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Folic Acid Deficiency: present with megaloblastic anemia. MCC is poor diet
and alcoholism. Phenytoin, primidone, phenobarbital inhibit folate absorption.
TMP and methotrexate inhibit DHFR causing folate deficiency.
Systemic Sclerosis: affects all organ systems. Cutaneous findings are that of
scleroderma. Thickening of the skin, edema -> obliteration of hair follicles and
sweat glands and flexion contractures. Mask like appearance to face.
Myofibroblast proliferation -> increased collagen and ground substance
production. Kidney involvement -> hypertension. Pulmonary hypertension ->
right heart failure. Esophageal and gastric dysmotility -> GERD. Find ANA and
anti-topoisomerase I antibodies.
Acute Limb Ischemia: sudden decrease in perfusion that threatens limb vitality
and presents 2 weeks of symptom onset. Pain, pulselessness, pallor,
parasthesias, paralysis. Due to embolism (MCC), thrombosis, trauma. Atrial
fibrillation -> embolism. Prevent with warfarin.
Rotator Cuff Tendonitis: shoulder pain with reaching or lifting arm overhead.
Due to repetitive activity at shoulder height (painters), MC in middle
aged/older. Confirmed on PE by Neer test with pain and guarding. Confirmed
with lidocaine injection -> improvement. MRI for definitive diagnosis.
Acute Cord Compression: back pain with associated tenderness at the site
of metastasis (usually prostate). Progressive or sudden compression with
neurological deficit can ensue. Medical emergency that needs prompt
treatment. First do neurological exam for signs of myelopathy (if so, give
steroids). Then do MRI or CT myelogram if no MRI. Radiotherapy to treat.
Respiratory Acidosis: decreased pH, primary increase in PCO2. Along with low
PO2 levels, suggest alveolar hypoventilation (MCC). Causes:
pulmonary/thoracic (COPD, OSA, CF, obesity, scoliosis, ankylosis),
neuromuscular (MG, LE, poliomyelitis, muscular dystrophy, GBS, ALS), drug
induced (anesthesia, narcotics, sedatives), primary CNS (brainstem lesion,
infection, stroke).
Aortic Dissection: three clinical findings: abrupt onset tearing pain in chest
or back, variation in pulse/BP between arms, wide mediastinum on CXR. Tear
in intima -> subintimal hematoma. HTN, smoking, family history of CAD. May
extend into pericardium, CA, carotids -> tamponade, MI, stroke.
Atypical Mycobacterium: HIV infected, unexplained fever, cough, CD4 < 50, no
history of or exposure to tuberculosis. If CD4 < 50, give azithromycin as
prophylaxis.
Toxic Adenoma: clinical features and lab findings of hyperthyroid with iodine
scan showing uptake in one area and suppression of rest of gland. Do not
have infiltrative ophthalmopathy.
Acute Pain: all patients should receive same standard pain management
regardless of drug history. Use IV morphine. Never undertreat pain even with
risk of abuse. Frequently reassess, outpatient follow up, referral to pain
specialist if abuse is suspected.
Chronic Wounds: until proven otherwise, suspect SCC in a chronic wound ->
non-healing, painless, bleeding ulcer. SCC is cancerous changes in the mid
epidermis -> extension into dermis. Skin and mucous membranes can be
affected. Sun-exposed or burn areas are involved. Rough scaly nodules ->
ulcerate -> metastasize. Tar derivatives, carcinogens, radiation predispose.
Immunosuppression increases risk. Punch biopsy confirms.
AAA: surgery if > 5 cm, rapid rate of growth, symptoms present. If smaller, do
periodic imaging. Atherosclerosis is precipitant. Smoking is major RF for
formation, enlargement, rupture. Cessation is best intervention to slow
progression.
HNPCC: Amsterdam Criteria I: at least 3 relatives with CoCa with one being
first degree of other 2, > 2 generations, one before 50 y/o, FAP excluded.
Lynch I is hereditary site specific CoCa. Lynch II is cancer family syndrome and
high rate of extracolonic tumors. MC is endometrial cancer (43% of affected
females).
Isoniazid: causes hepatits picture via idiosyncratic liver injury with histological
features similar to viral hepatitis.
Acute Bronchitis: common cause of blood tinged sputum due to virus. Lack of
history or physical indicating more severe disease. Have malaise, throat pain,
wheezing. No fever (rules out pneumonia). Weight loss or more blood suggest
TB or malignancy. Observe and follow.
Saline Responsive Metabolic Alkalosis: urine chloride < 20 mEq/L and due to
GI proton loss (ex vomiting in bulimia), volume depletion, diuretic abuse. Treat
with isotonic saline infusion.
False Negatives: patients with negative test who have the disease. When
cutoff levels are raised, FN increase.
Neurofibromatosis: neurocutaneous syndrome. Autosomal dominant,
chromosome 22. Type I has caf-au-lait spots, axillary freckles, Lisch nodules
of iris, neurofibromas, bony lesions. Type II has brain tumors especially BL
acoustic neuromas (diagnostic). Develop CNS, PNS, skin, visceral tumors.
Mutations: nonsense and frame shift mutations are typically more severe than
missense or splice site mutations. Silent (same sense) mutations do not affect
the protein structure.
Scatter Plots: useful for crude analysis. Can demonstrate association (linear or
non-linear) if one is present. If linear, correlation coefficient can be calculated.
Hemi Neglect: patient neglects one side and only senses the other. May only
shave, comb, ignore people on one side. Ask patients to fill in clock, will only
fill in one side. Caused by lesion in right (non-dominant) parietal lobe,
responsible for spatial organization.
Hemoptysis: can be blood streaked sputum to massive with respiratory failure.
Airway disease (bronchitis, bronchiectasis, trauma, tumors) are MCC.
Parenchymal disease (infections, diffuse alveolar hemorrhage), and vascular
(AV malformations, PE). With significant smoking -> think chronic bronchitis.
Do CXR to check for cancer.
Lipid Screening: start at age 35 in men, 45 in women. Risk factors are (+) FH,
smoking, HTN, low HDL, age. With 0-1, goal LDL < 160. With 2, goal LDL <
130. With known CAD or CAD equivalent (diabetes, AAA, symptomatic CVD, 10
year risk > 20%), goal LDL < 100.
Cushings Syndrome: high cortisol -> vasoconstriction -> secondary HTN. Also
enhance insulin resistance (hyperglycemia) and mineralocorticoid activity
(hypokalemia). Proximal weakness, central obesity, thin skin, psych problems.
Result from adrenal cortical hyperplasia, ACTH adenoma (Cushings disease),
ectopic ACTH, steroid administration.
Simple Renal Cyst: most commonly seen in patients > 50. Benign and
incidentally discovered. Usually asymptomatic. Sometimes can become
infected. Simply observe and no follow up needed. Make sure its not
multiloculated, does not have thick or irregular walls, thickened septae, or
contrast enhancement.
Anticholinergic Toxicity: red as beet, dry as bone, hot as hare, blind as bat,
mad as hatter, full as flask. Can have dizziness, headache, tachycardia. Can
precipitate acute glaucoma due to mydriasis. Trihexylphenidyl and
benztropine are used for Parkinsons and EPSEs.
Squamous Cell Carcinoma: ulcer that is solitary, not healed for a long time,
located in keratinized epithelium of the vermillion zone of lower lip. May also
be chronic infectious, chronic autoimmune. Will have invasive cords of
squamous cells with keratin pearls. Will have history of occupational sun
exposure. Major of lip cancers are well differentiated SCC.
Acute Back Pain: with positive straight leg raise -> herniated disk. With
neurological defecit and perianal anesthesia -> cauda equina syndrome.
Manage conservatively. Return to activities ASAP. Use NSAIDs and muscle
relaxants. If longer 4-6 weeks, do imaging MRI or CT with or without contrast.
Exercise and PT are not shown to be effective.
Case Control Study: retrospective study. Movement from effect to cause. Look
at population with outcome and subjects are either cases or controls. Looks
for presence of risk factors.
Prospective Cohort Study: or longitudinal. Divides group into exposed and not
exposed. Followed prospectively until onset of disease. Stronger than case
control or cross sectional. In cohort studies, subjects are free of outcome at
onset of study.
Cross Sectional Study: exposure and outcome are studied at one cross section
of time. Not possible to determine temporal association between exposure
and outcome.
Chemicals in the Eye: first priority is immediate flushing under running water
for at least 15 minutes. Call ER, 911, doctor after washing. Acid exposure has
likely full recovery. Alkaline will more likely have permanent corneal damage.
For foreign bodies or cuts/scratches, obtain medical care first.
Rotator Cuff Tear: present with shoulder pain and weakness. Occur as end
result of rotator cuff tendonitis or trauma (FOOSH). Aggravated by pushing,
pulling, lifting overhead, lying on affected shoulder. Limited arc abduction and
external rotation. Remains after lidocaine injection. Tendonitis resolves with
lidocaine injection. MRI is diagnostic.
HIV Pneumonia: acute onset, high grade fever, pleural effusion.
Pneumococcous is the MCC. Impaired humoral immunity -> susceptibility to
encapsulated organisms.
Febrile Transfusion Reaction: fever and chills that respond to NSAIDS and
acetaminophen. No hemodynamic abnormalities or renal dysfunction
indicating hemolytic reaction or bacterial contamination. Caused by patient Ab
to donor WBCs, usually HLA specific. Leukocyte depletion can reduce
possibility. Cell washing, using frozen deglycerolized cells, or leukocyte
depletion RBC filters.
Ventricular Remodeling: after MI, ventricle slowly dilates and walls thin -> CHF
which occurs over months to weeks. ACEs inhibit ventricular remodeling and
should be started within 24 hours of MI if no contraindication.
Tinea Corporis: ring shaped scaly patches with central clearing, distinct
borders. Trichophyton rubrum is MCC, other dermatophytes can also cause.
MC symptom is itching. KOH preparation shows hyphae. Treat with topical
terbinafine if local. If extensive, give systemic griseofulvin and investigate for
immunosuppresion (DM, HIV).
Vitamin B12 Deficiency: causes are strict vegetarian diet (more than 3-4
years), and pernicious anemia, autoimmune disease resulting in parietal cell
destruction -> measure intrinsic factor Ab and B12 levels.
DM: RF are AA race, positive FH in first degree relatives. Present with polyuria,
polydipsia, obesity. Measure fasting blood glucose (recommended screening
test). > 126 on 2 occasions is diagnostic. Between 100 and 125 is insulin
resistance or pre-diabetes.
Pleural Effusion: use Lights criteria: exudate will have fluid to serum protein
ratio > 0.5, fluid to serum LDH ratio > 0.6, or fluid [LDH] > 2/3 the upper limit
for serum LDH. Complicated will have positive gram stain & culture, pH < 7.2,
glucose < 60 and needs chest tube. Empyema is frank pus.
Alcohol Withdrawl: first 6-24 hours -> anxiety, insomnia, tremors, sweating.
First 48 hours -> seizures, hallucinations. Delerium tremens -> after 48-96
hours -> HTN, agitation, tachycardia, hallucinations, fevers. Treat with BZD
like chlordiazepoxide (Librium).
Status Epilepticus: ongoing seizures activity for > 5-10 minutes or lack of
interictal return to baseline. Resistant to medications. First step is appropriate
oxygenation and blood pressure, with endotracheal intubation. Use BZD or
phenytoin as second line.
Warfarin: inhibits vit K dependent clotting factors II, VII, IX, X, protein C, S.
Protein C has half life of 9 hours -> early signs of protein C deficiency ->
hypercoagulabilty -> thrombus formation -> skin necrosis. Common in
patients with congenital protein C deficiency.
Chronic Alcoholism: multiple electrolyte abnormalities (low Mg, low K, low
PO4). Hypomagnesemia causes refractory hypokalemia. Mg is an important
cofactor for K uptake and maintenance if IC K levels. Check Mg to correct low
K. Diuretics also causes low Mg.
Test Cut Off Points: lowering cut-off point increases sensitivity. Increase true
positives and false positives. PPV = TP/TP+FP. PPV will decrease and false
negatives will also decrease.
CAD: risk factors -> men > 45, women > 55, HTN, smoking, HDL < 40, family
history of early CAD (men < 55, women < 65). HDL > 60 negates one risk
factor. Risk equivalents impart equal risk for MI as having a previous MI. They
are DM, symptomatic CVD, AAA, PVD, 10 year risk > 20%.
Diverticulitis: history of constipation with little fiber. LLQ pain and fever. Give
IV antibiotics until symptoms resolve. If fail to response, do CT to evaluate for
perforation, abscess, fistula.
Febrile Neutropenia: ANC < 1500. Susceptibility increases < 1000. Ability to
control own flora decreases < 500. Fever in these patients classified as one
temperature > 100.9, or > 100.4 for over an hour. Bacteria from skin and flora
are MC, mostly G(+). Start antibiotics that are broad spectrum and cover
Pseudomonas. Ceftazidime, cefepine, imipenem, meropenem, or combination
of aminoglycoside and anti-pseudomonal beta-lactam.
Septic Arthritis: acute onset painful swollen joint, limited ROM, fever > 104,
fluid WBC 50-150k. Crystal induced presents similarly but WBCs between 10-
50k and lower fever. Prosthetic joint increases risk. Knee is most commonly
affected by hematogenous distribution. Staph aureus is MCC in prosthetic joint
septic arthritis.
Asthma: intermittent -> daytime symptoms < 2x/wk, nighttime awakenings <
2x/mo, use of beta agonists < 2x/wk, baseline FEV1/FVR ratio is normal, no
limitations of daily activities. Treat with short acting bronchodilator as needed.
Mild persistent -> symptoms > 2x/wk but < daily, nighttime awakenings 3-
4x/mo, minor limitation, normal PFTs. Add low-dose inhaled steroid as a
controller. Moderate persistent -> daily symptoms, weekly nighttime
awakenings, FEV1 < 60-80% predicted. Add long-acting inhaled beta 2
agonist. Severe persisent -> symptoms throughout the day, frequently
nighttime awakenings, extremely limited activity, FEV1 < 60% predicted. Treat
with as needed albuterol inhaler, long acting inhaled beta 2 agonist, high dose
inhaled corticosteroids. Possible oral steroids.
Radioactive Iodine: preferred treatment for Graves disease. Takes about 6-8
weeks for improvement. Contraindicated in pregnancy and very severe
ophthalmopathy. No higher incidence of cancer.
Cervical Spondylosis: chronic neck pain. Limited neck rotation and bending
due to osteoarthritis and muscle spasm. Osteophytes -> radiculopathy ->
sensory abnormalities. X ray -> bony spurs, sclerotic facet joints, narrowed
disc spaces, hypertrophic vertebral bodies. These findings are of low
specificity.
MEN I: non-beta cell pancreatic tumor like gastrinoma -> abdominal pain,
diarrhea. Endoscopy -> multiple ulcerations, prominent gastric folds. Also
have primary hyperparathyroidism, pituitary tumors, other neuroendocrine
pancreatic tumors.
Viral Arthritis: symmetric small joint inflammatory arthritis of acute onset and
short duration. Joint swelling and low grade fever suggest inflammation.
Symptoms resolve in 2 months. Caused by parvovirus, hepatitis, HIV, mumps,
rubella. Can see positive RF and weakly positive ANA. Use NSAIDS. Antivirals
are unnecessary.
HEV: RNA virus. Histology -> focal necrosis, ballooned hepatocytes, acidophilic
hepatic degradation. Transmitted through fecally contaminated water.
Commonly found in India, Africa, Asia, Central America. Diagnosed by
detection of HEV RNA by PCR in serum or feces or IgM Ab. Self limited, no
chronic carrier state. Fulminant hepatitis can occur, more common in pregnant
women, especially in 3rd TM, can be transmitted vertically.
TMJ Dysfunction: history of teeth grinding, interpret as ear pain. Pain is worse
with chewing. May have crepitus or clicks in the TMJ with movement. Exclude
all other ear conditions. Initial treatment is conservative, like nighttime mouth
guard. Surgery sometimes needed.
Multiple Myeloma: malignant plasma cell disease -> monoclonal protein and
increased plasma volume. Normocytic anemia, hypercalcemia, renal failure,
elevated protein, normal albumin, increased ESR, Bence Jones proteins.
Presents in old age with back pain, recurrent infections. 1/3 of patients have
leukopenia. Serum immunoelectrophoresis shows M spike.
Hyperthyroid: plasma TSH is best initial test -> usually low unless TSH
secreting adenoma. Free T4 is usually elevated. Do EKG to rule out
arrhythmia. Do 24 hour radioiodine uptake to differentiate Graves from other
disease. Use propranolol for symptomatic relief.
Enthesitis: inflammation and pain at sites where tendons and ligaments attach
to bones. MC seen with recurrent tendon or ligament stress and HLA-B27
associated arthropathies like AS, psoriatic arthritis, reactive arthritis.
Prominent in AS. Manifests with heel pain where Achilles inserts. Tibial
tuberosities and iliac crests also involved.
Heat Stroke: core temperature > 40 and altered mental status. Can be
exertional (factory workers, military, athletes) or non-exertional (at extremes
of age, cannot get fluids or move from heat). Ambient heat and humidity
prevent sweat production. Present as confusion, hyperthermia, tachycardia,
epistaxis. Complications are rhabdomyolysis, renal failure, ARDS,
coagulopathy.
ACE Cough: non productive cough occurs in 5-20%. Kinins are degraded by
ACE. Accumulation of kinins and some activation of the arachadonic acid
pathway are the cause. Discontinue drug. If cough persists, do CXR, PFT,
barium swallow, bronchoscopy.
Prevention of Back Injury: usually present with lumbar strain (relation to heavy
lifting, no radicular signs, good response to conservative therapy). Strengthen
supporting muscles (abdominals), avoid sleeping on stomach, learning proper
bending and lifting. No twisting and bending exercises. Bend at knees, not at
waist. Keep back straight. Do warm ups.
Lyme Disease: doxycycline is first line for early lyme. Also treats coexistant
ehrlichiosis. In pregnant/lactating women and children, treatment choice is
amoxicillin. Penicillin G is alternate for early localized during pregnancy or
disseminated. IV ceftriaxone or cefotaxine (3 rd generation) are used for early
disseminated or late.
Chest Pain: methods for diagnosing CAD are only helpful for those at
intermediate risk. A (-) non invasive test in a high risk patient is likely false (-).
A (+) test in a low risk patient is likely false (+). In young women, anxiety and
psychosocial issues are a common cause.
Infectious Mononucleosis: splenic rupture is a potential complication and
patients with splenomegaly should avoid excessive physical activity and
contact sports until spleen is not palpable (usually 1-3 months).
HCV: major cause of chronic hepatitis (~80%) and MC acquired via infected
blood. Recommended to get vaccinated against HAV and HBV (safe during
pregnancy). Low evidence of sexual transmission.
Colon Ulcer: on scope, questionable ulcer needs biopsy to rule out cancer and
distinguish UC from Crohns since treatment is different for both.
Elevated BUN/Cr Ratio: prerenal azotemia (elevated BUN with mild elevated
Cr), steroid administration, or GI bleed (bacterial breakdown of hemoglobin
with urea reabsorption).
Megaloblastic Anemia: due to folate or B12 deficiency. Smear shows large RBC
and hypersegmented neutrophils. Have elevated homocysteine (cant convert
to methionine). B12 converts methylmalonyl CoA to succinyl CoA. B12
deficiency -> elevated MMA.
D Dimer: a fibrin degradation product elevated with blood clots and other
inflammatory conditions. (+) test has a poor PPV and is not definitive. (-) test
is good for ruling out a DVT or PE.
Hypertension: has the strongest association with strokes. Increases the risk of
all types of strokes. Have 4x higher risk of strokes than non-hypertensives.
Smoking and DM are also risk factors. Hypercholesterolemia more associated
with CAD.
Vitamin K Deficiency: antibiotics and cystic fibrosis. Important cofactor in
gamma-glutamyl carboxylase -> factor II, VII, IX, X, protein C & S deficiency.
Carboxyl groups increase affinity for phospholipids on platelet surface.
Hypovolemic Shock: blood loss -> loss of intravascular volume -> decreased
CO, decreased PCWP (indirect measure of LAP) -> activation of SANS ->
vasoconstriction, increased HR.
Myocarditis: otherwise healthy young people with acute onset CHF and lack of
CAD risk factors. Usually viral due to coxsackie B virus. May have preceding
viral type symptoms.
Dihydropyridine CCB: cause peripheral edema along with CHF, renal disease,
venous insufficiency. Cause peripheral vasodilation. If significant, discontinue.
Labs will be normal. Not an allergy!
Crohns Disease: involves entire GI tract and has skip areas. Can have apthous
ulcers in the mouth (non specific) and can see granulomas. Associating
abdominal pain with extra-intestinal manifestations can help diagnose. Can
have weight loss and anemia.
Frostbite: best initial treatment is rapid rewarming with warm water (40-44).
Results in less tissue damage than slow rewarming at room temperature.
Immerse in room water that is continuously circulated. Do not attempt to
debride initially. Dry heat is not effective.
S4: low frequency heart sound at the end of diastole just before S1.
Associated with LVH from long standing HTN, or restrictive cardiomyopathy.
Sounds like Tennessee. Results from atrial kick hitting stiff LV.
HBV Vaccination: decreases incidence of HCC especially areas with high HBV
like Africa and Asia (chronic HBV secondary to vertical transmission major
cause of HCC). In US, MC contracted due to contaminated blood. 7 th & 9th MCC
cancer death in men and women.
Cardiac Disease: detailed history and physical is most effective way to screen
for cardiac disease and underlying hypertrophic cardiomyopathy. All school
and collegiate athletes should be offered pre-participation by skilled
healthcare workers.
Morning Hyperglycemia: due to Somogyi effect (high NPH dosing with peaks 4-
10 hours after injection -> overnight hypoglycemia -> epi, NE, glucagon
release -> glycogenolysis and gluconeogenesis -> morning hyperglycemia) or
Dawn phenomenon (decreased insulin sensitivity between 3 and 8 AM ->
hyperglycemia at 3 AM and 7 AM due to spikes of GH release which occurs
shortly after falling asleep) or waning circulating insulin (usually coexists with
Dawn phenomenon, 3 AM glucose is usually normal).
Cholesteatoma: congenital or acquired secondary to chronic middle ear
disease. New-onset hearing loss or chronic ear drainage despite antibiotics.
Granulation tissue and skin debris with retration pockets of TM. Also causes
CN palsies, vertigo, brain abscesses, meningitis. Need otologic exam, and CT
or surgical visualization.
Cut Off Point: lowering cut off point will increase sensitivity.
Zinc Deficiency: result from chronic TPN (lacks zinc) or malabsorption due to
SB resection due to IBD. Causes alopecia, bullous/pustulous lesions around
orifices or extremities, abnormal taste, impaired wound healing. Normally
digested in the jejunum.
Survival in CHF: ACE I, ARBs, beta blockers, spironolactone all confer survival
benefit. Digoxin and furosemide can reduce symptoms and hospitilzations, but
do not help survival.
Essential Tremor: AD, heads and UE are often affected, worse when arms
outstretched at the very end of goal directed activities (intention tremor).
Treat with propranolol.
COPD: often have CO2 retention -> respiratory acidosis. Use diuretics to treat
cor pulmonale but caution is needed because they have a reduction in CO
with subsequent development of renal failure.
Hydroxychloroquine: good for treatment of SLE with isolated skin and joint
involvement. Most serious SE is retinopathy & corneal damage. Need eye
exams every 6 months.
Urinary Retention: abdominal pain and suprapubic fullness after taking TCAs
(anticholinergic -> reduces detrussor contraction and sphincter relaxation).
Catheterize -> document PVRV > 50 mL (diagnostic for urinary retention) and
provides symptomatic relief.
Influenza: acute onset fever, chills, cough, malaise, myalgias. Occurs in winter.
Febrile with wheezes, crackles, course breath sounds. CXR may be normal or
have interstitial pattern. Nasal swabs confirm. Start antivirals within 48 hours.
Neuraminidase inhibitors (oseltamivir and zanamivir) are used, rimantadine
and amantadine are only effective against influenza A.
ARDS: non cardiogenic pulmonary edema due to inflammation of alveoli.
Sepsis, severe bleeding, trauma, toxic injury, burns can be causes. Diagnosed
via: acute dyspnea, inciting condition, bilateral infiltrates, PCWP < 18 (> 18
indicates impaired LV function), PaO2/FiO2 < 200.
SBE and IV Drugs: increased risk in both right and left heart. If tricuspid or
pulmonic valves are involved -> septic emboli to the lung -> cough, chest
pain, hemoptysis, round alveolar infiltrates. Proteinuria due to septic emboli or
immune complex in the kidney. Tricuspid regurgitation is common -> systolic
murmur that increase on inspiration.
PPD: detect patients with latent TB infection. Degree of induration required for
(+) test depends on pre-test probability. >15 mm is (+) for healthy patients
with no known TB risk factors. >10 mm is (+) in immigrants from endemic
area, IVDA, residents/employees of high-risk settings, patients with
diabetes/CKD/hematologic malignancies/fibrotic lung disease, children < 4 or
teens exposed to high risk adults. >5 mm is (+) in HIV, recent contact with TB,
signs of TB on CXR, organ transplant, patients on immunosuppression.
Pancreatic Cancer: 5th MCC of cancer related mortality. RF: male sex, >50
years, black race, smoking (most consistent reversible RF), chronic
pancreatitis, long standing diabetes, obesity, familial pancreatitis, and
pancreatic cancer in close relative. Alcohol, gallstones, coffee intake are not
RF.
Type 4 RTA: hyperkalemia, renal insufficiency, non-anion gap metabolic
acidosis (decreased bicarbonate and normal AG). Caused by aldosterone
deficiency or tubular insensitivity to aldosterone. Failure to secrete acid as
NH4+ and potassium retention. May occur due to diabetic nephropathy and
can be worsened by ACEs and ARBs that inhibit aldosterone.
Blastomycosis: broad based budding yeast endemic to north central and south
central US. Affects lungs, skin, bones, joints, prostate. Primary pulmonary
infection is asymptomatic or presents with flu-like symptoms. Can have
verrucous (crusted, heaped up, warty, violaceous hue, sharp borders,
surrounded by micro abscesses) or ulcerative skin disease. Wet mount shows
organism.
Kidney Stones: colicky flank pain with radiation to the groin. MC are calcium
oxalate that are envelope shaped. RF are small bowel disease, surgical
resection, chronic diarrhea -> bile salt and FA malabsorption -> calcium
chelation -> reabsorption of oxalate.
DVT: presents with calf pain, swelling, discoloration (other DDx is Bakers cyst,
muscle strain, venous insufficiency, cellulitis). Decision to anticoagulate based
on history, physical, and non-invasive testing: compression ultrasound. If low
risk, do D-dimer. If negative, no anticoagulation. If positive, do ultrasound.
Aspiration Pneumonia: fever, cough with foul smelling sputum after endoscopy
or other instrumentation. Poor dentition also RF. Add antibiotic with anaerobic
coverage like clindamycin.
Atrial Myxoma: MC primary intracardiac tumor, usually in LA. Can cause fever,
weight loss, neurologic symptoms due to embolization, and mass on echo.
Usually in elderly patients.
Chronic Liver Disease: all patients should be vaccinated against HAV and HBV
unless already immune (look at Ab levels), due to high risk for acute hepatic
failure or cirrhosis.
NPH: abnormal gait (slow broad based shuffle), incontinence (urinary, fecal in
late disease), dementia due to increased ventricular size without increased
pressure. Treat with large volume LP and, if successful, VP shunt.
Central Line Thrombosis: prolonged placement -> thrombosis -> swelling (arm
if SCV). Remove catheter and duplex to document thrombus and need for
anticoagulation. Common with TPN lines which should be in RA. Hyperosmolar
fluid -> irritation of vein. Have swollen arm with present pulses. Swelling may
extend into head and neck with distended veins.
Dehydration: altered MS, dry mucosa, high electrolytes/Hct, BUN/Cr > 20.
Elderly patients are predisposed due to decreased thirst response, impaired
sodium retention, impaired renal concentration. Treat with NS, but caution: Na
loading unmasks subclinical CHF.
Serum Sickness Like Reaction: can occur 1-2 weeks after administration of
penicillin, amoxicillin, TMP-SMX, or cefaclor after viral illness. Fever, urticarial
rash, polyarthralgia, LA. Distinct from immediate hypersensitivity reactions.
Discontinue offending agent.
Lumbosacral Strain: MCC of acute back pain usually after physical exertion,
absence of radiation, presence of paravertebral tenderness/contraction, (-)
straight leg raise, normal neurological exam. Treat with NSAIDS and early
mobilization.
ABCs: start in management of ANY patient coming into ER. Poor circulation
evidenced by hypotension, pallor, tachycardia, delayed capillary refill ->
volume resuscitate -> hemodynamically stable -> start with diagnosis.
Anal Fissure: slit like tears of anal canal usually on anterior or posterior anal
verge due to passage of large, hard constipated stools. Crypt abscesses,
explosive diarrhea, perianal dermatitis/infection, IBD, trauma, sexual abuse
can all be causes. Severe pain and bright red bleeding. Treat acute and
chronic with high fiber, lots of fluids, stool softener, local anesthetic.
GERD: patient with asthma like symptoms that occur only at night (especially
those who eat late or go straight to bed), sore throat, horseness, wheezing.
Start with lifestyle modification (avoid eating late, elevated head of bed), PPI.
Atrial Flutter: sawtooth pattern of atrial impulses on EKG with large P waves
that do not conduct all QRS complexes. Caused by re-entrant rhythm. Present
with palpitations, CP, SOB, lightheadedness. Ventricular rate determined by AV
node conduction. MC is 2:1 block, can have 3:1 or 4:1 (variable AV node
conduction).
Outlier: extreme and unusual value observed in dataset. Means are extremely
sensitive and shift towards them.
FAP: AD caused by mutations of APC gene. Causes hundreds of adenomatous
polyps in colon and has 100% risk of cancer if not treated with elective
proctocolectomy.
White Out Lung: have opacification with mediastinal shift towards affected
lung due to atelectatic volume loss. MC due to obstruction due to mucus
plugging, tumor, foreign body, external compression. Causes dyspnea,
tachypnea, diaphoresis, confusion, cyanosis. Urgent bronchoscopy for
diagnosis and possible relief of obstruction.
Hyperkalemia: removal of K from the body only done via dialysis, diuretics, or
exchange resins like Kayexalate acts in GIT to exchange Na for K. Treatment
also uses calcium gluconate, bicarb, insulin with glucose/dextrose, beta
agonists.
Case Control Study: pateitns with disease of interest (cases) and people
without disease (control) are asked about previous exposure and exposure
odds ratio is measured compared case rate to control rate.
Nitrates: venodilation -> improves cardiac chest pain by reducing preload ->
decreased myocardial O2 demand. Reduces ventricular volume and wall
stress. Also cause some arterial dilation -> some decreased afterload and
myocardial O2 consumption.
Iron Deficiency Anemia: MCC of anemia in the elderly. Cause pallor and
fatigue. Usually secondary to a nutritional deficiency. Can be due to chronic
blood loss (gastritis, PU, diverticulosis).
ARDS: endothelial injury -> fluid leakage from capillaries -> fills interstitium
and alveoli -> intrapulmonary shunting -> hypoxia refractory to O2. Acute
onset, PaO2/FiO2 < 200, bilateral infiltrates, Swan Ganz < 18/absense of
JVD/cardiomegaly (which indicates CHF).
ASA Intoxication: mixed respiratory alkalosis (due to increased drive) and
anion gap metabolic acidosis (accumulation of salicylate and decreased
excretion of organic acids like lactic acid and ketoacid). Use Winters formula:
PaCO2 = 1.5(HCO3)+8+2 to determine if its mixed or not.
Wilsons Disease: AR, abnormal copper deposits in liver, basal ganglia, cornea.
Liver disease (asymptomatic to fulminant), neuropsychiatric. Have low
ceruloplasmin, increased copper excretion, Kayser-Fleisher rings.
Liver Mass: isolated mass is more likely to be metastatic than primary. Primary
tumors of GIT, lung, breast are MC. Usually asymptomatic and present with
symptoms of primary malignancy. With chronic abdominal pain ->
colonoscopy.
Ventilation: RR x Vt. Respiratory alkalosis (pH > 7.4, decreased CO2) results
from hyperventilation. In setting of appropriate Vt, lower RR (decreased Vt ->
increased RR -> worsens situation). Normal Vt is 6 mL/kg ideal body weight.
Aortic Dissection: suspect with acute retrosternal pain and normal EKG. Check
BP in both arms and listen for diastolic murmur of AR. TEE is preferred
diagnosis to MRI (takes too long) or CT. HTN should be controlled before TEE.
PE: signs and symptoms are non specific and variable. Suspect in patient with
sudden onset SOB, pleuritic chest pain, low grade fever, hemoptysis,
tachypnea, tachycardia, hypoxia. Calf swelling and Virchows triad not always
present. Low O2 and atrial fibrillation = poor prognosis.
PE: patients with recent orthopedic surgery are at higher risk for DVT and PE
and anticoagulation will be needed. Will have elevated A-a O2 gradient due to
impaired gas exchange (also seen in interstitial disease, and other processes
that alter V/Q).
Statin Side Effects: elevated liver enzymes and myopathy. Inhibition of HM-
CoA reductase. Cannot make mevalonate -> dolichol, CoQ10 (reason for
myopathy).
Minimal BRBPR: on toilet paper, drops in toilet bowl, some on outside of stool,
not intermixed. MCC hemorrhoids, anal fissure, polyps, proctitis, rectal
ulcers/cancer. If patient < 50 with no risk factors, do anoscopy or proctoscopy,
then colonoscopy if no etiology found.
Central Retinal Vein Occlusion: subacute monocular vision loss with blood
and thunder appearance on fundoscopy of optic disc swelling, retinal
hemorrhage, dilated veins, cotton wool spots. Caused by coagulopathy,
hyperviscosity, atherosclerosis, chronic glaucoma.
Central Retinal Artery Occlusion: sudden, painless loss of vision in one eye
with optic disc pallor, cherry red fovea, boxcar segmentation of blood in retinal
veins.
COPD: progressive expiratory airflow limitation -> air trapping, decreased VC,
increased TLC/residual capacity and FEV1 is disproportionately decreased.
Accompanied destruction of alveolar-capillary membrane.
MCA Infarct: with aphasia, usually cerebral cortex on the left. Brocas is
common and patients will have word finding difficulties. Rapid irregular
rhythm -> atrial fibrillation -> cardiogenic source of embolus (could be caused
by MI due to CAD).
Serous Otitis Media: middle ear effusion without active signs of infection, dull
TM that is hypomobile. MC middle ear pathology in AIDS. HIV LA or obstructive
lymphomas -> auditory tube dysfunction. MC symptom is conductive hearing
loss.
Angioedema: ACE I are the MCC of acquired, usually one week after stopping
drug. Edema in the face, lips, tongue, glottis, larynx. Occurs due to
accumulation of bradykinin. Check for airway compromise and vasomotor
instability -> epinephrine.
Male Incontinence: MCC in older men is bladder outlet obstruction due to BPH
or carcinoma of the prostate. Present with post void dribbling, poor stream,
hesitancy, urgency, nocturia, urinary retention. Will have enlarged prostate
with high PVRV.
T2DM: most patients require more than one oral agent, and some eventually
need insulin. Metformin plus sulfonylurea (glyburide) is good combination.
Assess renal status, metformin causes lactic acidosis. Also helps some weight
loss.
PE: proximal deep leg veins (iliac, femoral, popliteal) are MC source of
symptomatic PE. Calf, renal, pelvic, upper extremity, and right heart are also
possible locations.
Ulcerative Colitis: most likely in a patient with subacute to chronic
presentation of abdominal pain, tenesmus, bloody diarrhea. If symptoms are
worsening, with signs of sepsis, toxic megacolon should be investigated with x
ray.
Diffuse Esophageal Spasm: spontaneous pain, odynophagia for hot and cold
foods. Nitrates and CCB also alleviate chest pain. Do esophageal manometry
to show repetitive, non-peristaltic, high amplitude contractions spontaneously
or after ergonovine stimulation.
Spinal Stenosis: MC caused by degenerative disk disease with low back and
leg pain. Also called neurogenic claudication. Pain worse with walking, but leg
pain is position dependent and persists when standing still. Claudication is
exertion dependent. Diagnosed by MRI. Treated conservatively or with
laminectomy.
Acid Base Status: pH and PaCO2 are best values to determine status. HCO3 is
calculated from Henderson-Hasselbalch equation. pKa of CO2/HCO3 pair is
6.1.
Ventricular Free Wall Rupture: occurs during remodeling post MI. MC presents
3-7 days after (along with papillary muscle rupture), upto 2 weeks. Rapid
onset PEA is a result of tamponade -> shock -> sinus tachycardia. Do
pericardiocentesis.
Drug Induced Pancreatitis: usually mild. CT is diagnostic. Diuretics
(furosemide, thiazides), IBD (sulfazalazine, 5 ASA), immunosuppressants
(azathioprine, L-asparaginase), seizures or bipolar (valproic acid), AIDS
(didanosine, pentamidine), antibiotics (metronidazole, tetracycline).
MI: ischemia -> diastolic dysfunction and stiff LV -> atrial gallop (S4).
Parvovirus B19: arthritis of MCP, PIP, wrist, ankle joints. Anti-B19 IgM is
diagnostic. Frequent contact with children is diagnostic. MCC of viral arthritis
(polyarticular and symmetric), also HIV, hepatitis, rubella. May not have other
symptoms, resolve in 2 months.
Airway Obstruction: always rule out first with sudden onset SOB. Will have
dyspnea, difficulty swallowing, may have history of food allergies, urticaria,
laryngeal edema. May have stridor and harsh respiratory sounds.
Flash Pulmonary Edema: usually due to acute heart failure (MI). Use diuretic
such as furosemide -> decreases preload and venodilates. Beta blockers are
CI because they can worsen heart failure. Also give morphine, nitrates,
oxygen, PTCA/thrombolysis, anticoagulation.
PAC: premature activation of atria from ectopic source. Early P wave, single or
bigeminy. Can cause palpitations. Can result in SVT. Treatment needed if cause
distress or SVT. Tobacco, alcohol, caffeine, stress can all precipitate. Beta
blockers are helpful in symptomatic patients.
Anserine Bursitis: localized pain over the anterior medial tibial plateau just
below the medial joint line. Valgus stress and x rays are normal. Can be
caused by abnormal gait, overuse, trauma. Pain may present overnight. Rest,
ice, steroid injections.
Iron Poisoning: disrupts basic cell processes (free radial and lipid peroxiation)
-> hematemesis, abdominal pain, shock, metabolic acidosis. Occurs in
children of pregnant mothers (supplements are brightly colored). Treat with
deferoxamine which binds iron and allows urinary excretion.
Polycythemia Vera: increased RBC mass and totcal circulating volume. Old
male with pruritis after bathing. Hyperviscosity symptoms. Thrombosis and
bleeding due to elevated platelet count and low functionality. Reversible
moderate HTN. Granulocytosis, splenomegaly, hypercelluar bone marrow,
elevated LAP, normal O2 saturation. Low serum/urine erythropoietin.
CLL: see smudge cells on smear with small mature lymphocytes. Can have
splenomegaly, anemia, thrombocytopenia (associated with poor prognosis).
Lateral Epicondylitis: pain with supination or extension of the wrist and point
tenderness just distal to the lateral epicondyle. Due to repeated forceful wrist
extension and supination (tennis, screwdriver) from degeneration of extensor
carpi radialis tendon.
Nocardia: filamentous, aerobic, G(+) soil bacterium that is partially acid fast
and causes pulmonary or disseminated disease in immunocompromised hosts.
Treat with TMP-SMX. Can be confused with TB or Actinomyces. Have cough
with purulent sputum. Can have alveolar infiltrates with nodules and
cavitation. Can have SQ or brain abscesses.
Brain Death: total loss of brain function and legally acceptable as definition of
death. Absent CN reflexes, fixed dilated pupils, no spontaneous breaths.
Confirm with another physician first.
G6PD Deficiency: can have positive Prussian blue stain in urine due to
hemosiderin due to hemolysis. Attacks precipitated by sulfa drugs,
antimalarials, nitrofurantoin.
Addisons Disease: aldosterone deficiency -> non anion gap hyperkalemic
hyponatremic metabolic acidosis. Can be caused by TB -> adrenals. Histo,
coccidio, crypto, sarcoid can also cause. Normally, aldosterone reabsorbs Na
for K/H. If deficienct, holds on to K/H.
3rd Degree Heart Block: complete independence of P waves from QRS. Needs
pacemaker placement due to risk of VT or VF. QRS usually > 120 msec. V rate
is usually low -> dizziness and hypotension.
TIA: cerebral ischemia -> focal neurological dysfunction < 24 hours. Always do
head CT to distinguish ischemia from bleed. If thrombosis is suspected, give
antiplatelet agent (ASA). Warfarin good for cardiogenic emboli. Treatment is
important due to high risk of another.
Sleep Apnea: morbidly obese middle aged man with daytime sleepiness,
morning HA, increased fatigability and snoring. Can see mild HTN which
improves with treatment. Treat with weight reduction, avoid sedatives/alcohol,
avoid supine sleeping as first step. CPAP and UPPP also help.
Mammogram: perform every 2 years starting at age 50 with average risk, and
not beyond 75. SBE is no longer emphasized.
Atrial Fibrillation: patients are at risk for strokes and need anticoagulation.
With no other RF, use ASA. With CHF, HTN, age > 75, DM, previous stroke/TIA,
valvular disease, use warfarin.
ED: in the setting of pelvic fractures with urethral injuries, usually caused by
parasympathetic nerve injury and altered arteral supply. Failure to achieve
erections during sleep (REM) and morning is pathognomonic. Venogenic can
occur after penile fracture. Sysetmic can be due to low testosterone or high
prolactin.
Cryptosporidium: major cause of chronic diarrhea in HIV patients with CD4 <
180. Modified acid fast stain of stool shows oocysts. Can occur in
immunocompetent and HIV with CD4 > 180 but is self-limited.
ESRD: treatment options are transplant or dialysis. Renal transplant has better
survival rates and QoL. Living related > living non-related > cadaver. Anemia,
bone disease, HTN persist with dialysis. Transplant patients have better return
to normal function. Autonomic neuropathy is worse with dialysis. Survival 95%
at 1 year, 88% at 2 years.
DKA: causes anion gap metabolic acidosis. Have polyuria, polydipsia, nausea,
vomiting, abdominal pain that may present like surgical abdomen.
Graft vs Host Disease: common after bone marrow transplant. Caused by
recognition of major and minor MHC by donor T lymphocytes and cell
mediated immune response. Affects skin (maculopapular rash on palms, soles,
face), intestine (bloody diarrhea), liver (abnormal LFTs and jaundice).
Heat Stroke: defined as temperature > 105. Exertional type occurs in healthy
individuals exercising in extreme heat. Dehydration, hypotension, tachycardia,
tachypnea. Seizures, ARDS, DIC, hepatic/renal failure may also occur. High
humidity may prevent sweating, can be exacerabated by medications with
anticholinergic activity.
Chronic Hepatitis B: elevated ALT, detectable HBsAg, HBeAg, and HBV DNA
should be treated with interferon and lamivudine. Degree of ALT elevation
indicates response to medication. ALT 2x normal is likely to respond versus
normal ALT. Lamivudine is oral and has less SE.
Amebic Liver Abscess: contain debris described as anchovy paste, but cyst
aspiration is not recommended. Treatment is oral metronidazole. Recent
immigration, RUQ pain, tender solitary abscess. Caused by Entamoeba
histolytica, can cause dysentery, brain, cardiac, pulmonary involvement. CT or
MRI plus leukocytosis and elevated ALP. Also serum testing.
DEXA scan: USPSTF recommends one time screening for all women > 65, > 60
with RF. T score compared to younger individual of same gender and race. -1.5
to -2.5 is osteopenia, < -2.5 is osteoporosis. High risk in post menopausal
women.
Diabetic Neuropathy: TCAs are DOC. Can worsen urinary symptoms and
cause orthostatic hypotension. Gabapentin is the alternative. Usually present
at rest and worse at night. As it progresses, pain subsides and disappears,
whereas sensory deficit stays. Small fiber is more pain and allodynia, large
fiber is more sensory loss, low proproceiption, no ankle jerk.
Acute Pericarditis: typically occurs in first several days after an MI. Sharp
pleuritic pain worse when lying down and better when sitting up and leaning
forward. Diffuse ST elevations with PR depression is common. Friction rub may
be heard.
Alpha 1 Antitrypsin Deficiency: non smoking adults < 45 years old with pan
lobular emphysema (centrilobular in smoking). Causes liver disease (may
present as neonatal hepatitis, cirrhosis, liver failure). Measure serum A1AT.
SAH: vasospasm is major cause of M&M. CCB (nifedipine) are used to prevent
vasospasm. Signs of ischemia appear 7 days after bleed.
Postictal Lactic Acidosis: transient anion gap metabolic acidosis that resolves
without treatment after 60 to 90 minutes after cessation of seizure activity.
Excess production of lactic acid and decreased hepatic uptake. Observe and
repeat chemistry panel in 2 hours.
Cellulitis: caused by beta hemolytic strep and Staph aureus. With systemic
signs of fever, chills, malaise, fatigue, treat with IV nafcillin or cefazolin.
Vancomycin for MRSA. Chronic fungal foot infections serve as a nidus for
celluitis and eradicate in patients with recurrance.
MS: patchy neurological problems, optic neuritis (painful loss of vision in one
eye with central visual defect. Do MRI to see cerebral or cerebellar plaques.
Precision: measurement of random error. Tighter the CI, the more precise.
Increasing sample size increases precision.
SCC: second most common non-melanoma skin cancer. Single most important
factor in development is sunlight. Have polygonal cells with atypical nuclei at
all levels of epidermis with zones of keratinization.
Endocarditis: viridans type strep (MC is strep mutans, also causes caries) is
MCC of endocarditis after dental procedures. Pre existing MS is RF. Other
viridans are mitis, sanguis, salivarius. Staph epidermidis causes prosthetic
valve endocarditis.
DKA: suspect in stuperous patients with rapid breathing, history of weight loss,
polydipsia, polyuria. Can be triggered by infection. Kussmauls respiration
(rapid deep breathing) due to acidosis. Measure glucose first. Then chemistry,
CBC, ABG.
Diabetic Foot Ulcers: RF are diabetic neuropathy (80%), PVD, poor glycemic
control, bony abnormalities, male sex, smoking, > 10 years, history of
previous ulcer or amputation. MCC of non traumatic amputations. Will have
loss of monofilament sensation.
Amebic Liver Abscess: history of travel with dysentery (bloody diarrhea) and
RUQ pain due to cyst in RIGHT lobe of liver. Caused by Entamoeba histolytica,
Primary colon infection -> portal circulation. Can be on superior surface ->
shoulder pain. Aspirate is sterile. Flagyl.
External Hordeolum: also called stye. Staph abscess of eyelid. Localized small
swelling along margin of eyelid. Use warm compresses. I&D is done if no
resolution in 48 hours.
PVCs: common in post MI patients. Even though they may indicate worse
prognosis, should not be treated unless causing symptoms (can worsen
survival). Beta blockers are first line.
Osteomalacia: low to low normal calcium, low phosphorus, low 25 Vit D, high
PTH (makes calcium near normal in beginning and worsens
hypophosphatemia). Have symmetrical looser zones, pseudofractures,
blurring of the spine.
Torticollis: focal dystonia involving SCM. Can occur idiopathically, but can be
medication related (typical antipsychotics, metoclopramide, procholperizine),
congenital, secondary to trauma or inflammation. Dystonia = sustained
muscle contraction -> twisting repetitive movements or abnormal posturing.
Acute MS: usually treated with steroids. Usually used when patients have
disabling symptoms. Not used for mild sensory symptoms. To reduce
frequency of exacerbations, use interferon, plasmapheresis,
cyclophosphamide, IVIG, glatiramer acetate.
Acute Limb Ischemia: consider in patient with 5 Ps. Angiography will show
abrupt cutoff in blood supply. Start IV heparin. Needs surgical embolectomy or
intra-arterial fibrinolysis/mechanical embolectomy. IV streptokinase is used for
STEMI.
SCC Lung: suspect in patient with smoking history, hilar mass, hypercalcemia
(may have symptoms). Due to production of PTHrP -> increased bone and
renal resorption of calcium. May be due to bone involvement in late cancer
(serious implication).
Situational Syncope: typical is middle aged or older male who has LOC after
urination (may have BPH symptoms and nocturia) or during coughing fits. Due
to autonomic dysregulation which can be explained by straining and rapid
bladder emptying. Can have cardioinhibitory and vasodepressor mechanisms
involved.
MS: total protein is usually normal, but have high Ig levels, usually IgG but
also IgM and IgA. Oligoclonal bands present in > 85-90%. Rest of CSF is
normal. Elevated Ig also seen in neuropathies, CNS infections or viral
syndromes. Not diagnostic for MS.
Warfarin: dose should be adjusted based on INR for condition. VTE (3 month
treatment) and atrial fibrillation should be between 2 and 3 for good
anticoagulation without bleeding risk. 2.5 to 3.5 in patients with prosthetic
valves.
Scleroderma: absence of peristaltic waves in lower 2/3 and low LES tone are
characteristic for esophageal dysmotility due to scleroderma. Sticking
sensation and dysphagia with heartburn.
Hyperthyroidism: untreated, are at risk for rapid bone loss due to increased
osteoclastic activity in bone cells. Also at risk for arrhythmias (atrial
fibrillaion). Will have hypercalcemia and hypercalciuria.
PE: CT angio is test of choice but V/Q scan is useful tool for those with contrast
allergy or renal disease. Will have large perfusion defect without ventilation
defect, called mismatched defect. < 50% have this.
Non Alcoholic Steatohepatitis: insulin resistance plays central role -> fat
accumulation by increasing rate of lipolysis and elevating circulating insulin
levels. FA oxidation -> increased oxidative stress -> inflammatory cytokines
-> inflammation, fibrosis, cirrhosis.
Loop Diuretic: given to cirrhotic patients with volume overload and ascites. SE
are hypokalemia, metabolic alkalosis, pre-renal renal failure. Inhibit Na/K/2Cl
transporter. Promote Na, K excretion. Volume depletion -> renal failure.
Aldosterone -> alkalosis.
Folic Acid Deficiency: tea and toast diet predisposes. Folic acid is head
sensitive (dont get from cooked foods). Causes macrocytic anemia. Can
deplete in 4-5 months.
PE: result in pulmonary hypertension with elevated RAP and PAP, can result in
shock. Normal RAP is 4-6, normal PAP is 25/15. Will have sudden onset. COPD
and L heart disease also cause pulmonary HTN.
Chronic Liver Disease: should be up to date on childhood vaccinations, HAV
and HBV, annual intramuscular influenza, invasive pneumococcal disease. And
should get Td booster every 10 years.
Left Atrial Enlargement: due to mitral stenosis. Can cause persistant cough
and elevation of left main stem bronchus. MCC is rheumatic fever. Loud S1,
opening snap, diastolic murmur. ECG will have atrial fibrillation or LAE. Echo
confirms. Surgery to treat.
Brown Sequard Syndrome: damage to the lateral STT -> contralateral loss of
pain and temperature beginning two levels below the lesion. Fibers cross early
in the cord.
Chest Pain: in a young person with RF, warrants cardiac workup. First drug to
give is ASA during suspicion of coronary event to prevent platelet
aggregation. >35, family history, smoking, estrogen therapy increase risk of
thrombosis.
Toxoplasmosis: HIV patient with fever, HA, confusion, ataxia, ring enhancing
lesion. Can have seizures and focal neurological deficits due to mass effects.
Occurs < 100 CD4. Due to reactivation, look for Ab at diagnosis. Treat
prophylactically with TMP/SMX if have Ab.
Influenza Vaccine: all individuals > age 50 should get it yearly. Younger adults
with medical problems, frequent exposure to small children, pregnant women,
healthcare workers should also get it annually. COPD needs pneumococcal as
well, but not annually.
MG: fatigable muscle weakness involving the ocular and bulbar muscles. 15%
have a thymoma which can be seen on CT chest, small % can be invasive.
Photo Protection: important in high risk groups. Sun avoidance is best method
of protection. Sunscreens should be applied 15-60 minutes before. Avoid
outdoor activities between 10 AM and 4 PM.
Intracranial HTN: diagnosed when ICP > 20. Presents with HA, vision changes,
nausea, vomiting, changes in awareness, focal neurological defecits. Trauma,
space occupying lesions, hydrocephalus, impaired CNS venous outflow. Worse
in morning, unsteadiness, Cushings reflex (hypertension and bradycardia). Do
CT or MRI.
VTE: treat initially with heparin & warfarin combination. If INR is therapeutic,
heparin is discontinued after 5 days. Warfarin should be continued for 6
months for first clot and lifetime for second.
Presbyopia: common age related decrease in lens elasticity that leads to
difficulty with near vision, prohibits accomadation. Middle aged individual who
holds books at arms length is classic.
FFP: given to patients with bleeding disorders and liver failure. Vitamin K will
not work because of liver disease.
CNS Lymphoma: HIV infected patient with altered mental status. EBV DNA in
the CSF, and solitary weakly ring enhancing periventricular lesion on MRI.
Statin Induced Myopathy: CPK levels of anyone on statin with muscle pain. If
highly elevated, stop the statin. Can progress to rhabdomyolysis (kidney
failure). Also causes increased LFTs.
Endocarditis: first draw blood for culture then give empiric antibiotics. IVDA
and valvular abnormalities are RF. When culture is available, antibiotics can be
changed.
Solitary Pulmonary Nodule: first step is to find old x rays. Absence of growth
over time rules out malignancy. If not available, decide if high or low risk (age,
smoking). Low -> serial CT. Intermediate -> PET, or biopsy. High -> surgical
removal.
Influenza: treat with bed rest and analgesia. Antivirals decrease symptoms
by 2-3 days but only effective if given within 48 hours. Amantadine and
rimantadine are only active against Influenza A. Zanamivir and oseltamivir
(neuraminidase inhibitors) active against both.
SVC Syndrome: malignancy is MCC (smoking, weight loss). Lung cancer (SC)
and NHL are usual causes. Fibrosing mediastinitis due to histoplasmosis or Tb
infection or thrombosis due to central catheters. Do CXR to diagnose.
Dyspnea, venous congestion, swelling of head, neck and arms.
HIV Esophagitis: start first with oral fluconazole directed against candidiasis.
Failure to respond in 3-5 days needs endoscopy. Usually CD4 < 50. Painful
swallowing and substernal burning. HSV and CMV are both causes as well.
NFII: young patient with acoustic neuroma and caf au lait spots. MRI with
gadolinium is best way to diagnose. Gradual tinnitus and hearing loss.
Frequently bilateral.
TB and HIV: Tb has a very high rate of progression. Positive PPD (> 5 mm in
HIV) needs INH and pyridoxine (to cover INH neuropathy, but does not prevent
hepatitis) for 9 months. Monitor LFTs.
BZD OD: slurred speech, unsteady gait, drowsiness -> BZD or opioid. BZD do
not have severe respiratory depression and no pupillary constriction. Alcohol
and phenytoin intoxication are similar but have nystagmus. Lithium has
tremor, hyperreflexia, ataxia, seizures.
Lye Ingestion: effects are instantaneous, effects are most pronounced in the
esophagus -> liquefactive necrosis. Early upper GI contrast studies and
endoscopy are critical for evaluating damage and deciding on treatment. Have
retrosternal pain, hypersalivation, dysphagia/odynophagia. Give IVH and
receive serial abdominal and chest x rays. Gastrograffin study if rupture is
suspected.
Primary Syphilis: dark field microscopy is good for evaluation. Patients may be
involved in high risk sexual activity so HIV counseling and screening with
ELISA should be offered.
HIT: seen in about 5-15% of patients with onset in 3-15 days and resolution 4-
5 days after stopping. Elevated PTT is therapeutic, thrombocytopenia is
adverse effect. Can have paradoxical thrombosis.
Opioid Intoxication: does not always present with miosis. Coingestions can
have normal pupil size or even mydriasis. Meperidine and propoxyphene do
not cause miosis. Decreased RR, obtundation, hypothermia, decreased bowel
sounds, hypotension. Needle marks on extremities. Administer naloxone.
Otitis Externa: any diabetic patient with severe ear pain, otorrhea, evidence of
granulation tissue in ear canal. Pseudomonas is MCC. Pain radiates to TMJ and
worse with chewing. Worsening with antibiotics -> malignant.
Inferior MI: right ventricular infarction -> right heart failure. Hypotension, JVD,
clear lung fields, Kussmauls sign (increased JVD with inspiration). Preload
dependent -> treat with IVF and avoid nitrates and diuretics to decrease
preload. STE in II, III, aVF and STD in I, aVL. Can use right sided EKG leads.
Low HR -> possible SA node involvement.
Retroperitoneal Hematoma: can occur even with normal INR. Back pain and
signs of hemodynamic compromise. Greater risk of bleed on warfarin in
diabetics, age > 60, hypertension, alcoholism. CT will show isodense
collection anterior to psoas, displacing kidney.
Myoglobinuria: suspect with large amount of blood on dipstick but few RBCs
on UA. Usually caused by rhabdomyolysis -> ARF (high BUN, Cr, K). Seizures
can be a cause.
AAA: USPSTF recommends screening male active/former smokers between 65
and 75 years old one time with abdominal US (low cost, non-invasive, no
radiation). Repair aneurysms > 5.5 cm. No recommendations for or against
men 65-75 who have never smoked.
OA: lack of physical exam findings and lab changes. Based on clinical
impression and radiographic evidence. Age > 50, crepitus, bony enlargement,
bony tenderness, lack of warmth/morning stiffness. If > 3, specificity is 69%.
New HIV Patient: VDRL, PPD, HAV/HBV serology, Ab titer for Toxoplasma are all
indicated.
ED: in treating patient with sildenafil and an alpha blocker (usually zosin),
give drugs 4 hours apart to decrease risk of hypotension. Diabetics are at high
risk for ED. Vascular complications, neuropathy, medications are usual causes.
First line is PDE inhibitors. CI in people taking nitrates, precaution in conditions
with priapism, concurrent use with drugs that may increase life
(erythromycin, cimetidine).
Portal HTN: MCC of ascites. Usually due to cirrhosis from chronic liver disease
(alcoholic or viral). IVDA -> cirrhosis due to possibility of HBV/HCV infection.
GERD: retrosternal burning after eating and lying down. May have horseness
and chronic cough especially when recumbent. Initial treatment is H2 receptor
antagonist (ranitidine) or PPI. Refractory -> fundoplication or endoscopic
treatment. Barretts and adenocarcinoma. May be trigger for asthma (upto
75% of cases). May have wheezing (all patients with asthma symptoms should
be asked about GERD symptoms as well).
Hypertriglyceridemia: can cause acute pancreatitis when levels > 1000. May
have eruptive xanthomas on PE. Diagnose with fasting lipid profile.
Hypercalcemia, recent ERCP, trauma, infection, medications also causes.
Euthyroid Sick: any patient with acute severe illness can have TFT
abnormalities. MC pattern is fall in total T3, normal T4 and TSH (low T3
syndrome). Due to caloric deprivation and cytokine release. More severe ->
lower T3. Longer sick -> T4 and TSH drop. Prognosis : severity of lab
abnormalities.
SBP: suspect in any patient with cirrhosis and ascites who presents with low
grade fever (cirrhotics may be hypothermic), abdominal discomfort, altered
mental status. Paracentesis with PMN > 250 and positive culture is diagnostic.
SAAG > 1.1 = portal HTN as cause.
Lithium: common cause of nephrogenic DI. Treated with salt restriction and
discontinuation. Complete DI -> urine osmolarity < 300, partial DI -> urine
osmolarity 300-600. Demeclocycline, foscarnet, cidofovir, amphotericin also
cause DI.
Power: the power of a study is its ability to detect the difference between two
groups. Increasing the sample size -> more power -> makes CI of the point of
interest tighter.
Herpes Encephalitis: temporal lobe affected, may present acutely (< 1 week)
with focal neurological signs. Present with lymphocytic pleocytosis, increased
number of erythrocytes, elevated protein. Do HSV PCR is gold standard for
diagnosis. Usually HSV-1 beyond neonatal period. Can present as seizures.
EEG -> intermittent high amplitude slow waves. IV acyclovir.
Parkinsons: three cardinal signs are resting tremor (resting pill rolling usually
focal to one hand and generalizes), bradykinesia, rigidity (lead pipe or
cogwheel), postural instability. 2/3 signs on physical exam grounds for clinical
diagnosis. Accumulation of alpha synuclein in substantia nigra.
Acute Pancreatitis: serum amylase and lipase are considered most sensitive
and specific tests for diagnosis. Early on there is dysfunction between
synthesis-secretion. Cells keep making enzymes when no secretion ->
leakage. Lipase is more sensitive and specific.
AS: three most common causes are senile calcific aortic stenosis, bicuspid
aortic valve, rheumatic heart disease. Bicuspid valve considered in anyone <
70. May have CHF signs, S4.
Papilledema: transient loss of vision for a few seconds with changes in head
position, confirmed by ophthalmologic examination. Caused by increased ICP
(morning HA, changes in HA intensity with position). When ICP increased ->
transmitted to optic nerve head -> swelling. Enlarging blind spot.
Aortic Dissection: tearing pain with radiation to the back and difference in BP
of > 30 mm Hg between the arms. TEE or CT with contrast to diagnose.
Collagen abnormalities also predispose to MVP.
Flecanide: used to treat ventricular arrhythmias and SVT like atrial fibrillation.
Class IC (blocks Na channels), elongates depolarization -> slow conduction
through AV node and bundle of His. Have use dependence where effect
increases (QRS increases) as HR increases (not as much time to dissociate).
Class IV also has use dependence but doesnt elongate QRS.
Atrial Fibrillation: irregularly irregular R-R interval with absent P waves and
narrow QRS complexes. In unstable patients, do immediate cardioversion. If
stable who have been in atrial fibrillation < 48 hours, cardioversion is
appropriate. > 48 hours, 3-4 weeks of rate control and anticoagulation before.
Use beta blocker or CCB.
Pleural Effusion: CHF is the MCC. Pleural fluid will be consistent with
transudate. Normal pleural fluid pH is 7.64. < 7.3 indicates pleural
inflammation. 7.35 would be transudative. Glucose < 60 favors
parapneumonic effusion, TB, or RA.
Breast Cancer: single most important RF is age. Women > 40-50 years of age
need regular annual mammograms. Only 10% have family history. Rare before
age 30.
NPV: probability of being free of a disease if test is negative. NPV will vary
with pretest probability. High probability = low NPV and vice versa.
HUS: child who has recently recovered from diarrheal illness and presents
with ARF, MAHA, fever, thrombocytopenia, schistocytes and giant platelets on
peripheral smear. GI bleeding is common. Purpura and HTN. Elevated LDH and
indirect BRN and reticulocyte.
SCC: of the head and neck in alcoholic smoker who presents with palpable
cervical LN. Panendoscopy (esophagoscopy, laryngoscopy, bronchoscopy) to
find primary tumor.
Dipstick: test for nitrites and esterase in suspected cases of UTI. (+) LE
signifies significant pyuria and (+) nitrites indicate Enterobacteraceae.
OA: predominantly involves DIP joints. Major radiographic features are joint
space narrowing, subchondral sclerosis, osteophytes, subchondral cysts.
TSH Adenoma: excessive TSH levels -> hyperthyroid state. Elevated T3 and T4
levels with inappropriately elevated TSH levels. Usually macroadenomas. Do
not have infiltrative ophthalmopathy or pretibial myxedema. Elevated alpha
subunit.
Bladder Cancer: screening is not recommended even in those who are at risk
of developing the disease. 2nd MC urologic cancer. Men > women. Smoking
and exposure to industrial chemicals are common causes.
Inferior Wall MI: most likely cause is RCA occlusion (could be left circumflex).
ST elevation in inferior leads (II, III, aVF). Bradycardia and hypotension
suggesting SA node involvement.
Follicular Carcinoma: invasion of the capsule and blood vessels required for
differentiating follicular carcinoma from adenoma. Tend to invade blood
vessels and metastasize to different organs.
Acute Limb Ischemia: in a patient with an MI who develops a cold leg, one has
to get an echo to rule out a thrombus in the LV.
Seborrheic Dermatitis: also called cradle cap. Papular scaly rash tends to
affect eyebrows, nasolabial folds, and scalp. Treat with moisturizers,
antifungals, topical steroids, anti-dandruff shampoo. Transparent yellow
papules. Severe cases may be due to immunodeficiency.
HIV and Dysphagia: give 1-2 weeks of fluconazle therapy since candidal
esophagitis is most likely. If symptoms persist, do endoscopy. HSV ulcers are
multiple, well circumscribed, volcano like (small and deep appearance) ->
treat with acyclovir. CMV ulcers are large, shallow, superficial and
intracytoplasmic/intranuclear inclusions -> treat with ganciclovir.
Scabies: highly contagious disease with presents with generalized itching and
pruritic papules over the penis and scrotum in males and on areolas and
breasts in females. Treat with 5% permethrin cream which is applied from
neck down and left overnight.
Pronator Drift: relatively sensitive and specific for UMN damage affecting
upper extremities. Supinators are naturally stronger but exaggerated with
UMN lesion. When people are feigning, they will tend to drop the affected
arm without pronating.
PCKD: heritable form of renal disease with multiple renal cysts and
intermittent flank pain, hematuria, UTI, and nephrolithiasis. Enlarged right
kidney is easier to palpate than enlarged left because its lower. Liver might be
enlarged due to cystic involvement.
Normal Distribution: symmetric and bell shaped. All its measures of central
tendency are equal, mean=median=mode. Skewed distributions do not have
the same tendency.
BNP: measurement of serum BNP can help distinguish between CHF and other
causes of dyspnea. Released from ventricles in response to volume overload.
Usually levels > 100 for CHF.
Orbital Cellulitis: pain with eye movement, proptosis, decreased visual acuity.
CT used to define extent or presence of abscess. Preseptal cellulitis presents
similarly with swollen, painful eye and fever. Sinusitis can cause orbital. Treat
with broad spectrum antibiotics.
Clubbing: new clubbing in patients with COPD can indicate cancer. NOT a
feature of simple COPD. Thickening of the nail bed, loss of angle between nail
bed and nail fold.
Primary HIV Infection: present with mononucleosis type syndrome with fever,
night sweats, LA, arthralgias, diarrhea. Make the diagnosis in an early stage.
Usually 2-4 weeks after the exposure. Can have mucosal ulcerations and skin
rash. Prolonged diarrhea and weight loss.
Gout: cessation of alcohol and low purine diet are important measures to
prevent future attacks. Ethanol -> lactate which competes with urate for
excretion. Also avoid drugs like diuretics and pyrazinamide. Treat acute attack
with colchicine, NSAIDs, or steroids.
HOCM: heart murmur at LLSB that decreases with increased preload (standing
to squatting) or intensifies with decreased preload (Valsalva). MC in AA. AD
disease inheritance.
Bacillus Cereus: causes nausea and vomiting after eating rice. Symptom onset
is 1-6 hours. Produces a heat stable toxin in inadequately refrigerated cooked
rice. Chemical irritants also cause abrupt onset nausea and vomiting.
Warfarin: vitamin K antagonist used for anticoagulation. Foods with high vit K
(dark green, vegetables) decrease efficacy while foods, supplements,
medications such as alcohol, vitamin E, garlic, ginko biloba, ginseng, St Johns
wort, antibiotics increase efficacy -> bleeding.
Crigler Najjar Type 2: AR with milder jaundice (< 20). Survival into adulthood
with no kernicterus or neurological impairment. LFT and histology are normal.
Phenobarbital decreases BRN level. Periodic phenobarbital or clofibrate can be
used if necessary.
Mallory Weiss Tears: increased intragastric pressure during vomiting -> tears
in cardial mucosa and sometimes esophagus. Account for upto 10% of GI
bleeds. Usually spontaneously stops but can use vasopressin, endoscopic
injection, electrocautery.
Coarctation: presents with rib notching on CXR. 3 sign is typically seen with
coarctation of longer duration implying proximal aortic dilatation, constriction,
descending aortic dilatation. MC location is at site of LA. HA, epistaxis, cold
extremities. Radiofemoral delay. Upper extremity may be preferentially well
developed.
Hepatorenal Syndrome: complication of liver disease characterized by renal
failure that does not respond to fluid resuscitation. Decreased GFR in absense
of shock, proteinuria, other clear cause of dysfunction. Results from
vasoconstricton due to decreased blood flow and low vasodilatory product
production. Type 1 is rapid and patients die within 10 weeks. Type 2 is slower
and survival is 3-6 months. MCC of death is hemorrhge or infection. Liver
transplant is only treatment.
Lactose Intolerance: positive hydrogen breath test, positive stool for reducing
substances, low stool pH, increased stool osmotic gap. No steatorrea. Osmotic
diarrhea, abdominal cramps, bloating, diarrhea. Breath test = positive
hydrogen level after ingestion = bacterial metabolism.
Anterior Cerebral Artery Stroke: contralateral motor and sensory deficits which
are more pronounced in the lower limb than the upper limb. May have urinary
incontinence, gait apraxia, primitive reflexes, abulia, paratonic rigidity.
Pica: appetite for non nutritive substances like ice, clay, dirt, paper products.
Can be a cause of iron deficiency (suspect chronic bleeding), especially with
ice. May also be a manifestation of psychiatric disease.
Metastatic Prostate Cancer: radiation therapy is done in patients with prostate
cancer who have undergone orchiectomy. Do focal external beam therapy.
WPW: if develop atrial fibrillation with rapid ventricular rate treat with
cardioversion or procainamide/quinidine. AV blockers like beta blockers, CCB,
digoxin, adenosine should be avoided since it can increase conductance
through accessory pathway.
Iron Deficiency: low serum iron, ferritin, transferrin saturation, high TIBC. Have
low MCV, MCH, reticulocyte count. Have anisocytosis, poikilocytosis,
hypochromia, microcytosis on smear.
Mitral Stenosis: left atrial dilatation with risk of atrial fibrillation and cardiac
emboli. Pressure is transmitted to pulmonary vasculature -> dyspnea, cough,
hemoptysis. Can present with stroke. Patient may have history of rheumatic
fever or be an immigrant.
Parapneumonic Effusion: when pH < 7.2, glucose < 60, probability is high that
fluid needs to be drained. Drained via a chest tube (tube thoracostomy).
Herpes Zoster: a painful reaction of the varicella zoster virus that causes
vesicular rash in dermatomal distribution. Acyclovir and other antivirals are
used to decrease duration and incidence of post herpetic neuralgia. Pain
precedes rash by 48 hours.
CMV Colitis: any HIV (+) patient with bloody diarrhea and normal stool
examination should have colonoscopy to look for CMV colitis. Bloody diarrhea
with abdominal pain. Colonoscopy shows multiple ulcerations and mucosal
erosions. Biopsy has characteristic cytomegalic cells with intracytoplasmic and
intranuclear inclusions.
Aortic Regurgitation: wide pulse pressure, felt as water hammer pulse. Lying
down and turning to the left brings the heart closer to the chest wall and
makes the patient more aware of forceful heartbeat. Aortic root and bicuspid
aortic valve are MCC. Rheumatic fever is CC.
PE: suspected in all patients at risk of DVT with acute onset tachypnea,
dyspnea, chest pain. Can have exudative (MC) or transudative effusion.
Diagnosed by helical CT of chest.
Acute Variceal Bleeding: first step is to establish vascular access with two
large bore IV needles or central line. Protect airway and decompress stomach
with NG to prevent aspiration. 50% stops spontaneously. Terlipression (analog
of vasopressin), octreotide, somatostatin can be used. Rebleeding is common
in 6 weeks following initial bleed.
Sickle Cell Trait: suspect in young black male who presents with painless
hematuria. Thought to be due to papillary ischemia due to low local oxygen
tension -> sickling.
Unfractionated Heparin: thrombocytopenia and hypercoagulation within days
of starting anticoagulation therapy. HIT -> abnormal intravascular thrombosis.
Heparin induced release of platelet factor 4 -> immunogenic heparin-PF4
complexes. IgG Ab -> activation of platelets and endothelial cells and
abnormal generation of intravascular thrombin. Elevated aPTT.
HIT: first step in management is to stop all heparin including LMWH. HIT I is
non immune -> direct heparin effect on platelets. HIT II is autoimmune, within
4-10 days. Give alternate anticoagulation like danaparoid and direct thrombin
inhibitor (argatroban, lepirudin).
Staph Endocarditis: IVDA are at increased risk usually on tricuspid valve. Also
those with skin infections, infected medical devices. Vegetations can embolize
to the lungs causing nodular infiltrate with cavitation.
Coagulopathy: FFP contains all the clotting factors and first line treatment
(esophageal variceal bleeding in patients with hepatic disease). Also has
plasma proteins and fluid. Fluid resuscitation is more important that diagnosis
in unstable patients.
Ectopic ACTH: lung cancer can cause. Important cause of Cushings. Sexual
dysfunction can be presenting complaint. Can have hypokalemic acidosis. Also
caused by adrenal neoplasia, pituitary adenoma, exogenous intake.
TCA OD: sodium bicarb (if QRS > 0.1 seconds) narrows QRS preventing
development of arrythmia by alleviating cardio-depressent action on sodium
channel. QRS prolongation -> ventricular arrhythmias.
HIV Ophthalmologic Disease: HSV and VZV can both cause severe, acute
retinal necrosis associated with pain, keratitis, uveitis, peripheral pale lesions
and central necrosis on fundoscopy. CMV retinitis is usually painless and not
associated with keratitis or conjunctivitis. Hemorrhage and fluffy or granular
lesions around retinal vessels.
Acute Hepatitis B: testing for both HBsAg and anti HBc is best screening.
ALT>AST. HBsAg is the first marker detected and is detectable during entire
symptomatic phase. Anti-HBs is found after immunization or clearance of
HBsAg, detectable for life. Indicator of noninfectivity and immunity. Window
period between disappearance of HBsAg and anti-HBs. HBcAg not usually
detectable. Anti-HBc appears after HBsAg, IgM is indicative of acute disease
and is present during window period, so is important between clearance of
HBsAg and anti-HBs. HBeAg detectable shortly after HBsAg, indicates viral
replication and infectivity. Cleared before HBsAg and followed by presence of
anti-HBe. Anti-HBe suggests cessation of active replication and low infectivity.
CIN II/III: should have Pap smears with or without coloposcopy and ECC every
6 months until 3 (-) results. May resume standard screening after that (annual
until 65 or 70). Can increase to every 2-3 years if 3 (-) results with same
monogamous partner.
Testicular Mass: after diagnosis of solid testicular mass is made (painless hard
mass in testicle + suggestive US), initial management is removal of the testis
and cord. Transcrotal biopsy is CI due to risk of spillage of cancer cells ->
spread through lymphatics and blood.
GBS: acute or subacute ascending paralysis. CSF has elevated protein with
normal glucose, WBC, RBCs. Acute idiopathic polyneuropathy. Motor > sensory
(can have distal parasthesias). Autonomic disturbances are rare & fatal. Treat
with IVIG and plasmapheresis.
Acute Otitis Media: consider in any patient with ear drainage and difficulty
hearing. Ear pain is also common, but may be absent in young patients. Fever,
irritability, diarrhea. Can have boggy nose and PND. Erythematous TM with
decreased motion.
PAC: benign and to not require any follow up or treatment. P waves that are
premature relative to the cardiac cycle and differ in morphology. Anxiety, CHF,
hypoxia, caffeine, electrolyte abnormalities.
AV Fistulas: cause high output cardiac failure -> increased cardiac preload.
Can be due to trauma. Circulation cannot meet O2 demands of the body. Wide
PP, brisk carotid upstroke, tachycardia. Flushed extremities, displaced PMI.
Thyrotoxicosis, Pagets disease, anemia, thiamine deficiency also cause high
output cardiac failure.
Anemia: the most appropriate blood product is PRBCs. In patient with pre-
existing heart disease, you want to keep Hgb > 10. Oxygenation can be
maintained at Hgb > 7 in patients with normal cardiac function. Transfusion is
often necessary with active bleeding.
Back Pain: common symptom. Identify signs of serious etiology: pain not
relieved by rest, night pain, constant or dull pain, lack of exacerbation with
movement or palpation, presence of neurologic changes. Cancer pain often
not tender to palpation. MC are lung, breast, prostate, renal, thyroid. In older
man, get PSA.
MEN IIa: AD, chromosome 10. Genetic testing has replaced serum calcitonin
as recommended screening test. If (+) for RET proto-oncogene, total
thyroidectomy is indicated.
Fibrocystic Disease: treat with aspiration of the cyst which should yield clear
fluid and result in disappearance of the mass. Afterwards patients are
observed for 4-6 weeks. No cytology needed. Rubbery, firm, mobile, painful
mass with more tenderness during menses.
PJP: occurs when CD4 < 200. Fever, dry cough, exertional dyspnea. CXR
shows diffuse bilateral interstitial infiltrates. Use TMP-SMX and prednisolone
when PaO2 < 70.
Metabolic Syndrome: 3/5 (waist > 40 in men and > 35 women, fasting
glucose > 100-110, BP > 130/80, TG > 150, HDL < 40 in men and < 50
women). Increased waist to hip ratio. Insulin resistance plays central role in
pathogenesis.
Homocysteine: vitamin B6, B12 and folate all play role in metabolism. B12
used by methionine synthetase to make methionine from folate and oxidize 5-
MTHF -> THF which is reduced back to 5-MTHF by MTHFR. B6 used by
cystathione B synthetase to convert homocysteine to cystathione to be
converted into cysteine. B6 lowers homocysteine levels. B12 can be added if
patient is deficient.
Ewings Sarcoma: LE > UE. MC sites are metaphysis and diaphysis of femur,
tibia, humerus. Metastasizes early to lungs and LN. White males in 1 st or 2nd
decade. Confused with osteomyelitis. Fevers, anemia, leukocytosis, elevated
ESR. Lamellated onion skin appearance with moth eaten mottled
appearance and extension into soft tissue.
PID: treat with appropriate antibiotics, council on safe sex practices, inform
any partners of the past 60 days so they can be treated. Also screen for HIV,
syphilis, HBV, cervical cancer (pap), HCV if have history of IVDA.
Gonococcal Arthritis: MCC septic arthritis in young sexually active adults. Can
present as asymmetric polyarthritis (with tenosynovitis and skin rash) or
isolated purulent arthritis affecting one or a few joints. Diagnosis may be
confirmed by gram stain of the synovial fluid, blood cultures, urethral cultures,
skin cultures.
Cauda Equina Syndrome: acute compression presenting with acute motor and
sensory loss, loss of rectal tone, urinary retention. Surgical emergency. MRI
should be performed to determine location. May occur with metastatic
prostate cancer.
Amiodarone: class III antiarrhythmic that causes lung fibrosis (total cumulative
dose). Thyroid dysfunction (85% hypothyroid), hepatotoxicity (stop only if >
2x normal), corneal deposits (benign), skin discoloration (blue gray
discoloration of the face) are also causes.
COPD: long term supplemental oxygen therapy has been shown to prolong
survival. PaO2 < 55, SaO2 < 88, erythrocytosis (Hcrt > 55), evidence of cor
pulmonale.
Vomiting: gastric contents are rich in acid, chloride, potassium. Vomiting ->
hypokalemic hypochloremic metabolic alkalosis. Bicarbonate levels rise due to
loss of hydrogen and activation of RAAS. Give isotonic NaCl with K to correct.
Anion Gap Metabolic Acidosis: gap is increased by presence of non-chlorinated
acids in the serum. Lactic acidosis, ketoacidosis, methanol/formaldehyde,
ethylene glycol, salicylate poisoning, uremia.
Hairy Cell Leukemia: type of B lymphocyte derived chronic leukemia. Fine hair
like irregular projections from cells. Can have dry tap bone marrow aspirates
due to fibrosis. TRAP staining (strong acid phosphatase reaction not inhibited
by tartaric acid) and CD11c.
Temporal Arteritis: suspected in patients > 50 with new onset temporal HA,
jaw claudication, vision loss, symptoms of polymyalgia rheumatica. Immediate
initiation of high dose steroids to prevent damage to the retinal artery and
other vessels. ESR is elevated.
Acute Glaucoma: suspect with sudden onset of eye pain, photophobia, mid-
dilated pupil, nausea, HA. Do ocular tonometry to diagnose. Damages the
optic nerve. Drugs that dilate pupil can cause.
MS: relapsing remitting form is well defined acute episodes with no significant
disease progression between episodes. Interferon beta decreases the
frequency of relapse and reduces disability in patients with this form.
Mild Persistent Asthma: proper treatment includes PRN albuterol and inhalted
corticosteroids.
PSGN: 10-20 days after skin or throat infection. Periorbital swelling, hematuria,
oliguria. May be hypertensive. UA will show hematuria with RBC casts and
proteinuria. Serum C3 levels are low.
Pancoast Syndrome: neoplasm in the pulmonary apex at the thoracic inlet can
compress inferior portion of the brachial plexus resulting in shoulder pain
radiating in the ulnar distribution. Causes Horners, hoarse voice, SVC
syndrome.
New Onset Seizures: CT scan of the head without contrast is the first
diagnostic test when patients presents with new unprovoked seizures. Exclude
intracranial hemorrhage.
Spinal Cord Compression: signs and symptoms of UMN (means CNS) distal to
the site of compression. Weakness, hyperreflexia, extensor plantar response.
Medical emergency needing MRI and surgery. Can be due to disc herniation,
abscess (IVDA), trauma, malignancy.
BPH: only required evaluation for BPH suggested by history and physical is UA
to assess for UTI and hematuria. Measurement of PSA can be considered to
help evaluate the likelihood of prostate cancer.
Methanol Intoxication: most severe consequences are vision loss and coma.
Optic disc hyperemia. Labs show anion gap metabolic acidosis. Increased
osmolar gap.
Lacunar Stroke: if patient presents with limited neurological deficit. Pure motor
(posterior limb of IC), pure sensory (VPL thalamus), ataxic hemiparesis
(posterior limb of IC), dysarthria clumsy hand syndrome (basis pontis).
Principle cause is HTN.
Lyme Disease: erythema migrans rash and facial nerve palsy. Can cause palsy
of any CN but VII is MC. EM rash may be present on arms, abdomen, moist
areas. Erythematous with central clearing or uniformly red.
Cor Pulmonale: term for right sided heart failure MC due to pulmonary
disease. Signs of right sided HF -> JVD, S3, RV heave, hepatomegaly, ascites,
dependent edema.
Acute Angle Closure Glaucoma: unilateral eye pain, redness, dilated pupil with
poor light response, photophobia, halos around things. Distinguish from
migraine, cluster headache, temporal arteritis, keratoconjunctivitis.
Colon Cancer: RF for polyps turning into colon cancer are villous adenoma,
sessile adenoma, size > 2.5 cm. Only adenomatous polyps are premalignant,
but < 1% turn into cancer. Hyperplastic are non neoplastic and do not require
further workup. Hamartomatous polyps are either juvenile or Peutz Jeghers.
Splenectomy: risk for sepsis present for > 30 years. Patients should receive
pneumococcal, meningococcal, Haemophilus vaccination several weeks
before operation and daily oral PCN for 3-5 years.
GBS: can cause respiratory muscle weakness -> failure. Best way to measure
is through serial measurements of VC. Risk for failure greatly increases when
VC < 15 mL/kg.
HIV Vaccinations: influenza, HBV, pneumococcus. HAV for MSM. Should not
receive live vacciation (BCG, varicella, anthrax, oral thyphoid, intranasal
influenza, oral polio, yellow fever). One exception is MMR, used if no evidence
of immunity and CD4 > 200 and no ADI.
Mohs Surgery: special surgery where microscopic shaving is done such that 1-
2 mm of clear margins are excised. Highest cure rate for BCC. Indicated in
patients with high risk features, lesions in functionally critical areas (face).
Amaurosis Fugax: visual loss that is usually monocular and trasient. Like a
curtain falling down. Whitened edematous retina in distribution of arterioles.
Retinal emboli from ipsilateral carotid. Do non invasive evaluation of carotid.
Giant Cell Bone Tumor: soap bubble appearance in epiphyseal end of long
bone. 20-40 year old female with knee pain and some mass. Oval or spindle
shaped cells with multinucleated giant cells. Benign but locally aggressive.
Recurs even after local curettage. Refer to ortho.
HTN: most patients will require pharmacotherapy but lifestyle changes can
make a difference. Weight control is the most important, then physical
activity, salt restriction, moderate alcohol consumption. Smoking decreases
CV risk, but will not affect HTN.
ARF: catheterization is most critical first step. Can resolve post renal
obstructions in addition to monitoring urine output in pre-renal and intrinsic
renal failure. Urinary retention common after lower abdominal/pelvic surgery.
Cirrhosis: if signs of portal HTN are present, do endoscopy to look for varices.
May be asymptomatic until they rupture. All patients with cirrhosis should be
screened for varices. Primary prophylaxis is beta blockers.
Proteus: most likely cause of UTI with alkaline urine. Produces urease.
Common in patients of long term care facilities and chronic indwelling
catheters. Candida, Pseudomonas, Klebsiella also cause alkaline urine.
Digitalis Toxicity: increased ectopy in atria and increased vagal tone. Atrial
tachycardia with AV block occurs from the combination of these two effects.
Massive PE: likely in post operative patient with JVD, new onset RBBB. PE
complicated by hypotension, right heart strain. Sycope occurs. Need
respiratory and hemodynamic support, along with fibrinolysis. Surgery in past
10 days is CI to fibrinolytics. > 50% die in 1 hour.
Acute Aortic Dissection: chest pain that is sudden, tearing, radiating to the
back. HTN is MC predisposing factor. Decrescendo diastolic murmur suggests
AR. Wide mediastinum.
Acute DVT: treat with combination warfarin and heparin for 5 days. After 5
days heparin can be discontinued if INR is therapeutic. Warfarin should stay
on for 6 months for first clot. Progressing clot with subtherapeutic INR needs
bridging heparin until INR is therapeutic.
Reyes Syndrome: found in children given ASA for viral induced fever. Can
cause fulminent hepatic failure. Elevation of ammonia levels, transaminases,
vomiting, mental status changes are common manifestations. Diffuse
mitochondrial disease -> extensive fatty vacuolization of liver. Treat with
glucose with FFP and mannitol to decrease cerebral edema.
Allergic Rhinitis: nasal eosinophilia is characteristic for allergic rhinitis, but not
specific. Absent in patients with infectious (neutrophils) or vasomotor rhinitis
(non allergic). Nasal polyposis (including ASA sensitivity) and non-allergic
rhinitis with eosinophilia.
HHNK: very high blood glucose, plasma hyperosmolarity, normal anion gap, (-)
ketones. Can get very dehydrated -> poor perfusion -> lactic acidosis. T2DM.
Enough endogenous insulin to suppress ketosis but not hyperglycemia. Serum
osmolarity is 2(Na)+(Glc/18)+(BUN/2.8).
Acute Pancreatitis: gallstones and alcoholism are the two MCC in US. Do US to
search for gallstones in all patients experiencing first attack. CT is used to
confirm the diagnosis and ID complications.
Vaccinations: all adults should have Td every 10 years. Adults with close
contact with children 0-59 months should have influenza vaccine.
Vaccinations: all adults should get Td booster every 10 years. 50 and older as
well as younger with certain comorbidities should get annual influenza.
Pneumococcal for those over 65 or those at risk for pneumococcal disease
(chronic illness, immunosuppression, smokers).
Massive PE: can cause RV dilatation and failure that results in hypotension,
tachycardia, syncope, SOB. Hemodynamic compromise is an absolute
indication, and RV strain is a relative indication, for thrombolytics. Have
history of DVT sometimes.
PJP: non productive cough, exertional dyspnea, fever, severe hypoxia, bilateral
interstitial infiltrates on CXR, normal white count. CD4 < 200. TMP-SMX is
DOC. Steroids decrease mortality. Indications for steroids are PaO2 < 70, A-a
gradient > 35.
Warfarin Induced Skin Necrosis: pain -> bullae formation -> skin necrosis.
Breast, buttocks, thighs, abdomen are commonly involved. Protein C
deficiency is commonly associated. Females are MC affected. Occurs within
weeks. Vit K should be given initially and warfarin discontinued if progresses.
Heparin should be used until heals.
Mitral Valve Prolapse: mid systolic click over the apex, with short systolic
murmur after the click. Squatting decreases the murmur. Associated with
chest pain, anxiety, palpitations, hyperventilation.
HTN in Diabetes: better to keep systolic < 130 to prevent slow end organ
damage in diabetes and CRF. Want to keep diastolic < 80.
Vitamin K Deficiency: seen in patients who are NPO for a long time and
receiving broad spectrum antibiotics. Labs show prolonged PT and then PTT.
PT elevated more than PTT. Fat soluble vitamin that serves as a cofactor for
enzymatic carboxylation of glutamic acid residues on prothrombin complex
proteins. FFP is used in acute hemorrhage.
Renal Stones: decrease protein (causes calcium stones) and oxalate in diet,
decrease sodium intake, increase fluid intake, increase dietary calcium. CT
scan is done to diagnose.
Dyspepsia: epigastric pain, bloating, nausea not secondary to biliary or
pancreatic disease. May be nothing, could be PUD or gastritis. Recommended
screen is H pylori serology. > 55, weight loss, dysphagia, persistent vomiting
would warrant endoscopy.
S3: low frequency diastolic sound heard just after S2 that is associated with
LVF. IV diuretics provide symptomatic benefits to patients with decompensated
HF. Can be normal in younger individuals and athletes.
Transplant Patients: should be given oral TMP-SMX for prophylaxis against PJP.
Can prevent toxoplasmosis, nocardiosis, UTI, pneumonia. Vaccinate against
influenza, pneumococcus, HBV. Gancyclovir or valgancyclovir can be used to
prevent CMV infections.
Babesiosis: patient from endemic area (NE US) who presents with tick bite
especially if there is evidence of hemolysis and patient is splenectomized.
Rash is not a feature (unless thrombocytopenia is present). Jaundice,
hemoglobinuria, renal failure, death. Giemsa stained thick and thin blood
smear. Use quinine-clindamycin or atovaquone-azithromycin.
COPD: all patients with PaO2 < 55 or SaO2 < 88 are candidates for long term
O2 therapy. Signs of pulmonary HTN or hematocrit > 55, start on home O2
when PaO2 < 60. If become hypoxic during exercise or sleep can use O2.
MG: pathology lies at NMJ. Mediated by autoantibodies against the Ach
receptor. Pupils are always spared (as opposed to botulism). Bulbar muscle
involvement -> myasthenia snarl, nasal speech, difficulty in chewing or
swallowing.
Cocaine Abuse: papillary dilatation and blood at the external nares in a patient
with chest pain can be a clue to cocaine induced vasospasm. STEMI can occur
as a consequence. Inhibits catecholamine reuptake in synapses. Give ASA and
nitrates but not beta blockers. CCB and alpha blockers.
CHF: elevated BNP and S3 are both signs of increased cardiac filling pressures.
Iron Deficiency Anemia: bone marrow iron stains is the most definitive way to
diagnose iron deficiency anemia.
PMR: pain and stiffness in the neck, shoulders, pelvic girdle in patient > 50
with elevated ESR and morning stiffness > 1 hour. Treatment when not
associated with GCA is low dose steroids. If GCA is coming along with it, treat
with high dose prednisone.
Heat Stroke: temperature is usually > 105. Results from inefficiency cooling
mechanisms. Treatment involves induction of evaporative cooling to reverse
hyperthermia. Dunking in cold water may work but difficult to monitor the
patient.
Effect Modification: present when the effect of the main exposure on the
outcome is modified by the level of another variable. Not a type of bias!
Uric Acid: highly soluble in alkaline urine -> oral potassium bicarbonate or
potassium citrate to get urine > 6.5. Radiolucent stones. Usually due to acidic
urine. Also hydrate, try low purine diet.
Aortic Dissection: sudden tearing chest pain that radiates to the back.
Mediastinal widening is sometimes present. Leg weakness can occur if
dissection progresses to involves arteries of spinal cord. Severe HTN is a RF.
Can have pleural effusion. Do contrast CT or TEE.
Primary HIV: manifests similarly to IM. Rash and diarrhea are LESS common in
IM, tonsillar exudate is not common in HIV. Splenomegaly with splenic rupture
is worrisome. Heterophile Ab can distinguish. Arise within 1 week and can
persist upto a year. Anti-EBV Ab as well.
Hematuria: bladder tumors are the MCC of painless hematuria in adults. Could
be a kidney or ureter malignancy as well. Do contrast CT or IVP as well as
cystoscopy of bladder/urethra. Infections, trauma, nephrolithiasis, GN,
prostatic disease are MCC of hematuria in US. Myoglobinuria, porphyria,
eating beets, rifampin can cause hematuria like picture.
CMV Retinitis: when CD4 < 50. Patients may be asymptomatic. Yellow white
patches of retinal opacifiation and hemorrhage are diagnostic. Initially eye is
usually white and quiet. Treatment is ganciclovir or foscarnet.
SBE: one the causative agent is identified, the antibiotics can be narrowed
from empiric to specific. Strep viridans is highly susceptible to IV PCN G and IV
ceftriaxone. Progressive fatigue and waxing waning low grade fever.
Nitroglycerin: main mechanism for pain relief in patients with anginal pain is
dilitaiton of veins (capacitance) and decreased ventricular preload. This
decreases myocardial oxygen demand.
COPD: causes airflow limitations and increased lung volumes. Latter results in
diaphragmatic flattening, evident on CXR, which exacerbates patients
dyspnea and work of breathing. Difficult to decrease intrathoracic pressure
enough.
Pericardial Effusion: electrical alternans when QRS varies from beat to beat
and is specific. Enlargement of cardiac silhouette. Echo will more definitively
diagnose. Recent URI usually precedes.
SLE: joint pain is common but not deforming. MC in hands or knees. Migratory
arthritis. Pain > physical findings. Lower incidence of joint erosion, synovial
abnormality, permanent joint deformity than RA.
Brain Death: clinical diagnosis. Absent cortical and brainstem functions and
proven irreversibility. Spinal cord may still be functioning -> DTRs may be
present. EEG can be used to confirm but not necessary. Some tools can
demonstrate cerebral blood flow cessation.
Epidural Abscess: consider in patients with fever and back pain. Espeically
those who are immunosuppressed or use injectable drugs. MRI is diagnostic
test of choice. Treat with antibiotics and surgical decompression. Can cause
direct compression -> cessation of blood flow. Draw blood cultures to
determine sensitivity.
AR: early diastolic murmur. Can also have hyperdynamic pulse (bounding,
water hammer, peripheral pulses).
Fibromyalgia: pain worse with exercise. Fatigue, IBS, depression are common.
Inflammation, joint swelling, muscle weakness are absent. No abnormal
studies. Women from 20-55. Disorder of pain regulation.
Urine Sediment: muddy brown granular = ATN, RBC = GN, WBC = interstitial
cystitis and pyelonephritis, fatty = nephrotic, broad waxy = CRF. Prolonged
hypotension -> ATN. Also have urine osm 300-350, urine Na > 20, FENA > 2%.
Hepatic Adenoma: benign tumor most often seen in young and middle aged
women who are taking OCP. Severe intra-tumor hemorrhage and malignant
transformation are dreaded complications. Sheets of enlarged adenoma cells
that contain glycocen and lipid.
Acute MR: occurs due to papillary muscle dysfunction in patients with acute
MI. Causes rise in LAP without significant increased LA size, LV size, or LV EF.
Also have pulmonary edema. PCWP shows increased pressure in LA.
HOCM: first line of treatment is beta blockers or cardiac acting CCB such as
diltiazem since they promote myocardial relaxation. Beta blockers also
prevent anginal pain.
Bacterial Pneumonia: all patients should have CXR done as first step and then
administer antibiotics without waiting for sputum gram stain or cultures.
DJD: OA, or wear and tear arthritis. Presents indolently in patients over 40
years with progressive anterior hip pain exacerbated by walking and relieved
by rest. Morning stiffness or stiffness after prolonged resting, usually < 30 to
60 years. No tenderness to palpation or systemic signs. Predisposing factors
are advanced age and obesity.
Angle Closure Glaucoma: predominantly in people aged 55-70 years. Presents
with acute onset severe eye pain and blurred vision associated with nausea
and vomiting. Examination reveals red eye with steamy cornea, moderate
pupil dilation not responsive to light. Results form pre existing narrow anterior
chamber angle. Anterior chamber is shallow with inflammatory changes.
Tonometry reveals increased IOP. Do laser peripheral iridotomy.
Leukoplakia: hard to remove white patches in the oral mucosa and may lead
to SCC. Only associated with tobacco. Caused by chronic irritation to the
mucosa due to tobacco, alcohol, poorly fitting dentures. Risk of transformation
to SCC.
Multiple Myeloma: any elderly patient with bone pain, renal failure,
hypercalcemia. 50% of patients develop some kind of renal insufficiency.
Likely due to obstruction of distal collecting tubules by large laminated casts
of Bence-Jones proteins.
Trigeminal Nerve: contains motor and sensory fibers. First branch carries
sensory fibers to the scalp, forehead, upper eyelid, conjunctiva, cornea, nose,
frontal sinuses. Damage to V1 -> corneal anesthesia and lesions on the eye
may not be noticed.
Stable Angina: with HTN, treat with beta blocker. Decreases threshold for
anginal episode and controls HTN. Also are cardioprotective and can
potentially reduce the risk of major CV events by decreasing sympathetic
output to the heart.
RA: morning stiffness presents with inability to do things in the morning but
fine by afternoon time. Affects MCP, PIP, wrist. Disease of systemic
inflammation. ESR will be high. Mostly peripheral joints. If affects axial ->
cervical spine -> C1-C2 instability -> subluxation.
Pancreatitis: nausea, vomiting, epigastric pain that radiates to the back. Low
grade fever also common. History, physical, elevated amylase and lipase.
Gallstones and alcohol are MCC. Hypertriglyceridemia, anatomic
abnormalities, infection, medications also cause. Can have left sided pleural
effusions when amylase is high, abdominal compartment syndrome,
intraabdominal hemorrhage, shock, diabetes, pseudocyst formation,
abdominal pseudoaneurysm.
Reactivation TB: