Pearlicious Pearly Pearls

• Need SPF 15+ with UVA (long wavelength) and UVB (short wavelength) protection to protect against aging and
cancer

• Pt w/PCOS w/irregular menses = does not ovulate; give a selective estrogen receptor modulator such as
clomiphene citrate as 1st line; inc dose if not working; can do gonadotropin tx if this doesn’t work but risk is
multiple gestation

• UTI more common w MS bc neurogenic bladder

• Infections worse w MS bc heightens immune response and potential relapse of MS so need immunizations

• Cellulitis

• TB needs AIRBORNE precautions (5 µm or smaller) so need NEGATIVE pressure airborne isolation to prevent
airborne droplets from escaping room
>>OTHER airborne MO: MEASLES, CHICKENPOX

àIf disseminated varicella ZOSTER being tx in hospital need both CONTACT AND AIRBORNE precautions as
pts who have not had chicken pox can get chickenpox from pt w zoster

• Contact precautions (C dif, vanc resisitant enterococci, Shigella, Hep A)

• Droplet isolation (large particle droplets 5 µm or greater) = N meningitidis, influenza, adenovirus, Bordetella
pertussis, Mycoplasma pneumoniae

• Chronic cutaneous lupus erythematosus, ie discoid lupus.

-May be classic “butterfly” malar rash, or more diffuse
-Discoid lupus can be present in full out SLE or may occur without other manifestations/SXS
-May have low ANA
-TX: topical glucocorticoids and calcineurin inhibitors 1st line but if fail need hydroxychloroquine
-Dapsone = sulfonamide; Dapson, methotrexate, mycophenolate mofetil, and systemic retinoids: 2nd line

• Migraines: tx with NSAIDS or oral triptans but if fail (esp w vomiting) need SUBCUTANEOUS sumatriptan; nasal
spray less effective

• On PFT: if no obstruction or restriction but decreased DLCO = Pulm HTN

• Lymphoma; IIIB nodular sclerosing Hodgkin lymphoma: NEEDS six cycles of doxorubicin, bleomycin,
vinblastine, and dacarbazine (ABVD)

-If good then DONE

-If recurs need 2 cycles of DICE: dexamethasone, ifosfamide, cisplatin, and etoposide

THEN when remission is carried out will need to:

-give hematopoietic growth factors, with or without chemotherapy, to mobilize, collect, and store
hematopoietic progenitor cells: collect >3 million CD34+ cells/kg patient body weight

THEN

-continue high-dose multiagent chemotherapy followed by reinfusion of the stored progenitor cells

• ONLY GIVE ALLOGENIC HEMATOPOIETIC STEM CELL TRANSPLANTATION if pt is not responding to chemo
OR if relapse after autologous hematopoietic stem cell transplantation

• In lymphoma if pt has primary limited disease can do RADIATION tx

• R mainstem bronchus intubation with atelectasis of R upper lobe bc

tube obstructing); needs repositioning of tube

• For methicillin SENSITIVE staph osteomyelitis: Nafcillin

-Need to monitor CBC and liver enzymes bc of bone marrow suppression risk AND creatinine bc need to adjust
dose based on kidney function
-Monitoring of oxacillin and carbapenems is similar to that of nafcillin
-Monitoring of other β-lactam antibiotics is similar to that of nafcillin except that liver enzyme testing is not
necessary
-antipseudomonal penicillins necessitate checking the serum potassium level weekly
• After TPA for acute ischemic stroke are treated keep BP UNDER 180/105 mm Hg (NICARDIPINE) to avoid
intracerebral hemorrhage; can give ASA, heparin 24 hours after IF stable, no internal bleed AND CT neg for
bleed

• If TBI do a NONcontrast CT head if: loss consciousness OR no LOC but focal deficit, N/V, HA, physical basilar
skull fx signs, GCS <15, coagulopathy, dangerous MOA of fall (including ejection during MVC or fall >3 ft)

• DEXA if >65 yo OR in younger with FX risk of >9.3% using FRAX

-Risks: first-degree relative with a history of hip fracture, alcohol abuse, smoking, low body mass, and
glucocorticoid use

• USE STATIN: if 40-75 and 10 year ASCVD 7.5% or higher and 1 or more ASCVD risk factor (ie dyslipidemia,
DM2, HTN or smoking); should screen in this pop

• Screen for blood glucose if 40-70 yo and overweight/obese; screen every 3 years; Screen ALL adults at age 45
regardless of weight

• Screen with PAP every 3 years or PAP and HPV testing every 5 years in women 30-65 yo

• Screen w/TFTs if symptomatic OR in women >50 yo w/ at least one symptom OR if have risk factors (ie-
autoimmune dz, neck radiation, thyroid surgery)

• Blepharospasm: a dystonia where pt has involuntary and sustained contraction of orbicularis oculi muscle leading
to freq blinking
-dystonia generally involves network involving basal ganglia, sensorimotor centers and cerebellum
-Treat focal dystonia with BOTULINUM TOXIN
-DEEP BRAIN STIMULATION considered in refractory cases

• Intertrigo: irritant skin fold dermatitis 2/2 moisture and rubbing

mostly in obese pts
-THIS IS NOT candidiasis (lacks same degree of redness and satellite lesions) and will be neg on KOH
• Cutaneous anthrax
-occurs in wild and domestic grazing animals (deer, cattle) wherever spores exist (West US)
-Initially pruritic and painless and then become vesicular and surrounded by non pitting edema and then become
hemorrhagic or necrotic and satellite lesions form
-Final stage: black eschar appears and disappears over 6 wks
-DX: blood or exudate culture or full thickness skin bx
-Doxy or cipro to TX

• If pt with fluctuating INR on warfarin GIVE LOW DOSE VITAMIN K SUPPLEMENT to reduce variation of dietary
Vit K intake

• Fever + sore throat, then resolve THEN have fatigue and joint pain that worsen and THEN have dark red spots

ankles/shins that spread

+ abd pain w/labs showing proteinuria, hematuria, erythrocyte casts and leukocytes in urine
=
IgA vasculitis
-fatigue, joint pain, abd pain, petechial/purpural skin lesions, glomerulonephritis following an upper respiratory
tract infection
-Dx: with biopsy
-Complement levels NORMAL

• Infection-related glomerulonephritis such as endocarditis activates the alternative pathway of complement = low
C3 and normal C4 levels

• Cryoglobulinemic vasculitis activates classical complement pathway = C4, and sometimes C3, is depressed;
assoc w Hep C
• Systemic lupus erythematosus = both C3 and C4 are low

• AV malformation
-soft tissue mass with feeding artery and draining vein

• DC Methothrexate in patient with RA 3 MONTHS BEFORE they get pregnant due to teratogenic and abortifacient
risks
-Can cont hydroxychloroquine
-Can cont low dose prednisone if risks of stopping > benefits BUT should hold, if possible, prior to 14 wks due to
cleft palate

• Vibrio parahaemolyticus can cause GI inf with bloody stools, fever and N/V; found in shellfish/seafood
-Worse if chronic liver dz (ie Hep C) and can become septic
-Does not grow on traditional stool cult so NEED to use saline enriched agar

• Yersiniosis can cause GI disease w/food or water

-DOES NOT cause bloody stool, can cause diarrhea tho OR MAY NOT cause diarrhea bc bacteria localize to
lymphoid tissue in Peyer patches and assoc mesenteric lymph nodes (mimics appendicitis)
-assoc w eating chitterlings (pork intestines)

• Corynebacterium sp. = blood cult contaminate

• In osteomyelitis with NEG blood cult NEED CT guided needle aspiration bx to direct abx tx
-OM sxs: neck/back pain persists or inc in severity over wks/months
-Can be complicated w epidural abscess formation and neuro deficits

• Can use 3 phase nuclear bone scanning for IM if need SENSITIVE TEST for OM
-BUT MRI IS MORE SPECIFIC

• ACUTE PROMYELOCYTIC LEUKEMIA: (15;17) translocation

-arrest of leukemic cells at promyelocyte stage
-leads to SXS and signs: Fatigue, easy bruising and bleeding, fever, hepatomegaly
-Labs show: anemia, leukopenia, thrombocytopenia, and DIC (prolonged APTT, pronlonged PT, decreased
fibrinogen); peripheral blood smear with immature blasts with prominent Auer rods
 -Tx w All-trans retinoic acid (ATRA) and chemotx without waiting for confirmation
-Dx: (which is not needed for tx) is via t(15;17) w/fluorescence in situ hybridization

• Primary open angle glaucoma

-increased cup:disc ratio, vertical extention of central cup and disc hemorrhages
-Inc intraocular pressure (>22 mm Hg) and loss of peripheral visual field depth
-SXS: bilateral peripheral vision loss that is gradual and painless
-TX: DECREASE IO PRESSURE: Beta blockers, prostaglandins 1st line
à2nd line: alpha adrenergic agonists, cholinergic agents and topical carbonic anhydrase inhibitors
-Also can do laser tx and surgery or trabeculectomy or iridectomy

• Optic neuritis: usually in MS (inflammatory and demyelinating)

-SXS: rapid onset eye pain (w/movement) and monocular visual loss
• Papilledema. = swelling of the optic disc 2/2 increased intracranial pressure
-inc intracranial pressure can be due to: intracranial mass lesions, cerebral edema, and cerebrospinal fluid
production or resorption abnormalities

On exam has: venous engorgement, blurring of the optic margins, and elevation of the optic disc
-Has stages/grades

• In SMALL CELL LUNG CA: if have complete or near complete response to chemotx OR chemotx + radiation
then DO PROPHYLACTIC CRANIAL IRRIADIATION TO REDUCE INCIDENCE OF BRAIN METS
-LIMITED STAGE small cell lung CA = dz on 1 hemithorax with hilar and mediastinal lymphadenopathy that can
be encompassed within one tolerable radiotherapy portal

• Herpes simplex virus infection

-IN pt w advanced HIV
-painful and acute nodules or non healing ulcers
• In supratheraputic INR
-If INR <5.0: HOLD warfarin and restart at lower dose
-If INR 5.0-9.0: HOLD warfarin and give 1-2.5 mg oral Vit K
-If INR >9.0 or if inc risk of bleeding give 2.5-5 mg of oral Vit K

-If pt. has serious bleed need REVERSAL of anti-coag regardless of INR level; use IV Vit K and 4 factor
prothrombin complex concentrate OR 3 factor PCC and fresh frozen plasma OR recombinant activated factor VII
-CAN GIVE FFP ALONE IF FACTOR CONCENTRATES UNAVAIL

• Superficial thrombophlebitis. = erythema and tenderness with a palpable cord overlying thigh (usually greater
saphenous vein on the proximal medial aspect of the left thigh up to the inguinal crease)
-NEED TO RULE OUT DVT associated with SVT so DO VENOUS DUPLEX US
àIF SVT IS NONEXTENSIVE (less than 5 cm and not near the deep venous system) can do analgesics and
warm/cold compresses

• DO NOT give Levetiracetam (Keppra) to pts w PTSD or psych probs bc can inc anxiety/irritability

• Need to rule out psychogenic non epileptic events EVEN IN PTS WITH SEIZURE D/O esp if seizure is long, eyes
closed and emo probs

• Polymyalgia rheumatica: usually elderly with hip girdle and shulder pain and limiting function due to systemic
inflammation, fever, wt loss, malaise and elevated ESR
-TX: prednisone 10-20 mg/d initially: should rapidly resolve symptoms; taper pred over 6 mo unless flares THEN
prolong tapering (1-3 years)
-Can try methotrexate as glucocorticoid sparing agent
àGiant cell arteritis can accompany PR and can give 81 mg ASA to reduce complications

• Breast MRI for BRCA ½ + breast CA that has been treated; mammogram not good enough

• Risks of treatments in breast CA:

à Cyclophosphamide and anthracyclines (adjunct tx) = 0.5% risk of developing myelodysplasia and acute
leukemia
àTamoxifen = 1/1000 per year risk of endometrial cancer in women over 55 years of age and a smaller risk of
uterine sarcoma in this age group
>>SINCE RISK IS LOW NO routine screening blood tests and imaging studies in asymptomatic pts

• W/tamoxifen can get menopausal symptoms

-Hot flashes: Tx w/ SSRIs or gabapentin
-Sex dysfunction: Tx w/ lubricants and CAUTIOUS very low dose vaginal estrogen
-There is also arthralgia, cog dysfunction, depression, fatigue, wt gain, dec bone density, CV dz,and thrombosis
•
Left lower lobe atelectasis
-opacification behind heart obscuring left hemidiaphragm (arrowheads)
-leftward displacement of mediastinum
-loss of volume of left lower lobe = medial movement and radiological appearance of left interlobar fissure
(arrows)
-ON LATERAL FILM: increase in density overlying lumbar vertebrae inferiorly (arrow) as opposed to a normal inc
in lucency

• PALLIATIVE CARE CAN BE INITIATED IN ANY SERIOUS LIFE LIMITING ILLNESS EVEN WHILE LIFE
PROLONGING THERAPIES OR EVEN CURATIVE INTENTION THERAPIES BEING DONE
-INITIATED EARLY and throughout dz to help optimize focus of care and pt’s goals and values
àHospitce is PART of palliative care (last 6 mo of life)
-pt does not need uncontrolled pain/sxs to initiate palliative care

• PT w COPD intubated with INC peak insp pressure and plateau pressure and DEC ox sat and DEC BP and INC
HR with INC JVD, FAINT heart sounds, DISTANT breath sounds
=
Auto positive end expiratory pressure (auto-PEEP)
àHAPPENS BC: COPD slows expiratory flow so she cannot completely exhale before next breath (breath
stacking) and volume of air builds up causing inc intrathoracic pressure
-can lead to hypoxemia, CV collapse (dec venous return and preload) and barotrauma
-TX: Disconnect ventilator circuit from ET tube to allow for a prolonged exhalation enabling trapped air to escape
and then returns to normal
-VENT SETTINGS should then be adjusted to allow for more effective exhalation (slowing resp rate, dec tidal
volume, inc resp flow rate and TOLERATING RESP ACIDOSIS)

• WILL HAVE ONLY INC PEAK INSPIRATORY PRESSURE if tube is obstructed (via kink or mucus plug) 2/2
resistance of flow through tube

• Anxiety in intubated pts = more freq breaths than set rate NEEDING MORE SEDATION to slow resp rate and
aovid potential auto-PEEP
-ANXIETY OCCURS w hypercapnia (stimulus to inc RR)
• Acute hypersensitivity pneumonitis

-Immune response to repeat inhalation of antigens occurring within 48 hrs of high level exposure
-SXS: fever, flulike sxs, cough, SOB
-Radiographs can show BL hazy opacities and high res CT finds ground glass opacities and centrilobular
miconodules (upper/mid lobe predom)
-SXS improve 24-48 hrs after removal of exposure

• Acute interstitial pneumonia

-uncommon diffuse lung injury in response to insult over short period of time (days-wks)
-Findings similar to ARDS with severe/progressive hypoxia
-Imaging shows diffuse bilateral ari space opacification
• Non specific intersitital pneumonia

-Younger patient;
-chronic process otherwise similar to acute hypersensitivity pneumonitis

• MEN2A = Multiple endocrine neoplasia type 2A. = mutation RET proto-oncogene

-primary hyperparathyroidism, pheochromocytoma and medullary thyroid cancer
-1 hyperparathyroid.in MEN2A is 2/2 multiple gland hyperplasia and presents w/ hypercalcemia (polydipsia,
polyuria, constipation, osteoporosis or nephrolithiasis)

• MEN1 2/2 one mutated gene of the MEN1 gene PLUS somatic mutation in the other allele
-Can have insulinoma and prolactinoma as well as primary hyperparathyroidism
-1 hyperparathyroidsim in MEN1 can be from ONE or MORE parathyroid adenomas

• Neurofibromatosis type 1: autosomal dominant

-Can have neurofibromas, café-au-lait spots and pheochromocytoma
• IN MITRAL REGURGITATION
-NEED MITRAL VALVE REPAIR if MR is severe AND have mild-mod LV dysfunction (30-60%) and/or LV end
systolic dimension >40 mm)
-Need valve repair with symptomatic acute MR
-Need valve repair with symptomatic chronic MR and LV EF >30%

àMV repair if valve suitable for repair

àMV replacement NEEDED if severe MR if MV not repairable or less than optimal result expected; try for
CHORDAL PRESERVATION
-can do MV clip (approximates edges of ant and post leaflets) if high risk for surgery
• DO mitral balloon valvuloplasty or valvotomy IF HAVE MITRAL STENOSIS
-IF surgeon thinks it will be successful AND
-IF no C/I (mod-severe mitral regurg or left atrial thrombus ARE C/I)

• Impetigo

-superfical skin inf

-painful, acute; yellowish crusted surface
-Strep or Staph
-If Staph a secretion of exfoliative toxin may result in superficial blister formation

• Squamous cell carcinoma---can be painful

-NEEDS SKIN BIOPSY

-Risks: sun exposure, smoking, HPV, immunosurppresion and ARSENIC
-Lip lesions are aggressive
àCryotherapy and electrodessication and curettage useful for SCC in situ but not in cancer
• Acrochordon AKA skin tag

-Soft pedunculated fleshy papules occurring on sides of neck, axillae, inframammary region, groin, and buttocks
-2/2 inc concentrations of insulin or insulin like growth factors and may be a marker for DM2

• Absolute risk reduction

• CANNOT TRUST HEMOGLOBIN A1C IN DM2 WITH CKD!!!!!!!!!!!!!

-IF YOU NOTE A A1C DROP IN CKD IT MAY BE DUE TO DEC RBC LIFE NOT IMPROVING DM2
-measure blood glucose post prandial
-Fasting and premeal glucose targets should be set to 80-130 mg/dL if trying to get A1c <7.0%
• Pulm nodules assoc w rheumatoid arthritits
•

- Rheumatoid nodules in the lung histologically resemble rheumatoid nodules occurring elsewhere
-Typically located in subpleural areas or near interlobular septa.
-solitary or multiple, and either solid or cavitary
-usually asymptomatic but may lead to complications including pneumothorax, bronchopleural fistula, and
hemoptysis.

• Pt w DM2 and OM tx w Vanc and Zosyn

-Surgical debridement

• Livedo reticularis
 -subtle lacy network of blue/purple vessels usually in LE
-nonspecific, usually no underlying condition
-Can be elicited by keeping leg in dependent position BUT if PERSISTS when leg straightened could be
pathological (ie slow flow or hypercoag state) ie SLE, RA, dermatomyositis (autoimmune) or polyarteritis nodosa,
GCA (vasculitis), or paraproteinemias like MM or cryoglobulinemia, hematologic dz ie polycythemia,
thrombocytosis and INFECTION
-STRONG assoc w antiphospholipid syndrome (esp w h/o miscarriage) w/ presence suggesting inc risk of
cerebral or ocular ischemia

• Antiphospholipid antibody syndrome needs 1 clinical criteria (vascular thrombosis NOT saphenous or preg
morbidity) and 1 lab criterion (antiphos ab on 2 or more occasions at least 12 wks apart)

• Amyloidosis -àinfiltrative causing skin thickening and development of petechiae and ecchymoses

à An abdominal fat pad biopsy showing amyloid deposition indicates light-chain (AL) amyloidosis, which
typically presents with a large tongue, restrictive cardiomyopathy, or nephrotic syndrome

• Autoimmune thyroid dz (Graves) assoc w pre-tibial myxedema (accumulated glycosaminoglycans in dermis over
lower legs)
• Systemic sclerosis =. Excessive prod of extracellular matrix w/inc collagen prod resulting in skin thickening

• In Rheumatoid arthritis --à pt on LEFLUNOMIDE w abd pain/tenderness and acute hepatitis = LEFLUNOMIDE
INDUCED hepatitis
-worse w NSAID use
-If elevated aminotransferase < 3x upper limit of normal can REVERSE w dose reduction or stopping med
-If >3x upper normal NEED TO ADD CHOLESTYRAMINE to quickly dec drug levels BC OTHERWISE undergoes
significant enterohepatic circulation
-NEED LIVER TESTS EVERY 8-12 WKS W LEFLUNOMIDE

• C dif diagnosis: >3 unformed stools in 24 hrs without laxatives

-NAAT alone or stool toxin test as part of multiple step algorithm (GDH plus toxin, GDH plus toxin and NAAT,
NAAT plus toxin) rather than toxin alone

• C dif tx: Oral vanc,(10 day) or Fidaxomicin ---now #1 even in mild cases
-First recurrence use fidaxomicin if vanc used initially
- If metronidazole used initially use tapered and dosed if Vanc used for >1st recurrence
-Fecal microbiota transplantation if fails

IF FIRST EPISODE AND IT IS FULMINANT (hypotension, shock, ileus or megacolon)-à use oral vanc plus rectal
-can add IV metronidazole if ileus
-consider tigecycline or IVIG if doesn’t work OR
-If doesn’t work do subtotal colectomy with preservation of rectum
• Rheumatoid arthritis
-Start methotrexate with folic acid; titrate
-Tx with prednisone for flares and NSAID for symptoms
-If fail start TNF alpha inhibitor ----entanercept
-If fails entanercept START RITUXIMAB

• PCOS pts àremain in stagnant follicular stage RESULTING IN UNOPPOSED ESTRADIOL SECRETION FROM
SMALL OVARIAN FOLLICLES and causing endometrium proliferation WITHOUT progesterone from corpus
luteum----àleads to endometrial hyperplasia and heavy periods (anovulatory bleeding)
-Intraovarian androgens also produced = hyperandrogenism and hirsutism
-TX: estrogen-progestin oral contraceptives are 1st line for menstrual irregularities and hirsutism
-Add spironolactone
àCOULD DO PROGESTIN ONLY and protect endometrium and stop irregularity BUT THIS DOES NOT
SUPPRESS ANDROGEN PRODUCTION AND DOES NOT TREAT HIRSUTISM
-Metformin is second line bc no endometrial protection or reduce serum androgens

• Silicosis àmine worker

 -independent risk factor for lung CA; made worse if smoking history
-Also has higher risk for TB

• Chest MRI best for ruling in/out CHEST WALL, PLEURAL AND MEDIASTINAL PATHOLOGY, not bronchial or
parenchymal lesions

• Cobalamin (Vit B12) def

-Vegans
-Can dev over months to years
-SXS: difficulty w ambulation and numbness both feet, dec sensation and vibratory sense BLE
-Labs: anemia and macrocytosis
-Blood smear shows typical hypersegmented neurtrophils 2/2 ineffective myelopoiesis

-check MMA if suspicious and B12 wnl; if HIGH then have B12 def
-If MMA normal can be FOLATE def

• In a ESRD patient in SHOCK if give ONE bolus and there is NO fluid overload despite kidney injury a SECOND
BOLUS should be given
-If line suspected REMOVE
-GIVE abx
-do NOT need a CVL; can use peripheral line

• Doxepin is an antidepressant but IN LOWER DOSES THAN FOR DEPRESSION is FDA approved for insomnia

• Cervicitis=inflamed and friable cervix (gon and chlam)

Vaginitis=inflamed vagina (candida and trich or non infectious atrophic vaginitis or vag irritation)
BV=non inflame
àCervicitis give Ceftriaxone and Azithro to cover
àCefixime if Ceftriaxone not avail but inc min inhib concentration of N gon
>>Cefotetan plus Doxy for PID requiring hospitalization; PID would have cervical motion, uterine or adnexal
tenderness
• Urticaria
-Itchy red wheals with sharp borders lasting min-hours; spares palms/soles

• HAART tx: two nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) plus a third agent (boosted
protease inhibitor, a nonnucleoside RT inhibitor, or an integrase inhibitor)
-Tenofovir and emtricitabine ALSO have activity against Hep B

• Gastric cancer (adenocarcinoma), even if metastatic, should be treated with chemoTx if pt has good caloric intake
and performance status
-Chemo is: Cisplatin plus 5-fluorouracil or capecitabine
-20% gastric ca and 30% GE junction ca overexpress HER2 growth factor receptor which MEANS Trastuzumab
can be added to systemic chemoTx

• BRAF mutation in melanoma

• K-ras genotyping NEEDED for metastatic colorectal cancer bc Kras mutations would INHIBIT activity of the
ANTI-EPIDERMAL GROWTH FACTOR RECEPTOR AGENTS (Cetuximab and Panitumumab) used in treating
metastatic colorectal cancer otherwise
--so if Kras mutation NO POINT in using above meds

• Tenofovir (tx Hep B and HIV) gives you TUBULOINTERSTITIAL DISEASE

-slowly progresses no inciting event
-subnephrotic proteinuria w/bland sediment and kidney US w atrophic kidneys
àCan show signs of abnormal handling of GLUCOSE, AMINO ACIDS, URIC ACID, PHOSPHATE AND BICARB:
Fanconi syndrome. <may have glucosuria in context of NORMAL blood glucose>
-RTA also common as well as concentrating defects = nocturia and polyuria
-If extensive can get anemia 2/2 destruction of erythropoietin producing cells in kidney
 VS Normal below

• HTN kidney dz = damage to vascular structures, glomeruli and tubulointerstitial regions

-progressive failure with elevated proteins (less than 1000 mg/d)

• Membranoproliferative glomerulonephritis =. Immune complex deposition in glomeruli

 -FREQ w/ HEMATURIA,
dymorphic erythrocytes or erythrocyte casts), varying proteinuria and reduced GFR
-can be assoc w Hep B

• Membranous glomerulopathy
-common in chronic Hep B 2/2 subendothelial and mesangial immune deposits in glomeruli between basement
membrane and epithelial cells
 -HIGH proteinuria bc affects glomeruli

• If have CLONAL PLASMA CELLS <10% and do NOT meet CRAB (hypercalcemia, RENAL FAILURE, ANEMIA,
BONE DZ) = monoclonal gammopathy of undetermined significance AND NOT MULTIPLE MYELOMA (which
has those things)
-MGUS can turn into MM and risks are: non IgG M protein, M protein 1.5 g/dL, abnormal serum free light chain
ratio (kappa/lambda)

• Bone lesion on MRI with smoldering (asymptomatic) MM = greater progression to MM needing tx

-Also if Beta 2 microglobulin and LDH elevated may need MM tx

• If shoulder injury and cannot ABDUCT beyond 90 deg or LOWER arm from 90 deg without dropping it or
MAINTAIN full external rotation when arm passively externally rotated at 20 deg of abduction = FULL
THICKNESS TEAR OF SUPRASPINATUS
-NEED MRI to confirm and then IMMEDIATE surgery is confirmed
-CAN use US to look for rotator cuff tears as well

• FOLLOWING Strep inf (fever, sore throat and swollen glands) can get INFECTION RELATED
GLOMERULONEPHRITIS
-Has 7-10 day latent period
-CHECK FOR rapid strep and antistreptolysin O Ab elevation
-results in nephritis syndrome with LOW C3 and normal C4---alternate path of complement activation
-Tx: supportive w abx, BP monitoring and diuretics

• IgA nephropathy
-MC form of glomerulonephritis
-asymptomatic microscopic hematuria +/- proteinuria
-BUT can have episodic GROSS hematuria following URI
-kidney manifestations occur WITH resp inf
-Complement levels NORMAL (HAS ALTERNATE COMPLEMENT PATHWAY)

• Lupus nephritis
-usually have rashes and arthritis THOUGH can have kidney limited dz
 -C3 and C4 decreased
-can be precipitated by infections

• SMALL VESSEL vasculitis glomerulonephritis

-Will have other clinical findings of vasculitis
-Complement levels wnl

• Erythema migrans

-EARLY LOCALIZED Lyme dz; uniformly red at first THEN form CENTRAL CLEARING as they expand
-Not painful but may itch

• If have gout BUT DEVELOP ADVERSE RX TO ALLOPURINOL can start Febuxostat

-need urate lowering tx if have 2 or more gout attacks/yr or 1 attack in setting of CKD stage 2 or worse, have tophi
or h/o urolithiasis
-Febuxostat can be used in mild/mod CKD
àSHOULD ALWAYS USE ANTI INFLAM PROPHYLAXIS WHEN STARTING URATE LOWERING TX bc will
flare with any urate levels changed (inc or dec)
-CANNOT use uricosuria drugs (probenecid and sulfinpyrazone) in CKD bc these promote kidney clearance of
uric acid by inhibiting urate anion exchange in prox tubule responsible for urate re-absorption
-PEGLOTICASE is last resort for treatment failure gout; it is immunogenic and ANTIBODIES WILL FORM
leading to reduced effectiveness and INC HYPERSENSITIVITY REACTIONS

• CUTANEOUS squamous cell carcinoma

-slowly evolving isolated keratotic or eroded macule, papule or nodule that appears on sun exposed skin
• IF A PATIENT DOES NOT BELIEVE HIS/HER HIV DIAGNOSIS and HAS HIGH CD4 COUNTS AND LOW VIRAL
LOAD then can defer HAART until chances for med adherence are improved through discussion
-bc if don’t then possible poor adherence and suboptimal tx AND resistance

• If have CUSHING SYNDROME-à ACTH independent Cushing with CT scan showing adrenal mass
-BENIGN adenoma if low attenuation on unenhanced CT (<10 hounsfield units) and rapid washout of IV iodine
contrast (>50% at 10 min)
-Can surgically remove it HOWEVER will NEED POSTOPERATIVE HYDROCORTISONE bc pts w adrenal
cushing may develop ACUTE ADRENAL FAILURE
-Adrenal failure occurs bc hypothal-pit-adrenal axis suppression and contralateral adrenal atrophy
-àNEED STRESS DOSE GLUCOCORTICOIDS and TAPER (up to 1 year)

• ADRENAL MASS that is ADRENOCORTICAL CARCINOMA will be/have:

-ACTH independent CUSHING syndrome (Cortisol high in 24 hr UOP x 2)
-LARGE (>4-6 CM) with irregular margins and area of necrosis or calcification
-HIGH attenuation <density >10 hounsfield units)
-washout of IV iodine contrast media less than 50% at 10 min
-NEEDS surgical excision after biohem assessment and imaging
-NEEDS adjunct MITOTANE (adrenal cytotoxic drug) and/or radiation if mets or persistant dz; can tx mets sites w
radiation

• PHEOCHROMOCYTOMA
-BEFORE removal need alpha blockade with PHENOXYBENZAMINE as intraoperative manipulation f tumor can
risk cardiovascular complications

• DO NOT evaluate low back pain in young healthy person without alarming features with radiography before 4-6
wks; should only order this if suspect FRACTURE, DEG ARTHRITIS, OR INFLAM PROCESS

• ANKYLOSING SPONDYLITIS has low back pain, morn stiff, sacroiliitis +/- uveitis
-Can check HLA B27 to support dx but it is not specific

TX:
à1st try physical tx and NSAIDs
àIf fail 2 NSAIDS can start TNF alpha inh (Adalimumab) for AXIAL sxs
à Methotrexate and sulfasalazine only may be indicated in PERIPHERAL sxs, not axial
(Ritux not indicated for AS).

• TIC DISORDER
-repetitive sterotyped suppressible movements preceded by an ABNL sensation (premonitory urge)
-TOURETTE syndrome usually + fam h/o, h/o simple tics, vocal and complex motor tics with symptoms >1 yr
AND comorbid OCD
-Tics wax and wane and can be replaced by new types

• DO NOT NEED COMPLETE PFTS (w lung volumes and diffusing capacity) AFTER DIAGNOSIS OF COPD
-JUST need spirometry if more symptoms
-PFTs only done after diagnosis IF lung volume reduction surgery or lung transplant being considered
• Erythema multiforme

-ACUTE, often recurrent, mucocutaneous eruption following ACUTE infection -àMC IS HSV inf
-idiopathic or drug related
-lesions: mm-cm and erythematous plaques with concentric rings of color and dusky center that may become
necrotic and form discrete blister or eschar
àMC on extremities (palms/soles) but do have MUCOSAL LESIONS

• Erythema marginatum
-is a symptom of disease such as RHEUMATIC FEVER, HEREDITARY ANGIOEDEMA, LYME DZ, ALLERGIC
RX

• Need blood cult AND sputum cult in CAP that is severe and requiring ICU admission; not needed for ambulatory
pts

• Oral hairy leukoplakia

 -usually 2/2 Epstein Barr virus, usually on lateral tongue BUT can be on other sites as painless white plaques that
cannot be scraped off
-occurs w immunoDEFICIENCY

• BALKAN endemic nephropathy---àINC RISK OF TRANSITIONAL CELL CARCINOMA

-progressive tubulointersitital dz (linked to aristolochic acid-a nephrotoxic alkaloid from plant used for wt loss)
-LOOKS like tubulointersitial dz: polyuria, dec concentrating ability, glucosuia without hyperglycemia and tubular
proteinuria
-Transitional cell CA risk bc aristolochic acid is MUTAGENIC to renal pelvis, ureters and bladder
-NEED annual urine cytology

• Autosomonal dominant polycystic kidney disease = INC RISK OF INTRACRANIAL CEREBRAL ANEURYSM

• LOCALLY advanced squamous cell carcinoma of head/neck -à surgery THEN combined chemo and radiation IF
positive surgical margins or lymph node metastases ASSOCIATED WITH EXTRACAPSULAR EXTENSION
àIF earlier stage disease and NO positive margins AND no pos LN with extracapsular extension then ONLY
NEED ADJUVANT RADIATION TX
-Can use cetuximab alone in advanced disease

• NEED MECHANICAL KIDNEY STONE REMOVAL IF >10 MM OR IF STONES FAILED TO PASS W MED TX
-shock wave lithotripsy or ureterocopy with uteroscopic lithotripsy
-IF STONE IMPACTED or OTHER SITUATIONS IN WHICH ABOVE TECHNIQUES WONT BE EFFECTIVE will
need percutaneous antegrade ureteroscopy or retroperitoneal laparoscopy
-NEED UROLOGIST if have urosepsis, AKI, anuria, or refractory pain OR if single kidney

• <10 mm kidney stones-à hydrate, analgesia, alpha blocker like Tamsulosin or Ca channel blocker like nifedipine

• Only need urinary cath when

-perioperative -à needs removal before end of 2nd post op day
-Need for accurate UOP measurement in ICU pts -critically ill
 -Tx acute urinary retention or bladder obstruction
-assistance w/open sacral or perineal wound healing for incontinent pts
-end of life comfort care

• If E faecalis ENDOCARDITIS can AND sensitivity to ampicillin, vancomycin and gentamicin CAN ADD
GENTAMICIN to amp or vanc (if those were intitially being used for tx); add ONLY IF high level aminoglycoside
resistance not present and for a LIMITED time in the early period

• Polymorphous light eruption

-Is pruritic pink to red papules or vesicles

-Can also have plaques and urticaria
-DX of exclusion (r/o SLE, photodrug rx and porphyria cutanea tarda)

• Exfoliative erythroderma
•
-AKA red man’s syndrome if idiopathic
-If idiopathic has palmoplantar keratoderma, dermatopathic LAD and raised IgE
-Can be due to cutaneous T cell lymphoma
-severe and potentially life threatening
-diffuse erythema and scaling all or most of skin surface

• In tumor lysis syndrome have release of uric acid, K and phos form lysis of malignant cells
-usually in large tumor burden malignancy ie high grade lymphoma OR high cell counts ie lymphoblastic leukemia
-will result in AKI and HYPERuricemia, HYPERkalemia, HYPERphosphatemia and HYPOcalcemia
-NEED hydration, manage hyperK and prevent hyperuricemia (allopurinol)
>>>>ALLOPURINOL blocks metabolism of hypoxanthine and xanthine to uric acid and DECREASES
FORMATION OF NEW URIC ACID BUT DOES NOT DECREASE EXISTING URIC ACID
SO
-If evidence of uric acid nephropathy NEED RASBURICASE to dec serum urate levels; works by converting uric
acid to allantoin (more soluble and excreted)
>>NEED dialysis IF oliguria or anuria, persistant HYPERkalemia, hyperphos induced hypocalcemia AND/OR
calcium phosphate product equal to or greater than 70 mg^2/dl^2 with AKI
-DO NOT ALKALINIZE URINE AS IT CAN CAUSE CALCIUM PHOS CRYSTALS IF HYPERPHOS

• IN VENT SETTING NEED TO DETERMINE

•
1) ? Breath sequence ----spontaneous vs mandatory

a) If resp fail needs MANDATORY

-mandatory can either be intermittent or continuous; intermittent allows fro spontaneous

breaths between mandatory ones BUT this can lead to dyssynchrony and lung injury

-àcritically ill pts need continuous mandatory ventilation: they can breathe above preset this
way BUT all breaths supported by vent

2) ? Breath control---pressure vs volume

a) Pressure controlled. = breath delivered according to a preset inspiratory pressure CAN

CAUSE VENTILATOR INDUCED LUNG INJURY

SO

b) VOLUME control. = tidal volume and inspiratory flow are designated

à IS PREFERRED INITIAL STRATEGY FOR VENT OF CRITICAL ICU PTS

• Normal pressure hydrocephalus

 -assoc w GAIT abnl, cognitive impairment, urinary disturbance
-imagining shows enlarged ventricles OUT OF PROPORTION to cortical atrophy
-imagining can also so PERIVENTRICULAR hyperintensities but does not infarction but rather transependymal
reabsorption of CSF
-can be reversible -à 1st do LARGE VOLUME LUMBAR PUNCTURE with removal 30-50 ml CSF
BEFORE doing ventriculoperitoneal shunt
-can assess for improvement of sxs after LP; if not improved then can do serial LP or continuous lumbar drain

• H/o ovarian AND endometrial cancer THINK LYNCH SYNDROME

-AKA hereditary nonpolyposis colon cancer
-FAM HISTORY OF COLON AND ENDOMETRIAL CA
-Lynch is an AUTOSOMAL DOMINANT cancer susceptibility syndrome in DNA mismatch replair genes (MLH1/2
and MSH6)
-have early onset cancers (MC colon, then endometrial and ovarian -least) BUT CAN BE OTHERS
-endometrial CA IS OFTEN THE SENTINEL CANCER
-diagnosis of lynch doesn’t change management in THAT patient BUT can then SCREEN the patient for other
cancers -àNEED COLO EVERY 1-2 YRS, ANNUAL SKIN EXAM, UPPER ENDO
ALSO GIVES OPPORTUNITY to screen fam members
>>>>>should check for ovarian CA even in pts w total abd hysterectomy and oophorectomy!!!!!!

• ANY pt w Ovarian CA eligible for BRCA1/2 screen bc inc risk breast CA

-BRCA 1 can participate in clinical trials ---pred PARP inh

• HERPES simplex encephalitis

-HSV 1 causes necrotizing inf of temporal lobes BUT can be atypical too
-PCR from CSF highly sens/spec BUT early on CAN BE NEG
-IF PCR NEG but still high suspicion C/W acyclovir and repeat PCR in 307 d
• West nile meningoencephalitis
-More severe in elderly BUT imagining either normal OR show up in thalami, basal ganglia or spinal cord

• Tinea cruris

-dermatophyte inf of groin, pubic area and thighs that = annular lesion with SLIGHT SCALE or erythematous
advancing edge and CENTRAL CLEARING
-pt above ALSO has DRY XEROTIC SKIN

• IN POLYURIA/POLYDIPSIA with lithium tx THINK NEPHROGENIC DI

-DI is either absence of antidiuretic hormone (ADH) secretion by hypothal OR renal resistance to ADH
(nephrogenic)
-Result: inability to CONCENTRATE urine in response to inc plasma osmolality so PLASMA OSMOLALITY IS
HIGH AND URINE OSMOLALITY IS LOW
-Lithium is one of MCC of nephrogenic DI
-Labs may show serum Na and plasma osmolality HIGH NORMAL or SLIGHTLY ELEVATED whereas urine
osmolality will be LOW
àFRANK HYPERNATREMIA NOT PRESENT BC INC THIRST STIMULATES WATER INTAKE MAINTAINING
SERUM Na NEAR UPPER NORMAL RAINGE
-NEED water deprivation test: tests urine volume, urine osmolality and plasma Na concentration HOURLY after
restriction
-IF urine osmolality inc (usually above 600 mOsm/kg H20) then polygenic polydipsia BUT
-IF URINE OSMOL STAYS LOW DESPITE RISIJNG PLASMA OSMOLALITY IT IS DI
-To find out if central or nephrogenic GIVE DESMOPRESSIN: If central DI the urine osmolality will INCREASE
but if nephrogenic DI Desmopressin will not inc urine osmolality

• Adrenal insufficiency: HYPOnatremia, dec plasma osmolality and inc urine osmolality
-Dx with cosyntropin stimulation testing
-Urine sodium helps to evaluate for urinary salt wasting
• Hypothyroidism can cause HYPONATREMIA, dec plasma osmolality and increased urine osmolality
-Will have high TSH

• Nodular melanoma

-Uniformly dark blue or black “BERRYLIKE” LESIONS

-can originate from previous nevi OR normal skin
-AGGRESSIVE and invades deep early on BC IT ESPANDS VERTICALLY RATHER THAN HORIZONTALLY

• Lentigo maligna melanoma

-Develops from lentigo maligna aka HUTCHINSON’S MELANOTIC FRECKLES

• Toxic epidermal necrolysis

-FLAT, PAINFUL, PURPURIC TARGETED LESIONS THAT COALESCE INTO DUSKY POORLY DEMARCATED
CONFLUENT PATCHES (TENS “with spots”
-or may consist of confluent tender erythema without iidentifiable individual lesions (TENS without “spots”
-Involved epidermis blisters and sloughs in sheets of skin leaving behind denuded dermis

• Need to r/o TB before any biologic (TNF alpha) tx started bc they inhibit formation of granuloma
-Interferron gamma release assay better (more sens) in immunosuppressive tx patients

• RECURRENT SINOPULMONARY INF, EAR INF AND CONJUNCTIVITIS = Common variable immunodef
(CVIID)
-IgG reduced and IgA and/or IgM frequently low as well
-can also develop CHRONIC LUNG DZ, AUTOIMMUNE DZ (ie RA), malabsorption, recurrent inf and lympthoma

• STATUS EPILEPTICUS = convulsive seizure >5 min without return to baseline mental status
-Tx w IV lorazepam (Ativan) followed by IV phenytoin or fosphenytoin
-Fosphenytoin preferred if avail bc faster and DOES NOT CAUSE SKIN NECROSIS sometimes seen w phenytoin
>>Use Valproic acid after Lorazepam if cannot take phenytoin OR in generalized epilepsy syndromes bc
phenytoin can cause ABSENCE SEIZURES or ABSENT STATUS EPILEPTICUS in GES
-à IV diazepam only if lorazepam not avail
>>>>If no IV established can do IM midazolam OR rectal diazepam
• If patient with IRON DEF ANEMIA will develop REACTIVE THROMBOCYTOSIS usually 2/2 bleeding
àIF YOU TREAT iron def with iron AND it is corrected BUT thrombocytosis PERSISTS then THINK OTHER
CAUSES: ie infection, inflammation and malignancy
-CHECK JAK2 V617F----------if mutation is present it supports diagnosis of a MYELOPROLIFERATIVE
NEOPLASM: ie--- polycythemia vera, essential thrombocythemia or primary myelofibrosis
-If JAK2 V617F mutation is NOT FOUND then it does NOT exclude diagnosis as this is present in only 50% of pts
w/ET
-If JAK2 V617F neg --àTHEN DO BCR-ABL testing THEN-à bone marrow aspiration and biopsy
-Normal BM in 1st pic
-IF SEE HYPERCELLULAR AND MEGAKARYOCYTE HYPERPLASIA (second pic) =. Essential
thrombocythemia
-3rd pic is inc # megakaryocytes that are large w hyperlobulated nuclei and arrow showing staghorn appearance
• ONLY test PT and aPTT and/or von Willebrand factor antigen in BLEEDING DIATHESIS, not thrombocytosis

• PTS w/myopia MC to have RETINAL DETACHMENT

-the neurosensory layer of retina separates from the retinal pigment epithelial layer and choroid
 -SXS: floaters, photopsias squiggly lines followed by SUDDEN peripheral visual field defect that resembles a
black curtain and progresses across field of vision; PROGRESS over 1 wk- 3 mo
-dilated ophthalmoscopy shows UNDULATING AND OUT OF FOCUS FUNDUS
-CAN LEAD to blindness
-MCC is posterior vitreous detachment mostly in 50-75 yo

• AGE related macular degeneration

-MCC blindness in elderly
-Can be dry or wet

-Dry: extracellular material (drusen) deposits in macular region of 1 or both eyes with GRADUAL loss of vision
-Wet: will have pre-exisiting dry AMD and then PROGRESS to have new vessel growth UNDER retina with
subsequent BLEEDING and exudation from these vessels that result in sudden or several week duration
PAINLESS blurring or warping of CENTRAL vision resulting in SEVERE vision loss

• Branch retinal vein occlusion

-caused by ARTERIAL COKMPRESSION OF RETINAL VEIN

-TYPICALLY asymptomatic
-Fundoscopy shows AFFERENT pupillary defect, congested retinal veins, scattered retinal hemorrhages and
cotton wool spots IN THE REGION OF OCCLUSION
• Central retinal artery occlusion

-2/2 vasospasm OR emboli; usually elderly

-PROFOUND and SUDDEN vision loss
-Fundoscopy shows afferent pupillary defect and CHERRY RED FOVEA and PALE RETINAL BACKGROUND

• NEED HIV testing (screen) 1 time for all adults aged 15-65 yo; younger and older and more freq dep on risks
-test with HIV ab and p24 Ag

• Allergic contact dermatitis

-Itchy, red, edematous, weepy and crusted +/- vesicles and/or bullae
-PATTERN (round, square or linear) provides info about allergen
• Atopic eczema

-red, dry, cracked

-characterized by LICHENIFICATION: leathery thickening bc of chronic scratching
-Pts w atopic dz

• Dyshidrotic eczema

-pruritic blisters develop on soles and palms and can be vesicular

-assoc w seasonal allergies or stress

• Erysipelas

-bacterial INFECTION (usually beta hemolytic group A strep) on upper DERMIS that extends into superficial
cutaneous lymphatics
-TENDER and intensely erythematous indurated plaque with sharply demarcated border

• Comparison of skin manifestations/conditions:

• Fixed drug eruption

-ALLERGIC reaction to a medicine that RECURS IN THE SAME SITE each time a particular drug is taken
-can have DELAY up to 2 wks from when drug first given until SXS

• ARDS
-If severe inc PEEP to achieve good O2 on FIO2 <0.6 that
Doesn’t cause hypotension

• Use US for breast mass if <35 yo

• Membranous GN
-Nephrotic proteinuria
-Primary: 2/2 phospholipase A2 receptor on podocyte surface; can test in serum or staining kidney bx
-Secondary: malignancy (solid tumors), autoimmune dz (lupus, MCTD), Inf (Hep B/C); meds (penicillamine, gold,
NSAIDs)
>>Need W/U for 2^ causes if PLA2R ab neg

• Odontogenic source of brain abscess (ie TMJ)àcover Fusobacterium, Prevotella and Bacteroides and Strep
-Use PCN (mouth flora –aerobic and anaerobic strep) + Metronidazole (add. Anaerobic)
• If brain abscess 2/2 neurosurg à Meropenem
• If brain abscess 2/2 neurosurg or traumaàVanc + 3rd gen cephlasporin

• In IVC related bacteremia 1st-àblood and cath culture 2ndà?? Remove catheter, 3rdà change abx based on cult
data +/- US IF CLOT SUSPECTED

• Erythrasma

>>IF FLUORESCES coral red WHEN ILLUMINATED with UV LIGHT FROM WOOD’S LAMP
-Scaly reddish brown; 2/2 Corynebacterium minutissimum

VS

-Acantosis Nigricans which does not

• DO NOT TRUST CHROMOSOMAL ANALYSIS FROM COMMERCIAL SOURCES bc apparently they are shit
and not to be trusted

• NPPV
-use in Neuromuscular dz w:
>>an FVC less than 50% of predicted,
>>vital capacity below 60% of predicted (or 1 L)
>> maximal inspiratory pressure of less than −30 cm H2O
>>usual initial method used, typically on an intermittent, nocturnal basis
******NPPV has been shown to improve quality of life and delay the progression of respiratory failure in patients
with progressive neuromuscular disease*******

• A SINGLE venous thromboembolism (VTE) due to a major transient risk factor NEEDs ONLY short-term
anticoagulation for 3 months
>>>PROVOKED VS UNPROVOKED > prognostic info regarding recurrence than THROMBOPHILIA TESTING
>>>Thrombophilia testing does not have to be done UNLESS strong influence on clot and/or impact on fam
members who may also be tested
>>Elevated plasma homocysteine levels = increased risk for a first venous or arterial thromboembolic event
>>>>Homocysteine levels can be lowered with folic acid, vitamin B6, and vitamin B12 BUT does not change risk
of clot >>>>
>>Homozygosity for the methylene tetrahydrofolate reductase (MTHFR) C677T polymorphism can be associated
with elevated homocysteine levels but alone is not a risk factor for VTE. Thus, no clinical indication exists for
testing for the MTHFR polymorphism in patients or first-degree relatives.

• MELANOMA

SUPERFICIAL SPREADING MELANOMA

-variant; well defined asymmetric patch or plaque w irregular border variation in color and expanding diameter
-Not on sun exposed skinàtends to occur on BACK in men and LEGS in women (intermittent sun but prone to
sunburn)

MELANOMA (in general)

àIf 1-4 mm thickness >> NEED sentinel lymph node biopsy for accurate staging
àIf 1 mm or less if HIGH RISK FEATURE (ie ulceration, more than 1 mitosis/mm^2, lymphovascular invasion)
>> 2 cm excision if melanoma 1 mm thick or deeper
>>>>>>>>METASTASIS TO REGIONAL LN IS MOST IMPORTANT PROGNOSTIC FACTOR IN EARLY
STAGE>>>>>
IF FIND + LN needs COMPLETE LYMPHADENECTOMY
àAdjuvant interferon alfa is an option for patients with positive lymph nodes and/or melanomas that are
4 mm or more thick; side effects are myalgia, fever, depression, autoimmune dz
• If give opioid for chronic pain also give SENNA (scheduled stimulant laxative) or BISACODYL +/- stool softner
such as docusate
àCan add osmotic agent if fail (polyethylene glycol, sorbitol or lactulose)
àIf refractory give METHYLNALTREXONE (injectable peripheral opioid antagonist) ONLY IF FAIL ABOVE

• Dermatomyositis assoc w malignancy; higher in presence of vasculitis or cutaneous necrosis or older pt

-AdenoCA of lung, cervix, ovaries, pancreas, colorectal, stomach and bladder AND non Hodgkin lymphoma
àRisk of ovarian CA esp inc -àSCREEN in worsening dermatomyositis sxs AND/OR ascites with
TRANSVAGINAL PELVIC US

• ENCEPHALOPATHY, high Anion gap and ELEVATED OSMOLAR GAP. = methanol and/or ethylene glycol

AG = Na – (Cl + HCO3); normal is ~ 10

OSMOLAR GAP = MEASURED SERUM OSMOLALITY - CALCULATED SERUM OSMOLALITY

PLASMA OSMOLALITY (calculated) = (2 x Na) + [(Glucose/18) + BUN]
Normal OG = 10

>> Methanol converted to formic acid (toxic to retina); ethylene glycol converted to oxalic acid (toxic to renal
tubules bc crystals)
-suspect if inc AG AND serum bicarb < 10 mEq/L and plasma osmolal gap > 10 mOsm/kg H20
àTx with IV FOMEPIZOLE and dialysis
àADD SODIUM BICARB IF PH <7.30

• Serotonin syndrome
-Fever, encephalopathy, agitation, muscle rigidity, hyperreflexia

• Maintain mean arterial blood pressure of 65 mm Hg in ICU pts (put on pressors)

• Abdominal compartment syndrome

-presents as OLIGURIA or inc creatinine w abd surgery or with MASSIVE fluid resuscitation with TENSE abd OR
in pts w liver or pancreatic dz w ascites
-INTRA ABDF PRESSURE >20 MM Hg
-check bladder pressure
-Tx with diuresis, dialysis, manage ascites if small BUT NEEDS SURGICAL DECOMPRESSION likely

• In sepsis tx Hg level w pRBCs if <7.0 g/dL only; do not above 10 g/dL

• Low bone mass in POSTmenopausal women who do NOT Have osteoporosis = WT BEARING EXERCISE,
avoid tobacco or alcohol, Vit D, Calcium
-need for pharmacologic tx based on 10 yr estimated fx risk (> or = 20% for major osteoporotic fx OR > or = 3%
for hip fx

>> Bisphosphonates are 1st line but only use if OSTEOPOROSIS, not low bone mass
 >>Raloxifene is a selective estogren receptor modulator: not 1st line bc inc CLOT and/or vasomotor sxs
-does inc bone mineral density and reduces risk of VERTEBRAL (not non vertebral) fx

• Dyspnea common in chronic progressive dz near end of life

-tx w oral morphine to manage SENSATION of dyspnea
-may ADD benzo if palliative but not 1st line

>>nebulized lidocaine can be used for intractable cough but not dyspnea

• PSEUDOTHROMBOCYTOPENIA

-platelet clumps in vitro by presene of ETHYLENEDIAMINETETRA ACETIC ACID AGGLUTININS (naturally occur
in 0.1% of pop) (EDTA)
-automated platelet counter DOES NOT RECOGNIZE clumps as platelets so says thrombocytopenia
-NEED TO RECHECK plt count in a CITRATED OR HEPARINIZED tube

• Immune or idiopathic thrombocytopenic purpura

-autoimmune condition in which autoantibodies directed against platelet surface proteins leading to destruction

-SXS: BLEEDING, purpura

-variants w abnl immune regulation or lupus, HIV, or lymphoprolif malignancy----à CHECK FOR THESE
 à dec # plts, normal erythrocytes and normal neutrophil
-Tx with PREDNISONE or METHYLPREDNISOLONE as 1st line if plts <30,000 to 40,000 uL OR with active
bleeding

• Thrombotic thrombocytopenic purpura

-abnl activation of platelets and endothelial cells, deposition of fibrin in microvasculature, and peripheral
destruction of erythrocytes and plts
-if sporadic à autoantibodies agaisngt protease that cleaves high molecular wt multimers of von Willebrand factor

-smear shows SCHISTOCYTES

àTX with PLASMA EXCHANGE

• INC ANTION GAP METABOLIC ACIDOSIS in SHORT BOWEL SYNDROME = D lactic acidosis
-Accum of D isomer of lactate in jenjunoileal bypass or small bowel resection
-MOA: excess carbs reaching colon metabolized to D LACTATE
-SXS : intermittent confusion, slurred speech and ataxia
-LABS: inc AG metabolic acisosis with NORMAL PLASMA LACTATE
-MEASURE D LACTATE

• W CHRONIC ACETAMINOPHEN
-PYROGLUTAMIC ACIDOSIS
-presents as MENTAL STATUS CHANGE AND inc anion gap metabolic acidosis in pt w critical illness, poor
nutrition, liver dz or CKD or vegans
>>Dx with urine levels of pyroglutamic acid

• PULMONARY HYPERTENSION

-GROUP 1: Pulmonary arterial hypertension

- rule out HIV, drug tox, connective tissue dz
-rule out Portopulmonary HTN
-Tx with epoprostenol (IV pulm vasodilator) or sildenafil (pulm vasodilator)

-GROUP 2: secondary to left sided heart disease

-Tx underlying cardiac dz
-If diastolic dz (preserved EF) usually 2/2 hypertension and LVH: tx BP using regular guidelines
 -GROUP 3: secondary to underlying lung dz (ie COPD, ILD)
-EVALUATE with O2 measurement during sleep and exertion as CHRONIC hypoxia causing diffuse
pulmonic vasoconstriction may lead to vascular remodeling and sustained PH
àpatient MAY HAVE NORMAL RESTING O2 àdon’t let this FOOL you

• PROTECT peripheral veins from future vascular access IN CKD in case need arteriovenous fistula
-AV fistula = lower mortality than other vascular accesses during ESKD tx
-PROTECT PERIPHERAL VEINS EVEN IF PT ALREADY HAS A FUNCTIONAL DIALYSIS ACCESS
-place small bore SINGLE LUMEN catheter in internal jugular vein(s) if need IV tx as these are less likely to
impair venous drainage from the arm than subclavian caths

• PULMONARY HYPERTENSION + PORTAL HYPERTENSION = PORTOPULMONARY HYPERTENSION

-GROUP 1 pulm artery hypertension
-MUST rule out HIV, drug tox, connective tissue dz
-TYPICAL w cirrhosis
-pulm HTN suggested by echo and confirmed w RH cath
-NO SHUNT PHYSIOLOGY

VS

HEPATOPULMONARY SYNDROME
-2/2 dilated small vessels in pulm vasculature = SHUNTING of blood
-setting: LIVER DZ + HYPOXIA
>>>>PULM HTN IS NOT DEFINING FEATURE>>>>
àSHUNTING confirmed by contrast (bubbles from agitated saline) in the LEFT HEART following injection in
peripheral vein

• PULMONARY VENO OCCLUSIVE DZ

-rare cause of pulm HTN 2/2 FIBROUS OCCLUSION DISTAL PULM VEINS
-MC in kids and young adults

-can see PLEURAL EFFUSION, prominent interstitium on xray and septal thickening on chest CT but definitive
needs PATHOLOGY

• ASYMPTOMATIC candiduria = NO ANTIFUNGAL TX

 -common in ICU, colonizing
-if indwelling cath REMOVE IT and get another sample in few days to re-assess
-ONLY TX candiduria if pt is NEUTROPENIC, or undergoing GU procedures OR if pt is symptomatic: TX with
fluconazole
-If tx Candida glabrata or krusei can do local amphotericin B into bladder short term

• Obesity is BMI > or = 30; waist circumfurance of > 102 cm (40 in) =inc CV risk
-1st tx: wt loss goal (0.5 to 1.0 kg per week) to achieve wt loss of 10% by negative 500 kcal/d deficit
àGive pharm tx if BMI >30 (or 27 with comorbid obesity condition) WHO DO NOT ACHIEVE significant wt loss
with lifestyle management:
-Orlistat (inh of gastric and pancreatic lipase) leads to malabsorption of fat
èside effect potential for AKI 2/2 àbc blocks fat uptake and results in calcium soaps from
unabsorbed fat SO calcium cannot bind oxalate resulting in ENTERIC HYPEROXALURIA
-Lorcaserin (appetite suppressant stim serotonin 2C receptors in brain)àDO NOT USE IN PTS ON
SSRIS AS IT CAN CAUSE SEROTONIN SYNDROME
-PHENTERMINE+TOPIRAMATE: contraindicated in GLAUCOMA

àBariatric surgery considered at BMI > or = 40 OR 35 WITH obesity related comorbid conditions

• ADRENAL INCIDENTALOMA
-adrenal mass on CT
-test for pheochromocytoma w/. 24 HOUR URINE FRACTIONAED METANEPHRINES AND CATECHOLAMINES
and autonomous secretion of cortisol w/ LOW DOSE DEXAMETHASONE SUPPRESSION TEST
à IF NEG then check CT again in 3- 6 mo; if unchanges then annually 1-2 yrs

• If pancreatic mass is local and potentially resectable then SURGICALLY REMOVE as likely is adenoCa if pt age
àDO NOT NEED BIOPSY
Risks inc if >50 yo and cig smoking or new onset DM with symptoms of wt loss, dyspepsia and CT shows discrete
solid low attenuating mass with dilation of upstream pancreatic duct and common bile duct (DOUBLE DUCT
SIGN)

DOUBLE DUCT SIGN

• If mild BPH can OBSERVE

-BPH can be assessed with AMERICAN UROLOGICAL ASSOCIATION SYMPTOM INDEX with 5 point scale
1-7 mild, 8-19 mod and 20-35 severe

àIf start tx can use alpha blocker (Tamsulosin) as 1st line

 à5 alpha reductase inhibitors such as finasteride used if LARGE prostate (40 mL) elevated PSA and/or SEVERE
symptoms

• IN pregnancy ger hypo-osmolality and hyponatremia DUE TO WATER RETENTION greater than sodium
rentention (plamsa osmol dec by 8-10 mOsm/kg H20 and serum sodium dec by 4.0 mEq/L

• In pt with head injury (ie subarachnoid hemorrhage) can have CEREBRAL SALT WASTING
-do not confuse with SIADH
-CSW = inc loss Na by kidney resulting in hyponatremia and occur over LONG TIMEFRAME

• Pituitary apoplexy
-acute hemorrhage into pit gland
-SXS: HA, vision change, ocular nerve compression and HYPOPITUITARISM
-hypopit: dec ACTH (leading to cortisol def and hypotension if rapid and/or mild hyponatremia if not acute)

• Folliculitis

-PINK papules and pustules CENTERED ON HAIR FOLLICULES

-TYPICAL in beard, pubic areas, axillae and thighs

Vs

Comedonal acne

-not centered on hair follicles

• If METABOLIC syndrome with 10 yr cardiovascular risk of 10% or higher need LOW DOSE ASPIRIN

• INTERFERON GAMMA RELEASE ASSAY preferred for TB screen in PTS AT HIGH RISK FOR NOT
RETURNING FOR INTERPRETATION OF SKIN TESTING
Or
Pts who had BCG vaccine
Or
For cancer tx

• PERFORM carotid endartectomy if > 60% ICA

-if symptomatic
-had stroke
-is on all right meds
-low risk for periop CV morbidity

àDO NOT DO ENDARTECTOMY if less than 70% or if 100% occlusion or if bad candidate for surgery or if stroke
risk <2% per year or if NOT ON statin (start statin 1st)

• Psoriasis vulgaris

-sharply marginated plaques with a thick adherent silvery scale

-MC on elbows, knees, presacral skin and scalp

VS

Lichen simplex chronicus

 VS

LICHEN simplex

- violaceous papules at the wrists with fine white lines on the surface. These are called Wickham's
striae (white crossed lines)

• FIBROMYALGIA is a CENTRAL PAIN SYNDROME

-dysregulation of sensory processing pathways within the nervous system amplifying sensory input resulting in inc
perception of pain

àCENTRAL PAIN CAN ALSO BE NEUROPATHIC (POST stroke or post spinal injury pain)

-pain constant w bursts of worse pain exacerbated by cough, temp change, movement and/or emotions

Vs

Nociceptive pain
-DULL adching or throbbing at site of tissue injury

• In sickle acute pain crisis tx with HYDRATION, non opioid and opioid analgesia and incentive spirometry to avoid
ACS
-Morphine and hydromorphone are analgesics of choice-àdeliver SCHEDULED or by patient controlled pump
that INCLUDES basal rate and demand option

• IN COPD with hypercapnia and icu admission w intubation

-do breathing trial and as long as awake and functional can extubate and start NPPV
-extubate when better and start NPPV

But

S/P extubation in nonsurgical patients at low risk for reintubation, immediate use of supplemental
oxygen by high-flow nasal cannula for 24 hours followed by conventional oxygen by nasal cannula
reduced the risk of reintubation ----no cpap

• S/P SUBARACHNOID HEMORRHAGE

-1st 48 hrs à inc risk of rebleed and hydrocephalus. Are main cause of neuro deterioration
-After 1st 48 hrsà seizures, hydrocephalus, infection, symptomatic cerebral vasospasm
-VASOSPASM RISK PEAKS ON DAYS 5 TO 10
 -Vasospasm can lead to decline in neuro function (somnolence)
-DX with CT angio preferred to doppler US due to inc sensitivity
-TX with vasopressors to augment blood pressure OR endovascular tx in MORE REFRACTORY CASES
Also CT looks at brain parenchyma (rule out edema, infarction) and ventricles (rule out hydrocephalus)

àIf CT angio neg and pt declining can do CONTINUOUS EEG monitoring to rule out unapparent seizures or
status epilepticus

• IF A PATIENT WITH SICKLE CELL NEEDS MODERATE RISK SURGERY SHOULD RECEIVE ERYTHROCYTE
TRANSFUSION TARGETING HEMOGLOBIN LEVEL OF 10 G/DL BEFORE PROCEDURE

• Disseminated gonococcal infection

-N gonorrhoeae can disseminate and cause 2 clinical presentations:

1) BACTEREMIA: vesiculopustular or hemorrhagic macular skin lesions, fever, poly arthralgia and
tenosynovitis with NONPURULENT arthritis
 >>Synovial fluid cult NEG
>>NEED blood cult or cult of GU tract or pharynx; really also need throat, skin and rectum

3) PURULENT ARTHRITIS: without rash or other bacteremia sxs/signs

BUT synovial fluid cult is POSITIVE

• BIOterrorism

>>Smallpox
 -INCUBATION 10-14 days
-PRODROME = fever, back pain, HA, vomiting, pharyngitis
-RASH = small dots on pharyngeal and buccal mucosa. (pt contagious when this starts); 1st MACULES to
PAPULES to VESICLES before crusting over; >> lesions spread centripetally—to hands and face followed by
arms, legs and feet

• Measles
-AKA rubeola
-FEVER, malaise, upper resp inf manifestations (conjunctivitis, cough and coryza) FOLLOWED BY EXANTHEM
2-4 DAYS LATER
-EXANTHEM: 1st small whitish spot on buccal mucosa (Koplik spot)-à Morbiliform rash on face and neck that
eventually spreads to extremities
-RASH does blanch and do not become vesicular
• Rickettsial pox
-2/2 Rickettsia akari,
-due to bite of a mite found on a reservoir mouse
>>>PAPULAR lesion forms @ site of inoculation, later becoming vesicular before eventually forming an eschar
and THEN healing

>>>>Occasionally, the rash may become more generalized but can be differentiated from that seen with smallpox
by its asynchronous mode of development. Fever and muscle aches accompany the skin lesion

• Varicella
-aka chickenpox
-RASH localized to trunk and spreads centrifugally to periphery of body
-FEVER simultaneous with rash

-CAN be in various stages on same body area and does NOT involve palms/soles; more prominent on trunk

• IN PTS W SHINGLES TREATED IN THE HOSPITAL

>>Considerered “disseminated” if pt is immunocompromised and rash is widespread involving 3 or more
dermatomesàNEEDS tx in hospital pt needs to be on AIRBORNE AND CONTACT PRECAUTIONS as varicella
Zoster can be transmitted from persons with zoster to persons WHO HAVE NEVER HAD CHICKENPOX through
Direct contact of active lesions or via airborne route from infected small (≤5 µm) respiratory droplet nuclei
that can remain suspended for extended periods or travel long distances on air currents. Airborne =
negative-pressure room

>>If immunocompetent and local rash only can just be on contact precautions
• AMYLOID = random oriented fibrils composed of proteins forming organized beta pleated sheets in tissues
>> If they are from monoclonal lambda or kappa light chains they are AL AMYLOID
àAL amyloid sxs: fatigue or wt loss common BUT ALSO presents w sxs assoc w INFILTRATION of different
organ systems (ie restrictive cardiomyopathy, peripheral neuropathy, hepatosplenomegaly, cutaneous purpura
and macroglossia) and autoimmune sxs (diarrhea and orthostatic hypotension)
>>KIDNEY: NEPHROTIC RANGE PROTEINURIA due to glomerular lesions BUT amyloid deposits in tubular
basement membrane, interstitum and blood vessels
>>BIOPSY OF KIDNEY: deposits stain apple green on Congo red staining under polarizing microscope and
electron microscopy

àAn abdominal fat pad biopsy showing amyloid deposition indicates light-chain (AL) amyloidosis,
which typically presents with a large tongue, restrictive cardiomyopathy, or nephrotic syndrome.

VS

Multiple Myeloma nephropathy

-2/2 filtering myeloma light chains w minimal albumin w/light chains accumulating in renal tubule causing tubular
injury and forming casts (cast nephropathy); FILTERED LIGHT CHAINS NOT SEEN ON DIPSTICK; NEED
URINE ELECTROPHORESIS

• IF CERUMEN IMPACTION FOUND INCIDENTALLY WITHOUT SYMPTOMS THEN OBSERVE, DON’T DO EAR
IRRIGATION

• STEROID induced rosacea

 -2/2 chronic topical glucocorticoid application

• NEED Vit D in MS patients bc less relapses if higher

-If someone in active MS relapse then start IV METHYLPREDNISOLONE
-Check levels of vit D as well

• Actinic keratoses
 -CHRONIC rough asymptomatic skin lesions confined to sun exposed skin
-1st are erythematous w/overlying hyperkeratosis
>>EASIER to FEEL than see so palpate
-ARE precancerousàcan develop into SCC

• Seborrheic keratosis

-Common, benign
-Yellow, tan, brown to black well demarcated “stuck on” appearing papules with waxy surfaces and horn cysts

• For latent TB can do Isoniazid for 9 mo OR 12 week regimen of OBSERVED once weekly isoniazid and
rifapentine
-CAN do 4 mo of Rifampin tx if that strain of TB resistant to isoniazid or if pt cannot take isoniazid

• Hypercalcemia

1) w/ elevated PTH

a) primary hyperparathyroid

b) Familial hypocalciuric hypercalcemia

2) NO elevated PTH

a) Cancer (2/2 osteolytic lesions of bone or humoral tumor secreted PTHrP

 b) Granulomatous disease (ie sarcoid) 2/2 hydroxylase in disease assoc macrophages converting 25
hydroxyvit D to HIGHLY ACTIVE 1, 25-dihydroxyvit D metabolite leading to inc absorptionof Ca in gut,
promotion of inc bone resorption of Ca and dec Ca and Phos excretion in kidney

c) Meds
>>HCTZ (thiazide) reduces Na reabsorption in distal convoluted tubule and inc reabsorption of Ca in
same place bc Na+/Cl- Ca cotransporter RESULTING IN MILD ELEVATION OF CA

3) High normal or mildly elevated PTH

a) Mutation in G coupled protein Ca sensing receptor (CASR) gene

>>receptors in parathyroid and kidneys
>>Mutation results in a SHIFT UPWARDS in the “normal” range of recognized Ca leading to mildly
elevated Ca (usually <11.0 mg/dL)

• RESISTANT HTN –2 definitions:

1) Hypertensive while being on 4 HTN drugs
2) Hypertensive while being on 3 drugs BUT diuretic must be one of those

>>almost always need thiazide for resistant BP due to volume expansion; prefer chlorthalidone---can be given
up to creatinine 1.5 and gfr 45

• If exposed to active influenza virus

>>GIVE Chemoprophylaxis with oseltamivir or zanamivir AND immunization with an influenza vaccine preparation
>>Do NOT give zanamivifr to ppl with chronic resp conditions (ie asthma or copd)
>>Usually give inactive vaccine; can give live attenuated vaccine by nasal mist to ppl aged 2-49 ONLY without
comorbidities

• IN COPD

>> PULM rehab if FEV1 <50% esp if recent hospitalization; also considered for those w/ FEV1 >50% but
symptomatic OR exercise limited pt

>>O2 therapy given if (just need 1)

-PO2 < or = 55 mg Hg
-O2 < or = 88% (confirmed twice over 3 wk period) w/wo hypercapnia
-Pulm HTN, peripheral edema suggesting RH fail, or polycythemia w PO2 <60 mm Hg or O2 sat less than
88%

>>Roflumilast added only w/ severe or very severe COPD and recurrent exacerbations

• Cushing syndrome
>> Must have at least 2 first line screening tests abnormal à low dose dexamethasone suppression test and 24
hour urine free cortisol or late night salivary cortisol
>> Then measure ACTH; if high then prob in pituitary; if low/undetectable it is ACTH independent and prob likely
is adrenal adenoma or adenocarcinoma so check Abd CT
• ORAL appliances such as oral mandibular advancement appliances whould be considered as alternate to CPAP
for mild-mod OSA if pt does not like CPAP
>>DO NOT DO SURGERY; maxillomandibular advancement > uvulopalatopharyngoplasty if must

• IF pt over 80 yo and have fatigue AND check TSH and it is mildly elevated with normal FT4 THEN RECHECK
TFTS in 6-12 weeks as TSH may be falsely mildly elevated in this age group (up to 8.0 uU/mL)

• Neonatal congenital heart block affects approximately 2% of pregnancies in which the mother is positive for anti-
Ro/SSA or anti-La/SSB antibodies
>>ALSO has risk of neonatal lupus erythematosus (rash and hematologic and hepatic abnL which resolve when
Ab dissipates)--àRASH GETS WORSE if phototherapy for neonatal hyperbili used

àCAN CONTINUE HYDROXYCHLOROQUINE (this even helps w congenital heart block)

• ANTIPSYCHOTIC DRUGS (ie risperidone) block dopamine and decrease inhibitionof prolactin release at pituitary
causing HYPERPROLLACTINEMIA and possible secondary amenorrhea and inability to conceive
>>LITHIUM does not cause this

>>EVEN IF seemingly antipsych drug causing hyperprolactinemia STILL recheck prolactin weeks after stopping
drug bc pt CAN have prolactinoma still; levels of 200 ng/mL are more likely 2/2 drugs while higher levels indicate
prolactinoma

• In elderly with OA consider topical first; then if still pain do celecoxib and add PPI

• Hereditary spherocytosis

-Autosomal dominant w variable penetrance; occasionally sporadic

-Alterations in membrane structure destabilize erythrocytes leading to spherocytic shape reduced deformability,
trapping and subsequent destruction in spleen
-suspect if: FAM hx of anemia, jaundice, splenomegaly or GALLSTONES
-May get aplastic crisis precipitated by acute parvovirus B19
-Will have spherocytes on blood smear and neg direct antiglobulin (Coombs) test
-DX: NEED OSMOTIC FRAGILITY TEST WITH 24 HOUR INCUBATION (in hypotonic saline) compared to
control erythrocytes

• Warm autoimmune hemolytic anemia

-rapid or insidious anemia and/or jaundice, mild splenomegaly
 -Spherocytes seen on blood smear but direct antiglobulin test (DAT) aka coombs test CAN diagnose

-in 10% DAT may be normal so need more sensitive test through reference lab or blood center
-TX with glucocorticoids
àOTHER causes: lymphoid neoplasm (ie CLL, lymphoma, myeloma), solid tumors, SLE, drugs (DOPA, PCN,
quinine and/or chloraquine)

• Paroxysmal nocturnal hemoglobinuria (PNH

>>acquired clonal progenitor cell disorder characterized by hemolytic anemia, pancytopenia, or unprovoked
thrombosis

>>NORMOCYTIC NORMOCHROMIC ANEMIA W MILD ANISOPOIKILOCYTOSIS AND ERYTHROCYTES WITH

HOWELL JOLLY BODIES (NUCLEAR REMNANTS)

DX: FLOW cytometry detecting CD55 and CD59 deficiency on the surface of peripheral erythrocytes or
leukocytes

• Glucose-6-phosphate dehydrogenase (G6PD)

>>deficiency 2/2 various mutations on the X chromosome
>>MC in men, often in blacks
 >>During acute hemolytic episode, bite cells may be seen on the peripheral blood smear, and a brilliant cresyl
blue stain may reveal Heinz bodies (denatured oxidized hemoglobin)
>>Acute hemolytic episode may be precipitated by: FOODs, DRUGS, infection or stress

• IN DKA with HYPOkalemia NEED IV fluids AND potassium replacement FIRST before insulin; K needs to be >3.3
mEq/L before insulin tx

• IN HYPOCALCEMIA and alcoholic: CHECK MAGNESIUM levels first as dec mag will impair release of PTH and
also assoc w resistance to PTH activity at bone
>>NEED to correct mag to at least 2 mg/dL first

• CHECK ionized Ca in suspected abnormal serum protein binding of Calcium ONLY

• CERVICAL CANCER
>> EARLY stage ---no spread to pelvic wall or lower third of vagina àTX with surgery
>>More locally advanced cancer (Stage 1 confined to cervix and stage II invading beyond uterus but not to pelvic
wall or lower 3rd of vagina) can get RADIATION only as alternative to hysterectomy
>>More locally advanced cancer (BULKY STAGE IIA –INVASION BEYOND UTERUS BUT NOT EXTENDING
TO PELVIC WALL OR LOWER 3RD OF VAG) NEEDS RADICAL HYSTERECTOMY
>>IF has BULKY DZ EXTENDING TO PELVIC WALL IT IS STAGE III AND needs RADIATION and CISPLATIN
instead of surgery

• SUBACUTE progression of PERSONALITY CHANGE, psychosis, and SEIZURES = PARANEOPLASTIC

ANTIBODY SYNDROME
>>LIMBIC encephalitis (inflame of emo and memory structures of the brain)
>>MC assoc w lung tumors (small cell), breast ca, thymoma, germ cell tumors and Hodgkin lymphoma
àanti-LG1 antibody syndrome MC assoc w limbic encephalitis and SIADH
>>>>DX with serum and/or cerebrospinal fluid for paraneoplastic antibodies
TX w immunotherapy and tx underlying tumor
à MAY NOT NECESSARILY BE ASSOC W A TUMOR, CAN JUST BE AUTOIMMUNE
• W MOD-HIGH CLINICAL SUSPICION OF TB PULMONARY EFFUSION CONFIRM WITH PLEURAL FLUID
ADENOSINE DEAMINASE MEASUREMENT; pos if >60 U/L, neg when <40 U/L
àPLEURAL fluid will show lymphocyte predominant exudate
>>>IF POSàtx empirically for TB and order PLEURAL BIOPSY to confirm diagnosis

• If pt w DM on insulin has unperceived hypoglycemia dec insulin and allow for 2-3 wk reset of counterregulatory
response to hypoglycemia

• Pramlintideà amylin mimetic that decreases glucagon secretion and increases satiety by decreasing gastric
emptying. Pramlintide should be considered when the intended reduction in A1c modest and when want wt loss
>>can cause hypoglycemia w/insulin

• In SUBACUTE hypothyroidism (mild elevation of TSH and normal T4) w/ symptoms can CHECK THYROID
PEROXIDASE ANTIBODYè1) repeat TFTs 2). Treat if repeat TFTs same esp if +thyroid peroxidase ab and
fam hx

• HYPERTHYROIDISM
-Graves is MC; low TSH, high T4 or T3 (can check T3 if T4 nl)
-radioactive iodine uptake will be elevated
-CAN CHECK thyroid stimulating immunoglobulins (TSIs) if diagnosis cannot be made bc lack radioactive iodine
capability or if it is contraindicated (preg and breastfeeding)

• PROGRESSIVELY WORSENING BACK PAIN + SEVERE LEG PAIN that improves with leaning forward and
WORSENS with spinal extension (standing and walking up steps) = SPINAL STENOSIS
-Spinal stenosis is 2/2 narrowing spinal canal usually 2/2 degenerative arthritis of spine that causes mechanical
compression and ischemia of lumbosacral spine nerve roots
>>DEGREE OF STENOSIS does not predict development of symptoms

• Epilepsy syndrome = recurrent unprovoked seizures

-When unsure if focal or generalized epilepsy tx should be started with a BROAD SPECTRUM anti epileptic drug
that can treat both : TOPIRAMATE, lamotrigine, levetiracetam, valproic acid and zonisamide
>>RISKS: topiramate: kidney stones, wt loss, word finding difficulty ALL AEDs: Steven Johnson’s syndrome

àCarbamazepine, gabapentin and phenytoin are narrow spectrum AEDs for partial onset epilepsies and can
even EXACERBATE generalized epilepsy and provoke absence status epilepticus; only use if seizure
characteristics and/or MRI and EEG show partial onset seizure
>>>>>CHARACTERISTICS OF PARTIAL ONSET SEIZURE: AURAS or epigastric sensation or unilateral clonic
shaking before onset

• In first few months to 1 yr after organ transplantation

+
Lymphadenopathy
+
 Fever, sweats, fatigue and chest pain (dull midchest) of several weeks duration
IN a patient that was SERONEGATIVE for Epstein barr virus BUT RECEIVED A TRANSPLANT FOR EBV + PT
=
POSTTRANSPLANT LYMPHOPROLIFERATIVE DISEASE

>>PTLD IS 2/2 B cell proliferation induced by infection by EBV in setting of CHRONIC IMMUNOSUPRRESION
and resulting decreased T cell immune surveillance

>>EBV after transplantation can also cause: -Mononucleosis syndrome, leukopenia and thrombocytopenia, and
hepatitis or pneumonitis
àDX PTLD with quantitative serum PCR for EBV and then CONFIRM with biopsy and histopath of swollen lymph
nodes or extranodal masses
àTX by: dec immunosuppression, if possible, and chemotx (rituximab)

• Post transplant CMV can cause nonspecific febrile syndrome but no lymphadenopathy

• Immunocompromised persons, including those with HIV, should receive the 13-valent pneumococcal
conjugate vaccine first, followed 8 weeks later by the 23-valent pneumococcal polysaccharide vaccine;
should have HEP B vaccine in HIV

• Hep A vaccine needed in pts who: have liver dz, MSM

• ACUTE compensation of bicarb: for each change in 10 mm Hg of PCO2 bicarb changes by 2 mEq/L
• CHRONIC compensation of bicarb: for each change in 10 mm Hg of PCO2 bicarb changes by 3-4 mEq/L
(happens in 24-48 hrs)

• RESISTANT GOUT
àsevere tophaceous gout and persistent hyperuriceia NOT responding to urate lowering therapy (allopurinol or
febuxostat) NEEDS trial of SYNTHETIC URICASE REPLACEMNT pegloticase
àPegloticase is IV and replaces allopurinol or febuxostat bc
-side effect of Pegloticase is infusion reaction
-body can make antibodies to pegloticase MAKING IT LOSE RESPONSE
-If pt on another urate lowering drug may MASK rising uric acid and therefore wont know about loss of
response to pegloticase and may cause SEVERE INFUSION REACTION
 àPEGLOTICASE SHOULD NOT BE GIVEN TO PT W G6PD DEF

>>Pt w resistant gout may not have many flares, ironically; if flares controlled with colchicine working then do not
need to change this med but if not working or contraindicated consider Anakinra (interluckin 1 beta inhibitor) for
prophylaxis and flare tx

• Back pain
-ACUTE <4 wks, subacute 4-12 wks, chronic >12 wks
-For acute/subacute: NSAIDS and muscle relaxants 1st line; can use massage tx for back pain as well

• If MRSA CELLULITIS AND/OR BACTEREMIA w Vanc contraindication can use Daptomycin

• If Von Willebrand dz and undergoing major surgeryàGIVE Factor VIII concentrates containing von Willebrand
factor
àIF MINOR SURGERY can use desmopressin as this leads to release of vWF and factor VIII from endothelial
cells and provides hemostasis

>>>Antifibrinolytic agents ( ε-aminocaproic acid and tranexamic acid) can be used in patients with mild vWD to
prevent dissolution of the hemostatic plug, particularly those associated with mucocutaneous bleeding
àProlonged use = thrombosis, especially in patients with an underlying thrombophilia.

• In BLEEDING PTS with hypofibrinogenemia from liver disease, thrombolytic therapy OR DIC give
CRYOPRECIPITATE--à CONCENTRATED source of factor VIII, vWF, factor XIII, fibronectin and fibrinogen

• Fresh frozen plasma (FFP) —>for warfarin reversal IN ACTIVELY BLEEDING PATIENTS, tx of TTP, dilution
coagulopathy during massive transfusion and in bleeding its w several factor def such as DIC or liver dz
-can be given alone or w/a 3-factor prothrombin complex concentrate
>>>RISKS : viral transmission, transfusion-related acute lung injury, and febrile, allergic, and anaphylactic
reactions

• Recombinant factor VIII is used to treat patients with hemophilia A

• Percutaneous device closure in patients with cryptogenic stroke and patent foramen ovale mau be indicated BUT
ALSO but also check for A fib

• BPs
 àBPs taken at home (ambulatory bp monitoring) UNDERESTIMATE BP so a correlating value that is HIGHER is
assumed and treatment based on that
>>an aver 24 ABPM of 130/80 equals a clinic bp of 140/90 and WARRANTS TREATMENT

• POLYARTERITIS NODOSA

Livedo reticularis

àMEDIUM sized vasculitis

-affects mesenteric and renal arteries
SXS-FEVER, arthralgia, myalgia, skin findings, abd pain, wt loss, peripheral nerve manifestations
(mononeuropathies or mononeuritis multiplex) + testicular involvement
àskin findings: Livedo reticularis, purpura, painful subcutaneous nodules)
>>>Kidney dz is bc of DEC RENAL ARTERY BLOOD FLOW and not bc of glomerulonephritis THEREFORE
THERE IS BLAND urine sediment
>>>Complements normal, ESR elevated
DX: biopsy which will show necrotizing arteritis OR medium sized artery aneurysms and stenosis on imaging or
mesenteric or renal arteries using angio or CT angio

>>Assoc w Hep B

• Granulomatosis with polyangiitis (GPA)

-Small and medium sized vasculitis; granulomatous inflammation and necrotizing vasculitis àinvolves kidneys,
and neuropathy and purpura can occur; saddle nose (below)
 àKIDNEY INVOLVEMENT DUE TO glomerulonephritis
à c-ANCA/anti-PR3 (~80%) or p-ANCA/anti-MPO (10-15%) has high specificity (>95%) for the diagnosis of GPA
but up to 10% patients with GPA can be ANCA negative
>>Definitive diagnosis is biopsy
>>Tx: high dose steroid for life threatening manifestations (lung hemorrhage), otherwise need 2 parts

1) Induction of remission
àhigh dose steroids (pred + IV methylpred)
PLUS METHOTREXATE or RITUXIMAB ---for non severe dz
Or
Cyclophosphamide or RTX for severe disease
Induction is 3-4 mo long but for smoldering dz can be up to 6 mo

>>Cyclophosphamide side effects: leukopenia, infection

2) Maintenance of remission
àSwitch from cyclophosphamide to:
Methotrexate (c/I in hepatic or renal dz)
Or
Azathiprine (c/I in homozygous recessive for thiopurine methyltransferase (TPMT) due to
leukopenia

• Henoch-Schönlein purpura (HSP)

àMC small vessel vasculitis; children predom but some adults
àAKA IgA vasculitis bc IgA deposits in vessel walls
àalso have complement (C3) deposition in small vessels (capillaries, venules or arterioles)

>>>Leukocytoclastic vasculitis =characteristic = neutophilic-mediated blood vessel inflammation

àINVOLVES: kidney, skin, GI = usually arthritis, PALPABLE purpura (without thrombocytopenia), abdominal pain
and renal failure

à; active urine sediment is common, complements (particularly C4) are typically low, and IgA levels may be
elevated
>>>CRITERIA = CLINICAL DIAGNOSIS but can biopsy skin or kidney for confirmation
>>>Direct immunofluorescence (DIF) is utilized in identifying the immunoglobulin and complement suspected of
inducing purpuric vasculitis
àTX: immediate is supportive (NSAID), complicated may respond to steroids; screen for kidney dz; cyclophos?
• ADRENAL INSUFFICIENCY
àfatigue, unintentional wt loss, N/V + likely personal and fam hx of autoimmune dz
àSIGNS: hyperpigmentation (over extensor surfaces and over buccal mucosa bc excessive secretion of
melanocyte stimulatijng hormone –common precursor with ACTH)
àLABS: hyperkalemia (bc aldosterone deficient)

>>>DIAGNOSIS is by low early morning serum cortisol (<3 ug/dL) w/signs and sxs aboveàIF FIND THIS THEN
CONFIRMED DIAGNOSIS AND NEEDS IMMEDIATE TREATMENT----------à
TX WITH Hydrocortisone and fludcortisone
--can check primary vs other causes of low cortisol with ACTH level; in primary adrenal insufficiency the ACTH is
very HIGH (>200 pg/mL)

àIF morning cortisol is nondiagnostic (4-12 ug/dL) needs a COSYNTROPIHN stimulatiojn test with synthetic
ACTH; normal response is A PEAK SERUM CORTISOL >20 ug/dL; IF LESS THEN CONFIRMED DIAGNOSIS
and treat

• Psoriatric arthritis

-In 15-20% of pts w psoriasis

-Assoc w psoriasis, enthesitis, dactylitis, tenosynovitis, arthritis of distal interphalangeal joints, asymmetric
oligoarthritis and spondylitis
-Psoriasiform skin lesions on umbilicus, gluteal cleft, extensor surfaces, posterior auricular region and scalp
-has nail pitting or onycholysis
àDiagnosis is by classification criteria for Psoriatic Arthritis (CASPAR) ---includes NEG RF
TX:
• Reactive arthritis
àAKA Reiter syndrome
àpostinfectious arthritis triggered by infections causing urethritis or diarrhea; but MAY BE ASYMPTOMATIC
à Arthritis, usually oligoarticular, develops several days to weeks after the infection
--NO SPECIFIC TX; steroids, NSAIDS

• Septic transfusion REACTION aka sepsis as result of transfusion transmitted bacterial infection = any of the
following within 5 hours of completion of a transfusion:

-temperature greater than 39.0 °C (102.2 °F) or

-temperature two degrees higher than pretransfusion,
-rigors,
-pulse rate greater than 120/min or
-more than 40/min higher than pretransfusion, or
-a decrease or increase in blood pressure of greater than 30 mm Hg

MC 2/2 staphylococcal species, although gram-negative organisms are also implicated. The blood product bag
should be sealed and sent to the microbiology laboratory for culture
—>START PT ON VANC AND CEFEPIME

• MYELODYSPLASTIC SYNDROME
-LOW risk: can be incidentally found on labs: shows pancytopenia, macrocytosis
NEED to rule out vit b12 and folate def!!!!! If ruled out then: bm bx
-BM bx then shows low risk cytogenetics and low marrow blasts (<2%)
-May need transfusions; Hb goal 10 g/dL but 9 is good too; transfuse if <7%

-For higher risk MDS to improve blood counts, delay progression or extend survival then add 5-Azacytidine

-For high risk MDS need allogenic hematopoietic stem cell transplantation
• In colon cancer, stage II, which has been resected but pt has NEW liver lesions in ONE LOBE = Oligometastatic
disease (usually to liver or lung) NEEDS surgical resection

-Colon ca needs monitoring with PE and serum CEA every 3-6 mo for first 3 years and then every 6 mo during
years 4 and 5; also needs CT scans of chest and abd annually for first 3 years post op

àfor unresectable lesions can do chemo regimen includingà OXALIPLATIN, 5 FLUOROURACIL, LEUCOVORIN
AND BEVACIZUMAB
àSE: Bevacizumab is a VEGF inhibitor and can cause THROMBOTIC MICROANGIOPATHY including
microangiopathic hemolytic anemia, low plt and kidney dysfunction

(SUNITINIB IS another VEGF inh that can cause TMA)

• Vascular tumors (ie hepatocellular carcinoma and neuroendocrine tuors) can get palliative HEPATIC ARTERY
EMBOLIZATION

• SOCIAL ANXIETY DISORDER (at least 6 mo) needs SSRI or SNRI Venlafaxine + CBT

• Coccidiomycosis
à Fungus from west found in soil ; transmit via inhalation of airborne spores
-most pts: asymptomatic primary lung inf and if dev sxs it is flu like +/- erythema nodosum on LE
-sxs weeks after travel
-CXR nonspecific (normal or diffuse infiltrate, nodules and cavities; unitlateral hilar LAD and pleural effusions)

-Can find ENDOSPORE CONTAINING SPHERULE IN BAL SPECIMEN

àCAN disseminate to skin bone, joints, peritoneum, and CNS esp if T cell mediated imunity impaired
àCAN treat with Fluconazole or itraconazole if mild-mod or amphotericin B deoxycholate forumation if severe

• Mycoplasma pneumonia
 -rare in adults; hardly ever severe PNA
-“walking pna”
-Dx w IgM ab assay BUT sens/spec is bad so CONFIRM by showing a four-fold increase or decrease in paired
sera titers or by detecting M. pneumoniae–specific antigens in respiratory secretions using newer immunoassays

• In bacterial meningitis WITH RECENT CNS SURGICAL PROCEDURE start Meropenem and Vancomycin to
cover Pseudomonas, Acinetobacter, Enterobacteriaceae and staph

• IN CKD/ESRD hyperkalemia will have prox muscle weakness, EKG with peaked T waves:
àTx with IV calcium gluconate and insulin and glucose

• DO NOT GIVE CPAP TO SUSPECTED OSA PTS IN THE HOSPITAL; just move head of bed to 30 deg and use
sedatives and opioids carefully and use continuous pulse ox

• IF do 4T pretest prob score for HITT

0-3 is low prob
4-5 intermediate prob
6-8 high prob
For intermediate or high probà

Confirmatory testing by direct antibody testing or by functional assays (test the ability of serum from patients with
HIT to activate test platelets)

à Direct antibody testing is typically performed by enzyme-linked immunosorbent assay (ELISA) that
detects antibodies directed toward heparin-platelet factor 4 complexes

à 2 Functional assays
1) serotonin release assay (SRA) ---gold standard study
2) heparin-induced platelet aggregation (HIPA) assay---HIPA is also very specific but has a
lower sensitivity than SRA

• IF ACTIVE TUBERCULOSIS
àMUST treat for 2 weeks (rifampin, isoniazid, pyrazinamide and ethambutol) with improvement of sxs and 3
consecutive neg sputum smears (collected at 8-24 hour intervals including one early morn specimen)
• Kidney transplant recipients predisposed to new-onset diabetes after transplantation 2/2 meds:
—>glucocorticoids, tacrolimus, and the mammalian target of rapamycin (mTOR) inhibitors sirolimus and
everolimus.
Also risk of dyslipidemia 2/2 to meds:
—> cyclosporine and mTOR inhibitors

• If gonorrhea pos but chlamydia neg must treat both anyway w/ ceftriaxone and azithromycin
• If chlamydia pos but gonorrhea neg can just tx chlamydia with azithro; other possibilities for tx are doxycycline,
FQ ofloxacin or levofloxacin

• CMV
à common s/p transplantation, esp 1st few months bc immunosuppression highest
àUnless donor and recipient CMV seronegative and the risk is low, prophylaxis with valganciclovir is often used
during this time period
à IF DEVELOPS COLITIS OR ESOPHAGITIS (or less commonly Hepatitis, gastritis, and small bowel enteritis)
after finishing valganciclovir the patiehnt CAN have reactivation of CMV
àDX: PCR for CMV suggestive BUT definitive diagnosis via colonoscopy w/biopsy

• Early tx does not improve survival in grade 1 and 2 FOLLICULAR LYMPHOMA (a non Hodgkin lymphoma)
(asymptomatic, non bulky dz without organ involvement or impingement and normal CBC)
-Follicular lymphoma 2nd MC; diffuse large cell is 1st
-MC age 60+ yo; has B cell markers (CD 10, 19, 20 and 22) and small cells on analysis
àDX confirmed by LN biopsy
-Stage 1 is 1 LN or LN area; stage 2 is 2 + LN on same side of diaphragm, Stage 3 LN both sides of diaphragm
and stage 4 is disseminated dz (BM, liver, CNS); grade 1 0-5 centroblasts, 2 is 6-15 and 3 is >15
-TRANSLOCATION t (14:18) causing overexpression of BCL2 oncogene
 à ONLY tx when symptomatic:

>>IF localized and pt symptomatic but not causing systemic dz: INVOLVED FIELD RADIATION +RITUXIMAB

>> IF systemic dz use multiagent tx; 1 of these 3

1) rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP);
(2) rituximab plus cyclophosphamide, vincristine, and prednisone (R-CVP); or
(3) rituximab plus bendamustine.

Radioimmunoconjugates (tositumomab and ibritumomab) have been used effectively to induce long-term
remissions.

>>can use Lenalidomide with rituximab for ADVANCED SYMPTOMATIC DZ

• In liver dz w coagulopathy do not give anticoag; do IVC filter

• B QUALITY CONTROL IMPROVEMENT TOOLS

>>Cause-and-effect diagram AKA Fishbone or Ishikawa diagram—>used for root cause analysis (discovering
factors contributing to a problem)

>>Control chart —>display variation in a process over time and can help determine if variation is from a
predictable or an unpredictable cause OR IF an intervention has resulted din positive change

>>Pareto chart —>USED FOR ROOT CAUSES; display on graph in descending order of frequency
****UNLIKE FISHBONE it can be used to identify potential causative factors of a problem and the potential
relationship between different variables

>>Spaghetti diagrams—> display flow through a system to find inefficiencies or redundancies in a system

• IF high breast density NEED digital screening mammography; high breast density has inc breast Ca risk

• For bipolar disorder need tx fitting for current phase of illness

>for manic or hypomanic phase 10 tx possible: 1 typical antipsychotic, lithium, two antiepileptic agents and six
atypical antipsychotics
>for depressive phase have 2 tx possible: Quetiapine monotx or combo olanzapine-fluoxetijne
>Diff options for maintenance phase: Lamotrigine

àSE of quietapine: hypersomnolence, wt gain, tardive dyskinesia and hyperglycemia

• THROMBOTIC MICROANGIOPATHY
 àLABS: ANEMIA, thrombocytopenia and elevated creatinine; peripheral smear with schistocytes
àCHEMOtx that causes this: mitomycin C, gemcitabine, tyrosine kinase inhibitors, mammalian target of
rapamycin (mTOR) inhibitors (sirolimus, everolimus) AND anti vascular endothelial growth factor
inhibitors
>>CAN appear like pre-eclampsia/eclampsia (HTN, KIDNEY FAILURE w/proteinuria and bland sediment)

• TYPES OF BIAS

Length-time bias àIN RANDOMIZED CONTROLLED TRIALS OF SCREENING TESTS

==>2/2 overrepresentation of indolent disease in the screen-detected cohort and overrepresentation of aggressive
disease in the symptom-detected (non-screened) cohort
==>A drastic type of length-time bias is termed overdiagnosis and occurs when a disease that is so indolent that it
would not otherwise have been clinically significant during a patient's lifespan is detected through screening

Contamination bias occurs when the control group is unintentionally exposed to the intervention, which biases the
estimate toward the null hypothesis

Observer bias occurs when knowledge of the hypothesis or intervention received influences data recording, IE
when NOT blinded

Selection bias refers to systematic error in a study resulting from the manner in which the subjects are selected
for the study. It can influence the results when the characteristics of the subjects selected for a study differ
systematically from those in the target population or when the study and comparison groups are selected from
different populations
==> IE volunteer bias, in which patients who seek participation in a screening study are often healthier than
those who do not undergo screening

• Sickle cell pts get aplastic crisis w Parvo B19 and PURE RED CELL APLASIA would be seen on bone marrow
biopsy
àPt DOES NOT have thrombocytopenia or leukopenia BUT WILL HAVE INEFFECTIVE (low) reticulocyte
response due to inf

• PREVENT pressure ulcers in pts with freq repositioning but ALSO ADVANCED STATIC MATTRESSES (made of
foam or gell that does not move when person lies on it)

• Chantix (Varenicline) is best single agent nicotine cessation tool BUT not better than nicotine patch PLUS gum,
spray or inhaler; can use either
• IN ADENOCA (non small cell Ca) if STAGE 2 or STAGE 3 and RESECTED should use CHEMO w/Cisplatin
based adjuvant REGARDLESS OF HISTOLOGICAL TYPE for 4 cycles

• If non small cell lung CA has mutation in epidermal growth factor receptor (EGFR) can use ERLOTINIB (a
tyrosine kinase inh)

• SYSTEMIC EXERTION INTOLERANCE aka chronic fatigue syndrome

àmyalgia, arthralgia, difficult concentrating, unrefreshing sleep and chronic headaches WITHOUT anhedonia or
thoughts of self harm >6 mo
TX with CBT and/or GRADED EXERCISE PROGRAM

• SEVERE CONTINUOUS boring ocular pain that radiates to surrounding face + redness, photophobia, and tearing
BILATERALLY =. Inflammation of fibrous layers of eye underlying the episclera and conjunctiva and overlying
choroid = SCLERITIS
àWORSE at night and worse w eye movement bc traction of extraocular muscles on the sclera `
àvision may be normal BUT may become impaired from inflame involvement of adjacent ocular structures or loss
of globe integrity
ALMOST 50% PTS W SCLERITIS HAVE UNDERLYING SYSTEMIC DZ--àinflam CTD (RA) or inf (TB)
>>>>SIGHT THREATENING SO NEED OPTHO

VS

EPISCLERITIS
àINFLAM of episclera which is a vacscular fibroelastic structure superior to sclera
>>>>>MUCH LESS PAIN THAN SCLERITIS; more red, irritated and tearing
àwont usually progress to risk of visual impairment

VS
UVEITIS
-unilateral eye pain, photophobia, and ciliary flush +/- pupillary miosis
 —>ciliary flush=circumferential redness around the border of the sclera and cornea (corneal limbus) = dilated
conjunctival vessels
—>Slit lamp examination commonly reveals inflammatory (“flare”) cells in the anterior chamber.
—>associated with autoimmune disorders, arthritides associated with HLA-B27 antigen, infection, malignancy,
and sarcoidosis

VS

IRITIS
àinflam limited to iris
àif ciliary body involved called iridocylitis

• Acute bacterial prostatitis

—>2/2 ascending urethral infection, although bacterial cystitis or epididymo-orchitis may be an underlying source
—> SXS: fever, chills, malaise, nausea and vomiting, dysuria, urgency, frequency, and pain in the lower
abdomen, perineum, and rectum
—>onset typically rapid
—>PE: prostate is tender and tense or boggy; do NOT palpate long bc = bacteremia
>>>NEED blood and urine cultures AND empiric broad-spectrum antibiotics against Escherichia coli ,
Serratia species, and Klebsiella species, are the most common causative agents in patients with uncomplicated
acute bacterial prostatitis who are at low risk for sexually transmitted infections (STIs)

—>TX w/ Cipro or levo for at least 14 days up to 4 wks; Trimethoprim-sulfamethoxazole is also an appropriate
first-line choice if the isolate is known to be susceptible or if the rate of E. coli resistance in the community is less
than 20%
—>>Treatment with a carbapenem, such as meropenem, should be reserved for systemically ill patients who
require hospitalization or when a fluoroquinolone-resistant organism is a concern. The incidence of
fluoroquinolone-resistant E. coli is very high (up to 90%) following prostate biopsy.

• Acquired cystic kidney dz (from ESRD) = large # small BL kidney cysts and reduced kidney size
èCONFERS 30x inc risk of RENAL CELL CA
>>ROUTINE SCREEN is not recommended, however

VS

Autosomal dom polycystic kidney disease = LARGE kidneys w mult cysts originating from renal collecting duct
è+ fam hx
HAS RISK OF HEMORRHAGIC CYST

VS
 RENAL ANGIOMYOLIPOMAS and bl renal cysts = TUBEROUS SCLEROSIS COMPLEX
à Auto dom so ALMOST ALWAYS fam hx

• Fatigue, weakness, and erectile dysfunction (ED) need —> MORN TOTAL TEST 1st
>If low, low/nl, need —>SECOND CONFIRMATORY TEST
>If low/low nl need —>R/o other causes of hypogonad
>If. a sex hormone–binding globulin abnormality is likely need —>a serum free testosterone level by equilibrium
dialysis or a calculated serum free testosterone level can determine whether hypogonadism is truly present

>When hypogonadism is confirmed need to find out —>?primary or ?secondary hypogonadism so need —>
luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels

>If supranormal LH and FSH levels = PRIMARY HYPOGONAD

>>>If secondary hypogonadism is confirmed by inappropriately normal or low LH and FSH levels NEED —>
serum prolactin level to evaluate for hyperprolactinemia and iron saturation level (transferrin saturation and ferritin
levels) to exclude hemochromatosis AND the presence of any additional pituitary hormone deficiencies should be
assessed

—>An MRI of the pituitary gland should be ordered to exclude hypothalamic or pituitary masses as the cause of
decreased gonadotropin production and secretion if any symptoms consistent with mass effect are present,
including headaches, visual field changes, a serum total testosterone level less than 150 ng/dL (5.2 nmol/L), an
increased prolactin level, or any additional pituitary hormonal deficiencies

• Neutropenia = absolute neutrophil count less than 1000/µL (1.0 × 109/L)

1st needs —>Monotherapy with a β-lactam agent with broad coverage of gram-positive and gram-negative
organisms with antipseudomonal activity IE piperacillin-tazobactam
BUT
add gram-positive coverage (vancomycin) if a central catheter infection is considered likely
AND
Add antifungal agents if mucosal barrier inflammation and prolonged neutropenia (>1 week),
AND
Add antiviral agents if dz or current tx = immunosuppression

>>Antimicrobial therapy should be narrowed if a specific organism or organisms are identified on culture

Because of resistance, fluoroquinolones not used qs initial monotherapy

BUT
they may have a role in selected low-risk patients with stable vital signs and an unremarkable physical
examination who might be eligible for outpatient oral therapy at experienced centers with close monitoring
capability. They may also be used as add-on therapy for specific infections or for directed therapy based on
culture results

Hematopoietic growth factors, including granulocyte-macrophage colony-stimulating factors, are effective in

preventing neutropenia and allowing for continued full-dose chemotherapy when appropriate.

Although gram-positive organisms are the most commonly identified cause of neutropenic fever, initial
monotherapy with vancomycin is not appropriate because of the potential virulence of gram-negative organisms.
Vancomycin is usually not a routine component of empiric broad-spectrum antibiotic therapy for neutropenic fever
without a specific indication

• SPONTANEOUS tumor lysis syndrome w/newly dx leukemia or lymphomaàGIVE HIGH VOLUME NS AND
RASBURICASE 1ST--- Bc want to minimize uric acid or calcium phosphate deposition in the renal tubules
>>>IN TLSà rapid cell breakdown results in hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia,
and disseminated intravascular coagulation (DIC)
 —>DIC would have dec fibrinogen level—>FFP if DIC after chemotx w/resultant depletion of procoagulant

• Orbital cellulitis

-inflam of structures of the orbit (including EOM and orbital fat) 2/2 CONTIGUOUS DENTAL OR SINUS INF
èSXS: eyelid swell, opthalmoplegia, pain with eye movement, +/- proptosis
àIS DEEP INF
àDX: W CT
>>>>TX: ?SURGICAL DRAINAGE AND IV ABX

VS

BLEPHARITIS

-INFLAM OF SEBACEOUS GLANDS OR LASH FOLLICULES THAT CAN PROGRESS TO CONJUNCTIVITIS

OR KERATITIS
-sxs: gritty burning sensation

VS

ENDOPHTHALMITIS

-inflam of AQUEOUS AND VITREOUS HUMORS

-sxs: vision loss, photophobia, ocular pain and discharge
à2/2 bacterial or fungal inf S/P SURGERY (ESP FOR CATARACTS) OR globe trauma and foreign body
àif within 6 wks of surgery is bc of GP BACTERIA
àif outside of 6 wk of surgery is bc of PROPIONIBACTERIUM ACNES or fungus
NEED BIOPSY
Tx: ?VITRECTOMY and inject abx or antifungal agents
 VS

PRESEPTAL CELLULITIS

-inflam limited to eyelids and FACIAL TISSUES ANTERIOR TO ORBITAL SEPTUM

-MC than orbital cellulitis
-DIFF FROM ORBITAL CELLULITIS IN THAT PAIN IS LOCALIZED TO ANTERIOR TISSUES WITHOUT
OPTHALMOPLEGIA (pain w eye movement) or PROPTOSIS
TX WITH: Clindamycin or TMP-SMX plus Amoxicillin-clavulanic acid or Cefpodoxime or Cefdinir. If the patient is
unimmunized by H.influenzae, antibiotic coverage with a beta-lactam is recommended.

• VERTIGO

>>Vestibular neuronitis—> acute, severe, and persistent nonpositional peripheral vertigo (NOT
PRECIPITATED BY HEAD MOVEMENT) + N/V
—>S/P viral upper respiratory tract infection
—>SXS 2/2 postviral inflammation of the vestibular portion of cranial nerve VIII
àDix-Hallpike maneuver POSITIVE WITH peripheral vertigo, with nystagmus that is provoked after a
brief latency period and is relatively severe and short in duration (<1 minute)

>>Benign paroxysmal positional vertigo (BPPV)—>MCC vertigo

—> precipitated by head movement and is caused by otoliths that perturb the labyrinthian sensory
receptors.
—> episodes of vertigo generally last less than 1 minute

Brainstem infarction or hemorrhage AND/OR cerebellar infarction or hemorrhage = vertigo of central

origin.
—>NO latency in the occurrence of nystagmus with the Dix-Hallpike maneuver
—>nystagmus generally lasts longer than 1 minute and symptoms are less severe

Labyrinthitis = SIMILAR TO vestibular neuronitis in etiology and presentation EXCEPT that in

labyrinthitis patients exhibit HEARING LOSS
• AGE RELATED MACULAR DEGENERATION

-DEGENERATIVE dz of macula that results in loss of CENTRAL VISION

-Dry AMD=subretinal deposits of yellowish or white extracellular material (drusen) and atrophy of the retinal
pigment epithelium
-Wet AMD =growth of abnormal blood vessels (neovascularization) into the subretinal space

—>Dry AMD MC BUT wet AMD is associated with a greater risk of vision loss

—>moderate dry AMD (defined as extensive intermediate size drusen or at least one large lesion, or significant
retinal pigment epithelium atrophy in one or both eyes) to advanced AMD

—>TX: W/ vitamins C and E, β-carotene, and the minerals zinc and copper for MODERATE DRY AMD (defined
as extensive intermediate size drusen or at least one large lesion, or significant retinal pigment epithelium atrophy
in one or both eyes) TO ADVANCED AMD
—>IN SMOKERS OR LUNG DZ SUBSTITUE BETA CAROTINE WITH ZEAXANTHIN (BETA CAROTENE
ASSOC W INC LUNG CA)

FOR WET AMD—>NEED Vascular endothelial growth factor inhibitors BC OF inhibitory effect on
neovascularization

• BLADDER CANCER
If no extension in muscle layer (just on mucosa layer)à1st do TURBT and BCG or mitomycin intravesicular
THEN NEED SERIAL CYSTOSCOPY
IF RECURSàDO ANOTHER TURBT AND BCG

BUT if develop recurrence within 6-12 mo of TURBT OR if recurs after 2 courses of BCG then need cystectomy

For muscle invasive disease need SYSTEMIC CHEMO then CYSTOSCOPY

• IN NEWLY DIAGNOSED COLON CANCER IT IS STAGING THAT IS MOST IMPORTANT PROGNOSTIC

FACTOR
àAmerican Joint Commission on Cancer (AJCC) TNM classification. “T” indicates the extent of the tumor (size
and/or depth of penetration), “N” represents the number of locoregional lymph nodes that contain cancer, and “M”
indicates whether metastases are present or absent. TNM scores are then classified on a scale of stage I to IV,
with stage I tumors having the best prognosis and stage IV having the worst
• LYMPHOMA
àMC IS DIFFUSE LARGE B CELL LYMPHOMA
-can involve mult organs including bowel and stomach AND CAN GROW AS BULKY FLESHY MASS

-cells LARGE
-TRANSLOCATION OF BD6 GENE
-express CD 20
>>>REVISED INTERNATIONAL PROGNOSTIC INDEX SCORE BEST COORELATES WITH CHANCE OF
OVERAL SURVIVAL>>>
-TX with rituximab

VS

MANTLE CELL LYMPHOMA

àRARE FORM of non Hodgkin lymphoma
-usually advanced dz at presentation including lymphadenopathy, wt loss, fever

àmonotonous prolif of small cells (larger forms are rare/absent)

-usually DIFFUSE SITES OF INVOLVEMENT including GI, BM, and blood stream
-OVEREXPRESSES CYCLIN D1 (cell cycle gene regulator) and is assoc w chromosomal
Translocation 11:14
àAlso CD20, CD 5 and CD 23
-poor prognosis but tx w Rituximab for induction with CYTARABINE followed by autologous
cell tx; then rituximab maintenance

• CANDIDEMIA
à if bc PICC remove and add antifungals for at least 2 weeks after symptoms resolve
-repeat blood cult until clear

• Aminoglycoside (GENTAMICIN) induced AKI

à nonoliguric ACUTE TUBULAR NECROSIS with granular casts
àfractional excretion of sodium >1%
àcreatinine rises 5 to 10 days after starting therapy
 VS

Cephalosporin AKI =acute interstitial nephritis

—>URINE SHOWS leukocytes, erythrocytes, and leukocyte casts
—>SXS: Fever, maculopapular rash, peripheral eosinophilia, and eosinophiluria can also occur
—>Onset 3 to 5 days with a second exposure, to as long as several weeks to months with a first exposure

VS

Iodinated contrast = vasospasm = ischemic injury or direct damage to the kidneys

=
increase in serum creatinine of 0.5 mg/dL or an increase in serum creatinine of 25% from baseline at 48 hours
after contrast administration
—>Low osmolar contrast safer than high osmolar contrast

• BACK PAIN + HYPERREFLEXIA AND WEAKNESS IN LOWER EXTREMITY = spinal cord compression
à 1st give steroids to dec inflame and reduce mass effect
àTHEN do radiation
àTHEN do possible neurosurgical intervention (maybe)

• Can do OUTPATIENT ANTICOAGULATION for pulm emobolism àFONDAPARINUX

àONLY need inpatient if supplemental O2 or pain meds or if comorbid conditions such as high bleeding risk

• THROMBOLYTIC therapy SHOULD BE SYSTEMIC and not catheter directed for PE but only if:
àsystolic BP <90 mmHg and without C/I (ie high bleed risk)

• ABD pain, N/V, loose stools w/progressive fever, headache + rash

+
Relative bradycardia
+
From endemic area (asia, africa and latin america)
+
Tender hepatosplenomegaly with scleral icterus
+
Low plt and elevated AST, anemia, elevated bilirubin
=

TYPHOID FEVER
àaka enteric fever 2/2 salmonella enterica
-fecal-oral
àserology can help but NEED ISOLATION OF MO via blood, stool, urine and/or BM to confirm
TX: CIPRO, azithro, ceftriaxone

VS

TX: doxy, streptomycin, cipro or ofloxacin, rifampin, Bactrim, tetracycline (sumycin)

VS
TX: RIBAVIRIN

VS

LEPTOSPIROSIS
èspirochetes
MC zoonosis in the world and spread by rodents in fresh water, mud or soil

àSXS: fever, rigors, HA, photophobia, muscle pain (calf and lumbar), conjunctival suffusion, dry cough, N/V/D
àDX: LEPTOSPIRA IGM ELISA DNA PCR of blood, urine, CSF, culture
àTX: Doxycycline, Ampicillin or amoxicillin, Azithromycin or clarithromycin, Fluoroquinolone such as
ciprofloxacin or levofloxacin
àTX IF IN HOSPITAL: Intravenous penicillin G, Intravenous third-generation cephalosporins (cefotaxime and
ceftriaxone), Intravenous ampicillin or amoxicillin (second-line agents), Intravenous erythromycin (in penicillin-
allergic pregnant women)
• ELDERLY PTS WHO DRIVE
Risk factors that increase the likelihood of an adverse driving event includeà
cognitive dysfunction, caregiver report of unsafe skills, history of citations or accidents, driving fewer than 60 miles
per week, alcohol or medications that affect the central nervous system, emotional aggression or impulsivity,
impaired mobility (including neck range of motion, range of motion of the extremities, and coordination), visual
impairment, and medical disorders that predispose to loss of consciousness

• IgG4-related interstitial nephritis

—>Tubulointerstitial pattern—>mild proteinuria and INFLAMMATORY CELLS WITH H/O AUTOIMMUNE DZ
(pancreatitis)
—>Can be acute or chronic renal fail as well as RENAL MASS-LIKE LESION ON IMAGING
—>KIDNEYS MAY BE DIFFUSELY ENLARGED 2/2 cellular infiltration
—>uncommon disorder 2/2 infiltration of different organs by lymphoplasmacytic infiltrates of IgG4-positive plasma
cells with resultant fibrosis associated with elevated serum IgG4 levels
==>Autoimmune pancreatitis is one form of IgG-related disease

—>NEED BIOPSY FOR Definitive diagnosis w/staining for IgG4-positive plasma cells
TX: steroids

VS

ANCA-associated vasculitis and anti–glomerular basement membrane antibody disease typically cause rapidly
progressive glomerulonephritis with significant proteinuria and hematuria in the sediment, occasionally with
erythrocyte casts

VS
 Lupus nephritis is primarily a glomerular lesion with significant proteinuria in the context of other clinical findings
suggestive of systemic lupus erythematosus and dec complement

• STOP SCREENING PAP in women age 65 years and older who

à have had three consecutive negative Pap smears or two consecutive negative Pap smears plus human
papillomavirus test results within the last 10 years, with the most recent test performed within 5 years NO
MATTER IF NEW SEXUAL PARTNER OR NOT

• Do GENETIC COUNSELING before GENETIC TESTING

àpurpose is to: inform of purpose of test, implications of test results, alternative test options (including
forgoing testing) and possible risk/benefit of testing

• CHRONIC MYELOID LEUKEMIA

àMYELOCYTES, METAMYELOCYTES AND BASOPHILS

àsmear mimics a BM aspirate
àINSIDIOUS fatigue, early satiety and progressive wt loss w/splenomegaly
àHAS BCR-ABL genetic mutation

• Acute promyelocytic leukemia

àassociated with disseminated intravascular coagulation and thrombocytopenia
 à PML-RAR protein mutation

• JAK2 gene mutation is associated with

àpolycythemia vera,
àessential thrombocytosis (ET), and
àprimary myelofibrosis

• The new oral anticoagulants (ie rivaroxaban) should be stopped 24 to 36 hours before surgeries with standard
risk for bleeding and 2 to 4 days before surgeries with a high risk for bleeding in patients with normal kidney
function
àNO BRIDGE unless high risk for VTE

• APLASTIC ANEMIA

BM bx with less than 10% cellularity

àcan be 2/2 infections or toxins OR WITHOUT PRECEEDING INSULT
àINSIDUOUS course; severe pancytopenia w ABSOLUTE NEUTROPHIL COUNT LOW
àdespite neutropenia AA does not have bad infections
àTX: immunosuppressive tx and allogenic hematopoietic stem cell transplantation
 VS

ACUTE LYMPHOBLASTIC LEUKEMIA

àCAN present w PANCYTOPENIA instead of hyperleukocytosis so can mimic labs in aplastic anemia BUT bone
marrow would show leukemic blasts making up hypercellularity

• HYPEREOSINOPHILIC syndrome

-elevated eosinophil count >1500/uL without secondary cause AND involvement of organ
-DUE TO CHINA-------à>> Connective tissue disease, helminthic inf, idiopathic, neoplasia, allergy
-MC organs affected: skin, lungs and GI tract and HEART
-possible 2/2 mutation in tyrosine kinase receptor gene--à TX WITH IMATINIB

VS

Acute EOSINOPHILIC LEUKEMIA

 àINC IMMATURE EOSINOPHILS in blood and bone marrow and infiltration of tissues with immature eosinophils
-can develp cardiac issues but, unlike hypereosinophilic syndrome, there would be ANEMIA,
THROMBOCYTOPENIA AND INFECTION
àMIDOSTAURIN for tx if aggressive

VS

SYSTEMIC MASTOCYTOSIS

àURTICARIA pigmentosa –unique; yellow to red to brown pruritic macules, papules, plaques and nodules
àMC non cutaneous finding is GI (abd pain, N/V/D)
TX: antihistamines, PPI, epinephrine for anaphylaxis, steroids to treat malabsorption, and MAST CELL
STABILIZERS (IE KETOTIFEN) FOR SKIN; CROMOLYN SODIUM TO TX GI SXS, BONE PAIN, HA AND SKIN

• Chronic myeloid leukemia (CML)

—>clonal hematopoietic stem cell disorder. = myeloid proliferation

In chronic-phase leukocyte count is high, the hemoglobin level is low/normal, and the platelet count is normal or
high
—>MAY BE associated with an absolute eosinophilia, but tissue or organ dysfunction is not common
 —>DX: (9;22) translocation by routine cytogenetics or fluorescence in situ hybridization or of the BCR-ABL fusion
transcript by reverse transcriptase-polymerase chain reaction
TX: HYDROXYUREA FOR CHEMOTX
àif fail 2 Tyrosine kinase inhibitors (imatinib) then ALLOGENIC HEMATOPOIETIC STEM CELL TRANSPLANT
and/or OMACETAXINE (if resistant to TKIs)

• COLD agglutinin disease

àagglutinated erythrocytes; these disappear when warmed

àSXS: Fatigue, progressive dyspnea; blue tint to fingers, toes when cold +/- scleral icterus, systolic murmur
àHAS ELEVATED LDH and reticulocytes
 àDISEASE MAY APPEAR AS PRIMARY DISORDER or assoc w a lymphoproliferative d/o or inf (ie Mycoplasma
pneumoniae or EBV)
àIgM ab directed toward Ag on surface of erythrocytes and then this fixes complement
DX: DIRECT antiglobulin (coombs) test
TX: Avoid cold

• IF >75 YO, CKD AND/OR ON MED THAT INTERACTS W STATIN (DILTIAZEM) THEN GIVE MODERATE
DOSE STATIN EVEN IF WOULD BENEFIT FROM HIGH DOSE

• FOR PRIMARY DYSMENORRHEA àPAINFUL CRAMPS W PERIOD

à1st NSAID or Cox 2 INH
àIf cannot take above or if doesn’t work give COMBINED ESTROGEN-PROGESTIN CONTRACEPTIVE PILL

• If PMS OR PMDD (PREMENSTRUAL DYSPHORIC DISORDER GIVE SSRI

• INCONTINENCE

àSTRESS àinvoluntary loss of urine when sneezing, coughing, laughing or physical exertion
-urethra weakened
-TX: pelvic floor muscle training +/- biofeedback, wt loss

àOVERACTIVE BLADDER
-Tx: Oxybutynin

àIMPAIRED MOBILITY OR COGNITION

-leads to overflow àprompted and scheduled voiding TX

• NEPHROLITHIASIS

àURIC ACID STONE

-Tx: inc urine output to at least 2L/d
-If fails then alkalinize urine (with POTASSIUM CITRATE OR POTASSIUM BICARB)
-3RD LINE: ALLOPURINOL if uric acid levels very high (1000 mg/24 hr)

àHYPEROXALURIA
-Tx w cholestyramine (binds oxalate in gut)

àCalcium stone
-Tx: HCTZ (inc prox Na re-absorption and passive Ca reabsorption in kidney)

• In immunosuppressed pt or liver dz or aspleniaàgive 3-5 day prophylactic Amox-clav for dog bite
àPLUS tetanus if not immunized in last 5 yrs

• PID
àLQ abd pain, cervical wall motion tenderness +/- cervix erythematous
àhospital admit if N/V and cant take oral meds OR if has abscess on US
àin hospital tx w/ Cefoxitin or cefotetan plus IV doxy
àoutptàtx with Ceftriaxone (single dose IM) plus 14 days Doxy +/- Flagyl

• HEMOPHILIA
Aàfactor VIII def
 Bàfactor IX def

-both have prolonged apt that fully corrects in mixing STUDY and both FAMILIAL
But
Hemophilia A is X linked so will be seen in MALES in fam
Whereas hemophilia B is autosomal recessive; also hem B is milder (mucocutaneous only) and unlikely to cause
bleed after procedures or cause major bleed (IC hemorrhage)

• PREP for HIV

àDaily combo Tenofovir-emtricitabine

• POST EXPOSURE PROPHYLAXIS FOR HIV

à Tenofovir-emtricitabine PLUS RALTEGRAVIR

• Stop warfarin 5 days before surgery w mod to high risk of surgery; can cont ASA
• Cont warfarin if placing cardiac device!!!!!
• HIGH RISK SURGERIES: CABG, kidney bx, procedure >45 min
à???BRIDGING
-IF JUST MECHANICAL AORTIC VALVE have low <5% annual risk of thromboembolism = NO
BRIDGING
-IF mechanical aortic valve PLUS ADDITIONAL STROKE RISK FACTORSàbridge
-IF MECHANICAL MITRAL VALVEàneed bridging
-IF A FIB AND HIGH RISK OF STROKE (CHADS2 OF 5-6) èBRIDGE
-If systemic embolism, VTE or TIA or stroke
1) within 3 moà try to delay surgery if can.
2). If cant delayàbridge
-IF recent coronary stentèbridge
-IF h/o VTE during interruption of anticoagàbridge

-PREFER LMWH for bridging bc can do as outpatient

• DO NOT NEED BRIDGING WITH NOACS BC SHORT HALF LIVES

• Pt w/ PAH who has NEG vasoreactivity test (NO) DO NOT USE CA CHANNEL BLOCKERS
àIF symptoms only w exertionàGIVE phosphodiesterase 5 inh (SILDENAFIL, TADALAFIL) OR endothelin
receptor antagonists (BOSENTAN, AMBRISENTAN)
àIF symptoms w exertion and rest OR if fail aboveà Give IV meds: EPOPROSTENOL or Give inhaled med:
ILOPROST

• IF patient w PAH has a pos vasoreactivity test (dec in mean PAP at least 10 mm Hg without significant reduction
in cardiac output or systemic blood pressure) then START W calcium channel blockers (Nifedipine)
• FOR KIDNEY TRANSPLANT PTS: in addition to age and sex appropriate screening for disease post op you
should screen for SKIN cancer (bc 200 x inc risk of SCC compared w general pop) AND lymphoproliferative
diseases

• CAN get ARDS from VENTILATOR INDUCED LUNG INJURY

-Tidal volume should be 6 mL/kg of IDEAL BODY WT
-PLATEAU PRESSURE should be < 30 cm H20

• TRALI
àTransfusion assoiated lung injury
àafter blood products (any) that activate recipient neutrophils
àcan cause ARDs but would be least severe form of ARDS
àRISK HIGHEST when blood product from a multiparous female

• HIGH RESOLUTION CT is gold standard test for bronchiectasisàWILL SHOW AIRWAY DILATATION W LACK
OF TAPERING, BRONCHIAL WALL THICKENING AND CYSTS, signet rings

àbronchiectasis àchronic cough w purulent sputum and recurrent PNA

àPFTS show only mild-mod airflow obstruction WITHOUT change w bronchodilator
àPE: +/- crackles/wheezing
àON CXRAY show “BRONCHOVASCULAR” MARKINGS AND/OR LINEAR ATELECTASIS OR DILATED AND
THICKENED AIRWAYS (TRAM OR PARALLEL LINES) or ring shadow
 PIC 1) thin arrow is ring shadow; thick arrow is tram tracking and double arrows are compensatory hyperinflation
PIC 2) Signet ring
PIC 3 & 4) IN PTS W CYSTIC FIBROSIS -àCYLINDRICAL (TUBULAR) BRONCHIECTASIS and lack of
bronchial tapering
PIC 5) in IPFàVARICOSE BRONCHIECTASIS

>>IF FIND BRONCHIECTASIS RULE OUT: cystic fibrosis, immunoglobulin def, mycobacterial dz

• ABSOLUTE RISK = (PTS W EVENT IN GROUP) / (TOTAL PATIENTS IN GROUP)

• ABSOLUTE RISK REDUCTION = (AR IN TX GROUP) – (AR IN CONTROL GROUP)

• NNT = 1 / (ARR)
• TILT TABLET TESTINGèTO DIAGNOSE REFLEX SYCOPE triggered by standing , unexplained syncope in
high risk setting, recurrent syncope in absence of heart dz or recurrent syncope in heart dz in which cardiac
causes ruled out

• STATINS, AC E INH, ARBS -àteratogenic and must be stopped before preg

• The American Heart Association, American College of Cardiology, and The Obesity Society (AHA/ACC/TOS)
guideline for the management of overweight and obesity recommends screening for overweight and obesity by
calculating BMI at annual visits or more frequently

==>The guideline ALSO recommends measuring waist circumference at the level of the iliac crest in overweight
and obese patients
—>Central adiposity (waist circumference >102 cm [40 in] in men and >88 cm [35 in] in women) is
associated with an increased risk for hypertension, type 2 diabetes mellitus, and coronary heart
disease, independent of BMI
—>(Measuring waist circumference in patients with a BMI >35 is unnecessary, as the waist circumference
will likely be elevated.)

Together, BMI and waist circumference can be used to risk stratify patients

• PROGRESSIVE SOMNOLENCE, HYPOTENSION, WIDENING OF QRS, SEIZURE AND ANTICHOLINERGIC

SIGNS (fever, tachycardia, mydriasis, reduced bowel sounds)
=
TRICYCLIC ANTIDEPRESSANT OVERDOSE
àTCAs inh fast Na channels in myocardium resulting in DECREASED ventricular function and inc duration of
repolarization PREDISPOSING TO vent arrhythmias
à QRS > 100 ms = signficicant TCA cardiotox

àTX with sodium bicarbonate which INCREASED SERUM PH AND INHIBITS THE IONIZED FORM OF THE
DRUG THAT BINDS SODIUM CHANNELS (makes it less avail) AND inc extracellular sodium which INC
electrochemical gradient across myocardial cell membranes and minimizes effect of Na channel block by TCA

• For Ca channel blocker OD à Tx with IV calcium gluconate

à In verapamil and diltiazem get BRADYCARDIA; but not with amlodipine

• For avg risk pts colorectal cancer screening strategies are:

FIRST TIER TESTING

àcolonoscopy every 10 years or
àannual fecal immunochemical testing (FIT) annually

SECOND TIER TESTING

àCT colonography every 5 years,
àFIT-fecal DNA testing every 3 years, or
àflexible sigmoidoscopy every 5 to 10 years

THIRD TIER TESTING

àcapsule colonography every 5 years
• WEIGHT LOSS DRUGS AND KIDNEY PROBS
—>Orlistat
-can cause calcium oxalate crystals BC med blocks fat uptake so unabsorbed fats bind w
calcium to make calcium soaps SO calcium not avail to bind w oxalate SO end up w enteric
HYPEROXALURIA

—>Aristolochic acid in herbal preparations and weight loss supplements

-cause nephropathy. This condition is characterized by extensive, primarily interstitial, fibrosis
with tubular loss,
-ALSO INC RISK FOR urothelial malignancies

—>Ephedrine
-INC risk of nephrolithiasis, and analysis of the stones reveals the presence of ephedrine,
norephedrine, and pseudoephedrine.
-ALSO INC RISK OF rhabdomyolysis

—>Phentermine is not known to cause AKI or other kidney disorders

• WOMEN W/MIGRAINES have inc risk of STROKE if take COMBINED hormonal contraception (including oral
AND vaginal ring), esp if migrane w aura
àdepot medroxyprogesterone acetate injection is progestin only; any progestin only method may have periods of
amenorrhea BUT MAY ALSO HAVE BREAKTHROUGH BLEEDING
àUSE IUD

• FACTOR V LEIDEN DEF

àEXTREMELY rare causing abnl bleding a result of failure of thrombin generation bc inadequate amt of factor V
àpoint mutation in factor V gene that causes it to be resistant to inactivation by activated protein C
àif evidence of VTE then can test for FVL with APC RESISTANCE ASSAYàassesses ability of protein C to
inactivate factor Va; can do confirmatory genetic PCR of FVL gene for point mutation in genetic material from
leukocytes from peripheral blood
àNO NEED to screen asymptomatic family members of people with FVL

• POSITIVE RADIOLABELED OCTREOTIDE SCAN means that somatostatin receptors are present and tumor is
NEUROENDOCRINE
• IF LOW GRADE METASTATIC CARCINOID TUMOR to liver REPEAT ABD IMAGING WITH CONTRAST CT
EVERY 3-4 MONTHS if the patient is ASYMPTOMATIC
àIF DZ PROGRESSES CONSIDER TX: hepatic artery embolization, Octreotide (somatostatin analogue)
CAN DO radiofrequency ablation IF small # of lesions ONLY

• TESTICULAR GERM CELL TUMORS

à SEMINOMAS
àNONSEMINOMATOUS GERM CELL TUMORS

>>SEMINOMAS = BETTER PROGNOSIS

>>STAGE 1 seminoma = DZ LOCALIZED TO TESTES: remove mass VIA RADICAL INGUINAL
ORCHIECTOMY;
 èTHEN ACTIVE SURVEILLANCE (regular assessment w serum tumor marker measurement and CT
scans of abd and pelvis and cxr)

OR

èADJUVANT THERAPY with a single agent carboplatin or para-aortic lymph node irradiation

>>MORE ADVANCED SEMINOMAS (or pts w NSGCT) NEED: bleomycin, etoposide and cisplatin; Treatment-
related complications : cardiovascular disease (specifically metabolic syndrome), kidney disease,
peripheral neuropathy, chronic pulmonary toxicity, secondary malignancy, and sexual dysfunction
>>pts w NSGCT need RETROPERITONEAL LYMPH NODE DISSECTION but pts w seminomas DO NOT

• Vitamin and/or mineral supplementation has not been shown to reduce CV dz or cancer

• PPROSTATE PROBLEMS:

TNM stage T1c tumor —> elevated PSA; absence of symptoms; a serum PSA level less than 10 ng/mL (10 µg/L),
and a Gleason score less than 8
-does not need further imaging

START IMAGING if —>PSA level of 20 ng/mL (20 µg/L) or higher, a PSA level of 10 ng/mL (10 µg/L) or higher
associated with a T2 tumor, a Gleason score of 8 or higher, or a T3 or T4 tumor

• In hereditary hemochromatosis
àDO need to avoid EXCESSIVE red meat, but can still eat SOME
àCOMPLETELY AVOID raw or undercooked seafood as there is risk for VIBRIO VULNIFICUS bc excess iron
inhibits host defenses (cannot phagocyte) resulting in inc VIRULENCE

• MENOPAUSE

àIF just GU symptoms can give èVAGINAL ESTRADIOL

àif still has uterus and >60 yo or has VTE history or h/o breast canceràcannot give hormonal intervention

àIF <60 yo without above risk factors (but still has uterus) can give COMBINED ESTROGEN-PROGESTIN med;
need progestin to counteract estrogen since pt has uterus

àIF HAD HYSTERECTOMY-àCAN GIVE TRANSDERMAL ESTRADIOL; does not need progestin to oppose
estrogen bc will not get uterine cancer since does not have uterus

• TYPES OF BIAS

—>Anchoring is a diagnostic cognitive error that results from locking onto features of a patient's initial
presentation despite the appearance of new clinical information

—>CONFIRMATION—>interpret tests in a way that confirms current hypothesis instead of looking objectively
 —>Framing—>way info is framed affects decisions based on that info; perception of inc effectiveness of a
specific tx presented in a relative instead of absolute way

—>Triage cueing—>way pt initially triaged influences management w eval and diagnosis

• HYPONATREMIA
àIF euvolemic the proper response is SUPPRESION of ADH with INCREASE in free water clarance AND URINE
OSMOLALITY LESS THAN PLASMA OSMOLALITY
But
IN SIADHàinc ADH URINE OSMOLALITY SIGNIFICNATLY AND INAPPROPRIATELY GREATER THAN
PLASMA OSMOLALITY IN SPITE OF EUVOLEMIA AND NO STIMULI FOR ADH RELEASE

• PRIMARY polydipsia
àsuspect in pt w mental illness and HYPONATREMIA, esp in schizo w psychotropic drugs
àpresents w/ HYPOnatremia, dec plasma osmolality, and DECREASED URINE OSMOLALITY reflecting
suppressed ADH in response to water overload
BUT
àpts may also have abnormalies of ADH regulation ie transient stim of ADH during PSYCHOTIC EPISODES and
INC RENAL RESPONSE TO ADH so that AT THE SAME LEVELS OF ADH PT MAY HAVE HIGHER URINE
OSMOLALITIES due to downward resetting of osmostat that regulates ADH release
SO
URINE may not be as dilute as you would expect-àDO NOT BE FOOLED

• BEER POTOMANIA
àBC WATER EXCRETION IS SOLUTE DEPENDENT then LIMITED SOLUTE INTAKE (due to alchol diet)
DECREASES free water excretion and hyponatremia results WITH MODEST INC OF FLUID INTAKE
àwill have LOW urine osmolality

• NEPHROGENIC DIABETES INSIPIDUS

àPOLYuria and POLYdipsia
àMC lithium induced: WORKS at ADH receptor in kidney and blocks
àPTS MAKE LOTS OF DILUTE URINE AND HAVE TO DRINK MORE TO AVOID HYPERNATREMIA

>>>so serum osmolality >300 with urine osmolality less than 300 and spec gravity of 1.005 or less<<<

àwill not become hypernatremic UNLESS WATER TAKEN AWAY

àtest for NDI by taking fluid away; deprivationà if serum osmol still high and urine osmol still low then DI

àcan test w desmopressinàto figure out if central or nephrogenic

IF NEPHROGENIC will NOT respond to ADHàTX W LOW SALT DIET AND HCTZ

èIF Central DI tx w desmopressin

• IN ACTIVE GI BLEED or any bleed NEED LARGE CALIBER PERIPHERAL IV ACCESS (14 gauge NOT 18
gauge)

• IVC only necessary for VASOPRESSOR TX bc this cannot be given through peripheral access
• Patients with HIV/AIDS with CD4 cell counts less than 50/µL and less than 200/µL should undergo prophylaxis
against Mycobacterium avium complex (Azithromycin) and Pneumocystis jirovecii (Bactrim), respectively
àEVEN IF HAVE CMV + do not treat prophylactically w valgangcyclovir bc of risk of HEMATOLOGICAL TOX
àan INDETERMINATE interferon gamma release assay CAN be due to VERY LOW CD4 and inability to react to
the postivive control used in testing so IN ABSENCE OF SYMPTOMS DO NOT TREAT

• Plasma Osmolality = 2 × Serum Sodium + Plasma Glucose / 18 + Blood Urea Nitrogen / 2.8
àUSE CALCULATION ABOVE TO GET CALCULATED PLASMA OSMOL AND SUBTRACT THIS FROM LAB
VALUE
àIF DIFFERENCE SIGNIFICANT THINK injested methanol or ethylene glycol THINK pseudohyponatremia 2/2
ELEVATED LIPIDS or ABNORMAL PARAPROTEINS (MM)

• GENERAL NECESSARY SCREENING IN >65 YO: palpate pulse to screen for A fib

• EXERCISE induced hemolysis

àrunner’s hemolysis àerythrocyte damage through repetitive mechanical trauma such as running or marching
resulting in intravascular hemolysis
àHEMOLYSIS = inc free Hg in plasma that is filtered by kidneys = hemoglobinuria àBLOOD BY DIPSTICK
without erythrocytes
àIF PROLONGEDàmay become secondarily iron def through iron loss in urine
àCan see iron def anemia w evidence of urine iron loss by presence of HEMOSIDERIN in sloughed tubular cells
by PRUSSIAN BLUE STAINING

• IF having surgery and TAKING LOW DOSES OF GLUCOCORTICOIDS (as in transplant pt on stable 5 mg/d) DO
NOT NEED STRESS DOSING àjust take normal pred morning of surgery
àwith surgery will NEED stress dosed hydrocortisone if have primary adrenal insuff or pt on HIGH dose steroid
(pred > or = 10 mg/d) OR those undergoing higher risk surgery

• Do modified Valsalva àvalsalva then supine repositioning and passive leg raiseà FOR supravent tachy

• ASCITES
 àMORRISON’S POUCH is area between liver and kidney
àthis area shows as WHITE if central obesity; PERINEAL FAT IS GREY NOT WHITE (NORMAL)
àthis area shows ascites if BLACK (fluid) there

• CROHN DISEASE
--AFFECTS ANY SEGMENT OF GI TRACT AND IS OFTEN DISCONTINOUS
--CAUSES TRANSMURAL INFLAM
--may cause fistulas

• Staph abscess

-tender erythematous fluctuant nodule topped by central pustule

• Squamous lung CA à if unresectable do CARBOPLATIN, PACLITAXEL and RADIOTHERAPY x 6

àIF progresses despite this do NIVOLUMAB –a PD-1 inhibitor
àNivolumab inc survival in both SCC and NSCL cancers
àPD-1 downregulates immune sxs by preventing T cell actiation
• ER+ PR + breast ca
àtx with Anastrozole (aromatase inh) AFTER lumpectomy OR radical mastectomy AND radiation
àEVEN less likely for VTE than tamoxifen

• HER2 + INVASIVE breast ca

àtx with TRASTUZUMABàmonoclonal Ab against epithelial growth factor receptor

• OVARIAN CA
àdo not biopsy if lesion in ovary as can seed
àIF ALREADY IN PERITONEUM can biopsy a peritoneal implant
àif peritoneal implant has stage IIIC ovarian ca
-1st line tx is: cytoreductive surgery AND then adjuvant chemo
UNLESS
has had process w high risk in perioperative period such as recent MI OR if pt unlikely to have optimal
tumor debulking w primary cytoreductive surgery (defined as residual tumor >1cm)
-If recent MI AND DES placement needs clopidogrel and cannot be stopped SO can do -------à
NEOADJUVANT CHEMO followed by cytoreductive surgery

àCHEMO would be done ALONE if mets extend out of abd or if refuses operative intervention OR if
unacceptable operative risk after chemotx (REEVAL AND SEE)

àpalliative care if pt thought not to be able to tolerate neoadjuvant chemo OR refused therapy

• DIFFUSE IDIOPATHIC SKELETAL HYPEROSTOSIS

 àchronic low back pain unresponsive to NSAIDS>>>>>
-MC in thoracic spine but lumbar in pic

-DISTINCTIVE FLOWING LINEAR CALCIFICATIONS AND OSSIFICATIONS ALONG ANTEROLATERAL

ASPECTS OF VERTEBRAL BODIES THAT CONT ACROSS DISC SPACE

àin cervical spine hyperostosis ON ANTERIOR SURFACE OF VERTEBRAL BODY (INF LIP) RESULTING IN
DOWNWARD POINTING SPUR

àIN LUMBAR SPINE SPURS POINT UPWARDS AND COMPLETE bridging of lumbar disk space by bone is
present

• CEREBRAL aneurysm

àpt most likely to dev SUBARACHNOID HEMORRHAGE in 4.5 mm saccular ACA aneurysm
àmay be symptomaticàheadache and focal neuro deficits
 àTX with coiling that thromboses and obliterates sac as shown:

NO BLOOD FLOW s/p coiling

IF STRONG FAM HX OF ANEURYSM

--AND symptomaticèCT ANGIO
--AND ASYMPTOMATICèMRA

• ISCHEMIC STROKE
àIF LARGE (determined by level of disability) prob fed by terminal IC artery or MCA àif not c/I do ALTEPLASE
BUT
Success w thrombolytic at recanalizing is low if occlusion at MCA or IC terminus
SO
àDO CT ANGIO to determine eligibility of ENDOVASCULAR TX (stent occlusion removers)

àALWAYS hold ASA after thrombolytic for 24 hours AND after repeat imaging

àKEEP BP UNDER 180/105àGIVE iv labetalol or nicardipine

àMRI gold standard for ischemic stroke BUT not to be done during acute stroke as it takes too much time; after
acute stroke tx do MRI to get àFINAL infarct size, ??hemorrhagic conversion, ??cerebral edema

• IN SQUAMOUS CELL LUNG CANCER that is LIMITED STAGE (1 hemothorax w hilar and mediastinal LAD that
can be encompassed within 1 tolerable radiotherapy portal
àDO either CHEMO or CHEMO +RADIATION tx 1st
Then IF GOOD RESPONSEà
àdo PROPHYLACTIC CRANIAL IRRADIATION as this will prevent mets if there is recurrence

èIF SCLC WITH VERY SMALL PRIMARY TUMOR AND NO LAD àcan do SURGICAL RESECTION of residual
lung mass ------------DO NOT DO CHEMO AND RADIATION AND THEN SURGERY; IF DO SURGERY
SURGERY IS DONE 1ST
• CAN CONFIRM A SLE FLARE with an anti – DS DNA Ab measurement as this correlates with SLE dz activity
particularly w active kidney dz or GN----it’s a marker for developing LUPUS NEPHRITIS

èANTI SMITH AB: most SPECIFIC for SLE but does not correlate w dz activity

àAnti Ro/SSA and Anti-La/SSB can be found in Sjogren BUT also found in SLE
AND
Associated with SLE rashes/photosensitivity
AND are risk factor for development of NEONATAL lupus
BUT DO NOT CORRELATE W DZ ACTIVITY

èAnti U1-ribonucleoprotein Ab found in pts w SLE AND MIXED CONNECTIVE TISSUE DISEASE

àMixed connective tissue disease is an overlap syndrome that includes features of systemic lupus
erythematosus, systemic sclerosis, and/or polymyositis in the setting of positive anti-U1-
ribonucleoprotein antibodies
-does not correlate w disease activity

• ACID BASE PROBLEMS

àto figure out if appropriate arterial PCO2 to compensate for a primary metabolic acidosis use WINTER’S
FORMULA

(1.5 x bicarb) + 8 +/- 2)

Or

ROUGH estimate is that the PCO2 should about equal THE LAST TWO DIGITS OF THE PH

àIF numbers same it means that there is APPROPRIATE RESP COMPENSATION

• CHRONIC OSTEO
àif sinus tract from site and CULTURE done you cannot believe results UNLESS growing Staph aureus
àIF growing staph do vanc
àIF DOESN’T grow staph DO BONE BIOPSY AND CULT to determine abx to be used

• CALCIUM PYROPHOSPHATE deposition àPSEUDOgout; is INFLAMMATORY

 àRHOMBOID OR ROD SHAPED crystals NOT BIREFRINGENT or are WEAKLY POS BIREFRINGENT

àCRYSTALS seen in articular cartilage (chondrocalcinosis)

LAST PIC: GOUT crystals on left and pseudogout on right

• SODIUM GLUCOSE TRANSPORTER 2 INHIBITOR ---CANAGLIFLOZIN----

àassoc w risk of amp of toe and mid foot most common
àRISK HIGHEST IN PT W PAD, prior amp and neuropathy

• IF PT USING ASA PRIOR TO ISCHEMIC STROKE and TAKING ALL OTHER NECESSARY MEDS
THEN
àadd DIPYRIDAMOLE to ASA

-do not add Clopidogrel to ASA w these pts (small subcortical infarcts-lacunes)

àticlopidine is 2nd line (after ASA) even tho it is superior to preventing second stroke BC HIGH RISK OF
AGRANULOCYTOSIS AND TTP

• EOSINOPHILIC ESOPHAGITIS
à MC young man w solid food dysphagia requiring endoscopy for removal
-parallels asthma/allergy and these pts have it
àDX W > 15 EOSINOPHILS / HPF on esophageal biopsy AND BY EXCLUSION OF GERDàhave to exclude
GERD 1st (w/ PPI trial for 8 wks)
-need to reassess clinically and maybe even via endoscopy after PPI tx

àendoscopy shows EOE has: RINGS, longitudinal furrows and sometimes strictures
TX w aerosolized topical glucocorticoids (fluticasone or budesonide)
• ACHALASIA
àAchalasia, an esophageal motility disorder is characterized by a combination of absent primary peristalsis and
impaired lower esophageal sphincter (LES) relaxation

PRIMARY àDEGEN OF INHIB GANGLION CELLS IN MESENTERIC PLEXUSES; NEEDS PNEUMATIC

DILATION
SECONDARY NEEDS TX OF UNDERLYING CONDITION (malignancy)===MC assoc malignancy for
PSEUDOACHALASIA is gastric cardia carcinoma; also Chagas, post op (gastric banding)

àMANOMETRY is gold standard but cannot figure out 1ary for 2ary
àBarium esophagogram USUALLY DONE FIRST though ----in achalasia demonstrates a dilated, esophagus with
smooth, tapered, symmetrical narrowing (“bird-beak narrowing”) at the GEJ and no primary peristalsis during
video fluoroscopy
• Barrett esophagus
à2/2 chronic reflux

àENDOSCOPY finds salmon colored mucosa at GE junction COMPARED W NORMAL PEARL COLORED
SQUAMOUS CELL MUCOSA; confirm histologically by metaplasia w acid mucin containing goblet cells

-if find low grade lesion repeat every 6 mo then annually until 2 neg tests
-if high grade every 3 mo

• DIFFUSE ESOPHAGEAL SPASM

è SXS: DYSPHAGIA or chest pain but NOT food compaction
 àmanometry shows intermittent high amplitude simultaneous non peristaltic contractions in response to
swallowing
àbarium swallow shows corkscrewing caused by mult simultaneous contractions
àLONGITUDINAL RINGS OR FURROWS seen on endoscoptic exam

• ZENKER’S DIVERTICULUM

The diverticulum on right and true esophageal lumen on left—separated by a bridge

• ACNE

àcomedonal acnea àBENZOYL PEROXIDE WASH 1st THEN + topical retinoid if worsened
-in preggos most topical retinoids are category C while topical TAZAROTENE is category X

àIN INFLAM ACNE

-IF mod-severe: topical 1st; then systemic abx if worsened or not better; need ENDOCRINE to r/o
hyperandrogenism

àIF MOD-SEVERE that is tx resistant or CAUSES SCARRING or distress à ORAL ISOTRETINOIN

-women of childbearing age NEED to be on oral contraceptive

• Digital pitting
à2/2 Raynaud phenomenon ischemic injury
-can be w primary (solo) Raynaud OR w ppl w progressive systemic sclerosis

VS

Skin findings in INFECTIVE ENDOCARDITIS

VS

SKIN findings Dermatomyositis

 VS

FINDINGS in takayasu’s arteritis

-pyoderma gangrenosum and erythema induratumm respectively

• Treatment options for diabetic polyneuropathy include the tricyclic antidepressants, other classes of
antidepressants (duloxetine, venlafaxine), anticonvulsants (pregabalin, gabapentin, valproate), and capsaicin
cream

• HIV-infected persons at least 2 months old or > NEED quadrivalent meningococcal vaccine (MenACWY
è Most cases of meningococcal disease among HIV-infected persons are caused by serogroups A, C,
W, and Y. Hence, adults with HIV infection are not routinely recommended to receive the
meningococcal B vaccine
 èSO JUST NEED two-dose primary series of the MenACWY vaccine, with doses administered at least 2
months apart, and he should be revaccinated every 5 years. Two vaccines are available, MenACWY-D
and MenACWY-CRM, either of which may be used in HIV-infected persons.

àRoutine vaccination with the meningococcal conjugate vaccine is also recommended for all healthy
adolescents

• Inappropriate sinus tachycardia (IST) —symptomatic sinus tachycardia that has no identifiable etiology;
MC young women
—>resting heart rate of more than 100/min, with an average 24-hour heart rate of more than 90/min.
—>Symptoms vary and can include palpitations, lightheadedness, syncope or near-syncope, dyspnea,
and fatigue +/- anxiety/depression
—>HAS assoc myocardial dysfunction

==>DX: 1st r/o hyperthyroidism, anemia, dehydration, pain, illicit drug use, and anxiety.

TX: Ivabradine may be used to reduce heart rate and ongoing symptoms if no obvious causative factor
is identified. Ivabradine is an inhibitor of the If or “I-funny” channel, which contributes to normal sinus
node function. Its sole effect is in slowing the heart rate by decreasing sinus node automaticity.
==>symptoms CAN persist despite tx; can add BBlocker in that case

Sinus node modification using radiofrequency ablation, surgical ablation, or denervation may be
considered when medical therapy is ineffective. These are aggressive measures and can have
significant complications, including symptomatic sinus bradycardia, phrenic nerve injury, or superior
vena cava syndrome. Symptoms may recur even after initial success with these procedures.

• Lyme disease, which has increased significantly in Virginia over the past decade, should be suspected in
patients who have possible recent exposure in the Southeastern United States, in addition to
previously identified geographic areas, presenting with a large solid erythematous lesion or one with
central clearing

• Miliary TB
- bilateral p innumerable 1- to 3-mm nodules, predominantly seen within the lower lung fields (arrows). These
findings, although not specific, are typical of dissemination of tuberculosis through the vasculature or the
lymphatic vessels. The small-sized nodules have been likened to millet seeds, from which the term miliary is
derived. Slight lower lobe predominance is likely a result of the effects of gravity on blood flow.

• Shigella isolates with a ciprofloxacin minimum inhibitory concentration of 0.12 μg/mL or greater should
be considered resistant to this agent, and alternative therapies should be used
àdon’t tx unless severe; other option is AZITHRO

• Vaginal lichen sclerosus è inflammation in the skin, which leads to thinning, hypopigmentation, and
scarring or sclerosus

àsymptomatic, with burning or itching and pain during intercourse. It can progress to severe thinning
of the skin, scarring of the labia and clitoral hood, and stricturing of the vaginal introitus, which can
lead to severe sexual dysfunction
AND
CAN EVEN LEAD TO squamous cell carcinoma, possibly because of the continued inflammation.

TX w/high-potency topical glucocorticoids

>>Low-potency topical corticosteroids are often inadequate in achieving disease control

>>Topical calcineurin inhibitors are often used to treat dermatitis in areas of thin or sensitive skin,
including genital skin; however, they are more often used for psoriasiform dermatitis and are not
potent enough to effectively treat lichen sclerosus.
• Multilobar PNA

-Bilateral alveolar opacifications with air bronchograms, consistent with pneumonia. The right and left
hemidiaphragms are each partially obscured, placing infiltrates within the right and left lower lobes, r
espectively. The right heart border is partially obscured, and an infiltrate within the right middle lobe is
also possible. Pneumonia involving multiple dependent areas of the lungs, such as the lower lobes, is
frequently the result of aspiration. Also seen on this chest radiograph is an endotracheal tube
terminating approximately 2 cm above the main carina and a right internal jugular central venous
catheter with its tip within the superior vena cava. An additional thin-walled tube is likely positioned
within the esophagus, although its course and tip cannot be satisfactorily established on this film
• In patients with prior exposure to macrolide antibiotics or those in areas with clarithromycin resistance
rates of 15% to 20% or higher, clarithromycin should be avoided in treatment regimens to
eradicate Helicobacter pylori
àuse amoxicillin, levofloxacin, and omeprazole.

• In patients with a recent history of ischemic cerebrovascular accident or transient ischemic attack and
insulin resistance without diabetes, pioglitazone treatment decreased the risk of developing diabetes
while also reducing the risk of subsequent ischemic events
Adverse effects = weight gain, edema, and bone fractures requiring hospitalization or surgery,

• Weight loss and several drugs, including metformin, have been used to decrease overt progression to
diabetes in patients with impaired glucose tolerance, but pioglitazone is the only therapy with proven
efficacy in patients with CVA

• According to a recent study, enzyme-linked immunosorbent assay for toxins A and B is the most
appropriate initial test for suspected Clostridium difficile infection.

• IMMUNOCOMPROMISED AT ANY AGE; needs 13-valent pneumococcal conjugate vaccine (PCV-13) 1 or

more years after the 23-valent pneumococcal polysaccharide vaccine (PPSV-23). A second dose of
PPSV-23 should be administered 5 or more years after the first dose. Because this patient was
immunized with PPSV-23 6 months ago, he should receive PCV-13 in 6 months and PPSV-23 in 4 years
and 6 months
èFor patients younger than 65 years of age with CKD who have not been previously immunized
against invasive pneumococcal disease, the ACIP recommends that PCV-13 be administered first
followed by PPSV-23 no sooner than 8 weeks later

• In patients with conditions in which increased protein binding of calcium may occur, such as
hyperalbuminemia or paraproteinemia, an artificially elevated total serum calcium level must be
excluded

• Lice
 ==>DX by identifying crawling lice in the scalp or pubic hair
—>Louse egg cases are called nits and are found sticking to the hair shaft in patients with lice. Nits are
generally easier to see than lice

• A serum-ascites albumin gradient (SAAG) of 1.1 g/dL (11 g/L) or greater with an ascitic fluid total
protein level of 2.5 g/dL (25 g/L) or greater indicates a cardiac cause of ascites

• Left lower lobe infiltrate that is consistent with pneumonia

—>LLL obscured by the heart shadow on the posterior-anterior view BUT the lateral view
demonstrates the “spine sign” in which an interruption occurs in the progressive increase in lucency
of the lumbosacral vertebral bodies from superior to inferior because of increased radiographic
density caused by an infiltrate in the left lower lobe

• Nicotinamide (vitamin B3) has been shown in a phase 3 clinical trial to lower the rate of nonmelanoma
skin cancers in high-risk patients
 • Lentigo maligna

begins as a uniformly pigmented, light-brown patch on the face or upper trunk that is confined to the
epidermis and as such is an in-situ melanoma
àOver time lesion expands and becomes more variegated in color
àLentigo maligna melanoma is the term applied to a lentigo maligna that has invaded the dermis
>>>both in-situ and invasive forms, melanoma cells extend far beyond the clinically apparent borders
of the lesion

• DECUB ULCERS

èHydrocolloid AKA foam dressing = reduce wound size by sticking to the skin and help absorb
exudates, leading to the formation of a protective gel around wounds; these dressings seem to
outperform gauze dressings in the management of pressure ulcer wounds
—>THIS is best option for incontinence
USE IN CONJUNCTION W/ turning the patient frequently, keeping her dry, ensuring adequate nutritional
intake, and encouraging her to get out of bed frequently, +/-protein or amino acid supplementation and
electrical stimulation (generally high-voltage pulsed stimulation) as adjunctive therapy to accelerate wound
healing

—>Maggot therapy can be used in areas of tissue necrosis requiring debridement but should not be
used for early stage decubiti

—>Vacuum-assisted closure devices are generally employed for much deeper wounds and would not
be indicated in this setting

èWet-to-dry gauze works by packing in wet gauze, which then dries out and, on removal, performs
mild debridement of wounds. This is generally used to help close deeper wounds with areas of necrotic
tissue and is not indicated in this patient
• Cholera vaccination ==>live oral attenuated; approved for use in the United States for adults aged 18
to 64 years who are traveling to an area of active cholera transmission
==>vaccination should be delayed until 14 days after therapy with an antibiotic with possible activity
against the vaccine strain

• Megaloblastic anemia

—>ASSOC W/ Neutrophil hypersegmentation = sign of impaired DNA synthesis a

—> Hypersegmentation is present when more than 5% of neutrophils have five lobes or when one or
more neutrophils have six lobes

• Patients with sudden-onset thunderclap headache

èunenhanced CT of the head using a modern-generation scanner has a greater than 99% sensitivity
and extremely low false-negative rates in detecting aneurysmal subarachnoid hemorrhage when
performed within 6 hours of symptom onset and interpreted by an attending radiologist
BUT
After 6 hrs small amt of SAH can be diluted by CSF
SO
NEEDàLP lookin for xanthochromia (yellow bc bili breakdown of rbcs)

• In Crohn disease

ENDOSCOPY shows—>superficial aphthous ulcers to discrete, deep ulcers; rectal sparing is typical, as
are areas of inflammation separated by normal mucosa (known as skip lesion
• MS DRUGS AND PREGNANCY

è oral disease-modifying therapy for multiple sclerosis (MS), fingolimod is a sphingosine-1-phosphate

receptor modulator that restricts activated lymphocytes to lymph nodes and may also have direct
neuroprotective effects. Fingolimod significantly reduces the relapse rate, risk of disability progression,
and accumulation of new lesions on MRI
==>This drug has been associated with rare but potentially harmful side effects, including increased
rates of serious herpesvirus infection, hypertension, bradycardia, lymphopenia, liver function
abnormalities, and macular edema
==>Fingolimod is classified as a pregnancy category C drug, and thus its safety in human pregnancy is
not clearly established. Although category C medications are indicated in some patients if the benefits
outweigh the risks, the hormonal state of pregnancy itself is protective against MS activity, and thus
discontinuing a disease-modifying drug during pregnancy is considered relatively safe

Mitoxantrone is an anthracenedione chemotherapeutic agent that reduces lymphocyte proliferation

and decreases the relapse rate and disability progression in MS
—>Despite mitoxantrone's efficacy, cardiac toxicity and the risk of secondary leukemia have
significantly limited its use
—>Mitoxantrone is classified as a pregnancy category X drug and is contraindicated during pregnancy

The MS drug teriflunomide is the active metabolite of leflunomide, which inhibits pyrimidine
biosynthesis and interferes with the interaction between T lymphocytes and antigen-presenting cells.
—>Teriflunomide is classified as pregnancy category X drug and is contraindicated during pregnancy

• Hyperkalemia

—>Tall, peaked T waves which begins with mild to moderate elevations of potassium (5.5-7.0 mEq/L
[5.5-7.0 mmol/L]) and tends to persist with more severe hyperkalemia
—>As potassium levels increase to above 7.0 to 8.0 mEq/L (7.0-8.0 mmol/L), decreases in P-wave
amplitude and widening of the QRS complex are seen
—>Levels above 9.0 to 100 mEq/L (9.0-10.0 mmol/L), the waveform will become sinusoidal, and
cardiac arrest may follow
 • Hypokalemia

—> U wave after the T wave, eventually replacing the T wave

—>Initially, T waves decrease in amplitude, and the ST segment flattens THEN U waves appear after
the T waves, as seen in this image
—>The U waves ultimately replace the T waves completely; this may give the impression of QT
prolongation, but it is really a QU interval

• For sjogren syndrome limited to eyes (keratoconjunctivitis sicca)

àTRY ENVIRONMENTAL MEASURES 1ST
àtopical cyclosporine (calcinurin inh)
àsystemic hydroxychloroquine

• IF HAVE ECZEMA UNRESPONSIVE TO TOPICAL STEROID CAN START àDUPILUMAB

àHUMAN monoclonal Ab against IL-4

• IF type 1 or 2 DM w/ HYPOGLYCEMIA 2/2 LONG ACTING insulin THENèCHANGE INSULIN TO DEGLUDEC

BC this has ½ life of 25 hrs (compared to glargine 12 hrs)
• Patients with an elevated alkaline phosphatase level in the absence of other abnormal liver chemistry
test results should undergo measurement of a serum γ-glutamyl transferase level or fractionation of
alkaline phosphatase isoenzymes to confirm a hepatic cause

• Mechanic’s hands

Assoc w Dermatomyositis and polymyositis

—>DZs w/ antisynthetase (myositis + Ab) syndrome are associated with mechanic's hands—
>hyperkeratotic and fissured skin on the tips and lateral aspects of the fingers

• Chronic hepatitis B virus (HBV) infection undergoing chemotherapy for solid tumors are at high risk for
HBV reactivation and should be treated with HBV reactivation prophylaxis using antiviral drugs before
or during chemotherapy
—>rophylactic antiviral therapy included lamivudine, telbivudine, adefovir, tenofovir, or entecavir
à if resolved Hep B OR if just using methotrexate or azathioprine CAN JUST MONITOR for reactivation
(use HBV DNA and aminotransferase)

• Gastric and duodenal ulcer, soft tissue sarcoma and obstructive uropathy are SE of radiation tx for testicular
disease

• In advanced COPD criteria for lung transplantation:

—> history of exacerbations associated with acute hypercapnia (arterial PCO2 >50 mm Hg [6.7 kPa]);
—>pulmonary hypertension, cor pulmonale, or both despite oxygen therapy; or
—>FEV1 less than 20% of predicted with DLCO less than 20% of predicted or
—>homogeneous distribution of emphysema

• Isotretinoin for severe nodulocystic acne vulgaris has potential complications.

—>teratogenic
—>cause pancreatitis secondary to severe hypertriglyceridemia,
—>bone marrow suppression, and
 —>drug-induced hepatitis

Because teratogenic there are mandated pregnancy prevention measures, and weekly or biweekly l
aboratory monitoring is recommended, at least initially
BUT
—>patients with only the expected, mild changes in lipid profiles, complete blood counts, and liver
chemistry tests on a stable dose of the medication do not need additional monthly monitoring

• Patients with long-standing colitis associated with inflammatory bowel disease are at increased risk for
colon cancer
—>COLITIS = ulcerative colitis involving more than the rectum and those with Crohn colitis involving
at least one third of the colon
—>These pts should undergo surveillance colonoscopy every 1 to 2 years beginning after 8 to 10 years
of disease

• Fundus shows arteriosclerosis:

—>arteriovenous nicking (disappearance of a short segment of the venule where it is crossed by the
arteriole and by a 90-degree-angle crossing of the arterioles and venules)

• EYE FINDINGS
• CT aortography as an appropriate first-line imaging approach in patients with suspected acute aortic
dissection
àsuspect AD w substernal CP tearing back pain and SOB

• In ACS tx w PCI NEED—> dual antiplatelet therapy (aspirin plus a P2Y12 receptor inhibitor [clopidogrel,
prasugrel, or ticagrelor]) for at least 12 months
BUT
—>dual antiplatelet therapy (DAPT) and an oral anticoagulant (“triple therapy”) for A fib are at
increased risk for bleeding complications
SO
DISCONTINUE THE P2Y12 inhibitor after 6 months

BC pt needs ASA AND needs anticoagulant for A fib

• Sudden withdrawal from dopaminergic medications, as may occur during hospitalization in patients
with Parkinson disease, can lead to an acute dopamine agonist withdrawal syndrome, termed
parkinsonian-hyperpyrexia syndrome, which resembles neuroleptic malignant syndrome (NMS)
 —>Patients who abruptly stop taking dopaminergic medications can develop acute altered mental
status, hyperthermia, rhabdomyolysis, and extrapyramidal symptoms, including severe rigidity and
dystonia
—>TX: RESTART LEVODOPA, supportive care

• Symptoms, signs, and laboratory studies characteristic of early rheumatoid arthritis (disease duration
of less than 6 months)

—>1st do DMARD monotherapy, regardless of the level of disease activity (METHOTREXATE)

Low-dose glucocorticoids, defined (10 mg or less of prednisone or equivalent), can be added in
patients with moderate or high disease activity, but NEVER as monotherapy

THEN—>IF does not respond to initial DMARD monotherapy, combination nonbiologic DMARD therapy
should be considered, (such as hydroxychloroquine and sulfasalazine)
Or
Tumor necrosis factor (TNF)-α inhibitors
—>etanercept, preferably with methotrexate, or
—>non-TNF biologic drugs such as tofacitinib, either as monotherapy or in conjunction with
methotrexate

• Right atrial enlargement on EKG:

—>tall (≥2.5 mm), peaked P waves (P pulmonale) in leads II, III, and/or aVF

• Chronic lymphocytic leukemia (CLL)

ONLY TX CLL if
—>bulky adenopathy,
 —>weight loss, and
—>disabling night sweats
STAGING IS BASED ON lymphocyte count, anemia and thrombocytopenia, lymphadenopathy, and
splenomegaly

FIRST LINE monoTX: IN PTS 65 AND > is Ibrutinib, a Bruton tyrosine kinase inhibitor
—>SE: can result in an initial increase in the lymphocyte count, but this finding does not require
change in therapy

First-line treatments in the past have included:

-combination therapy with rituximab, cyclophosphamide, fludarabine, and prednisone;
-combination rituximab and bendamustine
-or single-agent treatment with chlorambucil or fludarabine

NOW USE IBRUTINIB as single agent, not above; can use combos above for 1st line, however

—>Prednisone NOT TO BE USED as a single agent for CLL

BUT
—>Single-agent prednisone can be used in patients with CLL and warm-antibody hemolytic anemia
(hemolysis)

• Fibromyalgia—>DX based on: widespread pain index (WPI) score of seven (out of 19) or higher and a
symptom severity scale (SS) score of five or higher
Or
WPI score of three to six and a SS score of nine or higher
AND
SXS present for at least 3 mo
TX to fixàchronic widespread pain, fatigue, cognitive dysfunction, and insomnia

1st line = nonpharmacologic tx: aerobic exercise, as well as education and psychosocial support; IF
COMPLAINS THAT EXERCISE WORSENS PAIN REINFORCE gradual and modest increases in the amount
and duration of their exercise
Other nonpharmacologic modalities not proven effective
THEN

Consider: TCAs (ie amitriptyline and desipramine) or Cyclobenzaprine c

IF FAIL ABOVE: start gabapentin or pregabalin, or duloxetine (SNRI), or milnacipran can be used
AND then:
Combination therapy can be used for patients unresponsive to monotherapy (ie—amitriptyline with
fluoxetine, and pregabalin with duloxetine)
• Studies have failed to show efficacy for the use of NSAIDs, monoamine oxidase inhibitors, and selective
serotonin reuptake inhibitors. There is no role for the use of narcotic pain medications or
glucocorticoids

• Central nervous system lymphoma

àPT WILL HAVE PERSONALITY CHANGE

Contrast MRI preferred imaging
—>usually solitary, nonhemorrhagic mass in the deep white matter adjacent to the ventricular surface
with well-circumscribed borders

MC—> Periventricular lesions (of the thalamus, basal ganglia, or corpus callosum)
—>LESS COMMON LESIONS: frontal, parietal, temporal, and occipital lobes

VS

MENINGIOMA

àCAN CURE W SURGERY

VS
 BRAIN ABSCESS vs METS

• Echinocytes are erythrocytes

—>with spicules of uniform size and distribution that project from the cell surface

—>CAN be artifact from prep of peripheral blood smear BUT

ALSO assoc w UREMIA and/or LIVER DZ

—> Echinocytes are often confused with acanthocytes, but the projections of echinocytes are smaller,
more uniform/uniformly distributed AND appear contracted and dense on peripheral blood smears

• IN suspected toxic nodule

 àIF hyperthyroidism is mild= radioactive iodine (123I) uptake and scan 1st THEN tx w Methimazole

IF hyperthyroidism (thyrotoxicosis) is severe= BEGIN methimazole to lower the thyroid hormone l

evels prior to performing additional testing
AND
once the hormone levels are nearing the normal range, the thionamide should be withheld for 5 days
prior to the thyroid scan

• Hyperoxia (80% FIO2) administered intraoperatively and for 2 to 6 hours postoperatively AND 1 x abx
pre-procedure prophyaxisà is associated with a decreased risk of surgical site infection

• IN ELDERLY PT w SEVERE neuropathic pain 2/2 DMà

àGIVE Duloxetine (SNRI) or gabapentin or pregabalin
àDULOXETINE C/I IF PT ON MAO-I
à CAN give TCA to YOUNGER PT but for elderly too many anti cholinergic effects + risk of falls

• Bone marrow fibrosis

 —>ASSOC W/teardrop cells, nucleated erythrocytes, immature leukocytes, and giant megakaryocytes
AKA leukoerythroblastic reaction

—>Leukoerythroblastic rx= bone marrow fibrosis or invasion caused by myelofibrosis or metastatic ca

• Chronic hepatitis C virus (HCV)

-Sofosbuvir OR simeprevir + pegylated interferon + ribavirin —>to tx HCV genotype 1 infection—>BUT

DO NOT GIVE IN CKD 4 OR 5

-Sofosbuvir AND Simeprevir + ribavirin —>to tx HCV genotype 1 infection—>BUT DO NOT GIVE IN CKD
4 OR 5

èIN CKD 4 OR 5 W HEP C GENOTYPE 1—>GIVE oral grazoprevir and elbasvir

• CANDIDAL ESOPHAGITIS
—>white mucosal plaque-like lesions 2/2 esophageal candidiasis —>invasive mucosal infection
by Candida species and occurs most frequently in patients with deficiencies in cell-mediated immunity
associated with conditions such as AIDS and lymphoid malignancies

—>Diagnosis confirmed by biopsy —>shows pseudohyphae invading mucosal cells and culture that
grows Candida
Although esophagitis and thrush (oral candidiasis) often occur together in immunosuppressed patients,
the absence of thrush does not preclude the diagnosis of esophagitis
• CAN dx HSV clinically BUT in order to differentiate between HSV1, HSV2, and varicella infections DO —
—> direct-fluorescent antibody and polymerase chain reaction testing w/results in less than 24 hours

—>Viral culture = gold standard but can take over 48 hours up to 1 week for results
—>DO cult IF resistance testing is necessary for recalcitrant infections

• Hypertensive retinopathy
—>generalized arteriolar narrowing (white arrows) compared with venule diameter (black arrows)

—>arteriole-to-venule ratio of <1 suggests relative arteriolar narrowing; this patient's arteriole-to-
venule ratio is 0.63
—>Arteriolar narrowing is a predictor of future development of hypertension and increased risk for
stroke, coronary heart disease and kidney damage
 • Atrioventricular reciprocating tachycardia (AVRT)
—>HR of 130/min - 250/min
—>2nd MC supraventricular tachycardia (after atrioventricular nodal reentrant tachycardia [AVNRT])

—>Reentry —>2 pathways from atrium to ventricle in BOTH AVNRT and AVRT.

BUT—>In AVRT, accessory pathways or bypass tracts connect atrial with ventricular myocardium,
bypassing the AV node

The bypass tract and the normal pathway through the AV node may conduct the impulses in either an
anterograde (atria to ventricle) or retrograde (ventricle to atria) direction

AVRT may be initiated by an atrial premature beat or a ventricular premature beat

The most common form of AVRT is associated with a reentry circuit that travels anterograde to the
ventricles down the normal pathway and retrograde up to the atrium along the accessory pathway
 Because bypass-tract conduction is typically faster than conduction via the normal pathway through
the AV node, atrial activation occurs rapidly after the QRS complex, resulting in a “short RP”
tachycardia.

AVRT is recognized as a narrow complex tachycardia with P waves (typically inverted) located in the ST
segment (best seen in 1st ECG in leads II and V1 and best seen in 2nd EKG in leads II and V1) and an RP
interval that is less than one half the tachycardia R-R interval.

Only accessory pathways with anterograde conduction will show preexcitation (Wolff-Parkinson-White
pattern) on a sinus rhythm electrocardiogram

• D-dimer threshold in patients being evaluated for pulmonary embolism who are older than 50 years
should be adjusted based on age (age × 0.01 µg/mL)

• Glaucoma
—> vertical extension of the central cup, disc hemorrhages, and an increased optic cup:disc ratio (>0.5)
identified by the disappearance of vessels over the edge of the attenuated optic rim
BUT

Above are NON SPECIFIC for glaucoma so MUST HAVE H/O LOSS OF PERIPHERAL VISION to diagnose
VS
VS

VS
 VS

• Idiopathic pulmonary fibrosis

 —>fibrotic cystic changes AKA honeycombing
—>THOUGH NOT specific for a single disease is common in advanced interstitial lung diseases such as
IPF
AND = a poor prognosis

• In IRRITABLE BOWEL DISEASE syndrome WITH DIARRHEA

àTx w/ Rifaximin
IF relapse can tx w Rifaximin again 2 more times (550 mg TID x14 d)

• Listeria monocytogenes meningitis

—>Gram-positive rod-shaped organisms, short — singly or in short chains

HAVE gram-variable staining. SO MAY BE MISTAKEN FOR Strep pneumoniae, enterococci,
Corynebacteria, or, when it stains gram-variable, Haemophilus species
-causes meningitis in >50; TX with Ampicillin or PCN +/- aminoglycoside
• Subdural hematoma
ACUTE—> high-density crescentic collection across the hemispheric convexity
Subacute and chronic—>isodense or hypodense crescent-shaped lesions that deform the surface of
the brain
• Epidermal hematoma
Epidural blood produces a convex pattern on CT scans because its collection is limited by firm dural
attachments at the cranial sutures

• Pitting, onycholysis (lifting of nail off the nail bed), and the “oil drop” — areas of yellow-tan
discoloration at the distal end of the nail plate——sign are typical manifestations of psoriatic nail
dystrophy
• Neck pain, worsening balance, urinary urgency, and nocturia = myelopathy, a spinal cord process
—>CAN LOCALIZE w/where weakness is (nerve root dist), + upper motor neuron sign (inc tone and inc
relaxes and wide based gait)
—>IF MRI SHOWS COMPRESSIVE MYELOPATHY —>NEED SURGICAL DECOMPRESSION

DO NOT GIVE IV GLUCOCORTICOIDS HERE!!!!

ONLY GIVE IV GLUCOCORTICOIDS, such as dexamethasone, IF Spinal cord compression is due to trauma
WHEN administered within 24 hours of injury

• In patients with mitral regurgitation, transthoracic echocardiography (TTE) is used to evaluate the
degree and assess the causative valve abnormalities, thereby providing essential information for
guiding therapy; if visualization is inadequate with TTE, transesophageal echocardiography is indicated
to figure out particularly whether surgical repair is possible or indicated

• Upper GIB:
-hematemesis,
-melena detected on physical examination,
 -absence of blood clots in the stool, and
-an elevated blood urea nitrogen to creatinine ratio (>30)

—>The most common causes of upper GIB are peptic ulcer disease (34%), esophageal varices (33%),
esophagitis (8%), and Mallory-Weiss tear (6%)

Peptic ulcer disease (PUD) can cause severe upper GIB in the absence of coagulopathy. PUD is
asymptomatic in 4% to 20% of patients and is commonly diagnosed because of complications such as
bleeding.

Duodenal angiodysplasia severe GIB is rare in the absence of a bleeding diathesis or use of medications
that affect hemostasis, including NSAIDs, aspirin, and anticoagulants

Erosive gastritis does not cause severe GIB; the injury does not extend deeper than the mucosa, which
lacks arteries and veins

• Iron deficiency anemia

--microcytosis, hypochromia (increase in the central pallor of cells), changes in erythrocyte shape
(anisocytosis), and changes in erythrocyte size (poikilocytosis)

VS

Anemia of chronic dz

BASOPHILIC STIPPLING
Hepcidin--acute-phase reactant INC in inflammation
AND inflammation causes release of hepcidin by the liver
↑ hepcidin inhibits iron absorption from diet and prevents release of iron bound by ferritin from
macrophages
VS

Thalassemia Minor

TARGET CELLS

VS

Autoimmune hemolytic Anemia

SCHISTOCYTES

Spherocytes –can be seen in autoimmune hemolytic

anemia or hereditary spherocytosis
• Superficial incisional surgical site infection —>HAVE inflammatory changes at the incision site, w/wo
purulent drainage AND WITHOUT systemic signs of infection such as fever
—>OBTAIN SITE GRAM STAIN AND CULT

If suspect organ or deep space surgical site infection can —>GET US OR CT to localize the site of
infection, identify any fluid collections, and help to plan a drainage procedure
• Sarcoidosis
—>Granulomatous infiltrating disease either asymptomatic or w/ SXS of chronic, nonproductive cough
MC

—>cutaneous manifestations 2/2 granulomatous infiltration in the skin with papule formation at the
site of disease

—>skin lesions usually grouped around the nose and are sometimes seen around the eyes or mouth
and can involve tattoos and scars

Smoking may alter the pulmonary immune milieu, and smokers tend to have a lower incidence of
sarcoidosis, with some patients occasionally developing sarcoidosis after smoking cessation

—>Medium-potency topical glucocorticoids = first-line tx for cutaneous sarcoidosis on the face, with
high-potency agents used in other lower risk sites
—>Intralesional glucocorticoids also an option
• Dysentery —>diarrhea w blood +/= mucus in stool

Escherichia coli E. coli O157:H7—>Shiga toxin–producing E. coli (STEC) serotype, is the most common
cause of acute bloody diarrhea in the United States
—STEC in GI of animals so someone who drinks unpasteurized milk WILL GET THIS
—NO FEVER, usually

Complications: ABX AND ANTI MOTILITY AGENTS INC RISK OF —>Hemolytic uremic syndrome (HUS)—
>thrombotic microangiopathy characterized by fever, hemolytic anemia, consumptive
thrombocytopenia, neurologic findings, and kidney failure

• OTHER GI INF AND THEIR COMPLICATIONS

Aortitis is an inflammation of the aortic wall w/Salmonella infection, which has a propensity for
causing endovascular infection, particularly when there is significant atherosclerosis or graft material.

Guillain-Barré syndrome w/ Campylobacter infection

Several strains of Yersinia cause infection of the mesenteric lymph nodes and can mimic acute
appendicitis

Reactive arthritis can occur following Campylobacter, Shigella, Salmonella, or Yersinia infections in
patients who are positive for the HLA-B27 gene

• Cutaneous neurofibromas

—>The defining characteristics of neurofibromatosis (von Recklinghausen disease) are multiple

cutaneous neurofibromas (benign nerve sheath tumors) and café au lait spots
—>Cutaneous neurofibromas are recognized as soft, sessile, or pedunculated tumors with the greatest
number occurring on the trunk.
—>Neurofibromas vary in number from just a few to several hundred, and they increase in number
and size with age. T—>hey do not carry an increased risk of malignant transformation but may be
cosmetically significant
• Mobitz type 2 second-degree atrioventricular block

—>regularly occurring nonconducted P waves—>IN THE PIC—>two nonconducted P waves are seen
after the third QRS complex on the rhythm strip
—>Compared with Mobitz type 1 second-degree atrioventricular block, in which PR intervals are
increasingly longer before a nonconducted or blocked P wave, the PR intervals for conducted beats in
Mobitz type 2 block are constant

• Primary hypothyroidism
—> elevated thyroid-stimulating hormone level and a low free thyroxine (T4) level + SXS
—> Hypothyroidism is a cause of hyperprolactinemia
SO
WHEN PT PRESENTS W/ hyperprolactinemia and hypothyroidism the hypothyroidism should be treated
and then the patient should be reevaluated to ensure that the hyperprolactinemia resolves

• IN COPDà 1st line is is LONG ACTING MUSCARINIC AGENT (TIOTROPIUM) AND SHORT ACTING BETA
AGONIST
àIF WORSE ACCESS FOR O2 NEED
àIF NO O2 NEED GIVE LONG ACTING BETA AGONIST IN ADDITION TO LAMA

• Hip osteoarthritis (OA)

—>groin pain radiating to the anterior thigh and aggravation by weight bearing and flexion and
rotation movements
—>Pain that is reproduced with both passive and active motion indicates an intra-articular pathology
 MAY NOT HAVE ANY ABNL ON IMAGING (UNLIKE PIC ABOVE)

• Iliopsoas bursitis —>

à groin and anterior thigh pain when the bursa communicates with the hip joint AND IS aggravated
with passive hyperextension of the hip

• Ischial bursitis is 2/2 prolonged sitting, especially on hard surfaces AND aggravated with sitting or lying
down, and the pain usually radiates to the back of the thigh
• Osteoarthritis of the sacroiliac joint = pain in the lower paralumbar area or buttock and can be
aggravated by standing

• Hollenhorst plaque

—>golden-yellow intra-arterial refractile body characteristic of cholesterol emboli—> suggestive of

artery-to-artery embolization and may have originated from an ulcerative atherosclerotic plaque
located in the internal carotid artery
• Abrupt syncope = concerning for a cardiac etiology, arrhythmia

IF —>structurally normal heart on echocardiogram BUT electrocardiogram (ECG) shows right bundle
branch block (rSR’ in V1 and qRS in V6) and 2-mm ST-segment elevation in the precordial leads =
type 1 Brugada pattern
(coved or descendant ST-segment elevation followed by negative T waves) on ECG

Type 1 Brugada pattern and symptoms (cardiac syncope) or ventricular arrhythmia = Brugada
syndrome

CAN BE genetically heterogeneous, but often caused by mutations in the SCN5a sodium channel =
ALTERS VENT REFRACTORY PERIOD WHICH CAN = SUDDEN DEATH
MC in asians

TX: ICD

ALSO—>first-degree family members NEED inherited arrhythmia clinic (EP clinic specializing in genetic
disorders) for counseling and screening

IF Brugada pattern but are asymptomatic OFTEN do not require ICD placement
• TFTs/interpretation

• SUBCLINICAL usually 2/2 HASHIMOTO’S THYROIDITIS

àconfirm w Ab against THYROID PEROXIDASE
-ALWAYS treat if TSH > 10 uU/mL
 • Ulcerative colitis
àMC: abd pain and bloody diarrhea (chronic)
—>continuous pattern of inflammation of varying severity with mucosal granularity, edema, loss of the
normal vascular pattern, friability, and ulceration
—> diffuse pattern of microulcerations is commonly seen, and frank ulcers are atypical; more likely
SUPERFICIAL ULCERS and CRYPT ABSESSES
àsome p-ANCA +
àcolo done 8 yrs after dx and every 1-2 yrs afterwards bc inc colon ca

—>usually involves the rectum and extends proximally in a continuous and circumferential pattern,
with the transition from abnormal to normal tissue usually being abrupt with a very clear line of
demarcation
VS

Crohn disease = areas of discrete inflammation and ulceration separated by normal mucosa (“skip
lesions”)
-MOSTly in terminal ileum; rectum spared
-MC presentation: RLQ mass, wt loss and diarrhea (watery or bloody)
àDEEP ULCERS w/granuloma formation
àcan have positive ASCA (anti-Saccharomyces Cerevisiae antibodies) on labwork
àcolo done 8 yrs after dx and every 1-2 yrs afterwards bc inc colon ca (but risk not as high as UC)
 UC

Crohn dz
• ALLERGIC conjunctivitis

• MEN SYNDROMES
 MEN 1àMEN1 gene
MEN 2AàRET proto-oncogene

• Neurofibromatosis type 1.
—>AD

Neurofibromas, café-au-lait spots, and pheochromocytoma

COMPLICATIONS:
• Accelerated junctional rhythm AKA atrioventricular nodal rhythms
—>regular supraventricular rhythms in which the P wave in lead II is negative (preceding or following
the QRS complex) or absent
 —>An atrioventricular nodal escape rhythm occurs when the junctional rate is between 40/min and
60/min, and the sinoatrial node is delayed or fails to function as the pacemaker
—>An accelerated junctional rhythm occurs when the junctional rate is between 61/min and 99/min,
and the junctional rate takes over the pacemaker function
—>Junctional tachycardia occurs when the junctional rate is faster than 99/min and takes over the
pacemaker function

• Guttate psoriasis

àis characterized by small, droplike, scaly plaques. It most often occurs in children and adolescents
and is frequently triggered by prior infection, particularly streptococcal infection

• Multifocal atrial tachycardia

 —>irregular rhythm (often irregularly irregular) but with P waves of several different morphologies and
PR intervals (that is, from different foci).
—> 1:1 relationship of each P wave to a QRS complex
Premature ventricular complexes are also present in this tracing

• Glucose-6-phosphate dehydrogenase deficiency

—>“bite” cell—nonstaining, clear zone in the erythrocyte that is caused by puddling of the denatured
hemoglobin (the result of oxidative stress) to one side of the cell

• IF—>history of ovarian, endometrial, and/or colon cancer COULD BE Lynch syndrome (also known as
hereditary nonpolyposis colon cancer)
—>Autosomal dominant cancer susceptibility syndrome
—>germline mutation in one of the DNA-mismatch repair genes (MLH1, MSH2, and MSH6 being the
most common)

—> increased risk for several types of cancer, usually with early onset; MC COLON, then endometrial
then ovarian
—>LESS COMMON MALIGNANCIES: upper urinary tract, bladder, stomach, small bowel, gallbladder,
pancreas, brain, and sebaceous glands
 Endometrial or, less often, ovarian cancer, can be the sentinel cancer in a patient with Lynch syndrome

Although identification of a Lynch syndrome mutation will not change the management of this
patient's ovarian cancer, it will change screening for other cancers, including the need for
-colonoscopy every 1 to 2 years,
-annual skin examinations, and
-consideration of screening upper endoscopy

ALSO genetic counseling and screen should be offered to fam

• Cystitis

—>leukocytes in the urine=urinary tract infection

—>Leukocytes are fairly large cells with intracellular granular material and multilobed nuclei

• TOFACITINIB
àbiologic for RA
àSE: LIPID elevation

Candida albicans esophagitis

 —>odynophagia or dysphagia
—>C. albicans is the MCC of infectious esophagitis in immunocompromised patients and is often
associated with oropharyngeal candidiasis
—>curdy white esophageal plaques seen on upper endoscopy, which is confirmed with esophageal
brushings
—>RISK INC W IMMUNOCOMPROMISED
—TX with fluconazole

Cytomegalovirus = single ulcer in the esophagus

—>DX: biopsies from the ulcer base, and treatment should be with ganciclovir

Herpes simplex virus = ulcers, typically multiple

—>DX: biopsy of the ulcer edge, and treatment should be with acyclovir

• RISK FOR NSAID-related gastrointestinal complications include

 -a history of peptic ulcer disease or other gastrointestinal bleeding event;
-Helicobacter pylori infection;
-age 65 years or older;
-concomitant use of aspirin (of any dose),
-anticoagulants,
-other NSAIDs, or glucocorticoids;
-high-dose NSAID use; and chronic comorbid illness

àIf risks exist ADD OMEPRAZOLE 20 MG/D; if cannot use PPI then use misoprostol 200 ug QID

• Nicotinamide dec risk of NON MELANOMA skin Ca AND also resulted in fewer actinic keratoses as soon
as 3 months into therapy

• Pulmonary cryptococcosis

—>Cryptococcus is usually a CNS inf SO must check LP even if inf found elsewhere AND even if no CNS
sos
—>IF pt immunocompromised OR BECOMES SO LATER IN LIFE = inc risk of progressive or disseminated
inf
—>EVEN THO in immunoCOMPETENT pt Crypto can be asymptomatic and may resolve you ALWAYS
TREAT to prevent progressive/disseminated dz
—>TX with daily fluconazole for 6-12 mo

• When primary skin lesions absent + GENERALIZED pruritus NEED TO R/O systemic causes
 Hodgkin lymphoma
—>most strongly associated with pruritus
—>DO CXRAY to rule out

2nd pic widening of the superior mediastinum (asterisks).

3rd pic - well-circumscribed radiopaque mass in the right aspect of the mediastinum (arrows).

• Osteoarthritis
USUALLY affects weight-bearing joints. Affected non–weight-bearing joints in the hand typically include
the first carpometacarpal, distal interphalangeal (DIP), and proximal interphalangeal (PIP) joints

PE: bony enlargement and malalignment; Heberden and/or Bouchard nodes, or ossified growths at the
medial and dorsolateral aspects of the DIP or PIP joints, respectively, may be present

Left lung atelectasis

—>diffuse, dense opacification of the left hemithorax + loss of volume on the left, as indicated by the
leftward movement of the mediastinum

—>Mediastinal borders are difficult to discern, the absence of a right heart border to the right of the
spine indicates its leftward movement, and in this patient, the heart's position can be inferred by the
leftward position of the pulmonary artery catheter

Pitted keratolysis
—>small indented pits on a background of hyperkeratosis and results from increased sweating or
perspiration (hyperhidrosis) of the feet

—>superficial bacterial inf 2/2 Kytococcus sedentarius, Corynebacterium, or Actinomyces spp

—>First-line treatment includes clindamycin lotion or erythromycin lotion in conjunction with keeping
the feet dry
—>Oral therapy with clarithromycin or erythromycin also can be used
• Dalfampridine (4-aminopyridine) —> USED IN MS; is a voltage-gated potassium channel antagonist
that can potentiate action potentials along demyelinated axons
—>can improve lower extremity function and walking speed and endurance. Because of its mechanism
of action, seizures have been reported as a rare, dose-dependent adverse effect of this medication

Dalfampridine is excreted through the kidneys and thus is contraindicated in patients with kidney
disease or AKI because its resultant decreased clearance would significantly increase the seizure risk

• IN VTEà
MUST c/w Heparin or LWMH for no less than 5 days; can be dced at that time if INR therapeutic for 24 hrs or
more

• Minimal change glomerulopathy (MCG)

-MCC of idiopathic nephrotic syndrome in kids; 10% cases in adults
-dysfunction of epithelial foot processes causing MASSIVE protein loss and other macromolecules
—>SXS: ACUTE edema and weight gain due to fluid retention
LABS: urine protein-creatinine ratio typically 5000-10,000 mg/g; negative serologic tests, and a kidney
biopsy showing normal light microscopic findings and negative immunofluorescence are diagnostic
—> Electron microscopy is confirmatory and usually demonstrates the extensive effacement of the
podocyte foot processes

TX: Glucocorticoids such as prednisone; calcineurin inhibitors such as cyclosporine if cannot tolerate
pred;
Alkylating agents such as cyclophosphamide IF frequently relapsing or glucocorticoid-dependent p

COMPLICATIONS: the nephrotic-range proteinuria of MCG is associated with a significantly increased

risk for thromboembolism and infection
• Osteoarthritis with calcium pyrophosphate deposition (CPPD)—>symptoms consistent with
degenerative arthritis (pain worse with activity, brief morning stiffness)
—>XRAY shows calcification (also known as chondrocalcinosis) of the triangular fibrocartilage, seen as
calcific densities in the region of the distal ulna and ulnar styloid, consistent with CPPD; there is also
some narrowing of the carpal metacarpal joints consistent with osteoarthritis

—>In osteoarthritis with CPPD, patients often have osteoarthritis in joints not typically involved with
traditional osteoarthritis, including non–weight-bearing joints such as the shoulders and wrists.

• “Smudge” cells——flattened or distorted cells characteristically seen in chronic lymphocytic

leukemia (CLL)

—>CLL is recognized by an elevated blood leukocyte count and increased number of mature
lymphocytes and can also present with lymphadenopathy, hepatosplenomegaly, anemia, or
thrombocytopenia
• Adult atopic dermatitis characteristically
—>USUALLY antecubital and popliteal fossae and flexural wrists

—>if acute pruritic and red with poorly demarcated, eczematous, crusted, papulovesicular plaques and
excoriations
—>chronic= lichenified with accentuated skin lines (lichen simplex chronicus) and, particularly in dark
skin, hyperpigmented

• ONCE FOUND ANION GAP METABOLIC ACIDOSIS

FIGURE OUT WHAT serum bicarbonate level would have been if the patient did not have an anion
gap metabolic acidosis :
—>SUBTRACT normal anion gap from calculated AG.. then add that number back to the bicarb and if
falls in range of normal then ok; if not then you know there is another process

SO
Say pH is 7.23
If bicarb is 10 in the question
And you calculate AG from Na-(Cl+HCO3)
And for instance anion gap is 28, (elevated): you have an AG metabolic acidosis

TAKE 28 and subtract 12 (bc 12 is the normal anion gap)

28-12=16

TAKE that number and add it back to bicarb in the question, which was 10

16+10= 26

26 is within range for normal BICARB

So only have one process: AG metabolic acidosis
• Polymyositis and dermatomyositis are associated with a substantially increased risk of ischemic cardiac
events, including a fourfold risk of myocardial infarction
àALSO these are assoc w ILD, but would present in insidious manner; check PFTs if it does

• ANAEROBES in sputum cult

Organisms in the stain are gram-positive and gram-negative bacteria of multiple morphologies, an
appearance that is most consistent with an anaerobic infection resulting from aspiration of organisms
in the oropharynx

This image demonstrates a good sputum specimen with many neutrophils and no squamous epithelial
cells

• H flu in sputum
• Klebsiella on sputum cult
• MORAXELLA on sputum cult
• Pseudomonas on sputum cult
 • SECONDARY HEADACHE SYNDROME
àPapilledema + partial left palsy of the abducens nerve (cranial nerve VI), + cerebrospinal fluid (CSF)
opening pressure of 350 mm H2O suggests the presence of a secondary headache syndrome =
idiopathic intracranial hypertension (IIH)

--------------àPAPILLEDEMA

MUST RULE OUT SPACE OCCUPYING LESION BEFORE LP!!!!

—>MC IN young women with an elevated BMI

—>combined oral contraceptive=risk factor

—>Headache MC SXS
—> Papilledema MC PE FINDING

—>Carbonic anhydrase inhibitors, such as acetazolamide, are the only reliably effective medications
for IIH
These inhibitors have been shown to reduce headache and improve visual impairment in patients
with IIH
• Babesiosis

—>smear shows Intracellular so CONSIDER Babesiosis and Malaria IF pt has fever and hemolytic
anemia
—> presence of vacuolated, pleomorphic rings without pigment or gametocytes is characteristic
of Babesia infection
àALSO have maltese cross (tetrad form)
èTX for 7-10 days with a combination of two prescription medications — typically either:
-Atovaquone PLUS azithromycin; OR.
-Clindamycin PLUS quinine (this combination is the standard of care for severely ill patients)
• Malaria
 • Pancreatic pseudocyst
—>large fluid collection at the head of the pancreas with well-defined margins=pancreatic pseudocyst caused by
pancreatic inflammation and necrosis

—>may be single or multiple, small or large, and within or outside the pancreas

Most communicate with the pancreatic ductal system and contain high concentrations of digestive enzymes

The walls of pseudocysts are formed by adjacent structures, such as the stomach, transverse mesocolon,
gastrocolic omentum, and pancreas. In this case, the pancreatic pseudocyst also is causing gastric outlet
obstruction

Polymyalgia rheumatica (PMR)

—>MC in >50 years

—>SXS: symmetric pain and stiffness in the shoulder, neck, and hip; Mild synovitis may occur in the wrists
and hands
+/- Systemic inflammation, along with low-grade fever, malaise, and fatigue

Strength and muscle enzymes are generally normal

—>HIGHER RISK OF RELAPSE and LONGER PRED TAPER: In Women w/ESR >40 mm/h and associated
peripheral arthritis

—>IF HAVE RISKS FOR ADVERSE EFFECTS FROM STEROIDS and/or NUMEROUS COMORBIDITIES LIKELY TO BE
AFFECTED BY STEROIDS —>WANT TO TAPER OFF ASAP
SO
Start Methotrexate
 Crescent Sign in ruptured Baker cyst

—>A Baker (popliteal) cyst is a posterior herniation of a knee effusion associated with rheumatoid
arthritis or osteoarthritis
—>Rupture of a Baker cyst can cause leg pain mimicking deep venous thrombosis as well as
ecchymosis below the medial malleolus, a finding known as the “crescent sign”

àPatients with primary amenorrhea associated with hypergonadotropic hypogonadism should receive
hormone therapy with estrogen to prevent osteoporosis and cyclic progestin to prevent endometrial
hyperplasia

à “Maltese cross” appearance of oval fat bodies

Oval fat bodies are found frequently in association with the nephrotic syndrome. The Maltese cross pattern
is seen only under polarized light
CONSTRICTIVE PERICARDITIS

àSigns/sxs of right heart failure and congestion = exertion dyspnea, fatigue, elevated JVD and prominent y
descents, IVC enlarged on echo
àHemodynamic evidence of constriction on echocardiography = expiratory flow reversals in hepatic veins
àPE: pericardial knock

—>constriction can be transient and either spontaneously resolve or respond to medical therapy AND this
subtype = idiopathic, viral, or postsurgical causes

NEED TRIAL OF MED TX —>NSAID or Pred FOR 2-3 MONTHS

IF medical therapy is successful—>surgical pericardiectomy

Tardive dyskinesia-Extrapyramidal symptom that is drug-induced d/o 2/2 agents that block dopamine
receptors
àMCC first-generation antipsychotic medications that antagonize D2 dopamine receptors (typically >1
month)

Extrapyramidal symptoms: akathisia (a sense of motor restlessness with a compelling urge to move that
makes it difficult to sit still), dystonia (continuous, involuntary spasms and contractions of major muscle
groups), and parkinsonism (tremor, rigidity, and bradykinesia) AND TD = specific ES w/ orofacial dyskinesia,
facial grimacing, athetotic (slow, writhing) movements, and tics

SWITCH to 2nd gen antipsychàclozapine least likely to cause extrapyramidal symptoms AND ALSO the most
effective drug

Negative symptoms (flat affect, monotone speech, social withdrawal) respond better second-generation
antipsychotic medication

First gen antipsych:

Chlorpromazine
Thioridazine
Haloperidol has been shown to be significantly more likely to cause extrapyramidal symptoms than any other
first-generation or second-generation antipsychotic medication
R pneumothorax
2/2 R SC IVC
Avascular necrosis of the hip
IF early Xray is normal
—>earliest xray change is bony trabecular pattern
—>later the necrosis occurs in subchondral bone and subchondral fx = “crescent sign”

—>When the avascular necrosis occurs in the medullary space, far from the joint, a thick sclerotic zone can
develop in the area between living and necrotic bone

1st pic: deformity (loss of sphericity) of the left femoral head due to bony collapse
2nd pic: “crescent sign” that is typically seen before collapse of the femoral head.
Indications for Surgery for MR (Updated Figure 4 From the 2014 VHD guideline). *MV repair is preferred
over MV replacement when possible. AF indicates atrial fibrillation; CAD, coronary artery disease; CRT,
cardiac resynchronization therapy; EF, ejection fraction; ERO, effective regurgitant orifice; HF, heart failure;
LV, left ventricular; LVEF, left ventricular ejection fraction; LVESD, left ventricular end-systolic diameter;
MR, mitral regurgitation; MV, mitral valve; NYHA, New York Heart Association; PASP, pulmonary artery
systolic pressure; RF, regurgitant fraction; RVol, regurgitant volume; and Rx, therapy
ΔPm: mean transvalvular pressure gradient; AS: aortic stenosis; AVA: aortic valve area; CT: computed
tomography; EF: ejection fraction; LVEF: left ventricular ejection fraction; SVi: stroke volume index; Vmax:
peak transvalvular velocity
Surgery should be considered (IIa C) if one of the following is present: peak velocity >5.5 m/s; severe valve
calcification; peak velocity progression ≥0.3 m/s per year; markedly elevated neurohormones (>threefold
age- and sex-corrected normal range) without other explanation; severe pulmonary hypertension (systolic
pulmonary artery pressure >60 mmHg).
AS: aortic stenosis; LVEF: left ventricular ejection fraction; SAVR: surgical aortic valve replacement; TAVI:
transcatheter aortic valve implantation
àIn patients with symptoms of exercise-induced bronchospasm and/or asthma but normal spirometry
findings, bronchial challenge testing is warranted for further evaluationàMethacholine challenge

àAcute cutaneous lupus erythematosus (ACLE)

—>almost exclusively in patients with systemic lupus erythematosus and is typically precipitated by
sunlight.
—>SX: classic “butterfly rash,” which is characterized by confluent malar erythema or by generalized,
red, papular, or urticarial lesions on sun-exposed skinàHAVE UP TO 90% CHANCE OF DEV SLE
Vs

CHRONIC cutaneous lupus erythematosus

àCAN CAUSE ALOPECIA
AKA DISCOID lupus TX w high potency corticosteroids, topical calcineurin inh (pimecrolimus)
àHAVE 5% CHANCE OF DEV SLE
VS
Subacute cutaneous lupus erythematosus
àHAVE 15% CHANCE DEV SLE
POLYMORPHOUS LIGHT ERUPTION
àRx to sunlight; UVA driven prob
àIS PRURITIC OR BURNING
-r/o other dermatoses : ANA, anti Ro and La and urine/stool and blood porphyrin levels: if neg then
dx
TX- Topical steroids.Topical tacrolimus. Antihistamines. Oral corticosteroids.Hydroxychloroquine.

èPrimary central nervous system (CNS) lymphoma

—>AIDS or immunocompromised
—>SXS: HA, N/V
—>SIGNS: AMS, neuro deficits, papilledema, LOC

IF—> evidence of mass effect GIVE high-dose glucocorticoids

(dexamethasone) IMMEDIATELY

àAGE IS MOST IMPORTANT PROGNOSTIC FACTOR; BIOCHEM MARKERS BCL6 (GOOD) P53
OR C MYC (BAD)

Pretibial myxedema
à generally seen in patients with Graves hyperthyroidism
àdermal-based mucinous deposits in the skin of the anterior shins leads to the characteristic
thickening and other skin changes
VS

Necrobiosis Lipoidica

VS

èLipodermatosclerosis
VS

èSTASIS DERMATITIS
PNEUMONIA
èCAP
No comorbidities/previously healthy; no risk factors for drug-resistant S pneumoniae:
• Clarithromycin 500 mg PO bid or extended-release 1000 mg PO q24h or
• Doxycycline 100 mg PO bid

If received prior antibiotic within 3 months:

• Azithromycin or clarithromycin plus amoxicillin 1 g PO q8h or amoxicillin-clavulanate 2 g PO
q12h or
• Respiratory fluoroquinolone (eg, levofloxacin 750 mg PO daily ormoxifloxacin 400 mg PO daily)

Comorbidities present (eg, alcoholism, bronchiectasis/cystic fibrosis, COPD, IV drug user, post influenza, asplenia,
diabetes mellitus, lung/liver/renal diseases):
• Levofloxacin 750 mg PO q24h or
• Moxifloxacin 400 mg PO q24h or
• Combination of a beta-lactam ( amoxicillin 1 g PO q8h or amoxicillin-clavulanate 2 g PO
q12h or ceftriaxone 1g IV/IM q24hor cefuroxime 500 mg PO BID) plus a macrolide
(azithromycin orclarithromycin)

For hospitalized patients on the general wards:

—>anti-pneumococcal fluoroquinolone— levofloxacin moxifloxacin, gemifloxacin
—>the combination of a beta-lactam plus a macrolide
For severe CAP IN ICU
—>beta-lactam (ceftriaxone, cefotaxime, ampicillin-sulbactam) plus
- intravenous azithromycin or
-an anti-pneumococcal fluoroquinolone

IF CONCERN FOR Pseudomonas

-Need antipseudomonal agent (piperacillin-tazobactam, imipenem, meropenem, or cefepime) PLUS
-an antipseudomonal fluoroquinolone (ciprofloxacin or high-dose levofloxacin)

IF MRSA is a concern, either vancomycin or linezolid

èVAP

HAP
ASPIRATION PNEUMONITIS VS ASPIRATION PNEUMONIA
èH pylori
àHepatic abscess
—> heterogeneous lesion that is generally round or oval with irregular margins and possible peripheral
contrast enhancement

—> Internal septations are also common (but not well visualized in this image). Intra-abscess hemorrhaging
is sometimes seen, but gas is rarely evident in the abscess

Hypopyon
—>layered collection of pus in the anterior chamber—

POSSIBLE
-sight-threatening infectious keratitis or endophthalmitis or
-a noninfectious condition, such as uveitis associated with Behçet syndrome
Pterygium vs Pinguecula
CATARACT
èASD
Vague abdominal pain, fatigue, and hepatosplenomegaly+ leukocytosis with basophilia (defined as > 200
cells/µL)
=
Basophilic leukocytosis
=
basophilic variants of acute or chronic leukemia

Chronic myelogenous leukemia (CML), a myeloproliferative disorder ----MC in older men.

àCAN be asymptomatic or present with nonspecific systemic symptoms (e.g., fatigue), hepatosplenomegaly,
and peripheral eosinophilia and basophilia
à Nearly 90-95% of CML patients have a reciprocal translocation that fuses the ABL1 gene found on
chromosome 9 to the BCR gene on chromosome 22
=
The abnormal chromosome 22 (Philadelphia chromosome) with the BCR-ABL fusion gene results in the
BCR-ABL fusion protein, which can be detected in the peripheral blood to confirm diagnosis

Lead can inhibit heme synthesis and RNA breakdown, resulting in denatured RNA in the red cells on
peripheral smear (basophilic stippling)

HFE mutation helps differentiate hereditary hemochromatosis from other forms of hepatic iron overload

JAK2 (Janus kinase 2) mutations are found in polycythemia vera, essential thrombocytosis, and primary
myelofibrosis.

Sarcoidosis can cause hepatosplenomegaly and elevated alkaline phosphatase due to biliary obstruction by
granulomas
Viral encephalitis (eg, fever, confusion) ON empiric acyclovir needs IVFs bc Acyclovir is relatively insoluble
in urine and when given intravenously can precipitate within the renal tubules, leading to urinary
obstruction and acute kidney injury within 48 hours of drug initiation
à Hematuria, pyuria, and birefringent needle-shaped crystals may be noted on urinalysis
àOral acyclovir has lower bioavailability and therefore has minimal risk of crystalline nephropathy.

àIntravenous acyclovir should be given with normal saline hydration of at least 2 L/day, with a goal urine
output of 75 mL/hr to reduce renal tubule drug concentration and crystal formation

àIf renal failure develops, treatment is supportive and consists of drug withdrawal (if possible), aggressive
hydration, and administration of a loop diuretic to flush the crystals from the renal tubules. Hemodialysis is
occasionally necessary for severe toxicity.

Telemetry monitoring is indicated for

- active cardiac disease (eg, recent myocardial infarction, angina, arrhythmias) and
-critical illness (eg, hypotension)

Droplet precautions are indicated when there is concern for bacterial meningitis (eg, Neisseria
meningitidis, Haemophilus influenzae). Cerebrospinal fluid analysis in bacterial meningitis would typically
show very low glucose (<45 mg/dL), high protein (>250 mg/dL), AND elevated leukocyte count (>1,000/mm3)

Proton pump inhibitors are typically indicated as prophylaxis for critically ill patients with coagulopathies
(platelets <50,000/mm3, INR >1.5), mechanical ventilation >48 hours, or head trauma

à proton pump inhibitors are associated with increased risk of Clostridium difficile infection and pneumonia
Cervical myelopathy in RA is likely 2/2 atlanto-axial (C1-C2) subluxation
àRisk factors:
- late-onset RA,
-elevated C-reactive protein,
-rapidly progressive peripheral joint disease, and
-early subluxation of peripheral joints

à C1-C2 is the only spinal segment lined by a synovial membrane THEREFORE pts w RA can develop
synovitis with erosions that destroy adjacent ligaments anchoring C1-C2, causing eventual subluxation of C1
relative to C2 (most often anteriorly) CREATING pressure on the adjacent spinal cord and results in cervical
myelopathy
Clinical features of RA cervical myelopathy
• Neck pain radiating to occipital region
• Slowly progressive spastic quadriparesis
Symptoms
• Painless sensory deficits in hands or feet
• Respiratory dysfunction (eg, from vertebral artery compression)
• Protruding anterior arch of atlas
• Scoliosis with loss of cervical lordosis
Signs
• Upper motor neuron signs (eg, spastic paresis, hyperreflexia, Babinski sign)
• Hoffman sign
•

XRAY may show separation between C1 and C2

àA spinal MRI is preferred to visualize the cervical spine for spinal cord compression, bony erosions, and
synovitis
àPatients with subluxation without signs of cord compression can be treated medically with neck collars
and close monitoring with fall prevention
àPatients with signs of cord compression usually require surgery for spinal stabilization
Prolonged corrected QT interval (QTc) and family history of sudden death = congenital long QT
syndrome (LQTS)

àNORMAL QTc interval is 370-440 msec
àA QTc >450 msec in male patients and >470 msec in female patients is considered a prolonged QT
interval

>>>PTs may be asymptomatic or have palpitations, presyncope/syncope, seizures, or cardiac arrest

TX:
-avoid strenuous exercise, electrolyte abnormalities such as hypokalemia or hypomagnesemia
-avoid certain medications (eg, antipsychotics, fluoroquinolones, Class Ia antiarrhythmic) that may prolong
the QT interval
-beta blockers (eg, propanolol, nadolol
-implantable cardioverter-defibrillator (ICD) IF PT HAS syncope (especially if recurrent) or ventricular
tachycardia (eg, torsade de pointes) on beta blocker therapy OR if STRONG FAM HX OF SUDDEN
DEATH, but BBlocker should be used first otherwise

SEVERE PAIN (≥7/10) in a cancer pt NEEDS prompt initiation of a short-acting strong opioid, such as oral
morphine
àWhen pain control is adequate with a short-acting opioid, the cumulative dose of the short-acting opioid
can be used to calculate the effective dose for a long-acting opioid such as transdermal fentanyl

Infiltrative cardiomyopathy

àpresents w/
-increased left ventricular mass on echocardiogram that may be misdiagnosed as LVH
-low QRS voltage (< 5 mm in limb leads and < 10 mm in precordial leads) on ECG (abnormal
mass/voltage ratio)
-LE EDEMA, SOB, orthostatic hypotension and conduction ABNL
-renal manifestation of AL and AA amyloidosis is heavy proteinuria and associated glomerular
deposits

àLeft ventricular wall thickening eventually leads to diastolic dysfunction, right ventricular dysfunction,
and biatrial enlargement

àREMEMBER-àIF THERE WAS significant LVH from conditions such as hypertension, aortic stenosis, or
hypertrophic cardiomyopathy IT WOULD cause increased QRS voltage on ECG with a "strain" pattern NOT
LOW VOLTAGE

DX OF AMYLODIOSIS:
-amyloid deposits are seen with Congo red stain on endomyocardial biopsy or tissue biopsy of other
involved organs
-An abdominal fat pad biopsy showing amyloid deposition indicates light-chain (AL) amyloidosis
èTreatment is largely supportive with a median survival < 1 year in patients with cardiac amyloidosis
COMPLICATIONS: intracardiac thrombi that can lead to ischemic stroke
àHyperthyroidism is usually associated with high-output heart failure and atrial
fibrillation. Hypothyroidism can sometimes cause large pericardial effusions that lead to low voltage on
ECG

Subacute infective endocarditis (IE)

àCAN be due to bacteremia due to procedure (GU, dental) weeks before
àMED TX with IV abx (6 wks) needed in all

àEARLY surgical intervention (valve replari/replacement) prior to finishing abx NEEDED IF:
--Heart failure (signs: pulm edema) due to regurgitation
--Valve leaflet fistula
--NEW heart block
--PARAVALVULAR ABSCESS
--DIFFICULT to tx pathogen (ie fungi)
--PERSISTANT fever OR bactermia despite > or = 7 days of abx
--Embolic stroke WHILE ON ABX (not before initiation)
--MOBILE aortic or mitral valve vegetation > 10 mm with PRIOR SYSTEMIC EMBOLIC EVENT
WHEN suspect brain death based on TWO clinical brain death examinations/criteria (1st box below)

Do APNEA TESTING next:

1) IF negative (= NOT apneic) àthen not brain dead

2) IF unreliable/inconclusive àorder ancillary test

3) if pt cannot generate spontaneous breaths OR trigger vent in response to elevated PaCO2

levels after 10 min AFTER DISABLING control mode thenà REPEAT CLINICAL EXAM
àif EXAM does not meet brain death criteria then NOT BRAIN DEAD
àif inconclusive do ancillary testing
àif EXAM suggestive of brain death -àdeclare brain death

>>>ANCILLARY TEST OF CHOICE/GOLD STANDARD is Cerebral blood flow testing (e.g., cerebral
angiogram or cerebral scintigraphy)
THYROID PROBLEMS

PAINLESS thyroiditis
àtransient hyperthyroidism followed by possible hypothyroidism and then recovery
à generally occurs > 1 year after pregnancy, but it can also occur in non-postpartum women and men
àCAN be caused by lithium, interferon alpha, interleukin-2, and amiodarone
àDO TFTs: will show DEC TSH, ELEVATED T3 and T4 and ELEVATED THYROGLOBULIN

àDO radioactive iodine uptake (RAIU) scan in order to distinguish painless thyroiditis from Graves’ disease
-GRAVES WILL HAVE HIGH RAIU
-PAINLESS THYROIDITIS WILL HAVE LOW RAIU

PAINLESS thyrotoxicosis 2/2 pre-formed thyroid hormone release so has ELEVATED serum anti-TPO
antibodies and thyroglobulin
àinitially has MILD thyrotoxic symptoms for 1-3 months (usually no exophthalmos) followed by
àhypothyroid symptoms that last 3-6 months

èCAN RECOVER or have PERMANENT HYPOTHYROIDISM (usually with higher anti-TPO antibody
titers) and 10% can develop recurrent thyroiditis

TX:
àIF mild symptoms = no treatment; monitor with thyroid function studies in 6-8 weeks.
àIF SEVERE SYMPTOMS = NEED beta-blockers for symptom relief
Invasive ductal carcinoma
àprognostic factors for breast cancer include
-histopathological subtype (favorable: tubular, mucinous versus unfavorable: ductal, lobular, mixed
metaplastic),
-FAVORABLE: estrogen receptor/progesterone receptor (ER/PR) +, and HER2 receptor +

àTriple-negative breast cancers tend to recur and peak at 3 years post diagnosis, with higher incidence of
visceral and brain metastasis
THEREFORE
àrecommend lumpectomy with surgical lymph node staging followed by chemotherapy and then radiation

PAD

SOME PTS with typical symptoms of intermittent claudication can have normal ABI values at rest-
àNEED exercise testing with repeat ABI and:
-IF normal ABI after exercise = NO PAD
-IF ABI decreases by >20% following exercise = PAD

If have PAD:
-Need either ASA or Clopidogrel
-Can add Cilostazolif presistant PAD sxs despite antiplatelet tx

èDO CTA or other vascular imaging if considering surgical/therapeutic intervention

Aortic regurgitation (early diastolic murmur at the second right intercostal space)
+
long extremities
+
scoliosis
=
Marfan syndrome (MFS) with aortic root dilation
MFS is an autosomal dominant disorder that causes abnormalities in the skeleton, eyes (lens dislocation),
and cardiovascular system

SIGNS:
+ wrist (thumb overlaps other fingers when wrapped around the contralateral wrist) and
+ thumb (entire distal phalanx protrudes beyond the ulnar border of a clenched fist)
+long slender fingers (arachnodactyly)

DIAGNOSIS based on:

-AORTIC ROOT DILATION
-ectopia lentis,
-family history,
-fibrillin-1 (FBN1) gene mutation, and
-other systemic signs/symptoms of MFS

Aortic root dilation can be found AND Aortic dissection is the cause of death in 30%-45% of patients,
followed by heart failure

SO NEEDà
Transthoracic echocardiography -à@ initial diagnosis and at routine intervals for close monitoring of the
aortic root and ascending aorta
àElective operation is recommended for aortic root diameter >50 mm to
reduce the risk of aortic dissection or rupture.

èHomocystinuria
à autosomal recessive disorder that presents with fair complexion, Marfanoid body habitus, developmental
delays, and hypercoagulability but NOT associated with aortic root dilation
Chromosomal karyotype analysis is indicated for diagnosis of KS (47,XXY karyotype)
èSkin biopsy may be performed in the evaluation of patients with Ehlers-Danlos syndrome
èCeliac disease
àchronic malabsorptive disorder of the small intestine caused by immune-mediated hypersensitivity
to gluten

SXS: diarrhea, abdominal pain, and malabsorptive complications (eg, iron deficiency anemia, nutritional
deficiencies, weight loss)

Screen with serologic studies:

-anti-transglutaminase IgA or
-anti-endomysial IgA antibodies

DO total serum IgA levels ONLY IF HIGHLY SUGGESTIVE CLINICAL FEATURES AND NEGATIVE
SEROLOGICAL TESTING (ABOVE)
àTHERE IS A high prevalence of IgA deficiency in patients with celiac disease
àLow serum IgA levels should prompt IgG-based assays

èIF + SEROLOGIES or HIGHLY SUGGESTIVE SXSàDO small bowel enteroscopy with biopsy to
establish a diagnosis
àInitiation of a gluten-free diet should occur after biopsy, as the reduction in inflammation
decreases biopsy sensitivity
èAlternatively, a cutaneous biopsy showing dermatitis herpetiformis is also diagnostic

èHuman leukocyte antigen (HLA) testing ONLY IF:

à discordant serology and biopsy results,
àPT on a gluten-free diet prior to testing, or
àthose with refractory disease despite a gluten-free diet
àPatients with HLA DQ2 and DQ8 have an increased risk for celiac disease
Immune thrombocytopenic purpura (ITP) is presumed when
àthe patient’s history (e.g., drug exposure), physical examination, complete blood count, and
peripheral blood smear examination do not suggest other etiologies for isolated
thrombocytopenia
àBone marrow aspiration is indicated in patients > age 60 to rule out myelodysplastic syndromes

àmild to moderate asymptomatic thrombocytopenia (> 30,000 cells/µL) should not be treated
èAcute pancreatitis due to hypertriglyceridemia

àCAN BE
1) inherited hypertriglyceridemia
OR
2) acquired hypertriglyceridemia

EITHER WAY RISK INC WITH:

0pregnancy,
-alcohol intake,
-obesity, and
-uncontrolled diabetes

RISK INC W/ ALL ELEVATED LEVELS OF hypertriglyceridemia, but most cases occur in patients with
visibly lipemic serum and triglyceride levels >1000 mg/dL

Initial management JUST LIKE REGULAR PANCREATITIS:

ànothing by mouth,
àaggressive hydration, and
àpain control

AND
àIF moderate to severe hypertriglyceridemia-induced pancreatitis (eg, triglycerides >1000 mg/dL, lipase ≥3
times the upper limit of normal, evidence of organ dysfunction) NEED rapid lowering of serum triglyceride
levels via:
à IF BG very high >500 mg/dL GIVE IV INSULIN; insulin corrects triglyceride levels (IN 3-4 DAYS)
by enhancing lipoprotein lipase activity
-give IV glucose too to prevent hypoglycemia that will occur when BG falls below 200 mg/dL

àIF BG <500 mg/dL

Or
àIF PANCREATITIS SEVERE (w lactic acidosis, AKI, hypocalcemia)
-give therapeutic plasma exchange apheresis to quickly lower triglyceride levels

>>>Once stabilized long-term management should include dietary fat restriction and triglyceride-lowering
medication (eg, gemfibrozil)
Monoclonal gammopathies
à ELEVATED protein gap à (total protein - albumin EQUALING >4 g/dL)
àMonoclonal protein (M-protein) secreted 2/2 clonal proliferation of plasma cells

à the 2 main forms are

-intact immunoglobulin (Ig) or
-free light chain (FLC)

èEnd-organ damage can ensue; WILL SHOW: hypercalcemia, renal insufficiency, anemia, or bone lesions
(CRAB)

Monoclonal gammopathies are defined based on the amount of M-protein, bone marrow involvement, and
end-organ damage:
àA monoclonal protein spike <3 g/dL and no evidence of end-organ damage = monoclonal
gammopathy of undetermined significance (MGUS)

àAsymptomatic (smouldering) myeloma is defined by M-protein >3 g/dL and/or >10% bone marrow
clonal cells but no related end-organ damage

àMultiple myeloma (MM) is typically defined by >10% bone marrow clonal cells with evidence of
end-organ damage, or by >60% bone marrow clonal cells

IF pt has -à MGUS with

-M-protein <1.5 g/dL,
-IgG subtype (most common), and
-normal serum kappa:lambda FLC ratio
THEN have a low risk of progression to MM and may not need detailed workup

BUT

If has M protein > 1.5 g/dL, any other subtype AND/OR abnl serum kappa:lambda FLC ration àNEED bone
marrow biopsy (to confirm <10% clonal plasma cells) and skeletal survey
àAND patients with MGUS who are at high risk of progression to a malignant condition will need follow-
up every 3-6 months

è Metastatic skeletal/bone survey is required during the evaluation of monoclonal gammopathies to

exclude lytic bone lesions and severe osteopenia
àIF SKELETAL/BONE SURVEY IS NEGATIVE and the patient has symptomatic bone disease do àMRI
of the spine

***
IF pt has symptomatic multiple myeloma -àNEED fluorescence in-situ hybridization (FISH) and
cytogenetic analysis to determine eligibility for hematopoietic cell transplant and to risk stratify for
prognosis and treatment
3 major antimalarial drug groups:
1) Hepatic schizonticides (atovaquone-proguanil) attack the liver forms of the parasite

2) Hypnozoiticides (primaquine) are active against the quiescent (hypnozoite) liver forms seen
with P vivax and P ovale; and

3) Blood schizonticides (chloroquine, mefloquine, and doxycycline, as well as atovaquone-

proguanil and primaquine) attack the blood forms of the parasite once released from the liver.
 Jarisch-Herxheimer reaction
àACUTE fever, myalgias, and rash within 6-48 hours of secondary syphilis treatment with penicillin G
à2/2 release of Treponema pallidum components when organism dies (eg, lipopolysaccharide, which leads
to an abrupt release of inflammatory cytokines).

àMAY BE SCEEN W TX OF OTHER SPIROCHETE DZ (lyme, leptospirosis)

TX: SUPPORTIVE (IV fluids, acetaminophen, NSAIDs); typically self limiting within 48 hrs of onset

Factor differentiating asthma from COPD :

--spirometry before and after bronchodilator showing reversal in airway obstruction (>12% increase in FEV1,
absolute increase in FEV1 of >200 mL) indicates ASTHMA

ANTI THROMBOTIC TX IN VALVE REPLACEMENT

*Risk factors= A fib, severe LV dysfunction (EF <30 %) prior VTE or presence of hypercoag state
Parvovirus infection
àIN ADULTS IT IS A flu-like symptoms 5-10 days after exposure followed by acute symmetrical
arthralgias/arthritis (e.g., hands/wrists) that can resemble rheumatoid arthritis
àPATIENTS MAY GET + RHEUMATOID FACTOR
àParvovirus can cause a false-positive ANA
àarthritis is usually self-limited and lasts 1-2 mo
àTX: Supportive

àIF hematologic dz (ie sickle cell) can get APLASTIC CRISIS

àIF immunocompromised can get acute or chronic anemia due to bone marrow suppression of erythroid
precursors

DX: Confirm with parvovirus B19 IgM antibodies, which increase within the first month of illness and often
become undetectable after 2-3 months

àIF AT A HOSPITAL WITHOUT PCI CABABILITIESà

-IF can transfer quickly enough for pt to have PCI within 2 hours of eval then do so

-IF cannot transfer in time for PCI within 2 hours AND if pt does not have C/I can give FIBRINOLYTIC
THERAPY (tPa, tenecteplase, streptokinase) BUT TRANSFER RIGHT AFTERWARDS BC reocclusion can
occur

Acute decompensated heart failure (ADHF) with severe left ventricular (LV) systolic dysfunction with a
dilated and diffusely hypokinetic left ventricle = cardiomyopathy due to alcohol abuse

àCAN clinically deterioration if begins to have atrial fibrillation

èGoals of ADHF therapy

àhemodynamic stabilization,
àsupplemental oxygen and ventilation,
àoptimization of volume status,
àcongestion improvement,
àidentification and correction of precipitating factors, and
àeventual symptomatic relief

èIV diuretics (eg, furosemide) are the preferred therapy in patients with ADHF who have clinical evidence
of volume overload BC THESE LEAD TO symptomatic relief and improve oxygenation
àIV nitroglycerin is a vasodilator (venous >> arterial) THAT TEMPORARILY REDUCES LV
Preload AND CAN BE USED in the acute decompensated state IF THE PATIENT HAS DISTRESS
2/2 FLASH PULM EDEMA or IN PTS WHO HAVE RESPIRATORY SXS DESPITE AGGRESSIVE
DIURETIC TX
EVEN THOUGH Beta blockers (eg, carvedilol) and ACE inhibitors (eg, lisinopril) improve symptoms and
long-term mortality in chronic heart failure due to LV systolic dysfunction they are CONTRAINDICATED
IN THE FIRST 24 HOURS OF ACUTE DECOMPENSATED HEART FAILURE BC THEY
àworsen heart failure symptoms (beta blockers) and
àcause hemodynamic instability (ACE inhibitors)

èInotropic agents (eg, dobutamine, milrinone) are reserved for patients in cardiogenic shock evidenced
by hypotension, poor peripheral perfusion, and end-organ dysfunction (eg, altered mental status, renal
failure)

ACUTE CHEST SYNDROME=

-NEW infiltrate on CXR + any of following
-fever
-chest pain
-resp sxs

-etiologies for ACS = inf, asthma, hypovent, pulm vascoocclusion from fat emboli

èNEG C-XRAY during initial presentation DO NOT RULE OUT SUBSEQUENT DEVELOPMENT OF
ACS which occurs within 48-72 hrs of admission of pain crisis

àPROPHYLACTIC MEASURES FOR ACS

-Pulm monitoring
-cautious hydration
-pain control
-incentive spirometry
-Hydroxyurea

TX of ACS: BASED ON SEVERITY

àmild ACS: simple transfusion
àmod/severe ACS: exchange transfusion
(TARGET Hb 10 g/dL)
à empiric ABX covering for atypicals

>>>ABX should NOT BE USED prophylactically to prevent ACS<<<<

Exposure to bird feces is associated with

1) psittacosis due to Chlamydia psittaci

àDX: tissue cult of sputum; complement fixation test to detect Ab

àTX: TETRACYCLINE

And

2) cryptococcosis due to Cryptococcus neoformans

èfungus found in bird droppings
àusually only evident inf if immunocompromised (AIDS or transplant or autoimmune dz on
immunosuppressive tx)

SXS: chest pain, cough (dry), confusion, fatigue, fever, headache, pinpoint red spots (rash), wt loss,
weakness, bone paijn, blurred/double vision

TX:
IMMUNOCOMPETANT: Fluconazole (though some resistance), Itraconazole
IMMUNOCOMPROMISED: Ampho B, Flucytosine
Urinary incontinence

Etiology Symptoms

CAN DOàSACRAL NERVE STIMULATION via surgical lead placement if fail combo med tx and
behavioral modification
ADRENAL MASSES

Fine needle aspirationàONLY DONE IF RULE OUT PHEOCHROMOCYTOMA

AND ONLY IF:
àCT features suggestive of infection or malignancy such as irregular shape, higher density (Hounsfield
units > 10),
àlarger size (> 4 cm), and
àretention of contrast agent (> 50% after 10 minutes)

Repeat CT scan in 6 months is performed in patients with negative hormonal excess studies, no
evidence of malignancy, and tumor size < 4 cm.
INFLUENZA LIKE SXS AND ERYTHEMA MIGRANS (rash with central clearing) = LYME DZ
But
If pt has HIGH FEVER and CYTOPENIAS (thrombocytopenia, leukopenia) and ELEVATED
AMINOTRANSFERASES = COINFECTION WITH ANAPLASMA PHAGOCYTOPHILUM

HUMAN GRANULOCYTIC ANAPLASMOSIS

BOTH transmitted by Ixodes scapularis tick

HGA can also be caused by coinfection of anaplasma and rikettsial organism

DX:
àBuffy coat or PERIPHERAL BLOOD SMEAR ---to look for intraleukocytic morulae (less sens but rapid)
àSerology (sensitive but must be measured in acute or convalescent phases)

TX: Doxycycline
COMPLICATIONS: seizures, coma, resp/renal failure

I scapularis also transmits BABESIOSIS

àcharacterized by:
-anemia (hemolytic)
-thrombocytopenia

àMC in pts w splenectomy

Only need imaging (MRI) if other diagnoses need to be ruled out

àconsider tx if sxs >2 months

STEMI vs PERICARDITIS EKGs

Above is STEMI: ST elevation in I, aVL and V1-V5 WITH RECIPROCAL ST depression in leads II, III and
aVF = acute anterolateral ST segment myocardial infarction due to occlusion of LAD

Below is Pericarditis: DIFFUSE ST ELEVATION and depression of PR segment in limb and precordial leads
Acute dissection involving the ascending aorta can occasionally cause occlusion of the right coronary artery
with ST segment elevation in leads II, III, and aVF with reciprocal ST segment depression in the anterior
leads
àNEEDS CT scan of aorta

PTS ON PREP à
NEED TO RULE OUT ACTIVE HIV FIRST
2 drug regimen
Need f/u every 3 mo for HIV testing, risk red counseling, med adherence/side effect assessment
Need regular creatinine levels and screening for bacterial STIs

TESTICULAR PAIN ETIOLOGIES

TORSION bc of twisted spermatic cord ((nt spermatic artery and pampiniform plexus)
EVALUATE respiratory status of a patient with MYASTHENIA GRAVIS with: MAXIMAL INSPIRATORY
FORCE

Pts who cannot tolerate steroids should be started on:

AZATHIOPRINE
MYCOPHENOLATE MOFETIL
OR
CYCLOSPORINE

CAN RESTART PHYSICAL THERAPY

24 hours after starting anticoag for DVT
Prolactin increase during pregnancy 2/2 high estrogen THEN peak at delivery, THEN normalize within 1-2
months after delivery, even with continued breastfeeding
Other causes of high prolactin above

Prolactinoma (ie, lactotroph adenoma)

àcan present with
-headache
-visual disturbances
-secondary amenorrhea,
-bilateral milky nipple discharge (ie, galactorrhea), and
-hypogonadism

SIGNIFICANTLY elevated prolactin (>200 ng/mL) indicates a prolactinoma

DX: MRI of the head to screen for a pituitary mass

à formal visual field testing due to the potential for the pituitary mass to compress the optic chiasm.

TX: 1st Line: dopamine agonists (eg, cabergoline, bromocriptine) and followed with serial MRIs
èSurgery (eg, transsphenoidal resection) IF FAIL medical therapy
ELDERLY patient with MACROCYTIC ANEMIA, normal B12, folate, TSH and not on any meds that would
inc MCV (eg, hydroxyurea, zidovudine) should be screened for myelodysplastic syndrome (MDS).

MDS is a group of malignant hematopoietic stem cell disorders characterized by progressive bone marrow
failure leading to blood cell dysplasias and cytopenias

Labs: anemia (macrocytic or normocytic) with an inappropriately low reticulocyte response; leukopenia
(~50%) with monocytosis, thrombocytopenia (~25%), and thrombocytosis (~8%) also commonly occur

• Peripheral blood smear - typically reveals significant dysplasia (eg, ovalomacrocytosis,

hyposegmented neutrophils) in ≥1 cell lines

• Bone marrow aspirate/biopsy - usually reveals a hypercellular marrow with single- or multilineage
dysplasia (peripheral blood cytopenias are thought to occur due to increased intramedullary
apoptosis). Cytogenetics should be performed to classify, risk stratify, and stage the disease

AS AN ASIDE:
Methylmalonic acid levels can be used to diagnose vitamin B12 deficiency in patients with borderline levels
(200-300 pg/mL). However IF B12 level of >300 pg/mL THEN THIS ETIOLOGY IS UNLIKELY
ALSO low b12 = HYPERlobulated neutrophils, not hypolobulated
Cystic fibrosis (CF)

à chronic respiratory problems often labeled as asthma, COPD, and recurrent bronchitis bc adults have
milder lung disease with fewer pseudomonal infections than kids
à usually present with
-upper lobe bronchiectasis,
-recurrent pancreatitis,
-chronic sinusitis, or
-infertility (usually due to congenital absence of the vas deferens)

àAdult CF patients also tend to have nontuberculous mycobacterial infections, pancreatic insufficiency,
and unusual genetic mutations

DX confirmed by:
àsweat chloride test > 60 mmol/L on > 2 occasions but
if equivocal
TEST for CFTR mutation

If CFTR does not show two mutations but clinical suspicion STILL HIGH then need MORE WORKUP:
àExpanded DNA analysis or
àNasal potential difference measurement
Allergic bronchopulmonary aspergillosis (ABPA)
-usually in pts with asthma or CF

èPresents with
-moderate to severe persistent asthma,
-central bronchiectasis,
-elevated serum IgE,
-eosinophilia, and
-positive sputum cultures for Aspergillus species

 Obesity hypoventilation syndrome (OHS)
àmost have BMI > 35 kg/m2
àMOST have OSA and RXed CPAP BUT still c/o dyspnea and MAY have signs/sxs of COR PULMONALE

COR PULMONALE
à florid complexion, cyanosis, an enlarged neck circumference, crowded oropharynx, and signs of right-
sided heart failure

à Labs show
-elevated serum bicarbonate level
-secondary erythrocytosis
***THESE ARE CLUES TO chronic hypercapnia and chronic hypoxemia, RESPECTIVELY

DX: ABG on RA to
-confirm daytime hypercapnia and hypoxemia and to
-calculate A-a gradient (NORMAL rules out pulmonary parenchymal or airway dz)

If hypercapnia is present, additional studies (see table) should be performed to exclude other causes of
hypercapnia

ALSO:
à drugs or medications (e.g., excessive alcohol, sedative-hypnotics, narcotics) that can aggravate chronic
hypoventilation should be avoided if possible

à should be strongly urged to lose weight

àNEED nighttime polysomnography testing to identify the underlying sleep disorder and to individualize
treatment with either continuous positive airway pressure or noninvasive mechanical ventilation
Systemic sclerosis (SSc) is classified into

àlimited and
àdiffuse

based on the distribution of skin involvement

èlimited cutaneous SSc (LcSSc): skin sclerosis on the hands and distal forearm and, to a lesser extent, the
face and neck
èdiffuse cutaneous (DcSS), skin sclerosis extends to the chest, abdomen, and upper arms; POSSIBLE
COMPLICATIONs include renal failure, severe forms of interstitial lung disease, and/or cardiac dz

CREST syndrome = variant of the limited cutaneous form

àanti-centromere antibody positive and

àcarry a more favorable prognosis (in comparison to DcSS)
àPOSSIBLE COMPLICATION: pulmonary hypertension, often without interstitial fibrosis, and/or lung
cancer
Hepatitis B titer interpretation
o Hepatitis B surface Antigen (HbsAg) → active infection
o Hepatitis B surface Antibody (HbsAb) → past infection or vaccination
o Hepatitis Be Antigen (HbeAg) → active replication of the virus
o Anti Hepatitis B core IgM Antibody (Anti-HBc IgM) → acute infection
o Anti Hepatitis B core IgG Antibody (Anti-HBc IgG) → chronic infection

à both Chronic and Carrier Hepatitis B patients will have positive HBsAg and Anti-HBc IgG

SO
àChronic → Increased LFTs
àCarrier → Normal LFTs; (also no HBeAg)

Hepatitis D virus
o Hepatitis D can’t exist on its own. It requires Hepatitis B infection to be present
o Anti-Hbc IgM + Hepatitis D virus → acute co-infection and will not worsen hepatitis
o Anti-Hbc IgG + Hepatitis D virus → acute super-infection and can cause fulminant hepatitis
EYE ISSUES
• Optic nerve lesion → can lead to complete blindness in the ipsilateral eye (monocular blindness of
the ipsilateral eye)
• Optic chiasm lesion → Bitemporal hemianopiaàcommon in pituitary tumors that compress the optic
chiasm
• Optic tract lesion → contralateral homonymous hemianopia
• Optic radiation lesion → contralateral homonymous quadrantanopia
Lack of an ipsilateral adduction to a contralateral gaze is a Medial Longitudinal Fasciculus (MLF) lesion.
This condition, which is also known as intranuclear ophthalmoplegia, is seen in patients who have Multiple
Sclerosis.

In normal individuals, if asked to look the right, the right eye should abduct and the left eye should adduct. If
a patient with MS is asked to look to the right (for example), he/she will be able to abduct the right eye but
fails to adduct the left eye → Lesion is Left MLF.

Same concept applies when asked to look to the left. Normally, the left eye will abduct and the right eye
should adduct. In patients with MS, patients lose the ability to adduct the right eye → Lesion is Right MLF.

Argyll Robertson Pupil → eyes will be able to constrict when the patient focuses on a near object (eg.
bringing fingers to the nose). This is known as accommodation. However, patients with an Argyll Robertson
pupil lose the ability to constrict the eyes when bright light is shined into their eyes. In a nutshell, the eyes
can’t react to light but can accommodate. This condition is often seen in patients with syphilis.

Here’s a handy mnemonic to remember this feature of Argyll Robertson Pupil:

Marcus Gunn Pupil → This condition is also known as Relative Afferent Pupillary Defect (RAPD). In
normal individuals, when a swinging flashlight test is performed, both the direct and consensual eye should
constrict to light.

With Marcus Gunn pupil, let’s suppose the left eye is affected. If light is shined into the right eye, both the
direct and consensual will constrict. When light is shined into the left eye, both the direct and consensual
eye will seem dilated (lack of constriction) → Shows damage to the ipsilateral optic nerve
CT/MRI findings

• Multiple Sclerosis → increased T2 signal and decreased T1 signal. There will be increased
enhancement of active lesions with gadolinium.
• Multi-infarct dementia → multiple hypo-dense areas without enhancement.
• Toxoplasmosis, brain abscess, and lymphoma → Ring enhancing lesions seen on CT scan
• Cerebral atrophy → dilated ventricles with dilated sulci
• Normal pressure hydrocephalus → dilated ventricles without dilated sulci. Patient is “wet, wobbly,
and weird.” (urinary incontinence, ataxia, and dementia triad is often seen in these patients)
• Alzheimer’s Disease → Brain atrophy with or without periventricular white matter lesions
Ostium primum atrial septal defect (ASD)
àSXS volume overload of R heart with elevation of CVP and R ventricular lift
àSYSTOLIC murmur at base from INC FLOW across RV outflow tract FROM LàR SHUNT
àapical systolic murmur is from mitral regurgitation and is related to the mitral valve cleft
àHAS FIXED SPLITTING of S2

ON EKG: left axis deviation, first-degree atrioventricular block, and interventricular conduction delay

OTHER FORMS OF ASD

èCORONARY SINUS ASD = features of right heart volume overload but do not have mitral valve
disease and thus will not have a murmur of mitral regurgitation
àEKG normal or first-degree atrioventricular block and incomplete right bundle branch block

èostium secundum ASD = features of right heart volume overload but do not have mitral valve disease
and thus will not have a murmur of mitral regurgitation
àEKG may be normal first-degree atrioventricular block and incomplete right bundle branch block

è sinus venosus ASD = features of right heart volume overload but do not have mitral valve disease and
thus will not have a murmur of mitral regurgitation.
àEKG may be normal or demonstrate first-degree atrioventricular block and incomplete right bundle
branch block
Patients with patent foramen ovale have a normal electrocardiogram and physical examination
àgenerally asymptomatic.

Rheumatic fever
Narcotic equivalents:

Morphine (oral) 1
Morphine IV/SQ 1/3
Oxycodone (oral) 2/3
Oxymorphone (oral) 1/3
Methadone 1/3
Hydromorphone (oral) ¼
Hydromorphone (IV) 1/50

Thyroid meds interact w: CALCIUM, IRON, PPI

--look for celiac sprue

Warfarin interacts with bactrim, erythromycin, amiodareone, ketoconazole, flagyl to INC INR

WARFARIN AND TYLENOL = INC BLEED

Statin interacts with fibrates, azoles, amiodarone, erythromycin, verapamil

IF having myalgia with statin CHECK TSH AND VIT D LEVELS

TMP-SMX INTERACTS W METHOTREXATE

TMP-SMX causes hyperkalemia

CAN get edema with dihydro[yridines (Amlodipine), pioglitazone, estorogen, gabapentin, omeprazole

NSAIDS worsen heart failure

URIC ACID INC WITH

-diuretics (HCTZ)
-niacin
-cyclosporin
-ethambutol
-topiramate

Topiramate causes
-kidney stones
-metabolic non AG acidosis bc dec bicarb
SSRIS can cause inc risk of UPPER GI BLEEDING

BISPHOSPHONATES inc muscle pain

SSRIs can cause HYPONATREMIA (esp if older woman)

HCTZ causes
-HYPOnatremia, HYPOKALEMIA
-HYPERURICEMIA, HYPERCALCEMIA
-inc lipids

Carbamazepine causes
-HYPOnatremia

Proliferative DM retinopathy ----new vessels ofrm near optic disc

Non prolif DM retinopathy----hemorrhages, microaneurysms

Retinal detachment
-waving curtain lateral vision loss, MC in myopia
-no pain

Retinal vein occlusion = BIG hemorrhages

Retinal artery occlusion- sudden vision loss

-cherry red macula

Papilledema =. Short bursts of vision loss

-seen in pseudotumor cerebri
-optic disc blurred + hemorrhage

Glaucoma
-inc cup size to diameter
-gradual vision loss

Iritis + NEW SKIN PAPULES = sarcoid. ( get xray)

Uveitis (inc redness around iris). Seen in AK , reactive arthritis, sarcoid, granulomatous dz
Menses:
IF normal interval but inc amount/days. = fibroids
IF irregular intervals <18 d = abnormal luteal phase. (give OCPs)

INC menstrual bleeding with:

HYPOthyroidism
Liver dz and coagulopathy
Thrombocytopenia
CKD

FAMILIAL HYPERTRIGLYCERIDEMIA
-an use EVOLOCUMAB or ALIROSUMAB

Quinolones can cause insomnia, nightmares, hallucinations, esp in elderly

Use CHLORDIAZEPOXIDE for CIWA

Donepezil is cholinesterase inhibitor

-1st line in demenia
-can cause bradycardia and syncope

IF dementia mod-severe can add MEMANTINE (2nd line)

Vertical nystagmus + constant vertigo = central cause (stroke)

If vertigo dec w repeated movement = BPPV

Vestibular neurotis=. SUDDEN and SEVERE vertigo

Meniere syndrome
-ear fullness, vertigo, tinnitis, and hearing loss

Serotonin syndrome—
-tachy, inc BP, fever, rigid, HYPERREFLEXIA, TREMOR
-CAUSED BY: SSRIs, tramadol, linezolid, meperidine, dextromethomorphan, TCA, MAOI buspirone,
trazadone

CAN get NEUROLEPTIC MALIGNANT SYNDROME from stopping PARKINSON’S DRUGS

-SXS: fever, mental status change, muscle rigidity, autonomic dysfunction
-also can get from haloperidol, chlorpromexte, clozapine
BPH
-1st line: alpha blockers, tamsulosin BEST
-2nd line OR if HUGE PROSTATE OR if HEMATURIA: Finasteride
-3rd line TURP

ASA toxicity: N/V, tinnitus, lethargy, and hyper vent

1st resp alk
Then metabolic acidosis and HYPOKALEMIA and HYPOGLYCEMIA
Seizures, hyperPYREXIA, AND OCMA
-CAN DIE FROM cerebral and pulm edema
-alkalinize urine

Nitrite abuse = tachypnea, tachycardia, headache, HYPOTENSION, AND CYANOSIS UNRESPONSIVE TO

O2
-GIVE O2 AND METHYLENE BLUE

LITHIUM TOX
-course tremors, fasciculatiojns and N/V

Cyanide poisoning
-BRIGHT RED SKIN
-1st give AMYL NITRITE or Na nitrite to INDUCE METHEMAGLOBINEMIA
THEN give sodium thiosulfate

Avoid paroxetine bc shortest ½ life and BIGGEST RISK FOR SSRI DISCONTINUATION SYNDROME
FLUOXETINE HAS LONGEST ½ LIFE

PAROXETINE HAS most wt gain than other SSRIs

TCAs C/I in arrythnias, MI and BPH

URGE incontinence: due to detrusor overactivity; give oxybutynin

OVERFLOW: outlet OBSTRUCTION, or anticholinergic meds or detrusor HYPOACTIVITY (DM)

STRESS: outlet INCOMPETENCE (MC in women when sneeze, laugh)---do kegels

Polycycstic kidney dz has

-inc risk of cerebral aneuysm`
-inc risk of renal cell CA

Rinne test: TUNING FORK TO OUTSIDE OF EAR THEN ON MASTOID

-normal is air conduction > bone conduction

Weber: Fork in middle

Normal if hear in middle
IF lateralizes ---
-Either conductive loss in IPSILATERAL ear or SENSORINEURAL LOSS opposite ear

If pregnant CANNOT GIVE

-ISOretetinoin
-ACE/ARB
-benzos
-quinolone
-tetracyclines
-nitroprusside
-WARFARIN

IF PREGGO can give enoxaparin (LMWH)

If mom is anti Ro or La + = neonatal lupus = CONGENITAL HEART BLOCK

If the sensitivity of a test is 75% it means that 25% of pts have false neg

If the specificity of a test is 85% it means that 15% have false positive

POSITIVE PREDICTIVE VALUE -àWANT NO FALSE POSITIVES

NEGATIVE PRESDICTIVE VALUEàWANT NO FALSE NEGATIVES

IF YOU LOWER THE CUTOFF FOR A DISEASE YOU

àincrease sensitivity and decrease specificity
àbetter at RULING OUT DISEASE

If you increase the cutoff for a disease you

àIncrease specificity and decrease sensitivity
àBetter at ruling out disease

SHORT time for study to ID factors that may lead to a condition -àCASE CONTROL STUDY
A P VALUE OF <0.05 IS STATISTICALLY SIGNIFICANT; THE LOWER THE BETTER

IF THE CONFIDENCE INTERVAL CROSSES 0 = not significant

IF THE RELATIVE RISK CROSSES 1 = NOT SIGNIFICANT