With the recent US Preventive Services Task Force (USPSTF) guidelines, PSA screening

recommendations have become controversial. The USPSTF does not recommend any
population screening using PSA, but the American Cancer Society and the American
Urological Association guidelines disagree with this recommendation. Due to the
controversy, PSA screening should be determined on a case-by-case basis by the physician
and patient.

Tumor burden is the single most important prognostic consideration in the treatment of
patients with breast cancer. It is based on TNM staging.

After the diagnosis of a solid testicular mass has been made, (a painless hard mass in
testicle + suggestive ultrasound), the initial management is removal of the testis and its
associated cord.

Acute bacterial prostatitis presents in a manner similar to other urinary tract infections, but
with the addition of perineal pain, pronounced systemic symptoms (fever, chills, acute
illness), and a tender, boggy prostate on examination. Urine culture should be obtained to
help direct antibiotic therapy.

Anabolic steroid use by a man can produce infertility by suppressing the production of
GnRH, LH, and FSH.

Remember the common causes of priapism:

1. Sickle cell disease and leukemia - usually in children or adolescents
2. Perineal or genital trauma - results in laceration of the cavernous artery
3. Neurogenic lesions - such as spinal cord injury, cauda equina compression, etc.
4. Medications - such as trazodone and prazosin

If a patient presents with priapism, always check his medications first. This symptom is often
drug-induced.The most common drug that causes priapism is prazosin, although for the
boards, it is important to remember the association of priapism with trazodone

Chorio carcinoma 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 chest x-ray. An elevated beta hCG helps to confirm the diagnosis.

Patients with non-inflammatory chronic prostatitis are afebrile and have irritative voiding
symptoms.Expressed prostatic secretions show a normal number of leukocy1es and culture
of these secretions is negative for bacteria.

The most common cause of urinary retention in elderly males is an enlarged

prostate, which is usually revealed by rectal examination and characterized by a high
postvoid residual volume. An absent or decreased Achilles tendon reflex can be a
normal finding in elderly patients.

On physical examination, varicoceles typically manifest as a soft mass ("bag of

worms") that worsens with standing and Valsalva maneuvers but decreases when
supine. Patients may have no symptoms or a dull scrotal ache when standing.
Potential complications include infertility and testicular atrophy (due to increased

scrotal temperature.The mass does not transilluminate. Ultrasound is the imaging of choice
and may show retrograde venous flow, dilation of pampiniform plexus veins, and tortuous,
anechoic tubular structures adjacent to the testis. Treatment depends on the patient's age
and desire for fertility. Options include scrotal support and nonsteroidal anti-inflammatory
drugs (NSAIDs) or surgical correction.
Hydrocele is the accumulation of fluid around the testis and spermatic cord and between the
parietal and visceral layers of the tunica vaginalis. Communicating hydroceles usually present in
infancy and are frequently reducible but may also increase in size with the Valsalva maneuver.
Noncommunicating hydroceles do not usually change in size with positional changes.

Varicoceles are a tortuous dilation of the pampiniform venous plexus surrounding the
spermatic cord and testis in the scrotum. They usually result from left renal venous
compression between the aorta and superior mesenteric artery. Examination shows a soft
left-sided scrotal mass ("bag of worms") that worsens with standing and Valsalva maneuvers
but regresses when the patient is supine.

Antiphospholipid antibody syndrome (APS) is associated with a false positive VdRL,

prolonged PTI, and thrombocytopenia. APS can promote arterial and venous thromboses
and a resultant tendency toward spontaneous abortions. Prophylaxis with low dose aspirin
and LMWH are recommended to avoid pregnancy loss.

RENAL AND URINARY SYSTEM EDUCATIONAL OBJECTIVE.

Cushing's syndrome is caused by corticosteroid excess. Hypokalemia and hypernatremia

are the electrolyte abnormalities most commonly observed.
Primary hyperparathyroidism (PHP) or familial hypocalciuric hypercalcemia (FHH) can cause
hypercalcemia secondary to an elevated or inappropriately "normal" parathyroid hormone
level. Urinary calcium creatinine clearance ratio is usually <0.01 in FHH compared to >0.02
in PHP.
The most common cause of hypernatremia is hypovolemia. Mild cases can be treated with
5% dextrose in 0.45% saline. Severe cases should be initially treated with 0.9% saline.
Hypocalcemia can occur during or immediately after surgery in patients undergoing major
surgery and requiring extensive transfusions. Hyperactive deep tendon reflexes may be the
initial manifestation.
Rapid treatment with calcium gluconate is necessary in a patient with hyperkalemia who
develops significant EKG changes. Further treatment with agents such as insulin and/or
sodium polystyrene sulfonate will eventually be necessary as well to reduce the serum
concentration of potassium.
Acyclovir can cause crystalline nephropathy if adequate hydration is not also provided.
One should suspect myoglobinuria whenever test results demonstrate a large amount of
blood on urinalysis with a relative absence of RBCs on urine microscopy. Myoglobinuria is
usuaDrug induced interstitial nephritis is usually caused by cephalosporins, penicillins,
sulfonamides, NSAIDs,rifampin, phenytoin and allopurinol. Patients present with arthralgias,
rash, renal failure and the urinalysis will show eosinophiluria.lly caused by rhabdomyolysis,
which frequently leads to acute renal failure.
Long-term analgesic use with 1 or more analgesics (eg, nonsteroidal anti-inflammatory drug
such as aspirin,can cause chronic kidney disease due to tubulointerstitial nephritis and
hematuria due to papillary necrosis.

Contrast administration has the potential to cause contrast-induced nephropathy, particularly

in patients with renal insufficiency (Cr>1 .5) and/or diabetes. Non-ionic contrast agents are
associated with lower incidence of nephropathy than the older ionic hyperosmolar agents. In
addition to using non-ionic contrast agents,adequate IV hydration and acetylcysteine can
decrease the incidence of nephropathy.
Diuretic abuse leads to increased excretion of water and electrolytes by the kidneys.
Dehydration, weight loss, orthostatic hypotension as well as hypokalemia and hyponatremia
result. Urinary sodium and potassium will be elevated. Patients with eating disorders
sometimes abuse diuretics to induce weight loss.
High-dose intravenous acyclovir can cause crystalluria with renal tubular obstruction.
Administering intravenous fluids concurrently with the drug can help reduce the risk of acute
kidney injury.
Tuberculosis is a common cause of chronic primary adrenal insufficiency (Addison's
disease) in endemicareas. Addison's disease causes aldosterone deficiency and
presents with a non-anion gap and hyperkalemic and hyponatremic metabolic acidosis.
Chronic alcoholics typically present with multiple electrolyte abnormalities such as
hypokalemia,hypomagnesemia and hypophosphatemia. Hypomagnesemia, causes
refractory hypokalemia; therefore it is important to correct the magnesium along with the
potassium levels to be able to correct the electrolyte abnormalities of such patients.
Arterial pH or anion gap is the most reliable indicator of metabolic recovery in patients with
diabetic ketoacidosis.
Elderly patients with impaired thirst response are predisposed to prerenal azotemia due to
intravascular volume depletion and poor renal perfusion. Diuretics worsen volume depletion.
Nonsteroidal anti-inflammatory drugs and angiotensin 11-converting enzyme inhibitors impair
the normal physiologic response of renal arterioles, worsening glomerular filtration rate and
renal function.
Simple renal cysts are almost always benign and do not require further evaluation. Features
concerning for malignant renal mass include a multilocular mass, irregular walls, thickened
septae, and contrast enhancement.
Renal vein thrombosis is an important complication of nephrotic syndrome, which is most
commonly cause by membranous glomerulonephritis in adults.
Renal transplant dysfunction in the early post-operative period can be explained by a variety
of causes,including ureteral obstruction, acute rejection, cyclosporine toxicity, vascular
obstruction, and acute tubular necrosis. Radioisotope scanning, renal ultrasound, MRI, and
renal biopsy can be employed in conducting a differential diagnosis. Acute rejection is best
treated with intravenous steroids.
Screening for bladder cancer is not recommended, even in patients who are at risk of
developing the disease.
Severe pain in a patient with a mild urinary obstruction, such as BPH, may cause urinary
retention due to inability to Valsalva.
The classic findings in patients with amyloidosis are renal amyloid deposits that show applegreen birefringence under polarized light after staining with Congo red.
Aspirin intoxication should be suspected in a patient with the triad of fever, tinnitus, and
tachypnea. Adults with aspirin toxicity develop a mixed respiratory alkalosis and anion gap
metabolic acidosis. A normal pH in an acid-base disturbance typically signifies a mixed
respiratory and metabolic acid-base disorder.
Glomerular hyperfihration is the earliest renal abnormality seen in diabetic nephropathy. It
is also the major pathophysiologic mechanism of glomerular injury in these patients.
Thickening of the glomerular basement membrane is the first change that can be
quantitated.

Cardiovascular disease is the most common cause of death in dialysis patients. It accounts
for approximately 50% of all deaths in this population. Cardiovascular disease is also the
most common cause of death in renal transplant patients.
Hyperkalemia is a medical emergency. Therapy involves three steps: membrane stabilization
with calcium,shifting potassium intracellularly, and decreasing the total body potassium
content. Insulin/glucose administration is the quickest way to decrease the serum potassium
concentration.
Intravenous normal (0.9%) saline is preferred for treating hypovolemic hypernatremia. The
fluid can be switched to a hypotonic fluid (5% dextrose in water preferred over 0.45% saline)
for free water supplementation once the patient is euvolemic
Uric acid stones are often radiolucent but may be seen on ultrasound or CT scan. They are
highly soluble in alkaline urine; alkalinization of the urine to pH 6.0-6.5 with oral potassium
citrate is the treatment of choice.
The most common renal vascular lesions seen in hypertension are arteriosclerotic lesions of
afferent and efferent renal arterioles and glomerular capillary tufts. Diabetes mellitus
nephropathy is characterized by increased extracellular matrix, basement membrane
thickening, mesangial expansion, and fibrosis
Trimethoprim can cause hyperkalemia due to blockade of the epithelial sodium channel
in the collecting tubule. Trimethoprim also competitively inhibits renal tubular creatinine
secretion and may cause an artificial increase in serum creatinine without affecting the
glomerular filtration rate..
Platelet dysfunction is the most common cause of abnormal hemostasis in patients with
CRF. PT, PTI, and platelet count are normal. BT is prolonged. DDAVP is usually the
treatment of choice, if needed. DDAVP increases the release of factor Vlll :von Willebrand
factor multimers from endothelial storage sites. Platelet transfusion is not indicated because
the transfused platelets quickly become inactive.
Volume resuscitation with normal saline will correct contraction alkalosis. Hypokalemia
should be treated as well.
The nephrotic syndrome can result in alterations in lipid metabolism. This dyslipidemia puts
affected patients at increased risk for accelerated atherosclerosis. This atherosclerotic
tendency, along with intrinsic hypercoagulability, places patients with nephrotic syndrome at
risk for complications such as stroke and myocardial infarction.

Patients with diabetes for >1 0 years can develop diabetic microangiopathy, nephropathy,
and glomerulosclerosis. Risk factors include poor glycemic control, elevated blood pressure,
smoking, increasing age, and ethnicity (eg, African American, Mexican American). Clinical
findings include mild to moderate proteinuria and chronic kidney disease with elevated
creatinine.

In any patient, the pH and PaC02 are the two lab values that provide the best picture of acidbase status; the HC03- can be calculated from these values using the HendersonHasselbalch equation.

Metformin should not be given to acutely ill patients with acute renal failure, liver failure, or
sepsis as these conditions increase the risk of lactic acidosis.

Adrenal insufficiency and adrenal failure are characterized by nonspecific symptoms and
signs including anorexia, fatigue, Gl complaints, weight loss, and hypotension. Hyponatremia
is the most common associated electrolyte abnormality. Hyperkalemia is also common.

Contrast-induced nephropathy presents as a transient spike in creatinine within 24 hours of

contrast administration, with a return to normal renal function within 5-7 days. Patients with
diabetes and elevated baseline creatinine are at especially high risk. Adequate IV hydration
with isotonic bicarbonate or normal saline and administration of acetylcysteine help to
minimize the risk of contrast-induced nephropathy.

Nephrotic syndrome is a hypercoagulable condition which manifests as venous or arterial

thrombosis, and even pulmonary embolism. Renal vein thrombosis is the most frequent
manifestation. Complications of nephrotic syndrome include: protein malnutrition, ironresistant microcy1ic hypochromic anemia, increased susceptibility to infection, and vitamin D
deficiency.

The most common causes of hyperkalemia include acute or chronic kidney disease,
medications, or disorders impairing the renin-angiotensin axis. Common offending
medications include nonselective betaadrenergic blockers, potassium-sparing diuretics
(eg, triamterene), angiotensin-converting-enzyme inhibitors,angiotensin II receptor
blockers, and nonsteroidal anti-inflammatory drugs.

Based on urinary chloride levels and extracellular fluid volume status, metabolic alkalosis
can be classified as saline-responsive and saline-unresponsive. Saline-responsive metabolic
alkalosis is associated with low urinary chloride excretion and volume contraction, and
corrects with saline infusion alone.Saline-unresponsive metabolic alkalosis typically presents
with urinary chloride >20 mEq/L.

Methyl alcohol poisoning can cause visual changes (''snowfield vision") and acute
pancreatitis, but will not cause urine crystals and renal failure.

Calcium oxalate crystals (rectangular, envelope-shaped crystals) are seen in patients with
ethylene glycol (anti-freeze) poisoning. Ethylene glycol, methanol and ethanol intoxication
cause metabolic acidosis with both an anion gap and an osmolar gap.

The most common causes of hyperkalemia include acute or chronic kidney disease,
medications, or disorders impairing the renin-angiotensin axis. Common offending
medications include nonselective betaadrenergic blockers, potassium-sparing diuretics (eg,
amiloride), angiotensin-converting-enzyme inhibitors,angiotensin II receptor blockers, and
nonsteroidal anti-inflammatory drugs.

Autosomal dominant polycystic kidney disease is a potential cause of hypertension. Hepatic

cysts are the most common extrarenal manifestations. Intracranial berry aneurysms are seen
in 5 to 10 % of the cases. Although such aneurysms are common and dangerous when
coupled with hypertension, routine screening for intracranial aneurysms is not
recommended.

Hydration is the cornerstone of therapy for renal stone disease. A detailed metabolic
evaluation is not needed when a patient presents with his first renal stone.

Ureteral calculi may cause flank or abdominal pain radiating to the perineum, often
with nausea and vomiting.Ultrasonography or a noncontrast spiral CT scan of the
abdomen and pelvis are the imaging modalities of choice to confirm the diagnosis.
Ultrasonography is preferred in pregnant patients to reduce radiation exposure.

Membranoproliferative glomerulonephritis, type 2, is a unique glomerulopathy that is caused

by persistent activation of the alternative complement pathway.

Hyponatremia can be classified according to the patient's volume status (hypovolemic,

euvolemic hypervolemic). Hypovolemia increases the activity of the renin-angiotensinaldosterone and sympathetic nervous systems, and stimulates antidiuretic hormone (ADH)
release from the pituitary. The elevated ADH increases renal water reabsorption to cause
hyponatremia until correction of the hypovolemia.

Pulmonary-renal syndromes include a variety of disorders with simultaneous involvement of

the lung and kidney. Quick differential diagnosis is important because the management
differs per disease. Emergency plasmapheresis is required in patients with Goodpasture's
syndrome. Granulomatosis with polyangiitis (Wegener's) is treated with a combination of
cyclophosphamide and steroids.

Obstructive uropathy causes flank pain, low volume voids with or without occasional high
volume voids, and (if bilateral) renal dysfunction.

Succinylcholine is a depolarizing neuromuscular blocker that can cause life-threatening

hyperkalemia. It should not be used in patients with or at high risk for hyperkalemia, such as
burn and crush injury patients and patients with prolonged demyelination.

Transrectal ultrasound of the prostate is an outpatient procedure to help guide prostate

biopsy; it is indicated in patients with prostate nodules or persistently elevated PSA of >4
ng/dl. Current guidelines recommend evaluating all patients with probable benign prostatic
hyperplasia based on history and rectal examination with a urinalysis to assess for urinary infection
and hematuria. Patients with life expectancy >10 years should also have prostate-specific antigen
measured to screen for prostate cancer.

Measures to prevent urinary calcium stone formation include increasing fluid intake, following
a low-sodium, low-protein diet, maintaining moderate calcium intake, and taking thiazide
diuretics to lower urinary calcium excretion.
Aminoglycosides are antibiotics used to treat serious gram-negative infections. They are
potentially nephrotoxic and drugs levels and renal function must be monitored closely during
therapy.

Analgesic nephropathy is the most common form of drug-induced chronic renal failure.
Papillary necrosis and chronic tubulointerstitia/ nephritis are the most common
pathologies seen. Patients with chronic analgesic abuse are also more likely to develop
premature aging, atherosclerotic vascular disease, and urinary tract cancer.

Muddy brown granular cast -Acute tubular necrosis

RBC casts - Glomerulonephritis
WBC casts - Interstitial nephritis and pyelonephritis
Fatty casts - Nephrotic syndrome
Broad and waxy casts - Chronic renal failure
The common presentation of cryoglobulinemia includes palpable purpura,
glomerulonephritis, non-specific systemic symptoms, arthralgias, hepatosplenomegaly,
peripheral neuropathy, and hypocomplementemia. Most patients also have Hepatitis C.

Dipsticks are commercially available kits that detect the presence of leukocyte esterase and
nitrite in the urine of patients with suspected UTI. Positive leukocyte esterase signifies
significant pyuria and positive nitrites indicate the presence of Enterobacteriaceae.

Uncomplicated cystitis commonly occurs in otherwise healthy patients and has a low risk of
treatment failure.Urinalysis confirms the diagnosis. Patients can be treated without a urine
culture, which may be done later in those who fail initial therapy. Oral
trimethoprim/sulfamethoxazole, nitrofurantoin, and fosfomycin are effective first-line
treatment options.

Uncomplicated cystitis commonly occurs in otherwise healthy patients and has a low risk of
treatment failure.Urinalysis confirms the diagnosis. Patients can be treated without a urine
culture, which may be done later in those who fail initial therapy. Oral
trimethoprim/sulfamethoxazole, nitrofurantoin, and fosfomycin are effectivefirst-line treatment
options.

Collapsing focal and segmental glomerulosclerosis is the most common form of

glomerulopathy associated with HIV. Typical presentation of focal segmental
glomerulosclerosis includes nephrotic range proteinuria, azotemia, and normal sized
kidneys.

Cystinuria is an inherited disease causing recurrent renal stone formation. Look for a
personal history of recurrent kidney stones from childhood and a positive family history. The
characteristic stones are hard and radioopaque. Urinalysis shows typical hexagonal crystals.
The urinary cyanide nitroprusside test is widely used as a qualitative screening procedure.

Interstitial cystitis (painful bladder syndrome) is an idiopathic, chronic condition

characterized by bladder pain that is worsened by filling and relieved by voiding.
Dyspareunia, urinary frequency and urgency can also be present.

Nephrotic syndrome is defined as heavy proteinuria (>3.5 g/24 hr} with hypoalbuminemia
and edema. Focal segmental glomerulosclerosis (FSGS) and membranous nephropathy are
the most common causes of nephrotic syndrome in adults in the absence of a systemic
disease. FSGS is more common in African American patients and in those with obesity,
heroin use, and HIV.

Initial hematuria suggests urethral damage. Terminal hematuria indicates bladder or prostatic
damage, and total hematuria reflects damage in the kidney or ureters. Clots are not usually
seen with renal causes of hematuria.

70% of cases with interstitial nephritis are caused by drugs such as cephalosporins,
penicillins, sulfonamides,sulfonamide containing diuretics, NSAIDs, rifampin, phenytoin, and
allopurinol. Discontinuing the offending agent is the treatment of drug-induced interstitial
nephritis.

Aspirin intoxication causes a mixed respiratory alkalosis and metabolic acidosis. Respiratory
alkalosis is due to increased respiratory drive. Metabolic acidosis is due to increased
production and decreased renal elimination of organic acids (eg, lactic acid, ketoacids).

Unilateral varicoceles that fail to empty when a patient is recumbent raise suspicion for an
underlying mass pathology, such as renal cell carcinoma (RCC}, that obstructs venous flow.
CT scan of the abdomen is the most sensitive and specific test for diagnosing RCC.

Drugs with anticholinergic properties can cause acute urinary retention by preventing
detrusor muscle contraction and urinary sphincter relaxation. The treatment involves urinary
catheterization and discontinuing the medication.

Intravenous saline hydration is the immediate treatment of choice for patients with
symptomatic moderate (calcium 12-14 mg/dL} or severe (calcium >14 mg/dL}
hypercalcemia. Saline hydration helps to restore intravascular volume and promote urinary
calcium excretion. Calcitonin also reduces serum calcium concentration within 4-6 hours and
should be administered along with saline hydration. Bisphosphonates are recommended for
long-term management in addition to treatment of the underlying cause.

Agents used to shift potassium intracellularly include insulin and glucose, sodium
bicarbonate, and beta-2 agonists.

PULMONARY

Lung malignancies, cystic fibrosis, and right-to-left cardiac shunts are the most common
causes of secondary digital clubbing. Chronic obstructive pulmonary disease (with or without
hypoxemia) does not cause digital clubbing, and the presence of clubbing should prompt a
search for occult malignancy.Hypertrophic osteoarthropathy refers to digital clubbing along
with painful joint enlargement, periostosis of longbones, and synovial effusions.

Right mainstem bronchus intubation is a relatively common complication of endotracheal

intubation. It causes asymmetric chest expansion during inspiration and markedly decreased
or absent breath sounds on the left side on auscultation. Repositioning the endotracheal
tube by pulling back slightly will move the tip between the carina and vocal cords and solve
the problem.

Mild intermittent asthma, the least severe form, is defined as symptoms $ 2x/week, $ 2
nighttime awakenings/month, with a normal FEV1 and no limitations on activity. For this form
of asthma, only a PRN albuterol inhaler is required. Daily controller corticosteroids are
reserved for persistent asthma.

Recurrent bacterial infections in an adult patient may indicate a humoral immunity defect.
Quantitative measurement of serum immunoglobulin levels helps to establish the diagnosis.

Undiagnosed pleural effusion is best evaluated with thoracentesis, except in patients with
clear-cut evidence of congestive heart failure.

Of the main cell types of lung cancer, adenocarcinoma is the most common in both smokers
and nonsmokers. It accounts for most of the primary lung cancer in nonsmokers. It is usually
located peripherally and may present as a solitary nodule, with or without symptoms. Stage
at diagnosis is the most important prognostic factor, with survival determined primarily by
resectability.

In patients with acute asthma exacerbation, an elevated or even normal arterial partial
pressure of carbon dioxide suggests decreased respiratory drive (likely due to respiratory

muscle fatigue) and impending respiratory failure. In these patients, treatment involves
endotracheal intubation and mechanical ventilation,inhaled short-acting beta-2-agonist,
inhaled ipratropium, and systemic corticosteroids.

Idiopathic pulmonary fibrosis is due to excessive collagen deposition in peri-alveolar tissues.

This leads to decreased lung volumes (low total lung capacity, functional residual capacity,
and residual volume) with preserved or increased forced expiratory volume in 1
second/forced vital capacity ratio. Patients have impaired gas exchange resulting in reduced
diffusion capacity of carbon monoxide and increased alveolar -arterial gradient.

Granulomatosis with polyangiitis (Wegener's) is a vasculitis affecting small and mediumsized arteries. Patients present with a combination of glomerulonephritis and upper and
lower respiratory tract disease. Diagnosis is made by c-ANCA positivity and tissue biopsy.
Treatment involves high-dose corticosteroids and cy1otoxic agents.

Acute respiratory distress syndrome (ARDS) is associated with hypoxemia (PaO) Fi02 S300
mm Hg) and bilateral alveolar infiltrates. ARDS is due to impaired gas exchange, decreased
lung compliance (stiff lungs),and increased pulmonary arterial pressure (pulmonary
hypertension).

Mitral stenosis is most commonly due to rheumatic heart disease and presents with gradual
and progressively worsening dyspnea or orthopnea. Atrial fibrillation is a common
complication and can cause rapid decompensation in previously asymptomatic patients.
Longstanding mitral stenosis can cause severe left atrial enlargement leading to an elevation
of the left main bronchus on chest radiograph.

Indicators of a severe asthma attack include normal to increased Pco2 values, speech
difficulty, diaphoresis,altered sensorium, cyanosis, and 'silent' lungs.

Warfarin dosing should be adjusted to maintain a goaiiNR appropriate for the

condition being treated. For patients with idiopathic VTE or atrial fibrillation, a target
INR of 2.0 to 3.0 provides adequate anticoagulation without an excessive risk of
bleeding.

Malignancy is the most common cause of SVC syndrome. Lung cancer (particularly small
cell lung cancer} and NHL are often implicated. Other possible causes include fibrosing
mediastinitis (secondary to histoplasmosis or Tb infection} or thrombosis secondary to
indwelling central venous devices. When the history and physical examination are
suggestive, chest x-ray is warranted.

The kidney compensates for respiratory alkalosis by preferentially excreting bicarbonate in

the urine. The result is an alkalinized urine (increased urine pH).

When the pH of the pleural fluid is less than 7.2, the probability is very high that this fluid
needs to be drained.Glucose of less than 60mg/dL in pleural fluid is also an indication for
tube thoracostomy. Infected pleural space is usually initially drained with a chest tube.

Short-acting beta-adrenergic agonists administered 20 minutes before exercise are the firstline treatment for isolated exercise-induced asthma. The inciting trigger in exercise-induced
asthma is rapid ventilation of cold,dry air.

Physical examination in patients with pleural effusion usually shows decreased tactile
fremitus, dullness to percussion, and decreased breath sounds over the effusion.

In the U.S., sarcoidosis most commonly affects young- to middle-aged African American
females, causing insidious-onset dyspnea and dry cough in the absence of constitutional
symptoms. Sarcoidosis also typically affects the skin (protean manifestations, most
commonly erythema nodosum) and the eyes (uveitis).

Theophylline toxicity can manifest as central nervous system stimulation (eg, headache,
insomnia, seizures),gastrointestinal disturbances (eg, nausea, vomiting), and cardiac toxicity
(arrhy1hmia). Inhibition of the cy1ochrome oxidase system by other medications, diet, or
underlying disease can alter its narrow therapeutic window.

Blood in the chest, if it is 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.

A negative D-dimer is very helpful in excluding the diagnosis of pulmonary venous

thromboembolism in low-risk patients. A positive D-dimer, however, is far from diagnostic
and must be followed by more specific studies.

Secondary malignancy is common in patients with Hodgkin lymphoma treated with

chemotherapy and radiation. The most common secondary solid tumor malignancies are
lung (especially in smokers), breast,thyroid, bone, and gastrointestinal (eg, colorectal,
esophageal, gastric tumors).

In all patients with COPD, the two modalities that have been shown to decrease mortality are
home oxygen therapy and smoking cessation.

Aspirin-exacerbated respiratory disease (AERO} is a non-lgE-mediated reaction that results

from aspirin-induced prostaglandin/leukotriene misbalance. It is most often seen in patients
with a history of asthma or chronic rhinosinusitis with nasal polyposis. AERO is characterized
by bronchospasm and nasal congestion following aspirin ingestion. Treatment includes
avoidance of nonsteroidal anti-inflammatorydrugs (NSAIDs }, desensitization if NSAIDs are
required, and the use of leukotriene receptor antagonists ( eg,montelukast}.

P. jiroveci is an opportunistic pathogen, and an important cause of pneumonia in

immunocompromised hosts.Bilateral diffuse interstitial infiltrates beginning in the
perihilar region is a characteristic finding on chest x-ray.

long-term supplemental oxygen therapy has been proven to prolong survival in patients with
COPD and hypoxemia. Criteria for therapy include Pa02$55, Sa02$88%, erythrocy1osis
(hematocrit>55%), or evidence of cor pulmonale.

COPD is characterized by progressive expiratory airflow limitation which causes air trapping,
decreased VC and increased total lung capacity. FEV1 is disproportionately decreased as
compared to VC.

Patients with a history of recent orthopedic surgery followed by bed rest are at risk of
developing lower extremity deep venous thrombosis and pulmonary embolism. An elevated
A-a gradient is commonly seen in patients with pulmonary embolism.

Bronchogenic cysts are usually found in the middle mediastinum. Thymoma is usually found
in the anterior mediastinum. All neurogenic tumors are located in the posterior mediastinum.

The 3 most common causes of chronic cough are upper-airway cough syndrome (postnasal
drip), asthma,and gastroesophageal reflux disease. The diagnosis of upper -airway cough
syndrome is confirmed by the elimination of nasal discharge and cough with the use of H1
histamine receptor antagonists.

Acute massive pulmonary embolism can present initially with syncope and shock. Right
heart catheterization in patients with massive pulmonary embolism will show elevated right
atrial and pulmonary artery pressures,along with normal pulmonary capillary wedge
pressure.

Acute pancreatitis can cause adult respiratory distress syndrome (ARDS) in up to 15% of
patients. The first step in the initial ventilator management of ARDS is usually to decrease
the Fi02 to relatively non-toxic values(i.e. < 60%). PEEP may be increased as needed to
maintain adequate oxygenation after the Fi02 is lowered.

Acute pancreatitis can cause adult respiratory distress syndrome (ARDS) in up to 15% of
patients. The first step in the initial ventilator management of ARDS is usually to decrease
the Fi02 to relatively non-toxic values (i.e. < 60%). PEEP may be increased as needed to
maintain adequate oxygenation after the Fi02 is lowered.

Normal pleural fluid pH is approximately 7.60. Transudative fluid is usually due to systemic
factors (eg,increased hydrostatic pressure or hypoalbuminemia) and has a pleural fluid pH of
7.4-7.55. Exudate is usually due to inflammation with a pleural fluid pH of 7.30-7.45. Pleural
fluid pH <7.30 (with normal arterial pH and low pleural glucose) is usually due to increased
acid production by pleural fluid cells and bacteria (eg, empyema) or decreased hydrogen ion
efflux from the pleural space (eg, pleuritis, tumor, pleural fibrosis).

Bronchiectasis presents with cough, mucopurulent sputum, and hemoptysis that often
antibiotics. Chest x-ray is frequently abnormal but is not as sensitive or specific as highresolution computed tomography scan for definitive diagnosis.

Blastomycosis is a pulmonary fungal infection endemic to the Great Lakes, and Mississippi
and Ohio River basins. Systemic Blastomycosis may cause skin and bone lesions in addition
to pulmonary manifestations.Broad-based budding yeast grown from the sputum confirm the
diagnosis. ltraconazole or amphotericin B may be used to treat symptomatic disease.

The modified Wells criteria can assess pretest possibility of acute pulmonary embolism
(PE) as it can have variable presentations. Patients with likely PE based on these criteria
should be further evaluated with computed tomography angiography (CTA). Patients
with negative CTA are unlikely to have PE.

Know the complications of ventilation with a high PEEP: alveolar damage, tension
pneumothorax and hypotension. Tension pneumothorax may present with sudden-onset
shortness of breath, hypotension,tachycardia, tracheal deviation, and unilateral absence of
breath sounds.

All COPD patients with Pa02 < 55 mmHg or Sa02 < 88% are candidates for long-term home
oxygen treatment. Patient with signs of pulmonary hypertension or hematocrit > 55% should
be started on home oxygen when the Pa02 < 60 mmHg.

Patients with impaired consciousness, advanced dementia, and other neurologic

disorders are predisposed to aspiration pneumonia due to impaired epiglottic
function.

Bronchiectasis can be identified on CT by the presence of dilated bronchi with thickened

walls. It can occur in any patient where there is pulmonary infection accompanied by either
decreased airway drainage or impaired immune defense. Hemoptysis is a potential
complication of bronchiectasis.

Histoplasma capsulatum is a common and usually asymptomatic infection in endemic areas

like Mississippi and Ohio River valleys and Central America. It is usually found in soil with a
high concentration of bird or bat guano droppings.

Patients with massive pulmonary embolism usually present with signs of low arterial
perfusion ( eg,hypotension, syncope) and acute dyspnea, pleuritic chest pain, and
tachycardia. The thrombus increases pulmonary vascular resistance and right ventricular
pressure, causing right ventricular hypokinesis and dilation, decreased preload, and
hypotension.

For anticoagulation, unfractionated heparin is preferred over low-molecular-weight heparin,

fondaparinux, and rivaroxaban in patients with severe renal insufficiency (estimated
glomerular filtration rate <30 mUmin/1. 73m2} as reduced renal clearance increases anti-Xa
activity levels and bleeding risk.

Germ cell tumors typically affect young patients and display aggressive biologic behavior.
Nonseminomatous germ cell tumors typically produce both alpha fetoprotein and human
chorionic gonadotropin tumor markers.

PSYCHIATRY

Antipsychotic medications can cause hyperprolactinemia secondary to their dopamine

blockade effect. Prolactinomas tend to produce very high levels of prolactin (>200 ng/mL).
Some of the more serious adverse effects associated with lithium include nephrogenic
diabetes insipidus,hypothyroidism, and Ebstein's anomaly in the fetus.
The antidepressant of choice for depressed patients who do not respond to first-line
treatment with a selective serotonin reuptake inhibitor is another medication in the same
class.
Neuroleptic malignant syndrome is a potentially life-threatening condition that can occur after
administration of antipsychotic medications. Symptoms include fever, rigidity, altered mental
status, and autonomic instability.
The most effective strategy to prevent firearm injuries is to remove all firearms from the
home. Families who choose to keep firearms in the home should be advised to store
unloaded firearms and ammunition in separate, locked containers.
Unlike patients with anorexia nervosa, patients with bulimia nervosa maintain a normal body
weight and are not amenorrheic.

Patients who are an acute threat to themselves should be hospitalized (involuntarily, if

necessary) for treatment and stabilization. This principle also applies to minors, even without
parental or guardian consent.

The mechanism of action of antipsychotic medications primarily consists of

dopamine-02 receptor blockade.The added serotonin receptor binding of atypical
antipsychotics reduces the likelihood of extrapyramidal side effects.
Risperidone is a dopamine and serotonin antagonist that can cause weight gain and
hyperprolactinemia, the latter of which can lead to amenorrhea and galactorrhea.
Delusional disorder involves one or more delusions and the absence of other psychotic
symptoms in an otherwise high-functioning individual.
Benzodiazepines are used for the acute treatment of panic attacks. In panic disorder, a
selective serotonin reuptake inhibitor/serotonin norepinephrine reuptake inhibitor and/or
cognitive behavioral therapy should be used for long-term symptom relief.
Patients who have experienced 2 episodes of acute mania should be considered for longterm (years), if not lifetime, maintenance treatment with lithium, especially if the episodes
were severe or there is a family history. Patients with a history of 3 or more relapses are
recommended to have lifetime maintenance therapy.
PCP and LSD intoxication present similarly, but agitation and aggression occur more often in
patients using PCP. Visual hallucinations and intensified perceptions are hallmarks of LSD
use.
Acute dystonia is a type of extrapyramidal symptom associated with antipsychotic treatment.
It is most commonly seen with high-potency typical antipsychotics and is best treated with
anticholinergics (benztropine) or antihistamines (diphenhydramine).

For the general population, the lifetime risk of developing bipolar disorder is 1%.
However, an individual with afirst-degree relative ( eg, parent, sibling, or dizygotic
twin) who suffers from bipolar disorder has a 5-1 0% risk of developing the condition
in his lifetime.
Somatic symptom disorder involves one or more somatic complaints (including pain) that are
distressing or result in significant disruption of daily life, with excessive thoughts, feelings, or
behaviors related to these symptoms and lasting ~ months. Patients may have concurrent
medical illness, or the symptoms may represent normal bodily function.
Schizoaffective disorder is characterized by a significant mood episode (depressive or
manic) with concurrent psychotic symptoms in addition to a period of psychosis without
mood symptoms of at least 2 weeks.
Most antidepressants must be taken for 4-6 weeks before they provide symptomatic relief.

Minimizing conflict and stress in the home decreases the risk of relapse in patients
with schizophrenia.Family psychosocial interventions are indicated for patients with a
recent psychotic episode who have significant ongoing contact with family members.
Panic disorder is frequently associated with other psychiatric illnesses, including
agoraphobia, major depression, bipolar disorder, and substance abuse. It is also linked to a
higher rate of suicide attempts or suicidal ideations.
Antipsychotic medications are first-line treatment for psychosis. Second-generation
antipsychotics are generally preferred due to a comparatively lower risk of extrapyramidal
side effects and tardive dyskinesia.Due to the risk of agranulocytosis, clozapine is reserved
for patients who have failed at least 2 antipsychotic trials.
The dissociative disorders are characterized by forgetfulness and dissociation. Dissociative
fugue is the only condition within this group that is associated with travel.
Generalized social anxiety disorder is characterized by anxiety and fear of scrutiny in social
situations,resulting in avoidance, distress, and social-occupational dysfunction. The
preferred pharmacological treatment is a selective serotonin reuptake inhibitor or serotonin

norepinephrine reuptake inhibitor. Cognitive behavioral therapy can also be used as first-line
treatment.
Classification of psychiatric illnesses by phase is necessary to determine the appropriate
pharmacotherapy.Treatment response occurs when a patient demonstrates significant
improvement (with or without aremission), generally defined as a 50% reduction in the
baseline level of severity.
Cognitive-behavioral therapy focuses on reducing automatic negative thoughts and
avoidance behaviors that cause distress. It is effective as monotherapy or in combination
with medication for a wide range of psychiatric disorders.
Hoarding disorder is responsive to treatment with selective serotonin reuptake inhibitors and
cognitive behavioral therapy.
Persistent depressive disorder (dysthymia) refers to a depressed mood lasting most days for at least
2years. Symptoms of a major depressive episode may occur concurrently or intermittently in
persistent depressive disorder.
Vs
Patients with avoidant personality disorder desire social interaction but shy away due to feelings
of inadequacy or fear of criticism, failure, or rejection. This patient's fear of rejection by women
relates to his mood symptoms (low self-esteem) and not general avoidance of social situations.

Neuroleptic malignant syndrome (NMS) is an unusual but potentially lethal side effect from
the use of antipsychotics (neuroleptics). It is treated primarily with dantrolene sodium and
supportive care.
Cancer patients often have a depressed mood secondary to normal grieving. However,
major depression should be considered in patients with prominent somatic symptoms of
depression, guilt, feelings of hopelessness, or suicidal thoughts. There should be a low
threshold for beginning a selective serotonin reuptake inhibitor given the low risk of side
effects and large potential benefit to the patient.
The treatment of choice for adjustment disorder is cognitive or psychodynamic
psychotherapy.
Schizophreniform disorder is differentiated from schizophrenia by the duration of symptoms.
In schizophreniform disorder, symptoms must last for >1 month but <6 months. The
diagnosis of schizophreniarequires symptoms to be present for at least 6 months.
Serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors are first-line
medications for treating generalized anxiety disorder that can also potentially treat comorbid
major depression.Benzodiazepines should be reserved for nondepressed patients without a
history of substance abuse who fail to respond to or cannot tolerate antidepressants.
Disorganized speech is common in schizophrenics. Patients with a circumstantial thought
process deviate from the original subject but eventually return to it, while those with a
tangential thought process drift away without ever returning to the subject.
Because symptoms of hypochondriasis usually develop during periods of stress, patients
suffering from the condition should be asked about their current emotional stressors and then
referred for brief psychotherapy.
The extrapyramidal side effects of antipsychotics can be treated with anticholinergic
medications like benztropine.
Suspect heroin withdrawal in patients with pupillary dilatation, rhinorrhea, muscle and joint
aches, abdominal cramping, nausea, and diarrhea. The symptoms are severe and out of
proportion to physical findings.
Kleptomania is characterized by inability to resist the impulse to steal objects that are of low
monetary value or not needed for personal use. Treatment primarily involves cognitive
behavioral therapy.

First-line treatments for obsessive-compulsive disorder are selective serotonin reuptake

inhibitors or clomipramine.
POISONING AND IMMUNOLOGY
The 23-valent pneumococcal vaccine contains capsular polysaccharides and induces a
relatively T-cell-independent B-cell response. In contrast, the 13-valent pneumococcal
vaccine contains capsular polysaccharides conjugated to a protein antigen, which allows for
a more robust T -cell-dependent B-cell response.
Tricyclic antidepressant overdose can present with central nervous system, cardiac, and
anticholinergic findings. Sodium bicarbonate is used to treat cardiac toxicity, which is
characterized by prolonged QRS duration (>100 msec) and ventricular arrhythmias. Sodium
bicarbonate increases serum pH and extracellular sodium, thereby alleviating the cardiadepressant action on sodium channels.

Slurred speech, unsteady gait and drowsiness can be seen in the overdose of multiple
drugs.Benzodiazepine overdose can be distinguished from opioid overdose by the lack of
severe respiratory depression and the lack of pupillary constriction. Furthermore, while
alcohol and pheny1oin intoxication also share similarities with benzodiazepine overdose,
they can be distinguished by the presence of nystagmus.
Fluphenazine is a high potency "typical" antipsychotic medication that occasionally causes
hypothermia by disrupting thermoregulation and the body's shivering mechanism. Patients
taking antipsychotics should be advised to avoid prolonged exposure to extreme
temperatures.
Opioid intoxication does not always present with miosis. Coingestions can lead to normal
pupil size or even mydriasis and certain opioids (meperidine, propoxyphene) do not reliably
cause miosis even when taken alone. As a result, pupil examination is not as reliable as the
recognition of bradypnea in opioid intoxication.
TCA overdose is characterized by CNS depression, hypotension, and other anticholinergic
effects including dilated pupils, hyperthermia and intestinal ileus. It can also cause QRS
prolongation on EKG, leaving the patient susceptible to ventricular arrhythmias. Patients
suspected of TCA overdose should first undergo the ABC's and sodium bicarbonate should
then be administered to improve blood pressure, shorten the QRS interval, and prevent
arrhythmia
To prevent cardiorespiratory arrest and permanent neurologic disability, victims of smoke
inhalation injury should be treated empirically for cyanide toxicity with an antidote, such as
hydroxocobalamin or sodium thiosulfate, or with nitrites to induce methemoglobinemia.
Symptoms of opioid withdrawal include nausea, vomiting, cramps, diarrhea, dysphoria,
restlessness,rhinorrhea, lacrimation, myalgias, and arthralgias. Physical examination signs
include mydriasis, piloerection,and hyperactive bowel sounds. Oral or intramuscular
methadone is the treatment of choice to relieve the symptoms of opioid withdrawal in
dependent patients.
Caustic poisoning does not cause alteration in consciousness. It 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.
Neuroleptic Malignant Syndrome (NMS) is caused by the initiation of dopaminergic
antagonists and typically presents with fever, muscle rigidity, autonomic instability and
mental status change. An elevated creatine kinase, leukocytosis and electrolyte
abnormalities are also common.
Ethylene glycol is associated with hypocalcemia and calcium oxalate deposition in the
kidneys. This leads to flank pain, hematuria, oliguria, acute kidney injury, and anion gap
metabolic acidosis. Treatment involves administration of fomepizole or ethanol to inhibit

alcohol dehydrogenase, sodium bicarbonate to alleviate the acidosis, and hemodialysis in

cases of severe acidosis and/or end-organ damage.
Opioid intoxication presents with miosis, depressed mental status, decreased respiratory
rate, decreased bowel sounds, hypotension and bradycardia. Of these, decreased
respiratory rate is the best predictor of intoxication and is also a frequent cause of mortality.
The most severe consequences of methanol intoxication are vision loss and coma. Physical
exam in methanol intoxication reveals optic disc hyperemia while laboratory studies reveal
anion gap metabolic acidosis. An increased osmolar gap is often seen as well.\
All adults should have tetanus and diphtheria boosters at least every 10 years, with a onetime tetanus,diphtheria, and pertussis booster. All adults require yearly influenza
vaccinations. Cervical cancer screening can start at age 21 with either Pap smear every 3
years. For women age 30-65, screening is recommended with Pap smear every 3 years or
with a combination of Pap smear and human papillomavirus (HPV) testing every 5 years if
both initial tests are negative.