Equations

Alveolar-arterial oxygen Use if hypoxemia.

gradient 1. Calculate the alveolar oxygen
= (Patm - 47) x FiO2 - (PaCO2/0.8)
= 150-PaCO2/0.8.
2. Subtract arterial oxygen

Normal is < 15, over 30 is abnormal. If elevated, we have V/Q mismatch: pulmonary
embolism, atelectasis, pleural effusion, pulmonary edema

Distinguish iron Iron deficiency anemia has increased RDW and a Mentzer index > 13.
deficiency anemia from
thalassemia on labs Thalassemias have a normal RDW, normal total RBC count, and Mentzer index is <
13.

Mentzer index = MCV/RBCcount

Fluid compartments of Body is water

the body is extracellular, is intraceullar
- What percent of Of extracellular, is plasma, is interstitial
the body is
water?
- What percent is
intracellular and
what percent is
extracellular
- What percent of
extracellular is
plasma vs.
interstitial

Hendersen Hasselbalch pH = pKa + log (bicarb/0.03 CO2)

Winters formula Use to see if respiratory compensation for metabolic acidosis is appropriate
-when to use?
PCO2= 1.5 x bicarb + 8 +/- 2

If there is an anion gap Add the anion gap to the bicarb and see if it corrects
metabolic acidosis, how
can we see if there is
also a problem in
metabolic compensation

If metabolic alkalosis, PCO2 = 0.9 x bicarb + 16 +/-2

is respiratory
compensation
appropriate

How to tell whether For acute: pH changes by 0.08 for each 10 mm Hg change in CO2, for chronic its 0.03
respiratory problems are
acute or chronic

Metabolic alkalosis - can Look at urine chloride - if low, the person has lost NaCl and will respond. If high, the
be saline responsive or person has plenty of NaCl and it wont help (e.g., RAAS overactivity)
resistant

EKG change in Hyper Short QT, Hypo long QT

hypercalcemia and
hypocalcemia

Treatment for normal saline, mannitol, bicarb, ECG

rhabdomyolysis (can
cause hyperkalemia)

Calculation of stool 290- 2 (stool sodium + stool potassium). IT will be > 50 in all forms of osmotic diarrhea
osmotic gap:

Fluid replacement 100-50-20: 1st 10 kg: 100 mL/kg, next 10 kg 50 mL/kg, after that 20 mL/kg
formula - 24 hours and Or 4-2-1 rule per hour
per hour

Sodium, potassium, and Multiply by 3 mEq sodium, 2 mEq potassium, 2 mEq chloride
chloride needs per 100
mL of flulds

How to give a fluid bolus 10-20 mL/kg of NS or Righters

to a kid

Rule for correcting 6 mEq/L per day, or 6 in 6 hours for severe symptoms, then stop until the next day
hyponatremia

Preventative Health
Tdap schedule 11-18 years (ideally at 11-12), then Td every 10 years. Give Tdap once as an adult if
did not get it at 11-18.

Who gets a statin? Patients 40-75 years old with a 10 year risk of atherosclerotic cardiovascular disease
of at least 7.5%

How does a polysaccharide
vaccine work?
How does a conjugate
vaccine work?
Polysaccharide - creates moderate levels of intermediate affinity antibodies through
a pure B cell response
Conjugate - B cell recognizses the polysaccharide, chops it up along with the
attached protein for presentation to T cells. The protein component allows for T cell
activation get high levels of high affinity antibodies with memory B cell formation

When to screen for colon 50 years old for patients at average risk. For patients with a 1st degree relative,
cancer screen at 40 years or 10 years before the relatives diagnosis

Travel vaccinations - where - Hep A, Hep B, polio: developing countries

are the following indicated - Cholera - no where
- Hep A, Hep B, polio - Meningococcus - some asian countries, sub-saharan Africa, Mecca
- Cholera - Yellow fever - sub saharan africa, south America around the equator
- Meningococcus
- Yellow fever

Cardiology notes
What to avoid in right ventricular They become preload dependent, so avoid anything that decreases preload like
MI nitrates or diuretics. Give IVF.

Kussmauls sign Increase in JVD with inspiration

Post MI, when does rupture of - septum - 3-5 days. Get sudden onset hypotension, new holosystolic
interventricular septum happen? murmur, CHF.
What about ventricular free - wall - 5 days to 2 weeks. Get tamponade and shock, rapid progression to
wall? PEA and death

1
Time frame for PCI and
fibrinolysis
Use dependent antiarrhythmics
- when the effect of the drug
increases with heart rate. Which
drugs are these?
Treatment for symptomatic
bradycardia
Side effects of acetazolamide
Side effects of mannitol
EKG signs of posterior wall
infarct
Sequence of EKG changes in
MI
Woman has pulseless electrical
activity on day 7 after a lateral
wall STEMI. The ACLS protocol
is initiated. What is the next
best step?
Complications after MI - timeline
Lipid goals for healthy people,
2+ CAD risk factors, or CAD
Lipid goals if CAD risk factors
(1, 2+)
Lipid screening
Goal BP for health, diabetes,
renal disease
Effectiveness of lifestyle
90 min PCI, 12 hours fibrinolysis
Class IC antiarrhythmics - will prolong the QRS at higher heart rates. Calcium
channel blockers - will prolong the PR interval even more at higher rates.
Reverse reversible causes, IV atropine, followed by IV epinephrine, dopamine,
or transcutaneous pacing
Hyperchloremic metabolic acidosis
NH3 toxicity
Sulfa allergy
Neuropathy
Pulmonary edema - CIed in CHF
Dehydration
V1 & V2 - ST depression and dominant R waves
Over days to weeks:
Peaked T
ST elevation
Q waves
T wave inversion
ST normalization
T wave normalization
Emergent pericardiocentesis. She probably had a left ventricular free wall
rupture.
Day 1: HF, acute mitral regurgitation from papillary muscle displacement
Day 2-4: arrhythmias, pericarditis
Day 5-10: rupture - wall or papillary muscle (avoid corticosteroids for a few days
after MI because they increase risk of rupture)
Weeks - months: Dressler syndrome, ventricular aneurysm (CHF, arrhythmia,
persistent ST elevation, mitral regurg, thrombus)
Total cholesterol < 200 (diagnostic if on 2 occasions)
LDL < 160 if healthy, < 130 if 2+ CAD risk factors, < 100 if CAD, < 70 if DM
- start lifestyle mods if above goal, then drugs if > 30 points above goal
HDL > 40
- HDL > 60 is protective, negates one risk factor
TG < 150
LDL: < 130, < 100
Every 5 years for age > 35 years, or start at > 20 years if CAD risk factors.
Recheck more frequently if elevated.
Healthy: 140/90
Renal disease or DM: 130/80
From most effective to least effective:
2
interventions for lowering BP Weight loss
Diet - DASH
Exercise
Restrict daily sodium to less than 3 g
Reduce alcohol intake
Quitting smoking doesnt really affect BP!

Hypertensive urgency Elevated BP with mild/mod symptoms (HA, CP) and no end organ damage. Treat
signs/symptoms and treatment with oral meds to lower BP over 1-2 days

Hypertensive urgency Elevated BP with signs/symptoms of end organ damage (AKI, intracranial
signs/symptoms and treatment hemorrhage, papilledema, ECG changes, pulmonary edema).

Treat with IV meds (labetalol, nitroprusside, nicardipine) - goal is to lower MAP by

< 25% over the first 2 hours to avoid under perfusing the brain or coronary
arteries.

Phenoxybenzamine Alpha 1 blocker, like prazosin and terazosin. Causes vasodilation by blocking
norepi induced vasoconstriction. Orthostatic hypotension.

Methyldopa Like clonidine. Inhibits sympathetic nervous system by alpha 2 activation. Can
cause sleepiness, orthostatic hypotension, impotence, and rebound
hypertension.

Most common cause of aortic atherosclerosis

aneurysm

Treatment of aortic regurgitation Vasodilators (dihydropyridines or ACEs) for isolated aortic regurgitation until
symptoms become severe enough to warrant valve replacement.

Indications for surgery of aortic AAA: > 5.5 cm, thoracic > 6 cm. Or if rapidly progressing, symptomatic, or
aneurysm, both thoracic and ruptured.
abdominal

Most common cause of aortic Aneurysm = atherosclerosis

dissection and aortic aneurysm Dissection = HTN

Treatment of aortic dissection, - Ascending = surgical emergency!

ascending and descending - Descending is an emergency, but can often be managed with meds for
BP and HR. Give beta blockers, then vasodilators - the beta blockers
prevent reflex tachycardia

Ankle/Brachial Index - normal Normal is at least 90%. Pain with rest usually below 40%. Very high ABI can
and severe mean calcification of the arteries.

Diagnosis of vasovagal syncope Usually clinical, but can do upright table testing

Diagnosis of carotid sinus Carotid neck massage

hypersensitivity syndrome
(causes syncope)

Afib initial management Rate control - beta blockers or CCBs, or digoxin if CHF. Do cardioversion if the
patient is unstable or if the episode has been < 2 days - otherwise need to
anticoagulate first.

Hemochromatosis Joint pain, testicular atrophy, diabetes, bronze skin, cardiac problems (dilated
cardiomyopathy, conduction abnormalities like sick sinus syndrome), heart failure

Beta blocker or CCB overdose IVF and atropine are first line. Next step is glucagon, which will increase
intracellular cAMP

3
Murmur testing: 1. Increase preload: Passive leg raise, squatting
1. Ways to increase 2. Decrease preload: valsalva, standing
preload 3. Increase afterload: Sustained hand grip and squatting
2. Ways to decrease
preload
3. Ways to increase
afterload

Nitroprusside toxicity Cyanide poisoning - especially if renal insufficiency. AMS, lactic acidosis,
seizures, coma

Syncope with TIA or stroke - Only in the posterior circulation and brainstem
location of infarct?

Arrhythmia in digitalis toxicity Atrial tachycardia (increased ectopy) with AV block (increased vagal tone)

Approach to cardiac arrest: 1. Defibrillate if ventricular fibrillation or pulseless VT

1. When to defibrillate? 2. If asystole or pulseless electrical activity, start with CPR and epi and try
2. When to begin with to generate a shockable rhythm.
CPR and epi?
See Uworld 4725 for explanation of the protocol

INR Goals: - prosthetic valve: 2.5-3.5

- Prosthetic heart valves - VTE prophy or Afib: 2-3
- VTE
- A Fib

Prolonged QT treatment Propranolol, pacemaker if symptomatic

Treatment for cocaine toxicity IV benzodiazepenes to address agitation, reduce myocardial oxygen demand,
with cardiac ischemia and reduce cardiac symptoms. Can also give aspirin, nitro, and CCBs. No BBs

Treatment for heat stroke - Exertional: rapid cooling with ice water emersion
- exertional - Non-exertional: evaporative cooling with water mist
- non-exertional

Indications for CEA Men: consider if symptomatic and 50% higher, if asymptomatic 60% and
- Men higher
- Women Women: 70% and higher regardless of symptoms or not

Treatment for PVCs Nothing if asymptomatic. If symptomatic, beta blocker is first line, amiodarone is
second line.

1. Hypertensive urgency 1. Urgency is > 180/120, no signs of end organ damage

2. Hypertensive 2. Emergency - severe HTN assoced with either
emergency a. Malignant hTN - retinal findings are required for diagnosis. May
a. Malignant also have other organ findings, but not necessarily
hypertension b. Hypertensive encephalopathy - cerebral edema and non-
b. Hypertensive localizing neuro sx
encephalopathy

Drugs to use for Cardioversion or antiarrhythmics like procainamide. Avoid AV nodal blockers -
supraventricular and ventricular this can increase conductance through the accessory pathway
arrhythmias in WPW

Meds to hold for 48 hours Beta blocker, calcium channel blocker, nitrates
before cardiac stress test

Dx test for aortic dissection TEE or CT chest with contrast (but watch out for renal dz)

4
Bruit of aortic aneurysm and of
renal artery stenosis
Normal CVP
Pulmonary Notes
Side effects of theophylline
(PDE inhibitor)
Cromolyn
Parameters for intubation in
asthma
Definitions of mild intermittent,
mild persistent, moderate
persistent, and severe
persistent asthma
When to begin oxygen therapy
in COPD
Target for COPD oxygen
therapy
How to distinguish emphysema
from chronic bronchitis (though
most patients are mixed)
Treatment for COPD
exacerbation
Causes of digital clubbing
Causes of pulmonary fibrosis
Diagnosis of IPF
Sarcoidosis - symptoms and
diagnosis
Berilliosis
ARDS diagnosis
Aortic aneurysm: Systolic bruit with a pulsatile abdominal mass
Renal bruit is a systolic-diastolic bruit
< 3cm above the sternal angle
Cardiotoxicity, neurotoxicity
Prevents mast cell degranulation, not useful during acute asthma attacks
PCO2 > 50 or O2 < 50
Mild intermittent: symptoms 2 or fewer days week or 2 or fewer nights/month
- PRN albuterol
Mild persistent 3+ days/week, 3+ nights/month
- add low dose steroids
Moderate persistent: Daily, > 1 night/week
- add LABA and low-med dose inhaled steroids
Severe: continuous, frequent
- add LABA + high dose inhaled steroids, maybe PO steroids too
resting PaO2 < 55mmHg, SaO2 is 89% or lower, or if the patient has right heart
failure, pulmonary HTN, Hct > 55%, or nocturnal hypoxia
> 90% oxygen saturation for > 15 hours per day.
- Labs: only emphysema has low DLCO
- Symptoms: blue bloater vs. pink puffer, productive cough vs. no cough
oxygen, albuterol, anticholinergics (ipratropium, tiotropium), steroids IV and
maybe inhaled, antibiotics
Not caused by COPD! Consider lung cancer, bronchiectasis (also seen in cystic
fibrosis)
Amiodarone, busulfan, nitrofurantoin, bleomycin
Radiation
Long term high O2 concentrations
Biopsy - shows interstitial inflammation and fibrosis
Symptoms: arthritis, fever, cough, malaise, weight loss, dyspnea.
Additional signs to memorize: increased alk phos with liver involvement
Diagnosis: Chest xray, biopsy any enlarged lymph nodes
Causes hilar adenopathy, treat with chronic steroids!
Acute onset
Ratio PaO2/FiO2 = or < 300
Diffuse infiltration
5

Goal oxygenation parameters
for ARDS
Definition of pulmonary HTN
(mm Hg)
Lung nodule management
1. What to do for high risk
lesions?
2. What to do for low risk
lesions?
Small cell lung cancer
paraneoplastic syndromes
Squamous cell lung cancer
paraneoplastic syndrome
Indications for thoracentesis in
pleural effusion
Lights criteria for exudative
pleural effusion
When to do surgery for
empyema
Pneumonia treatments
1. CA
2. Anaerobic
Chlorpheniramine
Distinguish chronic bronchitis
vs. bronchiectasis. How is
bronchiectasis diagnosed?
Legionella pneumonia
treatment?
Ideal tidal volume for respirator?
Threshold for hypoxemia
Modified Wells Criteria for PE
Swan Ganz < 18 mm Hg
PaO2 > 60 mm Hg, or SaO2 > 90% on FiO2 <60%. But start with FiO2 of 80%.
Mean pulmonary arterial pressure > 25 mm Hg (normal is 15)
High risk: surgically remove (> 2 cm, etc)
Low risk: follow with CT or CXR every three months x4 (for one year), then
every 6 months x2 (another year)
ACTH,
SIADH hyponatremia,
peripheral neuropathy,
subacute cerebellar degeneration,
LEMS
PTHrP hypercalcemia
New effusions > 1 cm, unless bilateral and obviously from CHF
Exudate if any of the following:
- pleural protein/serum protein > 0.5
- pleural LDH/serum LDH > 0.6
- Pleural LDH > the upper limit of normal serum LDH
If the empyema is localized, complex, and with a thick rim, only surgery will do.
1. CAP: macrolide. If resistance, doxycycline
2. Suspect anaerobic PNA after GI procedures or if poor dentition. Treat
with clindamycin.
First generation H1 antihistamine
Bronchiectasis sputum - purulent, larger volume, recurrent fever, hemoptysis,
and frequent psuedomonas infections
Respiratory floroquinolones (levofloxacin) or newer macrolides
6 mL/kg
PaO2 < 70 mm Hg. But 55 mm Hg is a threshold for oxygen therapy in COPD/
3 Points:
- Signs of DVT
- PE is the most likely dx
1.5 points
- Previous DVT or PE
- Tachycardia (HR > 100)
6

Treatment for hospital acquired
pneumonia
Pneumonia in nursing home
Treatment of pyelonephritis
Definition of shunt
Goal O2 saturation in COPD
when using oxygen therapy?
When to use home oxygen
therapy for COPD
Heme/Onc
Serum markers for
- non-seminomatous
germ cell tumor
- seminomatous germ
cell tumor
- teratoma
Risk after treatment with
radiation and chemo for
Hodgkin lymphoma?
Hemoglobin H disease
Transfusion reactions
- Nonhemolytic febrile
rxn
- Minor allergic rxn
- Hemolytic transfusion
rxn
- Hospitalization within 4 weeks
- Immobilization for at least 3 days
1 point
- Cancer
- Hemoptysis
If at least 5 points PE CT. Otherwise, D-dimer. If D-dimer is > 500, follow with
PE CT.
Extended spectrum cephalosporin
OR carbapenem with psuedomonas coverage
AND aminoglycoside (gentamicin, neomycin, amikacin, tobramycin,
streptomycin) or fluoroquinolone for coverage of resistant bugs (psuedomonas)
until sensitivities are back
Strep pneumo is most common. Also most common cause of CAP in adults.
Start with IV floroquinolones, then after response, switch to oral floroquinolones
or bactrim (but it is best to wait for sensitivities)
Blood flow doesnt reach aerated lungs wont correct with supplemental
oxygen because that doesnt address the lack of blood flow. Seen in severe
ARDS, intracardiac shunts
90-94% - if you go higher, risk suppressing the respiratory drive
- PaO2 < 55
- Sa O2 < 88%
- PaO2 < 60 and Hct > 55 or pulmonary HTN
- PaO2 > 60 but hypoxic during sleep or exercise
- Non-seminomatous germ cell tumor: AFP and beta HCG (aggressive!)
- Seminomatous germ cell tumor: beta HCG
- Teratoma: No tumor markers
Big risk of cancers later, including solid tumors (lung cancer), acute leukemia,
and non-HL
alphas
- Nonhemolytic febrile rxn: cytokines from the donor blood fever, chills,
etc. within hours after transfusion. Treat with acetaminophen
- Minor allergic rxn: antibodies to donor proteins, usually plasma
containing product hives. Give antihistamines, or if serious, stop
transfusion and give epi
7
 - Hemolytic transfusion rxn: antibodies to donor RBCs fever, chills,
flushing, hypotension, tachycardia during or shortly after transfusion.
Stop! Give IV fluids to maintain good UOP

Treatment for CML imitinab - targets the bcr/abl tyrosine kinase receptor (philadelphia chromosome
fusion)

Treatment for multiple myeloma Melphalan (oral alkalating agent), prednisone, others

Cryoglobulinemia and cold similarity: both caused by IgM

aggluitinins differences:
- similarity - cryoglobulinemia is assoced with Hep C, causes joint pain and renal
- differences symptoms
- cold agglutinins: assoced with Waldenstroms macroglobulinemia, EBV,
and mycoplasma infection. Causes Raynauds phenomenon in the cold
and hemolytic anemia

Evaluation of a solitary lung 1. Compare to previous x rays - if no change in 2-3 years, its fine
nodule 2. If no previous imaging is available, follow CXR with CT, then decide
whether to bx or follow based on tumor features and risk factors

Causes of eosinophilia neoplasm, allergies, asthma, collagen vascular disorders, parasites

transfusion reactions 1. seconds to minutes: anaphylaxis from IgA in donation

2. Mins to hours: ABO incompatibility
3. 1 hour to several hours:
a. febrile nonhemolytic transfusion reaction: donor cytokines
b. Transfusion related acute lung injury: donor anti-leukocyte
antibodies cause respiratory distress within 6 hours of
transfusion
c. Primary hypotension reaction - if taking ACE inhibitors, happens
because of the donor bradykinin that cant be degraded

Treatment for NHL CHOP: cytoxan, adriamycine, vincristine

Amsterdam criteria for 3 relatives, 2 generations, 1 case before 50 years and 1 first degree.
hereditary nonpolyposis
colorectal cancer (lynch
syndrome)

Treatment for neutropenic fever Get blood cultures and then give empiric abx (pipercillin-tazobactam, cefepime,
meropenem, etc)

HER2neu positivity means Herceptin, anthracycline

sensitivity to which agents

Electrolyte changes in tumor

lysis syndrome
- Calcium
- Potassium
- Phosphate
- Uric acid

The Philadelphia chromosome CML, ALL (poor prognosis)

is diagnostic for ___ but may
also be present in ___

Most common blood cancer NHL

8
Ann Arbor staging system for Stage 1 = 1 node, 2 = 2+ nodes on the same side of the diaphragm, 3 = both
lymphoma sides of diaphragm, 4 = extralymphatic

What does the TRAP stain tartrate resistant acid phosphatase stain
stand for

Abnormal RBC findings in liver Target cells, burr cells, spur cells
disease

Infectious Disease
Outpatient CAP treatment - Healthy:
- Healthy patients - doxycycline
- Unhealthy (diabetes, - macrolide
cancer, etc) - Unhealthy:
- fluoroquinolone (levofloxacin or moxifloxacin)
- macrolide + beta lactam

Inpatient CAP treatment - non-ICU

- non ICU - same as for unhealthy outpatients: floroquinolone or beta lactam +
- ICU macrolide
- ICU:
- beta lactam and macrolide (IV)
- Beta lactam and floroquinolone

CURB 65 acronym for Confusion, uremia, respiratory rate > 30, blood pressure < 90/60, age > 65
inpatient CAP treatment

Chikungunya fever mosquito born viral illness, central and south america - e.g., caribbean vacation. High
fever, polyarthralgias, diffuse macular rash, lymphopenia and thrombocytopenia,
lymphadenopathy, peripheral edema. Do serology, lasts 7-10 days.

Anti-psuedomonas drugs - Ticarcillin, pipercillin

- Aminoglycosides (gentamicin, neomycin, amikacin, tobramycin, streptomycin)
- Ceftazadime, cefapime
- IV only - carbapenems (doripenem, imipenem, meropenem - not ertapenem)

Anti-anaerobe drugs - Clindamycin, metronidazole, ceftriaxone

Seriously ill with pneumonia Add vanco or linezolid for MRSA coverage
or worsening over 48 hours

Treatment for active TB RIPE for 2 months, RI for 4 months

infection

Centor criteria for GAS 3 of 4: Fever, tonsillar exudate, anterior cervical lymphadenopathy, no cough

Adults who have all 4 centor criteria get abx (penicllin). Adults w/2 or 3 should get
rapid strep test.

Kids need rapid strep test or culture before abx, because of the high rate of viral
pharyngitis.

Lemierres syndrome Thrombophlebitis of the jugular vein - GAS forms an abscess, then anaerobes can
grow. Fusobacterium, an oral anaerobe, is the bad guy. Can clot off the IVC or send
clots to the lungs

Treatment for acute sinusitis Most often caused by viruses, strep pneumo, h flu, moraxella. Treat if purulent
drainage, face pain, or symptoms > 1 week

9
 Amoxicillin clavulanic acid, bactrim, floroquinolone, macrolide (clarithro, azithro), or
second gen cephalosporin

Treatment for chronic Same as acute, just much longer course (weeks)
sinusitis
Amoxicillin clavulanic acid, bactrim, floroquinolone, macrolide (clarithro, azithro), or
second gen cephalosporin

Bartonella henselae Treat with azithromycin

Human or dog bite abx amoxicillin-clavulanic acid

Side effects of HIV meds: - Protease inhibitors: hyperglycemia, GI symptoms, lipodystrophy

- Protease inhibitors - Idinavir: crystal nephropathy
- Idinavir - Nucleoside reverse transcriptase inhibitors: bone marrow suppression, lactic
- Nucleoside reverse acidosis, neuropathy
transcriptase - Didanosine: pancreatitis
inhibitors - Abacavir: hypersensitivity
- Didanosine - Zidovudine: anemia
- Abacavir - Non nucleoside reverse transcriptase inhibitors: Stevens Johnson,
- Zidovudine hepatotoxicity
- Non nucleoside - Nevirapine: liver failure
reverse
transcriptase
inhibitors
- Nevirapine

When to start prophy for - Pneumocystis jiroveci: 200

AIDs related infections: - CMV: 50 and IgG or biopsy is positive
- Pneumocystis - Histo: 150, ohio & mississippi river valleys - use itraconazole
jiroveci - Toxo: 100
- CMV - Mycoplasma avium: 50 - azithromycin or clarithromycin
- Histo
- Toxo secondary prophy if hx of infections
- Mycoplasma avium - acyclovir for HSV
- fluconazole for candida

CD4 Count and - 200 - several hundred: bacterial infections, TB, HSV, candida, hairy
opportunistic infections leukoplakia, kaposis sarcoma
- 200 - several - 50 to 200: PCP, toxo, coccidio, crypto
hundred - < 50: Disseminated MAC, histo, CMV, CNS lymphoma
- 50 to 200
- < 50

When to start HIV meds, - if symptomatic, HIV related illness, etc

how to monitor response to - CD4 < 350
treatment - Pregnancy

Goal is viral count < 50. Check monthly until achieved, then every 3-6 months. Obtain
genotype first.

Which vaccines should HIV Basically all of the same vaccines that everyone gets, except
patients get? - No live vaccines except MMR and varicella are okay if CD4 >200, check titers
first
- pneumovax 13 then 23 (if CD4 > 200)
- Hep A and Hep B

Abx and vaccines for All transplant patients should get bactrim for PCP prophy!
transplant patients

10
 Also give influenza vaccine, strep pneumo, and Hepatitis B

Strep pneumo vaccine Adults < 65:

guidelines - PPSV23 alone for chronic heart/lung/liver disease, diabetes, smokers,
alcoholics
- 13 valent then 23 valent for very high risk patients - CSF leaks, cochlear
implants, sickle cell, no spleen, IC, CKD

If splenectomy - give meningococcus, strep pneumo 13 valent, and H influenza > 2

weeks before or > 2 weeks after the procedure - dont do it at the same time.

Adults 65+
- 13 valent (conjugate) then 23 valent (polysaccharide) 6 months to 1 year later

Lyme disease. When to Doxycycline prophy if tick attached > 36 hours

treat? What to use Ceftriaxone for neuro or cardiac manifestations

Normal CSF - glucose: serum

- glucose - protein: 15-45
- protein - WBCs: <5
- WBCs - RBCs: < 10
- RBCs - Opening pressure: 10-20
- Opening pressure

CMV transmission Sex, breast milk, respiratory droplets, blood transfusion. 70% of American adults have
been infected. Worry about first 100 days after bone marrow or tissue transplants

Signs/symptoms of Symptoms: Fever, night sweats, weakness, weight loss

disseminated MAC infection Signs: increased serum alk phos and LDH, anemia, hypoalbuminemia, foamy
macrophages with acid-fast bacilli

VDRL false positives Viruses - EBV, HSV, HIV, hepatitis

Drugs/IV drug use
Lupus
Rheumatoid arthritis
Rheumatic fever

Lymphogranuloma Lymphogranuloma venereum: chlamydia. Painless pustule painful inguinal lymph

venereum vs. granuloma
inguinale node swelling anogenital syndrome

Granuloma inguinale: klebsiella granulomatis, causes a beefy red painless ulcer

with a white border

Treatment is the same!

Treatment for haemophilus Azithromycin or ceftriaxone

ducreyi (chancroid)

Urine culture level for UTI > 10^5 CFUs

EHEC diarrhea and Watery to bloody diarrhea. Dx with stool assay for shiga toxin. Avoid abx b/c risk of
treatment HUS

Meningicoccal vaccine Indicated for 11-18. Ideally done at 11-12 yrs. Then all kids who got it before age 16
schedule get a booster between 16-21 years.

Give to older people if at risk (close living quarters, travel to Africa or to Mecca)

Abx that cover listeria Bactrim, ampicillin

11
Meningitis treatment - ceftriaxone for H flu and for meningococcus
- H Flu -
- Meningococcus
- S pneumo

SIRS criteria 2 of the following

Temperature: < 35 C or > 38.5 C
Tachypnea: RR > 20 or CO2 < 32
Tachycardia: > 90
WBC: < 4 or > 12

Sepsis = SIRS plus documented infection

Severe sepsis = signs of end organ dysfunction
Septic shock = hypotension

Watch for DIC! petechiae, ecchymoses, abnormal coagulation tests

Malaria stains Giemsa (also used for chlamydia)

Wright

Treatment of malaria Plasmodium vivax or plasmodium ovale: chloroquine + primaquine (the ox is

strong!).

IV quinidine for severe infections

Mefloquine - first line chemophrophylaxis

Malaria prophylaxis Usually mefloquine, atovaquone-proguanil, and doxycycline

Fever of Unknown Origin Rule of 3: > 38.3 (100.9) for 3 weeks that remains undiagnosed after 3 outpatient
visits or 3 days inpatient

Neutropenic fever - Fever when ANC < 500

- Definition - Do a work up - avoid rectal exam if thrombocytopenic.
- Management - Empiric abx. Admit and IV abx if high risk - give antipsuedomonal coverage
(cefepime, ceftazadime, imipenem, meropenem, pipercillin-tazobactam)

Diagnostic test for lyme ELISA indicates exposure, Western blot is confirmatory. Tissue culture and PCR not
disease routinely done.

Test for Rocky Mountain Tissue biopsy and indirect immunofluorescence

Spotted Fever Treat with doxy or chloramphenicol if pregnant

Bug vectors - Lyme disease: Ixodes tick

- Lyme disease - RMSF: dermacentor variabilis
- RMSF - Babesiosis: Ixodes tick (symptoms are similar to malaria, no rash)
- Babesiosis - Ehrlicheosis: lone start tick in south east and south central US
- Ehrlicheosis

Symptoms of Ehrlichiosis Acute fever with malaise and altered mental status, headache, nausea, vomiting.
Can have clonus and neck stiffness.
Labs show leukopenia and thrombocytopenia
Transmitted by a tick

Duke criteria for 2 Major, 1 Major + 3 minor, or 5 minor

endocarditis
Major
- 2 separate + blood cultures for a typical bug,

12
 - Persistent bacteremia,
- A single + culture for coxiella burnetti (Q fever pneumonia from tick feces
and farm placenta)
- + TEE or new murmur

Minor:
- Risk factors
- Fever
- Vascular phenomenon
- Immunologic phenomenon
- Microbio evidence that doesnt meet major criteria

Empiric treatment for Vancomycin

endocarditis

Who gets abx prophy 1. Previous endocarditis

before dental procedures? 2. Prosthetic valve or prosthetic material used to repair valve
3. Severe or partially repaired cyanotic heart defects (L R)
4. Heart transplant

Most common valvular Mitral valve regurgitation

disorder associated with
endocarditis?

Anthrax treatment Ciprofloxacin or doxycycline

- lung manifestation?
- GI?

Entamoeba histolytica Treat with oral metronidazole - generally dont need to drain the liver cyst, can seed
the peritoneum. Also give a luminal agent (paromomycin) to eradicate the intestinal
tract.

Echinoccous treatment Aspirate the cyst, treat with albendazole. Suspect if liver cyst (generally
asymptomatic - no pain, fevers, etc) with animal contact. Can have eosinophilia.

Diagnotic test for Urine or serum antigen test (not antibody test) - look for the fungus itself, not for
histoplasmosis antibodies to the fungus

Treatment for Itraconazole or amphotericin B for severe disease

histoplasmosis

Overlap between HIV and Both can present with fever, malaise, sore throat, and lymphadenopahy.
EBV
In HIV, more common to have
- diarrhea, other GI symptoms - bloating, gas
- rash (unless abx have been given for EBV)
- painful mucocutaneous manifestations (e.g., oral ulcers),
- no pharyngeal exudate

How to distinguish cellulitis Nec fasc has severe pain, crepitus

from necrotizing fasciitis

HIV screening tests Do both the p24 antigen and the HIV antibody test.

When to screen for syphillis Pregnancy, men who have sex with men, IV drug users, unprotected sex, another
STD. Dont just screen everyone because the VDRL has a lot of false positives (see
elsewhere)

When did we start 1992

13
screening blood supply for
Hep C?

Hep C in pregnancy - 2-5%

- Risk of - Breastfeeding is okay
transmission to - Vaccinate against Hep A and B
baby? - C sections arent protective.
- Breastfeeding? - Ribavirin is teratogenic, interferon has not been tested
- Vaccinations?
- C-section?
- Take ribavirin or
interferon?

Tdap/Td - Give Td every ten years as an adult, but should get tdap in place of a
- schedule booster once as an adult
- When to avoid - If encephalopathy within a week of administration or unstable neurological
pertussis disorder
- When to avoid tdap - If immediate anaphylaxis
entirely

When to observe AOM Kids > 2 yrs, normal immune system, minor symptoms, unilateral
instead of giving abx

Treatment for cervical Clindamycin - covers both staph aureus and group A strep. Note that bactrim covers
adenitis (infected cervical MRSA but does not cover group A strep.
lymph node)

Treatment for Pertussis Macrolide - erythromycin

CHARGE syndrome Colomboa, heart defects, atresia of the choanae, growth impairment, ear
problems/deafness

Most common cause of - CF kids: staph aureus - havent been colonized with psuedomonas yet
pneumonia in - CF adults: psuedomonas
- CF kids
- CF adults

Diamond-blackfan anemia - Macrocytic pure red cell aplasia (low retic count, no multisegmented PMNs)
- symptoms/signs associated with congenital anomalies like short stature, webbed neck,
- treatment shielded chest, and triphalangeal thumbs
- inheritance - corticosteroids
- usually sporadic

Fanconi anemia - AR
- inheritance - progressive pancytopenia and macrocytosis, cafe au lait spots,
- signs/symptoms microcephaly, microphthalmia, short, horseshoe kidney, no thumbs
- average age at - 8 years
diagnosis

Lead poisoning - Screen with capillary (fingerstick) testing, then confirm with venous lead
- Method of testing measurement
- treatment - DMSA for 45-69, EDTA for 70+ and for acute encephalopathy

Peds Notes
Homocystinuria Kid with marfan like body, except lens goes down instead of up, fair complexion,
intellectual disability, hypercoagulability - stroke!. Treat with B6, folate, and 12.

Toxic synovitis vs. - Septic arthritis: ESR > 40, CRP > 2, WBC > 12, fever, cant stand on it or bear

14
septic arthritis weight
- Toxic synovitis: Can bear weight, not febrile, none of the above features. If kid
looks well and has no red flags, can just give NSAIDs and rest. But still have
to get xrays on both sides to rule out LCP

If kid gets worse, consider LCP even if xray is negative - get an MRI

Significance of Child abuse. Also called bucket fracture

epiphyseal/metaphyseal
fracture in babies

When do x-rays and x-ray - may take 1-2 weeks

bone scans show bone scan - within 48 hours
fractures?

Shaken baby syndrome Noncontrast CT to look for subdural hematoma. Consider MRI to visualize white
cranial studeies matter changes associated with shaking and the extent of bleeds

Risk factors for thalidomide, phenytoin, alcohol, rubella, DM, PKI

congenital heart
disease (not obvious)

Congenital heart Transposition of the great vessels

disease the presents
with cyanosis within the
first few hours of life

Transposition of the Risk factors- most common cyanotic lesion in newborns (TOF is in kids)
great arteries - Diabetic mothers
- risk factors - DiGeorge syndrome (also transposition of the great arteries)
- signs
- treatment Signs
- single loud S2, murmur if VSD is present
- Egg on a string, increased pulmonary vasculature

Treatment
- Keep ductus open, surgery to switch the arteries
- If surgery is not possible or if ductus wont stay open, do balloon atrial
septostomy to create/enlarge ASD

Tetralogy of Fallot risk maternal PKU

factors DiGeorge

Aperts syndrome Cranial deformities, fusion of fingers and toes, often have ventral septal defects

ASD risk factors - Holt Oram (absent radii, ASD, first degree heart block)
- alcohol
- Down syndrome

Treatment for VSD
- monitor small defects, they usually close on their own
- Repair if symptomatic w/ meds, pulmonary HTN < 1 year of age, or large
VSDs that arent closing
- Get abx for dental procedures if prosthetic material is used
- Treat CHF with diuretics, ACEi

Risk factors for VSD Aperts syndrome

Trisomies - 13, 18, 21
Alcohol
Cri du Chat
TORCH syndromes

15
When to do surgery for - If indomethacin fails or if the kid is more than 6-8 months old
PDA

Ductal dependant -Severe coarctation of the aorta

congenital heart -severe tetrology of fallot
disease

Williams syndrome
- Microdeletion of the long arm of chromosome 7 (includes the elastin gene).
- Elfin face
- Intellectual disability
- Hypercalcemia - very sensitive to vitamin D (goes with their sunny
personalities)
- Very friendly
- Supravalvular aortic stenosis

Velocardiofacial 22q11 delon

syndrome - Palate and face defects
- Heart defect - conotruncal abnormalities

DiGeorge 22q11 deletion thymic, parathyroid, and cardiac defects (risk of transposition of the
great arteries, tetrology of fallot)

Cri du Chat Microdeletion of the short arm of chromosome 5. Intellectual disability, epicanthal
folds, VSD, classic cry.

Holt Oram Absent radii, ASD, first degree heart block

Normal weight gain for double by 4-5 months, triple by 1 year, quadruple by 2 years
the two years

How long to correct age 2 years

for prematurity when
assessing
development?

Puberty dating: - Precocious: any sign of puberty before 8 in girls, 9 in boys

- Average age for - Average age = 10.5 for girls (menarche at 12.5), 11.5 for boys
boys and girls? - Delayed puberty: No breast or hair development in girls by 13. No testicular
- Definition of enlargement by age 14
precocious
puberty?
- Delayed
puberty?

Puberty stages Girls: thelarche (breasts) pubarche (pubic hair) growth spurt menarche
- girls
- boys Boys: gonadarche pubarche adrenarche (axillary/face hair, voice change)
growth spurt

Diagnosis of - Target sign on ultrasound

intussusception - If high suspicion air contrast enema is dx and tx
- Test(s) to use
- Surgery if unstable, peritoneal signs, or enema reduction doesnt work
- when to to do
surgery?

Surgery for Two stages - colostomy then pull through

Hirschsprungs disease

16
Diagnosis of malrotation - Abdominal xray - bird beak
with volvulus - If stable - upper GI

Treatment for 1. Supportive measures - NPO, etc

necrotizing enterocolitis 2. Surgery if perforation or worsening xrays on serial xrays. Typically do an
ileostomy and reanastomose later

4 Pediatric B cell Brutons agammaglobulinemia:

disorders - x linked recessive only boys. No b cells recurrent infections with
encapsulated bugs after 6 months. No tonsils, no lymphoid tissue.
- IVIG

Common Variable Immunodeficiency

- Normal B cell numbers but low plasma cells all Ig levels are low
- upper and lower pyogenic respiratory infections, AI disease
- IVIG

IgA deficiency
- Most common!
- Recurrent respiratory and GI infections (giardia)
- anaphylactic transfusion rxn - dont give IVIG!

Hyper IgM
- Normal number of B cells, but they can only make IgM, cant class switch to
IgA or IgG

4 T cell disorders - Thymic aplasia (diGeorge)

- Ataxia telangectasia
- SCID
- Wiskott Aldrich

Treatment for thymic - BMT and IVIG for immune deficiency

aplasia (diGeorge) - PCP prophylaxis
- Can also transplant the thymus

Ataxia Telangiectasia - DNA repair defect

- cause - increased risk of cancer - NHL, leukemia, gastric cancer
- risk - Treatment - none. Maybe IVIG if severe Ig deficiency
- treatment

x-linked recessive Wiskott Aldrich, Bruton Agammaglobulinemia, of chronic granuloatous disease

immune deficiencies

Wiskott Aldrich - x linked recessive - mutated WAS gene so T cells cant reorganize
cytoskeleton
- Usually noted at birth
- WATER: Wiskott Aldrich, Thrombocytopenic purpura, eczema, recurrent
infections
- Bleeding, recurrent otitis media, eczema
- Treatment: IVIG, abx, BMT - rare to survive to adulthood

Chronic granulomatous - Defective NADPH oxidase - cant convert oxygen to superoxide (O2*) cant
disease
make hydrogen peroxide or bleach
- abnormal dihydrorhodamine and nitroblue tetrazolium tests
- PLACESS: psuedomonas, listeria, aspergillus, candida, e coli, seratia, staph
aureus

Jobs syndrome Defective neutrophil chemotaxis: Coarse face, Abscesses, retained teeth,

17
 increased IgE, eczema. Give penicillinase resistant abx, IVIG

Difference between Scarlet fever - no conjunctivitis or lip involvement

kawasaki and scarlet
fever sx

Stills disease - Systemic onset juvenile idiopathic arthritis (as opposed to pauciarticular or
- Features polyarthritis, which dont have systemic sx).
- ANA/RF status - Have high fever, hepatosplenomegaly, and salmon colored macular rash.
- Usually ANA and RF negative, as opposed to the nonsystemic ones, which
are usually ANA+.

Bronchiolitis - Wheezing, tachypnea, crackles in babies

- symptoms - treatment - can try albuterol (but dont continue if it doesnt help)
- treatment - DO NOT USE STEROIDS - NOT HELPFUL
- High risk babies with heart, lung, or immune disease - can try ribavarin.
- Winter prophylaxis for high risk kids until 2 years old with injectable poly or
monoclonal antibodies

Croup -inspiratory stridor, barking cough esp at night, steeple sign

- symptoms - mild: cool mist
- treatment - severe: steroids, nebulized racemic epi

Epiglottitis - thumbprint sign vs. subglottic narrowing, no psuedomembrane, higher fever,

- distinguish from usually H flu vs. staph aureus following viral prodrome, young kids (3-7 yrs)
tracheitis vs. babies and toddlers
- treatment - Intubate, then ceftriaxone or cefuroxime (2nd gen)

Pertussis - Culture is the gold standard. Labs will show increased lymphocytes (>70%)
- Dx - hospitalize babies < 6 months. Give erythromycin
- Treatment

Rash spread patterns - Parvo: arms trunk and legs, worse with fever and sun
- Measles and rubella: head to toe
- Varicella: face body
- Roseola (HSV 6 and 7): maculopapular rash appears when high fever breaks
- Hand-foot-mouth: hands, feet, butt only

APGAR A=appearance: 0 points for blue, 1 point for only acral cyanosis, 2 points for pink
P = pulse: 0 if no pulse, 1 if < 100, 2 if > 100
G = Grimace: 0 points for nothing, 1 point for grimace, 2 for grimace + cough
A = Activity: 0 points for nothing, 1 for some, 2 for vigorous
R = Respiration: 0 for nothing, 1 for irregular, 2 for regular

4-7: possible need for resuscitation. 0-3 needs immediate resuscitation

Threshold for jaundice 5 mg/dL, 25 mg/dL

and kernicterus - phototherapy for mild elevations if UNCONJUGATED or exchange
- Treatment for transfusions if severe (>20)
jaundice - Start phototherapy earlier (10-15) for preterm

Pathologic jaundice - > 10% conjugated

features - present in first 24 hours
- BR increase > 0.5 mg/dL/hr
- BR > 15 mg/dL

Transient tachypnea of CXR: prominent perihilar streaking in interlobar fissures, resolves with oxygen
the newborn

18
 - CXR and
treatment

VACTERL Vertebra, anal, cardiac, trachea, esophagus, renal, limbs

Gastroschisis vs. - Gastroschisis is next to the umbilicus, not covered, a surgical emergency
omphalocele - Omphalocele is at the umbilicus, in a sac. Associated with beckwith-wiedemann and
trisomies

Prevention of RDS in steroids if < 30 weeks

babies > 30 weeks: monitor L/S ratio or look for phosphatidylglycerol

Simple vs. complex - Complex if > 15 minutes, more than one in 24 hrs, focal (not generalized tonic
febrile seizures clonic).
- Complex has 10% risk of epilepsy

Management of febrile Simple seizure:

seizure - < 6 months: need sepsis work up
- > 18 months: Focus on finding infection. If CNS signs, look for ICP and then
do LP
- Give anti-pyretic meds (acetaminophen) - but will not reduce recurrence.
AVOID ASPIRIN

Complex seizure: EEG and MRI

Risk factors for Neurofibromatosis, hirschsprungs disease, n-myc

neuroblastoma

Wilms tumor - Beckwith weidemann (hemihypertrophy, macroglossia, big organs)

associations - Neurofibromatosis
- WAGR (wilms tumor, aniridia, genitourinary abnormalities, mental
Retardation)

When can car seat face > 2 years and > 40 lbs
forward?

Systemic symptoms in - Ewings: fever, anorexia, fatigue, in addition to the local pain & swelling
Ewings sarcoma, - -osteosarcoma: only local pain and swelling, constitutional symptoms are
osteosarcoma? usually absent!

What does leukocoria - retinoblastoma, congenital cataracts, retinopathy of prematurity

indicate?

When does strabismus > 3 months, before then its normal

need correction?

Egg allergy and No MMR or varicella - remember these are the same two live vaccines that are okay in
vaccines? HIV

Contraindications to - egg allergy no MMR or varicella

vaccines
- encephalopathy within 1 week of pertussis vaccination
- No live vaccines if immune compromised, pregnant, or HIV - except HIV can
have MMR and rubella

Precautions
- current moderate to severe illness, with or without fever
- prior reactions to pertussis
- IVIG within past year

19
 Okay with: mild fever, current abx, premature

Strongyloidiasis Symptoms: hives, abdominal pain, respiratory problems

- symptoms treatment: Ivermectin
- treatment

Enterobius vermicularis Albendazole or pyrantel pamoate

(pin worm infection
treatment

Who should be 12 and 24 months in high risk areas (homes < 1950s, zip code). Universal screening
screened for lead not recommended

Lead treatment < 45 and no symptoms: remove sources, retest in 3 months

45-69: inpatient EDTA or outpatient DMSA (succimer)
70+: this is the threshold for encephalopathy. inpatient EDTA and IM dimercaprol
(BAL)

Non polio enteroviruses Coxsackie, echovirus

(90% of peds
meningitis)

Foreign body Coins - can observe for 24 hours IF time of ingestion is known AND patient is
swallowing - asymptomatic. Otherwise remove with flexible endoscopy - or surgery if signs of
management abdominal problems (blood in stool, etc)

Batteries, magnets - if in the esophagus, must come out ASAP. If distal to the
esophagus, 90% will pass uneventfully

Foreign body aspiration Rigid bronchoscopy

management

Lymphoblast Tdt
identification tests (ALL) PAS positive

When to do head CT Generally do it to r/o herniation, but if kid is < 1 year, only do if the kid has signs of
before LP in meningitis ICP/hernation like coma, focal neuro findings, or a history of neurosurgical procedure
work up

Empiric abx for - kids: ceftriaxone and vancomycin, except that infants < 1 month cant get
meningitis ceftriaxone (increases risk of kernicterus)
- kids - newborns: ampicillin plus gentamicin
- newborns

Galactosemia - Young infant with FTT, bilateral cataracts, jaundice, hypoglycemia.

- symptoms - Galactose 1 phosphate uridyl transferase
- enzyme
deficiency

Definition of colic Rule of 3: More than 3 hours per day for more than 3 days per week for more than 3
weeks

Management of Generally just wait for them to regress. But if in a risky place (eyelid, trachea), treat
strawberry with beta blockers! (propranolol)
hemangiomas?

Name of monoclonal Palivizumab

antibody against RSV?

20
B2/Riboflavin deficiency Angular cheilitis, stomatitis, glossitis, normocytic-normochromic anemia, and
seborrheic dermatitis

Treatment of impetigo - Non-bullous (staph aureus or GAS) - topical abx (mupirocin)

- bullous - Bullous (staph aureus) - oral abx
- Non-bullous

Treatment for long QT Beta blockers. If symptomatic (syncope, palpitations), then beta blocker + pacemaker
syndrome

Inheritance of friedrich Autosomal recessive triplet repeat

ataxia

Goats milk is low in B12, Folate, Iron

When to do an MRI for Only if red flags - woken from sleep, focal neuro signs, numbness/tingling, or
new migraines in kids increasing frequency

Treatment for migraines First line - acetaminophen, NSAIDS, supportive. Triptans as second line.
in kids

Electrolyte anomalies in decreased potassium, magnesium, thiamine, and phosphorus, with increased salt and
refeeding syndrome water reabsorption, due to increased insulin

Wardenburg syndrome - Autosomal dominant

- inheritance - partial albanism (white forelock), deafness, heterochromic irises
- features

Brachio-oto-renal - Hearing impairment, preauricular pits, external ear abnormalities, renal

syndrome features impairment, brachial fistulas

Speech development - 1 - 2-4 words and mama, dada. 2: 50 words, 2-3 word sentences. 3: 250 words, 3
how many words by word sentences
age 1, 2, and 3

Average RR for an 30 bpm

infant

Inheritance of C1 Autosomal dominant

esterase deficiency

Aortic/vascular rings - expiratory stridor that improves with neck extension, esophageal difficulties,
- symptoms 50% have other cardiac anomalies
- dx tests - barium contrast esophagram, bronchoscopy, CT or MRA

When to give live 11 months

vaccines after IVIG

Vaccine timing - Hep B: birth

- Hep B - Hib: 2 months
- Hib - Dtap: 2 months
- Dtap - Polio: 2 months
- Polio - MMR: 1 year
- MMR - Hep A: 1 year
- Hep A - Meningococcus: 11-12 years, booster at 16
- Meningococcus

Serum sickness like - Type 3 hypersensitivity rxn 1-2 weeks after abx

21
reaction - beta lactams or bactrim
- mechanism - fever, hives/rash, polyarthralgia, look ill
- trigger abx - labs - reduced complement, elevated ESR and CRP
- symptoms - remove offending agent, or steroids for serious cases. Avoid the offending
- labs agent in the future even though its not a true allergy
- treatment

When to screen all kids Before and after puberty: 9-11 and 17-21
for lipid disorders

Rotavirus vaccine - 2-6 months.

- When to give - History of intussusception
- Contraindicatio - Uncorrected congenital malformation of the GI tract (E.g., Meckels)
ns - SCID

Dermatology Notes
Arthus reaction Type 3 hypersensitivity local reaction involving preformed antibodies
- mechanism
- time frame vascular necrosis and thrombosis
- examples - 4-12 hours after exposure (e.g., vaccine)
- example: vaccine, hypersensitivity pneumonitis

Serum sickness Antibodies to foreign proteins are made in approx five days. Immune
complexes form and deposit in membranes, where they lead to tissue
damage by fixing complement.
- Fever, hives, arthralgias, and lymphadenopathy happen 5-10 days
after exposure
- Usually a drug reaction

Sebhorrheic dermatitis - pityrosporum ovale

- bug - selenium sulfide or zinc pyrithione shampoo, routine bathing and
- treatment emollients for cradle cap

Treatments for psoriasis keratolytic agents, tar, anthralin, UV therapy. Severe cases - methotrexate.
Can also use retinoids and vitamin D

Drug eruptions - usually 1-2 weeks after starting the drug. If 1-2 days, consider
- time frame something else.
- features - widespread, relatively symmetric, itchy

Erythema multiform - mucous membranes, palms and soles

- locations - antipruretics. systemic corticosteroids dont help!!!
- treatment

- Differences - SJS has mucosal involvement, blisters and sloughing, and more
between SJS and systemic symptoms - people are sick. Erythema multiform is more
erythema about target lesions. Mucosal involvement is rare, and people
multiform arent all that sick.
- Difference - SJS < 10% of the body, TENS > 30%
between SJ and - SJS = degeneration of the basal layer, TENS is full thickness
TENS eosinophilic epidermal necrosis
- non-obviousl drug - NSAIDs, floroquinolones, corticosteroids
triggers - treatment is supportive, also systemic corticosteroids and IVIG
- treatment

Pemphigus vulgaris and Triggers:

bullous pemphigoid - PV: can be triggered by drugs - penicillin, penicillamine, ACE
- triggers inhibitors, phenobarbital

22
 - treatment and - BG: usually idiopathic, but can be triggered by furosemide,
prognosis NSAIDs, ACE inhibitors, penicillamine, abx

Treatment
- PV: Corticosteroids and immune therapy (IVIG, mycophenalate,
rituximab) - can be fatal!
- BG: steroids, rare and milder course

Treatment for molluscum The lesions will resolve over months to years, are usually left alone in kids.
contagiosum But can treat by any destructive method.

HPV straings - warts - 6 and 11

- genital warts - Dangerous - 16 and 18
- Dangerous

Treatment for genital cryotherapy, podophyllin, trichloroacetic acid, imiquimod, 5-FU

warts

Salmonella typhi - small pink papules on the trunk in groups of 10-20, fever, GI
- features involvement
- treatment - Treat with floroquinolones and third gen cephalosporins. Consider
cholecystectomy for chronic carriers

Treatment for scarlet Penicillin

fever

Ludwigs angina - Bilateral cellulitis of the submental, submaxillary, and sublingual

- what is it spaces
- typical cause - Usualy caused by infected tooth
- typical symptoms - Dysphagia, drooling, fever, red warm mouth - can die from
asphyxiation

Treatment for necrotizing - Penicillin G, clindamycin, metronidazole or third generation

fasciitis cephalosporin

Tinea versicolor - Spaghetti and meatballs - hyphae and spores

- histology - treat with ketoconazole or selenium sulfide
- treatment

Tinea treatments Oral treatment (Griseofulvin) for capitis and unguium. Other tineas can do
topical abx. Kinda makes sense - difficult to put cream in hair and on nails.

Treatment for scabies Permethrin from the neck down or oral ivermectin

Treatment for rosacea Topical metronidazole. For more severe disease, systemic antibiotics. Can
do accutane if that fails.

Pityriasis rosea - HSV 6 or 7

- virus - Rule out syphyllis and fungal infection
- rule outs

Which skin cancer is the Basal cell

least likely to metastasize

What is the threshold 6 mm

diameter to worry about
with melanoma

Mycosis fungoides Symptoms

23
 - symptoms - psoriatic appearing plaque that is palpable, often on the butt.
- histology - Later can have reddish brown nodules and palpable lymph nodes
- treatment (with or without actual tumor in the node)
- Can involve the internal organs - lymph nodes, liver, spleen
- Sezary syndrome = leukemic phase. Cells in the blood.
Histology
- cerebriform lymphocytes - get histology for any dermatitis that is
chronic and resistant to treatment, because it might be mycosis
fungoides
Treatment
- phototherapy is the go-to therapy. Then radiation. Can also do
steroids, chemo, retinoids, monoclonal antibodies, and interferon

Porphyria cutanea tarda - Deficiency of urophoryrin decaboxylase (part of heme synthesis)

- blisters in sun exposed areas
- triggers - hep c, ethanol, ocps
- treat with phlebotomy, hydroxychloroquine, alpha interferon

Graft vs Host Disease - maculopapular rash on the face, hands, and feet, GI symptoms
- symptoms (diarrhea with blood), liver dysfunction (abnormal LFTs, jaundice),
- pathophysiology obstructive lung disease
- treatment - Caused by activation of the donor T cells (think grafT vs host dz)
- Treat with high dose corticosteroids

Surgical treatment for 1. Excisional biopsy for diagnosis

melanoma 2. Breslow depth < 1 mm 1 cm margins, 99% 1 year survival
3. Breslow depth > 1 cm sentinel lymph node biopsy

Tuberous sclerosis - facial angiofibroma, seizures, MR

- symptoms - astrocytoma and cardiac rhabdomyoma
- cancers
associated

Type 2 HIT - thrombocytopenia after several days of heparin. Also causes

- Symptoms platelet activation and a pro-thrombotic state
- Treatment - Stop heparin, give lepirudin (direct thrombin inhibitor) or another
agent - but avoid warfarin until platelet count is normal!

Osler Webber Rendu - Diffuse telangiectasias, recurrent nosebleeds, widespread AV

syndrome malformations - in the lungs, can shunt blood and cause chronic
- Inheritance hypoxemia and reactive polycythemia.
- symptoms

What do do when a Rivaroxaban - similarly effective to LMWH and warfarin, and does not
patient needs require frequent monitoring, but not reversible
anticoagulation (e.g.,
DVT) but doesnt want to
do the dietary restrictions
or monitoring for warfarin?

Indications for IVC filter Lower extremity DVT when anticoagulation is contraindicated (e.g.,
hemorrhagic stroke, active bleed). Or anticoagulation failure while
adequately anticoagulated

Heme-Onc Notes - see info above

Next step after identifying a Radical orchiectomy - remove the testes and its associated cord. Do not
painless hard mass in biopsy (whether trans scrotal or FNA) because the risk of spilling the
24
testicle and ultrasound cancer cells, which can spread through lymph and blood
suggests cancer?

Cryoprecipitate benefits More concentrated source of factor 8 and fibrinogen

over FFP?

DDAVP helps the body to VWF and factor 8 - makes sense because VWF carries factor 8
increase levels of what
clotting substances

Glucagonoma Mild diabetes/hyperglycemia that is easily controlled, weight loss, watery

- symptoms diarrhea, necrotic migratory erythema, anemia.
- dx test - NME is erythematous papules or plaques that coalesce to form
large, painful, and inflammatory blister or crusting with central
clearing - usually on the face, perineum, and extremities.
Measure glucagon levels - if over 500 confirms the diagnosis. Then do
imaging to localize the tumor.

Characteristic feature of Flushing

carcinoid syndrome

Intramedullary hemolysis Defective RBC synthesis can lead to intramedullary hemolysis and the
and jaundice
release of heme (e.g., in B12 deficiency) end up with jaundice and
elevated LDH!

Management of malignancy If symptomatic/severe, then do normal saline immediately and

related hypercalcemia bisphosphonates for chronic management. Avoid loop diurectics unless
volume overloaded (heart failure)

Initial treatment for SIADH High salt intake and fluid restriction. If that doesnt correct, consider
demeclocycline, but rarely needed.

Most common tumor to Lung cancer, melanoma, renal cell cancer, breast cancer, and colon
metastasize to the brain cancer. Prostate cancer hardly ever goes to the brain

NSAIDs and iron deficiency NSAIDs can cause chronic GI blood loss
anemia - what is the link?

How does lupus cause Through immune mediated destruction of WBCs, RBCs, and platelets
pancytopenia??

Treatment for TTP Plasma exchange - it is caused by either a deficiency of ADAMTS-13 or

an autoantibody against it. ADAMTS13 cleaves VWF. Plasmapheresis
replaces the deficient enzyme and removes autoantibodies against it.

Milk-alkali syndrome Hypercalcemia, renal insufficiency, metabolic alkalosis

MEN1 features 1. pituitary tumors,

2. parathyroid adenomas/hyperplasia, and
3. pancreatic tumors (esp gastrinomas - hyperglycemia, necrolytic
migratory erythema, weight loss, anemia)

How long to give penicillin 3-5 years for adults, until adulthood for kids. Risk of strep pneumo
prophy after splenectomy sepsis is present up to 30 years.

Management of lung nodule 1. Low risk - monitor with serial CT

(< 3 cm) 2. intermediate - further imaging (PET) or biopsy
1. Low risk 3. High risk - just take it out

25
 2. Moderate risk
3. High risk

Chondrocalcinosis Happens due to calcium pyrophosphate deposition - attacks are

psuedogout. Assoced with hemochromatosis

Multiple myeloma IgG or IgA

immunoglobulins involved

When to test for G6PD 3 months after an episode - the hemolytic episode wipes out all of the
deficiency? low enzyme cells and leaves reticulocytes, which have higher levels

Pyruvate kinase deficiency chronic hemolysis, hepatosplenomegaly, skin ulcers, pigmented

symptoms gallstones. Hemolysis not precipitated by sulfa drugs.

Nonseminoma tumors yolk sac, choriocarcinoma, embryonal carcinoma, mixed germ cell.
- examples
- tumor markers Most have elevated AFP (normal in seminoma) and many have bHCG

Giant cell tumor Epiphysis, soap bubble appearance

- location
- xray features

Osteitis fibrosa cystica = Hyperparathyroidism from PTH cancer resorption of bone and
von Recklinghausen
disease replacement with fibrous tissue (brown tumors) that cause bone pain.

Symptoms of chronic lead fatigue, irritability, insomnia, HTN, neuropathy, nephropathy, neuropsych
exposure issues

Endocrine Notes
Symptoms of glucocorticoid Hyponatremia, eosinophilia, hypoglycemia, fatigue, loss of appetite
deficiency

HLA types associated with - DM1: DR3 and DR4

- DM1 - RA: DR4
- RA

Criteria for diagnosing 1. Fasting (8 hr) glucose > 126 (> 110 is impaired)
diabetes 2. Random glucose > 200 + symptoms
3. Two 2-hour glucose tests > 200
4. HgA1c > 6.5

When to screen for diabetes No risk factors: HbA1c at 45 and every 3 years. Impaired fasting
glucose - frequent retesting

Goal blood glucose range 80-120. Can tolerate over 200, especially in the very young, to avoid
with insulin hypoglycemia

Types of insulin - onset, peak, - regular: onset 0.5-1 hour, peaks 2-4 hours, lasts 5-8
duration - short (lispro, aspart, glulisine): 5-20 mins, peaks 0.5 to 5
- Regular hours, lasts 3-8
- Short acting - NPH: onset 2-4 hours, peaks 6-10, lasts 18-28
- NPH - long acting (detemir, glargine): 1-3 hours, no peak, 1 day
- Long acting

Managing diabetes - adults - 7, kids - 8

- goal HbA1c for kids - check lipids every 2-5 years
and adults

26
 - how often to check
lipids
Phenomenon and
management - Dawn and
Somogyi
Goal BP, LDL, TG in
diabetes. When to give a
statin and aspirin?
Time frame for eye
complications in diabetes
Metformin
- mechanism of action
- CIs
Thiazolidinediones
(rosiglitazone, pioglitazone)
- mechanism of action
- CIs
Alpha glucosidase inhibitors -
MOA
DDP-4 inhibitors (sitagliptin)
Incretins (exenatide,
liraglutide)
Pagets
- Alk phos, calcium,
and phosphate levels
- Dx testing
- Treatment
Treatment for acute
hypercalcemia
Prevention and treatment of
secondary hyperPTH in renal
insufficiency
Secondary hyperPTH:
causes, labs
Cushing syndrom
- symptoms
Dawn: AM hyperglycemia from nocturnal release of glucagon, epi,
cortisol. Increase evening NPH
Somogyi: AM hyperglycemia from excess insulin and overnight
hypoglycemia decrease evening NPH
130/80, LDL < 100, TG < 150. Everyone gets aspirin.
Statin if LDL > 100 or LDL > 70 with heart disease. But other resources
says that all diabetics 40-75 should be on a statin
3-5 years
- decrease hepatic glucose production and increase insulin
sensitivity
- Cant use in the elderly, or in failure of heart, kidney, liver
- increase insulin sensitivity
- Cant use in heart failure. Can cause liver failure and bone
loss.
Decrease intestinal absorption of carbs
Inhibit breakdown of glucagon like peptide. Can use in CKD. Do not
affect weight
GLP-1 agonists. Injections. Delay food absorption, increase insulin
secretion and decrease glucagon secretion. Nausea and pancreatitis.
Good second agent to add with metformin, especially if weight
loss is desired
- Normal calcium and phosphate, increased alk phos
- Radionucleotide bone scan is the earliest sensitive test, but
xray is critical to dx
- No cure. If symptoms or involvement of vulnerable site
(femoral neck), give bisphosphonates and calcitonin. NSAIDs
and acetaminophen for pain.
IV fluids, loop diuretics, and IV bisphosphonate. But dont need to treat
familial hypocalciuric hypercalcemia.
- Prevention: Oral phosphate binders (calcium salts, sevelamer
hydrochloride, and lanthanum carbonate), restrict dietary
phosphate.
- Treatment: Cinacalcet is a calcium mimetic that lowers PTH
levels
- Caused by renal insufficiency (retain phosphate), calcium or vit
D deficiency
- Calcium will be low or normal, but phosphate is high
- Start with screening test: elevated 24-hr free urine cortisol,
midnight salivary cortisol 2x, 1 mg dexamethasone
27
 - Dx tests suppression test (will not suppress cortisol from cushings
disease or adrenal problems)
- Distinguish ACTH-cause from non-ACTH cause: measure AM
cortisol and ACTH
- If high ACTCH, can do high dose dexamethasone suppression
test
- Imaging - pituitary MRI if ACTH is elevated, adrenal imaging if
not elevated

Treatment of bilateral adrenal Inhibit steroidogenesis - eplerenone, spironolactone

hyperplasia

Medical treatment for Octreotide (somatostatin analog) to suppress GH

acromegaly Pegvisomant to block peripheral GH receptors

Prolactinoma - > 200

- prolactin level - Dopamine agonists (bromocriptine, cabergoline). Surgery if
- treatment meds fail or if compressive symptoms

Treatment for nephrogenic 1. Restrict salt and increase water intake

diabetes insipidus 2. Thiazide diuretics can promote mild volume depletion and
increased water reabsorption

Treatment for SIADH 1. restrict fluid, address cause,

2. If symptomatic, can give isotonic saline
3. If hyponatremia is severe (<110), give hypertonic saline -
must be in the ICU to prevent central pontine myelinosis
4. Demeclocycline = ADH receptor antagonist

Adrenal insufficiency - labs: hyponatremia and eosinophilia (primary or secondary).

- labs Hyperkalemia if primary (no aldosterone)
- Dx testing - Dx test:
- 8am plasma cortisol - if < 3 diagnostic. (morning to
check for low levels, evening or all day to check for
high)
- Follow with ACTH test - failure to rise to > 18 is
diagnostic

Pheochromocytoma - Men 2A & 2B, VHL, neurofibromatosis

- genetic causes - 10% - extra adrenal, bilateral, malignant, kids, familial
- Rule of 10 - elevated plasma metanephrines or urine metanephrines and
- Dx catecholamines. CT and MRI, nuclear MIBG scan to look for
extra adrenal lesions and mets

Hyperprolactinemia Order TSH and pregnancy test. Generally > 200 is diagnostic of
prolactinoma

Subacute thyroiditis - pain? - lymphocytic: No

- lymphocytic - granulomatous: yes
- granulomatous/de
quervains

What to monitor in DKA pH, serum anion gap - correct before the ketoacidosis
treatment

Weird side effects of Anemia (normocytic normochromic), hyponatremia, asymptomatic AST

hypothyroid and ALT increase, hyperlipidemia.

28
Graves ophthalmopathy
- unique eye problems
in graves
- risk factors
- effect of radioiodine
therapy
Plasma aldosterone: renin
ratio - how to use it
Tolvaptan
Preferred therapy for
hyperaldosteronism caused
by
- unilateral hyperplasia
- bilateral hyperplasia
- adenoma
Kid with precocious puberty,
- LH is high
- LH is low
Best metrics for following
DKA response to treatment
Milk-alkali syndrome
Neuro Notes
Mnemonic for motor/sensory
function of the cranial nerves
Four kinds of basal ganglia
lacunar strokes
Imaging in acute stroke
Management of ischemic
stroke
- Window for tPA
- Window for intra
arterial thrombolysis
- Window for aspirin
When to treat HTN after
- Proptosis, decreased convergence, diplopia. Lid lag and
retraction are seen in Hyper TH in general
- female, older age, smoking
- radioactive iodine can make it worse!
Level < 20 indicates that renin is higher than expected, > 20 indicates
that renin is being suppressed by extra aldosterone
Vasopressin/ADH antagonist at the kidney - but can increase liver
enzymes and is expensive. Reserve for hypervolemic hyponatremia
(HF) or euvolemic SIADH that doesnt respond to fluid restriction
Meds for hyperplasia, surgery for adenoma
- LH high central precocious puberty. Get an MRI.
- LH low GnRH stimulation test. If LH is high, then get an MRI.
If low, then its peripheral do an ultrasound of the adrenal
gland, ovaries, or testes
Serum anion gap and beta hydroxybutyrate - NOT acetoacetate
Overdo it with antacids hypercalcemia, metabolic alkalosis, renal
failure
Some say marry money but my brother says big brains matter more
Pure motor (internal capsule - will affect contralateral side evenly throughout),
pure sensory, dysarthria clumsy hand, ataxic hemiparesis.
Lacunar strokes can be too small to see on non-contrast CTobtained shortly after
or during the event!
1. CT without contrast - look for hemorrhage, but wont see strokes < 6
hours old
2. Diffusion weighted MRI can see ischemic changes within 20 minutes
tpA: 3 hours
Intraarterial thrombolysis: 6 hours
aspirin 48 hours
SBP > 220 or DBP > 120
29
stroke? What agents to use? Hemorrhagic stroke (goal SBP < 150)
For tPA: must have SBP < 185 and diastolic < 110

IV labetalol or nicardipine

Contraindications to tPA - Past intracranial hemorrhage

- Stroke or head trauma within 3 months
- GI or urinary bleeding within 3 weeks
- Surgery within 2 weeks
- Recent MI
- Elevated BP: SBP > 185, DBP > 110
- INR > 1.7, prolonged PTT, low platelets (< 100)
- kids < 18 yrs, TIA, seizure
- BG > 400 or < 50

Non-obvious risk factors for Aortic coarctation, sickle cell, atherosclerosis

berry aneurysm

Empiric treatment for penicillinase resistant penicillin (nafcillin or oxacillin), 3rd or 4th generation
suspected cavernous sinus cephalosporin
thrombosis

Abnormal lab value with elevated prolactin

epileptic seizure

Imaging following a new focal CT or MRI with contrast

seizure

First line anticonvulsant in kids phenobarbital

Infantile spasms: Hypsarrhythmia on interictal EEK

- Abnormal EKG finding
- Treatment Treat with ACTH prednisone, and clonazepam or valproic acid (little effet on
prognosis)

Abnormal EEG finding in Interictal EEG shows slow spike and wave complexes
Lennox-Gastaut syndrome

Drugs to avoid in myasthenia Aminoglycosides, beta blockers

gravis

Treatment for Guillain Barre IVIG and plasmapheresis. Avoid corticosteroids!

Creutzfeldt Jakob Diffusion MRI: increased T2 and flair intensity in the putamen and the head of the
- MRI findings caudate
- EEG findings EEG: pyramidal signs and periodic sharp waves
- CSF lab values -CSF: elevated tau and 14-3-3

Mimics of Parkinsons that Progressive supranuclear palsy, multiple system atrophy

dont respond to L-dopa

Brain mets - what are the most Lung, breast, kidney, GI, melanoma
common primary sites

Mets that present with Renal cell carcinoma, thyroid papillary cancer, choriocarcinoma, and melanoma
hemorrhage

Eyedrops for closed angle timolol, pilocarpine, apraclonidine

glaucoma

30
Pilocarpine cholinergic agent, contracts the ciliary muscle and pupillary sphincter to treat both
open and closed angle glaucoma enables increased aqueous humor outflow

Early sign of age related Painless loss of central vision, distorted straight lines
macular degeneration

Central retinal artery occlusion intra arterial thrombolysis within 8 hours.

- treatment
Maybe also drain fluid from anterior chamber, ocular massage to dislodge the
clot, high flow oxygen, and IV acetazolamide - questionable benefit

Signs of hypertensive arteriovenous nicking, copper or silver wiring, exudates, or hemorrhages

retinopathy

Treatment for allergic Olopatadine, azelastine - stabilize mast cells

conjunctivitis

CMV retinitis Painless! retinal lesions and associated hemorrhages, usually no conjunctivitis or
keratitis

HSV and VSV retinitis Painful! Rapidly progressing bilateral necrotizing retinitis, with keratitis and
conjunctivitis, fast vision loss.

Medulloblastoma typical cerebellar vermis.

location

Neuroblastoma location and Adrenal glands usually. Opsoclonus myoclonus

associated symptoms

Pinealoma and parinaud limited upward gaze, bilateral ptosis and lid retraction. Also nausea and vomiting
syndrome from hydrocephalus.

Features of lateral and mid- Will affect the trigeminal nerve on the same side muscles of mastication,
pons strokes
reduced jaw jerk, reduced tactile and position sensation over the face.

Medial mid-pons infarct will have contralateral ataxia and hemiparesis of the
ipsilateral face

Lateral medullary infarct Hits CN 9 and 10 dysphasia, hoarse, diminished gag reflex
features

Features of medial medullary Contralateral paralysis of the arm and leg, tongue deviates towards the side of the
infarct lesion

Cerebellar tumor symptoms ipsilateral ataxia, nystagmus, intention tremors, loss of coordination, ICP

Imaging findings in AIDS - AIDS dementia presents with cortical and subcortical atrophy and
- AIDS dementia secondary ventricular enlargement
- Progressive multifocal - Not enhancing, no mass effects
leukoencephalopathy - Solitary, weakly ring-enhancing periventricular mass on MRI
- primary CNS
lymphoma

Conus medullaris lesion vs. Conus medullaris: back pain with bladder and rectal dysfunction, hyperreflexia,
cauda equina (spinal roots) more symmetric symptoms. weakness and sensory loss are less common.

Cauda equina syndrome causes radicular pain, lower extremity weakness, saddle
anesthesia, and bowel and bladder dysfunction. Affects sacral roots - will not

31
 affect the umbilicus, etc. Hyporeflexia.

Cerebellar tremor Can be action, postural, or intention. Usually associated with ataxia, nystagmus,
etc. Only 3-4 hz, slower than other types of tremors

Polymyalgia rheumatica Acting and morning stiffness, pain, decreased range of motion, but normal
muscle strength. Treat with glucocorticoids.

Trihexyphenidyl Anticholinergic used for Parkinsons and drug induced EPS, like benztropine

Prophylaxis for cluster Verapamil, lithium, ergotamine

headaches

Biggest risk factor for stroke HTN

Risks after SAH - rebleed - first day

- rebleed - vasospasm - 3-10 days, prevent with nimodipine
- vasospasm

Most common bugs in brain - sinusitis/head/neck: strep viridans, anaerobes

abscess - distal sites: staph aureus, gram negatives
- spread from sinusitis, - surgery or trauma: staph aureus
head and neck
infection Treat with 4-8 weeks of abx and drain whenever possible
- spread from more
distal sites
- surgery or trauma

Anti emetics used for acute chlorpromazine, prochlorperazine, metochlopramide

migraine

Most common early side hallucinations, headache, dizzy, agitation. After 5-10 years can get involuntary
effects of levodopa carbidopa movements

Treatments for essential Propranolol, also primidone. Side effects of primidone: It can precipitate acute
tremor intermittent porphyria. Colicky abdominal pain, confusion, headaches,
hallucinations, and dizziness. Check urine porphobilinogen

Electrolytes Notes
Treatment for Hyperkalemia 1. Severe: Calcium infusion as calcium glucuronate, shift
1. Severe w/ EKG potassium intracellularly - insulin and glucose is faster than
changes beta 2 agonists
2. Not immediately 2. Loop diuretics with normal saline
dangerous 3. sodium polystyrene sulfonate
3. Chronic management 4. NSAIDs, cyclosporine, heparin, anything that affects RAAS
4. Meds than can cause it

Hyponatremia Evaluate if hypovolemic, euvolemic, or volume overloaded. If mild,

1. Mild water restrict if possible. If need to give fluids, use hypertonic
2. Moderate/severe saline!

Hypernatremia 1. Mild - correct with D5/half normal saline

1. Mild 2. Severe - correct with normal saline
2. Severe
If hypervolemic or euvolemic, can give oral free water if the patient
can tolerate it

32
Renal Notes
Symptoms of ADPKD hypertension, hematuria, proteinuria, palpable renal masses, and progressive
renal insufficiency. May also have flank pain due to renal stones, cyst rupture or
hemorhage, or upper UTIs. HTN is often present before renal insufficiency.

Nephrotic syndrome and Nephrotic: > 3.5 g/day. Nephritic < 1.5 g/day
nephritic syndrome protein
levels

Liddle Syndrome features Overactive sodium channel in the distal tubule acts like hyperaldosteronism.
Treat with amiloride

Primary hyperaldosteronism > 20

renin/aldosterone ratio

Crystal induced kidney injury acyclovir, sulfonamides, methotrexate, ethylene glycol, protease inhibitors
- what meds cause it (indinavir)

Causes of papillary necrosis NSAID: nsaids, sickle cell, analgesics, infection, diabetes

What distinguishes RBC casts/dysmorphic RBCs, proteinuria

glomerular bleeding from
bleeding elsewhere in the Renal bleeding will not have clots
kidney? What distinguishes
renal bleeding from other
sites?

Nephrotic or nephritic Minimal change! Other solid tumors are associated with membranous
syndrome associated with nephropathy
- lymphoma?

Kidney stone size for Urethra: < 0.5 cm. Stones up to 3 cm can be treated with shock wave,
passing through the urethra percutaneous procedures, retrograde ureteroscopy
and for non-open surgeries

Infection prophy for amoxicillin if < 2 months of age, bactrim or nitrofurantoin otherwise
vesicoureteral reflux

When to do - most descend by 3 months. If not, orchiopexy by 6-12 months.

- orchiopexy for Orchiectomy if discovered later
undescended - Hydrocele surgery by 12-18 months - increased risk for inguinal hernia
testicle
- surgery on a
hydrocele

When to do radical Invasive cancers without metastasis. Otherwise just do intravesicular chemo.
cystectomy for bladder Even high grade recurrent lesions that dont invade get IVC. If invasive cancer
cancers has metastasized, just do chemo.

AFP is elevated in: Non-seminomas, especially yolk sac. Also hepatocellular cancer,
hepatoblastoma, and neuroblastoma

Mixed essential Palpable purpura, proteinuria, hematuria, joint pains, hepatosplenomegaly, low
cryoglobulinemia complement

Side effects of - cyclosporine: nephrotoxicity, hyperkalemia, HTN, gum hypertrophy,

- cyclosporine hirsutism, tremor
- tacrolimus - tacrolimus: nephrotoxicity, hyperkalemia, HTN, tremor
- mycophenalate - mycophenalate: bone marrow suppression

33
 - azathioprine - azathioprine: diarrhea, leukopenia, hepatotoxicity

-Earliest renal abnormality - glomerular hyperfiltration

seen in diabetic nephropathy - thickening of the glomerular basement membrane
- Earliest sign of injury that
can be quantitated

Who needs a urine culture Complicated patients - pregnant, diabetes, hospital acquired, etc.
before UTI treatment?
Bacterial prostatitis needs a urine culture.

Imaging modality for the Adults - CT, kids - ultrasound

urinary tract

Agent to alkalinize the urine Potassium citrate. Citrate both alkalinizes the urine and acts as a stone inhibitor
(eg. with uric acid stones) to reduce stone formation

Psychiatry notes
Second dangerous side effect Lowers the seizure threshold
of clozapine

When to notify parents about a When the kid is at risk of self harm or when starting psych meds
kids psych issues

GI notes
VIPoma WDHA syndrome - watery diarrhea, hypokalemia, achlorydia. Can cause flushing -
dont confuse with carcinoid syndrome (flushing, diarrhea, brochospasm)

Stepwise management for 1. Salt and water restriction

ascites 2. spironolactone
3. furosemide (< 1 L/day)
4. frequent abdominal paracentesis (2-4 L/day)

GERD treatment Start with antacids, ramp up to H2 antagonists or PPIs. If unresponsive to therapy,
do upper endoscopy with biopsy (EGD)

triple therapy for H pylori amoxicillin, clarithromycin, and omeprazole. If allergic to penicillin, use
metronidazole

Types of chronic gastritis: A A is in the fundus, involves antibodies to parietal cells (causes pernicious anemia).
and B Increased risk of gastric adenocarcinoma and carcinoid tumors.

B is in the antrum, can be caused by NSAIDs or by H pylori. Increased risk of PUD

and gastric cancer

H pylori causes what percent 70% gastric, 90% duodenal. Other non-obvious risk factors - corticosteroids,
of duodenal and gastric tobacco
ulcers?

Med that can help PUD misoprostol

patients that have to take
NSAIDs

C diff diarrhea abx vancomycin, metronidazole

Campylobacter treatment erythromycin

34
Treatment for salmonella
diarrhea (at risk patients or
bacteremia
Treatment for shigella
When is surgery indicated for
SBO?
How to tell SBO from ileus on
abdominal xray?
Treatment for diverticulitis
When should colon cancer
screening start?
- no risk factors
- family history (first
degree relative)
- ulcerative colitis
How to determine the etiology
of ascites?
SBP
- Diagnostic criteria
- most common bugs
- Treatment
- prophy
Treatment for hepatocellular
carcinoma
How to monitor for return of
colon cancer
Dx of diverticulosis and
diverticulitis
Treatment for ascites - which
diuretics to use?
How to confirm Hep B inactive
carrier?
Serum amylase can be
elevated in
Zinc deficiency
floroquinolone, bactrim
bactrim
Complete SBO, ischemic necrosis, or partial SBO symptoms lasting > 3 days
without resolution
SBO has no gas in the colon, while ileus does
Bowel rest, NG tube, broad spectrum abx (metronidazole and floroquinolone or
2nd/3rd generation cephalosporin)
- age 50 with colonoscopy every 10 years, DRE and stool guaiac every
year, or sigmoidoscopy every 5 years
- first degree relative: colonoscopy every 10 years starting at 40 or starting
10 years before the affected family member was diagnosed, whichever
comes first.
- UC: colonoscopy every 1-2 years starting 8-10 years after dx
Serum ascites-albumin gradient. If > 1.1, the intravascular space has decent
oncotic pressure problem with intravascular HTN (cirrhosis, etc). If < 1.1,
problem is a lack of oncotic pressure or increased permeability (pancreatitis,
cancer, nephrotic syndrome, TB)
> 250 PMNs/mL.
E Coli, klebsiella, strep pneumo
Treat with 3rd generation cephalosporin. Prophy with floroquinolone
Partial liver resection if < 5 cm and no cirrhosis. Orthotopic liver transplant if
cirrhosis
Colonoscopy 1 year later, then every 3 years
CEA every 3-6 months
Annual CT of the abdomen and pelvis for up to 5 years
Barium enema for diverticulosis - but dont do for diverticulitis because of the risk
of perforation.
Diverticulitis - do CT with oral and IV contrast
spironolactone, then furosemide if necessary. Be careful - diuretics hypokalemia
increased renal ammonia production. Also metabolic alkalosis makes
ammonium ammonia can cross BBB barrier
Need 3 normal ALT levels and 2-3 normal HBV viral tests over 1 year
Acute pancreatitis, mesenteric ischemia
skin lesions, abnormal taste, poor wound healing, alopecia
35
When to drain a pancreatic Lasts longer than 6 weeks, greater than 5 cm in diameter, or secondarily infected.
psuedocyst Dx with ultrasound. Tends not to have a fever

Normal liver span 6-12 cm in the mid-clavicular line

How to evaluate esophageal - Motility barium swallow, then maybe manometry

dysphasia
- Motility disorder - Obstruction endoscopy UNLESS at high risk for perforation (history of
- Mechanical obstruction cancer, radiation, complex strictures, caustic injury) - then do barium
swallow first and follow with endoscopy

Rheum/MSK Notes
Signs of herniated disk - Pain = sudden, severe, electricity-like, often preceded by months of
aches. Worsens with increased abdominal pressure/valsalva. Sciatica,
numbness, weakness, etc.
- Dx: passive straight leg test increases the pain (sensitive), crossed
straight leg test increases the pain (specific)
- Tx: NSAIDs, PT, heat. Not bed rest!

Location of tumors - metaphysis

- osteosarcoma

Empiric treatment for septic Ceftriaxone and vancomycin - to cover for staph, strep, and gram negative rods.
arthritis Also do debridement or serial aspirations

Gout - Negatively birefringent, yellow when parallel

- crystals - salicylates/aspirin (decrease uric acid secretion), cyclosporine
- Meds that can increase
uric acid

Psuedo gout - hemochromatosis, hyperparathyroid

- related diagnoses - rhomboid crystals
- crystal description

RF and ANA status of: - AS: ANA and RF negative

ankylosing spondylitis

Antibodies - Polymyositis: Anti-Jo

- dermatomyositis/polym - Dermatomyositis: Anti-Jo-1 (anti-synthetase) and anti Mi-2 helicase
yositis - scleroderma: antinuclear antibodies, Anti- Scl-70 (diffuse type, bad
- scleroderma prognosis), Anti-topoisomerase 1
- CREST variety of - CREST: anti-centromere
scleroderma - MCT: U1 RNP
- Mixed connective tissue - P-anca
disease
- Ulcerative colitis

Treatment for RA - NSAIDs

- Start DMARDs early! methotrexate is the best one to start with. Also
hydroxychloroquine, sulfasalazine
- Second line: TNF inhibitors, rituximab, leflunomide

Feltys syndrome RA, splenomegaly, neutropenia

36
Drug side effects - hydroxychloroquine: retinal toxicity (must do 6 month eye exams) and
- Hydroxychloroquine renal toxicity

Scoliosis management - < 20 degrees of curvature: observe

- 20-49: brace - but can get worse even with brace!
- 50+ degrees: surgery

Disseminated gonoccal Septic arthritis (50k WBC, may have negative culture) OR tenosynotivits,
infection migrating polyarthralgias, and rash

RF factor is positive in SLE, sjogrens, dermatomyositis, HCV, others

Trochanteric bursitis Pain over lateral hip, worse with palpation

Whats another name for Pagets disease

osteitis deformans?

Next step in a patient with new Kidney biopsy! Lupus nephritis can take many forms, need to sort out which kind
onset lupus nephritis? the person has before treating

Treatment for psoriatic arthritis NSAIDs, methotrexate, anti-TNF agents,

When to use cyclophosphamide Patients with serious renal or CNS problems

for lupus

Cervical spondylosis - what is Age related wear and tear of the cervical discs osteoarthritis with bony spurs
it?
that can cause nerve symptoms

Felty syndrome Neutropenia and splenomegaly + RA

Features of viral arthritis Acute onset, lack of inflammatory markers, resolves within 2 months

How to distinguish reactive Reactive arthritis: Afebrile, joint aspirate is sterile or has maybe 10k WBC. Maybe
arthritis from gonoccocal septic also tendonitis, mouth ulcers that arent present in septic arthritis. Classic is
arthritis uveitis, urethritis, and arthritis.

Medial meniscus tear - At accident: Popping sound, severe pain, but swelling takes several hours
- signs at accident because the meniscus is not well perfused.
- signs on exam - Swelling, snapping or locking with extension
- Full extension limited by pain or by locking

Emergency Medicine

Management of open pneumothorax Start with occlusive dressing (open on three sides to prevent tension
pneumothorax). The place a thoracostmy tube as soon as the primary survey is
done.

Replacement of fluids 3:1 ratio of fluids to blood. Give 1-2 L. If they are still unstable, consider packed
- Ratio of isotonic fluids to RBCs
blood lost. When move onto
something else.

Glascow Coma Scale - 4 eyes: spontaneous, to command, to pain, none

- Jackson 5 for speech: oriented, confused, inappropriate words,
incomprehensible, nothing

37

Head trauma - who gets a CT
- Definitely
- Either CT or observe 4-6
hours
- No CT
What to suspect when a previously
stable chest trauma patient dies
suddenly
Penetrating chest trauma
- When to intubate
- When to do an open
thoracotomy for patients with
penetrating chest trauma
causing cardiac arrest
Murmur of aortic dissection
Abdomen wound management
- Gunshot wounds - when do
they need ex lap?
- When do stab wounds need
ex lap vs. CT and
observation?
Signs of myocardial contusion
Management of lung contusion. Who
is most at risk?
Aortic disruption
- most common location
- causes
- Signs
- CXR findings
- Management
Hemothorax signs
Fat embolism signs - and when to
suspect?
What to do for asystole?
- Motor 6: Follows commands, localizes pain, withdraws to pain, flexion,
extension, none
- Definite CT: neuro findings, skull fracture, seizure, prolonged LOC,
persistent AMS
- Docs choice: GSC 15 with either headache, vomiting, brief or
questionable LOC, high risk or severe mechanism of injury (bad car
crash, fall > 5 ft)
- No CT: GSC 15 and non severe mechanism of injury and non severe
symptoms
Air embolism
- Intubate anyone who is unstable. Place bilateral chest tubes if the nature
of the injury isnt clear.
- If the patient arrested in the ER or shortly before arrival
New diastolic murmur
Gunshot wounds need ex lap if below 4th intercostal space (level of the nipple) -
usually even if stable
Stab wounds need ex lap if hemodynamically unstable, peritoneal signs,
evisceration. But can do CT with observation if patient is stable.
New bundle branch block, arrhythmia, hypotension
Maintain adequate ventilation and pain control. Hypoxia may worsen with fluid
hydration. More common in kids because less rigid protective chest wall
- location = just proximal to the ligamentum arteriosum
- Possible clinical findings: upper extremity HTN, impingement of the
recurrent laryngeal nerve hoarse, quiet voice.
- CXR: wide mediastinum, loss of aortic knob, pleural cap, deviation of the
trachea and esophagus to the right, depression of left mainstem bronchus
- CT or TEE before surgery. Aortography is the gold standard
Hypovolemia, decreased breath sounds and dullness to percussion on the
affected side
Fever, tachypnea, tachycardia, conjunctival hemorrhage, upper extremity
petchiae - especially after long bone fracture
CPR + epinephrine, search for underlying cause
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