE × heart murmur: Libman-
• anti-Smith, or ↓C3-C5 Sacks endocarditis
• Tx low-dose ASA > cytotoxic drugs (MTX, SLE × pancytopenia: auto-ab
• hydroxychloroquine, anti-TNFα) against blood cells → opsonized
• acute flares → Tx IV steroids in spleen
• new-onset renal sx → Dx renal bx to
• determine class of lupus nephritis
• Dx anti-histone
• Tx d/c meds
• Tx close management during prenatal care
• Dx ↑lupus anticoagulant, ↑anticardiolipin ab,
• ↑PTT (counterintuitive), VDRL is false positive
• Tx heparin + warfarin
• Dx screen w/ ↑CK and anti-Jo-1; confirm w/
• muscle bx
• Tx steroids
• Dx screen w/ ↑CK and anti-Jo-1; confirm w/ Complications: ovarian cancer
• muscle bx
• Tx steroids
• Dx slightly ↑CK, muscle bx
• Tx steroids
• Dx ↑↑ESR (CK is normal) Complications: aortic aneurysms,
• next step is careful physical exam to r/o temporal arteritis → blindness
• temporal arteritis (don’t need to bx artery)
• Tx steroids
• Dx physical exam (multiple trigger points) Complications: depression,
• Tx amitryptiline > cyclobenzaprine (Flexeril) anxiety, irritable bowel
syndrome, axis II diagnoses
• depression → Tx SSRIs
• Dx X-ray (bamboo spine) Complications: restrictive lung
• Tx NSAIDs + physical therapy dz, pathologic verterbral fx,
anterior uveitis (“blurry vision”)
• Dx joint aspiration (mainly to r/o infx arthritis,
• ↑WBC but no bacteria)
• Tx NSAIDs
• Dx X-ray (“pencil-in-cup” deformity) Complications: dactylitis
• Tx NSAIDs (“sausage fingers”)
• Dx anti-Scl-70 (anti-topoisomerase)
• Tx supportive care
• Dx anti-Centromere
• Tx supportive care
• Tx CCB (nifedipine) + keep hands warm
• Dx anti-U1-RNP
• Tx predominant dz
• Dx anti-SSA/SSB (anti-Ro/La)
• Tx pilocarpine, artifical tears, oral hygiene
 STEP 2 × MSK

PEDS MSK Dz Presentation Management Other

Juvenile rheumatoid arthritis RF (anti-IgG Fc domain) → type • Dx X-ray (osteopenia, sclerosis around
(JRA) 3 HS → nonmigratory arthritis • affected joints), RF may be false negative
lasting >3 months • Tx NSAIDs > MTX > steroids

Pauciarticular JRA: 0-4 joints, • uveitis → Dx slit-lamp eye exam, Tx steroids

Slipped capital femoral
epiphysis (SCFE)
Legg-Calves-Perthes disease
Osgood-Schlatter disease
Congenital hip dysplasia
Rickets
Clavicle fx
Physeal fx
can initially present w/ uveitis
rather than arthritis
Polyarticular JRA: >5 joints
Systemic JRA (Still dz):
systemic sx prior to onset of
arthritis (e.g. spiking fevers,
severe pain, maculopapular
rash)
painful limp in a fat boy w/ leg • Dx X-ray (displaced femoral head)
held in flexion + external • Tx surgical pinning
rotation; ↑risk of avascular
necrosis and osteoarthritis
avascular necrosis of femoral • Dx X-ray (dead bone, widened joint space)
head, presents as painless limp • Tx bracing vs. acetabular reconstruction
in a boy <10 y/o; ↑risk w/ sickle-
cell disease and steroid use
overuse injury of quads and • Dx physical exam
patellar tendon → tibial • Tx rest + NSAIDs
tubercle osteochondritis →
localized pain/swelling
uneven gluteal folds and • Dx U/S (not calcified for X-ray)
“snapping hips” during physical • Tx splinting
exam in a newborn, +Barlow
and Ortolani maneuvers
↓vit D → ↓Ca/↓P → ↓bone • Dx X-ray (physeal widening, bowing bones) X-linked hypophosphatemic
mineralization → soft bones, • Tx vitamin D + phosphorus supplements rickets: rickets in boy w/ ↓P only
bowed legs, rachitic rosary
FOOSH → pain overlying • Dx X-ray
midclavicle, holding arm up • Tx figure-of-8 splint
with other hand
• neonates → Tx reassurance (greenstick fx)
Neonatal clavicle fx: presents • bruits → Dx angiogram (r/o vascular injury)
w/ clavicular crepitus or callus in
neonates, ↑risk w/ macrosomia
and breech delivery
pain and swelling at injury site; • Dx X-ray Salter-Harris classification: type I
↑risk of growth arrest • Tx closed reduction + immobilization through physis (growth plate),
type II at metaphysis (MC), type
III at epiphysis, type IV at
meta+epi, type V is a crush fx

Nursemaid elbow pulling on hand → subluxation • Dx physical exam

of radial head from annular
ligament → kid holds arm in a
pronated position
Club foot congenital foot deformity w/
inward and downward-pointing
feet; ↑risk w/ spina bifida
Scoliosis lateral curvature of spine
Duchenne muscular dystrophy XR ∆dystrophin → muscle cells
(DMD) die off → ascending weakness
w/ Gowers maneuver, calf
pseudohypertrophy, death by
15 y/o
Myotonic dystrophy AD, neonatal respiratory
distress (newborn), distal
muscle wasting (older kids),
delayed muscle relaxation
(“can’t release handshake”)
Torticollis dystonic SCM → twisted neck
Metatarsus adductus congenital foot deformity w/
forefoot pointing inwards
Growing pains deep aching pain in leg muscles
w/o any “red flags” (fever,
swelling, systemic sx)
Patellofemoral syndrome chronic anterior knee pain,
worse w/ exercise or prolonged
sitting
• Tx manual reduction via supinating motion
• Dx physical exam
• <6 mo → Tx serial casting
• ≥6 mo → Tx surgery
• Dx physical exam, X-ray
• <30° → Tx reassurance
• ≥30° → Tx bracing or surgery
• Dx screen w/ ↑CK, confirm w/ muscle bx Becker muscular dystrophy: XR
• Tx supportive care ∆dystrophin → DMD-like sx but
less severe w/ late onset >5 y/o
(DMD is <5 y/o)
• Dx screen w/ ↑CK, confirm w/ muscle bx
• Tx supportive care
• Dx neck X-ray (r/o C-spine fx)
• Tx gentle stretching
• overcorrects into position → Tx reassurance
• corrects into position → Tx orthotics
• undercorrects into position → Tx surgery
• Tx reassurance
• Tx strengthening exercises

ALLERGIC SKIN DZ Type 1 HS: allergen exposure → IgE-mediated mast cell degranulation → HA release, atopic/anaphylactic
Type 2 HS: IgG or IgM against cell surface, cytotoxic
Type 3 HS: ab-ag complex deposition → complement activation → cell damage
Type 4 HS: T-cell mediated activation of macrophages, delayed-type
Dz
Urticaria
Erythema multiforme (EM)
Stevens-Johnson syndrome
(SJS)
Toxic epidermal necrolysis
(TEN)
Angioedema
Insect sting allergy
Anaphylactic shock
Contact dermatitis
SKIN NEOPLASMS Skin cancer prevention: avoid sunlight (best option), sunscreen 45-60 min before exposure (protects against SCC/BCC only)
Dz
Actinic (solar) keratosis
Basal cell carcinoma (BCC)
Squamous cell carcinoma (SCC)
Malignant melanoma
Presentation
type 1 HS → wheals (hives) that
cause intense pruritus
severe urticaria + target lesions
(“bulls-eye lesions”)
severe EM + mucus membrane
involvement (<10% skin
sloughing)
severe SJS (>30% skin
sloughing)
fluid extravasation into
subcutaneous tissue → painful
swelling of eyelids, lips, tongue,
genitalia, hands, or feet
Nonallergic rxn: localized
swelling, pain, pruritis, redness
Allergic rxn: resembles cellulitis
allergen exposure → systemic
type 1 HS → skin rash, shock
type 4 HS → delayed-onset skin
rash w/ linear vesicles and
oozing (acute) or crusted,
thickened skin (chronic)
Presentation
small, rough, scaly “sandpaper-
like” lesions on face of fair-
skinned people; precursor to
SCC
raised lesion w/ “pearly rolled
borders” or non-healing ulcer
(classically upper lip and above)
non-healing ulcer (classically
lower lip and below), can arise
from chronic wound site
(Marjolin ulcer)
ABCDE – Asymmetry, Border
irregularity, Colors, Diameter,
Evolution over time; prognosis
defined by depth of invasion
Superficial spreading: MC,
grows laterally before vertically
Nodular: grows vertically only
and becomes invasive quickly
Acral lentiginous: found in
nonpigmented areas (palms,
soles, under nails) classically in
Asian and Af-American pts
Lentigo maligna: long in situ
phase before vertical growth
Management
• Tx d/c offending agent, symptomatic relief
• Tx d/c offending agent, symptomatic relief
• Tx d/c offending agent, admit to burns unit
• Tx d/c offending agent, admit to burns unit
• Tx d/c offending agent, symptomatic relief
• laryngeal edema → Tx epinephrine
• nonallergic → Tx ice pack
• allergic → Tx antihistamines (not abx)
• anaphylaxis → Tx epinephrine
• first step is ABCs → 2 large-bore IVs + 2L IVF
• Tx epinephrine, antihistamines
• Dx patch test if unsure
• Tx cold compress, topical steroids, systemic
• steroids (severe)
Management
• Tx removal (cryotherapy, topical 5-FU) +
• send to path to r/o SCC
• Tx excisional bx w/ 1 mm margins
• BCC on face → Tx Mohs’ excision
• Tx excisional bx w/ 1 cm margins
• SCC on face → Tx Mohs’ excision
• Tx excisional bx w/ 1 cm margins
STEP 2 × DERM
Other
Etiology: ACE inhibitors (MCC)
Hereditary angioedema: C1-
esterase inhibitor deficiency →
↑C2b, ↑bradykinin → edema
Etiology: Hymenoptera spp.
(wasps, yellow jackets, honey-
bees, hornets)
Etiology: urushiol (found in
poison ivy, poison oak, sumac),
iodine, nickel, rubber, latex
(surgical gloves, condoms)
Other
Risk factors: sunlight (UVB)
Risk factors: sunlight (UVB)
Risk factors: sunlight (UVB),
arsenic, chronic wounds, HPV
Keratoacanthoma: variant of SCC
that grows rapidly and dies off
spontaneously
Risk factors: sunlight (UVB),
family hx
Dysplastic nevus: atypical mole,
precursor to melanoma
 STEP 2 × DERM

COMMON SKIN DZ Dz Presentation Management Other

Seborrheic dermatitis
Cherry hemangiomas
Psoriasis
Pityriasis rosea
Erythema nodosum (EN)
Pemphigus vulgaris
Bullous pemphigoid
Porphyria cutanea tarda
Seborrheic keratosis
Lichen planus
Vitiligo
Decubitus ulcers (pressure
sores)
chronic hyperproliferation of
epidermis → greasy, scaly
patches on scalp (dandruff),
hairline, behind ears, eyebrows;
↑risk w/ HIV and Parkinson dz
small red cutaneous papules in
aging adults
abnormal skin cell proliferation
→ thick silvery scales that bleed
upon removal (Auspitz sign)
herald patch (ringworm-like),
then generalized “Christmas
tree” rash
painful, red, subcutaneous
nodules over shins
anti-desmosome ab → tense
blisters on skin and oral mucosa
w/ +Nikolsky sign (acantholysis)
anti-hemidesmosome ab →
tense blisters on skin but not
oral mucosa, –Nikolsky sign
∆uroporphobilinogen
decarboxylase → ↑heme
metabolites in skin and urine →
photosensitivity, tea-colored
urine, recurrent abdominal pain;
↑risk w/ HCV and EtOH abuse
“pasted on” dark, oily plaques
common in older pts
4 Ps – pruritic, purple, polygonal
papules
autoimmune destruction of
melanocytes → irregular
depigmentation of skin; ↑risk w/
other autoimmune dz
prolonged pressure (>2 hrs) →
tissue ischemia and necrosis,
usually on sacrum and hips
• Tx sunlight + mild shampoo Cradle cap: seborrheic dermatitis
in newborns, presents as greasy
scaly rash on scalp
• Tx reassurance
• mild → Tx topical steroids Psoriatic arthritis: asymmetric
• severe → Tx cytotoxic drugs (MTX, anti-TNFα) polyarthritis + dactylitis (sausage
fingers)
• Tx reassurance
• Dx CXR, ASO titers, VDRL, CBC, ESR, skin bx to EN × diarrhea: IBD
• look for underlying cause EN × black female: sarcoidosis
• Tx underlying cause EN × kids: Strep pyogenes
EN × SW US: coccidioidomycosis
• Dx skin bx + IF staining (between cells)
• Tx systemic steroids
• Dx skin bx + IF staining (linear)
• Tx systemic steroids
• Dx ↑urine porphyrinogen
• Tx frequent phlebotomy
• Tx removal (cryotherapy, surgical excision)
• only for cosmetic reasons
• acute-onset multiple SKs → Dx abd CT scan
• (likely GI malignancy)
• Tx systemic steroids
• Tx topical steroids or photochemotherapy
• Tx local wound care, surgical debridement,
• wound care for deeper ulcers
• PPx turn and reposition q 2 hrs

Stage 1: nonblanching erythema

Ichthyosis vulgaris (lizard skin)
Frostbite
Acanthosis nigricans
Dermatitis herpetiformis
Acne rosacea
Stage 2: partial-thickness skin
loss
Stage 3: full-thickness skin loss
Stage 4: extends into muscle,
bone, joints, tendons
AD Δfilaggrin → dry, rough skin • Tx moisturizing cream
w/ horny plates over extensor
surfaces of limbs; worse during
winter months
cold exposure → dead tissue → • first step is rapid rewarming w/ warm water
numb/white extremities • dead fingers/toes → Tx amputation
followed by erythema and pain
on reexposure to heat
symmetrical, hyperpigmented, • younger pts → Dx fingerstick glucose
velvety plaques in axilla, groin, • older pts → Dx abd CT scan
and neck areas; ↑risk w/ DM
(younger pts) or GI malignancy
(older pts)
skin rash associated w/ celiac • Dx anti-gliadin or anti-endomysial ab
sprue (steatorrhea, etc.) • Tx dapsone
red forehead, nose, cheeks; • Tx topical metronidazole Rhinophyma: large, bulbous,
↑redness w/ hot drinks or greasy nose in men w/ rosacea
emotion
 STEP 2 × DERM

PEDS DERM Dz Presentation Management Other

Atopic dermatitis (eczema)
Staphylococcal scalded skin
syndrome (SSSS)
Henoch-Schonlein purpura
Rubeola (measles)
Rubella (German measles)
Roseola (sixth disease)
Scarlet fever
chronic pruritic rash on cheeks, • Tx moisturizers (calamine or eucerin lotion) + Atopy: asthma + allergic rhinitis +
behind ears, extensor surfaces, • topical steroids atopic dermatitis (eczema)
flexural areas; typically spares Wiskott-Aldrich syndrome: X-
diaper region linked recessive; triad of TIE –
thrombocytopenia (petechiae),
recurrent infx, eczema
Eczema herpeticum: herpes infx
over eczema rash site
Staph aureus exfoliatoxins A/B • Tx abx + local skin care
→ fever + severe, painful rash
that develops bullae, ruptures,
and desquamates
IgA-mediated small vessel • Tx steroids vs. symptomatic relief (will self-
vasculitis → “palpable purpura” • resolve)
on buttocks and legs, renal
disease (IgA mesangial
expansion), ileocecal edema →
colicky abdominal pain + ↑risk
for intussusception
cough, coryza (head cold), • Tx vitamin A
conjunctivitis, Koplik spots,
then diffuse maculopapular rash
diffuse maculopapular rash • Tx symptomatic relief Congenital rubella syndrome:
(starts on face and migrates cataracts + deafness + PDA
down) w/ polyarthralgia,
posterior cervical LAD
HHV-6 infx → high-grade fever • Tx symptomatic relief
for 3 days, then defervesence +
diffuse maculopapular rash
strep throat + GAS exotoxin → • Dx rapid strep test
strawberry tongue, “sandpaper • Tx amoxicillin
rash” w/ possible desquamation
of palms/soles

NEONATAL SKIN RASHES Milia: benign, tiny white bumps on nose

Salmon patch (nevus flammeus): benign, splotchy red rash on forehead, eyelids, or back of neck; more prominent with exercise or emotion
Pustular melanosis: benign, little pustules that leave a hyperpigmented spot when ruptured
Erythema toxicum: benign, yellow-white papules w/ surrounding erythema, fluid exam shows eosinophils
Mongolian spots: benign, bluish macules on back and buttocks
Neonatal acne: benign, pimples on healthy newborn due to maternal hormones
Strawberry hemangioma: benign, small reddish capillary malformations

Seborrheic dermatitis: greasy scaly rash, usually on scalp in newborns (“cradle cap”), can result in dandruff; Tx sunlight + mild shampoo
Sebaceous nevus: raised, yellow-orange hairless lesion on scalp; Tx resection before adolescence (can undergo malignant degeneration)
 STEP 2 × OB

PRENATAL CARE Naegele’s rule: EDC = LMP + 1y – 3m + 7d

Prenatal nutrition: ↑kcal, ↑folate (NTDs), ↑iron (RBCs), ↑calcium, ↑protein, ↓vitamin A (teratogen)
Prenatal exercise: permitted except supine (e.g. sit-ups)
Prenatal travel: permitted except airline travel if >36 wks
Prenatal intercourse: permitted except 3rd trimester or high-risk for SAB, PTL, placenta previa

Prenatal labs: Lab test Management

CBC • anemic → Tx FeSO4 supplements
Blood type • (for future transfusion)
Rh status • nonsensitized + Rh–→ Tx RhoGAM at 28 wks + during any incidence w/ risk of
• feto-maternal blood mixing (e.g. delivery, 3rd trimester bleed, etc.)
HBsAg • HBsAg+ → Dx LFTs and hepatitis panel to determine acute vs. chronic infx;
• Tx infant HBIG and HBV vaccine at birth
HIV ELISA • ELISA+ → confirm w/ Western blot
• WB+ → Tx anti-HIV meds, elective C/S, or IV ZDV during labor
RPR-VDRL • RPR+ → confirm with FTA-ABS
• FTA-ABS+ → Tx benzathine PCN G, desensitize if allergic
UA/UCx • >105 CFU → Tx nitrofurantoin + recheck UCx
• UCx grows GBS → Tx PCN during labor
Rubella ab • rubella nonimmune → stay away from sick ppl + vaccinate postpartum
GC/chlamydia (high-risk • GC/CT+ → Tx ceftriaxone + azithromycin
or ≤24 y/o only)
Quad screen (18 wk) • abnormal quad screen → confirm w/ amniocentesis
• abnormal amniocentesis → genetic counseling
Glucose challenge test • 1-hr GCT abnormal → confirm w/ 3-hr OGTT
(28 wk) • 3-hr OGTT abnormal → Tx exercise + diet ± insulin regimen
Prenatal diagnosis: Method Technique Advantages/disadvantages
Amniocentesis insert needle transabdominally into uterus  wait til 2nd trimester
and withdraw amniotic fluid  ↑risk of PTL, PROM, injury
Chorionic villus insert catheter into intrauterine cavity and  can do during 1st trimester
sampling (CVS) aspirate chorionic villi from placenta  ↑↑risk of PTL, PROM, injury
Periumbilical blood insert needle transabdominally into uterus  rapid karyotype analysis
sampling (PUBS) and withdraw umbilical cord blood  may take maternal blood

MEDICAL Dz Presentation Management Other

COMPLICATIONS Gestational diabetes mellitus human placental lactogen
(GDM) blocks insulin → ↑glucose,
↑risk of T2DM later in life
Pregestational DM: DM
present before pregnancy
Preeclampsia triad of HTN + proteinuria +
edema; can also have severe
headache, RUQ pain (liver
capsule distention)
HELLP syndrome: Hemolysis +
Elevated LFTs + Low Platelets
in preeclamptic pts
Eclampsia preeclampsia + sz
Morning sickness ↑β-HCG → nausea/vomiting in
first trimester
Hyperemesis gravidarum ↑β-HCG → severe, intractable
nausea/vomiting
Maternal UTI dysuria, ±hematuria,
frequency/urgency, suprapubic
tenderness
• Dx screen w/ 1-hr GCT, confirm w/ 3-hr OGTT
• Tx diet + exercise
• poor glucose control (>90) → Tx insulin
• 3rd trimester → Dx fetal U/S + echo (r/o cardiac
• and other defects)
• Dx screen w/ UA, confirm w/ 24hr urine
• protein (>300 mg/day), ↑LFTs
• Tx antihypertensives (labetalol, nifedipine,
• hydralazine, methyldopa) + MgSO4 (sz ppx)
• severe (BP >160/110) → Tx induction > C/S
• HELLP syndrome → Tx induction > C/S
• first step is r/o epilepsy as cause of sz
• Tx IV MgSO4 (continue 24 hrs postpartum for
• neuroprotection) then induction > C/S
• Tx supportive care, will resolve by 16 wk
• first step is r/o mole w/ β-HCG levels
• Tx NPO, IV fluids, antiemetics
• severe → Tx doxylamine + vitamin B6
• Dx UA/UCx (≥105 CFU w/o squamous cells)
• Tx nitrofurantoin > amoxicillin, cephalexin
Maternal complications:
polyhydramnios, preeclampsia
Fetal complications: macrosomia
→ shoulder dystocia, ↓calcium,
polycythemia → hyperviscosity,
cardiac defects (TGV), NTDs,
caudal regression syndrome
First-trimester preeclampsia:
hydatidiform mole
MgSO4 toxicity: pulmonary
edema, DTR depression (first
sign); Tx calcium gluconate
Nitrofurantoin toxicity: drug-
induced lupus, hemolytic anemia
(G6PD males)

Asymptomatic bacteruria: UA
shows ≥105 CFU but pt is asx,
↑risk of progressing to pyelo
 STEP 2 × OB

PHYSIOLOGIC CHANGES CV: hyperdynamic (↑CO), hypotensive (↓TPR → ↓BP) state

Pulmonary: ↑RR + ↑TV → respiratory alkalosis
GI: ↑β-HCG → morning sickness
Renal: ↑GFR → ↓BUN/↓Cr
Blood: ↑E → hypercoagulable; ↑RBC + ↑↑plasma → “dilutional anemia”
Endocrine: ↑E stimulates ↑TBG → ↑total T4 (bound to TBG) but normal free T4, normal TSH
MSK: lower center of gravity → hyperlordosis
Skin: ↑E → spider angiomata and palmar erythema; ↑MSH → linea nigra and melasma/chloasma

TERATOGENS Teratogen exposure: <3 wks = death or asx (“all or nothing”)

Teragoten exposure: 3-8 wks = abnormal organogenesis
Teragoten exposure: >8 wks = abnormal growth/function

Drug/teratogen Presentation
ACE inhibitors, ARBs renal dysgenesis
Alcohol Fetal alcohol syndrome: MR, abnormal facies, smooth philtrum, IUGR, congenital heart defects
Alkylating agents adactyly
AmiNOglycosides Nephrotoxicity, Ototoxicity
Caffeine ↑risk of SAB w/ >150 mg/day
Carbamazepine nail hypoplasia
Cocaine placental abruption, MR
Diazepam cleft palate
Diethylstibestrol (DES) vaginal clear-cell adenocarcinoma
Fluoroquinolones cartilage abnormalities (“fluoroquinolones break your bones”)
Folate antagonists NTDs
Iodide thyroid dysgenesis → cretinism
Lithium Ebstein anomaly
Maternal diabetes fetal macrosomia, caudal regression syndrome (anal atresia to sirenomelia), CV defects (TGV)
Nicotine IUGR, placental abruption, PTL, IUFD
Opioids Neonatal abstinence syndrome: tremors, crying, sweating, sleeplessness, diarrhea, seizures
Phenytoin Fetal hydantoin syndrome: microcephaly, digital hypoplasia, hirsutism, cleft palate
Retinoic acid CNS defects, hydrocephalus, microtia/anotia, micrognathia, athymia
Tetracyclines tooth discoloration
Thalidomide phocomelia (flipper limbs)
Valproic acid blocks folate absorption → NTDs
Warfarin bone deformities, fetal bleeding, abortion
X-rays, CT scans multiple anomalies

TORCHES INFX TORCHES infx: suspect in any neonate w/ microcephaly, HSM, deafness, chorioretinitis, or thrombocytopenia (petechiae)

Dz Presentation Management Other

Congenital toxoplasmosis chorioretinitis + hydrocephalus • Tx pyrimethamine + sulfadiazine
+ intracranial calcifications
Congenital rubella syndrome cataracts + deafness + PDA, • Tx supportive care
“blueberry muffin” rash
Congenital CMV deafness, blindness, HSM, • Tx ganciclovir + supportive care
periventricular calcifications
Neonatal HSV vesicular rash, HSV • Tx acyclovir
pneumonitis, temporal lobe • active lesions in mom → deliver by C/S
encephalitis (focal seizures)
Neonatal HIV suspect w/ thrush, generalized • Dx HIV PCR (not ELISA since mom’s ab can
LAD, hepatomegaly, and FTT • cause false positive)
• Tx IV ZDV to all neonates of infected mothers
Congenital syphlis Early congenital syphilis: • Dx screen w/ RPR-VDRL, confirm w/ FTA-ABS Saddle nose ddx: congenital
maculopapular rash, snuffles • Tx PCN + supportive care syphilis, cocaine abuse, leprosy,
(rhinitis w/ serous, purulent, or Wegener granulomatosis
bloody discharge), HSM,
jaundice, generalized LAD
Late congenital syphilis:
deafness, saber shins,
mulberry molars, Hutchinson
teeth, saddle nose
Congenital varicella syndrome limb hypoplasia, clear vesicles • PPx VZIG only if mom has chickenpox from
→ cutaneous scars, • 5 days prior to 2 days after delivery
chorioretinitis, cortical atrophy

rd
OBSTETRIC 3 trimester bleeding: placenta previa (painless), abruptio placenta (painful), uterine rupture (painful + “restless” pt)
COMPLICATIONS
Dz Presentation
Ectopic pregnancy zygote implants in ampulla of
fallopian tube → severe
RLQ/LLQ abd pain ± vaginal
bleeding
Heterotopic pregnancy:
normal + ectopic pregnancy
Spontaneous abortion (SAB) Threatened ab: closed cervix,
no expulsion
Inevitable ab: open cervix,
no expulsion
Incomplete ab: open cervix,
partial expulsion
Complete ab: closed cervix,
full expulsion
Missed ab: closed cervix,
no expulsion
Septic abortion retained POC get infected →
fever, abdominal pain, bloody
or purulent vaginal discharge
Multiple gestations Monozygotic twins: 1 sperm +
1 ova → identical DNA
Dizygotic twins: 2 sperm + 2
ova → separate DNA
Incompetent cervix painless dilation and cervical
effacement in 2nd trimester;
↑risk w/ prior LEEP
Intrauterine fetal demise (IUFD) fetal death in utero >20 wks;
↑risk of DIC if left >3 wks
Intrauterine growth restriction fetal growth <10th percentile
(IUGR)
Symmetric IUGR: overall ↓fetal
size, 2/2 congenital infx or abnl
chromosomes
Asymmetric IUGR: ↓torso size
but normal head/extremities,
2/2 maternal causes (e.g. HTN)
Oligohydramnios ↓amniotic fluid → pulmonary
hypoplasia + constraint
deformities (e.g. club foot)
Polyhydramnios ↑amniotic fluid
Premature rupture of rupture >1 hr before labor
membranes (PROM)
Preterm labor (PTL) labor <37 wks → uterine ctx,
cervical dilation/effacement,
ROM, etc.
Placenta previa Low-lying placenta: placenta
implanted in low uterus but
doesn’t cover internal os
Placenta previa: covers
internal os → painless 3rd
trimester bleeding
Vasa previa fetal blood vessel covers
internal os → massive 3rd
trimester bleeding s/p ROM
Placenta accreta/increta/percreta Placenta Accreta: placenta
Adheres to uterine wall
Placenta Increta: placenta
Invades into myometrium
Placenta Percreta: placenta
Penetrates through to serosa
Abruptio placenta premature separaion of
placenta from uterine wall →
painful 3rd trimester bleeding
STEP 2 × OB
Management Other
• Dx screen w/ β-HCG, confirm w/ TV U/S Risk factors: tubal scarring (STDs
• ruptured → Tx surgical excision or PID), IUD, endometriosis
• unruptured → Tx MTX + f/u β-HCG
• “rule-out ectopic” (β-HCG <1000) → repeat
• β-HCG + TV U/S in 48 hrs
• Dx U/S (viable fetus) Etiology: trisomy 16 (MCC 1st
• Tx reassurance + outpatient f/u trimester), maternal anatomic
• Tx D+C defects (MCC 2nd trimester)
• Tx D+C
• Dx U/S (no fetus)
• f/u serial β-HCG
• Dx U/S (nonviable fetus)
• Tx induction > D+C
• Dx pelvic exam (tender uterus, dilated cervix),
• blood/cervical cx
• Tx IV abx + gentle D+C
• Dx U/S Cleavage: chorion separates on
• vertex/vertex → okay to deliver vaginally day 4, amnion separates on day 8
• other presentations or 3+ gestations → deliver
• by C/S
• Dx U/S (“hourglass membranes”)
• <24 wks → Tx emergent cerclage
• ≥24 wks → Tx conservative management
• Dx U/S (absent fetal movement) IUFD vs. missed abortion: missed
• Tx induction > D+E abortion occurs in 1st trimester,
• f/u autopsy to search for underlying cause IUFD occurs in 2nd/3rd trimester
• Dx screen w/ ↓fundal height, confirm w/ U/S Normal fundal height: pubic
• (abd circumference is best measure) symphysis at 12 wks, umbilicus at
• Tx underlying cause + good nutrition 20 wks
• Dx U/S (amniotic fluid index <5 cm) Risk factors: renal agenesis
• low-risk → Tx expectant management (Potter sequence), post-term
• high-risk → Tx induction
• incompatible w/ life → Tx induction
• Dx U/S (amniotic fluid index >20 cm) Risk factors: maternal diabetes,
• <32 wks → Tx amnioreduction + indomethacin GI obstruction (e.g. duodenal
• ≥32 wks → Tx amnioreduction only (don’t atresia)
• want to close off PDA)
• Dx pool test (visualize amniotic fluid pooling), Fetal lung maturity: presence of
• nitrazine test (turns paper blue), microscopic phosphatidylglycerol in amniotic
• exam (ferning), tampon dye test fluid or lecithin:sphingomyelin
• <34 wks → Tx tocolytics + betamethasone, ratio (L:SM ratio) >2
• then check fetal lung maturity, then induction
• ≥34 wks → Tx induction
• <34 wks → Tx tocolytics + betamethasone,
• then expectant management
• ≥34 wks → Tx expectant management
• Dx U/S Risk factors: prior C/S, multiple
• previa → Tx deliver by C/S gestation, multiparity
• low-lying → okay to deliver vaginally
• do not perform manual or speculum vaginal
• exams (↑risk of bleeding)
• Dx fetal monitoring (sinusoidal pattern),
• Apt test (confirms fetal bleed)
• Tx emergent C/S (75% mortality rate)
• Dx U/S
• Tx deliver by C/S + postpartum hysterectomy
• Dx U/S Risk factors: HTN (#1), trauma,
• stable → Tx induction cocaine, smoking, preeclampsia
• unstable → Tx emergent C/S Concealed abruption: 20% of
abruptions don’t bleed b/c blood
pools behind placenta
 STEP 2 × OB

FETAL MONITORING Fetal monitoring: no fetal movements felt

Dx doppler U/S

+FHT –FHT

non-stress test real-time U/S (for IUFD)

reactive nonreactive
(2×15×15 accels)
biophysical profile

BPP<4 BPP=6 BPP>8

repeat NST q wk deliver contraction reassurance

stress test

Early decel: along w/ ctx, due to head compression → CN X stimulation; benign

Variable decel: no relation w/ ctx, due to cord compression (e.g. oligohydramnios); Tx 100% O2 + change maternal positioning
Late decel: happens after ctx, due to uteroplacental insufficiency; Tx emergent delivery
Accelerations: “reactive” if 2× (15 bpm × 15 sec) / 20 min; benign
Sinusoidal pattern: sine-wave shaped, due to fetal anemia (e.g. fetal vx rupture); Tx emergent delivery

LABOR + DELIVERY Labor: regular uterine ctx + cervical changes

False labor: irregular uterine ctx (Braxton-Hicks) w/o cervical changes

Dz Presentation Management Other

Fetal malpresentation fetus presents w/ face first, • Dx Leopold maneuvers or U/S
brow first, breech (butt first) • face presentation → okay to deliver vaginally
• brow presentation → okay to deliver vaginally
Complete breech: thighs and • breech presentation → Tx external cephalic
knees flexed • version at 37 wks, deliver by C/S if refractory
Frank breech: thighs flexed,
knees extended to face
Footling breech: one foot
comes through first
Postpartum hemorrhage (PPH) >500 mL blood loss s/p SVD,
>1000 mL blood loss s/p C/S
Uterine atony: uterus has • Tx IV oxytocin + bimanual uterine massage
↓muscle tone (MCC PPH); ↑risk • refractory → Tx methylergonovine or
w/ excessive uterine distention • carboprost
(e.g. multiple gestation,
macrosomia, polyhydramnios)
Retained POC: parts of • Tx manual extraction
placenta remain inside uterus • if unsuccessful → D+C and abx
Vaginal/cervical lac: trauma to • Tx surgical repair
mom during delivery
Shoulder dystocia anterior shoulder gets caught • Tx special maneuvers (suprapubic pressure,
behind pubic symphysis; ↑risk • flexion of maternal hips to ↑pelvic diameter,
of clavicle fx, brachial plexus • pressure behind fetal shoulders, deliver
injury, phrenic nerve palsy • posterior arm first)
• still stuck → cut clavicle or pubic symphysis
• still stuck → push head back in and do C/S
Endometritis polymicrobial infx of • Tx clindamycin + gentamicin
endometrial lining → fever,
uterine tenderness, foul-
smelling lochia; ↑risk w/
outside exposure (e.g. C/S,
prolonged ROM, prolonged
labor, instrumentation, etc.)
Acute mastitis breastfeeding women get • check for fluctuance (indicating abscess) Mastitis vs. engorgement:
Staph/Strep infection through • Tx dicloxacillin, do not stop breast-feeding mastitis is unilateral and has
cracks in nipple w/ yellowish overlying erythema
discharge
Postpartum mood disorder Postpartum blues: 30-70%, • self-resolves by day 10
dysthymia w/o functional
impairment
Postpartum depression: 10- • Tx SSRIs
20%, depression w/ functional
impairment
Postpartum psychosis: 0.1%, • Tx admit + psych consult
psychosis w/ functional
impairment
Arrest of labor lack of cervical changes >2 hrs • inadequate ctx → Tx IV oxytocin Platypelloid pelvis: small pelvis
(multigravida) or >1 hr • pelvic abnormality → Tx deliver by C/S in Asian pts, leads to deep
(primigravida), +1 hr if epidural transverse arrest

GESTATIONAL TROPHO- Dz Presentation
BLASTIC NEOPLASMS Hydatidiform mole Complete mole: empty egg +
sperm → 46/xx (both
paternal) → enlarged uterus +
“grape-cluster” villi, abnormal
vaginal bleeding, severe
hyperemesis, 1st trimester
preeclampsia
Partial mole: egg + 2 sperm →
69/XXY → presents as missed
abortion w/ fetal parts found
on autopsy
Choriocarcinoma malignant, necrotizing tumor
in uterus → abnormal vaginal
bleeding + s/sx of metastasis
STEP 2 × OB
Management Other
• Dx screen w/ ↑β-HCG (>100,000), confirm w/
• pelvic U/S (“snowstorm” pattern)
• Tx D+C
• f/u serial β-hCG and reliable contraception for
• 6 months (pregnancy could complicate dx)
• Dx pelvic U/S (“swiss cheese” uterus), β-HCG
• is normal
• Tx D+C
• f/u serial β-hCG and reliable contraception for
• 6 months (pregnancy could complicate dx)
• Dx screen w/ ↑β-hCG, confirm w/ pelvic U/S
• check for mets (lungs, brain, liver, kidney, GI)
• Tx hysterectomy ± chemotherapy
• f/u serial β-hCG and reliable contraception for
• 6 months (pregnancy could complicate dx)
 STEP 2 × GYN

MENSTRUAL CYCLE Ovarian follicle:

mi mi mittleschmerz, spinnbarkeit
Endometrium:

Sex hormones:

FSH: stimulates follicular growth

LH: “LH surge” induces ovulation
Estrogen: stimulates endometrial proliferation, follicle growth, 2° sexual development
Progesterone: stimulates endometrial gland development, ↑body temp, thickens cervical mucus, inhibits FSH/LH
β-HCG: LH analog, maintains corpus luteum viability in 1st trimester

HPO axis: GnRH DA TRH

FSH/LH PRL TSH stimulates

inhibits

E/P T3/T4

Hypothyroidism × infertility: ↓T3/T4 → ↑TRH → ↑prolactin → ↓GnRH → ↓FSH/LH

Hyperprolactinemia × infertility: ↑prolactin → ↓GnRH → ↓FSH/LH
Kallman syndrome: anosmia + congenital ↓GnRH → ↓FSH/LH

PUBERTY Normal development: “GRaB PAM”

Normal development: GRowth spurt
Normal development: Breast (thelarche)
Normal development: Pubic hair (pubarche)
Normal development: Axillary hair (adrenarche)
Normal development: Menstruation (menarche)

Tanner stages: Males Females

Tanner 1 kid kid
Tanner 2 scrotal darkening, thin long pubic hair breast buds
Tanner 3 dark curly pubic hair breast elevation, peak growth
velocity
Tanner 4 adult pubic hair but w/o full coverage, areolar mound (look 4 big
peak growth velocity nipples)
Tanner 5 adult adult
 STEP 2 × GYN

MENSTRUAL DZ Dz Presentation Management Other

Precocious puberty presence of any pubertal
changes <7 y/o (black girls), <8
y/o (white girls), <9 y/o (boys)
McCune-Albright syndrome precocious puberty in girls +
café-au-lait spots + polyostotic
fibrous dysplasia (bone zits)
Menopause cessation of menses for >1 yr →
hot flashes, atrophic vaginitis
(dyspareunia); ↑risk of
osteoporosis and coronary
artery dz
1° amenorrhea absence of menarche by 16 y/o
or absence of 2° sexual
characteristics by 14 y/o
2° amenorrhea absence of menses for 6 mo,
but had periods at one time
Asherman syndrome: repeat
D+C, surgery, or endometritis
→ intrauterine adhesions
Cervical stenosis: surgical or
obstetric trauma → scarring of
cervical os
• Dx FSH/LH Isolated precocious adrenarche:
• ↑FSH/LH → central etiology (MCC premature axillary hair <8 y/o due to adrenal
• HPO activation), Dx head CT for brain tumor gland activation, benign
• ↓FSH/LH → peripheral etiology Isolated precocious pubarche:
pubic hair <8 y/o, requires full
• premature HPO activation → Tx GnRH analog work-up for underlying dz
• Tx supportive care
• Dx ↑↑FSH/↑LH, ↓E Topical estrogen toxicity: ↑risk
• vaginal atrophy → Tx topical estrogen cream of breast cancer, c/i in pts with
• osteoporosis → Tx calcium + vitamin D + prior hx of breast cancer
• weight-bearing exercise (not swimming) Premature ovarian failure:
menopause <40 y/o
• first step is β-HCG to r/o pregnancy
• Dx FSH/LH, E
• ↓FSH/LH, ↓E → CNS problem (GnRH
• deficiency, prolactinoma)
• ↑FSH/LH, ↓E → ovarian problem (gonadal
• agenesis, ovarian failure, Turner syndrome)
• nl FSH/LH, nl E → outflow tract obstruction
• (imperf hymen, vaginal atresia, MRKH)
• first step is β-HCG to r/o pregnancy P challenge test: give P for 5
• Dx prolactin, TSH, FSH/LH, P4 challenge test days, then stop P and check for
withdrawal bleed (positive bleed
• ↑prolactin, ↑TSH → hypothyroidism = endometrium is estrogenized)
• ↑prolactin, nl TSH → prolactinoma
• nl prolactin, +P challenge test → PCOS
• (hirsutism), HPO dysfxn, anorexia nervosa
• nl prolactin, –P challenge test → Asherman
• syndrome, cervical stenois, premature ovarian
• failure, HPO dysfxn

• Asherman syndrome → Tx lysis of adhesions

1° dysmenorrhea
2° dysmenorrhea
Premenstrual syndrome (PMS)
Endometriosis
Abnormal uterine bleeding
Dysfunctional uterine bleeding
(DUB)
Polycystic ovarian syndrome
(PCOS)
Midcycle pain (mittelschmerz)
↑PGF2α → painful uterine ctx →
“lower abd pain that radiates to
upper thighs and back”
dysmenorrhea due to PID,
endometriosis, adenomyosis,
fibroids, ovarian cysts, etc.
dysphoric sx (HA, bloating,
weight gain, labile mood) for 2+
cycles during luteal phase only
endometrial tissue outside
endometrial cavity → 3 Ds –
Dysmenorrhea (“cyclic pelvic
pain” worst before menses)
Dyspareunia, Dyschezia
Adenomyosis: endometrial
tissue invades myometrium →
“tender boggy uterus”
Endometrioma: endometriosis
in the ovary (“chocolate cyst”)
Menorrhagia: heavy bleeding
(>80 mL or lasts >7 days)
Hypomenorrhea: light bleeding
Metrorrhagia: irregular timing
Menometrorrhagia: heavy
bleeding + irregular timing
Oligomenorrhea: slow cycles
(>5 wk interval)
Polymenorrhea: fast cycles
(<3 wk interval)
abnormal uterine bleeding w/o
underlying organic cause
Rotterdam criteria: 2/3 of the
following – polycystic ovaries
on U/S, anovulatory cycles, s/sx
of hyperandrogenism
ovulation → sudden-onset
nonradiating LLQ/RLQ pain,
2 wks after LMP
• cervical stenosis → Tx dilation vs. laminaria
• first step is β-HCG to r/o pregnancy
• Dx physical exam, vaginal cx, U/S to look for
• any underlying cause
• Tx NSAIDs > OCPs
• first step is β-HCG to r/o pregnancy
• Dx physical exam, vaginal cx, U/S to look for
• any underlying cause
• Tx underlying cause
• Dx menstrual diary
• Tx diet + exercise > vitamin B6 > SSRIs
• PMS sx throughout entire cycle → get psych
• eval for underlying mood disorder
• Dx physical exam (uterosacral nodularity, Etiology: 3 theories – coelomic
• fixed retroverted uterus), laparoscopy (gold metaplasia, retrograde menses,
• standard but not required) lymphatic/hematogenous spread
• temporary → Tx OCPs, leuprolide, danazol
• fertility desired → Tx surgical ablation
• definitive → Tx hysterectomy + LOA
• Dx labs (β-HCG, TSH, prolactin, FSH) +
• endometrial bx (if >35 or obese) + pelvic U/S
• Tx underlying cause
• Dx labs (β-HCG, TSH, prolactin, FSH) +
• endometrial bx (if >35 or obese) + pelvic U/S
• acute hemorrhage → Tx high-dose IV estrogen
• chronic DUB → Tx NSAIDs > OCPs
• Dx LH:FSH ratio >3:1 + ↑estrone Complications: ↑estrogen →
• Tx OCPs (regulates menstrual cycles), endometrial proliferation →
• clomiphene , metformin, weight loss/exercise ↑risk of endometrial cancer
• f/u screening tests for T2DM and HLD
• r/o other medical causes
• Tx reassurance
 STEP 2 × GYN

CONTRACEPTION Type Method Mechanism Benefits Risks

Hormonal (E/P) Combined OCP (COC)
Transdermal patch (Ortho Evra)
Intravaginal ring (NuvaRing)
Hormonal (P) Progestin-only OCP (POP)
Medroxyprogesterone acetate
(Depo-Provera)
Progestin implant (Implanon)
Emergency Emergency contraception
Barrier Condom
Diaphragm or cervical cap
Spermicide (nonoxynol-9)
Practice Abstinence
Natural family planning
Lactational amenorrhea
IUD Copper IUD (ParaGard copper-T)
Progestin IUD (Mirena)
Sterilization Tubal ligation
Vasectomy
blocks LH surge, thickens
cervical mucus, slows tubal
peristalsis, creates hostile
environment
COC as a transdermal patch
COC as a intravaginal ring
thickens cervical mucus
POP as injection q 3 months
POP as subcutaneous implant
either Plan B (levonorgestrel)
within 72 hrs or copper IUD
inserted within 5 days
prevents sperm/ova contact
prevents sperm/ova contact
kills sperm
no sex
avoid sex 5 days before to 2
days after ovulation (measure
body temp or cervical mucus)
prolactin-induced GnRH
suppression
inhibits sperm motility, creates
hostile environment
inhibits sperm motility, creates
hostile environment
blocks ova passage
blocks sperm passage, must
use alternative methods for 90
days while sperm die off
 normalizes cycles
 ↓cervical/ovarian cancer
 ↓dysmenorrhea
 no weight gain
" "
" "
 good for lactating women
 good for women who can’t
 take COCs
"  breakthrough bleeding
 good for 3 months
"  breakthrough bleeding
 good for 3 yrs
 no weight gain, depression
 90% effective
 not abortafacient
 low cost
 protects against STDs
---
 used in combo w/ others
 100% effective
 free
 free
 indicated for monogamous
 relationships
 good for 10 yrs
 low-maintenance
 indicated for monogamous
 relationships
 good for 5 yrs
 low-maintenance
 ↓↓menstrual flow
 99% effective
 99% effective
 hypercoagulability
 hepatic adenoma
 c/i in smokers >35, hyper-
 coagulable dz, liver dz,
 estrogen-dependent
 cancers, migraines w/ aura
 c/i in women >198 lbs
 must take at same time
 everyday
 breakthrough bleeding
 weight gain, depression
 prolonged amenorrhea
 weight gain, depression
 prolonged amenorrhea
 prolonged amenorrhea
 severe nausea/vomiting
 headaches
 breast tenderness
 can induce latex allergy
 can break
 uncomfortable
 ↑risk of UTI
 ↑risk of toxic shock
 syndrome
 needs to be placed by MD
 hard to dose correctly
 no fun
 ↑↑failure rate
 ↑↑failure rate
 only good for 6 months
 ↑↑menstrual flow
 ↑risk of PID, uterine perf,
 spontaneous abortions,
 ectopic pregnancies
 needs to be placed by MD
 ↑risk of PID, uterine perf,
 spontaneous abortions,
 ectopic pregnancies
 needs to be placed by MD
 permanent
 no STD protection
 ↑risk of regret, ratio of
 ectopic pregnancies
 permanent
 no STD protection
 ↑risk of regret, ratio of
 ectopic pregnancies
 STEP 2 × GYN

INFERTILITY Infertility: failure to conceive after 12 mo of unprotected sex (6 mo if woman >35)

Infertility management:

HIRSUTISM Dz Presentation Management Other

Hirsutism excess male-pattern hair
growth
Virilization: hirsutism + 2° male
sex characteristics (deep voice,
clitoromegaly, etc.)
• Dx free T, DHEAS, 17-OHP, cortisol
• ↑free T, ↑DHEAS → indicates adrenal source;
• Dx CT scan
• ↑free T, nl DHEAS → indicates ovarian source;
• Dx pelvic U/S or CT scan
• ↑17-OHP → congenital adrenal hyperplasia;
• Tx prednisone + fludrocortisone
• ↑cortisol → Cushing syndrome; Dx ACTH +
• dexamethasone suppression test

UTERINE DZ Pap smear screening: q 2 yrs (21-29), then q 3 yrs (>30 after 3 negative Paps)

Dz Presentation Management Other

Uterine fibroids benign, estrogen-sensitive
smooth muscle proliferation of
myometrium → usually asx, but
can cause menorrhagia,
abdominal pain, dysmenorrhea
Endometrial hyperplasia ↑estrogen exposure →
endometrial proliferation →
abnormal uterine bleeding
Endometrial cancer Type I: prolonged endometrial
hyperplasia becomes malignant
→ abnormal uterine bleeding,
postmenopausal bleeding
Type II: estrogen-independent,
aggressive, poor prognosis
Cervical dysplasia CIN I: dysplasia in basal 1/3 of
epithelium, 65% regression rate
CIN II: dysplasia in basal 2/3 of
epithelium
CIN III: dysplasia >2/3 to full
epithelium
• Dx pelvic U/S
• asx → close f/u to check for abnl growth
• temporary → Tx danazol, leuprolide (↓E)
• fertility desired → Tx myomectomy
• definitive → Tx hysterectomy
• nonsurgical candidate → Tx uterine artery
• embolization (will impair fertility)
• Dx endometrial bx
• simple, no atypia → Tx cyclic progestins
• simple, atypia → Tx cyclic progestins
• complex, no atypia → Tx cyclic progestins
• complex, atypia → Tx TAH-BSO (25% cancer)
• Dx endometrial bx
• Tx TAH-BSO
• f/u CA-125 tumor marker (if postmenopausal)
• Dx Pap smear
• ASC-US → Dx HPV DNA → colpo if +HPV,
• repeat Pap in 1 yr if –HPV
• ASC-H → Dx colpo
• LSIL, premenopausal → Dx colpo
• LSIL, postmenopausal → Dx colpo or repeat
• Pap in 1 yr or HPV DNA
• HSIL → Dx colpo
• SCC → Dx colpo
Fibroid subtypes: submucosal
(most likely to bleed), intramural
(MC), subserosal, pedunculated
Risk factors: anything that
causes ↑E or ↑total cycles
(obesity, PCOS, nulliparity, early
menarche, late menopause,
granulosa cell tumors, etc.)
HNPCC/Lynch syndrome: colon
cancer + endometrial cancer
Risk factors: early intercourse,
smoking, HPV-16-18/31/33/45 infx
LEEP complications: ↑risk of
incompetent cervix in future
pregnancies

• CIN I → repeat Pap q 6 mo ×2 or HPV DNA in

Cervical cancer squamous cell carcinoma w/
basement membrane invasion
→ usually asx, but can present
w/ postcoital bleeding
• 1 yr → Tx LEEP if persistent for 2 yrs
• CIN II-III → Tx LEEP
• Dx colpo
• <5 mm → Tx cold knife cone vs. simple
• hysterectomy
• >5 mm but noninvasive → Tx radical
• hysterectomy
• invasive → Tx chemoradiation

BREAST DZ Breast cancer screening: annual mammogram (>50, >40 if strong family hx)
Bloody discharge: intraductal papilloma
Milky discharge: pregnancy, hyperprolactinemia, hypothyroidism, drug-induced (e.g. antipsychotics)
Yellowish discharge: fibrocystic change, galactocele, acute mastitis
Green/sticky discharge: mammary duct ectasia
Purulent discharge: breast abscess
MC breast masses: <25 fibroadenoma
MC breast masses: 25-50 fibrocystic change
MC breast masses: >50 infiltrating ductal carcinoma
Breast mass management: age
<30 ≥30
U/S mammogram
cystic solid benign suspicious
(BIRADS 1-3) (BIRADS 4-5)
needle core close f/u core needle bx
aspiration needle bx
Dz Presentation
Fibrocystic change painful, multiple, bilateral lumps
that vary with menstrual cycle
Acute mastitis breastfeeding women get
Staph/Strep infection through
cracks in nipple w/ yellowish
discharge
Periductal mastitis: subareolar
mastitis in smokers (males too)
Breast abscess painful mass w/ fluctuance,
fever, overlying erythema, may
have purulent discharge
Mammary duct ectasia bilateral breast pain w/ green,
sticky discharge
Fibroadenoma firm, mobile, rubbery mass <5
cm in young women
Giant juvenile fibroadenoma:
≥5 cm, seen in teens with rapid
breast growth
Intraductal papilloma bloody nipple discharge
Dystrophic calcification breast lump following trauma,
but work up as a cancer until
proven otherwise
Breast cancer solid, immobile breast lump
(MC in upper/outer quadrant)
DCIS: mammogram shows
clustered microcalcifications, no
stromal invasion
LCIS: multiple/bilateral, no
stromal invasion
Infiltrating ductal carcinoma:
MC breast cancer (80%)
Infiltrating lobular carcinoma:
multiple/bilateral
Paget disease: “crusty” nipple
eczema, indicates underlying
adenocarcinoma
Inflammatory carcinoma:
resembles cellulitis w/ peau
d’orange, “tumor cells in dermal
lymphatics”
STEP 2 × GYN
malignant
(BIRADS 6)
tx
Management Other
• Dx physical exam (“lumpy bumpy”)
• Tx dietary ↓tea/caffeine/chocolate
• suspicious → Tx needle aspiration (clear
• yellow fluid), then f/u 4-6 wks
• check for fluctuance (indicating abscess)
• Tx dicloxacillin, do not stop breast-feeding
• Dx physical exam
• Tx I+D
• Dx physical exam
• Tx excision + bx to r/o cancer
• Dx physical exam
• suspicious → observe for several cycles
• still suspicious → Dx U/S or mammogram
• Tx elective removal
• giant juvenile fibroadenoma → Tx excision to
• avoid breast deformity
• Tx galactogram/ductogram-guided excision +
• bx to r/o cancer
• Dx core needle bx (foamy mass + fat globules)
• Tx reassurance
• Dx screen w/ mammmogram, confirm w/ core Surgical complications: winged
• needle bx scapula (cut long thoracic nerve),
arm lymphedema (cut lymphatic
• DCIS → Tx lumpectomy supply)
• LCIS → Tx close observation + tamoxifen
Trastuzumab toxicity:
• <2 cm → Tx lumpectomy + SLN bx cardiotoxicity (requires echo
• >2 cm or multifocal → Tx radical mastectomy + before starting chemotherapy)
• SLN bx Tamoxifen toxicity: ↑risk of
• single met → Tx resection endometrial cancer + DVTs
• multiple mets → Tx chemotherapy Raloxifene toxicity: ↑risk of DVTs
• SLN+ → Tx chemotherapy (no endometrial cancer)
• inflammatory → Tx chemotherapy + radical
• mastectomy + radiation
• ER+/PR+ → Tx tamoxifen
• HER2/neu+ → Dx FISH or immunohisto
• chemical stain, Tx trastuzumab (Herceptin)
 STEP 2 × GYN

VAGINAL DZ Dz Presentation Management Other

Lichen sclerosus vulvar thinning and “porcelain-
white” atrophy → pruritus in
postmenopausal women
Vaginal adenosis red spots/patches in upper 1/3
vagina in pts w/ DES exposure;
precursor to clear cell
adenocarcinoma
Vaginal cancer friable, bleeding vaginal mass
• Dx punch bx (r/o cancer)
• Tx topical steroids
• close f/u
• Dx punch bx
• <2 cm → Tx surgical resection
• >2 cm or invasive → Tx chemotherapy
• nonsurgical candidate → Tx radiation

OVARIAN DZ Ovarian cancer risk factors: family hx (#1), BRCA1/2, ↑cycles (nulliparity, early menarche, late menopause, old age, etc.)

Carcinomatous ileus: intraperitoneal tumor spread → ascites and bowel encasement → intermittent bowel obstruction
Sister-Mary-Joseph nodule: ovarian cancer metastasis to umbilicus

Dz Presentation Management Other

Ovarian cysts
Ovarian epithelial tumors
Ovarian germ cell tumors
Ovarian sex-cord/stromal tumors
Ovarian metastatic tumors
Follicular cysts: MC ovarian • Dx pelvic exam (palpable ovarian mass)
cyst, due to unruptured follicle • low-risk pts → Dx pelvic U/S
Corpus luteum cysts: due to • high-risk pts (premenarchal, postmenopausal,
hemorrhage into persistent • size >8 cm, lasts >60 days) → Tx laparotomy
corpus luteum
Theca-lutein cysts: multiple and • follicular cyst → Tx reassurance
bilateral, due to ↑↑FSH/LH • corpus luteum cyst → Tx reassurance
• theca-lutein cysts → Tx reassurance
Serous cystadenoma: bilateral, • Dx pelvic U/S
lined w/ FT-like epithelium • Tx TAH-BSO + omentectomy + LN-ectomy +
Serous cystadenocarcinoma: • post-op chemoradiation
bilateral, Dx Psamomma bodies
Mucinous cystadenoma: • f/u CA-125 tumor marker (if postmenopausal)
multilocular cyst lined w/
mucus-secreting epithelium
Mucinous cystadenocarcinoma:
pseudomyxoma peritonei
Endometrioid carcinoma:
resembles endometrial cancer
Clear cell carcinoma: glycogen-
filled clear cells, poor px
Brenner tumor: benign,
resembles bladder (transitional
epithelium)
Mature teratoma: benign, • Dx pelvic U/S
contains hair and teeth • Tx USO + post-op chemoradiation
Immature teratoma: malignant,
contains neural tissue • f/u CA-125 tumor marker (if postmenopausal)
Struma ovarii: monodermal,
contains thyroid tissue
Dysgerminoma: ↑LDH,
associated w/ Turner syndrome
Endodermal sinus (yolk sac)
tumor: ↑AFP, Dx Schiller-Duval
bodies resembling primitive
glomeruli
Choriocarcinoma: ↑β-hCG, also
a malignant type of GTD
Granulosa cell tumor: secretes • Dx pelvic U/S Meigs syndrome: fibroma +
estrogen → ↑risk of • Tx USO only ascites + right-sided hydrothorax
endometrial hyperplasia, Dx
Call-Exner bodies • f/u CA-125 tumor marker (if postmenopausal)
Fibroma: pulling sensation in
groin, Dx bundles of spindle-
shaped fibroblasts
Sertoli-Leydig cell tumor:
androblastoma, secretes
testosterone → virilization
Krukenberg tumor: metastatic • Dx pelvic U/S
stomach cancer, Dx mucin- • Tx underlying cause
containing “signet ring” cells
 STEP 2 × PEDS

GEN PEDS Goat milk: ↓folate → megaloblastic anemia

Cow milk: ↓iron → microcytic anemia ± pica, fatigue, pallor; Tx FeSO4
Breast milk: ↓vitamin D → nutritional rickets
Watered-down milk: hyponatremia → seizures

Pediatric growth curve: 3 mo 6 mo 1 yr 2 yr 3 yr 4 yr

Length 1× 1.5× 2×
Weight 1× 2× 3× 4×

Developmental milestones: 3 mo 6 mo 1 yr 2 yr 3 yr 4 yr
Gross holds head up, sits up walks climbs stairs rides tricycle hops on one
motor rolls front-to- foot
back
Fine --- raking grasp throws object, turns pages, draws circle, draws cross
motor 3 blocks 6 blocks 9 blocks
Speech cooing babbling 5-10 words 200 words, 900 words, counts to ten,
2-word phrases, 3-word phrases, tells stories,
50% clear 75% clear 100% clear
Social recognizes stranger comes when parallel play group play cooperative
parents, social anxiety called, object play, imaginary
smile permanence friends

Anticipatory guidance: 3 mo 6 mo 1 yr 2 yr 3 yr 4 yr
Daily don’t bathe introduce iron- introduce see dentist limit TV time to vision check
care daily (dry skin), fortified cereals whole cow’s (two-th) 2 hrs/day
“back to sleep” milk

VITAMINS Vitamin Deficiency Toxicity

Vitamin A: used to treat cystic acne,
measles, and AML (M3 type)
Vitamin B1 (thiamine): given w/ IV D5 to
prevent iatrogenic Wernicke-Korsakoff
Vitamin B2 (riboflavin)
Vitamin B3 (niacin): given to HLD pts w/
TG >500
Vitamin B6 (pyridoxine): given w/ INH to
prevent peripheral neuropathy; used to
treat homocystinuria, PMS, hyperemesis
Vitamin B7 (biotin)
Vitamin B9 (folate): given to sickle cell
pts to help hematopoiesis
Vitamin B12 (cobalamin)
Vitamin C (ascorbic acid)
Vitamin D: given to exclusively breast-fed
kids who don’t get enough sunlight
Vitamin E
Vitamin K: all infants get vitamin K shot
at birth
night blindness, dry skin increased CSF pressure (headache, blurry
vision), dry skin, teratogenic; found in animal
liver consumption
dry beriberi (peripheral neuropathy), wet ---
beriberi (CHF), Wernicke-Korsakoff (confusion,
ophthalmoplegia, ataxia, nystagmus, etc.)
angular cheilosis (dried cracks along corners of ---
lips), corneal vascularization
pellagra (diarrhea, dermatitis, dementia), flushing, pruritus (Tx ASA)
associated w/ carcinoid tumors and Hartnup
disease (AR Δneutral AA transporter)
peripheral neuropathy, sideroblastic anemia ---
seborrheic dermatitis, enteritis, alopecia; found ---
in kids who eat raw eggs (avidin binds biotin)
and biotinidase deficiency
megaloblastic anemia w/o neuro sx, neural tube ---
defects; found in babies fed goat’s milk
megaloblastic anemia w/ neuro sx; found in ---
strict vegan diets and pernicious anemia
scurvy (bleeding gums) uric acid stones
rickets in kids (bowed legs, rachitic rosary, large hypercalcemic sx, calcium oxalate stones
anterior fontanelles), osteomalacia in adults
hemolytic anemia hemorrhagic diathesis
hemorrhagic diathesis; found in home-delivery ---
infants and NPO/broad-spectrum abx pts

MINERALS Chromium deficiency: impaired glucose tolerance (essential for diabetics)

Fluoride deficiency: poor dentition
Iodine deficiency: cretinism
Iron deficiency: microcytic anemia
Selenium deficiency: cardiomyopathy
Zinc deficiency: alopecia, dysgeusia (abnormal taste), poor wound healing
 STEP 2 × PEDS

NEONATAL CARE Premature infants: ↑risk of necrotizing enterocolitis, neonatal RDS, intraventricular hemorrhage
APGAR score: 0 1 2
Appearance all blue mixed blue/pink all pink
Pulse 0 <100 >100
Grimace no response to stimulation grimace active cough
Activity limp some limb flexion active limb flexion
Respirations 0 irregular regular

Dz Presentation Management Other

Necrotizing enterocolitis (NEC)
Intraventricular hemorrhage
Neonatal RDS (hyaline
membrane disease)
Choanal atresia
Neonatal scalp swelling
Neonatal volvulus
Rh hemolytic disease
(erythroblastosis fetalis)
Neonatal polycythemia
Neonatal conjunctivitis
Transient tachypnea of the
newborn (TTN)
Meconium aspiration syndrome
Neonatal jaundice
Congenital hip dysplasia
Congenital diaphragmatic
hernia
Neonatal tetanus
Neonatal vaginal discharge
abdominal distention, vomiting,
GI bleed, decreased bowel
sounds in a premature infant
progressive hemorrhagic
hydrocephalus in a premature
infant
prematurity (<34 wks) or infant
of diabetic mother (↑insulin
blocks cortisol) → lack of
surfactant → respiratory
distress in a newborn
non-canalized nasal passages →
difficulty breathing while
feeding but normal when crying
caput succedaneum crosses
midline, cephalohematoma
doesn’t
twisting of redundant bowel →
abdominal distention, bilious
vomiting, bloody stools
Rh- mom w/ 2nd Rh+ baby
develops anti-D IgG → crosses
placenta and attacks fetal RBCs
→ causes fetal hydrops
delayed clamping of umbilical
cord → hyperviscosity → poor
pulmonary blood flow →
respiratory distress
Chemical conjunctivitis:
presents on day 0-1
Gonococcal conjunctivitis:
presents on day 2-5, ↑risk of
corneal ulceration
Chlamydia conjunctivitis:
presents on day 5-14, ↑risk of
chlamydial pneumonia
tachypnea, grunting, possible
cyanosis in a c/s infant due to
retained fetal lung fluid
suspect w/ meconium staining,
low Apgar scores, respiratory
distress in a newborn
hyperbili due to breastmilk,
breastfeeding failure, neonatal
sepsis, hypothyroidism, or other
congenital abnormalities
Breastfeeding failure jaundice:
failure to feed correctly →
↑enterohepatic circulation →
mild indirect hyperbili <1 wk old
Breastmilk jaundice: breastmilk
contains glucuronidase and
indirect bili → mild indirect
hyperbili >1 wk old
Biliary atresia: lack of CBD →
progressive direct hyperbili
Choledochal cyst: cyst in CBD →
biliary tree obstruction →
progressive direct hyperbili
uneven gluteal folds and
“snapping hips” during physical
exam in a newborn
bowels herniate into chest cavity
→ respiratory distress in a
newborn
tetanus toxin infects umbilical
stump → rigidity, trismus,
opisthotonus, risus sardonicus
maternal hormone withdrawal
→ vaginal bleeding in infant girls
• Dx KUB (pneumatosis intestinalis)
• unperforated → Tx NPO/IVF/abx
• perforated → surgical resection
• Dx head CT
• Tx VP shunt
• Dx L:SM ratio <2 or ↓phosphatidylglycerol in Complications: ↑risk of
• amniotic fluid developing asthma
• Tx surfactant + O2 therapy + CPAP
• PPx tocolytics + betamethasone for 48 hrs in
• deliveries <34 wks
• Dx nasal catheter or check for fog under nares
• Tx nasal tubes
• Tx reassurance
• Dx KUB
• Tx surgical correction
• Dx Coombs test
• Tx intrauterine blood transfusions
• PPx RhoGAM
• Dx hct >65%
• Tx IVF to dilute blood
• Tx reassurance Erythromycin toxicity: ↑risk of
developing pyloric stenosis
• Tx topical erythromycin + IV ceftriaxone
• Tx PO erythromycin
• Dx CXR (pulmonary vascular markings)
• Tx 100% O2 (will self-resolve)
• Tx tracheal suction + O2 mask, intubation if Complications: ↑risk of
• severe distress developing asthma
• Dx LFTs (T-bili >15, D-bili >2, or jaundice within Kernicterus: bili >20 → deposit
• 24 hrs indicates pathologic cause) in basal ganglia → brain damage
• physiologic → Tx phototherapy Jaundice w/o scleral icterus:
• pathologic → Tx underlying cause hypercarotenemia (kid eats too
• Tx increase feedings many carrots), benign
• Tx temporary stop feeds
• Dx abdominal U/S, confirm w/ HIDA scan
• Tx hepatoenterostomy (Kasai procedure)
• Dx abdominal U/S, confirm w/ HIDA scan
• Tx surgical excision
• Dx U/S (not calcified for X-ray)
• Tx splinting
• first step is drop an orogastric tube to
• decompress stomach
• Dx CXR (bowels in chest cavity)
• Tx surgical repair
• Tx supportive care
• Tx reassurance
 STEP 2 × PEDS

IMMUNE DZ B-cell markers: CD19+, CD20+, CD21+

B-cell deficiency: ↑susceptibility to bacterial infx, Giardia infx
T-cell markers: CD3+, CD4+ (T-helper), CD8+ (T-killer)
T-cell deficiency: ↑susceptibility to viral infx, fungal infx, TB infx

Serum Ig levels: IgM IgA IgG IgE

Bruton agammaglobulinemia ↓ ↓ ↓ ↓
IgA deficiency -- ↓ -- --
Hyper-IgM syndrome ↑↑ ↓ ↓ ↓
CVID ↓ ↓ ↓ ↓
SCID ↓ ↓ ↓ ↓
Wiscott-Aldrich syndrome ↓ ↑ -- ↑
Ataxia-telangiectasia -- ↓ -- --
Job syndrome -- -- -- ↑↑

Dz Presentation Management Other

DiGeorge/velocardiofacial
syndrome
Chronic mucocutaneous
candidiasis
Bruton agammaglobulinemia
IgA deficiency
Hyper-IgM syndrome
Common variable immuno-
deficiency (CVID)
Severe combined immuno-
deficiency syndrome (SCID)
Wiskott-Aldrich syndrome
Ataxia-telangiectasia
Chronic granulomatous disease
(CGD)
Job syndrome
Chédiak-Higashi syndrome
Leukocyte adhesion deficiency
Complement deficiency
22q11– → CATCH-22 – Cleft
palate, Abnormal facies, Thymic
aplasia (no T-cells), CV defects,
Hypocalcemia (no PTH)
T-cell deficiency → persistent
Candica albicans infx
XR B-cell defect → lack of all Ig
types → recurrent bacterial infx
(OM, PNA, etc.) after 6 months
since mom’s Ig confers passive
immunity
recurrent encapsulated bacterial
infx (respiratory infx, diarrhea) +
anaphylatic transfusion
reactions (reacts to donor IgA)
∆CD40 → B-cells can’t mature
from IgM to IgG/IgA forms →
recurrent encapsulated bacterial
infx (respiratory infx, diarrhea)
acquired B-cell defect (>10 y/o)
→ lack of all Ig types but normal
B-cell levels; ↑risk of lymphoma +
autoimmune disorders
XR/AR ∆adenosine deaminase →
lymphocytes can’t make DNA to
proliferate (both B- and T-cells)
→ severe infx → death at young
age
XR, TIE – thrombocytopenia
(petechiae), recurrent infx,
eczema
AR ΔATM (encodes p53) → triad
of ataxia, spider angiomas, IgA
deficiency; ↑risk of malignancy
XR ∆NADPH oxidase →
phagocytic defect → recurrent
abscesses
FATED – coarse Facies, recurrent
Abscesses, retained primary
Teeth, ↑↑IgE, Derm (eczema)
AR, microtubule polymerization
defect → recurrent abscesses
(↓phagocytosis), partial albinism,
peripheral neuropathy
recurrent infx + delayed
umbilical cord separation
C5-C9 deficiency predisposes to
recurrent Neisseria infx
• Dx intradermal Candida test (anergy)
• Tx thymus txp + bone marrow txp
• serial calcium levels at birth
• requires irradiated transfusions (prevent
• GVHD)
• Dx intradermal Candida test (anergy)
• Tx Diflucan
• Dx ↓serum Ig levels, no B-cells
• Tx repeated IVIG
• Dx ↓IgA
• Tx supportive care
• Dx ↑↑IgM, ↓IgG, ↓IgA
• Tx supportive care
• Dx ↓serum Ig levels, normal B-cells
• Tx repeated IVIG
• Dx ↓T-cells, ↓B-cells
• Tx bone marrow txp
• avoid live or attenuated vaccines
• Dx CBC (↓plt), ↓IgM, ↑IgA, ↑IgE
• Tx splenectomy
• Dx ↓IgA
• Tx supportive care
• Dx nitroblue tetrazolium (NBT) test
• Tx bone marrow txp
• Dx ↑↑IgE
• Tx supportive care
• Dx blood smear (large granules in neutrophils)
• Tx bone marrow txp
• Dx ↑neutrophils but defective chemotaxis
• Tx bone marrow txp
• Dx CH50 test
• Tx supportive care

GENETIC DZ Dz
Fragile X syndrome
Down syndrome
Edward syndrome
Patau syndrome
Turner syndrome
Klinefelter syndrome
47, XYY males
Noonan syndrome
Cri-du-chat syndrome
AngelMan syndrome
Prader-Willi syndrome
Kartagener syndrome
Achondroplasia
Friedreich ataxia
Sturge-Weber syndrome
VACTERL syndrome
Williams syndrome
Beckwith-Wiedemann
syndrome
McCune-Albright syndrome
Osler-Weber-Rendu syndrome
(hereditary telangiectasia)
STEP 2 × PEDS
Presentation Management Other
XR ∆FMR1 (CGG trinucleotide • Dx karyotype (chromosomal breaks)
repeats) → DSM-V – • Tx supportive care
Discontinued chromosomal
staining, Shows anticipation,
Males-only, MR, Macrognathia,
Macroorchidism, MVP
trisomy 21 (95%), Robertsonian • Dx quad screen (↑β-HCG, ↑inhibin, ↓αFP, Complications: AVSD, duodenal
translocation (5%) → MR, flat • ↓estriol), confirm w/ amniocentesis atresia > Hirschsprung dz, ALL,
facies, epicanthal folds, simian • Tx supportive care atlantoaxial instability (UMN sx),
crease, nuchal translucency on Alzheimer by 40 y/o
U/S; ↑risk in women >35 y/o
trisomy 18 → MR, VSD, • Dx triple screen (↓β-HCG, ↓αFP, ↓estriol),
micrognathia, clenched hands, • confirm w/ amniocentesis
rocker-bottom feet, death by 1 • Tx supportive care
y/o
trisomy 13 → MR, cleft lip/Palate, • Dx found on routine U/S, confirm w/
holoProsencephaly, Polydactyly, • amniocentesis
rocker-bottom feet, death by 1 • Tx supportive care
y/o
45, XO → CLOWNS – Coarcted • Dx karyotype
aorta, Lymphedema (“knuckle- • Tx GH replacement + bilateral gonadectomy
knuckle-dimple-knuckle”),
Ovarian dysgenesis, Webbed
neck (cystic hygroma), Nipples
spread (shield chest), Short
stature
47, XXY → female traits on a • Dx karyotype
male (e.g. long legs, small balls, • Tx supportive care
gyno, high-pitched voice, etc.)
47, XYY → aggressive, antisocial • Dx karyotype
behavior (controversial) • Tx supportive care
AD, “male Turner syndrome”, • Tx supportive care
associated w/ pulmonic stenosis
rather than aortic coarctation
5p– → MR, high-pitched • Dx FISH
“mewing” cry, microcephaly, • Tx supportive care
epicanthal folds, CV defects
Maternal 15q11– → “happy • Dx FISH
puppet syndrome” – MR, ataxia, • Tx supportive care
flailing arms, laughter outbursts
Paternal 15q11– → MR, • Dx FISH
hypotonia, hyperphagia/obesity, • Tx GH replacement + dietary caloric restriction
hypogonadism, “almond eyes”
∆dynein → immotile cilia → • Tx supportive care
situs inversus (right-sided heart),
bronchiectasis, infertility
AD ∆FGFR3 or associated w/ • Tx supportive care
advanced paternal age → short
limbs but normal-sized torso
AR ∆frataxin (GAA triplet • Tx supportive care
repeats) → staggering gait +
frequent falls, kyphoscoliosis,
pes cavus, hammer toes, death
by hypertrophic cardiomyopathy
facial “port-wine stain” w/ • Dx head CT (gyriform calcifications)
ipsilateral AVM • Tx anticonvulsants > hemispherectomy
Verbetral defects, Anal atresia, • Dx physical exam (presence of any of these
CV defect, TE fistula, Esophageal • abnormalities should increase suspicion for
atresia, Renal/Radial defects, • the others)
Limb defects
7q– → MR, elfin facies, extreme • Dx FISH
friendliness, English skills, • Tx supportive care
hypercalcemia, CV defects
(supravalvular aortic stenosis)
sporadic mutation; generalized • Tx supportive care BWS vs. infant of diabetic
overgrowth, large tongue, mother: only BWS has large
omphalocele, hypoglycemia; tongue and omphalocele
↑risk of Wilms tumor and
hepatoblastoma (Dx ↑AFP)
precocious puberty in girls + • Tx supportive care
café-au-lait spots + polyostotic
fibrous dysplasia (bone zits)
AD, diffuse telangiectasias, • Tx supportive care
recurrent epistaxis, widespread
AVMs → AV shunting → chronic
hypoxemia

METABOLIC DZ Dz
Phenylketonuria (PKU)
Maple syrup urine disease
(MSUD)
Galactosemia
Hereditary fructose intolerance
Von Gierke disease (glycogen
storage disease type 1)
Pompe disease (glycogen
storage disease type 2)
Homocystinuria
Gaucher disease
Niemann-Pick disease
Tay-Sachs disease
Lesch-Nyhan syndrome
OTHER PEDS DZ (common peds dz found in other sections)
Dz
Laryngomalacia
Rule-out sepsis
Cyclical vomiting
Infantile colic
Milk protein intolerance
Sudden infant death syndrome
(SIDS)
Infantile botulism
Impetigo
Presentation
AR ∆phenylalanine hydroxylase
→ MR, mousy body odor, blue
eyes, blond hair
AR ∆branched-chain amino acid
decarboxylase → inability to
digest isoleucine, leucine, valine
(“I LoVe maple syrup”) → PKU-
like sx w/ sweet-smelling urine
AR ∆gal-1P uridyltransferase →
juvenile cataracts, profound
illness following first milk
feedings
AR ∆aldolase B → profound
illness following first fruit juice
feedings
AR ∆glucose-6-phosphatase →
hypoglycemia, hepatomegaly,
lactic acidosis, “doll-like
appearance” (short w/ fat
cheeks, thin arms, big abdomen)
AR ∆acid maltase →
hypoglycemia, cardiomegaly
AR ∆cystathionine β-synthase →
MR, hypercoagulability,
Marfanoid habitus, downward
optic lens dislocation
AR ∆β-glucosidase → “wrinkled
paper” cells, “Erlenmeyer-flask”
appearance of long bones
AR ∆sphingomyelinase →
“cherry-red macula” w/ HSM
AR ∆hexosaminidase A →
“cherry-red macula” w/o HSM,
exaggerated startle response
(hyperacusis)
XR ∆HGPRT → impaired purine
metabolism → MR, self-
mutilation, hyperuricemia, gout
Presentation
congenital flaccid larynx →
collapses during inspiration →
chronic inspiratory noise in
infants
T >100.4 in any neonate (<28
days), MCC viral infx
idiopathic, recurrent self-limited
episodes of vomiting in kids;
↑risk w/ family hx of migraines
unexplained crying for >3 hrs in
an infant <3 months
bloody diarrhea in a neonate
sudden-death in infants w/o
underlying cause
ingestion of C. botulinum (not
toxin) in raw honey → bacteria
releases toxin in GI tract →
constipation (initial sx) then
gradual flaccid paralysis
Staph aureus infx → vesicles or
pustules on face and extremities
w/ classic “golden crust”
STEP 2 × PEDS
Management Other
• Dx Guthrie test
• Tx dietary ↓phe/↑tyr
• can relax dietary restrictions over time but
• must reinstate during pregnancy to prevent
• maternal PKU
• Tx dietary ↓ile/↓leu/↓val
• Tx dietary ↓lactose/↓galactose Galactosemia × sepsis: E. coli
• Tx dietary ↓sucrose/↓fructose
• Tx dietary ↑carbs
• Tx supportive care
• Tx high-dose vitamin B6 Homocystinuria vs. Marfan dz:
homocystinuria has downward
lens dislocation, Marfan has
upward lens dislocation
• Tx supportive care Erlenmeyer-flask bone ddx:
Gaucher dz, osteopetrosis,
rickets
• Tx supportive care
• Tx supportive care
• Tx supportive care
Management Other
• Dx larynogoscope (flaccid larynx, “epiglottis
• rolling from side to side”)
• Tx hold child upright for 30 min after feeding,
• will self-resolve
• admit any neonate w/ fever
• Dx UA/UCx, CSF, blood cx ×3, CXR
• Tx amp + gent until cx negative
• r/o medical causes
• Tx antiemetics
• Tx swaddle infant to calm him/her, will self
• resolve
• Dx ↑stool eosinophils
• Tx d/c milk
• prevent by putting infant on “back to sleep”,
• don’t smoke around kids
• Tx BabyBIG (botulinum immunoglobulin) +
• ventilator support
• Tx topical mupirocin

RESPIRATORY INFX Dz Bug(s)
Viral rhinosinusitis rhinovirus, coronavirus,
(common cold) adenovirus
Streptococcal Strep pyogenes
pharyngitis (strep
throat)
Acute sinusitis Strep pneumo > H. flu >
Moraxella catarrhalis (>10
days); viruses (<7 days)
Sinusitis × DM: mucormycosis
(Rhizopus)
Acute bronchitis viruses (MCC), Mycoplasma
pneumoniae (MC bacteria in
nonsmokers)
Pneumonia Typical CAP: Strep pneumo >
H. flu > Moraxella catarrhalis
Atypical CAP: Mycoplasma >
Chlamydia > Legionella
Nosocomial PNA: Staph
aureus > Pseudomonas >
aerobic GNR
PNA × alcoholics: Klebsiella
(“currant-jelly sputum”)
PNA × immigrants: TB
PNA × nursing home: Strep
pneumo > nosocomials
PNA × CF: Pseudomonas
PNA × AIDS: Strep pneumo
(CD4 >200), PCP (CD4 <200)
Lung abscess oral anaerobes (Prevotella,
Fusobacterium, Bacteroides,
Peptostreptococcus)
Tuberculosis M. tuberculosis
Influenza influenza virus
Nocardiosis Nocardia asteroides
Presentation
dry cough, sore throat, malaise, rhinorrhea,
nasal congestion
sore throat, cervical LAD, palatal petechiae,
peritonsillar exudates
Retropharyngeal abscess: Staph/Strep or
oral anaerobe infx of posterior pharyngeal
wall → fever, sore throat, “muffled voice”,
drooling
Peritonsillar abscess: Staph/Strep or oral
anaerobe infx → fever, sore throat, “hot
potato voice”, deviated uvula
nasal stuffiness, purulent discharge, cough,
sinus pain or pressure (maxillary sinuses
may resemble dental pain)
productive cough (can be blood-tinged),
fever, shortness of breath
Typical CAP: sudden-onset fever/chills,
productive cough, pleuritic chest pain
Atypical CAP: insidious-onset sore throat,
headache, nonproductive cough, dyspnea
Mycoplasma PNA: MC extrapulmonary sx is
erythema multiforme (“target lesions”)
Legionella PNA: hyponatremia, ↑LFTs
aspiration → cough w/ foul-smelling
sputum, SOB, fever/chills
1° TB: granulomatous inflammation in lower
lobes → infx contained → usually asx
2° TB: reactivation in upper lobes →
fever/chills, night sweats, weight loss,
productive cough w/ hemoptysis
Miliary TB: hematogenous “miliary seed”
spread of TB → sx depend on end-organ
(e.g. adrenal insufficiency)
Pott disease: TB in vertebral body → bone
pain, ↑risk of pathological fx
Rifampin toxicity: red-orange body fluids
INH toxicity: hepatotoxicity + peripheral
neuropathy (Tx vitamin B6)
PZA toxicity: hepatotoxicity
Ethambutol toxicity: optic neuritis
rapid-onset spiking fever, myalgias,
arthralgias, sore throat, nonproductive
cough
2° bacterial infx: pt gets better from flu,
then sick again 2/2 Staph aureus superinfx
productive cough, SOB, fever/chills
STEP 2 × ID
Management
• Tx symptomatic relief
• PPx hand washing
• Dx rapid strep test, tonsillar exudate cx
• Tx PCN ×10 days (prevent rheumatic heart dz)
• RPA/PTA → Tx emergent I+D
• Dx physical exam ± head CT if unclear
• viral → Tx symptomatic relief
• bacterial → Tx amoxicillin
• mucormycosis → Tx surgical debridement +
• IV amphotericin B
• Dx CXR (r/o PNA)
• suspect Mycoplasma → Dx cold agglutinin
• viral → Tx symptomatic relief
• bacterial → Tx amoxicillin
• Dx CXR (lobar consolidations) ± sputum cx
• suspect TB → Dx acid-fast stain
• suspect Legionella → Dx urinary ag
• HIV+ → Dx silver stain (fungi, PCP)
• ventilator-associated → Dx bronch + BAL
• admit if 2/5 of CURB-65 – Confusion, Uremia,
• RR ≥30, BP <90/60, age ≥65
• outpatient → Tx azithromycin (<60 y/o),
• ceftriaxone (≥60 y/o)
• inpatient → Tx azithromycin + either
• ceftriaxone or respiratory fluoroquinolone
• CF → Tx pip-taz + aminoglycoside (need to
• double-cover for Pseudomonas)
• PCP → Tx Bactrim, add steroids if PaO2 <70
• aspiration → add clinda (covers anaerobes)
• Dx CXR (cavitation w/ air-fluid levels, most
• commonly in right lower lobe)
• Tx IV abx
• Dx screen w/ tuberculin skin test (≥15 mm,
• ≥10 mm if high-risk, ≥5 mm if HIV+ or CXR+);
• confirm w/ CXR (cavitation in upper lobe)
• kids → Dx anergy test (Candida in other arm)
• to check for an appropriate immune response
• active TB → admit + respiratory isolation,
• then Tx RIPE (rifampin, INH, PZA, ethambutol)
• ×2 months, then INH/rifampin ×4 months
• latent TB → Tx INH ×9 months
• TB meningitis → Tx RIPE + steroids
• Dx nasal swab (rarely used)
• Tx hydration + oseltamivir if ≤48 hrs
• Dx CXR (cavitation w/ air-fluid levels),
• sputum Gram stain (G+ branching rods,
• partially acid-fast)
• Tx Bactrim

GI INFX Dz Bug(s)
Viral hepatitis HAV (fecal-oral)
HBV (blood or sex)
HCV (blood or sex)
HDV (blood or sex)
HEV (fecal-oral)
Botulism Clostridium botulinum
preformed exotoxin (from
canned food or wound infx)
Intra-abdominal abscess polymicrobial
Diarrhea Diarrhea × fever/blood:
Campylobacter (MCC),
Shigella, Salmonella, EHEC
Diarrhea × mayo: Staph
aureus (<6 hrs), Salmonella
Diarrhea × raw chicken:
Salmonella, Shigella
Diarrhea × raw seafood:
Vibrio parahaemolyticus
Diarrhea × fried rice: Bacillus
cereus
Diarrhea × hamburgers: EHEC
Diarrhea × chitterlings:
Yersinia enterocolitica
Diarrhea × travel: ETEC
Diarrhea × recent abx: C. diff
Diarrhea × daycare: rotavirus,
Shigella, Giardia
Diarrhea × AIDS: CMV
(bloody), MAI (watery),
Cryptococcus (profuse)
Diarrhea × PNA/↓Na:
Legionella
Esophagitis in HIV+ pts Candida >> CMV, HSV
PARASITIC INFX Dz Bug(s)
Giardiasis Giardia lamblii
Amebiasis Entamoeba histolytica
Cryptosporidiosis Cryptosporidium parvum
Ascariasis Ascaris lumbricoides
Hookworm Ancylostoma duodenale (old),
Necator americanus (new)
Pinworm Enterobius vermicularis
Tapeworm Taenia saginata (beef),
Taenia solium (pork),
Diphyllobothrium latum (fish)
Neurocysticercosis Taenia solium (pork)
Schistosomiasis S. haematobium, S. mansoni,
S. japonicum
Trichinosis Trichinella spiralis (pork)
Cutaneous larva Ancylostoma braziliense
migrans (dog/cat hookworm)
STEP 2 × ID
Presentation Management
Buzzwords: Asx (usually), daycare, travel • Dx HAV IgM = acute infx
• Dx HAV IgG = previous infx or immunity
• Tx supportive care
Buzzwords: polyarteritis nodosa, MGN • Dx HBsAg = acute/chronic infx
• Dx HBsAb = previous infx or immunity
• Dx HBeAg = infectiveness
• Dx HBcAb IgM = window period
• Tx IFN-α + lamivudine
Buzzwords: Chronic, Cirrhosis, Carcinoma, • Dx HCV RNA
Carriers, MPGN, porphyria Cutanea tarda, • Tx IFN-α + ribavarin
Cryoglobulinemia • severe → Tx liver txp
Buzzwords: Deadly, HBV superinfx • Dx HDV Ab
• Tx IFN-α
Buzzwords: cruise ships, fatal in pregnancy • Dx HEV Ab
• Tx supportive care
symmetric, descending flaccid paralysis • Dx toxin assay
• Tx admit + antitoxin
Infantile botulism: ingestion of C.
botulinum (not toxin) in raw honey
fever/chills, abd pain, mass • Dx CT scan (cavitation w/ air-fluid levels)
• Tx perc drain + IV abx
--- diarrhea
Campylobacter diarrhea: can also cause no red flags red flags
Guillain-Barre syndrome (paralysis) (blood, fever, HIV+)
EHEC diarrhea: can also cause hemolytic-
uremic syndrome (hemolytic anemia, Dx fecal leukocytes
thrombocytopenia, renal failure)
Laxative abuse diarrhea: voluminous –WBC +WBC
watery diarrhea w/ melanosis coli on
colonoscopy (dark colon w/ white spots) Tx symptomatic relief stool cx, O+P,
(hydration) C. diff toxin
• bacteria → Tx ciprofloxacin ×5 days
• C. diff → Tx metronidazole or PO vancomycin
• Salmonella → supportive care, abx can
• prolong infx
• HUS → Tx emergent plasmapheresis
dysphagia, odynophagia • start w/ Diflucan ×5 days
• refractory → Dx endoscopy to check for HSV
• (multiple, small, well-circumscribed lesions) or
• CMV (large, shallow, superficial lesions)
• HSV esophagitis → Tx PO acyclovir
• CMV esophagitis → Tx PO ganciclovir
Presentation Management
bloating, flatulence, foul-smelling fatty • Dx stool O+P
diarrhea • Tx metronidazole
flask-shaped ulcers in ascending colon → • Dx stool O+P
bloody diarrhea; portal drainge → liver • Tx metronidazole (for diarrhea and abscess)
abscess (“Mexican w/ RUQ pain”)
severe diarrhea in HIV+ pts • Dx acid-fast stain
• Tx nitazoxanide
usually asx, can cause bowel obstruction • Dx stool O+P
• Tx mebendazole
hooks onto bowel walls and sucks blood → • Dx stool O+P
iron-deficiency anemia • Tx mebendazole
perianal pruritus ± vulvar pruritus, worst in • Dx Scotch tape test
early mornings • Tx mebendazole
usually asx, D. latum eats vitamin B12 → • Dx stool O+P
macrocytic anemia • Tx praziquantel
focal neuro sx • Dx head CT (“swiss-cheese” brain)
• Tx praziquantel + supportive care
S. mansoni/japonicum cause fibrosis of liver • Dx stool O+P
and spleen; S. haematobium causes bladder • Tx praziquantel
infx → dysuria, bladder SCC
triad of myalgias + periorbital edema + • Dx muscle bx
eosinophilia • Tx mebendazole
multiple pruritic erythematous papules • Dx stool O+P
after playing in the sand • Tx mebendazole

GU INFX Dz Bug(s) Presentation
Asymptomatic E. coli > Staph saprophyticus > (asx)
bacteruria Enterococcus > other GNB
Lower UTI (acute E. coli > Staph saprophyticus > dysuria, ±hematuria, frequency/urgency,
cystitis) Enterococcus > other GNB suprapubic tenderness
UTI × alkaline urine: Proteus Risk factors: diabetes, females (shorter
mirabilis (urease → NH4) urethra), sexual intercourse, Foley catheter
Upper UTI (acute E. coli > Staph saprophyticus > (same as above) + fever/chills, flank pain,
pyelonephritis) Enterococcus > other GNB CVA tenderness
Urosepsis: UTI + septic shock
Chronic pyelonephritis: recurrent pyelo →
“blunting of calyces” in VUR pts
Prostatitis E. coli (kids/elderly), STDs Acute prostatitis: fever/chills, dysuria,
(young adults) frequency, urgency, low back pain
Chronic prostatitis: mild urinary discomfort
but otherwise asx
Interstitial cystitis (not an infx) presents like UTI, but bladder is extremely
(painful bladder tender to palpation and UA/UCx is normal
syndrome)
HEM INFX Dz Bug(s) Presentation
Sepsis GNB > GPC > Candida albicans Systemic inflammatory response
syndrome (SIRS): 2+ of the following –
Sepsis × galactosemia: E. coli ↑/↓T, ↑RR, ↑HR, ↑/↓WBC
Sepsis × sickle cell: Strep Sepsis: SIRS + positive blood cx
pneumo Septic shock: sepsis + ↓BP
Malaria Plasmodium parasites via cyclic fever/chills, headache, hemolytic
Anopheles mosquito vector anemia, splenomegaly
Antimalarial toxicity: hemolytic anemia in
G6PD-deficient males
Mononucleosis EBV > CMV triad of spiking fever, cervical LAD,
pharyngitis after making out w/ someone;
can also present as maculopapular rash s/p
amoxicillin for misdiagnosed strep throat
HIV/AIDS HIV-1/2 (via blood, sex, Primary infx: mononucleosis-like sx,
vertical, or breastmilk) generalized LAD, truncal rash
Asymptomatic stage: CD4 >500, asx
Symptomatic stage: CD4 200-500, mild sx
(generalized LAD, fungal infx, night sweats,
weight loss, diarrhea)
AIDS: CD4 <200 or presence of AIDS OI
NRTI toxicity: lactic acidosis
NNRTI toxicity: Stevens-Johnson syndrome
Didanosine toxicity: pancreatitis
Abacavir toxicity: hypersensitivity
Nevirapine toxicity: liver failure
Indinavir toxicity: crystal-induced
nephropathy
Babesiosis Babesia microtii via Ixodes tick hemolytic anemia → jaundice, malaise,
vector renal failure
STEP 2 × ID
Management
• Dx UA/UCx (≥105 CFU)
• pregnant → Tx nitrofurantoin
• prior to urologic surg → Tx Bactrim or Cipro
• everyone else → Tx reassurance
• Dx UA/UCx (≥105 CFU)
• Tx Bactrim or Cipro
• pregnant → Tx nitrofurantoin
• recurrent → PPx low-dose Bactrim
• screening VCUG indicated for all males w/ UTI,
• all girls <5 w/ UTI, or girls >5 w/ 2+ UTIs
• Dx UA/UCx (≥105 CFU + WBC casts)
• mild → Tx Bactrim or Cipro
• severe → Tx admit + IV amp/gent
• refractory → Dx U/S to r/o underlying process
• (e.g. stones, cancer)
• Dx DRE (boggy tender prostate) + UA/UCx
• kids/elderly → Tx Bactrim or Cipro
• young adults → Tx azithromycin + ceftriaxone
• do not do prostatic massage to induce
• secretions (can cause bacteremia)
• Dx potassium sensitivity test
• Tx amitriptyline or duloxetine
Management
• Dx blood cx ×3 (draw cx before starting abx)
• Tx broad-spectrum IV abx until cx are back
• Candida sepsis → Tx IV ampho B
• Dx blood smear w/ Giemsa stain
• Tx chloroquine
• resistant (e.g. India) → Tx mefloquine
• P. vivax and P. ovale → add primaquine for
• hypnozoites
• Dx Monospot (heterophile agglutination) test
• Tx supportive care + avoid contact sports to
• prevent splenic rupture
• pt can return to sports after splenomegaly has
• resolved (check on physical exam)
• Dx screen w/ HIV ELISA, confirm w/ WB
• neonates → Dx HIV PCR
• Tx HAART (2 NRTIs + 1 NNRTI or PI)
• CD4 <200 → PPx Bactrim (for PCP, toxo)
• CD4 <50 → PPx azithromycin (for MAI)
• accidental needlestick → Dx HIV serology,
• then start anti-HIV meds (2 NRTI ± 1 PI) while
• waiting for results
• HIV during pregnancy → start anti-HIV meds,
• elective C/S or IV ZDV during labor; do not
• breastfeed infant
• Dx blood smear w/ Giemsa stain (looks like
• malaria but has maltese cross forms too)
• Tx quinine + clindamycin
 STEP 2 × ID

CSF ANALYSIS WBC Glucose Other

Bacterial meningitis ↑PMN ↓
Viral meningitis ↑lymph --
Cryptococcal meningitis ↑lymph ↓ +India ink stain
TB meningitis ↑lymph ↓ +acid fast stain
HSV encephalitis ↑lymph ↓ +HSV PCR
Guillain-Barre syndrome -- -- ↑protein (albumino-cytologic dissociation)
Multiple sclerosis -- -- +oligoclonal bands
Pseudotumor cerebri -- -- ↑opening pressure

NEURO INFX Dz Bug(s) Presentation Management

Meningitis Meningitis × neonates: GBS
Meningitis × kids: Neisseria
meningitidis
Meningitis × adults: Strep
pneumo
Meningitis × elderly: Strep
pneumo
Encephalitis viruses (HSV-1 in temporal
lobe, arbovirus, enterovirus)
Brain abscess Staph aureus (neurosurg),
Strep pneumo (local spread)
triad of fever, nuchal rigidity, ∆MS;
Kernig and Brudzinski signs (may not be
present in kids)
Disseminated meningococcal infx:
meningitis, petechiae → purpura, bilateral
adrenal hemorrhage (W-F syndrome)
∆MS, focal neuro sx, s/sx of meningitis
HSV encephalitis: encephalitis + tonic-
clonic sz (temporal lobe infx)
mass effect → headache, ∆MS, seizures,
nausea/vomiting, focal neuro sx
• Dx head CT (check for ↑ICP), then LP
• kids → do not need CT scan before LP
• bacterial → Tx ceftriaxone + vancomycin ±
• ampicillin for elderly (covers Listeria)
• viral → Tx supportive care
• cryptococcal → Tx IV ampho B + flucytosine
• TB → Tx RIPE + steroids
• N. meningitidis → Tx Rifampin for Roommates
• Dx head CT or MRI
• Tx supportive care
• HSV encephalitis → Dx HSV PCR, Tx acyclovir
• Dx head CT or MRI
• Tx IV abx, surgical drainage, steroids

Abscess × AIDS: toxo, fungi Brain abscess vs. cerebral toxoplasmosis:

Abscess × DM: mucormycosis check for host immunocompetence
Poliomyelitis poliovirus (fecal-oral) bilateral LMN dysfxn → asymmetric muscle • Dx throat/stool/CSF cx
weakness w/ normal sensation • Tx supportive care
• PPx inactivated polio vaccine
Rabies rabies virus via animal host pain at bite location, fever, malaise; then • Dx viral cx
agitation, photophobia, hydrophobia • calm animal → observation ×10 days
(foaming); then paralysis, coma, death • rabid animal → kill + brain bx (Negri bodies in
• Purkinje cells)
• Tx emergent passive + active immunization
Progressive multifocal JC virus in AIDS pts multifocal CNS demyelination → rapidly • Dx CT scan (multiple nonenhancing lesions)
leukoencephalopathy progressive focal neuro sx • Tx supportive care

MSK INFX Dz Bug(s) Presentation Management

Septic arthritis Staph aureus (#1)
Arthritis × IVDA:
Pseudomonas
Arthritis × sickle cell:
Salmonella
Arthritis × sexually-active: N.
gonorrhoeae
Arthritis × prosthetic joint:
Staph epidermidis
Osteomyelitis Staph aureus (#1), Staph
epidermidis (#2)
red, hot, swollen, painful joint w/ ↓↓ROM • Dx arthrocentesis
• Tx admit + IV abx
Disseminated gonoccocal infx: migratory
arthritis + tenosynovitis + vesiculopustular • gonorrhea → Tx ceftriaxone + azithromycin
skin lesions
Septic arthritis vs. transient synovitis:
work-up for septic arthritis if 3/4 – WBC >12,
T >102, ESR >40, or refusal to bear weight;
otherwise advise rest + NSAIDs
bone pain w/ local inflammation • Dx needle aspiration + cx (best), MRI
• Tx admit + IV abx + debride dead bone

Osteo × IVDA: Pseudomonas • f/u serial ESR/CRP to monitor response to tx

Osteo × sickle cell: Salmonella
Osteo × IV catheter: Staph
aureus
Osteo × diabetic foot:
polymicrobial
Osteo × nosocomial:
Pseudomonas
Osteo × vertebra: TB
Osteo × animal bite:
Pasturella multocida
Osteo × “step on a nail”:
Pseudomonas
Lyme disease Borrelia burgdorferi via Ixodes Stage 1: erythema chronicum migrans • Dx screen w/ ELISA, confirm w/ WB
tick vector (target-shaped lesion) • high-suspicion → okay to skip dx testing
Stage 2: bilateral Bell palsy + AV block • Tx doxycycline
Stage 3: chronic arthritis
• kids → Tx amoxicillin (doxy discolors teeth)
• pregnant → Tx amoxicillin
 STEP 2 × ID

SKIN INFX Dz Bug(s) Presentation Management

Cellulitis skin flora (Staph, Strep, infx of skin and subcutaneous tissue → • r/o necrotizing fasciitis
MRSA) painful, red, hot, swollen, indurated skin • Tx Keflex + Bactrim

Cellulitis × human bite:
Eikenella
Cellulitis × animal bite:
Pasturella
Cellulitis × spider bite: MRSA
Skin abscess skin flora (Staph, Strep,
MRSA)
Erysipelas: Strep pyogenes cellulitis → • human or animal bite → Tx Augmentin
sudden-onset, well-demarcated “fiery red” • orbital cellulitis → c/s ophtho
rash w/ raised borders
pus pocket from overlying cellulitis → • Tx I+D, wound packing, PO abx
painful, red, hot, swollen, indurated skin w/
well-demarcated area of fluctuance

Hidadrenitis suppurativa: chronic follicular

occlusion and apocrine gland inflammation
→ recurrent axillary/groin abscesses
Necrotizing fasciitis (gas Strep pyogenes (#1), infx of deeper fascia → extreme fever and • Tx emergent surgical debridement + broad-
gangrene) Clostridium perfringens (#2) pain, tissue necrosis, crepitus, bullae • spectrum IV abx
Gangrene polymicrobial poor vascular supply → tissue necrosis ± • Tx debridement, PO abx
bacterial superinfx → severe pain, fever, • severe → Tx amputation
crepitus, rotten-smelling skin
Impetigo Staph aureus kids w/ vesicles/pustules on face and • Tx topical mupirocin (Bactroban)
extremities w/ classic “golden crust”
Acne vulgaris Propionibacterium acnes obstruction of sebaceous follicles → • Tx topical benzoyl peroxide (first line)
noninflammatory comedones (blackheads)
→ inflammatory acne (pimples); not • noninflammatory → add topical retinoids
associated with food or caffeine intake • inflammatory → add PO doxycycline
• nodulocystic or scarring → add isotretinoin
Doxycycline toxicity: photosensitivity,
tooth discoloration in kids <8 y/o
Isotretinoin toxicity: ↑ICP, teratogenic
(requires 2 negative β-HCG tests)
Herpes HSV-1/2 recurrent, painful oral (HSV-1) or genital • Dx Tzanck smear (multinucleated giant cells)
(HSV-2) vesicles that can rupture • or viral cx
• Tx acyclovir if onset <24 hrs + pain control
Herpetic whitlow: painful, paronychia-like
lesions in fingers of healthcare workers
Chickenpox (varicella) VZV “dew drops on a rose petal” vesicular rash • Tx acyclovir if onset <24 hrs + antihistamines
in an ill child
Shingles (zoster) VZV reactivation of latent VZV in dorsal root • Tx acyclovir + analgesics
ganglia → painful rash in dermatomal • PPx shingles vaccine for elderly
distribution

Postherpetic neuralgia: severe pain that

Warts HPV-1-4 (hand/foot warts),
HPV-6/11 (anogenital warts)
Molluscum poxvirus
contagiosum
Tinea versicolor Malassezia furfur
Dermatophytes Trichophyton, Microsporum,
Epidermophyton
Scabies Sarcoptes scabiei
Toxic shock syndrome Staph aureus TSST-1 exotoxin
Rocky Mountain Rickettsia rickettsii via tick
spotted fever (RMSF) vector
Ehrlichiosis Ehrlichia via tick vector
Cat scratch disease Bartonella henselae
Bacillary angiomatosis Bartonella henselae,
Bartonella quintana
Kaposi sarcoma HHV-8 (KSAV)
Actinomycosis Actinomyces israelii
Leprosy Mycobacterium leprae
lasts >1 month after shingles resides
fleshy thickened epithelium, plantar warts
can be painful during ambulation
highly contagious domed papules w/
umbilicated center, commonly found in
kids and HIV+ pts
hypopigmented patches on chest/back that
do not tan w/ sunlight
Tinea capitis: kids w/ boggy scalp lesion
and hair loss
Tinea corporis: ringworm, found on
body/trunk
Tinea unguium: onychomycosis, found on
fingernails and toenails
Tinea pedis: athlete’s foot, found on
webbing of toes
Tinea cruris: jock itch, found in groin and
inner thighs
skin mite tunnels in epidermis → burrows
and severe pruritus
septic shock + fever, rash w/ confluence,
desquamation of palms/soles; associated
w/ tampons and cervical caps
triad of HA + fever + rash (vasculitis that
starts on extremities and comes inward)
HA, fever, myalgias, malaise, no rash
(“spotless RMSF”)
local ulcer + ascending LAD
firm, red, exophytic nodules in HIV+ pt
dull, purple, exophytic papules in HIV+ pt
cervical/facial abscess draining yellow
sulfur granules
Asian pt w/ insensate, hypopigmented
patches
• Tx removal (cryotherapy, podophyllin,
• surgical or laser excision)
• Tx removal (cryotherapy, podophyllin,
• surgical or laser excision)
• Dx KOH prep (“spaghetti and meatballs”)
• Tx selenium sulfide (Selsun)
• Dx KOH prep
• tinea capitis → Tx PO griseofulvin
• onychomycosis → Tx PO griseofulvin
• other tineas → Tx topical antifungal cream
• Dx scrape lesions + microscopy
• Tx 5% permethrin cream
• Tx admit + stabilize + IV nafcillin (prevents
• recurrence, not current illness)
• Tx doxycycline (even for kids)
• Tx doxycycline
• Dx physical exam
• Tx azithromycin
• Dx tissue bx (neutrophilic infiltrates)
• Tx azithromycin
• Dx tissue bx (lymphocytic infiltrates)
• Tx supportive care
• Dx Gram stain (G+ branching rods)
• Tx high-dose IV penicillin
• Dx tissue bx (acid-fast bacilli)
• Tx CARD – clofazimine + rifampicin + dapsone

STDS Physiologic vaginal discharge: white/yellow, nonmalodorous, normal vaginal exam
Pathologic vaginal discharge: pruritus, burning, malodorous, abnormal vaginal exam
Dz Bug(s) Presentation
Chlamydia Chlamydia trachomatis Women: cervicitis w/ mucopurulent
discharge, ↑risk of PID/TOA, often asx
Men: urethritis
Gonorrhea Neisseria gonorrhoeae Women: cervicitis w/ mucopurulent
discharge, ↑risk of PID/TOA, often asx
Men: urethritis
Disseminated gonoccocal infx: migratory
arthritis + tenosynovitis + vesiculopustular
skin lesions
Pelvic inflammatory polymicrobial (usually infx of upper female genital tract →
disease (PID) including GC or CT) nonspecific lower abdominal pain; ↑risk of
infertility, adhesions, ectopics, abscesses
Tubo-ovarian abscess: suspect in PID pts
w/ pelvic mass, sepsis, or focal peritonitis
Fitz-Hugh-Curtis syndrome: perihepatitis →
RUQ pain, ↑LFTs, “violin string” adhesions
Syphilis Treponema pallidum 1° syphilis: painless chancre + inguinal LAD
2° syphilis: palmar/plantar rash, fever,
condyloma lata, generalized LAD
3° syphilis: neurosyphilis (tabes dorsalis),
CV syphilis (luetic heart), gummas
Jarisch-Herxheimer rxn: acute febrile rxn
s/p syphilis tx (MC w/ 2° syphilis), due to
dead spirochetes → endotoxin release
Chancroid Haemophilus ducreyi painful chancre + inguinal LAD
Pediculosis pubis Phthirus pubis severe itching, irritation, vesicles, burrows
(crabs)
Lymphogranuloma Chlamydia trachomatis, L1-L3 1° LGV: transient, painless ulcer
venereum (LGV) serotypes 2° LGV: painful inguinal LAD
3° LGV: “anogenital syndrome”
(proctocolitis, rectal strictures, recto-
vaginal fistulas, genital elephantiasis)
Granuloma inguinale Klebsiella granulomatis painless ulcer w/ “beefy red” borders
Vaginal candidiasis Candida albicans thick white “cottage cheese” discharge,
itching, satellite lesions, no odor
Bacterial vaginosis Gardnerella vaginalis thin gray-white homogenous discharge,
positive sniff test (fishy odor)
Trichomoniasis Trichomonas vaginalis frothy green-gray discharge, odor,
strawberry cervix (petechiae)
FUNGAL INFX Dz Bug(s) Presentation
Candidiasis Candida albicans Vaginal candidiasis: thick, white curd-like
discharge, itching, satellite lesions, no odor
Thrush: thick, white plaques in oral mucosa
Cutaneous candidiasis: erythematous,
eroded patches w/ satellite lesions
Thrush vs. leukoplakia: thrush scrapes off,
leukoplakia doesn’t
Aspergillosis Aspergillus fumigatus ABPA: asthma + pulmonary infiltrates +
Aspergillus allergy
Aspergilloma: prior lung cavitation
becomes filled up w/ Aspergillus ball →
chronic cough ± hemoptysis
Invasive aspergillosis: acute-onset fever,
cough, respiratory distress, hemoptysis
Cryptococcosis Cryptococcus neoformans via meningitis/encephalitis in HIV+ pts
pigeon droppings
Histoplasmosis Histoplasma capsulatum via usually asx, mild respiratory sx
bat/bird droppings in caves
Disseminated histoplasmosis: triad of
palatal ulcers + HSM + pancytopenia
Blastomycosis Blastomyces dermatitidis lung (inflammatory nodules) + bone (lytic
lesions) + skin (verrucous lesions)
Coccidioidomycosis Coccidioides immitis mild respiratory sx after earthquakes in SW
US + erythema nodosum
Sporotrichosis (rose Sporothrix schenkii via rose local ulcer + ascending LAD
gardener disease) thorn prick
STEP 2 × ID
Management
• Dx Chlamydia NAAT
• Tx azithromycin ± ceftriaxone
• Dx discharge Gram stain (G– diplococci),
• positive cx on Thayer-Martin (chocolate) agar
• Tx ceftriaxone ± azithromycin
• first step is β-HCG to r/o pregnancy
• Dx STD tests + pelvic exam (“chandelier sign”)
• admit if unable to take PO meds (e.g. severe
• vomiting) or risk of noncompliance
• Tx doxy + ceftriaxone
• Dx screen w/ RPR-VDRL, confirm w/ FTA-ABS;
• or definitive dx w/ Darkfield microscopy
• Tx Benzathine PCN G (1°/2°), IV PCN G (3°)
• allergic → Tx doxy or azithromycin
• allergic + pregnant → Tx PCN desensitization
• f/u screening for HIV and other STDs
• Dx Gram stain (G+ rods)
• Tx ceftriaxone
• Dx hair under microscope
• Tx permethrin shampoo
• Dx Chlamydia NAAT
• Tx doxycycline
• Dx tissue bx (Donovan bodies)
• Tx doxycycline
• Dx KOH prep (pseudohyphae)
• Tx fluconazole (Diflucan) or miconazole cream
• Dx wet prep (clue cells)
• Tx metronidazole
• Dx wet prep (mobile trichomonads)
• Tx metronidazole for both pt + partner
Management
• Dx KOH prep (pseudohyphae)
• vaginal → Tx Diflucan or Monostat cream
• cutaneous → Tx topical nystatin powder
• thrush → Tx nystatin swish/swallow
• sepsis → Tx IV amphotericin B
• Dx CXR (“air-crescent sign” or “halo sign”)
• ABPA → avoid exposure
• aspergilloma → Tx lobectomy
• invasive aspergillosis → Tx IV amphotericin B
• Dx LP + India ink stain (thick capsules)
• Tx IV amphotericin B + flucytosine
• Dx serum/urinary ag
• Tx itraconazole
• Dx tissue bx (Broad Based Buds)
• Tx itraconazole
• Dx tissue bx (huge spherule w/ endospores)
• Tx itraconazole
• Dx tissue bx (cigar-shaped yeasts)
• Tx itraconazole or potassium iodide
 STEP 2 × Ψ

MOOD D/O Major depressive episode: 5/9 SIGECAPS (including depressed mood or anhedonia) for 2 weeks – depressed mood, Sleep, Interest, Guilt, Energy,
Concentration, Appetite, Psychomotor activity, Suicidal ideation

Manic episode: 3/7 DIGFAST for 1 week – Distractibility, Insomnia, Grandiosity, FOI, ↑Activity, Speech pressured, Thoughtlessness
Hypomanic episode: 3/7 DIGFAST for >3 days, no functional impairment or psychotic features (vs. manic episodes)

MDD vs. bereavement vs. adjustment disorder: MDD lasts >6 mo, functional impairment
adjustment d/o lasts <6 mo, functional impairment
bereavement lasts <6 mo, no functional impairment

Dz Presentation Management Other

Major depressive disorder
(MDD)
Dysthymic disorder
Bipolar disorder (manic
depression)
Cyclothymic disorder
Adjustment disorder w/
depressed mood
↓5-HT/↓DA/↓NE (monoamine
hypothesis) → 1 major
depressive episode, no manic or
hypomanic episodes
Atypical depression: MDD w/
hypersomnia, hyperphagia,
reactive mood, hypersensitivity
to rejection
Seasonal affective disorder:
MDD w/ triad of irritability +
carb cravings + hypersomnia
during the winter months
depressive sx for >2 yrs without
major depressive episodes
Bipolar I: 1 manic episode (don’t
need depressive episode)
Bipolar II: 1 hypomanic episode
+ 1 major depressive episode, no
full manic episodes
alternating hypomania and
dysthymia for >2 yrs, without
major depressive or manic
episodes
depression after a stressful
event (e.g. death of a loved
one) that affects daily
functioning, lasts <6 mo
• first step is assess suicidal/homicidal ideation
• (admit if +SI/HI, even against pt’s will)
• Tx SSRI (6 wks for single episode, longer for
• multiple episodes)
• refractory → Tx ECT (can cause amnesia)
• atypical → Tx MAOI
• smokers → Tx buproprion (↓cravings)
• sexual dysfunction → Tx bupropion
• anorexic/cachectic → Tx mirtazapine
• seasonal affective → Tx light therapy
• Tx psychotherapy
• Tx lithium (1 yr for single episode, lifetime for
• multiple episodes)
• f/u creatinine and TSH levels
• refractory, renal failure, or hypothyroidism →
• Tx carbamazepine or valproic acid
• do not give antidepressants (will precipitate
• manic episode)
• Tx psychotherapy
• Tx psychotherapy
SSRI toxicity: takes 4-6 wks to
take effect,↑suicidality in teens,
sexual dysfunction
SNRI toxicity: ↑NE → HTN
TCA toxicity: anticholinergic sx +
widened QRS (Tx sodium bicarb)
MAOI toxicity: HTN crisis (w/
tyramines), serotonin syndrome
(w/ SSRIs or meperidine, Tx
cyproheptadine)
Buproprion toxicity: ↑seizures
w/ eating disorders and epilepsy
Trazodone toxicity: sedation,
priapism (Tx pseudoephedrine)
Mirtazapine toxicity: sedation,
weight gain
St. John’s wort toxicity: ↑P450
Lithium toxicity: LMNOP –
Lithium causes Movement
tremors (Tx propanolol),
Nephrogenic DI (Tx HCTZ),
Narrow TI, hypOthyroidism (Tx
Synthroid), Pregnancy (Ebstein
anomaly)

ANXIETY D/O Dz Presentation Management Other

Panic disorder recurrent panic attacks w/ • panic attack → Tx alprazolam (Xanax) Xanax toxicity: abrupt cessation
persistent concern of another • chronic ppx → Tx SSRI can result in confusion/seizures
attack, can present as chest
pain w/ normal EKG, ↑risk w/
mitral valve propalse

Agoraphobia: fear of public

places → avoidance
Specific phobia fear of specific objects or • Tx psychotherapy (desensitization)
situations → avoidance or
tolerated w/ intense anxiety
Social phobia (social anxiety fear of social situations (e.g. • Tx psychotherapy (assertiveness) + SSRIs
disorder) public speaking, eating out, • performance anxiety → Tx β-blockers can
using public restrooms) → • help w/ autonomic response
avoidance or tolerated w/
intense anxiety
Obsessive-compulsive disorder obsessions (intrusive thoughts) • Tx SSRIs (fluvoxamine) OCD vs. OCPD: OCD is ego-
(OCD) that can lead to compulsive • refractory → Tx cingulotomy dystonic (causes marked distress
behavior (ritualistic behaviors); over sx), OCPD is ego-syntonic
↑risk of ADHD and tic d/o
Post-traumatic stress disorder traumatic event (war for men, • Tx SSRIs
(PTSD) rape for women) → intense
fear >1 month w/ flashbacks,
avoidance of stimuli, ↑arousal,
emotional detachment

Acute stress disorder: PTSD for

<1 month
Generalized anxiety disorder excess anxiety → difficulty
(GAD) concentrating, restlessness,
irritability, fatigue, tense
muscles, sleep disturbance
• Tx SSRIs or buspirone GAD vs. phobias: anxiety is free-
floating in GAD, rather than
being fixed to specific situation
 STEP 2 × Ψ

PSYCHOTIC D/O Delusion vs. illusion vs. hallucination: delusion is a fixed, false belief
Delusion vs. illusion vs. hallucination: illusion is misinterpretation of sensory stimulus
Delusion vs. illusion vs. hallucination: hallucination is sensory perceptation w/o stimulus

Psychotic sx + abdominal pain: acute intermittent porphyria (Dx ↑urine porphobilinogen)

Dz Presentation Management Other

Schizophrenia
Brief psychotic disorder
Schizophreniform disorder
Schizoaffective disorder
Delusional disorder
Shared psychotic disorder
(folie à deux)
>6 months with 2/5 – delusions,
hallucinations, disorganized
speech, disorganized/catatonic
behavior, negative symptoms
Paranoid SCZ: excessive
paranoia, ideas of reference,
auditory hallucinations
Catatonic SCZ: rigid posture,
echolalia, echopraxia, “waxy
flexibility”
Disorganized SCZ: flat affect,
disorganized speech/behavior
Residual SCZ: prominent
negative sx (anhedonia, flat
affect, alogia, avolition, poor
attention)
Undifferentiated SCZ: doesn’t
fit into another subtype
SCZ for <1 month
SCZ for 1-6 months
SCZ + mood disorder
nonbizarre, fixed delusions for
>1 month without functional
impairment
pt picks up identical delusions
as a significant other
• first step is assess suicidal/homicidal ideation
• (admit if +SI/HI, even against pt’s will)
• Tx atypical antipsychotics (1st line), typical
• antipsychotics (2nd line) – similar efficacy so
• drug of choice depends on side-effect profile
• severe psychosis → Tx Haldol
• refractory → Tx clozapine
• poor compliance → Tx long-acting depot
• (decanoate) injections
• Tx antipsychotics
• Tx antipsychotics
• Tx antipsychotics + SSRIs
• Tx psychotherapy
• Tx separation + group psychotherapy
SCZ brain: ↑DA in mesolimbic
pathway → positive sx; ↓DA in
prefrontal ctx → negative sx
Atypical antipsychotic toxicity:
weight gain (esp. olanzapine),
DKA, metabolic syndrome
Typical antipsychotic toxicity:
extrapyramidal sx, ↑prolactin
(↓DA in tuberoinfundibular
pathway), tardive dyskinesia,
anticholinergic effects
Clozapine toxicity: ↑seizures,
agranulocytosis (f/u WBC q wk),
R-sided obstipation
Neuroleptic malignant
syndrome: high-spiking fever →
rhabdo → ↑CK w/ “lead pipe”
rigidity, tremors, autonomic
instability (Tx dantrolene)
Extrapyramidal sx: 5-HT block →
acute dystonia (Tx benztropine
or diphenhydramine), akathisia
(Tx β-blockers), parkinsonism (Tx
levodopa)
Tardive dyskinesia: choreo-
athetosis of mouth and tongue
after years of neuroleptic use,
irreversible

DEFENSE MECHANISMS Mature Altruism: performing acts that benefit others to feel better about oneself (e.g. soup kitchen)
Humor: using comedy to express thoughts or feelings w/o discomfort to self or others
Sublimation: satisfying socially objectionable impulses in an acceptable manner
Suppression: consciously avoiding unacceptable impulse or emotion (vs. repression)

Immature Acting out: giving into an impulse, even if it’s socially inappropriate (e.g. temper tantrums)
Controlling: regulating aspects of external environment to relieve anxiety
Denial: not accepting reality that is too painful (e.g. “I don’t have cancer”)
Displacement: redirecting thoughts or feelings about one thing onto something more tolerable (e.g. displacing work anger on wife)
Distortion: grossly reshaping external reality to suit inner needs
Fantasy: substituting fantasy for reality to resolve inner conflicts
Intellectualization: using excessive abstract thinking to avoid experiencing disturbing feelings (e.g. researching one’s dz)
Isolation of affect: separation of an unpleasant idea from the feelings it evokes
Passive aggression: nonconfrontational expression of aggression towards others
Projection: attributing one’s inappropriate thoughts onto another (e.g. stealing from a friend you suspect is stealing from you)
Rationalization: making reassuring but false explanations for outcome or behavior
Reaction formation: doing the exact opposite of an unacceptable impulse (e.g. racist helping immigrants)
Repression: unconsciously avoiding unacceptable impulse or emotion (vs. suppression)
Regression: reverting back to childlike behavior (e.g. enuresis)
Splitting: labelling people as all good or all bad, characteristic of borderline PD
Undoing: attempting to reverse a situation by adopting a new behavior
 STEP 2 × Ψ

PERSONALITY D/O Personality trait vs. personality disorder: personality d/o are inflexible, cause functional impairment
Personality trait vs. personality disorder: personality traits have no functional impairment

Cluster A: “weird” – paranoid, schizoid, schizotypal

Cluster B: “wild” – antisocial, borderline, histrionic, narcissistic
Cluster C: “worried” – avoidant, dependant, obsessive-compulsive

Dz Presentation Management Other

Paranoid PD general distrust of others → • Tx CBT
suspicious of spouse and
others, grudges, preoccupied
w/ doubts, non-trusting, quick
to counterattack, etc.
Schizoid PD voluntary social withdrawal → • Tx CBT
↓friends, indifferent to others,
emotional detachment, etc.
Schizotypal PD schizoid + eccentric thoughts • Tx CBT
(“magical thinking”)
Antisocial PD lack of empathy → selfish, • Tx CBT
oppressive, gets in trouble w/
law, nonconfrontational,
temper issues, “sets animals on
fire", etc.

Conduct disorder: antisocial

behavior <18 y/o
Borderline PD childhood sexual abuse → • Tx dialectical behavior therapy (DBT) +
unstable self-image → moody, • setting clear boundaries
impulsive, labile relationships,
emotionally vulnerable, feelings
of emptiness, suicidal, splitting
(“best doctor ever”), etc.
Histrionic PD excessive need for attention → • Tx CBT
attention-seeking behaviors,
inappropriately seductive,
prone to exaggeration, etc.
Narcissistic PD poor self-esteem → need for • Tx CBT
admiration, ↓empathy, sense of
entitlement, arrogance, fishing
for compliments, takes
advantage of others, etc.
Avoidant PD intense fear of rejection → • Tx CBT
avoids others, doesn’t take
criticism well, isolated from
relationships, etc.
Dependant PD excessive need for approval → • Tx CBT
obsessive about acceptance,
difficulty w/ decision-making,
fear of being alone, needs to be
in a relationship, etc.
Obsessive-compulsive PD preoccupation w/ orderliness, • Tx CBT OCD vs. OCPD: OCD is ego-
control, and perfection at the dystonic (causes marked distress
expense of efficacy over sx), OCPD is ego-syntonic

Obsessive-compulsive behavior
in med studs: not a personality
d/o unless it causes functional
impairment

EATING D/O Dz Presentation Management Other

Anorexia nervosa fear of being fat → ↓food → • first step is to screen for depression Complications: osteoporosis,
<85% ideal body weight • <75% ideal body weight or presence of medical secondary amenorrhea, lanugo,
• complication → admit hypothermia, arrhythmias,
• Tx TID sandwiches premature or SGA babies

• f/u electrolytes for refeeding syndrome

Bulimia nervosa binge-eating + behaviors to • Tx SSRIs + CBT Complications: sialadenosis,
counteract weight gain dental caries, Russell sign (dorsal
(purging, diuretics, exercise, knuckle callouses), Mallory-Weiss
fasting) and Boerhaave syndromes

Anorexia vs. bulimia: both can

Refeeding syndrome increasing nutrition in starving
pt → sudden shift from fat to
carb metabolism → uses up
electrolytes (especially K/phos)
have purging, but anorexia has
<85% ideal body weight
• Dx renal panel (↓K, ↓phos)
• Tx electrolyte replacement + supportive care

SUBSTANCE ABUSE Abuse vs. dependence: abuse is repetitive use w/ negative consequences
Abuse vs. dependence: dependence is presence of tolerance or withdrawal sx
Dz
Alcohol intoxication
Alcohol withdrawal
Wernicke-Korsakoff syndrome
Amphetamine intoxication
Benzodiazepine intoxication
Caffeine intoxication
Cocaine intoxication
Cocaine withdrawal
Ketamine intoxication
Marijuana intoxication
MDMA (ecstasy) intoxation
Nicotine withdrawal
Opioid intoxication
Opioid withdrawal
Phencyclidine (PCP) intoxication
DISSOCIATIVE D/O Dz
Dissociative amnesia
Dissociative fugue
Dissociative identity disorder
(multiple personality disorder)
Depersonalization disorder
Presentation
↓inhibition, impaired
coordination, ataxic gait, etc.
irritability, hand tremors,
insomnia, ↑sympathetic activity
Delirium tremens: anxiety,
insomnia, gross tremors,
delirium, tactile hallucinations
(“bugs crawling on my skin”)
Alcoholic hallucinosis: audio or
visual hallucinations, but VSS
and mental status intact
Wernicke encephalopathy:
acute thiamine deficiency →
reversible confusion, ataxia,
ophthalmoplegia (CN VI palsy)
Korsakoff psychosis: chronic
thiamine deficiency → amnesia,
confabulations
stimulant effects (dilated
pupils, ↑libido, sweating, chest
pain, etc.) + visual hallucinations
sedation, mild respiratory
depression
↑sympathetic activity, anxiety,
diuresis, insomnia, GI distress
euphoria, ↑self-esteem,
↑sympathetic activity, tactile
hallucinations, paranoia, nasal
erythema; ↑risk of MI, stroke,
epistaxis
severe depression and
exhaustion after coke binge;
↑risk of suicide
hallucinations, amnesia,
“flashbacks”
euphoria, red eyes, dry mouth,
munchies, anxiety, gyno,
laziness; ↑risk of SCZ
euphoria, “sense of closeness
with others”, death by
hyperthermia or dehydration;
consider in clubs/raves
intense craving and dysphoria,
anxiety, irritability, restlessness
sedation, severe respiratory
depression, “pinpoint pupils”
(not always present)
nausea, abdominal pain,
diarrhea, arthralgias, myalgias,
diaphoresis
violent behavior, vertical or
rotary nystagmus
Presentation
inability to recall personal
information but can remember
everything else (vs. transient
global amnesmia)
sudden, unexpected travel
away from home + inability to
recall one’s past
multiple identities + inability to
recall information about non-
dominant personalities
persistent or recurrent episodes
of feeling detached from one’s
body or mental processes
STEP 2 × Ψ
Management Other
• Dx blood/urine EtOH
• Tx banana bag (IVF w/ MVI, B1, folate, mag)
• Dx CIWA scale
• Tx chlordiazepoxide (Librium)
• dependence → Tx disulfiram (aversive rxn),
• naltrexone or acamprosate (↓cravings)
• Dx ↑LFTs (AST:ALT >2, ↑GGT, ↑CDT), ↑MCV
• Tx thiamine supplements
• Dx urine tox Cocaine vs. meth: both cause
• Tx IV fluids + evaporation cooling stimulant effects but only meth
causes visual hallucinations
• amphetamine + HTN → Tx α-blockers
• (phenoxybenzamine) then β-blockers
• Dx urine tox
• Tx flumazenil
• Tx gradual reduction
• Dx urine tox
• Tx IV diazepam
• severe agitation → Tx Haldol
• Dx urine tox
• Tx supportive care
• Dx urine tox
• Tx supportive care
• Dx urine tox
• Tx supportive care
• Dx urine tox
• Tx IV fluids + evaporation cooling
• Tx varenciline (Chantix), buproprion (Zyban),
• nicotine patch or gum
• smoking + depression → Tx buproprion
• Tx naloxone (Narcan)
• Dx COWS scale
• Tx methadone
• Dx urine tox
• Tx IV diazepam
• severe agitation → Tx Haldol
Management Other
• Tx psychotherapy Transient global amnesia: TIA in
temporal lobes or thalamus →
rapid retrograde memory loss +
confusion but preservation of
self-identity
• Tx psychotherapy
• Tx psychotherapy
• Tx psychotherapy

SOMATOFORM D/O Dz Presentation
Somatization disorder young women w/ multiple sx
(4 pain, 2 GI, 1 sexual, 1 neuro)
that are not intentionally
produced
Conversion disorder conversion of a psych issue into
a neuro one w/ indifference to
present condition (e.g. mutism,
paralysis, blindness, seizures,
parasthesias, globus hystericus
= “lump in my throat”)
Hypochondriasis preoccupation w/ fear of having
a serious illness, based on
misinterpretation of bodily sx
Pain disorder significant pain not fully
accounted for by a medical
condition, refractory to
analgesic use
Body dysmorphic disorder preoccupation w/ imagined
defect in appearance (“my
nose is too big”)
Münchhausen syndrome consciously feigning sx to play
(factitious disorder) the sick role, can have “grid
abdomen” from multiple
surgeries
Münchhausen by proxy:
intentionally producing sx in
someone else (usually children)
Malingering consciously feigning sx for
personal gain (“I need my
dilaudid”), pts will leave site if
confronted or don’t get meds
IMPULSE CONTROL D/O Dz Presentation
Intermittent explosive disorder recurrent episodes outbursts of
aggression against people or
property that remit quickly and
spontaneously
Kleptomania inability to resist urges to steal
objects not needed for personal
use or monetary reasons
Pathological gambling persistent and recurrent
maladaptive gambling behavior
Trichotillomania recurrent, repetitive,
intentional pulling out of one’s
hair causing visible hair loss
Pyromania deliberate fire setting w/
fascination or attraction to fire;
not for monetary gain, anger, or
political statement
SLEEP D/O Dz Presentation
Primary insomnia ↓sleep
Narcolepsy excessive daytime sleepiness,
cataplexy (suddenly fainting w/
intense emotion), hypnogogic +
hypnopompic hallucinations
Circadian rhythm sleep sleep schedule is messed up
disorders due to shift-work or travel
across multiple time zones
Somnambulism sleepwalking w/ “glassy look”
on eyes, remembers nothing in
the morning
Nightmare disorder child wakes up scared and
crying, remembers incident
Night terrors child wakes up screaming and
agitated, but falls back asleep
and remembers nothing in the
morning
Restless leg syndrome uncontrollable desire to move
legs at night → wakes up the
significant other
STEP 2 × Ψ
Management Other
• r/o medical causes Somatization vs. fibromyalgia:
• Tx psychotherapy both have chronic pain, but
somatization is worse w/ stress
and fibromyalgia is constant
• r/o medical causes Pseudocyesis: type of conversion
• Tx psychotherapy d/o where woman has s/sx of
pregnancy but β-HCG is normal
• r/o medical causes
• Tx psychotherapy
• r/o medical causes Pain disorder vs. fibromyalgia:
• Tx psychotherapy both have chronic pain, but pain
disorder is worse w/ stress and
fibromyalgia is constant
• Tx psychotherapy
• avoid cosmetic procedures (won’t fix
• underlying insecurity)
• Tx psychotherapy (if willing)
• avoid unnecessary treatment or procedures
• Münchhausen by proxy → call CPS
• report suspicious activity to authorities
• avoid unnecessary treatment or procedures
Management Other
• Tx SSRIs + lithium + propanolol
• (psychotherapy is useless)
• Tx psychotherapy
• Tx Gamblers Anonymous
• Tx psychotherapy
• Tx psychotherapy + close supervision
Management Other
• first step is fix sleep hygiene
• Tx short-term non-benzo hypnotics
• (Zolpidem, Zaleplon, esZopiclone)
• first step is fix sleep hygiene
• Tx stimulants (amphetamines, modafinil)
• cataplexy → Tx sodium oxybate (GHB)
• first step is fix sleep hygiene
• Tx light therapy (to help wake up) + melatonin
• (to help sleep)
• Tx ensure safety, do not force awakening
• Tx image rehearsal therapy
• Tx ensure safety
• Tx dopaminergics (pramipexole, ropinirole)
 STEP 2 × Ψ

SEXUAL D/O Dz Presentation Management Other

Hypoactive sexual desire ↓libido • Tx psychotherapy
disorder
Sexual arousal disorder ↓physiological response in • Tx psychotherapy
women despite good libido
Erectile dysfunction can’t get it up • Tx sildenafil Etiology: atherosclerosis (MCC),
meds (β-blockers), EtOH, etc.

Physiologic vs. psychogenic ED:

Sexual aversion disorder avoidance of genital contact w/
sexual partner
Dyspareunia genital pain before, during, or
after sexual intercourse
psychogenic ED can get it up at
other times (e.g. morning wood)
Sildenafil toxicity: hypotension
with nitrites (absolute c/i) and α1-
blockers (need 4 hr interval)
• Tx psychotherapy
• r/o medical causes Dyspareunia + dysmenorrhea +
• Tx psychotherapy dyschezia: endometriosis

Vaginismus: involuntary muscle • vaginismus → Tx Kegel exercises + gradual

contraction of vagina during • manual dilation
insertion
Paraphilias engagement or preoccupation • Tx psychotherapy
w/ unusual sexual urges or
fantasies, lasting >6 months
and interferes w/ daily life

Pedophilia: sexual pleasure

from kids <13 y/o
Frotteurism: sexual pleasure
from touching or rubbing up
against a nonconsenting person
Voyeurism: sexual pleasure
from watching unsuspecting
nude people
Exhibitionism: sexual pleasure
from exposing self to others
Sadism: sexual pleasure from
hurting or humiliating others
Masochism: sexual pleasure
from being hurt or humiliated
Fetishism: sexual pleasure from
inanimate objects
Transvestic fetishism: sexual
pleasure in men from wearing
women’s clothing
Necrophilia: sexual pleasure
from f-ing a corpse
Telephone scatologia: sexual
pleasure from calling
unsuspecting women and
having phone sex with them
 STEP 2 × Ψ

PEDS Ψ Hearing impairment vs. autism vs. ADHD: all can present w/ “doesn’t pay attention” and “doesn’t listen to commands”;
Hearing impairment vs. autism vs. ADHD: repetitive/stereotyped behaviors → think autism
Hearing impairment vs. autism vs. ADHD: poor language → think autism or hearing impairment

Dz Presentation Management Other

Attention-deficit hyperactivity short attention span, • first step is r/o hearing impairment Psychostimulant toxicity:
disorder (ADHD) impulsivity, hyperactivity for >6 • Dx Vanderbilt scale ↓appetite → weight loss,
months in 2+ settings (e.g. • Tx psychostimulants (dextroamphetamine or insomnia, nervousness
home and school) • methylphenidate)

• refractory → Tx atomoxetine or α2-agonists

• (clonidine, guanfacine)
Conduct disorder antisocial behavior <18 y/o • Tx CBT

Antisocial personality disorder:

antisocial behavior ≥18 y/o
Oppositional defiant disorder:
antisocial behavior w/ parents
and teachers, but act normally
w/ friends
Tourette syndrome most severe tic disorder w/ • Tx haloperidol or pimozide Coprolalia: involuntary swearing,
multiple daily motor/vocal tics, rare but pathognomonic for
onset before 18 y/o; associated Tourette syndrome
w/ OCD and ADHD
Learning disabilities achievement in reading, writing, • first step is r/o hearing impairment
or math that is significantly • Tx special education
lower than expected despite
normal intelligence
Autism problems w/ social interaction, • first step is r/o hearing impairment
impaired communication, and • Tx special education
repetitive patterns of behavior
and activity, onset <3 y/o
Asperger syndrome mild autism w/ normal language • first step is r/o hearing impairment
and cognitive development, • Tx special education
often rigid and overly formal in
social interaction (“little
professors”)
Childhood disintegrative normal development for several • Tx special education
disorder (CDD) years, then delayed-onset
autistic behavior (>3 y/o)
Mental retardation (MR/DD) IQ <70; MCC overall is fetal • Dx IQ test
alcohol syndrome, MC genetic • Tx special education
cause is Down syndrome, MC
inherited cause is Fragile X
syndrome
Breath-holding spells child holds breath and passes • Tx avoid reinforcing behavior
out, due to pain or being upset
Selective mutism refusal to speak in certain • Tx psychotherapy
situations despite normal
language and comprehension
skills
Separation anxiety disorder excessive fear of leaving • Tx psychotherapy
parents or other figures (may
feign illness to stay home from
school, etc.)
Enuresis involuntary urination >5 y/o • Dx UA to r/o UTI
• Tx bed-wetting alarm > desmopressin >
• imipramine
Encopresis constipation → diarrhea goes • Tx stool softeners ± bowel catharsis
around impacted stool →
involuntary defecation >5 y/o
 STEP 2 × HEALTH MAINTENANCE

SCREENING Dz Population Protocol

AAA current or former • Dx abdominal U/S
male smokers 65-75
Alcohol everyone >18 • Dx CAGE
• offer counseling
Bladder cancer -- • not recommended
Breast cancer women 50-75, >40 if • Dx annual mammogram
high-risk
Cervical cancer women 21-65 but not • Dx Pap smear q 2 yrs (21-29), then q 3 yrs (>30 after 3 negative Paps)
s/p hysterectomy
Colon cancer everyone 50-75 or • Dx annual FOBT + flex sig q 5 yrs or colonoscopy q 10 yrs
10 yrs before first-
degree relative
HLD men >35, women >45 • Dx fasting lipid panel q 5 yrs
HTN everyone >18 • Dx measure BP
Lung cancer -- • not recommended
Obesity everyone • Dx BMI
• offer counseling
Osteoporosis women >65, high-risk • Dx DEXA scan q 2 yrs
pts
Pancreatic cancer -- • not recommended
Prostate cancer -- • not recommended
• Dx PSA or DRE if pt desires testing (case-by-case basis)
Smoking everyone >18 • offer counseling + nicotine replacement therapy
• refractory → Tx buproprion (Zyban) or varenciline (Chantix)
STDs sexually active girls • Dx cervical sampling (for GC/CT), HIV ELISA, RPR-VDRL
<24, high-risk pts

VACCINATIONS Vaccine Population Protocol

BCG high-risk groups only • when indicated
DTaP everyone • give at 2/4/6 mo, 15 mo, 4 yr
• Td booster q 10 yrs
• DTaP allergy → give Td instead (allergy likely to pertussis component)
HAV high-risk groups only • when indicated
(kids, liver dz, travel)
HBV high-risk groups only • when indicated
(kids, liver dz, travel)
Hib kids, asplenia • give at 18 mo
Influenza high-risk groups only • annually
(healthcare workers,
elderly, Kawasaki dz)
Meningococcus high-risk groups only • when indicated
(asplenia, dorms,
barracks, freshmen)
MMR kids • give at 1 yr, 4 yr
Pneumococcus high-risk groups only • when indicated
(kids, elderly, HIV+ w/
CD4 >200, asplenia)
Polio kids • give at 2/4/6 mo, 15 mo, 4 yr
• immunocompromised → give Salk (inactivated) instead
Rabies high-risk groups • when indicated
(animal workers),
post-exposure ppx

ETHICS Situation
Suicidal or homicidal pt
Breaking bad news
Spousal abuse
Child abuse
Sexual assault
Medical error
Refusing treatment for self
Refusing treatment for child,
spouse, or parent
Refusing treatment for fetus
Minors
Inappropriate pt
Angry pt
Pt wants alternative therapy
(e.g. acupunture, chiropractor)
Pt wants medical records
Relative/boss wants pt info
STEP 2 × ETHICS
Management/response
• admit (even against pt’s will)
• 1. set the stage + assess pt knowledge (“what do you think of your sx?”)
• 2. ask how much pt would like to know
• 3. give a warning shot (“I’m afraid it’s bad news”)
• 4. break news if pt wants it
• 5. allow time for questions
• 6. give px and available options
• ask about abuse in empathetic, open-ended question
• 1. r/o medical causes (e.g. osteogenesis imperfecta)
• 2. do a complete physical exam
• 3. get whole-body X-rays (if necessary)
• 4. call CPS
• 1. call social worker
• 2. get detailed hx and complete physical exam
• 3. get oral/genital/anal swabs for STD testing + HIV test + β-HCG levels
• 4. start STD ppx
• 5. start emergency contraception (if desired)
• admit the mistake and apologize
• another MD’s mistake → admit the mistake and apologize, then talk to colleague
• obey pt’s wishes
• not life-threatening → get a court order
• life-threatening, no advance directives → go ahead w/ procedure anyways
• life-threatening, has advance directives → follow advance directives
• obey mother’s wishes
• emancipated (married, military, financially independent) → can sign own consent
• unemancipated → need parental consent (except prenatal care, STDs, mental health, substance abuse)
• respond firmly but politely, remain professional
• encourage discussion about what’s bothering the pt
• encourage discussion about why pt seeks alternative therapy
• give it to them
• get pt’s approval in writing first (HIPPA)
 STEP 2 × BIOSTATS

STUDY TYPES Incidence: % of population w/ new-onset dz in a year

Prevalence: % of population w/ dz at any given time;
Prevalence: ↓prevalence = ↑NPV, ↑prevalence = ↑PPV

Cohort study: prospective (or retrospective) study of population w/ specific risk exposure; determines relative risk
Case-control study: divide subjects into cases and controls and looks back at exposure; determines odds ratio
Cross-sectional survey: survey of population; determines prevalence
Case series: description of clinical presentation of rare dz
Meta-analysis: pooling of multiple studies to make a definitive statement

Case-control Cross-sectional Cohort

OR Prevalence (Q) RR

BIOSTATS Sensitivity: TP / (TP+FN) Disease+ Disease–

Specificity: TN / (TN+FP) Dx+ TP FP (type I) → PPV
Positive predictive value: TP / (TP+FP) Dx– FN (type II) TN → NPV
Negative predictive value: TN / (TN+FN) ↓ ↓
Odds ratio*: (TP×TN) / (FP×FN) sens spec
Relative risk*: PPV / NPV
Attributable risk: PPV – NPV (*OR = RR in rare diseases) ↑sens/↑NPV ↑spec/↑PPV

Number needed to treat: 1 / (difference in outcomes b/t control and experimental groups)
Number needed to harm: 1 / (difference in rate of dz b/t exposed and unexposed population)

“Spin-snout”: SPecificity rules IN, SENsitivity rules OUT

“Statistically significant”: p <0.05, correlation coefficient doesn’t contain 0, relative risk doesn’t contain 1.0

Null hypothesis: no association exists

Alternative hypothesis: association exists

p-value <0.05: <5% probability that study results occurred by chance

95% confidence interval: 95% of population will fall into this interval

Standard deviation: ±σ = 68%

Standard deviation: ±2σ = 95%
Standard deviation: ±3σ = 99.7%

Skew:

Chi-squared test: compares percentages or proportions

T-test: compares Two means
ANOVA test: compares 3+ means

Generalizability: applicability of study results to other populations

Precision/reliability: always producing same results

Accuracy/validity: how close it is to the truth

BIAS Admission rate bias: skewed data b/c hospital admits only certain types of pts
Confounding bias: presence of second variable linked to both first variable and outcome; control w/ randomization
Effect modification: presence of second variable linked to outcome (but not first variable), not a bias
Investigator bias: subjective interpretation of data by investigator (Pygmalion effect)
Lead-time bias: screening test detects dz earlier but has no effect on overall survival time (e.g. cancer test that claims to prolong survival)
Length bias: study length is too short for dz course (e.g. one week study for cancer)
Measurement bias: poor data collection
Nonresponse bias: people do not respond to surveys
Observational bias: subjects are aware of being observed and answer questions differently (Hawthorne effect); control w/ blinding
Publication bias: alternative hypothesis are more likely to be published than null hypothesis
Recall bias: subjects have poor recall of events
Selection bias: nonrandom selection of subjects, or loss to f/u afterwards
Self-selection bias: pts w/ certain medical history are more likely to participate in studies
Unacceptability bias: people do not respond w/ unacceptable answers (e.g. “I work out everyday”)