high yields

know the different types of shock- hypovolemic, septic, cardiogenic (CO, MAP,
SVR)
metabolic acidosis leads to hyperkalemia
diabetes mellitus and rhizopus/mucormycosis infections.
optic neuritis is associated with multiple sclerosis
hemolytic uremic syndrome after gastrointestinal illness w/ 1) acute renal failure
2) microangiopathic hemolytic anemia 3) thrombocytopenia
hypertension is most important risk factor for strokes
ACEi and diabetes mellitus. ACEis decrease GFR and FF (dilates efferent arteriole)
theophylline toxicity manifests as CNS (headache, insomnia),
gastrointestinal (nausea, vomiting), cardiac (arrhythmias)
renal transplant dysfunction can be caused by a variety of factors. acute
rejection is best treated w/ steroids.
thiazide diuretics cause hyperglycemia, increased LDL cholesterol,
increased triglycerides. hyperuricemia (gout), hypercalcemia (protects
against calcium stones)
beckwith-wiedemann syndrome has macrosomia, macroglossia,
visceromegaly, omphalocele, hypogylcemia, and hyperinsulinemia. Babies with
thyroid disorder will have umbilical herniation.
lifestyle modifications to decrease BP: lose weight > fruits and vegs > decrease
sodium > exercise > alcohol intake
hyperosmolar nonketosis (HONK) occurs in type 2 diabetes mellitus. have severe
hyperglycemia resulting in dehydration.
SIRS criteria 2 of the following: 1) temp > 101.3 or < 95 2) pulse > 90 3) resp >
20 4) WBC > 12k or <4k burn patients have SIRS with hypermetabolic syndrome
B. pertussis has bursts of whooping cough (loud inspiratory sound). first stage is
catarrhal (rhinorrhea and congestion) treatment is macrolide mycin
osteosarcoma has "sunburst" pattern and periosteal elevation (codman's
triangle). increased ALP/LDH. occurs at metaphyses of long bones
granulosa cell tumors (type of sex-cord stromal along with sertoli-leydig cell) give
precocious puberty if early. bi-modal distribution. excess estrogen.
not necessary to treat asymptomatic paget's disease. only when have bone pain,
hypercalcemia, neurological deficits, high output cardiac failure
diamond blackfan anemia has pure red cell aplasia with short stature, webbed
neck, cleft lip, shielded chest, triphalangeal thumbs, hypogonadism
craniopharyngioma is a suprasellar tumor leading to bitemporal
hemianopsia, headaches, and hypopituitarism.
steroids cause neutrophilia, lymphopenia, and eosinopenia.
familial hypocalciuric hypercalcemia (FHH) will have decreased urinary
calcium excretion despite hypercalcemia. The patiet will have normal or high PTH.
The PTH should be low (high calcium) but parathyroid gland is broken.
broca's aphasia is expressive aphasia where patient can't speak or articulate.
lesion in dominant frontal lobe. will have motor symptoms.

hypovolemic hyponatremia due to volume depletion leading to increased RAAS

and ADH. ADH will contribute to hyponatremia. hypovolemic hyponatremia =
diuretics, GI, skin
congestive heart failure has bi-basilar crackles at lung bases. decreased breath
sounds at lung bases could be due to pleural effusions. wheezing can be present
from cardiac asthma. respiratory alkalosis, hypoxia, hypocapnia.
S. pneumoniae, N. meningitidis, H. influenzae for asplenics.
marfan's syndrome is an autosomal dominant disorder resulting from mutations in
fibrillin-1 gene. it presents with tall stature, long and emaciated extremities,
arachnodactyly, hypermobility of joints, upward lens dislocation.
give 100% oxygen for an acute attack of cluster headache
patients with sheehans syndrome present post-partum with failure to lactate and
other features of pituitary hormonal deficiency.
cystic fibrosis has a wide range of manifestations: anemia, heat intolerance,
steatorrhea, wheezing, recurrent infections, hemoptysis, clubbing, rectal prolapse.
+sweat test to confirm.
syringomyelia has areflexic weakness in upper extremities and dissociated
anesthesia in a cape distribution. the presence of a cord cavity is the most
characteristic feature.
cyclosporine/tacrolimus toxicities: nephrotoxic, gum hypertrophy,
hyperkalemia, hypertension, hirsutism, tremor. (tacrolimus has no
hirsutism or gum hypertrophy) azathioprine: diarrhea, leukopenia,
hepatotoxic
mycophenolate: bone marrow suppression.
ulnar nerve entrapment occurs at site where ulnar nerve lies at medial
epicondylar groove, in the elbow. decreased sensation in 4th and 5th fingers
and weak grip due to interosseus muscles.
patient returning from a developing country with symptoms suggesting
malabsorption should be treated w/ metronidazole for giardiasis. pathogenesis
includes adhesive disks and malabsorption.
choanal atresia appears in an infant who has cyanosis during feeding and relieved
by crying. cant breathe while mouth is closed
patients with panic disorder have increased incidence of depression, agoraphobia,
generalized anxiety disorder and substance abuse.
understand pathophysiology, peristalsis and LES tone in diffuse esophageal
spasm (DES) / zenkers / achalasia / scleroderma / infectious esophagitis
to treat hyperkalemia use beta-2 agonist, it will shift potassium into cells.
otosclerosis in middle aged people due to conductive hearing loss
associated with bony overgrowth of stapes. presbycusis in older patients due
to sensorineural hearing loss
right coronary artery occlusion can cause inferior wall myocardial
infarction and posterior wall MI. inferior wall MI shows ST segment elevations in
inferior leads (II III aVF) w/ reciprocal depressions in V1 and V2. ST segment
depression in leads V1 and V2 suggest a posterior wall MI. inferior wall MI is
associated with hypotension, bradycardia, and AV blocks.
to break bad news follow steps: 1) make sure patient is comfortable environment
2) ask how much they know or what they think 3) ask what they want to know 4)
give them a warning shot 5) break the bad news 6) give prognosis
in hyperthyroidism give propanolol for symptomatic relief until the underlying
cause is identified and treated definitively.
FSGS is more common in african americans, obesity, heroin use, and HIV.
for aortic dissection do TEE or CT w/ contrast

in dubin-johnson you see a dark granular pigment present in hepatocytes but

not in patients with rotor syndrome.
shock liver arises from sepsis or ischemic hepatic injury. There is rapid rise in
transaminases
incentive spirometry has been shown to be the most effective measure in
decreasing the risk of post-op pneumonia
in consolidation the lungs have dullness to percussion and the breath sounds
are bronchial which are louder and have a more prominent expiratory
component. pleural effusion produces dullness to percussion also, but
decreased breath sounds (the liquid is outside of the lungs)
the most important complication of PPROM is pulmonary hypoplasia. give steroids
when premature rupture of membranes (PROM) occurs at less than 34 weeks of
gestation.
malignant otitis externa is caused by Pseudomonas. will have otorrhea,
granulation tissue in the ear canal.
for actinomyces use penicillin. anaerobic gram+ branching bacteria causing
cervicofacial, thoracic or abdominal infections. drains sulfur granules which
appear yellow.
loop diuretics (furosemide) cause hearing loss and tinnitus. aspirin usually
causes tinnitus but not hearing loss unless the doses are very very high.
can get hallucinations early after given levodopa/carbidopa. (excess dopamine)
after several years involuntary movements more likely to occur.
lynch syndrome/HNPCC. at least 3 relatives w/ colorectal cancer, one who is 1 st
degree relative. involvement of 2 or more generations, at least 1 case before 50,
FAP has been excluded. extracolonic tumors include endometrial carcinoma
occuring in 43% of females
hypoxia with respiratory failure, cardiogenic shock, and DIC can occur after
amniocentesis amniotic fluid embolism. immediately intubate and mechanically
ventilate and then give iv fluids
single non-healing ulcer in vermilion zone of lower lip is squamous cell carcinoma
showing squamous cells with keratin pearls. especially if sun exposure. herpetic
ulcer would heal in two weeks, would be multiple ulcers, would show giant cells
on tzanck smear.
mastitis associated with breast feeding is treated with analgesics, antibiotics, and
continuation of breast feeding.
rheumatic fever leads to mitral stenosis leading to enlargement of left atria and
pushes up left main stem bronchus. will have dyspnea, pulmonary edema,
and irritation of phrenic nerve and left main stem bronchus --> persistent
cough. Atrial fibrilation can also occur and/or left atrial enlargement
to avoid contrast induced nephropathy adequate hydration, acetylcysteine, and
non-ionic contrast.
whenever iv access cant be established in pediatric emergency cases, go for
intraosseus access. then once hydrated go for iv access again. dont go for
femoral because of perineal contamination.
orbital cellulitis has opthalmoplegia and pain w/ extraocular movements, but
preseptal cellulitis does not. preseptal cellulitis is a mild infection of the eyelid
anterior to orbital septum. orbital cellulitis is a serious infection posterior to the
orbital septum. orbital cellulitis can lead to blindness and intracranial
infection.
marfans features with mitral regurgitation, MVP, aortic root dilation, and
thromboembolic events +downward dislocation of the lens is
homocystinuria. autosomal recessive caused by cystathionine synthase
deficiency. treat with high doses of vitamin b6

when pleural effusion suspected or diagnosed, determine if transudate or

exudate. do diagnostic thoracentesis.
headache, elevated bp, renal bruit is suggestive of renovascular hypertension
secondary to renal artery stenosis. in young adults cause is most likely
fibromuscular dysplasia, in older patients its an atheromatous plaque.
treatment is angioplasty with stent placement for a young person
when patient presents with fall, stabilize and treat pain, then try to uncover
etiology of fall with appropriate investigation and assess pre-op risk.
insulin resistance plays a central role in the pathophysiology of non-alcoholic
fatty liver disease by increasing rate of lipolysis and elevating circulating
insulin levels. intrahepatic fatty acid oxidation leads to increase in oxidative
stress causing a release of local pro-inflammatory cytokines like tnf-alpha
and consequent liver inflammation leading to increased transaminase
levels.
reversible acetylcholinesterase inhibitors such as donepezil, rivastigmine, and
galantamine are of benefit in slowing cognitive decline associated with
alzheimers dementia.
paralysis of hand and ipsilateral horner syndrome result from injury to 7th and 8th
cervical nerve and 1st thoracic nerve, which is a rare form of brachial palsy called
klumpke paralysis. duchenne-erb is C5 - C6 waiters tip
whipples disease is a multi-systemic illness characterized by arthralgias, weight
loss, fever, diarrhea, and abdominal pain. PAS+ material in lamina propria of
small intestine is found on biopsy.
in a patient with (HONK) non-ketotic hyperglycemic coma start normal saline
(0.9%) first then replace with 0.45% saline.
when patient has compression of thecal sac and is presenting with neurological
symptoms like loss of bowel/bladder function do MRI but give steroids while
waiting to reduce risk of permanent neurological damage.
her2 is an oncogene, level of expression can be determined by FISH or
immunohistochemical staining (IHC). if its overexpressed can treat with
trastuzumab (herceptin).
sunscreens should be applied 15-60 min before sun exposure to allow enough
time for a protective film to develop. sun avoidance is the best method of photoprotection.
when adverse reaction to DTaP vaccine occurs, usually due to the pertussis
component of the vaccine.
herpetic whitlow is a common viral infection of the hand. caused by HSV1 or HSV2
and is self-limiting. health care workers who come into contact with infected
orotracheal secretions are at an increased risk of developing whitlow.
guillain barre syndrome (GBS) is an acute idiopathic inflammatory demyelinating
neuropathy. 20-30% of patients develop neuromuscular respiratory failure
requiring mechanical ventilation. serial measurement of vital capacity at the
bedside is the best way to monitor respiratory function in such cases.
osteogenesis imperfecta is caused by mutations in type 1 collagen. its typical
features are blue sclera and recurrent fractures.
premature adrenarche (axillary hair) and thelarche (breasts) often have no clinical
significance. adrenarche due to premature secretion of androgen by the adrenal
glands. but pubarche (pubic hair) requires a thorough evaluation as it may be due
to CNS disorder in 50% of cases.
diabetes insipidus (ADH problem) presents as polyuria, polydipsia and excretion
of dilute urine in the presence of elevated serum osmolality (not responding
to ADH, concentrated plasma). primary polydipsia has dilute urine and dilute
plasma.

SIADH has hyponatremia (too much water in blood), low serum osmolality, and
inappropriately high urine osmolality (urine is very conc)
platelet dysfunction is the most common cause of abnormal hemostasis in
patients with chronic renal failure. PT, PTT and platelet count are normal. BT is
prolonged. DDVAP is usually the treatment of choice if needed. DDVAP increases
release of factor 8: vwf.
accumulation of leukotrienes and changed prostaglandin/leukotriene balance
triggers characteristic reactions of bronchoconstriction, nasal polyp formation in
susceptible individuals. aspirin sensitivity syndrome is a pseudo allergic reaction.
treatment involves avoidance of NSAIDs and use of leukotriene receptor
antagonists.
give oral isoretinoin to patients with moderate-to-severe acne that is
predominantly nodulocystic form and to those who have developed scars. it
greatly decreases sebum excretion but is teratogenic.
anorexia nervosa are at risk for numerous complications including: miscarriage,
IUGR, hyperemesis gravidarum, premature birth, cesarean delivery, and
postpartum depression.
parkinsonism gives you a shuffling / hypokinetic gait. patient appears as if he
was chasing his center of gravity.
friedreich ataxia has neurological symptoms (gait ataxia, falls, dysarthria)
resulting from degeneration of the spinal tracts (spinocerebellar, posterior
columb, pyramidal). non-neurological manifestations include concentric
hypertrophic cardiomyopathy, diabetes and skeletal deformities (scoliosis and
hammer toes). most common cause of death is cardiomyopathy.
folic acid deficiency can be caused by some drugs that its absorption
(phenytoin) or antagonize its physiological effects (methotrexate,
trimethoprim)
depressed CO (normal is ~5L) with an elevated PCWP (indicates left atrial
pressure, and/or left ventricular end diastolic pressure) is indicative of left
ventricular failure. can be due to cardiogenic shock. systemic vascular
resistance will be elevated as a result of neurohumoral activation intended to
preserve CO (RAAS).
aseptic necrosis of the femoral head is a common complication of sickle cell
disease. occlusion of the end arteries supplying the femoral head, bone necrosis,
and eventual collapse of the periarticular bone and cartilage.
every case of leukocoria is considered a retinoblastoma until proven otherwise;
refer to an optholmologist.
cystinuria is an inherited disease causing recurrent renal stone formation.
look for a personal history of recurrent kidney stones from childhood and a
+family history. the characteristic stones are hard and radioopaque (can see
them). urinalysis shows hexagonal crystals. the urinary cyanide
nitroprusidde test is used as a qualitative screening measure.
in a patient with hepatitis c, give immunizations for hep A and B if not already
immune. both vaccinations are safe in pregnancy. treatment of chronic hep c is
contraindicated in pregnancy. should still breastfeed, and can still have sex
w/out condoms.
dietary recommendations for patients with renal calculi are: 1) decreased dietary
protein and oxalate 2) decreased sodium intake 3) increased fluid intake 4)
increased dietary calcium
antiviral meds can reduce the duration of influenza symptoms by 2-3 days.
however these drugs are only effective if adminstered within 48 hours of the
onset of illness. amantadine and rimantadine are only active against influenza a.

neuraminidase inhibitors zanamivir and oseltamivir are active against both a

and b.
treatment for TCA overdose includes sodium bicarbonate. this drug not only
helps correct the acidosis but to narrow the QRS complex. benzodiazepines are
given when patient presents with seizures.
seborrheic dermatitis (dandruff) is a common chronic inflammatory
papulosquamous diease that can affect all age groups. transparent to yellow
papules and occasional scaling plaques are characteristic. treat with
moisturizers, antifungals, and topical steroids.
tinea versicolor is a superficial fungal infection of the skin. characterized by
pale, velvety pink or whitish hypopigmented macules that do not tan and
do not appear scaly but scale on scraping. caused my Malassezia furfur. KOH
preparation reveals large blunt hyphae and thick walled budding spores
(spaghetti and meatballs). treat with selenium sulfide and ketoconazole.
surgical resection followed by whole brain radiation is the standard practice
in the management of solitary brain mets with stable extracranial disease.
multiple brain mets are best treated with palliative whole brain radiation.
cluster headache usually presents with acute, severe retroorbital pain that wakes
the patient from sleep. it may be accompanied by redness of the ipsilateral eye,
tearing, stuffed or runny nose, and ipsilateral horners syndrome. treatment is
100% oxygen.
patients with renal disease can have low levels of erythropoietin causing them to
have anemia that is normocytic and normochromic. treatment is recombinant EPO
which is given if hemoglobin < 10. the most common side effects are worsening
of hypertension (30%) headaches (15%) and flu-like symptoms (5%)
muddy brown granular cast acute tubular necrosis.
RBC cast glomerulonephritis.
WBC cast interstitial nephritis and pyelonephritis.
fatty cast nephrotic syndrome.
broad and waxy cast chronic renal failure.
weight gain is most common side effect of olanzapine.
consider C. difficile in a patient with diarrhea if they have recieved antibiotics
recently and develop nausea/vomiting/abdominal pain and elevated WBC.
cytotoxin assay in the stool is a highly sensitive test to diagnose this
condition.
most colon cancers develop from polyps. risk factors for polyp progressing ino
malignancy are villous adenoma, sessile adenoma, and size > 2.5cm. only
adenomatous polyps are clearly premalignant, but <1% of lesions progress to
malignancy. hyperplastic polyps are non-neoplastic and do not require further
workup.
prader-willi syndrome (obesity hypogonadism syndrome) hypotonia,
hypogonadism and obesity. severe hypotonia at birth or infancy,
hyperphagia, short stature and mental retardation. lesch-nyhan syndrome is
caused by a deficiency in HGPRT, and has self-mutilation, mental retardation,
hyperuricemia, and neurologic signs.
pataus syndrome- scalp defects, cleft lip or palate, microcephaly,
congenital heart defects, flexed fingers with polydactyly
edwards syndrome is characterized by closed fists, microcephaly,
prominent occiput, rocker bottom feet and renal/cardiac problems.
increased risk of sepsis for up to 30 years after splenectomy with encapsulated
organisms. get anti-pneumococcal, haemophilus and meningococcal vaccines
before splenectomy, and daily oral penicillin prophylaxis for 3-5 years after
splenectomy.

cardiology

homocysteine can be metabolized to cysteine or methylated to form methionine.

homocysteine to cysteine pathway is catalyazed by cystathionine beta synthase
using co-factor b6 (pyridoxine). homocysteine to methionine pathway uses
methylene-tetrahydrofolate-reductase and methionine synthase with cobalamin
(b12) as cofactor. give b12, folate, and b6 to a patient with elevated
homocysteine.
calcium channel blockers are contraindicated in myocardial infarction because
vasodilate -> reflex tachycardia
association between angiodysplasia and aortic stenosis (In Heydes
Syndrome with colonic angiodysplasia, associated with VWF issue so
coagulopathic with bloody stools)
endocarditis can have septic emboli to lungs causing nodular infiltrate
with cavitation
prolonged QRS is bradyarrhythmia, prolonged QT is tachyarrhythmia (leads to
torsades)
myocardial infarction -> ventricular aneurysm days to months after. presents like
congestive heart failure, arrhythmias, mitral regurgitation and/or thrombus
formation
treat aortic regurgitation with afterload reduction calcium channel
blocker or ACEi
prinzmetal angina occurs in young females, smoking is a risk fator. transient
ST elevation, treatment with calcium channel blockers or nitrates. betablocker and aspirin are contraindicated
aortic dissection leads to aortic regurgitation, will have normal EKG. dx with
transesophageal echocardiogram
1st degree heart block is when PR interval > 0.2
constrictive pericarditis is when pericardium is thickened. poor diastolic filling.
--> JVP, ascites, hepatic congestion (looks like right sided heart failure). Low
voltage EKG
arrhythmia most specific for digoxin toxicity is atrial tachycardia with AV
block. increased ectopy (tachy) and increased vagal tone (av block)
leriche's syndrome is 1) hip, thigh and buttocks claudication 2) impotence
3) symmetric atrophy of bilateral lower extremity
cholesterol embolization after cardiac angiogram. can have increased
eosinophils in blood/urine. decreased complement. livedo reticularis and
acute renal failure
stasis dermatitis is caused by venous valvular incompetence resulting in
venous hypertension. hemosiderin deposition colors the legs.
best 1st line diuretic is hydrochlorothiazide
supraventricular tachycardia includes multifocal atrial tachycardia, atrial
fibrillation, AV nodal reentrant tachycardia (AVNRT), atrioventricular reentrant
tachycardia (AVRT), junctional tachycardia. for PSVTs (narrow QRS complex
tachycardia) use vagal maneuvers or adenosine.
Hypertrophic obstructive cardiomyopathy (HOCM) (autosomal dominant)
murmur will increase as preload decreases (valsalva/standing) because the

ventricular cavity is a smaller size, and will have increased outflow

obstruction.
3 - 7 days post MI is interventricular/papillary/ventricular wall rupture.
infectious endocarditis leads to triscuspid regurgitation. holosystolic
murmur which increases with inspiration (decreased intrathoracic pressure, easier
to pump into lungs). distinguishing feature
hypertrophic obstructive cardiomyopathy has crescendo-decrescendo
murmur w/ no radiation to carotids and is found in lower left sternal border. AS
radiates to carotids.
hemodynamically stable supraventricular tachycardia should try vagal maneuver
and adenosine. if unstable then do dc cardioversion. adenosine will increase
conduction delay through the av node.
in systolic heart failure: cardiac index is decreased (measure of cardiac
output), total peripheral resistance is increased (neurohumoral activation of
RAAS), and left ventricular end diastolic volume is increased because the heart is
not pumping out
hypovolemic shock will have decreased CO, decreased PWCP, increased
SVR (raas), increased HR and decreased BP
in heart failure there is a decrease of blood going to kidney, activates RAAS.
angiotensin 2 constricts efferent arteriole, aldosterone absorbs more sodium -->
water retention and elevation of total body volume
pericardial effusions appear as enlarged "water bottle" shaped cardiac
silhouette. pericardial effusion will have a non-palpable point of maximal
impulse, diminished heart sounds
pericardial effusion and cardiac tamponade have: hypotension, distended
neck veins (high int. jugular venous pressure), and muffled heart sounds. will also
have positive hepatojugular reflex and pulsus paradoxus. fluid
accumulation in the pericardial cavity that increases the intrapericardial pressure
above the diastolic ventricular pressure. restricts venous return to the heart.
decreases diastolic filling and lowers preload.
infective endocarditis can present with systemic arterial emboli (cns, renal,
splenic), glomerulonephritis, roth spots, oslers nodes, janeway lesions, mycotic
aneurysms
dihydropyridine (-dipine) calcium channel blockers like amlodipine can
cause peripheral edema.
strongest influence on long-term prognosis for an ST-elevation MI is the duration
of time that passes before coronary blood flow is restored via PTCA or fibrinolysis.
for BP control weight loss is most important intervention. weight loss >
physical activity > salt restriction > alcohol
mitral regurgitation is a holosystolic murmur radiating to axilla. will have
soft s1 because improper closure of the mitral valve.
aortic regurgitation has a wide pulse pressure (systolic diastolic) which
patients experience as a pounding heartbeat. lying flat brings heart closer to
chest wall and patients are more aware of the forceful heartbeat.
constrictive pericarditis caused by pericardial fibrosis and obliteration of
pericardial space. presents like chf (fatigue, dyspnea on exertion, muscle wasting,
elevated jvp, ascites, positive kussmauls sign - increase jvp on
inspiration), pedal edema. in developing countries can be caused by
tuberculosis.
give nitroglycerine for cardiogenic pulmonary edema. will decrease
preload and relieve dyspnea and tachycardia. cardiogenic pulmonary edema will
have bibasilar rales and wheezing as well.

digoxin and furosemide/loop diuretics reduce congestive heart failure

symptoms but do not improve survival.
patients with a history of rheumatic fever have an increased risk of recurrent
episodes and progression of rheumatic heart disease with repeated infection by
group A streptococcus pharyngitis. need penicillin prophylaxis.
class IC anti-arrhythmics (flecainide/propafenone) block sodium channels.
they elongate period of depolarization, and prolong the action potential. slower
conduction through the AV node and his-purkinje system. class IC meds have the
slowest binding and dissociation from the sodium channel. flecainide is a
IC that demonstrates use-dependence where the HR increases flecainides
effect on the sodium channels. Flecainide is stronger at faster heart rates. there is
less time between APs for the medication to dissociate from its receptor. so the
QRS complex will prolong as the HR increases.
aortic stenosis needs echocardiogram to confirm diagnosis. if symptomatic
then treat with valve replacement.
long QT syndrome (congenital is Jervell syndrome, with deafness) can
present as syncopal episodes, hearing loss, and a family history of sudden
cardiac death. treat with beta blockers
mitral regurgitation can cause a holosystolic murmur that radiates to the
axilla. Mitral valve prolapse is the most common cause of mitral regurgitation.
mitral regurgitation can lead to left atrial dilation and atrial fibrillation.
digoxin toxicity side effects are gastrointestinal (anorexia, nausea, vomiting).
verapamil increases digoxin concentrations and predisposes to toxicity.
mitral stenosis has a loud s1 and a mid-diastolic rumble. can cause atrial
fibrillation because of left atrial dilation
causes of pulsus paradoxus include cardiac tamponade, tension
pneumothorax, and severe asthma. > 10 mmHg drop in systolic blood
pressure on inspiration.
cor pulmonale has hypotension, jvd, distant heart sounds, and pulsus
paradoxus. elevated jvp, hepatomegaly, ascites, lower extremity edema without
evidence of pulmonary congestion is suggestive of isolated right sided heart
failure, cor pulmonale. most common cause is COPD.
in a patient with an MI who develops a clot, do echocardiogram to rule out
thrombus in left ventricle.
in ventricular fibrillation and pulseless ventricular tachycardia, defibrillation is
the treatment. Ventricular fibrillation is recognized on EKG by fibrillatory
waves and absence of regular qrs complexes. time to defib is correlated with
survival.
a CXR should be obtained in all patients who undergo central venous
catheterization to confirm proper placement of the catheter tip before
administering drugs or other agents through the catheter.
acute MI presents with substernal chest pain with radiation to neck, diaphoresis,
shortness of breath. a new 4th heart sound is a classic finding of myocardial
infarction. ischemic damage may lead to diastolic dysfunction and a stiffened
left ventricle, resulting in an atrial gallop (4th heart sound)
abdominal ultrasound is the study of choice for diagnosis and follow-up of
abdominal aortic aneurysms. nearly 100% sensitive and specific for this
condition (smoking is the most common risk factor)
mitral stenosis classically presents during pregnancy. most often due to
rheumatic fever and occurs much more often in countries with limited access to
antibiotics. There is an increase in plasma volume with pregnancy.
an exercise stress test without imaging is the most reasonable first step if
baseline resting EKG is normal in a patient complaining of exertional cardiac pain.

if patients are hemodynamically unstable and have sustained monomorphic

ventricular tachycardia (SMVT) then electrically cardiovert, but if they are
stable and asymptomatic you can give anti-arrhythmics (amiodarone). SMVT is a
wide complex tachycardia.
in patients who present with abdominal pain and have risk factors for
myocardial infarction, rule out myocardial infarction before further
gastrointestinal workup
coarctation of the aorta presents with severe symptomatic hypertension
(headaches, epistaxis, and evidence of left ventricular hypertrophy). EKG will
show increased voltage of QRS complexes and ST and T wave changes in
left precordial leads. all patients (especially young) with systemic hypertension
should be evaluated for coarctation with simultaneous palpation of brachial and
femoral pulses to assess for brachial-femoral delay. also have supine bilateral
arm (brachial) and prone right and/or left leg (popliteal) blood pressures
measured to assess for differential pressures. coarctation may be congenital
(Turners) or acquired (Takayasus , pulseless disease)
cardiac tamponade produces a decrease in CO because the pressure exerted on
the heart by the pericardial fluid is greater than the venous pressure that fills the
right atrium during diastole. pulsus paradoxus is a feature of tamponade and is
defined as a large decrease in the systolic blood pressure on inspiration.
demonstrated by loss of a palpable radial pulse during inspiration.
Superior vena cava syndrome is a potential complication of lung malignancy, and
is manifested by headache, facial swelling, and jugular venous
engorgement without peripheral edema. headaches worse when leaning
forward due to decreased gravitational effects on the blood column. jvd is
present, but there is no peripheral edema to suggest cardiac failure. the primary
treatment is radiation therapy as a palliative measure.
EKG with wide-complex tachycardia with monomorphic ventricular
tachycardia in a stable patient is treated with amiodarone.
peripheral vascular disease should be suspected in a patient with risk factors
for atherosclerosis who has an extremity with shiny, thin, hairless skin,
particularly if a non-healing ulcer is present. use ankle-brachial index to assess
pvd.
septic shock has impaired circulation resulting in insufficient oxygen delivery to
the peripheral tissues and subsequent anaerobic metabolism. leads to an
increase in the production of lactic acid producing metabolic acidosis
myocarditis can lead to the development of dilated cardiomyopathy.
bibasilar crackles, pitting edema, and displacement of the point of
maximal impulse.
patients with mitral valve prolapse have a slightly higher risk of developing
infective endocarditis after certain invasive procedures. 2007 AHA guidelines for
the prevention of infective endocarditis do not recommend anti-microbial
prophylaxis for patients with mitral valve prolapse including those with
regurgitation. if you have prosthetic heart valves, previous history of
infective endocarditis, or unrepaired congenital heart disease you get
prophylaxis.
atrial fibrillation has irregularly irregular QRS complex, absent P waves.
treatment is rate control or rythm control and anti-coagulation. to treat rate use
beta-blocker or verapamil/diliazem.
Atrial septal defect has wide, fixed splitting of s2. patients with moderate to
severe left to right shunts may have a systolic murmur best heard at the upper
left sternal border from increased blood flow across pulmonic valve.

septic shock should be suspected in patients with hemodynamic instability and

evidence of an infection. initial treatment is IV fluids followed by vasopressors
(dopamine or norepinephrine) if they do not respond to fluids.
as mitral stenosis becomes more severe, the transvalvular gradient increases
and causes the murmur to be heard earlier in diastole at the apex. early
diastolic murmur at left lower sternal border is heard in patients with aortic
regurgitation.
systolic murmur that increases with decreased preload (standing) is mitral
valve prolapse or hypertrophic obstructive cardiomyopathy. in mvp there
is a mid-systolic click and a late systolic murmur best heard at apex. in hocm the
murmur increases when standing because of less venous return and the left
ventricular outflow tract obstruction worsens. more common in young
african americans.
Hypotension is caused by a decreased left ventricular preload in a
hemothorax. (similar mechanism as tension pneumo). hemothorax will have lack
of breath sounds, and dullness to percussion on the ipsilateral side as the
hemothorax due to accumulation of fluid in the pleural space. hemothorax is a
potential complication of thoracentesis and should be suspected in patients
who rapidly reaccumulate a pleural effusion, difficulty breathing, and
hemodynamic instability shortly after a thoracentesis
venodilation decreases the pain associated with acute myocardial infarction by
reducing preload, leading to a reduction in myocardial oxygen demand.
aortic regurgitation is a diastolic decrescendo murmur over left sternal
border. aortic regurgitation commonly due to aortic root dilation or a bicuspid
valve.
flattening of P wave, prolonged PR and QRS, Peaked T waves (huge) are
consistent with hyperkalemia. give calcium gluconate to stabilize cardiac cell
membrane. hypokalemia has u waves, flat and broad T waves.
ruptured abdominal aortic aneurysm is an important cause of abdominal and
referred lower abdominal pain. patients also have atherosclerosis of other vessels
such as coronary or carotid arteries.
cyanosis in highly vascularized tissues like lips and mucous membranes is
consistent witth central cyanosis. peripheral cyanosis usually only involves the
distal extremities. central cyanosis is caused by low arterial oxygen
saturation, peripheral cyanosis is due to increased oxygen extraction (slow
blood flow, allows the tissue to maximally extract the oxygen) secondary to
sluggish blood flow. in peripheral cyanosis the extremities are cool and
clammy.
lipemic serum (milky and opalescent) along with palmar xanthomas is
consistent with severe hypertriglyceridemia. treat with fibric acid derivatives
like fenofibrate.
arrhythmia has sudden-onset syncope without a prodrome. sotalol used to
maintain sinus rythm (in patients with atrial fibrillation) has a side effect of
prolongation of the QT interval which predisposes to torsades de pointes.
hypokalemia and hypomagnesemia (from diarrhea) are predisposing
factors. QT interval prolongation and PR interval prolongation. treat with
magnesium sulfate (not anti-arrhythmics) initially.
wolff-parkinson-white (wpw) synrome is characterized by an accessory pathway
between the atrium and ventricle resulting in preexcitation and increased risk for
tachyarrhythmias. the accessory pathway conducts antegrade (forward) from
atria to the ventricles faster than the conduction through the av node, which
allows part of the ventricle to depolarize early. shortened PR interval, slurred
initial portion of QRS (delta wave) and widened QRS complex.

before exercise EKG withhold medications that are anti-ischemic and/or slow
the heart. beta-blockers should be withheld 12-24 hours before the test.
most common cause of death in patients with acute myocardial infarction is
complex ventricular arrhythmia. acute ischemia creates a heterogeneity of
conduction in the myocardium. areas of partial block of conduction are
frequently formed that predispose the patient to reentrant arrhythmia.
Ventricular fibrillation is a typical example of reentrant arrhythmia.
paroxysmal supraventricular tachycardia most commonly results from
accessory conduction pathways through the av node. vagal maneuvers and
medications that decrease conduction through the av node (adenosine)
often resolve the PSVT.
pericarditis presents with pain that worsens with deep inspiration, improved
on leaning forward. EKG findings show diffuse ST elevation (and PR
depression in II, aVF) with the exception of reciprocal depression in aVR
where ST depression is seen. dresslers syndrome is pericarditis occuring weeks
after a myocardial infarction. NSAIDs are the mainstay of therapy for dresslers
syndrome.
progressive decrease in baroreceptor sensitivity and defects in the
myocardial response to this reflex are the main reasons for increased
orthostatic hypotension in the elderly. (blood pressure drops, heart rate should
increase to compensate)
screen patients who are 65 - 75 and who have EVER smoked cigarettes before
with abdominal ultrasound for abdominal aortic aneurysm.
athero-embolism results from dislodgement of cholesterol plaques from the aortic
root. blue toe syndrome in which emboli to the pedal circulation cause cyanotic
and painful toes with intact pulses is one common presentation of catheterinduced atheroembolism. may be accompanied by livedo reticularis (purple
mottled skin), and elevation of creatinine resulting in atheroembolism of
renal circulation.
all patients who have had a myocardial infarction should recieve secondary
prevention. the following medications have been shown to have a mortality
benefit when given as 2nd prevention: aspirin, beta-blocker, ACEi, lipid
lowering statin, clopidogrel/ticlopidine (if they are post percutaneous
coronary intervention).
digoxin is a cardiac glycoside with adverse effects that include gastrointestinal
disturbances, vision changes, and arrhythmias. patients taking digoxin should
have routine monitoring of their digoxin level.
peripheral vascular disease commonly caused by atherosclerosis. presents
with claudication, erectile dysfunction, and atypical leg pain or can be
asymptomatic. take the ankle-brachial index (abi) using doppler as the first step
to diagnose in high-risk of symptomatic patients. do exercise testing with preexercise and post-exercise abi measurement to confirm diagnosis.
fever, chills, LUQ pain, and splenic fluid collection suggests findings consistent
with infective endocarditis with septic emboli to the spleen. left sided
endocarditis can send septic emboli to regions rich in blood supply: brain,
kidneys, liver, spleen. right sided endocarditis tends to send septic pulmonary
emboli. will have elevated neutrophils.
fever and a new murmur in a patient who may abuse iv drugs should raise
concern for endocarditis. staphylococci (incl. MRSA) is a more common cause of
endocarditis in IVDA, therefore vancomycin is the initial empiric antibiotic
of choice.
abdominal aortic aneurysm rupture presents with profound hypotension,
abdominal or back pain followed by syncope, and possible pulsatile mass on
examination. aaa can rupure into the peritoneum and create an aortocaval

fistula with the inferior vena cava leading to venous congestion in

retroperitoneal structures (e.g. bladder). the fragile and distended veins in the
bladder can rupture and cause gross hematuria.
ascending aortic aneurysms are most often due to cystic medial necrosis or
connective tissue disorders (eg Marfans). Descending/thoracic aortic
aneurysms are usually due to atherosclerosis.
diastolic dysfunction is also called heart failure with preserved left
ventricular ejection fraction. systemic hypertension is the classical cause of
diastolic dysfunction. treatment is with diuretics and bp control.
dilated cardiomyopathy can occur secondary to acute viral myocarditis
(coxsackie b, parvo b19, hhv6, adeno, entero, Chagas). viral myocarditis causes
dilated cardiomyopathy via direct viral damage and as a result of humoral or
cellular immune responses to viral infections. diagnose via echocardogram which
shows dilated ventricles with diffuse hypokinesia resulting in a low ejection
fraction.
hepato-jugular reflex can be used to differentiate between heart and liver
disease-related causes of lower extremity edema. +hepato-jugular reflex
indicates that the venous pressure is elevated and suggests that heartdisease related edema is present. hepato-jugular reflex is negative in patients
with liver disease related edema.
cool dusky fingertips after vasopressors can be the result of
norepinephrine-induced vasospasm. norepinehrine has alpha-1 agonist
properties which cause vasoconstriction, which is good when trying to
increase the bp of hypotensive patients, however in patients with decreased
blood flow it can cause ischemia and necrosis of distal fingers/toes. can also
occur in intestines (mesenteric ischemia) or kidney (renal failure)
native valve bacterial endocarditis due to S. viridans highly susceptible to
penicillin is well-treated with iv penicillin g or iv ceftriaxone. do not use oral
antibiotics for subacute bacterial endocarditis.
symptomatic sinus bradycardia should be treated with iv atropine, followed
by trancutaneous pacing. if they are hemodynamically unstable the use of
epinephrine is appropriate. (do no confuse with adenosine for PSVT !!!!!)
three most common causes of aortic stenosis are 1) senile calcific aortic
stenosis, 2) bicuspid aortic valve and 3) rheumatic heart disease. bicuspid
aortic valve is the cause of aortic stenosis in the majority of patients < 70 y/o.
systolic murmur in right upper sternal border with radiation to the carotids.
aortic regurgitation causes an early diastolic murmur and can be associated
with a hyperdynamic pulse, including bounding or water hammer
peripheral puses.
acute pericarditis is characterized by sharp pleuritic chest pain that is worse
in the supine position and improved by sitting up and learning forward. occurs in
the first several days after myocardial infarction. diffuse ST elevations,
especially with PR depressions are typical EKG findings.
outflow obstruction in hypertrophic obstructive cardiomyopathy results from
both septal hypertrophy and systolic anterior motion (SAM) of the mitral
valve. hocm presents as crescendo-decrescendo murmur in the lower left
sternal border. increases during valsalva due to decreased preload and decreased
filling of left ventricle.
EKG findings in acute pericarditis are diffuse ST elevation and depression
of PR segment (except in aVR). most common cause is viral infection. can
also be caused by uremia (patient with renal problems). treatment of uremic
pericarditis is dialysis. indications for hemodialysis are 1) refractory
hyperkalemia 2) volume overload or pulmonary edema not responding to

diuretics 3) refractory metabolic acidosis (ph < 7.2) 4) uremic pericarditis 5)

uremic encephalopathy or neuropathy 6) coagulopathy due to renal failure
kussmauls sign (increased jvp on inspiration) is seen in: constrictive
pericarditis, cardiac tamponade, right heart failure. hypotension, jvd and
clear lung fields point to right ventricular infarction. treat with iv fluids and
avoidance of preload reducing medications (nitrates and diuretics), they are
preload dependent. right heart failure (preload dependent, eg Inferior MI)
= liquids
cardiac cath is typically done by cannulating the femoral artery to access the
cardiac vessels. a common complication is hematoma formation in soft
tissues of the upper thigh. if the arterial puncture was done above the
inguinal ligament, this hematoma can extend directly into the
retroperitoneal space and cause significant bleeding, with hypotension and
tachycardia. patients can also develop ipsilateral flank pain/back pain and
neurologic defects on the ipsilateral side. next step would be to obtain a CT
of the abdomen and pelvis without contrast to confirm.
acute heart failure can cause pulmonary edema or flash pulmonary edema
secondary to anterior wall myocardial infarction. a diuretic such as furosemide is
the drug of choice in this setting. decreases the cardiac preload thereby
decreasing the pulmonary capillary pressure. also causes venodilation which
further decreases preload.
clear lung fields, hypotension, and jugular venous distension in the setting of an
inferior wall mi are suggestive of a right ventricular infarct. fluid
resuscitation is the appropriate management, and nitrates should be
avoided because they decrease preload and will limit cardiac output.
anterolateral myocardial infarction can cause papillary muscle ischemia
or rupture, which can cause mitral regurgitation. will have bibasilar crackles,
orthopnea. measurement of pulmonary capillary wedge pressure (PWCP/left atrial
pressure) with a swan-ganz catheter will reveal increased pressure in the left
atrium
premature ventricular complexes (PVCs) are common in post-myocardial
infarction patients and can be recognized by their widened QRS > 120
msec, bizzare morphology, and compensatory pause. no treatment unless
symptomatic.
amyloidosis can result in a restrictive cardiomyopathy with thickened
ventricular walls and preserved ventricular dimensions as well as liver
(clotting, bruising) and kidneys (proteinuria)
calcium gluconate is given for hyperkalemia to protect the heart. on EKG
hyperkalemia will have peaked T waves, and prolongation of PR and QRS
intervals eventually leading to a sine wave. sodium bicarb is used in TCA and
aspirin overdose. magnesium sulfate is used for torsades de pointes. a
polymorphic ventricular tachycardia associated with a prolonged QT
interval. it commonly occurs in patients with long QT syndrome as well as
patients with a history of alcoholism and recent intiation of fluconazole and
moxifloxacin.
myocarditis presents as a flu-like illness with fever, anorexia, lethargy, irritability
in children. followed by respiratory distress from acute heart failure. CXR will
show cardiomegaly and pulmonary edema. EKG shows low voltage QRS and
sinus tachycardia. echocardiogram shows global hypokinesis, left
ventricular hypertrophy, left ventricular dysfunction, and pericardial
effusion. gold standard is myocardial biopsy (but no one really does that,
too invasive).

aortic stenosis can cause anginal chest pain because the left ventricle will
hypertrophy requiring additional oxygen. increased myocardial oxygen
demand
myocarditis presents like congestive heart failure with cardiomegaly,
paroxysmal nocturnal dyspnea, dyspnea on exertion, peripheral edema,
hepatomegaly, bilateral pleural effusions, and a third heart sound. viral
myocarditis is often due to coxsackie b virus.

dermatology

senile purpura is characterized by ecchymoses that occur on elderly patients

extensor surfaces due to perivascular connective tissue atrophy. renal
failure can also cause platelet dysfunction (uremia causes platelet dysfunction,
creatinine would be elevated.
basal cell carcinoma in sun exposure. nodule with pearly rolled borders and
telangiectasia
actinic keratosis described as erythematous papules with a central scale.
"sandpaper like" texture. sun exposed areas
stevens johnson = erythema multiforme major. target shaped muco-cutaneous
lesions and systemic signs of toxicity. type 3 hypersensitivity
eschar formation can compromise blood flow and lymphatic circulation. decreased
pulses and edema. do escharotomy.
sq. cell carcinoma with chronic wounds.
rosacea in middle-aged patietns with telangiectasias over cheeks, nose, and
chin. flushing made worse by hot/cold drinks, sun, emotion. has papules and
pustules. tx is metronidazole
porphyria cutanea tarda has painless blisters, photosensitivity, increased
skin fragility on dorsum of the hands, hypertrichosis. associated with hep c
infection (think liver stuff)
tinea corporis has ring-shaped scaly patches with a central clearing and
scaly borders. treatment is terbinafine.
normal skin @ birth with progression to dry, scaly skin with horny plates over
extensor surfaces is icythosis vulgaris. worsens in winter. looks like lizardy
skin
allergic contact dermatitis has vesicles at the site of exposure. can become
secondarily infected and have pus filled vesicles.
for SCC do a punch biopsy to confirm dx
vitiligo is due to autoimmune destruction of melanocytes
seborrheic keratosis is a benign growth that occurs in many places on the
body, but favors face/trunk. the lesions have a waxy, stuck on, warty and well
circumscribed appearance. actinic keratosis is a pre-malignant lesion that is
dry, scaly, flat papule with erythematous base.
bullous pemphigoid is autoimmune blistering disorder marked by tense bullae,
urticarial plaques. igg and c3 along basement membrane zone. Dermal layer
vs epidermal for pemphigus vulgaris.

the most common drugs in the treatment of acne to produce phototoxic drug
reactions are the tetracyclines, namely doxycycline. sunburn reactions with
erythema, edema, and vesicles over sun-exposed areas.
squamous cell carcinoma is the 2nd most common form of non-melanoma skin
cancer after basal cell carcinoma. exposure to sunlight is the most important
factor in the development of scc.
best way to prevent malignant melanoma is wearing protective clothing. sun
screen protects against non-melanoma skin cancer like sq. cell carcinoma
for basal cell carcinoma do mohs surgery, wherein microscopic shaving is
done such that 1-2mm of clear margins are excised. this technique has the
highest cure rate for basal cell cancer. but is indicated only in patients with highrisk features or in those with lesions in functionally critical areas (perioral, nose,
lips, ears)
pemphigus vulgaris is a mucocutaneous blistering disease that is characterized
by flaccid bullae and intercellular igg deposits in the epidermis. autoantibodies
are formed against desmoglein, an adhesion molecule. bullous pemphigoid
rarely has oral lesions. (not in mucous membranes)
dermatitis herpetiformis is associated with gluten-sensitive enteropathy
(celiac disease). dapsone is an effective treatment.
mild acne (non-inflammatory comedones) are treated with topical retinoids
first. topical antibiotics are added with mild-to-moderate inflammatory
acne. use oral isoretinoin for patients with nodulocystic and scarring acne.
seborrheic dermatitis is a common inflammatory disease that affects areas
with sebaceous glands, such as the scalp (dandruff) face (eyebrows
nasolabial folds and external ear canal/posterior ear), chest and
intertriginous areas. seborrheic dermatitis occurs in all ages but is found in
increased frequency in patients with parkinsons and HIV. pruritic erythematous
plaques with fine, loose, yellow, and greasy looking scales. acne rosacea is
a rosy hue with telangiectasia over the cheeks, nose and chin. flushing of
these areas is typically precipitated by hot drinks, heat, emotion, and other
causes of rapid body temp changes.
atopic dermatitis (eczema) in infancy affects face, scalp, and extensor
surfaces of the extremities. lesions usually begin with pruritis alone, and
evolve to erythematous excoriated papules and plaques that may weep and
become secondarily impetiginized. atopic dermatitis is the result of
decreased skin barrier function due to improper synthesis of components of
the epidermal cornified cell envelope. allergens can readily access deeper levels
of the epidermis where they may generate the immune resopnse. the diaper
region is typically spared.
excisional biopsy with narrow margins is the preferred study for the
diagnosis of melanoma. if the depth of the lesion is <1 mm the melanoma can
be excised with a 1 cm tumor free margin and they have a 99% 5 year survival.
tumors > 1 mm in depth should have a sentinel lymph node study. do not do
excision with wide margins (like 1 cm) until the diagnosis of melanoma
is made.
toxic epidermal necrolysis is a severe mucocutaneous exfoliative disease.
erythematous morbiliform eruption that rapidly evolves into exfoliation of
the skin. in steven johnson syndrome up to 10% of the body surface area is
involved, in TEN > 30% of the body surface is involved.
molluscum contagiosum caused by poxvirus. dome shaped lesions with
central umbilication.
acne from steroids has no comedones and monomorphous pink papules.
adolescent acne has both open and closed comedones.

electrolytes

chronic alcoholism -> pancreatitis -> malabsorption. low vitamin D means will
have low phosphorous and low calcium
malignancy is the most common cause of hypercalcemia in admitted patients.
osteolytic mets, secretion of pth-rp, increased vit d, and IL-6
hypocalcemia causes increased deep tendon reflexes. can occur after
multiple transfusions (due to calcium chelation by citrate in blood products).
hypermagnesemia has decreased deep tendon reflexes.
for hyperkalemia 1) stabilize membrane with calcium gluconate 2)
insulin/glucose and 3) remove from body (kayexalate)
for a patient with severe hypovolemic hypernatremia give 0.9% saline
(isotonic saline). patients with less severe hypovolemic hypernatremia are
treated with 5% dextrose in 0.45% saline
for calcium check the corrected calcium using ( 0.8 x 4.0 - measured alb) +
measured calc. do corrected calcium to see if hypoalbuminemia is causing
hypocalcemia. 0.8 x (4.0 serum alb) + calcium. if the calcium falls in normal
range its due to hypoalbuminemia
primary hyperparathyroidism is the most common cause of hypercalcemia in
ambulatory patients. in most cases its a solitary parathyroid adenoma.
in patient with acute hyponatremia correct sodium concentration with 3%
saline (hypertonic).
albuterol given for acute asthma attacks may cause hypokalemia, tremors,
palpitations and headache. beta-agonist (drives the membrane Na/K pump,
Na out and K in) --> hypokalemia
hypokalemia has u waves and flat and broad t-waves on ecg, and premature
ventricular beats.
meds causing hyperkalemia: digoxin, succinylcholine, tmp-smx, aceis,
nsaids, potassium-sparing diuretics like spironolactone and amiloride.
treat hypercalcemia with iv saline hydration (normal saline 0.9%) followed
with loop diuretics (furosemide)
bartter syndrome (cant absorb NaCl) presents like renin secreting tumor with
very high >40 urine chloride, elevated plasma renin/aldosterone, low serum
k, high serum bicarbonate, but in bartter / gitelman syndrome the serum
Na is normal, in a renin secreting tumor serum sodium is elevated. renin
secreting tumors will also cause hypertension. bartter syndrome has defective
Na and chloride reabsorption in the thick ascending limb of the loop of
henle so you get hypovolemia --> raas. gitelman syndrome is like bartter
but defect in distal conv. tubule. basically bartter = normal serum na + lots
of raas
asymptomatic hypercalcemia is the most common presentation for primary
hyperparathyroidism. 24 hour urinary calcium can help distinguish primary
hyperpth (>200 mg) from familial hypocalciuric hypercalcemia (<100).
both disorders have elevated serum calcium and elevated pth. indications for
surgery in an asymptomatic patient are 1) serum calcium at least 1 mg above
upper limit of normal 2) young age < 50 3) bone mineral density lower than t
2.5 at any site 4) reduced renal function (egfr < 60). before surgery most
surgeons order a sestamibi scan to localize the adenoma.

an acute rise in serum calcium is most commonly seen in hypercalcemia of

malignancy. primary hyperparathyroidism does not result in calcium levels as
high as those seen with malignancy.
SIADH causes hyponatremia (water retention), plasma hypoosmolality (water
retention), and a high urine osmolality (>200) and a high urine sodium
concentration ( urine na >30meq/l)
to determine cause of hyponatremia calculate serum osmolality = (2 * na) + (bun
/ 2.8) + (glucose/18) if they are hypotonic and hyponatremic then look at volume
status: hypovolemic, euvolemic, or hypervolemic. hypovolemic hypotonic
hyponatremia can be due to renal or exrarenal losses of sodium and water.
extrarenal losses have a urine na < 10, (renal losses will have urine Na > 20) and
can be secondary to diarrhea and vomiting
volume resuscitation with normal saline will correct contraction alkalosis.
hypokalemia should be treated as well.
in patients with malignancy, hypercalcemia is due to the increased resorption
of bone and release of calcium from bone. the pathology involves osteolytic
mets with local release of cytokines and tumor secretion of pth-rp.
bisphoshonates are the drug of choice for mild to moderate hypercalcemia due
to malignancy. IV fluids and furosemide are used in the treatment of
hypercalcemic crisis.
isotonic solutions such as normal saline (0.9%) are the fluid of choice for initial
resuscitation in severe hypovolemic hypernatremia.
chronic renal failure can increase pth leading to 2nd hyperparathyroidism. seen
with moderate to severe renal insufficiency. serum calcium levels are normal to
low in patients with 2nd hyperpth because the cause of elevated pth is
hypocalcemia.( also elevated phosphate will prevent Ca from rising too much)
primary hyperpth will have an elevation of pth and calcium levels along with a
history of renal stones and osteoporosis.
vigorous hydration with iv normal saline is first step in managing severe
symptomatic hypercalcemia
renal failure causes hypocalcemia. immobilization of an individual with a
high bone turnover results in increased osteoclastic activation that can
lead to hypercalcemia. bisphosphonate therapy in patients who are
immobilized is helpful in reducing hypercalcemia and preventing
osteopenia.
vomiting causes metabolic alkalosis (losing volume and losing H+) with
hypochloremia and hypokalemia. volume contraction causes secondary
hyperaldosteronism causing hypokalemia. it will have low urine chloride <20 (the
kidney is reabsorbing NaCl) and chloride sensitive.
increased extracellular pH (alkalosis) can cause an increase in the affinity of
serum albumin to calcium causing hypocalcemia.
siadh is a common complication of lung cancer, particularly small cell lung
cancer. low sodium and high potassium. initial treatment is fluid restriction.
addisons disease has aldosterone deficiency leading to non-anion gap,
hyperkalemic hyponatremic metabolic acidosis. (aldosterone removes h+
and k+, saves na+)
saline-responsive metabolic alkalosis has urine cl < 20 (Body is
dehydrated, wants to retain Na + Cl) and is typically due to conditions
caused by hypovolemia or gastrointestinal proton loss. treat with isotonic saline
infusion.
recognize diabetic ketoacidosis as metabolic acidosis, polyuria,
dehydration, decreased level of consciousness, and diffuse abdominal pain
after an infection . dka is characterized by an osmotic diuresis that reduces

total body potassium stores even though serum potassium may be

elevated.
loop diuretics give hypokalemia, and also result in increased distal solute
delivery as well as increased aldosterone level. increased hydrogen ion
excretion --> metabolic alkalosis

emergency

for ethylene glycol poisoning use fomepizole. will have calcium oxalate
stones in the kidneys. flank pain, hematuria, oliguria, acute renal failure, anion
gap metabolic acidosis.
iron poisoning has a corrosive effect on the gi mucosa. ab. pain, nausea,
vomiting, diarrhea and hematemesis. hypotension and venodilation lead to
hypoperfusion and leads to metabolic acidosis. iron is radio-opaque so it can be
seen in stomach on abdominal xr. To diagnose measure serum iron levels, to
treat use iv deferoxamine
when patient ingests acetaminophen, before giving n-acetylcysteine make
sure serum level is toxic (check at 4 hours). can give n-aceylcysteine within 8
hours of ingestion. give activated charcoal is good within 4 hours.
when a patient ingests lye (sodium hydroxide) which is a strongly alkaline
solution, must do upper gi endoscopy to assess extent of esophageal injury
and determine if any further management is needed. if perforation is
suspected do a gastrografin study.
sodium bicarbonate is used to treat TCA poisoning. tca overdose causes
hyperthermia, seizures, hypotension, and anti-cholinergic effects: dilated
pupils, flushed and dry skin, intestinal ileus and QRS prolongation. blind
as bat, dry as bone, hot as hare, mad as hatter, red as beet.
diphenhydramine overdose presents with anti-cholinergic symptoms,
drowsiness, and confusion. diphenhydramine is an anti-histamine but can give
anti-cholinergic effects as well. treatment involves giving administration of
physostigmine, a cholinesterase inhibitor which reverses its effecs.
for frostbite injuries, best treatment is rapid re-warming with warm water.
after warming, re-evaluate the extremity. amount of debridement is always less
after re-warming.
methanol intoxication can cause vision loss and coma. physical exam will
show optic disc hyperemia, lab studies will show anion gap metabolic acidosis.
increased osmolar gap is often seen as well.
in heat stroke the temperature is usually > 105F/40.5C. heat stroke results from
an insufficient evaporative cooling mechanism. treatment involves evaporative
cooling to reverse hyperthermia.
opioid withdrawal presents with symptoms of nausea, vomiting, abdominal
pain, diarrhea, arthralgias and myalgias. signs of opioid withdrawal on exam can
include increased bowel sounds, mydriasis and piloerection. treat with
methadone. C. difficile infections generally do not begin until 5-10 days after
antibiotic treatment is initiated.
bradycardia, av block, hypotension and diffuse wheezing indicate betablocker overdose. most common presentation of beta blocker toxicity is
bradycardia and hypotension, which can lead to cardiogenic shock.

bronchospasm (diffuse wheezing) neurological effects (delirium and seizures) and

hypoglycemia. first give iv fluids and atropine, then give glucagon to increase
cAMP and higher levels of intracellular calcium to augment cardiac contractility.
cocaine related cardiac ischemia is treated with benzodiazepines, nitrates,
and aspirin. beta-blockers are contraindicated.
iron tablet intoxication appears as abdominal pain and hematemesis,
hypovolemic shock and metabolic acidosis. will appear radioopaque (can see)
on xr. give deferoxamine.
sodium bicarbonate narrows QRS complex preventing development of
arrhythmia in patients with TCA toxicity by alleviating the cardio-depressant
action on sodium channels.
caustic poisoning does not cause alterations in consciousness. presents with
dysphagia, severe pain, heavy salivation and mouth burns. the damage is the
result of necrosis of the tissue that lines the gastrointestinal tract. in severe
cases perforation of the stomach or esophagus can occur, causing peritonitis or
mediastinitis.
give atropine to reverse organophosphate poisoning (acetylcholineeserase
inhibitor). will have cholinergic excess so atropine can reverse. but first remove all
clothes which may be soaked in the poison to prevent transcutaneous absorption.
treat cat bites prophylactically with amoxicillin/clavulanate. pasteurella
multicoda is resistant to erythromycin 50% of the time
heat stroke is temp > 40.5C / 105F. will have hot, dry skin and hypotension.
tachycardia, tachypnea and hemoconcentration. will have multiple organ
system effects, seizures, ARDS, dic, and hepatic/renal failure can occur.

endocrine

isoniazid causes hepatitis with similar pathological picture to viral hepatitis

(panlobular mononuclear cell infiltration and hepatic cell necrosis)
treat symptomatic syndrome of inappropriate antidiuretic hormone (SIADH)
with hypertonic saline 0.3% (patient will be hyponatremic)
hereditary hemochromatosis patients are vulnerable to infections of Listeria
monocytogenes, Yersinia enterocolitica, and Vibrio vulnificus
corticosteroids have mineralocorticoid like effects (hypokalemia, alkalosis,
hypernatremia)
in psychogenic polydipsia, water deprivation will increase urine
concentration, but in diabetes insipidus (DI) the water will not concentrate (ADH
is not functioning). The next step is to administer ADH and if it concentrates urine
then the patient has central diabetes insipidus, if the urine is still not
concentrated then the patient has nephrogenic diabetes insipidus.
hyperthyroidism can have rapid bone loss if left unreated. The patient will
have increased ALP
aromatase deficiency leads to high testosterone, no estrogen, and
virilization of females. A patient with congenital adrenal hyperplasia (CAH) will
still have estrogen. Aromatase converts testosterone into estrogen.
chronic supraphysiological doses of glucocorticoids suppress CRH from
hypothalamus. After removal of iatrogenic corticosteroids the HPA axis takes a
few months to recover.

MEN1 parathyroid, pituitary, pancreatic (insulinoma, glucagonoma).

MEN2a medullary thyroid, pheochromocytoma, parathyroid.
MEN2b medullary thyroid, pheochromocytoma, mucosal neuromas (Marfanoid
Habitus). All are associated with the RET oncogene
best test for Addisons is cosyntropin stimulation test. Addison's presents
with weakness, fatigue, depression, increased pigmentation (due to
increased ACTH). Causes of adrenal insufficiency 1) diseased adrenal gland 2)
pituitary not releasing ACTH 3) decreased CRH by hypothalamus
diabetes mellitus causes ischemic nerve damage. somatic nerve
oculomotor/CN3 - leads to down and out.
factitious thyrotoxicosis is caused by ingestion of exogenous thyroid,
causing the thyroid gland to atrophy and less release of thyroglobulins.
if urine osmolality < 300 (low conc, lots of water) then you have complete
diabetes insipidus. partial diabetes insipidus is urine osm between 300-600.
patients with psychogenic polydipsia have hyponatremia, and diabetes insipidus
presents with hypernatremia.
The 3 main categories of diabetic retinopathy are 1) simple microaneurysms,
hemorrhages, exudates, retinal edema 2) pre-proliferative cotton wool spots
3) proliferative neovascularization (most common result of poor
hyperglycemic control is retinopathy)
A pituitary adenoma < 10 mm is a microadenoma. if its a prolactinoma, will
have bilateral galactorrhea and amenorrhea. use cabergoline/bromocriptine
which are dopamine agonists.
diabetic nephropathy starts with increased GFR and microalbuminuria. once
you have > 300mg protein/day you have macroproteinuria and the only
intervention to reduce the decline in GFR at this point is intensive blood
pressure control. intensive glycemic control only lowers the progression to
microalbuminuria.
hypothyroidism is associated with myopathies including elevated serum CK,
myalgias, muscle hypertrophy (with myxomatous buildup), proximal
myopathy, rhabdomyolysis.
tricyclic antidepressants are drugs of choice for diabetic neuropathy. But
because they can worsen urinary symptoms and give orthostatic hypotension you
can use gabapentin as a backup.
sick euthyroid syndrome is when a patient has abnormally low T3 in acute, severe
illness (TSH normal)
diabetic neuropathy can lead to a denervated bladder leading to overflow
incontinence. The patient will present with urinary frequency, nocturia, frequent
leakage of small volumes of urine and the post residual volume will be high.
renal failure gives hypocalcemia, hyperphosphatemia, and increased
parathyroid hormone levels. The GFR falls and kidneys retain phosphate
causing hypocalcemia, leading to hyperparathyroidism.
TSH-secreting pituitary adenomas can cause a goiter due to the effect of TSH on
the growth of the thyroid follicles. The patient wont have extrathyroidal
manifestations of Graves such as infiltrative opthalmopathy and pretibial
myxedema.
Conns syndrome (hyperaldosteronism) causes hypertension, mild
hypernatremia, hypokalemia, and metabolic alkalosis (excreting more K+ and
H+).
popullary (papillary) carcinoma is the most common thyroid malignancy.
propylthiouracil and methimazole can cause agranulocytosis. If the patient
presents with fever, sore throat, stop anti-thyroid drug and do a CBC. if WBC <
1000 permanently stop drug.

insulin resistance for patients with central type obesity is a key pathogenic factor
in the development of type 2 diabetes mellitus and associated abnormalities.
Graves opthalmopathy is due to autoimmune lymphocytic infiltration of the
extraocular muscles resulting in fibroblast proliferation, hyaluronic acid
deposition, edema and fibrosis
DHEA-S is produced by the adrenal glands only. DHEA, androstenedione, and
testosterone are made by the ovaries and the adrenals. Use to differentiate
between
secondary (central) hypogonadism has low testosterone and
inappropriately normal gonadotropin levels (FSH/LH). measure serum prolactin
levels, prolactin inhibits the release of GnRH.
the most specific test for making a diagnosis of acromegaly is to measure
growth hormone levels following an oral glucose load (GH levels should
drop after oral glucose load). IGF-1 is a good screening test for acromegaly
(IGF-1 will be increased in acromegaly), but it is an indirect measure of GH, and
other diseases can lead to decreased IGF-1 levels.
normal saline is the initial fluid of choice in a hypotensive, dehydrated
patient with diabetes insipidus. hypotonic fluids can be started once the
intravascular volume improves.
glucagonoma has a triad of 1) hyperglycemia 2) necrotizing dermatitis 3)
weight loss. the skin lesion is called necrolytic migratory erythema.
diabetic patients develop neuropathy. when the small colon is involved it usually
causes diarrhea due to bacterial overgrowth, involvement of the large colon
causes constipation, involvement of the stomach causes gastroparesis,
which commonly presents as anorexia, nausea, vomiting, and abdominal bloating
and early satiety. treat with metoclopramide, bethanecol or erythromycin.
MEN2a consists of medullary carcinoma of the thyroid, hyperparathyroidism, and
pheochromocytoma. the serum calcitonin level is elevated in patients with
medullary thyroid cancer.
paraneoplastic Cushings syndrome is caused by ectopic ACTH production
by small cell lung carcinoma. It is not suppressed by dexamethasone and you
get clinical features of hyperpigmentation in sun exposed areas (skin, scars,
palmar creases, inner surface of lips, and/or buccal mucosa), easy bruising,
truncal obesiy, moon facies, buffalo hump, striae, hypertension, fatigue, glucose
intolerance, osteopenia, weakness, edema, electrolyte disturbances.
dizziness, palpitations, trembling and sweating with exercise are
consistent with hypoglycemia in patients who take insulin and exercise
intensely.
Cushings syndrome is caused by high levels of glucocorticoids/cortisol. proximal
muscle weakness, obesity, easy bruising, oily skin, acne, hirsutism.
treat diabetic ketoacidosis with 1) aggresive rehydration, 2) insulin therapy and 3)
potassium repletion.
The most effective treatment in slowing progression of diabetic nephropahy is
maintaining a blood pressure of < 130/80 with ACEis or ARBs.
Cushings syndrome causes secondary hypertension, hyperglycemia
(cortisol activates glucagon), hypokalemia, psychiatric problems (sleep,
depression, psychosis).
neurogenic arthropathy or charcots joint is a complication of neuropathy
and repeated joint trauma.
pseudohypoparathyroidism has low serum calcium, high serum
phosphate, and high serum PTH. (calcium and phosphate levels are as if PTH
levels are low, but PTH levels are elevated)

X-linked hypophosphatemic rickets have low serum phosphate due to

renal phosphate wasting.
patients with generalized resistance to thyroid hormones have high serum
T4 and T3 levels with normal to mildly elevated TSH. patients have features
of hypothyroidism despite having elevated free thyroid hormones.
subclinical hypothyroidism is characterized by mildly elevated TSH and
normal circulating thyroid hormones. These patients do not have features
of overt hypothyroidism.
hyperlipidemia, unexplained hyponatremia, and elevated serum muscle
enzymes are indications for thyroid function tests.
somogyi effect occurs when counterregulatory hormones react to nocturnal
hypoglycemia (too much insulin), thereby resulting in early morning
hyperglycemia. the patient will have low serum glucose at 3:00 AM. in the
dawn phenomenon the patient will have an increased 3:00 am glucose
concentration because of the secretion of nocturnal growth hormone.
hemosiderosis is the deposition of excessive iron to tissues. caused by a variety
of inherited metabolic disorders. not considered to be a distinct disease
entity. hemochromatosis is an autosomal recessive disorder characterized by
increased skin pigmentation, diabetes, cirrhosis, and arthralgia
(pseudogout) in the later stages. treatment is phlebotomy for 2-3 years to
deplete iron stores, and deferoxamine as a 2nd line treatment.
plasma aldosterone to plasma renin activity ratio (PA:PRA) is used as an initial
screening test for primary hyperaldosteronism. a ratio > 30 is suggestive of
the diagnosis.
hyperpigmentation of the skin and mucous membranes is characteristic of
primary adrenocortical deficiency, and is due to increased levels of ACTH.
this feature is not seen in secondary adrenal insufficiency due to
hypothalamo-pituitary failure. glucocorticoid deficiency presents as
weakness, fatigue, depression, irritability, hypotension, lymphocytosis,
neutropenia, and eosinophilia. hypothyroidism presents as cold intolerance,
constipation, dry and rough skin, bradycardia. mineralocorticoid deficiency
presents as hypokalemia, alkalosis, and mild hypernatremia.
when you find a thyroid nodule, first do serum TSH. if serum TSH is low, do
radionuclide thyroid scan. if hyperfunctioning then evaluate for
hyperthyroidism. if non-functioning nodule then do diagnostic ultrasound
of thyroid. if nodule is suspicious for malignancy do FNA of nodule. if the
FNA is benign, routine follow up and surveillance. if TSH is normal or high then
do ultrasound of nodule. Steps: 1) TSH, 2) radionuclide scan, 3) ultrasound, 4)
FNA
hypothyroidism leads to accumulation of matrix substances throughout the
body. if this occurs in the median nerve and the tendons of the carpal tunnel then
it may cause carpal tunnel syndrome.
treat diabetic ketoacidosis by giving IV normal saline followed by regular
insulin, and potassium.
hypertension in patients with thyrotoxicosis is predominantly systolic and
caused by hyperdynamic circulation. increased target organ sensitivity to
endogenous catecholamines by increasing the expression of adrenergic
receptors as well.
subacute lymphocytic (painless) thyroiditis can cause thyrotoxicosis with
reduced radioactive iodine uptake. other causes of thyrotoxicosis with
reduced radioactive iodine uptake include: subacute granulomatous (de
quervain) thyroiditis, iodine-induced thyroid toxicosis, levothyroxine
overdose, struma ovarii.

hyperthyroidism and hypothyroidism can cause proximal muscle

weakness. look for additional symptoms of thyroid dysfunction (fatiguability,
tremor, anxiety, weight changes, menstrual)

epidemiology

matching is frequently used in case-control studies because it is an efficient

method to control confounding.
Case control determine outcomes, then find exposure risk, can calculate OR
a two sample t-test is a statistical method commonly used to compare the means
of two groups of subjects. ANOVA is used to compare three or more means.
Cohort study is a study done based on presence/absence of risk factors, can
calculate RR
Number needed to treat = 1/absolute risk reduction
the correlation coefficient shows the strength and direction (positive or
negative) of linear association between two variables, but it doesnt imply
causality.
a factorial design uses 2 or more experimental interventions each with 2 or more
variables that are studied independently. (wtf??)
in a cross-sectional study, exposure and outcome are measured
simultaneously at a particular point of time (snapshot study, shows prevalence).
if the outcome of a case-control study is not common in the population, the odds
ratio is close to the relative risk.
the p value is the probability that the result of a study was obtained by chance
alone. a study is statistically significant when the p value is < 0.05 (lower p value
is less due to chance)
case control studies are also known as retrospective studies. researcher
begins with a population with a certain outcome and subjects are classified as
cases or controls based on outcome status. a retrospective cohort study starts at
some point between the exposure and outcome. the researcher reviews past
records, classifies subjects as exposed and not exposed and follows them until
the outcome.
use tests with high sensitivity to screen for diseases. (ELISA for HIV). specificity to
confirm (western blot). sn-out. sp-in
chi-square test is used to compare proportions.
precision is the measure of random error. the tighter the confidence interval, the
more precise the result. increasing the sample size increases precision.
PPV (TP/All Ps)depends on prevalence of disease. NPV also depends on the
prevalence of disease, but has an inverse association with the prevalence. as
prevalence of disease increases, NPV will decrease.

gastroenterolog
y

chronic pancreatitis can lead to pancreatic cancer. To look for pancreatic cancer
do a CT scan of abdomen
zinc def has alopecia, abnormal taste, bullous pustulous lesions, and can
occur in total paraenteral nutrition or malabsorption
acute iron intoxication has 5 phases. 1) gastrointestinal phase- nausea, vomiting,
hematemesis, melena, abdominal pain 2) asymptomatic 3) shock and metabolic
acidosis 4) hepatotoxicity 5) mucosal scarring leading to bowel obstruction
calcium channel blockers and nitrates relax myocytes in esophagus. relieves
diffuse esophageal spasm. diagnose with manometry
hepatic hydrothorax is a transudative pleural effusion in a patient with
cirrhosis. salt restriction and diuretics, and then TIPS
crohn's disease has non-caseating granulomas (pathognomonic for CD).
ulcerative colitis does not.
GI, lung, breast generally mets to liver. prostate mets to pelvic lymph nodes and
lumbar spine.
non-bleeding varices treated with beta-blockers. decreases risk of bleeding
by
bowel ischemia and infarction is an early complication of AAA repair.
pseudomembranous colitis takes 4-5 days after antibiotic use to develop.
ischemic colitis will show thickening of the bowel wall on CT.
in a patient with acute pancreatitis, check for underlying cause (gallstones) do
RUQ ultrasound
inflammatory bowel disease also occurs w/ inflammatory arthritis.
ankylosing spondylitis is an association. +P-anca and also erythema nodosum
biliary colic caused by ingestion of fatty meals. gall bladder contracts and presses
gallstone against cystic duct opening, increasing gall bladder pressure, causing
distension and colicky pain. gall bladder relaxes and stone falls back in duct.
Biliary colic is temporary, cholecystitis is more constant pain.
pyloric stricture (and gastric outlet obstruction) lead to early satiety,
succussion splash, non bilious vomiting.
acute appendicitis should have immediate surgery if clinical diagnosis is clear
hematochezia is bright red blood per stool. usually due to lower gastrointestinal
bleed. do colonoscopy, if negative then do labeled erythrocyte
scintigraphy.
laxative abuse on biopsy will show dark brown discoloration of colon with
lymph follicles shining through as pale patches (melanosis coli)
H. pylori is associated with gastric lymphoma/MALToma but not
adenocarcinoma. once diagnosis of cancer is made, next step is to find extent
of disease.

inflamm bowel disease has a bi-modal distribution. erythematous mucosa

possibly w/ ulcers. ulcerative colitis has shallow ulcers compared to crohn's
transmural.
persistence of HbsAg in serum for 7 months confirms diagnosis of chronic hep b
infection. for acute hepatitis use LFTs and serology but for chronic hepatitis do
liver biopsy.
acalculous cholecystitis is seen in severe trauma, ischemia, post-op
patients. similar to cholecystitis with thickening of gall bladder wall, and
pericholecystic fluid.
drug induced esophagitis caused by potassium chloride, NSAIDs,
alendronate, doxycycline.
mechanical small bowel obstruction presents with abdominal discomfort,
vomiting, abdominal distention, constipation, increased BS, dilated loops
of bowel on x-ray. most commonly b/c of adhesions from previous operations.
painless jaundice + conjugated hyperbilirubinemia + elevated ALP should raise
concern for intraabdominal malignancy that is obstructing the biliary system
pancreatic adenocarcinoma
chronic pancreatitis is diagnosed with stool elastase. serum amylase and
lipase concentrations can be normal or only modestly elevated.
acute diverticulitis is uncomplicated (75%) or complicated (25%). complicated
can lead to an abscess, if < 3 cm then treated with IV antibiotics. but if
fluid collection > 3 cm then should be percutaneously drained via CT
guidance. if drain doesnt work in 5 days then debridement and surgical drainage
can be attempted.
for hepatic encephalopathy use lactulose, neomycin or rifamixin, and laxatives.
sudden onset epigastric pain with air under diaphragm indicates perforated
peptic ulcer. can have diffuse abdominal pain due to peritonitis, do laparotomy
primary biliary cirrhosis has symptoms of xanthelasma, pruritis, jaundice,
steatorrhea, hepatosplenomegaly, increased ALP and serum bilirubin, and +antimitochondrial antibody. Due to destruction of the bile ducts in the portal triad.
Treat with ursodeoxycholic acid (can also give for symptomatic
cholelithiasis, can help dissolve stones, though recurrence rate very
high)
lactose intolerance has a +hydrogen breath test, +stool test for reducing
substances, low stool pH and increased stool osmotic gap.
new onset diabetes mellitus = hemochromatosis (bronze diabetes).
they can also have damage to liver, pituitary. will present with hepatomegaly,
hyperpigmentation, arthropahy, restrictive heart failure, and
hypogonadism. check iron levels.
carcinoid syndrome triad includes 1) diarrhea, 2) flushing 3) valvular heart
disease (tricuspid due to exposure on the R sided circulation). precursor
of serotonin is tryptophan so patients can get niacin deficiency. Niacin
deficiency presents as the 4 Ds diarrhea, dermatitis, dementia, and death
in patients with liver cirrhosis and who have esophageal varices give betablockers to decrease the risk of variceal hemorrhage.
hemorrhage is the most common complication of peptic ulcer. will present
as hematemesis with or without melena. if its massive upper gi bleeding it will
appear as hematochezia (bright red blood in stool).
Boerhaaves syndrome is spontaneous rupture of the esophagus when
intraabdominal pressure goes high. retrosternal pain and crepitus in the
suprasternal notch are the result of pneumomediastinum which can occur
after rupture of esophagus within the mediastinum.

duodenal ulcer presents with epigastric pain better upon eating. 90% infected
with h. pylori so give PPI + antibiotics (azithro, clarithro)
echinococcus granulosus causes hydatid cyst disease which appears as
eggshell calcifications on CT scan of liver.
emphysematous cholecystitis is a form of acute cholecystitis that arises due
to infection of gall bladder wall with gas forming bacteria. RUQ pain,
nausea, vomiting, low fever. diagnosis with abdominal XR demonstrating air
fluid levels in gall bladder or an ultrasound showing curvilinear gas
shadowing in the gall bladder.
if have patient with migratory thrombophlebitis/Trousseau syndrome try to
find occult tumor.
GERD is present in up to 75% of asthma patients. patients with adult-onset
asthma and symptoms that are worse after meals, exercise, or laying down are
likely to have gerd-induced disease. give PPI
patients with pernicious anemia have 1) antibodies to intrinsic factor
decreasing b12 absorption and 2) atrophic gastritis with decreased production
of intrinsic factor by parietal cells. atrophic gastritis increases the risk of
intestinal-type gastric cancer and gastric carcinoid tumors.
do anoscopy in a patient with no risk factors for colon cancer who has minimal
bright red blood per rectum
metoclopramide is a prokinetic agent used to treat nausea, vomiting,
gastroparesis. should be monitored closely for development of drug-induced
EPS (dopamine antagonist)
in a patient with complicated GERD (gerd + weight loss, odynophagia, bleeding)
do esophagoscopy.
vitamin D overdose gives you hypercalcemia. constipation, abdominal pain,
polyuria, polydipsia are signs of hypercalcemia.
Celiac sprue causes iron deficiency anemia, and is associated with
dermatitis herpetiformis. intensely burning, pruritic papulovesicular skin
disease. granular IgA deposits in upper dermis so test for IgA anti-endomysial
antibodies and IgG/IgA anti-gliadin antibodies (though in patients with
IgA deficiency, the antibody tests will no work)
clues for liver mets from the colon can be: abdominal pain, mildly elevated liver
enzymes, and firm hepatomegaly. microcytic anemia due to occult
gastrointestinal bleeding, and a right sided pleural effusion caused by
hepatic hydrothorax due to cirrhosis. do a CT of the abdomen with IV contrast
to evaluate for malignancy.
females are more susceptible to hepatic injury than males from alcohol ingestion.
alcoholic cirrhosis has an increased ratio of AST > ALT 2:1
Vanishing Bile Duct Syndrome is a rare disease involving progressive
destruction of the intrahepatic bile ducts. Primary Biliary Cirrhosis (Anti
Mitochondrial Abs) causes ductopenia in adults and is characterized by the
same pattern of liver injury.
spontaneous bacterial peritonitis should be suspected in any patient with
cirrhosis and ascites who presents with low-grade fever, abdominal
discomfort or altered mental status. paracentesis with PMN > 250 and
+culture confirms diagnosis.
pharyngoesophageal (Zenkers) diverticulum develops immediately above
the upper esophageal sphincter by herniating posteriorly between the fibers of
cricopharyngeal muscle. motor dysfunction and incoordination are responsible for
this problem. the surgical treatment of this disorder includes excision and
frequently cricopharyngeal myotomy.

a choledochal cyst is a congenital abnormality of the biliary ducts

characterized by the dilatation of intra or extra-hepatic biliary ducts or
both. in children in can cause abdominal pain, jaundice, and attacks of
recurrent pancreatitis, which may be evident by increases in the amylase and
lipase levels.
all patients with chronic liver disease should be immunized against HAV and HBV
gallstones are mainly cholesterol stones and mixed stones (80%). cholesterol
stones are radiolucent (not seen on xray).
patients > 55 with new-onset symptoms of dyspepsia and those of any age with
alarming symptoms (weight loss, dysphagia, persistent vomiting) should undergo
endoscopy (concerning for esophageal carcinoma). other patients should have
either H. pylori serology or empiric treatment with PPI.
peritoneal fluid can accumulate due to a number of diff. causes including portal
hypertension, trauma, infection, pancreatitis, and malignancy. to differentiate
transudative from exudative you can use the SAAG. serum albumin ascites
albumin. if > 1.1 then its a transudative process cirrhosis/portal
hypertension, CHF, SAAG < 1.1 is exudative tuberculosis, pancreatitis,
neoplasm
small bowel obstruction has colicky or paroxysmal abdominal pain with
episodic hyperactive bowel sounds attributable to peristaltic rushes,
abdominal distension, and diffuse abdominal tenderness. failure to stool or
flatus (obstipation) indicates a complete bowel obstruction has occurred.
small bowel obstruction also has nausea and vomiting more often than large
bowel obstruction. complete sbo requires surgical correction. patients get
metabolic acidosis/lactic acidosis due to ischemia of a strangulated loop of
small bowel. strangulation leading to ischemic necrosis and perforation of small
bowel is a major life- threatening complication of SBO. when this happens the
patient will have peritoneal signs.
in patients getting total parenteral nutrition, the stimulus for CCK release
is impaired because the gastrointestinal tract is bypassed. cck normally
stimulates gall bladder contraction, and when this doesnt occur there is stasis
and bile sludge tending to form gall stones predisposing to cholecystitis.
know these drugs causing Pancreatitis: 1) diuretics (furosemide, thiazides), 2)
inflamm bowel disease drugs (sulfasalazine, 5-ASA) 3) immunosuppresants
(azathioprine, l-asparaginase) 4) seizure/bipolar disorder (valproic acid) 5)
AIDS (didanosine, pentamidine) 6) antibiotics (metronidazole, tetracycline)
pernicious anemia can occur in the setting of other autoimmune diseases. and
while dietary deficiency is a common cause of folate deficiency (only a few
months of reserves), it usually does not cause B12 (years of reserves)
deficiency.
increased intragastric pressure during vomiting can cause tears in the mucosa of
the distal esophagus and proximal stomach. these are called Mallory-Weiss
tears and account for 10% of upper GI bleeds. tears cause bleeding from
submucosal arteries. bleeding stops in 90% of patients, however vasopressin,
endoscopic injection or electrocautery may be required in a few cases.
spontaneous bacterial peritonitis is a common complication of ascites in which
the peritoneal fluid becomes infected by an enteric organism. finding of > 250
PMN in the ascitic fluid is diagnostic. patients will have abdominal pain,
ascites, tachycardia, low-grade fever.
painless jaundice should be considered secondary to pancreatic cancer until
proven otherwise. elevated ALP and total bilirubin suggest a cholestatic pattern
of jaundice which could be caused by a pancreatic mass obstructing the common
bile duct.

treat alcohol withdrawal with benzodiazepines. treat hepatic encephalopathy

with lactulose. hepatic encephalopathy patient will have a cirrhotic liver
(hypoalbumminemia and increased INR)
hepatorenal syndrome is a deadly complication of cirrhosis characterized
by kidney failure that doesnt respond to volume resuscitation. it is best
treated with liver transplantation.
cirrhosis should be suspected in any patient with new ascites and pedal edema
and with stigmata of chronic liver disease like spider angiomata/gynecomastia.
most common causes of cirrhosis are chronic alcohol abuse and chronic viral
hepatitis.
alcohol hepatitis is characterized by mallory bodies, infiltration by
neutrophils, liver cell necrosis, and perivenular distribution of
inflammation. fatty liver, alcohol hepatitis, and even early fibrosis are all
potentially reversible if patient stops alcohol ingestion. true cirrhosis with
regenerative nodules is irreversible.
hypertriglyceridemia is a cause of acute pancreatitis. patients can have
yellow-red papules on the arms and shoulders, a description suggestive of
eruptive xanthomas. do a fasting lipid panel to see if the levels are >1000
and causing the pancreatitits.
steatorrhea with severe intermittent epigastric pain suggests chronic pancreatitis.
#1 cause is due to alcoholism.
portal hypertension is the most common cause of ascites. portal hypertension
is usually due to cirrhosis from chronic liver disease (alcoholic or viral). IVDA
predisposes to cirrhosis by putting individuals at increased risk for chronic
infection with Hep B or Hep C virus.
development of a palpable mass in the epigastrium 4 weeks after onset of
acute pancreatitis is suggestive of pancreatic pseudocyst. the pseudocyst is
comprised of inflammatory fluid, tissue, and debris that accumulate within the
pancreas. when the amylase-rich fluid leaks into circulation, serum
amylase becomes markedly elevated. ultrasound is the preferred means of
imaging pseudocysts. often resolves spontaneously so only drain if it persists for
> 6 weeks is > 5 cm in diameter or becomes secondarily infected. pancreatic
abscess presents with fever and leukocytosis. tender epigastric mass.
Niacin deficiency leads to pellagra (diarrhea, dermatitis, dementia, and death).
patients will have glossitis and dermatitis in sun exposed areas resembling a
sunburn. as the rash progresses the skin becomes hyperpigmented and
thickened. riboflavin deficiency can lead to cheilosis, glossitis, seborrheic
dermatitis, pharyngitis, and edema or erythema of the mouth.
for cholelithiasis do right upper quadrant ultrasound. signs are RUQ pain
after eating and at night. Boas sign is right subscapular pain of biliary colic.
suspect celiac disease in any patient with malabsorption and iron deficiency
anemia. celiac disease is associated with anti-endomysial antibodies. will
have deficiency of vit A (hyperkeratosis) vit d (osteomalacia, bone pain), vit k
(easy bruising), loss of subcutaneous fat, bulky foul smelling floating stools.
echinoccoccus infections are known as hydatid cysts and can be found in
almost any part of the body but the liver is most common. common in areas
where sheep and dogs are raised. hydatid cyst is a fluid filled cyst with an inner
germinal layer and an outer acellular laminated membrane. the germinal
layer gives rise to numerous secondary daughter cysts. eggshell
calcifications on liver.
bacterial overgrowth, pancreatic insuff, celiac disease, and crohns disease all
result in chronic diarrhea with increased fecal fat content. d-xylose test helps to
distinguish between bacterial overgrowth and celiac disease (intestinal
villous atrophy). d-xylose is a simple sugar, requires only an intact mucosa to

be absorbed. in normal individuals after 25g of d-xylose its urinary excretion will
be > 4.5g in 5 hours. in bacterial overgrowth there will be decreased
excretion of xylose due to bacterial consumption. in such cases urinary
excretion returns to normal after treatment with antibiotics. celiac
disease damages small intestinal mucosa, impairing xylose absorption.
acute variceal bleeding is a life-threatening emergency. the first step in
treatment is to establish vascular access with two large bore iv needles or
a central line. the second step is to control the bleeding itself by administering
vasoconstrictors like terlipressin, octeotride or somatostatin.
lab tests used in evaluation of liver disease either assess liver functionality (PT,
bilirubin, albumin, cholesterol) or structural integrity and cellular intactness
(transaminases, ggt, alp). a progressive decrease in transaminase levels
signals either recovery from liver injury or that few hepatocytes are
functional.
CT scan is the best for diagnosing and evaluating the abdomen of patients
during an acute episode of diverticulitis.
patients presenting with acute appendicitis but do not seek medical care until
> 48 hours after the onset of symptoms have a high risk of perforation into
the peritoneal and retroperitoneal spaces causing peritonitis or an
abscess. Psoas sign (flexion of hip producing abdominal pain) is suggestive of
a psoas abscess which is a known complication of a perforated appendix. treat
with interval appendectomy.
amoebiasis is a protozoal disease caused by entamoeba histolytica. the
primary infection is in the colon causing bloody diarrhea. however the
amoeba may be transported to the liver by portal circulation causing an
amoebic liver abscess. they are usually single and if its on the superior surface
of the liver it can cause pleuritic-type pain and radiation to the shoulder.
diagnose by stool exam for trophozoites, serology, and liver imaging. treat
with metronidazole
a jejunal ulcer is almost pathgnomonic for Zollinger-Ellison
syndrome/gastrinoma. patients may get steatorrhea because of increased
production of stomach acid inactivates pancreatic enzymes. to test for
zollinger-ellison do fasting serum gastrin levels.
post-cholecystectomy pain most commonly occurs due to one of three reasons:
1) common bile duct stone 2) sphincter of oddi dysfunction or 3)
functional causes. treat functional pain with analgesics and reassurance.
inflammatory bowel disease is most likely in a patient with a subacute to chronic
presentation of abdominal pain, tenesmus, and bloody diarrhea. in patients with
IBD and worsening symptoms accompanied by signs of sepsis, toxic
megacolon should be considered and an abdominal xr ordered to confirm.
diverticulosis is the most common cause of lower gastrointestinal hemorrhage
(gross bleeding) in an elderly patient. typically painless.
acute ascending cholangitis is characterized by Charcots triad of 1) fever
2) severe jaundice and 3) RUQ abdominal pain. 4) confusion and 5)
hypotension may also be observed with suppurative cholangitis producing
Reynolds pentad. if symptoms persist then there is an indication for urgent
biliary decompression preferably by endoscopic retrograde
cholangiopancreatography (ercp).
the absence of peristaltic waves in the lower 2/3 of the esophagus and
significant decrease in lower esophageal sphincter (LES) tone (versus
Chagas which is increased LES tone and achalasia) are characteristic for
esophageal dysmotility associated with Scleroderma. diffuse esophageal
spasm is characterized by chest pain and dysphagia, not heartburn.
manometry may reveal periodic, high-amplitude, non-peristaltic waves.

somatic pain is well-localized and in the abdomen is usually secondary to

peritoneal inflammation. visceral pain is vague in localization and due to
mechanical stretching of the abdominal viscera. visceral is vague, peritoneal
is precise
in a patient with direct hyperbilirubinemia the causes can be due to intrahepatic
or extrahepatic obstruction. hepatocellular diseases like viral/autoimmune
hepatitis, alcoholic hepatitis, will have elevated aminotransferases whereas when
there is a dominant elevation of ALP have predominant intra or extra hepatic
biliary obstruction.
the two drugs approved for Chronic Hepatitis B are interferon and
lamivudine. Chronic Hep B presents with persistently elevated ALT levels,
detectable serum HbsAg, HbeAg, and HBV DNA.
massive doses of asiprin and NSAIDs can cause acute erosive gastritis and
upper GI bleeding. alcohol can aggravate this effect.
NASH appears histologically similar to alcoholic hepatitis. impaired
responsiveness of fat cells to insulin, thereboy causing accumulation of fat in
the liver. steatosis can then progress to steatohepatitis and fibrosis,
secondary to lipid peroxidation and oxidative stress
bacterial overgrowth is a malabsorption syndrome which can be associated
with a history of abdominal surgery. physical exam findings may reveal
abdominal distention with identifiable succussion splash from palpable, soft,
fluid-filled loops of bowel.
Reye syndrome occurs in children who take aspirin. characterized by diffuse
mitochondrial injury leading to nausea, vomiting, headache, hypoglycemia,
liver failure and cns damage. extensive fatty vacuolization of the liver
without inflammation (microvesicular changes). liver is enlarged but there is
no icterus.
in patients with dysphagia where the differentials are broad, a barium
esophagram is usually performed before upper endoscopy.
progestins can help for cancer-induced cachexia
rupture of the esophagus (Booerhaaves Syndrome) occurs after severe
retching and presents as chest or epigastric pain, nausea, vomiting, fever, and
unilateral pleural effusion.
Zenkers diverticulum often have foul smelling beath secondary to pooling of
material in the diverticulum. increased risk for aspiration pneumonia. contrast
esophagram is the diagnostic test of choice.
treatment for ascites: salt and water restriction -> spironolactone -> loop
diuretic -> paracentesis (check renal function)
Gilberts syndrome is a familial disorder of bilirubin glucuronidation where
UDPGT enzyme production is reduced. manifests as icterus secondary to a mild,
unconjugated hyperbilirubinemia (should be < 3-4). certain events like
fasting, hemolysis, physical exertion, febrile illness etc are thought to trigger an
exacerbation. treatment is generally unnecessary. Crigler-Najjar type 1
has severe jaundice and neurological impairment due to kernicterus and
unconjugated hyperbilirubinemia (20-25 mg/dl). liver enzymes and histology are
normal. if IV phenobarbital is given the serum bilirubin remains unchanged. liver
transplant is only cure. Crigler-Najjar type 2 is milder disorder characterized by
lower serum bili < 20 mg/dl. no kernicterus.

hematology/oncolog
y

acute drop in hemoglobin caused by hyperhemolytic crisis, splenic sequestration,

or aplastic crisis
Proxysmal Nocturnal Hemoglobinuria (tx with Fe/Folate and Eclusimab)
can have hepatic vein thrombosis vs Acute Intermittent Porphyria
warfarin activity is increased by Vit E (supplements) and foods rich in
vitamin K will decrease it's efficacy
acute graft-vs-host disease (GVHD) presents with skin (maculopapular
rash) intestines (diarrhea with blood) and liver (abnormal LFTs and
jaundice)
bronchogenic cysts are located in the middle mediastinum. thymoma is
usually found in the anterior mediastinum. all neurogenic tumors (like
neuroblastoma) are located in the posterior mediastinum.
sickle cell patients can get stroke due to occlusion and sludging in the cerebral
vessels. treat with exchange transfusion
sickle cell anemia will have reticulocytosis due to chronic extravascular
hemolysis.
most head and neck cancers are sq. cell carcinomas. will have a normal cell
count
in tumor lysis syndrome you release all the K+ and phosphate in cells.
phosphate binds calcium leading to hypocalcemia.
Waldenstroms Macroglobulinemia (Type of Non Hodgkins Lymphoma,
excess abnormal B cells) can have demyelinating sensorimotor
neuropathy, easy bruising/bleeding, fatigue, hepatosplenomegaly.
hypersegmented neutrophils seen in folate def. and B12 (cobalamin) def which
will increase homocysteine. only B12 deficiency raises methylmalonic acid.
hereditary spherocytosis leads to cholecystitis due to pigment stones.
with chemotherapy and radiation for Hodgkins disease develop a secondary
malignancy (usually many years down the line since treatment is often
during childhood). risk is highest when chemotherapy is combined with
radiation.
Hodgkins Disease is a curable lymphoma tending to affect younger patients.
about 3% of patients treated
in a young child a microcytic anemia is likely to be iron deficiency or thalassemia.
RDW (RBC distribution width) can tell you the difference if its > 20% then
most likely to be iron deficiency anemia. Thalassemia have increased MCHC.
unconjugated bilirubin is highly insoluble in water (toxic, goes to brain), does not
go to urine. conjugated bilirubin goes to the urine.
hereditary telangiectasia (osler-weber-rendu syndrome) is an autosomal
dominant disorder characterized by 1) diffuse telangiectasias 2) widespread
AVMs 3) recurrent epistaxis. in this syndrome avms tend to occur in mucous
membranes, skin, GI tract. the avms in lung can shunt blood from right heart to
left heart, causing chronic hypoxemia and reactive polycythemia.

acute hemolytic transfusion reaction develops an hour after transfusion

starts. life-threatening reaction resulting from transfusion of mismatched
blood, typically ABO mismatch. rapidly develop fever, hemolysis, shock, and
DIC. delayed hemolytic transfusion results from anamnestic response to a
minor rbc antigen which has been previously encountered. low grade
hemolysis 2-10 days after transfusion. reaction to cytokines presents with
transient fevers, chills, malaise. wash RBC blood products especially for
IgA deficient patients, otherwise just do Leukoreduction.
patients with sickle cell disease have functional asplenia by 2-3 years. need
immunizations against h. influenza and s. pnuemoniae. high grade fever,
hypotension, altered mental status, elevated wbc with bandemia is suggestive of
sepsis, which is most commonly caused by pneumococcus in sickle cell.
multiple episodes of thrombosis without a clear precipitating factor should raise
concern for hypercoagulability due to a genetic defect in a younger patient, or a
primary malignancy in an older patient.
anemia of chronic disease has decreased iron, decreased TIBC (wants to bind iron
less to hide it from the bugs), and decreased iron saturation with increased or
elevated ferritin (storage iron, inflammatory marker) levels.
sinopulmonary and GI infections with transfusion reaction point to IgA
deficiency. patients form autoantibodies to IgA.
patients with sickle cell anemia may experience painful vaso-occlusive episodes
which may be triggered by infection, dehydration or hypoxia. hydroxyurea is
indicated in patients with frequent acute painful episodes (>6 / year). folic acid
supplementation is helpful in preventing aplastic crisis.
febrile reaction is a common transfusion reaction that is caused by antibodies in
the patients plasma reacting with the donors leukocytes. cell washing
decreases the probability of febrile non hemolytic transfusion reaction. no
hemodynamic abnormalities and renal dysfunction are usually present. acute
hemolytic = abo mismatch, delayed hemolytic = minor rbc antigen
in a patient who gets HIT (heparin induced thrombocytopenia) and needs to
be anti-coagulated stop heparin immediately and start argatroban. suspect
heparin induced thrombocytopenia when: platelet count < 50% from baseline,
arterial or venous thrombosis, necrotic skin lesions at heparin injection
sites, acute systemic reactions after heparin. diagnosis: serotonin release
assay is the gold standard
glucose-6-phosphate dehydrogenase deficiency is an x-linked recessive
disorder commonly seen in african-american men. hemolytic episodes in response
to oxidant drugs, infections, or fava eans. heinz bodies are seen in the
peripheral blood smear.
Howell-Jolly bodies are nuclear remnants within rbcs typically removed by
the spleen. their presence strongly suggests physical or functional
hyposplenism.
patients who develop serious bleeding (e.g. intracerebral hemorrhage) due to
excess anticoagulation with warfarin should be given FFP for the rapid
reversal of anticoagulation. vitamin k reverses warfarin action but takes 8-12
hours to be effective. (in real life give both)
warfarin inhibits protein C production in the first few days its given. --> skin
necrosis. protein C is anti-coagulation. with no protein c --> clot
HUS is
1) thrombocytopenia
2) renal involvement (bump in creatinine)
3) hemolytic anemia
(if you add neuro and fever you have TTP). Treatment for HUS is Plasmapheresis
(plasma exchange) and steroids, add fresh frozen plasma

DIC can present in a patient with breast cancer. lab values show
thrombocytopenia, decreased fibrinogen, increased INR, elevated LDH,
elevated reticulocyte count and bilirubin
macrocytic anemia with thrombocytopenia and leukopenia as well as
neutrophils with reduced segmentation can occur in myelodysplastic
syndromes. confirm with bone marrow biopsy
patients with a splenectomy will have thrombocytosis b/c spleen removes
old platelets from the circulation.
patients with DVT in whom anticoagulation is contraindicated requires
placement of inferior vena cava filter to prevent pulmonary embolism.
anaphylactic reactions to transfused blood products occur rarely, but are more
common in patients with IgA deficiency. rapid onset of symptoms with
associated bronchospasm and hypotension plus the absence of fever help to
distinguish anaphylaxis from other possible transfusion reactions. ABO
mismatching patients have rapid hemolysis with manifestations of fever,
flank pain, dark urine and dic. amamnestic antibody response to a minor
rbc antigen can lead to delayed hemolysis several days after transfusion.
reaction to cytokines = fever chills malaise.
patients with alpha-thalassemia minor or beta-thalassemia minor will have
impressive microcytosis (mcv can be in 70s) but only modest anemia.
reassurance is only intervention that is needed. patients with thalassemia
major are generally severely symptomatic and transfusion dependent.
spontaneous hemarthrosis should give suspicion for hemophilia for which
factor 8 assay is diagnostic. prolonged ptt, normal pt, normal bt, and normal
fibrinogen level and low serum factor 8 are the lab findings. treatment is to
replace factor 8. if mild can treat with demospressin. do coagulation studies to
diagnose followed by factor 8 and 9 levels.
arterial/venous thrombosis and thrombocytopenia in patients recieving heparin
therapy is suggestive of heparin induced thrombocytopenia. antibodies
against heparin-platelet factor-4 complex are responsible.
Schilling test helps differentiate between dietary deficiency from pernicious
anemia and malabsorption as causes of vit b12 deficiency and megaloblastic
anemia. give oral radio-b12 and intramuscular b12. check urinary excretion. if
urine has radioactive-b12 then absorption is normal and dietary deficiency.
if low radioactive b-12 in urine then its due to poor absorption. so do part 2 to
differentiate between pernicious anemia or malabsorption. give radio-b12 with
intrinsic factor and check urine. low excretion of b12 after giving if rules out
pernicious anemia and suggests malabsorption (pancreatic insuffic, bacterial
overgrowth, short gut syndrome). normal excretion after adding if suggests
pernicious anemia.
in a patient with a DVT, treat with heparin and warfarin for the first 5 days. after 5
days if the INR is therapeutic (2-3) then the heparin may be discontinued and
warfarin continued for 6 months. a progressing clot in a patient with a subtherapeutic INR requires bridging heparin until the inr is therapeutic.
FFP has all the clotting factors and is 1st line treatment for bleeding patients with
a coagulopahy.
factor 5 leiden is the most common inherited disorder causing
hypercoagulability and predisposition to thromboses.
hemolytic anemia in a patient with a malignant lymphoproliferative
disorder is likely to be of the warm autoimmune type, caused by anti-RBC
IgG antibodies. give prednisone, if not effective then do splenectomy.

vitamin k deficiency can be seen in a patient who has been kept npo for a
prolonged time and receiving broad-spectrum antibiotics. labs show
prolonged PT followed by prolonged ptt.
cystic fibrosis can lead to impaired absorption of fat soluble vitamins. vitamin k is
necessary for post-translational modification of several anticoagulant factors: 2 7
9 and 10 as well as protein c and s.
NSAIDs cause iron deficiency anemia through chronic low grade/occult
blood loss per the GI tract. anemia of chronic disease can be seen in rheumatoid
arthritis, but not generally seen in osteoarthritis. (osteoarthritis is NOT an
inflammatory condition)
radiation therapy is the most appropriate management for bone pain in a
patient with prostate cancer after androgen ablation (orchiectomy).
presence of thrombocytopenia has a poor prognosis in CLL.
stage 0 = lymphocytosis only.
stage 1 = lymphocytosis + adenopathy.
stage 2 = splenomegaly
stage 3 = anemia
stage 4 = thrombocytopenia
elderly patient with bone pain, renal failure and hypercalcemia has multiple
myeloma until proven otherwise. obstruction of distal and collecting tubules
by large laminated casts containing paraproteins (Bence Jones protein) causes
renal failure.
serotonin antagonists that block 5HT3 receptors are drugs of choice for
treating and preventing chemotherapy-induced nausea and vomiting.
(Ondansetron/Zofran)
elevated serum protein with normal albumin (gamma gap) suggests
disorders like multiple myeloma, waldenstroms macroglobulinemia, and
monoclonal gammopathy of undetermined significance. MGUS is an
asymptomatic elevation of a monoclonal (m) protein on SPEP. diagnosis is made
by excluding multiple myeloma (anemia, pancytopenia, hypercalcemia, bony
lytics lesions, and renal disease). mgus patients usually have < 3 g/dl with <10%
of plasma cells found in bone marrow. mm patients have > 3 g/dl m protein on
spep with >10% plasma cells in the bone marrow.
myeloproliferative disorders have the Jak2 mutation. if they have
polycythemia vera then the EPO will be low. will have symptoms like headache,
dizziness, visual disturbances due to hyperviscosity. pruritis due to release
of histamine and prosaglandins. facial plethora, hepatosplenomegaly.
BCR-ABL mutation is seen in CML patients.
ALL is the most common leukemia in children. may have a hx of viral
respiratory infection or exanthem. on physical exam there may be pallor,
hepatosplenomegaly, petechiae, and/or lymphadenopathy. diagnosis is
suggested by anemia, thrombocytopenia, and blast cells (>25%) on a
peripheral smear.
MM has back pain, anemia, renal dysfunction, and elevated ESR. hypercalcemia
from MM may manifest as severe constipation, anorexia, weakness, increased
urination, or neurologic abnormalities.
rituximab is a monoclonal antibody directed against the CD20 antigen on blymphocytes that is often used to treat patients with symptomatic CLL. patients
will have smudge cells and can have autoimmune hemolytic anemia and
immune thrombocytopenia.
malignant melanoma mets to variable places in the body and lie dormant for 1525 years and then recur even when the primary tumor was resected. malignant
melanomas are known for causing bleeding inside the metastatic mass in
the brain.

sq. cell carcinoma of the mucosa of the head/neck is common in people

with a significant history of alcohol and tobacco use. the first manifestation may
be a palpable cervical lymph node. best initial test is panendoscopy (triple
endoscopy = esophagoscopy, bronchoscopy, laryngoscopy) to detect the
primary tumor.
patients with multiple myeloma cant make functional antibodies and leukopenia
that develops as bone marrow is filled with malignant plasma cells so they are at
an increased risk for infection.
a reciprocal translocation of 9:22 results in philadelphia chromosome
containing the bcr/abl fusion gene. find this in CML. tyrosine kinase
inhibitors function by inhibiting the abnormal bcr/abl gene like imatinib are a
key component of treatment for CML. retinoic acid receptor is used to treat
acute promyelocytic leukemia.
PTH-rp is produced locally when the tumor mets into the bone to induce
bone resorption.
acute monocytic (fab m5) leukemia has a dramatic onset with headaches,
fevers, weight loss, and bleeding from the gums/nose. +alpha-naphtyl
esterase test is characteristic. Acute promyelocytic leukemia is
characterized by Auer rods in cells. high incidence of DIC in this leukemia.
TRAP+ in Hairy Cell Leukemia

infectious
disease

serous otitis media is most common middle ear pathology in AIDS. hiv
lymphadenopathy or lymphomas . dull tympanic membrane that is
hypomobile.
for disseminated histoplamosis (tx with itraconazole) check antigen in urine or
serum. Disseminated histoplasmosis can cause oral ulcers, and bone marrow
(pancytopenia)
give all patients > 65 or with co-morbidities pneumococcal vaccine
primary hiv-associated thrombocytopenia- asymptomatic thrombocytopenia is
presentation in 10% of HIV cases. Treat with zidovudine
malignant otitis externa treated with anti-pseudomonal (ciprofloxacin).
symptoms are granulation tissue and discharge
in rhinitis if you dont find cause by history and physical exam do nasal cytology.
neutrophils = infectious, eosinophils = allergic, vasomotor = no eosinophils
nasopharyngeal carcinoma can present w/ recurrent otitis media,
recurrent epistaxis. strongly associated with +serology for EBV. mediterranean
and far eastern descent.
necrotizing fasciits has purplish discoloration of the skin with gangrenous
changes and systemic toxicity. CT/MRI can show pockets of gas deep within
tissue. Can often feel skin crepitus.

the most feared complication of a retropharyngeal abscess is spread of

infection into the mediastinum, which can lead to acute necrotizing
mediastinitis (need Abx and surgical debridement). recent history of URI,
pharyngitis, otitis, sinusitis, etc. happens in children. symptoms are sore throat,
dysphagia, neck stiffness, muffled hot potato voice.
patients with retropharyngeal abscess complain of sore throat, fever, difficulty
swallowing (dysphagia) and pain with swallowing (odynophagia) and pain with
certain neck movements. treat rapidly to prevent the spread of infection into
the mediastinum.
EBV DNA in the CSF is specific for primary CNS lymphoma. will have a
solitary, weakly ring-enhancing mass in the periventricular area.
cutaneous larva migrans caused by helminth A. braziliense. found in tropical
regions. itchy, elevated serpiginous lesions. contact by sand
progressive multifocal leukoencephalopahy (PML) is caused by JC Virus.
MRI will show multiple non-enhancing lesions with no mass effects.
toxoplasmosis will be ring-enhancing. CNS lymphoma is single, weakly
enhancing.
bacillary angiomatosis has a cutaneous lesion of a large pedunculated
exophytic capsule with a collarette. like a cherry angioma. visceral angioma-like
blood vessel growths. Caused by Bartonella henselae infections, found in AIDS
patients.
herpes zoster opthalmicus has dendriform corneal uclers and conjunctivitis, and
vesicles around the orbit.
nocardia is treated with TMP-SMX. branching, beaded, aerobic gram+ partially
acid-fast pneumonia causing a cavitary pulmonary infection.
CMV retinits in HIV patient < 50 CD4. yellowish-white patches of retinal
opacification and retinal hemorrhages.
rubella has posterior cervical and post. auricular lymphadenopathy and
polyarthralgia. Rash begins at the head and moves down.
condyloma accuminata (anogenital warts) caused by HPV. skin colored
verrucous papilliform lesions around anus. treatment is podophyllin or
trichloroacetic acid.
erythema multiforme is an extrapulmonary manifestation of M.
pneumonia. dusky red, target shaped skin lesions.
malaria causes anemia and splenomegaly with cyclical fevers
HIV should get MMR and varicella live vaccines if their CD4 is > 200 and not
immune to MMR (titers)
amoxicillin-clavulanate is antibiotic of choice for polymicrobial human and
dog bites.
leukoplakia is a whitish plaque that has a granular appearance and is not
scraped off. can transform into SCC
epiglottitis is caused by H. influenza and S. pyogenes. high grade fever, sore
throat, odynophagia, drooling, muffled voice, shrill on expiration. has thumb
sign on lateral xray.
S. pneumoniae is a capsular polysaccharide vaccine that induces a T cell
independent B cell response
do a CT scan to diagnose intraabdominal abscess. psoas abscess can present
w/ fever, wbc count increased, lower abdominal or back pain. can occur due to
perforated appendicitis.
for local impetigo (superficial) use topical mupirocin or oral erythromycin.
not penicillin because S. aureus is resistant
long term sequelae associated with bacterial meningitis include: 1) loss of
cognitive function 2) hearing loss 3) seizures 4) MR 5) spasticity or paresis

most common cause of viral meningitis are the non-polio enteroviruses like
echovirus and coxsackieviruses.
Ludwigs angina is infection of the submandiblar and sublingual glands. the
source of infection is most commonly an infected tooth. asphyxiation is the
most common cause of death. presents with odynophagia, fever, dysphagia, and
drooling.
mycobacterium avium complex prophylaxis by giving azithromycin to aids
patients. CD4 < 50 will have cough and fever. for CMV infection give prophylaxis
when CD4 < 50 and serum CMV IgG is positive or +biopsy for CMV.
histoplasma capsulatum is common and usually asymptomatic infection in
endemic areas like mississippi/ohio/missouri river valleys and central america.
Disseminated goes to bones. Tx with itracanozole
treatment for toxoplasmosis is sulfadiazine and pyrimethamine.
Nocardia is gram+ partially acid-fast filamentous branching rod causing lung
cavities, or nodules in HIV patients. treatment is TMP-SMX. Disseminates to
skin and brain
a patient from Cali/arizona with pulmonary infection and cutaneous findings
like erythema multiforme and erythema nodosum has coccidiodomycosis.
septic arthritis can result in rapid and permanent joint destruction. synovial
fluid aspiration that shows >100k leukocytes > 90% pmns, and purulent fluid
should prompt orthopedic consultation for emergency surgical drainage.
in HIV patients both HSV and VZV can cause severe acute retinal necrosis
associated with pain, keratitis, uveitis, and fundoscopic findings of peripheral
pale lesions.CMV retinitis is painless, not associated with keratitis or
conjunctivitis, and has hemorrhages or fluffy/granular lesions around
retinal vessels.
TMP-SMX can cause hyperkalemia. so does succinylcholine, NSAIDs, heparin,
non-selective beta-blockers, and digoxin.
N. gonorrhea septic arthritis can present as an oligoarthritis that is
asymmetric with tenosynovitis and skin rash.
legionella causes gastrointestinal symptoms with pneumonia. abdominal
pain and loose stools and also can have hyponatremia and elevated LFTs.
fulminant hepatitis has a mortality rate of > 80% so put on liver transplant
list. not steroids, interferon or lamivudine.
rheumatic fever: sore throat, fever, pericarditis, erythema marginatum, arthritis,
chorea, subcutaneous nodules. JONES (joints, heart, nodules, erythema,
syndeham chorea)
Trichinella (roundworm) causes trichinellosis acquired by eating undercooked
pork. three phase disease 1) larvae invade intestinal wall. abdominal pain,
nausea, vomiting, diarrhea. 2) local and systemic hypersensitivity reaction
caused by larval migration, has splinter hemorrhages, conjunctival and
retinal hemorrhages, periorbital edema and chemosis. 3) larvae enter
muscle causing muscle pain, tenderness, swelling, and weakness.
Eosinophilia. Tx with mebendazole
Rubellas rash is erythematous and maculopapular. starts on face and
progresses to trunk and extremities. adult women usually present with arthritis.
occipital and posterior cervical lymphadenopathy also suggest this
diagnosis.
N. gonorrhea urethritis is less common than chlamydial urethritis. the
discharge is purulent and not mucopurulent like it is in chlamydia.
peritonsilar abscess presents with sore throat, muffled hot potato voice and
deviation of the uvula. its a complication of tonsilitis. generally have unilateral
lymphadenopathy. treat with needle peritonsillar aspiration.

If patient has uncomplicated pyelonephritis can switch to oral antibiotic after 2-3
days of parenteral therapy.
patient with +PPD should be given isoniazid + pyridoxine for 9 months.
blastomycosis occurs near the great lakes, mississippi and ohio river basins
(wisconsin). symptoms of lung infection may resemble tuberculosis and
histoplasmosis, however also causes ulcerated skin lesions and lytic bone
lesions. blasts the bone and skin
all newly diagnosed HIV patients should have: CD4 count, VDRL, PPD, antitoxoplasmosis titer, pneumococcal polysaccharide vaccine unless CD4 <200,
HAV/HBV vaccines if seronegative
patient with headaches and focal neuro symptoms after acute otitis media or
sinusitis most likely has brain abscess. will appear as ring-enhancing lesion on
CT or MRI
enterohemorrhagic E. coli (EHEC) causes abdominal pain, bloody diarrhea,
with no fever. it produces a shiga toxin that causes bloody diarrhea.
invasive/disseminated Aspergillosis occurs in immunocompromised
patients with fever, cough, dyspnea, or hemoptysis. CXR will show a cavitary
lesion, and CT will show pulmonary nodules with a halo sign, or with an air
crescent. histoplasmosis will show hilar lymphadenopathy and
coccidiodomycosis will have pulmonary infection and cutaneous findings, like
erythema multiforme and erythema nodosum and arthralgias.
if a wound is severe or dirty, and not immunized always give tetanusdipheria toxoid (td) and give tetanus immune globulin (tig). however if
immunized <10 years ago toxoid alone is fine. for minor/clean wounds if not
immunized toxoid alone is fine, if immunized < 10 years ago then no treatment.
blastomycosis affects lungs, skin, bones, joints and prostate. cutaneous
disease is either verrucous or ulcerative. verrucous lesions are
papulopustular then become crusted, heaped up and warty with a
violaceous hue. wet prep will show the yeast form of the organism.
oral tmp-smx is effective in preventing PCP infection in transplant patients.
doxycycline is good for treating lyme disease and coexisting anaplasma
phagocytophilum however in children (<8 years old) doxy is contraindicated so
use oral amoxicillin to treat lyme.
primary HIV infection can present with a mononucleosis-like syndrome consisting
of fever, night sweats, lymphadenopathy, arthralgias, and diarrhea.
common acute life-threatening reactions associated with HIV therapy include:
didanosine (nrti) pancreatitis
abacavir (nrti) hypersensitivity/rash
any nrti lactic acidosis
any nnrti (-vir-) stevens-johnson syndrome
efavirenz (nnrti) CNS
nevirapine (nnrti) hepatotoxicity
indinavir (protease inhibitor) crystal induced nephrotoxicity
in patients with chronic hepatitis c, if their liver enzymes are persistently
normal on multiple occasions have minimal histological abnormalities and do not
need treatment, just follow up.
ehrlichiosis is a type of tick-borne illness that is caused by one of three diff.
species of gram bacteria, each with a different vector. endemic in the se, southcentral, mid-atlantic, and upper midwest regions of us as well as california.
clinical features include: fever, malaise, myalgias, headache, nausea, vomiting.
usually no rash hence the name spotless rocky mountain spotted fever.
labs show leukopenia and/or thrombocytopenia along with elevated
aminotransferases. treatment is doxycycline.

in HIV patient with CD4 > 200 and no evidence of AIDS defining illness give
MMR vaccine.
disseminated N. gonorrhea infection often presents with a triad of 1)
polyarthralgias 2) tenosynovitis and 3) vesiculopustular skin lesions.
in the adult form of botulism, the patient eats the toxin and gets symptoms.
in infantile botulism the infant eats the bacteria (in food) and it then
produces the toxin in the intestinal tract. blocks ACh release. presents with
constipation and poor feeding, followed by hypotonia, weakness, loss of deep
tendon reflexes, cranial nerve abnormalities and respiratory difficulties. signs of
autonomic dysfunction can occur early in disease course.
S. pneumoniae is the most common pathogen causing pneumonia in nursing
home patients.
measles is characterized by a prodrome of cough, coryza, conjunctivitis,
followed by kopliks spots and maculopapular rash initially appearing on
the face caused by paramyxovirus.
in an immunocompromised patient a lesion on the foot that is erythematous
and edematous but later develops into a bulla surrounded by erythema and
then ruptures leaving a painless ulcer with a black center is P. aeruginosa.
lesion is called ecthyma gangrenosum, looks like anthrax. treat with antipseudomonal penicillins (piperacillin/ticarcillin)
aspiration pneumonia CXR typically shows consolidation of the dependent
lung segments, which includes the posterior basal segment of the right
lung if the patient aspirates while in a supine position.
CXR in tuberculosis will show a upper lobe infiltrate with cavitation and
hilar lymphadenopathy
patients who are incarcerated have an increased risk for tuberculosis.
tuberculosis involving the vertebrae (Potts disease) typically presents with
chronic back pain of insidious onset. epidural abscess in lumbar region of
spine has acute onset back pain and fever. diabetics, IVDA, and patients
with recent spinal trauma are at increased risk. S. aureus is the most common
etiological agent. treat with vancomycin and surgical drainage
rheumatic fever is linked to streptococcal pharyngitis (S. pyogenes) but
not usually seen following impetigo. strep impetigo can lead to
glomerulonephritis.
Efavirenz is an NNRTI that causes CNS side effects in up to 50% of patients,
weird vivd dreams.
Proteus is the most likely cause of UTI in patients with alkaline urine.
legionella pneumonia is intracellular gram organism spread by cooling towers
and water supplies. travel-associated infection is well documented. cough, fever
>39C, gastrointestinal symptoms and confusion. diagnose by urine antigen
testing or culture on charcoal agar. treat with azithromycin or levofloxacin.
also has hyponatremia and elevated LFTs
recurrent pneumonias in the same anatomic region of the lung suggests
bronchial obstruction, its a red flag for lung cancer. when lung cancer is
suspected do a CT scan of the chest. bronchoscopic or CT guided biopsy may
then be performed depending on whether the lesion has a peribronchial or
peripheral location.
herpes mainly affects temporal region of the brain and may present acutely
(<1 week duration) with focal neurological findings. CSF has lymphocytic
pleocytosis, increased erythrocytes and elevated protein. HSV polymerase
chain reaction is the gold standard.

chloroquine-resistant Plasmodium falciparum is particularly common in subsaharan africa and indian subcontinent. mefloquine is drug of choice for
chemoprophylaxis. me-flying to travel
use amoxicillin in the treatment of a pregnant patient or lactating patients with
lyme disease. doxycycline is contraindicated.
suspect CMV pneumonitis in any patient with a bone marrow transplant
(bmt) with lung and intestinal involvement. CXR will show multifocal diffuse
patchy infiltrates. CT will show parenchymal opacification or multiple small
nodules. bronchoalveolar lavage (bal) is diagnostic. other than pneumonitis
it manifests as upper/lower gastrointestinal ulcers, bone marrow
suppression, arthralgias, myalgias and esophagitis and colitis.
most common cause of dysphagia/odynophagia in HIV patient is candidal
esophagitis. if persists despite therapy (fluconazole) then investigate other
possibilities. HIV patients with severe odynophagia but without oral thrush
are likely to have ulcerative esophagitis caused most commonly by CMV.
triad of 1) focal substernal burning pain with odynophagia 2) evidence of
large, shallow, superficial ulcerations and 3) presence of intranuclear
and intracytoplasmic inclusions is diagnostic of CMV esophagitis. treatment is
ganciclovir
synovial fluid will show an inflammatory profile with average leukocyte count of
25,000 in lyme arthritis.
treat mucormycosis with amphotericin b. if necrotic tissue is present need
surgical debridement
erysipelas is a specific type of cellulitis. characterized by inflammation of the
superficial dermis, thereby producing prominent swelling. classic finding is a
sharply demarcated, erythematous, edematous, tender skin lesion with
raised borders. systemic signs usually present including fever and chills. legs
are most frequently involved site. most likely causative organism is group A
beta-hemolytic streptococcus (S. pyogenes).
N. meningitides vaccine should be given to a person regardless of HIV status.
college age or living in barracks or dormitories, patients who are asplenic and
those with travel exposures. all HIV patients should get Td booster every 10
years.
in an HIV-infected patient, bloody diarrhea and a normal stool exam are
suspicious for CMV colitis. CMV may cause esophagitis, gastritis, colitis,
proctitis or small bowel disease. colonoscopy will show multiple mucosal
erosions and colonic ulceration. biopsy will show the presence of large cells
with eosinophilic intranuclear and basophilic intracytoplasmic inclusions
(owls eye effect). treatment of choice is ganciclovir or foscarnet
treat tinea corporis (ringworm) with topical antifungals like terbinafine.
superficial fungal infection seen in hot, humid climates. lesions are pruritic,
erythematous, scaly and have a red ring with central clearing. most common
in preadolescents. diagnosed with skin scrapings and KOH examination.
HIV patients who develop esophagitis are first started on fluconazole directed
against candidiasis. failure to respond to 3-5 day course of oral fluconazole
warrants further investigation with endoscopy.
influenza pneumonia has symptoms of abrupt onset of fever, chills, malaise,
myalgias, cough, and coryza. typically occurs in an epidemic pattern in the winter.
patients will often be febrile and amy have a variety of pulmonary findings such
as wheezes, crackles, and coarse breath sounds. leukopenia is common and
proteinuria may be present. CXR may show an interstitial or alveolar pattern, or
be normal. confirm with nasal swab for influenza antigen and treat with
antivirals within 48 hours. neuraminidase inhibitors oseltamivir and

zanamivir. rimantadine and amantadine are other options but only work for
influenza a.
acute rheumatic fever after group a streptococcal pharyngitis (S. pyogenes).
major jones criteria include: carditis, migratory polyarthritis, sydenham chorea,
subcutaneous nodules, and erythema marginatum. minor criteria are arthalgias,
fever, elevated acute phase reactants (CRP or ESR), prolonged PR interval on
EKG. must have 2 major criteria, or 1 major + 2 minor along with preceding group
a strep infection.
a common cause of empyema is after a hemothorax. blood in the chest, if not
evacuated, can get infected. the majority of patients will present with a low-grade
fever, dyspnea, and chest pain. surgery is required to remove the clotted
blood and fibrinous peel.
bright red, friable, exophytic nodules in an HIV infected patient are most
likely bacillary angiomatosis. caused by bartonella, a gram bacillus. oral
erythromycin is the treatment of choice.
Babesiosis (malaria of the west) is transmitted by the ixodes tick (same
tick as lyme disease). endemic in the northeastern us. the parasite enters the
patients rbcs and causes hemolysis --> jaundice, hemoglobinuria, renal
failure, death. ehrlichiosis has leukopenia and thrombocytopenia, treat with
doxycycline. Q fever is caused by coxiella burnetii. main sources of infection
are infected cattle, goat, and sheep. meat processing workers and veterinarians.
manifestations of Q fever may include flu-like syndrome, hepatitis, or
pneumonia.
B. pertussis causes whooping cough. it is a highly contagious infection but its
incidence has dramatically decreased because of immunization. usually presents
with severe bouts of coughing spells after an URI. coughing spells can be so
severe that they cause rectal prolapse, epistaxis, and pneumothoraces. treat
with a macrolide.
infectious mononucleoisis causes fever, sore throat, jaundice, and mild
hepatosplenomegaly. symmetrical lymphadenopathy involving the posterior
cervical chain of lymph nodes more frequently than the anterior chain. inguinal
and axillary lymphadenopathy can also be present. tonsillar exudates,
tonsilitis, pharyngitis and mild palatal petechiae may be found, but also in
strep pharyngitis. a complication of im is autoimmune hemolytic anemia and
thrombocytopenia. IgM cold-agglutinin antibodies which lead to
complement-mediated destruction of RBCs.
disseminated N. gonorrhea infection presents with high fever, chills,
tenosynovitis, and migratory polyarthritis early in illness. skin lesions
ranging from 5 - 40 and are most commonly seen on the extremities. lesions are
discrete purpuric or pustular with hemorrhagic components and
occasionally central necrosis. blood cultures and cultures from the cutaneous
pustules are often negative due to specific growth requirements of the strain of
N. gonorrhea causing this disseminated form of infection. no pustules in acute HIV
syndrome.
immunocompromised patients get shingles (herpes zoster) in an area with
constant burning pain without any other physical abnormalities. the pain often
precedes the rash by several days, or they can appear together. the rash is
vesicular in a dermatomal pattern.
blood transfusion before 1986 should be screened for HBV. 1992 for hep c. b for
before hep c (1986 before 1992)
cant screen for hepatitis B using HbsAg and anti-Hbs because of the
window period. instead do IgM anti-Hbc.
firm, flesh colored, dome shaped, umbilicated papules are typical of
molluscum contagiosum (poxvirus). cellular immunodeficiency, corticosteroid

use, and chemotherapy predispose patients to molluscum contagiosum. common

in patients with HIV.
nail puncture wound resulting in osteomyelitis is most likely due to P.
aeruginosa
fever, headache, focal neuro signs, seizure, spasticity or signs of increased ICP
are presentation of brain abscess. brain abscess more likely to occur in patients
with congenital heart disease, head trauma, infections of jaw/mouth,
infections of scalp/face, meningitis, cranial instrumentation.
scabies caused by Sarcoptes scabiei. highly contagious disease presents with
generalized itching and pruritic papules over the penis and scrotum in
males, areolas and breasts in females, and in runs over the finger webs,
heels of palms, and wrist creases. treat with 5% permethrin cream
post-splenectomy patients are at an increased risk for sepsis from encapsulated
organisms due to impaired antibody-mediated opsonization in
phagocytosis. intracellular killing is defective in patients with chronic
granulomatous disease, a defect in NADPH oxidase.
aspergillosis may form a cavitary lesion because of destruction of the
underlying pulmonary parenchyma, and debris and hyphae may coalesce
and form a fungus ball (aspergilloma) which lies free in the cavity and
moves around with position change.
patients with HIV have a 10% risk per year of reactivating tuberculosis. manifests
as fever, night sweats, weight loss, fatigue, pleuritic pain, chronic cough and
hemoptysis. cxr findings classically include an apical cavitary lesion.
coccidiodomycosis results in a flu-like illness with dyspnea and a slightly
productive cough. miliary pattern is most common lung lesion (like little tiny
dots)
mild manifestations of a drug allergy (urticaria and pruritis without systemic
symptoms) are usually treated with anti-histamines and discontinuation of the
affending drug. rash from EBV infectious mononoculeosis who take
amoxicillin is polymorphous maculopapular and develops after 24 hours.
secondary syphilis presents as a diffuse maculopapular rash involving the
face trunk extremities palms and soles, in addition to generalized
lymphadenopathy with systemic/constitutional symptoms (fever, malaise,
sore throat? great imitator)
HIV patients with CD4 counts < 50 require MAC prophylaxis with
azithromycin or clarithromycin. mac for mac
lymphadenitis is diagnosed when the lymph node becomes tender and
erythematous in addition to being enlarged. usually caused by bacterial
infection with S. aureus being the most common pathogen isolated.
for community-acquired acute bacterial meningitis use vancomycin +
ceftriaxone in adults and children since it will cover the most frequent etiological
agents: S. pneumoniae (vancomycin) H. influenza (ceftriaxone) and N.
meningitidis (ceftriaxone). add ampicillin to cover L. monocytogenes
which can cause meningitis in patients > 55. immunocompromised patients are
at risk for listeria.
allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity
reaction to aspergillus colonization of the bronchi. it occurs most commonly in
patients with asthma/cystic fibrosis, and presents with fever, productive cough,
eosinophilia and hemoptysis. tuberculosis will have chronic cough, hemoptysis,
and intermittent fevers. CT can show upper lobe cavitary lesions (more than 1
possible!!) with surrounding alveolar infiltration.
facial/opthalmic venous system is valveless, uncontrolled infection of the
skin can reuslt in cavernous sinus thrombosis. red-flag symptoms include
severe headache, bilateral periorbital edema, and cranial nerve 3/4/5/6

deficits. orbital cellulitis can present similarly with fever, proptosis,

opthalmoplegia, and visual defects, however there will not likely be bilateral
periorbital edema, and bilateral cranial nerve findings.
nocardia is a gram+ partially acid-fast filamentous aerobe that is found in soil.
nocardiosis may be confused with tuberculosis or actinomyces infection. weight
loss, fever, night sweats. cough of purulent sputum CXR findings include alveolar
infilrates and nodules often with cavitation. disseminated disease is most
likely to manifest as subcutaneous or brain abscessess. usually occurs in
immunocompromised patients. treatment is tmp-smx.
whipple disease has PAS+ macrophage. symptoms are chronic malabsorptive
diarrhea, weight loss, migratory non deforming arthritis, lymphadenopathy,
and low-grade fever.
treatment for cat scratch disease is azithromycin. symptoms are tender
regional lymphadenopathy and cutaneous lesions.
use doxycycline or azithromycin in penicillin allergic patients who have
syphilis.
give tmp-smx and steroids in HIV patients with pneumocystis pneumonia if
PaO2 < 70 mmHg or A-a gradient > 35 mmHg. pcp occurs when CD4 < 200.
presents with dry cough, fever, exertional dyspnea. and cxr usually shows
bilateral interstitial infiltrates.
instrumentation of upper airway or esophagus can lead to anaerobic
pneumonia. fever + foul smelling sputum. clindamycin is most commonly
used for this infection.
inflamed fluctuant cervical lymph nodes are typically caused by strep or
staph infection. the antibiotic of choice is dicloxacillin. other effective
antibiotics are cephalexin or clindamycin.

msk/ct/rheum

fibromyalgia = pain in muscles, no weakness, no swelling. psychological, labs

normal. treat with TCAs/amitriptyline. Aerobic exercises also help.
systemic lupus erythematosus (anti Ds DNA abs) has 90% joint
involvement however joint deformity involving the hands is uncommon.
for myasthenia crisis, intubate and withdraw acetylcholinesterase inhibitors for a
few days
seronegative spondyloarthropathy (PAIR) like ankylosing spondylitis causes
lower back pain and stiffness in young men. symptoms are worse in the morning
and improve as the day progresses. Patients also get arthritis of peripheral joints
and anterior uveitis. will have elevated ESR and negative Rh factor. use TNFalpha antagonists.
viral arthritis secondary to parvo B19 infection has polyarticular and
symmetric arthritis. affects MCP, PIP, wrist, ankle and resolves within 2
months. will have elevated anti-b19 IgM antibodies. Common in teachers
or people who work in day care centers.
patients who have ankylosing spondylitis for two decades or longer are at an
increased risk of vertebral fracture due to decreased bone mineral density.
these fractures may occur with minimal trauma.

spondylolisthesis is a developmental disorder characterized by a forward slip

of vertebrae on the caudal vertebrae. most commonly at L4-L5 and L5-S1.
causes back pain and neurological dysfunction (urinary incontinence).
viral arthritis presents with symmetric arthritis of DIP, MCP and wrist like
rheumatoid arthritis, however it is acute in onset, and has no elevated
inflammatory markers.
Behets syndrome is a multi-systemic inflammatory disease. presents with
painful oral ulcers and genital ulcers and erythema nodosum like lesions of
the skin. also can have ocular lesions (anterior uveitis, optic neuritis), arthritis
and CNS lesions mimicking multiple sclerosis (meningoencephalitis). seen in
turkish, asian, and middle eastern populations.
systemic sclerosis (anti topoisomerase, etc) is a condition affecting every
organ system in the body. cutaneous findings include thickening of skin beginning
in acral sites (hand and feet) with edema, that transitions into dermal sclerosis
with obliteration of skin appendages (hair follicles and sweat glands) and flexion
contractures. raynaud phenomenon and calcinosis cutis are also common.
involvement of the kidneys produces hypertension, pulmonary artery
hypertension results in right heart failure in these patients. patients have
+anti-nuclear autoantibodies and +anti-topoisomerase-abs
Bakers cysts develop as a result of excessive fluid production by inflamed
synovium, as occurs in cases of rheumatoid arthritis, osteoarthritis and
cartilage tears.
ankylosing spondylitis is confirmed by plain film x-ray demonstrating fused
sacroiliac joints and/or bamboo spine.
Sjgren syndrome is autoimmune condition most commonly affects women in
their 50-60s. clinical findings include keratoconjunctivitis (xerophthalmia) and
xerostomia. increased incidence of dental caries (saliva is antimicrobial and
lubricating) and will complain of difficulty swallowing. lymphocytic infiltration
of salivary glands produces enlargement and firmness to palpation of these
glands. serum autoantibodies directed against anti-SSA/anti-Ro and/or antiSSB/anti-La
Osteoarthritis of the spine can cause LUMBAR SPINAL STENOSIS. narrowing
of the lumbar spinal canal leads to mechanical compression and ischemia of
the nerve roots. shows pseudoclaudication which is lower extremity pain
when walking and prolonged standing, especially walking downhill (extension). to
make better lean forward (resting on shopping cart, flexion).
polymyalgia rheumatica has proximal muscle tenderness and no elevations
of AST/ALT/CPK (elevated ESR) tx with low dose steroids. Strong
association with giant cell arteritis. weakness in proximal muscles with
elevated ferritin/LDH/CPK are consistent with breakdown of muscle tissue:
polymyositis.
anti-smith and anti-dsDNA are specific for systemic lupus erythematosus.
treat raynaud phenomenon (cold induced vasospasm) with calcium channel
blockers like nifedipine.
viral arthritis can present with symmetric small joint inflammatory
arthritis. + markers such as ana and rheumatoid factor may occur.
Polyarticular with joint swelling and low-grade fever. will resolve in less than 2
months so treat with NSAIDs alone is sufficient.
systemic lupus erythematosus systemic manifestations include nondeforming arthritis, oral ulcers, serositis, hematologic abnormalities,
proteinuria, rash. Systemic lupus erythematosus arthritis affects mcp and pip
commonly??

psoriatic artritis occurs in 5-30% of psoriasis patients. the classic presentation

involves the DIP joints. morning stiffness, deformity, dactylitis (sausage digit)
and nail involvement are common.
rheumatoid arthritis predisposes to the development of septic arthritis. (new joint
that is very tender, swollen)
systemic lupus erythematosus effects on the kidneys can range from minimal
mesangial lupus nephritis to advanced sclerosing lupus nephritis and are graded
class 1 - 4. the treatments and outcomes are different depending on the class of
lupus nephritis. renal biopsy is required in all patients with new onset
lupus nephritis.
steroid induced myopathy is a well-described result of chronic
corticosteroid use characterized by painless proximal muscle weakness. it
will slowly improve once the offending medication is discontinued.
Pagets disease of bone (osteitis deformans) is associated with normal serum
calcium and phosphate levels and increased ALP and urinary hydroxyproline
levels.
lumbar spinal stenosis is most commonly caused by
osteoarthritis/degenerative joint disease. the term neuropathic
claudication is often used to describe lumbar stenosis. exacerbation of leg
symptoms with walking, however unlike pvd, the symptoms are positional
and remain while standing still. pain is relieved by flexion of the spine.
diagnose by clinical history and MRI of spine.
muscular weakness in paraneoplastic syndromes can be due to a variety of
processes at different levels. skin rash + weakness suggests
dermatomyositis (associated with an increase incidence in cancer). will
have elevated CK/aldolase levels and inflammation in the muscle
wegeners is granulomatosis with polyangiitis. triad of 1) systemic
vasculitis 2) upper and lower airway granulomatous inflammation and 3)
glomerulonephritis. there can be cutaneous lesions (tender nodules,
palpable purpura, ulcerations) as well as joint and eye lesions. treat with
cyclophosphamide.
patients with rheumatoid arthritis are at increased risk of developing
osteopenia and osteoporosis.
treat polymyalgia rheumatica with low-dose prednisone. Pain (not really
weakness) and stifness in neck, shoulders, and pelvic girdle in a patient over 50
years old with elevated ESR and morning stiffness > 1 hour.
induction chemotherapy results in rapid tumor cell lysis and releases uric acid
into the circulation. for prevention of gout, allopurinol and probenecid are
used, while NSAIDs and colchicine and steroids are used during acute
attacks.
tenderness to gentle percussion over the lumbar vertebrae is an important
clue to vertebral osteomyelitis. vertebral compression fractures can also
cause local tenderness to palpation but this usually occurs in elderly patients
with a history of osteomalacia/osteoporosis. MRI is the most sensitive study
for vertebral osteomyelitis.
corticosteroid induced avascular necrosis of the femoral head presents as
progressive hip or groin pain without restriction of motion range, and normal
XR in early stages. MRI is gold standard for the diagnosis of avascular
necrosis of the hip
vertebral osteomyelitis is best diagnosed with MRI of spine. Patient will
have low-grade fever and elevated ESR. physical exam will reveal local
tenderness on percussion of the affected vertebrae and paravertebral
muscular spasm.

the pancytopenia in systemic lupus erythematosus is due to formation of

auto-antibodies against cells. a type of type 2 hypersensitivity reaction.
common side effects of methotrexate include mucositis/stomatitis, nausea,
abdominal pain, and fever. can also cause hepatotoxicity and
myelosuppression. Also teratogenic
reactive arthritis is a type of seronegative spondyloarthropathy. classic
reactive arthritis is a triad of 1) nongonococcal urethritis 2) asymmetric
oligoarthritis and 3) conjunctivitis. it often involves the knee and sacroiliac
spine. there are also mucocutaneous lesions and enthesitis (achilles tendon
pain). Look for gastrointestinal infection in the history as well. NSAIDs are first
line of therapy. cant see/cant pee/cant climb a tree
polymyositis is an inflammatory muscle disease. presents w/ muscle
weakness of proximal muscles (shoulder/hip). Will have elevated
ESR/CPK/aldolase. treat with high dose corticosteroids.
osteoarthritis has subchondral sclerosis, joint space narrowing, and
osteophytes. it affects weight bearing joints and manifests with deformity and
degenerative joint disease and loose bodies on imaging. XR will show loss
of cartilage, osteophyte development as well.
Paget's disease can present with asymptomatic increased ALP. due to bone
remodeling. can have hearing loss. treatment is bisphosphonates (due to
overactive osteoclasts)
lumbosacral strain is most common cause of back pain. after heavy lifting in the
lumbar area with no radiation. no sensory deficits.
fibromyalgia is musculoskeletal pain. patients (more often women) will
complained of disturbed sleep, muscle stiffness, labs are normal. TCAs like
amitriptyline will help restore sleep and can be effective treatment. Also treat
with aerobic exercises.
trendelenburg sign is a dropping of contralateral pelvis when asked to stand on
1 leg. indicates gluteal muscle weakness.
for hydroxychloroquine you have to do eye exams every 6 mos. to check for
retinopathy
cervical spondylosis is osteoarthritis of spinal vertebrae. Will have chronic
neck pain. radiology will show bony spurs (osteophytes) and sclerotic facet
joints.
in a rotator cuff tear, the patient has a positive drop arm test where the arm
is unable to be lowered slowly.
hairline fractures are common in athletes, especially of the second metatarsal.
treat with rest, analgesia, and a hard-soled shoe.
acute back pain and +straight leg raise test disk herniation (sciatica). pain
radiates down posterior surface of thigh. manage with NSAIDs and early
mobilization.
osteonecrosis/aseptic necrosis/avascular necrosis/ischemic
necrosis/osteochondritis dessicans is due to disrupted vasculature and bone is
not able to remodel, leading to trabecular thinning and collapse. early on xrays will not show abnormalities. MRI is the most sensitive test for this
condition.
stress fracture most common in anterior tibia. x-rays frequently normal during
initial eval.
most common cause of asymptomatic elevation of ALP in an elderly patient is
Pagets disease of bone (osteitis deformans), look out for increasing hat size or
hearing problems.
de quervain tenosynovitis is a condition affecting new mothers who hold
their infants with thumb outstretched. the abductor pollicis longus and extensor

pollicis brevis tendons are affected. passive stretching of those tendons elicits
pain.
lumbar spinal stenosis has back pain made worse by extension (narrowing
the canal) and made better by flexing (widening the canal). neurogenic
claudication is the leg pain of spinal stenosis that can be confused with PVD
but ankle-brachial index is normal and so are pulses.
posterior dislocations of the shoulder commonly occur after a tonic-clonic
seizure with the patient holding the arm adducted and internally rotated. todds
paralysis is a transient unilateral weakness following a tonic-clonic seizure.
acute shoulder pain after forceful abduction and external rotation at
glenohumeral joint suggests anterior shoulder dislocation which can cause
axillary nerve or axillary artery damage
scaphoid fractures are the most common of the wrist falling on outstretched
hand. immobilize wrist for 6-10 weeks.
tear of medial meniscus occurs during a twisting injury. patients complain of a
popping sound followed by severe pain at the time of injury. meniscus is
not directly perfused so effusion takes some time to present. McMurrays sign
is a palpable or audible snap occurring while slowly extending the leg at the knee
from full flexion while applying tibial torsion.
carpal tunnel syndrome presents with paresthesias of the first 3.5 digits and
thenar eminence atrophy.
radial nerve is most commonly injured nerve with fracture of midshaft
humerus.
pagets disease is due to increased bone turnover, due to osteoclast
dysfunction causing increased bone breakdown and a compensatory increase
in production. pelvis, skull, spine and long bones are most commonly involved.
symptoms may include skeletal deformities like femoral bowing. bone and
joint pain and hearing loss are less common symptoms.
lumbar spinal stenosis neurogenic claudication is a degenerative condition
where the spinal canal is narrowed. flexion of the spine gives pain. due to
enlarging osteophytes at the facet joints and hypertrophy of the
ligamentum flavum. back pain radiating to the buttocks and thighs. confirm
diagnosis with MRI.
double/soap bubble appearance in the epiphyseal end of long bone is a
giant cell tumor/osteoclastoma. presents in 20-40 y/o females with knee
pain.
pain to palpation of the vertebra on exam is suggestive of spinal infection
or lytic lesions in the spine. initial test of choice is a XR of the back to look
for lytic lesions and compression fractures. if test is non diagnostic then MRI/CT
can be done to evaluate for disc disease, cancer, and spinal infections.
trochanteric bursitis is inflammation of the bursa surrounding insertion of
the gluteus medius onto the femurs greater trochanter. patients with this
condition complain of hip pain when pressure is applied (ie: sleeping on that side)
and with external rotation or resisted abduction.
osgood-schlatter (traction apophysitis) is a common cause of knee pain,
particularly in adolescent male athletes. during periods of rapid growth where
the quadriceps tendon puts traction on the apophysis of the tibial tubercle
where the patellar tendon inserts. worsened by sports that involve repetitive
running, jumping, kneeling, and it improves with rest. pain can be reproduced by
extending the knee against resistance. radiograph findings are nonspecific and
include anterior soft tissue swelling, lifting of tubercle from the shaft, and
irregularity or fragmentation of the tubercle.

femoral nerve gives sensation to anterior thigh and medial leg. responsible
for knee extension and hip flexion.
tibial nerve supplies muscles of the posterior compartment of thigh,
posterior comparment of leg, and plantar muscles of the foot.
obturator nerve innervates the medial compartment of the thigh.
supracondylar humeral fractures are associated with brachial artery injuries
resulting in the loss of the radial pulse; assess radial pulse when fracture is
reduced.
meniscal tears are usually caused by a twisting injury when the foot is in a fixed
position. knee pain is felt initially but the swelling is worse the day after the injury
and is due to an effusion. confirm best with MRI
midshaft fracture of humerus will damage radial nerve.
MRI is the investigation of choice for defining soft tissue injuries of the knee.
high-stepping or steppage gait is due to foot drop. results from an inability
to dorsiflex the foot. to compensate patients must overly flex the hip/knee to
bring the foot forward with each step. the toes may also drag on the ground with
this type of gait. most commonly caused by peripheral neuropathy. may also
classically result from trauma to the common peroneal/fibular nerve or
radiculopathy to any of the spinal roots that contribute to the common peroneal
nerve (L4-S2). may also be congenital such as in charcot-marie-tooth disease.
osteomalacia has symmetrical looser zones or pseudofractures and
blurring of the spine. will have low or low-normal calcium and low
phosphate, high PTH and low vitamin d. vitamin d deficiency leads to
decreased intestinal calcium and phosphate reabsorption, resulting in
hypocalcemia and hypophosphatemia. hypocalcemia then stimulates parathyroid
gland.
vertebral compression fractures almost always occur when bone
demineralization is present. will present as intense, focal vertebral pain
without neurological symptoms. occurs in osteomalacia and osteoporosis.
spinal cord compression can be caused by cauda equina syndrome and
results in absent rectal tone, urinary incontinence, motor/sensory loss in
extremities.it is a surgical emergency. MRI to identify the site of
compression/fracture followed by surgery.

nephrology

ACEi are the most common cause of acquired angioedema. other effects are
cough, hyperkalemia, and precipitation of acute renal failure in patietns with
bilateral renal artery stenosis. angioedema can occur anytime taking the
med, not just within a few weeks of starting.
type 4 renal tubular acidosis (looks like hypoaldosteronism, build up of
ammonia and cant excrete H+) occurs w/ diabetic nephropathy or interstitial
renal disease. chronic renal failure/uremia is a cause of hypochloremic anion
gap metabolic acidosis. in type 4 can't excrete H+ and accumulation of organic
anions, so you get non-anion gap metabolic acidosis.

chronic pyelonephritis is characterized by focal parenchymal scarring and

blunting of calices
systolic-diastolic abdominal bruit in a patient with hypertension and
atherosclerosis is renal artery stenosis
normally calcium binds oxalate in gut and prevents re-absorption. when have fat
malabsorption, the calcium is bound by fat, and oxalate is unbound and reabsorbed, and forms stones (paradoxically, you treat by increasing calcium in
diet)
renal artery stenosis is most common cause secondary hypertension.
interstitial cystitis is triad of 1. urinary urgency 2. urinary frequency 3.
chronic pelvic pain, relieved by voiding. gives wbc casts.
elevations in bun/creatinine due to pre-renal failure, post-renal failure,
systemic steroids, or gastrointestinal bleeding (re-absorption of urea from
gastrointestinal tract after bacteria breakdown hemoglobin)
in diabetes mellitus first there is glomerular hyperfiltration (shows up as
increased GFR and microalbuminuria). thickening of glomerular basement
membrane and then comes mesangial expansion
goodpasture's disease affects lungs and kidney due to IgG antibodies
attacking collagen type IV. treat with plasmapheresis.
ultrasound or other imaging techniques are indicated when patients with
pyelonephritis do not respond after 48-72 hrs of appropriate antibiotic
therapy
renal stones present as flank pain (LLQ, RLQ) radiating to the groin along with
nausea and vomiting. to diagnose use non contrast CT of abdomen and
pelvis.
in pre-renal failure urine na < 10 meq/l (the kidney is reabsorbing salt to bring in
water, so there will be very little salt in the urine)
amyloid will give renal enlargement and hepatomegaly. suspect in patient with
chronic disease like rheumatoid arthritis
aminoglycoside are antibiotics used for severe gram negative infection and
potentially nephrotoxic. amikacin is an aminoglycoside
renal papillary necrosis due to NSAIDs is due to papillary ischemia by analgesia
mediated vasoconstriction of medullary blood vessels (vasa recta).
IgA nephropathy (Bergers) is most common cause of glomerulonephritis
in adults. recurrent episodes of gross hematuria beginning several days after
an upper respiratory infection (versus post strep GN which can take
weeks). In children IgA nephropathy is HSP with skin lesions and abdominal
bleeding. Goodpastures is a triad of 1) pulm hemorrhage 2) prolif.
glomerulonephritis and 3) IgG to anti-gbm
large blood on urinalysis with low RBCs on sediment microscopy is myoglobin.
during rhabdomyolysis myoglobin can result in tubular injury and acute renal
failure. seizures can cause rhabdomyolysis due to tonic-clonic movement.
Goodpastures syndrome is caused by circulating anti-gbm antibodies. early
removal of these antibodies by emergency plasmapheresis is imperative in
order to minimize extent of kidney damage. Wegeners (granulomatosis with
polyangiitis) is treated with a combination of cyclophosphamide and
steroids.

suspect mixed cryoglobulinemia in a patient with palpable purpura/skin

lesions, proteinuria/hematuria. other manifestations include nonspecific
systemic symptoms, arthralgias, hepatosplenomegaly, and
hypocomplementemia. majority of patients have underlying HCV infection
the strongest predictor of abdominal aortic aneurysm expansion and rupture are
1) large aneurysm diameter 2) rapid rate of expansion and 3) current cigarette
smoking. Smoking cessation has the greatest likelihood of slowing down
AAA expansion.
membranoproliferative glomerulonephritis (dense deposit disease) is
caused by persistent activation of the alternative complement pathway. dense
intramembranous deposits that stain for c3 is a characteristic finding. IgG
antibodies (c3 nephritic factor) directed against c3 convertase. HBV, HCV,
lupus, cryoglobulinemia
in chronic renal failure a reduction in GFR leads to phosphate retention and
poor vitamin d processing resulting in hypocalcemia. stimulates the parathyroid
glands leading to hypertrophy and 2nd hyperparathyroidism.
diabetes can cause neurogenic bladder causing overflow incontinence
(detrusor underactivity). overflow incontinence is marked by urinary
frequency, nocturia, frequent leakage of small volumes of urine, and high postvoid residual urine volumes. use cholinergic agents like bethanechol.
most common cause of renal failure in multiple myeloma is a toxic effect of
light chain casts on the renal tubules.
initial hematuria suggests urethral damage. terminal hematuria indicates bladder
or prostatic damage, and total hematuria reflects damage in the kidneys or
ureters. clots are not usually seen with renal causes of hematuria.
when patient has BPH do urinalysis to assess for urinary infection, obstruction,
or hematuria. transrectal ultrasound of the prostate is used to help guide prostate
biopsy, but not a sensitive screening test for prostate cancer or evaluating bph.
to treat hemolytic uremic syndrome (can have neurologic disturbances)
do plasmapheresis/FFP (plasma exchange).
ethylene glycol causes calcium oxalate crystals (rectangular envelope-shaped
crystals) methanol causes visual field changes (snowfield vision) and acute
pancreatitits.
cardiovascular disease is the most common cause of death in dialysis patients.
approx 50% of all deaths in this population
membranous nephropathy is most common nephropathy associated with
carcinoma, however nephrotic syndrome is a well known complication of
Hodgkins lymphoma and is usually caused by minimal change disease.
patients with recurrent hypercalciuric renal stones should be advised to
increase fluid intake, sodium restriction, and a thiazide diuretic. do not
restrict calcium.
uric acid stones are needle shaped on urinalysis. ureterolithasis can cause
ileus (no propulsion in the GI tract) due to a vagal reaction. evaluate uric
acid stones by CT of the abdomen or IV pyelography.
unilateral varicocele (dilated pampiniform plexus) that fails to empty
when a patient is recumbent (lying down) raise suspicion for an underlying
mass pathology such as renal cell carcinoma, that obstructs venous flow.

CT scan of the abdomen is the most sensitive and specific test for diagnosing
RCC.
renal vein thrombosis is an important complication of nephrotic syndrome.
antithrombin 3/protein C/protein S are lost in the urine and puts patients
at risk for venous and arterial thrombosis. presents with sudden onset of
abdominal pain, fever, and hematuria. it can occur in any form of nephrotic
syndrome but it is most common with membranous glomerulonephritis.
hypertension causes intimal thickening and arteriosclerotic lesions of
afferent and efferent renal arterioles and glomerular capillary tufts.
diabetes nephropathy is characterized by increased extracellular matrix,
basement membrane thickening, mesangial expansion, and fibrosis.
75 to 90% of kidney stones are composed of calcium oxalate. calcium oxalate
crystals are envelope-shaped and radioopaque (can be seen on XR)
when KUB shows no stone in a patient with typical renal colic think of three
scenarios: 1) radiolucent stone disease (uric acid stones), 2) calcium
stones < 1-3 mm and 3) non-stone causes (obstruction by a blood clot or
tumor). uric acid stones are most commonly seen in patients with an
unusually low urine ph. treatment includes hydration, alkalinization of urine
(potassium bicarb or potassium citrate), and low purine diet. uric acid stones
are highly soluble in alkaline urine. bring urine up to ph > 6.5
hyposthenuria is an impairment in the kidneys ability to concentrate urine. this
is found in patients with sickle cell disease, and also in sickle cell trait although
in a less severe manner. thought to result from RBCs sickling in the vasa
rectae of the inner medulla. this can result in nocturia.
acyclovir gives you nephrotoxicity. will precipitate causing obstruction and acute
kidney injury.
HBV, HCV, lupus is associated with membranous glomerulonephritis. FSGS
is ass. w/ HIV, heroin, blacks. membranoproliferative glomerulonephritis
is ass w/ HBV, HCV, lupus, and also cryoglobulinemia (proteins insoluble at
low temps) and c3 nephritic factor (too much complement pathway)
post-strep glomerulonephritis presents 10-20 days after streptococcal
throat or skin infection. hematuria, hypertension, red cell casts, proteinuria.
will have low serum c3 complement (immune complex deposition)
analgesic nephropathy causes papillary necrosis (constriction of vasa recta) and
chronic tubulointerstitial nephritis.
edema from glomerulonephritis results from glomerular damage and
decreased GFR (also the case in end-stage renal disease). as the volume
increases from third spacing, the GFR will drop, leading to renal sodium
retention (RAAS). the increasing volume from RAAS can cause a significant rise in
bp. the proteinuria also contributes to edema. edema from nephrotic syndrome
results from hypoalbuminemia. hypoalbuminemia does not usually cause
pulmonary edema b/c alveolar capillaries have a higher permeability to albumin
at baseline (so there is less of an oncotic pressure difference) and greater lymph
flow than skeletal muscle, protecting the lungs from edema.
first-generation h1-antihistamines such as diphenhydramine have
significant anticholinergic effects in addition to antihistamine effects. common
anticholinergic side-effects include dryness of eyes, oral mucosa and

respiratory passages, urinary retention and dysuria. urinary retention caused

by anticholinergic agents results from failure of detrusor contraction.
ethylene glycol poisoning causes renal tubular damage and formation of calcium
oxalate crystals. methanol intoxication causes visual disturbances. will have a
metabolic acidosis (low ph low bicarb)
renal tubular acidosis is a normal anion gap metabolic acidosis. type 1 is
distal cant secrete h+ so patient is acidotic, hypokalemia (kidney will excrete
K+ instead of H+) and have elevated urinary pH. patients get nephrolithiasis.
type 2 is proximal patients cant absorb bicarb in proximal tubule. Will have low
urine pH. fanconi syndrome is a cause in children. type 4 defect in na+/k+
exchange in distal tubule resulting in hyperkalemic, hyperchloremic acidosis.
(like having addisons disease, no aldosterone working) can present as growth
failure / failure to thrive. labs show low bicarb with an increase in Cl-

neurology

Alzheimers dementia has cortical and subcortical atrophy on CT scan.

cauda equina syndrome is caused by damage to nerve roots. The patient will
have bladder/bowel dysfunction, saddle anesthesia, decreased Achilles tendon
reflex.
for migraine headaches you can use prochlorperazine as adjuvant for antiemesis. propanolol is used for for prophylaxis.
vertigo is spinning sensation accompanied by nausea. vertigo can be central
or peripheral. ear fullness and preference for hearing with one ear over the
other is suggestive of a peripheral cause. ear fullness is particularly
suggestive of Menieres disease which results from abnormal accumulation of
endolymph within the inner ear. disorders of the middle ear can cause hearing
loss, but not typically vertigo
bone conduction > air conduction on the rinne test is suggestive of
conductive hearing loss and can be combined with the weber test to confirm
the findings. otosclerosis is a common cause of conductive hearing loss in
adults, due to bony overgrowth of stapes. ototoxic antibiotics usually result in
sensorineural hearing loss.
left frontal lobe infarction will give you Broca's aphasia and right motor
problems. if patient has a rapid heart rate that is irregular, check for cardiac
source of embolus.
"cerebral salt wasting" syndrome can happen in people with sub-arachnoid
hemorrhage.
1) release of vasopressin
2) release of BNP.
results in hyponatremia
diffuse axonal injury shows numerous minute punctate hemorrhages with
blurring of grey-white interface.
before starting -triptans check for pregnancy (contraindicated)

acute labrynthitis and vestibular neuritis both cause vertigo. Acute labyrinthitis
has hearing loss/tinnitus and vestibular neuritis does not.
meniere's disease (sensorineural hearing loss, tinnitus, vertigo) 1st line therapy
is reduced salt diet
no forehead movement means Bells palsy (both upper/lower). affects upper
and lower parts of face. if central facial paresis (UMN lesion) was the cause of
facial paralysis then the patient would be able to move forehead because of
contralateral innervation.
ring enhancing lesion on brain CT scan and fluid collection in maxillary
sinus is an abscess due to maxillary sinusitis. aerobic and anaerobic
streptococci (60-70%) are responsible and also Bacteroides (anaerobe 20-40%)
hemi-neglect syndrome is characterized by ignoring the left side of a space,
and involves the right (non-dominant) parietal lobe.
if patient has a normal neurologic exam but paresthesias, non-detectable
pulses, pallor in a limb, immediately anticoagulate and get surgical
intervention for embolectomy. (arterial thrombosis)
anterior cord syndrome is commonly associated with burst fracture of the
vertebra, characterized by total loss of motor function below the level of
the lesion with loss of pain/temp bilateral below the lesion. intact
proprioception (posterior/dorsal column)
status epilepticus is seizure activity > 5-10 minutes not responding to antiseizure medication. first step is making sure airway and blood pressure are stable
with endotracheal intubation. diazepam --> phenytoin --> phenobarbital
drug of choice for trigeminal neuralgia is carbamazepine.
Shy-Drager syndrome/multiple system atrophy has Parkinsonism +
autonomic dysfunction (orthostatics, erectile dysfunction, etc) and widespread
neurological signs (cerebellar, pyramidal, LMN)
can have subclavian arterial atherosclerosis wih a preference for the left artery
and may present with vertebrobasilar insufficiency secondary to subclavian
steal syndrome.
pseudotumor cerebri (idiopathic intracranial hypertension) in obese females.
vitamin A and OCPs. headache, blurry vision, papilledema and cranial nerve
palsies. Treat weight weight loss and acetazolamide.
cerebellar dysfunction is common in chronic alcoholics. gait instability,
difficulty with to and fro movements, intention tremor. A +babinski suggests an
upper motor neuron lesion.
cerebellar tumors usually produce ipsilateral ataxia, nystagmus, intention
tremors, and loss of coordination.
thiamine deficiency causes Wernickes which is 1) encephalopathy/confusion,
2) oculomotor dysfunction/ophthalmoplegia and 3) ataxia.
normal pressure hydrocephalus has abnormal gait, incontinence, and
dementia (wet, wacky, wobbly). treat with large volume lumbar punctures and
venriculoperitoneal shunt.
cerebellar dysfunction gives intention tremor, which gets worse near the
end of movement, but is improved by rest, will likely have other cerebellar signs
(ataxia, etc). essential tremor is similar (??) suppressed at rest and exacerbated
near the end of a movement.
medial medullary syndrome is associated with contralateral spastic
hemiplegia, contralateral vibratory and proprioception loss, and tongue
deviation to the injured side. Due to lesion of the anterior spinal artery.
(corticospinal fibers, dorsal column medial lemniscus, CN 12)
lateral medulla/wallenberg syndrome and has ipsilateral horners, loss of
pain and temp. in the face, and cerebellar ataxia. loss of pain and temp

on contralateral side of body. Due to lesion of the posterior inferior

cerebellar artery (PICA). (CN 5-face stuff,8-ataxia,9-dysphagia/gag,10-)
central cord syndrome/syringomyelia occurs with hyperextension injuries
in elderly patients with degenerative changes in the cervical spine. causes
damage to corticospinal tracts (motor) and the decussating fibers of lateral
spinothalamic tract (nociception, temperature). central cord syndrome is
characterized by weakness that is more pronounced in the upper extremities
than in the lower extremities.
Partial seizures are simple or complex. complex partial seizure: brief episodes
of impaired consciousness, failure to respond to various stimuli during the
episode, staring spells, automatisms, and post-ictal confusion. EEG pattern is
usually normal or may show brief discharges.
seizures are partial or generalized (generalized is tonic-clonic/grand mal and
absence).
partial seizures can be broken down into
1) simple partial (consciousness intact)
2) complex partial (impaired consciousness) or
3) partial with secondary generalization.
patients with complex partial have automatisms (lip smacking, hands moving)
and patients who have partial seizures w/ secondary generalization usually
have tonic-clonic movements. a patient with tongue biting or
bladder/bowel incontinence most likely has complex partial with secondary
generalization.
after having a subarachnoid hemorrhage patients are at risk for subsequent
vasospasm of the arteries at the base of the brain. major cause of morbidity and
mortality so use calcium channel blockers like nimodipine to prevent
vasospasm.
essential tremor has a tremor that is suppressed at rest and made worse at
the end of a goal-directed movement. parkinsons disease has a resting
tremor made better with movement. treat essential with propanolol/primidone
cerebral blood flow increases with hypercapnia (increased CO2) and increased
metabolic demand and hypoxia through cerebral vasodilation. interventions for
lowering intracranial pressure are 1) head elevation to increase venous
outflow,
2) sedation to decrease metabolic demand and control of hypertension
3) intravenous mannitol to extract water out of brain and
4) hyperventilation to remove CO2 leading to vasoconstriction.
most common site for a lacunar infarct is posterior internal capsule,
producing pure motor stroke. lacunar infarcts are often not appreciated on noncontrast CT obtained during or shortly after the event.
cerebellar hemorrhage presents with acute onset occipital headache,
repeated vomiting and gait ataxia. patients will be hypertensive, and might
have CN6/abducens nerve paralysis, conjugate deviation, coma.
hypertensive intracranial hemorrhages occur most commonly in the basal
ganglia, thalamus, pons, and cerebellum. patients tend to present initially with
focal symptoms but can rapidly progress to signs of elevated intracranial
pressure. intracerebral hemorrhage presents with focal neurological symptoms
early but is followed by features of increased intracranial pressure
(vomiting, headache, bradycardia, decreased alertness). lacunar strokes also
occur in hypertensive patients but present with severe focal neurological
symptoms depending on the affected area. Lacunar strokes do not cause
rapidly worsening global neurologic symptoms. Cerebellar symptoms are
vomiting, occipital headache, ataxia.

neurofibromatosis type 2 in a patient with bilateral acoustic neuroma,

cataracts and multiple cafe-au-lait spots (hypopigmented). MRI with
gadolinium enhancement is best method to diagnose acoustic neuromas
complex partial seizures often stare blankly for several minutes and engage in
automatisms (lip smacking or chewing). will have confusion after suggesting a
post-ictal state. can have todds paralysis after, a transient post-seizure
neurologic symptom (leg dragging, arm weakness, etc)
the prognosis of astrocytomas is most affected by tumor grade, with
increased atypia, mitoses, neovascularity or necrosis conveying a worse
prognosis (glioblastoma multiforme is just a severe type of astrocytoma)
flattening of nasiolabial fold is caused by abnormal function of the facial
nerve/CN7. There will be an inability to close the eye as well. facial nerve
nucleus is located in the pons.
co-administration of triptans and ergotamine may result in prolonged
vasospasm due to overactivation of 5-HT receptors. thus triptans should
not be given for at least 24 hours after ergotamine is given.
creutzfeldt-jakob disease should be suspected in an old patient with rapidly
progressive dementia, myoclonus, and a periodic high voltage complex on
EEG.
wernickes encephalopathy presents with the triad of 1) confusion 2) ataxia,
and 3) opthalmoplegia. caused by a deficiency of thiamine. its a cause of acute
delirium and/or acute ataxia especially malnourished/alcoholic patients.
internuclear opthalmoplegia is a characteristic finding of multiple sclerosis
(MS) and due to demyelination of the medial longitudinal fasciculus (MLF).
acute attacks of multiple sclerosis (MS) are treated with intravenous
steroids. to reduce frequency of acute exacerbations, use interferon,
plasmapheresis, cyclophosphamide, intravenous immunoglobulins and
glatiramer acetate
normal pressure hydrocephalus results from increased ventricular size
without elevations in intracranial pressure. distortion of periventricular brain
matter.
benign/idiopathic intracranial hypertension (pseudotumor cerebri)
presents with a headache that is pulsatile in nature, awakens patient from
sleep, and is associated with pulsatile tinnitus (whooshing sound in ears).
patients can complain of headaches becoming worse with lying flat, and better
standing up. visual loss, sluggish pupillary reflexes to light, papilledema on
fundoscopy and abducens nerve/CN6 palsy. obese young women, and
certain medications (vitamin A, OCPs). brain MRI will show an empty sella and
slit-like ventricles. get lumbar puncture with opening pressure (will be
elevated). treatment involves weight reduction and acetazolamide. blindness
is the most significant complication of this otherwise benign condition.
tick-borne paralysis is characterized by a rapidly progressive ascending
paralysis, absence of fever, absence of sensory abnormalities and normal
CSF function. botulism presents with a descending paralysis and affects
cranial nerves early. (a tick bites at feet, so ascends)
essential to distinguish between a seizure and a syncopal event. a seizure
resulting in loss of consciousness will often be followed by a post-ictal state of
clouded sensorium, whereas people rapidly return to their baseline mental
status after a syncopal event.
lewy body dementia (parkinsons + dementia) has alterations in
consciousness, disorganized speech, visual hallucinations, extra pyramidal
symptoms. lewy bodies of eosinophilic intracytoplasmic inclusions
representing accumulations of alpha-synuclein protein may be seen in

neurons of the substantia nigra. treatment includes acetylcholinesterase

inhibitors like rivastigmine. for hallucinations refractory to AChe inhibitors,
atypical antipsychotics may be of benefit. neurofibrillary tangles and senile
plaques are pathological hallmarks of alzheimers dementia.
cerebellar hemorrhage causes ataxia, vomiting, occipital headache, gaze
palsy, and facial weakness. there is no hemiparesis. pontine hemorrhage
presents with a deep coma and paraplegia that develops in a few minutes.
decerebrate rigidity and no horizonal eye movements.
neurocardiogenic syncope (vasovagal syncope) is characterized by nausea,
diaphoresis, tachycardia and pallor immediately prior to syncopal
episode. arrhythmias generally have no preceding signs or symptoms other than
palpitations in some. seizures have a post-ictal period after a syncopal event.
guillain-barre syndrome is treated with intravenous immunoglobulins and
plasmapheresis. ascending paralysis, areflexia, and sensory changes 3-4
weeks after an upper respiratory infection or gastroenteritis is the common
presentation.
riluzole is a glutamate inhibitor that is currently approved for use in patients
with amyotropic lateral sclerosis (ALS).
use trihexyphenidyl/benztropine (anticholinergic) for the treatment of patients
where tremor is the primary symptom of Parkinsons.
anterior cerebral artery occlusion --> contralateral weakness affecting
lower extremity, urinary incontinence.
middle cerebral artery --> contralateral hemiplegia affects upper
extremity more, aphasia, hemineglect. (Wernickes/Brocas)
post limb of internal capsule --> motor hemiparesis and visual field. (most
common lacunar)
vertebrobasilar --> contralateral hemiplegia and ipsilateral cranial nerve
spinal cord compression is characterized by signs and symptoms of upper
motor neuron dysfunction distal to the site of compression, such as weakness,
hyperreflexia, decreased sensation, and bowel/bladder dysfunction. cord
compression is a medical emergency requiring prompt diagnosis via spinal
MRI. stroke does not have bilateral leg weakness.
creutzfeldt-jakob disease includes rapidly progressive dementia,
myoclonus, and sharp, triphasic synchronous discharges on eeg.
the most common site of hypertensive hemorrhage is the putamen (35%).
the internal capsule next to the putamen is almost always involved leading
to hemiparesis. the eyes are deviated away from the paralytic side.
subarachnoid hemorrhage has a sudden dramatic onset of severe headache, and
usually no focal neurological signs.
with cerebral lesions, motor deficits are usually opposite the site of the lesion
whereas gaze deviation is usually towards the side of the lesion. hypertensive
bleeds occur most commonly in the basal ganglia.
primidone is an anti-convulsant agent used to treat benign essential tremors.
it can precipitate acute intermittent porphyria, which can be diagnosed by
checking for urine porphobilinogen. symptoms will include abdominal pain,
neurologic, and psychiatric abnormalities.
pronator drift is a sensitive and specific physical exam finding for upper motor
neuron nerve damage affecting upper extremities. close eyes and extend arms
with palms up, and will tend to pronate.
if a patient presents within 4-5 hrs after the onset of an ischemic stroke,
thrombolytic therapy with tpa should be started if the CT scan does not
show hemorrhage.

anterior cerebral artery stroke has contralateral motor and/or sensory

more pronounced in the lower limb. other features that may be seen are
urinary incontinence, gait apraxia.
middle cerebral artery characterized by contralateral motor and/or
sensory more pronounced in upper limb and homonymous hemianopia. if
dominant lobe involved may have aphasia, if non-dominant lobe involved
may have neglect and/or anosognosia.
posterior cerebral artery stroke characterized by homonymous
hemianopia, hallucinations, sensory symptoms, third nerve palsy with
paresis of eye movements.
hemi-sensory loss with severe dysesthesia of the affected area is typical for a
thalamic stroke.
anticholinergic excess is characterized by red as a beet, dry as a bone, hot as
a hare, blind as a bat, mad as a hatter, and full as a flask flushing, anhidrosis,
hyperthermia, mydriasis/vision, delirium/confusion, and urinary
retention/constipation. can also cause retro-orbital headache due to
precipitation of acute-glaucoma.
glatiramer acetate is a long term disease modifying treatment for multiple
sclerosis that works by modulating t-cell mediated autoimmunity to myelin
basic protein. recognize multiple sclerosis by periventricular white matter.
tonic-clonic seizures can result in lactic acidosis due to lactic acid production by
the muscle and reduced hepatic uptake of lactate. post-ictal lactic acidosis is
transient and resolves in 60-90 mins.

obstetrics/gynecology

chorionic villus sampling is done between 10-12 weeks of gestation.

indicated in women > 35 years following an abnormal ultrasound. serum
screening does not provide a confirmatory diagnosis. risks for CVS include
fetal death and limb reduction defects. an increase incidence of distal limb
reduction defects occurs when the procedure is carried out before 9-10
weeks gestational age. (most important risk factor)
lichen sclerosis chronic inflammation of anogenital region mostly affecting
women. white macules and patches with an atrophic "cigarette paper" quality.
do a vulvar punch biopsy because the lesion is pre-cancerous for squamous cell
carcinoma. use topical steroids to treat.
patients with polycystic ovarian syndrome (PCOS) have increased risk of
dyslipidemia, type 2 diabetes mellitus. do fasting lipid panel and oral
glucose tolerance test
endometritis has fever, uterine tenderness in post partum period, and foul
smelling lochia. risk factors are prolonged rupture of membranes, prolonged
labor, c-section. treatment for endometritis is clindamycin + gentamycin.
gentamycin (aminoglycoside) for gram-, clindamycin gives anaerobic
coverage
transvaginal ultrasound is "gold standard" for evaluating cervical
incompetence
hypogonadotropic hypogonadism is a decrease in sex hormones due to
decreased FSH/LH. increased risk of osteoporosis. can be due to strenuous
exercise, anorexia, marijuana use, stress, starvation, depression, and chronic
illness

intra-uterine fetal demise when the woman doesn't feel any movements after
20 weeks and can't hear fetal heart tones on doppler. next step is to do
ultrasound to confirm
if patient has high fever, can't take oral meds (nausea/vomiting) then hospitalize
and treat with intravenous cefotetan and doxycycline for PID.
intraductal papilloma is a benign breast mass presenting around
perimenopausal area. intermittent bloody discharge from one nipple. tend to
be small < 2mm
uterine rupture has intense abdominal pain and vaginal bleeding. the
fetal station retracts. deliver via emergency c-section.
for PCOS if patient wants to conceive give clomiphene citrate.
emergency contraception is effective up to 120 hours after intercourse, use
levonorgestrel (plan B). intramuscular medroxyprogesterone (depo-provera) is a
method of birth control, not an abortifacient.
for stopping lactation use ice packs and tight fitting bra. do not use
bromocriptine (dopamine agonist. stops prolactin)
T. vaginalis causes malodorous, gray-green, thin, frothy vaginal discharge.
wet mount will show flagellated motile organisms. will also have vaginal pruritis
and inflammation. bacterial vaginosis (gardenerella, increased vaginal
pH) will not have pruritis and inflammation.
depressed deep tendon reflex is first sign of magnesium sulfate toxicity.
discontinue and administer calcium gluconate.
endometriosis has pelvic pain before cycle begins. laparoscopy is gold
standard for diagnosing. endometriosis leads to increased risk of infertility.
Up to 30% of people worked up for infertility found to have endometriosis.
abruptio placentae can present w/ uterine tenderness, hyperactivity, and
increased uterine tone w/ 3rd trimester vaginal bleeding.
for ectopic pregnancy do transvaginal ultrasound to locate site of ectopic
implantation. laparoscopy as a last resort to visualize ectopic pregnancy, its more
invasive
to treat and prevent seizures in eclampsia use magnesium sulfate.
renal plasma flow and GFR increase in pregnancy causing a decrease in
BUN/creatinine.
missed abortion involves a dead fetus still retained in the uterus. disappearance
of nausea and vomiting in early pregnancy and arrest of uterine growth.
do TSH/T4 for amenorrhea, as well as FSH to rule out ovarian failure, prolactin for
hyperprolactinemia.
symmetric intrauterine growth restriction (IUGR) include:
-chromosomal abnormalities,
-congenital anomalies (tetralogy of fallot),
-congenital infections.
asymmetric growth restriction causes include:
-maternal hypertension,
-preeclampsia, uterine anomalies,
-maternal anti-phospholipid syndrome,
-collagen vascular disease,
-maternal cigarette smoking
if fetal movement is decreased or becomes imperceptible by the mother do a
non-stress test.
squamous cell carcinoma is is most common vaginal cancer. vaginal
bleeding and malodorous vaginal discharge are the most common symptoms.
stage I and stage II < 2 cm are surgically excised if > 2 cm then radiation therapy
is given.

TORCH infections cause microcephaly (symmetric IUGR). smoking causes IUGR

but not microcephaly (asymmetric IUGR).
obese post-menopausal women have higher estrogen levels because of
conversion of adrenal androgens to estrogens by adipose tissue.
if patients has sudden onset hirsutism/virilization during pregnancy do
pelvic ultrasound. 1) no ovarian mass then do abdominal CT to rule out
adrenal mass. 2) if on ultrasound you find bilateral cystic masses then
theca-lutein cysts. rule out high beta-hcg states. 3) if on ultrasound you find
bilateral solid masses then mostly pregnancy luteoma. 4) if on ultrasound
you find unilateral solid mass then do laparotomy to rule out malignancy.
normally patients have low-grade fever and leukocytosis and bloody vaginal
discharge following the delivery. if the lochia was foul smelling and the uterus
was tender, endometritis.
when patient has placental abruption manage aggressively to ensure rapid
vaginal delivery. can cause DIC. only do c-section when deterioration of the
fetus or obstetrical complications. uterine rupture -> immediate c-section
Trichomonas vaginitis presents as erythematous vaginal mucosa with thin
grayish vaginal discharge. treat with metronidazole and avoid alcohol.
menstrual diary for at least 3 cycles for premenstrual syndrome. bloating,
fatigue, breast tenderness, headaches, anxiety, mood swings, decreased libido
and irritability.
patients with inevitable or incomplete abortions should be hospitalized, given
IV fluids, suction curettage, and rhogam if Rh-. they may get septic, DIC, and
hemorrhage.
with a fetal anomaly incompatible with life, allow spontaneous delivery if preterm
labor with rupture of membranes.
give pulsatile GnRH (leuprolide) to someone with acquired
hypogonadotropic hypogonadism due to hypothalamic dysfunction.
copious vaginal discharge by itself without pruritis, burning, malodorous
discharge, erythema, edema and friability of the vaginal mucosa, tenderness of
the cervix, and green or curd-like vaginal discharge is not concerning. most likely
physiological leukorrhea.
bacterial vaginosis has thin gray-white vaginal discharge, vaginal ph >
4.5, +Whiff test with KOH prep, and clue cells which are vaginal epithelial
cells with adherent bacteria. no pruritis or inflammation. Treat with metronidazole.
pseudohyphae on wet mount are consistent with candida vulvovaginitis. will
have pruritis, thick white discharge that has a cottage cheese appearance. treat
with oral fluconazole.
after 32 weeks with preterm, premature rupture of membranes (PPROM) its
unclear if corticosteroids are beneficial, but give penicillin if their GBS status is
unknown.
dysmenorrhea, enlarged uterus, and heavy menses is uterine fibroids.
primary dysmenorrhea is caused by increased levels of prostaglandins and
presents with lower abdominal pain occurring with menstruation. NSAIDs and
OCPs can improve these symptoms.
early follicular phase follows menstruation. cervical mucus is thick, scant, and
acid in this phase. no penetration by spermatozoa. during ovulatory phase the
cervical mucus is profuse, clear and thin, and is >6.5 in pH and will stretch
>6 cm when lifted vertically. in mid and late luteal phases ovulation has occurred
and the mucus becomes thicker and inhospitable to sperm.
increase in blood pressure before 20 weeks of gestation is due to chronic
hypertension or h-mole. if ultrasound shows a normal sac then its not h-mole.

hypertension is the most commonly identified risk factor for placental

abruption.
lithium in pregnancy can give Ebsteins anomaly: atrialized right ventricle,
malformed tricuspid valve, and atrial septal defect.
fat necrosis of the breast associated with breast trauma or surgery. can mimic
breast cancer and presents as a fixed mass with skin or nipple retraction. has
calcifications on mammography. biopsy shows fat globules and foamy
histiocytes.
female phenotype lacking a normal vagina and uterus is either mullerian
agenesis (XX, but fully functioning ovaries), androgen insensitivity
(cryptorchidism, remove after puberty to maintain adult height growth, low risk of
malignancy (dysgerminoma) compared to Turners (remove the streak ovaries), or
5-alpha-reductase deficiency. in the latter 2 you have an XY genotype.
precocious puberty is defined as development of 2nd sex characteristics before
age 8 in girls, 9 in boys. accelerated bone growth and advanced bone age
are common. central cause is result of early activation of hypothalamicpituitary-ovarian axis by GnRH. FSH and LH are elevated. in peripheral
precocious puberty they have low FSH/LH levels, because of
gonadal/adrenal release of sex hormones (negative feedback). if central then
diagnose with brain imaging CT/MRI and treat with GnRH analog (leuprolide)
therapy.
uterine rupture has intense abdominal pain and vaginal bleeding along with
hyperventilation, and tachycardia. placenta previa causes painless vaginal
bleeding, the risk factors are prior c-section, advanced maternal age,
multiparity, smoking, multiple gestation, and previous placenta previa.
asymptomatic bacteruria progresses to pyelonephritis in 30-40% of cases, need
to treat asymptomatic pylenphritis.
hyperemesis can occur with gestational trophoblastic disease, so measure
beta-hcg (cause nausea). if beta-hcg is high, do an ultrasound. hyperemesis
gravidarum presents with ketonuria.
HCG from the syncytiotrophoblasts is mainly responsible for the maintenance of
the corpus luteum during pregnancy.
inflammatory breast carcinoma presents as an edematous cutaneous plaque with
a peau dorange appearance overlying a breast mass. presents with axillary
lymphadenopathy, and 25% have metastatic disease. clinically unable to
differentiate between an infectious process like breast abscess so a biopsy for
histology is needed.
raloxifene is a SERM that increases risk of thromboembolism. decreases
risk of breast cancer and prevents osteoporosis. no increased risk of
endometrial cancer (vs tamoxifen).
initial menstrual cycles in pubertal females are irregular and anovulatory.
this is due to the immaturity of the developing hypothalamic-pituitary-ovarian
axis that doesnt produce adequate quantities and proportions of FSH/LH required
to induce ovulation.
cigarette smoking is the most common preventable cause of fetal growth
restriction in the US.
trastuzumab with chemotherapy can lead to cardiac toxicity. do echo before
treatment. before you touch the breasts, check the chest !
majority of breech positions self-correct by 37th week of gestation, so there
is no indication to convert until then. routinely follow up
Pagets disease has an 85% chance of having underlying breast cancer. most
patients with pagets have an adenocarcinoma. skin biopsy typically
demonstrates large cells that appear to be surrounded by clear halos.

midcycle pain (mitelschmerz) presents as abdominal pain in a young female in

the middle of her cycle with a benign history and physical exam.
in a pregnant patient who has syphilis and is allergic to penicillin, do
desensitization.
galactorrhea can be yellow, brown, or green. first step to do in patient with
galactorrhea is to check TSH and prolactin levels. red flags are unilateral,
guaiac positive fluid and a breast lump.
tamoxifen carries an increased risk for endometrial carcinoma (raloxifene
doesn't, but does increase risk of thromboembolism). but is an antagonist
at breast tissue and prevention of breast cancer. also decreases risk of
osteoporosis.
in premenopausal women with simple or complex hyperplasia without
atypia use cyclic progestins to treat dysfunctional uterine bleeding (DUB). the
chance for progression to uterine cancer is very low 1% and 3% for simple and
complex respectively.
pre-eclampsia can cause centrilobular necrosis of the liver, with
hematoma formation and the formation of thrombi in the portal capillary
system. these processes can cause swelling of the liver with distention of
the hepatic (Glissons) capsule resulting in RUQ pain.
preterm labor is labor occuring > 20 weeks but < 37 weeks gestation. requires
the occurrence of documented uterine contractions at a rate of 4 per 20 min
or more, and documented cervical changes consistent with labor.
Respiratory distress syndrome (RDS) is a common complication in preterm infants
as fetal lung maturity has not yet been reached. other complications include
intraventricular hemorrhage, sepsis, nectrotizing enterocolitis and kernicterus.
the management dependens on the gestational age of fetus and presence or
absence of comorbidities that pose a risk to fetus and mother. in normal
pregnancies systemic corticosteroids are delivered when the gestational age
is 24-34 weeks. tocolysis should then be attempted with the goal of maintaining
the pregnancy for at least 48 hours to allow the steroids to work.
first treatment for variable decels (cord compression) is give oxygen to mother
and change maternal position. uterotonic drugs need to be discontinued and
maternal hypotension evaluated and treated. variable decels may require
amnioinfusion.
choriocarcinoma is a metastatic form of gestational trophoblastic disease. it
may occur after molar pregnancy or normal gestation and the lungs are the
most frequent site of metastatic spread. suspect choriocarcinoma in any
postpartum woman with pulmonary symptoms and multiple nodules on CXR.
elevated beta-hcg helps to confirm the diagnosis.
androgen insensitivity syndrome is characterized by a defect/absence of
androgen receptors resulting in androgen resistance of peripheral tissues. these
patients are XY and have testes. MIF is produced by the testes and prohibits
formation of uterus, fallopian tubes, and upper portion of the vagina. breasts
develop because conversion of testosterone to estrogen.
stress incontinence is characterized by loss of small amounts of urine with
increased intra-abdominal pressure. ineffective closure of urethral sphincter.
weakening of pelvic floor musculature leading to urethral hypermobility.
will show an angle > 30 with a cotton swab in the urethral orifice upon increase of
inra-abdominal pressure. treat with kegel exercises and urethropexy. use
oxybutynin to treat urge incontinence. results from detrusor hyperactivity
and is characterized by a sudden urge to urinate.
hypotension is a common side effect of epidural anesthesia. the cause of
hypotension is blood redistribution to lower extremities and venous
pooling.

thyroid function in pregnancy is affected by 2 separate mechanisms. 1)

increase in thyroid binding globulin (TBG) concentration and 2)
stimulation of the TSH receptor by chorionic gonadotropin (HCG). an
increase in estrogen leads to an increase in TBG production, which results in an
increase in TBG-bound T3 and T4. as a result elevated TBG leads to increased
total T4 and T3, but the free T4 and T3 remain normal. the elevated levels of
hcg in pregnancy can also cause a mild stimulation of TSH receptor, resulting
in a small increase in free T3 and T4 and a mild decrease in TSH.
infants born to patients with graves disease treated with surgery are at
risk for thyrotoxicosis because of the passage of thyroid stimulating IgG
across the placenta.
Chlamydia trachomatis is the most common cause of mucopurulent
cervicitis.
in a patient recieving estrogen therapy the requirement for l-thyroxine
increases. estrogen may cause induction of liver enzymes, increased level
of TBG, and increased volume of distribution of thyroid hormones.
weight gain is not associated with the use of combination oral contraceptives.
abdominal circumference is the most effective parameter for estimation of
fetal weight in cases of suspected fetal growth restriction.
protraction of labor refers to a slow progression of cervical dilatation, whereas
arrest disorders are diagnosed when the cervix ceases to dilate after
reaching at least 4 cm. if the membranes are still intact, an amniotomy is the
first step to promote progression.
ovarian malignancy can present as right adnexal fullness, and nodularity along
the rectovaginal septum (possible peritoneal mets). pleural effusion can
be due to metastatic spread to the pleura.
most common cause of malignant pleural effusions are breast cancer and
lung cancer. will be an exudative effusion (Lights criteria).
for LSIL/mild dysplasia/CIN 1 do a colposcopy with a targeted biopsy. cone
biopsy is for more aggressive CIN.
chlamydia does not involve the vagina, it causes cervicitis and urethritis.
candidiasis presents with perineal itching and a thick white curd-like
vaginal discharge and a vaginal ph of 4.0. trichomonas presents with an
elevated vaginal ph and a green frothy malodorous discharge. bacterial
vaginosis can cause similar symptoms to candidiasis but the discharge is
thinner and the vaginal ph is higher than normal, no inflammation or
itching.
treat prolactinoma with dopamine agonist like cabergoline/bromocriptine
to restore fertility. will have bilateral galactorrhea. Polycystic ovarian syndrome
will not have galactorrhea. treat infertility of PCOS with GnRH analog
(leuprolide) or clomiphene.
third trimester bleeding is often commonly placenta previa (painless) and
placental abruption (painful). if hemodynamically stable, the next step would be a
transabdominal ultrasound. do not do bimanual examination or speculum
vaginal examination until placenta previa has been ruled out by
abdominal ultrasound.
several tocolytic agents can cause pulmonary edema in rare cases. most
common with beta-agonists (terbutaline and ritodrine).
reassurance and outpatient follow up is standard of care for threatened
abortion. (bleeding, closed cervix before 20 weeks gestation)
one of the side effects of epidural anesthesia is overflow incontinence
caused by bladder denervation. patient cant sense a full bladder and then the
hypotonic bladder distends gradually. when the pressure rises above urethral

pressure the urine is lost and pressure equalizes. transient incontinence treated
by in-and-out catheterization. (same with diabetic neuropathy)
placental abruption presents with sudden onset abdominal pain in the third
trimester with the absence of trauma. bleeding is seen in 80% of cases and in
some cases it may be retroplacental and not appear on vaginal exam. most
common risk factor is maternal hypertension.
Anti-phospholipid antibody syndrome (APS) is associated with false +VDRL,
prolonged PTT and thrombocytopenia. can promote arterial and venous
thromboses and resultant tendency toward sponaneous abortions. prophylaxis
with LMWH is recommended.
polycystic ovarian syndrome (PCOS) patients are hyperandrogenic women
with adequate amount of active estrogens. androgens converted into estrogens in
peripheral tissues. they are oligo- or anovulatory and are deficient in
progesterone secretion, thus they have unopposed estrogen stimulation
leaving them at a risk for endometrial cancer.
during pregnancy the higher serum concentration of progesterone has a
stimulatory effect on the dorsal respiratory group (DRG) of the medullary
respiratory center. by stimulating this central respiratory center, high
progesterone concentrations lead to tachypnea and consequent chronic mild
respiratory alkalosis. will have high pH, decrease in PaCO2 and a decrease in
HCO3- to compensate
+pregnancy test but with no ultrasound findings of intra- or exrauterine
pregnancy has a differential of: early viable intrauterine pregnancy, ectopic
pregnancy, or nonviable intrauterine pregnancy. an intrauterine pregnancy
should be seen with transvaginal ultrasound at 1500-2000 beta-hcg. if the
level is < 1000, repeat both beta-hcg and transvaginal ultrasound in 2-3
days.
adenomyosis is the presence of endometrial glands in the uterine muscle.
occurs most frequenly in women > 40 with severe dysmenorrhea and
menorrhagia. physical exam will show an enlarged and generally symmetric
uterus. leiomyomas also present similarly with dysmenorrhea, menorrhagia,
and a large-sized uterus but it is asymmetrical/irregularly shaped.
dysfunctional uterine bleeding (DUB) refers to heavy vaginal bleeding that
occurs in the absence of structural or organic disease. DUB is most often the
result of anovulation. treatment depends on the severity of bleeding, if mild
then give iron supplementation. if moderate and no active bleeding then add
progestin. if moderate with active bleeding or if severe give estrogen. in
women > 35 with DUB, endometrial biopsy is indicated
a missed abortion is a form of spontaneous abortion that is characterized by
intrauterine fetal death before 20 weeks gestational age with complete
retained products of conception and a closed cervix. patients present with
loss of pregnancy symptoms and some brown vaginal discharge. a transvaginal
ultrasound is necessary to confirm the diagnosis. the most appropriate
treatment is removal of POC from the uterus with a dilation and curettage, or
medically with vaginal misoprostol or expectantly with serial imaging to ensure
complete natural expulsion of POC.
ABO incompatibility generally occurs in a group O mother with a group A or
B baby, but ABO incompatibility causes less severe hemolytic disease of the
newborn than does Rh(D) incompatibility. affected infants are usually
asymptomatic at birth with absent or mild anemia and develop neonatal jaundice,
which is usually successfully treated with phototherapy.
pseudocyesis is an uncommon condition in which a woman presents with
many signs and symptoms of pregnancy (amenorrhea, enlargement of
breasts and abdomen, morning sickness, sensation of fetal movement,

+pregnancy test reported) however ultrasound will reveal a normal endometrial

stripe and the pregnancy test in the office will be negative. usually seen in
women who have a strong desire to become pregnant. form of conversion
disorder and management requires psychiatric evaluation and treatment.
elevated prolactin levels suppress GnRH release thereby suppressing LH
and FSH production and ovulation. this is the reason for anovulation and
amenorrhea in lactating mothers.
palpable breast mass in woman < 30 years do an ultrasound. if simple cyst
then do needle aspiration. if complex cyst/mass (solid) then do image guided
core biopsy. in a woman > 30 years do mammo & ultrasound. if suspicious for
malignancy then do core biopsy.
the three hallmark features of endometriosis (the three ds) are dyspareunia,
dysmenorrhea, and dyschezia. definitively diagnosed via laparoscopy. the
most popular treatment is combined estrogen and progestin pills. other
possibilities include GnRH analogs (leuprolide) or danazol.
in androgen insensitivity syndrome, do a gonadectomy after completion
of puberty. this allows for completion of breast development and attainment of
adult height. immediate removal of gonads is indicated in cases of XY gonadal
dysgenesis (Swyer syndrome) or Turners Syndrome as malignant change can
occur at any age.
endometrial biopsy is indicated in cases of dysfunctional uterine bleeding
(DUB) affecting women > 35 y/o. also indicated in cases of DUB if hypertension,
diabetes, or obesity are present. if biopsy is negative then can be treated with
cyclic progestins. (if moderate and active bleeding, estrogens)
rapidly developing hyperandrogenism with virilzation is highly suggestive
of an androgen-secreting neoplasm of the ovary or adrenal gland. serum
testosterone and DHEA-S are very helpful in delineating the site of androgen
production. elevated testosterone levels with normal DHEA-S indicate an
ovarian source, whereas elevated DHEA-S with relatively normal
testosterone indicate an adrenal source. rapidly developing virilization is rare
in PCOS.
LSIL on pap smear gets colposcopy. in post menopausal woman also do HPV
testing and repeat pap smear at 6/12 months. if HPV is then routine
screening, if HPV is + then colposcopy.
ruptured fetal umbilical vessel presents with antepartum hemorrhage with
very characteristic fetal heart changes progressing from tachycardia to
bradycardia to a sinusoidal pattern. vasa previa is a rare condition where
the fetal blood vessels traverse the fetal membranes across the lower segment of
the uterus (between the baby and the internal cervical os). these vessels are
vulnerable to tearing during natural or artificial rupture of the
membranes. treatment is immediate c-section.
tmp-smx is contraindicated in pregnancy. to treat asymptomatic
bacteriuria in a pregnant woman use amoxicillin.
treatment for vaginismus is relaxation, kegel exercises to relax the vaginal
muscles, and insertion of objects gradually increasing their size to
encourage desensitization.
primary ovarian failure results in decreased estrogen levels, increased
FSH and LH levels. FSH:LH ratio will be > 1.0. FSH elevation in the setting of
>3 months of amenorrhea in a woman under age 40 confirms the diagnosis of
premature ovarian failure.
premature ovarian failure is characterized by amenorrhea,
hypoestrogenism, and elevated serum gonadotropin levels in women age
< 40 years. may be associated with autoimmune disorders such as
hashimotos thyroiditis, addisons, type 1 diabetes mellitus, and pernicious

anemia. women present with signs/symptoms similar to those seen in

menopause. confirm diagnosis with increased serum FSH/LH levels and
decreased estrogen levels. if you want to get pregnant, then do in-vitro
fertilization because they lack viable oocytes.
the ideal range of maternal fasting glucose is between 75 90 mg/dL.
treatment is best accomplished with subcutaneous insulin. does not cross
the placenta. gestational diabetes puts baby at risk for: macrosomia,
hypocalcemia, hypoglycemia, hyperviscosity due to polycythemia, respiratory
difficulties, cardiomyopathy and congestive heart failure.
mammogram for women every 2 years starting at 50 until they are 75 y/o
(UPSTF guideline for low risk women)
if patient has atypical squamous cells of undetermined significance (ASC-US on
pap smear) followed by colposcopy showing CIN 1 then do repeat pap
smear at 6/12 months or HPV testing in 12 months. if two smears, then
routine follow up in 1 year. if ASC-US or ASC-H (on repeat pap) or if HPV +
then do colposcopy again. if colposcopy shows persistent CIN then
diagnostic procedure. HGSIL, CIN 2, and CIN 3 require excisional
diagnostic/treatment modality like cold knife conization or LEEP.
intraamniotic infection should be suspected in the setting of prolonged or
premature rupture of the membranes (before 37 weeks) when maternal
fever, leukocytosis, and uterine tenderness or tachycardia are detected.
fetal tachycardia is another feature of chorioamnionitis. the most
appropriate treatment of chorioamnionitis associated with premature
rupture of the membranes is systemic broad spectrum antibiotic therapy
and expedited delivery of the fetus.
DES exposure in utero increases risk of clear cell vaginal adenocarcinoma in
offspring.
Kallmanns syndrome consists of a congenital absence of GnRH secretion
associated with anosmia. patients have a normal XX genotype and normal
female internal reproductive organs. present with amenorrhea and absent
secondary sexual characteristics such as breast and pubic hair development.
abnormal development of the olfactory bulbs / tracts results in hyposmia or
anosmia.
labor should be induced without delay in patients with intrauterine fetal demise
who develop coagulation abnormalities. fibrinogen and platelet levels in the
low-normal range can indicate developing DIC.
screen all pregnant women for syphilis, regardless of risk factors for STDs
(TORCH). only screen for chlamydia in women < 24 or at increased risk (multiple
sexual partners or history of STDs)
during pregnancy the primary goal of colposcopy is the exclusion of invasive
cervical cancer. the management of women with any cytological specimen
suggesting HSIL consists of colposcopy and directed biopsy. if the initial
biopsy is negative, repeat colposcopy and biopsy should be done at 6-8
weeks after delivery.
management for septic abortion is 1) cervical and blood cultures, 2)
antibiotics, and 3) gentle suction curettage. The patient will be febrile,
tachycardic, hypotensive, and have bloody purulent vaginal discharge from the
cervix.
contraindications to breastfeeding are active drug abuse, tuberculosis, HIV
infection. Hepatitis C is not a contraindication to breast feeding. If taking
metronidazole stop for 12-24 hours.
arrest of dilation is defined as lack of cervical change for 2 hours in
nulliparious/multiparous patients. arrest of descent is defined as lack of change of
station for 2 hours in primigravid patients and 1 hour in multigravid patients, with

extra hour allowed if epidural in place. prominent ischial spines can lead
cephalopelvic disproportion which is one of the three ps causing protraction
and arrest disorders (passenger, passage, power). do a c-section if there is an
abnormality in the maternal pelvis.
progestin-only contraceptives are the preferred hormonal contraceptives
in lactating women as they do not affect the volume or composition of milk
produced by the mother. they have no known effects on the infant and they do
not carry the risk of venous thrombosis associated with combination pills.
lactation alone is not considered a reliable form of birth control as ovulation can
resume while a mother is still breastfeeding.
corticosteroid treatment is not proven to have a benefit after 34 weeks
gestation. its use is limited to the period between 24 34 weeks. fetal distress
(repetitive late decelerations) is an indication for emergent cesarean
section.
a young woman presenting with a breast lump can be asked to return after her
menstrual period for re-examination which may reveal regression of the mass if
no obvious signs of malignancy are present.
in a patient with primary amenorrhea do pelvic exam or ultrasound: if a
uterus is present --> serum FSH. if FSH increased --> karyotyping, if FSH
decreased --> cranial MRI. if the uterus is absent on ultrasound -->
karyotyping. if normal karyotype and normal female testosterone levels
then most likely abnormal mullerian development. if 46 XY and normal male
testosterone levels then androgen insensitivity syndrome.
c-section should be performed on women with active genital herpetic lesions
(primary or secondary) in order to reduce risk of neonatal HSV.
low back pain is very common in third trimester of pregnancy. believed to be
caused by increase in lumbar lordosis and the relaxation of the ligaments
supporting the joints of the pelvic girdle.
in intrauterine fetal demise, there is a concern for DIC. low fibrinogen levels
and low platelets are indicators for DIC. if they are not low, you dont need
need to deliver the fetus promptly. weigh the delivery options.
C section shown to reduce maternal transmission of HIV to newborn by 50%.
Triple therapy with antivirals during pregnancy is over 90% effective. Also give
newborns AZT for 6 weeks

ophthalmolog
y

acute glaucoma has an injected eye and a mid-dilated pupil.

orbital cellulitis has opthalmoplegia, proptosis, diplopia, pain with eye
movement. Can be caused by bacterial sinusitis.
age-related macular degeneration presents with bilateral loss of central
vision, wavy line distortion on visual test.

vitreous hemorrhage presents with a sudden loss of vision and onset of

floaters. the fundus is difficult to visualize and there will be floating debris. Red
color
Post-operative endopthalmitis usually occurs within 6 weeks of surgery.
patients have pain and decreased visual acuity. will have swollen eyelids,
conjunctiva, hypopyon, corneal edema and infection.
amaurosis fugax is characterized by visual loss that is monocular and transient.
described as a curtain falling down similar to central retinal artery
occlusion, however opthalmoscopy in CRAO shows pallor of optic disc, cherry
red fovea and boxcar segmentation of blood in both arteries and veins. in
amaurosis fugax you see a white edematous retina following the distribution of
the retinal arterioles.
chalazion presents as a painful swelling that progresses to a nodular rubbery
lesion. its a chronic granulomatous condition that develops when a meibomian
gland becomes obstructed. persistent or recurrent chalazion may be due to
meibomian gland carcinoma. do a histopath if recurrent.
cataracts has blurred vision and glare. caused by thickening of the lens.
retinal detachment patients complain of a curtain coming down over my
eyes and photopsia (flashes of light) and floaters (spots in their visual field).
can be due to ocular trauma (previous surgery of the eye such as for cataracts).
opthalmoscopy will reveal a grey, elevated retina.
spontaneous subconjunctival hemorrhage is a benign finding. looks like eye is
colored bright red.
dacrocystitis is an infection of the lacrimal sac. it usually occurs in infants
and adults > 40. characterized by the sudden onset of pain and redness in
the medial canthal region. sometimes a purulent discharge is noted from the
punctum. s. aureus, beta-hemolytic strep are usual organisms. treat with
systemic antibiotic therapy
cataracts occur due to opacification of the lens. and presents with painless
blurring of vision. description of a glare while driving at night is classic
manifestation.
angle closure glaucoma in ppl age 55-70 years. acute onset of severe eye
pain, blurred vision associated with nausea and vomiting. examination reveals
a red eye with steamy cornea and moderately dilated pupil that is non
reactive to light.
treat central retinal a. occlusion with ocular massage and high-flow
oxygen administration. will present with painless monocular loss of vision.
fundoscopy will show diffuse ischemic retinal whitening and cherry red spots.
sympathetic opthalmia is characterized by damage of one eye (the
sympathetic eye) after a penetrating injury to the other eye. it is due to an
immunologic mechanism involving the recognition of hidden antigens.
external hordeolum (stye) is a common staphylococcal abscess of the eyelid.
it is treated with warm compresses. incision and drainage is performed if
resolution does not begin in the next 48 hours.
macular degeneration is the most common cause of blindness in industrialized
nations. activities that require fine visual acuity are usually the first affected and
patients with this condition may report that straight grid lines appear curved.
ocular tonometry is the best test for acute glaucoma (sudden onset of eye
pain, photophobia, and mid-dilated pupil)
atropine is a muscarinic antagonist. do not give in a patient with acute
glaucoma. will dilate the eye. instead use mannitol, acetazolamide,
pilocarpine, or timolol.

pediatrics

henoch-schonlein purpura = IgA mediated vasculitis of small vessels following

URI. rash, arthralgia, abdominal pain, renal disease. Rash on buttocks and
legs. Related to IgA nephropathy.
esophageal atresia occurs with trachoesophageal fistula. air enters stomach ->
distended stomach. acids pass fistula -> pneumonia
compartment syndrome (pallor, pain, paresthesias, poikilothermia,
pulselessness, paralysis) can lead to volkmanns ischemic contracture where
the dead muscle has been replaced with fibrous tissue.
kawasaki's disease - fever with
1) conjunctivitis
2) oropharyngeal changes
3) cervical adenopathy
4) truncal rash
5) changes in distal extremities
fetal hydantoin syndrome - caused by anti-convulsant medications
(phenytoin/carbamazepine). cleft palate, microcephaly, digital hypoplasia,
hirsutism
laryngomalacia is congenital flaccid larynx - causes inspiratory stridor. hold
child upright after feeding and not feed when lying down
conjunctivits after birth:
1 day = chemical
2 - 5 days = gonorrhea
5-15 days = chlamydia
Give oral erythromycin (not topical) to reduce risk of pneumonia
staphylococcal scalded skin syndrome - prodrome of fever. erythema and blisters
with a +nikolsky's sign
gauchers disease is a deficiency of beta-glucosidase. ashkenazi jew with
fatigue (anemia) easy bruising (thrombocytopenia) and pathological
fractures. radiology shows erlenmeyer flask deformity of distal femur and
gaucher cells with wrinkled paper appearance.
fanconi anemia is autosomal recessive disorder presenting with pancytopenia
(macrocytic anemia) and morphological abnormalities. horseshoe kidney,
thumb abnormalities, short stature, abnormal skin pigmentation.
LAD-1 has no CD18 so leukocytes can't exit vessels. no pus formation,
delayed umbilical cord separation. recurrent infections. increased WBC with
high neutrophils
epistaxis, mass, and bony erosion on the back of the nose is angiofibroma
febrile seizure when temp is > 100.4 and age < 6 associated with infection
henoch-schonlein-purpura seen after URI. give steroids and monitor renal
function. abdominal pain -> rule out gastrointestinal bleeding and
intussusception.
duodenal atresia has a "double bubble" sign, jejunal atresia has a "triple bubble"
on abdominal radiographs. will have air fluid levels and a gas-less lower
abdomen.

congenital hypothyroidism has hypotonia, large tongue, sluggish movement,

abdominal bloating, umbilical hernia.
todd's paralysis is a post-ictal condition with motor restoration occuring rapidly
after the seizure
vitamin D rickets has craniotabes (ping pong balls all over occiput), rachitic
rosary (enlargement of costo-chondral junctions), thickening of wrist and
ankles, cupping and fraying at the distal ends of long bones
cri du chat is deletion of 5p. hypotonia, short stature, microcephaly with
protruding metopic suture, moonlike facies, high arched palate, wide and flat
nasal bridges
patients with cystic fibrosis have recurrent pulmonary infections with
Haemophilus, Pseudomonas, Staphylococcus. you want 2 drugs that cover
pseudomonas. (penicillin/cephalosporin + aminoglycoside)
group b streptococcus (S. agalactiae) is most common cause of neonatal
sepsis. normal vaginal flora in women. late-onset presents with meningitis (tx
penicillin G, Amp, Vanc)
C. trachomatis causes follicular conjunctivitis and pannus
(neovascularization) formation in the cornea. Look for pneumonia after
conjunctivitis (no fever, eosinophilia)
all children < 24 months with a febrile UTI should have a renal/bladder
ultrasound to evaluate for any anatomic abnormalities.
infectious mononucleiosis has fever, tonsillar pharyngitis, posterior
cervical lymphadenopathy. (strep pharyngitis has anterior cervical
lymphadenopathy). Given antibiotics after suspected strep infection
(mostly amoxicillin) --> rash
parinaud's syndrome has paralysis of vertical gaze. may have pupillary
disturbances and eyelid retraction. endocrine dysruption by interrupting
hypothalamic inhibiting pathways. due to pinealoma or germinoma.
craniopharyngioma will have bitemporal hemianopsia.
at 12 months child should weigh 3 times their birthweight, and their length should
be 1.5x of initial length.
in foreign body aspiration for a child use direct laryngoscopy with rigid
bronchoscopy because it is diagnostic and therapeutic. for esophagus use
flexible bronchoscopy.
turner syndrome has ovarian dysgenesis and will have high FSH/LH and low
estrogen that gives no negative feedback.
vitamin A for measles reduces morbidity and mortality
posterior urethral valve leads to oliguria. distended bladder filled with
urine. most common cause of congenital urethral obstruction.
umbilical hernia due to poor closure at umbilical ring. soft swelling covered by
skin that protrudes when crying, coughing, straining, and is easily reducible.
most disappear spontaneously but if not then surgery at age of 3 - 4
years, or if enlarges
congenital toxoplasmosis: chorioretinitis, hydrocephalus, intracranial
calcifications. congenital rubella: 1) deafness, 2) cataracts, 3) cardiac
defects.
langerhans cell histiocytosis is a lytic bone neoplasm. painful overlying
bone swelling and hypercalcemia.
serum sickness like reaction is a hypersensitivity reaction after certain
drugs- penicillins cephalosporins, TMP-SMX. occurs after treating viral infection
with antibiotics fever, urticaria, lymphadenopathy, arthralgias (EBV pharyngitis
treated with penicillin for strep pharyngitis)

torus palatinus benign bony growth on the midline suture of the hard
palate.
most common cause of secondary hypertension in children is fibromuscular
dysplasia. hum or bruit in the CVA. angiography shows "string of beads"
pattern in renal artery
waterhouse friderichsen syndrome is characterized by sudden vasomotor
collapse and skin rash due to adrenal hemorrhage. (N. meningitidis)
infants who are small for gestational age at risk for: hypothermia,
hypoglycemia, hypocalcemia, polycythemia, meconium aspiration.
hyaline membrane disease (lungs are deficient in surfactant) presents
with subcostal retraction, nasal flaring, hypoxemia, tachypnea, duskiness within a
few minutes after birth. CXR will show fine reticular granularity of lung
parenchyma.
prolonged labor is a risk factor for cerebral anoxia which can lead to cerebral
palsy
short height, high arched palate, widely spaced nipples and XO is turner
syndrome. patients with turner have a higher risk of osteoporosis because
lower estrogen levels.
recurrent self-limiting episodes of vomiting and nausea in children in the absence
of any apparent cause, suggests cyclical vomiting
oral thrush, lymphadenopathy, hepatosplenomegaly may be the presenting
symptoms of AIDS in infants.
in an infant with congenital diaphragmatic hernia place an orogastric tube
to suction and decompress the bowels and prevent further lung
compression.
to prevent SIDS place infant in supine position while sleeping. (on their backs)
breath holding spells are episodes of apnea (no external breathing) associated
with loss of consciousness. common and self-limited. Reassurance is all that is
needed.
Turcots syndrome is an association between brain tumors (medulloblastoma
and glioma) and FAP or HNPCC.
for patients with cystic fibrosis need double coverage of pseudomonas when
they have pneumonia. use aminoglycoside (gentamycin) + antipseudomonal penicillin.
even with vaccination over 75% of household contacts will develop symptoms
of Bordetella pertussis so give erythromycin for prophylaxis to all
household contacts.
nursemads elbow is also called subluxed radial head, and is one of the more
common injuries in children. occurs when parents pull or lift children from the
arm or hand. child keeps arm in a pronated position. rotating the hand and
forearm to a supinated position with pressure over the radial head reduces the
annular ligament with an audible click and restores normal use of the
extremity.
in gastroschisis the bowel protrudes through a defect on the right of the
umbilical cord. its not covered by any membrane, it looks matted and is not
associated with any other abnormalities. in omphalocele the bowel is
covered by an amnioperitoneal membrane, and can be associated with
other congenital anomalies (chromosome 13/18/21)
transient synovitis is most common cause of hip pain in children. occurs
after viral infection. synovial inflammation leads to pain, decreased range of
motion, and limping. the affected hip is flexed, slightly abducted and externally
rotated. this position maximizes the joint space

in children approx 60% of CNS tumors are infratentorial and 25% are
supratentorial and 15% are in the midline. astrocytomas are the most common
for both supra/and infratentorial.
transposition of great vessels presents with cyanosis in the first 24 hours.
aorta located in front of pulmonary artery, so s2 aortic sound heard better than s2
pulmonic, and heard as a single loud s2 with no murmur.
severe coughing paroxysms may result in subcutaneous emphysema due
to the high intraalveolar pressure provoked by the cough. pneumothorax can
also occur this way, so get CXR to rule out.
fragile x is a CGG trinucleotide repeat disorder. large testicles, long
prominent jaw, autism, large low set ears.
Neisseria gives meningitis with petechial or purpural rash on axilla, wrists, flanks,
ankles.
Wilms tumor usually between ages of 2 - 5. most common primary renal
tumor of childhood. 80% have asymptomatic abdominal mass that does not
cross the midline. symptoms may be: hypertension, hematuria, abdominal pain,
vomiting. may also present with lung mets. associated with beckwithweidemann and denys-drash syndromes. neuroblastoma (neuroendocrine
tumor) will present with pain, fever, weight loss, hepatomegaly and hypertension,
and the crosses midline.
tetralogy of fallot has 1) overriding aorta 2) right vent. hypertrophy 3)
pulmonary stenosis (single s2) and 4) VSD (pansystolic murmur)
in esodeviation which is a type of strabismus, cover the unaffected eye.
Untreated it becomes the preferred eye leading to blindness of the deviated eye.
do cover test child fixes sight on a target and examiner covers eye and checks
for movement. the misaligned eye would shift to refixate.
Riboflavin (B2) deficiency gives you sore throat, hyperemic and edematous
oropharyngeal mucous membranes, cheilitis, stomatitis, glossitis, normocyticnormochromic anemia, seborrheic dermatitis and photophobia.
epiglottitis is caused by Haemophilus influenza type b. presentation includes
abrupt onset of fever, sore throat, dysphagia, drooling. can have airway
obstruction, signs pointing to this include a muffled hot potato voice. keep
neck hyperextended provides some relief.
myotonic muscular dystrophy is autosomal dominant transmission. involves
all types of muscle (smooth, striated, cardiac). slowly develop muscle weakness
and wasting. upper lip will be in shape of an inverted v.
celiac disease can cause kwashiorkor-like clinical features associated with
dermatitis herpetiformis (erythematous vesicles symmetrically distributed
over extensor surfaces of elbows and knees).
hyperIgM syndrome gives recurrent sinopulmonary infections and poor
specific antibody responses to immunizations. will have high IgM and low
other antibodies and B cells.
iron deficiency anemia is common in infants/toddlers who drink excessive
cows milk.
if child swallows a battery and x-ray shows its in the esophagus immediately
remove via endoscopy.
edwards syndrome (trisomy 18) has micrognathia, microcephaly, rocker
bottom feet, overlapping fingers and absent palmar creases. most common
congenital heart problem is VSD.
S. pneumoniae and H. influenzae are the most common causes of acute
bacterial rhinosinusitis. treat with amoxicillin / clavulanate.
immune thrombocytopenia in children after a viral illness presents with
isolated thrombocytopenia. relatively benign condition and will resolve most of

the time. if symptoms are severe and platelets < 30k then give
corticosteroids. (in adults, ITP, tx with IVIG, plasmapharesis) TTP (ADAMST13,
do plasma exchange)
mumps gives bilateral parotitis and orchitis is a serious complication.
cholesteatoma is an ear lesion with continued ear drainage despite
appropriate antibiotics. chronic middle ear disease leads to the formation of a
pocket in the tympanic membrane which can fill with granulation tissue and
skin debris. complications include hearing loss and CN palsies, vertigo, and
infections.
eczema herpeticum is a form of primary HSV that is associated with atopic
dermatitis. umbilicated vesicles over healing atopic dermatitis are typical.
associated with fever and lymphadenopathy. give acyclovir as soon as possible
because this condition is life threatening.
neuroblastoma arises from neural crest cells which are precursor cells of
sympathetic chains and adrenal medulla. calcifications and hemorrhages are
seen on XR and CT scan. levels of serum urine catecholamines and their
metabolites will be increased.
cystic calcified parasellar lesion on MRI in a young boy who has increased
intracranial pressure (headache, vomiting) bitemporal hemianopsia is a
craniopharyngioma.
vaginal foreign bodies should be suspected in children with purulent, foul
smelling vaginal discharge and bleeding, and is treated with irrigation with
warmed fluids
retropharyngeal abscess is a deep neck space infection seen most commonly
in children that ages range 6 mo 6 years. abscess forms by direct spread of
infection from pharyngitis, tonsilitis, otitis, sinusitis or other infections of the
pharynx. recent history of URI followed by constitutional symptoms and sore
throat, dysphagia, muffled or hot potato voice, and neck stiffness.
congenital syphilis- cutaneous lesions on palms, soles,
hepatosplenomegaly, jaundice, anemia, rhinorrhea.
congenital toxoplasmosis has chorioretinitis, intracranial calcifications,
hydrocephalus, congenital rubella has sensorineural hearing loss,
cataracts, heart defects, microcephaly, congenital CMV IUGR, petechia or
purpura, chorioretinitis and periventricular calcifications
increased gastric residual volume in pre-term neonate is highly suspicious for
necrotizing enterocolitis. usually presents 3 - 10 days after birth and is due to
bowel wall injury resulting from perinatal asphyxia.
sepsis in a neonate often presents with hypothermia, jaundice, lethargy and
poor feeding. do blood cultures and a lumbar puncture for all babies suspected of
sepsis
recognize kawasakis disease:
1) fever for > 5 days and 4 of the following:
2) bulbar conjunctival injection
3) desquamation of finger and toe tips, edema
4) erythema fissuring and crusting of lips, strawberry tongue, diffuse mucosal
injection of orpharynx
5) truncal rash
6) cervical lymphadenopathy
polycythemia in an infant manifests with respiratory distress, poor feeding
and neurological manifestations. decreased pulmonary blood flow due to
hyperviscosity of the blood leads to respiratory distress. hypoglycemia is
also seen in polycythemic infants.

manage idiopathic central precocious puberty with GnRH agonist

(leuprolide, -relin) therapy to prevent premature fusion of epiphyseal plates,
which would lead to short stature.
jaundice due to unconjugated hyperbilirubinemia can be due to
1) increased production of bilirubin (hemolysis),
2) decreased clearance of bilirubin (crigler-najjar and gilbert) or
3) increased enterohepatic circulation.
in breast feeding jaundice there is increased enterohepatic circulation
because they are not getting enough milk. treatment is better breastfeeding
techniques.
2 year old child has a vocabulary of 200 words with 50% of their speech being
understandable, three year old has a vocab of around 1000 words and 75% of
their speech will be understandable
a child with dilation of the entire ventricular system with distinct
enlargement of the subarachnoid space over the cerebral cortex is
suggestive of non-obstructing/communicating hydrocephalus secondary to
subarachnoid hemorrhage. SAH is the most common cause of
communicating hydrocephalus. blood accumulation in subarachnoid space
leads to destruction of arachnoid villi and cisterns, blocking flow or
decreasing absorption of CSF. SAH is common in premature infants. dandywalker anomaly shows a cystic expansion of the 4th ventricle, and chiari
malformation reveals protrusion of structures of the posterior fossa
through foramen magnum.
thyroid dysgenesis is the most common cause of congenital
hypothyroidism in the US.
a hydrocele is a fluid collection within the processus or tunica vaginalis the
peritoneal projection that accompanies the testis during its descent into the
scrotum. when it fails to obliterate, peritoneal fluid may accumulate within the
processus vaginalis causing a communicating hydrocele. a collection of fluid
within a tunica vaginalis that has properly obliterated its communication with
the peritoneum is a noncommunicating hydrocele. hydroceles can be
differentiated from other testicular masses by transillumination (hydroceles
transilluminate). most cases resolve spontaneously by the age of 12
months. if they dont resolve spontaneously they should be removed
surgically to reduce the risk of inguinal henia.
slipped capital femoral epiphysis (SCFE) is displacement of the capital
femoral epiphysis from the femoral neck. presents in obese children 10-16
years. insidious onset of dull hip or referred knee pain and altered gait with
no preceding trauma. patients hold hip in passive external rotation and exhibit
decreased internal rotation abduction and flexion. treatment is immediate
surgical screw fixation to reduce risk of avascular necrosis.
pubertal gynecomastia is seen in approx 50% of adolescent boys at an average
age of 14 years. it is often asymmetric or transiently unilateral and frequently
tender. in pre-pubertal males the testicular size is normally 2 cm in length and 3
mL in volume. reassurance and watchful observation.
in legg-calve-perthes disease you have idiopathic avascular necrosis of the
femoral capital epiphysis. xray will show a flattened and fragmented left
femoral head. causes unilateral subacute hip pain in a male child (more
commonly) with progressive antalgic gait, thigh muscle atrophy, decreased
hip range of motion, and collapse of ipsilateral femoral head on plain xr.
gastroesophageal reflux (frequent vomiting after feeding) is common in infants
and can usually be managed with thickened feeds and positioning. pyloric
stenosis would present with projectile vomiting and failure to thrive and
signs of dehydration.

neonatal tetanus is seen in developing countries in infants born to

unimmunized mothers frequently following umbilical stump infection due to
poor obstetric procedures, inadequate postnatal care or cultural practices. onset
is within first two weeks of birth and is characterized by poor suckling and
fatigue, followed by rigidity, spasms, and opisthotonus.
trisomy 21 (downs syndrome) is associated with congenital aganglionic
megacolon (hirschsprung disease). suspect hirschsprung disease in any
neonate with delayed passage of meconium as 99% of full term infants stool
within 48 hours of birth. failed development of enteric nervous system of a
portion of the distal gut and most commonly involves rectosigmoid. affected
segment cannot relax and is chronically contracted. newborns present with poor
feeding, abdominal distention, failure to pass meconium, and biliary
emesis. rectal exam produces an explosive expulsion of gas and stool
(squirt sign) from temporary relief from the obstruction. gold standard is
rectal biopsy demonstrating absence of ganglionic cells.
in tetralogy of fallot, squatting increases systemic vascular resistance
decreasing the right to left shunt across the VSD, making more blood go to the
lungs.
treat intussusception with an air contrast enema. intussusceptions are found
at the ileocolic junction with the ileum telescoping into the colon. presents with
colicky abdominal pain, vomiting, and red currant jelly stools. sausage
shaped mass is often palpated. abdominal radiographs will show air fluid
levels due to obstruction. ultrasound shows a targetoid lesion where one
bowel segment is nested inside another bowel segment.
suspect growing bone pain in a child with nocturnal pain and no obvious
physical or laboratory finding. in all cases the pain resolves in the morning.
Chlamydia is the most common causative agent of infectious neonatal
conjunctivitis. chlamydial pneumonia can develop in infected infants. (give
oral, not topical antibiotic)
midgut volvulus presents in a child < 1 month of age as bilious vomiting,
abdominal distension, and passage of blood stained stools.
anemia of prematurity is the most common anemia in premature and low
birth weight infants. diminished RBC producion, shortened RBC life span,
and blood loss. normocytic normochromic anemia.
constitutional growth delay is the most common cause of short stature and
pubertal delay in adolescents. affected individuals have a normal birth weight
and height, but between 6 months and 3 years of age, the height and
growth velocity slows. around 3 years of age the child regains a normal growth
velocity. puberty and the adolescent growth spurt are delayed, but eventually
occur.
self destructive behavior is usually associated with lesch-nyhan syndrome.
fragile x syndrome has clinical features of autism, mental retardation, an
elongated face and large testes.
juvenile myoclonic epilepsy starts out with absence seizures around the age
of 10 to myoclonic seizures at age 15. then generalized tonic-clonic
seizures.
viral infection is most common cause of pharyngitis in the pediatric
population. low-grade fever makes streptococcal pharyngitis unlikely. absence of
cervical lymphadenopathy makes EBV and group a streptococcus (S.
pyogenes) unlikely. enteroviruses like coxsackie a virus are capable of
producing vesicles on the palate and tonsillar pillars (herpangina)
henoch-schonlein-purpura is known as leukocytoclastic vasculitis. preceded
by URI. has palpable non-blanching symmetric purpuric lesions in the
buttocks/lower extremities. also joint pain which is oligoarticular in the knees

and ankles. abdominal pain and renal failure. skin biopsy shows
leukocytoclastic vasculitis in post-capillary venules with extensive
deposition of IgA.
cough coryza and conjunctivitis with kopliks spots in measles
(paramyxovirus). erythematous macules and papules beginning on the face and
spread down to involve rest of body. roseola infantum is known as exanthem
subitum or 6th disease, caused by HHV6/HHV7. presents with high fever,
periorbital edema and palatal or pharyngeal erythema. lasts 3 - 5 days and
patients can get febrile seizures. skin erupts as fever subsides. rose colored
macules and papules that begin on the neck and trunk and spread to the
face and extremities.
meconium ileus and hirschsprung disease should be considered in any
neonate with delayed passage of meconium as 99% of infants stool within 48
hours of birth. meconium ileus is obstructed at ileum with inspissated (thick,
congealed) consistency of meconium. hirschsprung disease is obstructed
at rectosigmoid junction with normal meconium consistency. meconium ileus
is diagnostic for cystic fibrosis. the meconium will be thick as glue and
difficult to propel, resulting in obstruction at ileum and a narrow underused
colon.
a child who accidentaly takes liquid alkali (oven cleaner) should be managed by
first ensuring there is airway patency. the next step is doing upper
gastrointestinal endoscopy to assess the extent of injury and to dictate
further management. upper GI endoscopy ---> gastrografin if perforation is
suspected (water soluble as Barium will irritate the mediastinum)
neonatal jaundice with (direct) conjugated hyperbilirubinemia is
suggestive of neonatal cholestasis. biliary atresia can cause neonatal
cholestasis. Will have pale stools / dark urine.
edwards syndrome patients have index digit overlapping the 3rd and the 5th digit
overlapping the 4th, rocker bottom feet, prominent occiput, micrognathia and
microcephaly.
VSD is a pansystolic murmur loudest at left lower sternal border. they can also
have diastolic murmurs at the apex because of increased flow across the
mitral valve. (blood from right ventricle returns back to left atrium)
think epiglottitis in a 3-7 year old with acute respiratory distress, toxic
appearance, drooling, stridor and high grade fever. tachycardia and
tachypnea are also present. manage with endotracheal intubation, but also
setup for possible tracheostomy. pre-vaccination it was caused by H. influenzae
type b (hib)
respiratory distress syndrome (hyaline membrane disease) is a respiratory
syndrome caused by immature lungs and surfactant deficiency. most important
risk factor for RDS is prematurity. other risk factors include male sex, c-section
without labor, perinatal asphyxia, and maternal diabetes. cxr will show diffuse
reticulogranular pattern and air bronchograms. presents with tachypnea,
retractions, and physical exam will show signs of distress (grunting, retractions,
tachypnea, nasal flaring, cyanosis)
bacterial sinusitis presents with nasal drainage, congestion, cough.
patients appear ill and have high fevers > 39C/102.2F and purulent nasal
discharge. the most common predisposing factor for acute bacterial sinusitis
is a viral URI. contaminating bacteria cannot be cleared by mucociliary clearance
due to mucosal inflammation from viral infection, leading to secondary bacterial
infection. (S. pneumoniae, H. influenza, M. catarrhalis)
acute otitis media can present with boggy nasal mucosa and post-nasal drip.
ear-drainage and difficulty hearing are highly suggestive of acute otitis

media. confirm with otoscopic examination which typically reveals erythema,

retraction, or decreased mobility of the tympanic membrane.
congenital rubella infection manifests as IUGR, deafness, cardiac
malformations (PDA, ASD), micropthalmia, cataracts, retinopathy,
hepatosplenomegaly, thrombocytopenia, and CNS involvement. chronic
infection may result in growth retardation, radiolucent bone disease, jaundice,
thrombocytopenia and purple skin lesions (blueberry muffin spots). classic
triad is 1) sensorineural deafness 2) cardiac malformations and 3)
cataracts
developmenta dysplasia of the hip (DDH) is a dislocation of the femoral head
from the acetalbulum. breech presentation, female sex, white ethnicity, and
family history of DDH increase the risk, most patients have no risk factors.
barlow and ortolani maneuvers should be performed to assess joint stability.
inguinal skin folds should also be inspected as extension beyond the anal orifice
suggests dislocation of the ipsilateral femoral head. at age 2 weeks 6 months
do hip ultrasound. after 4-6 months do x-ray of hip. shows better because
of ossification.
squatting increases systemic peripheral resistance, decreasing the right to
left shunt, and improves the cyanosis of tetralogy of fallot (ToF). tet spells
can be brought on by infection, crying, and exercise. severe tet spells may
precipitate seizures and loss of consciousness. immediate treatment is
administration of oxygen and placing child in a knee-chest position,
followed by fluids, morphine and propanolol.
viral uri are the most common predisposing factor of acute bacterial
rhinosinusitis. uncomplicated acute bacterial rhinosinusitis should be treated
with oral amoxicillin-clavulanic acid. features include 1) persistent symptoms
> 10 days without improvement OR 2) severe symptoms (fever>39C/102F),
purulent nasal discharge, face pain > 3 days, OR 3) worsening symptoms > 5
days after initially improving viral uri.
fetal alcohol syndrome is characterized by 3 pathognomonic facial
dysmorphisms: 1) small palpebral fissures 2) smooth philtrum (vertical
groove above upper lip) 3) thin vermilion border. fragile x has a long
narrow face with large ears and macrocephaly and macroorchidism.
infections after 6 months of age suggestive of genetic b-cell deficiency
because thats when maternal antibody levels start to drop. predisposed to
recurrent sinopulmonary infections with encapsulated organisms like H.
influenzae and S. pneumoniae.
deficiency in IgA which inhabits the gastrointestinal tract predisposes to
Giardia infection. patients with SCID have both B- and T- cell deficiencies
and would get bacterial, fungal and viral infections as well.
digeorge (thymic hypoplasia) is a T-cell deficiency only, would get
viral/fungal infections.
patients with x-linked agammaglobulinemia (brutons
agammaglobulinemia) have low B cells (cd19 lymphocytes). patients
should receive intravenous immunoglobulins.
neurofibromatosis 1 has cafe-au-lait spots, axillary freckles, lisch nodules
of the iris, neurofibromas and bony lesions.
sturge weber has port wine stains in V1 face region, angiomatous
malformations of the brain, seizures, hemiparesis
tuberous sclerosis has ash leaf hypopigmentation, cardiac
rhabdomyomas, kidney angioleiomyomas, mental retardation, retinal
hamartomas, and seizures.
do guthrie test (coloration) to detect the presence of metabolic products of
phenylalanine in the urine. phenylketonuria has a phenylalanine hydroxylase

deficiency, leads to the accumulation of phenylalanine. urine will have a

mousy odor, and will be fair skinned.
friedreich ataxia is autosomal recessive condition characterized by excessive
trinucleotide repeat sequences. associated with necrosis and degeneration of
cardiac muscle fibers leading to myocarditis, myocardial fibrosis, and
cardiomyopathy. T-wave inversion: myocardial infarction, myocarditis, old
pericarditis, myocardial contusion, digoxin toxicity.
sturge-weber syndrome is a neurocutaneous syndrome that is
characterized by a congenital unilateral cavernous hemangioma along the
trigeminal nerve distribution and radiographic evidence of intra-cranial
calcifications that resemble a tramline. seizures are the normal neurological
presentation.
mongolian spot is common among dark skinned races. the cause is
entrapment of melanocytes in the dermis during their migration from the
neural crest into the epidermis in fetal development. the lesion is a blue, bluishgray, bluish-green or blue-black, flat skin markign that usually appears at birth.
mostly located at base of spine, lower back, and on the buttocks.
painless rectal bleeding in a young child is often meckels diverticulum. do
a technetium-99m pertechnate scan
milk protein intolerance may present with vomiting and bloody diarrhea.
stool may show RBCs and eosinophils and there may be family history of an
atopic disorder. its a hypersensitivity reaction to cows milk proteins and
usually occurs in babies who are fed with cows milk. however may occur in
breastfed babies as the mothers milk may contain proteins from ingested cows
milk.
meconium ileus is characterized by bilious vomiting, failure to pass
meconium at birth, history of polyhydramnios, family history of cystic fibrosis,
and a ground glass appearance on abdominal xr. a possible complication of
meconium ieus is intestinal perforation. if the perforation occurs after birth
pneumoperitoneum will be seen on abdominal xr. if it occurs before birth,
intraabdominal calcifications will be seen. meconium plug syndrome is the
same thing but in babies without cystic fibrosis and intestinal perforation does not
occur.
iron supplementation in the form of oral ferrous salts or iron fortified milk
formula is warranted in premature infants to prevent anemia of
prematurity.
metatarsus adductus is a congenital foot deformity. most frequent in first-born
infants; attributed to the molding effect of the primigravid uterus. internal tibial
torsion is also a physiological finding in newborns. reassurance is all that is
needed. know when to give reassurance !
tricuspid atresia (no tricuspid valve) presents with a cyanotic infant with left
axis deviation. absent connection between the right heart cavities, and a
hypoplastic or absent right ventricle. VSD (holosystolic murmur) occurs in
90% of cases. there is left ventricular hypertrophy and since the left ventricle
is getting all the blood from the right atrium. blood goes from ra --> la --> lv -->
rv --> pulmonary --> back to la. treatment is PGE1 and balloon atrial
septostomy.
legg-calve-perthes disease is characterized by osteonecrosis of the
femoral head. typically presents in 4-10 y/o with insidious-onset hip and/or
knee pain and an antalgic gait. idiopathic avascular necrosis
thrombocytopenia with eczema and a history of bacterial infections is
characteristic of wiskott-aldrich syndrome (WAS). decreased platelet
production is the primary pathophysiologic cause of thrombocytopenia in
patients with was.

idiopathic thrombocytopenic purpura (ITP) is an immune-mediated disorder

caused by antibodies that bind to platelets and facilitate their removal
from the circulation. preceded by a viral infection. Treat ITP with steroids or
IVIG if severe.
von gierkes disease (type 1: glucose-6-phosphatase deficiency) is 3-4
months of age with hypoglycemia, lactic acidosis, hyperuricemia, and
hyperlipidemia. the characteristic is a doll-like face (fat cheeks), thin
extremities, short stature, and a protuberant abdomen (enlarged liver
and kidneys). hypoglycemic seizures may occur.
pompes disease (type 2: acid maltase) have hepatomegaly, and present
as a floppy baby with feeding difficulties, macroglossia, and heart
failure due to hypertrophic cardiomyopathy.
type iii/glycogen debranching enzyme, with a similar presentation as type
1, however their lab findings differ. they have elevated transaminases, fasting
ketosis, and normal blood lactate and uric acid concentrations.
splenomegaly but normal kidneys.
type 4 is amylopectinosis. presents in the first 18 months of life with
hepatosplenomegaly and failure to thrive. progressive cirrhosis of the
liver.
ewings sarcoma is a highly malignant tumor found in the lower extremity
more ofen than upper. most common sites are metaphysis and diaphysis of
femur, followed by tibia and humerus. aggresive and mets early to lungs and
lymph nodes. white males in their 10s-20s. patients may initially be
diagnosed with osteomyelitis because of intermittent fevers, leukocytosis,
anemia, and elevated ESR. but radiologically is characterized with a lamellated
appearance or onion skin periosteal reaction. lesion is usually lytic,
central, and accompanied by endosteal scalloping. onion skin appearance is
often followed with a moth-eaten or mottled appearance and extension into
soft tissue. treatment is surgery, radiation, and multi drug chemo.
interventricular hemorrhage is commonly seen in premature and low birth
weight infants. bleeding from the germinal matrix. incidence of IVH is
inversely proportional to birth weight. patients may present with pallor, cyanosis,
hypotension, seizures, focal neurological signs, bulging or tense fontanelle,
apnea, and bradycardia. many cases remain asymptomatic mandating
transfontanelle ultrasound for all newborns with predisposing risk
factors.
children w/ selective mutism are verbal and talkative at home but refuse to speak
in select settings.
erythema toxicum neonaturm is a benign, self limited condition in newborns
characterized by an evanescent rash with red haloes, and eosinophils in
the skin lesions. erythematous papules and vesicles surrounded by patches of
erythema.
urine dipstick can be positive for protein in 10% of school aged children.
can be transient, orthostatic, or persistent. transient can be caused by fever,
exercise, seizures, stress, volume depletion. orthostatic has increased protein
when patient is upright that returns to normal when patient is recumbent. if
urinalysis shows no hematuria and is otherwise normal repeat dipstick x2. if
negative then its transient proteinuria. usually benign condition. if proteinuria
persists then take to pediatric nephrologist.
maternal HIV infection is absolute contraindication to breastfeeding.
hospitalize patients with anorexia nervosa when there is evidence of medical
complications (amenorrhea) and/or when they weigh < 75% of avg body
weight for age sex and height.

Scarlet fever caused by group a streptococcus (S. pyogenes) that makes

erythrogenic exotoxins. may follow strep pharyngitis, wound infections,
burns, or strep skin infection. fever, chills, abdominal pain, pharyngitis. the
rash initially appears on the neck, axillae, and groin within 12 48 hours
and generalizes within 24 hours. punctate or finely papular texture which is
sometimes readily palpable sandpaper like. pharynx is erythematous
swollen and may have gray-white exudates. area around mouth appears
pale in comparison with the extremely red cheeks giving the appearance of
circumoral pallor
slipped capital femoral epiphysis is characterized by displacement of
femoral head on the femoral neck due to disruption of the proximal femoral
growth plate. seen in obese adolescent boys. groin or knee pain and limping.
as the hip is flexed the thigh goes into external rotation. knee pain is also a
common presentation. treat with surgical pinning of the slipped epiphysis in
order to decrease the risk of avascular necrosis.
medulloblastoma is the 2nd most common infratentorial tumor in children and
arises from the vermis. posterior vermis syndrome causes truncal
dysataxia.
characteristic features of neurofibromatosis 1, lisch spots in eyes include
cafe-au-lait spots, macrocephaly, feeding problems, short stature and
learning disabilities. patients may later develop fibromas, neurofibromas or
different tumors. neurofibromatosis type 2 has bilateral acoustic neuromas
and cataracts.
Reye syndrome (microvesicular changes) is seen in children < 15 years old
who were treated with salicylates for a viral infection. hyperammonemia,
normal or slightly elevated bilirubin and ALP, prolonged PT, hypoglycemia, and
moderate to severe elevations in AST/ALT/LDH.
croup is caused by parainfluenza virus and commonly presents in children < 3
with hoarseness, a barking cough,, and varying degrees of respiratory distress.
lateral xr shows (steeple sign) subglottic narrowing. give nebulized
epinephrine c is above e in alphabet. steeple (the top of building) is above
thumb (seen in epiglottitis)
turner syndrome should be considered in newborns with a webbed neck, high
palate, short fourth metacarpal and nail dysplasia. lymphedema frequently
occurs due to abnormal development of the lymphatic system.
all patients with a clavicular fracture should have a careful neurovascular
examination to rule out injury to the underlying brachial plexus and subclavian
artery. midshaft fracture = radial nerve epicondylar fracture = brachial artery
anterior shoulder dislocation = axillary nerve
clubfoot is initially managed with stretching and manipulation of the foot,
followed by serial plaster casts, malleable splints, or taping. surgical
treatment is indicated if conservative management gives unsatisfactory results
and is preferably performed between 3-6 months of age.
female infants < 3 months of age sometimes develop vaginal spotting or
bleeding. maternal estrogens crossing placenta entering fetal bloodstream
causing a pubertal effect in the newborn which disappears when the hormone is
cleared from the infants circulation.
if have a high lead on fingerstick, do serum testing to confirm for lead poisoning.
infant with failure to thrive, bilateral cataracts, jaundice, hypoglycemia and
hepato/splenomegaly most likely has galactosemia. caused by galactose-1phosphate uridyl transferase deficiency, leading to elevated levels of galactose.
Galactokinase deficiency = only cataracts
respiratory syncytial virus infection may increase the risk of asthma later
in life. RSV causes bronchiolitis.

in pyloric stenosis a mass will not always be palpable. do ultrasound of the

abdomen to establish diagnosis in an infant who is having projectile vomiting
that is non bilious.
niemann-picks disease/sphingomyelinase. presents with hypotonia,
hepatosplenomegaly, cervical lymphadenopathy, protruding abdomen and a
cherry red spot on retinal examination.
tay sachs disease/hexosaminidase A. characterized by hyperacusis,
hyperreflexia, MR, seizures, cherry red macula, but not hepatosplenomegaly or
cervical lymphadenopathy.
glucocerebrosidase deficiency/gauchers disease. hepatosplenomegaly,
anemia, leukopenia, and thrombocytopenia, but no cherry red macula.
galactocerebrosidase/krabbes disease. hyperacusis, irritability and
seizures.
(the gs dont have cherry red macula. Niemann picks his nose so he has
hepatosplenomegaly)
in chronic granulomatous disease there is a deficiency of the NADPH
oxidase enzyme so you get recurrent infections of catalase+ organisms: S.
aureus, Serratia, Burkholderia, Klebsiella, Neisseria, candida, pseudomonas,
nocardia, TB, cepacia, diphtheria, Aspergillus. most common clinical findings are
lymphadenopathy, hypergammaglobulinemia, hepatosplenomegaly, anemia
of chronic disease, chronic diarrhea, gingivitis and dermatitis. the diagnosis can
be made by the nitroblue tetrazolium (nbt) test which will be negative
(abnormal). treatment is tmp-smx prophylaxis and gamma-interferon. Bone
marrow transplant can be curative
Mccune-Albright syndrome is a rare condition characterized by 1) precocious
puberty, 2) cafe au lait spots and 3) multiple bone defects (polyostotic
fibrous dysplasia). may be associated with other endocrine abnormalities like
hyperthyroidism, prolactin/GH secreting pituitary adenomas, adrenal
hypercortisolism. three Ps: precocious puberty, pigmentation, polyostotic
fibrous dysplasia
bed wetting is normal upto 4 - 5 years. after that use bed alarms, and then
desmopressin

psychiatry

pseudodementia in elderly patients with severe depression. treatment is SSRI

inquire about stressors in hypochondriacs
NMS has fever, encephalopathy, autonomic instability, very high CK,
rigidity, use bromocriptine or dantrolene.
alcohol withdrawal has hallucinations, hypertension, hyperthermia,
agitation. treat with long acting benzodiazepines such as chlordiazepoxide
(Librium).
use SSRI as first line treatment for OCD (Tourettes is associated with it)
schizophrenia has 4 types 1) paranoid (delusions and hallucinations) 2)
disorganized (early onset and worst prognosis, wears weird hats, disinhibited
behavior) 3) catatonic (stupor/rigidity, but can also be highly excited and

figitidy) 4) undifferentiated and residual (mostly negative symptoms) when

they are no longer actively psychotic.
Acute pyschosis: treat with IM olanzapine (less side effects than Haldol) or
ziprasidone
Long acting injectable: use risperidone
for panic attacks use benzodiazepine for acute treatment, and SSRI for
long-term relief.
delayed sleep phase syndrome is a circadian rhythm disorder
characterized by inability to fall asleep at normal bedtimes. fall asleep late.
lithium toxicity presents with tremor, hyperreflexia, ataxia, seizures.
phenytoin toxicity presents with horizontal nystagmus, cerebellar ataxia,
and confusion. benzodiazepine overdose does not have nystagmus.
restless leg syndrome presents with uncomfortable sensation in the legs
alleviated by moving your legs (can happen at night where you cant fall asleep).
treated with dopamine agonists (pramipexole/ropinerole)
in altruism there is no overcompensation of the persons response with the
opposite reaction of how they actually feel. reaction formation is the complete
opposite response of what they actually feel, but in altruism they wish to help
people in a positive way.
when patients have renal dysfunction use carbamazepine or valproic acid
instead of lithium for bipolar disorder.
antipsychotic meds like risperdone are dopamine antagonists and can cause
hyperprolactinemia, leading to symptoms such as galactorrhea, gynecomastia,
menstrual dysfunction, and decreased libido.
olanzapine can be used for long-term maintenance of bipolar
disorder/mania. haldol can be used for acute mania. (in patients with renal
dysfunction use carbamazepine or valproic acid)
treatment for adjustment disorder is cognitive or psychodynamic psychotherapy.
the extrapyramidal side effects of antipsychotics can be treated with
anticholinergics like benztropine.
a single manic episode requires long-term maintenance of lithium for a
period of at least 1 yr. 3 or more relapses requires treatment with lifelong
maintenance therapy.
all atypical antipsychotics (including olanzapine) can cause weight gain,
hyperglycemia, dyslipidemia and hypertension.
risperidone (atypical antipsychotic) is a dopamine and serotonin antagonist
that can cause weight gain and hyperprolactinemia, the latter of which can
lead to amenorrhea and galactorrhea.
antipsychotics cause hyperprolactinemia by blocking dopamine activity
along the tuberoinfundibular pathway.
an important side effect of buproprion is decreased seizure threshold.
absolutely contraindicated in people with seizure disorders. individuals with
anorexia or bulimia frequently develop electrolyte abnormalities that can
precipitate seizures.
opioid intoxication presents with miosis, depressed mental status, decreased
respiratory rate, decreased bowel sounds, hypotension, bradycardia.
social phobia is best treated with assertiveness training/gradual exposure
therapy and an SSRI.
risperidone is 1st-line atypical antipsychotic for schizophrenia. clozapine is
reserved for patients who have had serious side effects from and/or who have not
responded to trials of other antipsychotics. atypicals work by blocking
dopamine and 5-HT2 receptors and have less EPS effects but more endocrine
effects (dm, weight gain). clozapine can cause agranulocytosis.

altered levels of the neurotransmitter serotonin play an important role in the

development of obsessive-compulsive disorder. (ocd is treated with SSRI)
tourettes syndrome is best treated with traditional antipsychotics like
haloperidol or risperidone (atypical antipsychotic) or pimozide.
ADHD: treat with atomoxetine
lithium toxicities include: nephrogenic diabetes insipidus,
hypothyroidism, and ebsteins anomaly in the fetus.
SSRIs and SNRIs are the 1st line medications for treating generalized anxiety
disorder (can use Buspirone and Venlafaxine)
abrupt cessation of a short acting benzodiazepine (Xanax, alprazolam) is
associated with significant withdrawal symptoms such as generalized seizures
and confusion.
Parents are NOT allowed to refuse life saving treatment in a child. Go get a court
order for those assholes

pulmonary
lobar pneumonia = increased tactile fremitus, bronchial breath sounds,
dullness to percussion
pleural effusion/hemothorax = decreased tactile fremitus, decreased breath
sounds, dullness to percussion
pneumothorax/copd = decreased tactile fremitus, decreased breath sounds,
hyperresonant to percussion

in COPD you get chronic hypoxemia -> pulmonary vasoconstriction ->

pulmonary hypertension -> right ventricular hypertrophy -> right
ventricular failure -> hepatosplenomegaly/ascites/elevated
jvp/peripheral edema
acute pulmonary embolism causes hypoxia and respiratory alkalosis.
severe asthma exacerbation will cause respiratory acidosis due to air
trapping and CO2 retention. aspirin intoxication causes a mixed respiratory
alkalosis and metabolic acidosis.
hypoventilation gives respiratory acidosis with high PCO2
CO toxicity causes anion gap metabolic acidosis/lactic acidosis. decreased
delivery of O2 to tissues
sarcoidosis has anterior uveitis (wbc in anterior chamber), hilar adenopathy and
reticulonodular infiltrates, can also cause SIADH
ARDS has intrapulmonary shunting, and the hypoxia is typically refractory
to oxygen administration
if moderate to high suspicious of DVT, do ultrasound first before anti-coagulation.
if low suspicion (want to rule out) do d-dimer. if d-dimer is negative you can rule
out clot. high sensitivity. sn-out
S. aureus can cause post-viral URI necrotizing pulmonary
bronchopneumonia with multiple nodular infiltrates that can cavitate to
cause small abscesses.

finger clubbing is not associated with COPD. suspect malignancy in COPD +

finger clubbing
subacute < 3-8 weeks and chronic > 8 weeks cough seen frequently in adults. 1)
postnasal drip 2) GERD 3) asthma cause 90% of cough w/ no pulmonary disease.
if cough after URI most likely post nasal drip. treat with 1st gen anti-histamine:
chlorpheniramine
in a parapneumonic effusion, if the pH < 7.2 the probability is very high that this
fluid needs to be drained, it is an empyema. glucose < 60 is also an indication
for this.
laryngeal edema presents with acute-onset dyspnea. due to allergies, similar
to asthma attack but with dysphagia
pulmonary contusion presents with tachypnea tachycardia, and hypoxia. will
have decreased breath sounds on the side of the contusion. CXR will reveal
patchy, irregular, alveolar infiltrate. ABG will show hypoxemia. (ARDS would
be bilateral patchy alveolar infiltrates)
complications of ventilation with high PEEP include: alveolar damage, tension
pneumothorax and hypotension. tension pneumothorax will present with sudden
onset shortness of breath, hypotension, tachycardia, tracheal deviation and
unilateral absence of breath sounds.
asbestosis is a pneumoconiosis and presents as dyspnea, digital clubbing and
bibasilar end-inspiratory crackles. can develop cor pulmonale. CXR can show
pleural plaques. will have decreased DLCO (interstitial lung disease)
in patient with acute exacerbation of COPD which is refractory to management
with oxygen, corticosteroids, bronchodilators, try non-invasive positive
pressure ventilation before you try to intubate and mechanically ventilate if the
patient is not crashing.
normal PCO2 indicates a severe asthma attack. it indicates CO2 retention
because of airway obstruction (air trapping) and/or respiratory muscle fatigue.
also silent lungs, cyanosis, and altered sensorium indicate this. PCO2 should be
low because of hyperventilation and respiratory alkalosis
right atrial pressure > 10mmhg and systolic pressure >40mmhg are used to
diagnose massive PE. septic shock has decreased right atrial pressure and warm
extremities.
sarcoid has hilar adenopathy and non-caseating granulomas. treat with
steroids.
Lights criteria:
1) pleural protein/serum protein > 0.5
2) pleural LDH/serum LDH > 0.6
3) pleural fluid LDH > 2/3 upper limit of normal for serum LDH
exudative effusions are due to: infection, malignancy, pulmonary embolism,
connective tissue disease, and iatrogenic
bronchoalveolar lavage (BAL) is useful for malignancy and opportunistic
infections. >90% sensitive for PCP, but not as diagnostic in other lung diseases
like sarcoid, interstitial pulmonary fibrosis, or connective tissue diseases.
carbon monoxide poisoning presents with headache, nausea, dizziness and has
high hematocrit due to no unloading of oxygen, so body makes more red blood
cells
hypersensitivity pneumonitis is inflammation of lung parenchyma caused by
antigen exposure. acute episodes present with cough, breathlessness, fever, and
malaise. chronic exposure can cause weight loss, clubbing, and
honeycombing of the lung. Tx: remove source, should go away
low glucose concentration in exudative effusions is due to high metabolic
activity of leukocytes within the pleural fluid. pH < 7.2, glucose < 30 suggests

empyema or rheumatic effusion. Glucose values of 30-50 suggests malignancy,

lupus, esophageal rupture, or tb.
cardiomyopathy due to hemochromatosis can be reversed if caught early,
however sarcoid, scleroderma and amyloidosis can not.
criteria for long term O2 supplementation in COPD patients are: PaO2 < 55,
SaO2 < 88, hematocrit >55, or evidence of cor pulmonale. shown to
prolong survival
acute exacerbation of COPD treated with: inhaled nebulized
bronchodilators and systemic steroids.
in an acute COPD exacerbation alveolar hypoventilation leads to hypoxia and
hypercapnia. avoid sedatives as they can exacerbate alveolar hypoventilation,
which can cause CO2 retention leading to lethargy, somnolence, seizures, coma,
and death.
anti-pneumococcal quinolones like levofloxacin or moxifloxacin are drugs of
choice for in-patient treatment of community acquired pneumonia. for
outpatient therapy use azithromycin or doxycycline.
patients with severe obesity (BMI > 55) and alveolar hypoventilation during
wakefulness have obesity hypoventilation syndrome (Pickwickian
syndrome). ABG will reveal respiratory acidosis, hypercapnia and hypoxemia.
due to a consequence of decreased chest wall compliance.
adenocarcinoma of the lung has the least association with smoking. this is
the most common type of lung cancer even in smokers. located peripherally
and consists of columnar cells growing along the septa. it presents as a
solitary nodule and may be detected incidentally.
large lung volumes and diaphragmatic flattening in COPD make it more
difficult to decrease intrathoracic pressure during inhalation and thus
increasing the work of breathing.
secondary pneumothorax should be suspected in COPD patients presenting
with worsening of their respiratory symptoms and is usually due to dilated
alveolar blebs that rupture air into the pleural space. symptoms include
acute onset of unilateral chest pain, shortness of breath, and on the
affected side breath sounds are markedly reduced and the chest is
hyperresonant to percussion.
use lights criteria to determine if pleural fluid is exudate or transudate. then
determine if the fluid is complicated or uncomplicated. complicated fluid has a
+ gram stain, + culture, ph < 7.2, and glucose < 60 and requires chest
tube drainage because it is unlikely to resolve spontaneously with antibiotic
therapy. complicated effusions can progress to empyema. infection
(pneumonia) is a much more likely cause of complicated parapneumonic effusions
than pulmonary embolism.
the development of clubbing and sudden-onset joint arthropathy in a
chronic smoker is suggestive of hypertrophic osteoarthropathy. this condition
is often associated with lung cancer, so do a CXR.
massive pulmonary embolism leads to syncope, right bundle branch block
due to acute right heart strain, jugulovenous distension. right heart strain will
progress to right ventricular dysfunction, decreased CO, left pump failure,
resulting in bradycardia. results in cardiogenic shock and CNS effects like
dilated pupils and unresponsive mental status.
suspect lung cancer in smokers who present with Horners syndrome. do a
CXR
causes of exudative pleural effusion: empyema, malignancy, rheumatoid
arthritis, esophageal rupture, pancreatitis, pulmonary infarction, and
tuberculosis. only TB is associated with a very high total protein, > 4g/dl.

tension pneumothorax has lack of breath sounds on one side, tracheal deviation
to the opposite side. leads to rapid development of hypotension because of
high intrathoracic pressures decreasing venous return/decreasing preload.
treatment consists of placing a large-bore needle in the 2nd intercostal
space in mid-clavicular line of the affected side to rapidly decompress the
pneumothorax and improve venous return.
know how to identify tension pneumo on CXR. faint white line (visceral
pleura) near the midline beyond which no pulmonary vasculature or lung
parenchymal markings are apparent. also usually flattening of the ipsilateral
hemidiaphragm. hemothorax and pleural effusion have similar appearances
on cxr: blunting of costophrenic angle and opacify the entire ipsilateral
chest.
apical lung tumor in thoracic inlet can compress cervical and thoracic nerve
roots that contribute to the ulnar nerve causing pain, numbness, and
weakness in ipsilateral arm. (look for radioopaque lesion in the apex)
granulomatosis with polyangiits (wegeners) is a form of granulomatous
vasculitis. renal and pulmonary symptoms are seen with goodpastures and
wegeners but upper airway and sinus are only seen with the latter. can
have systemic symptoms of weight loss, anorexia, and arthralgias as well. churgstrauss has asthma and eosinophilia.
in a patient with rapid, ongoing, massive hemoptysis >100-600ml in a 24hour period, intubate the patient to protect the airway and place the bleeding
lung in the dependent position to preserve gas exchange in the non-bleeding
lung. then give fluids and perform an emergent bedside bronchoscopy to both
visualize the lesion and control the bleeding.
intubate ---> fluids --->
bronchoscopy for bleeding control
exudative effusions are caused by increased capillary permeability.
transudates are caused by increased hydrostatic or decreased oncotic
pressure.
patients with obstructive sleep apnea have episodes of short-term hypoxemia
which is sensed by the kidneys and stimulates erythropoietin production.
this drives creation of more RBCs and results in polycythemia.
chronic and recurrent cough with mucopurulent expectoration most likely due
to bronchiectasis. will have recurrent infections producing cough responding to
antibiotics. chronic bronchitis has non-purulent expectoration. highresolution CT of the chest is the best imaging modality for diagnosing
bronchiectasis.
criteria for asthmamild intermittent: daytime symptoms < 2/week, nighttime awakenings <2
month, no limit on daily activites treatment is prn albulterol
mild persistent: symptoms > 2 days/week but not daily, nighttime awakenings
3-4/month, minor limit on ADL treatment is prn albuterol + inhaled
corticosteroid
moderate persistent: daily symptoms, weekly nighttime awakenings, moderate
limit on ADL and FEV1 60-80% treatment: daily inhaled corticosteroid or
cromolyn/nedocromil or methylxanthine or antileukotriene
severe persistent: symptoms throughout the day, frequent nighttime
awakenings, extremely limited ADLs, FEV1 <60% treatment: long acting betaagonist and high-dose inhaled corticosteroids and systemic corticosteroid
emphysema is a pathological diagnosis characterized by permanent and
destructive enlargement of airspaces distal to the terminal bronchioles
with loss of normal architecture. patients are generally severe and dyspneic
(pink puffers) and have hyperinflation of the chest, decreased vascular
markings, decreased DLCO (due to destruction of alveoli). panacinar

emphysema is typical for alpha-1-antitrypsin deficiency. centriacinar is more

characteristic for COPD. DLCO is normal in chronic bronchitis. chronic
bronchitis is a clinical diagnosis of chronic productive cough for at least 3 months
over 2 consecutive years.
most common adverse effect of inhaled corticosteroid therapy is
oropharyngeal thrush (oral candidiasis)
fever, confusion, decreased food intake, and +cultures points toward sepsis.
sepsis can cause ARDS. ARDS causes hypoxemia refractory to high
inspired oxygen concentrations. adequate oxygenation in ARDS often requires
positive end-expiratory pressure (PEEP) delivered via mechanical ventilation. try
to keep inspired O2 below 40%.
tension pneumothorax presents with decreased breath sounds, tachypnea,
tracheal deviation. treat with needle thoracostomy emergently.
obesity hypoventilation syndrome (OHS) is a long-term consequence of severe
obesity and untreated obstructive sleep apnea. chronic hypercapnic/hypoxic
respiratory failure, secondary erythrocytosis, and pulmonary hypertension. will
have respiratory acidosis, leading to an increased bicarbonate retention
and decreased chloride reabsoprtion in a compensatory effort to maintain a
normal pH.
a fixed upper airway obstrution (such as laryngeal edema) will show a
distinctive flow-volume loop. there is a flow limitation with both
inspiration (below the horizontal line) and expiration (above the horizontal
line). looks like an oval sideways.
v/q mismatch caused by: pulmonary embolism, obstructive lung disease,
atelectasis, pulmonary edema, pneumonia. shunt caused by intracardiac
shunt (VSD). shunt doesnt get better with O2. (n in shunt and n in not
better) they both have increased A-a gradient. hypoventilation and
decreased inspired O2 do not cause an increased A-a gradient.
in a steady resting state the respiratory quotient (RQ) near 1.0 suggests carbs are
the major nutrient being oxidized. when the ratio rises its due to excess carbs.
protein gives RQ of 0.8 and fats gives 0.7
solids in the lung make sounds travel faster so consolidation (lobar pneumonia)
has increased tactile fremitus. air or fluid outside the lung interrupts this
transmission of sound. patients with consolidated lungs have bronchial breath
sounds due to over-transmission of sound over the chest wall. breath sounds are
absent or diminished over pleural effusion, pneumothorax and COPD.
moving from supine to sitting can increase the FRC by 20 35%. increasing
the FRC can help prevent post-op atelectasis.
inhaled anti-muscarinic agents such as ipratropium are the mainstay of
symptom management in COPD.
lung consolidation causes bronchial breath sounds, dullness to percussion,
increased fremitus, bronchophony, egophony, and whispered pectoriloquy on
physical exam. bronchial breath sounds have a full exipratory phase.
aspiration pneumonia has foul-smelling sputum and is caused by excessive
alcohol intake. other risk factors are altered consciousness, dysphagia,
neurologic disorders, and sedative procedures.
causes of restrictive lung diseases include interstitial lung disease,
neuromuscular disease, alveolar edema, pleural fibrosis and chest wall
abnormalities. restrictive pattern may be caused by ankylosing spondylitis.
inflammation leads to fusion of the costovertebral joints resulting in
restriction of chest wall motion. will have normal or increased FRC due to fixation
of the chest wall in an inspiratory position.

the next step in investigational step of a solitary pulmonary nodule detected

on CXR is usually a CT scan. if CT is suspicious for malignancy or indeterminate
then do further investigation with a biopsy or PET scan.
carbon monoxide poisoning presents with headache, nausea, abdominal
discomfort. pinkish-red skin hue is noted on examination and diagnosis is
confirmed by carboxyhemoglobin levels.
in ventilated patients respiratory alkalosis can result from hyperventilation. if the
tidal volume is appropriate (6 mg/kl of body weight) the respiratory rate
should be lowered. reducing the tidal volume can trigger increased ventilatory
rate.
COPD can lead to cor pulmonale. will have elevated JVP, hepatomegaly and
peripheral edema with clear lung sounds. loop diuretics are often used to
lower right ventricular filling volumes and reduce peripheral edema (in
patients with COPD exacerbations). loop diuretics can cause decreased CO in
patients with cor pulmonale, leading to pre-renal azotemia (elevated BUN/Cr)
and bicarbonate will go down secondary to a metabolic acidosis from uremia
lambert eaton can be associated with small cell carcinoma of the lung.
autoantibodies to presynaptic voltage gated calcium channels.
ARDS patients typically are given PEEP and high FiO2 (80%ish) but then the
ventilator settings should be adjusted to decrease FiO2 to nontoxic values
slowly lower below 60%
the A-a gradient is increased in interstitial lung disease due to reduced
diffusion capacity and V/Q mismatch. CXR in idiopathic pulmonary fibrosis
(IPF) will show airway fibrosis giving a honeycomb pattern, and
pulmonary vascular congestion most evident in the hilum.
use lights criteria to determine if transudate or exudate. ph of 7.35 is consistent
with transudative pleural effusion.
pleural plaques are seen in 50% of asbestosis cases on XR. helps to distinguish
from other cases of pulmonary fibrosis. most common malignancy in asbestosis is
bronchogenic carcinoma. pleural mesothelioma can also occur due to
asbestosis exposure but it has a lower incidence and occurs in the pleura, not
in the lung fields.

surgery

pain relief and respiratory support are important in rib fracture trauma to
prevent hypoventilation and atelectasis
blunt abdominal trauma can cause splenic injury. left shoulder pain (referred
from diaphragm, kehr's sign). do abdominal ct with contrast
rhinoplasty can cause nasal septum perforation leading to a whistling noise
while breathing.
in blunt abdominal trauma if hemodynamically unstable, do fluid
resuscitation and ultrasound (FAST). if blood found intra-peritoneally on
FAST then do laparotomy.
post-operative atelectasis has hypoxemia and respiratory alkalosis
(hyperventilation, not deep enough breathings)

inflammation of diaphragm and peritonitis refers to the upper left shoulder

post-op cholestasis happens in surgeries with hypotension and blood
transfusions.
1) increased pigment load due to the transfusion
2) decreased liver function due to hypotension
3) decreased renal bilirubin excretion because of tubular necrosis.
AST/ALT normal or only mildly elevated. ALP can be high
pilonidal cyst is acute pain and swelling of the midline sacrococcygeal and
subcutaneous tissues.
when patient has blunt abdominal trauma (BAT) first step is to determine if
need exploratory laparotomy. assess for intraperitoneal free fluid/hemorrhage
with FAST (focused assessment with sonography)
scaphoid fracture has pain in anatomical snuffbox. can take up to 10 days to
show fracture on x-ray if compressed or minimally displaced.
supracondylar fracture of humerus can lead to acute compartment syndrome.
common in young children falling on outstretched hand. pain, pallor,
pulselessness, paralysis, paresthesias. volkmann's ischemic contracture is the
final sequence of comparment syndrome where dead muscle has been
replaced with fibrous tissue
to quickly reverse warfarin's effects give FFP. used in need of surgery.
vitamin k would take too long because it works via post-translational
modifications.
prolonged placement of central line can lead to subclavian vein thrombosis.
The patient will have a swollen and pale arm. remove catheter and do duplex
causes of fever post-op are the 5 Ws
1) wind (pneumonia/atelectasis) 1-2 days
2) water UTI 3-5 days
3) walking DVT 4-6 days
4) wound 5-7 days
5) wonder medications > 7 days
dehydrated and elderly post op patients are prone to acute bacterial
parotitis presenting with painful swelling of involved parotid gland, aggravated
by chewing. most common infectious agent is S. aureus. to prevent this
complication do adequate hydration and oral hygiene.
motor vehicle accident causes splenic rupture. will be hypotensive,
tachycardic, and have abdominal wall ecchymoses.
for upper gastrointestinal bleed that is ongoing use packed RBC
transfusion. in patient with heart disease a hgb > 10 should be maintained
meniscal tears in the knee associated with a popping sensation. subsequent join
swelling develops gradually in conrast to a ligamentous tear which is a rapid
joint swelling due to hemarthrosis.
in patients with liver dysfunction and renal dysfunction use atracurium
because it is spontaneously hydrolyzed in the plasma. succinylcholine may
cause hyperkalemia and apnea in patients with renal dysfunction.
in pulmonary contusion patients develop hypoxia and respiratory distress
hours later after pulmonary edema has set in. if given lots of IV fluids this
may happen quicker. CXR will show patchy, irregular alveolar infiltrates.
transtentorial herniation of the uncus can occur during head trauma and
leads to ipsilateral hemiparesis, ipsilateral mydriasis and strabismus,
contralateral hemianopsia, and altered mentation.
acute ruptured appendicitis can cause pelvic abscess. typically presents as
lower abdominal pain, malaise, low-grade fever, and tender pelvic mass on
rectal examination.

post-op atelectasis is a common surgical complication resulting from shallow

breathing and weak cough due to pain. most common on days 2-3 following
abdominal/thoracoabdominal surgery. weak cough predisposes to small airway
mucous plugging and shallow breathing limit recruitment of alveoli at lung bases.
will be hypoxemic and have respiratory alkalosis.
In a patient with minor head trauma with loss of consciousness, the patient can
be discharged if CT is normal. Just monitor for signs of altered mental status at
home
all trauma patients with suspected spinal injuries should be hemodynamically
stabilized and have a secure airway and then have a urinary catheter placed to
assess for urinary retention.
all hemodynamically unstable patients with penetrating abdominal trauma
must undergo immediate exploratory laparotomy to diagnose and treat source
of bleeding as well as to diagnose and treat perforation of any abdominal viscus
in an effort to prevent sepsis.
circumferential full-thickness burn involving extremities may cause an eschar to
form, and escharotomy may be necessary to prevent vascular compromise. will
have compartment syndrome presenting like arterial thrombosis. (pallor,
paresthesia, pain, pulseless)
fat embolism presents with dyspnea, confusion, and petechiae in the upper
part of the body and occurs after long bone fractures.
flail chest is caused by three or more adjacent rib fractures that break into two
places and create an unstable chest wall segment that moves in a paradoxical
motion with respiration. patients with flail chest will remain tachypneic and
hypotensive despite continuous fluid resuscitation.
peripheral artery aneurysms manifest as a pulsatile mass that can
compress adjacent structures and result in thrombosis and ischemia.
popliteal and femoral artery aneurysms are the most common peripheral
artery aneurysms.
fever with chills and deep abdominal pain suggests a retroperitoneal
abscess. blunt abdominal trauma can compress neck/body of pancreas
causing retroperitoneal abscess or pseudocyst. abdominal CT scans done
early may fail to detect a pancreatic injury. Splenic injury would be seen on CT,
and delayed splenic rupture would cause LUQ abdominal pain and hypotension
but no septic signs (fever). gastric perforation more likely in penetrating (instead
of blunt) trauma and would show free air under diaphragm.
blunt aortic injury has mediastinal widening on CXR. deviation of the
trachea or nasogastric tube to the right, or depression of the left main stem
bronchus may also be seen.
signs of necrotizing surgical infection are intense pain in wound, fever,
hypotension and tachycardia, decreased sensitivity at edges of wound, cloudygray discharge, subcutaneous gas with crepitus. treatment is early
surgical exploration to assess extent of process and debride the necrotized
tissue.
positive pressure mechanical ventilation increases intrathoracic
pressure, which decreases venous return to the heart and decreased
preload. in patients with hypovolemic shock this may cause circulatory
collapse if the patients intravascular volume is not replaced before mechanical
ventilation is attempted.
patients suffering from rapid deceleration blunt chest trauma are at high risk
for aortic injury. findings suggestive of aortic injury include a widened
mediastinum, large left-sided hemothorax, deviation of mediastinum and
disruption of normal aortic contour. diagnose with CT scan and treat with anti
hypertensive therapy (first line is Beta Blockers).

patients can get high-output heart failure from arteriovenous fistulas.

symptomatic AVF creates an abnormal connection between the arterial and
venous system that bypasses capillary beds. shunting of a large amount of
blood through the fistula decreases systemic vascular resistance, increases
cardiac preload, and increases cardiac output. widened pulse pressure,
strong peripheral arterial pulsation (brisk carotid upstroke), systolic flow
murmur, tachycardia, and flushed extremities. the left ventricle becomes
hypertrophied and point of maximal impulse is displaced to the left.
ischemia-reperfusion syndrome is a form of compartment syndrome. after
4-6 hours of ischemia tissues can suffer both intracellular and interstitial
edema upon reperfusion. when the extremities are invovled this creates a risk
for compartment syndrome. compartment syndrome is defined as an increase in
pressure within an enclosed fascial space causing ischemia of muscles and
nerves. patients will have severe pain that is out of proportion to the physical
exam findings and can be remembered by the 5 Ps: pain, paresthesia, pallor,
pulselessness, paresis/paralysis.
in case of amputation injury, amputated parts should be wrapped in salinemoistened gauze, sealed in a plastic bag, placed on ice, and brought into the
ED.
in flail chest, multiple contiguous ribs are fractured resulting in an isolated
segment of the thoracic wall that exhibits paradoxical motion during normal
respiration. the institution of positive pressure mechanical ventilation
causes the flail segment to move normally. pain control and
supplemental oxygen are the most important early steps in managing flail
chest.
tracheal deviation can be caused due to opposite-side pneumothorax,
hemothorax, or same side lung collapse. distended neck veins are due to
either pneumothorax or cardiac tamponade. untreated tension
pneumothorax can lead to pulseless electrical activity (PEA) and/or
asystole. in suspected tension pneumothorax with hemodynamic instability first
do immediate needle thoracostomy prior to intubation, as positive
ventilation following intubation usually exacerbates an existing
pneumothorax. (same with hypovolemic shock. positive pressure mechanical
ventilation decreases preload, decreases CO, so replace volume then do PPV)
most common and feared complication of TPN is catheter tip infection. TPN
can also cause electrolyte abnormalities and metabolic disturbances.
hypokalemia, hypophosphatemia and hypomagnesemia when rapidly given
in a chronically nutrionally deprived patient. known as refeeding
syndrome (increase insulin, use up all the bodys already low stores of
K, P, Mg, leading to arrhythmias and death)
esophageal rupture is the most feared complication of esophageal dilation
procedures. patient will have post-procedure chest pain, hematemesis, and
shortness of breath. an accompanying left-sided pleural effusion is
common. pneumomediastinum is another typical CXR finding and is
suggestive of mediastinitis which is usually caused by esophageal rupture.
patients who have had gastric bypass surgery have a higher incidence of
developing gallstones due to an increase in bile concentration.
prophylactic treatment with ursodeoxycholic acid
extrahepatic cholestasis can be caused by obstruction of the common bile
duct by carcinoma of the head of the pancreas. The patient will have pruritis, and
jaundice. ERCP placement of a CBD stent would relieve the obstruction and
cholestasis.
if there is no infection of a foot ulcer and does not involve bone, can debride the
necrotic tissue as sufficient treatment

workup widened mediastinum on CXR with a transesophageal

echocardiograph or CT scan of chest.
when hemorrhage/hypovolemia occurs, tachycardia and peripheral
vascular constriction are the first physiological changes.
tension pneumothorax is an emergency situation which needs immediate
needle thoracostomy. will have rapid onset shortness of breath, tachycardia,
tachypnea, hypotension, and distension of neck veins due to superior vena cava
(SVC) compression.
glasgow coma scale has 3 components. 1) eye opening 2) verbal response 3)
motor response
in a patient with upper gastrointestinal bleeding who has a depressed level of
consciousness and ongoing hematemesis, intubate first to protect the
airway. then endoscopic treatment with band ligation or sclerotherapy to
stop bleeding.
intubate ---> fluids ---> bronchoscopy
early dumping syndrome is a common postgastrectomy complication. up
to 50% of patietns with partial gastrectomy may experience this syndrome. rapid
emptying of hypertonic gastric content into the duodenum and small
intestine. leads to fluid shift from intravascular space to the small intestine,
release of intestinal vasoactive polypeptides, and stimulation of autonomic
reflexes. treat with dietary modification.
persistent pneumothorax and significant air leak following chest tube
placement in a patient who has sustained blunt chest trauma suggests
tracheobronchial rupture. other findings include pneumomediastinum and
subcutaneous emphysema.
flaccid paralysis after aortic surgery is consistent with spinal cord ischemia
with possible infarction, a rare complication of vascular surgery. the thoracic
spinal cord is particularly dependent on these radicular arteries and the most
vulnerable to infarction. surgery to repair thoracic and thoracoabdominal
aortic aneurysms is the most common cause of spinal cord ischemia and
infarction. present with anterior spinal artery syndrome consisting of flaccid
paralysis, bowel/bladder dysfunction, sexual dysfunction, possible
hypotension and loss of deep tendon reflexes.
worsening chest pain accompanied by shortness of breath, tachycardia and
tachypnea after an endoscopy is concerning for iatrogenic esophageal
rupture. common radiographic findings include a pleural effusion,
pneumomediastinum and pneumothorax. do a water-soluble
(gastrografin) esophagram to diagnose esophageal perforation.
Gastrograffin because barium will cause irritation and possible fibrosis
any gunshot wound below 4th intercostal is considered to involve the abdomen
and requires an exploratory laparotomy in unstable patients.
patients with esophageal perforations most commonly present with acuteonset severe substernal pain. physical exam sometimes shows
subcutaneous emphysema in the neck or a characteristic crunching sound
on auscultation of the heart due to mediastinal emphysema (hammans
sign). chest x-ray will show air in the paraspinal muscles, a widened
mediastinum, pneumomediastinum (mediastinal air), or pleural effusions
with or without pneumothorax. the diagnostic study for esophageal perforation is
gastrografin-contrast esophagography which will show contrast leakage at
the site of the perforation.
patients with cervical spine injuries should first have stabilization of the c-spine.
orotracheal intubation with rapid sequence intubation is the preferred way
to establish an airway in an apneic patient with a c-spine injury.
acute mediastinitis is a complication of cardiac surgery usually due to
intraoperative wound contamination. mediastinitis can complicate up to 5% of

sternotomies. patients typically present post-op with fever, tachycardia, chest

pain, leukocytosis, and sternal wound drainage or purulent discharge. CXR
will show a widened mediastinum in non-postoperative mediastinitis but this
can also be seen in postoperative mediastinitis after cardiac surgery.
postoperative mediastinitis required drainage, surgical debridement and
prolonged antibiotic therapy.
a morton neuroma commonly occurs in runners and is a mechanically induced
neuropathic degeneration with symptoms including numbness and burning of
the toes, aching, and burning in the distal forefoot that radiates forward from the
metatarsal heads to the third and fourth toes. physical exam typically shows pain
between the third and fourth toes on the plantar surface and a clicking
sensation (mulder sign) when simultaneously palpating this space and
squeezing the metatarsal joints. treatment involves using metatarsal support
with padded shoe inserts. do surgery for people where conservative treatment
fails.
diaphragmatic rupture is more common on the left side because the right
side is protected by the liver. patients tend to have respiratory distress
because of leakage of the intraabdominal contents into the chest causing
compression of the lungs and mediastinal deviation. elevation of the
hemidiaphragm on CXR might be the only abnormal finding, but ultrasound or CT
scan of the chest is sometimes required if the CXR does not visualize well. the
small bowel is sometimes present in the thoracic cavity. nasogastric tube in
pulmonary cavity indicates a diaphragmatic hernia.
dont use succinylcholine in a patient with hyperkalemia or high risk for it
(burn crush injury patients) and patients with prolonged demyelination like
guillain barre syndrome, or with tumor lysis syndrome
3-4% of patients with spinal cord injuries will develop post-traumatic
syringomyelia. whiplash is often the inciting injury. symptoms develop
months to years later. condition involves enlargement of the central canal of
the spinal cord due to cerebrospinal fluid retention, resulting in impaired
strength and pain/temperature sensation in upper extremities. MRI used
to diagnose. (same thing as central cord syndrome?)
compartment syndrome may be caused by direct trauma (hemorrhage),
prolonged compression of an extremity, or after revascularization of an
acutely ischemic limb. muscles of the extremity are encased in fascial
compartments that do not allow for expansion of tissue. hemorrhage or edema
within the muscles causes increased pressure within the non-distensible fascial
compartment. this increased pressure interferes with perfusion by disallowing
passage of blood from the arterial system into the capillary beds of the affected
muscles. this eventually leads to muscle necrosis. patients with compartment
syndrome classicaly complain of severe pain that is worsened on passive range of
motion, paresthesias, pallor, and paresis of the affected limb. pressures >
30 mmHg may result in cessation of blood flow through the capillaries and
should be treated emergently by fasciotomy.
acute adrenal insufficiency/addisons can cause nausea, vomiting,
abdominal pain, hypoglycemia, and hypotension after a stressful event
(surgical procedure) in a patient who is steroid-dependent (patient with
systemic lupus erythematosus).
posterior urethral injury is associated with pelvic fractures. patients present
with blood at the urethral meatus, a high riding prostate, scrotal hematoma,
inability to void despite sensing an urge to void, and a palpably distended
bladder. anterior urethral injuries will not have a high riding prostate. more
common with straddle injuries.

air under diaphragm indicates perforated viscus, a surgical emergency.

get a surgical consult for exploratory laparotomy.
duodenal hematomas most commonly occur after direct blunt abdominal
trauma and are more commmon in children. following trauma blood collects
between the submucosal and muscular layers of the duodenum causing
obstruction. most resolve spontaneously in 1-2 weeks and intervention of choice
is nasogastric suction and parenteral nutrition.
postoperative ileus follows most surgeries where the peritoneal cavity is
entered. morphine and other opiates compound this problem by decreasing
gastrointestinal motility. signs and symptoms of post-op ileus include
nausea, vomiting, abdominal distention, failure to pass flatus or stool, and
hypoactive or absent bowel sounds on physical exam. mechanical bowel
obstruction causes hyperactive tinkling bowel sounds.
all patients with smoke inhalation should be suspected to have acute carbon
monoxide poisoning and treated with 100% oxygen via a nonrebreather
facemask.
traumatic rupture of the diaphragm may follow blunt or penetrating trauma.
XR will show a deviated mediastinum with a mass in the left lower chest.
symptoms may be chest pain radiating to the shoulder, shortness of breath, and
abdominal pain followed by respiratory distress. do a barium swallow or CT
scan with oral contrast.
immediate management of splenic trauma caused by blunt abdominal injury
depends on patients hemodynamic status and response to intravenous fluids. if
unstable but becomes stable with fluids the next best step is CT scan. if stays
unstable after fluids then do exploratory lapaparotomy. hypotension not
responsive to fluid administration following trauma is suggestive of ongoing
occult blood loss. do exploratory laparotomy to find bleeding if abdominal
trauma
in an unstable patient if the FAST (focused assessment with sonography for
trauma) is inconclusive, do diagnostic peritoneal lavage (DPL), then do
laparotomy if deemed necessary by the DPL.

urology

pain with relief of elevation of the testicle helps in epididymitis. in testicular

torsion there is a lack of a cremasteric reflex.
in the treatment of a patient with erectile dysfunction and BPH remember to give
sildenafil and alpha-blocker at least 4 hours apart to reduce risk of
hypotension. sildenafil is contraindicated in patients with nitrates.
after diagnosis of solid testicular mass has been made (a painless hard mass in
testicle + suggestive ultrasound) the initial management is orchiectomy, do
NOT do FNA or needle biopsy (risk of seeding the cancer cells)
in acute prostatitis do a culture of mid-stream urine sample to direct antibiotic
therapy. dont massage the prostate as it may lead to bacteremia.
urge incontinence is known as overactive bladder. uninhibited bladder
contractions referred to as detrusor instability/hyperactivity. results in
involuntary leakage of urine accompanied by a severe sensation of urgency.

treatment involves bladder training and establishing a voiding schedule. can

use oxybutynin
germ cell tumors (seminoma and non-seminoma) affect young patients and
have aggressive behavior.
non-seminoma germ cell tumors (embryonal carcinoma // yolk sac //
choriocarcinoma // teratoma) typically produce both afp and hcg as tumor
markers (can also invade the anterior mediastinum)
leydig cell tumors can cause estrogen production (due to increased
aromatase expression) with secondary inhibition of LH and FSH. leydig cell
tumor is a type of testicular sex cord stromal tumor.
USPSTF does not recommend screening with PSA, but the american cancer
society and the american urological association guidelines disagree. discuss with
patient on a case-by-case basis.
patients with varicocele complain of a dull aching pain in the testis.
varicocele is most common on the left side. results from a swelling of the
pampiniform plexus of veins and feels like a bag of worms on exam. the
valsalva maneuver will typically cause this mass to enlarge.
cystoscopy can cause an enterococcal bacteremia in patients with chronic
genitourinary infections.
penile fracture requires urethral imaging (retrograde urethrogram) and
surgical repair.
retrograde urethrogram should be the first step in management of
suspected urethral injury. foley catheterization in the presence of urethral
injury will predispose the patient to abscess formation.