-

Bordatello pertussis:
-paroxysmal cough, inspiratory whoop, postussive emesis
-lymphocyte predominat leukocytosis
-Tx: MACROLIDE
-Confirm with bacterial culture or PCR from nasopharyngeal secretions in
1st month
-Serology after 1 month
Hereditary angioedema:
C1 inhibitor deficiency or dysfunction leads to elevated levels of edema
producing factors C2b and bradykinin
Characterized by:
Rapid onset of:
-noninflammatory edema of face limbs and genitalia
-laryngeal edema can be life threatening
-edema of intestines -> colicky abdominal pain
-NO evidence of urticaria
Neonatal tetanus:
-born to unimmunized mother
-Frequently following umbilical stump infection
-present in first two weeks of life with:
poor suckling and fatigue followed by rigidity, spasms, and
opisthotonus
-High mortality:
-first week apnea, second week sepsis
Neimann pick:
Sphingomyelinase deficiency
Auto rec
Age 2-6 months
Loss of motor milestones
Hyptonia
Feeding difficulties
Cherry red macula
Hepatosplenomegaly
Areflexia

Tay-sachs:
B-hexoaminisidase A def
Auto rec
Loss of motor milestones
Hypotonia
Fedding difficulties
Cherry red macula
HYPERreflexia

Down syndrome second trimester quadruple screen:

Low MSAFP(maternal serum a fetal protein), low estriol, increased B-hcg,
inc inhibin A
PAPP-A: pregnancy assoc plasma protein is a glycoprotein produced by the
trophoblast. During FIRST trimester PAPP-A can be measured with B-hcg
and US nuchal transluceny with detection rate of 85% for down syndrome
Not used in second tri

Hypercalcemia:
Mainfestations of Ca >12mg/dL:
-constipation 2/2 altered intestinal smooth m tone
-anorexia
-vomiting
-weakness
-polyuria 2/2 defect in concentrating ability of renal tubules (nephrogenic
diabetes insipidus)
-confusion/lethargy

Medulloblastoma: 2nd MCinfratentorial tumor in children

-highly radiosensitive
-can met through CSF
>90% develop in cerebellar vermis
-Posterior vermis syndrome:
-truncal dystaxia
-unbalanced gait
-horizontal nystagmus

Astrocytoma: MC infratentorial tumor in children

-develop in Cerebellar hemispheres
-Hemispheric syndrome:
-arm, leg and gait ataxia with ipsilateral cerebellar signs
------GBS screening at 35-37 weeks gestation. Results are valid for ~5weeks.

Anti-D Ig AKA Rh antibody testing: done between 28-32 WGA

-half life of anti-D abs is ~6weeks, covers any potential exposure through
majority of 3rd trimester

Mixed cryoglobulinemia
-seen in 30% of pts with Hepatitis C
-arthralgia of miced cryoglobulinemia a/w a chronic vasculitic syndrome
characterized by palpable purpura, lymphandenopathy, nephropathy, and
neuropathy
TB is a common cause of chronic primary adrenal insufficiency
Primary adrenal insuff:
Etiology: Autoimmune, infection (TB, HIV, fungal), hemorrhagic
infarction(meningococcemia), metastatic CA(lung)
Presentation:
Acute: shock, abd tenderness, unexplained F, n/v, anorexia
Hyponatremia, hyperkalemia, hypercalcemia, and eosinophilia
Chronic: fatigue, wt loss, n/v, abd pain, hyperpigmentation
HYPOTENSION, hyponatremia, hyperK, hyperCa, anemia, eosinophilia
All adrenal insufficiencies will have Non-anion gap metabolic acidosis
Dx: Measure ACTH and serum cortisol with high dose ACTH stim test
Primary adrenal insuff: low cortisol, high ACTH
Secondary adrenal insuff: low cortisol, low ACTH
HIV tx side effects:
Didanosine pancreatitis
Abacavir hypersensitivity syndrome
Any NRTIs- lactic acidosis, Steven johnsons syndrome
Nevirapine liver failure
Indinavir(protease inhibitor) crystal induced(needle shaped) nephropathy
Crystal induced nephropathy:
Common etiologies:
Acyclovir (IV >oral) low urine solubility -> precipitates in tubules -> renal
tubular obstruction
Sulfonamides
Methotrexate

Ethylene glycol
Protease inhibitors
Elevated creatinine w/in 1-7 days of starting drug
Urinalysis can show: hematuria, pyuria, crystal
Give IV fluids with drug to reduce risk of AKI
ADPKD:
HTN is common early finding, often present before decline in renal
function
-Ace inhibitors are preferred HTN tx in ADPKD
Also present with: hematuria, proteinuria, palpable renal masses, or
progressive renal insuff.
May have flank pain due to renal calculi, cyst rupture or upper UTI
Shock
EpinephrineAlpha - 1 agonist to increase vasoconstriction
Beta 2 agonist to relax bronchial smooth muscle and decrease vascular
permeability
Dopamine can be used as additional vasopressor for persistent
hypotension
High dose acts on beta 1 and alpha -1
Does not help respiratory symptoms due to lack of significant beta 2
activity
Adult smoker with hard, non-tender, submandibular or cervical nodes is
highly concerning for head and neck CA.
Vast majority of head and neck CA is Squamous Cell CA
Brain death refers to a total loss of brain function and is a legally
acceptable definition of death. Family permission is NOT legally required
to discontinue life support
Herediatary spherocytosis:
-auto dom. Disorder of spectrin that provides scaffolding for RBCs
-RBCs are not flexible and get trapped in fenestrations of spleens red pulp
findings: positive family hx, splenomegaly, spherocytosis with increased
retic count
Thalassemia minor
-heterozygous for B-thalassemia

-typically asymptomatic
-microcytic target cells on peripheral smear
G6PD def
-X linked rec
-G6PD required to create NADPH necessary to create glutathione and
prevent oxidation of hgb.
-Rxn occurs in response to oxidant stress(antimalarial drugs, sulfas) fava
beans, infection
-bite cells
-heinz bodies after crystal violet staining
Succinocholine is a depolarizing neuromusc blocker often used during
rapid sequence intubation
-rapid onset 45-60 seconds
-rapid offset 6-10 minutes
-Can cause significant potassium release and life threatening arrhythmias
-should NOT be used in pts at high risk for hyperkalemia
-crush or burn injury >8hrs old (high risk of rhabdo)
-pts with demyelinating syndroms (guillain-barre)
-pts with tumor lysis syndrome
Sick euthyroid syndrome AKA low T3 syndrome:
Any pt with an acute, severe illness (MI, shock, etc) may have abnormal
thyroid func tests.
-likely 2/2 caloric deprivation and increase in cytokine levels(IL-1 and IL-6)
-Most common hormone pattern:
-low total and free T3, 2/2 decreased peripheral conversion of T4>T3
-normal T4 and TSH
-If non-thyroidal illness persists, T4 and TSH levels also decrease
-On recovery, may see transient increase in TSH. Often misinterpreted as
subclinical hypothyroid.
-Therefore, Thyroid function test should not be performed in pts recovering
from major illness
Benzo overdose symptoms:
Slurred speech, drowsiness, unsteady gait
Distinguish from:
-Opioid OD by lack of respiratory depression and lack of pupillary
constriction
-Alcohol intoxication by lack of nystagmus
Myasthenia Gravis:

Can affect muscles anywhere in the body,

most common sx ptosis and double vision
DX: EMG and Acettlcholine receptor Ab test
CT of the chest to look for thymoma should be done in all newly
diagnosed MG pts
--Thymectomy is useful in such cases, results may not be seen for 3-4years
Lacunar stroke
Major risk factors: HTN, DM, hyperlipidemia, smoking
Pathology: likely 2/2 combination of microatheroma and lipohyalinosis
-infarcts are usually of thrombotic origin
-2/2 small size, lacunes are often missed on noncontrast CT scans during
or shortly after event.
-MC site for lacunar infarct is posterior limb of the internal capsule
leading to a pure motor stroke affecting the contralateral face, arm and
leg equally
-other lacunar stroke syndromes: ataxic hemiparesis, clumsy-hand
dysarthria, pure sensory stroke and mixed sensory-motor stroke
Creutzfield jakob disease:
Prion proteins cause rapid neuronal loss and death within 1yr
-should be suspected in pts 50-70yrs old with rapidly progressing
dementia and myoclonus
-other sx: insomnia, apathy, behavioral changes, impaired vision
Dx:
Spongiform changes on postmortem brain biopsy
Genetic testing for PNRP protein gene
Bi or tri phasic sharp wave complexes on EEG
Elevated 14-3-3 proteins on CSF samples
Key features of ds:
-long incubation period
-characteristic spongiform changes
-lack of inflammatory response(no change seen on cbc)
Prinzmetal angina(variant angina) : chest pain 2/2 coronary vasospasm
-risk factor: smoking
-pts often lack CV risk factors
-episodes characteristically occur at night 12A-8A and can be assoc
with transient ST elevations
-Negative cardiac enzyme panel
-Tx: CCB diltiazem
-Avoid aspirin and B-blockers bc they can promote vasoconstriction

Lewy body dementia:

Ley bodies = eosinophilic intracytoplasmic inclusion made of alpha
synuclein protein
Two of three essential for Dx:
-fluctuating cognition with pronounced variations in attention and
alertness
-Recurrent visual hallucinations that are typically well-formed and
detailed
-spontaneous motor features of parkinsonism
Tx of psych symptoms: acetylcholinesterase inhibitors -> Rivastigmine
Key to distinction between LBD and parkinsons is the early appearance of
dementia in LBD and of motor symptoms in parkinsons
Chronic pancreatitis is assoc/w increased risk of pancreatic CA
Abd US preferred intial test if jaundiced can detect biliary tract dilation
and obstruction
Abd CT w/ contrast preferred initial test without jaundice CT is more
sensitive for pancreatic CA, delineating tumor extent and staging tumor
Normal CA 19-9 values do NOT r/o pancreatic CA
-used as a marker of longitudinal ds in known pancreatic CA pts
Hypoxia in PNA occurs 2/2 alveolar and interstitial inflammation which
causes areas of V/Q mismatch
-Manifests as increase in alveolararterial gradient
Giardiasis:
Food borne, water borne, or p2p
Trophozoites ahere to mucosal surfaces by adhesive disks, producing
malabsorption
-generally chronic duration of sx
-Tx metronidazole
Glucagonoma: rare pancreatic tumor
-mild DM or hyperglycemia with necrotic migratory erythema
NME: erythematous plaques or papules that coalesce to form large
painful inflammatory blister and or crustingwith central clearing.
-typically on face, perineum, extremities
-diarrhea and wt loss

-anemia: normocytic normochromic likely 2/2 anemia of chronic ds or

glucagons direct effect on erythopoesis
-DX: Glucagon levels > 500
Stepwise approach to Tx of Ascites:
1. Sodium and water restriction (2L/day)
2. Spironolactone
3. Loop diuretic when max dose of spironolactone not enough
a. Not more than 1 L/ day of diuresis
4. Frequent abd paracentesis (2-4 L/day)
a. Watch for hepatorenal syndrome

Psoriatic arthritis:
-5-30% of pts with psoriasis
-Classically involves DIP joints
-Morning stiffness, deformity, dactylitis(sausage fingers)
-nail involvement ie onycholysis
-well demarcated red plaques with silver scale
Tx: NSAIDS, methotrexate, anti-TNF agents
Dermatomyositis:
-can present with Gottrons papules:
violaceous plaques, slightly scaly, over the MCP joints
CLL:
-MC leukemia in adults
-B-cell leukemia
-smudge cells on pathology: leukocytes that have undergone partial
breakdown during prep of stained smear bc of greater fragility
-Thrombocytopenia is a poor prognostic favor Stage IV
-characteristic findings:
-lymphadenopathy, splenomegaly, anemia, thrombocytopenia
-Avg life span 8-10 years
TCA overdose:
CNS, cardiac, anticholinergic findings
-TCAs inhibit fast sodium channels in his-purkinje system, decreasing
conduction velocity, increasing duration of repolarization and prolonging
refractory periods
-> hypotension, QRS widening, ventricular arrhythmias
-Tx: Sodium bicarb to reduce cardiac toxicity (pH goal 7.5)
-increased pH decreases drug avidity for Na channels
-increased extracellular sodium increases electrochem gradient
across cardiac cells and affects ability of TCAs to bind fast sodium channels

Clopidogrel: anti-platelet, acts by antagonizing ADP

-appropriate alternative for those who cannot tolerate aspirin
-Clop + aspirin better than apirin alone
Following pts post unstable angina/NSTEMI:
-clopidogrel for at least 12m + ASA indefinitely
Percutaneous coronary interventions (PCI):
-Clop + ASA better than ASA alone for first 30 days, helps prevent
subacute stent thrombosis
-Drug-eluting stents require longer duration bc epithelialization occurs
slowly
-30 days for bare metal stents
-up to 1 yr drug eluting stents
Polycythemia vera:
Clonal myeloproliferative dz of the pluripotent hematopoietic stem cell.
Characteristic features:
-increased RBC mass
-mild granulocytosis
-elevated platelets
-low EPO
May be present:
-HTN as a result of expanded blood volume
-increased incidence of peptic ulcer histamine release from basophils
-gouty arthritis increased cell turnover
Multiple myeloma:
Monoclonal proliferation of plasma cells
>3g/dL M protein on SPEP
>10% plasma cells in bone marrow
CRAB:
Calcium (hypercalcemia)
Renal impairment
Anemia
Bones (bone pain, lytic lesions, fractures)
Increased risk of infx due to a total decrease in functional antibodies and
leukopenia secondary to bone marrow crowding with malignant plasma
cells

----MGUS monoclonal gammopathy of undetermined significance

< 3g/dL M protein on SPEP
<10% plasma cells in bone marrow
1% per year risk of progression to MM

Trigeminal neuralgia tx of choice: Carbamazepine

Bronchiecstasis:
Dilated bronchi with thickened walls
Present with chronic cough and are often treated with repeated courses of
antibiotics
-CT is best method to confirm Dx
-hemoptysis is frequent complication
Spider angiomas:
-bright red central arterioles surrounded by radiating vessels
-BLANCH with pressure
-estrogen dependent, common in pregnancy, OCP use, and cirrhosis
related hyperestrogenemia
SJS & TEN
<10% of body surface area: SJS
10-30% BSA: SJS TEN overlap
>30%: TEN
4-28 days after exposure to trigger (2 days after repeat exposure)
Acute influenza like prodrome
Rapid onset erythematous macules, vesicles, bullae
Necrosis & sloughing of epidermis
Mucosal involvement
Signs:
F, tachycardia, hypoTN, AMS, conjunctivitis, seizures, coma
Drugs:
Allopurinol
Antibiotcs (eg sulfonamides)
Anticonvulsants (carbamazepine, lamotrigne, phenytoin)
NSAIDS
Sulfasalazine
M. pneumonia

Vaccination
Graft vs host disease
INFECTIOUSENDOCARDITIS:Amicrobialprocessoftheendocardium,usually

involvingtheheartvalves.

SerialbloodcxmostimportantpartofDx
Thefollowingperipherallesionsareonlypresentin25%ofcases
JANEWAYLESIONS:Painlesshemorrhagicmaculesonthepalmsandsolesthatare

consistentwithinfectiousendocarditis.

Oslernodes(tendernodulesonthefingerortoepads)

ROTHSPOTS:Hemorrhagicretinallesionswithwhitecenters,duetoinfectious

endocarditis.
Highlyvirulentspecies,suchasStaphylococcusaureus,produceacuteinfection,and
lessvirulentorganisms,suchastheviridansgroupofstreptococci,tendtoproducea
moresubacuteillness,whichmayevolveoverweeks
Fever is present in 95% of cases

HACEKorganisms(Haemophilusaphrophilus/paraphrophilus,Actinobacillus
actinomycetemcomitans,Cardiobacteriumhominis,Eikenellacorrodens,Kingella
kingae)
Pericardial tamponade:
Becks triad
1) HypoTN
2) JVD
3) Distant heart sounds
Most sensitive physical finding: Pulsus paradoxus- decrease in SBP
Pulsus paradoxus in tamponade:
During inspiration increased systemic venous return to R heart causes
interventricular septum to shift into the left ventricular cavity, reducing L
ventricular end diastolic volume -> decreased stroke vol -> reduced SBP
Pulsus paradoxus also seen in severe asthma and COPD: drop in
intrathoracic pressure is greatly exaggerated. Negative pressure leads to
pooling of blood in pulmonary vasculature decreasing LV preload

HIV+ pt:
Only live vaccines that can be administered ar MMR and varicella if:
-CD4 count > 200
-no history of AIDS defining illness
Acute glaucoma:
First line tx: IV mannitol
Also can administer:
Acetazolamide carbonic anhydrase inhibitor, decreases aqueous humor
production
Pilocarpine opens canals of schlemm, allowing drainage of aqueous
humor
Timolol B-blocker, decreases aqueous humor production
Avoid mydriatic agents such as atropine
Glucocorticoid induced myopathy:
-One of most common drug induced myopathies
-typically weeks to months after starting tx
-PAINLESS proximal muscle weakness (LE before UE) manifests as
difficulty in ADL such as getting out of chair, climbing stairs, brushing hair,
-No muscle inflammation, normal ESR, normal CK
-likely 2/2 increased muslcle catabolism and decreased anabolism as a
direct effect of the steroids
-improves with discontinuation of steroid therapy
Polymyalgia Rheumatic:
-seen in up to 50% of pts with temporal(giant cell) arteritis
-aching and morning stiffness
-Pain and decreased range of motion in shoulders, neck and hip girdle
-normal muscle strength
-ESR > 40
-Normal CK
-Symptoms improve rapidly with glucocorticoids
Metabolic effects of HCTZ:
-Decreased glucose tolerance -> hyperglycemia
-increased LDL
-increased triglycerides
-hyponatremia
-hypokalemia
-hypercalcemia
Dacrocystitis: infx of lacrimal sac

-occurs in infants and pts >40yo

-sudden onset of pain and redness in medial canthal region
-fever, prostration, elevated leukocyte count
-may express purulent fluid from lacrimal duct
-S. aureus and GAS common organisms
Episcleritis: infx of episcrleral tissue
-Acute onset of mild to mod discomfort, photophobia and watery discharge
Hordeolum: abscess on upper or lower eyelid
-MC cause S. aureus
-Red, tender swelling over the eyelid
Chalazion: chronic granulomatous infx of meibomian gland
-Hard, painless nodule
-presents as lid discomfort
Rabies:
Pts exposed to high risk wild animals raccoons, bats, skunks should
receive post exposure prophylaxis if animal is unavailable for testing.
-if animal can be tested, pt should start PEP but may discontinue if animal
tests negative
Subarachnoid hemorrhage:
Most commonly 2/2 ruptured berry aneurysm
Severe HA at onset
Meningeal irritation (neck stiffness)
Focal deficits uncommon
Complications:
Rebleeding first 24 hrs
Vasospasm 3-10 days after events.
-major cause of morbidity and mortality
-occurs in up to 30% of SAH pts
-prophylaxis: Nimodipine
-CT angiography to dx vasospasm
Hydrocephalus/inc ICP
Seizures
Hyponatremia 2/2 SIADH
Lumbar spinal stenosis: degenerative condition, spinal canal is
narrowed resulting in compression of one or more spinal roots
-back pain may radiate to buttocks and thighs
- worse during walking and extension

-lumbar flexion alleviates symptoms

-numbness and paresthesias may occur
-Dx confirmed with MRI
-Iliac artery stenosis:
Claudication in buttocks and thighs
-pain worse with activity, relieved with rest
-pain not affected by flexion or extension
-Lumbar disk herniation:
-Acute onset back pain with or without radiation down one leg
-lumbar flexion and sitting make pain worse
Sporotrichosis:
Sporothrix schenkii is a dimorphic fungus
-Initial lesion is reddish nodule that later ulcerates
-Fungus spreads from site of inoculation via lymphatis, forming
subcutaneous nodules and ulces
-adenopathy and systemic signs of infx are usually ABSENT
Tx: oral potassium iodide
Serum calcium decreases by 0.8mg/dL for every 1g/dL decrease in serum
albumin
-ionized plasma Ca (physiologically active form)is hormonally regulated
and remains stable
-Increased extracellular pH (alkalosis) causes an increase in the affinity of
serum albumin to calcium
.
Subdural hematomas:
Slow venous bleed
Elderly and alcoholics falls/blunt trauma
MC Sx: HA and gradual loss of consciousness
CT: white crescent +/- midline shift
Pseudotumor cerebri:
Young female, HA (days-weeks), +/- n/v, normal neuro imaging, elevated
CSF
Neurologic signs generally absent except papilledema, visual defects and
sometimes CN VI palsy
-May have Hx of provoking agents: glucocorticoids, Vit A, OCPs

-Pathology: impaired absorption of CSF by arachnoid villi

Tx:
-wt reduction
-Acetazolamide if wt reduction fails
-If continues to worsen, shunting or optic nerve sheath fenestration to
prevent blindness, the most significant complication
Renal Fibromuscular dysplasia:
Tx: percutaneous angioplasty with stent placement*****High yield
Macrocytic anemia in an alcoholic likely 2/2 folate deficiency
-alcohol abuse causes folate deficiency by impairing its enterohepatic
cycle and inhibiting its absorption
Tuberculosis induced adrenal insufficiency is the most common cause
of adrenal insufficiency worldwide
presents with hypotension, fatigue, weight loss, nausea/vomiting,
abdominal pain, hypoglycemia, hyperkalemia, and fever
It is recommended that patients' TSH levels be re-evaluated 4-6 weeks
after initiation of levothyroxine

Aortic stenosis:
-Exertional symptoms chest pain, dyspnea, dizziness, syncope
-Delayed and diminished carotid pulse pulsus parvus et tardus
-Single and soft S2
-audible S4
Harsh ejection crescendo-descendo systolic murmur in 2nd intercostal
space with radiation to carotis
Scleroderma:
May see esophageal dysmotility
Characteristic features of scleroderma dysmotility:
-absence of peristaltic waves in lower 2/3rds of esophagus
-significant decrease in lower esophageal sphincter tone
MVP is MCC of chronic mitral regurg in developed countries
-MVP occurs due to myxomatous degeneration of mitral valve leaflets and
chordae

Digitalis toxicity:
Causes increased ectopy and increased vagal tone
-Atrial tachycardia with AV block occurs from combination of
these effects and is relatively specific for dig toxicity
MCC brain metastases:
Lung > breast > unknown primary > melanoma > colon
Multiple brain metastases: lung CA, malignant melanoma
Solitary brain metastases: Breast, colon, renal cell CA
Complications after MI:
Reinfarction: hours 2 days
Ventricular septal rupture: hours 1 week
Free wall rupture: hours 2 weeks
Post infarction angina: hours 1 month
Papillary muscle rupture: 2 days 1 month
Pericarditis: 1 day 3 months
Left ventricular aneurysm: 5 days 3 months
Hallmark of LV aneurysm: persistent ST-segment elevation
after a recent MI and deep Q waves in the same leads
Progressive LV enlargement and remodeling can also lead to mitral
annular dilation with mitral regurg
HIV;
TMP-SMZ used as prophylaxis to prevent PCP and toxo
Azithromycin prophylaxis against MAC
*****High Yield***
MC site of ulnar nerve entrapment is the elbow where the ulnar n. lies at
the medial epicondylar groove
Carcinoid tumors are neuroendocrine tumors that cause flushing, secretory
diarrhea, bronchospasm and cardiac valvular abnormalities
Carcinoid cells cause increased production of serotonin from tryptophan
(required for niacin synthesis), resulting in niacin deficieny pellagra:
dermatitis, diarrhea, dementia
Hereditary nonpolyposis colorectal cancer (HNPCC), or Lynch syndrome
colorectal cancer, ovarian, gastric, biliary tract, brain, prostate, skin, and
especially endometrial cancers are all associated with this autosomal
dominant genetic defect.

family history of multiple cancers.

Colonoscopy every 1-2 years starting between the age of 20-25.
--Gardner's syndrome: adenomatous polyps - plus osteomas, lipomas,
fibromas, cysts, and dental abnormalities.
--Peutz-Jeghers syndrome: multiple pigmented spots most often found on
the lips, oral mucosa, and GI mucosa. Hamartomas are found on
colonoscopy.
--Familial adenomatous polyposis: hundreds to thousands of adenomatous
polyps.
--Turcot's syndrome: familial adenomatous polyposis and CNS malignancy.
Primary biliary cirrhosis presents with fatigue and pruritis, primarily
affecting women. Expected findings include jaundice,
hypercholesterolemia, elevated alkaline phosphatase and IgM levels. The
hallmark finding associated with this disease is antimitochondrial
antibodies. Treatment is supportive while UDCA may be used to slow the
progression of liver disease.
Dopamine agonists (pramipexole, ropinirole, levodopa/carbidopa, and
bromocriptine) are the first line treatment for restless leg syndrome.
Patients should also be placed on iron supplementation.

AML:patientsover30,bonemarrowbiopsyreactswithmyeloperoxidaseandsudanblack,
associatedwithauerrods.
Anemia, thrombocytopenia, and leukopenia (decrease in functioning white
cells even though total white count may be high due to proliferation of
immature white cells) associated with AML results in increased infections,
bleeding, fever, and lymphadenopathy. Leukocyte count may also be very
high.
Epididymitis
1st line Tx: ceftriaxone plus doxycycline.
MCCinpatientsunder35isChlamydia.EpididymitisinoldermenusuallyresultsfromE.
Coli.
Patients will present with fever/chills, an erythematous and tender
scrotum, and complain of frequency, urgency or dysuria. Uretheral
discharge may also be present. Cremasteric reflex is tested to rule out
testicular torsion
A. IgA Nephropathy: Follows viral illness, IgA and C3 on staining. Normal
C3
B. PSGN: Occurs at least 1 week after strep throat or skin infection.

High ASO. Low C3. Lumpy Bumpy pattern of deposition on

microscopy
C. Wegeners: Damages both lungs and kidneys. C-ANCA is positive.
Involves upper airway: sinusitis, otitis media, nasal ulceration.
D. Goodpastures: Damages both lungs and kidneys. Linear deposit
of anti glomerular basement membrane antibodies. Does not affect
upper airway.
E. MCD: fusion of podocyte foot processes. Asymptomatic child
becomes puffy and edematous.
F. Alports: Deafness and hematuria
G. Membranous nephropathy: Adult with proteinuria and a thickened
glomerular basement membrane. Spike and dome pattern.
H. Diabetic nephropathy: Kimmelstiel-Wilson nodules
I. FSGS: Associated with IV drug abuse and HIV. Sclerosis on biopsy
J. Lupus nephritis: Multiple types so biopsy is essential to determine
treatment
K. Amyloidosis: Apple green birefringence with Congo red staining
L. Membranoproliferative nephropathy: tram track appearance of the
basement membrane
Ascending cholangitis
-Charcot's triad: RUQ pain, fever, and jaundice.
More serious cases present with Reynold's pentad: Charcot's triad plus
hypotension and altered mental status
CREST syndrome: Calcinosis, Raynaud's phenomenon, Esophageal
dysmotility, Sclerodactyly, and Telangiectasias.
-Anti-centromere antibodies
C-ANCA (cytoplasmic-staining antineutrophil cytoplasmic antibodies)
are antibodies against proteinase-3 and are highly specific for
Wegener's granulomatosis
Autoantibodies against myeloperoxidase is the most common target of
p-ANCA (perinuclear-staining antineutrophil cytoplasmic antibodies)
found in many disease processes making its specificity relatively low.
Bullous pemphigoid affects patients over 65; blisters spread
throughout the skin but avoids mucous membranes; biopsy will
reveal a linear deposit of IgG.
-Negative nikolsky
-pemphigus vulgaris also causes blistering but more commonly in 30 to
60 year olds. It involves the mucous membranes and biopsy will show

IgG antibodies against desmoglein between the epidermal cells.

+Nikolsky sign
Renal tubular acidosis presents with a non-anion gap hyperchloremic
metabolic acidosis
RTA Type I: distal tubular defect
The deficiency is in H+ secretion leading to urinary pH over 6.0.
- hypokalemia.
- Increased excretion of calcium and phosphate 2/2 alkaline urine ->
inc risk nephrolithiasis -70% have stones
- Common causes of RTA Type I are Sjogren's, SLE, and other
autoimmune disorders.
- Tx: sodium bicarbonate.
RTA Type II is caused by a defect in proximal tubule's ability to reabsorb
bicarbonate.
Tx: alkali replacement
Low bicarb, high chloride, and low potassium are classic findings of
RTA II but may be seen with other RTAs. RTA IV can be ruled out because it
results in hyperkalemia. So to differentiate between RTA I and II, look
at urine pH. In RTA I, there is an inability to acidify urine beyond pH of 5.5
- most frequently occurs in children as part of Fanconis syndrome
(abnormal excretion of glucose, amino acids, citrate, and phosphate into
the urine, as well as vitamin D deficiency and hypokalemia). It is also
associated with multiple myeloma and carbonic anydrase inhibitor use.
Renal Tubular Acidosis (RTA) type IV:
-caused by HYPOaldosteronism.
-present with hyponatremia, hyperchloremia and hyperkalemia and an
acidic urine. -commonly seen in diabetes and interstitial nephritis
resulting in a hyporeninemic state.
-only RTA that presents with hyperkalemia
A good algorithm to follow if you get RTA questions:
Step one: Determine it is RTA (hyperchloremic acidosis with a normal anion
gap and near normal GFR in the absence of diarrhea = RTA)
Step two: Look at the potassium level, if it is higher than the normal range
(3.5-4.5) then it is automatically RTA-IV

Step three: Look at urine pH. If it is lower than 5.5 it is automatically RTA-II.
If it is higher than 5.5 go to step 4.
Step four: Look at the bicarb level. If the bicarb level is near normal it is
RTA-I. If the bicarb level is markedly decreased it is RTA-II.
Step five: confirm diagnosis as follows:
-RTA-I: administer ammonium chloride (an acid). If urine pH does not
drop below 5.5 as serum pH decreases, you have your diagnosis.
-RTA-II: administer bicarb. If the urine pH continually rises as bicarb is
given, you have your diagnosis.
-RTA-IV: salt restrictive diet. If urine sodium is persistently high, while
serum sodium begins to decrease, you have your diagnosis.

three most common causes of small bowel obstruction in by ABC.

Adhesions(previous abd surgx), bulges (hernia), cancer.
Hepatic encephalopathy:
elevated arterial ammonia level since the liver is responsible for clearing
ammonia. Tx: avoiding sedatives, and initiating lactulose which promotes
excretion of ammonia.
(inferior petrosal sinus sampling) is used to confirm the pituitary as the
source of ACTH production when there is no detectable adenoma on
imaging and ectopic sources have been ruled out.
McCune-Albright syndrome presents with short stature, caf au lait spots,
precocious puberty, bone lesions (polyostotic fibrous dysplasia), and
associated endocrinopathies
Thiamine deficiency:
Wet beriberi
-dilated cardiomyopathy dilated LV with decreased LVEF
-tachycardia
-peripheral edema
-DOE
Hyperthyroidismduringpregnancy:
MC2/2Grave'sdisease

Tx:
1sttrimester:PTU
2ndand3rdTri:Methimazole
Retinal artery occlusion is acute, painless, monocular loss of vision
due to an embolus. It presents with a pale retina with a cherry-red
macula (which gets continued blood supply from ciliary artery).
Churg-Strauss:
allergic rhinitis, asthma, blood eosinophilia, and positive p-ANCA
LambertEatonMyasthenicSyndrome:
- autoantibodiesagainstPREsynapticcalciumchannelscausingmuscleweakness
- mostprevalentinpatientswithsmallcelllungcarcinoma.
- Repeatednervestimulationimprovessymptoms.
ALL peaks between 3-5 years of age.
Bone invasion causes pancytopenia resulting in anemia, bone pain,
infections, and signs of low platelets.
Bone marrow biopsy: increased blasts of lymphoid lineage.
The board loves to test using side effects of one drug to treat another
condition so be aware of the following:
Beta Blockers: Used for essential tremor, thyrotoxicosis, migraines, and
some arrhythmias
Thiazide diuretics: Used for osteoporosis or kidney stones
-Reduced Ca+ excretion in the urine
Calcium channel blockers: Used for Raynauds, esophageal spasm, and
some arrhythmias
Alpha-1 antagonists: Used for benign prostatic hyperplasia (BPH)
-SE: Orthostatic HypoTN
The pheochromocytoma 10% rules are as follows:
10% recurrence rate after surgery
10% are familial
10% are bilateral
10% are extra-adrenal
10% are malignant
10% occur in children
(leftmaincoronaryarterybranchesintotheleftcircumflexandleftanteriordescending
arteries.

OcclusionoftheleftmainisassociatedwithSTTelevationinaVR.
LADsuppliestheanteriorleftventricleandseptum.ECGchangesareseeninV16(septal
leadsareV14).
LCXsuppliestheposterolateralleftventricleandtheanterolateralpapillarymuscle.
marginalbranchoftheleftcoronaryartery)suppliestheleftmarginofthehearttowardthe
apex.
Empyema:
-complication of pneumonia
-may have: pus, pH <7.3, low glucose, very high LDH, or positive gram
stain.
-CT scan findings: loculation and thickening of the pleural membrane.
Struvite crystals:
-proteus mirabilis, klebsiella, serratia
- produce urease, raising the pH and caused large staghorn calculi
that fill the renal pelvis.
Gastric ulcer: blood type A
Duodenal ulcer: Blood type O
Neurogenic shock:
-Low systemic vasc resistance
-Low cardiac output
-Low PCWP
Cardiogenic shock: Only shock with highPCWP
-Increased PCWP and JVD
-High SVR
-High cardiac output
Septic Shock:
-High CO
-Low SVR
-Low PCWP

---Spinal cord compression:

-common with metastasis to the spine
- severe back pain, upper motor neuron signs(hyperreflexia), decreased
sensation, and loss of bowel/bladder control
-Initial tx: high dose corticosteroids
-MRI is Dx test of choice
InsulinomasresultinanelevatedinsulinandCpeptidelevels,andhypoglycemiapersistence
ofhyperinsulinismaftera72hourfastconfirmsthediagnosis.
Copperdeficiencyoccursamongprematureinfants,disordersinabsorption,andgenetic
disorders.
Signsandsymptomsincludefatigue,anemia,osteoporosis,andleukopenia.
Labfindingsincludeneutropenia,thrombocytopenia,andamicrocytic,hypochromic
anemia.
TreatmentofchoiceforGuillainBarreSyndromeisplasmapheresisorIVIG
EKGchangesseenwithtricyclicantidepressanttoxicityaresinustachycardia,widenedQRS
complex,prolongedPRinterval,andprolongedQTcinterval.
Cavernous venous thrombosis
is a cause of headache associated with palsies of the cranial nerves that
pass through the cavernous sinus (III, IV, V1, V2, and VI)

-classically presents after manipulation of a skin lesion located in the

central face.
-septic thrombophlebitis
-Tx: IV antibiotics
Subacute granulomatous thyroiditis: due to stored hormones being
released from the inflamed gland.
- Radioactive iodide uptake scan reveals low uptake in conditions
causing hyperthyroidism that are not due to overproduction - such as
thyroiditis
- Tx: provide symptomatic relief and start with NSAIDs for pain relief
goal INR in a patient with chronic atrial fibrillation, and most other
conditions that require anticoagulation (think DVT and PE) is 2-3.
mechanical heart valves goal INR of 2.5-3.5
Symptomatic HIV infection is defined as having an illness that results from
being immunocompromised, but which is not serious enough to be an AIDS
defining illness. The ones you should remember are moderate-to-severe
cervical dysplasia (CIN II, CIN III or carcinoma in situ), bacillary
angiomatosis, peripheral neuropathy, and herpes zoster (shingles), and
thrush
AIDS defining diseases that you should remember are: candidiasis of the
esophagus, lungs, or trachea (not thrush); cryptococcal infection; intestinal
isosporiasis or cryptosporidiosis; Kaposis sarcoma; cerebral lymphoma;
Pneumocystis jiroveci pneumonia; cerebral toxoplasmosis; invasive
cervical cancer; and HIV wasting syndrome
ResponsetotreatmentofosteomyelitisismonitoredwithESRandCRP

Procainamide-induced lupus is a commonly tested cause of pericarditis

Leriche syndrome), also known as aorto-iliac occlusion, presents with
claudication and erectile dysfunction from atherosclerosis of the aortic and
iliac vessels
-look for decreased femoral pulses
Medullary thyroid carcinoma originates from the parafollicular cells (C
cells), which produce the hormone calcitonin. Therefore, an increased
calcitonin level is associated with this type of thyroid cancer.

papillary thyroid carcinoma is the most common type of thyroid cancer.

Histology will show calcified psammoma bodies and Orphan Annie
nucleus.
Spontaneous bacterial peritonitis (SBP) is an infection of ascites.
Dx: ascitic fluid polymorphonuclear (PMN) leukocyte count greater than
250/mm^3. Tx: Cefotaxime or another 3rd generation cephalosporin
should be initiated immediately pending culture results.
Silicosis sandblasting, glass
-silica is cytotoxic to alveolar macrophages
-nodular opacities in lung -> TUBERCULOSIS
Bordatellapertussis:
1stlinetx:macrolide
Theclassictriadoffatembolism:respiratorychanges(dyspnea,tachypnea,cough,hypoxia),neurological
abnormalities(mentalstatuschange),andpetechialrash.

Patients who present with benign paroxysmal positional vertigo (BPPV) are
best treated with the Epley maneuver to reposition the canalith. The
vertigo experienced is typically episodic, lasting about 30 seconds and
brought on by changes in head position. The diagnosis can be confirmed
by performing the Dix-Hallpike maneuver when a nystagmus is elicited.
Menieres disease:
Triad: vertigo, tinnitus, hearing loss.
In contrast to BPPV, the vertigo lasts much longer, hours to days. The
acute vertigo is managed with benzodiazepines (diazepam) or
vestibulosuppressants. Diuretic therapy and a low salt diet may help
prevent reoccurrences.
Antihistamines, anticholinergics, a low sodium diet, and diuretics may
lower endolymphatic pressure by reducing the amount of endolymphatic
fluid to reduce the disease process
Labyrinthitis: Look for someone with a viral infection who about a week
later develops vertigo, nausea/vomiting, hearing loss, and nystagmus.
Treatment is with steroids to reduce inflammation.
Remember: aminoglycosides are ototoxic
----

LP purple, polygonal, pruritic, papules. Wickham striae are fine white

reticulations seen on the surface of the lesions and in the oral cavity and
are very specific for the disease.
Half of patients with skin lesions will also have oral striae. Upon
observation of the initial
lesions, the disease will spread symmetrically over one to four weeks
histological characteristics of LP are 1) damaged basal epidermal
keratinocytes and 2) a linear arrangement of lymphocytic infiltrate in the
papillary dermis at the interface with the epidermis
Seborrheic keratosis:
Benign skin tumor
-stuck on appearance
-not related to sun-light exposre
- sudden appearance of multiple SKs associated with internal malignancy
(the sign of Leser-Trelat).
Renal vein thrombosis:
-can be complication of nephrotic syndrome
-antithrombin III is lost in the urine and leads to increased risk of
venous and arterial thrombosis
-Presents with sudden onset:
-abd pain
-fever
-hematuria
-Can occur in any form of nephrotic syn.
-Most common with Membranous glomerulonephritis
Lupus anticoagulant:
-antiphospholipid antibody
-leads to prolonged PTT
-Pt is HYPERCOAGUABLE
Common foci of A-fib:
Cardiac tissue surrounding pulm veins
-different type of myocytes which are more susceptible to aberannt
rhythms
SLE
Serositis: pleurisy, pericarditis, peritonitis
ANA

Anti-ds & anti-sm

Proteinuria and elevated Cr
Symmetric, migratory arthritis
Amenorrhea 2/2 Morbid obesity:
-amenorrhea is 2/2 anovulation
-FSH and LH wnl
-ovaries produce estrogen but progesterone is not being produced at the
normal post ovulation levels. Therefore progesterone withdrawal menses
at the end of the cycle does not occur
Premature ovarian failure:
Women less than 40yo
FSH > 40
LH >25
Cryoprecipitate:
Insoluble products from FFP: fibrinogen, vWF, F VIII, F XIII
Used for replacement therapy for pts with fibrinogen, vWF, or FVIII
deficiency
FFP:: contains all clotting factors and plasma proteins from one unit of
blood.
-indicated for active bleeding with severe coagulopathy:
-liver disease
-DIC
-supratherapeutic INR
Platelets transfusion indicated for:
Platelet <10-20K
Active bleeding + platelet <50K
Placenta Previa:
Painless 3rd tri bleeding ~80%
Bleeding with uterine contractions ~20%
Dx: Ultrasound
Digital vaginal exam should be avoided with low-lying placenta, can
trigger massive hemorrhage
Risk factors:
-Prior previa
-Prior cesarean or uterine surgery
-multiple gestations increased # of placentas covers more uterine
surface area
-advanced age

Placental abruption:
Painful vaginal bleeding
Vasa previa:
painless antepartum
-paid deterioration of FHTs as hemorrhage is of fetal origin
Aortic stenosis:
PND, fluid retention, and S3 sginify heart failure. In AS, mean survival
after HF is two years
Courvoisier's sign:
palpable nontender gallbladder as a result of common bile duct
obstruction/compression by pancreatic adenocarcinoma at the head of the
pancreas. Biliary obstruction below the level of the cystic duct is unlikely to
be caused by stone disease.
Appendiceal tumor:
<2cm, unlikely to metastasize Tx : simple appy
>2cm Tx: Right hemicolectomy
Iron Poisoning:
Within 30 minutes 4 days
-Abd pain
vomiting/hematemesis
diarrhea/melena
HYPOtensive shock
Anion gap Metabolic acidosis
Within 2 days: hepatic necrosis
Within 2-8weeks: pyloric stenosis
Dx:
Anion gap met acidosis
Radiopaque pills on abd xray
Serum iron levels
Tx:
Whole bowel irrigation
Deferoxamine
Acute acetaminophen OD:
N/V, many pts asymptomatic in first 24hrs
NOT assoc with hematemesis

Post-partum amenorrhea:
Elevated prolactin levels suppress GnRH release -> suppresses LH and FSH
production and ovulation
EPO injections:
ESRD + NORMOCYTIC NORMOCHROMIC anemia
Start EPO tx when Hgb <10 or Hct < 30
SE:
HTN 30%
HA 15%
Flu-like symptoms 5%