Exam things to note/review: Hypothyroid - can cause myopathy, see elevated CK -sxs: fatigue, weight loss, proximal muscle

weakness, may also see inc DTRs and a tremor (action tremor) Chronic hepatitis - to evaluate extent of damage need a liver bx Allergic rhinitis- see nasal eosinophillia, need to get a NASAL swab Marfan's see MR and MVP, also AR if threat of aortic dissection Hyper PTH- need to get a sestamibi scan Parkinsons- hypokinetic gait Mechanical ventilation! GO OVER IN DETAIL Hypoxemia- treat by increasing PEEP or by increasing FiO2 , measured through pO2 Note: Increasing FiO2 beyond 50-60% is contraindicated due to risk of O2 toxicity Tidal volume- inc would inc MV and peak inspiratory pressure (can worsen respiratory alkalosis) judge by looking at pCO2 RR- judge adequacy by looking at the pCO2 (if low then ok) Respiratory quotient = CO2/O2 -used to wean ppl off ventilator and to determine if overfeeding (if over feeding with carbs then there is an increase in CO2) -if close to 1, then carbs are major nutrient oxidized- net lipogenesis occuring -0.8 protein -0.7 fatty acids Antiarrhythmic drugsWPW- Digoxin, verapamil and adenosine contraindicated bc they favor conduction across accessory pathway -should use procainamide, or cardiovert when they develop a rapid ventricular rhythm Class 1c blocks Na channels Note: Flecainide prolong QRS Flow volume loopsNormal- (insert image)

Obstructive lung dzInspiratory- nl Expiratory concave shaped Restrictive lung dzInspiratory nl shape but shortened Expiratory- nl shape but shortened Laryngeal edemaInspiratory- fixed flat line Expiratory- fixed flat line Membranous GN can develop a renal vein thrombosis (abd pain, fever, hematuria) SAAG- ascites albumin - serum albumin (if >1.1 indicates a transudate) -Transudative process e.g. portal hypertension Infxn with Echinococcus (dogs)- can develop hydatid cysts unilocular lesion with egg shell calcifications -txt: DO NOT aspirate, instead surgical resection indicated + albendazole Succinylcholine releases K therefore CONTRAINDICATED in ppl with hyperK Intracranial pressure: Cerebral blood flow dysregulated in trauma and stroke -increased flow -increased cerebral vasodilation and elevated BP raises the ICP To lower ICP: Intervention Head elevation Sedation IV mannitol Hyperventilation Mechanism Increased venous outflow from head Decreased metabolic demand and control of HTN Extraction of free water out of brain tissue osmotic diuresis CO2 washout, leading to cerebral vasoconstriction

Gluconeogenesis- substrates: -gluconeogenic AA (protein from muscle) -lactate (anaerobic metabolism) -glycerol 3-phosphate (from TAG in adipose) alanine (gluconeogenic AA) via ALT- becomes pyruvate

MurmursHypertrophic cardiomyopathy- crescendo-decrescendo systolic murmur at LSB that does NOT radiate -associated with syncope Laxative abuse- dark brown discoloration of colon with lymph follicles shining through as pale patches (melanosis coli) RV infarct (in the setting of an inferior wall MI) see clear lungs, hypotension, and JVD -should STOP nitrates/nitroglycerin (bc they dec preload) and give fluids PE of R pulm artery MCC thrombus from deep veins in LE (ileofemoral etc) Risk factors for respiratory distress: (inversely proportional to gesteational age) -male sex -c section w/out labor -perinatal asphyxia -maternal diabetes Protective factors for RDS: -prolonger ROM -maternal hypertension -intrauterine growth restriction NOTE difference btwn: Esophageal stricture presenting symptom is dysphagia Pyloric stricture- sxs gastric outlet obstruction, postprandial pain, vomiting with early satiety Lead poisoning- vomiting, ataxia, colicky abdominal pain, encephalopathy, cerebral edema, irritability, seizures Hypertension of pregnancy diagnosed AFTER 20wks -if before 20 wks must r/o Hyatidform mole (do an US to see if there is anormal gestational sac) Children- acute unilateral lymphadenitis most likely BACTERIAL in origion -S. aureus MC, kids appear nontoxic, LN is warm, erythematous (can progress to induration and fluctuance) Erythema toxicum- infants, numerous eosinophils, self-limiting Temporal arteritis- at risk for developing aortic aneurysms! Arterial Thrombosis- slow, progressive, insidious onset, diminished pulses

Arterial Embolus- pain is sudden!, pulses diminished or absent in affected limb Lumbar spinal stenosis vertebral degenserative disk dz - exacerbated by extension (standing, walking)- bc narrows canal -improved by flexion (sitting, laying down) bc widens canal Stroke biggest RF is HTN! -smoking and DM also associated but not as strong! Blastomycosis- south-central and north-central US, has a cutaneous manifestation (violaceous hue with sharp demarcated borders) Paroxysmal noctural dyspnea- concerning for pul edema -give nitroglycerin to relieve dyspnea- works quickly and preduces preload -sometimes secondary to chronic HTN and LVF -due to diastolic dysfunction Parapneumonic effusions- LOW pH (<7.2) is indcative of a n empyema!, indication for removal via thoracostomy -glucose <60 in pleural fluid also indicative for removal via tube thoracostomy Zinc deficiency- alopecia, perioral and periorbital pustules , impaired wound healing -develops in some ppl with TPN due to lack of Zinc in mixture Side effects of Abx-Acute renal failure seen in Aminoglycosides (Amikacin) Digoxin can cause: Atrial tachycardia with AV block Trauma apneic pts with suspected c spine fxs- should perform orotracheal intubation -Nasotracheal intubation is a blind procedure that requires pt to be breathing, contraindicated in apneic/hypopneic pts -Needle cricothyroidotomy- good FIELD procedure in children. Not great for adults (may increase CO2 retention) -Tracheostomy- not a first option (prefer surgical cricoidotomy then convert to tracheostomy) Ob-gyn: Placenta previa- presents as painless bright red vaginal bleeding Abruptio placenta- presents as painful uterine contractions and dark red blood in vagina, can result in intrauterine death, associated with maternal hypertension Vasa previa- fetal blood vessels cross lower part of placenta near fetus and internal cervical os, can result in painless bleeding but associated with rapid deterioration of fetal heart rate

Multiple myeloma- also associated with renal disease, obstruction of distal and collecting tubules with paraproteins (Bence-Jones proteins) -Also see: hypercalcemia, hyperuricemia, pyelonephritis, , amyloid deposition Childhood exanthems- Rubella- rash starts at face and spreads downwards, also see posterior cervical and occipital LN, also see fever and malaise Measles- SAME presentation but pts with rubella are LESS sick DVT management steps: 1. Initial anticoagulation and clot stabilization done with heparin of LMWH 2. Chronic anticoagulation Warfarin 3. Treatment of DVT-related complications compression stockings etc. In US: Thyroid dysgenesis is the MCC of CONGENTIAL hypothyroidism GN after URI: ADULTS: IgA nephropathy CHILDREN: Post-streptococcal GN RhoGAM = anti-D gamma globulin -administer after abortion/traumatic event where fetal and maternal blood mixing occurs if mom has LOW titre <1:6 -administer for all moms Rh- at 28wks D/O of INCREASED Unconjugated bilirubin levels: 1. Gilberts- production of U-gly..transferases is reduced, only see levlevated unconjugated indirect bilirubin levels. Usually precipated by stress, fasting etc. 2. Crigler-Najjar Type 1- severe jaundice and neuro impairment iat birth. Indirect levels can be 20-25 but can increase to 50. Txt: liver transplant 3. Crigler-Najjar Type 2- milder autosomal recessive form. Txt: IV pheniobarbital Parinauds syndrome- paralysis of vertical gaze that may be associated with papillary disturbances and eyelid retraction (Colliers sign) -causes an endocrine syndrome: interuppts the hypothalamic inhibitory pattern -caused by pinealoma or germinoma Leprosy- chronic granulomatous dz, affects peripheral nerves and skin. Caused by mycobacterium leprae -dx: skin bx will see acid-fast bacilli Osgood-schlatter dz: associated with traction apophysitis -worsened by sports -reproducible by extending knee against resistance

Sickle cell anemia peripheral smear: reticulocytes and sickle cells Viral arthritis seen in adults that work with kids -due to Parvovirus B19 -acute onset -polyarticular, symmetric -affects MCP, PIP, wrist and ankle joints Pregnancy tests for all pts: -Cervical cytology -Rhesus type and Ab screen -Hct, Hb, MCV -Rubella immunity -Varicella immunity -Urine Cx -Syphilis testing -Hep B Ag -Chlamydia testing -HIV test -Influenza vaccine during flu season -Offer genetic screening for CF and Downs Syndrome At risk pregnant pts: -Thyroid fxn ONLY if sxs, personal or family h/o -TB -Toxoplasmosis serology -Hb electrophoresis (high risk ethnic background, MCV <80) -Lead levels Sickle cell trait (HbS)- very rare to have sxs -can get painless hematuria as MC sx Retinal detachment- photopsia (flashes of light) and floaters (spots in visual field) described as curtain coming down over my eyes Central retinal artery occlusion sudden painless loss of vision in one eye -cherry red fovea, boxcar segmentation of blood in retinal veins, pallor of optic disk Syphilis- painless papule that becomes ulcerated ulcer (can be found on vulva), also see bilateral inguinal lymphadenopathy Note: Differentiate from chancroid and HSV bc they both have painful ulcers Interstitial cystitis- urinary urgency, frequency, pelvic pain (dysparunia), chronic condition -Cystoscopy- submucosal petechiae or ulcerations

Childhood disintegrative d/o- MC in MALES, period of normal development for at least 2 yrs followed by a loss of previously acquired skills Autism- see the presence of sxs BEFORE age 3 Fetal Defects: Neonatal abstinence syndrome- occurs neonates that have been exposed to opiates (heroin) in utero -Sxs: occurs within 48hrs after birth see diarrhea, high pitched cry, tremors, seizures, poor feeding, tachypnea, vomiting -Txt: symptomatic, can give Morphine if symptomatic treatment does not work Valproic acid- causes neural tube defects, may cause cardiac anomalies, dysmophic facies (cleft lip, narrow bifrontal diameter) Cocaine- jitteriness, excessive sucking, hyperactive Moro reflexes, withdrawl not as severe as opiates Premature adrenarche- isolated appearance of axillary hair before age 6. -Due to premature androgen secretion from the adrenal glands AIN- drugs that cause: antibiotics (PCN, cephalosporins, rifampicin, trimethoprim), NSAIDs, diuretics, captopril NOTE: association between seborrheic dermatitis and parkinsons and HIV SE of PTU- agranulocytosis (most serious SE), MC SE is allergic reaction CJD- suspect in elderly with rapidly progressive dementia, myoclonus (+ extensor plantar response) -EEG periodic sharp waves -Bx: spongiform changes Condition Urine Chlorid e (mEq/L ) High (>20) Very low Very Plasma renin Plasma aldosteron e Elevated Elevated Elevated Seru mK Seru m Bicar b High High High Serum Na

Diuretic use Vomiting Bartter/Gitelman

Elevate d Elevate d Elevate

Low Low Low

Low/norma l Low/norma l Normal

syndrome Primary hyperadolsteronis m Renin-secreting tumor Factitious diarrhea

high (>40) Very high (>40) Very high (>40) Very low (<10)

d Low Elevate d Elevate d Elevated Elevated Elevated Low Low Low High High High Elevated Elevated Low/norma l

Bartters syndrome- defective Na and Cl resorption in thick ascending loop of Henle -presents as polyuria, polydipsia and mental retardtion in early life Gitelmans synd- milder form of Bartter due to defect in distal convoluted tubule Amniocentesis best performed btwn 16-18 wks gestation after triple screen abnormal CVS- best between 10-12wks in women with KNOWN genetic diseases for the purposes of aborting the fetus After Rubella vaccine wait for 1 month for conception! No cases of congential rubella from vaccine reported Erythema nodosum associated with: strep infxn, TB, sarcoidosis, histoplasmosis , IBD Necrotizing enterocolitis- find pneumatosis intestinalis on KUB, also gastric retention first sx Chagas = protozoal disease! Goodpastures emergency plasmapheresis is imperative to prevent kidney damage Wegners- give cyclophosphamide and steroids HIV pts: BLOODY diarrhea CMV colitis (MC cause) -other causes E. histolytica (will see flask shaped inclusion bodies) Watery diarrhea Cryptosporidium etc -MAC only involves small bowel Carpal tunnel synd in pregnancy due to estrogen med buildup of ground substance which causes interstitial edema in hands and face, can result in carpal tunnel

-txt: neutral position wrist splint first then if that fails can give local/oral CCS Viral arthritis- polyarticular and symmetric arthritis -can have a +Rf and +ANA Paralytic ileus- usually a rxn to abdominal surgery but also due to paralysis -see gas filled loops of small and large intestines Note: in SBO- bowl DISTAL to obstruction is NOT distended Primary hyperaldosteronism- see hypertension, muscle weakness and numbness -high aldosterone/renin ratio Ototoxic drugs: -Loop diuretics (furosemide) -Aminoglycoside abx -cyclophosphamide -ASA (more of a tinnitus) AI conditions associated with vitiligo: -Pernicious anemia -Autoimmune thyroid dz (Graves chronic autoimmune thyroiditis) -T1DM -Primary adrenal insufficiency -hypopituitarism -alopecia arreata Intraventricular hemorrhage associated with PREMATURITY Aplastic anemia see bone marrow hypocellularity and fatty infilteration Diamond-Blackfan anemia- pure RBC anemia. Early life- see pallor and poor feeding. CBC shows normocytic or macrocytic anemia with reticulocytopenia Fanconis anemia- pancytopenia with anomalies: hyperpig on trunk, neck intertriginous areas, short status, upper limb abnormalities, hypogonadism, skeletal anomalies Malaria- Plasmodium falciparum- prophylaxis with Chloroquine -Resistant areas: INDIA, Sub-Saharan Africa prophylaxis with mefloquine Plasmodium vivax/ovale- prophylax/treat with Primaquine -liver manifestations Resting tremor problem with basal ganglia! Not the same as essential tremor! = intention tremor Syncope + confusion afterwards = seizure! (complex partial or generalized seiqures)

Mixed cryoglobulinemia palpable purpura, proteinura, hematuria, arthlarlias, hepatosplenomegaly -seen with underlying Hep C infections Cystine stones hard, poorly solube, radioopaque, hexagonal crystals on UA Vertebral osteomyelitis best test to dx is an MRI of spine If suspect cord compression/spinal stenosis first step is to give CCS THEN get and MRI Pneumomediastinum seen in esophageal perforation, Boerhaave synd -NOT seen in Mallory-Weiss tears (bc incomplete) Primidone SE: colicky abd pain, confusion, headaches, hallucinations, dizziness, -used in txt of essential tremor (BBlockers also used) Note: if suspect anemia of chronic dz- check ESR to make sure inflammation is occurring, otherwise suspect Fe def or thalassemia Thyrotoxicosis hyperdynamic state causes secondary hypertension Drugs ok in Pregnancy for UTI: -Nitrofurantoin -Amoxicillin -Amox-clavulanate -Cephalexin Contraindicated in preg: -Tetracyclines- cause probs with bone and tooth development -Fluroquinolones cause arthropathies -TMP-SMX- class C interferes with folate metabolism (should be used in last trimester only) In HIT: -STOP heparin -cant use LMWH! Cross reacts with heparin Abs -Alternate treatments include: DIT (leupirudin, argatroban), danaproid Coarctation of aorta MC to get elevated BP in R arm Atherosclerosis of upper extremities- MC in L subclavian a. Specific phobia treated with BBlockers

Congential toxoplasmosis- hydrocephalus, chorioretinitis, microcephaly, cerebral calfications, hepatosplenomegaly NE induced vasospasm can cause ischemia and necrosis of distal fingers/toes -dusky appearance! -can also occur in intestines (resulting in mesenteric ischemia) or kidney (renal failure) ACL tear- immediate swelling, inability to weight bear on knee Meniscal tear- pain to palpation near knee joint, can weight bear afterwards Immunodeficiency Brutons agammaglobulinemia (XLA) Sxs 1. Onset of recurrent bacterial infxns in first 5 yrs of life 2. Serum IgG, IgM, IgA values that are decreased 3. Absent isohemagglutinins or poor response to vaccines 4. Less than 2% CD19+ B cells in peripheral circulation Low levels of IgM, IgA, IgG, sinopulm infxns, B cell number normal High levels of IgM with def in IgA, IgG, see neutropenia, opportunistic infections (PCP), sinopulmonary infxns Infxns of respiratory, GI and urogenital tract Seen in ppl with normal level of IgG yet still develop recurrent pulm infxns

Common variable immunodeficiency Hyper IgM syndrome (HIM) IgA def Selective IgG subclass deficiences

Lung findings Consolidation

Pleural effusion Pneumothorax Interstitial lung disease

Bronchial breath sounds increased during EXPIRATION Egophony Crackles Dullness to percurssion Decreased breath sounds Egophony sometimes heard at fluid level Hyperreasonant Decreased breath sounds Vesicular breath sounds Resonant on percussion Fine crackles at end of inspiration

Mucous plugging Emphysema

No breath sounds at portion Lungs hyper-reasonant to percussion bilaterally Vesicular breath sounds Fine crackles at end of inspiration

Hashimotos thyroiditis susceptible to develop lymphoma of thyroid Note: Bacilus cereus also produces a preformed toxin found in rice and starch based foods Restrictive lung disease- FEV1/FVC>80% Causes: interstitial lung disease, neuromuscular disease, alveolar edema, pleural fibrosis, and chest wall abnormalities -most have decreased FRC except Ankylosing spondylitis (FRC increased bc chest wall fixed in an inspiratory position) Rotator cuff tendonitis improved by injecting joint with steroids N-acetylcysteine- as long as given within 8hrs of ingestion will work equally well (therefore can wait to get a liver level of Acetaminophen before giving antidote for toxicity Bronchiectasis- mucopurulent expectorant, can also get clubbing of digits Chronic bronchitis- nonpurulent expectorant Pagets disease of breast- large cells that appear to have clear halos around then because cancer cells become retracted from adjacent keratinocytes -usually due to an underlying adenocarcinoma SBO- partial obstructions (still passing gas) can be observed -full obstructions ER laparotomy Pertussis- highly contagious despite immunization, should give all contacts erythromycin for 14d (despite vaccination) -transmitted via respiratory droplets Pulm embolismCXR: Westermarks sign: dilatation of pulm artery proximal to clot and collapse of vessels distal to the clot Hamptons hump: Pulm infiltrates corresponding to areas of pulmonary infarction EKG: MC finding, sinus tachycardia

HPV- vulvar lesions- pink, teardrop shaped growths, application of trichloroacetic acid/podophyllin leads to resolution of lesions Other vulvar lesions: Condyloma lata- secondary syphilis, see flat velvety lesions, respond to PCN Vulvar cancer- singular, fleshy lesion on labia majora Lichen sclerosus- white, thin, wrinkled skin over labia, pruitic Vulvar lichen planus- middle aged women, hyperkeratotic, erosive/papulosquamous in appearance, see pruitus, soreness and vaginal discharge Klumpke paralysis- paralysis of hand due to injury of 7th and 8th cervical n. and 1st thoracic n. -Note: can also see ipsilateral Horner syndrome due to miosis and ptosis Note: for ppl that do not want to undergo cholescystecomy can give ursodeoxycholic acid bile salt which decreases cholesterol content of bile by reducing hepatic secretion and intestinal resorption of cholesterol Levidopa/carbidopa- SE: hallucinations, somnolence, confusion, dyskinesia Amantadine- SE: livedo reticularis and ankle edema Ankylosing spondylitis- increased risk of vertebral fractures due to decreased bone mineral density Chronic Hep C associated with extra hepatic complications: -cryoglobulinemia -b-cell lymphomas -plasmacytomas -AI dz like Sjogrens and thyroiditis -Lichen planus -Porphyria cutanea tarda -Idiopathic thrombocytopenic purpura Crohns dz- associated with hyperoxaluria (due to fat malabsorption) Sickle cell- hemolytic anemia (reticulocytosis, high bilirubin, high LDH, LOW haptoglobin) Dubin-Johnson synd- conjugated chronic hyperbilirubinemia (not associated with hemolysis) -see dark pigment in liver -benign therefore no treatment needed Henoch-Schonlein Purpura- IgA mediated vasculitis of small vessels

-abdominal pain, rash, arthralgias, renal disease -may follow URI SLE- association between antiphospholipid Abs and fetal loss after 10 wks gestation -most likely due to thrombus formation in placenta Childhood strokes think SICKLE CELL ANEMIA Hypersensitivity pneumonitis- repeated inhalation of inciting Ag leading to alveolar inflammation -txt: remove exposure Raloxifene- SERM, SE: increased risk of venous thromboembolism, increase hot flashes and leg cramps Tamoxifen- increased risk of endometrial Ca Waldenstroms Macroglobulinemia- plasma cell neoplasm -production of excessive amts of IgM Ab in blood (causes thickening of blood) -IgM spike! -inc spleen size, liver sz, and LN -tendency of bleed/bruise easily -night sweats -headache and dizziness -various visual probs (retinal vein engorgement) -pain and numbness in extremities due to demyelinating sensorimotor neuropathy Multiple myeloma- spike of either IgG or IgA PBC- txt with ursodeoxycholic acid, slows disease progression and relieves symptoms Spondylolisthesis- palpable step off of lumbosacral area, forward slip of vertebrae (usually L5 over S1) -chronic back pain in KIDS Hydroxychloroquine used for txt of SLE -SE: damage to eye (retinopathy), routine eye exams needed STROKE think about TIME frame! -if within 3-5hrs of sx onset, give tPA (fibrinolytics), before administer get CT to r/o hemorrhagic stroke -if >5hrs, give ASA PUD- MC complication hemorrhage Bipolar d/o- look at BUN and Cr BEFORE starting Li, if renal impairment, start on Valproic acid instead

Toxic epidermal necrolysis- mucocutaneous exfoliative disease ->30% of BSA involved Stevens Johnsons- <10% BSA involved (less severe than TEN) Erythema multiforme minor- macular, popular, bullous or purpura, occur in extensor surfaces, palms, soles, and mucous membranes Duchennes- confirm dx with muscle biopsy Stable angina- FIRST use BBlocker or CCB, then use nitrates Pneumonia- hypoxia due to increased alveolar-arterial oxygen gradient Cushings- see HYPOKALEMIA Trastuzumab (Herceptin)- monoclonal Ab used in HER2 + breast cancers -SE: can cause cardio toxicity in conjunction with chemo -must get baseline Echo before starting treatment TB txt: use INH + pyridoxine for 9mo Rheumatoid arthritis- associated with stiffness in Cervical spine (C1-C2 instability and subaxial subluxation)