Ashhad's Step 2 CK UW Notes PDF

USMLE STEP 2 CK NOTES
STEP 2 CK NOTES THAT I COMPILED USING UWORLD QBANK FOR STEP

2 CK. PLEASE REFER TO UPTODATE OR UWORLD QBANK FOR THE
MOST RECENT TREATMENT GUIDELINES.
. . .
Ashhad Siddiqui, MD
ashhadsiddiquimd@gmail.com
Ashhadscknotes
Question Main
Sub Division Notes
Id Division
PPSV23:induces T-cell-INDEPENDENT B-cell response.Less effective in young children & elderly
PCV13:induces T-cell-DEPENDENT B-cell response.Causes improved immunogenicity due to formation of

higher-affinity antibodies & memory cells
2386 Medicine Allergy & Immunology
NK cells:lymphocytes that recognize stressed & abnormal cells.They attack cancer cells & virus infected cells
MMR & intranasal influenza vaccine:CD8+ T cell response
Oral polio vaccine:secretion of anti-poliovirus IgA antibodies in GI tract

Angioedema from ACE inhibitors can occur at ANYTIME, not just within weeks of starting the medication
One adverse effect of beta-blockers(metoprolol) is male sexual dysfunction

The most significant adverse reaction caused by Clopidogrel is thrombotic thrombocytopenic purpura
Aspirin & NSAIDs can cause allergic angioedema. It typically happens immediately after exposure & is
accompanied by itching & skin rash (urticaria)
Cyclosporine & Tacrolimus are both calcineurin-inhibitors. Side effects of both are nephrotoxicity,
hyperkalemia, hypertension, & tremor.
Gum hypertrophy & hirsutism seen w/ Cyclosporine toxicity.
Gum hypertrophy & hirsutism NOT seen w/ Tacrolimus toxicity.
Azathioprine toxicity- diarrhea, leukopenia, hepatotoxicity
Mycophenolate toxicity- marrow suppression
IgA deficiency: consider in pts w/ mild immunodeficiency consisting of recurrent sinopulmonary & GI
infections, & anaphylactic transfusion reaction. Dx confirmed by measurement of low serum IgA
concenrtaion w/ normal serum IgM & IgG levels
Hyper-IgM syndrome: elevated IgM & depressed IgG & IgA. Susceptible to both Giardia & recurrent
sinopulmonary infection. Lymphoid hyperplasia is common
Hepatitis A:
4080 Medicine Allergy & Immunology most common vaccine preventable disease among tavelers
give hepatitis A vaccine to pts traveling to developing countries like egypt
Recurrent bacterial infections in an adult pt may indicate a humoral immunity defect. Quantitative
measurement of *serum immunoglobulin levels* help to establish the diagnosis
Raising the cut-off point (e.g., The criteria 2 out of 4 positive responses to CAGE questions considered
Biostatistics &
2135 Medicine positive for alcoholism is changed so that 3 out of 4 positive responses labels pt as alcoholic) of a screening
Epidemiology
test results in an *increase in specificity & decrease in sensitivity*
Lowering the test cutoff point -> Increase in # of false positives & true positives -> *Decrease positive
Biostatistics & predictive value*
2136 Medicine
Epidemiology
[Refer to a diagram]
Lowering the cutoff value will increase sensitivity and decrease specificity
Biostatistics &
2138 Medicine
Epidemiology
Increasing the cutoff value will decrease the sensitivity and increase the specificity
Biostatistics &
3076 Medicine False negatives will increase when the cut-off level of a diagnostic test is raised
Epidemiology
Sample distortion bias is seen when the estimate of exposure & outcome association is biased because the
study sample is not representative of the target population w/ respect to the joint distribution of exposure &
Biostatistics & outcome
3646 Medicine
Epidemiology
Information bias occurs due to the imperfect assessment of association between the exposure and outcome
as a result of errors in the measurement of exposure and outcome status
The critical distinction between case control & retrospective cohort studies is the order in which outcomes &
Biostatistics &
3650 Medicine risk factors are assessed. Case control studies determine the outcome first & then look for associated risk
Epidemiology
factors; retrospective cohort studies first ascertain risk factor exposure & then determine the outcome
Relative risk > 1= postitive ass. between the risk factor and the outcome
Biostatistics &
3708 Medicine
Epidemiology
Relative risk < 1= negative ass. between the risk factor and the outcome
Lead time bias example: prolongation of apparent survival in pts to whom a test is applied, w/o changing the
prognosis of the disease
Biostatistics &
3880 Medicine Lead time bias should always be considered while evaluating any screening test
Epidemiology
USMLE tip: think of lead-time bias when you see "a new screening test" for poor prognosis diseases like
lung or pancreatic cancer
Ashhadscknotes
Biostatistics & PPV increases and NPV decreases w/ an increase in prevalence.
3886 Medicine
Epidemiology The greater the prevalence, the greater the PPV.
Observer bias occurs when investigator's decision is adversely affected by knowledge of the exposure status
Biostatistics &
3915 Medicine
Epidemiology Respondent bias is present when the outcome is obtained by the pt's response, and not by objective
diagnostic methods (e.g., migraine headache)
Cross-sectional study: exposure & outcome are measured simultaneously at a particular point of time
(remember: snapshot study)
Biostatistics &
3922 Medicine
Epidemiology
Case-control study is designed by selecting pts w/ a particular disease (cases), & w/o that disease
(controls), & then determining their previous exposure status
Biostatistics & The main measure of association is the *exposure odds ratio*, in which the exposure of people w/ the
3931 Medicine
Epidemiology disease (cases) is compared to the exposure of those without the disease (controls)
Biostatistics & The p-value is the probability of observing a given (or more extreme) result due to chance alone, assuming
3934 Medicine
Epidemiology the null hypothesis is true. A result is generally considered statistically significant when p <0.05
Latency period:
Applied to both disease pathogenesis and exposure to risk modifiers.
Biostatistics &
3941 Medicine Exposure to risk factors and the initial steps in disease pathogenesis sometimes occur years before clinical
Epidemiology
manifestations are evident.
Exposure to risk modifiers may need to be continuous over a certain period before influencing the outcome.
Effect modification example: Oral contraceptives significantly increased the risk of breast cancer in pts w/ a
Biostatistics &
3947 Medicine positive family hx of breast cancer but not in pts w/ a negative family hx of breast cancer. Positive family hx
Epidemiology
acts as an effect modifier to increase the risk of breast cancer in pts taking oral contraceptives
Generalizability or external validity pertains to the applicability of study results to other populations (eg, the
results of a study in middle-aged women would not be expected to be applicable to elderly men). External
Biostatistics & validity answers the question, "How generalizable are the results of a study to other populations?"
3960 Medicine
Epidemiology
Within the cohort(eg, middle aged women), the study could be valid. This property is called internal validity,
or validity
The null hypothesis is always the statement of no relationship between the exposure & the outcome
Biostatistics &
3961 Medicine
Epidemiology Alternate hypothesis opposes the null hypothesis. It states that there is a relationship between the exposure
& outcome
Median is the value that is located in the middle of a dataset
Biostatistics &
3982 Medicine
Epidemiology
Mode is the most frequent value of a dataset
A normal distribution is symmetric & bell shaped.
Mean = Median = Mode
Biostatistics &
3992 Medicine
Epidemiology Positively skewed: mean greater than median greater than mode
Negatively skewed: mean less than median less than mode

The *two-sample t test* is a statistical method that is commonly employed to compare the means of two
groups of subjects
Biostatistics &
3998 Medicine
Epidemiology The two sample z test can also be used to compare two means, but population (not sample) variances are
employed in the calculations. Because population variances are not usually known, the test has limited
applicability
Randomization is used to control for confounders during the design stage of a study
Effect modification: when external variable positively or negatively impacts the effect of a risk factor on the
Biostatistics & disease of interest (eg, venous thrombosis increased w/ estrogen therapy & this effect is augmented by
4001 Medicine
Epidemiology smoking)
Post-hoc analysis: performing unplanned statistical tests on patterns that were identified after the fact in
data from a completed study
Biostatistics & An outlier is an extreme & unusual value observed in a dataset. *The mean is very sensitive to outliers &
4002 Medicine
Epidemiology easily shifts toward them*. The median & mode are more resistant to outliers
Increasing the sample size increases the power of a study & consequently narrows the confidence interval
Biostatistics & surrounding the point estimate
4019 Medicine
Epidemiology
A wider confidence interval is due to a smaller sample size, which decreases the study's power
Chi-square test is used to compare proportions. 2 x 2 table may be used to compare the observed values
w/ the expected values
Two-sample z-test & two-sample t-test are used to compare two means, not proportions
Biostatistics &
4079 Medicine
Epidemiology
ANOVA is used to compare means of three of more variables
Meta-analysis is an epidemiologic method of pooling the data from several studies to do an analysis having
a relativly big statistical power
Ashhadscknotes
Biostatistics &
4107 Medicine The tighter the confidence interval, the more precise the result
Epidemiology
In a case-control study, if the outcome is uncommon in the population, *disease incidence(# of new cases)
Biostatistics &
4109 Medicine is low* & the *odds ratio is a close approximation of the relative risk*. This is called the rare disease
Epidemiology
assumption
Biostatistics & Randomization is said to be successful when a similarity of baseline characteristics of the pts in the
4121 Medicine
Epidemiology treatment & placebo groups is seen
Attributable risk percent (ARP) or etiologic fraction is an imp measure of the impact of a risk factor being
Biostatistics &
4157 Medicine studied. ARP represents the excess risk in the exposed population that can be attributed to the risk factor. It
Epidemiology
can be easily derived from the relative risk using the following formula: ARP=(RR-1)/RR
An increasing prevalence & stable incidence can be attributed to factors which prolong the duration of a
disease (e.g., improved quality of care-this scenario is typical for USMLE)
Biostatistics &
4172 Medicine
Epidemiology Incidence:measure of the appearance of new cases
Prevalence:measure of those w/ the disease in the population at a particular point in time

Biostatistics &
4178 Medicine Loss to follow-up in prospective studies creates a potential for attrition bias, a subtype of *selection bias*
Epidemiology
Matching is frequently used in case-control studies because it is an efficient method to control confounding.
Biostatistics & Remember: matching variables should always be the potential confounders of the study(eg;age,race).
4182 Medicine
Epidemiology Cases & controls are then selected based on the matching variables, such that both groups havge a similar
distribution in accordance w/ the variables
Biostatistics &
4189 Medicine If a test result is negative, the probability of having the disease is 1 - negative predictive value
Epidemiology
Biostatistics & Changing the cutoff point to increase the true-positive rate (directly proportional to sensitivity) will also
4262 Medicine
Epidemiology increase the false-positive rate (inversely proportional to specificity)
Biostatistics & A cohort study design is best for determining the incidence of a disease. Comparing the incidence of the
4686 Medicine
Epidemiology disease in 2 populations (with and without a given risk factor)
Biostatistics & Hazard ratios are proportions that indicate the chance of an event occurring in the tx group compared to the
7686 Medicine
Epidemiology chance of the event occurring in the control group
Factorial design studies involve randomization to different interventions w/ additional study of 2 or more
variables
Cluster analysis:grouping of different data point into similar categories

Biostatistics &
7689 Medicine
Epidemiology
Crossover study:group of participants is randomized to 1 tx & other group is given alternate tx for same
time period.At end of time period, the 2 groups switch tx for another set period of time
Parallel study:randomizes 1 tx to one group & diff tx to other group

Hazard ratio < 1 indicates that the treatment group had a lower event rate
Biostatistics &
7690 Medicine
Epidemiology
Hazard ratio > 1 indicates that the treatment group had a higher event rate
Biostatistics & When the treatment regimen selected for a pt depends on the severity of the pt's condition, a form of
7691 Medicine
Epidemiology selection bias known as susceptibility bias (confounding by indication) can result
Biostatistics & When comparing the effects of a treatment on a composite outcome, it's important to note any differences
7708 Medicine
Epidemiology between the individual endpoints
Biostatistics & The number needed to treat (NNT) is defined as the number of people that need to receive a treatment to
7709 Medicine
Epidemiology prevent 1 additional adverse event. It's calculated as the inverse of the absolute risk reduction (ARR).
Biostatistics & A shift in the receiver operating characteristic curve upward for a given cutoff indicates increased sensitivity.
7711 Medicine
Epidemiology A shift of the curve to the right for a given cutoff point indicates a decrease in specificity
Changing the cutoff value of a test in a way that alters the proportion of true-positive & false-negative
Biostatistics & results will change the sensitivity. Likewise, a change in the test that modifies the proportion of false-positive
7712 Medicine
Epidemiology & true-negative results will change the specificity. Alterations in test sensitivity & specificity, as well as
changes in disease prevalence, will affect the positive & negative predictive values
Biostatistics & In order to prevent medical error, interventions that target pharmacy personnel and high risk pt's appear to
9634 Medicine
Epidemiology have the most impact on quality of pt care
Pts w/ symptomatic sinus bradycardia(fatigue, dizziness, light-headedness, hypotension, syncope, angina,
and/or chf) should be tx initially w/ iv *atropine.* If inadequate response, tx w/ iv epinephrine or dopamine or
transcutaneous pacing
2141 Medicine Cardiovascular System
IV glucagon increases levels of CAMP & is effective in tx beta blocker or calcium channel blocker toxicity
Norepinephrine tx severe hypotension & shock (eg septic shock)
Ashhadscknotes
Acute coronary syndrome:
sx- abdominal pain, nausea/vomiting are atypical presentations
Cardiac causes must be excluded (eg. w/ electrocardiogram) prior to pursuing other etiologies
Abdominal ultrasound: useful for diagnosing acute cholecystitis

Serum amylase & lipase: helpful tests for supporting diagnosis of pancreatitis
Upper gi endoscopy: use in pts w/ evidence of acute gi blood loss or peptic ulcer disease
Upright abdominal xray: use in diagnosing PUD w/ perforation

Aortic stenosis:
sx- dizziness, syncope, delayed & diminished carotid pulse, diminished S2, S4 present, Harsh ejection
(crescendo-decrescendo) systolic murmur in second right intercostal space w/ radiation to carotids
managment-obtain a transthoracic echocardiogram in pts w/ syncope due to suspected structural heart
disease (like aortic stenosis) to confirm dx
If pt has severe, symptomatic AS, tx is aortic valve replacement
Upright tilt table test-to dx vasovagal syncope

Right ventricular myocardial infarction (RVMI) presents w/ hypotension, elevated jugular venous pressure, &
clear lung fields in the setting of acute inferior MI. Affected pts require increased RV preload to maintain
cardiac output & may need intravenous fluid support(eg,*normal saline bolus*). NITRATES, diuretics, &
opioids can reduce RV preload & should be avoided
Hemodynamic compromise 3-7 days after a MI raises suspicion for mechanical complications of MI.The
three major mechanical complications of MI include *mitral regurgitation due to papillary muscle rupture*,
2157 Medicine Cardiovascular System left ventricle free wall rupture, & interventricular septum rupture. While all three of these developments can
result in hypotension, *a pansystolic murmur heard loudest at the apex w/ radiation to the axilla is the
classic characterization of mitral regurgitation*
Pts initially dx w/ htn should have a detailed h&p. In addition, perform urinalysis for occult hematuria & urine
protein/creatinine ratio, chemistry panel, lipid profile, baseline electrocardiogram
Primary hyperaldosteronism: low plasma renin, hypokalemia, and htn

Renal ultrasound identifies asymmetrical kidney size or small atrophic kidneys, which suggests primary renal
disease
Duplex doppler ultrasound is useful in screening for renal artery stenosis in pts w/ severe htn
Loop diuretics cause hypokalemia & hypomagnesemia. These electrolyte abnormalities can cause
ventricular tachycardia, & also potentiate the side effects of digoxin. Ordering *serum electrolytes* & serum
2164 Medicine Cardiovascular System digoxin level is best next step.
Metolazone is a thiazide diuretic

Fibromuscular dysplasia: affects women age 15-50, can cause hypertension, tia, *amaurosis fugax*, stroke,
headache, pulsatile tinnitus, dizziness. Look for woman w/ transient vision loss, family hx of stroke, & carotid
bruit. Dx confirmed w/ *CT angiography of the abdomen* or duplex ultrasound. Aldosterone concentration to
renin activity ratio is ~10 (<20)
Dexamethasone suppression test can diagnose Cushing's syndrome

Uremic pericarditis results from inflammation of the visceral & parietal membranes of the pericardial sac.
2224 Medicine Cardiovascular System The typical electrocardiographic features of acute pericarditis are absent in uremic pericarditis due to lack of
involvement of the epicardium. The perimary tx is *hemodialysis*
Atheroembolism (cholesterol embolism): complication of cardiac catheterization & other vascular
procedures, characterized by cutaneous findings (eg, "blue toe syndrome," livedo reticularis), cerebral or
2310 Medicine Cardiovascular System intestinal ischemia, acute kidney injury, & Hollenhorst plaques. Tx- supportive & includes statin therapy for
risk factor reduction & prevention of recurrent cholesterol embolism. Combo of cyanotic toes, abdominal
pain, & renal failure post-cardiac catheterization.
Torsades de pointes (TdP): Immediate defibrillation in hemodynamically unstable pts. *IV magnesium* is 1st
line tx for stable pts
Amiodarone used both for atrial & ventricular tachycardia(VT). Occasionally used in pts w/ polymorphic VT
due to myocardial ischemia or infarction
Atropine used in tx symptomatic sinus bradycardia or av nodal block
Sodium bicarbonate used for pts w/ TdP due to quinidine use,cardiac arrest due to metabolic
acidosis,hyperkalemia,tca overdose
Beta blocker overdose: Wheezing is a feature! Also get bradycardia, hypotension, hypoglycemia, delirium,
seizures, & cardiogenic shock.
Management- first give iv fluids and atropine. If hypotension doesn't improve, give iv *glucagon*!
Digoxin toxicity: Wheezing is NOT a feature. Also get life threatening arrhythmias, color vision alterations,
anorexia, nausea & vomiting, abdominal pain, fatigue, confusion, weakness.
Ashhadscknotes
Acute arterial occlusion (limb ischemia):
sx- pain, pallor, pulselessness, paresthesia, and paralysis
tx- immediate anticoagulation and referral for emergency vascular surgery
Carotid artery atherosclerosis:
screen with doppler examination of carotid arteries
1st line medical tx for hypertrophic cardiomyopathy is either *B-blockers(slows heart,prolongs
diastole->more time for heart to fill,less outflow obstruction.Anti-anginal effect as well)* or a cardiac acting
2686 Medicine Cardiovascular System calcium channel blocker such as diltiazem since they promote diastolic relaxation.[Amlodipine is a
peripherally acting calcium channel blocker,so it doesn't have the diastole-prolonging effects of a drug such
as diltiazem.It acts primarily as an arterial vasodilator]
2687 Medicine Cardiovascular System Hypertrophic cardiomyopathy (HCM) is an *autosomal dominant* genetic disorder
Congestive heart failure due to alcoholic dilated cardiomyopathy: Look for CHF sx, along w/
thrombocytopenia, macrocytosis, & elevated transaminases(all of which suggest alcoholism).
Management-abstinence from alcohol may reverse this condition if employed earlier in the course of disease
Digitalis:for heart failure pts w/ systolic dysfunction & rapid ventricular rates due to a-fib or atrial flutter
ACE inhibitors:for heart failure pts w/ systolic dysfunction

Displaced apical impulse, holosystolic murmur, & 3rd heart sound are consistent w/ chronic severe mitral
regurgitation(MR). Mitral valve prolapse(MVP) is the mcc of chronic MR in developed countries. MVP occurs
2695 Medicine Cardiovascular System due to *myxomatous degeneration of the mitral valve leaflets & chordae* & causes a mid-systolic click
followed by a mid-to-late systolic murmur. Chronic severe MR can cause left atrial dilation, which can
eventually lead to atrial fibrillation(sx of palpitations)
Cardiac auscultation in pts w/ mitral valve prolapse typically shows a systolic click &/or mid to late systolic
2696 Medicine Cardiovascular System murmurs of mitral regurgitation. Squatting from a standing position increases preload & left ventricular
volume, decreasing the intensity of the murmur
*A bicuspid aortic valve is the cause of aortic stenosis in the majority of pts under 70 years old*. Senile
calcific aortic stenosis is the mcc of aortic stenosis in pts who are older than 70 years old. (Rheumatic heart
disease is also a cause of aortic stenosis BUT it's a much less common cause than either a bicuspid aortive
valve or senile calcific aortic stenosis)
*Cardiac dysfunction ass. w/ hemochromatosis can be reversed w/ early identification of the disease &
treatment*
Restrictive cardiomyopathy: can eventually result in CHF. May be caused by sarcoidosis, amyloidosis,
2699 Medicine Cardiovascular System hemochromatosis, endomyocardial fibrosis, or idiopathic. Diastolic dysfunction. Wall thickness normal or
symmetrically thickened. Signs of right sided heart failure predominate (JVD, bilateral ankle edema, tender
hepatomegaly)
Hemochromatosis tx- phlebotomy

Mitral stenosis -> left atrial dilatation -> atrial fibrillation
2700 Medicine Cardiovascular System ECG w/ an irregularly irregular rhythm & loss of 'P' waves describes atrial fibrillation. Atrial fibrillation causes
a lack of an "atrial kick", which could cause worsening flow thru the stenotic mitral valve & increased
congestion in the lungs, thus leading to the pt's acute onset of dyspnea
Mitral stenosis:can be due to rheumatic fever(rheumatic fever common in developing countries like
Cambodia). Causes left atrial dilation & risk of atrial fibrillation(palpitations/irregular heartbeats) & cardiac
2701 Medicine Cardiovascular System emboli(thrombus in left atrium cuz of untreated a-fib which can eventually embolize to cerebral circulation to
eventually cause stroke & eg, left sided weakness). The pressure is also transmitted to pulmonary
vasculature -> dyspnea, cough & hemoptysis
*Cardiac amyloidosis* should be suspected in pts w/ unexplained CHF(predominantly *diastolic
dysfunction*), echocardiogram findings of *increased ventricular wall thickness w/ normal left ventricular
cavity dimensions* (esp in the absence of HTN), & low voltage on electrocardiogram
Amyloidosis can present w/ waxy skin, macroglossia, hepatomegaly, & peripheral(carpal tunnel syndrome)
&/or autonomic neuropathy(orthostatic hypotension).Tissue biopsy(ab fat pad) confirms dx
The primary mitral valve abnormality in pts w/ hypertrophic cardiomyopathy is the presence of systolic
anterior motion of the mitral valve, leading to *anterior motion of mitral valve leaflets* toward the
interventricular septum. Contact between the mitral valve & the thickened septum during systole leads to left
ventricular outflow tract obstruction
Myxoma:benign "primary cardiac tumor".80% located in left atrium.Constitutional sx(fatigue,fever,weight
loss),systemic embolization(TIA,stroke,splenic infarcts,left sided weakness),& cardiovascular sx simulating
2713 Medicine Cardiovascular System mitral valve disease(dyspnea,orthopnea,cough,pulmonary edema,hemoptysis).Tx-surgical resection
[Don't confuse this w/ 'myxomatous valve degeneration' which is the pathologic cause of mvp,which causes
midsystolic click,& no systemic sx or mass on echocardiography]
2717 Medicine Cardiovascular System Abdominal ultrasound is the study of choice for diagnosis and followup of abdominal aortic aneurysms
Prinzmetal's angina/variant angina: Caused by temporary spasm of the coronary arteries, young women
2722 Medicine Cardiovascular System classically affected, *greatest risk factor is smoking*, absence of cardiovascular risk factors, ass. w/ other
vasospastic disorders like *Raynaud's phenomenon* & migraine headaches
Ashhadscknotes
Variant/Prinzmetal's angina tx: calcium channel blockers and/or nitrates to prevent coronary
vasoconstriction(NONSELECTIVE B-BLOCKERS & ASPIRIN SHOULD BE AVOIDED BECAUSE THEY CAN
PROMOTE VASOCONSTRICTION!)
2723 Medicine Cardiovascular System Variant/Prinzmetal's angina: typically occurs in young females. Greatest risk factor is smoking
Digoxin is also used as a rate control agent in pts w/ atrial fibrillation or flutter
Streptokinase: used for thrombolysis in tx of STEMI if PCI not available

Right ventricular myocardial infarction:
sx- hypotension, jugular venous distension
chest pain, autonomic signs(diaphoresis, vomiting), ST elevation in inferior leads II,III, & aVF, Kussmaul's
sign (increase in JVD w/ inspiration) -these are signs of RV failure-
These pts are preload dependent so treat w/ iv fluids(Do NOT give preload reducing meds such as nitrates
& diuretics!)
*Rupture of the ventricular free wall* is a mechanical complication that usually occurs within *5 days to 2
weeks* after an acute myocardial infarction (usually anterior)
Acute pericarditis: occurs in the first several days after MI, sharp pleuritic pain that's worse in supine
position & improves by sitting up & leaning forward, diffuse ST elevations esp w/ PR depressions on ECG
2729 Medicine Cardiovascular System Interventricular free wall rupture & papillary muscle rupture occur 3-7 days after MI & present w new onset
systolic murmur
Right ventricular infarction is most common w/ inferior wall MI

Ventricular aneurysm (VA) ECG findings:
persistent ST-segment elevation after a recent MI and deep Q waves in the same leads
Extension of aortic dissection frequently involves the right coronary artery & results in acute inferior MI w/
ST-segment elevation in leads II, III, & aVF
Right ventricular infarction occurs in the setting of inferior wall MI w/ occlusion of the proximal right coronary
artery. Pts usually develop hypotension, elevated jvp, & clear lung fields
Ventricular remodeling in the weeks to months following myocardial infarction can lead to dilatation of the
ventricle w/ thinning of the ventricular walls. *This process is lessened by ACE inhibitors*(so give ACE
inhibitors within 24 hours of MI in all pts w/o contraindication)
Aspirin: given after MI to inhibit platelet aggregation & prevent recurrence of coronary artery blockage.
Favored over warfarin in post MI pts
Digoxin:sx relief in pts w/ systolic heart failure

*Hypertension* is the MOST COMMON predisposing factor to Aortic dissection!!!
2735 Medicine Cardiovascular System (Pts w/ Marfan syndrome & Ehlers-Danlos syndrome are also at risk for aortic dissection, however they are
NOT the strongest risk factor & tends to cause aortic dissection in younger pts)
Premature discontinuation of antiplatelet therapy/*medication noncompliance* is the strongest predictor of
stent thombosis after intracoronary stent implantation. Such pts should be aggressively screened for, &
counseled regarding, medication compliance to reduce the risk of stent thrombosis
Atherosclerotic plaque rupture w/ thrombotic occlusion would be unlikely at the site of a recent intracoronary
stent (in the LAD)
Electrical alternans:when amplitudes of QRS complexes vary from beat to beat.Fairly specific for pericardial
effusion(pericardial effusions are often secondary to viral pericarditis.Look for hx of upper resp infection)
Presence of 'F' waves,or flutter waves is dx of atrial flutter
New onset right bundle branch block can sometimes be seen in PE

In otherwise young healthy pts who develop CHF, myocarditis should be considered. *Viral infection* esp. w/
Coxsackie B virus is the mcc!
Ischemic cardiac pain can sometimes be mistaken for epigastric pain, but should remain high on the
2742 Medicine Cardiovascular System differential, esp in the setting of sx worsened w/ exertion. An *exercise stress test/exercise EKG* w/o
imaging is the most reasonable first step if the baseline resting EKG is normal
Diuretics(eg,*furosemide*) are rec for acute pulmonary edema(S3,basilar crackles extending halfway up the
lung fields bilaterally) that is caused by an ischemic heart failure secondary to an acute myocardial
infarction. B-blockers are a standard therapy in myocardial infarction but should be avoided in pts w/
2743 Medicine Cardiovascular System decompensated congestive heart failure or bradycardia
Although Spironolactone is sometimes used for CHF & is shown to have a mortality benefit,its still a weak
diuretic
Tobacco & alcohol are reversible risk factors for premature atrial complexes.
2744 Medicine Cardiovascular System Beta blockers are often helpful in pts who are symptomatic. Beta blockers are the standard tx for
symptomatic PAC's
Ashhadscknotes
Strongest influence on long-term prognosis after an ST-elevation MI is the duration of time that passes
before coronary blood flow is restored.2 primary options for restoring coronary blood flow are PTCA &
fibrinolysis.PTCA has superior outcomes compared to fibrinolysis & should be used when available
2745 Medicine Cardiovascular System Meds that reduce myocardial oxygen demand used for angina
Arrhythmias should be tx only as they arise
Benefits of reperfusion outweigh the consequences of reperfusion injury

Beta-blockage(eg, w/ labetalol) is the most appropriate initial intervention for acute aortic dissection. Type A
dissections involve the ascending aorta and are treated w/ medical therapy & surgery, while Type B
dissections involve only the descending aorta & are usually treated w/ medical therapy alone
Nifedipine & Hydralazine shouldn't be used to treat aortic dissection. But vasodilators can be considered if
further BP lowering is needed after beta-blockers have been given
Chagas disease: causes megaesophagus, megacolon, & cardiac dysfunction. The *protozoan*
Trypanosoma cruzi, endemic to Latin America, is responsible.
In Wolff Parkinson White syndrome (WPW) an accessory pathway conducts depolarization directly from
atria to ventricles w/o traversing the AV node. A-fib occurs in a few pts w/ WPW and is a life threatening
emergency. Persistent AF can deteriorate into VF. Goal of tx A-fib in WPW pts is aimed at control of
ventricular response and termination of A-fib:
Hemodynamically unstable pts tx- electrical cardioversion
Stable pts- rhythm control w/ iv ibutilide or *procainamide*
Pts w/ severe aortic stenosis can have anginal chest pain due to increased myocardial oxygen demand
high pitched systolic murmur heard at the second right intercostal space describes aortic stenosis(occurs in
young pts due to congenitally bicuspid aortic valve)
Aortic regurgitation(AR): wide pulse pressure(increased systolic bp & decreased diastolic bp), "water
hammer" pulse, & LV enlargement. The left lateral decubitus position brings the enlarged left ventricle closer
to the chest wall & causes a pounding sensation & increased awareness of the heartbeat. Mcc of AR in
developing countries is rheumatic heart disease. In developed countries it's due to aortic root dilation or
congenital bicuspid valve
Murmur of aortic regurgitation (AR) is best heard along the left sternal border at the third & fourth
interspaces. May be heard by applying firm pressure w/ the diaphragm of stethoscope while pt is sitting up,
leaning forward, & holding the breath in full expiration. *Congenital bicuspid aortic valve is the mcc of AR in
young adults in developed countries.* Rheumatic heart diseae is the mcc in developing countries
Atrial septal defect: wide, fixed, & split second heart sound
Lifestyle modification should be the first-line intervention for newly diagnosed stage I hypertension. The
most effective lifestyle intervention for reducing blood pressure is weight loss in obese pts. All pts should en
encouraged to follow the *DASH diet*(rich in fruits, vegetables, & low fat dairy products), restrict dietary salt
intake, engage in regular aerobic exercise to maintain normal body weight, & limit alcohol intake
DASH(Dietary Approaches to Stop Hypertension)

*Atrial tachycardia w/ AV block* is the arrhythmia most specific for digitalis toxicity! (its due to the increased
ectopy & increased vagal tone caused by digitalis toxicity)
Atrial tachycardia is distinguished from atrial flutter by its somewhat slower atrial rate (150-250 bpm as
opposed to 250-350 bpm)
Elevated creatine phosphokinase (CPK) points towards muscle injury, a side effect of statins. The muscle
injury can progress to rhabdomyolysis w/ renal failure, so *statin medications should be stopped* in these pts
3158 Medicine Cardiovascular System Losartan: an ARB. Side effects-hyperkalemia, hypotension, renal failure
N-acetylcysteine uses: dissolution of mucus, protection against contrast indced renal failure, & therapy for
acetaminophen overdose
Cocaine induced vasospasm:
can cause ST elevation myocardial infarctions (STEMIs).
tx- with PTCA or thrombolysis. Aspirin and nitrates also appropriate
Avoid beta blockers because they allow unopposed alpha agonist activity, which worsens vasospasm
Acute pericarditis:
can cause ST elevations on EKG, accompanied by PR depressions
Pleurodynia:
chest pain of pulmonary etiology. Worse w/ deep breathing
Chest x-ray should be obtained in all pts who undergo central venous catheterization to confirm proper
3504 Medicine Cardiovascular System placement of the catheter tip and absence of complications before administering drugs or other agents thru
the catheter
Ashhadscknotes
*Pulmonary toxicity* is a serious adverse effect of long-term *amiodarone* use that can occur months to
3506 Medicine Cardiovascular System several years after the initiation of amiodarone therapy. *A baseline chest radiograph & pulmonary function
testing should be obtained prior to initiating therapy w/ amiodarone*
Pts w/ Dressler's syndrome(a pericarditis) present weeks after a myocardial infarction w/ chest pain that is
improved by leaning forward. Tx-*NSAIDs*
[EKG findings in pericarditis-diffuse ST elevation w/ the exception of reciprocal depression in aVR]
"EKG shows ST segment elevations in all limb & precordial leads except in aVR, where ST depression is
seen"
Acute limb ischemia after MI suggests possible arterial embolus from left ventricular (LV) thrombus.
3526 Medicine Cardiovascular System Management includes immediate anticoagulation, vascular surgery consultation, & transthoracic
*echocardiogram* to screen for LV thrombus & evaluate LV function
Carotid endarterectomy (CEA) is recommended for men & women w/ symptomatic carotid stenosis of
70%-99% & is also beneficial for men w/ asymptomatic carotid stenosis of 60%-99%(some experts
recommend CEA for asymptomatic women w/ high grade stenosis [70%-99%] but the data are less
3529 Medicine Cardiovascular System convincing)
Lesions <50% are monitored w/ annual Duplex ultrasound. Surgery is not indicated at this stage & pts are
medically managed w/ pharmacotherapy & risk factor optimization
Constrictive pericarditis:
Tuberculosis is a common cause in developing countries like africa, india, & china.
sx- dyspnea, fatigue, pedal edema, elevated jvp, ascites, pericardial thickening & calcification, jvp tracings
show x & y descents, early heart sound after S2(pericardial knock)
In atrial fibrillation (AF) w/ rapid ventricular response, rate control should be attempted initially w/ beta
blockers or calcium channel blockers(*Diltiazem*)
3697 Medicine Cardiovascular System Attempting cardioversion in pts w/ AF for an unknown duration or >48 hours w/o adequate anticoagulation
increases risk of systemic thromboembolism
Lidocaine:antiarrhythmic used for tx ventricular arrhythmias

In Ventricular fibrillation (VF) & pulseless Ventricular tachycardia (VT), *defibrillation* is of primary
importance! Time to defibrillation is strongly correlated w/ survival! Once defibrillation has been attempted,
epinephrine should be given. After a repeated attempt at defibrillation, use of
3698 Medicine Cardiovascular System antiarrhythmics(amiodarone,lidocaine,magnesium) is warranted.[Look at & compare EKGs for both
ventricular fibrillation & atrial fibrillation]
Digoxin used for atrial tachycardia

Atrial fibrillation (AF):common complication of CABG,occurring in up to 40% of pts.In CABG w/ aortic valve
replacement,the incidence jumps to over 50%. Features on EKG(google it)- irregularly irregular R-R interval
w/ absent P waves & narrow QRS complexes.In UNSTABLE pts,immediate *DC cardioversion* should be
performed.[Digoxin for rate control in hemodynamically stable AF]
Transcutaneous pacing:for symptomatic bradycardia
Lidocaine:for ventricular arrhythmias
Most pts w/ atrial premature beats (APBs) do not require any specific therapy & should be reassured about
the benign nature of the arrhythmia. Management of pts w/ frequent APBs should focus primarily on
evaluation for the presence or absence of underlying structural heart disease w/ a *transthoracic
echocardiogram*
Sustained monomorphic ventricular tachycardia (SMVT) [google ecg]:
Wide-complex tachycardia w/ 2 fusion beats. Presence of AV dissociation. Mcc is myocardial scarring from
previous MI. Electrical cardioversion for SMVT pts who are hemodynamically
unstable(hypotensive,respiratory distress), pulseless, or severely symptomatic(altered mental
status,pulmonary edema). Antiarrhythmics are given for hemodynamically stable SMVT pts(*Amiodarone* is
the preferred antiarrhythmic*)
Most cases of 1st-degree AV block(PR interval prolonged/>200 msec)w/ NORMAL QRS duration are due to
delayed AV nodal conduction & require no further evaluation.Best approach is *observation*
Pts w/ 1st-degree AV block & PROLONGED QRS duration have a conduction delay below AV node &
should have electrophysiology testing to determine its nature
24 hour ECG (Holter) monitoring used in symptomatic pts(dizzy,syncope) suspected of having

bradyarrhythmias or tachyarrhythmias
Ashhadscknotes
Mobitz type 1 av block: progressive prolongation of the PR interval leading to a non-conducted P wave and
a "dropped" QRS complex
Mobitz type 2 av block: PR interval is always constant w/ no progressive prolongation & QRS complexes
drop suddenly
3766 Medicine Cardiovascular System Atrial fibrillation:irregularly irregular rhythm,no discrete P waves
3rd degree/complete av block:P waves unrelated to QRS complexes,can be found before,after,or buried in
QRS complex
1st degree av block:prolonged PR interval
A pt w/ dizziness & worsening angina, and ECG showing P-wave activity which is temporally unrelated to
QRS complexes(can be found before, after, or buried in the QRS complex) suggests third-degree or
3768 Medicine Cardiovascular System complete AV block. Manage w/ temporary *pacemaker* insertion while looking for reversible causes to
correct(myocardial ischemia is a reversible cause,represented by T wave inversion & chest discomfort). If
no reversible causes of heart block found, we give a permanent pacemaker.
*Amiodarone* is a class III antiarrhythmic agent, well known for causing *pulmonary fibrosis*. Thyroid
3769 Medicine Cardiovascular System dysfunction (hypothyroidism 85% of the time & hyperthyroidism 15% of the time), hepatotoxicity, corneal
deposits & skin discoloration are other potential side effects
Pressors such as *norepinephrine* can cause ischemia of the distal fingers & toes secondary to
vasospasm. The dx is suggested by symmetric duskiness & coolness of all fingertips(google pic)
3777 Medicine Cardiovascular System Cholesterol emboli can occur in pts w/ atherosclerosis & can affect the distal portions of the digits "blue toe
syndrome". However symmetrical involvement of all digits would be unusual
Endocarditis can spread septic emboli thru out the body but wouldn't be expected to affect all fingers
ACE inhibitors, ARBs, beta-blockers, & spironolactone all confer a survival benefit in CHF. While *digoxin &
furosemide (loop diuretics)* can reduce CHF sx & hospitalizations, *they DO NOT improve survival*
The only class of diuretics w/ a demonstrated survival benefit in pts w/ heart failure is aldosterone
antagonists like spironolactone & eplerenone
*Diabetic pts age 40-75 should be treated w/ statin therapy in addition to lifestyle modification & glucose
control*
Niacin is effective in raising HDL & lowering triglycerides & has a modest effect in lowering very low density
lipoprotein & low density lipoprotein cholesterol. However it may worsen glucose control in diabetic pts
Lipid lowering therapy w/ *statin* medications is rec for primary prevention in pts age 40-75 w/ a 10 year risk
of atherosclerotic cardiovascular disease >7.5%
PCI is recommended within 90 min for acute, STEMI. Additional stabilization measures include oxygen, full
dose aspirin, platelet P2Y12 receptor blockers, nitroglycerin for pain control, beta blockers, &
3826 Medicine Cardiovascular System anticoagulation. Fibrinolysis may be administered within 12 hours of symptom onset for STEMI pts who
can't undergo PCI but is ass. w/ higher rates of recurrent myocardial infarction, intracranial hemorrhage, &
mortality compared to PCI
Acute limb ischemia: pain, pulselessness, paresthesias, poikilothermia(coldness), & pallor. Angiography will
show an abrupt cutoff of arterial blood flow. Start IV heparin upon suspicion. Tx- surgical embolectomy or
intra-arterial fibrinolysis/mechanical embolectomy via interventional radiology
Pts w/ acute limb ischemia are tx w/ direct intra-arterial(not IV) administration of a fibrinolytic agent on the
clot using an angiographic catheter
Syncope due to arrhythmia: sudden onset of syncope w/o warning signs, presence of structural heart
disease, frequent ectopic beats, use of thiazide diuretic(causes electrolyte disturbances predisposing to
ventricular arrhythmia)
3881 Medicine Cardiovascular System Vasovagal syncope is precipitated by emotional reaction & preceded by presyncopal dizziness, weakness, &
nausea
Clonic jerks may occur during any syncope if it is prolonged(due to brain hypoxia). Don't immediately
assume its a seizure!
Dihydropyridine Ca-channel antagonists (like amlodipine) can cause peripheral edema
Discontinue drug if edema is significant!
Congestive heart failure: sx- dyspnea, orthopnea, elevated neck vein pulsation & liver enlargement
Liver disease: sx- ascites dominates over peripheral edema, hypoalbuminemia, hyperbilirubinemia
Situational syncope: when a middle age or older male loses his consciousness immediately after urination,
or a man who loses his consciousness during coughing fits
3924 Medicine Cardiovascular System Coarctation of the aorta (COA) occurs in pts w/ Turner's syndrome. COA can lead to Rib notching!
Ashhadscknotes
Renovascular hypertension:
sx- resistant hypertension(persistent hypertension despite using >3 treatments) & diffuse atherosclerosis,
asymmetric kidney size, recurrent flash pulmonary edema, or elevation in serum creatinine > 30% from
baseline after starting ACE inhibitor or ARBs
continuous abdominal bruit highly specific for renovascular hypertension
Primary aldosteronism:
also causes resistant hypertension but you won't have diffuse atherosclerosis
Nitroglycerin relieves anginal pain by dilation of veins(*capacitance vessels*) & decrease in ventricular
preload
Cholesterol crystal emolism (atheroembolism):
can occur in pt w/ atherosclerosis risk factors who undergoes cardiac catheterization, recent arteriography,
or vascular procedure
sx- livedo reticularis, blue toe syndrome, acute kidney injury, hollenhorst plaques, eosinophila, eosinophiluria
Contrast induced nephropathy (CIN):
pts undergoing coronary angiography are at risk
urinalysis shows muddy-brown granular and epithelial cells casts
Acute aortic dissection: For rapid dx, use *Transesophageal echocardiogram (TEE)*. CT can also be used
just as effectively for dx but requires contrast and normal renal function in patient.
TEE and CT are less invasive modalities for rapid dx
The increased BUN/creatinine ratio is a sensitive indicator of hypovolemia leading to orthostatic hypotension
as a cause of syncope in an elderly pt
vasovagal/neurocardiogenic syncope:
caused by emotional/orthostatic stress, micturition, cough & defecation
3962 Medicine Cardiovascular System upright tilt table testing can be used to establish diagnosis
24 hour (Holter) monitoring indicated for pts w/ arrhythmia

High-dose niacin therapy to treat lipid abnormalities frequently produces cutaneous flushing & pruritus. This
is due to *prostaglandin-induced peripheral vasodilatation* & can be reduced by low-dose aspirin
Hypertensive emergency: severe htn ass. w/ 1)malignant htn or 2)hypertensive encephalopathy.
1)Malignant htn- *retinal hemorrhages, exudates, papilledema*
3977 Medicine Cardiovascular System 2)Hypertensive encephalopathy- cerebral edema
Hypertensive urgency: severe htn >180/120 w/ no sx of acute end-organ damage

Uremic pericarditis:
sx- sharp & pleuritic chest pain, pericardial friction rub, uremia
tx- hemodialysis
NSAIDs are used in uremic pericarditis pts not responding to dialysis. Glucocorticoids can be used in pts w/
inadequate response to initial dialysis(low success rate and high risk of recurrence)
Isolated systolic hypertension is an important cause of hypertension in elderly pts. It's caused by decreased
3994 Medicine Cardiovascular System elasticity of the arterial wall(As people age, the elastic properties of the arterial wall diminish & the *arteries
become more rigid*)
Pts w/ cocaine-ass. chest pain should be tx initially w/ IV *benzodiazepines*. These improve sx of
psychomotor agitation, reduce myocardial oxygen demand, & alleviate cardiovascular sx. Aspirin,
4042 Medicine Cardiovascular System nitroglycerin, & calcium channel blockers are also efective in the initial management of cocaine-ass chest
pain. Beta blockers are contraindicated(their use causes unopposed alpha adrenergic stimulation & worsens
coronary vasoconstriction!)
*Dipyridamole* can be used during myocardial perfusion scanning to reveal the areas of restricted
4054 Medicine Cardiovascular System myocardial perfusion. The redistribution of the coronary blood flow to 'non-diseased' segments induced by
this drug is called *coronary steal phenomenon*
Hx of recent URI followed by sudden onset of cardiac failure in an otherwise healthy pt is suggestive of
dilated cardiomyopathy, most likely secondary to acute viral myocarditis. Dx of dilated cardiomyopathy is
made by echocardiogram, which shows *dilated ventricles w/ diffuse hypokinesia* resulting in a low ejection
fraction. Tx-supportive,management of CHF sx
*Reentrant ventricular arrhythmias* (eg,ventricular fibrillation) are the mcc of sudden cardiac arrest in the
immediate post-infarction period in pts w/ acute MI
Pulseless electrical activity:presence of electrocardiographic rhythm in absence of adequate cardiac

4093 Medicine Cardiovascular System mechanical contraction to generate a palpable pulse
Asystole:complete absence of electrical & mechanical cardiac activity
Pts w/ prolonged duration of cardiac arrest->pulseless electrical activity or asystole

Diastolic & continuous murmurs are usually due to an underlying pathologic cause, & their presence should
prompt further evaluation w/ a transthoracic *echocardiogram*
Midsystolic murmurs in otherwise young, asymptomatic adults are usually benign & don't require further
evaluation
Ashhadscknotes
ST segment elevations in inferior leads II,III,& aVF w/ reciprocal ST depression in leads I & aVL are
consistent w/ acute inferior wall MI. Inferior wall MI is usually due to occlusion of the *right coronary artery
(RCA)*. RCA occlusion can cause AV block
LAD occlusion->ST elevation in all precordial leads but most commonly in V1-V4
LCX occlusion->ST elevation in leads I,II,III,aVL
Left main coronary artery occlusion->sudden cardiac death
*Beta blockers(propranolol)* are rec as initial tx for atrial fibrillation due to hyperthyroidism. Beta blockers
4126 Medicine Cardiovascular System help to control heart rate & hyperadrenergic sx. [Anxiety,weight loss,lig lag,fine tremor in hands,atrial
fibrillation all suggest hyperthyroidism]
*Beta blockers are 1st line tx for controlling sx & improving exercise tolderance in pts w/ stable angina
pectoris* (Calcium channel blockers or long acting nitrates are used if beta blockers are contraindicated/not
effective on their own)
Thiazide diuretics are effective initial tx for pts w/ essential htn
ACE inhibitors used for htn, esp in pts w/ diabetes, chronic kidney disease, & chf
Ascending aortic aneurysms are most often due to cystic medial necrosis or connective tissue disorders.
Descending aortic aneurysms are usually due to *atherosclerosis*. CXR can suggest thoracic aortic
aneurysm by showing a widened mediastinal silhouette, increased aortic knob & tracheal deviation(google
CXR)
Hepatojugular(or abdominojugular) reflux is a useful clinical tool that can differentiate between cardiac &
liver disease related causes of lower extremity edema.*Pts w/ peripheral edema due to heart failure have
elevated jugular venous pressure & positive hepatojugular reflux*. Those w/ peripheral edema from primary
hepatic disease & cirrhosis have reduced or normal jugular venous pressure & negative hepatojugular reflux
Hyponatremia in pts with CHF indicates severity of heart failure. Caused by increased renin, norepinephrine,
4190 Medicine Cardiovascular System and ADH.
tx- fluid restriction, ace inhibitors, & loop diuretics
In the tx of a pt using both sildenafil(for erectile dysfunction) & an alpha-blocker (eg, doxazosin, for BPH),
it's important to give the drugs w/ at least a 4-hour interval to reduce the risk of hypotension
4191 Medicine Cardiovascular System Although diabetics have a high risk for ED, tightening of glycemic control hasn't been shown to improve ED
Sildenafil is contraindicated in pts being tx w/ nitrates & in pts that are hypersensitive to sildenafil. It's used
w/ precaution in conditions causing priapism
Statins inhibit HMG-CoA reductase, a rate-limiting enzyme in the intracellular biosynthesis of cholesterol that
converts HMG-CoA to mevalonate, & also increases the number of cell membrane LDL receptors.[Statins
4227 Medicine Cardiovascular System mechanism of action is *inhibition of intracellular synthesis pathway*]. Statins also decrease coenzyme Q10
synthesis, which is involved in muscle cell energy production & possibly contributes to statin-induced
myopathy
*Anaphylaxis* can result from exposure to latex-containing products such as surgical gloves & condoms.
Health care workers & pts w/ atopic disease are at higher risk of latex allergy
Cardiogenic shock causes a reduced cardiac index & elevated pulmonary capillary wedge pressures due to
ventricular pump failure.Systemic vascular resistance is increased to maintain adequate tissue perfusion
pressure.Sx-depressed mental status,dyspnea,decreased urinary output & cool extremities
Sepsis:compensatory increase in cardiac output/index in early stages of shock.Peripheral vasodilation
causes less blood to return to heart. PCWP & SVR are reduced
Septic shock: low PCWP & high mixed venous oxygen saturation(due inability of tissues to extract oxygen)
4237 Medicine Cardiovascular System Cardiogenic shock: due to left ventricular dysfunction & reduced pump function, low cardiac output, elevated
PCWP, increased SVR, low mixed venous oxygen saturation(decreased C.O. decreases tissue perfusion,
causing tissues to extract more oxygen from blood)
Tachycardia-mediated cardiomyopathy: can develop in pts who have persistent or recurrent
tachyarrhythmia w/ prolonged periods of rapid ventricular rate. Initial tx aimed at *restoration of sinus
rhythm or aggressive control of ventricular rate* & can lead to significant improvement in left ventricular
function
Chronic tachycardia causes structural changes in the heart including LV dilation & myocardial dysfunction
CHF due to left ventricular systolic dysfunction:
decreased cardiac output/index -> increased systemic vascular resistance (due to rise in neurohormonal
activation) which maintains bp & vital organ perfusion & increases blood volume -> increase in left
ventricular end diastolic volume (LVEDV)
Ashhadscknotes
Indicators for surgery/aortic valve replacement in pts w/ aortic stenosis are "SAD":
"Syncope", "Angina", & "Dyspnea." Onset of any of these three sx indicates that the prognosis w/o surgery
is poor
Aortic valvotomy is not nearly as effective as aortic valve replacement. It should only be considered as a
bridge to surgery in the hemodynamically unstable pt or for poor surgical candidates
Excessive alcohol intake(>2 drinks a day)or binge drinking(>5 drinks in a row)is ass. w/ increased incidence
of htn compared to nondrinkers.In such pts,reduction in alcohol intake leads to improved bp control
If medication for htn is absolutely necessary,calcium channel blockers are preferred over beta blockers
unless there are compelling indications for beta blocker use (eg heart failure, asymptomatic left ventricular
dysfunction,post MI, hyperthyroidism, a-fib rate control
Dual antiplatelet therapy (aspirin & a *P2y12 receptor blocker*[eg,clopidogrel]) leads to a reduction in
recurrent MI & cardiovascular death compared to aspirin alone in pts w/ non-ST elevation MI. It also
reduces risk of stent thrombosis & is rec in all pts for at least 12 months following drug-eluting stent
placement
Postinfarction pericarditis(pericardial rub,chest pain) can be tx w/ colchicine
Apixaban used for anticoag in nonvalvular afib & mgmt of DVT & PE
B-blockers, calcium channel blockers, & nitrates are antianginal agents that should be withheld for at least
4300 Medicine Cardiovascular System 48 hours prior to cardiac stress testing.
Pt may continue to use ace inhibitors, arbs, digoxin, statins, diuretics
Pts presenting to ED w/ chest pain & suspected ACS should be administered *aspirin* ASAP. Early
antiplatelet therapy w/ aspirin reduces the rate of MI & overall mortality in pts w/ ACS
Lorazepam is a benzodiazepine used for chest pain stemming from an acute panic attack
Cardiac tamponade:Beck's triad-hypotension,distended neck veins(internal jugular venous pulsation >3-4
cm ),& muffled heart sounds.This is due to shift of interventricular septum toward the left ventricular
4345 Medicine Cardiovascular System cavity,which *reduces left ventricular preload*,stroke volume,& cardiac output.Lung exam shows clear lungs
to auscultation due to decreased preload.Can be due to an infectious etiology(eg,a viral pericarditis due to
possible recent upper resp viral illness)
GERD is charac by a retrosternal burning sensation after eating & w/ lying down. It may also be
accompanied by hoarseness & chronic cough, esp while recumbent. The initial tx is an H2-receptor
4346 Medicine Cardiovascular System antagonist or a proton pump inhibitor
[Cardiac chest pain is more typically a squeezing or pressure sensation;NOT A BURNING ONE]
Orthostatic hypotension: drop in bp after standing & is preceded by a lightheaded or presyncopal sensation
Syncope due to aortic stenosis occurs w/ activity. Hx of exertional dyspnea, chest pain, fatigue
Vasovagal syncope: excessive vagal tone, nausea, diaphoresis,& pallor prior to syncope.Occurs due to
stress, pain, urination. Common in young women.
Hyperventilation: rare cause of syncope
TIA: syncope occurs if posterior circulation & brainstem is affected by TIA

Cardiac tamponade can occur as a catastrophic complication of acute aortic dissection, w/ rupture of the
aorta & *rapid accumulation of blood in the pericardial space*. It should be suspected in pts w/ hypotension,
tachycardia, distended neck veins, & pulsus paradoxus(respiratory variation in systolic blood pressure) who
have sudden onset of severe tearing chest pain radiating to the back
Electrical alternans w/ sinus tachycardia is a highly specific sign for large pericardial effusion. This is due to
the swinging motion of the heart in the pericardial cavity causing a beat-to-beat variation in QRS axis &
amplitude. Pts w/ cardiac tamponade & hemodynamic compromise should have emergency
*pericardiocentesis*
Diagnostic testing for coronary artery disease (CAD) shouldn't be performed routinely in low risk patients as
they frequently can have false positive test results.
Pts w/ intermediate probability of CAD should receive appropriate stress testing based on ECG findings and
their ability to exercise
High risk pts sohuld be started on appropriate medical therapy w/ expert evaluation to consider coronary
angiography
Peptic ulcer perforation presents w/ acute abdominal pain w/ radiation to the back or right shoulder & signs
4396 Medicine Cardiovascular System of peritonitis. Upright chest radiograph may reveal pneumoperitoneum(gas within peritoneal cavity) w/ free
air under the diaphragm
Ashhadscknotes
IV drug users are at increased risk for bacterial endocarditis inolving the right sided heart valves. *Tricuspid
regurgitation* is commonly present in pts w/ tricuspid valve endocarditis(intensity of this murmur increases
w/ *inspiration*)
S4: normal in healthy older adults but abnormal in children/young adults
Paradoxical/reversed splitting: A2 follows P2, w/ maximal splitting noted during expiration. Seen in pts w/
fixed left ventricular outflow tract obstruction
URI,dyspnea,elevated JVP,increased cardiac silhouette suggests early cardiac tamponade due to large
pericardial effusion.*Inability to palpate point of maximal apical impulse* is consistent w/ large pericardial
effusion(appears on CXR as enlarged & globular cardiac silhouette "water bottle" heart shape w/ clear lung
fields)
Viral myocarditis:audible S3,pulm vascular congestion,bibasilar rales
Pulsus bisferiens:2 systolic peaks of aortic pulse separated by midsystolic dip

PSVT: re-entry into the *AV node*
tx- mechanical & medical therapies that decrease AV node conductivity eg. *immersion in cold water*,
valsalva, carotid sinus massage.
Adenosine is a short acting AV nodal blocker that is used as well.
Acute decompensated heart failure(ADHF): can cause acute pulmonary edema(dyspnea, orthopnea,
paroxysmal nocturnal dyspnea, bibasilar crackles, hypoxemia). Can be caused by uncontrolled htn. Manage
w/ supplemental oxygen & iv loop diuretics(eg, furosemide). Remember "Not all that wheezes is asthma"
Amiodarone: antiarrhythmic agent,

ass. w/ hepatotoxicity, hypothyroid sx such as fatigue, memory loss, constipation, weight gain, dry skin,.
Digoxin is a cardiac glycoside w/ adverse effects that include nausea, vomiting, diarrhea, vision changes, &
4454 Medicine Cardiovascular System arrhythmias. Pts chronically taking digoxin should have close & routine monitoring of their *blood digoxin
levels*
Aortic stenosis: typical sx are *exertional dyspnea*, syncope, & angina. Physical exam reveals a systolic
ejection murmur radiating to the apex & carotid arteries
4455 Medicine Cardiovascular System Capillary pulsations in the fingers & lips may be observed in aortic regurgitation
Late diastolic murmurs are heard most commonly in mitral stenosis. An opening snap is also characteristic
of mitral stenosis. Pts present w/ pulmonary edema & atrial fibrillation
Prolonged PR interval & intraventricular conduction delay(prolonged QRS duration) is suggestive of
*bradyarrhythmia* or high grade atrioventricular block and can lead to *syncopal episodes*
Torsades de pointes is due to polymorphic ventricular tachycardia in the setting of a prolonged QT interval
Arteriovenous fistula(eg,an AV fistula that develops due to stab wound to thigh) causes high output cardiac
failure by shunting the blood from the arterial to venous side, thereby *increasing cardiac preload*. The pt
develops heart failure despite maintaining a normal or high cardiac output because the circulation is unable
to meet the oxygen demand of the peripheral tissues
Digoxin toxicity: *Amiodarone*(or verapamil, quinidine, & propafenone) can increase serum levels of digoxin
& cause toxicity in a pt on a stable digoxin regimen. It's rec that digoxin dose be decreased by 25%-50%
4463 Medicine Cardiovascular System when initiating amiodarone therapy, w/ close monitoring of digoxin levels once weekly for several weeks.
Sx-LIFE THREATENING ARRHYTHMIAS, *anorexia*, *nausea/vomiting*, ab pain, fatigue, confusion,
*weakness*, COLOR VISION ALTERATIONS
Warfarin or target specific oral anticoagulants(rivaroxaban,apixaban,dabigatran) should be used to reduce
risk of systemic thromboembolism in pts w/ A-fib & moderate to high risk of thromboembolic
events(CHA2DS2-VASc score >2).
*Pts w/ "lone A-fib"(pts w/ paroxysmal,persistent,or permanent A-fib w/ no evidence of cardiopulmonary or
structural heart disease,age<60,score of 0) are at low risk of systemic embolization & anticoagulant tx is
NOT indicated*
*Acetaminophen*, NSAIDs, amiodarone, & abx may *potentiate the anticoagulant effects of warfarin*, lead
to varibale dose response, &/or *increase the risk of bleeding*
Marfan syndrome:Aortic dissection is most dangerous complication! Aortic regurgitation is a complication of
aortic dissection & presents w/ an *early diastolic mumur*
Wide & fixed splitting of second heart sound present in pts w/ ASD. Holt-Oram (heart-hand) syndrome is
4484 Medicine Cardiovascular System ass. w/ both upper-limb defects(eg,deformities of radius, carpal bones) & atrial septal defect
Mitral valve prolapse frequently seen in Marfan syndrome
Pulsus parvus et tardus seen in severe aortic stenosis

Elevated *brain natriuretic peptide* levels & an audible *3rd heart sound* are signs of increased cardiac
filling pressures & are noted in pts w/ CHF due to left ventricular systolic dysfunction
An abdominal or periumbilical bruit that lateralizes to one side can be heard in pts w/ renal artery stenosis
Ashhadscknotes
Survivors of Hodgkin lymphoma are at increased risk for cardiac disease, presenting 10-20 years after
mediastinal irradiation. Constrictive pericarditis is a complication of mediastinal irradiation and a cause of
4524 Medicine Cardiovascular System right heart failure. Look for sx of peripheral edema, elevated jvp, hepatomegally, ascites, hepatojugular
reflux, kussmaul's sign (lack of decrease or increase in jugular venous pressure on inspiration), & a
pericardial knock (mid-diastolic sound).
Screen male active or former smokers aged 65-75 years w/ a one-time *abdominal ultrasound* to evaluate
for an abdominal aortic aneurysm
Chronic venous insufficiency is a common cause of peripheral edema & should be suspected in pts w
4592 Medicine Cardiovascular System isolated lower-extremity edema &/or dilated veins w/ otherwise normal physical examination. Initial tx
includes conservative measures w/ *leg elevation*, exercise, & compression therapy
Cor pulmonale: impaired function of the right ventricle due to pulmonary hypertension that usually ocurs due
to chronic lung disease(COPD most common etiology)
COPD w/ cor pulmonale sx- Elevated jvp, enlarged liver, long term tobacco use, chronic cough,
barrel-shaped chest
In pts w/ CHF, activation of RAAS & production of angiotensin II causes preferential vasoconstriction of
efferent renal arterioles,which increases intraglomerular pressure in order to maintain adequate GFR
Vasoconstriction of both afferent & efferent glomerular arterioles->increase in renal vascular resistance &
net decrease in renal blood flow
Decreased plasma colloid pressure -> peripheral/generalized edema in pts w/ severe

proteinuria/hypoalbuminemia
*Weight control* is the most effective intervention to control blood pressure in overweight pts. Other
4646 Medicine Cardiovascular System effective measures include the DASH diet, low sodium intake, moderation of alcohol intake, regular
moderate exercise, & smoking cessation
Tx of systemic embolization in pts w/ nonvalvular atrial fibrillation(AF):antithrombotic therapy w/ warfarin(or
anticoagulants like dabigatran,rivaroxaban,& apixaban).[aspirin less effective than warfarin but can be used
as an alternative in pts w/ high risk of bleeding w/ anticoagulant tx.Combo of aspirin/clopidogrel better than
aspirin alone]
Amiodarone used for conversion & maintenance of sinus rhythm in pts w/ AF
Diltiazem/metoprolol for HR control in pts w/ rapid AF

Costochondritis: pain syndrome characterized by tenderness of the costochondral or costosternal junctions.
Chest pain that is reproducible w/ palpation suggests a musculoskeletal etiology
Impaired SA node automaticity leads to sick sinus syndrome, which is often due to degeneration &/or
fibrosis of SA node & surrounding atrial myocardium.
Sx-fatigue,lightheadedness,palpitations,presyncope,syncope. ECG shows bradycardia, sinus pauses/arrest,
SA exit block, or alternating bradycardia & atrial tachyarrhythmias (tachycardia-bradycardia syndrome)
Syncope in young pt w/ crescendo-decrescendo murmur at lower left sternal border is due to hypertrophic
obstructive cardiomyopathy (HOCM) "interventricular septal hypertrophy". Syncope in HOCM is often
multifactorial & can be due to outflow obstruction, arrhythmia, ischemia, & a ventricular baroreceptor
response that inappropriately causes vasodilation
aortic stenosis: murmur at right 2nd intercostal space w/ right carotid radiation
Mitral regurgitation: holosystolic murmur

Atrial fibrillation: irregularly irregular rhythm w/ varying R-R intervals, no clearly discernible P waves, &
narrow complex tachycadia(google ecg). Can be asymptomatic or present w/ palpitations, weakness,
4676 Medicine Cardiovascular System dizziness, presyncope, dyspnea, & chest pain. *Hyperthyroidism* is the most common cause of sudden
onset AF. Pts w/ new onset AF should have TSH and free T4 levels measured to screen for occult
hyperthyroidism as an underlying cause.
An abnormal *fourth heart sound (atrial gallop)* can often be heard during the acute phase of MI(vignette
4679 Medicine Cardiovascular System will mention MI sx like substernal discomfort, left sided neck pain, diaphoresis, dyspnea) due to left
ventricular stiffening & dysfunction induced by myocardial ischemia
Dx of autosomal dominant polycystic kidney disease (ADPKD) is based mainly on *abdominal ultrasound*
ADPKD-hypertension(common early finding),palpable abdominal masses(usually bilateral).

4680 Medicine Cardiovascular System [ACE inhibitors preferred for HTN ass w/ ADPKD]
Captopril radionuclide renal scan occasionally used to dx suspected renovascular disease or renal artery
stenosis as a cause of refractory htn
The net result of renin-angiotensin-aldosterone system (RAAS) activation is increased blood pressure, total
body sodium & water, & blood volume. As a result, any drug that blocks the effect of angiotensin II or
aldosterone enhances natriuresis.
Direct renin inhibitors (eg aliskiren) increase natriuresis, decrease serum angiotensin II concentration, and
decreases aldosterone production
Ashhadscknotes
Presence of a systolic-diastolic abdominal bruit in a pt w/ HTN & atherosclerosis is strongly suggestive of
renal artery stenosis
Abdominal aortic aneurysms seen in older men w/ atherosclerosis & smoking hx. Pulsatile abdominal mass.
Systolic bruit may be heard, but a systolic-diastolic bruit would be rare
Aortoenteric fistulas are rare causes of massive GI hemorrhage. May be primary or secondary(due to
surgery). Causes hypotension
Heart failure due to diastolic dysfunction: also called heart failure w/ preserved left ventricular ejection
fraction.*Systemic hypertension is a classic cause of diastolic dysfunction*. In severe cases, diastolic
dysfunction can cause decompensated heart failure. Tx- diuretics & BP control
High-output heart failure: supranormal ventricular function that can't meet body's metabolic demands.
Causes include anemia, hyperthyroidism, beriberi, Paget's disease, & av fistulas
*Pts w/ persistent tachyarrhythmia (narrow- or wide-complex) causing hemodynamic instability should be
managed w/ immediate synchronized DC cardioversion*. Pts who have minimal sx & remain
hemodynamically stable during an episode of regular, narrow-complex supraventricular tachycardia can be
managed initially w/ a trial of vagal maneuvers(eg, carotid sinus massage) and/or iv adenosine
ACLS guidelines recommend epinephrine only in pts w/ asystole, pulseless electrical activity, or refractory
ventricular arrhythmias unresponsive to defibrillation
Acute myocardial ischemia or infarction is leading cause of sudden cardiac arrest due to ventricular
tachycardia/fibrillation
Aortic dissection sequelae include *cardiac tamponade*, acute aortic regurgitation, stroke, & renal failure
Tension pneumothorax: chest pain, shortness of breath, & hypotension. Physical exam-absent breath
sounds in one hemithorax & a deviated trachea
Hyperparathyroidism: uncommon cause of secondary hypertension*
suspect in pts w/ hypertension, hypercalcemia, recurrent renal stones, muscle weakness & neuropsychiatric
sx
"bones, stones, abdominal moans, & psychic groans"
Majority of cases are due to parathyroid adenoma
Renal artery stenosis/Renovascular disease: severe htn after age 55, abdominal bruit, recurrent flash
pulmonary edema or resistant heart failure, elevated creatinine
[Pulseless electrical activity(PEA) is the presence of organized rhythm on cardiac monitoring w/o
measurable BP or palpable pulse in a cardiac arrest pt]
PEA/asystole should be managed w/ uninterrupted cardiopulmonary resuscitation(CPR/*chest
compressions*) along w/ vasopressor therapy to maintain adequate cerebral & coronary
perfusion.Reversible causes of PEA should also be investigated.Defibrillation or synchronized cardioversion
has no role in mgmt of these pts
Progressively *decreasing baroreceptor sensitivity* & defects in the myocardial response to this reflex are
4728 Medicine Cardiovascular System the main reasons for the increased incidence of orthostatic hypotension(postural decrease in bp by 20
mmHg systolic or 10 mmHg diastolic) in the elderly
*Main risk factors ass. w/ AAA expansion & rupture include 1) large diameter 2) rate of expansion 3) current
cigarette smoking*
[hypertension has a weak ass. w/ AAA formation & it's rate of expansion & rupture]
For unclear reasons, risk of AAA in pts w/ diabetes is lower than in those w/o diabetes
Sudden onset of chest pain, ST segment elevation, holosystolic murmur at apex, & bibasilar crackles is
consistent w/ acute inferior myocardial infarction (MI) w/ papillary muscle displacement, leading to acute
mitral regurgitation (MR) & pulmonary edema. It leads to abrupt & excessive volume overload, causing
*elevated left atrial & ventricular filling pressures* & acute pulmonary edema
The primary anti-ischemic & antianginal effects of NITRATES are due to systemic vasodilation rather than
coronary vasodilation. Systemic venodilation *LOWERS preload & left ventricular end-diastolic volume*,
reducing wall stress & myocardial oxygen demand
Systemic arterial dilation causes a decrease in afterload
[In contast, an increase in preload &/or afterload will cause an increase in wall stress w/ increased
myocardial oxygen demand & worsening angina]
Aspirin and beta blockers(esp. nonselective beta blockers) can trigger bronchoconstriction in pts w/ asthma.
acute onset dyspnea w/ wheezing and prolonged expiration indicates bronchoconstriction.

hx of rhinitis and eczema along w/ current intermittent dyspnea and coughing suggest asthma that is
exacerbated by aspirin or beta blocker therapy.
aspirin is common trigger for bronchoconstriction in asthmatics, esp those w/ chronic rhinitis & nasal polyps
Ashhadscknotes
Pulsus paradoxus: exaggerated fall in systemic blood pressure >10 mm Hg during inspiration. Frequent
4771 Medicine Cardiovascular System finding in cardiac tamponade but can also occur in conditions w/o pericardial effusion such as severe
*ASTHMA*, or COPD
Wolff-Parkinson-White (WPW) syndrome: *accessory pathway between the atrium & ventricle* resulting in
4894 Medicine Cardiovascular System preexcitation & an increased risk for tachyarrhythmias. Shortened PR interval, slurred initial portion of
QRS(delta wave), widened QRS complex
"ken-tuc-KY"-third syllable corresponds to S3.
The third heart sound (S3) is a low frequency diastolic sound heard just after S2 that is ass. w/ left
4908 Medicine Cardiovascular System ventricular failure. IV *diuretics* provide symptomatic benefits to pts w/ decompensated heart failure
[Although pts w/ heart failure will benefit from b-blockers in the long term, they are not as effective as
diuretics at providing symptomatic benefits in the short term]
Know what fourth heart sound (S4) sounds like![TEN-nes-see]
S4 is a low frequency sound heard at the end of diastole just before S1 that is commonly ass. w/ left
ventricular hypertrophy from *prolonged hypertension* (S4 corresponds w/ atrial contraction,results from the
sound of blood striking a stiffened left ventricle)
Miral valve prolapse: midsystolic click & late systolic murmur heard over cardiac apex
Pericardial effusions ass. w/ acute pericarditis

Aortic regurgitation: early diastolic mumur, bounding/water hammer peripheral pulse
Aortic stenosis: ass. w/ pulsus parvus (decreased pulse amplitude) & pulsus tardus (delayed pulse upstroke)
Mitral regurgitation: holosystolic murmur heard best at the apex w/ radiation to the axilla, exertional
dyspnea, fatigue, atrial fibrillation, & signs of heart failure
Ascending aortic aneurysm ass. w/ aortic regurgitation, which would result in a diastolic murmur
Tricuspid stenosis: Mcc is rheumatic heart disease
Constrictive pericarditis: signs of fluid overload, pulsatile hepatomegaly, exertional dyspnea, elevated jvp
SVT:
sx-palpitations,dizziness,lightheadedness, shortness of breath, diaphoresis, chest pain, syncope
ECG-narrow QRS complex tachycardia(P wave buried within or seen after QRS)
tx-adenosine
Panic attacks:
4920 Medicine Cardiovascular System sx- sinus tachycardia w/ normal P wave morphology and relationship with the QRS complex
tx- alprazolam
Amiodarone/lidocaine used in treatment of stable pts w/ wide QRS complex tachycardia (ventricular
tachycardia)
Amiodarone also used in atrial fibrillation
Use dependence refers to enhanced pharmacologic effects of a drug during faster heart rates & is seen w/
class I (especially IC) & class IV (calcium channel blockers) antiarrhythmic agents. Class IC agents
(eg,*Flecainide* & propafenone) cause a progressive decrease in impulse conduction w/ faster heart rates,
leading to an *increase in the QRS complex duration*
A supervised graded exercise program is the most useful intervention to improve functional capacity &
reduce symptomatic claudication in pts w/ peripheral arterial disease. Antiplatelet agents (eg, aspirin,
clopidogrel) reduce overall cardiovascular mortality. Lipid-lowering therapy w/ statins should also be given to
all pts w/ clinically significant atherosclerotic cardiovascular disease
Atrial fibrillation is caused by ectopic foci within the *pulmonary veins*
Atrial flutter involves a reentrant circuit around the tricuspid annulus
8472 Medicine Cardiovascular System Atrioventricular nodal reentry tachycardia results from a reentrant circuit formed by 2 separate conducting
pathways(one fast & the other slow) within AV node
Atrioventricular reentrant tachycardia is due to a reentrant circuit involving an accessory atrioventricular

bypass tract
All pts (esp young individuals) w/ systemic hypertension should be evaluated for the presence of coarctation
of the aorta w/ *simultaneous palpation of the brachial & femoral pulses* to assess for brachial-femoral delay
8819 Medicine Cardiovascular System [Late presentation of aortic coarctation can include sx such as symptomatic hypertension w/ headaches,
epistaxis, & left ventricular hypertrophy on ECG(increased/high voltage of QRS complexes & ST & T wave
changes in the left precordial leads)]
Development of av block in pt w/ infective endocarditis should raise suspicion for perivalvular abscess
extending into adjacent cardiac conduction tissues
Cardiovascular disease is the major cause of morbidity & mortality in pts w/ peripheral artery disease (PAD).
8927 Medicine Cardiovascular System Pts w/ PAD & intermittent claudication have an estimated 20% 5-year risk of nonfatal MI & stroke & a
15%-30% risk of death due to cardiovascular causes
Ashhadscknotes
An *Exercise program* should be recommended as initial tx for pts w/ intermittent claudication.
8928 Medicine Cardiovascular System Use cilostazol & percutaneous or surgical revascularization only for pts w/ persistent sx despite exercise
therapy
Single photon emission CT scan useful for evaluating for CAD.Decreased tracer uptake w/ stress but normal
uptake at rest is considered a reversible defect.It indicates inducible ischemia & likely CAD.Tx w/
antiplatelets for prevention of mi,b-blockers,& modification of pts risk factors
Normal tracer uptake at rest & exercise -> excellent prognosis w/ <1% risk of CAD
Decreased tracer uptake at rest & exercise (fixed defect)->indicates scar tissue w/ decreased perfusion &
CAD
*Peripheral edema is a common side effect of dihydropyridine calcium channel blockers (CCBs) eg,
10179 Medicine Cardiovascular System Amlodipine.* Addition of a renin-angiotensin system antagonist (ACE inhibitor or angiotensin receptor
blocker) can reduce CCB ass. peripheral edema
Cyanide toxicity occurs in pts treated w/ nitroprusside who receive prolonged infusions, higher doses, or
have underlying renal insufficiency. It presents w/ altered mental status, lactic acidosis, seizures, & coma
Alcohol withdrawal/seizures peaks during the second day following cessation. If pt gets seizures after 4 days
of discontinuing alcohol, its probably not due to alcohol withdrawal
Constrictive pericarditis:
results from thickened/calcified pericardium that limits diastolic filling, causes sx of right heart failure, normal
ventricular size
sx- progressive peripheral edema, ascites, elevated jvp, pericardial knock (middiastolic sound), & pericardial
calcifications on chest radiograph
Cardiac amyloidosis: Increased ventricular wall thickness w/ normal/nondilated left ventricular cavity, heavy
proteinuria, periorbital purpura, & hepatomegaly
HTN & AKI in the setting of systemic sclerosis suggests scleroderma renal crisis(SRC).SRC occurs within
first 5 years of diffuse cutaneous systemic sclerosis dx.SRC presents w/ acute renal failure,malignant
htn(headache,blurry vision,nausea).UA may show mild proteinuria.Peripheral blood smear shows
microangiopathic hemolytic anemia w/ fragmented rbcs(*schistocytes*) & thrombocytopenia
Spur cells(acanthocytes):RBCs w irregularly sized/spaced projections seen in liver disease

Chest/neck pain,syncope,hx of HTN & evidence of mediastinal widening(know how it looks on xray!) are all
suggestive of acute aortic dissection.Acute type A aortic dissection can extend into pericardial
space,causing hemopericardium & rapidly progressing to cardiac tamponade & cardiogenic shock.*Bedside
11104 Medicine Cardiovascular System transesophageal echocardiogram* for rapid dx & early tx
Emergency pericardiocentesis for pt w/ pericardial effusion & tamponade w/ HEMODYNAMIC INSTABILITY

or cardiogenic shock
GI/Esophageal causes of chest pain: recurrent episodes of chest pain not ass. w/ activity. Normal physical
exam, ECG, & exercise stress test.
Pulmonary hypertension(PH) due to left ventricular systolic or diastolic dysfunction:Tx w/ loop diuretics &
ACE inhibitors(or angiotensin II receptor blockers)
PH due to hypoxemia from chronic lung disease:Tx w/ oxygen and/or bronchodilator therapy
Symptomatic idiopathic PH:Tx w/ endothelian receptor antagonists(bosentan),phosphodiesterase-5
inhibitors(sildenafil),and/or prostanoids(epoprostenol)
PH from thromboembolic occlusion of pulm. vasculature:Tx-anticoagulation
Nodular basal cell carcinoma(BCC) on the face or cosmetically sensitive areas(perioral

region,nose,lips,ears):
2603 Medicine Dermatology Tx w/ Mohs micrographic surgery! Involves sequential removal of thin skin layers w/ microscopic inspection
to confirm that the margins have been cleared of malignant tissue. This technique has highest cure rate for
BCC
A nonhealing, painless, bleeding skin ulcer ass. w/ a chronic scar suggests squamous cell carcinoma(SCC).
SCC arising within a scar or chronic wound carries an increased risk of metastasis. Dx should be confimed
2604 Medicine Dermatology w/ *biopsy*. For small or low-risk lesions, manage w/ surgical excision or local
destruction(cryotherapy,electrodessication). Mohs micrographic surgery used for lesions that are high risk
or located in cosmetically sensitive areas
Tinea corporis: ring-shaped scaly patches w/ central clearing & distinct borders. Trichophyton rubrum is the
2746 Medicine Dermatology
most frequent culprit.
Tinea versicolor: hypopigmented areas that do not tan, & hyperpigmentation or salmon-color changes.
Tx-selenium sulfide or ketoconazole
Vitiligo: total depigmentation esp around the mouth or on fingertips

Seborrheic dermatitis:acute or chronic papulosquamous dermatitis characterized by dry scales & an
underlying erythema. Scalp, central face, presternal, interscapular area, umbilicus, & body folds are the
most commonly involved areas. Pigmentation changes not seen
Ashhadscknotes
Scabies:Sarcoptes scabiei mite.Intensely pruritic rash in flexor surfaces of wrist,lateral surfaces of fingers,&
finger webs.Pts have excoriations w/ small,crusted,red papules scattered around affectd areas
Dx-skin scrapings from excoriated lesions
2750 Medicine Dermatology Tx in adults-Topical permethrin 5% cream or oral ivermectin
Bed bugs:painless bites,pts develop pruritus & purpuric macules,bites appear as papules in clusters of 2 or
3 over exposed areas
Bullous pemphigoid(BP):IgG & C3 deposits atdermal-epidermal junction(basement membrane zone)
Pemphigus:antibodies target desmogleins.Keratinocyte surface-bound IgG throughout epidermis
2751 Medicine Dermatology Linear IgA bullous dermatosis:Linear IgA deposits at dermal-epidermal junction.AKA chronic bullous disease
of childhood when it occurs in pediatric setting
Intraepidermal blisters & erosions w/ multinucleated giant cells w/ molded steel-gray nuclei seen on biopsy
of HSV & VZV vesicles
Ichthyosis vulgaris:
aka "lizard skin"
2754 Medicine Dermatology sx- dry, rough skin w/ horny plates over extensor surfaces of limbs
history of normal skin at birth w/ gradual progression to dry scaly skin
condition worsens during winter months
Seborrheic dermatitis:
affects scalp (dandruff), face (eyebrows, nasolabial folds, external ear canal/posterior ear), chest, &
2755 Medicine Dermatology intertriginious areas
characterized by fine, loose, yellow, & greasy looking scales
tx- topical antifungal agents
Molluscum contagiosum:caused by a poxvirus.Small pink/skin colored papules w/ central umbilication.Can
occur anywhere except palms & soles.Can occur in linear pattern.Lesions can be either asymptomatic or
2761 Medicine Dermatology pruritic & can occasionally be accompanied by surrounding dermatitis.It's usually minor & self limited in
healthy pts.It may cause a more widespread & prolonged illness in immunocompromised pts,esp those w/
HIV & a CD4 count <100/uL
Rosacea: chronic inflammatory disorder, flushing, erythemia, telangiectasias, papules/pustules,& tissue
hyperplasia. Most often involves the central face & scalp
Sebaceous hyperplasia: small pale/yellow papules at central face. Lesions are stable in size & appearance
Sudden onset of multiple seborrheic keratoses may indicate an occult internal malignancy (Leser-Trelat sign)
Squamous cell carcinoma: much less common & faster growing than BCC. Arises from actinic keratosis
Seborrheic keratosis:more common w/ advancing age(stem may mention an eldery 80 y/o pt w/ a lesion
thats been present for a while & gradually darkened). Tends to favor the face & trunk. Lesions don't occur
on the palms & soles. Waxy/greasy, "stuck on", warty, & well-circumscribed appearance
Melanoma doesn't have "stuck-on", warty appearance. Hx of changing mole, blurring of borders, &
asymmetry are characteristic
Melanoma:pts complain of mole that changed in size or color or became pruritic,painful,or bleeding.Risk
factors-fair skin,hx of blistering sunburns,family hx of melanoma,dysplastic nevus syndrome,atypical nevi &
greater than 100 typical nevi
2765 Medicine Dermatology Blue nevi:blue,smooth,dome shaped melanocytic papules,develop from macules,< 1cm diameter
Melanocytic nevi:benign lesions in integument
Lentigo simplex:round macule,even pigmentation,due to intraepidermal melanocyte hyperplasia

2767 Medicine Dermatology *Excisional biopsy* w/ narrow margins is the preferred study for the dx of melanoma
Tetracyclines: imp cause of *phototoxic* drug eruptions(*Doxycycline is the most photosensitizing*).
Manifest as exaggerated sunburn reactions w/ erythema, edema & vesicles over sun-exposed areas
Photoallergic contact dermatitis can be caused by certain sunscreens,more eczematous,prior sensitization

required
Erythromycin can cause GI upset & cholestatic jaundice
Stevens Johnson syndrome: caused by drugs like TMP-SMX, NSAIDs, anticonvulsants.Mucosal surfaces
always involved
Warfarin-induced skin necrosis:pain,followed by bullae formation & skin necrosis.Breasts,butt,thighs &
abdomen commonly involved
Pyoderma gangrenosum:ulcerative skin lesion.Initial lesion described as bite like reaction w/ small papule or
pustule.Pain is main complaint. Malaise & arthralgia may also be present
Cholesterol embolization syndrome:Pt who develops worsening renal function,htn,or distal ischemia
following invasive arterial procedure. Livedo reticularis seen
Ashhadscknotes
Dermatitis herpetiformis (DH) Tx: gluten-free diet & *dapsone*
DH commonly ass. w/ gluten-sensitive enteropathy(celiac disease)
Pemphigus vulgaris: mucocutaneous blistering disease(often lesions first appear in oral mucous
membrane), flaccid bullae, *intercellular IgG deposits in the epidermis*. Autoantibodies formed against
desmoglein
2775 Medicine Dermatology Bullous pemphigoid:Oral lesions are very rare. Immunofluorescence microscopy shows IgG & C3 deposits
in the dermal epidermal junction
Dermatitis herpetiformis:IgA deposits along dermal papillae,circulating anti-endomysial antibodies, ass

gluten-sensitive enteropathy
Rosacea: suspect in 30-60 y/o pts w/ telangiectasia over cheeks, nose, & chin. Flushing of these areas is
precipitated by hot drinks, heat, emotion, & other causes of rapid body temperature changes. Topical abx
like metronidazole is the most frequently prescribed initial therapy
Flushing in rosacea lasts longer than flushing of carcinoid syndrome(20-30 sec)
SLE facial rash similar to rosacea facial rash but has no papules & pustules
Exfoliative dermatitis(aka erythroderma):widespread,scaly eruption of skin.May be
drug-induced,idiopathic,or secondary to an underlying dermatological or systemic disease
Staphylococcal scalded skin syndrome:syndrome of acute exfoliation of skin caused by a toxin that is
produced by S. aureus.The skin is tender & warm,w/ a sandpaper-like,diffuse erythematous rash.Other
features include bullae,+ Nikolsky's sign,facial edema,perioral crusting & dehydration.Children < 6 years
Vitiligo:
caused by autoimmune destruction of melanocytes
affects acral areas and around body orifices "pale white patches distributed symmetrically around pt's mouth
and similar lesions found over areola of pt's breasts"
Piebaldism:
inherited absence of melanocytes.
noticed at birth and confined to head and trunk
< 10% of body surface area- Stevens Johnson syndrome
10%-30% of BSA: SJS/TEN overlap
>30% of BSA: Toxic epidermal necrolysis
Erythema multiforme:
sx- target lesions, occurs after a herpes simplex infection
may appear similar to mild SJS but bullae and desquamation are less common & mucosal involvement is
rare and systemic sx not as prominent as SJS.
Cellulitis:
infection of the skin & subcutaneous tissue
3080 Medicine Dermatology risk factors- obesity, venous insufficiency, & skin disruption
sx- erythema, edema, & warmth, fever, lymphanditis, & regional lymphadenopathy.
Group A Streptococcus is mcc of non-purulent cellulitis. Staphylococci mcc of purulent cellulitis.
3811 Medicine Dermatology Poison ivy & *nickel* jewelry can cause allergic contact dermatitis, which is a type IV hypersensitivity reaction
Condylomata acuminata(anogenital warts):Serotypes 16 & 18 ass. w/ squamous cell carcinoma of the
anus,genital organs & throat.Tx-Chemical or physical agents(trichloroacetic acid, podophyllin), immune
therapy(imiquimod), surgery(cryosurgery,excision,laser tx)
HPV ass. w/ increased risk for other STD's esp HIV
Condyloma lata:manifestation of secondary syphilis,flattened pink/gray velvety papules,seen commonly at

mucous membranes & moist skin of genital organs,perineum,mouth
Herpetic whitlow: caused by either type 1 or 2 herpes simplex virus. Health care workers who come in direct
contact w/ infected orotracheal secretions are at increased risk of developing it. Multinucleated giant cells in
the Tzanck smear of pt's lesion. [EXTREMELY H.Y. FOR USMLE!!!]
Tailors can develop felon due to needle injuries. Felon is a bacterial infection of the distal volar space,
characterized by a tense abscess & intense throbbing pain. Tx-I&D w/ appropriate abx
Squamous cell carcinoma:
"non healing ulcer on forearm, scaling plaque w/ central ulceration & 1.5 cm in diameter, biopsy showing
polygonal cells w/ atypical nuclei at all levels of epidermis w/ zones of keratinization."
The single most imp risk factor for its development is exposure to sunlight!
Ashhadscknotes
Noninflammatory (comedonal) acne tx:
topical retinoids
Inflammatory acne tx:

4076 Medicine Dermatology topical retinoids & benzoyl peroxide
Moderate/moderate-to-severe inflammatory acne: addition of topical antibiotics
Severe/recalcitrant acne: oral antibiotics & isotretinoin

Inflammatory acne is tx w/ topical retinoids & benzoyl peroxide.Moderate & moderate-to-severe cases will
benefit from the addition of topical abx.Oral abx & isotretinoin reseved for severe or recalcitrant acne
Graft-versus-host disease (GVHD): common after bone marrow transplantation, up to 50% of pts w/ bone
4151 Medicine Dermatology marrow transplantation from matched siblings develop disease. Pathophys-recognition of host major &
minor HLA-antigens by *donor T-cells* & consequent cell-mediated immune response
Drug induced type 1 hypersensitivity reactions:immediate onset,mediated by IgE & mast
cells/basophils.Urticaria/pruritus w/o systemic sx usually tx w/ *antihistamines* & discontinuation of
drug.Most commonly implicated in type 1 reactions are beta lactam drugs(amoxicillin),neuromuscular
4267 Medicine Dermatology blocking agents,quinolones,platinum containing chemotherapeutic agents & foreign proteins(chimeric
antibodies)
Rash in Infec Mono pts develops 24 hours after amoxicillin/abx intake

Vitiligo is sometimes ass w/ other autoimmune conditions such as pernicious anemia, autoimmune thyroid
disease, type 1 diabetes mellitus, primary adrenal insufficiency, hypopituitarism, & alopecia areata
Keratoacanthoma: dome shaped nodule and central keratinous plug. Generally benign.
Porphyria cutanea tarda: painless blisters, hypertrichosis, & hyperpigmentation. Ass. w/ Hepatitis C
infection, & can be triggered by ingestion of certain substances(ethanol,estrogens), which should be
discontinued once suspected. Phlebotomy or hydroxychloroquine may provide relief, as can
interferon-alpha, in pts simultaneously infected w/ Hepatitis C virus
Squamous cell carcinoma: nonhealing ulcer in vermillion zone of lower lip w/ significant hx of sun exposure,
keratin pearls.
Basal cell carcinoma: clusters of spindle cells surrounded by palisaded basal cells. This cancer is rarely
found on lips & never found on lower lip!
Senile purpura: presents w/ ecchymoses in elderly pts in areas exposed to repeated minor trauma (eg,
extensor surfaces of the hands & forearms) It's due to age-related *loss of elastic fibers in perivascular
connective tissue*/*perivascular connective tissue atrophy*. Not dangerous, requires no further evaluation.
Lupus anticoagulant: an IgM or IgG immunoglobulin that prolongs the aPTT. It's not a physiologic
anticoagulant but actually increases the risk of thrombosis.
Cherry hemangiomas:small,red,cutaneous papules common in aging adults.They don't regress
spontaneously.Benign & don't require tx
Spider angiomas:Estrogen dependent & commonly seen in pregnancy,oral contraceptive use,& cirrhosis
related hyperestrogenemia
Cavernous hemangiomas:consist of dilated vascular spaces w/ thin-walled endothelial cells.Soft blue

compressible masses growing up to a few cm. May appear on skin,mucosa,deep tissues,viscera
Actinic keratoses: develops on chronically sun-exposed areas of skin, erythematous papules w/ central
scale & "sandpaper-like" texture. Can convert to squamous cell carcinoma in 1% of cases
4410 Medicine Dermatology Atopic dermatitis: type 1 (immediate) hypersensitivity reaction. Acute subtype has pruritic papules, vesicles
& plaques. Light microscopy shows spongiosis (edema of the epidermis)
Pityriasis rosea: pink/brown scaly plaque, herald patch, maculopapular rash in "Christmas tree" pattern
Pressure ulcers: locations include sacrum, heels, elbows, & ears
Diabetic foot ulcers: common on soles of the feet over the metatarsal heads & the top of the toes
Ashhadscknotes
Molluscum contagiosum: Pts w/ *impaired cellular immunity* (eg HIV) are at risk for more severe,
widespread disease
Hypersensitivity rashes due to circulating autoantibodies: Type II rashes manifest as blisters or

4685 Medicine Dermatology bullae(pemphigus vulgaris,bullous pemphigoid). Type III rashes are erythematous & maculopapular
C3 deficiency predisposes to pyogenic bacterial respiratory tract/sinus infections
Selective IgA deficiency: recurrent respiratory infections & chronic giardiasis

Mupirocin: topical antibiotic, treats superficial skin infections (eg. impetigo) & eradicates MRSA from nares
Topical 5-fluorouracil treats skin conditions caused by rapid cell division such as actinic keratoses &
superficial basal cell carcinomas
Allergic contact dermatitis: "intensely pruritic erythematous rash w/ vesicles at site of exposure." Pt can
even get this from poison sumac while cutting firewood
Steroid induced folliculitis/steroid acne: eg, secondary to pt taking prednisone for their SLE. Steroid acne is
4812 Medicine Dermatology characterized by monomorphous pink papules & absence of comedones. Erythematous follicular papules
distributed on face, trunk, & extremities.
Acanthosis nigricans(AN) ass. w/ insulin resistance states (eg, diabetes mellitus, *PCOS*) in younger pts &
GI malignancy in older pts
8821 Medicine Dermatology Skin tags(acrochordons) commonly present on regions affected by AN
Hyperpigmentation of the skin in primary adrenal insufficiency(Addison's disease) is generalized but more
prominent in areas exposed to friction (elbows, knees) & light (face, dorsum of hands)
Hidradenitis suppurative (acne inversa): painful tender masses w/ inflammation, scarring, & sinus tract
formation. Occurs most commonly at the axillae, groin, inner thighs, & perineal area. Dx based on clinical
findings
Furunculosis is an abscess ass. w/ a hair follicle, & is usually due to S. aureus
Intertrigo presents as well-defined erythematous plaques w/ satellite vesicles or pustules in intertriginous &
occluded skin areas. Infection usually due to Candida species
Acute urticaria (<6 weeks): due to infections(viral, bacterial, parasitic), NSAIDs, & IgE mediated(abx, insect
bites, latex, food) or direct(narcotics, radiocontrast medium) mast cell activation. 50% of pts have idiopathic
urticaria. Pts develop well-circumscribed & raised erythematous plaques w/ central pallor, along w/ intense
pruritus & resolution of individual skin lesions within 24 hours (google pic)
Dermatofibromas:firm,hyperpigmented nodules <1 cm in diameter.Due to fibroblast proliferation.Occur on
lower extremities.Have a fibrous component that causes central area to dimple when
pinched.Tx-(Cryosurgery or shave excision) not required,unless lesion symptomatic or for cosmetic reasons
Pyogenic granuloma:benign vascular skin tumor.Small red papule that grows rapidly over weeks/months to
a pedunculated or sessile shiny mass.Occur on lip/oral mucosa.Bleeds w/ minor trauma
Plantar warts(google pic): *due to HPV infection*. Occurs in young adults & immunocompromised
10485 Medicine Dermatology individuals. Lesions appear as hyperkeratotic papules on the sole of the foot that can be painful when
walking/standing
*Epidermal inclusion cyst(EIC)* is a benign nodule containing normal epidermis that produces keratin. Pts
usually develop a dome-shaped, firm, freely movable cyst or nodule w/ a small central punctum. The lesion
10670 Medicine Dermatology can remain stable or gradually increase in size but usually resolves spontaneously(but can often recur)
[In contrast to epidermal cysts, lipomas are usually soft to rubbery & irregular & don't typically regress &
recur]
Temporomandibular joint (TMJ) dysfunction:results in referred pain to the ear thats worsened w/
chewing.Pts report hx of nocturnal teeth grinding.Tx-nighttime bite guard.Surgical intervention sometimes
necessary
Ramsay Hunt syndrome:form of herpes zoster infection that causes Bell's palsy.Vesicles seen on outer ear
2194 Medicine Ear, Nose & Throat (ENT)
Glossopharyngeal neuralgia:condition in which pts experience intermittent,severe,stabbing pain in areas
innervated by cranial nerves IX & X,including the ear
3 day hx of fever, chills, & sore throat is most likely secondary to tonsillitis. However, development of a
muffled or "hot potato voice" & deviation of uvula suggests that a peritonsillar abscess has developed as a
complication of the tonsillitis. Pts w/ peritonsillar abscess have prominent unilateral lymphadenopathy.
Tx-*needle peritonsillar aspiration* & initiation of IV abx
Ashhadscknotes
Malignant otitis externa:infection of the ear seen in elderly pts w/ poorly controlled diabetes,caused by
Pseudomonas aeruginosa.Sx-ear pain,ear drainage,granulation tissue seen within ear canal.Progression of
infection can lead to osteomyelitis of the skull base & destruction of facial nerve(facial drooping,food
dropping out of mouth).Tx-ciprofloxacin
Ramsay Hunt syndrome:herpes zoster infection in the ear,facial nerve palsy & vesicles in the auditory canal
& auricle
Pts w/ presbycusis often have difficulty hearing in noisy, crowded environments. Difficulty hearing
high-pitched noises/voices
2836 Medicine Ear, Nose & Throat (ENT) Otosclerosis: a conductive hearing loss ass. w/ bony overgrowth of stapes, begins w/ low-frequency hearing
loss, often found in middle aged people
Meniere's disease: tinnitus, vertigo, sensorineural hearing loss

2838 Medicine Ear, Nose & Throat (ENT) Loop diuretics such as furosemide can cause ototoxicity. They are ass. w/ hearing loss and tinitus
Serous otitis media: most common middle ear pathology in pts w/ AIDS. Due to auditory tube dysfunction
arising from HIV lymphadenopathy or obstructing lymphomas.*Presence of middle ear effusion w/o
evidence of an acute infection*. Dull tympanic membrane that is hypomobile on pneumatic otoscopy
Progressive multifocal leukoencephalopathy (PML): demyelinating disease, occurs in pts w/ HIV/AIDS,less
likely in pts on HAART,only occurs in pts w/ CD4 <200/mm3
Aspirin exacerbated respiratory disease:
bronchospasm/nasal congestion after taking aspirin or NSAIDS
ass. w/ development of nasal polyps
sx- asthma, rhinosinusitis, bland tasting food, recurrent nasal discharge/congestion due to polyps
Pregnant woman have increased incidence of pyogenic granulomas on anterior nasal septum. They are
frequent sources of nose bleeds during pregnancy
Leukoplakia is a reactive precancerous lesion that represents hyperplasia of the squamous epithelium. *Oral
leukoplakia can't be scraped off*. Tobacco & alcohol use are risk factors(similar risk factors as squamous
cell carcinoma). We have to do a biopsy to rule out malignant transformation of the lesion
Oral candidiasis(thrush):occurs in pts w/ diabetes,immunodeficiency states,use of abx or inhaled
glucocorticoids.White plaques can be scraped off w/ tongue depressor
Suspect malignant otitis externa in any diabetic pt w/ severe ear pain, otorrhea, & evidence of granulation
3260 Medicine Ear, Nose & Throat (ENT) tissue in the ear canal. *Pseudomonas aeruginosa* is the most frequent cause of malignant otitis externa.
Pain often radiates to the temporomandibular joint & causes pain that is exacerbated by chewing
Dizziness can be classified as vertigo if pt describes a sensation of spinning that is accompanied by nausea.
Meniere's disease is the likely cause of vertigo if the pt also has a sensation of ear fullness(due to abnormal
accumulation of endolymph within the inner ear)
Lateral medullary infarction aka Wallenberg syndrome:presents w/ intense vertigo,gaze abnormalities,limb
ataxia,sensory loss,Horner's syndrome
Malignant(necrotizing)otitis externa:severe infection of external auditory canal & skull base due to
Pseudomonas aeruginosa.Sx-severe ear pain esp at night,purulent drainage w/ sense of fullness,conductive
4282 Medicine Ear, Nose & Throat (ENT) hearing loss on affected side,granulation tissue,edematous external auditory canal,fever,elevated ESR.Seen
most frequently in elderly pts w/ diabetes or immunosuppression.*IV ciprofloxacin* is empiric tx
[Otitis externa is not as severe.Tx-topical abx & corticosteroids]
Meniere's disease: vertigo, ear fullness, tinnitus, & hearing loss. Nystagmus seen during acute attack.
4376 Medicine Ear, Nose & Throat (ENT) Tx-environmental/dietary modifications, including *low-salt diet*. Medical therapy w/ diuretics,
antihistamines, or anticholinergics are considered if lifestyle modifications are unsuccessful.
Bone conduction(thats when tuning fork is placed on right mastoid process aka a "bone") that is greater
than air conduction(when vibrating tuning fork is immediately placed near her right external auditory meatus
4902 Medicine Ear, Nose & Throat (ENT) aka "air" since its held there and not touching anything) on the Rinne test is suggestive of conductive
hearing loss & can be confirmed w/ the Weber test. Otosclerosis is a common cause of conductive hearing
loss in adults in their 20s & 30s.
Sialadenosis:benign,noninflammatory enlargement of the salivary glands.Seen in pts w/ advanced liver
disease(*alcoholic* & nonalcoholic cirrhosis) as well as a variety of dietary & nutritional
disorders(diabetes,bulimia)
11906 Medicine Ear, Nose & Throat (ENT) Sialadenitis:focal tenderness,erythema,fever
Salivary gland stones:glandular swelling,pain w/ meals
Pleomorphic adenoma:benign neopasm affecting salivary glands that presents as a firm nodule
*Glucocorticoid nasal sprays* are the most effective single agent for Allergic rhinitis(sx-nasal
12123 Medicine Ear, Nose & Throat (ENT) congestion,clear rhinorrhea,pale/edematous nasal mucosa,nasal creases,pharyngeal
cobblestoning,conjunctival edema,or thick green nasal discharge)
Ashhadscknotes
Hyperandrogenism(hirsutism) which develops rapidly over a few months along w/ virilization(excessive
muscular development & clitoral enlargement) is due to either an ovarian or adrenal tumor secreting
Endocrine, Diabetes &
2170 Medicine excessive androgens. *Measure serum testosterone & DHEAS levels*
Metabolism
Elevated testosterone w/ normal DHEAS=ovarian source
Elevated DHEAS w/ normal testosterone=adrenal source
Diabetic ketoacidosis (DKA): Hx of weight loss & excessive water intake. Deep rapid breathing (Kussmaul's
2171 Medicine respiration) due to acidosis. Can be precipitated by a GI infection. Elevated ED *fingerstick glucose* levels
Metabolism
may confirm suspicion within minutes.
Cushing's syndrome(CS):due to ectopic ACTH production.Admin of high dose dexamethasone doesn't
suppress plasma cortisol levels
Endocrine, Diabetes & Cushing's disease:ACTH-producing pituitary adenoma

2173 Medicine
Metabolism
CS can be ACTH-dependent(high ACTH,due to Cushings disease,ectopic ACTH/CRHP)or
ACTH-independent(ACTH <5 pg/mL,due to exogenous glucocorticoids,adrenal adenoma,primary pigmented
nodular adrenocortical hyperplasia.Do CT on these pts to exclude adrenal adenoma)
Best initial screening tests for pts w/ suspected adrenal insufficiency are early-morning cortisol, ACTH, &
*cosyntropin (analogue of ACTH)* stimulation. An increase in serum cortisol levels >20 ug/dL 30-60 min
2174 Medicine after admin of 250 ug cosyntropin virtually rules out primary adrenocortical insufficiency (Addison's disease)
Metabolism
[this means adrenal gland is responding to ACTH fine & producing cortisol like it's supposed to...problem
here is w/ pituitary thats not producing ACTH]
Hypopituitarism:
Endocrine, Diabetes & characterized by glucocorticoid deficiency, hypogonadism, & hypothyroidism
2175 Medicine
Metabolism sx- fatigue, hypoglycemia, hyponatremia, eosinophilia, low libido, cold intolerance, & anorexia.
regular Aldosterone levels(unlike primary adrenal insufficiency in which you get hypoaldosteronism)
Parathyroidectomy for primary hyperparathyroidism is rec for pts who have any of the following clinical
features:
Endocrine, Diabetes & -Serum calcium level >1 mg/dL above the upper limit of normal
2176 Medicine
Metabolism -Young age (<50)
-Bone mineral density T-score <-2.5 at any site
-Reduced renal function (estimated glomerular filtration rate <60 mL/min)
Fever and sore throat in any pt taking antithyroid drugs(PTU & MMI) suggests agranulocytosis. Antithyroid
2178 Medicine drugs should be stopped & WBC count checked.
Metabolism
Agranulocytosis is the most feared side effect of pts tx w/ antithyroid drugs
*Radioactive iodine therapy*:preferred tx for most pts w/ hyperthyroidism, including Graves' disease.
Contraindications to radioactive tx are pregnancy & severe ophthalmopathy
Endocrine, Diabetes & Antithyroid drugs(propylthiouracil) are used in tx of hyperthyroidism during pregnancy & in prep for surgery
2179 Medicine
Metabolism or radioactive iodine therapy. It's less effective, less cost effective, & ass. w/ serious side effects
Iodinated contrast agents(iopanoic acid) given to control severe sx of thyrotoxicosis
Initial mgmt of DKA:rapid IV admin of *normal saline & regular insulin*
[DKA dx:blood glucose >250,pH <7.3 or low serum bicarbonate <15-20,detection of plasma ketones]
2184 Medicine NPH insulin:not 4 initial tx of DKA due to its delayed onset & prolonged action.Started when pts recover
Metabolism
from DKA & begin to tolerate oral feeding
Bicarbonate:cause cerebral edema in kids.Decrease tissue oxygenation.Lead to hypokalemia/alkalosis.Used

4 DKA pts w severe acidosis,bicarb<5,severe hyperkalemia
Despite normal or elevated serum K+ levels,pts w/ hyperosmolar hyperglycemic state (HHS) or diabetic
ketoacidosis have a total body K+ deficit due to excessive urinary loss caused by glucosuria-induced
osmotic diuresis. Aggressive insulin therapy for HHS can lower serum K+ levels further & cause severe
Endocrine, Diabetes & hypokalemia
2185 Medicine
Metabolism
Increase in extracellular pH->binding of calcium to albumin->low serum ionized calcium concentration
Severe hyperglycemia->phosphate depletion due to phosphaturia

2186 Medicine Fluid replacement is the most imp step in the management of non-ketotic hyperglycemia coma
Metabolism
Insulinoma(*Beta cell tumor*): Hypoglycemia along w/ elevated insulin, c-peptide & proinsulin levels
Sulfonylurea-induced hypoglycemia: difficult to differentiate from insulinoma since increased insulin &
c-peptide levels also seen in this situation. Dx confirmed w/ measuring plasma sulfonylurea level (if
negative, its prob an insulinoma)
2188 Medicine
Metabolism
Exogenous insulin induced hypoglycemia: very high serum insulin levels & low c-peptide levels
Non-beta cell tumors: produce IGF II
Ashhadscknotes
2189 Medicine Best markers indicating resolution of DKA are the serum anion gap & beta-hydroxybutyrate levels
Metabolism
Endocrine, Diabetes & The most beneficial therapy to reduce the progression of diabetic nephropathy is strict *blood pressure
2190 Medicine
Metabolism control*
Most important causes of thyrotoxicosis w/ low radioactive iodine uptake:
2191 Medicine subacute painless thyroiditis,subacute granulomatous thyroiditis,iodine-induced thyroid
Metabolism
toxicosis,levothyroxine overdose,struma ovarii(less likely in a pt w/ neck swelling suggesting thyroiditis)
*GLP-1 agonists(exenatide,liraglutide) induce weight loss & have lower hypoglycemia risk*
Metformin(biguanide):initial tx for most type 2 diabetics.Lactic acidosis is a complication
Endocrine, Diabetes & Sulfonylureas for pts w/ metformin failure.Weight gain & hypoglycemia occur
2192 Medicine
Metabolism
Pioglitazone(TZDs):S.E. like weight gain,edema,CHF,bone fracture,bladder ca.Can be used in renal
insufficiency
DPP-IV inhibitors(sitagliptin):low risk of hypoglycemia.Weight neutral.Can use w/ renal insufficiency

Carcinoid syndrome pts can develop *Niacin deficiency*(dermatitis,diarrhea & dementia). This is because
2220 Medicine carcinoid cells cause increased production of serotonin from tryptophan(required for niacin synthesis),
Metabolism
resulting in niacin deficiency
Pts w/ PCOS at increased risk of developing insulin resistance & type 2 diabetes. A 75 g 2-hour *oral
glucose tolerance test* can identify pts w/ impaired glucose tolerance better than a fasting glucose level
Metformin rec for diabetes prevention in very obese pts

2414 Medicine
Metabolism
Pts w/ PCOS are not at increased risk for breast cancer
BRCA testing should be offered to pts w/ hx of ovarian cancer in 1st or 2nd degree relatives at age <50 or
in multiple generations
Ectopic ACTH syndrome by a rapidly growing malignant tumor generally causes hypertension, hypokalemia,
Endocrine, Diabetes & metabolic alkalosis, & pigmentation w.o characteristic features of Cushing syndrome. When cortisol is
2592 Medicine
Metabolism produced in excess amounts, it results in mineralocorticoid effects by bypassing the enzyme 11 beta
hydroxyl dehydrogenase
Type 1 multiple endocrine neoplasia(MEN1):
3 P's-parathyroid,pituitary,pancreatic.
Hypercalcemia(constipation,polyuria),peptic ulcer(epigastric abdominal pain with occult bleeding),family hx of
2630 Medicine peptic ulcer & kidney stones.Gastrin producing tumors(gastrinomas) are the most common pancreatic
Metabolism
tumors in MEN1 & cause Zollinger-Ellison syndrome,charac. by severe & refractory peptic ulcer disease
Milk-alkali syndrome:hypercalcemia,renal insufficiency,metabolic alkalosis

Glucagonoma: sx-hyperglycemia w/ necrotic migratory erythema(inflammatory blister/crusting w/ central
clearing), diarrhea, anemia, & weight loss. Glucagon >500 pg/mL confirms dx.
2645 Medicine
Metabolism
Gastrinoma: gastrin producing neuroendocrine tumor that typically presents w/ abdominal pain (upper
gastrointestinal ulceration), diarrhea, anemia, & weight loss.
VIPoma:watery diarrhea,muscle weakness/cramps(due to hypokalemia),hypo-or achlorhydria(due to
decreased gastric acid secretion). Facial flushing, lethargy,nausea/vomiting,abdominal pain,weight loss.75%
Endocrine, Diabetes & of VIPomas are in the pancreatic tail. 60%-80% metastasize to liver.
2649 Medicine
Metabolism Tx-iv volume repletion,octreotide to decrease diarrhea,hepatic resection in pts w/ metastasis to liver
Systemic mastocytosis: steatorrhea,hepatomegaly,peptic ulcer disease,pruritis,facial flushing,urticaria

Primary hyperaldosteronism (Conn's syndrome): low renin, elevated aldosterone, & elevated serum
bicarbonate(metabolic alkalosis). Causes include aldosterone producing tumor or bilateral adrenal
Endocrine, Diabetes & hyperplasia
2725 Medicine
Metabolism
Secondary hyperaldosteronism: elevated renin, elevated aldosterone, & metabolic alkalosis. Causes include
renovascular hypertension, malignant hypertension, diuretics, & renin-secreting tumor
Endocrine, Diabetes & Clinical manifestations of vitamin D toxicity are mainly due to hypercalcemia & include constipation,
3083 Medicine
Metabolism abdominal pain, polyuria, & polydipsia
Pulmonary embolism->Hyperventilation->Respiratory alkalosis(increased extracellular pH))->dissociation of
Endocrine, Diabetes & hydrogen ions from albumin->increased binding of albumin to calcium->drop in unbound (ionized) calcium
3099 Medicine
Metabolism [Ionized calcium is the physiologically active form, & decreased levels can result in clinical manifestations of
hypocalcemia]
*Pts w/ hypoalbuminemia can have decreased total serum calcium*(ionized calcium remains stable)
3100 Medicine
Metabolism Pseudohypoparathyroidism: PTH resistance in target organs (kidney, bone). These pts have hypocalcemia,
elevated phosphorus, & high PTH levels
Ashhadscknotes
In pts/ w hypercalcemia,a single elevated serum calcium level must always be confirmed by a second serum
calcium value.After hypercalcemia is confirmed,next step is to check serum PTH level to distinguish
between PTH mediated hypercalcemia & non-PTH mediated hypercalcemia
3102 Medicine Vit D toxicity:elevated serum 25-hydroxy vitamin D level
Metabolism
1 or 3 hyperparathyroidism-high urine calcium/creatinine clearance ratio(cr)
Familial hypercalcemia hypocalciuria-low urine calcium/creatinine c.r.

If a pt presents w/ muscle cramps,weakness, palpitations & hypokalemia a couple of weeks after starting a
thiazide diuretic(hydrochlorothiazide),think primary hyperaldosteronism!Pts w/ mild primary
3230 Medicine hyperaldosteronism may not have spontaneous hypokalemia but are prone to developing diuretic induced
Metabolism
hypokalemia.*Best screening test is early morning plasma aldosterone concentration (PAC) to plasma renin
activity (PRA) ratio.* PAC/PRA ratio >20 w/ plasma aldosterone >15 ng/dL
Primary hyperaldosteronism: plasma aldosterone to renin ratio >20. Surgery preferred for unilateral adrenal
adenoma. Medical therapy w/ aldosterone antagonists (eg, spironolactone, *eplerenone*) rec for pts w/
Endocrine, Diabetes & bilateral adrenal hyperplasia or w/ unilateral adrenal adenoma who either refuse surgery or are poor surgical
3231 Medicine
Metabolism candidates
[Spironolactone can cause sig side effects in both men(gynecomastia) & women(breast
tenderness,menstrual probs). Eplerenone has fewer side effects]
Diabetic foot ulcers: occur on plantar surface of the foot under points of greatest pressure, such as under
the head of the first metatarsal bone
3451 Medicine
Metabolism
Ulcers resulting from venous insufficiency (venous valvular incompetence) occur on the medial aspect of the
leg above the medial malleolus. Often preceded by chronic lower extremity edema & stasis dermatitis
Measuring the Glycosylated hemoglobin (HbA1c)is the best way to check pts compliance with their diabetic
medication regimen/monitor chronic glycemic control. Reflects pt's average glucose levels over the
Endocrine, Diabetes & preceding 3 months
3454 Medicine
Metabolism Factors that increase red cell turnover (eg, hemolytic anemia) will give a falsely low HbA1c
C-peptide is useful as an indicator of endogenous insulin production

Hypothyroidism can cause hyperlipidemia,hyponatremia & asymptomatic elevations of creatinine kinase &
serum transaminases.Most pts have hypercholesterolemia alone or combined w/ hypertriglyceridemia
Hypothyroidism->hyponatremia due to decreased free water clearance

3483 Medicine
Metabolism Thyrotoxicosis->hypercalcemia due to increased bone resoption
Hypothyroid pts->normocytic normochromic anemia due to decreased RBC mass
Some hypothyroid pts develop von Willebrand syn w increased bleeding risk
Thyroid nodules:Usually benign.*TSH measurement & US are 1st steps in eval*.Radionuclide scan for pts w/
low TSH.Hot nodules are benign & can be tx for hyperthyroidism.FNA indicated for pts w/ normal or high
TSH,cold nodules,thyroid cancer family hx,or suspicious thyroid US findings
3484 Medicine
Metabolism
Hyperfunctioning"hot"nodule(increased isotope uptake in nodule w/ decreased surrounding uptake)
Indeterminate/Hypofunctioning"cold"nodule(decreased isotope uptake compared 2 surrounding tissue)

Generalized resistance to thyroid hormones:
Pts have high T4 & T3 levels w/ normal (or just slightly elevated) TSH levels. Look for pt to have features of
hypothyroidism despite having elevated free thyroid hormones
3486 Medicine
Metabolism
Secondary and tertiary hypothyroidism are characterized by low circulating thyroid hormone levels w/ low or
inappropriately normal TSH levels
Graves' disease can be tx w/ anti-thyroid drugs, radioactive iodine tx, or thyroidectomy. The most serious
3487 Medicine side effect of anti-thyroid drugs(eg,methimazole) is agranulocytosis (0.3% of pts). Pts developing sore
Metabolism
throat & fever should stop the drug & see a physician to check their wbc count
Radioiodine therapy is more likely to cause permanent hypothyroidism in pts w/ Graves' disease. Since the
3488 Medicine whole thyroid gland is hyperfunctional in Graves' disease, radioiodine is taken up by the entire thyroid gland,
Metabolism
thereby resulting in complete thyroid ablation
Osteomalacia: commonly due to vitamin D deficiency(*low vit D->low calcium,low phosphate->increased
PTH*).Vit D deficiency can be due to malabsorption(Crohn's),intestinal bypass surgery(small bowel
Endocrine, Diabetes & resection), celiac sprue, or chronic liver or kidney disease.Unlike in osteoporosis, pts complain of bone pain
3489 Medicine
Metabolism & muscle weakness. Xray-decreased bone density w/ thinning of cortex & pseudofractures(Looser zones)
Osteoporosis:bone pain(w/o fracture) & muscle weakness aren't present
Ashhadscknotes
Osteomalacia: defective *mineralization* of the organic bone *matrix*. Can be due to vitamin D deficiency,
which leads to decreased intestinal calcium & phosphorus absorption w/ resultant secondary
hyperparathyroidism. Labs-hypophosphatemia, hypocalcemia,elevated alkaline phosphatase. Sx-muscle
3490 Medicine weakness & bone pain
Metabolism
Pagets disease of bone: markers of bone resorption (c-telopeptide, n-telopeptide) & bone formation
(alkaline phosphatase, osteocalcin) are elevated
Dopamine-agonists such as bromocriptine or cabergoline treat prolactinomas.
Endocrine, Diabetes & Do Surgery only if pts don't respond to or can't tolerate dopamine agonists, or if impaired vision due to
3492 Medicine
Metabolism invasive prolactinomas doesn't improve w/ drug treatment
Do Radiotherapy for tumors that don't respond to medical or surgical therapy. Risk of panhypopituitarism.
3493 Medicine Serum prolactin levels >200 ng/mL are essentially diagnostic for prolactinoma
Metabolism
3494 Medicine Renal angiomyolipomas are seen in tuberous sclerosis
Metabolism
Euthyroid sick syndrome ("low T3 syndrome") is characterized by a fall in total & free T3 levels w/ normal T4
& TSH levels
Central hypothyroidism: low(or inappropriately normal) TSH levels ass. w/ low T4 & low or low-normal T3
3495 Medicine
Metabolism
Overt primary hypothyroidism: decreased free T4 levels w/ an elevated TSH
Subclinical hypothyroidism: elevated TSH w/ normal T4 levels. Serum T3 not useful in these pts, it remains
normal until late stages of hypothyroidism.
Anti-thyroid peroxidase (anti-TPO) & anti-thyroglobulin antibodies are present in more than 90% of pts w/
Hashimoto's thyroiditis
Endocrine, Diabetes & Thyroid stimulating immunoglobulins (TSI) are present in pts w/ Graves' disease. TSI stimulate TSH
3496 Medicine
Metabolism receptors on the thyroid follicular cells, thereby resulting in thyroid hormone overproduction
Antibodies against TSH receptors can be present in some pts w/ hypothyroidism. These pts have small
thyroid glands
Endocrine, Diabetes & Hashimoto's thyroiditis: positive anti-thyroperoxidase(TPO)antibodies w/ an enlarged rubbery goiter are
3497 Medicine
Metabolism virtually diagnostic. Pts are at increased risk for developing *thyroid lymphoma*
Papillary carcinoma of the thyroid is the most common thyroid malignancy(& has the best prognosis). Risk
factors include *exposure to radiation during childhood* & family hx. Spreads via lymphatic dissemination
Follicular thyroid cancer spreads via hematogenous route

3498 Medicine
Metabolism
Anaplastic carcinoma occurs in older pts & presents w/ a rapidly enlarging thyroid mass. Has the worst
prognosis of all thyroid cancers w/ median survival of only a few months
Follicular thyroid cancer: *invasion of the capsule & blood vessels* is seen histopathologically. Unlike
papillary cancer, follicular cancer is encapsulated.
3499 Medicine
Metabolism Papillary thyroid cancer (PTC): most common thyroid malignancy, slow infiltrative local spread affecting
other parts of the thyroid gland & regional lymph nodes, psamomma bodies are seen, FNAB reveals lage
cells w/ ground glass cytoplasm, PTC is unencapsulated, prognosis is excellent even w/ metastasis
MEN 2A & MEN 2B are autosomal disorders due to germline mutations in the RET proto-oncogene in >95%
of pts. Pts w/ positive DNA testing should undergo total thyroidectomy in early childhood (risk of acquiring
3520 Medicine invasive medullary thyroid cancer is nearly 100%).
Metabolism
The pheochromocytoma of MEN syndromes can be dx w/ metanephrines & free catecholamines or plasma
free metanephrines
Leydig cells are the principal source of testosterone & are capable of estrogen production, due to markedly
3594 Medicine increased aromatase expression. Common endocrine manifestations in adults is gynecomastia, however in
Metabolism
prepubertal cases,precocious puberty is common
Red flags for other secondary causes of hypogonadotropic hypogonadism: headaches,low testosterone
levels(<150 ng/dL),gynecomastia w/ or w/o galactorrhea,& evidence of other pituitary hormonal
Endocrine, Diabetes & deficiencies.MRI of pituitary indicated in pts w/ elevated serum prolactin,serum testosterone <150
3595 Medicine
Metabolism ng/dL,visual field defects,or features of other pituitary hormonal dysfunction
Testosterone tx required if pt's serum prolactin & MRI of pituitary are normal
Elevated serum dehydroepiandrosterone sulfate (*DHEA-S*) levels are specifically seen in pts w/ androgen
producing ADRENAL tumors.
3598 Medicine
Metabolism [Androstenedione(AS), DHEA, & DHEA-S aren't true androgens cuz they don't interact w/ the androgen
receptor. They can be converted to testosterone, & overproduction of these hormones can lead to clinical
features of androgen excess]
Ashhadscknotes
Pts w/ central diabetes insipidus(DI) increase their urine osmolality by 50% following administration of
desmopressin acetate tablets;pts w/ nephrogenic DI will not show much change. Desmopressin(intranasal)
is 1st line tx for central DI
Endocrine, Diabetes & Demeclocycline tx SIADH

3729 Medicine
Metabolism
HCTZ preferred for nephrogenic DI.Causes mild volume depletion that increases proximal water & Na+
reabsorption
Tolvaptan used for hypervolemic/euvolemic hyponatremia that doesn't improve w/ standard therapy
Diabetic neuropathy:
Endocrine, Diabetes & Monofilament testing predicts the risk of future ulcers
3781 Medicine
Metabolism
Ankle brachial index primarily measures large vessel peripheral arterial disease
*Symmetric distal sensorimotor polyneuropathy* is the most common type of diabetic neuropathy, & is
3795 Medicine charac by the classic "stocking glove" pattern of sensory loss. Aside from symmetric distal sensorimotor
Metabolism
polyneuropathy, diabetes can also cause mononeuropathies of cranial & peripheral nerves
Diabetic gastroparesis(delayed gastric emptying) presents w/ sx of anorexia, nausea, vomiting, early satiety,
postprandial fullness, & impaired glycemic control. Prokinetic agents(eg, *metoclopramide*, erythromycin,
Endocrine, Diabetes & cisapride) are useful in the management of sx
3797 Medicine
Metabolism
Progesterone analogs are useful in the palliation of anorexia & in improving appetite & weight gain in pts w/
cancer related anorexia/cachexia syndrome
TCAs(*amitriptyline*,desipramine,nortriptyline) used to tx diabetic neuropathy.Since TCAs can worsen
urinary sx(due to cystopathy) & orthostatic hypotension(due to cardiovascular autonomic
neuropathy),Gabapentin is an alternative for these pts
3800 Medicine
Metabolism Small fiber neuropathy:pain,allodynia,paresthesias;sensory loss isn't marked.Ankle jerks may be preserved
Large fiber neuropathy:less pain,more numbness;pressure,proprioception,vibratory sensations

decreased,ankle jerks usually lost
Screening for diabetes is recommended in pts w/ sustained bp >135/80 & may be considered in all pts over
age 45, as well as those w/ additional risk factors for diabetes(htn,overweight,family hx)
3807 Medicine
Metabolism For women w/ average risk for cervical cancer, a Pap test is recommended every 3 years from age 21-29.
Between ages 30-65, pts w/ initial negative testing may have either a Pap test alone every 3 years or a
combination of Pap test & HPV testing every 5 years (preferred)
Ratio of plasma aldosterone concentration to plasma renin activity is the preferred initial screening test for
Endocrine, Diabetes & primary hyperaldosteronism. Adrenal suppression testing can confirm the dx, & positive tests require further
3832 Medicine
Metabolism adrenal imaging. Adrenal venous sampling is the most sensitive test for differentiating adrenal adenoma &
bilateral adrenal hyperplasia in pts w/o discrete unilateral adrenal mass on imaging
Endocrine, Diabetes & Hypothyroidism should always be considered in pts w/ an unexplained elevation of serum CK concentration.
3878 Medicine
Metabolism Serum TSH is the most sensitive test to dx hypothyroidism.
Primary polydipsia: due to increased water intake, dilute urine(urine osmolality < 1/2 plasma osmolality) &
Endocrine, Diabetes & hyponatremia (sodium <137 mEq/L)
3899 Medicine
Metabolism
Diabetes insipidus: Serum Na >145 mEq/L w/ dilute urine
3902 Medicine ACE inhibitors slow the progression of diabetic nephropathy
Metabolism
Endocrine, Diabetes & Systolic hypertension in thyrotoxicosis(weight loss, tachycardia, tremor, lid retraction) is caused by
3952 Medicine
Metabolism hyperdynamic circulation which is due to *increased myocardial contractility* & heart rate
When treating pts w/ *pheochromocytoma*, do not give beta-blockers w/o alpha-blockers. *Always give an
3976 Medicine alpha-blocker first, followed by a beta-blocker*; doing this in the wrong order can precipitate a very
Metabolism
dangerous increase in blood pressure.
Hypomagnesemia causes hypocalcemia by inducing PTH resistance & decreasing PTH secretion. Serum
phosphate levels normal or low
3981 Medicine
Metabolism In addition to chronic kidney disease, vitamin D deficiency is one of the mcc of secondary
hyperparathyroidism. It usually causes low to low-normal serum phosphate & normal serum calcium in most
adult pts
PCOS tx: weight loss & *oral estrogen/progestin contraceptives/Combined hormonal contraceptive therapy*
3996 Medicine
Metabolism
Oral contraceptives significantly reduce hirsutism
Hypomagnesemia can cause hypocalcemia in alcoholics
Hypomagnesemia causes decreased release of parathyroid hormone (PTH) and PTH resistance. (This is
4082 Medicine how it causes hypocalcemia)
Metabolism
The hypoparathyroidism caused by low magnesium won't cause elevation of phosphorus levels(as seen
normally w/ hypoparathyroidism)
Ashhadscknotes
MEN 2 syndromes:
Endocrine, Diabetes & Genetic/DNA testing (RET proto-oncogen mutation) is recommended screening test
4128 Medicine
Metabolism Total tyroidectomy indicated for pts who test positive. (Biochemical testing helpful in monitoring residual
disease after thyroidectomy)
Radioiodine therapy complications (in Graves disease pts):
1) Hypothyroidism develops in more than 80% of pts. It's the most common side effect! Can easily be
Endocrine, Diabetes & treated w/ levothyroxine
4132 Medicine
Metabolism 2) Exacerbation of ophthalmopathy. Rate as high as 10% reported. Prevented w/ high dose corticosteroid
treatment before and after radioactive iodine

4134 Medicine Hypercalcemia of lung malignancy is most commonly due to the production of PTHrP by malignant cells
Metabolism
Oral estrogen therapy can increase thyroxine binding globulin (TBG) levels, so if a hypothyroid pt is already
4154 Medicine on tyroid meds and they are taking oral estrogen, they'll need to switch to a higher dose of thyroid meds to
Metabolism
saturate the increased TBG sites
Pelvic fracture w/ urethral injury -> Erectile dysfunction (ED) due to nerve injury/*neurogenic problem* and
altered arterial supply
4161 Medicine
Metabolism Venogenic ED develops after disruption of the tunica albuginea (eg penile fracture)
Hyperprolactinemia, Testosterone deficiency, and Diabetes mellitus can also cause ED

Metabolic syndrome: 3 of 5 criteria have to be met
1) Abdominal obesity
2) Fasting glucose >100-110 mg/dL
Endocrine, Diabetes & 3) Blood pressure > 130/80 mm Hg
4164 Medicine
Metabolism 4) Triglycerides > 150 mg/dL
5) HDL cholesterol (Men <40mg/dL; Women: <50 mg/dL)
Insulin resistance plays central role in pathogenesis of metabolic syndrome
(Extremely high yield for USMLE!!!)
Hypocalcemia can occur during or immediately after surgery in pts undergoing major surgery & requiring
extensive transfusions. Hyperactive deep tendon reflexes may be the initial manifestation. Muscle cramps &
rarely, convulsions may occur.
4216 Medicine
Metabolism Mild hypermagnesemia: decreased deep tendon reflexes. Severe hypermagnesemia causes loss of deep
tendon reflexes, muscle paralysis, apnea, & cardiac arrest
Hyperkalemia: muscle weakness, flaccid paralysis, ECG changes. Asystole may occur
Metabolic acidosis observed during diabetic ketoacidosis is typically accompanied by hyperkalemia(due to
*extracellular shift*); this is sometimes called paradoxical hyperkalemia because the body potassium
4247 Medicine reserves are actually depleted. H.Y.!!
Metabolism
Early K+ supplementation is very imp in tx DKA pts. Tx w/ insulin & IV fluids leads to rapid decrease in
serum K+ levels. All hyperkalemic pts should receive K+ once serum K+ level goes below 4.5 mEq/L
Endocrine, Diabetes & Alanine is converted to pyruvate during the process of gluconeogenesis (pyruvate is eventually converted to
4275 Medicine
Metabolism glucose, which is then released into the bloodstream)
In the management of pts w/ hyperthyroidism, propranolol is generally used for symptomatic relief until the
underlying cause is identified & definitively treated. Propranolol relives the tachycardia, termor, sweating, &
anxiety that occur w/ hyperthyroidism.
4286 Medicine
Metabolism
PTU is only used when radioactive iodine is contraindicated, such as in pregnancy
Alprazolam is a benzodiazepine which is useful in treating anxiety

Hyperosmolar hyperglycemic state occurs in type 2 diabetics. Severe hyperglycemia develops in these pts &
results in glycosuria & severe volume depletion. Pts get lethargy,weakness,altered mental status,& eventual
Endocrine, Diabetes & coma.
4289 Medicine
Metabolism Dx is establish by serum glucose, plasma osmolality, and absent ketonemia(*Serum chemistry profile*)
Hypothyroid crisis (myxedema coma): hypothermia, bradycardia, hypoventilation, or hypotension

Some longstanding chronic kidney disease pts(esp following renal transplant) can develop PTH-induced
hypercalcemia(tertiary hyperparathyroidism) w/ PTH levels >10x the upper limit of normal
4304 Medicine Pts w/ sarcoidosis have increased extra-renal conversion of 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D
Metabolism
(calcitrol) by the granulomatous tissue. This leads to increased calcium absorption from the GI tract &
subsequent hypercalcemia
Endocrine, Diabetes & In developed countries, more than 80% of pts have primary adrenal insufficiency due to autoimmune
4305 Medicine
Metabolism adrenalitis
The most likely dx in a pt who presents w/ clinical features of adrenal insufficiency & calcifications in the
adrenal glands is adrenal tuberculosis.Adrenal tuberculosis continues to be the promiment cause of primary
Endocrine, Diabetes & adrenal insufficiency in developing countries. In contrast, autoimmune adrenalitis is currently the mcc of
4306 Medicine
Metabolism primary adrenal insufficiency in developed countries
Adrenal insufficiency in adrenoleukodystrophy is caused by accumulation of very long chain fatty acids
Ashhadscknotes
Untreated hyperthyroid pts are at risk for rapid bone loss (due to increased osteoclastic activity in the bone
cells) and also at risk for cardiac tachyarrhythmias, including atrial fibrillation
4307 Medicine
Metabolism Infiltrative ophthalmopathy leading to proptosis only occurs w/ Graves disease (& not w/ toxic adenoma)
sx of coronary artery disease can be unmasked or worsened w/ thyrotoxicosis

Endocrine, Diabetes & Serum calcium levels are generally much higher (>13 mg/dL) in pts w/ hypercalcemia of malignancy than in
4308 Medicine
Metabolism those w/ primary hyperparathyroidism
Hypercalcemia due to immobilization:
Immobilization of an individual w/ high bone turnover results in increased osetoclastic activation that can
lead to hypercalcemia
Endocrine, Diabetes & tx- Bisphosphonate therapy
4309 Medicine
Metabolism
Rhabdomyolysis pts initially develop hypocalcemia due to precipitation of calcium with phosphorus released
from the damaged muscles. Hypercalcemia in rhabdomyolysis occurs during the diuretic/recovery phase of
the illness
Multinodular goiter-radioactive iodine uptake is patchy in distribution
Graves disease-diffusely increased radioactive iodine uptake
Endocrine, Diabetes & Toxic adenoma-radioactive iodine uptake in the nodule & suppression of uptake in the rest of the thyroid
4318 Medicine
Metabolism gland
Painless thyroiditis-radioactive iodine uptake is markedly reduced
Hashimoto's thyroiditis-thyroid scan shows heterogenous pattern

*Insulin-like growth factor-1 (IGF-1)* is the preferred screening test for acromegaly(coarse facial
features,arthralgias,uncontrolled HTN,increased ring size,skin tags,carpal tunnel syn).[Random
4323 Medicine measurement of growth hormone is not as sensitive due to wide fluctuations in circulating
Metabolism
levels].Measurement of nonsuppressible growth hormone levels following an oral glucose load is the most
sensitive dynamic test for acromegaly & is typically performed after initial IGF-1 levels
TSH secreting pituitary adenoma:central hyperthyroidism w/ elevated thyroid hormone &
elevated/inappropriately normal TSH. Ass. w/ sx due to mass effect like headache,visual field defects &
impaired function of surrounding pituitary tissue.Goiter present
4324 Medicine
Metabolism Resistance to thyroid hormone:elevated T3 & T4 & normal to elevated TSH levels,often w/ an ass. goiter.
Pts are clinically HYPO-thyroid
Pregnant women w/ clinical hyperthyroidism have suppressed TSH

Central adrenal insufficiency:
Chronic supraphysiologic doses of glucocorticoids cause central adrenal insufficiency by suppressing the
hypothalamic-pituitary-adrenal axis. Labs will show low ACTH & low cortisol levels & a relatively normal
aldosterone level
4325 Medicine
Metabolism
Primary adrenal insufficiency:
Increased ACTH & low cortisol. They have low levels of all adrenal cortical hormones, including cortisol,
adrenal sex steroids, & aldosterone. hyperpigmented, hyponatremic,hyperkalemic
*Diabetic pts age 40-75 should receive statin therapy regardless of baseline lipid levels*. If this same pt has
Endocrine, Diabetes & mild hypertriglyceridemia(<500 mg/dL), the statins can actually reduce the triglyceride level and correct the
4336 Medicine
Metabolism mild hypertriglyceridemia(classes of lipid lowering drugs other than statins are not routinely rec. for
mild-to-moderate hypertriglyceridemia as they haven't been shown to reduce the risk of cardiac events)
Hemolytic episodes in pts w/ G6PD deficiency can be precepitated by infections or meds that increase
*oxidative stress* (particularly sulfa drugs, antimalarials, & nitrofurantoin). TMP-SMX is an example of a
Endocrine, Diabetes & sulfa containing antibiotic used to tx UTIs. Prussian blue stain will indicate presence of hemosiderin, which is
4347 Medicine
Metabolism found in the urine during hemolytic episodes
Circulating immune complexes cause glomerulonephritis. Urine microscopy shows hematuria & RBC casts
Proximal muscle weakness w/ or w/o muscle atrophy can occur in 60%-80% of pts w/ untreated
hyperthyroidism & correlates to the duration of the hyperthyroid state. Hip flexors & quadriceps are
4382 Medicine predominantly affected, and the weakness can gradually progress to involve the proximal muscles of the
Metabolism
upper extremities. Also look for additional hints like fatigue, anxiety, tremor, weight loss, tachycardia which
favor hyperthyroidism
*Radioactive iodine is ass. w/ potential development or worsening of Graves' ophthalmopathy*
Glucocorticoids decrease the peripheral conversion of T4 to T3(biologically active thyroid hormone) & can
blunt hyperthyroid sx, esp in pts w/ severe hyperthyroidism or thyroid storm. Glucocorticoids also can help
Endocrine, Diabetes & reduce the acute worsening of ophthalmopathy
4415 Medicine
Metabolism
Side effects:
(PTU)-vasculitis, hepatic failure
(MMI)- 1st trimester teratogen, cholestasis
(PTU & MMI)-agranulocytosis
Ashhadscknotes
Cushing's syndrome: Hypokalemia & hypernatremia are seen.[hypokalemia occurs cuz most corticosteroids
have some mineralocorticoid activity & will bind to aldosterone receptors in the kidney,causing renal
potassium wasting.If severe, the hypokalemia of Cushing's syndrome can be tx w/ an aldosterone
Endocrine, Diabetes & antagonist like spironolactone]
4419 Medicine
Metabolism
Hypercalcemia is an occasional finding in adrenal failure
Corticosteroids are often used to tx hypercalcemia (sarcoid & lymphoma pts)

hypothyroidism:
can cause reversible changes in memory and mentation
Endocrine, Diabetes & look for weight gain, fatigue, constipation, hoarseness, and memory changes
4471 Medicine
Metabolism
pseudodementia:
memory changes and dementia in elderly due to depression
In hyperthyroidism, increased radioactive iodine uptake(RAIU) suggests de novo thyroid hormone synthesis,
whereas *decreased RAIU* suggests release of preformed hormone or *exogenous hormone intake*.
Endocrine, Diabetes & Thyrotoxicosis due to exogenous thyroid hormone is characterized by *low serum thyroglobulin levels*
4588 Medicine
Metabolism
Many TSH-secreting pituitary adenomas overproduce the alpha-subunit,& an elevated ratio of alpha-subunit
to TSH suggests a pituitary adenoma
Cushing syndrome:
sx- hypertension(which causes headaches), hyperglycemia, weight gain
Endocrine, Diabetes & causes- excess glucocorticoid intake, ACTH producing pituitary adenoma(eg, cushing disease), & ectopic
4721 Medicine
Metabolism ACTH production(eg, small cell lung cancer)
Associated hypokalemia suggests severe hypercortisolism & is most often seen w/ ectopic ACTH producing
tumors
Graves ophthalmopathy: bilateral proptosis, impaired extraocular motion(decreased convergence, diplopia),
Endocrine, Diabetes & eye irritation(gritty or sandy sensation), redness, photophobia, pain, & excess tearing. Female sex,
4726 Medicine
Metabolism advancing age, & *smoking* are risk factors. Proptosis results from *increased volume/expansion of
retro-orbital tissues* & is a direct result of anti-thyrotropin receptor autoantibodies
Management of hypocalcemic pts:
Endocrine, Diabetes & After confirmation of hypocalcemia, the next step is to check PTH level to distinguish between low PTH
8876 Medicine
Metabolism associated conditions (eg, parathyroid surgery, polyglandular autoimmune) and elevated PTH associated
conditions (eg, vitamin D deficiency, chronic kidney disease).
Endocrine, Diabetes & Primary hyperaldosteronism:
8897 Medicine
Metabolism sx- hypertension, mild hypernatremia, hypokalemia, metabolic alkalosis, & suppressed plasma renin activity.
Chronic GI disease(steatorrhea,celiac disease)->Vitamin D deficiency(due to
Endocrine, Diabetes & malabsorption)->*hypocalcemia,low phosphorus,& elevated PTH*
8901 Medicine
Metabolism [Pts can be asymptomatic or complain of bone pain or tenderness,muscle weakness or cramps,& gait
abnormalities]
Endocrine, Diabetes & Hypopituitarism w/ a mild to moderate increase in prolactin suggests a nonfunctioning (gonadotroph)
8918 Medicine
Metabolism adenoma
Thyroid storm: life-threatening thyrotoxicosis often triggered by thyroid or non-thyroid surgery, trauma,
10958 Medicine infection, iodine contrast, or childbirth. Sx- tachycardia, hypertension, cardiac arrhythmias, high fever,
Metabolism
tremor, altered mentation, & lid lag. [Don't let stem confuse you into thinking it's alcohol withdrawal sx]
Postpartum adrenal insufficiency (AI) may be due to adrenal (primary AI) or pituitary (secondary AI)
disease. Hyperpigmentation & signs of mineralocorticoid deficiency suggest primary rather than secondary
Endocrine, Diabetes & AI. *Autoimmune adrenalitis* is the most common etiology for primary adrenal insufficiency
11270 Medicine
Metabolism
Pts w/ secondary AI have only glucocorticoid & adrenal androgen deficiency w/ preservation of
mineralocorticoid production.Hyperkalemia,hypotension,hyperchloremic acidosis NOT SEEN!
Thyroid storm is a life-threatening *thyrotoxicosis* usually triggered by a specific event (eg, surgery, trauma,
11277 Medicine infection, *iodine contrast*, childbirth) in pts w/ undiagnosed or inadequately treated hyperthyroidism. Pts
Metabolism
can develop fever, hemodynamic instability, cardiac arrhythmias, & congestive heart failure
*Tight blood glucose control in pts w/ diabetes decreases the risk of microvascular complications(eg,
11367 Medicine retinopathy, nephropathy)*, increases the risk of hypoglycemia, & has an uncertain effect on macrovascular
Metabolism
complications (eg, myocardial infarction, stroke) & all-cause mortality
Urinary incontinence(UI) in elderly pts: initial evaluation should include *urinalysis & urine culture*. UTIs are
leading causes of urinary incontinence in elderly pts
Long term urinary catheter may be used in pts w/ neurogenic bladder or urinary retention due to anatomic
Female Reproductive issues
11063 Medicine
System & Breast
Tolterodine used for urge incontinence/overactive bladder sx
Urodynamic studies helpful for evaluating complicated stress/mixed UI or clarifying mechanism of overflow
incontinence
Ashhadscknotes
Fibrocystic breast changes are a common cause of cyclic premenstrual tenderness/breast pain in women of
reproductive age.Classic clinical findings are diffusely nodular (eg,cordlike thickening) breasts w/ nonfocal
tenderness & no nipple discharge or lymphadenopathy.Pts offered NSAIDs &/or oral contraceptives for
Female Reproductive
11970 Medicine symptomatic relief
System & Breast
Costochondritis->parasternal pain/discomfort due to rib cartilage inflammation.Pain sharp &/or pessure like
& worsens w/ coughing/deep inhalation
Chronic mesenteric ischemia: suspect in pts w/ unexplained chronic abdominal pain, weight loss, & food
2149 Medicine Gastrointestinal & Nutrition aversion. Evidence of ass. atherosclerotic disease is usually present. Abdominal exam may reveal a bruit
(50% of pts)
2166 Medicine Gastrointestinal & Nutrition Presence of "succussion splash" can indicate *gastric outlet obstruction*
Pts w/ proximal small intestinal mucosal disease (Celiac disease) can't absorb the D-xylose in the
intestine->urinary & venous D-xylose levels will be low
Pts w/ malabsorption due to enzyme deficiencies(chronic pancreatitis)->normal absorption of D-xylose

2198 Medicine Gastrointestinal & Nutrition
False-positive D-xylose test(decreased urinary excretion of D-xylose despite normal mucosal
absorption)->seen in pts w/ delayed gastric emptying or impaired glomerular filtration
SIBO->false positive D-xylose test
Esophageal malignancy at the esophageal gastric junction can mimic achalasia & should be excluded w/
*endoscopy* before starting tx for achalasia
Pts w/ gastroesophageal reflux sx require an upper GI endoscopy if they have alarm
sx(dysphagia,odynophagia,weight loss,anemia,GI bleeding,recurrent vomiting)or are men age >50 w/
chronic (>5 years) sx & cancer risk factors(eg, tobacco use).
Esophageal manometry/pH monitoring used for persistent GERD sx or normal upper GI endoscopy to
assess for other conditions (eg, motility disorders) that can occasionally mimic GERD
Suspect C.diff colitis in any pt who has been on antibiotics & complains of diarrhea or abdominal pain. *Stool
studies for C.diff toxin* should be sent to confirm dx. Pts w/ suspected colitis should receive empiric
metronidazole while awaiting results of stool studies
Severe colitis requires oral vancomycin with/without IV metronidazole or possible switch to intracolonic
vancomycin. Use fidaxomicin if can't tolerate oral vancomycin
Increased intragastric pressure during vomiting can cause tears in the mucosa of the distal esophagus &
proximal stomach. These are called Mallory-Weiss tears, & account for 10% of upper GI bleeds
Abdominal CT scan is the best diagnostic test for diverticulitis
IV pyelography is useful to evaluae for acute kidney stones

Calcium oxalate crystals are a frequent finding in urinary sediment & are not clinically significant unless the
pt has sx suggestive of acute nephrolithiasis
Toxic megacolon: complication of inflammatory bowel disease. Sx- colonic distension, fever, HR > 120,
neutrophilic leukocytosis >10,500 , anemia, volume depletion, altered sensorium, electrolyte disturbances,
2205 Medicine Gastrointestinal & Nutrition hypotension
Initial test of choice in cases of suspected toxic megacolon is *abdominal x-ray* to confirm the presence of
a dilated colon greater than 6 cm.
Always suspect *Crohn's disease* in a young pt w/ chronic diarrhea, abdominal pain, & weight loss. Lab
2207 Medicine Gastrointestinal & Nutrition findings of every chronic inflammatory disease can include anemia & reactive thrombocytosis(elevated
platelet count). Several shallow ulcers in pt's mouth also points toward Crohn's disease
Pt w/ epigastric pain(worse at night), food intolerance, weight loss, enlarged nontender gallbladder, & icterus
suggestive of biliary obstruction has findings consistent w/ pancreatic cancer. Most pancreatic cancers
originate in the head of the pancreas,& compress the pancreatic duct & the common bile duct as they
2209 Medicine Gastrointestinal & Nutrition expand.Subsequent backup of bile leads to intra-& extrahepatic biliary duct dilation & a nontender,
distended gallbladder
Portal vein thrombosis: ass. w/ cirrhosis

Iron deficiency anemia in elderly:
most common cause- GI blood loss
management- colonoscopy & endoscopy
*A negative occult blood test does not exclude the possibility of GI bleeding!*
Radioisotope scans are useful in determining the source of active bleeding (but aren't diagnostic in the
absense of an active bleed). Used in acute GI blood loss when source of bleeding remains unidentified on
colonoscopy and endoscopy.
Oropharyngeal dysphagia:difficulty initiating swallowing ass. w/ *coughing,choking,aspiration,nasal

regurgitation*. Other complications include aspiration pneumonia & weight loss.Underlying etiologies include
2212 Medicine Gastrointestinal & Nutrition stroke,advanced dementia,oropharyngeal malignancy or neuromuscular disorders(myasthenia gravis).Pts
are evaluated initially w/ *videofluoroscopic modified barium swallow* to evaluate swallowing
mechanics,degree of dysfunction,& severity of aspiration
Ashhadscknotes
Diffuse esophageal spasm: episodes of dysphagia, regurgitation, spontaneous pain, odynophagia for cold &
hot food,chest pain precipitated by emotional stress. Pt's chest pain will resolve after taking
nitroglycerin(nitrates relax myocytes in coronary vessels as well as esophagus).*Esophageal manometry*
2213 Medicine Gastrointestinal & Nutrition establishes the dx.
If GERD suspected in a pt, start pt on empiric trial of a proton pump inhibitor (rather than 24-hour pH
monitoring)
Zenker's diverticulum(ZD):common in elderly men.Presents w/ dysphagia,regurgitation,foul-smelling
2214 Medicine Gastrointestinal & Nutrition breath,aspiration,occasionally a palpable mass.Pts w/ ZD are at risk for aspiration pneumonia.*Contrast
esophagram* is the test of choice for confirming dx.Tx-surgical
Spontaneous bacterial peritonitis: sx- cirrhosis & ascites accompanied by either fever or a change in mental
2217 Medicine Gastrointestinal & Nutrition status. Paracentesis is the test of choice, w/ a positive ascites fluid culture & PMN level >250/mm3 being
the main criteria for making the dx
Tx for ascites:
1) sodium & water restriction
2218 Medicine Gastrointestinal & Nutrition 2) spirinolactone
3) loop diuretic
4) frequent abdominal paracentesis
Esophageal perforation can occur due to iatrogenic causes(eg, pt's condition worsened after endoscopy).
Chest radiography shows pleural effusion, pneumomediastinum, and/or pneumothorax. *Water-soluble
contrast esophagram* to confirm dx(its preferable to barium since it doesn't irritate the pleura if a leak is
present)
*Technetium-99 labeled erythrocyte scintigraphy*: used in cases of lower GI bleeding where source can't be
found by colonoscopy.Localizes source of blood loss so that region can be evaluated & treated by
colonoscopy or angiography
2340 Medicine Gastrointestinal & Nutrition Capsule endoscopy:for pts w/ chronic GI blood loss who have had a negative upper & lower endoscopy.
Used to examine small bowel
Laparotomy,for blind total abdominal colectomy & ileostomy,is reserved for persistent bleeding & if site can't
be found
Diverticulosis is the mcc of gross lower GI bleeding in adults. Bleeding is painless but may be ass. w/
2341 Medicine Gastrointestinal & Nutrition lightheadedness & hemodynamic instability. Diverticular hemorrhage usually resolves sponteneously but
occasionally requires endoscopic or surgical intervention
Acute pancreatitis is most commonly caused by gallstones & alcohol use. *Ultrasound* is the preferred test
to detect gallstones.
Carbachol is a cholinomimetic agent that stimulates contraction of the bowel musculature and might
contract the Oddi sphincter
Pt w/ chronic pancreatitis due to alcohol abuse: alcohol consumption exacerbates chronic pancreatitis ->
vomiting -> spontaneous rupture of the esophagus (Boerhaave syndrome).
Pneumomediastinum commonly occurs following rupture of the esophagus within the mediastinum. It
2369 Medicine Gastrointestinal & Nutrition presents as retrosternal pain & crepitus in the suprasternal notch
Mallory Weiss tear is an incomplete mucosal tear at the GE junction resulting from protracted vomiting.
Pneumomediastinum doesn't occur.
2581 Medicine Gastrointestinal & Nutrition *Neutrophilic cryptitis* can be seen in both Crohn's disease & Ulcerative colitis
Ulcerative colitis pts at increased risk for development of colorectal cancer. Once surveillance program is
started(usually after disease has been present for 8 years), colonoscopy should be repeated every 1-2
years to assess for development of dysplasia
If screening colonoscopies show dysplasia, pt will need prophylactic colectomy w/ construction of ileal pouch
Lynch syndrome II is distinctly ass. w/ a high risk of extracolonic tumors, the most common of which is
*endometrial carcinoma*, which develops in up to 43% of females in affected families
A pt w/ familial colonic polyposis has a 100% risk of cancer, if not treated appropriately w/ a
*proctocolectomy* at the time of diagnosis
Antibiotic therapy is the most accepted & recommended management for the eradication of H. pylori in pts
w/ gastric mucosa-associated lymphoid tissue (MALT) lymphoma w/o any metastasis. Such lymphomas
2596 Medicine Gastrointestinal & Nutrition may regress after the eradication of H.pylori using antibiotic therapy. Use chemotherapy if eradication of
H.pylori fails to produce regression of the lymphoma(eg, cyclophosphamide, adriamycin, vincristine,
prednisone or + Bleomycin).
Dx of esophageal cancer requires esophageal endoscopy w/ biopsy. Young, low-risk pts w/ undetermined
2601 Medicine Gastrointestinal & Nutrition esophageal sx may start w/ barium esophagram, but *those who are age >55 or w/ alarm sx (eg, weight
loss, gross or occult bleeding, early satiety) should proceed directly to endoscopy*
Carcinoid syndrome: episodic flushing(can cause "pounding sensation in the neck"), secretory diarrhea,
2625 Medicine Gastrointestinal & Nutrition wheezing, & murmur of tricuspid regurgitation(right sided valvular lesions). Elevated 24 hour urinary
5-hydroxyindoleacetic acid can confirm the dx in most pts
Painless jaundice in a pt w/ conjugated hyperbilirubinemia & markedly elevated alkaline phosphatase(eg,ALK
890 vs AST 67,ALT 52) should raise concern for *biliary obstruction due to pancreatic or biliary cancer*.[Pt
w/ conjugated hyperbilirubinemia, elevated alk phos, painless jaundice, & systemic sx(fatigue, weight loss)
suggest malignant obstruction of the biliary system]
Ashhadscknotes
Xanthelasma:cholesterol filled yellow plaques,appear on the medial aspects of eyelids bilaterally(upper/lower
eyelids may also be affected).Ass. w/ *primary biliary cirrhosis*
Chalazion:chronic,sterile,granulomatous inflammatory lesion of the meibomian glands

Hordeolum:purulent infection of one of the glands of the eyelid,caused by Staphylococcus
Stye:small,external hordeolum involving Zeis's or Moll's glands

Combo of cirrhosis, neuropsychiatric sx & Kayser-Fleischer rings(brownish or gray-green rings of fine
2895 Medicine Gastrointestinal & Nutrition granular copper deposits in the cornea) in a young adult is highly suggestive of Wilson's disease, also called
*hepatolenticular degeneration*
Primary biliary cholangitis (previously termed primary biliary cirrhosis) is a chronic liver disease charac by
intrahepatic cholestasis due to autoimmune destruction of small bile ducts. It presents in middle-aged
women w/ fatigue, pruritus, hepatomegaly,& elevated alkaline phosphatase. The dx is confirmed w/ serum
*anti-mitochondrial antibody* titers
Intrahepatic cholestasis (no biliary tract dilation)
Extrahepatic cholestasis (biliary tract dilation; eg,due to gallstones)

*Hyperestrogenism in cirrhosis leads to gynecomastia, testicular atrophy, decreased body hair, *spider
angiomas* & palmar erythema*
Portal htn causes esophageal varices, hemorrhoids, & caput medusae

Pathogenesis of cirrhotic ascites includes sinusoidal htn, seepage of hepatic lymph into peritoneal cavity,
leakage of intestinal fluid, & renal retention of sodium & water
Asterixis is a neurologic sign ass. w/ poor hepatic function & hyperammonemia

Pt's w/ rapidly progressing acute liver failure (ALF) can have decreasing transaminases with worsening
PT/INR & bilirubin
Spontaneous bacterial peritonitis (SBP): should be suspected in any pt w/ cirrhosis & ascites who presents
w/ low-grade fever, abdominal discomfort, or altered mental status.Ascitic fluid w/ *polymorphonuclear
leukocytes >250/uL* & positive peritoneal fluid culture confirm dx. Calculate the SAAG (serum albumin -
ascites albumin) which indicates SBP if its >1.1 g/dL
Tx-Treat empirically pending culture results w/ broad spectrum antibiotics such as 3rd-generation
cephalosporins
Acute cholecystitis:arises when gallstone impacts in the cystic duct,presents w/ sudden onset of steady
epigastric or RUQ pain after a large or fatty meal,pain may radiate to right scapula,fever, vomiting,
leukocytosis, mild elevations in transaminases[however alk phos usually NOT elevated unless there's ass.
2904 Medicine Gastrointestinal & Nutrition cholangitis or choledocholithiasis]
Common bile duct obstruction w/ stone or carcinoma causes obstructive jaundice(severe icterus & very high
alk phos levels)
Hepatitis A: fecal oral route transmission, common in areas w/ overcrowding & poor sanitation. Acute onset,
sx include malaise, fatigue, anorexia, nausea, vomiting, mild ab pain, aversion to smoking. Hepatomegaly
seen. Close contacts of individuals w/ hep A should be given immune globulin. High risk people should be
given hep A vaccine as prophylaxis
Cirrhosis should be suspected in any pt presenting w/ stigmata of chronic liver disease (eg, new-onset
ascites, pedal edema, spider angiomata, palmar erythema, caput medusae, nail changes, gynecomastia,
splenomegaly, testicular atrophy). Chronic alcohol abuse & *viral* hepatitis(hep C more than B) are the
2907 Medicine Gastrointestinal & Nutrition most common underlying causes of cirrhosis in the US
Statin induced hepatic dysfunction is usually dose dependent & presents w/ persistently elevated
aminotransferases
Serologic pattern of hepatitis B immunization: positive anti-HBs titer & negative markers for hepatitis B
surface antigen & core antibody
Alcoholic hepatitis: ratio of AST to ALT >2, elevated GGT, & elevated ferritin.[Absolute values of AST & ALT
are almost always <500 IU/L in alcoholic liver disease]
If marked elevations (>25x the upper limit) of AST & ALT are present, toxin-induced (eg, acetaminophen),
ischemic, or viral hepatitis should be suspected
2912 Medicine Gastrointestinal & Nutrition HBsAg & anti-HBc are the most appropriate diagnostic tests for acute hepatitis B infection
Acute liver failure is most often due to acute viral hepatitis, *medication induced liver injury eg,
acetaminophen/over-the-counter pain reliver toxicity*, & ischemic hepatopathy. Findings-acute onset of
2914 Medicine Gastrointestinal & Nutrition markedly elevated transaminases (often in the thousands), reduced hepatic synthetic function, &
encephalopathy
[Concurrent use of alcohol can increase the propensity to develop hepatotoxicity from acetaminophen]
*Isoniazid* causes idiosyncratic liver injury w/ histological features similar to those seen in pts w/ viral
hepatitis
Tuberculous hepatitis may develop in cases of miliary tuberculosis but would be characterized by
granulomas on liver biopsy
Ashhadscknotes
Gallstone disease is common in overweight women "fat, female, fertile woman of forty"
Cholesterol & mixed stones make up 80% of all gallstones in western population. They are radiolucent(not
2918 Medicine Gastrointestinal & Nutrition readily visible by abdominal radiograph).
Gallstones are more common in US. When gallstones do occur in those of Asian heritage, they are more
likely to be the pigment type.
*Primary sclerosing cholangitis:* chronic progressive disorder of unknown etiology w/ inflammation, fibrosis,
& stricturing of medium-sized & large intrahepatic & extrahepatic bile ducts. *It's frequently ass. w/
ulcerative colitis.* Lab studies show elevated liver function tests(more severely elevated alkaline
phosphatase & bilirubin) in a cholestatic pattern
Primary biliary cirrhosis:more common in women. No ass. w/ inflammatory bowel disease

Small nonbleeding varices:
tx- prophylaxis w/ nonselective beta blockers recommended to reduce progression to large varices and risk
of variceal hemorrhage.
In pts w/ contraindications to beta blocker therapy, use endoscopic variceal ligation
Endoscopic sclerotherapy is effective for bleeding esophageal varices
Octreotide is used to treat active variceal bleeding

Gilbert's syndrome:reduced production of UDP glucuronyl transferases.Icterus secondary to a mild
unconjugated hyperbilirubinemia(triggered by stress eg:fasting,illness,physical exertion).Tx unnecessary
Crigler-Najjar syndrome type 1:severe jaundice, neurologic impairment due to

kernicterus.Phototherapy/plasmapheresis helpful in the short term.Liver transplant is only curative option
Crigler-Najjar syndrome type 2: milder

tx- often unnecessary,phenobarbital or clofibrate
Dubin-Johnson syndrome: dark granular pigment is present in the hepatocytes. Causes conjugated
hyperbilirubinemia. Liver is strikingly black. Histo features reveal dense pigment composed of epinephrine
metabolites within the lysosomes.
Gilbert's syndrome: occurs in pts w/ no apparent liver disease, causes mild unconjugated hyperbilirubinemia
thought to be provoked by things like fasting, stress, illness
Resolved hepatitis B infection:anti-HBs positive, anti-HBc positive, HBsAg negative
Immunized w/ heptatitis B vaccine:anti-HBs positive, HBsAg negative,anti-HBc negative

[HBV vaccine doesn't contain the core antigen so antibodies are not made against it & pts are anti-HBc
negative]
Acute hepatitis B infection:presence of HBsAg & IgM anti-HBc
Chronic hepatitis B infection:presence of HBsAg in serum for >6 months
Recovery phase: presence of anti-HBs, anti-HBc(IgG), anti-HBe

In a pt w/ sx of acute pancreatitis like typical abdominal pain, elevated amylase/lipase,or epigastric pain
radiating to the back,we don't need to do confirmatory imaging for dx.Instead, perform *abdominal
ultrasound/RUQ ultrasound* in these pts to evaluate for cholelithiasis or choledocholithiasis (remember
gallstones [& chronic alcohol abuse] account for about 75% of cases of acute pancreatitis)
Oral ursodeoxycholic acid supplementation reduces sx from gallstones but doesn't lead to complete
dissolution. It's used to tx symptomatic gallstones in individuals who are poor surgical candidates
Lithotripsy(laser or mechanical fragmentation)sometimes used for gallstones in the bile duct that can't be
removed endoscopically
Hepatic adenoma:benign tumor often seen in young & middle-age women who take oral contraceptives.
Ultrasound shows well-demarcated, hyperechoic lesions. Possible long-term complications include
progressive growth, rupture, & malignant transformation. Needle biopsy not recommended. Surgical
excision preferred
Elevated alk phos & GGT suggests biliary compression/obstruction
Focal nodular hyperplasia: ass w/ anomalous arteries

Uncomplicated pts w/ acute onset of severe epigastric pain radiating to the back & *increased amylase or
lipase (>3 times normal)* do not need confirmatory imaging for diagnosing acute pancreatitis.
2934 Medicine Gastrointestinal & Nutrition Contrast-enhanced computed tomography scan of the abdomen may be performed in pts w/ unclear
diagnosis or those who fail to improve w/ conservative management. Abdominal ultrasound may identify
gallstones as the cause of pancreatitis
Ashhadscknotes
*Abdominal CT scan* is a sensitive & specific tool used in dx of pancreatic carcinoma(weight loss,
jaundice,increased serum bilirubin & alkaline phosphatase)
For jaundiced pts we first do abdominal ultrasound. If US nondiagnostic, we do abdominal CT. If CT also
nondiagnostic, we do the invasive ERCP(excellent in dx pancreatic cancer)
Percutaneous transhepatic cholangiogram is for pts who have previously identified biliary tract dilation but
aren't candidates for ERCP
Pts w/ cirrhosis should undergo screening *endoscopy* to exclude varices, indicate the risk of variceal
hemorrhage, & determine strategies(eg,nonselective beta blockers) for primary prevention of variceal
hemorrhage. All pts w/ cirrhosis, regardless of etiology, should also undergo surveillance for hepatocellulcar
carcinoma w/ ultrasound every 6 months
In evaluating the asymptomatic elevation of aminotransferases, the first step is to take a thorough history to
2937 Medicine Gastrointestinal & Nutrition rule out the more common hepatitis risk factors (eg, alcohol or drug use, travel outside of the country, blood
transfusions, high-risk sexual practices)
Ursodeoxycholic acid is used to dissolve small radiolucent gallstones in pts w/ normal gallbladders who are
2939 Medicine Gastrointestinal & Nutrition poor surgical candidiates. This medication is expensive and ass. w/ high risk of relapse when therapy is
halted
Postcholecystectomy syndrome: persistent abdominal pain or dyspepsia (eg, nausea) that occurs either
postoperatively or months to years after a cholecystectomy. Due to biliary or extra biliary causes. Pts notice
2943 Medicine Gastrointestinal & Nutrition same pain they had prior to surgery, new pain just after surgery, or the same pain that never went away.
Labs- elevated alkaline phosphatase, mildly abnormal serum aminotransferases, & dilated common bile duct
on abdominal ultrasound. Do *ERCP* after ultrasound for dx
Acalculous cholecystitis:acute inflammation of gallbladder in absence of gallstones,commonly seen in
hospitalized & severely ill pts.
Clinical presentation-unexplained fever, vague/RUQ abdominal discomfort, leukocytosis.
Dx-abdominal ultrasound(preferred). Cholescintigraphy (HIDA scan) or abdominal CT scan if ultrasound not
diagnostic
Subphrenic abscess:causes fever/ab pain.Develops due to peritonitis.Right sided pleural effusion can
develop
Hepatic encephalopathy: a CNS complication of liver failure due to inability to break down ammonia into
urea. Can present clinically as stage 1 (altered sleep pattern eg,insomnia/hypersomnia & impaired cognition)
& progress to stage 4 (stupor & coma). *Serum ammonia(though nonspecific) helps support dx in pts w/
high suspicion of hepatic encephalopathy*
Brain MRI can evaluate for structural causes of altered mentation(stoke, brain mass)
Primary biliary cirrhosis:
tx- Ursodeoxycholic acid
Most common malignancy of the liver is metastasis from another primary source.
Liver is the second most common site of metastatis spread (after lymph nodes)
2951 Medicine Gastrointestinal & Nutrition Hepatic adenomas: found in young & middle aged women w/ a lengthy hx of oral contracetive usage
Hepatic angiosarcoma: Common in older men that have been exposed to toxins such as vinyl chloride gas,
inorganic arsenic compounds, & thorium dioxide
Management of hepatic encephalopathy involves supportive care, tx the precipitating cause(eg, volume
depletion, electrolyte abnormalities), & lowering serum ammonia. Disaccharides (eg, lactulose, lactitol) are
initially preferred for lowering serum ammonia. Rifaximin can be added to lactulose in pts w/o improvement
after 48 hours or used as monotherapy in those unable to take lactulose
TIPS:for complications of portal HTN(variceal hemorrhage, ascites) & hepatorenal syndrome

Acute pancreatitis in pts without gallstones or hx of alcohol use:
etiology-Hypertriglyceridemia can cause acute pancreatitis
sx- eruptive xanthomas(crops of yellow-red papules on arms & shoulders)
management- confirm w/ fasting serum lipid profile
Cigarette smoking is the most consistent reversible risk factor for pancreatic cancer
2966 Medicine Gastrointestinal & Nutrition Studies haven't shown a significantly decreased incidence of pancreatic cancer w/ alcohol reduction (heavy
alcohol use can lead to chronic pancreatitis, which is ass. w/ a slightly higher risk of pancreatic cancer,
however it isn't as significant as the ass. between smoking & pancreatic cancer)
Hepatic hydrothorax causes transudative pleural effusions in pts w/ cirrhosis who have no underlying
cardiac/pulmonary disease to cause the effusion. Hepatic hydrothorax usually results in a right-sided pleural
effusion. Initial tx is w/ salt restriction & diuretics.
Refractory hepatic hydrothorax tx-*TIPS placement*
Combo of nitrates/hydralazine used to tx systolic heart failure
Pleurodesis is used to treat recurrent malignant pleural effusions
Ashhadscknotes
Elevated alkaline phos is indicative of cholestasis. These pts should be evaluated w/ RUQ *ultrasound* to
assess for intrahepatic/extrahepatic causes of biliary obstruction
2975 Medicine Gastrointestinal & Nutrition ERCP performed in pts when initial ultrasonography/CT scan suggests presence of obstruction due to
cholelithiasis/malignancy. ERCP is diagnostic & therapeutic;relieves obstruction & facilitates biliary drainage
The aminotransferases(AST & ALT)are elevated in viral hepatitis.If normal,viral hep unlikely
A positive urine bilirubin assay is typically indicative of a buildup of conjugated bilirubin
Rotor's syn: benign, chronic or fluctuating conjugated hyperbilirubinemia due to a *defect in hepatic
secretion of conjugated bilirubin* into the biliary system. Liver function tests normal.
Acute cholangitis tx- supportive care and broad spectrum antibiotics. Pts who don't respond to this should
undergo drainage of the biliary tree w/ *ERCP*
Transhepatic cholangiopancreatography is an alternative tx option when ERCP is unavailable or
contraindicated
Acute pancreatitis(pain radiating to back,leukocytosis,elevated serum amylase & lipase in chronic alcoholic
pt after binge drinking) can cause an acute abdomen(severe ab pain of unclear etiology).Should be
managed conservatively w/ analgesics,IV fluids & nothing by mouth
ERCP effective for managing severe biliary pancreatitis.Allows for sphincterotomy & stone removal
Orthotopic *liver transplantation* remains the only effective mode of treatment of fulminant hepatic
2986 Medicine Gastrointestinal & Nutrition failure[Fulminant hepatic failure is defined as hepatic encephalopathy that develops within 8 weeks of the
onset of acute liver failure]
3086 Medicine Gastrointestinal & Nutrition Vitamin E deficiency: RBC fragility, hyporeflexia, muscle weakness & blindness
Pellagra is due to niacin deficiency & is charac by dermatitis(on sun-exposed
areas,rough,hyperpigmented,scaly skin), diarrhea(w/ab pain,nausea,loss of appetite), & dementia(memory
3087 Medicine Gastrointestinal & Nutrition loss,affective sx,psychosis). *Prolonged isoniazid therapy* can interfere w/ niacin metabolism & occasionally
cause pellagra. In developing countries, niacin deficiency is seen in populations that subsist primarily on
*corn* products(niacin in corn occurs in a bound, unabsorbable form)
Chemical peritonitis(w/ peritonitis,you get sx like rebound tenderness & guarding) due to *perforated peptic
ulcer* should be suspected in pts presenting w/ sudden onset of severe epigastric pain that spreads over
the entire abdomen. Upright chest &/or abdominal radiographs typically reveal free air under the
diaphragm(pneumoperitoneum)[know what free air under diaphragm looks like on CXR]
Colovesical fistula:due to diverticular disease(extension of ruptured diverticulum/erosion of diverticular
abscess into bladder).Sx-pneumaturia(air in urine), fecaluria(stool in urine),recurrent UTIs(mixed flora).Ab
CT scan w/ oral or rectal(not IV)contrast confirms dx by showing contrast material in bladder w/ thickened
colonic & vesicular walls
Emphysematous pyelonephritis:pyelonephritis due to gas producing infection,esp in diabetics

Esophageal perforation is more likely than aortic dissection in pts w/ chest pain who have a widened
mediastinum ass. w/ mediastinal air(aortic dissection CAN'T cause pneumomediastinum). Diagnostic study
of choice for esophageal perforation is *water soluble Gastrografin-contrast esophagography* or CT
esophagography
Whipple's disease: arthralgias, weight loss, fever, & abdominal pain. PAS-positive material in the lamina
propria of the small intestine. Skin hyperpigmentation may also be seen.
Pancratic cancer:
Ultrasound of the abdomen is useful to exclude biliary obstruction in pts w/ jaundice.
Contrast enhanced CT of the abdomen is preferred for pts w/o jaundice
Secretin test measures the ability of pancreatic ductal cells to produce bicarbonate. It is used for dx chronic
pancreatitits but is not helpful for evaluating pancreating cancer.
*Zollinger-Ellison syndrome (gastrinoma) is ass. w/ multiple endocrine neoplasia (MEN) type 1 (parathyroid
tumors, pituitary tumors, & pancreatic tumors)*
Gastrinomas:non-beta islet cell tumors of the pancreas.Secrete high amounts of

3587 Medicine Gastrointestinal & Nutrition gastrin.Endoscopy-thickened gastric folds,multiple peptic ulcers,or ulcers distal to duodenum &
jejunum.These refractory ulcers can occur despite proton pump inhibitor or antacid use.Commonly seen in
MEN 1
Marfanoid habitus seen in MEN 2B

Pts w/ dyspepsia(epigastric fullness/discomfort after eating) who have risk factors for gastric or esophageal
cancer- age >55, weight loss, gross or occult bleeding, anemia, dysphagia, or early satiety should be
evaluated w/ upper gi endoscopy.
Pts w NSAID induced dyspepsia should receive a proton pump inhibitor.
Pts w/ risk factors for H. pylori may have testing for active infection(w/*H. pylori stool antigen testing/stool
assay* or breath test)
3589 Medicine Gastrointestinal & Nutrition Hemorrhage is the most common complication of peptic ulcer disease
Ashhadscknotes
If a pt has *multiple stomach ulcers* & *thickened gastric folds* on endoscopy, we should suspect
Gastrinoma (Zollinger-Ellison syndrome). Next step would be to measure *serum gastrin
concentration*.Fasting serum gastrin level >1000 pg/mL is diagnostic.Pts w/ non-diagnostic serum gastrin
3591 Medicine Gastrointestinal & Nutrition levels should be evaluated w/ a secretin stimulation test
Calcium infusion study:for pts who have gastric acid hypersecretion & are suspected of having gastrinoma
despite a neg secretin test
Peptic ulcer bleeds will stop spontaneously. Do Endoscopy next since it's diagnostic, therapeutic,& may
prevent rebleeding
Studies showed significantly less recurrent bleeding in pts receiving PPIs such as pantoprazole. However
studies on H2 antagonists have been disappointing
Somatostatin/octreotide acts by reducing splanchnic blood flow,inhibiting gastric acid secretion,exerting

gastric cytoprotective effects. Used when endoscopy unsuccessful/unavailable/contraindicated
Laxative abuse: sx- very frequent, watery, nocturnal diarrhea. Dx can be confirmed w/ biopsy finding of dark
brown discoloration of the colon w/ lymph follicles shining thru as pale patches (melanosis coli)
Celiac disease: *IgA anti-endomysial & anti-tissue transglutaminase antibodies* are highly predictive of
celiac disease but may be absent if there is a concurrent selective IgA deficiency
Collagenous colitis: uncommon disorder producing chronic watery diarrhea. Colon frequently involved but
colonoscopy shows normal mucosa. Biopsy shows mucosal subepithelial collagen deposition
Small intestine bacterial overgrowth (SIBO) is a malabsorption syndrome caused by anatomic
abnormalities(eg, surgery, strictures) or motility disorders(eg, diabetes, systemic sclerosis).
sx-abdominal bloating, flatulence, & diarrhea
dx-Endoscopy w/ jejunal aspirate showing
>10^5 organisms/mL is the gold standard
Partial small bowel obstruction presents w/ postprandial abdominal discomfort, nausea, and obstipation
(inability to pass flatus or stool)
Lactose intolerance: *positive hydrogen breath test*, positive stool test for reducing substances, low stool
pH & increased stool osmotic gap. No steatorrhea
Urine test for reducing substances is positive in pts w/ glucosuria, galactosuria, etc
*Chronic GERD & Barrett's esophagus* are risk factors for *adenocarcinoma* of the esophagus
Risk factors for squamous cell cancer of the esophagus are smoking and alcohol
Acute appendicitis:
The initial peri-umbilical pain is referred pain & visceral in nature; however, pain shifts to the right lower
3703 Medicine Gastrointestinal & Nutrition quadrant w/ involvement of the parietal peritoneum & becomes somatic in nature
The chronology of abdominal pain in acute appendicitis is typically visceral, followed by somatic pain
Massive doses of aspirin & NSAIDs can cause acute erosive gastritis & upper GI bleeding. Alcohol can
aggravate their effect
Mallory Weiss tears occur after repeat bouts of retching & vomiting
Porcelain gallbladder(google CT image): results from the intramural deposition of calcium salts. Ass. w/
*increased risk of gallbladder carcinoma* & requires surgical resection
Zinc deficiency: may result from chronic total parenteral nutrition or malabsoption. Sx-alopecia, skin
lesions(bullous,pustulous lesions surrounding body orifices & extremities), abnormal taste, & impaired
wound healing. Pts w/ inflammatory bowel disease at risk for impaired absorption of zinc. May cause growth
retardation in children
Most imp feature of Selenium deficiency is cardiomyopathy

3833 Medicine Gastrointestinal & Nutrition Acute pancreatitis can be caused by anti-seizure drug use (eg, valproic acid)
Toxic megacolon:total or segmental nonobstructive colonic dilation,bloody diarrhea,systemic
findings(fever,tachycardia).Pts w/ inflammatory bowel disease at higher risk of developing it.Dx confirmed by
plain ab xrays & >3 of the following:fever >100.4F, pulse >120/min, wbc count >10,500, & anemia. It's a
3834 Medicine Gastrointestinal & Nutrition medical emergency & requires prompt iv steroids, nasogastric decompression, abx, & fluid management
Right sided colon cancer->anemia

Left sided tumors->bowel obstruction
Office based anoscopy/proctoscopy should be the initial procedure in pts less than 50 years old who present
w/ minimal bright red blood per rectum & do not have any risk factors for colon cancer(blood intermixed w/
3857 Medicine Gastrointestinal & Nutrition stool is not included in this category)
You do Colonoscopy & sigmoidoscopy if pt is more than 50 years old or has risk factors for colon cancer
Ashhadscknotes
Giardiasis:persistent diarrhea & ab cramps.Transmitted via water in rural areas & developing
countries.Preferred dx test is *stool antigen assay*.Metronidazole is the 1st line tx
3887 Medicine Gastrointestinal & Nutrition Short course of ciprofloxacin advised for empiric tx of traveler's diarrhea(due to E.coli)
Upper endoscopy w/ small bowel biopsy(to rule out tropical sprue) & colonoscopy considered in pts w/
persistent diarrhea who remain undiagnosed after initial noninvasive testing(microscopy,stool antigen test)
Risk factors for a polyp progressing into malignancy are villous adenoma, sessile adenoma, and size >2.5
cm
Adenomas- these polyps are potentially premalignant, however <1% become malignant
Hyperplastic polyps are non-neoplastic
NSAIDs(like naproxen) and aspirin can cause gastritis and gastric ulcers leading to chronic gi blood loss &
depletion of iron stores which can eventually cause iron deficiency anemia
3936 Medicine Gastrointestinal & Nutrition management- withhold NSAIDs & aspirin and initiate antisecretory meds (such as proton pump inhibitors)
Anemia of chronic disease can occur in rheumatoid arthritis, lupus but is NOT ass. w/ osteoarthritis
Non-caseating granulomas are characteristic of Crohn's disease
Ulcerative colitis most commonly involves rectum, however it may sometimes involve terminal ileum
4074 Medicine Gastrointestinal & Nutrition (backwash ileitis)
Crohn's disease can affect any part of intestinal tract from mouth to anus but is most commonly limited to
the terminal ileum
Angiodysplasia:
common cause of recurrent or occult painless lower gi bleeding in pts age > 60 years
causes lower gi bleeding in pts with aortic stenosis (heyde's syndrome). look for stem to mention features of
aortic stenosis like "systolic ejection murmur in right intercostal space"
hyperplastic polyps:
are non-neoplastic
Diverticulosis: ass. w/ chronic constipation. Risk of complications is lower w/ a high intake of fruit &
vegetable fiber, & higher w/ heavy meat consumption, aspirin or NSAID use, obesity, & possibly smoking
Zollinger Ellison syndrome:
Caused by gastrin producing pancreatic tumor.
The uncontrolled gastrin secretion causes parietal cell hyperplasia to develop and causes an increase in
stomach acid production.
Multiple duodenal ulcers are typical & a jejunal ulcer is pathognomic.
Steatorrhea may develop cuz increased production of stomach acid inactivates pancreatic enzymes
Chronic inflammatory diarrhea is typically ass. w/ inflammatory changes in the blood (anemia, elevated
4150 Medicine Gastrointestinal & Nutrition ESR, acute phase reactants, reactive thrombocytosis). Blood/leukocyte-positive stool is another important
finding
Zenker (pharyngoesophageal) diverticulum: Develops immediately above the upper esophageal sphincter.
Occurs due to posterior herniation between the fibers of the cricopharyngeal muscle. Sx-dysphagia,
coughing, regurgitation, halitosis, aspiration & a neck mass. Pts usually over 60 years of age. Neck mass
may very in size depending on food & fluid intake. Dx confirmed w/ barium esophagram. Tx is surgical.
Diffuse esophageal spasm: intermittent chest pain & dysphagia.High amplitude peristaltic contractions on
manometric studies.LES has normal relaxation response. Corkscrew esophagus. Ass. w/ emotional factors
& functional GI disorders.Tx-antispasmodics,dietary modulation & psychiatric counseling
Achalasia:hypertrophied inner circular muscles w/ absent or degenerating neurons (ganglion cells) in
myenteric plexuses.Absent peristalsis.Condition in South America due to T.cruzi
Fatty liver (steatosis), alcoholic hepatitis(characterized by mallory bodies, infiltration by neutrophils) & early
fibrosis of the liver can be reversible w/ the cessation of alcohol intake.
True cirrhosis is characterized by the presence of regenerative nodules. This condition is irreversible, even
w/ the cessation of alcohol intake
Pts w/ upper GI bleeding often have an *elevated BUN & elevated BUN/creatinine ratio*, possibly due to
increased urea production(from intestinal breakdown of hemoglobin) & increased urea reabsorption(due to
hypovolemia)
The urine sodium (ie, fractional excretion of sodium [FENa]) is often low in pts who are volume depleted as
the kidney attempts to retain sodium to restore circulatory volume. Increased FENa is seen in intrinsic renal
disease
Nonalcoholic fatty liver disease(NAFLD): resembles alcohol induced liver injury on histology but occurs in pts
w/ minimal or no alcohol hx. The most likely mechanism is *insulin resistance*. Pt will have elevated liver
enzymes. Pts have hx of obesity, diabetes, hyperlipidemia, htn. Tx- diet & exercise. Consider bariatric
surgery if BMI >35
Ashhadscknotes
Boerhaave syndrome:esophageal TRANSMURAL tear,ESOPHAGEAL AIR/FLUID LEAKAGE in nearby
areas.CT/CONTRAST ESOPHAGOGRAPHY W/ GASTROGRAFIN confirms dx.Pleural
fluid-EXUDATIVE,LOW pH,HIGH AMYLASE.CXR-unilateral pleural effusion(usually left)w/ or w/o
pneumothorax,pneumomediastinum,subcutaneous/mediastinal emphysema & widended mediastinum
Mallory-Weiss tear:mucosal tear
Acute pancreatitis-high amylase,NO mediastinal widening
Aortic dissec-wide mediastinum,NO amylase related probs

Chronic pancreatitis: progressive inflammatory disorder of the pancreas characterized by upper abdominal
4362 Medicine Gastrointestinal & Nutrition pain, diarrhea/steatorrhea, weight loss. Presence of pancreatic calcifications on *computed tomography
scan* or plain film establishes dx
duodenul ulcer:
sx- pain relieved w/ eating, melena
4363 Medicine Gastrointestinal & Nutrition 90% of pts are infected w/ H. pylori
tx- antibiotic treatment w/ amoxicillin plus clarithromycin (to eradicate H. pylori) and proton pump inhibitor
(for acid suppression)
Upper gi bleeding can cause anemia. Tx severe anemia (only if stable pt's hemoglobin <7 g/dL) w/ packed
red blood cell transfusion.
A higher threshold of hemoglobin <9 g/dL considered for unstable pt w/ sx related to the anemia or acute
coronary syndrome w/ active ischemia
Cryoprecipitate used as replacement therapy for pts w/ fibrinogen, von Willebrand factor, or Factor VIII
deficiency
Whole blood transfusion rarely used except in pts w/ severe hemorrhage/major trauma
Tx of actively bleeding esophageal varices involves hemodynamic support, pharmacologic treatment (eg,
octreotide), endoscopic therapy, & prophylactic antibiotics. Coagulopathy, anemia, & thrombocytopenia are
common complications & may also require correction
Somatostatin analogues (octreotide) inhibit the release of vasodilator hormones, which leads indirectly to
splanchnic vasoconstriction & decreased portal flow
Colon cancer, metastatic to the liver sx: abdominal pain/RUQ pain, microcytic anemia(low hgb & low mcv),
mildly elevated liver enzymes,positive fecal occult blood, & hepatomegaly w/ a hard edge on liver palpation.
Pt can also have a small left-sided pleural effusion that may be malignant. [Most common site of colon
cancer metastasis is the liver]
Achalasia: Decreased esophageal body peristalsis & poor relaxation/no relaxation of the LES on
manometry. Progressive dysphagia, chest pain, food regurgitation & aspiration. Barium swallow shows
dilated esophagus & a "bird's beak" deformity of the LES
GERD: decreased LES pressure
Cricopharyngeal dysfunction: due to failure of cricopharyngeus to relax during swallowing, causes choking or
"food sticking" sensation & pain w/ swallowing
Biliary colic- gallbladder contracts against an obstructed cystic duct. Pain exacerbated by fatty meals. Pain
4433 Medicine Gastrointestinal & Nutrition is constant, in RUQ or epigastric region, causes nausea, vomiting, right sided shoulder pain(referred pain).
Pain resolution within 4-6 hours and absence of abdominal tenderness, fever, and leukocytosis
Acute pancreatitis classically causes nausea, vomiting, & epigastric pain(pt gets partial relief by sitting up &
4434 Medicine Gastrointestinal & Nutrition leaning forward). Alcohol abuse & gallstone disease are the mcc of acute pancreatitis. Complications include
pleural effusion, acute respiratory distress syndrome, ileus, & renal failure
Risk of *colorectal cancer* is elevated in Ulcerative colitis(UC) and surveillance colonoscopy is advised(even
in the absence of symptoms)
Although pts w/ UC have an increased risk for developing primary sclerosing cholangitis(PSC) and Toxic
megacolon, routine surveillance is currently not recommended for PSC and no form of regular surveillance
has been shown to prevent toxic megacolon
Low dose chest CT is recommended yearly for lung cancer screening in pts who are age 55-80, have a >30
pack year smoking hx, & are currently smoking or quit within the past 15 years
4505 Medicine Gastrointestinal & Nutrition Unfortunately, no screening options exist for pancreatic cancer
Pts w/ risk factors for hepatitis B virus should be *vaccinated*, which is esp important in pts already infected
w/ hepatitis C virus who are continuing their high-risk behaviors
Cirrhosis causes 80% of ascites cases in the US. Cirrhosis is caused by alcoholic liver disease & hepatitis
C(look for iv drug abuser)
Pts w/ nephrotic syndrome:anasarca,bilateral peripheral edema,ascites,hypercoagulable state

Paradoxical embolism:due to an embolus from the venous circulation across a patent foramen ovale or asd
into the systemic circulation.Can lead to a stroke
Chronic pulmonary emboli leads to pulmonary htn & subsequent right heart failure/cor pulmonale
Ashhadscknotes
Acute pancreatitis complicated by hypotension is thought to arise from intravascular volume loss secondary
to local & systemic vascular endothelial injury. This causes vasodilation, increased *vascular permeability*, &
plasma leak into the retroperitoneum, resulting in systemic hypotension. Tx- supportive care w/ several liters
of IV fluid to replace the lost intravascular volume
Colorectal cancer is the most common source of liver metastases (blood from the colon moves thru the
4612 Medicine Gastrointestinal & Nutrition portal circulation directly to the liver). In a pt w/ multiple liver lesions on CT, consider colorectal cancer as a
differential, even in the absence of specific sx(eg,alteration in bowel habits, GI bleeding)
Vanishing bile duct syndrome is a rare condition characterized by progressive ductopenia, or loss of
intrahepatic bile ducts. *Primary biliary cirrhosis* is the mcc of ductopenia in adults.
The pathologic hallmarks of primary sclerosing cholangitis are periductal portal tract fibrosis and segmental
stenosis of extrahepatic and intrahepatic bile ducts. (Bile duct loss is not classically observed)
Hepatic encephalopathy (HE) is a central nervous complication of cirrhosis due to liver's inability to convert
ammonia to urea.Tx-Nonabsorbable disaccharides(lactulose, lactitol) are preferred for lowering serum
4625 Medicine Gastrointestinal & Nutrition ammonia.Abx(rifaximin) can decrease the number of ammonia-producing bacteria in the colon.They are
usually added to lactulose if the pt doesn't improve within 48 hours.Catharsis using any laxative may also be
beneficial
If pt's Anti-HAV antibodies is negative, tx w/ Hepatitis A vaccination
Prednisone tx severe alcoholic hepatitis

Lamivudine (3TC) is a reverse transcriptase inhibitor used to tx HIV & chronic hepatitis B
Pts w/ cirrhosis are intravascularly depleted & impressive salt retainers. A low salt diet is beneficial in
decreasing ascites & peripheral edema
Chronic liver disease w/ resultant cirrhosis can cause hypogonadism. Findings in men w/ cirrhosis include
telangiectasias, palmar erythema, testicular atrophy, genecomastia, and erectile dysfunction
Cirrhosis in women can cause amenorrhea or irregular menses

Adrenal insufficiency in women results in decreased axillary & pubic hair & loss of libido(since women's
androgen production occurs in adrenal glands).This doesn't affect men since their androgens are produced
in testes
Ischemic hepatic injury(shock liver):occurs in the setting of hypotension & manifests as acute,massive
increases in the AST & ALT w/ milder associated increases in the total bilirubin & alkaline phosphatase. In
4648 Medicine Gastrointestinal & Nutrition pts who survive the inciting condition, liver enzymes return to normal within a few weeks.
Autoimmune hepatitis commonly affects young women

Chronic hepatitis C: extrahepatic sequelae include *essential mixed cryoglobulinemia*, porphyria cutanea
tarda(fragile skin, photosensitivity, & vesicles & erosions on the dorsum of hands), and
membranoproliferative glomerulonephritis
Lambert-Eaton syndrome: presents w/ muscle weakness & dry mouth
Polyarteritis nodosa: Necrotizing vasculitis in small/medium vessels due to deposition of circulating

antigen-antibody immune complexes in blood vessel walls.Ass w/ hepatitis B
GERD can predispose to 1) Barrett's esophagus & 2) esophageal (peptic) stricture formation, which will
cause symmetric & circumferential narrowing of the involved esophagus w/ dysphagia for solids but typically
no weight loss. As the stricture progresses, it can block the acid reflux, leading to improvement of heartburn
sx
Achalasia:dysphagia(both solids & liquids),"bird beak"pattern at ge junction
Hiatal hernia is a protrusion of stomach above the diaphragm

Anticoagulation w/ warfarin places pts at risk for hemorrhage. *Retroperitoneal hematoma*(look at CT
image) may occur even w/o a supratherapeutic INR. Hx of anticoagulation,back pain & signs & sx of
hemodynamic compromise(weakness,dizziness,anemia,tachycardia) should raise suspicion for
retroperitoneal hematoma
Serum to ascites albumin gradient (SAAG) is calculated by subtracting the peritoneal fluid albumin
concentration from the serum albumin concentration:
4747 Medicine Gastrointestinal & Nutrition SAAG >1.1 indicates portal hypertensive etiologies(cardiac ascites,cirrhosis) aka *increased hydrostatic
pressure* within hepatic capillary beds
SAAG <1.1 suggests non-portal hypertensive etiologies(malignancy,pancreatitis,nephrotic syndrome, tb)

Hepatorenal syndrome(HRS):
complication of end stage liver disease/cirrhosis
characterized by renal failure (elevated creatinine) that doesn't respond to volume resuscitation
tx- liver transplantation
diuretics worsen HRS
Ashhadscknotes
Total parenteral nutrition(or prolonged fasting) causes *gallbladder stasis* & predisposes to gallstone
formation & bile sludging, both of which may lead to cholecystitis.
Small bowel(ileal) resection can also cause gallstones due to decreased enterohepatic circulation of bile
acids -> increased concentration of bilirubin conjugates and total calcium in the gallbladder
4903 Medicine Gastrointestinal & Nutrition *Crohn's disease: Aphthous ulcers in the mouth, abdominal pain*
4919 Medicine Gastrointestinal & Nutrition Pain ass. w/ pancreatic cancer is usually subacute (days to weeks) and not present for a year
Pts w/ upper GI bleeding who have a depressed level of consciousness & ongoing hematemesis should be
4927 Medicine Gastrointestinal & Nutrition *intubated* to protect the airway as a part of initial stabilization & resuscitation. Prompt endoscopic tx w/
band ligation or sclerotherapy should then be performed to stop the bleeding
Pill esophagitis: sudden onset odynophagia & retrosternal pain that can sometimes cause difficulty
swallowing. It's most common in the mid-esophagus due to compression by the aortic arch or an enlarged
left atrium. Endoscopy shows discrete ulcers w/ relatively normal-appearing surrounding mucosa
Diffuse esophageal spasm: uncoordinated simultaneous contractions of lower esophagus. Pts have
recurrent episodes of liquid/solid dysphagia & chest pain
Prolonged gastric acid suppression w/ proton pump inhibitors or histamine 2 receptor antagonists is a risk
factor for Clostridium difficile infection. Dx of C difficile colitis can be confirmed w/ a *stool assay for toxins A
11067 Medicine Gastrointestinal & Nutrition & B*.Other than C diff infection,long term acid suppression w/ PPI's may result in impaired calcium
absoption w/ increased risk of osteoporosis & increased colonization of pathogens in the upper GI tract
leading to a higher risk of pneumonia
When breaking bad news, a doc should first set the stage & assess the pt's comprehension before
delivering the news in an empathetic yet comprehensible manner
Example
2197 Medicine General Principles
1) What do you think is going on w/ your back?
then
2) Have you considered whether you want to know the test results, regardless of the outcome?
Perform mammograms every 2 years in women > 50 years old. No need to do mammography after age 75.
incidence of cervical cancer peaks before age 50 and declines afterwards. Discontinue pap smears after
age 65 if pt has no malignant findings
Women should be screened for cervical cancer w/ a Pap smear every 3 years at age 21-65 (or w/ Pap
smear & HPV testing every 5 years at age 30-65).
A single dose of Tdap (tetanus toxoid, reduced diphtheria toxoid, & acellular pertussis) is recommended
beginning at age 11, w/ Td (tetanus & diphtheria toxoids) every 10 years thereafter
Malignancy(hx of smoking, back pain, weight loss) is a risk factor for venous thromboembolism (VTE).
Recommended testing for occult malignancy includes age appropriate screening (colonoscopy,
2208 Medicine Hematology & Oncology mammogram) & CXR in most pts w/ first unprovoked VTE. More detailed testing (*CT scan of
abdomen/pelvis/chest*) is indicated for high risk pts such as those w/ clinical findings concerning for
malignancy or recurrent or multiple-site (cerebral,hepatic vein) VTE
Autoimmune hemolytic anemia (AIHA) & hereditary spherocytosis (HS) can cause extravascular hemolytic
anemia. Peripheral blood smear in both conditions may show spherocytes w/o central pallor.
2248 Medicine Hematology & Oncology
AIHA: negative family hx & positive Coombs test
HS: positive family hx & negative Coombs test
MGUS: ABSENCE OF anemia,hypercalcemia,lytic bone lesions,renal insufficiency. *Metastatic skeletal bone
survey/xray* is rec. in MGUS pts to exclude lytic lesions suggesting multiple myeloma. Although MGUS is
asymptomatic, there is 1% per year risk of progression to multiple myeloma
Abdominal fat pad biopsy considered for amyloidosis
If pt's calcium level normal, checking serum PTH & vit D is unnecessary
Heparin induced thrombocytopenia(HIT):suspect when platelet counts fall >50% from baseline 5-15 days
after starting heparin,unexplained thrombocytpenia,or thrombosis(arterial or venous) in pts tx w/ heparin.
2250 Medicine Hematology & Oncology Tx- 1)stop all heparin products & confirm w/ lab testing 2)begin alternative anticoagulants like direct
thrombin inhibitors(argatroban,bivalirudin) or fondaparinux(synthetic pentasaccharide).Warfarin is started
after these treatments & after platelet count is >150,000
Paroxysmal nocturnal hemoglobinuria should be suspected in pts who have a combination of hemolytic
anemia, cytopenias, & hypercoagulable state (intraabdominal or cerebral venous thrombosis). Absence of
CD55 & CD59 proteins on surface or RBCs
Acute intermittent porphyria: abdominal pain & dark red/brown urine. Pigmented urine is due to porphyrins
and/or porphyrin precursors
Waldenstrom's macroglobulinemia is characterized by hyperviscosity of the blood owing to the excess
production of IgM. Two imp dx clues for this disorder are: 1) an IgM spike on electrophoresis, & 2)
hyperviscosity
[Excessive amounts of IgM antibody in the blood causes hyperviscosity (thickening) of the blood]
Ashhadscknotes
*Bisphosphonates*(zoledronic acid,pamidronate) are the drugs of choice for stabilizing bony metastatic
lesions to prevent hypercalcemia of malignancy & pathologic fractures.
[Bisphosphonates inhibit osteoclastic activity of bone,stabilizing destructive bony tumors & reducing the risk
2599 Medicine Hematology & Oncology of pathologic fracture & malignant hypercalcemia]
Corticosteroids are useful for hypercalcemia related to granulomatous disease as they reduce calcitrol
release from activated mononuclear cells
Suspect squamous cell carcinoma of the mucosa of the head & neck in an alcoholic smoker who presents
w/ a palpable cervical lymph node. The best initial test is *panendoscopy*(triple endoscopy =
esophagoscopy, bronchoscopy, laryngoscopy). Panendoscopy is followed by a biopsy which establishes a
histologic dx
Giant cell tumor of bone:pain,swelling,decreased range of joint motion at involved side.Osteolytic
lesions("soap-bubble" appearance/"expansile & eccentric lytic area") in EPIPHYSEAL regions of long bones
& most commonly involves distal femur & proximal tibia around knee joint
Osteitis fibrosa cystica:imaging-subperiosteal bone resorption on radial aspect of middle phalanges,distal
clavicular tapering,"salt & pepper" appearance of skull,bone cysts,& brown tumors of long bones
Give the appropriate pain medication to cancer pts. Don't be afraid to use a narcotic drug if it is the most
appropriate
Serotonin antagonists that block 5HT3 receptors are the drugs of choice for tx & preventing
chemotherapy-induced nausea & vomiting
Trousseau's syndrome:hypercoagulability disorder,recurrent/migratory superficial thrombophlebitis at
unusual sites(arm,chest).Usually ass. w/ an occult visceral malignancy such as pancreatic(most
common),stomach,lung,or prostate carcinoma.Refer pt for *CT scan of abdomen*(if one suspects
pancreatic carcinoma)
Peripheral septic thrombophlebitis:ass. w/ breaks in skin due to catheters,venipuncture,IV
injections.Fever/pain w/ swelling at infection site
D-dimer test:for DVT/PE

Tumor lysis syndrome: characterized by hypocalcemia, hyperphosphatemia, hyperkalemia, &
2641 Medicine Hematology & Oncology hyperuricemia. Tumors w/ high cell turnovers(eg poorly differentiated lymphomas & leukemias) are frequent
culprits. Allopurinol may greatly reduce the possibility of acute urate nephropathy
Progesterone analogs (megestrol acetate & medroxyprogesterone acetate) and corticosteroids increase
appetite & weight gain in pts w/ cancer related anorexia/cachexia syndrome. Progesterone preferred over
corticosteroids.
The tca Mirtazapine (Remeron) also increases appetite and weight gain. Commonly prescribed in clinical
practice
CLL:seen in elderly,marked leukocytosis w/ predominant lymphocytosis & smudge cells
CML: one of the myeloproliferative syndromes. Leukocytosis w/ a left shift(more myelomonocytes,

neutrophils), basophilia & marked splenomegaly[lymphocytosis is NOT a feature of CML]
Hodgkin's disease: presence of Reed-Sternberg cells

Hairy cell leukemia: Tartrate-resistant acid phophatase (TRAP) staining is important in the dx. Fine, hair-like
irregular projections seen from lymphocytes. CD11c marker is specific for it. Most pts present w/
pancytopenia & splenomegaly. 10-20% of pts have leukocytosis.
CML is one of the myeloproliferative syndromes. It is characterized by splenomegaly, neutrophilic
leukocytosis (left shift), *basophilia*, & *low leukocyte alkaline phosphatase*
ALL: commonly seen in younger pts. Increased blasts seen on peripheral smear
CLL: "the leukemia of old age." Mature small lymphocytes are the predominant cells in CLL
CML: one of the myeloproliferative syndromes, normally seen in adults, leukocytosis, basophilia, marked
splenomegaly
Megaloblastic (macrocytic) anemia: MCV >110 fL, low reticulocyte count, macroovalocyte RBCs,
hypersegmented neutrophils, anisocytosis, & poikilocytosis. Due to impaired DNA synthesis due to B12 or
2872 Medicine Hematology & Oncology folate deficiency
Non-megaloblastic (macrocytic) anemia: due to alcoholism, hypothyroidism, drugs, liver disease

Polycythemia Vera (PV): increased RBC mass, mild granulocytosis, elevated platelet count, & low
erythropoietin levels. Reversible moderate HTN occurs as a result of the expanded blood volume. Increased
incidence of peptic ulceration(histamine release from basophils) & gouty arthritis(increased cell turnover)
can be present. Physical exam shows plethoric face & splenomagaly. Tx-phlebotomy to keep HCT <45%
Polycythemia vera (PV): myeloproliferative disorder due to erythropoietin independent overproduction of
rbcs.
2884 Medicine Hematology & Oncology Sx-hyperviscosity(dizziness,headache), pruritus esp after shower & splenomegaly common. Dx confirmed
by JAK2 mutation & *LOW erythropoietin levels*.
[because blood viscosity is high in PV, ESR is normal or low]
Ashhadscknotes
CML: low leukocyte alkaline phosphate activity.Fatigue,weight loss, sweating,splenomegaly & leukocytosis
w/ marked left shift(eg,myelocytes,metamyelocytes,band forms). > proportion of immature myelocytes than
mature metamyelocytes. Basophilia & eosinophilia also seen.
AML: fever not commonly seen(if so, it suggests infection in AML). Splenomegaly is uncommon. Larger
number of myeloblasts
Absence of measurable erythropoietin in urine is an imp dx feature of polycythemia vera

2886 Medicine Hematology & Oncology Leukemoid reactions have high leukocyte alkaline phosphatase
2887 Medicine Hematology & Oncology Chronic lymphocytic leukemia (CLL) has "smudge cells." Confirm diagnosis w/ Flow cytometry!
The presence of thrombocytopenia indicates a poor prognosis in CLL.
"leukocytes that have undergone partial breakdown during preparation/have greater fragilitiy" aka Smudge
2888 Medicine Hematology & Oncology cells are characteristic of CLL.
CLL is a B-cell disease. Infection is the main cause of death in these pts. Mostly seen in older pts.
2889 Medicine Hematology & Oncology Suspect multiple myeloma in an elderly pt w/ anemia, renal failure, & hypercalcemia
Cladribine is the drug of choice for pts w/ hairy cell leukemia(leukemic reticuloendotheliosis)
2893 Medicine Hematology & Oncology Chlorambucil & prednisone are used for chronic lymphocytic leukemia
CHOP regimen used for non-Hodgkin's lymphoma

Chronic myeloid leukemia(CML):translocation of chromosomes 9 & *22* forming BCR-ABL fusion gene. This
2894 Medicine Hematology & Oncology gene creates a constitutively active **tyrosine kinase**. Tyrosine kinase inhibitors such as imatinib are a key
therapy in the tx of CML
*Fresh frozen plasma* is the therapeutic agent of choice for coagulopathy(bleeding) in pts w/ liver failure[pts
w/ liver failure often develop bleeding disorders]
Absent CD55 -> complement system causes destruction/hemolytic anemia -> Paroxysmal nocturnal
hemoglobinuria
3062 Medicine Hematology & Oncology Hereditary spherocytosis:autosomal dominant. Hemolytic anemia,jaundice,splenomegaly. Spherocytes on
peripheral blood smear,anemia w/ reticulocytosis,low MCV,& *elevated MCHC & RDW* Coombs test is
negative in HS.Dx-osmotic fragility test,eosin 5 maleimide binding test.
Tx- supportive(folic acid, transfusions).Splenectomy improves anemia & reduces gallstone risk in pts
Pernicious anemia(PA) is the mcc of vitamin B12 deficiency in whites of northern European ancestry. It
should be suspected in pts w/ megaloblastic anemia, atrophic glossitis (shiny tongue), vitiligo, thyroid
disease, & neurologic abnormalities. Pernicious anemia confirmed by anti-intrinsic factor antibodies
It would take 4-5 years of a pure vegan diet to cause dietary vitamin B12 deficiency. Folate deficiency can
occur within 4-5 months after dietary intake is diminished
Superior vena cava syndrome: a condition where obstruction of the SVC impedes venous return from the
head, neck & arms to the heart. Sx-dyspnea, venous congestion, & swelling of the head, neck, arms.
Malignancy is the mcc of obstruction accounting for >60% of cases. *Chest x-ray* can identify the cause of
SVC syndrome in >80% of cases. Abnormalities on CXR warrant follow up w/ chest CT & histology
*Compression ultrasonography* is the preferred initial test in pts w/ high pretest probability of DVT
In pts w/ low pretest probability, a negative D-dimer result is useful in excluding DVT
Proximal deep leg/thigh veins(*femoral vein*,iliac,popliteal)are MOST COMMON sources(>90%) of
symptomatic PE
Thrombi originating from renal veins are most common in pts w/ nephrotic syn.Prevalence of PE in neph syn
pts is 10%-30%
Thrombi originating in right atrium:more common in pts w/ intracardiac devices.Less likely to occur
spontaneously
Spontan upper extremity DVT:uncommon,less likely to cause PE.RF-prothrombotic state,indwelling

catheter,anatomical venous obstruction
Use IVC filters for hemodynamically stable pts[w/ minimal swelling] w/ DVT who have contraindications to
anticoagulation(recent surgery,hemorrhagic stroke,bleeding) or recurrent DVTs after tx w/ anticoagulation.
For proximal DVT & concurrent hemodynamically unstable PE or for a massive proximal DVT w/ severe
swelling or limb-threatening ischemia, thrombolytic tx preferred(if contraindications to thrombolytic tx,iliac
stenting or clot removal should be considered)
Ashhadscknotes
G6PD deficiency: sx-pallor & fatigue, dark urine, jaundice, abdominal/back pain. Labs-Bite cells w/ Heinz
bodies. G6PD activity is often normal during the hemolytic episode as G6PD-deficient rbcs are hemolyzed
early, & reticulocytes(which have normal G6PD enzyme levels) are abnormally high
Pyruvate kinase deficiency leads to chronic hemolysis w/ hepatosplenomegaly, skin ulcers, & pigmented
gallstones
Howell-Jolly bodies seen w/ Sickle cell crisis

Warm, antibody-type, autoimmune hemolytic anemia most commonly seen in women w/ some underlying
3610 Medicine Hematology & Oncology disease affecting the immune system (e.g., lymphoid neoplasm, collagen vascular disease, congenital
immunodeficiency diseases). It is characterized by a positive Coomb's test
Epidural spinal cord compression:suspect in pts w/ hx of malignancy who develop back pain w/ motor &
sensory abnormalities.Bowel & bladder dysfunction are late neurologic sequelae.*IV glucocorticoids* & MRI
are rec as initial management
Leuprolide used in tx of metastatic prostate cancer.Its NOT useful for neurologic sx of metastatic
disease.Tx w/ leuprolide causes initial rise in serum testosterone level->worsens bone pain & neuropathy &
causes bladder outlet obstruction
*Radiation therapy* is useful in managing bone pain in pts w/ prostate cancer who have undergone
orchiectomy
Etidronate disodium & other bisphosphonates are useful in controlling chronic pain from bony metastasis,
but its onset of action in alleviating acute bone pain is not as rapid as radiation therapy
Chronic liver disease or cirrhosis from almost any cause is a risk factor for hepatocellular cancer.
3890 Medicine Hematology & Oncology *Hereditary hemochromatosis is ass. w/ a 20- to 200-fold increased risk of hepatocellular carcinoma*
compared to the general population
Any elderly pt(even females) w/ bone pain, renal failure, & hypercalcemia has multiple myeloma until proven
otherwise. 50% of multiple myeloma pts develop some degree of renal insufficiency; this is most likely due
to obstruction of the distal & collecting tubules by large laminated casts containing *paraproteins* (mainly
Bence Jones protein)
Major cause of anemia in pts w/ ESRD is deficiency of erythropoietin. The anemia is normocytic &
normochromic. Tx of choice is recombinant erythropoietin, which is started if the Hb is <10g/dL, (and after
iron deficiency has been ruled out). The most common side effects are worsening of *hypertension* (30% of
pts), headaches (15% of pts) & flu-like sx (5% of pts)
*Factor V Leiden* is the most common inherited disorder causing hypercoagulability & predisposition to
thromboses, esp DVT of lower extremities
Hypercalcemia *an electrolyte disturbance* is a common finding in pts w/ multiple myeloma. Hypercalcemia
of >12 mg/dL may cause severe constipation, anorexia, weakness, polyuria, & neurologic sx
Sideroblastic anemia manifests as microcytic/hypochromic anemia simulating iron-deficiency anemia, but
4037 Medicine Hematology & Oncology iron studies reveal elevated serum iron level & decreased TIBC. In pts w/ an identifiable cause of vit B6
deficiency (alcoholism, drugs), administration of pyridoxine can easily correct the problem
4069 Medicine Hematology & Oncology HbA2 level is elevated in pts w/ thalassemia
Chronic GI blood loss is the mcc of iron-deficiency anemia in an adult male or a post-menopausal woman.
Doc needs to test for occult blood in the stool first. It isn't unusual for right sided colon cancer to manifest as
4081 Medicine Hematology & Oncology iron-deficiency anemia.
Dietary iron deficiency & malabsoption are rare causes of iron deficiency anemia
An acutely ill pt w/ underlying liver disease can become vitamin K deficient in 7-10 days. Labs show
prolonged PT followed by prolonged PTT
Factor V Leiden causes a hypercoagulable state due to activated protein C resistance

Hypersplenism can occur in pts w/ cirrhosis,portal htn & splenomegaly.Splenic sequestration leads to
thrombocytopenia.Pts rarely develop clinical bleeding or prolonged PT/PTT
TTP: caused by widespread platelet thrombi that form in the microcirculation

The mcc of folic acid deficiency is nutritional due to poor diet or alcoholism. Folic acid deficiency can be
caused by some drugs; these drugs can impair the absorption of folic acid (e.g. anti-epileptics like
*phenytoin*, primidone, & phenobarbital) or antagonize its physiologic effects (e.g. methotrexate,
trimethoprim). EXTREMELY HIGH YIELD QUESTION FOR USMLE!!!
Febrile nonhemolytic transfusion reaction: occurs within 1-6 hours of transfusion. Fever, chills, malaise w/o
hemolysis. *Leukoreduction* of donor blood prevents this.
4160 Medicine Hematology & Oncology Careful cross-matching of blood prevents acute hemolytic reactions within an hour of transfusion
IgA deficient pts develop antibodies against IgA. These antibodies react w/ IgA containing donor products &
cause an anaphylactic reaction. To reduce this risk, red cells should be washed
Studies have shown that the risk for sepsis is present *up to 30 years & probably longer after splenectomy*.
Current recommendations state that pts should receive anti-pneumococcal, Haemophilus, & meningococcal
vaccines several weeks before the operation, & daily oral penicillin prophylaxis for three to five years
following splenectomy. Extremely imp question for Step 2!!
Ashhadscknotes
The combo of arterial/venous thrombosis & thrombocytopenia in pts receiving heparin therapy strongly
suggests type 2 heparin-induced thrombocytopenia. Antibodies against heparin-platelet factor 4 complex are
4316 Medicine Hematology & Oncology responsible for the disease. [Venous thrombosis can lead to events such as DVT, pulmonary embolism, or
skin necrosis. Arterial thrombosis is less common but can lead to events such as acute limb ischemia, organ
infarction, & *stroke(neurologic complications)*]
The anemia of lymphoproliferative disorders is due to *bone marrow infiltration* w/ cancerous cells. Signs
4329 Medicine Hematology & Oncology suggesting a lymphoproliferative disorder like lymphoma include firm,enlarged cervical, inguinal &
supraclavicular lymph nodes[lymphadenopathy]
G6PD deficiency: Heinz bodies & Bite cells seen on peripheral blood smear
Acute glomerulonephritis: gross or microscopic hematuria, decreased GFR, & htn
Acute cholecystitis(sx-fever,RUQ pain,positive Murphy's sign,leukocytosis) from pigmented gallstones is a

4333 Medicine Hematology & Oncology common complication of hereditary spherocytosis(sx-increased mchc,hemolytic
anemia,jaundice,splenomegaly in pt of Northern European descent)
Thrombotic Thrombocytopenic Purpura (TTP):
thrombocytopenia(low platelets), hemolytic anemia(look for anemia & hyperbilirubinemia), & renal
failure(increased BUN & creatinine) accompanied by the clinical findings of altered mental status & low
grade fever. HIV is a risk factor. Management- we check the peripheral blood smear*, which will display
schistocytes
tx- plasma exchange
Thrombotic thrombocytopenic purpura(TTP):
tx- plasmapheresis
we do hemodialysis for renal failure
cryoprecipitate contains fibrinogen and is used to treat low fibrinogen states

B-thalassemia is common in people of Mediterranean descent & manifests as a hypochromic microcytic
anemia of moderate severity
Oral leukoplakia is a precancerous white patch or plaque on the oral mucoa. Approximately 1%-20% of
plaques will progress to cancer within 10 years
Anemia of chronic kidney disease is due to erythropoietin deficiency. One must be careful to ensure
4349 Medicine Hematology & Oncology adequate iron stores prior to erythropoietin replacement becasue the erythropoietin induced surge in RBC
production can precipitate an iron deficient state.
*Vitamin B12 deficiency causes defective DNA synthesis*
Vitamin B12 deficiency is common after a total or partial gastrectomy
Hard, unilateral, non-tender lymph nodes are always suspicious for cancer. In an older pt w/ a hx of
4352 Medicine Hematology & Oncology smoking, such lymph nodes in the submandibular or cervical region are highly concerning for head and neck
cancer. The vast majority of head and neck cancer is squamous cell carcinoma (SCC).
Pernicious anemia is the mcc of vitamin B12 deficiency. It's ass. w/ double the risk of gastric cancer as
compared to the general population. Monitor these pts for the development of gastric cancer (w/ periodic
4356 Medicine Hematology & Oncology stool testing for the presence of blood)
Vit B12 deficiency sx- macrocytic anemia, glossitis, neurologic changes including peripheral neuropathy.
Folic acid & cobalamin deficiencies both cause a macrocytic anemia w/ hypersegmented neutrophils.
Deficiencies in either nutrient will result in *increased homocysteine levels* because both are involves in
4357 Medicine Hematology & Oncology homocysteine metabolism
Increased urinary VMA seen in pts w/ pheochromocytomas

Anemia of chronic disease is a disorder of iron utilization that commonly occurs in the setting of chronic
inflammation. It's characterized by a normocytic anemia w/ decreased serum iron, decreased total iron
binding capacity, decreased iron saturaiton, & normal/elevated serum ferritin. Treating the underlying
inflammatory disorder (eg tx rheumatoid arthritis w/ *methotrexate*) will improve the anemia
Features of androgen abuse/exogenous steroid use: Recent improvement in athletic performance,
GYNECOMASTIA, elevated hematocrit
Vitamin B6(Pyridoxine) lowers homocysteine levels by acting as a cofactor for the enzyme cystathionine
B-synthase, which metabolizes homocysteine into cystathionine
Pts who have received the equivalent of more than one blood volume of blood transfusions or packed red
4402 Medicine Hematology & Oncology blood cells over 24 hours may develop elevated plasma levels of citrate (a substance added to stored
blood). *Citrate chelates calcium & magnesium & may reduce their plasma levels, causing paresthesias*
The lupus anticoagulant, an anti-phospholipid antibody, is a pro-thrombotic immunoglobulin that causes a
spuriously *prolonged partial thromboplastin time* in vitro
Pancytopenia (decreased rbcs,wbcs,platelets) common in SLE pts. Indicates concurrent *peripheral
immune-mediated destruction of all 3 cell lines*
Focal proliferative glomerulonephritis seen in SLE

Hypersplenism less common in SLE & more common in cirrhosis, malaria, sickle cell disease
Dilutional thrombocytopenia occurs in pts w/ massive blood transfusion requiring a large number of packed
rbc transfusions, which have no platelets
Ashhadscknotes
Hyposthenuria: A condition in which there is an impairment in kidney's ability to concentrate urine. Causes
nocturia. Found in pts w/ sickle cell disease
Pts w/ sickle cell anemia may develop membranoproliferative glomerulonephritis or end-stage renal diseae
due to focal segmental glomerulosclerosis. These diseases typically manifest w/ significant abnormalities in
the urinary sediment, such as red blood cell casts
Autoimmune hemolytic anemia: normocytic anemia, splenomegaly, reticulocytosis, jaundice w/ elevated
indirect bilirubin, increased serum lactate dehydrogenase, & decreased serum haptoglobin levels. Tx-high
dose glucocorticoids(to decrease autoantibody production). Splenectomy or immunosuppressive agents for
pts who can't tolerate glucocorticoids
Pts w/ B-thalassemia trait(minor) usually are asymptomatic w/ mild anemia, disproportionately high rbc
count, low mcv, & hg >10 g/dL. No specific therapy is required for B-thalassemia minor
Don't confuse B-thal w/ iron deficiency anemia(low rbc count, rarely becomes microcytic until hg <10 g/dL)
Carboxyhemoglobinemia is carbon monoxide(CO) poisoning. The CO binds hemoglobin w/ an affinity 250x
that of oxygen
Pts w/ hereditary telangiectasia (Osler-Weber-Rendu syndrome) can develop pulmonary AV malformations
4447 Medicine Hematology & Oncology (AVMs) ass w/ hemoptysis & right to left shunt physiology. This dx must be entertained in a pt w/ recurrent
nose bleeds & oral lesions
Hypoxemia-induced increases in erythropoietin production are responsible for the polycythemia observed in
obstructive sleep apnea
Multiple myeloma:
monoclonal proliferation of plasma cells
CRAB mnemonic: calcium(hypercalcemia), renal impairment, anemia, & bones(bone pain, lytic lesions,
fractures)
Pts are at increased risk for infection due to a *decrease in functional antibodies* & leukopenia that
develops as the bone marrow is filled w/ malignant plasma cells.
Look for a BIG gap in the total protein and albumin concentrations! (normally only a 3-4 difference
separating total protein and albumin)
In sickle cell disease, folate deficiency can occur due to increased red blood cell turnover & increased
consumption of folate in the bone marrow. Tx w/ daily folic acid supplementation
Hydroxyurea*, trimethoprim, phenytoin, methotrexate can lead to macrocytosis
2 forms of heparin induced thrombocytopenia(HIT):
Type 1 HIT-nonimmune direct effect of heparin on platelet activation, presents within first 2 days of heparin
exposure, platelet count normalizes w/ continued heparin tx
Type 2 HIT-immune mediated,antibodies to platelet factor 4 (PF4) complexed w/ heparin.Platelet
aggregation,thrombocytopenia,thrombosis(arterial & venous).5-10 days after starting heparin,platelet count
drop >50% from baseline,life threatening
Post-splenectomy pts are at increased risk for sepsis from encapsulated organisms due to impaired
antibody-mediated opsonization in *phagocytosis*
Conditions ass. w/ thymic aplasia, like DiGeorge syndrome, cause defective cell-mediated immunity
*Rivaroxaban* is a direct factor Xa inhibitor w/ rapid onset of action that can be used as a single agent in
the tx of acute DVT or PE.It doesn't require frequent lab monitoring or daily injections; however,there is no
antidote in the event of major hemorrhage
Thrombolytic therapy is reserved for hemodynamically unstable PE pts.Less commonly, it's used for
massive proximal lower-extremity thrombosis or iliofemoral thrombosis ass. w/ sig. symptomatic swelling or
limb ischemia
Acute hemolytic transfusion reaction: Develops within an hour after transfusion is started. Due to ABO
incompatibility. Sx-fever,chills,hemoglobinuria,flank pain,discomfort at infusion site,may advance to renal
failure & DIC(bleeding from iv sites)
4671 Medicine Hematology & Oncology Febrile nonhemolytic(most common reaction): within 1-6 hours of transfusion
Delayed hemolytic: within 2-10 days after transfusion
IgA deficient pts: Anaphylaxis in seconds to minutes. Angioedema,hypotension,difficulty breathing

Anaphylactic reactions to transfused blood products:rapid onset(within seconds to minutes) of resp. distress
& hypotension,which progress to resp failure & shock
Febrile nonhemolytic transfusion reaction:most common adverse reaction to transfusion,occurs within 1-6
hours of transfusion.During blood storage, leukocytes release cytokines that,when transfused,cause
transient fevers,chills,malaise.No resp distress & shock
Aspirin inhibits COX-1, thereby inhibiting TXA2 synthesis
4736 Medicine Hematology & Oncology Heparin activates antithrombin III, which in turn inactivates factor IIa(thrombin), factor IXa, & factor Xa
Simvastatin functions by inhibiting 3-hydroxy-3-methylglutaryl-coenzyme reductase
Ashhadscknotes
Heparin-induced thrombocytopenia(HIT): immune-mediated process that causes thrombocytopenia several
4859 Medicine Hematology & Oncology days after starting heparin therapy(eg,enoxaparin). Although there can be significant thrombocytopenia,
*HIT is highly thombogenic & pts must be monitored closely for arterial and venous clots*
Idiopathic thrombocytopenia purpura is usually dx after excluding other possible causes of
thrombocytopenia. *These pts should be tested for hepatitis C & HIV as thrombocytopenia may be the initial
presentation of HIV infection(up to 5%-10% of pts).* Tx of the underlying infection can affect the platelet
count
Adult lead toxicity: Usually due to *occupational exposure* (eg, battery manufacturing, plumbing, mining,
painting, paper hanging, auto repair). Sx-fatigue, irritability, insomnia, myalgias, htn, nephropathy,
4862 Medicine Hematology & Oncology neurocognitive deficits, & peripheral neuropathy
Dx- blood lead levels, cbc w/ blood smear, xray fluorescence to measure bone lead concentration
Tx- chelation therapy
*Salvage therapy* is defined as tx for a disease when standard therapy fails eg: radiation therapy given for
PSA recurrence after radical prostatectomy(for prostate cancer) was already done
Adjuvant therapy is tx given in addition to standard therapy eg: radiation therapy given at the same time as
radical prostatectomy in a pt
Neoadjuvant therapy is tx given before the standard therapy for a particular disease eg: radiation given
before radical prostatectomy
HIT:Complication of heparin therapy.HIT antibodies bind against the surface of platelets->platelet
aggregation,thrombocytopenia,& thrombotic complications(classic one in pts receiving heparin
subcutaneously is *skin necrosis at the abdominal injection site*)
6993 Medicine Hematology & Oncology Warfarin is an ORAL anticoagulant
Delayed hypersensitivity reactions cause skin erythema,vesicles,bullae.If severe,fever/systemic sx occur
Cholesterol embolization causes skin findings that affects lower extremities

Preconception counseling & testing can help identify couples who are at risk for hemoglobinopathies that
might affect their offspring during pregnancy or after birth. *The most important initial screening test in a
female is a complete blood count*. Based on the results, other appropriate screening tests should be
obtained
Testing the pts partner is offered if an abnormal hemoglobin level is dx in the pt

Cellulitis:
sx- swelling which is erythematous, warm, tender, not very well demarcated, high fever w/ rigors and chills,
malaise, fatigue, & confusion
2161 Medicine Infectious Diseases
tx- nafcillin or cefazolin when pt presents w/ systemic signs
Chronic fungal foot infection can serve as a nidus for bacterial cellulitis
Chlamydial urethritis: Mucopurulent urethral discharge in a sexually active pt, absence of identifiable
bacteria on culture or Gram stain("culture-negative" urethritis). Dx made w/ nucleic acid amplification testing
2236 Medicine Infectious Diseases of a first-catch urine sample w/o pre-cleaning genital area. Tx- Azithromycin or doxycycline
Acute bacterial cystitis: mucopurulent urethral discharge isn't seen

*E.coli* is the most frequent cause of non-sexually transmitted acute epididymitis(seen in older men).[In
older men, acute epidiymitis is caused by gram-negative rods]
Chlamydia & gonococcus are the most frequent causes of sexually transmitted acute epididymitis(seen in
younger pts)
Isoniazid side effects:

Peripheral neuropathy-start pt on pyridoxine
Hepatitis
Jarisch-Herxheimer reaction:
It may develop in the tx of syphilis. When primary or secondary syphilis is tx w/ penicillin, the spirochetes die
rapidly, thereby leading to the release of antigen-antibody complexes in the blood, and consequent
immunologic reaction, which seems like an acute flare-up of syphilis
Toxoplasmosis ring enhancing lesions:
2264 Medicine Infectious Diseases tx- sulfadiazine & pyrimethamine
Prophylaxis w/ trimethoprim-sulfamethoxazole.
2267 Medicine Infectious Diseases Encapsulated bacteria, esp *Pneumococcus/S.pneumoniae*, are the mcc of pneumonia in HIV pts
2269 Medicine Infectious Diseases antiviral drugs are not associated with clostridium difficile infection (unlike antibacterial agents)
CMV infection: mononucleosis-like sx, atypical lymphocytes(large basophilic cells w/ vacuolated
appearance) on blood smear, negative heterophile antibody (monospot) test. [Unlike EBV ass. infection,
2270 Medicine Infectious Diseases CMV mononucleosis presents WITHOUT pharyngitis & cervical lymphadenopathy!]
Chronic fatigue syndrome: sx > 6 months
Ashhadscknotes
Pneumocystis jirovecii pneumonia: Tx-Trimethoprim-sulfamethoxazole(pt may experience worsening of
pulmonary function following abx tx).
Corticosteroids have been shown to minimize the initial abx induced worsening of respiratory function. They
2273 Medicine Infectious Diseases should be given w/ antibiotics in pts w/ PaO2 <70 mmHg on room air or an A-a gradient >35 to minimize
pulmonary complications
IV pentamidine, oral atovaquone, clindamycin-primaquine are 2nd line tx for PCP

Esophagitis is common complication of HIV,esp when CD4 count <100/uL. Sx- painful swallowing &
substernal burning. Most common etiology of esophagitis in HIV pts is Candida.
Candida esophagitis is likely in pts w/ oral thrush "white plaques that are removable."
Tx- Oral *fluconazole*
Antiretroviral drugs do not cause "pill esophagitis!"
Potassium supplements, tetracyclines, bisphosphonates cause "pill esophagitis."

Progressive multifocal leukoencephalopathy (PML):sx-hemiparesis & disturbances in speech,vision & gait.
MRI findings-multiple demyelinating, non-enhancing lesions w/ no mass effects
[Cerebral toxoplasmosis is the most common ring-enhancing mass lesion in HIV pts. It's unlikely to be the
culprit if pt in vignette is receiving TMP-SMX]
[Primary CNS lymphoma-second most common cause of mass lesions in HIV pts.Solitary,weakly enhancing
& periventricular.Dx-EBV DNA in CSF]
Suspect an anaerobic lung infection in pt w/ fever & cough productive of foul-smelling sputum after an upper
GI endoscopy or any other instrumentation of upper airway or esophagus. Tx-Clindamycin
Doxycycline for outpt CAP where macrolide resistance is suspected

Ciprofloxacin has good gram negative coverage
TMP+SMX for pneumocystis pneumonia,gram-negative & gram-positive agents
Ampicillin/gentamicin combo for gram-negative aerobes. Used for Ab infections w/ metronidazole

Reactivation tuberculosis:
organism- Mycobacterium tuberculosis
etiology- HIV pts have higher risk of reactivation tuberculosis
chest xray shows upper lobe infiltrates w/ cavities
Aspiration pneumonia:
Pts are much sicker, present more acutely w/ fever, productive cough, dyspnea, usually involves lower
lobes and occasionally upper lobes if pt aspirates while supine
Bronchoalveolar lavage (BAL): is most useful in the evaluation of suspected malignancy & opportunistic
infection. BAL is >90% sensitive & specific for PCP(common opportunistic infection in HIV pts). BAL is of
2304 Medicine Infectious Diseases less diagnostic utility in evaluating other forms of interstitial lung disease, such as interstitial pulmonary
fibrosis, sarcoidosis, & connective tissue diseases. PCP has classic appearance of bilateral interstitial and/or
alveolar infiltrates
Pts w/ febrile neutropenia(absolute neutrophil count <1500/uL) should be started on empiric broad-spectrum
abx as soon as possible after blood cultures are obtained. Empiric monotherapy w/ an anti-pseudomonal
beta-lactam agent (eg, cefepime, meropenem, *piperacillin-tazobactam*) is rec for initial management as it
provides both gram-negative & gram-positive coverage
The most common organisms responsible for the development of epiglottitis, esp in the adult population, are
2845 Medicine Infectious Diseases *Haemophilus influenzae & Streptococcus pyogenes*. Epiglottitis is a medical emergency, & rapid tx must
be initiated in order to prevent obstruction of the airway
Individuals w/ hx of high risk sexual intercourse(unprotected or gay men) should be screened for HIV & hep
2916 Medicine Infectious Diseases B infection. Individuals who use injection drugs, have high risk needlestick exposure, or received blood
transfusions before 1992 should be screened for hepatitis C.
Consider tx Hepatitis B pts esp if they have sx like acute liver failure, clinical cirrhosis, high serum hep B
virus DNA, cirrhosis w/ positive HBeAg, hep B DNA >20,000 IU/mL, & serum alanine transaminase >2x
upper limit of normal. *Entecavir & tenofovir* are preferred for tx!
Lamivudine isn't used for Hep B due to drug resistance.
Interferon is a short term tx used for young Hep B pts w/ compensated liver disease(can't use in pts w/
decompensated cirrhosis)
Entamoeba histolytica is a protozoan, which can cause *amebic liver abscess*. Remember the Mexico trip
Pyogenic liver abscess is secondary to surgery, a GI infection, or acute appendicitis. More severe than
amebic liver abscess
Ashhadscknotes
Hepatic hydatid cysts:due to Echinococcus granulosus.Dogs are definitive host.Cystic hepatic lesion w/
eggshell calcification
Pyogenic liver abscess:develop following surgery,GI infection,acute appendicitis.Pain,fever,leukocytosis

Simple hepatic cysts:congenital.Pathphys related to fluid secretion by epithelial lining.Dull RUQ pain,ab
bloating,early satiety
Amebic liver abscess:fever,RUQ pain, extraintestinal manifestation of amebiasis

10-20% of pts on isoniazid will develop mild aminotransferase elevation in first few weeks of tx.It's
self-limited & will resolve w/o intervention
If TB pt's sputum is -ve for acid-fast bacilli,they still haven't fully cleared the dormant bacilli after 1 mo of tx
Many 1st line anti-tb drugs are hepatotoxic & should be replaced by 2nd line anti-tb drugs in pts who
develop significant hepatotoxicity
Do liver biopsy in pts w/ elevation of liver enzymes of unknown etiology

Chronic hepatitis B can have 4 phases:immune tolerance,immune clearance,inactive carrier state, &
HBeAg-negative chronic hepatitis.In the immune clearance phase,fluctuating levels of liver inflammation can
2984 Medicine Infectious Diseases produce variable liver transaminase levels and eventual clearance of HBeAg.During this phase,the presence
of HBeAg indicates active replication of virus,even in pts with normal ALT. Such pts need serial
measurements of both ALT & HBeAg every 3-6 month until viral clearance
Mycobacterium tuberculosis infection is unlikely in an HIV pt if their PPD test is negative, for example 3 mm
induration (>5 mm considered positive in HIV pts). Also Mycobacterium tb demonstrates acid-fast bacilli
Nocardia is a gram-positive, weakly acid-fast, filamentous branching rod. It can also cause pulmonary
cavitation in an HIV pt.
tx- trimethoprim-sulfamethoxazole
Pneumococcus: mcc of community acquired pneumonia; manifests as lobar pneumonia

Mucormycosis: MCC is Rhizopus. Can affect nose & maxillary sinus
Poorly controlled diabetes mellitus predisposes to this disease [H.Y. fact for USMLE]
2993 Medicine Infectious Diseases Sx-low grade fever, bloody nasal discharge, nasal congestion, involvement of the eye w/ chemosis,
proptosis & diplopia. Involved turbinates often become necrotic. Invasion of local tissues can lead to
blindness, cavernous sinus thrombosis & coma. If left untreated, can lead to death in days to weeks
Mucormycosis, most often caused by the fungus Rhizopus, requires aggressive surgical debridement plus
early systemic chemotherapy w/ amphotericin B
Histoplasmosis closely mimics the presentation of sarcoidosis & should be considered when a pt w/
suspected sarcoidosis deteriorates after immunosuppressive therapy. In endemic regions, dimorphic fungi
(eg, Histoplasma, Blastomyces, Coccidioides) should be excluded before immunosuppression is initiated
Blastomyces ass. w/ contact w/ soil or rotting wood, w/ dissemination in immunocompromised hosts
presenting as skin lesions, osteolytic bone lesions, or prostate involvement
Coccidiodomycosis: usually seen in pts from Arizona/California. Look for erythema nodosum (erythematous
nodules on anterior surface of both legs)
Blastomycosis: Affects pts in south central and north central US. Infection in immunocompetent hosts is
uncommon
Blastomycosis: fungal infection endemic to central USA. Causes mild pulmonary illness(eg,dry cough w/
malaise) but disseminated infection can occur even in immunocompetent individuals. Cutaneous
blastomycosis manifests as well-circumscribed verrucous nodules & plaques that progress to
2999 Medicine Infectious Diseases microabscesses
Actinomyces: Gram-positive rod, causes abscesses primarily at the head & neck w/ granular yellow pus
"sulfur granules", can also cause indolent pulmonary disease
Sporotrichosis: Initial lesion, a reddish nodule that later ulcerates, appears at the site of the thorn prick/skin
3000 Medicine Infectious Diseases injury. From the site of inoculation, the fungus spreads along the lymphatics forming subcutaneous nodules
& ulcers
Rabies post-exposure prophylaxis(PEP):
Pts exposed to healthy animal-

3002 Medicine Infectious Diseases animal can be observed for 10 days w/o PEP
Unvaccinated pts who are bitten by animals that could have rabies-
Pt should receive PEP w/ active and passive immunization
Ashhadscknotes
Viral encephalitis:elevated wbc,lymphocytic predominance,normal glucose & elevated protein. Tx-*acyclovir*
for suspected HSV encephalitis until confirmatory tests return
Cryptococcal meningoencephalitis:common in immunocompromised pts(HIV).Sx due to increased

intracranial pressures(headache)from capsular swelling.Elevated opening pressure on spinal tap.
Tx-amphotericin+flucytosine
Bacterial meningitis:tx empirically w/ ceftriaxone & vancomycin(ampicillin in adults age >50)

Pts w/ infectious mononucleosis(IM) are at risk for splenic rupture. Avoid contact sports for *>3 weeks.*
Splenomegaly difficult to palpate in athletic pts w/ firm ab muscles. Also spleen may not be palpable until it's
2-3x its normal size
Pts w/ S. pharyngitis are not contagious after 24 hours of antibiotics
Antibiotics are not used in IM as it's caused by a virus. Antibiotics can cause a maculopapular rash in pts w/
IM
Amoxicillin-clavulanate: antibiotic of choice for prophylaxis/tx of infections caused by a human bite. Also the
drug of choice for dog bites. Coverage for Gram positives, Gram negatives, & anaerobes
Clindamycin is effective against Gram-positive bacteria & anaerobes. Used for tx lung abscesses &
infections of the female genital tract
Erythromycin is drug of choice for Legionnaire disease & is also used for outpatient tx of community
acquired pneumonia
Blood cultures from separate venipuncture sites should be obtained over a specified period in all pts w/
suspected infective endocarditis prior to initiating antibiotic therapy
Empiric antibiotic tx for native valve endocarditis should be geared towards MRSA, streptococci, &
enterococci. tx- *Vancomycin*
Ampicillin-sulbactam recommended for penicillin resistant enterococcus & HACEK organisms
Streptococcus sanguinis belongs to the viridans group of streptococci, which also includes S mitis, S oralis,
S mutans, S sobrinus, and the S milleri group. Infective endocarditis(IE) w/ viridans group streptococci is
commonly encountered after dental procedures
3014 Medicine Infectious Diseases IE due to S bovis (S gallolyticus) is seen in pts w/ colon cancer
Enterococci:common cause of healthcare ass. nosocomial UTIs
S. aureus & S epidermidis:pts w/ iv catheters, prosthetic valves, iv drug users

Blastomycosis:fungal infection,occurs in region of Great Lakes, Mississippi river & Ohio River basins
3037 Medicine Infectious Diseases (Wisconsin has highest infection rate). Pulmonary sx & CXR findings may resemble TB & histoplasmosis.
However, systemic Blastomycosis may cause ulcerated skin lesions & lytic bone lesions
Treat Legionella pneumophilia w/ macrolides or fluroquinolones
Amoxicillin/clavulanate is used to treat sinusitis, otitis media, & some cases of CAP. It has activity against
beta-lactamase-producing Haemophilus & Moraxella species
Ceftriaxone has good activity against pneumococcus as well as Haemophilus & Moraxella
Vancomycin treats pts w/ nosocomial pneumonia when probability of MRSA is high

Enterococci, esp Enterococcus faecalis, are a common cause of endocarditis ass. w/ nosocomial UTIs(IE
3068 Medicine Infectious Diseases ass. w/ viridans group streptococci is usually related to dental or upper respiratory source of infection. It isn't
ass. w/ genitourinary tract manipulation/infections)
Herpes simplex esophagitis: round/ovoid ulcers & intranuclear inclusions. Tx- acyclovir
CMV esophagitis: linear ulcers & intranuclear/intracytoplasmic inclusions. Tx-ganciclovir
3103 Medicine Infectious Diseases Pentamidine used for prevention/tx of Pneumocystis pneumonia in pts w/ advanced HIV who can't tolerate
tmp-smx
Candidiasis resistant to fluconazole may be tx w/ voriconazole, an echinocandin(caspofungin), or

amphotericin
Suspect babesiosis in a pt from northeastern US who presents w/ a tick bite,esp if there is evidence of
hemolysis & the pt has been splenectomized. Tx-quinine-clindamycin & atovaquone-azithromycin
Ehrlichiosis "spotless Rocky Mountain spotted fever":tick borne illness,fever,malaise,headache,

nausea/vomiting.Leukopenia & thrombocytopenia
Q fever: Coxiella burnetti
Source-infected cattle,goat,sheep.Meat handlers & vets at risk
Sx-Flu like syndrome, hepatitis, pneumonia
Ashhadscknotes
All posttransplant pts should receive prophylaxis w/ TMP-SMX
3105 Medicine Infectious Diseases TMP-SMX is effective in preventing Pneumocystis Pneumonia (PCP) infection in transplant pts
These pts should also be vaccinated against influenza, pneumococcus, and Hepatitis B
Bright red, firm, friable, exophytic nodules in an HIV infected pt are most likely *bacillary
3107 Medicine Infectious Diseases angiomatosis*(google pic). Bacillary angiomatosis is caused by Bartonella, a gram-negative bacillus. Oral
erythromycin is the abx of choice.
Pts w/ infectious mononucleosis may develop *autoimmune hemolytic anemia & thrombocytopenia* up to
2-3 weeks after the onset of initial sx(initial labs may not show anemia or thrombocytopenia). This due to
3131 Medicine Infectious Diseases cross reactivity of the EBV induced antibodies against RBCs & platelets
[IM-fever,sore throat,jaundice,mild hepatosplenomegaly,symmetrical lymphadenopathy involving posterior
cervical chain of lymph nodes more than anterior chain,inguinal/axillary lymphadenopathy]
Parvovirus B19: can cause an acute symmetric arthritis of the hands (metacarpophalangeal, proximal
interphalangeal, & wrist), knees, & ankle joints. Commonly affects adults who have frequent contact w/
children(school teachers, daycare workers).Dx confirmed w/ anti-parvovirus B19 IgM. Syndrome is
self-limited & doesn't require specific tx.
Rheumatoid arthritis-joint stiffness >1 hour in morning, joint swelling, sx for >6 weeks
Lyme disease: Doxycycline is the tx of choice in pts who are not pregnant & > 8 years old. Amoxicillin is
3243 Medicine Infectious Diseases used for children age < 8 years & pregnant women (We want to avoid doxycycline's negative side effects
like tooth discoloration, skeletal problems in children & fetuses)
Bacterial meningitis:Don't delay empiric abx while awaiting results of CT scan or lumbar puncture.
*Vancomycin + ampicillin + cefepime(or ceftazidime)* is tx of choice for immunocompromised pts w/
3245 Medicine Infectious Diseases suspected bacterial meningitis(provides coverage for S.pneumoniae,N.meningitidis,Listeria,Gram-neg rods
like pseudomonas). Corticosteroids(dexamethasone)must be started at the same time as abx & should be
discontinued if cultures show an organism other than S.pneumoniae
HIV pts are at high risk for TB. A positive PPD (>5mm in HIV pts) requires prophylaxis with *isoniazid and
pyridoxine for 9 months*
In this stem, the pt was asymptomatic and his chest xray was negative. I mention this because a
combination of 3-4 drugs is typically used to treat ACTIVE tb infection
Ehrlichiosis: suspect in pt from endemic region w/ hx of tick bite,febrile illness w/ systemic sx,LEUKOPENIA
&/or THROMBOCYTOPENIA,& ELEVATED AMINOTRANSFERASES.Rash is uncommon,drug of choice is
*doxycycline*
Ceftriaxone used for tx of neuro & cardio sx of Lyme disease(ABSENCE OF A RASH & PRESENCE OF A
HIGH FEVER & HEMATOLOGIC & LIVER ENZYME ABNORMALITIES make Lyme disease LESS LIKELY)
Erythromycin has activity against Legionella & Mycoplasma
RMSF tx: Doxycycline 1st line

MCC of bloody diarrhea in the absence of fever is E coli. The enterohemorrhagic E coli (EHEC) strain
produces Shiga toxin, which causes an inflammatory diarrhea syndrome w/ acute watery to bloody stools &
abdominal pain. EHEC ass. w/ consumption of raw or undercooked meats. Dx confirmed w/ a stool assay
3248 Medicine Infectious Diseases for Shiga toxin. If EHEC suspected,avoid empiric antibiotic tx as it increases risk of hemolytic uremic
syndrome
C.perfringens:nonbloody diarrhea ass. w/ unrefrigerated food

Cryptosporidium is an emerging & important cause of travelers' diarrhea & should be considered in pts w/
persistent, nonbloody, watery diarrhea for >2 weeks
The GI sx of strongyloidiasis are nausea, vomiting, & abdominal pain rather than diarrhea
Postexposure HIV prophylaxis w/ 3 drug antiretroviral therapy for 4 weeks is rec following high risk
3251 Medicine Infectious Diseases occupational exposure to blood or body fluids from an HIV infected individual. Therapy should be started as
soon as possible, preferably in the first few hours
HIV infected pts w/ CD4 counts <50 cells/uL require primary prophylaxis against Mycobacterium avium
complex with azithromycin or clarithromycin
Acyclovir or valacyclovir can be used to prevent frequent/severe herpes simplex virus

recurrences(secondary prophylaxis) regardless of CD4 count. In our Uworld question stem, the pt wasn't
experiencing recurrences.
Although Fluconazole is effective for candidiasis, prophylaxis against Candida infection is not rec. in HIV pts
Kaposi sarcoma in HIV pts is caused by human herpesvirus 8 (HHV-8). Lesions are asymptomatic(no pain,
itching, or burning)
[google pic]
Cryptococcus is an important cause of meningitis in HIV pts
HPV causes common & genital warts, as well as cervical cancer
Ashhadscknotes
Primary syphilis: single dose of IM benzathine penicillin G is tx of choice.
*In nonpregnant pts w/ penicillin allergy, a 2 week course of doxycycline can be used.* Pregnant pts w/
3256 Medicine Infectious Diseases penicillin allergy should undergo desensitization before penicillin therapy(doxycycline is contraindicated
during pregnancy & only penicillin based regimens are aceptable, even among those w/ hx of penicillin
allergy)
Amoxicillin is tx of choice for pregnant & lactating pts w/ early localized Lyme disease(doxycycline
contraindicated in young children & pregnant & lactating women)
Pregnant women should be reassured that Lyme diseae is not known to cause congenital anomalies or fetal
demise
IV 3rd-generation cephalosporins(ceftriaxone & cefotaxime)reserved for meningitis, encephalopathy,or
carditis
Untreated Lyme disease progresses to facial palsy,aseptic meningitis,heart block,arthritis

Chloroquine-resistant Plasmodium falciparum is common in Sub-Saharan Africa, the Amazon basin, &
Southern & Southeast Asia. *Mefloquine*, atovaquone-proguanil, & doxycycline are recommended
chemoprophylaxis options for travelers to edemic regions of chloroquine-resistant malaria
Primaquine:well tolerated antimalarial but doesn't kill the schizont forms of P falciparum & used in regions
where P ovale & P vivax are the dominant malaria species(eg,Korean peninsula)
Ramsay Hunt syndrome(herpes zoster oticus):manifestation of varicella zoster virus reactivation charac by
triad of ipsilateral facial paralysis, ear pain, & vesicles in the auditory canal & external auricle
Classic rash in syphilis is a diffuse maculopapular eruption involving the palms and soles
Proteus most likely cause of uti in pts w/ alkaline urine (check question stem for urinalysis pH value being >
7.45 aka alkalotic)
Although E. coli is the most commonly isolated pathogen in pts w/ UTI, it deosn't alter the normal acidic pH
of urine
The sudden onset of a sharply demarcated, erythematous, edematous, tender skin lesion w/ raised borders
3263 Medicine Infectious Diseases in a febrile pt suggests erysipelas(a specific type of cellulitis). The most frequently implicated organism is
*group A beta-hemolytic streptococcus (S.pyogenes)*
Rubella presents w/ fever & occipital or posterior cervical lymphadenopathy followed by a maculopapular
rash that spreads in a cranial-caudal pattern & spares the palms & soles. Affected adult women also suffer
from arthritis that can last up to a month after resolution of other sx
Measles: diff from Rubella cuz w/ measles, cranial caudal spread of rash is more gradual over days. Also
arthritis doesn't occur w/ measles
Trichinellosis:GI complaints(ab pain,nausea,vomiting)followed by PERIORBITAL EDEMA,MYOSITIS,&
EOSINOPHILIA(hallmark of disease).Fever,subungual splinter hemorrhages,& conjunctival or retinal
hemorrhages also seen.Infection more common in Mexico,China,Thailand,parts of central Europe &
3267 Medicine Infectious Diseases Argentina.Occurs after eating undercooked/raw meat(pork)
Dengue fever:fever,headache,RETRO-ORBITAL PAIN,rash,& significant myalgia & arthralgias.Pts can also

develop hemorrhagic dengue fever
Disseminated gonococcal infection causes high fever, chills, tenosynovitis, polyarthralgia, & pustular
lesions/rash on the trunk & extremities. Routine blood & pustule cultures can be negative due to the
fastidious nature of Neisseria gonorrhoeae
The rash ass. w/ parvovirus is a malar rash (on the face)
Toxic shock syndrome: look for hypotension and classic diffuse erythematous rash on body including palms
& soles
Valacyclovir is the drug of choice in the tx of herpes zoster(shingles); *acyclovir* is an alternative.[Oral
steroids can be combined w/ acyclovir (not w/ valacyclovir) if initial sx are severe & pt has no
contraindications to steroids]
Postherpetic neuralgia can be prevented &/or tx w/ tricyclic antidepressants such as amitriptyline or
nortriptyline along w/ acute antiviral therapy(however this shouldn't be primary tx)
Leprosy:
3425 Medicine Infectious Diseases asian pt w/ insensate, hypopigmented patch of skin. can progress to cause muscle atrophy
diagnose w/ acid-fast bacilli on skin biopsy
In a pt w/ Acute pyelonephritis, *urological imaging is reserved for pts w/ persistent clinical sx despite 48-72
3475 Medicine Infectious Diseases hours of therapy, hx of nephrolithiasis, complicated pyelonephritis, or unusual urinary findings(gross
hematuria, suspicion for urinary obstruction)*
Ashhadscknotes
Ludwig's angina:
Infection of the submandibular & sublingual glands, usually caused by Streptococcus & anaerobes
Source of infection is commonly an infected tooth. sx- fever, dysphagia, odynophagia, drooling, induration of
3530 Medicine Infectious Diseases submandibular space, presence of anaerobes can cause crepitus due to gas formation.
Asphyxiation is mcc of death in this disease.
management- monitor for respiratory difficulty, intubate if necessary
tx- antibiotics & removal of infected tooth
Cervicofacial actinomycosis most commonly presents in the mandibular region as a slowly growing,
nontender mass w/ characteristic yellow granular pus ("sulfur granules"). The infection can extend thru
3561 Medicine Infectious Diseases tissue planes & form abscesses, fistulas, & draining sinus tracts. Dx is confirmed by Gram stain
(Gram-positive branching bacilli) & culture. *Penicillin* is the preferred therapy. [Actinomyces is an
anaerobic bacteria that colonizes oral cavity]
Cryptosporidium parvum:major cause of chronic diarrhea in HIV infected pts w/ CD4 counts < 180
cells/mm3.Modified acid-fast stain will show oocysts in the stool
MAC:ass. w/ lung infections in immunocompetent pts w/ chronic lung disease.Causes disseminated disease
w/ bowel infiltration & malabsorption in pts w/ severe immune compromise
Microsporidia,Enterocytozoon bieneusi,Encephalitozoon intestinalis:diarrhea in immunocompetent

hosts,severe malabsorption/diarrhea in HIV pts
Consider *CMV* as a late complication in post-bone marrow transplant recipients who present w/
pneumonitis(lung involvement) & colitis(intestinal involvement). Diarrhea & Ab pain occurs in these pts due
to upper & lower GI ulcers. CXR findings-multifocal diffuse patchy infiltrates
Incidence of PCP has fallen w/ use of prophylactic tmp-smx during pre-transplant period
In GVHD, skin rash is always seen(most common organ involved is the skin)
*Cutaneous larva migrans*, or creeping eruption, is common in travelers in tropical regions, & is charac by
pruritic, elevated, serpiginous lesions on the skin, which elongate at the rate of several mm per day as the
larvae migrate in the epidermis. Infection is often acquired thru contact w/ sand. It's caused by the
infective-stage larvae of Ancylostoma braziliense, the dog & cat hookworm.
*Malaria*:Fever in returning traveler,cyclical fever w/ nonspecific constitutional & GI sx,anemia,&
thrombocytopenia
Mosquito-borne dengue fever:sx develop 4-7 days(& never >2 weeks)following mosquito
bite.Fever,headache,muscle/joint pain,retroorbital pain,rash,leukopenia(dx useful)
In East Africa, human African trypanosomiasis(sleeping sickness),transmit by tsetse flies,causes acute

febrile illness w/ skin lesion(trypanosomal chancre),myocarditis,prog to CNS involvement
Toxic shock syndrome due to S.aureus ass. w/ menstruation(tampons),*nasal packing*,post-surgery
infections.Pts develop fever,myalgias,hypotension & diffuse erythematous macular rash (erythroderma) that
can progress to multiorgan involvement
3743 Medicine Infectious Diseases Acute meningococcemia:petechial rash that progresses to ecchymosis,bullae,vesicles,& ultimately
gangrenous necrosis
Scarlet fever:1st fever,headache,vomiting,sore throat.12-48 hrs later,pink blanching papules appear on

neck/upper trunk
Echinococcosis:
majority of human infections are due to sheep strain of E. granulosus. Dogs are definitive hosts, sheep are
intermediate hosts, humans are accidental intermediate host. Sheep breeders at high risk/common in areas
where sheep are raised
Hydatid cysts (containing inner germinal layer and outer acellular membrane) can form. The liver, followed
by the lung, is the most common viscus involved
Pig farmers are at high risk of neurocysticercosis

Neurocysticerosis: caused by the larval stage of the pork tapeworm Taenia solium. It's the most common
3808 Medicine Infectious Diseases parasitic infection of the brain. It's most prevalent in rural areas w/ poorer sanitary conditions & where pigs
are raised.
Amebiasis should be considered in pts w/ a liver abscess who have lived/traveled in an endemic area for
Entamoeba histolytica(eg,Mexico).Elevated alk phos is common & elevated transaminases may be seen.Pts
3819 Medicine Infectious Diseases that are symptomatic(fever,RUQ pain) can develop desentery.Initial evaluation includes imaging,serologic
testing & empiric tx w/ *metronidazole*(to tx abscess) & a luminal agent eg,paromomycin (to edadicate
intestinal colonization).Cyst drainage not recommended routinely
Strong ass. between infections w/ Streptococcus gallolyticus (S bovis biotype 1) & colonic neoplasms &
such pts should have further evaluation w/ colonoscopy to look for underlying occult malignancy.
S gallolyticus (S bovis biotype 1) is 1 of the 4 major species that belong to group D streptococci (also known
as S bovis/S equinus complex)
Ashhadscknotes
*Pts w/ HIV should receive vaccination for MMR if their CD4 cell count is >200/uL*,have no hx of AIDS
defining illness,& have no evidence of immunity(birth before 1957,documented evidence of prior
vaccination,or positive titers)
[Most live vaccines(BCG,anthrax,oral typhoid,oral polio,yellow fever) are contraindicated in pts w/
HIV.Exceptions are MMR & VZV vaccines;these can be used in pts w/o evidence of immunity if their CD4
>200/uL & have no hx of AIDS defining illness]
Recent immunization guidelines for HIV positive individuals recommend a Tdap in adulthood,followed by
tetanus-diphtheria (Td) boosters every 10 years(sooner if required due to a contaminated wound).Tdap is
also indicated w/ every pregnancy to protect the infant;this applies to all women(including those who are HIV
3888 Medicine Infectious Diseases positive)
The hpv vaccine is effective at preventing cervical & anal cancer due to HPV infection.Rec for men &
women aged 9-26,but not FDA approved beyond age 26
3892 Medicine Infectious Diseases Nontypable Haemophilus influenzae is a common cause of exacerbations of chronic bronchitis in adults
Any pt w/ HIV who has BLOODY diarrhea & CD4 count <50/mm3 should have colonoscopy w/ biopsy to
look for *CMV* colitis.CMV colitis is charac by frequent,small-volume,bloody stools & ab pain.Any pt w/ HIV
who has active CMV disease requires ocular examination to rule out concurrent retinitis
Cryptosporidiosis causes chronic,profuse,watery diarrhea in pts w/ CD4 counts <180/mm3;typically no sx of
colitis
Diarrhea due to Mycobacterium avium complex infxn is watery,not bloody

Risk factors for Group B streptococcal endocarditis include diabetes mellitus, carcinoma, alcoholism, hepatic
failure, elective abortion, and iv drug use
S. epidermidis is an important cause of prosthetic valve endocarditis. It is also seen in infants w/ IE
secondary to umbilical venous catheter infection in neonatal intensive care units
Pneumocystis pneumonia (PCP) is likely in pts w/ HIV who have a nonproductive cough, exertional dyspnea,
fever, severe hypoxia, bilateral interstitial infiltrates on CXR, & a normal white count, esp if their CD4 count
3938 Medicine Infectious Diseases is <200/mm3. *Trimethoprim-sulfamethoxazole* is the drug of choice. *Corticosteroids* have been shown to
decrease mortality in pts w/ severe PCP infection. Indications for corticosteroid use in PCP include PaO2
<70 mmHg or A-a gradient >35 mm Hg on room air
Nocardiosis:
Branching, filamentous, partially acid-fast bacteria
Common in immunocompromised or elderly pts
Presents w/ pulmonary (most common), CNS, or cutaneous manifestations
Pulmonary nocardiosis- manifests as pneumonia. Pulmonary nodules also seen.
Tx-trimethoprim-sulfamethoxazole
Actinomyces-can cause sulfur granules

Aspergillus- branching, septated hyphae
Mucormycosis-caused by Rhizopus, appear ribbonlike,nonseptated hyphae
Mycobacteria are fully acid fast rods
Cat-scratch disease:cutaneous lesion & regional lymphadenopathy following cat scratch or bite.Dx can be
made clinically & *observation* is sufficient for immunocompetent individuals w/ mild-to-moderate
sx.Azithromycin rec in disseminated disease(liver,spleen,eye,bone,brain) or for immunocompromised
4057 Medicine Infectious Diseases hosts.[Biopsy when dx uncertain,material needed for culture, or malignancy is a concern]
Amoxicillin-clavulanic acid:tx mammalian bites(covers oral anerobic flora & Pasteurella)
Ventilator-ass. pneumonia(VAP) usually occurs within >48 hours after intubation & presents w/
fever,purulent secretions & abnormal chest x-ray.Pts should have lower respiratory tract sampling(Gram
stain & culture) & receive empiric antibiotics.Fever,leukocytosis & lobar infiltrates are consistent w/ VAP
CT scan of chest used to evaluate for VAP complications(empyema)if pt doesn't improve clinically.Also used
to evaluate for alternate causes if Gram stain/culture are -ve
C difficile colitis: sx- watery diarrhea, fever, abdominal pain, & leukocytosis. Also can get toxic
megacolon(worse case scenario).
White/yellow pseudomembranes on sigmoidoscopy
4092 Medicine Infectious Diseases risk factors- recent hospitalization, advanced age, antibiotic use
dx- *stool studies for C difficile toxin/Stool toxin testing* (NOT STOOL CULTURES)
tx- metronidazole or oral vancomycin
Unexplained leukocytosis in hospitalized pts should also raise suspicion for C difficile, even w/o diarrhea
P. jiroveci causes pneumonia in immunocompromised hosts.
4115 Medicine Infectious Diseases Bilateral diffuse interstitial infiltrates is finding on chest x-ray
pts have nonproductive cough
Ashhadscknotes
Vertebral osteomyelitis presents w/ fever, back pain, & focal spinal tenderness. Evaluation includes blood
cultures & inflammatory markers. *MRI of the spine* is the modality of choice for dx, followed by CT-guided
bone biopsy
Technetium bone scan is less specific than gallium imaging in the dx of vertebral osteomyelitis as it also
detects fractures & may result in false-positive findings
Mitral valve disease, usually mitral valve prolapse w/ coexisting mitral regurgitation, is the most common
valvular abnormality detected in pts w/ infective endocarditis
S. pneumoniae is the most common pathogen causing pneumonia in nursing home pts.
4166 Medicine Infectious Diseases Its also the mcc of community acquired pneumonia in adults.
Vaccination w/ Pneumovax can help prevent it.
4167 Medicine Infectious Diseases Intermittent catheterization is an effective measure to reduce the risk of UTI in pts w/ neurogenic bladder
In diabetic pts, the pathogenic mechanism of osteomyelitis adjacent to a foot ulcer is *contiguous* spread of
infection
Hematogenous spread is the most likely pathogenic mechanism of hematogenous osteomyelitis, which is
typically observed in children
Diabetic pts w/ acute pyelonephritis are generally tx w/ parenteral abx for 48-72 hours. Once the pt has a
clear response, tx can be switched to oral abx for a total course of 10-14 days. Fluoroquinolones &
trimethoprim-sulfamethoxazole are good options for oral therapy, w/ the choice of abx usually individualized
4169 Medicine Infectious Diseases based on culture & sensitivity results
Gentamicin used in combination therapy for UTI in pts w/ severe infection or risk for drug resistant
organisms
Dx for Legionnaires disease can be confirmed w/ urine antigen testing in combination w/ culture.
Tx Legionnaires disease w/ a macrolide or fluoroquinolone
Nail puncture wound in an adult resulting in osteomyelitis is most likely due to *Pseudomonas aeruginosa*.
Tx-oral/parenteral quinolones & surgical debridement
S.aureus(coagulase positive) is the mcc of osteomyelitis in children & adults
CSF findings of elevated wbc count, elevated protein level, & decreased glucose level are suggestive of
bacterial meningitis. Typical skin lesions during *meningococcal infection* include petechiae & purpura.
4265 Medicine Infectious Diseases Myalgias are common & can be more intense & painful than those seen in viral influenza
Arboviruses cause encephalitis & include eastern equine, western equine, St. Louis, & West Nile virus
Influenza:
sx-fever,myalgias,headaches,abrupt onset of sx,systemic symptoms out of proportion to mild respiratory sx
tx-If within 48 hrs of sx onset,treat w/ Neuraminidase inhibitors(oseltamivir,zanamivir) which can decrease
severity & duration of influenza by 2-3 days.If pt presents later, manage w/ symptomatic treatment
Viral URI:slow onset of sx, rhinorrhea, coryza, sneezing
S.pharyngitis:tonsillar exudates,tender anterior cervical adenopathy,fever,absence of cough
Crystal induced nephropathy:

well known side effect of indinavir therapy (indinavir is a protease inhibitor)
HIV therapy complications:

4327 Medicine Infectious Diseases didanosine-induced pancreatitis
abacavir- related hypersensitivity syndrome
lactic acidosis due to NRTI use
Stevens Johnson syndrome due to NNRTI use
nevirapine-associated liver failure
Way to differentiate between Infectious mononucleosis and HIV:
4354 Medicine Infectious Diseases IM- tonsillar exudate is more common
HIV- rash and diarrhea are more common

Tenderness to gentle percussion over spinous process of the involved vertebra is the most reliable sign for
spinal(vertebral) osteomyelitis. Pt will also have hx of injection drug use or recent distant site infection(eg uti)
Lumbar disk herniation: acute onset of back pain w/ or w/o radiation down a leg. Pts can recall an inciting
event. Pain worse w/ activity & improves w/ rest. Spine won't be tender to palpation
Bacillary angiomatosis: Caused by *Bartonella*, occurs in immunocompromised pts, classic lesion shows a
4373 Medicine Infectious Diseases large pedunculated exophytic papule w/ a collarette of scale-resembles a large pyogenic granuloma or
cherry angioma. Be careful when biopsying these lesions because they are prone to hemorrhage
Haemophilus influenzae:
causes upper respiratory tract infections, bronchitis in pts w/ copd, & pneumonia. Noncavitating infiltrates
Streptococcus pneumoniae (pneumococcus):
mcc of community acquired pneumonia. Typically causes lobar pneumonia
Ashhadscknotes
Nocardia: filamentous, aerobic, gram-positive bacteria that is partially acid-fast. Causes pulmonary or
disseminated disease (particularly to the brain[brain abscess->seizures]) in immunocompromised hosts.
Tx-*TMP-SMX*
4417 Medicine Infectious Diseases Aztreonam tx gram-neg infections, including Pseudomonas aeruginosa
Myocbacterium tuberculosis-acid fast rods that DO NOT gram stain
Penicillin G tx for Actinomyces(anaerobic)

Influenza pneumonia: abrupt onset of fever,chills,malaise,myalgias,cough,coryza.Occurs in epidemic
pattern,often in the winter.Pts will often be febrile & have wheezes,crackles,coarse breath
4418 Medicine Infectious Diseases sounds.Leukopenia & proteinuria may be present.CXR may be normal or show interstitial/alveolar
pattern.Antiviral tx must be started within 48 hours. Newest therapies are the neuraminidase inhibitors
*oseltamivir & zanamivir*. Rimantadine & amantadine are only effective agaisnt influenza A
Tuberculin skin testing is used to identify pts w/ latent TB infection & a high risk of reactivation TB. In the
US, an induration size of <15 mm is considered negative in healthy pts w/ a low likelihood of TB infection
PCV13 recommended for all adults age >65 followed by the PPSV23 6-12 months later
Sequential PCV13 & PPSV23 recommended for adults age <65 w/ very high risk conditions (eg, csf leaks,
sickle cell disease, cochlear implants, congenital/acquired asplenia, immunocompromised status, chronic
renal failure)
PPSV23 alone is recommended for adults age <65 who are current smokers or have chronic medical
conditions including heart or lung disease, diabetes, & chronic liver disease
In addition to the vaccines recommended for the general population(Td every 10 years w/ one time
substitution of Tdap, influenza vaccine), pts w/ HIV infection should receive pneumococcal
4478 Medicine Infectious Diseases vaccination(PCV13 followed by PPSV23 8 wks later & every 5 years thereafter). Most pts w/ HIV should
also receive vaccination for hepatitis A & B if they don't have documented evidence of immunity to these
viruses. Live vaccines are generally contraindicated
Pts w/ PID are at an increased risk for other STDs & should also be screened for HIV, *syphilis(w/ RPR)*,
hepatitis B, cervical cancer (pap smear), & hepatitis C(if they have a hx of IV drug use)
S. aureus can cause post viral URI necrotizing pulmonary bronchopneumonia w/ multiple nodular infiltrates
that can cavitate to cause small abscesses
Reactivation toxoplasmosis in HIV pt:
4611 Medicine Infectious Diseases sx-fever, headaches, confusion, ataxia, & ring enhancing lesion on brain MRI. Tx prophylactically w/
*trimethoprim/sulfamethoxazole*. This also helps prevent PCP.
Following splenectomy, pts are at increased risk for sepsis due to encapsulated organisms including
Streptococcus pneumoniae, Neisseria meningitidis, & Haemophilus influenzae. *Vaccinations against each
of these organisms should be administered either >14 days before scheduled splenectomy or >14 days
after splenectomy*
Secondary syphilis:diffuse maculopapular rash involving trunk & extremities,including palms & soles,w/
generalized lymphadenopathy & systemic sx(fever,malaise,sore throat)
Rickettsial diseases including Rocky Mountain spotted fever or Ehrlichiosis: rash begins as maculopapular
eruption on wrists & ankles that spreads to the trunk,extremities,palms,& soles around day 5 of illness.Pts
are toxic appearing,w/ high fever,conjunctivitis,severe headache & diffuse myalgias
Ticks should be removed asap. Best removed w/ tweezers. Mouthparts that break off & remain in skin can
4662 Medicine Infectious Diseases be left alone cuz infective body of tick no longer attached. Pt should seek medical attention if "bull's eye
rash" develops. One dose of doxycycline given if criteria for prophylaxis are met.
Adult Still's disease:
4668 Medicine Infectious Diseases inflammatory disorder characterized by recurrent high fevers, rash and arthritis. The rash if often
maculopapular and nonpruritic, affecting the trunk and extremities during febrile episodes
Pulmonary tuberculosis:
sx- productive cough, hemoptysis, recurrent fevers, weight loss, chest CT w/ upper lobe cavitary lesions
surrounded w/ alveolar infiltration
risk factor- travel to country where TB endemic eg: Mexico
Allergic bronchopulmonary asperfillosis:
occurs in pts w/ asthma or cystic fibrosis
sx- fever, malaise, productive cough, eosinophilia, hemoptysis
Splenic abscess: fever, leukocytosis, left upper quadrant abdominal pain, left sided pleuritic chest pain, left
pleural effusion, splenomegaly. Ass. w/ *Infective endocarditis*
Tx-splenectomy is rec. for all pts(Abx alone has high mortality rate). Percutaneous drainage for pts that are
poor surgical candidates
Abx tx in pts w/ infective endocarditis(IE):
4727 Medicine Infectious Diseases Most viridans group streptococci(*S.mutans*) are highly *susceptible to penicillin* & should be treated w/ IV
aqueous penicillin G or *IV ceftriaxone* for 4 weeks[oral abx are generally not rec. as initial tx in pts w/ IE]
Most rapid and sensitive test to diagnose disseminated histoplasmosis in immunocompromised pts is urine
or serum assay for histoplasma antigen
Histoplasmosis:
tx- Itraconazole
Ashhadscknotes
Eikenella corrodens is a Gram-negative anaerobe & a common constituent of normal human oral flora.
Infective endocarditis due to E corrodens is usually seen in the setting of poor dentition &/or periodontal
infection, along w/ dental procedures that involve manipulation of the gingival or oral mucosa[S. aureus is
the mcc of infective endocarditis seen among injection drug users]
Viral esophagitis: sx-severe odynophagia (pain w/ swallowing) WITHOUT dysphagia (difficulty swallowing) or
thrush
Candida esophagitis:sx-oral thrush, odynophagia is mild to moderate
8959 Medicine Infectious Diseases Medication related chemical esophagitis ("pill esophagitis") is caused by potassium chloride, tetracyclines,
bisphosphonates, & nonsteroidal anti-inflammatory drugs
HSV: round/ovoid ulcers
CMV: deep linear ulcers

Pts w/ HIV who have subacute onset of low grade fever, headache, & signs of increased intracranial
9885 Medicine Infectious Diseases pressure(papilledema) should be evaluated for *cryptococcal meningitis*. Dx is established by detection of
the cryptococcal antigen or isolation of the organism in csf
HIV screening is recommended for all pts age 15-65 regardless of risk factors
Use the 4th generation assay that detects both the HIV p24 antigen & HIV antibodies
Meningococcal vaccination is important for military recruits, college students living in dormitories, travelers
10904 Medicine Infectious Diseases to sub-Saharan Africa, & travelers to Mecca for hajj. Vaccination should be provided to all adolescents at
age 11-12. A booster is recommended at age 16.
Condyloma acuminata (anogenital warts):
due to human papillomavirus
sx- pts develop skin colored, whitish, or grayish verrucous and filiform papules in the anal area(often in
men), penile shalft, or vulvovaginal and cervial areas
Leukocytoclastic vasculitis:
due to infections, medications, inflammatory conditions, or malignancy
presents as non-blanching, 1-3 mm violaceous papules that can cluster/coalesce into plaques
older lesions are brown-red; new ones are more violaceous
Chikungunya fever:in Central/South America,tropical African regions,South Asia,Caribbean.Vector is Aedes
mosquito.Sx-fever,malaise,rash,lymphadenopathy,polyarthralgias(almost always
present),lymphopenia,&thrombocytopenia
Disseminated gonococcemia:tenosynovitis,polyarthralgias & dermatitis(pustular or vesiculopustular lesions)
Reactive arthritis:occurs 1-4 weeks after GI/genitourinary infection w/ asymmetric

oligoarthritis,conjunctivitis,oral lesions
Acute bacterial prostatitis:presents similarly to other utis but w/ the addition of perineal pain, systemic
sx(fever,chills,acute illness),& tender boggy prostate on exam. *Mid-stream urine culture* should be
obtained to help direct antibiotic tx.While awaiting culture results,start empiric tx w/ TMP-SMX or a
fluoroquinolone
2246 Medicine Male Reproductive System
CT scan can be useful to dx prostatic abscess
Pts w/ acute bacterial prostatitis w/ urinary retention may require suprapubic catheterization of bladder
Testicular cancer: After the dx of a solid testicular mass has been made, (a painless hard mass in testicle +
suggestive ultrasound), the inital management is removal of the testis & it's associated cord (*Radical
ochiectomy*). The testis & abnormal tissue present is then examined under the microscope to determine
the type of cancer. This is the tumor that we "kill first & investigate later".
Due to controversy, PSA screening should be determined on a case-by-case bases by the physician &
patient
Colonoscopy is rec. every 10 years for colorectal cancer screening if the initial screen is normal
Anabolic steroid use causes infertility by suppressing production of GnRH, LH, & FSH
Klinefelter syndrome: i.e., XXY semineferous tubule dysgenesis, characterized by testicular fibrosis (primary
hypogonadism), azoospermia, gynecomastia, decreased intelligence, increased axial skeletal growth, high
FSH & LH
Myotonic dystrophy: testicular atrophy, widespread muscular atrophy, weakness, low testosterone level,
high FSH & LH
Cryptorchidism: failure to palpate two testes
Ashhadscknotes
Most common drug that causes Priapism is Prazosin.For boards,rmr the association of priapism w/
*trazodone*[Trazodone is an antidepressant which is mainly used for sleep disturbances]
Fluoxetine causes sexual dysfunction,resulting in impotence,decreased libido & ejaculatory probs.SSRIs

3916 Medicine Male Reproductive System cause delayed orgasm & can be used in tx of premature ejaculation
Antihypertensives & Nonselective b-blockers cause impotence
Some degree of erect dysfunc ass. w/ use of simvastatin(rare!)

An absent or decreased Achilles tendon reflex can be a normal finding in elderly pts
Pts w/ a hx of pelvic surgery or irradiation can develop a urinary fistula w/ continuous loss of urine thru the
fistula. Dx made w/ iv pyelography, which shows dye leaking from the fistula
Primary CNS lymphoma: Presence of EBV DNA in the CSF is specific for this condition. MRI reveals a
weakly ring-enhancing mass that is usually solitary & periventricular
2276 Medicine Nervous System
In pts w/ AIDS dementia complex imaging studies reveal cortical & subcortical atrophy & secondary
ventricular enlargement
Frontotemporal dementia(FTD) aka Pick's disease: early personality changes (euphoria, disinhibition,
apathy) & compulsive behaviors (peculiar eating habits, hyperorality), earlier age of onset, & strong
2281 Medicine Nervous System hereditary component. Affects pts at 40-60 years of age
Lewy body dementia: Visual hallucinations

Lewy body dementia: fluctuating cognitive impairment, recurrent visual hallucinations(eg,old lady saying she
sees a lion roaring in the backyard or sees cats in her room, despite her son not seeing any) & motor
features of parkinsonism
Picks disease(fronto-temporal dementia): personality change(euphoria, disinhibition, apathy), compulsive
behaviors (peculiar eating habits, hyperorality), & impaired memory. Visual-spatial functions remain intact
Internuclear ophthalmoplegia is a charactertistic finding of multiple sclerosis. Its due to demyelination of the
medial longitudinal fasciculus
Lesion of the medial lemniscus affects touch and vibration sensations bilaterally
Destruction of the frontal lobe causes ipsilateral deviation of the eyes

Parkinson's tremor is a resting tremor. Anticholinergic drugs (e.g., benztropine) are the drugs of choice
2287 Medicine Nervous System Huntington's chorea: characterized by chorea & dementia. Tx- Haloperidol
Sodium valproic acid & clonazepam used for myoclonus

Acute ischemic stroke: First do noncontrast head CT to rule out intracranial bleeding. Then assess whether
iv thrombolytic therapy (alteplase) can be used. Thrombolytic therapy w/ iv recombinant *tissue plasminogen
2288 Medicine Nervous System activator (alteplase)* is rec. in pts w/ acute ischemic stroke if it can be initiated within 3-4.5 hours of sx
onset(unless contraindicated). Also, antiplatelet agents shouldn't be used within the first 24 hours after
thrombolytic therapy
Tick-borne paralysis:ascending paralysis over hours to days(asymmetrical),no fever,no sensory
problems,normal CSF exam.Paralysis due to neurotoxin release.Ticks feed for 4-7 days & are found on pts
after meticulous searching.Removal of tick results in improvement
Guillain Barre syndrome:ascending symmetrical paralysis over days to weeks,autonomic
dysfunction(tachycardia,urinary retention,arrhythmias)
Botulism:descending paralysis,cranial nerve involvement,pupillary problems

Guillain Barre syndrome(GBS): Ascending muscle weakness after recent infectious illness(respiratory or GI
infection). Tx-*IVIG* or plasmapheresis
[Glucocorticoids were used previously in the tx of GBS but studies show that they aren't beneficial & so are
no longer recommended]
Most common cause of Lumbar spinal stenosis is degenerative joint disease (DJD).In DJD,disc herniation &
facet osteophytes impinge upon spinal cord.DJD commonly seen in middle-aged & elderly pts
Lumbar spinal stenosis sx are exacerbated by extension of spine(standing,downhill walking),& improved by

flexion of the spine(sitting,uphill walking)
Bone scans:identify areas of high bone turnover.Used for metastatic disease,suspected

fractures,osteomyelitis,sometimes low back pain
Lung cancer is the mcc of brain metastasis in pts w/ a hx of smoking
"multiple brain lesions in both hemispheres w/ surrounding edema" suggests metastatic disease to the brain.
Ashhadscknotes
Pts w/ an established dx of myasthenia gravis(fluctuating & fatigable ocular/bulbar weakness + confirmation
w/ acetycholine receptor antibodies) should subsequently receive *chest imaging (eg, CT scan or MRI)* to
evaluate for thymoma
Myasthenia gravis is caused by autoantibodies (originating in the thymus) directed against nicotinic
acetylcholine receptors at the neuromuscular junction
*Myasthenia gravis*:fluctuating,fatigable muscle weakness that worsens w/ repetitive motions of same
muscle groups & improves w/ rest.Ocular(diplopia,ptosis) or bulbar (dysarthria,dysphagia) dysfunction is the
2667 Medicine Nervous System presenting symptom in most pts.Proximal muscle involvement(hip flexors,quadriceps,deltoids) can cause
difficulty climbing stairs or blow-drying hair.Respiratory muscle weakness is a life-threatening complication
that may lead to respiratory failure(myasthenic crisis)
Basal ganglia hemorrhage: Eyes deviate *away from* hemiparesis(eg. right sided weakness but left
conjugate gaze deviation)
Thalamic hemorrhage: Eyes deviate *toward* the side of hemiparesis
Pons hemorrhage: *Pinpoint* reactive pupils

Lesion in the *upper thoracic spinal cord*->paraplegia,bladder & rectal incontinence & absent sensation
from nipple downwards
Lesion in cerebellum->posterior fossa sx (nausea,vomiting,ataxia)

Lesion in posterior colums->ataxia
Lesion in lower thoracic spinal cord->absent sensation from umbilicus downwards
Lesion located supratentorially->partial or complete hemiparesis

*Vasospasm* is the major cause of delayed morbidity & mortality in [SAH]subarachnoid hemorrhage(days
3-10 after presentation) & can result in cerebral infarction. Vasospasm can best be prevented w/ initiation of
nimodipine.
2678 Medicine Nervous System [Rebleeding causes death within first 24 hours, esp within 6 hours of untreated SAH]
Hemiplegic migraine: rare familial disorder that presents w/ migraine headache ass. w/ unilateral motor
deficits. Neuro deficits occur at the time of the headache
Diabetic neuropathy usually presents w/ alterations in sensation,including loss of proprioception.Motor
findings may be a late manifestation in the most severe cases.Hyperactive reflexes & an upgoing plantar
2679 Medicine Nervous System reflex are incompatible w/ diabetic neuropathy & are suggestive of an upper motor neuron process.Along w/
this,if a pt has back pain,we worry about a mass lesion in the spine(diabetic pts are prone to developing
epidural abscesses).A *spine MRI* should be performed
Aminoglycosides can cause ototoxicity(hearing loss) by damaging the cochlear cells, & some
aminoglycosides (esp gentamicin) can also damage the motion-sensitive hair cells in the inner ear to cause
2837 Medicine Nervous System selective vestibular injury (vestibulopathy) w/o significant ototoxicity. Pts experience oscillopsia(sensation of
objects moving around in the visual field when looking in any direction). An abnormal head thrust test helps
detect vestibular dysfunction due to gentamicin
Wilson's disease:children present w/ liver disease(asymptomatic aminotransferase elevations,fulminant
hepatic failure).Young adults have neuropsychiatric disease(tremor & rigidity,depression,paranoia &
catatonia).Dx by decreased serum ceruloplasmin,increased urinary copper & Kayser-Fleischer rings seen on
slit lamp exam of eye
Neuro sx of Wilson's disease are secondary to copper deposition in the basal ganglia
Mallory hyaline-seen w/ Wilson's & alcohol liver injury

Creutzfeldt-Jakob disease: suspect in an older pt(between age 50-70) w/ rapidly progressive dementia,
myoclonus, *sharp wave complexes on EEG*, &/or elevated 14-3-3 proteins in CSF samples
Pseudotumor cerebri: Young obese female w/ headache suggestive of brain tumor but w/ normal
neuroimaging & elevated CSF pressure. *Blindness* is the most significant complication. Tx- weight
reduction & acetazolamide. Shunting or optic nerve sheath fenestration may be performed to prevent
blindness.
Alzheimer's disease:
usually pts > 60 years old
neuroimaging demonstrates atrophy that is more prominent in the temporal and parietal lobes
Frontotemporal dementia:
age of onset is earlier than Alzheimers (40-60 years)
marked atrophy of the frontal and temporal lobes seen on CT
initially you get more personality changes and loss of social restraints
Hypertensive intracerebral hemorrhage(intracranial bleeding):evolves over a course of minutes to hours.Pts
initially present w/ focal neurologic sx(hemiplegia,hemiparesis,hemisensory disturbances).These are quickly
followed by sx of increased ICP(vomiting,headache,bradycardia,decreased alertness)
Lacunar strokes are quite small.The rapidly worsening global neurologic sx(vomiting,stupor,bradycardia)
won't be seen[unlike hypertensive intracerebral hemorrhage]
Ashhadscknotes
central cord syndrome:
causes- hyperextension injuries in elderly pt's with degenerative changes in cervical spine, elderly pt's with
3072 Medicine Nervous System spondylosis
sx- weakness that's more pronounced in upper extremities than lower
selective loss of pain and temperature in arms
3074 Medicine Nervous System Alzheimer's disease: CT shows generalized cortical atrophy
Idiopathic intracranial hypertension (IIH) (Pseudotumor cerebri) can occur secondary to isotretinoin. Lumbar
puncture shows increased opening pressure (>250 mm H2O)
Neuroleptic malignant syndrome: recent onset confusion, fever, muscle rigidity, & diaphoresis.
Its a drug induced idiosyncratic reaction
Idiopathic intracranial HTN (pseudotumor cerebri): pts present w/ holocranial headache, vision
3162 Medicine Nervous System changes(blurry vision & diplopia), & pulsatile tinnitus ("whooshing" sounds in ears). Seen in young obese
women. Dx involves ocular examination, neuroimaging, & *lumbar puncture*
CT scan of a diffuse axonal injury shows numerous minute punctate hemorrhages w/ blurring of grey white
interface.
MRI more sensitive than CT scan for diagnosing diffuse axonal injury.
Epidural hematoma- biconvex collection
Subdural hematoma- crescentic collection

Anterior cord syndrome:ass. w/ burst fracture of vertebra.Total loss of motor function below level of lesion
w/ loss of pain & temperature on both sides below the lesion.Intact proprioception
Central cord synd:burning pain/paralysis in upper extremities,relative sparing of lower extremities

Acute disk prolapse:severe radicular pain w/ positive straight leg raising test
Cauda equine synd:paraplegia,variable sensory loss,urinary/fecal incontinence

Because the facial/ophthalmic venous system is valveless, uncontrolled infection of the skin can result in
3327 Medicine Nervous System cavernous sinus thrombosis. Red-flag sx include severe headache; bilateral periorbital edema; & cranial
nerve III,IV,V, & VI deficits
Reversible acetylcholinesterase inhibitors such as donepezil, rivastigmine, and galantamine are of benefit in
slowing the cognitive decline ass. w/ Alzheimer's disease
Amantadine is a dopamine agonist used to delay the onset and minimize the severity of dementia in pts w/
parkinson's diease
Creutzfeldt-Jakob disease is charac by rapidly progressive dementia, myoclonus & *sharp, triphasic,
synchronous discharges on EEG*
Pick's disease: resembles Alzheimer's dementia clinically, but is more commonly seen in females. Onset of
sx is around 50 years. Personality & language changes are often more prominent than cognitive sx
Huntington's dementia is caused by defect in autosomal dominant gene on chromosome 4. Path involves
striatal neuro-degeneration
Pts w/ advanced HIV can develop neurologic manifestations from HIV encephalopathy (triad of cognitive
3446 Medicine Nervous System impairment, mood, and movement disorders), CNS toxoplasmosis, lymphoma, & other conditions. Sx's
gradually worsen.
Carotidynia:
neurological condition
causes by inflammation of carotids and vagus
pain is sharp and localized to the carotid artery distribution in neck
Burning mouth syndrome:
rare cause of facial pain
viral
sx- reddened mucosa, significant pain, aggravated by dryness
Drug of choice for trigeminal neuralgia is *carbamazepine*[Aplastic anemia occurs w/ prolonged
carbamazepine use,so routine CBC done for these pts.If med fails to control pain, surgical gangliolysis or
suboccipital craniectomy for decompression of the trigeminal nerve are options]
Lithium:primary agent for manic depression.Its levels must be monitored as it can be toxic
Carbidopa prevents peripheral decarboxylation of levodopa & decreases peripheral side effects
multiple sclerosis:
young female with bilateral trigeminal neuralgia
"33 y/o white female, severe bilateral lightning like pain on face, pain is burning and sharp in nature and
occurs 20-30 times/day, episodes last a few seconds, transient arm weakness"
Ashhadscknotes
Primidone is an anticonvulsant agent which can be used to tx benign essential tremors. Its administration
can precipitate acute intermittent porphyria, which manifests as abdominal pain, neurologic & psychiatric
abnormalities
Beta blockers are 1st line tx for essential tremors. Not rec if pt bradycardic or has severe COPD
Lithium tx mania. Monitor levels cuz it can cause hypothyroidism

Amaurosis fugax: painless loss of vision from emboli, warning sign for an impending stroke. Most emboli
occur from the carotid bifurcation; hence, a *duplex ultrasound of the neck* should be performed
When pts present w/ sx suggesting an increased intracranial pressure, always do neuroimaging(e.g. CT)
before doing a lumbar puncture to avoid any chances of herniation
Hemorrhages are seen as hyperdense(bright/white) areas on CT scan(google pic)
Infarcts have hypodense(less dense than reference structure,hypodense relative to the adjacent gray &
white matter,looks darker/blacker than surrounding area) parenchymal areas on CT scan(google pic)
Lacunar infarcts present w/ pure motor stroke, pure sensory stroke or clumsy-hand dysarthria
Acute spinal cord compression:loss of motor & sensory function,loss of rectal tone,& urinary retention
Management-emergency surgical consultation, neuroimaging,& possibly iv glucocorticoids
Conus medullaris:back pain w/ bladder & rectal dysfunction but weakness & sensory loss are less common.
Symmertric motor weakness. Hyperreflexia.
Cauda equina: lower extremity weakness,saddle anesthesia,bowel/bladder dysfunction. Asymmetric motor

weakness. Hyporeflexia/areflexia
Migraine: unilateral headache w/ *pulsatile* quality,*vomiting* & *photophobia*. Common in younger
females. Tx- IV antiemetics (chlorpromazine, *prochlorperazine*, or metochlopramide) can be used as
3619 Medicine Nervous System monotherapy or as adjuvant therapy in combo w/ NSAIDs or triptans for tx of acute migraine headaches
Amitriptyline & Propranolol are used for migraine prophylaxis but are not helpful in the acute setting
Non traumatic subarachnoid hemorrhage(*google CT pic*):due to *ruptured saccular/berry
aneurysm*.Noncontrast head CT scan shows acute bleeding in cisterns along major proximal cerebral blood
vessels arising from circle of Willis
Amyloid angiopathy:2nd mcc of intracerebral hemorrhage,lobar in location,in pts age >75
IIH:due to impaired cerebral spinal fluid absorption or excess production.Acute thunderclap headache(worse
while flat) ass w/ vision changes/nausea
Huntington's chorea: pts present in their forties or fifties w/ chorea and/or behavioral disturbance. *Atrophy
of the caudate nucleus*(seen on neuroimaging as enlargement of lateral ventricles)
Alzheimer's: diffuse atrophy of cerebral cortex

Wilson's disease: atrophy of lentricular nucleus
Pick's disease: atrophy of frontal and/or temporal lobes, dementia & personality changes also seen
Idipathic intracranial hypertension or Pseudotumor cerebri:
sx- features of increased intracranial pressure in alert pt, absence of focal neurologic signs, no evidence for
other causes (eg tumors) on neuroimaging, normal csf examination except for increased CSF opening
pressure
3637 Medicine Nervous System tx- acetazolamide is 1st line!
Migraine headache tx: sumatriptan
Timolol drops treat glaucoma

*Oligoclonal bands* are present in 85-90% of cases of multiple sclerosis. CSF pressure, protein & cell count
are grossly normal
[Multiple Sclerosis presents w/sx such as paraplegia,urinary incontinence/urgency,spasticity & hyperreflexia
3644 Medicine Nervous System in lower extremities,impaired vibration/proprioception in forearm]
Albumino-cytologic (elevated protein & normal cell count) dissociation is a CSF finding of Guillain Barre
Syndrome
Exertional heat stroke:charac by a temp >40 C (104 F) & CNS dysfunction.Management involves *rapid
cooling,preferably w/ ice water immersion*
When ice water immersion not available or is difficult,other cooling techniques may be considered(they are
less effective than ice water immersion)
Evaporative cooling preferred for nonexertional or classic heat stroke(seen in elderly pts w/ underlying
comorbidities that limit their ability to cope w/ excessive heat)
Ashhadscknotes
Aspirin:Reduces risk of early recurrence of ischemic stroke.Give within 24 hrs to all pts presenting w/ stroke.
Aspirin + dipyridamole OR clopidogrel is rec. for pts who have recurrent stroke on aspirin therapy
Alteplase rec. for eligible pts presenting w/ acute ischemic stroke sx within 3-4.5 hours of sx
Anticoagulation (eg, dabigatran, warfarin) rec. for stroke prevention in pts w/ atrial fibrillation
Avoid unfractionated/LMWH heparin in acute stroke. Risk of bleeding!

Levodopa/carbidopa:most effective symptomatic tx for parkinsonism(but it doesn't stop progression of
disorder).Most common early side effects are *hallucinations*,dizziness,headache & agitation.After several
years of tx,involuntary movements are more likely to occur
Choreiform dyskinesia commonly seen earlier w/ COMT inhibitors(entacapone/tolcapone)
Livedo reticularis(mottled vascular pattern on lower extremities) commonly seen w/ amantadine

Trihexyphenidyl is an anticholinergic medication used in the tx of Parkinson's disease in younger pts where
tremor is the primary sx
The beta blocker propranolol is considered first line tx of essential tremor
Myasthenia Gravis:
Oral anticholinesterase(*pyridostigmine*) is the initial tx of choice for myasthenia gravis
Edrophonium is used for dx purposes only

Corticosteroids are used in pts who show a poor respone to anticholinesterase
Plasmapheresis is used in seriously ill pts when other tx are not effective/contraindicated. Not used for long
term basis.Used for stabilization of pt before thymectomy and myasthenia crisis.
IV Igs used in the same setting as plasmapheresis

Syringomyelia: fluid filled cavity in the cervical & thoracic spinal cord, loss of pain/temperature sensation
"cape" distribution, vibration/proprioception preserved, lower motor neuron signs in upper limbs as cavity
enlarges
Anterior spinal cord syndrome: sudden flaccid paralysis(spinal shock) & loss of pain/temperature sensation
below level of spinal injury. Autonomic dysfunction may occur
3725 Medicine Nervous System Glioblastoma multiforme: CT/MRI shows butterfly appearance w/ central necrosis (google image)
*Cerebellar hemorrhage*: presents w/ occipital headache, vomiting, gaze palsy or nystagmus, neck
stiffness, & gait ataxia. There is no hemiparesis or sensory loss. Early dx w/ noncontrast head CT scan is
imp as emergency surgical decompression may be life-saving
Cerebral lobe hemorrhage: Contralateral hemiparesis(frontal lobe),Contralateral hemisensory loss(parietal
lobe), Homonymous hemianopsia(occipital lobe), Eyes deviate away from hemiparesis, High incidence of
seizures
Management of myasthenia crisis w/ respiratory failure consists initially of endotracheal intubation followed
by treatment w/ corticosteroids as well as IVIGs or plasma exchange(preferred)
3727 Medicine Nervous System Myasthenia crisis can be exacerbated by an underlying respiratory tract infection
Administration of edrophonium(AChE inhibitor) leads to a notable improvement of strength in pts w/

myasthenic crisis, but it causes worsening weakness & cholinergic sx in pts w/ MG cholinergic crisis
The most common (30%) site of hypertensive hemorrhages is the *putamen*. The internal capsule that lies
adjacent to the putamen is almost always involved, leading to contralateral dense hemiparesis
Pts w/ pontine hemorrhage present w/ complete paraplegia followed by deep coma within a few minutes.
The pupils are pinpoint but reactive to light. Decerebrate rigidity is present
Pts who develop serious bleeding (eg. intracerebral hemorrhage) due to excess warfarin use should have it
reversed w/ IV *vitamin K and prothrombin-complex concentrate*
Protamine sulfate is used for urgent reversal of heparin

Over the counter cold meds contain acetaminophen which can potentiate the anticoagulant effect of warfarin
Tranexamic: antifibrinolytic agent used to tx heavy menstrual bleeding and prevent excessive blood loss
during certain types of surgeries
Ashhadscknotes
Dominant parietal lobe lesion:contralateral sensory loss,contralateral inferior homonymous quadrantanopsia
Nondominant frontal lobe lesions: affect the way a person conveys emotion thru speech(motor aprosodia),
contralateral weakness, & apraxia
Nondominant temporal lobe lesions:can impair ability to comprehend emotional gestures(sensory
aprosodia). These pts can develop a contralateral homonymous quadrantanopsia due to inferior optic
radiations involvement
Riluzole is a glutamate inhibitor that is approved for use in pts w/ amyotrophic lateral sclerosis. It may
prolong survival & the time to tracheostomy. Side effects are dizziness, nausea, weight loss, elevated liver
3771 Medicine Nervous System enzymes & skeletal weakness
Donepezil is a cholinesterase inhibitor that is used to improve cognitive function in pts w/ Alzheimer's disease
Pts w/ acute, severe pain should receive the same standard of pain management regardless of drug history.
3804 Medicine Nervous System IV morphine is appropriate treatment for acute, severe pain. Never undertreat pain, even if there is a risk of
abuse.
The basic pathology in myasthenia gravis lies at the *neuromuscular junction* & is mediated by
auto-antibodies against the acetylcholine receptor.
3837 Medicine Nervous System Eaton Lambert syndrome: ass. w/ small cell carcinoma of the lung
*MRI* is the test of choice for dx multiple sclerosis(MS)
MS: look for patchy neurological problems (eg, right upper extremity, left lower extremity, & optic neuritis).
Predominant immunoglobulin type is IgG. IgG index is elevated in 90% of pts w/ MS.
Pts w/ hypertension have 4x risk of stroke! Very strong association of hypertension with stroke(compared to
the other risk factors of stroke)
Myasthenia gravis is caused by autoantibody-mediated *degradation of acetylcholine receptors* at the
neuromuscular junction, which often leads to fatigable ocular(prosis,diplopia) & bulbar muscle
3891 Medicine Nervous System weakness(fatigable chewing,dysphagia w/ nasopharyngeal regurgitation,dysarthria). Most pts w/
acetylcholine receptor antibodies have thymic abnormalities(thymoma, thymic hyperplasia), which appear as
an anterior mediastinal mass on chest imaging
The dexamethasone suppression test (DST) may be used clinically to detect endogenous depression. In up
to 50% of pts w/ depression, DST will be abnormal
Difference b/w psudodementia & dementia of Alzheimer's origin is that pts w/ pseudodementia tend to be
"overly concerned" about their memory loss & often seek help. Pts w/ Alzheimer's tend to be indifferent to
their memory loss & are usually brought by their families
Normal pressure hydrocephalus: "wet, wacky, wobbly." MRI or CTshows enlarged/dilated ventricles
Pseudotumor cerebri: shrunken ventricles are seen on MRI
*100% oxygen tx of choice to abort an ACUTE ATTACK of cluster headache*
Verapamil,prednisone,ergotamine,methysergide,cyproheptadine,indomethacin used for prophylaxis of

cluster headaches(started asap after onset of acute attack)
Lithium for prophylaxis of chronic cluster headaches
Cluster headache: Pathophys related to alterations in circadian pacemaker, due to hypothalamic

dysfunction, often occurs at the same time of the day. NOT ASS. W/ NAUSEA OR VOMITING!
Huntington's disease: affects both males & females around the age of 30-50 years. Sx- mood disturbances
(depression, apathy), dementia, & choreiform movements (facial grimacing, ataxia, dystonia, tongue
protrusion, writhing movements of extremities)
Pick's disease is seen more frequently in females. It doesn't cause any extrapyramidal sx, and is not
genetically acquired
ACA stroke:contralateral motor or sensory deficits predominantly in lower extremity.Urinary incontinence
seen occasionally
MCA stroke:contralateral somatosensory & motor deficit(more pronounced in the face or upper limb than
4022 Medicine Nervous System lower limb)
PCA stroke:homonymous hemianopia,alexia w/o agraphia(dominant hemisphere),visual

hallucinations,sensory sx,3rd nerve palsy w/ paresis of vertical & horizontal eye movements,contralateral
motor deficits
Suspect Neurofibromatosis type II in a young pt w/ acoustic neuroma & multiple cafe-au-lait spots. *MRI w/
gadolinium* enhancement is the best method to dx acoustic neuromas
Pseudodementia/reversible cognitive impairment: is largely reversible w/ the tx of depression using meds
such as *SSRIs*
Pts w/ pseudodementia are frequently distressed by their impaired memory; those w/ Alzheimer dementia
are often relatively unconcerned & confabulate
Ashhadscknotes
Solitary brain metastasis: Surgical resection is recommended
Multiple brain metastases: Whole brain radiation therapy is used

Brachytherapy: implantation of radioactive source directly into an intracerebral mass allowing higher
radiation doses to be delivered directly into the brain w/o affecting other organs
Brain that has seized for >5 min is at increased risk of developing permanent injury due to excitatory
cytotoxicity (excitatory cytotoxicity generally only affects the cortex). Cortical laminar necrosis is the
hallmark of prolonged seizures.
Cerebellar atrophy is caused by chronic use of certain antiepileptic drugs (eg, phenytoin) & alcohol abuse
Persistent seizure activity may cause an increased intracranial pressure & could lead to an intracranial
hemorrhage
Multiple system atrophy (Shy-Drager syndrome): when pt w/ Parkinsonism experiences orthostatic
hypotension, impotence, incontinence, or other autonomic sx.
Riley-Day syndrome (familial dysautonomia):
autosomal recessive disease seen in children of Ashkenazi Jewish ancestry. Characterized by gross
dysfunction of the autonomic nervous system w/ severe orthostatic hypotension
Subdural hematoma: Can also occur w/ minor trauma if pt is on anticoagulation therapy(combo of aspirin
and warfarin/coumadin).CT shows semi-lenticular hematoma.
4153 Medicine Nervous System Epidural hematoma: middle meningeal artery injury from trauma to temporal bone, biconvex hematoma on
CT
Meningoma: tumor of the arachnoid granulation. Usually seen over the convex surfaces of the brain
Brain death: absent cortical & brain stem functions. Spinal cord may still be functioning, therefore *deep
tendon reflexes may be present!*
4159 Medicine Nervous System Pupillary light reaction & oculovestibular reaction are absent in pts w/ brain death. HR fails to accelerate
after atropine injection cuz vagal control of heart is lost & heart becomes invariant. Apnea test shows no
spontaneous respiration at PCO2 values of 50 mmHg & more, thereby demonstrating no functioning of
lower brainstem center
4170 Medicine Nervous System Most common site of ulnar nerve entrapment is the elbow! HIGH YIELD!
Thalamic stroke (Dejerine-Roussy syndrome): Hemi-sensory loss w/ severe dysesthesia (touching a body
part causes pain, burning, tingling) of the affected area(aka thalamic pain phenomenon)
Strokes that affect the mid-brain or medulla classically involve the nuclei of the cranial nerves
Hemi-neglect syndrome is characterized by ignoring the left side of a space, & involves the right
(non-dominant) *parietal* lobe
Frontal cortex lesion results in hemiparesis (w/ motor aphasia if the dominant lobe is involved)
Left temporal lobe involvement leads to receptive aphasia

Nonsense & frameshift mutations are more severe than missense mutations.
Silent (same sense) mutations do not affect the structure of the protein
Interferon-beta decreases the frequency of relapse, & reduces disability in pts w/ the relapsing-remitting
4240 Medicine Nervous System form of multiple sclerosis(MS)
Corticosteroids are administered during the acute attack of the disease
Cluster headache: intense unilateral retroorbital pain which starts suddenly(usually at night, wakes pt from
sleep), more common in men, accompanied by redness of ipsilateral eye, tearing, stuffed or runny nose, &
ipsilateral Horner's syndrome. Prophylaxis is key to management. Prophylactic meds- verapamil, lithium, &
4253 Medicine Nervous System ergotamine
tx for acute attack- inhalation of 100% oxygen & subcutaneous sumatriptan
Extremely high yield for USMLE!!!

Craniopharyngiomas: Common in children but nearly 50% occur in individuals age >20, esp between ages
4255 Medicine Nervous System 55-65. Can compress optic chiasm, leading to bitemporal blindness. Sx of pituitary hormonal deficiencies
eg, decreased libido due to hypogonadism
Lesion in posterior limb of internal capsule:unilateral motor weakness of face,arm & leg w/o any higher
cortical dysfunction or visual field abnormalities
Lesions in vertebrobasilar system that supply brainstem are characterized by "alternate" syndromes,w/
contralateral hemiplegia & ipsilateral cranial nerve involvement
Ashhadscknotes
Lateral medullary infarct(Wallenberg syn):loss of pain/temp over ipsilateral face & contralateral
body,ipsilateral bulbar muscle weakness,vestibulocerebellar impairment(vertigo,nystagmus) & Horner's
syn.Motor function of face & body spared
Medial medullary syn:pts develop contralateral paralysis of arm & leg & tongue deviation toward lesion
Medial mid pontine infarct:contralateral ataxia & hemiparesis of face,trunk,limbs

Brown Sequard syndrome:
damage to the lateral spinothalamic tracts, causing contralateral loss of pain & temperature sensation
beginning two levels below the level of the lesion
4274 Medicine Nervous System eg 1: a lesion of the right sided lateral spinothalamic tracts at T10 will result in a left sided loss of pain and
temperature sensation beginning at T12.
eg 2: a lesion at right sided T12 would result in a loss of pain and temperature sensation on the left side
beginning at L2.(12 thoracic vertebrae)
Cerebellar tumors:ipsilateral ataxia,nystagmus,intention tremors,loss of coordination.Pt falls towards side of
lesion
Tabes dorsalis:Destruc of posterior colums leads to loss of proprioception.Pt walks w/ legs wide apart,feet
lifted higher than usual w/ slapping sound when in contact w/ floor
Hemiparetic pt:hx of stroke,affected arm adducted,affected leg extended,leg swung outward in semicircle as
pt walks
Muscular dystrophy:waddling gait due to weaknes of gluteal muscles

Parkinsonism: mask-like,immobile facial expression,bradykinesia,resting tremor,rigidity,general slowing of all
motor activity(*hypokinetic gait*),stooped posture,feet shuffle & scrape floor,arms remain immobile & don't
swing. Overactivity of cholinergic neurons & underactivity of dopaminergic neurons in substantia nigra.
Sensory ataxia: loss of proprioception causes wide based, high stepping gait
Vestibular ataxia: staggering gait, accompanied by vertigo & nystagmus

Metoclopramide: prokinetic agent, treats nausea, vomiting, & gastroparesis. Can cause *drug-induced
extrapyramidal symptoms* eg, tardive dyskinesia, dystonic reactions, & Parkinsonism
Tx for dystonic reaction: discontinue the med causing it & give benztropine or diphenhydramine
Cervical nerve root compression causes chronic neck pain & inilateral radiculopathy
Acute angle-closure glaucoma:
can be caused from meds like anticholinergics, sympathomimetics, or even dim light
sx- severe unilateral eye pain w/ conjunctival injection, dilated pupil, pt may see halos around lights,
headaches w/ subsequent nausea & vomiting
4367 Medicine Nervous System complication- permanent vision loss within 2-5 hours of sx onset
Herpes zoster ophthalmicus: unilateral rash in trigeminal distribution
Optic neuritis: acute vision loss, pain, occurs in women age <50, initial sx of MS
Epidural abscess:fever,focal spinal tenderness/back pain,& neurologic dysfunction. RF-IV drug
use,immunocompromised state(eg diabetes, HIV, alcoholism), infectious spread from distant source, spinal
trauma/surgery.
Evaluation includes urgent *MRI of spine*, blood cultures, inflammatory markers & CT-guided aspiration &
culture.Antibiotics along with emergency surgical decompressoin & drainage of the abscess are
recommended for most pts
Pronator drift is relatively sensitive & specific for *upper motor neuron disease*. Upper motor neuron lesions
cause a weakness in supination that results in the pronator muscles becoming dominant. When these pts
4381 Medicine Nervous System close their eyes & extend their arms w/ palms up, the affected arm will tend to pronate
Parietal lobe is involved in sensation, perception, & the integration of sensory input
Spinal cord compression is characterized by signs & sx of upper motor neuron dysfunction distal to the site
of compression. These include weakness, hyperreflexia, & an extensor plantar response. Cord compression
4391 Medicine Nervous System is a medical emergency requiring prompt dx by *spinal MRI*
Edrophonium test used to dx myasthenia gravis

Cauda equina lesion: *Spinal nerve roots* are compressed(eg,from metastatic prostate cancer). Causes
lower motor neuron signs. Severe bilateral RADICULAR PAIN. ASYMMETRIC motor weakness.
HYPOREFLEXIA/AREFLEXIA
Conus medullaris lesion: causes both upper & lower motor neuron sx. SYMMETRIC motor weakness.
HYPERREFLEXIA
hypokalemia:
sx- weakness, fatigue, muscle cramps
can lead to paralysis and arrhythmia when severe.
ECG may show U waves, flat and broad T waves, premature ventricular beats
Ashhadscknotes
Subdural hematomas: occur due to tearing of bridging veins. Blunt trauma is the mcc. Common in older pts
and alcoholics due to brain atrophy and vessel fragility. Appears as white crescent on noncontrast CT
4394 Medicine Nervous System Lacunar strokes: caused by small vessel hyalinosis. HTN and diabetes are risk factors. Affects internal
capsule & causes pure motor dysfunction
Subarachnoid hemorrhage: ruptured aneurysms are leading cause

Neurocardiogenic/Vasovagal syncope: due to excessive vagal tone -> transient profound hypotensive
reaction & bradycardia. Benign, lasts about 10 seconds to a few minutes. Triggered by prolonged standing,
emotional distress, or painful stimuli. Pts experience dizziness, nausea, pallor, diaphoresis, abdominal pain,
general sensation of warmth prior to episode.
Myoclonus: involuntary jerking of muscle/muscle group. Can be rhythmic, usually initiated by contraction or
relaxation
Chorea: brief, irregular, unintentional muscle contractions. Movements tend to flow from one to another but
are NOT rhythmic/repetitive
Athetosis: slow, writing movements affecting hands & feet, charracteristic of Huntington's disease, chorea &
athetosis often occur together
Resting tremor is seen in Parkinson's disease. Tremor goes away w/ movement and reemerges when
movement is stopped
Essential tremors present as action/postural tremors.They worsen at the end of goal directed
activities.Relieved w/ alcohol
Orthostatic tremor:postural tremor,occurs in legs right after standing & relieved by sitting down
Large fiber peripheral neuropathy: action/postural tremors. Pt get weakness,loss of proprioception,sensory

ataxia,areflexia, paresthesias
Trihexyphenidyl: a med used for Parkinson's disease & drug-induced extrapyramidal sx. It's anticholinergic
effects can lead to acute glaucoma(headache & retro-orbital pain). Other sx include dry skin, dry mouth,
constipation, urinary retention, flushing, vision changes, & confusion
Co-administration of selegiline(a MAO-B inhibitor) w/ SSRIs &/or tricyclic antidepressants can precipitate
serotonin syndrome[agitation,confusion,tachycardia,muscle rigidity,& sometimes seizures]
Diabetic mononeuropathy often involves CN III. Nerve damage is *ischemic*, & only somatic nerve fibers
are affected. Parasympathetic fibers of CN III retain function. Ptosis & a "down & out" gaze in conjunction w/
normal light & accommodation reflexes indicate diabetic CN III neuropathy
CN III neuropathy can occur due to nerve compression. Causes include transtentorial (uncal) herniation or
aneurysm of the posterior communicating artery
Unilateral foot drop: "steppage" gait: exaggerated hip & knee flexion while walking. Caused by L5
radiculopathy & compression *peroneal neuropathy*. L5 radiculopathy may also have weak foot inversion &
planter flexion, while these will be normal in peroneal neuropathy
Pyramidal tract/corticospinal tract lesions cause spastic ataxia. Gait appears stiff or rigid w/ circumduction &
planter flexion of affected limb
*Glucocorticoid-induced myopathy*:complication of chronic corticosteroid use(eg,when tx giant cell temporal
arteritis).Charac by painless proximal muscle weakness,thats more prominent in lower extremities.No
muscle inflammation or tenderness.CK level & ESR are normal.It slowly improves once offending medication
4443 Medicine Nervous System is discontinued
Mononeuritis multiplex:usually seen in vasculitis,caused by nerve damage in 2 or more nerves in separate

parts of the body.Pts develop wrist/foot drop
Benign paroxysmal positional vertigo(BPPV):Due to crystalline deposits(canaliths) in semicircular canals that
disrupt normal flow of fluid in the vestibular system->contradictory signaling from corresponding canals on
4457 Medicine Nervous System each side, which is interpreted as spinning/vertigo sensation.Triggered by changes in head position.Dx
confirmed w/ Dix-Hallpike maneuver(vertigo & nystagmus on quickly lying back into a supine position w/ the
head rotated 45 degrees)
4461 Medicine Nervous System Ophthalmic branch (V1) of the trigeminal nerve controls corneal sensation
Myasthenia gravis (MG): *neuromuscular junction disease.* Extra-ocular muscle weakness (eg, diplopia &
4464 Medicine Nervous System ptosis) w/ symmetrical proximal weakness of the extremities (upper more than lower), neck (flexors &/or
extensors), & bulbar muscles (eg, dysarthria or dysphagia)
Guillain Barre syndrome: CSF analysis shows an *elevated protein level w/ normal cell count(normal wbc
count,normal rbc count,normal glucose)*
Bacterial, fungal, & tubercular meningitis presents w/ elevated protein, low glucose, elevated WBC counts
Viral meningitis has elevated WBC count, & normal RBC & glucose counts. Protein normal to slightly
elevated. [Exception is herpes meningoencephalitis, which has high RBC & protein levels reflecting temporal
lobe hemorrhge]
Ashhadscknotes
Lacunar strokes occur due to microatheroma formation & lipohyalinosis in the small penetrating arteries of
4482 Medicine Nervous System the brain. They often affect the internal capsule & result in pure motor hemiparesis. Htn, hyperlipidemia,
diabetes, & smoking are major risk factors
Cerebral septic emboli are one of the most dreaded consequences of endocarditis. They occur when pieces
4483 Medicine Nervous System of infected valvular vegetations break off & enter the CNS circulation, causing focal neurologic deficits.
Cerebral septic emboli are tx w/ antibiotics
*Viridans streptococci* (eg,S.intermedius,S.mitis,S.oralis,S.mutans) & other head & neck anaerobes
(eg,Prevotella,Peptostreptococcus,Bacteroides) are the most common pathogens when brain abscess
4513 Medicine Nervous System results from sinusitis
[Brain abscess sx-headache,focal neuro deficit,ring enhancing intracranial lesions on CT scan of brain in
immunocompetent pt w/ adjacent bacterial infection.Fever present in only 50% of cases]
Parkinson disease(PD): To date, there are no imaging or laboratory tests that can be used to confirm this
dx w/ any greater accuracy than *physical examination*
Postural instability signs like flexed axial posture, loss of balance during turning or stopping, loss of balance
when pushed slightly from stationary bipedal stance, frequent falls are some physical exam findings that
contribute to clinical dx of PD. Others signs are usual stuff like tremor, rigidity, bradykinesia
Cerebellar dysfunction: common among chronic alcohol abusers. Sx-gait instability, truncal ataxia,
nystagmus,difficulty w/ rapid alternating movements, hypotonia, *intention tremor*, dysmetria(limb-kinetic
tremor when attempting to touch a target), muscle hypotonia(leading to pendular knee reflex-persistent
swinging movements of the limb after eliciting deep-tendon reflex)
Lewy body dementia: alterations in consciousness, disorganized speech, visual hallucinations,
extrapyramidal sx, relatively early compromise of executive functions
How to differentiate between Alzheimers and Normal pressure hydrocephalus:
NPH- Gait impairment is earliest feature
Alzheimers- Gait impairment is a later finding
Chronic subdural hematomas are usually found in elderly & alcoholic pts due to decreased brain volumes
and their propensity for falls
Pts w/ dementia have an increased risk of developing agitated delirium in the hospital. Typical(*haloperidol*)
and atypical(quetiapine,risperidone) antipsychotics are useful for treating acute agitation in elderly pts w/
dementia
4622 Medicine Nervous System Amitriptyline:treats depression,sleep disorders & neuropathic pain
Lorazepam/benzodiazepines:Tx agitation in young pts
Memantine:Tx moderate to severe Alzheimer disease. Blocks action of glutamate on NMDA receptor
Multiple sclerosis(MS): pts w/ acute relapse tx w/ high-dose iv glucocorticoids(methylprednisolone).
Corticotropin injection gel, a purified form of adrenocorticotrophic hormone can be used as alternate
therapy. Plasma exchange also reserved for those who don't respond to high-dose glucocorticoids.
4641 Medicine Nervous System Glatiramer, interferon, mitoxantrone, cyclophosphamide, methotrexate, & cladribine can be used for
long-term disease-modifying therapy
Argatroban used for tx of thrombosis in HIT

Common precipitating causes of delirium include infections (eg, urinary tract infection), polypharmacy,
medication side effects, volume depletion, & *electrolyte or metabolic disturbances*
Normal pressure hydrocephalus(NPH): due to *decreased CSF absorption*
CSF production tends to increase at night, but increases in CSF production is not ass. w/ a particular
disease process
Normal pressure hydrocephalus(NPH) [wet,wacky,wobbly] is tx w/ large volume lumbar punctures & if
successful, *ventriculoperitoneal shunting*
In NPH, urinary incontinence is classic, but fecal incontinence may develop in advanced disease
Donepezil is an acetylcholinesterase inhibitor used to slow the progression of Alzheimer's dementia

*Fibrinolytic therapy* improves neuro outcomes in pts w/ ischemic strokes(eg,pt w/ left sided
weakness,positive Babinski sign,risk factors of HTN & type II diabetes) when given within 3 to 4.5 hours of
sx onset.Before giving tPA, non-contrast head CT should be performed to rule out hemorrhagic stroke & the
pt should be screened for other contraindications to therapy
4675 Medicine Nervous System Dementia: *impairment of daily functioning* is the most specific symptom
Restless legs syndrome:
sx- urge to move legs, crawling/itching feelings on legs
4687 Medicine Nervous System tx- dopamine agonists (pramipexole, ropinirole)
if pts have insomnia, chronic pain, or anxiety, then give alpha 2 delta calcium channel ligands (gabapentin)
if nothing works, then give opioids
Ashhadscknotes
Neoplastic epidural spinal cord compression:
gradual worsening focal back pain,bilateral lower extremity weakness,sensory loss,gait ataxia.Bower/bladder
disturbances are late findings.In acute phase of spinal cord injury,pts develop spinal shock w/ absence of
4691 Medicine Nervous System reflexes & flaccid paraplegia as a result.Exam shows focal point tenderness in spine,exaggerated deep
tendon reflexes in legs,upgoing plantar reflexes
Spinal cord infarction:abrupt weakness,loss of pain/temp sensation

Wernicke encephalopathy is due to thiamine (vitamin B1) deficiency & is most commonly seen in
4700 Medicine Nervous System malnourished pts w/ underlying alcoholism. Features include encephalopathy, ocular dysfunction, & gait
ataxia. Pts should be tx empirically w/ *thiamine* prior to or along w/ glucose administration
A pt's new-onset neurological deficits, occipital headache, & past medical hx of vascular disease,
4702 Medicine Nervous System hypertension, & atrial fibrillation raise suspicion for stroke. *Non-contrast head CT* is the initial dx test of
choice
Acute confusion, extreme hyperthermia >105 F, tachycardia, & coagulopathic bleeding after heavy work
under direct sunlight are most likely due to exertional heat stroke
Hypothalamic stroke may disrupt normal neural thermoregulatory mechanisms & result in neurogenic fever
(NF). In NF, the hypothalamic set-point becomes pathologically elevated
Intracranial HTN:headache(worse at night),focal neuro sx(vision changes eg blurry vision,unsteady gait eg
falls).Sx worsen w/ maneuvers that increase intracranial pressure(eg leaning forward,Valsalva,cough)
[Cushing reflex(htn,bradycardia,resp depression) is a worrisome finding suggestive of brainstem
4708 Medicine Nervous System compression]
Sinusitis can cause frontal headache that worsens w/ leaning forward;however it's ass. w/ nasal congestion
& purulent nasal discharge
*HIV* & hepatitis C infection should be suspected in pts w/ weight loss & hx of IV drug abuse. Pts w/ HIV
are at risk of developing depression & dementia
*Papilledema*: caused by increased intracranial pressure. Presents w/ *transient vision loss lasting a few
seconds w/ changes in head position*. *Blind spot enlarges* in those w/ papilledema. Requires urgent dx
evaluation as persistent papilledema can lead to vision loss
Anterior uveitis presents w/ eye pain & redness
Posterior uveitis is often painless & ass. w/ floaters or reduced visual acuity
4913 Medicine Nervous System Essential tremor is suppressed at rest and exacerbated at the end of goal directed movements
1st line tx for essential tremor is the beta-blocker propranolol. Alternate meds include primidone &
topiramate.
Embolic strokes:sudden onset w/ maximal sx at the beginning.Occur in pts w hx of structural cardiac
disease(eg, atrial fibrillation[irregularly irregular],endocarditis).Pts w/ atrial fibrillation PLUS existing structural
heart disease have an increased risk of cardioembolic strokes
Subcortical lacunar strokes:occluded single penetrating branch of large cerebral artery.Presents w/ pure
motor,ataxic hemiparesis,pure sensory,sensorimotor stroke,dysarthria w/ clumsy hand.
Focal neurologic findings(eg, right sided hemiparesis, sensory deficits) are common in vascular dementia
but not normal pressure hydrocephalus
*Vascular dementia*: sudden/stepwise decline in executive function after stroke, which interferes w/
10448 Medicine Nervous System activities of daily living. Pts have abnormal neuro findings on exam(eg, hemiparesis, pronator drift, Romberg
sign)
Vit B12 deficiency: *Serum methylmalonic acid (MMA) levels* should be obtained in pts w/ borderline B12
levels as elevations in MMA are more sensitive in detecting Vit B12 deficiency than serum vitamin levels
alone
10499 Medicine Nervous System D-lactic acidosis:occur in pts w/ short-bowel syndrome.Pts are asymptomatic but can develop
confusion,ataxia,dysarthria during carb loading
Hypothyroidism:can cause macrocytic anemia & polyneuropathy.Reduction in deep tendon reflexes &
delayed relaxation phase
IV antibiotics decrease risk of septic embolic events in pts w/ native valve infective endocarditis.
Surgery can be onsidered in pts w/ significant valvular dysfunction, persistent/difficult to treat infection, or
recurrent embolism.
Postconcussive syndrome:
Caused by traumatic brain injury. Can last a few hours or days.
sx- headache, confusion, amnesia, difficulty concentrating or multitasking, vertigo, mood alteration, sleep
disturbance, & anxiety
tx- sx resolve w/ symptomatic tx
Delayed subdural hematoma will present w/ focal neurologic deficits (eg, hemiparesis, slurred speech,
aphasia, gait disturbance, hemianesthesia)
Ashhadscknotes
The initial diagnostic workup of a 1st-time seizure in an adult should include basic blood tests (eg, serum
electrolytes, glucose, calcium, magnesium, complete blood count, renal & liver function tests) & a toxicology
screen to evaluate for metabolic & toxic causes. Unprovoked seizures generally require further evaluation w/
neuroimaging & EEG.
[Routine EEG is useful for risk-stratifying pts after a 1st time seizure once metabolic & toxic etiologies have
been excluded]
Prrogressive bilaterally symmetric hearing loss w/ subjective bilateral tinnitus, advanced age, & absence of
other neurologic signs suggest *presbycusis*
Acoustic neuroma arises from the Schwann cells covering the vestibular branch of the 8th cranial nerve. As
the tumor grows, it can cause sx such as vertigo, unilateral tinnitus, & sensorineural hearing loss
Dx of myasthenia gravis(MG) can be supported w/ the bedside ice pack test.In this test,an ice pack is
applied over eyelids for several minutes,leading to an improvement in ptosis.Pts w/ positive test results
should undergo confirmatory testing for *acetycholine receptor antibodies*(highly specific)
MG:caused by autoantibody mediated degradation of acetylcholine receptors at the neuromuscular
junction.Muscle weakness may be precipitated by SURGERY,infection,medications
Phenytoin is an antiepileptic drug w/ known teratogenic effects(eg, fetal hydantoin syndrome). Women of
childbearing age who have a low risk of seizure recurrence may safely discontinue phenytoin if considering
becoming pregnant; however, the medication should be slowly tapered as rapid withdrawal may result in
seizure recurrence
Foodborne botulism:due to ingestion of food(improperly canned fruits/veggies,cured fish) contaminated w/
botulinum toxin.Sx occur within 36 hours of ingestion & begin w/ bilateral cranial neuropathies(blurred
12120 Medicine Nervous System vision,diplopia,facial weakness,dysarthria,dysphagia) followed by symmetric descending muscle
weakness(initially affecting upper extremities & trunk & then lower extremities).Tx-*horse derived
antitoxin/Equine serum heptavalent botulinum antitoxin*
Late neurosyphilis can manifest years after untreated T.pallidum infection w/ tabes dorsalis(sensory
ataxia,lancinating pains[brief shooting or burning pain in face,back,or extremities],reduced/absent deep
tendon reflexes) & Argyll Robertson pupils(normal pupillary constriction w/ accommodation but not w/
light).Neurogenic urinary incontinence also occurs. *IV penicillin* is tx of choice
External hordeolum or stye: common staphylococcal abscess of eyelid.
Tx- *warm compresses*
2374 Medicine Ophthalmology Incision & drainage performed if resolution doesn't begin in the next 48 hours
Chalazion: granulomatous inflammation of the meibomian gland. Tx- incision and curettage
Age-related *macular degeneration*: seen in pts above 50 years of age, presents w/ progressive & bilateral
loss of central vision. Peripheral fields & navigational vision are always maintained, but may become
impaired by the development of cataracts
2375 Medicine Ophthalmology
Open angle glaucoma: gradual loss of peripheral vision(over a period of years) & consequent tunnel vision.
Central vision spared
Central retinal artery occlusion & retinal detachment are acute conditions w/ complete vision loss
Chalazion presents as painful swelling that progresses to a rubbery lesion. Develops when meibomian gland
becomes obstructed. Persistent/recurrent chalazion may be due to meibomian gland carcinoma(sebaceous
2760 Medicine Ophthalmology carcinoma). For this reason, recurrent chalazion requires *histopathologic examination.* Additionally, basal
cell carcinoma is the most common malignancy of the lid margin & may appear clinically similar to a
chalazion
Allergic conjunctivitis(AC):acute hypersensitivity reaction caused by environmental exposure to allergens.
Characterized by intense itching, hyperemia, tearing, & edema of the conjunctiva & eyelids
Atopic keratoconjunctivitis:Severe form of ocular allergy.More severe sx from AC & has a prolonged
course,potential visual impairment due to corneal involvement,& thickening of eyelids & surrounding
skin.Itching,tearing,thick mucus discharge,photophobia,& blurred vision
Cataract: oxidative damage of the lens occurs w/ aging & leads to cataract formation. RF-advancing age,
diabetes, smoking, chronic sunlight exposure, & glucocorticoid use. Pts report blurred vision, glare, & often
halos around lights. Tx- lens extraction & artificial lens implantation is indicated when loss of vision impairs
activities of daily living
Angle closure glaucoma:severe eye pain & blurred vision ass w/ nausea & vomiting.Occurs following
pupillary dilation(can occur in darkened movie theaters,times of stress,due to drug intake).Red eye w/
steamy cornea & moderately dilated pupil that is non reactive to light.Increased intraocular pressure on
tonometry.Permanent cure w/ laser peripheral iridotomy
open angle glaucoma:
more common in african americans & those with family hx of glaucoma and diabetes
sx- gradual loss of peripheral vision, eventual tunnel vision
tx- B-blocks like timolol eye drops for initial management
2852 Medicine Ophthalmology laser trabeculoplasty for adjunctive measure
surgical trabeculectomy only when continuous increase in intraocular pressure
angle closure glaucoma:

sudden onset of sx, blurred vision, severe eye pain, nausea, vomiting, red eye w/ hazy cornea, dilated pupil
Ashhadscknotes
Postoperative endophthalmitis: most common form of endophthalmitis, usually occurs within 6 weeks of
surgery, pts present w/ pain & decreased visual acuity, exam reveals swollen eyelids & conjunctiva,
hypopyon, corneal edema & infection
Uveitis:blurred vision w/ moderate pain,conjunctival injection, & constricted pupils. Hypopyon seen in severe
anterior uveitis. Keratic precipitates ("mutton fat") & iris nodules may be seen. Ass. w/ HLA B27 conditions
Herpes zoster ophthalmicus:dendriform corneal ulcers & vesicular rash in trigeminal
distribution.Sx-fever,malaise,burning/itching sensation in periorbital region
Dacryocystitis:infection of lacrimal sac due to obstruction of nasolacrimal duct.Pain,swelling,tenderness &

redness in tear sac area.Mucous/pus can be expressed
Bacterial keratitis:seen in contact lens wearers & following corneal trauma.Cornea is hazy w/ central ulcer &
adjacent stromal abscess.Hypopyon present
CMV retinitis occurs when CD4 count is <50/ul.Pts may be asymptomatic.Fundoscopic findings of
yellow-white patches of retinal opacification & hemorrhages are diagnostic.Tx-ganciclovir or foscarnet
Ocular toxoplasmosis in immunocompromised host charac by necrotizing retinochoroiditis.More than half of
pts w/ ocular sx have encephalitis.The necrosis involves inner layers of retina which appears as white,fluffy
lesions surrounded by retinal edema & vitritis
Optic neuritis:suspect in pt w/ central scotoma, afferent pupillary defect, changes in color perception &
decreased visual acuity. Rapid impairment of vision in one eye(or rarely both) & pain on eye movement
Episcleritis: inflammation of episcleral tissue between conjunctiva & sclera. Acute onset of mild to moderate
discomfort, photophobia, watery discharge. Exam reveals diffuse or localized bulbar conjunctival injection, &
episcleritic nodules may be present
Dacryocystitis:inflammatory changes in *medial canthal region* of the eye. Staphylococcus aureus &
beta-hemolytic Streptococcus are the usual infecting organisms
Hordeolum:abscess located over upper or lower eyelid,usually caused by Staphylococcus aureus,appears

as localized red,tender swelling over eyelid
Orbital cellulitis:infection posterior to orbital septum,unilateral,more common in

children,fever,proptosis,restriction of extraocular movements & swollen, red eyelids
Herpes simplex keratitis: corneal vesicles & dendritic ulcers
Fungal keratitis occurs after corneal injury in agricultural workers or immunocompromised pts. The cornea
shows multiple stromal abscesses
Amaurosis fugax: visual loss that is transient & usually monocular. Described as "a curtain falling down."
Most commonly caused by *retinal emboli from the carotid artery/displaced retinal embolus*. Once the clot
2861 Medicine Ophthalmology is displaced or breaks up, blood flow is restored & vision returns
Detached retina: light flashes, floaters, curtain coming across visual field(starting from periphery)
Retinal detachment: floaters, "curtain over my eyes", flashes of light
tx- laser therapy & cryotherapy
Choroidal rupture: blurred vision following blunt trauma
2862 Medicine Ophthalmology Central retinal artery occlusion: sudden painless loss of vision in one eye, pallor of optic disc, cherry red
fovea, boxcar segmentation of blood in retinal veins
Exudative macular degeneration: painless blurring of central vision, bilateral, central scotoma, growth of
abnormal vessels in retinal space
Vitreous hemorrhage:sudden loss of vision & onset of floaters.Occurs in pts w/ diabetic retinopathy.Fundus
hard to visualize & even if it's visualized,details may be obscured.[once a diabetic pt presents w/ sudden
onset of visual loss w/ numerous floaters,vitreous hemorrhage has most likely occurred]
Retinal detachment:separation of inner layers of retina.May be ass. w/ metabolic disorders,trauma,vascular
disease,myopia,degeneration. Fundoscopy-elevated retina w/ folds/tear
Central retinal vein occlusion(CRVO):acute or subacute painless monocular visual loss.Funduscopic
examination shows "blood & thunder" appearance consisting of optic disk swelling,retinal
hemorrhages,dilated veins,cotton wool spots.CRVO caused by thrombosis of the central retinal
3328 Medicine Ophthalmology vein-common in pts w/ coagulopathy,hyperviscosity,chronic glaucoma,atherosclerotic risk
factors(age,diabetes,htn)
Amaurosis fugax: due to atheroemboli from carotid arteries, temporary vision loss
Ashhadscknotes
The 3 main categories of diabetic retinopathy are background or simple (microaneurysms, hemorrhages,
exudates, retinal edema), pre-proliferative (cotton wool spots), & proliferative or malignant
(neovascularization). Visual impairment occurs with the development of macular edema. Argon laser
3330 Medicine Ophthalmology photocoagulation is performed for the prevention of complications
Retinal detachment:occurs unilaterally,presents as blurred vision that progressively worsens,retina hanging

in vitreous
Presbyopia:age-related *decrease in lens elasticity*,leads to difficulty w/ near vision. Eg,middle-aged dude
who has to hold books at arms length to read
Nonspherical cornea leads to astigmatism(blurry vision at distance & close up)

Cataracts: difficulty w/ night vision/driving, increased lens opacity
Primary open-angle glaucoma: peripheral visual field defects followed by central visual loss
Acute angle closure glaucoma:
sx- headache, nausea, eye pain, mid-dilated pupil
can be triggered by decongestants, antiemetics, or anticholinergics
3429 Medicine Ophthalmology Gonioscopy is gold standard for dx
Ocular tonometry helpful if opthalmological consultation is not available
Fluorescein staining of the eye performed to detect corneal abrasions or herpes keratitis
Acute glaucoma:
The increased intraocular pressure is reduced w/ mannitol(1st line tx and works immediately),
acetazolamide(a carbonic anhydrase inhibitor that reduces production of aqueous humor), timolol(beta
blocker that decreases production of aqueous humor) or pilocarpine(allows drainage of aqueous humor)
Avoid Atropine! It can dilate the pupil and worsen the glaucoma.
Sometimes mydriatic agents like atropine can precipitate glaucoma
Spontaneous subconjunctival hemorrhage is a benign finding, & doesn't require any treatment. It may be
due to simple trauma from rubbing the eyes vigorously, violent coughing spells, hypertensive episodes or
coagulopathy. The condition is from minor bruising & doesn't require any workup at all. Hemorrhage
disappears in 24-48 hours. *Observation* is the best treatment
Occasional pt on anticoagulation meds may develop a subconjunctival hemorrhage. Tx is conservative

3988 Medicine Ophthalmology Central retinal artery occlusion is emergently tx w/ an *ocular massage & high-flow oxygen administration*
Be overly suspicious for an intraocular foreign body in pts w/ high-velocity injuries (drilling,grinding,etc).If the
initial pen light exam doesn't reveal any conjunctival & corneal abrasions or foreign bodies, proceed w/
*fluorescein examination*. If still no foreign body seen despite suspicion,CT/US can be considered.[MRI
contraindicated since it can dislodge foreign body]
Topical abx applied after foreign body removed
Tonometry performed if penetration of globe ruled out

Sympathetic ophthalmia aka "spared eye injury": characterized by damage of one eye (the sympathetic eye)
after a penetrating injury to the other eye. It's due to an immunologic mechanism involving the *recognition
of 'hidden' antigens*. Typical manifestation is anterior uveitis, but panuveitis, papillary edema, & blindness
may develop
Circulated immune complexes can affect the eye in systemic lupus erythematosus
In HIV pts, both HSV & VZV can cause severe, acute retinal necrosis ass. w/ PAIN, keratitis, uveitis, &
funduscopic findings of peripheral pale lesions & central retinal necrosis.
In contrast, CMV retinitis is PAINLESS, NOT usually ass. w/ keratitis or conjunctivitis, & characterized by
funduscopic findings of hemorrhages & fluffy or granular lesions around the retinal vessels
Candida can cause endophthalmitis, esp w/ disseminated candidiasis infection

*Optic glioma* occurs in 15% of pts w/ neurofibromatosis type 1[NF1-axillary freckling,cafe au lait
4202 Medicine Ophthalmology spots,slowly progressive unilateral visual loss & dyschromatopsia,exophthalmos,optic disk may be normal
swollen or atrophic]
Type 2 diabetics are prone to developing nonketotic hyperosmolar syndrome after encountering physiologic
stressors eg. upper respiratory infection -> severe hyperglycemia -> osmotic diuresis causing dehydration
-> altered conciousness, confusion, coma, blurred vision(due to intraocular hypotension secondary to
hyperosmolarity)
Macular degeneration: pts report that straight lines appear curved. Driving & reading are often affected first.
(Visualization of straight lines is controlled by centrally located macula)
risk factors- increasing age, smoking
Visual loss from cataracts: lens opacification is a cause
Enlarged blind spot seen w/ papilledema
Ashhadscknotes
Viral conjunctivitis("pink eye"):conjunctival inflammation & watery discharge in the setting of an upper
respiratory illness,most cases caused by adenovirus,outbreaks common among small children & caregivers
in late summer & early fall, no specific tx needed.Uncomplicated viral conjunctivitis can be managed
8925 Medicine Ophthalmology symptomatically (eg, warm or cold compresses).Some pts may develop bacterial superinfection which
requires topical abx
Olopatadine/azelastine-mast cell stabilizing agents

Contact lens-ass. infectious keratitis:
medical emergency,painful red eye & opacification & ulceration of cornea.Caused by Gram-negative
organisms like *Pseudomonas* & Serratia, Gram-postive organisms,& certain fungi & amoebas
8926 Medicine Ophthalmology Anterior uveitis (iritis):inflammation of anterior uveal tract,esp the iris. Ass. conjunctival inflammation
adjacent to cornea but cornea itself is spared
Episcleritis:red eye,localized/patchy distribution,doesn't affect vision or involve cornea
Caustic ingestion w/ sodium or potassium hydroxide (lye) causes immediate esophageal injury w/
Poisoning &
2377 Medicine liquefaction necrosis & potential perforation. *Endoscopy* is recommended within the first 12-24 hours to
Environmental Exposure
assess the severity of damage & guide further therapy.
Diphenhydramine overdose:drowsiness,confusion,anticholinergic effects like dry mouth,dilated pupils,blurred
vision,reduced bowel sounds,urinary retention. Physostigmine,a cholinesterase inhibitor can counteract
these anticholinergic effects
Poisoning &
2662 Medicine Salicylate intoxication:tinnitus,nausea/vomiting, fever,altered mental status & acid-base
abnormalities.Tx-alkalinization of urine w/ sodium bicarbonate
Theophylline intoxication:
seizures,hyperthermia,cardiac arrhythmias, hypotension
Benzodiazepine overdose: pts have slurred speech, unsteady gait, & drowsiness. Pupil size is normal. Only
mild respiratory depression. (It's distinguished from opiod overdose by lack of severe respiratory depression
and lack of pupillary constriction)
Poisoning &
2664 Medicine
Phenytoin toxicity:horizontal nystagmus,cerebellar ataxia,confusion
Lithium toxicity: tremor & hyperreflexia, ataxia & seizures

Chemical contact w/ the eye: begin flushing eye w/ running water
Poisoning &
3125 Medicine
Cut/scratch/foreign body in eye: seeking immediate medical care is the proper course of action
TCA overdose: hyperthermia, seizures, hypotension along w/ anticholinergic effects(dilated pupils,
flushed/dry skin, intestinal ileus). Causes QRS prolongation & increases risk of ventricular arrhythmia. EKG,
Poisoning &
3126 Medicine w/ specific attention to the *QRS complex*, is the *best indicator of the extent of overdose*. QRS duration
predicts likelihood of seizures & venticular arrhythmia. Tx-Sodium bicarbonate(it narrows QRS complex &
decreases incidence of ventricular arrhythmia)
Organophosphate poisoning side effects are reversed w/ Atropine. Always make sure to remove any
Poisoning & contaminated clothing and wash off the skin to prevent transcutaneous absorption
3134 Medicine
TCA overdose: obtain an emergent ECG & analyze the QRS complex
If pt ingests toxic dose of acetaminophen(asymptomatic during first 24 hours after ingestion),first step is
*gastric decontamination w/ activated charcoal & measurement of acetaminophen levels*esp if pt presents
within 4 hours of ingestion
Poisoning &
3136 Medicine
Environmental Exposure Rumack-Matthew nomogram provides the likelihood of hepatotoxic effects of acetaminophen overdose &
helps guide admin. of N-acetylcysteine in pts w/ elevated acetaminophen levels
Aspirin overdose ass. w/ increased risk of arrhythmias

TCA overdose can cause cardiac toxicity(characterized by prolonged QRS duration (>100 msec) &
ventricular arrhythmias.
Poisoning & *Sodium bicarbonate* increases serum pH and extracellular sodium, thereby *alleviating the
3138 Medicine
Environmental Exposure cardio-depressant action on SODIUM channels*
With aspirin overdose, sodium bicarbonate increases salicylate excretion via urine alkalinization
*Fluphenazine is a high potency "typical" antipsychotic medication that occasionally causes hypothermia*.
Fluphenazine is commonly injected every 2-3 weeks in schizophrenics w/ poor compliance. Pts taking
antipsychotic meds should be advised to avoid prolonged exposure to extreme temperatures
Poisoning &
3139 Medicine Ibuprofen in excess -> hypotension
Amitriptyline s.e. -> weight change,dizziness,insomnia. Sometimes hypotension
Cephalexin s.e.-> skin rash, vomiting, diarrhea & abdominal pain
Ashhadscknotes
Opioid intoxication: MIOSIS, BRADYCARDIA, HYPOTENSION(due to histamine release), depressed mental
status, decreased respiratory rate(best predictor of intoxication/frequent cause of mortality), decreased
Poisoning & bowel sounds
3156 Medicine
Cocaine intoxication: mydriasis, tachycardia & hypertension[exact opposite of this is seen in opioid
intoxication]
Methanol's immediate effects cause disinhibition. However within 24 hours, it can lead to headache, nausea,
vomiting & epigastric pain. The most severe consequences of methanol intoxication are vision loss & coma.
Poisoning & Physical exam in methanol intoxication reveals optic disc hyperemia while laboratory studies reveal anion
3161 Medicine
Environmental Exposure gap metabolic acidosis. An increased osmolar gap is often seen as well
Whereas methanol damages the eyes, ethylene glycol damages the kidneys
Poisoning & All pts w/ smoke inhalation should be suspected to have acute carbon monoxide poisoning & tx w/ 100%
3223 Medicine
Environmental Exposure oxygen via a nonrebreather facemask
Exertional heat stroke occurs in healthy people that are training in exteme heat/humidity (eg dude in military
training) due to *thermoregulation failure.* Heat stroke sx- fever 105 F, altered mental status, hypotension,
Poisoning & tachycardia, & tachypnea
3690 Medicine
Heat exhaustion is due to inadequate fluid & salt replacement. CNS dysfunction (eg, altered mental status)
is not present in heat exhaustion.
Caustic poisoning: doesn't cause alteration in consciousness(it's the least likely to affect pt's cognition).
Poisoning & Presents w/ dysphagia, severe pain, heavy salivation & mouth burns. The damage is the result of necrosis
3856 Medicine
Environmental Exposure of the tissue that lines the GI tract(leads to white tongue, heavy salivation, dysphagia). In severe cases,
perforation of the stomach or esophagus can occur, causing peritonitis or mediastinitis.
Poisoning &
3876 Medicine For frostbite injuries, the best tx is *rapid re-warming w/ warm water*
TCA overdose: sx- cns, cardiac, & anticholinergic findings. *Sodium bicarbonate* used to tx cardiac
Poisoning &
4035 Medicine toxicity(characterized by prolonged QRS duration & ventricular arrhythmias(eg, ventricular tachycardia,
ventricular fibrillation). Benzodiazepines tx seizures due to TCA overdose.
Carbon monoxide poisoning: suspect in smoke inhalation cases, multiple people from same confined area
present w/ headache, nausea & abdominal discomfort. Pinkish-red skin hue. Dx-obtain carboxyhemoglobin
levels. Tx-hyperbaric oxygen
Poisoning &
4084 Medicine Cyanide poisoning: Burning of rubber or plastic (not wood) can cause cyanide inhalation. Bitter almond
breath is characteristic
Methemoglobinemia: cyanosis & bluish discoloration of skin & mucous membranes
The major cause of mortality in TCA overdose is due to TCA induced hypotension
Severe hypothyroidism can cause myxedema coma which has systemic effects such as CNS depression &
Poisoning &
4487 Medicine hypotension, hypothermia & bradycardia
Hyperkalemia presents on EKG as peaked T waves, followed by lengthening of the PR & QRS intervals,
eventually resulting in a sine wave. [Calcium gluconate is cardio-protective in cases of hyperkalemia]
Sx of opioid withdrawl include nausea, vomiting, cramps, diarrhea, dysphoria, restlessness, rhinorrhea,
Poisoning &
4509 Medicine lacrimation, myalgias, & arthralgias. Physical exam signs include mydriasis, piloeretion, & hyperactive bowel
sounds. Oral or IM *methadone* is the tx of choice to relieve the sx of opioid withdrawal in dependent pts
Opioid intoxication doesn't always present w/ miosis.Coingestions can lead to normal pupil size or even
mydriasis & certain opioids(meperidine,propoxyphene) don't cause miosis even when taken alone.Pupil
Poisoning & examination isn't as reliable as the recognition of bradypnea(decreased respiratory rare) in opioid
4510 Medicine
Environmental Exposure intoxication.Tx-*naloxone(opioid antagonist)* to increase resp rate & improving O2 saturation
Methadone:opioid agonist.Used for long term management of opioid addiction

Ethylene glycol ass. w/ hypocalcemia & calcium oxalate deposition in kidneys -> leads to flank
pain,hematuria,oliguria,acute kidney injury,anion gap metabolic acidosis.Tx-fomepizole or ethanol to inhibit
alcohol dehydrogenase,sodium bicarbonate to alleviate acidosis,hemodialysis in cases of severe acidosis or
Poisoning & end-organ damage
4511 Medicine
Methemoglobinemia:Dapsone/anesthetics can cause it.Tx-Methylene blue
Cyanide poisoning:Due to fires,mining,pesticides.Tx-Sodium thiosulfate

Neuroleptic malignant syndrome(NMS) tx: *Dantrolene*(muscle relaxant) is the most common drug used to
reverse the condition, followed by bromocriptine(dopamine agonist) & amantadine(antiviral drug w/
Poisoning &
4522 Medicine dopaminergic properties)
Tx of NMS involves cessation of all dopaminergic antagonists
Ashhadscknotes
Cyanide binds to Fe3+, inhibiting its reduction to Fe2+ and blocking production of ATP from oxidative
phosphorylation. This promotes anaerobic metabolism, causing lactic acidosis.
Poisoning & Impaired excretion of lactic acid occurs in renal failure

10145 Medicine
Increased gut absoption of lactic acid may occur in blind loop syndrome
Increased ketogenesis occurs during starvation & w/ lack of insulin dependent diabetics
Smoke inhalation injury:
etiology- victims of house fire
tx- treat empirically for cyanide toxicity w/ hydroxocobalamin or sodium thiosulfate, or with nitrites to induce
methemoglobinemia
complications- cardiorespiratory arrest and neurologic disability
Poisoning &
10146 Medicine
Hydrogen cyanide (HCN) and carbon monoxide (CO) are the 2 major products of combustion in closed
spaces.
Methemoglobinemia occurs after exposure to oxidizing agents (eg, dapsone, nitrates, topical/local
anesthetics).
Endurance athletes w/ mild hypothermia are managed w/ passive rewarming. More severe hypothermia
Poisoning &
11466 Medicine requires aggressive tx, including active external(heated blankets) & internal(heated peritoneal irrigation)
rewarming. Dopamine may be needed if iv fluids/rewarming measures are ineffective in restoring normal bp.
Antiphospholipid antibody syndrome (APS):
Pregnancy, Childbirth & ass w/ false positive VDRL, prolonged PTT, & thrombocytopenia
2256 Medicine
Puerperium can promote arterial and venous thromboses and cause spontaneous abortions
tx- prophylaxis with low dose aspirin and LMWH
Psychiatric/Behavioral &
2653 Medicine Phencyclidine: hallucinogenic drug, causes vertical nystagmus, psychotic & violent behavior,
Substance Abuse
2661 Medicine Chlordiazepoxide(Librium) is a benzodiazepine & a common choice of tx for alcohol withdrawel
Substance Abuse
Advanced sleep phase disorder: inability to stay awake in the evening, pts complain of early morning
insomnia due to their early bedtime
Psychiatric/Behavioral & Decreased levels of melatonin seen w/ normal aging & can cause sleep disturbances. In Alzheimer
8822 Medicine
Substance Abuse pts/senile dementia pts, the melatonin drops exceed the regular melatonin drop of normal aging
Delayed sleep phase syndrome: inability to fall asleep at normal bedtimes, pts sleep at 4-5 am, normal
sleep if pt allowed to sleep until late morning
Delayed sleep phase syndrome:circadian rhythm disorder.Inability to fall asleep at "normal" bedtimes(10
PM-midnight).Sleep is normal if allowed to continue until late morning.Sx-insomnia & excessive daytime
sleepiness
8823 Medicine Advanced sleep phase disorder:inability to stay awake in the evening(after 7 PM).Early morning insomnia
Substance Abuse
due to early bedtime
Shift work sleep disorder:recurring pattern of sleep interruption due to shift work.Work schedule incongruent
w/ normal circadian clock
Returning combat veterans are at high risk for developing post-traumatic stress disorder. Common
11811 Medicine presenting sx include sleep disturbance, nightmares, emotional numbing & detachment, intrusive
Substance Abuse
flashbacks, amnesia, & hypervigilance
"Bath salts"[not related to epsom salts or substances used in bathing] have amphetamine properties that
can cause severe agitation, combativeness, delirium, and psychosis. Tachycardia is often present. Effects
Psychiatric/Behavioral & of bath salt intoxication may take several days or weeks to subside
11815 Medicine
Substance Abuse
Compared to bath salts, Phencyclidine(PCP) intoxication sx are usually of shorter duration. PCP is also
included in routine hospital urine toxicology screens
massive pulmonary embolism likely in postoperative pt w/ hypotension, jugular venous distension, and new
onset right bundle branch block.
2145 Medicine Pulmonary & Critical Care syncope occurs in massive pulmonary embolism
pts can eventually get cardiogenic shock and suffer cns effects eg. dilated pupils, unresponsive mental
status
Complications of ventilation w/ a high PEEP include:
1) alveolar damage
2297 Medicine Pulmonary & Critical Care 2) tension pneumothorax(sudden-onset shortness of breath,hypotension,tachycardia,tracheal deviation,&
unilateral absence of breath sounds)
3) hypotension
Hypertrophic osteoarthropathy:
sx- clubbing, sudden onset joint arthropathy in a chronic smoker
2298 Medicine Pulmonary & Critical Care
ass. w/ lung cancer
management- do chest x-ray to rule out malignancy or other lung pathology
Ashhadscknotes
In pts w/ pulmonary embolism, low oxygen saturation & atrial fibrillation(irregular RR intervals, no P waves,
narrow QRS complexes) are ass. w/ poor prognosis
Mitral valve stenosis presents w/ a mid-diastolic rumble & opening snap at the apex
Pulmonary edema(pt w/ CAD hx w/ sudden dyspnea after IV fluids) increases the A-a gradient & the excess
fluid reduces lung compliance(alveoli can't expand). Supplemental O2 corrects hypoxemia,V/Q mismatch,&
A-a gradient
Reduced inspired O2 tension(high altitude) & hypoventilation(cns depression)->normal A-a gradient &
hypoxia correction w/ O2
COPD increases lung compliance & A-a gradient
Shunt->high A-a gradient,hypoxemia doesn't correct w/ O2,low compliance

Pancoast tumors(superior pulmonary sulcus tumors) present w/ shoulder pain.Other findings include
Horner's syndrome(ipsilateral ptosis/miosis),weakness/atrophy of hand muscles,pain/paresthesias in
arm/forearm, enlarged supraclavicular lymph nodes.Initial evaluation includes chest imaging(*CXR*) in pts
2602 Medicine Pulmonary & Critical Care w/ suspected lung cancer.
Pts w/ Horner's syn can develop increased sympathetic activity in the contralateral side w/ flushing & facial
sweating during exercise(Harlequin sign)
Adenocarcinoma: seen in nonsmokers, located peripherally, presents as a solitary nodule.
[Differentiate it from TB. Xray findings in TB often include hilar adenopathy and/or cavitary/patchy lung
2615 Medicine Pulmonary & Critical Care lesions.Solitary nodules are not typical]
Large cell carcinoma is ass. w/ Gynecomastia and Galactorrhea

Squamous cell carcinoma of the lung->hypercalcemia (remember: sCa++mous)
Small cell carcinoma of the lung->ACTH production & SIADH

Hypercalcemia sx: anorexia, constipation, increased thirst, & easy fatigability
Adenocarcinoma is a peripheral lesion ass. w/ hypertrophic pulmonary osteoarthropathy

Small cell lung cancer: causes the majority of cases of malignancy ass. SIADH, ectopic adrenocorticotropic
hormone production(leading to Cushing syndrome), & Lambert-Eaton syndrome. Smoking is the most imp
2635 Medicine Pulmonary & Critical Care risk factor
Hypertrophic osteoarthropathy usually ass. w/ adenocarcinoma

SIADH is a common complication of small cell lung cancer. Initial tx of choice is *fluid restriction*. Severe
symptomatic or resistant hyponatremia from SIADH requires administration of 'hypertonic' saline.
Demeclocycline is rarely necessary & should only be considered if fluid restriction & high salt intake fail to
correct the hyponatremia
ARDS can be due to acute pancreatitis. Look for pt to develop new or worsening respiratory sx during the
2702 Medicine Pulmonary & Critical Care past week. sx- respiratory distress, diffuse crackles, severe hypoxemia, bilateral alveolar infiltrates on chest
imaging
Alpha-1 antitrypsin deficiency: ass. w/ panacinar emphysema & cirrhosis. Histologically, the granules evident
in the hepatocytes of afflicted individuals are thought to represent the unsecreted A1AT. They stain w/ the
2919 Medicine Pulmonary & Critical Care periodic acid-Schiff (PAS) reaction & resist digestion by diastase
Whipple's disease:caused by Tropheryma whippelii & affects the bowel, causing malabsorption
Invasive *aspergillosis* occurs in immunocompromised pts, who may present w/ fever, cough, dyspnea, or
hemoptysis. CXR may show a cavitary lesion, & CT scan shows pulmonary nodules w/ a halo sign or lesions
w/ an air crescent
Blastomycosis affects lungs,skin,bones,joints,& prostate.Infection in immunocompromised hosts is
uncommon.Primary pulmonary infection may be asymptomatic or present w/ flu-like sx
Hypersensitivity pneumonitis: inflammation of lung parenchyma due to antigen exposure. Examples include
aerosolized bird droppings "bird fancier's lung" and molds ass. w/ farming "farmer's lung." sx- cough,
3016 Medicine Pulmonary & Critical Care breathlessness, fever, malaise after antigen exposure. Chronic exposure leads to pulmonary fibrosis,
restrictive pattern on lung spirometry. Radiographic findings include ground glass opacity, or "haziness" of
lower lung fields. tx- avoidance of antigen exposure
ARDS can be due to pneumonia.
Lung injury -> alveolar damage -> *decreased lung compliance (stiff lungs)* & increased pulmonary arterial
pressure (pulmonary htn)
ARDS causes shunting w/ an increased A-a oxygen gradient. In contrast, hypoventilation & decreased FiO2
cause hypoxemia w/ a normal A-a gradient
Ashhadscknotes
Asbestos exposure:
increases risk of pulmonary fibrosis and malignancy
Bronchogenic carcinoma is the most common malignancy(more common than mesothelioma)
Smoking acts synergistically w/ asbestos to further increase the risk of lung cancer
Occupations associated w/ asbestosis-
plumbers, electricians, carpenters, pipefitters, insulation workers, construction, shipbuilding, plastic or
rubber manufacturing.
"Pleural plaques" on imaging are pathognomonic for asbestosis

Restrictive pattern(on pulmonary function tests) shows decreased lung volumes w/ normal or elevated
FEV1/FVC ratio
FEV1/FVC ratio is reduced to <80% of normal in obstructive lung diseases. In restrictive lung diseases, the
values of FEV1 & FVC may also be reduced, but the ratio is >80%
3 month hx of wheezing & chest tightness in pt is concerning for new-onset asthma. GERD is present in
3024 Medicine Pulmonary & Critical Care 75% of asthma pts(half of pts don't report heartburn sx). Obesity, hoarseness, & erythematous pharynx &
larynx also point toward GERD as etiology of pt's asthmatic sx.
Inhaled albuterol & systemic steroids are appropriate treatments for acute asthma attacks. Pts on high
doses of beta-2 agonists may develop hypokalemia, which may present w/ muscle weakness, arrhythmias &
EKG abnormalities. Other common side effects of beta-2 agonists include tremor, palpitations & headache.
*Obtaining a serum electrolyte panel* would be helpful to confirm & assess severity of pts hypokalemia
Recurrent pneumonia in same anatomic location is red flag for bronchial obstruction. Smoking is primary
risk factor for bronchogenic carcinoma.*CT of chest is indicated for suspected lung cancer.* Bronchoscopic
or CT-guided biopsy may be performed for any suspected lesion seen on CT scan
CF causes infections in different areas of the lung.Rarely presents in adulthood
Immunodeficiencies cause recurrent pneumonia in different regions of lung

Alpha 1 antityrpsin (AAT) deficiency:
3031 Medicine Pulmonary & Critical Care classic radiographic pattern is emphysematous changes of the lower lobes. The involvement is panlobular.
Diagnosis of AAT deficiency can be made by measuring the serum alpha 1 antitrypsin level.
Obstructive sleep apnea(OSA): common in obese population. Affected pts at risk for hypertension, heart
disease, cor pulmonale, & accidents. *Polysomnography used for dx*
Surgery for OSA should only be considered when CPAP, oral appliances, & weight loss have proven
ineffective
Pulmonary function testing is not used in the dx of OSA, as affected pts tend to breathe normally while
awake
Bronchiectasis presents w/ cough, mucopurulent sputum, & hemoptysis that often responds to abx. CXR is
3038 Medicine Pulmonary & Critical Care frequently abnormal but isn't as sensitive or specific as *high resolution computed tomography scan* for
definitive dx
3042 Medicine Pulmonary & Critical Care long term oxygen therapy prolongs survival in pts w/ COPD and hypoxemia
Idiopathic pulmonary fibrosis is due to excessive collagen deposition in peri-alveolar tissues. This leads to
decreased lung volumes (low total lung capacity, functional residual capacity, & residual volume) w/
3045 Medicine Pulmonary & Critical Care preserved or increased forced expiratory volume in 1 second/forced vital capacity ratio. Pts have impaired
gas exchange resulting in reduced diffusion capacity of carbon monoxide & *increased alveolar arerial
gradient*.
Sarcoidosis:
also affects the skin (protean manifestations, most commonly erythema nodosum) and the eyes (uveitis)
In mechanically ventilated pts w/ respiratory alkalosis(low pCO2 due to hyperventilation) in the setting of an
appropriate tidal volume, the respiratory rate should be lowered
Incentive spirometry is used to prevent atelectasis in bed-bound pts following surgical procedures
Chest physiotherapy used in pts w/ pneumonia or atelectasis to loosen and promote expectoration of
secretions i.e. pts w/ bronchiectasis require chest physiotherapy
Granulomatosis w/ polyangiitis (Wegener's):

systemic vasculitis, upper & lower airway granulomatous inflammation, & glomerulonephritis. Onset around
3049 Medicine Pulmonary & Critical Care age 40, Upper respiratory tract common site of involvement, inflammation of nasopharynx causes epistaxis,
purulent rhinorrhea, otitis, sinusitis, saddle nose deformity. Cutaneous manifestations also seen such as
painful subcutaneous nodules, palpable purpura, pyodergma gangrenosum like lesions.
Ipratropium: more effective in pts with COPD(than asthma pts)
Treatment for Exercise induced bronchoconstriction:
short acting beta-adrenergic agonists e.g. albuterol, used 10-20 min before exercising
Ashhadscknotes
Bee stings cause anaphylaxis -> tx w/ *Intramuscular* epinephrine
Intravenous epinephrine infusion carries greater risk for adverse effects so it's only reserved for pts who
3400 Medicine Pulmonary & Critical Care don't respond to intramuscular epinephrine
High doses of dopamine act on beta 1 & alpha 1 adrenergic receptors. They can be used as an additional
vasopressor for persistent hypotension
In ARDS, mechanical ventilation w/ low tidal volumes & PEEP can improve oxygenation
Hypoxemia is the major derangement in ARDS

Low tidal volumes help prevent lung damage & decrease mortality rates in ARDS. A 6 ml/kg tidal volume is
rec. Increasing the tidal volume further could result in barotrauma
Solitary pumonary nodule:
first step is to obtain previous radiographic lung images (absence of growth over 2-3 years rules out
malignancy)
if previous films not available, CT should be performed
Bronchiectasis:
Presence of dilated bronchi on CT.
Hemoptysis is a potential complication.
Can result in right-sided heart failure by cor pulmonale.
Goodpasture's disease affects the lungs (causing cough, dyspnea, & hemoptysis) & kidneys (causing
nephritic range proteinuria, acute renal failure, & dysmorphic red cells/red cell casts on urinalysis). Systemic
symptoms are uncommon. Diagnosis is made by renal biopsy showing linear IgG *antibodies along the
glomerular basement membrane*
Wegeners disease:sx- pt presents w/ combination of glomerulonephritis & upper and lower respiratory tract
3580 Medicine Pulmonary & Critical Care disease. Chest xray shows nodular densities & alveolar/pleural opacities. dx- made by *c-ANCA* positivity
and tissue biopsy. tx- high dose corticosteroids & cytotoxic agents
Warfarin dosing should be adjusted to maintain a goal INR appropriate for the condition being treated. For
pts w/ idiopathic VTE or atrial fibrillation, a target INR of 2.0 to 3.0 provides adequate anticoagulation w/o an
3606 Medicine Pulmonary & Critical Care excessive risk of bleeding
INR of 2.5 to 3.5 is desired in pts w/ prosthetic heart valves

In all pts w/ COPD, the two modalities that have been shown to decrease mortality are home oxygen
therapy & *smoking cessation*
Acute pulmonary embolism: Pt w/ sudden onset of pleuritic chest pain, dyspnea, tachypnea, tachycardia, &
hypoxemia after a period of prolonged immobilization. Early anticoagulation decreases mortality risk! Initiate
early empiric anticoagulation in pts w/ high clinical suspicion of acute PE, even before pursuing confirmatory
diagnostic testing
Pts positive for PE but w/ contraindication to anticoagulation should undergo tx w/ IVC filter
Nonseminomatous germ cell tumors produce both alpha fetoprotein and human chorionic gonadotropin
tumor markers(seminomatous ones don't produce AFP)
Large mediastinal mass w/ ass. elevations of AFP and B-hCG is diagnostic of a nonseminomatous germ cell
3775 Medicine Pulmonary & Critical Care tumor
Bronchogenic cysts: congenital, arise due to abnormal development of foregut, appear as fluid filled or
air/fluid filled cystic structures on imaging
Pancoast syndrome: neoplasm in the pulmonary apex at the thoracic inlet can compress the inferior portion
of the brachial plexus resulting in shoulder pain radiating in an ulnar distribution
3776 Medicine Pulmonary & Critical Care Carcinoid tumors are slow growing & have the best prognosis of all lung cancers. Carcinoid syndrome is a
rare presentation
Aspergilloma is usually mobile & moves w/ position. Dx made by finding hyphae in specimen
3846 Medicine Pulmonary & Critical Care The most common adverse effect of inhaled corticosteroid therapy is oropharyngeal thrush (oral candidiasis)
Pts w/ likely pumonary embolism (based off Wells criteria) should be further evaluated with computed
tomography angiography (CTA)
Compression ultrasonography should be initial test for diagnosing DVT
pulmonary thromboembolism/pulmonary embolism:
findings- large area of perfusion defect w/o ventilation defect. this is called a mismatched defect
4009 Medicine Pulmonary & Critical Care ct angiography is test of choice
area of ventilation defect without perfusion defect suggests a respiratory problem

Asthma:
you see reversal of airway obstrution with bronchodilator use
tx- inhaled corticosteroids
COPD:
only partial bronchodilator response
tx- long acting anticholinergic inhaler
Ashhadscknotes
Community acquired pneumonia(CAP): Sx-dyspnea,productive cough,fever,lung infiltrate on CXR
Causes-S.pneumoniae,Haemophilus,atypical organisms(Mycoplasma)
4024 Medicine Pulmonary & Critical Care Tx-Empiric outpatient tx of healthy pts includes doxycycline or macrolides
Hospitalized pts require extended spectrum fluoroquinolone(levofloxacin,moxifloxacin) OR a beta-lactam +
macrolide
Sleep apnea syndrome:
dx- polysomnography
Tx mild to moderate disorder-*weight reduction*, avoidance of sedatives & alcohol, avoidance of supine
posture during sleep.
Other tx modalities include uvulopalatopharyngoplasty & nasal CPAP during sleep.
Tracheostomy used in pts w/ severe disorder & when other tx modalities have failed
Glucocorticoids cause neutrophilia by increasing the bone marrow release & mobilizing the marginated
neutrophil pool. Eosinophils & lymphocytes are decreased.
Acute exacerbation of COPD:
tx- antibiotics, esp in pts w/ 2 of 3 cardinal sx (increased dyspnea, cough, sputum production), moderate to
severe exacerbation, or those needing mechanical ventilation.
4039 Medicine Pulmonary & Critical Care Recommended antibiotics- macrolides, fluoroquinolones, penicillins/beta-lactamase inhibitors
Roflumilast: phosphodiesterase inhibitor w/ anti-inflammatory properties that help decrease mucociliary

malfunction & pulmonary remodeling
The use of noninvasive positive-pressure ventilation (NPPV) in pts w/ acute exacerbation of COPD has been
shown to decrease mortality, rate of intubation, hospital length of stay, & incidence of nosocomial infections.
4040 Medicine Pulmonary & Critical Care Endotracheal inubation w/ mechanical ventilation rec for pts who fail a 2 hour trial of NPPV
[NPPV refers to ventilatory support delivered by facemask rather than endotracheal tube]
*Theophylline toxicity* can manifest as central nervous system stimulation(eg,
headache,insomnia,seizures), gastrointestinal disturbances(eg,nausea,vomiting), & cardiac
4048 Medicine Pulmonary & Critical Care toxicity(arrhythmia,atrial tachycardia,supraventricular tachycardia,&/or ventricular arrhythmias). Inhibition of
the cytochrome oxidase system by other medications(eg,ciprofloxacin), diet, or underlying disease can alter
its narrow therapeutic window
*Bronchogenic cysts are usually found in the middle mediastinum.* They are benign entities.
Thymoma is usually found in the anterior mediastinum

All neurogenic tumors(meningocele,enteric cysts,lymphomas,diaphragmatic hernias,esophageal
tumors,aortic aneurysms) are located in the posterior mediastinum
CHF causes transudative effusions.Transudative fluid has pleural fluid pH of 7.4-7.55(normal is 7.60)
Exudates have:
Pleural fluid protein/serum protein ratio >0.5
Pleural fluid lactate dehydrogenase(LDH)/serum LDH ratio >0.6
Pleural fluid LDH >2/3 of the upper limit of normal serum LDH
Transudates/exudative effusion:pleural fluid glucose similar to blood glucose con.
High pleural fluid amylase:due to pancreatitis ass. effusion or esophageal rupture(from saliva)
Aspirin exacerbated respiratory disease:Non-IgE mediated reaction,results from aspirin induced
prostaglandin/leukotriene misbalance (pseudoallergic reaction to NSAIDs).Seen in pts w/ hx of asthma or
chronic rhinosinusitis w/ nasal polyposis.Sx-bronchospasm & nasal congestion following aspirin
4065 Medicine Pulmonary & Critical Care ingestion.Tx-avoid NSAIDs, desensitization if NSAIDs are required, use leukotriene receptor antagonists(eg,
montelukast)
Cell-mediated(delayed) hypersensitivity: prominent skin findings

*Pleural fluid pH* is the most helpful lab test in determining the need for chest tube placement in
parapneumonic effusion(usually occur from pneumonia). When the pH of the pleural fluid is < 7.2, the
probability is very high that this fluid neds to be drained. Glucose of < 60mg/dL in pleural fluid is also an
indication for tube thoracostomy. Infected pleural space is usually initially drained w/ a chest tube
Undiagnosed pleural effusion is best evaluated w/ *thoracentesis*, except in pts w/ clear cut evidence of
congestive heart failure.(Extremely H.Y. for USMLE!)
4087 Medicine Pulmonary & Critical Care [Bronchoscopy is a close alternative but requires sedation & is an invasive procedure. It'll be the next step if
pleural fluid cytology is non-diagnostic & the pt has lung mass. If pleural fluid cytology is positive for lung
cancer, then the pt doesn't require a bronchoscopy]
4097 Medicine Pulmonary & Critical Care All pts w/ suspected pneumonia should be assessed w/ a *chest x-ray*
Indicators of a severe asthma attack include *normal PCO2*/increased PCO2 values, speech difficulty,
diaphoresis, altered sensorium, cyanosis, & 'silent' lungs
Ashhadscknotes
The main subtypes of COPD include predominant emphysema or chronic bronchitis:
Predominant emphysema- pts are generally thin w/ severe dyspnea, hyperinflated chest, decreased
vascular markings, decreased DLCO(carbon monoxide diffusing capacity of the lung), & moderate oxygen
desaturation
Predominant chronic bronchitis- pts have chronic productive cough for >3 months over 2 consecutive
years,prominent bronchovascular markings,normal DLCO,mildly flattened diaphragm
Humoral immune deficiency: leads to impaired antibody production that usually presents w/ recurrent,
severe, & upper & lower respiratory tract infections due to encapsulated bacteria
Cell-mediated immunity: helps eliminate infected cells w/ pathogens that replicate intracellularly. Pts w/
depressed cell-mediated immunity present w/ infections from ordinarily benign viruses, opportunistic
pathogens, or fungi
Pts w/ impaired consciousness, advanced dementia, & other neurologic disorders are predisposed to
aspiration pneumonia due to impaired epiglottic function
All COPD pts w/ PaO2 <55 mmHg or SaO2 <88% are candidates for long term home oxygen treatment. Pts
4131 Medicine Pulmonary & Critical Care w/ signs of pulmonary htn or hematocrit >55% should be started on home oxygen when the PaO2 <60
mmHg
Primary pulmonary hypertension: Seen in middle aged pts, exertional breathlessness, lungs clear to
4177 Medicine Pulmonary & Critical Care auscultation, enlargement of pulmonary arteries on cxr, enlargement of right ventricle("enlarged right heart
border")
Sarcoidosis: underlying pathologic lesion is presence of noncaseating granuloma on tissue biopsy. Up to
4200 Medicine Pulmonary & Critical Care 30% of pts present initially w/ extrathoracic manifestations such as erythema nodosum(google x-ray of
bilateral adenopathy seen in sarcoidosis)
Nonallergic rhinitis(NAR) aka vasomotor rhinitis: predominant nasal congestion or stuffiness(erythematous
nasal mucosa), postnasal drip(dry cough), & no specific identifiable triggers. Depending on the severity of
sx, pts should be tx w/ an intranasal antihistamine, *intranasal glucocorticoids*, or combo therapy
Allergic rhinitis: pts have predominant eye sx, itching, & sneezing, along w/ specific identifiable triggers in
most cases
Elevated A-a gradient commonly seen in pts w/ pulmonary embolism
Bibasilar opacities on CXR could be caused by pulmonary infarcts from pulmonary emboli, but bibasilar
pneumonia or atelectasis would be more likely
Hemithorax opacification on CXR would most likely be secondary to a very large pleural effusion or
complete collapse of a lung, possibly secondary to a mucus plug in the mainstem bronchus. Side of tracheal
deviation is helpful to distinguish among these etiologies
Pulmonary aspergillosis: fungal balls(aspergilloma),most commonly in pre-existing lung cavities(eg,from
prior TB infection).Southeast Asia is a TB endemic area
Actinomycosis causes pneumonia in the lower lung fields. The pneumonia can progress to abscess &
4210 Medicine Pulmonary & Critical Care empyema w/ chest wall extension & rib osteomyelitis
Bronchoalveolar carcinoma:grows along alveolar septa. Nodule or lobar consolidation
Histoplasmosis imaging: calcified nodes,calcification on chest xray,solitary nodule

Solitary pulmonary nodule is a lesion <3 cm that is completely surrounded by pulmonary parenchyma & has
no ass. lymphadenopathy:
Pt >60 years old w/ a 2 cm nodule w/ irregular margins & quit smoking <5 years ago is at high risk for
malignancy. Such*Nodules should be surgically excised.*
Lesions w/ low risk can be monitored w/ serial CT scans
Lesions w/ intermediate risk for malignancy should undergo further imaging & biopsy depending on
radiographic findings
Cor pulmonale:Isolated right sided heart failure (RHF) from pulmonary htn,due to COPD.Sx of
RHF-jvd,increased intensity of P2(pulmonic component of the 2nd heart sound),right ventricular
heave,*hepatomegaly*,dependent pitting edema,ascites
Coronary artery disease may cause left sided or biventricular cardiac failure w/ pulmonary
congestion.Inferior wall MI may cause isolated right sided heart failure.Sx-chest
pain,nausea,diaphoresis,hypotension,elevated jvd,clear lungs
Comorbid GERD: Sx-sore throat, morning hoarseness, worsening cough at night, & increased need for
albuterol inhaler following meals, recent weight gain/obesity also increases risk of developing GERD. Tx-
PPI eg, *esomeprazole*
The anticholinergic effect of diphenhydramine is useful in tx of chronic cough caused by rhinitis in pts w/
upper airway cough syndrome(UACS),previously known as postnasal drip syndrome
Ashhadscknotes
Pleuritic chest pain(pain increasing w/ inspiration) in the setting of prolonged immobility(recent travel),
hemoptysis, dyspnea, tachypnea, tachycardia, & OCP use is concerning for pulmonary embolism(PE). 10%
of pts w/ PE have occlusion of a peripheral pulmonary artery by thrombus, causing *pulmonary infarction*.
CT pulm angiography used for dx
A *consolidation* presents w/ dullness to percussion, bronchial breath sounds(assuming patent airways), &
egophony
Emphysema: lungs are hyper-resonant to percussion bilaterally. Breath sounds are vesicular & intensity of
breath sounds is significantly decreased. Wheezing may be present
Interstitial lung disease: lungs that are resonant on percussion & have vesicular breath sounds. Fine
crackles heard at end of inspiration
Obstructive sleep apnea(OSA): airflow impeded by upper airway obstruction, normal arterial blood gas
4413 Medicine Pulmonary & Critical Care Obesity hypoventilation syndrome(OHS) aka Pickwickian syndrome: obesity impedes expansion of the chest
& abdominal wall during breathing, unverventilation of the lungs during all hours -> chronically elevated
PaCO2 & reduced PaO2(we WON'T have normal arterial blood gas here)
Light's criteria states that pleural fluid is *exudative* if the fluid protein/serum protein ratio is >0.5, the fluid
LDH/serum LDH is >0.6, or the pleural fluid LDH is >2/3 the upper limits of normal serum LDH.*Exudates
are caused by increased capillary permeability(eg, infection,autoimune disease,neoplasm)* while
transudates are caused by increased hydrostatic pressure(eg, CHF) or decreased oncotic pressure(eg, liver
failure)
Obesity hypoventilation syndrome (OHS) aka Pickwickian syndrome: obesity (BMI>30 kg/m^2), daytime
hypercapnia (PaCO2 >45mmHg), & alveolar hypoventilation. Arterial blood gas will show hypercapnia,
hypoxemia, & respiratory acidosis as a result of altered lung mechanics due to obseity and *nocturnal
hypoventilation.* Tx-weight loss & noninvasive positive pressure ventilation
The 3 mcc of chronic cough are upper airway cough syndrome (postnasal drip), asthma, & GERD. The dx
4519 Medicine Pulmonary & Critical Care of upper-airway cough syndrome is confirmed by the elimination of *nasal discharge* & cough w/ the use of
H1 histamine receptor antagonists
In a pt w/ COPD presenting w/ catastrophic worsening of their respiratory sx, spontaneous secondary
pneumothorax(due to dilated alveolar blebs that rupture air into pleural space) should always be suspected.
Smoking increases risk of pneumothorax. Pts w/ pneumothorax present w/ acute onset of chest pain &
4520 Medicine Pulmonary & Critical Care shortness of breath
Presence of coarse crackles bilaterally on physical exam is more consistent w/ CHF, while wheezes are
more commonly heard in COPD
Lung malignancies,CF,& right-to-left cardiac shunts are mcc of secondary digital clubbing.Presence of
clubbing should prompt search for malignancy
[COPD DOES NOT cause digital clubbing!]

Hypertrophic osteoarthropathy:digital clubbing along w/ painful joint enlargement,periostosis of long bones,&
synovial effusions
Megakaryocytes entrap in fingertips->they release PDGF & VEGF->they increase connective tissue
hypertrophy,capillary permeability & vascularity->clubbing
In a pt w/ hx of food allergies & urticaria, laryngeal edema can cause sx of upper respiratory
obstruction(dyspnea, difficulty swallowing). Pts w/ laryngeal edema present w/ acute-onset dyspnea. In a pt
4523 Medicine Pulmonary & Critical Care w/ sudden onset of severe shortness of breath, *upper airway obstruction* should be immediately ruled out
Dysphagia is unusual for an asthma attack

Acute pancreatitis can cause ARDS in 15% of pts. First step in the initial ventilator management of ARDS is
to decrease the FiO2 to non-toxic values (<60%). PEEP may be increased as needed to maintain adequate
oxygenation after the FiO2 is lowered.
4536 Medicine Pulmonary & Critical Care [In pts w/ ARDS, mechanical ventilation improves oxygenation by providing an increased fraction of inspired
oxygen (FiO2) & by providing PEEP to prevent alveolar collapse]
Normal paCO2=normal ventilation

Sepsis(fever,confusion,decreased food intake,blood cultures positive for E.coli) is a common cause of
ARDS.ARDS causes hypoxemia refractory to high inspired oxygen concentrations.Adequate oxygenation in
4562 Medicine Pulmonary & Critical Care ARDS often requires *PEEP* delivered via mechanical ventilation.
[High FiO2 is contraindicated due to risk of pulmonary oxygen toxicity. Goal should be to keep the FiO2
below 40% at all times. Reduce a pt's FiO2 by first increasing oxygenation via increasing PEEP]
Acute bronchitis:
viral
common cause of blood tinged sputum(due to erosion of superficial blood vessels)
tx- supportive care (assuming no signs of serious disease present)
Flexible bronchoscopy useful in emergent management of major, life threatening hemoptysis. Non-emergent
bronchoscopy may be used both as a diagnostic tool to find the cause of hemoptysis and as a therapeutic
tool to treat the source of bleeding
Ashhadscknotes
Empyema can be caused by direct inoculation of bacteria into the pleural space during surgical procedures.
The bacterial causes of empyema mirror those that cause pneumonia, namely Streptococcus pneumoniae,
Staphylococcus aureus & Klebsiella pneumoniae.
4568 Medicine Pulmonary & Critical Care Tx- drainage & antibiotics
Bronchopleural fistula is a possible cause of empyema. Typically occurs following surgical procedures
involving the bronchi (eg. pneumonectomy), recurrent pneumothoraces, sequela of infection
Acute exacerbation of chronic obstructive pulmonary disease: exam shows wheezes, prolonged expiration,
crackles at lung bases, & use of accessory muscles
CHF: risk factors-hx of coronary artery disease, htn, smoking hx, bibasilar crackles, decreased breath
sounds at the bases(due to pleural effusions from CHF), wheezing sometimes (cardiac asthma), hypoxia,
4570 Medicine Pulmonary & Critical Care hypocapnia, respiratory alkalosis
COPD: you get respiratory acidosis

Ankylosing spondylitis: Low back pain in young dude, improves w/ exercise but not w/ rest, pain at night,
limited chest expansion & spinal mobility, elevated ESR. Pulmonary function tests show a mildly restrictive
pattern w/ reduced vital capacity & total lung capacity but normal FEV1/FVC. FRC & RV are normal or
4575 Medicine Pulmonary & Critical Care increased
Pulmonary fibrosis: restrictive pattern, reduced FVC & FEV1, normal or increased FEV1/FVC ratio. FRC,
TLC, & RV also reduced
Evaluation of a solitary pulmonary nodule detected on CXR includes comparison w/ old imaging studies, if
available, followed usually by *chest computed tomography*
4596 Medicine Pulmonary & Critical Care Bronchoscopy can be used to biopsy accessible lesions(central lesions)
Percutaneous biopsy rec. for lesions that appear malignant & in pts w/ high clinical suspicion for malignancy.
CT helps evaluate whether lesion can be accessed percutaneously w/o risk for pneumothorax
Sudden onset dyspnea, chest pain, & tachycardia w/ a hemorrhagic, exudative pleural effusion & absence
of consolidation on chest imaging suggest pulmonary embolism (PE)
4613 Medicine Pulmonary & Critical Care Light's criteria defines exudate as having at least one of the following:
-Pleural fluid protein/serum protein ratio >0.5
-Pleural fluid LDH/serum LDH >0.6
-Pleural fluid LDH >2/3 of the upper limit of normal for serum LDH
*Tx of mild persistent asthma(Sx >2 days/week,3-4 nighttime awakenings/month):PRN albuterol inhaler &
inhaled corticosteroids*
Tx of moderate persistent asthma(sx daily,weekly nighttime awakenings):PRN albuterol inhaler,low dose

inhaled corticosteroids,long-acting inhaled beta 2 agonist inhaler
Tx of severe persistent asthma(sx throughout day,frequent nighttime awakenings):PRN albuterol

inhaler,long acting beta 2 agonist inhaler,high dose inhaled corticosteroids
A negative D-dimer (a type of fibrin split product) is very helpful in excluding the dx of pulmonary venous
thromboembolism in low risk pts
Chest xray findings in PE pts: pleural based densities representing lung infarction (Hampton's hump) &
4628 Medicine Pulmonary & Critical Care prominent central pulmonary artery w/ local oligemia (Westermark's sign). Not that useful for dx of PE since
many PE pts have normal xrays
Venous ultrasonography sensitive & specific for dx dvt but only 70% of PE pts have dvts
For anticoagulation, *unfractionated heparin* is preferred over low-molecular-weight heparin, fondaparinux,

4629 Medicine Pulmonary & Critical Care & rivaroxaban in pts w/ severe renal insufficiency (estimated glomerular filtration rate <30 mL/min/1.73m^2)
as reduced renal clearance increases anti-Xa activity levels & bleeding risk
Pt w/ SOB & low grade fever w/ right middle lobe infiltrate & right-sided pleural effusion(pleural effusions
common in pts w/ pneumonia) suggests underlying *pneumonia* w/ complicated parapneumoic
effusion(complicated cuz of bacterial invasion.Pleural fluid w/ very low pH [<7.2] & glucose [<60 mg/dL]).
They require drainage(eg,chest tube) in addition to abx
Right mainstem bronchus intubation is a common complication of endotracheal intubation.It causes
asymmetric chest expansion during inspiration and markedly decreased or absent breath sounds on the left
side on auscultation.Repositioning the endotracheal tube by pulling back slightly will move the tip between
4632 Medicine Pulmonary & Critical Care the carina & vocal cords & solve the problem.Look for decreased breath sounds immediately after intubation
in question stem.
Tension pneumothorax tx-needle thoracostomy

Alveolar-capillary membrane is the site of respiratory gas exchange. This membrane is destroyed in COPD,
resulting in increased lung distensibility & compliance. [lung distensibility is decreased in pulmonary fibrosis]
Respiratory muscle fatigue occurs in diseases like botulism, Guillain Barre syndrome, amyotrophic lateral
sclerosis, & myasthenia gravis
Ashhadscknotes
Obesity hypoventilation syndrome: long term consequence of severe obesity & untreated obstructive sleep
apnea. It causes pulmonary hypertension w/ cor pulmonale, secondary erythrocytosis, hypoxia, chronic
hypercapnia(due to persistent hypoventilation) & respiratory acidsis. In a compensatory effort to maintain a
normal pH, *the kidney increases bicarbonate retention & decreases chloride reabsorption*
COPD pts have increased total lung capacity, functional residual capacity, & residual volume leading to
hyperinflation & diaphragmatic flattening. Flattening of the diaphragm increases the work of breathing
In COPD, pulmonary compliance is increased due to loss of alveolar & elastic tissue.
In contrast, pts w/ restrictive lung disease have decreased lung compliance.
Inhaled anti-muscarinic agents/*Muscarinic antagonists* such as ipratropium are the mainstay of sx
management in COPD. These anti-cholinergic meds can be combined w/ short acting beta adrenergic
agonists(eg,albuterol) for greater sx relief
4667 Medicine Pulmonary & Critical Care a-blockers tx benign prostatic hypertrophy & htn
Dopamine agonists tx parkinsons, prolactinomas, & restless leg syndrome
a2-adrenergic agonists: Clonidine & methyldopa tx htn. Dexmedetomidine is used for sedation in the ICU
Hypoventilation is a major cause of respiratory acidosis & may occur in the post-ictal state
Renal failure commonly results in a metabolic acidosis, which is eventually compensated by a mild
4677 Medicine Pulmonary & Critical Care respiratory alkalosis. ABG in renal failure shows a low pCO2 & low bicarbonate level
Vomiting induces a metabolic alkalosis due to loss of acid gastric secretions. This causes a high pH &
elevated serum HCO3 concentrations
4689 Medicine Pulmonary & Critical Care *Secondary malignancy* is common in pts w/ Hodgkin lymphoma tx w/ chemotherapy & radiation
Pulmonary emboli classically present w/ sudden onset pleuritic chest pain, cough, dyspnea, and hemoptysis.
Low grade fever & mild leukocytosis also common. Chest CT showing a wedge-shaped infarction(google
pic!) is pathognomonic for pulmonary embolism.
4690 Medicine Pulmonary & Critical Care Pneumocystis pneumonia: occurs in pts w/ CD4+ counts <200/uL. Imaging shows diffuse interstitial pattern
Bacterial pneumonia: Alveolar infiltrates may be seen
Lung cancer: rounded/spiculated mass

4692 Medicine Pulmonary & Critical Care Lung consolidation causes dullness to percussion and increased fremitus
In pts w/ acute asthma exacerbation, an elevated or even normal arterial partial pressure of carbon dioxide
suggests decreased respiratory drive (likely due to respiratory muscle fatigue) & impending respiratory
failure. In these pts, tx involves *endotracheal intubation* & mechanical ventilation, inhaled short acting beta
2 agonist, inhaled ipratropium, & systemic corticosteroids
Epinephrine is indicated in bronchospasm ass. w/ anaphylaxis

The plateau pressure is the pressure measured during an inspiratory hold maneuver
Plateau pressure = elastic pressure + PEEP

Because elastic recoil is inversely related to *lung compliance*, the elastic pressure can be calculated as
tidal volume/*compliance*
Massive Pulmonary embolism:
risk factor- pt w/ underlying malignancy(prothrombotic state) can get this
4716 Medicine Pulmonary & Critical Care sx- dyspnea, chest pain, tachycardia, hypoxia, clear lungs, pt w/ massive PR can have syncope, high
jugular venous pressure, right ventricular dilation/obstruction, increased pumonary vascular resistance,
hypoinesis of right ventricle
Pneumonia(pt w/ hypoxia,fever,mucosal candidiasis[suggesting an immunosuppressed state]) causes a
*ventilation/perfusion mismatch*, as indicated by an increased alveolar-arterial oxygen gradient.
4717 Medicine Pulmonary & Critical Care [Fever induces a hyperdynamic state, & an audible flow murmur(soft crescendo/decrescendo systolic
murmur) may be heard. Inflammation of the alveolar membrane & interstitium impairs gas exchange. Areas
of ventilation/perfusion(V/Q) mismatch develop, & the A-a gradient increases]
*Supplemental oxygen in pts w/ advanced COPD can worsen hypercapnia* due to a combo of increased
dead space perfusion causing ventilation-perfusion mismatch, decreased affinity of oxyhemoglobin for CO2,
& reduced alveolar ventilation.[The hypercapnia causes reflex cerebral vasodilation & may induce
seizures].The goal oxyhemoglobin saturation in these pts is 90%-93%
Acute exacerbation of COPD: IV glucocorticoids (eg, methylprednisolone) rec. for severe exacerbations &
for pts unable to take oral meds
Inhaled corticosteroids indicated for long term management of asthma. Their role in COPD is less beneficial,
except as maintenance therapy in pts w/ advanced disease. Also ass. w/ slightly increased risk of
pneumonia & fractures from long term use
Long acting B2 agonists used in maintenance therapy of COPD. Not rec. for acute exacerbations
Ashhadscknotes
Empyemas:exudative effusions w/ low glucose concentration due to *high metabolic activity of leukocytes &
bacteria within pleural fluid*
[Pleural fluid glucose <60 mg/dL usually due to rheumatoid pleurisy,complicated parapneumonic effusion or
4753 Medicine Pulmonary & Critical Care empyema,malignant effusion,tuberculous pleurisy,lupus pleuritis,or esophageal rupture.Pleural glucose <30
mg/dL suggests an empyema or rheumatic effusion]
Exudative effusion:low pleural glucose,high pleural LDH

Early phases of acute pneumonia w/ consolidation can have persistent blood flow to areas w/ impaired
ventilation. This leads to a *physiologic intrapulmonary (right-to-left) shunt* & arterial
4770 Medicine Pulmonary & Critical Care hypoxemia[consolidated regions act as a physiologic shunt, increasing delivery of deoxygenated blood to the
left heart & reducing systemic arterial oxygenation saturation]. Positioning of pt w/ the affected lung in the
dependent position can worsen this shunt
Acute massive pulmonary embolism can present initially w/ syncope & shock. Right heart catheterization in
4772 Medicine Pulmonary & Critical Care pts w/ massive pulmonary embolism will show elevated right atrial & pulmonary artery pressures, along w/
normal pulmonary capillary wedge pressure
Normal or increased FEV1/FVC ratio w/ a low VC is seen in restrictive lung disease
DLco is decreased w/ interstitial lung disease
Bronchiectasis ass. w/ hx of recurrent respiratory tract infections & chronic cough w/ daily production of
copious mucopurulent sputum
Chronic bonchitis: chronic productive cough for 3 months in 2 successive years, with cigarette smoking as
the leading cause
Postnasal drip, GERD, & asthma account for >90% of chronic cough in nonsmokers who do not have
pulmonary disease. For pts w/ suspected postnasal drip initial empiric tx includes oral 1st-generation
antihistamine (chlorpheniramine) or combined antihistamine-decongestant (brompheniramine &
pseudoephedrine)
*Pleural Effusion:decreased fremitus,dullness to percussion,decreased breath sounds,mediastinal shift away
from effusion
Pneumothorax: decreased tactile fremitus, hyperresonant to percussion,decreased breath

sounds,mediastinal shift(small:none tension:away from pneumothorax)
8818 Medicine Pulmonary & Critical Care Consolidation:increased fremitus,dullness to percussion,presence of crackles,bronchial breath
sounds,bronchophony,egophony,pectoriloquy
COPD:decreased fremitus,hyperresonant,decreased breath sounds
Reversible airway obstruction/positive bronchodilator response(>12% increase/improvement in FEV1)

8905 Medicine Pulmonary & Critical Care combined w/ sx like dyspnea,wheezing,& cough w/ normal diffusion capacity for carbon monoxide suggests
*asthma* regardless of age
If pt has chronic cough that worsens overnight and doesn't improve w/ antihistamine therapy, suspect
asthma as the cause.
Evaluate w/ spirometry to assess bronchodilator response.
If no bronchodilator response, perform methacholine challenge test.
Alternatively, we can treat pt w/ glucocorticoids and if their cough improves, diagnosis of asthma can be
made.
Hypothermia tx: active external rewarming & warmed iv fluids. Bradycardia of hypothermia improves w/
correction of hypothermia
IV magnesium sulfate used to treat polymorphic ventricular tachycardia ass. w/ acquired QT prolongation
(torsades de pointes)
Aspiration pneumonitis:
acute lung injury due to chemical burn from (witnessed) aspirated sterile gastric contents
presents hours after aspiration
no sx, nonproductive cough,
tx- supportive
Aspiration pneumonia:
infectious disease caused by aspiration of infected oropharyngeal secretions
presents days after (unwitnessed) aspiration event
fever, cough, sputum production
tx- clindamycin or B-lactam & B-lactamase inhibitor
Primary hyperparathyroidism (PHP) or familial hypocalciuric hypercalcemia (FHH;it's due to abnormal
Renal, Urinary Systems & calcium-sensing receptors on parathyroid cells & renal tubules) can cause hypercalcemia secondary to an
2165 Medicine
Electrolytes elevated or inappropriately "normal" parathyroid hormone level. Urinary calcium creatinine clearance ratio is
usually <0.01 in FHH compared to >0.02 in PHP
Ashhadscknotes
The most common causes of hyperkalemia include acute or chronic kidney disease, *medications*, or
disorders impairing the renin-angiotensin axis. Common offending medications include nonselective
Renal, Urinary Systems & beta-adrenergic blockers, potassium-sparing diuretics(eg,triamterene),angiotensin-converting-enzyme
2167 Medicine
Electrolytes inhibitors,angiotensin II receptor blockers,& nonsteroidal anti-inflammatory drugs
Uncontrolled hyperglycemia due to insulin deficiency can shift K+ out of cells to cause hyperkalemia
*IV saline hydration*:immediate tx of choice for pts w/ symptomatic moderate/severe hypercalcemia
Hemodialysis(or peritoneal dialysis) w/ calcium free dialysate:for pts w/ severe hypercalcemia in the setting
Renal, Urinary Systems &
2169 Medicine of renal insufficiency &/or heart failure in whom adequate hydration can't be administered safely
Electrolytes
Corticosteroids:useful for tx hypercalcemia in chronic granulomatous disorders.Reduce calcitrol production
by activated mononuclear cells in the lungs/lymph nodes
SIADH: low plasma osmolality (<280 mOsm/Kg) w/ high urine osmolality (>100-150 mOsm/Kg) is diagnostic
2180 Medicine
Electrolytes
NSAID therapy can cause SIADH. NSAIDs potentiate the action of ADH
Asymptomatic pts or pts with mild sx from SIADH usually respond to fluid restriction and salt tablets.
Severe symptomatic hyponatremia requires tx w/ *hypertonic (3%) saline* [effective management of SIADH
2181 Medicine requires infused fluid to have higher electrolyte concentration than the urine & plasma]
Electrolytes
D5W is a hypotonic solution used to tx hypernatremia
*Intravenous normal (.9%) saline is preferred for treating hypovolemic hypernatremia.* The fluid can be
switched to a hypotonic fluid (5% dextrose in water preferred over .45% saline) for free water
supplementation once the pt is euvolemic
2182 Medicine
Electrolytes
Hemodialysis indicated for serum lithium level >4 mEq/L or lithium level >2.5 mEq/L plus signs of lithium
toxicity (eg, seizures, depressed mental status) or inability to excrete lithium (eg, renal disease,
decompensated heart failure)
Development of nephropathy is preceded by development of excessive protein excretion, the initial stages
2183 Medicine of which is termed microalbuminuria. *Spot urine collection & timed urine collection* for the measurement of
Electrolytes
urine *microalbumin to creatinine ratio* are accepted as good screening methods for microalbuminuria
Hepatorenal syndrome is seen in pts w/ severe liver cirrhosis secondary to systemic & renal hypoperfusion.
Pts have acute renal failure (creatinine >1.5 mg/dL) w/ a very low urine sodium level, typically <10 mEq/L, &
an absence of blood, casts, or protein in urine. Renal function doesn't improve w/ intravenous fluid
Renal, Urinary Systems & resuscitation
2219 Medicine
Electrolytes
Membranoproliferative glomerulonephritis is ass w/ hepatitis C infection
Interstitial nephritis presents w/ eosinophils or leukocytes in the urine

Renal cell carcinoma:
2221 Medicine sx- look for unilateral varicocele that fails to empty when pt is recumbent. It obstructs venous flow.
Electrolytes
dx- *CT scan of the abdomen* is most sensitive and specific test for dx RCC!
Focal segmental glomerulosclerosis (FSGS) is more common in African American pts & in those w/ obesity,
heroin use, & HIV
Renal, Urinary Systems & IgA nephropathy: hematuria following an upper respiratory infection
2223 Medicine
Electrolytes
Minimal change disease: more common in children. In adults, it's ass. w/ NSAID use & lymphoma(usually
Hodgkin)
If pt presents w/ his first renal stone, a detailed metabolic eval is not needed. Just do hydration tx.
Stones <5mm pass spontaneously w/ conservative management, which includes fluid intake > 2L daily
Renal, Urinary Systems & Pt w/ recurrent renal stones: 24 hour urine is collected to identify underlying metabolic disorder
2227 Medicine
Electrolytes
Recurrent stone formation due to citrate deficiency: tx- Potassium citrate
Recurrent calcium stone due to hyperoxaluria: tx- restriction of dietary oxalate

75% to 90% of the kidney stones are composed of calcium oxalate
2228 Medicine
Electrolytes
Calcium phosphate stones are common in primary hyperparathyroidism & renal tubular acidosis
Suspect myoglobinuria whenever test results demonstrate a large amound of blood on urinalysis w/ a
2229 Medicine relative absence of RBCs on urine microscopy. Myoglobinuria is usually caused by *rhabdomyolysis*, which
Electrolytes
frequently leads to acute renal failure
IgA nephropathy:mcc of glomerulonephritis in adults(esp young adult men age 20-30).Recurrent episodes of
gross hematuria,usually within 5 days after an upper respiratory tract infection(synpharyngitic).Normal
serum complements
2230 Medicine
Electrolytes
Postinfectious glomerulonephritis:gross hematuria,10-21 days after URI(post-pharyngitic), more common in
children.Adults asymptomatic or develop acute nephritic syndrome.Labs-low C3 complement & elevated
anti-streptolysin O &/or anti-DNAse B
Ashhadscknotes
Cryoglobulinemia/Mixed cryoglobulinemia: palpable purpura, glomerulonephritis, arthralgias,
hepatosplenomegaly, peripheral neuropathy, hypocomplementemia, & non-specific systemic sx. Most pts
Renal, Urinary Systems & also have Hepatitis C. Other sx include proteinuria & hematuria
2232 Medicine
Electrolytes
Henoch Schonlein purpura: palpable purpura on butt, ab pain, arthralgias, proteinuria & hematuria w/ RBC
casts on UA. Normal complement levels. Not ass w/ HCV!
Uncomplicated cystitis:sx-dysuria,urinary frequency,suprapubic tenderness.Pts CAN BE TX W/O URINE
CULTURE,which may be done later in those who fail initial therapy.UA confirms dx.Tx-oral
TMP/SMX,*Nitrofurantoin*,fosfomycin
2235 Medicine Complicated cystitis:ass. w/ infections.Tx-Fluoroquinolones,extended-spectrum
Electrolytes
abx(ampicillin/gentamicin/ceftriaxone)for severe cases.Urine culture b4 tx
Pyelonephritis:Outpt tx-Fluoroquinolones.
Inpt tx-IV abx(fluoroquinolone,aminoglycoside +/-ampicillin)
Post-streptococcal glomerulonephritis is seen 10-20 days after streptococcal throat or skin infections.
Presenting features may include periorbital swelling, hematuria & oliguria. The pt may be hypertensive &
2241 Medicine urinalysis shows hematuria w/ RBC casts & proteinuria. Serum C3 complement levels are low
Electrolytes
Drug-induced interstitial nephritis: RBC casts are RARE
Drug-induced interstitial nephritis occurs w/ many drugs such as penicillins,cephalosporins &
sulfonamides.Clinical features include fever,rash & arthralgias.Other features are peripheral
Renal, Urinary Systems & eosinophilia,hematuria,sterile pyuria & eosinophiluria.WBC casts may be present in the urine,but red cell
2242 Medicine
Electrolytes casts are rare.Dicontinuing the offending agent is tx of drug induced interstitial nephritis
Oral ciprofloxacin or IV ampicillin & gentamicin are used to tx acute pyelonephritis

Renal, Urinary Systems & Renal vein thrombosis (sx- abdominal pain, fever, & hematuria) is a complication of all causes of nephrotic
2243 Medicine
Electrolytes syndrome. However, it's most commonly ass. w/ *membranous glomerulopathy*
Nephrotic syndrome -> alterations in lipid metabolism -> increased risk for accelerated
2244 Medicine *atherosclerosis*/hypercoagulable state -> risk of stroke/mi
Electrolytes
tx- statins or meds to lower cholesterol levels
Uric acid stones: Pts can develop ileus(due to vagal reaction caused by ureteral colic). Needle shaped
crystals on urinalysis. Radiolucent. Evaluated by *CT of abdomen*,ultrasonography, or intravenous
2324 Medicine pyelography. Ileus will resolve when ureterolithiasis is treated
Electrolytes
Enteroclysis is used to dx small bowel tumors & other pathology, which can cause intestinal obstruction
Severe symptomatic hypercalcemia(calcium >14 mg/dL):1st step in management is *vigorous hydration w/
IV normal saline*.[Hemodialysis w a calcium-free dialysate is tx of last resort.Used when pt doesn't improve
after medical tx]
2633 Medicine Asymptomatic/mild hypercalcemia (<12 mg/dL) doesn't require immediate aggressive therapy
Electrolytes
Bisphosphonates used for long-term management of hypercalcemia of malignancy
Glucocorticoids effective in tx vit D related hypercalcemia(sarcoidosis,lymphoma)

Causes of hyponatremia include SIADH secretion & primary polydipsia.Primary polydipsia more common in
pts w/ psych conditions(schizophrenia),possibly due to central defect in thirst regulation.Pts develop
hyponatremia & dilute urine w/ urine osmolality <100 mOsm/kg.Those w/ sig hyponatremia can develop
2657 Medicine confusion,lethargy,psychosis & seizures
Electrolytes
Serum osmolality >290 mOsm/kg suggests either marked hyperglycemia or advanced renal failure as likely
causes of hyponatremia
Classic causes of metabolic acidosis can be recalled using the mnemonic MUDPILES (anion-gap):
2786 Medicine Methanol, Uremia (renal failure), DKA, Paraldehyde, INH, Lactic acidosis, Ethylene glycol, Salicylates.
Electrolytes
Diarrhea & renal tubular acidosis are other causes (non-anion gap)
Renal, Urinary Systems & In any pt, the pH & PaCO2 are the two lab values that provide the best picture of acid-base status; the
2787 Medicine
Electrolytes HCO3 can be calculated from these values using the Henderson-Hasselbalch equation
Anion gap= Measured cations (positive charge) - Measured anions (negative charge)
Anion gap= Na+ - (HCO3- + Cl-)

2793 Medicine
Electrolytes
Normal anion gap is <11. So lets say the calculated anion gap is 38; that's considered an abnormally
elevated value! We can therefore conclude that w/ a value of 38 we have an "Anion gap metabolic
acidosis"(as opposed to non-anion gap metabolic acidosis)
Plasma anion gap must always be calculated in pts w/ metabolic acidosis
AG = Na - (HCO3 + Cl)
2798 Medicine Normal AG is between 6 & 12 mEq/L. Increase in the AG indicates presence of non-chloride acids that
Electrolytes
contain inorganic, organic, exogenous or unidentified anions. Finding an increased anion gap narrows the
differential dx of metabolic acidosis to a few common causes (Lactic acidosis, ketoacidosis, methanol
ingestion, ethylene glycol infestion, salicylate poisoning, uremia[ESRD])
Ashhadscknotes
Ethylene glycol (anti-freeze) poisoning: calcium oxalate crystals (rectangular, envelope-shaped crystals) are
seen
Ethylene glycol, methanol, & ethanol intoxication cause metabolic acidosis w/ both an anion gap & an
2799 Medicine osmolar gap
Electrolytes
Methyl alcohol poisoning can cause visual changes ("snowfield vision") & acute pancreatitis
Uremia(renal failure) causes an anion gap metabolic acidosis due to failure to excrete acids as NH4+
Aspirin intoxication should be suspected in a pt w/ the triad of fever, tinnitus, & tachypnea. Adults w/ aspirin
2803 Medicine toxicity develop a mixed respiratory alkalosis & anion gap metabolic acidosis. A normal pH in an acid-base
Electrolytes
disturbance typically signifies a mixed respiratory & metabolic acid-base disorder
Type 4 renal tubular acidosis(hyperkalemic renal tubular acidosis) characterized by non-anion gap metabolic
acidosis(low bicarbonate),hyperkalemia,& mild to moderate renal insufficiency.Occurs in pts w/ poorly
controlled diabetes
2810 Medicine
Electrolytes Pre-renal azotemia(renal hypoperfusion): BUN/creatinine ratio is more than 20:1 due to increased urea
absorption.Renal perfusion is due to either systemic hypovolemia or impaired cardiac output
ASS PP:Aldosterone Saves Sodium & Pushes Potassium out

Recurrent vomiting causes depletion of fluid,acid,& sodium chloride,leading to metabolic alkalosis,activation
of RAAS,& urinary K+ loss.Volume resuscitation w/ normal saline corrects contraction alkalosis.Hypokalemia
should be tx as well
Renal, Urinary Systems & Acetazolamide:diuretic,inhibits proximal renal bicarb reabsorption,used in pts w/ hypervolemia & metabolic
2813 Medicine
Electrolytes alkalosis
IV sodium bicarb tx severe metabolic acidosis
Propranolol:prophylaxis of variceal hemorrhage in pts w/ liver cirrhosis

Tuberculosis: sx- fever, cough, upper lobe cavitary lesion, fatigue, weakness, hypotension, hyperkalemia,
hypoglycemia, & eosinophilia. TB can cause chronic primary adrenal insufficiency in endemic areas(eg
Renal, Urinary Systems & Russia). Primary adrenal insufficiency (Addison's disease) causes aldosterone deficiency and presents with
2817 Medicine
Electrolytes a *non-anion gap & hyperkalemic & hyponatremic metabolic acidosis*
Metabolic alkalosis most commonly occurs w/ vomiting

Saline responsive metabolic alkalosis: ass. w/ low urinary chloride excretion (<20mEq/L) & volume
contraction, & corrects w/ saline infusion alone(e.g. vomiting/nasogastric aspiration, diuretic use )
2819 Medicine
Electrolytes Saline unresponsive metabolic alkalosis: typically presents w/ a higher level of urinary chloride (>20 mEq/L)
(e.g. Bartter & Gitelman syndromes, Excess mineralocorticoid activity such as primary hyperaldosteronism,
cushing disease, ectopic ACTH production)
Aspirin intoxication causes a mixed respiratory alkalosis and metabolic acidosis
Renal, Urinary Systems & Asthma exacerbation usually leads to an acute respiratory alkalosis due to tachypnea
2820 Medicine
Electrolytes
Persistent vomiting causes hypochloremic metabolic alkalosis resulting from H+ losses in the gastric
contents
Postictal lactic acidosis can occur following a grand mal(tonic-clonic) seizure.It's a transient anion gap met
acidosis that *resolves w/o tx within 60 to 90 min following resolution of seizure activity*
2821 Medicine
Electrolytes
Bicarb in tx lactic acidosis/ketoacidosis is controversial.Rec only in severe acute acidosis(pH<7.2).Full
correction w/ bicarb shouldn't be sought;only sufficient amount of bicarb should be given to correct pH to 7.2
*Loop diuretics* are frequently administered to cirrhotic pts w/ volume overload & ascites. Potential side
effects include hypokalemia, metabolic alkalosis, & prerenal kidney injury
2826 Medicine
Electrolytes Acute kidney injury causes an anion gap metabolic acidosis & hyperkalemia
Bowel ischemia results in an anion gap acidosis from increased circulating lactate
Mixed cryoglobulinemia ass. w/ hepatitis C:
2958 Medicine sx- arthralgia, palpable purpura, elevated transaminases (ast and alt), increased rheumatoid factor
Electrolytes
dx- confirmed serologically (serum cryoglobulins, low complement levels) or w/ kidney/skin biopsy
Renal, Urinary Systems & Drug induced interstitial nephritis: pts present w/ arthralgias, rash, renal failure & urinalysis will show
3061 Medicine
Electrolytes eosinophiluria
Diuretic abuse leads to increased excretion of water & electrolytes by the kidneys. Dehydration, weight loss,
3085 Medicine orthostatic hypotension as well as hypokalemia & hyponatremia result. Urinary sodium & potassium will be
Electrolytes
elevated. Pts w/ eating disorders sometimes abuse diuretics to induce weight loss
Ashhadscknotes
Surreptitious vomiting:sx-scars/calluses on dorsum of hands & dental erosions. Causes hypokalemic
alkalosis. LOW urine chloride concentration
Renal, Urinary Systems & Pts w/ diuretic abuse & Bartter/Gitelman's syndrome may also present w/ hypokalemia, alkalosis &
3228 Medicine
Electrolytes normotension, but their urine chloride concentrations are HIGH
Pts w/ chronic diarrhea have metabolic acidosis & hypokalemia. Metabolic acidosis occurs due to loss of
bicarbonate in the stool
Renal, Urinary Systems & Pts w/ severe benign prostatic hyperplasia can eventually progress to urinary obstruction & renal failure. A
3336 Medicine
Electrolytes *renal ultrasound* is advised for assessment of hydronephrosis & worsening kidney function
Oxalate absorption is increased in Crohn disease & all other intestinal diseases causing fat malabsorption.
Increased absoption is the mcc of symptomatic hyperoxaluria and oxalate stone formation. The
3435 Medicine nephrolithiasis caused by this will present w/ flank pain, hematuria, nausea & vomiting.
Electrolytes
Bile salt recycling & fatty acid absorption are decreased in Crohn disease
Benign prostatic hyperplasia (BPH) tx: alpha 1-blockers (eg, tamsulosin, doxazosin) alone or in combo w/
5-alpha reductase inhibitors (eg, finasteride) for symptomatic relief
Renal, Urinary Systems & BPH affects central portion (transitional zone).
3477 Medicine
Electrolytes Prostate cancer usually affects lateral lobes of prostate
In a BPH pt w/ sx, if bladder scanner shows <100 mL of urine, then that is considered a normal amount.
This means that there is no obstruction & so we won't need to place a Foley catheter.
evaluate benign prostatic hyperplasia (BPH) pts with urinalysis to assess for urinary infection and hematuria
cystoscopy not generally required in evaluation of BPH unless there is hematuria

3481 Medicine
Electrolytes
indications for intravenous urography include hematuria, renal stones, or previous urinary tract surgery
transrectal ultrasound of prostate helps guide prostate biopsy in pts w/ prostate nodules or elevated PSA
Rapid treatment w/ calcium gluconate is necessary in a pt w/ hyperkalemia who develops significant EKG
Renal, Urinary Systems & chances/arrhythmia
3648 Medicine
Electrolytes
Sodium polystyrene sulfonate removes potassium via the gi tract
Pts w/ hyperkalemia in the setting of chronic kidney disease, esp those on ACE inhibitors have excess total
body K+. They need to remove K+ from the body w/ either diuretics, cation exchange resins, & hemodialysis.
Moderate hyperkalemia w/o sig. ECG abnormalties- use a *loop diuretic*, along w/ saline hydration(to
3654 Medicine enhance urine production & Na+ delivery to the distal tubule)
Electrolytes
Severe hyperkalemia/ESRD-urgent hemodialysis
Severe hyperkalemia w/o ESRD-cation exchange resins

Acute pyelonephritis:
Renal, Urinary Systems & sx- pyuria, significant bacteriuria
3693 Medicine
Electrolytes positive for both nitrites and esterase
Renal, Urinary Systems & Increased incidence of urinary tract infections in women is due to the *shorter length of the female urethra
3884 Medicine
Electrolytes compared to males*
Fibromuscular dysplasia(FMD):causes renal artery stenosis(RAS) in young adults. Renal artery stenosis ->
renovascular hypertension -> headache,elevated BP,renal bruit
Tx-angioplasty w/ stent placement (HIGH YIELD!)
Renal, Urinary Systems & [Surgery rec. only if angioplasty fails]
3894 Medicine
Electrolytes
Medical therapy for FMD:only partially effective.Reserved for older pts w/ renal artery stenosis(due to
atherosclerosis) who aren't good candidates for surgery/refuse surgery.ACE inhibitors contraindicated in
bilateral RAS
Dietary recommendations for pts w/ renal calculi:
1. increased fluid intake
2.*decreased/limited sodium intake*
3. normal dietary calcium intake
3895 Medicine
Electrolytes [Most common renal stones are calcium stones]
Calcium binds oxalate to form inabsorbable calcium oxalate in the GI tract.Calcium restriction increases free
oxalate absorption,leading to hyperoxaluria & urinary calcium oxalate stone formatoin.Increased vit C also
promotes hyperoxaluria.Advise to restrict oxalate containing foods
Main mechanism of kidney damage in SLE pts is immune complex-mediated
3898 Medicine IgE mediated reaction is imp in allergic interstitial nephritis like methicillin-induced interstitial nephritis
Electrolytes
Cytotoxic antibodies cause Goodpasture's syndrome
Ashhadscknotes
Autosomal dominant polycystic kidney:
3939 Medicine sx- hypertension, palpable bilateral abdominal masses, hematuria
Electrolytes
Intracranial berry aneurysm/intracranial bleeding is a common complication
The most common renal vascular lesions seen in hypertension are arteriosclerotic lesions of afferent &
efferent renal arterioles & glomerular capillary tufts
3942 Medicine
Electrolytes
Diabetes mellitus nephropathy is charac by increased extracellular matrix, basement membrane thickening,
mesangial expansion, & fibrosis
Membranoproliferative glomerulonephritis:
sx- nephrotic range proteinuria & hematuria
Deposits that stain for C3 is characterristic for membranoproliferative glomerulonephritis type 2, caused by
3946 Medicine IgG antibodies (aka C3 nephritic factor) directed agaisnt C3 convertase -> Persistent activation of the
Electrolytes
alternative complement pathway
Cell mediated injury may be important in idiopathic crescentic glomerulonephritis

Cystinuria:group of disorders charac by *impaired amino acid transport*.Causes recurrent renal stone
3949 Medicine formation,personal hx of recurrent kidney stones from childhood & positive family hx,UA shows hexagonal
Electrolytes
crystals,urinary cyanide nitroprusside test used as a qualitative screening procedure. Extremely H.Y.!!!
Renal, Urinary Systems & Abnormal hemostasis in pts w/ chronic renal failure is most commonly due to *platelet dysfunction*. PT,
3951 Medicine
Electrolytes PTT, & platelet count are NORMAL. Bleeding time is prolonged! Tx-DDAVP (desmopressin)
Prolonged hypotension from any cause -> Acute tubular necrosis (ATN) -> muddy brown granular casts
Glomerular disease or vasculitis -> RBC casts
Interstitial nephritis & pyelonephritis -> WBC casts

3955 Medicine
Electrolytes
Nephrotic syndrome -> Fatty casts
Chronic renal failure -> Broad & waxy casts
HIGH YIELD!
Minimal change disease (MCD) is the most common form of nephrotic syndrome in pts w/ Hodgkin
lymphoma. Nephrotic syndrome will usually resolve w/ successful tx of the lymphoma
3966 Medicine
Electrolytes
Crescentic glomerulonephritis:pts will have acute kidney injury(present in almost all cases),hematuria, or
hypertension.Ass w/ autoimmune disorders
Focal and segmental glomerulosclerosis aka HIV related nephropathy:
3984 Medicine is the most common form of glomerulopathy ass. w/ HIV
Electrolytes
more common in blacks
Glomerular hyperfiltration is the earliest renal abnormality & also the major pathophysiologic mechanism of
glomerular injury seen in pts w/ diabetic nephropathy.
3986 Medicine Thickening of the glomerular basement membrane is the first change to be quantified. This is followed by
Electrolytes
mesangial expansion. Nodular sclerosis is superimposed later & is specific for diabetic nephropathy.
ACE inhibitors reduce intraglomerular htn -> decrease glomerular damage
High-dose iv acyclovir can cause crystalluria w/ *renal tubular obstruction*. Administering iv fluids along w/
drug can help reduce the risk of acute kidney injury
Crystal induced acute kidney injury also caused by sulfonamides, methotrexate, ethylene glycol, & protease
3987 Medicine inhibitors, along w/ acyclovir
Electrolytes
Acute interstitial nephritis: ass. w/ exposure beta lactams & proton pump inhibitors, 7-10 days after drug
exposure, skin rash, eosinophilia/uria, pyruria
Rheumatoid arthritis predisposes to amyloidosis. Renal involvement is characterized by nephrotic syndrome.
Renal, Urinary Systems & The classic pathologic finding is amyloid deposits that stain w/ Congo red & demonstrate apple-green
3997 Medicine
Electrolytes birefringence under polarized light. Multiple myeloma is the mcc of AL amyloidosis, & rheumatoid arthritis is
the mcc of AA amyloidosis
Analgesic nephropathy:
ass w/ long term use of 1 or multiple analgesics (like aspirin or ibuprofen)
usually asymptomatic but can have chronic *tubulointerstitial nephritis* or hematuria due to papillary necrosis
4004 Medicine labs- elevated creatinine, hematuria, sterile pyuria, mild proteinuria
Electrolytes
Glomerulonephritis: look for dysmorphic red blood cells, nephrotic range proteinuria, and RBC casts
Analgesic nephropathy is the most common form of drug induced chronic renal failure(eg pts on aspirin &
naproxen). *Papillary necrosis* & *chronic tubulointerstitial nephritis* are the most common pathologies
4007 Medicine seen.
Electrolytes
Pts w/ chronic analgesic abuse are more likely to develop premature aging, atherosclerotic vascular
disease, & urinary tract cancer.
4026 Medicine Cardiovascular disease is the mcc of death in dialysis pts & renal transplant pts
Electrolytes
Ashhadscknotes
*Uric acid stones* [usually seen in pts w/ low urine pH] are highly soluble in alkaline urine; alkalinization of
the urine to pH 6-6.5 w/ oral *potassium citrate* is tx of choice
4027 Medicine
Electrolytes Purine-restricted diet indicated in pts w/ uric acid stones secondary to hyperuricosuria
Uric acid stones are often radiolucent but may be seen on US or CT scan
Elderly pts are predisposed to dehydration after a minor febrile illness.Sx of dehydration-dry
mucosa,marginally high values for hematocrit & serum electrolytes, BUN/creatinine ratio > 20. Tx-*IV
sodium-containing crystalloid solutions (0.9% NaCl=normal saline)*
4034 Medicine
Electrolytes Rehydration therapy in elderyly pts should be undertaken w/ caution cuz sodium loading can unmask
subclinical heart failure
Colloid solutions (albumin) are used in burns or conditions accompanied by hypoproteinemia

*Thiazide diuretics* lower urinary calcium excretion -> prevent urinary calcium stone formation
4058 Medicine Calcium binds w/ oxalate in the gut to form unabsorbable calcium oxalate. Reduced dietary calcium leads to
Electrolytes
an increase in oxalate absorption in the gut, which is then excreted into the urine & binds urinary calcium to
form calcium oxalate stones. Excess calcium supplementation is also ass. w/ increased stone formation
Renal, Urinary Systems & Renal transplant dysfunction in the early post-operative period manifests as oliguria, hypertension, &
4152 Medicine
Electrolytes increased creatinine/BUN. Acute rejection is best tx w/ *IV steroids* Extremely high yield!!!
Thiazide diuretics have unfavorable metabolic side effects like *hyperglycemia*, increased LDL cholesterol,
4171 Medicine and plasma triglycerides. Electrolyte abnormalities that can be induced by thiazide diuretics include
Electrolytes
hyponatremia, hypokalemia, & hypercalcemia
Simple renal cysts(thin,smooth,unilocular,no septae,homogenous content,asymptomatic) are almost always
benign & do not require further evaluation. *Reassure pt*.
Malignant renal mass have a multilocular mass, irregular walls, thickened septae, & contrast enhancement.
4181 Medicine
Electrolytes
Percutaneous aspiration considered if cyst is large & painful or infected w/ purulent material
Ureteral stent placement indicated for urinary obstruction at the ureter or renal pelvis
Renal, Urinary Systems & Diabetic autonomic neuropathy -> neurogenic bladder w/ urinary retention & distended bladder -> overflow
4228 Medicine
Electrolytes incontinence
Gastric contents are rich in hydrogen, chloride, & potassium. Therefore vomiting causes hypochloremic
4236 Medicine metabolic alkalosis & hypokalemia. Bicarbonate levels rise as a result of hydrogen loss & activation of the
Electrolytes
renin angiotensin system.
Renal, Urinary Systems & *Nephrotic syndrome is a hypercoagulable condition.* Manifests as venous or arterial thrombosis, & even
4266 Medicine
Electrolytes pulmonary embolism. Renal vein thrombosis is the most frequent manifestation.
Renal, Urinary Systems & Common medications that cause hyperkalemia include nonselective beta-adrenergic blockers, potassium
4288 Medicine
Electrolytes sparing diuretics (eg, triamterene, *amiloride*), ACE inhibitors, ARBs, & NSAIDs
Ureteral calculi may cause flank/ab pain radiating to perineum,often w/ nausea/vomiting.*Ultrasonography*
or noncontrast spiral CT scan of ab & pelvis to confirm dx.US preferred in pregnant pts to reduce radiation
exposure
4361 Medicine Exploratory laparotomy indicated when there is evidence of peritonitis
Electrolytes
Intravenous pyelogram uses IV contrast & plain xray to visualize urinary system
HIDA scan:used for pts w/ acute cholecystitis when US fails to show obstruction at neck of gallbladder
Aminoglycosides(eg Amikacin): treats pyelonephritis(gram-negative rod)/serious gram-negative infections.
Urine sediment won't have wbcs[wbc casts & eosinophils present in AIN]. Has adverse effects & needs
Renal, Urinary Systems & monitoring. Used w/ decreasing frequency, esp in older pts.Look for pt to have sudden rise in creatinine in
4379 Medicine
Electrolytes question stem(an acute renal failure all of a sudden in the setting of chronic kidney disease)
Nafcillin:causes acute renal failure due to AIN.Targets MSSA

Acyclovir can cause crystalline nephropathy if adequate hydration is not also provided
4414 Medicine
Electrolytes
Pre-treatment w/ prednisone may be used to minimize radiocontrast-induced allergic reactions
*Insulin/glucose administration is the quickest way to decrease the serum potassium concentration(drives
potassium intracellularly in 15-30 minutes)*
Hemodialysis is the most definitive way to remove K+ from the body in pts w/ renal failure
4422 Medicine Sodium polystyrene sulfonate (Kayexalate) is a K+ binding resin that decreases total body K+ content by
Electrolytes
catharsis in the gut. Na+ is exchanged for K+
Furosemide: promotes renal K+ excretion
B2 agonists: transiently moves K+ into cells
Ashhadscknotes
Chronic alcoholics present w/ hypokalemia,hypomagnesemia,& hypophosphatemia.*Hypomagnesemia
causes refractory hypokalemia*; therefore it's imp to correct the magnesium along w/ potassium levels
4423 Medicine Hypophosphatemia:causes weakness,rhabdomyolysis,paresthesias,respiratory failure in severe cases
Electrolytes
Hypoalbuminemia:seen in alcoholics.May indicate poor nutrition,decreased hepatic synthetic
function,proteinuria.May result in spurious hypocalcemia since calcium is largely albumin-bound
Renal, Urinary Systems & MCC of hypernatremia is hypovolemia. Mild cases can be tx w/ 5% dextrose in 0.45% saline. Severe cases
4424 Medicine
Electrolytes should be initially tx w/ 0.9% saline
Lithium(used to tx bipolar disorder) is a common cause of nephrogenic diabetes insipidus
4425 Medicine Pts w/ Diabetes insipidus are hypernatremic
Electrolytes
Pts w/ psychogenic polydipsia are hyponatremic
Succinylcholine is a depolarizing neuromuscular blocker often used during rapid sequence intubation.
4428 Medicine It can cause life threatening hyperkalemia. Don't use it in pts w/ high risk for hyperkalemia!
Electrolytes
Hyperkalemia is a contraindication to the use of succinylcholine.
Drugs w/ anticholinergic properties(amitriptyline) can cause acute urinary retention -> abdominal pain,
Renal, Urinary Systems & suprapubic fullness. Tx-urinary catheterization, discontinuing med w/ anticholinergic property
4432 Medicine
Electrolytes
Barium enemas are used to dx luminal abnormalities of the colon(colon cancer or diverticulosis)
Pts w/ COPD often have chronic CO2 retention, resulting in respiratory acidosis & compensatory metabolic
4435 Medicine alkalosis. *Diuretics* are often administered to tx cor pulmonale sx but must be used cautiously as they can
Electrolytes
lead to a reduction in cardiac output & subsequent development of *prerenal acute renal injury*
Contrast-induced nephropathy:Spike in creatinine within 24 hours of contrast administration followed by a
return to normal renal function within 5 days.Pts w/ hx of diabetes & chronic renal insufficiency @ increased
risk.Adequate *IV hydration* w/ isotonic bicarbonate or normal saline & administration of acetylcysteine help
4491 Medicine to minimize risk
Electrolytes
Prednisone prevents hypersensitivity reactions to contrast media in pts w/ known allergy.It DOESN'T
prevent contrast-induced nephropathy
4502 Medicine Screening for bladder cancer is not recommended, even in pts who are at risk of developing the disease
Electrolytes
4506 Medicine Bladder tumors are the most common malignancy ass. w/ painless hematuria in adults
Electrolytes
Pts w/ diabetes for >10 years can develop diabetic microangiopathy, nephropathy, & glomerulosclerosis.
Risk factors include poor glycemic control, elevated blood pressure, smoking, increasing age, &
4515 Medicine ethnicity(african american, mexican american). Clinical findings include mild to moderate proteinuria &
Electrolytes
chronic kidney disease w/ elevated creatinine. Pts also have evidence of retinopathy/decreased visual acuity
or neuropathy.
Type 2 renal tubular acidosis (RTA) aka proximal RTA: defective tubular bicarbonate reabsorption in the
proximal tubules. Often inherited & may be a component of Fanconi syndrome. Can also occur w/ use of
carbonic anhydrase inhibitors (acetazolamide)
4535 Medicine
Electrolytes
Renal tubular chloride loss as seen in aggressive loop or thiazide diuretic use causes metabolic
alkalosis(loss of extracellular volume along w/ chloride loss->Renin Angio Aldo stimulated->increased urinary
excretion of H+)
Acute nephritic syndrome w/ fluid overload:
*primary glomerular damage*->decreased GFR->volume overload
sx-anasarca,pulmonary & facial edema,hypertension,& abnormal urinalysis w/ proteinuria & microscopic
hematuria
Renal, Urinary Systems & Decreased GFR causes edema in pts w/ esrd
4591 Medicine
Electrolytes
Hypoalbuminemia can cause significant peripheral edema but doesn't cause pulmonary edema
Cirrhotic pts:edema in lower extremities
Renal hypoperfusion in heart failure ->increased renal Na+ & water retention & edema
Severe pain in a pt w/ a mild urinary obstruction, such as BPH, may cause urinary retention due to inability
to Valsalva
Renal, Urinary Systems & Disk herniation can cause nerve root injury aka cauda equina syndrome:sx-bladder atony w/ overflow
4615 Medicine
Electrolytes incontinence, bilateral sciatica, saddle anesthesia, and loss of anal sphincter tone
Detrusor instability aka urge incontinence: incontinence preceded by sudden urinary urgency. Caused by
unregulated spontaneous contractions of the bladder
SIADH: hyponatremia, decreased serum osmolarity, elevated urine osmolarity, increased urine sodium
4643 Medicine concentration, & failure to correct w/ normal saline infusion(urine sodium excretion appears to increase while
Electrolytes
serum sodium in unaffected when you give saline)
Ashhadscknotes
20% of cocaine overdoses are complicated by rhabdomyolsis(look for elevations in serum CPK). Main
danger ass. w/ CPK levels >20,000 U/L is acute renal tubular necrosis due to myoglobinuria
4683 Medicine Aseptic meningitis: no causative organisms found on routine CSF stains & cultures. Commonly caused by
Electrolytes
Coxsackie virus or Echovirus
Post transplant EBV-mediated pseudolymphoma can predispose to splenic rupture

Urgent bladder scan & *catheterization* should be performed in all pts w/ oliguria & acute renal failure due
4701 Medicine to suspected bladder outlet obstruction in the 'postoperative' setting. Placement of *bladder catheter* in a
Electrolytes
timely fashion can rapidly improve sx, reverse acute renal failure, & prevent long-term renal damage
1st generation H1-antihistamines such as *diphenhydramine* have anticholinergic effects & can result in
urinary retention from *failure of detrusor contraction*
Renal, Urinary Systems & Detrusor-sphincter dyssynergia occurs in the setting of neuro disease. Detrusor muscle contracts while the
4733 Medicine
Electrolytes urethral sphincter contracts causing difficulty in initiating urination & inadvertent interruption of the urinary
stream
Overactive bladder defined by sx of urgency, frequency, & nocturia

Kidney compensates for respiratory alkalosis by excreting bicarbonate in the urine->alkalinized urine
*increased urine pH*
Renal, Urinary Systems & "Contraction alkalosis" occurs in states of intracellular volume contraction,where increased levels of
4739 Medicine
Electrolytes aldosterone function to restore intravascular volume but also cause increased proton loss
High serum anion gap occurs in met. acidoses resulting from diabetic ketoacidosis,renal failure,lactic
acidosis,& methanol,ethylene glycol,or salicylate poisoning
Obstructive uropathy:
flank pain, low volume voids with or without occasional high volume voids, and (if bilateral) renal dysfunction
4749 Medicine
Electrolytes
Renal artery stenosis does not cause flank pain or urinary sx
Diabetic nephropathy:
Renal, Urinary Systems & etiology- longstanding diabetes mellitus
4750 Medicine
Electrolytes sx- proteinuria
nodular glomerulosclerosis, diffuse glomerulosclerosis
Renal, Urinary Systems & Agents used to shift potassium intracellularly(eg, in a hyperkalemic pt) include insulin & glucose, sodium
4760 Medicine
Electrolytes bicarbonate, & *beta-2 agonists*
Interstitial cystitis (painful bladder syndrome): bladder pain that is worsened by filling & relieved by voiding.
Renal, Urinary Systems & Dyspareunia, urinary frequency & urgency can also be present
4807 Medicine
Electrolytes
Cystocele: bladder prolapse into the anterior vaginal wall
In saline responsive metabolic alkalosis(rmr met. alk. has increased bicarbonate), normal saline
administration restores arterial volume, corrects hypochloremia, & increases urinary bicarbonate excretion
4866 Medicine Acetazolamide can improve alkalosis a little, however it can worsen a pts volume depletion. It can also
Electrolytes
cause hypokalemia. Give to edematous pts w/ metabolic alkalosis
Calcium gluconate & insulin used as acute therapy for hyperkalemia

Renal, Urinary Systems & Hypovolemia->ADH release->elevated ADH increases renal water reabsorption to cause hyponatremia until
7722 Medicine
Electrolytes correction of hypovolemia
Trimethoprim: can cause *hyperkalemia*. Occurs commonly in HIV infected pts tx w/ trimethoprim. May
also cause an artificial increase in serum creatinine(w/o affecting gfr).
TMP-SMX commonly used for tx uncomplicated UTIs(Gram-negative rods), Pneumocystis jirovecii

pneumonia, community acquired MRSA skin infections, & nocardiosis
8331 Medicine
Electrolytes
Albuterol & insulin lower serum K+ (drives K+ intracellularly)
Macrolides cause prolonged QT & cholestasis
Ceftriaxone ass. w/ cholestasis

Cystoscopy is next step in management of pts w/ gross hematuria or with microscopic hematuria and other
Renal, Urinary Systems & risk factors for bladder cancer(eg 30 pack year smoking hx), even if they have BPH sx at the same time.
8929 Medicine
Electrolytes Once bladder ca is ruled out, then we can focus on the BPH tx with alpha adrenergic antagonishs or with
5-alpha reductase inhibitors
Glomerular hematuria: microscopic hematuria, Blood AND Protein on UA.[source of hematuria is more likely
to be glomerular if the urine studies reveal proteinuria, dysmorphic RBCs or RBC casts]
10287 Medicine Non-glomerular hematuria: gross hematuria, Blood but NO protein
Electrolytes
Papillary necrosis: "NSAID" Nonsteroidal antiinflam drugs,Sickle cell dis,Analgesic
abuse,Infection(pyelonephritis),Diabetes
Ashhadscknotes
Asterixis is seen in hepatic encephalopathy, uremic encephalopathy, & CO2 retention. Uremic
encephalopathy is an indication for urgent *hemodialysis*, which will improve neurological status & resolve
Renal, Urinary Systems & asterixis
10776 Medicine
Electrolytes
An asymptomatic anemic pt w/ hemoglobin >8 g/dL who doesn't have ongoing bleeding will NOT need a
blood transfusion
Alpha-1 receptor blockers such as tamsulosin facilitate ureteral stone passage
Furosemide is a loop diuretic that promotes calciuria,which can predispose to renal calculi
Renal, Urinary Systems & Bethanechol tx urinary retention/atonic bladder. Oxybutynin tx overactive bladder(detrusor instability)
11109 Medicine
Electrolytes
Phenazopyridine:analgesic for urinary tract mucosa,used to tx the dysuria of cystitis(after
infection/instrumentation)
Imipramine is an antidepressant, tx childhood enuresis,promotes urinary retention

Cyanide toxicity: can be caused by prolonged infusion of sodium nitroprusside at high rates, esp in pts w/
chronic kidney disease. Sx-headache, confusion, arrhythmias, flushing, & respiratory depression. Tx-
Renal, Urinary Systems & sodium thiosulfate
11566 Medicine
Electrolytes
Uremic encephalopathy can present w/ altered mentation & occasional myclonus & usually occurs in pts w/
advanced renal failure
1st line tx for URGENCY incontinence are bladder training & pelvic floor muscle exercises. Nonresponders
can use an antimuscarinic agent(eg, *oxybutynin*) to decrease detrusor activity
Renal, Urinary Systems & Vaginal pessary is used for STRESS incontinence when surgical correction fails/is contraindicated[Pessary
12033 Medicine
Electrolytes would exacerbate an urge incontinence!]
Duloxetine(serotonin/norepinephrine reuptake inhibitor) may be considered for tx of stress incontinence in

pts w/ unipolar depression
[UPTODATE] Moyamoya disease:a chronic progressive cerebrovascular disease characterized by bilateral
stenosis or occlusion of the arteries around the circle of Willis w/ prominent arterial collateral circulation.
Rheumatology/Orthopedics
2144 Medicine High incidence among Japanese & Asian population. Ischemic cerebrovascular events,either TIA or
& Sports
infarction are more prevalent than hemorrhagic events in children w/ moyamoya while hemorrhagic stroke is
more common in adults
Acetaminophen should be initial tx for pts w/ mild to moderate pain from osteoarthritis(OA)
2305 Medicine Ketorolac is an NSAID. NSAIDs are 2nd line agents for OA due to gi & renal side effects w/ long term use
& Sports
Colchicine tx OA that is refractory to NSAIDs & intra-articular steroids
SLE's effects on the kidneys range from minimal mesangial lupus nephritis to advanced sclerosing lupus
nephritis & are graded class I-VI. Tx & outcomes are different depending on the class of lupus nephritis.
2306 Medicine Therefore, renal biopsy is required in all pts w/ new onset lupus nephritis. Biopsy also provides baseline
& Sports
histology against which future biopsies may be compared to monitor disease progression.
Immunosuppressive therapy is given once the lupus nephritis is classified
Pseudogout: acute form of *calcium pyrophosphate dihydrate (CPPD) crystal disease.* Rhomboid, positively
birefringent crystals are seen on synovial fluid analysis. Knee most commonly affected.
Monosodium urate crystal deposition is seen in gout. These crystals are needle-shaped & negatively
2314 Medicine birefringent on synovial fluid analysis.
& Sports
Hydroxyapatite: complexed form of calcium found in teeth & bones. Can exist in cartilage of pts w/
degenerative osteoarthritis.
Systemic lupus erythematosus (SLE): Common in African-American women aged 20-40 years. Fatigue,
arthritis affecting MCP & PIP joints of hands, oral ulcers, proteinuria
2315 Medicine Dermatomyositis: proximal muscle weakness, rash of the shoulders & back, & scales on the hands
& Sports
X-ray in Rheumatoid arthritis (RA) may show joint space erosions, juxtaarticular demineralization, & soft
tissue swelling
Erythema Nodosum(EN): painful, subcutaneous, pretibial nodules. Can be a symptom of more serious
Rheumatology/Orthopedics disease processes including sarcoidosis, TB, histoplasmosis, recent streptococcal infection, & inflammatory
2317 Medicine
& Sports bowel disease. Association of EN w/ sarcoidosis is strong in young, African American women. Cough,
arthritis, uveitis & hilar adenopathy on *chest x-ray* ass. w/ sarcoidosis
Stress fractures are common in pts who suddenly increase their physical activity, esp in female runners w/
the female athlete triad (oligomenorrhea, osteoporosis, & decreased caloric intake). Typical sx include
Rheumatology/Orthopedics localized pain to palpation & possible swelling
2329 Medicine
& Sports
Morton neuroma ass w/ pain between 3rd & 4th toes on the plantar surface & w/ a clicking sensation
(Mulder sign) that occurs when simultaneously palpating this space & squeezing the metatarsal joints
The USPSTF recommends a one time screening for osteoporosis in all women age >65 w/ *dual-energy
2380 Medicine x-ray absorptiometry (DEXA) scan*. [xrays are less sensitive & specific than DEXA & don't provide
& Sports
quantitative data to follow the course of the disease]
Ashhadscknotes
Rheumatology/Orthopedics Positive *anti-Smith antibodies* &/or anti-double stranded DNA antibodies is specific & confirmatory for the
2450 Medicine
& Sports dx of *SLE*
Hemochromatosis is commonly ass. w/ calcium pyrophosphate dihydrate deposition in joints, leading to
chondrocalcinosis & ass. sx including acute episodic synovitis (pseudogout) & chronic arthropathy. Other
2880 Medicine manifestations include diabetes, hyperpigmentation, dilated cardiomyopathy, & liver disease w/
& Sports
hepatomegaly & fibrosis. Dx is suggested by iron overload on serum iron studies, & can be confirmed by
genetic tests (HFE) or liver biopsy. Tx-phlebotomy
Polymyositis & dermatomyositis are two forms of inflammatory myopathy. Dx of inflammatory myopathy is
3059 Medicine made w/ elevated ESR & CK, & confirmed by muscle biopsy. Inflammatory myopathies are best tx w/ high
& Sports
dose *corticosteroids*
Gouty arthritis:punched out erosions w/ a rim of cortical bone on xray
Rheumatology/Orthopedics Rheumatoid arthritis:periarticular osteopenia & joint margin erosions

3148 Medicine
& Sports
Pseudogout/calcium pyrophosphate dihydrate (CPPD) deposition:calcification of cartilaginous
structures(chondrocalcinosis) seen.Acute swelling,stiffness & pain of knee after surgery or medical illness
*Synovial fluid* should be obtained urgently for cell count, Gram stain, & culture in any pt w/ possible septic
arthritis. Preexisting joint disorders can increase the risk for secondary infection of the joint. In pts w/
Rheumatology/Orthopedics crystal-induced arthritis (eg, gout), the presence of crystals in the synovial fluid does not rule out septic
3149 Medicine
& Sports arthritis as these will be present between attacks
Lyme arthritis develops months after initial infection

Gout presents as an acute monoarticular arthritis that quickly progresses to maximum intensity within 12-24
3150 Medicine hours. Triggers include alcohol use, surgery/trauma, recent hospitalization, dehydration, & certain
& Sports
medications(eg,diuretics)
*Hyperparathyroidism predisposes to the development of pseudogout(affects knee)*.Look for sx of
hypercalcemia in these pts like constipation,fatigue,excessive urination,OR abdominal pain,urinary
stones,mental status changes,osteoporosis
Rheumatology/Orthopedics Struvite crystals have shape of coffin lids,seen in nephrolithiasis caused by chronic uti w/ urease-producing
3151 Medicine
& Sports organisms
Polymorphonuclear cells filled w/ gram positive cocci->septic arthritis
Lymphocytes & budding yeast->fungal arthritis

3153 Medicine Neisseria gonorrhoeae is the mcc of septic arthritis in young, sexually active pts
& Sports
Lumbar spinal stenosis: leg pain aggravated by spinal extension(standing, walking upright) & relieved w/
flexion(sitting, leaning forward).
Flexion of spine causes widening of the spinal canal. Extension causes narrowing of the canal. This is
Rheumatology/Orthopedics known as "neurogenic claudication"
3157 Medicine
& Sports Caused by narrowing of spinal canal -> compression of lumbar nerve roots. Occurs in older pts since it's a
degenerative disorder.
dx- MRI of spine
tx- physical therapy, exercise program, surgical
Pts w/ suspected giant cell arteriris (temporal arteritis) who have visual sx should be started IMMEDIATELY
on *high-dose systemic glucocorticoids* to reduce the progression of visual complications
3164 Medicine
& Sports
Anterior ischemic optic neuropathy is the most common ocular manifestation of giant cell arteritis & is
detected on funduscopy by the presence of a swollen & pale disc w/ blurred margins
Ankylosing spondylitis(AS): *anterior uveitis* is the most common extraskeletal complication. Back pain
improves w/ activity/exercise, warm showers, nonsteroidal agents
AS is ass w/ aortic valve disease, typically aortic regurgitation, due to scarring of the valve cusps
3165 Medicine
& Sports
Episcleritis is ass. w/ rheumatoid arthritis & inflammatory bowel disease
Ischemic optic neuropathy: feared complication of temporal arteritis. Results from vasculitis of retinal artery.
May cause blindness
3166 Medicine Glutamic acid decarboxylase antibodies are seen in 70% of type I diabetics at the time of dx
& Sports
Ankylosing spondylitis(AS):In young pts(even females) w/ characteristic pain, *plain x-rays* showing
Rheumatology/Orthopedics *sacroiliitis* can confirm dx. Fusion of vertebral bodies w/ ossification of intervertebral discs(bamboo spine)
3167 Medicine
& Sports also suggests the dx. [AS strongly ass. w/ HLA-B27, but HLA-B27 isn't specific for AS & not necessary for
dx]
Ashhadscknotes
Long term cyclophosphamide use is ass w/ the increased incidence of acute hemorrhagic cystitis & *bladder
carcinoma*
Cisplatin,carboplatin,aminoglycosides can cause cochlear dysfunction

3169 Medicine
& Sports Ethambutol & hydroxychloroquine can cause optic neuritis
Beta-blockers & ergotamine can cause digital vasospasm (Raynaud's phenomenon)
Cyclosporine can cause gout as a side effect

Lidocaine injection ameliorates the pain & weakness of rotator cuff tendonitis, while it doesn't improve sx of
a rotator cuff tear. MRI is study of choice for dx rotator cuff tears
3170 Medicine MRI is excellent at visualizing soft tissue structures
& Sports
Cervical radiculopathy:results from disc herniation (osteophytes), sx-arm weakness, paresthesias, & neck
pain
Viral infection may present w/ symmetric arthritis. Viral arthritis is distinguished from rheumatoid arthritis &
other causes of symmetric arthritis by its acute onset(eg,sx started only 1 week ago), lack of elevated
3171 Medicine inflammatory markers, lack of joint swelling, morning stiffness <30 min,absence of systemic sx, & resolution
& Sports
within two months. Parvovirus is the mcc of viral arthritis & likely in adults who have frequent contact w/
children(daycare workers)
Hydroxychoroquine:
Rheumatology/Orthopedics excellent choice for SLE pts w/ isolated skin & joint involvement
3173 Medicine
& Sports side effect:may damage the eye, cause retinopathy, damage cornea. Thats why you have to you have to do
eye exams every 6 months in pts taking hydroxychloroquine
Sarcoidosis:common in African American woman durin 3rd & 4th decades of life.Lungs are affected.
3176 Medicine Sx-cough,erythema nodosum,anterior uveitis(red eye w/ leukocytes in anterior chamber),& arthritis
& Sports
seen.Hilar adenopathy & reticular opacities on CXR
3177 Medicine Pts w/ symptomatic Sarcoidosis should be given systemic *glucocorticoids*
& Sports
Rheumatology/Orthopedics Fibromyalgia management: *Exercise* is the foundation of management, w/ medications(duloxetine,tricyclic
3202 Medicine
& Sports antidepressants) reserved for pts who fail initial measures
Carpal tunnel syndrome(CTS) occurs in 30% of pts w/ hypothyroidism due to deposition of
mucopolysaccharide protein complexes/accumulation of matrix substances within the perineurium &
endoneurium of the median nerve
tx- sx of CTS improve w/ thyroid hormone replacement therapy.
accumulation of fluid in carpal tunnel can cause CTS in pregnancy

3203 Medicine most common CTS due to amyloid deposition occurs in ESRD or chronic hemodialysis
& Sports
Pts w/ acromegaly and RA can have CTS
Fibromyalgia(FM): pain syndrome, occurs in young to middle aged women.Sx- fatigue, widespread pain, &
Rheumatology/Orthopedics cognitive/mood disturbances. Initial FM tx should be aerobic exercise & good sleep hygiene. Pts that don't
3205 Medicine
& Sports respond to this need meds. TCAs eg,*Amitriptyline* is an effective initial therapy. Pregabalin, duloxetine, &
milnacipran are alternate therapies for pts not responding to tricyclic antidepressants
Dermatomyositis is charac by classic cutaneous findings accompanied by proximal muscle weakness. Over
15% of adult pts will have or develop an internal *malignancy*, most commonly ovarian, lung, pancreatic,
stomach, or colorectal cancers, or non-Hodgkin lymphoma. Regular, age-appropriate cancer screening is
3208 Medicine essential in these pts
& Sports
The classic autoantibodies ass. w/ dermatomyositis are anti-Jo-1(antisynthetase antibody) & anti-Mi-2
(against helicase)
Polymyositis(PM): slowly progressive proximal weakness of lower extremities, difficulty ascending &
descending stairs, rising from a seated position. Proximal arm weakness follows leading to difficulty combing
Rheumatology/Orthopedics hair or working w/ hands overhead. Pts may develop dysphagia. NO skin findings in PM, distinguishing it
3209 Medicine
& Sports from dermatomyositis.*Muscle biopsy* is best dx test
EEG used to evaluate pts w/ seizure or sleep disorders

disc herniation:
Rheumatology/Orthopedics sx- low back pain radiating down buttock and below the knee in dermatomal distribution
3211 Medicine
& Sports positive straight leg and crossed straight leg tests are specific for disc herniation
Ashhadscknotes
Anserine bursitis:sharply localized pain over anteromedial part of tibial plateau just below the joint line of the
knee.Valgus stress test fails to reproduce pain,thereby ruling out damage to the medial collateral
ligament.Radiographs are normal
3303 Medicine
& Sports
Prepatellar bursitis:pain/swelling over patella, cystic swelling over patella w/ variable signs of inflammation.
Trauma is mcc
The mcc of an asymptomatic elevation of alkaline phosphatase in an elderly pt is *Paget disease of bone*,
which is frequently discovered incidentally on routine blood tests. X-rays will show osteolytic or mixed
Rheumatology/Orthopedics lytic-sclerotic lesions, & radionuclide bone scan can fully stage the disease
3304 Medicine
& Sports
Statins and alcoholic liver disease cause a hepatocellular pattern(predominant elevations in transaminases)
rather than a cholestatic pattern(predominant elevation in alkaline phosphatase)
Whipple disease sx: chronic malabsorptive diarrhea, weight loss, *migratory non-deforming arthritis*,
lymphadenopathy & a low grade fever
3311 Medicine
& Sports
Intestinal lymphoma sx: ab pain, weight loss, nausea/vomiting,distension,occult blood in stool.
[malabsorption is not a typical feature].Histopath would show a diffuse infiltrate by atypical lymphocytes
Inflammatory bowel disease may occur in ass. w/ an inflammatory arthritis. Ankylosing spondylitis & IBD are
both ass. w/ HLA-B27 & may occur in ass. w/ one another. Both conditions may also be ass. w/ a positive
Rheumatology/Orthopedics p-ANCA despite the absence of vasculitis in both conditions
3312 Medicine
& Sports
Ulcerative colitis: young age, hx of acute-onset bloody diarrhea, anemia & negative stool cultures. p-ANCA
is positive
Polymyalgia rheumatica(PMR): affects pts age >50 & is charac by pain & STIFFNESS in the neck,
shoulders, & pelvic girdle, along w/ an elevated ESR. Tx-*low dose prednisone* which results in rapid relief
of sx
3317 Medicine
& Sports
PMR is frequently ass w/ giant cell temporal arteritis(GCA). GCA sx-headache,jaw claudication,vision
loss,tenderness over temporal artery. If GCA suspected, pts should be considered for an expedited
temporal artery biopsy & receive higher doses of glucocorticoids
Treat rheumatoid arthritis pts w/ Methotrexate, a disease modifying antirheumatic drug, early in the disease
course. Methotrexate is the preferred DMARD for RA.
Before giving methotrexate, test pt for Hep B & C and TB. Also don't give it to pregnant pts or those
3318 Medicine planning pregnancy, those w/ renal insufficiency, liver disease, excessive alcohol intake.
& Sports
If no response to 6 month DMARD therapy, give TNFa inhibitors
Azathioprine- ass. w/ hematologic & gi toxicity

Rheumatology/Orthopedics Lymphocytic infiltration of the salivary glands in Sjogren syndrome will cause enlargement & firmness to
3321 Medicine
& Sports palpation of these glands
3322 Medicine Systemic sclerosis: Antinuclear autoantibodies & *anti-topoisomerase-I antibodies* present
& Sports
CREST syndrome:
1)Calcinosis cutis-localized dystrophic deposition of calcium in the skin, manifests as subcutaneous
pink-to-white nodules on upper extremities, may ulcerate & drain a chalky material
Rheumatology/Orthopedics 2)Raynaud phenomenon
3515 Medicine
& Sports 3)Esophageal dysmotility-food "stuck" in esophagus/GERD
4)Sclerodactyly-fibrosis of the skin of the fingers distal to mcp joints resulting in shiny appearance of skin &
flexion contractures & joint pain
5)Telangiectasias-"mat-like" patches on face & palms
Rheumatology/Orthopedics Paget disease of bone (osteitis deformans): normal serum calcium and phosphate levels. Increased alkaline
3516 Medicine
& Sports phosphatase and urinary hydroxyproline levels. Pt will have lower extremity pain, headaches/deafness
Paget's disease pts that are symptomatic are tx w/ *bisphosphonates*. Bisphosphonates inhibit osteoclasts
3518 Medicine to suppress bone turnover.
& Sports
[Calcitonin has a weaker effect than bisphosphonates. It's reserved for pts intolerant to bisphosphonates]
Subacromial bursitis: due to repetitive overhead motions.Pts complain of pain w/ active range of motion of
shoulder.Passive internal rotation & forward flexion at the shoulder elicits tenderness
Tear of the proximal end of the long head of bicep tendon ass. w/ rotator cuff injury
3574 Medicine
& Sports
Axillary nerve supplies deltoid and teres minor w/ motor innervation
Axillary nerve injury may occur as a result of anterior dislocation of the humerus out of the glenoid fossa
Lateral epicondylitis (tennis elbow) manifests as pain w/ supination or extension of the wrist & point
tenderness just distal to the lateral epicondyle
3575 Medicine
& Sports Rotator cuff injury: Result of impingement of the supraspinatus tendon
Posterior interosseous nerve entrapment results in weakness of the extrinsic extensors of the hand & fingers
Ashhadscknotes
De Quervain tenosynovitis affects new mothers who hold their infants w/ the thumb outstretched
(abducted/extended)
Trigger thumb results in pain over the palmar aspect of the first metacarpophalangeal joint and locking of
Rheumatology/Orthopedics the thumb in flexion
3576 Medicine
& Sports
Scaphoid fractures occur during forceful hyperextension of wrist as may occur in a fall on outstretched
hand.Pain localizes to anatomic snuffbox
Flexor carpi radialis tenosynovitis:pain w/ radial flexion of wrist, tender trapezium

Chronic tophaceous gout:
Rheumatology/Orthopedics urate crystals can be deposited in the skin resulting in the formation of tumors w/ a chalky white appearance
3778 Medicine
& Sports (known as tophi). If they take thiazide diuretics for their high bp, that will cause a hyperuricemic effect due
to hypovolemia associated enhancement of uric acid reabsoption in proximal tubule
Behcet syndrome:recurrent oral/genital ulcers.Skin & ocular involvement is common. Thrombosis is a major
cause of morbidity.Common in pts of Turkish, Middle Eastern, & Asian descent
3815 Medicine
& Sports
Reactive arthritis:arthritis,uveitis,oral ulcerations.Follows an acute GI(salmonella,yersinia) or GU(chlamydia)
infection & causes subacute to chronic sx
In pts w/ acute 'mechanical' back pain w/o significant neurologic deficit, conservative approach is preferred
for a period of 4-6 weeks. This includes *early mobilization, muscle relaxants, & NSAIDs*. Bed rest &
physical therapy hasn't been shown to be helpful
4000 Medicine
& Sports Emergency surgical decompression indicated in case of significant or rapidly progressive neuro deficit(foot
drop, weakness of legs)
Plain roentgenogram used in pts w/ osteoporosis & possible vertebral crush fractures
Rheumatology/Orthopedics The most common pulmonary complication in pts w/ systemic sclerosis (SSc) is *interstitial
4014 Medicine
& Sports fibrosis/interstitial lung disease*
Aseptic/Avascular necrosis of the femoral head is a common complication of sickle cell disease
sx- Pain in the hip that gradualy progresses
4038 Medicine Very High Yield!
& Sports
Aseptic necrosis of the femoral head is uncommon children
Corticosteroid-induced avascular necrosis of the femoral head usually presents as progressive hip or groin
4047 Medicine pain w/o restriction of motion range & normal radiograph on early stages. *MRI* is gold standard for the dx
& Sports
of avascular necrosis of hip
Lumbosacral strain: acute onset of back pain after physical exertion, absence of radiation, presence of
paravertebral tenderness, negative straight-leg raising test, & normal neurologic examination
4078 Medicine Ankylosing spondylitis & multiple myeloma are characterized by chronic back pain
& Sports
Herniated disk charac by acute pain that radiates to thighs & typically below the knee. Straight leg raising
test positive
Vertebral compression fracture (VCF):complication of advanced osteoporosis.Pts w/ osteoporosis can
develop compression fracture w/ acute back pain following minimal trauma(lifting).Examination shows point
tenderness.Neuro exam usually normal
4083 Medicine
& Sports Herniated disk:radicular pain radiating along thigh to below the knee(sciatica).Positive straight leg raise test
Lumbosacral strain:seen after specific event.Increased pain w/ movement,decreased pain w/ rest.Pain in

paraspinal area
*Osteoarthritis* involves the DIP joints. Radiographic features include joint space narrowing, subchondral
sclerosis, osteophytes, & subchondral cysts. (*Google image xray*)
Rheumatroid arthritis spares the DIP joints & involves MCP & PIP joints. (Google image xray)
4110 Medicine
& Sports
Hemochromatosis ass. arthropathy: Radiographic findings- squared off bone ends & hook like osteophytes
in 2nd & 3rd MCP joints
Reactive arthritis: follows an infectious illness, asymmetric oligoarthritis

Pts w/ suspected malignancy can develop paraneoplastic syn due to tumor producing hormones/cytokines.
Paraneoplastic syn are not directly related to cancer's invasion. Paraneoplastic syn affecting peripheral
4123 Medicine nerve or muscle(myasthenia gravis,Lambert-Eaton synd,dermatomyositis) commonly presents w/ muscle
& Sports
weakness. Dermatomyositis pts have symmetrical proximal muscle weakness & erythematous rash on
dorsum of fingers(Gottron's sign) &/or upper eyelids(heliotrope eruption)
Carpal tunnel syndrome(CTS):Pain & parestheias in the first 3 digits & the radial half of the fourth. *Nerve
Rheumatology/Orthopedics conduction studies* confirm the dx
4173 Medicine
& Sports
CTS risk factors:female sex, obesity, hypothyroidism
Ashhadscknotes
Cervical spondylosis: affects 10% of people older than 50 years of age. Hx of chronic neck pain is typical.
Rheumatology/Orthopedics Limited neck rotation & lateral bending due to osteoarthritis & secondary muscle spasm. Sensory deficit due
4205 Medicine
& Sports to osteophyte-induced radiculopathy. Radiographic findings-*bony spurs* & sclerotic facet joints. Other
findings include narrowing of disk spaces & hypertrophic vertebral bodies
Rheumatology/Orthopedics When lifting a heavy object, one should also bend the knees, keeping the back straight; this technique is
4264 Medicine
& Sports useful in preventing strains & back injuries
Methotrexate can cause a macrocytic anemia(Hb < 12 g/dl & MCV > 100)
Rheumatology/Orthopedics Common adverse effects of Hydroxychloroquine are GI distress, visual disturbances, & hemolysis in G6PD
4295 Medicine
& Sports deficiency
Azathioprine is ass. w/ pancreatitis, liver toxicity & dose dependent bone marrow suppression
4328 Medicine systemic sclerosis causes decreased LES pressure
& Sports
In pts with signs of back pain of serious etiology, initial workup should be plain x-ray films of the back(to look
for lytic lesions and compression fractures) along with ESR. If x-rays or ESR are abnormal, MRI of back
should be done to evaluate for possible disc disease, cancer, and spinal infections
4368 Medicine
& Sports
For simple/acute low back pain, NSAIDs more effective than acetaminophen
For chronic low back pain, physical therapy is effective

*Lumbar spinal stenosis*:common cause of back pain in pts age >60. Charc by back pain radiating to thighs
that's worse w/ lumbar extension & persists while standing still.Its an example of a neurogenic claudication.
4369 Medicine [Neurogenic claudication is relieved by walking while leading forward & exercise w/ the spine
& Sports
flexed(cycling,walking uphill,leaning on cane) doesn't incite sx. Vascular claudication on the other hand is
exertion-dependent & resolves w/ standing still]
Low back pain due to inflamatory causes include Ankylosing spondylitis, reactive arthritis, psoriatic arthritis,
4370 Medicine & inflammatory bowel disease. Features include gradual onset of pain, onset at age <40, pain at night that
& Sports
doesn't improve w/ rest, & pain that improves w/ activity or exercise
The most common causes of nontraumatic vertebral compression fractures are osteoporosis(*loss of bone
mineral density*) & osteomalacia
Rheumatology/Orthopedics [acute back pain & point tenderness after strenuous activity suggests a vertebral compression fracture]
4375 Medicine
& Sports
Ligamentous back sprain:pain increases w/ movement & decreases w/ rest. Pain is typically in the
paraspinal area w/o significant tenderness to palpation of the vertebra
Rheumatology/Orthopedics Gout is a common complication of *myeloproliferative disorders(eg,polycythemia vera)* due to excessive
4449 Medicine
& Sports turnover of purines & the resulting increase in uric acid production
4460 Medicine Aortic aneurysm is a complication of giant cell or temporal arteritis
& Sports
Degenerative joint disease(osteoarthritis) presents in adults over age 40 w/ indolent progressive anterior hip
pain worsened by activity & relieved by rest. The hip is not tender & systemic sx are absent. Short-lived
Rheumatology/Orthopedics morning stiffness may occur
4564 Medicine
& Sports
Cutaneous nerve compression may cause hip pain in meralgia paresthetica, a condition where compression
of lateral femoral cutaneous nerve causes lateral hip paresthesia unaffected by motion or palpation
Chronic corticosteroid use & chronic excessive ingestion of alcohol account for over 90% of cases of
avascular necrosis of bone(osteonecrosis).In the hip,pts present w/ slowly progressive anterior hip pain w/
limitation of range of motion
4565 Medicine
& Sports
Trochanteric bursitis:inflammation of trochanteric bursa.Due to friction between tendons of gluteus medius &
tensor fascia lata over greater trochanter of femur.Pain localized over lateral hip & worsened by
palpation(interferes w/ sleep)
Septic arthritis is charac by acute monoarthritis, often w/ fever & restricted range of motion. It's more
Rheumatology/Orthopedics common in pts w/ underlying joint disease such as rheumatoid arthritis. Tx-IV *antibiotics* & joint drainage
4571 Medicine
& Sports
Repeated glucocorticoid injections are an imp risk factor for septic arthritis
Rheumatoid arthritis pts at increased risk of developing osteopenia,osteoporosis & bone fractures esp if risk
factors for osteoporosis(low body weight,female sex,family hx of osteoporosis,cigarette
smoking,postmenopausal state,excessive alcohol use) are present
4572 Medicine
& Sports
Osteitis fibrosa cystica(Von Recklinghausen disease of bone):bony pain,osteoclastic resorption of
bone,replacement w/ fibrous tissue(brown tumors),seen in pts w/ parathyroid carcinoma & 1*/2*/3*
hyperparathyroidism
Methotrexate (MTX) is the DMARD of choice in tx pts w/ rheumatoid arthritis(RA). MTX side effects include
GI sx, *oral ulcers* or stomatitis, rash, alopecia, hepatotoxicity(rise in serum transaminases), pulmonary
Rheumatology/Orthopedics toxicity, & bone marrow suppression. Folic acid supplementation shown to reduce adverse effects of MTX tx
4573 Medicine
& Sports w/o loss of efficacy
Felty syndrome: Pts w/ RA >10 years. Both neutropenia AND splenomegaly seen!
Ashhadscknotes
Rheumatoid arthritis:
Improves w/ activity
Affects the cervical spine joints -> eventually get spinal cord compression
Rheumatoid nodules present (esp on elbows)
"reduced grip strength is a sign of early disease"
4574 Medicine
& Sports
Thoracic spine: has great stability, rarely affected by arthritis, disc herniation, or spinal disorders
Lumbar spine: common site of disc herniation and spinal stenosis
Sacroiliac joints: affected in seronegative spondyloarthropathies

Enthesitis: inflammation & pain at site of tendon & ligament attachment to bone,common finding in
4576 Medicine ankylosing spondylitis(AS).Typical sites include heels,tibial tuberosities & iliac crests.Shoulder & hip
& Sports
pain,stiffness,low back pain,& *limited spinal mobility* are common manifestations of AS
Reactive arthritis:seronegative spondyloarthropathy resulting from enteric or genitourinary
infection.Findings-urethritis,conjunctivitis,mucocutaneous lesions(mouth ulcers),enthesitis(Achilles tendon
pain) & asymmetric oligoarthritis(arthritis often involves knee & sacroiliac spine[back pain]).Not all
Rheumatology/Orthopedics extra-articular manifestations need to be present to suspect dx.*NSAIDs* are 1st line therapy
4577 Medicine
& Sports
Colchicine tx acute gout
Allopurinol for management of chronic hyperuricemia

Pts w/ long-standing ankylosing spondylitis can develop bone loss due to increased osteoclast activity in the
setting of chronic inflammation. In addition, spinal rigidity in these pts can increase the risk of vertebral
4578 Medicine fracture, which often results from minimal trauma
& Sports
A murmur suggesting aortic regurgitation is a common finding in chronic ankylosing spondylitis
Viral arthritis can present w/ symmetric small joint inflammatory arthritis. It tends to resolve within 2 months.
4579 Medicine Positive inflammatory markers such as ANA and rheumatoid factor may occur.
& Sports
Tx- NSAIDs for resolution of sx
Polymyalgia rheumatica: occurs in pts age >50. Pain/stiffness of shoulders/pelvic girdle. No significant
muscle tenderness. ESR elevated. Ass w/ temporal arteritis
Rheumatology/Orthopedics Giant cell (temporal) arteritis: ass w/ polymyalgia rheumatica.Systemic sx, headache,jaw claudication,visual
4580 Medicine
& Sports disturbances,elevated ESR
Polyarteritis nodosa presents w/ systemic sx, skin findings(livedo reticularis,purpura),kidney disease,ab pain,
muscle aches or weakness. ESR elevated
Psoriatic arthritis: involves DIP joints, morning stiffness, dactylitis ("sausage digit," diffusely swollen finger),
nails show pitting & onycholysis (separation of nail bed), well demarcated red plaques w/ silvery scaling seen
Rheumatology/Orthopedics on dorsum of each hand. tx- NSAIDs, methotrexate, & Anti-TNF agents (google pic)
4581 Medicine
& Sports
Dermatomyositis: presents w/ Gottron's papules (violaceous plaques, slightly scaly) over MCP joints. Not
ass. w/ dactylitis or nail changes(onycholysis or nail pitting)
Pseudogout: radiographic evidence of chondrocalcionsis (calcified articular cartilage)
Rheumatology/Orthopedics Tophi: collections of urate crystals which form firm, yellowish nodules at the sites of involved joints in pts w/
4582 Medicine
& Sports chronic gout
Heberden nodes occur in the DIP joints in osteoarthritis & form from calcified cartilaginous spurs
Baker cysts develop as a result of excessive fluid production by an inflamed synovium, as occurs in cases
of rheumatoid arthritis, osteoarthritis & cartilage tears. The excess fluid accumulates in the popliteal bursa
Rheumatology/Orthopedics which expands, creating a tender mass in the popliteal fossa. Baker cysts occasionally burst & release their
4583 Medicine
& Sports contents into the calf, resulting in an appearance similar to a DVT
Crystal deposition in the knee joint may lead to a painful, red & swollen knee
Secondary amyloidosis (AA):nephrotic syndrome(bilateral lower extremity edema,proteinuria),palpable
kidneys,hepatomegaly,& ventricular hypertrophy(audible fourth heart sound) in setting of chronic
inflammatory disease(recurrent pulmonary infections,bronchiectasis). Tx-Colchicine for both tx & prophylaxis
4585 Medicine of AA
& Sports
Hypertensive nephrosclerosis:seen in pts w/ chronic htn,ass w/ retinopathy,left ventricular
hypertrophy,progressive renal failure,mild proteinuria,small kidneys
Six criteria used to establish the dx of osteoarthritis (OA) in the setting of a painful knee: age >50, crepitus,
4586 Medicine bony enlargement, bony tenderness, & lack of warmth/morning stiffness. If three or more criteria are met,
& Sports
specificity for OA is 69%
Disseminated *gonococcal* infection often presents w/ a triad of polyarthralgias(wrist,elbow,& ankle pain),
4590 Medicine tenosynovitis(pain along tendon sheaths), & vesiculopustular skin lesions. Hx of recent unprotected sex w/ a
& Sports
new partner ass w/ disseminated gonococcal infection
Rheumatology/Orthopedics Paget disease of bone: *increased bone remodeling* & abnormal osteoid formation. Headaches, deafness,
4627 Medicine
& Sports neuropathy, bone/back pain. Elevated alkaline phosphatase. Tx-bisphosphonates
Ashhadscknotes
Carpal tunnel syndrome can occur in pregnancy. Initial tx involve neutral position *wrist splinting* and
NSAIDs. Local corticosteroid injection is used when wrist splinting doesn't relieve sx. Surgical
Rheumatology/Orthopedics decompression of the carpal tunnel is performed when conservative management fails.
4636 Medicine
& Sports
NSAID use during pregnancy is ass. w/ an increased risk of miscarriage & may promote premature closure
of the fetal ductus arteriosus
Paget's disease: *osteoclast dysfunction*, femoral bowing, hearing loss
4659 Medicine
& Sports Overproduction of calcitrol(active form of Vit D) is seen in granulomatous diseases such as sarcoidosis &
tuberculosis. Hypercalciuria & hypercalcemia may occur
Neurogenic arthropathy (charcot joint) is a complication of neuropathy & repeated joint trauma. It affects
weight-bearing joints & manifests w/ functional limitation, deformity, & degenerative joint disease & loose
Rheumatology/Orthopedics bodies on joint imaging
4743 Medicine
& Sports
Gout: from uric acid deposition within joints. X-rays of joints reveal punched out erosions w/ an overhanging
rim of cortical bone known as a "rat bite" lesion
Morton neuroma: Mechanically induced degenerative neuropathy.Common in runners. Numbness or pain
between the 3rd & 4th toes. Clicking sensation when palpating space between 3rd & 4th toes while
Rheumatology/Orthopedics squeezing the metatarsal joints. Tx-conservative, w/ metatarsal support or padded shoe inserts
4933 Medicine
& Sports
Tarsal tunnel syndrome: compression of tibial nerve as it passes thru ankle. Burning,numbness & aching of
the distal plantar surfaces of the foot/toes
Fluoroquinolone use is ass w/ tendinopathy & tendon rupture (Achilles most common)
8866 Medicine Osteonecrosis(aka aseptic,avascular,atraumatic or ischemic necrosis) typically presents w/ gradual onset of
& Sports
pain in weight bearing joints(hip most common). Risk factors include corticosteroid use, excessive alcohol
intake, SLE, sickle cell disease
Patellofemoral syndrome:In young female athletes.Pain that increases w/ squatting,running,prolonged
sitting,using stairs.Patellofemoral compression test(pain elicited by extending knee while compressing the
patella)
8886 Medicine
& Sports Patellar tendonitis:In athletes("jumper's knee").Episodic pain/tenderness at inferior patella
Osgood-Schlatter disease:In preadolescent/adolescent athletes,recent growth spurt.Increase in pain w/

sports,relieved by rest.Tenderness/swelling at tibial tubercle
ACL injuries present w/ rapid onset of pain & swelling w/ hemarthrosis
MCL tears: tenderness at medial knee,laxity when foot is forced into abduction w/ the knee stationary.No
8895 Medicine hemarthrosis unless there is concurrent ACL injury
& Sports
Rupture of popliteal cyst(Baker cyst): posterior knee pain, common in older adults, ass. w/ osteoarthritis of
knee, swelling at posterior knee & calf. Knee effusions & hemarthrosis are usually not present.
Acute gout:acute monoarthritis, usually in the first metatarsophalangeal joint or knee. Synovial fluid analysis
shows leukocytosis & *monosodium urate crystals*, which are needle-shaped(google pic) & negatively
birefringent
8933 Medicine
& Sports Google what Calcium pyrophosphate crystals look like! They are rhomboid shaped
Sarcoid arthritis:charac by noncaseating granulomas involving synovial membrane.Presents w/ gradual

onset symmetrical oligoarticular arthritis,commonly in the ankles
Rheumatology/Orthopedics Primary Raynaud phenomenon: Tx involves mainly calcium channel blockers (eg, nifedipine, amlodipine) &
9906 Medicine
& Sports avoiding aggravating factors
Rheumatology/Orthopedics Pts w/ suspected secondary Raynaud phenomenon should be tested for autoantibodies(eg,*antinuclear
9939 Medicine
& Sports antibodies*) & inflammatory markers
Pyoderma gangrenosum causes a rapidly progressive & painful ulcer w/ a purulent base & violaceous
borders. More than 50% of pts have associated systemic disease (eg, inflammatory bowel disease). Dx w/
skin biopsy. Tx w/ corticosteroids.
10434 Medicine
& Sports
Ecthyma gangrenosum (EG): hemorrhagic pustules w/ surrounding erythema that evolve into necrotic
ulcers. Often due to Pseudomonas aeruginosa & occurs in the setting of profound neutropenia & P
aeruginosa bacteremia
Adhesive capsulitis(frozen shoulder): More stiffness than pain. Decreased passive & active range of
motion(ROM)
Glenohumeral osteoarthritis: sx gradual in onset, hx of past trauma to shoulder

11254 Medicine
& Sports Rotator cuff tears:fall on outstretched arm,pain on lifting or abduction,defect in active ROM,passive ROM is
preserved,age >40,weakness w/ external rotation
Rotator cuff tendinopathy:pain w/ abduction,external rotation,normal ROM w/ positive impingement

tests,subacromial tenderness
Ashhadscknotes
Autoimmune sialadenitis in Sjogren syndrome causes enlargement of the parotid & submandibular glands.
Involvement of salivary & other exocrine glands (eg, lacrimal glands) can produce sicca syndrome,
characterized by generalized dryness of mucous membranes, leading to dry mouth, irritated/itchy eyes,
11915 Medicine cough, & *dyspareunia*
& Sports
Pts w/ atopic diathesis present w/ seasonal allergies characterized by nasal congestion, rhinorrhea, & often
allergic conjunctivitis
Felty syndrome: triad of inflammatory arthritis,splenomegaly,& neutropenia. It's most common in pts w/
Rheumatology/Orthopedics established rheumatoid arthritis(RA) but can sometimes precede this dx. Pts have severe, seropositive RA
11980 Medicine
& Sports w/ increased risk for extra-articular manifestations(vasculitis,skin ulcers). Usually improves w/ tx of the
underlying RA(eg,methotrexate)
*Antinuclear antibody* is a very sensitive but nonspecific marker for systemic lupus erythematosis. If
antinuclear antibody is elevated, more specific autoantibodies (eg, anti-double-stranded DNA) can confirm
Rheumatology/Orthopedics the diagnosis. Complement levels & erythrocyte sedimentation rate or C-reactive protein can assess
11988 Medicine
& Sports ongoing disease activity
Anti-cyclic citrullinated antibodies are a specific marker for rheumatoid arthritis

Takayasu arteritis:large artery vasculitis,most common in young Asian women.Initial
sx-fever,'arthralgias','weight loss'.Later features-arterio occlusive sx('exertional arm
pain[claudication]',ulcers) in upper extremities,'BP discrepancies',pulse deficits.Also get arterial
12057 Medicine bruits,elevated inflam markers(ESR,CRP).CT/MRI can reveal aneurysm formation or lumenal
& Sports
narrowing.Tx-systemic glucocorticoids
Aortic coarctation cause pulse deficits & BP discrepancies in lower extremities

Mngmt of chronic back pain(>12 wks) should include an *exercise program* emphasizing stretching &
strengthening of the back muscles & aerobic conditioning.Acetaminophen or NSAIDs can be used
intermittently.Some pts may benefit from tricyclic antidepressants or duloxetine.[Opioids, benzodiazepines,
12059 Medicine & muscle relaxants ARE NOT advised!]
& Sports
Pts w/ acute low back pain(<4 wks) should be advised to maintain moderate activity w/ short courses of
acetaminophen or NSAIDs for pain relief
Hinged knee orthotic braces are primarily used for the prevention & tx of ligamentous injuries
Rheumatology/Orthopedics Rigid knee immobilizers are used acutely for patellar fractures or tears of the quadriceps or patellar tendon
12060 Medicine
& Sports
Surgery is rarely needed in patellofemoral pain syndrome & generally only rec when pts have failed 6-12 mo
of conservative management
Doc can respond to an employer's request for health info only if pt has provided verbal or written
authorization for release of info to the employer.[A written (rather than verbal) release of info document is
Social Sciences
3614 Medicine preferred to protect pt & physician from any misunderstanding,but this is not a HIPAA requirement].Doc
(Ethics/Legal/Professional)
should disclose only minimum amount of protected health info needed to respond to specific request(no
need to disclose pts dx to employer)"minimum necessary" disclosure
Meningococcal meningitis is a highly contagious disease that can lead to devastating complications &
Social Sciences outbreaks in the community. Tx involves isolation, IV abx, & supportive care in an intensive care setting to
3625 Medicine
(Ethics/Legal/Professional) monitor disease progression. A pt who doesn't comply voluntarily needs to be hospitalized against his/her
wishes. It's ethical for the doc to isolate a noncompliant pt until the pt no longer poses a risk
Social Sciences
4653 Medicine Brain death is a legally acceptable definition of death, and artificial life support does not need to be continued
Social Sciences
8942 Medicine Hospice requirement: Pts w/ prognosis of <6 months
Social Sciences Communication failures between physicians during pt handoffs are a large contributor to medical errors &
10660 Medicine
(Ethics/Legal/Professional) adverse pt outcomes
Medical errors resulting from communication failures between medical providers are most effectively
Social Sciences
10661 Medicine addressed by implementing a systematic signout process that includes *checklists* to improve efficacy &
accuracy
Accepting gifts from interested third parties can influence a physician's practice in subtle or subconcious
ways. Only nonmonetary gifts that are of minimal value & that directly benefit the pt, such as unbiased
Social Sciences
11911 Medicine educational material or drug samples, should be considered.
[A flash drive(example used in question), although not of high monetary value, doesn't directly benefit pt
care & shouldn't be accepted]
Obstetrics Congenital rubella syndrome: cataracts, patent ductus arteriosus, sensorineural hearing loss, intrauterine
4734 & Allergy & Immunology growth retardation, & purpura.
Gynecology Best way to protect infant is by maternal vaccination prior to conception
Obstetrics
Biostatistics & Hemophilia A is an X-linked recessive disorder. Carrier mothers & unaffected fathers- 25% of their children
10505 &
Epidemiology would be expected to have hemophilia A, 25% would be silent carriers, & 50% would be unaffected
Gynecology
Obstetrics 1st line agents for managment of essential htn during pregnancy are *labetalol* & methyldopa. Calcium
2400 & Cardiovascular System channel blockers & hydralazine are acceptable alternate therapies.(ACE inhibitors & ARBs are
Gynecology contraindicated in pregnancy!)
Ashhadscknotes
Obstetrics
3914 & Cardiovascular System An oral contraceptive can cause hypertension, & discontinuing its use can correct the problem in most pts
Gynecology
Mitral stenosis:
sx- worsening dyspnea, orthopnea, hemoptysis
Obstetrics causes left atrial enlargement
4715 & Cardiovascular System 70% of pts develop atrial fibrillation
Gynecology rheumatic heart disease is leading cause of mitral stenosis
physical exam reveals diastolic rumble at apex and/or opening snap
occurs in countries with limited access to antibiotics e.g. eastern europe
*Infants born to women w/ Graves' disease* at risk for thyrotoxicosis due to passage of maternal *TSH
receptor antibodies* across placenta(antibodies bind to infant's TSH receptors & cause excessive thyroid
Obstetrics
Endocrine, Diabetes & hormone release). Affected infants are irritable,tachycardic,& gain weight poorly.Methimazole + B blocker
2423 &
Metabolism are given to symptomatic pts until the condition self-resolves over few weeks to months
Gynecology
TSH levels surge in newborns after delivery->rise in T3 & T4 (physiologic)
Adrenocortical cancers are rare,aggressive tumors.Androgen producing adrenal tumors
(androblastoma,arrhenoblastoma,stromal & hilus cell tumor) typically present in adulthood w/ rapidly
Obstetrics progressive hirsutism & sometimes virilization.Serum DHEA-S,an adrenal androgen,is markedly elevated w/
2425 & concentrations >700 ug/dL
Metabolism
Gynecology
Ovarian germ cell tumors:present w ab enlargement,precocious puberty,abnormal vaginal
bleeding,pregnancy sx due to increased B-hCG.Dont usually cause hirsutism
Obstetrics Pregnant women have increased thyroid hormone production(increased total T4 & T3) as well as increased
4124 & thyroxine binding globulin, w/ a net result of slightly elevated free T4 & T3, & decreased TSH compared to
Metabolism
Gynecology non-pregnant women
The major source of estrogen in menopausal women is from peripheral conversion of adrenal androgens by
the aromatase enzyme present in adipose tissue/peripheral fat. This process is increased in obese women
Obstetrics
Endocrine, Diabetes & & may result in milder menopausal sx
4149 &
Metabolism
Gynecology
Increased levels of FSH are a response to the decrease in estrogen levels (via feedback to the pituitary
gland)
Secondary amenorrhea: absence of menses for >3 cycles or >6 months in women who menstruated
previously. Initial evaluation includes B-hCG to exclude pregnancy. Next order serum prolactin, TSH, & FSH
Obstetrics
Endocrine, Diabetes & to differentiate between the mcc of secondary amenorrhea (hyperprolactinemia, thyroid dysfunction,
4220 &
Metabolism premature ovarian failure)
Gynecology
Pts w/ hx of uterine procedures or infection may have scarring of the uterine cavity (Asherman syndrome)
Sheehan syndrome(postpartum ischemic necrosis of the anterior pituitary) is a potentially life-threatening
complicatoin of massive postpartum hemorrhage. It typically presents w/ lactation failure (prolactin
Obstetrics
Endocrine, Diabetes & deficiency) as well as hypotension & anorexia (secondary adrenal insufficiency)
4678 &
Metabolism
Gynecology
Pituitary apoplexy: spontaneous hemorrhage into pituitary gland,sudden pituitary enlargement can compress
oculomotor nerves & cause acute headache,diplopia,vision loss
*Levothyroxine dose is increased* during pregnancy in the majority of patients w/ hypothyroidism
Obstetrics
8888 &
Metabolism It is essential to adequately treat hypothyroidism during pregnancy. Studies have shown that children of pts
Gynecology
w/ inadequately treated hypothyroidism have a lower IQ
Obstetrics
Female Reproductive Diagnostic peritoneal lavage: invasive procedure to evaluate for intraabdominal bleeding. Performed on pts
2330 &
System & Breast w/ trauma.
Gynecology
Lactational mastitis: breast feeding women are at risk for it if there are missed nursing sessions leading to
Obstetrics
Female Reproductive inadequate milk drainage. Tx- analgesics, frequent breastfeeding(every 2-3 hours) w/ both breasts, &
2344 &
System & Breast antibiotics directed at S.aureus(dicloxacillin or cephalexin for MSSA & clindamycin,TMP-SMX, vancomycin
Gynecology
for MRSA)
Palpable breast mass in pt < 30 years of age -> evaluate w/ ultrasound
Palpable breast mass in pt > 30 years of age -> evaluate w/ mammogram & ultrasound
Obstetrics
Female Reproductive
2345 &
System & Breast Bottom line, palpable breast masses should have an imaging evaluation done even if the findings are benign
Gynecology
on physical exam(physical exam alone is not sufficient for excluding the possibility of malignancy). Don't
provide reassurance without doing imaging.
[Family hx of breast cancer in first degree relative is concerning]
Obstetrics Fat necrosis shows clinical & radiographic findings similar to those seen in breast cancer, including skin or
Female Reproductive
2362 & nipple retraction & calcifications on mammography. Biopsy of the mass will reveal fat globules & foamy
System & Breast
Gynecology histiocytes in fat necrosis. No tx is indicated for this self-limited condition
*Endometrial biopsy* is indicated for evaluating abnormal uterine bleeding in:
-Women >45 & all postmenopausal women
Obstetrics
Female Reproductive -Women age <45 w/ persistent sx or risk factors for endometrial cancer(obesity,diabetes,unopposed
2391 &
System & Breast estrogen exposure,PCOS,early menarche/late menopause)
Gynecology
-Unopposed estrogen exposure(eg,obesity,PCOS)
-Prolonged amenorrhea w/ anovulation
Ashhadscknotes
Obstetrics
Female Reproductive Combination estrogen/progestin oral contraceptive pills (OCPs) contain a low dose of estrogen. *A potential
2392 &
System & Breast side effect is an increase in blood pressure.*
Gynecology
Copper UID:most effective postcoital contraceptive.Can insert within 5 days after sex. Age & parity are not
contraindications. Only contraindications are acute cervicitis & PID
Obstetrics
Female Reproductive Depot medroxyprogesterone acetate & etonogestrel subdermal implant:precoital contraceptive.Inhibit GnRH
2393 &
System & Breast secretion->inhbit follicular development dependent on FSH/LH
Gynecology
Levonorgestrel & ulipristal:pills for emergency contraception only. Most effective before ovulation.Less
effective than copper IUD
Primary dysmenorrhea: crampy lower abdomen &/back pain DURING menses, absence of dyspareunia or
GI sx, & normal physical examination. Tx-NSAIDs & hormonal contraception for pain relief
Obstetrics
Female Reproductive Endometriosis:pain peaks before menses,dyspareunia,infertility
2394 &
System & Breast
Gynecology
Adenomyosis:menorrhagia,bulky globular & tender uterus,dysmenorrhea,pelvic pain
Pelvic congestion:dull & ill-defined pelvic ache that worsens w/ standing,dyspareunia

Stress incontinence:loss of urine w/ increased intra-abdominal
pressure(laughing,coughing,sneezing).Urethral hypermobility(demonstrates angle >30 degrees upon
increase in intra-abdominal pressure).Tx-Kegel exercises & restoration of urethrovesical angle by
Obstetrics *urethropexy*
Female Reproductive
2398 &
System & Breast
Gynecology Urge incontinence:sudden urge to urinate that can occur at any time(not just w/ increases in intra-abdominal
pressure),due to detrusor hyperactivity.Tx-Oxybutynin
Overflow incont. tx:bethanechol & a-blockers

Raloxifine: Antagonist in breast & vaginal tissue. Agonist in bone tissue(increases bone mineral density). 1st
Obstetrics line agent for prevention of osteoporosis. Decreases breast cancer risk. *Increased risk of venous
Female Reproductive
2408 & thromboembolism* so it's *contraindicated in pts w/ a hx of DVT*
System & Breast
Gynecology
Unlike tamoxifen, raloxifine doesn't increase the risk for endometrial cancer
Tamoxiden:
*Antagonist of estrogen receptors in the breast(prevention of breast cancer)
Obstetrics *Partial-agonist of estrogen on the endometrium & increases risk for endometrial carcinoma
Female Reproductive
2410 & *Agonist of estrogen receptor on osteoclasts,thus decreasing risk of osteoporosis
System & Breast
Gynecology Tamoxifen tx shows an overall mortality benefit, which outweighs the increased risk of endometrial cancer
Ischemic optic neuropathy ass. w/ use of phosphodiesterase inhibitors like sildenafil(Viagra) & vardenafil
Pt w/ abnormal uterine bleeding:
Obstetrics First do endometrial biopsy
Female Reproductive
2418 & 1) If hyperplasia w/o atypia, do Progestin therapy.
System & Breast
Gynecology 2) If hyperplasia with atypia,no plans for pregnancy, or fails medical management, perform Hysterectomy.
3) If hyperplasia with atypia but considering future pregnancy, do Progestin therapy
Premenstrual syndrome (PMS): bloating, fatigue, headaches, & breast tenderness, anxiety, mood swings,
difficulty concentrating, decreased libido, & irritability. Sx begin 1-2 weeks prior to menses and regress
Obstetrics around the time of menstural flow.
Female Reproductive
2419 & In order to confirm diagnosis, recommend pt keep a *menstrual diary* for 2-3 months and note associated
System & Breast
Gynecology sx.
Premenstrual dysphoric disorder (PMDD) is a severe variant of PMS, w/ prominent irritablitiy & anger
Tx for PMS/PMDD- SSRI's
Vaginismus: caused by involuntary contraction of the perineal musculature. Underlying cause is
psychological(fear of vaginal penetration). Tx-*relaxation, Kegel exercises(to relax vaginal muscles), &
insertion of dilators, fingers, etc. to bring about desensitization*
Obstetrics
Female Reproductive
2420 & Tx for anorgasmia: self stimulation techniques
System & Breast
Gynecology
Tx for postmenopausal women w/ vaginal dryness: lubricants
Tx for hypoactive sexual desire: referral to a sex therapist

Obstetrics Endometriosis is a common cause of infertility and chronic pelvic pain. Commonly affects women w/
Female Reproductive
2546 & nulliparity or early menarche. A cystic ovarian mass (endometrioma) can be seen on pelvic ultrasound
System & Breast
Gynecology dx- laparoscopy, which shows "chocolate" appearing material representing old blood
Estrogenic effects of tamoxifen increase the risk of endometrial cancer, which arises in the lining of the
Obstetrics
Female Reproductive uterus and uterine sarcoma, which arises in the muscular wall of the uterus. Also increases risk of venous
2606 &
System & Breast thrombosis. Women taking tamoxifen but have had a hysterectomy are not at increased risk for these
Gynecology
cancers.
Paget's disease of breast:
Obstetrics
Female Reproductive suspect in pt w/ no prior hx of skin disease who presents w/ an eczematous rash near nipple that doesn't
2607 &
System & Breast improve w/ topical treatments.
Gynecology
pts w/ pagets disease have an underlying breast adenocarcinoma
Ashhadscknotes
Obstetrics TRASTUZUMAB aka Herceptin is used to tx breast cancer that is HER2 positive. *Echocardiogram* rec
Female Reproductive
2608 & before tx as there is a risk of developing CARDIOTOXICITY, esp in pts w/ baseline low ejection
System & Breast
Gynecology fractions(less than 55%)
Fibrocystic disease: rubbery, firm, mobile & painful mass in a young pt, more tenderness during menses,
aspiration of cyst yields clear fluid & results in disappearance of the mass. Observe pts afterwards for 4 to 6
weeks
Obstetrics
Female Reproductive
2611 &
System & Breast Mammograms in women < 35 years of age isn't useful since the dense breast tissue at this age doesn't
Gynecology
allow adequate visualization of any masses if present
We do cytology if aspirated fluid(from cyst in breast) is bloody or foul smelling

Obstetrics
Female Reproductive Overexpression of the oncogene HER2 can be detected either by immunohistochemial staining or FISH.
2612 &
System & Breast Positivity predicts a positive response to trastuzumab & anthracycline chemotherapy.
Gynecology
Obstetrics Despite the fact that serum antigen CA125 & pelvic ultrasound can help to dx ovarian cancer in pts w/ sx or
Female Reproductive
2613 & as a screening tool in pts w/ an increased risk secondary to hereditary factors(BRCA gene), *SCREENING
System & Breast
Gynecology IS CURRENTLY NOT REC FOR PTS AT AVERAGE RISK OF OVARIAN CANCER*
Adenomyosis: common in multiparous women age >40. Ass. w/ early menarche, short menstrual cycles,
Obstetrics prior uterine surgery, & preterm birth. Symmetrically enlarged uterus may feel boggy, globular, & soft. Sx of
Female Reproductive
3120 & dysmenorrhea, menorrhagia, & sometimes mid-cycle bleeding. Eventually, untreated pts have chronic pelvic
System & Breast
Gynecology pain. Dx made w/ surgical pathology after hysterectomy.[Sx of mass effect, such as constipation & urinary
frequency are not features of adenomyosis]
First trimester ultrasound w/ crown rump length measurement is the most accurate method of determining
gestational age.
It becomes less accurate as the pregnancy progresses.
Obstetrics
Female Reproductive
3278 & After first trimester, fetal abdominal circumference, biparietal diameter, femur length, & head circumference
System & Breast
Gynecology are used to estimate gestational age
After 20 wks gestation, fundal height can be used to determine gestational age(however it's confounded by
leiomyomata and obesity)
Obstetrics There is no role for meds in the suppression of breast milk production. Pts are advised to wear a tight-fitting
Female Reproductive
3338 & bra, avoid nipple manipulation & use ice packs & analgesics to relieve ass. pain
System & Breast
Gynecology [Emptying of the breasts will only maintain milk production & thus, make the condition worse]
Obstetrics
Female Reproductive Progestin only oral contraceptives:
3339 &
System & Breast preferred form of hormonal contraception for lactating mothers
Gynecology
Amenorrhea occurs in lactating mothers due to high levels of circulating prolactin, which has an inhibitory
effect on GnRH(GnRH production from hypothalamus is necessary for production of LH & FSH by anterior
Obstetrics pituitary. LH & FSH induce ovulation. Menses can't occur when ovulation is suppressed in this manner)
Female Reproductive
3340 &
System & Breast
Gynecology Oxytocin imp for uterine involution in postpartum period
hPL->maternal lipolysis & insulin resistance->increased delivery of fatty acids/glucose to fetus

Important side effects of oral contraceptive pills include breakthrough bleeding, htn, & increased risk of
Obstetrics venous thromboembolism. Weight gain is usually not an ass. adverse effect
Female Reproductive
3359 &
System & Breast
Gynecology Cervical cancer screening should only begin at age 21, regardless of when pt started sexual activity. The
only exceptions are women w/ HIV or SLE or organ transplant pts receiving immunosuppression
Obstetrics
Female Reproductive A *hysterosalpingogram* is used to dx an anatomic cause of infertility such as tubal obstruction from prior
3365 &
System & Breast pelvic infection
Gynecology
Because the ovaries are functional in pts w/ PCOS, ovulation can be induced by tx w/ *clomiphene citrate*
(CC). CC is an estrogen analog that improves GnRH release & FSH release thereby improving the chances
Obstetrics of ovulation. PCOS pts are also tx w/ metformin, which has been independently shown to improve ovulation
Female Reproductive
3367 &
System & Breast
Gynecology Luteal phase defect: give progesterone supplementation
In vitro fertilization may be appropriate after other less costly avenues for fertility tx have been exhausted
Infertility in premature ovarian failure:
tx-in vitro fertilization w/ donor oocytes
Some cases of idiopathic premature ovarian failure are of autoimmune origin

Obstetrics
Female Reproductive
3368 &
System & Breast Clomiphene citrate induces ovulation in anovulatory women who have some ovulatory reserve eg PCOS pts.
Gynecology
Metformin also used for PCOS
Progesterone corrects luteal phase defect (failure of corpus luteum to produce progestone to maintain
endometrium & allow implantation of an embryo)
Ashhadscknotes
In the ovulatory phase of the menstrual cycle, cervical mucus is profuse, clear & thin. It will stretch to
Obstetrics approximately 6 cm(spinnbarkeit) & exhibit ferning on a microscope slide smear preparation. pH is 6.5 or
Female Reproductive
3370 & greater(more basic than other phases)
System & Breast
Gynecology
Mucus of the post- & pre-ovulatory phases is scant, opaque, & thick
Midcycle pain (Mittelschmerz): abdominal pain in a young female in the middle of her cycle(2 weeks after
LMP). Benign hx & clinical exam
Obstetrics
Female Reproductive Ovarian torsion: Medical emergency. Sudden onset lower quadrant abdominal pain that radiates to the groin
3480 &
System & Breast or back. Accompanied by nausea & vomiting. Adnexal mass present.
Gynecology
Ovarian hyperstimulation syndrome:complication of ovulation inducing drugs. Abdominal pain due to ovarian
enlargement. Accompanied by ascites & respiratory difficulty.
Obstetrics
Female Reproductive The proteinuria in preeclampsia is best evaluated by a *urine protein-to-creatinine ratio* or a *24-hour urine
3509 &
System & Breast collection for total protein (gold standard)*
Gynecology
Obstetrics
Female Reproductive
3656 & Treat Candida vaginitis w/ Fluconazole
System & Breast
Gynecology
*Genital warts*(condyloma acuminata):caused by *HPV*,present as clusters of pink/skin-colored lesions w/
smooth,teardrop appearance on genitalia.Small lesions can be tx in office w/ *trichloroacetic acid* or
podophyllin
Obstetrics
Female Reproductive
3757 &
System & Breast Condyloma lata:caused by secondary syphilis,charac by flat velvety lesions,responds to penicillin
Gynecology
Vulvar lichen planus affects middle-aged women.Lesions may be hyperkeratotic,erosive or papulosquamous
in appearance.Pruritus,soreness,vaginal discharge common
Causes of premature ovarian failure include *chemotherapy*, radiation, autoimmune ovarian failure,
Obstetrics Turner's syndrome, & fragile X syndrome
Female Reproductive
3814 &
System & Breast
Gynecology Sx of premature ovarian failure include amenorrhea, hot flashes, vaginal & breast atrophy, anxiety,
depression, & irritability
Genito-pelvic pain/penetration disorder (vaginismus):female pt expressing pain w/ intercourse/penetration
Gender dysphoria:incongruence between pt's expressed gender & assigned gender for at least 6
Obstetrics
Female Reproductive months.Pts may wish to be treated as the other gender or to be rid of their sexual characteristics
3861 &
System & Breast
Gynecology
Sexual masochism disorder:sexual arousal from being humiliated,beaten,suffering
Testicular feminization:male genotype has female phenotype due to in utero resistance to androgens
Endometriosis(the "3 Ds"): dyspareunia, dysmenorrhea(painful menstruation), & dyschezia(pain w/
Obstetrics
Female Reproductive defecation). For pts w/ pelvic pain w/o complications, tx w/ NSAIDs, *combined oral contraceptives*,
3862 &
System & Breast progestins, or gonadotropin-releasing hormone agonists. For complicated endometriosis(eg, bowel/bladder
Gynecology
obstruction, rupture of endometrioma) & for pts refractory to medical therapy, laparoscopy useful for dx & tx
Obstetrics Transverse vaginal septum: is due to malformation of urogenital sinus & Mullerian ducts. Breast
Female Reproductive
3913 & development occurs. Normal axillary & pubic hair. Normal uterus and ovaries. Abnormal vagina. Can cause
System & Breast
Gynecology amenorrhea. 46,XX karyotype
*hCG is responsible for the preservation of the corpus luteum in early pregnancy*
Obstetrics
Female Reproductive Progesterone is responsible for preparing the endometrium for implantation of a fertilized ovum. It also
4135 &
System & Breast helps to inhibit uterine contractions
Gynecology
Estrogen is responsible for induction of prolactin production during pregnancy
Obstetrics
Female Reproductive Hyperthyroidism & menopause can have similar presentations, & serum TSH & FSH levels should be
4136 &
System & Breast checked in pts w/ these sx
Gynecology
Obstetrics
Female Reproductive *Prolactin production* is *stimulated by* serotonin & *TRH* & inhibited by dopamine. Hypothyroidism may
4221 &
System & Breast result in amenorrhea & galactorrhea
Gynecology
Stress incontinence: hx of loss of small amounts of urine simultaneously occurring w/ activities that increase
intraabdominal pressure(coughing,sneezing,laughing), common in older women, high parity is a risk
Obstetrics
Female Reproductive factor,*pelvic floor weakness*(due to high number of vaginal deliveries).[Uterine prolapse and/or cystocele
4224 &
System & Breast indicate pelvic floor weakness]
Gynecology
Urge incontinence:sudden/frequent loss of moderate to large amounts of urine,nocturia & frequency,urgency
Obstetrics
Female Reproductive
4283 & Secondary amenorrhea is relatively common in elite female athletes & results from estrogen deficiency
System & Breast
Gynecology
Ashhadscknotes
Functional hypothalamic amenorrhea: suppression of HPO axis w/o a known anatomic or metabolic cause.
Obstetrics May occur in women who undergo excessive physical training(w/ or w/o weight loss or caloric restriction).
Female Reproductive
4480 & Factors implicated in suppression of HPO axis are low body fat mass & leptin, & elevated Ghrelin,
System & Breast
Gynecology neuropeptide Y, GABA, beta-endorphine, & corticotropin-releasing hormone. Pts at high risk for *bone loss*
due to low estrogen levels
Aromatase deficiency:hx of normal internal genitalia w/ ambiguous external genitalia,clitoral
hypertrophy,high FSH/LH w/ low estrogen,& multiple ovarian cysts/polycystic ovaries
Obstetrics Congenital adrenal hyperplasia: pseudohermaphroditism in females w/ virilization,salt wasting

Female Reproductive
4496 &
System & Breast
Gynecology McCune-Albright syndrome:cafe au lait spots, polyostotic fibrous dysplasia,endocrine
hyperfunction,precocious puberty
Kallmans syndrome:hypogonadotropic hypogonadism w/ anosmia,delayed puberty,low FSH & LH

Obstetrics Intraductal papilloma:
Female Reproductive
4542 & intermittent bloody discharge from one nipple
System & Breast
Gynecology no masses
Obstetrics Physiologic galactorrhea is usually bilateral & can be milky(most common), yellow, brown, gray, or green.
Female Reproductive
4543 & Hyperprolactinemia is the mcc of physiologic galactorrhea. Galactorrhea should be evaluated w/ *serum
System & Breast
Gynecology prolactin, thyroid-stimulating hormone, & possible brain MRI.*
Obstetrics
Female Reproductive 37 y/o lady w/ regular menstrual cycles is having a difficult time getting pregnant due to age related
4756 &
System & Breast *decreased ovarian reserve*
Gynecology
Pregnant women w/ high-grade squamous intraepithelial lesion on Pap testing should be evaluated w/
Obstetrics
Female Reproductive colposcopy. If initial colposcopy is negative, repeat cytology & colposcopy are recommended after delivery.
4758 &
System & Breast Cervical biopsy & LEEP are not performed during pregnancy unless there is a lesion suggestive of invasive
Gynecology
cancer
Obstetrics An intrauterine pregnancy should be seen w/ transvaginal ultrasonography at B-HCG levels of 1,500-2,000
Female Reproductive
4759 & mlU/mL. If the level is <1,000 mlU/ml, *both B-HCG & transvaginal ultrasonography should be repeated in
System & Breast
Gynecology 2-3 days*
PCOS: *anovulation*, excessive LH (& insufficienct FSH). Excess LH stimulates excess androgen
production by ovarian theca cells resulting in male-pattern hair growth & acne, & ovarian cysts
Obstetrics
Female Reproductive
4768 & Luteal phase defect indicates poor preparation of the endometrium for implantation due to progesterone
System & Breast
Gynecology deficiency. Following ovulation, progesterone is produced in increased amounts by corpus luteum
Abnormal cervical mucus(as in cervicitis) can be a cause of infertility

Most menstrual cycles in the first 1-2 years following menarche are anovulatory(due to immature hpo axis
that fails to produce LH & FSH in the amount needed to induce ovulation). They are irregular & may be
Obstetrics complicated by menorrhagia
Female Reproductive
4769 &
System & Breast
Gynecology Bleeding disorders cause unusually heavy menses(not irregular). Needs blood transfusions
Cervical polyps can cause bleeding following trauma ie during sex

*Laparoscopy* w/ visualization & biopsy of implants is the only definitive way to dx endometriosis. It's
indicated when NSAIDs & hormonal contraceptive tx have failed
Obstetrics
Female Reproductive Endometriosis:pts can be asymptomatic or develop dysmenorrhea, dyspareunia, & chronic pelvic pain that
4773 &
System & Breast worsens before onset of menses
Gynecology
Hysterosalpingogram explores uterine cavity & patency of fallopian tubes[however in endometriosis,
endometrial tissue is outside of the uterus]
Obstetrics
Female Reproductive
4774 & Pts w/ endometriosis at increased risk of impaired fertility or *infertility*
System & Breast
Gynecology
Copious vaginal discharge by itself is not necessarily pathologic. The amount of vaginal discharge can vary
Obstetrics between women.
Female Reproductive
4787 & Copious vaginal discharge that is white or yellow in appearance, nonmalodorous(doesn't have odor), &
System & Breast
Gynecology occurs in the absence of other sx or findings on vaginal exam is referred to as physiologic leukorrhea. It
doesn't require tx, & women w/ this condition should receive reassurance.
Obstetrics Bacterial vaginosis: Thin, gray white vaginal discharge, vaginal pH > 4.5, positive "whiff" test upon addition
Female Reproductive
4788 & of KOH to the vaginal discharge, "clue cells"(vaginal epithelial cells w/ adherent coccobacilli) on wet mount.
System & Breast
Gynecology Tx- metronidazole
Ashhadscknotes
Genital ulcers of Chancroid* and Herpes* genitalis are both painful*
Genital ulcers/chancre of primary syphilis* is painless*

Obstetrics
Female Reproductive Primary syphilis:accompanied by painless inguinal adenopathy.If left untreated, heals on its own in 1-3 mo
4791 &
System & Breast
Gynecology
Granuloma inguinale (Donovanosis):also has painless ulcers like syphilis but no adenopathy.Also it doesn't
resolve on its own. Need antibiotic tx!
Basal cell carcinoma:sun exposure,pearly colored papules covered w/ telangiectasias, face/trunk

Obstetrics Screening for syphilis can be done w/ VDRL,RPR and confirmation can be done w/ FTA-ABS. Since there is
Female Reproductive
4792 & high rate of false-negatives w/ these tests, we actually use Darkfield microscopy to diagnose syphilis(it's
System & Breast
Gynecology highly effective in dx)
in HELLP syndrome, the microangiopathic hemolytic anemia causes hepatocellular necrosis and thrombi in
Obstetrics portal system therefore causing elevated liver enzymes, liver swelling, distension of hepatic (Glisson's)
Female Reproductive
4795 & capsule
System & Breast
Gynecology
Preeclampsia is a risk factor for premature placental separation
Lichen sclerosus:affects postmenopausal women.Sx-vulvar pruritus,dyspareunia,dysuria,painful
defecation,discomfort.Exam shows porcelain-white polygonal macules & patches w/ atrophic "cigarette
Obstetrics
Female Reproductive paper" quality. *Peform biopsy(vulvar punch biopsy) to rule out vulvar SCC!*
4810 &
System & Breast
Gynecology
Estrogen cream used for tx of menopause-related atrophic vaginitis, which also can be a cause of vaginal
pruritus & dyspareunia
*High potency topical steroids are 1st line tx for lichen sclerosus(lichen sclerosus et atrophicus, LS&A)*
Obstetrics Vaginal candidiasis tx: clotrimazole cream

Female Reproductive
4811 &
System & Breast
Gynecology Genital warts tx: cryotherapy
Radical vulvectomy used for treatment of high risk vulvar malignancies such as invasic SCC or melanoma
Finding of atypical squamous cells of undetermined significance (ASC-US) on cytology:
Women age 21-24 years- Repeat cytology in 1 year.
Obstetrics Women age >25 years- HPV DNA test. If positive, do colposcopy. If negative, do repeat pap smear & HPV
Female Reproductive
8877 & test in 3 years
System & Breast
Gynecology
For "atypical squamous cells can't rule out high-grade squamous intraepithelial lesion" (ASC-H), atypical
glandular cells, or high grade squamous intraepithelial lesion, we do colposcopy!
Obesity is a common cause of amenorrhea. The amenorrhea is the result of anovulation. The FSH and LH
levels are usually normal
Obstetrics
Female Reproductive Menopause: 1 year of no menses. FSH and LH levels are elevated
8892 &
System & Breast
Gynecology
Pituitary dysfunction: FSH and LH levels are very low
Premature ovarian failure: FSH and LH levels are elevated

PMS sx like mood swings,irritability,fatigue,bloating & breast tenderness occur 1-2 weeks prior to menses
and resolves w/ onset of menstrual flow.Dx confirmed w/ menstrual diary
Obstetrics Premenstrual dysphoric disorder (PMDD) is a severe variant of PMS w/ prominent irritability & anger sx
Female Reproductive
8899 &
System & Breast
Gynecology Perimenopausal women w/ PMS develop irregular menstruation,ass w/ mood swings,irritability,& somatic sx
& worsening of sx until menses cease
Menstrual cycle is a common trigger for migraine sx

adnexal/pelvic mass in asymptomatic postmenopausal women:
evaluate initially with transvaginal ultrasonography and then cancer antigen (CA)-125 level
Obstetrics
Female Reproductive elevation of CA-125 suspicious for ovarian cancer
8903 &
System & Breast needle aspiration contraindicated due to poor sensitivity and risk of spillage and seeding of cancer cells into
Gynecology
peritoneal cavity
HPV vaccine recommended for all girls and women(except those who are pregnant) age 9-26 regardless of
HPV status or sexual activity. It's also recommended for boys and men age 9-21.
Obstetrics
Female Reproductive
8917 &
System & Breast Pts w/ HIV, SLE, organ transplant, or immunocompromised pts, are at increased risk for cervical cancer
Gynecology
due to HPV infection so screening in these pts is recommended at the onset of sexual activity. Screen
annually.
Ovarian/adnexal torsion: affects women of reproductive age. RF-pregnancy, ovulation induction during
Obstetrics infertility tx & ovarian masses (esp >5 cm). [Look for stem to mention hx of ovarian cyst even if its 4 cm].
Female Reproductive
8939 & Sx-sudden onset of moderate to severe pelvic pain (right side more common), nausea/vomiting, possible
System & Breast
Gynecology low grade fever. Vaginal bleeding is uncommon! Dx confirmed w/ ultrasound using color Doppler.
Management includes laparoscopic surgery
Ashhadscknotes
Ruptured ovarian cyst:unilateral pelvic pain immediately after strenous activity/sex. Pelvic ultrasound shows
free fluid in the pelvis
Adnexal torsion:unilateral lower abdominal pain,nausea,vomiting,enlarged,edematous ovaries w/ decreased

Obstetrics
Female Reproductive blood fow
8941 &
System & Breast
Gynecology
Mittelschmerz:mild,unilateral midcycle pain due to follicular enlargement prior to ovulation
Tubo-ovarian abscess:RF-multiple sex partners,PID hx,fever,low ab pain,vaginal discharge.Complex

multilocular fluid seen on ultrasound
Uterine fibroids:
feels enlarged,firm, irregular on examination. Large fibroids cause local compressive sx like constipation,
Obstetrics urinary frequency/retention, & back/pelvic pain. Many pts have heavy and prolonged menstrual bleeding
Female Reproductive
8948 & management- Ultrasound! It's highly sensitive for detecting uterine fibroids & ovarian pathology. Preferred
System & Breast
Gynecology imaging modality for suspected gynecological tumors
Diagnostic laparoscopy is used to confirm suspicion of endometriosis or pelvic adhesions

Uterine leiomyomas (fibroids): most common pelvic tumor seen in women. Present as pelvic masses w/ sx
due to compression of adjacent organs(constipation, urinary frequency) & heavy, prolonged menstrual
Obstetrics bleeding
Female Reproductive
8953 &
System & Breast
Gynecology Pelvic adhesions: seen in women w/ hx of previous surgery or pelvic infection(chlamydia). Pelvic adhesions
can present w/ pain or infertility (tubal factor). Physical examination findings range from a normal exam to
an immobile uterus
Obstetrics Premenopausal prophylactic *bilateral salpingo-oophorectomy (BSO)* in BRCA1-positive pts causes a
Female Reproductive
11985 & significant decrease in the risk of ovarian cancer. BSO is rec for mutation carriers as soon as childbearing is
System & Breast
Gynecology complete, but not for pts w/o a hereditary ovarian cancer syndrome
Urinary stress incontinence can be a presenting sx of leiomyomata uteri(fibroids) due to direct pressure on
the bladder from an irregularly enlarged uterus. The best imaging modality to dx fibroids is US of the pelvis
Obstetrics
Female Reproductive
11987 & A pelvic organ prolapse(eg,cystocele), which can cause urinary incontinence,pelvic pressure,& bulging
System & Breast
Gynecology sensation in the vagina is less likely in a pt that is nulliparous
Nucleic acid amplification testing can dx chlamydia infection

Submucous fibroids can prolapse thru the cervical os & cause labor-like pain due to cervical distension by
Obstetrics the solid mass
Female Reproductive
12004 &
System & Breast
Gynecology Advanced carcinoma of the cervix could present as an exophytic driable, irregularly shaped lesion &
postcoital spotting. It takes many years to develop & is unlikely in a pt w/ a recent normal Papanicolaou test
Pregnancy contraindicated during breast cancer tx due to teratogenic agents like chemotherapy/radiation.All
hormone containing contraception is contraindicated in pts w/ breast cancer(cuz of proliferative effect on
Obstetrics breast tissue).*Copper intrauterine device* is a safe,effective,hormone free,long term method of
Female Reproductive
12012 & contraception
System & Breast
Gynecology
Progesterone IUD is an effective contraceptive,but it's contraindicated in setting of current breast cancer
due to systemic absorption of progesterone
Dysmenorrhea & heavy menstrual bleeding(soaking a pad/tampon more than every 2 hours) w/
*progression to chronic pelvic pain* are typical of adenomyosis. A boggy, tender, uniformly enlarged uterus
Obstetrics
Female Reproductive on exam is characteristic of adenomyosis
12020 &
System & Breast
Gynecology
Cervical cancer can present w/ postcoital spotting or bleeding, but not pain. Exam would show an exophytic
cervical mass
A woman has a 1 in 8 lifetime risk for breast cancer. *Alcohol consumption is a dose-dependent risk factor,
& reduced intake will decrease the risk of breast cancer*. Protective lifestyle aspects include exercise &
breastfeeding
Obstetrics
Female Reproductive
12021 &
System & Breast Long term use of systemic hormone replacement therapy increases the risk of breast cancer
Gynecology
Oral contraceptive use decreases the risk of ovarian cancer(it has no effect on the incidence of breast
cancer!)
Risk of breast cancer in women increases w/ *chronological age*
Obstetrics
Female Reproductive
12026 & Screening mammography is initiated at age >50 due to increasing risk of breast cancer w/ age. Other imp
System & Breast
Gynecology risk factors include nulliparity, obesity, & prolonged hormone replacement therapy, all of which contribute to
increased lifetime estrogen exposure
Leiomyoma uteri (fibroids) are a proliferation of smooth muscle cells within the myometrium. They are a
common cause of heavy menstrual bleeding->iron deficiency anemia->syncope,palpitations,tachycardia,low
Obstetrics
Female Reproductive Hg,low MCV. Pts may present w/ acute sx of anemia & an irregularly enlarged uterus
12027 &
System & Breast
Gynecology
Hallmark of von Willebrand disease is impaired platelet aggregation due to a von Willebrand factor
deficiency. Causes abnormal uterine bleeding & anemia but w/o uterine enlargement
Ashhadscknotes
A palpable adnexal mass on physical exam is best evaluated by *pelvic ultrasonography* to rule out
malignant features[pelvic US is 1st line test for evaluation of palpable adnexal mass]
Obstetrics
Female Reproductive Ultrasonography is superior to CT scan for evaluation of the pelvic organs, & CT scan is reserved for
12050 &
System & Breast detection of metastases from ovarian cancer
Gynecology
CA-125 testing has low sensitivity for initial screening of ovarian cancer in PREMENOPAUSAL pts. CA-125
is useful mainly in POSTMENOPAUSAL women
Ovarian cancer:adnexal mass w/ pelvic pain/bloating due to *abnormal proliferation of ovarian/tubal
epithelium* or peritoneum.US-*solid mass w/ thick septations & presence of ascites*
Obstetrics Endometriomas:arise from ectopic implantation of endometrial gland on ovarian surface .US-homogenous
Female Reproductive
12051 & cyst w/ internal echoes"ground glass"
System & Breast
Gynecology
Mature cystic teratoma:US-hyperechoic nodules+calcifications
Hydrosalpinx:fluid accumulation in fallopian tube due to blockage.US-mass separate from ovary

Advanced ovarian cancer may present w/ a pelvic mass & ascites(SOB,decreased appetite,ab
distension,decreased bowel sounds). Management involves *exploratory laparotomy* w/ cancer resection &
Obstetrics
Female Reproductive staging w/ inspection of the entire abdominal cavity
12052 &
System & Breast
Gynecology
Hysteroscopy allows for direct visualization of the uterine cavity for the dx & tx of intrauterine pathology (eg,
endometrial polyp, submucous myoma, adhesions)
Postmenopausal bleeding w/ a thickened endometrium & a large ovarian mass is concerning for endometrial
Obstetrics hyperplasia/cancer in the setting of a granulosa cell ovarian tumor(secretes estrogen). *Endometrial biopsy*
Female Reproductive
12053 & is the gold standard test to rule out endometrial malignancy
System & Breast
Gynecology
There is an association of endometrial hyperplasia w/ granulosa cell tumors(secretes estrogen)
Obstetrics
Female Reproductive Menopausal genitourinary syndrome refers to vulvovaginal atrophy & related urinary sx due to
12054 &
System & Breast *hypoestrogenism*. Vaginal estrogen is indicated for moderate to severe sx w/ urinary involvement
Gynecology
Low estrogen levels affect the vulvovaginal tissue, leading to 'thin' vulvar skin, narrowed introitus, & 'dry'
vaginal canal. Irritation & dyspareunia result from vulvovaginal *atrophy*
Obstetrics Chronic candidiasis:ass w/ vulvar erythema,labial swelling/thickening,& moist erythematous rash w/ central
Female Reproductive
12055 & clearing.Inguinal area frequently involved
System & Breast
Gynecology
Contact dermatitis->thickened,erythematous, hypertrophied skin
Lichen planus->'erythematous' lesions on vulva w/ 'erosive' areas

Key findings of breast abscess include fever, focal erythema/pain, & fluctuance reflecting pus collection.
*Needle aspiration & abx are 1st line tx*
Obstetrics
Female Reproductive Incision & drainage w/ packing are rec for abscesses not responsive to needle aspiration & abx, suspected
12078 &
System & Breast necrotic material, & large pus collections
Gynecology
MRI used for breast cancer screening in BRCA gene carriers & in pre- & postoperative management of
breast cancer
Obstetrics Ovarian torsion: presents w/ nausea/vomiting, 'lower ab pain' & ultrasound findings of an 'adnexal mass
Female Reproductive
12093 & without Doppler flow to ovary'. Management is w/ prompt *laparoscopy* & surgical restoration of anatomy w/
System & Breast
Gynecology cystectomy
Mature cystic teratomas (dermoid cyst) are benign ovarian cysts containing sebaceous material w/ epithelial
components (hair, teeth). Intraperitoneal spillage of cyst contents can lead to chemical peritonitis. Evaluate
w/ ultrasound. Tx w/ laparoscopic cystectomy
Obstetrics
Female Reproductive
12094 &
System & Breast Endometrioma:collection of old blood,commonly occurs as an ovarian mass.Cyst contents are a
Gynecology
pathognomonic "chocolate-colored" fluid
Hydrosalpinx(fluid collection in fallopian tube):long term complication of PID

*Rectovaginal fistula* may occur after obstetric trauma & presents w/ incontinence of flatus & feces thru the
vagina(malodorous brown/tan discharge). Red, velvety rectal mucosa may be seen on the posterior vaginal
Obstetrics
Female Reproductive wall. Tx is surgical repair of the fistulous tract
12109 &
System & Breast
Gynecology
Vesicovaginal fistula presents w/ clear watery vaginal discharge (urine) w/ a fistulous tract on the anterior
vaginal wall
Ashhadscknotes
Bartholin cysts:soft,mobile,nontender masses located at base of labia majora.Larger cysts cause discomfort
during sex,walking,sitting,exercise.Symptomatic cysts require I&D,followed by Word catheter placement
Infected Bartholin gland can evolve into an abscess(localized erythema,induration & fluctuancy,+/- fever)
Obstetrics
Female Reproductive
12110 & Vulvar inclusion cysts:from local trauma(episiotomy,laceration)
System & Breast
Gynecology
Epidermal cysts:from ductal blockage of sebaceous glands
Epithelial cysts:on hair bearing sites
*Vesicovaginal fistulas*:may occur after pelvic surgery,presents as painless loss of urine into
vagina.Physical exam shows pooling of 'clear watery fluid' in vagina
Obstetrics
Female Reproductive Urethral diverticulum:local outpouching of urethra into anterior vaginal wall that presents as well
12143 &
System & Breast circumcised,isolated cystic mass.[Differs from urethrocele(urethral prolapse into vagina due to loss of
Gynecology
ligamentous support)]
Vaginal cuff dehiscence:postoperative complication after hysterectomy

Intrahepatic cholestasis of pregnancy (ICP): Marked pruritus(esp on palms & soles;worsens at night) &
elevated total bile acids &/or aminotransferases in pregnancy. Jaundice is uncommon in these
Obstetrics pts.Tx-Ursodeoxycholic acid to increase bile flow & relieve itching. Early delivery rec. once fetal maturity is
2925 & Gastrointestinal & Nutrition achieved.
Gynecology
PUPPP: skin condition that develops in 3rd trimester. Abdominal exam shows red papules within striae w/
sparing around umbilicus, can extend to extremities
When suspecting acute appendicitis in pregnant pts, do an *ultrasound* since it safe and doesn't expose
fetus to ionizing radiation. Nonvisualization of the appendix on ultrasound does not exclude the dx of acute
Obstetrics
appendicitis.
8910 & Gastrointestinal & Nutrition
If ultrasound is nondiagnostic, MRI can be performed.
Gynecology
If ultrasound is nondiagnostic and MRI not available, then CT is used (theoretical risk of ionizing radiation to
the fetus)
ABO incompatibility generally occurs in a group O mother w/ a group A or B baby,but *ABO incompatibility
Obstetrics causes less severe hemolytic disease of the newborn* than does Rh(D) incompatibility.Affected infants are
4162 & Hematology & Oncology usually asymptomatic at birth w/ absent or mild anemia & develop neonatal jaundice,which is usually
Gynecology successfully tx w phototherapy.[ABO incompatibility reactions can occur in the 1st pregnancy because both
A & B antigens are found in food & bacteria in the environment]
Woman w/ O-negative blood type indicates that she is Rh negative & the anti-D antibody titer of 1:32
Obstetrics reflects that she is alloimmunized. Alloimmunization is when the mom is Rh negative & has an Rh-positive
4193 & Hematology & Oncology fetus.Mom's first pregnancy w/ placental abruption puts her at risk for alloimmunization so we administer
Gynecology anti-D immune globulin at 28 weeks gestation & within 72 hours of delivery.Regular dose usually prevents
alloimmunization but 50% of Rh-negative women need higher dose*
Pelvic inflammatory disease(PID): fever, purulent cervical discharge, adnexal tenderness, lower abdominal
Obstetrics
tenderness. Can cause tubo-ovarian abscess, abscess rupture, pelvic peritonitis, & sepsis if left untreated.
2416 & Infectious Diseases
Hospitalization & parenteral antibiotics rec. esp if pt has inability to take oral meds due to nausea/vomiting.
Gynecology
Regimens for hospitalized pts include *cefoxitin or cefotetan/doxycycline, & clindamycin/gentamicin (all IV)*
Obstetrics
Clindamycin & gentamicin are indicated for polymicrobial infection w/ an anaerobic component, such as
tubo-ovarian abscess or postpartum endometritis
Gynecology
If a pt has signs of Trichomonas infection, tx both the pt and their sexual partners w/ oral metronidazole and
tell them to abstain from sex until tx has been completed to prevent recurrence
Obstetrics
Oral metronidazole and tinidazole are 1st line tx options for Trichomonas vaginalis
Gynecology
Male sexual partners of pts w/ bacterial vaginosis do not require tx as this doesn't reduce recurrence risk
Obstetrics
3676 & Infectious Diseases Congenital toxoplasmosis: chorioretinitis, hydrocephalus, & intracranial calcifications
Gynecology
*Maternal combination antiretroviral therapy
(2 NRTIs + 1NNRTI or protease inhibitor)* during pregnancy & neonatal zidovudine therapy can reduce
Obstetrics perinatal HIV transmission to <1%. If the dx is made late in the pregnancy, intrapartum zidovudine & infant
3678 & Infectious Diseases tx should still be offered.
Gynecology
Generally zidovudine tx alone is administered to infant. However for moms who didn't receive antenatal
antiretroviral tx, addition of nevirapine reduces risk of mother-to-child HIV transmission
Obstetrics
Trichomonas vaginitis: wet mount microscopy shows highly motile pear-shaped organisms w/ *3-5 flagella*
[*flagellated motile organisms*]
Gynecology
Ashhadscknotes
Trichomonal vaginitis: thin vaginal discharge, erythematous vaginal mucosa, & motile pear-shaped
organisms on wet-mount. Tx- Metronidazole(pts on metronidazole should avoid alcohol as it's ass. w/
Obstetrics
disulfiram-like reaction)
Gynecology
Grapefruit juice: inhibits P450 system. Avoid when taking meds which are processed by the P450 system
e.g. cyclosporine
Bacterial vaginosis: caused by Gardnerella vaginalis. Profuse ivory to gray malodorous discharge. Amine or
Obstetrics "fishy" odor. "Clue cells"(epithelial cells coated w/ bacteria). Tx- Oral metronidazole in both pregnant and
3707 & Infectious Diseases non pregnant pts. Vaginal metronidazole and clindamycin are alternatives
Gynecology
Erythromycin estolate can cause acute cholestatic hepatitis
Mcc of mucopurulent cervicitis is Chlamydia trachomatis, followed by Neisseria gonorrhoeae
Obstetrics
4158 & Infectious Diseases Chlamydial cervicitis tx: Azithromycin
Gynecology
Gonorrheal cervicitis tx: Ceftriaxone
The incidence of vertical transmittion of HCV is 2%-5%. All pts w/ chronic hepatitis C infection, including
pregnant women, should be immunized against hepatitis A & B if they are not already immune
Obstetrics
Combination of interferon-a and ribavirin is used for tx of nonpregnant pts w/ chronic hepatitis C &
Gynecology
compensated liver disease. However Ribavirin is highly teratogenic! And we don't know how safe
interferon-a actually is during pregnancy
Obstetrics Pregnant women w/ asymptomatic bacteriuria should be tx w/ abx to decrease the risk of pyelonephritis,
4472 & Infectious Diseases preterm birth, low birth weight, & perinatal mortality. *Amoxicillin*, nitrofurantoin, & cephalexin are 1st line
Gynecology abx options during pregnancy
asymptomatic pt's that are positive for chlamydia:
Obstetrics
tx- single dose of azithromycin or 7 day course of doxycycline (no need to treat for gonorrhea if screening
for gonorrhea is already negative)
Gynecology
also treat partner
Pts w/ painful genital ulcerations & associated lympadenopathy should be evaluated for genital herpes
caused by herpes simplex virus
Obstetrics
10068 & Infectious Diseases Chlamydia trachomatis: causes lymphogranuloma venereum, large & painful lymphadenopathy "buboes"
Gynecology
HPV cause genital warts which can progress to squamous cell carcinoma if not treated
Semen analysis is a simple test that helps to identify male factor as the cause of infertility. Semen analysis
Obstetrics should be performed early in the evaluation of an infertile couple as the initial screening test
4194 & Male Reproductive System
Gynecology Anovulation as a potential cause of infertility can be evaluated using basal body temperature(BBT)
measurement, serum progesterone measurement, & endometrial sampling
Posterior dislocations of the shoulder commonly occur after a tonic-clonic seizure w/ the pt holding the arm
adducted & internally rotated(inability of external rotation)
Obstetrics Todd paralysis:transient unilateral weakness following a tonic-clonic seizure that usually spontaneously
Miscellaneous
2372 & resolves
(Multisystem)
Gynecology
Anterior dislocation:most common form of shoulder dislocation,caused by direct blow or fall on outstretched
arm,pt holds arm abducted & externally rotated
Hyperemesis gravidarum: severe vomiting during 1st-early 2nd trimesters, weightloss, volume depletion, &
ketonuria, *metabolic alkalosis* due to loss of gastric acid
Asthma:respiratory alkalosis(due to tachypnea). Respiratory or metabolic(lactic)acidosis may also occur &

Obstetrics suggests severe exacerbation
Miscellaneous
2806 &
(Multisystem)
Gynecology Diarrhea:metabolic acidosis(due to loss of organic anions & bicarbonate)
Late pregnancy:Respiratory alkalosis(hyperventilation)
Obesity:respiratory acidosis(hypoventilation)
Fetal hydantoin syndrome presents w/ small body size,microcephaly,digital hypoplasia,nail
hypoplasia,midfacial hypoplasia,hirsutism,cleft palate & rib anomalies.It can be caused by exposure to many
Obstetrics
anticonvulsant meds during fetal development,esp *Phenytoin* & carbamazepine
2572 & Nervous System
Gynecology
Fetal alcohol syndrome:midfacial hypoplasia,microcephaly,stunted growth. Also CNS damage manifested as
hyperactivty,mental retardation,or learning disability.Cleft palate & excess hair are not typical
Gestational trophoblastic disease(GTD): Choriocarcinoma is a form of it. Sx-irregular vaginal
Obstetrics
Pregnancy, Childbirth & bleeding(bleeding beyond 8 weeks post-partum is abnormal & raises suspicion for GTD), enlarged uterus, &
2299 &
Puerperium pelvic pain. GTN is locally invasive. Choriocarcinoma is highly metastatic(spreads to lungs & presents w/
Gynecology
chest pain, dyspnea, & hemoptysis; multiple nodules on CXR). Obtain B-HCG to confirm dx
Ashhadscknotes
All women of childbearing age w/ absence of menses for >1 month should be evaluated for pregnancy. Side
effects of depot medroxyprogesterone acetate(DMPA) have some overlap w/ pregnancy symptoms. A urine
Obstetrics
Pregnancy, Childbirth & pregnancy test should be performed.
2389 &
Puerperium
Gynecology
DMPA is used to prevent pregnancy by suppressing ovulation. MCC of pregnancy while on DMPA is
mistiming of a subsequent DMPA shot.
Obstetrics
Pregnancy, Childbirth & *Oral glucose tolerance testing* should be performed in all *pregnant women at 24-28 weeks gestation* to
2404 &
Puerperium screen for gestational diabetes.[1-hour 50-g OGTT followed by confirmation with a 3-hour 100-g OGTT]
Gynecology
Obstetrics Bilateral edema of the lower extremities in pregnancy(benign edema of pregnancy) is most commonly a
Pregnancy, Childbirth &
2406 & benign problem. Preeclampsia & DVT should also be considered, but are unlikely in the absence of other
Puerperium
Gynecology classic sx of these conditions
VEAL CHOP
Variable decelerations- Cord compression/prolapse; oligohydramnios
Early decelerations- Head compression

Obstetrics
2407 &
Puerperium Accelerations- OK (normal fetal oxygenation)
Gynecology
Late decelerations- Placental insufficiency
Vaginal bleeding seen in 80% of placental abruptions but a lack of vaginal bleeding doesn't rule out a
placental abruption! You can have concealed bleeding w/ placental abruption as well!
Obstetrics Pregnant bipolar pts that are taking Lithium should be slowly tapered off/weaned off the lithium.
2409 &
Puerperium
Gynecology If pregnant pt is taking isotretinoin, immediately stop the isotretinoin!
Transvaginal ultrasonogram is more accurate than transabdominal ultrasonogram in diagnosing ectopic
pregnancy, & should be performed when beta-hCG levels are between 1,500 & 6,500 IU/L
Obstetrics
2411 & Gram stain & culture are indicated in cases of PID. PID is very unlikely in an afebrile pt
Puerperium
Gynecology
Culdocentesis is an invasive & uncomfortable test that requires insertion of a needle into the posterior
vaginal wall to identify peritoneal fluid in the cul de sac
"Palpation of the vertex at the fundus" = breech presentation!
Obstetrics Breech presentation before 37th week doesn't require any intervention (since they convert to vertex before
2412 & the 37th week).
Puerperium
Gynecology If breech presentation persists after 37th week, then we do external cephalic version.
If external cephalic version fails, only then do we do cesarean delivery
Luteoma of pregnancy:30% of pts get new-onset hirsutism/acne.Management-*clinical monitoring* & US
evaluation since masses & sx regress spontaneously after delivery.Symptomatic maternal luteoma puts
female fetus at high risk of virilization
Obstetrics
2415 &
Puerperium Theca luteum cysts:can also cause hyperandrogenism in pregnancy.Unlikely to cause virilization in female
Gynecology
offspring.Suction curettage if underlying cause is molar pregnancy
PCOS pt would have hx of chronic hirsutism/fertility challenges

Obstetrics Placenta previa:presents w/ painless third-trimester vaginal bleeding. Prior c-section is a risk factor
2523 &
Puerperium
Gynecology Placental abruption & uterine rupture cause abdominal pain in addition to vaginal bleeding
Obstetrics
Pregnancy, Childbirth & Placenta previa management: If mom is stable & the fetus is at term, scheduled *cesarean section* is the tx
2524 &
Puerperium of choice
Gynecology
In a preterm placenta previa pt w/ active, uncontrolled antepartum hemorrhage & unstable vital signs &
unreassuring fetal heart rates,do an *emergent caesarian section delivery*
Obstetrics
Pregnancy, Childbirth & Pts w/ prior c-section have 25% risk of developing placenta accreta & 2/3 of placenta accreta cases require
2525 &
Puerperium hysterectomy to stop bleeding
Gynecology
Forceps are used when the fetus whose head is engaged begins to exhibit an abnormal heart rate pattern
or when the second stage of labor is prolonged
Placental abruption: sudden onset vaginal bleeding, abdominal pain, hypertonic/tender uterus. Risk factors-
maternal hypertension, smoking, and cocaine use
Passing clots raises suspicion for an abruption
Obstetrics
2527 &
Puerperium Placenta accreta: implantation of the villi to the myometrium. Prior cesarean delivery is a risk factor.
Gynecology
Uterine rupture: sudden abdominal pain,abnomal uterine contractions,vaginal bleeding,abnormal fetal heart
tracing,cessation of uterine contractions,palpable fetal parts.
Ashhadscknotes
Abruptio placentae: premature separation of the placenta from the uterine decidua. Presents w/ painful
vaginal bleeding & a firm, tender uterus. Maternal complications include hypovolemic shock & *disseminated
Obstetrics intravascular coagulation*
2528 &
Puerperium
Gynecology Fetal anemia ass. w/ vasa previa
Uterine rupture is ass w/ prior uterine surgery, vaginal & intra-abdominal hemorrhage, & loss of fetal station
Placental abruption: diagnosed clinically by 'sudden vaginal bleeding' & hypertonic, tender uterus.
Obstetrics
Pregnancy, Childbirth & Hypertension during pregnancy is an important risk factor. Fetal heart tracing will be
2530 &
Puerperium nonreassuring(bracycardia; heart rate <110-160/min). *Emergency cesarean delivery* is the tx of choice
Gynecology
when there is rapid maternal or fetal deterioration
Uterine rupture:potentially catastrophic complication in women who had prior cesarean
delivery/myomectomy.Presents w/ vaginal or intra-abdominal bleeding,pain & fetal distress/demise.Palpable
Obstetrics fetal parts abdominally at rupture site & no presenting fetal parts vaginally
2531 &
Puerperium
Gynecology Umbilical cord prolapse:occurs after rupture of membranes when fetal cord prolapses thru cervix below fetal
head.Presents w/ abrupt onset of persistent fetal variable decelerations or severe bradycardia
Sudden onset of abdominal pain, recession of the presenting fetal part(*loss of fetal station*) during active
Obstetrics labor, & fetal heart rate abnormalities(fetal tachycardia, recurrent decelerations) are red flags for *uterine
2532 & rupture*. Risk factors include a pre-existing uterine scar (eg, cesarean delivery). To prevent maternal &/or
Puerperium
Gynecology fetal exsanguination, suspected uterine rupture necessitates emergency laparotomy to confirm dx &
expedite delivery
Vasa previa:
Obstetrics sx- painless antepartum hemorrhage w/ fetal deterioration after rupture of membrances (fetal heart
2533 & monitoring shows tachycardia followed by bradycardia, & eventually a sinusoidal pattern)
Puerperium
Gynecology maternal vital signs/abdominal exam are unchanged since bleeding is from fetus
tx- cesarean delivery
Obstetrics
2535 & most common causes of antepartum hemorrhage are placenta previa and abruptio placenta
Puerperium
Gynecology
Incomplete abortion:bleeding,cramping,partial passage of fetal tissue.Depending on pt
preference,hemodynamically stable pts can undergo expectant management(observation & follow-up in
office),misoprostol,or dilation & evacuation
Obstetrics
2536 & Progesterone used for prevention of preterm labor of a singleton pregnancy in a pt w/ a hx of spontaneous
Puerperium
Gynecology preterm delivery
Cerclage placement for pt w/ hx of incompetent cervix or hx of preterm delivery & short cervix on US during
2nd trimester
Spontaneous abortion:
If pt/mom has excessive bleeding, low hemoglobin, or unstable vital signs, manage surgically w/ dilation and
Obstetrics
Pregnancy, Childbirth & suction curettage
2541 &
Puerperium
Gynecology
Oxytocin not effective in stimulating uterine contractions/expulsion of tissue in first or second trimester due
to few oxytocin uterine receptors in early pregnancy
Complete abortion: passage of a whole conceptus thru the cervix. Cervix then closes and pain & uterine
Obstetrics
Pregnancy, Childbirth & contractions subside. Occurs before 20 weeks gestation. Passage of embryonic tissue described as "solid
2542 &
Puerperium white mass covered w/ blood." Ultrasonography shows empty uterus. Urine B-hCG will be positive but
Gynecology
gradually will become undetectable after a few weeks
Anti-D immune globulin (RhoGAM) is indicated in unsensitized, Rh-negative women at 28 weeks gestation
or within 72 hours of any procedure or incident in which there is any possibility of feto-maternal blood
Obstetrics
Pregnancy, Childbirth & mixing[Anti-D immune globulin binds the D antigens on the fetal erythrocytes in the pregnant woman's
2543 &
Puerperium circulation, thereby preventing formation of anti-D antibodies]
Gynecology
Great analogy. D antigen on fetal rbc can screw us over. So Anti-D is used to stop it
Inevitable abortion(spontaneous abort.):vaginal bleeding/fluid discharge,lower ab cramps & dilated cervix
thru which products of conception visualized
Obstetrics
Pregnancy, Childbirth & Threatened abortion:hemorrhage before 20th week gestation with live fetus.Cervix closed,no passage of
2544 &
Puerperium fetal tissue.Mild lower ab pain
Gynecology
Missed abortion(form of spontaneous abort.):fetus expires in utero but products of conception aren't
discharged from uterus spontaneously.Retained fetus/placenta,no fetal heart motion
Septic abortion:due to infxn of retained products of conception following missed,incomplete,inevitable or
elective abortion.It's a medical emergency that should be tx w/ broad spectrum abx & surgical evacuation of
Obstetrics
Pregnancy, Childbirth & the uterus(*suction curettage*).After initial tx,pt should be monitored closely for signs of systemic sepsis
2545 &
Puerperium
Gynecology
Misoprostol:used to terminate pregnancies <49 days gestation.Causes uterine contractions.May expel
retained products.Slow compared to surgical evacuation
Ashhadscknotes
Obstetrics
Pregnancy, Childbirth & Induce labor in pt w/ intrauterine fetal demise who develop coagulation abnormalities. A fibrinogen and
2549 &
Puerperium platelet levels in the low-normal range can indicate a developing DIC
Gynecology
Obstetrics Depression of the deep tendon reflexes(eg,hyporeflexia) is the earliest sign of *magnesium sulfate toxicity*.
2561 & The second sign of toxicity is respiratory depression. *Tx requires stopping the magnesium sulfate infusion
Puerperium
Gynecology & administration of calcium gluconate*
Htn in a pregnant female in the setting of massive proteinuria, a malar rash, & a strongly positive ANA titer
is most likely due to systemic lupus erythematosus. *Glomerulonephritis* in general will cause proteinuria,
Obstetrics *hematuria & RBC casts*
2563 &
Puerperium
Gynecology Differentiate between SLE & preeclampsia during pregnancy! Treating preeclampsia w/
corticosteroids(normal treatment of SLE) can aggravate the preeclampsia.*RBC casts* in UA along w/
proteinuria favor SLE over preeclampsia
Obstetrics
Pregnancy, Childbirth & Elevated maternal serum a-fetoprotein is seen in fetal abnormalities such as open neural tube defects,
2567 &
Puerperium gastroschisis, & omphalocele. It's also elevated in a multiple-gestation pregnancy
Gynecology
Pregnant woman w/ low MSAFP,low estriol,increased B-hCG & increased inhibin A are ass. w/ Down
syndrome.*Ultrasound* is performed next (esp at 18-20 weeks) to evaluate fetal growth & identify any
Obstetrics
Pregnancy, Childbirth & structural malformations (endocardial cushion defects,duodenal atresia,cystic hygroma)
2568 &
Puerperium
Gynecology
Pregnancy associated plasma protein A (PAPP-A): Glycoprotein prodcuced by trophoblast.Fetuses w/ Down
syn. produce less PAPP-A.Less accurate w/ increasing gestational age.Not used in 2nd trimester
Down syndrome:
elevated B-hCG, elevated inhibin A,
low maternal serum alpha-fetoprotein(MSAFP), low estriol
Trisomy 18:
normal inhibin A,
Obstetrics
Pregnancy, Childbirth & low MSAFP, low estriol, low B-hCG
2569 &
Puerperium
Gynecology
Neural tube or abdominal wall defects:
elevated MSAFP,
the rest of the markers are normal
Pts abnormal quadruple screening results can be offered cell-free fetal DNA testing, which measures free
maternal & fetal DNA in maternal plasma. Ultrasound should be performed to evaluate for fetal anomalies
Obstetrics
Pregnancy, Childbirth & Women who inadvertently receive vaccination for rubella during or shortly before pregnancy can be
3106 &
Puerperium reassured that there is little risk to the fetus & they can proceed w/ routine prenatal care
Gynecology
Obstetrics If fetal movement decreases or becomes impreceptible by mother, do a nonstress test.
3110 &
Puerperium
Gynecology If fetal demise suspected, do ultrasonography
Obstetrics Maternal comorbidities such as chronic hypertension require antepartum fetal surveillance to diagnose fetal
3111 & compromise & prevent death. *Nonstress tests should be performed at least weekly in the third trimester
Puerperium
Gynecology until delivery*. A normal result consists of 2 heart rate accelerations & is reassuring
Late-term pregnancies(eg, 41 weeks gestation) are at risk for uteroplacental insufficiency
Obstetrics
Pregnancy, Childbirth & Diffuse placental calcifications on ultrasound are common in late-term pregnancies, suggesting a mature
3112 &
Puerperium placenta
Gynecology
Polyhydramnios(single deepest pocket >8 cm or AFI >24 cm)
Arrest of labor in the first stage is diagnosed when dilation is >6 cm w/ ruptured membranes and 1 of the
following:
-No cervical change for >4 hours despite ADEQUATE contractions
Obstetrics
Pregnancy, Childbirth & OR
3116 &
Puerperium -No cervical change for >6 hours w/ INADEQUATE contractions
Gynecology
[Pts who do not meet criteria should be observed if there is no fetal distress]
[If pt has no cervical change for >4 hours despite adequate contractions(arrest of labor), cesarean delivery
should be performed]
External cephalic version (ECV):can be attempted in women w/ breech pregnancies at >/= 37 weeks
gestational age if there are no contraindications to vaginal delivery & fetal well-being has been
Obstetrics
Pregnancy, Childbirth & established.Reduces the rate of c-section.Contraindications include ruptured membranes,hyperextended
3118 &
Puerperium fetal head,fetal/uterine abnormalities & non-reassuring fetal monitoring
Gynecology
Internal podalic version:performed in twin delivery, converts second twin from transverse/oblique to breech
Preterm labor:regular contractions causing cervical dilation and/or effacement at <37 weeks gestation.Pts in
preterm labor at <34 weeks should receive a tocolytic agent(eg, calcium channel blockers),magnesium
Obstetrics sulfate for neuroprotection & corticosteroids for acceleration of fetal lung maturity
3269 &
Puerperium
Gynecology Presence of fetal fibronectin & a shortened cervix ass. w/ preterm birth
Progesterone reduces risk of preterm birth in pts w/ short cervical length on vaginal u/s at <24 wks gestation
Ashhadscknotes
In false labor, progressive cervical changes are absent, contractions are irregular & felt in the lower
abdomen,& discomfort is readily relieved by sedation. All such pts need reassurance
Obstetrics
3271 &
Puerperium True labor is characterized by contractions that occur at regular intervals w/ a progressively shortening
Gynecology
interval & increasing intensity. The pain in true labor occurs in the back & upper adbomen & is not relieved
by sedation. Cervical changes are typically observed
Obstetrics Labor should be allowed to proceed in pts where the fetus has been dx w/ a severe congenital anomaly
3273 & incompatible w/ life(eg, bilateral renal agenesis). Pts w/ bilateral renal agenesis will not survive outside the
Puerperium
Gynecology uterus cuz of severe pulmonary hypoplasia ass. w/ renal agenesis
Preterm premature rupture of membranes (PPROM):
Obstetrics
Pregnancy, Childbirth & rupture occuring before term (earlier than 34 weeks)
3274 &
Puerperium complication- pulmonary hypoplasia (immaturity)
Gynecology
If Lecithin/Sphingomyelin ratio less than 2.0, use steroids like Betamethasone to enhance fetal lung maturity
Obstetrics
3275 & Fetal distress (repetitive late decelerations) is indication for emergent cesarean section
Puerperium
Gynecology
Group B Streptococcus(GBS) sceening is most accurate if performed 3-5 weeks prior to the estimated
Obstetrics delivery date.[Exceptions to universal screening include a hx of GBS bacteriuria at any point during current
3277 & pregnancy or invasive early-onset GBS disease in a prior child. These high-risk pts should receive
Puerperium
Gynecology intrapartum antibiotic prophylaxis(IAP) as their urogenital tract colonization is more likely to persist & spread
to the newborn]. Penicillin is prophylactic agent of choice
Etiologies of *fetal growth restriction (weight <10th percentile)* include maternal vascular
Obstetrics
Pregnancy, Childbirth & disease(*HTN*,preeclampsia,diabetes), fetal anomalies, aneuploidy, intrauterine infection, & substance
3279 &
Puerperium abuse. *Hypertension is a risk factor for asymmetric fetal growth restriction* secondary to uteroplacental
Gynecology
insufficiency
Symmetric growth restriction(fetal factors): Usually caused by fetal anomalies, abnormal fetal karyotype,
Obstetrics *intrauterine infection*
3280 &
Puerperium
Gynecology Asymmetric fetal growth restriction(maternal factors): appears later in pregnancy. Caused by maternal
vascular disease, including HTN, diabetes, & smoking
Obstetrics
Pregnancy, Childbirth & Oligohydramnios is a common complication of late-term(beyond 41 weeks) and postterm(>42 weeks)
3281 &
Puerperium pregnancies
Gynecology
In the immediate postpartum period, a low-grade fever, leukocytosis & vaginal discharge are normal
Obstetrics
Pregnancy, Childbirth & findings. Intrapartum & postpartum chills are also common. The vaginal discharge (lochia) is initially bloody,
3337 &
Puerperium then serous & finally white to yellow in color days following delivery. If a foul smelling lochia is noted,
Gynecology
endometritis should be suspected.
Obstetrics Eclampsia is the mcc of new onset seizures in a pregnant pt. Additional manifestations include HTN,
3510 & proteinuria, headache, & visual changes(blurry vision,photopobia,loss of vision). During the postictal phase
Puerperium
Gynecology of an eclamptic seizure, pts are typically fatigued & sleepy
Intermittent variable decelerations do not require intervention. Recurrent variable decelerations require
evaluation & maternal intrauterine resuscitative measures
Obstetrics
3869 & Amnioinfusion: entails instilling fluid back into the uterine cavity thru catheter to decrease symptomatic cord
Puerperium
Gynecology compression. May be indicated for recurrent variable decelerations, a potential sign of fetal acidemia
Terbutaline(beta-2 agonist tocolytic):acts rapidly to stop uterine contractions

Lupus anticoagulant can cause recurrent pregnancy loss due to thrombus development within the placenta
Obstetrics
3893 &
Puerperium Congenital heart block is a complication seen in children of mothers w/ SLE, but fetuses usually are not
Gynecology
spontaneously aborted
High yield concepts for USMLE!!!
Pregnant women w/ a current or previous dx of anorexia nervosa are at risk for giving birth to premature
Obstetrics infants,*small for gestational age infants(due to IUGR)* or both, miscarriage, hyperemesis gravidarum,
3953 & premature birth, cesarean delivery, & postpartum depression. Children born to anorexic mothers suffer from
Puerperium
Gynecology poor growth & intellectual impairment.
Osteoporosis is a common finding in anorexic pts, whether pregnant or not.
Obstetrics
Pregnancy, Childbirth & Low back pain is very common in 3rd trimester of pregnancy. Caused by the increase in *lumbar lordosis* &
4050 &
Puerperium the relaxation of the ligaments supporting the joints of the pelvic girdle
Gynecology
Epidural anesthesia->blood redistribution to the lower extremities & venous pooling from sympathetic
blockade->hypotension
Obstetrics
Pregnancy, Childbirth & High spinal/total spinal:Complication of epidural anesthesia.Local anesthesia ascends toward the head
4146 &
Puerperium resulting in depression of cervical spinal cord & brainstem activity.Sx-hypotension,bradycardia,respiratory
Gynecology
difficulty & later diaphragmatic paralysis,cardiopulmonary arrest
Wet tap:leakage of spinal fluid after dura is punctured.Sx-postural headaches
Ashhadscknotes
Obstetrics
Pregnancy, Childbirth & Serum BUN & creatinine are usually decreased in pregnant pts due to an increase in renal plasma flow &
4148 &
Puerperium GFR
Gynecology
Klumpke palsy(extended wrist,hyperextended mcp joints,flexed interphalangeal joints,absent grasp
reflex):potentially permanent complication of shoulder dystocia.*Injury to 8th cervical & 1st thoracic
nerves*->hand paralysis & ipsilateral Horner syndrome(ptosis,miosis)
Obstetrics
4198 &
Puerperium Perinatal asphyxia:from compromised placental/pulmonary gas exchange.Severe hypoxia->poor
Gynecology
perfusion/acidosis initially in peripheral tissues followed by brain
Perinatal stroke:hyperreflexia & hypertonia

Blood typing & antibody screening should be performed at the first prenatal visit. An Rh (D)-negative woman
w/ a negative antibody screen is unsensitized (not alloimmunized) & should receive *anti-D immune
Obstetrics globulin*. Anti-D immune globulin should be given at 28-32 weeks gestation & again after delivery if the baby
4528 & is Rh positive
Puerperium
Gynecology
Routine GBS rectovaginal screening should be performed at 35-37 wks gestation(pt that's negative at 28
wks can become positive at 37 wks)
All pregnant women w/o contraindications should be vaccinated against influenza. Vaccine is recommended
during flu season & can be given in any trimester. Vaccine is safe for pregnant women!
Obstetrics All pregnant women should have oral glucose tolerance test at 24-28 weeks gestation
4529 &
Puerperium
Gynecology High risk sexually active women(including pregnant women) should be screened for gonorrhea
Hemoglobin electophoresis rec. for pts at high risk for transmitting a hemoglobinopathy based on family
history
All pregnant women should be screened for syphilis (w/*RPR* or VDRL), HIV, & hepatitis B, regardless of
Obstetrics
Pregnancy, Childbirth & risk factors. Screening for chlamydia, gonorrhea, hepatitis C is based on pt's risk factors.
4530 &
Puerperium
Gynecology
Unlike in children, lead-based paint is not an important exposure source for pregnant women
Breast engorgement is common 3-5 days after delivery when colostrum is replaced by milk. Sx include
Obstetrics breast fullness, tenderness, & warmth, w/o fever. Improvement is expected as breastfeeding is established
4666 &
Puerperium
Gynecology Lochia refers to vaginal discharge containing blood & mucus & is normal up to 6-8 weeks postpartum.
Heavy bleeding that soaks >2 pads per hour is considered excessive
The management of a stillbirth in a singleton pregnancy is delivery & all pts should be counseled on the risks
Obstetrics
Pregnancy, Childbirth & & benefits of all delivery methods first. The timing of delivery is not urgent; immediate induction of labor is
4745 &
Puerperium unnecessary. Although a dead fetus can release thromboplastin & lead to coagulopathy, this is rare &
Gynecology
usually occurs after 4 weeks of retention
Pts w/ PPROM whos health records/group B streptococcus status is unknown should receive antibiotic
prophylaxis. *Penicillin* prophylaxis is 1st line. Alternative antibiotics include ampicillin, cefazolin,
Obstetrics
Pregnancy, Childbirth & clindamycin, or vancomycin.
4757 &
Puerperium
Gynecology
If a woman is admitted to the hospital after 34 weeks gestation w/ PPROM, delivery is usually
recommended(risks of prematurity are diminished after this age)
Chronic htn:BP >140/90 prior to conception or 20 weeks gestation
Gestational htn:New onset elevated bp at >20 weeks gest. No proteinuria or end organ damage
Obstetrics
Pregnancy, Childbirth & Preeclampsia:New onset elevated bp at >20 weeks gest. AND proteinuria/end-organ damage
4777 &
Puerperium
Gynecology
Eclampsia:Preeclampsia AND seizures
Chronic htn w/ superimposed preeclampsia: Chronic htn AND new onset proteinuria or worsening of existing
proteinuria at >20 weeks gestation OR sudden worsening of htn OR signs of end organ damage
*Hypertension is the most common risk factor for placental abruption.* Other complications of htn include
superimposed preeclampsia, intrauterine growth retardation/fetal growth restriction, preterm birth,
oligohydramnios & cesarean delivery
Obstetrics
4778 &
Puerperium Post-term birth (>42 weeks gestation) occurs in women w/ a personal or family hx
Gynecology
Risk factors for placenta previa include prior cesarean delivery, multiparity, multiple gestation, & advanced
maternal age
Preeclampsia w/ severe features:
They'll have new onset htn >140/90 at >20 weeks gestation plus proteinuria (protein/creatinine ratio >.3).
Look for facial swelling, creatinine >1.1 mg/dL, pitting edema in legs, pulmonary edema
Obstetrics Multiple gestation and nulliparity are risk factors
4779 &
Puerperium
Gynecology Chronic htn: elevated bp <20 weeks gestation or prior to conception
Gestational htn: new onset elevated bp at >20 weeks gestation, no proteinuria or end organ damage
Ashhadscknotes
Pts presenting w/ preeclampsia w/ severe features who experience a hypertensive emergency in pregnancy:
Tx- hydralazine, labetalol, nifedipine for hypertensive emergencies in pregnancy. Magnesium sulfate given
Obstetrics to preeclamptic pts to prevent seizures
4780 &
Puerperium
Gynecology Methyldopa- not used for hypertensive emergencies due to slow onset and sedative side effect
Sodium nitroprusside- last resort for htn due to cyanide forming as byproduct
Obstetrics
Pregnancy, Childbirth & Acute fatty liver of pregnancy (AFLP): nausea, vomiting, abdominal pain, elevations of liver markers in the
4781 &
Puerperium third trimester, leukocytosis, hypoglycemia, & acute kidney injury.
Gynecology
*Pulmonary edema is a life-threatening complication of severe preeclampsia*
Obstetrics Preeclamptic pts have generalized arterial vasospasm->increased systemic vascular resistance & high
4782 & cardiac afterload->heart becomes hyperdynamic to try to overcome the systemic htn->pulmonary edema
Puerperium
Gynecology
Magnesium sulfate toxicity: neuromuscular depression,decreased respiratory effort/apnea, muscle
paralysis, somnolence, visual disturbances, & decreased/absent deep-tendon reflexes
Eclampsia:
when grand mal seizures occur in the setting of preeclampsia
Obstetrics
Pregnancy, Childbirth & tx- magnesium sulfate
4783 &
Puerperium
Gynecology
Preeclamptic hypertensive emergency:
tx- Labetalol & hydralazine
Preeclampsia-eclampsia syndrome:
Obstetrics
Pregnancy, Childbirth & tx- stabilize pt, initiate tx for seizure(w/ magnesium sulfate), & proceed w/ delivery
4784 &
Puerperium
Gynecology
Amniocentesis helps evaluate fetal lung maturity
Perform ultrasound in pts w/ hyperemesis gravidarum(severe vomiting & >5% weight loss of pre-pregnancy
Obstetrics weight)
4789 & risk factors- Pregnant pts w/ increased placental mass (eg multifetal gestation, molar pregnancy). These pts
Puerperium
Gynecology have higher B-hCG levels due to increased placental mass.
tx- dietary modification, hydration, ginger, pyridoxine +/- doxylamine
gestational diabetes mellitus (GDM):
tx- initially dietary modifications
Obstetrics
Pregnancy, Childbirth & failure to achieve glycemic control (glucose levels not within range of < 95 fasting or < 140 1hr or <120 2hr)
4793 &
Puerperium warrants pharmacotherapy with insulin or oral antidiabetic meds.
Gynecology
dont use older sulfonylureas during pregnancy. they cross placenta
Persistent maternal hyperglycemia can cause hyperviscosity due to polycythemia. Polycythemia dangerous
cuz viscous blood is at risk for sludging, ischemia, and infarction of vital organs.
Obstetrics
4794 & small left colon syndrom:
Puerperium
Gynecology occurs in infants of pregestational and gestational diabetic mothers
sx- transient inability to pass meconium
Chorioamnionitis/intraamniotic infxn:Maternal fever & >1 of these:uterine tenderness,maternal/fetal

tachycardia,malodorous/purulent amniotic fluid (sometimes,not always).Prolonged rupture of membranes is
risk factor
Obstetrics
Pregnancy, Childbirth & Pyelonephritis sx:dysuria,flank pain,lack of persistent uterine tendernes
4797 &
Puerperium
Gynecology
PID is rare after 1st trimester due to cervical mucus & decidua sealing off & protecting uterus from
pathogens
Uterine tenderness suggests upper genital infxn rather than cervicitis

Obstetrics
Pregnancy, Childbirth & The most appropriate tx of chorioamnionitis is prompt admin of broad spectrum abx followed by delivery(we
4798 &
Puerperium can accelerate labor w/ *oxytocin*) to reduce risk of life threatening neonatal infxn & maternal complications
Gynecology
Obstetrics
Pregnancy, Childbirth & Endometritis:fever,uterine tenderness in postpartum period,ass w/ foul-smelling lochia. RF-prolonged ROM,
4799 &
Puerperium prolonged labor,operative vaginal delivery & caesarian section
Gynecology
Obstetrics
Pregnancy, Childbirth & Postpartum endometritis is most commonly a *polymicrobial infection* composed of gram positive & gram
4800 &
Puerperium negative organisms, aerobic & anaerobic organisms & occasionally other organisms
Gynecology
Obstetrics
Pregnancy, Childbirth & The tx of choice for postpartum endometritis, which is a polymicrobial infection, is intravenous *clindamycin
4801 &
Puerperium & gentamicin*
Gynecology
Obstetrics Missed abortion is a form of spontaneous abortion defined as intrauterine fetal death before 20 weeks
4802 & gestational age w/ complete retained products of conception & a closed cervix. Pts often develop loss of
Puerperium
Gynecology pregnancy sx & scant to light vaginal discharge. Pelvic *ultrasound* is necessary for dx
Ashhadscknotes
Inevitable,missed,& incomplete abortions can be managed surgically,medically,or expectantly.Although all 3
methods are effective,surgery achieves more complete evacuation than medical or expectant
Obstetrics management.In the case of medical & expectant management,US is generally performed to confirm that
4803 & there are no retained products of conception
Puerperium
Gynecology
Oxytocin is used to augment labor,tx postpartum hemorrhage,& expel retained fetus following fetal demise
in late 2nd or 3rd trimester
Obstetrics
Pregnancy, Childbirth & Threatened abortion:
4804 &
Puerperium sx- hemorrhage occuring before 20th week of gestation, closed cervix
Gynecology
Obstetrics Reassurance and outpatient follow up is the standard of care for threatened abortion
4805 &
Puerperium
Gynecology Methotrexate used to terminate pregnancy. Used for ectopic pregnancy.
Uterine atony: *mcc (80%) of postpartum hemorrhage within 24 hours of delivery*
sx- soft, "boggy" poorly contracted uterus
Obstetrics
Pregnancy, Childbirth & Risk factors- multiple gestation, polyhydramnios, macrosomia) & uterine fatigue (prolonged labor)
4808 &
Puerperium
Gynecology
Inverted uterus: Firm mass below/near the cervix. Inversion can occur before or after placental separation.
Forceful traction on the umbilical cord to remove placenta/abnomally adherent placenta are potential causes
Obstetrics Mcc of excess postpartum blood loss is uterine atony
4809 & Treat Uterine atony w/ uterotonic agents such as *oxytocin*, which will control bleeding within 10-40 minutes
Puerperium
Gynecology after administration
Active/untreated TB, HIV, active illicit drug & alcohol abuse are contraindications to breastfeeding. Hepatitis
B & C are not considered contraindications & moms w/ these conditions should be encouraged to
Obstetrics breastfeed. Galactosemia is the only condition in the infant which is an absolute contraindication to
4892 & breastfeeding
Puerperium
Gynecology
Women w/ H1N1 or other strains of influenza should be separated from their infants while febrile but should
be encouraged to pump
Obstetrics Risk factors for cervical insufficiency (cervical incompetence):
4915 & prior gynecological surgery esp a LEEP procedure or cone biopsy of cervix, prior obstetrical trauma, multiple
Puerperium
Gynecology gestation, mullerian anomalies, hx of preterm birth or a second trimester pregnancy loss
Obstetrics Transvaginal ultrasound:
4916 & considered the "gold standard" for evaluating the cervix for possible cervical incompetence. It's used to look
Puerperium
Gynecology for the presence of funneling of cervix or shortening of cervical length.
African American boys are at increased risk for fetal macrosomia,which is a risk factor for shoulder
dystocia.Excessive traction on the neck during a delivery can result in Erb-Duchenne palsy & the
Obstetrics characeristic "waiter's tip" posture.*Fortunately,most infants recover arm function spontaneously within a
8868 & few months*
Puerperium
Gynecology
Intracranial hemorrhage:potential complication of vaccum use that can cause upper motor neuron injury
leading to decreased arm movement,hyperreflexia,& hypertonia
Ruptured ectopic pregnancy: lightheadedness, diffuse abdominal pain, adnexal tenderness, & hemodynamic
Obstetrics instability
8945 &
Puerperium
Gynecology Lower abdominal discomfort, constipation, & nausea are common sx of normal pregnancy.[On the other
hand, diffuse abdominal pain plus adnexal & cervical motion tenderness are not normal]
Early decelerations are caused by fetal head compression leading to a vagal response & do not indicate
Obstetrics fetal distress. In contrast, variable & late decelerations indicate risk for fetal hypoxemia & acidosis
8962 &
Puerperium
Gynecology Spontaneous fetal activity is often ass. w/ accelerations on fetal heart monitoring. Accelerations may also be
induced w/ stimulation of the fetal scalp. Accelerations generally indicate normal fetal oxygenation
Obstetrics Fetal heart decelerations during spontaneous or induced contractions are concerning for fetal compromise
9984 &
Puerperium
Gynecology Umbilical artery flow velocimetry has been shown to be beneficial in monitoring growth restricted fetuses
Obstetrics
Pregnancy, Childbirth & Normal contraction test -> fetal compromise is unlikely -> repeat antepartum fetal testing(nonstress test &
9985 &
Puerperium biophysical profile or CST) 1 week later
Gynecology
Obstetrics *Cell-free fetal DNA testing* is a noninvasive & highly sensitive & specific screening test for fetal
10441 & aneuploidy(eg, Down syndrome). It can be ordered at >10 weeks gestation; abnormal results can be
Puerperium
Gynecology confirmed by chorionic villus sampling at 10-12 weeks or amniocentesis at 15-20 weeks
Obstetrics
Pregnancy, Childbirth & Uterine inversion requires expedient *manual replacement of the uterus*. Placental removal & admin of
11947 &
Puerperium uterotonic drugs should be initiated only after the uterus is replaced
Gynecology
Uterine inversion:can result from excessive fundal pressure & traction on umbilical cord before placental
separation.The fundus collapses into endometrial cavity & prolapses thru the cervix, resulting in a
Obstetrics
Pregnancy, Childbirth & smooth,round mass protruding thru cervix or vagina. The uterine fundus is no longer palpable
11948 &
Puerperium transabdominally.Severe pain & postpartum hemorrhage also present
Gynecology
Uterine atony:failure of uterus to contract & compress placental bed blood vessels after placental delivery
Ashhadscknotes
Obstetrics Placenta accreta: occurs when uterine villi attach directly to the myometrium. Placental adherence &
11963 & hemorrhage at the time of attempted placental delivery. RF- prior cesarean delivery, hx of dilation &
Puerperium
Gynecology curettage, advanced maternal age
Labor & vaginal delivery are contraindicated after a classic cesarean delivery or extensive myomectomy due
to significant risk of uterine rupture. Laboring pts at high risk of uterine rupture require *laparotomy &
Obstetrics delivery*
11966 &
Puerperium
Gynecology Amnioinfusion involves the placement of an intrauterine pressure catheter for an intrauterine infusion to
decrease umbilical cord compression & resolve variable decelerations. Amnioinfusion is contraindicated in a
pt w/ hx of uterine surgery
Placenta previa management: *Pelvic rest recommended*. Intercourse, digital cervical examination, &
vaginal delivery are contraindicated
Obstetrics
Pregnancy, Childbirth & Cerclage:procedure involving a suture or synthetic tape to reinforce the cervix in pts w/ hx of 2nd trimester
11969 &
Puerperium deliveries or a short cervical length at 16-23 weeks gestation
Gynecology
Doppler ultrasound:can evaluate for vasa previa(often ass. w/ resolved placenta previa). Also used in
surveillance of fetal growth restriction
Subserosal/pedunculated *uterine leiomyomata* cause bulk-related sx(pelvic pressure,*sensation of
incomplete voiding*,constipation.Leiomyomata cause *irregularly enlarged uterus* & *size date discrepancy*
during pregnancy.Pt will have hx of heavier,longer menses w/ pelvic pressure suggesting a condition
Obstetrics predating current pregnancy
11998 &
Puerperium
Gynecology Complete molar pregnancy:vaginal bleeding,hyperemesis gravidarum,diffusely enlarged uterus w/ regular
contour
Endometriosis:immobile uterus
Chorioamnionitis: look for fetal tachycardia(baseline heart rate >160/min), & maternal fever. It's ass. w/
prolonged rupture of membranes(>24 hours). Foul-smelling amniotic fluid also present. Tx-broad spectrum
Obstetrics iv abx to tx mom & fetus
12015 &
Puerperium
Gynecology Fetal anemia presents w/ sinusoidal fetal heart tracing, a smooth, undulating waveform w/ no variability
Inactive fetal sleep & hypoglycemia ass w/ nonreactive nonstress tests

Complications of oxytocin use include *tachysystole*(abnormally frequent contractions[>5 contractions in 10
min averaged over a 30 min period], hyponatremia, & hypotension)
Obstetrics
Pregnancy, Childbirth & Tachysystole is ass w/ an increased risk for cesarean delivery,low umbilical cord pH,& neonatal intensive
12016 &
Puerperium care unit admission
Gynecology
Precipitous labor:fetal delivery that occurs within 3 hours of the initiation of contractions. Most sig risk factor
is multiparity. Usually occurs spontaneously
Obstetrics Fetal sleep is a common cause of a nonreactive nonstress test (eg, no accelerations). Because a fetal sleep
12017 & cycle can last as long as 40 minutes, a nonreactive nonstress test should be extended to 40-120 minutes to
Puerperium
Gynecology ensure that fetal activity outside of sleep is captured
Obstetrics Acute postpartum urinary retention (eg, inability to void, urinary dribbling) results from prolonged labor,
12034 & perineal trauma, & regional analgesia. The condition is typically related to *bladder atony*, which is
Puerperium
Gynecology temporary and reversible
Fetal anemia is ass w/ a sinusoidal FHR tracing
Obstetrics
12037 & Placental calcifications are ass w/ uteroplacental insufficiency & late decelerations
Puerperium
Gynecology
Amniotomy(AROM) can result in umbilical cord prolapse, which can cause variable decelerations
Intermittent variable decelerations(occurs w/ <50% of contractions) are common in labor & tolerated well by
Obstetrics fetus.Persistent variable decelerations(occurs w/ >50% of contractions) require tx.O2 admin,maternal
12038 & repositioning,fluid bolus is initial tx.Should they fail, *amnioinfusion* can be
Puerperium
Gynecology implemented.[Amnioinfusion-instillation of saline thru intrauterine pressure catheter into amniotic sac to
decrease cord compression during contractions to eliminate variable decelerations]
A hemodynamically UNSTABLE pt(hypotension,tachycardia) w/ hemoperitoneum(sx like acute abdomen w/
Obstetrics decreased bowel sounds,diffuse ab pain,cervical motion tenderness,or shoulder pain[referred from
12056 & diaphragm], or urge to defecate[blood in posterior cul-de-sac]) due to ruptured ectopic pregnancy requires
Puerperium
Gynecology emergency *surgical exploration*. Dx of a cornual ectopic pregnancy is made by ultrasound showing a
gestational sac at the upper outer corner of the uterine fundus
Fetal complications due to maternal preeclampsia include oligohydramnios & *fetal growth restriction/small
Obstetrics for gestational age infants* due to chronic uteroplacental insufficiency
12064 &
Puerperium
Gynecology Maternal complications from preeclampsia include abruptio placentae, disseminated intravascular
coagulation, & eclampsia
Ashhadscknotes
Endometriosis:can be found incidentally during unrelated surgery.Findings-adhesions,powder-burn
lesions,nodules,"chocolate cysts."Asymptomatic pts don't require tx;simply *observe* for development of
future sx & initiate tx as needed
Obstetrics
12087 &
Puerperium Conservative tx of symptomatic endometriosis includes NSAIDs,oral contraceptives,or progesterone
Gynecology
IUD(copper IUD has no effect on endometriosis)
Leuprolide tx endometriosis by suppressing estrogen stimulation of ectopic endometrial glands

The most significant risk factor for spontaneous preterm delivery is a *hx of spontaneous preterm delivery in
Obstetrics a prior pregnancy*. Pts w this hx can be managed w/ progesterone supplementation & serial cervical length
12098 & measurements
Puerperium
Gynecology
Gastric bypass & other bariatric surgeries increase the risk of anemia in pregnancy & for cesarean delivery
*Most fetuses in transverse lie spontaneously convert to vertex presentation prior to term*
Internal podalic version is performed to facilitate the breech extraction of a malpresenting second twin but
Obstetrics isn't used in the management of a singleton fetus in transverse lie
12117 &
Puerperium
Gynecology Although placenta previa is a contraindication to vaginal delivery, a placenta >2 cm from the cervical os is
not
A trial of labor(TOL) is safe in a pt w/ one prior low-transverse cesarean delivery

Obstetrics
Psychiatric/Behavioral & Pseudocyesis is a rare psychiatric condition in which a woman presents w/ nearly all signs & sx of
2552 &
Substance Abuse pregnancy; however, ultrasound reveals a normal endometrial stripe & negative pregnancy test
Gynecology
Lithium exposure in the 1st trimester of pregnancy increases the risk of *cardiac malformations* including
septal defects & possibly Ebstein's anomaly(atrialization of right ventricle). In the second & third trimesters,
Obstetrics
Psychiatric/Behavioral & goiter & transient neonatal neuromuscular dysfunction are of concern
4192 &
Substance Abuse
Gynecology
Anticonvulsant meds like carbamazepine & valproate are mood stabilizers known to cause craniofacial
defects, neural tube defects, & genital anomalies in the unborn child
Amniotic fluid embolism syndrome: rapid respiratory failure(hypoxia leads to seizures & loss of
conciousness),hypotension,& DIC during labor or immediate postpartum period.Survivors have high
Obstetrics incidence of neurological damage.
2405 & Pulmonary & Critical Care RF-advanced maternal age & high gravida(>5 live births or stillbirths)
Gynecology Tx-correct hypoxemia(eg *mechanical ventilation,intubation*,oxygen) & hypotension(eg,vasopressors)
IM/IV magnesium prevents/tx eclamptic seizures. Magnesium can potentially lower bp

Asymptomatic bacteriuria during pregnancy:
positive urine culture (>100,000 colonies/mL) w/o sx of cystitis (eg, dysuria, increased urinary frequency or
Obstetrics
Renal, Urinary Systems & urgency). E.coli accounts for >70% of cases. Tx-accepted regimens include nitrofurantoin for 5-7 days,
2399 &
Electrolytes amoxicillin or amoxicillin-clavulanate for 3-7 days, or fosfomycin as a single dose.
Gynecology
Fluoroquinolones should be avoided during pregnancy. TMP/SMX should be avoided in the 1st & 3rd
trimesters.
Epidural anesthesia in labor impairs bladder function -> urinary retention & overflow incontinence
tx- retention is teated w/ short-term indwellling catheterization
Obstetrics
4225 &
Electrolytes Pessaries are used to manage urinary stress incontinence and pelvic organ prolapse
Gynecology
Oxybutynin used in urge incontinence. Causes retention
Asymptomatic bacteriuria:occurs when urine culture grows >100,000 CFU per ml of a single organism in an
asymptomatic pt.It's important to tx infection to prevent progression to pyelonephritis in the pregnant pt
Obstetrics
Renal, Urinary Systems & Chorioamnionitis:due to PROM,intrauterine instrumentation,STDs & prolonged labor
4256 &
Electrolytes
Gynecology
Endometritis:due to PID due to STDs, TB,instrumentation of genital tract,& after caesarean delivery
Difficult labor due to fetal macrosomia & postpartum hemorrhage seen in diabetic pts
Renal colic: flank pain that radiates to the groin w/ microscopic hematuria. Ultrasound of the kidneys &
pelvis is rec to evaluate renal colic in pregnant pts. Low dose CT urography may be considered only in the
Obstetrics
Renal, Urinary Systems & second & third trimesters
4294 &
Electrolytes
Gynecology
If a pregnant pt w/ kidney stones fails to improve w/ conservative measures, ureteroscopy or nephrostomy
may be considered
Obstetrics Risk factors that increase the likelihood of osteoporosis include advanced age, thin body habitus, cigarette
4122 & smoking, *excessive alcohol consumption*, corticosteroid use, menopause, malnutrition, family hx of
& Sports
Gynecology osteoporosis, & Asian or Caucasian ethnicity
Obstetrics
Social Sciences A pregnant woman who has capacity has the right to refuse treatment, even if it places her unborn child at
3748 &
(Ethics/Legal/Professional) risk
Gynecology
Ashhadscknotes
Genetic B-cell deficiency/Defect in B lymphocyte maturation:
2134 Pediatrics Allergy & Immunology sx- hx of Giardia, recurrent sinopulmonary infections after 6 months of age (w/ H.influenzae and S.
pneumoniae)
Hereditary angioedema presents in late childhood. Episodes usually follow an infection, dental procedure, or
2769 Pediatrics Allergy & Immunology trauma. C1q levels are normal in hereditary angioedema & depressed in acquired forms, which usually
present much later in life(age >30). C4 levels are depressed in all forms of angioedema
Bruton (x-linked/XLA) agammaglobulinemia:serum immunoglobulins(IgG,IgA,IgM,IgE) & B cell concentration
will be low!Recurrent sinopulmonary(acute otitis media,pneumonia) & gi(salmonella,campylobacter) infections
3195 Pediatrics Allergy & Immunology Common variable immunodeficiency:low serum Ig's. NORMAL B cell concentrations!
Physical exam in older children w/ XLA shows underdeveloped lymphoid tissue(eg,tonsils,lymph

nodes).However these tissues aren't prominent even in healthy kids until after age 2 years
Primary humoral immune deficiency syndromes present w/ recurrent or severe sinopulmonary infections.
Hyper-IgM syndrome is caused by a defect in the CD40 ligand & is characterized by high IgM levels, low or
absent IgG & IgA, & normal lymphocyte populations
3196 Pediatrics Allergy & Immunology
Common variable immunodeficiency: low IgG,IgM,& IgA in the setting of a normal B-lymphocyte count
Low serum IgG levels after age 6 mo is termed transient hypogammaglobulinemia of infancy as it resolves
by age 12 months
SCID: recurrent bacterial, viral, & fungal infections. Absent lymph nodes & tonsils, lymphopenia, absent
thymic shadow on chest x-rays, & abnormal T,B, & natural killer cell enumeration by flow cytometric analysis
3197 Pediatrics Allergy & Immunology Bruton's agammaglobulinemia:Recurrent pyogenic infections,begin after 6-9 months of life.Decreased
serum IgG,IgA,IgM & IgE w/ absent/decreased B cells on smear
CVID:similar to Bruton's but less severe sx,age 15-35 years, No absence or decrease in number of B cells
Chronic granulomatous diseas: recurrent/unusual lymphadenitis, hepatic abscesses, osetomyelitis at
3198 Pediatrics Allergy & Immunology multiple sites, infections w/ catalase-positive organisms. Tx- Prevention of infection w/ daily TMP/SMX &
gamma-interferon three times a week. Bone marrow transplantation is experimental but curative.
"Herd immunity": the disease resistance of the majority confers protection upon the disease susceptible
minority
HBV vaccine can significantly decrease one's risk of developing hepatocellular carcinoma, esp in regions like
Asia and Africa
Leukocyte adhesion deficiency type 1: caused by deficient expression of CD18, as essential component of
certain integrins present on the surface of leukocytes
4143 Pediatrics Allergy & Immunology SCID: Adenosine deaminase deficiency
Chronic granulomatous disease: nitroblue tetrazolium test is negative (abnormal). The dihydrorhodamine
123 test is more sensitive & can quantify the severity of illness
Leukocyte adhesion deficiency: 'severe periodontal disease seen'. Marked leukocytosis w/ neutrophil
4143 Pediatrics Allergy & Immunology predominance is common. Recurrent skin & mucosal bacterial infections (w/o purulence). Delayed umbilical
cord separation.
Diphtheria-tetanus-acellular pertussis(DTaP) vaccine contains acellular pertussis antigens w/ diphtheria &
tetanus toxoid.[Acellular pertussis antigens have replaced previous killed whole-cell Bordetella pertussis
4258 Pediatrics Allergy & Immunology formulation.Whole-cell pertussis component confers longer immunity but is ass. w/ severe neurologic
disorders(encephalopathy,seizures)]. Febrile seizures after DTaP vaccinations are rare.Personal/family hx
of febrile seizures isn't a contraindication to immunization
All vaccines should be administered according to chronologic rather than gestational age in preterm infants.
The only exception to scheduling vaccines by age is the hepatitis B vaccine, which should be administered
when the pt weights >2kg (4 lb 6 oz)
Live attenuated vaccines can be safely administered to immunocompetent infants regardless of gestational
age. First dose of MMR is given around 1 year of age.
Chronic granulomatois disease:
"neutrophils filled with bacteria" is a classic finding on gram stain
SCID presents in infancy w/ severe infections, failure to thrive, & chronic diarrhea. Absence of T
cells(absent CD3+) & dysfunctional B cells(low CD19+) are diagnostic. Tx-urgent *stem cell transplantation*
*Rota virus vaccine is contraindicated in pts w/ hx of intussusception due to the risk of this side effect*
Live virus vaccines shouldn't be administered to pregnant women due to risk of fetal infection. However, live
virus vaccinations can be safely administered to household contacts of pregnant women because the virus
is weak and not contagious. Vaccination of household contacts reduces the potential spread of infection to
pts who can't receive vaccinations
Tetralogy of Fallot (TOF): presents w/ varying degrees of cyanosis depending on severity of right ventricular
outflow tract obstruction."Tet" spells(sudden hypoxemia & cyanosis) result from sudden spasm of right
2429 Pediatrics Cardiovascular System ventricular outflow tract during exertion. Murmur is typically a harsh crescendo-decrescendo systolic
murmur over the left upper sternal border, reflecting turbulence at the stenotic pulmonary artery. Tx Tet
spells w/ knee-chest positioning & inhaled oxygen
Ashhadscknotes
*Trisomy 18/Edward's syndrome: Ventricular septal defect*
Trisomy 21: Atrial septal defect & endocardial cushion defects
Williams' syndrome: Supravalvular aortic stenosis
Conotruncal abnormalities(Truncus arteriosus, Tetralogy of Fallot, interrupted aortic arch) are ass. w/
2468 Pediatrics Cardiovascular System CATCH-22 syndromes, including DiGeorge & velocardiofacial syndromes
Neonatal lupus: Congenital heart block
Congenital rubella: PDA
Kawasaki disease: Coronary artery aneurysm
Athletes w/o preexisting cardiac disease can develop fatal ventricular fibrillation after sudden blunt chest wall
trauma, also known as commotio cordis(commonly occurs during baseball)
2688 Pediatrics Cardiovascular System
Long QT syndrome(LQTS) is an inherited cause of sudden cardiac death but HCM is a more common
cause of sudden cardiac death
In pts w/ hypertrophic cardiomyopathy(HCM), maneuvers that increase preload or afterload (eg, squatting,
leg raise, hand grip) increase left ventricular (LV) cavity size & decrease outflow obstruction, thereby
2691 Pediatrics Cardiovascular System decreasing the intensity of the murmur. Maneuvers that decrease LV cavity size by decreasing preload (eg,
Valsalva, abrupt standing, amyl nitrate administration) cause worsening of LV outflow tract obstruction &
increase the intensity of the murmur
Pts w/ hx of rheumatic fever have an increased risk of recurrent episodes & progression of rheumatic heart
disease w/ repeated infection w/ group A Streptococcus pharyngitis. All such pts should receive continuous
abx prophylaxis to prevent recurrent group A Streptococcus pharyngitis & limit the progression of rheumatic
heart disease. The preferred regimen is admin of intramuscular benzathine *penicillin* G every 4 weeks
Kawasaki disease: aspirin & IV immunoglobulin can reduce incidence of complications such as coronary
artery aneurysms
Scarlet fever: potential complication of untreated streptococcal pharyngitis, tonsillar exudates present, rash
has sandpaper texture & spares the palms & soles
Rocky Mountain spotted fever: rash on palms & soles, best tx w/ doxycycline for 5-7 days. Headache & GI
sx are prominent features
*Complete AV septal defect*:most common heart defect w/ Down syndrome.Features-heart failure in early
infancy,systolic ejection murmur due to increased pulmonary flow from atrial septal defect & holosystolic
murmur due to VSD
Symptomatic Ebstein anomaly:cyanosis & heart failure due to severe tricuspid regurg.Auscultation-widely
split S1 & S2 sounds + loud S3 &/or S4 & holosystolic or early systolic murmur at left lower sternal border
Truncus arteriosus/TGA ass w/ DiGeorge's

Tetralogy of Fallot: Squatting improves cyanosis & increases intensity of systolic murmur
Ventricular septal defect: squatting increases intensity of systolic murmur
Turner syndrome: Most common anomalies include *bicuspid aortic valve*, coarctation of the aorta, & aortic
root dilation
PDA ass. w/ congenital rubella syndrome & Char syndrome
*Newborns w/ DiGeorge syndrome (DGS) must be assessed immediately for potentially life-threatening
hypocalcemia*
Truncus arteriosus is strongly ass. w/ DGS. Lymphopenia(not neutropenia) is also a feature of DGS
3545 Pediatrics Cardiovascular System Down syndrome pts at risk for duodenal atresia
Congenital rubella syndrome pts have congenital heart disease & thrombocytopenia
Folic acid antagonists (eg,phenytoin, methotrexate) increase the risk of neural tube defects & possibly
cardiac anomalies & oral clefts
Fibromuscular dysplasia:
3866 Pediatrics Cardiovascular System Mcc of secondary htn in children(can present as new onset htn in children). Bruit or venous hum may be
heard at the costovertebral angle. Angiogram reveals the "string of beads" sign
Prolonged QT intervals caused by meds,electrolyte
derangements(hypocalcemia,hypokalemia,hypomagnesemia),& inherited(Jervell & Lange-Nielsen
syndrome;family hx of sudden death,congenital sensorineural deafness,due to molecular defects in K*
channels).Pt's w/ congenital long QT intervals at risk for syncope,ventricular arrhythmias & sudden cardiac
death.Avoid electrolyte derangements & meds that block K+ channels. *B-blockers w/ pacemaker
placement prevents cardiac arrest*
Ashhadscknotes
Ventricular septal defect murmur: harsh, holosystolic murmur best heard at the left lower sternal border.
3990 Pediatrics Cardiovascular System *Echocardiography* should be performed to determine location & size of defect & to rule out other defects.
Most small ventricular septal defects close spontaneously & require no treatment
Tricuspid valve atresia:left axis deviation on ecg,decreased pulmonary markings on chest radiograph due to
hypoplasia of right ventricle & pulmonary outflow tract,family hx of congenital heart disease. Ass. ASD &
VSD necessary for survival->tall peaked P waves on ECG & holosystolic murmur loudest at left lower
3991 Pediatrics Cardiovascular System sternal border
Total anomalous pulmonary venous return:Right atrium receives blood from pulmonary & systemic venous
systems->right atrial & ventricular enlargement
Transposition of the great vessels:
Most common congenital cyanotic heart defect in neonatal period. Presents in the first few hours of life w/
cyanosis, a single loud second heart sound, & a narrow mediastinum "egg on a string" on x-ray
tx- prostaglandins to optimize intra-circulatory mixing
Tetralogy of Fallot is the mcc of cyanotic heart disease after the neonatal period
Vascular rings:Presents before age 1 year. Encircles trachea &
esophagus.Respiratory(stridor,wheezing,cough) & esophageal(dysphagia) sx.Stridor improves w/ neck
extension.Sx do not improve w/ corticosteroids,racemic epinephrine,or bronchodilators. Ass. w/ cardiac
4497 Pediatrics Cardiovascular System abnormalities.Tx-surgical correction
Croup(laryngotracheobronchitis) is the mcc of inspiratory stridor in children age 6 months to 6 years.

Responds to tx w/ racemic epinephrine & corticosteroids
Prostaglandin E1 infusion maintains patency of the ductus arteriosus. It's potentially life-saving in pts w/
ductus-dependent congenital heart disease until definitive surgery can be performed
Excessive inspired oxygen & indomethacin should be avoided as these interventions constrict the ductus
arteriosus
Large ventricular septal defects can cause failure to thrive, easy fatigability, and heart failure. They
4705 Pediatrics Cardiovascular System classically cause a pansystolic murmur that is loudest at the left lower sternal border and a diastolic rumble
at the apex due to increased flow across the mitral valve
Postpericardiotomy syndrome:
occurs days or months after cardiac surgery or injury. Can occur in infants and children. Inflammation from
surgical intervention can lead to reactive pericarditis, pericardial effusion, or even cardiac tamponade.
tx- pericardiocentesis/pericardiectomy
Tetralogy of Fallot:Right ventricular outflow tract obstruction->increase in pulmonary vascular
resistance->right to left shunt (deoxygenated blood from right ventricle crosses VSD and goes into
aorta)->sudden cyanosis ("tet spell","hypercyanotic", "hypoxic").
4842 Pediatrics Cardiovascular System Tet spells are dangerous! Manage pt w/ placement in a knee-chest position.This increases systemic
vascular resistance, which reduces degree of right to left shunting
IV fluids increase systemic venous return/preload

Pediatric myocarditis-Viruses(coxsackie B v/adeno v) are mcc. Fever,lethargy,sx of heart
failure(tachypnea,dyspnea,wheezing,crackles) after viral prodrome(eg,upper respiratory infection).
Cardiomegaly on CXR(cardiothoracic ratio >50%). Monitor pts in ICU due to risk of acute decompensation &
4854 Pediatrics Cardiovascular System fatal arrhythmias.Gold standard for dx is myocardial biopsy
Strep.pharyngitis uncommon in kids <3 yrs(fewer epithelial cell attachment sites in throat->Acute rheum.
fever less likely)
Patent ductus arteriosus: ass. w/ continuous flow murmur(listen to sound). Small PDAs are often
asymptomatic & detected incidentally on routine cardiac auscultation
4912 Pediatrics Cardiovascular System Endocardial cushion defect is often ass. w/ Down syndrome
Williams syndrome: ass. w/ several cardiac abnormalities including supravalvular aortic stenosis, pulmonary
stenosis, or septal defects
Coarctation of aorta:imp cause of peds HTN.Results from *thickening of tunica media of aortic arch* near
ductus arteriosus & can lead to upper extremity HTN & lower extremity hypoperfusion.[Severe aortic
11968 Pediatrics Cardiovascular System narrowing makes systemic blood flow dependent on ductus arteriosus.As ductus begins to close,infants
develop heart failure w/ tachypnea,poor feeding,fussiness,lethargy.Also @ risk for shock->prolonged
capillary refill,met acid,decreased renal perfusion & renal output]
Allergic contact dermatitis: erythema, edema, pruritus, tiny vesicles & weepy/crusted lesions 24-48 hours
2756 Pediatrics Dermatology
after contact w/ allergen. It's due to *cell-mediated* (delayed, type IV) hypersensitivity.
Eczema herpeticum: potential complication of severe atopic dermatitis. Superinfection w/ herpes simplex
virus can cause a vesicular eruption on preexisting inflamed skin. Fever & pain often seen
Erythroderma (exfoliative dermatitis): these pts have erythema & scaling in >90% of the body. Bright red
patches coalesce & gradually peel
Seborrheic dermatitis/"cradle cap" in infants: Adherent greasy scales w/ a mildly erythematous base seen
on the scalp
Ashhadscknotes
Staphylococcal scalded skin syndrome(SSSS): caused by exfoliative toxin-producing strains of S.aureus.
Starts w/ a prodrome of fever, irritability, & skin tenderness, which is followed by generalized erythema &
2778 Pediatrics Dermatology superficial flaccid blisters w/ a positive Nikolsky sign. Scaling & desquamation follow, before resolution of the
disease process. SSSS usually affects children below age 10, but adults w/ kidney disease or immune
compromise may also be affected
Erythema toxicum neonatorum: ("toxicum" is a misnomer since rash is benign)
benign neonatal rash, asymptomatic blanching erythematous papules/pustules. Common in full term
neonates. Can occur anywhere on the body except the palms and soles.
Tx- Reassurance. It resolves spontaneously 2 weeks after birth
Neonatal HSV & Varicella are both treated w/ Acyclovir

Congenital dermal melanocytosis aka "Mongolian spots"(google pic): benign, flat, blue-grey patches usually
3755 Pediatrics Dermatology present over lower back & butt. Seen in african, asian, hispanic, & native american infants. Usually fade
spontaneously during childhood
Eczema herpeticum: form of primary herpes simplex virus infection ass. w/ atopic dermatitis. Numerous
vesicles over area of atopic dermatitis are typical. Infection can be life-threatening in infants so tx w/
acyclovir should be initiated
Varicella: characterized by a vesicular eruption that isn't localized, but tends to spread over the head & to
the trunk
Although dark fabrics attract more heat than light fabrics, they actually offer greater UV protection because
the rays can't penetrate the fabric as well
Cherry hemangiomas are seen in adults. They are small, bright red, and widespread on the trunk and
increases in number as pt ages
*Superficial infantile hemangiomas* are the same as strawberry hemangiomas

Beta blockers are recommended for pts at risk for complications from the infantile hemangioma lesions
Nevus simplex: blanchable, pink-red patches occuring on eyelid & midline of nape of neck. Present at birth
and fade by age 1-2
Tinea corporis "ringworm": Lesions are pruritic, erythematous, scaly, & have a red ring w/ central clearing.
4704 Pediatrics Dermatology Seen in hot, humid climates. Exposure to infected animals, people, & public places(swimming pool) are risk
factors.Common in preadolescents.Tx w/ topical antifungals like *Terbinafine*
Seborrheic dermatitis: common pediatric skin condition. Papular scaly rash that affects eyebrows, nasolabial
4711 Pediatrics Dermatology folds & scalp. In infants, if often begins on the scalp & is called cradle cap. Tx-moisturizers, antifungals, &
topical steroids
Henoch-Schonlein purpura (HSP): IgA-mediated *vasculitis* of childhood, palpable purpura on the lower
extremities, abdominal pain, arthralgias, & renal involvement. Typically follows a minor infection. Normal
platelet count
Purpura fulminans: life threatening condition seen w/ bacterial infections (eg, Neisseria meningitidis,
Streptococcus pneumoniae) that presents w/ blue or black hemorrhagic, purpuric lesions. Pts are very ill w/
fever, hypotension, & evidence of DIC
Tinea capitis: occurs in children
sx- scaly, erythematous patch that can progress to alopecia, sometimes w/ inflammation, lymphadenopathy,
and scarring, postauricular lymphadenopathy. Black dot tinea capitis is common in african americans
dx- confirmed w/ potassium hydroxide
10553 Pediatrics Dermatology tx- oral griseofulvin
Alopecia areata: smooth & discrete circular areas of hair loss w/o scaling
Discoid lupus erythematosus: inflammation/scarring of hair follicles, cutaneous lesions, photosensitivity

Deliberate scald injuries/Child abuse: sharp lines of demarcation, uniform burn depth, *spared flexor
surfaces(where ankles,knees,hips are flexed)*
Accidents: splash marks, poorly defined wound margins, non-uniform burn depth, immediate presentation
after injury
Laryngomalacia: Due to increased laxity of supraglottic structures. Inspiratory stridor-worse when
supine,crying,or feeding. Peaks at age 4-8 moths. Dx-flexible laryngoscopy. Self-resolves by age 18 months
Stertor: snoring-type sound, originates from turbulence in the naso- or oropharynx

2432 Pediatrics Ear, Nose & Throat (ENT)
Stridor: squeaky, whistlelike sound resulting from turbulence between supraglottis & trachea
Wheezing, rhonci, rales: due to narrowing/congestion of bronchioles

Any male adolescent who presents w/ epistaxis, a localized mass, & a bony erosion on the back of the nose
has an *angiofibroma* until proven otherwise
Ashhadscknotes
Acute otitis media(AOM):otalgia(earache),middle ear effusion & signs of eardrum inflammation(BULGING
EARDRUM,fever).Fluid in middle ear space limits eardrum mobility on pneumatic insufflation
Bullous myringitis:complication of AOM.Serous liquid-filled blisters on tympanic membrane

Cholesteatoma:abnormal growth of squamous epithelium in middle ear.Large growths damage
ossicles->conductive hearing loss
Hemotympanum:purple/red eardrum +/-bulging.Due to barotrauma/blunt trauma

*Cholesteatomas* in children can be congenital or acquired secondary to chronic middle ear disease.
*New-onset hearing loss* or chronic ear drainage despite abx tx are typical presenting sx of
cholesteatomas, & *granulation tissue* & *skin debris* may be seen within retraction pockets of tympanic
membrane
Osteoma is benign,solitary area of bony overgrowth that can form in outer ear & lead to hearing loss
Meniere's dis:innear ear fluid->hearing loss,vertigo,tinnitus

Acute bacterial rhinosinusitis:
Persistent sx > 10 days w/o improvement
or
3285 Pediatrics Ear, Nose & Throat (ENT) Severe sx, fever >102 F, purulent nasal discharge, or face pain > 3 days
or
Worsening sx > 5 days after initially improving viral upper respiratory infection
Tx- *antibiotics* so Oral amoxicillin-clavulanic acid
Acute otitis media (AOM):affects children,esp w/ cigarette smoke exposure,recent/concurrent upper
respiratory infection,day care attendance & formula intake.Caused by S. pneumoniae,non-typeable H.
influenzae & Moraxella catarrhalis.Tx-Oral amoxicillin.If AOM returns within a month of initial tx,give
3972 Pediatrics Ear, Nose & Throat (ENT) amoxicillin-clavulanic acid
Tympanocentesis & culture during myringotomy w/ tympanostomy tube placement should be considered in
childen w/ multiple episodes of AOM despite abx tx
*Deficiency of 21-hydroxylase: you get increased 17-hydroxyprogesterone levels*
3600 Pediatrics
Metabolism
17a-hydroxylase deficiency: Male pts usually appear phenotypically female & are raised as girls
Congenital hypothyroidism:
infants initially appear normal at birth but eventually develop apathy, weakness, hypotonia, large tongue,
sluggish movement, abdominal bloating, & umbilical hernia.
3662 Pediatrics Wednig Hoffman syndrome:
Metabolism
degeneration of anterior horn cells. Causes floppy baby syndrome (other cause is infant botulism).
Myotonic congenital myopathy:

muscle weakness & atrophy, myotonia, testicular atrophy, baldness
Decreased activity, hoarse cry, & jaundice in an infant are commonly ass w/ congenital hypothyroidism but
majority of infants w/ congenital hypothyroidism are asymptomatic.
*Thyroid dysgenesis*(aplasia, hypoplasia, ectopic gland) is the mcc of congenital hypothyroidism worldwide
3721 Pediatrics
Metabolism Maternal iodine deficiency->neonatal hypothyroidism
Maternal Grave's disease->transplacental passage of TSH-receptor antibodies->affected infants have signs

of hyperthyroidism(thyrotoxicosis)
Endocrine, Diabetes & Gynecomastia by iself carries a low cancer risk. The exception is Klinefelter syndrome, which does carry an
3783 Pediatrics
Metabolism increased risk of male breast cancer
Isolated premature adrenarche(early sexual maturation) is caused by increased adrenal androgen secretion.
sx- body odor, oily hair & skin, acne, pubic hair, & axillary hair
Malignant testosterone secreting hepatoblastomas are a rare cause of premature adrenarche & occur
Endocrine, Diabetes & almost exlusively in boys
3867 Pediatrics
Metabolism
The absence of thelarche (breast development) makes the ovaries an unlikely source of a childs premature
adrenarche
Adrenarche means early sexual maturation!

Central precocious puberty:
presents with increased FSH and LH
is the result of early activation of the hypothalamic pituitary ovarian (HPO) axis.
do brain imaging with CT or MRI in these pts
3868 Pediatrics
Metabolism
Peripheral precocious puberty:
presents with low FSH and LH
Treatment for precocious puberty is with GnRH analog therapy
Ashhadscknotes
Gonadotropin dependent (central) precocious puberty:premature adrenarche(axillary & pubic
hair),premature thelarche(breast development),& advanced bone age.LH is elevated at baseline or after
stimulation w/ GnRH agonist.Tx-GnRH agonist therapy to prevent premature epiphyseal plate fusion &
3875 Pediatrics maximize adult height potential
Metabolism
Pts w/ gonadotropin independent precocious puberty have low basal LH levels w/ no response to GnRh.Do
U/S to find peripheral source of sex hormone secretion
Late-onset (nonclassic) congenital adrenal hyperplasia: Gonadotropin-independent (peripheral) precocious
puberty, LH levels low at baseline & don't increase after stimulation w/ a GnRH agonist, advanced bone
Endocrine, Diabetes & age, accelerated linear growth, coarse axillary & pubic hair, severe cystic acne, normal electrolytes
4239 Pediatrics
Metabolism
Idiopathic precocious puberty: premature activation of hypothalamic pituitary gonadal axis,occurs in girls,LH
elevated & increases w/ GnRH stimulation
Diabetic ketoacidosis (DKA) is characterized by an osmotic diuresis that *reduces total body K+ stores*
even though the serum K+ level may be elevated
Endocrine, Diabetes & DKA characterized by an increase in circulating free fatty acids due to an underlying relative excess of
4514 Pediatrics
Metabolism glucagon to insulin & consequent increase in lipolysis
In a DKA pt, hepatic gluconeogenesis is increased due to increased ratio of circulating glucagon to insulin &
increased circulating levels of catecholamines & cortisol
Constitutional growth delay: mcc of short stature & pubertal delay in adolescents. Puberty & adolescent
Endocrine, Diabetes & growth spurt are delayed, but eventually occur. Child will have a normal growth spurt & reach a normal adult
4830 Pediatrics
Metabolism height. If a 13 y/o boy comes in complaining of constitutional growth delay, schedule a *follow up visit in 6
months*
Refeeding syndrome:potentially fatal complication of nutritional rehabilitation in anorexia
nervosa.Carbohydrate intake stimulates *insulin activity*,which in turn promotes cellular uptake of
phosphorus,potassium & magnesium.Clinical manifestations-arrhythmias & cardiopulmonary
8871 Pediatrics failure(jvd,bibasilar lung crackles,increased pulse & respiratory rate)
Metabolism
Pts w/ anorexia nervoasa have euthyroid hypothyroxinemia(charac. by normal TSH & normal to decreased
serum T3 & T4)
1 amenorrhea:due to hypothalamic/pituitary(central) abnormalities or gonadal (peripheral)
abnormalities.*Measure FSH level*.Increased FSH(hypogonadotropic amenorrhea) indicates peripheral
cause,decreased FSH(hypogonadotropic amenorrhea) indicates central cause.If amenorrhea is of central
Female Reproductive
2388 Pediatrics origin,pituitary MRI is indicated to look for lesion in sella turcica. If amenorrhea is of peripheral
System & Breast
origin,karyotyping is next step
GnRH stim test used to evaluate for precocious puberty

Acute abnormal uterine bleeding (AUB) in adolescents:
Due to anovulatory cycles from immature hypothalamic pituitary ovarian axis.Evaluation for pregnancy &
bleeding disorders is generally advised
Female Reproductive tx-high dose estrogen is 1st line treatment for pts w/ moderate to severe bleeding!
2390 Pediatrics
System & Breast Progesterone may be used if estrogen is contraindicated in pt.Tranexamic acid,an antifibrinolytic may be
used if both estrogen & progestin are contraindicated
Primary dysmenorrhea:pelvic cramping during the first few days of menses in the context of a normal
physical exam.It's caused by increased prostaglandin release from endometrial sloughing during
menses.Tx-NSAIDs since they are prostaglandin synthetase inhibitors & decrease prostaglandin production
Female Reproductive
2395 Pediatrics
System & Breast Adenomyosis:dysmenorrhea in women age >35,bulky,globular & tender uterus
Endometriosis:can occur in adolescents,pain precedes menses by few days,dyspareunia w/ deep

penetration
Testing the urine for human chorionic gonadotropin (hCG) is the first step in evaluation for any
Female Reproductive reproductive-age female who is unsure of her LMP. Pts w/ positive hCG should undergo transvaginal
2421 Pediatrics
System & Breast ultrasound (TVUS) to confirm the location of the gestational sac(eg when we're suspecting a possible
ectopic pregnancy)
Levonorgestrel(plan B, efficacy decreases w/ time over course of 72 hours) AND
Ulipristal(more effective but difficult to obtain, can be taken up to 5 days after sex) are widely available oral
Female Reproductive emergency contraceptive options. In most states, adolescents seeking pregnancy prevention options may
3241 Pediatrics
System & Breast receive confidential medical care w/o parental consent
Mifepristone & misoprostol comprise the medication abortion regimen

Female Reproductive Vaginal discharge in the newborn is due to the effects of maternal estrogens. In such cases, reassurance of
3773 Pediatrics
System & Breast the mother is all that is required
Ashhadscknotes
Mullerian agenesis(Mayer-Rokitansky-Kuster-Hauser syndrome):failure of mullerian ductal system to
differentiate into uterus,cervix,upper vagina.Pts don't menstruate due to congenitally absent or
Female Reproductive underdeveloped uterus,cervix & upper vagina.Gonads(ovaries) & external genitalia(labia, clitoris) develop
3911 Pediatrics
System & Breast normally.Breast development & body hair growth is normal.Phenotypically & genotypically female
Imperforate hymen:cyclic ab pain,amenorrhea from vaginal obstruction,uterus present

Pts w/ Turner syndrome have ovarian dysgenesis, which results in low estrogen levels & inability to
Female Reproductive menstruate. The poor ovarian function causes *FSH levels to be high* due to lack of negative feedback
4142 Pediatrics
System & Breast
Inhibin is a marker of ovarian function, & therefore will be low in pts w/ Turner syndrome
Androgen insensitivty syndrome:Phenotypic female(defective androgen receptors)w/ 46,XY
karyotype,absent uterus/upper vagina,cryptorchid testes,axillary/pubic hair minimal/absent,breast
Female Reproductive
4217 Pediatrics develops(due to estrogen.Testosterone aromatizes to estrogen).Bilateral gonadectomy rec. after
System & Breast
*completion of puberty(attainment of adult height)* to decrease risk of gonadal malignancy(1%-5% risk of
developing dysgerminoma or gonadoblastoma after puberty). Give Estrogen postoperatively!
*Granulosa cell tumors* produce excessive amounts of estrogen & can present w/ precocious puberty in
younger children(secondary sexual charac,hypertrophy of breasts/external genitalia,pubic hair
growth,hyperplasia of uterus) & postmenopausal bleeding in elderly pts
Female Reproductive
4230 Pediatrics
System & Breast
Sertoli-Leydig cell tumors produce androgens & cause defeminization & then masculinization.Women
complain of altered body contour,breast flattening,irregular menstruation/amenorrhea.Hirsutism,clitoris
enlargement
Female Reproductive An adolescent w/ a single, rubbery, mobile breast mass most likely has a fibroadenoma. Breast tenderness
4242 Pediatrics
System & Breast preceding menses typically *improves after the menstrual period has ended*
Mammary gland enlargement, leukorrhea, & mild uterine bleeding are common, benign, & transient in
Female Reproductive
4244 Pediatrics newborns. These are physiologic responses to transplacental maternal estrogen exposure. *No work-up is
System & Breast
indicated*
Hypothalamic pituitary gonadal axis immaturity (doesn't produce adequate LH & FSH to induce ovulation) is
Female Reproductive a cause of irregular menstrual cycles in women shortly following menarche
4767 Pediatrics
System & Breast
Intrauterine adhesions: causes include uterine instrumentation (during operative delivery) and endometriosis
Vaginal foreign bodies in children: foul-smelling vaginal discharge & vaginal spotting or bleeding. Toilet paper
Female Reproductive is the most common vaginal foreign body. Removal w/ calcium alginate swab or *irrigation w/ warmed fluid*
4870 Pediatrics
System & Breast should be attempted after a topical anesthetic has been applied. Sedation & general anesthesia may be
required in some cases
Turner syndrome(TS) dx confirmed by *karyotype analysis* showing complete or partial deletion of an X
Female Reproductive chromosome. If karyotype normal but clinical suspicion for TS remains high, fluorescence in situ
9563 Pediatrics
System & Breast hybridization should be performed to detect mosaicism (eg, 45,XO/46,XX) that is beyond the resolution of
standard karyotyping
If we suspect that pt has Turner syndrome, *pelvic ultrasound* should be performed to evaluate internal
female anatomy
Female Reproductive
9566 Pediatrics
System & Breast
Serum 17-hydroxyprogesterone is elevated in 21-and 11-hydroxylase deficiencies & is decreased in
17-hydroxylase deficiency
Bilious vomiting in the first 2 days of life & a "double bubble" sign on abdominal x-ray are strongly suggestive
of duodenal obstruction. *Duodenal atresia* is strongly ass. w/ Down syndrome(prenatal ultrasound will
show polyhydramnios due to inability to swallow & remove amniotic fluid)
2452 Pediatrics Gastrointestinal & Nutrition
Sigmoid volvulus:ab pain,distension,constipation due to torsion of sigmoid colon.Xray shows inverted
U-shaped appearance of distended sigmoid loop("coffee bean sign").Occurs in elderly
In children, recurrent self limiting episodes of vomiting & nausea w/o an apparent cause suggest the dx of
cyclical vomiting. A family hx of migraine is often present
Intestinal malrotation can present w/ recurrent vomiting that is generally bilious. Upper gi series is the gold
standard test for malrotation
Mesenteric adenitis:abdominal pain(often RLQ), abdominal guarding & tenderness.Can be mistaken for
appendicitis, identifiable on abdominal CT. No recurrent vomiting
Necrotizing enterocolitis(NEC):Increased gastric residual volume,vomiting,& ab distension in a preterm
neonate. Xray-*pneumatosis intestinalis (intramural air) & portal venous air*. Path involves combo of gut
2456 Pediatrics Gastrointestinal & Nutrition immaturity & exposure to bacteria from enteral feeds,leading to a cascade of inflammation & damage to
bowel wall.The premature intestinal mucosa has increased permeability & bacterial penetration.
Leukocytosis & met acidosis reflects inflammation & intestinal ischemia
Older children w/ recurrent intussusception:
2463 Pediatrics Gastrointestinal & Nutrition sx- sudden excruciating abdominal pain, child draws up their legs
suspect Meckel's diverticulum as cause
Milk-or soy-protein proctocolitis:exclusive to infants,suspect it when a well-appearing neonate has painless
bloody stools & severe reflux or vomiting. Eczema may also be present. Rectal bleeding stops within 2
weeks of eliminating dietary dairy & soy products
Bacterial colitis: when bloody diarrhea is accompanied by fever, decreased appetite, & irritability. Rare in
breastfed infants due to lack of exposure to contaminated foods or animals
Ashhadscknotes
Malrotation w/ midgut volvulus presents in neonates w/ bilious vomiting & ab distension. Untreated volvulus
can progress to frank bowel ischemia, bloody stools, & perforation.
2465 Pediatrics Gastrointestinal & Nutrition Dx-An *Upper GI contrast study* is the gold standard for dx malrotation.
Tx-Ladd procedure fixes bowel in non-rotated position to minimize recurrent volvulus risk
Bowl obstruction/distal intestinal obstruction in neonate:

sx- bilious emesis, meconium ileus
management- immediate xray to determine the need for emergency surgery or further diagnostic studies(in
case there is a perforation or pneumoperitoneum)
If pt stable, and there is no perforation/pneumoperitoneum, perform contrast studies/imaging to determine
level of obstruction
Hirschsprung disease:
sx- newborn w/ failure to pass meconium Strongly ass. w/ Down syndrome!!
Rectal exam produces explosive expulsion of gas and stool "squirt sign" from temporary relief from
obstruction
2467 Pediatrics Gastrointestinal & Nutrition Transition zone seen between narrowed aganglionic segment and the normally innervated dilated colon
(megacolon)
Failure of neural crest cell migration during fetal intestinal development
Cystic fibrosis: meconium ileus, meconium thick & difficult to propel, microcolon
Necrotizing enterocolitis:newborn w/ feeding intolerance,ab distension,bloody
stools.RF-prematurity,HYPOTENSION,CONGENITAL HEART DISEASE eg truncus arteriosus(congenital
heart disease & hypotension both causes reduced mesenteric perfusion).Xray-pneumatosis
intestinalis(google image!)
Symptomatic disease due to C diff is rare in 1st year of life
Intussusception is uncommon in neonate
Malrotation w/ midgut volvulus xray: gasless abdomen due to obstruction involving duodenum
Jaundice is the 1st sign of biliary atresia. The obstructed biliary tract can't transport bile to the intestine,
resulting in hepatic bile retention (cholestasis), direct hyperbilirubinemia, & jaundice
Galactosemia can cause hyperbilirubinemia but also feeding intolerance (eg, vomiting, diarrhea)
Newborns of mothers w/ blood group O- or Rh-negative are at risk for hemolytic anemia & severe
hyperbilirubinema
Sepsis can cause hemolysis & exacerbate hyperbilirubinemia
Breastfed infants have *decreased risk of developing otitis media*;respiratory, gastrointestinal,& utis; and
necrotizing enterocolitis. They also have lower rates of type 1 diabetes mellitus & childhood cancer.
Only absolute contraindication to breastfeeding is galactosemia
Breast feeding benefit for mom is reduced risk of breast & ovarian cancer.
Only contraindication for this is if mom has untreated tb, hiv infection, abuses street drugs or alcohol
Preterm infants(eg,baby born at 34 weeks gestation) are at increased risk for iron deficiency anemia. *Iron
supplementation* should be started at birth in exclusively breastfed preterm infants & continued until age 1
year. *All exclusively breastfed infants should also be started on vitamin D supplementation*
American Academy of Peds recommends exclusive breastfeeding until age 6 months given that earlier intro
of solid foods is ass. w an increase in GI infections
[Thiamine deficiency ass. w/ infantile & adult beriberi]
Infantile beriberi-appear @ age 2-3 mo, fulminant cardiac syndrome w/ cardiomegaly, tachycardia,
cyanosis, dyspnea, & vomiting
2480 Pediatrics Gastrointestinal & Nutrition [Adult beriberi charac. as dry or wet]
Dry beriberi-symmetrical peripheral neuropathy accompanied by sensory & motor impairments, esp at distal
extremities
Wet beriberi-includes this neuropathy in addition to cardiac

involvement(cardiomegaly,cardiomyopathy,CHF,peripheral edema,tachycardia)
Batteries lodged in the esophagus on x-ray should be removed immediately under *endoscopic* guidance to
2656 Pediatrics Gastrointestinal & Nutrition prevent mucosal damage & esophageal ulceration. Batteries located distal to the esophagus pass
uneventfully & need only to be observed w/ stool examination and/or follow up x-rays to confirm excretion
Iron deficiency anemia in a young pt is most likely due to celiac disease. Common associations w/ celiac
2773 Pediatrics Gastrointestinal & Nutrition disease include type 1 diabetes & dermatitis herpetiformis. IgA anti-tissue transglutaminase antibody is
highly sensitive for celiac disease
Reye syndrome: Microvesicular fatty infiltration
Macrovesicular fatty changes seen in alcoholic hepatitis & in obese pts w/ nonalcoholic fatty liver disease
Ashhadscknotes
Biliary cysts(or choledochal cyst) are congenital or acquired dilatations of the biliary tree. They may be
single or multiple, & extrahepatic or intrahepatic. Abdominal pain, jaundice, & a palpable mass are
characteristic findings. Biliary cysts(can transform into cholangiocarcinoma) require surgical excision(relives
the obstruction & reduces risk of malignancy)
Biliary atresia presents in early infancy w/ obstructive jaundice & acholic stools & is fatal w/o intervention
Infantile hypertrophic pyloric stenosis:
causes gastric outlet obstruction
Risk factors- first born boy, erythromycin, formula feeding
3078 Pediatrics Gastrointestinal & Nutrition sx- projectile nonbilious emesis, olive shaped abdominal mass, poor weight gain, dehydration
lab- hypochloremic metabolic alkalosis
diag. studies- abdominal ultrasound
tx- iv rehydration, pyloromyotomy
Systemic carnitine deficiency (SCD) is an inherited defect in fatty acid oxidation. Sx-hypoglycemia,
3194 Pediatrics Gastrointestinal & Nutrition hyperammonemia, hypoprothrombinemia, & acute episodes of encephalopathy. Acyl-carnitine levels are
elevated
Management of Infantile hypertrophic pyloric stenosis:
First you do *IV rehydration and normalization of electrolytes!*
Then you perform a pyloromytomy
3465 Pediatrics Gastrointestinal & Nutrition This decreases the risk of postoperative apnea.
Infantile hypertrophic pyloric stenosis: common in first born boys, begins around age 3-5 weeks,
projectile/nonbilious vomiting, palpable olive shaped mass, hypochloremic, hypokalemic metabolic alkalosis
Beckwith-Wiedemann syndrome(BWS): macrosomia, macroglossia, umbilical hernia/omphalocele,
hemihyperplasia(eg,right upper & lower extremities larger than left extremities), & hypoglycemia. Child must
be closely monitored for development of Wilms tumor or hepatoblastoma w/ *serum a-fetoprotein,
abdominal ultrasound, & renal ultrasound*.
[Don't confuse BWS w/ congenital hypothyroidism, which doesn't have macrosomia, hypoglycemia, &
hemihyperplasia]
Esophageal atresia w/ tracheoesophageal fistula: Newborn drools,chokes,coughs,regurgitates w/ initial
feeding attempts right after birth.Prenatal u/s shows polyhydramnios.Presence of enteric tube in proximal
3849 Pediatrics Gastrointestinal & Nutrition esophagus on x-ray & inability to pass feeding tube into stomach suggests esophageal atresia(google xray
image).Gastric fluid can reflux into distal esophagus thru fistula & into trachea/lungs,causing aspiration
pneumonia. Workup for VACTERL ass. should be considered
Choanal atresia: suspect in a well appearing infant w/ intermittent cyanosis & distress during feeding(or
anything that will keep infant's mouth closed) that is relieved by crying. Failure to pass a catheter thru the
nose into the oropharynx is suggestive of the dx. Condition may be isolated or part of CHARGE syndrome:
3872 Pediatrics Gastrointestinal & Nutrition Coloboma, Heart defects, Atresia of the choanae, Renal anomalies, Growth impairment, and Ear
abnormalities/deafness
TOF pts become cyanotic when stressed

Growth failure & recurrent respiratory infections should raise concern for cystic fibrosis. Pancreatic enzyme
deficiency causes steatorrhea & fat-soluble vitamin malabsoption, resulting in poor weight gain
*Biliary atresia* in newborns:sx-'conjug hyperbilirubinemia','hepatomegaly','jaundice','light colored
stools'.Caused by progressive obliteration of extrahepatic biliary ducts connecting liver to small
3970 Pediatrics Gastrointestinal & Nutrition bowel.Newborns initially well but develop conjug hyperbilirubinemia in 1st 2 mo of life.1st step in evaluat is
ab US,which may show an absent or abnormal gallbladder.W/o tx, liver will fibrose.Early tx w/ Kasai
procedure improves outcomes.Eventually will need liver transplant!
Meconium ileus is diagnostic for cystic fibrosis. Inspissated meconium is responsible for life threatening
obstruction at the level of the ileum. Narrow, underused colon (microcolon).
Hirschsprung disease: level of obstruction is Rectosigmoid. Meconium consistency is normal(not inspissated
like in meconium ileus). Ass. w/ Down syndrome.
Gastroschisis: isolated defect lateral to the umbilical cord w/ uncovered bowel herniating thru the abdominal
wall(bowel gets exposed to amniotic fluid->inflammation/edema of bowel wall->increased risk of
4290 Pediatrics Gastrointestinal & Nutrition complications like necrotizing enterocolitis,short bowel syndrome). Maternal serum a-fetoprotein is elevated
during pregnancy. *After delivery*, the exposed bowel should be covered w/ sterile saline dressings & plastic
wrap. *Immediate surgery* is required
Vitamin B2 (riboflavin) deficiency: angular cheilosis, stomatitis(hyperemic/edematous oropharyngeal mucous
4302 Pediatrics Gastrointestinal & Nutrition membranes, sore throat), glossitis, normocytic anemia, seborrheic dermatitis.
Common in underdeveloped countries w/ severe food shortages.
Breastfeeding failure jaundice: unconjugated hyperbilirubinemia & dehydration in the 1st week of life.
Inadequate stooling results in decreased bilirubin elimination & increased enterohepatic circulation of
bilirubin. Look for infrequent breastfeeding(4 hour feeding intervals) and signs of dehydration(infant loses a
small % of birth weight, slightly decreased urine output, "brick-red" urate crystals in diapers)
Breast milk jaundice: infant has no signs of dehydration
Ashhadscknotes
Breastfeeding failure jaundice tx: Optimize lactation & increase breastfeeding frequency
Neonates should breastfeed 8-12 times a day (every 2-3 hours) for >10-20 minutes per breast during the
first month of life
Rh-negative moms should receive Rho(D) immune globulin to prevent Rh-antibody hemolytic disease of
newborn
Phototherapy for infant w/ bilirubin >20 mg/dL.

Exchange transfusion for infant w/ bilirubin >25 mg/dL.
Galactosemia: STOP breast/cow milk! Give soy formula

*Painless hematochezia* in a young toddler is most likely due to *Meckel's diverticulum*. The outpouching
usually contains gastric mucosa that is best diagnosed by technetium-99m pertechnetate scanning.
Tx-surgical resection
Meckel's diverticulum is a potential lead point for intussusception
Milk protein allergy: painless rectal bleeding that resolves w/ elimination of dietary cow's milk. Exclusive to
infants & resolves by age 1
Pellagra:deficiency of niacin(vit B3),seen in pts w/ bowel disease that inferferes w/ vitamin
absorption(ulcerative colitis),GI complaints(nausea,ab pain,epigastric discomfort),glossitis(beefy red
tongue),watery diarrhea,dermatitis in sun exposed areas & resembles a sunburn,rash progresses,skin
becomes hyperpigmented & thickened,poor concentration,irritability,aggressiveness,& dementia
Pyridoxine deficiency:irritability,depression,dermatitis,stomatitis,elevated homocysteine

Intussusception:
Diagnosis made w/ ultrasound (1st line modality)
A positive "target sign" should prompt reduction w/ *air or water-soluble contrast enema*
Air enemas preferred!
Do laparotomy if enema reduction is ineffective or if lead point (that caused intussesception) is identified, or
if pt gets signs of perforation
4856 Pediatrics Gastrointestinal & Nutrition Colic: crying that occurs in a healthy infant for >3 hours daily, >3 times a week & for a duration of >3 weeks
Human milk is ideal for infants. The major protein source is whey, which is *more easily digested* than
casein & *helps to improve gastric emptying*
*Jejunal atresia* presents w/ bilious vomiting & abdominal distension. Abdominal x-ray shows a "triple
bubble" sign & gasless colon(google xray image). Risk factors include prenatal exposure to cocaine & other
vasoconstrictive drugs
One third of infants w/ duodenal atresia have chromosomal abnormalities, most commonly Down syndrome
Necrotizing enterocolitis: abdominal distension, bloody stools, vital sign instability in premature infants.
Pneumatosis intestinalis on xray.
4925 Pediatrics Gastrointestinal & Nutrition Moderate to severe dehydration in children should be tx w/ an *IV bolus of isotonic fluid*
Physiologic Gastroesophageal reflux is extremely common in infants due to their shorter esophagus,
incomplete closure of the lower esophageal sphincter, and greater time spent in the supine position. Parents
4926 Pediatrics Gastrointestinal & Nutrition should be reassured and advised to hold the infant upright after feeds.
Pyloric stenosis is diagnosed by abdominal ultrasound

Foreign body ingestion:Difficulty swallowing,feeding refusal,vomiting.Most commonly coins in children.Coin
should be removed by flexible endoscopy.
Rigid endoscopy has higher risk of esophageal abrasion & perforation & is usually reserved for impacted
8791 Pediatrics Gastrointestinal & Nutrition sharp objects in the proximal esophagus. Coins that reach the stomach allowed to pass spontaneously.
Tracheobronchial foreign body aspiration: toddlers w/ sudden onset stridor,wheeze,cough,dyspnea. Use

Rigid bronchoscopy
Constipation in children:Initiation of solid food & *cow's milk* is a risk factor.Oral laxatives(polyethylene
glycol,mineral oil) used for tx.Encopresis(fecal incontinence) is a potential complication
Hirschsprung disease:presents in neonatal period w/ delayed meconium passage & abdominal
distension.Mild disease may manifest later in childhood & is an uncommon cause of chronic constipation.Dx
by rectal biopsy.If constipation persists despite tx,screen w/ anorectal manometry
Bedwetting is normal before age 5. Mastery of nighttime continence can take months to years, & boys
2433 Pediatrics General Principles
generally achieve this milestone later than girls
Edward's syndome(trisomy 18): microcephaly, prominent occiput, micrognathia, closed fists w/ index finger
overlapping the 3rd digit & the 5th digit overlapping the 4th, & rocker bottom feet
Patau's syndrome (trisomy 13): cleft lip, flexed fingers w/ polydactyly, ocular hypotelorism, bulbous nose,
low-set malformed ears, small abnormal skull, cerebral malformation, microphthalmia, cardiac
malformations, scalp defects, hypoplastic or absent ribs, visceral & genital anomalies
Cri-du-chat syndrome: due to *5p deletion*. Presents as microcephaly, hypotonia, short stature, & a cat-like
cry
Ashhadscknotes
Intraosseous(IO) lines can be placed rapidly when emergency access is necessary & peripheral access
can't be obtained.Intraosseous access can be performed w/ less required skill and practice than central
venous access. Common site for IO access is the proximal tibia.Contraindications to IO placement include
infection over access site, fractures or previous IO attempts in chosen extremity or bone fragility
Arterial lines used for continuous BP monitoring & to draw lab studies
6 month old infant should be able to sit momentarily on propped hands, transfer objects from hand to hand,
and respond to name. Stranger anxiety also develops at this age
9 month old child:
should babble, use mama/dada, respond to her own name. If pt babbled before but stopped doing so and
has hx of otitis media, we worry about potential hearing problem. An audiology evaluation should be done
next!
Healthy infants normally lose up to 7% of birth weight in the first 5 days of life. No tx is required, & exclusive
breastfeeding should be continued. Birth weight should be regained by age 10-14 days
Dry,flaky peeling skin of the hands & feet is expected in newborn as the skin adjusts to the dry extrauterine
environment
Pink stains or "brick dust" in neonatal diapers represent uric acid crystals. Commonly seen during 1st week
as mother's milk is coming in
Stroke is a common complication of sickle cell disease secondary to sludging & occlusion in the cerebral
vasculature.
Exchange transfusion is the recommended treatment acutely since it helps to decrease the percentage of
2253 Pediatrics Hematology & Oncology sickle cells & prevent a second infarct from occurring.
Don't rule out stroke even if CT is negative because its difficult to detect stroke in the first few hours on a CT
Fibrinolytic therapy, heparin, & warfarin are helpful for a true thrombus(not sludge)
Acute lymphoblastic leukemia:
predominantly a disease of children. Pts present w/ infections, lymphadenopathy, & splenomegaly. Anemia.
neutropenia, & thrombocytopenia.
TdT positive. TdT is expressed only by pre B and pre T lymphoblasts
2867 Pediatrics Hematology & Oncology
Auer rods seen in AML
Myelodysplastic syndromes are seen in elderly, characterized by pancytopenia

Hereditary spherocytosis: Coombs-negtive hemolytic anemia, jaundice, & splenomegaly. *A key lab finding
is elevation of MCHC*. Suspect in pts w/ reticulocytosis, hyperbilirubinemia, spherocytosis, & family hx of
anemia. Dx confirmed w/ an abnormal eosin-5-maleimide binding test and increased osmotic fragility on
2870 Pediatrics Hematology & Oncology *acidified glycerol lysis tests*
Warm-agglutinin autoimmune hemolytic anemia:low hemoglobin,reticulocytosis & positive Coombs

testing.Glucocorticoid therapy helpful
Iron deficiency anemia: Most common nutritional deficiency in infants. Decreased MCV, increased RDW,
2875 Pediatrics Hematology & Oncology decreased serum iron, decreased transferrin saturation, & increased TIBC. Peripheral smear will show
small, hypochromic rbcs
DIC results in consumption of all clotting factors. PT & aPTT prolonged; platelets are low
Pts w/ impaired platelet function have mucocutaneous bleeding & petechiae in the setting of normal PT,
aPTT, & platelet count
Aplastic anemia can occur after viral infections or exposure to toxins
Fanconi's anemia:pancytopenia, hyperpigmentation on trunk,neck,cafe-au-lait spots,short stature,upper limb

abnormalities,hypogonadism,skeletal anomalies, eye/eyelid changes, & renal malformations
Diamond Blackfan anemia: or congenital pure red cell aplasia, presents in first 3 mo of life w/ pallor and
poor feeding.
Transient erythroblastopenia of childhood: pallor, decreased activity, tachycardia

3282 Pediatrics Hematology & Oncology Antibody-mediated hemolysis would cause a positive Coombs test
Acute lymphoblastic leukemia is the most common leukemia in children. The presence of >25%
lymphoblasts on bone marrow biopsy confirms the diagnosis. Bone marrow infiltration results in anemia and
thrombocytopenia.
Clinical features- nonspecific systemic sx, bone pain, lymphadenopathy, hepatosplenomegaly, pallor(from
anemia), petechiae(from thrombocytopenia)
*Bone marrow biopsy* required to confirm the type of leukemia
Down syndrome pts also at risk for ALL

Immune thrombocytopenia should be suspected in children who develop isolated thrombocytopenia &
petechiae after a viral infection. Children usually recover spontaneously within 6 months & require only
3440 Pediatrics Hematology & Oncology *observation*, regardless of platelet count. Children w/ bleeding should receive intravenous immunoglobulin
or glucocorticoids. Splenectomy is a last resort for catastrophic bleeding or chronic ITP that is refractory to
IVIG & glucocorticoids
Ashhadscknotes
Presence of Howell-Jolly bodies suggests splenectomy or functional asplenia
Heinz bodies seen in pts w/ hemolysis due to G6PD deficiency & thalassemia
Benign astrocytomas are the most common CNS tumor in children!
Medulloblastoma is the second most common tumor in children

Pinealoma sx- endocrine syndrome, intracranial htn, Parinaud's sign (paralysis of vertical gaze), & Collier's
sign (retraction of eyelid)
Parinaud syndrome occurs in most pts w *pineal gland masses* & presents as limitation of upward gaze,
3665 Pediatrics Hematology & Oncology bilateral ptosis, & bilateral lid retraction. Other sx of pineal gland tumors include headaches & vomiting due
to obstructive hydrocephalus
3713 Pediatrics Hematology & Oncology Pts w/ sickle cell anemia suffer from chronic *extravascular* & intravascular hemolysis
Anemia of prematurity: mcc of anemia in preterm infants. It's due to diminished erythropoietin levels,
shortened rbc life span, & blood loss. Usually asymptomatic. Labs show decreased hemoglobin &
hematocrit and a relatively low reticulocyte count
tx- minimize blood draws, iron supplementation, transfusions
Dactylitis/Hand-foot syndrome: earliest manifestation of *vaso-occlusion* in sickle cell anemia. Pts present
at age 6 mo-2 yrs w/ acute onset of pain & symmetric swelling of hands/feet. Soft tissue swelling initially
seen, fever sometimes present. Pathophys- vascular necrosis of metacarpals & metatarsals, seen on plain
radiographs as osteolytic lesions
Sickle cell disease path:point mutation resulting in substitution of valine for glutamic acid
Sickle cell trait:
3787 Pediatrics Hematology & Oncology pts lead normal, healthy lives.
sx- painless hematuria
Diamond blackfan syndrome (DBS): macrocytic pure red aplasia ass. w/ short stature, webbed neck, cleft
lip, shielded chest & triphalangeal thumbs. tx- corticosteroids. Transfusion for unresponsive pts
Fanconi's anemia: progressive pancytopenia, macrocytosis, cafe-au-lait spots, microcephaly,

microphthalmia, short stature, horseshoe kidneys & absent thumbs
Transient erythroblastopenia of childhood: pure red cell aplasia w/o macrocytosis. No ass. congenital
anomalies
In pts w/ sickle cell disease, acute severe anemia(severe drop in hemoglobin) w/ low or absent
reticulocytes(reticulocytes <1%) is consistent w/ an aplastic crisis.[Aplastic crisis in sickle cell disease differs
from aplastic anemia]
Splenic sequestration:rapidly enlarging spleen

Acute chest syndrome:fever,chest pain,infiltrate on CXR
Vasoocclusive crisis:acute onset of pain,vasoocclusion secondary to sickling of rbcs,due to changes in

weather,dehydration,infection
Suspect HUS in a child who has recently recovered from a diarrheal illness & presents w/ acute renal failure,
*microangiopathic hemolytic anemia*, fever, thrombocytopenia, & characteristic peripheral smear finding of
schistocytes(Extremely H.Y. for USMLE!!!)
DIC: PT & aPTT are prolonged

Thalassemia:hepatosplenomegaly,target cells,microcytosis,hypochromia,anisopoikilocytosis
ITP:isolated thrombocytopenia
Bleeding in renal failure pt due to dysfunctional platelets

Hemophilic arthropathy: delayed consequence of recurrent hemarthrosis. It's ass. w/ hemosiderin deposition
leading to synovitis & fibrosis within the joint. Tx- prophylactically w/ factor concentrates
Avascular necrosis of the femoral head is seen in children w/ sickle cell disease and in Legg-Calve-Perthes
disease
LCP or idiopathic avascular necrosis of the femoral head, presents w/ limp or hip pain & is most common in
children age 4-12
In pts w/ sickle cell anemia (SCA), the *Howell-Jolly bodies* seen on peripheral smear reflect splenic
dysfunction(normally the spleen removes the Howell-Jolly bodies which are basically nuclear remnants).
Sickled red cells & polychromasia also seen. The pain crises due to SCA can be precipitated by hot summer
weather & dehydration
Burr cells: spiculated rbcs, seen in uremia
Pappenheimer bodies:iron containing inclusion bodies found in rbcs, seen in sideroblastic anemia
Ashhadscknotes
Osteonecrosis (aka avascular necrosis):complication of sickle cell anemia due to vaso-occlusion of the
bone.Causes significant joint pain & functional limitation.Humerus & femer most frequently affected
Most bone & joint infections in pts w/ sickle cell disease caused by S. aureus & gram-negative
organisms,like Salmonella
Charcot arthritis aka Charcot's joint or neurogenic arthropathy: joint destruction due to deterioration of
proprioception & pain/temperature sensation.
Sickle cell pts become hyposplenic at an early age due to splenic autoinfarction.They are susceptible to
S.pneumoniae,H.influenzae & N.meningitidis.Pneumococcal vaccination(*conjugated capsular
polysaccharide*)+penicillin prophylaxis can prevent all cases of pneumococccal sepsis in these pts.[Blood
transfusions don't decrease incidence of infection in pts w/ sickle cell anemia]
Live vaccines:measles,mumps,rubella,chicken pox
Bacterial toxoid vaccines:tetanus & diphtheria

Howell-Jolly bodies(single, round, blue inclusions on Wright stain) are nuclear remnants within red blood
4359 Pediatrics Hematology & Oncology cells typically removed by the spleen. Their presence strongly suggests *physical absence of the spleen* or
functional hyposplenism
Fanconi anemia (FA) is the most common congenital cause of aplastic anemia in children.
Sx-aplastic anemia/bone marrow failure,short stature,microcephaly,abnormal thumbs,hypogonadism,
4438 Pediatrics Hematology & Oncology hypopigmented/hyperpigmented areas,cafe au lait spots,large freckles,strabismus,low set ears, middle ear
abnormalities(eg, hemorrhage[ear pounding], incomplete development, chronic infections, deafness)
Dx of FA is made by *chromosomal breaks on genetic analysis* combined w/ clinical findings
Sickle cell anemia can cause childhood stroke[signs & sx of stroke include sudden difficulty walking,
"clumsy" hand]
Electromyography(EMG) tests peripheral nerve function. It's helpful in distinguishing nerve disease from
muscle disease
Polycythemia is defined as a hematocrit >65% in term neonates.Risk factors include delayed clamping of
umbilical cord(resulting in excess transfer of placental blood),in-utero hypoxia(maternal
4819 Pediatrics Hematology & Oncology hypertension,smoking) & poor placental gas exchange(maternal diabetes).Symptomatic neonates have a
combo of respiratory distress,hypoglycemia & neurologic manifestations. Cyanosis in these pts occur due to
high RBC mass & hyperviscosity
4825 Pediatrics Hematology & Oncology Hydroxyurea benefits pts w/ sickle cell disease by increasing fetal hemoglobin
Wiskott-Aldrich syndrome: "WA ITER"-infections, thrombocytopenia, eczema, recurrent bacterial infections.
Thrombocytopenia due to *decreased/impaired platelet production*. The few platelets that exist are small
Iron deficiency anemia is common in infants & toddlers who drink excessive amounts of cow's milk(eg,1
year old girl drinking 6 glasses of whole milk a day). Tx w/ empiric *oral iron therapy*
Thalassemia trait (aka thalassemia minor): normal RDW
Iron deficiency anemia: increased RDW
Iron deficiency: most common nutritional deficiency in children, caused by excessive intake of cow's milk
(>24 ounces [700 mL] per day) & results in a microcytic anemia. Decreased MCHC. *Elevated red cell
distribution width*. RDW is a measure of how variable the RBCs are in size.
Nucleated RBCs normally found in bone marrow. If present in peripheral bloodstream, that means there is
significant bone marrow stress eg, severe hemolysis or myelofibrosis
Osteosarcoma:Boys between ages 13-16 years are at high risk.Occurs at metaphyses of long
bones(femur,tibia,humerus).Fever,weight loss,malaise are USUALLY ABSENT.Tender soft tissue
mass.(google xray)Xray-spiculated "sunburst" pattern & periosteal elevation known as Codman
triangle.Alkaline phosphatase,lactate dehydrogenase,ESR are elevated.Tx-tumor excision & chemotherapy
Ewing sarcoma:osteolytic lesion w/ periosteal reaction that produces layers of reactive bone "onion skin"
Group A streptococcal pharyngitis in children should always be confirmed by rapid streptococcal antigen
testing or throat culture prior to initiation of antibiotics.
2193 Pediatrics Infectious Diseases
GAS pharyngitis tx- Penicillin & amoxicillin
Epiglottitis:abrupt onset of fever,sore throat,dysphagia,and drooling.In unimmunized children,H.influenzae
type b is a likely cause.Airway obstruction is the most concerning potential complication(restlessness,
anxiety, impaired inspiration,& a muffled "hot potato" voice).Keeping the neck hyperextended provides some
relief
Peritonsillar abscess:unilateral tonsillar swelling w/ uvular deviation
Vascular rings:aortic arch remnants encircle and compress trachea or esophagus

Atypical pneumonia presents w/ a more indolent course,non-productive cough,& higher incidence of
extrapulmonary manifestations(headache,sore throat,skin rash) than pyogenic pneumonia. Erythema
multiforme("target shaped skin lesions") is a characteristic extrapulmonary manifestation of *Mycoplasma
pneumonia*, the mcc of atypical pneumonia. Polymorphonuclear cells on sputum Gram stain analysis
Ashhadscknotes
Always give epinephrine in cases of croup before intubation. Epinephrine decreases the need for intubation
in these pts.
epinerphrine's alpha adrenergic effect helps the asthma by reducing bronchial secretions and mucosal
edema. It's beta adrenergic effect helps croup pts by promoting smooth muscle relaxation
Neonatal sepsis: temperature instability(fever or hypothermia), poor feeding, & lethargy. *Blood, urine, &
2428 Pediatrics Infectious Diseases CSF cultures should be obtained* before providing abx in most cases. Infants who are critically ill may
require abx before lumbar puncture
Measles(rubeola): cough, coryza, conjunctivitis, & Koplik spots(bluish-white lesions on buccal mucosa).
Reddish-brown rash appears on days 3-5 on the face & spreads downward to the rest of the body
Rocky Mountain spotted fever: the non-pruritic macular rash begins on the distal extremities (including
palms/soles) & spreads centripetally
Roseola(exanthema subitum,sixth disease):due to human herpes virus 6.Maculopapular rash appears as

the fever resolves
Septic arthritis:
etiology- often preceded by skin or upper respiratory tract infections
sx- fever, knee pain & swelling, refusal to bear weight
2447 Pediatrics Infectious Diseases labs- leukocytosis, elevated C-reactive protein, & ESR
tx- Arthrocentesis
(obtain blood and synovial fluid cultures before administering empiric antibiotics that way you can isolate the
offending organism. If pt still fails to improve, perform an MRI to evaluate for osteomyelitis)
Impetigo: painful non-itchy pustules & honey-crusted lesions caused by S.aureus & S.pyogenes
Eczema herpeticum: superinfection of HSV in areas of severe eczema. Accompanied by fever

Erysipelas: small erythematous patch that progresses to a red, indurated, tense, & shiny plaque. Raished,
sharply demarcated margin. Overlying skin streaking & regional lymphadenopathy= lymphatic involvement
Hand foot mouth disease: vesicles on posterior oropharynx, hands, and/or feet
measles virus is spread only by humans and no other species
bathing pts with chlorhexidine gluconate can reduce risk of bloodstream infections and colonization with drug
resistant organisms among critically ill pts
rubella pts have patchy erythema (Forschheimer spots) on the soft palate
Erythema multiforme usually follows herpes simplex infection

conjunctivitis is not a feature of scarlet fever
conjunctivitis is a feature of rubella infection
Newborns of mothers w/ active hepatitis B infection should be passively immunized at birth w/ hepatitis B
immune globulin followed by active immunization w/ recombinant HBV vaccine
3005 Pediatrics Infectious Diseases *Staphylococcus aureus* is the mcc of osteomyelitis in both infants & children
3009 Pediatrics Infectious Diseases Parotitis(painful bilateral parotid enlaregment) can occ
Measles:
Vitamin A reduces the morbidity and mortality rates of pts w/ measles.
Leukopenia and thrombocytopenia can be seen w/ measles infection.
Acute bacterial rhinosinusitis:

sx > 10 days w/o improvement, can have fever, purulent nasal discharge, or face pain > 3 days, or
worsening sx > 5 days after initially improving viral uri
caused by Streptococcus pneumoniae, nontypeable Haemophilus influenzae, & Moraxella catarrhalis
tx- amoxicillin-clavulanic acid
3286 Pediatrics Infectious Diseases Chronic sinusitis:

inflammation of sinuses >12 weeks
mcc-S.aureus
P. aeruginosa:
nosocomial situations, esp. in immunocompromised pts w/ nasal tubes & catheters
Orbital(poststeptal)cellulitis:serious bacterial infection posterior to the orbital septum.Alarming sx like pain w/

extraocular movements,visual impairment,ophthalmoplegia. Complications-orbital abscess,intracranial
infection,cavernous sinus venous thrombosis
Preseptal(periorbital)cellulitis:mild infection of the eyelid anterior to the orbital septum
Cavernous sinus thrombosis: sx-unbearable headache,periorbital edema, exophthalmos,papilledema,dilated

tortuous retinal veins
Ashhadscknotes
*Sickle cell trait ass. w/ decreased morbidity from Malaria*. Misshapen rbcs create suboptimal environment
for parasitic proliferation
Pts w/ past hx of malarial infection are at low risk for severe disease on reinfection due to partial immunity
Neisseria meningitides vaccination prevents infection from serogroups A,C,Y & W-135
Infants/children affected w/ malaria at increased risk for cerebral malaria(seizures,delirium,coma)
Ciprofloxacin can treat traveler's diarrhea

Suspect hemolytic uremic syndrome in a child w/ sudden-onset abdominal pain, bloody diarrhea, & triad of
anemia, thrombocytopenia, & renal failure
3437 Pediatrics Infectious Diseases [hemolytic-uremic syndrome is caused by a toxin released by *E.coli*]
Even though Campylobacter jejuni can cause bloody diarrhea, it doesn't cause thrombocytopenia
Meningococcal meningitis: mcc of bacterial meningitis in children & young adults. Fever, headache, neck
stiffness, altered mental status, & petechial or purpuric rash
GBS mcc of meningitis in INFANTS. No rash
In an infant w/ meningococcemia (look for nuchal rigidity), watch out for Waterhouse-Friderichsen syndrome
3442 Pediatrics Infectious Diseases which is characterized by a sudden vasomotor collapse & skin rash (petechial & purpuric lesions) due to
adrenal hemorrhage
acute rheumatic fever(ARF):
systemic complication of pharyngitis(due to streptococcus pyogenes/group A steptococcus)
suspect in child with pericarditis (friction rub, diffuse ST elevations), chorea, subcutaneous nodules, &
elevated esr following hx of untreated sore throat and fever
tx- 10 day course of oral penicillin recommended to prevent ARF
Coxsackievirus:
can cause vesicular pharyngitis (herpangia) in young children
Infectious mononucleosis:
caused by EBV
sx-exudative pharyngitis/tonsillitis, posterior or diffuse cervical lymphadenopathy, & fever
polymorphous, maculopapular rash develops after administation of amoxicillin or ampicillin
Herpangina: vesicles & ulcers on posterior oropharynx
Herpes gingivostomatitis: vesicles & ulcers on anterior oral mucosa & around mouth
Bordetella pertussis causes "whooping cough," which has 3 phases:cararrhal(resembles common
cold),paroxysmal,& convalescent.The paroxysmal phase is characterized by severe paroxysms of coughing
& posttussive emesis.Macrolide antibiotics are the 1st line tx
Parainfluenza is a common cause of laryngotracheobronchitis (croup) in children. "barky" cough &
inspiratory stridor
RSV mcc of bronchiolitis in children age <2 years. Fever, rhinorrhea, cough,& mild respiratory distress
Salmonella & Staph aureus are the mcc of osetomyelitis in pts w/ sickle cell disease. Although controversial,
more recent studies have shown that S. aureus is more common than Salmonella in children w/ sickle cell
disease
E.coli & group B strep: casue septic arthritis & osetomyelitis in neonates. Group B strep. is responsible for
osteomyelitis in children <1 year of age
Pseudomonal osteomyelitis:seen in diabetic pts & after puncture wounds of the foot
Septic arthritis:
sx- fever, acute joint pain, turbid synovial fluid, inability to bear weight ass. w/ marked leukocytosis and
3577 Pediatrics Infectious Diseases elevated ESR
can result in permanent joint destruction
tx- emergency surgical drainage and intravenous antibiotics
Heterophile antibody test (monospot) is a rapid and specific diagnostic test for EBV induced infectious
mononucleosis(IM).
3611 Pediatrics Infectious Diseases IM- Positive heterophile antibody test
CMV- Negative heterophile antibody test
Ashhadscknotes
Enterobius vermicularis: Tx-Albendazole OR pyrantel pamoate(for pregnant pts)
Chagas disease: sx-cardiomyopathy, RBBB, megacolon, & megaesophagus. Benznidazole is the 1st line tx
Strongyloidiasis: sx-urticaria,abdominal pain,dry cough,dyspnea,wheezing.Tx-Ivermectin

Onchocerciasis "river blindness" causes ocular lesions & dermatitis: Tx-Ivermectin
Quinine:antimalarial, treats chloroquine-resistant malaria
Metronidazole: treats amebiasis,anaerobic intrabdominal infections

Bacterial meningitis in infants:
management- do urgent lumbar puncture before giving antibiotics.
If infant critically ill e.g. status epilepticus, septic shock, then give antibiotics before lumbar puncture
3633 Pediatrics Infectious Diseases tx- third generation cephalosporins effective for S. pneumoniae and N meningitidis; vancomycin given for
resistant strains of S. pneumoniae
dexamethasone reduces risk of sensorineural hearing loss when H. influenzae type b is the cause
Lyme disease tx in children age <8: *Amoxicillin* or Cefuroxime
IV ceftriaxone reserved for Lyme meningitis & heart block, manifestations of early disseminated Lyme
disease
Topical corticosteroids used for nummular dermatitis(google pic)

Sickle cell anemia ass. w/ functional asplenia due to recurrent splenic infarction, which puts these pts at risk
of dangerous infection w/ encapsulated organisms. *Pneumococcus is the mcc of sepsis in this population.*
H influenzae type B is the second mcc of sepsis. Vaccination & penicillin prophylaxis are extremely
important infection prevention measures
Salmonella species & Staphylococcus aureus are the mcc of osteomyelitis in sickle cell pts in the US
Non-bullous impetigo: painful pustules, honey-crusted lesions; dx is clinical. Tx- *topical mupirocin* [antibody
titers can take weeks to rise & are not useful in acute illness. Culture of pustular fluid considered for pts who
fail empiric therapy]
Use anti-streptolysin O titers for pts who develop post-streptococcal glomerulonephritis & rheumatic fever
Bullous impetigo: flaccid bullae containing yellow fluid.Due to S aureus.Tx oral cephalexin, dicloxacillin, or
clindamycin
Universal maternal prenatal testing & tx for chlamydia are rec to prevent neonatal infection. ORAL
erythromycin is tx for neonatal chlamydia. [Erythromycin ophthalmic ointment can prevent neonatal
gonococcal but not chlamydial conjunctivitis]
Dacryostenosis:mcc of neonatal eye discharge due to poor drainage of tears thru nasolacrimal duct.
Benign.Gentle massage over nasolacrimal duct rec
Chemical conjunctivitis:lubrication drops/ointment alleviates it

Maternal-fetal transmission of the rubella virus is most teratogenic during the first trimester of pregnancy.
The classic triad of congenital rubella syndrome consists of sensorineural deafness, cardiac defects(eg,
patent ductus arteriosus), and cataracts
Congenital varicella syndrome: characterized by microcephaly, limb hypoplasia, intrauterine growth
retardation, & cataracts w/ a maternal history of a pruritic, generalized vesicular rash
HIV infection should be suspected when an infant has failure to thrive, diarrhea, lymphadenopathy, and
thrush in the setting of maternal intravenous drug abuse
dx- polymerase chain reaction testing
Although pregnant women normally undergo HIV antibody screening in 1st trimester, those w/ high risk
behaviors(drugs, multiple sex partners) should be screened again in the 3rd trimester or at delivery as it can
take up to 3 months for antibodies to become detectable
Sepsis in term infants->GBS
Sepsis in preterm infants -> E coli
Children who aren't immunized for H.influenzae type b at risk for meningitis,pneumonia,epiglottitis
3671 Pediatrics Infectious Diseases Pregnant women w/ listeriosis have flulike sx eg-fever,body aches,fatigue prior to delivery
Meningococcal meningitis:petechial rash prominent on axilla,wrists,flanks,ankles
Congenital toxoplasmosis:maculopapular rash,hepatosplenomegaly,microcephaly,

chorioretinitis,hydrocephalus,intracranial calcifications
Ashhadscknotes
Neonatal chlamydial conjunctivitis:occurs at 5-14 days of life,eyelid swelling,chemosis,watery/mucopurulent
discharge.Blood stained eye discharge.Tx-*ORAL erythromycin*
3758 Pediatrics Infectious Diseases Gonococcal conjunctivitis(ophthalmia neonatorum):Tx-ceftriaxone or cefotaxime[avoid ceftriaxone in infants
w/ hyperbilirubinemia since it displaces bilirubin from albumin binding sites,increasing risk of kernicterus]
Topical erythromycin->prophylaxis against gonococcal conjunctivitis

All children w/ recurrent pruritis at night should be examined for pinworms using the scotch tape test and tx
w/ mebendazole
The most common pulmonary pathogens in Cystic fibrosis(CF) are Staphylococcus aureus, Pseudomonas
aeruginosa, Haemophilus influenzae, & Streptococcus pneumoniae
S pneumoniae-mcc of pneumonia in all pts

S aureus-mcc of CF related pneumonia in infants & young children
P aeruginosa infection-occurs as early as infancy & is the mcc of CF related pneumonia in adolescents &
adults. Contributes to life-threatening decline of pulmonary function
Lyme disease prevention:
3900 Pediatrics Infectious Diseases Pts traveling to tick infested areas should wear permethrin treated pants, long sleeved shirts, and apply
insect repellents to the skin, check body for ticks, & bath right after exposure to tick infested environment
Pertussis: suspect in an a pt w/ lapse in vaccinations(eg, its been 5 years since pt last received
vaccinations), w/ severe, paroxysmal cough, inspiratory whoop, or posttussive emesis. CBC shows a
3905 Pediatrics Infectious Diseases lymphocyte-predominant leukocytosis. During the first month of illness, the dx is confirmed by *cultures &/or
polymerase chain reaction* of nasopharyngeal secretions. Tx-Macrolide antibiotics(eg, azithromycin,
clarithromycin). They should be initiated w/o waiting for confirmatory dx
*Macrolides are the abx of choice for pertussis tx & post-exposure prophylaxis.* All close contacts should be
given a macrolide antibiotic regardless of age, immunization status, or sx.
3906 Pediatrics Infectious Diseases [Contacts age >1 month should receive azithromycin, erythromycin, or clarithromycin]
[Those age <1 month should receive only azithromycin for 5 days as erythromycin use in neonates is ass.
w/ pyloric stenosis & safety data of clarithromycin is not available]
Scarlet fever: fever,toxicity,pharyngitis,sandpaper-like rash, circumoral pallor & strawberry tongue.Caused
by strains of Group A streptococcus that produce erythrogenic exotoxins.Penicillin V is drug of choice.[In a
real clinical setting,it's difficult to distinguish scarlet fever from Kawasaki disease; however,a rapid response
to penicillin therapy confirms dx of scarlet fever]
Toxic epidermal necrolysis:mucous membranes severely affected & shedding of nails may occur
Staphylococcus aureus is the mcc of bacterial pneumonia in young children w/ cystic fibrosis, esp w/
coexisting influenza infection.
tx- IV *Vancomycin* is tx of choice for severe pneumonia in this setting
4030 Pediatrics Infectious Diseases If sx don't improve, do bronchoscopy & bronchoalveolar lavage to identify bacteria flora of lungs
Signs of severe pneumonia- hypoxia, respiratory distress (eg, nasal flaring, retractions, grunting)
Immunocompetent pts who are asymptomatic & nonimmune should receive the varicella vaccine for
post-exposure prophylaxis within 3-5 days of exposure. Immunocompromised hosts who are asymptomatic
& nonimmune should receive varicella zoster immune globulin
Nonimmune neonates & immunocompromised pts should receive passive immunoprophylaxis w/ varicella
zoster immunoglobulin (VZIG) within 10 days of exposure
Acyclovir: tx of choice for ACTIVE varicella infection

4317 Pediatrics Infectious Diseases Cat bites should be treated prophylactically with a five day course of amoxicillin/clavulanate
Small cervical lymph nodes are a common observation in children & young adults. Pts w/ asymptomatic,
soft lymph nodes can be *observed* for node growth or the development of sx
Nodes <1cm diam=benign

4351 Pediatrics Infectious Diseases Nodes >2cm diam=greater likelihood of malignancy/granulomatous disease
[Nodes ass w/ cancer are firm & immobile]
Erythromycin is among 1st line agents for treating streptococcal pharyngitis & mild community acquired
pneumonia
Acute unilateral cervical lymphadenitis:
sx- rapidly enlarging fluctuant cervical lymph nodes in children, caused by streptococcal or staphylococcal
infections
tx- incision & drainage + Clindamycin (covers streptococci, Staphylococcus aureus, & is effective against
most strains of MRSA)
Although amoxicillin is effective for streptococcal infections, staphylocci produce beta lactamase which
makes penicillin/aminopenicillins ineffective. Amoxicillin poor choice for S. aureus!
4814 Pediatrics Infectious Diseases Raccoons are the most prevalent rabid animal in the US, esp on the east coast
Ashhadscknotes
Viral meningitis: Infants most commonly affected(incidence decreases w/ increasing age). CSF will show
lymphocytic predominance, normal to slightly elevated protein level, & normal glucose. CSF gram stain will
not show any organisms. MCC are the non-polio enteroviruses such as *echoviruses* & coxsackieviruses
Bacterial meningitis caused by S.pneumoniae or N.meningitidis: CSF will show neutrophils, increased
protein, & decreased glucose. Gram stain will show bacteria
Acute, unilateral cervical lymphadenitis(enlarged,tender,erythematous lymph nodes) in children is usually
caused by bacterial infection. Most common pathogen is *S. aureus*,followed by group A strep.
4843 Pediatrics Infectious Diseases EBV presents w/ bilateral subacute-chronic lymphadenopathy along w/ systemic sx like fever, pharyngitis,
hepatosplenomegaly
Peptostreptococcus:anaerobic bacteria,seen in older children w/ hx of periodontal disease

Orbital cellulitis causes pain w/ extraocular movements, *diplopia*(VERY SPECIFIC FOR ORBITAL
CELLULITIS), & ophthalmoplegia. Dangerous complications include blindness & intracranial infection
Preseptal cellulitis can be tx w/ outpt oral abx. In contrast, orbital cellulitis requires inpt IV abx
The most common predisposing factor for acute bacterial sinusitis(nasal
4850 Pediatrics Infectious Diseases drainage,congestion,cough,fever,purulent nasal drainage) is a *viral upper respiratory infection*. 1st line tx
for acute bacterial sinusitis is amoxicillin + clavulanic acid
Congenital syphilis:hepatosplenomegaly,cutaneous lesions,jaundice,anemia & rhinorrhea.Metaphyseal
dystrophy & periostitis may be seen on radiography
Congenital rubella:sensorineural hearing loss,cataracts,heart defects,hepatosplenomegaly,microcephaly &

thrombocytopenic purpura("blueberry muffin" rash)
Congenital CMV:intrauterine growth retardation,hepatosplenomegaly,petechiae or

purpura,microcephaly,chorioretinitis,sensorineural hearing loss,periventricular calcifications
Retropharyngeal abscess: suspect in children who present w/ fever, dysphagia, inability to extend the neck,
muffled voice, & lateral x-ray showing a widened prevertebral space. If no signs of respiratory compromise,
perform CT scan w/ contrast to confirm presence & size of abscess. Abscess is usually
polymicrobial(S.pyogenes,S.aureus,& anaerobes)
Epiglottitis:lateral x-ray shows swollen epiglottis "thumb sign"

Herpangia: caused by a coxsackie viral infection & presents w/ posterior oropharyngeal gray
vesicles/ulcerations, fever, & pharyngitis. Tx is supportive & consists of hydration & pain control
The vesicles in HSV gingivostomatitis localize to the anterior oropharynx & lips
Cat-scratch disease(CSD):due to *Bartonella henselae*.Localized papule w/ ipsilateral regional
lymphadenopathy in setting of cat exposure.Affected lymph nodes are enlarged,tender & have overlying
erythema.Tx-azithromycin rec,although mild cases will self-resolve
Salmonella enteritidis:carried by reptiles/turtles.Cause severe mesenteric adenitis in conjuction w/ enteritis
S.aureus & Strep.pyogenes can cause acute bacterial lymphadenitis(warm,tender,erythematous lymph

node)
Hydroceles transilluminate. Most hydroceles will spontaneously resolve by the age of 12 months.
2373 Pediatrics Male Reproductive System Communicating hydroceles that persist beyond 12 months of age are unlikely to resolve spontaneously ->
risk of indirect inguinal hernia -> tx w/surgical intervention!
Testicles that haven't descended by age 6 are unlikely to descend spontaneously & require surgery.Perform
orchiopexy before 1 year of age. These pts have patent processus vaginalis that is repaired concurrently to
8956 Pediatrics Male Reproductive System prevent inguinal hernia. Testicular torsion risk is also removed this way(since testis is surgically affixed to
scrotal wall).Early surgery improves fertility but sperm count/quality remain substandard.Surgery decreases
but doesn't eliminate testicular cancer risk
Hemolytic uremic syndrome:
etiology-90% due to E coli O157:H7 & Shigella. 10% due to S.pneumoniae(look pneumonia or meningitis
instead of diarrhea)
sx-bloody diarrhea, lethargy, irritability, pallor, bruising or petechiae, origuria, edema,
Miscellaneous
3438 Pediatrics labs-hemolytic anemia, thrombocytopenia, increased creatinine, hematuria, proteinuria, casts, increased
(Multisystem)
bilirubin
tx-fluid & electrolyte management, blood transfusions, dialysis
HSP:leg/butt purpura in the setting of normal platelet count

Duchenne muscular dystrophy(DMD):suspect in boys age <5,absent dystrophin gene & undetectable
dystrophin protein confirm diagnosis
wheelchair dependent by adolesence,death by age 20-30 from respiratory or heart failture
Miscellaneous
3544 Pediatrics Becker:onset age 5-15,milder weakness compared to DMD,death by age 40-50 from heart failure.
(Multisystem)
Decreased dystrophin
Myotonic dystrophy: occurs in teenage years, muscle weakness, myotonia, cataracts, & cardiac conduction
abnormalities, delayed muscle relaxation
Ashhadscknotes
Henoch-Schonlein purpura:common in children(esp. boys) age <15. Can occur after an URI.Palpable
purpura,hematuria,abdominal pain,arthralgias & scrotal swelling.Increased risk for ileo-ileal *intussusception*
(most cases of intussusception in children are ileo-colic)
Miscellaneous
3554 Pediatrics
(Multisystem) Increased incidence of colonic diverticula & abdominal wall/inguinal hernias seen w/ ADPKD
Meckel diverticulum: painless rectal bleeding in young children, ass. w/ an increased risk of recurrent
intussusception
Serum creatine phosphokinase & aldolase levels are elevated in screening for muscular dystrophies.
Miscellaneous
3669 Pediatrics Fibrosis & fatty infiltration on calf muscle biopsy support the dx. *Genetic studies* are the gold standard for
(Multisystem)
confirmation(it'll show deletion of the dystrophin gene on Xp21)
Marfan syndrome: upward lens dislocation
Homocystinuria: downward lens dislocation

Miscellaneous
3686 Pediatrics
(Multisystem)
Congenital contractural arachnodactyly is an autosomal dominant condition resulting from mutations of the
fibrillin-2 gene. These pts have tall stature, arachnodactyly, & multiple contractures involving large joint.
Ocular & cardiovascular sx are not present
Prader-Willi syndrome:Loss of dads copy of 15q11-q13.Sx-hypotonia,hyperphagia,obesity, weak
suck/feeding problems during infancy,intellectual disability,narrow forehead,almond shaped
eyes,downturned mouth.Pts at risk for sleep apnea,type 2 diabetes,& gastric rupture
Miscellaneous
3821 Pediatrics
(Multisystem) Angelman syndrome: Loss of moms copy of 15q11-q13, frequent smiling/laughter,
hand-flapping,ataxia,seizures
Beckwith-Wiedemann syndrome: macroglossia,rapid growth,umbilical hernia,omphalocele,hemihyperplasia

3 P's of McCune-Albright syndrome: Precocious puberty, Pigmentation(cafe au lait spots), & Polyostotic
fibrous dysplasia(multiple bone defects)
Miscellaneous
3871 Pediatrics
(Multisystem)
McCune-Albright syndrome has been attributed to a defect in the G-protein cAMP-kinase function in the
affected tissue, thereby resulting in autonomous activity of that tissue
Kallman syndrome:Disorder of migration of fetal GnRH & olfactory neurons.Delayed/absent puberty &
Miscellaneous anosmia.The karyotype will be consistent w/ their male or female phenotype(eg,Female w/ Kallmann
3912 Pediatrics
(Multisystem) syndome will have *46 XX* karyotype).FSH & LH levels are low,consistent w/ gonadotropin-releasing
hormone deficiency(absence of GnRH secretion results in short stature & delayed/absent puberty)
Friedreich ataxia is the most common type of spinocerebellar ataxias.Rmr the combo of
Miscellaneous neurologic(ataxia,dysarthria),skeletal(scoliosis,feet deformities) & cardiac(concentric hypertrophic
3985 Pediatrics
(Multisystem) cardiomyopathy) manifestations of the disease.The mcc of death are cardiomyopathy & resp complications.
*Very high-yield topic for USMLE*
congenital lymphedema:
Miscellaneous
4764 Pediatrics occurs in newborn girls that have turner syndrome
(Multisystem)
occurs due to abnormal development/dysgenesis of lymphatic system
Pts w/ Turner syndrome have higher risk of osteoporosis due to lower estrogen levels.
There is also thought to be increased risk from having only one copy of X chromosome genes that may be
involved in bone metabolism.
Miscellaneous
4765 Pediatrics
(Multisystem) Most pts w/ Turner syndrome have normal cognitive abilities
Pts w/ Turner syndrome don't have any additional risk of breast cancer(Turner pts have low estrogen and
breast cancer is ass. w/ high estrogen levels)
Absence seizures Tx: ethosuximide or *valproate/valproic acid*
2279 Pediatrics Nervous System Prednisone can be used for tx of infantile spasms
Phenytoin is the initial drug of choice for partial seizures. Gabapentin is also effective
Complex partial seizure:
lasts for a few minutes,failure to respond to various stimuli during episode,staring spells, automatisms e.g.lip
smacking, swallowing, picking movements of the hand), & post-ictal confusion.EEG pattern is usually normal
or may show brief discharges
2280 Pediatrics Nervous System
Typical absence seizure:lasts for a few seconds, No post-ictal state,3Hz spike & wave pattern
Lennox Gastaut syndrome- seizures, in childhood, impaired cognitive function, slow spike&wave activity on
EEG
Friedreich Ataxia(FA): ass. w/ necrosis & degeneration of cardiac muscle fibers leading to
myocarditis(T-wave inversion seen), myocardial fibrosis & cardiomyopathy. Cardiac arrhythmia & CHF
contribute to a significant number of deaths. *Genetic counseling is rec for prenatal dx for parents w/ one
affected child*
Fragile X syndrome: large head, long face, prominent forehead & chin, protruding ears, joint laxity, large
testes. Behavioral abnormalities like hyperactivity, short attention span, autism. Due to full mutation in
FMR1 gene caused by increased number of CGG trinucleotide repeats accompanied by aberrant
methylation of the FMR1 gene
Ashhadscknotes
Long-term neurologic sequelae ass. w/ bacterial meningitis: hearing loss, loss of cognitive functions(due to
neuronal loss in the dentate gyrus of hippocampus), seizures, mental retardation, spasticity or paresis
2442 Pediatrics Nervous System Ceftriaxone use has been ass. w/ eosinophilia, thrombocytosis, leukopenia, bleeding, skin rash, & increased
creatinine, AST, ALT, & bilirubin levels
Alexia: acquired disorder of reading due to brain injury in a person who was previously literate
Cerebral palsy:
nonprogressive motor dysfunction
2443 Pediatrics Nervous System etiology- multifactorial, prematurity is leading risk factor
sx- hypertonia & hyperreflexia involving lower extremities w/ feet pointing down and inward (equinovarus
deformity). Resistance to passive muscle movement.
Fetal hydantoin syndrome:
sx- hypoplastic fingers/nails and cleft lip/palate
phenytoin increases rate of fetal vitamin K degradation so pregnant women (who are on phenytoin during
their last trimester) are given prophylactic vitamin K to prevent neonatal bleeding
Niemann-Pick disease type A:sphingomyelinase deficiency,presents at age 2-6 months w/
AREFLEXIA,HEPATOSPLENOMEGALY,"cherry-red" macula & developmental milestone regression
Tay-Sachs:B-hexosaminidase A deficiency.Loss of motor milestones,hypotonia,"cherry-red"

macula.HYPERREFLEXIA & NO HEPATOSPLENOMEGALY
Gaucher dis:anemia,thrombocytopenia,hepatosplenomegaly
Hurler syndrome:at 6mo-2 yrs w/ coarse facial features,inguinal/umbilical hernias,corneal

clouding,hepatosplenomegaly
Infant botulism:ingestion of *Clostridium botulinum spores*->colonization of gut->production/release of
neurotoxin that causes descending flaccid paralysis.Dx-previously healthy infant who presents w/ bulbar
palsies,constipation & hypotonia,even if infant hasn't been fed honey.Tx-Human-derived botulism immune
2469 Pediatrics Nervous System globulin
Foodborne botulism:from ingestion of canned food containing preformed botulinum

toxin.Nausea,vomiting,ab pain,diarrhea PRECEDE the descending flaccid paralysis
Cephalohematoma:
Limited to the surface of one cranial bone. No discoloration of the overlying scalp. Swelling not visible until
several hours after birth.
tx- no tx since they resorb spontaneously over time
2472 Pediatrics Nervous System Caput succedaneum: diffuse/ecchymotic swelling of scalp involving portion of head presenting during vertex
delivery. Extend across midline & suture lines
Cranial meningocele: pulsations, increased pressure upon crying, bony defects
Craniopharyngiomas:calcified(look at an MRI/CT image),intracranial tumors that occur in the suprasellar

region. Sx-bitemporal hemianopsia(causing pts to run into corners of walls/furniture) & pituitary hormonal
deficiencies(eg, diabetes insipidus[polyuria/polydipsia,high-normal serum sodium,dilute urine] and growth
hormone deficiency)
1 year old female w/ neurofibromatosis 1:
sx- cafe-au-lait spots, macrocephaly, feeding problems, short stature, & learning disabilities
Partial seizure w/ secondary generalization: Tonic clonic manifestations(diffuse muscle aches/soreness,
elevated CPK/creatine kinase). Presence of blood tinged sputum would suggest pt bit his tongue, making
this type of seizure more likely. Loss of bladder or bowel control(eg,urinary incontinence) more likely w/
2680 Pediatrics Nervous System these types of seizures
Lennox-Gastaut syndrome:variety of diff seizure types.Pts usually age <7 years & have coexisting mental
retardation (intellectual disability)
Sturge Weber syndrome:
presentation-mental retardation, port wine stain or nevus flammeus along trigeminal nerve
territory(represents a unilateral cavernous hemangioma)
sx- seizures, hemianopia, hemiparesis, hemisensory disturbance, ipsilateral glaucoma, gyriform intracranial
calcifications
tx- control seizures, reduce intraocular pressure, argon laser therapy to remove skin lesions
Cuteneous abnormality in tuberous sclerosis is called adenoma sebaceum

Phenylketonuria: severe intellectual disability, seizures, musty/mousy body odor, hypopigmentation of skin,
hair, eyes & brain nuclei. Dx- Newborn screening, *Quantitative amino acid analysis for later in life(it'll show
elevated phenylalanine levels)*. Tx-low phenylalanine diet
Hereditary fructose intolerance: Aldolase B deficiency, infants can get vomiting, poor feeding, lethargy.
Seizures/encephalopathy follow if fructose not removed from diet
Ashhadscknotes
Glucose 6 phosphatase def:3-4 mo old,hypoglycemia,lactic acidosis,hyperuricemia,hyperlipidemia,doll
face(fat cheeks),thin extremities,short stature,protuberant abdomen(enlarged liver/kidneys),seizures
Acid maltase def:floppy baby,feeding difficulties,macroglossia,heart failure(hypertrophic cardiomyopathy)
Debranching enzyme deficiency:mild form of type 1 w/ normal lactate

Branching enzyme def:pt in first 18 mo of life,hepatosplenomegaly,failure to thrive,cirrhosis
Galactosemia: *galactose-1-phosphate uridyl transferase deficiency* -> elevated blood levels of galactose.
Failure to thrive, bilateral cataracts, jaundice & hypoglycemia.Tx-elimination of galactose from the diet(early
tx reverses growth failure & organ dysfunctions,improve eyesight[cataracts may regress])
Galactokinase deficiency:cataracts only
Uridyl diphosphate galactose-4-epimerase deficiency: Rare. Hypotonia & nerve deafness,in addition to sx of
transferase deficiency
Abusive head trauma(shaken baby syndrome): mcc of death from child abuse. Repetitive
acceleration-deceleration forces cause *shearing of the dural veins* & vitreoretinal traction. Seizures,
altered mental status, increasing head circumference, bilateral retinal hemorrhages
Cortical dysplasia is a congenital abnormality of neurons that is a common seizure focus in children w/
epilepsy
Absence (petit mal) seizures are characterized by a sudden cessation of mental activity. An episode is very
short, but may occur repeatedly throughout the day. There are no ass complex automatisms or tonic clonic
activity. The dx is best confirmed by *EEG studies*
EMG studies are used to diagnose peripheral nerve disorders. EMG is used to analyze the neuromuscular
system, differentiate diseases of the neuromuscular system from primary neuropathies
For symptomatic Neurofibromatosis type 1 pts, do MRI of brain and orbits. It's more sensitive and specific
than CT.
NF1 tumor supressor gene; codes the protein neurofibromin
NF2 tumor suppressor gene; codes the protein merlin
Intraventricular hemorrhage:
sx- infant w/ seizures, bulging fontanel, focal neurologic signs
3657 Pediatrics Nervous System results from bleeding in the germinal matrix
seen in premature and low birth weight infants
it's asymptomatic so necessary to do transfontanel ultrasound for newborns w/ risk factors
Myotonic muscular dystrophy type 1 (Steinert disease): *autosomal dominant disorder*, facial weakness,
hand grip myotonia(delayed muscle relaxation;notable when pt unable to release hand after handshake),
dysphagia(risk of aspiration pneumonia), foot drop, & cardiac conduction anomalies. Other problems include
cataracts, testicular atrophy/infertility, & baldness
Guillain-Barre syndrome:suspect in pt w/ ascending polyneuropathy after recent GI or respiratory infection.
3664 Pediatrics Nervous System Underlying pathology involves mainly the *peripheral motor nerves* (sensory & autonomic nerves may also
be affected)
*Intraventricular hemorrhage* is a common complication in premature & underweight neonates.
Accumulation of blood in the subarachnoid space can impair the ability of the arachnoid villi to absorb CSF,
3666 Pediatrics Nervous System resulting in communicating hydrocephalus. Affected neonates are at risk for permanent neurodevelopmental
problems & death. Prevention of preterm labor & antenatal admin of maternal corticosteroids can reduce
incidence of IVH & improve mortality
Over 90% of medulloblastomas develop in the vermis
Cerebellar hemispheres are the site of astrocytoma & cerebellar abscess
Migraine headaches:common in pediatric population.Unilateral or bifrontal

pain,photophobia,phonophobia,nausea,vomiting,visual/auditory/or linguistic
aura.Tx-acetaminophen,NSAIDs,supportive management.Triptans used if these measures aren't effective
Indications for neuroimaging in a child w/ headache include hx of coordination difficulties,presence of
numbness,tingling,focal neurologic signs,hx of headache that causes awakening from sleep,hx of increasing
headache frequency
Ashhadscknotes
Homocystinuria:
sx- marfanoid features, along with intellectual disability, thrombosis, downward lens dislocation, fair complex
eg "child with fair hair and eyes, developmental delay, cerebrovascular accident"
Fabry disease:
sx- angiokeratomas, peripheral neuropathy, corneal dystrophy. Pts can develop renal and heart failure &
risk for thromboembolic events
Krabbe disease:
sx- intellectual disability, blindness, deadness, paralysis, neuropathy, seizures
Neuroblastoma:Common in peds population.Arises from*neural crest cells*.Most common site is
abdomen(adrenals or retroperitoneal ganglia).Calcifications & hemorrhages on plain x-ray/CT scan.Levels of
serum & urine catecholamines & their metabolites(HVA & VMA) are elevated
3824 Pediatrics Nervous System Wilms' tumor arises from metanephros(precursor of renal parenchyma)
Mesonephros -> seminal vesicles,epididymis,ejaculatory ducts,ductus deferens
Paramesonephron -> fallopian tubes,uterus,part of the vagina

*Internal carotid artery dissection* is a potential cause of stroke in children that is usually ass. w/ a hx of
trauma to the soft palate w/ a foreign body(eg pencil accidentally lodging to the roof of the mouth in a child)
Todd paralysis is a transient, focal neurologic deficit(usually hemiparesis) that occurs after a seizure. Sx are
self-limited as the hemiparesis usually resolves within hours
Nocturnal headaches & morning vomiting are red flags for intracranial pathology. Contiguous spread of
bacteria from otitis or mastoiditis can result in life-threatening brain abscess formation. Dx is confirmed by
4248 Pediatrics Nervous System the presence of a ring-enhancing lesion on *computed tomography scan(CT better at depicting bone) or
magnetic resonance imaging(MRI superior for soft tissue details)*
[Headaches are the most common sx of brain abscess]
Guillain-Barre syn presents w/ ascending flaccid paralysis(ascending muscle weakness &
areflexia).Involvement of respiratory & bulbar muscles puts pts at high risk for respiratory failure.Serial
measurements of FVC w/ *spirometry* are best means of monitoring respiratory function
If spirometry not readily available or is difficult in an unstable pt,peak flow meter testing should be
performed(peak expir flow rate is less accurate than FVC in determining ventilation adequacy)
Syncope: preceded by nausea, warmth, lightheadedness, diaphoresis. Pallor & weak pulses suggest
syncope over seizures. Immediate sponteneous return to baseline neurologic function
Seizures: can be due to alcohol withdrawal, sleep deprivation, exposure to flashing lights. Pt can get tongue
laceration. Delayed return to baseline neurologic function
Simple febrile seizures do not require any workup. Pts can be discharged home from the ER w/ reassurance
about a good prognosis
Rectal, IM, or IV abortive therapy should be provided for seizures >5 minutes as prolonged seizures
increase the risk of airway compromise
Pts w/ hx of cyanotic congenital heart disease(TOF) & recurrent sinusitis are at risk for brain abscesses.
TOF->right to left shunt of blood thru VSD bypasses pulmonary circulation(where bacteria are typically
filtered & removed by phagocytosis)->poor perfusion to brain->bacterial seeding at gray white matter
junction. [Brain abscess can present w/ fever, headache, focal neurologic deficits, & seizure]
Unrepaired TOF->venous clot crosses VSD & into left ventricle->stroke

Increasing head circumference & signs of increased intracranial pressure in children should be evaluated w/
an imaging study such as a *CT scan* of the brain. Infants w/ hydrocephalus present w/ poor feeding,
irritability, decreased activity, vomiting, tense/bulging fontanelle, prominent scalp veins, widely spaced
cranial sutures, rapidly increasing head circumference
Breath holding spells:
occur in children age 6 months-2 years
Cyanotic breath holding spell is benign, brief period of apnea & skin color change ass. w/ emotional trigger
4872 Pediatrics Nervous System "Infant turns blue after a scream & becomes unresponsive for a few seconds, then goes back to normal"
Pallid spells are triggered by minor trauma, sx- pallor & diaphoresis
management-obtain a complete blood count and serum ferritin levels(iron defcicency anemia ass. w/ breath
holding spells)
7741 Pediatrics Nervous System A two-year old should be able to combine words into two-word phrases
Trachoma: caused by Chlamydia trachomatis serotype A-C. Major cause of blindness worldwide. Presents
w/ follicular conjunctivitis & pannus (neovascularization) formation in the cornea. Concurrent infection occurs
in nasopharynx, leading to nasal discharge. Tx-topical tetracycline or oral azithromycin
2857 Pediatrics Ophthalmology
Herpes simplex keratitis: pain, photophobia, decreased vision. Dendritic ulcer is the most common
presentation. Minute clear vesicles in corneal epithelium
Ashhadscknotes
Gonococcal conjunctivitis: Copious purulent ocular drainage & eyelid swelling in a 2-5 day old newborn.
Prevent w/ topical erythromycin ointment within 1 hour of birth.
Conjunctivitis caused by Chlamydia trachomatis is milder & presents 5-14 days after birth
Silver nitrate eye drops cause chemical conjunctivitis
Dacryostenosis: nasolacrimal duct obstruction, chronic unilateral tearing. Sx resolve w/ gental massage of
nasolacrimal sac
Every case of leukocoria(white reflex in the eye) is considered a retinoblastoma, until proven otherwise;
therefore, such cases should be promptly referred to an ophthalmologist. [Extremely high yield question!!!]
Initial tx for strabismus in children involves covering the normal eye
Strabismus after age 4 months is abnormal and requires tx to prevent amblyopia. Asymmetric corneal light
reflections & deviation on cover test are concerning findings. Tx- Occlusion (patching) or penalization
(blurring) of the normal eye
White reflex on abnormal eye can result from opacities of the lens (eg, cataract), or tumor (eg,
retinoblastoma)
Congenital glaucoma:Children have sensitivity to light & have excessive lacrimation
Reassurance indicated for pseudostrabismus

Visual acuity testing should begin at age 3 w/ the tumbling E or Snellen chart
Pre-1978 housing is a risk factor for environmental lead exposure
Quadrivalent meningococcal vaccination: administered at age 11-12 followed by booster dose at age 16 due
to risk of college outbreaks.Children w/ asplenia,HIV & complement deficiency may be vaccinated as early
as 2
Rotavirus vaccine recommended at age 2-8 months as infants are at risk for dehydration from severe
gastroenteritis
*Bacterial sinusitis* is the most common predisposing factor for orbital cellulitis.
Orbital cellulitis sx- proptosis, ophthalmoplegia, & diplopia
Caustic ingestions: Upper gi endoscopy is the dx study of choice to evaluate extent of injury
Poisoning &
2378 Pediatrics
Environmental Exposure All pts w/ persistent dysphagia or significant esophageal burns on endoscopy should undergo barium
contrast studies 2-3 weeks after ingestion to assess for esophageal strictures or pyloric stenosis
Children can confuse mom's pre-natal vitamins(bright colored iron pills) for candy and accidentally ingest
Poisoning & them -> Iron poisoning(abdominal pain,hematemesis, shock, metabolic acidosis)
2655 Pediatrics
Environmental Exposure Tx-*deferoxamine*
[Pre-natal vitamins rich in iron appear as radiopaque tablets on abdominal x-ray]
Acute iron poisoning:ab pain,hematemesis,metabolic acidosis.Severely affected pts get hypotensive shock
& anion-gap metabolic acidosis.Survivors at risk of gastric scarring.Iron is RADIOPAQUE & ingested tablets
can be seen on x-ray
Poisoning &
3827 Pediatrics Lead poisoning:chronic process,identified on lab screening.NOT corrosive to gastric mucosa
Acute aspirin poisoning:tinnitus,fever,hyperpnea(resp alk),met acid
Vit K toxicity:rare,can cause hemolytic anemia & hyperbilirubinemia in infants

Children w/ lead toxicity:
Can be asymptomatic. Require screening if they live in home build before 1978 or play w/ toys from older
generations.
Measure the venous lead level!
Poisoning &
4837 Pediatrics
Dimercaptosuccinic acid (DMSA, Succimer) is used when lead levels are 45-69 ug/dL
Dimercaprol plus calcium disodium edetate (EDTA) is used on an emergency basis for levels >70 ug/dL or
acute encephalopathy
Neonatal displaced clavicular fracture:
sx-crepitus over the clavicle, asymmetric moro reflex, crying/pain w/ passive motion of affected extremity
RF-fetal macrosomia(maternal diabetes,post term pregnancy), instrumental delivery(vacuum or forceps),
Pregnancy, Childbirth & shoulder dystocia.
2485 Pediatrics
Puerperium Management-most neonatal clavicular fractures heal spontaneously, so *provide parental reassurance &
guide them on gentle handling*
Scalp edema(caput succedaneum):result of vacuum used to assist delivery

Pregnancy, Childbirth & Thermoregulatory center is underdeveloped in newborns and they can lose heat easily. Thats why quick
4174 Pediatrics
Puerperium drying & keeping warm is important in early neonatal care
Ashhadscknotes
Maternal hyperglycemia is a significant risk factor for fetal macrosomia. Euglycemia during pregnancy is
4223 Pediatrics extremelly important to prevent perinatal & neonatal morbidity. Prophylactic cesarean section & induction of
Puerperium
labor have not been consistently shown to prevent complications related to shoulder dystocia
Small for gestational age infants may have complications such as
Pregnancy, Childbirth & hypoxia,polycythemia,hypoglycemia,hypothermia & hypocalcemia(polycythemia is due to fetal hypoxia).
4889 Pediatrics
Puerperium
Large for gestational age infants are at risk for developing hip subluxation and talipes calcaneovalgus
Give anorexia nervosa pts Olanzapine if no response to cognitive behavioral therapy or nutritional
rehabilitation
Psychiatric/Behavioral & Give bulimia nervosa pts SSRI meds in combination w/ cognitive behavioral therapy & nutritional
2353 Pediatrics
Substance Abuse rehabilitation
Bupropion is contraindicated in pts w/ eating disorders as it can provoke seizures

Autism spectrum disorder: suspect in children w/ imparied social interaction & communication, restricted
interests, insistence on routine, delayed language development(Autism spectrum disorder can occur w/ or
2471 Pediatrics w/o language impairment), varying degrees of intellectual impairment.
Substance Abuse
Asperger syndrome is high functioning autism
Psychiatric/Behavioral & Methylphenidate is used to treat ADHD. Side effects include nervousness,*decreased appetite*, weight loss,
2504 Pediatrics
Substance Abuse insomnia, & abdominal pain
Psychiatric/Behavioral & Social(pragmatic) communication disorder is characterized by impaired communication w/o evidence of
2516 Pediatrics
Substance Abuse restricted interests or repetitive behavioral patterns
Tourette disorder is best treated w/ second-generation antipsychotics such as *risperidone* along w/ habit
reversal training
3375 Pediatrics
Substance Abuse Benztropine is an anticholinergic medication used to treat & prevent extrapyramidal side effects ass. w/
antipsychotics
Stranger anxiety is normal in children until age 3 years.After that age, its attributed to other causes
Separation anxiety:excessive distress when separated from home,excessive worry about losing attachment
3380 Pediatrics figures,refusal to go to school due to fear of separation,nightmares about separation from attachment
Substance Abuse
figure, physical complains like headaches,nausea,abdominal pain
Selective mutism: child talks at home but refuses to speak at school/other settings
Trichotillomania: patches will have broken hair of varying lengths. Tx- habit reversal training (a form of
Psychiatric/Behavioral & cognitive behavioral therapy)
3384 Pediatrics
Substance Abuse
Alopecia areata: patches will be devoid of hair
Pyromania: deliberate fire setting on more than 1 occasion, tension/arousal prior to act, fascination w/ fire &
its consequences, pleasure or relief when setting/witnessing fires, no external gain,revenge,political
motivation, not done to attract attention
3386 Pediatrics
Substance Abuse
Dx of conduct disorder requires at least 3 of 15 behaviors that fall into 4 categories: aggresion toward
people & animals, deceitfulness or theft, destruction of property(includes fire setting),& serious violation of
rules
4041 Pediatrics Cocaine abuse: pt w/ weight loss, behavioral changes, & erythema of turbinates & nasal septum
Substance Abuse
Psychiatric/Behavioral & Dx of ADHD is based on clinical evaluation of sx & associated impairment in 2 different settings. Teacher
4855 Pediatrics
Substance Abuse evaluations are important for assessing behavior in the school environment.
Neonatal abstinence syndrome:caused by infant withdrawal to opiates(*heroin*,methadone) & presents in
4893 Pediatrics the first few days of life.Sx-irritability,high pitched cry,poor
Substance Abuse
sleeping,tremors,seizures,sweating,sneezing,tachypnea,poor feeding,vomiting,& diarrhea
8923 Pediatrics OCD tx: SSRI's and psychotherapy
Substance Abuse
The first step in management of a newborn w/ respiratory compromise & suspected congenital
diaphragmatic hernia is *endotracheal intubation*. Bag-and-mask ventilation can exacerbate respiratory
decline. A gastric tube should be placed immediately to decompress the stomach and bowel
2435 Pediatrics Pulmonary & Critical Care
Congenital diaphragmatic hernia:pulmonary hypoplasia,pulmonary htn,85% occur on left,15% occur on
right.Polyhydramnios due to esophageal compression,concave abdomen,barrel-shaped chest
Foreign body aspiration(FBA): sudden onset respiratory distress in a toddler. Hx of choking. Focal
monophonic wheezing on affected side. Diminished aeration on affected side. Hyperinflation or atelectasis of
affected side(radiographic findings not always seen). More than half of aspirated FBs end up in the right
mainstem bronchus. Tx-immediate *bronchoscopy* to remove foreign body
Respiratory distress syndrome(RDS) should be suspected when a premature infant presents w/ grunting,
flaring, retractions, cyanosis immediately after birth. Surfactant deficiency is the primary problem. Chest
2473 Pediatrics Pulmonary & Critical Care x-ray includes characteristic fine reticular granularity (ground-glass) of the lungs. Risk of RDS reduced by
administration of maternal antenatal glucocorticoids, which stimulates fetal surfactant. Neonatal tx includes
early continuous positive air pressure ventilation
Ashhadscknotes
Epiglottitis:
sx- fever, sudden respiratory distress, dysphagia, drooling, children are toxic appearing and may be
3289 Pediatrics Pulmonary & Critical Care "tripoding" (sitting up and leaning forward) with inspiratory stridor
tx- first secure pt's airway with endotracheal intubation
if endotracheal intubation unsuccessful, emergency tracheotomy should be performed
Severe coughing paroxysms can cause subcutaneous emphysema wherein air leaks from chest well into
the subcutaneous tissues due to the high intraalveolar pressure provoked by the cough. By a similar
process, pneumothorax can occur, therefore in such pts *chest x-rays* must be obtained emergently to rule
out pneumothorax
Pts w/ asthma(reactive airway disease) unresponsive to meds who have fatigue, altered mental status, CO2
retention, worsening hypoxemia, & poor air movement on examination require *endotracheal intubation &
3459 Pediatrics Pulmonary & Critical Care mechanical ventilation*
[Tracheostomy is used to relieve upper airway obstruction. It's never done to treat asthma, which is a
disease of lower airways]
cystic fibrosis:
sx- recurrent sinopulmonary infections, chronic cough, nasal polyps, digital clubbing
3531 Pediatrics Pulmonary & Critical Care parents often first cousins or stem will mention parental consanguinity
tx- glucocorticoids for symptomatic relief
can do surgical resection of nasal polyps but polyps will regrow
cystic fibrosis:
sweat chloride testing by quantitative pilocarpine iontophoresis is gold standard for diagnosis
Exhaled nasal nitric oxide is a screening test for primary ciliary dyskinesia
Bronchiolitis: winter respiratory tract infection, caused by RSV, wheezing, crackles, respiratory distress.
Tx-supportive(hydration,saline nasal drops, nasal bulb suction). Palivizumab used for prophylaxis in children
age <2 years who are at high risk. Infants age <2 months at high risk for developing *apnea* & respiratory
failure & at risk for recurrent wheezing throughout childhood
Bronchiolitis ass. w/ increased risk of acute otitis media

Kartagener's syndrome:Autosomal recessive disorder.Sinusitis,bronchiectasis,dextrocardia. Caused by
primary ciliary dyskinesia.
CF:bilateral lung transplantation is the only life-saving tx

Aspiration of foreign body/endobronchial masses leads to endobronchial obstruction
Congenital bronchiectasis occurs at site of pre/postnatal development defect of the bronchial system.
Formation of cysts,cul de sacs,or bronchomalacia leads to pooling of secretions & bacterial infections
Pts w/ hx of anaphylaxis should carry self-injectable epinephrine at all times(even if they are adolescents eg,
4638 Pediatrics Pulmonary & Critical Care a 12 year old boy). Triggers from hymenoptera stings should prompt referral to an allergist for venom
immunotherapy.
Treat anaphylaxis w/ intramuscular epinephrine (1st line treatment)
Delays in administering epinephrine in anaphylactic pts can increase the risk of respiratory decline
Pts w/ signs of respiratory decline (eg. worsening of severe hypoxia, stridor) and/or altered mental status
require emergent intubation.
(Google image) Large thymic silhouette is a normal finding on frontal CXR in children age <3 years due to
its relatively large size compared to the young child's thorax. Recognized as the "sail sign" due to triangular
4829 Pediatrics Pulmonary & Critical Care shape(can shrink/get large). Thymus is an important organ in utero/infancy/childhood for lymphocyte
production & maturation. Thymus normally atrophies & is replaced by fat after puberty. Residual thymic
tissue can undergo malignant transformation-> thymoma.
Respiratory distress syndrome(RDS) is caused by surfactant deficiency. Important risk factors include
*prematurity & maternal diabetes mellitus*(maternal hyperglycemia->fetal hyperglycemia->fetal
hyperinsulinism->high levels of circulating insulin antagonize cortisol & block maturation of sphingomelin, a
4831 Pediatrics Pulmonary & Critical Care vital component of surfactant
Intrauterine growth restriction, maternal HTN, & chronic intrauterine stress from prolonged rupture of
membranes decrease risk of RDS
Cystic fibrosis (CF) pt's have infertility (>95% men, 20% women)
CF pts get exocrine pancreatic insufficiency, however rarely do they get pancreatitis (only 10% of pts)
CF pts can also get CF related diabetes, osteopenia, kyphoscholiosis, and digital clubbing
Risk of gi malignancies is increased in CF, esp if pts have undergone lung transplantation
Ashhadscknotes
Recurrent cystitis:sx-suprapubic pain, dysuria, pyuria, & bacteriuria. Chronic constipation is a risk factor in
toddlers. Impacted stool can cause rectal distension, which in turn compresses the bladder, prevents
complete voiding, & leads to urinary stasis
2226 Pediatrics
Electrolytes Risk factors of constipation include dietary changes, such as transition from breast milk to cow's milk & solid
foods
Voiding cystoureterogram is the imaging study of choice to detect structural abnormalities

Alport's syndrome: presents in childhood as recurrent gross hematuria & proteinuria. Sensorineural
deafness usually occurs. Electron microscopy findings include alternating areas of thinned & thickened
2233 Pediatrics capillary loops w/ splitting of the glomerular basement membrane
Electrolytes
Thin basement membrane disease presents in adulthood as microscopic hematuria w/o proteinuria
Transient proteinuria: mcc of isolated proteinuria in children
2234 Pediatrics can be caused by fever, exercise, seizures, stress, or volume depletion
Electrolytes
Reevaluate w/ a repeat urine dipstick testing on two separate occasions to rule out persistent proteinuria
Monosymptomatic (isolated) enuresis:
urinary incontinence in children age >5
tx- *Desmopressin* 1st line esp for bedwetting
Tricyclic antidepressants(imipramine,amitriptyline, desipramine) are 2nd line. For pts w/ no response to
Renal, Urinary Systems & Desmopressin.
2513 Pediatrics
Electrolytes
Oxybutynin causes urinary retention. It's used in combination w/ desmopressin for children w/ daytime
incontinence
Voiding cystourethrogram diagnoses urinary reflux

Pyloric stenosis presents at age 3-5 weeks w/ projectile, nonbilious vomiting that occurs after each feed.
Protracted vomiting produces a *hypochloremic, hypokalemic metabolic alkalosis* that should be corrected
Renal, Urinary Systems & prior to pyloromyotomy
2794 Pediatrics
Electrolytes
Metabolic acidosis can occur when vomiting is accompanied by diarrhea as significant amounts of
bicarbonate are lost in the stool
Renal, Urinary Systems & Polyuria & polydipsia are classic features of new-onset type 1 diabetes mellitus(*autoimmune destruction of
3548 Pediatrics
Electrolytes pancreatic beta cells*). Nocturnal enuresis can be a presenting sx in toddlers
Wilms tumor: suspect in a toddler w/ a firm, smooth, unilateral abdominal mass & hematuria. It's the most
common pediatric renal malignancy
3552 Pediatrics
Electrolytes
Neuroblastoma: common in first year of life, can arise anywhere in the sympathetic nervous system but
typically involves the adrenal glands & presents as abdominal mass that crosses the midline w/ systemic sx
Vesicoureteral reflux(VUR) is a risk factor for recurrent urinary tract infections, which can lead to
progressive renal scarring.
Renal, Urinary Systems & The gold standard modality for dx VUR is a voiding cystourethrogram(VCUG). VCUGs rec. in pts w/
3688 Pediatrics
Electrolytes recurrent UTIs.
Risk factors for the development of renal cell carcinoma include cigarette smoking, hypertension, & diabetes
mellitus
Children age <2 years w/ a first febrile UTI should be tx w/ 1-2 weeks of abx. A renal & bladder *ultrasound*
Renal, Urinary Systems & should be ordered to evaluate for abnormalities that lead to recurrent UTIs. Voiding cystourethrogram is
3692 Pediatrics
Electrolytes generally not indicated for a first febrile UTI unless there are abnormalities on renal ultrasound or if the pt is
a neonate
Severe vesicoureteral reflux can cause recurrent or chronic pyelonephritis. Complications include
parenchymal scarring, hypertension, & renal insufficiency. Definitive diagnosis is made by voiding
Renal, Urinary Systems & cystourethrogram.
3694 Pediatrics
Electrolytes
Posterior urethral valves are the mcc of chronic renal insufficiency/failure in children. The distal urinary tract
obstruction can cause secondary urinary reflux but the condition affects only boys
*Membranous nephropathy* is a common cause of nephrotic syndrome(edema, proteinuria, &
3940 Pediatrics hypoalbuminemia) in adolescents(eg a 14 y/o) & adults. *Active heptatitis B infection is an imp risk factor*, &
Electrolytes
vaccination reduces this risk
Pts w/ sickle cell trait have no specific clinical sx of sickle cell disease & no change in overall life expectancy.
3967 Pediatrics Renal complications include painless hematuria(due to renal papillary ischemia or *renal papillary necrosis*),
Electrolytes
UTIs, & renal medullary cancer. UA shows normal-appearing RBCs
Perform urinalysis & urine culture as preliminary studies in all children w/ suspected uti.Pts in diapers should
undergo straight catheterization(to avoid contamination)
Renal, Urinary Systems & UTI RF in infants-girls any age(short urethra),uncircumcised boys age <1,& underlying renal anomaly.Sx
4005 Pediatrics
Electrolytes during infancy are vague(fever, fussiness,decreased urine output).Fever in any child <3 years prompts
evaluation for UTI
Mid stream clean catch urine specimen: use for pts who don't wear diapers
Ashhadscknotes
Minimal change disease(MCD): Path- T cell mediated injury to podocytes causes increased molecular
permeability to albumin.
Renal, Urinary Systems & Mcc of nephrotic syndrome in young children. Renal biopsy is not required for initial diagnosis! *Instead,
4018 Pediatrics
Electrolytes proceed directly with giving steroids(Prednisone).* 85% of children will respond to their first steroid course
Renal scintigraphy is used to evaluate renal function & is useful in the setting of kidney dysfunction
Minimal change disease:renal biopsy shows normal kidney architecture but isn't usually obtained in pts age
<10.Diffuse effacement of foot processes of podocytes on EM
Focal glomerulosclerosis:crescent formation,mcc of nephrotic syn in adults,may be rapidly progressive

4059 Pediatrics
Electrolytes
Membranous glomerulonephritis:thickened basement membrane,subepithelial spikes,2nd mcc of nephrotic
syn in adults
membranoproliferative glomerulonephritis:mesangial hypercellularity,nephritic syndrome

Renal, Urinary Systems & UTI most commonly arises by bacteria ascending into the bladder from the vaginal introitus. Sexual
4196 Pediatrics
Electrolytes intercourse is an important risk factor for UTIs in women.
Henoch-Schonlein purpura: IgA mediated vasculitis of the small vessels that is most common in children.
4279 Pediatrics Palpable purpura on lower extremities, arthralgias/arthritis affecting knees & ankles, abdominal pain, & renal
Electrolytes
disease. *Deposition of IgA in the mesangium*
Posterior urethral valves(mcc of urinary tract obstruction in newborn boys)->poor urine output in
utero->oligohydramnios(low amniotic fluid)->restriction of fetal movement,physical anomalies like flat facies
& limb deformities[Potter sequence]->high perinatal portality(normal amniotic fluid levels required for lung
Renal, Urinary Systems & development)
4548 Pediatrics
Electrolytes
Wilms tumor-presents at age 2-5 years w/ large,palpable flank mass but no sx
Atretic duodenum obstructs amniotic fluid clearance->polyhydramnios

Renal tubular acidosis: caused by a defect in either hydrogen excretion or bicarbonate resorption in the
kidney. In infancy, it presents w/ failure to thrive due to a chronic, normal anion gap metabolic acidosis. Tx-
oral bicarbonate replacement
4828 Pediatrics Type 1 RTA:often a genetic disorder,ass. w/ nephrolithiasis
Electrolytes
Type 2 RTA:component of Fanconi syndrome(glucosuria,aminoaciduria,& phosphaturia)
Type 4 RTA:obstructive uropathy & aldosterone insufficiency are common causes in children
Renal, Urinary Systems & Isotonic solutions such as normal saline are the fluid of choice for initial resuscitation in severe hypovolemic
4853 Pediatrics
Electrolytes hypernatremia
Vitamin D deficiency ricks:
RF-exclusive breastfeeding, increased skin pigmentation & lack of sun exposure
Exam findings-craniotabes, rachitic rosary(costochondral joint hypertrophy) & genu varum(femoral & tibial
bowing)
2486 Pediatrics X-ray-cupping & fraying of the metaphyses of the long bones
& Sports
Costochondral joint enlargement is always pathologic & should prompt evaluation for rickets
Child abuse:"bucket-handle" fractures aka classic metaphyseal lesions & rib fractures
Ewing's sarcoma: found in lower extremity more than upper extremity. Common sites are the metaphysis &
diaphysis of the femur, followed by the tibia & humerus. Pts are typically white males in their first or second
Rheumatology/Orthopedics decade of life. Lamellated appearance/"onion skin" periosteal reaction. The "onion skin" appearance is
2629 Pediatrics
& Sports followed w/ a "moth eaten" or mottled appearance & extension into soft tissue
Osteomyelitis:central lytic bone defect w/ surrounding sclerosis (Brodie's abscess)

In neonates/infants, a soft click, leg-length discrepancy, or asymmetric inguinal skin folds require diagnostic
3402 Pediatrics imaging w/ ultrasound (age <6 months) or x-rays (age >4-6 months).
& Sports
tx- Pavlik hip harness for age <6 months
Slipped capital femoral epiphysis occurs in obese, early-adolescent boys. Knee pain(referred pain) is a
common complaint w/ this condition. Loss of abduction/internal rotation of the hip. External rotation of the
3403 Pediatrics thigh while the hip is being flexed. Frog-leg, lateral-view x-ray is dx imaging of choice. It should be tx w/
& Sports
*surgical pinning* of the slipped epiphysis where it lies(i.e.in situ) in order to lessen the risks of avascular
necrosis of the femoral head & chondrolysis
Legg Calve Perthes disease: as the disease progresses, internal rotation & abduction at the hip joint can
3404 Pediatrics become markedly limited. Tx aimed at maintaining femoral head within the acetabulum via splinting or
& Sports
surgery
Subluxation of the radial head (nursemaid's elbow) is common in preschool children. Classic mech is
3416 Pediatrics swinging or pulling a child by the arm. Full recovery after closed reduction by *forearm hyperpronation*
& Sports
confirms the dx
Growing pains: Unrelated to growth, despite name. Bilateral, lower extremity pains that occur at night in
3555 Pediatrics children age 2-12 years. Children w/ growing pains have no systemic sx, normal activity levels, & normal
& Sports
physical examinations. Tx- observation, parental reassurance, massage, & over the counter pain meds
Ashhadscknotes
Radial head subluxation(nursemaid's elbow): occurs when infants/children are lifted or pulled by the hand or
arm. Child will keep hand in pronated position & will refuse attempted forearm supination. Reduction by
Rheumatology/Orthopedics forearm hyperpronation or supination plus flexion is diagnostic & therapeutic
3668 Pediatrics
& Sports
Panner disease: osteochondrosis of the capitellum. Typical pt is an adolescent engaged in sports involving
throwing. Chronic dull pain, crepitation, & loss of pronation & supination
Type I metatarsus adductus: feet that *overcorrect both passively & actively into abduction*. Spontaneously
correct by themselves so no tx necessary. *Give reassurance*. Seen in first-born infants.
3684 Pediatrics Type II metatarsus adductus: feet that correct to the neutral position w/ passive & active movements.
& Sports
Managed w/ orthosis or corrective shoes, & sometimes plaster casts.
Type III metatarsus adductus: rigid feet & do not correct. Managed w/ serial casts
Clubfoot (talipes equinovarus): pt will have equinus & varus of the calcaneum & talus, varus of the midfoot,
& adduction of the forefoot. Initially managed w/ *stretching & manipulation of the foot, followed by serial
3685 Pediatrics plaster casts*, malleable splints, or taping. Surgical tx is indicated if conservative management gives
& Sports
unsatisfactory results, & is preferably performed between 3 & 6 months of age. [Rmr that the tx of clubfoot
should be started immediately!]
Osteogenesis imperfecta: due to mutations in type 1 collagen. Blue sclera & recurrent fractures
Congenital syphilis: early manifestations include jaundice, rash, lymphadenopathy, rhinitis &
hepatosplenomegaly. Late manifestations occur around two years of age; these include shaber shins,
keratitis, Hutchinson's teeth, saddle-nose deformity & deafness
3770 Pediatrics
& Sports
Children w/ rickets have slow growth & skeletal deformities
Marfan syndrome: mutation of fibrillin 1 gene.
Lyme arthritis:late manifestation of untreated Lyme disease.Hx of travel to northeastern/upper midwestern

Rheumatology/Orthopedics USA.Untreated early localized disease can progress to an inflammatory monoarticular or oligoarticular
3836 Pediatrics
& Sports arthritis,most commonly involving the knee.Synovial fluid shows an average leukocyte count of 25,000
cells/uL
Spondylolisthesis: developmental disorder charac by a forward slip of vertebrae(usually L5 over S1) that
4064 Pediatrics manifests in preadolescent children. In the typical clinical scenario, back pain, neurologic dysfunction (e.g.
& Sports
urinary incontinence), & a palpable "step-off" at the lumbosacral area are present if the disease is severe
legg calve perthes disease:
aka idiopathic avascular necrosis of the femoral capital epiphysis
boys age 4-10
Rheumatology/Orthopedics sx- hip, groin, knee pain with antalgic gait
4533 Pediatrics
& Sports tx- manage conservatively with observation and bracing
surgery needed only when femoral head not well contained in acetabulum
slipped capital femoral epiphysis (SCFE): obese adolescent male with complaints of pain
Positive Trendelenburg sign:caused by *weakness/paralysis of gluteus medius & minimus muscles*, which
are innervated by superior gluteal nerve
Tensor fascia lata:hip abduction,maintenance of knee extension

4534 Pediatrics Psoas major:flex/laterally rotate thigh
& Sports
Quadratus lumborum:rib cage fixation/lateral flexion of trunk
Quadriceps femoris:leg extension at knee

[Rectus femoris(part of quadriceps femoris) also functions as a hip flexor]
Serum sickness-like reaction: type III hypersensitivity that occurs 1-2 weeks after administration of
B-lactams(eg, penicillin, amoxicillin, cefaclor) or TMP/SMX. Sx-fever, urticaria, polyarthralgia/joint pain w/ no
mucosal involvement. Tx-remove offending agent. Steroids used for severe cases
4584 Pediatrics
& Sports
Mononucleosis pts tx w/ aminopenicillin can develop rash on trunk. It spares extremities. No arthralgia seen
Scarlet fever: fever, "sandpaper rash" following strep. pharyngitis.

The differential diagnosis of a solitary, painful, lytic long bone lesion w/ overlying swelling & hypercalcemia in
a child should include Langerhans cell histiocytosis as well as other neoplastic processes.
Rheumatology/Orthopedics Sarcoidosis has its onset between ages 20-35 years. Sarcoidosis affecting the bone targets the hands &
4642 Pediatrics
& Sports feet.
Osteogenesis imperfecta: defect in Type 1 collagen. Pts have blue sclerae, diffuse cortical thinning,
attenuation of trabeculae & pathological fractures
Ashhadscknotes
Acquired torticollis(neck twisting due to asymmetric muscle activity) is common in children. The most
Rheumatology/Orthopedics common causes include upper respiratory infections, minor trauma, cervical lymphadenitis, &
4761 Pediatrics
& Sports retropharyngeal abscess. *Cervical spine radiographs/xray of neck* should be obtained in children w/
acquired torticollis to ensure there is no cervical spine fracture or dislocation
Osteogenesis imperfecta(OI): ass w/ blue sclerae, hearing loss, recurrent fractures, & *opalescent teeth*.
Pts w/ osteogenesis imperfecta have normal intelligence. Inhereted from an autosomal dominant mutation
4832 Pediatrics of COL1A1.[Many pts w/ OI have dentinogenesis imperfecta, an opalescent blue-gray to yellow-brown
& Sports
discoloratoin caused by discolored dentin shining thru the translucent & weak enamel. Both primary &
permanent teeth affected]
Acute rheumatic fever(ARF):age 5-15,twice as common in girls,polyarthritis(migratory),erythema
marginatum(evanescent pink rash w/ sharp edges)[google pic],fever, elevated CRP & ESR.Prevented w/
penicillin tx of s.pharyngitis
4836 Pediatrics Juvenile idiopathic arthritis:arthritis present for >6 weeks.Rash can be seen.Arthritis isn't migratory like in
& Sports
ARF
Henoch Schonlein purpura: migratory arthritis & rash. But rash is purpuric & arthritis involves lower
extremity joints (hip/knee/ankle)
Atlantoaxial instability should be suspected in any pt w/ Down syndrome who presents w/ upper motor
neuron findings
4840 Pediatrics
& Sports
Spinal cord infarction presents w/ the acute onset of severe pain, weakness, & paresthesias. This condition
is rare & commonly seen in adults.
Slipped capital femoral epiphysis:
commonly seen in overweight children aged 10-16 years(boys affected slightly more than girls).
sx-pt holds affected hip in passive external rotation and exhibits decreased internal rotation, abduction, and
flexion
4844 Pediatrics dx- made w/ plain radiographs of hip (anteroposterior and frog leg lateral views)
& Sports
tx-Immediate surgical screw fixation in order to avoid avascular necrosis of hip
Legg-Calve-Perthes disease: affects boys age 5-7 years
Osgood-Schlatter disease:*traction apophysitis* of tibial tubercle.Cause of knee pain in adolescent male

athletes ages 13-14 (ages 10-11 for affected females). Edema/tenderness over tibial tubercle.Pain
reproduced by extending knee against resistance
4849 Pediatrics
& Sports Patellar tendonitis:anterior knee pain after exercise.Point tenderness at inferior pole of patella
Patellofemoral stress syn:Anterior knee pain that worsens upon descending steps or hills. Pain localized to
patella
Transient synovitis: most common cause of hip pain in children, typically occurring in boys age 3-10 years.
Usually follows a viral infection or mild trauma. Synovial inflammation leads to pain, decreased range of
Rheumatology/Orthopedics motion, & limping. Affected hip is typically flexed, slightly abducted, & externally rotated(This position
4857 Pediatrics
& Sports maximizes joint space & provides pain relief). Pts rarely have fever or significant laboratory abnormalities.
<1 month = transient synovitis
>1 month = LCP
The most common elbow fracture in children is a supracondylar humerus fracture. Typical hx is a fall onto
4873 Pediatrics an outstretched arm w/ elbow extended. Supracondylar humerus fractures may be complicated by
& Sports
neurovascular injury or compartment syndrome(increasing pain from swelling)
Osteoid osteoma(google xray pic):benign bone forming tumor, progressively increasing pain that worsens at
Rheumatology/Orthopedics night w/o relation to physical activity.Plain x-rays of the leg shows the typical small,round lucency w/
11441 Pediatrics
& Sports sclerotic margins & sometimes central ossification. Proximal femur commonly affected. Pain improves w/
NSAIDs. Pts should be followed w/ serial examination & x-rays every 4-5 months to monitor the lesion
Social Sciences Courts in the US have ruled that parents are not allowed to refuse life-saving tx for a child, including refusal
3235 Pediatrics
(Ethics/Legal/Professional) for religious reasons
When caring for an unemancipated minor, informed consent from one parent or guardian is considered
Social Sciences
3624 Pediatrics legally sufficient to jusify proceeding w/ therapy. Physicians should also provide care in urgent situations w/o
waiting for parental consent
Social Sciences Physicians should have a high index of suspicion for physical/sexual abuse in children w/ sudden behavioral
4320 Pediatrics
(Ethics/Legal/Professional) problems, families w/ unstable economic backgrounds, or parents w/ a hx of drug/alcohol abuse
Social Sciences Don't wait to obtain consent from parents for emergency procedures like unstable airway, blood
4846 Pediatrics
(Ethics/Legal/Professional) transfusions, & surgery. That will cause unecessary delay and potential harm!
2350 Psychiatry Nervous System Bereavement usually does not last longer than 2 months
Benzodiazepines(alprazolam) should be used w/ extreme caution in elderly population due to increased risk
of cognitive impairment,falls,& paradoxical agitation(increased agitation,confusion,aggression & disinhibition
within an hour of benzodiazepine administration). *Discontinuing pt's alprazolam* is the most appropriate
3383 Psychiatry Nervous System
next step in management if they are experiencing above sx
As an alpha blocker,terazosin may cause orthostatic hypotension or syncope, esp w/ 1st dose
Ashhadscknotes
Narcolepsy: excessive daytime sleepiness & episodes of cataplexy. When meds are needed, give
*modafinil(Provigil)* & armodafinil(NuVigil). Amphetamines stimulants & sodium oxybate(Xyrem)[reduces
3470 Psychiatry Nervous System cataplexy] aren't 1st line for tx due to risk of abuse/significant side effects
Benzodiazepines, opiates, antipsychotics, & alcohol increase daytime sleepiness

Second generation antipsychotics are preferred for treating psychosis due to their low risk of extrapyramidal
side effects & tardive dyskinesia.
Use clozapine only if pt fails 2 antipsychotic trials(since it's ass. w/ agranulocytosis) . Clozapine is gold
standard for treatment resistant schizophrenia.
Antipsychotics cause hyperprolactinemia by blocking dopamine activity in the tuberoinfundibular pathway
decreased dopamine activity in the mesolimbic pathway accounts for the therapeutic effects of
antipsychotics
increased dopamine activity in the mesolimbic pathway accounts for the euphoria accompanying drug use
as well as delusions & hallucinations experienced by pts w/ schizophrenia
Alcoholic hallucinations (due to alcohol withdrawal) develops within 12 to 24 hours of last drink. It resolves
within 24 to 48 hours.
DO NOT CONFUSE ALCOHOLIC HALLUCINATIONS WITH DELIRIUM TREMENS! THEY ARE NOT THE
Psychiatric/Behavioral & SAME! THESE TERMS CAN'T BE USED SYNONYMOUSLY!
2349 Psychiatry
Substance Abuse
Brief psychotic episode: presence of hallucinations, delusions, disorganized speech/behavior for >1 day but
<1 month. Don't make this dx if drug or alcohol is responsible for crazy behavior
Loss of a loved one can trigger the onset of a major depressive episode.Bereaved pts who experience
depressive sx for at least 2 weeks after a major loss should be considered for tx w/ both psychotherapy & a
Psychiatric/Behavioral & trial of antidepressants(SSRIs such as sertraline)
2351 Psychiatry
Substance Abuse
Electroconvulsive tx:used for pts who don't respond to an adequate course of antidepressants. 1st line tx for
depressed pts who aren't eating or drinking, or who may be acutely suicidal, catatonic, or psychotic
Psychiatric/Behavioral & Bulimia nervosa: normal body weight, regular menstrual cycles(pts aren't amenorrheic)
2354 Psychiatry
Substance Abuse Borderline personality disorder is frequently diagnosed in pts suffering from bulimia nervosa
In a pt w/ bipolar I disorder w/ psychosis(grandiose delusions) & escalating agitation(angrily
shouting,threatening,banging on door),antipsychotics[1st gen-haloperidol or 2nd
gen-risperidone,olanzapine]preferable due to rapid onset of action.[lithium,valproate,carbamazepine require
2355 Psychiatry gradual titration over several days to achieve therapeutic blood levels so are less effective in controlling pt's
Substance Abuse
acute agitation]
Lamotrigine tx bipolar depressive episodes(not manic episodes)

Long term side effects of lithium include nephrogenic diabetes insipidus, hyperparathyroidism w/
hypercacemia, and thyroid dysfunction.
Psychiatric/Behavioral & Calcium, renal function, and thyroid function should be monitored prior to starting lithium and periodically
2356 Psychiatry
Substance Abuse during therapy.
Atypical antipsychotics predispose pts to lipid or glucose abnormalities.

1st line tx for bipolar disorder: Atypical antipsychotics (eg, risperidone, aripiprazole, olanzapine), Lithium,
Psychiatric/Behavioral & Valproic acid. Don't use lithium in pts w/ renal dysfunction(its excreted thru the kidneys)!
2357 Psychiatry
Substance Abuse
SSRI's like fluoxetine or bupropion can aggravate manic sx in a bipolar pt!
All depressed pts should be screened for suicidal ideation, intent, & plan
Hospitalization is indicated for pts w/ active suicidal ideation that includes a plan & intent to act
2360 Psychiatry
Substance Abuse
Pts w/ suicidal ideation but NO specific plan or intent need intensive outpatient treatment, but not
necessarily hospitalization(tx underlying disorder w/ meds &/or psychotherapy,increase frequency of clinical
contact, mobilize supports)
Bupropion is FDA-approved for smoking cessation
Varenicline is a partial agonist of the nicotinic acetylcholine receptor that has recently been released. It is
2387 Psychiatry somewhat more effective than bupropion at increasing short & long term smoking cessation rates
Substance Abuse
Tricyclic antidepressants (like amitriptyline) are moderately effective in increasing smoking cessation rates,
though no tricyclic is FDA approved for this purpose
Ashhadscknotes
1st like tx for depression: SSRI's(fluoxetine).
*Most antidepressants (such as SSRI's) must be taken for 4-6 weeks before they provide symptomatic
relief*
2494 Psychiatry If sx don't improve within 4-6 weeks, the dosage should be increased
Substance Abuse
If one SSRI(at max dose) fails to fix the problem, then prescribe another SSRI in its place
TCAs (amitriptyline) are less appealing for tx depression due to side effects. Used TCAs only when SSRIs
are deemed inappropriate or ineffective
Following acute stabilization, pts w/ bipolar disorder should receive the following maintenance therapy:
1) Atypical antipsychotics are preferred for mild to moderately ill pts (monotherapy w/ lithium or valproic acid
2495 Psychiatry can be used as alternate therapy)
Substance Abuse
2) For more severe episodes, combination therapy w/ lithium or valproate plus atypical antipsychotics is
usually preferred over monotherapy
Panic attacks: Benzodiazepines used for acute/immediate tx
2496 Psychiatry Panic disorder: SSRI/SNRI and/or cognitive behavioral therapy used for long-term sx relief
Substance Abuse
Midazolam is a benzodiazepine used most often to induce conscious sedation during medical procedures
2497 Psychiatry Antipsychotics cause hyperprolactinemia by blocking dopamine
Substance Abuse
Psychiatric/Behavioral & One of the most common side effects of electroconvulsive therapy (ECT) is amnesia, both retrograde &
2498 Psychiatry
Substance Abuse anterograde
Psychosis is ass. w/ increased dopaminergic activity and is therefore best tx w/ drugs that primarily block
the dopamine-D2 receptors. [Risperidone is an example of an atypical antipsychotic that works in this
fashion]
2499 Psychiatry
Substance Abuse
Risperidone binds w/ a very high affinity to serotonin receptors, which results in an improvement in the
negative sx of schizophrenia, a reduction in the incidence of extrapyramidal side effects, & concomitant tx of
depression
Neuroleptic malignant syndrome(hyperthermia,autonomic instability,muscular rigidity, & altered sensorium)
is an unusual but potentially lethal side effect from the use of antipsychotics (neuroleptics) eg, haloperidol.
It's tx primarily w/ *dantrolene sodium* & supportive care
2501 Psychiatry
Substance Abuse
The anticholinergic medication benztropine can be used to tx antipsychotic-induced extrapyramidal sx
Propranolol is sometimes used to tx the antipsychotic side effect akathisia

Clomipramine is a tricyclic antidepressant used as a 2nd line tx of obsessive compulsive disorder
Phenelzine is a monoamine oxidase inhibitor that is effective in generalized social anxiety disorder. However
2502 Psychiatry it's not considered a 1st line tx due to dietary restrictions & the risk of hypertensive crisis
Substance Abuse
Sertraline is an SSRI used in the tx of depression & a variety of anxiety disorders, including generalized
social anxiety disorder
SSRI meds(Citalopram, Fluoxetine, Paroxetine, Sertraline) are 1st line tx for pts w/ moderate to severe
depression. If there is no improvement and/or side effects, switch to a different medication in the *SAME*
class.
Psychiatric/Behavioral & If there is still no improvement and/or side effects after 2 trials, switching to a DIFFERENT class of
2503 Psychiatry
Substance Abuse antidepressants is indicated.
Trazodone used for tx of insomnia related to depression. Has antidepressant properties &
sedation/priapiasm as side effects
Acute dystonia:type of extrapyramidal symptom seen w/ high potency typical antipsychotic
treatment(haloperidol). Tx-anticholinergics(benztropine) or antihistamines(diphenhydramine)
2505 Psychiatry
Substance Abuse Amantadine: dopamine agonist, treats drug-induced parkinsonism
Beta-blockers used to tx akathisia

Psychiatric/Behavioral & Obsessive compulsive disorder: Tx-SSRIs or clomipramine. If pt fails to respond to initial tx w/ SSRI, a trial
2506 Psychiatry
Substance Abuse of a different SSRI(or clomipramine) is recommended.
Clozapine indicated for tx of psychotic pts who don't respond to other antipsychotics(tx resistant
schizophrenia/schizoaffective disorder;pts failed >2 antipsychotic trials).Pts must undergo regular monitoring
of white blood cell & absolute neutrophil counts due to the risk of *leukopenia* (neutropenia) &
2507 Psychiatry agranulocytosis
Substance Abuse
Creatinine & thyroid function tests are periodically monitored (eg, every 3-6 months) in lithium-treated pts
due to risks of hypothyroidism & renal toxicity
Ashhadscknotes
Brief psychotic disorder: sx >1 day & <1 month
2508 Psychiatry Schizophreniform disorder: sx last >1 month but <6 months
Substance Abuse
Schizophrenia: sx present for at least 6 months
Psychiatric/Behavioral & Disruptive mood dysregulation disorder: chronic irritablity, manifested as temperamental outbursts &
2510 Psychiatry
Substance Abuse persistent angry/irritable mood
Somatic symptom disorder: Excessive anxiety & preoccupation w/ >1 unexplained sx
Factitious disorder: intentional falsification w/ goal to assume sick role

2521 Psychiatry Malingering: Falsification/exaggeration of sx to obtain external incentives (secondary gain) e.g. avoiding jail,
Substance Abuse
obtain disability benefits
Illness anxiety disorder(hypochondriasis): fear of having serious illness despite few or no sx & consistently
negative evaluations
[Wikipedia] Russell's sign: a sign defined as calluses on the knuckles or back of the hand due to repeated
self-induced vomiting over long periods of time
3140 Psychiatry
Substance Abuse Binge-eating disorder: Recurrent episodes of binge eating. Lack of control during eating. NO
COMPENSATORY BEHAVIORS! (unlike Bulimia nervosa in which there is compensatory behavior after
binge eating)
Risk of developing bipolar disorder is 1% in the general population.
However, the risk increases to 5-10% in individuals w/ a first-degree relative who suffers from bipolar
disorder.
3185 Psychiatry
Substance Abuse Child whose parents both suffer from bipolar disorder has a 60% risk of developing the condition
Monozygotic twin of an individual who suffers from bipolar disorder has a 70% risk of developing the
condition
Tx alcohol withdrawal w/ benzodiazepine (eg, lorazepam, diazepam, chlordiazepoxide)
Alcohol withdrawal peaks during second day following cessation. Seizures occur at 12-48 hours. Delirium
tremens occurs 2-4 days after last drink.
3187 Psychiatry
Substance Abuse
Cefazolin: 1st generation cephalosporin, frequently provided as prophylaxis in biliary surgery
Phenobarbital: an anticonvulsant used as an adjunct to benzodiazepines in treatment-refractory alcohol

withdrawal syndrome. Never use as monotherapy!
Heroin withdrawal sx: pupillary dilatation, rhinorrhea, muscle & joint aches, abdominal cramping, nausea, &
diarrhea
3189 Psychiatry
Substance Abuse
Since amphetamines and cocaine are both stimulants, their withdrawal effects would be irritability, fatigue,
increased appetite, psychomotor disturbance
3190 Psychiatry Amphetamine intoxication: sx of sympathetic system overload, agitation, irritability, diaphoresis, mydriasis
Substance Abuse
LSD side effect: colors are richer, tastes are heightened, and sensation is enhanced
3191 Psychiatry
Substance Abuse
Cocaine intoxication: pt is convinced there are bugs crawling all over him "cocaine bugs"
Dissociative amnesia:isolated impairment in autobiographical memory.Inability to recall imp personal
info.Usually of a traumatic or stressful nature.Not explained by another disorder(substance
use,post-traumatic stress disorder)
Psychiatric/Behavioral & [Dissociative fugue subtype characterized by either seemingly purposeful travel or wandering in a
3372 Psychiatry
Substance Abuse dissociated state]
Depersonalization/derealization disorder:pt experiences repeated or chronic feelings of unreality or

detachment from one's self
Schizophrenia: Enlargement of the lateral cerebral ventricles
Autism: Increased total brain volume
Psychiatric/Behavioral & OCD: abnormalities in orbitofrontal cortex & striatum

3378 Psychiatry
Substance Abuse
Panic disorder: decreased volume of amydala
PTSD: decreased hippocampal volume
adjustment disorder:
Psychiatric/Behavioral & emotional/behavioral sx that develop within 3 months of stressor. Rarely lasts more than 6 months after
3382 Psychiatry
Substance Abuse stressor ends.
tx- brief cognitive psychotherapy or psychodynamic psychotherapy
Ashhadscknotes
Kleptomania: inability to resist the impulse to steal objects that are of low monetary value or not needed for
3385 Psychiatry personal use. Tx is *psychotherapy*, involving a cognitive behavioral therapy orientation, focusing on
Substance Abuse
techniques to resist & manage urges & anxiety. [Kleptomania doesn't respond well to medication]
Displacement: unacceptable feelings about an object or person are displaced onto another "safer" object or
person
Projection: involves attributing unacceptable internal thoughts or emotions to others eg. husband w/
3533 Psychiatry thoughts of cheating on his wife ends up accusing his wife of cheating on him
Substance Abuse
Dissociation: man rescued from fire has no memory of it, describes a missing block of time
Distortion: Drug user gets HIV and blames it on inadequate control of disease in community
Introjection: an immature defense mechanism. Assimilating another person's attitude into one's own
perspective (e.g. a battered woman who believes her husband is right when he says she is worthless)
3535 Psychiatry
Substance Abuse Dissociation: a neurotic defense mechanism. Completely blocking off disturbing thoughts or feelings from
consciousness in an attempt to avoid emotional upset(dude rescued from a burning building, now denies
any memory of it)
Psychiatric/Behavioral & Pts w/ psychiatric diagnoses can give informed consent as long as their judment and decision-making
3638 Psychiatry
Substance Abuse abilities are determined to be intact
Contraindications to the use of Bupropion:
hx of seizure disorder/Epilepsy and hx of anorexia nervosa/bulimia
3702 Psychiatry
Substance Abuse
Bupropion benefits: antidepressant, inhibits re-uptake of norepinephrine, dopamine, & serotonin, improves
the impaired concentration & diminished energy that depressed pts get, doesn't cause sexual dysfunction.
Alprazolam (Xanax), a short acting benzodiazepine, is the most likely to result in seizures **following abrupt
discontinuation**
3762 Psychiatry
Substance Abuse A potential dose dependent side effect of bupropion use (not withdrawal) is seizures
Lamotrigine is an anticonvulsant used in the tx of bipolar disorder

Rationalization involves offering a rational, logical reason for an upsetting event or behavior rather than
admitting the true reason in order to avoid anxiety or protect self-esteem
Psychiatric/Behavioral & Dissociation:immature def mech. Disruptions in memory,identity,consciousness,perception in the face of

3799 Psychiatry
Substance Abuse uncomfortable events/emotions
Repression:immature def mech. Upsetting feelings blocked from entering conscious awareness.Involves
blocking inner states.Occurs subconsciously
Generalized social anxiety:
tx- Perferred pharmacological tx is an SSRI or SNRI (e.g. Paroxetine). Cognitive behavioral therapy can
also be used as 1st line treatment (Supportive psychotherapy helpful but not as effective as cognitive
Psychiatric/Behavioral & behavioral therapy)
3839 Psychiatry
Substance Abuse
Performance only social anxiety disorder:
anxiety limited to public speaking/performance situations
tx- benzodiazepines, beta-blockers(propranolol), cognitive behavioral therapy
When tx a single episode of major depression, the antidepressant should be continued for a period of *six
Psychiatric/Behavioral & months* following the pt's response.
3843 Psychiatry
Substance Abuse If multiple episodes of depression have occurred, maintenance therapy will likely need to be continued for a
longer period.
3844 Psychiatry Minimizing conflict & stress in the home decreases the risk of relapse in pts w/ schizophrenia
Substance Abuse
Psychiatric/Behavioral & Sx of hypochondriasis usually develop during periods of stress. Pts should be asked about their current
3845 Psychiatry
Substance Abuse emotional stressors & then referred for brief psychotherapy.
Pts who have experienced 2 episodes of acute mania should be considered for long-term (years), if not
4043 Psychiatry lifetime, maintenance tx w/ lithium, esp if the episodes were severe or there is a family hx. Pts w/ a hx of 3
Substance Abuse
or more relapses are rec. to have lifetime maintenance tx
Although primarily a serotonin-dopamine antagonist,olanzapine also has affinity for histamine,alpha-1
adrenergic,& muscarinic receptors.Most common side effects of olanzapine are sedation & *weight
4046 Psychiatry gain.*Weight gain is ass. w/ antagonism of histamine (H1) & 5-HT2c receptors.Sedation due to antagonism
Substance Abuse
at the histamine receptor.Other metabolic side effects like hyperglycemia,dyslipidemia,& new onset diabetes
mellius are ass. w/ olanzapine but are less common than weight gain
4051 Psychiatry Pts w/ dysthymia (persistent depressive disorder) often describe feeling depressed their entire lives
Substance Abuse
Psychiatric/Behavioral & Altered levels of serotonin play an imp role in obsessive compulsive disorder. The tx of choice is an SSRI
4063 Psychiatry
Substance Abuse such as paroxetine
Noncompliance w/ antipsychotic meds is a common cause of relapse & rehospitalization in pts w/
4067 Psychiatry schizophrenia. Long-acting injectable antipsychotics are useful in pts who are chronically noncompliant but
Substance Abuse
have responded to oral antipsychotics.
Ashhadscknotes
Circumstantial thought process: Pts deviate from original subject but eventually return to it
4137 Psychiatry
Substance Abuse
Tangential thought process: Pts drift away without ever returning to the subject
SSRIs(*escitalopram*) or SNRIs are 1st-line meds for tx Generalized anxiety disorder that can also
4141 Psychiatry potentially tx comorbid major depression. Benzodiazepines should be reserved for nondepressed pts w/o a
Substance Abuse
hx of substance abuse who fail to respond to or can't tolerate antidepressants
Ppl w *grandiose delusions* believe they have special powers,extraordinary accomplishments,or a special
relationship w/ God
Magical thinking:belief that one's thoughts can control events in a manner not explained by natural cause &
4195 Psychiatry effect. It also includes the attribution of casual incidents to supernatural forces
Substance Abuse
Individuals w/ ideas of reference believe that everyday occurrences have a special implication for them
Perseveration:repetition of words or ideas during a convo

Panic disorder: frequently ass. w/ other psychiatric illnesses, including agoraphobia(fear of public places),
Psychiatric/Behavioral & *major depression*, bipolar disorder, & substance abuse. It's also linked to a higher rate of suicide attempts
4285 Psychiatry
Substance Abuse or suicidal ideations
[Panic disorder has a very common association w/ depression!]
Obsessive-compulsive personality disorder: characterized by impairment resulting from perfectionism &
intense concerns about time & the need to complete tasks meticulously
Psychiatric/Behavioral & Obsessive compulsive disorder: marked by obsessions that cause anxiety, resulting in compulsive behaviors
4815 Psychiatry
Substance Abuse to decrease the anxiety
Pts w/ Asperger's disorder have impairments in reciprocal social interactions & restricted interests. They
often desire relationships but lack awareness of social conventions
Persistent depressive disorder(dysthymia):
Psychiatric/Behavioral & look for pt w/ low energy, fatigue, low self esteem, poor concentration or difficulty making decisions, feelings
4816 Psychiatry
Substance Abuse of hopelessness. Sx last 2 years or more.
tx- antidepressants/therapy can improve sx & quality of life
Valproic acid side effects: blood dyscrasias & liver toxicity
4848 Psychiatry Carbamazepine: treats both bipolar & seizure disoders. Side effects include aplastic anemia & SIADH
Substance Abuse
Lamotrigine: treats epilepsy & bipolar disorder
Somnambulism=sleep walking
Psychiatric/Behavioral & Benign paroxysmal vertigo consists of episodes in which the child is off-balance & may be ass. w/
4869 Psychiatry
Substance Abuse nystagmus, fear, nausea, vomiting, or diaphoresis. The child may try to reach out to steady themselves.
Episodes are short (<1 minute) & are not ass. w/ a change in level of consciousness. Usually, this disorder
resolves as the child ages
Psychiatric/Behavioral & Pts taking monoamine oxidase inhibitors like phenelzine should avoid foods high in tyramine, as the
4879 Psychiatry
Substance Abuse combination can result in *hypertensive crisis*
Acute stress disorder: sx lasting from 3 days to 1 month following traumatic event. Dx requires exposure to
actual or threatened death, injury, sexual violation accompanied by characteristic sx of re-experiencing
4883 Psychiatry (intrusive memories & flashbacks), avoidance, negative mood, dissociation, & hyperarousal
Substance Abuse
Insomnia disorder: dx requires insomnia for at least 3 nights a week for at least 3 months
Bupropion is an antidepressant & a smoking cessation aid
4884 Psychiatry
Substance Abuse
Amitriptyline has been used for diabetic neuropathy & prevention of migraine headaches
Although they have a lower risk of extrapyramidal side
effects,Second-generation(atypical)antipsychotics,especially Clozapine & *Olanzapine*,cause metabolic side
effects(eg, weight gain,hyperglycemia,dyslipidemia).We have to routinely monitor *BMI,fasting plasma
Psychiatric/Behavioral & glucose & lipids,bp,waist circumference in pts taking these meds*
4885 Psychiatry
Substance Abuse
The atypical antipsychotic ziprasidone is ass. w/ QT prolongation at higher doses
Hyperprolactinemia occurs w/ 1st gen antipsychotics & risperidone

Risperidone is an atypical antipsychotic that acts as a dopamine receptor antagonist(look for pt on it to have
sx of dopamine blockage like bradykinesia, masked facies, micrographia). Although it's less likely than
4886 Psychiatry typical antipsychotics to cause parkinsonian extrapyramidal side effects(EPS), risperidone is the most likely
Substance Abuse
atypical antipsychotic to cause EPS(rigidity,tremor,akathisia). The anticholinergic med *benztropine* is used
to reduce the extrapyramidal sx.
Psychiatric/Behavioral & Serotonin syndrome appears clinically similar to neuroleptic malignant syndrome with high fevers and
4887 Psychiatry
Substance Abuse rigidity. However serotonin syndrome often begins with diarrhea, restlessness, and autonomic instability.
Delusional disorder: involves one or more delusions & the absence of other psychotic sx in an otherwise
4897 Psychiatry high-functioning individual. NO HALLUCINATIONS OR DISORGANIZED THOUGHTS OR BEHAVIOR AS
Substance Abuse
SEEN W/ SCHIZOPHRENIA & SCHIZOPHRENIFORM DISORDER
Ashhadscknotes
1st line tx for specific phobia is behavioral therapy(superior to pharmacological tx)
Psychiatric/Behavioral & Buspirone used for tx of generalized anxiety disorder

4905 Psychiatry
Substance Abuse
Eye movement desensitization & reprocessing treatment is a complex method of psychotherapy that
integrates therapy w/ eye movements. It's helpful for pts w/ post-traumatic stress disorder
Adjustment disorder eg: college student living by herself for first time, within the first 3 months feeling
anxious that someone will break into home, feels tense, difficulty sleeping at night, feels tired all day,
difficulty sleeping at night
4906 Psychiatry
Substance Abuse
Generalized anxiety disorder:excessive worry or anxiety over many aspects of one's
life(work,family,finances,health) for at least 6 months
The slightly increased risk of antidepressant-related suicidality in child & adolescent pts must be weighed
7289 Psychiatry against the established efficacy of antidepressants. Depressed pts should be carefully monitored for
Substance Abuse
worsening depression & suicidality at the beginning of antidepressant therapy
Pts w/ depression & comorbid medical conditoins, including terminal illnesses, can benefit from tx w/
antidepressant meds to improve their quality of life.
7723 Psychiatry SSRIs are the best option in pts w/ a longer life expectancy(SSRIs take a longer time[compared to
Substance Abuse
psychostimulants] to reach full therapeutic effect).
Psychostimulants (eg, methylphenidate, modafinil) are more appropriate for pts w/ a shorter life expectancy
Clozapine:reserved for pts w/ tx resistant schizophrenia(failure to respond to at least 2 antipsychotic trials)
or those at high risk for suicidality due to the risk of agranulocytosis.Other serious adverse effects include
7957 Psychiatry seizures,myocarditis,& metabolic syndrome
Substance Abuse
Lamotrigine & lithium are mood stabilizers used in tx of bipolar disorder
Remission: absence of or minimal sx, w/ a return to the pt's premorbid functioning or wellness
8841 Psychiatry
Substance Abuse Treatment response: pt demonstrates significant improvement(with or without a remission), 50% reduction
in the baseline level of severity
Hoarding disorder:
8875 Psychiatry pt has difficulty getting rid of cheap items, thought of parting with items causes distress.
Substance Abuse
tx- cognitive behavioral therapy and SSRIs
Psychiatric/Behavioral & Survivors of sexual assault are at high risk for developing post-traumatic stress disorder, depression, &
8915 Psychiatry
Substance Abuse suicidality
Psychiatric/Behavioral & Cognitive behavioral therapy focuses on reducing automatic negative thoughts & avoidance behaviors that
8938 Psychiatry
Substance Abuse cause distress
Drug induced parkinsonism presents w/ bradykinesia(eg. slow finger tapping), rigidity, & tremor
Acute dystonia: sudden onset of sustained muscle contractions resulting in twisting & abnormal postures
Psychiatric/Behavioral & (eg, torticollis, sustained contraction of neck, mouth, tongue, eye muscles)
10780 Psychiatry
Substance Abuse
Tardive dyskinesia: dyskinetic movements involving mouth/face & extremities
Lewy body dementia: older adults, fluctuating cognition, parkinsonism, visual hallucinations
High dose glucocorticoids given for allergic,inflammatory(eg,asthma),or autoimmune conditions may cause
11790 Psychiatry glucocorticoid induced psychosis in pts w/ no underlying psychiatric illness. This is an example of
Substance Abuse
substance/medication-induced psychotic disorder
inhalant abuse:
11794 Psychiatry boys age 14-17
Substance Abuse
perioral skin changes (glue sniffer's rash). this dermatitis can be seen around mouth or nostrils
Electroconvulsive therapy (ECT) is an evidence-based tx for major depression refractory to antidepressants
& is also indicated to achieve a rapid response in depressed geriatric patients who are unable to eat & drink,
11827 Psychiatry psychotic, or actively suicidal
Substance Abuse
[Antidepressants take up to 6-8 weeks for response & need to be combined w/ an antipsychotic med to
effectively tx major depression w/ psychotic features]
*Ecstasy* aka Molly aka MDMA(3,4-methylenedioxy-methamphetamine) is a synthetic amphetamine w/
hallucinogenic properties. It can cause euphoria, increased sexual desire, & empathy. Intoxication may lead
11853 Psychiatry to hypertension, tachycardia, hyperthermia, SEROTONIN SYNDROME, & HYPONATREMIA. Coma,
Substance Abuse
seizures, & death may occur.[Combining MDMA w/ other serotonergic drugs such as serotonergic
antidepressants can increase the risk of serotonin syndrome]
Second-generation antipsychotics (*quetiapine*, lurasidone) are effective in the *depressed phase of bipolar
11884 Psychiatry illness*.[Antidepressant monotherapy should be avoided in pts w/ bipolar I disorder due to risk of
Substance Abuse
precipitating mania]
Panic disorder:recurrent & unexpected panic attacks w/ >4 of the following: Chest
pain,palpitations,SOB,trembling,sweating,nausea,dizziness,paresthesias,derealization,depersonalization,fear
of losing control,dying,worry about additional attacks,avoidance behavior.Sx resolve within minutes
11894 Psychiatry
Substance Abuse
In somatic sx disorder,physical sx are persistent over time
Illness anxiety disorder:excessive health anxiety w/o significant somatic sx
Ashhadscknotes
Neuroleptic malignant syndrome (NMS): ass w/ antipsychotic use. Sx-delirium, high fever, autonomic
instability, severe rigidity, elevated creatine kinase, & leukocytosis
11897 Psychiatry Serotonin syndrome:neuromuscular irritability(tremor,hyperreflexia,myoclonus)rather than the rigidity seen in
Substance Abuse
NMS.Fever in this syndrome not as high as in NMS. GI sx more common(vomiting/diarrhea).[Wait 2 weeks
between discontinuing MAOI & start of serotonergic antidepressant to avoid Serotonin syndrome]
Akathisia should be considered if a psychotic pt worsens clinically as the dose of antipsychotic is increased.
Tx-*reduction of antipsychotic dose & tx w/ B-blocker(propranolol) or benzodiazepine(lorazepam)*
Psychiatric/Behavioral & [Make sure not to discontinue the antipsychotic altogether cuz doing so could place pt at higher risk of
11898 Psychiatry
Substance Abuse further decompensation]
Acute dystonia tx:Benztropine & diphenhydramine

The sudden onset of psychosis in a child or adolescent is rare, & it's important to search for potentially
Psychiatric/Behavioral & reversible conditions such as medical disorders or substance use. Common medical conditions to rule out
11967 Psychiatry
Substance Abuse include SLE(check for *antinuclear antibodies* esp if child has arthralgia & psychosis w/ hematuria &
proteinuria), thyroiditis, metabolic or electrolyte disorders, CNS infection, & epilepsy
Nightmare disorder: involves recurrent awakenings from REM sleep associated w/ full alertness & dream
recall. It should be differentiated from non-REM sleep terrors, which are characterized by partial arousals,
unresponsiveness, & lack of dream content
12002 Psychiatry
Substance Abuse
Sleep terror disorder: is a non-REM arousal disorder charac by incomplete awakenings, unresponsiveness
to comfort, & no recall of dream content. Charac by marked autonomic arousal & amnesia for the episode in
the morning.
Narcolepsy is ass. w/ low csf levels of orexin-A/hypocretin-1
12003 Psychiatry
Substance Abuse Hypersomnolence disorder is charac by persistent daytime sleepiness (not sleep attacks) & is diagnosed
only when excessive sleepiness is not better explained by another sleep disorder
Chronic methamphetamine abuse can cause psychotic sx, including paranoid delusions & auditory, visual, &
12140 Psychiatry tactile hallucinations (bugs crawling under the skin). Other signs include marked weight loss, severe tooth
Substance Abuse
decay, & excoriations due to skin picking
Catatonia: a syndrome seen in severe psychiatric & medical illness & is charac by immobility, mutism, &
posturing. Benzodiazepines(*lorazepam*) & electroconvulsive therapy(ECT) are the tx of choice.[ECT is tx
of choice in pts who don't improve w/ benzodiazepines]
12145 Psychiatry
Substance Abuse Antipsychotics can worsen catatonia & should be avoided
Cyproheptadine(serotonin antagonist):tx severe cases of serotonin syndrome(triad of autonomic

instablity,altered mental status, & neuromuscular irritability)
Trauma-focused cognitive-behavioral therapy & SSRIs(*escitalopram*)/SNRIs are 1st line tx for
post-traumatic stress disorder
12186 Psychiatry
Substance Abuse
Bupropion: is a norepinephrine dopamine reuptake inhibitor. It can be stimulating and therefore cause
insomnia. Commonly used to tx major depression.
Most effectic strategy to prevent firearm injuries is to remove all firearms from the home. If families choose
Social Sciences
9848 Psychiatry to keep firearms in the home, they should be advised to at least store unloaded firearms & ammunition in
separate, locked containers
Tetanus-diphtheria toxoid vaccine should be given to individuals w/ severe or dirty wounds who received a
booster >5 years ago & those w/ minor clean wounds who received a booster >10 years ago. Tetanus
3325 Surgery Allergy & Immunology
immune globulin should be given to any individual w/ a severe or dirty wound & an unclear or incomplete
immunization hx
Acute mediastinitis:can occur following cardiac surgery & present w/ fever,chest pain,leukocytosis &
mediastinal widening on CXR.It's a serious condition that requires drainage,surgical debridement &
prolonged antibiotic therapy
2337 Surgery Cardiovascular System
Postpericardiotomy syndrome:fever,leukocytosis,tachycardia & chest pain.Usually autoimmune & occurs a
few weeks following a procedure w/ a pericardium incision.NSAIDs or steroids tx inflammation. Pericardial
puncture is indicated if tamponade occurs
*Bowel ischemia is a complication of abdominal aortic aneurysm repair*.Due to inadequate colonic collateral
arterial perfusion to the left & sigmoid colon after loss of the inferior mesenteric artery during aortic graft
placement.Sx-ab pain,bloody diarrhea,fever,leukocytosis
Aortoenteric fistula is a rare & late complication where the duodenum erodes into the proximal part of the
aortic graft
Aortic dissection: can extend into the major vessels (eg, carotid, renal, & spinal arteries) & lead to
2734 Surgery Cardiovascular System impending stroke, acute renal failure, & *lower extremity weakness/paraplegia* respectively. Dx confirmed
w/ contrast chest computed tomography or transesophageal echocardiogram
Edema, stasis dermatitis & venous ulcerations result from lower extremity venous insufficiency due to valve
3455 Surgery Cardiovascular System incompetence -> *venous hypertension*/increased pressures in postcapillary venules
Xerosis is most common early finding; lipodermatosclerosis & ulcerations characterize late disease
Pts who present w/ acute onset of back pain & profound hypotension should be evaluated for a presumptive
dx of *ruptured abdominal aortic aneurysm* & emergently taken to the operating room
Ashhadscknotes
Venous insufficiency (valvular incompetence): mcc of lower extremity edema. Worsens throughout the day
& resolves overnight when pt is recumbent
Femoral artery aneurysm:pulsatile groin mass below inguinal ligament.Anterior thigh pain occurs due to
compression of femoral nerve that runs lateral to the artery.2nd most common peripheral artery aneurysm
after popliteal aneurysm. Ass. w/ abdominal aortic aneurysm
4241 Surgery Cardiovascular System Femoral hernias:located below inguinal ligament, NOT pulsatile
Inguinal hernias:located above inguinal ligament
Femoral vein dilatation results from AV fistula(typically traumatic);venous HTN results

Ankle-brachial index (ABI) is highly sensitive and specific for peripheral arterial disease (PAD)
arterial ultrasound of lower extremities can diagnose PAD but is less sensitive and specific than ABI. Only
do it in symptomatic pts w/ abnormal ABI who are being considered for interventional procedures
Retroperitoneal hematoma: Can occur as a local vascular complication of cardiac catheterization, & often
presents w/ sudden hemodynamic instability & ipsilateral flank or back pain. Dx is confirmed w/
*non-contrast CT scan of abdomen & pelvis* or abdominal ultrasonography. Tx is supportive w/ bed rest,
intensive monitoring, & iv fluids and/or blood transfusion
embolic arterial occlusion:
sudden/severe pain, diminished pulses, pallor, coolness to touch, neurologic deficits and muscle dysfunction
in affected extremity
arterial thrombosis:
slow, progressive narrowing of lumen, insidious onset, diminished pulses bilaterally
venous thrombosis (DVT):

pain and edema of lower extremity, warmth to touch, dull & aching pain, no pulselessness
Aortoiliac occlusion (Leriche syndrome):

sx- triad of bilateral hip, thigh, & buttock claudication, impotence & symmetric atrophy of the bilateral lower
extremities due to chronic ischemia. Men w/ a predisposition for atherosclerosis such as smokers are at
greatest risk of this condition.
Aortic injury findings:
widened mediastinum, large left sided hemothorax, deviation of mediastinum to the right and disruption of
4527 Surgery Cardiovascular System the normal aortic contour.
Dx can be confirmed w/ CT scanning.
Manage pts w/ antihypertensive therapy and immediate operative repair.
In a pt who develops hypovolemic shock after a mva, an elevated pulmonary capillary wedge pressure at
baseline should raise the suspicion of myocardial dysfunction due to cardiac contusion(the PCWP is is
4541 Surgery Cardiovascular System slightly elevated at baseline & increases significantly after infusion of saline) This is suggestive of elevated
intracardiac filling pressures due to left ventricular dysfunction, which is most likely caused by myocardial
contusion(injury to the myocardium) from accident
Acute cardiac tamponade: suspect in adult pts w/ blunt chest trauma who present w/ JVD, tachycardia,&
hypotension despite aggressive fluid resuscitation. CXR reveals normal cardiac silhouette
Esophageal rupture: severe retrosternal chest pain & mediastinal free air on CXR
Reperfusion of a limb following arterio-occlusive ischemia for longer than 4-6 hours can lead to intracellular
and interstitial edema. Compartment syndrome may occur when edema causes the pressure within a
muscular fascial compartment to rise above 30 mm Hg, leading to further ischemic injury.
[Compartment syndrome - pain increases on passive stretch, paresthesia(early)]
blunt aortic injury:
pt's in MVA or falls > 10 ft
4696 Surgery Cardiovascular System chest xray initial screening study
mediastinal widening most sensitive finding
deviation of trachea or nasogastric tube to the right or depression of left mainstem bronchus also seen
Dx of malignancy should be suspected in all non-healing wounds. Squamous cell carcinoma (SCC) may
arise within chronically wounded, scarred or inflamed skin. SCC arising within burn wounds is known as
Marjolin ulcer. Biopsy should be obtained in all chronic wounds failing to heal in order to rule out malignancy
3456 Surgery Dermatology
Dysplastic nevi: melanocytic nevi, size > 6mm, irregular borders & irregular pigmentation, demonstrate
varying degrees of architectural disorder & cytologic atypia
In pts w/ significant total body surface area burns, the major cause of morbidity & mortality is hypovolemic
shock. In the setting of adequate initial fluid resuscitation, *bacterial infection*(usually bronchopneumonia or
burn wound infection) leading to sepsis & septic shock is the leading complication
4550 Surgery Dermatology
Hypermetabolic phase: after a severe burn injury, significant increases in catecholamines & cortisol cause
protein losses(muscle degradation is used for gluconeogenesis)
Ashhadscknotes
*Most feared complication of a retropharyngeal abscess is spread of infection into the mediastinum*,which
can lead to acute necrotizing mediastinitis.Early dx & debridement of the mediastinum is essential in the tx
of this severe complication
2846 Surgery Ear, Nose & Throat (ENT) Major complication of an infection in the parapharyngeal space is involvement of the carotid sheath,which
leads to erosion of the carotid artery & jugular thrombophlebitis
Sublingual space is a division of the submandibular space
Retropharyngeal abscess: pain w/ neck EXTENSION. Usually caused by local penetrating trauma(eg after
instrumentation, or following an injury from a chicken bone)
2847 Surgery Ear, Nose & Throat (ENT)
Meningitis: increased pain w/ neck FLEXION
Torus palatinus: young pt w/ fleshy immobile mass on midline hard palate. Thought to be due to both
genetic/congenital & environmental factors. usually <2 cm in size but can increase in size throughout a
person's life. No medical/surgical tx required unless the growth becomes symptomatic or interferes w/
speech or eating
nasal septal perforation due to septal hematoma:
sx- whistling noise during respiration following rhinoplasty
Nasopharyngeal carcinoma:
Undifferentiated carcinoma
Occurs in people of mediterranean or far eastern descent
3500 Surgery Ear, Nose & Throat (ENT) These pts often present w/ recurrent otitis media, recurrent epistaxis, & nasal obstruction
Strongly ass. w/ EBV
Helicobacter pylori gastritis can cause gut associated lymphoid tissue (GALT) lymphoma
Acute adrenal insufficiency:potentially lethal postoperative complication.Features include nausea,vomiting,ab
pain,hypoglycemia,& hypotension.Pts taking chronic glucocorticoids may have glucocorticoid-induced
Endocrine, Diabetes & suppression of hypothalamic-pituitary-adrenal axis & require stress-dose perioperative glucocorticoids
4077 Surgery
Metabolism
Pts w/ Cushingoid features who are taking glucocorticoids are at risk for HPA suppression & won't respond
appropriately to stress(surgery,infection,bleeding,MI)
Kidneys are responsible for converting 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D by the enzyme
1-alpha-hydroxylase. Impaired 1-alpha hydroxylation occurs w/ chronic kidney disease, which can lead to
Endocrine, Diabetes & hyperphosphatemia, hypocalcemia, & secondary hyperparathyroidism
4254 Surgery
Metabolism
Precipitation of calcium w/ phosphate in peripheral tissues can cause hypocalcemia(occurs in renal
failure,rhabdomyolysis,phosphate administration,acute pancreatitis,diffuse osteoblastic metastases)
Thyroidectomy or removal of 3 1/2 parathyroid glands -> post-surgical hypoparathyroidism ->
hypocalcemia(QT-interval prolongation,tetany of lips face extremities, fatigue anxiety depression)
8882 Surgery Vit D toxicity -> hypercalcemia -> shortened QT interval
Metabolism
Persistent hypothyroidism can be seen post-thyroidectomy & can cause hyponatremia w/o thyroid hormone
supplementation
Ruptured ovarian cyst:may present w/ an acute abdomen(sudden onset,severe,unilateral lower ab pain
immediately following strenuous or sexual activity) due to hemoperitoneum(labs will show decreased Hct
Female Reproductive due to intra-abdominal blood loss). Hemodynamically unstable pts require immediate surgical intervention
12160 Surgery
System & Breast
Ovarian torsion:may present w/ sudden lower ab pain;it doesn't typically result in an acute abdomen on
physical exam & doesn't cause a drop in Hct
Acalculous cholecystitis:occurs in critically ill pts in icu w/ multiorgan failure,severe
trauma,surgery,burns,sepsis,or prolonged parenteral nutrition.Gallbladder wall thickening & distension &
pericholecystic fluid on imaging.Emergency tx of choice is antibiotics & percutaneous
2245 Surgery Gastrointestinal & Nutrition cholecystostomy,followed by cholecystectomy when medical condition stabilizes
Duodenal perforation:sudden onset,diffuse ab pain,ab rigid on initial exam(becomes distended later),sx of

peritonitis
Small bowel obstruction (SBO): sx-colicky abdominal pain, vomiting, no bowel movement or passing
gas(obstipation), abdominal distention, & diffuse tenderness. Abdominal radiographs reveal dilated bowel
2322 Surgery Gastrointestinal & Nutrition loops w/ multiple air-fluid levels. Pt's who don't improve w/ conservative measures or develop signs of
increased risk of strangulation(fever, tachycardia, leukocytosis,& metabolic acidosis) should be referred for
*urgent surgical intervention*
Blunt abdominal trauma is most frequently caused by motor vehicle accidents, & the most common solid
2327 Surgery Gastrointestinal & Nutrition organs injured are the liver & *spleen*. Free intraperitoneal fluid should raise suspicion for a liver or splenic
laceration
Umbilical hernia: common finding in African American infants. Generally reducible & close spontaneously
before age 5. Surgery not usually required
2476 Surgery Gastrointestinal & Nutrition
Umbilical granuloma: appears after the umbilical cord has separated & presents as a soft, moist, pink,
pedunculated, friable lesion. Tx- Silver nitrate
Ashhadscknotes
Acute mesenteric ischemia:diffuse abdominal tenderness,metabolic acidosis(low bicarbonate) from
increased serum lactate levels,sudden onset of severe periumbilical pain out of proportion to exam
findings,leukocytosis,elevated amylase levels. Mesenteric angiography is gold standard for dx.
Tx-supportive(iv fluids & antibiotics, ng tube)
Dx of bowel ischemia depends on a high index of clinical suspicion in pts w/ known risk factors for
thromboembolic disease(a-fib, pvd)
The development of a palpable mass in the epigastrium four weeks after the onset of acute pancreatitis is
highly suggestive of *pancreatic pseudocyst* formation.Ultrasound is the preferred means of imaging
pseudocysts.Because the pseudocyst often resolves spontaneously, drainage should only be performed if it
persists for >6 weeks, is >5 cm in diameter, or becomes secondarily infected
Pancreatic abscess: localized collection of pus,tender epigastric mass,fever & leukocytosis

Abdominal ultrasound is the best tool for the initial investigation of gallbladder pathology
ERCP is the preferred procedure when cholangitis or biliary obstruction w/ a stone appears likely
2903 Surgery Gastrointestinal & Nutrition HIDA scan is superior to abdominal ultrasound in confirming suspected acute cholecystitis(esp. acalculous
type)
Percutaneous transhepatic cholangiography (PTC) is not commonly utilized due to better alternative
procedures. Good for studying intrahepatic and extrahepatic biliary tree.
The first step in the treatment of acute variceal bleeding is to establish vascular access w/ two large bore
intravenous needles or a central line.[The second step is to control the bleeding]
Balloon tamponade w/
Sengstaken-Blakemore,Minnesota,or Linton-Nachlas tubes used for short term control of acute variceal
bleeding when endoscopy is unavailable or when meds are not working quickly. Surgical tx or creation of
TIPS used for pts who have failed medical or endoscopic tx
Acute pancreatitis in non-alcoholics:
sx-mid epigastric pain radiating to back, leukocytosis, elevated serum amylase & lipase
etiology- Gallstones are responsible for this in non-alcoholics
tx- Cholecystectomy(after pt improves), in order to prevent recurrent attacks of acute pancreatitis
secondary to gallstones
Perform ERCP in pts w/ severe biliary pancreatitis, chronic pancreatitis, ampullary cancers, the need to
obtain tissue samples, & the need for bile duct exploration
Emphysematous cholecystitis:common form of acute cholecystitis in diabetic males(aged 50-70 years).
Arises due to infection of the gallbladder wall w/ gas-forming bacteria.Sx-RUQ
2940 Surgery Gastrointestinal & Nutrition pain,nausea,vomiting,low-grade fever.Abdominal radiograph shows air fluid levels in the
gallbladder.Ultrasound shows curvilinear gas shadowing in the gallbladder.Tx-fluid & electrolyte
resuscitation,early cholecystectomy,& parenteral antibiotic therapy
Sphincter of Oddi dysfunction can cause post cholecystectomy pain. An elevated biliary sphincter pressure
is highly specific for sphincter of Oddi dysfunction. Sphincter dysfunction is characterized by RUQ pain &
elevation of liver enzymes during the pain attack, which resolve when the attacks subside. *ERCP w/
sphincterotomy* is the tx of choice for sphincter of oddi dysfunction
Postoperative cholestasis can develop after a prolonged surgery. Look for jaundice, decreased liver
functionality, & decreased renal bilirubin excretion.
ALK phos. elevated significantly
AST & ALT either normal or mildly elevated
Pts w/ classic presentation of acute appendicitis (migratory pain, nausea, vomiting, fever, leukocytosis,
McBurney point tenderness, Rovsing sign) should have IMMEDIATE appendectomy! Imaging studies used
for pts w/ nonclassic sx, equivocal findings on assessment, or delayed presentation
Pts w/ appendicitis w/ sx for >5 days usually have a phlegmon w/ an abscess that has walled off. Manage
them w/ iv antibiotics, bowel rest, & delay appendectomy for weeks later
Paralytic (adynamic) ileus:due to retroperitoneal hemorrhage ass. w/ vertebral fractures.Failure to pass
stool/flatus,nausea/vomiting,distended ab w/ tympany & decreased/absent bowel sounds.Ab xray-air fluid
levels,distended gas filled loops of small & large intestines
Acue colonic pseudoobstruction:nausea,ab pain/distention,tympanitic bowel sounds,hyperactive bowel
sounds.Ab film-dilated colon w/o sig. small bowel dilation
SBO:bowel distal to obstruction wont be distended

Psoas abscess:
sx- fever, low abdominal or back pain. Deep abdominal palpation is required to elicit tenderness due to the
deep location of the psoas on the posterior abdominal wall
etiology- hematogenous spread of bacteria from furuncles, or contiguous spread from nearby bone/bowel
Confirm dx with a CT scan*. If CT negative, then do exploratory laparoscopy is suspicion is high
tx- drainage & antibiotics
Ashhadscknotes
CT guided percutaneous drainage is tx for complicated diverticulitis w/ abscess formation. If this fails, then
surgical drainage can be attempted
3182 Surgery Gastrointestinal & Nutrition Fluid collection <3 cm can be treated w/ iv antibiotics & observation
Fluid collection >3 cm should initially be drained w/ CT guided drainage (if drain doesn't control sx by fifth
day, surgery for drainage is next step)
Blunt abdominal trauma can cause splenic injury which can present w/ delayed onset hypotension, LUQ
abdominal pain, & left shoulder pain(due to diaphragmatic irritation). Pts should have an *abdominal CT
3358 Surgery Gastrointestinal & Nutrition scan* w/ iv contrast for dx. Those w/ persistent hemodynamic instability require urgent laparotomy
Transesophageal echocardiogram is indicated for suspected aortic injury

Isolated duodenal hematoma:
occurs in children following blunt abdominal trauma
tx- nasogastric suction & parenteral nutrition. If this fails, only then do we consider surgery(either
laparotomy or laparoscopy)
Ischemic colitis:common complication of vascular surgery(eg,repair of an AAA),as pts are older & have
underlying atherosclerosis.CT shows thickening of bowel wall.Colonoscopy shows cyanotic mucosa &
hemorrhagic ulcerations
Acute diverticulitis causes LLQ pain.Diverticula causes rectal bleeding. Both are independent events
Although ulcerative colitis causes ab pain/bloody diarrhea,we can rule it out/eliminate it as dx if sx presents
for the first time at age 75
Dumping syndrome is a common postgastrectomy complication. The sx usually diminish over time &
4062 Surgery Gastrointestinal & Nutrition *dietary changes are helpful to control the sx*. In resistant cases, octreotide should be tried. Reconstructive
surgery is reserved for intractable cases
Suspect ischemic colitis in pts who have evidence of atherosclerotic vascular disease, present w/ abdominal
pain followed by bloody diarrhea, & have minimal abdominal exam findings. The most commonly involved
4098 Surgery Gastrointestinal & Nutrition segment of the colon is the *splenic flexure*, because it is supplied by end arteries.
The two watershed zones in the colon are 1)splenic flexure 2)recto-sigmoid junction. These areas are most
vulnerable to ischemia during systemic hypotension.
Anal fissure tx includes increased fiber/fluid intake, stool softeners, sitz baths, & *topical
ansesthetics(eg,lidocaine) & vasodilators(eg,nifedipine,nitroglycerin)*
Pts who present w/ appendicitis >5 days after onset of sx have a high incidence of perforation w/ abscess
formation.They often have a contained abscess.If pts are stable,tx w/ iv hydration,abx, bowel rest,& interval
appendectomy
In pts w/ appendiceal rupture w/ a contained abscess,maneuvers that assess deep abdominal
spaces(psoas sign,obturator sign,rectal exam) are useful
Psoas sign suggests presence of abscess posterior to appendix adjacent to psoas muscle
Adhesions(typically from abdominal operations/inflammatory processes/postoperative) are the mcc of small
bowel obstruction. They may be congenital in children(eg, Ladd's bands)
Recent weight loss can predispose pts to superior mesenteric artery syndrome
Decompressing the gi tract (via suctioning and stopping oral intake) is part of the tx of a partial or complete
small bowel obstruction
Air under diaphragm indicates perforated viscus, which is a surgical emergency. Once diagnosed, obtain
surgical consultation for emergent exploratory laparotomy
gastric outlet obstruction:
sx- early satiety, nausea, nonbilious vomiting, weightloss
can be caused by acid ingestion, leading to stricture (with pyloric stenosis)
phys exam will show abdominal succussion splash
confirm with upper endoscopy
tx- surgical
diabetic gastroparesis: occurs in pt's w/ diabetes for longer than a decade

Pts presenting w/ blunt abdominal trauma and/or shock should be assessed initially w/ a bedside abdominal
ultrasound or FAST examination (Focused Assessment w/ Sonography for Trauma). In hemodynamically
4498 Surgery Gastrointestinal & Nutrition unstable pts who have an equivocal or inconclusive FAST examination, diagnostic peritoneal lavage can
accurately determine the presence of active intraperitoneal hemorrhage & subsequent need for emergency
laparotomy
Blunt trauma to the upper abdomen can cause a *pancreatic* contusion, crush injury, laceration, or
transection. Pancreatic injuries may be missed by CT scan immediately following trauma. An untreated
pancreatic injury can later be complicated by a retroperitoneal abscess or pseudocyst
Initial CT scan would have diagnosed a splenic injury. Delayed splenic rupure would cause acute LUQ ab
pain & possibly hypotension, but not signs of sepsis
Ashhadscknotes
Acute gastrointestinal perforation(subdiaphragmatic free intraperitoneal air on abdominal xray) requires
emergent laparotomy. If the affected pt is already taking warfarin from before(for an old health problem like
a-fib), then reversal of anticoagulation must be rapidly achieved pre-operatively by infusion of *fresh frozen
plasma*[Vit K takes time so not used for emergency situations]. Otherwise pt at risk for intraoperative &
post-operative bleeding complications
Postoperative ileus(sx-abdominal distention, decreased/absent bowel sounds)follows most abdominal

surgeries.*Morphine* and other opiates compound this problem by decreasing GI motility
Occasionally after cholecystectomy,diarrhea can occur due to bile acid malabsoption & shortened intestinal
transit times
Chronic poor glucose control -> gastroparesis: early satiety,nausea,postprandial vomiting
Erythromycin and Metoclopramide have promotility effects
pilonidal disease:
4640 Surgery Gastrointestinal & Nutrition acute pain & swelling of the midline sacrococcygeal skin & subcutaneous tissues is due to infection of a
pilonidal cyst
Acute cholecystitis: manage conservatively, followed by cholecystectomy within 72 hours(early
cholecystectomy within 72 hours reduces disease duration, duration of hospitalization, & cholecystitis
associated mortality when compared to delayed cholecystectomy). Laparoscopic cholecystectomy is the
4655 Surgery Gastrointestinal & Nutrition procedure of choice
Percutaneous transhepatic gallbladder drainage is used to decompress the gallbladder in pts who are
unstable or have a contraindication to surgery
Pts w/ *blunt abdominal trauma* should undergo initial evaluation by focused assessment w/ sonography for
4930 Surgery Gastrointestinal & Nutrition trauma(FAST) to evaluate for *intraperitoneal hemorrhage*. Positive findings on FAST require emergent
exploratory laparotomy
Perforated viscus:presents w/ severe ab pain,fever,tachycardia,& signs of
peritonitis(guarding,rigidity,reduced bowel sounds,rebound tenderness).Can occur in the setting of 'peptic
12142 Surgery Gastrointestinal & Nutrition ulcer disease',which is often ass. w/ 'NSAID & alcohol use'[positive stool guaiac test raises suspicion for
peptic ulcer disease as the cause of perforation].Dx of GI perforation confirmed w/ *upright xray of chest &
abdomen* showing free intraperitoneal air under diaphragm(pneumoperitoneum)
*Glasgow coma scale assesses the pt's ability to open his/her eyes, motor response, & verbal response*
3213 Surgery General Principles
Exaggerated deep tendon reflexes can be seen in locked-in syndrome
Any penetrating wound below the 4th intercostal space(ie, level of the nipples) is considered to involve the
abdomen & requires an exploratory laparotomy in unstable pts
Diagnostic peritoneal lavage is done in hemodynamically unstable pts w/ blunt abdominal trauma &
inconclusive FAST examination
FAST can be done in a few minutes on all pts & has high sensitivity & specificity for detecting
hemoperitoneum, pericardial effusion, & intraperitoneal fluid
Hypotension not responsive to fluid administration following trauma is suggestive of ongoing occult blood
loss. Pts in this scenario must be treated emergently w/ *surgical intervention* to stop further hemorrhage
Intraabdominal hemorrhage: pt will have abdominal distention, absent bowel sounds & abdominal bruising
Orotracheal intubation preferred for establishing an airway(unless pt has significant facial trauma) in an
apneic pt w/ a cervical spine injury
Laryngeal mask placement is a temporary measure
3227 Surgery General Principles Nasotracheal intubation is contraindicated in apneic/hypopneic pts and pts w/ basilar skull
fractures(periauricular hematomas, raccoon eyes)
Needle cricothyroidotomy not ideal for pts w/ head injury due to CO2 retention
Tracheostomy no longer a 1st option for establishing an airway

All hemodynamically unstable pts(low systolic bp,obtunded mental status,abdominal distention) w/ sharp
penetrating abdominal trauma & gunshot wounds must be treated w/ emergent *exploratory laparotomy*.
Don't delay exploratory laparotomy for imaging procedures in these pts!
Laparoscopy used in assessing hemodynamically stable pts who have suffered penetrating abdominal
trauma in which injury to a hollow viscus or other organ can't be readily determined clinically
Ashhadscknotes
Coagulase negative staphylococci(S.epidermidis) causes nosocomial bloodstream infections in pts w/
intravascular devices
Febrile nonhemolytic reaction:cytokine accumulation during blood storage
Acute hemolytic reaction:pink plasma

Delayed hemolytic r:anamnestic antibody response
Anaphylactic r:recipient anti-IgA antibodies
Transfusion related acute lung injury:in 6 hours of transfusion,anti-leukocyte antibodies,resp distress,sx of

noncardiogenic pulm. edema
Persistent pneumothorax & significant air leak following chest tube placement in a pt who has sustained
3503 Surgery General Principles blunt chest trauma suggests tracheo*bronchial* rupture. Other findings include pneumomediastinum &
subcutaneous emphysema
Tension pneumothorax management: emergency needle thoracostomy in the 2nd intercostal space in the
mid-clavicular line
In case of amputation injury, amputated parts should be wrapped in saline moistened gauze, sealed in a
plastic bag, placed on ice & brought to the emergency department w/ the pt
A change in the *pulse rate* is the first indicator of hypovolemia.
When hemorrhage occurs, tachycardia & peripheral vascular constriction are the first physiological changes
Splenic trauma pts:
if pt initially unstable and improves w/ fluids, do CT
if pt initially unstable and unresponsive to fluids, do emergent exploratory laparotomy
better to repair spleen rather than remove it
For hemodynamically unstable pts(collapsed neck veins & hypotension) in whom blunt abdominal trauma is
suspected, fluid resuscitation should be initiated, followed by ultrasound examination. If ultrasound reveals
intraperitoneal blood, the pt should then undergo urgent *laparotomy* for surgical repair
Hemodynamically stable pt w/ intraperitoneal blood identified on ultrasound should undergo CT scan of the
abdomen w/ contrast. CT scan helps identify site of injury
Intraabdominal pathology causing pain in one or both shoulders suggests subdiaphragmatic peritonitis.
4557 Surgery General Principles Among the possible blunt traumatic bladder injuries, only an intraperitoneal rupture of the *bladder dome*
could, by itself, cause a chemical peritonitis.
Nonseminomatous germ cell tumor can also present as a *mixed germ cell tumor* so it'll have the usual
elevated AFP and elevated B-HCG
2590 Surgery Hematology & Oncology
Seminomas have elevated B-HCG but AFP is normal
Major surgery is a risk factor for DVT. Pts should be tx w/ a *heparin* product acutely & warfarin for several
months. The goal of therapy is to prevent extension of the clot & development of future clots rather than
lysis of the present clot. Anticoagulation can begin as early as 48-72 hours after surgery.
4493 Surgery Hematology & Oncology
Aspirin is a platelet inhibitor & doesn't modify the coagulation cascade
Streptokinase & TPA are clot-lysing enzymes used to tx ST elevation MIs & thrombotic strokes
Necrotizing fasciitis: A rapidly spreading infection involving the subcutaneous fascia, generally following
trauma. Sx-fever, hypotension, erythema, swelling, pain out of proportion to physical exam finding. Tx-
surgical debridement & broad-spectrum antibiotics
2749 Surgery Infectious Diseases
Pyomyositis(muscle abscess): fever, erythema, swelling, pain. Limited to one muscle group, doesn't spread
rapidly
Thrombophlebitis: erythema, tenderness, swelling of distal extremity w/ palpable "cord-like" vein

Necrotizing surgical infections: common in pts w/ diabetes. Polymicrobial. Characterized by intense pain in
4102 Surgery Infectious Diseases the wound, decreased sensitivity at the edges of the wound, cloudy-gray discharge, & sometimes crepitus.
Early *surgical exploration* is essential
Febrile nonhemolytic transfusion reaction can occur within 1-6 hours of transfusion & can cause immediate
postoperative fever in pts receiving blood during or after surgery
4526 Surgery Infectious Diseases Risk of infection due to indwelling urinary catheters & central venous catheters increases w/ duration of
catheterization. Fever & infection develop later in the 1st week after surgery
Drug fever occurs 1-2 weeks after medication administration. Accompanied by rash & peripheral eosinophilia
Acute bacterial parotitis:presents w/ painful *swelling of the parotid gland* that is aggravated by chewing.
High fever & a tender, swollen & erythematous parotid gland are common. This post-operative complication
*can be prevented w/ adequate fluid hydration & oral hygiene*. The most common infectious agent is
Staphylococcus aureus
Ashhadscknotes
Delayed-onset prosthetic joint infection(>3 months after primary arthroplasty) -> S.epidermidis
Early-onset prosthetic joint infection(within 3 months of primary arthroplasty) -> P.aeruginosa & S.aureus
C. trachomatis & Salmonella species can be ass. w/ reactive arthritis following an initial genitourinary or GI
infection. Sx-arthritis w/ urethritis/enteritis & conjunctivitis
Penile fracture: First do *retrograde urethrogram* to rule out a urethral injury. Then do Surgery.
3352 Surgery Male Reproductive System
Circumcision:tx of choice for phimosis,paraphimosis & Zoon's balanitis. Also ass. w/ lower risk of squamous
cell carcinoma
Varicoceles:tortuous *dilation of the pampiniform venous plexus*.Left-sided scrotal mass("bag of worms")
that worsens w/ standing & Valsalva maneuvers but regresses when pt is supine
4525 Surgery Male Reproductive System Spermatocele:painless fluid-filled cyst of head of epididymis,located on superior pole of testis,contains
nonviable sperm,mass outside of testis that doesn't change w/ position
Femoral hernias:more common in older women.Dx uncommon in men compared to varicocele

short term hyperventilation helps lower increased intracranial pressure by causing cerebral washout of CO2,
3226 Surgery Nervous System
leading to vasoconstriction and decreased cerebral blood flow
Acute epidural hematoma:unconsciousness followed by a lucid interval followed by a gradual deterioration of
consciousness. Head CT scan shows a biconvex hematoma(look at pic)
Acute subdural hematoma:head trauma causing tearing of the bridging veins.Head CT shows semilunar
hematoma that crosses the suture lines
Concussion ass. w/ confusion/amnesia
Diffuse axonal injury is due to traumatic acceleration/deceleration shearing forces that diffusely damage
axons in brain
Anterior spinal cord infarction is a potential complication of thoracic aortic aneurysm surgery.Sx-spinal
shock(abrupt onset of bilateral flaccid paralysis & loss of pain/temperature sensation below the level of
spinal injury).Upper motor neuron signs(spasticity & hyperreflexia) develop over days to
4204 Surgery Nervous System weeks.Vibration/proprioception preserved
Ischemic stroke due to right carotid artery atherosclerosis: abrupt onset of contralateral neurologic
deficits(not bilateral deficits!)
Femoral nerve: innervates muscles of anterior compartment of the thigh. It's responsible for knee extension
& hip flexion. Provides sensation to anterior thigh & medial leg via saphenous branch
Transtentorial herniation of the parahippocampal uncus can occur during head trauma & leads to ipsilateral
hemiparesis, ipsilateral mydriasis & strabismus, contralateral hemianopsia, & altered mentation.[The uncus
4552 Surgery Nervous System is the innermost part of the temporal lobe & herniates thru the tentorium to cause pressure on the ipsilateral
*oculomotor nerve*, ipsilateral posterior cerebral artery, & contralateral cerebral peduncle against the edge
of the tentorium]
Parotid surgery involving the deep lobe of the parotid gland carries a significant risk of facial nerve palsy
resulting in facial droop
Jaw asymmetry can result from unilateral paralysis of the muscles of mastication, which are innervated by
the mandibular division of the tigeminal nerve V3
Strabismus(improper alignment of the eyes) can result from disorders of the extraocular muscles or of the
nerves that innervate them (CN III, IV, or VI). Brainstem lesion are responsible
Anterior shoulder dislocation: acute shoulder pain after forceful abduction & external rotation at the
glenohumeral joint. May cause injury to *axillary nerve* or artery
Radial nerve injury can be due to use of improperly fitted crutches
In a pt w/ a shoulder injury,a positive drop arm sign suggests rotator cuff tear.In the drop arm test,pt's arm
is abducted to greater than 90 degrees,& pt is then asked to lower the arm slowly.With a complete rotator
cuff tear,pt will be unable to lower the arm smoothly & it will appear to drop rapidly from near the 90 degree
4605 Surgery Nervous System position
Injury to inferior trunk of the brachial pleuxus: Klumpke's palsy. Weakness/atrophy of hypothenar &
interosseous muscles. "Claw hand"
Cervical spondylosis:
4698 Surgery Nervous System etiology- disc degeneration in pts > 40 years old
sx- neck pain & stiffness. Pt can develop spinal stenosis, resulting in neurologic deficits
Epidural hematoma: ass. w/ lucid interval followed by rapid neurological deterioration. Biconvex mass on CT
4923 Surgery Nervous System of head(google image). Pts w/ deteriorating neurological status or increased ICP require an *emergent
craniotomy*
The presence of an extra axial, well circumscribed, dural based mass that is partially calcified on
neuroimaging is strongly suggestive of a meningioma. Meningiomas are benign primary brain tumors;
however, they can present w/ headache, seizure, & focal neurologic deficits due to mass effect. In such
cases, *complete surgical resection* is recommended
Ashhadscknotes
Poisoning & When circumferential full-thickness burns involving the extremities or chest are present, an *escharotomy*
3395 Surgery
Environmental Exposure may be necessary to prevent vascular compromise & respiratory difficulty, respectively.
Escharotomy is indicated for circumferential full-thickness burns of an extremity w/ an eschar causing
significant edema & constriction of the vascular supply & decreased peripheral pulses. Pts should be
evaluated for clinical signs of adequate perfusion after escharotomy, & fasciotomy should be performed if
Poisoning &
3398 Surgery there is no sign of relief
Fasciotomy involves incision thru all fascial layers & is the tx for compartment syn. Escharotomy involves
incision of only eschar layer
The most important steps in the management of lactic acidosis from septic shock are IV normal saline(IV
2812 Surgery Pulmonary & Critical Care 0.9% saline) with or without vasopressor therapy to maintain the intravascular pressure & antibiotics to
correct the underlying infection
Tension pneumothorax: can occur as a complication of subclavian central venous catheter placement. This
condition develops when injured tissue forms a one-way valve allowing air to enter the pleural space but
3216 Surgery Pulmonary & Critical Care preventing it from escaping naturally. Sx-rapid onset severe shortness of breath, tachycardia, tachypnea,
hypotension, & distention of the neck veins due to SVC compression. Tx-*Needle thoracostomy* to
decompress pleural cavity
Pain relief should be the prime objective in the management of rib fracture as it will allow proper ventilation
3220 Surgery Pulmonary & Critical Care & prevent atelectasis & pneumonia. Opiates and NSAIDS are commonly utilized, but an intercostal nerve
block w/ a long acting local anesthetic can also be used.
Diaphragmatic rupture should be suspected in pts w/ hx of blunt trauma/motor vehicle accident, abnormal
CXR, left lower lung opacity, elevated hemidiaphragm, & mediastinal deviation. Children can have a delayed
3731 Surgery Pulmonary & Critical Care
presentation w/ expansion of the diaphragmatic defect & herniation of abdominal organs. *Chest CT can
confirm the dx* in pts w/ suggestive CXR findings
*Pulmonary contusion* is common after high-speed car accidents. Sx usually develop in the first 24 hours &
a *patchy alveolar infiltrate* on CXR is typical
Diaphragmatic rupture: more common on the left side(right side protected by the liver). Pts have respiratory
distress & can have deviation of the mediastinal contents to the opposite side. Elevation of the
hemidiaphragm on chest x-ray is the only abnormal finding. Chest x-ray showing a nasogastric tube in the
4229 Surgery Pulmonary & Critical Care pulmonary cavity is diagnostic
Aortic rupture:can result in instantaneous death. Rarely can get profound hypotension. Cxr shows widened
mediastinum
Severe blunt chest trauma causes injury to pulmonary parenchyma & pulmonary
contusions.Dyspnea,tachypnea,chest pain,hypoxemia worsened by intravascular volume expansion &
patchy irregular alveolar infiltrates on CXR
4537 Surgery Pulmonary & Critical Care Myocardial contusion:arrhythmia,heart failure,chest pain.Cardiac rupture is an uncommon
manifestation.PCWP increased
Aortic rupture:mediastinal widening,left main bronchus depression,displacement of trachea/esophagus to

right,obliteration of aortic knob shadow
Tension pneumothorax: sx- tachypnea, tachycardia, distended neck veins, & tracheal deviation
tx- needle thoracostomy
After blunt chest trauma, hemorrhagic shock ass. w/ decreased breath sounds & dullness to percussion
over one hemithorax & contralateral tracheal deviation is most likely due to a large ipsilateral *hemothorax*
Tracheobronchial tear:dyspnea, hemoptysis, subcutaneous emphysema, Hamman sign(audible crepitus on
cardiac auscultation) & sternal tenderness
Risk factors for postoperative pneumonia:
smoking, preexisting pumonary disease, age >50, thoracic or abdominal surgery, surgery lasting >3 hours,
poor general health eg. CAD, diabetes, htn.
4545 Surgery Pulmonary & Critical Care Tx- Spirometry is very effective in decreasing risk of pneumonia since it encourages lung expansion! 1st line
tx!
Prophylactic antibiotic use prior to surgery is only used for pts w/ preexisting respiratory infection. Using it in
pts w/o respiratory infection DOES NOT improve outcomes
Flail chest should be suspected in pts w/ multiple rib fractures & respiratory distress. CXR shows multiple rib
fractures overlying a lung contusion(google CXR image for flail chest!)
Diaphragmatic tear: herniation of abdominal contents into the left pleural space
In burn victims w/ signs of thermal inhalation injury to the upper airway and/or smoke inhalation injury to the
lungs, early *intubation* is required in order to prevent upper airway obstruction by edema
Elevation of the head of the bed(moving from supine to sitting) can increase functional residual lung
capacity(FRC) by 20% to 35%. Increasing the FRC can help prevent postoperative atelectasis.
Respiratory quotient close to 1= carbohydrate is the major nutrient being oxidized
4606 Surgery Pulmonary & Critical Care Respiratory quotient of .8= protein
Respiratory quotient of .7= lipid

Atelectasis is a common postoperative complication(usually following abdominal or thoracoabdominal
surgery) that results from *shallow breathing and weak cough* due to pain
Ashhadscknotes
Atelectasis is one of the most common postoperative pumonary complications & is usually due to airway
obstruction from retained airway secretions, decreased lung compliance, postoperative pain, & medications
that interfere w/ deep breathing. Arterial blood gas levels typically show hypoxemia, hypocapnia, &
respiratory alkalosis
Preoperative pt education & a program of inspiratory muscle training(*breath exercises*, forced expiration
techniques, incentive spirometry) should be conducted to prevent postoperative atelectasis. Postoperative
breathing exercises & incentive spirometry are also effective in reducing the risk of pulmonary complications
Smoking cessation reduces risk of postoperative pulmonary complications. Have to quit smoking at least 8
weeks prior to surgery
Pts w/ hemoptysis & high clinical suspicion for pulmonary tb should be placed in respiratory isolation
Bronchoscopy should be performed to directly visualize & control the site of bleeding in pts w/ massive
4936 Surgery Pulmonary & Critical Care hemoptysis
Endotracheal intubation should be performed to protect airway in pts w/ hemoptysis who are
hemodynamically unstable or have poor gas exchange, severe dyspnea, or massive hemoptysis
Pt w/ massive hemoptysis: Greatest danger is asphyxiation due to the airway flooding w/ blood. Pt should
be placed w/ the bleeding lung in the dependent position (lateral position) to avoid blood collection in the
4937 Surgery Pulmonary & Critical Care airways of the opposite lung. Bronchoscopy is initial procedure of choice. Pulmonary arteriography is
performed when initial bronchoscopy is unable to localize the source. Urgent thoracotomy/surgical
intervention is used for pts who bleed despite bronchoscopy
Renal, Urinary Systems & Posterior urethral injury: ass w/ pelvic fractures. Blood at urethral meatus, high riding prostate, scrotal
3348 Surgery
Electrolytes hematoma, inability to void despite sensing an urge to void, palpably distended bladder
A *retrograde urethrogram* should be the first step in management of a suspected urethral injury.
[Foley catheterization in the presence of a urethral injury will predispose the pt to abscess formation &
worsening of the urethral damage]
3349 Surgery
Electrolytes Retrograde cystogram w/ post void films is used for dx of bladder injury
Most cases of urethral injury are tx w/ urinary diversion via a suprapubic catheter while the primary injury &
ass hematomas are allowed to heal
In pts w/ traumatic spinal cord injuries, urinary catheter placement can assess for urinary retention &
prevent acute bladder distension & damage(we suspect spinal cord injury if pt has sx like weakness &
decreased pain sensation in both of their legs)
3784 Surgery
Electrolytes
IV atropine/external pacing used for symptomatic bradycardia
IV cefazolin commonly used for antimicrobial prophylaxis before surgery to prevent wound infections
Oliguria,azotemia,elevated BUN/creatinine ratio of >20:1 in post-operative state indicates acute pre-renal
failure from hypovolemia,though urinary catheter obstruction should first be ruled out.The next step in the
dx/management of acute renal failure manifesting as oliguria or anuria is an *IV fluid challenge*
4607 Surgery
Electrolytes
Low-dose dopamine infusion dilates renal arterioles,thereby increasing GFR & urine output
IV pyelogram dx renal calculi,genitourinary neoplasms, & papillary necrois

Initial hematuria suggests urethral damage. Terminal hematuria(urine turning red by the end of the stream)
4751 Surgery indicates *bladder* or prostatic damage. Total hematuria reflects damage in the kidney or ureters.[Clots
Electrolytes
aren't usually seen w/ renal causes of hematuria]
Adhesive capsulitis(frozen shoulder): characterized by pain & contracture. Inability to lift arm above head.
Even after injection of lidocaine, the arm still can't be lifted above head due to fibrosis of the shoulder
capsule
3168 Surgery
& Sports
Thoracic outlet syndrome: vascular compression may occur, presents w/ combo of numbness, weakness &
swelling due to compression of subclavian vessels & lower trunk of brachial plexus. Weakened radial pulse
& reproduction of sx w/ specific arm movements
Fat embolism:dyspnea,confusion, petechiae in upper part of body. Occurs after multiple fractures of long
bones.Dx can be confirmed by presence of fat droplets in urine or presence of intra-arterial fat globules on
Rheumatology/Orthopedics fundoscopy
3302 Surgery
& Sports
Air embolism can occur in a trauma pt who is on a respirator. It can also occur w/ subclavian vein access. It
can result in sudden collapse & cardiac arrest
The Radial nerve is the most commonly injured nerve in ass. w/ fracture of the *midshaft* of the humerus.
Rheumatology/Orthopedics Radial nerve passes thru radial groove, which is on the posterior surface of the humerus
3413 Surgery
& Sports
Brachial artery is commonly injured in supra condylar fracture of humerus,commonly seen in children
*Wrist immobilization* is recommended in the tx of all nondisplaced scaphoid fractures.
Scaphoid fractures-tenderness in anatomic snuffbox hints at scaphoid fracture, xrays can be normal or
3415 Surgery show fine radiolucent lines(in nondisplaced scaphoid fractures)
& Sports
Rest, ice, compression, & elevation (RICE tx) are the tx for a minor ligament sprain but not for a fracture
Ashhadscknotes
Compartment syndrome:
Common-pain out of proportion to injury, pain increased on passive stretch, rapidly increasing & tense
swelling, paresthesia/pins & needles sensation (early)
3463 Surgery Uncommon-decreased sensation, motor weakness (within hours), paralysis (late), decreased distal pulses
& Sports
(uncommon)
If index of suspicion high, compartment pressures must be measured immediately. Fasciotomy is tx of
choice.
Supracondylar fractures:Due to fall on outstretched hand.Radial & brachial pulses must be assessed before
& after reduction as *brachial artery* can be impinged.Also risk of median nerve injury
Axillary nerve injured during proximal humerus fractures

3556 Surgery
& Sports Brachial plexus injury:complication of neonatal clavicle fracture or high-impact trauma to neck/shoulder
Ischemia/infarct from compartment syn->Volkmann contracture
Supracondylar fractures of humerus->cubitus varus deformity

All pts w/ a clavicular fracture should have a careful neurovascular examination to rule out injury to the
underlying brachial plexus & subclavian artery. If bruit heard beneath the clavicle on auscultation, an
*angiogram* will be necessary to rule out injury to the underlying vessel
3557 Surgery
& Sports Fractures of middle third of clavicle:account for most clavicular fractures. Tx- nonoperatively w/ brace, rest
& ice
Fractures of distal third of clavicle:tx- open reduction & internal fixation

Pts w/ clinical signs of a scaphoid fracture following an injury likely to cause such a fracture should be
3562 Surgery presumed to have the fracture & have an initial x-ray. If the x-ray is negative, the next step is thumb
& Sports
immobilization in a spica cast & repeated x-rays in 7-10 days
Rheumatology/Orthopedics Older pts w/ hip fracture should undergo definitive surgical correction as soon as reasonably possible.
3564 Surgery
& Sports However, surgery may be delayed up to 72 hours to evaluate surgical risk & ensure medical stability
Rheumatology/Orthopedics Stress fractures occur in the anterior part of the middle third of the tibia in pts involved in jumping
3566 Surgery
& Sports sports(ballet dancers) & the posteromedial part of the distal third of the tibia in runners
Rheumatology/Orthopedics MRI is the investigation of choice for assessment of soft tissue injuries of the knee.
3569 Surgery
& Sports Arthroscopy is invasive. It's only used when MRI is inconclusive or surgical tx of lesion is necessary
Medial meniscus: more commonly injured than lateral meniscus, pt complain of popping sound & severe
pain at time of injury, effusion not clinically apparent for many hours following injury. McMurray's
sign(indicative of medial meniscus tear) is an audible snap occurring while slowly extending the leg at the
Rheumatology/Orthopedics knee from full flexion while simultaneously applying tibial torsion
3572 Surgery
& Sports
ACL tear: Effusion seen rapidly following injury
Meniscal injury: commonly caused by twisting injury, swelling & pain gradually occurs within 24 hours after
injury, knee worse w/ twisting movements, occasionally causes a popping sensation. Do *MRI* if sx are
Rheumatology/Orthopedics persistent. Surgery (arthroscopic or open) often necessary to correct problem
4250 Surgery
& Sports
Intraarticular steroid injections can be used in pts w/ secondary meniscal injury due to degenerative joint
disease
Stress (hairline) fractures of the metatarsals are common in athletes & military recruits. Second metatarsal
is most commonly injured. Tx w/ rest, analgesia & a hard-soled shoe
4485 Surgery
& Sports
Surgical intervention reserved for fractures of the fifth metatarsal, such as Jones fractures, or for displaced
fractures not amenable to closed reduction
Rheumatology/Orthopedics *Trochanteric bursitis*: Can occur in a middle aged adult. Superficial unilateral hip pain that is exacerbated
4546 Surgery
& Sports by external pressure to the upper lateral thigh (as when lying on the affected side in bed)
Meniscal tears in knee joint:pt can recall when it occurred, popping sensation, joint swelling develops
gradually and noticed the next day
Ligamentous tears:also ass. w/ popping sensation but cause rapid joint swelling due to hemarthrosis
4554 Surgery
& Sports
Stress fractures are due to repeated stress eg. in long distance runners.Tibia & fibula most vulnerable
Anserine bursitis causes tenderness over medial aspect of knee,affects athletes & obese middle aged to
elderly women. No pop reported
Prepatellar bursitis(housemaid's knee) is characterized by anterior knee pain, tenderness, erythema, &
localized swelling, & is common in occupations requiring repetitive kneeling(concrete work,carpet
11976 Surgery laying,plumbing). It's often due to Staphylococcus aureus, which can infect the bursa via penetrating
& Sports
trauma, repetitive friction, or extension from local cellulitis. If gram stain/culture are negative, manage w/
activity modification & NSAIDs. Otherwise tx w/ drainage & Abx
Ashhadscknotes

Ashhad's Step 2 CK UW Notes PDF

Uploaded by

Copyright:

Available Formats

Ashhad's Step 2 CK UW Notes PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ashhad's Step 2 CK UW Notes PDF

Uploaded by

Copyright:

Available Formats

USMLE STEP 2 CK NOTES

STEP 2 CK NOTES THAT I COMPILED USING UWORLD QBANK FOR STEP

PCV13:induces T-cell-DEPENDENT B-cell response.Causes improved immunogenicity due to formation of

MMR & intranasal influenza vaccine:CD8+ T cell response

Oral polio vaccine:secretion of anti-poliovirus IgA antibodies in GI tract

One adverse effect of beta-blockers(metoprolol) is male sexual dysfunction

Mycophenolate toxicity- marrow suppression

Negatively skewed: mean less than median less than mode

Prevalence:measure of those w/ the disease in the population at a particular point in time

Cluster analysis:grouping of different data point into similar categories

Parallel study:randomizes 1 tx to one group & diff tx to other group

Norepinephrine tx severe hypotension & shock (eg septic shock)

Abdominal ultrasound: useful for diagnosing acute cholecystitis

Upright abdominal xray: use in diagnosing PUD w/ perforation

Upright tilt table test-to dx vasovagal syncope

Primary hyperaldosteronism: low plasma renin, hypokalemia, and htn

Metolazone is a thiazide diuretic

Dexamethasone suppression test can diagnose Cushing's syndrome

ACE inhibitors:for heart failure pts w/ systolic dysfunction

Hemochromatosis tx- phlebotomy

Streptokinase: used for thrombolysis in tx of STEMI if PCI not available

Right ventricular infarction is most common w/ inferior wall MI

Digoxin:sx relief in pts w/ systolic heart failure

New onset right bundle branch block can sometimes be seen in PE

Arrhythmias should be tx only as they arise

Benefits of reperfusion outweigh the consequences of reperfusion injury

DASH(Dietary Approaches to Stop Hypertension)

Lidocaine:antiarrhythmic used for tx ventricular arrhythmias

Digoxin used for atrial tachycardia

Lidocaine:for ventricular arrhythmias

24 hour ECG (Holter) monitoring used in symptomatic pts(dizzy,syncope) suspected of having

1st degree av block:prolonged PR interval

24 hour (Holter) monitoring indicated for pts w/ arrhythmia

Hypertensive urgency: severe htn >180/120 w/ no sx of acute end-organ damage

Pulseless electrical activity:presence of electrocardiographic rhythm in absence of adequate cardiac

Asystole:complete absence of electrical & mechanical cardiac activity

Pts w/ prolonged duration of cardiac arrest->pulseless electrical activity or asystole

Left main coronary artery occlusion->sudden cardiac death

Hyperventilation: rare cause of syncope

TIA: syncope occurs if posterior circulation & brainstem is affected by TIA

Pulsus bisferiens:2 systolic peaks of aortic pulse separated by midsystolic dip

Amiodarone: antiarrhythmic agent,

Mitral valve prolapse frequently seen in Marfan syndrome

Pulsus parvus et tardus seen in severe aortic stenosis

Decreased plasma colloid pressure -> peripheral/generalized edema in pts w/ severe

Diltiazem/metoprolol for HR control in pts w/ rapid AF

Mitral regurgitation: holosystolic murmur

ADPKD-hypertension(common early finding),palpable abdominal masses(usually bilateral).

acute onset dyspnea w/ wheezing and prolonged expiration indicates bronchoconstriction.

Pericardial effusions ass. w/ acute pericarditis

Atrial flutter involves a reentrant circuit around the tricuspid annulus

Atrioventricular reentrant tachycardia is due to a reentrant circuit involving an accessory atrioventricular

Spur cells(acanthocytes):RBCs w irregularly sized/spaced projections seen in liver disease

Emergency pericardiocentesis for pt w/ pericardial effusion & tamponade w/ HEMODYNAMIC INSTABILITY

PH from thromboembolic occlusion of pulm. vasculature:Tx-anticoagulation

Nodular basal cell carcinoma(BCC) on the face or cosmetically sensitive areas(perioral

Vitiligo: total depigmentation esp around the mouth or on fingertips

Pemphigus:antibodies target desmogleins.Keratinocyte surface-bound IgG throughout epidermis

Melanocytic nevi:benign lesions in integument

Initial mgmt of DKA:rapid IV admin of normal saline & regular insulin