USMLE WORLD: MEDICINE notes

Primary Adrenal Insufficiency: hypotension, pigmentation, hyponatremia,

hyperkalemia, eosinophilia, elevated ACTH, low cortisol. MCC in developed
countries is autoimmune adrentalitis with Ab against steroidogenic enzymes.
History of other AI diseases (especially endocrine).

Endocarditis: fever, generalized weakness, new right sided heart murmur

(increase with inspiration). History if IVDA and cellulitis. Staph if IVDA, strep
and entero if not. Vancomycin is most commonly used as empiric therapy in
IVDA due to MRSA coverage.

Folic Acid Deficiency: present with megaloblastic anemia. MCC is poor diet
and alcoholism. Phenytoin, primidone, phenobarbital inhibit folate absorption.
TMP and methotrexate inhibit DHFR causing folate deficiency.

Huntingtons Disease: autosomal dominant that presents 30-50 years. Mood

disturbances (depression, apathy), dementia, choreiform movements, positive
family history. Symptoms are progressive -> severe disability.

UTI: lower abdominal discomfort, burning, increased frequency, suprapubic

tenderness, significant bacteriuria. Predisposing factors: antibiotics, genital
infections, contraceptives (diaphragm, spermicide), poor hygiene. Occur via
ascending route.

Systemic Sclerosis: affects all organ systems. Cutaneous findings are that of
scleroderma. Thickening of the skin, edema -> obliteration of hair follicles and
sweat glands and flexion contractures. Mask like appearance to face.
Myofibroblast proliferation -> increased collagen and ground substance
production. Kidney involvement -> hypertension. Pulmonary hypertension ->
right heart failure. Esophageal and gastric dysmotility -> GERD. Find ANA and
anti-topoisomerase I antibodies.

Clostritidum difficile Diarrhea: antibiotic treatment predisposes. Diffuse

watery, non bloody, diarrhea with abdominal cramps and fever. Nausea,
vomiting, elevated WBC. Toxin to intestinal epithelial cells. Detect toxin in the
stool. Treat with IV/oral metronidazole. Oral vancomycin can also be used.

Acute Limb Ischemia: sudden decrease in perfusion that threatens limb vitality
and presents 2 weeks of symptom onset. Pain, pulselessness, pallor,
parasthesias, paralysis. Due to embolism (MCC), thrombosis, trauma. Atrial
fibrillation -> embolism. Prevent with warfarin.

Essential Tremor: action/intention tremor in the absence of other neurological

signs. Difficulty holding newspaper, writing legibly, drinking coffee, feeding
themselves. Treat with beta blocker (propranolol). Primidone or topiramate
also work. BZDs can be helpful but run risk of addiction.

Creutzfeldt Jakob Disease: rapidly progressive dementia, myoclonus, sharp

periodic bi/triphasic synchronous discharges on EEG. Caused by a prion ->
spongiform encephalopathy. CSF is usually normal. Most patients die within 1
year.

Rotator Cuff Tendonitis: shoulder pain with reaching or lifting arm overhead.
Due to repetitive activity at shoulder height (painters), MC in middle
 aged/older. Confirmed on PE by Neer test with pain and guarding. Confirmed
with lidocaine injection -> improvement. MRI for definitive diagnosis.

HIV Infection: increased risk of viral, bacterial, fungal, protozoan infections.

Need vaccinations at diagnosis, especially influenza, hepatitis, Strep pneumo.
MMR is necessary (measles can be fatal in HIV). Can give with CD4 > 200, and
no history of AIDS defining illness.

Lung Adenocarcinoma: least association with smoking. MC type of lung

cancer, even in non smokers. Located peripherally. Columnar cells growing
along septa. Presents as solitary nodule. Bronchoalveolar type is most
important. Related to pulmonary scars as in fibrosis. Metastisizes early to
adrenals, bone, CNS.

HIV: presents with nonspecific symptoms such as weight loss, malaise,

neurological changes, anorexia, weight loss. Usually present early, can
present late with PJP or Candida esophagitis. HIV Dementia: waxing and
waning, difficulty with complex tasks, poor memory, apathy.

Mixed Cryoglobulinemia: palpable purpura, proteinuria, hematuria, non-

specific systemic symptoms, arthralgias, hepatosplenomegaly,
hypocomplementemia, peripheral neuropathy. Demonatrate circulating
cryoglobulins to confirm. Usually have underlying HCV infection.

Acute Cord Compression: back pain with associated tenderness at the site
of metastasis (usually prostate). Progressive or sudden compression with
neurological deficit can ensue. Medical emergency that needs prompt
treatment. First do neurological exam for signs of myelopathy (if so, give
steroids). Then do MRI or CT myelogram if no MRI. Radiotherapy to treat.

Respiratory Acidosis: decreased pH, primary increase in PCO2. Along with low
PO2 levels, suggest alveolar hypoventilation (MCC). Causes:
pulmonary/thoracic (COPD, OSA, CF, obesity, scoliosis, ankylosis),
neuromuscular (MG, LE, poliomyelitis, muscular dystrophy, GBS, ALS), drug
induced (anesthesia, narcotics, sedatives), primary CNS (brainstem lesion,
infection, stroke).

Bronchodilator Response Test: used to demonstrate reversibility if airway

obstruction. Differentiates COPD from asthma, but subset of COPD will have
airway reactivity (diseases are on a continuum). Measure FEV1 before and
after bronchodilator (beta agonist). Increase of 15% needed for reversibility.
Low DLCO and CT findings support COPD.

Iron Deficiency Anemia: hypochromic/microcytic anemia, low iron/ferritin. MCC

is chronic blood loss. Can be caused by dietary deficiency or malabsorption.
Adult male or post menopausal female -> test for occult blood in stool. PUD,
angiodysplasia, diverticulosis are other causes.

Niacin: used to treat lipid abnormalities. Frequently produces flushing and

pruritis due to vasodilation. Caused by drug induced release of histamine and
PG. Low dose ASA can help alleviate if taken 30 minutes prior. Usually improve
after 2-4 weeks of therapy.

TCA Overdose: CNS depression, hypotension, hyperthermia, anticholinergic

effects (dilated pupils, blocks SLUD). Decreases myocardial conduction
 velocity -> wide QRS (best indication of extent of OD) -> ventricular
arrhythmia. Treat with NaHCO3 (narrows QRS).

Renovascular Hypertension: headache, elevated BP, renal bruit due to RAS

(fibromuscular dysplasia in young women, atherosclerotic in older).
Interventional therapy is better than medical alone. Attempt angioplasty and
stent. If patient is older, not good candidate or refuses surgery, can use
medications alone (ACE and diuretics).

Generalized Resistance to Thyroid Hormones: hypothyroid can be caused by

thyroid (primary), pituitary (secondary), hypothalamus (tertiary), or GRTH.
Results from receptor defects on peripheral tissues. Present early with growth
and mental retardation. Elevated thyroid hormones and normal/elevated TSH.
Features of hypothyroid with elevated T3/T4.

Lambert Eaton Syndrome: caused by Ab against voltage gated calcium

channels in presynaptic motor nerve -> decreased Ach release -> proximal
muscle weakness and loss of DTR. History of features of SCC of the lung.
Muscle response increases with repetitive simulation. Treat with
plasmapheresis and immunosuppressants.

Myasthenia Gravis: caused by Ab to postsynaptic receptors -> reduction of

Ach receptors -> muscle weakness and preserved or brisk DTRs. History of
features of SCC of the lung. Muscle response decreases with repetitive
stimulation.

Microangiopathic Hemolytic Anemia: elevated serum LDH and schistocytes.

Have decreased haptoglobin, reticulocytosis, elevated indirect BRN. One
cause are artificial valves.

Pulseless Electrical Activity: presence of rhythm with no palpable pulses. Any

patient with arrest with nonshockable rhythm (anything other than VF/VT) ->
give CPR, establish airway, give 100% O2. Atrial fibrillation is not a
shockable rhythm during arrest with no pulses. IV access for
epinephrine, vasopressin, atropine. Caused by 6Hs (hypovolemia, hypoxia,
hydrogen/acidosis, hypoglycemia, hyper/hypokalemia) or 6Ts (tamponade,
tension pneumothorax, thrombosis/MI/PE, trauma/hypovolemia, tablets/drugs,
toxins).

Vitamin B12 Deficiency: common after total or partial gastrectomy (gastric

derived IF binds B12 and facilitates absorption in the stomach). Necessary
cofactor for demethylation of methyl-THF -> THF needed for purine synthesis.
Other causes: pernicious anemia, gastritis, intestinal disorders, old age.
Presents as megaloblastic anemia with glossitis and neurologic changes.

Aortic Dissection: three clinical findings: abrupt onset tearing pain in chest
or back, variation in pulse/BP between arms, wide mediastinum on CXR. Tear
in intima -> subintimal hematoma. HTN, smoking, family history of CAD. May
extend into pericardium, CA, carotids -> tamponade, MI, stroke.

Nephritic Syndrome: dependent edema, hypertension, hematuria with or

without dysmorphic RBC or RBC casts. Decreased GFR -> fluid overload ->
weight gain, hypertension, exertional dyspnea. Rash, low grade fever possibly
due to systemic disease. UA -> RBC with or without casts. May have
proteinuria. Biopsy to determine exact type of GN.
 Testicular Cancer: AFP, beta-HCG, placental ALP are useful for diagnosis,
staging, monitoring patients. Seminoma: PLAP, embryonal carcinoma: AFP +
beta-HCG (50%), choriocarcinoma: beta-HCG. LDH and CEA have some use
but are non-specific.

Pneumocystis Jiroveci Pneunonia: an important cause of progressive dyspnea

and hypoxia in HIV/AIDS patients. Hypoxia in pneumonia results from alveolar
and interstitial inflammation -> V/Q mismatch -> increased A-a oxygen
gradient.

Polymyositis: inflammatory muscle disease. Slowly progressive proximal

muscle weakness -> difficulty standing or climbing stairs, difficulty combing
hair or working overhead. Muscles of mastication and facial expression are
spared. May develop dysphagia due to involvement of upper pharyngeal
muscles. Weakness is primary, may have mild tenderness. Muscle biopsy is
diagnostic. Shows mononuclear infiltrate surrounding necrotic/regenerating
fibers or overt fibrosis.

COPD: recurrent pulmonary infections, chronic cough, smoking history,

increased AP diameter, wheezing. Chronic hypoxemia -> constriction of
pulmonary arterial system -> pulmonary hypertension -> RVH -> RVF ->
elevated JVP, hepatosplenomegaly, hepatojugular reflex, lower extremity
edema. NO PULMONARY EDEMA.

Lactic Acidosis: if results from poor O2 delivery to tissues is called type A.

Shock and CO poisoning are causes. CO binds with high affinity to Hgb ->
displaces O2 -> decreases O2 content and causes left shift of Hgb O2
dissociation curve -> decreased unloading of O2 -> increased anaerobic
metabolism -> lactic and anion gap metabolic acidosis.

Acute Pancreatitis: pain radiating to the back, leukocytosis, elevated serum

amylase and lipase. Causes acute abdomen. Managed conservatively with
analgesics (meperidine or fentanyl), IVF, NPO. Can use NG if necessary to
decrease gastrin release.

Dipyridamole: is a coronary vasodilator along with adenosine. With CAD,

diseased arteries are maximally dilated and cannot increase blood flow and is
redistributed to non-diseased segments. Used during myocardial perfusion
scanning to reveal areas of restricted perfusion. Redistribution of coronary
blood flow to non-diseased segments is called coronary steal.

Hypertensive Hemorrhage: focal neurological signs that gradually worsen over

minutes to hours. Onset is not abrupt like SAH or embolism. Can develop HA,
vomiting, altered mental status. MC site is the putamen (35%). Internal
capsule is adjacent -> hemiparesis. Can have hemi-sensory loss,
homonomous hemianopia, stupor, coma. Eyes deviate away from paralytic
side.

Amiodarone: causes pulmonary toxicity. Avoid in patients with pre-existing

lung disease. Can cause chronic interstitial pneumonitis, organizing
pneumonia, acute respiratory distress syndrome. Side effects are dose
dependent.

Rheumatoid Arthritis: symmetric polyarthritis, ulnar deviation, swan neck,

boutonniere, morning stiffness > 1 hour. Fever, weight loss, malaise. Lab tests
 show rheumatoid factor and anti-cyclic citrullinated peptide. Radiographs
show joint erosions, juxta-articular osteoporosis, narrowing of joint spaces. PIP
and MCP joints are affected. DMARDs are used early to promote remission.
First line is methotrexate. Can also use hydroxychloroquine, sulfasalazine,
leflunomide, etanercept, infliximab, azathioprine.

Postoperative Cholestasis: hypotension, extensive blood loss into tissues,

massive blood replacement. Jaundice due to increased pigment (transfusions),
decreased liver function (hypotension), decreased BRN excretion (tubular
necrosis).

Breaking Bad News:

o Quiet, private, comfortable environment
o Ask patient how much they know or what they think
o Ask patient how much they want to know
o Give warning shot saying you have bad news
o Break the news if they want you to
o Give prognosis, keep aware of options available
o Explain everything as clearly and simple as possible

Tamoxifen: mixed agonist and antagonist on estrogen. Reduces risk of

recurrence and new cancer in the other breast. Increases endometrial cancer
and uterine sarcoma. Also have increased risk of venous thrombosis.

Celiac Disease: intermittent abdominal distension, flatulence, greasy stool.

Iron deficiency is one of the most common presentations (iron absorbed in
duodenum). Dermatitis herpetiformis is also associated (chronic intensely
burning pruritic papulovesicular rash) with granular IgA deposits in upper
dermis.

Atypical Mycobacterium: HIV infected, unexplained fever, cough, CD4 < 50, no
history of or exposure to tuberculosis. If CD4 < 50, give azithromycin as
prophylaxis.

Migraine: suspected with unilateral headache with a pulsatile quality,

especially if accompanied by vomiting and photophobia. Sometimes have an
aura of neurological symptoms. No concerning features are present. Give IV
antiemetics (chlorpromazine, prochlorperazine, metoclopramide) acutely solo
or with NSAIDS. Triptans can also be effective if used early in course of
migraines.

Diarrhea in HIV: Salmonella, Shigella, Campylobacter, C diff, Giardia,

Cryptosporidium, Mycobacterium avium complex, CMV. Evaluate with stool
culture, O&P, and test for C diff toxin.

Complicated GERD: dysphagia, odynophagia, weight loss, overt or occult

bleeding, iron deficiency anemia in addition to typical symptoms. Endoscopy
is indicated and possible biopsy. Endoscopy is also indicated if medications
fail. pH monitor if (-) endoscopy.

Inflammatory Monoarthritis: septic, trauma, crystal induced. Septic should be

considered until proven otherwise. History of RA predisposes to septic
arthritis, especially with Staph aureus. Do fluid analysis, gram stain, culture.
Treat with antibiotics and joint drainage.
 Staph Aureus Pneumonia: most often affects hospitalized patients, nursing
home residents, injection drug users, patients with CF, people with recent
influenza. Serious complication of influenza. G(+) clusters on gram stain. Treat
with antibiotics.

Necrotizing Fasciitis: infection involving fascia of deep muscles. Occurs after

trauma or foreign bodies. GAS or Staph aureus are usual cause. Sudden onset
pain and swelling. Purple discoloration and gangrene. Systemic signs of
toxicity can be present. Surgical debridement is necessary and antibiotics
(ampicillin+sulbactam and clindamyacin). History of DM.

Vanishing Bile Duct Syndrome: progressive destruction of intrahepatic bile

ducts with ductopenia on biopsy. PBC is MCC of ductopenia in adults.

Toxic Adenoma: clinical features and lab findings of hyperthyroid with iodine
scan showing uptake in one area and suppression of rest of gland. Do not
have infiltrative ophthalmopathy.

Emphysema: permanent airway destruction without obvious fibrosis. Smoking

cessation and home O2 therapy are the only two things shown to decrease
mortality.

Myasthenia Gravis: decreasing muscular strength with continued contraction.

A disease of the NMJ. Fluctuating weakness in voluntary muscles -> diplopia,
ptosis, extremity weakness. Extraocular symptoms are the most common.

Medial Medullary Syndrome: contralateral spastic hemiplegia, contralateral

vibration and proprioception loss, tongue deviation towards injured side.
Occlusion of vertebral artery or one of branches.

Acute Pain: all patients should receive same standard pain management
regardless of drug history. Use IV morphine. Never undertreat pain even with
risk of abuse. Frequently reassess, outpatient follow up, referral to pain
specialist if abuse is suspected.

Chronic Wounds: until proven otherwise, suspect SCC in a chronic wound ->
non-healing, painless, bleeding ulcer. SCC is cancerous changes in the mid
epidermis -> extension into dermis. Skin and mucous membranes can be
affected. Sun-exposed or burn areas are involved. Rough scaly nodules ->
ulcerate -> metastasize. Tar derivatives, carcinogens, radiation predispose.
Immunosuppression increases risk. Punch biopsy confirms.

Pellagra: dietary deficiency of niacin, common in people on corn based diets.

Also in alcoholics, carcinoid syndrome, Hartnups disease. Triad of Ds:
diarrhea, dermatitis in sun exposed areas, dementia. Untreated -> death.

Cardiac Arrest: leading cause for witnessed, outside hospital events is

ventricular arrhythmia. Immediate defibrillaion in the first 4-5 mins improves
survival. For unwitnessed or when defibrillator is not available, 2 mins CPR
prior to shock improves survival.

Myasthenia Crisis: weakness of respiratory/pharyngeal muscles that is life

threatening. Treat with intubation and withdrawl of anti-AChE for several days.
MCC is intercurrent infection, also use antibiotics. Monitor PFTs bedside when
suspected.
 Thyrotoxicosis: weight loss, irritability, tachycardia, tremors, lid retraction.
Systolic HTN and increased PP. Hyperdynamic state -> HTN. Due to increased
myocardial SR Ca-dependent ATPase, or decrease in Ca-inhibiting protein and
phospholamban. Increased sensitivity to catecholamines by increasing
adrenergic receptors. Can cause high output failure.

PCP: bilateral interstitial opacification, no hilar LA, cavitation, pleural effusion,

cardiomegaly. Mycoplasma or Chlamydia also suspected. DOC is TMP-SMX or
pentamidine. Also give azithromycin until PCP confirmed and evaluate for HIV
infection.

Nephrotic Syndrome: proteinuria (>3-3.5 g/day), hypoalbuminemia, edema,

hyperlipidemia, lipiduria. Altered permeability of GBM due to MCD,
membranous, MPGN, FSGN, mesangial proliferative. Complicated by
hypercoagulation due to loss of antithrombin 3. Renal vein thrombosis, arterial
thrombosis, PE can occur. Can cause protein malnutrition, iron resistant
microcytic hypochromic anemia due to transferrin loss, vit D deficiency due to
loss of cholecalciferol binding protein, decreased thyroxine levels due to loss
of thyroxine binding globulin, increased susceptibility to infection.

Absence Seizures: sudden cessation of ongoing mental activity, < 30 seconds.

Return is also abrupt. No post ictal state or confusion. Diagnosed by EEG with
activation procedures.

Atrial Fibrillation: causes LV diliation and decreased EF due to tachycardia, no

atrial kick, AV dissociation. Control rate and/or rhythm to improve LV function.

AAA: surgery if > 5 cm, rapid rate of growth, symptoms present. If smaller, do
periodic imaging. Atherosclerosis is precipitant. Smoking is major RF for
formation, enlargement, rupture. Cessation is best intervention to slow
progression.

Confounding: bias that results in exposure-disease relationship with effect of

extraneous factors. Influence both exposure and outcome. Match case and
control based on confounding factor or stratify based on confounding factor.

Pulsus Paradoxus: usual drop in systolic pressure during inspiration is < 10

mm Hg due to increased venous return to right -> impeding LV filling. PP when
drop in systolic > 12 mm Hg with inspiration. Caused by tamponade, tension
pneumothorax, severe asthma (elevated intrathoracic pressures ->
impedence of LV pumping).

HNPCC: Amsterdam Criteria I: at least 3 relatives with CoCa with one being
first degree of other 2, > 2 generations, one before 50 y/o, FAP excluded.
Lynch I is hereditary site specific CoCa. Lynch II is cancer family syndrome and
high rate of extracolonic tumors. MC is endometrial cancer (43% of affected
females).

Isoniazid: causes hepatits picture via idiosyncratic liver injury with histological
features similar to viral hepatitis.

Drug Induced Liver Injury: rash, fever, arthralgias, leukocytosis, eosinophilia.

Occurs via direct cytotoxic effects or idiosyncratic reaction. Direct is dose
dependent with short latent periods (tetrachloride, Tylenol, tetracycline).
Idiosyncratic is not dose dependent with variable latent periods (INH,
 chlorpromazine, halothane, antiretrovirals). Catagorized by morphology: 1)
Cholestatic, 2) Fatty liver, 3) Hepatitis, 4) Toxic/fulminant liver failure, 5)
Granulomatous.

Acute Bronchitis: common cause of blood tinged sputum due to virus. Lack of
history or physical indicating more severe disease. Have malaise, throat pain,
wheezing. No fever (rules out pneumonia). Weight loss or more blood suggest
TB or malignancy. Observe and follow.

Howell Jolly Bodies: nuclear remnants in RBCs usually removed by spleen.

Single, round, blue inclusions on Wright stain. Usually due to physical or
functional asplenia due to infarction, infiltration, congestion.

Fibromuscular Dysplasia: MCC secondary HTN in children. Also seen in

premenopausal women. Have hum or bruit at CVA due to collateral circulation.
Right more affected than left. Angiography shows string of beads pattern.

Anemia of Chronic Disease: usually normocytic. Decreased iron, TIBC,

transferrin. Ferritin can be normal or high. Involves iron trapping by
macrophages. Associated with chronic inflammatory conditions, heart disease,
DM, acute inflammation. Treat underlying cause.

Saline Responsive Metabolic Alkalosis: urine chloride < 20 mEq/L and due to
GI proton loss (ex vomiting in bulimia), volume depletion, diuretic abuse. Treat
with isotonic saline infusion.

Antihistamines: first generation anti-H1 (diphenhydramine, chlorpheniramine,

doxepin, hydroxizine) have anti-Ach effects -> dry eyes, mouth, respiratory
tract, urinary retention due to failure of contration of detrussor (worse in
patients with BPH), and dysuria.

Hypertrophic Cardiomyopathy: crescendo-decrescendo systolic murmur along

LSB without carotid radiation. Location and no radiation differ from AS.
Symptoms of syncope (due to outflow obstruction, arrhythmia, ischemia,
baroreceptor -> vasodilation), dyspnea, chest pain. Left ventricular
hypertrophy is present.

Diabetic Nephropathy: starts with hyperfiltration (increased GFR) and

microalbuminuria. Progresses to macroproteinuria (> 300 mg/d) and
decreased GFR. Intensive BP control reduces decline in GFR, < 130/80. ACE
and ARB are preferred and decrease decline GFR in patients with significant
azotemia and proteinuria > 1 g/d. Hyperkalemia can ensue.

Confidence Interval: mean + standard score (z) * Standard Error of Mean

(SD/root n). As SD increases, SE and CI increase. As n increases, SE decreases.
Larger CI indicates wider range of effects.

Boerhaave Syndrome: spontaneous esophageal rupture. Acute, severe chest

pain or epigastric pain after retching. Fever and dyspnea common. No
hematemesis. See tachycardia, tachypnea, subcutaneous ephysema, widened
mediastinum, contrast extravasation from swallowing. Pleural fluid has high
amylase, low pH, can contain food.

False Negatives: patients with negative test who have the disease. When
cutoff levels are raised, FN increase.
 Neurofibromatosis: neurocutaneous syndrome. Autosomal dominant,
chromosome 22. Type I has caf-au-lait spots, axillary freckles, Lisch nodules
of iris, neurofibromas, bony lesions. Type II has brain tumors especially BL
acoustic neuromas (diagnostic). Develop CNS, PNS, skin, visceral tumors.

Sturge Weber: neurocutaneous syndrome. Port wine stains in V1 distribution,

angiomatous malformations of the brain, seizures, hemiparesis.

Tuberous Sclerosis: neurocutaneous syndrome. Ash leaf hypopigmentation,

cardiac rhabdomyomas, kidney angiomyolipomas, mental retardation,
seizures.

Hypercalcemia: malignancy is a common cause via cytokines, PTHrP, calcitriol,

ectopic PTH. Metastases to bone cause osteolysis due to IL-1 and TNF (usually
lung and breast). With non metastatic solid tumors produce PTHrP -> low PTH
levels. Ovarian, lung, neuroectodermal tumors can ectopically produce PTH.
Hodgkins disease has increased calcitriol.

Hypertension and Hypokalemia: caused by primary hyperaldosteronism,

renovascular disease (2 most common), renin secreting tumor, syndrome of
apparent mineralocorticoid excess, some forms of CAH, glucocorticoid
suppressible hyperaldosteronism. Primary HA has low plasma renin activity,
renovascular disease has high plasma renin activity.

Obstructive Uropathy: flank pain (capsular distension), poor urine output

(obstruction), intermittent high volume (obstruction overcome). UA shows RBC
and WBC but no casts.

Mutations: nonsense and frame shift mutations are typically more severe than
missense or splice site mutations. Silent (same sense) mutations do not affect
the protein structure.

Renal Cell Carcinoma: usually asymptomatic. Classic triad: flank pain,

hematuria, palpable abdominal renal mass, only seen in 10%, suggests
advanced/metastatic disease. Hematuria is frequent (40%). Varicoceles
(usually left) fail to empty when patient lies down. Increased erythropoietin ->
polycythemia, thrombocytosis. Abdominal CT to diagnose.

Bacterial Pharyngitis: MCC is GAS. Fever, painful cervical LA, exudative

pharyngitis. Viral pharyngitis: conjunctivitis, rhinorrhea, exanthum. Lots of
overlap -> confirm with rapid strep test. Penicillin V to treat. (+) rapid strep do
not need culture confirmation, (-) do.

OSA: recurrent transient obstruction of upper airway due to pharyngeal

collapse. Patients are overweight, have excessive daytime sleepiness, snoring,
morning headaches, impotence, HTN. Hypoxia -> erythropoietin ->
polycythemia. Treatment improves polychythemia.

Scatter Plots: useful for crude analysis. Can demonstrate association (linear or
non-linear) if one is present. If linear, correlation coefficient can be calculated.

Hemi Neglect: patient neglects one side and only senses the other. May only
shave, comb, ignore people on one side. Ask patients to fill in clock, will only
fill in one side. Caused by lesion in right (non-dominant) parietal lobe,
responsible for spatial organization.
 Hemoptysis: can be blood streaked sputum to massive with respiratory failure.
Airway disease (bronchitis, bronchiectasis, trauma, tumors) are MCC.
Parenchymal disease (infections, diffuse alveolar hemorrhage), and vascular
(AV malformations, PE). With significant smoking -> think chronic bronchitis.
Do CXR to check for cancer.

Anemia in ESRD: normocytic, normochromic due to erythropoietin deficiency.

Attempt iron first, then erythropoietin injections (Hgb < 10, Hct < 30 if iron
deficiency is ruled out). 30% have worsening HTN (10 mm Hg in SQ route,
remove fluid by dialysis and give beta blockers or vasodilators). 15% have
headaches. 5% have flu like symptoms (in IV route, use anti-inflammatories).
Rare red cell aplasia.

Incidence: frequency of new cases over a period of time. To determine,

subjects without disease must be followed for a period of time to see if they
develop it. Cohort study is best option. A prospective observational study
where group is chosen based on presence or absence of certain factors. Then
are observed for development of disease.

Brain Metastases: most common type of intracranial brain tumor. Usually at

gray-white junction, single or multiple, seen frequently in NSCLC. Median
survival is 1 month without treatment. If single with stable extracranial
disease, surgery is done first to relieve mass effect, diagnose, improve local
control. Then do whole brain radiotherapy to destroy residual. Steroids are
symptom control, do not increase survival. If multiple, just do whole brain
radiation.

Syphilis: chronic systemic infection. Primary -> chancre. Secondary ->

systemic infection with malaise, headaches, anorexia, generalized MP rash,
moist skin or mucous membrane papules. Involves trunk, extremities, palms,
soles. Develop condyloma lata: broad exophytic formations in anogenital
region or upper thighs that ulcerate. Serology is positive.

Lipid Screening: start at age 35 in men, 45 in women. Risk factors are (+) FH,
smoking, HTN, low HDL, age. With 0-1, goal LDL < 160. With 2, goal LDL <
130. With known CAD or CAD equivalent (diabetes, AAA, symptomatic CVD, 10
year risk > 20%), goal LDL < 100.

Colon Cancer Screening: regular screening at 50 years old. Can do FOBT,

flexible sigmoidoscopy, colonoscopy, double contrast barium enema. Interval
to repeat depends on test.

Pseudotumor Cerebri: benign intracranial HTN. Young, obsese female with

headache suggestive of brain tumor, with normal imaging, elevated CSF
pressure. Can have papilledema, visual field defects, VI nerve palsy. Can have
history of steroid use or vitamin A. OCP also associated. There is impaired CSF
absorption. Treat with weight reduction. Acetazolamide if no weight reduction.
If fail or visual field deficits progress -> shunt or optic nerve sheath
fenestration to prevent blindness, most significant complication.

Cushings Syndrome: high cortisol -> vasoconstriction -> secondary HTN. Also
enhance insulin resistance (hyperglycemia) and mineralocorticoid activity
(hypokalemia). Proximal weakness, central obesity, thin skin, psych problems.
Result from adrenal cortical hyperplasia, ACTH adenoma (Cushings disease),
ectopic ACTH, steroid administration.
 Simple Renal Cyst: most commonly seen in patients > 50. Benign and
incidentally discovered. Usually asymptomatic. Sometimes can become
infected. Simply observe and no follow up needed. Make sure its not
multiloculated, does not have thick or irregular walls, thickened septae, or
contrast enhancement.

Anticholinergic Toxicity: red as beet, dry as bone, hot as hare, blind as bat,
mad as hatter, full as flask. Can have dizziness, headache, tachycardia. Can
precipitate acute glaucoma due to mydriasis. Trihexylphenidyl and
benztropine are used for Parkinsons and EPSEs.

Squamous Cell Carcinoma: ulcer that is solitary, not healed for a long time,
located in keratinized epithelium of the vermillion zone of lower lip. May also
be chronic infectious, chronic autoimmune. Will have invasive cords of
squamous cells with keratin pearls. Will have history of occupational sun
exposure. Major of lip cancers are well differentiated SCC.

Decubitus Ulcer: common in patients with diseases that impair normal

sensation or movement. Develop rapidly when preventative measures not
taken. May develop during hospitilization for acute issue. Occur over bony
prominences (sacrum, heels, elbows, ears). Constant unrelieved pressure ->
necrosis of overlying skin and muscle, when pressure > 32 mm Hg (normal
arteriolar pressure). Change position every 2 hours.

Radioiodine: most popular treatment of hyperthyroid. Taken up by thyroid ->

destruction via beta emission. May develop permanent hypothyroidism,
greatest in patients with Graves disease, since whole gland is hyperfunctional
-> general uptake -> complete ablation.

Constrictive Pericarditis: thickened or scarred -> impaired diastolic filling ->

decreased CO -> JVP, ascites, hepatic congestion, dyspnea, weakness.
Kussmauls sign (decrease of JVP on inspiration) can be present but not
specific. MCC are cardiac surgery, viral pericarditis, radiation. CXR -> calcified
pericardium. CT/MRI -> thickened pericardium. Increased pressures on cardiac
cath. Treat with diuretics or pericardiectomy.

TCA Overdose: hyperthermia, anticholinergic effects (dilated pupils, ileus).

Decreases myocardial conduction velocity -> QRS widening -> risk of
ventricular arrhythmia. Majority of mortality due to hypotension. Secure ABCs.
With hypotension, QRS prolongation, arrhythmia, give sodium bicarbonate.

Acyclovir: can cause nephrotoxicity. Causes crystalluria and renal tubular

obstruction -> renal failure. Occurs with large parenteral doses, especially
with inadequate hydration.

Disseminated Gonorrhea: gonococcal bacteremia due to untreated mucosal

gonorrhea infections. Usually during menstrual periods. High fevers,
tenosynovitis, migratory polyarthralgias. Skin lesions on extremities from 5-
40, purpuric or pustular with hemorrhagic necrosis. May cause supperative
arthritis (different from early arthralgias). Blood cultures often negative.

Acute Back Pain: with positive straight leg raise -> herniated disk. With
neurological defecit and perianal anesthesia -> cauda equina syndrome.
Manage conservatively. Return to activities ASAP. Use NSAIDs and muscle
 relaxants. If longer 4-6 weeks, do imaging MRI or CT with or without contrast.
Exercise and PT are not shown to be effective.

Epidemiological Studies: goals are to be descriptive and analytical. Descriptive

deals with rates, ratios, distribution. Analytical tests hypothesis created by
descriptive and consists of observational and experimental studies.

Case Control Study: retrospective study. Movement from effect to cause. Look
at population with outcome and subjects are either cases or controls. Looks
for presence of risk factors.

Prospective Cohort Study: or longitudinal. Divides group into exposed and not
exposed. Followed prospectively until onset of disease. Stronger than case
control or cross sectional. In cohort studies, subjects are free of outcome at
onset of study.

Retrospective Cohort Study: starts between exposure and outcome. Reviews

past records, classifies into exposed or not exposed, and follows until
outcome. In cohort studies, subjects are free of outcome at onset of study.

Cross Sectional Study: exposure and outcome are studied at one cross section
of time. Not possible to determine temporal association between exposure
and outcome.

Randomized Control Trial: gold standard for studying efficacy of treatment or

procedure. Randomly assigned to treatment or control group. Has least bias
and shows strong causal relationship.

Idiopathic Pulmonary Fibrosis: restrictive lung disease. Chronic inflammation of

alveolar walls -> widespread fibrosis -> destruction of architecture. Dyspnea,
non productive cough, digital clubbing. Dry, end-inspiratory crackles.
Decreased lung volumes, normal FEV1/FVC. Diffusion capacity is reduced due
to V/Q mismatch -> A-a gradient. CXR -> decreased lung volume, honeycomb
pattern, vascular congestion at hilum.

Amaurosis Fugax: painless loss of vision from emboli. Cholesterol particles

(Hollenhorst bodies) may be seen. Warning of impending stroke due to emboli
-> mostly occur from carotid bifurcation -> do US of neck.

Viral Arthritis: acute onset polyarticular symmetric arthritis that resolves in 2

months. MCC is Parvovirus, usually with those that work with children. Usually
involve MCP, PIP, wrist. RA has chronic onset, elevated ESR/CRP, no resolution
in 2 months.

Chemicals in the Eye: first priority is immediate flushing under running water
for at least 15 minutes. Call ER, 911, doctor after washing. Acid exposure has
likely full recovery. Alkaline will more likely have permanent corneal damage.
For foreign bodies or cuts/scratches, obtain medical care first.

Rotator Cuff Tear: present with shoulder pain and weakness. Occur as end
result of rotator cuff tendonitis or trauma (FOOSH). Aggravated by pushing,
pulling, lifting overhead, lying on affected shoulder. Limited arc abduction and
external rotation. Remains after lidocaine injection. Tendonitis resolves with
lidocaine injection. MRI is diagnostic.
 HIV Pneumonia: acute onset, high grade fever, pleural effusion.
Pneumococcous is the MCC. Impaired humoral immunity -> susceptibility to
encapsulated organisms.

Febrile Transfusion Reaction: fever and chills that respond to NSAIDS and
acetaminophen. No hemodynamic abnormalities or renal dysfunction
indicating hemolytic reaction or bacterial contamination. Caused by patient Ab
to donor WBCs, usually HLA specific. Leukocyte depletion can reduce
possibility. Cell washing, using frozen deglycerolized cells, or leukocyte
depletion RBC filters.

Ventricular Remodeling: after MI, ventricle slowly dilates and walls thin -> CHF
which occurs over months to weeks. ACEs inhibit ventricular remodeling and
should be started within 24 hours of MI if no contraindication.

Radioiodine Therapy: treatment of hyperthyroid in non-pregnancy. Become

euthyroid in 2-6 months. MC SE is hypothyroid (especially in Graves disease)
due to follicle destruction, but is easily treated with synthroid. Eye disease
may worsen at beginning of therapy.

Complications of MI: mitral regurgitation due to papillary muscle rupture, LV

free wall rupture, IV septum rupture. Present as hemodynamic compromise at
3-7 days when infracted myocardium is softest. Pansystolic murmur, loudest
at the apex, with radiation to the axilla, soft S1, pulmonary edema & LVF ->
SOB & crackles = acute mitral regurgitation.

DI: presents as polyuria & polydipsia due to ADH deficiency or resistance.

Excrete dilute urine, increased plasma osmolarity. Water deprivation -> fluid
loss dehydration, increased plasma osmolarity -> CNS dysfunction. Lithium
accumulates in kidneys -> tubular damage. Amiloride prevents Li
accumulation. Give NS with CNS dysfunction and dehydration. When
intravascular volume improves, then use hypotonic solutions.

Chalazion: painful swelling -> nodular rubbery lesion. Meibomian gland

obstruction -> chronic graulomatous inflammation. If persistent, can also be
due to meibomian gland carcinoma. Basal cell carcinoma presents similarly.
Do histopathology to rule out cancer.

Tinea Corporis: ring shaped scaly patches with central clearing, distinct
borders. Trichophyton rubrum is MCC, other dermatophytes can also cause.
MC symptom is itching. KOH preparation shows hyphae. Treat with topical
terbinafine if local. If extensive, give systemic griseofulvin and investigate for
immunosuppresion (DM, HIV).

Aspergillosis: fungal infection with coarse fragmented septae, hyphae usually

seen. CXR may show cresecent radiolucency next to rounded mass.
Destruction of parenchyma -> cavitation -> debris and hyphae coalesce into
ball. Mobile mass with intermittent hemoptysis.

PML: opportunistic infection in immunocompromised patients. Caused by JC

virus Involves white matter of cortex. No mass effect. Gradual onset of
hemiparesis, disturbances in vision/gait/speech. MRI shows multiple
demyelinating non-enhancing lesions.
 Limb Embolus: normal neurological exam with paresthesias, change in
temperature, non detectable pulse. Immediate anticoagulation with heparin
and embolectomy are needed. Tissue death and amputation if not treated
within hours.

BPH: increased frequency, urgency, weak stream, nocturia, sense of

incomplete voiding. Starts in the center of the prostate (cancer in peripheral).
If acute renal failure (one of MCC), place FC. If large volume is obtained, BPH
is likely. If progresses for 2 weeks, can have permanent kidney damage. US
can show hydronephrosis.

Vitamin B12 Deficiency: causes are strict vegetarian diet (more than 3-4
years), and pernicious anemia, autoimmune disease resulting in parietal cell
destruction -> measure intrinsic factor Ab and B12 levels.

ACE Inhibitors: shown to prolong life in asymptomatic to severe heart failure.

Started on low dose and titrated up (mortality improvement is dose
dependent). Reduce preload and afterload. Beta blockers, spironolactone, and
ARBs also improve mortality.

PSC: inflammation, fibrosis, structuring of intra and extrahepatic biliary tree.

Onion skin fibrosis -> ESLD & portal HTN, biliary stricture, cholangitis,
cholelithiasis, cholangiocarcinoma, colon cancer. 25-90% have underlying IBD
(usually UC). It is a multifactorial disorder. Present with fatigue or pruritis.
Cholestatic pattern on labs -> elevated alk phos and BRN. IBD causes
hypoalbuminemia. Can see positive p-ANCA. Cholangiography -> beading
pattern. Treat with UDCA, dilatation & stenting, transplant.

DM: RF are AA race, positive FH in first degree relatives. Present with polyuria,
polydipsia, obesity. Measure fasting blood glucose (recommended screening
test). > 126 on 2 occasions is diagnostic. Between 100 and 125 is insulin
resistance or pre-diabetes.

Pleural Effusion: use Lights criteria: exudate will have fluid to serum protein
ratio > 0.5, fluid to serum LDH ratio > 0.6, or fluid [LDH] > 2/3 the upper limit
for serum LDH. Complicated will have positive gram stain & culture, pH < 7.2,
glucose < 60 and needs chest tube. Empyema is frank pus.

Hospital Infection: common source of confusion. Check blood and urine

cultures with new fever or WBC elevation. With recent abx, diarrhea, tender
abdomen -> C diff colitis. Stool toxin assay and empiric metronidazole.
Multiple stool samples are necessary.

Hyperkalemia: > 5 mEq/L. Present with weakness, paralysis, respiratory

insufficiency, cardiac toxicity -> sine wave or ventricular fibrillation. Use
binding resin. MCC is medications, so review them. ACEs, ARBs,
spironolactone block aldosterone. TMP and pentamidine also cause.

Beta Thalassemia: microcytic anemia not responsive to iron, especially with

Mediterranean origin. Point mutation in one of beta globin genes -> reduced
synthesis. Minor is due to 1 defective gene with Hct between 28-40 and MCV
55-75. Major is due to 2 defective -> severe.
 Zollinger Ellison: also called gastrinoma. Prominent gastric folds, ulcer located
beyond duodenal bulb on endoscopy. Measure serum gastrin levels. > 1000 is
diagnostic. If not, do secretin stimulation test.

Hypocalcemia: hypoalbuminemia -> decreased serum, normal ionized

calcium, no symptoms. Excess alcohol -> chronic pancreatitis -> vitamin D
deficiency -> hypocalcemia and hypophospatemia due to malabsorption.
Acute pancreatitis can also be a cause.

Histoplasmosis: dimorphic fungus found as mold in soil. Present in bat and

bird droppings in Mississippi and Ohio river areas. History of bat or bird
exposure. Disseminates in IC patients. Nonspecific symptoms. Targets
histiocytes and RE system -> LA, pancytopenia, hepatosplenomegaly. Palatal
ulcers. CXR -> hilar LA, interstitial pneumonitis.

Cocaine Intoxication: present with venous track marks, EKG changes of

myocardial ischemia/infarction due to sympathetic effects -> tachycardia and
hypertension. Treat with BZD (decreases anxiety & sympathetic effects), ASA
(for clots), nitrates (for constriction).

Alcohol Withdrawl: first 6-24 hours -> anxiety, insomnia, tremors, sweating.
First 48 hours -> seizures, hallucinations. Delerium tremens -> after 48-96
hours -> HTN, agitation, tachycardia, hallucinations, fevers. Treat with BZD
like chlordiazepoxide (Librium).

Nephropathy: preceded by protein excretion in urine. Starts with

microalbuminuria -> 30-300 mg/d. Spot urine and timed urine collection for
microalbumin to Cr ratio are good screening methods. 24 hour urine is more
inconvenient, but preferred.

Lung Exam: inspection, palpation, percussion, auscultation. Normal will be

resonant with vesicular sounds (quiet inspiratory, inaudible expiratory).
Consolidation will have dullness, louder expiratory component if airways are
open. If blocked, will decrease. Will also hear egophany and crackles.

OCP: common cause of secondary hypertension. 5% of patients. Caused by

estrogen mediated increase in synthesis of angiotensinogen. Discontinuation
can correct the problem.

HIT: combination of AV thrombosis and thrombocytopenia in patients receiving

heparin. May manifest as acute ischemic stroke. Ab to heparin-platelet-factor
4. Antibodies activate platelets -> premature removal and thrombotic
complications.

Status Epilepticus: ongoing seizures activity for > 5-10 minutes or lack of
interictal return to baseline. Resistant to medications. First step is appropriate
oxygenation and blood pressure, with endotracheal intubation. Use BZD or
phenytoin as second line.

Warfarin: inhibits vit K dependent clotting factors II, VII, IX, X, protein C, S.
Protein C has half life of 9 hours -> early signs of protein C deficiency ->
hypercoagulabilty -> thrombus formation -> skin necrosis. Common in
patients with congenital protein C deficiency.
 Chronic Alcoholism: multiple electrolyte abnormalities (low Mg, low K, low
PO4). Hypomagnesemia causes refractory hypokalemia. Mg is an important
cofactor for K uptake and maintenance if IC K levels. Check Mg to correct low
K. Diuretics also causes low Mg.

Diabetic Mononeuropathy: can be cranial or somatic. CNIII is affected most

often of CN. Ischemia of somatic fibers and sparing of PS fibers -> ptosis and
down-and-out gaze. Pupil response and accommodation are intact. If
compression causes it, both fibers will be affected.

Acute Pyelonephritis: acute febrile illness, CVA tenderness, pyuria, bacteriuria.

Treat initially with antibiotics. With no response in 72 hours, do renal CT or US
to look for other pathologies (obstruction) or complications (abscess).

Pulmonary Hypertension: > 25 mm Hg at rest, > 30 mm Hg with exercise.

Caused by respiratory disorders, venous/cardiac, chronic thromboemboli,
arterial (primary/ idiopathic), vascular malformations. Dyspnea, fatigue,
weakness, chest pain, hemoptysis, syncope, hoarseness. Causes RVH and
failure. CXR -> pulmonary artery enlargement, tapering of distal vessels, RVH.
Can cause cor pulmonale.

Pagets Disease: persistent dermatitis. Typically red, oozing, crusted,

unresponsive to steroids or antibiotics. Biopsy -> proliferation of malignant
epithelial cells scattered as well as cells with lots of pale staining cytoplasm
surrounding hyperchromatic nuclei with prominent nucleoli. Usually underlying
breast cancer. Could be DCIS or infiltrating ductal.

Test Cut Off Points: lowering cut-off point increases sensitivity. Increase true
positives and false positives. PPV = TP/TP+FP. PPV will decrease and false
negatives will also decrease.

Bisphosphanates: drugs of choice for mild to moderate hypercalcemia. Non

toxic and more potent than IV saline. May reduce bone pain and fractures.
May improve survival in patients with multiple myeloma or breast cancer.
Zoledronic acid recommended in all women with metastatic breast cancer and
radiographic lytic bone disease, receiving hormone or chemotherapy.

CAD: risk factors -> men > 45, women > 55, HTN, smoking, HDL < 40, family
history of early CAD (men < 55, women < 65). HDL > 60 negates one risk
factor. Risk equivalents impart equal risk for MI as having a previous MI. They
are DM, symptomatic CVD, AAA, PVD, 10 year risk > 20%.

Risk Category LDL Goal When lifestyle When drug therapy

changes start starts
CAD or Equivalent < 100 > 100 > 130
2+ RF < 130 > 130 > 160
0-1 RF < 160 > 160 > 190

Diverticulitis: history of constipation with little fiber. LLQ pain and fever. Give
IV antibiotics until symptoms resolve. If fail to response, do CT to evaluate for
perforation, abscess, fistula.

Febrile Neutropenia: ANC < 1500. Susceptibility increases < 1000. Ability to
control own flora decreases < 500. Fever in these patients classified as one
 temperature > 100.9, or > 100.4 for over an hour. Bacteria from skin and flora
are MC, mostly G(+). Start antibiotics that are broad spectrum and cover
Pseudomonas. Ceftazidime, cefepine, imipenem, meropenem, or combination
of aminoglycoside and anti-pseudomonal beta-lactam.

Acute Monocytic Leukemia: M5. Dramatic onset, headaches, fever, weight

loss, gum or nose bleeding. Gingival hyperplasia and skin lesions.
Leukocytosis with blasts. Positive alpha-naphthyl esterase test.

Acute Myeloblastic Leukemia: M2. Predominance of myeloblasts.

Acute Promyelocytic Leukemia: M3. Predominance of hypergranular

promyelocytes with Auer rods. High incidence of DIC.

Acute Lymphoblastic Leukemia: predominance of lymphoblasts that are PAS+.

Acute Erythroleukemia: M6. Predominance of erythroblasts which have

irregular outline and high N/C ratio.

Gastric Cancer: early detection is critical since surgery and excision of

affected tissues is mainstay therapy. Most are diagnosed at stage III-IV. Do CT
scan to assess extent of disease after diagnosis is made. Also detects
metastases, especially liver metastases.

HCV: chronic hepatitis C with persistently normal LFTs on multiple occasions

have minimal histological abnormalities and do not need to be treated with
interferon or antivirals.

Septic Arthritis: acute onset painful swollen joint, limited ROM, fever > 104,
fluid WBC 50-150k. Crystal induced presents similarly but WBCs between 10-
50k and lower fever. Prosthetic joint increases risk. Knee is most commonly
affected by hematogenous distribution. Staph aureus is MCC in prosthetic joint
septic arthritis.

HIV Immunizations: polyvalent pneumococcal vaccine recommended for all

HIV patients whose CD4 count > 200. Annual influenza vaccination is also
recommended.

Contrast Nephropathy: caused by renal vasoconstriction and tubular injury.

History of diabetes and chronic renal insufficiency are increased risk. Spike of
Cr within 24 hours. Adequate hydration is most important. IV bicarbonate or
NS. Mucomist also helps.

SLE Nephropathy: classic presentation of young woman with joint pain,

fatigue, ankle edema, facial rash. Mechanism is immune complex mediated
kidney damage -> circulate and deposit in renal glomeruli -> complement
activation and C3 level decrease.

AI Hemolytic Anemia: acquired disorder that causes extravascular hemolysis.

Pallor, jaundice, splenomegaly, elevated indirect BRN, reticulocyte count and
LDH. Spherocytes with central pallor, (+) fragility test, (+) Coombs (not
required). Can do micro-Coombs. Hereditary spherocytosis has spherocytes
with no central pallor, (+) AD family history.
 Graves Disease: insomnia, fatigablilty, weight loss, lid lag, tremor. Atrial
fibillation is common due to increased sensitivity of beta receptors. Best
choice for stable patients is a beta blocker. Controls atrial fibrillation and other
symptoms of hyperthyroidism.

Vitamin D Overdose: seen in patients trying to lose weight. Can cause

hypercalcemia -> constipation, abdominal pain, polyuria, polydipsia.
Individuals trying to lose weight should be counciled about weight loss as
vitamin and mineral toxicities are common.

Asthma: intermittent -> daytime symptoms < 2x/wk, nighttime awakenings <
2x/mo, use of beta agonists < 2x/wk, baseline FEV1/FVR ratio is normal, no
limitations of daily activities. Treat with short acting bronchodilator as needed.
Mild persistent -> symptoms > 2x/wk but < daily, nighttime awakenings 3-
4x/mo, minor limitation, normal PFTs. Add low-dose inhaled steroid as a
controller. Moderate persistent -> daily symptoms, weekly nighttime
awakenings, FEV1 < 60-80% predicted. Add long-acting inhaled beta 2
agonist. Severe persisent -> symptoms throughout the day, frequently
nighttime awakenings, extremely limited activity, FEV1 < 60% predicted. Treat
with as needed albuterol inhaler, long acting inhaled beta 2 agonist, high dose
inhaled corticosteroids. Possible oral steroids.

Radioactive Iodine: preferred treatment for Graves disease. Takes about 6-8
weeks for improvement. Contraindicated in pregnancy and very severe
ophthalmopathy. No higher incidence of cancer.

Diabetic Glomerulosclerosis: renal insufficiency, moderate levels of

proteinuria. 50% of diabetics. Evident after 12-22 years of diabetes,
progresses to CRF and ESRD in 4-5 years. Microalbuminuria can be detected
within 4-5 years of onset. Secondary to microangiopathy.

Human Bite: clenched fist injury. Amoxicillin-clavulanate (beta lactamase

inhibitor) is antibiotic of choice. Usually polymicrobial wounds and G(+), G(-),
anaerobic coverage needed. Also drug of choice for dog bites.

Sideroblastic Anemia: defective heme synthesis, MC due to pyridoxine-

dependent impairment in early steps of protoporphyrin synthesis. Present with
microcytic hypochromic anemia but can see normochromic cells (dimorphic
population). Will have high iron and low TIBC. Isoniazid and alcoholism can be
a cause. Give B6 to treat. Bone marrow biopsy will show ringed sideroblasts.

Normal Distribution: 68% within 1 SD of mean, 95% within 2 SD of mean,

99.7% within 3 SD of mean.

Lyme Arthritis: caused by untreated Lyme infection by Borrelia burgdorferi.

Arthritis happens in late disease, commonly involves knee. Warmth, swelling,
restriction of movements differ from arthralgias in early disease. History of
intermittent inflammatory arthritis. First episode within 6 months of erythema
migrans and travel to endemic area.

Fronto-temporal Dementia: characteristic are personality changes (euphoria,

disinhibition, apathy), compulsive behaviors (peculiar eating habits,
hyperorality), impaired memory. Visuospatial functions intact. Possible family
history.
 Pseudogout: hyperparathyroidism -> elevated calcium & low phosphorus ->
constipation, fatigue, polyuria, abdominal pain, stones, mental status
changes, osteoporosis. Couples with acute painful monoarthritis due to CPP
crystals -> rhomboid, (+) birefringent.

ADPKD: hypertension, palpable abdominal masses, microhematuria. Hepatic

cysts are MC extrarenal manifestation. Also berry aneurysm (5-10%, bad when
coupled with HTN, screening not recommended), MVP or AR, diverticulosis,
abdominal wall & inguinal hernias.

Schistocytes: also called helmet cells, are fragmented RBCs. Due to

mechanical destruction: MAHA (DIC, HUS, TTP), or prosthetic valves.
Mechanical are more traumatic than porcine. Labs show decreased
haptoglobin, increased LDH & BRN.

Drug Hypersensitivity: if mild (urticaria and pruritis without systemic

symptoms), treat with antihistamines and discontinuation. Ampicillin and
amoxicillin associated with urticaria, morbilliform rash, late maculopapular
rash.

PCP Intoxication: causes hallucinations, dissociative feelings, agitation,

confusion, papillary dilatation, tachycardia, nystagmus (only drug that causes
vertical, can be horizontal or rotary). Causes violent behavior. Cause severe
HTN, seizures, hyperthermia. Give BZD for severe psychomotor agitation.

Hyperkalemia: in fall with weakness, long time on floor -> due to

rhabdomyolysis. Tall T waves on EKG indicates cardiotoxicity -> treat with IV
calcium gluconate -> cardiac myocyte membrane stabilization.

Cervical Spondylosis: chronic neck pain. Limited neck rotation and bending
due to osteoarthritis and muscle spasm. Osteophytes -> radiculopathy ->
sensory abnormalities. X ray -> bony spurs, sclerotic facet joints, narrowed
disc spaces, hypertrophic vertebral bodies. These findings are of low
specificity.

MEN I: non-beta cell pancreatic tumor like gastrinoma -> abdominal pain,
diarrhea. Endoscopy -> multiple ulcerations, prominent gastric folds. Also
have primary hyperparathyroidism, pituitary tumors, other neuroendocrine
pancreatic tumors.

Lewy Body Dementia: fluctuating cognitive impairment, hallucinations,

parkinsonism resistant to therapy. Progressive decline that impedes
functioning. Memory impairment in the long term. Deficits in attention,
visuospatial ability, executive functions. Falls, syncope, transient loss of
consciousness, neuroleptic sensitivity, systematized delusions.

ARDS: inflammatory mediators due to tissue injury -> leaky alveolar

capillaries -> pulmonary edema. Caused by sepsis, bleeding, infection, toxins,
burns. Present with dyspnea, tachypnea, hypoxemia, infiltrates on CXR.
Ventilation with low TV and PEEP (increases FRC, decreases work of
breathing). PEEP may go upto 15 in ARDS, can improve oxygenation.

SAH: rupture of saccular aneurysms is the MCC (2/3 of cases) of nontraumatic

SAH. Saccular aneurysms occur in 3-4% of population, rupture is rare, high
 risk when > 7 mm. Common in anterior circle of Willis. Diagnose with cerebral
angiography and treat surgically.

Viral Arthritis: symmetric small joint inflammatory arthritis of acute onset and
short duration. Joint swelling and low grade fever suggest inflammation.
Symptoms resolve in 2 months. Caused by parvovirus, hepatitis, HIV, mumps,
rubella. Can see positive RF and weakly positive ANA. Use NSAIDS. Antivirals
are unnecessary.

HEV: RNA virus. Histology -> focal necrosis, ballooned hepatocytes, acidophilic
hepatic degradation. Transmitted through fecally contaminated water.
Commonly found in India, Africa, Asia, Central America. Diagnosed by
detection of HEV RNA by PCR in serum or feces or IgM Ab. Self limited, no
chronic carrier state. Fulminant hepatitis can occur, more common in pregnant
women, especially in 3rd TM, can be transmitted vertically.

TMJ Dysfunction: history of teeth grinding, interpret as ear pain. Pain is worse
with chewing. May have crepitus or clicks in the TMJ with movement. Exclude
all other ear conditions. Initial treatment is conservative, like nighttime mouth
guard. Surgery sometimes needed.

Cushings Syndrome: excessive systemic cortisol levels. Can result from

exogenous steroids or own overproduction. Present with fatigue, weight gain,
easy bruising, central adiposity, proximal muscle weakness, hyperglycemia,
osteopenia, osteoporosis, HTN, acne, cataracts, susceptibility to infections.
Hypokalemia is most common electrolyte abnormality due to some
mineralocorticoid activity. Can see hypernatremia. Treat with spironolactone.

Multiple Myeloma: malignant plasma cell disease -> monoclonal protein and
increased plasma volume. Normocytic anemia, hypercalcemia, renal failure,
elevated protein, normal albumin, increased ESR, Bence Jones proteins.
Presents in old age with back pain, recurrent infections. 1/3 of patients have
leukopenia. Serum immunoelectrophoresis shows M spike.

Pinworms: enterobiasis caused by Enterobius vermicularis. Adult lives in

cecum and appendix. Female crawls out at night and deposits skin ->
nocturnal anal pruritis. Diagnosed by scotch tape test which demonstrates
eggs. Albendazole or mebendazole is first line, but not in pregnant patients.
Pyrantel pamoate is an alternative.

Lumbar Spinal Stenosis: degenerative condition where spinal canal is

narrowed -> compression of one or more spinal roots. Due to enlarging
osteophytes at facet joints and hypertrophy of ligamentum flavum. > 60 y/o,
back pain that radiates into buttocks and thighs, worse with walking and
extension, better with flexion. MRI confirms diagnosis.

Hyperthyroid: plasma TSH is best initial test -> usually low unless TSH
secreting adenoma. Free T4 is usually elevated. Do EKG to rule out
arrhythmia. Do 24 hour radioiodine uptake to differentiate Graves from other
disease. Use propranolol for symptomatic relief.

Myeloproliferative Disorder: polycythemia vera -> splenomegaly and pruritis

with hot baths due to histamine release from increased basophils. 40%
develop gout due to overproduction of uric acid because of increased
catabolism and turnover of purines.
 Vitreous Hemorrhage: sudden loss of vision and onset of floaters. MCC is
diabetic retinopathy. Fundus is hard to visualize or details obscured. Needs
immediate ophthalmology consult. Conservative treatment (sleeping upright)
is recommended.

Familial Hypocalciuric Hypercalcemia: benign AD condition. Increased serum

calcium and increased/normal PTH levels. Also seen in primary hyper PTH.
Obtain 24 hour urine calcium and creatinine. FHH have decreased urine
calcium. Hyper PTH have high urine calcium.

Infective Endocarditis: major criteria -> > 2 blood cultures positive,

endocardial involvement on echo, presence of new murmur. Minor criteria ->
predisposing condition, fever > 38, vascular phenomenon (septic emboli),
immunologic phenomenon (glomerulonephritis). Diagnosed with 2 major, 1
major & 3 minor, 5 minor. Mycotic aneurysms, abdominal abscesses, septic
PE, renal abscesses, conjunctival hemorrhages, Janeway lesions all related to
septic emboli. Oslers nodes (painful fingertip nodules) and GN due to
immunologic phenomenon. Arthritis can be due to immune complex
deposition.

Enthesitis: inflammation and pain at sites where tendons and ligaments attach
to bones. MC seen with recurrent tendon or ligament stress and HLA-B27
associated arthropathies like AS, psoriatic arthritis, reactive arthritis.
Prominent in AS. Manifests with heel pain where Achilles inserts. Tibial
tuberosities and iliac crests also involved.

Pyelonephritis: if uncomplicated, can be switched to oral antibiotic after 48-72

hours of IV therapy. Switch based on sensitivities. Average duration of therapy
is 2 weeks. Oral is more convenient and less expensive.

Heat Stroke: core temperature > 40 and altered mental status. Can be
exertional (factory workers, military, athletes) or non-exertional (at extremes
of age, cannot get fluids or move from heat). Ambient heat and humidity
prevent sweat production. Present as confusion, hyperthermia, tachycardia,
epistaxis. Complications are rhabdomyolysis, renal failure, ARDS,
coagulopathy.

Cut Off Point: raising -> increased specificity, decreased sensitivity.

Herniated Disk: unilateral radicular pain in dermatomal distribution. Back

tenderness due to spasm of paraspinous muscles. Symptoms worse during
straight leg raise. Cauda equina -> saddle anesthesia, no sphincter tone,
urinary retention. Severe pain with mild obstruction (like BPH) inhibits ability
to valsalva -> urinary retention.

Severe Asthma Attack: normal or increased PCO2, speech difficulty,

diaphoresis, altered sensorium, cyanosis, silent lungs. Tachypnea, increased
work of breathing, low PO2. PCO2 should be decreased due to
hyperventilation. Severe obstruction -> increased PCO2. Lung inflation and
tachycardia are also normal.

Endotracheal Intubation: to provide a secure airway. Should sit at the carina

for safety and efficacy. Right bronchus intubation is a common complication
due to acute angle -> overinflation of the right and underinflation of the left.
Asymmetric breath sounds. CXR confirms. Pull back on ET tube slightly.
 Pseudotumor Cerebri: benign/idiopathic intracranial hypertension. Headache,
blurry vision, papilledema, vision loss, CN palsies (especially CNVI). LP shows
increased pressure. Can be due to isotretinoin in acne treatment. Derived from
vitamin A -> similar to vitamin A OD.

ACE Cough: non productive cough occurs in 5-20%. Kinins are degraded by
ACE. Accumulation of kinins and some activation of the arachadonic acid
pathway are the cause. Discontinue drug. If cough persists, do CXR, PFT,
barium swallow, bronchoscopy.

Paroxysmal Nocturnal Hemoglobinuria: intravascular hemolytic anemia,

hypercoagulable state, bone marrow aplasia. Hemolysis is complement
mediated. Elevated LDH and low haptoglobin. Pancytopenia -> reticulocytosis.
Loss of urinary iron -> iron deficiency anemia. High incidence of thrombosis in
hepatic, portal veins, Budd Chiari. Diagnose with flow cytometry for CD55 and
CD59.

TPN: GI tract is bypassed stimulus for GI hormone release is gone. CCK is

stimulated by proteins and FA in duodenum. No CCK -> no GB contraction ->
stasis -> bile sludge and gallstones -> cholecystitis.

Humoral Immunodeficiency: history of recurrent bacterial infections. If

selective, IgA or IgG can be deficient. Food allergies and autoimmune diseases
may be present. IgA deficiency and CVID (suppressed cellular immunity and
increased risk of malignancy). Diagnose with quantitative immunoglobulin
levels.

Compression Fracture: acute onset of back pain without trauma. Common

complication of osteoporosis. Age and steroid use are RF. Localized
tenderness. Absent ankle reflex is common in elderly people, otherwise
neurological exam is normal.

Hyperemesis Gravidarum: causes metabolic alkalosis with respiratory

compensation via hypercapnea. ABG shows pH > 7.45, primary increase in
HCO3, secondary increase in PCO2. Vomiting -> decreased HCl -> metabolic
alkalosis (generation phase). Volume loss -> contraction metabolic alkalosis
due to RAAS activation (maintenance phase).

Prevention of Back Injury: usually present with lumbar strain (relation to heavy
lifting, no radicular signs, good response to conservative therapy). Strengthen
supporting muscles (abdominals), avoid sleeping on stomach, learning proper
bending and lifting. No twisting and bending exercises. Bend at knees, not at
waist. Keep back straight. Do warm ups.

Lyme Disease: doxycycline is first line for early lyme. Also treats coexistant
ehrlichiosis. In pregnant/lactating women and children, treatment choice is
amoxicillin. Penicillin G is alternate for early localized during pregnancy or
disseminated. IV ceftriaxone or cefotaxine (3 rd generation) are used for early
disseminated or late.

Chest Pain: methods for diagnosing CAD are only helpful for those at
intermediate risk. A (-) non invasive test in a high risk patient is likely false (-).
A (+) test in a low risk patient is likely false (+). In young women, anxiety and
psychosocial issues are a common cause.
 Infectious Mononucleosis: splenic rupture is a potential complication and
patients with splenomegaly should avoid excessive physical activity and
contact sports until spleen is not palpable (usually 1-3 months).

HCV: major cause of chronic hepatitis (~80%) and MC acquired via infected
blood. Recommended to get vaccinated against HAV and HBV (safe during
pregnancy). Low evidence of sexual transmission.

Allergic Conjunctivitis: environmental exposure -> acute hypersensitivity.

Itching, hyperemia, tearing, edema. Possible photophobia and burning. Family
history of asthma, allergies, atopic dermatitis are common. Reduce exposure,
dont rub eyes, topical antihistamines, artificial tears, cool compresses to
treat.

Colon Ulcer: on scope, questionable ulcer needs biopsy to rule out cancer and
distinguish UC from Crohns since treatment is different for both.

Solitary Pulmonary Nodule: < 3 cm circular lesion in middle or lateral 1/3 of

lung surrounded by normal tissue. Mostly benign. Calcification favors benign.
Popcorn calcification is hamartoma. Bulls eye calcification is granuloma. Look
at old x-ray in low risk patients. If no change in 12 months -> benign. Follow
by CXR every 3 months for 1 year, if no change -> benign. High risk patients
need CT, FNA, possible excisional biopsy.

Anabolic Steroids: SE are suppressed testicular function, gynecomastia,

erythrocytosis, hepatotoxicity, psychological disturbance, cardiac disease, low
HDL/high LDL, increased coagulation, premature epiphyseal closure.
Virilization in females.

Eyelid Lesion: squamous papilloma is frond like or lobular and MC benign

tumor. Basal cell is MC malignant tumor and most common malignancy in
humans. Fair skinned, long sun exposure are risks. Pearly lesions with rolled
border, telangiectasias that can bleed or ulcerate and cause loss of eyelashes.
Locally invasive, can -> enucleation. Resect to treat.

Percarditis: non radiating, retrosternal pain relieved by sitting forward. ST

elevation that is concave up and PR depression in aVR and friction rub. MCC is
viral infection. Caused by bacterial infections, lupus, uremia (which is an
indication for dialysis).

Indication for Dialysis: refractory hyperkalemia, volume overload/pulmonary

edema not responsive to diuretics, refractory metabolic acidosis (< 7.2),
uremic pericarditis, uremic encephalopathy/neuropathy, coagulopathy due to
renal failure.

Gallstones: cholesterol, pigment (calcium bilirubinate), or mixed. Cholesterol

and mixed > 80%. With GB hypomotility or excess cholesterol compared to
bile salts -> precipitaiton. RF for cholesterol stones: Caucasian, obesity, rapid
weight loss, female hormones/OCP, glucose intolerance, GB hypomotility
(pregnancy, age, fasting, high TG, TPN), ileal disease -> bile salt
malabsorption, clofibrate, octreotide, ceftriaxone. RF for pigment stones:
chronic hemolysis, biliary tract infections and parasite infections, old age. Low
carbs, exercise, coffee ingestion, aspirin/NSAIDS are protective. US for
diagnosis. Surgery or UDCA for treatment.
 Lacunar Stroke: due to occlusion of single deep artery in brain due to
microatheroma or hyalinosis. Better prognosis. HTN and DM are risks. Not
usually seen on CT. MC site is posterior internal capsule -> pure motor stroke.
Can have ataxia, pure sensory, or mixed.

Elevated BUN/Cr Ratio: prerenal azotemia (elevated BUN with mild elevated
Cr), steroid administration, or GI bleed (bacterial breakdown of hemoglobin
with urea reabsorption).

ACE I: reduces urinary albumin excretion and decline in Cr clearance. Slows

the progression of diabetic nephropathy (reduces intraglomerular pressure).
Used in patients with microalbuminuria, even with normal BP.

Recurrent Thrombosis: thrombophlebitis with multiple DVTs, elevated PT/PTT

and fibrin split products indicate activation of systemic cascade. Due to
genetic defect in young or malignancy in elderly (gastric, pancreatic, ovarian).
Do CT chest, abdomen, pelvis in old.

Cirrhosis: gynecomastia and spider angiomata due to decreased estrogen

metabolism, abdominal distension due to ascites, pedal edema due to
decreased oncotic pressure due to decreased albumin. Palmar erythema, nail
changes, caput medusa, hair loss, parotid swelling. MC cause is alcohol or
viral hepatitis. Diagnose with biopsies and vial serology.

B12 Deficiency: megaloblastic macrocytic anemia. Usually due to decreased IF

-> malabsorption -> peripheral neurophaty, posterior column defects due to
defective myelin synthesis. B12 and folate convert homocysteine to
methionine. Folate can improve B12 deficiency but worsen neurological
defects.

Megaloblastic Anemia: due to folate or B12 deficiency. Smear shows large RBC
and hypersegmented neutrophils. Have elevated homocysteine (cant convert
to methionine). B12 converts methylmalonyl CoA to succinyl CoA. B12
deficiency -> elevated MMA.

D Dimer: a fibrin degradation product elevated with blood clots and other
inflammatory conditions. (+) test has a poor PPV and is not definitive. (-) test
is good for ruling out a DVT or PE.

Pleural Effusion: diagnosed by Lights Criteria: fluid is exudative if fluid/serum

protein > 0.5, fluid/serum LDH > 0.6, fluid LDH > 2/3 ULN. Exudates are
caused by increased capillary permeability, transudates caused by high
hydrostatic/low oncotic pressure. Exudates caused by infection, autoimmune,
neoplasm. Elevated lymphocytes in fluid: TB, sarcoid, lymphoma, RA.

Herpes Zoster: reactivation of varicella zoster virus. Virus is latent in DRG

after primary infection. Stress, age, HIV, lymphoma -> impaired cellular
immunity -> reactivation along sensory nerve, usually T3-L3. Pain prior to
rash. Valacyclovir or acyclovir to treat. Post herpetic neuralgia prevented with
TCA with anti virals.

Hypertension: has the strongest association with strokes. Increases the risk of
all types of strokes. Have 4x higher risk of strokes than non-hypertensives.
Smoking and DM are also risk factors. Hypercholesterolemia more associated
with CAD.
 Vitamin K Deficiency: antibiotics and cystic fibrosis. Important cofactor in
gamma-glutamyl carboxylase -> factor II, VII, IX, X, protein C & S deficiency.
Carboxyl groups increase affinity for phospholipids on platelet surface.

ALL: disease of children. Present with infections, lymphadenopathy,

splenomegaly. Have lymphoblasts, with
anemia/neutropenia/thrombocytopenia. Lymphoblasts have no peroxidase (+)
granules, have PAS(+) material. Are also TdT(+) (only in pre B and pre T).

HTN Management: pharmacologic and non-pharmacologic. Lifestyle

modification is necessary: smoking cessation, weight loss, sensible alcohol,
reduce salt in diet. With multiple readings of > 140/90, and not improved with
lifestyle, JNC guidelines are to put on medication. Best first line is a thiazide.
Asthma is a contraindication for beta blockers. D

Parkinsonism: mask like immobile face, bradykinesia, tremors, rigidity, and

hypokinetic gait. Stooped over, series of short accelerating steps, feet that
shuffle and scrape the floor. Arms do not swing while walking. Degeneration of
neurons in substantia nigra -> decreased DA and increased Ach activities.
Treat with dopaminergic or anticholinergic drugs.

Ischemic Colitis: suspect with evidence of atherosclerotic disease, abdominal

pain, bloody diarrhea, minimal exam findings. Most commonly involves splenic
flexure, or rectosigmoid junction, both watershed areas supplied by terminal
SMA/IMA. Exacerbated by hypotension. Increased lactic acid, x ray can show
thumb printing.

Diabetic Nephropathy: diabetes is leading cause of ESRD in US. Most common

histologic finding is diffuse glomerulosclerosis. Nodular glomerulosclerosis
(Kimmelsteil Wilson lesion) is pathognomonic. Slow by strict glycemic control,
treatment of HTN, ACE I.

Stevens Johnson Syndrome: also called erythema multiforme major. Due to

immune complex mediated hypersensitivity due to sulfonamides, NSAIDs,
phenytoin. Sudden onset mucutaneous lesions over two sites, characteristic
target appearance, systemic signs of toxicity. Treat with supportive
management, assessment of hemodynamic stability, fluids.

COPD Exacerbation: if refractory to steroids and bronchodilators, but patient is

not crashing -> use NIPPV before intubation. Has decreased incidence of
complications such as infection. Recommended with pH<7.35 or PaCO2>45 or
RR>25. Better ventilation and less exhaustion of respiratory muscles. CI in
patients that are septic, hypotensive, dysrhythmic patients.

Hypovolemic Shock: blood loss -> loss of intravascular volume -> decreased
CO, decreased PCWP (indirect measure of LAP) -> activation of SANS ->
vasoconstriction, increased HR.

Gastric Outlet Obstruction: rare complication of PUD. Prepyloric inflammation

-> edema, fibrosis, scarring of the pylorus -> early satiety and intractable
vomiting -> dehydration and hypokalemic hypochloremic metabolic alkalosis
due to hyperaldosteronism from volume contration and renal potassium
wasting to retain hydrogen. NG suction, hydration of NaCl, IV potassium
initially, then treatment of the ulcer with possible surgery.
 Vertebral Fracture: patients suffering from ankylosing spondylitis for > 20
years are at risk due to decreased bone density and can result from minimal
trauma and clinical suspicion should be high especially with history and onset
of severe back pain.

Pulmonary Embolus: anticoagulation with heparin should be initiated

immediately in any patient with high likelihood PE and respiratory distress
before diagnosis. RF: surgery in last 3 months, immobilization, malignancy,
history of DVT. Present with dyspnea, cough, pleuritic chest pain, DVT
symptoms, tachycardia, tachypnea, loud S2, hypoxemia by ABG.

Symptomatic Hypercalcemia: vigorous hydration with IV normal saline is first

step in management.

Nephrolithiasis: 1) Imaging: CT scan without contrast. 2) Narcotics and

NSAIDs: relieve pain of renal colic, NSAIDs do not exacerbate nausea and
vomiting. 3) Size: < 5mm typically pass with fluid intake > 2L (dilutes urine).
4) Urology referral: if anuric, septic, ARF. Metabolic evaluation not necessary
with first stone.

Multiple Myeloma: proliferation of single transformed plasma cell producing

IgG with lytic bone lesions, marrow plasmacytosis, urine and serum
monoclonal proteins. Usually in elderly, have back pain, recurrent infections,
renal failure, hypercalcemia, hyperviscosity.

Achalasia: decreased esophageal body peristalsis and poor relaxation of the

LES is typical. Presents with progressive dysphagia, chest pain, food
regurgitation, and aspiration. Barium swallow shows dilated esophagus and
birds beak deformity.

Chronic Hepatitis: evaluation of liver damage is based on liver biopsy, acute

hepatitis is evaluated by LFTs and viral serology. Chronic hepatitis persists for
6 months. HBsAg confirms HBV as cause.

Acute Glaucoma: emergency. Treat with mannitol, acetazolamide, pilocarpine,

timolol. Avoid mydriatic agents such as atropine (dilates the pupil and worsens
the problem, or can be the cause). Use narcotics to control pain.

Rubella: erythematous and maculopapular rash that starts of face and

progresses to trunk and extremities. Prodrome of fever, occipital/posterior LA,
malaise, arthritis, mild coryza, conjunctivitis.

Tinea Corporis: also called ringworm is a superficial fungal infection with

erythematous, scaly, pruritic rash with central clearing. Seen in hot/humid
clients. Exposure to infected animals, people, public places are RF. Diagnosed
with skin scraping and KOH. Topic antifungals to treat.

Malaria: protozoan disease caused by plasmodium, RBC parasite transmitted

by Anopheles mosquito. Endemic to Africa, Asia. Can be falciparum, vivax,
ovale, malariae. Falciparum causes most deaths, vivax and ovale cause
relapses. Cyclic fever is hallmark that coincides with RBC lysis. Vivax and
ovale has fever every 48 hours, malariae every 72 hours, not seen with
falciparum. See anemia and splenomegaly, hypotension and tachycardia.
 GBS: ascending paralysis, areflexia, sensory changes 3-4 weeks after a URI or
GE. CSF albumino-cytologic dissociation is specific. Facial nerve paralysis and
autonomic dysfunction can occur. Treat with IVIG and plasmapheresis.

Myocarditis: otherwise healthy young people with acute onset CHF and lack of
CAD risk factors. Usually viral due to coxsackie B virus. May have preceding
viral type symptoms.

SAH: causes cerebral salt wasting syndrome due to inappropriate secretion of

vasopressin -> water retention, increased ANP/BNP -> salt excretion. Causes
hyponatremia. Can see SIADH which causes hyponatremia and is treated with
water restriction.

Central/Tertiary Adrenal Insufficiency: low CRH due to chronic

supratherapeutic doses of steroids -> low ACTH and cortisol, normal
aldosterone levels (not under CRH control). MCC of adrenal insufficiency.

Sinus Bradycardia: HR < 60, regular rhythm, constant PR interval. Caused by

physical training, excess vagal tone, sick sinus syndrome, hypoglycemia,
medications (CCB, BB, digoxin). May get lightheaded and dizzy, syncope. Give
IV atropine -> decreases vagal tone.

Dihydropyridine CCB: cause peripheral edema along with CHF, renal disease,
venous insufficiency. Cause peripheral vasodilation. If significant, discontinue.
Labs will be normal. Not an allergy!

Bacillary Angiomatosis: bright red, firm, friable, exophytic nodules in HIV

patient. Caused by Bartonella, a G(-) rod. Treat with oral erythromycin.

Crohns Disease: involves entire GI tract and has skip areas. Can have apthous
ulcers in the mouth (non specific) and can see granulomas. Associating
abdominal pain with extra-intestinal manifestations can help diagnose. Can
have weight loss and anemia.

Decubitus Ulcers: elderly, critically ill, immobile, poor nutrition, sensory

impairment are all risks. Due to uninterrupted pressure on tissue over bony
prominences like elbows, coccyx, hips, heels. Repositioning patients every 2
hours (point at which pressure begins to induce tissue damange) and pressure
reducing devices prevent. Also maximize nutrition.

Frostbite: best initial treatment is rapid rewarming with warm water (40-44).
Results in less tissue damage than slow rewarming at room temperature.
Immerse in room water that is continuously circulated. Do not attempt to
debride initially. Dry heat is not effective.

Vitiligo: autoimmune disease with areas of depigmentation due to lack of

melanocytes. Associated with other AI: pernicious anemia, AI thyroid disease,
type 1 DM, primary adrenal insufficiency, hypopituitarism, alopecia areata.

RAS: systolic-diastolic abdominal bruit in patient with HTN, atherosclerosis.

Causes secondary HTN and CKD. Bruit is due to turbulent blood flow and
found in 85% of RAS vs. 25% of patients with HTN.

Hereditary Spherocytosis: AD and MC cause of hereditary hemolytic anemia in

caucasians. Congenital RBC membrane defect. Have increased reticulocytes,
 increased BRN, (-) Coombs, spherocytes. Can be severely anemic with
jaundice and splenomegaly on presentation. MCV is normal or high, MCHC >
36%. Osmotic fragility test is next best test.

Pulmonary Tuberculosis: productive cough, hemoptysis, recurrent fevers,

possible weight loss. Imaging shows upper lobe cavitary lesions with
surrounding alveolar infiltration. Suspect in patients from endemic areas with
subacute/chronic pulmonary complaints.

S4: low frequency heart sound at the end of diastole just before S1.
Associated with LVH from long standing HTN, or restrictive cardiomyopathy.
Sounds like Tennessee. Results from atrial kick hitting stiff LV.

HBV Vaccination: decreases incidence of HCC especially areas with high HBV
like Africa and Asia (chronic HBV secondary to vertical transmission major
cause of HCC). In US, MC contracted due to contaminated blood. 7 th & 9th MCC
cancer death in men and women.

ASA Sensitivity Syndrome: pseudoallergic reaction due to ASA induced PG/LT

misbalance in susceptible individuals. Have persistent nasal blockage,
episodes of bronchoconstriction. ASA blocks COX -> increased lipoxygenase
-> accumulation of LT. Treat with leukotriene inhibitors, topical steroids, ASA
desensitization therapy.

Cardiac Disease: detailed history and physical is most effective way to screen
for cardiac disease and underlying hypertrophic cardiomyopathy. All school
and collegiate athletes should be offered pre-participation by skilled
healthcare workers.

Metabolic & Respiratory Acidosis: low pH (<7.35) = acidosis, decreased HCO3

= metabolic acidosis, inappropriately normal PaCO2 = primary respiratory
acidosis. Use Winters formula to calculate what PaCO2 should be: PaCO2 =
1.5(HCO3)+8+2.

Megaloblastic Anemia: elevated MCV, elevated MCH, normal MCHC. Large

RBC, hypersegmented neutrophils, anisocytosis, poikilocytosis, basophilic
stippling. Caused by B12 deficiency, folic acid deficiency, other (hypothyroid,
liver disease, anti-metabolites).

Brain Lesion in HIV: MCC is toxoplasmosis. TMP-SMX for prophylaxis,

sulfadiazine & pyrimethamine for treatment. If dont respond, then do brain
biopsy. Brain irradiation is for CNS lymphoma (afebrile and weakly enhancing).

Acyclovir: causes acute elevation of Cr. Is excreted by glomerular filtration and

tubular secretion. When concentrations -> crystallization, crystalluria, renal
tubular damage. Can be prevented with adequate hydration and slowing rate
of infusion.

Morning Hyperglycemia: due to Somogyi effect (high NPH dosing with peaks 4-
10 hours after injection -> overnight hypoglycemia -> epi, NE, glucagon
release -> glycogenolysis and gluconeogenesis -> morning hyperglycemia) or
Dawn phenomenon (decreased insulin sensitivity between 3 and 8 AM ->
hyperglycemia at 3 AM and 7 AM due to spikes of GH release which occurs
shortly after falling asleep) or waning circulating insulin (usually coexists with
Dawn phenomenon, 3 AM glucose is usually normal).
 Cholesteatoma: congenital or acquired secondary to chronic middle ear
disease. New-onset hearing loss or chronic ear drainage despite antibiotics.
Granulation tissue and skin debris with retration pockets of TM. Also causes
CN palsies, vertigo, brain abscesses, meningitis. Need otologic exam, and CT
or surgical visualization.

Cut Off Point: lowering cut off point will increase sensitivity.

Zinc Deficiency: result from chronic TPN (lacks zinc) or malabsorption due to
SB resection due to IBD. Causes alopecia, bullous/pustulous lesions around
orifices or extremities, abnormal taste, impaired wound healing. Normally
digested in the jejunum.

Survival in CHF: ACE I, ARBs, beta blockers, spironolactone all confer survival
benefit. Digoxin and furosemide can reduce symptoms and hospitilzations, but
do not help survival.

Isoniazid: can cause B6 deficiency -> peripheral neuropathy -> tingling in

extremities, numbness, ataxia. Start on 10 mg/day prophylaxis, 100 mg/day
for treatment. Hepatitis is another known side effect.

Essential Tremor: AD, heads and UE are often affected, worse when arms
outstretched at the very end of goal directed activities (intention tremor).
Treat with propranolol.

COPD: often have CO2 retention -> respiratory acidosis. Use diuretics to treat
cor pulmonale but caution is needed because they have a reduction in CO
with subsequent development of renal failure.

Hydroxychloroquine: good for treatment of SLE with isolated skin and joint
involvement. Most serious SE is retinopathy & corneal damage. Need eye
exams every 6 months.

Urinary Retention: abdominal pain and suprapubic fullness after taking TCAs
(anticholinergic -> reduces detrussor contraction and sphincter relaxation).
Catheterize -> document PVRV > 50 mL (diagnostic for urinary retention) and
provides symptomatic relief.

Metastatic Disease of the Vertebrae: metastases are the MC malignancy of

bone. Lung, breast, prostate, thyroid, kidney can all metastasize. Pain is
usually constant and worse at night with rest vs. degenerative which is worse
with exercise and better with rest. History of malignancy makes diagnosis
likely.

Primary Polydipsia: problem of excessive water ingestion. Kidneys work

property excreting dilute urine. Confirm by withholding water -> increases
urine osmolality and specific gravity. Common in patients with schizophrenia,
and phenothiazines given to them cause dry mouth increasing thirst.
Hyponatremia -> seizures.

Influenza: acute onset fever, chills, cough, malaise, myalgias. Occurs in winter.
Febrile with wheezes, crackles, course breath sounds. CXR may be normal or
have interstitial pattern. Nasal swabs confirm. Start antivirals within 48 hours.
Neuraminidase inhibitors (oseltamivir and zanamivir) are used, rimantadine
and amantadine are only effective against influenza A.
 ARDS: non cardiogenic pulmonary edema due to inflammation of alveoli.
Sepsis, severe bleeding, trauma, toxic injury, burns can be causes. Diagnosed
via: acute dyspnea, inciting condition, bilateral infiltrates, PCWP < 18 (> 18
indicates impaired LV function), PaO2/FiO2 < 200.

Nephrotic Syndrome: edema, hypoalbuminemia, elevated urine protein

(3g/day). Diabetes and amyloidosis are common causes. Minimal change
disease is the MCC in children. FSGS and membranous are most common in
adults. Active HBV infection causes membranous GN -> nephrosis. Common
association with HBeAg (+) due to deposition of Ag or Ab. HBV associated
membranous GN more common in children than adults.

Thyroid Function Tests: hyperlipidemia, unexplained hyponatremia, elevated

serum muscle enzymes are indications for TFTs. Most commonly see
hypercholesterolemia (increased LDL) or combined with high TG. Due to
decreased LDL receptors. May be difficult to control cholesterol even with
thyroid control. Caution: increased risk of myopathy with statin use.

Empyema: intrapleural collection of pus. Due to bacterial seeding of a

parapneumonic effusion or inoculation of bacteria during surgery. MCC strep
pneumo, staph aureus, klebsiella. Have fever, cough, SOB, pleuritic chest
pain. CXR shows free flowing (early) or loculated (late) effusion. Opacity
typically has abnormal contour. Treat via drainage and antibiotics.

NF Type I: intensive axillary freckling, caf-au-lait spots, optic gliomas in ~

15% of patients, usually those < 6. Slow progressive unilateral vision loss and
dyschromatopsia. Can see exophthalmos, with swollen, atrophic, or normal
optic disk.

Lead Time Bias: always consider in evaluation of a screening test. Incorrect

assumption of prolonged survival time and better prognosis. Actually,
detected earlier so patients seem to live longer. Think of this with new
screening test for poor prognosis diseases.

SBE and IV Drugs: increased risk in both right and left heart. If tricuspid or
pulmonic valves are involved -> septic emboli to the lung -> cough, chest
pain, hemoptysis, round alveolar infiltrates. Proteinuria due to septic emboli or
immune complex in the kidney. Tricuspid regurgitation is common -> systolic
murmur that increase on inspiration.

PPD: detect patients with latent TB infection. Degree of induration required for
(+) test depends on pre-test probability. >15 mm is (+) for healthy patients
with no known TB risk factors. >10 mm is (+) in immigrants from endemic
area, IVDA, residents/employees of high-risk settings, patients with
diabetes/CKD/hematologic malignancies/fibrotic lung disease, children < 4 or
teens exposed to high risk adults. >5 mm is (+) in HIV, recent contact with TB,
signs of TB on CXR, organ transplant, patients on immunosuppression.

Pancreatic Cancer: 5th MCC of cancer related mortality. RF: male sex, >50
years, black race, smoking (most consistent reversible RF), chronic
pancreatitis, long standing diabetes, obesity, familial pancreatitis, and
pancreatic cancer in close relative. Alcohol, gallstones, coffee intake are not
RF.
 Type 4 RTA: hyperkalemia, renal insufficiency, non-anion gap metabolic
acidosis (decreased bicarbonate and normal AG). Caused by aldosterone
deficiency or tubular insensitivity to aldosterone. Failure to secrete acid as
NH4+ and potassium retention. May occur due to diabetic nephropathy and
can be worsened by ACEs and ARBs that inhibit aldosterone.

Blastomycosis: broad based budding yeast endemic to north central and south
central US. Affects lungs, skin, bones, joints, prostate. Primary pulmonary
infection is asymptomatic or presents with flu-like symptoms. Can have
verrucous (crusted, heaped up, warty, violaceous hue, sharp borders,
surrounded by micro abscesses) or ulcerative skin disease. Wet mount shows
organism.

Kidney Stones: colicky flank pain with radiation to the groin. MC are calcium
oxalate that are envelope shaped. RF are small bowel disease, surgical
resection, chronic diarrhea -> bile salt and FA malabsorption -> calcium
chelation -> reabsorption of oxalate.

Allergic Contact Dermatitis: MC sensitizer is plant urushiol (poison

ivy/oak/sumac, ginko, mango skin) in NA. Nickel, formaldehyde, fragrances,
preservatives, rubber are also common. Type IV hypersensitivity: initial
sensiztization -> 10-14 d -> re exposure -> reaction in 12-48 hours. Avoid
contact. Can use calamine lotion, topical antihistamines, steroids.

LFTs: PT is the most important test of functionality. Elevated transaminases =

cellular injury. Decrease in transaminases = recovery or few functional
hepatocytes (look at other tests). Rise in PT with decreased transaminases =
low functionality = fulminant hepatic failure.

DVT: presents with calf pain, swelling, discoloration (other DDx is Bakers cyst,
muscle strain, venous insufficiency, cellulitis). Decision to anticoagulate based
on history, physical, and non-invasive testing: compression ultrasound. If low
risk, do D-dimer. If negative, no anticoagulation. If positive, do ultrasound.

Osteomyelitis: if coupled with chronic foot ulcer in a diabetic (due to

neuropathy and arterial insufficiency) or other causes of arterial insufficiency,
caused by contiguous spread.

Aspiration Pneumonia: fever, cough with foul smelling sputum after endoscopy
or other instrumentation. Poor dentition also RF. Add antibiotic with anaerobic
coverage like clindamycin.

Thoracic Aortic Aneurysm: MC site is ascending due to cystic medial necrosis.

2nd MC is descending distal to L SCA, fusiform, due to atherosclerosis. May also
have AAA. Usually have comorbid CAD or pulmonary disease.

Atrial Myxoma: MC primary intracardiac tumor, usually in LA. Can cause fever,
weight loss, neurologic symptoms due to embolization, and mass on echo.
Usually in elderly patients.

Horners Syndrome: suspect lung cancer in a smoker. Cancer can cause

cough, chest pain, weight loss, decreased appetite, weakness, swallowing
difficulty, hoarseness, shoulder pain due to direct extension. Do simple CXR to
start.
 Histoplasmosis: common and asymptomatic infection in Mississippi and Ohio
River Valley and Central America. Commonly found in bird and bat droppings
-> inhalation. Not common to get symptomatic disease. Will have fever, chills,
non productive cough, with patchy infiltrates. Cavitary lesions can form in
older adults with COPD which can be fatal. Can disseminate in
immunocompromised and children. Can present as solitary nodule.

Chronic Liver Disease: all patients should be vaccinated against HAV and HBV
unless already immune (look at Ab levels), due to high risk for acute hepatic
failure or cirrhosis.

Post Splenectomy Sepsis: normally pathogens are phagocytosed by dendritic

cells in white pulp -> MHC II presentation to TH2 cells -> marginal zone -> B
bells in primary follicles -> secondary follicles and plasma cells -> Ab
formation -> binding Ag -> phagocytosis by opsonization. No spleen ->
impaired Ab mediated opsonization for phagocytosis -> risk for sepsis due to
Strep pneumo, N meningitidis, H flu.

NPH: abnormal gait (slow broad based shuffle), incontinence (urinary, fecal in
late disease), dementia due to increased ventricular size without increased
pressure. Treat with large volume LP and, if successful, VP shunt.

Caustic Ingestion: no alteration of consciousness, dysphagia, pain, heavy

salivation, mouth burns. Causes necrosis of GI tissue and can cause
perforation of stomach or esophagus -> peritonitis and mediastinitis.

Central Line Thrombosis: prolonged placement -> thrombosis -> swelling (arm
if SCV). Remove catheter and duplex to document thrombus and need for
anticoagulation. Common with TPN lines which should be in RA. Hyperosmolar
fluid -> irritation of vein. Have swollen arm with present pulses. Swelling may
extend into head and neck with distended veins.

Pheochromocytoma: do not give beta blockers without alpha blockers. Beta

block -> unopposed alpha activity. Give alpha first and then beta to treat
tachycardia, otherwise can cause dangerous increase in BP. Labetalol has
alpha and beta activity and can be given.

Hereditary Spherocytosis: AD disorder of spectrin -> increased RBC fragility.

Not deformable and gets trapped in red pulp fenestrations. (+) family history,
splenectomy, spherocytosis, can cause cholecystitis due to pigmented stones
-> treat with folate and splenectomy.

Whipples Disease: multi system infection caused by Tropheryma whippelli.

Presents with arthralgias, weight loss, fever, diarrhea, abdominal pain. Can
have chronic cough and myocardial/valvular involvement -> CHF or
regurgitation. Have PAS(+) material in lamina propria on biopsy. Can have
hyperpigmentation, LA, supranuclear ophthalmoplegia, myoclonus.

Chronic Hepatitis C: waxing and waning of transaminase levels with few

symptoms. May have arthralgias/myalgias. Can have cryoglobulins, porphyria
cutanea tarda, GN. 20% develop cirrhosis. Hepatic function worsens in times
of stress.

Dehydration: altered MS, dry mucosa, high electrolytes/Hct, BUN/Cr > 20.
Elderly patients are predisposed due to decreased thirst response, impaired
 sodium retention, impaired renal concentration. Treat with NS, but caution: Na
loading unmasks subclinical CHF.

Aortic Stenosis: causes exertional syncope along with ventricular tachycardia

and HOCM. AS will have symptoms of CHF (fatigue, dyspnea on exertion).
Symptomatic with valve area < 1. Have systolic murmur at R 2 nd ICS with
carotid radiation, pulsus parvus et tardus, and prolonged PMI.

Neurocysticercosis: MC parastitic infection of the brain caused by larval Taenia

solium. Adult lives in intestine -> eggs -> animal consumed -> larvae encyst
in tissue -> eat animal -> adult tapeworm in intestine. If person consumes
eggs -> embryos in intestine -> invade wall -> disseminate to brain, muscle,
SQ tissue, eye. Multiple, small, fluid filled cysts with invaginated scolex on
neuroimaging. Usually asymptomatic and found on autopsy.

Hypercalcemia: abdominal pain/constipation, polyuria, psychiatric

disturbances (usually calcium > 12). Treat with normal saline and then loop
diuretic. Can be seen in MM with back pain and pancytopenia, due to
osteoclast activating factor -> lytic lesions and hypercalcemia.

Serum Sickness Like Reaction: can occur 1-2 weeks after administration of
penicillin, amoxicillin, TMP-SMX, or cefaclor after viral illness. Fever, urticarial
rash, polyarthralgia, LA. Distinct from immediate hypersensitivity reactions.
Discontinue offending agent.

Hematuria: initial hematuria = urethral damage. Terminal hematuria =

prostate or bladder damage. Total hematuria = kidney or ureter damage. Clots
not usually seen with kidney damage. Painless terminal hematuria ->
investigate bladder cancer.

Cavernous Sinus Thrombosis: occur in patients with infections of the skin

adjacent to the eye or nose, ethmoid/sphenoid sinusitis. HA (neuropathic due
to V1/V2) is MC early symptom. Fever, periorbital edema due to obstructed
flow. Lateral gaze palsy due to CN VI involvement. CN III, IV, V1, V2 can be
affected. Do MRI/CT of orbits. Use IV antibiotics.

Hyperandrogenism: rapidly developing suggests androgen secreting neoplasm

in adrenal or ovary. Look at testosterone and DHEAS. High testosterone with
normal DHEAS = ovary. Normal testosterone with high DHEAS = adrenal.

Lumbosacral Strain: MCC of acute back pain usually after physical exertion,
absence of radiation, presence of paravertebral tenderness/contraction, (-)
straight leg raise, normal neurological exam. Treat with NSAIDS and early
mobilization.

Minor Thalassemia: alpha or beta will have impressive microcytosis with

modest anemia (Hgb level, adult diagnosis, lack of severe symptoms), target
cells, with no GI bleeding. Common in Mediterranean descent. Reassure and
followup.

ABCs: start in management of ANY patient coming into ER. Poor circulation
evidenced by hypotension, pallor, tachycardia, delayed capillary refill ->
volume resuscitate -> hemodynamically stable -> start with diagnosis.
 Anal Fissure: slit like tears of anal canal usually on anterior or posterior anal
verge due to passage of large, hard constipated stools. Crypt abscesses,
explosive diarrhea, perianal dermatitis/infection, IBD, trauma, sexual abuse
can all be causes. Severe pain and bright red bleeding. Treat acute and
chronic with high fiber, lots of fluids, stool softener, local anesthetic.

GERD: patient with asthma like symptoms that occur only at night (especially
those who eat late or go straight to bed), sore throat, horseness, wheezing.
Start with lifestyle modification (avoid eating late, elevated head of bed), PPI.

Ichthyosis Vulgaris: history of normal skin at birth with gradual progression to

dry, scaly skin. Hereditary or acquired. Usually dry and rough with horny
plates over extensor surfaces. Sparing of diaper/face in children. Worse in
winter. Sometimes called lizard skin.

Subacromial Bursitis: result of repetitive overhead motions -> chronic

microtrauma to the supraspinatus tendon by compression between acromian
and humeral head. Pain with active ROM, passive internal rotation/forward
flexion (Neers).

Atrial Flutter: sawtooth pattern of atrial impulses on EKG with large P waves
that do not conduct all QRS complexes. Caused by re-entrant rhythm. Present
with palpitations, CP, SOB, lightheadedness. Ventricular rate determined by AV
node conduction. MC is 2:1 block, can have 3:1 or 4:1 (variable AV node
conduction).

Hyatid Cysts: due to infection with Echinococcus granulosus from close

contact with dogs (definitive host). Causes unilocular cystic lesion in liver,
lung, muscle, bone. Usually asymptomatic, or symptoms are due to
compression. Have eggshell calcifications and can cause anaphylaxis. Treat
with resection under cover of albendazole.

OA: narrowed joint space, osteophytes, subchondral sclerosis or cysts, < 30

minutes morning stiffness, joint pain. Obesity is most readily modifiable RF for
OA and can slow progression and improve joint pain and function.

Herpes Zoster: reactivation of VZV in DRG in patient with previous chickenpox.

Can be due to immunocompromise (HIV, chemo, diabetes), stress, old age.
Pain and vesicular rash in dermatome. Pain may precede rash.

CO Poisoning: colorless, odorless gas emitted automobiles, charcoal grills,

furnaces. Acute exposure presents with HA, nausea, vomiting, abdominal
discomfort, confusion, coma, with pinkish skin hue. Diagnosed by
carboxyhemoglobin levels. Treat with hyperbaric O2. History is helpful.

Hypercalcemia of Malignancy: due to production of PTH-rP by malignant cells.

MC paraneoplastic syndrome usually associated with SCC of lung. Causes
increased bone resorption, increased tubular calcium resorption, phosphate
secretion.

Outlier: extreme and unusual value observed in dataset. Means are extremely
sensitive and shift towards them.
 FAP: AD caused by mutations of APC gene. Causes hundreds of adenomatous
polyps in colon and has 100% risk of cancer if not treated with elective
proctocolectomy.

MJ Intoxication: MC used illicit drug in US. History of slowed reaction time,

impaired short term memory, increased appetite. Have conjunctival injection,
dry mouth, hypertension, tachycardia. Involved in 10-50% of car accidents.

White Out Lung: have opacification with mediastinal shift towards affected
lung due to atelectatic volume loss. MC due to obstruction due to mucus
plugging, tumor, foreign body, external compression. Causes dyspnea,
tachypnea, diaphoresis, confusion, cyanosis. Urgent bronchoscopy for
diagnosis and possible relief of obstruction.

Hyperkalemia: removal of K from the body only done via dialysis, diuretics, or
exchange resins like Kayexalate acts in GIT to exchange Na for K. Treatment
also uses calcium gluconate, bicarb, insulin with glucose/dextrose, beta
agonists.

Graves Ophthalmopathy: MCC of exophthalmos in adults. Caused by

autoimmune periorbital lymphocytic infiltration of extraocular muscles ->
fibroblast proliferation, hyaluronic acid deposition, edema, fibrosis. Sclera
seen above and below iris which is pronounced by sympathetic stimulation of
lid retraction. Will have dry eye due to keratitis and exposure.

Primary Syphilis: treatment is single intramuscular injection of benzathine

penicillin. With penicillin allergic, use single dose azithromycin or 2 weeks of
doxycycline or tetracycline.

PJP Pneumonia: opportunistic pathogen and important cause of pneumonia in

IC adults. Bilateral diffuse infiltrates on CXR in perihilar region. Have dyspnea,
fever, non productive cough. Can have involvement of LN, spleen, liver, bone
marrow.

Rifampin: causes red/orange discoloration to bodily fluids and can cause

discoloration of soft contacts. Do a UA to rule out more worrisome conditions,
such as renal TB or TB associated glomerulopathy. Otherwise is a benign drug
effect.

Trigeminal Neuralgia: paroxysmal, lightning-like pain on the face which is

severe, intense, burning, electric-shock like. Carbamazepine is the drug of
choice for treatment.

ALS: characterized by involvement of UMN (spasticity, bulbar symptoms,

exaggerated DTR) and LMN (fasciculations). Weakness and wasting is
characteristic of UMN and LMN lesions.

Hypokalemic Alkalosis: 1) Vomiting: scars on dorsum of hand, dental erosions,

hypovolemia, hypochloremia, hypochlouria. 2) Diuretic Abuse: same
presentation but elevated urine chloride, history of diuretic use, positive urine
assay for medication. 3) Bartter/Gitelmans: same as diuretic abuse.

Echinococcus Granulosus: majority are asymptomatic infections. Liver is MC

affected in 2/3, and lung in 1/4. Dogs are definitive hosts, sheep are
intermediate hosts, humans are dead-end accidental hosts. Seen where sheep
 are raised, transmission when dogs live close to humans and are fed viscera
of slaughtered animals. Human ingestion -> intestinal penetration ->
dissemination. Cysts are have germinal layer (can give rise to daughter cysts)
and laminated layer.

Case Control Study: pateitns with disease of interest (cases) and people
without disease (control) are asked about previous exposure and exposure
odds ratio is measured compared case rate to control rate.

Cut Off Point: raising decreases sensitivity, increases specificity.

PBC: autoimmune destruction of intrahepatic bile ducts and cholestasis. Starts

with pruritis especially at night, fatigue, hepatomegaly, xanthomas, jaundice,
steatorrhea, portal hypertension, osteopenia. Elevated ALP, cholesterol, IgM,
(+) anti-mitochondrial Ab. Increased risk of hepatobiliary malignancy. UDCA is
treatment of choice: relieves symptoms and lengthens transplant free survival
time.

Nitrates: venodilation -> improves cardiac chest pain by reducing preload ->
decreased myocardial O2 demand. Reduces ventricular volume and wall
stress. Also cause some arterial dilation -> some decreased afterload and
myocardial O2 consumption.

Iron Deficiency Anemia: MCC of anemia in the elderly. Cause pallor and
fatigue. Usually secondary to a nutritional deficiency. Can be due to chronic
blood loss (gastritis, PU, diverticulosis).

Cardiovascular Disease: MCC of death in patients on dialysis (50% of deaths,

20% due to MI, 60% to sudden death) and MCC of death in renal transplant
patients.

Osteomyelitis in SCD: Salmonella is the MCC (upto 70% of cases), Staph

aureus for < 25%.

Wernicke Korsakoff: caused by thiamine (B1) deficiency. Wernicke:

encephalopathy, oculomotor dysfunction, gait ataxia. Can be induced by
giving glucose without thiamine. Korsakoff: irreversible amnesia,
confabulation, apathy.

Cystitis: dysuria, frequency, suprapubic discomfort, no unusual vaginal

discharge, no high risk sexual behavior, bacteriuria, pyuria = acute
uncomplicated cystitis. Cultures are not needed. Oral TMP-SMX is best empiric
threatment.

Fluphenazine: high potency typical antipsychotic that is injected every 2-3

weeks that can cause hypothermia by disrupting thermoregulation and
shivering mechanism. Patients taking antipsychotics should be advised to
avoid prolonged exposure to extreme temperatures.

ARDS: endothelial injury -> fluid leakage from capillaries -> fills interstitium
and alveoli -> intrapulmonary shunting -> hypoxia refractory to O2. Acute
onset, PaO2/FiO2 < 200, bilateral infiltrates, Swan Ganz < 18/absense of
JVD/cardiomegaly (which indicates CHF).
 ASA Intoxication: mixed respiratory alkalosis (due to increased drive) and
anion gap metabolic acidosis (accumulation of salicylate and decreased
excretion of organic acids like lactic acid and ketoacid). Use Winters formula:
PaCO2 = 1.5(HCO3)+8+2 to determine if its mixed or not.

Mesenteric Ischemia: unexplained chronic abdominal pain especially after

eating, weight loss, food aversion. Evidence of other atherosclerotic diseases
and non-specific physical findings. 50% patients may have a bruit. Diagnosis
requires angiography or Dopper US.

Cardiac Tamponade: hypotension, tachycardia, JVD. ECG shows electrical

alternans: amplitude of QRS changes. Needs massive fluid resuscitation and
emergent pericardiocentesis.

Wilsons Disease: AR, abnormal copper deposits in liver, basal ganglia, cornea.
Liver disease (asymptomatic to fulminant), neuropsychiatric. Have low
ceruloplasmin, increased copper excretion, Kayser-Fleisher rings.

Malignant Otitis Externa: serious infection of the outer ear caused by

Pseudomonas. Seen in elderly with uncontrolled diabetes, ear pain, drainage,
granulation tissue in ear canal. Can develop osteomyelitis of the skull base,
TMJ (worse with chewing), CN involvement. Give IV ciprofloxacin.

Hodgkins Disease: curable lymphoma of young patients. Due to

chemo/radiation, can develop secondary malignancies (usually lung or
breast). Occurs in 3.2% of patients within 20 years.

Liver Mass: isolated mass is more likely to be metastatic than primary. Primary
tumors of GIT, lung, breast are MC. Usually asymptomatic and present with
symptoms of primary malignancy. With chronic abdominal pain ->
colonoscopy.

Ventilation: RR x Vt. Respiratory alkalosis (pH > 7.4, decreased CO2) results
from hyperventilation. In setting of appropriate Vt, lower RR (decreased Vt ->
increased RR -> worsens situation). Normal Vt is 6 mL/kg ideal body weight.

Ulcerative Colitis: bloody diarrhea, tenesmus, cramping, weight loss, anemia.

Complications are PSC, uveitis, erythema nodosum, spondyloarthropathy,
toxic megacolon, colon cancer. Routine colonoscopies beginning 8 to 10 years
after diagnosis.

PPV: depends on prevalence of disease of interest in population and increases

with increases in prevalence. The more common a disease, the greater
probability that a patient from the population with a positive test actually has
the disease. Opposite is true for NPV.

New Drugs: consider natural history of a disease in evaluating effectiveness of

a new drug in a trial. Control groups help prevent this.

Spinal Cord Compression: signs and symptoms of UMN dysfunction distal to

site of compression (weakness, hyperreflexia, decreased sensation,
bowel/bladder dysfunction). Medical emergency requires prompt diagnosis
with MRI. Could be herniation, abscess, trauma, malignancy.
 Adrenal Deficiency: hyperpigmentation of skin and mucous membranes is
characteristic of primary deficiency due to increased ACTH. Not seen in
secondary deficiency which is due to hypothalamic-pituitary failure. Can also
have other manifestations of pituitary insufficiency.

Aortic Dissection: suspect with acute retrosternal pain and normal EKG. Check
BP in both arms and listen for diastolic murmur of AR. TEE is preferred
diagnosis to MRI (takes too long) or CT. HTN should be controlled before TEE.

Sjogrens Syndrome: subjective and objective evidence of dry eyes

(keratoconjunctivitis sicca) and mouth (xerostomia, increased caries) exists
with histologic evidence of lymphocytic infiltration of salivary glands or SSA
(Ro)/SSB (La) Ab.

AAA: usually asymptomatic and discovered incidentally. Life threatening

complication -> rupture. Ultrasound has nearly 100% sensitivity and
specificity, facilitates measurement of size, shows presence of thrombus.

Myasthenia Gravis: MC manifestation is weakness of muscles that lift lid

(ptosis) or move eyes (double vision). SOB and dysphagia are worrisome.
Does not produce pain or numbness. EMG and Ach receptor test are
diagnostic. Use CT to look for thymoma after diagnosis is established.

Pseudomonas Pneumonia: G(-) bacilli in sputum in intubated ICU patient with

fever and leukocytosis. MC considered G(-) aerobic bacilli and common cause
of nosocomial pneumonia. Linked to contaminated water faucets, respiratory
therapy equipment, therapy pools, plant products. Cefepime, azotreonam,
ciprofloxacin, imipenem/cilastatin, tobramycin, gentamycin, amikacin,
piperacillin/tazobactam.

HOCM: sudden cardiac death in young individual, usually during exertion. MC

in African Americans and usually have no prior symptoms. Can have
ventricular tachycardia or ventricular fibrillation due to abnormal myocytes
and myocardial scarring. Can also have heart failure and stroke but would not
cause sudden death.

Dubin Johnson Syndrome: conjugated chronic hyperbilirubinemia not

associated with hemolysis. Asymptomatic, jaundice, non-specific complaints.
Icterus can be worse during stress. Have normal amounts of total urinary
coproporphyrin but have > 80% type I (vs. normal individuals with majority
type III). Liver is usually black due to dense pigment of epinephrine
metabolites in lysosomes.

Chlamydial Urethritis: presence of mucopurulent urethral discharge, history of

multiple sexual partners, dysuria, frequency. UA has no bacteriuria, UCx < 100
colonies/mL.

Succinylcholine: depolarizing neuromuscular blocker that can cause life

threatening hyperkalemia and arrhythmias. Should not be used in patients
with high risk for hyperkalemia: crush or burn injuries > 8 hours old
(rhabdomyolysis), GBS and other demyelinating syndromes, tumor lysis
syndrome. Non-depolarizing blockers are better.

NMS: fever, muscle rigidity, autonomic instability, mental status change,

elevated CK. Dantrolene (a muscle relaxant) is used to treat followed by
 bromocriptine (DA agonist) and amantadine (antiviral with dopaminergic
properties). Usually seen with typical antipsychotics and usually start within
2 weeks of starting medication. Stop medication.

Mitral Regurgitation: holosystolic murmur that radiates to the axilla. MCC is

MVP (can hear mid systolic click). Can cause left atrial dilation and atrial
fibrillation (intermittent palpitations). Due to myxomatous degeneration of the
valve.

Case Control Study: exposure-odds ratio is the measure of association (odds of

exposure in cases to odds of exposure in control) and is not the same as
relative risk (risk in exposed vs. risk in unexposed). If population is small, RR
can equal odds ratio.

PE: signs and symptoms are non specific and variable. Suspect in patient with
sudden onset SOB, pleuritic chest pain, low grade fever, hemoptysis,
tachypnea, tachycardia, hypoxia. Calf swelling and Virchows triad not always
present. Low O2 and atrial fibrillation = poor prognosis.

Intraocular Foreign Body: suspect in patients with high velocity injuries

(drilling, grinding). If initial pen light exam does not reveal anything, do
fluorescein exam with Woods lamp or slit lamp.

Non Ketotic Hyperosmolar State: occurs in T2DM. Insulin is enough to

prevent ketosis but not hyperglycemia. Have glucosuria and severe
dehydration. High osmolarity -> lethargy, weakness, altered mental status,
focal neurological deficits, coma. Usually some kind of precipitant event
(infection, MI, stroke). Hyperglycemia (>600), hyperosmolarity (>320), absent
ketonemia.

Macrovascular Hemolysis: elevated reticulocyte count, increased LDH, low

haptoglobin -> iron loss -> microcytic anemia. Occurs with valve replacement
or severely calcified aortic valves. Helmet cells or fragmented RBCs on smear.

PE: patients with recent orthopedic surgery are at higher risk for DVT and PE
and anticoagulation will be needed. Will have elevated A-a O2 gradient due to
impaired gas exchange (also seen in interstitial disease, and other processes
that alter V/Q).

Statin Side Effects: elevated liver enzymes and myopathy. Inhibition of HM-
CoA reductase. Cannot make mevalonate -> dolichol, CoQ10 (reason for
myopathy).

Obesity Hypoventilation: long term consequence of severe obesity and

untreated OSA -> chronic hypercapneic/hypoxic respiratory failure, secondary
erythrocytosis, pulmonary HTN, cor pulmonale. To keep pH, bicarbonate is
retained -> decreased choride absorption.

Alpha 1 Antitrypsin Deficiency: inhibits many different proteolytic enzymes,

acute phase reactant, highly pleomorphic gene on chromosome 14. Usually
northern European. Liver cells will have PAS(+) granules, resist digestion by
diastase. Develop panacinar emphysema (MCC death) and liver disease (2 nd
MCC death). Diagnose by serum measurement and genetic testing. Usually
done in patients with early onset emphysema. Treat with purified A1AT or
lung/liver transplant.
 Atrial Fibrillation: irregularly irregular, narrow QRS, no P waves. Can present
with chest pain, palpitations, weakness, SOB. Due to cardiac, pulmonary,
metabolic (hyperthyroidism), or drugs.

Atracurium: neuromuscular blocking agent that is metabolized by serum

esterases and degrades spontaneously. Safe for use in patients with renal/liver
failure.

Bullous Pemphigoid: tense blisters in flexural areas. Elderly patients with

pruritis, urticaria. Due to UVR, NSAIDs, antibiotics. Auto Ab formed against
basmement membrane proteins BP230, BP 180. See IgG and C3 and dermal
epidermal junction. Treat with steroids.

Minimal BRBPR: on toilet paper, drops in toilet bowl, some on outside of stool,
not intermixed. MCC hemorrhoids, anal fissure, polyps, proctitis, rectal
ulcers/cancer. If patient < 50 with no risk factors, do anoscopy or proctoscopy,
then colonoscopy if no etiology found.

Diabetic Ketoacidosis: when treating, serum/urine ketones falls behind

changes in pH or anion gap and are more reliable indicators of recovery.

Central Retinal Vein Occlusion: subacute monocular vision loss with blood
and thunder appearance on fundoscopy of optic disc swelling, retinal
hemorrhage, dilated veins, cotton wool spots. Caused by coagulopathy,
hyperviscosity, atherosclerosis, chronic glaucoma.

Central Retinal Artery Occlusion: sudden, painless loss of vision in one eye
with optic disc pallor, cherry red fovea, boxcar segmentation of blood in retinal
veins.

COPD: progressive expiratory airflow limitation -> air trapping, decreased VC,
increased TLC/residual capacity and FEV1 is disproportionately decreased.
Accompanied destruction of alveolar-capillary membrane.

Nonketotic Hyperglycemic State: fluid replacement is the most important step,

especially when hypovolemia is present. Start with NS, then NS. May need
8-10 liters. 5% dextrose given when blood glucose < 250 to prevent cerebral
edema.

MCA Infarct: with aphasia, usually cerebral cortex on the left. Brocas is
common and patients will have word finding difficulties. Rapid irregular
rhythm -> atrial fibrillation -> cardiogenic source of embolus (could be caused
by MI due to CAD).

Infectious Mononucleosis: fever, sore throat, toxic symptoms, pharyngitis,

tonsillitis with exudates, LA usually in posterior chain, inguinal, axial. Can
have jaundice and hepatitis. Can develop hemolytic anemia and
thrombocytopenia due to anti-I Ab and usually Coombs (+).

Non Inflammatory Chronic Prostatitis: afebrile with irritative voiding

symptoms. Expressed secretions show no bacteria and normal WBCs. No
history of UTI, but voiding problems may have been present in past.

Bronchoalveolar Lavage: useful with suspected malignancy or opportunistic

infection. >90% sensitive and specific for PJP (HIV, CD4 < 200) and less useful
 for diagnosis of interstitial disease. Can use sputum induction with hypertonic
saline (high specificity, 50% sensitivity).

ARDS: develops in setting of sepsis, pneumonia, toxins, trauma, burns.

Alcoholism is further RF. PCWP < 18 (normal) indicates non-cardiogenic
pulmonary edema.

Serous Otitis Media: middle ear effusion without active signs of infection, dull
TM that is hypomobile. MC middle ear pathology in AIDS. HIV LA or obstructive
lymphomas -> auditory tube dysfunction. MC symptom is conductive hearing
loss.

Clopidogrel: secondary prevent in UA/NSTEMI for at least 12 months along

with ASA, beta blocker, ACE, statins. Used for 30 days with bare metal stents
and 1 year for drug eluting stents (epithelialization occurs slowly). Antagonize
ADP as antiplatelet. Good in place of ASA in those who cannot tolerate.

Pumonary Mechanics: compliance calculated by doing end inspiratory hold

maneuver (elastic pressure is pressure at end of inspiration, higher with
decreased compliance), airway resistance calculated by PAP, PEEP calculated
by end-expiratory hold maneuver.

Aortic Dissections: beta blockade is most appropriate initial intervention

(lower HR and BP -> decreased wall stress). Type A (ascending) need
medication and surgery. Type B (descending) need medication only. HTN is
leading risk factor. CT is good for diagnosis, TEE for those who cannot tolerate
contrast.

Malaria Prophylaxis: for chloroquine resistant (sub Saharan Africa, Indian

subcontinent), mefloquine is the drug of choice. Use chloroquine for sensitive
areas. Start 1 week before, and continue for 4 weeks after returning.

Wegeners Granulomatosis: triad of systemic vasculitis, upper and lower

airway granulomatous inflammation, GN (RBC casts, proteinuria, sterile
pyuria). Nasal cartilage destruction (saddle nose, purpulent rhinorrhea,
epistaxis, otitis, sinusitis) and vasculitic cutaneous lesions (tender nodules,
palpable purpura, ulcerations). Positive c-ANCA to proteinase 3 and elevated
CRP. Treat with cyclophosphamide.

Treatment of Hepatitis: for hepatitis C: elevated ALT, detectable HCV RNA,

histologic evidence of chronic hepatitis are candidates for treatment interferon
and ribavirin. Interferon and lamivudine used for hepatitis B.

Systemic Sclerosis: MC underlying mechanism of pulmonary disease is

interstitial fibrosis. Vascular lesions can develop as well, but uncommon to be
without fibrosis. Increased risk of aspiration due to esophageal dysmotility.
Increased risk of lung cancer.

Gonnococcemia: triad of polyarthralgia, tenosynovitis, painless

vesiculopustular skin lesions. Can have fever and chills. History of recent
unprotected sex with new partner. Usually no symptoms of symptomatic
venereal disease.

Angioedema: ACE I are the MCC of acquired, usually one week after stopping
drug. Edema in the face, lips, tongue, glottis, larynx. Occurs due to
 accumulation of bradykinin. Check for airway compromise and vasomotor
instability -> epinephrine.

Crohns Disease: suspect in young patient with diarrhea, abdominal pain,

weight loss. Involves entire GIT. Associated with fistulae, structures, anal
disease. Have anemia and reactive thrombocytosis.

Asbestosis: pneumoconiosis from inhalation of particles. Progressive dyspnea,

clubbing, end-inspiratory crackles, restrictive lung pattern, decreased lung
volumes, decreased DLCO, normal FEV1/FVC.

Analgesic Nephropathy: MCC of drug induced chronic renal failure. Papillary

necrosis and tubulointerstitial nephritis. Usually seen after 2-3 kg of drug
ingestion. Polyuria and WBC casts, microscopic hematuria, renal colic. HTN,
mild proteinuria, impaired urinary concentrating ability in late disease.
Develop premature aging, vascular disease, urinary tract cancer.

Acute Appendicitis: initial peri-umbilical pain is referred and visceral in nature.

Pain shifts to RLQ with involvement of parietal peritoneum and becomes
somatic in nature.

NE Induced Vasospasm: alpha 1 agonist -> vasoconstriction, useful when

trying to increase BP of hypotensive patients. Vasoconstriction ->
ischemia/necrosis of distal fingers/toes that is symmetric. Can occur in
intestines (mesenteric ischemia) or kidneys (renal failure).

Cyclophosphamide: immunosuppressant used in SLE, vasculitis, cancers. SE

are hemorrhagic cystitis, bladder carcinoma, sterility, myelosuppression. Drink
fluids, void frequently, taking MESNA help prevent all complications.

Male Incontinence: MCC in older men is bladder outlet obstruction due to BPH
or carcinoma of the prostate. Present with post void dribbling, poor stream,
hesitancy, urgency, nocturia, urinary retention. Will have enlarged prostate
with high PVRV.

T2DM: most patients require more than one oral agent, and some eventually
need insulin. Metformin plus sulfonylurea (glyburide) is good combination.
Assess renal status, metformin causes lactic acidosis. Also helps some weight
loss.

Bradyarrhythmia: SSS or conduction abnormality -> recurrent syncope (when

HR < 30). Prolonged QRS suggests this (vs. prolonged QT ->
tachyarrhythmia).

CREST Syndome: calcinosis cutis (deposition of calcium in skin that manifests

as nodules that may ulcerate and drain chalky material), Raynauds (white,
blue, red), esophageal dysmotility (food stuck, GERD), sclerodactyly (fibrosis
of skin distal to MCP joint -> shiny appearance, flexion contractures, joint
pain), telangiectasias (mat like patches on face/palms). Limited form of
systemic sclerosis.

PE: proximal deep leg veins (iliac, femoral, popliteal) are MC source of
symptomatic PE. Calf, renal, pelvic, upper extremity, and right heart are also
possible locations.
 Ulcerative Colitis: most likely in a patient with subacute to chronic
presentation of abdominal pain, tenesmus, bloody diarrhea. If symptoms are
worsening, with signs of sepsis, toxic megacolon should be investigated with x
ray.

Carcinoid Syndrome: classic triad of flushing, diarrhea, wheezing. Tumors are

in SI, appendix, colon, bronchi. Serotonin causes vasodilation. May also have
abdominal pain, heart palpitations, hypotension. Surgery to treat. If cannot be
removed, use octreotide. Plaques of fibrous tissue can deposit on
endocardium of right heart.

Nasal Polyps: chronic rhinosinusitis, asthma, ASA/NSAID induced

bronchospasm (aspirin exacerbated respiratory disease, AERD). Symptoms of
bilateral nasal obstruction, nasal discharge, anosmia. Bilateral gray glistening
mucoid masses in nose.

Diffuse Esophageal Spasm: spontaneous pain, odynophagia for hot and cold
foods. Nitrates and CCB also alleviate chest pain. Do esophageal manometry
to show repetitive, non-peristaltic, high amplitude contractions spontaneously
or after ergonovine stimulation.

CLL: MC type of leukemia in western countries. Older patients with incidental

lymphocytosis. Lymphadenopathy, infections (low IgG), small over mature
lymphocytes, smudge cells. Do LN biopsy to confirm.

Pituitary Tumor: prolactinoma is the MC and present with galactorrhea and

hypogonadism. Others: somatotroph, corticotroph, thyrotroph, gonadotroph,
craniopharyngioma. Due to rich blood supply, it is susceptible to metastases.

Hypothyroidism: important cause of reversible change in memory and

mentation. Accompanied with weight gain, fatigue, constipation, hoarseness.

Triptans: pregnancy testing should always be done in women of reproductive

age. It is a CI. Other CI: familial hemiplegic migraine, uncontrolled HTN, CAD,
Prinzmetals angina, ischemic stroke, basilar migraine.

Aspergillosis: occurs in immunocompromised patients with fever, cough,

dyspnea, hemoptysis. CXR shows cavitary lesion, CT shows nodules with halo
sign or lesions with air cresecent.

Leprosy: suspect in Asian patient with insensate hypopigmented patch of skin

caused by Mycobacterium leprae. Peripheral nerve damage -> muscle
atrophy. Diagnosis made by acid fast bacilli on skin biopsy.

Lymphadenopathy: small (< 1 cm) cervical LN are common in children and

young adults. Asymptomatic soft LN can be observed. MC due to URI.
Malignant/granulomatous disease are hard and immobile, > 2 cm. Fevers,
chills, weight loss, enlarging are worrisome. In older smoker -> metastatic or
oropharyngeal cancer.

Mycoplasma Pneumonia: atypical with indolent course, non productive cough,

and higher likelihood of extrapulmonary manifestations. CXR out of proportion
to PE. Erythema multiforme (dusky red target lesions over extremities). No cell
wall = no stain. Only PMN in sputum. MCC of atypical pneumonia.
 Respiratory Alkalosis: increased pH with primary decrease in PaCO2.
Commonly due to hyperventilation due to pneumonia, high altitude, salicylate
intoxication. Bicarbonate will decrease slowly due to renal compensation.

Spinal Stenosis: MC caused by degenerative disk disease with low back and
leg pain. Also called neurogenic claudication. Pain worse with walking, but leg
pain is position dependent and persists when standing still. Claudication is
exertion dependent. Diagnosed by MRI. Treated conservatively or with
laminectomy.

Community Acquired Pneumonia: levofloxacin or moxifloxacin are first choice

for inpatient treatment. Azithromycin or doxycycline for outpatient.
Pneumonia Severity Index determines inpatient vs. outpatient. MCC is
pneumococcus. Also H flu and Moraxella.

Diphenhydramine Overdose: antihistamine effects of drowsiness, confusion,

and anticholinergic effects like dry mouth, dilated pupils, blurred vision,
decreased bowel sounds, urinary retention. Physostigmine (cholinesterase
inhibitor) can help reverse.

Open Angle Glaucoma: more common in AA and is asymptomatic in the

beginning. Gradual loss of peripheral vision -> tunnel vision. High IOP, optic
disc cupping. Do annual eye exams. Use timolol drops initially. Then can do
laser or surgical trabeculectomy.

TTP HUS: unexplained normocytic hemolytic anemia with reticulocyte

response and thrombocytopenia in patient with renal failure and neurological
symptoms. HIV increases risk (but causes FSGS independently). Fever does
not have to be present. MAHA can occur in DIC (abnormal coagulation) and
malignant hypertension (high BP and retinopathy).

CHF: low CO -> increased pulmonary vascular pressure -> transduction of

fluid into air spaces -> edema and effusion -> absence of lung sounds,
dullness to percussion.

Pagets Disease: osteoclast dysfunction & compensatory bone formation ->

mosaic bone pattern, high ALP, femoral bowing. Bone, joint pain, skeletal
deformities, hearing loss (CN VIII trapping), increasing hat size are common.
Can have fractures and osteosarcoma.

Mitral Stenosis: atrial fibrillation, signs of pulmonary edema. Rheumatic fever

is MCC. Due to strep pyogenes infection, common in countries without
antibiotics. Presents during pregnancy due to increased intravascular volume.
Have diastolic rumble and opening snap.

Acid Base Status: pH and PaCO2 are best values to determine status. HCO3 is
calculated from Henderson-Hasselbalch equation. pKa of CO2/HCO3 pair is
6.1.

Ventricular Free Wall Rupture: occurs during remodeling post MI. MC presents
3-7 days after (along with papillary muscle rupture), upto 2 weeks. Rapid
onset PEA is a result of tamponade -> shock -> sinus tachycardia. Do
pericardiocentesis.
 Drug Induced Pancreatitis: usually mild. CT is diagnostic. Diuretics
(furosemide, thiazides), IBD (sulfazalazine, 5 ASA), immunosuppressants
(azathioprine, L-asparaginase), seizures or bipolar (valproic acid), AIDS
(didanosine, pentamidine), antibiotics (metronidazole, tetracycline).

MI: ischemia -> diastolic dysfunction and stiff LV -> atrial gallop (S4).

Vasovagal Syncope: also called neurocardiogenic, due to excessive vagal tone.

Preceded by nausea, diaphoresis, tachycardia, pallor. Pain, stress, situations
with needles and urination can precipitate. Common in young women.
Diagnosed with tilt table test.

Parvovirus B19: arthritis of MCP, PIP, wrist, ankle joints. Anti-B19 IgM is
diagnostic. Frequent contact with children is diagnostic. MCC of viral arthritis
(polyarticular and symmetric), also HIV, hepatitis, rubella. May not have other
symptoms, resolve in 2 months.

Wernickes Encephalopathy: patients with acute delerium or acute ataxia,

especially in low BMI or alcoholism. Other treatments for acute delerium:
dextrose for hypoglycemia (thiamine before), oxygen for hypoxia, naloxone for
opiate overdose.

Primidone: anticonvulsant used to treat essential tremor. Can precipitate

acute intermittent porphyria -> abdominal pain, neurologic, psychiatric
abnormalities. Diagnosed by checking urine porphobilinogen.

Adrenal Tuberculosis: clinical features of adrenal insufficiency and

calcifications in adrenal glands. MCC of primary insufficiency in developing
countries. Autoimmune is MCC in developed countries. Fungal, CMV are other
causes. Treatment of TB does not help adrenal. Need lifelong glucocorticoid
and mineralocorticoid treatment.

Acute Iron Intoxication: 5 phases: GI phase (30min-6hrs) of direct mucosal

damage, latent phase (6-24hrs) is asymptomatic, shock and acidosis (6-
72hrs), hepatotoxicity (12-96hrs), obstruction (several weeks) due to scarring.
Serum iron to diagnose (usually > 350 mcg/dL).

Airway Obstruction: always rule out first with sudden onset SOB. Will have
dyspnea, difficulty swallowing, may have history of food allergies, urticaria,
laryngeal edema. May have stridor and harsh respiratory sounds.

Atrial Fibrillation: MC chronic arrhythmia in adults, irregularly irregular with

rapid heart rate. Need rhythm/rate control and anticoagulation.

Flash Pulmonary Edema: usually due to acute heart failure (MI). Use diuretic
such as furosemide -> decreases preload and venodilates. Beta blockers are
CI because they can worsen heart failure. Also give morphine, nitrates,
oxygen, PTCA/thrombolysis, anticoagulation.

Lower Extremity Edema: venous hypertension (not likely in dehydrated

patient), lymphatic obstruction (with history of lymphadenectomy,
lymphadenopathy, lymphangitis), capillary leak (will have hemosideran
depisition), trauma, infection. In malnourished patient, decreased oncotic
pressure -> edema.
 Thyroid Cancer: MC is papillary carcinoma and has best prognosis. Papillary,
follicular, and anaplastic all arise from follicular/epithelial cells. History of
radiation and family history are important risk factors. More common in
women.

Compression Fracture: occur with decreased bone mineralization and density.

Diagnosing underlying cause is important in decreasing risk of future
fractures.

Bartters Syndrome: hypokalemia, urine chloride > 20, metabolic alkalosis,

normal BP. Have polyuria, polydipsia, growth & mental retardation. Defective
sodium and chloride reabsorption in LOH -> hypovolemia and activation of
RAAS -> K and H excretion.

Metformin: causes lactic acidosis (which is potentiated by renal failure) and

should be discontinued in setting of renal failure, hepatic failure, sepsis.

PAC: premature activation of atria from ectopic source. Early P wave, single or
bigeminy. Can cause palpitations. Can result in SVT. Treatment needed if cause
distress or SVT. Tobacco, alcohol, caffeine, stress can all precipitate. Beta
blockers are helpful in symptomatic patients.

Interstitial Nephritis: cephalosporins, PCNs, sulfonamides, NSAIDs, rifampin,

phenytoin, allopurinol. Can have fever and rash. Discontinue offending agent.

Gluconeogenesis: main substrates are alanine, lactate, and glycerol-3-

phosphate. Pyruvate is an intermediate of alanine during the process (via
ALT).

Orthostatic Hypotension: postural decrease in BP by 20 mmHg systolic or 10

mmHg diastolic. Due to inefficient constriction of resistance and capacitance
vessels in LE due to defect in reflexes, medications, low volume state. Arterial
stiffness, decreased NE content of nerve endings, and decreased myocardial
sensitivity contribute.

Prerenal ARF: due to insufficienct arterial perfusion (dehydration). Reversible

with fluids, but prolonged hypoperfusion -> renal failure due to ischemia.
Elderly at greatest risk. Worse with ACE, diuretics, NSAIDs which blunt
response to low volume.

Insulinoma: classic symptoms of hypoglycemia. MC pancreatic tumor. Have

high insulin and high C peptide. Whipple Triad: episodic hypoglycemia,
temporary CNS dysfunction, reversal of CNS abnormalities by glucose
administration.

Pericardial Effusion: enlarged, water bottle shaped cardiac silhouette.

Diminished heart sounds, difficult to palpate PMI.

Anserine Bursitis: localized pain over the anterior medial tibial plateau just
below the medial joint line. Valgus stress and x rays are normal. Can be
caused by abnormal gait, overuse, trauma. Pain may present overnight. Rest,
ice, steroid injections.

Iron Poisoning: disrupts basic cell processes (free radial and lipid peroxiation)
-> hematemesis, abdominal pain, shock, metabolic acidosis. Occurs in
 children of pregnant mothers (supplements are brightly colored). Treat with
deferoxamine which binds iron and allows urinary excretion.

Secondary Amyloidosis (AA): result of chronic systemic inflammation with AI,

chronic infections, IVDA, psoriasis, IBD. Causes nephrotic and palpable
kidneys, hepatomegaly, cardiomyopathy, pseudohypertrophy, peripheral
neuropathy. Proteins deposit as beta pleated sheets in tissue.

New Drugs: if prolongs survival, incidence does not change, prevalence

increases.

Water Disturbances: DI: polyuria, polydipsia, excretion of dilute urine with

elevated serum osmolarity. Primary polydipsia: excessive water drinking, both
plasma and urine are dilute. SIADH: hyponatremia, serum dilute, urine very
concentrated.

MI: strongest influence on long term prognosis of STEMI is duration that

passes before blood flow is restored via PTCA or fibrinolysis. PTCA is choice
treatment and should be done within 90 minutes. Fibrinolysis should be done
within 30 minutes.

Corrected Calcium: 0.8 (4 measured albumin) + measured calcium. Suspect

in patients with liver disease.

Polycythemia Vera: increased RBC mass and totcal circulating volume. Old
male with pruritis after bathing. Hyperviscosity symptoms. Thrombosis and
bleeding due to elevated platelet count and low functionality. Reversible
moderate HTN. Granulocytosis, splenomegaly, hypercelluar bone marrow,
elevated LAP, normal O2 saturation. Low serum/urine erythropoietin.

Cutaneous Larva Migrans: common in travelers to tropical regions. Have

pruritic, elevated, serpiginous, brown-red lesions on the skin which elongate.
Infection often acquired by contact with sand. Caused by dog and cat
hookworm and infection occurs by contact with feces.

SIADH: euvolemic hyponatremia, decreased serum osmolarity, elevated urine

osmolarity (> serum), high urine sodium, failure to correct with NS.

Non Alcoholic Steatohepatitis: RF are obesity, DM, hyperlipidemia, TPN, use of

certain medications (steroids, amiodarone, diltiazem, tamoxifen, HAART).
Impaired responsiveness of fat cells to insulin -> steatosis -> steatohepatitis
-> fibrosis due to lipid peroxidation and oxidative stress. Mild ALP elevation,
AST/ALT < 1. Control underlying condition. UDCA helps decrease transaminase
levels.

Arrhythmia: sudden onset syncope without warning, presence of heart disease

(post infarction, ectopic beats. Diuretics -> electrolyte abnormalities ->
arrhythmia. Clonic jerks can occur due to brain hypoxia.

G6PD Deficiency: XLR common in AA men. Episodic hemolysis in response to

oxidant drugs, infections, fava beans. Heinz bodies seen on blood smear.
G6PD needed to make NADPH to make glutathione to prevent Hgb oxidation.
Otherwise denatures into Heinz bodies -> disrupts RBC membranes ->
hemolysis.
 PE: common cause of pleuritic chest pain. Young person with tachycardia,
dyspnea particularly if on OCP. Will have subsequent minor or massive
infarction.

CLL: see smudge cells on smear with small mature lymphocytes. Can have
splenomegaly, anemia, thrombocytopenia (associated with poor prognosis).

Allergic Contact Dermatitis: can be due to exposure to toxic plants, appear in

linear fashion -> edema, vesiculation, erosion with weeping drainage. Type IV
cell mediated hypersensitivity.

Lateral Epicondylitis: pain with supination or extension of the wrist and point
tenderness just distal to the lateral epicondyle. Due to repeated forceful wrist
extension and supination (tennis, screwdriver) from degeneration of extensor
carpi radialis tendon.

Septic Shock: distributive shock due to vasodilation. Hyperdynamic

circulation and elevated CO. Normal MVo2 due to hyperdynamic circulation
and improper distribution of CO. Indicates not normal tissue perfusion! Also
have low RAP and PCWP.

Psoriatic Arthritis: usually involves DIP joints. Morning stiffness, deformity,

dactylitis (sausage digit), nail involement. NSAIDs, anti-TNF, methotrexate.
Steroids are CI. Can also see classic psoriasis lesions on hands (red plaques
with silvery scale).

Klebsiella: encapsulated, G(-) bacillus that can cause pneumonia in subjects

with debilitating conditions such as alcoholics. Also called Friedlanders
pneumonia usually affects upper lobe and has currant jelly sputum. Usually
due to microaspiration. G(-) pneumonia more common in infants, elderly,
alcoholics, immunocompromised. Grows as mucoid colonies.

Cardiac Tamponade: deadly consequence of aortic dissection. Hypotension,

tachycardia, heart failure. Blood impairs filling -> decreased preload and CO.
Syncope from decreased cerebral blood flow. Pulsus paradoxus: disappearance
of pulse on inspiration.

Pseudogout: acute inflammatory arthritis due to CPPD crystals which are

rhomboid shaped and (+) birefringent. Also have radiographic evidence of
chondrocalcinosis (calcified cartilage releases crystals). Occurs during recent
surgery or medical illness.

Nocardia: filamentous, aerobic, G(+) soil bacterium that is partially acid fast
and causes pulmonary or disseminated disease in immunocompromised hosts.
Treat with TMP-SMX. Can be confused with TB or Actinomyces. Have cough
with purulent sputum. Can have alveolar infiltrates with nodules and
cavitation. Can have SQ or brain abscesses.

Beta Blocker Overdose: AV block, bradycardia, hypotension, wheezing,

potential cardiogenic shock. Treat with atropine and IVF, if not, treat with
glucagon -> increased cAMP and higher calcium levels -> cardiac contractility
augmentation.
 G6PD Deficiency: acute hemolysis after ingesting primaquine or sulfa drugs.
G6PD activity is normal during acute hemolytic episode. Smear reveals bite
cells.

Febrile Neutropenia: medical emergency with single temperature > 38.3/101.3

or > 38/100.4 for 4 hours in neutropenic patient. ANC < 500. Chemotherapy
-> impaired immune function & disruption of skin/mucosal barrier. Seen in GIT
and are usually G(-) and Pseudomonas. Take blood cultures and start 3 rd or 4th
generation cephalosporin (ceftazidime or cefepime).

Brain Death: total loss of brain function and legally acceptable as definition of
death. Absent CN reflexes, fixed dilated pupils, no spontaneous breaths.
Confirm with another physician first.

SLE: pancytopenia is common. Occurs due to formation of autoantibodies

against blood cells (Type II hypersensitivity). Anemia due to autoimmune
hemolysis due to warm IgG Ab against RBCs. Thrombocytopenia is ITP like.
Neutropenia is less common.

Central Hypogonadism: low testosterone and low or inappropriately normal

FSH/LH. Uncontrolled diabetes -> low GnRH. With well controlled diabetes,
measure prolactin which inhibits GnRH release (possible pituitary adenoma).

Molluscum Contagiosum: multiple dome shaped lesions with central

umbilication caused by pox virus. Opportunistic skin infection in HIV infected
patients but can occur in normal individuals. Occurs with CD4 < 100.
Conjunctivitis can occur if lid margins are involved.

Parkinsons Disease: resting tremor that improves with activity is often

presenting symptom. Usually starts in one hand and then involves all
extremities. Loss of DA neurons in basal ganglia that causes tetrad of rigidity,
tremor, bradykinesia, postural instability. Tremor will not involve entire head,
unlike essential and cerebellar tremors.

Pseudodementia: suspect in elderly patients with dementia in setting of

severe depression. Treat with antidepressants.

Herpetic Whitlow: common viral infection of the hand caused by HSV 1 or 2.

Self limiting. Health care workers that come into contact with orotracheal
secretions (dentists) are increased risk. Seen also in women with genital
herpes or children with herpetic gingivostomatitis. Throbbing pain in pulp
space, (+) exposure history, multinucleated giant cells on Tzank smear.

PE: CXR is normal in most cases. Sinus tachycardia is MC EKG finding.

Tophaceous Gout: urate crystals can deposit in skin resulting in formation of

chalky white tumors. Starts with asymptomatic hyperuricemia ->
monoarticular arthritis, podagra (great toe), nephrolithiasis of uric acid stones.
Tophi can ulcerate and drain chalky material. Can be seen in RA and
calcinosis. Diuretics are RF due to hypovolemia associated uric acid
reabsorption.

G6PD Deficiency: can have positive Prussian blue stain in urine due to
hemosiderin due to hemolysis. Attacks precipitated by sulfa drugs,
antimalarials, nitrofurantoin.
 Addisons Disease: aldosterone deficiency -> non anion gap hyperkalemic
hyponatremic metabolic acidosis. Can be caused by TB -> adrenals. Histo,
coccidio, crypto, sarcoid can also cause. Normally, aldosterone reabsorbs Na
for K/H. If deficienct, holds on to K/H.

3rd Degree Heart Block: complete independence of P waves from QRS. Needs
pacemaker placement due to risk of VT or VF. QRS usually > 120 msec. V rate
is usually low -> dizziness and hypotension.

Aortic Dissection: pregnancy is associated due to connective tissue changes.

Bicuspid valve, Marfans, coarctation are also risks. If HTN is present, must be
controlled before any other studies are done. ECG changes due to
involvement of ostia (usually RCA) -> inferior ischemia.

TIA: cerebral ischemia -> focal neurological dysfunction < 24 hours. Always do
head CT to distinguish ischemia from bleed. If thrombosis is suspected, give
antiplatelet agent (ASA). Warfarin good for cardiogenic emboli. Treatment is
important due to high risk of another.

Sleep Apnea: morbidly obese middle aged man with daytime sleepiness,
morning HA, increased fatigability and snoring. Can see mild HTN which
improves with treatment. Treat with weight reduction, avoid sedatives/alcohol,
avoid supine sleeping as first step. CPAP and UPPP also help.

Ankylosing Spondylitis: seronegative spondyloarthropathy that affects men <

40. Classically back pain is worse in morning and gets better during day. Low
back pain and stiffness that limits back motion and chest expansion. Also
have arthritis of peripheral joints and uveitis. X ray shows SI inflammation.
Elevated ESR, negative RF, associated with HLA-B27. Anti-TNF used for
treatment.

Hypercalcemia of Malignancy: due to osteolytic metastases, increased

production of PTHrP, increased Vit D production, increased IL-6. Usually have
low PTH levels. Higher calcium than in hyperparathyroid. MCC of
hypercalcemia in inpatients.

Asymptomatic Thrombocytopenia: presenting symptom of HIV in upto 10% of

people. May have a history of travel -> possible multiple sexual partners.

Mammogram: perform every 2 years starting at age 50 with average risk, and
not beyond 75. SBE is no longer emphasized.

Cholesterol Screening: age 35 in men, 45 in women in those with average risk.

Yield decreases in the elderly. Check every 5 years in patients with normal risk
and previously normal lipids.

Acute Pyelonephritis: present with fever, chills, nausea, vomiting,

flank/suprapubic/ costovertebral angle tenderness. Require hospitilization and
IV antibiotics for complicated cases like with hypotension.

Atrial Fibrillation: patients are at risk for strokes and need anticoagulation.
With no other RF, use ASA. With CHF, HTN, age > 75, DM, previous stroke/TIA,
valvular disease, use warfarin.
 ED: in the setting of pelvic fractures with urethral injuries, usually caused by
parasympathetic nerve injury and altered arteral supply. Failure to achieve
erections during sleep (REM) and morning is pathognomonic. Venogenic can
occur after penile fracture. Sysetmic can be due to low testosterone or high
prolactin.

Nephrotic Syndrome: membranous is the most common associated with

malignancy. MCD is a common association with Hodgkins lymphoma, but can
also see FSGS. Will resolve with lymphoma treatment.

Angiofibroma: male adolescent with epistaxis, localized mass, bony erosion on

back of nose. Usually found in nose or nasopharynx. Only treated by
specialists. Sometimes no treatment is needed. If enlarging, obstructing the
airway, frequent epistaxis -> removal, but high recurrence.

Sarcoid: presents in black females with hilar LA presenting with dyspnea,

fever, weight loss. High association with erythema nodosum (painful skin
lesions on the shins). Non caseating granulomas on biopsy, serum Ca and ACE
are elevated. Treat with steroids.

Metabolic Acidosis: always calculate AG [Na (Cl+HCO3)] to narrow DD.

Normal is 6-12. Increase means there is an accumulation of non chloride acids
-> lactic acidosis, ketoacidosis, methanol ingestion (formic acid), ethylene
glycol (oxalic and glycolic acid), salicylates, uremia (NH4).

Cataract: vision impairing disease characterized by blurred vision and glare

(night driving) due to lens thickening. Oxidative damage occurs with aging.
Treat with lens extraction. Will have loss of transparency of the lens.

Nail Puncture Wound: if results in osteomyelitis in an adult, likely

Pseudomonas, especially through rubber sole. Do blood culture or bone
biopsy. Treat with IV quinolones and surgical debridement. Staph aureus is
MCC of regular osteomyelitis in children and adults. Tetanus does not cause
osteomyelitis.

SBP: can have subtle presentation and should be considered in cirrhotic

patients with ascites and fever/mental status changes. TOC is paracentesis
(before antibiotics) with (+) culture and > 250 PMNs. Abdominal pain is often
less prominent. E coli and Klebsiella are common. Give 3rd generation
cephalosporin.

Thyroid Nodule: first step in management is TSH level.

Chronic Hepatitis C: can cause membranoproliferative (or membranous) GN

characterized by proteinuria. Can cause cryoglobulins, B-cell lymphoma,
plasmacytomas, AI disease, lichen planus, porphyria cutanea tarda, ITP.

Alzheimers Disease: MCC of dementia in US. Early signs are visuospatial

defetcs (getting lost in neighborhood) and anterograde memory loss.
Personality and behavior changes may occur as disease goes on.
Hallucinations, change in alertness, gait impairment, urinary incontinence are
late findings.
 X Linked Hypophosphatemic Rickets: suspect in patients with rickets with
normal calcium, ALP, PTH, 25 vitamin D. Have low phosphate due to renal
wasting. May be deficit in 1 hydroxylase and can have low calcitriol.

Hypercalcemia of Immobilization: prolonged rest -> accelerated bone

resorption likely due to osteoclastic activation. Usually occurs within days,
upto weeks. Develop severe osteopenia, and bisphosphanates decrease
osteoclast activity and reduce risk of osteopenia. Renal failure usually ->
hypocalcemia due to binding of phopsphate.

Wilsons Disease: AR, also called hepatolenticular degeneration. Low

formation and secretion of ceruloplasmin and low secretion of copper in biliary
system. Causes free radical formation. Likely in patient < 30 with unexplained
chronic hepatitis. Low ceruloplasmin, increased copper excretion, and Kayser-
Fleisher rings are diagnostic. Have neuropsychiatric symptoms due to
deposition in basal ganglia. Treat with d-penicillamine, trientene to chelate
copper. Zinc also prevents copper absorption. Can have liver transplantation.

Multiple Sclerosis: female with recurrent attacks of focal neurological

dysfunction with non-predictable time intervals. Focal demyelination usually in
periventricular or subpial white matter of cerebrum, optic nerves, brain stem,
spinal cord. Do MRI to diagnose.

Steatorrhea: diarrhea secondary to fat malabsorption -> pale, malodorous,

voluminous stools that are difficult to flush. If accompanied with epigastric
pain -> chronic pancreatitis (alcohol is MCC). Do 72 hour quantitative fecal fat
to diagnose. Can have glucose intolerance. CT can show calcifications and
ductal dilation.

Schilling Test: differentiates dietary deficiency from pernicious anemia. Dietery

deficiency: oral radiolabeled B12 is absorbed in gut and excreted in urine in
normal amounts. Diminished excretion -> impaired absoroption. Give next
dose with IF. Normal excretion = pernicious anemia. Low excretion = short
gut, pancreatic insufficiency, bacterial overgrowth.

Steroids: cause neutrophilia by increasing bone marrow release and

demarginating neutrophil pool. Eosinophils and lymphocytes are decreased.

Cryptosporidium: major cause of chronic diarrhea in HIV patients with CD4 <
180. Modified acid fast stain of stool shows oocysts. Can occur in
immunocompetent and HIV with CD4 > 180 but is self-limited.

ESRD: treatment options are transplant or dialysis. Renal transplant has better
survival rates and QoL. Living related > living non-related > cadaver. Anemia,
bone disease, HTN persist with dialysis. Transplant patients have better return
to normal function. Autonomic neuropathy is worse with dialysis. Survival 95%
at 1 year, 88% at 2 years.

Hypertrophic Pulmonary Osteoarthropathy: clubbing and sudden onset

arthropathy in a chronic smoker or other pulmonary disease (cancer, TB,
bronchiectasis, emphysema). Associated with lung cancer, do a CXR to rule
out or look for other pathology.

DKA: causes anion gap metabolic acidosis. Have polyuria, polydipsia, nausea,
vomiting, abdominal pain that may present like surgical abdomen.
 Graft vs Host Disease: common after bone marrow transplant. Caused by
recognition of major and minor MHC by donor T lymphocytes and cell
mediated immune response. Affects skin (maculopapular rash on palms, soles,
face), intestine (bloody diarrhea), liver (abnormal LFTs and jaundice).

H1 Antihistamines: decrease nasal inflammation and PND (dry cough) in

patients with allergic rhinitis by blocking nasal secretions. Chlophenirimine
blocks H1 receptors and is anti-inflammatory blocking histamine release from
mast cells.

Cerebellar Tumors: ipsilateral ataxia, nystagmus, intention tremor, loss of

coordination, ipsilateral muscular hypotonia, difficulty performing rapid
alternating movements. Fall towards side of lesion. Sway to affected side.
Obstruction of CSF -> HA, nausea, vomiting, papilledema.

Central Retinal Artery Occlusion: painless loss of monocular vision due to

embolism. Ophthalmic artery is first intracranial branch of ICA -> CRA and
ciliary branches to the anterior globe and choroid. Associated with amaurosis
fugax before occlusion. May have retinal whitening or cherry red spots. Treat
with high flow O2 and ocular massage.

Dacryocystitis: inflammatory changes at medial canthus, infection of the

lacrimal sac. Occurs in infants or > 40. Staph aureus and beta hemolytic strep
are MCC. Responds to systemic antibiotics.

Aspiration Pneumonia: consider in patient with recurrent pneumonias, usually

due to excessive alcohol intake. Foul smelling sputum and RLL pneumonia.
Also occurs in altered consciousness, dysphagia, neurological disorders,
sedation.

Factitious Thyrotoxicosis: ingestion of exogenous thyroid hormone. Have signs

or symptoms of hyperthyroid but no goiter or exophthalmos. TFT shows low
TSH, high T3 and T4. Diffusely decreased radioiodine uptake. Biopsy shows
follicular atrophy. Consider in patient trying to lose weight, psychiatric disease,
low BMI.

DKA: teenager presenting with metabolic acidosis, polyuria, dehydration,

decreased consciousness, abdominal pain in setting of ongoing infection
(releases cortisol and catecholamines which are anti-insulin). Excess glucagon
-> hyperglycemia, ketonemia, osmotic diuresis -> loss of potassium stores
even with normal/high serum K. Acidosis and low insulin pushes K into
extracellular fluid.

DM: fasting blood glucose is MC screening test. Diagnosis requires 2 separate

FBG measurements > 126.

Pernicious Anemia: MCC B12 deficiency -> macrocytic anemia, glossitis,

peripheral neuropathy. Anti-intrinsic factor decreases absorption, also develop
chronic atrophic gastritis -> increased risk of intestinal type cancer and
carcinoid tumors by 2-3x. Period FOBT for cancer is needed.

Heat Stroke: defined as temperature > 105. Exertional type occurs in healthy
individuals exercising in extreme heat. Dehydration, hypotension, tachycardia,
tachypnea. Seizures, ARDS, DIC, hepatic/renal failure may also occur. High
 humidity may prevent sweating, can be exacerabated by medications with
anticholinergic activity.

Dejerine Roussy Syndrome: thalamic stroke. Usually VPL thalamus which

transmits sensory information from contralateral side of body. Contralateral
hemianesthesia with transient hemiparesis, athetosis, ballistic movements.
Severe dysesthesia (thalamic pain) is common.

OA: non-inflammatory arthritis presenting with pain worse with activity

improved with rest X rays show joint space narrowing and osteophytes.
Synovial fluid analysis shows WBC < 2000, no organisms, no crystals.
Increasing age is leading RF. Morning stiffness < 30 minutes.

Chronic Hepatitis B: elevated ALT, detectable HBsAg, HBeAg, and HBV DNA
should be treated with interferon and lamivudine. Degree of ALT elevation
indicates response to medication. ALT 2x normal is likely to respond versus
normal ALT. Lamivudine is oral and has less SE.

Loop Diuretics: cause reversible or permanent hearing loss or tinnitus.

Typically occur in those taking high dose, those with renal failure, or patients
taking other ototoxic drugs (aminoglycosides, chemotherapy, ASA).

Neonatal Hepatitis: newborns of mothers with active HIV infection should be

passively immunized with HBIG followed by active immunization with the
recombinant HBV vaccine. Common in infections during 3 rd TM. Higher with
HBeAg(+), high chance of chronic hepatitis.

Nocardia: crooked, branching, beaded, G(+), partially acid fast filaments on

microscopy. Treat with TMP-SMX (prophylaxis too). Minocycline is alternative.
Present in soil, causes pulmonary, CNS, skin infections. Deficiency cell
immunity at high risk. Usually starts as subacute pneumonia.

Amebic Liver Abscess: contain debris described as anchovy paste, but cyst
aspiration is not recommended. Treatment is oral metronidazole. Recent
immigration, RUQ pain, tender solitary abscess. Caused by Entamoeba
histolytica, can cause dysentery, brain, cardiac, pulmonary involvement. CT or
MRI plus leukocytosis and elevated ALP. Also serum testing.

Primary Hyperparathyroidism: MCC hypercalcemia in ambulatory patients.

Usually asymptomatic and found on routine screening. Usually solitary
adenoma. Could be hyperplasia, multiple adenomas, cancer. May have stones
and low bone density.

Correlation Coefficient: shows the strength and direction of a linear

association between two variables and does not imply causality.

Respiratory Acidosis: acidosis with hypercarbia and normal/elevated

bicarbonate. Hypoventilation is a major cause, especially in the post-ictal
state (could be due to aspiration). Can also have hypoxia.

Lupus Anticoagulant: also called anti-phospholipid antibody. Prothrombotic Ab

that causes a long PTT. Present with VTE and lupus symptoms, previous
miscarriages. IgM or IgG that binds to phospholipids used in assay (laboratory
effect). Will not correct on mixing study. Russell viper venom test is prolonged.
 Sarcoidosis: MC in AA women during 3rd or 4th decades. Lungs are MC affected.
Cough, erythema nodosum, anterior uveitis (red eye with leukocytes in
anterior chamber), arthritis. Hilar LA and reticular opacities on CXR.

Microcytic Anemia: iron studies are always indicated. Useful in diagnosis of

iron deficiency as the cause. Thalssemia (normal to high iron and ferritin), ACD
(low TIBC, normal or high ferritin), sideroblastic (normal to high iron and
ferritin) are also causes.

Pneumococcal Vaccine: 23 valent capsule polysaccharide pneumococcal

vaccine induces a T cell independent B cell response. Recommended over 65,
infants/young children, < 65 with heart failure, renal failure, cirrhosis, chronic
lung disease. Polysaccharides cannot be presented to T cells, only peptides.

DEXA scan: USPSTF recommends one time screening for all women > 65, > 60
with RF. T score compared to younger individual of same gender and race. -1.5
to -2.5 is osteopenia, < -2.5 is osteoporosis. High risk in post menopausal
women.

Diabetic Neuropathy: TCAs are DOC. Can worsen urinary symptoms and
cause orthostatic hypotension. Gabapentin is the alternative. Usually present
at rest and worse at night. As it progresses, pain subsides and disappears,
whereas sensory deficit stays. Small fiber is more pain and allodynia, large
fiber is more sensory loss, low proproceiption, no ankle jerk.

Dysphagia: do a barium esophagram first before endoscopy. Dysphagia for

liquids and solids suggets a motility disorder whereas obstruction presents
with solid dysphagia -> progresses. Barium study is safer in those with upper
esophageal lesions or stricture.

Condyloma Acuminata: verrucous, papilliform anogentical lesions that are skin

colored or pink versus condyloma lata which are flat and velvety. Treat with
chemical/physical agents (tricholoacetic acid, 5FU epinephrine gel,
podophyllin), immune therapy (imiquimod, interferon alpha), surgery
(cryosurgery, excision, laser).

Neonatal Conjunctivitis: chemical is usually mild and due to prophylactic silver

nitrate drops. Gonococcal is purulent copious drainage 3-5 days after birth.
Chlamydial is milder and is > 5 days after birth. Gonococcal -> contact with
infected secretions -> ulceration and blindness. Can do stain and culture on
Thayer Martin agar.

Primary Hyperaldosteronism: persistently elevated BP, hypokalemia,

metabolic alkalosis, mild hypernatremia, low renin, absent edema. Increased
salt and water retetion with aldosterone escape and natriuresis.

Acute Pericarditis: typically occurs in first several days after an MI. Sharp
pleuritic pain worse when lying down and better when sitting up and leaning
forward. Diffuse ST elevations with PR depression is common. Friction rub may
be heard.

Bacillary Angiomatosis: Bartonella is the cause in immunocompromised

individuals. Present with cutaneous and visceral angioma like blood vessel
growths. Antibiotics lead to regression.
 Whipples Disease: multisystem disorder caused by G(+) bacillus, Tropheryma
whippelli. Chronic malabsoptive diarrhea, migratory non deforming arthritis,
LA, low grade fever, damage to eye, CNS, myocardium. SB biopsy with PAS(+)
macrophages.

Vomiting: produces metabolic alkalosis due to unbalanced loss of H+ ions and

due to contraction alkalosis. Produces a compensatory respiratory acidosis
with hypoventiation.

Esophageal Varices: do screening endoscopy in all new diagnoses of cirrhosis

to detect varices. If detected, use beta blocker as prophylaxis to reduce
hemorrhage risk. Nitrates are sometimes added.

Hypernatremia: MCC is hypovolemia. Mild cases can be treated with D5W

NS. Severe cases should be treated with NS switched to NS. Correct at 1
mEq/L/h. Greater can cause cerebral edema.

Hyperkalemia: give IV calcium gluconate to stabilize cardiac membrane. Use

insulin, glucose, sodium bicarbonate and beta-2 agonists (albuterol) to drive K
intracellularly.

Craniopharyngiomas: benign tumors of Rathkes pouch. More common in

children and older adults. Presents with hypopituitarism -> retarded growth in
children (GH and TH deficiency) and sexual dysfunction in adults
(amenorrhea). Have bitemporal hemianopsia and HA. Treat with surgery or
radiotherapy.

Alpha 1 Antitrypsin Deficiency: non smoking adults < 45 years old with pan
lobular emphysema (centrilobular in smoking). Causes liver disease (may
present as neonatal hepatitis, cirrhosis, liver failure). Measure serum A1AT.

SAH: vasospasm is major cause of M&M. CCB (nifedipine) are used to prevent
vasospasm. Signs of ischemia appear 7 days after bleed.

Postictal Lactic Acidosis: transient anion gap metabolic acidosis that resolves
without treatment after 60 to 90 minutes after cessation of seizure activity.
Excess production of lactic acid and decreased hepatic uptake. Observe and
repeat chemistry panel in 2 hours.

Prolactinoma: < 10 mm is a microadenoma. Presents as amenorrhea and

galactorrhea, hypogonadism in males. Primary treatment is DA agonists such
as bromocriptime or cabergoline (better drug).

Emphysematous Cholecystitis: secondary infection of the GB wall with gas-

forming bacteria. Typically older males. RF are vascular compromise,
immunosuppression, gallstones. Complications are gangrene and perforation.
Air fluid levels in GB. Treat with fluids, electrolytes, early surgery, and
antibiotics.

Normal Aging: tiredness, occasional forgetfulness, occasional word finding

difficulty, trouble falling asleep. Dementia not diagnosed until there are
functional impairments.

Cellulitis: caused by beta hemolytic strep and Staph aureus. With systemic
signs of fever, chills, malaise, fatigue, treat with IV nafcillin or cefazolin.
 Vancomycin for MRSA. Chronic fungal foot infections serve as a nidus for
celluitis and eradicate in patients with recurrance.

Cancer Pain Management: try non-narcotic measures first unless patient is in

severe pain. Do not be afraid to give narcotics. Prescribe adequate amounts.
After NSAIDs, try short acting morphine until under control, then use long
acting patches or narcotics.

MS: patchy neurological problems, optic neuritis (painful loss of vision in one
eye with central visual defect. Do MRI to see cerebral or cerebellar plaques.

Sheehans Syndrome: postpartum failure to lactate and other features of

hormone deficiency. Other cause is lymphocytic hypophysitis.

MEN Type I: hypercalcemia/hypophosphatemia due to hyperparathyroidism,

and intractable ulcers due to ZE. May have parathyroid tumors.

Cherry Hemangioma: small red cutaneous papules. Do not regress

spontaneously and increase in number with age. Light microscopy shows
proliferation of capillaries and PCV in papillary dermis. MC benign vascular
tumor of adults.

Acanthosis Nigricans: symmetrical hyperpigmented velvety plaques in axilla,

groin, neck. Associated with DM in younger adults, and GI malignancy in older
adults. Also associated with Addisons Disease.

Hypertensive Intraparenchymal Hemorrhage: MC in basal ganglia, thalamus,

pons, cerebellum. Present initially with focal symptoms that deteriorate into
symptoms of increased ICP. Do noncontrast CT.

Precision: measurement of random error. Tighter the CI, the more precise.
Increasing sample size increases precision.

SCC: second most common non-melanoma skin cancer. Single most important
factor in development is sunlight. Have polygonal cells with atypical nuclei at
all levels of epidermis with zones of keratinization.

Endocarditis: viridans type strep (MC is strep mutans, also causes caries) is
MCC of endocarditis after dental procedures. Pre existing MS is RF. Other
viridans are mitis, sanguis, salivarius. Staph epidermidis causes prosthetic
valve endocarditis.

Cauda Equina Syndrome: serious neurological disorder characterized by

saddle anesthesia, bowel and bladder dysfunction, low back pain, variety of LE
findings. Consists of spinal nerves before they leave spinal canal. Emergent
MRI. Can be caused by trauma, lumbar disc, malignancy, abscess. Nerves
have poorly developed epineurium.

Pancreatic Pseudocyst: encapsulated area of enzyme rich fluid, tissue, debris

that accumulates in pancreas -> inflammation. Occurs in acute < chronic,
diagnosed by US, and resolves on its own. Usually a few weeks after attack.
Amylase can be high due to leakage. Drain if > 6 weeks, > 5 weeks, becomes
infected. Can erode into blood vessels.
 Diabetic Neuropathy: MC is symmetric distal polyneuropathy with classic
stocking glove distribution of sensory loss. Also mononeuropathies of CN and
peripheral nerves, proximal neuropathy, and autonomic neuropathy.

DKA: suspect in stuperous patients with rapid breathing, history of weight loss,
polydipsia, polyuria. Can be triggered by infection. Kussmauls respiration
(rapid deep breathing) due to acidosis. Measure glucose first. Then chemistry,
CBC, ABG.

COPD Exacerbation: acute worsening of symptoms in a patient with COPD.

Classically caused by URI (cough and fever). Bilateral wheezes, respiratory
acidosis and hypoxia, accessory muscle use, prolonged expiratory phase.

Diabetic Foot Ulcers: RF are diabetic neuropathy (80%), PVD, poor glycemic
control, bony abnormalities, male sex, smoking, > 10 years, history of
previous ulcer or amputation. MCC of non traumatic amputations. Will have
loss of monofilament sensation.

Drug Induced Interstitial Nephritis: caused by cephalosporins, penicillins,

sulfonamides, NSAIDs, rifampin, phenytoin, allopurinol, trimethoprim,
diuretics, captopril. Have arthralgias, rash, renal failure. UA will show
eosinophils.

Hemochromatosis: vulnerable to Listeria infections. High iron is also a RF for

infection with Yersinia enterolitica, septicemia from Vibrio vulnificans.

Dermatomyositis: proximal symmetric muscle weakness with skin rash.

Normal sensation and reflexes. Elevated CK, myopathic EMG to diagnose. Can
be paraneoplastic from lung cancer. Often manifests as muscle weakness at
different levels, determine by H&P.

AS: if severe, can have anginal CP due to increased myocardial O2 demand.

Exertional CP with systolic murmur and 2nd R ICS. In young, due to bicuspid
valve. Prolonged contraction and impaired filling due to LVH reduces CA blood
flow. Also consider HOCM.

Amebic Liver Abscess: history of travel with dysentery (bloody diarrhea) and
RUQ pain due to cyst in RIGHT lobe of liver. Caused by Entamoeba histolytica,
Primary colon infection -> portal circulation. Can be on superior surface ->
shoulder pain. Aspirate is sterile. Flagyl.

Isolated Systolic Hypertension: important cause in elderly. Caused by

decreased elasticity of arterial walls (may cause decreased diastolic BP).
Always treat. Decreased dumping by arteries -> widened pulse pressure
(important CV RF). HCTZ is DOC.

External Hordeolum: also called stye. Staph abscess of eyelid. Localized small
swelling along margin of eyelid. Use warm compresses. I&D is done if no
resolution in 48 hours.

Menieres Disease: cause of vertigo (sensation of spinning with nausea) if

patient also has sensation of ear fullness. Abnormal accumulation of
endolymph in the ear. Often have hearing loss and tinnitus. Peripheral cause.
Central vertigo lasts longer.
 Nephrotic Syndrome: heavy proteinuria (>3g/24h), hypoalbuminemia,
peripheral edema. Many cases due to systemic disease (diabetes,
amyloidosis). MCC intrinsic are MCD, membranous, FSGS (more common in
AA, obesity, heroin use, HIV).

ARDS: hypoxemia refractory to high O2 administration. Adequate oxygenation

requires PEEP (prevents collapse and reopens collapsed alveoli). High FiO2
could be used, but can cause pulmonary oxygen toxicity (below 40%
required).

Carbamazepine: used to treat atypical bipolar and trigeminal neuralgia.

Aplastic anemia can occur, follow with CBC. If medication fails, can do surgical
gangliolysis or suboccipital craniectomy.

PVCs: common in post MI patients. Even though they may indicate worse
prognosis, should not be treated unless causing symptoms (can worsen
survival). Beta blockers are first line.

ED: nocturnal penile tumescence helps differentiate psychogenic from organic

ED. Indicates intact vascular and nervous supply. (+) in psychogenic, (-) in
organic. Do sleep study or use RigiScan device.

Osteomalacia: low to low normal calcium, low phosphorus, low 25 Vit D, high
PTH (makes calcium near normal in beginning and worsens
hypophosphatemia). Have symmetrical looser zones, pseudofractures,
blurring of the spine.

Diabetic Retinopathy: background/simple (microaneurysms, hemorrhages,

exudates, retinal edema), pre-proliferative (cotton wool spots),
proliferative/malignant (new blood vessel formation). Macular edema -> vision
loss. Use photocoagulation to prevent complications. Leading cause of
blindness in USA.

Torticollis: focal dystonia involving SCM. Can occur idiopathically, but can be
medication related (typical antipsychotics, metoclopramide, procholperizine),
congenital, secondary to trauma or inflammation. Dystonia = sustained
muscle contraction -> twisting repetitive movements or abnormal posturing.

B12 Deficiency: suspect in vegetarians with anemia and neurological

complications. FA will correct anemia, but not neurological dysfunction. Also
have fatigue, weight loss, constipation, decreased appetite.

Kidney Stones: patients with recurrent hypercalciuric stones should be treated

with increased fluid intake, sodium restriction, thiazide diuretic. Calcium
restriction is not advised. Treatment of first stone is hydration and
observation.

Molluscum Contagiosum: single or multiple rounded dome shaped papules

with central umbilication caused by poxvirus. Self limited and resolves
spontaneously in immunocompetent individuals. Genital lesions should be
treated to prevent spread. Curretage and apply liquid nitrogen. Considered an
STD. Seen in AIDS with CD4 < 100.

Iron Deficiency Anemia: MCC in elderly patients is GI blood loss. Do a

colonoscopy. 1 (-) FOBT is not enough to rule out occult blood loss. Do iron
 studies to confirm. If colonoscopy is (-), do endoscopy (NSAID history, H
pylori). If (-), do capsule endoscopy.

Obesity Hypoventilation Syndrome: severe obesity (> 150% ideal body

weight), alveolar hypoventilation during wakefulness. Have hypercapnea,
hypoxia, respiratory acidosis due to decreased lung and chest wall
compliance. Weight loss, ventilator support, O2 therapy, progestins
(respiratory stimulants). Thick neck, distant heart sounds, low voltage QRS on
EKG, poor quality CXR = obesity. Respiratory wall weakness is not major
cause.

Herpes Encephalitis: MC affects temporal lobe -> bizarre behavior and

hallucinations. Abrupt onset, fever, MS changes. No meningeal signs. CSF: low
glucose, high lymphocytes). Do PCR for herpes, and start IV acyclovir
immediately.

Esophageal Adenocarcinoma: chronic GERD and Barretts are RF along with

obesity, high calorie/fat intake, smoking. Barretts has 1% per year risk of
carcinoma. Major RF for SCC are smoking and alcohol along with hot food and
drink, N-nitroso foods.

Asthma Exacerbations: use inhaled B2 agonists/anticholinergics, IV steroids.

Respiratory failure (with hypercapnea and hypoxia) and somnolence need
intubation and ventilation. CO2 retention is bad.

Hyposthenuria: impairment in kidneys ability to concentrate. Found in

patients with SCD and less commonly, SCT. AA with family history of blood
disorder. Thought to be due to RBC sickling in vasa rectae which impairs
countercurrent exchange and free water absorption.

Wenckebach: or mobitz type I. Narrow QRS, increase in PR until beat is

dropped. Benign and transient. Unless patient is symptomatic, no treatment
needed. Seen in digitalis toxicity, increased vagal tone, inferior wall MI. Pacing
may be needed.

Cluster Headache: men>women. Hypothalamic dysfunction -> alterations in

circadean pacemaker. Repetative episodes. Unilateral, sudden, severe, deep,
excruciating, continuous, explosive. Wake from sleep. Retroorbital ->
hemicranium spread. Associated with lacrimation, rhinorrhea, red eye, stuffy
nose, pallor, Horners. 100% O2 is the best treatment.

GBS: 2/3 have antecedant respiratory or GI infection. Campylobacter is MCC.

Herpes, Mycoplasma, Haemophilus are other causes. MC in patients with
lymphoma, sarcoid, lupus. Recent HIV infection and immunization also.

Mucormycosis: MC agent is Rhizopus species. Poorly controlled diabetes is

risk. Fever, bloody nose, congestion, chemosis, proptosis, diplopia. Necrotic
turbinates. Can cause blindness, cavernous sinus thrombosis, coma.

Partial Seizures: auras are common manifestation of partial seizures. LOC

means generalization. Post ictal state usually indicates a generalized seizure
as well. Complex partial seizures have repetitive motion with no LOC/aura.
 NPH: caused by decreased CSF absorption or chronic increases in ICP ->
enlargement without chronically increasing ICP. Dementia, gait disturbances,
incontinence.

Acute MS: usually treated with steroids. Usually used when patients have
disabling symptoms. Not used for mild sensory symptoms. To reduce
frequency of exacerbations, use interferon, plasmapheresis,
cyclophosphamide, IVIG, glatiramer acetate.

Bronchogenic Cyst: usually found in middle mediastium on CXR. Diagnosis

made with CT scan. Tracheal tumors, pericardial cysts, lymphoma, LN
enlargement, aortic aneurysms cause middle mediastinal masses. Neurogenic
tumors and esophageal leiomyomas are in posterior and thymomas and
retrosternal thyroids are in anterior.

Acute Limb Ischemia: consider in patient with 5 Ps. Angiography will show
abrupt cutoff in blood supply. Start IV heparin. Needs surgical embolectomy or
intra-arterial fibrinolysis/mechanical embolectomy. IV streptokinase is used for
STEMI.

Sarcoidosis: history, CXR with hilar LA with or without reticulonodular

infiltrates, noncaseating granulomas on biopsy. Elevated ACE. Treat with
steroids for symptomatic disease.

Pulmonary Renal Syndromes: Goodpastures is due to anti-GBM Ab. Emergent

removal by plasmapheresis minimizes kidney damage and improves
prognosis. Wegeners is treated with cyclophosphamide and steroids.
Plasmapheresis is used as adjunct.

CHF Exacerbation: causes tachypnea as LV dysfunction -> pulmonary edema,

effusion, hypoxemia due to decreased ventilation. Causes hypocapnea and
respiratory alkalosis. Signs of fluid overload, S3/S4, cardiomegaly, bibasilar
crackles. History of CAD, HTN, smoking. Can have cardiac asthma (wheezing).
Can test for BNP and PCWP to confirm.

SCC Lung: suspect in patient with smoking history, hilar mass, hypercalcemia
(may have symptoms). Due to production of PTHrP -> increased bone and
renal resorption of calcium. May be due to bone involvement in late cancer
(serious implication).

Conjugated Hyperbilirubinemia: mainly because of intra or extrahepatic

obstruction or congenital impaired hepatic excretion of BRN. Defined as >50%
BRN is conjugated (vs. unconjugated when > 90% indirect). Can be due to
intrahepatic obstruction (viral, autoimmune, alcohol, drugs, pregnancy, post
op), congenital (DJ or Rotors), obstruction. Elevated transaminases = liver
problem. Elevated ALP = obstructive. Do US or CT first.

Dermatomyositis: classic cutaneous findings with proximal muscle weakness.

> 10% will have internal malignancy (MC ovarian). Regular age-appropriate
cancer screening is crucial. Have proximal extensor myositis and rash
(heliotrope). Have shawl sign on chest and lateral neck. Gottrons sign on
knuckles, elbows, knees. Gottron papules on joints are pathognomonic. Ab
against anti-Mi-2 against helicase.
 PE: sudden-onset pleuritic CP, cough, dyspnea, hemoptysis. Chest CT will
show wedge shaped infarction (CXR = Hamptons Hump). Can have
transudative or exudative effusions.

Angina: can sometimes be mistaken for epigastric pain. Keep high on

differential especially worsening with activity. Do exercise stress without
imaging if EKG is normal. SLE and steroid use = accelerated CAD. If stress is
normal, think about GI problems.

NMS: initiation of DA antagonists, fever, muscle rigiditiy, autonomic instability,

mental status change. Elevated CK, leukocytosis, electrolyte abnormalities. It
is a drug induced idiosyncratic reaction. Typical antipsychotics are MCC.
Usually 2 weeks after starting.

BPH: eventually can progress to obstruction and renal failure. Do US as initial

test to look for hydronephrosis (if so, place catheter. TURP for long term
correction). Will have smooth firm enlargement. Elevated Cr = renal failure.

Situational Syncope: typical is middle aged or older male who has LOC after
urination (may have BPH symptoms and nocturia) or during coughing fits. Due
to autonomic dysregulation which can be explained by straining and rapid
bladder emptying. Can have cardioinhibitory and vasodepressor mechanisms
involved.

OA: acetaminophen should be first line treatment in mild to moderate pain.

Proven efficacy and good SE profile. Consider diagnosis in 40 y/o with knee
pain aggravated by activity and relieved with rest. 10 minutes morning
stiffness. Crepitus due to incongruent joint surfaces.

MS: total protein is usually normal, but have high Ig levels, usually IgG but
also IgM and IgA. Oligoclonal bands present in > 85-90%. Rest of CSF is
normal. Elevated Ig also seen in neuropathies, CNS infections or viral
syndromes. Not diagnostic for MS.

Melanoma: suspect in older individual with changing mole and ABCDE.

Diameter > 6 mm. Enlargement. Back is MC area in men, legs in women.
Increasing in prevalence. Can be symptomatic. RF are fair skin, history of
sunburns, family history, dysplastic/atypical nevi.

Methotrexate: an antimetabolite agent with side effects are stomatitis,

nausea, anemia, hepatotoxicity, myelosuppression. Give with folic acid to
reduce SE.

Hepatitis A: prodromal phase, icteric phase, convalescent phase. Recent travel

to endemic country and sick contacts. RNA picornavirus that has fecal oral
transmission. Malaise, fatigue, anorexia, nausea, vomiting, mild abdominal
pain, aversion to smoking. Hepatomegaly, increases in AST/ALT followed by
increases in ALP/BRN. Treat supportively. Give Ig to individuals in contact.
Those at risk should be vaccinated.

Pneumonia: placing consolidated lobe in dependent position (down) increases

blood flow, increases right to left shunting -> drop in O2 saturation. Alveoli are
filled with exudate and are perfused but not ventilated.
 Pancreatic Cancer: primary differential in patients with chronic pancreatitis. Do
US (dilated ducts) in patients with jaundice, but CT is better for diagnosis of
cancer. Older age and weight loss are common. Elevated BRN and ALP due to
compression.

Acute Bacterial Meningitis: sick, elevated neutrophils, signs of meningitis.

Vancomycin, ceftriaxone to cover Strep pneumo, H flu, Neisseria. Vancomycin
needed for resisitant pneumococcus and does not penetrate brain well.
Ampicillin for Listeria (> 55, immunocompromised, patients with
malignancies, taking steroids).

TSS: possibly fatal condition caused by toxins produced by certain strains of

staph, including epidermal exfoliating toxin and is related to tampons and
other intravaginal articles. Flu, high fever, hypotension, erythematous rash.
After 1-2 weeks, skin of palms and soles will peel. Hydrate, debride wound,
remove source of infection, anti-staph antibodies.

Muscle Weakness: usually caused by muscle problem. Both hyper/hypothyroid

can cause proximal muscle weakness. Look for other symptoms of thyroid
dysfunction like fatigue, tremor (action tremor), anxiety, weight loss for
hyperthyroid. Improve with thyroid.

Carbon Dioxide Narcosis: alveolar hypoventilation (COPD) causes CO2

retention -> lethargy, somnolence, seizures, coma, death. Viral URI incites
COPD exacerbation. Sedatives should be avoided.

Venous Insufficiency: due to incompetent venous valves. Chronic edema,

stasis dermatitis, ulceration are complications. Leg elevation, compression
stockings, wound care are best treatment. Will have varicose veins.

Endocarditis: cystoscopy can cause enterococcal bacteremia in patients with

chronic GU infections. Underlying valvular lesions are increased risk. Fever,
malaise, new murmur, painful lesions (Oslers nodes). Viridans usually from
upper airway and staph from skin.

Primary Adrenal Insufficiency: best screening test is cosyntropin stimulation

test. Increase in levels above 20 30-60 minutes after 250 mcg cosyntropin
rules out Addisons. Eosinophilia is seen. Steroids are used to treat especially
for adrenal crisis while waiting for tests.

PCV: myeloproliferative disease of pluripotent stem cell. Increased RBC mass,

granulocytosis, elevated platelets, low erythropoietin. HTN due to increased
volume. Increased ulcers (histamine release from basophils), gouty arthritis
(increased cell turnover). Plethoric face and splenomegaly. Hypercellular bone
marrow. Keep Hcrt < 45.

Immunosuppressants: cyclosporine and tacrolimus are both calcineurin

inhibitors (inhibit IL-2). Cyclosporine causes nephrotoxicity, hyperkalemia,
HTN, gum hypertrophy, hirsutism, tremor. Tacrolimus does not have gum
hypertrophy and hirsutism. Azathioprine has done related diarrhea,
leukopenia, hepatotoxicity. Mycophenolate causes marrow suppresion.

Warfarin: dose should be adjusted based on INR for condition. VTE (3 month
treatment) and atrial fibrillation should be between 2 and 3 for good
 anticoagulation without bleeding risk. 2.5 to 3.5 in patients with prosthetic
valves.

Scleroderma: absence of peristaltic waves in lower 2/3 and low LES tone are
characteristic for esophageal dysmotility due to scleroderma. Sticking
sensation and dysphagia with heartburn.

RAAS: renin made by JG cells when hypoperfused. Renin converts

angiotensinogen to AT1. ACE in lung converts AT1 to AT2 -> vasoconstrictor,
promotes ADH release, aldosterone production. Aldosterone promotes Na and
H2O absorption in DCT and CD. Direct renin inhibitors will promote natriuresis,
decrease AT2, decrease aldosterone.

Hyperthyroidism: untreated, are at risk for rapid bone loss due to increased
osteoclastic activity in bone cells. Also at risk for arrhythmias (atrial
fibrillaion). Will have hypercalcemia and hypercalciuria.

Sphincter of Oddi Dysfunction: causes post cholecystectomy pain (also caused

by CBD stones). Normal ERCP and US rule out CBD stones. Elevated sphincter
pressure. RUQ pain, elevated LFTs. ERCP with sphincterotomy is most
appropriate treatment.

PE: CT angio is test of choice but V/Q scan is useful tool for those with contrast
allergy or renal disease. Will have large perfusion defect without ventilation
defect, called mismatched defect. < 50% have this.

Non Alcoholic Steatohepatitis: insulin resistance plays central role -> fat
accumulation by increasing rate of lipolysis and elevating circulating insulin
levels. FA oxidation -> increased oxidative stress -> inflammatory cytokines
-> inflammation, fibrosis, cirrhosis.

Diabetic Nephropathy: glomerular hyperfiltration is the earliest abnormality

and major pathophysiologic mechanism of disease. Intraglomerular HTN ->
damage and functional loss. ACE I reduce intraglomerular pressure. Thick GBM
is first change that can be quantitated.

Stroke: new neurological defecits, occipital headache, history of vascular

disease, HTN, atrial fibrillation. Do non contrast CT to decide of ischemic
(thrombolysis) or hemorrhagic (surgery). Warfarin, HTN, occipial HA worrisome
for bleed (hyperdense).

Loop Diuretic: given to cirrhotic patients with volume overload and ascites. SE
are hypokalemia, metabolic alkalosis, pre-renal renal failure. Inhibit Na/K/2Cl
transporter. Promote Na, K excretion. Volume depletion -> renal failure.
Aldosterone -> alkalosis.

Acute Arthritis: gouty vs pseudogout vs septic cannot be accurately

distinguished from each other based on clinical presentation. Synovial analysis
is crucial.

Tick Removal: should be removed promptly to reduce risk of tick borne

diseases. Grasp the ticks mouthparts with tweezers and remove using slow
constant pressure. Risk for disease is less if removed within 24 hours.
 Propranolol: DOC in patients with HTN and benign essential tremor (intention
tremor). Sometimes AD inheritance. Inhibited by alcohol.

Confounder: extraneous factor which has properties linking it with exposure

and outcome of interest.

MGUS: asymptomatic elevation of monoclonal protein on electrophoresis,

usually < 3 g/dL. Differs from MM: absence of renal insufficiency,
hypercalcemia, anemia, lytic bone lesions. Can progress to MM. Do bone scan
after labs to look for lytic lesions.

Congenital Rubella Syndrome: if women becomes pregnant within 3 months

after rubella immunization, reassure. No cases reported with vaccines early in
pregnancy.

Second Degree Heart Block: identified by prolongation of PR interval with

dropped beats. Due to AV node dysfunction.

Aminoglycosides: antibiotics to treat serious G(-) infections (like complicated

UTI). Nephrotoxic, so drug levels and renal function should be monitored.

Hypernatremia: severe symptomatic hypernatremia requires 3% saline. Rapid

correction -> CPM. Rate should be 0.5 to 1 mEq/L/hr.

Peritonsillar Abscess: muffled voice makes for more than uncomplicated

pharyngitis or tonsillitis. Needs IV antibiotics and needle drainage. Deviation
of the uvula and cervical LA help differentiate from epiglottitis. Can cause
airway obstruction or spread into parapharyngeal space. Surgery if aspiration
cannot relieve.

Folic Acid Deficiency: tea and toast diet predisposes. Folic acid is head
sensitive (dont get from cooked foods). Causes macrocytic anemia. Can
deplete in 4-5 months.

Thyroid Myopathy: consider hypothyroidism in patients with elevated CK and

myopathy. Can cause myalgia, hypertrophy, and rhabdomyolysis. Will have
sluggish tendon reflexes. Measure TSH.

Charcots Joint: also called neuropathic arthropathy. Due to neuropathy and

repetitive joint trauma. Affects weight bearing joints and manifests with
functional limitation deformity, degenerative joint disease, loose joints on
imaging. Caused by diabetes, nerve damage, syringomyelia, spinal cord
injury, B12 deficiency, tabes dorsalis. Use special shoes.

Hemophilia: hemarthroses are MC manifestation. Treat by replacing missing

coagulation factor. Hematoma after minor injury is suggestive, especially in
males. Measure factor VIII and IX levels. Also have bleeding at mucosal sites.
Will have history of joint swelling.

PE: result in pulmonary hypertension with elevated RAP and PAP, can result in
shock. Normal RAP is 4-6, normal PAP is 25/15. Will have sudden onset. COPD
and L heart disease also cause pulmonary HTN.
 Chronic Liver Disease: should be up to date on childhood vaccinations, HAV
and HBV, annual intramuscular influenza, invasive pneumococcal disease. And
should get Td booster every 10 years.

Exudative Effusion: low glucose is due to high metabolic activity of leukocytes

and bacteria within fluid. < 30 suggest empyema or rheumatic effusion. 30-50
is malignancy, lupus, esophageal rupture, TB.

Vomiting: causes hypokalemic hypochloremic metabolic alkalosis. Loss of H+

plus no use of HCO3 by the pancreas (due to no acid) retains it in the blood.
Contraction alkalosis also occurs. Restore ECF with NS and potassium to treat.

Rabies: if animal is not captured, it is assumed rabid and post exposure

prophylaxis is needed (active and passive). If captured, but shows no signs of
rabies, observe for 10 days. If develops signs, use PEP, and analyze brain. PEP
for any exposure around head or neck.

Left Atrial Enlargement: due to mitral stenosis. Can cause persistant cough
and elevation of left main stem bronchus. MCC is rheumatic fever. Loud S1,
opening snap, diastolic murmur. ECG will have atrial fibrillation or LAE. Echo
confirms. Surgery to treat.

Tamponade: pulsus paradoxus (inspiration -> more blood to RV -> IV septum

to bow to left -> reduces LV filling) and Becks triad: hypotension, JVD, muffled
heart sounds. Ventricles cannot expand to receive fluid and preload
decreases. Can have hepatojugular reflex.

Stroke: can be a common manifestation of sickle cell disease due to sludging

and occlusion. Do exchange transfusion to decrease percentage of sickled
cells and prevent secondary infarct. CT can be negative. Continue
hydroxyurea to increase Hgb F.

Brown Sequard Syndrome: damage to the lateral STT -> contralateral loss of
pain and temperature beginning two levels below the lesion. Fibers cross early
in the cord.

Asbestosis: increases risk of malignancy, pulmonary fibrosis, and pleural

plaques. Bronchogenic carcinoma and mesothelioma are both caused but
bronchogenic is more common. Start with dyspnea with cough or sputum
production.

Aminoglycosides: cause nephrotoxicity and ototoxicity. Causes severe

vestibulotoxicity (especially gentamycin) -> potentially permanent vertigo and
ataxia. Damages hair cells of inner ear.

HOCM: outflow obstruction due to septal hypertrophy and systolic anterior

motion (SAM) of mitral valve (may be of more consequence). Disease is MC in
AA. Murmur increases on Valsalva.

Antithyroid Drugs: fever and sore throat while taking suggests

agranulocytosis. Stop drug and check WBC count. Do not do routine CBC in
patients on these drugs. Due to immune destruction of WBC. < 1000 warrants
permanent cessation. > 1500 means drug not cause.
 Nodulocystic Acne: give oral isotretinoin with moderate to severe acne that
is nodulocystic, those with scars, acne resistant to other therapy. Topical
retinoids are for non inflammatory comedones. Benzoyl peroxide and topical
antibiotic is for mild inflammatory acne.

IBS: functional bowel disorder of GI tract characterized by pain, diarrhea,

constipation. No pathologic or lab hallmark. Exacerbated by stress. More in
women than men.

Primary Hyperaldosteronism: hypertension, hypokalemia (muscle cramps,

polyuria due to ADH resistance), low plasma renin, high glucose (due to
impaired insulin secretion). MCC is aldosterone producing adenoma. Do
morning PA/PRA, > 30 is suggestive. CAH, syndrome of apparent
mineralocorticoid excess, glucocorticoid/licorice ingestion also causes HTN,
low K.

Chest Pain: in a young person with RF, warrants cardiac workup. First drug to
give is ASA during suspicion of coronary event to prevent platelet
aggregation. >35, family history, smoking, estrogen therapy increase risk of
thrombosis.

Toxoplasmosis: HIV patient with fever, HA, confusion, ataxia, ring enhancing
lesion. Can have seizures and focal neurological deficits due to mass effects.
Occurs < 100 CD4. Due to reactivation, look for Ab at diagnosis. Treat
prophylactically with TMP/SMX if have Ab.

Murmurs: diastolic, continuous, or loud systolic murmurs should be evaluated

with Echo. Midsystolic soft murmurs (I to II/VI) do not need to be investigated
if asymptomatic.

Androgens: women produce androstenedione, DHEA, testosterone, DHEA-S.

AS, DHEA, T are produced by the ovaries. DHEA-S is produced by the adrenals
(elevated with tumors). DHEA/S are not true androgens, but can be converted.
Overproduction -> hirsutism.

Thiazides: cause hyperglycemia, increased LDL/TG. Also cause

hyponatremia, hypokalemia, hypercalcemia. Still have desirable affects on CV
mortality even in diabetics. Also causes hyperurecemia.

Influenza Vaccine: all individuals > age 50 should get it yearly. Younger adults
with medical problems, frequent exposure to small children, pregnant women,
healthcare workers should also get it annually. COPD needs pneumococcal as
well, but not annually.

MG: fatigable muscle weakness involving the ocular and bulbar muscles. 15%
have a thymoma which can be seen on CT chest, small % can be invasive.

Choriocarcinoma: metastatic gestational trophoblastic disease. Occurs after

molar pregnancy or normal gestation. Lungs are most frequent site of
metastasis. Suspect in postpartum woman with lung symptoms and multiple
nodules on CXR. Elevated b-HCG. Will have enlarged uterus, bleeding > 8
weeks post partum, pelvic pain.
 Hepatitis B: (+) HBsAg & (-) HBsAb means active infection. HBeAg indicates
high infectivity. Needle stick in unvaccinated individual -> give HPV vaccine
and Ig. Has higher rate of seroconversion than HCV and HIV.

Photo Protection: important in high risk groups. Sun avoidance is best method
of protection. Sunscreens should be applied 15-60 minutes before. Avoid
outdoor activities between 10 AM and 4 PM.

Vertigo: senseation of excessive motion compared to reality. MC due to

vestibular dysfunction. Distinguish from imbalance, lightheadedness, syncope.
Causes nausea and vomiting. Menieres, perilymphatic fistulas, BPV,
labyrinthitis, acoustic neuromas.

Hypocalcemia: occurs during or immediately after surgery in patients

undergoing major surgery and transfusions. Hyperactive DTRs may be initial
manifestation. Occurs due to hypoalbuminemia and dilution. Citrate from
transfusions binds. Hypomagnesemia presents with hypocalcemia and causes
decreased PTH secretion and decreased peripheral response to PTH.

Macular Degeneration: common cause of blindness in US. Activities that

require fine vision affected first. Straight grid lines may appear wavy.
Increasing age is cause, smoking maybe. Driving or reading are first activities
affected. See drusen deposits in the macula.

Ovarian Cancer: no evidence that regular abdominal US help decrease

mortality.

Laryngeal Edema: causes fixed upper airway obstruction which decreases

airflow during inspiration, active expiration, and passive expiration. Flow
volume shows pancake. Asthma causes intrapulmonary obstruction and has
scooped out patter on exhalation.

Seizure: if results in LOC (complex partial or generalized) will be followed by

post-ictal state. Rapidly return to baseline with syncopal event. Stress and
poor sleep trigger seizures. Tongue biting and sore muscles indicate seizure.
Needs CBC, drug screen, EEG, brain MRI.

Intracranial HTN: diagnosed when ICP > 20. Presents with HA, vision changes,
nausea, vomiting, changes in awareness, focal neurological defecits. Trauma,
space occupying lesions, hydrocephalus, impaired CNS venous outflow. Worse
in morning, unsteadiness, Cushings reflex (hypertension and bradycardia). Do
CT or MRI.

Alzheimers Disease: MCC dementia in western world. Memory loss, language

difficulties, apraxia -> impaired judgement and personality changes. CT shows
atrophy. Age, female, family history, head trauma, Downs. Psychotic features
appear later.

Cholecystectomy: indicated in all patients with symptomatic gallstones who

are stable enough to undergo surgery. Gallstones are MC responsible in non-
alcoholics.

VTE: treat initially with heparin & warfarin combination. If INR is therapeutic,
heparin is discontinued after 5 days. Warfarin should be continued for 6
months for first clot and lifetime for second.
 Presbyopia: common age related decrease in lens elasticity that leads to
difficulty with near vision, prohibits accomadation. Middle aged individual who
holds books at arms length is classic.

Osteomalacia: defective mineralization of bones. Rickets is defective

mineralization of bone bone and growth plate cartilage. Disordered skeletal
remodeling in specific bones is Pagets disease. Osteoporosis is low bone
mass, but normally mineralized per unit volume. Vit D deficiency -> decreased
availability of calcium and phosphorus at mineralization sites -> softening.

Carboxyhemoglobinemia: consider in patients with RF and headaches, nausea,

dizziness, polycythemia. Susceptible when working in closed space with
exposure to car fumes.

Infectious Mononucleosis: fatigue, malaise, sore throat, fever, generalized

maculopapular rash. Posterior cervical LA and palatal petechiae.
Splenomegaly. Heterophile Ab are good test, but (-) in early illness. Repeat
test. Transmitted by oropharyngeal secretions.

FFP: given to patients with bleeding disorders and liver failure. Vitamin K will
not work because of liver disease.

Extreme LFTs: marked AST/ALT consistent with hepatocellular injury. Usually

due to alcohol (2:1 AST:ALT) or medication induced. Usually acetominophen
which can be compounded by alcohol. AST/ALT can be > 5000.

Membranoproliferative GN: Type II, unique glomerulopathy caused by

persistent activation of the compliment pathway. Dense intramembranous
deposits of C3 are present. Also called dense deposit disease. IgG Ab (C3
nephritic factor) against C3 convertase -> constant active.

PUD: hemorrhage is the MC complication. May have melena or hematochezia.

Blood or coffee grounds on NG aspirate. Fluid and blood resuscitation, medical
therapy, endoscopic when appropriate.

CNS Lymphoma: HIV infected patient with altered mental status. EBV DNA in
the CSF, and solitary weakly ring enhancing periventricular lesion on MRI.

Null Hypothesis: always a statement of no relationship between exposure and

outcome.

SIADH: hyponatremia, elevated urine osmolarity in presence of decreased

plasma osmolarity. Seen with SCC of the lung. Metastasizes early. Smoking is
most important RF.

Foot Drop: steppage gait. MCC are neuropathy, L5 radiculopathy (or

radiculopathy of any of the common peroneal roots L4-S2), traumatic damage
to common peroneal nerve. Charcot Marie Tooth disease has congenital foot
drop.

Marfans Syndrome: most dangerous complication is aortic dissection. Tearing

chest pain that radiates to the back and neck. Causes aortic regurgitation ->
early diastolic murmur. CXR may have wide mediastinum. Disease is due to
fibrillin defect.
 Chagas Disease: caused by Trypanosoma cruzei protozoan. Causes
megaesophagus, megacolon (both due to neural destruction) cardiac disease
(CHF type due to prolonged myocarditis).

Statin Induced Myopathy: CPK levels of anyone on statin with muscle pain. If
highly elevated, stop the statin. Can progress to rhabdomyolysis (kidney
failure). Also causes increased LFTs.

Herpes Zoster Ophthalmicus: characterized by dendriform corneal ulcers and

vesicular rash in CNV distribution. Due to VZV. May have fever, malaise,
burning itching sensation in distribution. Treatment within 72 hours of high
dose acyclovir reduces complications.

OSA: common in obese population. Snoring, daytime sleepiness, apneic

episodes. At rish for HTN, heart disease, cor pulmonale, accidents. Use
nocturnal polysomnography to diagnose. Have morning headaches, poor
concentration. Due to tonsillar hypertrophy, excessive soft tissue,
micrognathia.

Hypokalemia: causes weakness, fatigue, muscle cramps. Severe -> paralysis,

arrhythmia, hyporeflexia, tetany, rhabdomyolysis. EKG may show U waves,
flat broad T waves, PVCs, ST depression. Diuretics, diarrhea, vomiting,
hyperaldosteronism are all causes.

CMV: consider in patients after BMT with pneumonitis (after 2 weeks to 4

months, multifocal diffuse pathy infiltrates, multiple nodules on CT, diagnosed
on BAL) and colitis (upper and lower GI ulcers) bone marrow suppression,
arthralgias, myalgias, esophagitis.

Wegeners Granulomatosis: vasculitis affecting small and medium sized

arteries. Comination of GN and upper/lower airway disease. Diagnosed with c-
ANCA and tissue biopsy (affected nasal mucosa). Treat with steroids and
cytotoxic agents. CXR may have multiple nodular densities and
alveolar/pleural opacities.

Endocarditis: first draw blood for culture then give empiric antibiotics. IVDA
and valvular abnormalities are RF. When culture is available, antibiotics can be
changed.

Calcium in Alkalosis: increased pH increases serum albumin affinity for

calcium. Increases albumin bound and decreases ionized calcium -> clinical
manifestations of hypocalcemia.

Randomization: said to be successful when similar baseline characteristics are

seen in treatment and placebo individuals.

Pagets Disease of the Bone: osteitis deformans. Associated with normal

calcium and phosphate levels and increased ALP and urine hydroxyproline,
deoxypyridinoline, N-telopeptide, C-telopeptide levels. Accelerated and
disordered osteoclastic resorption -> disorganized woven and lamellar bone.
Weight bearing bones have pain and bowing. Skull hypertrophy -> increased
hat size and deafness.

Solitary Pulmonary Nodule: first step is to find old x rays. Absence of growth
over time rules out malignancy. If not available, decide if high or low risk (age,
 smoking). Low -> serial CT. Intermediate -> PET, or biopsy. High -> surgical
removal.

Influenza: treat with bed rest and analgesia. Antivirals decrease symptoms
by 2-3 days but only effective if given within 48 hours. Amantadine and
rimantadine are only active against Influenza A. Zanamivir and oseltamivir
(neuraminidase inhibitors) active against both.

Cancer Associated Anorexia: treat with megestrol acetate, synthetic progestin.

Used as appetite stimulant in advanced malignancies. Prednisone may be
added. Better to have oral than TPN. All efforts to make patient eat.

Shingles: vesicular eruption that occurs in dermatomal distribution. Often

preceded by pain for 48 hours. Caused by VZV which also caused chicken pox.
Usually in elderly or immunosuppressed during periods of stress. Disseminates
in very immunocompromised.

SVC Syndrome: malignancy is MCC (smoking, weight loss). Lung cancer (SC)
and NHL are usual causes. Fibrosing mediastinitis due to histoplasmosis or Tb
infection or thrombosis due to central catheters. Do CXR to diagnose.
Dyspnea, venous congestion, swelling of head, neck and arms.

Thyrotoxicosis with low I Uptake: subacute painless thyroiditis, subacute

granulomatous thyroiditis, iodine induced thyroid toxicosis, levothyroxine OD,
struma ovarii.

HIV Esophagitis: start first with oral fluconazole directed against candidiasis.
Failure to respond in 3-5 days needs endoscopy. Usually CD4 < 50. Painful
swallowing and substernal burning. HSV and CMV are both causes as well.

Lead Poisoning: microcytic anemia and basophilic stipping. Seen in children in

old houses or lead based paint. Can have anorexia, behavior changes,
clumsiness, nausea, vomiting. Do fingerstick in all suspcions. > 10 is
abnormal. X ray may show lead lines at metaphyses.

Uremic Pericarditis: absolute indication for dialysis. Pericardial fluid is usually

hemorrhagic. Usually BUN > 60 and anemia. Other dialysis indications: fluid
overload or hyperkalemia that is not responsive, refractory metabolic acidosis.
Sometimes if GFR < 10 (< 15 in diabetes), Cr > 8 (> 6 in diabetes) or severe
symtoms.

Graves Disease: treatment is radioactive thyroid ablation, antithyroid drugs,

thyroidectomy. Agranulocytosis is major SE of antithyroid drug therapy. MC SE
is allergic reaction. PTU can cause hepatitis picture, ANCA vasculitis. MMI can
cause cholestatic jaundice.

Carcinoid Syndrome: at risk of niacin deficiency due to increased formation of

serotonin from tryptophan. Classic triad is flushing, diarrhea, valvular disease.
5-HIAA present in blood and urine. Tryptophan is precursor of serotonin and
niacin. Niacin deficiency -> pellagra.

NFII: young patient with acoustic neuroma and caf au lait spots. MRI with
gadolinium is best way to diagnose. Gradual tinnitus and hearing loss.
Frequently bilateral.
 TB and HIV: Tb has a very high rate of progression. Positive PPD (> 5 mm in
HIV) needs INH and pyridoxine (to cover INH neuropathy, but does not prevent
hepatitis) for 9 months. Monitor LFTs.

BZD OD: slurred speech, unsteady gait, drowsiness -> BZD or opioid. BZD do
not have severe respiratory depression and no pupillary constriction. Alcohol
and phenytoin intoxication are similar but have nystagmus. Lithium has
tremor, hyperreflexia, ataxia, seizures.

Lye Ingestion: effects are instantaneous, effects are most pronounced in the
esophagus -> liquefactive necrosis. Early upper GI contrast studies and
endoscopy are critical for evaluating damage and deciding on treatment. Have
retrosternal pain, hypersalivation, dysphagia/odynophagia. Give IVH and
receive serial abdominal and chest x rays. Gastrograffin study if rupture is
suspected.

Primary Syphilis: dark field microscopy is good for evaluation. Patients may be
involved in high risk sexual activity so HIV counseling and screening with
ELISA should be offered.

HIT: seen in about 5-15% of patients with onset in 3-15 days and resolution 4-
5 days after stopping. Elevated PTT is therapeutic, thrombocytopenia is
adverse effect. Can have paradoxical thrombosis.

Opioid Intoxication: does not always present with miosis. Coingestions can
have normal pupil size or even mydriasis. Meperidine and propoxyphene do
not cause miosis. Decreased RR, obtundation, hypothermia, decreased bowel
sounds, hypotension. Needle marks on extremities. Administer naloxone.

Otitis Externa: any diabetic patient with severe ear pain, otorrhea, evidence of
granulation tissue in ear canal. Pseudomonas is MCC. Pain radiates to TMJ and
worse with chewing. Worsening with antibiotics -> malignant.

Inferior MI: right ventricular infarction -> right heart failure. Hypotension, JVD,
clear lung fields, Kussmauls sign (increased JVD with inspiration). Preload
dependent -> treat with IVF and avoid nitrates and diuretics to decrease
preload. STE in II, III, aVF and STD in I, aVL. Can use right sided EKG leads.
Low HR -> possible SA node involvement.

Retroperitoneal Hematoma: can occur even with normal INR. Back pain and
signs of hemodynamic compromise. Greater risk of bleed on warfarin in
diabetics, age > 60, hypertension, alcoholism. CT will show isodense
collection anterior to psoas, displacing kidney.

Pancreatic Cancer: painless jaundice in a patient with conjugated

hyperbilirubinemia and elevated ALP. Do CT of abdomen to confirm. No pain
rules out acute obstruction such as choledocholithiasis. US can confirm GB
pathology.

Primary Hyperparathyroid: MCC of hypercalcemia in ambulatory patients.

Have elevated or inappropriately normal PTH levels. Chronic renal failure ->
secondary hyperparathyroidism. PTH is higher and calcium is normal
(hypocalcemia is the stimulus).
 Priapism: always check medications first. MCC is prazosin. Major association
with trazodone. Antidepressant used for sleep disturbances. Painful and long
erection without stimulation. Other causes are SCD and leukemia,
perineal/genital trauma, neurogenic lesions.

ARDS: acute pancreatitis may be a cause (15%). Decrease FiO2 to nontoxic

levels (< 60). PEEP may need to be increased to maintain oxygenation after
FiO2 is decreased. PEEP and FiO2 determine PaO2. RR and TV determine
PaCO2.

Hypoparathyroidism: characterized by low calcium and elevated phosphorus

levels with normal renal function. Causes are post-surgical, autoimmune
destruction (APECED = autoimmune polyglandular endocrinopathy candidiasis
ectodermal dysplasia), defective calcium sensing receptor, congenital
absence. Pseudohypoparathyroid = PTH resistance.

Dilated Cardiomyopathy: viral myocarditis (post partum) usually due to

Coxsackie B. Echo shows dilated ventricles and diffuse hypokinesia -> systolic
dysfunction (low EF). Will have antecedent URI. Can be due to direct viral
damage or immune response. Toxins also cause.

Opioid Intoxication: miosis, depressed mental status, decreased RR (best

indicator, cause of mortality, improves with naloxone), decreased bowel
sounds, hypotension (histamine release), bradycardia.

Angiodysplasia: common cause of intermittent and occult lower GI bleeding in

patients > 65. Can be missed on colonoscopy. Controversial association with
AS. Common in cecum. Anemia with normal MCV = episodic (not chronic)
bleeding.

Fibromyalgia: chronic widespread pain disorder associated with fatigue, poor

sleep, depression. Have multiple trigger points of tenderness. Women 20-50
years old. Sleep disorder, depression, viral illness can be cause. Improve with
TCA and exercise. Normal labs.

ASA Intoxication: triad of fever, tinnitus, tachypnea. Mixed respiratory

alkalsosis (stimulates respiratory center) and anion gap metabolic acidosis
(uncouples oxidative phosphorylation -> increased O2
consumption/hyperpyrexia, inhibit carbohydrate and lipid metabolism ->
accumulation of lactate etc., impairs renal function -> accumulation of
sulfuric/phosphoric acid). Near normal pH, primary decrease in PaCO2,
primary decrease in HCO3.

Reliable Tests: gives similar results on repeat measurements. Reliability is

maximal when error is minimal.

Osler Weber Rendu: hereditary hemorrhagic telangiectasia (AD). Develop

pulmonary AVMs -> AV shunting -> hypoxia -> erythrocytosis, increased
Hgb/Hcrt. Suspect with recurrent nosebleeds and oral lesions. May be in liver,
brain, lung. Can have massive hemoptysis.

Myoglobinuria: suspect with large amount of blood on dipstick but few RBCs
on UA. Usually caused by rhabdomyolysis -> ARF (high BUN, Cr, K). Seizures
can be a cause.
 AAA: USPSTF recommends screening male active/former smokers between 65
and 75 years old one time with abdominal US (low cost, non-invasive, no
radiation). Repair aneurysms > 5.5 cm. No recommendations for or against
men 65-75 who have never smoked.

Cerebellar Dysfunction: common in chronic alcoholics. Have gain

instability/ataxia/broad based gait, difficulty with rapid alternating
movements, intention tremor, dysmetria, nystagmus. Muscle hypotonia can
result -> pendular knee reflex.

Ulnar Nerve Syndrome: MC site of ulnar nerve entrapment is at the elbow

where ulnar nerve lies at medial epicondylar groove. Decreased sensation in
4th and 5th digit. Weak grip due to intrinsic hand muscle denervation. Typically
prolonged leaning on elbows at desk job. Can occur at the wrist. Occurs at
forearm rarely, and mostly in diabetics.

Transfusion Reactions: relatively common and life threatening. Acute

hemolytic reaction due to transfusing mismatched blood and Ab reaction (ABO
mismatch). Fever, chills, flank pain, hematuria, hemolysis, shock, ARF, DIC.
Can occur in patients with acquired alloantibodies. Have positive Coombs
test, plasma free Hgb is pink with Hgb > 25. Supportive treatment.

Tinea Versicolor: pale velvety pink/white appearing hypopigmented macules

that do not tan and do not appear scaly but scale on scraping. Topical
treatment with selenium sulfide lotion and ketoconazole shampoo. Caused
by Malassezia furfur (spaghetti and meatballs). Color change requires months
to return to normal.

Malignant Otitis Externa: seen in eldery and uncontrolled diabetics. MCC is

Pseudomonas. Ear pain and drainage, granulation tissue in ear canal. Can
cause osteomyelitis of skull base and destruction of facial nerve. Not
responsive to topicals. CT or MRI. Use systemic cipro.

OA: lack of physical exam findings and lab changes. Based on clinical
impression and radiographic evidence. Age > 50, crepitus, bony enlargement,
bony tenderness, lack of warmth/morning stiffness. If > 3, specificity is 69%.

Epiglottitis: MC organisms are H flu and Strep pyogenes, especially in adults.

Medical emergency and rapid treatment is needed to secure airway. Fever,
sore throat, drooling, stridor (harsh thrill). Can be seen in adult immigrants
with improper vaccination.

Isolated Proteinuria: evaluation should begin by testing urine on at least two

other occasions. Can be transient during period of stress or febrile illness.

Conns Syndrome: primary hyperaldosteronism. HTN, mild hypernatremia,

hypokalemia, metabolic alkalosis. Will have low renin, high aldosterone, high
HCO3. Suspect in young non-obese, non-black person. Muscle weakness and
exercise intolerance are due to hypokalemia.

Strep Bovis Endocarditis: associated with colorectal cancer or upper GI

malignany. Colonoscopy should be pursued for further evaluation and after do
radiographic surgey for UGI cancer. Also can cause septicemia.
 Brain Hemorrhage: usually due to HTN. Putamen is MC place, and internal
capsule is often involved -> hemiparesis. Cerebellum is 2 nd MC place ->
ataxia, vomiting, occipital HA, gaze palsy, facial weakness, no hemiparesis.
Pons is 3rd MC place -> deep coma, paraplegia, pinpoint pupils reactive to
light, decrerebrate rigidity, no horzontal eye movements.

New HIV Patient: VDRL, PPD, HAV/HBV serology, Ab titer for Toxoplasma are all
indicated.

Ankylosing Spondylitis: occurs in adults 20-30 years. Limited spine mobility

and progression of back pain > 3 months. Pain and stiffness worse in morning,
improve with exercise. Bilateral sacroiliitis on x ray. MC extraarticular
manifestation is anterior uveitis.

ED: in treating patient with sildenafil and an alpha blocker (usually zosin),
give drugs 4 hours apart to decrease risk of hypotension. Diabetics are at high
risk for ED. Vascular complications, neuropathy, medications are usual causes.
First line is PDE inhibitors. CI in people taking nitrates, precaution in conditions
with priapism, concurrent use with drugs that may increase life
(erythromycin, cimetidine).

Portal HTN: MCC of ascites. Usually due to cirrhosis from chronic liver disease
(alcoholic or viral). IVDA -> cirrhosis due to possibility of HBV/HCV infection.

AS: indications for AV replacement: symptomatic, severe AS undergoing CABG

or other valve surgery, asymptomatic with severe AS and either poor LV
function, LVH > 15 mm, valve area < 0.6, abnormal response to exercise.
Symtoms are SAD (syncope, angina, dyspnea).

GERD: retrosternal burning after eating and lying down. May have horseness
and chronic cough especially when recumbent. Initial treatment is H2 receptor
antagonist (ranitidine) or PPI. Refractory -> fundoplication or endoscopic
treatment. Barretts and adenocarcinoma. May be trigger for asthma (upto
75% of cases). May have wheezing (all patients with asthma symptoms should
be asked about GERD symptoms as well).

Hypothyroidism: accumulation of matrix substances all over body causes

many manifestations of hypothyroidism. Matrix accumulation in median nerve
and tendons of carpal tunnel may cause carpal tunnel syndrome. Untreated ->
generalized myxedema, myxedema psychosis, myxedema coma.

IM: heterophile Ab test (Monospot) is sensitive and specific for diagnosis

(appear within a week and may be positive upto a year). EBV specific Ab test
is for patients with suspected IM and (-) heterophile Ab test. Atypical
lymphocytes are seen but not specific. (-) heterophile Ab in the first few weeks
does not rule out.

PUD: melena is a common manifestation of UGI bleeding. Pain from duodenal

ulcers gets better with food, pain from gastric ulcers gets worse. UGI proximal
to hepatic flexure can cause melena. Have abdominal pain, nausea, vomiting,
hematenesis. H pylori and NSAIDs.

Hypertriglyceridemia: can cause acute pancreatitis when levels > 1000. May
have eruptive xanthomas on PE. Diagnose with fasting lipid profile.
Hypercalcemia, recent ERCP, trauma, infection, medications also causes.
 Euthyroid Sick: any patient with acute severe illness can have TFT
abnormalities. MC pattern is fall in total T3, normal T4 and TSH (low T3
syndrome). Due to caloric deprivation and cytokine release. More severe ->
lower T3. Longer sick -> T4 and TSH drop. Prognosis : severity of lab
abnormalities.

Rubella: maculopapular rash, posterior cervical and posterior auricular LA and

polyarthralgia. Exposure -> fever, malaise, LA after 2-3 weeks -> rash 1-5
days later (starts on face and speads, usually for < 3 days). Treat with
acetaminophen.

SBP: suspect in any patient with cirrhosis and ascites who presents with low
grade fever (cirrhotics may be hypothermic), abdominal discomfort, altered
mental status. Paracentesis with PMN > 250 and positive culture is diagnostic.
SAAG > 1.1 = portal HTN as cause.

Behcets Syndrome: multisystemic inflammatory condition with recurrent

genital/oral ulcers, skin lesions (erythema nodosum), anterior uveitis, seen in
Turkish, Asian, Middle Eastern. Treat with steroids -> do not prevent
progression to dementia and blindness.

Exercise EKG: recommended for patients with an intermediate pre-test

probability of angina based on clinical features and RF. Anti-ischemics should
be withheld (digoxin and meds that slow heart rate like beta blockers).

Non Ketotic Hyperosmolar Syndrome: T2DM. Decreased consciousness is MC

symptom. Blurred vision is caused by myopic increase in legs thickness and
intraocular hypotension due to hyperglycemic hyperosmolarity. Usually
triggered by infection. Stress -> increased cortisol and catecholamines ->
insulin resistance.

Viridans Group Strep: frequent cause of SBE in patients with pre-existing

vascular disease. Staph aureus is cause of acute infective endocarditis and is
seen in IVDA.

Lithium: common cause of nephrogenic DI. Treated with salt restriction and
discontinuation. Complete DI -> urine osmolarity < 300, partial DI -> urine
osmolarity 300-600. Demeclocycline, foscarnet, cidofovir, amphotericin also
cause DI.

Power: the power of a study is its ability to detect the difference between two
groups. Increasing the sample size -> more power -> makes CI of the point of
interest tighter.

Costochondritis: chest pain that is reproducible with palpation suggests

musculoskeletal. Sharp, focal, long lasting, worsens with inspiration and
movement.

Hypokalemia: high levels of B2 agonists present with muscle weakness,

arrhythmias, EKG abnormalities. B2 agonists can also cause tremors,
palpitations, headaches. High levels of B2 agonists are used along with
steroids in acute asthma. Do electrolyte panel.

Herpes Encephalitis: temporal lobe affected, may present acutely (< 1 week)
with focal neurological signs. Present with lymphocytic pleocytosis, increased
 number of erythrocytes, elevated protein. Do HSV PCR is gold standard for
diagnosis. Usually HSV-1 beyond neonatal period. Can present as seizures.
EEG -> intermittent high amplitude slow waves. IV acyclovir.

Parkinsons: three cardinal signs are resting tremor (resting pill rolling usually
focal to one hand and generalizes), bradykinesia, rigidity (lead pipe or
cogwheel), postural instability. 2/3 signs on physical exam grounds for clinical
diagnosis. Accumulation of alpha synuclein in substantia nigra.

Amyloidosis: restrictive CM with thickened ventricles and preserved

dimensions (diastolic dysfunction without systolic changes) as well as
involvement of liver (easy bruisibility) and kidneys (proteinuria). Caused by
MM (AL), chronic inflammation like RA (AA).

Dehydration: elderly patients are particularly sensitive to fluid loss. Mild

hypovolemia can predispose them to orthostatic syncope, especially on
waking. BUN/Cr ratio is useful indicator (sensitive but not specific).

Subconjunctival Hemorrhage: if spontaneous, is a benign finding and does not

require treatment. May be due to trauma from rubbing eyes, coughing fits,
hypertension, coagulopathy. If HTN, try lowering BP.

Acute Pancreatitis: serum amylase and lipase are considered most sensitive
and specific tests for diagnosis. Early on there is dysfunction between
synthesis-secretion. Cells keep making enzymes when no secretion ->
leakage. Lipase is more sensitive and specific.

Torsades des Points: polymorphic ventricular tachycardia that occurs in setting

of prolonged QT: familial long QT, hypomagnesemia (malnourished alcoholics),
drugs (TCAs), antiarrhythmics (amiodarone, sotalol), antiinfectives
(moxifloxacin, fluconazole). Treat with stopping cause and starting magnesium
sulfate.

Papillary Necrosis: presentation of woman with hematuria and headaches =

analgesic nephropathy. Years of analgesics -> chronic tubulointerstitial
damange. Analgesics -> vasoconstriction. Sometimes clots form -> renal colic.

Rosacea: suspect in 30 to 60 year olds with telangiectasias over cheeks, nose,

chin. Flushing caused by hot drinks, heat, emotion, other causes of rapid body
temperature change. Topical metronidazole is usually prescribed as initial
therapy. May have papules and pustules.

FSGS: most common type of glomerulopathy associated with HIV. Have

nephrotic range proteinuria, azotemia, normal sized kidneys. Have rapid
development of renal failure. More prevalent in blacks. Can manifest even if
rest of HIV markers are normal.

AS: three most common causes are senile calcific aortic stenosis, bicuspid
aortic valve, rheumatic heart disease. Bicuspid valve considered in anyone <
70. May have CHF signs, S4.

Measles: paramyxovirus. Exposure -> prodrome of cough, coryza,

conjunctivitis after 10 days -> Kopliks spots that appear 48 hours before rash
and fade as soon as rash appears -> erythematous maculopapular rash
 initially over face and then spreads. Complicated by pneumonia, vitamin A
deficiency, bronchiectasis. Later by immunosuppression and SSPE.

Papilledema: transient loss of vision for a few seconds with changes in head
position, confirmed by ophthalmologic examination. Caused by increased ICP
(morning HA, changes in HA intensity with position). When ICP increased ->
transmitted to optic nerve head -> swelling. Enlarging blind spot.

Aortic Dissection: tearing pain with radiation to the back and difference in BP
of > 30 mm Hg between the arms. TEE or CT with contrast to diagnose.
Collagen abnormalities also predispose to MVP.

Haloperidol: good for treating agitation in elderly regardless of underlying

cause of dementia. Can also use quetiapine and risperidone. Antipsychotics
can be deadly in elderly but good for acute agitation. BZDs are not good. Do
not use in Lewy Body dementia.

Laxative Abuse: frequent, watery, nocturnal diarrhea. Characteristic finding of

dark brown discoloration of the colon with lymph follicles shining through as
pale patches (melanosis coli). Usually seen in those abusing anthraquinone
containing (bisacodyl).

Flecanide: used to treat ventricular arrhythmias and SVT like atrial fibrillation.
Class IC (blocks Na channels), elongates depolarization -> slow conduction
through AV node and bundle of His. Have use dependence where effect
increases (QRS increases) as HR increases (not as much time to dissociate).
Class IV also has use dependence but doesnt elongate QRS.

Reactive Arthritis: Reiters syndrome. Seronegative spondyloarthropathy from

enteric or GU infection. Also have conjunctivitis, urethritis, mucocutaneous
lesions, enthesitis, asymmetric oligoarthritis. NSAIDs are first line therapy.

GI Manifestations of Autonomic Neuropathy: postprandial bloating, early

satiety, constipation, diarrhea. Metoclopramide (DOC), bethanacol,
erythromycin are used for gastroparesis (difficult to control glucose). Bacterial
overgrowth occurs in SI. Constipation in LI.

Lung Consolidation: bronchial breath sounds, dullness to percussion, increased

fremitus, bronchophony, egophany, whispered pectoriloquy on PE. Bronchial
sounds have full expiratory phase. Elderly patients with pneumonia may not
have elevated temp or WBC.

Bronchiectasis: identified on CT by presence of dilated bronchi with thickened

walls. Can occur in any patient where there is a pulmonary infection
accompanied by either decreased airway drainage or impaired immune
defense. Hemoptysis is a potential complication. Presents similarly to COPD
where abnormal aiways cause obstruction. Persistant cough. Antibiotics with
some resolution.

MM: hypercalcemia is a common finding -> constipation, anorexia, weakness,

renal tubular dysfunction, neurologic symptoms. Combination back pain,
anemia, renal dysfunction, elevated ESR.

Cholesterol Emboli: acute renal failure, skin changes in lower extremities

(bluish discoloration or livedo reticularis), GI symptoms, elevated eosinophils
 in blood/urine, decreased compliment levels. History of recent angiography.
Can develop pancreatitis.

Hepatojugular Reflex: useful tool to differentiate between heart and liver

disease related cause of lower extremity edema. (+) = heart. (-) = liver.

Tropical Sprue: malabsorption (B12, folate), history of living in endemic area

for > 1 month, involves SI, characterized by blunted villi with infiltration of
chronic inflammatory cells, lymphocytes, plasma cells, eosinophils.
Hyperactive bowel sounds and borborygmi.

Generaliziability: external validity. Pertains to the applicability of the results to

the study of other populations. Restriction of the study to a certain population.

Erysipelas: sudden onset of sharply demarcated, erythematous, edematous,

tender skin lesions with raised borders. Most frequently implicated organism is
group A beta hemolytic strep. Inflammation of the superficial dermis. Legs are
most frequently involved.

Pancreatic Cancer: RF are family history, chronic pancreatitis, smoking,

diabetes, obesity, high fat diet. Alcoholism is not a risk factor. Higher in males
and blacks. Jaundice and weight loss. Recent onset diabetes,
thrombophlebitis, previous pancreatitis attacks.

Hypocalcemia: can be due to low albumin. Always measure albumin in order

to correct for it. Measured calcium + 0.8 (4 measured albumin). Every gm/dL
decrease in albumin is 0.8 mg/dL decrease in calcium.

Two Sampled T Test: statistical method that is commonly employed to

compare means of two groups of subjects. Need two means, the sample
variances, the sample size. If p < 0.05, reject the null hypothesis.

Atrial Fibrillation: irregularly irregular R-R interval with absent P waves and
narrow QRS complexes. In unstable patients, do immediate cardioversion. If
stable who have been in atrial fibrillation < 48 hours, cardioversion is
appropriate. > 48 hours, 3-4 weeks of rate control and anticoagulation before.
Use beta blocker or CCB.

Hawthorne Effect: tendency of a study population to affect the outcome

because these people are always aware that they are being studied. Try to
keep subjects unaware that they are being studied.

Pleural Effusion: CHF is the MCC. Pleural fluid will be consistent with
transudate. Normal pleural fluid pH is 7.64. < 7.3 indicates pleural
inflammation. 7.35 would be transudative. Glucose < 60 favors
parapneumonic effusion, TB, or RA.

Alports Syndrome: recurrent episodes of hematuria/proteinuria, sensorineural

deafness with a family history of renal failure. EM shows alternating areas of
thinned and thickened capillary loops with splitting of the GBM.

Bacterial Overgrowth: a malabsorption syndrome associated with a history of

abdominal surgery. Symptoms may be nonspecific and include abdominal
pain, watery diarrhea, dyspepsia, weight loss. May have tetany (hypocalcemia
due to Vitamin D deficiency), night blindness (Vit A deficiency), neuropathy
 (B12 deficiency), dermatitis, arthritis, hepatic injury. Abdominal distension
with succussion splash (palpable, soft, fluid-filled loops of bowel). Can have
macrocytic anemia.

Breast Cancer: single most important RF is age. Women > 40-50 years of age
need regular annual mammograms. Only 10% have family history. Rare before
age 30.

Acute Pyelonephritis: potentially results in G(-) sepsis. Urine and blood

cultures before giving antibiotics. Give cipro or ceftriaxone. Hypotensive
patients need fluids and maybe pressors. CT or US only if diagnosis is not
clear or acute episode does not respond.

Acanthosis Nigricans: thickening and hyperpigmentation of skin in flexural

areas with velvety texture. Common in insulin resistant states (DM,
acromegaly, obesity) and GI malgnancies (MCC is gastric adenocarcinoma).

Celiac Disease: malabsorption and iron deficiency anemia. Bulky, foul

smelling, floating stool. Bone pain (osteomalacia), pallor (anemia), easy
bruising (vit K deficiency), hyperkeratosis (vit A deficiency). ELISA for IgA Ab
to gliadin, TTG, and anti-endomysial antibodies.

Renal Transplant Dysfunction: in early post operative period = ureteral

obstruction, acute rejection, cyclosporine toxicity, vascular obstruction, ATN.
Acute rejection is best treated with IV steroids. Can do radioisotype scanning,
US, MRI, renal biopsy to diagnose.

NPV: probability of being free of a disease if test is negative. NPV will vary
with pretest probability. High probability = low NPV and vice versa.

HUS: child who has recently recovered from diarrheal illness and presents
with ARF, MAHA, fever, thrombocytopenia, schistocytes and giant platelets on
peripheral smear. GI bleeding is common. Purpura and HTN. Elevated LDH and
indirect BRN and reticulocyte.

SCC: of the head and neck in alcoholic smoker who presents with palpable
cervical LN. Panendoscopy (esophagoscopy, laryngoscopy, bronchoscopy) to
find primary tumor.

Anemia: if in CKD, due to erythropoietin deficiency (normocytic,

normochromic). Be sure iron stores are adequate prior to erythropoietin
replacement, otherwise can precipitate iron deficient state. In dialysis
patients, give IV iron dextran.

Toxic Megacolon: UC is MCC. Medical emergency. Give IV steroids, NG

decompression, fluid management. Emergency surgery may be needed.
Ischemic colitis, volvulus, diverticulitis, infection, obstructive colon cancer can
also cause.

Dipstick: test for nitrites and esterase in suspected cases of UTI. (+) LE
signifies significant pyuria and (+) nitrites indicate Enterobacteraceae.

Diuretic Abuse: increased excretion of water and electrolytes by the kidneys.

Dehydration, weight loss, orthostatic hypotension, hypokalemia,
hyponatremia. High urine sodium and potassium. Common in eating disorders.
 Leydig Cell Tumor: estrogen production can be increased with secondary
inhibition of LH and FSH. MC type of testicular sex cord stromal tumors.
Principle source of testosterone and capable of estrogen production. MC
presentation of gynecomastia or precocious puberty.

PE: MC S&S are dyspnea, pleuritic CP, tachypnea, tachycardia. Helical CT

angiogram is investigation of choice in patients with normal creatinine. V/Q
scan for those with kidney problems or allergic to dye.

GN after URI: IgA nephropathy is MCC of GN in adults. Recurrent episodes of

gross hematuria several days after URI. Serum compliment is normal. PSGN is
10 days for pharyngitis, 21 days for impetigo.

OA: predominantly involves DIP joints. Major radiographic features are joint
space narrowing, subchondral sclerosis, osteophytes, subchondral cysts.

COPD: inhaled muscarinic antagonists like ipratroprium are mainstay therapy.

May be combined with short acting beta agonists. Gradual decreasing flow
rates, increasing lung compliance and volumes. Smoking cessation, O2, lung
reduction only for increased survival.

Hyperparathyroidism: indications for surgery are serum calcium at least 1

mg/dL above upper limit of normal, 24 hour urinary calcium > 400 mg, < 50,
BMD < -2.5, reduced renal function.

Pleural Effusion: undiagnosed effusion is best evaluated with thoracocentesis

except in patients with clear cut evidence of CHF. Can determine of transudate
or exudate. Lung, breast, lymphoma cause 75% of malignant effusions
(exudative).

Huntingtons Chorea: present in 40s or 50s with chorea and/or behavioral

disturbance. Atrophy of caudate nucleus is characteristic (enlargement of
lateral ventricles). AD neurodegenerative disorder. Chorea is sudden jerky
irregular movements.

TSH Adenoma: excessive TSH levels -> hyperthyroid state. Elevated T3 and T4
levels with inappropriately elevated TSH levels. Usually macroadenomas. Do
not have infiltrative ophthalmopathy or pretibial myxedema. Elevated alpha
subunit.

Ventricular Tachycardia: in presence of stable BP does not need cardioversion.

Best treatment is amiodarone (DOC) or lidocaine.

Bladder Cancer: screening is not recommended even in those who are at risk
of developing the disease. 2nd MC urologic cancer. Men > women. Smoking
and exposure to industrial chemicals are common causes.

Inferior Wall MI: most likely cause is RCA occlusion (could be left circumflex).
ST elevation in inferior leads (II, III, aVF). Bradycardia and hypotension
suggesting SA node involvement.

Cross Sectional Study: exposure and outcome are measured simultaneously at

particular point in time (snapshot study). Temporal relationship is not always
clear.
 Acne: if patient has mild acne (non inflammatory comedones) use topical
retinoids. Topical antibiotics are used if mild to moderate inflammation. Oral
antibiotics are used if papular and inflammatory acne. Oral isotretinoin for
nodulocystic or scarring.

ITP: autoimmune platelet destruction is common cause of thrombocytopenia

and suspect in patients with ecchymoses, petechiae, mucosal bleeding
without S&S of TTP/HUS, pancytopenia, marrow failure, splenomegaly.

Papillary Thyroid Carcinoma: MC thyroid malignancy. Slow infiltrative local

spread and spreads to LN. Presence of psammoma bodies. Cells with ground
glass cytoplasm with inclusion bodies and central grooving. Unencapsulated.

Follicular Carcinoma: invasion of the capsule and blood vessels required for
differentiating follicular carcinoma from adenoma. Tend to invade blood
vessels and metastasize to different organs.

MS: suspect in young female patient with bilateral trigeminal neuralgia.

Presents in 3rd or 4th decade with recurrent focal neurological dysfunction.

Acute Limb Ischemia: in a patient with an MI who develops a cold leg, one has
to get an echo to rule out a thrombus in the LV.

RA: patients with rheumatoid arthritis are at increased risk of developing

osteoporosis and osteopenia. Likely due to combined effects of disease itself,
steroid therapy, female sex, inability to perform weight bearing exercise.

Erythema Nodosum: condition of painful, subcutaneous, pretibial nodules. Can

be symptom of sarcoidosis, TB, histoplasmosis, streptococcal infection, IBD.
Association is strong in AA women. Do CXR. Cough, arthritis, uveitis, hilar
adenopathy are also common.

Metoprolol: selective beta 1 antagonist that, in high doses, can block

bronchodilatory beta 2 receptors and cause bronchoconstriction in susceptible
individuals. History of intermittent dyspnea and coughing, possible history of
eczema -> possible asthma.

Alcoholic Liver Disease: fatty liver (steatosis), alcoholic hepatitis (Mallory

bodies, infiltration by neutrophils, liver cell necrosis, perivenular inflammation
distribution), early fibrosis can be reversible with cessation of alcohol intake.
True cirrhosis is irreversible regardless of alcohol abstinence.

Lacunar Stroke: can cause lesion in posterior limb of internal capsule

characgterized by unilateral motor hemiparesis of the face, arm, leg without
any higher cortical dysfunction or visual field abnormalities.

Seborrheic Dermatitis: also called cradle cap. Papular scaly rash tends to
affect eyebrows, nasolabial folds, and scalp. Treat with moisturizers,
antifungals, topical steroids, anti-dandruff shampoo. Transparent yellow
papules. Severe cases may be due to immunodeficiency.

HIV and Dysphagia: give 1-2 weeks of fluconazle therapy since candidal
esophagitis is most likely. If symptoms persist, do endoscopy. HSV ulcers are
multiple, well circumscribed, volcano like (small and deep appearance) ->
 treat with acyclovir. CMV ulcers are large, shallow, superficial and
intracytoplasmic/intranuclear inclusions -> treat with ganciclovir.

Defibrillation: in VF and pulseless VT, it is of primary importance. Time to

defibrillation is strongly correlated with survival. Complication of MI. 200-320
joules. If unwitnessed or > 5 minutes, do cycle of CPR before defibrillation.

Polycystic Kidney Disease: relatively common autosomal dominant disease.

Presents with hematuria and HTN but can cause abdominal masses and pain.
Associated with intracerebral aneurysms. Do abdominal US.

Scabies: highly contagious disease with presents with generalized itching and
pruritic papules over the penis and scrotum in males and on areolas and
breasts in females. Treat with 5% permethrin cream which is applied from
neck down and left overnight.

Infectious Endocarditis: in high risk patients presenting with fever, chills,

evidence of septic emboli or abscesses. Can have LUQ pain and splenic fluid
collection. Left sided lesions -> brain, kidneys, liver, spleen septic emboli.
Right sided lesions -> septic pulmonary emboli.

Pernicious Anemia: MC megaloblastic anemia -> B12 deficiency due to

decreased IF. Antibodies to parietal cells have been reported -> achlorhydria.
Have low B12, positive IF Ab, and extremely elevated LDH.

Anaphylactic Reactions: rare to occur to transfused blood products. More

common in patients with IgA deficiency. Rapid onset of symptoms with
associated bronchospasm and hypotension plus absensce of fever helps to
distinguish from other types of transfusion reactions. Stop transfusion, start
epinephrine, IV fluids, possibly pressors.

Pronator Drift: relatively sensitive and specific for UMN damage affecting
upper extremities. Supinators are naturally stronger but exaggerated with
UMN lesion. When people are feigning, they will tend to drop the affected
arm without pronating.

PCKD: heritable form of renal disease with multiple renal cysts and
intermittent flank pain, hematuria, UTI, and nephrolithiasis. Enlarged right
kidney is easier to palpate than enlarged left because its lower. Liver might be
enlarged due to cystic involvement.

Healthcare HIV Exposure: whenever healthcare worker is exposed to HIV, do

baseline HIV testing immediately. PEP with 2-3 antiretroviral drugs should be
stated without delay. Repeat testing at 6 weeks, 3 months, 6 months. Use 2
NRTI and 1 protease if adding a third.

Hypercapnea: if respiratory acidosis is compicating metabolic acidosis ->

lethargy due to hypoventilation.

Bronchiectasis: bronchial dilatation -> impaired clearance of secretions ->

obstruction. Can be acquired due to Tb or pneumonia. Inherited can be due to
CF. Cough, mucopurulent sputum, hemoptysis. CXR -> prominent bronchioles,
peripheral opacities, linear atelectasis. High resolution CT scan is used for
definitive diagnosis.
 Vetricular Aneurysm: late complication of MI, persistent ST elevations on EKG.
CHF, arrhythmias, thrombus formation with mitral regurgitation. Echo can be
used to diagnose.

Zollinger Ellison Syndrome: MC cause is a gastrinoma in pancreas -> parietal

cell hyperplasia -> increased stomach acid -> multiple duodenal ulcers,
possible jejunal ulcers. Steatorrhea can develop due to inactivation of
pancreatic enzymes by stomach acids.

Normal Distribution: symmetric and bell shaped. All its measures of central
tendency are equal, mean=median=mode. Skewed distributions do not have
the same tendency.

Turcots Syndome: AR, association between FAP/HNPCC and brain tumors

(primary medulloblastomas and gliomas in FAP, high grade gliomas in HNPCC).
Occurs in teens.

Gardners Syndrome: AD, colonic polyps with desmid tumors, sebaceous or

epidermoid cysts, lipomas, osteomas (especially of the mandible),
supernumery teeth, gastric polyps, juvenile nasopharyngeal angiofibromas.

Cowden Syndrome: multiple hamartoma syndrome, GIT hamartomas with

breast, thyroid cancer and nodular gingival hyperplasia.

Cronkhite Canada Syndrome: juvenile type polyps and ectodermal

abnormalities like alopecia, hyperpigmentation, nail loss (oncholysis).

First Degree Heart Block: characterized by PR > 0.2 seconds. Completely

benign and requires no treatment. Can be secondary to increased vagal tone
or digoxin.

BNP: measurement of serum BNP can help distinguish between CHF and other
causes of dyspnea. Released from ventricles in response to volume overload.
Usually levels > 100 for CHF.

Fanconis Anemia: AR, congenital marrow failure, poor growth, other

morphological abnormalities (microcephaly, abnormal thumbs,
hypogonadism), areas of skin hypopigmentation. Anemia is usually
macrocytic. Aplastic anemia (fatigue and pounding in ears). Treat aplastic
anemia with BMT.

Orbital Cellulitis: pain with eye movement, proptosis, decreased visual acuity.
CT used to define extent or presence of abscess. Preseptal cellulitis presents
similarly with swollen, painful eye and fever. Sinusitis can cause orbital. Treat
with broad spectrum antibiotics.

Anasarca: results from organ failure or hypoalbuminemia. With GN, is due to

decreased GFR with some proteinuria and hypoalbuminemia in some cases.
Will have RBCs, RBC casts, WBCs, protein in urine.

Inflammatory Diarrhea: inflammatory changes in the blood (anemia, elevated

ESR, elevated acute phase reactants, reactive thrombocytosis). Blood and
leukocyte positive stool.
 Contrast: potential to cause nephropathy in patients with chronic renal
insufficiency (Cr > 1.5) or diabetes. Non-ionic are better than hyperosmolar
ionic agents. Also use hydration and acetylcysteine prior to giving. Consider
alternative studies.

Clubbing: new clubbing in patients with COPD can indicate cancer. NOT a
feature of simple COPD. Thickening of the nail bed, loss of angle between nail
bed and nail fold.

Ehrlichiosis: history of tick bite, systemic symptoms (fever, malaise, myalgias,

HA, nausea, vomiting), leukopenia/thrombocytopenia, elevated LFTs, endemic
area (SE, SC, mid-atlantic, upper MW, California). No rash present. Treat with
doxycycline without delay.

Alcoholic Hepatitis: AST:ALT > 2, thought to be due to hepatic deficiency of

pyridoxal-6-phosphate (needed for ALT activity). Usually < 500. If higher,
consider viral, shock liver, or Tylenol use.

Nephrotic Syndrome: results in alterations in lipid metabolism. Dyslipidemia

puts patients at increased risk of for accelerated atherosclerosis. Added to
increased risk of thrombosis (usually venous, especially renal) -> risk for MI
and stroke. Have high LDL and low HDL.

Hypersensitivity Pneumonitis: inflammation of the lung parenchyma caused by

antigen exposure. Cough, breathlessness, fever, malaise occurring within 4-6
hours of exposure. Chronic -> weight loss, honeycombing, clubbing. Avoid
antigen. Can be bird fanciers lung or farmers lung.

Primary HIV Infection: present with mononucleosis type syndrome with fever,
night sweats, LA, arthralgias, diarrhea. Make the diagnosis in an early stage.
Usually 2-4 weeks after the exposure. Can have mucosal ulcerations and skin
rash. Prolonged diarrhea and weight loss.

Duodenal Ulcer: epigastric pain that improves with eating (otherwise

unopposed acidic fluid goes into duodenum). 90% are due to H pylori. Use PPI
and antibiotics as long term treatment (amoxicillin, clarithromycin, PPI).

Parkinsonism: most effective symptomatic therapy is L-dopa, but does not

stop progression. Greater risk of dyskinesia. SE are nausea, vomiting,
hypotension. Better for older patients. Other medications are DA agonists,
anticholinercics, amantadine. Young -> DA agonist.

VIPoma: pancreatic cholera. Diarrhea, hypokalemia (leg cramps), achlorhydria.

Women > men. Can become dehydrated, have abdominal pain, cramping,
weight loss, flushing. Test for VIP in blood. CT or MRI to confirm.

Pancreatic Cancer: enlarged, non tender gallbladder, evidence of biliary

obstruction (elevated direct BRN and ALP). US can show dilated ducts.
Abdominal CT to diagnose.

Gout: cessation of alcohol and low purine diet are important measures to
prevent future attacks. Ethanol -> lactate which competes with urate for
excretion. Also avoid drugs like diuretics and pyrazinamide. Treat acute attack
with colchicine, NSAIDs, or steroids.
 HOCM: heart murmur at LLSB that decreases with increased preload (standing
to squatting) or intensifies with decreased preload (Valsalva). MC in AA. AD
disease inheritance.

Dermatitis Herpetiformis: presence of pruritic papules and vesicles over

extensor surfaces and presence of anti-endomysial antibodies. Also have GI
symptoms of malabsorption. Increased risk of GI lymphomas (reduced with
gluten free diet).

Choledochal Cysts: congenital abnormalities of the biliary tree characterized

by dilatation of the intra and/or extra hepatic biliary tracts. Most cases related
to anomalous pancreaticobiliary junction. Leads to weakness and dilatation of
the biliary wall due to reflux of pancreatic secretions. Present with jaundice
and passage of acholic stools. Abdominal pain, jaundice, attacks of acute
pancreatitis (elevated amylase and lipase). Can degenerate into
cholangiocarcinoma. Do US followed by CT/MRI.

Bacillus Cereus: causes nausea and vomiting after eating rice. Symptom onset
is 1-6 hours. Produces a heat stable toxin in inadequately refrigerated cooked
rice. Chemical irritants also cause abrupt onset nausea and vomiting.

Tetracyclines: important cause of phototoxic drug eruptions. Manifest as

exaggerated sunburn reactions with erythema, edema, vesicles over sun-
exposed areas. Consider in patient being treated for mild-moderate acne.
Doxycycline is most photosensitizing. Produce reactive oxygen products with
exposure to UV radiation.

Jaundice: determine if conjugated or unconjugated. Dipstick with bilirubin

suggests conjugated. Rotors syndrome is a possible cause (benign condition
with defective hepatic storage of conjugated BRN -> leaking into plasma.
LFTs are normal. No treatment necessary.

SIADH: water restriction is first step in managing their hyponatremia. Can

occur from lung cancer. If Na < 120 or if patient is having seizures, use 3%
NaCl to raise to 125. If evidence of fluid overload, CHF, resistant to treatment,
use loop diuretics. Lithium or demeclocycline for chronic treatment.

Gout: caused by overproduction or underexcretion. Chemotherapy -> rapid

tumor cell lysis -> uric acid release. Give allopurinol to prevent formatin of
uric acid with chemotherapy. To prevent, use allopurinol or probenecid. To
treat, use colchicine, NSAIDs, steroids.

SLE: presence of antibodies to DS DNA is highly specific for and confirms

diagnosis. Also have lack of or reduced suppressor T cell functions and
hyperproduction of helper T cells. Concurrent B cell hyperactivity -> increased
serum Ab and IgG -> immune complexes.

De Quervains Tenosynovitis: classically affects new mothers that hold their

infants with the thumb outstretched. Abductor pollicis longus and extesor
pollicis brevis tendons affected. Tenderness to palpation of radial side of wrist.
Finkelsteins test (passive stretch of tendons with thumb gripped inside fist
and ulnar deviation).

Warfarin: vitamin K antagonist used for anticoagulation. Foods with high vit K
(dark green, vegetables) decrease efficacy while foods, supplements,
 medications such as alcohol, vitamin E, garlic, ginko biloba, ginseng, St Johns
wort, antibiotics increase efficacy -> bleeding.

Vitiligo: macular depigmentation that involves acral and peri-orificial areas.

Caused by autoimmune destruction of melanocytes. Pale white macules with
hyperpigmented borders.

Isoniazid: 10-20% of patients develop mild aminotransferase elevation within

first few weeks of treatment. Injury is self limited and resolves without
intervention. LFTs usually < 100. Can continue taking it as long as LFTs are
regularly monitored and remain mildly elevated.

Unconjugated Hyperbilirubinemia: Gilberts, Crigler-Najjar Type 1 and 2 are

causes.

Gilberts Syndrome: familiar disorder of BRN glucuronidation, production of

UDP glucuronyl transferase is reduced. Icterus secondary to mild
unconjugated hyperbilirubinemia (< 3). Have malaise, fatigue, abdominal
discomfort. Hemolysis, fasting, consuming fat free diet, physical exertion,
febrile illness, stress or fatigue will precipitate.

Crigler Najjar Type 1: AR with severe jaundice and neurological impairment

due to kernicterus. 20-25, can be upto 50. LFT and histology are normal.
Phenobarbital does not change BRN level. Phototherapy and plasmapheresis
for short term, liver transplant for long term.

Crigler Najjar Type 2: AR with milder jaundice (< 20). Survival into adulthood
with no kernicterus or neurological impairment. LFT and histology are normal.
Phenobarbital decreases BRN level. Periodic phenobarbital or clofibrate can be
used if necessary.

Mallory Weiss Tears: increased intragastric pressure during vomiting -> tears
in cardial mucosa and sometimes esophagus. Account for upto 10% of GI
bleeds. Usually spontaneously stops but can use vasopressin, endoscopic
injection, electrocautery.

Pseudotumor Cerebri: LP only after completely ruling out space occupying

lesion with CT/MRI. Have pulsatile HA that awakens patient from sleep. Can
have neck pain, double vision, visual loss, tinnitus. Can have papilledema or VI
nerve palsy. Most patients have empty sella (caused by downward herniation
of arachnocele due to high CSF pressure). LP has high opening pressure.
Remove sufficiency CSF to decrease pressure to 150.

Brain Hemorrhage: hypertension and atrial fibrillation on anticoagulation are

major RF. Regularly assess general well being and current medication list in
elderly patients. Hyperdense area on CT indicative of bleed. Stop
anticoagulation and give FFP and Vit K.

Coarctation: presents with rib notching on CXR. 3 sign is typically seen with
coarctation of longer duration implying proximal aortic dilatation, constriction,
descending aortic dilatation. MC location is at site of LA. HA, epistaxis, cold
extremities. Radiofemoral delay. Upper extremity may be preferentially well
developed.
 Hepatorenal Syndrome: complication of liver disease characterized by renal
failure that does not respond to fluid resuscitation. Decreased GFR in absense
of shock, proteinuria, other clear cause of dysfunction. Results from
vasoconstricton due to decreased blood flow and low vasodilatory product
production. Type 1 is rapid and patients die within 10 weeks. Type 2 is slower
and survival is 3-6 months. MCC of death is hemorrhge or infection. Liver
transplant is only treatment.

Disseminated Histoplasmosis: occurs in patients with HIV. Treat with IV

amphotericin B to decrease fungal load with lifelong itraconazole to prevent
relapse.

Pagets Disease: osteitis deformans. MCC of asymptomatic elevation of ALP in

elderly.

Dyslipidemia: first line treatment is statin therapy. Is increased to maximum

dose as needed. With persistently low HDL, after max statin, start nicotinic
acid. Usage usually limited by SE like flushing, pruritis, nausea, paresthesias.
Use controlled form for decreased SE.

Glucagonoma: patient with hyperglycemia, necrolytic migratory erythema,

diarrhea. Triad of hyperglycemia, necrotizing dermatitis, weight loss. Usually
malignant and metastasizes to the liver. Elevated glucagon in the blood.
Pancreatic tumor on CT scan. Surgery to treat.

Lactose Intolerance: positive hydrogen breath test, positive stool for reducing
substances, low stool pH, increased stool osmotic gap. No steatorrea. Osmotic
diarrhea, abdominal cramps, bloating, diarrhea. Breath test = positive
hydrogen level after ingestion = bacterial metabolism.

Cerebellar Hemorrhage: sudden onset vertigo, occipital headache, vomiting in

hypertensive patient. Can have VI paralysis, conjugate deviation,
blepharospasm, coma. Generally evolves over hours. Fever is common with
any brain hemorrhage. Immediate evacuation needed.

Pneumoconiosis: causes restrictive interstitial lung disease with normal or

high FEV1/FVC and decreased DLCO (normal DLCO would be neuromuscular).
Can result in fibrosis from occupational exposure. Asbesosis -> pleural
calcifications (can be from hemorrhage or empyema).

Hyperparathyroidism: uncommon cause of secondary HTN. Asymtomatic

hypercalcemia in a hypertensive patient or presence of symptoms of
hypercalcemia.

Anterior Cerebral Artery Stroke: contralateral motor and sensory deficits which
are more pronounced in the lower limb than the upper limb. May have urinary
incontinence, gait apraxia, primitive reflexes, abulia, paratonic rigidity.

Systolic Heart Failure: depressed CI (measure of cardiac output), increased

TPR (due to sympathetic output and RAAS activation), increased LVEDV (may
be normal in diastolic failure).

Pica: appetite for non nutritive substances like ice, clay, dirt, paper products.
Can be a cause of iron deficiency (suspect chronic bleeding), especially with
ice. May also be a manifestation of psychiatric disease.
 Metastatic Prostate Cancer: radiation therapy is done in patients with prostate
cancer who have undergone orchiectomy. Do focal external beam therapy.

WPW: if develop atrial fibrillation with rapid ventricular rate treat with
cardioversion or procainamide/quinidine. AV blockers like beta blockers, CCB,
digoxin, adenosine should be avoided since it can increase conductance
through accessory pathway.

Iron Deficiency: low serum iron, ferritin, transferrin saturation, high TIBC. Have
low MCV, MCH, reticulocyte count. Have anisocytosis, poikilocytosis,
hypochromia, microcytosis on smear.

Steroid Induced Myopathy: painless proximal muscle weakness that improves

when medication was discontinued. Have normal ESR (unlike PMR). May have
history of disease that was or should be treated with steroids.

Syringomyelia: areflexic weakness of upper extremities and dissociated

anesthesia in cape distribution. Presence of cord cavity is most
characteristic feature. Caudal displacement of 4 th ventricle, cerebellar tonsils,
focal cord enlargement may occur.

Mitral Stenosis: left atrial dilatation with risk of atrial fibrillation and cardiac
emboli. Pressure is transmitted to pulmonary vasculature -> dyspnea, cough,
hemoptysis. Can present with stroke. Patient may have history of rheumatic
fever or be an immigrant.

Multisystems Atrophy: Shy Drager Syndrome. Patient with Parkinsonism

presents with orthostatic hypotension, impotence, incontinence, other
autonomic symptoms. Also have widespread neurological symptoms. Can
have accompanying bulbar dysfunction or laryngeal stridor. Treat with
intravascular volume repletion, fludricortisone, salt, alpha agonists.

Dilated Cardiomyopathy: can be secondary to alcoholism. Thrombocytopenia,

macrocytosis, elevated transaminases suggest alcoholism. Total abstinence
from alcohol may reverse condition if employed early in the disease.

Macular Degeneration: usually seen in patients over 50 years old. Presents

with bilateral progressive loss of central vision. Navigational and peripheral
vision is preserved but may be complicated by cataracts. Degeneration of
outer retina, pigment epithelium.

Parapneumonic Effusion: when pH < 7.2, glucose < 60, probability is high that
fluid needs to be drained. Drained via a chest tube (tube thoracostomy).

Ischemic Strokes: fibrinolytic therapy improves outcomes if given within 3 to

4.5 hours of onset. Non contrast CT should be done prior to rule out
hemorrhage and patient should be screened for other CI to therapy.

Herpes Zoster: a painful reaction of the varicella zoster virus that causes
vesicular rash in dermatomal distribution. Acyclovir and other antivirals are
used to decrease duration and incidence of post herpetic neuralgia. Pain
precedes rash by 48 hours.

CMV Colitis: any HIV (+) patient with bloody diarrhea and normal stool
examination should have colonoscopy to look for CMV colitis. Bloody diarrhea
 with abdominal pain. Colonoscopy shows multiple ulcerations and mucosal
erosions. Biopsy has characteristic cytomegalic cells with intracytoplasmic and
intranuclear inclusions.

Aortic Regurgitation: wide pulse pressure, felt as water hammer pulse. Lying
down and turning to the left brings the heart closer to the chest wall and
makes the patient more aware of forceful heartbeat. Aortic root and bicuspid
aortic valve are MCC. Rheumatic fever is CC.

Adrenal Insufficiency: characterized by non specific symptoms like anorexia,

fatigue, GI complaints, weight loss, hypotension, hyperpigmentation.
Hyponatremia is MC electrolyte abnormality and hyperkalemia is common as
well. Due to volume loss and low aldosterone.

PE: suspected in all patients at risk of DVT with acute onset tachypnea,
dyspnea, chest pain. Can have exudative (MC) or transudative effusion.
Diagnosed by helical CT of chest.

Chi Square Test: used to compare proportions. A 2 by 2 table may be used to

compare the observed values with expected values.

Cholelithiasis: UDCA is a medication used to dissolve small radiolucent

gallstones in patients with normal functional GB who are poor surgical
candidates. Medication is very costly and associated with high risk of relapse.
Also tell to avoid fatty foods.

Factor V Leiden: MC inherited disorder causing hypercoagulability and

predisposition to thromboses, especially DVT of lower extremities. Mutation ->
resistance to deactivation by protein C.

DVT: treated to prevent PE. CI to anticoagulation are recent surgery,

hemorrhagic stroke, bleeding diathesis, active bleeding. HIT and developing
DVT/PE even with anticoagulation are indications to put in an IVC filter.

Acute Variceal Bleeding: first step is to establish vascular access with two
large bore IV needles or central line. Protect airway and decompress stomach
with NG to prevent aspiration. 50% stops spontaneously. Terlipression (analog
of vasopressin), octreotide, somatostatin can be used. Rebleeding is common
in 6 weeks following initial bleed.

Sarcoidosis: most commonly affects young to middle aged AA females causing

insidious onset dyspnea and dry cough in the absence of constitutional
symptoms. Also affects skin (erythema nodosum, protean manifestations),
and eyes (uveitis). Diffuse interstitial infiltrates on CXR.

Loop Diuretics: cause hypokalemia and hypomagnesemia which can cause

ventricular tachycardia and potentiate effects of digoxin. Order serum
electrolytes and digoxin level.

Vibrio Parahemolyticus: diarrhea usually transmitted by ingestion of seafood

(shrimp, crab, raw oysters). Have fever, abdominal cramps, nausea after 4
hour to 4 day incubation period. Can be watery or bloody diarrhea.
 Tuberculosis: most cases occur in people who have immigrated to this country
from endemic geographic regions. Have chronic low grade fever, sweats,
weight loss, cough productive of blood tinged sputum.

Chronic Liver Disease: hyperestrogenism as a result of decreased clearance of

estrogen from blood by the liver due to increased portosystemic shunting.
Decreased sex hormone binding globuin synthesis increases ability of
estrogen to exert its biologic effects. Have telangiectasias, palmar erythema,
testicular atrophy, gynecomastia, impotence. Can have hypothalamic-pituitary
dysfunction as well -> secondary hypothyroidism.

Seborrheic Dermatitis: characterized by waxy scales with underlying erythema

on the scalp, central face, presternal region, interscapular areas, umbilicus,
body folds. May be in association with Parkinsonism or HIV. Pityrosporum ovale
plays role. Use antifungals.

GBM: typical CT/MRI findings are heterogeneous and serpiginous contrast

enhancement with classic butterfly pattern. Change in personality and strange
behavior -> frontal lobe.

Acute Prostatitis: presents similarly to UTI, addition of perineal pain and

tender boggy prostate. Cystitis is uncommon in men. Vigorous prostatic
massage should be avoided -> bacteremia. Obtain a mid stream urine sample
to direct antibiotic therapy.

Radioactive Iodine: in hyperthyroid patients not initially treated with

antithyroid medications, treatment with RI may initially cause exacerbations
of thyrotoxic state. Especially in elderly patients with cardiovascular disease.

Diffuse Esophageal Spasm: seen in young females, can present with

intermittent episodes of chest pain and dysphagia. Barium swallow may reveal
corkscrew esophagus. Have high amplitude peristaltic contractions. Treat with
antispasmodics, diet changes, counseling.

Exercise Induced Asthma: short acting beta agonists administered 20 minutes

before exercise are first line treatment. Induced trigger is rapid ventilation of
cold dry air. Atopic dermatitis and allergic rhinitis. Long acting beta agonists
may be used in children and athletes.

Optic Neuritis: central scotoma, afferent pupillary defect, changes in color

perception, decreased visual acuity. Associated with MS. Presents in women
20-45 years old. Have pain with eye movement.

Risk: probability of getting disease over a certain period of time. Divide

number of diseased subjects by total number of subjects at risk.

HIV Vaccinations: follow same immunization schedule as the general

population for Td. Should get it every 10 years. Patients < 65 who have never
had Tdap should get one dose. Get influenza, HBV, pneumococcus. HAV for
MSM.

Sickle Cell Trait: suspect in young black male who presents with painless
hematuria. Thought to be due to papillary ischemia due to low local oxygen
tension -> sickling.
 Unfractionated Heparin: thrombocytopenia and hypercoagulation within days
of starting anticoagulation therapy. HIT -> abnormal intravascular thrombosis.
Heparin induced release of platelet factor 4 -> immunogenic heparin-PF4
complexes. IgG Ab -> activation of platelets and endothelial cells and
abnormal generation of intravascular thrombin. Elevated aPTT.

Thrush: MC SE of inhaled steroid therapy. Cornerstone of asthma therapy. High

doses for long period -> systemic symptoms of adrenal suppression, cataract
formation, decreased growth in children, interference with bone metabolism,
purpura.

Ankylosing Spondylitis: seronegative spondyloarthropathy, HLA-B27

association. Young men with progressive inflammatory back pain and stiffness.
Reduced lower back ROM and sacroiliitis. MC extraarticular manifestation is
anterior uveitis (monocular pain, blurring, photophobia).

Hereditary Spherocytosis: AD defect in spectrin. Anemia, spherocytosis,

splenomegaly, increased osmotic fragility. May present with cholecystitis.
Complicated by episodes of aplastic crisis. Life threatening, due to parvovirus
infection. Should be on folate to prevent severe anemia. Smear ->
spherocytes and polychromatophilia. MCV is normal. MCHC is elevated.

Metaclopramide Induced Dystonia: DA antagonist and prokinetic agent used to

treat nausea, vomiting, gastroparesis. Can cause agitation and loose stools as
well. EPS occur less frequently. NMS may occur rarely. Treat with
discontinuation and benztropine or Benadryl.

Secondary Hyperparathyroidism: hypocalcemia and hyperphosphatemia with

increased PTH, usually due to CRF. Almost university in ESRD. Phosphate
retention -> hypocalcemia which stimulates PTH. High phosphate blocks
calcium receptors on PTH gland. Low formation of Vit D3 -> no inhibitory
effect on PTH. PTH resistance is similar but earlier.

HIT: first step in management is to stop all heparin including LMWH. HIT I is
non immune -> direct heparin effect on platelets. HIT II is autoimmune, within
4-10 days. Give alternate anticoagulation like danaparoid and direct thrombin
inhibitor (argatroban, lepirudin).

Respiratory Alkalosis: kidney compensates by preferentially excreting

bicarbonate -> alkalinized urine with high pH.

PSVT: most commonly results in accessory conduction pathways through AV

node. Vagal maneuvers (cold water dunking, valsalva, carotid massage) and
medications (adenosine) resolve and decrease conduction through AV node.

Staph Endocarditis: IVDA are at increased risk usually on tricuspid valve. Also
those with skin infections, infected medical devices. Vegetations can embolize
to the lungs causing nodular infiltrate with cavitation.

Delerium: acute confusional state due to organic illness commonly

superimposed on dementia in the elderly. Urosepsis and metabolic
disturbances are common precipitants. Do UA and CMP initially. Are confused,
disoriented, have hallucinations. MCC in hospitalized patients is withdrawl or
substance abuse.
 SCC: firm solitary LN are highly suspicious for LN metastases, particularly in
older patients with a significant smoking history. Non-tender solitary nodes in
head and neck (submandibular and cervical) are concerning for SCC. Do
prompt biopsy.

Exertional Heat Stroke: occurs in otherwise healthy individuals undergoing

conditioning in extreme heat and humidity due to thermoregulation failure.
Temperature > 105 (can cause rhabdomyolysis -> large blood but no RBC in
urine, organ system damage), altered mental status, dehydration,
hypotension, tachycardia, tachypnea.

Diverticulosis: if asymptomatic only needs dietary modification in the form of

high fiber intake -> bulky stools -> increase width of colon -> decreased
pressure. Causes constipation and abdominal pain in elderly patients.

Coccidiomycosis: endemic in the southwestern US, as well as Central and

South America. Primary pulmonary infection has non-specific features like
fever, fatigue, dry cough, weight loss, pleuritic chest pain. Can have erythema
multiforme, erythema nodosum, arthralgias.

Actinic Keratosis: develop in predisposed individuals in chronically sun

exposed individuals. Erythematous papules with central scale and
sandpaper texture. 1% convert to SCC. Hyperkeratosis -> cutaneous horns.

Skin Histology: acanthosis (thickening of epidermis), parakeratosis (retention

of nuclei into stratum corneum), dyskeratosis (abnormal keratinization),
hyperkeratosis (thickening of stratum corneum). All seen in AK.

Ethylene Glycol Poisoning: hypocalcemia and calcium oxalate deposition in the

kidneys. Flank pain, hematuria, oliguria, ARF, anion gap metabolic acidosis.
Give fomepizole or ethanol to achieve alcohol dehydrogenase inhibition,
bicarb to alleviate acidosis, dialysis for acidosis or organ damage.

Coagulopathy: FFP contains all the clotting factors and first line treatment
(esophageal variceal bleeding in patients with hepatic disease). Also has
plasma proteins and fluid. Fluid resuscitation is more important that diagnosis
in unstable patients.

Ectopic ACTH: lung cancer can cause. Important cause of Cushings. Sexual
dysfunction can be presenting complaint. Can have hypokalemic acidosis. Also
caused by adrenal neoplasia, pituitary adenoma, exogenous intake.

Acromegaly: gold standard test is measurement of GH levels following oral

glucose load. Patients are unable to suppress GH levels after glucose. IGF1 is a
good screening tool. Have uncontrolled HTN, increase in ring size,
doughy/sweaty hands, skin tags, CTS. Normal individuals suppress GH < 1
mcg/dl after 75g glucose,

Porphyria Cutanea Tarda: painless blisters, hypertrichosis, hyperpigmentation.

Associated with HCV infection. Triggered by ingestion of certain substances
(ethanol, estrogen) which should be discontinued. Deficiency of
uroporphyrinogen decarboxylase. Elevated urine porphyrin levels. Phlebotomy
or hydroxycholoquine may provide relief. IFN-alpha for HCV.
 Hemochromatosis: increased intestinal iron absorption results in deposition of
excessive amount of iron -> tissue damage and organ failure. Have > 45%
transferrin saturation and > 1000 ferritin. HCC is the most serious
complication and causes 30% of deaths.

Aspiration Pneumonia: impaired consciousness, advanced dementia, other

neurologic dysfunction due to impaired epiglottic function. Aerobic oral flora
are usual pathogens like viridans strep. May be necrotic -> abscess.

Acute Vertigo: sensation of spinning head, due to dysfunction of the labyrinth.

BPPV have symptoms related to head position. Cerebral ischemia ->
presyncome -> lightheadedness. 30% of cases can occur after trauma.

Pseudomonas: common cause of severe, pulmonary infections in CF patients.

Preferred therapy is aminoglycoside (tobramycin), and antipseudomonal PCN
(piperacillin). Can use antipseudomonal cephalosporin (ceftazidime,
cefepime), and aminoglycoside. Fluoroquinolone can be used in adults as AG
alternative.

Metastatic Breast Cancer: local therapy is rarely curative (resection of

metastases, local radiation) but can be tried in patients with soliary focus
without signs of metastatic involvement.

Recurrent Pneumonia: in same anatomic location is red flag for cancer or

some obstruction. Smoking is another RF for cancer. When suspected, do CT
chest. Bronchoscopic of CT guided biopsy depending on location. Could be due
to bronchiectasis, foreign body, bronchial stenosis.

TCA OD: sodium bicarb (if QRS > 0.1 seconds) narrows QRS preventing
development of arrythmia by alleviating cardio-depressent action on sodium
channel. QRS prolongation -> ventricular arrhythmias.

Vertebral Osteomyelitis: MRI of the spine is most sensitive indicator. It will

reveal if there is an abscess or cord compression. Blood cultures are important
for targeting antibiotic therapy. Usually hematogenous, and lower back. Low
grade fever, ESR. Local tenderness to percussion and paraspinal spasm.

Dementia vs Normal Aging: impairment in ADLs is essential for differentiating

dementia from normal changes in aging. Patients with dementia have
functional impairments.

Buproprion: FDA approved for smoking cessation. Use in conjugation with

counseling and nicotine replacement. TCAs like amytriptyline are also used
but not FDA approved. Varenicline is a partial agonist of the nicotinic receptor
and is somewhat more effective.

Subdural Hematoma: serious intracranial hemorrhages that occur due to

tearing of bridging veins. Blunt trauma is the MCC and surgical evacuation is
usually required. Develop more slowly than epidural. Have HA and LOC.
Common in older patients. White cresecent on CT with possible midline shift.

Respiratory Acidosis: can be due to chronic hypercapia from COPD. Body

compensates by increasing HCO3 reabsorption from renal tubules. Can also be
due to obesity hypoventilation, neuromuscular. Patients typically do not
normalize or overcorrect pH.
 MS: suspect in female patient with multiple neurologic presentations
interspaced between time periods. Optic neuritis can result in blurring of
vision and is often associated with retrobulbar pain. Brainstem involvement ->
diplopia, nystagmus, vertigo, facial weakness, hemispasm.

HIV Ophthalmologic Disease: HSV and VZV can both cause severe, acute
retinal necrosis associated with pain, keratitis, uveitis, peripheral pale lesions
and central necrosis on fundoscopy. CMV retinitis is usually painless and not
associated with keratitis or conjunctivitis. Hemorrhage and fluffy or granular
lesions around retinal vessels.

Acute Hepatitis B: testing for both HBsAg and anti HBc is best screening.
ALT>AST. HBsAg is the first marker detected and is detectable during entire
symptomatic phase. Anti-HBs is found after immunization or clearance of
HBsAg, detectable for life. Indicator of noninfectivity and immunity. Window
period between disappearance of HBsAg and anti-HBs. HBcAg not usually
detectable. Anti-HBc appears after HBsAg, IgM is indicative of acute disease
and is present during window period, so is important between clearance of
HBsAg and anti-HBs. HBeAg detectable shortly after HBsAg, indicates viral
replication and infectivity. Cleared before HBsAg and followed by presence of
anti-HBe. Anti-HBe suggests cessation of active replication and low infectivity.

Overflow Incontinence: autonomic neuropathy may lead to denervated

bladder -> overflow incontinence. Characterized by high PVR. Can be due to
diabetes.

Acute Hepatic Encephalopathy: lactulose and reduced protein diet. Increased

levels of ammonia -> inhibitory neurotransmission via GABA. Non responders
to lactulose, use ornithine-aspartate infusion, oral sodium benzoate. Neomycin
also (long term -> ototoxicity and nephrotoxicity).

CTS: most common mononeuropathy of upper extremity. Paresthesias of first

3 digits and occasionally thenar eminence atrophy.

Empyema: infection of pleural space. Can occur from parapneumonic

effusions. Common cause is hemothorax. Present with low grade fever and
best diagnosed with CT. When localized, complex, thick rim, surgery is answer.

CIN II/III: should have Pap smears with or without coloposcopy and ECC every
6 months until 3 (-) results. May resume standard screening after that (annual
until 65 or 70). Can increase to every 2-3 years if 3 (-) results with same
monogamous partner.

Tumor Lysis Syndrome: hyperphosphatemia, hypocalcemia, hyperkalemia,

hyperuricemia. Tumors with high cell turnover (poorly differentiated
lymphomas and leukemias). Allopurinol can decrease incidence of acute urate
nephropathy. Phosphate binds calcium and causes hypocalcemia.

Testicular Mass: after diagnosis of solid testicular mass is made (painless hard
mass in testicle + suggestive US), initial management is removal of the testis
and cord. Transcrotal biopsy is CI due to risk of spillage of cancer cells ->
spread through lymphatics and blood.

Nephrosclerosis: usually due to HTN. MC lesions are arteriosclerotic lesions of

afferent and efferent renal arterioles and glomerular capillary tufts. As HTN
 progresses -> decreased blood flow and GFR -> glomerulosclerosis. Hematuria
and proteinuria. Kidneys are small.

Mitral Stenosis: due to rheumatic heart disease (MC valvular manifestation),

especially in immigrants. 70% of patients develop atrial fibrillation due to LA
dilation. Irregularly irregular with no p waves. Lack of atrial kick -> pulmonary
congestion -> dyspnea.

GBS: acute or subacute ascending paralysis. CSF has elevated protein with
normal glucose, WBC, RBCs. Acute idiopathic polyneuropathy. Motor > sensory
(can have distal parasthesias). Autonomic disturbances are rare & fatal. Treat
with IVIG and plasmapheresis.

Acute Otitis Media: consider in any patient with ear drainage and difficulty
hearing. Ear pain is also common, but may be absent in young patients. Fever,
irritability, diarrhea. Can have boggy nose and PND. Erythematous TM with
decreased motion.

Mitral Regurgitation: MC valvular abnormality observed in patients with

endocarditis not related to IVDA. Subacute endocarditis affects previously
damaged valuves (previous murmur).

PAC: benign and to not require any follow up or treatment. P waves that are
premature relative to the cardiac cycle and differ in morphology. Anxiety, CHF,
hypoxia, caffeine, electrolyte abnormalities.

Hypocalcemia: patients who receive multiple transfusions or PRBCs over 24

hours may develop elevated levels of citrate which chelates calcium
(paresthesias) and magnesium. Usually in massive transfusions of > 1 blood
volume over 24 hours.

Toxic Epidermal Necrolysis: severe mucocutaneous exfoliative disease.

Erythematous morbilliform eruption that rapidly evolves into exfoliation of the
skin. (+) Nikolskys sign. Painful oral blisters. Reaction to drug (sulfonamides,
barbiturates, phenytoin, NSAIDs). In the spectrum of SJ and SJ/TEN overlap. SJ
< 10% of body. TEN > 30%.

Hemochromatosis: causes a restrictive cardiomyopathy (diastolic dysfunction).

Symmetric thickening. Signs of right heart failure and sometimes left heart
failure. Can be reversed with early treatment (phlebotomy).

AV Fistulas: cause high output cardiac failure -> increased cardiac preload.
Can be due to trauma. Circulation cannot meet O2 demands of the body. Wide
PP, brisk carotid upstroke, tachycardia. Flushed extremities, displaced PMI.
Thyrotoxicosis, Pagets disease, anemia, thiamine deficiency also cause high
output cardiac failure.

MG: oral anticholinesterases are initial treatment of choice. Increase Ach at

the synapse. Use pyridostigmine or neostigmine. SE are abdominal cramps,
fasciculations, muscular weakness. Immunosuppression and thymectomy are
also used to treat.

Cellulitis: infection of the skin and subcutaneous tissue. Obseity, venous

insufficiency, disruption of the cutaneous barrier, previous cellulitis are RF.
 Red, edematous skin that is hot to the touch is consistent. Fever,
lymphangitis, LA (masses) are seen. GAS and Staph.

Melanoma: excisional biopsy with narrow margins is preferred study. If depth

< 1 mm, can be excised with 1 cm tumor free margin, with 99% 5 year
survivial. > 1 mm depth should have sentinal node study. Excision allows
multiple parameters to be determined. Do not excise with wider margins until
diagnosis is made -> may disrupt lymph flow and ability to ID sentinal nodes.

MEN IIa: medullary carcinoma of the thyroid, hyperparathyroidism,

pheochromocytoma. Serum calcitonin is elevated, use this to screen.

CAH: 21 hydroxylase deficiency is the MC form. Partial deficiency presents in

adulthood with signs of hyperandrogenism. 17 alpha hydroxyprogesterone
accumulates. Also have salt wasting due to aldosterone deficiency. 17
hydroxylase deficiency -> delayed puberty and mineralocorticoid excess. 11
beta hydroxylase deficiency -> androgen and mineralocorticoid excess. 3 beta
hydroxysteroid dehydrogenase deficiency -> DHEA-S excess.

Autoimmune Hemolytic Anemia: in patient with malignant lymphoproliferative

disorder is likely due to anti-RBC IgG warm immunoglobulins. Treat with
prednisone. If ineffective, splenectomy. May have enlarged LN. Have elevated
BRN, LDH, low haptoglobin. Coombs (+).

Hepatic Encephalopathy: alteration in CNS function due to decreased

clearance of toxins. Typically clear precipitant and symptoms may range from
mild confusion to coma. Treat with lactulose, neomycin or rifaximin, laxatives.
Will have asterixis in exam.

Strawberry Hemangiomas: benign vascular tumors of childhood. Appear

during first few weeks of life, initially grow rapidly, regress by 5-8 years.
Composed of capillaries separated by connective tissue. Can be found in deep
tissues (liver). Endothelium rapidly proliferates.

Transfusions: individuals who received transfusions before 1992 should be

screened for HCV. Before 1986, HBV.

UTI: common in diabetics, elderly, postoperative. Elderly may present with

confusion and absence of GU complaints. UA will help diagnose. (+) nitrites,
LE, bacteria, > 5 WBC. TMP-SMX is appropriate treatment.

HIV Pulmonary Cavitation: can be caused by Tb, atypical mycobacteria,

Nocardia (weakly acid fast, branching, filamentous G(+) rod), G(-) rods,
anaerobes. Nocardia is found in soil and water. Infects immunocompromised
-> nodules, reticulonodular, diffuse infiltrates, abscess, cavity. Treat with TMP-
SMX.

Post Cholecystectomy Pain: MC occurs due to CBD stones, sphincter of Oddi

dysfunction, or functional causes. Normal LFTs and no bile duct dilatation rule
out first two causes. Treat symptomatically with analgesics and reassurance.

Kaposi Sarcoma: caused by HHV-8. Asymptomatic, elliptical, linearly arranged

papules -> plaques, nodules. Involve legs, face, oral cavity, genitalia. No
necrosis of skin or underlying structure involvement.
 Cluster HA: acute severe retroorbital pain that wakes patient from sleep.
Accompanied by redness of ipsilateral eye, tearing, redness, stuffed or runny
nose, ipsilateral Horners syndrome. Occur in clusters, daily, for 6-8 weeks,
followed by remission for a year. Acute attack: treat with 100% O2 and SQ
sumatriptan.

Iron Deficiency Anemia: decreased serum iron/percent saturation, elevated

TIBC. Decreased MCV/MCH. MCC in infants is inadequate intake. In older
children and adults, is chronic blood loss. Children with diet primarily of milk
without iron supplemented foods in early years.

Anemia: the most appropriate blood product is PRBCs. In patient with pre-
existing heart disease, you want to keep Hgb > 10. Oxygenation can be
maintained at Hgb > 7 in patients with normal cardiac function. Transfusion is
often necessary with active bleeding.

Secondary Pneumothorax: suspect in patient with COPD presenting with

catastrophic worsening of symptoms. Dilation of airspace, especially in apices
-> present with acute chest pain and SOB. Worsening is slower in COPD
exacerbation caused by infection.

Subdural Hematoma: rupture of bridging veins. Can occur with severe

trauma, or minor trauma when patient is anticoagulated, especially
combination of ASA and warfarin. Semi lenticular hematoma on CT. More
common in elderly and alcoholics with brain atrophy.

Hashimotos Thyroiditis: anti-TPO are present in 90% of HT, tend to appear

later in life, are higher in early stages of disease, decrease with time and
treatment. Also have anti-thyroglobulin Ab.

Rheumatic Fever: patient with previous attack should receive antibiotic

prophylaxis with penicillin to prevent further attacks until 18. Due to untreated
streotococcal pharyngitis. Jones criteria require evidence of GAS infection and
evidence of 2 major, or 1 major/2 minor.
o Major: carditis, polyarthritis, chorea, rash (erythema marginatum), SQ
nodules
o Minor: arthralgias, fever, elevated acute phase reactants, prolonged PR

Metabolic Alkalosis: can be chloride sensitive (hypochloremic, saline

responsive) or chloride resistant (normochloremic, saline unresponsive) based
on urinary chloride levels and ECF volume status. Chloride sensitive
associated with low urinary chloride excretion and volume contraction.
Diuretics, loss of gastric secretions. Correct with saline. Chloride resistant has
urinary chloride > 20 and volume expansion. Primary hyperaldosteronism,
Bartter syndrome, Gitelmans syndrome, excessive black licorice. Not
corrected by saline.

Latex Allergy: anaphylactic reaction on exposure to things like surgical gloves

and condoms. Common in patients with spina bifida.

Back Pain: common symptom. Identify signs of serious etiology: pain not
relieved by rest, night pain, constant or dull pain, lack of exacerbation with
movement or palpation, presence of neurologic changes. Cancer pain often
 not tender to palpation. MC are lung, breast, prostate, renal, thyroid. In older
man, get PSA.

Bowel Ischemia: common cause of lactic acidosis (anion gap metabolic

acidosis) in patients with severe atherosclerotic disease and atrial fibrillation
without anticoagulation.

Anemia: can be due to decreased RBC production, increased RBC destruction,

frank blood loss. Anemia of lymphoproliferative disorders is due to marrow
infiltration with cancerous cells (will have LA and splenomegaly). Treatment if
malignancy may improve anemia.

MEN IIa: AD, chromosome 10. Genetic testing has replaced serum calcitonin
as recommended screening test. If (+) for RET proto-oncogene, total
thyroidectomy is indicated.

Fibrocystic Disease: treat with aspiration of the cyst which should yield clear
fluid and result in disappearance of the mass. Afterwards patients are
observed for 4-6 weeks. No cytology needed. Rubbery, firm, mobile, painful
mass with more tenderness during menses.

PJP: occurs when CD4 < 200. Fever, dry cough, exertional dyspnea. CXR
shows diffuse bilateral interstitial infiltrates. Use TMP-SMX and prednisolone
when PaO2 < 70.

Insulinoma: elevated insulin, c-peptide, proinsulin levels > 5. In normal

individuals, glucose < 60 results in near complete suppression of insulin.
Hypoglycemia and elevated insulin indicates. Hypoglycemia in nondiabetics =
insulinoma or insulin/sulfonylurea use.

Atopic Dermatitis: in infancy, presents with pruritis, skin lesions typically

distributed symmetrically over the face, scalp, chest, extensor surfaces of
extremities. Diaper region is usually spared. Erythematous excoriated papules
that may weep. Decreased skin barrier function due to improper synthesis of
components of epidermal cornified cell envelope. Allergens readily access
deeper levels to generate immune response.

Pagets Disease of the Bone: characterized by increased bone remodeling and

abnormal osteoid formation. May be asymptomatic or accompanied by pain
and deafness. ALP elevation is only abnormality. Normal GGT. Treat with oral or
IV bisphosphanates.

Intermittent Catheterization: effective measure to reduce risk of UTI in

patients with neurogenic bladder or spinal cord injuries. Better than indwelling
catheters. Bacteria can form biofilm. Longer catheterization -> higher risk.

Mumps: parotitis. Orchitis is one of the most frequent complications of

mumps, 20% of cases. Common in 15-29. Rarely bilateral, rarely infertility
results. Apply cold compresses to parotid and testes. Aseptic meningitis and
encephalitis can be complications.

Aortic Dissection: tearing chest pain radiating to the back. Cardiac

tamponade, acute AR, stroke, renal failure can be complications. Tamponade
-> hypotension, increased JVP, pulsus paradoxus, pericardial effusion.
Difference in blood pressures between two arms.
 Chronic Pancreatitis: inflammatory condition characterized by chronic
abdominal pain and pancreatic insufficiency (diarrhea). Fecal elastase is most
sensitive and specific to diagnose pancreatic exocrine failure. Serum amylase
and lipase are usually normal.

Metabolic Syndrome: 3/5 (waist > 40 in men and > 35 women, fasting
glucose > 100-110, BP > 130/80, TG > 150, HDL < 40 in men and < 50
women). Increased waist to hip ratio. Insulin resistance plays central role in
pathogenesis.

Cryptococcal Meningitis: IV amphoterocin plus flucytosine. Usually have

underlying HIV infection. Encapsulated yeast that causes meningitis in HIV
patients. Tb can also be a cause. Once there is clinical improvement, changed
to oral fluconazole as maintenance.

Homocysteine: vitamin B6, B12 and folate all play role in metabolism. B12
used by methionine synthetase to make methionine from folate and oxidize 5-
MTHF -> THF which is reduced back to 5-MTHF by MTHFR. B6 used by
cystathione B synthetase to convert homocysteine to cystathione to be
converted into cysteine. B6 lowers homocysteine levels. B12 can be added if
patient is deficient.

Osteosarcoma: Codmans triangle and sunburst appearance are two classic

radiologic features. MC malignant bone tumor of youth. Average 15 y/o.
Usually boys > girl except early on when are they same. Occur in distal thigh,
proximal leg, proximal humerus. MC initial symptom is pain. Surgery to treat,
either limb saving or amputation.

AS: echo is needed for definitive diagnosis. Symptomatic requires

replacement. MCC of LV outflow obstruction. Angina, dyspnea, syncope are
symptoms. Crescendo-decrescendo systolic murmur. Pulsus parvus et tardus,
weak S2, S4.

Porcelain GB: intramural deposition of calcium salts and diagnosed on

abdominal x ray. Increased risk of carcinoma of the GB. Occurs in chronic
cholecystitis. Needs cholecystectomy.

Liver Metastases: MC site of colon cancer metastasis. RUQ pain, mildly

elevated LFTs, firm hepatomegaly. Diagnosed by abdominal CT. Microcytic
anemia and (+) FOBT indicate possible GI malingnancy.

DI: administration of DDAVP after water deprivation distinguishes between

nephrogenic and central. Central DI will increase urine osmolarity by 50%.
Peripheral will not. Treatment is intranasal DDAVP. Urine osmolarity will be less
than plasma. Concentrated urine after water deprivation = psychogenic
polydipsia.

IBD: may occur in association with inflammatory arthritis, especially UC. AS

and IBD are both associated with HLA B27. Both may be inherited with (+) p
ANCA despite absence of vasculitits. Can have erythema nodosum, pyoderma
gangrenosum, episcleritis, cholangitis.

Seborrheic Keratosis: common benign overgrowths with warty or cerebriform,

stuck on appearance. Typically pigmented but may lack pigment. Less
 common in dark skinned populations. Favor face and back. Slow enlargement
with increasing thickness.

Ewings Sarcoma: LE > UE. MC sites are metaphysis and diaphysis of femur,
tibia, humerus. Metastasizes early to lungs and LN. White males in 1 st or 2nd
decade. Confused with osteomyelitis. Fevers, anemia, leukocytosis, elevated
ESR. Lamellated onion skin appearance with moth eaten mottled
appearance and extension into soft tissue.

Acute Pancreatitis: hypotension indicates intravascular volume loss due to

local and systemic vascular endothelial injury -> increases vascular
permeability and transudation of plasma. Systemic vasodilation may occur.
Several liters of IVF may be needed.

PID: treat with appropriate antibiotics, council on safe sex practices, inform
any partners of the past 60 days so they can be treated. Also screen for HIV,
syphilis, HBV, cervical cancer (pap), HCV if have history of IVDA.

Gonococcal Arthritis: MCC septic arthritis in young sexually active adults. Can
present as asymmetric polyarthritis (with tenosynovitis and skin rash) or
isolated purulent arthritis affecting one or a few joints. Diagnosis may be
confirmed by gram stain of the synovial fluid, blood cultures, urethral cultures,
skin cultures.

Vaccinations: can decrease morbidity and mortality in certain patients. DM ->

up to date on Td, pneumococcal, and influenza vaccines. Td should be given
every 10 years after 18 and single Tdap between 19 and 64. Influenza to all
adults 50 and older, all adults with chronic disease, healthcare workers, close
contacts of children, nursing home workers. Healthy non-pregnant may get
intranasal. PCV to all 65 and older and all with chronic disease. If before 65,
need booster after 5 years.

Cauda Equina Syndrome: acute compression presenting with acute motor and
sensory loss, loss of rectal tone, urinary retention. Surgical emergency. MRI
should be performed to determine location. May occur with metastatic
prostate cancer.

Crohns Disease: non-caseating granulomas are characteristic. GI Tb,

sarcoidosis, Yersinia also cause GI granulomas. Shows transmural
involvement, skip lesions, cobblestone appearance, creeping fatty appearance
of the mesentery, fistulas, fissures, perianal disease.

Amiodarone: class III antiarrhythmic that causes lung fibrosis (total cumulative
dose). Thyroid dysfunction (85% hypothyroid), hepatotoxicity (stop only if >
2x normal), corneal deposits (benign), skin discoloration (blue gray
discoloration of the face) are also causes.

COPD: long term supplemental oxygen therapy has been shown to prolong
survival. PaO2 < 55, SaO2 < 88, erythrocytosis (Hcrt > 55), evidence of cor
pulmonale.

Vomiting: gastric contents are rich in acid, chloride, potassium. Vomiting ->
hypokalemic hypochloremic metabolic alkalosis. Bicarbonate levels rise due to
loss of hydrogen and activation of RAAS. Give isotonic NaCl with K to correct.
 Anion Gap Metabolic Acidosis: gap is increased by presence of non-chlorinated
acids in the serum. Lactic acidosis, ketoacidosis, methanol/formaldehyde,
ethylene glycol, salicylate poisoning, uremia.

Intrahepatic Cholestasis of Pregnancy: functional disorder of bile formation in

2nd or 3rd TM. Intense pruritis, increased serum bile acid concentation.
Significant itching on palms and soles, worse at night, skin excoriations, ALP
and total/direct BRN increased, AST/ALT can be high. Treat with UDCA.

PBC: autoimmune destruction of intrahepatic bile ducts and cholestasis. Anti-

mitochondrial antibodies are seem. Nocturnal pruritis, fatigue,
hepatosplenomegaly, xanthomas, elevated ALP, cholesterol, IgM. Treat with
UDCA. Can use methotrexate or colchicine.

Postoperative Endophthalmitis: MC form of endophthalmitis. Occurs within 6

weeks of surgery. Present with pain and decreased visual acuity. Swollen
eyelids, conjunctiva, hypopyon, corneal edema, infection. Can do intravitreal
antibiotic injection or vitrectomy.

Amyloidosis: causes nephrotic syndrome. History of RA or other chronic

inflammatory condition, enlarged kidneys, hepatomegaly. Have apple green
birefringence under polarized light after staining with congo red. Extracellular
amyloid fibrils on EM.

Antiphospholipid Antibody Syndrome: false (+) VDRL, prolonged PTT,

thrombocytopenia. Arterial and venous thromboses, tendency to spontaneous
abortions. Prophylaxis with low dose ASA and LMWH during pregnancy.

Angioedema: rapid onset non-inflammatory edema of the face, acral

extremities, genitals, trachea, abdominal organs. Due to C1 esterase inhibitor
deficiency which results in elevated edema producing factors of C2b and
bradykinin. C1q levels are normal in hereditary and low in acquired. C4 is
depressed. Episodes follow infection or trauma.

Hepatorenal syndrome: severe liver disease -> systemic hypoperfusion and

subsequent renal failure. Elevated Cr, low urine sodium (<10). Renal
hypoperfusion is the cause. Can be secondary to generation of NO in
splanchnic circulation due to portal HTN. Can use midodrine and octreotide.

Pseudodementia: elderly patients with depression can present with memory

loss. Can mimic other causes of dementia like Alzheimers. CT findings are
usually normal and non-contributory. Dexamethasone suppression test
abnormal in 50%.

Vasovagal Syncope: MCC syncope. Frequently recurrent. Neurally mediated or

neurocardiogenic syncope. Lightheaded, weak, blurry vision prodrome.
Provoked by emotional stimulus with rapid recovery. Upright tilt table test to
diagnose.

SLE Nephropathy: minimal mesangial lupus nephritis -> advanced sclerosing

lupus nephritis, graded I to VI. Treatment and outcomes are different. Must do
kidney biopsy in all patients with new onset lupus nephritis.
Immunosuppressive therapy given after grading.
 Breast Cancer: tumor burden is single most important prognostic
consideration in the treatment of patients with breast cancer. Based on TNM
staging. Stage IV is the worst. Decreasing significance: ER+ PR+ are good,
over expression of Her-2/neu is bad, histological grade.

Menieres Disease: disorder resulting from distention of the endolymph

compartment of the inner ear. Vertigo that lasts from 20 minutes to 24 hours.
Have ear fullness, tinnitus, hearing loss. First line therapy consists of
environmental and dietary modification, including maintenance of low salt
diet. Alcohol, caffeine, nicotine should also be avoided.

Hyperkalemia: ACE-I, NSAIDs, potassium sparing diuretics like spironolactone

and amiloride.

Leukamoid Reaction: marked increase in leukocytes due to severe infection or

inflammation. Increase in LAP is typical. CML is indistinguishable on smear but
LAP is usually low. Look for Philadelphia chromosome if unsure.

SIADH: hypotonic hyponatremia with euvolemia. Low plasma osmolarity

(<280), high urine osmolality (> 100-150) in suspected patients is diagnostic.
NSAIDs potentiate action of ADH. Hypothyroidism and adrenal insufficiency
should be ruled out.

GERD: predisposes to Barretts esophagus, erosive esophagitis, peptic

stricture formation. Strictures are symmetric narrowing of the involved
esophagus and dysphagia to solids but no weight loss. Radiation, scleroderma,
caustic ingestions also cause strictures. Adenocarcinoma occurs with long
GERD, asymmetric narrowing, weight loss. Any case of stricture with Barretts
should be biopsied.

Internuclear Ophthalmoplegia: characteristic of MS due to demyelination of

the MLF in the dorsta pontine tegument.

Vetricular Fibrillation: a reentrant ventricular arrhythmia. MCC death in

patients with acute MI. Caused by areas of partial block in conduction that
predispose to reentrance.

CML: increased number of mature granulocytic forms, segmented neutrophils,

band forms. Hypercellular bone marrow with promininent granulocytic
hyperplasia. Crisis phase can cause visual blurring and altered mental status.
BMT after high dose chemotherapy and radation needed. Can also give
imitinib, tyrosine kinase inhibitor.

Prsbycusis: sensorineural hearing loss due to aging. Noticed in 6 th decade with

high frequency bilateral hearing loss. Difficulty hearing in crowded noisy
environments. Medications, genetics, history of infection, exposure to loud
noise can also cause.

Hairy Cell Leukemia: type of B lymphocyte derived chronic leukemia. Fine hair
like irregular projections from cells. Can have dry tap bone marrow aspirates
due to fibrosis. TRAP staining (strong acid phosphatase reaction not inhibited
by tartaric acid) and CD11c.

Edema in CHF: due to both mechanical impedence to fluid removal and

increased renal sodium retention. Renal hypoperfusion -> RAAS -> afferent
 and efferent vasoconstriction and sodium reabsorption. Elevate total body
water volume further exacerbating CHF.

Temporal Arteritis: suspected in patients > 50 with new onset temporal HA,
jaw claudication, vision loss, symptoms of polymyalgia rheumatica. Immediate
initiation of high dose steroids to prevent damage to the retinal artery and
other vessels. ESR is elevated.

Cat Scratch Disease: Bartonella henselae. May be transmitted by cat stratch,

cat bite, flea bite. Localized cutaneous and LN disorder. Rare involvement of
liver, spleen, eye, CNS. Rash goes vesicular -> erythematous -> papular
phases. Localized tender/suppurative regional LA. Diagnose with (+) antibody,
tissue with (+) Warthin Starry stain. Give 5 days azithromycin.

Cardiogenic Pulmonary Edema: results from left heart failure and

characterized by crackles on pulmonary exam. NO is the most rapidly acting
medication to relieve symptoms of pulmonary edema. Works quicker than
morphine or loop diuretics. Caution in hypotension.

Acute Glaucoma: suspect with sudden onset of eye pain, photophobia, mid-
dilated pupil, nausea, HA. Do ocular tonometry to diagnose. Damages the
optic nerve. Drugs that dilate pupil can cause.

Hip Avascular Necrosis: can be corticosteroid induced. Progressive hip or groin

pain without ROM restriction and normal radiograph early on. MRI is the
golden standard for diagnosis. Can be traumatic or non traumatic. Alcoholism
and hemoglobinopathies.

MS: relapsing remitting form is well defined acute episodes with no significant
disease progression between episodes. Interferon beta decreases the
frequency of relapse and reduces disability in patients with this form.

OSA: MC medical cause of daytime sleepiness in US. Due to poor

oropharyngeal tone -> daytime sleepiness, morning HA, depression. Obesity,
tonsillar hypertrophy, hypothyroidism are RF. Increased soft tissue in pharynx.
Erythrocytosis. Can cause pulmonary HTN -> RVF.

Trousseaus Syndrome: migratory thrombophlebitis. Usually have occult

tumor, not always detectable at time of presentation. MC tumor is
adenocarcinoma. Pancreatic, lung, prostate, stomach, acute leukemia, colon.

Acute Epididymitis: fever, painful enlargement of the testis, irritative voiding

symptoms. Sexually (adults, urethritis, urethral discharge, gonorrhea,
chlamydia) or non sexually transmitted (associated with UTI, gram negative
rods).

ACE I: DOC for lowering BP to target levels in diabetics (<130/80). Tight BP

control in diabetes delays cardiovascular disease and renal failure. ACE I have
kidney protective effects and decrease proteinuria. Use for BP higher than
target, diabetic nephropathy (> 30 alb/Cr).

Mild Persistent Asthma: proper treatment includes PRN albuterol and inhalted
corticosteroids.
 PSGN: 10-20 days after skin or throat infection. Periorbital swelling, hematuria,
oliguria. May be hypertensive. UA will show hematuria with RBC casts and
proteinuria. Serum C3 levels are low.

Cysteinuria: inherited disease causing recurrent renal stone formation. Look

for personal history of recurrent kidney stones from childhood and (+) family
history. Hard and radioopaque. UA shows hexagonal crystals. Urine sodium
nitroprusside test is widely used.

Pancoast Syndrome: neoplasm in the pulmonary apex at the thoracic inlet can
compress inferior portion of the brachial plexus resulting in shoulder pain
radiating in the ulnar distribution. Causes Horners, hoarse voice, SVC
syndrome.

New Onset Seizures: CT scan of the head without contrast is the first
diagnostic test when patients presents with new unprovoked seizures. Exclude
intracranial hemorrhage.

Reinfarction: CK MB is the most useful lab test in assessing for coronary

reocclusion after an MI because it returns to normal in 1-2 days. Troponin T is
better indicator, takes upto 10 days to return to normal. Also do repeat EKG.

Temporal Arteritis: aortic aneurysms are a well known complication due to

involvement of the branches of the aorta. Follow with serial CXR.

Mucormycosis: requires aggressive surgical debridement plus early systemic

chemotherapy with amphotericin B. Most often caused by fungus Rhizopus.

Brain Abscess: isolated, round, smooth bordered, ring enhancing lesion on

contrast CT in an immunocompetent patient with known extracranial bacterial
infection (sinusitis). Aerobic and anaerobic streptococci and Bacteroides
(anaerobic) are MC. HA, focal neurological signs.

Spinal Cord Compression: signs and symptoms of UMN (means CNS) distal to
the site of compression. Weakness, hyperreflexia, extensor plantar response.
Medical emergency needing MRI and surgery. Can be due to disc herniation,
abscess (IVDA), trauma, malignancy.

Dermatitis Herpetiformis: dapsone is an effective treatment. Occurs in

association with celiac sprue.

Nephrotic Syndrome: renal vein thrombosis is common complication

(abdominal flank pain, fever, gross hematuria). MCC membranous GN in
adults and most likely to cause RVT. Antithrombin III is lost in urine.

Trichinellosis: GI complains followed by triad of periorbital edema, myositis,

eosinophilia. Subungal splinter hemorrhage and conjunctival/retinal
hemorrhage.

Tension Pneumothorax: complication of high PEEP. Alveolar damage -> tension

pneumothorax -> hypotension. Sudden onset SOB, hypotension, tachycardia,
tracheal deviation, unilateral absence of breath sounds. ARDS is predisposed
since tissue is already compromised.
 HOCM: murmur is located at LLSB and is worsened by maneuvers that
decrease preload (Valsalva, standing). AD inheritance pattern.

Pneumococcus: MC pathogen causing pneumonia in nursing homes.

Pneumonia is the leading cause of death in nursing homes. Vaccinate with
pneumovax.

BPH: only required evaluation for BPH suggested by history and physical is UA
to assess for UTI and hematuria. Measurement of PSA can be considered to
help evaluate the likelihood of prostate cancer.

Trachoma: presents with follicular conjunctivitis and pannus

(neovascularization) formation in the cornea. Caused by Chlamydia
trachomatis A-C. Concurrent nasopharyngeal infection -> discharge.
Diagnosed by Giemsa stain of conjunctival scraping. Topital tetracycline or
azithromycin. Repeated infections are due to corneal scarring.

MALT Lymphoma: antibiotic therapy is most accepted and recommended

management for eradication of H pylori in MALT lymphoma without
metastases. May regress after treatment. Treat with amoxicillin,
clarithromycin, omeprazole. If not, use systemic chemotherapy.

Methanol Intoxication: most severe consequences are vision loss and coma.
Optic disc hyperemia. Labs show anion gap metabolic acidosis. Increased
osmolar gap.

COPD: reduced FEV1 compared to FVC, low FEV1/FVC ratio (normal in

restrictive lung disease). DLCO is decreased in emphysema and normal in
chronic bronchitis (productive cough for 3 months over 2 consecutive years.
Prolonged exposure of tracheobronchial tree to irritants.

Lacunar Stroke: if patient presents with limited neurological deficit. Pure motor
(posterior limb of IC), pure sensory (VPL thalamus), ataxic hemiparesis
(posterior limb of IC), dysarthria clumsy hand syndrome (basis pontis).
Principle cause is HTN.

CMV: consider in patients with mononucleosis symptoms, atypical

lymphocytes, negative monospot. Sore throat and LA are uncommon in CMV.
Atypical lymphocytes are large basophilic cells with vacuolated appearance.

Warfarin: patients who develop serious bleeding due to excess anticoagulation

with warfarin should be given FFP for rapid reversal. If INR is excessive but < 5
with no significant bleeding, omit next dose. 5-9 with no significant bleeding,
stop temporarily. > 9, stop warfarin and give vitamin K.

Achalasia: complaints of dysphagia for both liquids and solids as well as

regurgitation. Pseudoachalasia secondary to a neoplasm at the GE junction
can have similar presentation. Endoscopy is recommended for patients
presenting with above symptoms > 60 and weight loss. Results from
degeneration of the nerves in the esophagus. Can be due to Chagas disease,
amyloidosis, sarcoidosis.

Prinzmetals Angina: variant angina. Vasospastic disorder that typically occurs

in young female smokers. Chest pain occurs in middle of the night and
episodes have transient ST elevations in EKG. Associated with Raynauds and
 migraine HA. Precipitated by exercise, hyperventilation, emotional stress, cold,
cocaine. Use CCB or nitrates.

Lyme Disease: erythema migrans rash and facial nerve palsy. Can cause palsy
of any CN but VII is MC. EM rash may be present on arms, abdomen, moist
areas. Erythematous with central clearing or uniformly red.

Constrictive Pericarditis: pericardial fibrosis and diastolic dysfunction. Signs of

decreased cardiac output and venous overload. Common etiologies include
viruses, radiation, idiopathic. In third world, TB is a common cause. Have
fatigue, dyspnea, muscle wasting, elevated JVP, ascites, positive Kussmauls
sign, pedal edema, sharp x y descents on central venous tracing.

Zenkers Diverticulum: MC in elderly males and present with dysphagia,

regurgitation, foul smelling breath secondary to pooling of material in the
pouch. May be palpable. Contrast esophagram is diagnostic test of choice.
Usually repaired surgically.

Pregnancy Induced Respiratory Alkalosis: causes physiological compensated,

chronic respiratory alkalosis due to stimulatory effect of progesterone on
medullary respiratory center. Metabolic compensation occurs in later
pregnancy.

Cor Pulmonale: term for right sided heart failure MC due to pulmonary
disease. Signs of right sided HF -> JVD, S3, RV heave, hepatomegaly, ascites,
dependent edema.

Acute Angle Closure Glaucoma: unilateral eye pain, redness, dilated pupil with
poor light response, photophobia, halos around things. Distinguish from
migraine, cluster headache, temporal arteritis, keratoconjunctivitis.

Colon Cancer: RF for polyps turning into colon cancer are villous adenoma,
sessile adenoma, size > 2.5 cm. Only adenomatous polyps are premalignant,
but < 1% turn into cancer. Hyperplastic are non neoplastic and do not require
further workup. Hamartomatous polyps are either juvenile or Peutz Jeghers.

Malignant HTN: suspect in patients with very high BP (>200/140). Presence of

papilledema confirms the diagnosis. End organ damange is due to fibrinoid
necrosis of small arterioles. Renal failure occurs, but not necessary for
diagnosis.

Randomization: method to control confounders. Helps to control known risk

factors as well as unknown and difficult to measure confounders.

Relative Risk: used as a measure of association in cohort studies. Ratio of risk

in exposed group vs. unexposed group. RR > 1 shows association, stronger as
it goes larger.

Intracranial Hemorrhage: HTN is a common cause. MC locations are basal

ganglia, cerebellum, thalamus, pons. If in cerebrum (basal ganglia), will have
contralateral motor deficit and ipsilateral conjugate gaze.

Splenectomy: risk for sepsis present for > 30 years. Patients should receive
pneumococcal, meningococcal, Haemophilus vaccination several weeks
before operation and daily oral PCN for 3-5 years.
 GBS: can cause respiratory muscle weakness -> failure. Best way to measure
is through serial measurements of VC. Risk for failure greatly increases when
VC < 15 mL/kg.

Liver Metastases: MC malignant neoplasms of the liver. Second MC site of

spread after LN. GIT, lung, breast, skin are MC. Do US, CT, or MRI. Multiple
nodules can be seen. Biopsy confirms.

HIV Vaccinations: influenza, HBV, pneumococcus. HAV for MSM. Should not
receive live vacciation (BCG, varicella, anthrax, oral thyphoid, intranasal
influenza, oral polio, yellow fever). One exception is MMR, used if no evidence
of immunity and CD4 > 200 and no ADI.

Malignant Melanoma: consider in patients with metastatic mass bleeding

inside brain. Can go almost anywhere, lie dormant, and present much later.
Non melanomatous skin, oropharyngeal, esophageal, prostate have never
reported brain metastases.

GERD: cough can be presenting symptom. 24 hour pH recording is most

specific test. Used to diagnose cause of chest pain or supraesophageal
esophageal complications in patients with negative endoscopy. Water brash
(regurgitation of sour fluid into mouth) also present.

Mohs Surgery: special surgery where microscopic shaving is done such that 1-
2 mm of clear margins are excised. Highest cure rate for BCC. Indicated in
patients with high risk features, lesions in functionally critical areas (face).

Rhabdomyolysis: nearly 20% of cocaine ODs are complicated by this. Marked

elevation in CPK (> 20,000 -> risk of ATN due to myoglobinuria). Prolonged
immobilization can also cause this. Elevated K levels. Dipstick will be positive
for blood, UA will have no RBCs. Use mannitol and alkalinization of urine.

CML: low LAP with leukocytosis. Anemia, increased number of mature

granulocytic forms, Seen after age 50. Night sweats and fever due to
increased cell turnover. BM shows prominent granulocytic hyperplasia.
Presence of Philadelphia chromosome.

D Xylose Test: abnormal in bacterial overgrowth and celiac disease.

Normalizes in bacterial overgrowth with antibiotic administration. Absorption
only requires intact mucosa, no enzymes needed.

Acute Erosive Gastritis: severe hemorrhagic erosive lesions after exposure of

mucosa to injurious agents or decresed blood flow. ASA decreses PG
production, ASA and alcohol both cause direct damage. Decreases normal
protection -> acid leaks into LP -> vascular damage -> hematemesis and
abdominal pain.

Amaurosis Fugax: visual loss that is usually monocular and trasient. Like a
curtain falling down. Whitened edematous retina in distribution of arterioles.
Retinal emboli from ipsilateral carotid. Do non invasive evaluation of carotid.

Hashimotos Thyroiditis: increased risk of thyroid lymphoma. Rapid

enlargement of the gland with pre-existing disease. Compressive symptoms
are common. CT shows enlargement of the thyroid around the trachea
(doughnut sign). Pseudocystic on US.
 Opioid Withdrawal: nausea, vomiting, abdominal pain, diarrhea, restlessness,
arthralgias, myalgias. Increased bowel sounds, mydriasis, piloerection. Does
not cause seizures. Methadone is appropriate treatment.

Congenital Long QT: syncopal episode, hearing impairment, normal physical

exam, family history of sudden death. Predisposed to torsades -> syncope and
sudden death. Beta blocker is MC used treatment modality. If patient is
symptomatic, use beta blocker with DDD pacer.

Giant Cell Bone Tumor: soap bubble appearance in epiphyseal end of long
bone. 20-40 year old female with knee pain and some mass. Oval or spindle
shaped cells with multinucleated giant cells. Benign but locally aggressive.
Recurs even after local curettage. Refer to ortho.

HTN: most patients will require pharmacotherapy but lifestyle changes can
make a difference. Weight control is the most important, then physical
activity, salt restriction, moderate alcohol consumption. Smoking decreases
CV risk, but will not affect HTN.

ARF: catheterization is most critical first step. Can resolve post renal
obstructions in addition to monitoring urine output in pre-renal and intrinsic
renal failure. Urinary retention common after lower abdominal/pelvic surgery.

Dihydropyridine CCB: like nifedipine can worsen cardiac ischemia due to

peripheral vasodilation and reflex tachycardia. CI in MI. Verapamil and
diltiazem can be used after beta blockers are used but do not improve
mortality.

Gallbladder Carcinoma: rare malignancy that occurs in Hispanic and SW

Native American females with history of gallstones. Diagnosed during or after
cholecystectomy. Increases with age, history of gallstones, porcelain GB,
salmonella typhi, anatomic variations, carcinogen exposure. Tends to be late
presenting and has spread at time of diagnosis. Surgery to remove GB and the
bed, pancreatic head, LN, portions of the liver/biliary tree. If confined to LP,
simple cholecystectomy is all that is needed.

Legionella Pneumonia: presents similarly to other pneumonias, but can cause

GI symptoms (abdominal pain, diarrhea), hyponatremia, LFT abnormalities.
Diagnose with urinary Ag. Treat with quinolone or macrolide.

Cirrhosis: if signs of portal HTN are present, do endoscopy to look for varices.
May be asymptomatic until they rupture. All patients with cirrhosis should be
screened for varices. Primary prophylaxis is beta blockers.

Proteus: most likely cause of UTI with alkaline urine. Produces urease.
Common in patients of long term care facilities and chronic indwelling
catheters. Candida, Pseudomonas, Klebsiella also cause alkaline urine.

Digitalis Toxicity: increased ectopy in atria and increased vagal tone. Atrial
tachycardia with AV block occurs from the combination of these two effects.

Allergic Contact Dermatitis: type IV hypersensitivity inflammatory skin

condition caused by poison sumac (encountered while cutting firewood),
cosmetics, nickel. Days to weeks after exposure -> intensely pruritic
 erythematous rash with vesicles. Scratching -> secondary infection
(impetiginized) by strep or staph suggested by pustules.

Secondary Syphilis: diffuse maculopapular rash involving soles and palms.

Accompanied by generalized LA, fever, arthritis, iritis, hepatitis, meningitis,
osteitis. Serology will be positive.

MG: MC in women 18-25. Intermittent dysarthria, dysphagia, ptosis, diplopia.

Generalized weakness often develops within a year of onset. Weakness gets
worse as day progresses. Resolves with rest.

Massive PE: likely in post operative patient with JVD, new onset RBBB. PE
complicated by hypotension, right heart strain. Sycope occurs. Need
respiratory and hemodynamic support, along with fibrinolysis. Surgery in past
10 days is CI to fibrinolytics. > 50% die in 1 hour.

Restless Leg Syndrome: potentially debilitating condition characterized by

uncomfortable desire to move ones legs at night or at rest. Treat with DA
agonists (abnormalities in DA system may be cause). Sensation is better with
massage/warming. Common in middle aged to older, especially with CKD, iron
deficiency.

Cat Bites: should be treated prophylactically with 5 day course of

amoxicillin/clavulanate. Can cause deep wounds, and can be infected with
Pasturella -> pain, erythema, swelling. Localized cellulitis and LA.

Acute Aortic Dissection: chest pain that is sudden, tearing, radiating to the
back. HTN is MC predisposing factor. Decrescendo diastolic murmur suggests
AR. Wide mediastinum.

Acute DVT: treat with combination warfarin and heparin for 5 days. After 5
days heparin can be discontinued if INR is therapeutic. Warfarin should stay
on for 6 months for first clot. Progressing clot with subtherapeutic INR needs
bridging heparin until INR is therapeutic.

Reyes Syndrome: found in children given ASA for viral induced fever. Can
cause fulminent hepatic failure. Elevation of ammonia levels, transaminases,
vomiting, mental status changes are common manifestations. Diffuse
mitochondrial disease -> extensive fatty vacuolization of liver. Treat with
glucose with FFP and mannitol to decrease cerebral edema.

SVT: if hemodynamically stable, treat with vagal maneuvers followed by

adenosine and AV nodal blockers. Unstable patients should be cardioverted.
Tachycardia with narrow QRS.

Carotid Artery Stenosis: aymptomatic patients with stenoses of 60-99% are

considered to have proven indication for CEA. Complete occlusion is a CI to
surgery.

Pemphigus Vulgaris: mucocutaneous blistering disease characterized by

flaccid bullae and intracellular IgG deposits in epidermis. Autoantibodies
against desmoglein, an adhesion molecule. Start in oral mucosa. (+) Nikolsky
sign. Treat with steroids. Azathioprine and methotrexate can be used.
 Scalded Skin Syndrome: disease of children. Sudden diffuse erythema, skin
tenderness, fever, flaccid bullae, facial edema, perioral crusting. Caused by
toxins produced by phage group 2 Staph aureus. Replace fluids, topical wound
care (similar to burns), antibiotics against staph. Have (+) Nikolsky sign.

COPD: recommended therapy for acute COPD exacerbation is supplemental

O2 (caution, can suppress hypoxia fueled respiratory drive), inhaled
bronchodilators (B2 agonists, anticholinergics), antibiotics, two week steroid
taper (decreases inflammation, edema in bronchial mucosa), smoking
cessation.

RAS: common cause of resistant HTN in patient with advanced atherosclerosis

(CAD, claudication, difference in BP between arms, risk factors). Auscultate
periumbilical area to reveal continuous murmur.

Warfarin: anticoagulant that functions by inhibition of synthesis of vitamin K

dependent factors II, VII, IX, X, protein C and protein S. Can cause false
positive deficiency in any of these factors.

Methotrexate: DMARD. Inhibits DHFR. Macrocytic anemia is a common SE.

Also causes nausea, stomatitis, rash, hepatotoxicity, interstitial lung disease,
alopecia, fever. May cause pancytopenia. Supplement with folic acid.

Acute COPD Exacerbation: inhaled/nebulized bronchodilators, systemic

steroids (usually methylprednisolone).

Platelet Dysfunction: MCC of abnormal hemostasis in patients with CRF. PT,

PTT, platelet count is normal. BT is prolonged. DDAVP is usual treatment
(increases release of VIII:vWF multimers). Platelet transfusion will not work.
Caused by uremic toxins (guanidinosuccinic acid).

Cholecystitis: abdominal ultrasound is the best tool for initial investigation of

GB pathology. Asymptomatic patients do not need treatment. Laproscopic
cholecystectomy is the treatment of choice for those with symptomatic
disease.

Pagets Disease: asymptomatic patients rarely need treatment. Symptomatic

patients are best treated with oral bisphosphanates. If there is bone pain,
hypercalcemia, neurological deficit, high output cardiac failure, preparation for
surgery, involvement of weight bearing bones, then treat. Full extent
determined by bone scan, followed by x ray.

Osteomyelitis: staph aureus is MCC osteomyelitis in both infants and children.

GBS and E coli in infants and strep pyogenes in children.

Allergic Rhinitis: nasal eosinophilia is characteristic for allergic rhinitis, but not
specific. Absent in patients with infectious (neutrophils) or vasomotor rhinitis
(non allergic). Nasal polyposis (including ASA sensitivity) and non-allergic
rhinitis with eosinophilia.

Chlamydia Screening: USPSTF recommends routine screenining for chlamydial

infection in all sexually active women 24 years and younger and in
asymptomatic women at increased risk for this infection (other STDs, multiple
partners).
 HIV Screening: ELISA is the preferred screening test. Western blot is
confirmatory.

CF Vaccinations: should adhere to regular schedule with some additions.

Yearly influenza is needed and may need pneumococcal booster shots
(between 4 and 6). Egg allergies -> do not give influenza, yellow fever,
caution with MMR. Children 6-59 months should get influenza.

HHNK: very high blood glucose, plasma hyperosmolarity, normal anion gap, (-)
ketones. Can get very dehydrated -> poor perfusion -> lactic acidosis. T2DM.
Enough endogenous insulin to suppress ketosis but not hyperglycemia. Serum
osmolarity is 2(Na)+(Glc/18)+(BUN/2.8).

Cushings Syndrome: central obesity, limb wasting, purple striae, excess

bruising, HTN. Have high 24-hour urine cortisol. Will have low low-dose
dexamethasone suppression test. ACTH will be high in Cushings disease and
ectopic production. High-dose dexamethasone suppression test is used. If fails
to suppress by > 50% = ectopic.

Confounding: matching is frequently used in case-control studies to control

confounding. Match variables that could be confounders. Cases and controls
are then selected based on matching variables so that both groups have
similar distribution.

Acute Pancreatitis: gallstones and alcoholism are the two MCC in US. Do US to
search for gallstones in all patients experiencing first attack. CT is used to
confirm the diagnosis and ID complications.

Diabetic Neuropathy: presents with alterations in sensation, including loss of

proprioception. Motor findings are late. Can have tingling and imbalance.
Hyperactive reflexes and upgoing plantar response are suggestive of UMN
lesion, not compatible with diabetes -> do spinal MRI.

Mitral Regurgitation: holosystolic murmur heard best at the apex with

radiation to the axilla. Exertional dyspnea, fatigue, atrial fibrillation, signs of
heart failure. Could be due to rheumatic heart disease, IE, trauma, ischemia,
HOCM.

Vaccinations: all adults should have Td every 10 years. Adults with close
contact with children 0-59 months should have influenza vaccine.

HTN: lifestyle modification should be first line intervention for newly

diagnosed Stage 1 HTN. Reduction of alcohol/sodium intake, weight loss,
aerobic exercise. For men, should be < 2 drinks per day, for women, should be
< 1.

SAAG: serum ascites albumin gradient. Used to distinguish between different

causes of ascites. 1.1 g/dL or greater is consistent with portal HTN. Ascites can
be due to trauma, infection, pancreatitis, malignancy.

Hyperestrogenism: in cirrhosis -> gynecomastia, testicular atrophy, decreased

body hair, spider angiomas, palmar erythema.

Liver Functions: can be synthetic (clotting factors, cholesterol, protein),

metabolic (drugs, steroids, detoxification), excretory (bile excretion).
 Germ Cell Tumors: typically affect young patients and display aggressive
biologic behavior. Nonseminomatous germ cell tumors produce both AFP and
HCG. Can occur in mediastinum. HCG is elevated in both seminomatous and
non. Pure seminomas do not produce AFP.

Pseudogout: cannot be reliably distinguished from gout and septic arthritis

based on history and physical alone. Rhomboid, (+) birefringent crystals,
chondrocalcinosis (calcified articular cartilage). Crystals are calcium
pyrophosphate. Pain, swelling redness of the joint.

Vaccinations: all adults should get Td booster every 10 years. 50 and older as
well as younger with certain comorbidities should get annual influenza.
Pneumococcal for those over 65 or those at risk for pneumococcal disease
(chronic illness, immunosuppression, smokers).

Meningococcal Meningitis: CSF with elevated white count, elevated protein,

decreased glucose = bacterial meningitis. Petechiae and purpura. Myalgias
are common and can be severe like in flu. Develops very rapidly. RMSF does
not cause meningitis. Pneumococcal meningitis is similar but no skin rash.

DKA: managed by restoring intravascular volume with normal saline,

correction of hyperglycemia, electrolytes (potassium), acidosis, treatment of
precipitating cause (usually antibiotics). Give IV normal saline and regular
insulin.

Massive PE: can cause RV dilatation and failure that results in hypotension,
tachycardia, syncope, SOB. Hemodynamic compromise is an absolute
indication, and RV strain is a relative indication, for thrombolytics. Have
history of DVT sometimes.

Ischemic Stroke: if patient presents within 4.5 hours, thrombolytic therapy

with tPA (after CT scan to rule out hemorrhage) should be started. Improved
neurological outcomes.

Cardiogenic Shock: depressed CO (normal is 5L/min for male, 4.5L/min for

female) and elevated PCWP (>18, indicator of LAP and usually LVEDP). SVR
will be elevated as result of neurohumoral activation (sympathetic, RAAS) to
preserve CO and maintain tissue perfusion.

CHF: hyponatremia is a bad prognostic factor. Indicates presence of severe

heart failure and high level of neurohumoral activation (water retention).
Associated with high aldosterone, vasopressin, NE. Survivcal is significantly
reduced if sodium < 137. Hypo and hyperkalemia may reflect the activity of
the RAAS or may be due to different drugs. Decrease water intake to help with
electrolyte abnormalities.

Acromegaly: MCC death is cardiovascular (38-62% of death). High GH -> high

IGF-1 -> excessive growth of bone and soft tissue. Increased CAD,
cardiomyopathy, arrhythmias, LVH, diastolic dysfunction. Respiratory (0-25%)
and malignancy (9-25%). HTN is common but not only cause of CV disease.
Can have strokes, colon cancer, renal failure (HTN, hyperglycemia), adrenal
failure.
 Hypoxemia: 1) Hypoventilation, 2) Decreased FiO2, 3) Shunting, 4) V/Q
mismatch. Look at ABG, A-a gradient, if 100% O2 improves picture. PAO2 =
FiO2(760-47) PaCO2/0.8
o Hypoventilation: elevated PaCO2 with normal A-a gradient
o Decreased FiO2: normal PaCO2 with normal A-a gradient
o Shunting: normal PaCO2 with elevated A-a gradient (O2 does not help)
o V/Q Mismatch: normal PaCO2 with elevated A-a gradient (O2 does
help)

Ankylosing Spondylitis: seronegative spondyloarthropathy presenting with

progressive inflammatory back pain and stiffness. In setting of suggestive
H&P, AS is confirmed by plain film x-ray demonstrating fused SI joints and/or
bamboo spine. Any young patient with low back pain and spinal stiffness > 3
months should be investigated.

PJP: non productive cough, exertional dyspnea, fever, severe hypoxia, bilateral
interstitial infiltrates on CXR, normal white count. CD4 < 200. TMP-SMX is
DOC. Steroids decrease mortality. Indications for steroids are PaO2 < 70, A-a
gradient > 35.

Esophageal Cancer: heart burn, significant weight loss, fatigue, smoking

history. Barium swallow, EGD & biopsy, PET scan (useful to determine the
stage or whether surgery is possible). When localized, surgery is treatment.
Chemotherapy and radiation may be used in conjunction.

Acute Abdominal Pain: one of the differential diagnoses is MI and should be

ruled out first before GI workup in patients with RF.

Vertebral Osteomyelitis: focal pain, fever, chills, elevated ESR. Common in

IVDA (as is all osteomyelitis). SCA and immusuppressed are also at risk for
OM. Staph aureus is MCC, other G(-) as well. MRI is most sensitive study.
Treatment is long term IV antibiotics with or without surgery.

Herpes Simplex Keratitis: characterized by corneal vesicles and dendritic

ulcers. Frequent cause or corneal blindness in the US. Pain, photophobia,
blurred vision, tearing, redness. Recurrences precipitated by excessive sun
exposure, outdoor occupation, fever, immunodeficiency. Scrapings show
multinucleated giant cells. Topical or oral antivirals.

Primary Hyperaldosteronism: suspect in young person with HTN, muscle

weakness, numbness (potassium depletion). Most specific lab is high
aldosterone/renin ratio.

Selection Bias: loss to follow up in prospective studies causes selection bias.

Warfarin Induced Skin Necrosis: pain -> bullae formation -> skin necrosis.
Breast, buttocks, thighs, abdomen are commonly involved. Protein C
deficiency is commonly associated. Females are MC affected. Occurs within
weeks. Vit K should be given initially and warfarin discontinued if progresses.
Heparin should be used until heals.

Stroke: do CT scan without contrast to determine ischemic or hemorrhagic. If

there is evidence of ischemic stroke, carotid dopper and TEE are done to look
for possible sources of emboli.
 Esophageal Cancer: may mimic achalasia radiographically and manometrically
(called pseudoachalasia). Older age, shorter history, rapid weight loss,
inability of esophagoscope to pass through LES. CT can show asymmetric
thickening.

Tick Borne Paralysis: rapidly ascending paralysis, absence of a fever, absence

of sensory abnormalities, normal CSF. Search and removal of a tick usually
results in improvement within an hour and complete recovery in several days.

UC: patients with UC and pancolitis should begin surveillance colonoscopy

after 8 years of having the disease. 4 biopsies should be taken every 10 cm
from cecum to rectum. Any suspicious lesions or masses should be biopsied.
Should be done every 1-3 years.

Bakers Cyst: excessive fluid production by inflamed synovium as occurs in RA,

OA, cartilage tears. Excess fluid accumulates in popliteal fossa -> tender
mass. Occasionally burst and release contents and present similarly to a DVT.

Waldenstroms Macroglobulinemia: hyperviscosity of blood owing to excess

production of IgM. Need IgM spike on electrophoresis and hyperviscosity. Rare
chronic plasma cell neoplasm.

Mitral Valve Prolapse: mid systolic click over the apex, with short systolic
murmur after the click. Squatting decreases the murmur. Associated with
chest pain, anxiety, palpitations, hyperventilation.

HTN in Diabetes: better to keep systolic < 130 to prevent slow end organ
damage in diabetes and CRF. Want to keep diastolic < 80.

Vitamin K Deficiency: seen in patients who are NPO for a long time and
receiving broad spectrum antibiotics. Labs show prolonged PT and then PTT.
PT elevated more than PTT. Fat soluble vitamin that serves as a cofactor for
enzymatic carboxylation of glutamic acid residues on prothrombin complex
proteins. FFP is used in acute hemorrhage.

Complex Partial Seizure: brief episodes of impaired consciousness, failure to

respond to various stimuli during the episode, staring spells, automatisms,
post-ictal confusion. EEG is usually normal or has brief discharges.
Hyperventilating does not cause seizure (differs from absence).

Atheroembolism: dislodgement of cholesterol plaques from the aortic root.

Blue toe syndrome in which emboli to the pedal circulation cause cyanotic
and painful toes with intact pulses, is one common presentation of catheter
induced atheroembolism. Also cause ARF.

Orthostatic Hypotension: characterized by a drop in blood pressure after

standing and is typically preceded by a lightheaded or presyncopal sensation.
Defined as a drop in systolic > 20 mmHg. Common in elderly, hypovolemic,
autonomic neuropathy. Diuretics, vasodilators, adrenergic blocking agents.

Renal Stones: decrease protein (causes calcium stones) and oxalate in diet,
decrease sodium intake, increase fluid intake, increase dietary calcium. CT
scan is done to diagnose.
 Dyspepsia: epigastric pain, bloating, nausea not secondary to biliary or
pancreatic disease. May be nothing, could be PUD or gastritis. Recommended
screen is H pylori serology. > 55, weight loss, dysphagia, persistent vomiting
would warrant endoscopy.

Melanoma: one of the most practical methods of primary prevention is

wearing protective outer clothing. Little to no protection from sunscreen
lotions SPF 15-30 but can protect against SCC.

S3: low frequency diastolic sound heard just after S2 that is associated with
LVF. IV diuretics provide symptomatic benefits to patients with decompensated
HF. Can be normal in younger individuals and athletes.

Thyroid Nodule: MC a colloid nodules which are benign.

Eczema Herpeticum: form of primary HSV associated with atopic dermatitis.

Numerous umbilicated vesicles over area of atopic dermatitis as its healing.
Can be life threatening in children. Treat promptly with acyclovir. Accompanied
by fever and adeopathy.

Amiodarone: effective antiarrhythmic but its use is associated with several

potential side effects. Can cause pulmonary fibrosis, hepatotoxicity, thyroid.
PFT, LFT, TFT should be monitored. Difficulty concentrating, fatigue, dry skin,
weight gain while receiving treatment for HTN and atrial fibrillation.

Pneumatocele: Staph aureus can cause secondary pneumonia complicating a

viral URI. Can cause necrotizing bronchopneumonia resulting in
pneumatoceles (blood streaked sputum and mupltiple midfield lung cavities).
Pneumococcus and H flu both cause secondary pneumonia.

Odansetron: drug of choice for chemotherapy induced emesis. 5-HT3

antagonist. Small frequent meals, avoiding bland food, attractive food
presentation, giving patient his/her preferred meals.

Transplant Patients: should be given oral TMP-SMX for prophylaxis against PJP.
Can prevent toxoplasmosis, nocardiosis, UTI, pneumonia. Vaccinate against
influenza, pneumococcus, HBV. Gancyclovir or valgancyclovir can be used to
prevent CMV infections.

Zenkers Diverticulum: pharyngoesophageal. Develops immediately about

the UES by herniating through the fibers of the cricopharyngeal muscle. Motor
dysfunction and incoordination are responsible. Surgical treatment is
cricopharyngeal myotomy. > 50 with oropharyngeal dysphagia and neck
mass.

Babesiosis: patient from endemic area (NE US) who presents with tick bite
especially if there is evidence of hemolysis and patient is splenectomized.
Rash is not a feature (unless thrombocytopenia is present). Jaundice,
hemoglobinuria, renal failure, death. Giemsa stained thick and thin blood
smear. Use quinine-clindamycin or atovaquone-azithromycin.

COPD: all patients with PaO2 < 55 or SaO2 < 88 are candidates for long term
O2 therapy. Signs of pulmonary HTN or hematocrit > 55, start on home O2
when PaO2 < 60. If become hypoxic during exercise or sleep can use O2.
 MG: pathology lies at NMJ. Mediated by autoantibodies against the Ach
receptor. Pupils are always spared (as opposed to botulism). Bulbar muscle
involvement -> myasthenia snarl, nasal speech, difficulty in chewing or
swallowing.

Sympathetic Ophthalmia: characterized by damage of one eye (the

sympathetic eye) after a penetrating injury to the other eye due to uncovering
of hidden antigens. Can have anterior or panuveitis, papillary edema,
blindness. Can involve auto antibodies and cell mediated.

Cocaine Abuse: papillary dilatation and blood at the external nares in a patient
with chest pain can be a clue to cocaine induced vasospasm. STEMI can occur
as a consequence. Inhibits catecholamine reuptake in synapses. Give ASA and
nitrates but not beta blockers. CCB and alpha blockers.

SVT: suspected on an EKG with a regular, narrow QRS complex tachycardia

without definite P waves. Adenosine is initial treatment of choice. Terminates
the arrhythmia and diagnoses and treats. Caused by AVRT or AVNRT. If does
not work, try CCB, beta blocker, CV.

Increasing Prevalence: but stable incidence can be attributed to factors which

prolong the duration of disease (improved quality of care).

Molluscum Contagiosum: firm, flesh-colored, dome-shaped, umbilicated

papules. Cellular immunodeficiency, steroid use, chemotherapy predispose.
Common in HIV patients. On trunk, limbs, anogenital regions. Can be due to
sexual contact.

Senile Purpura: characterized by ecchymoses that occur on elderly patients

extensor surfaces due to perivascular connective tissue atrophy. Develop
rapidly and resolve over several days leaving brownish discoloration due to
hemosideran deposition.

CHF: elevated BNP and S3 are both signs of increased cardiac filling pressures.

Acute Cholangitis: provision of supportive care and broad spectrum

antibiotics. If they do not respond, they should undergo biliary drainage, stone
removal/stenting with ERCP. Charcots triad: fever, jaundice, RUQ pain.
Hypotension and mental status change -> Reynolds pentad. Usually
secondary to infection or obstruction. US is first study to do.

Latent Period: exposure must be continuously present for a certain period of

time (latent period) to influence the outcome.

Iron Deficiency Anemia: bone marrow iron stains is the most definitive way to
diagnose iron deficiency anemia.

MS: focal neurological deficits in young adult with asymmetric periventricular

white matter signal changes on MRI. Glatiramer acetate is a long term disease
modifying treatment for MS that works by modulating T cell mediated
autoimmunity to MBP.

HCC: have either chronic viral hepatitis or cirrhosis, but otherwise

asymptomatic. Weight loss, abdominal pain, palpable mass, worsening signs
of portal HTN. AFP measurement is first reasonable step.
 Diastolic Dysfunction: impaired ventricular filling due to poor myocardial
relaxation or diminished ventricular compliance. Usually due to HTN, treated
with diuretics and antihypertensives. Can cause decompensated HF.

Melanoma: MCC fatal malignancy in young adults. Recently changed mole is

strongest RF for malignancy, with RR of at least 10.

Cerebral Emboli: most dreaded consequences of endocarditis. Pieces of

infected valve vegetations break off and enter CNS circulation. Can affect
lung, kidney, intestines, extremities. IVDA with chills, evidence of cardiac
disease on EKG. Treat with antibiotics.

PMR: pain and stiffness in the neck, shoulders, pelvic girdle in patient > 50
with elevated ESR and morning stiffness > 1 hour. Treatment when not
associated with GCA is low dose steroids. If GCA is coming along with it, treat
with high dose prednisone.

Alcohol Abuse: MCC of nutritional folate deficiency -> megaloblastic anemia.

Impairs enterohepatic cycle and inhibits absorption. Can have microcytic
anemia due to chronic blood loss, anemia of chronic disease,
thrombocytopenia, macrocytosis.

Heat Stroke: temperature is usually > 105. Results from inefficiency cooling
mechanisms. Treatment involves induction of evaporative cooling to reverse
hyperthermia. Dunking in cold water may work but difficult to monitor the
patient.

Effect Modification: present when the effect of the main exposure on the
outcome is modified by the level of another variable. Not a type of bias!

Bells Palsy: peripheral lesion. Absence of forehead furrows indicates

peripheral lesion. Central lesions still have forehead furrows because
contralateral motor innervation of the forehead remains intact.

HIV Therapy: didanosine (induced pancreatitis), abacavir (related

hypersensitivity syndrome), lactic acidosis (any of NRTIs), Stevens-Johnson
(any of the NNRTIs), nevirapine (liver failure), indinavir (protease inhibitor ->
crystal induced nephropathy).

Acute Acalculous Cholecystitis: acute inflammation of the GB in the absence of

gallstones most commonly seen in hospitalized/severely ill patients -> burns,
trauma, prolonged TPN, prolonged fasting, mechanical ventilation.

Multiple Myeloma: increased risk of infection due to total decrease in

functional antibodies and leukopenia that develops as bone marrow is filled
with malignant plasma cells. CRAB (calciu, renal, anemia, bones). Paraprotein
gap = protein albumin.

Uric Acid: highly soluble in alkaline urine -> oral potassium bicarbonate or
potassium citrate to get urine > 6.5. Radiolucent stones. Usually due to acidic
urine. Also hydrate, try low purine diet.

Primary Hyperaldosteronism: PA to PRA is used as initial screening test. > 30

suggests diagnosis. No suppression of aldosterone after saline or oral salt
loading. Abdominal CT to confirm. Withdraw drugs that may suppress RAAS 2-
 4 weeks prior. Hypokalemia should be corrected since this can suppress
aldosterone.

Digoxin: cardiac glycoside whose SE are nausea, vomiting, diarrhea, vision

changes (blurry yellow), arrhythmias. Treatment for atrial fibrillation and heart
failure. Scooped ST, prolonged PR, short QT, T wave inversion. Renal failure
and hypokalemia exacerbate.

Sporotrichosis: gardners disease. Initial lesion is reddish nodule that later

ulcerates, appears at the site of thorn prick or other skin injury. Spreads along
lymphatics forming SQ nodules and ulcers. Adenopathy and systemic signs
usually absent.

Travelers Diarrhea: ETEC is MCC. Abdominal cramps, diarrhea, malaise.

Aortic Dissection: sudden tearing chest pain that radiates to the back.
Mediastinal widening is sometimes present. Leg weakness can occur if
dissection progresses to involves arteries of spinal cord. Severe HTN is a RF.
Can have pleural effusion. Do contrast CT or TEE.

Primary HIV: manifests similarly to IM. Rash and diarrhea are LESS common in
IM, tonsillar exudate is not common in HIV. Splenomegaly with splenic rupture
is worrisome. Heterophile Ab can distinguish. Arise within 1 week and can
persist upto a year. Anti-EBV Ab as well.

Hyperkalemia: membrane stabilization with calcium, shift potassium

intracellularly, decreasing total body potassium. Insulin/glucose administration
is the quickest way to decrease serum potassium. Shifts are only transient and
must try to decrease potassium.

Hematuria: bladder tumors are the MCC of painless hematuria in adults. Could
be a kidney or ureter malignancy as well. Do contrast CT or IVP as well as
cystoscopy of bladder/urethra. Infections, trauma, nephrolithiasis, GN,
prostatic disease are MCC of hematuria in US. Myoglobinuria, porphyria,
eating beets, rifampin can cause hematuria like picture.

CMV Retinitis: when CD4 < 50. Patients may be asymptomatic. Yellow white
patches of retinal opacifiation and hemorrhage are diagnostic. Initially eye is
usually white and quiet. Treatment is ganciclovir or foscarnet.

HAV: MC vaccine preventable disease in travelers. Consider in patients

traveling to developing countries. North Africa will also need HBV, thyphoid,
polio booster. Single dose can be enough for young adult, second dose for
long term immunity.

ALS: riluzone is a glutamate inhibitor approved for use in ALS. Prolongs

survival and time to tracheostomy. Dizziness, nausea, weight loss, elevated
liver enzymes, and skeletal weakness.

Goodpastures Disease: affects lungs (cough, dyspnea, hemoptysis), kidney

(nephritis, ARF, dysplastic RBCs, casts). No systemic symptoms. Renal biopsy
shows linear immunofluorsence of IgG Ab along GBM (to alpha-3 chain of type
IV collagen).
 TTP: requires emergency treatment with plasmapheresis (plasma exchange).
Rates of recovery (usually defined as normalization of platelets and LDH level)
are high if started soon. Renal impairment and schistocytes may persist for
several weeks. Deficiency or autoantibody against vWF cleaving protease.

Lidocaine: not used prophylactically in ACS. Decreases risk of ventricular

fibrillation but increases risk of asystole. Little effect on myocardial
contractility.

Hepatic Encephalopathy: CNS complication of liver failure secondary to

accumulation of ammonia in blood due to livers inability to detoxify ammonia
to urea. Reversal of sleep cycle, asterixis, progressive coma, delta waves on
EEG.

SBE: one the causative agent is identified, the antibiotics can be narrowed
from empiric to specific. Strep viridans is highly susceptible to IV PCN G and IV
ceftriaxone. Progressive fatigue and waxing waning low grade fever.

Lead Poisoning: MCC in adults is work exposure. GI complaints, poor

concentration, anemia. Treat with exposure reduction and lead chelator such
as EDTA or succimer. Neuropathy is common. Diagnose with blood lead levels.
Basophilic stippling.

Shock Liver: occurs in the setting of hypotension. Acute massive increases in

ALT/AST with milder increases in total BRN and ALP. Typically return to normal
in a couple weeks.

PBC: xanthalesma are cholesterol plaques on the medial aspects of the

eyelids. Upper and lower eyelids may be affected. Can occur in PBC but MC
idiopathic. Pruritis, jaundice, hepatomegaly, increased ALP.

Ascites: treat with sodium/water restriction, spironolactone, loop diuretic (not

more than 1L/day), then frequent abdominal paracentesis (2-4 liters/day as
long as kidneys work).

Upper Thoracic Spinal Cord Lesion: paraplegia, bladder and rectal

incontinence, absent sensation from nipple downward.

Impetigo: presents as erythematous macule which rapidly evolves into

vesicles and pustules that rupture and leave honey colored crusted exudates.
Caused by staph or strep.

Parkinsons Disease: suspected in patients with 4-6 Hz tremor that is

asymmetric and associated with rigidity. Tremor is often presenting symptom.
Trihexylphenidyl is an anticholinergic medicaton used in younger individuals
where tremor is presenting symptom.

Nitroglycerin: main mechanism for pain relief in patients with anginal pain is
dilitaiton of veins (capacitance) and decreased ventricular preload. This
decreases myocardial oxygen demand.

Blastomycosis: pulmonary fungal infection endemic to Great Lakes, Mississippi

and Ohio river basins. Wisconsin has highest rate. May cause ulcerated skin
and lytic bone lesions. Broad based budding yeast grown from the sputum.
Itraconazole or amphotericin B may be used to treat systemic disease.
 NF1: caf au lait spots, macrocephaly, feeding problems, short stature,
learning disabilities. Later develop fibromas, neurofibromas, different tumors.

COPD: causes airflow limitations and increased lung volumes. Latter results in
diaphragmatic flattening, evident on CXR, which exacerbates patients
dyspnea and work of breathing. Difficult to decrease intrathoracic pressure
enough.

Hemochromatosis: AR disorder, increased skin pigmentation, diabetes,

cirrhosis, arthralgias. Mutation on chromosome 6. Avoid iron containing foods,
weekly phlebotomy for 2-3 years. Deferoxamine is second line treatment for
those who cannot undergo phlebotomy.

Metabolic Acidosis: observed during DKA and is typically accompanied by

hyperkalemia which is paradoxical. Extracellular shift of potassium in
exchange for H+ ions. Impaired insulin dependent cell entry of the potassium
ion. Should get potassium once dips below 4.5.

HBV Exposure: reassurance is the most appropriate course of action for a

patient with known immunity to HBV who is exposed. HBIG and HBV
vaccination should be given to patients with unknown immunity.

Elevated Aminotransferases: if patient is asymptomatic, first step is to take

thorough history to rule out more common hepatitis risk factors (alcohol,
drugs, travel, blood transfusions, high risk sexual practices). Also medications
(statins, antiepileptics, anti TB, herbals). If transaminases persist, test for HBV,
HCV, hemochromatosis, fatty liver. Then polymyositis and thyroid.

HIT: immune mediated process that causes thrombocytopenia several days

after heparin therapy is started. Highly thrombogenic and can cause A or V
thromboses.

Lyme Disease: erythema chronicum migrans in a patient with a history of a

tick bite warrents immediate treatment with doxycycline. Serologic testing is
not needed if patient presents with classic EM (usually in moist areas, bulls
eye, asymptomatic).

Avascular Hip Necrosis: chronic corticosteroid use and chronic excessive

alcohol ingestion account for > 90% of cases of avascular necrosis. Present
with slowly progressive anterior hip pain with limited ROM. Unable to remodel
-> trabecular thinning occurs. Pain is worse with activity. X rays fail to show in
first few months. MRI is most sensitive. Trauma and antiphospholipid
syndrome can be causes.

EHEC: bloody diarrhea. Presence of abdominal pain with lack of fever in a

patient without travel. Most cases due to ingestion of undercooked beef.
Shigella, salmonella, campylobacter also cause bloody diarrhea but have
fever. TTP-HUS can also result. Stool culture.

Septic Shock: most important steps in management of lactic acidosis from

septic shock are IV NS with or without pressors to maintain volume and
antibiotics to correct underlying condition.
 Attributable Risk Percent: represents the excess risk in exposed populations
that can be attributed to RF. ARP = (RR-1)/RR or (risk in exposed risk in
unexposed)/risk in exposed.

Retinal Detachment: sudden onset of photopsia (flashes of light) and floaters.

Described as curtain coming down over eyes. Myopia or trauma can cause
breaks -> allows fluid to seep in and separates the retinal layers. Can occur
after surgery. Gray elevated retina. Laser and cryotherapy are done to create
permanent adhesions.

Pericardial Effusion: electrical alternans when QRS varies from beat to beat
and is specific. Enlargement of cardiac silhouette. Echo will more definitively
diagnose. Recent URI usually precedes.

Digoxin: medication with narrow therapeutic window. Verapamil increases

digoxin levels and predisposes to toxicity. MC SE is GI (anorexia, nausea,
vomiting). Bidirectional ventricular tachycardia and accelerated junctional
rhythms are relatively specific.

Expressive Aphasia: lesions in dominant frontal lobe. Also contains motor

cortex whose damage -> contralateral hemiparesis.

Absence Seizures: ethosuximide is treatment along with valproic acid. Works

against calcium channels. Drowsiness, nausea, vomiting, hyperactivity, sleep
disturbance. Not useful for generalized tonic clonic and partial epilepsy.

SLE: autoimmune disease MC affecting AA women 20-40 years old. Fatigue,

fever, weight loss, non-deforming arthritis, oral ulcers, serositis, hematologic
abnormalities, proteinuria, rash. > 90% have arthritis usually of MCP and PIP.
Similar to RA.

Glycosylated Hgb: excellent way to measure chronic glycemic control.

Measurement of average glucose readings for 100-120 days. Formed by non
enzymatic glycosylation of Hgb. 1% increase -> blood glucose of 35.

Inflammatory Myopathy: polymyositis and dermatomyositis. Both present with

proximal muscle weakness. Supported by elevated ESR and CPK. Confirmed
with muscle biopsy. 40-50 years. Women > men. Drug induced, hypothyroid,
muscular dystrophy, MG present similarly. Treat with high dose corticosteroids.

PE: when occurs with hemodynamic compromise, best treatment is

fibrinolysis. If patient has CI (previous surgery, bleed), an embolectomy is
treatment of choice. Will still need to be on warfarin for a few months.

SLE: joint pain is common but not deforming. MC in hands or knees. Migratory
arthritis. Pain > physical findings. Lower incidence of joint erosion, synovial
abnormality, permanent joint deformity than RA.

Retropharyngeal Abscess: most feared complication is spread of the infection

to the mediastinum -> acute necrotizing mediastinitis. Partiularly the anterior
and posterior portions.

Spinal Stenosis: MC caused by DJD. Neuropathic claudication. Exacerbation

of symptoms with walking. Symptoms are positional and remain while
 standing still. Pain relieved by flexion of spine. Diagnosis made on history and
MRI of spine -> bony abnormality, neural structures, soft tissue seen well.

Brain Death: clinical diagnosis. Absent cortical and brainstem functions and
proven irreversibility. Spinal cord may still be functioning -> DTRs may be
present. EEG can be used to confirm but not necessary. Some tools can
demonstrate cerebral blood flow cessation.

Epidural Abscess: consider in patients with fever and back pain. Espeically
those who are immunosuppressed or use injectable drugs. MRI is diagnostic
test of choice. Treat with antibiotics and surgical decompression. Can cause
direct compression -> cessation of blood flow. Draw blood cultures to
determine sensitivity.

Hepatic Hydrothorax: cause of transudative pleural effusions with no

underlying cardiac/pulmonary abnormalities. Usually right sided. Treat with
salt restriction and diuretics. TIPS is done if refractory. Small defects in
diaphragm allow fluid to flow into pleural space.

Ethylene Glycol Poisoning: calcium oxalate crystals (rectangular envelope

shaped crystals) are seen. Causes metabolic acidosis with anion and osmolar
gap (as so methanol and ethanol).

MAC Prophylaxis: HIV patients with CD4 < 50 require azithromycin or

clarithromycin.

Asymptomatic Gallstones: should not be treated. Laproscopic

cholecystectomy is only for symptomatic disease unless have high risk of GB
carcinoma or gallstone complications. 20% of these patients will develop
symptoms in 15 years.

Pancreatic Cancer: no serologic or radiologic test has been proven effective in

screening in adults.

Absence Seizures: suspect in a 4-8 year old with frequent daydreaming

episodes, brief staring spells, decline in school performance, no post ictal
phase. Treatment is ethosuxamide or valproic acid. Classic EEG is 3 Hz spike
and wave activity.

Observer Bias: when investigators decision is adversely affected by

knowledge of exposure status.

AR: early diastolic murmur. Can also have hyperdynamic pulse (bounding,
water hammer, peripheral pulses).

Fibromyalgia: pain worse with exercise. Fatigue, IBS, depression are common.
Inflammation, joint swelling, muscle weakness are absent. No abnormal
studies. Women from 20-55. Disorder of pain regulation.

Cystic Fibrosis: affects a variety of organ systems including respiratory tract,

sinuses, pancreas, intestines, reproductive systems secondary to abnormal
secretions. Recurrent pulmonary infections and bronchiectasis. Decreased
exocrine gland function of the pancreas -> fat malabsorption.
 Fulminent Hepatic Failure: hepatic encephalopathy that develops within 8
weeks of acute onset liver failure. Heavy users of Tylenol, alcohol,
methamphetamines, co-infection with HBV and HDV. High priority on liver
transplant and only effective mode of treatment.

Dresslers Syndrome: present weeks after MI with chest pain improved by

leaning forward. NSAIDs are the treatment of choice. Avoid anticoagulation to
prevent hemorrhagic pericardial effusion. Malaise, fever, elevated ESR. Likely
immunologic phenomenon.

Urine Sediment: muddy brown granular = ATN, RBC = GN, WBC = interstitial
cystitis and pyelonephritis, fatty = nephrotic, broad waxy = CRF. Prolonged
hypotension -> ATN. Also have urine osm 300-350, urine Na > 20, FENA > 2%.

Lewy Body Dementia: 10-20% of dementia in US. Alterations in consciousness,

disorganized speech, hallucinations, EPS, early compromise of executive
functions. Eosinophilic intracytoplastic inclusions = accumulations of alpha-
synuclein. Treat with AchE inhibitors, atypical antipsychotics. Lewy bodies
found in Parkinsons.

Hepatic Adenoma: benign tumor most often seen in young and middle aged
women who are taking OCP. Severe intra-tumor hemorrhage and malignant
transformation are dreaded complications. Sheets of enlarged adenoma cells
that contain glycocen and lipid.

Acute MR: occurs due to papillary muscle dysfunction in patients with acute
MI. Causes rise in LAP without significant increased LA size, LV size, or LV EF.
Also have pulmonary edema. PCWP shows increased pressure in LA.

MEN 2b: AD disorder. Medullary carcinoma of the thyroid, pheochromocytoma,

mucosal neuromas (most distinguishing feature), marfanoid habitus. MEN 2a
has medullary carcinoma and pheochromocytoma but has primary parathyroid
hyperplasia, not adenoma.

HOCM: first line of treatment is beta blockers or cardiac acting CCB such as
diltiazem since they promote myocardial relaxation. Beta blockers also
prevent anginal pain.

AR: diastolic decrescendo murmur at left 3 rd ICS. Medical therapy is afterload

reduction with CCB or ACE-I. Handgrip increases vascular resistance ->
increased regurgitation. Regurgitant blood flow causes dilation of the LV.

Bacterial Pneumonia: all patients should have CXR done as first step and then
administer antibiotics without waiting for sputum gram stain or cultures.

Cervicofacial Actinomycosis: classically presents as slowly progressive, non-

tender, indurated mass, which evolves into abscesses, fistulae, draining sinus
tracts with sulfur granules, which appear yellow. High dose PCN for 6-12
weeks. Anaerobic G(+) branching bacteria.

DJD: OA, or wear and tear arthritis. Presents indolently in patients over 40
years with progressive anterior hip pain exacerbated by walking and relieved
by rest. Morning stiffness or stiffness after prolonged resting, usually < 30 to
60 years. No tenderness to palpation or systemic signs. Predisposing factors
are advanced age and obesity.
 Angle Closure Glaucoma: predominantly in people aged 55-70 years. Presents
with acute onset severe eye pain and blurred vision associated with nausea
and vomiting. Examination reveals red eye with steamy cornea, moderate
pupil dilation not responsive to light. Results form pre existing narrow anterior
chamber angle. Anterior chamber is shallow with inflammatory changes.
Tonometry reveals increased IOP. Do laser peripheral iridotomy.

Toxin Induced GE: caused by staph aureus. Because illness is due to

preformed toxin, emesis is predominant feature and starts in < 6 hours.
Mayonnaise containing salads are often implicated in staph food poisoning. No
P2P transmission.

Legionella: intracellular G(-) organism commonly spread by cooling towers and

water supplies. Travel associated infection. Cough, fever > 39, GI symptoms,
confusion. Diagnosis confirmed by urine antigen or culture on charcoal agar.
Treat with azithromycin and levofloxacin. Stains poorly. Sputum will have
neutrophils with no organisms.

Fibromyalgia: amitriptyline and cyclobenzaprine have been shown to be

effective in the treatment of fibromyalgia. Increase amount of restorative
phase 4 sleep. One possible etiology is lack of phase 4 sleep. In patients with
co-existing depression, add SSRIs.

Benign Intracranial HTN: acetazolamide is first line medical treatment

(reduces choroid plexus bicarbonate production). Can use steroids, or treat
underlying disorder. Then can do repeated lumbar punctures.

Leukoplakia: hard to remove white patches in the oral mucosa and may lead
to SCC. Only associated with tobacco. Caused by chronic irritation to the
mucosa due to tobacco, alcohol, poorly fitting dentures. Risk of transformation
to SCC.

Acetaminophen Overdose: first data point occurs at 4 hours when decision to

give antidote can be made based on levels. Get level at that time. As long as
given within 8 hours, will not have adverse outcome. Give activated charcoal
within 4 hours while waiting for level.

Retropharyngeal Abscess: patients have sore throat, fever, difficulty

swallowing, pain with certain neck movements, especially extension. Initiate
treatment rapidly to prevent spread of infection to mediastinum. Give
antibiotics and drain.

Symptomatic Hypernatremia: medical emergency requiring prompt increase in

sodium levels. Cells have not had time to adjust -> acutely symptomatic. Give
3% saline. Chronic hyponatremia can be slowly corrected because cells have
had time to adjust and rapid increases in sodium -> CPM.

Multiple Myeloma: any elderly patient with bone pain, renal failure,
hypercalcemia. 50% of patients develop some kind of renal insufficiency.
Likely due to obstruction of distal collecting tubules by large laminated casts
of Bence-Jones proteins.

Theophylline: usually manifests as CNS stimulation (headache, insomnia), GI

disturbances (nausea, vomiting), cardiac toxicity (arrhythmia). PDE inhibition,
 adenosine antagonism, stimulation of epinephrine relase. Ciprofloxacin and
erythromycin decrease clearance and raise plasma concentration.

Hemochromatosis: patient with new onset diabetes, arthropathy,

hepatomegaly. AR. Iron absorption is increased. Cirrhosis -> possible
hepatoma. Do serum iron studies. Liver biopsy confirms.

Trigeminal Nerve: contains motor and sensory fibers. First branch carries
sensory fibers to the scalp, forehead, upper eyelid, conjunctiva, cornea, nose,
frontal sinuses. Damage to V1 -> corneal anesthesia and lesions on the eye
may not be noticed.

Hairy Cell Leukemia: leukemic reticuloendotheliosis. Characterized by

lymphocytes with fine hair like projections with TRAP stain. Bone marrow ->
fibrotic -> dry taps. Cladribine is DOC for hairy cell leukemia. Toxic to bone
marrow. Has neurological and kidney damage.

Stable Angina: with HTN, treat with beta blocker. Decreases threshold for
anginal episode and controls HTN. Also are cardioprotective and can
potentially reduce the risk of major CV events by decreasing sympathetic
output to the heart.

RA: morning stiffness presents with inability to do things in the morning but
fine by afternoon time. Affects MCP, PIP, wrist. Disease of systemic
inflammation. ESR will be high. Mostly peripheral joints. If affects axial ->
cervical spine -> C1-C2 instability -> subluxation.

Hemochromatosis: cirrhosis, pancreatic fibrosis (diabetes), increased skin

pigmentation, and abnormalities of cardiac conduction. Can have
hypogonadism, arthropathy, dilated or restrictive cardiomyopathy. Can deposit
in pituitary and cause hypogonadotropic hypogonadism.

Pancreatitis: nausea, vomiting, epigastric pain that radiates to the back. Low
grade fever also common. History, physical, elevated amylase and lipase.
Gallstones and alcohol are MCC. Hypertriglyceridemia, anatomic
abnormalities, infection, medications also cause. Can have left sided pleural
effusions when amylase is high, abdominal compartment syndrome,
intraabdominal hemorrhage, shock, diabetes, pseudocyst formation,
abdominal pseudoaneurysm.

Reactivation TB: