Professional Documents
Culture Documents
20142015
DISCLAIMER
Thispresentationdoesnotpretendtobeallinclusivebutto
brieflycoverfrequentlytestedtopicsinInternalMedicine.
ThispresentationdoesNOTcontainanymaterialsor
questionsfromtheNBMESubjectExamination,andsoany
resemblancebetweenthispresentationandtheexamispure
coincidence.
ExamDistributionbySystem
Generalprinciples
15%
Immunologicdisorders
510%
Diseasesofthebloodandbloodformingorgans
510%
Diseaseofthenervoussystemandspecialsenses
510%
Cardiovasculardisorders
1520%
Disordersoftherespiratorysystem
1520%
Nutritionalanddigestivedisorders
1015%
Gynecologicdisorders
Renal,urinary,andmalereproductivedisorders
15%
1015%
Disordersoftheskinandsubcutaneoustissue
510%
Diseasesofthemusculoskeletalsystemandconnectivetissue
510%
Endocrineandmetabolicdisorders
510%
ExamDistribution
Promotinghealthandhealthmaintenance
1015%
Understandingthemechanismofdisease
2025%
Establishingadiagnosis
4045%
Applyingprinciplesofmanagement
2025%
DoNOTRelyonStatisticalAdjustments!
YourrawscoreisadjustedaccordingtotheNational18th
percentile
DoNOTRelyonStatisticalAdjustments!
So,forexample,ifyourrawscoreis68
70/69=1.014
68x1.014=69.0
TipsfortheExam
Theexamconsistsof100110questions,usually96
multiplechoicequestions,and4matches
Youhaveatotalof2hours30minutestocompletethe
exam,thatisroughly1.5minutesperquestion
Vignettesarelooooooooong
SometimesanswersgofromAtoN
Littlephysicalexaminformationandscantlaboratory
results
TipsfortheExam
Readquestionandanswersfirst!!!
Sometimesyoudontneedtoreadthewholethingto
getthequestionright,soyousaveaminutehereand
there
Ruleoutanswersasyoureadthrough
Ifyoudontimmediatelyknowtheanswer,MARKyour
gutguessandkeepon.Ifyouhavetime,checklater
Dontgetstuckononequestion!Youmightendupmissing
thisoneandseveralothersifyourunoutoftime!
Cardiology
MustKnowECGs
Atrial fibrillation
Atrial flutter
MustKnowECGs
Torsades depointes
Ventriculartachycardia
MustKnowECGs
Ventricularfibrillation
MustKnowECGs
STelevationMI
MustKnowECGs
Acutepericarditis
MustKnowECGs
Pericardialeffusion
ArterialHypertension
DefinedbytwoseparateBPmeasurements> 140/90mmHg
Secondarycausesofhypertensionshouldbeconsidered,
particularlyifveryyoungorveryoldatonset
Pharmacologictherapyisstartedassoonasdiagnosisis
established,usuallywiththiazide diuretic(alwaysathiazide for
exams!)
Renovascular Hypertension
Fibromuscular Dysplasia
Usuallyaffectsthedistaltwothirds
andbranchesoftherenalarteries
inyoungwomen
AtheroscleroticDisease
Usuallyaffectstheproximalthirdof
therenalarteriesinoldermen
PrimaryHyperaldosteronism
Syncope
Mechanism
Vasovagal
Orthostatic
Subclavian steal
syndrome
Cardiogenic
Clue
Young females.Heraldedbydizziness,
diaphoresis,nausea.Situational.
Bradycardia withhypotension.
Older individuals.OrthostaticBPandHR
changes.Hypovolemia.
Syncopewhile combinghair.Occlusionof
thesubclavian arteryreversesflowin
vertebralartery. Stenosis canbedueto
cervicalrib,arteritis.
Valvular disease, cardiomyopathies,
arrhythmias
HeartMurmurs
Descriptionsareusuallyvague,somustrelyonothercluesfor
diagnosis
Unlikelytogetquestiononmaneuvers,butjustincase:
Allrightsidedmurmursincreaseduringinspiration,
EXCEPTpulmonarystenosis
AllmurmursdecreasewithValsalva andstandingfrom
squatting,EXCEPTmitralvalveprolapse andhypertrophic
cardiomyopathy
Pericardium
Thinkpericardiumwhenheartsoundsaremuffledordistant.
Thinkpericardialeffusionsandtamponade inthesettingof
acuteMI,renalfailure,malignancy,trauma
Hypotension
Enlargedcardiacsilhouette
Pulsus paradoxus (fallinBPduringinspiration)
LowQRSvoltages
Thinkconstrictivepericarditis whenthereislongstanding
historyofprogressiveheartfailuresymptoms
HeartFailure
Mostcommonetiologyofheartfailureisischemic
cardiomyopathy
Treatmentaccordingtostageofheartfailure
StageA Riskforheartfailurebutnostructuraldisease:
treathypertension,DM,considerACEinhibitors/BB
StageB Structuraldiseasebutnosymptoms:ACE
inhibitors/BB
StageC Symptoms:Digoxin,spironolactone,diuretics
StageD Refractorysymptoms:transplantation,
ventricularassistdevices,inotropes
ComplicationsofMI
Characteristic
VentricularSeptal
Rupture
VentricularFreeWall
Rupture
PapillaryMuscle
Dysfunction
Clinical
manifestations
Chestpain,shortnessof
breath,hypotension
Syncope,hypotension,
arrhythmia,sudden
death
Abruptonsetof
shortnessofbreath
andhypotension
Physicalfindings
Harshholosystolic
murmur,thrill,S3,
pulmonaryedema.
Pulsus paradoxus,
electromechanical
dissociation,shock
Asoftmurmurin
somecases,nothrill,
pulmonaryedema,
Rightheart
catheterization
Increaseinoxygen
saturationfromright
atriumtoright
ventricle,largev waves
Hypertesive Crisis
Hypertensiveemergencyisdefinedashypertension> 180/120
mmHgwithacutedysfunctionofoneormoreorgansystems
DecreaseMAPby25%withinthefirsttwohours,then
lowerBPslowlytoreachgoalBP.
UseIVmedications:betablockers,calciumchannel
blockersornitrates(betablockerspreferredovernitrates)
Hypertensiveurgencyisdefinedasseverehypertension
withoutevidenceofendorgandamage
Useoralantihypertensive
AorticDissection
Usuallypresentswithchestpainthatradiatestothe
interscapular areaanddelayedorabsentpulsesdistalto
dissection.
IfTypeA,maybeassociatedwithSTelevationsininferior
leadsduetoextensionintoRCA,acuteaorticregurgitation,and
pericardialeffusion(whichyoushouldnotdrainuntilyou
correctdissection!!!)
Ifsuspected,startIVbetablockerstoHR<60andSBP<120
andobtainimagingstudies.Avoidnitrates.
TypeAtreatedsurgically;typeBtreatedmedically.
ACLS
Wheneverapatientisunresponsive,thereisasystole,
pulseless electricalactivity,checkforthefollowing:
Hyperkalemia andhypokelamia
Hypothermia
Hypoglycemia
Hydrogen(acidosis)
Hypoxemia
Hypercapnea
Tamponade
Thrombosis(stroke,MI,PE)
Tensionpneumothorax
Endocarditis Prophylaxis
Bacterialendocarditis prophylaxisisrecommendedfor
patientswith:
Valvular replacement
Defectsrepairedusingprostheticmaterial
Priorhistoryofendocarditis
Unrepairedorincompletelyrepairedcyanoticcongenital
heartdefects
Hearttransplantwithanyvalvulopathy
Warfarin Overdose
INR
Management
INR<5.0;nosignificant
bleeding
Lowerdose
INR> 5.0but<9.0;no
significantbleeding
SkiponeortwodosesandmonitorINR
OR givevitaminK< 5mgPOifhighriskforbleeding
INR> 9.0;nosignificant
bleeding
Holdwarfarin therapyANDgivenvitaminK510mg
POandmonitorINR
Serious bleedingatany
INR
Holdwarfarin andgivefreshfrozenplasma
Mayalso supplementwithvitaminK10mg
OralvitaminKisthetreatmentofchoice,unlessthepatientcannottoleratePO
SubQvitaminKisslowerbutsaferthanIVvitaminK,whichmayinduceanaphylactic
reactionsandsuddendeathhasbeenreported
Pneumology
PulmonaryDiseasesoftheYoung
CysticFibrosis
Alpha1AntitrypsinDeficiency
Pathogenesis
Abnormalchloridetransport
Defectivegenefor enzyme,
leadingtothicksecretionsand leadingtoexcessive
bronchiectasis
destructionofelastin and
strutural proteins
Presentation
Otherfindings
Exocrinepancreatic
insufficiency with
malabsorption
Chronicsinusitisandnasal
polyps
Staphylococcusand
Pseudomonasinfections
Liver cirrhosis
PulmonaryFunctionTests
Obstructive
Restrictive
FEV1
Verylow
Low
FVC
Normalorlow
Verylow
Very low
Normalorhigh
Increasedornormal
Decreased
FEV1/FVC
TLC
Examples
Emphysema
Chronicbronchitis
Bronchiectasis
Asthma
Pulmonaryfibrosis
Chest deformity
Neuromuscular
Morbidobesity
DecreasedDLCOareconsistentwithparenchymal disease;
IncreasedDLCOseeninalveolarhemorrhageandcongestiveheartfailure
BronchialAsthma
Usuallypresentswithshortnessofbreath,wheezing,non
productivecough
Precipitantsmayincludeexercise,upperrespiratorytract
infections,rhinitis,sinusitis,postnasaldrip,GERD,changesin
weather,andstress.
Associatedfindingsincludeallergicrhinitis,nasalpolyps,
asthatic shinersandatopicdermatitis.
BronchialAsthma
Characteristic
Controlled(allof
thefollowing)
Partlycontrolled
(anyoffollowing)
Uncontrolled
< 2times/week
>2times/week
Limitationof
activities
None
Any
Threeormore
featuredof
partlycontrolled
asthma
Nocturnal
symptoms
None
Any
Needfor
reliever/rescue
inhaler
< 2times/week
>2times/week
Lungfunction
(PEForFEV1)
Normal
<80%predicted
Daytime
symptoms
BronchialAsthma
CONTROLLED
STEP2
Addlowdoseinhaledcorticosteroid
STEP3
Addlongactingagonist
STEP4
Increasetomediumorhighdose
inhaledcorticosteroid
STEP5
Addoralcorticosteroid
UNCONTROLLED
STEP1
Rapidactingagonistasneeded
SolitaryPulmonaryNodules
Roundedopacitymeasuringlessthan3cm,notassociated
withinfiltrate,atelectasis oradenopathy
Evaluationshouldstrivetoidentifymalignantdiseasewithout
performinginvasiveproceduresinbenigndisease
Firstevaluateoldchestxraystoevaluategrowth
Inpatientsolderthan30andsmokers,thechancesoflung
cancerishigher,soconsidermorespecificimaging(eg,CTscan)
earlyon
Sarcoidosis
Usuallypresentsasasymptomaticbilateralhilar adenopathy
inanAfricanAmericanwomaninher40s
Somepatientsmaypresent:
Erythema nodosum
Hypercalcemia
Arthritis
Heartblock
Ventriculartachycardia
Constitutionalsymptoms
DeepVenousThrombosis
Wellscriteria:
Cancer
Paralysisorrecentcasting
Immobility>3days
Localveintenderness
Limbswelling
Unlitaral calfswelling>3cm
Pittingedema
Collateralsuperficialvein
DeepVenousThrombosis
PulmonaryEmbolism
Wellscriteria:
ClinicallysuspectedDVT 3points
AlternativediagnosisislesslikelythanPE 3.0points
Tachycardia>100bpm 1.5points
Immobilization> 3days 1.5points
Surgeryinprevious4weeks 1.5points
HistoryofDVTorPE 1.5points
Hemoptysis 1.0points
Malignancywithin6months 1.0points
PulmonaryEmbolism
LungCancer
CancerType
Squamous cell
carcinoma
Paraneoplastic Syndromes
Hypercalcemia (PTHrp) mostcommon
Hornerssyndrome(miosis,ptosis,
anhydrosis)duetoinvasionsympathetic
chain
Ulnar radiculopathy (Pancoast tumor)
Smallcellcarcinoma Cushingssyndrome
SIADH hyponatremia andconfusion
EatonLambert (Absagainstpresynaptic
Ca++channels) weaknessthatimproves
withexertion
Adenocarcinoma
Pulmonaryosteoarthropathy
CriticalCareMedicine
TypesofShock
TypeShock
Distributive
SVR
CO
PaOP
CVP
Cardiogenic
Obstructive
Hypovolemic
Examples
Septic
Anaphylactic
Adrenalcrisis
Neurogenic
AcuteMI
Heartfailure
Tamponade
PE
Pneumothorax
Hemorrhage
Burns
Nephrology
AcidBaseDisorders
Disorder
Metabolicacidosis
Metabolicalkalosis
Respiratoryacidosis
Respiratoryalkalosis
pH
pCO2
HCO3
AcidBaseDisorders
Startbyestablishingwhattheprimarydisorderis:
pH7.31
pCO2 34
CO2 16
Inthiscase,thisisametabolicacidosis.So,thesecondstepis
toverifyappropriatenessofrespiratorycompensation.
ExpectedpCO2iscentralCO2 +10.Inthiscase16+10=
26.AspCO2 ishigherthanexpected,thereisconcomitant
respiratoryacidosis.
AcidBaseDisorders
Thenextstepwhendealingwithmetabolicacidosisistocheck
aniongap:
Na+142
Cl 101
CO2 16
Aniongap=Na+ (Cl +CO2)=142 (101+16)=25
Sothisishighaniongap(>12)metabolicacidosis
MetabolicAcidosis
MetabolicAcidosis
Highaniongap
Normalaniongap
Ketones +
Ketones
DKA,alcoholic
ketoacidosis,
starvation
Lactic,uremia
Intoxication
Negativeurine
aniongap
Positiveurine
aniongap
Diarrhea,
dilutional
RTA
Osmolar gap
Noosmolar
gap
Methanol
Ethyleneglycol
Salicylates
Paraldehyde
AcuteRenalFailure
Incitingfactors
BUN/creatinine ratio
Urinarysodium
FENa+
PreRenal
Dehydration
Hypovolemia
Radiocontrast
NSAIDs
>20
<20mEq/L
Urineosmolality
<1%
>500mOsm/L
Urinesediment
Bland
Intrinsic
Toxins
Ischemia
Medications
<20
>20mEq/L
>1%
<350mOsm/L
Muddybrown
casts
AcuteRenalFailure
Theleastcommontypeofrenalfailureisobstructiveorpost
renal,butitisimportanttoidentifyasitisreversible
Recoveryfromacuterenalfailuremayleadtopolyuric phase,
inwhichfluidlossmustberepleted toavoidprerenal
azotemia.
Rhabdomyolysis
Cluetodiagnosisisurinarydipstickthatispositiveforbloodin
absenceofredbloodcellsinsediment.
Laboratoryanomaliesassociatedwithrhabdomyolysis
include:
Hyperkalemia
Hyperphosphatemia
Hypocalcemia
Nephrotic Syndrome
Nephrotic syndromeisdefinedas:
Proteinuria >3.5gm/24hours
Hypoalbuminemia
Edema
Hyperlipidemia
Systemiccausesinclude:diabetes,amyloidosis,multiple
myeloma
Causeslimitedtothekidneyinclude:minimalchangedisease,
focalsegmentalglomerulosclerosis,andmembranous
gromerulonephritis
Nephrotic Syndrome
Cause
Minimalchange
disease
Focal segmental
glomerulosclerosis
Membranous
glomerulopathy
PreRenal
Mostly inchildren,though10%inadults
MaybecausedbyNSAIDs
Goodprognosis
Tx:steroids
MostcommoninAfricanAmericans
Associatedwithheroinuse,HIV,andsickle
cellanemia
Associatedwithhepatitis B,syphilis,
endocarditis,SLE
NephriticSyndrome
Nephriticsyndromeisdefinedas:
Hematuria
Proteinuria
RBCcasts
Etiologiesinclude:
PostinfectiousGN
Membranoproliferative GN
Cryoglobulinemia
Goodpasteure
Vasculitis
Glomerulonephritis AfterURTI
Cause
Latentperiod
PostStreptococcal
Three weeksafter
infection
Usuallychildren
Findings
Lowcomplement
PositiveASLOtiter
Antibiotics
Treatment
IgA Nephropathy
Threedaysafter
infection
Mostcomon causeof
GN,especially inAsian
men
Normalcomplement
SerumIgA elevated
ACEinhibitors
Hyponatremia
Hyponatremia
Isoosmolar
(280295mOsm/kg)
Hypoosmolar
(<280mOsm/kg)
Nonosmolar substance
occupyinglargeportionof
plasma(hyperlipidemia,
hyperproteinemia)
Hyperosmolar
(>295mOsm/kg)
Osmolar ubstance
occupyinglargeportionof
plasma(hyperglycemia)
Hypovolemic
Euvolemic
Hypervolemic
Renalorextrarenal losses
(vomiting,diarrhea,
diuretics)
SIADH,psychogenic
polydypsia,
hypothyroidism
Congestiveheartfailure,
chronicliverdisease,
renalfailure
Gastroenterology
Dysphagia
EsophagealDysphagia
Intermittent
Solidsonly
Solidsandliquids
Progressive
Solidsonly
Solidsandliquids
Carcinoma
Esophagealrings
Diffuse
esophageal
spasms
NoHeartburn
Heartburn
Achalasia
Scleroderma
Malabsorption
Fatmalabsorption
(>7gm/day)
Dxylose test
Positive(serumlevel<25
gm/dL in1hour)
Negative(serumlevel>
25gm/dL in1hour)
Intestinalmalabsorption
Pancreaticinsufficiency
Trialantibioticsorglucose
breathtest
AbdominalxrayorCT
scan
Smallbowelbiopsy
ERCP
AcuteDiarrhea
Characteristics
Presentation
Causing agents
Inflammatory
Frequent,bloody,
smallvolume
Feverandcramps
Affectscolon
Fecalleukocytes+
Salmonella
C.jejuni
C.difficile
E.coliO157:H7
Shigella
Yersinia
Noninflammatory
Largevolume, watery
diarrhea
Nausea,vomiting
Affectssmallintestine
Fecalleukocytes
Bacilluscereus
Giardia lamblia
Enterotoxigenic E.coli
Staphylococcus
Vibrio cholerae
Norwalkvirus
Rotavirus
IrritableBowelSyndrome
Atleastthreemonthsof:
Abdominaldiscomfortrelievedbydefecation
Onsetofpainassociatedwithchangeinstoolfrequency
and/orconsistency
Usuallypresentswithassociatedsomaticsymptoms,suchas
musculoskeletalpain,headaches,fatigue,anxiety
Treatment:reassurance,education,andsupport;frequent
officevisits
IschemicColitis
Chronicischemiccolitispresentsaspostprandialpainand
bloatingleadingtoavoidanceoffood.Itresultsfrom
atheroscleroticdisease.
Acutebowelischemiapresentsasseverepainwithminimal
physicalexaminationfindings.Laboratoryanalysesmayshow
markedhighaniongapacidosis.Causesinclude:
Embolicocclusion(50%cases) lookforatrial fibrillation
Thrombosisofatheroscleroticvessel
Lowflowstateduetohemorrhageorshock
ColonCancerScreening
PatientHistory
No personalorfamily
history
Familyhistoryinarelative
olderthan60years
Familyhistoryinarelative
youngerthan60years
Personalhistoryofcolon
cancerfollowingresection
FrequencyofScreening
Colonoscopyatage50,then every10
yearsifnormal
Colonoscopyatage40,then every10
yearsifnormal
Colonoscopyat age40or10years
youngerthanrelativesageattimeof
diagnosis;thenevery5years
Colonoscopy every3years
HepatitisBSerology
Stage
HBsAg
Anti
HBsAb
Anti
HBcAb
HBeAg
Anti
HBeAb
AcuteHepatitis B
ChronicHepatitis B
Recoveryfrom
HepatitisB
Vaccination
againstHepatitisB
Falsepositiveor
pastinfection
+/
+
IgM
IgG
+/
+/
+/
IgG
+/
IgG
CluestoHepaticDisease
Etiology
Toxic hepatitis,
Acuteviralhepatitis,
Shockliver
Alcoholic hepatitis
Autoimmune
Nonalcoholic
steatohepatitis
Hemochromatosis
Clues
ASTandALT elevationscloseorabove
1,000IU/L
MaycauseincreaseinPT/INR
AST/ALTratio>2
ASTelevation<300IU/L
Usuallyinyoungwomen
Otherautoimmune conditionspresent
Obesefemale
AST/ALTratio <2
Skin discoloration
Diabetes,arthralgias
Jaundice
Pattern
Unconjugated
(indirect)
Mechanism
Increasedbilirubin
production
Impairedbilirubin uptake
Hepatocellular damage
Conjugated
(direct)
Obstruction toflow
Impaired secretionfrom
hepatocytes
Examples
Hemolysis
Gilberts
CriglerNajar
Toxichepatitis
Choledocholithiasis
Pancreaticcancer
Rotor
DubinJohnson
Ascitic Fluid
SerumAlbuminGradient
> 1.1g/dL
Transudate
<1.1g/dL
Exudate
Portalhypertension
Malignancy,tuberculosis,
pancreatitis
Ascitic fluidtotalprotein
<2.5g/dL
Livercirrhosis
>2.5g/dL
Congestiveheartfailure
Pancreatitis
Ranson Criteriadictateseverity:
Uponadmission:
Age>55years
WBC>16,000/mm3
Glucose>200mg/dL
AST>250IU/L
LDH>350IU/L
At48hours:
Calcium<8mg/dL
Hematocrit fall
PO2<60mmHg
BUNincreaseby>5mg/dL
Sequestrationoffluid
Rheumatology
Arthritis
Arthritis
Osteoarthritis
Pathogenesis
Findings
Degenerationof
Narrowingofjoint
cartilagedueto tear space
andwear
Knee obese
Hands hereditary
Rheumatoidarthritis Lymphocytic
Symmetricarthritis
infiltrationofjoint
Atleast3joints,
includinghands
Morningstiffness
Goutyarthritis
Depositionofurate
Monoarticular: toe,
monosodium
knees
Tophi
Pseudogout
DepositionofCa++ Chondrocalcinosis
pyrophosphate
Usuallyfollowing
dihydrate
surgery
Osteoarthritis
Bouchardsnodes
Hebedens nodes
Gout
Inpresenceoftophi,giveallopurinol
Foracuteattacks:NSAIDs
Goutvs.Pseudogout
Characteristic
Setting
Gout
Males,afteralcohol
consumption
Hyperuricemia
Crystals
Needlelikewith
negativebirefringens
Pseudogout
Olderthan60
Usually2448hours
aftermajorsurgery
Associatedwith
hemochromatosis
Rhomboidshaped
weaklypositive
birefringens
MuscularWeaknessSyndromes
Dermatomyositis
Polymyalgia
rheumatica
Polyarteritis
nodosa
Presentation
Proximalweakness
Heliotroperash
Grottons papules
Proximalmuscle
inflammationand
pain
Weakness
secondarytopain
Vasculitis with
sparingoflung
Footdrop
Renalfailure
Seizures
Findings
HighCPKandESR
AbnormalEMG
HighESR
NormalCPKand
EMG
HighESR andWBC
Anemia
Associations
Ovariancancer
Temporalarteritis
HepatitisBandC
Treatment
Highdose steroids
Lowdosesteroids,
unlesstemporal
arteritis present
Highdosesteroids,
cyclophosphamide
AutoimmuneDisordersInvolvingLungs
Wegeners
Granulomatosis
Goodpasteures
Syndrome
ChurgStrauss
Vasculitis
Presentation
Rhinosinusitiswith
nasalseptal
perforationand
saddlenose
Cough,hemoptysis
Glomerulonephritis
Nonasal
involvement
Glomerulonephritis
Alveolar
hemorrhage
Asthma
Eosinophilia
Fleeting infiltrates
Sinusitis
Neuropathy
Renalinvolvement
Antibody
CANCA
AntiGBM
PANCA
AutoAntibodies
Antibody
AntidsDNA
Antihistone
AntiSmith
Anticentromere
AntiSSA(Ro)
AntiSSB (La)
AntiCCP
Condition
SLE goodfordiagnosisandprognosis;
absentindruginducedlupus
Druginducedlupus
VeryspecificforSLE
Limited scleroderma
Scleroderma,Sjgrens
Sjgrens
Rheumatoidarthritis
MusculoskeletalComplaints
Bicipetal
Tendinitis
Presentation Anterior
shoulder pain,
worsebylifting
armoverhead
Worsewhen
lyingover
affectedside
Signs
Tendernessto
palpationlateral
toacromion
Difficultyto
abductshoulder
Lateral
Epicondylitis
Medial
Epicondylitis
Tenderness
causedbyuse
ofextensor
musclesof the
elbow
Tenderness
causedbyuseof
flexormusclesof
theelbow
Painby
resistedwrist
extension
Painby
resistedwrist
flexion
HematologyOncology
Anemia
Type
Normocytic
normochromic
Microcytic
hypochromic
Etiology
Anemiaof chronic
disease
Irondeficiency
Betathalassemia
Findings
Highferritin
Low ferritin andiron
RDW>15%
Normalferritin andiron
RDW<15%
HemolyticAnemias
Etiology
Mechanism
Membranedefects
Intrinsic
Oxydation
Hemoglobinopathies
Defective metabolism
Immunemediated
Extrinsic
Microangiopathic
Infection
Examples
Hereditary spherocytosis
Paroxysmalnocturnal
hemoglobinuria
G6PDdeficiency
Sicklecellanemia
Pyruvate kinase deficiency
Autoimmuneanemia
Drugtoxicity
TTP
DIC
Malaria
Aplastic Anemia
Fattyinfiltrationofbonemarrow,resultingindecreasecounts
inallcelllines.
Noabnormalcells,hepatosplenomegaly,lymphoadenopathy,
orbonetenderness.Retic countisdecreased.
Thrombocytopenia
Mechanism
Decreased production
Increaseddestruction
Sequestration
Pseudothrombocytopenia
Examples
VitaminB12defficiency
Leukemias
Aplastic anemia
ITP
TTP
DIC
Chronicliverdisease
Hypersplenism
False positiveduetoclumping
MultipleMyeloma
Plasmacellexpansion,
characterizedby:
Anemia
Proteinuria
Backpain
Recurrentinfections
Heartfailuresymptoms
Lytic bonelesions
hypercalcemia
Roleaux formationonblood
smear
Lymphoma
Hodgkin
NonHodgkin
Painlesslymphoadenopathy,
Retroperitoneal,pelvic,or
mostcommonlyofneckarea
abdominallymphoadenopathy
Usuallyinmales
Prognosisispoor
Contiguousspreadintothorax
andmediastinum
Prognosisisgood
BreastMasses PremenopausalWomen
Breastmass
Clinically
benign*
Mammogram
Cystic
Aspirate
Nonbloody&
resolves
Excisionif
recurrent
Clinically
malignant*
Mammogram
Solidbutbenign
looking
Possibly
malignant
Biopsy
Biopsyvs.
reexaminationin
14months
Biopsyif
persistent
*Clinicallymalignant:asymmetric
breasts,edema,erythema,bloody
discharge,nippleretraction,skin
retraction,poorlydemarcatedborders
BreastCancer
Breastconservingsurgerywithradiationisthepreferred
formoftreatment
Endocrinetherapy(eg,tamoxifen)isgivenforhormone
receptorpositivecases
Chemotherapyimprovessurvival,particularlyinnode
positive,hormonereceptornegative,and/orHER2/neu
positivecases
Trastuzumab maybeusedforHER2/neupositivecases
Endocrinology
DiabetesMellitus
Diabetesisdiagnosedbyanyofthefollowing:
Fastingglucose> 126mg/dL ontwooccasions
Plasmaglucose> 200mg/dL 2hoursafter75gmoral
glucoseloadingafterovernightfasting
Randomglucse > 200mg/dL withsymptoms
HgbA1c> 6.5%(screening,notdiagnostic)
Cushings
Usuallypresentwith:
Hypertension
Centralobseity
Easybruising
Amenorrhea
Diabetes
Striae
Cushings
Cushings
Low
SerumACTH
ACTHindependent
NormalorHigh
Highdosesuppression
test(8mg)
AbdominalCT
(adrenaltumor)
Suppresses=Pituitary
Doesnotsuppress=
ectopic
PituitaryMRI
Chest/abdominalCT,
somatostatin scan
Negative
InferiorPetrosal Sinus
Sampling
DiabetesInsipidus
Urine
osmolality
Normal
Central DI
Nephrogenic
DI
Psychogenic
polydypsia
Noincrease
(noADH)
Noincrease
(noresponse
toADH)
Partialincrease
After
dehydration
Increased
After
vasopressin
<5%increase >50%increase
(already
maximally
concentrated)
Lithiumcausesnephrogenic DI
Noincrease
Minimal
(noresponse increase(<9%)
tovasopressin) kidneys
concentration
abilityis
impaired
ThyroidDisorders
Characteristic
Hashimotos
Subacute
thyroiditis
Gravesdisease
Presentation
Painlessgoiter
withinitial
hyperthyroidism
followedby
hypothyroidism
Painfulgoiterwith
hyperthyroidism
followedby
hypothyroidism
Mostcommon cause
ofhyperthyroidism
withexophthalmos +
goiter
Etiology
Autoimmune
destructionof
thyroidgland
Viral
Antibodiesagainst
TSHreceptor
HormoneReplacement
TheindicationforHRTissymptomaticrelief.Forpreventionof
osteoporosis,tamoxifen maybeusedinstead.
Unopposedestrogentherapyincreasesriskofendometrial
cancer,soavoidinwomenwithintactuterus.
Progesteroneincreasesriskofbreastcancermoresothan
estrogen
FamilialHypercholesterolemia
LDLcholesterollevelsextremelyhighinthesettingoffamily
historyofprematurecoronaryarterydisease
Xanthomas common
DuetodecreasedconcentrationofordefectiveLDLreceptors
Allergy/Immunology
HypersensitivityReactions
TypeIreactionsareIgEmediated
degranulation ofmastcells(examples:
anaphylaxis,asthma,allergicrhinitis)
IgE
IgG
TypeIIreactionsconsistofcomplement
ativation duetoIgG adheringtocell
membraneantigens(examples:drug
reactions)
HypersensitivityReactions
IgG
TypeIIIreactionsareduetosoluble
antigensthatcreatecomplexeswithIgG
andactivatecomplementandphagocytes
(example:serumsickness)
TypeIVreactionsareduetoactivationof
Thelpercellsbymacrophagesupon
detectionofsolubleantigen(examples:
contactdermatitis)
TH1
InfectiousDiseases
Gonorrhea
Urethritis usuallysymptomaticinmale;symptomsinfemales
usuallywhenPIDhasdeveloped.
Gramnegativediplococci andWBCs
Concomittant Chlamydiainfection,sotreataswell
Pharyngealinfection
Disseminatedinfectionpresentswithpustular rash,
asymmetricarthritis
Syphilis
Primarysyphilispresentsaspainlesschancre
Secondarysyphilistypicallypresentspruritic rashoftheplms
andsoles
Tertiarysyphilismaycauseaortitis,damagetoCNS,
dementia,etc.
HIV/AIDS
ScreenallpatientsforHIV!
AIDSisdefinedby:
CD4+Tlymphocytecount<200cells/mm3
CD4+Tlymphocyte<14%oflymphocytes
AIDSdefiningconditions:esophagealcandidiasis,cervical
cancer,Kaposisarcoma,lymphoma,TB,Pneumocystis
jirovecii pneumonia,Toxoplasmosis,etc.
HIV/AIDS P.jirovecii
Usuallypresentsfever,cough,dyspnea,highLDH,lowpO2,
anddiffuseinterstitialinfiltrates.
SteroidsaddedtotherapyifSO2<90%,pO2<70%and/orA
agradient>35mmHg
Endocarditis
Majorcriteria:
Newregurgitant murmur
Bloodculturespositivefortypicalorganism
Typicalechocardiographic findings
Minorcriteria:
Riskfactors(ie,poordentition,IVdruguse)
Fever>38C
Embolicevents(ie,Janeway lesions,pulmonaryemboli)
Rheumatologicevents(ie,Rothspots,Oslernodes,ANA+,
glomerulonephritis)
Nontypicalechocardiographic findings
Nontypicalorganisminbloodculture
Endocarditis
RothsSpot
Whitecentered
retinal
hemorrhage
OslerNodes
Tender,red,
raisedlesions
onthefingers
andtoes
Janeway Lesions
Bacterialembolitoskinvessels
JarischHerxheimer Reaction
Sepsislikesyndromecausedbyantibiotictreatmentof
spirochetal diseasesduetoreleaseofbacterialendotoxins.
Seeninrelapsingfever,leptospirosis,syphilis,Lymedisease
Presentsusuallywithintwohoursofantibiotictherapywith
fever,chills,hypotension,tachycardia
Treatment:antiinflammatory drugs
LymeDisease
Tickbitefromendemicareas,lastingatleast24hours
Stage1consistsoferythema chronicum migrans atthesiteof
bite
Stage2maypresentwitharthralgias andheartblock
Stage3presentsneuropathy
LymeDisease
Tickbitefromendemicareas,lastingatleast24hours
(usually36hours).Iflessthanthistime,noneedfor
prophylactictreatment
Stage1consistsoferythema chronicum migrans atthesiteof
bite
Stage2maypresentwitharthralgias andheartblock
Stage3presentsneuropathy
MostCommon
Condition
Pneumonia
Sinusitis
MostCommonOrganism
Streptococcuspneumoniae
Haemophilus influenzae usedtobemore
commonbeforevaccine;
NowStreptococcuspneumoniae and
Moraxella catarrhalis
UTI
Catheterrelated
infections
Meningitis
Escherichiacoli
Staphylococcusepidermidis
Neisseria meningitidis
VaccinationsforAdults
PrecautionswithVaccines
Livevaccines,suchasVaricella,Zoster,andMMRare
contraindicatedinpatientswith:
HIVandCD4+Tlymphocytecount<200cells/mm3
Pregnancy
Immunocompromised state
Neurology
StrokeTerritories
Artery
Middlecerebral
artery
Posteriorcerebral
artery
Anteriorcerebral
artery
Vertebral artery
Findings
Aphasia (Wernicke orBroca)
Spatialneglect
Contralateral facialandarmparalysis
Verticalgazepalsy(3rd nerve)
Sensorydeficit
Agitation
Hyperactivity
Lefthandapraxia
Contralateral lossofposition and
vibratorysense
Contralateral hemiparesis
Dementia
Type
Alzheimers
Presentation
Mostcommon causeofdementia
Usuallyolderagebutyoungerpossible
withfamilyhistory
Multiinfarct
Second mostcommon
Riskfactorsforatheroscleroticdisease
Stepwiseprogression
Hungtintons disease Usuallybetween35and45yearsofage
Changedinpersonality
Jerky, randommovements
Lewy body
OverlapswithAlzheimersand
Parkinsons
Visualhallucinations
SerotoninSyndrome
Excessserotonergic activityasresultfromSSRIuse,overdose
orinteractionswithotherdrugs,aswellasuseofcertain
recrational drugs.
Symptoms:
Cognitive:Hypomania,confusion,hallucinations,agitation
Autonomic:Shivering,sweating,hypertension,
tachycardia,nausea,diarrhea,hypertheremia
Somatic:Myoclonus,hyperreflexia,tremor
Neuroleptic MalignantSyndrome
Adversereactiontoneuroleptic orantipsychoticdrugsaswell
aswithdrawalfromanticholinergic drugs(ie,Parkinsons)
Symptomsinclude:
Musclerigidity
Fever
Autonomicinstability
Delirium
HighCPK
Treatment:dantrolene,bromocriptine,benzodiazepines,
antipyretics
MyastheniaGravis
Autoantibodies bindtoacetylcholinereceptors,causing
weaknessandfatiguethatincreaseswithmuscleuseand
improveswithrest(oppositetoLambertEatonsyndrome)
Usuallyassociatedwiththymoma
Anticholinesterase drugsmaybehelpful(ie,Neostigmine,
pyridostigmine)
Crisismaybetreatedwithplasmapheresis orintravenous
immunoglobulin
Headaches
Type
Migraine
Cluster
Tension
Presentation
Lateralized,dullorthrobbing
Associatednausea, anorexia,
photophobia,phonophobia
Familyhistory
Treatment:sumatriptan,NSAIDs,
ergotamine
Prevention:propanolol,SSRIs
Behind andaroundtheeyewith
lacrimation,flushing,nasalcongestion
Usuallyseveraldaysinarow
Treatment:oxygen
Bandlike aroundhead
Treatment:NSAIDs,amitryptiline
PeripheralNeuropathies
Type
Ulnar nerve
Radialnerve
Mediannerve
Presentation
Clawhand
Commonincyclists
Wristdrop
Saturdaynightpalsy
Carpaltunnelsyndrome
Mostcommoncauseispregnancy
Dermatology
RashestoKnow
RashestoKnow
RashestoKnow
RashestoKnow
Psoriasisisanautoimmunemanifestationcausingsilvery
whitescalesorplaques
Maybeassociatedwithpsoriaticarthritis
Treatment:topicalcorticosteroids,phototherapy
RashestoKnow
SkinCancers
Type
Appearance
FactstoKnow
Melanoma
The mostimportantfactorfor
prognosisisdepthofthelesion
Sunexposureishighestrisk
factor
Highriskformetastasis
Squamous cell
carcinoma
Hardraisededgednecrotic
ulcers
Actinickeratosis predisposes
Sun exposureandsmokingare
riskfactors
Basalcell
carcinoma
Sun exposureisriskfactor
Presentsclearlydefinedmargins
withtelangiectasia
Metastaticpotentialislow
KaposisSarcoma
AIDSdefiningneoplasmcausedbyHerpesvirus 8
Reddishbrownnodulesorblotches,usuallypapular,typically
foundonsunexposedskin
Blisters
Cause
Pemphigus vulgaris
FactstoKnow
Painfulbullae
PositiveNikolskys sign
Treatment:coticosteroids,IVIg
Bullous pemphigoid
Epidemiology
NumberNeededtoTreat
Simplycalculateabsoluteriskreductionin%:
ARR=8% 5%=3%
Thendivide100byabsoluteriskreduction:
NNT=100/ARR=100/3=33
Question
Healthy
Diseased
Aboveisshowndistributionoftestresultsforscreeningofprostate
cancer.Thearrowindicatesthecutoffpointatwhichthetestis
consideredpositive.
Whichofthefollowingistrue?
a.
b.
c.
d.
Specificityishigh;sensitivityislow
Specificityislow;sensitivityishigh
Bothspecificityandsensitivityarelow
Bothspecificityandsensitivityarehigh
Sensitivity
Sensitivityistheabilityofatesttoidentifyindividualsafflictedby
adisease
Sensitivity= Individualswithdiseaseandpositivetest
Allindividualswithdisease
=
Truepositive
Truepositive+Falsenegative
Specificity
Specificityistheabilityofatesttoidentifyhealthyindividuals
Specificity= Healthyindividualswithnegativetest
Allhealthyindividuals
=
Truenegativetests
Truenegative+Falsepositive
PositivePredictiveValue
PPVistheprobabilityofapositiveresultpredictingtruedisease
PPV=
Truepositiveresults
Allpositiveresults
Truepositive
Truepositive+Falsepositive
NegativePredictiveValue
NPVistheprobabilityofanormalresultpredictingabsenceof
disease
NPV=
Truenegativeresults
Allnegativeresults
Truenegative
Truenegative+Falsenegative
GoodLuckontheExam!