UWorld 2 CK Notes

UWorld Notes: Step 2 CK malingering: intentional production of false physical symptoms for secondary gain  factitious disorder: intentional production of false physical or psychological signs or symptoms to assume a sick role; no secondary gain  hypochondriasis: fear of disease & preoccupation with the body, manifests as multiple somatic complaints; at least 6 months o prominent during psychological stress o inquire about current emotional stressors o Rx: refer for brief psychotherapy  conversion disorder: unexplained neuro symptoms preceded by an obvious emotional trigger; symptoms are not artificially produced, unexplained by any medical condition; cause social & functional impairment (la belle indifference) --------------------------------------------------------------- conduct disorder: middle childhood/adolescent o Dx: at least 3 symptoms from the following categories: (1) aggression towards people or animals, (2) destruction of property, theft, deceitfulness, or (3) serious violation of rules  oppositional defiant disorder: pattern of angry, irritable mood & argumentative toward authority o children; less severe vs. conduct disorder  antisocial personality disorder: age 18 yrs or older; evidence of conduct disorder as minors --------------------------------------------------------------- borderline personality disorder show a pattern of unstable relationships, impulsivity, reckless; identity disturbance, suicidal or self-mutilating behavior, feelings of emptiness; “splitting”  histrionic personality disorder: excessively labile emotions & attention seeking behavior; uses physical appearance to draw attention  paranoid personality disorder: suspiciousness & distrust; negatively interpret actions, words & intentions of others; holds grudges  dependent personality disorder: submissive & clingy; fear of separation, indecisive, does not take initiative; difficulty expressing disagreement 

avoidant personality disorder: shyness, feelings of inferiority with a desire for friends, but intense fear of embarrassment or rejection; low self-esteem --------------------------------------------------------------- prolonged hypotension from any cause can lead to acute tubular necrosis o U/A: muddy brown granular casts consist of renal tubular epithelial cells o serum BUN:Cr ratio < 20:1 o urine osmolality 300 - 350 mOsm/L o urine Na+ > 20 mEq/L, FENa > 2% --------------------------------------------------------------- broad casts: a/w chronic renal failure o arise in dilated tubules of enlarged nephrons that undergone compensatory hypertrophy in response to the reduced renal mass  waxy casts: chronic renal disease o shiny & translucent  RBC casts: glomerulonephritis or vasculitis; o Wegener’s, SLE, Henoch-Schonlein  WBC casts: interstitial nephritis & pyelonephritis o WBCs that originate in kidneys  fatty casts: nephrotic syndrome  hyaline casts: asymptomatics & prerenal azotemia o proteins that pass unchanged along urinary tract ---------------------------------------------------------------Neonatal conjunctivitis etiologies onset features Rx Chemical ˂ 24 mild conjunctival eye lubricant hrs irritation/injection & tearing after silver nitrate ophthalmic prophylaxis Gonococcal 2 - 5 eyelid swelling, IV or IM days purulent exudate, ceftriaxone or corneal ulceration cefotaxime Chlamydia 5 - 14 eyelid swelling; oral l days chemosis; watery erythromycin or mucopurulent discharge 

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best way to prevent neonatal chlamydial & gonococcal conjunctivitis: screen, Dx, Rx pregos screen for chlamydia @ 1st & 3rd prenatal visit

 maternal infection may be asymptomatic --------------------------------------------------------------- ceftriaxone should be avoided in infants with hyperbilirubinemia  displacement of bilirubin from albumin-binding sites,  risk of kernicterus  oral erythromycin: Rx chlamydial conjunctivitis & pneumonia o risk of infantile hypertrophic pyloric stenosis  topical erythromycin: prophylaxis for neonatal gonococcal conjunctivitis; regardless of screening  topical silver nitrate: prophylaxis against penicillinase-producing strains of N. gonorrhea (not available in the US)  nasolacrimal duct obstruction (dacryostenosis): unilateral chronic tearing & minimal conjunctival injection; Rx massage nasolacrimal ducts --------------------------------------------------------------- neonatal gonococcal conjunctivitis: acquired through infected genital secretions  prophylaxis: erythromycin ophthalmic ointment  Rx: IV or IM ceftriaxone or cefotaxime  complications: corneal ulcers, scarring, blindness --------------------------------------------------------------- meniscal & ligamentous tears can both be a/w a popping sensation following precipitating injury  meniscal injury: gradual joint swelling, 12 – 24 hr  ligamentous injury (ACL): rapid joint swelling & effusion due to hemarthrosis (ligaments have greater vascular supply than menisci, which rely on diffusion for nourishment)  definitive Dx: MRI --------------------------------------------------------------- Ulcerative colitis: MC in females, Ashkenazi Jew, peak @ age 15 - 25  MC site: rectum, confined to mucosal layer  bloody diarrhea, tenesmus, pseudopolyps  severe disease: weight loss, fever, or anemia  +p-ANCA  confirm Dx: friable mucosa on colonoscopy & biopsy with mucosal inflammation  extraintestinal: erythema nodosum, uveitis, sclerosing cholangitis, spondyloarthropathy  complications: toxic megacolon & colorectal ca  surveillance: annual colonoscopies beginning at 8 - 10 yrs after Dx for colon cancer detection

colonic dysplasia is a/w progression to adenocarcinoma; Rx: total colectomy --------------------------------------------------------------- young patient, aphthous ulcer, chronic diarrhea, abdominal pain, weight loss: Crohn’s  non-caseating granulomas, “cobblestone”, transmural inflammation, skip lesions, creeping fat, non-lymphoid aggregates  MC site: terminal ileum; rectum is spared --------------------------------------------------------------- primary features of Chagas disease: recent immigrant from Latin America with chronic megacolon/megaesophagus & cardiac disease (CHF: pedal edema, JVD, S3, cardiomegaly)  systolic & diastolic heart failure, RBBB  Rx: benznidazole or nifurtimox --------------------------------------------------------------- adjustment disorder: emotional or behavioral symptoms within 3 months of identifiable stressor; rarely > 6 months after the stressor ends  marked distress in excess of expected from exposure to the stressor, with significant impairment  Rx: cognitive or psychodynamic psychotherapy to develop coping mechanisms, response to & attitude about stressful situations  SSRIs can be an adjunct for depressive symptoms --------------------------------------------------------------- generalized anxiety disorder: excessive worry over many aspects of life, at least 6 months  acute stress disorder: PTSD-like symptoms develop within 4 wks, last > 3 days, but < 1 month  PTSD: anxiety symptoms > 1 month  OCD: recognizes unreasonable nature of behavior o ego-dystonic beliefs  OCPD: preoccupied with orderliness & perfection; does not see the behavior as a problem o ego-syntonic beliefs --------------------------------------------------------------- altered levels of serotonin involved in OCD  Rx: SSRI or clomipramine (TCA) --------------------------------------------------------------- weight loss = most effective lifestyle intervention to reduce BP o

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DASH diet is the next most effective approach in prevent & treat HTN especially non-obese; then exercise, dietary sodium, alcohol intake  smoking causes a transient rise in BP --------------------------------------------------------------- HPV vaccine for all girls/women age 9 – 26 (except pregos) regardless of HPV status or sexual activity (also immunocompromised)  all boys/men age 9 - 21  routine HPV screening (Pap) should not begin prior to age 21, regardless of sexual activity  **sexually active women age < 21 can be HPV+ & develop cervical dysplasia that is transient with regression within 2 yrs o thus no Pap smear  age 21 – 29: cytology every 3 years  routine HPV testing not for women age < 30 o HPV in most young women is transient, clearing within 2 years o age 30 – 65: cytology every 3 yrs, OR cytology + HPV testing every 5 yrs Routine cervical cancer screening Immunocompromised  screen at onset of (HIV, SLE, organ intercourse transplant patients)  6 months x2 then annual Age ˂ 21 No screening** 21 to 29 Pap (cytology) every 3 years  cytology every 3 years 30 to 65  OR cytology + HPV test every 5 years no screening if negative ≥ 65 prior screens & not high-risk no screening if no Hx of Hysterectomy high-grade lesions, cervical without cervix cancer, or exposure to DES --------------------------------------------------------------- atypical squamous cells of undetermined significance (ASC-US) is MC cervical cytological abnormality, but risk of invasive cervical cancer is low  atypical squamous cells, cannot rule out high-grade squamous epithelial lesion (ASC-H) is a/w premalignant lesions  ASC-US/LSIL in age 21 – 24: repeat pap in 1 yr

HPV infection is transient & malignant transformation is rare  colposcopy only if ASC in 3 consecutive paps or ASC-H, atypical glandular cells, or HSIL  ASC-US in age ≥ 25: HPV testing o HPV positive  colposcopy o HPV negative  repeat pap & HPV in 3 yrs ---------------------------------------------------------------High-grade squamous intraepithelial lesion (HSIL)  age 21 – 24: colposcopy o if no CIN 2,3  repeat colposcopy & cytology @ 6-month intervals for 2 yrs  age ≥ 25: LEEP (except postmenopause & pregos)  pregos with HGSIL  colposcopy o if colposcopy is negative  repeat cytology & colposcopy @ 6 wks after delivery o 50% of HGSIL & CIN 2 or 3 regress spontaneously during pregnancy o no cervical biopsy or LEEP during pregnancy, unless colposcopy suggests invasive cancer --------------------------------------------------------------- cephalohematoma: subperiosteal hemorrhage, does not cross suture lines; presents several hours after birth; resolves spontaneously  Caput Succedaneum: diffuse, ecchymotic swelling of the scalp that Crosses Suture lines --------------------------------------------------------------- Rheumatoid arthritis o morning stiff >30 min, improves with activity o tenosynovitis of palms (“trigger finger”) o cervical joint involvement can lead to spinal subluxation  cervical cord compression o positive anti-cyclic citrullinated peptide (anti-CCP) o  CRP & ESR correlates with disease o XR: soft-tissue swelling, bony erosions, joint space narrowing  greatest risk for osteoporosis  Rx: physical activity, optimize Ca++ & Vit D intake, minimize corticosteroids, bisphosphonates --------------------------------------------------------------- Paget’s disease of bone = osteitis deformans; due to osteoclast overactivity, leads to replacement of lamellar bone with abnormal woven bone ---------------------------------------------------------------o

Osteitis fibrosa cystica (Von Recklinghausen disease of bone): due to hyperparathyroidism 2/2 parathyroid carcinoma  excessive osteoclastic resorption, leads to replacement with fibrous tissue & bony pain  XR: subperiosteal bone resorption, “salt-&-pepper” appearance of skull, bone cysts, & brown tumors of long bones --------------------------------------------------------------- Bronchiolitis: MCC is RSV  older children  self-limited, mild URI  age < 2 yrs involves lower respiratory tract o wheezing/crackles & respiratory distress with waxing/waning; peaks @ days 5-7  Rx: supportive care  prophylaxis: Palivizumab for high risk cases  complications: apnea & respiratory failure; develops recurrent wheezing through childhood o increased risk of acute otitis media; but rarely bacterial pneumonia or sepsis ---------------------------------------------------------------Caustic ingestion features chemical burn or liquefaction necrosis results in:  laryngeal damage: hoarseness, stridor, orofacial inflammation  esophageal damage: dysphagia, odynophagia  gastric damage: epigastric pain, GI bleeding management  ABCs  remove contaminated clothing, irrigate exposed skin  upper GI XR with water-soluble contrast for suspected perforation  CXR if respiratory symptoms  upper endoscopy within 24 hr  barium contrast (2 – 3 wks) complications  esophageal strictures  pyloric stenosis  ulcers, perforation  cancer 

avoid interventions that provoke vomiting (activated charcoal, milk, vinegar, NG lavage)  in absence of perforation, upper endoscopy within 12 – 24 hr to assess damage & guide therapy --------------------------------------------------------------- chronic GERD with new dysphagia & symmetric LES narrowing: esophageal stricture  body’s reparative response to chronic acid exposure  other causes: radiation, systemic sclerosis, caustic  Dx: endoscopic biopsy to r/o adenocarcinoma  DDx: adenocarcinoma (asymmetric narrowing), hiatal hernia, achalasia (aperistalsis) --------------------------------------------------------------- early-onset HTN, progressive renal insufficiency, gross hematuria, flank pain, B/L abdominal masses 

symptoms

clinical signs extra-renal manifestation

diagnosis management

ADPKD most are asymptomatic hematuria flank pain (due to renal calculi, cyst rupture, hemorrhage, or upper UTI) early onset HTN B/L upper abdominal masses mild proteinuria, CKD cerebral aneurysm hepatic/pancreatic cysts cardiac valves (MVP, AR) diverticulosis ventral/inguinal hernias abdominal USS monitor BP, renal Fx, & potassium control cardiovascular risk factors ACE-inhibitors for HTN ESRD: dialysis, renal transplant

DDx  central obesity, facial plethora, proximal weakness, abdominal striae, ecchymosis: Cushing’s  headaches, palpitations, diaphoresis a/w paroxysmal BP elevations: pheochromocytoma o urinary vanillylmandelic acid, & metanephrines --------------------------------------------------------------- alpha-1-antitrypsin: protease inhibitor that protects from neutrophil elastase, which breaks down elastin  AAT deficiency: uninhibited elastase cause bullous, panacinar emphysema of lower lobes

(smoking-induced emphysema is centrilobular) also causes liver disease: cirrhosis, or HCC liver Bx: hepatocyte inclusion stain +PAS & resists digestion by diastase  Rx: purified human AAT --------------------------------------------------------------- chemotherapy-induced peripheral neuropathy from vincristine (also cisplatin, paclitaxel) begins after several weeks  symmetric paresthesia in fingers/toes, spreads proximally in stocking-glove pattern  loss of ankle jerk reflexes, pain/temp sensation, occasional motor neuropathy (B/L foot drop) --------------------------------------------------------------- Pinworm infection: erythematous vulvovaginitis in prepubertal females; absence of vaginal discharge  recurrent episodes of nocturnal itching should be examined with “Scotch tape” test  empiric Rx: mebendazole --------------------------------------------------------------- early Lyme disease: erythema chronicum migrans  also a/w headache, malaise, fatigue, fever  unilateral Bell’s palsy  early Dx is based on trademark rash & recent travel  MCC: B. burgdorferi (spirochete)  Rx: oral doxycycline (age > 8)  Rx: oral amoxicillin (age < 8, pregos, or lactating) or cefuroxime --------------------------------------------------------------- doxycycline A/E: permanent tooth discoloration & skeletal retardation in children & fetuses --------------------------------------------------------------- avascular necrosis is a/w heavy alcohol use, SLE, chronic systemic corticosteroids, sickle cell disease --------------------------------------------------------------- sudden onset C/L lower extremity motor & sensory deficits with UMN signs, urinary incontinence: anterior cerebral artery (ACA) occlusion  MCC: ischemic stroke ---------------------------------------------------------------Spinal cord compression causes spinal injury (MVA), disk herniation, malignancy (lung, breast, prostate, MM), infection (epidural abscess) features gradual, severe focal back pain;  

pain worse when recumbent & at night early: B/L LE weakness, absent DTRs, flaccid paraplegia late: B/L +Babinski, absent rectal tone, paraparesis with  DTRs, sensory loss, bowel/bladder dysfunction, urinary retention manage high-dose IV glucocorticoids, emergency spinal MRI, radiation-oncology, neurosurgery consult  pain worse on recumbent due to distension of epidural venous plexus --------------------------------------------------------------- anterior spinal cord infarct: abrupt onset flaccid paralysis, loss of pain & temp sensation (anterior spinal artery), & autonomic dysfunction --------------------------------------------------------------- recurrent pneumonia in the same anatomic region o bronchial obstruction or recurrent aspiration  bronchogenic carcinoma obstruction is most concerning with a smoking history  chest CT is indicated initially o central masses or negative CT: bronchoscopy o peripheral lesions: CT-guided biopsy  recurrent aspiration, same lung region o seizures o ethanol/drug use o GERD, dysphagia, achalasia  recurrent pneumonia in different regions o sinopulmonary disease (CF, immotile cilia) o immunodeficiency (HIV, leukemia) o vasculitis, bronchiolitis obliterans --------------------------------------------------------------- painless vesiculopustular rash, tenosynovitis, & migratory polyarthralgia: disseminated gonococcal infection  2 - 10 skin lesions similar to furuncles or pimples  Hx of recent unprotected sex with a new partner  all patients should undergo HIV screening --------------------------------------------------------------- hypotension, tachycardia, poor skin turgor, lethargy, confusion: hypovolemic hypernatremia o Rx: IV normal saline (0.9%) until euvolemic, then 5% dextrose

serum Na+ should be corrected by 0.5 mEq/dL/hr, as cerebral edema can result if too rapid --------------------------------------------------------------- high serum & low urine osmolality due to inadequate ADH response is most likely due to lithium-induced nephrogenic DI  Lithium induces ADH resistance, resulting in acute-onset nocturia, polyuria, & polydipsia  hypovolemic hypernatremia  Rx: discontinue lithium; salt restriction & diuretics (amiloride: K+ sparing diuretic)  Rx: hemodialysis for lithium level ˃ 4 mEq/L or ˃ 2.5 mEq/L + signs of toxicity or renal disease --------------------------------------------------------------- normal aging: stage 4 sleep (deep sleep) becomes shorter & eventually disappear --------------------------------------------------------------- increased contractility & reflex tachycardia are secondary effects provoked by nitroglycerin due to changes in baroreceptor activity in response to decrease BP from venodilation --------------------------------------------------------------- fever, headache, N/V, petechial rash, stiffness, & photophobia: meningococcemia  fever, arthralgia, sore throat, lymphadenopathy, mucocutaneous lesions, diarrhea, weight loss: acute HIV infection  migratory arthritis of large joints, carditis, erythema marginatum (raised ring-shaped lesions over trunk & extremities), subcutaneous nodules, Sydenham chorea: acute rheumatic fever o pharyngitis precedes onset by 2 - 4 wks --------------------------------------------------------------- best method of reducing maternal-fetal transmission of HIV infection: triple HAART therapy for the mother throughout pregnancy  HAART: dual NRTI + NNRTI or protease inhibitor  test viral load monthly until undetectable, then every 3 months; CD4 cell count every 3 months  avoid amniocentesis until viral load undetectable  mothers with undetectable viral loads at delivery have ˂ 1% risk for transmission  intrapartum mother not on HAART: Zidovudine  intrapartum viral load > 1000 copies/mL: Zidovudine + C-section 

infants: Zidovudine for ≥ 6 wks & serial HIV PCR testing ---------------------------------------------------------------PDA-dependent congenital heart disease  aortic coarctation  transposition of great vessels  hypoplastic left lung syndrome  total anomalous pulmonary venous connection  tricuspid atresia  normal ductus arteriosus constricts ~day 3 of life  prostaglandin E1 keep ductus arteriosus open  inspired O2 stimulates PDA constriction  indomethacin is a potent prostaglandin inhibitor, stimulates PDA closure ---------------------------------------------------------------Common complications after acute MI  hours – 2 days  reinfarction  hours – 7 days  ventricular septal rupture  days – 2 wks  LV free wall rupture  hours – 1 month  post-infarct angina  1– 3 days  acute pericarditis  2 – 7 days  papillary muscle rupture  5 days – 3 months  LV aneurysm  weeks – months  Dressler’s pericarditis --------------------------------------------------------------- acute pericarditis occur 1 - 3 days post-MI o pericardial friction rub with/without chest pain o self-limited, resolves with supportive care  posted-MI pericarditis occurring wks to months after an MI: Dressler syndrome o immune-mediated pericarditis o Rx: NSAIDs --------------------------------------------------------------- MCC blunt abdominal trauma: MVAs  MC injured: liver & spleen o free peritoneal fluid should raise suspicion for liver or splenic laceration  hemodynamically unstable & free intraperitoneal fluid on USS  emergency laparotomy  hemodynamically stable splenic lacerations & no evidence of other intra-abdominal injuries  non-operative management --------------------------------------------------------------- ventricular septum rupture: 3 to 5 days post-MI 

sudden onset hypotension, holosystolic murmur @ LLSB (VSD), CHF --------------------------------------------------------------- papillary muscle rupture: 3 to 5 days post-MI  hypotension 2/2 severe acute mitral regurgitation, holosystolic murmur & pulmonary edema -------------------------------------------------------------- ventricular free wall rupture: mechanical complication 5 days – 2 wks post- MI (anterior)  hemopericardium & cardiac tamponade  acute onset chest pain & profound shock, JVD, with rapid progression to PEA & death  LV free wall rupture should be suspected in patients with PEA after a recent first MI & no signs of heart failure --------------------------------------------------------------- ventricular aneurysm: late complication of acute STEMI (5 days to 3 months)  MC complication of anterior MI  scarred or fibrotic myocardial wall resulting from healed transmural MI  decompensated CHF, refractory angina, ventricular arrhythmias, or mural thrombus  EKG: persistent STEMI with deep Q waves unchanged from discharge after recent MI  Dx: echo shows dyskinetic LV wall motion --------------------------------------------------------------- LV free wall rupture: hemopericardium & cardiac tamponade  PEA  death --------------------------------------------------------------- hypotension or shock, JVD, clear lungs, Kussmaul sign: RV infarct o Kussmaul sign:  JVD with inspiration  EKG: inferior MI &/or ST elevation in V4R –V6R  Rx: IV fluid bolus to improve RV preload  nitro, diuretics, opioids may worsen hypotension ---------------------------------------------------------------Mechanical complications of acute MI time artery features echo RV failure Acute RCA hypotension, hypokinetic clear lungs, RV Kussmal sign papillary Acute, RCA acute, severe severe MR muscle 3-5 pulmonary with flail rupture days edema; new leaflet 

holosystolic murmur IV septum Acute, LAD shock & left-to-right rupture 3-5 = chest pain, shunt VSD days apical holosystolic RCA murmur, = biventricular basal failure free wall 5 days LAD shock & pericardial rupture of - 2 wks chest pain, effusion ventricle JVD, distant with heart sounds, tamponade PEA  large pericardial effusion presenting as cardiac tamponade post-MI: LV free wall rupture o dyspnea, hypotension, pulsus paradoxus, JVD o EKG: low voltage QRS, electrical alternans --------------------------------------------------------------- Sarcoidosis: no definitive diagnostic test  CXR: hilar adenopathy, reticulonodular infiltrates  Bx: noncaseating granulomas; serum ACE  erythema nodosum, acute polyarthritis, cough, anterior uveitis, dyspnea  asymptomatics Rx: followed without treatment due to high rate of spontaneous remission  symptomatic Rx: systemic glucocorticoid --------------------------------------------------------------- sudden onset abdominal pain a/w vaginal bleed, fetal distress, loss of fetal station in active labor: uterine rupture o risk factors: pre-existing uterine scar, abdominal trauma, macrosomia o prior low transverse c-section: < 1% risk o prior vertical c-section: as high as 9%  HTN & cocaine use: risk for placental abruption  sinusoidal fetal HR tracing: vasa previa  fever, tender uterus, foul-smelling lochia, progression to sepsis: endometritis o polymicrobial infection o Rx: IV clindamycin & gentamicin  clindamycin for Gram+ & anaerobes  gentamicin for Gram-negatives ----------------------------------------------------------------

strabismus after age 4 months is abnormal & requires Rx to prevent amblyopia (vision loss from disuse of deviated eye)  intermittent strabismus can be expected in infants < 4 months due to immaturity of extraocular muscles; reassurance & observation  new onset strabismus can be a sign of retinoblastoma if accompanied by white reflex  acute onset strabismus can result from intracranial hemorrhage, brain abscess, or encephalitis --------------------------------------------------------------- first 5 years of life are critical to development of visual acuity, a time of visual cortex maturity  esotropia beyond infancy must be treated to prevent amblyopia  deviated eye can be strengthened by patching the normal eye (occlusion therapy) or blurring the normal eye with cycloplegic drops (penalization) --------------------------------------------------------------- Rx for SLE, malaria prophylaxis, acute malaria, rheumatoid arthritis: hydroxychloroquine  Rx for Crohn’s, ankylosing spondylitis, RA, psoriasis: infliximab (TNF-α-blocker)  Rx for histoplasmosis: itraconazole  Rx SLE with renal involvement: cyclophosphamide --------------------------------------------------------------- encephalopathy, ocular dysfunction, gait ataxia: Wernicke encephalopathy  giving IV fluids containing glucose prior to thiamine can precipitate or worsen WE  thiamine is given along with or before glucose --------------------------------------------------------------- acute onset back pain after physical exertion, paravertebral tenderness, absence of radiation, negative straight leg raise test, normal neuro exam: lumbosacral strain o Rx: NSAIDs, early mobilization --------------------------------------------------------------- acute back pain, local spinal tenderness, & decreased spinal mobility after minimal trauma, coughing, lifting: vertebral compression fracture  worse with standing, walking, laying on back  point tenderness, but normal neuro exam  risk factors: postmenopausal or senile osteoporosis 

also: steroid Rx, osteomalacia, osteomyelitis, trauma, bone mets, hyper-PTH, Paget’s  complications: risk of future fractures, hyperkyphosis ( respiratory capacity, risk of atelectasis, early satiety, weight loss) --------------------------------------------------------------- Eikenella corrodens: G-negative anaerobe part of normal oral flora o infective endocarditis due to E. corrodens is seen in poor dentition, periodontal infection, or manipulative dental procedures o E. corrodens belongs to the HACEK group  congenital heart lesions (bicuspid aortic valve, PDA, ToF, VSD) predisposes to risk of IE  ulcerative colon lesions due to colonic neoplasia or inflammatory bowel disease predisposes to IE due to Strep gallolyticus (S. bovis type I)  S. aureus is the MCC of IE among IVDA  Enterococci (E. faecalis) MC endocarditis a/w nosocomial UTIs --------------------------------------------------------------- flumazenil: GABA/benzodiazepine Rc antagonist o Rx benzodiazepine overdose (slurred speech, ataxia, hypotension, depressed mental status)  labetalol: Rx hypertensive encephalopathy (BP ≥ 180/120 mmHg, headache, N/V, confusion)  nitroprusside: hypertensive emergency (BP > 220/120 with evidence of organ damage) ---------------------------------------------------------------Cryptococcal meningoencephalitis Features develops over 2 weeks (subacute)… headache, fever, malaise, vomiting, altered mental status, B/L papilledema more acute & severe in HIV (CD4 ˂100) Dx CSF features…  high opening pressure  low glucose, high protein  WBC ˂ 50/μL (mononuclear predominance)  cryptococcal antigen positive  transparent capsule on India ink  culture on Sabouraud agar Rx initial: amphotericin B with flucytosine maintenance: fluconazole o

serial LPs may be required to reduce  ICP antiretroviral therapy should be deferred at least 2 weeks after completing induction antifungal therapy for cryptococcal meningitis o initiating retroviral therapy with acute infection  risk of immune reconstitution syndrome  itraconazole does not cross the BBB --------------------------------------------------------------- sulfadiazine–pyrimethamine: Rx cerebral toxo (headache, focal neurologic deficits, seizures); multiple ring-enhancing lesions with edema --------------------------------------------------------------- prostaglandin-only oral contraceptives are preferred for hormonal contraception for lactating mothers o does not affect volume or composition of milk produced, or risk of venous thrombosis a/w combination OCPs  lactation causes anovulation, thus some degree of contraception due to high prolactin levels which inhibit GnRH release, but not reliable --------------------------------------------------------------- CMV retinitis: MC when CD4 < 50 o yellow/white patches of retinal opacification & hemorrhages o Rx: ganciclovir or foscarnet  HSV encephalitis: cognitive & personality changes, focal neurologic deficits; temporal lobe hemorrhage  PML: JC virus detected on PCR of CSF, patchy areas of white matter due to demyelination o focal neurologic deficits; no mass effect o hemiparesis; speech, vision, & gait dysFx o no cure; 6 month survival --------------------------------------------------------------- mononucleosis-like symptoms, atypical lymphocytes, negative Monospot: CMV mono  absence of pharyngitis & lymphadenopathy  large basophilic lymphocytes with a vacuolated appearance --------------------------------------------------------------- +HIV, bloody diarrhea, normal stool: CMV colitis  typically CD4 < 50 cells/μL  Dx: colonoscopy multiple ulcers, mucosal erosions  biopsy: large cells with eosinophilic intranuclear & basophilic intracytoplasmic inclusions  

 Rx: ganciclovir (or Foscarnet)  complications: toxic megacolon --------------------------------------------------------------- bone marrow transplant recipient with lung & interstitial involvement: CMV pneumonitis  develops 2 wks – 4 months post-transplant  CXR: multi-focal, diffuse patchy infiltrates  high-resolution CT: parenchymal opacification or multiple small nodules  Dx: bronchoalveolar lavage --------------------------------------------------------------- dizziness, “spinning sensation” with nausea: vertigo  vertigo classification: central or peripheral o peripheral vertigo has a shorter interval o ear fullness suggests peripheral vertigo o CN VIII lesions lead to central vertigo  vertigo with a sensation of ear fullness suggests Meniere’s disease, from abnormal accumulation of endolymph in the inner ear  tinnitus, vertigo, sensorineural hearing loss --------------------------------------------------------------- Baker cysts: excess fluid produced by an inflamed synovium accumulates in popliteal bursa, results in a tender mass; a/w RA, osteoarthritis, cartilage tears  Baker cyst rupture presents similar to DVT o cystic fluid leaks down the inner leg, results in a hematoma over medial malleolus (“crescent sign”)  DDx: subcutaneous abscess, lymphedema --------------------------------------------------------------- ARDS: non-cardiogenic pulmonary edema caused by leaky alveolar capillaries  mechanical vent.: FiO2 improves oxygenation, PEEP prevents alveolar collapse  arterial pO2 measures oxygenation  influenced by FiO2 & PEEP  arterial pCO2 measures ventilation  affected by respiratory rate & tidal volume  initial ventilator management is decrease FiO2 to non-toxic values (< 60%); goal = paO2 ≥ 60  PEEP can be increased to maintain oxygenation o decreasing PEEP lowers oxygenation by decreasing availability of alveoli

hypoxemia is best treated by increasing PEEP PEEP complications: barotrauma, tension pneumoTx (resulting hypotension) --------------------------------------------------------------- ARDS can develop in the setting of sepsis, severe bleeding, severe infection, toxic ingestion, burns, or acute pancreatitis  inflammatory mediators are released locally or to distant tissues, damage the alveoli   alveolar capillary permeability allows fluid to leak into alveoli, resulting in pulmonary edema  excessive IV fluids  hydrostatic pressure, thus can worsen pulmonary edema  Rx: mechanical ventilation with low tidal volumes & PEEP to  work of breathing &  oxygenation --------------------------------------------------------------- ventilation = product of RR & tidal volume  mechanically ventilated patients with respiratory alkalosis in the setting of appropriate tidal volume  RR should be lowered o reducing tidal volume can trigger an  RR  worsens alkalosis o increasing tidal volume would  ventilation  worsens alkalosis --------------------------------------------------------------- hypotension, tachycardia, flat neck veins, confusion, & cold extremities despite IV fluid resuscitation: hypovolemic/hemorrhagic shock  cardiogenic shock: decreased C.O. causes  SVR,  PCWP, venous filling pressures & JVD  loss of vascular tone occurs in septic & neurogenic shock with compensatory  C.O./index o less blood return:  PCWP & SVR ---------------------------------------------------------------Hemodynamic measurements in shock Normal Hypovole Cardiogen Septic mmHg mic shock ic shock shock RA 4   nrml pressure or  (preload) PCWP 9   nrml (preload) or  Cardiac 2-4    index L/min/ (pump m2  

function) SVR (afterload) Mixed venous O2 saturation

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intravascular volume loss leads to  LV preload   C.O. & systemic BP   HR & SVR o  pulmonary capillary wedge pressure (PCWP) measures of LA & LVED pressure  cardiogenic shock leads to  C.O. & BP o  PCWP due to heart failure o  HR & SVR maintains organ perfusion   C.O. decreases tissue perfusion, thus signals tissues to extract more O2  vasodilatory/distributive shock, MC due to sepsis, anaphylaxis, SIRS, or CNS injury o peripheral vasodilation   SVR & BP, with compensatory  HR & C.O. o hyperdynamic circulation, which decreases organ perfusion   venous O2 saturation o as sepsis progresses  vasoconstriction is a/w  SVR &  C.O. --------------------------------------------------------------- acute massive PE can present as hypotension & syncope, leading to PEA in some patients  PE occluding part of pulmonary artery results in  RA, RV, & pulmonary artery pressure  compensatory hyperdynamic LV function: early  cardiac index, but no effect on PCWP or SVR --------------------------------------------------------------- RV infarct:  RA & RA pressures   PCWP & cardiac index 2/2 reduced preload --------------------------------------------------------------- exertional dyspnea, syncope, angina: aortic stenosis o systolic murmur, radiates to apex & carotids o peripheral pulse: pulsus parvus et tardus (decreased amplitude & delayed upstroke)  hypotension, tachycardia, distended neck veins, electrical alternans, pulsus paradoxus, (exaggerated decrease (> 10 mmHg) in systemic arterial BP with inspiration): cardiac tamponade 

pulmonary edema, a-fib, late diastolic murmur with opening snap: mitral stenosis --------------------------------------------------------------- sudden severe chest pain radiating to back, severe HTN, decrescendo diastolic murmur of aortic regurgitation: acute aortic dissection o systolic BP > 20 mmHg difference between arms, & weak/absent peripheral pulses o heard @ right sternal border  CXR & EKG to exclude other Dx  serum creatinine, contrast allergy?  Dx: transesophageal echo (TEE) is preferred over chest CT with contrast in patients with kidney disease or contrast-induced nephropathy  Rx: IV labetalol o patients should not receive antiplatelets (ASA, clopidogrel) or anticoagulation without first excluding aortic dissection o nifedipine is a vasodilator that can induce reflex tachycardia &  aortic shear stress  complications: Horner’s, LE weakness/ischemia, hemothorax, abdominal pain  DDx: acute pericarditis, acute pancreatitis, PE, MI, angina, mediastinal tumor, pleuritis --------------------------------------------------------------- aortic dissection can extend to aortic valve, carotids, renal arteries, or pericardium, leading to aortic regurgitation, stroke, ARF, or tamponade --------------------------------------------------------------- blunt abdominal trauma can cause splenic injury  delayed onset hypotension, LUQ pain radiating to left shoulder 2/2 diaphragmatic irritation (Kehr sign)  Dx: abdominal CT with contrast if hemodynamically stable  hemodynamic instability despite IV fluids requires laparotomy --------------------------------------------------------------- bipolar disorder is an episodic illness; periods of severe irritability during discrete mood episodes  strong genetic component  bipolar I: manic episodes with/without Hx of major depressive episodes o Dx can be made with a first manic episode  bipolar II:, hypomanic episodes (less severe, less functional impairment, no psychotic symptoms) 

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o Hx of ≥ 1 depressive episodes required o never met criteria for a past manic episode cyclothymic disorder: ≥2 years of fluctuating, mild hypomania & mild depressive symptoms that do not meet criteria for hypomanic episodes nor major depressive episodes

Manic episode Hypomanic episode Symptoms more severe, Symptoms less severe, one week (unless ≥ 4 consecutive days hospitalized) symptoms not severe marked impairment in enough to cause marked social or occupational impairment or necessitate functioning, hospitalization, psychotic features no psychotic features --------------------------------------------------------------- bipolar disorder is at high risk of relapse after remission from an acute episode  #1 maintenance Rx: atypical + lithium or valproate Guidelines for maintenance Rx of bipolar disorder  first episode  maintenance at least 1 yr  2 episodes  long-term maintenance (years) if episodes were severe or +family Hx  ≥ 3 relapses  lifetime maintenance --------------------------------------------------------------- sunscreen: 30 min before exposure  reapply every 2 hrs  avoid sunscreen in infants < 6 months --------------------------------------------------------------- long-acting injectable antipsychotics (depot) Rx chronic noncompliance, who previously responded to oral antipsychotics o must assess tolerability of oral medication o 1st & 2nd generations available as depot o given as IM every 2 – 4 wks  Rx-resistant schizophrenia: clozapine o fail to respond to ≥ 2 antipsychotics o risk of agranulocytosis o requires routine monitoring: CBC ---------------------------------------------------------------Lithium therapy Indications mania due to bipolar C/I  chronic kidney disease  cardiovascular disease  hyponatremia or diuretic use

Baseline studies

A/E

 BUN/creatinine, U/A  Ca++  Thyroid function  EKG if coronary risk factors Acute  tremor, ataxia, weakness  polyuria, polydipsia  vomiting, diarrhea, weight gain  cognitive impairment Chronic  nephrogenic DI  thyroid dysfunction  hyperPTH with hyperCa++

Lithium has a narrow therapeutic window, thus monitor every 6 – 12 months or 5 – 7 days after dose changes or drug interactions (diuretics, SSRIs, NSAIDs, ACE-I, phenytoin, carbamazepine)  pregnancy: Ebstein’s anomaly, polyhydramnios, nephrogenic DI, floppy infant syndrome  no effect on liver function, lipids, or glucose --------------------------------------------------------------- complications following rhinoplasty: dissatisfaction, nasal obstruction, epistaxis  nasal septum has poor blood supply & regenerating capacity, thus trauma or surgery may result in septal perforation  presents as a whistling during respiration due to a septal hematoma following rhinoplasty --------------------------------------------------------------- > 2 weeks of persistent, high-volume, non-bloody watery diarrhea after recent travel; no fever, tenesmus or vomiting: Cryptosporidium parvum  travel-associated diarrhea > 2 weeks; parasitic o cryptosporidium cystoisospora, microsporidia, Giardia  diarrhea < 1 week: viral or bacterial o rotavirus/norovirus: vomiting o ETEC/EPEC: contaminated food/water o Campylobacter: abdo pain, bloody diarrhea, “pseudoappendicitis” o Salmonella: frequent fever o Shigella: fever, bloody diarrhea, abd pain 

Entamoeba histolytica causes amebiasis, resulting in abdo pain & bloody diarrhea --------------------------------------------------------------- constrictive pericarditis is a complication of mediastinal irradiation (Hodgkin lymphoma), TB, & cause of right heart failure (hepatomegaly, progressive peripheral edema, JVD, ascites)  can present 10 – 20 yrs after irradiation or anthracycline therapy  scarring & inelastic pericardium results in diastolic dysfunction  CXR: pericardial calcifications  confirm Dx: echo show pericardial thickening, abnormal septal motion, bi-atrial enlargement  Rx: diuretics for temporary relief; pericardiectomy for refractory symptoms 

Constrictive pericarditis idiopathic or viral, cardiac surgery, radiation therapy (Hodgkin’s), TB (developing countries) Features fatigue, dyspnea on exertion, right heart failure (peripheral edema, ascites, JVD, Kussmaul sign ) hepatojugular reflux pericardial knock (mid-diastolic sound) pulsus paradoxus complication: cardiac cirrhosis Dx EKG: a-fib, or low voltage QRS pericardial calcifications & thickening prominent x & y descents Rx NSAIDs, diuretics, pericardiectomy --------------------------------------------------------------- spontaneous esophageal rupture after severe retching/vomiting: Boerhaave’s  CXR: left-sided pleural effusion with/without pneumothorax, subcutaneous emphysema, & widened mediastinum  exudative pleural fluid: low pH, high amylase (>2500 IU)  Dx: CT or contrast esophagogram w/ Gastrografin (water-soluble contrast) Mallory-Weiss Boerhaave etiology mucosal tear transmural tear 2/2 2/2 forceful retching; Etiology

features

Dx

Rx

forceful retching; submucosal arterial or venule plexus bleeding vomiting, retching epigastric pain hematemesis EGD endoscopy

pleural fluid shows elevated WBCs, protein, & LDH, but not amylase --------------------------------------------------------------- RA, moderate anemia, low serum iron, low TIBC,  transferrin: anemia of chronic disease  a/w chronic inflammatory diseases (RA)  iron trapping within macrophages, leads to poor iron availability for Hb synthesis  low reticulocyte count  Rx underlying cause can improve anemia --------------------------------------------------------------- stress fractures: MC in anterior middle third of the tibia in jumping sports & posteromedial distal third of the tibia in runners  microfractures within cortical bone that coalesce  risk factor: “female athlete triad” ( caloric intake, oligo-/amenorrhea, osteoporosis)  MC site: 2nd metatarsal  XR is normal initially, 6 wks  Dx: MRI or bone scan  Rx: rest & analgesia  Rx: surgery for displaced fx or 5th metatarsal fx --------------------------------------------------------------- child with severe headache of gradual onset a/w N/V, photophobia, visual aura: migraine  most common form of headache < age 20  migraines in children are often bifrontal & shorter duration than adult migraines  Rx in < age 12: supportive (dark, quiet room, & cool cloth on forehead), acetaminophen or NSAID (ibuprofen)  alternative Rx: triptans --------------------------------------------------------------- indications for neuroimaging in a child with headache: Hx of coordination difficulties, tingling, numbness, focal neurologic signs; headache that awakens from sleep,  headache frequency --------------------------------------------------------------- obese boy with a limp, knee pain, decreased ROM, pain with hip internal rotation: slipped capital femoral epiphysis (SCFE)  MC in obese boys, age 10 – 16 yrs  insidious onset dull hip or referred knee pain, altered gait with no preceding trauma  affected hip is held in passive external rotation o

esophageal perforation with air/fluid leakage vomiting, retching, retrosternal pain,  WBC odynophagia, fever, dyspnea, or septic shock subcutaneous emphysema CT or contrast esophagography with Gastrografin CXR: pneumomediastinum & exudative pleural effusion (low pH, high amylase) cervical perforations: conservative measures thoracic perforations: surgery

self-limited; endoscopic Rx as needed (clipping or coagulation) --------------------------------------------------------------- allergic rhinitis: rhinorrhea, nasal pruritus, cough; nasal mucosa is edematous & pale; polyps?  nasal furunculosis: 2/2 staphylococcal folliculitis due to nose-picking or hair plucking o pain, tenderness, erythema in nasal vestibule o life-threatening if spreads to cavernous sinus --------------------------------------------------------------- fetal distress (repetitive late decelerations) is an indication for emergent c-section --------------------------------------------------------------- chronic ankylosing spondylitis (> 20 yrs) are at  risk for vertebral fractures with minimal trauma  DDx: spinal root compression, bone mets --------------------------------------------------------------- acute pancreatitis can cause unilateral, left-sided pleural effusion with high amylase concentration, but not widened mediastinum  cocaine use predisposes to aortic dissection with wide mediastinum & unilateral pleural effusion, but not high amylase content  aspiration pneumonia is MC in right lower lobe & unilateral pleural effusion due to parapneumonic effusion or empyema

a/w children with endocrinopathies (hypothyroidism, growth hormone deficiency) have B/L disease & present at an earlier age  Dx: XR in frog-leg lateral view  Rx: surgical screw fixation at current slippage  complication: avascular necrosis --------------------------------------------------------------- Legg-Calve-Perthes: idiopathic avascular necrosis of femoral capital epiphysis  MC in boys, age 5 – 7 yrs  insidious hip, groin, or knee pain & antalgic gait (indication of pain with weight bearing)  limited internal rotation & hip abduction  Dx: high suspicion; early XR may be negative  Rx: observation & bracing; surgery if severe  DDx: SCFE, transient synovitis --------------------------------------------------------------- MCC of hip pain in children: transient synovitis  boys age 3 – 10 yrs; after viral infection or trauma  well-appearing, able to bear weight  affected hip is flexed, slightly abducted & externally rotated which maximizes joint space  Dx: XR to exclude bone lesions, fx, Legg-Calve  Rx: ibuprofen & rest, F/U in 1 wk o recovery within 1 – 4 wks; no complications --------------------------------------------------------------- amenorrhea > 3 months, hypoestrogenism,  FSH, age < 40: premature ovarian failure  may be secondary to accelerated follicle atresia or low number of primordial follicles  MC is idiopathic; or a/w mumps, oophoritis, irradiation, chemotherapy, autoimmunity (Hashimoto’s, Addison’s, DM Type I, pernicious anemia)  Dx:  FSH/LH, hypoestrogen o do not wait for 1 yr of amenorrhea for Dx  early Dx prevents osteoporosis  Rx: in vitro fertilization with donor oocytes --------------------------------------------------------------- pulsatile GnRH agonists: induces ovulation  progesterone: corrects luteal phase defect (failure of corpus luteum to produce progesterone to maintain the endometrium for implantation) ---------------------------------------------------------------

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exertional dyspnea, fatigue, pale conjunctiva iron deficiency is MCC of microcytic anemia iron studies confirm Dx Microcytic/Hypochromic anemias Iron-def anemia  ferritin,  TIBC Thalassemias normal/ serum iron & ferritin Anemia of  ferritin & transferrin, chronic disease  TIBC Sideroblastic normal/ iron & ferritin, anemia  TIBC

iron deficiency: 2/2  intake or  blood loss o  RDW,  reticulocyte count  thalassemia or hemaglobinopathies:  globin production & elevated HbA2 o  reticulocyte count & total bilirubin 2/2 hemolysis  anemia of chronic disease: defective utilization of storage iron, due to suppression of RBC production by inflammatory cytokines o  ferritin = ongoing inflammation  lead poisoning or sideroblastic anemia: reduced heme synthesis  hemochromatosis:  intestinal iron absorption & deposition o  iron, ferritin, & transferrin,  TIBC --------------------------------------------------------------- child with a painful, solitary, lytic long bone lesion with overlying tender swelling & hypercalcemia: Langerhans histiocytosis  locally destructive, but resolves spontaneously  benign, Rx conservative --------------------------------------------------------------- thin vaginal discharge, erythematous mucosa, motile pear-shaped organisms: trachomonal vaginitis  Rx: metronidazole  alcohol intake with metronidazole is a/w disulfiram-like reaction; acetaldehyde accumulates, causes flushing, N/V, hypotension --------------------------------------------------------------- chronic inflammatory diarrhea (< 4 wks): anemia, weight loss,  ESR, acute phase reactants, reactive thrombocytosis, +occult blood/leukocyte stool ---------------------------------------------------------------

infant with failure to thrive, B/L cataracts, jaundice, hypoglycemia: galactosemia  galactose-1-phosphate uridyl transferase deficiency  also vomiting, hepatomegaly, convulsions   risk for E.coli neonatal sepsis  early Dx & Rx: eliminating galactose from diet o breastfeeding is C/I  complications: cirrhosis, mental retardation --------------------------------------------------------------- galactokinase deficiency: cataracts only --------------------------------------------------------------- Dx for PCOS (≥ 2 criteria) o androgen excess (hirsutism, acne, alopecia) o olio- or anovulation o polycystic ovaries on USS o exclusion of other hyperandrogenic states  Rx for PCOS  weight loss  combined OCPs: Rx hyperandrogenism & menstrual dysfunction, progestin  risk of endometrial hyperplasia o clomiphene citrate: estrogen analog; induces ovulation with some ovulatory reserve o Metformin: promotes ovulation in PCOS prevented by insulin resistance; also for prevention or coexisting DM Type II  Comorbidities of PCOS o obesity o insulin resistance/glucose intolerance/DM o dyslipidemia o OSA o endometrial ca risk 2/2 chronic anovulation --------------------------------------------------------------- DM screening: sustained BP > 135/80 mmHg  OGTT is preferred to screen glucose intolerance & DM Type II  Dx: Type II DM  2 hr OGTT ≥ 200 mg/dL o fasting blood glucose > 126 o HbA1c ≥ 6.5% o random plasma glucose ≥ 200 --------------------------------------------------------------- age > 60, dysphagia, regurgitation, halitosis, cough, variable neck mass: Zenker diverticulum 

most important pathogenic factor in development of Zenker: motor dysfunction  develops above the upper esophageal sphincter, with posterior herniation between cricopharyngeal muscle fibers  risk for aspiration pneumonia  Dx: barium esophagram  Rx: excision, cricopharyngeal myotomy --------------------------------------------------------------- battery ingestion requires an XR  batteries in the esophagus should be removed under endoscopic guidance to prevent mucosal damage & esophageal ulceration  batteries distal to the esophagus need observation with stool exam or follow-up XR  do not use NG tube or induce vomiting --------------------------------------------------------------- aortic dissection is the most dangerous complication of Marfan o aortic regurgitation is a complication o autosomal dominant; fibrilin-1 mutation  all Marfan patients with chest pain require evaluation for aortic dissection  aortic regurgitation: early decrescendo diastolic murmur along the LSB, 3rd/4th IC space, sitting upright, leaning forward, after full expiration 

Clinical features of Marfan syndrome Skeletal arachnodactyly  upper:lower body segment ratio  arm:height ratio pectus deformity, scoliosis/kyphosis joint hypermobility Ocular ectopia lentis (lens subluxation) Cardio aortic dilation, regurgitation, dissection MVP Pulmonar spontaneous pneumothorax due to y apical blebs --------------------------------------------------------------- aortic dissection risk factors o HTN (most significant) o Marfan o cocaine use ----------------------------------------------------------------

office-based anoscopy/proctoscopy is the initial procedure for age < 50 with minimal bright red blood per rectum & no colon cancer risk factors o blood intermixed with stool is not included  MCC: hemorrhoids, anal fissure, polyps, proctitis, rectal ulcers, cancer  anoscopy has higher sensitivity for hemorrhoids than flexible endoscopy  colonoscopy/sigmoidoscopy for age > 50 or other risk factors for colon cancer --------------------------------------------------------------- DNA testing for RET proto-oncogene germline mutation is screening test for suspected MEN 2 o no further monitoring for a negative result o total thyroidectomy for a positive test result; risk of invasive MTC is 100% 

Multiple endocrine neoplasia classification Type I o Pituitary tumors o Primary hyperPTH (90%) o Pancreatic/GI tumors (gastrinoma) Type 2A o Medullary thyroid cancer (MTC) (Sipple’s) o Pheochromocytoma o Parathyroid hyperplasia Type 2B o MTC o Pheochromocytoma o Mucosal neuromas o marfanoid habitus MEN1 pancreatic tumors: gastrinoma, insulinoma, glucagonoma, VIPoma o gastrinoma causes recurrent peptic ulcers --------------------------------------------------------------- firm, flesh-colored, umbilicated, dome-shape plaques on trunk, limbs, anogenital areas; spares palms/soles: molluscum contagiosum (poxvirus)  MCC due to sexual contact MC occur on genitalia, lower abdomen, inner thighs  transmitted: skin-skin or fomites  self-limited, localized infection  linear pattern due to spread 2/2 scratching  MC a/w cellular immunodeficiency (HIV), corticosteroid use, chemotherapy 

DDx: HSV-1 (vesicular eruption), HPV (verrucous papules), Staph (furuncles, carbuncles) --------------------------------------------------------------- Staph aureus is MCC of healthcare-associated infective endocarditis (S. epidermidis) o prosthetic valves, indwelling catheters, IVDA, implanted devices (pacemakers, defibrillators)  Streptococci is MCC of community-acquired IE o viridans strep: S. sanguinis, S. mutans o after dental procedures or procedures involving incision/biopsy of respiratory tract  Enterococci: E. faecalis: a/w nosocomial UTIs  Strep bovis: S. gallolyticus o colon cancer & inflammatory bowel disease ---------------------------------------------------------------Endocarditis overview risk poor dentition, congenital heart disease, factors valve abnormalities (MVP, MR), IVDA, intravascular catheters features subungal hemorrhages, petechiae, Janeway lesions, Osler’s nodes, Roth spots, splenomegaly, mitral valve disease (MVP, MR) labs positive blood cultures,  WBCs, glomerulonephritis, septic emboli Rx vancomycin (initially), based on cultures  Janeway lesions: macular, erythematous, nontender lesions of palms/soles  Osler’s nodes: painful, violaceous nodules on fingertips/toes  Roth spots: edematous, hemorrhagic retinal lesions --------------------------------------------------------------- blood cultures from 2 separate venipuncture sites for suspected IE prior to initiating ABX 

Duke Criteria for Infective Endocarditis Major Criteria Minor Criteria 2 positive blood culture Vascular phenomena: for typical IE organisms systemic arterial emboli, (strep viridans or bovis, pulmonary infarcts, mycotic S. aureus, enterococcus aneurysms, Janeway HACEK) lesions, conjunctival hemorrhages Echocardiogram with Immunologic phenomena: oscillating intracardiac glomerulonephritis,

mass on valve

rheumatoid factor, Osler nodes, Roth spots Dx : 2 Major, 0 Minor predisposing heart condition Dx : 1 Major, 3 Minor or IVDA Dx : 0 Major, 5 Minor fever: > 38.0° C (100.4°) ---------------------------------------------------------------Acute rheumatic fever epidemiology MC in females, age 5 – 15 yrs MCC: group A Strep pharyngitis precedes onset of ARF by 2 – 4 wks Major o Joints (migratory arthritis) criteria o ♥ (carditis, mitral stenosis) (“J♥NES”) o Nodules (subcutaneous) o Erythema marginatum o Sydenham chorea Minor fever, arthralgias, elevated ESR/CRP criteria prolonged PR interval late features mitral regurgitation/stenosis prevention PCN (regardless of +/- pharyngitis)   

Dx: 2 major, or 1 major + 2 minor criteria supportive findings: ASO titer, Strep antigen test DDx: SLE, Henoch-Schonlein, Juvenile arthritis

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Hx of rheumatic fever increases risk of recurrence & progression of rheumatic heart disease Dx: continuous ABX prophylaxis to prevent recurrent group A Strep pharyngitis

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ABX prophylaxis for rheumatic fever (RF)  IM benzathine PCN G every 4 wks RF without carditis 5 yrs or until age 21 RF with carditis, but no 10 yrs or until age 21 heart or valvular disease RF with carditis & 10 yrs or until age 40 persistent ♥ or valve dz --------------------------------------------------------------- sore throat, skin infection, generalized edema, dark urine, HTN: post-strep glomerulonephritis  recurrent high fevers, rash, arthritis: Adult Still’s o maculopapular, non-pruritic rash on the trunk & extremities during febrile episodes  hypotension, hyperpigmentation, hyponatremia: adrenal insufficiency (Addison’s) ----------------------------------------------------------------

cutaneous Kaposi sarcoma appear as violaceous papules due to increased vascularity  MC on face, oral mucosa, genitalia, lower extremity  Dx is clinical, but may need biopsy to exclude bacillary angiomatosis 2/2 Bartonella --------------------------------------------------------------- condyloma acuminata (anogenital warts) is due to HPV; appear as skin-colored, white or gray verrucous & papilliform lesions  HPV 16, 18 a/w risk of SCC  Rx: HIV screening  Rx: self-limited; trichloroacetic acid, podophylin --------------------------------------------------------------- 20 syphilis: condyloma lata, flat pink/gray velvety papules o MC at mucous membranes & moist genital skin, perineum, mouth  30 syphilis: ascending aortitis, tabes dorsalis, psychosis, tumors (gumma) of skin, bone, liver o brief stabbing pains, Argyll-Robertson pupils (“accommodate but do not react”) ---------------------------------------------------------------Neurofibromatosis Type I  AD inheritance; neurocutaneous syndrome  café-au-lait spots, Lisch nodules, neurofibromas (benign peripheral nerve sheath tumors), short stature  risk of intracranial neoplasms: optic glioma (chronic headache, early morning vomiting, HTN, progressive unilateral vision loss, dyschromatopsia (disorder of color vision)) o Dx: MRI brain & orbits ---------------------------------------------------------------Neurofibromatosis Type II  B/L acoustic neuromas (vestibular schwannoma) cause sensorineural hearing loss  screening: audiometry; Dx: MRI with gadolinium --------------------------------------------------------------- tuberous sclerosis: neurocutaneous genetic syndrome 2/2 intracranial tumors  ash leaf spots, facial angiofibromas, cardiac rhabdomyomas, renal agnioleiomyomas --------------------------------------------------------------- allergic reaction with stridor: laryngeal edema, results in respiratory acidosis (CO2 retention) 

asthma exacerbation leads to acute respiratory alkalosis due to tachypnea  persistent vomiting & excessive diuresis causes volume contraction with increased HCO3 & metabolic alkalosis  persistent vomiting results in hypochloremic metabolic alkalosis from gastric H+ losses --------------------------------------------------------------- primary respiratory alkalosis decreases arterial PaCO2, leading to metabolic compensation that  serum HCO3 by 2 mEq/L for every 10 mmHg decrease in PaCO2  acute respiratory acidosis leads to metabolic compensation that  serum HCO3 by 1 mEq/L for every 10 mmHg increase in PaCO2 --------------------------------------------------------------- ASA toxicity causes mixed respiratory alkalosis (low PaCO2) & metabolic acidosis (low HCO3)  respiratory alkalosis is due to direct stimulation of medullary respiratory center causing tachypnea  metabolic acidosis is due to the  production &  renal elimination of lactic acids & ketoacids --------------------------------------------------------------- A-A women age 20 – 40 are at great risk for SLE  arthritis in 90%, may be a presenting symptom, non-deforming arthritis affects MCP & PIP  fatigue, low-grade fever, painless oral ulcers,  malar/discoid rash, weight loss, serositis (pleuritis), proteinuria (RBC casts)  hematologic abnormalities: anemia, leukopenia, thrombocytopenia --------------------------------------------------------------- joint space erosion, articular demineralization, soft tissue swelling: rheumatoid arthritis  osteophytes, narrowed joint spaces, subchondral sclerosis & subchondral cysts: osteoarthritis  arthropathy of MCP joints, hepatomegaly, diabetes, bronze skin, erectile dysfunction, hypogonadism, dilated cardiomyopathy: hemochromatosis  dactylitis (sausage digits), DIP joints, nail pitting, psoriatic plaques: psoriatic arthritis o can occur without skin changes --------------------------------------------------------------- pancytopenia following drug intake, exposure to toxins, radiation, or viral infection: aplastic anemia 

pallor, fatigue, weakness, anorexia, easy bruising, petechiae, mucosal hemorrhage, fever  bone marrow Bx: hypocellularity & fatty infiltration --------------------------------------------------------------- pallor & poor feeding in first 3 months of life, normocytic anemia with reticulocytopenia: Diamond-Blackfan anemia (aka congenital pure red cell aplasia) --------------------------------------------------------------- short stature, café-au-lait spots, pancytopenia, congenital abnormalities, hyperpigmentation on trunk, neck & intertriginous areas, hypogonadism, renal malformations: Fanconi’s anemia  initial manifestation: thrombocytopenia  neutropenia  anemia --------------------------------------------------------------- recent ABX use, watery bowel movements, mild abdominal tenderness: C. difficle colitis  unexplained leukocytosis in hospitalized patients should raise suspicion, even without diarrhea  complications: toxic megacolon, severe ileus  Dx: stool studies for C. difficle toxin  Rx mild/moderate: empiric oral metronidazole  Rx severe: oral vancomycin (+ IV metronidazole if ileus is present) o fidoxomicin: Rx recurrent colitis or severe colitis who cannot tolerate oral vancomycin  surgical consult for acute peritoneal signs or severe C. difficile colitis (toxic megacolon, ileus, WBC > 20,000/μL): subtotal colectomy --------------------------------------------------------------- Gentamicin: Rx resistant G-negative bacteria  IV vancomycin: empiric Rx for bacteremia secondary to a cutaneous source (central line) or infection (pneumonia) due to resistant G-positive o not excreted into the colon, thus not effective against C. difficile colitis --------------------------------------------------------------- solitary pulmonary nodule: coin-shaped lesion, 3 cm or less surrounded by normal parenchyma; evidence of calcification is considered benign  low-risk patients (age < 40, non-smoker): compare with old XR; F/U CXR every 3 months for 12 month  high-risk patients: chest CT & FNA 

 bronchoscopy cannot reach peripheral lesions --------------------------------------------------------------- headache, jaw claudication, proximal muscle weakness, temporal area tenderness,  ESR: giant cell arteritis  Dx: temporal artery biopsy  complication: blindness, aortic aneurysms o F/U: serial CXR --------------------------------------------------------------- asymptomatic carotid artery stenosis (CAS) can progress to TIA or embolic stroke  symptomatic CAS: sudden onset focal neurologic symptoms within 6 months  indications for carotid endarterectomy (CEA) o asymptomatic carotid stenosis, men: > 60% o symptomatic carotid stenosis: > 70%  < 50% stenosis: Duplex USS annually, & medical management alone  patients with CVD should start on ASA & statins --------------------------------------------------------------- emphysematous cholecystitis is a common form of acute cholecystitis in elderly diabetic males (age 50 – 70)  gallbladder infection with gas-forming bacteria (Clostridium, Escherichia, Strep, Staph, Pseudomonas, Klebsiella)  RUQ pain, N/V, fever, abdo pain & crepitus  complications: gangrene, perforation  Dx: abdominal XR shows air fluid levels in the gallbladder; USS shows curvilinear gas shadows  Rx: cholecystectomy within 72 hrs, IV ABX --------------------------------------------------------------- beta-cell tumor (insulinoma): hypoglycemia with  insulin, c-peptide, & pro-insulin  non-beta cell tumor: large mesenchymal tumors that produce IGF-II with insulinomimetic action after binding insulin receptors o insulin & c-peptide are suppressed  sulfonylureas  output of endogenous insulin from beta cells;  insulin & c-peptide o confirm Dx with plasma sulfonylurea level  glucagonoma causes necrotic migratory erythema ----------------------------------------------------------------

pelvic exam is contraindicated in a patient with antepartum hemorrhage until placenta previa is ruled out by transvaginal USS  management depends on gestational age & severity of bleeding  stable mother, fetus at term: scheduled c-section  stable mother, fetus not at term: expectant management; amniocentesis @ 36 wks to assess lung maturity  extended/massive bleeding, regardless of gestation: emergency c-section --------------------------------------------------------------- polymyositis & dermatomyositis are inflammatory myopathies;  ESR & CK  confirm Dx: muscle biopsy  Rx: high-dose corticosteroids ---------------------------------------------------------------Dermatomyositis features proximal, symmetric extensor muscle weakness; UE = LE Grotton’s papules, heliotrope rash extramuscular interstitial lung disease, findings dysphagia, myocarditis Dx  CPK, aldolase, LDH anti-RNP, anti-Jo-1, anti-Mi2 equivocal: EMG, muscle biopsy Rx high-dose glucocorticoids PLUS glucocorticoid-sparing agent, screen for malignancy --------------------------------------------------------------- Riluzole slows progression of ALS  TCAs decrease the pain of fibromyalgia --------------------------------------------------------------- Herpes zoster is a reactivation of VZV due to decreased cell-mediated immunity  pain precedes onset of vesicular rash by 48 hr  Rx: valacyclovir, or oral acyclovir (cheaper); reduces incidence of post-herpetic neuralgia  TCAs can also prevent/Rx post-herpetic neuralgia --------------------------------------------------------------- hyposthenuria: inability to concentrate the urine  nocturia & polyuria  MC a/w sickle cell disease & trait  RBC sickling in the vasa rectae impairs countercurrent exchange & free water absorption 

--------------------------------------------------------------- negative D-dimer (fibrin split product) best excludes pulmonary VTE in low-risk patients (negative predictive value > 95%)  positive D-dimer requires further studies with CT angiography --------------------------------------------------------------- brain death: irreversible loss of function of the whole brain & brainstem; legal definition of death  no further steps are legally required to remove a patient from artificial life support --------------------------------------------------------------- clingy & submissive, crave protection & care, avoids taking initiative due to feeling inadequate, indecisive: dependent personality disorder  hypersensitive to criticism, social inhibition, desire friendships, but fear embarrassment or ridicule: avoidant personality disorder  restricted range of emotions, social detachment, do not enjoy close relationships, aloof, indifferent to praise/criticism: schizoid personality disorder  odd & eccentric behavior, “magical thinking”, clairvoyant,  capacity for close relationships: schizotypal personality disorder --------------------------------------------------------------- schizoaffective disorder: lifetime Hx of delusions & hallucinations co-occurring with depressive or manic episodes & Hx of at least 2 weeks of psychotic symptoms without mood episodes  mood symptoms are present for majority of illness --------------------------------------------------------------- dysphagia, Raynaud’s, extensive skin thickening: diffuse systemic sclerosis  pulmonary complication are MCC of death o MC is interstitial fibrosis --------------------------------------------------------------- chronic cough after a recent URI, primarily at night, no expectoration: postnasal drip  cough is caused by mechanical stimulation of the afferent limb of cough reflex in upper airway  Rx: empiric 1st-generation antihistamine or combined antihistamine-decongestant  Dx: elimination of nasal discharge & cough with empiric H1-antagonisists  no response after 2 - 3 wks require investigation

--------------------------------------------------------------- upper airway cough syndrome (postnasal drip), GERD, asthma: > 90 % of chronic cough (> 8 wks) in non-smokers without pulmonary disease  Rx… o postnasal drip  1st-generation H1 blocker o on ACE inhibitors  stop ACE inhibitors o asthma  PFTs, inhaled corticosteroids o GERD  empiric PPI  CXR if no improvement after these interventions --------------------------------------------------------------- CXR is indicated in those with no clear etiology or possible parenchymal disease, purulent sputum, immunocompromised, or smoking Hx Common etiologies of chronic cough  postnasal drip  ACE inhibitors  asthma & cough-variant asthma  GERD or laryngopharyngeal reflux o post respiratory tract infection o chronic bronchitis or sinusitis o bronchiectasis o lung cancer o non-asthmatic eosinophilic bronchitis --------------------------------------------------------------- anemia of prematurity is the most common anemia in premature & low birth weight infants  due to diminished RBC production, shorter RBC lifespan in neonates, & fetoplactental transfusion (baby held above placenta after delivery)  poor weight gain, poor feeding, pallor, lethargy, tachypnea, tachycardia  labs: normocytic/normochromic anemia, low reticulocyte count, normal WBC & total bilirubin  Rx: iron supplementation; but does not prevent falling Hb levels; iron deficiency is not the cause --------------------------------------------------------------- hemolytic disease of the newborn is due to Rh or ABO incompatibility  jaundice, hepatosplenomegaly, pallor, & hydrops fetalis in severe cases  Type II hypersensitivity   reticulocyte count due to hemolysis ----------------------------------------------------------------

EOM weakness (diplopia, proptosis) with symmetrical proximal muscle weakness (upper more than lower), neck, bulbar muscles (dysarthria, dysphagia): myasthenia gravis  neurodegenerative disease, men age 40 to 60; asymmetric muscle atrophy, muscle weakness (distal more than proximal), hyperreflexia, spasticity, fasciculations: ALS  DDx: electrolyte disturbance, fibromyalgia, polymyositis, multiple sclerosis, Guillain-Barré, thyroid-related myopathy --------------------------------------------------------------- sickle cell anemia presents after the first 6 months of life, due to presence of Hb F  dactylitis may be the initial presentation that warrants further workup --------------------------------------------------------------- hypothyroidism can cause reversible changes in memory & mentation; accompanied by systemic changes such as weight gain, fatigue, constipation  Rx: levothyroxine will improve cognitive symptoms --------------------------------------------------------------- best indicator of dementia: functional impairment of ADLs (hygiene, dressing, self-medicating)  occasional forgetfulness, word finding aphasia, & insomnia can occur with normal aging ---------------------------------------------------------------DDx of dementia subtypes Alzheimer’ early: insidious anterograde memory loss, s visuospatial & language deficits, word finding difficulty late: personality changes, hallucinations, dyspraxia, urinary incontinence Vascular stepwise decline, cerebral infarction, dementia early executive dysfunction (ADLs), focal neuro deficits (+pronator drift, +Romberg, unsteady gait) Pick’s early personality changes, apathy, disinhibition, compulsive, +primitive reflexes, +family Hx late: memory deficits Lewy body fluctuating cognition, altered alertness, visual hallucinations, parkinsonism late: memory deficits NPH dementia, gait ataxia, urinary incontinence 

CJD Huntington chronic subdural hematoma pernicious anemia

MRI: enlarged ventricles rapidly progressive behavior changes, myoclonus, akinetic mutism choreoathetosis, behavioral disturbances, dementia insidious decrease in consciousness, headache, cognitive & memory deficits, aphasia, or motor deficits dementia with megaloblastic anemia, posterior spinal column deficits

ataxia, ophthalmoplegia, confusion (Wernicke); with confabulation & amnesia (Korsakoff) --------------------------------------------------------------- fluctuating cognition, insomnia, decreased alertness, visual hallucinations, Parkinsonism, repeated falls: Lewy body dementia  Lewy bodies: eosinophilic intracytoplasmic inclusions due to alpha-synuclein accumulation  early appearance of dementia  Dx: progressive, cognitive decline, interferes with social & occupational functions  DDx: Parkinson’s (motor symptoms present early), Alzheimer’s (early anterograde memory loss), lacunar strokes (patchy neurologic findings), NPH --------------------------------------------------------------- NPH: urinary incontinence, dementia, abnormal gait  dementia is characterized by memory loss, but no focal neurologic changes  broad-based, shuffling gait  transient increase in intracranial pressure or due to decreased CSF absorption causing permanent ventricular enlargement  Dx: LP, enlarged ventricles on CT or MRI  Rx: serial large volume LPs, with subsequent ventriculoperitoneal shunt --------------------------------------------------------------- insidious decreased consciousness, headache, cognitive & memory deficits, frequent falls, aphasia, motor deficits: chronic subdural hematoma  MC in elderly & alcoholics  Dx: noncontrast CT shows a white crescent with or without midline shift ---------------------------------------------------------------

dietary modification & exercise is the first step in treating GDM  if nutritional therapy fails, insulin or oral agents (metformin, glyburide)  insulin does not cross the placenta --------------------------------------------------------------- GDM screening @ 24 - 28 wks gestation  GDM target blood glucose levels o fasting ≤ 95 mg/dL o 1-hour postprandial ≤ 140 mg/dL o 2-hour postprandial ≤ 120 mg/dL  GDM is at increased risk for gestational HTN, preeclampsia, & fetal macrosomia  GDM resolves after childbirth, 50% develop Type 2 DM --------------------------------------------------------------- uncontrolled maternal hyperglycemia causes fetal hyperglycemia  fetal hyperinsulinemia  1st trimester: spontaneous abortion, congenital malformations (small left colon syndrome), NTDs  2nd/3rd trimester complications… o macrosomia (shoulder dystocia) o neonatal hypoglycemia o polycythemia o organomegaly (heart, liver)  since the fetus is in constant anabolism, placenta may not be able to meet  metabolic demands, leading to fetal hypoxemia;  erythropoietin production causes polycythemia --------------------------------------------------------------- small left colon syndrome: transient inability to pass meconium; resolves spontaneously  risk: infants of GDM mothers --------------------------------------------------------------- prego with HTN, proteinuria & edema: preeclampsia o ANA may be weakly positive in pregnancy  HTN in a prego with massive proteinuria, malar rash, & strongly positive ANA titer: SLE  signs that favor lupus as the origin of proteinuria include rapid aggravation of proteinuria, clinical signs of active SLE, & RBC casts indicates nephritis rather than simple protein loss  Dx: renal biopsy after delivery ---------------------------------------------------------------

physiologic jaundice of the newborn is common on days 2 – 4, benign, resolves by age 1 – 2 wks   indirect hyperbilirubinemia is due to physiologic differences in bilirubin metabolism… o  bilirubin production: elevated RBC concentration & shorter RBC life span o  bilirubin clearance: immature hepatic UGT levels (especially Asians) o  enterohepatic recycling: sterile newborn gut cannot break down bilirubin to urobilinogen for fecal excretion;  bilirubin is resorbed/recycled  encourage frequent feedings to promote gut colonization & fecal excretion  Rx: phototherapy for rapidly rising hyperbilirubinemia to prevent kernicterus; exchange transfusion for severe cases --------------------------------------------------------------- newborns of mothers with Rh-negative or Oblood group are at risk for hemolytic anemia & severe hyperbilirubinemia  neonatal sepsis can cause hemolysis & exacerbate hyperbilirubinemia o fever & risk factors for neonatal sepsis (PROM, +GBS screen) --------------------------------------------------------------- β-thalassemia can cause hemolysis & unconjugated hyperbilirubinemia  newborns are asymptomatic due to fetal Hb = alpha + gamma globin chains  hemolytic anemia symptoms after age 6 months as gamma chains  replaced with beta chains --------------------------------------------------------------- sellar mass o visual defect (diplopia, vision loss, bitemporal hemianopsia) o headache o symptoms of pituitary hormonal deficiency (decreased libido, amenorrhea)  benign causes o pituitary adenoma (most common) o craniopharyngioma (common in children) o meningioma  Dx: CT scan or MRI ---------------------------------------------------------------

bitemporal hemianopia: pressure on optic chiasm exerted by a pituitary tumor, craniopharyngioma, or anterior communicating artery aneurysm --------------------------------------------------------------- progressively worsening headache, focal motor weakness, visual disturbance, cognitive deficits: glioblastoma multiforme  acute/subacute painful vision loss with abnormal pupillary response to light in the affected eye: optic neuritis a/w multiple sclerosis  headache, transient visual symptoms, tinnitus: idiopathic intracranial HTN o papilledema, visual field loss, 6th nerve palsy  homonymous superior quadrantanopsia (“pie in the sky”): temporal lobe stroke affecting the inferior optic radiations in the Myer’s loop --------------------------------------------------------------- vision assessment should be performed at every well-child visit  evaluate infants by observing fixation & tracking  cover-uncover test for older infants/children to assess for strabismus  visual acuity begins at age 3 with Snellen or tumbling E chart --------------------------------------------------------------- dyslipidemia universal screening: age 9 – 11 & again @ 17 – 21 o lipid levels are stable prior to & after puberty  also if high risk for CVD (obesity, DM, tobacco, family Hx of premature CAD) & men age ≥ 35 ---------------------------------------------------------------Minors & consent medical circumstances emergencies, STDs, prenatal that do not need consent care, mental health services, substance abuse, contraception unemancipated minors consent from one parent or guardian is legally sufficient emancipated minors homeless, parent, married, do not need consent financially independent, military, high school grad  minors who are parents can consent for Rx of their own minor children  parents cannot deny their children life-saving treatment unless benefits are minimal or would not alter the prognosis 

--------------------------------------------------------------- innocent murmurs result from blood flow from a structurally normal heart; grade I or II intensity, & changes intensity with position ( with standing)  Rx: reassurance  pathologic murmurs are ≥ grade III --------------------------------------------------------------- live-attenuated virus vaccine can be given with routine inactivated vaccinations  live virus vaccines  given 4 weeks apart of routine vaccinations o do not give to pregnant women o can be given to household contacts of pregos --------------------------------------------------------------- quadrivalent meningococcal vaccine: 11 – 12 yrs followed by a booster at age 16  rotavirus vaccine: @ age 2 – 8 months due to risk of dehydration from severe gastroenteritis --------------------------------------------------------------- MCC of gastroenteritis in infants & young children worldwide: Rotavirus  highly contagious, fecal-oral transmission  fever, vomiting, watery osmotic diarrhea results in severe dehydration  prevention: rotavirus vaccine o age 2 – 6 months o live attenuated virus vaccine o A/E: risk of intussusception  C/I: Hx of intussusception, Hx of uncorrected GI malformations (Meckel’s), SCID --------------------------------------------------------------- isolated thrombocytopenia & petechiae after viral infection (URI): immune thrombocytopenia o petechiae & ecchymosis most common o also mucocutaneous bleeds (epistaxis, hematuria, GI bleed) if severe  antibodies bind to PLTs, with destruction of Ab/PLT complexes in the spleen  labs: PLT < 100,000 μL, megakaryocytes on PBS  Rx children: age 2 – 5 yrs; spontaneous recovery within 6 months, regardless of PLT count  Rx: skin manifestations only = observe  Rx: +bleeding = IV Ig or glucocorticoids  Rx adults:

Rx: PLT ≥ 30,000 μL, no bleeding = observe Rx: PLT ˂ 30,000 μL, OR bleeding = IV Ig or glucocorticoids --------------------------------------------------------------- APGAR: Appearance, Pulse, Grimace, Activity, Respiratory effort; measured at 1 & 5 minutes  blue extremities, pink body is common/benign  cyanosis of face or central body is concerning  score of 7 – 9/10 = no intervention  score < 7/10 = further evaluation & resuscitation  if HR < 100 & irregular respiration  pulse oximetry & positive-pressure ventilation  if HR < 60  CPR --------------------------------------------------------------- confounder: extraneous factor which is independently a/w both exposure & outcome of interest; mixing up the effect of exposure with the effect of an extraneous factor  smoking explains part of the association observed between alcohol consumption & oral cancer --------------------------------------------------------------- peripheral edema is a common side effect with dihydropyridine CCB (amlodipine) due to dilated peripheral vessels, leads to increased capillary hydrostatic pressure  also headache, flushing, dizziness  Rx: ACE-I or ARBs causes post-venodilation  DDx of peripheral edema: CHF, renal disease, liver disease, venous insufficiency --------------------------------------------------------------- sudden, diffuse periumbilical tenderness out of proportion to exam findings, metabolic acidosis: acute mesenteric ischemia  MC site: SMA  labs: metabolic acidosis from  serum lactate, leukocytosis,  amylase  CT: focal or segmental bowel wall thickening, dilation, & mesenteric stranding  Dx: high index of suspicion with risk factors for thromboembolic dz (a-fib, PVD, atherosclerosis)  confirm Dx: angiography  Rx: supportive, IV fluids, ABX, NGT  complications: bowel infarct, perforation, peritonitis, sepsis, death  

DDx: acute pancreatitis, DKA, gastric outlet syndrome, peptic ulcer perforation --------------------------------------------------------------- diuretic abuse: technique for rapid weight loss  hypovolemia, orthostatic hypotension, dizziness  hyponatremia, hypokalemia;  urine Na+ & K+  suspect an eating disorder  DDx: self-induced vomiting, laxative abuse, mineralocorticoid deficiency (low serum Na+, high serum K+) --------------------------------------------------------------- acute limb ischemia post-MI suggests possible arterial embolus from LV thrombus  large anterior STEMI are high risk, LV thrombus  Rx: immediate IV heparin, vascular surgery consult, TTE to screen for LV thrombus --------------------------------------------------------------- always obtain a CXR to confirm placement of a central venous catheters before use o catheter tip should lie in the SVC  complications: arterial puncture, pneumothorax, hemothorax, thrombosis, air embolism, sepsis, myocardial perforation  tamponade ---------------------------------------------------------------Heparin-induced thrombocytopenia (HIT)  MCC: unfractionated heparin, LMWH  50% drop in PLT count from baseline  Type I HIT: non-immune direct effect of heparin on PLT activation; within 48 hr of exposure; o mild, non-immune PLT degradation o PLT count normalizes with continued heparin; no clinical consequences o no Rx; spontaneous recovery  Type II HIT: immune-mediated antibodies to PF4-heparin complex; occurs within 5 – 10 days; life-threatening; stop all heparin products o necrotic skin lesions at injection sites o prone to arterial & venous thrombosis: warmth, erythema, swelling, tenderness o Rx: direct thrombin inhibitor (argatroban) or fondaparinux; “Treat first, test later” o confirm Dx: serotonin release assay 

thrombosis consumes PLTs & worsens thrombocytopenia --------------------------------------------------------------- protamine sulfate: Rx heparin reversal; HIT  directly binds heparin ---------------------------------------------------------------Initial Rx of HTN  blacks: thiazide or CCB, alone or combo (ACE/ARB not first-line) o all others: thiazide, ACE-I/ARB, or CCB alone or combo o all with CKD or diabetes: ACE-I/ARB alone or combo ( intraglomerular pressure) --------------------------------------------------------------- statins: Rx all diabetics age 40 – 75, regardless of baseline lipids --------------------------------------------------------------- dyspnea, tachypnea, pleuritic chest pain: PE --------------------------------------------------------------- factitious disorder: intentional falsification of S/S to assume a sick role  Munchausen’s: severe factitious disorder, seeks invasive/life-threatening surgical procedures  somatic symptom disorder: excessive anxiety & preoccupation with ≥ 1 unexplained symptoms  illness anxiety disorder (aka hypochondriasis): prolonged fear of a serious illness despite few/no symptoms & negative evaluations  conversion disorder: neurologic symptoms incompatible with any neurologic disease; acute 

onset, a/w a stressor; not intentional, unconcerned (la belle indifference) --------------------------------------------------------------- diabetic nephropathy begins with hyperfiltration ( GFR) & microalbuminuria, then progresses to macroproteinuria with progressive decline in GFR  screening: spot urine mciroalbumin/Cr ratio  hallmark: nodular glomerulosclerosis  intensive BP control is proven to slow GFR decline once azotemia develops o diabetics target BP: 140/90 mmHg o diabetics with nephropathy: 130/80 mmHg  Rx: ACE inhibitors  intraglomerular pressure; but may induce acute GFR decline & hyperkalemia --------------------------------------------------------------- abdominal USS for Dx & follow-up of AAA ---------------------------------------------------------------Metastatic brain tumors o MC type of intracranial tumors o MC @ grey-white matter junction o MC mets from non-small cell lung cancer  Rx solitary brain mets in patients with good performance status & stable extracranial disease: surgical resection  whole brain radiation for multiple brain mets or poor performance status  chemotherapy for mets from small cell lung cancer, lymphoma, choriocarcinoma --------------------------------------------------------------- HTN, mild hypernatremia, hypokalemia, metabolic alkalosis, no peripheral edema: primary hyperaldosteronism  MCC: mineralocorticoid-producing adrenal tumor found incidentally  rapid hypokalemia in response to diuretics o  aldosterone,  renin,  bicarbonate  secondary hyperaldosteronism: Cushing’s, renal artery stenosis, renin-secreting tumor o  aldosterone,  renin, &  bicarbonate --------------------------------------------------------------- Cushing’s causes secondary HTN  ACTH-dependent hormones cause vasoconstriction (HTN),  insulin resistance (hyperglycemia), &  mineralocorticoid activity (hypokalemia)

also central obesity, facial plethora, ecchymosis, proximal muscle weakness, erectile dysfunction, amenorrhea, thin skin, abdominal striae  causes: exogenous steroid use, ectopic ACTH, adrenal cortical adenoma, ACTH pituitary adenoma (Cushing’s disease)  DDx: pheochromocytoma, renal artery stenosis, hypothyroidism, renal parenchymal disease --------------------------------------------------------------- primary hyperparathyroidism: hypercalcemia (polyuria, polydipsia, constipation), kidney stones, confusion, depression, psychosis --------------------------------------------------------------- renal artery stenosis: flash pulmonary edema, resistant heart failure, chronic kidney disease, severe HTN > 180/120 after age 55  systolic-diastolic abdominal bruit  DDx: AAA (systolic bruit) --------------------------------------------------------------- all chronic hepatitis C patients, including pregos, should be immunized against hepatitis A & B; both are safe during pregnancy  vertical transmission is a/w maternal viral load o c-section is not protective  breastfeeding does not increase transmission risk, unless nipple is actively bleeding  Ribavirin is teratogenic, avoid in pregos --------------------------------------------------------------- frostbite Rx: rapid rewarming with warm water immersion, continuously circulated  do not debride any devitalized tissue initially --------------------------------------------------------------- splenectomy: Rx autoimmune hemolytic anemia, symptomatic hereditary spherocytosis, massive splenomegaly a/w β-thalassemia major or HbH --------------------------------------------------------------- splenectomy  risk of sepsis by encapsulated spp (S. pneumo, N. meningitides, H. influenza) o impaired Ab-mediated phagocytosis by opsonization   risk of sepsis for up to 30 yrs after splenectomy  Rx: pneumococcal, Hib, & meningococcal vaccine 2 wks prior to or post-splenectomy  daily oral PCN prophylaxis 3 - 5 yr post-splenectomy ---------------------------------------------------------------

chronic granulomatous disease: defective intracellular killing by phagocytes o XR defect in NADPH oxidase  SCID:  number of circulating lymphocytes  leukocyte adhesion defect: impaired chemotaxis  DiGeorge: defective cell-mediated immunity o fungal & viral infections are common --------------------------------------------------------------- Guillain-Barré: ascending radiculoneuropathy preceded by URI or diarrhea illness (C. jejuni)  distal paresthesia, ascending flaccid paralysis, diminished DTRs, respiratory compromise  autonomic disturbances: tachycardia, HTN, orthostatic hypotension, urinary retention  risk of respiratory failure  monitor autonomic & respiratory function with serial spirometry measurements of FVC o declining FVC requires intubation  Rx: IV Ig or plasmapheresis ---------------------------------------------------------------CSF Analysis WBC Glucose Protein Normal 0–5 40 -70 < 40 bacterial meningitis    TB meningitis    viral meningitis  normal normal Guillain-Barré normal normal  

Guillain-Barré: albuminocytologic dissociation (high protein, normal WBC count)  herpes meningoencephalitis: high RBC & protein, 2/2 temporal lobe hemorrhage --------------------------------------------------------------- empyema occur from untreated pneumonia with parapneumonic effusions or 2/2 hemothorax  low-grade fever, cough, dyspnea, chest pain  MCC: S. aureus, Strep pneumo, Klebsiella  CXR: loculated, abnormally contoured effusion with adjacent consolidation  Dx: CT scan  Rx recent onset empyema: fibrinolytic (streptokinase, urokinase) into the chest tube; but contraindicated in MVAs  Rx: ABX for early empyema 

Rx: complex, loculated effusion with thick rim  surgery for decortication & drainage --------------------------------------------------------------- CHF due to LV systolic dysfunction is characterized by  cardiac output/index,  SVR, & LVEDV  a holosystolic murmur at the apex is likely due to functional mitral regurgitation, from mitral annulus enlargement with LV dilatation &/or papillary muscle displacement due to remodeling ---------------------------------------------------------------Hemodynamics Cardia Systemic LVED c index vascular volum resistanc e e    Distributive shock    Intravascular volume loss    LV systolic dysFx --------------------------------------------------------------- epigastric pain, weight loss, jaundice, distended GB: pancreatic cancer  nontender but palpable gallbladder in a jaundiced patient is unlikely gallstones (Courvoisier’s sign)   bilirubin & ALP suggest bile duct obstruction, leading to intra- & extrahepatic bile duct dilation  Dx: abdominal USS for patients with jaundice  Dx: CT with contrast, patients without jaundice  ERCP is reserved for nondiagnostic USS & CT  percutaneous transhepatic cholangiogram (PTC) if ERCP is not indicated  CA 19-9 is only useful for post-op monitoring & evaluate response to chemotherapy --------------------------------------------------------------- CA-125 antigen testing & pelvic USS can be used to Dx ovarian cancer only for those with suggestive symptoms or physical findings  women with a strong family Hx of ovarian cancer, should test for BRCA1/BRCA2 genes o positive results should be screened with pelvic USS &/or CA-125  no screening for average risk patients ---------------------------------------------------------------

management of splenic trauma depends on hemodynamic status & response to IV fluids  hemodynamically unstable & improves with IV fluids: abdominal CT, admit to ICU  unresponsive to fluids: exploratory laparotomy --------------------------------------------------------------- transient, painless, monocular vision loss, “curtain falling down”: amaurosis fugax  MCC: retinal emboli due to atherosclerosis  fundoscopy may show zones of whitened retina following the distribution of retinal arterioles; Hollenhorst bodies (cholesterol particles)  Dx: duplex USS (MC site: carotid bifurcation) --------------------------------------------------------------- light flashes, floaters, or “curtain coming across visual field” from the periphery: detached retina  fundoscopy: wrinkled, detached retina --------------------------------------------------------------- central retinal artery occlusion: painless monocular vision loss; ophthalmic emergency!!  ophthalmic artery is 1st intracranial branch of ICA; a/w amaurosis fugax  fundoscopy: diffuse ischemic retinal whitening & cherry red fovea  Rx: ocular massage & high flow O2 --------------------------------------------------------------- central retinal vein occlusion: painless, sudden vision loss 2/2 venous thrombosis  fundoscopy: dilated, tortuous veins leading to diffuse hemorrhages (“blood & thunder”) with disk swelling, & cotton wool spots --------------------------------------------------------------- floaters in the visual field: vitreous hemorrhage  MCC: diabetic retinopathy  fundoscopy: fundus is difficult to visualize --------------------------------------------------------------- progressive dyspnea on exertion, orthopnea, hemoptysis, young immigrant: mitral stenosis  symptoms are precipitated by conditions causing tachycardia (fever, anemia, pregnancy)  severe LA enlargement, leads to elevation of left main bronchus on CXR, compresses recurrent laryngeal nerve (hoarseness), or a-fib  CXR: pulmonary vascular congestion with cephalization of blood flow to upper lobes 

DDx: acute pericarditis, interstitial lung disease, malignancy, sarcoidosis --------------------------------------------------------------- orotracheal intubation with rapid-sequence intubation is preferred for an apneic patient with cervical spine injury, unless there is facial trauma  nasotracheal intubation is a blind procedure; C/I in apneic/hypopneic patients & basilar skull fx  cricothyroidotomy is preferred over surgical tracheostomy, but converted to formal tracheostomy in 5 – 7 days if prolonged airway is necessary --------------------------------------------------------------- p-value: probability of observing a given result by change alone, assuming null hypothesis is true  if p = 0.001, there is a 0.1% probability of observing a given relative risk by chance alone  both p-value & confidence interval measures statistical significance  a confidence interval containing 1.0 (null value) is not statistically significant --------------------------------------------------------------- extreme fatigue, malaise, sore throat, fever, generalized maculopapular rash, palatal petechiae, posterior cervical adenopathy, splenomegaly: infectious mono  labs: leukocytosis with atypical lymphocytes  Dx: heterophile antibodies peak 2 – 6 wks after primary EBV infection; thus, an initial negative antibody test does not exclude IM  repeat test  alt Dx: anti-EBV antibodies --------------------------------------------------------------- screen all pregos for syphilis, HIV, & Hep B regardless of STI risk factors  screening for chlamydia, gonorrhea, & Hep C is based on risk factors --------------------------------------------------------------- cyanide toxicity can occur with nitroprusside, for rapid BP control in hypertensive emergency o nitroprusside metabolism releases nitric oxide (arteriolar & venous dilation) & cyanide ions  altered mental status, lactic acidosis, seizures, coma  occurs with prolonged infusions or higher doses of nitroprusside, MC with renal insufficiency  Rx: sodium thiosulfate 



DDx: alcohol withdrawal, excessive hypotensive response, hypertensive encephalopathy

Manifestations of cyanide toxicity flushing (cherry-red) headache, altered mental status, hyperreflexia, seizure, coma CVS arrhythmias respirator tachypnea followed by respiratory y depression, pulmonary edema GI abdominal pain, N/V renal metabolic acidosis 2/2 lactic acidosis, renal failure --------------------------------------------------------------- delusion: fixed, false beliefs not consistent with cultural norms; grandiose, paranoid, or somatic  magical thinking: one’s thoughts can control events not explained by natural cause & effect  illusion: misinterpretation of external stimuli  hallucinations: sensory perception in the absence of external stimuli ----------------------------------------------------------------- polycythemia: Hct > 65% in term neonates  lethargy, irritability, jitteriness, poor feeding, cyanosis, respiratory distress  risk factors: in utero hypoxia (maternal HTN, smoking), poor gas exchange (maternal diabetes), delayed cord clamping, IUGR  hypoglycemia & hypocalcemia 2/2  cell uptake  asymptomatic Rx: hydration only by feeding or parenteral fluids  symptomatic Rx: partial exchange transfusion to normalized Hct  DDx: cyanotic heart disease, dehydration, RDS, transient tachypnea of the newborn --------------------------------------------------------------- anasarca, facial edema, HTN, pulmonary edema, JVD, proteinuria & microscopic hematuria: acute nephritic syndrome with fluid overload  primary glomerular damage leads to  GFR & retention of sodium & water resulting in volume overload & peripheral edema  MCC: post-streptococcal glomerulonephritis, lupus nephritis, IGA nephropathy, RPGN, membranoproliferative GN skin CNS

abnormal urinary sediments: RBCs, red cell casts DDx: pretibial myxedema in Graves’, cirrhosis, hypoalbuminemia in nephrotic syndrome, renal hypoperfusion 2/2 heart failure, RV failure ---------------------------------------------------------------Causes of peripheral edema   capillary hydrostatic pressure (CHF, cirrhosis, renal disease)   capillary oncotic pressure (hypoalbuminemia, nephrotic syndrome, cirrhosis)   capillary permeability (burns, trauma, sepsis, ARDS)   interstitial oncotic pressure (lymphatic obstruction) --------------------------------------------------------------- uncomplicated diverticulitis: fever, leukocytosis, LLQ pain/tenderness, Hx of constipation o Dx: CT scan shows soft tissue stranding & colonic wall thickening o stable patients are managed as outpatient: bowel rest, oral ABX, observation o immunocompromised, comorbidities, or elderly  hospitalization & IV ABX  complicated diverticulitis: a/w abscess, perforation, obstruction, or fistula o Dx: CT scan o fluid collection ˂ 3 cm Rx: IV ABX & observe  fluid collection ˃ 3 cm Rx: CT-guided drainage  failure of CT drainage: surgical drainage  CT guided percutaneous drainage is standard Rx for complicated diverticulitis with abscess  surgery with sigmoid resection is reserved for patients with fistulas, perforations with peritonitis, obstruction, or recurrent diverticulitis --------------------------------------------------------------- B/L hip, thigh, or buttock claudication, impotence, symmetric atrophy of LE’s due to chronic ischemia: aortoiliac occlusion (Leriche syndrome)  arterial occlusion at the aortic bifurcation into the common iliac arteries; pulse is soft/absent B/L  impotence is always present in men; otherwise seek out another Dx --------------------------------------------------------------- Mycoplasma pneumonia is MCC of atypical pneumonia the ambulatory setting  

indolent course, nonproductive cough, higher incidence of extrapulmonary symptoms (headache, sore throat, skin rash)  CXR out of proportion to physical findings  erythema multiforme is typical of Mycoplasma  Gram stain reveals only PMNs, but no organisms --------------------------------------------------------------- Strep pneumoniae (Gram+ diplococci): MCC of community-acquired pneumonia  productive cough, rusty colored sputum  few extrapulmonary symptoms; more virulent  Rx: high-dose oral amoxicillin --------------------------------------------------------------- Legionella pneumophilia causes pneumonia with extrapulmonary symptoms: bradycardia, headache, confusion, watery diarrhea  Dx: urine antigen testing --------------------------------------------------------------- fever, tender posterior cervical lymphadenopathy, significant fatigue, pharyngitis, tonsillar exudates, palatal petechiae, young adult: infectious mono  heterophile (Monospot) test: 25% false-negative rate during the first week; initial negative test does not rule out IM  mild leukocytosis with atypical lymphocytes  can cause autoimmune hemolytic anemia & thrombocytopenia up to 2 – 3 wks after onset due to cross-reactivity of EBV-induced antibodies against RBCs & PLTs; Coomb’s positive  DDx: Strep pharyngitis, acute HIV infection --------------------------------------------------------------- acute HIV infection causes febrile illness similar to infectious mono o rash & diarrhea more common in HIV o tonsillar exudate common in mono ---------------------------------------------------------------Centor criteria for pharyngitis o fever by history o tender anterior cervical lymphadenopathy o tonsillar exudates o absence of cough  score 0 to 1: no testing or treatment  score 2 to 3: rapid streptococcal antigen testing; oral PCN or amoxicillin for positive results 

score 4: antigen testing; or empiric oral PCN or amoxicillin --------------------------------------------------------------- endothelial cell dysfunction or vasospasm is the pathophysiologic finding in preeclampsia due to abnormal placental vasculature development in early pregnancy  previously normotensive patients, preeclampsia is diagnosed as new onset HTN (≥ 140/90 mmHg) @ ≥ 20 wks gestation, with new onset proteinuria OR signs of end-organ damage  proteinuria is not required for Dx if signs of end-organ damage is present  end-organ damage (severe headache, RUQ or epigastric pain, renal insufficiency, pulmonary edema) are considered to have preeclampsia with severe features Preeclampsia with severe features o BP ≥ 160/110, ≥ 4 hrs apart during bedrest o thrombocytopenia < 100,000  serum creatinine > 1.1 or doubling o elevated transaminases o pulmonary edema o new onset visual or cerebral symptoms --------------------------------------------------------------- normal pregnancy:  C.O., renal perfusion, & GFR, results in low baseline creatinine (0.4 – 0.8) --------------------------------------------------------------- chronic HTN: BP ≥ 140/90 mmHg @ < 20 wks gestation or prior to conception  gestational HTN: new onset HTN @ ≥ 20 wks gestation; no proteinuria or end-organ damage  chronic HTN with superimposed preeclampsia: chronic HTN + new onset proteinuria or worsening proteinuria @ ≥ 20 wks gestation above baseline, worsening HTN, or signs of end-organ damage --------------------------------------------------------------- IV hydralazine & labetalol (or PO nifedipine) used for pregos, Rx hypertensive emergencies o (BP ≥ 160/110)  methyldopa is safe for pregos but not for hypertensive emergencies; slow onset & sedative  magnesium sulfate for seizure prophylaxis o definitive Rx: removal of the placenta ---------------------------------------------------------------

ACE inhibitors are contraindicated in pregos o fetal growth restriction, renal failure, pulmonary hypoplasia, oligohydramnios, skeletal abnormalities in 2nd or 3rd trimester --------------------------------------------------------------- viral arthritis presents as symmetric polyarticular small joint inflammation; resolves within 2 months  positive ANA & rheumatoid factor may occur  Rx: NSAIDs; no antivirals necessary  DDx: RA, OA, polyarthritis in sarcoidosis, septic & psoriatic arthritis, ankylosing spondylitis, polymyalgia rheumatica --------------------------------------------------------------- earliest manifestation of vaso-occlusive disease in sickle cell anemia = dactylitis  presents @ age 6 months - 2 years with acute onset pain, symmetric swelling of hands & feet --------------------------------------------------------------- clubbing of toes & fingers, enlarged extremities, swollen joints: hypertrophic osteoarthropathy  MCC: pulmonary adenocarcinoma --------------------------------------------------------------- staphylococcal osteomyelitis: localized bone pain, soft tissue swelling, erythema  sinus tracts with purulent drainage on skin surface  XR: initially normal but later show periosteal elevation & necrotic areas --------------------------------------------------------------- elevated DHEA-S levels are specifically seen with androgen producing adrenal tumors  DHEA-S is produced in adrenal glands only  androstenedione, testosterone, & DHEA are hormones produced by ovaries & adrenals  androstenedione, DHEA, DHEA-S are not true androgens because they do not interact with androgen receptors, but converted to testosterone o overproduction of these hormones can lead to clinical features of androgen excess --------------------------------------------------------------- dihydrotestosterone (DHT) is a product of testosterone conversion in peripheral tissues by 5- alpha-reductase  a potent androgen that interacts with testosterone Rc ---------------------------------------------------------------

always consider substance abuse in any child/adolescent with significant changes in behavior, emotions, & social circles  interview the patient & parents individually  urine toxicology screen is indicated --------------------------------------------------------------- null hypothesis: statement of no relationship between exposure & outcome  alternative hypothesis opposes the null hypothesis ---------------------------------------------------------------Feature of anorexia  osteoporosis**   cholesterol & carotene  prolonged QT, arrhythmias  euthyroid sick syndrome  anovulation, amenorrhea, estrogen deficiency 2/2 hypothalamic-pituitary axis dysfunction  hyponatremia 2/2 polydipsia  pregos are at risk of IUGR, prematurity, hyperemesis gravidarum, postpartum depression --------------------------------------------------------------- anorexia nervosa patients require hospitalization for unstable vital signs, severe bradycardia or cardiac arrhythmias, or electrolyte disturbances  Rx: CBT, nutritional rehab & weight gain; monitor for refeeding syndrome  Rx: olanzapine, if failure to gain weight & lack response to CBT --------------------------------------------------------------- Rx bulimia nervosa: SSRI + CBT, nutrition rehab; does not aid in weight gain  Rx anorexia nervosa: CBT, nutrition rehab; olanzapine if no response --------------------------------------------------------------- olanzapine A/E: weight gain & sedation mainly o also hyperglycemia, dyslipidemia, new DM  clozapine A/E: weight gain, agranulocytosis, & lowers seizure threshold --------------------------------------------------------------- Bupropion is C/I with eating disorders as it can provoke seizures --------------------------------------------------------------- refeeding syndrome: potentially fatal complication of nutritional rehabilitation in anorexia nervosa 

resuming CHO intake, PO or IV, stimulates an insulin surge, which promotes cellular uptake of phosphorus, K+, & Mg++ o phosphorus is the primary deficient electrolyte o K+ & Mg++ deficiency potentiate arrhythmias  aggressive initiation of nutrition rehab without adequate electrolyte repletion results in clinical manifestations… o arrhythmias, cardiopulmonary failure o CHF (pulmonary edema, peripheral edema) o seizures o Wernicke encephalopathy  anorexia nervosa: a/w euthyroid hypothyroxinemia (normal TSH, low/normal T3/T4) 2/2 starvation & malnutrition --------------------------------------------------------------- African-American, gradual peripheral vision loss, high ocular pressure with cupping of optic disc: open angle glaucoma  annual fundoscopic exam in high-risk groups  Rx: Timolol ( aqueous humor production) o laser trabeculoplasty as adjunct Rx --------------------------------------------------------------- acute severe U/L eye pain, “halo” around lights, blurred vision, non-reactive fixed & dilated pupil, & unilateral orbitofrontal headache a/w N/V: angle closure glaucoma  conjunctival erythema, corneal opacification  aggravated by pupil dilation 2/2 darkness, stress, medications (decongestants, anticholinergics, sympathomimetics)  avoid atropine (mydriatic; precipitates glaucoma)  Dx: tonometry (increased IOP) o gonioscopy is gold standard  #1 Rx: IV mannitol (rapid effect)  #2 Rx: acetazolamide & timolol ( aqueous humor production), topical pilocarpine ( drainage)  untreated complication: permanent vision loss --------------------------------------------------------------- moderate pain, blurred vision, hazy cornea, anterior chamber shows flare & cells on slit lamp, constricted pupil & poor light response: uveitis --------------------------------------------------------------- diabetic retinopathy: MCC of acquired blindness; MC 2/2 vitreous hemorrhage 

non-proliferative: retinal hemorrhages, dilated veins, microaneurysms, hard exudates o proliferative: neovascularization --------------------------------------------------------------- ToF presents with varying degrees of cyanosis, depends on the degree of RV outflow obstruction  “tet spell”: sudden hypoxemia & cyanosis due to sudden spasm from exertion or agitation o  pulmonary vascular resistance  Rx: knee-chest position decreases right-to-left ventricular shunt & improves cyanosis by  SVR,  pulmonary blood flow  Rx: inhaled O2 stimulates pulmonary vasodilation o  pulmonary vascular resistance  DDx: VSD typically does not cause cyanosis, late stage pulmonary HTN with shunt reversal leads to cyanosis (Eisenmenger’s) --------------------------------------------------------------- maternal risk factors for fetal macrosomia: advanced age, obesity, diabetes, multiparity  African & Hispanic males are at increased risk for fetal macrosomia & shoulder dystocia  excessive traction on the neck during delivery can result in Erb-Duchenne palsy o involves 5th, 6th, 7th CN o most recover spontaneously within 3 months o Rx: gentle massage, PT to prevent contractures ---------------------------------------------------------------MS  females, 30s – 40s  unpredictable, erratic, focal neurologic dysFx  symptoms last a few weeks; variable recovery  transient arm weakness  B/L trigeminal neuralgia** --------------------------------------------------------------- depression, subcortical dementia, chorea, atrophy of caudate nucleus (enlarged lateral ventricles): Huntington’s --------------------------------------------------------------- periodic back pain radiating to thigh & buttocks, related to walking & climbing stairs, numbness & tingling of lower extremities, relieved with lumbar flexion: lumbar spinal stenosis  aka neurogenic claudication o

compression of spinal roots due to enlarging osteophytes at facet joints &/or hypertrophy of ligamentum flavum; degenerative joint disease  normal peripheral pulses  neuro exam can be normal  confirm Dx: spinal MRI  DDx: lumbar disk herniation, metastatic disease, iliac artery atherosclerosis, ankylosing spondylitis --------------------------------------------------------------- low back pain radiating to calf & foot, worsens with prolonged sitting, positive straight leg test, unilateral symptoms: herniated lumbar disk  exertion-dependent pain, relieved with rest; decreased peripheral pulses, cool extremities, decreased hair growth: vascular claudication  back pain, paralysis, hyperreflexia, urinary & fecal incontinence: spinal cord compression  chronic back pain, worse at night, non-radiating, dull, does not change with activity: metastatic disease of the vertebrae --------------------------------------------------------------- progressive back stiffness, worse in AM, improves with activity, young male: ankylosing spondylitis  apophyseal (facet) joint arthritis   lumbar spine mobility & tender SI joint  anterior uveitis (monocular pain, redness, blurring)  Dx: sacro-iliac XR shows B/L sacroiliitis, fusion of SI joint &/or bamboo spine  HLA-B27 is not specific for AS, not needed for Dx --------------------------------------------------------------- pulmonary aspergillosis: fever, chronic cough, dyspnea, weight loss, intermittent hemoptysis  risk factors: immunocompromised, asthma, COPD, TB, sarcoidosis, malignancy  aspergilloma MC with pre-existing lung cavity (TB)  CXR: rapidly progressing, mobile cavitary lesion  CT scan: pulmonary nodules with a halo sign or lesions with an air crescent  Dx: CXR & Aspergillus IgG  Aspergilloma Rx: surgical resection  invasive aspergillosis: itraconazole or caspofungin --------------------------------------------------------------- histoplasmosis: SE & central US o acute pneumonia, cough, fever, malaise 

o CXR: hilar adenopathy, areas of pneumonitis blastomycosis: north/south central, Ohio/Miss o flu-like S/S; severe in immunocompromised o ulcerated skin lesion, lytic bone lesions  coccidioidomycosis: southwestern US o primary pulmonary infection, arthralgia  erythema multiforme & erythema nodosum  sporotrichosis: subcutaneous papules at inoculation site, ulcerates; along lymphatic flow --------------------------------------------------------------- suspected sarcoidosis (cough, hilar adenopathy, erythema nodosum, noncaseating granulomas) that deteriorates after high-dose corticosteroids: histoplasmosis  sarcoidosis & histoplasmosis present with similar symptoms & CXR  biopsy reveals yeast forms in histoplasmosis  Dx: urine antigen testing --------------------------------------------------------------- fever, night sweats, productive cough, weight loss, acute & chronic pneumonia, wart-like violaceous nodules & skin ulcers with yeast: blastomycosis  primary infection via inhalation  pulmonary infection with hematogenous spread to skin  heaped-up verrucous ulcerated skin lesions that evolve into microabscesses  sputum: broad-based budding yeast  CXR: upper lobe consolidation & lytic lesions  Dx: urine antigen testing  Rx mild pulmonary dz, immunocompetent: no Rx  Rx moderate pulmonary disease: oral itraconazole  Rx severe pulmonary disease, immunocompromised: IV amphotericin B --------------------------------------------------------------- MCC of priapism o drug-induced (trazodone, prazosin) o sickle cell disease & leukemia (children) o perineal or genital trauma (laceration) o neurogenic lesions (SCI, cauda equina) --------------------------------------------------------------- SSRIs: a/w impotence, sexual dysfunction, delayed orgasm o Rx: premature ejaculation ---------------------------------------------------------------

lightening-like pain on the face, 20 -30x per day, distributed in CN V branches: trigeminal neuralgia  Rx: carbamazepine (A/E: aplastic anemia, fetal hydantoin syndrome)  DDx: maxillary sinusitis, herpes zoster  MS can present with B/L trigeminal neuralgia --------------------------------------------------------------- hypopituitarism with mild/moderate  prolactin (35 ng/mL): non-functioning pituitary adenoma  central hypogonadism & hypothyroidism  arise from gonadotrophs in pituitary gland; dysfunctional cells overproduce only α-subunits of dimeric hormones (LH, FSH)  symptoms 2/2 mass effect with disruption of dopaminergic pathways that normally suppress prolactin  Rx: trans-sphenoidal surgery  DDx: prolactinoma (> 200 ng/mL), Klinefelter, excessive alcohol intake, antipsychotics ---------------------------------------------------------------Common etiologies of interstitial lung disease o sarcoidosis, amyloidosis o vasculitis (granulomatosis with polyangitis) o infection o occupational/environmental (silicosis, hypersensitivity pneumonitis) o connective tissue disease (SLE, scleroderma) o idiopathic pulmonary fibrosis o cryptogenic organizing pneumonia --------------------------------------------------------------- idiopathic pulmonary fibrosis: excess collagen deposition in peri-alveolar tissue, causes interstitial lung disease  scarring leading to  lung volumes (TLC, FRC, RV) with preserved or  FEV1/FVC ratio  impaired gas exchange;  DLCO,  A-a gradient, results in hypoxemia due to V/Q mismatch  progressive exertional dyspnea, persistent dry cough, fine crackles, digital clubbing o resting ABG may be normal o exertion can cause significant hypoxemia  CXR: reticular or nodular opacities  CT: fibrosis, honeycombing, traction bronchiectasis o lung biopsy required for equivocal Dx 

 > 50% with significant +smoking Hx --------------------------------------------------------------- cryptogenic organizing pneumonia: dry cough, chronic systemic symptoms  CXR: B/L ground glass infiltrates --------------------------------------------------------------- receiver operating characteristic (ROC) curve: shifting upward,  sensitivity  shifting ROC curve to the right,  specificity  accuracy = total area under the ROC curve

--------------------------------------------------------------- sensitivity & specificity depend on the cutoff value  raising the cutoff value, it is harder to obtain a true positive result & easier to obtain a negative o causes FN to increase & TP to decrease, leads to  sensitivity &  specificity  lowering the cutoff point increases # of TP (directly proportional to  sensitivity), but also decreases # of FP ( specificity)  specificity is important for confirmatory tests to minimize FPs

|------specificity------||--sensitivity--| --------------------------------------------------------------- syringomyelia: fluid-filled cavity within the cervical & thoracic spinal cord  a/w Arnold Chiari malformation type I & SCIs  areflexic upper extremities weakness, dermatomal cape-distribution loss of pain/temp, with preserved vibration & proprioception (“dissociated sensory loss”)  may present with burn injury 2/2 loss of sensation  Dx: MRI  DDx: anterior cord syndrome (2/2 aortic surgery), transverse myelitis (2/2 MS), ALS (no sensory loss), subacute combined degeneration (2/2 Vit B12 def.), cervical spondylosis (neck pain & stiffness) --------------------------------------------------------------- Rx of hyperkalemia depends on severity, cause & rapidity of rise in K+ levels 3 approaches to Rx hyperkalemia 1. antagonize cardiac effects of K+ with Ca++ o hyperkalemia a/w EKG changes (peaked T, PR prolonged, wide QRS)  IV calcium gluconate o rapid & transient effect 2. drive extracellular K+ into cells o moderate hyperkalemia, no EKG change  insulin/glucose (fastest), beta-2-agonist (albuterol), sodium bicarbonate o rapid-acting, but transient effects 3. remove excess K+ from the body o severe hyperkalemia, ESRD  sodium polystyrene sulfonate (Kayexelate), diuretics (furosemide), cation exchange resins (stool elimination), hemodialysis (definitive Rx) o slow-acting (2 – 24 hr)

---------------------------------------------------------------Classification of psychiatric illness by phase  acute phase aims to achieve remission of acute symptoms (absent/minimal symptoms) o “treatment response” = 50% reduction from baseline of severity; significant improvement  continuation phase: sustained remission to prevent relapse  maintenance phase: recovery signifies the episode is over; prevent recurrence --------------------------------------------------------------- sarcoidosis: young/mid-aged African-American females, insidious onset dyspnea & dry cough, absence of constitutional symptoms  erythema nodosum & anterior uveitis is common  B/L ankle arthritis  auscultation: dry rales  CXR: B/L hilar lymphadenopathy, diffuse interstitial infiltrates  DDx: PCP pneumonia, CHF (bibaslar infiltrates), idiopathic pulmonary fibrosis, ankylosing spondylitis --------------------------------------------------------------- Pneumococcus is MCC of sepsis in patients with sickle cell anemia  clumping of sickled cells slows blood flow in the spleen, permits splenic sequestration of RBCs, results in auto-infarction & functional asplenia  susceptible to encapsulated species (S. pneumo, H. influenza, N. meningitides)  pneumococcal vaccination & PCN prophylaxis until age 5 prevents pneumococcal sepsis o 13-valent conjugate & 23-valent polysacch o H. influenza Type B vaccine o meningococcal conjugate vaccine  PCN prophylaxis protects against other pneumococcal serotypes --------------------------------------------------------------- renal biopsy is required for classification of all new onset lupus nephritis for baseline histology & determine appropriate Rx  low complement levels & positive antibodies (ANA, anti-dsDNA, anti-Smith) ---------------------------------------------------------------

thermal or smoke inhalation injury in burn victims, warrant early intubation to prevent supraglottic airway obstruction by edema & blistering  carboxyhemoglobin > 10%, stridor, Hx of confinement in a burning building, blistering  Rx: high-flow O2 with non-rebreather, with a low threshold for intubation --------------------------------------------------------------- weakness & decreased pain sensation of B/L LE after a MVA suggests a spinal cord injury  in absence of pelvic injury & blood at the urethral meatus, urinary catheter can assess for retention & prevent bladder injury due to acute distension ---------------------------------------------------------------Medications to withhold prior to cardiac stress testing 48 hr hold β-blocker, CCB, nitrates continue ACE-I/ARBs, digoxin, statins, diuretics 

stress tests detect reversible ischemia or prior MI medications should be continued for those with CAD undergoing stress testing to assess the efficacy of antianginal therapy --------------------------------------------------------------- TB is a common cause of primary adrenal insufficiency (Addison’s) in endemic areas  no rise in serum cortisol with cosyntropin  CT: B/L adrenal calcification (hallmark)  non-anion gap metabolic acidosis with hyperK+, hyponatremia, hypoglycemia, eosinophilia  deficiency of aldosterone results in inappropriate sodium loss, while retaining K+ & H+  Rx of TB does not normalize adrenal function  Rx: lifelong glucocorticoid & mineralocorticoid --------------------------------------------------------------- candida vaginitis & bacterial vaginosis are caused by an imbalance of vaginal flora, not sexual transmission; but increases risk for STDs  recent systemic corticosteroid use, ABX, DM  

Bacterial Vaginosis thin, off-white discharge, fishy

DDx of vaginitis Trichomoniasis vaginitis thin, frothy, green-yellow, malodorous;

Candida vaginitis thick, cottage cheese-like;

NO inflammation

inflammation

inflammatio n normal pH pseudohyphae

pH > 4.5 ph > 4.5 clue cells, +Whiff motile, pear-shape (amine odor in trichomonads, KOH) strawberry cervix oral metronidazole metronidazole; fluconazole (OK for pregos) treat partner (pregos OK)  normal: white/transparent, odorless discharge  vaginal inflammation: vulvar pruritus, erythema, burning, dyspareunia, dysuria  confirm Dx: wet mount & vaginal pH --------------------------------------------------------------- patients with PID should also be screened for HIV, syphilis, hepatitis B, cervical cancer (pap); also hepatitis C if Hx of IVDA --------------------------------------------------------------- N-acetylcysteine o acetaminophen hepatotoxicity o mucolytic for cystic fibrosis o contrast-induced nephropathy prevention --------------------------------------------------------------- child with sudden-onset respiratory distress without preceding illness, focal findings on pulmonary exam: foreign body aspiration  MC in right mainstem bronchus  focal monophonic wheezing on affected side  generalized wheezing, inspiratory stridor, hoarse  CXR: hyperinflation in partial obstructions, or atelectasis in complete obstructions  Dx & Rx: rigid bronchoscopy --------------------------------------------------------------- umbilical hernia: MC in A-A infants; reducible, low risk of incarceration or strangulation o defects at linea alba, covered by skin o a/w Beckwith-Wiedemann, hypothyroidism, prematurity o spontaneously resolves by age 5 yr  gastroschisis: protrusion of bowel to the right side of normal umbilicus; no membrane coverage o elevated AFP o Rx: cover with sterile saline dressing & plastic wrap, NGT, ABX o surgical repair with single-stage closure

omphalocele: umbilical cord inserts at apex of defect; covered by peritoneum o Rx: surgical staged closure with silastic silo ---------------------------------------------------------------  AFP in pregos: a/w open NTD (anencephaly), ventral wall defects, multiple gestation  Dx: USS, clarify # of fetuses  DDx: HCC, gonadal tumors, viral hepatitis --------------------------------------------------------------- regression of milestones can be a complication of previous episode of bacterial meningitis  long-tern neurologic sequelae a/w meningitis o loss of cognitive function o hearing loss o seizures o mental retardation o spasticity or paresis ---------------------------------------------------------------Liver disorders of pregnancy  HELLP  intrahepatic cholestasis of pregnancy  acute fatty liver of pregnancy --------------------------------------------------------------- life-threatening complication of pre-eclampsia 

  

HELLP Syndrome Hemolysis: microangiopathic hemolytic anemia, schistocytes,  bilirubin,  haptoglobin Elevated LFTs: AST or ALT x2 upper limit Low Platelets: < 100,000 μL

abnormal placentation triggers systemic inflammation, with activation of coagulation & PLT consumption  hepatocellular necrosis cause elevated LFTs, liver swelling, & distension of Glisson’s capsule  RUQ or epigastric pain, N/V  proteinuria, elevated LDH  Rx: prompt delivery at ≥ 34 wks, Mg-sulfate o c-section only for normal OB indications  complication: DIC with multi-organ failure  DDx: acute fatty liver of pregnancy, ITP, HUS, intrahepatic cholestasis, placental abruption ---------------------------------------------------------------

complication of severe preeclampsia: acute pulmonary edema  acute onset dyspnea, hypoxia, crackles, LE edema  due to generalized arterial vasospasm leading to  SVR &  pulmonary capillary pressure  also due to  renal function,  albumin, &  vascular permeability  Rx: supplemental O2, fluid restriction, & diuretics with caution due to third-spacing --------------------------------------------------------------- intrahepatic cholestasis of pregnancy: functional disorder of bile formation during 2nd & 3rd trimester  intense pruritus on palms & soles, worse at night   bile acids; hyperbilirubinemia; no jaundice   aminotransferases x10 (r/o viral hepatitis)  Dx of exclusion  Rx: symptomatic, pruritus resolves after delivery; ursodeoxycholic acid may be helpful --------------------------------------------------------------- acute fatty liver of pregnancy: acute hepatic failure in 3rd trimester; due to acute microvesicular fatty infiltration of hepatocytes  N/V, abdominal pain  significantly elevated LFTs, prolonged PT & PTT, hypoglycemia, leukocytosis, encephalopathy  Rx: prompt delivery --------------------------------------------------------------- Dressler’s: pericarditis presenting weeks – months post-MI; immune-mediated  chest pain, worse with deep inspiration, improves by leaning forward  elevated ESR  EKG: diffuse ST elevation, except aVR; consistent with pericarditis  Rx: NSAIDs; corticosteroids for refractory cases --------------------------------------------------------------- primary Raynaud phenomenon:  vascular response to cold temp or emotional stress  symmetric episodic attacks; women age < 30  absence of peripheral vascular disease, tissue injury, or abnormal nailfold capillary exam  Rx: CCB (nifedipine, amlodipine) & avoid aggravating factors, smoking cessation ---------------------------------------------------------------

 secondary Raynaud’s: a/w connective tissue dz  asymmetric attacks; males, age > 40  tissue ischemia & digital ulcers  work-up: ANA, RF, ESR  Rx: underlying cause, CCB --------------------------------------------------------------- Tourette disorder: multiple motor tics & at least 1 vocal tic; must persist for 1 yr after initial onset before age 18; exacerbated by stress  a/w comorbid OCD & ADHD  Rx: risperidone & habit reversal training  only haloperidol & pimozide are FDA-approved --------------------------------------------------------------- pleuritic chest pain, dyspnea, tachypnea, tachycardia in a long-distance truck driver: PE  CXR has poor sensitivity & specificity, but can exclude other causes of chest pain & dyspnea  DDx for chest pain & dyspnea: acute MI, pneumonia, pneumothorax, aortic dissection, pericardial effusion, peptic ulcer perforation --------------------------------------------------------------- very large PE’s may cause hypotension due to acute RV failure --------------------------------------------------------------- SIRS: non-infectious causes of sepsis  two out of four criteria  a/w pancreatitis, autoimmune dz, vasculitis, burns Systemic Inflammatory Response Syndrome (SIRS) Temp ˃ 38.5°C (101.3°F) or ˂ 35°C (95°F) Pulse ˃ 90 bpm RR ˃ 20/min WBC ˃ 12,000, ˂ 4000 cells/mm3, or ˃ 10% bands sepsis: SIRS with known infection o infection or injury leading to inflammation & dysregulated host response o severe sepsis = end-organ dysfunction (hypotension, thrombocytopenia, oliguria, metabolic acidosis, hypoxemia) --------------------------------------------------------------- patients with severe burns manifest evidence of SIRS & hypermetabolic response in the 1st week 

if significant total body surface area burns, major cause of morbidity/mortality is hypovolemic shock  in the setting of adequate fluid resuscitation, bacterial infection (bronco pneumonia or burn wound infection) leading to sepsis & septic shock are pneumonia & wound infections  MCC: S. aureus & P. aeruginosa  criteria indicating development of sepsis: worsening hyperglycemia (worsening insulin resistance), leukocytosis, thrombocytopenia, hyperthermia, tachypnea, tachycardia  following a severe burn injury,  in circulating cortisol & catecholamines cause protein losses as muscle degradation is used for gluconeogenesis; extensive protein breakdown is a normal response = hypermetabolic phase --------------------------------------------------------------- weakness, cold intolerance, hoarseness, dry skin, constipation, depression, menorrhagia, bradycardia, myxedema: hypothyroidism --------------------------------------------------------------- plasmapheresis removes pathogenic autoantibodies: Rx TTP --------------------------------------------------------------- S. aureus is MCC of lactational mastitis  Dx: based on history & exam  Rx: nurse every 2 to 3 hours; direct feeding with both breasts to completely drains milk ducts  Rx: ibuprofen, frequent feeding/pumping, ABX  empiric Rx for MSSA: dicloxacillin, cephalexin  empiric Rx for MRSA: clindamycin, TMP-SMX, or vancomycin --------------------------------------------------------------- benztropine: Rx/prevent EPS a/w antipsychotics  clozapine: Rx treatment-resistant schizophrenia  methylphenidate: Rx ADHD --------------------------------------------------------------- Duchenne muscular dystrophy: age 2 – 5 yrs, X-linked recessive, B/L calf pseudohypertrophy  screening:  serum creatine kinase & aldolase  fibrosis & fatty infiltration on calf muscle biopsy support the Dx  confirm Dx: genetic studies show deletion of dystrophin gene ---------------------------------------------------------------

progressive dyspnea,  exercise tolerance, a-fib with rapid ventricular response, LV systolic dysFx: tachycardia-mediated cardiomyopathy  develops in patients with persistent or recurrent tachyarrhythmias with prolonged periods of rapid ventricular rate (a-fib, a-flutter, AVNRT)  Rx: aggressive rate or rhythm control using AV nodal blocking agents, antiarrhythmics, or catheter ablation --------------------------------------------------------------- infants with hydrocephalus may present with the following findings: 

symptoms poor feeding irritability decreased activity vomiting

physical findings tense & bulging fontanelle prominent scalp veins widely spaced cranial sutures rapidly increasing circumference

Dx: brain CT scan o USS requires a widely open anterior fontanelle; infants < age 6 months  lumbar puncture for suspected meningitis  skull radiograph to evaluate abnormal head shape ---------------------------------------------------------------Serum Serum Serum Ca++ phosphate PTH    10 hyper-PTH    hypoparathyroidism /nrml   osteomalacia normal normal normal osteoporosis/Paget’s --------------------------------------------------------------- osteomalacia due to vitamin D deficiency: o mildly low serum Ca++ o marked hypophosphatemia o  PTH &  alkaline phosphatase o low plasma 25-OH vitamin D o decreased urinary Ca++  secondary hypo-PTH brings serum Ca++ to normal/near-normal by increasing bone & renal Ca++ reabsorption &  urinary phosphate excretion  bone pain, muscle weakness, cramps  causes: malabsorption (Crohn’s, Celiac), GI bypass surgery, chronic liver/kidney disease 

XR: reduced bone density, thinning cortex, symmetric pseudofratures (Looser zones) --------------------------------------------------------------- 2 major treatment issues for all new-onset a-fib 1. rate or rhythm control strategy 2. risk assessment of systemic embolization  CHA2-DS2-VASc score: assesses long-term stroke risk in patients with non-valvular a-fib o score 0: low risk, no therapy o score 1: intermediate risk, no therapy or ASA or oral anticoagulation o score ≥ 2: high risk, oral anticoagulation  warfarin reduces risk of embolization in groups at moderate- to high-risk of thromboembolism 

CHA2-DS2-VASc score CHF 1 HTN 1 Age ≥ 75 2 DM 1 Stroke/TIA 2 vascular disease (prior-MI, 1 PAD, aortic plaque) A Age 65 – 74 1 Sc Sex 1 Max score 9 --------------------------------------------------------------- DM Type 2 a/w physiologic stressor (infection) are prone to nonketotic hyperosmolar syndrome (NKHS)  risk factors: URI, MI, stroke, trauma, burns  stress causes  catecholamines & cortisol, both insulin counterregulatory hormones  severe hyperglycemia (> 600 mg/dL), with resultant osmotic diuresis, causes dehydration & serum hyperosmolarity (> 320 mOsm/L)  altered consciousness (confusion) & acute onset of blurred vision are common  #1 Rx: IV fluids can reduce hyperglycemia o if hypovolemic: NS until euvolemic, then replace with 0.45% saline  #2 Rx: insulin  #3 Rx: K+ supplementation once K+ reaches normal levels  DDx: cataracts, diabetic retinopathy, uveitis C H A2 D S2 V

--------------------------------------------------------------- altered mental status, volume depletion, polyuria: hyperosmolar hyperglycemic state (HHS)  hyponatremia in HHS is due to osmotic shift of H2O into extracellular space & Na+ renal loss from osmotic diuresis DKA HHS Type I diabetics Type II diabetics younger age older age rapid onset of symptoms gradual symptoms onset hyperventilation altered mental status abdominal pain neurologic symptoms glucose 250 – 500 mg/dL glucose > 600 mg/dL bicarbonate < 18 mEq/L bicarbonate > 18 mEq/L anion gap metab. acidosis normal anion gap ketonemia negative ketones serum Osm < 320 serum Osm > 320 total body K+ deficit due to osmotic diuresis Thiazides can precipitate HHS by reducing intravascular volume, thus  GFR, leads to decreased renal glucose excretion   osmolality leads to altered mentation, lethargy, & weakness  Dx: serum glucose, plasma Osm, absent ketonemia --------------------------------------------------------------- best markers for resolution of DKA o serum anion gap o beta-hydroxybutyrate assay (ketones)  measure serum glucose every hour  measure electrolytes & anion gap every 2 – 4 hr 

Management of DKA & HHS high-flow 0.9% NS; change to D5% in 0.45% @ serum glucose < 200 mg/dL IV initial continuous IV infusion; regular switch to SC when patient is able to eat, insulin glucose < 200, anion gap < 12, or HCO3 > 15 IV K+ if < 5.2 mEq/L HCO3only if pH < 6.9 phosphate if phosphate < 1.0, cardiac dysFx, or respiratory depression, monitor serum Ca++ IV fluids

--------------------------------------------------------------- cataracts can manifest in chronic diabetics with suboptimal glycemic control  gradual accumulation of intralenticular sorbitol --------------------------------------------------------------- unexplained thrombocytopenia & hemolytic anemia in a patient with renal failure & neuro deficits (headache, confusion): TTP-HUS o schistocytes are characteristic  idiopathic TTP-HUS: ADAMTS-13 deficiency, a von Willebrand factor cleaving protease; accumulation of large von Willebrand factor multimers & PLTs  Rx: plasmapheresis (removes autoantibodies & repletes ADAMTS-13) o PLT transfusion is contraindicated --------------------------------------------------------------- advanced COPD: supplemental O2 improves hypoxia, but worsens hypercapnia due to… 1) increased dead space perfusion & loss of compensatory vasoconstriction worsens V/Q mismatch 2) decreased affinity of oxyHb for CO2; reduces uptake of CO2 from tissue 3) reduced alveolar ventilation due to decreased respiratory drive; slows RR  lethargy, confusion, seizures (reflex cerebral vasodilation) --------------------------------------------------------------- pre-existing atopic dermatitis (eczema) increases risk for latex allergy --------------------------------------------------------------- adrenal insufficiency should be suspected in patients who becomes suddenly hypotensive under stress (surgery) --------------------------------------------------------------- risk factors for aspiration pneumonia include altered consciousness due to excessive alcohol, neurologic dysphagia, disruption of GE junction (GERD), mechanical disruption of glottis closure  recurrent pneumonia involving same lung region is 2/2: bronchial obstruction or recurrent aspiration  CXR: infiltrate in lower or posterior upper lobes  Dx: chest CT scan ----------------------------------------------------------------

humoral immune deficiency leads to impaired antibody production; presents with recurrent, upper & lower RTI due to encapsulated bacteria --------------------------------------------------------------- MCC of hypernatremia is hypovolemia  mild cases: 5% dextrose in 0.45% saline  severe cases (mental status changes): 0.9% saline initially (isotonic saline is hypoosmolar compared to the hypernatremic plasma); once volume deficit is restored, switch to 0.45% saline  plasma Na+ correction 1 mEq/L/hr; rapid correction of hypernatremia leads to cerebral edema --------------------------------------------------------------- 5% dextrose in water (D5W): Rx euvolemic & hypervolemic hypernatremia  IV free water can cause RBC lysis due to osmotic shock --------------------------------------------------------------- isolated, symmetric lower extremity weakness, loss of sensation & UMN signs: spinal cord compression  causes: disk herniation, abscess, malignancy  epidural abscess is common with IVDA  Dx: spine MRI; medical emergency! o lumbar puncture is contraindicated for possible epidural abscess  Rx: high-dose IV glucocorticoids --------------------------------------------------------------- acute Lyme disease: erythema migrans, headache, arthralgia, myalgia  late disseminated Lyme disease (months/yrs) can manifest as subacute encephalopathy --------------------------------------------------------------- Beck’s Triad (hypotension, JVD, muffled heart sounds) suggests cardiac tamponade  MC: viral pericarditis due to recent viral URI  due to an exaggerated shift of the interventricular septum towards the left ventricular cavity which reduces LV preload, stroke & C.O.  clear lungs, pulsus paradoxus, hepatojugular reflux; worsens with inspiration --------------------------------------------------------------- pulmonary HTN can be due to  pulmonary arterial pressure (primary pulmonary HTN), or  pulmonary venous pressure (LV failure) 

 loud S2 --------------------------------------------------------------- macrovesicular steatosis, polymorphonuclear infiltrates, & necrosis in a non-drinker: nonalcoholic steaohepatitis (NASH)  risk factors: obesity, DM, hypertriglyceridemia, medications, TPN, endocrinopathies  impaired responsiveness to insulin causes fat accumulation in the liver, progressing to fibrosis & steatohepatitis; 2/2 lipid peroxidation & oxidative stress  hepatomegaly is common, mild LFT elevations  Dx: percutaneous liver biopsy  complications: hepatic fibrosis, cirrhosis  Rx: treat underlying conditions, ursodeoxycholic acid to improve LFTs --------------------------------------------------------------- cyclosporine & tacrolimus: calcineurin-inhibitors (immunosuppressants)  both: nephrotoxic, HTN, hyperkalemia, tremor  cyclosporine A/E: gum hypertrophy & hirsutism --------------------------------------------------------------- azathioprine A/E : dose-related marrow suppression, leukopenia, hepatotoxic, pancreatitis  mycophenolate A/E: bone marrow suppression  glucocorticoid A/E: Cushing’s, osteoporosis, poor wound healing, adrenocortical atrophy --------------------------------------------------------------- female, jaundice, marked pruritus, +AMA: primary biliary cirrhosis  noncaseating granulomatous inflammation  portal tracts are infiltrated by lymphocytes, macrophages, plasma cells, eosinophils  portal tract scarring & bridging fibrosis leads to cirrhosis; a/w ductopenia of intrahepatic ducts --------------------------------------------------------------- inflammation, fibrosis, & stricturing of intrahepatic & extrahepatic bile ducts Primary sclerosing cholangitis fatigue & pruritus, or asymptomatic a/w comorbid ulcerative colitis labs, imaging cholestatic pattern:  LFTs,  ALP +p-ANCA liver Bx fibrous obliteration of small bile ducts, features

concentric replacement by connective tissue = “onion skin” pattern Dx cholangiogram: periductal portal tract fibrosis; segmental stenosis of extrahepatic & intrahepatic bile ducts Rx: ursodeoxycholic acid, liver transplant complications biliary stricture, cholangitis, cholelithiasis, cholestasis end-stage liver disease, portal HTN cholangiocarcinoma, colon cancer  cholangiogram: ERCP or MRCP --------------------------------------------------------------- asymptomatic bacteriuria in pregos  risk of cystitis, pyelonephritis, low birth weight, prematurity, & perinatal mortality  MCC is E. coli  screen all pregos @ 12 – 16 wks gestation  Dx: positive urine culture ˃ 100,000 colonies/mL without symptoms of cystitis  Rx options o nitrofurantoin 5 - 7 days o amoxicillin or augmentin 3 - 7 days o fosfomycin as a single dose  fluoroquinolones (fetal cartilage abnormalities) & TMP-SMX should be avoided  F/U urine culture after one week to document resolution of bacteriuria, then monthly for the duration of pregnancy to monitor recurrent infections --------------------------------------------------------------- benign growths with a waxy, well-circumscribed “stuck on,” appearance: seborrheic keratosis o Dx: clinical appearance; no therapy  sudden onset of multiple occurrence may indicate occult internal malignancy  papulosquamous patches with a fine, loose, & greasy yellow scale on an erythematous base: seborrheic dermatitis o scalp, central face, eyebrows, nasolabial folds o all age groups; infant “cradle cap” o MC a/w Parkinson’s, HIV o Rx: moisturizer, antifungals, dandruff shampoo  dry, scaly papules with an erythematous base & central scale; “sandpaper-like”; may turn into “cutaneous horns”: actinic keratosis

o genetically predisposed @ age 40 – 60 o excessive sun exposure; premalignant for SCC  patchy, fine, white, adherent scales on the scalp: tinea capitis o Rx: oral griseofulvin  pruritic ring-shaped, scaly, erythematous rash with central clearing: tinea corporis o MCC: Trichophyton rubrum o Dx: KOH reveals hyphae o Rx: topical antifungals (terbinafine) or griseofulvin (extensive disease)  recurrent, pruritic, eczematous eruption on flexors & extensor surfaces: atopic dermatitis (eczema) o Type I hypersensitivity o light microscopy: spongiosis  erythematous, pruritic vesicles & edema 2/2 to contact with allergen/irritant: contact dermatitis  salmon-colored, sharply demarcated, scaling lesions that coalesce into oval plaques on extensors, covered by a thick silvery scale: psoriasis  slow-growing papule or nodule with a pearly rolled border & overlying telangiectasia with ulceration: basal cell carcinoma  solitary, firm, reddish, dome-shaped nodule & central keratinous plug: keratoacanthoma  smooth-surfaced, dome-shaped melanocytic plaque < 1 cm with blue color: blue nevi  “skin tag”, flesh-colored or pedunculated papules in high friction regions: acrochordon --------------------------------------------------------------- rosy hue with telangiectasia on cheeks, nose, chin, & scalp; 30 – 60 y/o: rosacea  chronic inflammatory disorder  intermittent flushing precipitated by hot drinks, heat, emotion, rapid body temp changes  papules & pustules may be present  Rx: metronidazole or laser surgery ---------------------------------------------------------------Clinical features of melanoma (screening)  Asymmetry  Border irregularities  Color variegation  Diameter ≥ 6 cm  Evolving size, shape, color

---------------------------------------------------------------Tinea capitis  dermatophyte infection, MC in A-A children feature scaly erythematous patch on scalp, s alopecia with residual black dot, lymphadenopathy, transmission: human-human or fomite Dx clinical; KOH of hair shaft: spores Rx oral griseofulvin, household contacts: selenium sulfide or ketoconazole shampoo --------------------------------------------------------------- flank pain, N/V, fever ˃ 38°C (100.4°F), CVA tenderness: acute pyelonephritis in pregnancy  Rx: hospitalization for IV ABX (ceftriaxone), then switch to oral ABX for 10 - 14 days after being afebrile for 24 hours  avoid aminoglycosides in pregnancy --------------------------------------------------------------- Whipple’s disease: rare, multi-systemic illness  Tropheryma whippelii (G+ bacillus)  white males, age 40 - 60  chronic malabsorptive diarrhea (weight loss, steatorrhea, flatulence, distension)  intermittent low-grade fever, chronic cough, pigmentation, lymphadenopathy  migratory polyarthropathy, myocardial/valvular involvement leads to CHF or regurgitation  late stage: dementia, ophthalmoplegia, myoclonus  PAS-positive macrophages in lamina propria of small intestine biopsy  DDx: Celiac’s, Crohn’s, cystic fibrosis, HIV --------------------------------------------------------------- gallstones & chronic alcohol abuse are MCC of acute pancreatitis o other etiologies: hyperlipidemia, medications, infections, trauma, iatrogenic (post-ERCP)  Dx requires 2 out of 3 criteria: acute epigastric pain radiating to back,  lipase ˃ 3x normal, imaging o imaging not necessary if first two criteria met  Dx: abdominal USS to evaluate for cholelithiasis or choledocholithiasis o equivocal USS  endoscopic USS or ERCP  abdominal CT is used for those who fail to improve with conservative Rx for pancreatitis

HIDA scan to diagnose acute cholecystitis if USS is non-diagnostic  complications: pleural effusion, ileus, ARDS, pancreatic pseudocyst/abscess/necrosis, ARF --------------------------------------------------------------- HIV a/w fever, malabsorptive diarrhea, weight loss: Mycobacterium avium-intracellulare  PAS-positive macrophage & acid-fast --------------------------------------------------------------- intussusception: ileocecal junction is MC  preceding viral infection (gastroenteritis) inflames intestinal lymphatic tissue (Peyer patches) can serve as a lead point  risk factors: Meckel’s, polyps, rotavirus vaccine, hematomas (Henoch-Schonlein purpura)  periodic abdominal pain with drawing up the legs  emesis may follow episodes of abdominal pain  ongoing obstruction causes mucosal ischemia, leading to “currant jelly” stools  RUQ “sausage-shaped” mass  Dx: abdominal USS shows “target sign”  Rx: air enema (or water-soluble contrast)  complications: bowel necrosis --------------------------------------------------------------- hypercalcemia of malignancy: 80% due to PTHrP production  breast cancer MC 2/2 locally produced PTHrP via bone metastasis  metastatic tumor cells do not directly cause bone resorption, but secrete factors that activate osteoclasts  ectopic PTH is a rare cause --------------------------------------------------------------- Technetium-99m scan can detect gastric mucosa in Meckel’s diverticulum --------------------------------------------------------------- COPD have increased TLC, FRC, & RV leading to hyperinflation & diaphragmatic flattening, thus increases work of breathing  lung hyperinflation preserves max expiratory airflow as higher lung volume increases elastic recoil pressure, thus more difficult to decrease intrathoracic pressure during inhalation  Rx: lung volume reduction surgery ---------------------------------------------------------------

Schizoaffective disorder: significant manic episodes with concurrent psychotic symptoms & at least 2 weeks without mood symptoms  delusions/hallucinations ≥ 2 wks in absence of major mood episode (depressive or manic)  mood symptoms present for majority of illness  DDx o bipolar disorder or major depression with psychotic features: psychotic symptoms occur only during mood episodes o schizophrenia: absence of mood symptoms --------------------------------------------------------------- schizophreniform: > 1 month, but < 6 months  schizophrenia: > 6 months --------------------------------------------------------------- maculopapular eruption on wrists & ankles, spreads to trunk, extremities, palms & soles on day 5: rickettsial infection  fever, conjunctivitis, headache, diffuse myalgias --------------------------------------------------------------- erythema, edema, severe pruritus, vesicles & weepy crusted lesions 24 – 48 hr after contact with an allergen: contact dermatitis  cell-mediated hypersensitivity (Type IV)  involves T-cell activation  due to allergic reaction or chemical irritant  requires sensitization before a reaction develops  antigen is presented to sensitized lymphocytes, which release cytokines within 24 – 48 hr  Rx: topical glucocorticoids  also seen in PPD skin test, SJS/TEN --------------------------------------------------------------- Type I hypersensitivity: IgE- mediated; allergen binds & cross-links IgE molecules on a mast cell releases vasoactive substances  causes mast cell & basophil degranulation  atopy, urticaria, anaphylaxis --------------------------------------------------------------- Type II hypersensitivity: antibody-mediated; cytotoxic reaction of IgG or IgM to cell antigens  leads to complement activation & cell damage  Rh hemolytic anemia of newborns ---------------------------------------------------------------

Type III hypersensitivity: immune-complex mediated; antibodies of IgG or IgM form complexes with antigens to activate complement  Serum sickness, Arthus reaction, drug fever --------------------------------------------------------------- prodrome fever & influenza-like symptoms, conjunctivitis, mucositis, mucocutaneous lesions, erythematous & pruritic macules, desquamation & bullae progressing to epidermal necrosis & sloughing, +Nikolsky sign: SJS  inflammatory hypersensitivity reaction  < 10% of body surface area = SJS  > 30% = Toxic epidermal necrolysis (TEN)  triggers: allopurinol, sulfonamides, lamotrigine, phenytoin, carbamazepine, NSAIDs, sulfadiazine, Mycoplasma pneumo, vaccination, GVHD  Rx: supportive, wound care, IV fluids --------------------------------------------------------------- asymmetric tingling & burning of the hand a/w vesicular rash: herpetic whitlow  inoculation of HSV 1 or 2 by direct contact with orotracheal secretions via broken skin  non-purulent vesicles on volar hand  Dx: Hx of exposure & multinucleated giant cells on Tzank smear  Rx: self-limited; oral acyclovir --------------------------------------------------------------- cutaneous flushing & intense generalized pruritus: A/E of high-dose niacin therapy for hypertriglyceridemia  prostaglandin-induced peripheral vasodilatation  Rx: prevented with low-dose ASA, taken 30 min prior to niacin --------------------------------------------------------------- painless chancres that resolves in 3 – 6 wks: primary syphilis o recurs weeks/months later as 20 syphilis  fever, malaise, sore throat, lymphadenopathy, diffuse maculoopapular rash on the trunk that spread peripherally to extremities + palms & soles, condyloma lata: secondary syphilis  Rx: IM benzathine penicillin o A/E: Jarisch-Herxheimer reaction (acute febrile reaction with headache & myalgias)  non-prego, PCN-allergic: doxycycline x14 days 

Rx pregos: PCN o PCN-allergic should confirm with skin testing, then undergo PCN desensitization  DDx: cutaneous drug reaction. pityriasis rosea, psoriasis, rickettsial infection --------------------------------------------------------------- black stool, epigastric pain, nausea, pain relieved with food, weight gain: PUD  MCC: H. pylori or NSAIDs  duodenal ulcer symptoms occur in absence of food buffers (2 -5 hr after meals, nighttime)  PUD is MCC of melena  Dx: upper endoscopy  DDx: gastric cancer, colon cancer, diverticulosis, inflammatory bowel disease, ischemic colitis, mesenteric ischemia --------------------------------------------------------------- ischemic colitis: inflammation & injury of the colon result from inadequate blood supply  a/w procedures on aortoiliac vessels  MC @ splenic flexure  abdominal pain, fever, vomiting; followed by hematochezia or bloody diarrhea within 24 hr  risk factor: atherosclerosis  Dx: colonoscopy or flexible sigmoidoscopy --------------------------------------------------------------- mesenteric ischemia: injury of small intestine occurs due to inadequate blood supply  abdominal pain out of proportion to relatively normal physical exam  pain exacerbated by eating, bloody diarrhea, food aversion, weight loss  risk factors: atherosclerosis, a-fib, heart failure, CRF, risk of forming blood clots, previous MI  Dx: angiography --------------------------------------------------------------- megaloblastic (impaired DNA synthesis due to B12 or folate deficiency) vs. nonmegaloblastic (alcoholism, hypothyroidism, liver disease) macrocytic anemia o  MCV & MCH, normal MCHC  megaloblastic: MCV > 110, low reticulocytes, macroovalocytes, hypersegmented neutrophils, anisiocytosis, poikilocytosis  nonmegaloblastic: reticulocyte count varies 

alcoholism can also cause basophilic stippling; nonspecific to lead poisoning & Thalassemias --------------------------------------------------------------- all patients with hypotension/shock after MVA should be presumed to have hypovolemic shock   PCWP at baseline & increases after saline infusion without systolic BP change: myocardial contusion o LV dysfunction results in  filling pressures  Dx: urgent echocardiogram --------------------------------------------------------------- anaphylaxis: a type of distributive/vasodilatory shock due to severely decreased SVR o /normal PCWP, improves with fluids  hypovolemic shock:  C.O.,  SVR o  PCWP at baseline, improves with fluids --------------------------------------------------------------- tension pneumothorax after MVA can present with hypotension & shock due to extracardiac compression of the right/left ventricle  PCWP is /normal, only slight change with fluids --------------------------------------------------------------- massive PE after MVA (air/fat embolism) can lead to hypotension & shock  PCWP is /normal; minimal change with fluids ---------------------------------------------------------------Gross painless hematuria  initial test: U/A to rule out UTI & confirm microhematuria  bladder tumors are MC malignancy a/w painless hematuria in age > 35 & smoking Hx o Dx: CT urogram & cystoscopy  DDx: neoplasms, infection, trauma, ADPKD, nephrolithiasis, glomerulonephritis, BPH --------------------------------------------------------------- obesity is a common cause of amenorrhea secondary to anovulation  anovulation: FSH/LH are normal, ovaries are producing estrogen, but progesterone is not produced at normal post-ovulation levels, thus progesterone withdrawal menses does not occur --------------------------------------------------------------- premature ovarian failure:  FSH > LH; age < 40 ---------------------------------------------------------------Pulmonary auscultation findings

Auscultation



Consolid ation (lobar) Pleural effusion COPD PnmTX

TVF Percussn Mdstinum  dull none bronchial breath sounds ( expiratory) crackles, egophony ( sound transmission), bronchophony, whisper pectoriloquy  breath  dull away from sounds effusion (large)  breath  hyperres none onant sounds  breath  hyperres away onant (tension) sounds

sound travels faster in solids (consolidation), resulting in increased TVF in lobar pneumonia  consolidation presents with bronchial breath sounds, airway patency causes over-transmission of sound  consolidation does not cause blunting of the costophrenic angles --------------------------------------------------------------- Torsades de pointes due to prolonged QT  Rx: Mg++ sulfate --------------------------------------------------------------- CNS, cardiac, & anticholinergic abnormalities  altered mental status, hypotension, hyperthermia, miosis, urinary retention,: TCA overdose  decreases myocardial conduction velocity, leads to prolonged QRS & risk of ventricular arrhythmia  Rx: ABCs, supplemental O2, IV fluids  activated charcoal if within 2 hr of ingestion  Rx: sodium bicarbonate improves systolic BP, shortens QRS, & prevents arrhythmias  QRS > 100 msec is an indication for NaHCO3  Rx: benzos for seizures 2/2 GABA Rc inhibition --------------------------------------------------------------- intrauterine fetal death < 20 wk gestation; retained products of conception, non-viable: missed o closed cervix; Dx: transvaginal USS  any hemorrhage before 20th week of gestation with active fetal heart tones: threatened abortion o closed cervix, no passage of fetal tissue  vaginal discharge of blood/tissue, abdo cramps, partial expulsion: incomplete abortion o dilated cervix; retain conception products 

vaginal bleeding, abdo cramps radiates to the back & perineum, dilated cervix: inevitable abortion o ruptured/collapsed gestational sac o no fetal cardiac motion on USS  acute onset abdo pain, dark red vaginal bleed in the 1st trimester, adnexal mass: ectopic pregnancy o no gestational sac in uterus on USS  fever, malaise, foul-vaginal discharge, uterine & cervical motion tenderness: septic abortion o infection of retained products of conception o MC with induced abortions  Rx: suction curettage, IV fluids, IV ABX o Rx: hysterectomy for severe cases  1st trimester vaginal hemorrhage a/w expulsion of vesicles, N/V, enlarged uterus: molar prego o  β-hCG, no fetal heart tones --------------------------------------------------------------- Rx threatened abortion o ascertain fetus is present & alive with USS o reassurance & F/U USS in one week  no hospitalization required --------------------------------------------------------------- hyperkalemia: peaked T-wave, followed by PR & QRS lengthening; eventually bradycardia & “sine wave” pattern  Rx: calcium gluconate (rapid, but transient) --------------------------------------------------------------- smoking cessation has the greatest impact on decreasing risk of pancreatic cancer  hereditary risk factors: hereditary pancreatitis, pancreatic cancer in 1st degree relative, germline mutation (BRCA 1/2, Peutz-Jegher)  environmental: obesity, low physical activity, chronic pancreatitis  alcohol or caffeine reduction, & glycemic control do not significantly  incidence of pancreatic ca ---------------------------------------------------------------Causes of neonatal bacterial sepsis Group B Strep, MC of early- & late-onset sepsis E. coli (preterm MC due to E.coli) S. aureus skin, bone, or joint infections Listeria early-onset sepsis during outbreaks Enterococcus preterm infants Coagulaseindwelling umbilical venous catheters 

negative Staph in neonatal ICU (S. epidermidis) other Gram(Klebsiella, Enterobacter, Pseudomonas) negatives late-onset sepsis, ICU hypotonia, full/bulging fontanelles, nuchal rigidity, seizures: bacterial meningitis  poor feeding, lethargy, hyper- or hypothermia, respiratory distress, vomiting, jaundice: sepsis  neonatal sepsis: infants < 28 days old o early-onset: age < 3 – 7 days  preterm infants: more likely hypothermic  MC infection during passage through birth canal  Dx: CBC, blood cultures PRIOR to ABX (ampicillin + gentamicin) without waiting for LP  neutrophilia with significant left shift indicates neonatal sepsis from bacterial infection  neonates have low risk of herniation after LP due to their open fontanelles; head CT not required --------------------------------------------------------------- Group B Strep: MC neonatal infection acquired by exposure to amniotic fluid after ROM  screening: 3 -5 wks prior to estimated delivery (@ 35 – 37 wks); vagina & rectum cultures  GBS negative status do not need prophylaxis for prolonged ROM > 18 hr  ABX prophylaxis in labor without testing if… o Hx of GBS bacteriuria o GBS UTI o prior birth to infant with GBS  missed screening or unknown GBS status is treated in labor if… o < 37 wks gestation o intrapartum fever o ROM > 18 hr  Rx: PCN (prophylaxis 4 hr prior to delivery) --------------------------------------------------------------- neonatal HSV encephalitis presents with seizures; acquired from infected genital tract --------------------------------------------------------------- fever, headache, stiff neck nausea, hypotension: meningococcal meningitis  MC in age 3 yr to adolescence; high contagious  myalgia is common 

petechial or purpuric rash within 24 hrs on the axilla, wrists, flanks, ankles  Rx: isolation, IV ABX, ICU setting --------------------------------------------------------------- jaundice, maculopapular rash, microcephaly, chorioretinitis, hepatosplenomegaly, hydrocephalus, intracranial calcifications: congenital toxoplasmosis  maternal infection by feces of infected cats, ingest infected raw meat, or unpasteurized goat’s milk --------------------------------------------------------------- midshaft humerus fracture is a/w radial nerve, passes via radial groove on the posterior humerus o a/w wrist drop  supracondylar fracture is a/w brachial artery o ischemia (pain, pallor, pulselessness, paresthesia, paralysis) --------------------------------------------------------------- winged scapula: injury of long thoracic nerve results in paralysis of serratus anterior muscle  MC after axillary lymphadenectomy for breast ca --------------------------------------------------------------- hypotension, hyperpigmentation, hyponatremia, hyperkalemia, eosinophilia, low serum cortisol, elevated ACTH: primary adrenal insufficiency  MC developed countries: autoimmune adrenalitis  infectious causes: CMV, fungal, TB  a/w autoimmune dz (vitiligo, pernicious anemia) --------------------------------------------------------------- patients on warfarin can have adrenal hemorrhage from acute stress (sepsis), even if INR is therapeutic  stress increases ACTH levels, which increase adrenal blood flow, predisposing to hemorrhage --------------------------------------------------------------- B/L, lower-extremity pain, occur only at night, age 2 – 12 yrs: growing pains  monitor pain for increased frequency/intensity  Rx: observation, reassurance, massage, heat, stretching, OTC analgesics  DDx: osteoid osteoma, osteosarcoma, osteomyelitis --------------------------------------------------------------- sclerotic, cortical lesion with a central nidus of lucency: osteoid osteoma  pain worse at night, unrelated to activity  benign, bone-forming tumor  MC in adolescent males 

Rx: NSAIDS (suggestive of Dx); spontaneous resolution over several years --------------------------------------------------------------- changing the cutoff point of a quantitative diagnostic test inversely affects sensitivity & specificity  lower the cutoff INCREASES sensitivity & decreases specificity (more true positives)  raising the cutoff DECREASES sensitivity & increases specificity (more true negatives) --------------------------------------------------------------- recurrent sinopulmonary infections, persistent diarrhea, oral candidiasis, viral infections: SCID  adenosine deaminase (ADA) deficiency  Dx: absent lymph nodes & tonsils, lymphopenia, absent thymic shadow on CXR, abnormal T, B, & natural killer cell count by flow cytometry --------------------------------------------------------------- Bruton’s (X-linked) agammablobulinemia: male infant, asymptomatic until age 6 – 9 months; recurrent pyogenic infections (S. pneumo, H.infl) o decreased IgG, IgA, IgM, IgE, & absent/decreased B cells o sinusitis, bronchitis, otitis media, Giardia  CVID presents similar to Bruton’s, but CVID has less severe symptoms & later onset (age 15 – 35 yrs) o normal circulating B cells o decreased IgG, IgA, IgM, IgE --------------------------------------------------------------- thrombocytopenia, eczema, recurrent infections: Wiskott-Aldrich (“WAITER”)  XR, defective WASP gene  young boy with eczema, thrombocytopenia, recurrent encapsulated spp infections o Strep pneumo, N. meningitidis, H. influenza  @ birth: petechiae, bleeding from circumcision, bruises, bloody stools   PLT production, small PLTs  low IgM, high IgA & IgE --------------------------------------------------------------- Chronic granulomatous disease (CGD): defective phagocytes due to NADPH oxidase dysfunction  impaired oxidative metabolism within phagocytes; defective intracellular killing 

recurrent catalase-positive infections (S. aureus)  lymphadenitis, skin abscesses  Gram stain: neutrophils filled with bacteria  Dx: nitro blue tetrazolium test --------------------------------------------------------------- Chediak-Higashi:  chemotaxis, degranulation, & granulopoiesis  mild coagulopathy, pancytopenia  partial albinism, peripheral & cranial neuropathy, hepatosplenomegaly, infections (S. aureus), progressive lymphoproliferative syndrome  Dx: neutropenia, giant lysosomes in neutrophils  Rx: daily TMP-SMX & ascorbic acid --------------------------------------------------------------- Leukocyte adhesion defect (LAD): failure of innate host defenses due to defective tethering, adhesion, & targeting of myeloid leukocytes to sites of microbial infection o absence of neutrophils/pus at infection sites  recurrent bacterial infections of skin & mucosal surfaces, necrotic periodontitis, gingivitis, delayed umbilical cord separation (> 30 days)  early loss of deciduous & permanent teeth  leukocytosis with neutrophil predominance  cultures: S. aureus, G-negative bacilli --------------------------------------------------------------- increased gastric residual volume, vomiting, & abdominal distension in a preterm neonate: necrotizing enterocolitis (NEC)  risk factors: prematurity, very low birth weight  gut immaturity & exposure to bacterial from enteral feeds result in inflammation & damage to bowel wall  XR: pneumatosis intestinalis (intramural air with “train tracks”) & air in portal vein  leukocytosis, metabolic acidosis  Rx: decreased rates of NEC in premature infants who are breastfed  complications: pneumoperitoneum  DDx: duodenal atresia, pyloric stenosis, Hirschsprung ---------------------------------------------------------------DDx of delayed passage of meconium (within 48 hrs) level of meconium 

obstruction consistency Hirschsprung rectosigmoid normal meconium ileus ileum inspissated  meconium ileus results in microcolon  Dx: contrast enema --------------------------------------------------------------- Hirschsprung disease should be suspected in a newborn with failure to pass meconium within 48 hr, in the setting of Down syndrome  poor feeding, abdo distension, absent air in rectum  failure of neural crest cell migration in the rectosigmoid; positive “squirt sign” on exam  Dx: rectal biopsy show absence of ganglion cells --------------------------------------------------------------- C3 deficiency predisposes to encapsulated bacteria  C5 – C7 deficiency: recurrent Neisseria infections  C1 esterase deficiency: hereditary angioedema --------------------------------------------------------------- anticholinesterase toxicity due to organophosphate poisoning  bradycardia, miosis, salivation  Rx: atropine & pralidoxime --------------------------------------------------------------- hazard ratio: ratio of an event rate occurring in treatment vs. control group  ratio < 1 = treatment group has lower event rate  ratio > 1 = treatment group has higher event rate --------------------------------------------------------------- asymptomatic bacteriuria of pregnancy is treated with ABX to prevent pyelonephritis, preterm birth, low birth weight, perinatal mortality  risk of pyelonephritis is due to  progesterone causing smooth muscle relaxation, thus ureteral dilation  screen all pregos @ 12 – 16 wks gestation  Rx: amoxicillin, nitrofurantoin, cephalexin are safe  C/I: tetracycline, fluoroquinolones, TMP-SMX (interferes with folate metabolism in 1st trimester, & risk of kernicterus in 3rd trimester) --------------------------------------------------------------- strongest indicator for future suicide attempt: Hx of previous attempt(s) --------------------------------------------------------------- β-blocker A/E: worsening of CHF, bradyarrhythmia,  airway resistance (asthma), sexual dysfunction

--------------------------------------------------------------- loop diuretics can cause hearing loss &/or tinnitus  ototoxicity occur with high doses, renal failure, or combo with other ototoxic drugs (aminoglycosides) --------------------------------------------------------------- HCTZ/thiazides can cause photosensitivity, orthostatic hypotension, hypercalcemia --------------------------------------------------------------- HTN & hypokalemia: 10 hyperaldosteronism  prone to diuretic-induced hypokalemia, resulting in weakness & muscle cramps  also metabolic alkalosis, mild hypernatremia  no peripheral edema due to spontaneous diuresis (aldosterone escape)  screening: morning aldosterone:renin ratio o ratio > 20, with aldosterone > 15 ng/dL suggests primary hyperaldosteronism  confirm Dx: adrenal suppression testing after oral saline load  positive result requires adrenal CT  MCC: unilateral adenoma or B/L hyperplasia  Dx: CT scan to confirm unilateral mass; equivocal results require adrenal venous sampling  U/L adenoma Rx: surgery (#1) or aldosterone antagonist (spironolactone, eplerenone)  B/L hyperplasia Rx: aldosterone antagonists --------------------------------------------------------------- spironolactone: aldosterone/progesterone/androgen Rc antagonist  A/E:  libido, gynecomastia, breast tenderness, menstrual irregularities  eplerenone: selective mineralocorticoid antagonist --------------------------------------------------------------- dehydration is a risk factor for venous thrombosis due to hemoconcentration  sudden pleuritic chest pain, cough, dyspnea, hemoptysis: PE  also tachycardia, tachypnea, & hypoxemia  chest CT: wedge shaped infarction  contrast-enhanced CT: filling defects  CXR: “Hampton’s hump”, “Westermark” sign  causes transudative & exudative pleural effusion  DDx: TB, PCP, bacterial pneumonia, lung cancer ----------------------------------------------------------------

older patient with rapidly progressive dementia, myoclonus, akinetic mutism, behavior changes: Creutzfeldt-Jakob disease (CJD)  triphasic sharp wave complexes on EEG, &/or 14-3-3 CSF proteins  Dx: brain biopsy show spongiform changes  Rx: supportive; death within one year of onset  DDx: ALS, Lewy body dementia, Alzheimer’s, NPH, peudodementia --------------------------------------------------------------- scheduled cholecystectomy is indicated for all symptomatic gallstones (acute pancreatitis), once medically stable due to  risk of recurrent episodes  Rx poor surgical candidate: ursodeoxycholic acid  asymptomatic gallstones should not be treated, except morbidly obese undergoing gastric bypass or presence of porcelain GB --------------------------------------------------------------- genital HSV eruptions: painful vesicles on an erythematous base that evolve to shallow, “punched-out” ulcerations/erosions  Hx of genital HSV: Rx prophylactic acyclovir or valacyclovir @ 36 wks to  risk of outbreak during delivery  neonatal HSV risk factors: maternal infection, vaginal delivery with active lesions  Rx: c-section for pregos with active genital lesions or prodromal symptoms (burning, pain)  vaginal delivery only in absence of active lesions --------------------------------------------------------------- burning, localized pain & regional hyperesthesia or allodynia, in the context of recent cancer therapy: herpes zoster (shingles)  pain may precede rash by several days --------------------------------------------------------------- acute arthritis of right knee, fatigue, constipation, polyuria: pseudogout  hyperparathyroidism predisposes to pseudogout  acute formation of calcium pyrophosphate dehydrate (CPPD) crystals, leading to chondrocalcinosis (calcified articular cartilage)  attacks are precipitated by trauma, surgery, illness  Dx: synovial fluid (rhomboid-shaped positively birefringent crystals)  DDx: gout, septic arthritis 

--------------------------------------------------------------- hydroxyapatite: osteoarthritis  monosodium urate: gout  calcium oxalate: renal calculi  struvite: renal calculi; UTI of urease spp (Proteus) --------------------------------------------------------------- osteoarthritis: non-inflammatory arthritis  age > 50, morning stiffness < 30 min  decreased ROM, stiffness after prolonged rest; anterior hip pain exacerbated by walking  crepitus, no TTP, no warmth of joint  bony enlargement; Heberden & Bouchard nodes  XR: joint space narrowing, osteophytes, subchondral sclerosis & subchondral cysts  Rx: weight loss slows OA progression --------------------------------------------------------------- Rx mild/moderate OA pain: acetaminophen  Rx OA exacerbation: NSAID, intra-articular steroid  Rx OA refractory to NSAID & intra-articular steroid: colchicine --------------------------------------------------------------- recurrent hemarthrosis & skeletal muscle hemorrhage after mild trauma: hemophilia A & B  menorrhagia & mucosal bleeding is common in women with von Willebrand disease (AD) --------------------------------------------------------------- MCC of nephrotic syndrome in children age < 10: minimal change disease  periorbital edema in the AM, pretibial pitting, nephrotic range proteinuria, hypoalbuminemia  T-cell mediated injury to podocytes cause increased permeability to albumin  renal biopsy not required for Dx  Rx: empiric steroids upon suspicion of Dx o 90% have complete remission of proteinuria  renal biopsy indicated in age > 10, or if unresponsive to steroid Rx; exclude other causes --------------------------------------------------------------- bradycardia, miosis, rhonchi, fasciculations, salivation, lacrimation, urination, defecation: organophosphate poisoning  Rx: removal of clothing & washing of the skin prevents transcutaneous absorption  Rx: atropine & pralidoxime

--------------------------------------------------------------- TCA overdose Rx: sodium bicarbonate & EKG --------------------------------------------------------------- bicuspid aortic valve, aortic coarctation, & aortic root dilation; risk of aortic dissection: Turner’s  ovarian dysgenesis; low estrogen & amenorrhea results in a high FSH/LH & low inhibin  normal GH levels ---------------------------------------------------------------Social anxiety disorder (social phobia)  anxiety about ≥ 1 social situations, > 6 months  fear of scrutiny, humiliation, embarrassment  marked functional impairment generalized social anxiety disorder o Rx: SSRI (paroxetine) & CBT  performance-only social anxiety disorder o Rx: propranolol 30 - 60 minutes prior & CBT o alt: benzodiazepine (avoid if substance abuse)  Buspiron: Rx GAD only, not social anxiety --------------------------------------------------------------- ischemic cardiac pain can be mistaken for epigastric pain  SLE & chronic steroid use are risk factors for accelerated coronary atherosclerosis  exercise stress test without imaging if baseline EKG is normal o positive stress test  coronary angiography --------------------------------------------------------------- acute exacerbation of MS Rx: methylprednisone (high-dose IV corticosteroid)  long-term steroid therapy provides no benefit & does not prevent future relapses  long-term Rx: beta-interferon can decrease frequency of acute exacerbations & relapses o also glatiramer acetate, IV Ig, cyclophosphamide, or plasmapheresis --------------------------------------------------------------- MCC of constrictive pericarditis in developing countries: TB  MCC in the US: viral pericarditis  pericardial scarring & thickening results in diastolic dysfunction; pericardial calcifications  decreased cardiac output & venous overload 

pericardial knock, pulsus paradoxus, Kussmaul sign, prominent x & y descents --------------------------------------------------------------- CXR: parenchymal nodules (silicosis)  CXR: pleural plaques (asbestosis) --------------------------------------------------------------- hard, irregular, fixed breast mass: malignancy  rubbery, firm, freely mobile mass: fibroadenoma  Hx of 1st-degree relative with breast cancer requires diagnostic (vs. screening) breast imaging  palpable breast mass age < 30: USS  palpable mass age > 30: mammogram, then USS  simple cyst Rx: needle aspiration  complex cyst/solid mass: image-guided core Bx  suspicious malignancy: core needle biopsy --------------------------------------------------------------- both folate & Vit B12 are involved in conversion of homocysteine  methionine, thus a deficiency in either results in  homocysteine levels  Vit B12 is involved in conversion of methylmalonyl-CoA  succinyl-CoA  Vit B12 deficiency results in methylmalonic acid --------------------------------------------------------------- haptoglobin binds free Hb to form Hb-haptoglobin complexes removed by the liver   haptoglobin in hemolytic anemias --------------------------------------------------------------- alpha-fetoprotein is elevated in HCC & testicular germ cell tumors --------------------------------------------------------------- low-grade fever & leukocytosis are common during the first 24 hr postpartum  intrapartum & postpartum chills are common  lochia rubra (bloody discharge) is characteristic postpartum; after 3 – 4 days  lochia serosa (pale)  lochia alba (white/yellow)  foul-smelling lochia suggests endometritis  fever & elevated WBCs beyond 24 – 48 hr requires UTI work-up: U/A, blood cultures --------------------------------------------------------------- blunt deceleration trauma (MVA, fall from > 10 ft), must rule out blunt aortic injury  high mortality rate  Dx: CXR  widened mediastinum 

 DDx: myocardial contusion (tachycardia) --------------------------------------------------------------- ipsilateral ataxia, nystagmus, intention tremor, loss of coordination: cerebellar tumor  patient falls/sway TOWARD the lesion side --------------------------------------------------------------- age > 40, personality change, dementia, chorea: Huntington’s  wide-based gait, steppage gait: Tabes dorsalis  affected arm adducted, affected leg extended; leg is swung out in a semicircle: hemiparesis/stroke  waddling gait: muscular dystrophy --------------------------------------------------------------- risk factor for cervical insufficiency: Hx of maternal OB trauma, prior GYN surgery (LEEP, cone Bx), multiple gestation, Hx preterm birth, or 2nd trimester abortion o Dx: transvaginal USS  risk factors for placental abruption: chronic HTN, smoking, cocaine use, Hx of maternal trauma, Hx of external cephalic version  risk factors for uterine rupture: multiparity, Hx of c-section or myomectomy, adv maternal age, fetal macrosomia --------------------------------------------------------------- abdo pain that refers to one or both shoulders suggests subdiaphragmatic peritonitis due to irritation of subdiaphragmatic parietal peritoneum  blunt traumatic bladder injuries, bladder dome is the only region covered by peritoneum, most susceptible to rupture  MC site of extraperitoneal bladder rupture: bladder neck --------------------------------------------------------------- unfractionated heparin is preferred over enoxaparin (LMWH), fondaparinux, & rivaroxaban for severe renal insufficiency  reduced renal clearance  anti-Xa levels, thus  bleeding risk  monitor unfractionated heparin with aPTT  once therapeutic, initiate warfarin o warfarin takes 5 – 7 days to be therapeutic; must bridge with heparin ----------------------------------------------------------------

Rivaroxaban has immediate onset of action, does not require bridging with heparin; but no antidote --------------------------------------------------------------- upper GI bleeding, depressed consciousness level, & ongoing hematemesis due to esophageal variceal hemorrhage should first be intubated  Rx: endoscopic band ligation or sclerotherapy after patient is stabilized & intubated ---------------------------------------------------------------Acute intoxication Marijuana  appetite, dry mouth, conjunctival injection, tachycardia, slow reaction time, euphoria/dysphoria/paranoia, psychomotor impairment (days) gynecomastia (chronic use) phencyclidin violent behavior, impulsivity, e hallucinations, amnesia, P dissociation, vertical C nystagmus, P mydriasis, ataxia LSD visual hallucinations, mydriasis, euphoria/dysphoria/panic, perceptual intensification, tachycardia/palpitations/HTN, Cocaine euphoria, agitation, formication (“cocaine bugs”) chest pain, stroke, MI, seizures tachycardia, HTN, mydriasis Meth violent behavior, tooth decay diaphoresis, tachycardia, HTN, choreiform movements, psychosis Heroin euphoria, miosis, (opioid) respiratory depression, depressed mental state, constipation, hypotension, hypothermia, & bradycardia amphetamin agitation, paranoia, delirium, e palpitations, tachycardia, HTN, diaphoresis, mydriasis, seizures, hyperthermia, intracerebral hemorrhage Alcohol slurred speech, unsteady gait, disinhibition, nystagmus 

esophageal perforation MC occurs following instrumentation of the esophagus o less commonly due to Boerhaave’s  retrosternal pain & crepitus @ suprasternal notch due to pneumomediastinum  DDx: Mallory-Weiss (self-limited hematemesis) --------------------------------------------------------------- cat bites: prophylactic augmentin for 5 days  Pasteurella multocida --------------------------------------------------------------- fluoroquinolones is a/w tendon rupture in children --------------------------------------------------------------- large thymic silhouette in the anterior mediastinum is a normal finding on CXR in age < 3 yrs  triangular shape, “sail sign”, scalloped border  residual thymic tissue can undergo malignant transformation into a thymoma  DDx: lymphoma --------------------------------------------------------------- home O2 therapy & smoking cessation have been shown to decrease mortality in COPD --------------------------------------------------------------- hyperpigmentation of palmar creases, anorexia, fatigue, GI complains, weight loss, hypotension: primary adrenal insufficiency (Addison’s)  hyponatremia, hyperkalemia  hyponatremia is due to volume contraction (aldosterone deficiency) & increased vasopressin (lack of cortisol suppression)  mild hyperchloremic acidosis --------------------------------------------------------------- hypernatremia, hypokalemia: Cushing’s --------------------------------------------------------------- Wolff-Parkinson-White: accessory pathway that bypasses AV node; atrioventricular reentrant tachycardia (AVRT)  persistent a-fib with rapid ventricular response can deteriorate to v-fib  Rx hemodynamically unstable: cardioversion  Rx hemodynamically stable: procainamide  AV nodal blockers (adenosine, β-blocker, CCB, digoxin) can  accessory pathway conduction, thus worsen WPW ---------------------------------------------------------------

best predictor of opioid intoxication:  RR Rx of severe psychomotor agitation a/w PCP intoxication: benzo --------------------------------------------------------------- cocaine withdrawal: dysphoria,  appetite, hypersomnia, difficulty concentrating  opioid withdrawal: yawning, mydriasis, lacrimation, rhinorrhea, diaphoresis, N/V, diarrhea, arthralgia, muscle spasms --------------------------------------------------------------- recurrent fractures, hearing loss, opalescent teeth, blue sclerae: osteogenesis imperfecta (AD)  normal intelligence, osteopenia --------------------------------------------------------------- pain, followed by well-demarcated lesions & bullae with skin necrosis: warfarin-induced necrosis  MC @ breasts, buttocks, thighs, abdomen  a/w protein C deficiency  Rx: vitamin K; discontinue warfarin if lesions progress, maintain anticoagulation with heparin --------------------------------------------------------------- worsening renal function, HTN, & distal ischemia following an invasive arterial procedure: cholesterol embolization  livedo reticularis on skin exam --------------------------------------------------------------- plantar warts are due to HPV infection  painful hyperkeratotic papules on the soles  common in young adults & immunocompromised --------------------------------------------------------------- scaly, erythematous, ulcerated skin lesion that is slow-growing, non-resolving with irregular growth on sun-exposed area: squamous cell ca --------------------------------------------------------------- suspected appendicitis with delayed presentation (> 5 days) after onset of symptoms: appendiceal abscess (contained, perforated abscess = phlegmon)  Dx: CT scan  if stable, Rx: hydration & IV ABX, bowel rest, elective appendectomy --------------------------------------------------------------- anemia, constipation, weight loss: colon cancer  fever, dysuria, flank pain: pyelonephritis --------------------------------------------------------------- 

AV nodal reentry tachycardia (AVNRT) 2 separate conducting pathways (slow/fast) within AV node  sudden onset & termination, absent P, narrow QRS --------------------------------------------------------------- abrupt onset of sharply-demarcated, edematous, erythematous, tender skin lesion with raised border, & fever: erysipelas  inflammation of superficial dermis  legs most common, or face  MCC: Group A strep --------------------------------------------------------------- Todd’s paralysis: focal neurologic deficit following a seizure --------------------------------------------------------------- muscle weakness & dry mouth: Lambert-Eaton  a/w lung small cell carcinoma & Hodgkin’s  antibodies against presynaptic voltage-gated Ca++ channels in motor nerves  muscle response to motor nerve stimulation increases with repetitive stimulation  diminished/absent DTRs  Rx: plasmapheresis & immunosuppressants --------------------------------------------------------------- Myasthenia crisis can be exacerbated by RTI  diplopia, ptosis, proximal muscle weakness, & weakness of bulbar muscles & diaphragm can lead to respiratory distress  Rx MG with respiratory failure: intubation, then corticosteroids + IV Ig or plasmapheresis (preferred) --------------------------------------------------------------- Myasthenic crisis: exacerbation of symptoms due to undermedication of AChE-ases or infection  Rx: withhold AChE-ase inhibitors (pyridostigmine), remove respiratory secretions  Cholinergic crisis: exacerbation of symptoms due to overmedication with AChE-ases  Rx: atropine (anticholinergic, prevents A/E of AChE inhibitor therapy)  Dx: edrophonium (Tensilon) test (short-acting AChE-inhibitor) o myasthenic crisis  improves muscle strength o MG cholinergic crisis  worsens weakness --------------------------------------------------------------- polyuria & polydipsia are classic for new-onset Type I DM 

bimodal onset: age 4 – 6 yrs or early puberty nocturnal enuresis can be a presenting symptom in toddlers  DDx: UTI, maturational delay of sphincter, psychological stress, nephrogenic DI --------------------------------------------------------------- enuresis: urinary incontinence in age ≥ 5 yrs  primary enuresis: never achieved dryness  secondary enuresis: return of incontinence after ≥ 6 months of dryness --------------------------------------------------------------- immune-mediated muscle inflammation: polymyositis  multicentric CNS inflammation & demyelination: MS --------------------------------------------------------------- infertility: inability to conceive for > 1 yr  infertility for women age > 35: > 6 months o MCC of fertility in the 4th decade who are menstruating: age-related decreased ovarian reserve  Dx: early follicular phase FSH level, clomiphene challenge test, or inhibin-B level  DDx: premature ovarian failure (amenorrhea & menopause before age 40) --------------------------------------------------------------- rapid & massive increase in transaminases with modest elevations in total bilirubin & ALP in the setting of hypotension (septic shock, heart failure): ischemic hepatic injury  DDx: alcoholic liver disease (AST rarely >300), acute hepatitis (significant hyperbilirubinemia), TB, sarcoidosis, acalculous cholecystitis, autoimmune hepatitis (elevated bilirubin) --------------------------------------------------------------- if suspicion for subarachnoid hemorrhage is high, but head CT is negative  lumbar puncture --------------------------------------------------------------- sudden & unexpected travel, confusion about personal identity, inability to remember the past: dissociative fugue  episodes of inability to recall important personal info; related to a traumatic or stressful event: dissociative amnesia  

two or more distinct identities that alternatively assume control behavior: dissociative identity disorder (multiple personality disorder)  persistent/recurrent feelings of detachment from one’s own physical or mental processes, with intact sense of reality; significant impairment: depersonalization disorder  experiencing familiar persons & surroundings as if strange or unreal: derealization disorder --------------------------------------------------------------- proximal DVT of lower extremities; MCC of PE o continue warfarin for 3 months for patients with reversible risk factors o continue warfarin for 6 – 12 months for idiopathic DVT --------------------------------------------------------------- glucose-6-phosphatase deficiency (Von-Gierkes’): Type I glycogen storage disease  affects liver, kidneys, intestinal mucosa  @ age 3 – 4 months, hypoglycemia, lactic acidosis, hyperuricemia, hyperlipidemia  doll-like face (fat cheeks), thin extremities, protuberant abdomen, short stature  hypoglycemic seizures --------------------------------------------------------------- Acid maltase deficiency (Pompe’s): Type II glycogen storage disease  “floppy baby” with feeding difficulties, macroglossia, cardiomegaly, hepatomegaly --------------------------------------------------------------- glycogen debranching enzyme deficiency: Type III glycogen storage disease  elevated liver transaminases, fasting ketosis, normal blood lactate & uric acid levels --------------------------------------------------------------- branching enzyme deficiency: Type IV glycogen storage disease (amylopectinosis)  age 18 months, hepatosplenomegaly, failure to thrive, progressive liver cirrhosis --------------------------------------------------------------- new onset neurologic deficits (confusion), occipital headaches, Hx of HTN & a-fib & vascular disease, on warfarin: stroke  Dx: non-contrast head CT o ischemic stroke  not evident until > 24 hrs 

o hemorrhagic stroke  white hyperdense regions --------------------------------------------------------------- all patients with B/L carpal tunnel syndrome (CTS) should be screened with TSH  CTS 2/2 hypothyroidism is a/w deposition of mucopolysaccharide protein complexes within perineurium & endoneurium of median nerve; commonly B/L, more severe --------------------------------------------------------------- accumulation of fluid can cause CTS in pregos  amyloid fibril deposition causes CTS in systemic amyloidosis (ESRD, chronic hemodialysis)  soft-tissue enlargement due to synovial edema & tendon hyperplasia causes CTS in acromegaly  inflammation of tendon & synovial sheaths cause CTS in RA --------------------------------------------------------------- severe hypovolemic hypernatremia Rx: isotonic normal saline or lactated Ringer’s  hypernatremia causes weakness, lethargy, irritability, altered mental status, seizures, muscle cramps & decreased DTRs --------------------------------------------------------------- periodic abdo pain, multiple duodenal ulcers & a jejunal ulcer: Zollinger-Ellison syndrome  steatorrhea due to pancreatic enzyme inactivation --------------------------------------------------------------- pancreatic enzyme deficiency: chronic pancreatitis  reduced bile salt absorption: ileal resection --------------------------------------------------------------- hyperventilation decreases CO2 concentration  promotes vasoconstriction  syncope ---------------------------------------------------------------brief psychotic > 1 day, < 1 month; sudden onset, disorder return to full function Schizophreniform > 1 month, < 6 months; functional decline not required Schizophrenia at least 6 months; functional decline required Schizoaffective at least 2 week Hx of psychotic symptoms w/o mood symptoms delusional ≥ 1 delusion, at least > 1 month, disorder no other psychotic symptoms, normal functioning otherwise ----------------------------------------------------------------

asthma may present with chronic cough (> 8 wk) that is predominantly nocturnal  Dx: spirometry to asses bronchodilator response o Methacholine challenge test if no bronchodilator response is seen  Rx: empiric inhaled glucocorticoids 2 – 4 wks; improvement is diagnostic --------------------------------------------------------------- febrile seizures are common, benign causes of convulsions in children; no not cause brain injury  risk factors: family Hx of febrile seizures, fever from infection, recent immunization  Dx: age 6 months – 6 yrs, ≥ 380C (100.40F), no previous of afebrile seizure, no CNS infection; normal neurologic exam  Rx: acetaminophen & reassurance  no hospitalization for observation or work-up  prognosis: normal development & intelligence --------------------------------------------------------------- #1 Rx of acute variceal bleeding: vascular access o 2 large bore IV needles or central line o prophylactic ABX  #2 Rx: control bleeding with terlipressin (vasopressin analogue), IV octreotide, or somatostatin (splanchnic vasoconstriction)  Rx within 12 hrs: endoscopic sclerotherapy or band ligation for active bleeding o Rx: balloon tamponade is temporary Rx for uncontrollable bleeding o Rx: TIPS for refractory or recurrent cases  secondary prophylaxis once bleeding controlled: βblocker (propranolol) + endoscopic band ligation 12 wk later o Rx small, non-bleeding varices o β-blocker decreases progression to large varices & risk of variceal hemorrhage due to unopposed alpha-mediated vasoconstriction & decreased portal venous flow --------------------------------------------------------------- hydroxyurea: increases HbF  Rx frequent vaso-occlusive crises episodes a/w sickle cell disease;  frequency & severity  also  risk of acute chest syndrome & need for blood transfusions 

A/E: myelosuppression (pancytopenia) predisposes to infection  acute Rx: hydration, analgesia (NSAIDs)  maintenance Rx: folate, pneumococcal vaccine, PCN until age 5 yrs, hydroxyurea --------------------------------------------------------------- thyroid storm is triggered by trauma, infection, surgery, iodine contrast, or childbirth; due to underdiagnosed or undertreated hyperthyroidism  tachycardia, HTN, arrhythmias (a-fib), high fever, N/V, tremor, altered mentation, lid lag, goiter  Dx: clinical & thyroid function studies  thyroid storm Rx o propranolol (symptom control) o PTU (block new hormone synthesis) o iodine solution (block hormone release) o glucocorticoids ( peripheral conversion) --------------------------------------------------------------- epidural hematomas do not cross suture lines  Rx: emergent craniotomy --------------------------------------------------------------- glucocorticoids cause neutrophilia by mobilizing marginated neutrophil pool &  bone marrow release  also  eosinophils & lymphocytes --------------------------------------------------------------- dark brown discoloration with lymph follicles shining as pale patches on colon biopsy: laxative abuse (factitious diarrhea) o “melanosis coli” develops within 4 months --------------------------------------------------------------- PLT dysfunction is MCC of abnormal hemostasis in patients with chronic renal failure o abnormal bleeding & bruising o due to uremic coagulopathy  BT is prolonged (normal PT, PTT, PLT count)  Rx: desmopressin (DDAVP), which increases release of factor VIII:von Willebrand multimers from endothelial storage sites  do not transfuse PLTs (quickly become inactive) --------------------------------------------------------------- respiratory quotient (RQ): steady-state ratio of CO2 produced to O2 consumed per unit time  steady state RQ close to 1.0 indicates predominant oxidation of CHO as fuel source 

RQ for lipid (0.7) & protein (0.8) as sole sources of energy  normal full-body steady-state RQ ~ 0.8  assessment of RQ is used when weaning patients from mechanical ventilation --------------------------------------------------------------- chronic HTN: ≥ 140/90 @ < 20 wks gestation or persisting beyond 12 wks postpartum o Rx: labetalol  gestational HTN & preeclampsia: HTN ≥ 20 wks  trace urine protein & mild peripheral edema is common in normal pregnancy o 3+ proteinuria is abnormal  HTN is MC risk factor for placental abruption o other complications: preterm birth, IUGR, oligohydramnios, superimposed preeclampsia --------------------------------------------------------------- risk factors for placental abruption: HTN, DM, prior placental abruption, cocaine use, smoking  risk factors for placenta previa: prior c-section, multiparity, multiple gestation, adv maternal age --------------------------------------------------------------- 10 amenorrhea: absence of menses by age 15, normal growth & secondary sexual character o can be normal up to age 16 o MCC is Turner’s Evaluation of primary amenorrhea  initial test: pelvic exam & pelvic USS  uterus absent  karyotype & serum testosterone o 46,XX & normal female testosterone = abnormal Mullerian development o 46,XY & normal male testosterone = androgen insensitivity syndrome  uterus present  serum FSH   FSH (peripheral)  karyotype (hypergonadotropic amenorrhea)   FSH (central)  pituitary MRI (hypogonadotropic amenorrhea) --------------------------------------------------------------- secondary amenorrhea: absence of menses ≥ 6 months in those who menstruated previously  initial test: β-hCG for pregnancy  next: prolactin, TSH, FSH o  prolactin  brain MRI 

o  TSH  hypothyroidism o  FSH  premature ovarian failure  if Hx of uterine procedure or infection, may have scarring of uterine cavity (Asherman syndrome) o hormone therapy to test for ability to grow a uterine lining o hysteroscopy to visualize uterine adhesions ---------------------------------------------------------------boobs organs axillary, pubic hair Complete 46, Yes absent uterus minimal androgen XY & upper or absent insensitivit vagina y Mullerian 46, Yes absent or normal agenesis XX rudimentary uterus & upper vagina Transverse 46, Yes abnormal normal vaginal XX vagina, septum normal uterus Turner’s 45, streak ovaries normal X normal uterus ---------------------------------------------------------------Androgen insensitivity syndrome (46, XY)  end-organ resistance to androgens  testicular descent is an androgen-dependent process  cryptorchid testes secretes testosterone which is aromatized to estrogen  breast development  external female genitalia  no axillary or pubic hair  primary amenorrhea; no uterus or upper vagina due to anti-Mullerian hormone from testes o Wolffian ducts degenerate  cryptorchid gonads  risk of dysgerminoma or gonadoblastoma after puberty  Rx: gonadectomy after puberty + estrogen --------------------------------------------------------------- Mullerian agenesis (Mayer-Rokitansky-KusterHauser syndrome): hypoplastic/absent mullerian ductal system; normal ovaries  genotypic & phenotypic female  no menstruation due to absent/underdeveloped uterus, cervix, & upper 2/3 vagina ----------------------------------------------------------------

5-α-reductase deficiency: 46, XY o male gonads o female/undermasculinized/ambiguous external genitalia at birth o often raised as girl, but male identity o masculinization at puberty;  phallus size, muscle growth, but lack breasts o infertility; risk of cryptorchidism --------------------------------------------------------------- Lyme arthritis is the MC late manifestation of untreated Lyme disease (months/years)  migratory arthralgias progress into monoarticular arthritis of the knee; travel history  Dx: synovial fluid show inflammatory profile  confirm Dx: ELISA & Western blot  Rx: doxycycline or amoxicillin  DDx: reactive arthritis (1 – 4 wks after urethritis or diarrheal infection), acute osteomyelitis, gout ---------------------------------------------------------------  17-hydroxyprogesterone = nonclassic CAH due to 21-hydroxylase deficiency  hyperandrogenism in late childhood  male pattern hair distribution, severe acne  non-classical CAH presents similar to PCOS --------------------------------------------------------------- DDx of stridor: croup, foreign body aspiration, epiglottitis, laryngomalacia, vascular rings, retropharyngeal abscess  laryngomalacia is MCC of chronic stridor --------------------------------------------------------------- high-grade fever, sore throat with odynophagia, muffled voice, drooling, stridor: epiglottitis  “tripoding” with inspiratory stridor  neck hyperextension provides relief  MCC in adults: Hib & Strep pyogenes o especially unvaccinated immigrants  CXR: enlarged epiglottis “thumbprint”  Dx: clinical, high suspicion  Rx: emergency intubation in the OR  DDx: peritonsilar abscess (uvular deviation), angioedema, vascular ring, croup, foreign body --------------------------------------------------------------- inspiratory stridor that worsens when supine & with crying or feeding: laryngomalacia 

laxity of supraglottic structures peaks @ age 4 – 8 months increased risk for GERD Dx: flexible laryngoscopy, shows collapse of supraglottic structures on inspiration; “omega sign”  Rx: reassurance; self-limited by age 18 months; PPI for GERD symptoms; supraglottoplasty for severe symptoms (cyanosis, apnea)  DDx: vocal cord paralysis --------------------------------------------------------------- biphasic stridor, difficult feeds: vascular rings  screening: barium swallow  Dx: MRI with angiography --------------------------------------------------------------- fever, drooling, dysphagia, neck pain, stridor: retropharyngeal abscess  high risk of infection into posterior mediastinum  acute necrotizing mediastinitis  Dx: neck CT scan --------------------------------------------------------------- headache, palpable B/L abdominal masses, microhematuria, +family Hx: ADPKD  hepatic cysts are the MC extrarenal manifestation  intracranial berry aneurysms also common; MVP or aortic regurgitation, colonic diverticula, abdominal wall & inguinal hernia --------------------------------------------------------------- distortion: altered perception of disturbing aspects of external reality to make it more acceptable  displacement: shifting of emotions a/w an upsetting object/person to a safer alternate object/person that represents the original  acting out: directly expressing an unconscious wish or impulse to avoid addressing the accompanying emotion (temper tantrum)  introjection: assimilating of another person’s attitude into one’s own perspective  suppression: intentionally postponing exploration of anxiety-provoking thought by substituting other thoughts  denial: failure to accept a disturbing aspect of external reality  dissociation: blocking disturbing thoughts/feelings from consciousness to avoid emotional upset ---------------------------------------------------------------   

N/V, myalgias, arthralgias, diarrhea, rhinorrhea, lacrimation, cramps: opioid withdrawal  mydriasis, piloerection, hyperactive bowel sounds  within 6 – 12 hr, peaks @ 24 – 48 hr  Rx: methadone --------------------------------------------------------------- Streptokinase is a fibrinolytic for STEMI only  Cilostazol: anticoagulant for chronic claudication, not acute limb ischemia --------------------------------------------------------------- GnRH stimulation test: precocious puberty --------------------------------------------------------------- anovulation & amenorrhea in lactating mothers is due to  prolactin, which suppresses GnRH, thus  LH/FSH o not a reliable method of birth control --------------------------------------------------------------- human placental lactogen (hPL): insulin antagonist  causes maternal lipolysis & insulin resistance, thus  delivery of fatty acids & glucose to the fetus --------------------------------------------------------------- significant blood loss from MVA, receives several units of pRBCs  whole blood is mixed with citrate coagulant  pRBCs derived from whole blood contains citrate  infused citrate chelates Ca++ & Mg++, thus reducing serum levels  paresthesia 2/2 hypoCa++  Rx: Ca++ gluconate --------------------------------------------------------------- spontaneous abortion: < 20 wks gestation  advanced maternal age is a significant risk factor  absent fetal movement on USS is the most significant indicator of fetal loss 

Threatened Missed Inevitable Incomplete Complete

Types of miscarriages bleeding cervix products of conception yes closed +fetal heart tones none closed no cardiac activity, or empty sac yes dilated no cardiac activity, collapsed sac yes dilated partial expulsion maybe closed conceptus expelled

Complete abortion  whole conceptus expelled before 20 wks gestation  “solid white mass covered with blood”  abdo pain & contractions subsides  β-hCG still positive; undetectable after 4 -6 wks  risk factors: smoking, advanced maternal age, previous spontaneous abortion Management of spontaneous abortion Threatene expectant management until… d symptom resolution OR progression to inevitable, incomplete, or missed abortion Missed, hemodynamically unstable, heavy bleed: Inevitable, surgical evacuation (D&C) Incomplet hemodynamically stable, mild bleeding: e expectant O/P management, misoprostol, or surgical evacuation Septic blood & endometrial cultures, broad-spectrum ABX, surgical evacuation (D&C) Ectopic MTX (inhibits actively proliferating fetal cells) --------------------------------------------------------------- IV oxytocin: augment labor, Rx postpartum hemorrhage, expel a retained fetus or POC --------------------------------------------------------------- progesterone: prevention of preterm labor of a singleton pregnancy in patients with a Hx of spontaneous preterm delivery ---------------------------------------------------------------Congenital diaphragmatic hernia  pulmonary hypoplasia, pulmonary HTN, polyhydramnios from esophageal compression, right heart deviation, gasless abdomen  worsened with positive-pressure ventilation as air into GIT compresses the lungs  Rx: intubation, then gastric tube to prevent bowel distension against the lungs --------------------------------------------------------------- pulmonary cavitation in HIV patients DDX: TB, atypical mycobacteria, Nocardia, G-negative rods, anaerobes  Nocardia: aerobic, G-positive, weakly acid-fast, beaded, branching, filamentous rod

o CXR: pulmonary nodules o Rx: TMP-SMX --------------------------------------------------------------- persistent culture-negative monoarthritis that fails to respond to ABX: TB arthritis --------------------------------------------------------------- pain, pulselessness, paresthesia, poikilothermia (coldness), pallor (5 “P’s”): acute limb ischemia  sudden-onset severe pain  numbness due to nerve ischemia (not compression)  Dx: angiography  Rx: IV heparin immediately  definitive Rx: intra-arterial thrombolysis or surgical embolectomy  DDx: thrombosis (insidious), arterial vasculitis --------------------------------------------------------------- patients with acute renal failure, liver failure, or sepsis (community-acquired pneumonia) should discontinue metformin until renal function returns  risk of lactic acidosis --------------------------------------------------------------- ACE-I/ARB can temporarily worsen renal function & hypotension, thus should not be started in the setting of acute kidney injury --------------------------------------------------------------- bedwetting is normal before age 5 yrs  interventions including enuresis alarms & desmopressin should not begin before age 5 --------------------------------------------------------------- status epilepticus (any single seizure > 5 min)  risk of permanent injury due to excitatory cytotoxicity  cortical necrosis is hallmark  may cause  intracranial pressure --------------------------------------------------------------- chi-square test: compares two proportions o if the difference between observed vs expected values is large, assumes an association is present  two sample z-test/t-test: compares two means o t-test: uses sample variance o z-test: uses population variance o both are used to obtain the p-value  ANOVA: compares means of 3 or more variables ----------------------------------------------------------------

# needed to treat (NNT): # that need to receive treatment to prevent 1 additional adverse event  NNT = 1/ARR (absolute risk reduction) --------------------------------------------------------------- ankylosing spondylitis patients can develop restrictive lung disease due to diminished chest wall & spinal mobility  PFT show a mild restrictive pattern (reduced VC & TLC, but normal FEV1/FVC)   FRC & RV due to fixation of the rib cage in an inspiratory position --------------------------------------------------------------- obstructive lung disease o  FEV1 (< 80%) &  FEV1/FVC (< 70%)  restrictive lung disease o  FEV1 (< 80%) &  FEV1/FVC (> 70%) --------------------------------------------------------------- pupil dilation, rhinorrhea, myalgia & arthralgia, cramps & spasms, nausea, diarrhea, lacrimation, HTN, diaphoresis: heroin withdrawal o resolves within 24 hrs; not life-threatening ---------------------------------------------------------------Alcohol withdrawal  acute phase (12 – 48 hr): sweating, hyperreflexia, insomnia, seizures, then acute hallucinosis in absence of autonomic symptoms  final phase (2 – 4 days): delirium tremens, HTN, fever, agitation, tachycardia, hyperthermia  Rx: chlordiazepoxide (long-acting benzo) --------------------------------------------------------------- nicotine withdrawal: irritability, anxiety, insomnia, depression, poor concentration, increased appetite, weight gain, bradycardia --------------------------------------------------------------- 3 treatment options for Graves’ o radioactive iodine (RAI) o antithyroid drugs (PTU, methimazole) o thyroidectomy  RAI is preferred, hypothyroid within 2 – 6 months  RAI is a/w worsening of Grave’s ophthalmopathy due to destroyed thyroid cells  Rx: prophylactic glucocorticoids or antithyroidal to deplete existing stores prior to RAI  C/I to RAI: severe ophthalmopathy & pregos ---------------------------------------------------------------

normally, newborns have enlarged RV appears as right-axis deviation & R waves in V1 – V3 on EKG since blood is shunted away from the lungs by the PDA in utero  newborn with left-axis deviation & small/absent R-waves in precordial leads: tricuspid valve atresia due to a hypoplastic RV o cyanotic congenital defect o ASD & VSD are necessary for survival  CXR:  pulmonary markings  Rx: surgical repair --------------------------------------------------------------- complete AV canal defect o a/w Down syndrome o CXR:  pulmonary markings, cardiomegaly  Ebstein’s anomaly o a/w lithium use during pregnancy o droopy tricuspid valve  RA enlargement & tricuspid regurgitation o EKG: tall P wave, right-axis deviation  Total anomalous pulmonary venous return o pulmonary veins fail to make normal connections to left atrium o right atrium receives blood from pulmonary & systemic circulation o RA & RV enlargement --------------------------------------------------------------- hyperkalemia-inducing medications: nonselective β-blockers, ACE-I/ARBs, NSAIDs, K+ sparing diuretics (amiloride) --------------------------------------------------------------- E. histolytica: bloody diarrhea, trophozoites on stool exam; “flask-shaped” colonic ulcers --------------------------------------------------------------- fatigue, dyspnea, abdo pain, dark urine, hypercoagulable state (portal vein thrombosis): paroxysmal nocturnal hemoglobinuria (PNH)   LDH,  haptoglobin, hemoglobinuria, hemolytic anemia, pancytopenia  Dx: flow cytometry  absence of CD55 & CD59 on RBC surfaces, which normally inhibits activation of complement on RBCs o absence of CD55 causes hemolytic anemia induced by the complement system  Rx: eculizumab (inhibits complement activation) 

DDx: acute intermittent porphyria, aplastic anemia, G6PD deficiency, hereditary spherocytosis --------------------------------------------------------------- ectopic ACTH production is commonly a/w small cell lung cancer & carcinoid  rapidly growing malignant tumors cause HTN, hypokalemia, metabolic alkalosis, hyperpigmentation without other features of Cushing’s (moon facies, dorsal hump, central obesity, striae) o benign/slow-growing tumors cause more characteristic features of Cushing syndrome  high levels of cortisol from ectopic ACTH can saturate 11-beta hydroxyl dehydrogenase & bind to mineralocorticoid receptors directly to cause HTN & hypokalemia -------------------------------------------------------------- uncomplicated cases of acute epigastric pain with  amylase or lipase (˃ 3x normal) do not need imaging for diagnosing acute pancreatitis  risk factors: alcohol, gallstones, hyperTGemia  Dx: abdominal CT with contrast for patients with unclear diagnosis or failing to improve with conservative Rx --------------------------------------------------------------- hypochromic/microcytic anemia, depressed iron & ferritin levels: iron deficiency anemia  MCC: chronic blood loss  initial management: test for blood in stool  DDx: right-sided colon cancer, PUD, diverticula, angiodysplasia --------------------------------------------------------------- acute respiratory distress, hypoxemia, smoking Hx: acute exacerbation of COPD COPD management o supplemental O2 (target: 88 – 92%) o inhaled bronchodilators  albuterol (beta-2-agonist)  ipratropium (short-acting anti-muscarinic) o systemic glucocorticoids  oral prednisone (mild/moderate)  IV methylprednisolone (severe) o ABX if ˃ 1 cardinal symptom ( dyspnea, cough, sputum)  azithromycin, levofloxacin, or augmentin 

noninvasive positive pressure ventilation (NPPV) for moderate/severe exacerbations o tracheal intubation (no improvement after 2 hr trial of NPPV or NPPV is C/I)  NPPV is a/w decreased mortality, rate of intubation, hospital stay, & incidence of nosocomial infections  maintenance Rx: salmeterol (long-acting β2 agonist)  inhaled corticosteroids are indicated in long-term Rx of asthma, not COPD --------------------------------------------------------------- acetylcysteine: mucolytic (Rx cystic fibrosis) --------------------------------------------------------------- phenelzine: MAOI; Rx refractory depression  MAOIs are a/w dietary restriction, foods high in tyramine (aged meats, cheese, wine) o a/w hypertensive crisis --------------------------------------------------------------- anemia, painless GI bleed, aortic stenosis murmur: angiodysplasia (AVM) of GIT  MC @ age > 60  MC discovered with underlying aortic stenosis or ESRD (uremic PLT dysfunction)  angiodysplasia: dilated, distended, thin-walled vessels lined by endothelium, prone to recurrent & chronic painless bleeding  Dx: colonoscopy or endoscopy ---------------------------------------------------------------  homocysteine levels predisposes to venous thrombosis & atherosclerosis  thus, patients with DVT in the setting of elevated homocysteine requires supplementation with pyridoxine (B6) & folate --------------------------------------------------------------- statins inhibit intracellular HMG-CoA reductase, prevent conversion of HMG-CoA to mevalonic acid, &  LDH receptors to remove circulating LDH  A/E: statin-induced myopathy ( CPK) --------------------------------------------------------------- osteophytes are MC finding in cervical spondylosis o also narrowing of disk spaces & hypertrophic vertebral bodies  Hx of chronic neck pain, limited neck rotation & lateral bending ---------------------------------------------------------------o

chronic diarrhea, malabsorption, Hx of living in endemic areas ˃ 1 month: tropical sprue  glossitis, cheilosis, protuberant abdomen, pallor, pedal edema, fatty diarrhea, fatigue, weight loss  hyperactive bowel sounds (boborygmi)  Dx: biopsy: blunting of villi with infiltration of chronic inflammatory cells (lymphocytes, eosinophils, plasma cells) --------------------------------------------------------------- hypotension is a common side effect of epidural anesthesia due to blood redistribution to lower extremities & venous pooling from sympathetic blockade  prevented by aggressive IV fluids prior to epidural placement  Rx: left decubitus position to improve venous return, or vasopressors --------------------------------------------------------------- episodes of dysphagia, regurgitation, &/or chest pain radiating to the back, precipitated by emotional stress: diffuse esophageal spasm  resolution of chest pain with nitroglycerin  Dx: esophageal manometry shows repetitive, non- peristaltic, high amplitude contractions --------------------------------------------------------------- acute otitis media  MCC: Strep pneumo, H. influenza, Moraxella  MC age 6 – 36 months  otalgia, middle ear effusion + acute inflammation (bulging, fever, erythema)  Rx: empiric amoxicillin; or augmentin  Rx: myringotomy with tympanostomy tube placement for recurrent episodes  complications: conductive hearing loss, mastoiditis, meningitis ---------------------------------------------------------------DDx of menorrhagia endometriosis chronic pelvic pain, endometrioma, pain peaks 1-2 days before menses, dyspareunia, infertility, endometrial glands outside uterus fibroids heavy menses with clots, firm, irregular, enlarged uterus, constipation & urinary frequency due to extrinsic compression 

adenomyosis endometrial hyperplasia/c a endometritis

dysmenorrhea, menorrhagia, chronic pelvic pain, bulky, globular, tender uterus Hx chronic anovulation, obesity, nulliparity (estrogen excess), irregular, intermenstrual, postmenopausal bleeding, small, nontender uterus recent procedure of the uterus (instrumentation, IUD, abortion), PROM, prolonged labor, foul-smelling discharge, fever, tender uterus

adenomyosis: endometrial glands invade the uterine myometrium, results in blood deposition between smooth muscle fibers o risk factors: multiparous, age > 40 o Dx: surgical pathology after hysterectomy  fibroids: benign, smooth muscle tumor arising from myometrium; does not cause intermenstrual or postmenopausal bleeding o Dx: pelvic USS --------------------------------------------------------------- all women age > 45 with irregular bleeding require endometrial biopsy --------------------------------------------------------------- side effects of depot medroxyprogesterone acetate (DPMA) can overlap with pregnancy symptoms o weight gain, nausea, breast tenderness o Rx: offer alternative contraception method  initial test: exclude pregnancy  DPMA suppresses ovulation, given every 3 months  causes menstrual irregularities in the 1st 6 months  amenorrhea after 1 yr of use --------------------------------------------------------------- otitis media with effusion: middle ear effusion without acute inflammation  otitis externa: erythematous & swollen external auditory canal, ear discharge, hearing loss, & pain with tragal traction  chronic suppurative otitis media: hearing loss, otorrhea > 6 wks, lack of fever & ear pain, tympanic membrane perforation ---------------------------------------------------------------

B/L retinal hemorrhages: suspect child abuse repetitive acceleration-deceleration forces cause shearing of subdural veins  seizures,  head circumference, bulging/tense anterior fontanelle, altered mental status  Dx: non-contrast head CT & skeletal survey ---------------------------------------------------------------Phenylketonuria  AR mutation of phenylalanine hydroxylase for conversion of phenylalanine to tyrosine o  phenylalanine is neurotoxic  severe intellectual disability, musty body odor, seizures, fair complexion (skin, hair, eyes)  Dx: tandem mass spectrometry (newborn screening); quantitative amino acid analysis (late presentations)  Rx: dietary restriction of phenylalanine --------------------------------------------------------------- aldolase B deficiency: fructose intolerance  accumulation of fructose-1-phosphate  vomiting, poor feeding, lethargy, seizures  Rx: restrict fructose from diet (fruits, veggies) --------------------------------------------------------------- jaundice, hepatomegaly, failure to thrive after first few days after consumption of breast milk or regular formula: galactosemia  absent galactose-1-phosphate uridyl transferase  G-1-P accumulates in liver, brain, kidney, leads to cirrhosis, mental retardation, Fanconi’s  Rx: breastfeeding is C/I --------------------------------------------------------------- acute onset dyspnea, tachypnea, normal lung exam, right-axis deviation on EKG: PE  Dx: CT angiography (test of choice)  contrast allergic or renal insufficient Dx: V/Q scan o large perfusion defect without ventilation defect --------------------------------------------------------------- chronic TPN or fasting causes gallbladder stasis, predisposes to gallstones & bile sludging, leading to cholecystitis o due to absence of stimulus for CCK release & GB contraction  small bowel resection & ileal Crohn’s contributes to gallstones, due to  enterohepatic circulation of bile acids  

--------------------------------------------------------------- estrogen-induced cholesterol secretion results in cholesterol gallstones during pregnancy & on OCPs  progesterone contributes by reducing bile acid secretion & slows GB emptying --------------------------------------------------------------- ADHD is a clinical diagnosis  Hx of core inattention & hyperactive/impulsive symptoms for ≥ 6 months & prior to age 7  functional impairment in at least 2 settings  Rx: methylphenidate (A/E: loss of appetite, weight loss, nausea, insomnia, nervousness) --------------------------------------------------------------- sickle cell trait have no specific clinical symptoms & no change in life expectancy  renal complications: painless hematuria, UTI, renal medullary cancer, hyposthenuria  MCC of hematuria is papillary necrosis due to low pO2 in the vasa rectae  U/A: normal-appearing, intact RBCs  DDx: acute cystitis, acute glomerulonephritis, AIN, ATN --------------------------------------------------------------- dysuria, urinary frequency, WBC’s on U/A, positive nitrite & LE: acute cystitis o MCC: Staph saprophyticus  hematuria, HTN, proteinuria, dysmorphic RBCs, RBC casts: acute glomerulonephritis  medication use, rash, eosinophilia,  serum Cr, WBC casts: acute interstitial nephritis  cola-colored urine, hematuria, elevated creatinine, granular casts, renal tubular epithelial cells: ATN --------------------------------------------------------------- delayed sleep phase syndrome: inability to fall asleep at “normal” hours (10 pm – midnight)  advanced sleep phase disorder: inability to stay awake in the evening (after 7 pm) --------------------------------------------------------------- dominant frontal lobe lesion: expressive (Broca’s) aphasia, C/L hemiparesis, C/L apraxia  conjugate gaze deviation TOWARD the lesion --------------------------------------------------------------- dominant parietal lobe lesion: C/L sensory loss, C/L inferior homonymous quadrantanopsia (superior optic radiations)

--------------------------------------------------------------- dominant temporal lobe lesion: receptive & conductive aphasia, C/L superior homonymous quadrantanopsia (Meyer’s loop)  intact expressive speech, motor, primary sensory --------------------------------------------------------------- hepatojugular reflux can differentiate between cardiac vs. liver disease-related cause of LE edema  + test: due to heart failure (reflects a failing RV) o constrictive pericarditis, RV infarction, restrictive cardiomyopathy  - test: due to hepatic disease/cirrhosis o increase in venous return below the liver --------------------------------------------------------------- subtle memory loss, language difficulties, apraxia, followed by impaired judgement & personality changes: Alzheimer’s o CT scan: diffuse cortical atrophy, especially temporal & parietal lobes, hippocampus; used to exclude other causes, not diagnostic  euphoria, disinhibition, apathy, compulsive behavior, hyerorality, impaired memory: Pick’s o visuospatial function intact  fluctuating cognitive impairment, Parkinsonism, visual hallucinations: Lewy body o worsening of features with neuroleptics  sudden deterioration of cognitive, motor, sensory function with each attack: multi-infarct dementia o MRI: multiple hypodense areas, periventricular --------------------------------------------------------------- anterior horn cells impaired: ALS, poliomyelitis, spinal muscular atrophy  peripheral nerves impaired: Guillain-Barre, diabetic neuropathy  muscle fibers impaired: muscular dystrophy, polymyositis, dermatomyositis, hypothyroidism  neuromuscular junction impaired: botulism (descending flaccid paralysis), Myasthenia Gravis, Lambert-Eaton, organophosphate poisoning --------------------------------------------------------------- acute ascending polyneuropathy after a recent URI or GI infection: Guillain-Barre  demyelination of peripheral motor nerves  ascending weakness, then flaccid paralysis with absent DTRs & autonomic symptoms

 CSF: elevated proteins, normal WBCs --------------------------------------------------------------- S. epidermidis is a common cause of prosthetic valve endocarditis  Enterococcal endocarditis affects older men after GU manipulation or women after OB procedures --------------------------------------------------------------- transient spike in Cr within 24 hr; returns to baseline 5 – 7 days: contrast-induced nephropathy  Rx: non-ionic contrast, pre-CT IV hydration & acetylcysteine  prednisone minimizes hypersensitivity reactions to contrast media & dye allergies  withhold NSAIDS; causes renal vasoconstriction --------------------------------------------------------------- painless hematochezia in a toddler: Meckel’s  due to incomplete obliteration of vitelline duct  ectopic gastric tissue causes mucosal ulceration  severe anemia or hemorrhagic shock  Dx: technicium-99m pertechnitate scan  complications: intussusception, obstruction --------------------------------------------------------------- pruritic lesions on flexor wrist, web spaces, elbows, &/or penis with short, linear burrows: scabies  excoriations with small, crusted, red papules  contagious by direct person-to-person contact  delayed Type IV hypersensitivity reaction  Dx: skin scrapings under light microscopy  Rx: topical permethrin or oral ivermectin  Rx: sheets & clothing cleaned or in plastic bag for 3 days (mites cannot live without humans)  DDx: eczema, tinea, seborrheic dermatitis --------------------------------------------------------------- stroke is a complication of sickle cell disease  2/2 sludging & occlusion in cerebral vasculature  Rx: exchange transfusion, continue hydroxyurea o fibrinolytics, heparin, & warfarin are not useful; not a true thrombus --------------------------------------------------------------- I/L shoulder pain, Horner’s (I/L ptosis, miosis, anhidrosis), supraclavicular node enlargement, weakness/atrophy of hand muscles, pain/paresthesia in the arm: Pancoast tumor  MCC non-small cell lung cancer

Horner’s occurs due to tumor invasion of paravertebral sympathetic chain or inferior cervical ganglion  Dx: CXR initially, chest CT for staging --------------------------------------------------------------- dilated pupils, blood-crusted nose: cocaine abuse o Rx: CCB & alpha blocker (phentolamine)  severe cocaine-induced vasospasm can cause cocaine-induced STEMI o Rx: PTCA or thrombolysis  avoid β-blockers, due to unopposed alpha activity  avoid fibrinolytics due to ICH risk  avoid thrombolytics for suspected aortic dissection 

Acute cocaine intoxication tachycardia, HTN, dilated pupils, atrophic nasal mucosa, chest pain (coronary vasoconstriction) psychomotor agitation, seizures complications o acute myocardial ischemia o aortic dissection o intracranial hemorrhage management supplemental O2, IV benzodiazepine (BP & anxiety), ASA (prevent thrombus formation), nitro & CCB (prevent vasoconstrict’n)  cocaine enhances thrombus formation by promoting PLT activation & aggregation --------------------------------------------------------------- IVDA are at risk for tricuspid valve endocarditis with pulmonary septic emboli  MCC: S. aureus  cough, chest pain, & hemoptysis  CXR: scattered, round alveolar infiltrates; peripheral cavitary lesions  Rx: vancomycin (native valve) covers MRSA --------------------------------------------------------------- pruritic, elevated, serpiginous skin lesions, through contact with sand: cutaneous larva migrans o helminthic disease by dog/cat hookworm --------------------------------------------------------------- Vit B12 deficiency: subacute degeneration of dorsal & lateral spinal columns  ataxia, B/L paresthesias, loss of vibration/position, memory deficits, irritability features

--------------------------------------------------------------- Legionella: MC in immunosuppressed receiving corticosteroids o fever with bradycardia, cavitary lesions, watery diarrhea  S. epidermidis: a/w infection of prosthetic valves, intravascular shunts, & prosthetic joints o uncommon cause of native valve endocarditis --------------------------------------------------------------- premenstrual syndrome (PMS) begins 1 – 2 wks prior to menses & regress around menstrual flow  symptoms occur repeatedly & predictably  confirm Dx: menstrual symptom diary  Rx: SSRI, caffeine reduction --------------------------------------------------------------- DDx of hematochezia in a toddler: Meckel’s, infectious colitis, intussusception, hemorrhoids, milk protein allergy, inflammatory bowel disease --------------------------------------------------------------- bloody, mucousy, loose stools or severe constipation: milk protein allergy causes painless rectal bleed  exclusive to infants, resolves by age 1 yr  Rx: elimination of milk/soy from maternal diet if breastfed; hydrolyzed formula if formula-fed --------------------------------------------------------------- 5-HT antagonists (ondansetron) to Rx/prevent chemotherapy-induced N/V o add corticosteroids for better prophylaxis --------------------------------------------------------------- scopolamine: anticholinergic to Rx vomiting & reduce motion sickness --------------------------------------------------------------- IV erythromycin is a motilin receptor agonist o Rx nausea 2/2 gastroparesis; prokinetic  metoclopramide: DA Rc antagonist o prokinetic & anti-emetic o  peristalsis, gastric contractions, relaxation of pyloric sphincter o Rx: diabetic gastroparesis & N/V o A/E: EPS, NMS --------------------------------------------------------------- relative risk (RR): probability of an outcome of interest occurring in the exposed group compared to the non-exposed group; a/w cohort studies

RR = 1.0: null value; no association; outcome occurs with equal frequency o RR > 1.0: exposure is a/w  risk of disease o RR 12 wks): S. aureus --------------------------------------------------------------- Jarisch-Herxheimer reaction: a/w syphilis Rx  10 or 20 syphilis Rx with PCN  spirochetes die rapidly  releases antigen-antibody complexes  immunologic reaction  appears like an acute flare-up of syphilis --------------------------------------------------------------- epistaxis, turbinate destruction, palatal eschars, maxillary cyanosis: fungal sinusitis  MCC: Aspergillus fumigatus, Rhizopus  risk factors: poorly controlled DM, HIV --------------------------------------------------------------- acute pancreatitis is MCC by gallstones & alcohol use  Dx: USS of RUQ to detect gallstones  Rx: IV fluids, NG tube section, NPO, analgesia; monitor Ca++ & Mg++  stable patients should undergo cholecystectomy for biliary pancreatitis prior to discharge --------------------------------------------------------------- Marfan: AD, fibrillin-1 gene mutation  upward lens dislocation, aortic root dilation resulting in aortic regurgitation  complications: aneurysms, aortic dissection, MVP --------------------------------------------------------------- homocysteinuria: AR cystathionine synthase deficiency; a/w metabolism of methionine  elevated homocyteinuria & methionine  marfanoid habitus, fair complexion, thrombosis, (CVA, stroke), intellectual disability  downward lens dislocation  Rx: Vit B6, folate, Vit B12; anticoagulation --------------------------------------------------------------- scoliosis, joint laxity, aortic dilation: Ehlers-Danlos --------------------------------------------------------------- seizure, diaphoresis, tremulousness, elevated pulse & BP one day following hospitalization: alcohol withdrawal  seizures likely at 12 – 48 hr 

delirium tremens at 2 – 4 days; altered sensorium & autonomic instability  Rx: lorazepam, diazepam, or chlordiazepoxide o IV lorazepam for liver diseased o phenobarbital (anti-convulsant) can be adjunct in refractory cases --------------------------------------------------------------- hematuria, arthralgia, colicky abdominal pain, purpuric rash on LE without thrombocytopenia following a minor infection (viral URI): Henoch-Schonlein purpura  IgA-mediated leukocytoclastic vasculitis  normal PLT count  hematuria, RBC casts, proteinuria, mild  Cr  renal biopsy: mesangial deposition of IgA  Rx: hydration & NSAIDs (pain control) o severe Rx: hospitalize, systemic glucocorticoids  complications: intussusception, GI hemorrhage --------------------------------------------------------------- hemophilia-associated arthropathy is a delayed consequence of recurrent hemarthrosis, a chronic inflammatory process  a/w hemosiderin deposition & fibrosis of joints  joint contractures & limited ROM  Dx: MRI  Rx: prophylaxis with factor concentrates --------------------------------------------------------------- clenched fist injury, human bite, dog bite  Rx: amoxicillin-clavulanate (augmentin) --------------------------------------------------------------- erythromycin: Rx Legionnaire’s & outpatient Rx of community-acquired pneumonia --------------------------------------------------------------- VZV incubation period: up to 3 weeks o contagious from 2 days prior to rash onset until all vesicles are crusted Varicella post-exposure prophylaxis  Hx of immunity  observation  if asymptomatic & no Hx of immunity… o immunocompetent  varicella vaccine only within 3 – 5 days of exposure o immunocompromised  VZ Ig within 10 days  varicella vaccine is live, attenuated, thus contraindicated in pregos & immunocompromised 

--------------------------------------------------------------- returning from a developing country with chronic symptoms of malabsorption: giardiasis  trophozoites adhere to mucosal surfaces by adhesive disks, producing malabsorption  Rx: empiric metronidazole --------------------------------------------------------------- female between age 30s – 40s, recurrent attacks of multiple focal neurologic presentations, & interspersed episodes,: MS  optic neuritis  blurry vision, retrobulbar pain, afferent pupillary defect --------------------------------------------------------------- TIAs: emboli from carotid artery plaques, which occlude the distal ophthalmic artery o painless loss of vision --------------------------------------------------------------- Stevens-Johnson syndrome involve mucosal surfaces --------------------------------------------------------------- chronic scar (burn) that develops into a painless, non-healing, bleeding skin ulcer suggests squamous cell carcinoma  risk factors: smoking, radiation, immunosuppression  Dx: biopsy (punch, shave, excisional) that includes deep reticular dermis --------------------------------------------------------------- primary spontaneous PTX: no preceding event or Hx of lung disease  secondary spontaneous PTX: complication of underlying lung disease (COPD)  tension PTX: trapped air, with mediastinal shift AWAY from affected side, & compromised cardiopulmonary function  suspected tension PTX should be treated prior to intubation, as PPV will worsen the PTX  PTX Rx: o small: observation & O2 o large/stable: needle aspiration or chest tube o unstable: urgent needle thoracostomy, then chest tube under water seal  needle decompression @ 2nd or 3rd IC space, midclavicular line  chest tube @ 5th IC space, mid-axillary line ----------------------------------------------------------------

neurocardiogenic (vasovagal) syncope: preceded by nausea, diaphoresis, bradycardia, pallor  pallor & weak pulses suggest syncope  triggers: prolonged standing, stress, pain  benign & self-limited  immediate spontaneous return to baseline neuro --------------------------------------------------------------- essential tremor: action tremor in absence of additional neurologic signs  affects any part of the body, B/L hands MC  resolves with sleep, improves with alcohol  Rx: propranolol (especially if also hypertensive); primidone or topiramate (anticonvulsants) o primidone may precipitate acute intermittent porphyria (abdominal pain, headaches, confusion, hallucinations, dizziness) o Dx: urine porphobilinogen --------------------------------------------------------------- HTN is the most important risk factor for intracerebral hemorrhage  MC site: putamen (basal ganglia) --------------------------------------------------------------- occipital headache, neck stiffness, gait ataxia, N/V, gaze palsy or nystagmus: cerebellar hemorrhage o no hemiparesis or sensory loss  risk factor: HTN  Dx: non-contrast head CT, surgical decompression --------------------------------------------------------------- intracranial hemorrhage: focal neuro deficits worsen over minutes – hours; not maximal at onset  headache, N/V, decreased LOC  MC risk factor: HTN 

Intraparencymal brain hemorrhage neurologic findings basal C/L hemiparesis & hemisensory loss ganglia homonymous hemianopsia (putamen) gaze palsy AWAY from lesion** cerebellum no hemiparesis, occipital headache, neck stiffness, gait ataxia, nystagmus thalamus C/L hemiparesis, hemisensory loss (“toward”) nonreactive pinpoint pupil upward gaze palsy eyes deviate TOWARD hemiparesis** cerebral frontal: C/L hemiparesis

lobe (rare)

parietal: C/L hemisensory loss occipital: homonymous hemianopsia eyes deviate AWAY from hemiparesis pons total paralysis in minutes followed by (“pinpoint”) deep coma, pinpoint reactive pupils, decerebrate rigidity  internal capsule lies adjacent to putamen, leads to C/L dense hemiparesis --------------------------------------------------------------- elderly with dementia have increased risk of agitated delirium in the hospital  MCC: medications, infection, electrolytes, metabolic, systemic illness, CNS  Rx: low-dose haloperidol for acute agitation in elderly with dementia o typical & atypical antipsychotics are safe o prolonged use increases mortality in elderly  typical antipsychotics not for Lewy body dementia --------------------------------------------------------------- benzos OK for Rx agitation in young patients --------------------------------------------------------------- firm, hyperpigmented nodule with dark edges, & central dimple when pinched: dermatofibroma o benign fibroblast proliferation; MC on LE o Rx: no treatment unless symptomatic, bleeds, change color or size  pearly plaque/papule with small telangiectasias on sun-exposed areas: BCC  firm, scaly papule/plaque/nodule on sun-exposed area: SCC  multicentric, red/purple/brown macules/papules, or nodule on trunk/face/extremities: Kaposi  small red papule grows rapidly into a pedunculated or sessile shiny mass on lip or oral mucosa, bleeds with minor trauma: pyogenic granuloma o benign vascular skin tumor --------------------------------------------------------------- hazard ratio: chance of an event occurring in the treatment group compared to control group  HR < 1: event is more likely in the control group  HR > 1: more likely in the treatment group  HR = 1: no difference --------------------------------------------------------------- cyclophosphamide: alkylating immunosuppressant Rx for SLE, vasculitis, & cancer

a/w hemorrhagic cystitis & bladder carcinoma caused by acrolein  Rx: mesna, hydration, frequent voiding --------------------------------------------------------------- cisplatin & carboplatin: a/w cochlear dysfunction  β-blockers & ergotamine: a/w Raynaud’s  cyclosporine: a/w gout  amiodarone & lithium: a/w thyroid dysfunction ---------------------------------------------------------------

--------------------------------------------------------------- breech presentation before 37th wk gestation does not require intervention; routine follow-up  external cephalic version is indicated ≥ 37th wk o contraindications: placental abnormalities, feto-pelvic disproportion, hyperextended head --------------------------------------------------------------- heat stroke: thermoregulatory center fails to dissipate heat at the necessary rate o risk factors: hot/humid weather, obesity, meds (anticholinergics, TCAs, antihistamines)  non-exertional heat stroke: chronic illness or medication causes impaired thermoregulation o Rx: evaporative cooling  exertional heat stroke: failure of thermoregulation in healthy individuals in extreme heat/humidity o > 400C (1050F)  CNS dysfunction (altered mental status), hypotension, tachycardia, tachypnea, ARDS o rhabdomyolysis (large blood, but no RBCs), coagulopathic bleeding (epistaxis), DIC  Rx: ice water immersion, fluids & electrolytes; no antipyretics  DDx: anticholinergic toxicity, serotonin syndrome, malignant hyperthermia, --------------------------------------------------------------- heat exhaustion: inadequate fluid & Na+ replacement; unable to maintain C.O. o no CNS dysfunction

--------------------------------------------------------------- fever results from the thermoregulatory center’s temporary upregulation of body temp by the hypothalamus --------------------------------------------------------------- high fever, muscle rigidity, rhabdomyolysis, metabolic acidosis, hemodynamic instability: malignant hyperthermia  uncontrolled sarcoplasmic reticulum Ca++ efflux  AD inheritance; +family Hx  MCC: inhaled halothane & succinylcholine ---------------------------------------------------------------Serotonin syndrome  HTN, hyperthermia, diaphoresis, agitation, tremor, muscle rigidity, clonus, hyperreflexia  Rx: benzo (lorazepam) --------------------------------------------------------------- extracellular pH promotes binding of Ca++ to albumin, thus  ionized Ca++ --------------------------------------------------------------- warfarin-induced skin necrosis: due to rapid decline of protein C in those with underlying protein C deficiency  occurs within the first few days  skin lesions on extremities, breast, trunk, penis; marginates over hours  Rx: stop warfarin, protein C concentrate --------------------------------------------------------------- heparin-induced thrombocytopenia (HIT): autoantibodies to PF4 complexes with heparin  occurs within 5 – 10 days  necrotic skin lesions @ injection sties  a/w arterial or venous thrombosis  PLT count reduction > 50 %  Rx: stop heparin; direct thrombin inhibitor (argatroban, fondaparinux) --------------------------------------------------------------- Factor V Leiden mutation increases risk for venous thromboembolism (DVT, PE) due to protein C resistance --------------------------------------------------------------- risk of tick-borne disease is low if removed < 24 hr --------------------------------------------------------------- Histoplasma is MC in bird/bat droppings  dimorphic fungus: yeast in tissue, mold in culture

endemic to Mississippi & Ohio River valley usually asymptomatic; can cause acute pneumonia CXR: asymptomatic pulmonary nodule or patchy/multinodular infiltrates --------------------------------------------------------------- rapidly developing hyperandrogenism with virilization suggests an androgen-secreting tumor of the ovary or adrenal  Dx: serum testosterone & DHEA-S o elevated testosterone  ovarian source o elevated DHEA-S  adrenal source  DHEA is secreted by ovaries & adrenals --------------------------------------------------------------- panic disorder is a/w other psychiatric illnesses: major depression, agoraphobia, bipolar, substance abuse  high rate of suicide attempts & suicide ideations  immediate Rx: benzos  long-term Rx: SSRI/SNRI &/or CBT --------------------------------------------------------------- pulmonary contusion symptoms develop in the first 24 hours  tachypnea, tachycardia, hypoxia  CXR: patchy irregular alveolar infiltrates  DDx: ARDS (manifests after 24 to 48 hrs) --------------------------------------------------------------- “3 Ds”: dyspareunia, dysmenorrhea, dyschezia (pain with defecation), infertility: endometriosis  disappears/improves during pregnancy  risk factors: nulliparity, early menarche, short menstrual cycles, menstrual flow obstruction --------------------------------------------------------------- tachypnea, tachycardia, mental status changes, hypotension, thrombocytopenia, petechiae on the chest after long bone fracture: fat embolism --------------------------------------------------------------- hypotension unresponsive to IV fluids, tachycardia, JVD after blunt thoracic trauma: acute pericardial tamponade  CXR: may appear normal  Rx: pericardiocentesis or surgical pericardiotomy --------------------------------------------------------------- exertional dyspnea, nocturnal cough, hemoptysis  rheumatic fever is MC in developing countries   

mitral stenosis increases pulmonary vascular pressure thus causing pulmonary congestion --------------------------------------------------------------- temporal headache, jaw claudication, vision loss,  ESR: Giant cell (temporal) arteritis  chronic vasculitis of medium & large vessels  anterior ischemic optic neuropathy presents as swollen pale optic disc with blurred margins  a/w polymyalgia rheumatica  Rx vision problems: high-dose IV corticosteroids (methylprednisolone) immediately  Rx mild cases: oral prednisone  Rx polymyalgia rheumatica only: low-dose oral glucocorticoids --------------------------------------------------------------- acetazolamide: Rx open angle glaucoma & benign intracranial HTN (ICH) --------------------------------------------------------------- anovulation, hirsutism, acne, ovarian cysts: PCOS  abnormal GnRH secretion stimulates the pituitary to secrete excess LH & insufficient FSH o excess LH stimulates androgen production by ovarian theca cells  anovulation is due to LH/FSH imbalance & insulin resistance ---------------------------------------------------------------Pathogenesis of endometriosis  ectopic endometrial tissue form beneath pelvic mucosal/serosal surfaces  cyclic hyperplasia & degeneration  chronic hemorrhaging leads to pelvic adhesions  risk of impaired fertility or infertility --------------------------------------------------------------- chronic pelvic pain, dyspareunia, infertility, bowel/bladder symptoms: endometriosis  rectovaginal tenderness or movement of uterus  MC in nulliparous, age 25 - 35  evaluation: pelvic USS to r/o endometrioma (cystic ovarian mass); normal lab studies  Rx if no complications: empiric NSAIDs +/combined OCPs (ovulation suppression)  Rx if complications, or refractory to medical Rx: laparoscopy (Dx & Rx) ---------------------------------------------------------------

pernicious anemia: MCC of Vit B12 deficiency in N. European whites  atrophic glossitis, neurologic abnormalities  loss of position & vibration sense  comorbid autoimmune dz: vitiligo, thyroid disease  complication: gastric cancer risk --------------------------------------------------------------- Ca++-phosphate stones: primary hyper-PTH  uric acid stones: acidic urine or  cell turnover  cysteine stones: inborn error of metabolism; hexagonal crystals on U/A, positive family Hx  struvite stones: alkaline urine due to infection with urease-producing bacteria (Proteus)  struvite stones that fill the entire renal pelvis: staghorn calculi --------------------------------------------------------------- Td vaccine: every 10 yrs to all adults after age 18  Tdap vaccine: one-time dose in place of Td; also with each pregnancy, regardless of status  influenza vaccine: annually to all adults o healthy, non-pregnant adults age < 50 may receive live-attenuated intranasal vaccine --------------------------------------------------------------- 13-valent pneumococcal conjugate (PCV13) induces a T-cell-dependent B-cell response o improves immunogenicity o Rx all infants & young children  23-valent polysaccharide vaccine (PPSV23) induces a T-cell independent B-cell response o less effective in children & elderly o Rx adults age < 65 with comorbidities --------------------------------------------------------------- 13-valent pneumococcal conjugate (PCV13) & 23-valent polysaccharide vaccine (PPSV23) o all age ≥ 65, 6 – 12 months apart o age < 65 at high-risk: sickle cell disease, CSF leaks, cochlear implants, asplenia, immunocompromised, chronic renal failure  PPSV23 alone o age 19 – 64 with chronic heart, lung, or liver disease; diabetic, alcoholic, current smoker o subsequent PCV13 & PPSV23 @ age 65 ---------------------------------------------------------------

small bowel disease, surgical resection or chronic diarrhea leads to malabsorption of fatty acids & bile salts, predisposing to calcium oxalate stones o unabsorbed fatty acids chelate calcium, making oxalate free for absorption --------------------------------------------------------------- posterior shoulder dislocation is common after a tonic-clonic (grand mal) seizure  arm is held adducted & internally rotated  XR: light bulb sign, rim sign, trough line sign --------------------------------------------------------------- anterior shoulder dislocation is a/w direct blow, forceful abduction, or fall on outstretch arm  arm is held slightly abducted & externally rotated  Dx: evaluate axillary nerve function --------------------------------------------------------------- transient unilateral weakness following a tonicclonic seizure that is self-limited: Todd paralysis ---------------------------------------------------------------Infantile hypertrophic pyloric stenosis risk first-born male, age 3 – 5 wks factors erythromycin use, formula feeding features projectile non-bilious emesis poor weight gain, good appetite, dehydration, sunken fontanelles tachypnea, olive-shaped mass Lads hypochloremic, hypokalemic metabolic alkalosis with compensatory respiratory acidosis Dx abdominal USS Rx IV hydration pyloromyotomy 

formula-fed infants have slow gastric emptying & consume more volume in less time, which stimulates growth of the pylorus muscle  prior to surgery, stabilize electrolytes with IVF; alkalosis increases risk of post-op apnea ---------------------------------------------------------------Pediatric immunizations inactivated (killed) polio, hepatitis A toxoid (inactivated) diphtheria, tetanus subunit (conjugate) hepatitis B Pertussis H. influenza Type B 

Pneumococcal Meningococcal HPV influenza (injection) live attenuated rotavirus MMR varicella influenza (intranasal)  administer vaccines according chronologic age  except Hep B: weight should be ≥ 2 kg --------------------------------------------------------------- compartment syndrome can be a complication of supracondylar humerus fractures  severe pain, pallor, poikilothermia, paresthesia; late findings of pulselessness or paralysis  Rx: remove bandages, measure compartment pressures, orthopedic evaluation for fasciotomy  complication: Volkmann contracture --------------------------------------------------------------- precocious puberty: 20 sexual development; girls < 8 yrs, boys < 9 yrs o initial test: bone age o next: test: basal serum LH  all elevated LH requires MRI with contrast to r/o hypothalamic or pituitary tumors  next test: GnRH stimulation test  high or low baseline LH,  with GnRH stimulation: gonadotropin-dependent (central) precocious puberty o idiopathic precocious puberty: premature hypothalamic-pituitary-gonadal axis activation; MC in girls;  LH/FSH  premature adrenarche (axillary, pubic hair), thelarche (breasts), & menarche  advanced bone age o Dx: brain CT or MRI o Rx: continuous GnRH agonist  low LH/FSH at baseline, does not increase with GnRH stimulation = gonadotropin-independent (peripheral) precocious puberty o gonadal or adrenal  release of sex hormones  Dx: USS of adrenals, ovaries/testes o advanced bone age, coarse axillary/pubic hair, severe cystic acne, normal testicular volume: non-classic (late-onset) CAH

MCC: 21-hydroxylase deficiency  accumulation of 17-hydroxyprogesterone  normal bone age with isolated premature thelarche or adrenarche  Rx: reassurance --------------------------------------------------------------- classic CAH neonates present with adrenal insufficiency, ambiguous genitalia, salt-wasting  late-onset CAH occurs in late childhood with androgen excess: premature adrenarche/pubarche, Rx-resistant cystic acne, advanced bone age, accelerated linear growth --------------------------------------------------------------- Leydig cell tumor  gonadotropin-independent precocious puberty o unilateral testicular enlargement/mass --------------------------------------------------------------- MCC of primary hypogonadism: Klinefelter’s o small testes, small phallus, hypospadias, cryptorchidism, gynecomastia, ---------------------------------------------------------------o Calcium (hypercalcemia) o Renal failure (IgG or Bence Jones proteins) o Anemia (Hb < 12) o Bones (lytic lesions, fractures)  “CRABs” present in multiple myeloma  monoclonal plasma cell proliferation of IgG   functional antibodies & leukopenia,  risk for recurrent infection  elevated protein:albumin gap > 4  paraproteinemia results in renal failure due to obstruction by large laminated casts ---------------------------------------------------------------Normal physiologic changes during pregnancy o  GFR & renal size o  BUN & creatinine o  urinary frequency, nocturia o mild hyponatremia ( ADH) o dilutional anemia ( plasma volume & RBC mass) o prothrombotic state (risk of DVT/PE) o  cardiac & renal blood flow  progesterone directly stimulates central medullary respiratory centers:  tidal volume & minute ventilation, PaO2,  PaCO2 o

chronic respiratory alkalosis with metabolic compensation ( HCO3) --------------------------------------------------------------- neonate with lethargy, hypocapnia, high-pitch cry, rapidly  head circumference, bulging fontanelles  intraventricular hemorrhage is a common complication premature & underweight neonates born at < 32 wk gestation or < 1500 g  due to capillary fragility of subependymal germinal matrix  screening: serial head USS, shows B/L IVH & dilated ventricles  Rx: antenatal corticosteroids  complication: communicating hydrocephalus, cerebral palsy --------------------------------------------------------------- Arnold-Chiari & Dandy-Walker: congenital malformations that cause non-communicating hydrocephalus due to obstruction a CSF flow in the posterior fossa --------------------------------------------------------------- hepatic hydatid cysts are due to Echinococcus granulosus from close contact with dogs or sheep  causes unilocular cystic lesion in any organ  mostly asymptomatic or compressive symptoms  hepatomegaly, RUQ pain, N/V  encapsulated cysts containing fluid & budding cells that become daughter cysts  CT scan: “egg shell” calcifications  Rx: surgical resection/aspiration & albendazole o aspiration  risk of anaphylactic shock --------------------------------------------------------------- RUQ pain, nausea, liver USS shows a smooth, round cyst with daughter cells: Echinococcosis  definitive host: dogs  intermediate host: sheep  dead end host: humans  transmission: dogs living in close proximity to humans are fed viscera of home-slaughtered animals; eggs excreted by dogs in feces --------------------------------------------------------------- brachial artery injury is a concern with supracondylar humerus fractures --------------------------------------------------------------- hyperemesis gravidum occurs early in pregnancy o

significant vomiting leads to hypochloremic metabolic alkalosis ( HCO3) --------------------------------------------------------------- diabetics are at high risk of erectile dysfunction  tight glycemic control does not improve symptoms  Rx: sildenafil (PDE inhibitor) o if taking sildenafil & alpha-blocker together, wait at least 4 hours in between --------------------------------------------------------------- survivors of sexual assault are at highest risk for PTSD, depression, & suicidality --------------------------------------------------------------- consider carbon monoxide poisoning in patients with environmental/occupational risk factors  20 polycythemia, headache, nausea, dizziness   Hct is due to carboxyhemaglobinemia --------------------------------------------------------------- polycythemia can cause pulmonary HTN by increasing viscosity in the pulmonary vasculature  severe pulmonary HTN can cause polycythemia --------------------------------------------------------------- dyspnea, hemoptysis, ankle edema, dark urine, U/A with proteinuria, dysmorphic RBCs, & red cell casts, CXR: B/L alveolar infiltrates: Goodpasture’s  pulmonary-renal syndrome as a manifestation of anti-GBM antibodies against collagen IV, damages glomeruli & alveolar lining  affects lungs (cough, dyspnea, hemoptysis) & kidneys (nephritic proteinuria, ARF, dysmorphic RBCs & red cell casts)  a/w alveolar hemorrhage & glomerulonephritis  Dx: renal biopsy shows linear IgG deposits along glomerular BM  Rx: emergency plasmapheresis to remove anti-GBM antibodies minimizes kidney damage --------------------------------------------------------------- fever, exertional dyspnea, non-productive cough, severe hypoxia, CD4 < 200: PCP pneumonia  CXR: B/L diffuse interstitial infiltrates  Dx: bronchoalveolar lavage  TMP-SMX for PCP pneumonia may experience initial worsening of pulmonary function o add corticosteroids to minimize the initial pulmonary complications 

alt Rx for PCP: TMP + dapsone, IV pentamidine, oral atovaquone, or clindamycin-primaquine --------------------------------------------------------------- male adolescent with epistaxis, visible nasal mass, bony erosion in back of nose: angiofribroma  benign, but can erode & invade locally --------------------------------------------------------------- reactive nasal polyps do not cause bony erosions  a/w chronic infections or allergies --------------------------------------------------------------- giant cell tumor of bone: locally aggressive skeletal neoplasm, benign; MC in adolescents  knee pain, swelling, decreased joint ROM  distal femur or proximal tibia  XR: osteolytic bone lesion, “soap-bubble” in the epiphyseal region of long bones  Rx: surgery --------------------------------------------------------------- loss to follow-up in prospective studies has potential for attrition bias (selection bias)  can over- or under-estimate the association between exposure & disease ---------------------------------------------------------------Celiac’s screening:  IgA anti-tissue transglutaminase Ab assay o IgA anti-endomysial antibodies  may be absent with selective IgA deficiency  Dx: if suspicion is high, measure total IgA  confirm Dx: upper GI endoscopy with biopsy 

Features of malabsorption in celiac disease Nutrient Symptoms fat bulky, foul-smelling, floating stools protein loss of subcutaneous fat & muscle mass iron pallor, fatigue, iron deficiency anemia Ca++, vit osteoporosis, osteomalacia D Vit K easy bruising Vit A hyperkeratosis Extraintestinal symptoms of Celiac’s general fatigue, weight loss skin dermatitis herpetiformis, vitiligo MSK osteopenia/osteoporosis

hematology iron deficiency anemia neuro peripheral neuropathy, headache endocrine autoimmune thyroiditis, Type I DM psych depression, psychosis --------------------------------------------------------------- lidocaine: class IB anti-arrhythmic   frequency of PVCs &  risk of v-fib  do not use prophylactically to prevent v-fib in patients with acute MI   risk of asystole ---------------------------------------------------------------Pain management for terminal cancer  initially Rx: short-acting morphine; subsequent doses titrated to achieve complete pain control  once established, switch to long-acting narcotics (patches), with short-acting morphine PRN for break-through pain --------------------------------------------------------------- vesiculoureteral reflux (VUR) is a risk factor for recurrent UTIs, leading to renal scarring  all children age 2 – 24 months, first febrile UTI should undergo renal USS  Dx recurrent UTIs: voiding cystourethrogram o not routine for first UTI  not a/w bladder cancer, RCC, abscess, or calculi ---------------------------------------------------------------Immunologic blood transfusion reactions anaphylactic rapid onset shock, hypotension, (seconds – minutes) angioedema/urticaria, respiratory distress/failure recipient anti-IgA IgG primary transient hypotension, hypotension patients on ACE-I, caused by reaction (minutes) bradykinin in blood products normally degraded by ACE acute hemolytic fever, flank pain, hemolysis, (within 1 hr) hemoglobinuria, DIC medical emergency! direct Coombs test positive** ABO incompatibility febrile fever & chills (most common) nonhemolytic cytokine accumulation during (within 1 – 6 hrs) blood storage (from leukocytes) urticarial/allergic urticarial, flushing, pruritus, (within 2 – 3 hr) angioedema

transfusion-related acute lung injury (within 6 hrs) delayed hemolytic (within 2 – 10 days)

recipient IgE & mast cell activation respiratory distress, noncardiogenic pulmonary edema donor anti-leukocyte Ab’s mild fever & hemolytic anemia direct Coombs test positive anamnestic Ab response to RBC antigen

leukocytes release cytokines during blood storage that cause transient fever, chills, & flank pain; causes febrile non-hemolytic reaction o prevented by using leuko-reduced blood  IgA-deficient individuals are at risk for anaphylactic transfusion reactions o Rx: IM epinephrine, vasopressors, histamine blockers, glucocorticoids o future transfusions: IgA-deficient plasma & washed RBC products --------------------------------------------------------------- altered mental status, acute renal failure, fever, hemolytic anemia, thrombocytopenia: TTP  reticulocytosis,  indirect bilirubin, schistocytes  Dx: clinical; ADAMTS13 not used for diagnosis  Rx: plasma exchange 

Indications for specialized RBC treatments Irradiated BM transplant recipients, cellular immunodeficiency, blood donated by 10 or 20 relative Leukoreduced chronic transfusions, CMV at-risk patients (AIDS), Hx of febrile non-hemolytic rxn, potential transplant recipient, Washed IgA deficiency, complement-dependent autoimmune hemolytic anemia, urticaria despite antihistamines --------------------------------------------------------------- Cat-scratch disease: Bartonella henselae  local skin lesion evolves through vesicular, erythematous, papular phases  tender, localized, regional lymphadenopathy

Rx: azithromycin (5 days) to reduce symptoms, but mainly self-limited --------------------------------------------------------------- membranous glomerulonephritis is a/w Hep B  focal segmental glomerulosclerosis are MC a/w HIV, blacks, HTN, obesity, IVDA, sickle cell o segmental sclerosis & hyalinosis --------------------------------------------------------------- collagenous colitis: chronic watery diarrhea  colonoscopy: normal mucosa  biopsy: mucosal subepithelial collagen deposits --------------------------------------------------------------- anorexia, fatigue, weight loss, cognitive impairment, Hx of IVDA: HIV testing  HIV patients are at risk of depression & dementia  DDx: MDD, chronic primary adrenal insufficiency, iron deficiency anemia --------------------------------------------------------------- phenytoin & carbamazepine: block voltage-gated Na+ channels  Rx primary generalized tonic-clonic seizures with/without secondary generalization  A/E for both: SJS/TEN, fetal hydantoin syndrome  phenytoin A/E: gingival hypertrophy --------------------------------------------------------------- phenobarbital: acts at GABA receptors by extending GABA-mediated Ca++ channels open  A/E: sedation ---------------------------------------------------------------A-a PaCO2 corrects gradient with O2? reduced inspired O2 normal normal yes tension (high altitude) hypoventilation normal  yes (CNS depression) diffusion limitation  normal yes (interstitial lung dz) intracardiac shunt,  normal NO extensive ARDS V/Q mismatch  normal yes (obstructive disease, or  pulmonary edema, atelectasis, pneumonia) 

Alveolar-arterial gradient: estimates the degree of alveolar oxygen transfer to blood o normal: < 15 ( with age); > 30 is elevated  patients with Hx of CAD & sudden onset dyspnea after IV fluids is likely pulmonary edema o pulmonary edema  the A-a gradient due to V/Q mismatch; excess fluid reduces lung compliance by preventing alveolar expansion o Rx: supplemental O2  extensive ARDS results in a poorly aerated lung that is stiff & less compliant  left-to-right shunts (VSD) lowers lung compliance by  pulmonary blood flow, causing fluid leakage into the interstitium --------------------------------------------------------------- Hx of travel to endemic area (Mexico), dysentery, RUQ pain, single cyst in right lobe of liver: amebic liver abscess (E. histolytica)  primary infection in the colon  bloody diarrhea   ALP  Dx: trophozoites in stool, serology, or imaging to r/o pyogenic abscess  Rx: empiric metronidazole o also paromomycin (luminal agent to eradicate intestinal colonization) o do not drain the abscess  DDx: pyogenic liver abscess (2/2 surgery, GI infection, acute pancreatitis), hepatic adenoma (solid lesion), hydatid cyst (Echinococcus) --------------------------------------------------------------- gross hematuria a/w URI, HTN, proteinuria, RBC casts, AKI: glomerulonephritis 

features

IgA nephropathy within 5 days of URI (synpharyngitic) men, age 20 – 30 yrs, recurrent gross hematuria

Dx

normal C3 Bx: mesangial IgA

Post-infectious GN 10 – 21 days after URI (post-pharyngitic) age 6 – 10 or adults gross hematuria adults: asymptomatic or acute nephritic syndrome low C3** elevated ASO &/or anti-DNase B Bx: subepithelial

deposits humps with C3 benign, children: good if RPGN or nephrotic adults: CKD syndrome (worse Px) --------------------------------------------------------------- B/L sensorineural hearing loss, recurrent hematuria, ocular abnormalities, renal insufficiency: Alport’s  X-linked defect in collagen IV formation  normal complement levels  EM: thin & thick capillary loops, GBM splitting, tram-track appearance --------------------------------------------------------------- necrotizing fasciitis: erythema & swelling, severe pain out of proportion to physical exam  involves subcutaneous tissue & deep fascia  systemic symptoms: fever, hypotension  signs of tissue necrosis: crepitus, purulent drainage, radiographic evidence of gas in deep tissues  rapidly progresses to discoloration, bullae, necrosis  MCC: Group A Strep  Rx: surgical debridement & ABX  DDx: abscesses, cellulitis, deep muscle hematoma, thrombophlebitis --------------------------------------------------------------- anti-ischemic & anti-anginal effects of nitrates are due to systemic vasodilation o concomitant use of β-blockers prevents reflex tachycardia caused by nitrates --------------------------------------------------------------- recurrent epistaxis, ruby-colored papules on the lips that blanch, widespread AVMs: hereditary telangiectasia (Osler-Weber-Rendu syndrome)  AVMs occur in mucous membranes, skin, GIT  diffuse telangiectasias, digital clubbing  pulmonary AVMs can cause R-to-L cardiac shunt, resulting in hypoxemia & reactive polycythemia; & massive hemoptysis --------------------------------------------------------------- Henoch-Schonlein Purpura: systemic form of IgA involvement of glomeruli, skin, joints, intestines ---------------------------------------------------------------Causes of postoperative fever (> 380C) Wind PE, pneumonia, aspiration Wound SSI Water UTI

Px

Walk Wonder drugs

DVT drug fever, IV lines blood products

Timeline course of post-operative fever  immediate (0 -2 hr): prior trauma/infection, transfusion reaction, malignant hyperthermia  acute (1 day – 1 wk): nosocomial infections (UTI), SSI (GAS, or C. perfringens), MI, PE/DVT  subacute (> 1 wk, < 1 mo): drug fever, PE/DVT, C. difficile, other SSIs, catheter site infection  delayed (> 1 mo): viral, indolent SSIs, IE --------------------------------------------------------------- fever, rash, peripheral eosinophilia: drug fever --------------------------------------------------------------- severe, acute-onset mid-abdominal pain out of proportion to physical exam findings, N/V: acute mesenteric ischemia  MCC is an embolus  progression to bowel infarction causes peritoneal signs & bloody stool --------------------------------------------------------------- coagulase-negative staphylococci (S. epidermidis) is the MCC of nosocomial bloodstream infections with intravascular devices (triple-lumen catheter) --------------------------------------------------------------- Staph saprophyticus (coagulase negative): common cause of uncomplicated acute cystitis a young, sexually active females --------------------------------------------------------------- MCC of community-acquired pneumonia: Strep pneumo, H. influenza, Mycoplasma  Rx: empiric ABX; isolating causative organism is difficult  management of CAP requires risk assessment for hospitalization using the CURB-65 algorithm o Confusion o Uremia (BUN > 20 mg/dL) o Respiratory (RR > 30) o BP (< 90/60 mmHg) o age > 65  score > 2: inpatient  score ≥ 4 : ICU outpatient

healthy: doxycycline or macrolide

comorbidities: fluoroquinolone, OR beta-lactam + macrolide inpatient fluoroquinolone, OR (non-ICU) beta-lactam + macrolid inpatient beta-lactam + macrolide (IV), OR (ICU) beta-lactam + fluoroquinolone  ICU patient ABX to cover: S. aureus, Legionella, Pseudomonas --------------------------------------------------------------- copious white/yellow vaginal discharge, nonmalodorous, absence of other findings on vaginal exam: physiologic leukorrhea --------------------------------------------------------------- stillbirth: ≥ 20 wks gestation  risk factors: HTN, DM, adv maternal age, smoking Stillbirth delivery options D&C (up to 24 wks) induction spontaneous delivery 3rd trimester induction with oxytocin (preferred) (after 28 wks) spontaneous delivery c-section  spontaneous delivery occurs within 2 wks  vaginal birth after c-section increases risk of uterine rupture, but vaginal delivery is preferred regardless of prior cesarean --------------------------------------------------------------- hemarthrosis after minor trauma in a young child is suspicious for bleeding disorder  screening: coagulation studies & CBC --------------------------------------------------------------- fever, dysphagia, odynophagia, neck pain with movement (particularly neck extension), trismus (jaw spasm): retropharyngeal abscess  Dx: neck CT &/or lateral radiographs  Rx: IV ABX, drainage  DDx: meningitis, herpangina, epiglottitis, IM --------------------------------------------------------------- high fever, severe sore throat with dysphagia, ulcerative lesions on palate, tonsils, & pharynx: herpangina  MCC: Coxsackie A  gray vesicles/ulcers on posterior oropharynx  lesion on palms & soles = hand-foot-mouth disease 2nd trimester

 Rx: supportive; self-limited within 1 wk  DDx: gingivostomatitis (anterior oropharynx) --------------------------------------------------------------- peritonsilar abscess is a complication of tonsillitis  muffled voice, uvula deviation, & prominent unilateral lymphadenopathy  Rx: IV ABX & urgent abscess needle aspiration --------------------------------------------------------------- retroperitoneal hematoma can occur without a supratherapeutic INR while on warfarin  back pain, hemodynamic compromise  Dx: abdominal CT  DDx: RCC, vertebral fracture, hydronephrosis --------------------------------------------------------------- primary inciting event of acute cholecystitis is gallstone obstruction in cystic duct; no jaundice   ALP is a/w cholangitis or choledocholithiasis; + jaundice --------------------------------------------------------------- OGTT in all pregos @ 24 – 28 wk gestation to screen for gestational diabetes o screen with 1 hr 50g OGTT o confirm with 3 hr 100g OGTT  risk factors: obesity, family Hx of DM, excessive weight gain during pregnancy  high risk or symptomatics (polyuria, polydipsia) should undergo HbA1C & fasting glucose at the first prenatal visit --------------------------------------------------------------- pregos at high risk of fetal aneuploidy require cell-free fetal DNA testing ---------------------------------------------------------------Rx acute cystitis & pyelonephritis in non-pregos uncomplicated oral nitrofurantoin (5 days) cystitis TMP-SMX (3 days) fosfomycin (single dose) complicated **requires urine culture prior to Rx cystitis fluoroquinolones (5 – 14 days), but not for pregos pyelonephritis **requires urine culture prior to Rx outpatient: oral fluoroquinolones (ciprofloxacin, levofloxacin) inpatient: IV fluoroquinolones, or aminoglycoside +/- ampicillin

dysuria, urinary frequency, suprapubic tenderness: uncomplicated cystitis  Dx: U/A; urine culture only if initial Rx fails --------------------------------------------------------------- complicated cystitis: factors that increase risk of ABX resistance or Rx failure (diabetes, CKD, urinary tract obstruction, nosocomial infection, indwelling catheters, pregos, immunocompromised)  Dx: obtain urine culture prior to Rx --------------------------------------------------------------- failure to thrive, persistent diarrhea, lymphopenia  recurrent fungal, viral & bacterial infections  ADA deficiency (SCID): deficient formation of mature B & T lymphocytes 2/2 toxic accumulation of adenosine --------------------------------------------------------------- complement deficiencies  risk of autoimmune conditions --------------------------------------------------------------- chronic granulomatous disease: defective intracellular killing due to impaired respiratory burst from active phagocytes --------------------------------------------------------------- opsonization defects result from asplenia o infection with encapsulated bacteria --------------------------------------------------------------- insulin-like growth factor (IGF-1) is used to screen for acromegaly o GH levels fluctuate (diurnal)   IGF-1  oral glucose suppression test o adequate GH suppression rules out acromegaly o inadequate GH suppression  brain MRI to look for a pituitary mass --------------------------------------------------------------- psychological defense mechanisms serve to decrease anxiety  immature defense mechanisms: used by children/adolescents, socially unacceptable behavior that prevents coping with reality  neurotic defense mechanisms: used by adults, short-term relief, with long-term complications  mature defense mechanisms: used by adults; healthy & constructive approach to reality ---------------------------------------------------------------

reaction formation: substituting behavior/feelings that are opposite of their own unacceptable feelings  sublimation: consciously unacceptable instinctual drives are diverted into socially or personally acceptable activities (channeling explosive anger into athletic pursuits)  dissociation: temporarily eliminating a memory or perception of themselves or environment to avoid a problem or distressing situation  suppression: intentionally postponing the exploration of anxiety-provoking thoughts by substituting other thoughts  displacement: shifting emotions a/w an upsetting object/person to a safer alternative that represents the original in some regard  acting out: enacting an unconscious wish or fantasy through impulsive physical action to avoid painful feelings --------------------------------------------------------------- fluid resuscitation & IV dexamethasone: Rx acute adrenal insufficiency  IV dantrolene: Rx malignant hyperthermia --------------------------------------------------------------- renal compensation for respiratory alkalosis: excretion of HCO3 in urine (high urine pH)  “contraction alkalosis” occurs in states of intracellular volume contraction, where  levels of aldosterone restores intravascular volume, but also  urinary H+ loss --------------------------------------------------------------- orchitis is the MC complication of mumps  other complications: aseptic meningitis, encephalitis --------------------------------------------------------------- SIDS is more frequent in males, age 2 – 4 months, & low socioeconomic status --------------------------------------------------------------- HTN can be a presenting sign of polycythemia  plethoric face, splenomegaly   incidence of peptic ulcers (histamine release from basophils) & gouty arthritis ( cell turnover) --------------------------------------------------------------- abrupt onset severe headache, meningeal irritation with neck pain/stiffness: SAH  Dx: non-contrast head CT within 24 hr o lumbar puncture if CT is normal 

rebleeding is a major cause of death within 24 hrs vasospasm is a delayed complication of SAH (after 3 days), resulting in cerebral infarct  Dx: CT angiography  Rx: prevented with nimodipine (CCB) --------------------------------------------------------------- “lone A-fib”: paroxysmal, persistent, or permanent a-fib without cardiopulmonary or structural heart disease; CHADS2 score = 0  Rx: no anticoagulation --------------------------------------------------------------- smoke inhalation injury victims (house fire): empiric Rx for cyanide toxicity o HCN & CO  Rx: empiric IV hydroxocobalamin, or sodium thiosulfate (directly binds CN) o nitrates to induce methemoglobinemia; increases ferric iron (Fe3+) to bind CN  Rx cyanide ingestion: activated charcoal --------------------------------------------------------------- CN potently inhibits cytochrome oxidase a3 of the ETC & binding Fe3+, thus prevents reduction to Fe2+ & ATP production  promotes anaerobic metabolism  metabolic acidosis (lactic acidosis) with respiratory compensation (tachypnea) --------------------------------------------------------------- methmoglobinemia occurs with exposure to oxidizing agents: dapsone, nitrates, topical/local anesthetics; formed by oxidation of Fe2+  Fe3+   affinity of Fe2+ to O2 (left shift), thus reduces O2 delivery to tissues  Fe3+ binds avidly to CN; unable to bind O2  Rx: methylene blue --------------------------------------------------------------- all pregos should receive inactivated influenza & TdaP vaccinations ---------------------------------------------------------------Colon cancer screening options begin at age 50 o colonoscopy every 10 yr (most sensitive & specific test, but $$$) o FOBT annually o flexible sigmoidoscopy every 5 yr + FOBT every 3 yr  high risk polyps: F/U colonoscopy ever 3 – 5 yrs --------------------------------------------------------------- 

granulosa cell tumor: solid malignant ovarian tumor that produce excess estrogen  bimodal age distribution o presents as isosexual precocious puberty or postmenopausal bleeding & uterine myohyperplasia  Rx: tumor removal results in symptom regression --------------------------------------------------------------- dysgerminoma: malignant ovarian tumor  women age < 20 yr  unilateral; can undergo torsion  undifferentiated gonadal germinal cells  neutral; does not secrete sex hormones  testes equivalent = seminoma --------------------------------------------------------------- sertoli-leydig cell tumor: produce androgens, causes defeminization, then masculinization in child-bearing age women  serous cystadenomas: MC benign cystic ovarian neoplasm; no estrogen or androgens o ovarian mass & abdominal pain ---------------------------------------------------------------Constipation in children risk factors transition to solid foods & cow’s milk, toilet training, & school entry 

complications Rx

anal fissures, hemorrhoids, vomiting, encopresis, enuresis, recurrent cystitis dietary fiber, limit cow’s milk < 24 oz oral laxative (polyethylene glycol, mineral oil)

recurrent cystitis in toddlers 2/2 constipation can cause rectal distension  compresses the bladder  resulting in urinary stasis --------------------------------------------------------------- musculoskeletal infections (osteomyelitis, abscess) results from hematogenous spread from other sites such as the skin (furuncles)  MCC S. aureus --------------------------------------------------------------- if anion gap is markedly elevated with absence of frank uremia, calculate osmolar gap to assess for ethanol, methanol, or ethylene glycol intoxication o high osmolar gap & severe metabolic acidosis 

--------------------------------------------------------------- ethylene glycol poisoning (anti-freeze) is a/w hypocalcemia & calcium oxalate deposition  flank pain, hematuria, oliguria, AKI, profound anion gap metabolic acidosis (HCO3 < 8)  U/A: rectangular, enveloped-shaped crystals is a/w Ca++ oxalate  Rx: fomepizole or ethanol to inhibit alcohol dehydrogenase; sodium bicarbonate to relieve acidosis, & hemodialysis for severe acidosis &/or end-organ damage --------------------------------------------------------------- methanol poisoning: vision loss & coma  within 24 hr: headache, N/V, epigastric pain  optic disc hyperemia ---------------------------------------------------------------Toxicity Features Labs alcohol slurred speech, high osmolar gap, ketoacidosis unsteady gait, anion gap altered mentation metabolic acidosis due to ketosis methanol visual burning, high osmolar gap, (EYES) central scotoma, anion gap afferent pupil defect, metabolic acidosis altered mentation, acute pancreatitis ethylene flank pain, oliguria, high osmolar gap, glycol hematuria, tetany, anion gap (KIDNEYS) CN palsy metabolic acidosis, Ca-oxalate crystals isopropyl CNS depression, high osmolar gap, alcohol disconjugate gaze, NO anion gap, absent ciliary reflex NO metabolic acidosis --------------------------------------------------------------- NPV: probability of being disease-free if test result is negative  NPV varies with the pretest probability of disease o high probability of disease = low NPV o low probability of disease = high NPV  prevalence is directly related to pretest probability o sensitivity & specificity to not vary with pretest probability ----------------------------------------------------------------

#1 Rx major depression: SSRI Dx: must have depressed mood or anhedonia with at least 4 symptoms of SIGECAPS  for patients with advanced cancer, also consider adjustment disorder w/ depressive features o symptoms must occur within 3 months ---------------------------------------------------------------Antipsychotic extrapyramidal effects (related to degree of D2 blockade) a/w high-potency typical antipsychotic, acute dystonic onset after 4 hours to 4 days, reaction sudden, sustained contraction of neck, mouth, tongue, EOM, opisthotonus Rx: benztropine (anticholinergic) or diphenhydramine (antihistamine) subjective restlessness, akathisia onset can occur at anytime Rx: benzodiazepine (lorazepam) or beta-blocker (propranolol) onset within 4 days to 4 months; drug-induced tremor, rigidity, bradykinesia Parkinsonism Rx: benztropine or amantadine onset within 1 – 6 months; Tardive dyskinesia of mouth/face, extremities; dyskinesia lip smacking, puckering, biting, grunting, tongue protrusion no effective treatment --------------------------------------------------------------- atypical antipsychotic most likely to cause EPS: risperidone  Rx: replace with clozapine; least likely for EPS o CBC before starting clozapine --------------------------------------------------------------- amiodarone: Rx conversion & maintenance of sinus rhythm for patients with a-fib  does not prevent thrombus formation ---------------------------------------------------------------Running injuries of the foot &ankle a/w sudden  in activity, Stress fracture insidious, localized pain in navicular or metatarsals; microfractures that coalesce within cortical bone, burning pain, worse when initiating Plantar first steps of the day, fasciitis pain decreases with activity, but  

worsens with prolong weight-bearing burning pain or stiffness 2 to 4 cm Achilles above posterior calcaneus tendinopathy numbness/pain between 3rd & 4th toe, Morton clicking sensation when palpating neuroma plantar space between 3rd & 4th toes while squeezing metatarsal joints compression of tibial nerve at ankle Tarsal tunnel burning, numbness, aching of distal syndrome plantar surface; MCC: ankle fx --------------------------------------------------------------- placenta previa: painless, 3rd trimester bleeding  hemorrhage is fetal origin  no fetal deterioration  risk factors: prior placenta previa, prior c-section or uterine surgery, multiparity, adv maternal age  Dx: transabdominal, then transvaginal USS  no digital vaginal exam before USS due to risk of massive hemorrhage  Rx unstable mother, regardless of gestational age: emergency c-section  Rx stable mother, fetus at term: scheduled c-section  Rx stable mother, fetus not at term: expectant; amniocentesis @ 36 wks to assess lung maturity o if lungs mature  scheduled c-section --------------------------------------------------------------- abruptio placenta: hypertonic, uterine tenderness  premature separation due to hemorrhage in decidua basalis; hemorrhage is maternal origin  MC risk factor: HTN --------------------------------------------------------------- vasa previa: painless, antepartum hemorrhage upon ROM with rapid deterioration of fetal tracing (sinusoidal tracing); no maternal symptoms  hemorrhage is fetal origin  fetal death by exsanguination  Dx: antenatal transvaginal Doppler USS  Rx: emergency c-section --------------------------------------------------------------- uterine rupture: sudden onset intense pain, vaginal bleeding, hyperventilation, tachycardia  hemorrhage is maternal origin  fetal deterioration, palpable fetal parts --------------------------------------------------------------- cord prolapse occurs with rupture of membranes

 deep, recurring variable decelerations; painless --------------------------------------------------------------- placenta acreta: implantation of villi into myometrium; abdominal pain & vaginal bleeding  risk factor: prior c-section when placenta is next to uterine scar (low-lying anterior) --------------------------------------------------------------- uterine atony: painless postpartum hemorrhage --------------------------------------------------------------- PEP after a bite wound from wild carnivore o MCC raccoons; exposure to saliva  rabies post-exposure prophylaxis: rabies Ig & rabies vaccine immediately (passive & active)  hydrophobia & aerophobia: encephalitic rabies  ascending flaccid paralysis --------------------------------------------------------------- post-menopausal female with vaginal dryness, pruritus, dysuria; pale, dry vaginal mucosa, diminished labial fat pad, scarce pubic hair: atrophic vaginitis  Dx: Hx & physical findings  Rx: vaginal estrogen (moderate/severe cases), moisturizers/lubricants (mild)  DDx: UTI --------------------------------------------------------------- Rx vulvar lichen planus & lichen sclerosis: high-potency corticosteroid cream --------------------------------------------------------------- risk stratification of stroke using CHADS2 for all a-fib to assess for long-term anticoagulation  anti-thrombotic therapy with warfarin (or dabigatran, rivaroxaban, apixaban) is the most effective at  risk of systemic embolization with nonvalvular a-fib  ASA is less effective in preventing thromboembolic events  ASA + clopidogrel is better than ASA alone, but inferior to warfarin --------------------------------------------------------------- tinnitus, fever, hyperventilation: ASA overdose o mixed anion gap metabolic acidosis & respiratory alkalosis; no osmolar gap  Rx: sodium bicarbonate ---------------------------------------------------------------Complications in DES exposed daughters

 clear cell adenocarcinoma of vagina & cervix  structural abnormalities of reproductive tract  infertility --------------------------------------------------------------- endometrial adenocarcinoma risk factors: prolonged estrogen stimulation (early menarche, late menopause, obesity, chronic tamoxifen use) --------------------------------------------------------------- #2 highly malignant bone tumor, common with children in lower extremity: Ewing’s sarcoma  white males, < age 20 yr  joint pain & swelling for weeks or months  MC sites: metaphysis & diaphysis of femur; also tibia & humerus  commonly mets to lungs & lymph nodes  XR: central lytic lesion was endosteal scalloping; “onion-skin” periosteal reaction, followed with “moth-eaten” or mottled appearance  DDx: osteomyelitis (fevers, leukocytosis, local joint pain, swelling, anemia,  ESR) --------------------------------------------------------------- asbestos exposure  risk of pulmonary fibrosis & malignancy (x6)  MC malignancy is bronchogenic carcinoma  smoking synergistically  lung cancer risk  symptoms develop ≥ 20 yrs after initial exposure  cough, sputum, & wheezing not typically present  progressive dyspnea, bibasilar end-inspiratory crackles & clubbing  CXR: bibasilar reticulonodular infiltrates, honeycombing, B/L pleural thickening o pleural plaques --------------------------------------------------------------- asbestos is the only risk factor for malignant pleural mesothelioma  CXR: unilateral pleural abnormality with a large pleural effusion --------------------------------------------------------------- pulsus paradoxus is a frequent finding of cardiac tamponade, but also severe asthma or COPD --------------------------------------------------------------- Proteus is the most likely cause of UTI in those with alkaline urine, due to its secretion of urease, forming struvite stones, a source of bacteria  formation of ammonium increases urine pH

chronic indwelling urinary catheters are a source of urease-producing bacteria (Proteus) --------------------------------------------------------------- elderly patients with anemia, renal failure, hypercalcemia, back pain, recurrent infections: multiple myeloma   total serum protein, normal albumin   ESR > 100, +Bence Jones proteins  Dx: serum immunoelectrophoresis shows M-spike due to IgG production by plasma cells --------------------------------------------------------------- internal carotid artery dissection is a potential cause of stroke in children o delayed stroke symptoms after trauma  Hx of trauma to the soft palate with a foreign body --------------------------------------------------------------- acute bronchitis commonly cause new onset blood-tinged sputum; MCC is viral URI  mild wheezing & ronchi that clear with coughing  epithelial sloughing makes yellow/purulent sputum  Rx: supportive, observation  if recurrent/active bleeding > 30 mL, risk factors for malignancy, or abnormal CXR… o Dx: high-resolution chest CT --------------------------------------------------------------- pulmonary airway disease (chronic bronchitis, bronchogenic carcinoma, bronchiectasis) is MCC of hemoptysis in adults with a Hx of smoking  chronic bronchitis: chronic productive cough for 3 months in 2 successive years; a/w smoking  bronchiectasis: irreversible dilation & destruction of bronchi results in chronic productive cough & inadequate mucus clearance o high-resolution CT: dilated bronchi & bronchial thickening o complication: hemoptysis o Rx: bronchial artery embolization  a/w Hx of recurrent URI & chronic production of mucopurulent sputum with  airway drainage  crackles, ronchi, & wheezing are common ---------------------------------------------------------------Common causes of hemoptysis pulmonary chronic bronchitis, PE, bronchiectasis, Mallory-Weiss, 

lung cancer MS/acute pulmonary edema TB, lung abscess coagulopathy AVMs, severe thrombocytopenia Wegener’s, Goodpasture’s, SLE, vasculitis ---------------------------------------------------------------Diabetic autonomic neuropathy cardiac tachycardia, postural hypotension, impaired exercise tolerance peripheral dry skin, pruritus, retinopathy, nerves foot ulcers, poor would healing Charcot arthropathy ( fx risk) GI gastroparesis, delayed gastric emptying esophageal dysmotility, dyspepsia GU erectile dysfunction, decreased libido neurogenic bladder, urinary retention, overflow incontinence, high PVR, nephropathy --------------------------------------------------------------- foot ulcers are graded from 0 - 5 Management of diabetic foot ulcers o off-loading o debridement o wound dressing o ABX o revascularization o amputation --------------------------------------------------------------- Hx of cyanotic congenital heart disease & recurrent sinusitis predisposes to brain abscess o direct spread from sinuses to frontal lobe  cyanotic heart disease  hematogenous spread  fever, headache, focal neurologic deficits, seizure  indolent process --------------------------------------------------------------- urinary diverticulum: outpouchings of the bladder or urethra into adjacent tissue  MC in women  post-void dribbling, dysuria, dyspareunia  urinary stasis leads to recurrent cystitis/UTI --------------------------------------------------------------- post-op adhesions cause mechanical SBO  congenital adhesions: Ladd’s bands cardiac infectious hematologic vascular systemic

DDx: acute cholecystitis, acute pancreatitis, PUD, Crohn’s, SMA syndrome --------------------------------------------------------------- prodromal fever, irritability, skin tenderness, followed by generalized erythema & superficial flaccid blisters; + Nikolsky sign: Staphylococcal scalded skin syndrome  scaling & desquamation (5 days), then resolution within 1 – 2 wks  children age < 10 yrs  superficial flaccid blisters with flexural accentuation, perioral crusting, & facial edema --------------------------------------------------------------- erythema multiforme: targetoid papule or plaque, acrofacial distribution, involves palms & soles  a/w HSV, coccidiomycosis, Mycoplasma --------------------------------------------------------------- use dependence: enhanced pharmacologic effects during faster HR (Class IC & IV antiarrhythmics)  flecainide (class IC): Rx a-fib for maintenance of sinus rhythm with structurally normal hearts o slowest rate of drug binding & dissociation from Na+ channel receptors o normally does not prolong QRS or QT o faster HR causes progressive  impulse conduction, leading to wide QRS  Rx: supraventricular arrhythmia --------------------------------------------------------------- non-dihydropyridine CCB (verapamil, diltiazem)  displays use dependence by prolonging AV node refractory period, thus  PR interval --------------------------------------------------------------- Digoxin: inhibits ATPase-dependent Na+/K+ pump, thus  intracellular Na+ o results in decreased Na+/Ca++ exchanger, thus  intracellular Ca++  enhances vagal tone & slows AV node conduction  Rx: systolic dysfunction (+inotrope) --------------------------------------------------------------- excisional biopsy with narrow margins & depth through SC fat is preferred for Dx of melanoma  tumors > 1 mm in depth should have a sentinel lymph node study  depth is the most important prognostic factor ---------------------------------------------------------------

mild TBI with GCS 13 – 15, vomiting, headache, seizure, LOC < 5 min, focal neurologic finding, altered mental status: CT without contrast & observation 4 – 6 hr  hospitalization unnecessary unless CT is abnormal  provide detailed “return precautions” upon discharge --------------------------------------------------------------- minor head trauma: GCS = 15 with non-severe mechanism, no vomiting, no headache, no LOC, no signs of skull fx: no head CT  serious TBI: GCS < 13, prolonged LOC, neurologic deficits, signs of basilar skull fx: requires neuroimaging, inpatient monitoring (neuro exam q2h), & neuro consult ---------------------------------------------------------------DDx of stridor in infants/children Croup age 6 mo – 6 yrs (laryngotracheo parainfluenza virus -bronchitis) “barky” cough, inspiratory stridor fever, rhinorrhea, congestion Rx: nebulized racemic epinephrine Epiglottitis stridor, dysphagia, excess drooling, high fever, tachypnea, tachycardia muffled “hot potato” voice lateral XR: thick aryepiglottic folds Laryngomalaci age 4 – 8 months a stridor worsens when supine, improves when prone foreign body age 6 mo – 4 yr aspiration acute onset inspiratory stridor, focal monophonic wheezing, moderate/severe respiratory distress Vascular ring age < 1 yr; difficulty feeding wheezing, cough, dysphagia improves with neck extension, a/w cardiac abnormalities 

vascular ring: does not improve with corticosteroids, racemic epinephrine, or bronchodilators; requires high index of suspicion o Dx: barium contrast esophagogram, bronchoscopy, CT or MRA o Rx: surgical correction ---------------------------------------------------------------

dry, rough skin with horny plates over extensor surfaces: ichthyosis vulgaris  “lizard skin”; worsens in winter --------------------------------------------------------------- medulloblastoma: pediatric tumor  nocturnal or morning headaches, ataxia  a/w posterior vermis syndrome: truncal dystaxia --------------------------------------------------------------- method to improve communication of relevant info during patient transfers: sign-out checklist --------------------------------------------------------------- exercise-induced bronchoconstriction Rx: short-acting β-agonist (albuterol) 10 – 20 min prior  alt Rx: montelukast or inhaled steroids daily --------------------------------------------------------------- cirrhosis & ascites with fever or mental status change: spontaneous bacterial peritonitis (SBP)  hypotension, hypothermia, or paralytic ileus indicates severe infection  MCC: E. coli & Klebsiella  Dx/Rx: paracentesis (performed before ABX)  Dx =  PMN count > 250, +culture  SAAG > 1.1 g/dL (indicates portal HTN)  Rx: empiric 3rd gen cephalosporin (cefotaxime) --------------------------------------------------------------- Riluzole (glutamate inhibitor) Rx: ALS  corticosteroids: Rx acute exacerbations of MS --------------------------------------------------------------- hepatic adenoma: benign tumor common in young/mid-aged women; chronic OCP use  solitary mass in right hepatic lobe   ALP & GGT  Bx: sheets of enlarged hepatocytes containing glycogen & lipid deposits  Rx: surgical resection if symptomatic  complications: intra-tumor hemorrhage & malignant transformation ( AFP) --------------------------------------------------------------- abdominal fat pad Bx for suspected amyloidosis --------------------------------------------------------------- IgM spike on electrophoresis, hyperviscocity due to excess IgM: Waldenstrom’s  anemia, lymphadenopathy, hepatosplenomegaly 

DDx: MM (involve IgG or IgA), MGUS (mild symptoms or asymptomatic) ---------------------------------------------------------------  serum protein with normal albumin (gamma gap) o DDx: multiple myeloma, amyloidosis, Waldenstrom’s, MGUS  monoclonal gammopathy uncertain significance (MGUS) can be differentiated from MM by absence of renal insufficiency, hypercalcemia, anemia, & lytic bone lesions o MGUS is asymptomatic; 1% per year risk of progression to MM  Dx: metastatic skeletal bone survey to exclude lytic bone lesions that suggest MM --------------------------------------------------------------- single photon emission CT (SPECT) scan is useful for evaluating CAD; indicates inducible ischemia when a reversible defect is noted on stress & at rest  Rx: antiplatelets (ASA) --------------------------------------------------------------- metformin can cause lactic acidosis if given to patients predisposed to hypoxia (CVD, CKD) --------------------------------------------------------------- male infant, recurrent pneumonia & otitis media after age 6 – 9 months: Bruton’s  XR defect in B-cell tyrosine kinase  all serum Ig’s & B-cells levels decreased  recurrent pyogenic infections (S. pnemo, H. infl)  maternal IgG maintained for first 6 months --------------------------------------------------------------- CVID: serum Ig’s decreased; similar to Bruton’s  less severe symptoms & later onset (age 15 – 35 yrs)  normal circulating B cells --------------------------------------------------------------- neonate with hypocalcemic seizures: DiGeorge --------------------------------------------------------------- mortality benefits in CHF: ACE-I, β-blockers, ARB, spironolactone  digoxin decreases hospitalizations in CHF  dobutamine: temporary Rx for severe decompensated CHF to improve contractility, but  risk for arrhythmia --------------------------------------------------------------- Friedrich ataxia: MC spinocerebellar ataxia  AR, median survival rarely beyond 20 yrs 

gait ataxia, frequent falls, dysarthria concentric cardiac hypertrophy, scoliosis, hammer toes  MCC death: cardiomyopathy ---------------------------------------------------------------Causes of AUB in premenopausal women o structural: fibroids, adenomyosis, endometrial polyp, malignancy o non-structural: coagulopathy, infection o ovulatory dysFx: prolactinoma, PCOS, thyroid disorder, eating disorder, weight loss  #1 Dx: exclude pregnancy  Dx: endometrial Bx --------------------------------------------------------------- postmenopausal women with AUB are at high risk for endometrial cancer  Dx: transvaginal USS, then endometrial Bx  

endometrial biopsy is indicated for evaluating abnormal uterine bleeding for….  all women ≥ 45 & all postmenopausal bleeding  women < 45 with persistent symptoms or risk factors for endometrial cancer  unopposed estrogen exposure (obesity, PCOS)  prolonged amenorrhea with anovulation ---------------------------------------------------------------Risk factors Endometrial carcinoma Breast cancer  advancing age  family Hx  unopposed estrogen  BRCA1/BRCA2  chronic tamoxifen  early menarche  obesity  late menopause  nulliparity  prolonged HRT  chronic anovulation  nulliparity (PCOS)  HNPCC ---------------------------------------------------------------Endometrial biopsy for AUB  hyperplasia without atypia (< 3% cancer risk)  Rx: progestin therapy to oppose estrogen  F/U in 3 months to assess response  hyperplasia with atypia (30% cancer risk)  if considering pregnancy  progestin  if no pregnancy plans  hysterectomy

--------------------------------------------------------------- endometrial ablation is contraindicated with endometrial hyperplasia; prevents future evaluation of the endometrium by biopsy --------------------------------------------------------------- peripheral artery aneurysm: pulsatile mass that compresses adjacent structures, results in thrombosis & ischemia  anterior thigh pain 2/2 femoral nerve compression  popliteal & femoral artery aneurysm are a/w AAA ---------------------------------------------------------------Cervicitis  #1 MCC: C. trachomatis  #2 MCC: N. gonorrhea (urethritis & PID) o 50% asymptomatic o friable cervix with easy bleeding, mucopurulent discharge  Rx uncomplicated gonococcal cervicitis/urethritis: ceftriaxone + azithromycin or doxycycline, which covers resistant gonococci & simultaneous Rx C. trachomatis  do not delay empiric Rx to confirm Dx  Dx: nucleic acid amplification testing --------------------------------------------------------------- amiodarone causes pulmonary toxicity  related to cumulative dose  avoid in patients with pre-existing lung disease 2/2 decreased pulmonary reserve --------------------------------------------------------------- IM epinephrine can prevent/reverse progression of anaphylaxis to anaphylactic shock  β2-agonist effect: bronchodilation &  systemic release of inflammatory mediators  α1-agonist effect: vasoconstriction raises BP &  upper airway edema  bee stings: refer for venom immunotherapy --------------------------------------------------------------- ASA/salicylate intoxication leads to respiratory alkalosis by stimulating respiratory center, & anion gap metabolic acidosis by uncoupling oxidative phosphorylation, leads to anaerobic metabolism  triad: fever, tinnitus, tachypnea  ABG: low PaCO2, low HCO3, normal pH  mixed respiratory alkalosis & metabolic acidosis

--------------------------------------------------------------- acute Hep B markers: HBsAg & IgM anti-HBc o both are elevated during “window period”  HBsAg: first to appear 4 -8 wk after infection  HBcAg is not detectable --------------------------------------------------------------- fever, lethargy, signs of heart failure after a viral prodrome in a child: viral myocarditis  MCC: Coxackie B, Adenovirus  myocyte necrosis impairs systolic/diastolic function  heart failure signs: dyspnea, syncope, N/V, tachycardia, hepatomegaly  CXR: cardiomegaly, pulmonary edema  echo: diffuse hypokinesis  Dx: myocardial biopsy shows inflammatory infiltrate of myocardium with myocyte necrosis  Rx: diuretics, inotropes, ICU --------------------------------------------------------------- Paget’s disease of bone is typically asymptomatic, with incidentally  ALP o normal Ca++, phosphorous, & GGT  symptomatics present with pain a/w long bone fx resulting in secondary arthritis of hip or knee  defective osteoid formation at sites of high bone turnover; abnormal bone remodeling  Dx: elevated ALP; also nuclear bone scan to determine extent of skeletal involvement  Rx: bisphosphonates only if symptomatic  highest risk for hearing loss & osteosarcoma  DDx: prostate ca with bone mets, MM, statins, biliary obstruction, osteoporosis ---------------------------------------------------------------Indications for treating Paget’s disease of bone  symptomatic bone & joint pain  hypercalcemia of immobilization  neuro-compressive symptoms  high-output cardiac failure  involvement of weight-bearing bones  symptomatic pseudofractures --------------------------------------------------------------- sudden worsening of asthma & nasal congestion 30 min – 3 hr after NSAIDs ingestion

ASA-exacerbated respiratory disease (AERD): non-IgE mediated reaction due to ASA-induced prostaglandin/leukotriene imbalance o arachidonic acid is diverted to production of leukotrienes via 5-lipoxygenase pathway  development of asthma & chronic rhinosinusitis with nasal polyps, bronchospasm & nasal congestion following ASA or NSAID ingestion: pseudoallergic drug reaction  Rx: montelukast, avoid NSAIDs --------------------------------------------------------------- volume overload & ascites are complications of decompensated liver cirrhosis  Rx: loop diuretics; A/E: hypokalemia, metabolic alkalosis, prerenal azotemia --------------------------------------------------------------- pulmonary HTN: long-standing primary pulmonary or cardiac disease o dyspnea on exertion, fatigue, LE edema  pulmonary edema: fluid accumulation in air spaces & parenchyma of the lungs, leading to impaired gas exchange, due to either LV failure to adequately remove blood from the pulmonary circulation ("cardiogenic "), or injury to the lung parenchyma or vasculature of the lung ("noncardiogenic ") ---------------------------------------------------------------Infectious etiology of genital ulcers HSV multiple, grouped shallow ulcers (genital herpes) with erythematous base, (PAINFUL) tender lymph nodes, recurrence is common H. ducreyi single/multiple deep ulcers with (chancroid) irregular/ragged border, friable base, gray/yellow exudate, (PAINFUL) matted & tender lymph nodes 

T. pallidum (10 syphilis) (PAINLESS) C. trachomatis (LGV) (PAINLESS) Donovanosis (granuloma

single, indurated, well-circumscribed papule/chancre that ulcerates punched-out, clean base, painless inguinal lymphadenopathy painless, small shallow ulcers, large & painful “buboes” ulcers with red, beefy base no lymphadenopathy

inguinale)

does not resolve with ABX

vulvar pain, malaise, dysuria, painful labial ulcers a/w inguinal lymphadenopathy: genital herpes due to HSV  non-tender pedunculated lesions (genital warts) due to HPV; can progress to SCC if untreated  primary syphilis Dx: dark field microscopy o high rate of false negatives with RPR, FTA-ABS serologic testing --------------------------------------------------------------- familial colonic polyposis (FAP): 100% cancer risk  AD inheritance, APC gene mutation  Rx: elective proctocolectomy --------------------------------------------------------------- EEG: symmetrical 3 Hz spike-and-wave activity on a normal background; provoked/simulated by hyperventilation: absence seizure (petit mal)  MCC: age 4 – 8 yrs  daydreaming episodes, no post-ictal state  Rx: valproate or ethosuximide --------------------------------------------------------------- complex partial seizures: brief episodes of impaired consciousness, postictal confusion, staring spells, failure to respond to stimuli, automatisms (swallowing, lip smacking, hand picking movements)  EEG: normal or brief discharges; hyperventilation cannot simulate complex partial seizures --------------------------------------------------------------- Lennox-Gastaut syndrome: childhood seizures of multiple types, mental retardation, age < 7 yrs  EEG: slow spike-and-wave --------------------------------------------------------------- H. pylori with MALT lymphoma w/o metastasis  Rx: omeprazole + clarithromycin + amoxicillin o Rx: CHOP chemotherapy if ABX fails (cyclophosphamide, adriamycin, vincristine, prednisone) --------------------------------------------------------------- Toxic megacolon is a complication of UC  UC: multiple bloody BMs, fever, weight loss  megacolon: total or segmental nonobstructive colonic dilation, severe bloody diarrhea, fever, tachycardia, leukocytosis 

also volume depletion, altered mental status, hypotension, electrolyte abnormalities  XR: dilated right or transverse colon (> 6 cm)  Dx: XR, +anemia, fever > 380C, pulse > 120, WBC > 10,000  medical emergency!!  Rx: IV fluids, ABX, bowel rest o IV steroids if IBD-induced --------------------------------------------------------------- right-sided colon cancer presents with anemia  left-sided colon cancer presents with obstruction  both are a/w change in bowel habits --------------------------------------------------------------- intestinal lymphoma: diffuse infiltrate by atypical lymphocytes  occult blood in stool, abdo pain, weight loss, N/V --------------------------------------------------------------- clinical evidence of PE should be anticoagulated before undergoing diagnostic evaluation  Rx:  presence of DVT features should have Dx confirmed before starting anticoagulation Wells criteria for pretest probability of PE +3 points o clinical signs of DVT o alternate Dx less likely than PE +1.5 points o previous PE or DVT o HR > 100 o recent surgery or immobilization +1 point o hemoptysis o cancer Total score < 2  low risk 2 – 6  moderate risk > 7  high risk 



evaluation of DVT: assess pretest probability using Modified Wells Criteria o if DVT not likely  D-dimer testing  low D-dimer  DVT unlikely  high D-dimer  compression USS

if DVT likely  compression USS  negative USS  DVT unlikely  positive USS  anticoagulate  DDx of DVT: venous insufficiency, cellulitis, ruptured Baker cyst, post-thrombotic syndrome --------------------------------------------------------------- tachypnea, weight loss, polydipsia, polyuria: DKA  Dx: fingerstick glucose --------------------------------------------------------------- atlantoaxial instability should be suspected in Down syndrome presenting with UMN findings  behavioral changes, urinary incontinence, torticollis, dizziness, vertigo, diplopia  Rx: surgical fusion ---------------------------------------------------------------DDx of metabolic alkalosis  low urine chloride o vomiting, NG aspiration, laxative abuse o volume depletion, decreased oral intake o prior diuretic use**  high urine chloride o hypovolemic/euvolemic  current diuretic use* o hypervolemic  excess mineralocorticoid (primary hyperaldosteronism, Cushing’s, ectopic ACTH, severe hypokalemia)  saline-resistant type: high urine chloride o Rx underlying disorder  saline-responsive type: low urine chloride o Rx: isotonic saline corrects hypochloremia & promotes urinary HCO3- excretion  loop diuretics would worsen metabolic alkalosis, hypokalemia, & volume depletion --------------------------------------------------------------- blood type & Ab screen @ first prenatal visit  HIV screen @ first prenatal visit; rescreen @ 3rd trimester if high-risk  asymptomatic bacteriuria screen @ 1st trimester  routine GBS rectovaginal screen @ 35 – 37 wk, results valid for 5 weeks ---------------------------------------------------------------Rh alloimmunization/sensitization  anti-D antibodies that form after prior pregnancy or blood transfusion to Rh+ fetus/blood  antepartum prophylaxis not need if father is Rho

prophylactic anti-D Ig for unsensitized Rh- mom o @ 28 – 30 wk gestation  repeat within 72 hr of delivery of Rh+ infant or spontaneous, threatened, or induced abortion o ectopic or hydatidiform pregnancy o after CVS or amniocentesis o abdominal trauma, 2nd or 3rd trimester bleed o external cephalic version  Kleihaur-Betke test: calculates anti-D Ig dose; performed if placental abruption occurs in pregos --------------------------------------------------------------- OCPs can cause HTN o switch to an alternate birth control method  if HTN persists Dx: essential HTN  initial Rx: diet & exercise  Rx: low-dose thiazide --------------------------------------------------------------- hypertrophic cardiomyopathy (HCM): asymmetric LVH leads to outflow tract obstruction  AD inheritance, MC in African-Americans  crescendo-decrescendo systolic murmur @ LLSB  due to interventricular septal hypertrophy & systolic anterior motion (SAM) of mitral leaflet  dual upstroke carotid pulse  Rx: β-blocker (prolongs diastole); or diltiazem Effect of maneuvers on HCM   preload =  intensity (Valsalva, standing, nitro)   preload/afterload =  murmur intensity (hand grip, squatting, passive leg raise) --------------------------------------------------------------- no detailed metabolic evaluation needed for a first renal stone Management of nephrolithiasis  Dx: abdominal CT without contrast  Rx: NSAIDs & narcotics are equally effective o narcotics can exacerbate N/V  < 5 mm can pass spontaneously o conservative Rx: fluid intake > 2 L/day  urology referral for anuria, urosepsis, ARF --------------------------------------------------------------- uric acid stones are radiolucent, seen on USS or CT  MC in patients with low urine pH  Rx: hydration, urine alkalization, low protein diet 

Rx: potassium citrate to alkalinize urine o citrate inhibits stones &  crystallization o Rx recurrent stones due to citrate deficiency  allopurinol can be added if hyperuricosuria --------------------------------------------------------------- mucormycosis due to Rhizopus: direct extension of rhinosinusitis via paranasal sinuses  MC in immunocompromised & uncontrolled DM  fever, bloody nasal discharge, nasal congestion  also eye involvement: chemosis, proptosis, diplopia  necrotic nasal turbinates shows hyphae on KOH  Rx: surgical debridement & IV amphotericin B  complication: blindness, cavernous sinus thrombosis, coma & death if untreated --------------------------------------------------------------- MTX: purine antimetabolite, DMARD  A/E: oral ulcers, stomatitis, hepatotoxicity, rash, pulmonary toxicity, bone marrow suppression, alopecia, macrocytic anemia  folic acid supplementation reduces A/E’s --------------------------------------------------------------- β-thalassemia major: impaired β-globin production, leads to excess α-globin chains  chronic hemolysis, transfusion-dependent anemia  β-thalassemia minor: one normal β-globin allele o mainly asymptomatic, mild anemia o high RBC count, low MCV, Hb > 10  Rx: no therapy required o can present similar to iron deficiency anemia  iron deficiency: low RBC count, becomes microcytic when Hb < 10 ---------------------------------------------------------------

---------------------------------------------------------------iron αβ-

MCV RDW RBC count PBS

deficiency anemia   low

thalassemia

thalassemia

 normal

 normal high

microcytic, hypochromi c  ferritin,  TIBC  Hb

target cells

target cells

iron normal/ iron normal/ iron studies & ferritin & ferritin response does not does not to iron improve improve Hb normal normal  Hb A2 electro  thalassemia trait: often found incidentally on universal screening for anemia at age 1 yr  low MCV,  total RBC count, normal RDW o rarely require Rx, but Dx for genetic counseling o iron Rx can cause hemochromatosis  iron deficiency:  RDW,  total RBC count --------------------------------------------------------------- folic acid supplementation: megaloblastic anemia, hereditary spherocytosis, PND, sickle cell disease, β-thalassemia major, on MTX --------------------------------------------------------------- prednisone: Rx autoimmune hemolytic anemia --------------------------------------------------------------- TNF-α inhibitors: anti-cytokine o infliximab, etanercept  Rx: chronic RA  A/E: neutropenia, latent TB reactivation, CHF, demyelination, risk of malignancy --------------------------------------------------------------- renal vein thrombosis is a/w nephrotic syndrome  membranous glomerulopathy  due to loss of anti-thrombin III in urine --------------------------------------------------------------- conversion disorder: sudden onset of neurologic symptoms incompatible with neuro exam  unexplained weakness, non-epileptic seizures, paralysis, ataxia, aphonia, blindness, or paresthesia  triggered by stress or emotions  not feigned or intentional; “la belle indifference”  #1 Rx: education, encouragement, support

 #2 Rx: CBT --------------------------------------------------------------- somatic symptom disorder: ≥1 persistent physical symptom; excessive anxiety, concern & energy devoted to symptoms; persists ≥ 6 months  physiologic symptoms: pain, heartburn, fatigue  Rx: regularly scheduled appointments focusing on psychological distress; emphasize reassurance --------------------------------------------------------------- depression with comorbid medical conditions, including terminal illness  short life expectancy Rx: rapid psychostimulants (methylphenidate, modafinil)  long life expectancy Rx: SSRI (takes longer to reach therapeutic effect) --------------------------------------------------------------- preterm labor: uterine contractions @ < 37 wks gestation; cervical dilation &/or effacement  preterm labor @ < 34 wks should receive… o tocolytic (CCB, β-blockers, NSAIDs) o Mg-sulfate for neuroprotection o corticosteroids for lung maturity --------------------------------------------------------------- crampy lower abdominal & back pain during menses, normal exam: primary dysmenorrhea o Rx: NSAIDs & OCPs  pain 1 to 2 days before menstruation, dyspareunia, dysmenorrhea, infertility: endometriosis  heavy menses with clots, constipation, urinary frequency, pelvic pain; irregular/enlarged uterus: fibroids  dysmenorrhea, menorrhagia, pelvic pain; bulky, globular & tender uterus: adenomyosis  dull & ill-defined pelvic pain that worsens with standing & relieved with menses, dyspareunia: pelvic congestion ---------------------------------------------------------------DDx of acute pelvic pain Mittelschmer recurrent mild, unilateral mid-cycle z pain 2/2 normal follicular enlargement prior to ovulation ectopic crampy abdominal pain, amenorrhea, pregnancy vaginal bleed, +β-hCG ovarian acute onset unilateral abdominal pain, torsion N/V, tender adnexal mass,

pelvic USS: enlarged, edematous ovary with  blood flow ruptured sudden onset U/L abdominal pain ovarian cyst after strenuous or sexual activity, pelvic USS: free fluid near cyst PID fever/chills, new vaginal discharge, dysuria, cervical motion tenderness, transvaginal USS: r/o tubo-ovarian abscess  uncomplicated ovarian cyst rupture: no fever, hypotension, tachycardia, or hemoperitoneum o Rx: analgesics as outpatient --------------------------------------------------------------- situational syncope: 2/2 autonomic dysregulation (LOC after urination or during coughing fits) --------------------------------------------------------------- postexposure HIV prophylaxis: immediately start with 3-drug antiviral therapy for 4 weeks following high-risk occupational exposure to blood or body fluids from HIV-infected individuals  Rx: tenofovir, emtricitabine, + raltegravir  HIV testing immediately to establish baseline status; repeat @ 6 weeks, 3 months, & 6 months --------------------------------------------------------------- Strep pneumoniae: MCC of community-acquired pneumonia & nursing homes --------------------------------------------------------------- pivoting/twisting injury or knee struck from lateral side with foot planted: MCL tear  immediate swelling of knee joint 2/2 effusion  Rx: bracing & early ambulation o surgery is rarely needed --------------------------------------------------------------- high index of suspicion for physical/sexual abuse in children with sudden behavioral problems, unstable economic backgrounds, or parents with a Hx of drug/alcohol abuse --------------------------------------------------------------- vertigo, ear fullness, tinnitus, & hearing loss: Meniere’s disease  endolymph accumulation in inner ear  horizontal nystagmus during acute attacks  #1 Rx: environmental & dietary modifications  low-salt diet; avoid caffeine, nicotine, alcohol ----------------------------------------------------------------

inflammation of pericolic fat, thickened bowel wall, soft tissue mass (phlegmons), pericolic fluid suggesting abscess: diverticulitis  Dx: abdominal CT --------------------------------------------------------------- calcium oxalate crystals are a frequent finding in urinary sediment, not clinically significant unless symptoms suggest acute nephrolithiasis --------------------------------------------------------------- persistent PTX & significant air leak following chest tube placement in a patient with sustained blunt chest trauma: tracheobronchial rupture  pneumomediastinum & subcut. emphysema  confirm Dx: high-resolution CT, bronchoscopy, or surgical exploration --------------------------------------------------------------- painless blisters on back of hand, hypertrichosis, hyperpigmentation: porphyria cutanea tarda  uroporphyrinogen decarboxylase deficiency  a/w Hep C  triggers: alcohol, estrogens  Dx: elevated urine porphyrin  Rx: phlebotomy, hydroxychloroquine, interferon-alpha ---------------------------------------------------------------Prenatal testing for fetal aneuploidy advantages disadvantages cff DNA high sensitivity & (≥ 10 wks) specificity for not diagnostic aneuploidy 1st trimester combined noninvasive not diagnostic test (9 – 13 wks) 2nd trimester quad screen noninvasive not diagnostic (15 – 20 wks) CVS early definitive pain, vaginal (10 – 13 wks) karyotypic Dx spotting, risk of pregnancy loss amniocentesi definitive pain, risk of bleed s karyotypic Dx & amniotic fluid (15 – 20 wks) leak 2nd trimester fetal growth, cannot identify all USS anatomy, placenta abnormalities; 

(18 – 20 wks)

position

soft markers

pregos age ≥ 35 at increased risk of aneuploidy should be offered cell-free fetal DNA o abnormal cffDNA should be confirmed by fetal karyotyping with CVS (1st trimester) or amniocentesis (2nd trimester)  low risk of aneuploidy: 1st trimester combined test o PAPP, β-hCG, USS nuchal translucency  2nd trimester (18 – 20 wks) Quad screen o maternal AFP, β-hCG, estriol, inhibin A o  AFP & estriol, with  β-hCG & inhibin A is a/w Down’s  next: transabdominal USS to evaluate fetal anatomy & growth; abnormal markers  risk o next: amniocentesis to confirm abnormal quad screen --------------------------------------------------------------- aminoglycosides cause ototoxicity (hearing loss) by damaging cochlear cells  gentamicin causes selective vestibular injury (vestibulopathy) without significant ototocity  oscillopsia: sensation of objects moving around in the visual field when looking in any direction; leads to gait disturbance  Dx: head thrust test (inability to maintain eyes on a target) --------------------------------------------------------------- myasthenia gravis: diplopia, jaw fatigue after prolonged chewing, dysarthria with talking  normal reflexes  hallmark: resolution of weakness with rest  Dx: EMG & ACh Rc antibody test  also chest CT to screen/exclude for thymoma --------------------------------------------------------------- Rx options for myasthenia gravis o pyridostigmine: symptomatic relief only (A/E: cramps, fasciculations, weakness) o atropine: anticholinergic; prevents muscarinic A/E of anticholinesterases o immunosuppressives: induce remission (prednisone, azathioprine, cyclosporine) o thymectomy: induces remission o plasmapheresis: Rx myasthenia crisis 

edrophonium: short-acting anticholinesterase; Dx only --------------------------------------------------------------- atropine: Rx to prevent muscarinic side effects of AChE inhibitor with myasthenia gravis --------------------------------------------------------------- incentive spirometry is the most effective at preventing post-op pulmonary complications --------------------------------------------------------------- PAPP-A is produced by trophoblast  1st trimester screen with PAPP-A + β-hCG along with USS nuchal translucency to detect Down’s o Down’s produces less PAPP-A --------------------------------------------------------------- well-appearing infant with intermittent cyanosis & distress during feeing, relieved by crying: choanal atresia  Dx: head CT --------------------------------------------------------------- CHARGE syndrome: Coloboma, Heart defects, Atresia of choanae, Renal anomalies, Growth impairment, Ear abnormalities --------------------------------------------------------------- dermatitis herpetiformis is a/w Celiac’s  intensely pruritic papules, vesicles over elbows, knees, buttocks, posterior neck, scalp  IF: granular IgA deposits along dermal papillae  +anti-endomysial antibodies  Rx: dapsone (heals within hours) --------------------------------------------------------------- benign paroxysmal positional vertigo (BPPV): Ca++ crystals in semicircular canals (canaliths)  MCC of vertigo  brief, recurrent episodes of “room spinning” with head movements or position change  no neurologic or auditory symptoms  Dx: Dix-Hallpike maneuver cause nystagmus  Rx: Epley maneuver --------------------------------------------------------------- lateral cerebellar infarction: dizziness, ataxia, weakness, swaying TOWARD the lesion side --------------------------------------------------------------- hypercalcemia, renal insufficiency, metabolic alkalosis: milk-alkali syndrome  normal phosphate & ALP levels o

--------------------------------------------------------------- methamphetamine: CNS stimulant  HTN, tachycardia, agitation, aggressiveness  acne or facial sores due to skin picking --------------------------------------------------------------- drug-induced hypersensitivity reaction, Type I: drug-specific IgE occupy receptors on mast cells & basophils; immediate onset o Rx: antihistamines for urticarial & pruritus o Rx: epinephrine & corticosteroids for anaphylaxis with systemic symptoms  ABX-induced rash due to infectious mononucleosis 2/2 EBV develops after 24 hr --------------------------------------------------------------- confusion, lethargy, fatigue, anorexia, polyuria, constipation, CXR suggestive of lung cancer: hypercalcemia of malignancy  2/2 PTHrP production  a/w squa-Ca++-mous cell lung cancer --------------------------------------------------------------- tremor is often first manifestation of Parkinson’s, can present asymmetrically  Rx: trihexyphenidyl (anticholinergic) for younger patients if tremor is the primary symptom --------------------------------------------------------------- all suspected BPH: U/A & serum creatinine   Cr suggests bladder outlet obstruction  Dx: renal USS  Rx: urinary catheter, tamsulosin, finasteride o TURP for refractory symptoms --------------------------------------------------------------- Charcot joint: neurogenic arthropathy  a/w Vit B12 deficiency, diabetes   proprioception, pain & temp sensation  unknowingly traumatizes weight-bearing joints, results in secondary DJD & joint deformities  XR: loss of cartilage, osteophytes, loose bodies  Rx: underlying disease, mechanical devices to decreased further trauma --------------------------------------------------------------- patchy neurological deficits, painful loss of vision, central visual field defect, normal fundoscopy: MS  optic neuritis, Uhthoff phenomenon, Lhermitte sign  scanning speech

CSF: normal pressure & total protein, elevated IgG & oligoclonal bands (not diagnostic)  Dx: MRI show cerebral or cerebellar plaques as hypo/hyperdense lesions involving white matter --------------------------------------------------------------- contraindication for use of succinylcholine for rapid-sequence intubation: hyperkalemia  also burn & crush injury (rhabdomyolysis), prolonged demyelination (Guillain-Barre, tumor lysis syndrome)  succinylcholine causes significant K+ release & life-threatening arrhythmias  safe alternatives: vecuronium, rocuronium --------------------------------------------------------------- CBT: reduces automatic negative thoughts & avoidance behaviors that cause distress  uses: depression, anxiety, PTSD, OCD, somatoform disorders, eating disorders --------------------------------------------------------------- psychodynamic psychotherapy focuses on the role that unconscious conflict causes symptoms; emphasize ways in which passive experiences shape the present situations --------------------------------------------------------------- chorioamnionitis: maternal fever PLUS ≥ 1: uterine tenderness, maternal or fetal tachycardia, malodorous amniotic fluid, or purulent discharge  risk factor: PROM (> 18 hr)  MCC: polymicrobial  Dx: IV ABX & oxytocin to accelerate labor o c-section for normal OB indications --------------------------------------------------------------- cor pulmonale: isolated RHF 2/2 pulmonary HTN; MCC is COPD  exertional syncope, exertional angina, JVD, ascites  RV heave, dependent pitting edema, hepatomegaly  Dx: right heart catheterization show RV dysFx, pulmonary HTN, & absence of left heart disease --------------------------------------------------------------- DDx of anterior mediastinal mass: “4 Ts” = thymoma, teratoma, thyroid, terrible lymphoma  bronchogenic cysts: middle mediastinum  all neurogenic tumors: posterior mediastinum 

meningocele, enteric cysts, lymphoma, esophageal tumors, diaphragmatic hernias, aortic aneurysms --------------------------------------------------------------- seminomas:  β-hCG only  non-seminomatous germ cell tumors o yolk sac tumors, choriocarcinoma, embryonal carcinoma o  AFP,  β-hCG ---------------------------------------------------------------Neonatal bowel obstruction  if stable, initial test: abdominal XR to rule out pneumoperitoneum due to bowel perforation, which would require emergency surgery  next test: water-soluble contrast enema  microcolon is caused by viscous meconium accumulation in terminal ileum due to CF o Rx: Gastrografin hyperosmolar enema  narrow rectosigmoid & dilated megacolon transition zone: Hirschsprung disease o next test: rectal biopsy (absent ganglion cells) --------------------------------------------------------------- CXR: widened mediastinum, left-sided hemothorax, right-sided mediastinal deviation, disruption of normal aortic contour  rapid deceleration blunt chest trauma are high risk for aortic injury with contained aortic rupture  confirm Dx: CT angiogram --------------------------------------------------------------- pneumomediastinum & pleural effusion: esophageal rupture  Dx: water-soluble contrast esophagography --------------------------------------------------------------- sudden onset dyspnea, colicky abdominal pain, rapid-onset for edema of the face, extremities, & genitals without urticaria: hereditary angioedema  complement C1 inhibitor deficiency results in elevated bradykinin; normal C1q levels,  C4  episodes following infection, dental procedures, or trauma --------------------------------------------------------------- MCC of acquired isolated angioedema: ACE-I  low C1q levels  can occur at anytime o

also, ACE-I can precipitate ARF in patients with B/L renal artery stenosis --------------------------------------------------------------- child with nocturnal headaches, morning vomiting, with coexisting otitis & mastoiditis: temporal brain abscess  intracranial pressure increases in supine position & stimulates medullary vomiting center  Dx: solitary ring-enhancing lesion on CT with contrast or MRI  Rx: high-dose corticosteroids --------------------------------------------------------------- 3 phases of viral hepatitis: prodromal, enteric, convalescent Hep A Hep B Hep C incubation 30 days 1–3 40 – 50 period months days transmssn contaminated sexual, parenteral food or water, parenteral, fecal-oral vertical risk factors recent travel IVDA prognosis self-limited cirrhosis, HCC 

acute onset malaise, anorexia, N/V, mild abdo pain, aversion to smoking: Hep A  hepatosplenomegaly, AST/ALT spike  Rx: supportive; close contacts: Hep A Ig --------------------------------------------------------------- dysphagia, salivation, mouth burns, severe pain, white tongue: caustic poisoning  does not cause altered mental status  complications: peritonitis, mediastinitis --------------------------------------------------------------- hyperthermia, mydriasis, delirium, dry, mouth, urinary retention, decreased bowel sounds: anticholinergic toxicity o Rx: physostigmine  CNS depression, arrhythmias, hypotension, anticholinergic signs: TCA poisoning o Rx: sodium bicarbonate  anticholinergic symptoms, drowsiness, confusion: diphenhydramine toxicity o Rx: physostigmine 

headache, vomiting, abdo pain, phosphorus skin, bitter almond odor: cyanide toxicity o Rx: sodium thiosulfate  tinnitus, N/V, fever, acid-base abnormalities: salicylate intoxication o Rx: sodium bicarbonate to alkalinize urine  HTN, hyperthermia, tachycardia, diaphoresis, mydriasis, hyperreflexia: serotonin syndrome o Rx: benzo (lorazepam)  horizontal nystagmus, cerebellar ataxia, confusion: phenytoin toxicity  tremor, hyperreflexia, ataxia, seizure: lithium tox. o Rx: hemodialysis --------------------------------------------------------------- undiagnosed pleural effusion is best evaluated with thoracocentesis  Dx: diagnostic thoracocentesis o if clear evidence of CHF  trial of diuretic  transudate or exudate?  transudative effusion rules out malignancy  lung carcinoma, breast carcinoma, & lymphoma: MCC malignant exudative pleural effusion --------------------------------------------------------------- artificial heart valves or severely calcified valves cause microangiopathic hemolytic anemia   LDH,  haptoglobin,  indirect bilirubin, reticulocytosis, schistocytes  chronic hemolysis leads to iron loss & microcytic anemia --------------------------------------------------------------- autoimmune hemolysis: +direct Coombs, +spherocytes --------------------------------------------------------------- AL amyloidosis (primary): MM, Waldenstrom  AA amyloidosis (secondary to chronic inflmmation): RA, TB, Crohn’s, lymphoma, vasculitis --------------------------------------------------------------- rheumatoid arthritis predisposes to AA amyloidosis  causes nephrotic syndrome  enlarged kidneys, hepatomegaly  renal Bx: amyloid deposits stain with Congo red & apple-green birefringence ---------------------------------------------------------------

elderly, memory impairment, social withdrawal, depressed mood: pseudodementia  poor effort with cognitive testing  distressed by impaired memory (Alzheimer’s are indifferent & confabulate)  Rx: SSRI improves depression & cognition --------------------------------------------------------------- crescent formation on light microscopy: RPGN  hyalinosis of afferent & efferent arterioles: diabetic nephropathy  linear deposits & anti-IgM: Goodpasture’s  granular deposits: immune complex GN (postinfectious GN, lupus nephritis, IgA neph) --------------------------------------------------------------- unexplained chronic & severe abdo pain, weight loss, food aversion: chronic mesenteric ischemia  chronic occlusion of visceral arteries leads to worsening postprandial pain & food avoidance  evidence of atherosclerotic disease (HTN, CAD, DM type II, hypercholesterolemia, PVD)  nonspecific physical exam, XR, CT scan  Dx: angiography or Doppler USS --------------------------------------------------------------- acute aortic dissection can cause hemopericardium, progress to cardiac tamponade & cardiogenic shock  Dx: TEE (hemodynamically stable)  Rx: IV labetalol  Rx: pericardiocentesis (hemodynamically unstable) --------------------------------------------------------------- sharp, pleuritic chest pain, pericardial friction rub, uremia (BUN > 60): uremic pericarditis  do not have classic EKG changes  Rx: hemodialysis --------------------------------------------------------------- brain infarct: hypodense on CT scan  IC hemorrhage: hyperdense on CT scan o Rx: stop warfarin & ASA, give FFP & Vit K --------------------------------------------------------------- after blunt chest trauma, hemorrhagic shock a/w decreased breath sounds & dullness to percussion over one hemithorax & C/L tracheal deviation: massive hemothorax  MCC: traumatic laceration of lung parenchyma or damage to intercostal/internal mammary artery 

DDx: tension PTX (hyperressonance), pulmonary contusion (no hemorrhagic shock) ---------------------------------------------------------------

--------------------------------------------------------------- case-control study: determines outcome first  then compares past associated risk factors  retrospectively assess outcomes with risk factors  obtained by interviews, health records, lab reports  used to measure odds ratio --------------------------------------------------------------- retrospective cohort: reviews prior records for risk factor exposure  then determine incidence o both risk factors & outcome occur in the past --------------------------------------------------------------- prospective cohort study: chose subjects based on risk factors, then compare disease incidence  allows for calculation of relative risk  observational  better ability to prove causation than case control & cross-sectional studies --------------------------------------------------------------- cross-sectional study: current risk factor exposures  compare disease prevalence  observational  assess exposure & outcome simultaneously  shows an association, but not causation --------------------------------------------------------------- informed consents obtained from either parent of a minor prior to performing a procedure

exception is emergency conditions, transfusions, & surgery --------------------------------------------------------------- alopecia, skin lesions, abnormal taste, impaired wound healing: zinc deficiency  2/2 chronic TPN or malabsorption  found in animal protein, whole grains, beans, nuts  digested in the jejunum --------------------------------------------------------------- selenium deficiency: cardiomyopathy --------------------------------------------------------------- fever, focal spinal tenderness, neurologic dysFx: spinal epidural abscess  risk factors: IVDA, immunocompromised, infectious hematogenous spread, vertebral body osteomyelitis, steroid injections, epidural anesthesia  MCC: S. aureus  Dx: spine MRI with gadolinium, ESR, CRP, CTguided aspiration & culture  Rx: ABX, surgical decompression & drainage  complications: cord compression, cauda equina ---------------------------------------------------------------Common skin infections fiery red, tender, painful plaque Erysipelas with demarcated edges; limited to (S. pyogenes) epidermis & superficial dermis folliculitis: purulence in hair follicle Cellulitis in areas of heavy friction/sweating (purulent) furuncles: folliculitis extending into S. aureus dermis, leads to abscess carbuncle: severe infection due to aggregation of multiple furuncles erythema, edema, tenderness Cellulitis flat subcut. lesions, less demarcated (non-purulent) regional lymphadenopathy Group A Strep 

risk factors: venous insufficiency, skin disruption, obesity  Rx: oral ABX; or IV ABX if systemic involvement (hypotension, tachycardia) o nafcillin: IV anti-staphylococcal --------------------------------------------------------------- flail chest Rx: pain control, supplement O2, PPV ---------------------------------------------------------------DDx of depressed mood 

MDD o ≥ 2 wks, 4/9 SIGECAPS o significant functional impairment o no lifetime Hx of mania  Adjustment disorder with depressed mood o onset within 3 months of identifiable stressor o marked stress & significant impairment o does not meet other DSM-5 criteria  Normal stress response o not excessive or out of proportion to severity of stressor o no functional impairment --------------------------------------------------------------- impaired social & occupational functioning is a DSM-5 requirement for all psychiatric disorders ---------------------------------------------------------------Herpes simplex (HSV) keratitis  pain, photophobia, blurred vision, tearing  dendritic ulcers is MC presentation  recurrence due to excessive sun exposure  complication: corneal blindness --------------------------------------------------------------- dendriform corneal ulcers & vesicular rash in V1 trigeminal distribution: herpes zoster (VZV) ophthalmicus  MC in elderly; or a presenting sign of HIV  vesicular rash in CN V1 cutaneous branch  periorbital burning & itching, fever, malaise  conjunctivitis & dendriform corneal ulcers  Dx: high-dose acyclovir within 72 hrs --------------------------------------------------------------- HIV retinopathy: benign, cotton-wool spots which remit spontaneously --------------------------------------------------------------- bacterial keratitis: MC in contact lens wearers  hazy cornea + central ulcer; adjacent stromal abscess  MCC: Pseudomonas --------------------------------------------------------------- Todd paralysis: post-ictal hemiparesis, restoration of motor function within 24 hr --------------------------------------------------------------- hydatid cysts caused by Echinococcus spp affect the liver & lungs  MC in sheep breeders & exposure to dogs 

--------------------------------------------------------------- T. solium: neurocysticercosis  consuming T. solium eggs in human feces  not contracted by eating infected pork  multiple, small fluid-filled cysts in brain parenchyma --------------------------------------------------------------- Enterobius vermicularis (pinworm) infection  Rx: albendazole or pyrantel pamoate; including all household contacts --------------------------------------------------------------- risk factors for gallstones: “fat, fertile, female, 40”, Native American, DM, rapid weight loss, OCPs  Dx: abdominal USS  Rx #1: lap chole  Rx #2 (poor surgical candidates): ursodeoxycholic acid (bile acid, dissolves gallstones) high recurrence --------------------------------------------------------------- HIDA scan: visualizes bile duct obstruction, GB disease, & bile leaks  ERCP Rx: therapeutic intervention for bile duct obstruction or cholangitis  PTC: visualize interahepatic & extrahepatic biliary tree; invasive ---------------------------------------------------------------Indications for aortic valve replacement  all symptomatic aortic stenosis (AS)  SAD: syncope, angina, dyspnea  severe AS undergoing CABG or valvular surgery  asymptomatics with severe AS & poor LV systolic function, LVH > 15 mm, valve area < 0.6 cm2, or abnormal response to exercise --------------------------------------------------------------- only left-sided murmurs  on expiration --------------------------------------------------------------- cholesterol embolism is a complication of cardiac catheterization & vascular procedures  “blue toe syndrome”, livedo reticularis, Hollenhorst plaques in the retinal artery, AKI, cerebral infarction, intestinal ischemia  Rx: supportive, statins prevent recurrence --------------------------------------------------------------- acute, unilateral cervical lymphadenitis in children: S. aureus  enlarged, tender & erythematous lymph node ----------------------------------------------------------------

Isotretinoin: must not be taken by reproductive age women unless 2 effective forms of contraception are used for at least 1 month prior to initiating, during, & 1 month after treatment  pregnancy test 1 wk before starting & periodically during therapy --------------------------------------------------------------- hemolytic anemia, jaundice, splenomegaly; or infant with persistent jaundice despite photo-Rx: hereditary spherocytosis  AD inheritance, northern European descent  ankyrin gene mutation  spectrin deficiency & extravascular hemolysis  jaundice, dark urine, acute cholecystitis due to pigmented gallstones   MCHC,  RDW, negative Coombs  Dx: acidified glycerol lysis test o & eosin-5-maleimide binding test  Rx: folate, blood transfusions, splenectomy o chronic hemolysis consumes folate  complications: pigmented gallstones, aplastic crises 2/2 parvovirus B19 --------------------------------------------------------------- Tularemia: Francisella tularensis (rabbits)  U/L cervical lymphadenopathy, fever/chill, headache --------------------------------------------------------------- Toxic shock syndrome due to S. aureus exotoxin  a/w tampons, nasal packing, post-surgery infection  fever, marked hypotension, altered mentation, myalgia, multi-organ injury  diffuse erythematous macular rash on the trunk, spreads to extremities (includes palms/soles), desquamation 1 – 2 wk after onset  thrombocytopenia --------------------------------------------------------------- meningococcemia: petechial rash  ecchymosis, bullae, vesicles  gangrenous necrosis  fever, N/V, myalgias, meningeal signs --------------------------------------------------------------- lightheadedness, diffuse abdo pain, adnexal & cervical motion tenderness, hemodynamic instability: ectopic pregnancy  Hx of syncope, hypotension, tachycardia: ruptured ectopic pregnancy  Dx: β-hCG & transvaginal USS 

o hemodynamic instability requires surgical eval. --------------------------------------------------------------- Hepatic metabolism of bilirubin 1. bilirubin uptake from bloodstream 2. storage within hepatocyte 3. conjugation with glucuronic acid 4. biliary excretion --------------------------------------------------------------- Dubin-Johnson: conjugated hyperbilirubinemia, dark granular pigment in hepatocytes (black liver) o normal urinary coproporphyrin o elevated coproporphyrin I o normal AST, ALT, & ALP o no Rx needed, benign, good prognosis  Rotor syndrome: defect of hepatic storage of conjugated bilirubin with leakage into plasma o conjugated bilirubinemia; +urine bilirubin o dark urine; normal AST, ALT, & ALP o no Rx, benign, absence of “black liver”  Crigler-Najjar Type I: severe jaundice, kernicterus, neurologic impairment & death o unconjugated bilirubinemia  if given IV phenobarbital  bilirubin unchanged o Rx: liver transplant  Crigler-Najjar Type II: less severe than Type I o survival into adulthood o if given IV phenobarbital  bilirubin is reduced o no Rx in mild cases  Gilbert’s: familial disorder of reduced bilirubin glucuronidation; unconjugated bilirubin o triggers: fasting, fat-free diet, illness, stress o normal LFTs, CBC, blood smear, reticulocytes  Alloimmune hemolytic disease (erythroblastosis fetalis): unconjugated, +Coomb’s o Rh disease, ABO incompatibility  physiologic jaundice: unconjugated, appears after 24 hr of life, resolves within 1 wk  breast milk jaundice: unconjugated, appears after 2nd wk of life, benign --------------------------------------------------------------- hemolysis leads to unconjugated hyperbilirubin & +urine urobilinogen assay o urine bilirubin assay is negative since there is no hepatic dysfunction

--------------------------------------------------------------- liver steatosis: 2/2 long-term OCP usage --------------------------------------------------------------- hypoalbuminemia can  total serum Ca++, but ionized Ca++ is hormonally regulated & stable o serum Ca++  by 0.8 mg/dL for every 1 g/dL  in serum albumin --------------------------------------------------------------- lymphocytic infiltration of salivary glands in Sjogren syndrome causes enlarged & firm submandibular glands --------------------------------------------------------------- CHF causes preferential vasoconstriction of efferent renal arterioles, thus increased intraglomerular pressure to maintain GFR o also  ADH secretion to maintain C.O. --------------------------------------------------------------- salmon-colored, hypopigmented & hyperpigmented macules on the upper trunk: Tinea versicolor  MCC: Malassezia globosa  exposure to hot & humid weather  KOH: large, blunt hyphae & thick-walled budding spores (“spaghetti & meatballs”)  Rx: selenium sulfide, ketoconazole, terbinafine --------------------------------------------------------------- ring-shaped lesions with enlarging raised, scaly border & central clearing, or patchy scales on the trunk: Tinea corporis (“ringworm”)  scalp = Tinea capitis (a/w hair loss)  Rx: terbinafine or itraconazole --------------------------------------------------------------- ABI ≤ 0.9 is abnormal --------------------------------------------------------------- ASA: antiplatelet; early Rx of acute ischemic stroke --------------------------------------------------------------- recombinant tPA (alteplase): Rx acute ischemic stroke; initiated within 3 – 4.5 hr of onset  Dx: head CT r/o intracranial hemorrhage  C/I: unknown duration, severe & persistent HTN, small deficits, rapid recovery of deficits --------------------------------------------------------------- acute mitral regurgitation can occur due to papillary muscle displacement during acute MI  abrupt & excessive volume overload

elevated LA & LV filling pressures results in acute pulmonary edema  does not change chamber size or compliance --------------------------------------------------------------- moderately obese middle-aged male, fatigability, daytime somnolence, morning headaches, snoring, mild HTN: sleep apnea syndrome  hypoxemia-induced  in EPO causes polycythemia  Rx: weight reduction, avoid sedative & alcohol, avoid sleeping supine  polycythemia improves with OSA Rx  complications: pulmonary HTN, RV failure --------------------------------------------------------------- OSA alone causes nocturnal hypoventilation, resulting in transient hypoxia & hypercarbia that resolves during wakefulness o morning headaches, impotence, arterial HTN o normal ABG  obesity hypoventilation syndrome (Pickwickian): due to obesity & untreated OSA  chronic hypercapnic respiratory failure, hypoxia, secondary erythrocytosis, pulmonary HTN, & cor pulmonale  chronic respiratory acidosis  compensatory metabolic alkalosis   Cl reabsorption due to  HCO3 retention --------------------------------------------------------------- obesity hypoventilation syndrome: obesity impedes chest & abdomen expansion in breathing  BMI > 30; daytime hypersomnolence  obesity reduces chest wall & lung compliance, thus  tidal volume, TLC, & FRC  persistent hypoventilation  awake daytime hypercapnea:  PaCO2 > 45  increases respiratory work,  respiratory drive due to decreased chemosensitivity to hypercapnia   renal HCO3 retention compensates for respiratory acidosis, which blunts the ventilatory response to  CO2  hypoventilation  normal A-a gradient  #1 Rx: nocturnal positive-pressure ventilation o also: weight loss, bariatric surgery o avoid sedatives ---------------------------------------------------------------

initial evaluation of suspected BPH: urinalysis to assess for UTI & hematuria  cytoscopy if U/A shows hematuria  PSA screen for prostate cancer if life expectancy > 10 yrs --------------------------------------------------------------- severe persistent HTN: > 185/110 is a C/I to thrombolytics  Rx: labetalol or nicardipine --------------------------------------------------------------- intravascular hemolysis: RBC structural damage (PNH, DIC) o  haptoglobin,  LDH  extravascular hemolysis: RBCs destroyed by phagocytes in spleen RES (AIHA, HS, G6PD def.) o less Hb release, slight elevation of LDH, normal haptoglobin --------------------------------------------------------------- autoimmune hemolytic anemia, G6PD deficiency & hereditary spherocytosis all cause extravascular hemolytic anemia & +spherocytes o AIHA: negative family Hx, +Coomb’s o HS: +family Hx, negative Coomb’s o G6PD deficiency: Heinz bodies, neg Coomb’s --------------------------------------------------------------- decreased passive & active ROM, more stiffness than pain: adhesive capsulitis (frozen shoulder)  inability to lift arm above head; due to fibrosis  risk factors: idiopathic, rotator cuff tendinopathy, subacromial bursitis, paralytic stroke, DM, humoral head fracture --------------------------------------------------------------- factors that aggravate prerenal azotemia: decreased fluid intake, ACE-I, NSAIDs  decreased effective renal blood flow activates the RAA axis, which constrict glomerular arterioles (efferent > afferent) to maintain intraglomerular pressure & GFR  continued volume depletion   GFR  persistent untreated renal hypoperfusion leads to intrinsic renal failure due to ischemia o tubules undergo acute ischemic necrosis & reabsorption of solutes is impaired o BUN/Cr ratio falls (< 20:1) ---------------------------------------------------------------

compartment syndrome: pain out of proportion to injury, pain with passive ROM, paresthesia  sensory loss & motor weakness present later  arterial pulses are present  Dx: measure compartment pressures  Rx: urgent fasciotomy --------------------------------------------------------------- Kawasaki disease (mucocutaneous lymph node syndrome) is a clinical diagnosis o common in age < 5 o fever ≥ 5 days o B/L non-exudative conjunctivitis o cervical lymphadenopathy > 1.5 cm o mucositis (injected/fissured lips or strawberry tongue) o swelling/erythema of palms/soles o polymorphous rash  Rx: ASA & IV immunoglobulin within 10 days of fever to prevent cardiac complications, but usually self-limited (Reye syndrome risk with ASA; life-threatening hepatic encephalopathy)  complications: coronary artery aneurysms, leading to MI & ischemia o perform a baseline echocardiography in all suspected cases; repeat to monitor changes --------------------------------------------------------------- congenital syphilis: rhinorrhea, cataracts, sensorineural hearing loss; no cardiac defects  congenital CMV: unilateral deafness, IUGR, chorioretinitis; no cardiac defects  congenital toxoplasmosis: chorioretinitis, hydrocephalus, intracranial calcifications, sensorineural hearing loss; no cardiac defects ---------------------------------------------------------------Rubella (German measles, RNA togavirus) features congenital: sensorineural deafness, cardiac defects (PDA), glaucoma/cataracts, microcephaly, thrombocytopenic “blueberry muffin rash” purpura children: low-grade fever, coryza, conjunctivitis, cervical lymphadenopathy, Forschheimer spots (petechiae on soft palate) transient (< 3 days) cephalo-caudal blanching maculopapular rash in centrifugal pattern 

adults: PLUS arthralgias/arthritis mild disease 2 – 3 wks after inhalation of respiratory droplets Dx PCR, anti-rubella IgM & IgG Rx supportive, acetaminophen prevent live attenuated rubella vaccine (MMR)  first trimester infection results in spontaneous abortion & congenital rubella; teratogenic ---------------------------------------------------------------Measles (rubeola) transmission respiratory droplets (hours) manifest 1 – 3 wks after exposure features prodrome fever, malaise, anorexia; cough, coryza, conjunctivitis, & Koplik spots, followed by… blanching, red-brown maculopapular rash with cephalocaudal/centrifugal spread; spares palms/soles Dx PCR, anti-measles IgM & IgG prevention live, attenuated vaccine Rx supportive, anti-pyretics, hydration Vitamin A ( morbidity/mortality) complications otitis media, pneumonia, gastroenteritis, encephalitis (subacute sclerosing panencephalitis) transmit

known/suspected cases: immediate isolation with negative air pressure, N95 mask  Koplik spots: tiny, white lesions in conjunctiva & buccal mucosa --------------------------------------------------------------- complication of untreated Strep pharyngitis: Scarlet fever  preceding Group A Strep infection (tonsillitis, pharyngitis) with tonsillar gray/white exudates  produces erythrogenic exotoxins  incubation: 1 – 7 days  prodromal fever, headache, vomiting, sore throat, circumoral pallor, then 12 – 48 hr later…  fine pink blanching papules on neck, axilla, groin; sandpaper-like texture; spares palms/soles  Dx: throat culture  Rx: rapid response to PCN V; or amoxicillin  complications: rheumatic fever  DDx: Kawasaki’s (B/L conjunctival injection) 

--------------------------------------------------------------- Viridans group Streptococci (S. mutans) causing native-valve IE are susceptible to PCN  IV ABX is preferred for initial Rx  empiric Rx: IV vancomycin  Rx: IV aqueous PCN G or IV ceftriaxone  PCN-allergic: vancomycin --------------------------------------------------------------- ALL: lymphoblasts lack peroxidase positive granules but contain cytoplasmic aggregates of PAS positive material  positive TdT: expressed only by pre-B & pre-T lymphoblasts  recurrent infection, lymphadenopathy, splenomegaly  Dx: > 25% lymphoblasts --------------------------------------------------------------- myeloblasts contain peroxidase positive material --------------------------------------------------------------- mass involving mandible or abdominal viscera, high mitotic index, “starry sky” appearance: Burkitt lymphoma  Rx: high-dose chemotherapy --------------------------------------------------------------- abdominal pain, constipation, polydipsia  a single elevated Ca++ must be confirmed with a second serum Ca++ to confirm hypercalcemia  next: measure PTH levels  elevated PTH  measure urinary Ca++ o high urine Ca++  10 & 30 hyperPTH o low urine Ca++  familial hypercalcemic hypocalciuria  suppressed PTH  measure PTHrP, 25(OH)D, & 1,25(OH)D o  PTHrP  malignant tumor o  25(OH)D  Vit D toxicity o  1,25(OH)D  CXR for lymphoma, sarcoid o all normal  hyperthyroidism, MM, acromegaly, milk-alkali syndrome --------------------------------------------------------------- antipsychotics cause hyperprolactinemia by blocking DA activity of tuberoinfundibular path, projects from hypothalamus to pituitary o amenorrhea, galactorrhea, gynecomastia, sexual dysfunction

therapeutic effects of antipsychotics work on the mesolimbic pathway, projects from ventral tegmental area (VTA) to limbic system  decrease DA activity in the nigrostriatal path causes EPS effects of antipsychotics, extend from the substantia nigra to basal ganglia o  DA activity causes chorea & tics --------------------------------------------------------------- chorioretinitis: posterior uveitis --------------------------------------------------------------- shortened PR, widened QRS, delta waves: WPW  due to an anterograde accessory AV pathway, allow early depolarization of the ventricle  causes pre-excitation & risk of tachyarrhythmia  retrograde conduction can result in SVT --------------------------------------------------------------- Hx of caustic ingestion  pyloric stricture  abdominal succussion splash  Dx: upper endoscopy --------------------------------------------------------------- odorless vaginal spotting/bleeding in a newborn: effects of maternal estrogen  Rx: reassurance --------------------------------------------------------------- initial management of children with speech delay: audiology evaluation --------------------------------------------------------------- massive hemoptysis: > 600 mL/24 hr or 100 mL/hr  complication: asphyxiation Management of ongoing hemoptysis  establish an adequate patent airway & ventilation  ensure hemodynamic stability  place bleeding lung in the dependent position  bronchoscopy to localize bleed site --------------------------------------------------------------- radioiodine therapy causes permanent hypothyroidism with Graves’ since the entire thyroid gland is hyperfunctional  toxic adenoma & multinodular goiters remain euthyroid after radioiodine; only destroys autonomous areas --------------------------------------------------------------- ABO incompatibility occur in group O mother with a group A or B baby 

Ab’s to ABO antigens cause mild disease in most newborns compared to Rh incompatibility  can occur in the first pregnancy --------------------------------------------------------------- MCC of postpartum hemorrhage within 24 hr of delivery: uterine atony  soft, “boggy”, poorly contracted uterus  risk factors: multiple gestation, polyhydramnios, macrosomia, prolonged labor  Rx: fundal or bimanual uterine massage, crystalloid infusion, oxytocin  alternative Rx: uterine packing --------------------------------------------------------------- Henoch-Schonlein purpura are at  risk for ileo-ileal intussusception o does not reduce spontaneously compared to ileocolic intussusceptions  Rx: surgical --------------------------------------------------------------- statin A/E: hepatotoxicity & myopathy  ASA & NSAIDs A/E: allergic angioedema --------------------------------------------------------------- VSD is common in Edward’s (trisomy 18) --------------------------------------------------------------- liver Bx is required for HCV staging Candidates for chronic Hep C therapy  age > 18  detectable HCV RNA in serum  liver Bx with bridging fibrosis  compensated liver disease (no ascites)  stable lab studies  willingness for Rx & compliance  no contraindications (ongoing alcohol/drug abuse, major uncontrolled depression)  Rx: peginterferon & ribavirin o HCV genotype 1 also receive protease inhibitor: telaprevir or boceprevir --------------------------------------------------------------- recurrent, predictable, self-limited episodes of vomiting without apparent cause in a child: cyclic vomiting syndrome  no symptoms between episodes  a/w family Hx of migraines  resolution in 5 – 10 yrs 

DDx: bulimia, GERD, malrotation, Munchausen, mesenteric adenitis, viral gastroenteritis --------------------------------------------------------------- severe bilious emesis & hypovolemic shock  upper GI series to Dx intestinal malrotation --------------------------------------------------------------- transient proteinuria is MCC of isolated proteinuria in children  2/2 fever, exercise, seizure, stress, volume depletion  repeat urine dipstick on 2 subsequent occasions to r/o persistent proteinuria --------------------------------------------------------------- diarrhea, weight loss, anemia, mild DM or hyperglycemia, necrotic migratory erythema: glucagonoma  necrotic migratory erythema: papule/plaques that coalesce to form a large, painful blister &/or crusting with central clearing; perineum, face  Dx: glucagon > 500 pg/mL  DDx: gastrinoma, late-onset Type I DM, thyrotoxicosis, carcinoid syndrome --------------------------------------------------------------- MCC of pneumonia in HIV: Strep pneumo  CXR: pleural effusion  also susceptible to other encapsulated spp ---------------------------------------------------------------Causes of fetal growth restriction (weight < 10th %) asymmetric vascular disease (HTN, preeclampsia, DM) (maternal antiphospholipid Ab syndrome factors) autoimmune disease (SLE) cyanotic cardiac disease substance abuse (tobacco, alcohol, cocaine) symmetric genetics (aneuploidy) (fetal congenital heart disease factors) intrauterine infection (malaria, CMV, rubella, toxoplasmosis, varicella) 

impaired blood flow due to suboptimal maternal factors result in asymmetric growth, as fetal blood flow redistributes to vital organs (brain, heart) & appears late in pregnancy ---------------------------------------------------------------Natural history of diabetic nephropathy (DN)  hyperfiltration (0 – 5 yr after onset) o glomerular hypertrophy,  GFR 

incipient DN (5 – 15 yrs) o microangiopathy 2/2 advanced glycation end (AGE) products o mesangial expansion, glomerular sclerosis, glomerular BM thickening, microalbuminuria, arteriolar hyalinosis, HTN  overt DN (15+ yrs) o mesangial nodules (Kimmelstiel-Wilson), tubulointerstitial fibrosis, nephrotic syndrome,  GFR; CKD --------------------------------------------------------------- air in the biliary tract: gallstone ileus --------------------------------------------------------------- porcelain gallbladder results from deposition of Ca++ salts 2/2 chronic cholecystitis  incidental finding, a/w risk of GB carcinoma  definitive Rx: cholecystectomy --------------------------------------------------------------- ASD, VSD, PDA, & dextrocardia are acyanotic congenital heart diseases ---------------------------------------------------------------Congenital cyanotic heart diseases MCC in the neonatal period, Transposition cyanosis within 24 hr, single S2 of great CXR: narrow mediastinum vessels “egg-on-a-string” Rx: prostaglandins keep PDA open MCC after the neonatal period, ToF harsh pulmonary stenosis murmur, VSD murmur, single S2, CXR: RVH, “boot-shaped” heart single S2, minimal pulmonary flow Tricuspid VSD murmur, hypoplastic RV atresia newborn with left-axis deviation single S2, systolic ejection murmur, Truncus increased pulmonary flow, edema arteriosus severe cyanosis, pulmonary edema, Total respiratory distress anomalous RA & RV enlargement pulmonary CXR: “snowman” sign venous return --------------------------------------------------------------- fever, muscle rigidity, autonomic instability, diaphoresis, confusion, elevated CPK: NMS  MCC: haloperidol; occurs within 2 weeks 

#1 Rx: discontinue drug, ICU, aggressive cooling, antipyretics, fluids & electrolytes, alkaline diuresis  Rx: dantrolene (muscle relaxant) or bromocriptine (DA agonist) or amantadine (DA properties)  complication: rhabdomyolysis --------------------------------------------------------------- management of placenta previa depends on gestational age & bleeding severity  active, uncontrolled antepartum hemorrhage with unstable vital signs & non-reassuring fetal HR, regardless of gestational age  c-section o induction of labor will aggravate bleeding by triggering uterine contractions  prior c-section increases risk for placenta accreta --------------------------------------------------------------- Fibromuscular dysplasia: causes arterial stenosis, aneurysm, or dissection; MCC of secondary HTN o renal artery involvement  resistant HTN o cerebrovascular arteries  TIA, stroke, amaurosis fugax, Horner’s o non-specific: headache, dizziness, tinnitus --------------------------------------------------------------- increased intragastric pressure during vomiting causing tears in submucosal arteries of distal esophagus & proximal stomach: Mallory-Weiss  rupture of dilated submucosal veins at GE junction: esophageal varices --------------------------------------------------------------- complication of IE: cerebral septic emboli  DDx: carotid thrombosis, drug-induced vascular spasm, migraine, lacunar stroke --------------------------------------------------------------- post-ictal lactic acidosis occurs following a tonic-clonic seizure  transient anion gap metabolic acidosis resolves without Rx within 60 – 90 min following resolution of seizure activity  Rx: repeat labs after 2 hrs --------------------------------------------------------------- painless hematuria, sterile pyuria, WBC casts: analgesic nephropathy  females chronically using combined analgesics  asymptomatic; incidental increase in Cr  painless hematuria due to papillary ischemia from analgesia-induced vasoconstriction of vas recta 

papillary necrosis & tubulointerstitial nephritis with focal glomerulosclerosis  results in CKD & ESRD  severe cases: nephrotic range proteinuria  CT: small kidneys, B/L papillary calcifications --------------------------------------------------------------- simple renal cyst: thin wall, no solid component, no contrast enhancement on CT, no septae o incidental finding; no Rx, no follow-up  malignant cystic mass: irregular septae walls, multilocular, heterogeneous (solid & cystic), contrast enhancement on CT --------------------------------------------------------------- HTN, low plasma renin, hypokalemia,: primary hyperaldosteronism --------------------------------------------------------------- COPD exacerbation with cor pulmonale (peripheral edema, hepatomegaly, clear lungs, JVD, pulmonary HTN)  #1 Rx: bronchodilators, glucocorticoids  Rx: furosemide is used to lower RV filling & reduce peripheral edema o caution: C.O. reduction & prerenal azotemia ---------------------------------------------------------------Medication side effects levodopa/carbidopa early: hallucination, agitation, (DA precursor dizziness, headache, confusion late: dyskinesia, dystonia trihexyphenidyl dry mouth, blurry vision, (anticholinergic) constipation, urinary retention amantadine livedo reticularis, ankle edema bromocriptine, somnolence, hypotension, ropinirole confusion, hallucination (DA agonist) entacapone dyskinesia, hallucinations, (COMT inhibitor) confusion, orthostatic hypotension selegiline insomnia, confusion (MAO-B inhibitor) --------------------------------------------------------------- trihexyphenidyl: anti-muscarinic used for Parkinson’s & drug-induced EPS  “red as a beet, dry as a bone, hot as a hare, blind as a bat, mad as a hatter, full as a flask” 

flushing, anhidrosis, hyperthermia, mydriasis, delirium, urinary retention/constipation --------------------------------------------------------------- BPH: affects central portion; @ transitional zone  prostate cancer: lateral lobe of prostate; firm --------------------------------------------------------------- initial BPH workup: one-time PSA measurement --------------------------------------------------------------- prostate Bx: suspected prostate cancer with abnormal prostate exam, or persistently elevated PSA > 4 ng/dL --------------------------------------------------------------- initial evaluation of essential HTN should assess possible secondary causes o U/A for occult hematuria & protein/Cr ratio o chemistry panel o lipid profile (risk stratification for CAD) o baseline EKG --------------------------------------------------------------- unexplained elevation of serum CK & myopathy: hypothyroidism  fatigue, myalgia, proximal muscle weakness, sluggish ankle reflexes, normal ESR  Dx: TSH, T4  DDx: polymyositis (normal DTRs,  ESR) ---------------------------------------------------------------Major stroke types local artery obstruction, ischemic symptoms fluctuate, stuttering progress (thrombotic) Hx of a-fib, endocarditis, carotid bruit, ischemic abrupt onset, (embolic) maximal symptoms at the start focal neurologic deficits early, progress over minutes to hours, then intracerebral features of increased ICP (vomiting, hemorrhage headache, bradycardia) ruptured berry aneurysm or AVM, severe headache at onset, subarachnoid meningeal irritation, hemorrhage focal deficits are uncommon** 

 ADPKD:  risk of berry aneurysm, results in SAH --------------------------------------------------------------- hypertensive intracranial hemorrhage MC in basal ganglia, thalamus, pons, & cerebellum

focal deficits initially (hemiplegia, hemiparesis, hemisensory disturbances), then ICH symptoms (vomiting, headache, bradycardia)  Dx: brain CT --------------------------------------------------------------- lacunar stroke: occluded single penetrating branch of a large cerebral artery; MC basal ganglia  unilateral pure motor impairment  no cortical signs (aphasia, hemianopsia)  main cause: HTN, which induces microatheroma & lipohyalinotic thickening o small vessel hyalinosis  MC site: posterior limb of internal capsule  symptoms over a short period, slow progression over 24 – 36 hr; limited neurologic deficits  pure motor, pure sensory, or ataxic hemiparesis; or dysarthria-clumsy hand syndrome  pure sensory stroke (VPL nucleus of thalamus) ---------------------------------------------------------------Brain lesions pure motor hemiparesis, posterior limb pure sensory stroke, clumsy-hand, of int. capsule no visual field abnormalities (lacunar infarct) C/L somatosensory & motor deficit @ face & upper limbs, conjugate eye deviate toward infarct, MCA occlusion homonymous hemianopia, aphasia (dominant hemisphere), hemineglect (non-dominant parietal) C/L somatosensory & motor deficit in lower extremities, ACA occlusion abulia (lack of will or initiative), dyspraxia, urinary incontinence homonymous hemianopia, alexia without agraphia (dominant), PCA occlusion visual hallucinations, 3rd nerve palsy, C/L motor deficits alternate syndrome: vertebrobasilar C/L hemiplegia, system lesion I/L cranial nerve deficits (brainstem)  anterior vasculature: internal carotid artery, ACA & MCA  posterior circulation: paired vertebral arteries form the basilar artery, then divide into PCAs ---------------------------------------------------------------

causes of  BUN/Cr: prerenal azotemia (dehydration), GI bleeding, systemic steroids o GI bleeding results in bacterial breakdown of Hb in the GIT with resultant urea absorption --------------------------------------------------------------- Kallmann syndrome: XR disordered migration of fetal GnRH & olfactory neurons  hypogonadotropic hypogonadism & anosmia  normal genotype & internal reproductive organs  primary amenorrhea, low FSH & LH  absent breast development, small phallus  no body hair, short stature  Rx: hormone replacement --------------------------------------------------------------- bilious vomiting, abdominal distension, gassless colon, “triple bubble” sign: jejunal atresia  risk factors: prenatal cocaine or tobacco exposure  DDx: necrotizing enterocolitis, pyloric stenosis, duodenal atresia, Hirschsprung’s ---------------------------------------------------------------Antepartum fetal surveillance o NST: Nonstress test; #1 test o BPP: Biophysical profile; #2 test o CST: Contraction Stress test; #2 test o umbilical artery Doppler velocimetry --------------------------------------------------------------- NST is performed when there is loss of perception of fetal movements or in high-risk pregnancies at 32-34 wks gestation; fetal heart tones by Doppler  “reactive”: within 20 min, ≥ 2 accelerations at least 15 beats/min > baseline, lasting ≥ 15 seconds  high negative predictive value  abnormal result yields a low PPV  MCC of non-reactive NST: fetal sleep cycle (20 min) o Rx: vibroacoustic stimulation  weekly NST for 3rd trimester pregos requiring 

ongoing antenatal surveillance

 non-reactive NST requires  BPP or CST --------------------------------------------------------------- Biophysical profile (BPP): assess fetal well-being o NST o amniotic fluid volume o fetal movement o fetal tone

o fetal breathing movements if abnormal NST  amniotic fluid volume & fetal activity are assessed with real-time USS, 30 min  score 8 – 10 = normal  score 6 = equivocal  score ≤ 4 = delivery! --------------------------------------------------------------- contraction stress test (CST): infusion of oxytocin sufficient to result in 3 contractions every 10 min  normal CST suggests a low likelihood of stillbirth within 1 wk of the test; F/U testing in 1 wk  late decelerations is an indication for delivery --------------------------------------------------------------- umbilical artery Doppler velocimetry: evaluation of IUGR only --------------------------------------------------------------- Dx of intrauterine fetal demise: real-time USS  occurs @ >20 wks, before onset of labor  fetal heart tone not heard by Doppler  autopsy of fetus & placenta should be performed in the first episode of intrauterine fetal demise  also perform maternal coagulation profile --------------------------------------------------------------- ovulation occurs on day 14  fertilization is possible 24 hr after ovulation  pregnancy = embryo implants @ 6 – 12 days after fertilization; β-hCG produced by blastocyst can be detected on a pregnancy test ---------------------------------------------------------------Combined estrogen/progestin OCPs  early A/E: nausea, bloating, breast tenderness; improves with use; does not cause weight gain  MC A/E: breakthrough bleeding due to lower estrogen dose  benefits   endometrial & ovarian cancer risk o  risk of iron deficiency anemia  risks  HTN o venous thromboembolism o hepatic adenoma (chronic OCP use) o amenorrhea   risk of cervical cancer   triglycerides 

o rare: stroke, MI women who smoke, with uncontrolled HTN, end-organ damage, or age > 35 should consider contraception without estrogen ---------------------------------------------------------------Emergency contraception method mechanism time frame efficacy copper inflammatory rxn is 0 – 120 hr IUD toxic to sperm, (5 days) 99% impairs implantation ulipristal anti-progestin, 0 – 120 hr ≥ 85% pill delays ovulation (5 days) levonorg progestin, 0 – 72 hr estrel delays ovulation (3 days) 85% (Plan B) OCPs progestin 0 – 72 hr) 75% delays ovulation 

copper IUD & OCPs are also precoital methods copper IUD is the most effective emergency contraceptive method, regardless of parity or age o C/I: acute cervicitis & PID --------------------------------------------------------------- DPMA & etonogestrel subdermal implants are systemic progestin-based precoital contraceptives that inhibit GnRH secretion, thus FSH/LH --------------------------------------------------------------- newborns with suspected DiGeorge must be assessed for life-threatening hypocalcemia (tetany, seizures, arrhythmias) o Conotruncal defects (truncus arteriosus) o Abnormal facies o Thymic aplasia/hypoplasia o Cleft palate o Hypocalcemia  T-cell lymphopenia  risk for bacterial, viral, & fungal infections --------------------------------------------------------------- appendicitis begins as vague periumbilical visceral pain caused by stretching of the appendiceal wall  peritoneum becomes inflamed & localize to RLQ ---------------------------------------------------------------Neonatal rashes Features Dx Rx asymptomatic, blanching Erythema resolves  

erythematous macules, toxicum in 2 wks papules, or pustules neonatorum vesicular clusters on skin, eyes, mucous membranes, neonatal acyclovir CNS infection (seizures), HSV multi-organ disease fever, ranges from neonatal vesicular clusters to varicella acyclovir disseminated disease fever, irritability, diffuse (SSSS)Staph oxacillin, erythema; blistering & scalded skin nafcillin, exfoliation, +Nikolsky syndrome vanco --------------------------------------------------------------- hoarseness, barking cough, respiratory distress: croup (laryngotracheitis) o age < 3 yrs; due to Parainfluenza o lateral XR: subglottic narrowing --------------------------------------------------------------- exertional dyspnea, heart pounding sensation, widened pulse pressure: aortic regurgitation  MMC in developing countries: rheumatic fever  MCC in developed countries: aortic root dilation or congenital bicuspid valve ---------------------------------------------------------------Features of TCA overdose CNS drowsiness, delirium, coma, seizure, respiratory depression cardio sinus bradycardia, hypotension, (MCC death) prolonged PR/QRS/QT, ventricular tachycardia, v-fib anticholinergi dry mouth, blurred vision, c mydriasis, flushing, hyperthermia, urinary retention  TCAs inhibit fast Na+ channels, thus  conduction velocity,  duration of repolarization, & prolongs absolute refractory period --------------------------------------------------------------- TCA overdose decreases myocardial conduction velocity, leading to QRS prolongation & risk of ventricular arrhythmia or seizure  QRS complex duration is the best prognostic indicator of TCA overdose  supportive Rx: supplemental O2, IV fluids, activated charcoal if within 2 hrs of ingestion

Rx: sodium bicarbonate narrows the QRS complex &  incidence of ventricular arrhythmia o indicated when QRS > 100 msec o  pH decreases TCA avidity for Na+ channels  sodium load alleviates depressant action on myocardial fast sodium channels --------------------------------------------------------------- B/L hydronephrosis, B/L hydroureters, bladder distension: posterior urethral valves (PUV)  diagnosed prenatally; can present later in life as recurrent UTIs & renal failure; only boys  Potter sequence o urinary tract anomaly  oliguria in utero  oligohydramnios  pulmonary hypoplasia, flat facies, & limb deformities  Dx: voiding cystourethrogram & cytoscopy --------------------------------------------------------------- hypercalcemia of malignancy can be due to tumor production of PTHrP, osteolytic metastasis, tumor production of 1,25(OH) vitamin D, or increased IL-6 levels, IL-3, TNF-α  PTH is suppressed; Ca++ > 13 mg/dL  N/V, polyuria, polydipsia, constipation, fatigue, poor appetite, Hx of smoking --------------------------------------------------------------- pain, swollen eyelid,  visual acuity, hypopyon, conjunctivitis, corneal edema: post-operative endophthalmitis  MC within 6 wk; due to infection of the vitreous  hypopyon = pus in anterior eye chamber ---------------------------------------------------------------Classification & management of asthma intermittent daytime symptoms ≤ 2 days/wk, nighttime awakenings ≤ 2x/month, β-agonist use ≤ 2x/wk normal baseline FEV1 & FEV1/FVC no limitations of daily activities Rx: short-acting β-agonist (albuterol) PRN mild symptoms ˃ 2x/wk, but not daily, persistent nighttime awakenings 3 – 4x/month, normal PFTs, minor limitations Rx: add low-dose inhaled corticosteroid moderate daily symptoms, weekly nighttime persistent awakenings, FEV1 60 – 80% of predicted Rx: add long-acting inhaled β2-agonist 

severe persistent

symptoms throughout, frequent nighttime awakenings, extreme limitations, FEV1 50 yrs S. pneumo, vancomycin,

immunocomp.

N. meningitidis, Listeria pneumococcus, N. meningitidis, Listeria, G- rod

ampicillin, & 3rd gen cephalosporin vancomycin, ampicillin, & cefepime

 alternative to ampicillin: TMP-SMX for Listeria --------------------------------------------------------------- empiric Rx for bacterial meningitis for immunocompromised: vancomycin, ampicillin, + cefepime with dexamethasone o adding corticosteroids prevent complications of meningitis due to S. pneumoniae  if there is delay in performing LP, empiric Rx must be given after obtaining blood cultures --------------------------------------------------------------- Rx dehydration: IV Na+-containing crystalloid (0.9% NS)  can unmask subclinical heart failure in elderly --------------------------------------------------------------- colloid solutions contain albumin  Rx: burns, hypoproteinemia --------------------------------------------------------------- post-op cholestasis is a benign condition after prolonged surgery characterized by hypotension, extensive blood loss into tissues, & massive blood replacement --------------------------------------------------------------- liver has dual blood supply: hepatic arteries & portal veins --------------------------------------------------------------- raising the cut-off point of a test… o  specificity &  sensitivity --------------------------------------------------------------- CKD causes decreased renal production of Vit D, leading to hypocalcemia, hyperphosphatemia, & secondary hyperPTH  circulating PTH increases with declining GFR, correlates with severity of renal failure  hyperphosphatemia directly stimulates parathyroids to synthesize & release PTH  DDx: Vit D deficiency (low/normal phosphate, normal serum Ca++)

--------------------------------------------------------------- diabetic, severe ear pain, granulation tissue in ear canal, otorrhea,: malignant otitis externa MCC is P. aeruginosa  MC in elderly with poorly controlled diabetes  aggravated by chewing, difficulty eating  worsens despite topical ABX  Dx: CT or MRI  Rx: systemic anti-pseudomonals (ciprofloxacin)  risk factor: immunosuppressed conditions  complications: osteomyelitis of skull base & CN damage (facial drooping) --------------------------------------------------------------- anxiety restricted to social & performance, also fear of scrutiny & embarrassment: social phobia  DDx: specific phobia, panic disorder, GAD ---------------------------------------------------------------Specific phobia  marked anxiety > 6 months  no fear of scrutiny by others  #1 Rx: behavior therapy  #2 Rx: short-acting benzo (limited role) --------------------------------------------------------------- anemia, bone disease, & HTN persist with dialysis, but controlled with renal transplantation  transplant patients have return or normal endocrine, sexual, & reproductive functions --------------------------------------------------------------- bupropion inhibits re-uptake of NE, DA, 5-HT  C/I to use of bupropion: Hx of anorexia/bulimia since development of electrolyte abnormalities can precipitate seizures --------------------------------------------------------------- acute pancreatitis can cause an acute abdomen  Rx: analgesics, IV fluids, NPO  Px: self-limited, subsides in 4 – 7 days --------------------------------------------------------------- medial meniscus is injured during forceful torsion of the knee with foot planted  delayed evidence of effusion  swelling & pain within 24 hrs  limited ROM, popping, catching, locking (inability to extend the knee)  joint line tenderness

 evaluation: positive McMurray’s & Apley’s  Dx: MRI --------------------------------------------------------------- ACL tear from forceful hyperextension  swelling & effusion immediately  Dx: positive Lachman’s --------------------------------------------------------------- theophylline has a narrow therapeutic window o CNS (headache, insomnia, seizure), N/V, cardiac toxicity (palpitations, arrhythmia)  Dx: measure serum levels --------------------------------------------------------------- HIV patient with altered mental status  primary CNS lymphoma: MCC is EBV  MRI: solitary, weakly ring-enhancing periventricular mass  CSF: EBV DNA --------------------------------------------------------------- multiple, ring-enhancing lesions in basal ganglia: Toxoplasmosis o @ cortical grey-white matter interface  multiple, non-enhancing lesions, no mass effect: PML  solitary, periventricular ring-enhancing lesion: primary CNS lymphoma  solitary ring-enhancing lesion, bacterial infection, sinusitis, immunocompetent: brain abscess o direct extension from contiguous infection (sinusitis, mastoiditis, otitis media) o MCC: Viridans strep (S. mutans), anaerobes --------------------------------------------------------------- brain abscesses from hematogenous spread from lung infection or endocarditis o MCC is S. aureus --------------------------------------------------------------- fatigue, memory loss, constipation, weight gain, dry skin: amiodarone-induced hypothyroidism  monitor thyroid & hepatic function  pulmonary symptoms require CXR & PFTs  corneal deposits does not necessitate disuse

cardiac

Major side effects of amiodarone sinus bradycardia, heart block QT prolongation, TdP

pulmonary

chronic interstitial pneumonitis, pulmonary fibrosis endocrine hypothyroid (MC), hyperthyroid GI/hepatic  transaminases, hepatitis ocular optic neuropathy, corneal deposits skin blue-gray discoloration (face) neuro peripheral neuropathy --------------------------------------------------------------- Dofetilide A/E: risk of TdP  Procainamide A/E: drug-induced lupus, agranulocytosis, QT prolongation --------------------------------------------------------------- quinidine A/E: diarrhea, tinnitus, QT prolongation, TdP, hemolytic anemia & thrombocytopenia  hydralazine A/E: peripheral edema, salt & fluid retention, palpitations, orthostatic hypotension, drug-induced lupus  metoprolol A/E: worsening of heart failure, bradyarrhythmia, bronchoconstriction, fatigue, depression, weight gain, sexual dysfunction ---------------------------------------------------------------Antihypertensive in pregnancy first-line contraindicated **labetalol ACE-I/ARBs **methyldopa (slow) spironolactone hydralazine direct renin inhibitor nifedipine furosemide second-line thiazides clonidine --------------------------------------------------------------- labetalol & hydralazine: Rx pre-eclamptic hypertensive emergencies (BP ≥ 160/110) o not methyldopa (slow onset) --------------------------------------------------------------- severe antepartum hemorrhage first requires hemodynamic resuscitation, then emergency USS o vaginal exam is C/I for risk of aggravating possible placenta previa bleeding --------------------------------------------------------------- healthy infants can lose up to 7% of birth weight in the first 5 days of life  no Rx required; continue exclusive breastfeeding  F/U @ age 10 – 14 days for weight gain

 infants losing > 7%: formula supplementation --------------------------------------------------------------- # of wet diapers = age in days for 1st wk  ≥ 6 diapers/day after the 1st wk is normal  “pink stains” or “brick dust” in neonatal diapers = uric acid crystals, common in first few weeks --------------------------------------------------------------- dysthymia (persistent depressive disorder)  depressed mood ≥ 2 yrs (1 yr in childhood) o MDE symptoms may occur concurrently or intermittently --------------------------------------------------------------- hairy cell leukemia: bone marrow is fibrotic, leading to dry taps of aspirates  pancytopenia & splenomegaly  +tartrate resistant acid phosphatase (TRAP)  Rx: cladibine (2-CdA) --------------------------------------------------------------- Hep B vaccination decreases HCC incidence, especially if from Asia & Africa; MCC due to vertical transmission --------------------------------------------------------------- hemodynamically unstable with penetrating abdominal trauma  exploratory laparotomy  any penetrating wound below the 4th IC space is considered to involve the abdomen --------------------------------------------------------------- detrusor instability, bladder irritation from neoplasm, interstitial cystitis results in urge incontinence o sudden, infrequent loss of moderate to large amounts of urine, nocturia & frequency --------------------------------------------------------------- diabetic neuropathy causes overflow incontinence  loss of small amounts of urine from overdistended bladder;  residual volume --------------------------------------------------------------- cerebellar astrocytoma: #1 MC posterior fossa tumor, MC site is lateral hemispheres  medulloblastomas MC arise from the vermis o #2 MC posterior fossa tumor; infratentorial  posterior vermis syndrome: truncal dystaxia o highly radiosensitive --------------------------------------------------------------- idiopathic thrombocytopenic purpura (ITP) is a Dx of exclusion

  

antecedent viral infection, mucocutaneous bleeding isolated thrombocytopenia < 100,000 inhibition of megakaryocyte PLT production due to IgG autoantibodies against PLT membrane glycoproteins & PLT destruction children adults

Management of ITP no bleeding: observe bleeding: IV Ig or glucocorticoids PLT > 30,000, no bleeding: observe PLT < 30,000 or bleeding: IV Ig or glucocorticoids

r/o pseudothrombocytopenia due to PLT clumping by EDTA, abciximab, or inadequate coagulation  isolated thrombocytopenia can be the initial presentation of chronic HIV  also test for HIV & Hep C  DDx: Bernard-Soulier, aplastic anemia, DIC, dilutional thrombocytopenia, TTP, HUS --------------------------------------------------------------- chronic GI disease (steatorrhea, Celiac) can cause Vit D deficiency due to malabsorption  results in hypocalcemia, hypophosphatemia, & secondary hyperPTH  bone pain, muscle weakness, abnormal gait --------------------------------------------------------------- CREST syndrome: calcinosis cutis, Raynaud’s, esophageal dysmotility, sclerodactyly, telangiectasias  calcinosis cutis: localized dystrophic Ca++ skin depositions; subcutaneous pink/white nodules on upper extremities  Raynaud’s: fingers progress through white, blue, & hyperemic stages  sclerodactyly: fibrosis of skin distal to MCP joint  telangiectasias: mat-like patches on face & palms ---------------------------------------------------------------Clinical features of cystic fibrosis respiratory bronchiectasis, recurrent pneumonia, chronic rhinosinusitis, nasal polyps GI meconium ileus, steatorrhea, fat-soluble vitamin malabsorption (night blindness, rickets, neuropathy, coagulopathy), exocrine pancreatic insufficiency 

reproductive MSK

microcolon infertility ( 95% males) growth failure, osteopenia (fractures), clubbing, kyphoscoliosis

inspissated mucus predisposes to rhinosinusitis fecal elastase testing (exocrine pancreas status) Dx: sweat chloride test via quantitative pilocarpine iontophoresis  Strep pneumo: MCC pneumonia overall  S. aureus is MCC of CF-pneumonia in age < 20 yr  Rx: IV vancomycin  P. aeruginosa is MCC of CF-pneumonia in adults  Rx: IV ceftazidime or aminoglycosides  frequent Rx with aminoglycosides can result in sensorineural hearing loss  Rx: high-calorie diet, fat-soluble vitamin & pancreatic enzyme replacement --------------------------------------------------------------- male infertility 2/2 CF is due to congenital B/L absence of vas deferens o inspissated mucus in fetal genital tract obstructs vas deferens development  spermatogenesis is normal, but no ejaculation (obstructive azoospermia) --------------------------------------------------------------- diarrhea, dermatitis, dementia, death: pellagra o niacin (Vit B3) deficiency  scaly dermatitis on sun-exposed areas become thick & hyperpigmented, resembles a sunburn  abdominal pain, watery diarrhea, glossitis, anorexia  irritability, aggressiveness, poor concentration  a/w bowel disease (UC) that interfere with vitamin absorption, immigrants on corn-based diets, alcoholics, carcinoid syndrome, Hartnup’s  DDx: SLE (no diarrhea), seborrheic dermatitis, acute intermittent porphyria (no photosensitivity) --------------------------------------------------------------- cheilosis, glossitis, seborrheic dermatitis, pharyngitis, oral erythema: riboflavin (Vit B2) deficiency --------------------------------------------------------------- irritability, depression, dermatitis, stomatitis, homocysteine : pyridoxine (Vit B6) deficiency ---------------------------------------------------------------  

 diabetics have  risk of atherosclerotic CV disease Indications for statins  all diabetics age 40 – 75 regardless of baseline lipid levels  statin o  CHD risk for any baseline lipid levels  clinical CVD: ACS, MI, angina, TIA, stroke  LDL ≥ 190 (no recommended LDL goal)  10-year atherosclerotic CVD risk ≥ 7.5% --------------------------------------------------------------- hemorrhagic pancreatitis: life-threatening illness, retroperitoneal hemorrhage & pancreatic necrosis  bluish discoloration of the flanks (Grey Turner sign) or periumbilical region (Cullen sign) due to blood accumulation intra-abdominal fascial planes --------------------------------------------------------------- Felty syndrome: a/w rheumatoid arthritis o neutropenia, recurrent infections, splenomegaly --------------------------------------------------------------- constitutional growth delay: simultaneous deceleration in length & weight before age 2 yrs; normal growth velocity after age 2 yrs; idiopathic  MCC of short stature & delayed puberty o family Hx of delayed puberty  catch-up growth, onset of puberty, & growth spurt occur later than average  delayed bone age, but final adult height is normal --------------------------------------------------------------- familial short stature: standing height > 2 SDs below the mean for age & gender  normal height velocity, puberty, & bone age  predicted adult height appropriate to familial pattern

--------------------------------------------------------------- post-op patient with hypotension, syncope, JVD, new-onset right BBB: massive PE  massive PE = PE complicated by hypotension &/or acute right heart strain

syncope is common right heart strain  ventricular dysFx   C.O., bradycardia, & cardiogenic shock  Dx: CT angiography  Rx: fibrinolysis (relative C/I: surgery within preceding 10 days) --------------------------------------------------------------- pancreatic pseudocyst: fibrous capsule containing enzyme-rich fluid, tissue, & debris accumulates within the pancreas  elevated amylase  palpable epigastric mass a/w chronic pancreatitis  Dx: USS  Rx: resolves spontaneously --------------------------------------------------------------- diffuse infection of necrotic pancreatic tissue, MC 1 – 2 wks after acute pancreatitis episode: infected pancreatic necrosis  Rx: surgical debridement ---------------------------------------------------------------DDx of flaccid paralysis infant botulism foodborne Guillain-Barre botulism C. botulinum C. botulinum autoimmune spore ingestion preformed peripheral nerve from environmt toxin demyelination dust/soil descending descending ascending flaccid flaccid paralysis flaccid paralysis paralysis CA, PA, UT prodrome N/V, absent DTRx diarrhea Rx: botulism Ig Rx: anti-toxin IV Ig or plsmphrss  previously healthy infant with B/L bulbar palsies (ptosis, sluggish pupillary response, poor suck or gag reflexes), symmetric hypotonia, constipation, drooling  Rx: empiric IV botulism Ig --------------------------------------------------------------- mucopurulent vaginal discharge, friable cervix: cervicitis  #1 MCC: C. trachomatis; #2: N. gonorrhea  Dx: nucleic acid amplification --------------------------------------------------------------- solitary pulmonary nodule on CXR: compare with previous CXR  stable lesion, 2 – 3 yrs  no further testing  

no previous imaging  chest CT o benign features  serial CT scans o intermediate suspicion  Bx or PET o high suspicion  surgical excision  ≥ 2 cm, low density, speculated/irregular, eccentric calcification favors carcinoma  high risk: age > 60, current smoker, weight loss, previous malignancy  Bx central lesions: bronchoscopy  Bx peripheral lesions: CT-guided percutaneous Bx --------------------------------------------------------------- uncomplicated proximal LE DVT Management of SIADH asymptomatic/mild fluid restriction (< 800 mL/day), (forgetfulness, oral Na+ tablets, unstable gait) furosemide if urine Osm > 2x serum Osm moderate hypertonic saline (3 – 4 hrs) to  (confusion, lethargy) Na+ > 120 mEq/L severe hypertonic saline bolus until (mental status symptoms resolve, change, seizure, +/- conivaptan (ADH Rc &/or coma) antagonist; cause water diuresis)  Rx: anticoagulation (unfractionated or LMWH)  anticoagulation C/I: recent surgery, active bleed, Hx of HIT, hemorrhagic stroke, bleeding diathesis  Rx: IVC filter  proximal DVT with hemodynamically unstable PE or massive proximal DVT with severe swelling or limb-threatening ischemia  Rx: thrombolytics o if C/I: iliac stenting, mechanical or surgical thrombectomy --------------------------------------------------------------- middle-aged woman, widespread pain, fatigue, cognitive/mood disturbance: fibromyalgia  normal lab findings, normal ESR  symptoms > 3 months  Dx: widespread pain index/symptom severity scale  #1 Rx: education, exercise, & sleep hygiene  #2 Rx: amitriptyline (TCAs)  alt Rx: pregabalin, duloxetine, milnacepran ---------------------------------------------------------------Polymyalgia rheumatica 

age > 50 with B/L pain & stiffness >1 month, morning stiffness > 1 hr, constitutional symptoms,  ESR, normal CK   active ROM of shoulder, neck, & hip  no focal tenderness or weakness  Rx: low-dose prednisone (rapid, thorough relief)  a/w giant cell arteritis o Dx: temporal artery Bx if suspected o Rx: high-dose prednisone --------------------------------------------------------------- euvolemic hyponatremia due to renal Na+ losses  when normal saline bolus is given,  urine Na+ excretion, while serum Na+ is unaffected SIADH findings o serum osmolality < 290  urine osmolality > 300 (concentrated urine)  urine Na+ > 40 mEq/L o absence of hypovolemia (euvolemic) o normal Cr, K+, acid-base o normal renal, adrenal, & thyroid function  asymptomatic or mild symptoms of SIADH respond to fluid restriction &/or Na+ tablets  severe, symptomatic hyponatremia requires hypertonic saline   serum Na+ correction: 0.5 – 1 mEq/L/hr or 10 mEq/24 hr to prevent osmotic demyelination --------------------------------------------------------------- demeclocycline:  responsiveness to ADH  Rx SIADH by inhibiting ADH-mediated aquaporin insertion  A/E: nephrotoxic --------------------------------------------------------------- effective management of SIADH required the infused fluid to have a higher electrolyte concentration than urine & plasma  NS (0.9%) is only slightly higher than serum osmolality & leads to NaCl excretion  excessive ADH causes more water retention, thus concentrates the urine, dilutes the serum, & worsens hyponatremia --------------------------------------------------------------- ACE-I are recommended for patients with proteinuria, heart failure, or CKD with HTN  C/I in B/L renal artery stenosis 

--------------------------------------------------------------- cirrhosis causes signs of total body water overload (ascites, interstitial edema) 2/2 hypoalbuminemia  edema causes relative depletion of intravascular volume, causing kidney to maximally retain water, resulting in low urine Na+ --------------------------------------------------------------- sodium bicarbonate: Rx severe metabolic acidosis, hyperkalemia, & TCA overdose --------------------------------------------------------------- chronic phenytoin can cause megaloblastic anemia due to impaired absorption of folic acid  also primidone, phenobarbital, TMP, MTX --------------------------------------------------------------- low-dose prednisone: Rx polymyalgia rheumatica  high-dose prednisone: Rx giant cell arteritis  MTX: Rx rheumatoid arthritis  hydroxychloroquine: Rx SLE for skin & joint --------------------------------------------------------------- mittelschmerz: mid-cycle pain is due to ovulation  unilateral abdo pain, 2 wks after LMP  regular menstrual periods, not on OCPs --------------------------------------------------------------- nephrotic syndrome can cause dyslipidemia, increasing risk for accelerated atherosclerosis & intrinsic hypercoagulability (venous)  complications: stroke, MI --------------------------------------------------------------- Metabolic syndrome (at least 3/5) o abdomen (men: > 40 in, women > 35 in) o fasting glucose > 100 mg/dL o BP > 130/80 mmHg o triglycerides > 150 mg/dL o HDL (men < 40, women < 50)  pathogenesis: insulin resistance (results in increased insulin secretion to compensate) o endothelial dependent vasodilatation is impaired in insulin resistance --------------------------------------------------------------- blood at urethral meatus, inability to void, & high-riding prostate: posterior urethral injury  Dx: retrograde urethrogram prior to Foley o Foley catheter will predispose to abscess, hematoma, or urethral damage

 perineal or scrotal hematomas are a/w pelvic fx ---------------------------------------------------------------Histoplasmosis  immunocompetent: asymptomatic or mild pulmonary disease  immunocompromised: pneumonia, pancytopenia, adenopathy, hepatosplenomegaly, mucocutaneous lesions  Dx: urine or serum antigen  Rx (mild): oral itraconazole  Rx: (severe): amphotericin B, then oral itraconazole --------------------------------------------------------------- short-acting benzos (alprazolam) is a/w seizures & confusion following abrupt discontinuation  dose-dependent A/E of bupropion use: seizures --------------------------------------------------------------- AAA screening: 1x abdominal USS for male active or former smokers ager 65 – 75  selective screening for male never smokers  women age 65 - 75 who have ever smoked o insufficient evidence  surgical Rx AAA ≥ 5.5 cm --------------------------------------------------------------- acute onset back pain & profound hypotension: evaluate for presumptive ruptured AAA  Rx: emergent surgical AAA repair  complication: AAA can rupture into retroperitoneum, creating an aortocaval fistula with the IVC  venous congestion in the bladder  fragile, distended veins can rupture  gross hematuria  DDx: renal colic, mesenteric ischemia, pancreatitis, diverticulitis, biliary disease --------------------------------------------------------------- symptoms of impending eclampsia: persistent frontal/occipital headache, visual disturbance, altered mental status, RUQ or epigastric pain, SOB  tonic-clonic (grand mal) seizures last 3 – 4 min & self-limited  fetal bradycardia is common during seizures; resolves once patient is stabilized  Rx: Mg++ sulfate prevents seizure recurrence; continued through labor & postpartum period  Rx: labor induction/augmentation if no evidence of fetal distress o c-section reserved for typical OC reasons

--------------------------------------------------------------- chronic Rx with supra-physiologic doses of glucocorticoids (Rx giant cell arteritis) is a/w hyperglycemia, bone loss, chronic myopathy  glucocorticoid-induced myopathy progresses over weeks to month after Rx initiation  painless proximal weakness, no tenderness  normal CK & ESR, no inflammation  DDx: MS, Myasthenia, polymyalgia rheumatica ---------------------------------------------------------------DDx of myopathy features ESR CK glucocorticoid progressive proximal nrml nrml -induced weakness, mainly LE, no pain or tenderness statin-induced pain & tenderness, nrml  w/without weakness, rhabdomyolysis hypothyroid pain, cramps, weakness nrml  myopathy of proximal muscles, delayed DTRs, hypothyroid features polymyalgia pain & stiffness  nrml rheumatica decreased ROM at hip & shoulders rapid response to glucocorticoids inflammatory proximal weakness,   myopathies pain & tenderness, rash, arthritis --------------------------------------------------------------- Management of blunt abdominal trauma in hemodynamically unstable: FAST exam o positive  laparotomy o negative  abdominal CT o inconclusive  DPL --------------------------------------------------------------- hearing tests for children with behavioral concerns, poor language & social skills, “inattentive”  MCC: conductive hearing loss due to recurrent ear infections --------------------------------------------------------------- SGA infant: weight < 10th percentile  complications: hypoxia, polycythemia, hypoglycemia, hypothermia, hypocalcemia

o polycythemia is 2/2 hypoxia --------------------------------------------------------------- preseptal cellulitis: anterior to orbital septum  orbital cellulitis: posterior to orbital septum presepta orbital l celluliti cellulitis s eyelid edema & erythema + + fever, leukocytosis +/+/ophthalmoplegia, diplopia + pain with eye movement + proptosis + decreased visual acuity +  Dx: orbital CT scan  Rx preseptal: outpatient, oral ABX  Rx orbital: inpatient, IV ABX  complication: cavernous sinus thrombosis --------------------------------------------------------------- circumferential full-thickness burns of extremity o Rx: IV fluids, analgesia, topical ABX, & wound dressing  eschar: firm necrotic tissue on exposed tissue following burn wounds o compromises blood & lymph circulation  compartment syndrome: deep pain out of proportion to injury, pulselessness, paresthesia  Dx: Doppler USS to document peripheral pulses & tissue compartment pressure  Rx: escharotomy for edema & constriction of vascular supply or  peripheral pulses o evaluate for signs of adequate perfusion  fasciotomy: Rx compartment syndrome --------------------------------------------------------------- decreased appetite, behavioral changes, erythema of turbinates in nasal septum: cocaine abuse --------------------------------------------------------------- primary dysmenorrhea: lower abdo cramping with menses, in absence of other pathology o MC onset during adolescence  cramping in 1st few days of menses, due to release of prostaglandins from sloughing endometrium causes uterine contractions  normal physical exam  Rx: NSAIDs & OCPs

Anti-diabetic medications  A1c features Metformin 1 – 2% initial therapeutic agent weight neutral low risk of hypoglycemia A/E: lactic acidosis C/I: renal insufficiency Sulfonylurea 1 – 2% added for metformin failure weight gain, hypoglycemia Pioglitazone 1 - 1.5% 2nd line to metformin/sulfon. (TZDs) low risk of hypoglycemia can use in renal insufficiency A/E: weight gain, edema, CHF, bone fx, bladder cancer Insulin 1 - 3.5% basal insulin added in metformin failure, A1c >8.5% weight gain, hypoglycemia Sitagliptin .5 - .8% weight neutral (DPP-IV low risk of hypoglycemia inhibitors) can use in renal insufficiency Exenatide 0.5 - 1% 2nd agent to metformin (GLP-1 Rc weight loss** agonist) low hypoglycemia risk A/E: acute pancreatitis --------------------------------------------------------------- secondary dysmenorrhea: age 20s – 30s, previous Hx of non-painful menses  MCC: endometriosis, adenomyosis, fibroids, pelvic infection --------------------------------------------------------------- chronic corticosteroids & chronic alcohol are a/w avascular necrosis  progressive hip pain, normal ROM; normal XR  Dx: MRI --------------------------------------------------------------- hemodynamic compromise 3 – 7 days post-MI: MR due to papillary rupture, LV free wall rupture, or interventricular septum rupture --------------------------------------------------------------- young patient with a fleshy, immobile mass on the midline hard palate: torus platinus o benign, congenital lesion --------------------------------------------------------------- elevated ALP indicates cholestasis  Dx: RUQ USS; intrahepatic or extrahepatic cause of biliary obstruction

o biliary dilatation: extrahepatic cholestasis --------------------------------------------------------------- polyuria, polydipsia, mild hypernatremia (> 145) & serum hypertonicity: diabetes insipidus  nephrogenic DI: intact thirst mechanism o serum Na+ ~ 145  central DI: no intact thirst mechanism o serum Na+ > 150 o desmopressin: #1 Rx for central DI ---------------------------------------------------------------10 polydipsia central DI nephrogenic DI  H2O intake  ADH release ADH resistance anxious idiopathic, trauma chronic lithium, middle-age pituitary surgery, hyperCa++, female on ischemic hereditary antipsychotics encephalopathy polyuria, low urine osmolality (dilute urine) Na+ < 137 Na+ > 150, Na+ 142 – 150, thirst impairment intact thirst mech --------------------------------------------------------------- diuretic: hypoK+, hyperglycemia, hyperuricemia o stimulates ADH  concentrated urine --------------------------------------------------------------- demeclocycline: Rx SIADH by inhibiting the ADH-mediated aquaporin insertion --------------------------------------------------------------- tolvaptan: V2 vasopressin Rc antagonist, causes selective free water loss  Rx severe hypervolemic/euvolemic hyponatremia --------------------------------------------------------------- hypersensitivity pneumonitis: inflammation of lung parenchyma due to antigen exposure  cough, dyspnea, fever, malaise within 4 – 6 hr  chronic: weight loss, clubbing, honeycomb lung  CXR: ground-glass opacity, “haziness”  Rx: avoidance of antigen  complications: pulmonary fibrosis --------------------------------------------------------------- SSRIs take 4 – 6 wks for benefits o should be continued if no significant A/E  initial change:  dosage  next: prescribe another SSRI --------------------------------------------------------------- PTU A/E: hepatic failure (black box)

methimazole A/E: 1st trimester teratogen patients with sore throat & fever  stop med & check WBC for agranulocytosis (WBC < 1,000)  Rx: IV ABX (anti-pseudomonals)  30 - 40% on anti-thyroidal after 1 yr go into permanent remission --------------------------------------------------------------- hyperactive DTRs post-surgery: hypocalcemia  MCC: volume expansion & hypoalbuminemia in patients requiring multiple transfusions caused by citrate binding to ionized Ca++ --------------------------------------------------------------- severe hypoMg++ can mimic hypocalcemia   PTH secretion & peripheral PTH resistance  serum phosphate level is normal --------------------------------------------------------------- severe hyperMg++: loss of DTRs, paralysis, apnea, cardiac arrest --------------------------------------------------------------- sensorineural hearing loss due to aging: presbycusis o B/L high-frequency hearing loss o difficulty hearing in noisy, crowded spaces --------------------------------------------------------------- chronic conductive hearing loss a/w overgrowth of stapes bone: otosclerosis o low-frequency hearing loss o women age 30s – 40s --------------------------------------------------------------- steatorrhea can be due to pancreatic insufficiency (chronic pancreatitis, CF), impaired bile salt absorption (Crohn’s), impaired intestinal surface epithelium (Celiac’s), or Whipple’s  MCC of chronic pancreatitis: alcohol abuse ---------------------------------------------------------------Seizures  generalized seizure: diffuse brain involvement  partial seizure: arise from a discrete focus; can be preceded by an aura (burning smell) o simple partial: no loss of consciousness o complex partial: a/w LOC & automatisms (chewing, picking, lip smacking)  partial with secondary generalization: tonic-clonic manifestations (muscle aches,  CK, loss of bowel/bladder control)  

--------------------------------------------------------------- clavicle fractures require a neurovascular exam; proximity of subclavian artery & brachial plexus  bruit heard under the clavicle requires angiogram  middle 1/3 fx Rx: brace/sling, ice, rest  distal 1/3 fx Rx: ORIF to prevent non union --------------------------------------------------------------- MCC of aortic stenosis o senile calcific aortic stenosis (MC age > 70)  bicuspid aortic valve (MC age < 70) o rheumatic heart disease  DDx: hypertrophic cardiomyopathy (heard @ LLSB, does not radiate to carotids) --------------------------------------------------------------- young female immigrant with a-fib & symptoms of pulmonary edema: mitral stenosis 2/2 rheumatic heart disease  females become symptomatic during pregnancy due to increased blood volume --------------------------------------------------------------- lateral epicondylitis: pain with supination, passive wrist flexion, or resisted wrist extension  point tenderness distal to lateral epicondyle  extensor carpi radialis brevis tendon degeneration  DDx: radial tunnel syndrome --------------------------------------------------------------- medial epicondylitis: pain with passive wrist extension or resisted wrist flexion --------------------------------------------------------------- ASA & β-blockers can trigger bronchoconstriction in asthmatics (acute dyspnea, prolonged expiration) o especially with chronic rhinitis & nasal polyps  cardioselective β-blockers (metoprolol, atenolol) act on β-1; safe for mild/moderate asthmatics --------------------------------------------------------------- stress incontinence Rx: Kegel exercise, urethropexy  Dx: urethral hypermobility (> 300 urethrovesical angle with increased intra-abdominal pressure) --------------------------------------------------------------- oxybutynin: Rx urge incontinence  bethanechol & α-blockers: Rx overflow incont. --------------------------------------------------------------- most predictive sign of opioid intoxication: bradypnea (respiratory depression)

obtunded,  bowel sounds, miosis, hypotension, hypothermia ---------------------------------------------------------------GBS prophylaxis for unknown GBS status  delivery @ < 37 wks  membrane rupture > 18 hr  GBS bacteriuria during current pregnancy  prior Hx of newborn with GBS sepsis --------------------------------------------------------------- presence of a VSD requires an echo to determine location & size, also r/o other defects  small VSDs close spontaneously by age 2 yrs --------------------------------------------------------------- V-fib (reentrant ventricular arrhythmias) is MCC of sudden cardiac arrest, immediately post-MI o re-entry is the predominant mechanism  causes syncope ---------------------------------------------------------------Neonatal displaced clavicle fracture risk fetal macrosomia, shoulder dystocia, factors instrumentation delivery features crying with passive motion, crepitus, asymmetric Moro reflex Dx XR Rx reassurance, gentle handling, analgesics, spontaneous healing in 7 – 10 days, place affected arm in long-sleeved garment & pin to chest with elbow flexed 900 --------------------------------------------------------------- fat necrosis of the breast: fixed mass with skin or nipple retraction, appears solid on USS  coarse calcification on mammography (breast malignancy: microcalcifications)  fat globules & foamy histiocytes/macrophages  Rx: routine F/U, no intervention, self-limited --------------------------------------------------------------- ALT is predominant in the liver, more specific for hepatocyte injury  screen Hx for hepatitis risk factors: drugs, alcohol, travel outside US, transfusions, sexual practices  repeat LFTs: if chronically elevated transaminases (> 6 months); evaluate for Hep B & C, fatty liver, & hemochromatosis ---------------------------------------------------------------o

pallor, fatigue, bloody diarrhea, scattered petechial rash, oliguria: HUS  hemolytic anemia, thrombocytopenia, ARF  MCC: E. coli O157:H7; also S. pneumo (causes pneumonia or meningitis instead of diarrhea)  progressive renal involvement: oliguria, microscopic hematuria, hyaline casts  results in fluid overload (pulmonary edema, CHF)  Rx: supportive, plasmapheresis, dialysis  DDx: Henoch-Schonlein (normal PLT count), ITP, post-strep GN, RMSF --------------------------------------------------------------- Chikunguna fever: mosquito-borne viral illness  incubation: 3 – 7 days  flu-like illness, symmetric polyarthralgia, maculopapular rash, cervical lymphadenopathy, peripheral edema  lymphopenia, thrombocytopenia  Rx: supportive, resolves in 7 – 10 days --------------------------------------------------------------- initial hematuria: urethral damage  terminal hematuria: bladder or prostate damage o Dx: cystoscopy (r/o bladder ca)  total hematuria: kidney, glomerular, or ureter --------------------------------------------------------------- conjunctivitis, urethritis, arthritis: reactive arthritis  1 – 4 wks after GI/GU infection (urethritis)  asymmetric oligoarthritis, conjunctivitis, mucocutaneous oral lesions (stomatitis)  Chlamydia infection can cause reactive arthritis --------------------------------------------------------------- infant with failure to thrive, lymphadenopathy, diarrhea, thrush, maternal IVDA: HIV infection  high risk mother: HIV antibody test @ 1st & 3rd trimesters; Ab detection can take up to 3 months, occurs after the “infectious window period”  infants (birth – 18 months) Dx: PCR testing --------------------------------------------------------------- diabetic foot ulcers result from neuropathy, microvascular insufficiency, immunosuppression  a/w Charcot joint deformities  MC site: plantar surface of 1st metatarsal head, under bony prominences 

best assessment for risk of diabetic foot ulcers: monofilament testing --------------------------------------------------------------- venous insufficiency ulcers: stasis dermatitis @ medial aspect above medial malleolus  arterial ulcers: tissue necrosis @ tip of toes --------------------------------------------------------------- factorial design study: randomization to 2 or more interventions with assignment to 2 or more variables studied independently  effect of two or more independent variables upon a single dependent variable --------------------------------------------------------------- trichotillomania: recurrent hair pulling, results in hair loss, distress, & functional impairment o shared features & comorbidity with OCD  Rx: CBT  DDx: alopecia acreta, body dysmorphic disorder, GAD, SLE, OCD --------------------------------------------------------------- fever, productive cough, RLL infiltrate, extremely  WBC with lymphocyte predominance: CLL  atypical lymphocytes with smudge cells  MC in elderly age > 70  risk of recurrent infections  presence of thrombocytopenia = poor prognosis  Dx: flow cytometry --------------------------------------------------------------- Howell-Jolly bodies: nuclear remnants of RBCs generally removed by a functional spleen  single, round, blue inclusions on Wright stain  suggests functional asplenia or splenectomy  a/w sickle cell anemia --------------------------------------------------------------- Heinz bodies: aggregates of denatured Hb o Hb is oxidized & become insoluble precipitants  a/w G6PD deficiency & thalassemia  phagocytes extract Heinz bodies  bite cells --------------------------------------------------------------- basophilic stippling: ribosomal precipitates appear as blue granules in RBC cytoplasm  thalassemia, lead/heavy metal poisoning, alcoholism ---------------------------------------------------------------

chronic alcoholics present with hypoK+, hypoMg+ +, & hypophosphatemia  Mg++ regulates K+ uptake & intracellular levels  hypoMg++ causes refractory hypoK+ despite K+ supplementation --------------------------------------------------------------- hypoalbuminemia in alcoholics can result in hypocalcemia o Ca++ is largely albumin-bound --------------------------------------------------------------- vaccines for chronic liver disease o Tdap 1x substitute (Td every 10 yrs) o influenza annually (IM inactivated)  PPSV23 1x, then PCV13/PPSV23 @ age 65 o Hep A & B --------------------------------------------------------------- all sexually active women age ≤ 24 should be screened for C. trachomatis & N. gonorrhea by nucleic amplification testing --------------------------------------------------------------- screen for chlamydia: all sexually active women age ≤ 24 or > 25 if new/multi partners, Hx of STD or incarceration  MCC of urethritis, cervicitis, vaginitis  asymptomatic in 80% of women  intracellular organisms (-wet mount, -Gram stain)  Dx: nucleic acid amplification  Rx: azithromycin (single dose) or doxycycline; also treat partners  complications: PID, infertility --------------------------------------------------------------- gonorrhea screen: high-risk sexually active women, age < 24 yrs, new/multi sexual partners, Hx of STIs; including pregos in this category --------------------------------------------------------------- febrile neutropenia: absolute neutrophil count < 1500 (severe < 500); medical emergency!  no obvious focus of infection; normal CXR & U/A  MCC is P. aeruginosa  Rx: empiric anti-pseudomonal (cefepime, meropenem, piperacillin-tazobactam)  Dx: blood & urine cultures --------------------------------------------------------------- communicating hydrocele: processus vaginalis fails to obliteration 

non-communicating: fluid within tunica vaginalis most spontaneously disappear by age 1 yr Rx: reassurance & observation for 1 yr unresolved communicating hydrocele  surgical removal due to risk of inguinal hernia --------------------------------------------------------------- sick sinus syndrome: impaired SA node automaticity o 2/2 degeneration or fibrosis of SA node  fatigue, lightheadedness, palpitations, syncope  EKG: tachycardia-bradycardia syndrome, sinus pause/arrest, SA exit block --------------------------------------------------------------- painless, hard testicular mass + suggestive USS: radical orchiectomy (testis & cord) o “kill first, investigate later” o determine cancer type to guide treatment  highest cure rate of all cancers --------------------------------------------------------------- burst fracture of vertebra, loss of motor function below lesion, loss of pain/temp B/L below lesion, intact proprioception: anterior cord syndrome  B/L loss of vibratory & proprioception, weakness, paresthesias, urinary incontinence or retention: posterior cord syndrome (MS)  burning pain & weakness in upper extremities from forced hyperextension neck injury with pre-existing degenerative cervical changes: central cord o localized deficit in pain & temp  I/L motor weakness, spasticity, loss of vibration & proprioception, C/L loss of pain & temp 2 levels below lesion: Brown-Sequard  paraplegia, variable sensory loss, urinary & fecal incontinence, saddle anesthesia: Cauda equina --------------------------------------------------------------- Cauda equina syndrome: sacral nerve root compression 2/2 herniation, spinal stenosis, metastasis, tumors, infection, iatrogenic injury  provides sensory innervation to saddle area, motor to sphincters, PNS to bowel & bladder  LMN signs, hyporeflexia  gradual, severe back pain with U/L radiculopathy, saddle numbness, asymmetric weakness ---------------------------------------------------------------Cauda equina Conus medullaris syndrome syndrome    

LMN signs UMN & LMN signs B/L radicular pain sudden severe back pain saddle anesthesia perianal anesthesia asymmetric motor weak symmetric motor weak hypo-/arefflexia hyperreflexia late-onset bowel/bladder early-onset bowel/bladder  Rx: MRI, IV glucocorticoids, neurosurg consult --------------------------------------------------------------- acute “mechanical” back pain w/o neuro deficits, pain radiation, +Straight-leg raise: disc herniation  unilateral radicular pain in dermatome distribution  Rx: early mobilization, relaxants, NSAIDs o 4 – 6 wks  return to daily activities ASAP o bed rest, exercise program, & PT not helpful  severe pain may result in urinary retention due to inability to Valsalva in those with BPH ---------------------------------------------------------------Opportunistic infections in HIV P. jirovecii CD4 < 200 TMP-SMX (10) Toxoplasma CD4 < 100 TMP-SMX (10) MAC CD4 < 50 azithromycin (10) Histoplasma CD4 < 150 Itraconazole optimal approach to preventing opportunistic infections: anti-retrovirals, vaccination  primary prophylaxis (CD4 < 200) o TMP-SMX & azithromycin  secondary prophylaxis: after an infection to prevent relapse or recurrence; regardless of CD4 o acyclovir/valacyclovir for HSV o fluconazole for Cryptococcus --------------------------------------------------------------- sudden onset back pain, pallor, dark urine, jaundice, bite cells: G6PD deficiency  X-linked; MC in A-A, Asian, Mediterranean  hemolytic anemia after oxidative stress/injury ( indirect bilirubin,  LDH,  haptoglobin)  precipitated by infection, meds (TMP-SMX, sulfa, antimalarial, nitrofurantoin), fava beans  G6PD activity assay can be normal during attack as G6PD deficient RBCs are hemolyzed early  +Prussian blue stain = hemosiderin  PBS: bite cells with Heinz bodies 

G6PD catalyzes reduction of NADP to NADPH; NADPH is necessary to reduce glutathione, which protects RBCs from oxidation by oxidizing agents (bacterial toxins, meds) o without G6PD, Hb become oxidized & denatured into Heinz bodies  hemolysis  Rx: supportive; manage underlying cause --------------------------------------------------------------- arteriovenous fistula causes high-output cardiac failure by shunting blood from arterial to venous  increase preload o also  systemic vascular resistance  circulation is unable to meet O2 demands of peripheral tissues  MCC: trauma, iatrogenic (femoral catheterization), atherosclerosis (aortocaval fistula)  wide pulse pressure, brisk carotid upstroke, systolic murmur, flushed extremity, LVH  Dx: Doppler USS ---------------------------------------------------------------Primary humoral deficiencies Bruton /absent B-cells agammaglobulinemi  all Ig a CVID normal B-cells  all Ig IgA deficiency normal B-cells  IgA only Hyper-IgM normal B-cells syndrome  IgG & IgA,  IgM 

all result in recurrent sinopulmonary infections with encapsulated spp, viruses, opportunistics  hyper-IgM syndrome prevents class switching due to CD40 ligand deficiency o lymphoid hyperplasia o Giardia & sinopulmonary infections  IgA def: recurrent respiratory, GI, GU infections & anaphylactic transfusion reaction o episodic diarrhea: Giardia --------------------------------------------------------------- diabetic foot ulcers allow contiguous spread of infection, resulting in osteomyelitis ---------------------------------------------------------------

episodic vision loss, diplopia, sensory deficits, motor weakness, gait/balance disturbance: MS  relapsing-remitting pattern  optic neuritis, internuclear ophthalmoplegia  MRI: multiple, B/L, asymmetric hyperintense lesions in periventricular white matter  acute exacerbation Rx: high-dose IV methylprednisolone o plasma exchange if no response --------------------------------------------------------------- M. tuberculosis occurs when droplets of bacilli reach the alveolar space & replicate; accumulation of macrophage & neutrophils, with bacilli proliferation form a tubercle  tubercle + lymphadenopathy = Gohn complex  cell-mediated immune response forms a granuloma, resulting in latent TB --------------------------------------------------------------- initial menstrual cycles at menarche are anovulatory  2/2 immature hypothalamic-pituitary-ovarian axis  causes irregular cycles &/or menorrhagia  some cyclic bleeding due to breakthrough --------------------------------------------------------------- acute low back pain o no red flags, sciatica or cord compression  Rx: conservative therapy 4 – 6 wks  back XR & ESR if no improvement o red flags or sciatica: back XR & ESR  MRI if results abnormal  cord compression signs/symptoms: MRI  red flags: age > 50, nighttime pain, constitutional symptoms (fever, weight loss), unrelieved by rest, not exacerbated with movement or palpation, neurologic symptoms, Hx of malignancy, IVDA  cord compression signs: back pain, paralysis, hyperreflexia, urinary & fecal incontinence --------------------------------------------------------------- atelectasis: common post-op complication  peak severity: 2nd post-op day  MC due to airway obstruction from retained airway secretion,  lung compliance, post-operative pain, & medications interfering with deep breathing  results from shallow breathing & weak cough  V/Q mismatch evident 

ABG: hypoxemia, hypocapnia, resp. alkalosis Rx: pain control, breathing exercises, directed coughing, early mobilization, incentive spirometry ---------------------------------------------------------------Preventing post-op pulmonary complications  pre-operative  smoking cessation at least 8 wks prior o COPD symptom control o Rx respiratory infections o education on lung expansion maneuvers  post-operative o incentive spirometry, deep breathing exercises o CPAP, chest PT ---------------------------------------------------------------Rome criteria for irritable bowel syndrome  recurrent abdo pain/discomfort, ≥ 3 days/month for the last 3 months + ≥ 2… o improves with bowel movement o change in stool frequency o change in stool form  diarrhea- or constipation-predominant, or mixed  no extensive workup if no alarm features, & no family Hx or IBD or CRC  colonoscopy: normal colonic mucosa --------------------------------------------------------------- severe vulvar itching with numerous excoriations, & skin is thin, dry, & white; post-menopause: lichen sclerosis  porcelain-white polygonal macules & papules with atrophic, “cigarette paper” quality  premalignant lesion  SCC  Dx: vulvar punch biopsy (r/o vulvar SCC)  Rx: high-potency topical corticosteroids --------------------------------------------------------------- clusters of small teardrop-shaped growths at vestibule of the vulva: HPV genital warts (condyloma acuminata)  clusters of smooth, pink/skin-colored lesions  Rx: trichloroacetic acid (complete resolution) or podophyllin  DDx: condyloma lata (20 syphilis; flat & velvety), vulva ca (single, fleshy lesion), lichen sclerosis, vulvar lichen planus --------------------------------------------------------------- 

itchy, painful, erosive purple lesions on the vulva: vulvar lichen planus  MC in middle-aged women ---------------------------------------------------------------Down syndrome comorbidities cardiac AV septal defect, VSD, ASD GI duodenal atresia, Hirschsprung neuro intellectual disability early-onset Alzheimer’s hematologi acute leukemia c endocrine hypothyroidism, Type I DM MSK atlanto-axial instability --------------------------------------------------------------- Small intestinal bacterial overgrowth:  native & non-native bacteria causing excess fermentation, inflammation, & malabsorption  causes: anatomic or dysmotility disorders (strictures, fistulas, systemic sclerosis, diabetes, immunodeficiency, chronic pancreatitis, cirrhosis)  bloating, flatulence, abdominal pain, diarrhea, weight loss, malabsorption  Dx: endoscopy with jejunal aspirate  Rx: ABX, trial of metoclopramide, diet changes  DDx: IBD, IBS, lactose intolerance, SBO --------------------------------------------------------------- post-op DVT prophylaxis: LMWH ---------------------------------------------------------------Breastfeeding failure Breast milk jaundice jaundice 1st week of life 3 -5 days, peak @ 2 wks lactation failure,  β-glucuronidase in  unconjugated breast milk deconjugate hyperbilirubinemia, intestinal bilirubin, &   bilirubin elimination, & enterohepatic circulation  enterohepatic circulation sub-optimal feeding, adequate breastfeeding dehydration signs, normal exam, inadequate stooling no dehydration Rx: feeding 15 minutes per side every 2 -3 hrs 



causes of lactation failure: inadequate milk supply, infrequent feedings, cracked/clogged nipples, engorgement, poor latching

inadequate stooling results in  bilirubin elimination &  enterohepatic circulation  yellow-seedy stool = normal  “brick-red” urate crystals in diaper = dehydration --------------------------------------------------------------- all newborns have mild unconjugated hyperbilirubinemia due to high Hb turnover & immature hepatic UDGT activity ---------------------------------------------------------------Biliary atresia features jaundice, acholic stool, dark urine, conjugated hyperbilirubinemia & hepatomegaly in first 2 months of life Dx USS: absent/abnormal GB hepatobiliary scintigraphy: failure of tracer excretion into small bowel cholangiogram: biliary obstruction; done intraoperatively (gold std) liver Bx: expanded portal tracts with bile duct obstruction & proliferation; portal tract edema, fibrosis, inflammtn Rx hepatoportoenterostomy (Kasai), liver transplant inevitable  MC indication for pediatric liver transplant --------------------------------------------------------------- cerebellar ataxia @ vermis (truncal ataxia) or hemisphere (I/L ataxia): staggering, swaying, impaired tandem gait & titubation (nodding) TOWARD the affected side ---------------------------------------------------------------Acute Lymphoblastic Leukemia (ALL) etiology MC childhood cancer peak age: 2 – 5 yrs; M > F features bone pain, pallor (anemia), petechiae (thrombocytopenia) nontender lymphadenopathy, hepatosplenomegaly confirm bone marrow Bx Dx shows > 25% lymphoblasts Rx chemotherapy --------------------------------------------------------------- aphthous ulcers, granulomatous inflammation, weight loss, vague abdominal pain: Crohn’s ---------------------------------------------------------------

confounding: the exposure-disease relationship is obscured by the effect of an extraneous factor that is associated with both exposure & disease Methods to control confounding  matching: used in case-control studies; selecting matched known or suspected variables (age, race), both groups having a similar distribution o “stratified analysis”  restriction: limited specific characteristics  randomization: used in clinical trials, minimizes selection bias o controls known, unknown, & difficult-tomeasure confounders --------------------------------------------------------------- effect modification: an external variable that positively or negatively impacts the effect of a risk factor on the disease of interest  distinguished from confounding by performing a stratified analysis on the variable of interest o if the variable is a cofounder  no significant association in risk between stratified groups as the confounding effect is removed o if the variable is an effect modifier  strong association exists between stratified groups  example: family Hx increases the risk of breast ca in patients taking OCPs --------------------------------------------------------------- observer bias: investigator’s decision is adversely affected by knowledge of exposure status  recall bias: inaccurate recall by participants o MC with case-control studies --------------------------------------------------------------- Tumor lysis syndrome: oncologic emergency  releases K+, phosphate & uric acid into circulation o  Ca++,  K+,  phosphate,  uric acid  MCC: massive lymphoma or leukemia, chemoRx  Rx: allopurinol reduces acute urate nephropathy --------------------------------------------------------------- eye exposure to acid: full recovery likely  alkaline exposure: corneal damage likely --------------------------------------------------------------- parkinsonism, orthostatic hypotension, impotence, incontinence: multiple system atrophy (Shy-Drager syndrome)  parkinsonism + autonomic & neurologic dysFx 

--------------------------------------------------------------- hyperkalemia can cause ascending muscle weakness with flaccid paralysis  initial evaluation: EKG  next: exclude acute treatable secondary causes (CKD, hyperglycemia, tumor lysis syndrome)  next: review current/recent meds (non-selective β-blockers, triamterene, ACE-I/ARB, NSAIDs) --------------------------------------------------------------- steppage gait: unilateral foot drop 2/2 weakness of foot dorsiflexion; exaggerated hip/knee flexion  L5 radiculopathy: back pain radiates to foot, weak foot inversion & plantar flexion  common peroneal neuropathy: lateral fibula compression, paresthesia & sensory loss over foot dorsum; normal inversion & plantar flexion  Dx: electromyography or NCV --------------------------------------------------------------- normocytic anemia, splenomegaly, reticulocytosis, indirect bilirubin,  LDH,  haptoglobin: autoimmune hemolytic anemia  MCC: infectious mono, CLL, SLE, PCN  spherocytes (not schistocytes)  confirm Dx: +direct Coomb show IgG or C3 on RBC surface  Rx: high-dose glucocorticoids if symptomatic o splenectomy or immunosuppressives for refractory cases  DDx: sickle cell, microangiopathic hemolytic anemia (DIC) --------------------------------------------------------------- renin is produced in juxtaglomerular cells in response to hypoperfusion  renin cleaves angiotensinogen  angiotensin I, converted to angiotensin II by ACE in the lung  angiotensin II is a potent vasoconstrictor & also promotes aldosterone production in adrenal cortex  aldosterone Rc antagonist: induce natriuresis  angiotensin II Rc blocker: cause natriuresis &  aldosterone production  direct renin inhibitor (aliskiren):  angiotensin I/II & aldosterone

--------------------------------------------------------------- loop diuretics induce natriuresis, but the decreased blood volume stimulates renin, angiotensin II, & aldosterone ---------------------------------------------------------------Causes of Vit K deficiency  fat malabsorption, fat-soluble vitamin deficiency  ABX  hepatocellular disease --------------------------------------------------------------- fever, migratory polyarthralgia, & pustular rash on trunk & extremities, with Hx of high-risk sexual behavior: disseminated gonococcal infection  MC STD causing septic arthritis  Dx: nucleic acid amplification  DDx of fever, rash, arthritis: IE, parvovirus B19, secondary syphilis, toxic shock syndrome feature s

Disseminated gonococcal infection septic arthritis without skin lesions OR

triad: tenosynovitis, dermatitis, migratory asymmetric polyarthritis without purulent arthritis Dx synovial fluid: > 50,000 (septic), urethral, cervical, or rectal cultures, HIV & syphilis screen Rx IV ceftriaxone, joint drainage for purulent arthritis, empiric azithromycin for Chlamydia, treat sexual partners  purulent arthritis in a sexually active individual is gonococcal arthritis until proven otherwise --------------------------------------------------------------- causes of high-output cardiac failure: anemia, thyrotoxicosis, bone Paget’s, thiamine deficiency ---------------------------------------------------------------Bacterial meningitis in children age > 1 month MCC S. pneumoniae & N. meningitidis features fever, vomiting/poor feeding, lethargy, irritability, seizures, bulging anterior fontanelle nuchal rigidity, +Kernig, +Brudzinski Dx CBC, electrolytes, blood cultures, LP Rx IV vancomycin & ceftriaxone (newborns ≤ 28 days: cefotaxime) PLUS dexamethasone for HiB meningitis (reduces risk of sensorineural hearing loss) Rx: LP first, then prompt empiric ABX o ABX can sterilize CSF hindering definitive Dx  ceftriaxone displaces bilirubin from albumin & increases risk for kernicterus in newborns  herniation is rare in infants, thus head CT is reserved only for comatose, focal neuro signs, or Hx of neurosurgical procedures --------------------------------------------------------------- milk production at delivery o sudden  in estrogen & progesterone which normally interferes with actions of prolactin o suckling  stimulatory effects on prolactin & oxytocin release  suppression of breast milk: tight-fitting bra, avoid nipple stimulation, ice packs, analgesics  do not use DA agonists (bromocriptine) ---------------------------------------------------------------

toxic adenoma presents as thyroid toxicosis o RIU uptake only in the nodule  Graves’: diffuse RIU uptake, infiltrative ophthalmopathy, pretibial myxedema  multinodular goiter: patchy RIU uptake  painless thyroiditis: reduced RIU uptake --------------------------------------------------------------- all diastolic, continuous, & loud systolic murmurs require transthoracic echo --------------------------------------------------------------- primary tumors of the GIT, lungs, & breast are MCC of liver metastasis (multiple liver masses) o Dx: colonoscopy  solitary mass in the setting of chronic liver disease: MCC is HCC o Dx: AFP & USS (poorly defined mass)  liver abscess: DDx amebic vs. pyogenic o Dx: serology  encapsulated, calcified cyst with fluid & budding cells; immigrant or exposure to sheep & dogs o hydatid cyst (Echinococcus)  benign epithelial liver tumor, solitary mass in right hepatic lobe, young female, chronic OCPs o hepatic adenoma  exposure to vinyl chloride gas, thorium dioxide arsenic,; vascular spaces with malignant cells o angiosarcoma of the liver --------------------------------------------------------------- Prinzmetal angina is a/w Raynaud’s & migraines  precipitated by emotional stress, hyperventilation, exercise, cold, cocaine use  greatest risk factor: smoking  Rx: CCB or nitrates o non-selective β-blockers (β2) & ASA promote vasoconstriction --------------------------------------------------------------- protease inhibitors (indinavir) commonly cause crystal-induced nephropathy o periodic monitoring of U/A & serum Cr  NRTI: a/w lactic acidosis  NNRTI: a/w SJS  nevirapine: a/w liver failure ---------------------------------------------------------------

intermittent chest pain, dysphagia, young female: diffuse esophageal spasm  a/w emotional factors & functional GI disorders  relieved by nitrates & CCBs  barium swallow: “corkscrew” or normal  Dx: manometry  simultaneous high amplitude contractions & normal LES  Rx: anti-spasmodics, diet, psych counseling  DDx: Zenker, achalasia, scleroderma, infectious esophagitis (candida, HSV, CMV) --------------------------------------------------------------- scleroderma can present with loss of distal peristalsis of esophagus  fibrosis & atrophy of esophageal smooth muscle  LES is incompetent  reflux  stricture --------------------------------------------------------------- CVD is MCC of morbidity & mortality in PAD & intermittent claudication  5-yr risk of nonfatal MI & stroke  PAD is a CAD risk equivalent  #1 Rx: supervised graded exercise program o goal: reproduce claudication symptoms o reduces symptoms & improve distance  #2 Rx: low-dose ASA & statin reduces atherosclerotic CV mortality  #3 Rx: add cilostazol for persistent symptoms  #4 Rx: percutaneous or surgical revascularization for persistent symptoms --------------------------------------------------------------- aminoglycosides: Rx multi-drug resistant pyelonephritis or serious G-negative infections  aminoglycosides (amikacin) are nephrotoxic o can cause acute renal failure in setting of CKD o monitor drug levels & renal function --------------------------------------------------------------- Nafcillin is used for Rx MSSA o MCC of AIN (eosinophils & WBC casts) --------------------------------------------------------------- daytime drowsiness & cataplexy (sudden loss of muscle tone triggered by strong emotions), sleep paralysis, hypnagogic/hypnopompic hallucination: narcolepsy  #1 Rx: modafinil (psychostimulant)  alt Rx: methylphenidate, amphetamines 

--------------------------------------------------------------- primipexole (DA agonist): Rx RLS & Parkinson --------------------------------------------------------------- circumstantial thought: deviates from original subject, but eventually return  tangential thought: drift away, never returns  “flight of ideas”: loosely associated thoughts that move from topic to topic  loose association: lack of logical connection between thoughts or ideas; severe tangentiality --------------------------------------------------------------- signs of deliberate scald injury in toddlers o linear demarcation, no splash marks o extensive burns to back/buttocks o sparing of flexural creases, “zebra” pattern --------------------------------------------------------------- positive pressure mechanical ventilation acutely  intrathoracic pressure, thus  venous return, ventricular preload, & C.O.  can cause circulatory collapse in hypovolemic shock if intravascular volume is not replaced before mechanical ventilation --------------------------------------------------------------- flexible bronchoscopy: Rx life-threatening hemoptysis, locate & treat bleeding source --------------------------------------------------------------- MCC of dyspepsia: GERD, NSAIDs, GI cancer, functional dyspepsia, H. pylori  dyspepsia + alarm symptoms  upper endoscopy o alarm symptoms for gastric or esophageal cancer: age > 55, weight loss, dysphagia, persistent vomiting, early satiety, anemia, gross/occult bleed  dyspepsia, no alarm symptoms… o GERD symptoms  PPI or H2 blocker o NSAID-induced dyspepsia  PPI o if no GERD, no NSAID use  H. pylori test (breath test or stool assay, not serology) o if no improvement  upper endoscopy --------------------------------------------------------------- GERD can present as chronic cough or hoarseness  Rx: H2 antagonist (ranitidine) or PPI --------------------------------------------------------------- atypical antipsychotics (olanzapine, clozapine) is a/w weight gain, hyperglycemia, dyslipidemia

o monitor BMI, fasting glucose & lipids --------------------------------------------------------------- monitor renal & thyroid function: lithium o a/w nephrogenic DI, interstitial nephritis, hypothyroidism  monitor CBC weekly: clozapine o a/w agranulocytosis, lowers seizure threshold  1st gen anti-psychotics & risperidone are a/w hyperprolactinemia o galactorrhea, amenorrhea, decreased libido --------------------------------------------------------------- clomaphine citrate (estrogen analogue) improves GnRH & FSH release in PCOS  metformin also improves ovulation --------------------------------------------------------------- unvaccinated or unknown vaccination Hx with exposure to blood from Hep B infected patients require post-exposure prophylaxis (PEP) o Rx: HBV Ig + HBV vaccine (within 24 hr)  known vaccinated workers do not require PEP, but recommend a HBV booster vaccine --------------------------------------------------------------- anti-Jo antibodies = polymyositis --------------------------------------------------------------- MC foreign body ingestion: coins in esophagus  Rx: observe for 24 hrs if asymptomatic o Rx: flexible endoscopy if symptomatic or time of ingestion is unknown  ingested batteries, sharp objects, & magnets require preemptive removal o Rx: endoscopy or laparotomy --------------------------------------------------------------- child with sudden onset stridor, dyspnea wheezing, coughing,: tracheobronchial foreign body aspiration  Rx: rigid bronchoscopy --------------------------------------------------------------- situs inversus, recurrent sinusitis, bronchiectasis: Kartagener’s  AR disorder of dysmotile cilia; dextrocardia --------------------------------------------------------------- normal: air conduction is 2x > bone conduction  bone conduction > air conduction on Rinne test suggests conductive hearing loss

 

Weber test to confirm Dx otosclerosis causes conductive hearing loss in females age 20s – 30s; autoimmune process

Interpretation of Rinne & Weber tests Rinne result Weber result normal air > bone midline conduction B/L Conductive BC > AC affected lateralizes hearing loss AC > BC unaffected toward affected ear Sensorineura AC > BC both ears lateralize to l hearing loss (diminished AC & unaffected ear, BC in both) away from affected ear sensorineural hearing loss: involves inner ear, cochlea, or auditory nerve o MCC ototoxic ABX, Meniere’s  conductive hearing loss: decreased movement of small ear bones, otitis media, otosclerosis ---------------------------------------------------------------Manifestations of sarcoidosis  non-caseating granulomatous inflammation pulmonary B/L hilar adenopathy, interstitial infiltrates ophthalmic anterior uveitis reticuloendothelia peripheral lymphadenopathy, l hepatosplenomegaly MSK acute polyarthritis (ankles) chronic arthritis CNS central DI, hypercalcemia Lofgren o erythema nodosum syndrome (painful shin lesions) o hilar adenopathy o migratory polyarthralgia o fever 

 mostly asymptomatic  cough, dyspnea, fever, malaise, weight loss  elevated ACE & hypercalcemia  Dx: mediastinoscopy/bronchoscopy tissue Bx  Rx: systemic corticosteroids if symptomatic ----------------------------------------------------------------

fever, localized back pain, neurologic deficits (motor weakness, paresthesia, bowel/bladder): spinal epidural abscess  radicular pain below the knee, +straight leg test, pain improves with rest: herniated disk  chronic back pain, fatigue, weight loss, anemia, hypercalcemia, elevated Cr: MM  low back pain radiates to buttocks & thighs, neuro deficits, worse with walking or standing: lumbar spinal stenosis  low back pain, claudication of hip muscles, impotence: iliac artery thrombosis  age > 50, pain worse at night, point tenderness, cauda equina syndrome, Hx of malignancy: cancer mets to bone  local tenderness to palpation after minor trauma, in elderly with Hx of osteoporosis: vertebral compression fracture  chronic progressive pain, local point tenderness, low-grade fever,  ESR/CRP, soft tissue infection: vertebral osteomyelitis --------------------------------------------------------------- tenderness to gentle percussion over spinous processes of involved vertebrae, not relieved with rest,  ESR: vertebral osteomyelitis  MCC: S. aureus  MC in IVDA or recent distant infection (UTI)  initial tests: CBC, blood cultures, ESR/CRP, spine XR  Dx: spinal MRI  confirm Dx: CT-guided aspiration & Bx  Rx: long-term IV ABX +/- surgery  complications: epidural abscess, paralysis --------------------------------------------------------------- hyperplastic polyp: MC non-neoplastic polyp in the colon; no CRC risk; no further work-up  hamartomatous polyp: juvenile & Peutz-Jegher polyps; non-malignant  adenomatous polyp: premalignant potential  sessile villous adenoma, > 2.5 cm --------------------------------------------------------------- fevers, chills, malaise, cough, dyspnea, tachypnea & diffuse fine crackles; diffuse reticular or ground-glass opacities on CXR: hypersensitivity reaction or pneumonitis 

--------------------------------------------------------------- sarcoidosis causes hypercalcemia by extra-renal conversion of 25(OH) VitD to 1,25(OH) VitD in granulomatous tissue   intestinal Ca++ absorption ---------------------------------------------------------------Approach to hypercalcemia  first: confirm by repeat testing  next: measure PTH o high/normal PTH (PTH-dependent): 10 or 30 hyperPTH, familial hypercalcemic hypocalciuria, Lithium, teriparatide o suppressed PTH (PTH-independent)  measure PTHrP, 25(OH)D, 1,25(OH)D  malignancy, Vit D toxicity, sarcoidosis --------------------------------------------------------------- fatigue, anxiety, depression, tetany Approach to hypocalcemia  always confirm with repeat Ca++ measurement  correct serum albumin or measure ionized Ca++  evaluate Mg++, medications (Ca++ chelators, bisphosphonates, phenytoin), recent transfusion o correct underlying cause  next: measure serum PTH… normal/low PTH radical neck surgery, parathyroidectomy, thyroidectomy autoimmune Wilson’s, hemochromatosis genetic: PTH gene, Ca+ +- sensing Rc gene

high PTH Vit D deficiency, CKD pancreatitis, sepsis tumor lysis syndrome PTH resistance (pseudo-hypoPTH)

hypoMg++ causes hypoCa++ in alcoholics; due to decreased PTH release & PTH resistance  not a/w hyperphosphatemia --------------------------------------------------------------- total serum Ca++ varies with albumin levels o 50% of Ca++ is albumin bound --------------------------------------------------------------- hypophosphatemia coexists with hypoMg++ in alcoholics   GI absorption &  renal loss of phosphate 

---------------------------------------------------------------Prolactinoma premenopausal: oligo/amenorrhea, infertility, galactorrhea, hot flashes,  bone density postmenopausal: mass effect (headache, vision) men: infertility, impotence,  libido, gynecomastia due to hypogonadotropic hypogonadism **serum prolactin > 200 ng/mL (diagnostic) r/o renal insufficiency & hypothyroidism brain MRI Rx: cabergoline, transphenoidal surgery prolactin inhibits GnRH production & release low LH, low/normal TSH detected early in premenopausal due to associated endocrine symptoms --------------------------------------------------------------- pituitary tumor < 10 mm = microadenoma  MC prolactin-only secreting tumor o amenorrhea & galactorrhea in women o hypogonadism in men  Rx: cabergoline (fewer A/E) if symptomatic --------------------------------------------------------------- non-functional pituitary adenoma: large mass effect; low TSH & LH, mild prolactin elevation  hypogonadism & hypothyroidism  2/2 compression of thyrotrophs & gonadotrophs, & compression of dopaminergic pathway --------------------------------------------------------------- primary hypothyroidism can cause mild/moderate hyperprolactinemia due to TRH-induced lactotroph (prolactin) stimulation --------------------------------------------------------------- child with acute bacterial sinusitis; congestion, nasal drainage, & cough for 10 – 30 days without improvement; high fever, purulent nasal drainage  MC predisposing factor: viral URI  due to impaired mucociliary clearance  Dx: clinical  Rx: augmentin --------------------------------------------------------------- menopause symptoms are similar to hyperthyroid  Dx: measure TSH & FSH ---------------------------------------------------------------  

inhibin is made by granulosa cells of ovarian follicles  causes feedback inhibition on FSH --------------------------------------------------------------- CXR: pulmonary venous congestion, cardiomegaly, cephalization of pulmonary vessels, Kerley B lines, & pleural effusion: CHF --------------------------------------------------------------- CHF exacerbation causes tachypnea as LV dysFx results in pleural effusion, hypoxemia, hypocapnia & respiratory alkalosis  dry cough, exertional dyspnea, bibasilar crackles  cardiomegaly, S3, S4  Dx: BNP, PCWP  DDx: COPD (respiratory acidosis, hypoxia), PE ( A-a gradient) --------------------------------------------------------------- diffuse esophageal spasm due to dysFx of inhibitory neurons cause chest pain & dysphagia  manometry: periodic high-amplitude, non-peristaltic ---------------------------------------------------------------Features of systemic sclerosis (scleroderma) systemic fatigue, arthralgia skin telangiectasia, sclerodactyly, digital ulcers, calcinosis cutis vascular Raynaud’s cardiac myocarditis, pericarditis pericardial effusion pulmonary pulmonary fibrosis, pulmonary HTN GI esophageal dysmotility, dyspepsia, dysphagia, angiodysplasia of stomach (“watermelon stomach”), malabsorption (bacterial growth) scleroderma renal crisis o acute oliguric renal failure with malignant HTN o thrombocytopenia Rx: ACE-I o microangiopathic hemolytic anemia  lower esophagus smooth muscle atrophy & fibrosis, causes  peristalsis &  LES tone o dysphagia, heartburn, hoarseness --------------------------------------------------------------- failure of postpartum lactation, amenorrhea, hyponatremia, loss of sexual hair, anorexia, weight loss, lethargy, delayed DTRs: Sheehan  prolactin deficiency 

deficient anterior pituitary hormones only: ACTH, GH, FSH, LH, TSH  posterior pituitary (ADH, oxytocin) is unaffected  no effective Rx to restore lactation --------------------------------------------------------------- non-pitting edema seen in Turner’s is due to congenital lymphedema from dysfunctional development of lymphatic network o leads to webbed neck, cystic hygroma --------------------------------------------------------------- progressive dysphagia of solids & liquids, weight loss, regurgitation, nighttime cough: achalasia  CXR: widened mediastinum  barium studies: dilated esophagus with smooth tapering of distal esophagus  Dx: manometry shows aperistalsis,  LES tone  Dx: endoscopy to r/o malignancy  Rx: surgical pneumatic dilatation or myotomy --------------------------------------------------------------- polymyositis: idiopathic inflammatory muscle disease; progressive proximal muscle weakness  weakness is prominent than pain or tenderness  dysphagia due to weakness of striated muscles in upper esophagus; regurgitation, aspiration  Dx: muscle biopsy  DDx: MG, MS, polymyalgia rheumatica, Guillain-Barre, ACE-I (hyperkalemia) --------------------------------------------------------------- postpartum > 8 wks with chest pain, dyspnea, & multiple nodules on CXR: choriocarcinoma  metastatic gestational trophoblastic disease (GT neoplasia is only locally invasive)  can occur after molar or normal prego, abortion  enlarged uterus, pelvic pain  irregular vaginal bleed > 8 wks post-partum  MC site of mets: lungs  confirm Dx: quantitative β-hCG --------------------------------------------------------------- severe headache, vomiting, B/L periorbital edema: cavernous sinus thrombosis  2/2 uncontrolled infection of skin, sinuses, or orbit (insect bite on the face)  CN 3, 4, 5, 6 deficits, intracranial HTN  MC is severe headache 

fundoscopy: papilledema, dilated tortuous veins Dx: MRI with venography Rx: IV ABX DDx: brain abscess, cluster headache, migraine, preseptal cellulitis --------------------------------------------------------------- dacryocystitis: infection of lacrimal sac  acute onset pain & redness in medial canthal, sometimes purulent drainage  normal visual acuity  MC in infants & adults > 40  MCC: S. aureus  Rx: systemic ABX --------------------------------------------------------------- episcleritis: between conjunctiva & sclera o acute mild/moderate discomfort, photophobia, watery discharge; bulbar conjunctival injection  hordeolum: abscess over upper/lower eyelid o localized red, painful eyelid swelling o MCC: S. aureus o #1 Rx: warm compress o Rx: I&D if not resolved in 48 hrs  stye: external hordeolum of Zeis or Moll gland  chalazion: chronic, granulomatous inflammation of Meibomian gland o hard, painless lid nodule o Rx: incision & curettage  orbital cellulitis: posterior to orbital septum o unilateral; abrupt onset of fever, proptosis, restricted EOM movement, swollen eyelids o MC predisposing factor: bacterial sinusitis --------------------------------------------------------------- traumatic deceleration injury resulting in vegetative state: diffuse axonal injury  CT: numerous minute punctate hemorrhages, blurring of gray-white matter interface ---------------------------------------------------------------Interventions to lower ICP head elevation increase venous outflow from brain sedation decrease metabolic demand & control HTN IV mannitol osmotic diuresis (free water) hyperventilatio cerebral vasoconstriction n (CO2 washout)    

CSF removal

reduce volume & pressure

3 distinct brain compartments: parenchyma, CSF, cerebral blood flow (CBF)  CBF is regulated by BP, paO2 & paCO2  paCO2 is a potent regulator of CBF o as cerebral paCO2 , also CBF  ---------------------------------------------------------------  FSH in the setting of ≥ 3 months of amenorrhea in women < 40 = premature ovarian failure  primary hypogonadism   estrogen,  FSH,  LH (FSH: LH > 1.0; slower FSH clearance)  causes: chemotherapy, radiation, autoimmunity, Turner’s, Fragile X  all secondary amenorrhea require a pregnancy test, prolactin & FSH level --------------------------------------------------------------- transudate is due to systemic factors; B/L effusion (hypoalbuminemia,  hydrostatic pressure) o pleural fluid pH 7.4-7.55 (normal pH: 7.6) o MCC: CHF, cirrhosis o no further workup; Rx underlying cause  exudate is due to inflammation (pH 7.3 – 7.45) results in  capillary permeability o requires further diagnostics o MCC: infection, pneumonia, TB, malignancy, PE, sarcoidosis, lymphoma, RA ---------------------------------------------------------------Light’s criteria for exudative effusion (“Excess”) at least one of the following…  pleural fluid/serum protein ratio > 0.5  pleural fluid/serum LDH ratio > 0.6  pleural fluid LDH > 2/3 upper limit of normal Next determine if effusion is…  uncomplicated  complicated: persistent bacterial invasion, which  pleural fluid glucose &  LDH; culture is negative, easily cleared with ABX  empyema: low pH < 7.2 (or glucose < 60) are indications for chest tube drainage o low pleural glucose also indicates exudate (complicated parapneumonic effusion, empyema, RA, malignancy, TB, drug-induced lupus, or esophageal rupture) 

low glucose in empyema is due to high metabolic activity of leukocytes/bacteria in pleural fluid --------------------------------------------------------------- fever, leukocytosis, parenchymal infiltrates: aspiration pneumonia --------------------------------------------------------------- GB carcinoma is Dx incidentally during or after cholecystectomy o sufficient Rx if confined to GB mucosa --------------------------------------------------------------- Bacillus cereus: preformed toxin o 1 – 6 hrs after contaminated rice ingestion  S. aureus: preform toxin o dairy, salad, meat, eggs  C. perfringens: spore-forming o meat, poultry, gravy o watery diarrhea, 8 – 14 hr after ingestion --------------------------------------------------------------- scatter plots are used for crude analysis of data; can show a linear association, used to calculate the correlation coefficient  0 = no association  -1 or +1 = strong correlations closer to margins  does not imply causal relationships, nor account for cofounders --------------------------------------------------------------- during fasting, glycogen reserves drop within the first 12 hrs & gluconeogenesis begins  main substrates of gluconeogenesis: alanine, glutamine, lactate, glycerol-3-phosphate  alanine & lactate are converted to pyruvate  glycerol-3-phosphate is released during breakdown of adipose ---------------------------------------------------------------Manifestations of hemochromatosis  AR inheritance; mutated HFE gene   intestinal iron absorption & deposition general weight loss, weakness, polydipsia, polyuria, decreased libido, ED skin hyperpigmentation (bronze diabetes) MSK arthralgia, arthropathy, chondrocalcinosis (pseudogout) GI elevated LFTs, hepatomegaly, cirrhosis, risk of HCC endocrine DM, secondary hypogonadism 

cardiac infection

hypothyroidism dilated cardiomyopathy, systolic dysFx, conduction defect (sick sinus syndrome) Listeria, Vibrio vulnificus, Yersinia

 transferrin & serum ferritin,  TIBC o if elevated in absence of an inflammatory condition, genetic testing should be done --------------------------------------------------------------- cervicofacial actinomycosis presents in the mandibular region as a slowly growing, nontender mass with yellow pus (sulfur granules)  Actinomyces: anaerobic Gram+ branching filamentous bacilli; not acid-fast  colonizes the oral cavity  risk factors: poor dental hygiene, irradiation, malnutrition, immunosuppression, DM  complication: abscess, fistula, draining sinus tract  Dx: tissue culture; can take 3 wks to grow  Rx: high-dose PCN (12 wks) --------------------------------------------------------------- skin infection, fever & purulent crusting lesions or ulcers following puncture wound (gardening): Nocardia  aerobic, Gram+ weakly acid fast, filamentous rod  subacute pneumonia that mimics TB  Rx: TMP-SMX --------------------------------------------------------------- acute ischemic stroke due to atherosclerotic thrombosis or emboli: ASA within 48 hr o risk of recurrent stroke &  mortality --------------------------------------------------------------- pruritus, jaundice, steatorrhea, hepatosplenomegaly,  ALP & bilirubin, anti-mitochondrial antibodies: primary biliary cirrhosis  nocturnal pruritus can be severe  autoimmune destruction of intrahepatic bile ducts leads to cholestasis & cirrhosis   ability to absorb fat-soluble vitamins can lead to osteoporosis  a/w xanthomas & xanthelasmas  a/w Sjogren’s, Raynaud’s, scleroderma, Celiac’s  Dx: anti-mitochondrial antibodies in serum 

Rx: ursodeoxycholic acid relieves symptoms & slows disease progression o definitive Rx: liver transplant --------------------------------------------------------------- post-partum adrenal insufficiency can be primary (adrenal) or secondary (pituitary)  hyperpigmentation & signs of mineralocorticoid deficiency suggests an adrenal cause  weakness, fatigue, abdominal pain, anorexia, mild hyponatremia, postural hypotension, hyperkalemia ---------------------------------------------------------------Adrenal insufficiency 10 (adrenal) 20 (pituitary) MCC autoimmune chronic glucocorticoid Rx ACTH   cortisol   aldosteron  normal e features severe symptoms less severe hyperpigmenttn no hyperpigment, hyperkalemia no hyperkalemia, hyponatremia possible hypotension hyponatremia  glucocorticoid > 3 wks  suppress secretion of CRH & ACTH  central adrenal insufficiency  screening: morning basal cortisol, ACTH, & cosyntropin stimulation test basal cortisol: low basal cortisol: low ACTH: high ACTH: high cosyntropin: minimal cosyntropin: suboptimal 10 adrenal insufficiency 20 or 30 adrenal insuff.  chronic central AI develop adrenal gland atrophy, thus a suboptimal response to cosyntropin --------------------------------------------------------------- weakness, fatigue, weight loss, anorexia, depression, hypotension, hyperpigmentation, eosinophilia, hyponatremia, hyperkalemia Primary adrenal insufficiency (Addison’s)  MCC: autoimmune adrenalitis  humoral & cell-mediated destruction of adrenal cortex  loss of glucocorticoid, mineralocorticoid, & adrenal androgens 2/2 adrenal cortex destruction  hyperchloremic acidosis 

hyperpigmentation due to increased ACTH & melanocyte-stimulating hormone  ketoconazole can precipitate adrenal insufficiency by inhibiting adrenal steroid synthesis  a/w other autoimmune disorders  Rx: hydrocortisone ---------------------------------------------------------------Secondary (central) adrenal insufficiency  loss of only glucocorticoid & adrenal androgen secretion; preserved mineralocorticoid production  aldosterone is regulated by RAA system  no hypotension, hyperK+, or hyperCl- acidosis  MCC: lymphocytic hypophysitis & Sheehan --------------------------------------------------------------- screen for Cushing’s: 24-hr urine free cortisol & low-dose dexamethasone suppression test --------------------------------------------------------------- ursodeoxycholic acid: Rx primary biliary cirrhosis & primary sclerosing cholangitis ---------------------------------------------------------------

recurrent oral & genital ulcers, anterior uveitis, erythema nodosum: Behcet syndrome  MC in Turkish, Asian, Middle Eastern  immune-mediated small-vessel systemic vasculitis  Dx: triple-symptom complex: recurrent aphthous ulcers, genital ulcers, anterior uveitis o also erythema nodosum  Rx: high dose corticosteroids  complications: aneurysm, dementia, & blindness ---------------------------------------------------------------Tamoxifen: SERM  antagonist on breast o Rx breast cancer & prevention in other breast 

agonist on endometrium   endometrial cancer risk o  uterine sarcoma risk  agonist on osteoclasts (inhibits turnover) o  risk of osteoporosis   venous thrombosis risk ---------------------------------------------------------------Raloxifene: SERM  antagonist on breast & endometrium o  breast cancer risk  does not increase risk of endometrial cancer  agonist in bone o #1 Rx prevents osteoporosis  A/E:  risk of VTE; C/I if Hx of DVT --------------------------------------------------------------- early decelerations: due to fetal head compression leading to a vagal response o does not indicate fetal distress o normal finding of active labor  variable & late decelerations indicate risk for fetal hypoxemia & acidosis o variable: cord compression or prolapse, oligohydramnios; abrupt drop in fetal HR o late: uteroplacental insufficiency ---------------------------------------------------------------Alcohol withdrawal syndrome features last drink mild anxiety, tremulousness, 6 hrs withdrawal sweating, palpitations withdrawal single or multiple in short 12 – 48 hr seizures period of time alcohol auditory, visual, tactile 12 – 24 hr hallucinosis hallucination; normal vitals resolves & intact sensorium in 24 – 48 hr delirium fever, HTN, tachycardia, tremens diaphoresis, hallucinations, 48 – 96 hr disorientation --------------------------------------------------------------- polymorphic ventricular tachycardia in the setting of congenital or acquired prolonged QT interval: Torsades de Pointes (TdP)  can resolve spontaneously or degenerate to V-fib  Rx hemodynamically unstable: defibrillation  Rx hemodynamically stable: Mg++ sulfate 

 soltalol causes prolonged QT & TdP --------------------------------------------------------------- adenosine: Rx PSVT  amiodarone: Rx hemodynamically stable atrial & ventricular wide-complex tachycardia; also a-fib  atropine: symptomatic sinus brady, AV block  sodium bicarbonate: TCA overdose, hyperK+, ASA overdose --------------------------------------------------------------- small, rubbery lymph nodes < 1 cm are commonly benign in children & young adults o asymptomatic, soft lymph nodes can be observed for growth or symptoms  cancerous nodes are firm & immobile, > 2 cm  hard cervical nodes in adults or smokers suggest metastatic cancer or oropharyngeal neoplasia ---------------------------------------------------------------Peripheral facial palsy Central facial palsy (Bell’s palsy) loss of forehead & brow preservation of forehead movement & brow movement inability to close eye & C/L lower face weakness drooping eyelids loss of nasolabial folds, drooping lower lip



Bell’s: CN VII neuropathy, lesion below the pons

 tearing, hyperacusis, loss of taste over anterior 2/3 of tongue  forehead muscle sparing suggests intracranial lesion  brain imaging for ischemia or tumor o lesion above facial nucleus o C/L hemiparesis, hemianesthesia, dysarthria --------------------------------------------------------------- Vit K deficiency in newborns result from poor placental transfer, absent gut flora, immature liver function, inadequate levels in breast milk  bruising, bloody stools, intracranial hemorrhage  initially prolonged PT, followed by aPTT  Rx: Vit K replenishes in 8 – 10 hrs  FFP for acute hemorrhage --------------------------------------------------------------- ACTH does not affect aldosterone production, which is regulated by RAA system ---------------------------------------------------------------Muscular dystrophy Duchenne Becker Myotonic XR deletion of dystrophin, Xp21 AD inheritance, CTG repeats, DMPK gene onset: age 2 – 3 age 5 – 15 age 12 - 30 progressive mild weakness facial weakness, weakness, Gower, (*decreased hand grip pseudohypertroph dystrophin*) myotonia, y dysphagia (asp. pneumonia), foot drop scoliosis, cardiomyopath arrhythmias, cardiomyopathy; y cataracts, bald, wheelchair-bound testicular by adolescence atrophy/infertilit y death by 20 – 30; death by 40 respiratory or respiratory or 50 heart failure heart failure heart failure o

 DMD: absent dystrophin on immuno staining  CPK & aldolase are elevated before manifestations --------------------------------------------------------------- medullary thyroid cancer: calcitonin secretion  follicular & papillary cancers: a/w Hurthle cells ----------------------------------------------------------------

follicular thyroid cancer: invasion of tumor capsule & blood vessels; encapsulated  early hematogenous spread to lung, brain, bone --------------------------------------------------------------- papillary thyroid cancer: MC thyroid malignancy  slow, infiltrative spread to thyroid gland & regional lymph nodes; unencapsulated  Dx: psammoma bodies  FNAB: large cells with ground-glass cytoplasm, pale nuclei with inclusion bodies & central groove  Px: excellent ---------------------------------------------------------------Neuroimaging in psychiatric disorders  autism: increased brain volume  OCD: abnormal Orbitofrontal Cortex & striaDum  pAnic disorder: decreased Amygdala volume  PTSD: decreased hippocampal volume  schizophrenia: enlarged cerebral ventricles --------------------------------------------------------------- chemotherapy can cause rapid tumor cell lysis, releasing uric acid (DNA by-product), predisposing to gout attacks  Rx: allopurinol decreases uric acid production --------------------------------------------------------------- Rx gout attacks: NSAIDs, steroids, colchicine  gout prevention: allopurinol ( production), probenecid ( excretion) --------------------------------------------------------------- Mesna: prevents hemorrhagic cystitis caused by cyclophosphamide --------------------------------------------------------------- chronic liver disease  immunized for Hep A & B  risk for acute hepatic failure or cirrhosis --------------------------------------------------------------- cirrhosis causes intravascular volume depletion & salt retention  Rx: low-salt diet decreased ascites & edema  Rx: furosemide prevents hypervolemia --------------------------------------------------------------- child refuse to bear weight, knee pain & swelling, high fever: septic arthritis  preceded by skin or URI; MCC is S. aureus  leukocytosis,  ESR & CRP 

Dx/Rx: arthrocentesis, blood & synovial cultures before empiric IV ABX (vancomycin) o ABX can interfere with cultures  Rx: synovial fluid aspiration & drainage prevents long-term disability & joint destruction  DDx: transient synovitis, acute rheumatic fever, osteomyelitis --------------------------------------------------------------- malaria causes cyclical fever, nonspecific GI & constitutional symptom, anemia & thrombocytopenia  cyclical fever coincides with RBC lysis  up to 2 wks after mosquito bite  Dx: thin & thick peripheral blood smears  protective: hemaglobinopathies (HbS, HbC, thalassemia, sickle cell trait, Hx of malaria) --------------------------------------------------------------- Dengue fever: leukopenia is common --------------------------------------------------------------- cholestyramine: bile acid sequestrant o  fecal loss of bile salts & cholesterol  Rx: hypercholesterolemia, pruritus a/w liver failure, bile acid diarrhea, absorb C. difficile toxins A & B --------------------------------------------------------------- fever, jaundice, hepatomegaly, dark urine, pruritus, acholic stools: Hep A  incubation: 30 days --------------------------------------------------------------- headache, abdominal pain, vomiting, diarrhea, salmon rose spots, bradycardia: typhoid fever --------------------------------------------------------------- inhaled albuterol & systemic steroids Rx acute asthma attacks  high-dose β2-agonists can cause hypokalemia, resulting in weakness, arrhythmias, EKG changes  check serum electrolytes --------------------------------------------------------------- muscle cramps, weakness, palpitations, HTN after initiating a thiazide  HTN & hypokalemia: suspect hyperaldosteronism  test: plasma renin & aldosterone

 aldosterone



Causes of HTN & hypokalemia  renin, Primary

 renin,  aldosterone (ratio > 20)

 renin,  aldosterone

adrenal adenoma B/L adrenal hyperplasia Dx: adrenal CT Secondary diuretics, cirrhosis, CHF, renovascular HTN, renin-secreting tumor, malignant HTN, coarctation of aorta Other CAH, Cushing’s, glucocorticoid resistance, exogenous mineralocorticoids

easily induced hypokalemia after starting a thiazide suggests primary hyperaldosteronism  metabolic alkalosis (loss of H+)  mild hypernatremia only (aldosterone escape) --------------------------------------------------------------- recurrent episodes of flash pulmonary edema  screen for renovascular HTN: abdominal CT angiography  MCC: renal artery stenosis, fibromuscular dysplasia --------------------------------------------------------------- acute, painless vision loss, fundoscopy: optic disk swelling, retinal hemorrhages, dilated & tortuous veins, & cotton wool spots: central vein occlusion  “blood & thunder” appearance  monocular loss of vision caused by thrombosis  Dx: fluorescein angiography  Rx: conservative, observation  DDx: angle closure glaucoma, anterior uveitis, amaurosis fugax, optic neuritis --------------------------------------------------------------- acute, severe eye pain, blurred vision, N/V, steamy cornea with non-reactive, dilated pupils: acute angle-closure glaucoma  acute, severe eye pain, unilateral vision loss, afferent pupillary defect: optic neuritis --------------------------------------------------------------- fever > 390C (102.20F) in any child age < 3 should prompt evaluation for UTI Dx tests for UTI  serum BUN/Cr, urine dipstick, U/A, urine culture 

children in diapers require straight catheter for sterile specimen --------------------------------------------------------------- chronic productive cough of mucopurulent sputum (> 100 mL/day), dyspnea, hemoptysis, fatigue, weight loss, clubbing: bronchiectasis  due to damage of bronchial walls from infection or inflammation  diffuse ronchi & wheezes, bibasilar crackles  Dx: high-resolution CT bronchial dilation, bronchial wall thickening  Dx: sputum analysis & bronchoscopy  Rx: underlying cause, corticosteroids, macrolides, chest PT  DDx: chronic bronchitis (less sputum, nonpurulent) --------------------------------------------------------------- acute adrenal crisis: post-op complication in patients with chronic glucocorticoids-induced HPA-axis suppression (SLE, RA)  daily prednisone > 3 wks can cause central adrenal insufficiency: ( ACTH & cortisol)  N/V, hypoglycemia, hypotension  Rx: pre-op stress-dose glucocorticoids  patients with Cushingoid features are also at risk for HPA suppression o Rx: short-term stress-dose of glucocorticoids --------------------------------------------------------------- femoral nerve: hip flexion, knee extension o innervates anterior thigh o sensation to anterior thigh & medial leg via saphenous branch  tibial nerve: supplies posterior thigh & leg, plantar foot muscles o sensation to the leg (except medial side) & plantar foot  obturator nerve: innervated medial thigh o thigh adduction o sensation to medial thigh  common peroneal: supplies anterior & lateral leg o sensation to anterolateral leg & foot dorsum o superficial peroneal: foot eversion o deep peroneal: sensation bwtn 1st & 2nd toe ---------------------------------------------------------------

IVDA with fever, aortic vegetation, cerebral infarct: native valve endocarditis with cardioembolic stroke  high risk of TIA or stroke due to septic emboli  ischemic stroke: Rx underlying cause  Rx: IV ABX reduces risk of septic cardioemboli in native valve IE  Rx: aortic valve surgery for severe cases  IV heparin is a/w risk of intracranial hemorrhage --------------------------------------------------------------- evidence of acute pericarditis & renal failure: uriemic pericarditis  inflammation of visceral & parietal membranes of pericardial sac; BUN > 60  no evidence of pericarditis on EKG  definitive Rx: hemodialysis --------------------------------------------------------------- acute viral or idiopathic pericarditis Rx: NSAIDs & colchicine ---------------------------------------------------------------hypertensive BP ≥ 180/120 mmHg urgency without symptoms or end-organ damage hypertensive headache, dyspnea, blurred vision, emergency + acute, end-organ complications… (BP > 220/120)  malignant HTN: exudates, retinal hemorrhage, papilledema Rx:  hypertensive encephalopathy: nitroprusside: cerebral edema, neuro symptoms, SAH or ICH --------------------------------------------------------------- most intussusceptions before age 2 following viral illness have no identifiable lead point o gastroenteritis  hypertrophied Peyer patches  pathological lead point should be suspected in older children with recurrent intussusception o MCC: Meckel’s  other risk factors: Henoch-Schonlein, rotavirus vaccination --------------------------------------------------------------- ventilator-associated pneumonia occurs 48 hr after intubation  MCC: P. aeruginosa, E. coli, Klebsiella, MRSA  Dx: CXR, lower respiratory tract culture  Rx: empiric ABX (after obtaining sample) ---------------------------------------------------------------Prostatitis overview 

Acute Chronic fever, chills, malaise, no fever, dysuria, myalgia, perineal pain, frequency, cloudy urine recurrent UTI Dx **mid-stream urine sample** pyuria, tender prostate, pyuria, +urine culture (E. coli) +urine culture Rx empiric TMP-SMX for fluoroquinolones 4 – 6 wks  complication: prostatic abscess (CT scan) --------------------------------------------------------------- all present with irritative voiding symptoms (frequency, urgency, suprapubic or perineal pain)  acute bacterial prostatitis: very tender prostate feature s

Prostatitis feve U/A prostatic secretions r leukocyte bacteria + +  + nrml  + _ nrml  _

acute bacterial chronic bacterial chronic inflammatory chronic _ nrml nrml _ non-inflammatory ---------------------------------------------------------------Glasgow Coma Scale  eye opening (4), verbal (5), motor (6)  not used to Dx coma o Dx coma: impaired brainstem activity, motor dysfunction, impaired LOC --------------------------------------------------------------- hypoglycemic episodes can occur with pre-meal insulin administration in diabetic gastroparesis  metoclopramide: Rx N/V & gastroparesis o DA receptor antagonist; prokinetic & antiemetic  monitor for drug-induced EPS, dystonic reaction  rarely, NMS may occur  Rx: discontinue; benztropine or diphenhydramine  alt Rx: erythromycin (prokinetic) --------------------------------------------------------------- fibrocystic disease of the breast: B/L tenderness & palpable mass during luteal phase ----------------------------------------------------------------

weight loss, anorexia, fatigue, recent onset DM, migratory superficial thrombophlebitis (Trousseau): pancreatic adenocarcinoma  important risk factor: Hx of smoking  insidious, gnawing abdo pain, worse at night  Dx with jaundice: USS (head tumor)  Dx w/o jaundice: CT scan (body & tail tumors) --------------------------------------------------------------- connective tissue thickening 2/2 product of myofibroblast proliferation, collagen & ground substance production: systemic sclerosis  a/w HTN, GERD, right heart failure  Dx: ANA, anti-topoisomerase antibodies  Rx scleroderma renal crisis: ACE-I --------------------------------------------------------------- anti-smooth Ab: autoimmune hepatitis --------------------------------------------------------------- anti-psychotics mainly block DA D2 receptors o can cause hyperprolactinemia o breast tenderness, amenorrhea, galactorrhea  risperidone also binds 5-HT receptors o improves negative symptoms of schizophrenia & Rx depression o most likely atypical to cause EPS at high dose  Rx: benztropine  aripiprazole: partial DA D2 agonist o does not cause galactorrhea --------------------------------------------------------------- rigidity, bradykinesia, tremor, akathisia: EPS --------------------------------------------------------------- carbamazepine A/E: aplastic anemia, SIADH o monitor with routine CBC  lamotrigine A/E: rash, SJS/TEN --------------------------------------------------------------- well-circumscribed pale white patches around acral area & body orifices: vitiligo  autoimmune destruction of melanocytes  peaks @ age 20 - 30  a/w Grave’s, Type I DM, hypopituitarism, pernicious anemia, 10 adrenal insufficiency, alopecia areata --------------------------------------------------------------- Babinski is the only primitive reflex that may persist up to age 2 yrs 

--------------------------------------------------------------- PVCs are common post-MI; a/w worse prognosis  no Rx unless symptomatic (β-blockers) --------------------------------------------------------------- initial Rx of acute & chronic anal fissures: diet, stool softener, local anesthetic  chronic or refractory cases: lateral sphincterotomy ---------------------------------------------------------------MCC of esophagitis in HIV Candida white plaques, oral thrush Rx: empiric fluconazole, endoscopy if no improvement HSV small, round/ovoid ulcers Rx: acyclovir CMV large, linear ulcers in distal esophagus Rx: IV ganciclovir MC when CD4 < 100 odynophagia without dysphagia: MCC is viral Dx: esophagoscopy acyclovir is not effective Rc for CMV due to its lack of thymidine kinase to convert to active form --------------------------------------------------------------- dysphagia, heartburn, refractory to GERD Rx: eosinophilic esophagitis  comorbid asthma, seasonal allergies  manometry shows hypercontractility --------------------------------------------------------------- acute odynophagia, retrosternal chest pain, epigastric burning: pill esophagitis  direct mucosal injury due to prolonged contact result in discrete ulcers on endoscopy  MCC: KCl, tetracycline, aldendronate, NSAIDS, quinidine, iron --------------------------------------------------------------- alcoholic with altered mental status, gait instability, nystagmus, conjugated gaze palsy: Wernicke’s  no labs or radiological studies necessary  can be induced iatrogenically by giving glucose without thiamine --------------------------------------------------------------- apathy, irreversible amnesia, confabulation,: Korsakoff’s ---------------------------------------------------------------   

large head, prominent forehead & jaw, protruding ears, joint laxity, macroorchidism: Fragile X  hyperactivity, short attention, autism  FMR1 gene with CGG repeats ---------------------------------------------------------------Breastfeeding Benefits Contraindications Maternal  breast & ovarian ca active untreated TB (resume feeds after 2 wks risk (not endometrial) of anti-TB therapy) maternal HIV infection rapid uterine involution, herpetic breast lesions  post-partum bleeding, varicella infection (< 5 rapid return to pre-partum days prior or 2 days after weight, delivery) chemotherapy/radiation improved child spacing, drug or alcohol abuse maternal-infant bonding Infant immunity, GI function, prevention…otitis media, respiratory/GI illness, UTI galactosemia  risk of childhood ca, Type I DM, NEC 

exclusively breastfed infants require Vit D suppl until age 6 months  mastitis & Hep B or C are not C/I to breastfeeding ---------------------------------------------------------------Indications for cytoscopy  gross hematuria with no glomerular disease  microscopic hematuria without evidence of glomerular disease, but risk for malignancy  recurrent UTIs  obstructive symptoms (strictures, stones)  irritative symptoms without infection  abnormal bladder imaging or urine cytology --------------------------------------------------------------- risk of bladder cancer: smoking, chronic cystitis, cyclophosphamide, pelvic radiation, occupational  screening is not recommended, even those at risk --------------------------------------------------------------- severe ear pain especially at night, exacerbated by chewing, purulent drainage with fullness, & conductive hearing loss;  ESR 

malignant otitis externa: MCC P. aeruginosa risk factors: elderly with uncontrolled DM otoscopy: granulation tissue & edematous external auditory canal  complications: osteomyelitis of skull base or TMJ  Rx: empiric anti-psuedomonal (IV ciprofloxacin)  alt Rx: piperacillin, ceftazidime  DDx: cholesteatoma: keratinized epithelial growth & discharge in the middle ear; Rx: surgical --------------------------------------------------------------- cholesteatoma: abnormal squamous epithelium in middle ear; continuous ear drainage despite ABX o 2/2 chronic middle ear disease; MC in children  granulation tissue & skin debris accumulation  damage to ossicles result in conductive hearing loss  otoscopy: granulation tissue & skin debris within retraction pockets of tympanic membrane  Rx: surgery --------------------------------------------------------------- anovulation as a cause of infertility can be evaluated with serum progesterone performed in mid-luteal phase --------------------------------------------------------------- MVP = MCC of chronic MR in developed countries 2/2 myxomatous degeneration of leaflets & chordae o chronic severe MR can cause LA dilation, & lead to a-fib  infective endocarditis can cause MR due to inadequate leaflet coaptation or leaflet perforation --------------------------------------------------------------- immunocompromised with lung nodules, seizures, Gram+, partially acid-fast, aerobic filamentous branching rod: Nocardia  weight loss, fever, night sweats  causes seizures 2/2 brain abscess (disseminated)  CXR: pulmonary nodules, with cavitation  Rx: TMP-SMX  DDx: TB --------------------------------------------------------------- Actinomyces Rx: PCN  anaerobic, G+ filamentous bacilli (not acid-fast)  yellow pus with sulfur granules ---------------------------------------------------------------  

orthostatic hypotension is a common cause of syncope in elderly due to impaired baroreceptor sensitivity &/or volume depletion --------------------------------------------------------------- long-standing progressive heartburn, weight loss, fatigue, smoking Hx: esophageal cancer  2 histologic types  SCC: a/w smoking & alcohol  adenocarcinoma: a/w Barrett’s, obesity  Dx: barium swallow followed by EGD & Bx, & PET scan (disease staging) --------------------------------------------------------------- maternal hyperglycemia  fetal hyperglycemia & fetal hyperinsulinemia   metabolic demand  fetal hypoxia  erythropoiesis  polycythemia --------------------------------------------------------------- young patient with cataracts, tinnitus hearing loss: neurofibromatosis II  acoustic neuroma Dx: MRI with gadolinium --------------------------------------------------------------- IV diuretics: Rx symptomatic relief of decompensated CHF --------------------------------------------------------------- dyspnea, JVD, clear lungs,  cardiac silhouette: early cardiac tamponade 2/2 pericardial effusion  MCC recent viral URI  non-palpable PMI; Beck’s triad (hypotension, JVD, muffled heart sounds), pulsus paradoxus  CXR: enlarged/globular silhouette, “water bottle”  EKG: electrical alternans, low voltage QRS  Dx if hemodynamically stable: echo  hemodynamically unstable Rx: pericardiocentesis --------------------------------------------------------------- healthy, young patient with CHF, & recent URI: viral myocarditis due to Coxackie B  dyspnea, JVD, cardiomegaly, S3, bibasilar rales  CXR: pulmonary vascular congestion --------------------------------------------------------------- bisferiens pulse: a/w aortic insufficiency with or w/o aortic stenosis, severe aortic insufficiency, HOCM --------------------------------------------------------------- rivaroxaban: direct factor Xa inhibitor  oral anticoagulant with rapid onset (2 – 4 hrs)  similar efficacy to LMWH & warfarin for acute DVT & PE 

 no antidote for major hemorrhage  Rx: recurrent or refractory DVT --------------------------------------------------------------- thrombolytics are reserved for hemodynamically unstable PE  IVC filter: Rx lower extremity DVT when anticoagulation is C/I (hemorrhagic stroke, active bleeding) or anticoagulation failure --------------------------------------------------------------- ventricular tachycardia: wide QRS  hemodynamically stable  IV amiodarone  hemodynamically unstable  synch cardioversion Hemodynamic instability  hypotension  altered mental status  signs of shock  ischemic chest discomfort  acute heart failure --------------------------------------------------------------- SVT with aberrancy (PSVT): narrow complex  hemodynamically stable:  vagal maneuvers (carotid massage, rate control) or IV adenosine can slow SA & AV node o #2 Rx: CCB (verapamil) slow AV conduction  hemodynamically unstable  synch cardioversion --------------------------------------------------------------- cyclophosphamide: Rx SLE with renal  hydroxychloroquine: Rx SLE with isolated skin & joint involvement  A/E: retinopathy (eye exam every 6 months) --------------------------------------------------------------- HTN, bradycardia, & respiratory depression (Cushing’s reflex):  intracranial pressure --------------------------------------------------------------- Prader-Willi: paternal 15q11 deletion o maternal uniparental disomy o poor suck & feeding in infancy o binge-eating & obesity  Angelman: maternal 15q11 deletion o paternal unilateral disomy o hand flapping, ataxia, seizures ----------------------------------------------------------------

changing a drug regimen, prodrome viral illness or diuretic use can cause digoxin toxicity o neuro (lethargy, confusion, disorientation) o vision (color vision, scotomas, blindness) o cardiac (life-threatening arrhythmias) o GI (anorexia, N/V, abdominal pain)  risk factors: hypokalemia (diuretics)  amiodarone, verapamil, quinidine, propafenone can  serum digoxin levels o Rx:  digoxin dose by 25 – 50%  evaluation: digoxin level, EKG, PT/INR --------------------------------------------------------------- atrial tachycardia with AV block is specific for digitalis toxicity  digitalis  ectopy  atrial tachycardia  digitalis  vagal tone  disrupts AV conduction --------------------------------------------------------------- child with sudden-onset abdominal pain, bloody diarrhea, anemia, thrombocytopenia, uremia: HUS  MCC: E. coli O157:H7  Rx: supportive, plasmapheresis; dialysis, steroids --------------------------------------------------------------- lactose intolerance Dx: hydrogen breath test --------------------------------------------------------------- fever, chills, deep abdominal pain after blunt abdominal trauma: retroperitoneal abscess 2/2 pancreatic laceration  early findings: normal abdominal CT  devitalized tissue or pseudocyst becomes infected  Dx: serial CT  Rx: percutaneous drainage catheter, culture of drained fluid, & surgical debridement --------------------------------------------------------------- duodenum is mostly retroperitoneal, vulnerable to crush injury overlying vertebral bodies  duodenal hematoma & obstruction can occur --------------------------------------------------------------- transtentorial herniation due to head trauma, leads to uncus compression against the tentorium  I/L CN III  I/L down-&-out gaze, mydriasis, & ptosis  I/L PCA  C/L homonymous hemianopsia o I/L hemiparesis & altered mentation ---------------------------------------------------------------

acute onset lower abdominal pain, followed by bloody diarrhea within 12 – 24 hr, fever, N/V: ischemic colitis  a/w complication of procedures on the aortoiliac vessels (AAA)  MC sites: splenic flexure & recto-sigmoid junction 2/2 impaired flow through inferior mesenteric artery  dull abdominal pain overlying ischemic bowel & hematochezia  CT scan: thickened bowel wall  Dx: colonoscopy  discrete ischemic segment of cyanotic mucosa with ulcerations  DDx: acute diverticulitis, radiation proctitis, IBD, C. difficile colitis --------------------------------------------------------------- diarrhea, rectal bleeding, tenesmus, incontinence: radiation proctitis  strictures & fistulae may form --------------------------------------------------------------- BUN & Cr are decreased in pregos due to increased renal plasma flow & GFR --------------------------------------------------------------- macroglossia, hemihyperplasia, umbilical hernia  overgrowth disorder & predisposed to neoplasms 

Beckwith-Wiedemann syndrome pathogenesis dysregulation of imprinted gene expression features fetal macrosomia, rapid growth, omphalocele or umbilical hernia, macroglossia, hemihyperplasia complication Wilms nephroblastoma, s heptapoblastoma surveillance abdominal/renal USS & AFP  monitor newborns for hypoglycemia --------------------------------------------------------------- EPS (dystonia, choreoathetosis), mental retardation, self-mutilation: Lesch-Nyhan --------------------------------------------------------------- lymphadenopathy, hepatosplenomegaly jaundice, rash, rhinitis: early congenital syphilis  saber shin, Hutchinson’s teeth, saddle-nose, keratitis, deafness: late manifestations (2 yrs) ----------------------------------------------------------------

child with sore throat, dysphagia, odynophagia, pharyngeal/tonsillar erythema: pharyngitis o cough, rhinorrhea, conjunctivitis, oral ulcers = viral pharyngitis  Rx: symptomatic o exudates, edema, palatal petechiae, absence of viral symptoms  rapid antigen test & throat culture (gold std)  negative  viral pharyngitis  positive  Strep pharyngitis (GAS)  Rx: oral PCN or amoxicillin  reduces risk of rheumatic fever  Group A Strep is MC in age 5 – 15 yrs o tender anterior cervical lymph nodes, tonsillar erythema & exudates, palatal petechiae  all negative rapid Strep antigen test must be confirmed with throat culture (high sensitivity)  ASO antibodies peak 1 month after infection, not useful in Dx acute pharyngitis --------------------------------------------------------------- MCC of cirrhosis: alcohol abuse, viral hepatitis, non-alcoholic fatty liver disease  evaluate family Hx, alcohol Hx, Hep B/C serology, iron studies/HFE protein for hemochromatosis Clinical features of cirrhosis  non-specific: anorexia, weight loss, weakness, fatigue, muscle cramps, jaundice, pruritus  GI bleeding, caput medusa, palmar erythema  encephalopathy (sleep disturbance, confusion)  women: amenorrhea/anovulation  men: hypogonadism  decreased libido, ED, gynecomastia, testicular atrophy   synthesis of thyroxine-binding globulins   total T3/T4 (normal TSH) --------------------------------------------------------------- adrenal insufficiency: fatigue, weakness, anorexia, weight loss  women: androgen production occurs in adrenals   axillary & pubic hair, loss of libido  men: androgens produced in testes; no findings --------------------------------------------------------------- aortic coarctation Rx: balloon angioplasty +/- stent  a/w Takayasu arteritis: large vessel granulomatous vasculitis with massive intimal fibrosis & vascular narrowing; young Asian females ---------------------------------------------------------------

gait instability, truncal ataxia, nystagmus, intention tremor, dysmetria: cerebellar dysRx  common in chronic alcoholism  hypotonia leads to pendular knee reflex --------------------------------------------------------------- Type I collagen mutation: Osteogenesis imperfecta  recurrent fractures, hearing loss, joint laxity, short stature, scoliosis, blue sclera --------------------------------------------------------------- mood disturbances (depression, apathy), dementia, chorea, writhing, facial grimace, ataxia, dystonia: Huntington’s ---------------------------------------------------------------Ascites fluid SAAG (serum-to-ascites albumin gradient) ≥ 1.1 g/dL portal HTN 2/2 cirrhosis, Budd-Chiari, cardiac ascites < 1.1 g/dL absence of portal HTN 2/2 malignancy, pancreatitis nephrotic syndrome, TB  portal HTN:  capillary hydrostatic pressure  non-portal HTN:  capillary permeability ---------------------------------------------------------------Management of ascites  Na+ & water restriction  spironolactone (up to max dose)  furosemide (not > 1 L/day diuresis; risk of hepatorenal syndrome or encephalopathy)  paracentesis (monitor renal function) --------------------------------------------------------------- nephrotic syndrome with palpable kidneys, hepatomegaly, recurrent pulmonary infections, ventricular hypertrophy: secondary amyloidosis  2/2 chronic inflammation (RA, IBD, TB, lymphoma bronchiectasis)  extracellular deposition of fibrils in tissues/organs  Dx: abdominal fat pad Bx  Rx: underlying inflammatory disease  Rx: colchicine (Rx & prophylaxis) --------------------------------------------------------------- flutamide: non-steroidal anti-androgen that binds DHT receptors; Rx: prostate cancer  no benefit for those underwent orchiectomy ---------------------------------------------------------------

  

acute renal failure (Cr > 1.5) with severe cirrhosis 2/2 systemic & renal hypoperfusion does not respond to fluid resuscitation** complication of cirrhosis

Hepatorenal syndrome risk factors advanced cirrhosis with portal HTN precipitating  renal perfusion: GI bleed, vomiting, factors sepsis, excessive diuretics, SBP  glomerular pressure & GFR: NSAIDs (constricts afferents) Dx renal hypoperfusion: FeNa < 1% prerenal azotemia absence of tubular injury (no RBC, protein, or granular casts) does not respond to fluid resuscitation Rx address precipitating factors, splanchnic vasoconstrictors (midodrine, octreotide, NE), definitive Rx: liver transplant --------------------------------------------------------------- progressive worsening back pain, focal tenderness, increased radionuclide uptake in lumbar region  radiation therapy: Rx bone pain a/w Hx of prostate cancer & bone mets after orchiectomy --------------------------------------------------------------- patients with hypothyroidism have in increased requirement for levothyroxine after starting estrogen (estrogen replacement, OCPs)  oral estrogen decrease clearance of TBG  elevated TBG levels, thus  free T4 &  TSH  Rx: higher dosing of levothyroxine --------------------------------------------------------------- pregnancy is a/w up-regulation thyroid hormone due to  TBG by estrogen & stimulation of TSH receptors by β-hCG Thyroid hormones during pregnancy Total T4  β-hCG stimulates TH production 1.5x & estrogen stimulates  TBG Free T4  slight increase TSH  suppressed ----------------------------------------------------------------

rifampin, phenytoin, & carbamazepine increase hepatic clearance of thyroid hormones by  enzyme metabolism (deiodination) ---------------------------------------------------------------Idiopathic intracranial HTN (aka pseudomotor cerebri)  impaired CSF absorption by arachnoid villi risk obese women of child-bearing age, OCPs, factors tetracycline, isotretinoin, excess Vit. A symptom o headache (holocranial, pulsatile) s worse at night, awakens from sleep o transient vision loss, diplopia o pulsatile tinnitus (“whooshing”) exam papilledema, peripheral vision defect, CN VI palsy (lateral rectus) Dx MRI: normal (may see empty sella) LP: normal CSF analysis  opening pressure > 250 mmHg (communicating hydrocephalus) Rx stop offending medication, weight loss, acetazolamide (if weight reduction fails) definitive Rx: surgery complication: blindness DDx: migraine, cluster headache, viral encephalitis, MS, NPH 

papilledema is not C/I to LP unless evidence of obstructive hydrocephalus or mass lesion  acetazolamide inhibits choroid plexus carbonic anhydrase, thus  CSF production --------------------------------------------------------------- protracted vomiting a/w pyloric stenosis results in hypochloremic hypokalemic metabolic alkalosis  Rx: IV rehydration & normalize electrolytes prior to pyloromyotomy  alkalosis  risk of post-op apnea --------------------------------------------------------------- acute appendicitis: peri-umbilical pain is referred & visceral; RLQ pain involves parietal peritoneum is somatic pain --------------------------------------------------------------- by age 12 months, weight should triple, & height should double ---------------------------------------------------------------

Dx ureteral stones: USS or non-contrast spiral CT of abdomen & pelvis  USS for pregos  IV pyelogram: old test for stones --------------------------------------------------------------- Parkinson’s is a clinical Dx: at least 2/3 o resting tremor, rigidity, bradykinesia  no imaging or labs needed to confirm Dx --------------------------------------------------------------- chronic acid suppression with PPI or H2 blocker is a risk factor for…  C. difficile o Dx: stool PCR assay for toxin A & B o osteoporosis 2/2 impaired Ca++ absorption o pneumonia 2/2 upper GIT colonization --------------------------------------------------------------- suspected community-acquired pneumonia or atypical pneumonia (Mycoplasma)  Dx: clinical & CXR  Rx: empiric ABX --------------------------------------------------------------- TSH-secreting pituitary adenoma: macroadenoma  causes central hyperthyroidism  symptoms MC due to mass effect  presents with goiter, but no Graves’ findings --------------------------------------------------------------- Hashimoto’s: lymphocytic infiltration of thyroid  anti-TPO Ab’s, elevated TSH, low T4  enlarged, rubbery goiter  can cause transient hyperthyroidism 2/2 initial inflammatory destruction of thyroid follicles --------------------------------------------------------------- thyroid lymphomas: MC a/w Hashimoto’s  rapid thyroid gland enlargement with compressive symptoms (dysphagia, voice changes)  reduced RAIU --------------------------------------------------------------- TMP-SMX: prophylactic Rx for toxoplasmosis, PCP, community-acquired skin MRSA, nocardia, & uncomplicated UTI  prophylaxis for all post-transplant patients o vaccines: influenza, pneumococcus, Hep B ---------------------------------------------------------------

Trimethoprim (TMP) causes hyperkalemia 2/2 blockade of epithelial Na+ channels in collecting tubule @ high doses  serial K+ monitoring required  also competitively inhibits tubular Cr secretion, results in artificial increase of serum Cr without affecting GFR --------------------------------------------------------------- glomerular hyperfiltration is the earliest renal abnormality in diabetic nephropathy o detectable several days after DM Dx o creates intraglomerular HTN & progressive glomerular damage  Rx: ACE-I reduces intraglomerular HTN  first quantified change: glomerular BM thickening, followed by mesangial expansion, nodular sclerosis --------------------------------------------------------------- rapid onset respiratory failure, severe hypotension, & DIC during labor or immediately post-partum: amniotic fluid embolism  cardiogenic shock, seizures, or coma  risk factors: adv maternal age, high gravida  Dx: clinical  Rx: respiratory & hemodynamic support  DDx: eclampsia, peripartum cardiomyopathy, PE --------------------------------------------------------------- severe aortic stenosis can cause anginal chest pain due to  myocardial O2 demand  accompanying prolonged myocardial contraction & impaired diastole  coronary blood flow --------------------------------------------------------------- HCM: murmur @ LLSB; dual upstroke carotids  aortic stenosis: murmur located in 2nd IC space with radiation to carotids --------------------------------------------------------------- myocardium meets increased O2 demand by inducing dilation of coronary vessels o unable to increase O2 extraction --------------------------------------------------------------- anti-tissue transglutaminase Ab: Dx Celiac’s --------------------------------------------------------------- heparin inactivates antitrhombin III, which inactivates thrombin, factor IXa & Xa --------------------------------------------------------------- mean values are extremely sensitive to outliers 

---------------------------------------------------------------Preconception counseling  initial screening of hemaglobinopathies for non-African American: CBC of the female only o further testing if anemic & reduced MCV  African Americans: CBC & Hb electrophoresis --------------------------------------------------------------- iron level, TIBC, & ferritin are normal in thalassemia; abnormal with iron deficiency --------------------------------------------------------------- ceftriaxone use is a/w cholestasis  C/I in newborns at high risk of cholestasis ---------------------------------------------------------------Skin conditions & associated diseases acanthosis nigricans insulin resistance (PCOS, obesity, DM), GI malignancy multiple skin tags insulin resistance, pregnancy, Crohn’s (perianal) porphyria cutanea tarda & palpable purpura 2/2 Hep C cryoglobulinemia dermatitis herpetiformis Celiac’s sudden onset psoriasis, recurrent herpes zoster, HIV molluscum contagiosum severe seborrheic dermatitis HIV, Parkinson explosive, itchy seborrheic GI malignancy dermatitis pyoderma gangrenosum Crohn’s erythema nodosum sarcoidosis, UC, TB, coccidiomycosis, histoplasmosis, Bechet DDx of hyperpigmentation: Addison’s, pellagra, hemochromatosis --------------------------------------------------------------- pyoderma gangrenosum: neutrophilic ulcerative skin disease; purulent base, violaceous borders  a/w underlying systemic disorder (IBD, RA, AML)  Dx: skin biopsy  Rx: local or systemic corticosteroids ---------------------------------------------------------------

ecthyma gangrenosum: hemorrhagic pustule with surrounding erythema  necrotic ulcers o MCC: P. aeruginosa --------------------------------------------------------------- erythema nodosum: painful, discrete, pretibial subcutaneous nodules  MCC: recent Strep pharyngitis  a/w sarcoidosis, UC, TB, coccidiomycosis, histoplasmosis, Behcet  evaluation: CXR, PPD, ASO titers --------------------------------------------------------------- hidradenitis suppurativa: chronic inflammatory occlusion of skin follicles o nodules or abscess with purulent drainage  scar tissue @ axilla, groin, perineum, scalp result in linear rope-like bands & sinus tracts o risk factors: family Hx, smoking, obesity, mechanical stress on skin o Dx: clinical; no skin biopsy or cultures --------------------------------------------------------------- well-defined erythematous plaques with satellite vesicles or pustules in interigenous & occluded skin areas (axilla, groin, skin folds): intertrigo  MCC: Candida albicans --------------------------------------------------------------- hyperpigmented plaques in flexural & interigenous areas with hyperkeratosis: acanthosis nigricans  risk factors: family Hx, diabetes, obesity, PCOS, Cushing’s --------------------------------------------------------------- erythematous papules & pustules in central face: acne (papulopustular) rosacea  not acne vulgaris, no comedones --------------------------------------------------------------- biliary colic: increased intra-GB pressure against an obstructed cystic duct  referred pain; exacerbated by fatty meals  spontaneous resolution within 4 -6 hrs  no fever, TTP, or leukocytosis; no inflammation  DDx: cholecystitis (pain > 6 hrs, Murphy’s sign) --------------------------------------------------------------- intestinal ileus can be due to a vagal reaction caused by uereteral colic (renal stone)  RLQ pain, constipation, no flatus  U/A: needle-shaped crystals (uric acid stones) 

 Dx: abdominal CT (detects radiolucent stones)  ileus resolves when ureterolithiasis is treated --------------------------------------------------------------- sudden onset epigastric pain, N/V, hematemesis, peritoneal signs (guarding, rigidity, rebound tender), pneumoperitoneum: perforated peptic ulcer  gastric content released into peritoneal cavity, results in peritonitis, rebound tenderness, guarding  surgical emergency!!!  DDx: acute cholecystitis, gallstone pancreatitis, aortic dissection, biliary colic --------------------------------------------------------------- acute onset focal neurologic findings (confusion, ataxia, hyperreflexia, seizures), fever, headache, behavior changes: herpes encephalitis  MCC of fatal sporadic encephalitis: HSV-1  damages the temporal lobe  CSF: marked lymphocytic pleocytosis,  proteins,  erythrocytes (2/2 hemorrhagic destruction of temporal lobes), normal glucose  Dx: CSF shows HSV DNA on PCR  Rx: empiric IV acyclovir after LP --------------------------------------------------------------- bacterial meningitis CSF: polymorphonuclear leukocytes,  glucose --------------------------------------------------------------- hyperCa++, hypophosphatemia,  urinary Ca++,  PTH: primary hyperPTH  Dx: 24 hr urine Ca++  Rx: parathyroidectomy criteria for asymptomatic hypercalcemia o serum Ca++ ≥ 1 mg/dL above upper limit o young age < 50 yrs o bone mineral density < 2.5 o reduced renal function (GFR < 60)  DDx: familial hypocalciuric hypercalcemia, hypercalcemia of malignancy --------------------------------------------------------------- hypercalcemia without polyuria, polydipsia, or constipation: familial hypocalciuric hyperCa++  abnormal Ca++-sensing receptor on parathyroid cells & renal tubules; excess Ca++ reabsorption  AD inherited, benign, asymptomatic hypercalcemia  high/normal PTH, low urine Ca++

 Rx: do not treat hyperCa++, no parathyroidectomy --------------------------------------------------------------- pRBC transfusion can  O2-carrying capacity for severe anemia  when to transfuse pRBCs… o stable patients, no comorbidities: Hb < 7 g/dL o unstable, symptomatic anemia: Hb < 9 g/dL --------------------------------------------------------------- eczematous rash on the nipple, Bx: large cells surrounded by halo-like areas invading epidermis: breast Paget’s  localized to the nipple, ulcerating eczematous appearance with underlying adenocarcinoma --------------------------------------------------------------- FFP: contains all clotting factors & plasma proteins from 1 unit of blood  Rx: active bleeding with severe coagulopathy (liver disease, DIC, supratherapeutic warfarin) --------------------------------------------------------------- cryoprecipitate contains insoluble products from cold FFP (fibrinogen, vWB factor, factor VIII, factor XIII)  Rx: replacement therapy --------------------------------------------------------------- PLT transfusion: Rx PLT < 10,000 o or PLT < 50,000 with active bleeding --------------------------------------------------------------- kleptomania: impulse control disorder to steal  Rx: CBT --------------------------------------------------------------- abdo pain, palpable mass, jaundice, dark urine, age < 10 yrs: congenital biliary cyst o no fever, N/V, or anorexia  single, extrahepatic cystic dilation of bile duct  Dx: USS (or ERCP for biliary obstruction)  Rx: surgical resection reduces malignancy risk  complications: cholangiocarcinoma  DDx: biliary atresia (early infancy, acholic stools), cholangitis (fever), pancreatic pseudocyst --------------------------------------------------------------- chronic diarrhea, short stature, gingivitis, recurrent lymphadenitis, osteomyelitis at multiple sites, catalase+ infections: chronic granulomatous dz o S. aureus, Aspergillus, Serratia, Klebsiella

not susceptible to catalase-negative (S. pyogenes, S. pneumo, H. influenza)  underweight, dermatitis, lymphadenopathy, hypergammaglobulinemia, hepatic abscesses, hepatosplenomegaly, anemia of chronic disease  Dx: nitroblue tetrazolium test  Rx: daily TMP-SMX, gamma-INF 3x/wk --------------------------------------------------------------- lethargy, bradycardia, AV block, hypotension, diffuse wheezing: β-blocker overdose  wheezing is hallmark  hypoglycemia, bronchospasm, delirium, seizures  initial Rx: isotonic fluid bolus, IV atropine  Rx: IV glucagon ( intracellular cAMP) for refractory hypotension --------------------------------------------------------------- prematurity & LBW infants are risk factor for intraventricular hemorrhage  Dx: transfontanelle USS of all newborns with predisposing risk factors --------------------------------------------------------------- Parinaud syndrome: due to pineal gland tumor (pineal produces melatonin)  MCC: germ cell tumors  central precocious puberty:  β-hCG  pressure on pretectal midbrain region near superior colliculus & CN II  limited upward gaze (“sun-setting” sign), ptosis, B/L eyelid retraction (Collier’s sign)  pseudo-Argyll-Robertson (minimally reactive)  obstructive hydrocephalus: headache, vomiting, papilledema  Dx: MRI, AFP & β-hCG --------------------------------------------------------------- ecchymosis on areas exposed to repeated minor trauma (extensors) in elderly: senile purpura  age-related loss of elastic fibers in perivascular connective tissue   incidence & severity a/w anticoagulants, NSAIDs, & corticosteroids  normal labs; no further evaluation --------------------------------------------------------------- precocious puberty, pigmentation, polyostotic fibrous dysplasia (3 P’s): McCune Albright o café au lait spots, multiple bone defects 

o moon facies, bruises GI hamartomatous polyps, mucocutaneous pigmentation: Peutz-Jeghers  sporadic phakomatosis, mental retardation, seizures, visual impairment: Sturge-Weber --------------------------------------------------------------- MCC of secondary digital clubbing: CF, lung malignancies, right-to-left shunts  2/2 trapping of megakaryocytes in distal fingertips, releasing PDGF & VEGF  hypertrophic osteoarthropathy: clubbing & painful joint enlargement, synovial effusions, periostosis of long bones; a/w lung cancer --------------------------------------------------------------- MC complication of PUD: hemorrhage ---------------------------------------------------------------Obstructive Restrictive lung disease lung disease FEV1 < 80% < 80% FEV1/FVC < 70% () > 70% (normal) FVC normal or  < 80% 

 

positive bronchodilator response (> 12%  FEV1), normal DLCO, dyspnea, wheezing, cough: asthma COPD & asthma both show airflow obstruction  only asthma shows complete reversible airway obstruction with bronchodilators o asthma: normal or  DLCO (if severe)

emphysema COPD:  DLCO due to alveolar destruction --------------------------------------------------------------- DLCO = function of alveolar-capillary membrane DDx based on DLCO obstructive restrictive normal pattern pattern spirometry  DLCO emphysema interstitial anemia, PE, (COPD) lung disease, pulmonary sarcoidosis, HTN asbestosis, heart failure normal chronic MSK DLCO bronchitis deformity, (COPD), neuromuscula asthma r disease  DLCO severe morbid pulmonary asthma obesity hemorrhage, polycythemi a Causes of  DLCO (look at FEV pattern)  restrictive pattern: interstitial fibrosis, bleomycin, idiopathic pulmonary fibrosis  obstructive pattern: emphysema COPD  normal spirometry: PE, anemia, pulmonary HTN Causes of  DLCO  due to  pulmonary blood volume  exercise, supine position, pulmonary hemorrhage, severe asthma, smoking, polycythemia ---------------------------------------------------------------  DLCO in emphysema due to "adjoining capillary beds" (decreased surface area)   DLCO in asthma due to "increased pulmonary blood volumes" --------------------------------------------------------------- chronic bronchitis: COPD subtype a/w smoking  productive cough ≥ 3 months in 2 successive yrs  hypersecretion of mucus & structural changes to tracheobronchial tree; normal DLCO  CXR: prominent bronchovascular markings ---------------------------------------------------------------Evaluation of hyperthyroidism  Dx: measure TSH & free T4 o  TSH,  free T4  20 hyperthyroidism o Dx: MRI  pituitary adenoma o

 TSH,  free T4  10 hyperthyroidism o goiter, ophthalmopathy  Graves’ o Dx: radioactive iodine uptake (RIU)   RIU = de novo hormone synth   RIU = preformed or exogenous  high RIU: diffuse  Graves’  high RIU: nodular  adenoma, multi-nodular goiter  low RIU  thyroglobulin low  exogenous TH  low RIU  thyroglobulin high  thyroiditis --------------------------------------------------------------- thyroglobulin: produced by follicular cells of the thyroid; used only within the thyroid gland --------------------------------------------------------------- fever, neck pain, tender thyroid, elevated ESR: subacute thyroiditis (de Quervain)  self-limited < 8 wks due to depletion of preformed thyroid hormone --------------------------------------------------------------- upper GI bleed Rx: supplemental O2, IV fluids, NPO, monitor CBC & vitals for ongoing bleeding ---------------------------------------------------------------Manifestations of SLE feature constitutional: fever, fatigue, weight loss s non-deforming migratory arthritis butterfly rash & photosensitivity serositis: pleurisy, pericarditis, peritonitis thromboembolic events (antiphospholipid) cognitive dysfunction & seizures labs hemolytic anemia, thrombocytopenia, leukopenia proteinuria, elevated Cr hypocomplementemia (C3, C4) ANA, anti-dsDNA, anti-Smith false-positive RPR test for syphilis o

SLE joint Rx: NSAIDs, low-dose glucocorticoids, hydroxychloroquine --------------------------------------------------------------- cough & wheezing with ASA-exacerbated respiratory disease is preceded by refractory chronic rhinosinusitis a/w nasal polyposis --------------------------------------------------------------- child with morning headaches, seizures, irritable, decorticate posturing, space-occupying lesion  infratentorial, benign astrocytomas: MC in kids 

--------------------------------------------------------------- fatigue, malaise, fever, night sweats, anorexia, weight loss, pallor, abdominal pain: CML  leukocytosis with left shift, basophilia, anemia, thrombocytosis, splenomegaly   myelocytes > metamyelocytes  reciprocal t(9, 22) form Philadelphia Xome containing the BCR/ABL fusion gene causes dysregulated tyrosine kinase activity   LAP score (leukocyte alkaline phosphatase)  Rx: tyrosine kinase inhibitors (imatinib) inhibit BCR/ABL tyrosine kinase activation ---------------------------------------------------------------  leukocyte alkaline phosphatase (LAP) score: leukemoid reaction, polycythemia vera   LAP score: CML (Dx: Philadelphia Xome) --------------------------------------------------------------- acute promyelocytic leukemia (APL) is a/w retinoic acid receptor  +Auer rods, +myeloblasts  no fever, no splenomegaly  Rx: all-trans retinoic acid (ATRA) --------------------------------------------------------------- MC thyroid malignancy: papillary carcinoma  best prognosis  MC mets to local lymph nodes  risk factors: childhood head/neck irradiation, family Hx of thyroid ca --------------------------------------------------------------- follicular thyroid carcinoma: hematogenous  anaplastic thyroid ca: rapidly enlarging mass; worst prognosis (months) --------------------------------------------------------------- resistant HTN: despite ≥ 3 anti-hypertensives Secondary causes of HTN renal  serum Cr, proteinuria, RBC casts parenchymal disease renovascular continuous abdominal bruit, disease severe HTN (≥ 180/120), (MCC) diffuse atherosclerosis (PAD, PVD) recurrent flash pulmonary edema  serum Cr (after starting ACE-I) primary HTN, mild hyponatremia, aldosteronism easily provoked hypokalemia

pheochromocytoma Cushing’s hypothyroidis m primary hyperPTH aortic coarctation

aldosterone/renin > 20:1 headache, palpitations, diaphoresis paroxysmal elevated BP adrenal incidentaloma central obesity, facial plethora, proximal weakness, striae, amenorrhea/erectile dysfunction fatigue, dry skin, cold intolerance, constipation, weight gain hypercalcemia, renal stones polyuria, polydipsia confusion, depression, psychosis differential HTN, headache, epistaxis, blurred vision,, LVH brachial-femoral delay, rib notching continuous “to-&-fro” machine-like murmur (posterior chest) due to large collateral circulation

hypercalcemia: “bones, stones, moans, groans” hyperPTH can cause HTN, arrhythmias, ventricular hypertrophy, vascular & valvular calcifications  significant HTN & 10 hyperPTH; MEN syndrome ---------------------------------------------------------------Acute decompensated heart failure feature acute dyspnea, orthopnea, PND, HTN, s accessory muscle use, tachycardia, tachypnea, bibasilar crackles, JVD, S3, peripheral edema Rx stable: supplemental O2, IV furosemide, IV vasodilator (nitro) hypotension or shock: supplemental O2, IV furosemide, IV vasopressor (NE)  

acute decompensated HF can present with acute pulmonary edema ---------------------------------------------------------------Tetanus prophylaxis wound clean, minor dirty, severe ≥ 3 tetanus tetanus toxoid if tetanus toxoid if toxoid doses last dose was last dose was ≥ 10 yrs ago ≥ 5 yrs ago no TIg no TIg unimmunized, tetanus toxoid tetanus toxoid uncertain, or vaccine only, vaccine + TIg 

< 3 tetanus doses no TIg --------------------------------------------------------------- diastolic dysfunction = heart failure with preserved LV ejection fraction (contractility)  elevated diastolic pressure  reduced C.O. ---------------------------------------------------------------Drugs/supplements that affect warfarin metabolism p450 acetaminophen* NSAIDs inhibitors ABX/antifungals thyroid hormone (metronidazole) SSRI  warfarin amiodarone cranberry juice cimetidine Gingko biloba ( bleed risk) omeprazole Vit E p450 inducers carbamazepine phenobarbital ginseng rifampin  warfarin spinach (greens) St. John’s wort effects/efficacy OCPs --------------------------------------------------------------- lupus anticoagulant: causes artificially prolonged aPTT by binding phospholipids   risk of thrombosis --------------------------------------------------------------- episodic flushing, secretory diarrhea, wheezing, tricuspid regurgitation feature s Dx Rx 



Carcinoid syndrome episodic flushing, telangiectasias, cyanosis, secretory diarrhea, cramping, bronchospasm, tricuspid regurgitation, niacin deficiency (pellagra)  24 hr urine 5-HIAA CT/MRI abdomen/pelvis localizes tumor OctreoScan (detect mets), echo octreotide only if symptomatic & prior to surgery for liver mets

carcinoid tumors can secrete histamine, 5-HT, VIP that are metabolized in the liver o liver mets results in hormone release into systemic circulation hallmark: plaque-like deposits of fibrous tissue on endocardium  tricuspid regurgitation & right heart failure

5-HT is synthesized in carcinoid cells from tryptophan, also used for niacin o  5-HT production  pellagra  DDx: right-sided IE (fever, malaise, arthralgias) --------------------------------------------------------------- folic acid depletion: 4 – 5 months  elderly on a tea & toast diet  Vit B12 stores: 3 – 4 yrs --------------------------------------------------------------- perifollicular hemorrhage, poor wound healing, swollen gums: Vit C deficiency  RBC fragility, hyporeflexia, muscle weakness, blindness: Vit E deficiency --------------------------------------------------------------- unilateral pulsatile headache, vomiting, photophobia, 4 – 72 hrs duration: migraine  Rx acute attacks: IV anti-emetics (chlorpromazine, prochlorperazine, metoclopramide), esp. w/ N/V o monotherapy or adjunct to NSAIDs & triptans  migraine prophylaxis: amitriptyline, propranolol --------------------------------------------------------------- most effective in reducing UTI risk a/w neurogenic bladder: intermittent catheterization  indwelling catheters can acquire a biofilm ---------------------------------------------------------------Nephritic syndrome Nephrotic syndrome HTN, oliguria, edema, hypoalbuminemia, periorbital edema hyperlipidemia, VTE hematuria, RBC casts no hematuria, fatty casts proteinuria < 3.5 g/day proteinuria > 3.5 g/day pediatric etiologies post-strep GN, HUS minimal change disease adult etiologies IgA nephropathy, focal segmental GN, crescentic GN membranous nephropathy, (rapidly progressive GN) membranoproliferative, lupus nephritis, amyloidosis, Alport’s diabetic glomerularnepho 

Hep B is a risk factor for membranous nephropathy o immunofluorescence: granular  membranoproliferative glomerulonephritis is a/w Hep C infection o can cause nephritic or nephrotic syndrome ---------------------------------------------------------------

Nephrotic histopathology  crescent formation: focal segmental GN  thick BM & subepithelial “spikes”: membranous  mesangial hypercellularity: membranoproliferative --------------------------------------------------------------- parents are not allowed to refuse life-saving Rx for a child, including religious reasons  obtain court order to proceed with intervention --------------------------------------------------------------- adolescents can receive confidential care w/o consent for contraception, pregnancy, & STDs --------------------------------------------------------------- presbyopia: age-related  lens elasticity  prohibits accommodation, thus loss of near vision  peaks at age 40, Hx of eye problems --------------------------------------------------------------- weakness, postprandial epigastric pain, +FOBT: gastric cancer  Dx: endoscopy/Bx positive for adenocarcinoma Staging gastric adenocarcinoma  initial staging: abdomen & pelvis CT  limited stage  surgical resection  advanced stage  chemotherapy +/- laparotomy --------------------------------------------------------------- nocturnal wheezing & cough: GERD ---------------------------------------------------------------Esophageal perforation etiology Boerhaave’s, endoscopy, esophagitis (infectious/pill/caustic), ulcer features chest/abdo pain, fever, subcutaneous emphysema, crepitus Dx CXR: wide mediastinum, pneumoTx, pneumomediastinum CT: esophageal wall thickening, mediastinal air-fluid level water soluble contrast esophagogram Rx ABX, parenteral nutrition, supportive care surgical repair --------------------------------------------------------------- β-blockers can exacerbate severe reactive airway disease, but safe with mild/moderate COPD/asthma o Rx: use cardioselective β-blockers ----------------------------------------------------------------

MCC of sudden cardiac arrest is sustained ventricular tachycardia or fibrillation due to acute MI or ischemia  survival rated depends on effective CPR, prompt rhythm analysis & defibrillation for V-fib o #1 Rx: compression-only CPR  Rx: epinephrine for asystole, PEA, or refractory ventricular arrhythmias after defibrillation --------------------------------------------------------------- hereditary non-polyposis CRC (HNPCC): aka Lynch Syndrome  MC a/w endometrial carcinoma ---------------------------------------------------------------MCC of osteomyelitis  children & adults: S. aureus (coagulase+)  sickle cell disease: Salmonella & S. aureus  neonates: E. coli & group B strep  age < 1 yr: group B strep  diabetics: Pseudomonas  foot puncture: Pseudomonas o Rx: fluoroquinolones & surgical debridement  vertebral body: S. aureus --------------------------------------------------------------- recent onset confusion, fever, muscle rigidity, diaphoresis,  CK: NMS o drug-induced idiosyncratic reaction  MCC: haloperidol, some atypicals o within 2 wks of initiation ---------------------------------------------------------------Features of compartment syndrome o pain on passive stretching o pain out of proportion to injury o rapidly increasing & tense swelling o paresthesia  reperfusion of a limb following arterio-occlusive ischemia > 4 – 6 hr can lead to intracellular & interstitial edema  increased pressure  muscle & nerve ischemia  Rx: elevated compartment pressures that do not show rapid improvement  fasciotomy  DDx: necrotizing fasciitis, gas gangrene, embolic occlusion, DVT (vague pain)  complication: Volkmann contracture ---------------------------------------------------------------

Hep C can be asymptomatic or nonspecific ALT can be normal or 2x normal consideration for Rx requires liver biopsy as the best clinical predictor of disease progression & assess response to treatment  liver biopsy determines staging & guide Rx  Rx: peginterferon & ribavirin  HHC surveillance for cirrhosis: USS every 6 months --------------------------------------------------------------- early phase of acute pneumonia with consolidation can have persistent blood flow to areas of impaired ventilation (V/Q mismatch)  leads to physiologic intrapulmonary (right-to-left) shunting & arterial hypoxemia (deoxygenated blood to left heart)  laterally positioning the affected lung in the “dependent (lowest) position” will worsen the shunt --------------------------------------------------------------- conditions that cause decreased perfusion of well-ventilated alveoli (PE)  amount of physiologic dead space, resulting in wasted ventilation, but not hypoxemia  poor ventilation of well-perfused alveoli (consolidated lung) leads to hypoxemia --------------------------------------------------------------- monthly bloating, headaches, breast tenderness, irritability decreased libido, anxiety: PMS  occurs 1 – 2 wks before menses  resolves with onset of menses  DDx: hypothyroid, perimenopause, migraine, somatization --------------------------------------------------------------- bipolar: not required to have depressive episode o antipsychotics have rapid onset of action, best for Rx acute mania o mood stabilizers require gradual titration Bipolar disorder Rx  mild/mod  monotherapy with atypicals (risperidone, olanzapine, aripiprazole)  alternative  lithium or valproate as monotherapy  severe mania  atypical + lithium or valproate Maintenance Rx lithium aripiprazole risperidone lamotrigine olanzapine ziprasadone valproate quetiapine  haloperidol can Rx acute mania, not maintenance   

valproate A/E: weight gain & acute pancreatitis lamotrigine: Rx of bipolar depressive episodes; A/E: SJS --------------------------------------------------------------- post-menopausal asymptomatics with adnexal mass require transvaginal USS, then CA-125  elevated CA-125 in post-menopause suggests ovarian cancer  if simple cyst < 10 cm & normal CA-125: follow conservatively with periodic USS  needle aspiration is C/I --------------------------------------------------------------- Rx emergency reversal of warfarin-induced anticoagulation: FFP --------------------------------------------------------------- desmopressin can be used pre-operatively for mild hemophilia A to prevent excess bleeding o indirectly increases factor VIII by causing vWF release from endothelial cells --------------------------------------------------------------- paraplegia, bladder/fecal incontinence, sensation absent from nipple downward: upper thoracic cord lesion  absent sensation from umbilicus downward: lower thoracic cord lesion --------------------------------------------------------------- ipratropium: anti-muscarinic  Rx acute COPD exacerbation, combined with short-acting β-agonists (albuterol) --------------------------------------------------------------- Rx proven to prolong COPD survival: cessation of smoking, supplemental O2, lung reduction surgery --------------------------------------------------------------- Hep A is the MC vaccine-preventable disease of travelers, especially developing countries  yellow fever vaccine o sub-Saharan Africa, S. America --------------------------------------------------------------- alcohol cessation & low purine diet can prevent acute gouty arthritis  ethanol is metabolized to lactate; competes with urate for renal excretion  also avoid diuretics & pyrazinamide  Rx: NSAIDs, colchicine --------------------------------------------------------------- 

headache, N/V, abdominal discomfort, confusion, pink-red skin: carbon monoxide poisoning  Dx:  carboxyHb level o pulse oximetry may be normal; unreliable  Rx: 100% O2  CO half-life from 5 hr to 1 – 2 hr or hyperbaric O2 ---------------------------------------------------------------Causes of inadequate response to anti-hypertensives o NSAIDs, decongestants, glucocorticoids o excess alcohol o screen for secondary causes --------------------------------------------------------------- sudden onset syncope without warning signs, structural heart disease, ectopic beats: arrhythmia  thiazides can predispose to ventricular arrhythmia  DDx: vasovagal, autonomic dysFx, postural --------------------------------------------------------------- methadone is for pregos addicted to heroin to prevent uncontrolled withdrawal in the fetus  prenatal exposure to heroin & methadone increases risk of IUGR, macrocephaly, SIDS Neonatal abstinence syndrome  irritability, high-pitched cry, poor sleep, tremors, seizures, sweating, sneezing, vomiting, diarrhea o heroin withdrawal: within 48 hr o methadone withdrawal: 48 – 72 hr  Rx: symptomatic, morphine (systematically wean) --------------------------------------------------------------- penile fracture: due to crush injury  tearing of tunica albuginea, forms a hematoma  Rx: retrograde urethrogram to r/o urethral injury, then surgical exploration ---------------------------------------------------------------o phenytoin: Rx partial seizures o carbamazepine: Rx trigeminal neuralgia  fetal hydantoin syndrome: nail/digit hypoplasia, cleft lip/palate, MR, cardiac defects, microcephaly o phenytoin  rate of fetal Vit K degradation o pregos on phenytoin during last trimester should receive prophylactic Vit K to prevent neonatal bleeding --------------------------------------------------------------- fetal exposure to valproate: risk of NTDs, cardiac anomalies, dysmorphic facies ---------------------------------------------------------------

large anterior mediastinal mass,  β-hCG,  AFP: non-seminomtous germ cell tumor  young males, locally invasive  most are primary tumors  Dx: testicular USS (r/o primary tumor)  DDx: seminoma ( β-hCG only), benign teratoma, bronchogenic cyst, Hodgkin’s --------------------------------------------------------------- choriocarcinoma:  β-hCG  seminoma:  β-hCG only  non-seminomtous tumor:  β-hCG,  AFP  benign teratoma: no markers  HCC:  AFP ---------------------------------------------------------------#1 testicular sex cord stromal tumor: leydig cell tumor  gynecomastia, precocious puberty   estrogen due to  aromatase expression with secondary inhibition of LH & FSH  undetectable β-hCG & AFP --------------------------------------------------------------- subacute combined degeneration: neurologic complication of Vit B12 deficiency  progressive symmetric polyneuropathy (legs)  degeneration of dorsal spinal column, gait ataxia  corticospinal disease (UMN signs)  peripheral neuropathy, memory loss, dementia  Dx: elevated methylmalonic acid --------------------------------------------------------------- Toxoplasmosis Rx: empiric sulfadiazine & pyrimethamine  prophylaxis: TMP-SMX --------------------------------------------------------------- large sample size: decreases p-value & narrows CI ---------------------------------------------------------------Wilms tumor (nephroblastoma) epidemiolog arise from metanephros y (precursor of renal parenchyma) MC renal malignancy of childhood peak @ age 2 – 5 yrs; sporadic, associated syndromes… o WAGR (Wilms, Aniridia, GU anomalies, mental Retardation) o Beckwith-Wiedemann o Denys-Drash 

features Dx Rx prognosis

asymptomatic, firm abdominal mass, does not cross midline USS, then contrast-enhanced CT excision or nephrectomy, chemotherapy +/- radiation 5 yr survival with Rx: 90% MC site of mets: lungs

DDx: neuroblastoma o arises from neuro crest cells (precursor of sympathetic chain & adrenal medulla) o can arise anywhere in sympathetic NS, but typically the adrenals  firm, nodular mass that crosses midline o metastatic sites: long bones, bone marrow, skull, liver, lymph nodes, skin o  urine HVA, VMA catecholamines o XR: calcifications & hemorrhages --------------------------------------------------------------- relative risk can be calculated from cohort studies by comparing incidence  odds ratio measures association in case-control studies; compares the odds of exposure o if outcome/disease is uncommon, odds ratio is a close approximation of relative risk (“rare disease assumption”)  if low incidence  OR approximates RR ---------------------------------------------------------------Thoracic aortic aneurysm  ascending aortic aneurysm: cystic medial necrosis (aging) or connective tissue disorders (Marfan)  descending aortic aneurysm: atherosclerosis o HTN, hypercholesterolemia, smoking  CXR: wide mediastinum, increased aortic knob, tracheal deviation  Dx: contrast-enhanced CT --------------------------------------------------------------- De Quervain tenosynovitis: inflammation of abductor pollicis longus & extensor pollicis brevis  MC in new mothers holding infants  Finkelstein test (grasps thumb & ulnar deviate the wrist) --------------------------------------------------------------- acute, severe retro-orbital pain, same time of day, wakes patient from sleep, male: cluster headache 

attacks occur in clusters: daily for 6 – 8 wks, then remission for up to 1 yr  redness, I/L tearing, rhinorrhea, I/L Horner’s  acute Rx: 100% O2, subcutaneous sumatripan  prophylaxis Rx: verapamil, lithium, ergotamine ---------------------------------------------------------------Iron deficiency anemia in age < 2 yr risk factors prematurity** lead exposure infants who consume… o low-iron formula  cow, soy, or goat milk introduced before age 1 yr o exclusive breastfeeding after age 6 months toddlers who consume… o 24 oz/day milk (> 3 glasses) o < 3 servings/day iron-rich food universal CBC in all age 9 – 12 months screening Rx empiric iron supplementation, recheck Hb in 4 wks,  start cow milk @ age 1 yr 

term infants have adequate iron stores for 6 months excess cow milk is low in iron & causes occult intestinal blood loss  goat milk is folate deficient --------------------------------------------------------------- all pregos without C/I: influenza vaccination o @ any trimester --------------------------------------------------------------- cough, erythema nodosum, anterior uveitis, arthritis: sarcoidosis  most are asymptomatic, incidental CXR findings  DDx: acute HIV, TB, histoplasmosis, Hodgkin’s --------------------------------------------------------------- primary CNS lymphoma Rx: irradiation  suspected if no response to ABX --------------------------------------------------------------- all exclusively breastfed infants should start on VitD daily within 1st month of life  solid foods @ < 6 months  risk of GI infections  

Vit B12 supplements for exclusively breastfed infants born to strict vegetarian mothers --------------------------------------------------------------- acute confusion, fluctuating LOC, inability to sustain attention: delirium --------------------------------------------------------------- epinephrine (Rx asthma, croup)  α-agonist effect: reduces bronchial secretions & mucosal edema  β-agonist effect: smooth muscle relaxation --------------------------------------------------------------- fibromuscular dysplasia: non-inflammatory, non-atherosclerotic condition; women age < 50  abnormal development of arterial wall  primarily affect renal arteries  HTN  involvement of carotid or vertebral arteries cause TIA, amaurosis fugax, stroke, headache, dizziness  secondary hyperaldosteronism 2/2 decreased perfusion to kidneys (aldosterone: renin ratio < 20)  Dx: abdominal CT angiography or duplex USS  Rx: angioplasty with stent placement o Rx: ACE-I if poor surgical candidate  ACE-I is C/I in B/L renal artery stenosis --------------------------------------------------------------- painful non-itchy pustules & honey-crust lesions on mouth, nose, & neck: non-bullous impetigo  MCC: S. aureus, group A Strep (S. pyogenes)  risk factors: eczema, abrasion, insect bites  no fever, no systemic symptoms  Rx: topical mupirocin  complications: post-strep GN  DDx: HSV (orolabial region), VZV, erysipelas --------------------------------------------------------------- 3+ proteinuria, hematuria, dense intramembranous deposits staining for C3: membranoproliferative glomerulonephritis  caused by IgG against C3 convertase of alternative complement pathway, leads to persistent complement activation --------------------------------------------------------------- cor pulmonale: RV failure from pulmonary HTN due to COPD, PVD, or OSA 

Findings of cor pulmonale

etiology

COPD, interstitial lung disease, pulmonary vascular disease, OSA symptom dyspnea on exertion, fatigue, lethargy, s exertional syncope, exertional angina exam peripheral edema, loud S2, JVD + prominent ‘a’ wave, RV heave, tricuspid regurgitation imaging EKG: partial/complete RBBB, RAD, RVH, RA enlargement echo: pulmonary HTN, dilated RV, tricuspid regurgitation right heart catheterization (gold std Dx): RV dysfunction, pulmonary HTN, absence of left heart disease --------------------------------------------------------------- constrictive pericarditis is an important cause of right heart failure --------------------------------------------------------------- adrenal vein sampling: Dx adrenal hyperplasia vs. adenoma (primary hyperaldosteronism)  aldosterone > 15; aldosterone:renin ratio > 20 --------------------------------------------------------------- symptoms of CAD can be unmasked or worsened with thyrotoxicosis Cardiovascular effects of thyrotoxicosis rhythm sinus tachycardia, PACs, PVCs a-fib hemodynamics systolic HTN,  pulse pressure,  contractility & C.O.,  SVR,  myocardial O2 demand heart failure high-output failure angina coronary vasospasm, anginal symptoms in pre-existing coronary atherosclerosis systolic HTN in thyrotoxicosis is due to hyperdynamic circulation from  contractility  hypothyroidism causes HTN due to  SVR --------------------------------------------------------------- thiazide A/E: hyperglycemia,  LDL & TGs, hyponatremia, hypokalemia, hypercalcemia, uric acid retention (risk of acute gout) ---------------------------------------------------------------

arrest of labor in stage 1: ≥ 6 cm with ROM & no cervical changes for ≥ 4 hr despite adequate, OR no change ≥ 6 hr & inadequate contractions o Rx: c-section  protracted labor: slower than expected progress Stages of labor 1 latent 0 – 6 cm dilated active 6 – 10 cm dilated (complete) 2 10 cm dilated  delivery 3 delivery  placenta expulsion --------------------------------------------------------------- bloody/purulent nasal discharge, oral ulcers, sinusitis, dyspnea, hemoptysis, renal insufficiency, microscopic hematuria, RBC casts: Wegener’s  granulomatosis with polyangiitis  URI & lower respiratory infections & RPGN  CXR: nodular densities & alveolar/pleural opacities  Dx: c-ANCA & tissue Bx  Rx: high-dose corticosteroids & cyclophosphamide --------------------------------------------------------------- unilateral, intermittent bloody nipple discharge: intraductal papilloma  benign, no palpable masses (too small)  MC in perimenopausal --------------------------------------------------------------- painful, rubbery, firm breast mass with cyclic symptoms with menstruation: fibrocystic change o premenopausal women o Dx/Rx: aspiration shows clear fluid, mass disappears, observe for 4 – 6 wks o biopsy if the mass recurs  painless, firm, mobile, solitary breast lump in women age 15 – 25: fibroadenoma  nipple discharge, breast mass, or incidental finding on mammography: DCIS o postmenopausal  eczematous nipple changes & discharge: Paget’s --------------------------------------------------------------- scleroderma renal crisis: acute onset renal failure (w/o previous kidney disease) & malignant HTN (headache, blurry vision, nausea)  microangiopathic hemolytic anemia with schistocytes & thrombocytopenia  Rx: ACE-I 

---------------------------------------------------------------Antiphospholipid antibody syndrome clinical arterial/venous thrombosis (VTE, PE) pregnancy… o ≥ 3 consecutive unexplained fetal loss before 10th wk o ≥ 1 unexplained fetal loss after 10th wk o ≥ 1 premature birth of normal neonate before 34th wk due to preeclampsia, eclampsia or placental insufficiency labs  lupus anticoagulant  anti-cardiolipin antibody  anti-β2-glycoprotein 1 antibody Dx 1 clinical & 1 lab criterion  lupus anticoagulant: prolongs PTT in vitro --------------------------------------------------------------- young female, decreased visual acuity in one eye, pain on eye movement, change in color perception: optic neuritis  afferent pupil defect & central scotoma  DDx: orbital cellulitis, anterior uveitis --------------------------------------------------------------- anterior uveitis: unilateral eye is painful & red  blurred vision, perilimbal injection  keratic precipitates & corneal stromal edema --------------------------------------------------------------- splenomegaly, pruritus with hot baths due to histamine release: polycythemia vera  myeloproliferative disorders are common causes of uric acid overproduction;  purine catabolism o gouty arthritis is a common manifestation ---------------------------------------------------------------Vasovagal syncope inciting age < 60: emotional stress, orthostatic stress events (prolonged standing, venipuncture) age > 60: micturition, cough, defecation feature prodrome pallor, dizziness, nausea, sweating s short duration of syncope (minutes) symptoms improve in supine position Dx mainly clinical upright tilt table test if uncertain Rx self-limited; avoid triggers ----------------------------------------------------------------

Rx for a single episode of major depression: continue for 6 months following patient response  multiple episodes Rx: maintenance therapy ---------------------------------------------------------------Asbestosis  occupational (shipyard, construction, mining, pipes)  latency period: > 20 yrs  progressive dyspnea (months), clubbing, bibasilar end-expiratory crackles (no cough, sputum, or wheezing)  risk for lung cancer & malignant mesothelioma  CXR: benign pleural plaques, interstitial fibrosis   DLCO, PFT: restrictive pattern  complication: cor pulmonale (RV heave) ---------------------------------------------------------------Enzyme deficiencies 21-hydroxylase (CAH)  cortisol & aldosterone ambiguous genitalia (girls) salt waste ( Na+,  K+)  testosterone hypotension 17-OH-progesterone 11β- hydroxylase  cortisol & aldosterone ambiguous genitalia (girls) fluid & Na+ retention,  testosterone  11-deoxycorticosterone HTN (weak mineralocorticoid) 17α-hydroxylase  cortisol & testosterone all phenotypic female fluid & Na+ retention,  mineralocorticoids HTN  corticosterone hypogonadism @ puberty (weak glucocorticoid) 

classic CAH Dx:  17-OH-progesterone partial deficiency of 21-hydroxylase present in childhood: non-classic CAH o precocious puberty, hirsutism/virilism, medication-resistant acne, accelerated growth o Dx: cosyntropin stimulation test (gold std)  licorice is known to inhibit 11β- hydroxylase; chronic consumption can result in pseudohyperaldosteronism --------------------------------------------------------------- post-operative pneumonia deteriorating into septic shock with lactic acidosis 2/2 tissue hypoxia  Rx: IV normal saline, ABX --------------------------------------------------------------- 

external validity: how generalizable are results to other populations?  internal validity: are results in this specific cohort valid? (design, method, analysis) ---------------------------------------------------------------Vaccines for adults with HIV HAV chronic liver disease (HBV, HCV) men/men sex, IVDA HBV all unimmunized to HBV HPV all age 9 – 26 influenza all annually (IM inactivated) all age 11 – 18 meningococcu large groups in close quarters, s asplenia or complement deficiency pneumococcus PCV13 once, then… PPSV23, 8 wks later & every 5 yrs Td, Tdap Tdap once, then Td every 10 yrs Tdap for each pregnancy 

live vaccines (MMR, varicella, intranasal influenza, zoster) are C/I for CD4 < 200  MMR should be given if CD4 > 200 & no evidence of immunity o HIV+ are at increased risk for measles --------------------------------------------------------------- vaccinate ≥ 14 days before or after splenectomy Vaccines for asplenic adults pneumococcus sequential PCV13, then PPSV23; PPSV23 again in 5 yrs & age 65 H. influenza 1x Hib vaccine meningococcu quadrivalent vaccine every 5 yrs s influenza IM inactivated vaccine annually others HAV, HBC, Tdap 1x, Td every 10 yr  S. pneumo is MCC of sepsis post-splenectomy --------------------------------------------------------------- late-term pregnancies (41 – 42 wks)  risk for uteroplacental insufficiency  antenatal fetal surveillance begin @ 41 wks: BPP  diffuse placental calcifications on USS are common in late-term; indicates a mature placenta --------------------------------------------------------------- D-dimer: product of cross-linked fibrin degradation ---------------------------------------------------------------

monosymptomatic (isolated) enuresis: urinary incontinence > 2x/wk in age ≥ 5 yrs  workup: U/A; imaging for +daytime symptoms or recurrent UTIs  #1 Rx: behavior modification, enuresis alarm  #2 Rx: (short-term) desmopressin; alt Rx: TCAs --------------------------------------------------------------- acute onset severe liver injury with encephalopathy & INR > 1.5, without cirrhosis or underlying liver disease: fulminant hepatitis  acute liver failure: MCC are acute viral hepatitis, acetaminophen toxicity, ischemic hepatopathy (“shock liver”), Wilson’s o concurrent alcohol use increases propensity of hepatotoxicity from acetaminophen  RUQ pain, pruritus, jaundice, encephalopathy  acute  AST & ALT (1000s),  PTT,  bilirubin  decreasing aminotransferases & worsening PT/INR, indicates progressive liver failure  PT is the most important prognostic indicator ---------------------------------------------------------------Intrapartum fetal HR monitoring Early fetal head compression can be normal Late uteroplacental insufficiency Variable cord compression, cord prolapse, oligohydramnios 

intermittent variable decelerations (< 50%) are well tolerated by the fetus; does not require a change in management  recurrent variable decelerations (> 50%) are concerning for fetal academia; prompt intervention o #1 Rx: O2 & change maternal position o discontinue uterotonic drugs o #2 Rx: artificial ROM & amnioinfusion o #3 Rx: c-section --------------------------------------------------------------- terbutaline: β2-agonist tocolytic  Rx tachysystole (> 5 contractions in 10 min) ---------------------------------------------------------------Rhabdomyolysis  MCC: cocaine overdose, tonic-clonic seizures  rhabdomyolysis releases K+, CPK, & myoglobin 

 CPK is a/w acute tubular necrosis due to myoglobinuria  U/A: +blood, but no RBCs on microscopy  Rx: hydration, mannitol, urine alkalinization o avoid β-blockers: unopposed α activation worsens HTN & causes coronary vasospasm --------------------------------------------------------------- aseptic meningitis MCC: Coxsackie or Echovirus ---------------------------------------------------------------Management of acute STEMI o supplemental O2 (if O2 Sat < 90%) o chewed ASA o clopidogrel o sublingual nitrate (not for RV infarct, hypotensive, severe aortic stenosis) o metoprolol (not for hypotensive, bradycardia, decompensated CHF, heart block) o high-dose statin o LMWH or unfractionated heparin  persistent pain, HTN, or heart failure: IV nitro (not for hypotension, RV infarct, severe AS)  persistent severe pain: IV morphine (anxiolytic & preload reduction)  unstable sinus bradycardia: IV atropine  acute pulmonary edema: IV furosemide (not for hypotensive or hypovolemic)  reperfusion: PCI within 90 min; thrombolysis if PCI not available within 120 min ---------------------------------------------------------------Guidelines for primary PCI of acute STEMI  within 12 hr of symptom onset, AND  within 90 min of first medical contact to device time at PCI-capable facility, OR o within 120 min at non-PCI-capable facility --------------------------------------------------------------- fibrinolytics is a/w  recurrent MI, ICH, mortality compared to PCI --------------------------------------------------------------- headaches worse at night, N/V,  LOC, cognitive dysFx, vision changes, worse with maneuvers that  ICP (leaning forward, Valsalva, coughing): intracranial HTN  Cushing reflex: HTN, bradycardia, resp depressn; suggests brainstem compression 

DDx: sinusitis (purulent nasal discharge), acute angle closure glaucoma, temporal arteritis --------------------------------------------------------------- oliguria, azotemia & BUN/Cr > 20:1 in post-op: acute prerenal failure from hypovolemia  #1: rule out urinary catheter obstruction  Dx: IV fluid challenge --------------------------------------------------------------- low-dose dopamine infusion can dilate renal arterioles   GFR & urine output (temporary) ---------------------------------------------------------------Chronic Hep C strongly a/w…  porphyria cutanea tarda (photosensitivity, vesicles/erosions on dorsum hand)  essential mixed cryoglobulinemia (circulating immune complexes deposit in small/med vessels) o IgM complexes with anti-hepatitis C IgG o vasculitis of skin, kidney, nerves, joints  membranoproliferative GN ---------------------------------------------------------------Chronic Hep C features  fatigue, arthralgia, Raynaud’s  low complement  intermittent elevations of AST/ALT,  RF  Dx: viral hepatitis serology  confirm Dx: kidney/skin Bx  Rx: plasmapheresis (cryoglobulins), glucocorticoids & cyclophosphamide  complications: cirrhosis & HCC ---------------------------------------------------------------MCC of nephrotic syndrome focal segmental African-Am & Hispanics, glomerulosclerosis obesity, HIV, heroin use membranous adenocarcinoma (breast, nephropathy lung), NSAIDs, Hep B, SLE membranoproliferativ Hep B & C e glomerulonephritis minimal change adults: NSAIDs, lymphoma disease (Hodgkin’s) IgA nephropathy upper URI 

 secondary: diabetes & primary amyloidosis (MM) ---------------------------------------------------------------MCC of nephritic syndrome  IgA nephropathy

 rapidly progressive GN  thin BM disease  lupus nephritis (low complement)  post-streptococcal GN (low complement)  membranoproliferative GN (low complement)  mixed cryoglobulinemia (low complement) --------------------------------------------------------------- atypical presentations of ACS: N/V, dyspnea, epigastric pain; MC in women, elderly, diabetics  initial evaluation: EKG  DDx: acute cholecystitis, pancreatitis, PUD --------------------------------------------------------------- hilar mass, mediastinal adenopathy, cough, dyspnea, weight loss: small cell lung cancer Paraneoplastic syndromes a/w lung cancer endocrine SIADH** PTHrP (hypercalcemia) ACTH (Cushing’s)** hematologic hypercoagulability (Trousseau’s) neurologic Lambert-Eaton** ataxia, autonomic/sensory neuropathy MSK hypertrophic osteoarthropathy (a/w adenocarcinoma) dermatomyositis & polymyositis **a/w small cell lung cancer Trousseau's: spontaneous recurrent or migratory venous thromboses, arterial emboli caused by non-bacterial thrombotic endocarditis --------------------------------------------------------------- shoulder pain & weakness with arm lifting: rotator cuff pathology (tendonitis or tear)  limited mid-arc abduction & external rotation  Dx: lidocaine injection o improvement = tendonitis/impingement o no improvement = tear  Dx rotator cuff tear: drop arm test, shoulder MRI o MCC: fall on outstretched hands --------------------------------------------------------------- nephrosclerosis 2/2 HTN  atherosclerotic lesions of afferent & efferent arterioles & glomerular capillary tufts  nephrosclerosis  glomerulosclerosis 

nephrosclerosis = hypertrophy & intimal medial fibrosis of renal arterioles o glomerulosclerosis = progressive loss of glomerular capillary surface area with glomerular & peritubular fibrosis --------------------------------------------------------------- diabetic nephropathy: #1 cause of ESRD  1st year:  GFR, glomerular hyerperfusion, renal hypertrophy  extracellular matrix, BM thickening, mesangial expansion, & fibrosis  5 – 10 yrs: microalbuminuria, overt nephropathy --------------------------------------------------------------- hypoparathyroidism (PTH deficiency): hypoCa++, hyperphosphatemia, normal renal function  hypoCa++: perioral tingling/numbness, tetany, cramps, carpopedal spasm, seizures  causes: post-surgical, autoimmune, DiGeorge, defective Ca++-sensing receptors, irradiation --------------------------------------------------------------- phenytoin, carbamazepine, rifampin can cause Vit D deficiency by inducing p450  resulting in secondary hyperparathyroidism: hypoCa++, hypophosphatemia --------------------------------------------------------------- CKD impairs 1-α-hydroxylase, which converts 25-OH Vit D to 1,25-OH Vit D  Vit D deficiency  resulting in secondary hyperparathyroidism: hypoCa++, hyperphosphatemia --------------------------------------------------------------- inadequate Ca++ intake  20 hyperparathyroidism   bone resorption   Ca++   25-OH Vit D to 1,25-OH Vit D, which stimulates gut Ca++ absorption  renal phosphate loss  hypophosphatemia --------------------------------------------------------------- weight loss, anorexia, constipation, easy fatigue, dry mucous membranes, confusion, polyuria  hypercalcemia induces urinary Na+ wasting, resulting in volume depletion, further impairing renal clearance of Ca++ o

Management of hypercalcemia severe short-term: aggressive hydration; (Ca++ > 14) normal saline & calcitonin

or symptomatic

long-term: bisphosphonate (zoledronate) moderate no immediate Rx unless (12 – 14) symptomatic (same as above) mild (< 12) or no immediate Rx asymptomatic avoid thiazides, lithium, volume depletion & prolonged bed rest  saline hydration restores intravascular volume & promotes urinary Ca++ excretion  loop diuretics only if volume overloaded o avoid diuretics if volume-depleted --------------------------------------------------------------- hyperthyroidism-related tachysystolic a-fib  Rx: propranolol --------------------------------------------------------------- atypical community-acquired pneumonia with CNS & GI features: Legionnaires’  fever with relative bradycardia  intracellular G-negative rod  CXR: unilateral patchy infiltrates  Dx: urine antigen testing & culture  Rx: fluoroquinolone or macrolide Suspicion of Legionella pneumonia exposure recent travel within previous 2 wks (cruise ships, hotel) nosocomial (hospital, nursing home) features fever > 39 (102.20 F) with bradycardia, confusion (CNS), watery diarrhea (GI), unilateral lung diffuse crackles labs hyponatremia, mild hepatitis, hematuria, proteinuria CXR: unilateral interstitial infiltrates Gram stain: neutrophils, no organisms Dx urine antigen testing & culture Rx: fluoroquinolones  Legionella stains poorly; intracellular  DDx: influenza, mycoplasma, PCP, TB --------------------------------------------------------------- amoxicillin/clavulanate: Rx sinusitis, otitis media  ceftriaxone: Rx pneumococcus, H. influenza  clindamycin: Rx aspiration pneumonia  vancomycin: Rx nosocomial pneumonia (MRSA) --------------------------------------------------------------- PPV & NPV depend of prevalence of a disease

shifting the cutoff point to the left: &  FP will decrease PPV (PPV = TP/ (TP + FP)) --------------------------------------------------------------- selective survival bias occurs in case-control studies; cases are selected from the entire disease population instead of newly diagnosed (cancer) --------------------------------------------------------------- strongest predictor of AAA expansion & rupture: active smoking  other risks: large diameter & rate of expansion o HTN has a weak association  indications for AAA repair… o > 5.5 cm o expansion rate > 1 cm/yr o symptomatic (regardless of size) --------------------------------------------------------------- MC complication of AAA repair: bowel ischemia  due to inadequate colonic collateral perfusion to left colon & sigmoid 2/2 loss of IMA perfusion  presents with abdominal pain & bloody diarrhea  Rx: check sigmoid perfusion after graft placement --------------------------------------------------------------- morphine contributes to post-op ileus by decreasing GI motility o post-op ileus: hypoactive/absent bowel sounds  mechanical obstruction: hyperactive BS --------------------------------------------------------------- child with meningeal signs & erythematous petechial/purpuric rash: N. meningitides (meningococcal meningitis)  rash appears within 24 hr of infection --------------------------------------------------------------- HSV causes temporal lobe encephalitis in neonates & infants; presents with seizures --------------------------------------------------------------- causes of anatomic defects in the uterus or fallopian tubes: Hx of PID, in utero DES, endometriosis, congenital malformations  Dx: hysterosalpingogram --------------------------------------------------------------- elevated serum prolactin suppresses ovulation by inhibiting GnRH release  amenorrhea --------------------------------------------------------------- mid-luteal serum progesterone tests for ovulation  ovulation  corpus luteum produces progesterone 

--------------------------------------------------------------- excess androgens in PCOS suppress ovulation by suppressing GnRH & FSH by feedback inhibition --------------------------------------------------------------- inhibin B: use to determine ovulatory reserve;  with declining reserves --------------------------------------------------------------- MCC of acute pancreatitis: alcohol, gallstones  others: hypertriglyceridemia, hypercalcemia, recent ERCP, trauma, viral infection, medications  eruptive xanthomas  Dx: fasting lipid profile o triglycerides > 1000 causes pancreatitis --------------------------------------------------------------- club foot Rx: stretching, manipulation, serial casts  surgery if conservative management fails --------------------------------------------------------------- acute urticaria (< 6 wks)  well-circumscribed, raised erythematous plaques with central pallor; intense pruritus  worsen over minutes – hrs; resolve within 24 hr  mast cell activation in superficial dermis, which  histamine release  pruritus & swelling  angioedema can occur in deep dermal & SC tissues  MCC: IgE mediated, direct mast cell activation, NSAIDs, infection, idiopathic --------------------------------------------------------------- atopic dermatitis (eczema): pruritic erythematous, scaly patches on extensor surfaces  epidermal dysfunction of stratum corneum synthesis  MC in infancy; cheeks, scalp, extensor limbs  MC site (adults): flexural areas, face, wrist, forearm o lichenified plaques on flexural creases  risk factors: low humidity, stress, overheating, excessive bathing, irritants  complication: eczema herpeticum, cellulitis/abscess --------------------------------------------------------------- eczema herpeticum: HSV superinfection in areas of severe atopic dermatitis (eczema) o numerous umbilicated vesicles over erythematous skin o a/w fever & adenopathy o Rx: acyclovir  erysipelas: red, indurated, tense, shiny plaque with raised, sharply demarcated margin

o a/w fever & chill o MCC: Group A strep --------------------------------------------------------------- contact dermatitis: direct skin exposure to irritant  erythematous papules & vesicles; indistinct margins  Type IV hypersensitivity  vesicular fluid can be 20 infected by Strep or Staph --------------------------------------------------------------- chronic follicular occlusive disease on intertriginous skin (axilla, groin) with painful nodules & sinus tracts: suppurative hidradenitis --------------------------------------------------------------- erythema multiforme: target lesions with erythematous, iris-shaped macules  painful, pruritic, symmetrical on extensors, including palm/soles  a/w HSV, coccidiomycosis, Mycoplasma --------------------------------------------------------------- pityriasis rosea: self-limited, cutaneous reaction following a viral etiology  papulosquamous rash of oval-shaped lesions whose long axes are oriented along skin folds ('Christmas tree' pattern); trunk & proximal extremities  initial lesion: pink to salmon-colored 'herald' patch plaque with raised margin & collarette scale, with eruption into scaly & ovoid papules & plaques on the back or flexor surfaces --------------------------------------------------------------- infant with failure to thrive, normal anion gap acidosis, & alkalotic urine: renal tubular acidosis o Type I RTA: poor K+ & H+ excretion  a/w nephrolithiasis o Type II RTA: poor HCO3 resorption  a/w Fanconi’s o Type IV RTA: aldosterone resistance  a/w CAH (hyperkalemic, hyperchloremic metabolic acidosis)  labs: low serum HCO3 & hyperchloremia, leads to normal anion gap metabolic acidosis  Rx: oral sodium bicarbonate --------------------------------------------------------------- fluphenazine: typical antipsychotic, injection  A/E: hypothermia by inhibiting autonomic thermoregulation  Rx: avoid prolonged cold exposure

--------------------------------------------------------------- congenital syphilis: transplacental transmission  XR: metaphyseal dystrophy & periostitis  initially asymptomatic  early sign: cutaneous palm/sole lesions, rhinorrhea, hepatosplenomegaly, jaundice, anemia  late findings (age > 2 yr): frontal bossing, Hutchinson teeth, high arched palate, saddle nose, interstitial keratitis, perioral fissures --------------------------------------------------------------- scaphoid fx: MCC is fall on outstretched arm  proximal fragment vulnerable to avascular necrosis  XR can take up to 10 days to show abnormalities  Rx: thumb spica 6 – 10 wks, repeat XR in 1 wk --------------------------------------------------------------- glucosuria, phosphaturia, aminoaciduria: Fanconi syndrome --------------------------------------------------------------- 2 day Hx of periorbital swelling, skin infection 3 wks ago (Rx: dicloxacillin), dark urine, HTN  U/A: RBC casts & mild proteinuria  labs: low C3  Dx: post-strep GN --------------------------------------------------------------- hematuria 5 days after URI, normal C3: IgA nephropathy --------------------------------------------------------------- fever, rash, arthralgia; hematuria, sterile pyuria, peripheral eosinophilia, medication use (NSAIDs, sulfonamides, PCN, cephalosporins, diuretics): acute interstitial nephritis  U/A: WBC casts, eosinophiluria, mild proteinuria --------------------------------------------------------------- likely PE based on modified Wells criteria o confirm Dx: CT angiography: filling defect  unlikely PE criteria  evaluate with D-dimer o D-dimer < 500 excludes PE o D-dimer > 500  CT angiography --------------------------------------------------------------- COPD: progressive  in expiratory flow rate; FEV1/FVC < 0.7  air trapping & airflow obstruction   TLC,  vital capacity  destruction of alveolar-capillary membrane ----------------------------------------------------------------

COPD: chronic bronchitis +/- emphysema long-term supplemental O2 prolongs survival indications: PaO2 < 55, SaO2 < 88%, Hct > 55%, or evidence of cor pulmonale or pulmonary HTN  survival benefits if used for ≥ 15 hrs/day --------------------------------------------------------------- cellulitis MCC: β-hemolytic strep & S. aureus  systemic signs: high fever, chills, malaise, fatigue, confusion  Rx (+systemic signs): IV nafcillin or cefazolin  Rx (no systemic signs): oral dicloxacillin  chronic fungal foot infections (tinea pedis) can be a nidus for recurrent bacterial cellulitis o Rx: itraconazole, terbinafine --------------------------------------------------------------- acyclovir nephrotoxicity: acyclovir accumulation in collecting ducts exceed solubility  crystalluria  MC with high-dose IV acyclovir  Rx: adequate hydration & dosage adjustment --------------------------------------------------------------- hypothyroidism can cause… o hyperlipidemia & hypercholesterolemia o hyponatremia ( free water clearance) o asymptomatic  creatinine kinase,  ALT/AST --------------------------------------------------------------- hypothyroidism & adrenal insufficiency must be ruled out before Dx of SIADH --------------------------------------------------------------- thyrotoxicosis can cause hypercalcemia due to  bone resorption --------------------------------------------------------------- bulimia: binging at least 2x/wk, 3 months o no amenorrhea  binge-eating disorder: no compensatory behavior to prevent weight gain (purging) ---------------------------------------------------------------Interstitial cystitis (painful bladder syndrome) epidemiolog women, a/w psychiatric disorders y (anxiety) & fibromyalgia features pain with filling, relief with voiding chronic pelvic pain  frequency, urgency, dyspareunia Dx bladder pain, no other cause ≥ 6 wks normal U/A   

Rx

not curative; focus on quality of life, behavior modification, avoid triggers, amitriptyline analgesics for exacerbations  DDx: cystocele, PID, stress incontinence, UTI ---------------------------------------------------------------Acetaminophen intoxication  first 24 hrs, can be asymptomatic  single dose ≥ 7.5 g & ≤ 4 hr since ingestion o Rx: activated charcoal & check serum levels  nomogram showing hepatotoxic levels o Rx: N-acetylcysteine o non-toxic levels  repeat levels in 2 hr --------------------------------------------------------------- cough with blood-tinged sputum: TB  highest risk: emigration from endemic area --------------------------------------------------------------- ARPKD: infant with large flank mass, respiratory distress from pulmonary hypoplasia, Potter facies  ADPKD: asymptomatic in childhood ---------------------------------------------------------------Management of severe hematochezia (lower GI bleed)  initial evaluation: NGT aspiration o +blood, +/- bile  upper endoscopy o no blood, +bile  colonoscopy  if bleed continues  Technitium-99 labeled RBC scintigraphy is less invasive, more sensitive than arteriogram o if RBC scan identifies bleed, follow up with angiography or repeat colonoscopy  capsule endoscopy: Dx chronic GI bleed with negative upper & lower endoscopy --------------------------------------------------------------- vesicoureteral reflux Dx: voiding cystourethrogram  screen for hydronephrosis: renal USS  long-term eval for scarring: renal scintigraphy  evaluate renal function: serial Cr --------------------------------------------------------------- Hep C is a risk factor for cirrhosis, HCC, cryoglobulinemia, membranoproliferative GN --------------------------------------------------------------- Burr cells (echinocytes): speculated, serrated RBCs o MC in liver disease & ESRD  Spur cells (acanthocytes): irregular RBC projections

o MC in liver disease Howell-Jolly: basophilic remnants of nuclei o Hx of splenectomy or functional asplenia  Target cells: bull’s eye RBC o thalassemia, chronic liver disease, alcoholics --------------------------------------------------------------- medication-induced torticollis: metoclopramide, typical antipsychotics, prochlorperazine --------------------------------------------------------------- MCC of acquired torticollis: URI, minor trauma, cervical lymphadenitis, retropharyngeal abscess  Dx: XR to r/o cervical fx or dislocation --------------------------------------------------------------- erectile dysfunction in diabetics can be due to autonomic neuropathy, medications, circulation, or hypogonadotropic hypogonadism o gynecomastia, testicular atrophy  Dx: early-morning total testosterone; all diabetics  Dx: serum prolactin  excess prolactin suppresses GnRH  Rx: sildenafil (diabetics, normal testosterone) --------------------------------------------------------------- acquired hypogonadotropic hypogonadism 2/2 hypothalamic dysfunction  insufficient GnRH pulses,  LH & FSH only  amenorrhea, irregular menses  MCC: significant stressor, eating disorder, excessive exercise  #1 Rx: reduce stress & exercise intensity  #2 Rx: pulsatile GnRH --------------------------------------------------------------- respiratory distress, tachycardia, tachypnea, fever, upper petechial rash, sub-conjunctival hemorrhage, multiple long bone fx,: fat embolism  12 – 72 post-injury  CNS: confusion, agitation  stupor, coma  Dx: fat droplets in urine or intra-arterial fat globules on fundoscopy  Rx: respiratory support --------------------------------------------------------------- chronic non-healing wound (burns) with scarred or inflamed skin: squamous cell ca  SCC arising within burn wounds: Marjolin ulcer  Dx: Bx to r/o malignancy 

DDx: malignant melanoma, dysplastic nevi, BCC, actinic keratosis --------------------------------------------------------------- Hx of recurrent unexplained DVTs  Dx: factor V Leiden mutation is resistant to protein C inactivation --------------------------------------------------------------- increased dead space ventilation in COPD worsens respiratory acidosis  chronic hypercapnic respiratory failure in COPD maintains a normal pH due to renal compensation ( HCO3 retention) --------------------------------------------------------------- MCC euvolemic hypernatremia: diabetes insipidus  dilute urine, elevated serum osmolality --------------------------------------------------------------- isolated systolic HTN:  elasticity  increases CV risk in elderly  Rx: monotherapy with low-dose thiazide, ACE-I, or long-acting CCB --------------------------------------------------------------- circulating BNP correlates with severity of LV filling pressure & mortality; a/w S3 --------------------------------------------------------------- +Anti-HBs, +Anti-HBc, -HBsAg: resolved HBV  +Anti-HBs only: HBV vaccinated  +IgM anti-HBc: window phase  HBsAg: first marker; precedes symptoms  HBcAg: not detectable  +HBsAg, +IgG anti-HBc > 6 months: chronic HBV --------------------------------------------------------------- B/L proptosis & impaired extraocular motion (decreased convergence, diplopia), exophthalmos: Graves’ ophthalmopathy  also gritty/sandy sensation, photophobia, tearing  infiltrative ophthalmopathy from accumulation of glycosaminoglycans in retro-orbital muscles, leads to proptosis (specific to Graves’)  risk factors: females, advanced age, smoking  anti-thyrotropin receptor auto-antibodies directly cause retro-orbital tissue expansion --------------------------------------------------------------- bacterial meningitis Rx: IV ceftriaxone & vanco  CSF:  WBC (neutrophil predominance), low glucose, elevated protein 

--------------------------------------------------------------- MCC of atrial flutter: reentrant circuit around tricuspid annulus, slows the impulse through the cavotricuspid isthmus  MC location of ectopic foci causing a-fib: pulmonary veins (myocardial sleeve)  AVNRT: reentrant circuit by 2 separate pathways within the AV node  AVRT: reentry circuit via accessory bypass tract --------------------------------------------------------------- lung cancer & malignant melanoma can present with multiple brain metastases  MC site of brain metastases: lung cancer  Dx: chest CT --------------------------------------------------------------- mitral regurgitation:  murmur with squatting  MVP:  murmur intensity with squatting --------------------------------------------------------------- preoccupation with a slight or imagined defect, significant impairment: body dysmorphic disorder  related to OCD, with repeated thoughts & compulsive behavior to hide or “treat” the defect  Rx: therapeutic alliance, psychotherapy, SSRI --------------------------------------------------------------- COPD patient with catastrophic worsening of respiratory symptoms: spontaneous pneumoTx  risk factor: smoking leads to chronic destruction of alveolar sacs, forming large alveolar blebs which eventually rupture & leak into pleural space ---------------------------------------------------------------Evaluation of bilious emesis  #1 Rx: stop feeds, IV fluids, NG tube  #2 Rx: abdominal XR…  if pneumoperitonium, hematemesis, unstable vitals  surgery  if dilated loops of bowel  contrast enema o microcolon  meconium ileus a/w CF o rectosigmoid transition zone  Hirschsprung  if NG tube misplaced  upper GI contrast series (barium) shows Ligament of Treitz on right side & “corkscrew” pattern  malrotation/volvulus o Rx: Ladd procedure (fixed bowel)  if ”double bubble” sign  duodenal atresia ----------------------------------------------------------------

congenital aganglionic megacolon (Hirschsprung) may be a/w Down’s  delayed passage of meconium > 48 hr  XR: dilated loops of small & large bowel  Dx: rectal biopsy show absence of ganglion cells --------------------------------------------------------------- diffuse bronchial obstruction &  purulent sputum: acute exacerbation of COPD o diffuse rhonchi & wheezing,  PaCO2  Dx: spirometry FEV1/FRC < 0.70 --------------------------------------------------------------- dullness to percussion, decreased breath sounds, B/L coarse crackles: CHF o due to transudative pleural effusion --------------------------------------------------------------- immobility is MCC of decubitus ulcers  MC over bony prominences; ischemic necrosis --------------------------------------------------------------- lesions on skin & viscera, abdo pain, fever, malaise, weight loss: bacillary angiomatosis o large, pedunculated exophytic papules  CT: nodular, contrast-enhanced intrahepatic lesions  Dx: tissue biopsy; prone to hemorrhage  Rx: ABX --------------------------------------------------------------- pleuritic chest pain, dyspnea, tachypnea, tachycardia, hypoxemia after immobilization Approach to suspected PE  stabilize with O2 & IV fluids  contraindications to anticoagulation?  IVC filter  assess with Modified Well’s (pretest probability)  PE likely  IV heparin, then order diagnostics o PE unlikely  CT angiogram (or V/Q scan)  +PE  anticoagulate  -PE  stop anticoagulation  early empiric anticoagulation should be initiated prior to pursuing confirmatory diagnostics in patients with likely PE  anticoagulation prevents further clotting, but does not lyse existing clots --------------------------------------------------------------- MCC of isolated aortic stenosis in elderly: age-dependent idiopathic sclerocalcific changes 

MCC of isolated aortic regurgitation in young adults in developed countries: bicuspid aortic valve  MCC of aortic regurgitation in developing country: rheumatic heart disease --------------------------------------------------------------- GVHD is common after bone marrow transplant  due to activation of donor T lymphocytes  maculopapular rash on palms & soles, face  occult-positive diarrhea, abnormal LFTs, jaundice  pulmonary: bronchiolitis obliterans --------------------------------------------------------------- activation of host T lymphocytes mediates graft rejection, resulting in depression of myelopoiesis  severe neutropenia for several days  risk of infection --------------------------------------------------------------- Reye syndrome: children age < 15 yrs  vomiting & agitation, progressing to lethargy, stupor, restlessness  hyperammonemia, hypoglycemia, prolonged PT,  bilirubin, ALP, AST/ALT, & LDH  liver Bx: microvesicular steatosis  Rx: supportive --------------------------------------------------------------- troponin T is most sensitive & specific for MI, but slow to return to normal (10 days)  CK-MB normalizes within 1 – 2 days; reinfarction ---------------------------------------------------------------C. difficile colitis risk factors recent ABX, advanced age, PPIs pathogenesis Enterotoxin A: watery diarrhea Cytotoxin B: colonic epithelial cell necrosis & fibrin deposition presentation fever, watery diarrhea, leukocytosis fulminant colitis with toxic megacolon, white/yellow pseudomembranes Dx stool toxin via PCR Rx metronidazole or oral vancomycin ---------------------------------------------------------------Causes of normal anion gap metabolic acidosis  diarrhea, laxative abuse  fistulas (pancreatic, ileocutaneous)  carbonic anhydrase inhibitors  renal tubular acidosis (RTA) 

 ureteral diversion  iatrogenic --------------------------------------------------------------- non-anion gap metabolic acidosis & hyperkalemia with mild renal dysfunction: renal tubular acidosis  aldosterone resistance  retention of H+ & K+  MC in poorly controlled diabetes --------------------------------------------------------------- diarrhea/laxatives cause hypokalemia due to K+ loss in stool &  aldosterone from volume depletion --------------------------------------------------------------- “Aldosterone Saves Sodium & Pushes Potassium” --------------------------------------------------------------- renal artery stenosis  20 hyperaldosteronism due to low kidney perfusion o hypokalemia, metabolic alkalosis, HTN --------------------------------------------------------------- GERD can be the primary trigger of asthma  all patients with asthma-like symptoms should be inquired about reflux symptoms  Dx & Rx: oral PPI --------------------------------------------------------------- most effective non-pharmacologic measure to decrease BP: weight loss  also DASH diet, low Na+, moderate alcohol --------------------------------------------------------------- supracondylar humerus fx: outstretched hand fall  MC complication: entrapment of brachial artery or median nerve --------------------------------------------------------------- proximal humerus fx: axillary nerve injury --------------------------------------------------------------- fibrates decrease triglycerides & increase HDL  no improvement in CV outcome or mortality --------------------------------------------------------------- surreptitious vomiting causes hypokalemic, hypochloremic metabolic alkalosis o hypokalemia due to  aldosterone caused by volume depletion --------------------------------------------------------------- newborns of mothers with active HBV should be passively immunized: HBV Ig & HBV vaccination o HBV Ig provides temporary protection ----------------------------------------------------------------

somatostatin & octreotide act by reducing splanchnic blood flow, inhibiting gastric acid secretion, & gastric cytoprotective effects  Rx upper GI bleed when endoscopy is unsuccessful, C/I, or unavailable; or adjunct --------------------------------------------------------------- asthma-like symptoms for several days, diffuse wheezes, fine inspiratory crackles, peripheral eosinophilia: eosinophilic pneumonia --------------------------------------------------------------- iatrogenic esophageal rupture (recent endoscopy)  #1 Dx: CXR may show left-sided pleural effusion, pneumomediastinum, & pneumoTx  confirm Dx: water-soluble contrast esophagram  Rx: surgical closure of esophagus & drainage of mediastinum within 6 hrs  complications: mediastinitis --------------------------------------------------------------- bullous pemphigoid: autoimmune blistering, triggered by medications (furosemide, NSAIDs, captopril); MC in elderly  pruritus, tense bullae & urticarial plaques with an erythematous or urticarial base  IgG & C3 linear deposits @ dermal-epidermal Jx --------------------------------------------------------------- pemphigus: autoantibodies against desmogleins  superficial, flaccid blisters; +Nikolsky sign  MC on skin & oral mucous membranes  IgG deposits between epidermal cells  antibodies against desmoglein  Rx: prednisone, MTX; azathioprine --------------------------------------------------------------- selegiline: MAO-B inhibitor  if taken with SSRI or TCA  serotonin syndrome  agitation, confusion, tachycardia, muscle rigidity ---------------------------------------------------------------  FRC prevents post-op atelectasis  atelectasis is a common complication 24 hr post-op; reduces vital capacity & FRC  moving from supine to sitting increases FRC o also chest physiotherapy, incentive spirometry, coughing, repositioning, & ambulation  opioid analgesics suppress respiratory drive ---------------------------------------------------------------

congenital long QT syndrome increases risk for syncope, TdP, & sudden death  Rx: refrain from vigorous exercise, avoid meds that prolong QT, monitor electrolytes  Rx: propranolol  symptomatics Rx: propranolol & pacemaker  C/I: sotalol (class III) prolongs QT --------------------------------------------------------------- electrolyte imbalances causing prolonged QT: hypoCa++, hypoK+, hypoMg++ --------------------------------------------------------------- greatest risk factor for cerebral palsy: prematurity o comorbidities: intellectual disability, epilepsy, strabismus, scoliosis --------------------------------------------------------------- GAD: ≥ 3 symptoms, at least 6 months o impaired sleep, poor concentration, irritability, easy fatigue, muscle tension, restlessness  #1 Rx: CBT & SSRI/SNRI  #2 Rx: benzos, buspirone o benzos: adjunct for acute anxiety o buspirone: monotherapy or with SSRIs --------------------------------------------------------------- systemic vasculitis, upper & lower airway granulomatous inflammation, glomerulonephritis: Wegener’s (granulomatosis with polyangiitis)  epistaxis, chronic purulent rhinorrhea, otitis, sinusitis, saddle nose deformity  painful subcutaneous nodules, palpable purpura, ulcerative lesions  labs: +c-ANCA,  CRP  U/A: RBC casts, proteinuria, sterile pyuria  Rx: cyclophosphamide & corticosteroids ---------------------------------------------------------------Osteoporosis risk factors  excess alcohol causes a dose-dependent risk  modifiable: low estrogen, malnutrition, low Ca++, low Vit D, glucocorticoid or anticonvulsant use, immobility, smoking, excess alcohol, low BMI  non-modifiable: advanced age, small body size, female, late menarche or early menopause, Caucasians & Asians, family Hx ---------------------------------------------------------------

child with chronic back pain, neurologic dysFx (urinary incontinence), & palpable “step-offs” in lumbosacral area: spondylolisthesis  forward slippage of vertebrae (L5 over S1)  DDx: lumbosacral strain, herniated disk, ankylosing spondylitis, epidural abscess, tumor --------------------------------------------------------------- daily alcohol intake (≥ 3 men, ≥ 2 women) can raise BP, causing refractory HTN --------------------------------------------------------------- exogenous testosterone use: gynecomastia, erythrocytosis, hepatotoxicity,  LDL,  HDL  DDx: autologous blood transfusion & EPO do not cause gynecomastia --------------------------------------------------------------- diarrhea in HIV+ patients requires stool culture, exam for ova & parasites, & test for C. difficile for Dx prior to ABX --------------------------------------------------------------- follicular conjunctivitis, corneal neovascularization with concurrent nasopharynx infection & discharge  trachoma: major cause of blindness worldwide  Chlamydia trachomatis serotypes A – C  Dx: Giemsa stain of conjunctival scrapings  Rx: topical tetracycline or oral azithromycin  complication: corneal scarring --------------------------------------------------------------- eye pain, photophobia, decreased vision, dendritic ulcer: herpes simplex keratitis  abrupt fever, proptosis, swollen eyelids, restricted EOM movements: orbital cellulitis --------------------------------------------------------------- female athletes have  GnRH & LH, resulting in estrogen deficiency o secondary amenorrhea, infertility, osteopenia, vaginal & breast atrophy ---------------------------------------------------------------Treatment of acne vulgaris comedonal closed/open comedones on face; acne minimal inflammation Rx: topical retinoid; or add salicylic, azelaic, or glycolic acid inflammatory inflamed papules (< 5 mm), acne pustules, erythema 

nodular (cystic) acne

mild Rx: topical retinoid + benzoyl peroxide moderate Rx: add topical ABX (erythromycin, clindamycin) severe Rx: add oral ABX large (> 5 cm) nodules, may form sinus tracts & scarring severe Rx: add oral ABX unresponsive: oral Isotretinoin (diminishes sebum excretion)

 benzoyl peroxide: Rx inflammatory features  isotretinoin A/E: teratogenic, hyper-TG-emia --------------------------------------------------------------- diabetic retinopathy: microaneurysms, exudates, hemorrhages, macular edema  non-proliferative: cotton-wool spots  proliferative: neovascularization  Rx: laser photocoagulation --------------------------------------------------------------- sudden, unilateral visual impairment noted upon waking, disc swelling, venous dilation & tortuosity, retinal hemorrhages, cotton-wool spots: central retinal vein occlusion --------------------------------------------------------------- smoking increases risk of macular degeneration  primary risk factor: age  grid test: straight lines appear wavy  atrophic form: multiple sores in macular region  exudative form: new blood vessels may leak, bleed, & scar the retina --------------------------------------------------------------- myasthenia gravis: normal reflexes, sensory, & coordination  symptoms seen on exertion, resolves with rest  nasal speech, difficulty chewing or swallowing --------------------------------------------------------------- vegans are at risk for low Vit D & bone loss ---------------------------------------------------------------Vaginal cancer Squamous cell Clear cell adenocarcinoma onset age > 60 age < 20 risk HPV 16 or 18, in utero exposure factors cervical dysplasia Hx, to DES

locatio n features Dx

smoking upper 1/3 wall of upper 1/3 wall of posterior vagina anterior vaginal malodorous vaginal discharge, postmenopausal or post-coital bleeding, irregular vaginal mass, plaque, or ulcer lesion biopsy

risk factors for SCC are similar to cervical cancer: smoking & HPV 16 or 18 --------------------------------------------------------------- neutrophilic crypttis is seen in UC & Crohn’s  bimodal age: 20s & 60s --------------------------------------------------------------- fever, colicky abdo pain, chronic diarrhea with bloody stool, weight loss: UC  crypt abscesses --------------------------------------------------------------- dyspnea, orthopnea, LE edema, B/L crackles, displaced apical impulse: decompensated CHF due to LV systolic dysfunction  hyponatremia parallels disease severity & independent predictor of adverse clinical outcomes  2/2  renin, NE, & ADH  free water retention & dilutional hyponatremia  Rx: fluid restriction, furosemide, & ACE-I o furosemide enhances K+ excretion --------------------------------------------------------------- anaphylaxis usually have prior exposure to the offending substance from preformed IgE to cause Type I hypersensitivity  Rx: IM epinephrine o alpha-1 increases vasoconstriction o beta-2 relax bronchial smooth muscles & decrease vascular permeability --------------------------------------------------------------- reversible cholinesterase inhibitors (donepezil, rivastigmine, galantamine) slows cognitive decline a/w Alzheimer’s ---------------------------------------------------------------Thyroid nodule evaluation  initial evaluation: TSH & USS  cancer risk factors: family Hx, childhood radiation exposure, cervical lymphadenopathy 

suspicious USS findings: hypoechoic, microcalcifications, internal vascularity  abnormal USS & +risk factors  require FNA  normal USS, no risk factors, nrml/ TSH  FNA  low TSH  iodine-123 scintigraphy o  uptake = hyperfunctional “hot” nodule = low cancer risk  Rx for hyperthyroidism o  uptake = hypofunctional “cold” nodule = high cancer risk  FNA --------------------------------------------------------------- AV block in patients with infective endocarditis is suspicious for perivalvular abscess extending into adjacent cardiac conduction tissues  aortic valve endocarditis & IVDA is a/w risk of periannular extension of endocarditis --------------------------------------------------------------- mitral valve perforation is a complication of mitral endocarditis  presents as acute CHF & mitral regurgitation --------------------------------------------------------------- insoluble renal crystal deposition resulting in acute renal failure: hyperuricemia, indinavir, acyclovir, sulfonamides ---------------------------------------------------------------“SPIKES” for delivering bad news  Set up situation: privacy, include participants  Perception: open-ended questions to assess patient perception of the situation  Invitation: ask how much info is wanted  Knowledge: give bad news in simple, straightforward language  Empathy: use empathetic statements  Strategy: summarize & make a plan --------------------------------------------------------------- secondary malignancy is common in patients with Hx of Hodgkin’s treated with chemotherapy & radiation within 20 yrs  MC secondary solid tumor: lung o cough, hemoptysis, chest pain, dyspnea  also risk of subsequent acute leukemia & non-HL --------------------------------------------------------------- aspergilloma: a/w pre-existing lung cavity 2/2 TB, sarcoidosis, bronchial cysts, & neoplasms  mobile, intra-cavitary mass with air crescent ---------------------------------------------------------------

diverticula: high intraluminal pressure causes mucosa & muscularis mucosa to herniate  do not include all bowel layers: false diverticula  MC risk factor: chronic constipation  MC site: sigmoid; bleeds occur from right colon --------------------------------------------------------------- discrete skin nodule containing normal epidermis, produces keratin: epidermal inclusion cyst  dome-shaped, firm, freely mobile with a central punctum  Rx: resolves spontaneously, but can recur  Rx: excision for cosmetic reasons --------------------------------------------------------------- benign, painless subcutaneous mass with overlying epidermis; soft/rubbery & irregular: lipoma --------------------------------------------------------------- episodes of apnea precipitated by emotional trigger in age 6 months – 2 yrs: breath-holding spell  cyanotic-type: crying followed by breath-holding in forced expiration, apnea, limpness, LOC o brief episodes with rapid return to baseline  pallid-type: triggered by minor trauma followed by LOC, breath-holding, pallor, diaphoresis o brief episode, then confusion & sleepiness  a/w iron deficiency anemia  Dx: CBC, serum ferritin  Rx: reassurance; no long-term sequelae ---------------------------------------------------------------HBV Treatments  interferon-alpha: short-term Rx; young patients with compensated liver disease  lamivudine: increasing drug resistance  entecavir: use in decompensated cirrhosis; lower rate of drug resistance  tenofovir: most potent, limited drug resistance --------------------------------------------------------------- pegylated interferon & ribavirin: Rx HCV  add teleprevir for chronic Hep C --------------------------------------------------------------- male with dysuria, pyuria, urinary frequency & urgency, mucopurulent urethral discharge: chlamydial urethritis  negative Gram stain & culture: C. trachomatis Dx: nucleic acid testing of first-catch urine 

Rx: azithromycin or doxycycline DDx: gonococcal urethritis (G-negative cocci), acute bacterial cystitis --------------------------------------------------------------- erythematous & edematous cutaneous plaque with “peau d’ orange” overlying breast mass with spontaneous discharge & axillary lymphadenopathy: inflammatory breast carcinoma  Dx: biopsy for histology --------------------------------------------------------------- child with macrocytic anemia, low reticulocyte count, & congenital abnormalities: Diamond-Blackfan syndrome (congenital hypoplastic anemia) o intrinsic defect of erythroid progenitor cells result in increased apoptosis  macrocytic: no hypersegmentation of nucleus  congenital abnormalities: short stature, webbed neck, cleft lip, shield chest, triphalangeal thumb  Rx: corticosteroids --------------------------------------------------------------- café-au-lait spots, microcephaly, microphthalmia, short stature, horseshoe kidney, absent thumbs, progressive pancytopenia & macrocytosis in a child: Fanconi’s anemia --------------------------------------------------------------- cancer-related anorexia/cachexia syndrome: hypercatabolic state a/w accelerated loss of skeletal & adipose tissue  Rx: progesterone analogs (megestrol acetate, medroxyprogestone acetate) o  appetite, weight gain, & well-being o alt Rx: mirtazapine (TCA) --------------------------------------------------------------- seizures, mental retardation, port wine stain or nevus inflammeus along trigeminal nerve: Sturge-Weber  hemianopia, hemiparesis, hemisensory loss, ipsilateral glaucoma  skull XR: tramline intracranial calcifications  DDx: tuberous sclerosis (adenoma sebaceum) ---------------------------------------------------------------Indications for urgent dialysis (AEIOU) Acidosis metabolic acidosis (pH < 7.1) Electrolytes symptomatic hyper-K+, severe hyper-K+ (> 6.5)  

Ingestion

methanol, ethylene glycol, salicylate, lithium,, carbamazepine Overload volume overload refractory to diuretics Uremia symptomatic encephalopathy, bleeding, pericarditis --------------------------------------------------------------- functional hypothalamic amenorrhea: suppression of hypothalamic-pituitary-ovarian axis without a anatomic or metabolic cause   GnRH,  LH/FSH,  estrogen  causes: excess physical training, anorexia nervosa, marijuana use, starvation, stress, depression, chronic illness  risk of  bone mineral density due to  estrogen  progestin challenge: no withdrawal bleeding ---------------------------------------------------------------Risk factors for cholelithiasis  40, Fat, Fertile, Females  rapid weight loss, bariatric surgery  HRT, OCPs, pregos --------------------------------------------------------------- monomorphous pink papules on face, arms, trunk, in absence of comedones 2/2 prednisone use for SLE: steroid-induced folliculitis  DDx: adolescent acne, androgen abuse, PCOS, SLE --------------------------------------------------------------- wound site with abundant cloudy-gray discharge & dusky, friable subcutaneous tissue, decreased sensation at wound edges: necrotizing SSI  fever, hypotension, tachycardia  “dishwasher drainage”, crepitus  MC in diabetics, MCC is polymicrobial  Rx: early surgical exploration, IV ABX --------------------------------------------------------------- invasive ductal carcinoma: determine Px & Rx by overexpression of HER2 oncogene via FISH or immunohistochemical staining  HER2/neu overexpression = worse prognosis  +HER2 Rx: trastuzumab & anthracycline o trastuzumab + chemotherapy can lead to cardiotoxicity  obtain baseline echocardiogram --------------------------------------------------------------- fixed upper-airway obstruction (laryngeal edema 2/2 food allergy)  inspiratory & expiratory airflow

flattens the top & bottom of a flow-volume curve Rx: epinephrine, systemic corticosteroids, antihistamines --------------------------------------------------------------- asthma causes  airflow during effort-independent phase of exhalation, causing the flow-volume loop to have a “scooped out” exhalation pattern, smaller, & shifted to the left (obstructive pattern)  flow-volume look remains normal in panic attacks  pneumoTx & pulmonary edema causes reduced lung compliance; increased expiratory flow rates, smaller, shifted to the right (restrictive pattern)  

--------------------------------------------------------------- microangiopathic hemolytic anemia (DIC, HUS, TTP) & artificial mechanical valves  schistocytes:  serum haptoglobin,  LDH,  indirect bilirubin, &  urinary urobilinogen urine urine bilirubin urobilinogen normal none low hemolytic negative increased disease hepatic + or increased disease biliary positive low obstruction --------------------------------------------------------------- white granular patch/plaque over the buccal mucosa that cannot be scraped off, Hx of alcohol & tobacco: oral leukoplakia

 hyperplasia of squamous epithelium  reactive precancerous lesion for SCC  resolves with cessation of tobacco  development of induration or ulceration  Bx --------------------------------------------------------------- white plaques on oral mucosa, oropharynx, or tongue with underlying erythema; can scrape off: oral candidiasis  localized, shallow, painful oral ulcers on gray base: aphthous stomatitis  multiple vesicular lesions with erythematous border within oral cavity & perioral area: gingivostomatitis (HSV-1)  persistent, nodular, erosive/ulcerative lesion with surrounding erythema or induration: SCC --------------------------------------------------------------- fever, painful enlargement of testes, & irritative voiding symptoms (urinary frequency & urgency): acute epididymitis  as STD: a/w urethritis, pain, urethral discharge o MCC: chlamydia & gonococcus  as non-STD: elderly, a/w UTI o MCC: E. coli --------------------------------------------------------------- bright red, firm, friable, exophytic nodules in HIV: bacillary angiomatosis (Bartonella)  Rx: oral erythromycin --------------------------------------------------------------- weakness, fatigue, muscle cramps: hypokalemia  EKG: broad, flat T-waves, U-waves, ST depression, & PVCs  MCC: HCTZ, diarrhea, anorexia, hyperaldosteronism --------------------------------------------------------------- most accurate estimate of gestational age: crown-rump length via 1st trimester USS  pregnancy dating by LMP assumes a normal 28-day cycle with fertilization on day 14 --------------------------------------------------------------- karyotyping of fetal tissue is not indicated after one spontaneous abortion, but after recurrent pregnancy loss, or loss in 2nd trimester --------------------------------------------------------------- abdominal pain after traumatic injury with vertebral fracture & retroperitoneal hemorrhage: paralytic ileus

also 2/2 abdominal surgery XR: air-fluid levels & distended gas-filled loops in small & large intestines  Rx: bowel rest, supportive care  DDx: mesenteric ischemia, SBO ---------------------------------------------------------------Evaluation of chest pain assess pre-test probability of CAD…  low risk: men < 40, women < 50, atypical chest pain & no cardiac risk factors  no Dx testing  intermediate risk: able to exercise? o yes & normal EKG  exercise EKG test o yes & abnormal EKG  exercise imaging test o no  pharmacologic stress imaging test  any positive result  coronary angiography  high risk: coronary angiography evaluation & pharmacologic Rx for CAD --------------------------------------------------------------- fever, fatigue, pharyngitis, exudative tonsillitis, & polymorphous rash after taking amoxicillin: infectious mono  posterior cervical lymphadenopathy  Rx: supportive management for several weeks ---------------------------------------------------------------Common oropharyngeal lesions in children aphthous recurrent ulcers on anterior oral stomatitis mucosa (“canker sore”) no fever or systemic symptoms herpangina vesicles & ulcers on posterior oropharynx & hard palate, MCC: fever, pharyngitis Coxackie A Rx: supportive; self-limited in 1 wk gingivostomatitis vesicles & ulcers on anterior oral mucosa & perioral area, fever, MCC: HSV-1 pharyngitis, erythematous gingiva Rx: oral acyclovir Group A Strep tonsillar exudates, fever, pharyngitis anterior cervical lymphadenopathy infectious mono tonsillar exudates, posterior cervical adenopathy +/- hepatosplenomegaly --------------------------------------------------------------- dipyridamole (& adenosine) is a coronary vasodilator used in myocardial perfusion scanning to reveal areas of restricted perfusion  

redistribution of coronary blood flow from ”diseased” segments to “non-diseased” segments = coronary steal --------------------------------------------------------------- secondary bacterial pneumonia: prodrome viral URI, high fever, blood-streaked sputum  MCC: S. aureus  CXR: B/L mid-field infiltrates, thin-walled abscess cavities suggesting necrotizing bronchopneumonia with secondary pneumatoceles --------------------------------------------------------------- high PaCO2 & low PaO2 is a/w hypoventilation  MCC: COPD, OSA, obesity, scoliosis  hypoventilation & reduced inspired O2 is a/w normal A-a gradient --------------------------------------------------------------- PE, atelectasis, pleural effusion, PCP, pulmonary edema cause V/Q mismatch &  A-a gradient   A-a gradient: any process that results in impaired gas exchange  hypoxia ---------------------------------------------------------------Meningococcal vaccination primary all adolescents age 11 – 12; vaccine optional at age 19 – 21 for high risk & 1st year college students booster age 16 – 21 (if primary vaccine given vaccine before age 16) age > 21 considered if @ high risk ---------------------------------------------------------------Live-attenuated vaccines  oral polio  intranasal  MMR influenza  yellow fever  rotavirus  varicella  avoid in patients on TNF antagonists --------------------------------------------------------------- MCC of macrocytic anemia in sickle cell disease is folate deficiency  sickle cell disease is a chronic hemolytic anemia with an appropriate reticulocyte response   RBC turnover & consumption of folate in bone marrow  folate deficiency --------------------------------------------------------------- fever, pharyngitis, tonsillar exudates, absent cough, & tender, anterior cervical lymphadenopathy: 

Strep pharyngitis --------------------------------------------------------------- subdural hematoma is MC in elderly & alcoholics due to tearing of bridging veins 2/2 brain atrophy  ruptured aneurysm results in subarachnoid hemorrhage  headache, confusion, somnolence, focal neural deficits within hours of trauma: epidural hematoma --------------------------------------------------------------- tumor of arachnoid granulation = meningioma --------------------------------------------------------------- episodic numbness, weakness, spastic paraparesis, paresthesia, gait abnormalities, vision loss: MS --------------------------------------------------------------- middle ear effusion without signs of acute infection, + conductive hearing loss: serous otitis media  due to auditory tube dysfunction 2/2 HIV lymphadenopathy or obstructing lymphomas  dull tympanic membrane & hypomobile --------------------------------------------------------------- boy with gout, hypotonia & persistent vomiting: Lesch-Nyhan  deficiency of HPRT for purine metabolism   uric acid accumulates in peripheral tissue  MC @ age 6 months  mental retardation, choreoathetosis, spasticity, dystonia, self-mutilation, gouty arthritis & tophi  Rx: allopurinol --------------------------------------------------------------- knee pain, adolescent male athlete: Osgood-Schlatter  traction apophysitis @ tibial tubercle\  absence of knee swelling  pain reproduced by knee extension with resistance --------------------------------------------------------------- anterior knee pain that worsens with descending steps or hills; MC overuse injury in runners: patellofemoral stress syndrome --------------------------------------------------------------- MC predisposing factor for aortic dissection: HTN --------------------------------------------------------------- intermittent vision loss with changes in head position: papilledema ----------------------------------------------------------------

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most significant factor in suicide risk assessment: previous attempts & clear plan

Assessment of suicidality “SAD PERSONS” Sex, Age, Depression, Previous attempt, EtOH use, Rational thought loss (psychosis), Social support (lack of), Organized plan, No spouse or significant other, Sickness/injury --------------------------------------------------------------- colicky abdominal pain & distension, N/V, obstipation, diffuse tenderness: SBO  mild leukocytosis & modest  amylase  XR: multiple air-fluid levels  Rx #1: bowel rest, NG tube decompression, pain control, fluids  fever, tachycardia, leukocytosis, metabolic acidosis  risk of strangulation o Rx: surgical exploration ---------------------------------------------------------------Indications for prophylactic anti-D immune globulin for unsensitized Rh-negative prego  no antepartum prophylaxis if father is Rh-negative  @ 28 – 32 wk gestation  within 72 hr of delivery of Rh+ infant; spontaneous, threatened, or induced abortion  ectopic pregnancy  hydatidiform molar pregnancy  CVS or amniocentesis  abdominal trauma  2nd or 3rd trimester bleeding  external cephalic version --------------------------------------------------------------- anti-D immune globulin binds D antigens on fetal RBCs in the mother’s circulation to prevent formation of anti-D alloimmunization  if mother is sensitized (elevated antibody titers), Rx: fetal monitoring for hemolytic disease --------------------------------------------------------------- intravascular hemolysis: RBC breakdown in blood vessels; schistocytes o prosthetic valves, DIC, TTP, HUS, PNH  extravascular hemolysis: a/w spleen & RES o autoimmune hemolytic anemia in CLL

---------------------------------------------------------------Acute HIV infection  presents 2 – 4 wks after exposure  mononucleosis-like syndrome (fever, night sweats, diarrhea, weight loss, lymphadenopathy, arthralgia)  generalized macular rash  painful mucocutaneous ulcerations  GI: diarrhea, abdominal distension, flatulence  Dx: low threshold for HIV testing;  viral load; negative HIV Ab, normal CD4  Rx: combination anti-retrovirals  DDx: IBD, connective tissue disease, lymphoma, Whipple’s, hyperthyroidism, Celiac’s ---------------------------------------------------------------Rx chronic stable angina antianginals β-blocker (#1; improves survival) CCB (peripheral & coronary vasodilation) nitrates (long-acting) prevention ASA, statin smoking cessation, exercise, weight loss, BP & diabetes control  avoid β-blockers if hypotensive or bradycardic --------------------------------------------------------------- reddish nodule that later ulcerates @ site of injury, spreads along lymphatics forming subcutaneous nodules & ulcers: sporotrichosis --------------------------------------------------------------- leprosy: chronic granulomatous disease that affects peripheral nerves & skin; MC in Asians  MCC: Mycobacterium leprae  early: insensate, hypopigmented plaque  peripheral nerve damage & muscle atrophy with crippling deformities  face, ears, wrists, buttocks, knees, eyebrows  Dx: skin biopsy (acid-fast bacilli) --------------------------------------------------------------- child with unsteady wide-based gait & weakness of lower limbs, decreased vibratory & position sense, absent B/L ankle jerks, high plantar arches: Friedreich Ataxia  AR inheritance, excess trinucleotide repeats  a/w necrosis & degeneration of cardiac muscle fibers  myocarditis, fibrosis, cardiomyopathy  MCC of death: arrhythmia & CHF

 Rx: prenatal counseling for subsequent pregnancy ---------------------------------------------------------------Pertussis in infants & children Catarrhal phase mild cough, rhinitis (1 – 2 wks) Paroxysmal phase coughing paroxysms with (2 – 6 wks) inspiratory “whoop”, posttussive emesis, apnea & cyanosis (infants) Convalescent symptom resolution phase (wks – months)    

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total duration if untreated: 3 months lymphocyte predominant leukocytosis Dx: Pertussis PCR or culture of nasopharyngeal secretions Rx on clinical suspicion: empiric macrolides (azithromycin, erythromycin, clarithromycin) o respiratory isolation at home for 1st 5 days prevention: acellular pertussis vaccine o 5 doses of DTaP between age 2 months – 6 yrs o Tdap booster once at age 11 – 18 & pregos o does not provide lifelong immunity complications: pneumonia, weight loss, pneumoTx, subconjunctival hemorrhages, respiratory failure, death (infants)

Pertussis Rx & post-exposure prophylaxis age < 1 azithromycin x5 days month age ≥ 1 azithromycin x5 days, or month clarithromycin x7 days, or erythromycin x14 days  ABX prophylaxis for all close contacts regardless of vaccination status ---------------------------------------------------------------Indications for renal & bladder USS  age < 2 yrs with a first febrile UTI to evaluate for anatomic abnormalities  any age child with recurrent febrile UTI  UTI in a child of any age with family Hx of renal or urologic disease, HTN, or poor growth  child does not respond to appropriate ABX

persistent or worsening symptoms to assess for renal abscess --------------------------------------------------------------- voiding cystourethrogram: newborns < 1 month, children age < 2 yrs with recurrent UTI, or first UTI from organism other than E.coli ---------------------------------------------------------------Screening for average risk patients Breast cancer 50 -75 mammogram (2 yrs) Cervical cancer 21 – 65 Pap every 3 yrs Colon cancer 50 – 75 annual FOBT or colonoscopy (10 yrs) HIV 15 – 65 HIV antibody 1x Hyperlipidemi men 35+ lipid panel every 5 yrs a HTN 18+ BP every 2 yrs Osteoporosis female 65+ DEXA scan --------------------------------------------------------------- chronic, intermittent, painful eyelid swelling that regresses with hot compresses: chalazion  nodular, rubbery lesion; no redness or discharge  chronic granulomatous obstruction of a Meibomian gland  recurrent lesions  histology to r/o malignancy (Meibomian gland carcinoma)  DDx: BCC, hordeolum (stye) --------------------------------------------------------------- acute infection of an eyelid gland: hordeolum  Rx: anti-staphylococcal ABX --------------------------------------------------------------- retinoblastoma: MC intraocular tumor of children  inactivation of Rb suppressor gene  strabismus, decreased vision, ocular inflammation, glaucoma, orbital cellulitis  Dx: USS or CT of a mass with calcifications  MCC of death: liver & brain mets --------------------------------------------------------------- MCC of bronchiolitis in age < 2 yrs: RSV  fever, rhinorrhea, cough, mild respiratory distress --------------------------------------------------------------- solitary, non-healing ulcer in the keratinized epithelium of the vermillion zone of lower lip & Hx of sun exposure, immunocompetent: SCC  invasive cords of squamous cells & keratin pearls ---------------------------------------------------------------

invasive clusters of spindle cells surrounded by palisaded basal cells: BCC  elevated or rolled border with central ulceration  Rx low-risk & superficial: 5-FU or imiquimod  Rx low-risk lesions on trunk or extremities: electrodessication & curettage (ED&C)  Rx high-risk nodular BCC on face: Mohs surgery --------------------------------------------------------------- shallow, fibrin-coated ulcerations with underlying mononuclear infiltrates: aphthous ulcer  Rx: topical corticosteroids --------------------------------------------------------------- hoarding disorder Rx: CBT & SSRI --------------------------------------------------------------- DDx of T-wave inversion: MI, old pericarditis, myocarditis, myocardial contusion, digoxin toxicity --------------------------------------------------------------- adult with palpable purpura, proteinuria, hematuria: mixed cryoglobulinemia  also hepatosplenomegaly, peripheral neuropathy, arthralgia, hypocomplementemia  MC a/w Hep C  Dx: circulating cryoglobulins  DDx: Henoch-Schonlein (normal complement) --------------------------------------------------------------- ranolazine: late Na+ channel blocker  Rx stable angina with recurrent symptoms, already on β-blocker, CCB, or nitrates o not for initial therapy --------------------------------------------------------------- Klumpke palsy: excessive traction of C8 & T1 during delivery; intact Moro & biceps reflexes  “Claw hand”, Horner’s (ptosis, miosis)  Rx: gentle massage & PT to prevent contractures --------------------------------------------------------------- D-xylose test of proximal small bowel absorption  normal:  D-xylose excretion in urine  abnormal: high fecal D-xylose excretion, minimal D-xylose in urine (MCC: Celiac’s)  false+: bacterial overgrowth, urinary retention, delayed gastric emptying, renal dysfunction, ascites --------------------------------------------------------------- anemia of lymphoproliferative disorders is due to bone marrow infiltration with cancerous cells 

o lymphadenopathy, hepatosplenomegaly --------------------------------------------------------------- new-onset a-fib should have TSH & T4 screening for hyperthyroidism --------------------------------------------------------------- Rx uncomplicated diverticulosis:  dietary fiber o resultant large, bulky stools  colon width  Rx uncomplicated diverticulitis: bowel rest & ABX o fever, leukocytosis, peritoneal inflammation ---------------------------------------------------------------Maternal estrogen effects on newborns o breast hypertrophy (boys & girls) o swollen labia o physiologic leukorrhea (non-purulent) o uterine withdrawal bleeding  Rx: routine care & observation --------------------------------------------------------------- uncomplicated pyelonephritis Rx: urine culture & empiric oral ABX against Go Rx: oral fluoroquinolone or TMP-SMX  hypotensive patients require hospitalization & blood cultures, fluids, & empiric IV ABX  abdominal & pelvic CT if symptoms persist despite 48 -72 hr of Rx, Hx of nephrolithiasis, gross hematuria, urinary obstruction or complicated pyelonephritis  complicated pyelonephritis: progression to renal abscess or papillary necrosis, sepsis with multi-organ failure, shock, renal failure o MC with immunosuppression, diabetes, renal stones, anatomic abnormalities o Rx: IV ceftriaxone, cefepime, fluoroquinolones --------------------------------------------------------------- acute pyelonephritis in pregos: hospitalization  Rx: IV ceftriaxone +/- gentamicin, aztreonam --------------------------------------------------------------- diabetics with acute pyelonephritis are managed with IV ABX for 48 – 72 hrs, then switched to oral fluoroquinolone or TMP-SMX; 10 – 14 days  non-diabetics with mild/moderate pyelonephritis, Rx: oral ABX only  gentamicin: Rx UTI with severe infection or risk for drug-resistant organisms ----------------------------------------------------------------

post-operative fever, leukocytosis, parotitis: acute bacterial parotitis  MCC: S. aureus  MC in elderly & post-op dehydration  purulent saliva from parotid duct  prevention: adequate hydration & oral hygiene --------------------------------------------------------------- young woman with a breast lump: return after menstrual period, if no signs of malignancy --------------------------------------------------------------- left-sided weakness, +Babinski, Hx of HTN & DM Type II: acute ischemic stroke  Dx: head CT without contrast to r/o hemorrhage  Rx: fibrinolytics (IV alteplase (tPA))  ASA should be held for 24 hrs  Rx with ASA is indicated if fibrinolytics are C/I  heparin would increase risk of IC hemorrhage --------------------------------------------------------------- well-appearing infant that regurgitates milk, eczema, painless bloody stools: milk protein allergy  infants age 2 – 8 wks  family Hx of allergies, eczema, or asthma  non-IgE-mediated rectal & colonic inflammation  Rx: eliminate dairy & soy protein from maternal diet if breastfed; hydrolyzed formula o resolves within 2 wks of diet modification o can resume/tolerate dairy & soy by age 1 yr --------------------------------------------------------------- failure to thrive, irritability, Sandifer syndrome: infantile GERD  Sandifer syndrome: periodic opisthotonic posturing  Rx: thickened feeds, PPI, esophageal pH probe monitoring, upper endoscopy --------------------------------------------------------------- somatic & parasympathetic fibers of CN III have separate blood supplies  in diabetics, CN III neuropathy is ischemic; affect somatic fibers only o “down & out” gaze & ptosis only  nerve compression affects BOTH somatic & parasympathetic fibers o “down & out” gaze, ptosis, fixed & dilated pupil, loss of accommodation ---------------------------------------------------------------

symmetrical distal sensorimotor polyneuropathy is MC type of diabetic neuropathy  “stocking glove” sensory loss  neuropathic pain is present at rest, worse at night  Rx: TCAs (amitriptyline), gabapentin, NSAIDs o TCAs may worsen urinary symptoms & orthostatic hypotension; Rx: gabapentin o NSAIDs: C/I in renal dysfunction --------------------------------------------------------------- pronator drift  assess UMN damage o seen in some stroke patients  Romberg’s assess proprioception --------------------------------------------------------------- any patient with an acute, severe illness can have abnormal thyroid function tests: euthyroid sick syndrome (aka low T3 syndrome)   total & free T3, normal T4 & TSH  thyroid function tests are not recommended in acutely ill patients; unreliable  DDx: subclinical hypothyroidism ( TSH, normal T4) ---------------------------------------------------------------Non-allergic rhinitis Allergic rhinitis  nasal congestion,  watery rhinorrhea, rhinorrhea, postnasal sneezing, eye itching drainage (dry cough)  early age of onset  late age onset (> 20)  allergen or seasonal  no allergic triggers  pale/blue nasal  perennial symptoms mucosa  erythematous nasal  a/w asthma, eczema mucosa mild Rx: intranasal Rx: intranasal antihistamine spray or glucocorticoids or intranasal glucocorticoids antihistamines mod/severe Rx: combo --------------------------------------------------------------- all cirrhotic patients require diagnostic endoscopy to asses risk for variceal hemorrhage  small, non-bleeding varices Rx: propranolol as primary prophylaxis, results in unopposed alpha-mediated vasoconstriction  endoscopic band ligation is an alternative Rx  endoscopic sclerotherapy is for active bleeding 

octreotide: Rx active variceal bleeding by causing splanchnic vasoconstriction & reduced portal blood flow by inhibiting glucagon release --------------------------------------------------------------- molar pregnancy: abnormal trophoblastic proliferation following abnormal fertilization o Rx: D&C o F/U: serial β-hCG post-evacuation o complication: gestational trophoblastic neoplasia  complete mole: 2 sperm + 1 empty ovum o no fetal tissue (“completely empty”) o symptomatic: theca lutein ovarian cysts,  β-hCG, hyperemesis graviarum  partial mole: 2 sperm + 1 haploid ovum (triploid) o abnormal placenta + fetal tissue ---------------------------------------------------------------Manifestations of hyperthyroidism symptom o anxiety, insomnia s o palpitations o heat intolerance o  perspiration o weight loss o goiter findings o HTN, tachycardia o tremors of fingers/hands o hyprreflexia o proximal muscle weakness o lid lag o a-fib  chronic thyrotoxic myopathy: inability to comb hair, difficulty holding arms up, muscle atrophy ---------------------------------------------------------------Suspected hyperthyroidism…  initial Dx test: plasma TSH  if plasma TSH is low  measure free T4 o elevated free T4  clinical hyperthyroidism  24-hr RIU scan to differentiate Graves’ from toxic adenoma  next test: EKG to r/o arrhythmia  initial Rx: propranolol for symptomatic relief  definitive Rx: radioactive iodine  complications if untreated: rapid bone loss 2/2 direct osteoclastic bone resorption, & a-fib ---------------------------------------------------------------

cobalamin deficiency can result in peripheral neuropathy or posterior column defects due to defective myelin synthesis  folate supplementation can improve the anemia, but may precipitate or worsened neuro deficits  folate & Vit B12 are cofactors in homocysteine to methionine conversion --------------------------------------------------------------- autoimmune hemolysis: IgG autoantibodies bind to RBC membrane & promotes removal in the spleen reticuloendothelial system --------------------------------------------------------------- OCD in a child after recent group A Strep infection: pediatric autoimmune neuropsychiatric disorders a/w streptococcal infections (PANDAS)  OCD #1 Rx: CBT & high-dose SSRI --------------------------------------------------------------- acalculous cholecystitis: MC in critically ill o extensive burns, severe trauma, prolonged TPN or fasting, mechanical ventilation  presents similar to calculous cholecystitis  due to cholestasis & GB ischemia, leading to secondary infection by enteric organisms  no prior Hx of GB disease  Dx: CT shows GB wall thickening & distension with pericholecystic fluid  Rx: ABX & percutaneous cholecystostomy, then cholecystectomy once stable  complications: sepsis & death if undetected --------------------------------------------------------------- severe N/V during 1st trimesters, a/w ketonuria & metabolic alkalosis: hyperemesis gravidarum  volume depletion causes contraction metabolic alkalosis & R-A-A system activation 

risk factors features

Hyperemesis gravidarum HG in a prior pregnancy, multifetal gestation, gestational trophoblastic disease (molar) severe, persistent N/V in 1st trimester, enlarged uterus than expected, abnormally elevated β-hCG, > 5% loss of pre-pregnancy weight, ketonuria, metabolic alkalosis

workup

pelvic USS, thyroid function, electrolytes, U/A, BUN, Cr, Rx dietary modification, hydration, ginger Vit B6 +/- doxylamine --------------------------------------------------------------- hypocapnia is a normal phenomenon of late pregos due to direct stimulation by progesterone on central respiratory center   respiratory drive & relative hyperventilation --------------------------------------------------------------- fever, cough, abdo pain, diarrhea, night sweats, weight loss, splenomegaly &  ALP, CD4 < 50: disseminated Mycobacterium avium complex  Dx: blood cultures  Rx: azithromycin or clarithromycin  CD4 < 50 prophylaxis: azithromycin  DDx: TB, CMV ---------------------------------------------------------------Solitary pulmonary nodule  rounded opacity, < 3 cm, surrounded by pulmonary parenchyma, no lymphadenopathy  step #1: determine if low, intermediate or high probability for malignancy o low risk  no follow-up o intermediate risk  FDG-PET scan o high risk  surgical resection  step #2: FDG-PET scan for nodules ≥ 0.8 cm & intermediate risk o suspicious for malignancy  surgical resection o negative results  serial CT scans ---------------------------------------------------------------Chronic HBV infection  immune tolerance phase: high levels of HBV replication, normal ALT; can last 10 – 30 yrs  immune clearance phase causes immune-mediated destruction of infected hepatocytes & fluctuating ALT levels  inactive carrier state: measure ≥ 3 normal ALT & 2 – 3 normal HBV DNA levels; 3 – 6 months --------------------------------------------------------------- a-fib with rapid ventricular response: rate control should be attempted with β-blocker or CCB (diltiazem)  hemodynamically unstable: synch cardioversion

rhythm control with digoxin: Rx patients unable to achieve rate control, recurrent symptoms, or LV systolic dysfunction  all patients require CHA2DS2-VASc score to assess thromboembolic risk --------------------------------------------------------------- narrow-complex SVT with abrupt onset/offest: PSVT o includes AVRNT, AVRT, atrial tachycardia, & junctional tachycardia  Rx: IV adenosine or vagal maneuvers if hemodynamically stable o temporarily slow AV node conduction to unmask “hidden” P waves with a-flutter or atrial tachycardia o terminates PSVT by interrupting AV nodal reentry circuit --------------------------------------------------------------- B/L digital clubbing with sudden onset arthropathy & tenderness affecting wrist & hand joints, Hx of smoking: hypertrophic osteoarthropathy  screening: CXR to r/o malignancy --------------------------------------------------------------- HIV+: HSV & VZV can cause severe, acute retinal necrosis a/w pain, keratitis, uveitis o most cases due to reactivation  initially: keratitis & conjunctivitis with pain, followed by rapid progressive visual loss  fundoscopy: central retinal necrosis & pale peripheral lesions --------------------------------------------------------------- CMV retinitis: painless  fundoscopy: fluffy or granular lesions around retinal vessels & associated hemorrhages o no keratitis or conjunctivitis --------------------------------------------------------------- untreated complete heart block can lead to ventricular arrhythmias or asystole  symptomatic 3rd degree heart block Rx: temporary pacemaker & ID reversible causes  permanent pacemaker if no reversible causes ---------------------------------------------------------------Niemann-Pick Tay-Sachs Sphingomyelinase def. β-hexosaminidase A def. AR inheritance; MC in Ashkenazi Jews 

onset: age 2 – 6 months loss of motor  loss of motor milestones milestones  hypotonia  hypotonia  feeding difficulties  feeding difficulties  “cherry red” macula  “cherry red” macula  hepatosplenomegal  hyperreflexia y  hypo-/areflexia --------------------------------------------------------------- constitutional growth delay: normal birth weight & height, but between age 6 mo – 3 yrs, height velocity slows, then regains normal growth velocity at 5th – 10th percentile  delayed puberty & growth spurt, but eventually occurs, reaching normal adult height  bone age is delayed  Rx: F/U in 6 months after puberty has occurred; no supplement with testosterone or GH --------------------------------------------------------------- oropharyngeal dysphagia: difficulty initiating swallowing; a/w coughing, choking, nasal regurgitation  esophageal dysphagia initially with solids, then liquids is MC mechanical obstruction o Hx of prior radiation, caustic injury, complex stricture, or surgery for laryngeal or esophageal cancer  Dx: barium swallow, then upper endoscopy  esophageal dysphagia for both solids & liquids is MC motility disorder  Dx: barium swallow, confirm with manometry --------------------------------------------------------------- folate deficiency is MCC of megaloblastic anemia in chronic alcoholics by impairing enterohepatic cycle & absorption ---------------------------------------------------------------Approach to childhood lead poisoning  risk factors: home built before 1978, pica, sibling with lead poisoning, low socioeconomics, immigrant or international adoptee  no risk factors  no further testing  +risk factors  draw venous lead levels o mild Rx: no meds, repeat level in < 1 month o moderate Rx: DMSA, oral succimer 

severe Rx: Dimercaprol + Ca++ EDTA  also for acute encephalopathy --------------------------------------------------------------- easy fatigue, difficulty concentrating, insomnia, muscle weakness, clumsiness, memory loss, peripheral neuropathy: chronic lead exposure o inquire about occupation Hx  microcytic anemia, basophilic stippling --------------------------------------------------------------- nasopharyngeal carcinoma presents with recurrent otitis media, epistaxis, & nasal obstruction  a/w EBV, smoking, nitrosamine consumption --------------------------------------------------------------- V-fib & sustained V-tach are complications of MI  Rx: early defibrillation before epinephrine or amiodarone  in unwitnessed cardiac arrest or witnessed arrest occurring > 5 min before defibrillator arrival, a cycle of CPR should precede defibrillation --------------------------------------------------------------- MCC of thyrotoxicosis with reduced RIU uptake is subacute lymphocytic (painless) thyroiditis o leakage of thyroid hormone due to inflammatory damage of thyroid follicles ---------------------------------------------------------------MCC of thyrotoxicosis with low RIU uptake  subacute painless thyroiditis (painless)  subacute granulomatous thyroiditis (de Quervain, painful)  iodine-reduced thyroid toxicosis  levothyroxine overdose  struma ovarii ---------------------------------------------------------------Aromatase deficiency  in utero: no placental estrogen  masculinization of mother that resolves after delivery  gestational androgens results in virilized XX child, normal internal genitalia, ambiguous externally;  delayed puberty, 10 amenorrhea, clitoromegaly, osteoporosis, polycystic ovaries  undetectable estrogens, high LH/FSH  DDx: CAH (virilized female, normal internals), Kallman (delayed puberty, absent LH/FH) ---------------------------------------------------------------o

involuntary contraction of perineal musculature, at least 6 months: vaginismus  pain with intercourse or attempted penetration  underlying cause is psychologic  Rx: relaxation, Kegels, dilators to desensitize --------------------------------------------------------------- Varenicline: partial agonist at nicotinic ACh Rc, more effective than bupropion  all meds are enhanced by nicotine replacement Rx --------------------------------------------------------------- sudden cardiac death 2/2 CVD is MCC of death in dialysis & renal transplant patients --------------------------------------------------------------- nocturnal respiratory symptoms can occur as GERD can exacerbate asthma  GERD exacerbates airflow obstruction by  vagal tone,  bronchial reactivity, & microaspiration of gastric contents  initial Rx of GERD: lifestyle modification (elevation of bed head, diet, weight loss)  Rx: PPI improves peak expiratory flow, nocturnal respiratory symptoms, & GERD --------------------------------------------------------------- MCC of vulvovaginitis in pre-pubertal kids: vaginal foreign bodies; MC is toilet paper o foul-smelling discharge, intermittent bleeding or spotting, urinary complaints  Rx small foreign body: Ca++ alginate swab or irrigation with warm fluids after topical anesthetic  sedation or general anesthesia may be required  never perform bimanual exam in a child ---------------------------------------------------------------Serum sickness-like reaction etiology ABX (PCN, β-lactams, TMP-SMX), Type III hypersensitivity reaction features fever, urticarial rash, polyarthralgia (1 – 2 wks after first exposure); headache, edema, lymphadenopathy, splenomegaly (less common) labs hypocomplementemia,  ESR & CRP Rx avoid offending agent; resolves with 48 hrs, steroids for severe cases 

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DDx: untreated Strep pharyngitis, arthritis, fever, erythema marginatum (acute rheumatic fever)

--------------------------------------------------------------- dizziness, headache, pruritus after shower, & splenomegaly: polycythemia vera  high histamine release also cause peptic ulcers o hypercellular bone marrow o  production of all three cell lines, esp. RBCs o risk of thrombosis & bleeding due to elevated PLT count & impaired PLT function o low serum iron due to  iron utilization  primary polycythemia: low erythropoietin o polycythemia vera o primary familial & congenital polycythemia  secondary: high/normal erythropoietin o hypoxemia, congenital, hepatic or renal tumors, post-renal transplant, testosterone supp/abuse --------------------------------------------------------------- SCC of the mucosa of head & neck is common with a Hx of alcohol & tobacco use  firm, non-tender, palpable solitary cervical node  Dx: panendoscopy (laryngoscopy, bronchoscopy, esophagoscopy) to detect primary tumor o F/U lymph node biopsy for histologic Dx ---------------------------------------------------------------MCC of Vit B12 deficiency: pernicious anemia 1. anti-intrinsic factor antibodies  functional IF for Vit B12 absorption 2. chronic atrophic gastritis  IF production by parietal cells &  risk of gastric cancer  periodically monitor for gastric cancer --------------------------------------------------------------- Vit B12 deficiency is common after total or partial gastrectomy or chronic gastritis o 2/2 loss of intrinsic factor  Vit B12 is a cofactor in purines & DNA synthesis  ineffective erythropoiesis  megaloblastic anemia  total RBC count & reticulocyte count are low  shiny tongue (glossitis) & pale palmar creases --------------------------------------------------------------- ineffective erythropoiesis is a hallmark of both Vit B12 & folate deficiency  delayed nuclear maturation   # of megaloblasts  ineffective erythropoiesis due to  transition to mature RBC &  death of immature precursors  total RBC count & reticulocyte count are low ----------------------------------------------------------------

antiviral Rx for influenza: oseltamivir o must be started within 48 hrs for efficacy  confirm Dx: nasal swab for influenza antigens --------------------------------------------------------------- fever, leukocytosis, LUQ pain: splenic abscess  left pleuritic chest pain, left pleural effusion, splenomegaly  MCC: Staph, Strep, Salmonella  MC risk factors: infective endocarditis with hematogenous spread  Rx: ABX + splenectomy  percutaneous drainage for poor surgical candidate  DDx: malaria, Hodgkin’s, infectious mono, TB --------------------------------------------------------------- anorexia, constipation,  thirst, easy fatigue, hypercalcemia, smoking Hx: SCC of lung o sCa++mous cell carcinoma  PTHrP  Ca++ resorption from bone &  renal Ca+ + resorption from distal tubule  CXR: hilar mass  DDx: small cell carcinoma (a/w ACTH or SIADH), adenocarcinoma (a/w hypertrophic osteoarthropathy) --------------------------------------------------------------- OTC cold meds containing acetaminophen & phenylephrine can provoke warfarin-associated IC hemorrhage  acetaminophen potentiates warfarin effects  phenylephrine elevates BP  Rx: prothrombin-complex concentrate (rapid & short-term warfarin reversal) & IV Vit K (promotes clotting factor synthesis; 12 – 24 hr)  alt Rx: FFP if PCC not available; FFP takes longer to prepare/administer & more volume infusion ---------------------------------------------------------------VIPoma feature watery diarrhea, weight loss, lethargy, s facial flushing, N/V, muscle weakness labs hypokalemia ( intestinal K+ secretion), acholrhydria (  gastric acid secretion), hypercalcemia ( bone resorption), hyperglycemia ( glycogenolysis), secretory diarrhea:  Na+,  osmolal gap Dx watery diarrhea, VIP > 75 pg/mL abdominal CT (usually pancreatic tail) Rx IV fluids, octreotide to decrease diarrhea 

VIP binds intestinal epithelial cells to increase fluid & electrolyte secretion into intestinal lumen  maybe a/w MEN Type I --------------------------------------------------------------- steatorrhea, hepatomegaly, PUD: systemic mastocystosis o pruritus, facial flushing, urticaria --------------------------------------------------------------- striatal neuro-degeneration: Huntington’s  spongiform encephalopathy: CJD  loss of nigrostriatal DA neurons: Parkinson’s  selective loss of cholinergic neurons: Alzheimer’s  neurodegeneration of frontal/temporal lobes: Pick’s --------------------------------------------------------------- rationalization: excusing an unacceptable behavior/emotion in a false, but logically rational way to avoid the true reason for a behavior, to prevent anxiety & protect self-esteem  can result in a delay in care or difficult Rx course --------------------------------------------------------------- repression: blocking upsetting ideas/impulses from entering consciousness; blocking inner states  denial: blocking external sensory data --------------------------------------------------------------- acute dyspnea, pleuritic chest pain, tachycardia, follwed by hypotension, syncope: acute massive PE  accompanied by RV dilation & hypokinesis 2/2 occlusion of the pulmonary artery, which  RA, RV, & pulmonary artery pressure  can cause RBBB & right axis deviation  septal deviation toward LV results in  LV preload &  cardiac output  PCWP & SVR are not affected --------------------------------------------------------------- hypovolemic shock:  RA, RV, pulmonary artery, & PCWP;  SVR to maintain organ perfusion  cardiogenic shock:  PCWP & SVR,  C.O. o  cardiac index,  RA pressure  septic shock: peripheral vasodilation &  SVR,  RA, pulmonary artery, & PCWP,  C.O. o  mixed venous O2 saturation --------------------------------------------------------------- acute mitral regurgitation as a complication of MI can result in cardiogenic shock 

o flash pulmonary edema & crackles --------------------------------------------------------------- MCC of 20 HTN in children, to-&-fro bruit @ CVA: fibromuscular dysplasia  angiogram: “sting of beads” --------------------------------------------------------------- viral meningitis: self-limited inflammation of leptomeninges cause by viral infection  MCC: echovirus or coxsackie virus  MC in infants; incidence decreases with age  prodrome constitutional & URI symptoms; next 36 – 48 hrs  high fever, headache, irritability, & nuchal rigidity   WBC (lymphocyte predominance), normal glucose, mildly elevated protein  Rx: supportive; resolves in 7 – 10 days  DDx: bacterial (neutrophils,  protein,  glucose), TB meningitis (lymphocytes,  protein,  glucose) --------------------------------------------------------------- hemolytic anemia, cytopenias, hypercoagulability: PND  Dx: RBC CD55 & CD59 testing --------------------------------------------------------------- oral corticosteroids: Rx acute asthma exacerbation ---------------------------------------------------------------Management of GERD  no cancer risk factors or alarm symptoms  PPI o if refractory, try another PPI or  to 2x daily  male, age > 50, symptoms for > 5 yrs, or cancer risk factors or alarm symptoms  upper endoscopy o if no evidence of esophagitis  manometry GI alarm symptoms hematemesis, persistent vomiting, anemia, melena, weight loss, dysphagia/odynophagia --------------------------------------------------------------- intrauterine fetal demise: in utero fetal death after 20 wks gestation, before labor onset o Dx: USS  next: coagulation profile to detect incipient DIC o retention of dead fetus can cause chronic consumptive coagulopathy due to gradual release of thromboplastin from the placenta

low/normal fibrinogen may indicate early signs of consumptive coagulopathy if a/w  PLT count,  PT, PTT, or fibrin split products o fibrinogen is usually higher in pregos  if any coagulation derangements  prompt delivery  if normal coagulation parameters… o watchful expectancy or labor induction o expectant management complications: chorioamnionitis & DIC ---------------------------------------------------------------Congenital hypothyroidism etiology thyroid dysgenesis (MCC) features most are asymptomatic, jaundice, lethargy, hoarse cry, dry skin, poor feeding, constipation, large tongue Dx  TSH,  free T4, via newborn screening Rx levothyroxine --------------------------------------------------------------- maternal Graves’: transplacental passage of TSH receptor antibodies  congenital Grave’s: poor feeding, jitteriness, tachycardia, weight loss --------------------------------------------------------------- synchronized cardioversion: Rx a-fib, a-flutter, stable monomorphic v-tach  temporary transvenous pacemaker: sick sinus syndrome, 2nd or 3rd degree heart block --------------------------------------------------------------- duodenal hematoma: MCC direct blunt abdominal trauma; MC in children  Dx: CT with oral contrast  #1 Rx: NG suction & parenteral nutrition; spontaneous resolution in 1 – 2 wks  #2 Rx: surgical removal if conservative Rx fails ---------------------------------------------------------------Vaccines for pregos all pregos Tdap & inactivated influenza special Hep A & B (high risk) circumstances Pneumococcus (2nd & 3rd trimester if high risk), H. influenza (if asplenic), Meningococcus (if high risk), Anti-D Ig (if Rh-negative mother) not HPV, MMR, Varicella, smallpox, recommended intranasal influenza **avoid conception for 4 wks 

unvaccinated pregos with confirmed rubella exposure are offered termination of pregnancy or Rx prego with IV Ig  serology not needed if documentation of vaccine ---------------------------------------------------------------Evaluation of nipple discharge  unilateral  likely malignant  Dx: mammogram +/- USS, surgical evaluation  bilateral  color of discharge?? o bloody or serous  mammogram o milky, non-bloody…  palpable mass or skin changes??  yes  mammogram  no  likely physiologic discharge  physiologic galactorrhea o painless, B/L milky-brown-gray-green o MCC: hyperprolactinemia  Dx: pregnancy test, TSH & prolactin o Dx: pituitary MRI if prolactin is elevated --------------------------------------------------------------- frequent exposure to ototoxic agents (aminoglycosides for P. aeruginosa) for CF Rx can cause sensorineural deafness --------------------------------------------------------------- back pain, constipation, anemia, renal dysfunction,  ESR: MM o hypercalcemia causes polyuria, constipation, confusion, or acute pancreatitis --------------------------------------------------------------- acute onset polyarticular & symmetric arthritis that resolves within 2 wks: viral arthritis 2/2 Parvovirus B19 o adults in frequent contact with children  morning stiffness < 30 min, no joint swelling o MCP, PIP, wrist, knees, ankles  transient aplastic anemia  Dx: anti-B19 IgM antibodies  Rx: resolves spontaneous in 2 – 3 wks, no Rx  DDx: RA (arthritis > 6 wks), SLE, rheumatic fever --------------------------------------------------------------- progressive dyspnea, tricuspid regurgitation, peripheral edema: pulmonary HTN due to LV systolic dysfunction 

mean pulmonary arterial pressure ≥ 25 mmHg @ rest (normal ≤ 20 mmHg)  #1 initial Rx: furosemide & ACE-I ---------------------------------------------------------------Impetigo Non-bullous Bullous-type MCC S. aureus or S. aureus Group A Strep feature localized painful, rapidly enlarging s non-itchy pustules flaccid bullae with & honey-crusted yellow fluid, lesions; “collarette” of scale @ lymphadenopathy periphery of lesion Rx topical mupirocin oral ABX (cephalexin, dicloxacillin, clinda) 

secondar y latent tertiary

pregos

congenital syphilis: failure to thrive, meningitis, seizures, congenital defects --------------------------------------------------------------- MCC of complicated influenza pneumonia: S. aureus  MC in hospitalized, nursing homes, IVDA, CF  Gram+ cocci in clusters  Rx: anti-staphylococcal ABX --------------------------------------------------------------- TNM staging is most important prognostic factor in breast cancer --------------------------------------------------------------- depressed patients must be closely monitored for suicidality within the first few weeks of initiating pharmacotherapy; more likely to act on impulses as motivation & initiative improve before a depressed outlook --------------------------------------------------------------- tachypnea, retractions, grunting, nasal flaring, & cyanosis @ birth: respiratory distress syndrome  MCC are immature lungs & surfactant deficiency  risk factors: prematurity, maternal diabetes, cesarean without labor  maternal diabetes delays surfactant maturation due to fetal hyperinsulinemia, which antagonizes cortisol, thus blocks sphingomyelin maturation  CXR: “ground glass” opacities, air bronchograms ---------------------------------------------------------------Cholesterol embolism (atheroembolism) risk cardiac catheterization or angiography; factors with comorbid hypercholesterolemia, 

predisposing factors: warm, humid climates, poverty, crowding, pre-existing skin trauma, atopic dermatitis  prevention: hand-washing  complications: post-strep GN, rheumatic fever --------------------------------------------------------------- melena, episodic gnawing, nocturnal abdominal pain relieved by eating: duodenal ulcer  unopposed acid enters duodenum causing pain  high a/w H. pylori infection  Rx H. pylori-associated PUD: triple therapy with PPI + amoxicillin + clarithromycin  Rx PUD only: PPI or H2 blocker  DDx: gastric ulcer (pain worse with eating) --------------------------------------------------------------- CHF 2/2 restrictive cardiomyopathy, bibasilar rales, right-sided pleural effusion: hemochromatosis  LV volume is normal with symmetric thickening  Rx of hemochromatosis (phlebotomy) can reverse the cardiac dysfunction  DDx: amyloidosis, sarcoidosis, & scleroderma all cause non-reversible cardiac dysfunction ---------------------------------------------------------------Stages of syphilis primary painless chancre Dx: spirochetes on darkfield microscopy Rx: IM benzathine PCN G 1x PCN-allergic: oral doxycycline x14 days 

diffuse rash (+ palms/soles), hepatitis, condyloma lata, lymphadenopathy Rx: IM PCN G 1x PCN-allergic: oral doxycycline x 14 days asymptomatic Rx: IM PCN G 3x doses PCN-allergic: doxycycline x 28 days Tabes dorsalis, Argyll-Robertson pupil, dementia, aortic insufficiency, gummas Rx: IV PCN G x14 days PCN-allergic: ceftriaxone x 14 days intrapartum transmission Rx: PCN G PCN-allergic: desensitize to PCN

DM Type II, HTN livedo reticularis, blue toe syndrome, acute kidney injury, amaurosis fugax, Hollenhorst plaques, intestinal ischemia Dx  Cr, eosinophilia, hypocomplementemia, eosinophiluria confirm Dx: skin or renal Bx (biconcave, needle-shaped clefts within occluded vessel) --------------------------------------------------------------- patient undergoing coronary angiography are at risk for contrast-induced nephropathy  U/A: muddy-brown granular & epithelial casts  Rx: benign, resolves in 3 – 5 days --------------------------------------------------------------- pseudocyesis is a form of conversion disorder  normal endometrial stipe, pregnancy test negative  Rx: psych evaluation  DDx: missed abortion (intrauterine collapsed gestational sac, +pregnancy test), ectopic (adnexal mass & empty uterus, +pregnancy test) --------------------------------------------------------------- neoadjuvant therapy: given before standard Rx  adjuvant therapy: given in addition to standard Rx  induction therapy: initial dose of treatment to rapidly kill tumor cells & induce remission  consolidation therapy: given after induction Rx with multi-drug regimen to further reduce tumor  maintenance therapy: given after consolidation Rx to kill residual tumor cells; keep patient in remission  salvage therapy: Rx for a disease when standard Rx fails (radiation for PSA recurrence after radical prostatectomy) --------------------------------------------------------------- cirrhosis increases risk for HCC, but HCC does not  risk of cirrhosis Management of cirrhosis  periodic surveillance of LFTs, INR, albumin, etc  compensated: asymptomatic or vague symptoms  USS for HCC +/- AFP; every 6 months  decompensated: jaundice, pruritus, upper GI bleed; assess complications o varices: start non-selective β-blockers, repeat EGD annually** o ascites: dietary Na+ restriction, diuretics, paracentesis, abstain from alcohol feature s

hepatic encephalopathy: lactulose, Rx underlying cause --------------------------------------------------------------- childhood Hx of recurrent renal stones, +family Hx, +urinary cyanide nitroprusside screening test, & hexagonal crystals on U/A: cystinuria  defective transport of dibasic amino acids (Lys, Arg)  poor solubility of cysteine leads to renal stones --------------------------------------------------------------- persistent abdo pain or dyspepsia post-op or years after cholecystectomy: post-cholecystectomy syndrome  due to biliary or extra-biliary causes  elevated ALP, mildly abnormal ALT/AST, & dilated common bile duct on USS  MCC: common bile duct stones or sphincter dysFx  Dx: endoscopic USS, then ERCP or MRCP ---------------------------------------------------------------Management of Cushing’s  #1 test: ACTH levels & urinary cortisol  low ACTH  adrenal CT o MCC: exogenous glucocorticoids o exclude adrenal adenoma & hyperplasia  normal/high ACTH  pituitary MRI o mass > 6 mm  dexamethasone supp test  no mass or < 6 mm  inferior petrosal sinus sampling (invasive)  MCC: ACTH-producing pituitary adenoma, ectopic ACTH, or ectopic CRH  ectopic ACTH: rapid onset HTN, hypokalemia, proximal muscle weakness, metabolic alkalosis, hyperglycemia; less likely to have central obesity, moon facies ---------------------------------------------------------------Prevention of recurrent nephrolithiasis dietar fluids (produce > 2 L urine/day) y reduce Na+, reduce protein, reduce oxalate, normal Ca++ intake, increase citrate Rx thiazides (passive Ca++ reabsorption), potassium citrate (urine alkalization), allopurinol (for uric acid stones)  reduced dietary Ca++ leads to  oxalate absorption in the gut  excreted into urine & binds urinary Ca++  Ca++ oxalate stones ---------------------------------------------------------------o

fever, odynophagia, dysphagia, drooling, stiff neck, muffled voice, inability to extend neck & widened prevertebral space: retropharyngeal abscess  MC in age 6 months – 6 yrs  prodrome URI  direct spread of infection  polymicrobial (Group A Strep, S. aureus, anaerobes)  Dx: CT with contrast  complications: airway compromise, bacteremia, carotid artery rupture, jugular venous thrombosis --------------------------------------------------------------- young adult with cirrhosis, neuropsych symptoms, & Kayser-Fleischer rings: Wilson’s (aka hepatolenticular degeneration)  AR inheritance  resting tremor, muscle rigidity, slurred speech, depression, paranoia, catatonia  impaired ceruloplasmin secretion, thus decreased secretion of copper in biliary system  Cu++ deposition in liver, basal banglia, cornea  also a/w Fanconi’s, hemolytic anemia, neuropathy  Dx: liver biopsy, low ceruloplasmin, slit lamp,  urinary Cu++ excretion  #1 Rx: D-penicillamine or trientine o oral zinc prevents copper absorption  #2 Rx: liver transplant --------------------------------------------------------------- liver disease, hyperpigmentation, arthropathy, diabetes, impotence, dilated cardiomyopathy: hemochromatosis --------------------------------------------------------------- productive cough, hemoptysis, recurrent fevers, recent travel: pulmonary TB  chest CT: upper lobe cavitary lesions with surrounding alveolar infiltrates --------------------------------------------------------------- MC benign cutaneous vascular tumor in adults: cherry angioma (aka senile hemangioma)  age 3rd – 4th decade, increases with age  sharply circumscribed areas of congested capillaries & post-capillary venules in papillary dermis  benign, no Rx required --------------------------------------------------------------- MC benign vascular tumor in children: superficial infantile (strawberry) hemangioma 

red, demarcated plaques that blanch grows rapidly in first 1 – 2 yrs of life, then spontaneously regress in childhood  Rx: propranolol if at risk for complications --------------------------------------------------------------- spider angiomas are estrogen dependent  MC in pregos, OCP use, cirrhosis (hyperestrogen)  dilated cutaneous arterioles with a central papule & radiating blanching capillaries --------------------------------------------------------------- recurrent sinopulmonary & GI bacterial infections in adults may indicate humoral immunity defect o a/w food allergies & autoimmune disease  Dx: quantitative serum Ig levels --------------------------------------------------------------- NSAIDs can cause SIADH o NSAIDs potentiate the action of ADH  hypotonic hyponatremia with euvolemia  Dx: r/o hypothyroidism & adrenal insufficiency  Dx: urine & plasma osmolality  low plasma osmolality with high urine osmolality  serum uric acid is low due to  urinary excretion & hemodilution --------------------------------------------------------------- mineralocorticoid deficiency: hypotonic hyponatremia with hypovolemia; elevated K+ --------------------------------------------------------------- nephrotic syndrome & advanced renal failure: hypotonic hyponatremia with hypervolemia ---------------------------------------------------------------  incidence of carpal tunnel syndrome in pregos 2/2 estrogen-mediated depolymerization of ground substance, causing interstitial edema  initial Rx: wrist splinting  #2 Rx: NSAIDS (risk of miscarriage), local corticosteroid injection, surgical decompression ---------------------------------------------------------------Urinary incontinence Stress loss of urethral support, intraabdominal pressure exceeds urethral sphincter leaking with cough, sneeze, laugh, lifting Urge detrusor overactivity sudden, overwhelming, frequent need Overflow impaired detrusor contractility, bladder outlet obstruction  

constant involuntary dribbling & incomplete emptying epidural anesthesia: block afferent & efferent nerves from the bladder; can cause overdistension  post-partum urinary retention: indwelling catheter for 24 hr to decompress the bladder --------------------------------------------------------------- ankylosing spondylitis & IBD (UC) are a/w HLA-B27; may occur together  both are +p-ANCA, despite absence of vasculitis --------------------------------------------------------------- infantile colic: crying ≥ 3 hr/day, ≥ 3 days/wk, for ≥ 3 wks; typically evenings o resolves spontaneously by age 4 months  Rx: calming techniques, reassurance --------------------------------------------------------------- misoprostol: synthetic prostaglandin, used with mifepristone to terminate pregnancies ≤ 49 days --------------------------------------------------------------- cyanosis & respiratory distress immediately after birth, scaphoid-abdomen: congenital diaphragmatic hernia  XR: displaced cardiac silhouette, gasless abdomen --------------------------------------------------------------- acute gout Rx: NSAIDs (indomethacin), colchicine, corticosteroids  prophylactic Rx: allopurinol --------------------------------------------------------------- male pubertal gynecomastia resolves within a few months – 2 yrs without intervention; reassurance --------------------------------------------------------------- antiphospholipid antibody syndrome promotes arterial/venous thromboses & recurrent spontaneous abortions o thrombocytopenia & prolonged PTT  prophylactic Rx: LMWH & low-dose ASA --------------------------------------------------------------- leukopenia & thrombocytopenia in SLE is due to peripheral immune-mediated destruction o pancytopenia is common with SLE --------------------------------------------------------------- alcoholic hepatitis: AST:ALT > 2; < 300 IU/L o also  GGT & ferritin (acute phase reactant) ---------------------------------------------------------------

dermatomyositis is an idiopathic inflammatory myopathy with immune-mediated muscle injury that can be due to a paraneoplastic syndrome from malignancy (lung cancer)  Dx: muscle biopsy --------------------------------------------------------------- Achilles tendon reflex can be decreased or absent with age  lower extremity weakness,  rectal tone, bowel/bladder incontinence, & brisk LE DTRs: possible spinal cord compression --------------------------------------------------------------- ovulatory phase: cervical mucus is profuse, clear & thin, stretches 6 cm, exhibits “ferning”, & pH > 6.5 (more basic than usual) o ideal for spermatozoa entering uterus  pre- & post-ovulatory: scant, opaque, & thick mucus --------------------------------------------------------------- Hx of pelvic surgery or irradiation can develop a urinary fistula  Dx: intravenous pyelography --------------------------------------------------------------- young male with lower abdominal pain, tenesmus, bloody diarrhea with acutely worsening fever, leukocytosis, hypotension, & tachycardia: ulcerative colitis complicated by toxic megacolon  may be the first presentation of UC  Dx: abdominal XR with colonic distension > 6 cm  + 3 signs… o fever > 380C, HR > 120, leukocytosis, anemia  Rx: bowel rest, NG tube, steroids (if UC), ABX o sigmoidoscopy is used to confirm UC, but risk of perforation in toxic megacolon  severe cases: subtotal colectomy & end-ileostomy --------------------------------------------------------------- sulfasalazine: Rx Crohn’s, UC, RA --------------------------------------------------------------- fever, malaise, productive cough, eosinophilia, hemoptysis: allergic bronchopulmonary aspergillosis (ABPA)  hypersensitivity reaction to Aspergillus  MC a/w asthma & CF ---------------------------------------------------------------

academia alone does not lead to CNS depression, but the underlying cause results in lethargy & altered mental status  CO2 retention due to underlying COPD can lead to CO2 narcosis (PaCO2 > 60 mmHg) --------------------------------------------------------------- DIC depletes clotting factors & 20 fibrinolysis  thrombocytopenia, prolonged PT & PTT, decreased fibrinogen, schistocytes --------------------------------------------------------------- predominant unconjugated hyperbilirubinemia o  bilirubin production (hemolysis) o  bilirubin uptake (portosystemic shunt) o abnormal conjugation (Gilbert’s)  predominant conjugated hyperbilirubinemia o hepatocellular injury o  bilirubin excretion in bile canaliculi (Dubin-Johnson) o intrahepatic cholestasis (10 biliary cirrhosis) o extrahepatic cholestasis (biliary obstruction)  normal transaminases & ALP suggest inherited bilirubin metabolism disorders  elevated transaminases & normal ALP suggest intrinsic liver disease (viral, hemochromatosis)  elevated ALP suggest intrahepatic cholestasis or biliary obstruction --------------------------------------------------------------- painless jaundice, fatigue, weight loss, pruritus, acholic stools with dark urine,  ALP,  GGT: malignant biliary obstruction  MCC: adenocarcinoma, cholangiocarcinoma  Dx: USS or CT; ERCP if non-diagnostic  DDx: acute choledocholithiasis (acute RUQ pain), chronic autoimmune hepatitis, chronic pancreatitis --------------------------------------------------------------- elderly patient with hip fracture should undergo definitive surgical correction  surgery can be delayed up to 72 hrs to evaluate surgical risk & address unstable comorbidities ---------------------------------------------------------------Ovarian & adnexal torsion risk factors ovarian mass ≥ 5 cm, reproductive age, infertility Rx with ovulation induction features sudden onset unilateral pelvic pain, tender adnexal mass, N/V, 

Dx Rx

vaginal bleeding is uncommon β-hCG to exclude ectopic pregnancy, USS with color Doppler laparoscopy with detorsion

rotation of ovary around infundibulopelvic (suspensory ligament) & utero-ovarian ligaments  adnexal torsion: includes fallopian tube  MC right-side: longer ligament  DDx: appendicitis, ruptured ovarian cyst, endometriosis, tubo-ovarian abscess --------------------------------------------------------------- gradual onset fever, chills, lower abdominal pain, vaginal discharge: tubo-ovarian abscess  risk factors: multiple partners, young age, Hx of PID --------------------------------------------------------------- ovarian hyperstimulation syndrome: ovarian enlargement from multiple cysts with fluid shifts out of the intravascular space o results in ascites & hypovolemia  complication of gonadotrophin Rx for infertility --------------------------------------------------------------- major depressive disorder (MDD): persistent & pervasive sadness, self-critical ruminations, & suicidality a/w feeling worthlessness & hopeless ≥ 2 wks  can be diagnosed anytime during acute grief; bereavement period is not an exception  Rx: SSRI & psychotherapy --------------------------------------------------------------- electroconvulsive Rx: refractory to antidepressants o #1 Rx if not eating/drinking; acutely suicidal, catatonic, or psychotic --------------------------------------------------------------- first-time DVT with a reversible inciting incident (surgery)  Rx: unfractionated or LMWH within 48 – 72 hrs if hemodynamically stable o prevents extension of the clot & future clots rather than lysis of the present clot o streptokinase & tPA: only Rx STEMI --------------------------------------------------------------- low bone mass with normal mineralization: osteoporosis  normal serum Ca++, phosphorus, PTH, & ALP 

--------------------------------------------------------------- defective mineralization of organic bone matrix: osteomalacia 2/2 Vit D deficiency  defective mineralization of growth plates in kids: rickets ---------------------------------------------------------------Rickets risk  skin pigmentation, factors exclusive breastfeeding, inadequate sun exposure, maternal Vit D deficiency feature craniotabes (“ping-pong ball” skull), s delayed fontanelle closure, frontal bossing, costochondral hypertrophy (rachitic rosary) genu varum XR metaphyseal cupping & fraying, epiphyseal widening, osteopenia labs  Ca++ & phosphorus,  ALP & PTH Rx Vit D fortified baby food or formula; or supplementation --------------------------------------------------------------- Vit D deficiency causes marked hypophosphatemia,  ALP, normal Ca++, secondary hyperPTH  XR:  bone density with thin cortex, “codfish” vertebral bodies, & pseudofractures (Looser zones) --------------------------------------------------------------- large anterior fontanelle, lethargy, poor feeding, macroglossia: congenital hypothyroidism  frontal bossing, anterior shin bowing, saddle-nose, notched/gap teeth: congenital syphilis  “bucket-handle” fx = classic metaphyseal lesion: child abuse --------------------------------------------------------------- large tender, soft-tissue mass with localized pain  MC primary malignant bone tumor in children, MC @ metaphysis of long bones: osteosarcoma o distal femur, proximal tibia & humerus  XR: “sunburst” periosteal rxn, Codman triangle   ALP,  LDH,  ESR (inflammation)  risk factors: Paget’s, radiation & chemotherapy  Rx: tumor excision, chemotherapy --------------------------------------------------------------- deficits in reciprocal social communication, limited play, poor eye contact, speech delay, repetitive behaviors: autism

absence of language delay distinguishes Asperger’s from autism --------------------------------------------------------------- sensorineural deafness, cataracts, purpura, hepatosplenomegaly: congenital rubella --------------------------------------------------------------- young female with fever, rash that started on face that spreads to body that spares palms & soles, joint pain, B/L conjunctival injection, cervical lymphadenopathy: rubella  polyarthritis is MC in young females  Rx: supportive  complication: post-infectious encephalitis  DDx: measles (high fever > 104), RMSF (starts on wrist & ankles, involve palms/soles) --------------------------------------------------------------- liver transplant is the only effective Rx of fulminant hepatic failure (Hep B infection)  fulminant hepatic failure: hepatic encephalopathy that develops within 8 wks of acute liver failure  high mortality rate, high priority for transplant --------------------------------------------------------------- interferon & lamivudine: Rx acute Hep B infection --------------------------------------------------------------- cross-sectional study = prevalence study  simultaneous measure of exposure & outcome  calculate odds ratio --------------------------------------------------------------- case-control study: selects patient with/without outcome, & determine previous exposure status --------------------------------------------------------------- iron stores must be evaluated prior to starting supplemental erythropoietin for CKD/ESRD o Rx: IV iron if on dialysis  A/E: worsening HTN, headache, flu-like syndrome, red cell aplasia --------------------------------------------------------------- rapid testing for Strep pharyngitis for those with ≥ 2 Centor criteria: fever, tonsillar exudates, tender anterior cervical adenopathy, absent cough --------------------------------------------------------------- pagophagia: pica for ice; iron deficiency anemia ---------------------------------------------------------------

influenza: sudden & dramatic onset with systemic symptoms out of proportion to mild nasal & respiratory symptoms  self-limited 3 – 10 days  Rx: oseltamivir (neuraminidase inhibitor) for all confirmed or suspected cases within 48 hrs & those at high risk for complications  Rx > 48 hrs: rest, analgesics, cough suppressants --------------------------------------------------------------- post-exposure prophylaxis of animal bites from a healthy-appearing domesticated animal can be observed for 10 days, without PEP o animals that become sick should be euthanized & brain tested for rabies  start PEP  low-risk animal bite (squirrel, chipmunk): no PEP  exposure to high-risk wild animal (raccoon, bat, skunk)  PEP if animal is unavailable for testing o if available for testing, start PEP, then discontinue if test is negative  PEP: receive both active & passive immunization  rabies vaccine & human rabies Ig o if previously vaccinated  revaccination only --------------------------------------------------------------- symptomatic sinus bradycardia (fatigue, syncope, dizziness, hypotension, angina, CHF)  #1 Rx: identify & Rx reversible causes  #2 Rx: IV atropine  alt Rx: IV epinephrine, dopamine, transcutaneous or transvenous pacing --------------------------------------------------------------- adenosine: transient block of impulse conduction @ AV node; Rx PSVT --------------------------------------------------------------- IV glucagon: Rx β- blocker or CCB toxicity --------------------------------------------------------------- although depressive symptoms can develop in response to a stressor, meeting full criteria for major depressive episode rules out adjustment disorder & grief reaction  symptoms cause significant functional impairment --------------------------------------------------------------- symmetric duskiness & coolness of fingertips/toes: norepinephrine-induced vasospasm o α-1 agonist vasoconstriction results in ischemia & necrosis of distal fingers & toes 

--------------------------------------------------------------- Raynaud’s causes finger ischemia, progressing from pallor  cyanosis  erythema  MC due to cold exposure or stress --------------------------------------------------------------- drug-induced immune hemolytic anemia is a rare complication of ibuprofen  gastric ulcers, GI bleeding, epigastric pain --------------------------------------------------------------- corneal abrasion: absence of eye pain suggests trigeminal nerve (V1) dysfunction, which controls corneal sensation --------------------------------------------------------------- peak airway pressure = airway resistance + plateau pressure  plateau pressure = elastic pressure + PEEP  PEEP is calculated with end-expiratory hold maneuver --------------------------------------------------------------- incidence of a disease is not changed by any Rx  prevalence may be affected by Rx of disease --------------------------------------------------------------- hypercalcemia of immobilization:  osteoclastic bone resorption; pre-existing high bone turnover  median onset: 4 wks after immobilization  prevention: hydration & bisphosphonates --------------------------------------------------------------- MCC of respiratory alkalosis: hyperventilation 2/2 pneumonia, high altitude, salicylate intoxication ---------------------------------------------------------------Obesity & precocious sexual development  adiposity can stimulate sexual hormone production centrally & peripherally  adipocytes cause  insulin &  leptin   insulin stimulates…  adrenal androgens  peripheral adrenarche (body odor, pubic & axillary hair, acne)  risk factor for PCOS, DM Type II   DHEA-S & low testosterone o ovarian estrogen  peripheral thelarche   leptin stimulates activation of… o hypothalamic-pituitary-gonadal axis & pulsatile GnRH  central precocious puberty  LH/FSH stimulation  thelarche ----------------------------------------------------------------

first indicators of hypovolemia:  pulse rate & peripheral vascular constriction to maintain BP --------------------------------------------------------------- acute pain & swelling of mid-line sacrococcygeal skin & subcutaneous tissue: pilonidal cyst  MC in young males with  body hair  infection of hair follicles form an abscess that ruptures, forming a pilonidal sinus tract  Rx: drainage & excision of sinus tracts  DDx: perianal abscess, perianal fistula --------------------------------------------------------------- unexplained CHF with diastolic dysfunction,  ventricular wall thickness with normal LV size, proteinuria, easy bruising: cardiac amyloidosis  waxy skin, macroglossia, hepatomegaly, CTS  AA amyloidosis 2/2 RA, Crohn’s, osteomyelitis, TB, lymphoma, vasculitis  Dx: abdominal fat pad biopsy with amyloid deposits ---------------------------------------------------------------Causes of hyponatremia hypovolemic volume depletion (acute blood loss), hyponatremia primary adrenal insufficiency, GI loss (diarrhea, vomiting, bleed), renal loss (diuretics) euvolemic SIADH (drugs, malignancy), hyponatremia psychogenic polydipsia, secondary adrenal insufficiency, hypothyroidism hypervolemi CHF, cirrhosis, c CKD, nephrotic syndrome hyponatremia 

hypovolemic hyponatremia has appropriate  ADH, also  renin,  angiotensin, &  aldosterone, resulting in hypokalemic metabolic alkalosis  Rx: isotonic saline repletion suppresses ADH & allow kidneys to excrete excess water --------------------------------------------------------------- radial head subluxation (nursemaid’s elbow): axial traction on forearm with elbow extended  arm held extended & pronated  no swelling or deformity  Dx: clinical, radiographs are normal  Rx: closed reduction with forearm supination & elbow flexion, OR forearm hyperpronation 

--------------------------------------------------------------- Trendelenburg sign: weakness of gluteus medius & minimus; or superior gluteal nerve impingement --------------------------------------------------------------- MCC of acute abnormal uterine bleed in adolescent: immature hypothalamic-pituitary-ovarian axis, resulting in anovulatory cycles  anovulation cause persistent endometrial proliferation followed by heavy menses  #1 Dx: r/o pregnancy & bleeding disorders Rx for acute abnormal uterine bleeding if hemodynamically stable…  #1 Rx: high-dose IV or oral conjugated equine estrogen (rapid endometrium regrowth)  Rx: high-dose combined OCPs  high-dose progestin  tranexamic acid (anti-fibrinolytic)  estrogen promotes regrowth of endometrium over the denuded epithelium from heavy bleeding --------------------------------------------------------------- hypoventilation causes respiratory acidosis in the post-ictal state  post-ictal state can be complicated by lactic acidosis 2/2 prolonged, forceful skeletal muscle activity o manifest as metabolic acidosis --------------------------------------------------------------- MCC cause of aplastic anemia in kids: Fanconi’s  short stature, microcephaly, abnormal thumbs, hypogonadism, café-au-lait spots, low-set ears  macrocytic anemia, thrombocytopenia  Dx: chromosomal breaks on genetic analysis  Rx: stem cell transplant --------------------------------------------------------------- prolactin is stimulated by TRH & 5-HT; inhibited by DA  hypothyroidism  TRH/TSH   prolactin   prolactin inhibits GnRH   LH/FSH result in hypogonadism o amenorrhea,  libido,  bone density --------------------------------------------------------------- malaria chemoprophylaxis in areas with chloroquine-resistant P. falciparum o sub-Saharan Africa, south & southeast Asia  Rx: mefloquine (safe for pregos)  alt Rx: doxycycline, atovaquone-proguanil

--------------------------------------------------------------- duodenal atresia 2/2 to Down syndrome requires surgical repair  pre-op cardiac assessment is essential (VSD, ASD) --------------------------------------------------------------- repeated vomiting causes hypokalemic, hypochloremic metabolic alkalosis  loss of H+ as HCl results in HCO3- retention & no stimulus for HCO3- release by pancreas  ECV loss decreases renal perfusion  activates the R-A-A system  aldosterone causes hypokalemia & contraction alkalosis  Rx: IV normal saline & K+ --------------------------------------------------------------- anion gap = Na+ - (HCO3- + Cl-) o normal anion gap: 6 – 12 mEq/L ---------------------------------------------------------------MCC of anion gap metabolic acidosis  lactic acidosis (hypoxia, poor tissue perfusion)  ketoacidosis (DKA, starvation, alcoholism)  methanol ingestion  ethylene glycol ingestion (oxalate accumulation)  salicylate poisoning (with respiratory alkalosis)  uremia (ESRD) --------------------------------------------------------------- venous blood that contains a similar O2 content as arterial blood may indicate cyanide poisoning --------------------------------------------------------------- osmolar gap: calculated for suspected ethanol, methanol, or ethylene glycol toxicity --------------------------------------------------------------- HIV screening test: p24 antigen & HIV antibodies o +result: confirm Dx with HIV-1/HIV-2 antibody differentiation immunoassay  initial HIV screen: 1x scene for age 15 – 65 regardless of risk factors o Rx for TB, Rx for another STD  annual screening for high-risk groups: IVDA, MSM, sex workers, sex partner of +HIV, STD Hx, homeless shelter living, correctional facility  HIV testing with each pregnancy --------------------------------------------------------------- Hep C screening criteria: elevated ALT, +HIV status, HCV risk factors (IVDA Hx, blood transfusion before 1992, chronic hemodialysis)

 sexual contacts of +HCV should be screened --------------------------------------------------------------- suspected acute appendicitis during pregnancy  MC symptom: RLQ pain  Dx: USS with graded compression --------------------------------------------------------------- acute pancreatitis: most patients recover with conservative management in 3 – 5 days  severe acute pancreatitis: +organ failure  local release of activated pancreatic enzymes into the vascular system &  vascular permeability, leads to systemic hypotension, capillary leak, shock, & end-organ damage risk factors features

Dx Rx complications

Severe pancreatitis age > 75, obesity, alcoholism, CXR: infiltrates or pleural effusion fever, hypotension, tachycardia, tachypnea, basilar crackles, abdominal tenderness or distension, worsening BUN, low urine output Cullen sign: periumbilical bluish discoloration; hemoperitoneum Grey-Turner sign: reddish-brown around flanks; retroperitoneal bleed CT or MRCP to look for… pancreatic necrosis & extrapancreatic inflammation supportive, IV fluids to replace lost intravascular volume pseudocyst, necrotizing pancreatitis, peripancreatic fluid collection, ARDS, acute renal failure, GI bleeding

pancreatic pseudocyst: fluid collection surrounded by a necrotic or fibrous capsule o complication of acute pancreatitis; 3 – 4 wks --------------------------------------------------------------- tick bite, acute febrile illness, altered mental status, no rash: Ehrlichiosis (lone star tick) o “RMSF without spots”  SE & south central US  leukopenia & thrombocytopenia,  LFTs & LDH  Rx: empiric doxycycline ---------------------------------------------------------------

ceftriaxone: Rx neuro & cardiac manifestations of Lyme disease --------------------------------------------------------------- furosemide can cause hypoK+ & hypoMg++, leading to V-tach  hypoK+ also potentiates effects of digoxin --------------------------------------------------------------- PSVT: MCC is re-entrant pathway into AV node  sudden onset palpitations & generalized weakness  MCC of paroxysmal tachycardia without structural heart disease  Rx: IV adenosine or vagal maneuvers  AV node conduction to unmask “hidden” P-waves within QRS to clarify Dx of a-flutter or atrial tachycardia o carotid massage, cold water face immersion, Valsalva, eyeball pressure --------------------------------------------------------------- pulseless electrical activity (PEA) Rx: CPR & 

vasopressor (epinephrine every 3 – 5 min) continue CPR & identify reversible causes Reversible causes of asystole/PEA 5 H’s 5 T’s hypovolemia tension pneumoTx hypoxia tamponade H+ ions (acidosis) toxins (narcotics,benzos) hypo- or hyperK+ thrombosis hypothermia trauma  no role for synch. cardioversion or defibrillation --------------------------------------------------------------- synchronized cardioversion: Rx symptomatic or sustained monomorphic VT & hemodynamic unstable a-fib with rapid ventricular response --------------------------------------------------------------- DDx of asthma vs COPD: spirometry before/after inhaled bronchodilator challenge (albuterol) Spirometry  low FEV1/FVC  obstructive disease o after bronchodilator challenge…   FEV1 > 12% = asthma  no change = COPD  normal/high FEV1/FVC, low VC  restrictive  normal DLCO = chest wall weakness, OSA   DLCO = interstitial lung disease (asbestosis) ---------------------------------------------------------------

long-term Rx asthma: inhaled corticosteroids long-term Rx COPD: inhaled long-acting anticholinergic --------------------------------------------------------------- Ebstein’s anomaly causes “atrialization” of the RV  risk factor: lithium exposure in 1st trimester --------------------------------------------------------------- child with fever, preceding acute diarrheal illness, pallor, purpura, acute renal failure: HUS  microangiopathic hemolytic anemia o  LDH, reticulocytosis, thrombocytopenia  schistocytes & giant platelets  U/A: hemosiderin, albumin, RBC & WBC casts --------------------------------------------------------------- elderly patients with iron deficiency anemia require colonoscopy & endoscopy despite a single negative FOBT; MCC is GI blood loss --------------------------------------------------------------- PSA screening: case-by-case basis by physician & patient discussion --------------------------------------------------------------- severe aortic stenosis is a/w GI angiodysplasia resulting in occult GI bleed --------------------------------------------------------------- acute mediastinitis: complication of cardiac surgery 2/2 intraoperative wound contamination  chest pain, fever, tachycardia, leukocytosis, & sternal wound drainage or purulent discharge within 14 days post-op  CXR: widened mediastinum  Rx: surgical debridement & prolonged ABX  Dx: surgical evidence of pus in mediastinum --------------------------------------------------------------- a-fib is common within days after CABG & resolution within 24 hrs; self-limited  Rx: rate control with β-blocker or amiodarone  hemodynamic unstable a-fib with rapid ventricular response Rx: synchronized cardioversion  Rx a-fib > 24 hr after CABG: anticoagulation or cardioversion --------------------------------------------------------------- MCC of bloody diarrhea without fever: E. coli  EHEC produces Shiga toxin, causing inflammatory diarrhea with bloody stools  Dx: stool assay for Shiga toxin  

 Rx: supportive; ABX may  risk of HUS --------------------------------------------------------------- abdominal pain, N/V, Hx recent travel, myositis, periorbital edema, eosinophilia: Trichinellosis  fever, diarrhea, splinter hemorrhages  ingestion of undercooked meat; up to 4 wks  MC in Mexico, China, Thailand ---------------------------------------------------------------Evaluation of chest pain in the ER  if unstable: stabilized, & assess underlying causes (PE, pericarditis, aortic dissection)  if stable: O2, IV access, EKG, CXR o possible ACS & low risk of aortic dissection  Rx ASA --------------------------------------------------------------- premature newborn with poor feeding, abdominal distension, bloody stools: necrotizing enterocolitis  CXR: pneumatosis intestinalis (extravasation of bowel gas into damaged bowel wall) Necrotizing enterocolitis risk factors prematurity, very low birth weight,  mesenteric perfusion (hypotension, congenital heart disease), enteral feeding (formula > breast) features poor feeding, vomiting, blood stools, abdominal distension CXR pneumatosis intestinalis, portal venous gas, pneumoperitoneum Rx supportive, bowel rest, empiric IV ABX, parenteral nutrition, +/- surgery complications septic shock, intestinal strictures, short bowel syndrome, death  DDx: intussusception, milk-protein enterocolitis --------------------------------------------------------------- child with mild/moderate dehydration: oral fluids  child with moderate/severe dehydration: IV bolus o IV isotonic crystalloids only ---------------------------------------------------------------Rx for ischemic stroke symptom onset within 3 – 4.5 hrs, IV alteplase no C/I within 24 hr of stroke onset, ASA no prior anti-platelet Rx recurrent stroke, already on ASA ASA +

stroke, with a-fib (CHADS2)

clopidogrel warfarin

ASA reduces risk of early recurrence of ischemic stroke; continue indefinitely to prevent future strokes  clopidogrel: not for ASA-naïve patients with stroke  unfractionated heparin/LMWH: should be avoided in acute stroke; risk of bleeding ---------------------------------------------------------------Evaluation of suspected gastrinoma  initial test: endoscopy shows thickened gastric folds & stomach/duodenal ulcers  next: fasting serum gastrin (off PPI for 1 wk)  if gastrin < 100 pg/mL = no gastrinoma  if gastrin > 1000  check gastric pH o pH < 4 requires testing to localize gastrinoma o pH > 4 = no gastrinoma  if gastrin is 110 – 1000  secretin stimulation test o secretin stimulates gastrin release by gastrinoma  normal G-cells are inhibited by secretin --------------------------------------------------------------- Turner’s is prone to osteoporosis 2/2 low estrogen due to gonadal dysgenesis  Rx: HRT --------------------------------------------------------------- Hx of nocturnal teeth grinding, pain with chewing, referred ear pain: TMJ dysfunction  Rx: nighttime bite guard or surgery --------------------------------------------------------------- non-glomerular hematuria: gross hematuria with normal-appearing RBCs, no proteinuria  glomerular hematuria: microscopic hematuria, MC due to glomerulonephritis or BM disease; proteinuria, dysmorphic RBCs or RBC casts --------------------------------------------------------------- proteinuria, transient gross hematuria following acute pharyngitis: IgA nephropathy  hematuria within 5 days of URI (synpharyngitic) --------------------------------------------------------------- MCC of papillary necrosis: “NSAID” o NSAIDs, Sickle cell disease, Analgesic abuse, Infection (pyelonephritis), Diabetes --------------------------------------------------------------- bronchoalveolar lavage: samples lung cells 

Dx: suspected malignancy & opportunistic infection Dx: suspected PCP pneumonia o non-productive cough, progressive dyspnea, weight loss, tachypnea o CXR: B/L interstitial alveolar infiltrates o Dx sputum induction with hypertonic saline o Dx: bronchoalveolar lavage if sputum is not diagnostic --------------------------------------------------------------- proximal deep veins (iliac femoral, popliteal) of LE are the MC sources of symptomatic PE --------------------------------------------------------------- adolescent female with hirsutism, irregular menses, acne,  17-hydroxyprogesterone: CAH 2/2 partial deficiency of 21-hydroxylase  precocious puberty in boys  concomitant aldosterone deficiency results in salt wasting  androgen excess impairs hypothalamic sensitivity to progesterone, resulting in  GnRH secretion,  LH/FSH   gonadal steroids  DDx: classic CAH 2/2 21-hydroxylase deficiency (infant virilization & salt wasting), Cushing’s (hypercortisolism), PCOS (amenorrhea) --------------------------------------------------------------- diastolic rumble at the apex may be heard in a large VSD due to  flow across mitral valve  Dx: echo to determine location & size of defect  complications: pulmonary HTN & Eisenmenger’s --------------------------------------------------------------- infant with meningitis, nuchal rigidity, lethargy, large purpuric lesions, hypotensive: adrenal hemorrhage 2/2 meningococcemia (Waterhouse-Frederickson syndrome)  sudden vasomotor collapse & purpuric skin rash  MCC of death: adrenal gland failure ---------------------------------------------------------------Features of hypopituitarism  central hypothyroidism  amenorrhea, infertility, loss of libido, small testes  ACTH/cortisol deficiency (20 adrenal insufficiency): pale skin, fatigue, hyponatremia, hypoglycemia, eosinophilia  normal aldosterone, normal serum K+ --------------------------------------------------------------- 

fever, progress to abdominal pain & salmon-colored rash, then hepatosplenomegaly with intestinal bleed: typhoid fever --------------------------------------------------------------- gout begins with asymptomatic hyperuricemia & progression to monoarticular arthritis o swelling & pain in great toe due to deposition of monosodium urate = podagra  uric acid in renal tubules = nephrolithiasis  chronic urate deposits in soft tissues = tophi  risk factors: HCTZ enhance uric acid reabsorption ---------------------------------------------------------------Dx panic disorder  ≥ 1 unexpected full-symptom panic attack  Dx: clinical; drug screen, monitor vital signs, EKG, & cardiac enzymes Rx panic disorder  immediate: benzo, then tapered  long-term: SSRI/SNRI &/or CBT ---------------------------------------------------------------Water-soluble vitamin deficiencies Wernicke-Korsakoff, B1 (thiamine) peripheral neuropathy (dry), dilated cardiomyopathy (wet) angular cheilosis, stomatitis, B2 (riboflavin) glossitis, seborrheic dermatitis, normocytic anemia pellagra (dermatitis, diarrhea, B3 (niacin) dementia, death) glossitis cheilosis, stomatitis, glossitis, B6 (pyridoxine) irritability, confusion, depression megaloblastic anemia, NTDs B9 (folate) megaloblastic anemia, B12 (cobalamin) confusion, paresthesia, ataxia scurvy (punctate hemorrhage, C (ascorbic acid) gingivitis, corkscrew hair), ecchymosis, petechiae 

angular cheilosis: fissures at corners of lips glossitis: hyperemic tongue stomatitis: hyperemic/edematous oropharyngeal mucous membranes, sore throat ---------------------------------------------------------------  

hard, unilateral, non-tender solitary submandibular or cervical lymph nodes in an older patient with smoking Hx: SCC head & neck cancer  Dx: panendoscopy & biopsy --------------------------------------------------------------- painful, fluctuant cervical lymphadenopathy: bacterial infection ---------------------------------------------------------------DDx of hyperandrogenism in females  PCOS  non-classic CAH  ovarian/adrenal tumors  hyperprolactinemia  Cushing’s syndrome  acromegaly --------------------------------------------------------------- H1-antihistamines (diphenhydramine, chlorpheniramine, hydroxyzine) have significant anticholinergic effects 2/2 inhibition on muscarinic receptors  urinary retention results from detrusor inactivity controlled by pelvic splanchnic nerves --------------------------------------------------------------- midazolam: induce conscious sedation during medical procedure --------------------------------------------------------------- young boy with headache, vomiting, bitemporal hemianopsia, & calcified lesion above sella: craniopharyngioma  located suprasellar & inferior to optic chiasm  a/w diabetes insipidus; growth failure 2/2 hypothyriodism or GH deficiency  Dx: MRI; cystic calcified parasellar lesion  Rx: surgical removal --------------------------------------------------------------- Brown-Sequard: damage to lateral spinothalamic  C/L loss of pain & temp, 2 levels below lesion  I/L motor weakness, spasticity, loss of vibration & proprioception 1 – 2 levels below the lesion  I/L loss of all sensation at the lesion level --------------------------------------------------------------- B/L lower extremity edema, stasis dermatitis, & venous ulcerations 2/2 venous insufficiency 

 pressures in post-capillary venules damages capillaries causing loss of fluids, plasma proteins, & RBCs into tissues  RBC extravasation cause hemosiderin deposition & discoloration; MC @ above medial malleolus  Rx: leg elevation, exercise, compression stocking o if refractory  venous duplex USS o Rx: endovenous ablation --------------------------------------------------------------- Ludwig’s angina: infection of submandibular & sublingual glands 2/2 tooth infection  rapidly progressive B/L cellulitis, firm induration of submandibular space  dysphagia, drooling, fever, palpable crepitus  MCC of death: asphyxiation 2/2 airway constriction  Rx: ABX & tooth removal --------------------------------------------------------------- fever, acute monoarthritis, hot, swollen joint with  ROM,  ESR & CRP: septic arthritis  risk factors: underlying joint abnormality (RA, OA, gout, prosthetic joint), intra-articular glucocorticoid joint injections  Dx: synovial fluid analysis show leukocytosis >50,000, +Gram stain, culture  Rx G+ cocci: IV vancomycin  Rx G- rod: IV 3rd gen cephalosporin  Rx negative microscopy: vancomycin --------------------------------------------------------------- most significant risk factor for stroke = HTN  4x increased risk for all stroke types ---------------------------------------------------------------

 standard deviation of normal distribution ----------------------------------------------------------------

Hx of blunt trauma or MVA, CXR with left lower lung opacity, elevated hemidiaphragm, & mediastinal deviation: diaphragmatic rupture  confirm Dx: abdominal & chest CT --------------------------------------------------------------- hemineglect: right (non-dominant) parietal lobe --------------------------------------------------------------- provoked seizure 2/2 severe hyponatremia  Rx: 3% saline, corrected @ 0.5 mEq/L/hr to avoid osmotic demyelination or central pontine myelinosis 2/2 rapid correction of hyponatremia with excess water moving intra-  extracellularly  DDx: rapid correction of hypernatremia results in cerebral edema --------------------------------------------------------------- MCC of death from acromegaly: cardiovascular o excess IGF-1  risk of coronary heart disease, cardiomyopathy, arrhythmias, LVH, & diastolic dysfunction --------------------------------------------------------------- brain death is a clinical Dx o absent cortical & brain stem functions  HR does not accelerate after atropine injection due to absence of vagal control  spinal cord may be intact: DTRs present --------------------------------------------------------------- newborn with tachycardia, warm/flushed skin, poor feeding, irritability, low birth weight, maternal Hx of Graves’: neonatal thyrotoxicosis  transplacental passage of maternal anti-TSH Rc antibodies that bind to infant’s TSH receptors  can occur despite maternal Rx for Graves’  Dx: maternal anti-TSH Rc antibodies  self-limited in 3 months o Rx: methimazole + β-blocker to prevent A/E on developing nervous system --------------------------------------------------------------- long-term tobacco use, chronic cough, JVD, barrel-shaped chest, & hepatomegaly: COPD with cor pulmonale  cor pulmonale: RV dysfunction caused by pulmonary HTN due to underlying lung disease (COPD), OSA, or pulmonary arterial HTN  dyspnea, angina, syncope, peripheral edema, RV S3  Dx: clinically & echo 

definitive Dx: right heart catheterization showing  pulmonary artery systolic pressure (> 25) --------------------------------------------------------------- portal HTN:  portal venous resistance  2/2 cirrhosis or extrahepatic portal vein thrombosis  palmar erythema, spider angiomata, caput medusae, gynecomastia  complications: ascites, SBP, variceal bleeding --------------------------------------------------------------- Rx acute psychosis: 2nd gen antipsychotic o lorazepam as adjunct only for agitation --------------------------------------------------------------- recent cardiac catheterization, anticoagulation with heparin, sudden onset hypotension, tachycardia, flat neck veins, & back pain: retroperitoneal hematoma 2/2 bleeding from arterial access site  arterial puncture sites above the inguinal ligament can extend into retroperitoneal space  Dx: non-contrast CT  Rx: supportive, bed rest, IV fluids, transfusion  avoid strenuous activity for one week --------------------------------------------------------------- preterm fetus with severe congenital anomalies incompatible with life (B/L renal agenesis)  Rx: spontaneous vaginal delivery --------------------------------------------------------------- unilateral breast pain with isolated, firm, tender, erythematous area, & fever: mastitis  Rx: frequent breastfeeding or pumping, analgesia, anti-Staph ABX  DDx: breast abscess, plugged ducts, engorgement ---------------------------------------------------------------Iron poisoning  elemental iron is corrosive to GI mucosa  free radical production & lipid peroxidation feature 30 min – 4 days: abdominal pain, s hematemesis, melena, hypotensive shock within 2 days: hepatic necrosis within 2 – 8 wks: pyloric stenosis 2/2 gastric scarring Dx anion gap metabolic acidosis, serum iron, XR: radiopaque tablets Rx whole bowel irrigation, IV deferoxamine (binds ferric iron  urinary excretion)  pre-natal vitamins appear as radiopaque on XR 

--------------------------------------------------------------- progressively worsening dyspnea, bibasal crepitus. S3, cardiomegaly, macrocytosis,  AST > ALT: dilated cardiomyopathy 2/2 alcoholism, resulting in CHF  Rx: abstinence from alcohol reverses disease process  Rx: ACE-I slows progression  Rx: digoxin for systolic dysFx & rapid ventricular rates due to a-fib or a-flutter --------------------------------------------------------------- young healthy female with recent upper URI with sudden onset CHF: dilated cardiomyopathy 2/2 acute viral myocarditis  MCC Coxackie B virus  Dx: echo shows dilated ventricles & diffuse hypokinesia, resulting in low EF  Rx: supportive, manage CHF symptoms --------------------------------------------------------------- concentric hypertrophy: 2/2 chronic pressure overload (valvular stenosis)  eccentric hypertrophy: 2/2 chronic volume overload (valvular regurgitation) --------------------------------------------------------------- chronic mitral stenosis can cause RV hypertrophy & RV heave 2/2 pulmonary HTN --------------------------------------------------------------- young female with chronic anterior knee pain, worse with climbing stairs on knee extension: patellofemoral syndrome  a/w chronic overuse  Dx: patellofemoral compression test  Rx: exercises to stretch & strengthen thigh muscles --------------------------------------------------------------- MC renal stones: calcium  high protein diet is a/w calcium stones  increased Na+ intake enhances Ca++ excretion  Dx: CT without contrast detects radiopaque & radiolucent (uric acid) stones  Rx:  dietary protein, oxalate, & Na+ o  fluids & dietary Ca++  hypercalciuria & recurrent stones Rx: HCTZ --------------------------------------------------------------- acute acetaminophen overdose: N/V or asymptomatic for 24 hr

acute ASA poisoning: tinnitus, fever, hyperpnea (respiratory alkalosis), & metabolic acidosis --------------------------------------------------------------- acute Vit A overdose: N/V, blurry vision, dry skin  chronic Vit A toxicity: pseudomotor cerebri --------------------------------------------------------------- abrupt onset B/L flaccid paralysis, loss of pain & temp sensation below the lesion  anterior cord syndrome 2/2 spinal cord infarct MC due to thoracic aortic aneurysm repair  anterior spinal artery is dependent on blood supply from radicular arteries of thoracic aorta  UMN signs develop over days to weeks  vibration & proprioception are intact --------------------------------------------------------------- sudden, painless loss of vision in one eye, with pallor of optic disc, cherry red fovea, & boxcar segmentation of blood in retinal veins: central retinal artery occlusion --------------------------------------------------------------- premature atrial contractions (PACs)  Rx if symptoms cause stress or SVT: β-blocker  avoid precipitating factors: alcohol, tobacco, stress --------------------------------------------------------------- post-MI secondary prevention; mortality benefits o ASA, β-blocker, ACE-I, statin  add clopidogrel for unstable angina/NSTEMI, & post-PCI  clopidogrel is an ASA alternative  clopidogrel + ASA for post-PCI is more effective than ASA alone; prevents subacute stent thrombosis  clopidogrel for STEMI with primary PCI --------------------------------------------------------------- LMWH: only Rx post-MI for 48 hrs or until angiography is performed o not necessary after hospital discharge ---------------------------------------------------------------Lung cancer types location associations adenocarcinom peripheral, clubbing, a solitary hypertrophic (non-smokers) osteoarthropathy SCC central, (squ-Ca++mous) necrosis & hypercalcemia cavitation 

small cell carcinoma large cell carcinoma

central peripheral

Cushing’s, SIADH, Lambert-Eaton gynecomastia, galactorrhea

large, peripheral, irregular pulmonary nodule a/w hemoptysis & weight loss: adenocarcinoma --------------------------------------------------------------- painless, monocular vision loss, photopsia (light flashes), floaters, & “curtain coming down over my eyes”: retinal detachment  grey, elevated retina  Rx: laser therapy & cryotherapy --------------------------------------------------------------- sudden loss of vision & onset of floaters: vitreous hemorrhage  MCC: proliferative diabetic retinopathy  fundoscopy: loss of fundus detail, floating debris, dark red glow --------------------------------------------------------------- mask-like, immobile facial expression, bradykinesia, resting tremor, & fenestrating, hypokinetic gait: Parkinson’s  substantia nigra degeneration &  DA activity with  anticholinergic activity --------------------------------------------------------------- waddling gait: muscular dystrophy  spastic gait: UMN lesions (cerebral palsy)  wide-based, high-stepping gait: sensory ataxia, loss of proprioception  staggering gait: vestibular ataxia, a/w vertigo & nystagmus  broad-based gait: multiple system atrophy --------------------------------------------------------------- non-tender ulcer on penis shaft with raised border & smooth base, B/L inguinal lymphadenopathy: primary syphilis (chancre)  Dx: dark field microscopy o also HIV screening with ELISA --------------------------------------------------------------- first-degree heart block: no further evaluation  a/w risk of heart failure, a-fib, & mortality  first-degree heart block with prolonged QRS likely have conduction delays below AV node o Dx: electrophysiology testing 

--------------------------------------------------------------- lactose intolerance Dx: hydrogen breath test  indicates bacterial CHO metabolism --------------------------------------------------------------- resting “pill-rolling” tremor in Parkinson’s starts in one hand, progress to other extremities  more pronounced with distractibility (mental tasks) --------------------------------------------------------------- physiologic tremor: benign postural tremor (holding arms ourstretched); usually not visible; low amplitude, high frequency o worsens with emotions, stress, caffeine --------------------------------------------------------------- anterior urethra injury: distal to urogenital diaphragm  MCC: straddle injuries, urethra instrumentation  perineal tenderness or hematoma, bleeding urethra, normal prostate --------------------------------------------------------------- posterior urethra injury: contains prostatic & membranous urethra  MC a/w pelvic fractures  high-riding prostate, suprapubic pain, blood at urethral meatus, scrotal hematoma, inability to void, distended bladder --------------------------------------------------------------- long-term prognosis of STEMI: duration of time before restoration of coronary blood flow o PTCA door-to-balloon time: < 90 min o fibrinolysis door-to-needle time: < 30 min --------------------------------------------------------------- androgens are produced in adrenals  estrogens are formed through conversion of androgens by aromatase in granulosa cells of the ovary in child-bearing women o aromatase activity in ovaries ceases after menopause  peripheral fat tissue also contains aromatase  conversion of adrenal androgens to estrogen by adipose tissue alleviates menopausal symptoms & mild hot flashes  estrogen is not produced in peripheral fat ----------------------------------------------------------------

initial menstrual cycles in pubertal females are usually irregular & anovulatory 2/2 immaturity of the hypothalamic-pituitary-gonadal axis  endometrium builds up under estrogen influence in absence of progesterone o progesterone is produced by corpus luteum following ovulation; withdrawal of progesterone as corpus luteum degenerates results in menses  menstrual-like bleeding occurs due to estrogen break-through bleeding --------------------------------------------------------------- acute severe anemia with low/absent reticulocytes in patient with sickle cell disease: aplastic crisis o transient arrest of erythropoiesis results in a severe drop in Hb  MCC: parvovirus B19  Rx: blood transfusion  DDx: aplastic anemia (pancytopenia), hyperhemolytic crisis (appropriate reticulocytosis), splenic sequestration (persistent reticulocytosis & rapidly enlarging spleen) --------------------------------------------------------------- neonatal tetanus: MC in infants of unimmunized mothers, following umbilical stump infection  within 1st 2 wks of birth  poor suckling, fatigue, rigidity, spasm, opisthotonus  MCC of death: apnea or septicemia --------------------------------------------------------------- pulmonary contusion is not clinically evident immediately after injury; hypoxia & respiratory distress develops hours later as pulmonary edema sets in  IV fluids may exacerbate hypoxia  CXR: patchy, irregular alveolar infiltrates  DDx: myocardial contusion ( PCWP) ---------------------------------------------------------------Screen for developmental dysplasia of hips (DDH)  age 0 – 12 months  serial hip exam at each visit until walking  +Barlow or +Ortolani  refer to orthopedics  asymmetric inguinal folds extending beyond the anal aperture, & negative Barlow/Ortolani…  hip laxity at birth resolves by age 2 wks  age 2 wks – 6 months  hip USS 

 age ≥ 4 – 6 months  hip XR Rx: Pavlik hip harness for infants < 6 months complications of delayed Dx: Trendelenburg gait, scoliosis, arthritis, avascular necrosis --------------------------------------------------------------- Barlow method identifies a loose hip that can be pushed out of the socket with gentle pressure  Ortolani method identifies a dislocated hip that can be reduced into the socket; audible “clunk”; confirms Barlow  “B comes before O” o Barlow: we are going out tonight; hip can be popped out o Ortolani: Oh, it’s time to gO home; femoral head is reduced --------------------------------------------------------------- screening occult spina bifida: lumbosacral USS  abnormal USS  spinal MRI --------------------------------------------------------------- early pregnancy: N/V, bloating, constipation  serum quantitative pregnancy test can be positive within 4 days of implantation  urine pregnancy test may take one week  Dx: pelvic USS for intrauterine vs. ectopic --------------------------------------------------------------- sensitivity determines how well a test identifies people with disease (to rule it out; SNOUT)  specificity determines how well a test identifies people without disease (to rule it in; SPIN) --------------------------------------------------------------- tick-borne paralysis: absence of prodrome fever, rapidly ascending paralysis, normal CSF  Rx: meticulous search for tick results in spontaneous improvement  DDx: Guillain-Barre (ascending symmetrical paralysis, albuminocytologic dissociation) ---------------------------------------------------------------2nd degree AV block Mobitz I Mobitz II blockage AV node below AV node EKG progressive PR PR & R-R prolongation remain constant leads to a unpredictable nonconducted nonconducted P-wave P-wave  

QRS narrow narrow or wide exercise or improves worsens atropine AV block AV block vagal maneuvers worsens improves risk of complete low risk, high risk; heart block benign pacemaker  AV node blockers: digoxin, β-blockers, CCB --------------------------------------------------------------- unexplained syncope evaluation: EKG  prolonged PR & QRS suggests intermittent bradyarrhythmia or high-grade AV block  isolated PVCs with normal EF is not a/w syncope ---------------------------------------------------------------Rx symptomatic ureteral stone < 1 cm  hydration  pain control  α-blocker (tamsulosin) facilitate stone passage --------------------------------------------------------------- bethanechol: cholinergic agonist; Rx urinary retention, atonic bladder  oxybutynin: anticholinergic; Rx overactive bladder (detrusor instability)  imipramine: TCA with anticholinergic activity; Rx childhood enuresis --------------------------------------------------------------- Mg++-sulfate toxicity: depression of DTRs & respiratory depression o Mg++ blocks neuromuscular transmission & cause CNS depression  Rx: Ca++ gluconate, stop Mg++-sulfate, monitor DTRs ---------------------------------------------------------------Neonatal respiratory distress syndrome  tachypnea (RR > 60/min), grunting, nasal flaring, intercostal retractions, cyanosis  surfactant deficiency results in alveolar collapse & diffuse atelectasis  risk factors: prematurity, very low birth weight  CXR: diffuse, reticulogranular (ground-glass) opacities, bronchograms  Rx: continuous PAP ventilation --------------------------------------------------------------- MCC of respiratory distress in full-term infants: transient tachypnea of the newborn

inadequate alveolar clearance at birth results in mild pulmonary edema  CXR: B/L perihilar linear streaking  resolves by day 2; no long-term sequelae --------------------------------------------------------------- persistent pulmonary HTN of the newborn should be suspected in all term & post-term neonates with cyanosis  high pulmonary vascular resistance result in right-to-left shunting of deoxygenated blood through foramen ovale & ductus arteriosus  tachypnea & severe cyanosis  CXR: clear lungs,  vascularity --------------------------------------------------------------- dry cough, weight loss, right arm pain, smoking Hx: superior sulcus tumor  compressive symptoms: Horner’s, hoarse voice, SVC syndrome, Pancoast syndrome (brachial plexus invasion @ C8, T1)  shoulder pain radiating in ulnar distribution --------------------------------------------------------------- swelling of head, neck, & arms upon waking; plethoric face, engorged chest veins, smoking Hx: superior vena cava syndrome  MCC: small cell lung cancer, non-Hodgkin’s  Dx: CXR with F/U CT & histology --------------------------------------------------------------- painful, red corneal opacification & ulceration a/w contact lens use: contact lens keratitis o medical emergency!!  MCC: Pseudomonas  Rx: topical ABX  DDx: anterior uveitis, viral conjunctivitis, episcleritis --------------------------------------------------------------- MC benign primary intracardiac tumor in LA: cardiac myxoma  fever, weight loss, Raynaud’s  mimics mitral valve disease; obstruction of blood flow across mitral valve, early diastolic rumble  complication: systemic embolization (stroke, TIA)  Dx: TEE  Rx: surgical resection ---------------------------------------------------------------

chest pain, fever, chills, cough, purulent sputum, bronchial breath sounds, dullness to percussion, TVF, & egophony: lobar pneumonia --------------------------------------------------------------- unregulated spontaneous bladder contractions that are unresponsive to cortical inhibition: urge incontinence (detrusor instability) overactive --------------------------------------------------------------- cirrhosis & portal HTN is a/w ascites & peripheral edema 2/2 low albumin  hepatic hydrothorax can cause transudative pleural effusion 2/2 cirrhosis without underlying cardiac or pulmonary disease  #1 Rx: salt restriction & diuretics  #2 Rx: TIPS for refractory cases  definitive Rx: liver transplant --------------------------------------------------------------- pleurodesis: prevents recurrent pleural effusion or pneumothorax o pleural space is artificially obliterated by adhesion of the two pleurae --------------------------------------------------------------- sickle cell trait patients are generally asymptomatic  MC complication: painless hematuria  isosthenuria: impaired concentrating ability presents as nocturia & polyuria --------------------------------------------------------------- “halo around lights”  gradual onset blurred vision, difficulty with nighttime driving & fine print, glare: cataract  oxidative damage with aging causes progressive lens thickening & loss of transparency  risk factors: advancing age, diabetes, smoking, chronic sun exposure, glucocorticoid use --------------------------------------------------------------- iron deficiency anemia is common in elderly taking NSAIDs & ASA, resulting in chronic GIT blood loss  elderly have low-grade chronic anemia at baseline; “idiopathic anemia of aging”  evaluation: CBC, iron studies, FOBT  definitive Dx: upper GI endoscopy  Rx: withhold NSAIDS & ASA, initiate PPI ---------------------------------------------------------------

non-traumatic subarachnoid hemorrhage is MC due to ruptured saccular or berry aneurysm  #1 Dx: non-contrast CT shows hyperdense regions  suspected SAH with negative CT requires lumbar puncture o  opening pressure & xanthochromia  Rx: cerebral angiography & surgical clipping --------------------------------------------------------------- night terrors occur during non-REM sleep  episodes of fear, screaming, crying, child cannot be fully awakened; no recollection of the incident  triggered by acute stress, sleep deprivation, illness, medications affecting CNS  DDx: nightmares (during REM, does not cry, scream, or tachycardic; can recall incident) --------------------------------------------------------------- hypokalemia, hypochloremia, metabolic alkalosis, & normotensive: surreptitious vomiting  DDx: diuretic abuse (high urine chloride) --------------------------------------------------------------- meningococcal meningitis: highly contagious  Rx: isolation, IV ABX, ICU setting --------------------------------------------------------------- hCG is secreted by syncytiotrophoblast  doubles every 48 hr, peaks @ 6 – 8 wks gestation  maintains corpus luteum, which maintains progesterone secretion until placenta takes over  also promotes male sexual differentiation  also stimulates maternal thyroid --------------------------------------------------------------- progesterone inhibits uterine contractions during pregnancy  estrogen induces prolactin during pregnancy --------------------------------------------------------------- S4 can be heard during acute phase of MI due to ischemia induced myocardial dysfunction  can be normal in healthy older adults --------------------------------------------------------------- paradoxical splitting of S2 seen with myocardial ischemia/infarction due to delayed myocardial relaxation & delayed aortic valve closure --------------------------------------------------------------- pulsus paradoxus seen with cardiac tamponade, severe asthma, COPD, hypovolemic shock ---------------------------------------------------------------

Crohn’s or fat malabsorption are predisposed to hyperoxaluria 2/2  oxalate gut absorption, leads to oxalate stone formation  fatty acid absorption & bile salt recycling are reduced in Crohn’s  normally, Ca++ binds oxalate in the gut, thus preventing its absorption  in fat malabsorption, Ca++ preferentially binds fat, leaving oxalate unbound & absorbed in the gut  also, failure to absorb bile salts damages colonic mucosa, contributing to oxalate absorption --------------------------------------------------------------- first unprovoked VTE: age-appropriate screening (colonoscopy, mammogram) & CXR can identify occult malignancy  unprovoked & recurrent VTE (thrombophlebitis, DVT), smoking Hx, back pain, & weight loss requires further workup: CT chest/abdomen/pelvis --------------------------------------------------------------- osteonecrosis is a common complication of sickle cell anemia 2/2 vaso-occlusion  MC sites: humeral & femoral heads --------------------------------------------------------------- Charcot arthritis: joint destruction 2/2 deterioration of proprioception, pain & temp  MC a/w diabetic neuropathy, syringomyelia, spinal cord injury, Vit B12 def, tabes dorsalis --------------------------------------------------------------- infection can precipitate DKA due to systemic release of insulin counterregulatory hormones: catecholamines & cortisol o resultant excess glucagon causes hyperglycemia, ketnonemia, & osmotic diuresis  depletion of total body K+ stores  osmotic diuresis activates the R-A-A system, thus accelerates K+ loss  osmotic diuresis  urinary excretion of glucose, ketones, Na+, Mg++, & phosphate --------------------------------------------------------------- tumor lysis syndrome MC a/w Burkitt’s, ALL   Ca++,  phosphate,  K+,  uric acid o K+ & phosphate are intracellular ions o released phosphate binds Ca++  Rx: allopurinol reduces acute urate nephropathy ---------------------------------------------------------------

dry beri beri: symmetric peripheral neuropathy with sensory & motor impairments  wet beri beri: neuropathy + cardiac involvement (cardiomegaly, cardiomyopathy, CHF) --------------------------------------------------------------- denial: behaving as if an aspect of reality does not exist; block acceptance of external sensory data  repression: blocking upsetting feelings from entering consciousness; blocking inner states  dissociation: disrupting memory, identity, & consciousness to cope with an event  isolation of affect: separating a though from its emotional component --------------------------------------------------------------- sublimation: channeling impulses into socially acceptable behaviors  suppression: putting unwanted feelings aside to cope with reality --------------------------------------------------------------- transabdominal USS cannot visualize gestational sacs when β-hCG < 6,500  transvaginal USS can visualize an intrauterine gestational sac when β-hCG @ 1500+ o #1 Dx: r/o ectopic pregnancy o failure to detect intrauterine or adnexal sac, serial β-hCG is required in 48 hrs  normal pregos, β-hCG doubles every 48-72 hrs until 10,000 - 20,000 IU/mL  ectopic pregnancies, β-hCG levels increase less --------------------------------------------------------------- respiratory alkalosis causes H+ dissociation from albumin   albumin-Ca++   ionized Ca++  total Ca++ is unchanged  crampy pain, paresthesia, carpopedal spasm  DDx: acidosis   ionized Ca++ --------------------------------------------------------------- stool sample with oocysts on modified acid-fast staining: Cryptosporidium parvum  severe diarrhea with malaise, nausea, anorexia MC seen in HIV CD4 < 180 ---------------------------------------------------------------Management options of ectopic pregnancy  Expectant: asymptomatic & no evidence of rupture or hemodynamic instability o demonstrates declining β-HCG levels 

tension (closed) pneumoTx: air within pleural space pushes mediastinum to the opposite side, obstructing venous return  Rx: needle thoracostomy (2nd IC, mid-clavicular) before CXR or IV access for fluid resuscitation --------------------------------------------------------------- dry eyes, photophobia, difficulty adapting to darkness, dry scaly skin, follicular hyperkeratosis on extensors: Vit A deficiency  MC @ age 2 – 3 yrs  keratomalacia (wrinkled, cloudy cornea)  Bitot spots (dry, silver-gray plaques on bulbar conjunctiva) --------------------------------------------------------------- sore throat, cheilitis, hyperemic & edematous oropharyngeal mucous membranes, stomatitis, glossitis, photophobia, normocytic anemia, seborrheic dermatitis: riboflavin (B2) deficiency --------------------------------------------------------------- ecchymosis, petechiae, hyperkeratosis, Sjogren’s, arthralgias, depression, neuropathy, coiled hair: Vit C deficiency ---------------------------------------------------------------

Methotrexate: single-dose IM injection o Rx unruptured ectopic pregnancy o hemodynamic stability, normal baseline liver & renal function  Laparoscopy: last resort Dx of ectopic ---------------------------------------------------------------Sodium bicarbonate therapy  Rx TCA overdose by alleviating depressant action on myocardial sodium channels when QRS > 100  Rx salicylate/ASA overdose by alkalinizing urine  Rx severe hyperK+ by driving extracellular K+ into cells --------------------------------------------------------------- child with acute, U/L cervical lymphadenitis, tender, rapidly enlarging & fluctuant  MCC: Strep pyogenes, S. aureus  Rx: I&D + clindamycin (covers Strep & Staph) --------------------------------------------------------------- child with U/L cervical lymphadenitis & Hx of periodontal disease or dental caries  MCC: anaerobes  Rx: clindamycin or amoxicillin/clavulanate --------------------------------------------------------------- amoxicillin covers streptococcal infections, but not S. aureus, which produce β-lactamase --------------------------------------------------------------- dyspnea on exertion, weakness, fatigue, chest pain, hemoptysis, clear lungs: pulmonary HTN  mean pulmonary artery pressure > 25 at rest  CXR: prominent pulmonary arteries with rapid tapering of distal vessels (pruning) & enlarged right heart border  untreated complication: cor pulmonale --------------------------------------------------------------- severe persistent bronchial asthma requiring multiple medications, recent weight gain, HTN, bruising, acne, proximal muscle weakness: Cushing’s 2/2 excess systemic corticosteroids  hypokalemia due to corticosteroids which have mineralocorticoid activity that bind aldosterone Rc  Rx: spironolactone --------------------------------------------------------------- morning stiffness, deformities, enthesitis, dactylitis “sausage digits” @ DIP joints, onycholysis, & nail pitting: psoriatic arthritis 

Rx: NSAIDs, methotrexate, anti-TNF agents DDx: tophi (gout), enterohepatic arthritis (UC, Crohn’s), Gottron’s papules (dermatomyositis), Charcot joint (diabetes), osteoarthritis, RA --------------------------------------------------------------- urethritis, asymmetric oligoarthritis, conjunctivitis, mouth ulcers, & enthesitis (Achilles pain): reactive arthritis  seronegative spondyloarthropathy  synovial fluid analysis is sterile  Rx: NSAIDs  DDx: gonococcal septic arthritis --------------------------------------------------------------- enthesitis: pain @ tendon & ligament insertion sites  MC a/w ankylosing spondylitis, psoriatic arthritis, & reactive arthritis --------------------------------------------------------------- pain with eye movement, proptosis, diplopia, ophthalmoplegia: orbital cellulitis  MC predisposing factor: bacterial sinusitis  complications: cavernous sinus thrombosis, subperiosteal abscesses --------------------------------------------------------------- heel pain & tenderness, recent UTI on cipro: Achilles tendinopathy 2/2 fluoroquinolone use  complication: tendon rupture  Rx: stop medication, avoid exercise --------------------------------------------------------------- child with tachycardia, tachypnea, muffled heart sounds 1 wk after cardiac surgery, with new cardiomegaly on CXR: pericardial effusion with progression to cardiac tamponade 2/2 post-pericardiotomy syndrome  inflammation from surgical intervention leads to reactive pericarditis, pericardial effusion, &/or tamponade (Beck’s triad: distant heart sounds, JVD, hypotension)  Rx: pericardiocentesis or pericardiectomy --------------------------------------------------------------- classic CAH: ambiguous genitalia (clitoromegaly) & salt-wasting  nonclassic CAH: premature pubarche, hirsutism, severe acne ---------------------------------------------------------------Management of RA  

#1 Rx: DMARDs ASAP  MTX o MTX not for pregos, severe renal insufficiency, liver disease, or excess alcohol intake  NSAIDs, COX-2 inhibitors, & glucocorticoids are adjuncts for symptomatic relief, but do not reduce disease progression or joint destruction  persistent symptoms > 6 months… o Step-up therapy with biological DMARDs (etanercept, infliximab, adalimumab) + MTX  if inadequate response  switch to an alternate TNF-α inhibitor & continue MTX --------------------------------------------------------------- chronic abdominal pain, diarrhea, weight loss, Hx of daily alcohol intake Chronic pancreatitis etiology alcohol, CF, duct obstruction, autoimmune features chronic epigastric pain, malabsorption, DM labs amylase/lipase can be normal, dilated ducts, enlarged pancreas Dx CT scan show calcifications Rx pain management, alcohol & smoking cessation, pancreatic enzyme supplements --------------------------------------------------------------- glycosylated Hb (HbA1c) is dependent on plasma glucose concentration, reflective of blood glucose over the average RBC lifespan (3 months)  hemolytic anemia causes a falsely low HbA1c --------------------------------------------------------------- confusion, lethargy, psychosis, seizures Evaluation of hyponatremia  test #1: serum osmolality > 290 o marked hyperglycemia o advanced renal failure  if serum osmolality < 290… test #2: urine osmolality < 100 o primary polydipsia  if urine osmolality > 100… test #3: urine sodium < 25 o volume depletion, CHF, cirrhosis  if urine sodium > 25 o SIADH (concentrated urine), hypothyroid, adrenal insufficiency --------------------------------------------------------------- adrenal insufficiency  lack of aldosterone 

presents with hypovolemia, leading to  ADH & hyponatremia, thus concentrated urine --------------------------------------------------------------- central & nephrogenic DI decreases ADH action, thus  renal water reabsorption, hypernatremia, thus dilute urine --------------------------------------------------------------- primary polydipsia is common with psychiatric conditions (schizophrenia) 2/2 central defect in thirst regulation --------------------------------------------------------------- fever, productive cough, foul-smelling sputum after upper GI endoscopy: anaerobic infection  Rx: clindamycin --------------------------------------------------------------- ventricular remodeling occurs weeks – months post-MI, causing LV dilatation with thinning of ventricular walls, resulting in CHF  Rx: ACE-I within 24 hr post-MI to limit ventricular remodeling ---------------------------------------------------------------Late-term & post-term complications Fetal Maternal  oligohydramnios  cesarean delivery  meconium aspiration  infection  macrosomia  postpartum  convulsions hemorrhage  perineal trauma  stillbirth 

aging placenta has decreased fetal perfusion oligohydramnios is an indication for delivery risk factors: nulliparity, Hx of postterm pregnancy, obesity, fetal anomalies --------------------------------------------------------------- fever, diaphoresis, malaise, jaundice, dark urine following a tick bite: Babesiosis  MC in NE U.S.; MC in post-splenectomy  parasite enters RBCs  hemolytic anemia  no rash  Dx: Giemsa stain thick & thin  Rx: quinine-clindamycin or atovaquone-azithromycin --------------------------------------------------------------- shoulder pain with passive internal rotation & flexion @ shoulder: subacromial bursitis 2/2 microtrauma to supraspinatus tendon   

--------------------------------------------------------------- gaze abnormalities, limb ataxia, sensory loss, vertigo, Horner’s: Wallenberg syndrome (lateral medullary infarct) --------------------------------------------------------------- dizziness, inability to walk, stabbing facial pain, topples over when sitting, reduced corneal reflex, ptosis, horizontal nystagmus: Wallenberg syndrome  MC site: lateral medulla 2/2 vertebral artery or PICA occlusion  Dx: MRI  Rx: IV thrombolytics (tPA) Wallenberg syndrome (lateral medullary syndrome) vestibulo- vertigo, falling TOWARD the lesion, cerebellar difficulty sitting upright, nystagmus (horizontal & vertical), sensory abnormal facial sensation/pain, pain/temp loss on I/L face & C/L body bulbar dysphagia, aspiration, dysarthria, hoarseness, diminished gag reflex autonomic I/L Horner’s (ptosis, miosis, anhidrosis)  motor function of face & body are spared --------------------------------------------------------------- medial medullary syndrome: C/L hemiparalysis, tongue deviates toward lesion, C/L loss of tactile, vibration & position sense --------------------------------------------------------------- lateral mid-pontine lesion: affect motor & sensory nuclei of I/L trigeminal nerve  weak muscles of mastication,  jaw jerk reflex, impaired tactile & position sense in the face --------------------------------------------------------------- medial mid-pontine lesion: C/L ataxia & hemiparesis of face, trunk, & limbs --------------------------------------------------------------- infant develops weakness, lethargy, poor appetite, constipation, macroglossia, umbilical hernia: congenital hypothyroidism  MCC: thyroid dysgenesis  infants appear normal at birth due to maternal hormones in circulation  screening: T4 & TSH ----------------------------------------------------------------

varicocele: worsens with standing & Valsalva, decreases when supine  spermatocele: painless, fluid-filled cyst @ head of epididymis; mass outside the testes that contains non-viable sperm; no change with position --------------------------------------------------------------- flank pain, hematuria, left-sided varicocele that fails to empty when recumbent: renal cell ca  also anemia or polycythemia, thrombocytosis, fever, hypercalcemia, cachexia  obstruction of gonadal vein results in varicocele  Dx: abdominal CT ---------------------------------------------------------------Effect of intensive glycemic control in DM Type II  macrovascular complications (acute MI, stroke): no change  microvascular (nephropathy, retinopathy) complications: reduces risk  target HbA1c: 6 – 7%; no change in mortality --------------------------------------------------------------- non-productive cough a/w ACE-I is due to accumulation of kinins, which are normally degraded by ACE --------------------------------------------------------------- Hx of wheezing with ASA or NSAIDs, rhinitis, post-nasal drainage: ASA-exacerbated respiratory disease (AERD)  asthma, chronic rhinosinusitis with nasal polyps, & bronchospasm or nasal congestion following ingestion of ASA or NSAIDs  B/L glistening mucoid masses in nasal cavities  nasal polyps tend to recur ---------------------------------------------------------------MI infarction location vessel EKG anterior LAD lead V1 – V6 inferior RCA or ST elevation in II, III, aVF LCX posterior LCX or ST depression in V1 – V3 RCA ST elevation in I & aVL (LCX) ST depression in I & aVL (RCA) lateral LCX, ST elevation in I, aVL, V5 & V6 diagonl ST depression in II, III, aVF RV RCA ST elevation in V4R – V6R 

RCA occlusion a/w inferior wall MI can lead to hypotension, AV block, & sinus bradycardia --------------------------------------------------------------- Rx pheochromocytoma: always α-blocker first, then β-blocker  β-blockers first lead to unopposed stimulation of vascular α-receptors by catecholamines, results in rapid, catastrophic  BP o α-blockers decrease BP o β-blockers Rx tachycardia & tremors  labetalol can be used as initial Rx --------------------------------------------------------------- SSRI A/E: anorexia & sexual dysfunction --------------------------------------------------------------- personal Hx or family Hx of febrile seizures is NOT a C/I to immunization (DTaP) o febrile seizure are benign; no sequelae  immediate anaphylaxis following DTaP is the only C/I for avoiding all vaccine components  unstable neurologic disorders or encephalopathy within a week of DTaP are C/I to pertussis component of the vaccine --------------------------------------------------------------- fever, lower abdo pain, adnexal tenderness, purulent discharge, cervical motion tenderness, leukocytosis,  ESR: PID  MCC of infertility in age < 30  N/V is an indication for hospitalization  Rx: IV ABX before cultures o cefoxitin, or cefotetan/doxycycline, & clindamycin/gentamicin  untreated complications: tubo-ovarian abscess, pelvic peritonitis, sepsis --------------------------------------------------------------- MS neurologic deficits can be exacerbated by exercise or hot weather  internuclear ophthalmoplegia is caused by demyelination of the MLF --------------------------------------------------------------- fever, acute RUQ pain, jaundice, confusion, hypotension: acute ascending cholangitis  infection of common bile duct 2/2 obstruction by gallstones or stricture or bacterial contamination   ALP & WBC  Dx: USS 

 #1 Rx: supportive & IV ABX  refractory cases: ERCP biliary decompression ---------------------------------------------------------------Medications a/w pancreatitis o valproic acid o diuretics o sulfasalazine, 5-ASA (Rx IBD) o azathioprine o metronidazole  CT scan: swelling of pancreas with peripancreatic fluid & fat-stranding  Rx: resolves with supportive care --------------------------------------------------------------- cirrhosis, heart failure, diabetes, hypogonadism,  libido, pseudogout: hemochromatosis  AR inheritance   intestinal iron absorption & deposition in tissues leads to oxidative damage  initial evaluation: serum iron studies o serum iron, ferritin, & transferrin,  TIBC  Dx: genetic testing for mutated HFE gene o liver biopsy for staging  Rx: phlebotomy relieves iron overload  complications: hepatic fibrosis, cirrhosis, HCC --------------------------------------------------------------- hemochromatosis is a/w Ca++ pyrophosphate dihyrate (CPPD) deposition in joints, leading to chondrocalcinosis (calcified articular cartilage), which is a/w pseudogout ---------------------------------------------------------------MCC of male infertility  anabolic steroid use (testicular atrophy)  Klinefelter’s (testicular fibrosis)  mumps (orchitis)  myotonic dystrophy (testicular atrophy)  CF (B/L absence of vas deferens)  5-α-reductase deficiency  Prolactinoma (hypogonadism) --------------------------------------------------------------- urine dipstick o leukocyte esterase indicates pyuria o nitrites indicate Enterobacteraceae (E. coli)  negative dipstick & +UTI symptoms require a urine culture

---------------------------------------------------------------Prosthetic joint infection  MCC early onset: S. aureus, Pseudomonas  MCC delayed onset (> 3 months): S. epidermidis ---------------------------------------------------------------Unprovoked first seizure  Dx: brain CT without contrast if unstable o identify intracranial/subarachnoid hemorrhage  Dx: MRI if stable/non-emergency situations o identify structural causes of epilepsy, TBI, cerebral infarct, CNS tumors, infections ---------------------------------------------------------------Hemorrhagic stroke sub-categories 1. subarachnoid hemorrhage: sudden onset severe headache, N/V, meningismus 2. intracerebral hemorrhage: acute focal neurologic deficits that worsen over minutes – hrs o headache, vomiting, altered mental status  Dx: head CT without contrast to r/o hemorrhage --------------------------------------------------------------- child with lethargy, altered mental status, N/V; Hx of fever, malaise, headache, cough, coryza, & sore throat treated with ASA: Reye syndrome  pediatric ASA Rx: juvenile idiopathic arthritis & Kawasaki ‘s Reye syndrome pathophysiolog microvesicular fatty infiltration & y on liver Bx hepatic mitochondrial dysfunction etiology pediatric ASA use for influenza or VZV infection features o hepatomegaly o acute liver failure o encephalopathy labs o  transaminitis o  PT/INR, PTT o  hyperammonemia --------------------------------------------------------------- macrovascular fatty infiltration: alcoholic hepatitis & nonalcoholic fatty liver disease (NAFLD)  asymptomatic --------------------------------------------------------------- NAFLD is MC due to peripheral insulin resistance with  peripheral lipolysis & hepatic FA uptake o a/w metabolic syndrome, obesity, DM  Rx: diet/exercise, bariatric surgery for BMI ≥ 35

--------------------------------------------------------------- vague abdominal pain, fatigue, microcytic anemia, positive FOBT, hepatomegaly with a firm edge: colon cancer with mets to liver  liver is MC site of mets for colon cancer  Dx: abdominal CT with contrast --------------------------------------------------------------- Werdnig-Hoffman (spinal muscular atrophy): autosomal recessive degeneration of anterior horn & motor nuclei  symmetric proximal weakness & hyporeflexia  does not affect pupils (vs. botulism)  “floppy baby” syndrome (also infant botulism) ---------------------------------------------------------------Hyperandrogenism in pregnancy  Luteoma of pregnancy o B/L, solid ovarian masses of large lutein cells o benign, MC in A-A o new onset hirsutism & acne o Rx: spontaneous regression after pregnancy o high risk of female fetus virilization  Theca luteum cyst o B/L multi-septated ovarian cysts on USS o arise from high β-hCG levels a/w molar pregnancy or multiple gestation o Rx: spontaneous regression after pregnancy; suction curettage for complete moles o low risk of female fetus virilization  Krukenberg tumor o B/L solid ovarian masses on USS o new onset hirsutism o mets from primary GIT cancer o high risk of female fetus virilization  DDx: PCOS (hyperandrogenism in non-pregos) ---------------------------------------------------------------ADHD  ≥ 6 inattentive &/or ≥ 6 hyperactive/impulsive symptoms, ≥ 6 months in at least 2 setting  functional impairment, before age 12 yrs  subtypes: inattentive, hyperactive/impulsive, or combined type ----------------------------------------------------------------

impaired social interaction & communication, restricted interests, insistence on routine, delayed language: autism spectrum disorder  can occur without language impairment --------------------------------------------------------------- risk factors for cholesterol gallstones: Caucasian, obesity, female, rapid weight loss, OCPs, GB hypomobility (fasting, prolonged TPN, pregnancy)  protective factors: low-CHO diet, exercise, caffeinated coffee, ASA or NSAID use --------------------------------------------------------------- female with joint pain, fatigue, ankle edema, facial rash, proteinuria, & decreased C3: SLE 2/2 immune complex-mediated kidney damage, resulting in complement activation ( C3)  DDx: cytotoxic antibodies (Goodpasture’s) --------------------------------------------------------------- thalamic stroke involving VPL nucleus, which transmits sensory info from C/L body  C/L hemianesthesia with transient hemiparesis, athetosis, or ballistic movements  dysesthesia in areas affected by sensory loss: “thalamic pain phenomenon”  DDx: internal capsule strokes (motor symptoms) ---------------------------------------------------------------Causes of urinary incontinence in elderly GU  detrusor contractility, detrusor overactivity, bladder/urethra obstruction (tumor, BPH) urogenital fistula neurologic dementia (Alzheimer’s, Parkinson, NPH), MS, SCI, disk herniation potentially “DIAPPERS” reversible Delirium Infection (UTI) Atrophic urethritis/vaginitis Pharma (α-blockers, anticholinergics) Psych (depression) Excess urine output (diuretics, DM, CHF) Restricted mobility (post-op) Stool impaction  Dx: U/A with culture ---------------------------------------------------------------

Hx of painful, itchy, red streaks on chest, then arms; Hx smoking: superficial migratory thrombophlebitis 2/2 Trousseau’s syndrome  Trousseau’s: hypercoagulable disorder with recurrent, migratory superficial venous thrombosis at unusual sites (arms, chest); Dx prior to or during occult visceral malignancy; MC pancreas  evaluate: abdominal CT r/o pancreatic carcinoma --------------------------------------------------------------- oliguria s/p renal transplant, HTN,  BUN & Cr, renal Bx: lymphocytic infiltration & vascular involvement with intima swelling: acute rejection  Rx: IV steroids ---------------------------------------------------------------Late presentation of aortic coarctation features asymptomatic HTN, chest pain, claudication, headache, epistaxis, heart failure exam brachial-femoral delay, continuous cardiac murmur from large collaterals studies EKG: LVH CXR: rib-notching, “3” sign confirm Dx: echo Rx balloon angioplasty +/- stent associatio bicuspid aortic valve, VSD, Turner’s n ---------------------------------------------------------------Hypothermia  mild: tachycardia, tachypnea, ataxia, dysarthria,  shivering  moderate: bradycardia, lethargy, hypoventilation,  shivering  severe: coma, CV collapse, v-fib, acidosis --------------------------------------------------------------- bradycardia a/w hypothermia is refractory to Rx with atropine & cardiac pacing, but improves with correction of hypothermia Rx hypothermia  warmed crystalloid IV fluids for hypotension  intubation if comatose  rewarming techniques to improve hemodynamic status o mild cases: passive external rewarming (cover with blankets) 

moderate: active external rewarming (warm blankets, heating pads, warm bath) o severe: active internal rewarming (warmed pleural or peritoneal irrigation, warmed humidified oxygen) --------------------------------------------------------------- TBI of any severity can lead to post-concussive syndrome  headache, confusion, amnesia, mood alteration, difficulty concentrating, vertigo, sleep disturbance  resolves with symptomatic treatment within weeks to months following TBI  DDx: delayed subdural hematoma (neuro deficits) --------------------------------------------------------------- hypochromic, microcytic anemia unresponsive to iron supplementation: thalassemia  2/2 reduced Hb synthesis --------------------------------------------------------------- acute bleeding with liver failure Rx: FFP to replace clotting factors o liver failure hepatocytes cannot utilize Vit K ---------------------------------------------------------------Aspiration syndromes pneumonia pneumonitis pathophy lung parenchyma lung parenchyma s infection, inflammation, aspiration of oral aspiration of cavity anaerobes gastric contents with acid injury onset days after aspiration hours after aspiration features fever, cough, sputum range from asymptomatic to non-prod cough, hypoxemia, resp distress CXR infiltrate in dependent infiltrates in one lung (RLL) or both lower lobes; resolves without ABX Rx ABX: clindamycin, supportive, or β-lactams & no ABX β-lactams inhibitors o

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aspiration pneumonitis: acute lung injury 2/2 chemical burn from gastric contents

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aspiration pneumonia: infection by oropharyngeal secretions 2/2 impaired consciousness (overdose, seizure, anesthetics)

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