Terms / Facts

! Peptic ulcer Gastritis

DDx: Abdominal pain of gastroduodenal origing
Malignancy
(3)
! Appendicitis Obstruction Diverticulitis Gastroenteritis
DDx: Abdominal pain of
Mesenteric adenitis Strangulated hernia
intestinal origin (6)
! Acute cholecystitis Chronic cholecystitis
DDx: Abdominal pain of hepatobiliary
Cholangitis
origin (3)
! Acute pancreatitis Chronic pancreatitis
DDx: Abdominal pain of pancreatic
Malignancy
origin (3)
! Cystitis Acute retention of urine Acute
DDx: Abdominal pain of urinary
pyelonephritis Ureteric colic
tract origin (4)
! Rupture of extopic pregnancy Rupture/Torsion of
DDx: Abdominal pain of ovarian cyst Salpingitis Endometriosis Mittelschmerz
gynecological origin (6) Severe dysmenorrhea

! Aortic aneurysm Mesenteric embolus

DDx: Abdominal pain of vascular origin (2)
! Primary periotonitis Secondary
DDx: Abdominal pain of peritoneal origin
peritonitis
(2)
! Myocardial infarction Pericarditis
DDx: Abdominal pain referred from
Testicular torsion
other locations (3)
! Right kidney carcinoma Right colonic carcinoma
DDx: Abdominal swelling in
Feces Diverticular mass
the RUQ (4)
! Splenomegaly Gastric carcinoma Left kidney carcinoma
DDx: Abdominal
Feces Diverticular mass Pancreatic pseudocyst
swelling in the LUQ (6)
! Lipoma Epigastric hernia Carcinoma of the
DDx: Abdominal swelling in the
transverse colon Feces Diverticular mass
epigastrium (5)
! Paraumbilical/umbilical hernia Malignancy
DDx: Abdominal swelling in
Carcinoma Feces Diverticular mass
the umbilical region (5)
! Appendix mass/abscess Carcinoma of the cecum
DDx: Abdominal swelling
Carcinoma of the ascending colon Feces Crohn's disease
in the RLQ (5)
! Carcinoma of the sigmoid colon Diverticular
DDx: Abdominal swelling in the
mass Feces
LLQ (3)
! Acute/chronic bladder retention Pregnancy
DDx: Abdominal swelling in the
Fibroids Diverticular mass
suprapubic region (4)
DDx: Acute anorectal
! Fissure-in-ano Perianal hematoma Thrombosed
pain (4)

! 1!
 Terms / Facts
hemorrhoids Perianal abscess

! Fistula-in-ano Anorectal malignancy Chronic perianal

DDx: Chronic anorectal pain
spesis
(3)
! Disc lesion Cervical spondylosis Myocardial ischemia Repetitive
DDx: Arm
strain injury Carpal tunnel syndrome
pain (5)
! Trauma Infection (cellulitis, lymphangitis)
DDx: Arm swellings (2)
! Cirrhosis Cardiac failure Nephrotic syndrome Carcinomatosis
DDx: Ascites
Abdominal/pelvic tumor
(5)
! Acute abscess Sebaceous cyst Lipoma Lymphadenopathy
DDx: Axillary swellings
Breast lump
(5)
! Kyphoscoliosis Spina bifida Spndylolithesis
DDx: Backache (congenital) (3)
! Vertebral fractures Ligamentous injury Joint strain
DDx: Backache of traumatic
Muscle tears
origin (4)
! Ankylosing spondylitis Rheumatologic
DDx: Backache of inflammatory
disorder
origin (2)
! Metastases Primary tumors
DDx: Backache of neoplastic origin (2)
! Osteoarthritis Intervertebral disc lesions
DDx: Backache of degenerative origin (2)
! Osteoporosis Osteomalacia
DDx: Backache of metabolic origin (2)
! Pelvic inflammatory disease
DDx: Backpain of gynecological origin
Endometrosis
(2)
! Renal calculus Renal carcinoma
DDx: Backpain of renal origin (2)
! Breast carcinoma Fibroadenoma Cyst (cystic mastitis) Duct
DDx: Breast lumps
ectasia Sebaceous cyst
(discrete) (5)
! Pregnancy Lactation Puberty
DDx: Breast lumps due to generalized swelling
Mastitis
(4)
! Non-/Cyclical mastalgia Duct ectasia Breast abscess Pregnancy
DDx: Breast
Lactation
pain
! Angina/Myocardial infarction GERD Pneumonia/Pneumothorax
DDx: Chest
Chest wall injury Depression
pain (5)
! 300/ # large boxes between 2
How does one quickly calculate heart rate when
QRS complexes
rhythm is normal with an EKG?
How does one calculate heart rate ! Count the number ofo complexes that occur in

! 2!
 Terms / Facts
from an EKG if the rhythm is a 6-second interval (30 boxes) and multiply by
irregular? 10 to get a rate

! If p waves are present in all leads and upright

What rule determines whether the
in leads I and aVF, then the rhythm is sinus
rhythm is sinus on an EKG?
! Normal sinus
What kind of rhythm is indicated by an EKG where each QRS
rhythm
wave is preceded by a p wave?
What EKG findings indicate a normal ! I and aVF are both upright and positive
axis?
! I is upright and aVF is upside
What EKG findings indicate a left axis
down
deviation?
! I is upside down and aVF is
What EKG findings indicate right axis
upright
deviation?
! I and aVF are both upside down or
What EKG findings indicate extreme right axis
negative
deviation?
! 0.12 to 0.20 seconds
What is the time range of a normal PR interval?
! Wolff-Parkinson-White
What disease is a short PR interval associated
syndrome
with?
What kind of EKG appearance characterizes Wolff-Parkinson-White ! Delta wave
syndrome?
! PR > 0.2 seconds
What PR interval indicates a first-degree block?
! ≤ 0.12 s
What is the length of a normal QRS complex?
! R I > 15 mm
What R wave width on lead I indicates LVH?
! > 20 mm
What R wave width on lead II indicates LVH?
! > 20 mm
What R wave width on lead aVF indicates LVH?
! > 11 mm
What R wave width on lead aVl indicates LVH?
! > 26 mm
What R wave width on lead V5 indicates LVH?
! > 26 mm
What R wave width on lead V6 indicates LVH?
If the sum of the widths of R I and S III is > 25 mm, what cardiac ! LVH
pathology is indicated?
! Tall or peaked p waves in limb or
What EKG morphology indicates right atrial
precordial leads
hypertrophy?
! Broad or notched p waves in limb
What EKG morphology indicates left atrial
leads
hypertrophy?

! 3!
 Terms / Facts
! Old infarction
The presence of a Q wave indicates what cardiac pathology?
! Ventricular contraction
What mechanical event does the QRS complex
(initiation)
represent?
What electrical event does the QRS complex ! Ventricular depolarization
represent?
! Plateau phase of venricular
What electrical event does the ST segment
repolarization
represent?
! The horizontal segment of baseline that
The horizontal segment of baseline that
follows the QRS complex is known as
follows the QRS complex is known as the
the ST segment.
[...] segment.
! The rapid phase of ventricular
What electrical event does the T wave
repolarization
represent?
What are the boundaries of the ST ! End of the S to the beginning of the T
segment?
! Beginning of the QRS complex to the end
What parts of the EKG represent
of the T wave
ventricular systole?
! Begininng of the Q to the end of
What are the boundaries of the QT interval?
the T; ventricular systole
What cardiac event does it represent?
What is a simple rule of thumb for ! A QT interval should be less than half
determining whether a QT interval is of the R-to-R interval at normal rates
normal?
! Ca2+
What ion is responsible for conduction in the AV node?
! The direction of a wave on an EKG
What is deflection with respect to an EKG?
Positive deflections are [...] on the ! Positive deflections are upward on the EKG.
EKG.
! Negative deflections are downward on the
Negative deflections are [...] on the
EKG.
EKG.
! Movement of positive charges
What kind of electrical activity
(depolarization) toward a positive skin
produces a positive deflection on an
electrode
EKG?
! 0.04 s
How much time is represented by a small square on an EKG?
! 12 leads
How many leads does a standard EKG have?
! Right arm positive
In the aVR lead, what limb electrode is positive?
! Left arm positive
In the aVL lead, what limb electrode is considered positive?
! Foot (left)
In the aVF lead, what limb electrode is considered positive?

! 4!
 Terms / Facts
! Leads I and AVL
What are the lateral leads?
! These leads have a positive electrode positioned
Why are leads AVL and I called
laterally at the left arm
the lateral leads?
! Leads II, III and AVF
What are the inferior leads? (3)
! They have positive electrodes positioned
Why are leads II, III and AVF called
inferiorly on the left foot
inferior leads?
! Positive
What is the charge of the chest electrodes?
! AV node
Through what part of the heart are the chest leads oriented?
! Front to back of the patient
What is the orientation of electrode V2?
! Negative
What is the deflection of V1 and V2 normally?
! Positive
What is the deflection of V6 normally?
What part of the heart are the V3 and V4 leads oriented ! Interventricular septum
over?
! Frontal plane
What plane do the six limb leads lie in?
! Horizontal plane
What plane do the six chest leads lie in?
! 60-100 bpm
What is the normal heart rate range?
! SA node
What is the heart's normal pacemaker?
! 40-60 bpm
What is the inherent rate of the AV junctional automaticity focus?
! 60-80 bpm
What is the inherent rate of the atrial automaticity focus?
! An imbalance between blood supply and oxygen demand,
What is coronary
leading to inadequate perfusion.
ischemia?
! Stable angina occurs when oxygen demand exceeds
When does stable angina
available blood supply.
occur?
! Due to fixed atherosclerotic lesions that narrow the
What causes stable angina
major coronary arteries.
pectoris?
! When thinking CAD, ASSUMe the following
What are the possible clinical presentations: Asymptomatic Stable angina pectoris
presentations of coronary Sudden cardiac death Unstable angina pectoris
artery disease? (5) Myocardial infarction e

What are the risk

! Don't get LASHeD by Stable Angina Pectoris Low HDL
factors for stable
Age (m>45, w>55) Smoking Hyperlipidemia, Hypertension,
angina pectoris? (8)
! 5!
 Terms / Facts
↑ Homocysteine, History (family) Diabetes mellitus

! > 50%
What is the normal left ventricular ejection fraction (%)?
! Crushing retrosternal chest pain Exertional
What is the clinical presentation of
dyspnea Radiation of pain to left side
stable angina pectoris? (3)
! Left main coronary artery
Involvement of what coronary artery has the because it serves nearly 2/3 of
worst prognosis for stable angina pectoris? Why? the heart.

! EF <
What ejection fraction is associated with increased mortality in stable
50%
angina pectoris?
! Confirmation of diagnosis of angina Evaluation of response to
In what situations is
therapy in CAD Indentification of patients with CAD with high
stress ECG used?
risk for acute coronary events
(3)
! Rest Nitroglycerin
What relieves stable angina pectoris? (2)
! Not usually, unless a prior
Are there normally any abnormalities on an ECG
cardiac pathology is present
in a patient with stable angina pectoris?
! Test that involves recording ECG before, during and after
What is a stress
excerise on a treadmill.
ECG?
! Patient must be able to achieve 85% of
What condition must be met to make a
maximum predicted heart rate for age.
stress ECG most sensitive?
! ST-segment
How does excerise-induced ischemia present on a stress ECG in
depression
a patient with stable angina pectoris?
! Cardiac catheritization should be
What is the course of treatment for a patient with
performed
a positive stress test?
What is the preferred test for assessing stable angina ! Stress echocardiography
pectoris?
! Cardiac catherization
What is the course of treatment for a patient with a
should be performed.
positive stress echocardiograph?
! Any of the following: ST segment depression Chest
What criteria make a stress
pain Hypotension Significant arrhythmias
test positive? (4)
! Stress echo is more sensitive, can assess LV
Why is stress echocardiography size and function, and can diagnose vascular
preferred to stress ECG? disease.

! Coronary angiography for

What procedure is almost always performed
visualization
concurrently with cardiac catherization? Why?
What is the most accurate method of identifying the presence ! Coronary

! 6!
 Terms / Facts
and severity of CAD? arteriography

What stress test should be used if a patient cant' ! Pharmacologic stress test
exercise?
! IV adenosine IV dipyramidole IV
What drugs are used in a pharmacologic
dobutamine
stress test? (3)
! Adenosine/dipyramidole are vasodilators; because
What is the mechanism by
diseased coronary arteries are already maximally dilated
which IV adenosine and
at rest to increase blood flow, they received relatively
dipyramidole work in
less blood flow when the entire coronary system is
pharmacologic stress
dilated pharmacologically.
testing?
! Viable myocardial cells extract the radioisotope (thallium
Explain how myocardial
201) during exercise; no radioisotope uptake means no
perfusion scintigraphy
blood flow to an area of the myocardium.
works.
What is the mechanism by which ! Dobutamine → ↑ myocardial O2
dobutamine works in pharmacologic stress demand → ↑ HR/BP/Contractility
testing.
! Holter monitoring (ambulatory
What diagnostic tool is used to detect silent
ECG)
ischemia?
! 50% reduction 1 year
By how much is the risk of coronary heart disease reduced
after cessation
with smoking cessation? In what time frame?
! Aspirin β-blockers Nitrates
What pharmacological agents are used for
Calcium-channel blockers
treatment of stable angina pectoris? (4)
! Blockage of sympathetic stimulation → ↓
How do β-blockers work in the
HR/BP/contractility → ↓ cardiac work (O2
treatment of stable angina
consumption)
pectoris?
! ↓ morbidity - reduces risk
What is the net therapeutic effect of aspirin on stable
of MI
angina pectoris?
! Reduces the frequency of
What is the net therapeutic effect of β-blockers on
coronary events
stable angina pectoris?
! Generalized vasodilation → ↓ preload →
What is the mechanism by which nitrates
↓ cardiac work ↓ angina
treat stable angina pectoris?
! Nitrates make you feel SHOT S yncope H eadache O
What are the side effects of
rthostatic hypotension T olerance
nitrates? (4)
! Nitrates
What drug can prevent angina if taken before exertion?
What is the mechanism by which calcium ! Vasodilation and afterload reduction
channel blockers treat stable angina → decreased work → ↓ angina
pectoris?
Are calcium channel blockers primary or secondary treatment ! Secondary

! 7!
 Terms / Facts
agents for stable angina pectoris? treatment

! PTCA (Percutaneous transluminal coronary

What are the methods of
angioplasty) CABG (Coronary artery bypass graft)
revascularization? (2)
! Does not reduce incidence; improves
What is the effect of revascularization on
symptoms, however.
incidence of MI?
! Risk factor
What management decisions are indicated for all patients
modification Aspirin
with stable angina pectoris? (2)
! Nitrates β-blockers. Calcium-
What management decisions are indicated in
channel blockers if needed.
patients with mild stable angina pectoris? (3)
! Normal EF Mild angina Single-vessel
What are the criteria for mild stable
disease
angina? (3)
! Normal EF Moderate angina Two-
What are the criteria for moderate stable
vessel disease
angina? (3)
! Nitrates β-blockers Calcium-channel
What management decisions are indicated in
blockers CABG/PTCA if above don't
patients with moderate stable angina
work.
pectoris? (4)
! Decreased EF Severe angina Three-
What are the criteria for severe stable
vessel/left main/LAD disease
angina pectoris? (3)
! Coronary angiography and
What management decision is indicated for patients
consider for CABG
with severe stable angina pectoris?
! Restenosis; up to 40%
What is the most significant complication of PTCA?
within first 6 months
What is the risk and in what time frame?
! Stents
What intervention helps reduced the rate of restenosis in PTCA?
! Patients with one- or two-vessel stable
What patients should be considered
angina pectoris.
for PTCA?
What is the treatment of choice in patients with high-risk stable angina ! CABG
pectoris?
! Left main disease Three-vessel disease with
What are the indications for
reduced LV function Two-vessel disease with
CABG in patients with stable
proximal LAD stenosis Severe ischemia
angina pectoris? (4)
! Proximal lesions
What kind of lesions are most responsive to PTCA?
! With unstable angina, oxygen demand is
How does the pathophysiology of unchanged; in stable angina, there is
unstable angina pectoris differ from that increased demand, which precipitates the
of stable angina pectoris? angina.

! 8!
 Terms / Facts
! Reduced resting coronary blood flow &rarr
What is the pathophysiology of
with no change in O2 demand → angina
unstable angina pectoris?
! It indicates stenosis that has enlarged via thrombosis,
Why is unstable angina
hemorrhage, or plaque rupture.
pectoris significant?
! Patients with angina at rest Patients with new-onset
Patients with what angina that is severe and worsening Patients with
presentations are said to have chronic angina with increasing frequency, duration
unstable angina pectoris? (3) or intensity of pain.

! Unstable angina or acute MI

What does acute coronary syndrome refer to? (2)
! Patients should be medically managed
What precautions should be taken before
or should undergo cardiac
stress testing patients with unstable angina
cathertization initially.
pectoris?
! In non-ST elevation MI,
How is non-ST elevation MI differentiated from
cardiac enzymes are elevated.
unstable angina pectoris diagnostically?
! Enoxaparin is the drug of choice for treatment of
What was the key finding of the
unstable angina pectoris.
ESSENCE trial?
! Establish IV access Give
How does one treat unstable medical angina
supplemental oxygen
upon hospital admission? (2)
! Aspirin β-blockers LMWH or unfractionated
What pharmacogical interventions
heparin (Enoxaparin) Nitrate (first-line)
are indicated for unstable angina
Glycoprotein IIb/IIIa inhibitors (second line)
pectoris? (5)
! At least 2
For how long should LMWH/unfractionated heparin therapy be given
days
for unstable angina pectoris?
! 2 to 2.5x
What target value of PTT should be maintained with unfractionated
normal
heparin administration in unstable angina pectoris?
! No
Should PTT be followed with LMWH treatment in unstable angina pectoris?
! An unstable rhythm with a continuously varying
What is catecholaminergic
QRS complex in any recorded ECG lead in a
polymorphic ventricular
patient without any structural heart disease.
tachycardia?
! Rupture of atheromatous plaque → acute coronary
What is the pathogenesis of thrombosis → interruption of blood supply → necrosis
myocardial infarction? of myocardium

! Acute coronary
What is the most common cause of myocardial
thrombosis
infarction?
! 30%
What is the mortality rate of myocardial infarction?
The combination of substernal chest pain ! The combination of substernal chest pain
! 9!
 Terms / Facts
persisting for longer than 30 mins and persisting for longer than 30 mins and
diaphoreis strongly suggests [...] (disease). diaphoreis strongly suggests acute MI
(disease).

! 'Crushing' retrosternal chest pain Radiation

What is the classic clinical presentation
of pain to left side Diaphoresis
of myocardial infarction? (3)
! Post-op patients Elderly
In what patient groups are myocardial infarctions
Diabetics Women
often asymptomatic? (4)
! Inferior EKG changes Hypotension Elevated
What is the clinical presentation of
JVP Hepatomegaly Clear lungs
right ventricular infarct? (5)
! Transmural injury; diagnostic of
What does S-T segment elevation indicate?
an acute infarct
What can it be diagnostic for?
! Evidence of necrosis
What are Q waves indicative of?
! Usually seen late; not acute
When are Q waves seen in the course of an MI?
! Subendocardial injury
What is an S-T segment depression indicative of?
! Occur very
When in the course of an MI are peaked T waves observed on an
early
EKG?
! ST segment elevation infarct (STEMI)
What are the categories of infarct in Non-ST segment elevation infarct
terms of EKG morphologies? (2) (NSTEMI)

! Transmural; entire thickness

How much of the heart wall is affected by STEMI?
! Subendocardial; partial involvement of
How much of the heart wall is affected by
heart wall
NSTEMI?
! Cardiac enzymes are present in
What diagnostic test is used to differentiate
NSTEMI but not USA
NSTEMI from unstable angina pectoris?
What test is the diagnostic gold standard for myocardial ! Cardiac enzymes
injury?
! 4 to 8 hours; peak at
When does CK-MB increase after myocardial injury?
24 hours
When is the peak reached?
! Every 8 hours for
At what interval should total CK and CK-MB be measured
24 hours
after admission? For how long?
! Troponins I and T
What are the most important cardiac enzymes to order?
! Increase within 3 to 5 hours
When do troponins I and T increase after a
Reach a peak in 24 to 48 hours
myocardial infarction? When do they peak?

! 10!
 Terms / Facts
! 5 to 14 days
When do troponins return to normal after myocardial infarction?
! Greater sensitivity and
Why are troponins preferred to CK-MB for diagnosis of
specificity
myocardial infarction?
! At admission and every 8 hours until three
When should cardiac enzymes be
samples are obtained
drawn?
! Troponin I can be falsely elevated in
Troponin I can be falsely elevated in
patients with r enal failure (disease).
patients with r [...] (disease).
! Aspirin ACE inhibitors β-
What are the only three agents shown to reduce
blockers
mortality in MI?
! Antiplatlet activity reduces coronary reoccclusion
What is the rationale for using
by inhibiting platelet aggregation on top of the
aspirin in a patient with acute
thrombus
MI?
! ↓ HR, contractility and afterload
What is the rationale for using β-blockers in a
→ ↓ mortality
patient with acute MI?
! Within hours of hospitalization if there
When should ACE inhibitors be
are no contraindications.
administered to a patient with acute MI?
! Showed that carvedilol reduces risk of death in
What was the key finding of the
patients with post-MI LV dysfunction
CAPRICORN trial?
! ST segement elevation in
Myocardial infarction in the anterior region of the
V1-V4 Q waves in V1-V4
heart has what EKG morphologies? (2)
! Large R wave in V1 and V2 ST segment
Myocardial infarction in the posterior
depression in V1 and V2 Upright and
region of the heart has what EKG
prominent T wave in V1 and V2
morphologies? (3)
! Q waves in leads I
Myocardial infarction in the lateral region of the heart has
and aVL
what EKG morphologies? (1)
! Q waves in leads II,
Myocardial infarction in the inferior region of the heart has
III and aVF
what EKG morphologies? (1)
! Stabilizes plaques and lowers cholesterol →
What is the rational for using statins in
↓ risk of further coronary events
mainenance therapy of MI?
! Oxygen Nitroglycerin β-blockers Aspirin
What pharmacologic agents are
Morphine ACE inhibitors IV Heparin
indicated in patients with MI? (7)
! Dilate coronary arteries (increase supply)
What is the rationale for using
Venodilation (decrease preload and demand)
nitrates in patients with acute
Reduce chest pain
MI? (3)
What did the
! ACE inhibitor ramipril reduces mortaliti, MI, stroke and renal
HOPE trial find?
! 11!
 Terms / Facts
disease in patients with high-risk cardiovascular disease

! t-PA plus heparin gives the greatest mortality benefit in

What did the GUSTO
patients with acute MI
trial find?
! PTCA
What are the two types of revascularization used in acute MI
Thrombolysis
patients?
! Timing; must be
What is the most important criterion for effectiveness of
given early
revascularization in acute MI patients?
! Prevention of progression of
What is the rationale for giving heparin to
thrombus formation.
patients with acute MI?
What is the most common cause of in-hospital mortality related to acute ! CHF
MI?
! Acute MI is a RAMP to lots of complications R
What are the classes of
ecurrent infarction A rrhthymias M echanical
complications related to acute
complications P ump failure (CHF)
MI? (4)
! Physician-supervised regimen of exercise and risk factor
What is cardiac
reduction after MI
rehabilitation?
! Observation; no need for
What treatment does premature ventricular
antiarrhythmics
contractions call for in a patient post acute MI?
! Electrical
What treatment does ventricular tachycardia call for in the
cardioversion
context of hemodynamic instability?
! Antiarrhythmic therapy (IV
What treatment does ventricular tachycardia call for
amiodarone)
in the context of hemodynamic stability.
! Immediate unsynchronized defibrillation
What treatment does ventricular
and CPR
fibrillation call for?
! Electrical defribillation followed transcutaneous
What treatment does asytole call
pacing
for?
! In the setting of an
In what setting does a second- or third-degree AV block
anterior MI
have a dire prognosis?
! Emergent placement of a
What treatment does 2nd- or 3rd-degree AV block
temporary pacemaker
call for in the setting of anterior MI?
! IV atropine followed by temporary
What is the initial treatment for 2nd- or 3rd-
pacemaker if conduction is not
degree AV block in the setting of inferior
restored
MI?
! Extension of existing infarction or reinfarction of a
What is a recurrent
new area.
infarction?

! 12!
 Terms / Facts
! CK-MB because it returns to normal
What cardiac enzyme is best for assessing
faster so a re-elevation is detectable.
recurrent infarction? Why?
! 48 to 72 hours
When does CK-MB return to normal after an acute MI?
! Repeat thrombolysis or urgent cardiac catheterization
What is the treatment for
and PTCA followed by standard medical therapy for MI
recurrent infarction?
! Repeat ST segment elevation within
What EKG finding suggests reinfarction
first 24 hours
after an acute MI?
! Catastrophic, usually fatal event that occurs during
What is a free wall rupture?
the first 2 weeks after MI (most common 1 to 4
When does it occur most
days)
commonly?
! 90%
What is the mortality rate of a free wall rupture?
What is the result of free wall rupture? ! Hemopericardium and cardiac temponade
(2)
! You need to fix HIS free rupture Hemodynamic
What is the treatment for stabilization Immediate pericardiocentesis Surgical
free wall rupture? (3) repair

! The lower the EF, the greater the

How does ejection fraction post-MI relate to
risk for stroke in the next 5 years.
the risk for stroke? In what time range?
! 10 days post-
In what time range post-MI does rupture of the interventricular
MI
septum occur?
What cardiac pathology results from papillary muscle ! Mitral regurgitation
rupture?
! Emergent surgery (mitral valve
What is the treatment for mitral
replacement) Afterload reduction with
regurgitation secondary to papillary
nitrprusside or intra-aortic baloon pump
muscle rupture? (2)
! Incomplete free wall rupture (myocardial rupture is
What is a ventricular
contained by pericardium)
pseudoaneurysm?
! Emergent surgery because VP can
What is the treatment for a ventricular
become free wall rupture.
pseudoaneurysm? Why?
! Ventricul aneursym is associated with a high
Ventricul aneursym is associated
incidence of ventricular tachyarrhythmias .
with a high incidence of [...] .
! Aspirin
What is the treatment for acute pericarditis secondary to MI?
! NSAIDs and corticosteroids; may
What drugs are contraindicated in acute
hinder myocardial scar formation
pericarditis secondary to MI? Why?
What is Dressler's
! Immunologically based syndrome occurring weeks to
syndrome?

! 13!
 Terms / Facts
months after MI

! Fever Malaise Pericarditis

What is the clinical presentation of Dressler's
Leukocytosis Pleuritis
syndrome? (5)
! Aspirin
What is the most effective therapy for Dressler's syndrome?
! Angina (stable, unstable, variant) MI
DDx: Chest pain due to heart,
Pericarditis Aortic dissectoin
pericardium or vascular causes. (4)
! Wheezing Cough Dyspnea
What is the classic triad of asthma?
! Chronic with episodic
In what manner do the symptoms of asthma
exacerbation
usually appear?
! Viral infection Environmental allergens Drugs
What are the triggers of asthma? (3)
! Frequency Duration Required
What information should one note about
treatment Severity
asthma exacerbations? (4)
! Wheezing Prolonged expiratory
What breath sounds are heard in asthma? (2)
! Nasal polyps Rhinitis
What external signs are observed with physical exam in
Rash
asthma? (3)
! Asthma exams have HARD, Paradoxical
What physical exam findings does
Pulses ↑ HR Accessory muscle use ↑ RR
one observe in asthma with
Diaphoresis Pulsus paradoxis
exacerbation? (5)
! Hyperventilation Panic attacks Upper airway obstructor or inhaled
DDx:
foreign body COPD Bronchiectasis CHF
Asthma (6)
! Asthma + allergic rhinitis + atopic dermatitis
What is the triad of atopic asthma?
What is the triad of ASA-sensitive ! Asthma + ASA sensitivity + nasal polyps
asthma?
! Asthma + pulmonary infiltrates +
What is the clinical triad of allergic
allergic rxn to Aspergillus
bronchopulmonary aspergillosis?
! Short-acting inhaled β 2 -agonists: albuterol,
What are the 'reliever'
levoalbuterol. Inhaled anticholinergics
medications used to quickly
(ipratropium; ↑ bronchodilation)
relieve the sx of asthma? (2)
! Asthma + eosinophilia + granulomatous
What is the clinical triad of Churg-
vasculitis
Strauss?
! Inhaled corticosteroids (fluticasone, beclamethasone) Long
What are the controller
acting β 2 -agonists (salmeterol) Nedocromil/cromolyn
medications used for
Theophylline Leukotriene modifiers Anti-IgE
asthma? (6)
What should long-acting β 2 agonists always ! Always use with inhaled

! 14!
 Terms / Facts
be used with in asthma? Why? corticosteroids; ↑ mortality without.

! Check transcription of genes for

What test can be used to predict response to
5-lipoxygenase
leukotriene modifiers in asthma?
! ↓ sx and # of exacerbations (but no
What benefit does bronchial thermoplasty
change in FEV 1 )
offer patients with asthma?
! To achieve complete control = daily sx ≤
What is the goal of asthma therapy?
2/week, ø nocturnal sx, reliever med ≤ 2/wk
What does that goal consist of? (3)
! ↓FEV 1 ↓FEV 1 /FVC ↑ RV and
What happens to FEV 1 , FEV 1 /FVC, RV and
TLC coved flow-volume loop
TLC and flow volume loops in asthma?
! Curschmann's spirals (mucus casts of distal
What are the distinct pathologic
airways) Charcot-Leyden crystals (eosinophil
features in the sputum samples of
lysophospholipase)
patients with asthma? (2)
! ≥ 60 L/min ↑ after bronchodilation
What PEF (peak expiratory flow) findings
≥20% diurnal variation
suggest asthma? (2)
! Low-dose ICS
What is the treatment for Step 2 in asthma stepwise therapy?
What is the treatment for Step 3 in asthma stepwise ! Low-dose ICS + LABA
therapy?
! Med/high dose ICS +
What is the treatment for Step 4 in asthma stepwise
LABA
therapy?
! Oral steroids
What is the treatment for Step 5 in asthma stepwise therapy?
! Previous need for
What is a good predictor of risk of death with asthma
intubation
exacerbation?
! Suspicion of pneumothorax
What suspicions should prompt a CXR in an asthma
or pneumonia
patient with exacerbation? (2)
! Insulin deficiency Infection or inflammation Ischemia
What are the precipitants of
or infarction Intoxication
DKA? (4)
! T1D and ketosis-prone T2D
What type diabetes does DKA occur in mostly?
! ↑ anion gap metabolic acidosis
What happens to acid-base status with DKA?
! β-hydroxybutyrate
What is the predominant ketone in DKA?
! Corrected Na = measured Na +
What is the value for the corrected serum [Na+] [2.4 x (measured glucose-
in the context of DKA-related hyperglycermia? 100)/100]

What happens to serum [K+] with

! Hyperkalemia due to exchange with H+
DKA? Why?

! 15!
 Terms / Facts
(acidosis) from ICF

! ↓ K+
What happens to total body K+ with DKA?
! Leukocytosis
What happens to the CBC with DKA?
! Decreases
What happens to total body phosphorous with DKA?
! ↑ amylase
What pancreatic enzyme is elevated with DKA?
! Rule out possible precipitants Aggresive hydration
What is the general treatment
Insulin Electrolyte repletion
strategy for DKA?
! Aggresive (10-14 mL/kg/h) hydration with normal saline
What does fluid
(add 5% glucose once blood glucose reached 250 mg/dL
management consist of in
to prevent hypoglycemia)
DKA?
! (1) 10 U IV push of insuin followed by 0.1 U/kg/h;
What does insulin treatment
continue insulin until AG normal (2) When AG is
consist of in the management
normal, give subcutaneous insulin.
of DKA?
! Replace K+ (20-40 mEq/L) if < 4.5 (within 1 to 2
What does electrolyte
hours of starting insulin); insulin ↓ shift of K+ into
management consist of in
cells → hypokalemia. Replace PO 4 if < 1
DKA? Explain.
! Cerebral edema (if glucose levels decrease too rapidly)
What are the complications
Hyperchloremic nongap metabolic acidosis (due to
of DKA treatment? Explain.
rapid infusion of a large amount of saline)
(2)
! Alcoholic ketoacidosis Hyperosmolar hyperglycemic nonketotic syndrome
DDx:
(HHNS) Hypoglycemia Sepsis Intoxication
DKA (5)
! Arterial blood gas Blood glucose/BUN
What lab tests should be
CBC/Creatinine/CXR/Cultures Electrolytes/ECG
ordered if a patient presents
UA
with DKA? (10)
! Bacterial infection of the subarachnoid space
What is acute bacterial meningitis?
! S.pneumoniae N. meningitidis H.
List the bacteria that cause adult
influenzae L. monocytogenes
meningitis in descending order? (4)
! Fever Headache Stiff neck
What are the clinical manifestations of acute
Photosensitivity AMS Seizures
bacterial meningitis? (6)
! Lethargy w/o
What is the atypical presentation of acute bacterial meningitis that
fever
may occur in the elderly and immunosuppressed?
! Nuchal rigidity Kernig's sign
What physical exam signs are present in Brudzinski's sign Focal neuro findings
acute bacterial meningitis? (5) Rash

! 16!
 Terms / Facts
! CSF leak Dermal sinus
What are the possible causes of recurrent
Congenital/acquired defects
bacterial meningitis?
! Blood culutres should be taken before
Blood culutres should be taken [...]
antibiotic therapy in bacterial meningitis
antibiotic therapy in bacterial meningitis
! > 10,000 WBC
What is the WBC count in bacterial meningitis?
! Lumbar puncture
What test should be performed if meningitis is suspected?
! Empiric antibiotic therapy should be
Empiric antibiotic therapy should be
initiated immediately after LP is
initiated immediately [...] LP is
performed.
performed.
! CSF WBC > 2k glc <20 TP > 200 > 98%
What are the Rule of 2s
specificity for bacterial meningitis
(bacterial meningitis)?
! Cloudy
What is the appearance of CSF in bacterial meningitis?
! 18-30
What is the opening pressure of CSF in bacterial meningitis? (cm H20)
! 100-10,000
What range of WBCs is found in the CSF with bacterial
PMNs
meningitis? What is the predominant type?
! < 45
What is the glucose level in CSF in bacterial meningitis?
! Ceftriaxone +
What is the empiric abx treatment for a normal adult
Vancomycin
with meningitis?
! Ceftriaxone + Vancoymcin +
What is the empiric abx treatment for an adult
Ampicillin
> 50 y/o?
What other treatment may be initiated in ! Dexamethasone if cerebral edema is
bacterial meningitis? What is the suspected. Must be administered before
indication? When should it be or w/ 1st dose of abx.
administered?
! Rifampin or
What prophylaxis should be given to the contacts of a patient
ceftriaxone
with bacterial meningitis?
! Negative bacterial microbiologic data
What is the definition of aseptic meningitis?
! Enterovirus HIV HSV (type 2
What are the most common viral etiologies of
>1) VZV
aseptic meningitis? (4)
! Cell count < 500 w/ > 50% lymphs TP < 80-100
What CSF findings suggest viral
mg/dL Normal glucose
meningitis? (3)
! Antimycobacterial Rx + dexamethasone
Tx: TB meningitis
! Amphotericin B + 5-FU
Tx: Fungal meningitis

! 17!
 Terms / Facts
! Urethra Urinary
What anatomic regions are affected in lower urinary tract
bladder
infections? (2)
! Kidneys (pyelonephritis)
What anatomic regions are affected in upper urinary
Prostate
tract infections?
! Cystitis in immunocompetent nonpregant women w/o
What is an
underlying structural or neurologic disease
uncomplicated UTI?
! Upper tract infection in women UTI in men UTI in pregnant
What is a
women UTI with underlying structural disease or
complicated UTI?
immunosuppression
(4)
! E.coli
What is the number one culprit in uncomplicated UTIs?
! E. coli Enterococci Pseudomonas S.
What microbes are responsible for
epidermidis
complicated UTIs? (4)
What organisms are the most frequent causes of catheter-associated ! Yeast E.coli
UTIs? (2)
! Dysuria Urgency Frequency
What are the clinical manifestations of cystitis? (3)
! Urethral discharge may be
How does the clinical presentation of urethritis differ
present
from that of cystitis?
! Perineal pain Fever Tenderness on
What is the clinical presentation of acute
prostate exam
prostatitis? (3)
! Fever w/ shaking chills Flank/back pain
What is the clinical presentation of
Nausea/vomiting
pyelonephritis? (3)
! Persistent fever despite
How does the clinical presentation of a renal abscess
appropriate antibiotics
differ from that of pyelonephritis?
! Pyuria + Bacteriuria +/- hematuria +/-
What are the urinalysis findings of
nitrites
UTIs? (4)
! > 8 WBC/HPF
What is the definition of pyuria?
! > 1 organism per oil-immersion field.
What is the definition of bacteriuria?
! ≥ 10 5
What is the criterion for a UTI based on urine culture for an
CFU/ml
asymptomatic woman?
! ≥ 100
What is the criterion for a UTI based on urine culture in a
CFU/ml
symptomatic woman?
! ≥ 1000 CFU/ml
What is the criterion for a UTI based on urine culture in a man?
What does the presence of squamous cells in a
! Vulvar or urethral
urinalysis indicate?

! 18!
 Terms / Facts
contamination

! FQ or TMP-SMX x 3
What is the empiric treatment for uncomplicated
day
cystitis? (2)
! FQ or TMP-SMX PO x 10-
What is the empiric treatment for complicated
14 d
cystitis? (2)
! Ampicillin Amoxicillin Oral
What is the empiric treatment for
cephalosporins x 7 to 10 days
pregnant women with UTI? (3).
! Treat as in women, except for 7
What is the empiric treatment for UTIs in
days
men?
! Ceftriaxone 125 mg IM x 1
What is the empiric treatment for urethritis?
(Neisseria) Doxy 100 mg PO bid x 7
(2) What is the indication for each part of
d (Chlamydia)
this treatment?
! FQ or TMP-SMX Po x 14-28
What is the empiric treatment and duration for
d (acute)
acute prostatitis?
! FQ or TMP-SMX Po x 6-12
What is the treatment with duration for chronic
weeks
prostatitis?
What is the inpatient treatment with duration for ! Ceftriaxone IV x 14 d
pyelonephritis?
What is the treatment for a renal ! Drainage + antibiotics for pyelonephritis
abscess?
! CT to r/o
What test should be conducted in patients with pyelonephritis who
abscess
fail to defervesce within 72 hours? Why?
! Pain Swelling Impaired function of joints
What is the clinical presentation of
Morning stiffness
rheumatoid arthritis?
How many joints are involved in the majority of cases of ! Polyarticular
rheumatoid arthritis?
! Adenomas
What is the precursor lesion to almost all cases of CRC?
! Colonoscopy
What is the most specific and sensitive test for CRC?
What test is used to complement flexible sigmoidoscopy in ! Barium enema
evaluating CRC?
! Liver
What is the most common site of distant spread of CRC?
! > 50 y/o
What age group is at increased risk for CRC?
What kind of adenoma has the highest malignant potential for ! Villous adenomas
CRC?
! CT scan of abdomen and CXR
How is staging performed for CRC?
What other gastrointestinal diseases increase the risk ! Ulcerative colitis Crohn's
! 19!
 Terms / Facts
for CRC? (2) disease

! Limited to muscualris mucosa; T1-2, N0,

What does Stage A colorectal cancer
M0
mean?
! Limited to submucosa/muscularis propria
What does Stage B1 CRC mean?
! Through the entire bowel wall
What does Stage B2 CRC mean?
! Through bowel wall and into adjacent structures
What does Stage B3 CRC mean?
! Positive regional lymph nodes
What does Stage C CRC mean?
! Distant metastases
What does Stage D CRC mean?
! Prophylactic
What is the recommended treatment for familial
colectomy
adenomatous polyposis?
! Age 40
At what age is the risk of CRC 100% with Gardner's Syndrome?
! Polyps + cerebellar medulloblastoma
What is the clinical presentation of Turcot's
or GBM
syndrome? (2)
! Early onset CRC with an absence of antecendent multiple
What is Lynch I
polyposis
syndrome?
! Lynch syndrome I features + early occurence of other
What is Lynch syndrome
cancers
II?
! Abdominal pain Weight loss Blood
What is the clinical presentation of CRC?
in stool Colonic perforation
Which symptom is most common? (4)
! CRC
What is the most common cause of large bowel obstruction in adults?
! Anemia Weakness RLQ
What is the clinical presentation of right-sided
mass
CRCs? (3)
! Melena: right side
CRCs on what side of the colon present with
Hematochezia: left side
melena? And with hematochezia?
! Large luminal diameter
Why is obstruction unusual with right-sided CRCs?
! Changes in bowel habits secondary to bowel
What is a common symptom of left-
obstruction
sided CRC?
! Hematochezia
What is the most common symptom of rectal cancer?
! Resection of tumor-containing bowel as well as the
What is the surgical treatment
regional lymphatics
for CRC?
What blood marker should be ! CEA; levels are checked periodically every 3
! 20!
 Terms / Facts
obtained before surgical resection of to 6 months. Elevations strongly suggest
CRC? Why? recurrence.

! Postoperative chemotherapy:5-FU and

What is the adjuvant therapy for Dukes'
leucovorin
C colon cancer?
! 5-FU + radiation therapy
What is the adjuvant therapy for Dukes' B2 or C
postoperatively
rectal cancer?
! Stool guaiac Annual CT of abdomen/pelvis
What follow-up studies are used s/p
CEA levels
CRC resection?
! Within 3 years of
In what time frame do the majority of recurrences take place
surgery
for CRC s/p resection?
! Radiation therapy is not indicated in the
[...] therapy is not indicated in the
treatment of colon cancer.
treatment of colon cancer.
! Ischemic stroke
What is the leading cause of neurologic disability?
! Stroke that is worsening
What is an evolving stroke?
! One in which the maximal deficit has occurred.
What is a completed stroke?
! Reperfusion occurs due to collateral circulation or
Why are symptoms transient
embolus break up.
in a TIA?
! Embolism
What is the usual cause of a TIA?
! TIA = high risk of stroke in subsequent
What is the association between TIA and
months.
stroke risk?
! 30%
What is the 5-year stroke risk with a TIA?
! Age HTN
What are the most important risk factors for TIA? (2)
! Ischemic strokes Hemorrhagic strokes
What are the types of strokes? (2)
! Heart (mural
What is the most common source of emboli in ischemic
thrombus)
stroke?
! Ischemia due to atherosclerosis Atrial fibrillation with clot
What are the major
emboli to the brain Septic embolic from endocarditis
causes of stroke? (3)
! Bifurcation of the common carotid artery
In what vessels does thrombotic stroke
Middle cerebral artery
occur most frequently? (2)
What predisposing factor is found in nearly all cases of lacuanr ! Hypertension
stroke?
What is the pathogenesis ! Narrowing of the arterial lumen by thickening of the
of lacunar strokes? vessel wall (hyaline arteriolosclerosis) → microinfarcts

! 21!
 Terms / Facts
result (lacunes)

! Patient awakens from sleep with

What is the classic presentation of a
neurologic deficits
thrombotic stroke?
! Murmur referred from the heart Turbulence in the
What are the two causes of a
internal cartoid artery
carotid bruit?
! Very rapid with maximal
Describe the onset and severity of symptoms with
deficits initially
embolic stroke.
! MCA stroke can cause CHANGes Contralateral
Clinical paresis/sensory loss in face and arm Homonymous
manifestations: MCA hemianopia Aphasia (dominant) Neglect (nondominant) Gaze
stroke (5) preference toward the side of the lesion

! Internal capsule
Where is the location of a lesion with pure motor lacunar stroke?
! Thalamus
Where is the location of a lesion with pure sensory lacunar stroke?
! Incoordination ipsilaterally
What is ataxic hemiparesis?
! Pons
With clumsy hand dysarthria, where is the lesion?
! Contralateral lower extremity and face
What kind of deficit and occurs with
weakness and sensory loss
anterior cerebral artery stroke? Where?
! The term subclavian steal has been used to describe retrograde
What is subclavian blood flow in the vertebral artery associated with proximal
steal syndrome? ipsilateral subclavian artery stenosis or occlusion

! Sternum protrudes from the narrowed thorax

What is pectus carinatum?
! Many small breaths from a position of
How do people with small airways
relative inspiration but without very deep
disease breath when dyspneic or
breaths.
tachypneic?
! Place hands on lateral chest wall from the
How should one assess thoracic
posterior view
expansion?
! Inward inspiratory movements alternating with normal outward
What is respiratory
inspiratory movements due to diaphragmatic weakness.
alternans?
! Chronic cough productive of sputum for at least 3 months per
Definition: Chronic
year for at least 2 consecutive years
bronchitis
! Permanent enlargement of air spaces distal to the terminal
Definition:
bronchioles due to destruction of the alveolar walls
Emphysema
Risk factors:
! Tobacco smoke α 1 -antitrypsin deficiency Environmental factors
COPD (4)

! 22!
 Terms / Facts
(second hand smoke) Chronic asthma

! < 0.75-0.80
Below what value is the FEV1/FEV in COPD?
! Greater than or equal to 6
What happens to the forced expiratory time in
secs
COPD?
! Pulmonary function testing
What is the definitive diagnostic test for COPD/
! Decrease
What happens to FEV1/FVC in COPD?
! Mild: 70%
What percent reduction in FEV1 compared to the predicted
Severe: 50%
value is indicative of mild disease? And severe disease?
! Increased TLC
What happens to TLC in COPD?
! Increased RV
What happens to residual volume in COPD?
! Increased FRC
What happens to FRC in COPD?
! Decreased vital capacity
What happens to vital capacity in COPD?
! Predominant emphysema
What disease is predominant in COPD of pink puffers?
! Predominant chronic
What disease is predominant in COPD of blue
bronchitis
bloaters?
! Hyperinflation Diminished vascular
What are the radiographic featuers of
markings Flattened diaphragm
COPD on CXR? (3)
! Peak expiratory flow for
What is a good screening test for pulmonary
screening; < 350 L/min should
obstruction? What value should prompt PF
prompt PFT
testing?
What is the most important intervention for COPD ! Smoking cessation
treatment?
! Serial FEV1 measurements Pulse
What does clinical monitoring of COPD
oximetry Exercise tolerance
patients entail? (3)
! 1
Within what time range do respiratory symptoms improve in COPD after
year
cessation of smoking?
! Decline of FEV1 returns to the rate of
What happens to the FEV1 of a COPD
someone who has never smoked
patient after smoking cessation?
! Corticosteroids Oxygen Prevention (smoking cessation, pneumococcal
Tx: COPD
vaccine) Dilators (beta agonists, anticholinergics)
(4)
What are the criteria for continous or
! PaO2 55 mm Hg OR O2 saturation < 88%
intermittent long-term oxygen therapy
OR PaO2 55-59 mm Hg + polycythemia or
in COPD? (3)

! 23!
 Terms / Facts
evidence of cor pulmonale

! 1st line: metered-dose inhaler of bronchodilator 2nd:

Tx guidelines for mild to inhaled glucocorticoids can be used as well; start w/ low
moderate COPD? (2) dose

! Bronchodilators Continuous oxygen therapy Pulmonary

Tx guidelines for severe
rehabilitation
COPD? (3)
! Persistent increase in dyspnea (not relieved w/
Definition: Acute COPD
bronchodilators)
exacerbation
! CXR → β 2 -agonist → systemic corticosteroids →
Tx: acute
antibiotics → supplemental oxygen → non-invasive positive
exacerbations of
pressure ventilation
COPD (6)
! azithromycin
What antibiotics should be used in acute exacerbations of
levofloxacin
COPD? (2)
! Acute exacerbations Secondary polycythemia
What are the complications of
Pulmonary HTN and cor pulmonale
COPD? (4)
! Permanent, abnormal dilation and destruction of bronchial
What is
walls.
bronchiectasis?
! Cystic Fibrosis
What is the most common cause of bronchiectasis?
! Chronic cough Dyspnea Hemoptysis Recurrent or
Clinical presentation:
persistent pneumonia
bronchiectasis (4)
! High-resolution CT scan PFTs Bronchoscopy
Dx: Bronchiectasis (3)
! Abx for acute exacerbations Bronchial hygiene (hydration, chest
Tx: Bronchiectasis
physiotherapy, inhaled bronchodilators)
(2)
! Small cell lung cancer (25%) Non-small cell
What are the two pathologic subtypes
lung cancer (75%)
of lung cancer?
! Cigarette smoke COPD Radon Asbestos Passive
Risk factors: Lung cancer
smoke
(5)
! TNM system
How is non-small cell lung cancer staged?
! Limited - confined to chest plus supraclavicular nodes, but not
How is small cell
cervical or axillary nodes Extensive - outside of chest and
lung cancer staged?
supraclavicular nodes
(2)
! Small cell lung
What cancer is most commonly associated with superior vena
cancer
cava syndrome?

! 24!
 Terms / Facts
! Squamous cell carcinoma
What type of neoplasm is Pancoast's tumor generally?
! CXR CT scan Tissue biopsy
Diagnosis: lung cancer (3)
! Central but not
Cytologic examination of sputum detects lung neoplasms
peripheral
from wht location?
! Surgery w/ radiation therapy as adjunct
Tx: non-small cell lung cancer
! 14%
What is the 5-year survival rate for lung cancer patients?
! chemotherapy
Tx: small cell lung cancer
! radiation is useful in limited stage
For what stage of small cell lung cancer is
disease but not extensive
radiation therapy a useful adjunct? When not?
! No; tumors are usually
Is surgery a useful treatment in small cell lung
unresectable
cancer? Explain.
What is the most comon cause of mediastinal mass in older ! Metastatic cancer
patients?
! Thyroid Teratogenic tumors Thymoma Terrible
Ddx: anterior mediastinal mass
lymphoma
(4)
! cyst lung cancer lymphoma aneurysm morgani
Ddx: middle mediastinal mass
hernia
(5)
! Neurogenic tumor Esophageal mass Enteric cyst
Ddx: posterior mediastinal
Aneurysms Bochdalek's hernia
mass (5)
! CT scan
What is the test of choice for diagnosing a mediastinal mass?
! Asymptomatic
What is the most common presentation of a mediastinal mass?
! SVC syndrome Dysphagia Nerve compression
What are the clinical
(hoarseness, horner's, diaphragmatic paralysis)
manifestations of a mediastinal
Chest pain Dyspnea
mass? (5)
! Oropharyngeal: inability to propel food from mouth
What is oropharyngeal
through UES into esophagus
dysphagia?
! Esophageal: difficulty swallowing & passing food from
What is esophageal
esophagus into stomach
dysphagia?
! idiotpathic (most common) pseudoachalasia (due to GE jxn
Etiology: achalasia
tumor) chagas disease
(3)
! dysphagia (solid and liquid) chest pain regurgitation
Sx: achalasia (3)
! barium swallow
Dx: achalasia

! 25!
 Terms / Facts
! dilated esophagus w/ distal
What radiologic finding is associated with barium
'bird's beak'
swallow in achalasia?
! Heller myotomy Balloon dilation Botulinum toxin
Tx: achalasia (3)
! congenital GVHD Fe-deficiency anemia
Etiologies: esophageal webs (3)
! Excessive transient relaxations of lower esophageal sphincter
Pathophysiology: (LES) or incompetent LES → Mucosal damage (esophagitis) due
GERD to prolonged contact w/ acid can evolve to stricture

Risk factors: GERD ! hiatal hernia obesity hypersecretory states delayed emptying
(4)
! supine position fatty foods caffeine alcohol cigarettes CCB
Precipitants: GERD
pregnancy
(7)
! heartburn atypical chest pain regurgitation
Clinical manifestations
dysphagia water brash
(esophageal): GERD (5)
! cough asthma laryngitis dental
Clinical manifestations (extraesophageal):
erosions
GERD (4)
! Hx and Empiric trial of PPI
Dx: GERD (2)
! Failure to respond to PPI Alarm features (dysphagia,
When is EGD indicated for
odynophagia, vomiting, wt loss, palpable mass, age
diagnosis of suspected GERD?
> 55 y)
(2)
! high res manometry w/ 24-h
What diagnostic study is indicated for uncertain
esophageal pH monitoring
dx of GERD w/ a normal EGD?
! avoid precipitants lose weight avoid large and late meals
Tx (lifestyle): GERD
elevate head of bed
(4)
! PPI
Tx (medical): GERD
! fundoplication
Tx (surgical): GERD
! Barrett esophagus Esophageal adenocarcinoma
Complications: GERD (2)
! surveillance EGD w/ biopsy
How does one manage the complications of GERD?
! q3
How frequently should one perform EGD w/ bx surveillance if a patient has
y
Barrett's esophagus w/ no dysplasia?
! q6
How frequently should one perform EGD w/ bx surveillance if a patient
mos
has Barrett's esophagus w/ low grade dysplasia?
! Endoscopic mucosal resection to r/o cancer,
How does one manage Barrett's
then RFA or other ablative Rx
esophagus w/ high grade dysplasia?

! 26!
 Terms / Facts
! upper abdominal sx (discomfort, pain, fullness, bloating,
Definition:
burning)
dyspepsia
! visceral afferent hypersensitivity abnormal gastric
Etiology (functional):
motility
dyspepsia (2)
! GERD PUD Gastric cancer
Etiology (organic): dyspepsia (3)
! H. pylori eradication PPI
Tx: functional dyspepsia (2)
! Pericarditis/myopericarditis Unstable angina MI
What are the cardiac causes of
Aortic dissection
chest pain? (4)
! Substernal pressure that radiates into the neck, jaw and L arm
Sx: unstable
Dyspnea Diaphoresis N/V
angina (4)
! ↑ w/ exertion ↓ w/ NTG or
What exacerbates unstable angina? And improves?
rest
(2)
! EKG Stress test (make sure to stabilize with medical
Dx: unstable angina
management beforehand)
(2)
What kind of EKG changes are seen in unstable angina? ! ↑/↓ ST T-wave inversion
(2)
! Substernal pressure that radiates into the neck, jaw and L arm
Sx: myocardial
Dyspnea Diaphoresis N/V
infarction
! EKG changes (↑/↓ ST, T-wave inversion) tropinin I/T
Dx: myocardial infarction
CK-MB
(3)
! Sharp pain that radiates into the trapezius pericardial friction rub
Sx: pericarditis
pericardial effusion
(2)
What exacerbates pericarditis? and ! ↑ w/ respiration ↓ w/ sitting forward
improves?
! Diffuse ST segment elevation ↓
What kind of EKG changes are associated with
PR interval
pericarditis? (2)
! Sharp pain that radiates into the trapezius pericardial friction rub
Sx: myocarditis
pericardial effusion ↓ EF +/- s/s CHF
(5)
! EKG changes ↑ troponin
Dx: myocarditis (2)
! abrupt onset severe tearing, knifelike pain radiating anteriorly or to
Sx: aortic the posterior mid-scapular region HTN or HoTN Weak pulses Focal
dissection (5) neurological deficits Aortic insufficiency

! Widened mediastinum on CXR False

What are the radiologic findings of aortic
lumen on CT
dissection? (2)
What are the pulmonary causes ! Pneumonia Pleuritis Pneumothorax Pulmonary

! 27!
 Terms / Facts
of chest pain? (5) embolism Pulmonary hypertension

! Pleuritic pain dyspnea fever cough w/ sputum ↑ RR crackles

Sx: pneumonia (6)
! pulmonary infiltrate
CXR: pneumonia
! sharp, pleuritic pain friction rub
Sx: pleuritis (2)
! sudden onset, sharp, pleuritic pain hyperressonance ↓ breath
Sx: pneumothorax
sounds
(3)
! air in the pleural space
CXR: pneumothorax
! sudden onset pleuritic pain ↑ RR &HR ↓S a O 2 EKG
Sx: pulmonary emobolism
changes
(4)
! CT
What imaging study should be ordered for suspected pulmonary
angiogram
embolism?
! Exertional pressure dyspnea ↓ SaO2
Sx: pulmonary hypertension (3)
! Loud P2 right sided S3 and/or S4
Auscultation: pulmonary hypertension (2)
! Esophageal reflux Esophospasm Mallory-Weiss tears
What are the GI causes
Boerhaave syndrome PUD Biliary disorder Pancreatitis
of chest pain? (7)
! intense substernal pain
Sx: esophageal spasm
! ↑ swallowing ↓ nitroglycerin and
Aggravating/alleviating factors:
calcium-channel blockers
esophageal spasm (1/2)
! manometry
Dx: esophageal spasm
! Vomiting
Precipitating factors: Mallory-Weiss tears
! EGD
Dx: mallory weiss tears
! Severe pain Palpable subcutaneous emphysema
Sx: Boerhaave syndrome
! ↑ w/ swallowing
Aggravating factor: Boerhaave syndrome
! vomiting
Precipitating factor: Boerhaave syndrome
! mediastinal air on chest CT
Radiologic finding: Boerhaave syndrome
! RUQ pain N/V
Sx: biliary disorders (2)
! ↑ fatty foods
Aggravating factor: biliary disorder

! 28!
 Terms / Facts
! RUQ U/S LFTs
Dx: biliary disorder (2)
! Epigastric/back discomfort
Sx: pancreatitis
! ↑ amylase ↑ lipase abd CT
Dx: pancreatitis (3)
! Chostochondritis Herpes Zoster
What are the miscellaneous causes of chest
Anxiety
pain? (3)
! Localized sharp pain that ↑ w/ movement and is reproduced by
Sx:
palpation
chostochondritis
! Intense unilateral pain dermatomal rash w/ sensory findings
Sx: herpes zoster (2)
! Focused hx Targeted exam 12 lead EKG
What is the initial approach to a
cardiac biomarker (CK-MB and Tn) CXR
patient presenting with chest pain (5)
! Fasting glucose >/= 126 mg/dL x 2 Random glc >/= 200 mg/dL x 2
Definition:
(or 1 if severe hyperglycemia w/ acute metabolic decompensation)
Diabetes
75 g OGTT w/ 2-h glc >/= 200 mg/dL
Mellitus
! ~40%
What percentage of the US population has pre-Diabetes?
! 100-124 mg/dL
Definition: Impaired fasting glucose
! 140-199 mg/dL 2h after 75 g OGTT
Definition: Impaired glucose tolerance
! TZD (60%) >
What inteventions can be used to prevent progression
Diet/exercise (58%) >
of pre-diabetes to frank DM? Give them in order of
metformin (31%)
risk reduction.
! >/= 6.5%
HbA1c above what level is sufficient to diagnose DM?
! islet cell destruction → absolute insulin deficiency
Pathogenesis: Type 1 DM
What autoantibodies are found in type I ! anti-GAD anti-islet cell anti-insulin
DM?(3)
! FHx Obesity Sedentary lifestyle
Risk factors: type II DM (3)
! Polyuria Polydipsia Polyphagia w/ unexplained
Clinical manifestations: Diabetes
weight loss
Mellitus
What is the first line therapy for T2DM w/ HbA1c >/= ! Metformin + lifestyle mod
7%
! ~ 1.5%
By how much does metformin reduce HbA1c?
! Renal (Cr> 1.5) or liver failure
Contraindications: metformin (2)
! Retinopathy
What complications does DM cause to the eye?

! 29!
 Terms / Facts
! photocoagulation surgery
How does one treat proliferative retinopathy 2/2 DM?
With what other diabetic complication does diabetic nephropathy ! retinopathy
present?
! strict BP control using ACE inhibitors or ARBs
Tx: diabetic nephropathy
! symmetric distal sensory loss paresthesias +/-
Sx: symmetric diabetic
motor loss
neuropathy (3)
! gastroparesis constipation neurogenic bladder erectile
Sx: autonomic diabetic
dysfunction orthostasis
neuropathy (5)
! sudden onset peripheral or CN deficit
Sx: diabetic mononeuropathy
! Necrobiosis lipoidica diabeticorum
Complications (dermatologic):
Lipodystrophy Acanthosis nigricans
Diabetes Mellitus (3)
! JNC VII
What criteria are used to classify hypertension?
! Systolic < 120 mm Hg Diastolic < 80 mm
Definition (JNC VII): Normal
Hg
pressure
! Systolic: 120-139 mm Hg Diastolic: 80-89 mm Hg
Definition (JNC VII): Pre-HTN
! Systolic: 140-159 mm Hg Diastolic: 90-99 mm
Definition (JNC VII): Stage 1
Hg
HTN
! Systolic: ≥ 160 mmHg Diastolic ≥ 100 mmHg
Definition (JNC VII): Stage 2 HTN
! 25-55 yr
When is the onset of essential HTN?
! Essential Secondary
What are the etiologies of HTN? (2)
! UTI Candidiasis Osteomyelitis of foot
What infections are diabetics
Mucormycosis Necrotizing extern otitis
more susceptible to? (5)
! q3-6 mo;
How often should HbA1c be checked? What is the target goal?
! (1) failure of the heart to pump blood forward at sufficient rate to
Definition: meet metabolic demands of peripheral tissues or (2) ability to do so
Heart failure only at abnormally high cardiac filling pressures

! anorexia fatigue exercise intolerance weakenss

Sx: low output heart failure (4)
! dyspnea orthopnea paroxysmal nocturnal
Sx: congestive heart failure (left
dyspnea
sided) (3)
! peripheral edema RUQ discomfort bloating
Sx: congestive heart failure (right
satiety
sided) (4)

! 30!
 Terms / Facts
! no sx w/ ordinary activity
Definition: class I heart failure (NYHA)
! sx w/ ordinary activity
Definition: class II heart failure (NYHA)
! sx w/ minimal activity
Definition: class III heart failure (NYHA)
! sx @ rest
Definition: class IV heart failure (NYHA)
! MI renal failure hypertensive crisis drugs worsening
Precipitants: acute heart
aortic stenosis
failure (5)
! Lasix w/ monitoring of UOP Morphine Nitrates
Tx: acute decompensated
Oxygen Position (sitting up & legs danging over bed)
heart failure (5)
! (1) identify CV risk factors or other diseases that would modify
Goals of
prognosis or rx (2) reveal 2° causes of HTN (3) assess for target
workup: HTN
organ damage
(3)
! renal parenchymal renovascular (atherosclerosis, FMD,
What are renal causes of 2°
PAN, scleroderma)
HTN? (2)
! ARF induced by ACEI/ARB recurrent flash
What findings are suggestive of
pulm edema renal bruit hypokalemia
renovascular 2° HTN? (4)
What is the most common cause of new cases of blindness among ! Diabetes
working-age people?
! Diabetes
What is the most common cause of end stage renal disease?
! tension Migraine cluster
What are the primary headache syndromes? (3)
! periodic, paroxysmal brief, sharp orbital headache lacrimation
Sx: cluster
rhinorrhea unilateral horner's syndrome
headache (4)
! oxygen triptans CCB
Tx (acute): cluster headache (3)
! Headache diary Stress
What does non-pharmacologic treatment of headache
reduction
consist of? (2)
! worst ever, worsening over days, wakes from sleep
What warning signs should
vomiting, aggravated by exertion or Valsalva age
prompt neuroimaging w/
> 50 y fever abnl neuro exam
headache? (5)
! POUNDing P ulsatile duration 4-72 h O urs U nilateral N
Sx: ausea/vomiting D isabling LR= 3 if 3 critera are met, LR=24 if 4 or
migraine (5) more

! TCA Beta-blockers CCB Valproic

What doex prophylactic treatment of
acid Topiramate
migraine consist of? (5)
Definition: complicated
! accompanied by stereotypical neurologic deficit tha
migraine

! 31!
 Terms / Facts
tmay last hours

! HA w/o aura
Definition: common migraine
! HA w/o aura
Definition: classical migraine
! Triptans ASA/acetaminophen/high-dose NSAIDs
What does abortive therapy
Metoclopramide IV Prochlorperazine IV/IM
of migraine consist of? (4)
! H. pylori
What is the most common cause of peptic ulcer disease?
! Epigastric abdominal pain
Sx: PUD
! UGIB Perforation & penetration Gastric outlet obstruction
Complications: PUD (3)
What drug class is responsible for almost half of gastric and duodenal ! NSAIDs
erosions?
! Stool antigen test
What diagnostic test is used to confirm eradication of H.pylori
! EGD
What diagnostic test is required to make definitive diagnosis of PUD?
! Serology can stay (+) for
Why is a serologic test not used to confirm
weeks to years
eradication of H. pylori in PUD?
! Sequential Rx (PPI + abx x 5d -> PPI + 2 different abx x 5
Tx: H. pylori-related
d)
PUD
! Gastric acid suppression w/ PPI Lifestyle changes
Tx: H. pylori-negative PUD
! Misoprostol H2-receptor
What drugs can be given in conjunction with
antagonist
NSAID/ASA to prevent PUD in susceptible persons? (2)
! Peptic ulcer (50%) Varices (10-30%)
Etiologies: upper Gastritis/gastropathy/duodenitis (15%) Mallory-weiss tear (10%)
GI bleed (6) Vascular lesions (5%)

! lesion of superficial ectatic artery usually in cardia ->

What is Dieulafoy's
sudden, massive UGIB
lesion?
! Diverticular hemorrhage Neoplastic disease Colitis
Etiologies: Lower GI
Angiodysplasia Anorectal
bleed (5)
! N/V Hematemesis Coffee-grind emesis Epigastric
Clinical manifetations: UGIB
pain Melena
(5)
! diarrhea tenesmus hematochezia brbpr
Clinical manifestations: LGIB (4)
! Assess severity Resuscitation Transfuse
What does initial management of GI
Reverse coagulopathy Triage
bleeding consist of? (5)
Tachycardia in a patient with GI bleeding indicates approximately ! 10% volume
! 32!
 Terms / Facts
how much blood loss? loss

Orthostatic hypotension in a patient with GI bleeding suggests how much ! 20%

volume loss?
! 30%
Shock in a patient with GI bleeding suggests how much volume loss?
! Infected
If a patient presents with monoarticular joint pain, what is the first
joint
problem to rule out?
! monosodium urate (MSU) crystal deposition in joints and other
Definition:
tissues
Gout
! 9:1 men to women
What is the ratio of prevalence of gout in men to women?
What is the most common cause of inflammatory arthritis in men over 30 ! Gout
y?
! ↑ serum uric acid related to metabolic syndrome HTN CKD ↑
Risk factors:
intake of meat, seafood, EtOH
gout (4)
! primary hyperuricemia secondary hyperuricemia
Etiologies: gout (2)
! Gout is for BRATS Bursitis Renal sx (urate stones, urate
Clinical
nephropathy) Asymptomatic hyperuricemia Tophi Sudden
manifestations: gout
onset, painful monoarticular arthritis
(5)
! I SWEAR it's gout serum UA, WBC, ESR, athrocentesis (definitive
Dx: gout
diagnosis has negative birefringent crystals), radiographs
(5)
! 4 criteria must be fulfilled Morning stiffness
What are the ARA diagnostic Involvemnet of 3+ joints Involvement of hand
criteria for rheumatoid arthritis? joints Symmetric arthritis Presence of
(7) How many must be fulfilled rheumatoid nodules Positive rheumatoid factor
for diagnosis of RA? Radiologic changes

! Metatarsophalangeal joint of the first toe (big toe -

What joint is classically involved
podagra)
in gout?
! NSAIDs Colchicine Corticosteroids
Tx (acute): gout (3)
! The pt HAD gout, but no longer hydration antihyperuricemic therapy
Tx (chronic):
(allopurinol, febuxostat, probenecid) dietary changes
gout (3)
! calcification of cartilage visible on radiographs, resulting
Definition: from CPPD deposition in articular cartilage, fibrocartilage or
chondrocalcinosis menisci

! 3 H's Hemochromatosis Hypothyroidism

Etiologies (metabolic):
Hyperparathyroidism
CPPD (3)
! Pseudogout Pseudo-RA Premature OA
Clinical manifestations: CPPD (3)

! 33!
 Terms / Facts
! (1) ↑ synovial & joint fluid levels of inorganic pyrophosphate
produced by articular chondrocytes from ATP hydrolysis in response
Pathogenesis: to various insults or inherited defects favors CPPD crystallogenesis
CPPD and deposition in the cartilage matrix (2) Crystals activate cryopyrin
inflammasome → IL-1β → inflammation

! acute mono- or asymmetric oligoarticular

Clinical manifestations:
arthritis
pseudogout
! knees wrists MCP joints
What joints are affected by pseudogout? (3)
! chronic polyarticular arthritis w/ morning stiffness +/- RF
Definition: pseudo-RA
! arthrocentesis radiographs CMP
Dx: CPPD (3)
! rhomboid-shaped, weakly positively birefringent
What are the findings on
crystals WBC 2000-100,000/mm3, > 50% polys
athrocentesis w/ CPPD? (2)
! NSAIDs colchicine corticosteroids
Tx (acute): CPPD (3)
! morning stiffness polyarthritis > monoarthtiris joint
Clincial manifestations
deformities (ulnar deviation, swan neck, boutonierre,
(MSK): rheumatoid
cock up toes) C1-C2 instability rheumatoid nodules
arthritis (5)
! ILD (COP, fibrosis, nodules, Caplan's syndrome)
Clinical manifestations pleural disease (pleuritis, pleural effusions) airway
(pulmonary): rheumatoid disease (bronchiolitis, bronchiectasis, cricoarytenoid
arthritis (3) arthritis)

Clinical manifestations (cardiac): rheumatoid arthritis ! pericarditis myocarditis

(2)
! glomerulonephritis nephrotic
clinical manifestations (renal): rheumatoid
syndrome
arthritis (2)
! anemia of chronic disease leukemia
clinical manifestations (heme): rheumatoid
lymphoma
arthritis (3)
! fever weight loss
clinical manifestations (constitutional): rheumatoid
malaise
arthritis (2)
! scleritis episcleritis
clinical manifestations (ocular): rheumatoid
keratoconjunctivitis sicca
arthritis (3)
! gout infectious arthritis
What are the major diagnoses that have to be osteoarthritis rheumatoid
considered in a nontraumatic swollen joint? (4) arthritis

! Rheumatoid factor ACPA or anti-CPP ↑ ESR and CRP

Dx (studies): rheumatoid
radiographs of hands and wrists
arthritis (4)
Tx: rheumatoid
! nonselective NSAIDs glucocorticoids DMARD (disease-
arthritis (3)
! 34!
 Terms / Facts
modifying anti-rheumatic drugs) w/in 3 mo

! Hct/plt PT/PTT
What laboratory studies are included in the workup of GI
LFTs
bleeding? (3)
! EGD
Diagnostic study: UGIB
! First ru/o UGIB then colonoscopy
Diagnostic study: LGIB
! arteriography tagged RBC
What studies should be used to assess recurrent or
scan
unstable GI bleeding? (2)
! octreotide w/ Abx (ceftriaxone/norfloxicin)
Tx (pharmacologic): GI
prophylaxis
varices
! endoscopic band ligation (> 90% success)
Tx (non-pharamcologic): GI varices
! usually stops spontaneously
Tx: Mallory-Weiss tear
! PPI H2RA
Tx: bleeding 2/2 esophagitis/gastritis (2)
! PPI + endoscopic therapy
Tx: bleeding 2/2 PUD
! usually stops spontaneously (75%) endoscopic rx if
Tx: bleeding 2/2 diverticular
doesn't stop
disease
Tx: bleeding 2/2 ! usually stops spontaneously Endo Rx if doesn't stop
angiodysplasia
! continued bleeding despite (-) EGD & colonoscopy
Definition: Obscure GIB
! Dieulafoy's lesion Small bowel angiodysplasia CRC Crohn's
Etiologies: Obscure
disease Meckel's diverticulum
GIB (5)
! repeat EGD w/ push enteroscopy/colonoscopy (perform when bleeding
Dx: obscure
is active) video capsule Tc-99m pertechnetate scan (meckel's scan)
GIB (2)
! Conjunctival pallor
What is a reliable sign of anemia in the elderly?
! fatigue exertional dyspnea angina (if CAD)
Sx: anemia (3)
! pallor tachycardia orthostatic hypotension
Signs: anemia (3)
! CBC w/ measurement of RBC indices Peripheral
What should initial workup of
blood smear Reticulocyte count
anemia consist of? (3)
! angular cheilosis atrophic glossitis pica
Clinical manifestations: iron deficiency
koilonychia
anemia (4)
! oral Fe tid (6 wks to correct anemia, 6 mo to replete Fe
Tx: iron deficiency
stores)
anemia

! 35!
 Terms / Facts
! severe anemia hemolysis splenomegaly
Signs: HbH disease (3)
! transfusions + deferoxamine, deferasirox splenectomy HSCT in
Tx: thalassemias
children w/ β-thal major
(3)
! Fe-inclusion bodies seen in sideroblastic anemia
What are Papenheimer bodies?
! MCV/RBC < 13
What is the MCV/RBC in the thalassemias?
! HbA2
What hemoglobin increases in β-thalassemia minor?
! fever significant abd pain blood or pus in stools
What are the "warning signs"
severe dehydration > 6 stools/d
of diarrhea? (6)
! vol depletion (VS, UOP, axillae, skin turgor, MS) fever
PEx findings: acute
abd tenderness ileus rash
diarrhea (5)
! Fecal WBC Stool cx BCx Electrolytes Stoop O&P
Labs: acute diarrhea (5)
! CT/KUB if suspected toxic megacolon sig/colo if
Imaging: acute
immunosupp or cx (-)
diarrhea (2)
! Infectious Preformed toxin Med-induced Initial presentation of
Ddx: acute
chronic diarrhea
diarrhea (4)
! oral hydration loperamide bismuth
Tx: acute diarrhea w/ no warning
subsalicylate
signs (3)
! 50-200 mL/kg/d of oral solution (gatorade,
Tx: acute diarrhea w/ moderate
etc)
dehydration
! bismuth or rifaximin
Prophylaxis: traveler's diarrhea
! May increase risk of
Why should abx therapy be avoided if E. coli O157:H7 is
HUS
suspected?
! FQ x 5-
What is the empiric abx treatment for non-hospital acquired
7d
inflammatory diarrhea?
! Stool ELISA Stool cytotoxin assay
Dx: c.difficile-associated diarrhea (2)
! Metronidazole 500 mg PO tid x 10-14 d
Tx: mild c.difficile-associated diarrhea
! vancomycin 125-500 mg PO qid x 10-14
Tx: moderate c.difficile-associated
d
diarrhea
! vancomycin PO + metronidazole IV
Tx: severe c.difficile-associated diarrhea
! T-cell lymphoma Small bowel adenocarcinoma
Complications: celiac disease (2)
Tx: whipple's ! PCN + streptomycin of 3rd-gen cephalosporin x 10-14d →
! 36!
 Terms / Facts
disease bactrim for 1+ year

! + fecal WBC + lactoferrin +

What are the lab findings of inflammatory
caloptectin + FOB
chronic diarrhea? (4)
! + fecal fat
What lab test does one perform to assess for malabsorption?
! bulk laxatives → osmotic laxatives → stimulant laxative
Tx: constipation
! Methylnaltrexone
What drug is used for opiod-induced constipation?
! H&P w/ DRE
Dx: constipation
! opioids anticholinergics CCB diuretics
Etiologies (medication): constipation
NSAIDs
(5)
! The CARS can't move through the bowel cancer anal
Etiologies (obstruction):
stenosis rectocele stricture
constipation (4)
! Parkinson's Hirschsprung's Amyloid MS Spinal
Etiologies (neurological):
injury Autonomic neuropathy
constipation (6)
! Electrolyte imbalance (↑ Ca, ↓ K, ↓ Mg) DM
Etiologies (metabolic/endo): hypothyroidism uremia pregnancy panhypopit
constipation (7) porphyria

! loss of intestinal peristalsis in absence of mechanical

Definition: adynamic
obstruction
ileus
! acute colonic adynamic ileus in presence of competent
Definition: Ogilvie's
ileocecal valve
disease
! intra-abdominal process (surgery, pancreatitis, peritonitis)
Precipitants: severe medical illness intestinal ischemia meds electrolyte
adynamic ileus (5) abnl

! NPO Mobilize decompression erythromycin neostigmine

Tx: adynamic ileus (5)
! abd. discomfort N/V abd. distention ↓ or absent
clinical manifestations: adynamic
bowel sounds hiccups
ileus (5)
! supine & upright KUB vs. CT
Dx: adynamic ileus
!
Describe the workup algorithm for chronic diarrhea.
!
Pathophysiology: CHF
! Inability to expel sufficient blood
Definition: Systolic Heart Failure
! Failure to relax and fill normally
Definition: Diastolic Heart Failure

! 37!
 Terms / Facts
! CXR BNP Echo PA Catheterization EKG Coronary
Dx: Heart Failure
angiography
(6)
! Pulm edema Pleural effusions +/- cardiomegaly
What are the CXR findings
Cephalization Kerley B lines
with HF? (4)
! ↑ BUN ↑ Cr ↓ serum Na
In HF, what findings suggest ↓ perfusion to vital
Abnormal LFTs
organs? (4)
! ↑ EF ↑ chamber size
Echo findings: systolic dysfunction (HF)
! ↑ PCWP ↓ CO ↑ SVR
PA Cath findings: HF (3)
! Mild restriction of sodium intake (< 4 g/day) Start loop diuretic
Tx: Mild CHF
if volume overload or pulmonary congestion present ACE
(NYHA Class I to II)
inhibitor as first-line
(3)
! Start loop diuretic and an ACE inhibitor Add
Tx: Mild to Moderate CHF (NYHA
β-blocker if moderate disease
Class II to III) (2)
! Add Digoxin (to loop diuretic and ACE inhibitor)
Tx: Moderate to Severe CHF
Add spironolactone if still symptomatic
(NYHA Class III to IV) (2)
! Displaced PMI pathologic S3 pathologic S4 rales/crackles
Signs: Heart
dullness to percussion
Failure (5)
s/s: RHF ! Peripheral pitting edema Nocturia JVD Hepatomegaly Ascites RV heave
(6)
! Echocardiogram
What is the initial test of choice for CHF workup?
! BNP > 100
What BNP level is strongly associated with the presence of
pg/ml
decompensated CHF?
! EF < 40%
What EF level is the cutoff for systolic dysfunction?
! Spironolacton reduces morbidity and mortality in
What was the major finding of
patients with class III/IV HF
the RALES trial?
! Diuretic + ACE
What should be the initial treatment in most symptomatic
inhibitor
patients with HF?
! ACE inhibitors reduce mortality, prolong
What did the CONSENSUS and
survival and alleviate sx in CHF
SOLVD studies find?
! Carvedilol led to significant improvement in survival
What did the COMET
compared to metoprolol in HF
trial find?
What are the indications for digoxin in HF? ! EF < 30% Severe CHF Severe a-fib
(3)
! 50%
What is the overall 5-year mortality for all patients with CHF?

! 38!
 Terms / Facts
! Total body water = 60% of body weight ICF = 40% of body weight
What is the 60-
(2/3 TBW) ECF = 20% of body weight (1/3 TBW)
40-20 rule?
! 2/3 ECF
What percentage of ECF is interstitial fluid?
! 1/3 ECF
What fraction of ECF is plasma?
! 800 to 1500 mL
What is the normal output range of urine/day?
! transient loss of consciousness/postural tone 2/2 acute decrease in
Definition:
cerebral blood flow
Syncope
! Arrhythmias (SSS, VT, AV block, RSVT) Obstruction of
Etiologies
flow (AS, hypertrophic CMP, pulmonary HTN, etc.)
(cardiogenic): syncope
Massive MI
(3)
! Vasovagal syncope
What is the most common cause of syncope?
! ↑ sympathetic tone → vigorous contraction of LV →
Pathophysiology: mechanoreceptors in LV trigger ↑ vagal tone (hyperactive
vasovagal syncope Bezold-Jarisch reflex) → ↓ HR and/or ↓ BP

! Tilt-table study
What study can reproduce the symptoms of vasovagal syncope?
! Pallor Diaphoresis Lightheadedness
What are the premonitory sx of vasovagal
N/V
syncope? (4)
! midodrine fludrocortisone disopyramide SSRI
Tx: vasovagal syncope (4)
! emotional stress pain fear extreme fatigue
Precipitants: vasovagal syncope (4)
! Hypovolemia Diuretics Vasodilators Autonomic neuropathy
Etiologies: orthostatic
(DM, PD, Shy-Drager, Lewy Body Dementia, Amyloidosis)
hypotension (4)
! increase sodium intake and fluids
Tx: syncope 2/2 orthostatic hypotension
! TIA involving the vertebrobasilar
What is a common cerebrovascular cause of
circulation
syncope?
! Differentiate between cardiac and noncardiac etiologies
What is the main goal of because prognosis is poorest for those with underlying
diagnosis of syncope? heart disease

! H&P EKG (all patients) Tilt-table testing Echocardiogram (if there is

Dx:
evidence of structural heart disease or abnormal EKG)
syncope
! 8 days
How long does one treat nosocomial pneumonia?
! pneumonia acquiried withing 3 months of a
Definition: hospital-acquired
hospital admission
pneumonia

! 39!
 Terms / Facts
! Early beats arising within the atria, firing on its
What are premature atrial
own
complexes?
! Adrenergic excess EtOH/tobacco Electrolyte
Etiologies: premature atrial
imbalances Ischemia infection
complexes (5)
! early P waves that differ in morphology from the
EKG finding: premture atrial
normal sinus P wave
complexes
! early beat that fires on its own from a focus in the
Definition: premature
ventricle and then spreads to the other ventricle
ventricular complex
! wide QRS complexes
EKG finding: premature ventricular complexes
! Patients with frequent, repetitive PVCs and
Patients with frequent, repetitive
underlying heart disease are at increased risk
PVCs and underlying heart disease
for SCD due to cardiac arrhythmia
are at increased risk for [...]
! chaotic, uncordinated firing of multi foci of automaticity in the
Definition: atrial
atria leading to rapid ventricular beating
fibrillation
! paroxysmal (self-terminating) vs. persistent (sustained > 7 d)
Classification: atrial vs. permanent (typically > 1 y when cardioversion has failed)
fibrillation (6) Valvular vs. nonvalvular Lone AF

! CHF myo/pericarditis ischemia/MI hypertensive

Etiologies (cardiac): atrial
crisis cardiac surgery
fibrillation (5)
! acute pulmonary disease (COPD flare,
Etiologies (pulmonary): atrial
pneumonia) PE
fibrillation (2)
! high catecholamine states (stress, infection, postop,
Etiologies (metabolic): atrial
pheo), thyrotoxicosis
fibrillation (2)
! alcohol (holiday heart) cocaine amphetamines
Etiologies (drugs): atrial
theophylline caffeine
fibrillation (5)
! subarachnoid hemorrhage ischemic
Etiologies (neurogenic): atrial fibrillation
stroke
(2)
! Ectopic foci → chaotic, uncoordinated beating → loss of
Pathophysiology: atrial atrial contraction → HF; LA stasis → thromboemboli;
fibrillation (3) tachycardia → CMP

! fatigue exertional dyspnea palpitations dizziness angina

Sx: atrial fibrillation
syncope
(6)
! EKG
Dx: atrial fibrillation
! irregularly irregular rhythm
EKG findings: atrial fibrillation

! 40!
 Terms / Facts
! immediate electrical cardioversion
Tx: acute atrial fibrillation in a
to sinus rhythm
hemodynamically unstable patient
! Rate control → anticoagulation →
What are the general treatment goals of
cardioversion
atrial fibrillation? (3)
! 60 to 100 bpm
What is the target rate for rate control in a-fib?
What drugs are used to ! CCBs (preferred) Beta-blockers (alternative)
achieve rate control in AFib? Digoxin/amiodarone (LV systolic dysfunction)
(3)
How is cardioversion achieved in afib tx? ! Electrical (preferred) Pharmacological
(2)
! Ibutilide Procainamide Flecainide
What drugs can be used for pharmacological
Sotalol Amiodarone
cardioversion in AFib? (5)
! Obtain TEE to image left atrium. If no thrombus is present,
If a patient has been in
start IV heparin and perform cardioversion within 24 hours.
AFib > 48 hrs, how
Anticoagulation required for 4 weeks after cardioversion
should one treat?
! Beta blocker CCB
What drugs are used for rate control with chronic AFib? (2)
! chronic anticoagulation (warfarin(
Tx: chronic AFib
! Leads II, III and AVF
Which leads are the inferior leads? (3)
! Leads I and AVL, V5, V6
Which leads are left lateral? (4)
! 60
Angle of Lead II?
! 120
Angle of Lead III?
! 90
Angle of Lead AVF?
! 0
Angle of Lead I?
! -30
Angle of Lead AVL?
! -150
Angle of Lead AVR?
! Leads V1 and V2
Which precordial leads lie over the right ventricle?
! Leads V5 and V6
Which precordial leads overlie the left ventricle?
! Leads V3 and V4
Which precordial leads overlie the interventricular septum?
! V1-V4
Which leads are the anterior group?
! Septal depolarization
What causes the Q wave?
What is R-wave ! pattern of progressively increasing R-wave amplitude moving
! 41!
 Terms / Facts
progression? right to left in the precordial leads is called R-wave progression

! time from the beginning of ventricular depolarization to

What does the QT interval
the end of ventricular repolarization
encompass?
! The duration of the QT interval is
The duration of the QT interval is
proportionate to the heart rate
proportionate to the [...]
! Arrhythmias of sinus origin Ectopic rhythms Reentrant
What are the five basic
arrhythmias Conduction blocks Preecitation syndromes
types of arrhythmias?
! Sinus node stops firing
What is sinus arrest?
! Prolonged electrical inactivity
What is asystole?
! 60-75 bpm
What is the intrinsic rate of atrial pacemakers?
! 40-60 bpm
What is the intrinsic rate of junctional pacemakers?
! 30-45 bpm
What is the intrinsic rate of ventricular pacemakers?
! 60-100 bpm
What is the intrinsic rate of the SA node?
! P wave inversion in leads II and
What does a junctional escape look like on
AVR
EKG?
! Origin of ventricular depolarization is within the
What does a wide QRS
ventricles themselves
usually imply?
! From AV node or ventricles;
If no p waves are present, what does that say about
from below atria
the origin of an arrhythmia?
! Are normal P waves present? Are the QRS complexes
What four questions
narrow or wide? What is the relationship between P waves
should one ask to assess
and QRS complexes? Is the rhythm regular or irregular?
rhythm?
! Paroxysmal superventricular tachycardia (PSVT)
What are the five types of
Atrial flutter Atrial fibrillation Multifocal atrial
sustained supraventricular
tachycardia Paroxysmal atrial tachycardia
arrhythmias?
! Reentrant circuit looping within the
What is the most common mechanism
AV node
driving PSVT?
! Saw-toothed pattern
What is the appearance of atrial flutter on EKG?
! reentrant circuit that runs largely around the
What is the usual mechanism of
annulus of the tricuspid valve
atrial flutter?
! 2:1 block
What ratio AV block is common with atrial flutter?
What is the appearance of atrial ! Irregularly irregular appearance of QRS

! 42!
 Terms / Facts
fibrillation on EKG? complexes in the absence of discrete p waves

! first 6 hours, but up to 24 hrs

Thrombolytic therapy within what time frame gives
from onset of pain
the best results in acute MI?
! ST elevation in two contiguous EKG leads in patients with
Indications:
onset within 6 hours who have been refractory to
thrombolytic therapy
nitroglycerin
(MI)
! t-PA
What is the first line thrombolytic medication in most medical centers?
! Trauma (head or traumatic CPR) Recent invasive
Contraindications: procedure/surgery Acute PUD Previous stroke
thrombolytic therapy (MI) Uncontrolled HTN (>180/110) Dissecting aortic
(6) aneurysm

! PTCA reduces mortality more than t-PA

What did the PAMI trial show?
! Aspirin Beta-blocker ACE
What are the only agents shown to reduce
inhibitors
mortality in MI? (3)
! Oxygen Nitroglycerin Beta-blocker Aspirin Morphine
Tx (acute): myocardial
ACE inhibitor IV heparin
infarction (7)
! Maintenance therapy; reduce risk of further
How do statins figure into the
coronary events
therapy of MI? Why?
! BP > 220 and/or diastolic BP > 120 in addition to
Definition: Hypertensive
end-organ damage
emergency
! Elevated BP levels alone without end-organ
Definition: Hypertensive
damage
urgency
! Noncompliance with antihypertensive tx/dialysis Cushing's
Etiologies:
syndrome Drugs (cocaine, LSD, methamphetamines)
Hypertensive
Hyperalodosteronism Eclampsia Vasculitis Pheochromocytoma
emergency (7)
! Step 1: lower BP with antihypertensive agent Step 2:
Approach to a patient with
order CT scan of the head to r/o intracranial bleeding
severe headache and
Step 3: If CT negative, proceed to LP
markedly elevated BP? (3)
! Severe headache Visual disturbances
Clinical presentation: hypertensive
Altered mentation
emergency (3)
! reduce MAP by 25% in 1 to 2 hrs If severe (diastolic > 130) or if
Tx: hypertensive HTN encephalopathy is present, lower BP with IV agents
emergencies (2) (nitroprusside/labetalol)

! BP should be lowered within 24 hours using oral agents

Tx: hypertensive urgencies
What are the effects of
! CNS depression ↓ Pulmonary Blood Flow Arrhythmias
metabolic acidosis? (5)
! 43!
 Terms / Facts
Impared myocardial function Hyperkalemia

! ↓ cerebral blood flow arrhythmias

What are the effects of alkalosis?
tetany/seizures
(3)
! AG (mEq/L) = [Na+] - ([Cl-]+[HCO3-])
Definition: anion gap
! 8 to 15 mEq/L
What is the normal range for angion gap?
! Step 1: Acidemia (pH < 7.38) or alkalemia (pH>7.42) Step 2:
Primary or metabolic disturbance (Look at PCO2 on ABG or HCO3
Give the five
on metabolic panel) Step 3: Is there appropriate compensation? Step
step analysis of
4: Is there anion gap metabolic acidosis? Step 5: If there is
acid-base
metabolic acidosis, is there another concomitant metabolic
disorders.
disturbance?

! Look at pH. < 7.38 = acidemia > 7.42

How does one determine if there is acidemia
=alkalemia
or alkalemia?
! Look at HCO3 or PCO2 on
How does one determine if an acid-base
Chem 7 or ABG respectively
disturbance is primary respiratory or metabolic?
What formula is used to determine if appropriate ! PCO2 = [1.5x(serum
compensation has occured with primary metbaolic HCO3)] +8 (+/-2)
acidosis?
With what acid-base disorder does Kussmaul breathing ! Metabolic acidosis
occcur?
! Decreased CO and tissue perfusion by diminishing the
How does acidosis affect
responsiveness of the myocardium to catecholamines
cardiac output? Explain.
! ↑ PaCO2 = 0.75 x
What equation gives the predicted respiratory compensation
ΔHCO3
for a metabolic alkalosis?
! ↑ HCO3= 0.1 x
What equation gives the compensation for acute
ΔPaCO2
respiratory acidosis?
! ↓ HCO3 = 0.2 x Δ
What equation gives the compensation for acute
PaCO2
respiratory alkalosis?
! ↑ HCO3 = 0.4 x Δ
What equation gives the compensation for chronic
PaCO2
respiratory acidosis?
! ↓ HCO3 = 0.4 x
What equation gives the compensation for chronic
ΔPaCO2
respiratory alkalosis?
! 1° resp.
If PaCO2 is too low by prediction, what other acid-base disorder is
alkalosis
concomitantly occurring?
! 1° resp.
If PaCO2 is too high by prediction, what other acid-base disorder is
acidosis
concomitantly occurring?

! 44!
 Terms / Facts
! 1° met.
If HCO3 is too low by prediction, what other acid-base disorder is
acidosis
concomitantly occurring?
! 1° met.
If HCO3 is too high by prediction, what other acid-base disorder is
alkalosis
concomitantly occurring?
! One irritable automaticity focus in the atria fires at about 250
to 350 bpm, giving rise to regular atrial contractions;
Patholophysiology:
ventricular rate is one-half to one-third of atrial rate because
atrial flutter
only every two or three flutter waves conduct to the ventricles

! COPD (most common) Heart disease: RHD, CAD, CHF

Etiologies: atrial
Atrial Septal Disease
flutter (3)
! EKG: saw-tooth baselines with QRS every second or third
EKG findings: atrial
wave
flutter
! similar to AFib
Tx: atrial flutter
! Severe pulmonary disease
Patients with what other disease usually display
(COPD)
multifocal atrial tachycardia?
What is the most common cause of supraventricular ! Paroxysmal SVT
tachyarrhythmia?
! All automaticity foci pace with a regular
All automaticity foci pace with a
rhythm
regular [...]
! normal (but minimal) increase in HR during inspiration and
Definition: sinus
minimal decrease in HR during expiration
arrhythmia
! Distal (junctional). No automaticity foci in the
Where are the automaticity foci in
proximal AV node
the AV node?
! Left bundle branch; has terminal fibers in
Which bundle branch depolarizes the
the septum. Right bundle branch does not.
interventricular septum? Why?
! Final phase of Purkinje repolarization following a T
What does a U wave
wave
represent?
! The mechanism whereby the automaticity focus with the
Definition: overdrive highest pacing rate suppresses all slower automaticity foci in
suppression the heart

! Rhythms that lack a constant duration

Rhythms that lack a constant duration between paced cycles are said to be
between paced cycles are said to be [...] irregular

! The focus paces but can't be overdrive

What does it mean for an
suppressed because of an entrance block (due to
automaticity focus to be
a structural pathology or hypoxia)
parasystolic? Explain.
Definition: wandering ! Irregular rhythm produced by the pacemaker activity
! 45!
 Terms / Facts
pacemaker wandering from the SA node to nearby atrial automaticity foci

! Atrial depolarization by an automaticity focus as opposed to

What does the P' wave
the normal Sinus-paced P waves
represent?
! < 100 bpm
What is the HR of wandering pacemaker?
! Irregular ventricular
Describe the ventricular rhythm of a wandering
rhythm
pacemaker?
! Atrial automaticity foci are damaged, showing early
Why does multifocal atrial signs of parasystole → resistance to overdrive
tachycardia occur? suppression

! Irregular ventricular rhythm

Describe the ventricular rhythm of MAT.
! No discernbible P' waves; chaotic atrial
What kind of waveform can't be discerned
spikes
in AFib?
! An automaticity focus escapes overdrive suppression to pace
Definition: escape
at its inherent rate
rhythm
! An automaticity focus transienty escapes overdrive suppression
Definition: escape
to emit one beat
beat
! Very sick SA node ceases pacemaking completly
Definition: sinus arrest
! Heart rhythm determined by the pacing of the junctional
Definition: idiojunctional
automaticity foci
rhythm
! Sinus arrest
What abnormality in the SA node gives rise to en escape rhythm?
! Sinus block
What abnormality in the SA node gives rise to en escape beat?
! Junctional automaticity
What automaticity focus can produce retrograde atrial
focus
depolarization?
! inverted p' wave with upright QRS
EKG finding: retrograde atrial depolarization
! (1) Complete conduction block high in the ventricular
What conditions can give
conduction system (2) Total failure of SA node and all
rise to a ventricular escape
automamticity foci above the ventricles
rhythm? (2)
! When pacing from a ventricular focus is so slow that blood
Definition: Stokes- flow to the brain is significantly reduced to the point of
Adams syndrome syncope

! Burst of cardiac parasympathetic innervation depresses

Explain how ventricular
the SA node, atrial and junctional foci but not the
escape beats happen most
ventricular foci, leading to a ventricular escape beat
commonly.

! 46!
 Terms / Facts
! an irritable focus spontaneously fires a single stimulus
Definition: premature beat
Which automaticity foci are most sensitive to O2 ! Ventricular automaticity foci
status?
! Digitalis Adrenergic excess/sympathetic stimulation
What are the causes of atrial
Stimulants (caffeine, cocaine, amphetamines)
and junctional foci
Hyperthyroidism Stretch
irrititability? (5)
! Resets the automaticity
What is the effect of a premature stimulus on the other
center
automaticity centers?
! Premature atrial impulse reaches one of the bundle
Explain the mechanism of a
branches while it is still refractory (and the other is
premature atrial beat with
not). This causes asynchronous depolarization of the
aberrant ventricular
ventricles, leading to a widened QRS
conduction.
! Premature P' with no QRS response followed
EKG finding: non-conducted
by reset sinus rhythm
premature atrial beat
! Coupling of a PAB to end of each normal cycle
Definition: atrial begeminy
! When a PAB fires after two normal cycles
Definition: atrial trigeminy
! Lone QRS complexes
With a junctional escape rhythm with no retrograde atrial
without P waves
depolarization, what does the EKG look like?
! Irrititable junctional focus within the AV node fires suddently,
Definition:
conducting a premature stimulus to the ventricles, and
premature
sometimes, retrograde to the atria
junctional beat
! When a premature junctional beat is coupled to a normal
Definition: junctional
(SA-node generated) cycle
bigeminy
! When a premature junctional beat is coupled with two
Definition: junctional
consecutive normal cycles
trigeminy
! Low O2 Low K+ Structural pathology (MP,
What are the causes of ventricular
myocarditis, stretch)
focus irritability? (3)
! Premature ventricular beat produced by an irritable
Definition: premature
ventricular automaticity focus
ventricular contraction
! (1) Great width and enormous amplitude QRS
EKG finding: premature complex early in cycle (2) QRS opposite polarity of
ventricular contraction (2) the normal QRS

! The wave of depolarization originating in the left

Why is the QRS of a PVC
ventricle spreads unopposed to the right ventricle
wider than a normal QRS?
What EKG
! Compensatory pause; the PVC doesn't depolarize the SA so the
feature follows the
SA discharges on schedule, but the ventricles are refractory and
PVC? Why?
! 47!
 Terms / Facts
the SA-generated impulse can't progress

! 6 PVC's per minute

What number of PVC's is considered pathological?
! PVC coupled to a normal beat
Definition: ventricular bigeminy
! PVC coupled to two normal cycles
Definition: ventricular trigeminy
! Ventricular automaticity focus that suffers from entrance block
Definition:
and is not vulnerable to overdrive suppression; paces at its
ventricular
inherent rate in the background of dominant sinus rhythm
parasystole
! Weakness Weight loss Hyperpigmentation Hyponatremia
Clinical presentation: Anorexia Nausea Orthostatic hypotension Abdominal
adrenal insufficiency (8) pain

! Idiopathic (autoimmune) Infectious

Etiologies:
(tuberculosis/fungal/cryptococcus/toxoplasmosis) Iatrogenic
primary adrenal
(bilateral adrenalectomy) Metastatic disease
insufficiency (4)
! long-term steroid therapy
Etiologies: secondary adrenal insufficiency
hypopituitarism
(2)
! hypothalamic disease
Etiologies: Tertiary adrenal insufficiency
! cortisol levels (am) cosyntropin stimulation test MRI if
Dx: adrenal
secondary/tertiary suspected
insufficiency (3)
! ≥ 18 ug/ml within 60
What is the normal repsonse to a cosyntropin stimulation
mins
test?
! volume resusication w/ normal saline +
Tx (acute): adrenal
hydrocortisone IV
insufficiency
! Hydrocortisone or prednisone Fludrocortisone (not
Tx (chronic): adrenal
needed in secondary insufficiency)
insufficiency (2)
! Mineralcorticoids are decreased as well as
Why is hyponatremia seen in primary
glucocorticoids
adrenal insufficiency?
! Aldosterone is normal but decreased cortisol
Why is hyponatremia seen in
removes suppresion on ADH → SIADH
secondary adrenal insufficiency?
!
Give the stepwise workup of adrenal insufficiency.
! Negative
In lead V1, what is the polarity of the QRS complex normally?
! Positive
In lead V6, what is the polarity of the QRS complex normally?
! Septum
Over what part of the heart do leads V3 and V4 lie?

! 48!
 Terms / Facts
! Severe cardiac hypoxia
What condition produces multifocal PVCs?
! When a PVC falls on a T wave; vulnerable period.
What is the R on T
Dangerous arrhythmias may result.
phenomenon?
! Paroxysmal atrial tachyarrhythmia is usually a
Paroxysmal atrial tachyarrhythmia
sign of digitalis excess or toxicity
is usually a sign of [...]
! two p' waves for each QRS response on EKG
EKG findings: PAT with block
! sudden, rapid firing of a very irritable atrial
Definition: paroxysmal atrial
automaticity focus
tachycardia
! 150-250 bpm
Rate: paroxysmal atrial tachycardia
! tachyarrhythmia caused by the sudden rapid pacing of a
Definition: paroxysmal
very irritable automaticity focus in the AV junction
junctional tachycardia
! QRS complexes with either (1) no p' wave
EKG findings: paroxysmal junctional
or (2) retrograde p waves
tachycardia (PJT)
! either PAT or PJT
Definition: supraventricular tachycardia
! tachyarrhythmia produced by a very irritable
Definition: paroxysmal
ventricular automaticity focus
ventricular tachycardia
! 150-250 bpm
Rate: VTach
! When a sinus pased depolarization stimulus meets a
What is a fusion beat on
depolarization progressing from a ventricular focus
the EKG of VT?
! A normal appearing QRS in the midst of ventricular tachycardia
What is a capture
produced by a sinus-paced depolarization that is able to pass
beat on the EKG of
normally through the AV node
VT?
! Ventricular tachycardia often indicates coronary
Ventricular tachycardia often
insufficiency
indicates [...]
! 0.14 sec or greater
What width range do QRS complexes in VT fall in?
! form of very rapid VT caused by low K+, meds that block
Definition: torsades de
K+ channels or Long QT syndrome
pointes
! 250 to 350 bpm
Rate: torsades de pointes
! 250 to 350 bpm
Rate: atrial flutter
! Sine wave pattern
EKG findings: ventricular flutter
! 250-350 bpm
Rate: ventricular flutter

! 49!
 Terms / Facts
! totally erratic rhythm caused by continuous, rapid rate discharges
What is from numerous automaticity foci in either the atria or in the
fibrillation? ventricles

! The irritable atrial foci are parasystolic

Why do atrial foci all pace at once in AFib?
! Rapid-rate discharges from many irritable, parasystolic
What causes
ventricular automaticity foci, producing an erratic, rapid
ventricular
twitching of the ventricles
fibrillation?
! totally erratic appearance and lack of any identifiable
EKG findings: ventricular
waves on EKG
fibrillation
! Ventricular fibrillation
What does ventricular flutter usually evolve into?
! 350-450 bpm
Rate: ventricular fibrillation
! 350-450 bpm
Rate: atrial fibrillation
! Ventricular fibrillation is a type of cardiac
Ventricular fibrillation is a type of
arrest
cardiac [...]
! a cardiac arrest situation in which a heart rhythm is observed
Definition: pulseless on the electrocardiogram that should be producing a pulse, but
electrical activity is not.

! Delta wave
EKG findings: Wolff-Parkinson-White syndrome
! (1) rapid conduction: SVTs may be rapidly
Give the mechanisms by which conducted 1:1 through accesory pathway (2)some
Wolff-Parkinson-White Kent bundles may have automaticity foci that can
syndrome can produce a initiate a paroxysmal tachycardia (3) re-entry
paroxysmal tachycardia.(3) through Kent bundle (circus re-entry loop)

! AV node is bypassed by an extension of the anterior internodal

Mechanism: Lown- tract (James); with no conduction delay, the James bundle can
Ganong-Levine conduct atrial depolarizations directly to the His Bundle without
Syndrome delay, which can cause rapid ventricular arrhythmias

! Shortened PR interval (<0.12 s) QRS complex is

EKG findings: Lown-Ganong-
not widened No delta waves
Levine syndrome (3)
! Missed cycle (with no p wave)
EKG findings: sinus block
! Lengthens delay between atrial and ventricular
Definition: First degree AV
depolarizations
block
! Intermittent block between atrial and ventricular
Definition: second degree AV
depolarizations
block
Definition: third degree AV
! Complete block of conduction of atrial stimuli to the
block
! 50!
 Terms / Facts
ventricles

! < 0.2 s
What is the normal duration of the PR interval?
! PR interval > 0.2 s consistently, and P-QRS-T is normal
EKG finding: 1st degree
in every cycle
AV block
! AV node
Wenckebach blocks correspond to what part of the conduction system?
! His Bundle and Bundle
Mobitz blocks correspond to what part of the
Branches
conducting system?
! Total block of several (2 or more) pace atrial depolarizations
What happens in a
(P waves) before conduction to the ventricles is successful
Mobitz AV block?
! Successively proloned PR intervals followed by a
What happens in a
completely dropped QRS
Wenckebach block?
! (1) Initial dose of prednisone 40-60 mg (2) Taper down to 10
Tx: temporal
mg/day over by 10% decrements every 1-2 weeks (3) Slow taper
(giant cell)
in 1 mg decrements over 9 months to 1 year (4) Low dose aspiring
arteritis (4)
! Clinical prediction rule for estimating the risk of stroke in
What is the
patients with non-rheumatic atrial fibrillation
CHADS2 score?
! CHF = 1 Hypertension =1 Age > 75 years=1 Diabetes
What are the criteria in the
Mellitus=1 Stroke (prior) or TIA=2
CHADS2 score?
! 0 = low risk = none or aspirin 1 =
Give the risk stratification designations for
moderate = aspirin or warfarin 2+ =
CHADS2 scores and the corresponding
moderate or high = warfarin
anticoagulation therapy
! Radiofrequency ablation of one arm of reentrant
Tx: Wolff-Parkinson-White
loop
Syndrome
! Drugs active on the AV node (digoxin) because they
What types of drugs should
accelerate conduction through the accessory pathway
one avoid in WFW?
! CAD with prior MI (most common) Hypotension Active
Etiologies:
ischemia Prolonged QT syndrome Cardiomyopathies
Ventricular
Congenital defects Drug toxicity
tachycardia (7)
! VFib/VT
What is the most common cause of cardiac arrest?
! VT > 30 s
Definition: sustained VT
! VT is an independent risk factor for sudden
Why should patients with nonsustained death when CAD and LV dysfunction are
VT have a through cardiac workup? present

Clinical presentation: ventricular ! Palpitations Angina Lightheadedness Impaired

! 51!
 Terms / Facts
tachycardia (5) consciousness Dyspnea

! Cannon a waves in the neck S1 that varies in

Physical exam: ventricular
intensity
tachycardia (2)
! Pharmacological cardioversion w/ IV
Tx: sustained VT in
amiodarone, IV procainamide, or IV sotalol IDC
hemodynamically stable patient
placement
(SBP > 90)
! Immediate synchronous DC cardioversion Follow
Tx: sustained VT in
with IV amiodarone to maintain sinus rhythm IDC
hemodynamically unstable
placement
patient (3)
! No treatment if no underlying heart disease If underlying cardiac
Tx:
disease, order an echo; if inducible, sustained VT found, ICD
nonsustained
placement recommended
VT
! QT: Prolonged QT syndrome W: WPW I: Infarction D: Drugs
What are the causes T: Torsades H: Hypokalemia, hypocalcemia,
of prolonged QT? hypomagnesemia

! Wide QRS with R and

What do the QRS complexes in a bundle branch block
R'
look like?
! Non-simulataneous depolarization of the right
Explain the appearance of the
and left ventricles due to the slow conduction
wide QRS complex in a bundle
down one blocked bundle branch
branch block EKG.
! 3 squares (> 0.12 s)
How wide should a QRS be in order to diagnose BBB?
! V1-V2
In what leads should one look for a RBBB?
! V5-V6
In what leads should one look for a LBBB?
! Area of ischemia
What does an inverted T wave indicate?
! V1-V6
In what leads should one look for an inverted T wave?
! That the myocardial infarction is acute
What does ST-segment elevation signify?
! RBBB pattern QRS w/ ST elevation in V1-V3
EKG findings: Brugada syndrome
! ST segment elevation T wave elevation (sometimes)
EKG findings: pericarditis (2)
! Digitalis
What drug can cause ST segment depression?
! Necrosis due to MI
What do significant Q waves signify?
! 1 small square wide or 1/3 of QRS
How wide and tall are significant Q
amplitude
aves?

! 52!
 Terms / Facts
! Positive electrode sees through the necrotic void
Explain how Q waves are formed
and produces negative deflection
in the setting of MI.
What is the recurrence rate of VFib that is not associated with ! 30% within 1 year
MI?
! Ischemic heart disease (most common) Antiarrhythmic drugs
Etiologies:
(prolonged QT) AFib with rapid ventricular rate in WFW
VFib (3)
! Cannot measure BP; absent heart sounds and pulse
Clinical presentation:
Patient is unconscious
VFib (2)
! Immediate defibrillation and CPR
Tx: VFib
! Epinephrine (1 mg IV bolus and then
If VFib persists despite defribillation, what
every 3 to 5 mins) IV amiodarone
pharmacological interventions are called
followed by shock
for? (2)
! Sinus rate < 60 bpm
Definition: Sinus bradycardia
Etiologies: sinus bradycardia ! ischemia increased vagal tone antiarrhythmic drugs
(3)
! Sinus node dysfunction characterized by persistent
Definition: sick sinus
spontaneous sinus bradycardia
syndrome
! Dizziness Confusion Fatigue CHF
Clinical presentation: sick sinus syndrome (4)
! Pacemaker implantation
Tx: sick sinus syndrome
! Pacemaker implantation
Tx: Mobitz type II block
! pacemaker implantation
Tx: 3rd-degree heart block
! Digoxin, diuretics, vasodilators and cardiac transplantation
Tx: Dilated
Remove offending agent if possible Anticoagulation
Cardiomyopathy (3)
! Dyspnea Angina
Clinical presentation: hypertrophic cardiomyopathy
Arrhythmias
(3)
! Sustained PMI Loud S4 Systolic ejection murmur
Physical exam: hypertrophic
Rapidly increasing carotid pulse with two upstrokes
cardiomyopathy (4)
! CXR Echo EKG
Dx: hypertrophic cardiomyopathy (3)
! β-blockers CCBs Treat AFib if present
Tx: hypertrophic
Myomectomy (90% cure rate)
cardiomyopathy (4)
! idiopathic scleroderma carcinoid syndrome
Etiologies: restrictive
amyloidosis sarcoidosis hemochromatosis
cardiomyopathy (6)
Clinical presentation: ! right sided>left sided heart failure w/ peripheral edema
restrictive cardiomyopathy diuretic refractoriness thromboembolic events poorly

! 53!
 Terms / Facts
(4) tolerated tachyarrhythmias

! ↑ JVP +/- Kussmaul's sign S3/S4 Congestive

Physical exam: restrictive
hepatomegaly +/- ascites and jaundice
cardiomyopathy (3)
! Treat underlying disease Gentle diuresis
Tx: restrictive cardiomyopathy
Anticoagulation
(3)
! Can precipitate
Why shouldn't digoxin be given to someone with
arrhythmias
amyloidosis
! Infectious Neoplastic (metastatic cancer) Autoimmune (SLE,
Etiologies: acute RA, scleroderma, drug induced lupus) Uremia Dressler's
pericarditis (5) syndrome

! Chest pain (pleuritic, positional) Fever

Clinical presentation: acute
Pericardial effusions
pericarditis (3)
! pericardial friction rub best heard at LLSB w/ diaphragm
Physical exam: acute
[sound:rub2.mp3]
pericarditis
! Diffuse ST elevation and PR depression
EKG findings: acute pericarditis
! EKG CXR Echo
Dx: acute pericarditis (3)
! NSAIDs +/- colchicine glucocorticoids
Tx: acute pericarditis (2)
! RHF > LHF
Clinical presentation: constrictive pericarditis
! JVD Kussmaul's sign Pericardial knock Ascites
Physical exam: constrictive
dependent edema
pericarditis (5)
! EKG CXR Echo Cardiac cath
Dx: constrictive pericarditis (4)
! Elevated and equal diastolic pressures
What should cardiac catheterization show
in all chambers square root sign
in constrictive pericarditis? (2)
! Low QRS voltages Generalized T wave
EKG findings: constrictive
flattening or invesion
pericarditis (2)
! Complete resection of the pericardium is definitive
Tx: constrictive
therapy
pericarditis
! Muffled heart sounds Soft PMI Dullness at left lung
Physical exam: pericardial
base Pericardial fricction rub
effusion (4)
! Echocardiogram CXR
Dx: pericardial effusion
! Echocardiogram
What is the imaging study of choice for pericardial effusion?

! 54!
 Terms / Facts
! Low QRS voltages T wave flattening
EKG findings: pericardial effusion (2)
! pericardiocentesis (if cardiac tamponade suspected)
Tx: pericardial
observation (if minor)
effusion (2)
! penetrating trauma to the thorax iatrogenic (central line,
Etiologies: cardiac pacemaker, pericardiocentesis( pericarditis post-MI with free
tamponade (4) wall rupture

! Elevated JVP most common finding Narrowed pulse

Physical exam: cardiac
pressure Pulsus paradoxus
tamponade
! cardiogenic shock w/o pulmonary edema
Clinical presentation: cardiac
dyspnea
tamponade (2)
! Echocardiogram CXR EKG Cardiac cath
Dx: cardiac tamponade (4)
! pericardiocentesis (nonhemorrhagic) emergent surgery w/
Tx: cardiac
pericardiocentesis as temporizing measure (hemorrhagic)
tamponade (2)
! Rheumatic heart disease Mitral annular calcification
Etiologies: mitral stenosis (2)
! Dyspnea Pulmonary edema AFib
Clinical manifestations: mitral stenosis (3)
! Loud S1 Opening snap following S2 Low-pitched mid-
Physical exam:
diastolic rumble at apex [sound:ms.mp3]
mitral stenosis
! mismatch between myocardial oxygen demand and
Definition: demand
supply
ischemia
! Coronary artery spasm Coronary embolism Anemia
Etiologies: demand
Arrhythmias Hyper/hypotension
ischemia (6)
! S. pneumoniae H. flu Klebsiella and other
Etiologies: community acquired
GNR S. aureus
pneumonia (6)
! GNR bugs including pseudomonas, klebsiella, e.coli,
Etiologies: hospital-acquired
enterobacter MRSA
pneumonia
! acute onset fever cough w/ purulent sputum dyspnea
Sx: "typical"
pleuritis chest pain
pneumonia (4)
! insidious onset dry cough extrapulm sx (N/V, diarrhea,
Clinical manifestations: headache, myalgias, sore throat) patchy interstitial
"atypical" pneumonia (4) pattern on CXR

! Cough increases in frequency and severity Sputum

Definition: COPD
production increases in volume and/or changes
exaccerbation (GOLD
character Dyspnea increases
criteria)
Physical exam: "typical" ! Tachycardia/tachypnea Late inspiratory crackles

! 55!
 Terms / Facts
community-acquired Pleurla friction rub Dullness to percussion
pneumonia (4)
! lobar consolidation
CXR: community acquired pneumonia
! Sore throat and headache followed by a
What is the classic clinical
nonproductive cough and dyspnea
presentation of atypical pneumonia?
! Mycoplasma pneumoniae C. pneumoniae C. psittaci Coxiella
Etiologies: atypical burnetti Legionella spp. Viruses (influenza, adenoviruses, RSV,
pneumonia (6) parainfluenza)

! Pulse-temperature dissociation (normal pulse in the setting

Physical exam: atypical
of high fever) Wheezing Rhonchi Crackles
pneumonia (4)
! diffuse reticulonodular infiltrates absent/minimal
CXR: atypical pneumonia
consolidation
(2)
! sputum gram stain sputum bacterial culture blood cultures (before
Dx: pneumonia
abx) CXR
(4)
! 3rd-generation cephalosporin (ceftriaxone) + macrolide
Tx (empiric): community-
(azithromycin) New generation FQs
acquired pneumonia,
(moxifloxacin/levofloxacin)
hospitalized (2)
! No recent abx: macrolide or doxycycline Recent
Tx (empiric): community-
abx: macrolide + high-dose augmentin or 2nd.
acquired pneumonia,
generation ceph.
outpatient (2)
! Vancomycin + Zosyn + FQ
Tx (empiric): hospital-acquired pneumonia
! Clinical prediction rule for mortality in community-acquired
Definition:
pneumonia Confusion Uremia RR ≥ 30 BP < 90/60 Age ≥65
CURB-65
! Score of ≥2
What CURB-65 score warrants inpatient admission?
! Pleural effusion Pleural empyema ARDS
Complications: pneumonia (3)
! CXR Lab tests - CBC w/ diff, BUN, creatinine, glucose,
Workup/tx
electrolytes O2 saturation Pretreatment cultures (2) Gram stain
sequence:
and sputum culture Abx therapy (empiric)
pneumonia (6)
! Leads I and AVL
In what leads are Q waves seen with a lateral infarct?
! Leads V1-V4
In what leads are Q waves seen with an anterior infarct?
! Leads II, III and AVF
In what leads are Q waves seen with an inferior infarct?
! Large R wave in V1-V2 ST segment
EKG findings: posterior infarct in
depression in V1-V2
left ventricle

! 56!
 Terms / Facts
! ST elevation and Q waves in V1-V2 Q waves
EKG findings: anerior infarct (2)
! Left bundle branch; Q wave would
In what circumstance is it nearly impossible to occur in the middle of QRS
diagnose an infarction from EKG? Why? complex

A posterior infarct is usually caused by occlusion of wht ! Right coronary artery

vessel?
! blocks of either the anterior or posterior division of the left
Definition:
bundle branch
hemiblock
! Q waves in lead I Wide/deep S wave in lead III
EKG findings: anterior hemiblock
! Left axis deviation
What happens to the axis in anterior hemiblock?
! Right axis deviation
What happens to the axis with posterior hemiblocks?
! Deep or wide S in lead I Q wave in lead III
EKG findings: posterior hemiblock (2)
! Large Q wave and T wave inversion V1-V4 Transient
EKG findings: pulmonary
Right BBB Wide S in Lead I
embolus (3)
! QRS complexes of small amplitude in all leads
EKG findings: COPD
! Peak T waves Wide, flat P waves QRS widening
EKG findings: Hyperkalemia (3)
! T wave flattening U waves
EKG findings: Hypokalemia
! Short QT
EKG findings: Hypercalcemia
! Prolonged QT
EKG findings: hypocalcemia
! curved ST segment depression
EKG findings: Digitalis effect
! Wide, notched P wave Wide QRS Depressed ST
EKG findings: Quinidine
segment Prolonged QT interval
effects (4)
! Deviation toward the ventricle that is
What happens to the mean QRS vector in
hypertrophied
hypertrophy?
! Points away from infarct due to
What tends to happen to the mean QRS vector
unopposed depolarization
(axis) of the heart with an infarct? Why?
! Right axis
A negative QRS in lead I indicates deviation of the axis to
deviation
what side?
! Points into the negative sphere
What does a negative QRS in lead AVF say
(away from AVF)
about mean QRS vector?
! Leads I and AVF
A normal axis has positive QRS complexes in which leads?

! 57!
 Terms / Facts
! Positive QRS in lead I Negative QRS in lead
How does one find left axis
AVF
deviation? (2)
! Negative QRS in lead I Positive QRS in lead
How does one find right axis
AVF
deviation? (2)
! Negative; the thick left ventricle is
What is the normal sign of QRS complex
mostly posterior
in V2? Why?
! V3-V4
Which precordial leads are usually isoelectric?
! isoelectric (transitional) QRS in leads V5-V6
EKG findings: leftward axis rotation
EKG findings: rightward axis ! Isoelectric (transitional) QRS in leads V1-V2
rotation
! Lead V1
What EKG lead gives the most accurate information about the atria?
! A wave that has both positive and negative portions
What is a diphasic wave?
! Atrial enlargement
What is a diphasic P wave characteristic of?
! If the initial portion of the diphasic P
If the initial portion of the diphasic P wave
wave is the larger of the two phases,
is the larger of the two phases, then there
then there is right atrial enlargment
is [...] atrial enlargment
! Small initial component and larger terminal
EKG findings: left atrial
component in diphasic P wave
enlargement
! Large R wave
What does V1 look like with right ventricular hypertrophy?
! Deep S wave
What is the normal appearance of QRS in lead V1?
! Really deep S wave
What does V1 look like with left ventricular hypertrophy?
! Very tall R wave in V5
What does V5 look like with left ventricular hypertrophy?
! mm of S in V1 + mm of R in V5
How does one check an EKG for left ventricular
> 35 = LVH
hypertrophy?
! Inverted T wave with a gradual downslope
What do T waves look like in the left
and very steep return
chest leads with LVH?
! Depressed and humped ST
What does right ventricular strain look like? In
segment in V1
what lead?
! Depressed and humped ST segment
What does left ventricular strain look like? In
in V5
what lead?
! The characteristic EKG sign of ischemia is an
The characteristic EKG sign of
inverted T wave
ischemia is an [...]

! 58!
 Terms / Facts
! V1-V6
In which leads are T wave inversion most common in ischemia?
! Wellens syndrome; stenosis
Marked T wave inversion in leads V2-V3 is
of the LAD
indicative of what syndrome?
! ST segment
What EKG sign is indicative of acute myocardial
elevation/depression
injury?
! ↑ AP diameter hyperressonance ↓ diaphragmatic excursion ↓
Physical exam:
breath sounds ↑ expiratory phase rhonchi wheezes
COPD (6)
! Chronic cough Sputum production Dyspnea
Clinical manifestations: COPD (3)
! Infxn (S. pneumoniae, H. influenzae, M. catarrhalis)
Exacerbation triggers:
Cardiopulmonary disease, incl. PE
COPD (2)
! PaO2 55 mg or O2 sat < 88% PaO2 55 to
What are the criteria for continous or
59 plus polycythemia or evidence of cor
intermitten long-term oxygen therapy in
pulmonale
COPD? (2)
! FEV1/FVC <70% FEV1 ≥ 80%
Definition (GOLD): COPD Stage I (mild)
! Bronchodilator prn
Tx: Stage I (GOLD) COPD
Definition (GOLD): Stage II (moderate) COPD ! FEV1/FVC < 70% FEV1 50-80%
(2)
! Standing LA dilator (tiotropium > Beta agonist)
Tx: Stage II (GOLD) COPD
Rehabilitation
(2)
! Fev1/FVC < 70% Fev1 30-50%
Definition (GOLD): Stage III COPD (severe) (2)
! Standing LA dilator + inh. steroid if increased
Tx: Stage III (GOLD)
exacervations
COPD
! Standing LA dilator + inh. steroids + O2
Tx: Stage IV (GOLD) COPD (3)
! Fev/FVC < 70% FEV1 < 30%
Definition: Stage IV (GOLD) COPD
! Sigmoid colon
What is the most common location for diverticulosis?
! Usually asymptomatic; incidentally found by barium
Clinical manifestations: enema or colonoscopy Vague, LLQ discomfort, bloating,
diverticulosis (2) constipation/diarrhea

! Barium enema
Dx: diverticulosis
! High-fiber foods Psyllium
Tx: diverticulosis (2)
! Painless rectal bleeding Diverticulitis
Complications: diverticulosis (2)
Pathophysiology: ! Impaction of food and bacteria in diverticulum → fecalith
! 59!
 Terms / Facts
diverticulutis formation → obstruction → compromise of the diverticulum's
blood supply, infection, perforation

! Abdominal/pelvic CT w/w/o oral contrast (test of choice) Abd

Dx: diverticulitis
radiograph
(2)
! Barium enema and colonscopy due to
Which diagnostic tests are contraindicated
acute risk of perforation
in diverticulutis? Why?
! LLQ abdominal pain Fever
Clinical manifestations:
Nausea/Vomiting/Constipation
diverticulutis (3)
! IBD Infectious colitis PID Tubal pregnancy Cystitis Colorectal
DDx: diverticulutis
cancer
(6)
! Metronidazole + FQ 7-10d Liquid diet
Tx: diverticulutis (mild) (2)
! Inpatient - NPO, IV fluids, NG tube IV abx -
Tx: diverticulitis (severe)
amp/gent/MNZ or zosyn
(2)
! If medical management doesn't work or if
When is surgery indicated for tx of
there are 2+ episodes
diverticulitis?
! Tortuous, dilated veins in the submucosa of the
Definition: angiodysplasia of the
colon wall
colon
! Lower GI bleeding (low grade usually)
Complication: angiodysplasia of the colon
! Colonoscopy
Dx: angiodysplasia of the colon
! self-resolving colonoscopic coagulopathy if
Tx: angiodysplasia of the
persistent
colon
! SMA embolism Nonocculusive mesenteric ischemia SMA
Etiologies: acute
thrombosis Venous thrombosis Focal segmental ischemia of
mesenteric ischemia
the small bowel
(5)
! Sudden onset abd pain out of proportion to the abd
Clinical manifestations:
tenderness on examv (occlusive) Abd distension & pain
acute mesenteric ischemia
(nonocclusive) N/V Hematochezia Intestinal angina
(5)
! Peritoneal signs Abd distention (FOBT ~ 75% pts)
Physical exam: acute mesenteric
May be unremarkable
ischemia (2)
! Mesenteric angiography (definitive) CT
Dx (studies): acute mesenteric
angiogram (test of choice)
ischemia (2)
! ↑ WBC ↑ amylase ↑ LDH acidosis w/ ↑
Lab findings: acute mesenteric ischemia
lactate
(4)

! 60!
 Terms / Facts
Tx: acute mesenteric ischemia ! IV fluids Broad-spectrum abx Resection if necrotic
(3)
! Fibrinolytics Surgical
Tx: acute mesenteric ischemia due to SMA
embolectomy
embolism (2)
! When SMA spasm
When is intra-arterial infusion of papaverine
(nonocclusive) is suspected
indicated in acute mesenteric ischemia?
! percutaneous or sugical
Tx: acute mesenteric ischemia due to SMA
revascularization
thrombosis
! Dx prior to infarction of
What is the strongest predictor of survival of acute
bowel
intestinal ischemia?
! Hypotension Tachypnea Fever AMS Lactic acidosis
Signs: intestinal infarction (5)
! Embolic: sx are more sudden and painful
How do clincial presentations of an
Thrombotic: sx are more grandual and
embolic vs thrombotic acute mesenteric
less severe
ischemia differ?
What drug class should be avoided acute mesenteric ischemia is ! Vasopressors
occurring?
! Atherosclertoic occlusive disease of main
Etiology: chronic mesenteric
mesenteric vessels
ischemia
! Abdominal angina (postprandially) Significant
Clinical presentation: chronic
weight loss due to abdominal angina
mesenteric ischemia (2)
! Mesenteric arteriography
Dx: chronic mesenteric ischemia
! surgical revascularization (definitive)
Tx: chronic mesenteric ischemia
! s/s of large bowel obstruction w/o mechanical
Definition: Ogilvie's
obstruction
syndrome
! recent surgery/trauma serious medical illness
Etiologies: Ogilvie's syndrome
medications
(3)
! Stop offending agent Supportive measures (IV fluids, electrolyte
Tx: Ogilvie's
repletion) Decompression with gentle enemas or NG suction
syndrome (3)
! Toxic megacolon Colonic perforation
Complications:
Anasarca/electrolyte imbalances
pseudomembranous colitis (3)
! Profuse, watery diarrhea Crampy abdominal
Clinical manifestations:
pain Toxic megacolon w/ risk of perforation
pseudomembranous colitis (3)
! Twisting of a loop intestine about its mesenteric
Definition: colonic
attachment site
volvulus
What are the most common sites of colonic ! Sigmoid colon (75%) Cecal volvulus

! 61!
 Terms / Facts
volvulus? (2) (25%)

! Acute onset colicky abdominal pain Obstipation,

Clinical manifestations: colonic
abdominal distention Anorexia N/V
volvulus (4)
! Plain films Sigmoidoscopy (dx and tx for sigmoid volvulus)
Dx: colonic volvulus
Barium enema
(3)
! nonoperative reduction (decompression vs sigmoidoscopy)
Tx: sigmoid volvulus
What is Reynold's ! Fever Severe jaundice RUQ pain Confusion Hypotension
pentad?
! Cholangitis: Fever Severe Jaundice
What is Charcot's triad? In what disease
RUQ pain
is it seen?
! Infection of the biliary tract 2/2 obstruction → biliary stasis &
Definition:
bacterial overgrowth
cholangitis
! BD stone (85%) Malignant or benign stricture Flukes
Etiologies: cholangitis (3)
! Blood cultures IV fluids IV abx after cultures
Workup/approach:
Decompress CBD when patient stable
cholangitis (4)
! RUQ U/S Labs (CBC, LFTs, amylase) ERCP (don't perform during
Dx: cholangitis
acute phase)
(3)
! IV abx IV fluids ERCP (patients who dont' respond to abx and
Tx:cholangitis
supportive care)
(3)
! HBV and HAV vaccinations, if not
What vaccinations should all patients with
already immune
HCV receive?
! Subacute painless thyroiditis Subacute
What are the most important granulomatous thyroiditis Iodine-induced
causes of thyrotoxicosis w/ low thyroid toxicosis Levothyroxine overdose
radioactive iodine uptake? (5) Struma ovarii

! Dyspnea Tachycardia Sudden-onset pleuritic

Clinical manifestations:
chest pain Cough Hemoptysis
Pulmonary embolism (4)
What kind of lesion does positive pronator drift ! Upper motor neuron lesion
indicate?
! Low pH <
What laboratory value in a parapneumonic effusion is most
7.2
indicative of empyema?
! Tube
A low pH (<7.2) in a parapneumonic effusion is an indication for
thoracostomy
what intervention?
! 6 ml/kg
What is the ideal tidal volume on a ventilator?
What is the ideal FIO2 for a patient on ventilation? ! <40%; avoid oxygen

! 62!
 Terms / Facts
Why? toxicity

! Vague epigastric or RUQ pain

Clinical presentation: choledochal cyst (adult)
! Abdominal pain Jaundice Attacks of
Clinical presentation: choledochal
rucurrent panccreatitis
cyst (child) (3)
! Cholangiosarcoma Cholangitis
Complications: choledochal cyst (2)
! U/S followed by
What is the initial investigation of choice for a
CT/MRI
choledochal cyst?
! High-resolution CT
What is the definitive test for diagnosis of bronchiectasis?
! Bronchiectasis: mucopurulent expectoration and
How does the cough of
occasional episode of hemoptysis Chronic bronchitis:
bronchiectasis differ from
nonpurulent expectoration
that of chronic bronchitis?
! Fibrosis and nodualr regeneration resulting from hepatocellular
Definition:
injury
Cirrhosis
! Alcohol (60-70%) Viral hepatitis Autoimmune hepatitis Metabolic
disease (hemochromatosis, Wilson's disease, a1-antitrypsin) Biliary
Etiologies:
tract diseases (primary biliary cirrhosis, PSC) Vascular diseases (Budd-
cirrhosis (7)
chiari, RHF, constrictive pericarditis) NAFLD

! Ascites Varices Gynecomastia Palmar erythema

Clinical manifestations: Spider angiomas Hemorrhoids Caput medusae
chronic liver disease (8) Testicular atrophy

! ↑ bilirubin ↓ albumin ↑ PT
Lab findings: cirrhosis (3)
! Anemia Thrombocytopenia Neutropenia
CBC findings: cirrhosis (3)
! Abdominal U/S w/ dopller Assess fibrosis (FibroSURE biomarkers)
Workup: Determine etiology (hepatitis serologies, autoimmune serologies) +/-
cirrhosis (3) liver bx

! Transjugular intrahepatic portal-systemic shunt to lower portal

Tx: portal
pressure
hypertension
! massive hematemesis melena
Clinical manifestations: varices (2)
! ↓ Na intake (1-2 g/d) diuretics
Tx: ascites (2)
! Large-volume paracentesis (1st line because of TIPS
Tx: refractory
complications( transjugular intrahepatic portosytemic shunts
ascites (2)
! AC, 9H Ascites coagulopathy Hypoalbuminemia Portal
Complications:
Hypertension Hepatic encephalopathy Hepatorenal syndrome
liver failure (11)
Hypoglycemia Hyperbilirubinemia/jaundice Hyperestrinism

! 63!
 Terms / Facts
Hepatocellular carcinoma

In what disease is spontaneous bacterial peritonitis a common ! Cirrhosis

complication?
! E. coli Klebsiella S. pneumo
Etiologies: spontaneous bacterial peritonitis (3)
! Abd pain Fever Vomiting Rebound
Clinical manifestations: spontaneous bacterial
tenderness
peritonitis (4)
! paracenntesis and exam of ascitic fluid
Dx: spontaneous bacterial peritonitis
! IV cefotaxime IV albumin
Tx: spontaneous bacterial peritonitis (2)
! AMS Asterixis Rigidity/hyperreflexia Fetor
Clinical manifestations: hepatic
hepaticus (musty breath odor)
encephalopathy (4)
! Lactulose Neomycin Limited-protein diet
Tx: hepatic encephalopathy (3)
! Hemodynamic stabilization (IV fluids) Emergent upper
Tx: bleeding 2/2
GI endoscopy IV octreotide infusion emergently Beta-
esophageal/gastric varice
blockers long term therapy to prevent rebleeding
rupture (4)
! octreotide + midodrine + albumin
Tx: hepatorenal syndrome
! Albumin: > 3.5 Bili: < 2.0 Encephalopathy: None
Definition: Child's
Ascites: none Nutritional status: Excellent
classification (A)
! Albumin: 3.0-3.5 Bili: 2.0-2.5 Encephalopathy: minimal
Definition: Child's
Ascites: controlled Nutritional status: good
classification (B)
! Albumin: < 3.0 Bili: > 3.0 Encephalopathy: Severe
Definition: Child's
Ascites: uncontrolled Nutritional status: Poor
classification (C)
At what Child's score should a cirrhotic patient be evaluated for ! Child class B
transplant?
! > 1.1 g/dL
What serum ascites albumin gradient indicates portal HTN?
! Order period labs (LFTs 3-4 months) Perform endoscopy
How does one monitor a to determine presence of esophageal varices CT-guided
patient w/ cirrhosis? (3) biopsy if HCC suspected

! Fatigue Arthralgias Bronze skin Hypogonadism DM

Sx: hemochromatosis (5)
! Labs (serum iron, ferritin, iron sat. TIBC) Liver bx required
Dx: hemochromatosis
for dx
(2)
! ↑ serum iron ↑ serum ferritin ↑ Fe sat ↓ TIBC
Lab findings: hemochromatosis (4)
! Repeated phlebotomies Deferoxamine Treat complications
Tx: hemochromatosis
Consider liver transplant
(4)

! 64!
 Terms / Facts
! ↑ 24-hr urine Cu ↓ serum ceruloplasmin ↓ penicillamine
Lab findings: Wilson's
challenge with ↑ urine Cu excretion
disease (3)
! Cheltion therapy w/ penicillamine + pyridoxine Zinc (decreases
Tx: Wilson's
intestinal uptake of copper)
disease (2)
! Nonfibrolamellar (hep B/C associated)
What are the two pathologic types of
Fibrolamellar
HCC? (2)
! abdominal pain weight loss anorexia fatigue s/s of chronic
Clinical presentation:
liver disease paraneoplastic syndromes
HCC (6)
! Liver biopsy Labs (hep B/C, LFTs, PT/PTT, tumor markers) Imaging
Dx: HCC (3)
! Liver resection Liver transplantation
Tx: HCC (2)
! Blood draining into the duodenum via CBD
Definition: hemobilia
! IV metronidazole
Tx: amebic liver abscess
! Biliary tract obstruction GI infection
Etiologies: liver abscess (2)
! Surgical resection Mebendazole
Tx: hydatid liver cyst (2)
! Liver disease caused by occlusion of hepatic venous outflow, which
Definition:
leads to hepatic congestion and subsequent microvascular ischemia
Budd-Chiari
! Myeloproliferatie disorder Hypercoagulable state Tumor
Etiologies: Budd-
invasion Pregnancy
Chiari (4)
! Hepatic venography Serum ascites albumin gradient > 1.1 g/dl
Dx: Budd-Chiari (2)
! Medical therapy - anticoagulation, thrombolytics, diuretics Surgery
Tx: Budd-
(balloon angioplasty w/ stent, TIPS) Liver transplantation
Chiari (3)
! Pale stools Dark urine
What are the signs of a conjugated hyperbilirubinemia? (2)
! Stones in the gallbladder
Definition: cholelithiasis
! Biliary colic = episodic RUQ or epigastric abd painn
Clinical manifestations:
Radiation of painn to scapula Nausea
cholelithiasis (3)
! RUQ U/S
Dx: cholelithiasis
! Referred right subscapular pain w/ biliary colic
Definition: Boas' sign
! Cholecystitis w/ prolonged obstruction of cystic duct
Choledocholithiasis Gallstone ileus Malignancy Mirizzi's
Complications:
syndrome: common hepatic duct compression by cystic duct
cholelithiasis (5)
stone

! 65!
 Terms / Facts
! Cholecystectomy (laparoscopic) Ursodeoxycholic acid (rare)
Tx: symptomatic for cholesterol stones if poor surgical candidate or
cholelithiasis (2) uncomplicated biliary pain

! EKG w/ wide QRS

What is the best indicator of the severity of TCA overdose?
! First line: dopaminergic agents (cabergolin/bromocriptine) Second
Tx:
line: surgery only if impaired vision does not improve with drug
prolactinoma
treatment
(2)
! Decompensation - intubation
A normal/high pCO2 in the context of an acute
may be required
asthma exacerbation is indicative of what?
! Inhaled B2 agonist (first-line) via nebulizer/MDI
Tx: acute severe asthma Corticosteroids (IV or PO) Oxygen (titrate to achieve
exacerbation (3) >90% SaO2)

! Exudative Transudative
What are the types of pleural effusions? (2)
! Rapid decline in renal function, with an increase in serum
Definition: Acute creatinine level (relative increase of 50% or absolute of 0.5-1.0
renal failure mg/dL)

! Weight gain
What are the most common clinical manifestations of acute
Edema
renal failure? (2)
! Infection
What is the most common cause of death with ARF?
! Hypovolemia CHF Peripheral vasodilation (sepsis, etc.)
Etiologies:
Cirrhosis/hepatorenal syndrome Drugs (NSAIDs, ACE inhibitors,
prerenal failure
cyclosporin)
(5)
! Daily weights, I/Os BP Serum electrolytes Hb/Hct
How does one monitor a
for anemia Watch for infection
patient with ARF? (5)
! H&P Urine evaulation Renal U/S Serologies (if
Workup: acute renal
indicated)
failure
! Dry mucous membranes Hypotension Tachycardia
Clinical manifestations: pre-
Decreased tissue turgor Oliguria/anuria
renal ARF (5)
! Oliguria BUN:Cr > 20:1 Urine osmolality > 500 FeNa < 1%
Lab findings: pre-
Bland urine/hyaline casts
renal ARF
! Prerenal Intrinsic Postrenal
Categories: ARF (3)
! Ischemia Toxins
Etiologies: acute tubular necrosis
! BUN:Cr < 20 FeNa > 2% Urine osmolality < 350 mOsm/kg
Lab findings: ATN
Brown muddy casts
(4)

! 66!
 Terms / Facts
! urethral obstruction 2/2 BPH nephrolithiasis obstruction of
Etiologies:
solitary kidney retroperitoneal fibrosis obstructing neoplasms
postrenal ARF (5)
! Urinalysis Urine chemistry Serum
What tests/procedures should be electrolytes Bladder cath (dx and tx) Renal
ordered for any patient with ARF? (5) U/S

! Hyperkalemic cardiac arrest

In the early phase of ARF, what are the most
Pulmonary edema
common mortal complications? (2)
! Avoid meds that decrease renal blood flow Correct fluid
Tx: acute renal
imbalance Correct electrolyte imbalances Optimize cardiac output
failure (general)
Order dialysis if symptomatic uremia
(5)
! Pyelonephritis Acute interstitial
WBC casts suggest what etiologies of renal
nephritis
failure?
! Glomerular disease
RBCs and RBC casts suggest what etiology of ARF?
! treat underlying disorder give NS to maintain euvolemia and restore
Tx: prerenal
BP Eliminate offending agents
ARF (3)
! Supportive therapy for ATN Furosemide trial if patient is
Tx: intrinsic ARF
oliguric
(2)
! bladder catherization to decompress urinary tract
Tx: postrenal ARF
! ≥ 3 mos of reduced GFR (
Definition: chronic kidney disease
! Diabetes (most common) HTN Chronic GN AIN PKD
Etiologies: CKD (5)
! GFR > 90 ml/min
Definition: Stage I CKD
! GFR 60-89 ml/min
Definition: Stage 2 CKD
! 30-59 ml/min
Definition: Stage 3 CKD
! 15-29 ml/min
Definition: Stage 4 CKD
! GFR < 15 ml/min or dialysis
Definition: Stage 5 CKD
! Signs and symptoms associated with accumulation of nitrogenous
Definition:
wastes due to impaired renal function
uremia
! N/V anorexia malaise fetor uremicus
Clinical manifestations (general):
metallic taste
uremia (5)
! Uremic frost Pruritis Calciphylaxis NSF
Clinical manifestations (skin): uremia (4)
Clinical manifestations (cardiovascular): uremia ! pericarditis hypertension CHF
(3)

! 67!
 Terms / Facts
! Encephalopathy seizures Neuropathy
Clinical manifestations (neurologic):
restless legs
uremia (4)
! anemia bleeding
Clinical manifestations (Hematologic): uremia (2)
! Hyperkalemia Hyperphosphatemia Acidosis
Clinical manifestations
Hypocalcemia 2° hyperparathyroidism/osteodystrophy
(metabolic): uremia (5)
! Urinalysis Chem 7 CBC Renal US
Dx: CKD (4)
! ACE inhibitors are first line Goal 130/80
Tx (BP control): CKD
! Low protein Low salt Restrict K+
Tx (diet): CKD (3)
! Treat with erythropoietin
Tx (anemia): CKD
! Oral bicarb or sodium citrate if HCO3 < 22
Tx (metabolic acidosis): CKD
! calcium citrate/acetate vitamin D/calcium
Tx (electrolytes): CKD (2)
! Acidosis Electrolyte imblances Intoxications/ingestions
Indications (absolute):
Overload Uremia
dialysis (5)
! Hemodialysis Peritoneal dialysis
What are the two major methods for dialysis?
! AV fistula
What is the preferred access route for hemodialysis?
! > 150 mg protein/24hr
Definition: proteinuria
! Glomerular Tubular Overflow
What are the classifications of proteinuria?
! Urine protein > 3.5g/24hr Hypoalbuminemia
Clinical manifestations:
Hyperlipidemia Hypercoagulable state Edema
nephrotic syndrome (5)
! Primary glomerular disease Systemic disease Drugs/toxins
Etiologies: nephrotic
Infection Multiple myeloma Malignant HTN
syndrome (6)
! Urine dipstick Urinalysis renal biopsy (if other methods
Dx: nephrotic syndrome
don't help)
(3)
! Treat underlying disease ACE inhibitors (decreases protein loss)
Tx: nephrotic
Diuretics Treat HL Vaccinate against influenza and pneumococcus
syndrome (5)
! > 3 erythrocytes/HPF on urinalysis
Definition: hematuria
What is the general etiology of ! Microscopic: glomerular Gross:
microscopic hematuria? And gross nonglomerular or urologic
hematuria?
! Bladder cancer Kidney
What diseases should be suspected with gross painless
cancer
hematuria? (2)

! 68!
 Terms / Facts
Etiologies (extrarenal): hematuria ! Nephrolithiasis Neoplasms Foley trauma BPH
(4)
! Vascular (renal thrombosis, infarcts, etc) Glomerular
Etiologies (intrarenal):
disease PKD Nephrolithiasis Neoplasms Trauma/exercise
hematuria (6)
! Urine dipstick Urinalysis Cytology Renal bx
Dx: hematuria (4)
! treat underlying disease maintain urine volume
Tx: hematuria (2)
! Fever Myalgia Rapidly progessive renal failure
Clinical manifestsion:
Hemoptysis Cough Dyspnea
Goodpasture's syndrome (6)
! steroids ASAP + cyclophosphamide + plasmapheresis
Tx: ANCA+/Anti-GBM GN
! IV cyclophosphamide + steroids
Tx: SLE nephritis
! Inflammation involving interstitium that surrounds
Definition: Acute Interstitial
glomeruli and tubules
Nephritis
! Toxins (most common) Infection Collagen vascular diseases (e.g.
Etiologies: AIN
sarcoidosis)
(3)
! Fever Eosinophilia Acute renal insufficiency Rash
Clinical manifestations: AIN
FEAR AIN
(4)
! Renal function tests (BUN/Cr) Urinalysis (eos strongly suggestive)
Dx: AIN (2)
! Remove offending agent Treat infection if present
Tx: AIN (2)
! Renal bx
What is the definitive diagnosis for AIN?
! Slowly progressive form of interstitial nephritis that can lead
Definition: Chronic to progressive scarring of the interstium, renal failure and
interstitial nephritis ESRD over time

! urinary tract obstruction reflux nephropathy heavy

Etiologies: chronic analgesic use heavy metal exposure arteriolar
interstitial nephritis (5) nephrosclerosis w/ HTN

What are the sequelae of RTA I that leads to ! Nephrocalcinosis/nephrolithiasis

symptom manifestations?
! MM Autoimmune diseases Meds (analgesics)
Etiologies: RTA I (3)
! correct acidosis w/ sodium bicarb administer phosphate salts
Tx: RTA I (2)
! Fanconi's syndrome Cystinosis Wilson's Paraprotein (MM,
Etiologies: Type II RTA
amyloid)
(4)
! Na restriction (increases bicarb reabsorption) Don't give bicarb to
Tx: RTA II
correct acidosis
(2)

! 69!
 Terms / Facts
! Hematuria Abd pain HTN Palpable kidneys
Clinical manifestations: PKD (4)
! U/S
Dx: PKD
! Drain cysts if symptomatic Treat infection w/ abx Control HTN
Tx: PKD (3)
! IVP
Dx: medullary sponge kidney disease
! HTN Renal insufficiency
Clinical manifestations: renal artery stenosis (2)
! Abdominal bruit
Physical exam: renal artery stenosis
! Renal arteriogram (w/o contrast if possible) MRA
Dx: renal artery stenosis (2)
! Revascularizaztion w/ PRTA Conservative medical therapy
Tx: renal artery
(ACEi, CCBs) if PRTA or surgery contraindicated
stenosis (2)
! Systemic HTN increases capillary hydrostatic pressure
Definition: Hypertensive
in the glomeruli, leading to benign or malignant sclerosis
Nephrosclerosis
! ACEi
What common antihypertensive is contraindicated in renovascular HTN?
Clinical manifestations: nephrolithiasis ! Hematuria Flank pain N/V Dysuria UTI
(5)
! Noncrast helic CT scan Strain urine for stone 24-h urine
Workup: nephrolithiasis
x2
(3)
! Analgesia Aggresive PO/IV hydration Abx if UTI
Tx (acute): Lithotripsy/percutaneous nephrolithotomy if ongoing
nephrolithiasis (4) obstruction

! Increase fluid intake (> 2 L/d) Limit Ca+ intake Thiazide

Tx (chronic):
diuretics Allopurinol (uric acid stones)
nephrolithiasis
! Loop diuretic + thiazide
What diuretics should be used in renal insufficiency? (2)
! Loop diuretic + thiazide
What diuretics should be used for CHF? (2)
! Lasix + spironolactone (1:2.5
What diuretics should be used with cirrhosis?
ratio)
(2)
! Acetazolamide
What diuretic should be used with severe metabolic alkalosis?
! Renal colic/pain oliguria recurrent UTIs
Clinical manifestations: urinary
hematuria/proteinuria renal failure
tract obstruction (5)
! renal U/S initial test IVP Urinalysis
Dx: urinary tract obstruction (3)
! urethral catheter prostatectomy (if BPH)
Tx: lower urinary tract obstruction (2)

! 70!
 Terms / Facts
! nephrostomy tube drainage ureteral stent
Tx: upper urinary tract obstruction (2)
! Single, well circumscribed nodule seen on CXR with no
Definition: Solitary
associated mediastrinal or hilar lymph node involvement
Pulmonary Nodule
! CT scan + Hx
What does the initial evaluation of SPN consist of?
! PET Transthoracic needle biopsy Video assisted thorascopic surgery
Dx: SPN (3)
! Serial CT q3mo
Management: low risk SPN
! PET or bx
Management: medium-risk SPN
! VATS w/ lobectomy if malignant
Management: high risk SPN
! CHF Pneumonia Malignancies (lung/breast/lymphoma)
Etiologies: pleural effusion
PE
(4)
! Exterional dyspnea Peripheral edema
Clinical manifestations: pleural
Orthopnea
effusion
! Dullness to percussion Decreased breath sounds over
Physical exam: pleural
effusion Decreased tactile fremitus
effusion (3)
! CXR Thoracentesis
Dx: pleural effusion (2)
! Diuretics Na restriction Therapeutic thoracentesis (if
Tx: transudative effusions
massive)
(3)
! Abx Chest tube drainage if complicated
Tx: parapneumonic effusions (2)
! Sawtooth P waves
Classic ECG finding in atrial flutter.
! Angina is new, is worsening, or occurs at rest
Definition of unstable angina.
! ACEI
Antihypertensive for a diabetic patient with proteinuria.
! Hypotension, distant heart sounds, and JVD
Beck's triad for cardiac tamponade.
! ?-blockers, digoxin, calcium channel
Drugs that slow AV node
blockers
transmission.
! Niacin
Hypercholesterolemia treatment that ? flushing and pruritus.
! Anticoagulation, rate control, cardioversion
Treatment for atrial fibrillation.
! Immediate cardioversion
Treatment for ventricular fibrillation.
! Dressler's syndrome: fever,
Autoimmune complication occurring 2-4
pericarditis, ? ESR
weeks post-MI.

! 71!
 Terms / Facts
! Treat existing heart failure and
IV drug use with JVD and holosystolic murmur
replace the tricuspid valve
at the left sternal border. Treatment?
! Echocardiogram (showing thickened left
Diagnostic test for hypertrophic
ventricular wall and outflow obstruction)
cardiomyopathy.
! Pulsus paradoxus (seen in cardiac
A fall in systolic BP of > 10 mmHg with
tamponade)
inspiration.
! Low-voltage, diffuse ST-segment elevation
Classic ECG findings in pericarditis.
Definition of ! BP > 140/90 on three separate occasions two weeks apart
hypertension.
! Renal artery stenosis, coarctation of the aorta,
Eight surgically pheochromocytoma, Conn's syndrome, Cushing's syndrome,
correctable causes of unilateral renal parenchymal disease, hyperthyroidism,
hypertension. hyperparathyroidism

Evaluation of a pulsatile abdominal mass and ! Abdominal ultrasound and CT

bruit.
! > 5.5 cm, rapidly enlarging,
Indications for surgical repair of abdominal
symptomatic, or ruptured
aortic aneurysm.
! Morphine, O2, sublingual nitroglycerin, ASA, IV ?-
Treatment for acute coronary
blockers, heparin
syndrome.
What is the ! Abdominal obesity, high triglycerides, low HDL, hypertension,
metabolic insulin resistance, prothrombotic or proinflammatory states
syndrome?
Appropriate diagnostic test? ? A 50-year-old male with ! Exercise stress
angina can exercise to 85% of maximum predicted heart treadmill with ECG
rate.
Appropriate diagnostic test? ? A 65-year-old woman ! Pharmacologic stress test
with left bundle branch block and severe (e.g., dobutamine echo)
osteoarthritis has unstable angina.
! Angina, ST-segment changes on ECG, or
Signs of active ischemia during stress
? BP
testing.
! ST-segment elevation (depression means ischemia), flattened
ECG findings
T waves, and Q waves
suggesting MI.
! Prinzmetal's
A young patient has angina at rest with ST-segment elevation.
angina
Cardiac enzymes are normal.
! CHF, shock, and altered mental
Common symptoms associated with silent
status
MIs.
! V/Q scan
The diagnostic test for pulmonary embolism.
! Protamine
An agent that reverses the effects of heparin.

! 72!
 Terms / Facts
! PT
The coagulation parameter affected by warfarin.
! Hypertrophic
A young patient with a family history of sudden death
cardiomyopathy
collapses and dies while exercising.
! Oral surgery—amoxicillin; GI or GU procedures—
Endocarditis
ampicillin and gentamicin before and amoxicillin after
prophylaxis regimens.
! Pain, pallor, pulselessness, paralysis,
The 6 P's of ischemia due to
paresthesia, poikilothermia
peripheral vascular disease.
! Stasis, hypercoagulability, endothelial damage
Virchow's triad.
! OCPs
The most common cause of hypertension in young women.
! Excessive EtOH
The most common cause of hypertension in young men.
! Seborrheic keratosis
Stuck-on appearance.
! Psoriasis
Red plaques with silvery-white scales and sharp margins.
! Basal cell
The most common type of skin cancer; the lesion is a pearly-colored
carcinoma
papule with a translucent surface and telangiectasias.
! Impetigo
Honey-crusted lesions.
A febrile patient with a history of diabetes presents with a red, swollen, ! Cellulitis
painful lower extremity.
! Pemphigus vulgaris
+ Nikolsky's sign.
! Bullous pemphigoid
- Nikolsky's sign.
A 55-year-old obese patient presents with ! Acanthosis nigricans. Check fasting
dirty, velvety patches on the back of the blood sugar to rule out diabetes
neck.
! Varicella zoster
Dermatomal distribution.
! Lichen planus
Flat-topped papules.
! Erythema multiforme
Iris-like target lesions.
! Contact
A lesion characteristically occurring in a linear pattern in areas
dermatitis
where skin comes into contact with clothing or jewelry.
! Pityriasis rosea
Presents with a herald patch, Christmas-tree pattern.
! Alopecia areata
A 16-year-old presents with an annular patch of
(autoimmune process)
alopecia with broken-off, stubby hairs.
Pinkish, scaling, flat lesions on the chest and back. KOH prep has
! Pityriasis
a "spaghetti-and-meatballs" appearance.
! 73!
 Terms / Facts
versicolor

! Asymmetry, border irregularity, color

Four characteristics of a nevus
variation, large diameter
suggestive of melanoma.
! Actinic
Premalignant lesion from sun exposure that can ? squamous cell
keratosis
carcinoma.
! Lesions of 1° varicella
Dewdrop on a rose petal.
! Seborrheic dermatitis. Treat with antifungals
Cradle cap.
Associated with Propionibacterium acnes and changes in androgen ! Acne vulgaris
levels.
A painful, recurrent vesicular eruption of mucocutaneous ! Herpes simplex
surfaces.
! Lichen
Inflammation and epithelial thinning of the anogenital area,
sclerosus
predominantly in postmenopausal women.
! Squamous cell
Exophytic nodules on the skin with varying degrees of scaling
carcinoma
or ulceration; the second most common type of skin cancer.
! Hashimoto's thyroiditis
The most common cause of hypothyroidism.
! High TSH, low T4, antimicrosomal
Lab findings in Hashimoto's
antibodies
thyroiditis.
! Graves' disease
Exophthalmos, pretibial myxedema, and ? TSH.
! Iatrogenic steroid administration. The second most
The most common cause of
common cause is Cushing's disease
Cushing's syndrome.
A patient presents with signs of hypocalcemia, high ! Hypoparathyroidism
phosphorus, and low PTH.
Stones, bones, groans, psychiatric ! Signs and symptoms of hypercalcemia
overtones.
A patient complains of headache, weakness, and ! 1° hyperaldosteronism (due to
polyuria; exam reveals hypertension and tetany. Conn's syndrome or bilateral
Labs reveals hypernatremia, hypokalemia, and adrenal hyperplasia)
metabolic alkalosis.
A patient presents with tachycardia, wild swings in BP,
! Pheochromocytoma
headache, diaphoresis, altered mental status, and a sense of
panic.
! ?-antagonists (phentolamine and
Should ?- or ?-antagonists be used first in
phenoxybenzamine)
treating pheochromocytoma?
! Nephrogenic diabetes
A patient with a history of lithium use presents with
insipidus (DI)
copious amounts of dilute urine.
Treatment of central
! Administration of DDAVP ? serum osmolality and free water
DI.

! 74!
 Terms / Facts
restriction

! SIADH due to
A postoperative patient with significant pain presents with
stress
hyponatremia and normal volume status.
! Metformin
An antidiabetic agent associated with lactic acidosis.
! 1° adrenal insufficiency (Addison's
A patient presents with weakness, nausea,
disease). Treat with replacement
vomiting, weight loss, and new skin
glucocorticoids, mineralocorticoids,
pigmentation. Labs show hyponatremia and
and IV fluids
hyperkalemia. Treatment?
! <6.5
Goal hemoglobin A1c for a patient with DM.
! Fluids, insulin, and aggressive replacement of electrolytes (e.g.,
Treatment of
K+)
DKA.
! They can mask symptoms of
Why are ?-blockers contraindicated in
hypoglycemia
diabetics?
! Observational
Bias introduced into a study when a clinician is aware of the
bias
patient's treatment type.
! Lead-time
Bias introduced when screening detects a disease earlier and thus
bias
lengthens the time from diagnosis to death.
If you want to know if race affects infant mortality rate but most ! Confounding
of the variation in infant mortality is predicted by socioeconomic variable
status, then socioeconomic status is a _____.
The number of true positives divided by the number of patients with ! Sensitivity
the disease is _____.
! Out
Sensitive tests have few false negatives and are used to rule _____ a disease.
! Highly
PPD reactivity is used as a screening test because most people with
sensitive for
TB (except those who are anergic) will have a +PPD. Highly
TB
sensitive or specific?
Chronic diseases such as SLE—higher prevalence or ! Higher prevalence
incidence?
! Higher incidence
Epidemics such as influenza—higher prevalence or incidence?
! Prevalence
Cross-sectional survey—incidence or prevalence?
! Incidence and prevalence
Cohort study—incidence or prevalence?
! Neither
Case-control study—incidence or prevalence?
! High reliability, low
Describe a test that consistently gives identical results, but
validity
the results are wrong.
Difference between a ! Cohort studies can be used to calculate relative risk (RR),

! 75!
 Terms / Facts
cohort and a case-control incidence, and/or odds ratio (OR). Case-control studies
study. can be used to calculate an OR

! The incidence rate (IR) of a disease in exposed ? the IR of a disease

Attributable
in unexposed
risk?
! The IR of a disease in a population exposed to a particular factor ÷ the
Relative
IR of those not exposed
risk?
! The likelihood of a disease among individuals exposed to a risk factor
Odds
compared to those who have not been exposed
ratio?
! 1 ÷ (rate in untreated group ? rate in treated group)
Number needed to treat?
! Patients with IBD; those with familial adenomatous
In which patients do you polyposis (FAP)/hereditary nonpolyposis colorectal cancer
initiate colorectal cancer (HNPCC); and those who have first-degree relatives with
screening early? adenomatous polyps (

! Prostate cancer is the most common

The most common cancer in men and the
cancer in men, but lung cancer causes
most common cause of death from cancer
more deaths
in men.
! 68%, 95.5%,
The percentage of cases within one SD of the mean? Two SDs?
99.7%
Three SDs?
! Number of live births per 1000 population
Birth rate?
! Number of live births per 1000 women 15-44 years of age
Fertility rate?
! Number of deaths per 1000 population
Mortality rate?
! Number of deaths from birth to 28 days per 1000 live births
Neonatal mortality?
Postnatal ! Number of deaths from 28 days to one year per 1000 live births
mortality?
! Number of deaths from birth to one year of age per 1000 live births
Infant
(neonatal + postnatal mortality)
mortality?
! Number of deaths from 20 weeks' gestation to birth per 1000 total
Fetal
births
mortality?
! Number of deaths from 20 weeks' gestation to one month of life
Perinatal
per 1000 total births
mortality?
! Number of deaths during pregnancy to 90 days postpartum per
Maternal
100,000 live births
mortality?
True or false: Once patients ! False. Patients may change their minds at any time.
sign a statement giving Exceptions to the requirement of informed consent
consent, they must continue include emergency situations and patients without

! 76!
 Terms / Facts
treatment. decision-making capacity

! No. Parental consent is not

A 15-year-old pregnant girl requires
necessary for the medical
hospitalization for preeclampsia. Should her
treatment of pregnant minors
parents be informed?
! Conflict of interest
A doctor refers a patient for an MRI at a facility he/she owns.
! The patient is a danger to self, a danger to
Involuntary psychiatric hospitalization
others, or gravely disabled (unable to
can be undertaken for which three
provide for basic needs)
reasons?
! False. Withdrawing and withholding
True or false: Withdrawing life-sustaining
life are the same from an ethical
care is ethically distinct from withholding
standpoint
sustaining care.
! When there is no rationale for treatment, maximal
When can a physician refuse to intervention is failing, a given intervention has
continue treating a patient on already failed, and treatment will not achieve the
the grounds of futility? goals of care

! Treat immediately. Consent is

An eight-year-old child is in a serious accident. She
implied in emergency
requires emergent transfusion, but her parents are
situations
not present.
! Real threat of harm to third parties; suicidal
Conditions in which
intentions; certain contagious diseases; elder and
confidentiality must be
child abuse
overridden.
! When treatment noncompliance
Involuntary commitment or isolation for
represents a serious danger to public
medical treatment may be undertaken for
health (e.g., active TB)
what reason?
! Treat because the disease represents an
A 10-year-old child presents in status
immediate threat to the child's life.
epilepticus, but her parents refuse
Then seek a court order
treatment on religious grounds.
! A patient's family cannot require that a
A son asks that his mother not be told doctor withhold information from the
about her recently discovered cancer. patient

Patient presents with sudden onset of severe, diffuse ! Emergent laparotomy to

abdominal pain. Exam reveals peritoneal signs and repair perforated viscus,
AXR reveals free air under the diaphragm. likely stomach
Management?
The most likely cause of acute lower GI bleed in patients > 40 ! Diverticulosis
years old.
Diagnostic modality used when ultrasound is equivocal for ! HIDA scan
cholecystitis.
! Acute pancreatitis
Sentinel loop on AXR.

! 77!
 Terms / Facts
! Fat, female, fertile, forty, flatulent
Risk factors for cholelithiasis.
! Murphy's sign, seen in acute
Inspiratory arrest during palpation of the
cholecystitis
RUQ.
Identify key organisms causing diarrhea: ? Most common ! Campylobacter
organism
Identify key organisms causing diarrhea: ? Recent antibiotic ! Clostridium difficile
use
! Giardia
Identify key organisms causing diarrhea: ? Camping
! ETEC
Identify key organisms causing diarrhea: ? Traveler's diarrhea
! S. aureus
Identify key organisms causing diarrhea: ? Church picnics/mayonnaise
Identify key organisms causing diarrhea: ? Uncooked ! E. coli O157:H7
hamburgers
! Bacillus cereus
Identify key organisms causing diarrhea: ? Fried rice
! Salmonella
Identify key organisms causing diarrhea: ? Poultry/eggs
! Vibrio, HAV
Identify key organisms causing diarrhea: ? Raw seafood
! Isospora, Cryptosporidium, Mycobacterium
Identify key organisms causing
avium complex (MAC)
diarrhea: ? AIDS
! Yersinia
Identify key organisms causing diarrhea: ? Pseudoappendicitis
A 25-year-old Jewish male presents with pain and watery diarrhea ! Crohn's
after meals. Exam shows fistulas between the bowel and skin and disease
nodular lesions on his tibias.
! Ulcerative colitis
Inflammatory disease of the colon with ? risk of colon cancer.
! Uveitis, ankylosing spondylitis, pyoderma gangrenosum,
Extraintestinal
erythema nodosum, 1° sclerosing cholangitis
manifestations of IBD.
! 5-aminosalicylic acid +/? sulfasalazine and steroids during
Medical treatment for
acute exacerbations
IBD.
! Mallory-Weiss—superficial tear in the esophageal
Difference between Mallory- mucosa Boerhaave—full-thickness esophageal
Weiss and Boerhaave tears. rupture

! RUQ pain, jaundice, and fever/chills in the setting of ascending

Charcot's
cholangitis
triad.
! Charcot's triad plus shock and mental status changes, with
Reynolds'
suppurative ascending cholangitis
pentad.
Medical treatment for hepatic ! ? protein intake, lactulose, neomycin
encephalopathy.
! 78!
 Terms / Facts
First step in the management of a patient with acute GI ! Establish the ABCs
bleed.
! Hemolytic-uremic
A four-year-old child presents with oliguria,
syndrome (HUS) due to E.
petechiae, and jaundice following an illness with
coli O157:H7
bloody diarrhea. Most likely diagnosis and cause?
! HBV immunoglobulin
Post-HBV exposure treatment.
! TB medications (INH, rifampin, pyrazinamide),
Classic causes of drug-
acetaminophen, and tetracycline
induced hepatitis.
! Biliary tract
A 40-year-old obese female with elevated alkaline phosphatase,
obstruction
elevated bilirubin, pruritus, dark urine, and clay-colored stools.
Hernia with highest risk of incarceration—indirect, direct, or ! Femoral hernia
femoral?
! Confirm the diagnosis of acute
A 50-year-old man with a history of alcohol pancreatitis with elevated amylase and
abuse presents with boring epigastric pain lipase. Make patient NPO and give IV
that radiates to the back and is relieved by fluids, O2, analgesia, and "tincture of
sitting forward. Management? time"

! TICS—Thalassemia, Iron deficiency, anemia of Chronic

Four causes of
disease, and Sideroblastic anemia
microcytic anemia.
! Fecal occult blood test and
An elderly male with hypochromic, microcytic sigmoidoscopy; suspect colorectal
anemia is asymptomatic. Diagnostic tests? cancer

! Sulfonamides, antimalarial drugs,

Precipitants of hemolytic crisis in patients with
fava beans
G6PD deficiency.
The most common inherited cause of ! Factor V Leiden mutation
hypercoagulability.
! Hereditary spherocytosis
The most common inherited hemolytic anemia.
! Osmotic fragility test
Diagnostic test for hereditary spherocytosis.
! Diamond-Blackfan anemia
Pure RBC aplasia.
Anemia associated with absent radii and thumbs, diffuse ! Fanconi's
hyperpigmentation, café-au-lait spots, microcephaly, and anemia
pancytopenia.
! Chloramphenicol, sulfonamides, radiation, HIV,
Medications and viruses chemotherapeutic agents, hepatitis, parvovirus B19,
that ? aplastic anemia. EBV

! Both have ? hematocrit and RBC mass, but

How to distinguish
polycythemia vera should have normal O2 saturation
polycythemia vera from 2°
and low erythropoietin levels
polycythemia.

! 79!
 Terms / Facts
! Pentad of TTP—"FAT RN":Fever, Anemia,
Thrombotic thrombocytopenic Thrombocytopenia, Renal dysfunction, Neurologic
purpura (TTP) pentad? abnormalities

! Anemia, thrombocytopenia, and acute renal failure

HUS triad?
! Emergent large-volume plasmapheresis, corticosteroids,
Treatment for
antiplatelet drugs
TTP.
Treatment for idiopathic ! Usually resolves spontaneously; may
thrombocytopenic purpura (ITP) in require IVIG and/or corticosteroids
children.
! Fibrin split products and D-dimer are
Which of the following are ? in DIC: fibrin
elevated; platelets, fibrinogen, and
split products, D-dimer, fibrinogen, platelets,
hematocrit are ?.
and hematocrit.
! Hemophilia A or B; consider
An eight-year-old boy presents with
desmopressin (for hemophilia A) or
hemarthrosis and ? PTT with normal PT
factor VIII or IX supplements
and bleeding time. Diagnosis? Treatment?
A 14-year-old girl presents with prolonged bleeding ! von Willebrand's disease;
after dental surgery and with menses, normal PT, treat with desmopressin,
normal or ? PTT, and ? bleeding time. Diagnosis? FFP, or cryoprecipitate
Treatment?
! Monoclonal gammopathy, Bence Jones
A 60-year-old African-American male
proteinuria, "punched-out" lesions on x-ray
presents with bone pain. Workup for
of the skull and long bones
multiple myeloma might reveal?
! Hodgkin's lymphoma
Reed-Sternberg cells
A 10-year-old boy presents with fever, weight loss, and night ! Non-Hodgkin's
sweats. Examination shows anterior mediastinal mass. Suspected lymphoma
diagnosis?
! Anemia of chronic
Microcytic anemia with ? serum iron, ? total iron-binding
disease
capacity (TIBC), and normal or ? ferritin.
Microcytic anemia with ? serum iron, ? ferritin, and ? ! Iron deficiency anemia
TIBC.
! Chronic
An 80-year-old man presents with fatigue, lymphadenopathy,
lymphocytic
splenomegaly, and isolated lymphocytosis. Suspected
leukemia (CLL)
diagnosis?
! Blast crisis (fever, bone pain,
A late, life-threatening complication of chronic
splenomegaly, pancytopenia)
myelogenous leukemia (CML).
! Acute myelogenous leukemia (AML)
Auer rods on blood smear.
! M3
AML subtype associated with DIC.
Electrolyte changes in tumor lysis ! ? Ca2+ , ? K? , ? phosphate, ? uric acid
syndrome.

! 80!
 Terms / Facts
! Retinoic acid
Treatment for AML M3.
A 50-year-old male presents with early satiety, splenomegaly, and ! CML
bleeding. Cytogenetics show t(9,22). Diagnosis?
! Intracellular inclusions seen in thalassemia, G6PD deficiency, and
Heinz
postsplenectomy
bodies?
! Glanzmann's
An autosomal-recessive disorder with a defect in the
thrombasthenia
GPIIbIIIa platelet receptor and ? platelet aggregation.
Virus associated with aplastic anemia in patients with sickle cell ! Parvovirus B19
anemia.
! O2, analgesia, hydration,
A 25-year-old African-American male with sickle cell
and, if severe,
anemia has sudden onset of bone pain. Management of
transfusion
pain crisis?
! Iron overload; use
A significant cause of morbidity in thalassemia
deferoxamine
patients. Treatment?
! Infection, cancer, and
The three most common causes of fever of
autoimmune disease
unknown origin (FUO).
! Fever, pharyngeal erythema, tonsillar
Four signs and symptoms of
exudate, lack of cough
streptococcal pharyngitis.
! Postinfectious
A nonsuppurative complication of streptococcal infection
glomerulonephritis
that is not altered by treatment of 1° infection.
! Encapsulated organisms--pneumococcus,
Asplenic patients are particularly meningococcus, Haemophilus influenzae,
susceptible to these organisms. Klebsiella

! 105
The number of bacterial culture on a clean-catch specimen to
bacteria/mL
diagnose a UTI.
! Pregnant women. Treat this group aggressively
Which healthy population is
because of potential complications
susceptible to UTIs?
A patient from California or Arizona presents with ! Coccidioidomycosis.
fever, malaise, cough, and night sweats. Diagnosis? Amphotericin B
Treatment?
! 1° syphilis
Nonpainful chancre.
A "blueberry muffin" rash is characteristic of what congenital ! Rubella
infection?
! Group B strep, E. coli, Listeria. Treat with
Meningitis in neonates. Causes?
gentamicin and ampicillin
Treatment?
! Pneumococcus, meningococcus, H. influenzae. Treat
Meningitis in infants.
with cefotaxime and vancomycin
Causes? Treatment?

! 81!
 Terms / Facts
! Check for ? ICP; look for papilledema
What should always be done prior to LP?
! Bacterial meningitis
CSF findings: ? Low glucose, PMN predominance
! Aseptic (viral)
CSF findings: ? Normal glucose, lymphocytic
meningitis
predominance
! Subarachnoid hemorrhage
CSF findings: ? Numerous RBCs in serial CSF
(SAH)
samples
! MS
CSF findings: ? ? gamma globulins
! Cutaneous anthrax. Treat
Initially presents with a pruritic papule with regional
with penicillin G or
lymphadenopathy and evolves into a black eschar after
ciprofloxacin
7-10 days. Treatment?
! Tabes dorsalis, general paresis, gummas, Argyll Robertson pupil,
Findings in 3°
aortitis, aortic root aneurysms
syphilis.
! Arthralgias, migratory polyarthropathies, Bell's palsy,
Characteristics of 2° Lyme
myocarditis
disease.
! Mycoplasma
Cold agglutinins.
! Candidal thrush. Workup should
A 24-year-old male presents with soft white
include an HIV test. Treat with
plaques on his tongue and the back of his
nystatin oral suspension
throat. Diagnosis? Workup? Treatment?
Begin Pneumocystis carinii pneumonia (PCP) ! ? 200 for PCP (with TMP); ? 50-100
prophylaxis in an HIV-positive patient at for MAI (with
what CD4 count? Mycobacterium avium- clarithromycin/azithromycin)
intracellulare (MAI) prophylaxis?
! Pregnancy, vesicoureteral reflux, anatomic anomalies,
Risk factors for
indwelling catheters, kidney stones
pyelonephritis.
! 7-10 days
Neutropenic nadir postchemotherapy.
! Lesion of 1° Lyme disease
Erythema migrans.
! Fever, heart murmur, Osler's nodes, splinter
Classic physical findings for
hemorrhages, Janeway lesions, Roth's spots
endocarditis.
! Parvovirus B19
Aplastic crisis in sickle cell disease.
! Taenia solium (cysticercosis)
Ring-enhancing brain lesion on CT with seizures
! Actinomyces israelii
Name the organism: ? Branching rods in oral infection.
! Haemophilus ducreyi
Name the organism: ? Painful chancroid.

! 82!
 Terms / Facts
! Pasteurella multocida
Name the organism: ? Dog or cat bite.
! Sporothrix schenckii
Name the organism: ? Gardener.
! Toxoplasma gondii
Name the organism: ? Pregnant women with pets.
! Neisseria meningitidis
Name the organism: ? Meningitis in adults.
! Streptococcus pneumoniae
Name the organism: ? Meningitis in elderly.
! Klebsiella
Name the organism: ? Alcoholic with pneumonia.
! Klebsiella
Name the organism: ? "Currant jelly" sputum.
! Pseudomonas
Name the organism: ? Infection in burn victims.
! Pseudomonas
Name the organism: ? Osteomyelitis from foot wound puncture.
! Salmonella
Name the organism: ? Osteomyelitis in a sickle cell patient.
A 55-year-old man who is a smoker and a heavy drinker presents
! Legionella
with a new cough and flulike symptoms. Gram stain shows no
pneumonia
organisms; silver stain of sputum shows gram-negative rods. What
is the diagnosis?
! Lyme disease,
A middle-aged man presents with acute-onset monoarticular
Ixodes tick,
joint pain and bilateral Bell's palsy. What is the likely
doxycycline
diagnosis, and how did he get it? Treatment?
! S. aureus or S.
A patient develops endocarditis three weeks after receiving a
epidermidis.
prosthetic heart valve. What organism is suspected?
! All-compartment fasciotomy
A patient presents with pain on passive movement,
for suspected compartment
pallor, poikilothermia, paresthesias, paralysis, and
syndrome
pulselessness. Treatment?
! Spinal
Back pain that is exacerbated by standing and walking and relieved
stenosis
with sitting and hyperflexion of the hips.
! MCP and PIP joints; DIP joints are
Joints in the hand affected in rheumatoid
spared
arthritis.
Joint pain and stiffness that worsen over the course of the day and ! Osteoarthritis
are relieved by rest.
! Osteogenesis
Genetic disorder associated with multiple fractures and
imperfecta
commonly mistaken for child abuse.
! Suspect ankylosing
Hip and back pain along with stiffness that improves
spondylitis. Check HLA-
with activity over the course of the day and worsens at
B27
rest. Diagnostic test?
Arthritis, conjunctivitis, and ! Reactive (Reiter's) arthritis. Associated with

! 83!
 Terms / Facts
urethritis in young men. Associated Campylobacter, Shigella, Salmonella,
organisms? Chlamydia, and Ureaplasma

! Gout. Needle-shaped, negatively

A 55-year-old man has sudden, excruciating
birefringent crystals are seen on joint
first MTP joint pain after a night of
fluid aspirate. Chronic treatment with
drinking red wine. Diagnosis, workup, and
allopurinol or probenecid
chronic treatment?
Rhomboid-shaped, positively birefringent crystals on joint fluid ! Pseudogout
aspirate.
An elderly female presents with pain and stiffness of the ! Polymyalgia
shoulders and hips; she cannot lift her arms above her head. rheumatica
Labs show anemia and ? ESR.
! Osgood-Schlatter
An active 13-year-old boy has anterior knee pain.
disease
Diagnosis?
! Distal radius (Colles' fracture)
Bone is fractured in fall on outstretched hand.
! Avascular necrosis
Complication of scaphoid fracture.
! Wrist drop, loss of thumb
Signs suggesting radial nerve damage with
abduction
humeral fracture.
! Duchenne muscular
A young child presents with proximal muscle weakness,
dystrophy
waddling gait, and pronounced calf muscles.
A first-born female who was born in breech ! Developmental dysplasia of the hip.
position is found to have asymmetric skin If severe, consider a Pavlik harness
folds on her newborn exam. Diagnosis? to maintain abduction
Treatment?
! Slipped capital femoral
An 11-year-old obese, African-American boy
epiphyses. AP and frog-leg
presents with sudden onset of limp. Diagnosis?
lateral view
Workup?
! Multiple myeloma
The most common 1° malignant tumor of bone.
! Cluster
Unilateral, severe periorbital headache with tearing and
headache
conjunctival erythema.
! ?-blockers, Ca2+ channel blockers, TCAs
Prophylactic treatment for migraine.
! Prolactinoma. Dopamine agonists (e.g.,
The most common pituitary tumor.
bromocriptine)
Treatment?
! Broca's aphasia. Frontal
A 55-year-old patient presents with acute "broken
lobe, left MCA
speech." What type of aphasia? What lobe and vascular
distribution
distribution?
! Trauma; the second most common is berry
The most common cause of
aneurysm
SAH.

! 84!
 Terms / Facts
! Subdural hematoma—bridging
A crescent-shaped hyperdensity on CT that does
veins torn
not cross the midline.
! Epidural hematoma. Middle
A history significant for initial altered mental
meningeal artery.
status with an intervening lucid interval.
Neurosurgical evacuation
Diagnosis? Most likely etiology? Treatment?
! Elevated ICP, RBCs, xanthochromia
CSF findings with SAH.
! Guillain-Barré (? protein in CSF with only a modest ?
Albuminocytologic
in cell count)
dissociation.
Cold water is flushed into a patient's ear, and the fast phase of the ! Normal
nystagmus is toward the opposite side. Normal or pathological?
! Lung, breast, skin (melanoma),
The most common 1° sources of metastases
kidney, GI tract
to the brain.
! Absence
May be seen in children who are accused of inattention in class
seizures
and confused with ADHD.
! Headache
The most frequent presentation of intracranial neoplasm.
! Infection, febrile seizures, trauma,
The most common cause of seizures in
idiopathic
children (2-10 years).
! Trauma, alcohol withdrawal,
The most common cause of seizures in young
brain tumor
adults (18-35 years).
! IV benzodiazepine
First-line medication for status epilepticus.
! Wernicke's encephalopathy due to a
Confusion, confabulation,
deficiency of thiamine
ophthalmoplegia, ataxia.
! Seventy percent if the stenosis is
What % lesion is an indication for carotid
symptomatic
endarterectomy?
! Alzheimer's and multi-infarct
The most common causes of dementia.
! ALS
Combined UMN and LMN disorder.
! Parkinson's disease
Rigidity and stiffness with resting tremor and masked facies.
! Levodopa/carbidopa
The mainstay of Parkinson's therapy.
! IVIG or plasmapheresis
Treatment for Guillain-Barré syndrome.
! Huntington's
Rigidity and stiffness that progress to choreiform movements,
disease
accompanied by moodiness and altered behavior.
A six-year-old girl presents with a port-wine ! Sturge-Weber syndrome. Treat
stain in the V2 distribution as well as with symptomatically. Possible focal

! 85!
 Terms / Facts
mental retardation, seizures, and cerebral resection of affected lobe
leptomeningeal angioma.
! Neurofibromatosis 1
Café-au-lait spots on skin.
! Klüver-Bucy syndrome
Hyperphagia, hypersexuality, hyperorality, and
(amygdala)
hyperdocility.
Administer to a symptomatic patient to diagnose myasthenia ! Edrophonium
gravis.
! Placental abruption and placenta previa
1° causes of third-trimester bleeding.
Classic ultrasound and gross ! Snowstorm on ultrasound. "Cluster-of-
appearance of complete hydatidiform grapes" appearance on gross examination
mole.
! 46,XX
Chromosomal pattern of a complete mole.
! Partial mole
Molar pregnancy containing fetal tissue.
! Continuous, painful vaginal bleeding
Symptoms of placental abruption.
! Self-limited, painless vaginal bleeding
Symptoms of placenta previa.
When should a vaginal exam be performed with suspected placenta ! Never
previa?
! Tetracycline, fluoroquinolones, aminoglycosides,
Antibiotics with teratogenic
sulfonamides
effects.
! Obstetric conjugate: between the sacral promontory and
Shortest AP diameter
the midpoint of the symphysis pubis
of the pelvis.
! Betamethasone or dexamethasone × 48
Medication given to accelerate fetal lung
hours
maturity.
! Uterine atony
The most common cause of postpartum hemorrhage.
Treatment for postpartum ! Uterine massage; if that fails, give oxytocin
hemorrhage.
! IV penicillin or
Typical antibiotics for group B streptococcus (GBS)
ampicillin
prophylaxis.
! Sheehan's syndrome (postpartum
A patient fails to lactate after an emergency C-
pituitary necrosis)
section with marked blood loss.
! Inevitable
Uterine bleeding at 18 weeks' gestation; no products expelled;
abortion
membranes ruptured; cervical os open.
! Threatened
Uterine bleeding at 18 weeks' gestation; no products expelled;
abortion
cervical os closed.
The first test to perform when a woman
! ?-hCG; the most common cause of
presents with amenorrhea.
! 86!
 Terms / Facts
amenorrhea is pregnancy

Term for heavy bleeding during and between menstrual ! Menometrorrhagia

periods.
! Asherman's
Cause of amenorrhea with normal prolactin, no response to
syndrome
estrogen-progesterone challenge, and a history of D&C.
! Weight loss and OCPs
Therapy for polycystic ovarian syndrome.
! Clomiphene citrate
Medication used to induce ovulation.
! Endometrial
Diagnostic step required in a postmenopausal woman who
biopsy
presents with vaginal bleeding.
! Stable, unruptured ectopic pregnancy of < 3.5
Indications for medical treatment of
cm at < 6 weeks' gestation
ectopic pregnancy.
! OCPs, danazol, GnRH agonists
Medical options for endometriosis.
! Chocolate cysts, powder burns
Laparoscopic findings in endometriosis.
! Ampulla of the oviduct
The most common location for an ectopic pregnancy.
! Ultrasound
How to diagnose and follow a leiomyoma.
! Regresses after menopause
Natural history of a leiomyoma.
! Trichomonas
A patient has ? vaginal discharge and petechial patches in the
vaginitis
upper vagina and cervix.
! Oral or topical metronidazole
Treatment for bacterial vaginosis.
! Intraductal papilloma
The most common cause of bloody nipple discharge.
! OCP and barrier contraception
Contraceptive methods that protect against PID.
! Endometrial or estrogen receptor-
Unopposed estrogen is contraindicated in
breast cancer
which cancers?
! Consider Fitz-Hugh-Curtis
A patient presents with recent PID with RUQ
syndrome
pain.
! Paget's
Breast malignancy presenting as itching, burning, and erosion of
disease
the nipple.
! CA-125 and transvaginal
Annual screening for women with a strong family
ultrasound
history of ovarian cancer.
! Kegel exercises, estrogen,
A 50-year-old woman leaks urine when laughing
pessaries for stress incontinence
or coughing. Nonsurgical options?

! 87!
 Terms / Facts
! Anticholinergics (oxybutynin) or ?-
A 30-year-old woman has unpredictable
adrenergics (metaproterenol) for urge
urine loss. Examination is normal.
incontinence.
Medical options?
! ? serum FSH
Lab values suggestive of menopause.
! Endometriosis
The most common cause of female infertility.
Two consecutive findings of atypical squamous cells of ! Colposcopy and
undetermined significance (ASCUS) on Pap smear. endocervical curettage
Follow-up evaluation?
! Lobular carcinoma in
Breast cancer type that ? the future risk of invasive
situ
carcinoma in both breasts.
Nontender abdominal mass associated with elevated VMA and ! Neuroblastoma
HVA.
The most common type of ! Esophageal atresia with distal TEF
tracheoesophageal fistula (TEF). (85%). Unable to pass NG tube
Diagnosis?
! Mild illness and/or low-grade fever, current antibiotic
Not contraindications to
therapy, and prematurity
vaccination.
! Ophthalmologic exam, CT, and MRI
Tests to rule out shaken baby syndrome.
! CF or Hirschsprung's disease
A neonate has meconium ileus.
! Duodenal atresia
Bilious emesis within hours after the first feeding.
! Correct metabolic abnormalities.
A two-month-old presents with nonbilious
Then correct pyloric stenosis with
projectile emesis. What are the appropriate
pyloromyotomy
steps in management?
! Selective IgA deficiency
The most common 1° immunodeficiency.
! Febrile seizures (roseola
An infant has a high fever and onset of rash as fever
infantum)
breaks. What is he at risk for?
! High-dose aspirin for inflammation and fever; IVIG to
Acute-phase treatment for
prevent coronary artery aneurysms
Kawasaki disease.
! Phototherapy (mild) or exchange
Treatment for mild and severe unconjugated
transfusion (severe)
hyperbilirubinemia.
! Reye's
Sudden onset of mental status changes, emesis, and liver
syndrome
dysfunction after taking aspirin.
! Suspect retinoblastoma
A child has loss of red light reflex. Diagnosis?
! HBV, DTaP, Hib, IPV, PCV
Vaccinations at a six-month well-child visit.

! 88!
 Terms / Facts
! Precocious puberty
Tanner stage 3 in a six-year-old female.
! RSV bronchiolitis
Infection of small airways with epidemics in winter and spring.
! Surfactant deficiency
Cause of neonatal RDS.
! Chronic
What is the immunodeficiency? ? A boy has chronic granulomatous
respiratory infections. Nitroblue tetrazolium test is +. disease

! Wiskott-Aldrich
What is the immunodeficiency? ? A child has eczema,
syndrome
thrombocytopenia, and high levels of IgA.
! Bruton's X-linked
What is the immunodeficiency? ? A four-month-old
agammaglobulinemia
boy has life-threatening Pseudomonas infection.
! Intussusception
A condition associated with red "currant-jelly" stools.
! Coarctation of the aorta
A congenital heart disease that cause 2° hypertension.
! Amoxicillin × 10 days
First-line treatment for otitis media.
! Parainfluenza virus type 1
The most common pathogen causing croup.
! Kwashiorkor (protein
A homeless child is small for his age and has peeling
malnutrition)
skin and a swollen belly.
! Lesch-Nyhan syndrome (purine salvage
Defect in an X-linked syndrome with
problem with
mental retardation,
! HGPRTase deficiency)
gout, self-mutilation, and choreoathetosis.
! Patent ductus arteriosus
A newborn female has continuous "machinery
(PDA)
murmur."
! SSRIs
First-line pharmacotherapy for depression.
! MAOIs
Antidepressants associated with hypertensive crisis.
! Patient on dopamine
Galactorrhea, impotence, menstrual dysfunction, and
antagonist
? libido.
! Conversion
A 17-year-old female has left arm paralysis after her boyfriend
disorder
dies in a car crash. No medical cause is found.
Name the defense mechanism: ? A mother who is angry at her ! Displacement
husband yells at her child.
Name the defense mechanism: ? A pedophile enters a ! Reaction formation
monastery.
Name the defense mechanism: ? A woman calmly describes a grisly ! Isolation
murder.
! 89!
 Terms / Facts
Name the defense mechanism: ? A hospitalized 10-year-old begins to ! Regression
wet his bed.
! Neuroleptic malignant
Life-threatening muscle rigidity, fever, and
syndrome
rhabdomyolysis.
Amenorrhea, bradycardia, and abnormal body image in a young ! Anorexia
female.
! Panic
A 35-year-old male has recurrent episodes of palpitations,
disorder
diaphoresis, and fear of going crazy.
! Agranulocytosis
The most serious side effect of clozapine.
! Schizophreniform disorder (diagnosis
A 21-year-old male has three months of
of schizophrenia requires ? 6 months of
social withdrawal, worsening grades,
symptoms)
flattened affect, and concrete thinking.
Key side effects of atypical ! Weight gain, type 2 DM, QT prolongation
antipsychotics.
! Acute dystonia (oculogyric crisis).
A young weight lifter receives IV haloperidol
Treat with benztropine or
and complains that his eyes are deviated
diphenhydramine
sideways. Diagnosis? Treatment?
Medication to avoid in patients with a history of alcohol withdrawal ! Neuroleptics
seizures.
! Conduct
A 13-year-old male has a history of theft, vandalism, and violence
disorder
toward family pets.
! Rett's
A five-month-old girl has ? head growth, truncal dyscoordination,
disorder
and ? social interaction.
! Acute mania. Start a
A patient hasn't slept for days, lost $20,000 gambling, is
mood stabilizer (e.g.,
agitated, and has pressured speech. Diagnosis?
lithium)
Treatment?
After a minor fender bender, a man wears a neck brace and ! Malingering
requests permanent disability.
! Factitious disorder
A nurse presents with severe hypoglycemia; blood
(Munchausen syndrome)
analysis reveals no elevation in C peptide.
! Substance
A patient continues to use cocaine after being in jail, losing his job,
abuse
and not paying child support.
! Phencyclidine hydrochloride (PCP)
A violent patient has vertical and
intoxication
horizontal nystagmus.
! Depersonalization
A woman who was abused as a child frequently feels
disorder
outside of or detached from her body.
! Frotteurism (a
A man has repeated, intense urges to rub his body against
paraphilia)
unsuspecting passengers on a bus.

! 90!
 Terms / Facts
! Tardive dyskinesia. ? or discontinue
A schizophrenic patient takes haloperidol for haloperidol and consider another
one year and develops uncontrollable tongue antipsychotic (e.g., risperidone,
movements. Diagnosis? Treatment? clozapine)

! Dissociative
A man unexpectedly flies across the country, takes a new name,
fugue
and has no memory of his prior life.
! Stasis, endothelial injury and hypercoagulability (Virchow's
Risk factors for
triad)
DVT.
! Pleural/serum protein > 0.5; pleural/serum LDH >
Criteria for exudative
0.6
effusion.
! Think of leaky capillaries. Malignancy, TB, bacterial or viral
Causes of
infection, pulmonary embolism with infarct, and pancreatitis
exudative effusion.
! Think of intact capillaries. CHF, liver or kidney disease,
Causes of transudative
and protein-losing enteropathy
effusion.
! Fatigue and impending
Normalizing PCO2 in a patient having an asthma
respiratory failure
exacerbation may indicate?
Dyspnea, lateral hilar lymphodenopathy on CXR, noncaseating ! Sarcoidosis
granulomas, increased ACE, and hypercalcemia.
! Obstructive pulmonary disease (e.g., asthma)
PFT showing ? FEV1/FVC.
! Diffuse interstitial pulmonary fibrosis.
Honeycomb pattern on CXR.
Supportive care. Steroids may help
Diagnosis? Treatment?
! Radiation
Treatment for SVC syndrome.
Treatment for mild, persistent ! Inhaled ?-agonists and inhaled corticosteroids
asthma.
! Hypoxia and hypocarbia
Acid-base disorder in pulmonary embolism.
! Squamous cell
Non-small cell lung cancer (NSCLC) associated with
carcinoma
hypercalcemia.
! Small cell lung cancer (SCLC)
Lung cancer associated with SIADH.
! SCLC
Lung cancer highly related to cigarette exposure.
! Spontaneous pneumothorax. Spontaneous
A tall white male presents with acute
regression. Supplemental O2 may be
shortness of breath. Diagnosis?
helpful
Treatment?
! Immediate needle thoracostomy
Treatment of tension pneumothorax.
Characteristics favoring ! Age > 45-50 years; lesions new or larger in
carcinoma in an isolated comparison to old films; absence of calcification or

! 91!
 Terms / Facts
pulmonary nodule. irregular calcification; size > 2 cm; irregular
margins

Hypoxemia and pulmonary edema with normal pulmonary capillary ! ARDS

wedge pressure.
! Mycobacterium tuberculosis
? risk of what infection with silicosis?
! Right-to-left shunt, hypoventilation, low inspired O2 tension,
Causes of
diffusion defect, V/Q mismatch
hypoxemia.
! Cardiomegaly, prominent pulmonary vessels, Kerley B lines,
Classic CXR findings "bat's-wing" appearance of hilar shadows, and perivascular
for pulmonary edema. and peribronchial cuffing

! Type I (distal)
Renal tubular acidosis (RTA) associated with abnormal H+
RTA
secretion and nephrolithiasis.
! Type II (proximal) RTA
RTA associated with abnormal HCO3 ? and rickets.
! Type IV (distal) RTA
RTA associated with aldosterone defect.
! Hypernatremia
Doughy skin.
! Cirrhosis, CHF, nephritic syndrome
Differential of hypervolemic hyponatremia.
! Hypocalcemia
Chvostek's and Trousseau's signs.
! Malignancy and hyperparathyroidism
The most common causes of hypercalcemia.
! Hypokalemia
T-wave flattening and U waves.
! Hyperkalemia
Peaked T waves and widened QRS.
! IV hydration and loop diuretics
First-line treatment for moderate
(furosemide)
hypercalcemia.
! Prerenal
Type of ARF in a patient with FeNa
A 49-year-old male presents with acute-onset flank pain and ! Nephrolithiasis
hematuria.
! Calcium oxalate
The most common type of nephrolithiasis.
! Cerebral berry
A 20-year-old man presents with a palpable flank mass and
aneurysms (AD
hematuria. Ultrasound shows bilateral enlarged kidneys with
PCKD)
cysts. Associated brain anomaly?
! Nephritic syndrome
Hematuria, hypertension, and oliguria.
! Nephrotic
Proteinuria, hypoalbuminemia, hyperlipidemia,
syndrome
hyperlipiduria, edema.

! 92!
 Terms / Facts
! Membranous glomerulonephritis
The most common form of nephritic syndrome.
! IgA nephropathy (Berger's disease)
The most common form of glomerulonephritis.
! Alport's syndrome
Glomerulonephritis with deafness.
! Wegener's granulomatosis and Goodpasture's
Glomerulonephritis with
syndrome
hemoptysis.
Presence of red cell casts in urine ! Glomerulonephritis/nephritic syndrome
sediment.
! Allergic interstitial nephritis
Eosinophils in urine sediment.
! Nephrotic
Waxy casts in urine sediment and Maltese crosses (seen with
syndrome
lipiduria).
! Uremic syndrome seen in patients
Drowsiness, asterixis, nausea, and a
with renal failure
pericardial friction rub.
! Wait, surgical resection, radiation
A 55-year-old man is diagnosed with
and/or androgen suppression
prostate cancer. Treatment options?
! DI
Low urine specific gravity in the presence of high serum osmolality.
! Fluid restriction, demeclocycline
Treatment of SIADH?
! Renal cell carcinoma (RCC)
Hematuria, flank pain, and palpable flank mass.
! Choriocarcinoma
Testicular cancer associated with ?-hCG, AFP.
! Seminoma—a type of germ cell tumor
The most common type of testicular cancer.
! Transitional cell carcinoma
The most common histology of bladder cancer.
! Central pontine
Complication of overly rapid correction of
myelinolysis
hyponatremia.
! Anion gap acidosis and 1° respiratory alkalosis
Salicylate ingestion ? in what type
due to central respiratory stimulation
of acid-base disorder?
! Respiratory alkalosis
Acid-base disturbance commonly seen in pregnant women.
! DM, SLE, and amyloidosis
Three systemic diseases ? nephrotic syndrome.
! RCC or other erythropoietin-
Elevated erythropoietin level, elevated
producing tumor; evaluate with CT
hematocrit, and normal O2 saturation
scan
suggest?
A 55-year-old man presents with irritative
! Likely BPH. Options include no
and obstructive urinary symptoms.
treatment, terazosin, finasteride, or
Treatment options?
! 93!
 Terms / Facts
surgical intervention (TURP)

Class of drugs that may cause syndrome of muscle ! Antipsychotics (neuroleptic

rigidity, hyperthermia, autonomic instability, and malignant syndrome)
extrapyramidal symptoms.
! Acute mania, immunosuppression, thin skin, osteoporosis,
Side effects of
easy bruising, myopathies
corticosteroids.
! Benzodiazepines
Treatment for DTs.
! N-acetylcysteine
Treatment for acetaminophen overdose.
! Naloxone
Treatment for opioid overdose.
! Flumazenil
Treatment for benzodiazepine overdose.
! Dantrolene or bromocriptine
Treatment for neuroleptic malignant syndrome.
! Nitroprusside
Treatment for malignant hypertension.
! Rate control, rhythm conversion, and anticoagulation
Treatment of AF.
! Rate control with carotid massasge or other
Treatment of supraventricular
vagal stimulation
tachycardia (SVT).
! INH, penicillamine, hydralazine, procainamide
Causes of drug-induced SLE.
! B12 deficiency
Macrocytic, megaloblastic anemia with neurologic symptoms.
Macrocytic, megaloblastic anemia without neurologic ! Folate deficiency
symptoms.
! Treat CO poisoning with
A burn patient presents with cherry-red flushed 100% O2 or with hyperbaric
skin and coma. SaO2 is normal, but O2 if severe poisoning or
carboxyhemoglobin is elevated. Treatment? pregnant

! Bladder rupture or urethral

Blood in the urethral meatus or high-riding
injury
prostate.
! Retrograde cystourethrogram
Test to rule out urethral injury.
! Widened mediastinum (> 8 cm), loss of aortic knob,
Radiographic evidence of
pleural cap, tracheal deviation to the right, depression
aortic disruption or
of left main stem bronchus
dissection.
! Free air under the diaphragm, extravasation of
Radiographic indications for
contrast, severe bowl distention, space-occupying
surgery in patients with acute
lesion (CT), mesenteric occlusion (angiography)
abdomen.
! Pseudomonas
The most common organism in burn-related infections.

! 94!
 Terms / Facts
! Parkland formula
Method of calculating fluid repletion in burn patients.
! 50 cc/hour
Acceptable urine output in a trauma patient.
! 30 cc/hour
Acceptable urine output in a stable patient.
! Third-degree heart block
Cannon "a" waves.
! Hypotension and bradycardia
Signs of neurogenic shock.
! Hypertension, bradycardia, and abnormal
Signs of ? ICP (Cushing's
respirations
triad).
! Hypovolemic
? CO, ? pulmonary capillary wedge pressure (PCWP), ?
shock
peripheral vascular resistance (PVR).
! Cardiogenic shock
? CO, ? PCWP, ? PVR.
! Fluids and antibiotics
Treatment of septic shock.
! Identify cause; pressors (e.g., dobutamine)
Treatment of cardiogenic shock.
! Identify cause; fluid and blood repletion
Treatment of hypovolemic shock.
! Diphenhydramine or epinephrine 1:1000
Treatment of anaphylactic shock.
! Continuous positive airway pressure
Supportive treatment for ARDS.
! A patient with chest trauma who was previously stable
Signs of air
suddenly dies
embolism.
! AP chest, AP/lateral C-spine, AP pelvis
Trauma series.
! HTN Endocrine Anemia Rheumatic heart disease Toxins Failure to take
Etiologies:
meds Arrhythmia Infection Lung (PE) Electrolytes Diet (excess Na+)
CHF
! Pleural effusio in the presence of pneumonia
Definition: parapneumonic effusion
! Air in the normally airless pleural space
Definition: pneumothorax
! Spontaneous Traumatic
Categories: pneumothorax (2)
! Iatrogenic
What is the usual cause of traumatic pneumothoraces?
After what procedures should ! Pneumothorax: Transthoracic needle aspiration
CXR always be obtained? Thoracentesis Central line placement
Why? (3)
! Ipsilateral chest pain, sudden onset Dyspnea
Clinical manifestations:
Cough
Pneumothorax (3)
Physical exam: ! Decreased breath sounds over affected side Hyperresonance
! 95!
 Terms / Facts
Pneumothorax (4) over the chest Decreased or absent tactile fremitus on affected
side Mediastinal shift toward side of pneumothorax

Tx: primary ! Small/asymptomatic:observation Large/symptomatic: O2

spontaneous administration, chest tube insertion
pneumothorax
! chest tube drainage
Tx: secondary spontaneous pneumothorax
! accumulation of air within the pleural space such that tissues
Definition: tension surrounding the opening into the pleural space act as valves,
pneumothorax allowing air to enter but not to escape

! mechanical ventilation w/ associated barotrauma

Etiologies: tension
CPR Trauma
pneumothorax (3)
! hypotension distended neck veins trachael shift away
Physical exam: tension from pneumothorax decreased breath diminished breath
pneumothorax (4) sounds

! medical emergency (1) chest compression with a large-bore

Tx: tension
needle (2) chest tube placement
pneumothorax (2)
! Inflammatory process involving the alveolar wall that can lead
Definition:
to irreversible fibrosis, distortion of lung architecture and
Interstitial Lung
impair gas exchange
Disease
! Dyspnea (first with exertion, then with rest) Cough
Clinical presentation:
(nonproductive) Fatigue
ILD
! Rales at base Digital clubbing Cyanosis/pulmonary HTN in
Physical exam: ILD
advanced disease
(3)
! CXR High resolution CT PFTs Bronchoalveolar lavage Tissue Bx
Dx: ILD
Serologies
(6)
! erythema nodusum lupus pernio
Clinical manifestion (skin): sarcoidosis (2)
! Uveitis (anterior)
Clinical manifestations (eyes): sarcoidosis
! arrhythmias heart block sudden
Clinical manifestations (cardiac): sarcoidosis
death
(3)
! arthalgias bone lesions
Clinical manifestations (MSK): sarcoidosis (2)
! Cardiac disease
What is the most common cause of death with sarcoidosis?
! CXR - bilateral hilar lymphadenopathy ACE levels Lung biopsy
Dx: sarcoidosis
PFTs
(4)
! systemic corticosteroids methotrexate for refractory disease
Tx: sarcoidosis

! 96!
 Terms / Facts
! young male smoker
What is the typical patient presenting with histiocytosis X?
! Sarcoidosis Iatrogenic Environmental/occupational exposure Collagen
Etiologies:
vascular disease Hypersensitivity disease Alveolar filling disease
ILD (6)
! Exertional dyspnea Cough w/ sputum
Clinical presentation: asbestosis (2)
Clinical presentation: hypersensitivity pneumonitis ! Fever Chills Cough Dyspnea
(4)
! removal of offending agent glucocorticoids
Tx: hypersensitivity pneumonitis (2)
! acute hypoxic febrile illness
Clinical presentation: eosinophilic pneumonia
! steroids
Tx: eosinophilic pneumonia
! DAH + RPGN
Clinical presentation: goodpasture syndrome
! plasmapheresis cyclophosphamide corticosteroids
Tx: goodpasture syndrome (3)
! lung lavage GM-CSF
Tx: pulmonary alveolar proteinosis (2)
! supplemental O2 corticosteroids w or w/o
Tx: idiopathic pulmonary
cyclophosphamide lung transplantation
fibrosis (3)
! inflammatory lung disease w/ similar clinical and
Definition: cryptogenic
radiographic features to infectious pneumonia
organizing pneumonitis
! cough dyspnea flu-like
Clinical manifestations: cryptogenic organizing
symptoms
pneumonitis
! steroids - relapses common after cessation
Tx: cryptogenic organizing pneumonitis
! Acute onset (< 24hr) Bilateral patchy airspace disease Noncsardiogenic
Criteria:
pulmonary edema (PCWP < 18) Severe hypoxemia (PaO2/FiO2 ≤ 200)
ARDS
! Hypoxemic respiratory failure
What are the two major types of acute
Hypercarbic (ventilatory)
respiratory failure?
! V/Q mismatch
What are the major pathophysiologic mechanism of
Intrapulmonary shunting
hypoxemic respiratory failure? (2)
! Little or no ventilation in perfused areas (due to collapsed or
What is
fluid-filled alveoli); venous blood is shunted into the arterial
intrapulomonary
circulation w/o being oxygenated
shunting?
! V/Q mismatch responsive to O2 Shunt -
Hypoxia due to what cause is responsive to
not responsive
O2? And not?
! dyspnea cough +/-
Clinical presentation: respiratory failure (2)
Physical exam: ! inability to speak in complete sentences tachypnea
! 97!
 Terms / Facts
respiratory failure (5) tachycardia cyanosis impaired mentation

! Vasodilation of cerebral vessels (with increased

What is the effect of severe
intracranial pressure and papilledema, headache,
hypercapnia on cerebral
impaired consciousness)
vasculature?
! PaCO2
What parameter is used to monitor ventilation?
! O2 saturation PaO2
What parameters are used to monitor oxygenation? (2)
! Increase FIO2 Increase PEEP Extend inspiratory
What techniques are used to
time fraction Decrease O2 requirements (work of
improve tissue oxygenation?
breathing, fever, agitation)
(4)
! BIPAP/CPAP
What are the forms of noninvasive positive pressure ventilation?
! Hypoventilation
What is the primary indication for BIPAP use?
!
Provide an algorithm for evaluating a patient with hypoexemia.
! ABG CXR or chest CT CBC and CMP
Dx: respiratory failure (3)
! Treat underlying disease Provide supplemental O2 if patient is
Tx: respiratory hypoxemic NPPV or intubation w/ mechanical ventilation if
failure (3) condition worsens

! Only for conscious patients with possible impending

What patients are respiratory failure. If patient cannot breathe on his own,
candidates for NPPV? intubate!!!

! O2 can decrease respiratory drive

Why are high concentrations of supplemental
by decreasing hypoxia, worsening
O2 contraindicated in hypercarbic (e.g. COPD)
hypercapnia
patients?
! ↑ intrapulmonary shunt → hypoxemia ↑ dead space
Pathophysiology: ARDS
fraction ↓ compliance
(3)
! Sepsis (most common) Pneumonia Aspiration of gastric contents
Etiologies: Severe trauma/fractures Acute pancreatitis Cardiopulmonary bypass
ARDS (8) Intracranial HTN Drug overdose

! Dyspnea Tachypnea Tachycardia Unresponsive to

Clinical presentation: ARDS
O2
(4)
! CXR - diffuse bilateral pulmonary infiltrates ABG Pulmonary artery
Dx: ARDS
catheter Bronchoscopy w/ BAL
(4)
! Oxygenation (> 90%) Mechanical ventilation w/ PEEP Fluid
Tx: ARDS
management Treat underlying disease
(4)
Complications: ! permanent lung injury ventilator induced lung injury line

! 98!
 Terms / Facts
ARDS (4) associated infections renal failure

! PA mean pressure > 25 mm Hg at rest or 30 mm Hg w/

Definition: pulmonary
exertion
HTN
! Pulmonary arterial HTN Left heart disease Lung
Classification: disease/chronic hypoxemia Chronic thrombotic/embolic disease
pulmonary HTN (5) Miscellaneous (sarcoid, histiocytosis X, lymphangiomatosis)

! Dyspnea Exertional syncope (hypoxia, decreaed CO)

Clinical manifestations:
Exertional chest pain (RV ischemia) RHF sx
pulmonary HTN (4)
! prominent P2 R-sided S4 RV heave
Physical exam: pulmonary HTN (3)
! EKG PFTs ABG Echo Cardiac cath
Dx: pulmonary HTN (5)
! prevent and reverse vasoactive substance imbalance and vascular
Tx: pulmonary remodeling (O2, vasodilators, anticoags,etc) prevent RV failure
HTN (2) (diuretics, digoxin)

! pulmonary HTN in the absence of diseases of the

Definition: primary pulmonary
heart or lung
HTN
! pulmonary vasodilators (IV prostacycline, CCBs, bosentan,
Tx: primary
etc.) Anticogulation w/ warfarin lung transplantation
pulmonary HTN (3)
! RVH w/ eventual RV failure resulting from pulmonary HTN
Definition: cor
2/2 pulmonary disease
pulmonale
! COPD (most common) other lung diseases (PE, ILD, asthma,
Etiologies: cor
CF, etc.)
pulmonale
! Decrease in exercise tolerance Cyanosis and digital
Clinical manifestations: cor
clubbing s/s RHF parasternal lift polycythemia
pulmonale (5)
! CXR (enlargement of the RA, RV and pulmonary arteries)
Dx: cor pulmonale
EKG Echo
(3)
! Treat underlying pulmonary disorder diuretic therapy O2 therapy
Tx: cor
long term Digoxin if coexistent LV failure
pulmonale (4)
! Polydipsia Polyuria Growth/mental
Clinical presentation: Barrter
retardation
syndrome (3)
! Progression to fulminant
In a patient with viral hepatitis, what does ↑ PT and ↓
hepatitis
transaminases reflect?
! Prothrombin time
What is the single most important test to assess function of
(PT)
the liver?
How can pregnancy ! Accumulation of fluid in the carpal tunnel can cause CTS,

! 99!
 Terms / Facts
cause CTS? especially in the third trimester

! Synovial tendon hyperplasia causes

What is the mechanism by which acromegaly
median nerve compression
causes carpal tunnel syndrome?
! Decreased protein and oxalate Decreased
What are the dietary
sodium intake Increased fluid intake
recommendatiosn for patients with
Decreased dietary calcium
renal calculi? (4)
! Renal artery
A systolic-diastolic abdominal bruit is strongly suggestive of
stenosis
what disease?
! Punch biopsy
Dx: squamous cell carcinoma of the skin
! SHIT can lead to SCC Sun exposure H/o of burns
Risk factors: squamous cell
Immunosuppression Tar derivatives
carcinoma of the skin (4)
! Hyperuricemic effect resulting from hypovolemia-associated
How do diuretics
enhancement of uric acid absorption in the PCT
promote gout attacks?
! Diarrhea Dermatitis Dementia
Clinical presentation: pellagra (3)
! Serial chest x-rays to look for
What kind of surveillance is necessary in patients
aortic aneurysms
with giant-cell arteritis? Why?
! Fluid protein/serum protein > 0.5 Fluid LDH/serum LDH > 0.6 Fluid
Light's
LDH > 2/3 ULN serum LDH
criteria (3)
! Determine whether a pleural effusion is transudative or
What are Light's criteria
exudative
used for?
! Tense bullae Urticarial plaques Pruritus
Physical exam: bullous pemphigoid (3)
! Hyperviscosity (HA, dizziness, tinnitus, blurred vision)
Clinical manifestations: Thrombosis (DVT, MI, stroke, budd-chiari, amaurosis
polycythemia vera (4) fugax) Pruritus Bleeding (epistaxis, GI bleed)

! plethora splenomegaly HTN engorged retinal

Physical exam: polycythemia vera
veins
(4)
! phlebotomy low-dose ASA hydroxyurea supportive:
Tx: polycythemia
allopurinol (gout), H2-blockers (pruritus)
vera (4)
! CBC Epo level BM bx
Dx: polycythemia vera (3)
! Hypercellular w/ megakaryocytic
What will a BM bx in polycythemia vera
hyperplasia
show?
! ↓ EPO
What will EPO levels show in polycythemia vera?
Definition: ! ↑ in RBC mass +/- granulocytes and platelets in the absence

! 100!
 Terms / Facts
polycythemia vera of physiologic stimulus

! CBC (thrombocytopenia) Peripheral smear (w/ schistocytes)

Dx: TTP-HUS (2)
! Plasmapheresis Corticosteroids FFP if delay to plasma exchange
Tx: TTP (3)
! Hypertonic saline (3%) because equiilbration
What kind of saline solution
has not occurred yet and thus the risk of CPM is
should be used to correct acute
low; correction can happen more rapidly
hyponatremia? Why?
! Swelling of the lower leg Skin changes (thin,
Clinical manifestations: chronic
scaly, atrophic) Venous ulcers
venous insufficiency (3)
! Prior h/o DVT
What is the most common cause of chronic venous insufficiency?
! Incompetence of venous valves in the deep venous
Pathophysiology: chronic
system→ ambulatory HTN → edema
venous insufficiency
! Leg elevation Avoiding long periods of sitting or
Tx: chronic venous
standing Compression stockings
insufficiency (3)
! Memory loss Apraxia Aphasia Personality changes
Clinical presentation:
and impaired judgment (later)
Alzheimer's Disease (4)
! acinar injury via direct or indirect toxicity → release or
Pathophysiology: impaired secretion of enzymes → autodigestion → fat necrosis
pancreatitis → profound acute inflammatory response

! Gallstones (40%) Alcohol

What are the most common etiologies of
(30%)
pancreatitis? (2)
! Epigastric abdominal pain, constant, radiating to back,
Clinical manifestations:
some relief w/ leaning forward N/V
pancreatitis (3)
! acute cholecystitis perforated viscus intestinal obstruction
Ddx:
mesenteric ischemia IMI AAA ruptured ectopic pregnancy
pancreatitis (7)
! abdominal tenderness and guarding fever tachycardia
Physical exam:
hypotension ↓ bowel sounds
pancreatitis (5)
! serum amylase and lipase levels Abd CT (test of choice)
Dx: pancreatitis (2)
! Fluid resuscitation Nutrition (enteral vs TPN) Analgesia (IV
Tx:
meperidine/morphine) Prophylatic systemic abx (imipenem)
pancreatitis (4)
! ARDS Pseudocyst Necrosis (sterile vs. infected) Acute
Complications:
fluid collection Infection
pancreatitis (5)
! Glucose > 200 mg/dl Age > 55 yrs LDH > 350 AST >
Ranson's criteria
250 WBC > 16000
(admission) (5)

! 101!
 Terms / Facts
! C alcium < 8 mg/dl ↓ H ct > 10% Pa O 2 8 mg/dl BUN increase
Ranson's criteria
> 8 mg/dl B ase deficit > 4 mg/dl Fluid S equestration > 6 L
(48 hours) (6)
! Alcoholism (80%) Hereditary Autoimmune
Etiologies: chronic pancreatitis (3)
! Epigastric pain N/V Steatorrhea and wt loss
Clinical manifestation: chronic
over time
pancreatitis (3)
! CT scan - calcifications ERCP (gold standard but not done
Dx: chronic pancreatitis
much)
(2)
! low fat diet enzyme replacement
Tx: chronic pancreatitis (2)
! acute onset polyarticular and symmetric
Clinical presentation (adult):
arthritis
parvovirus B19
! Acute onset Lack of elevated
What features distinguish viral arthritis inflammatory markers Resolution within 2
from other causes of arthritis? (3) months

! Antibodies in the patient's plasma react

Explain the mechanism of a febrile
with donor leukocytes; washing the
transfusion reaction. What procedure can
cells depletes leukocytes
reduce risk of this from happening?
! Endotracheal intubation Withdrawal of anticholinesterases for
Tx: myasthenia
several days
crisis
! Oral metronidazole
Tx: amebic abscess
! RUQ pain Diarrhea Leukocytosis Elevated
Clinical presentation: amebic abscess
ALP
(4)
! None; observation
Tx: first-degree heart block
! Vasospasm with symptomatic
What is the most important cause of morbidity
ischemia and infarction
and mortality in subarachnoid hemorrhage?
! Headache Nausea Dizziness Exposure
Clinical presentation: carbon monoxide
to CO
poisoning (4)
! Thunderclap headache Transient LOC N/V
Clinical presentation: subarachnoid
Meningismus
hemorrhage (4)
! Ruptured berry aneurysm (most common) Trauma
Etiologies: subarachnoid
AV malformation
hemorrhage (3)
! Non-contrast CT LP if CT is unrevealing and clinical
Dx: subarachnoid suspicion is high Cerebral angiogram (once SAH is
hemorrhage (3) diagnosed)

Complications: SAH ! Vasospasm (50%) Rerupture Hydrocephalus Seizures

! 102!
 Terms / Facts
(5) SIADH

! Reverse anticoagulation HTN control Surgery (berry aneurysm) Nimodipine

Tx: SAH
(for vasospasm) Phenytoin (seziure prophylaxis)
(5)
! Plain film x-ray
What is the initial test of choice for back pain?
! Sore throat and
How does the presentation of CMV mononucleosis lymphadenopathy are
differ from that of EBV mononucleosis? uncommon

! Fever Sore throat Malaise Myalgias

Clinical manifestations: infectious
Weakness
mononucleosis (5)
! Lymphadenopathy Pharyngeal erythema/exudate
Physical exam: infectious
Splenomegaly Maculopapular rash Hepatomegaly
mononucleosis (5)
! Monospot test Peripheral blood smear (atypical
Dx: infectious
lymphocytes) Throat culture (r/o strep pharyngitis)
mononucleosis (3)
! Enterobius vermicularis (roundworm)
What is the causative agent in enterobiasis?
! Fecal oral (usually self transmission in children)
Transmission: enterobiasis
! Perianal pruritus, worse at night
Clinical presentation: enterobiasis
! Tape test; see eggs on tape after it is placed near anus
Dx: enterobiasis
! Albendazole/mebendazole; pyrantel pamoate is alternative
Tx: enterobiasis
! Enterobiasis
What is the most common helminthic infection in the US?
! Firm, flesh color, dome shaped umbilicated
Describe the lesions of molluscum
papules
contagiosum
! Cellular immunodeficiency (AIDS)
What conditions predispose to
Corticosteroids Chemotherapy
molloscum contagiosum? (3)
! Marked increase in leukocytes due to a severe infection or
Definition: leukemoid
inflammation
reaction
! Flacid paraparesis and absent reflexes (acute) vs. spastic
Clinical manifestations: paraparesis and hyperactive reflexes (chronic) Sensory loss
spinal cord compression below lesion Bilateral prominent Babinski signs Posterior
(4) column dysfunction in legs

! STAT MRI
Dx: spinal cord compression
! Nerve roots (LMN) and
What is the localization of cauda equina
Unilateral
syndrome?

! 103!
 Terms / Facts
! Severe, radicular > back
Describe the pain in cauda equina syndrome
What is the pattern of sensory loss in cauda equina ! Assymetric saddle/leg
syndrome?
! Marked asymmetric
What is the pattern of motor dysfunction in cauda
weakness
equina syndrome?
! Loss of rectal tone Urinary
What happens to bowel/bladder function in cauda
incontinence
equina syndrome? (2)
! Redistribution of coronary blood flow to 'non-diseased' segments
What is
induced by pharmacological vasodilation (dipyridamole)
coronary steal?
! In the night (midnight to 8
When do episodes of variant angina occur most
am)
frequently?
! transient ST elevations on EKG
EKG findings: variant angina
! CCBs/nitrates avoidance of triggers
Tx: variant angina (2)
! Cholecystectomy is indicated for all patients with
Tx: symptomatic
symptomatic gallstones
cholelithiasis
! Joint pain (often monoarticular) that worsens with activity and
Clinical improves with rest Stiffness in the morning or after a period of
presentation: inactivity Limited range of movement Lack of systemic
osteoarthritis (4) symptoms

! Plain film x-ray

Dx: osteoarthritis
! Joint space narrowing Osteophytes Subchondral
Radiographic findings:
sclerosis Subchondral cysts
osteoarthritis (4)
! Lifestyle changes Acetaminophen/NSAIDs Intrarticular injections
Tx: osteoarthritis
(steroids) Surgery for serious debility
(4)
! Respiratory depression Hypotension Decreased
Clinical presentation: opioid
bowel sounds Miosis (sometimes)
intoxication (4)
! hypersomnolence fatigue
Clincial manifestations: obesity hypoventilation
exertional SOB
syndrome (3)
! Extreme obesity Thick neck
Physical exam: obesity hypoventilation
Hypoventilation
syndrome (3)
! hypercapnia hypoxemia respiratory
ABG findings: obesity hypoventilation
acidosis
syndrome (3)
! weight loss ventilator support O2 therapy
Tx: obesity hypoventilation
progestins
syndrome (4)

! 104!
 Terms / Facts
! Pap smears q6 mos until 3 negative tests obtained, then
Surveillance: women
resume age appropriate screening (annually)
treated for CIN II/III
! unilateral, severe eye pain redness dilated
Clinical presentation: acute angle
pupil w/ poor light response
closure glaucoma (3)
! Verrucous lesions (papulopustular, then
Describe the cutaneous lesions progressively crusted, warty and violaceous)
of blastomycosis. (2) Ulcerative

! Polyarthralgia Tenosynovitis Painless

Clinical presentation: disseminated
vesiculopustular skin lesions
gonococcal infection (3)
! Abnormalities in dopaminergic
What neurotransmitter is implicated in
transmission; dopamine agonists used
restless leg syndrome?
! Tremor that is increased at the end of goal-
Clinical presentation: essential
directed activities
tremor
! propranolol
Tx: essential tremors
! Sharply localized pain over the anteromedial part of the
Clinical presentation:
tibial plateau just below the joint line of the knee
anserine bursitis
! Well defined area of tenderness over the medial tibial plateau
Physical exam: just below the joint line Valgus stress test does not aggravate
anserine bursitis (2) the pain

! Corticosteroid injections into the bursa

Tx: anserine bursitis
! Conjugated (direct) hyperbilirubinemia; only the
Bilirubin in the urine is
conjugated bili is water soluble and unbound to albumin,
indicative of what
and so it is filtered in the urine
condition? Why?
! Pulmonary infarction
What causes the pleuritic pain associated with PE?
! GI losses (vomiting, diarrhea) Renal losses
Etiologies: hypovolemic
(diuretics)
hyponatremia (2)
! Aldosterone
What is the primary hormone that regulates total body sodium?
What is the primary hormone that regulates total body sodium ! ADH
concentration?
! excess of water relative to sodium; almost always due
Pathophysiology:
to ↑ ADH
hyponatremia
! Hypovolemic Euvolemic
What are the three classes of hypotonic
Hypervolemic
hyponatremia?
Etiologies: euvolemic ! SIADH Glucocorticoid deficiency Hypothyroidism
hypotonic hyponatremia (5) Psychogenic polydipsia Low solute (beer potomania,

! 105!
 Terms / Facts
tea&toast)

! CHF Cirrhosis Nephrotic syndrome

Etiologies: hypervolemic hypotonic
Advanced renal failure
hyponatremia (4)
! volume repletion w/ normal saline
Tx: hypovolemic hyponatremia
! volume restrict treat underlying cause hypertonic saline (if sx or
Tx: SIADH
restriction doesn't help) conivaptan if refractory SIADH
(4)
! free water restrict aquaresis (conivaptan)
Tx: hypervolemic hyponatremia (2)
! Measure plasma osmolality → determine tonicity → for
Workup:
hypotonic determine volume status → measure U osm
hyponatremia
! Urinalysis Serum
What labs should be ordered on all patients with
creatinien
suspected BPH? (2)
! SAAG > 1.1
What serum ascites albumin gradient level indicates that portal
g/dl
hypertension is the cause of ascites?
! p-ANCA
What antibody is positive in ulcerative colitis?
What is the initial diagnostic procedure in patients < 50 ! Anoscopy/proctoscopy
y/o who present with BRBPR?
! Pruritic, elevated, serpiginous lesions in the skin;
Clinical presentation:
infection often acquired through contact w/ sand
cuteaneous larva migrans
! Pain Pulselessness Paresthesia Poikilothermia
What are the 5 P's of embolic
Pallor
occlusion?
! IV heparin (immediately) Surgical embolectomy or intra-
Tx: acute limb
arterial/mechanical embolectomy
ischemia (2)
! Peripheral
What is a common side effect of the dihydropyridine Ca-channel
edema
antagonists?
! Proximal deep leg veins (iliac, femoral and
What is the most common source of
popliteal veins)
pulmonary emboli?
! Initial thyrotoxicosis due to destruction
What is the initial effect of radioactive
of follicular cells
iodine on the thyroid?
! Form of acute cholecystitis that arises due to secondary
Definition:
infection of the gallbladder wall with gas-forming
emphysematous
bacteria
cholecystitis
! RUQ pain Nausea Vomiting Low grade fever
Clinical presentation:
Crepitus in abdominal wall adjacent to GB
emphysematous cholecystitis (5)
Radiographic findings: emphysematous ! Air fluid levels in GB by plain film US w/

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cholecystitis (2) curvilinear gas in GB

! stone impaction in cystic duct → inflammation behind

Pathogenesis: acute obstruction → GB swelling → secondary infection of
calculous cholecystitis biliary fluid (50%)

! Mucosal GB calcification GB
What are the indications for asymptomatic
polyps > 10 mm Native American
patients with cholelithiasis to receive
Stone > 3 cm
cholecystectomy? (4)
! When a GB stone erodes through the GB into the
Definition: cholecystoenteric
bowel
fistula
! SBO due to stone in intestine that passed through fistula
Definition: gallstone ileus
! RUQ/epigastric pain N/V Fever +/- radiation to R
Clinical manifestations:
shoulder/back
cholecystitis (4)
! RUQ tenderness Murphy's sign
Physical exam: cholecystitis (2)
! RUQ U/S HIDA scan (most sensitive)
Dx: cholecystitis (2)
Tx: cholecystitis ! NPO IV fluids Abx (zosyn, ceftriaxone, or FQ) Cholecystectomy
(4)
! Gallstone lodged in bile duct
Definition: choledocholithiasis
! Asymptomatic (50%) RUQ/epigastric pain due to
Clinical manifestations:
obstruction of bile flow
choledocholithiasis
! ↑ bilirubin ↑ ALP
Lab findings: choledocholithiasis (2)
! Passage of the
What does a spike in amlyase or ALT in the context of
stone
choledocholithiasis indicate?
! ERCP & papillotomy w/ stone extraction CCY w/in 6
Tx: choledocholithiasis
weeks
(2)
Complications: choledocholithiasis ! cholangitis cholecystitis pancreatitis strictures
(4)
! Weak urinary stream Urgency Frequency Sensation of
Clinical presentation:
incomplete voiding
BPH (4)
! Placement of a Foley
What is the most important initial step in patients who
catheter
present with acute renal failure?
! FEV1 measurement with and
What diagnostic test is most useful in
without a bronchodilator
distinguishing asthma from COPD?
! 10 years before the age the
When should screening for CRC begin in high risk
relative was diagnosed
patients (e.g. with first degree relative w/ CRC)?

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! Ring-shaped scaly patches with central clearing and
Clinical manifestation: tinea
distinct borders
corporis
! 2% antifungal lotions (e.g. terbinafine) or griseofulvin for extensive
Tx: tinea
disease
corporis
! Binding of amyloid fibrils to the liver can inhibit
Account for the increased
the synthesis of coagulation factors, resulting in
bruisability of patients with
increased bruisability
amyloidosis.
! Lumbosacral strain
What is the most common cause of back pain?
! L. monocytogenes Yersinia
What bacterial infections are patients with
enterolitica V. vulnificus
hemochromatosis more susceptible to? (3)
! Back pain that radiates to buttoms and thigh Worse
Clincal presentation: lumbar during walking and lumbar extension Alleviated by
spinal stenosis (3) flexion

! Fanconi anemia
What is the most common congenital cause of aplastic anemia?
! Apalstic anemia and progressive bone
Clinical manifestations (bone marrow):
marrow failure
Fanconi anemia
! hypopigmented/hyperpigmented areas cafe au lait
Clinical manifestations (skin):
spots large freckles
Fanconi anemia (3)
! Short stature Microcephaly Abnormal
Describe the appearance of patients with
thumbs Hypogonadism
Fanconi anemia (4)
! Strabismus Low-set ears
What are the eye/ear abnormalities that patients
Middle ear abnormalities
with Fanconi anemia present with? (3)
! 3-7 days s/p anterior wall
When is the peak incidene of ventricular free wall
MI
rupture s/p MI?
! Acute decompensation PEA 2/2
Complications: ventricular free wall
tamponade
rupture (2)
! fever sore throat dysphagia headache
Clinical manifestations: tonsillitis (4)
! swollen, hyperemic red tonsils +/- exudate unilateral cervical
Physical exam:
lymphadenopathy
tonsillitis (2)
! acute bacterial infection next to the tonsils and
Definition: peritonsillar
pharynx
abscess
! Acute tonsillitis
What disease precudes peritonsillar abscess?
! Incision and drainage IV abx
Tx: peritonsillar abscess (2)

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! Muffled voice Fever Chills Sore
Clinical manifestations: peritonsillar abscess
throat
(4)
! uvula deviation prominent unilateral
Physical exam: peritonsillar
lymphadenopathy
abscess (2)
Massive doses od NSAIDs can cause what problem ! Acute erosive gastritis
acutely?
! Acute onset severe eye pain Blurred
Clincial manifestations: acute angle
vision Nausea Vomiting
closure glaucoma (4)
! Arises when the peripheral iris occludes the anterior
Mechanism: acute angle chamber angle, blocking aqueous outflow and causing a
closure glaucoma sudden increase in IOP

! intravenous acetazolamide laser peripheral iridotomy

Tx: acute angle closure
(definitive)
glaucoma (2)
! red eye w/ steamy cornea moderately dialted pupil
Physical exam: acute angle
that is not reactive to light
closure glaucoma (2)
What vaccinations should patietns with chronic hepatitis C receive? ! Hep A Hep B
(2)
! ribavirin + interferon-alfa
Tx: chronic hepatitis C
! Esophageal varices by
What vascular problem should all cirrhotic patients be
endoscopy
screened for? How?
! Beta
What does primary prophylaxis for esophageal varices 2/2 cirrhosis
blockers
consist of?
! Papillary thyroid cancer
What is the most common thyroid cancer?
! Head/neck irradiation during childhood Positive family
Risk factors: thyroid
history Female sex
cancer (3)
! Digitalis toxicity Increased vagal tone Inferior
Etiologies: Wenkebach heart
wall MI
block (3)
! Extreme hyperglycemia w/o ketoacidosis
Definition: hyperglycemic hyperosmolar
+ hyperosmolarity + AMS
non-ketotic syndrome
! Hyperglycemia → osmotic diuresis → vol
Mechanism: hyperglycemic
depletion → pre-renal azotemia → ↑ glc, etc.
hyperosmolar non-ketotic syndrom
! Volume depletion AMS
Clinical manifestations: HHNK syndrome (2)
! ↑ serum glc, ↑ serum osmolality, ↑ BUN/Cr
Lab findings: HHNK syndrome (3)
! aggresive hydration (initially NS then 1/2 NS) Insulin
Tx: HHNK syndrome (2)

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! Pulmonary
A wedge-shaped pulmonary infarct is virtually pathognomonic
embolism
for what problem?
! Right atrial pressure > 10 Pulmonary
What are the criteria for a massive
artery systolic pressure > 40
pulmonary embolism? (2)
! Hypotension PEA
Clinical manifestations: massive PE (2)
! ↑ JVP R-sided S 3 Graham Steel murmur
Physical exam: massive PE (3)
! Infections cause systemic release of insulin
Explain why infections are counterregulatory hormones like catecholatimes and
precipitants for DKA. cortisol

! 8-10 years after diagnosis;

When does surveillance for CRC begin in a patient
yearly colonoscopy
with IBD? What does it consist of?
! folate (all patients) splenectomy for moderate/severe
Tx: hereditary spherocytosis
HS
(2)
! infection ofbone due to hematogenous seeding or direct spread
Definition:
from contiguous focus
osteomyelitis
! S.
What bacteria are most commonly responsible for osteomyelitis by
aureus
hematogenous spread?
! S. aureus S.
What bacteria are most commonly responsible for osteomyelitis
epidermidis
by spread from a contiguous focus? (2)
! fever chills malaise focal pain
Clinical manifestations: osteomyelitis (4)
Physical exam: vertebral ! tenderness to gentle percussion over the spine
osteomyelitis
! Spine
What is the most common site of osteomyelitis in IV drug users?
! Data from tissue cultures Blood cultures ESR (> 70 greatly
Dx: osteomyelitis
increases likelihood of OM) Needle aspiration MRI
(5)
What is the preferred imaging modality for osteomyelitis? MRI
Tx: osteomyelitis • Antibiotics based on culture data x 4-6 wks Surgery if indicated
(2) (treatment resistant, chronic, vertebral)
What is the typical pattern of • distal symmetrical sensorimotor
neuropathy in DM? polyneuropathy
Clinical manifestations: • Sudden onset of mucocutaneous lesions over two
Stevens Johnson syndrome sides (oral and conjunctival) Targetoid lesions Fever
(5) Tachycardia Hypotension AMS
Definition: dacryocystitis • Infection of lacrimal sac
Clinical manifestations: • sudden onset of pain and redness in the medial
dacryocystitis canthal region
What are the common infecting organisms in • S. aureus beta-hemolytic
dacryocystitis? (2) strep

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What parameter is added to mechanical ventilation in • PEEP; prevent alveolar
ARDS? Why? collapse
What is the most common site of metastasis of colorectal cancer? • Liver
What skeletal diseases are patients with RA more at risk • Osteopenia
of developing? (2) Osteoporosis
What is the cause of senile • Perivascular connective tissue atrophy due to
purpura? age
What vitamin can cause pseudotumor cerebri? • Vitamin A/isotretinoin
What are the characteristic histological • Yellow-white patches of retinal
findings of CMV retinitis? opacification and hemorrhages
What is the characteristic histological finding of herpes simlpex • Dendritic
keratitis? ulcer
What is the characteristic • Necrosis of the inner layers of the retina,
histological findings of ocular which appears as white, fluffy lesions
toxoplasmosis? surrounded by retinal edema and vitritis
Physical exam: rosacea • rosy hue with telangiectasia over the cheeks, nose and chin
Precipitants: rosacea (4) • hot drinks heat emotion rapid body temp changes
Tx: rosacea (2) • initial: metronidazole telangiectasias require laser surgery
Clinical manifestations: primary • Mononucleosis-like syndrome (fever, nigh
HIV infection sweats, LAD, arthralgias, diarrhea)
What is the most common causative organism in UTI with alkaline • P.
urine? mirabilis
What is the most common causative agent of esophagitis in an • Candida
HIV patient? albicans
Tx: candida esophagitis in • (1) 3-5 day course of fluconazole (2) if unresponsive,
HIV patient (2) esophagoscopy with cytology is warranted
Antidote: anti-histamine overdose • Physostigmine
Clinical manifestations: Meniere's disease • Vertigo Ear fullness Tinnitus Hearing
(4) loss
Tx: Meniere's • Dietary modification (low-salt diet) - first-line Medical therapy
disease (2) (diuretics, antihistamines, anticholingergics)
Definition: epidural abscess • enclosed infections in the epidural space
Clinical manifestations: epidural • Back pain Fever Chills Focal neurological
abscess (4) deficits 2/2 cord compression
Dx: epidural abscess (3) • MRI Blood cultures Aspiration of abscess fluid
Lab findings: epidural abscess • Leukocytosis
Tx: epidural • Antibiotics +/- surgery (decompressive laminectomy and
abscess debridement)
In most cases of inferior MI, what vessel is occluded? • Right coronary artery
• Eye examinations due to risk
What routine screening is necessary in patients
of retinopathy and corneal
with SLE taking hydroxychloroquine? Why?
damage
What drug is commonly used for SLE with isolated skin •
and joint involvement? Hydroxychloroquine
How is a cold (hypothermic) extremity best • Rapid re-warming with warm
treated? water
Definition: • Whitish patch or plaque that cannot be clinically or
leukoplakia pathologically characterized
Clinical manifestations: • Saddle anesthesia Bowel/bladder dysfunction Low
cauda equina syndrome (4) back pain Lower extremity weakness/reflex

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abnormalities
Etiologies: cauda equina • Trauma Lumbar disk disease Malignancy
syndrome (4) Abscesses
What is the cause of cauda equina • Comrpession of the nerves of the cauda
syndrome? equina
Tx: sphincter of Oddi dysfunction • ERCP w/ sphincterotomy
Etiologies: post-cholecystectomy • Functional pain Sphincter of Oddi dysfunction
pain (3) CBD stones
What arrhythmia is most specific for digitalis • Atrial tachycardia w/ AV
toxicity? block
What are the most common • Peripheral neuropathy L5 radiculopathy
etiologies of foot drop? (3) Trauma to the common peroneal n.
What is the most common cause of excessive daytime • Obstructive sleep
sleepiness? apnea
Give the stepwise approach to • 1. Sodium and water restriction 2. Spironolactone
the treatment of ascites. (4) 3. Loop diuretic 4. Frequent abdominal paracenteses
What electrolyte abnormality may result from immobilization? • Hypercalcemia
Tx: hypercalcemia of immobilization • bisphosphonates
What diagnostic method is used in suspected PCP when • BAL (90%
sputum induction does not confirm the diagnosis? sensitivity)
What is the best way to monitor respiratory function in • serial bedside vital
GBS? capacity
What is the treatment for symptomatic
• Ursodeoxycholic acid +
cholelithiasis in patients who are poor surgical
avoidance of fatty foods
candidates?
Tx: toxic • Bowel rest IV fluids IV abx IV corticosteroids Emergency
megacolon (5) surgery (subtotal colectomy w/ end ileostomy) if severe
What is the most sensitive test for diagnosing disseminated • Urine antigen
histoplasmosis? detection
Clinical manifestations: cerebellar • Vertigo Vomiting Occipital headache
hemorrhage (4) Abducens nerve palsy
A history of diarrhea, weight loss, bloating and
• Malabsorption 2/2
flatulence in a patient with past abdominal surgery is
bacterial overgrowth
likely due to what?
Clinical manifestations: central • Sudden, unilateral visual impairment that is
retinal vein occlusion usually noted upon waking in the morning
• Disc swelling Venous dilation and
What does opthalmoscopy reveal in
tortuosity Retinal hemorrhages Cotton wool
central retinal vein occlusion? (4)
spots
Clinical manifestations: macular • Distorted vision and central
degeneration scotoma
Clinical manifestations: retinal • Unilateral blurred vision that progressively
detachment (3) worsens Floaters Photopsia
What does opthalmoscopy reveal in open angle • Pathological cupping of the
glaucoma? optic disc
Tx: diabetic retinopathy • Argon laser photocoagulation
Antidote: β-blocker overdose (2) • 1. Atropine and IV fluids 2. Glucagon
What underlying pathology is suggested by initial hematuria? • Urethral damage
What underlying pathology is suggested by terminal • Bladder or prostatic
hematuria? damage

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What underlying pathology is suggested by total • Damage to the kidney or
hematuria? ureters
True or false: clots are not usually seen with • True; more likely a bladder
renal causes of hematuria pathology (cancer perhaps)
Clinical manifestations: acute • severe, tearing pain w/ radiation to the back
aortic dissection that is maximal at onset
Physical exam: acute aortic • Hypo/Hyper-tension Difference in BP of > 30 mm
dissection (3) Hg between arms AI murmur
Risk factors: aortic • HTN (most common) Male sex Connective tissue disease
dissection (6) Congenital aortic anomaly Aortitis Pregnancy Trauma
What are the diagnostic studies of choice in suspected aortic • TEE or chest
dissection? (2) CT
Definition: classic aortic • intimal tear leading to extravasation of blood into
dissection the aortic media
Definition: incomplete • intimomedial tear w/o significant intramural
dissection extravasation
Definition: intramural • vasa vasorum rupture leading to medial
hematoma hemorrhage
Definition: penetrating ulcer • Ulceration of plaque penetrating intima leading
(aortic dissection) to medial hemorrhage
• β-blockers first to blunt reflex ↑ HR & inotropy that will occur
Tx (medical):
in response to vasodilators → ↓ SBP w/ IV vasodilators
aortic dissection
(nitroprusside)
Tx: descending aortic • medical management (beta blockers,
dissection vasodilators)
Tx: ascending (proximal) aortic dissections • root replacement (surgery)
Complications: aortic • Rupture → pericardial tamponade Obstruction of branch
dissection (3) artery (MI, CVA, bowel ischemia, etc) Aortic insufficiency
Tx: external hordeolum • Warm compression (first-line) I&D if resolution does
(stye) (2) not begin in 48 hours
What is the normal response to a • Urinary excretion > 4.5 grams in 5 hours after
D-xylose test? a 25 gram ingestion
How does one distinguish between
• bacterial overgrowth: normal D-
malabsorption due to bacterial
xylose response after abx Celiac:
overgrowth vs. celiac disease using the D-
abnormal D-xylose despite abx
xylose test?
What type of glomerular disease is especially • Membranous nephropathy
common in patients with HBV? (glomerulopathy)
What type of glomerular disease is especially • Membranoproliferative
common in patients with HCV? glomerulonephritis type I
• Fasting plasma glucose ≥ 126 mg/dl or 2-hour plasma glucose
Criteria: diabetes
level of ≥ 200 mg/dl Casual plasma glucose ≥ 200 mg/dl if
mellitus (3)
symptomatic
• 2-hour glucose levels of 140-199 mg/dl during an oral
Criteria: Prediabetic
glucose tolerance test Fasting glucose level of 100-125
glycemic states (2)
mg/dl
What is the insulin regimen • 0.5 units of insulin per kg body weight with 40 to
for the average patient w/ 50% delivered as long-acting basal insulin; the
type I DM? remainder is short-acting (lispro) meal boluses
What are the ideal postprandial glucose • 30-50 mg/dl above premeal
excursions in a diabetic? glucose levels
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What is the next step in treating a patient • Add another class of drug, i.e.
with type 2 DM who is failing adding metformin to an existing
pharmacological monotherapy? sulfonylurea regimen
True or false: increasing sulfonylurea doses beyond half the maximal •
dosing range has minimal further benefits on treating hyperglycemia. True
Contraindication: • Contraindicated in patients with asthma because of risk
zanamavir of bronchospasm
Persistent rhinitis symptoms in the • Persistent rhinitis symptoms in the setting
setting of nasal decongestant spray of nasal decongestant spray overuse suggest
overuse suggest [...] rhinitis medicamentosa.
Criteria: acute • Duration of sx > 1 week Worsening sx after initial
bacterial rhinosinusitis improvement Maxillary tenderness Purulent drainage Poor
(5) response to decongestants
Tx: acute bacterial rhinosinusitis (3) • Abx: amoxicillin, TMP-SMX, doxycycline
What oral abx can be used for outpatient treatment of • Levofloxaxin x 7-
pyelonephritis? 14 d
Clinical manifestations: • Dysphagia Dysarthria Dysphonia Diplopia
botulism (5) Descending paralysis
Clinical manifestations: • Weakness Fatigue Muscle cramps
hypokalemia Arrhythmia/tetany/flaccid paralysis when < 2.5 mEq/ml
Thrombocytopenia and • Thrombocytopenia and hypercoagulation
hypercoagulation within days of within days of initiating anticoagulant
initiating anticoagulant therapy are therapy are most likely cause by
most likely cause by [...] unfractionated heparin
What is the most common type of lung cancer? • Adenocarcinoma of the lung
Tx: febrile neutropenia • IV cefipime to cover gram positives and
(abx) pseudomonas
Clinical manifestations: nasal • Epistaxis Nasal obstruction Visible
angiofibroma (3) nasal mass
How long after splenectomy are patients with hereditary • Up to 30
spherocytosis susceptible to sepsis? years
What are the major risk factors for lacunar infarcts? (2) • Diabetes Hypertension
Definition: transient ischemic • neurological deficit that lasts from a few minutes
attack (TIA) to no more than 24 hours
Clincial manifestations: ACA • Hemiplegia (leg > arm) Confusion Abulia Urinary
stroke (5) incontinence Primitive reflexes
Clinical manifestations: • Contralateral hemisensory disturbance Macular-
PCA stroke (3) sparing homonymous hemianopia Aphasia
What are the 4 "deadly D's" of posterior • Diplopia Dizziness Dysphagia
circulation strokes? Dysarthria
Clinical manifestations: • Pinpoint pupils Long tract signs (Quadriplegia/sensory
basilar stroke (4) loss) Cranial nerve palsies Cerebellar dysfunction
Clinical manifestations: • numbness of ipsilateral face and contralateral limbs
vertebral stroke (4) Diplopia Dysarthria Ipsilateral horners
Clinical manifestations: lacunar stroke (internal • Pure motor
capsule) hemiparesis
Clinical manifestations: lacunar strok (pons) (2) • Dysarthria Clumy hand
Clinical manifestations: lacunar stroke (thalamus) • Pure sensory deficit
• Posterior limb of the internal capsule
What are the possible locations for
Ventral pons Corona radiata Cerebral
pure motor hemiparesis strokes? (4)
peduncle
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Dx: stroke (4) • Noncontrast CT EKG CMP CTA (after noncontrast)
Tx: • Heparin IV with bridge to warfarin Antiplatelet therapy: ASA, clopidogrel
TIA (3) or ASA + dipyridamole Carotid revascularization if > 70% stenosis
• ABCD2: Age ≥ 60 y; BP ≥ 140/90 Clinical
What scoring system is used
features: unilateral weakness or speech impairment
to predict risk of progression
w/o weakness, Duration ≥ 60 mins or 10-59 min;
of TIA to stroke?
Diabetes
Tx: ischemic • Supportive treatment Thrombolytic therapy (t-PA) if administered
stroke (3) within 4.5h of onset Antiplatelet therapy: ASA, dipyridamole + ASA
• SAMPLE STAGES Stroke or head trauma within the last
3 monts Anticoagulation w/ INR > 1.7 MI (recent) Prior
Contraindications: t-PA
intracranial hemorrhage Low platelet count (< 100K)
therapy s/p ischemic
Elevated BP: SBP > 185 Surgery in past 14 days Age < 18
stroke (12)
GI or urinary bleeding in past 21 days Elevated blood
glucose Seizures at onset of stroke
Etiologies: hemorrhagic stroke (2) • Intracerebral (90%) Subarachnoid (10%)
Clinical manifestations: hemorrhagic stroke (3) • AMS Vomiting Headache
Etiologies: • HTN (most common) AVM Amyloid angiopathy (lobar)
intracerebral stroke (5) Anticoagulation/thromblysis Tumors
Dx: hemorrhagic • CT scan CT angiography LP to check for xanthrochromia if
stroke (3) no evidence of hemorrhage on CT or suspicious for SAH
Tx: hemorrhagic • Admission to ICU ABCs BP reduction (gradual) with
stroke (3) nitroprusside w/ goal of SBP < 140
What conditions makes • Marfan's syndrome Aortic coarctation Kidney
subarachnoid hemorrhage disease (PKD) Ehlers-Danlos syndrome Sickle cell
more likely? (7) anemia Atherosclerosis History (familial)
Tx: cerebral vein thrombosis • angicoagulation w/ IV heparin
• Optimize preload (IV fluids; don't give nitrates) ↑ contractility
Tx: RV
(dobutamine) reperfusion mechnical support pulmonary vasodilators
infarct (5)
(inhaled NO)
What is the single most important intervention for • Adequate pre-CT
preventing contrast nephropathy? intravenous hydration
What is the histopathological criterion for • Demonstration of invasion
differentiating thyroid follicular adenomas from of the capsule and blood
follicular carcinomas? vessels
What is the drug of choice for chemoprophylaxis against P. •
falciparum malaria? Mefloquine
How does the clinical presentation of EHEC differ from that of • EHEC
other bacteria that cause bloody diarrhea? lacks fever
What electrolyte abnormality makes a
• Hypomagnesemia makes
concurrent hypokalemia refractory to
hypokalemia refractory
treatment?
Tx: symptomatic hypercalcemia • Vigorous hydration with IV normal saline
What neuromuscular blocker should be used in • Atracurium; degraded
patients with renal or hepatic insufficiency? Why? independent of kidneys or liver
Definition: malignant otitis • severe pseudomonal infection of the external
externa auditory canal
Clinical manfiestations: malignant otitis externa • Severe ear pain w/ drainage
(2) Fever
Otoscopic finding: malignant otitis • granulation tissue in the external auditory
externa canal
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What is the drug of choice for malignant otitis externa? • Ciprofloxacin
If suspicion for an intraocular foreign body is high, what • Fluorescein
test should be performed? examination
What agents most quickly reduce serum • Calcium gluconate Insulin Beta
potassium levels? (3) agonists
Tx: sinus bradycardia • IV atropine Permanent pacemaker if bradycardia doesn't
(2) resolve
Complications • Cryoglobulinemia B-cell lymphomas Plasmacytomas
(extrahepatic): Hepatitis Autoimmune disease (Sjogren's, thyroiditis) Lichen planus
C (7) Porphyria cutanea tarda ITP
What type of contrast agent is the least nephrotoxic? • Non-ionic contrast agent
Definition: presbycusis • Sensorineural hearing loss that occurs with aging
Clinical manifestation: • High-frequency, bilateral hearing loss Difficulty
presbycusis (2) hearing in noisy, crowded environments
What is the test of choice for diagnosisng renal cancer? • CT abdomen
What positioning makes the • Lying supine and turning to the left brings the
patient more aware of aortic heart closer to the chest wall and makes the
regurgitation? Why? patient more aware of the forceful heartbeat
What is the most common middle ear pathology in patients • Serous otitis
with HIV? media
Definition: serous otitis • Presence of middle ear effusions without the evidence of
media acute infection
Tx (pharmacological): hepatitis B (2) • intereron lamivudine
How does the clinical presentation of • CMV retinitis is typically painless and
CMV retinitis in and AIDS patient does not cause initial conjunctivitis or
differ from that of HSV/VZV? keratitis (in contrast to HSV/VZV)
What are common middle • Bronchogenic cysts Tracheal tumors Lymphomas
mediastinal masses? (5) Aortic arch aneurysms Pericardial cysts
What are anterior mediastial • Thymoma Teratoma "Terrible" lymphoma
masses? (4) Retrosternal thyroid
Tx: uncomplicated • IV abx in first 48-72 h Transition to oral abx (e.g.
pyelonephritis (2) TMP-SMX) if responsiv to parenteral abx
Dx: diffuse esophageal spasm • Manometry
Account for the metabolic acidosis • Lactic acidosis due to accelerated production
that follows a grand-mal seizure. of lactic acid and reduced hepatic lactate uptake
How does one manage post-ictal lactic • Observation; resolves without tx in 60-
acidosis? 90 mins
Tx: ventricular • Loading w/ lidocaine or amiodarone (drug of choice)
tachycardia (2) Cardioversion if hemodynamically unstable
HIV patients with what CD4 count warrant pneumococcal • CD4 > 200
vaccination? cells/uL
Tx: bleeding 2/2 coagulopathy • Fresh frozen plasma administration and IV fluids
When should colonoscopic surveillance begin in a patient • 8 years after diagnosis
with ulcerative colitis? How frequently should it be and then q1-2y
conducted thereafter? thereafter.
Definition: • A cyst in the eyelid caused by inflammation of a blocked
chalazion meibomian gland, usually in the upper eyelid
Clinical manifestations: • Painful swelling that progresses to a nodular
chalazion rubbery lesion
What is the usual cause of persistent or recurrent • Meibomian gland

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chalazion? carcinoma
What diagnostic test should be • Histopathological examination to r/o
performed on recurrent malignancy (meibomian gland carcindoma or
chalazion? BCC)
• DOPAMINE RASH Discoid rash Oral ulcers Photosensitivity Arthritis
Criteria: Malar rash Immunologic critera (anti-Sm, anti-dsDNA, anti-Ro/La)
SLE (11) Neurologic changes ESR increased Renal disease ANA+ Serositis
Hematologic disease (hemolytic anemia, thrombocytopenia, leukopenia)
Is the arthritis of SLE deforming or non-deforming? • Non-deforming
What are the most common side effects of digoxin • GI distress: N/V,
toxicity? anorexia
• Diffuse erythema that starts on the trunk Strawberry
Clinical manifestations:
tongue Conjunctival hyperemia Desquamation (1-2
toxic shock syndrome (4)
weeks later)
What animals are the definitive hosts for E. granulosis? • Dogs
What is the preferred test for HIV screening? • ELISA for gp120
Dx: prostatitis • 1. Mid-stream urine sample 2. Blood culture 3. CBC 4. Prostatic
(4) massage
[...] should always be considered in a • Hypothyroidism should always be
patient with an unexplained elevation considered in a patient with an unexplained
of serum CK and myopathy. elevation of serum CK and myopathy.
Complications: central lines • Venous thrombosis (subclavian in particular)
(2) Infection
Tx: venous thrombosis 2/2 • First: catheter removal Second: carotid duplex
central lines (3) Third: anticoagulation
Indications: cardioversion (4) • AFib Atrial flutter VT w/ pulse SVT
Indications: defibrillation (2) • VFib VT w/o pulse
Clinical manifestations: atrial • Fatigue Exertional dyspnea Palpitations
fibrillation (6) Dizziness Angina Syncope
What is the most common cause of atrial flutter? • COPD
EKG findings: multifocal • variable P wave morphology and variable PR and RR
tachycardia intervals (at least 3 different ones for dx)
EKG findings: PSVT • narrow QRS complexes w/ no discernible P waves
Pathophysiology: paroxysmal • (1) AV nodal reentry due to circuit within
supraventricular tachycardia (2 AV node (2) orthodromic AV reentry via
mechanisms) accessory pathway
Tx: PSVT (2) • Vagal maneuvers IV adenosine (agent of choice)
What drug is used for prevention of PSVT? • Digoxin
Tx: Wolff-Parkinson-White • Radiofrequency ablation of one arm of
syndrome reentrant loop
Tx: hemodynamically stable • pharmacological therapy: IV amiodarone,
VT (3) procainamide or sotalol
Tx: hemodynamically • immediate synchronous cardioversion Follow w/ IV
unstable VT (2) amiodarone to maintain sinus rhythm
What is the imaging study of choice for pericardial effusion or •
tamponade? Echocardiogram
Tx (medical): mitral • Diuretics for pulmonary edema Infective endocarditis
stenosis (3) prophylaxis Chronic anticoagulation (warfarin)
Clinical manifestations: aortic stenosis (3) • Angina Syncope HF sx
Physical exam: • 1. harsh crescendo-decrescendo systolic murmur in right 2nd

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aortic stenosis intercostal space w/ radiation to carotids 2. precordial thrill 3.
(5) sustained PMI 4. S4 5. Carotid pulses parvus et tardus
Tx: aortic • AV replacement is tx of choice; indicated in all symptomatic
stenosis patients
Dx: aortic stenosis • CXR EKG Echocardiogram Cardiac catheterization
(4) (definitive)
Clinical manifestations: • Exertional dyspnea PND Orthopnea Palpitations
aortic regurgitation (6) Angina Cyanosis/shock in acute aortic regurgitation
Physical exam: aortic • Widened pulse pressure Diastolic decrescendo murmur at
regurgitation (4) LSB Austin-Flint murmur Head-bobbing/uvula bobbing
What compensatory structural changes does the heart • LV dilation and
make in response to aortic regurgitation? hypertrophy
What is the definitive treatment for aortic regurgitation? • AV replacement
Tx: acute aortic • Medical emergency - perform emergent aortic valve
regurgitation replacement
Tx: unruptured • If aneursym > 5 cm in diameter or symptomatic,
abdominal aortic surgical resection w/ synthetic graft placement is
aneurysm recommended
Tx: ruptured abdominal aortic aneurysm • emergent surgical repair
Clinical triad: ruptured • abdominal pain hypotension palpable pulsatile
AAA abdominal mass
Definition: peripheral vascular • occlusive atherosclerotic disease of the lower
disease extremities
Clinical manifestations: PVD • Intermittent claudication Rest pain, prominent at
(2) night
Physical exam: • Dimished/absent pulses Muscular atrophy Decreased hair growth
PVD (5) Ischemic ulcertation Thick toenails
Dx: peripheral vascular • Ankle-to-brachial index < 1.0 Pulse volume recordings
disease (3) Arteriography (gold standard)
Tx (medical): peripheral • Smoking cessation Graduated exercise program
vascular disease (4) Atherosclerotic risk factor reduction Aspirin
Tx (surgical): peripheral vascular disease • Surgical bypass grafting
(2) Angioplasty
Dx: acute arterial occlusion • Ateriogram
Classification: Shock (4) • Hypovolemic Cardiogenic Septic Neurogenic
When shouldn't IV fluids be used in • If LV pressures are elevated, IV fluids
cardiogenic shock? are likely to be harmful
Tx: cardiogenic • ABCs Identify and treat underlying cause Vasopressors
shock (4) (dopamine/dobutamine) IABP
What are the recommendations for screening • One-time screening of all
with DEXA scans for osteoporisis? women who are 65 and older
Tx: acute acalculous • Percutaneous drainage followed by
cholecystitis cholecystectomy
Dx: biliary dyskinesia • HIDA scan
• Motor dysfunction of the sphincter of Oddi which leads to
Definition:
recurrent episodes of biliary colic w/o evidence of gallstones on
biliary dyskinesia
diagnostic imaging studies
Tx: biliary dyskinesia • Laparoscopic cholecystectomy Endoscopic
(2) sphincterectomy
Tx: appendicitis • Appendectomy (laparoscopic)

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What is the best test for evaluating a patient with epigastric • Upper GI
pain? endoscopy
What is the test of choice for initial evaluation of a thyroid • Fine-needle
nodule? biopsy
Tx: normal pressure • Large volume serial LPs followed by
hydrocephalus ventriculoperitoneal shunting
Tx: central diabetes insipidus • Intranasal desmopressin acetate
Clinical presentation: ventricular • CHF sx MR Ventricular arrhythmias
aneurysm 2/2 MI (4) Thrombus formation
Tx: uric acid stones • Urine alkalinazation w/ oral potassium citrate/bicarobinate
What is the appropriate tx for the management of bone pain in • Radiation
patients with prostate cancer who have undergone orchiectomy? therapy
Tx (acute): MS exacerbation • IV steroids
Clinical presentation: phenytoin • Horizontal nystagmus Cerebellar ataxia
toxicity (3) Confusion
What class of drugs is first-line for diabetic neuropathy? • TCAs
Contraindications: anticoagulation • Recent surgery Hemorrhagic stroke Bleeding
therapy (4) diathesis Active bleeding
Tx (pharmacological): fibromyalgia (2) • TCAs (amitriptyline) Cyclobenzaprine
Dx: lupus • Renal biopsy is required in all patients with new onset lupus
nephritis nephritis
Etiologies: • Sickle cell disease Perineal or genital trauma Neurogenic lesions
priapism (4) (spinal cord injury) Medications (trazadone, prazosin)
Tx: S. viridans endocarditis (2) • IV penicillin G or IV cefriaxone
Tx (pharmacologic): diabetic • Metaclopramide (drug of choice) before meals
gastroparesis (3) Bethanechol Cisapride
Side effects: ACE • Cough Angioedema Proteinuria Taste changes hypOtension
inhibitors (9) Pregnany problems Rash Increased renin Lower angiotensin II
What is the initial DMARD of choice for RA? • Methotrexate
What is the prophylactic treatment for a • Five day course of
cat bite? amoxicillin/claulanate
Hyperactive deep tendon reflexes in a • Due to hypocalcemia from multiple
post-op patient is usually caused by blood transfusions and citrate chelating
what? calcium
What is the most common manifestation of hemophilia? • Hemarthrosis
Clinical presentation: cavernous • Headache Low-grade fever Periorbital
sinus thrombosis (4) edema Cranial nerve palsies
What is the most common • Most cases are secondary to an infection located in
etiology of cavernous sinus the medial aspect of the face around the eyes and
thrombosis? nose; sinus infections can be causes too.
Dx: cavernous venous thrombosis • MRI/CT w/ contrast
When should therapy for PE be initiated • If suspicion is high, start treatment
with respect to diagnostic testing if clinical immediately, then do dx tests; stop
suspicion is high? heparin if negative
What is the major toxicity of mycophenolate? • Bone marrow suppression
What are the major toxicities of azathioprine? • Diarrhea Leukopenia
(3) Hepatotoxicity
Tx: Legionnaire's disease (2) • Azithryomycin Levofloxacin
Side effects: erythropoietin (3) • Wordening of hypertension Headaches Flu-like sx
Describe the progression of • Patients tend to present initially with
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hypertensive intraparenchymal focal sx but can rapidly progress to signs of
hemorrhages elevated ICP
• (1) inappropriate secretion of vasopressin, which
Pathophysiology: cerebral
causes water retention (2) increased secretion of
salt-wasting syndrome (2)
ANP/BNP, which causes naturesis
What class of drug can be used as monotherapy in • Antiemetics such as
migraine headaches that present with vomiting prochlorperazine or
and photophobia? metoclopramide
Tx: opiod withdrawal • methadone
Suspect [...] in patients with • Suspect tropical sprue in patients with
malabsorption along with a history of malabsorption along with a history of
living in tropical areas for more than living in tropical areas for more than one
one month month
What cause of hypoxemia presents with an elevated PCO2 and •
normal A-a gradient? Hypoventilation
Describe the PaCO2 and A-a gradient in hypoxemia • Normal PaCO2 Normal A-
caused by low FIO2. a gradient
Describe the PaCO2 and A-a gradient in V/Q • PaCO2 normal A-a gradient
mismatch increased
Describe the PaCO2 and A-a • Normal PaCO2 Increased A-a gradient that
gradient in shunting is refractory to O2
Complications: high PEEP • alveolar damage tension pneumothorax
ventilation (3) hypotension
What is the classic antibody associated with dermatomyositis? • anti-Mi-2
What other disease is more common in patients • Internal malignancies such as
with dermatomyositis compared to the normal ovarian cancer; 10% of DM
population? patients
What are the ways in which potassium can be • Dialysis Cation-exchange resins
removed from the body? (3) (kayexalate) Diuretics
Tx: primary biliary cirrhosis (2) • Ursodeoxycholic acid Cholestyramine
Tx: comedonal • topical retinoids (first line) topical abx (mild-moderate) oral
acne abx (severe)
Tx: nodulocystic acne • oral isotretinoin
What is appropriate blood product to administer for • Packed red blood
anemia? cells
Indications: platelet transfusion • platelet count < 10K
Indications: thyroid • Hyperlipidemia Unexplained hyponatremia Elevated
function testing (4) serum muscle enzymes Anemia
[...] is likely in a postoperative • Massive pulmonary embolism is likely in a
patient with JVP and new-onset postoperative patient with JVP and new-onset
RBBB RBBB
• Recurrent pneumonia in the same
Recurrent pneumonia in the same
anatomic location is a red flag for lung
anatomic location is a red flag for [...]
cancer
Clinical presentation: charcot joints • Functional limitation Deformity
(neurogenic arthropathy) (3) Degenerative joint disease
Tx (pharmacological): WFW w/ • Pharmacological (procainamide, e.g.) or
Afib and RVR electrical cardioversion; avoid AV nodal blockers
At what time point s/p acetaminophen ingestion does the Rumack- • 4
Matthew nomogram start? hours
Within what time frame should N-acetylcysteine be administered • Within 8
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s/p acetaminophen ingestion? hours
If a patient presents with acetaminophen toxicity, what • Activated charcoal
is the first step in treatment? administration
Definition: eczema • Form of primary herpes simplex virus infection
herpeticum associated w/ atopic dermatitis
Tx: eczema herpticum • Acyclovir immediately (in infants)
A copious amount of purulent eye • A copious amount of purulent drainage in
drainage in newborns who are two to newborns who are two to five days old is
five days old is most consistent with most consistent with gonococcal
[...] conjunctivitis.
• New clubbing in patients with COPD
New clubbing in patients with COPD
often indicates the development of lung
often indicates the development of [...]
cancer
What is the treatment of choice • IM benzathine pencillin; single oral dose of
for primary syphilis? What are azithromycin or two-week course of doxycycline
the alternatives? for penicilli-allergic patients
What classes of diuretic most commonly causes • Aminoglycosides Loop
ototoxicity? (2) diuretics
Tx (acute): ischemic stroke in a sickle cell patient • Exchange transfusion
Prophylaxis: human bite • Augmentin
What is the most common nephropathy associated with • Minimal change
Hodgkin's lymphoma? disease
What is the most common nephropathy associated with • Membranous
carcinomas? nephropathy
What is the most sensitive test to diagnose pancreatic exocrine • Fecal elastase
failure? study
An alcoholic patient preenting with • An alcoholic patient preenting with
chronic abdominal pain and diarrhea chronic abdominal pain and diarrhea is
is classic for [...] classic for chronic pancreatitis
In what situations is the medial meniscus • Forceful torsion of the knee w/ the
injured? foot planted
Physical exam: • Localized tenderness on medial side of knee Locking of the knee
medial joint on extension McMurray's sign (palpable or audidible snap
meniscus tear occurring while slowly extending the leg at the knee from full
(3) flexion while simultaneously applying tibial torsion)
Where do the majority of clavicular fractures occur? • Middle third of the bone
What is the classic event leading to • Fall on an outstreched arm or direct
clavicular fracture? blow to shoulder
• Pain and immobility of the affected arm Contralateral hand
Clinical presentation:
is used to support weight of the affected arm Shoulder on
clavicular fracture (3)
affected side is displaced inferiorly or posterioly
Why must a careful neuromuscular exam be • Rule out damage to underlying
performed on patients with suspected clavicular brachial plexus and subclavian
fracture? artery
If a bruit is heard just below the clavicle (fractured), what •
diagnostic study is indicated? Angiogram
Clinical manifestations: acute • Abdominal pain (McBurney's to RLQ
appendicitis (3) progression) Fever N/V
If a patient waits more than 48 hours to seek medical • High incidence of
attention w/ sx of appendicitis, what complications can rupture w/ abscess
occcur? formation
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Tx: suspected perforation 2/2 appendicitis • exploratory laparotomy
If a patient w/ suspected psoas abscess (2/2
• IV hydration Abx Bowel rest
appendicitis) and is stable, what is the treatment?
Interval appendectomy
(4)
What carpal bone is most commonly injured in acute injury of • Scaphoid
the wrist? bone
What injury usually leads to scaphoid • Fall on outstreched hand w/
fracture? dorsiflexion
What are scaphoid fractures of particular • Risk of avascular necrosis due to
concern in acute wrist injury? tenuous blood supply
• Pain on the radial aspect of the anatomic snuffbox
Physical exam:
Minimally decreased range of motion Decreased grip strength
scaphoid fracture (4)
Swelling
Dx: scaphoid fracture • Plainn film x-rays
Tx: scaphoid fracture • thumb spica cast for 7-10 days followed by repeat x-rays
Risk factors: developmental • Caucasian race First-born infants Breech
dysplasia of the hip (4) position Family history
Dx: developmental dysplasia of the hip • Hip ultrasound (< 4 mo) Plain films (> 4
(2) mo)
Tx: developmental dysplasia of the hip (2) • Hip harness Spica cast
What organs are most commonly injured with blunt • Spleen > liver >
abdominal trauma? (3) intestines
Definition: Kehr • Ipsilateral shoulder pain referred from the abdomen due to
sign irritation the phrenic nerve and diaphragm
Dx: blunt abdominal • (1) FAST (2) CT w/ IV contrast (if FAST negative but
trauma (2) suspicion high)
What radiographic sign on CXR indicates • free air in the peritoneal cavity
perforation of a hollow viscus? (usually under the diaphragm)
What diagnostic test should be used to confirm proper placement of a • Chest x-
central venous catheter? ray
Definition: Leriche • Bilateral hip/buttock/thigh claudication Impotence
syndrome Symmetric atrophy of bilateral extremities
Pathophysiology: Leriche • Atherosclerosis at the bifurcation of the aorta into
syndrome the common iliac arteries
On what side of the body is diaphragmatic • Left side because right side is
rupture more common? Why? protected by the liver
What is the most commonly injured ligament of the knee? • MCL
What kind of insult causes • Forceful abduction of the knee, often with a
MCL injury? torsional component of motion
Physical exam: MCL tear • Swollen knee due to effusion Positive valgus stress
(2) test
Dx: MCL tear • MRI
Tx: MCL tear • bracing and early ambulation
What are the components of the • Motor response (6) Verbal response (5)
Glasgow Coma Score? Eye opening (4)
At what GCS level does one intubate? • GCS of 8 = intubate
What is the most common site for metatarsal stress fracture? • Second metatarsal
Tx: stress fracture (metatarsal) • Rest, analgesia, hard-soled shoe
Tx: sharp, penetrating abdominal trauma in a • Exploratory
hemodynamically unstable patient laparotomy

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Tx: sharp, penetrating abdominal trauma in a • exploratory
hemodynamically stable patient laparoscopy
Definition: • Subluxation of head of radius at elbow joint; due commonly
nursemaid elbow to swinging children by the arm
Tx: nursemaid • Closed reduction by gentle passive elbow flexion and forearm
elbow supination
• Selective damage to central spinal cord due to hyperextension
Definition: central
injuries in elderly patients w/ degenerative changes in the
cord syndrome
cervical spine
Clinical manifestations: central cord • Upper extremity > lower extremity
syndrome weakness
Clinical manifestations: anterior cord syndrome • bilateral spastic motor paresis
What is the most common etiology of anterior cord • Occlusion of the vertebral
syndrome? artery
What features distinguish • Unilateral infiltrate (usually bilateral in ARDS)
pulmonary contusion from Onset: usually within 24-48 hrs in ARDS vs within
ARDS? (2) first 24 hours for contusion
What does treatment of asymptomatic patients
• Asymptomatic: no treatment
with Paget's disease of bone consist of? And of
Symptomatic: bisphosphonates
symptomatic patients?
• Stones (nephrolithiasis/nephrocalcinosis) Bone (bone aches/pains,
Sx:
osteitis fibrosa cystica) Groans (muscle pain, abdominal pain, gout,
hypercalcemia
constipation) Psychiatric overtones (depression, fatigue, anorexia,
(4)
lethargy, etc.)
Etiologies: primary • Adenoma (80%) Hyperplasia (15-20%)
hyperparathyroidism (3) Carcinoma (< 1% cases)
• BMP (Ca++ levels ↑) PTH levels normal or
Lab studies & findings: primary
elevated Urine cAMP elevated
hyperparathyroidism (4)
Chloride/phosphorous ratio > 33
Radiographic findings: primary • Subperiosteal bone resoprtion
hyperparathyroidism (2) Osteopenia
What imaging study is obtained before surgical treatment of • Sestamibi
primary hyperparathyroidism? scan
• Serum calcium at least 1 mg/dl
What are the indications for
above ULN Young (< 50 y/o) BMD
parathyroidectomy in asymptomatic patients
less than T -2.5 at any site Reduced
with primary hyperparathyroidism? (4)
renal function
If a sestamibi scan in a patient with primary • Bilateral neck
hyperparathyroidism is negative but shows many exploration w/
abnormal glands, what kind of surgery is indicated? intraoperative PTH level
What is the most common mechanism of atrial • Re-entrant rhythm in within the
flutter? atria
• Progesterone → ↑ respiratory rate via stimulation
Pathophysiology: respiratory
of dorsal respiratory group → chronic compensated
alkalosis of pregnancy
respiratory alkalosis
Tx: congenital prolonged QT syndrome (Jervell-Lange-Nielson • beta
syndrome or Romano-Ward) blockers
Clinical manifestations: Jervell-Lange- • Syncopal episodes w/o following
Nielson syndrome (2) disorientation Hearing impairment
What is the most common form of drug-induced chronic • Analgesic
renal failure? nephropathy

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What is the best initial screening test for • Cosyntropin stimulation test w/
adrenal insufficiency? cortisol and ACTH levels
What is the most common cause of ductopenia in • Primary biliary
adults? cirrhosis
What is the only drug FDA approved for ALS treatment? • Riluzole; glutamate
What is its mechanism? inhibitor
What kind of immunological response is induced by the • T-cell-independent B-
23-valent pneumococcal vaccine? cell response
• Chest CT to look for
What diagnostic study is required whenever a new
thymoma (present in 15% of
diagnosis of myasthenia gravis is made? Why?
cases)
Hypocalcemia with concordant
• Hypocalcemia with concordant changes
changes of serum calcium and
of serum calcium and phosphate levels are
phosphate levels are usually caused by
usually caused by vitamin D deficiency
[...]
Clinical manifestations: primary • painless chancre that resolves in 3-6
syphilis weeks
Clinical manifestations: • truncal rash that extends to the periphery, including
secondary syphilis (2) palms and soles generalized lymphadenopathy
What type of urethral injury is most commonly associated • Posterior urethral
with pelvic fractures? injury
Clinical manifestations: posterior • Suprapubic pain Inability to void
urethral injury (2) following major trauma
Physical exam: • blood at the urethral meatus high-riding prostate due to
posterior urethral displacement of the prostate by a pelvic hematoma scrotal
injury (3) hematoma
Tx: Carbon monoxide poisoning • 100% oxygen via nonrebreather facemask
If a patient with suspected PVD has normal ABIs, what further • Exercise
testing should be pursued? ABIs
What injury is most commonly associated with anterior • Burst fracture of the
cord syndrome? vertebra
What is the next step in a patient with a gunshot wound below • Exploratory
the nipple who is hemodynamically unstable? laparotomy
What are the first compensatory physiological • Tachycardia Peripheral
changes to hemorrhage? (2) vasoconstriction
Clinical manifestations: retroperitoneal abscess • Fever Chills Deep abdominal
(3) pain
Tx: pancreatic • Immediate placement of a percutaneous drainage catheter with
abscess culture of the drained fluid and surgical debridement
Tx: mastitis • antibiotics (dicloxacillin or cephalosporins) Analgesics Continuation
(3) of breast-feeding from the affected breast
What is the radiologic finding for blunt aortic injury? • Widened mediastinum
What is the most common cause of spinal • Thoracic and thoracoabdominal aortic
cord ischemia and infarction? aneurysm repair surgeries
• Flaccid paralysis Bowel/bladder Incontinence
Clinical presentation: anterior
Sexual dysfunction Hypotension Loss of tendon
spinal artery syndrome (5)
reflexes
Dx: esophageal perforation • Water-soluble contrast esophagram
Where do diabetic foot ulcers • Plantar surface of the foot under points of
classicaly occur? greatest pressure
What surgery commonly causes early dumping syndrome? • Partial gastrectomy
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Clinical manifestations: early • postprandial abdominal cramps weakness
dumping syndrome (4) light-headedness diaphoresis
What imaging modalities is can detect uric acid stones? (2) • CT abdomen IVP
Parotid surgery involving the deep lobe • Parotid surgery involving the deep lobe
of the parotid gland carries a of the parotid gland carries a significant
significant risk of [...] palsy risk of facial nerve palsy
What is the most common bone in the body to be affected by stress •
fractures? Tibia
Where do tibial stress fractures classically • Anterior part of the middle third of
occur? the tibia
What are the best diagnostic modalities for tibial stress • MRI Bone
fractures? (2) scan
What are the most common • Arnold-Chiari malformation Prior spinal cord
causes of syringomyelia? (2) injuries (classically, whiplash from MVA)
Definition: Ludwig • rapidly progressive bilateral cellulitis of the submandibular
angina and sublingual spaces
What is the classic etiology of Ludwig • Infector second or third mandibular
angina? molar
Clinical manifestations: Ludwig angina • Fever Dysphagia Odynophagia
(4) Drooling
What is the most common cause of death with Ludwig angina? • asphyxiation
Tx: Ludwig angina (2) • Antibiotics Removal of infected molar
Definition: Legg-Calve-Perthes • Idiopathic avascular necrosis of the femoral
disease capital epiphysis
Tx: Legg-Calve- • Observation and bracing Surgery if the femoral head is not
Perthes disease (2) well contained within the acetabulum
What is the typical course of a congenital • Spontaneous resolution by 12
hydrocele? months
If a congenital hydrocele does not disappear within a • Surgical repair due to the
year, what treatment may be indicated? Why? risk of inguinal hernia
Clinical presentation: • GI sx followed by triad of:Periorbital edema
trichinellosis (4) Myositis Eosinophilia
Tx: severe symptomatic hyponatremia (< 120 • hypertonic saline (3%)
meq/L) infusion
What type of catherization is best for minimizing • Intermittent
UTIs? catheterization
• abdominal pain w/ diarrhea and/or constipation pain
Clinical manifestations:
relief with bowel movements bloating sense of
irritable bowel syndrome (4)
incomplete emptying
Prophylaxis: M. avium complex in HIV patient • Azithromycin or
(2) clarithromycin
What is the mechanism by which
• Disrupts thermoregulation and the
fluphenazine (antipsychotic) causes
body's shivering mechanism
hypothermia?
• All sexually active women < 24 y/o and other
What are the routine screening
asymptomatic women at increased risk for
guidelines for C. trachomtis?
infection
What is the best initial diagnostic test for • Panendoscopy (esophagoscopy,
squamous cell carcinoma of the head/neck? bronchoscopy, laryngoscopy)
Describe the following parameters in • Calcium: decreased Phosphate:
tumor lysis syndrome: calcium, Increased Potassium: increased Uric acid:
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phosphate, potassium, uric acid increased
What is the most significant cause of morbidity in patients with • Diffuse axonal
traumatic brain injury? injury
In cases of suspected child abuse, what test should be • Complete skeletal
ordered? survey
What is the leading complication of • Bacterial infection leading to sepsis
surface body burns? and septic shock
Clinical presentation: • acute-onset severe substernal pain subcutaneous
esophageal perforation (2) emphysema in the neck/mediastinal emphysema
Clinical presentation: acute • Fever Chest pain leukocytossis sternal wound
mediastinitis (5) drainage mediastinal widening on chest x-ray
Tx: acute mediastinitis • Drainage Surgical debridement Prolonged antibiotic
(3) therapy
• Conservative medical therapy initially CT guided
Tx algorithm:
percutaneous drainage (if > 3 cm); if < 3 cm, IV abx and
diverticulitis
observation If unresolved after drainage, surgery for drainage
complicated by abscess
and debridement
• Sigmoid resection; fistulas, perforation
What surgery should be performed for
with peritonitis, obstruction and recurrent
diverticulitis? What are the indications?
attacks
What is the only region of the bladder covered by • Dome of the
peritoneum? bladder
Definition: Volkmann's • Final end point of compartment syndrome in which
ischemic contracture the dead muscle has been replaced by fibrous tissue
What is the immediate management of splenic • IV fluids first, then: Stable:
trauma in a hemodynamically stable patient? And CT abdomen Unstable:
hemodynamically unstable? exploratory lapartomy
Definition: torus • benign bony growth (exostosis) located on the midline
palatinus suture of the hard palate
After blunt trauma to the chest, if • After blunt trauma to the chest, if an x-ray
an x-ray shows a deviated shows a deviated mediastinum with a mass in
mediastinum with a mass in the left the left lower chest, one should suspect a
lower chest, one should suspect a diaphragmatic hernia w/ herniation of
[...] abdominal viscera
Dx: diaphragmatic hernia (2) • Barium swallow or CT scan w/ oral contrast
What can happen to the extremities upon • Ischemia-reperfusion injury leading
reperfusion after ischemia (4-6 hours)? to compartment syndrome
Tx: compartment syndrome • emergent fasciotomy
Tx: cardiac • immediate decompression by pericardiocentesis or surgical
tamponade pericardiotomy
Radiologic findings: acute cardiac • normal cardiac silhouette w/o tension
tamponade pneumothorax
[...] is the preferred way to • Orotracheal intubation with rapid sequence
establish an airway in an apneic intubation is the preferred way to establish an
patient with a cervical spine airway in an apneic patient with a cervical spine
injury injury
What are the best methods for • preoperative intensive active breathing
prevention of post-operative exercises incentive spirometry forced
atelectasis? (3) expiration techniques
Tx: penile • emergent surgery to evacuate penile hematoma and mend torn
fracture tunica albuginea

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Dx: penile fracture • emergent urethrogram to assess for urethral injury
What is the most common cause of penile • Sexual intercourse with the woman
fracture? on top
• Acute pain and swelling of the midline
Acute pain and swelling of the midline
sacrococcygeal skin and subcutaneous
sacrococcygeal skin and subcutaneous
tissues are most commonly due to pilonidal
tissues are most commonly due to [...]
disease
Tx: pilonidal disease • drainage of abscesses and excision of sinus tracts
If a FAST exam is inconclusive, what is the test of choice for
• diagnostic
detecting intraperitoneal hemorrhage in an unstable trauma
peritoneal lavage
patient?
Diangose: patient with anterior chest trauma w/ elevated
• myocardial
CVP/PCWP and unrepsonsive hypotension after bolus of IV
contusion
fluid
Clinical presentation: flail chest • respiratory distress tachypnea w/ shallow
(2) breaths
Clinical manifestations: gastric • early satiety w/ postprandial pain nausea
outlet syndrome (4) nonbilious vomiting weight loss
Physical exam: gastric outlet syndrome • abdominal succussion splash
Definition: Mohs • Microscopic shaving of basal cell cancer such that 1-2 mm of
surgery clear margins are achieved
Indications: Mohs surgery for • Patients with high risk features Lesions in
BCC (2) functionally critical areas
Tx (pharmacological): condylomata • TCA Podophyllin 5-Fu epi gel
acuminata (5) Imiquimod Interferon alpha
What is the glucose concentration • Low glucose (< 30 mg/dl) because of
exudative pleural effusion? Why? high leukocyte metabolic activity
Drug of choice: dermatitis herpetiformis • Dapsone
What physical exam sign excludes the diagnosis of a • Absence of forehead
central facial paresis? furrows
Tx (pharmacological): • alpha blockers (phentolamine,
pheochromocytoma phenoxybenzamine) before beta-blockers
In what order should adrenergic • alpha before beta blockers; if beta blockers
blockers be given in given first, there will be unopposed alpha
pheochromocytoma? Why? receptor stimulation, resulting in hypertension
Tx (pharmacological): aortic • afterload reduction w/ CCBs or ACE
regurgitation inhibitors
Tx: heat stroke • Induction of evaporative cooling to reverse hyperthermia
What is the initial effect of radioactive • Initial thyrotoxicosis due to dying
iodine treatment on thyroid levels in the follicular cells; can exacerbate the
hyperthyroid patient? hyperthyroid state
What are the two ways in which • (1) Asymmetric polyarthritis (associated with
Gonoccocal septic arthritis may tenosynovitis and skin rash) (2) isolated
present? purulent arthritis
Diagnostic • Serum osmolality < 270 Urine osmolaltiy > Serum osmolality
criteria: SIADH Urine sodium > 20 mEq/L Absence of hypovolemia Normal renal,
(5) adrenal and thyroid function
How is toxic epidermal necrolysis distinguished • TEN > 30% of body Stevens
from Stevens Johnson syndrome? John up to 10% of body
Clinical presentation: vitreous hemorrhage • Sudden loss of vision Onset of
(2) floaters
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What is the most common etiology of vitreous • Diabetic
hemorrhage? retinopathy
What is the most feared complication • Spread of infection into the mediastinum,
of a retropharyngeal abscess? leading to acute necrotizing mediastinitis
Describe the G6PD levels in patients with G6PD deficiency • G6PD levels are
suffering a hemolytic episode. often normal
What is the first line medical treatment for idiopathic benign •
intracranial hypertension? Acetazolamide
What organism is commonly responsible for nosocomial • P.
pneumonia in intubated patients? aeruginosa
What nasal cytology finding is characteristic of allergic • nasal
rhinitis? eosinophilia
What is the appropriate first-line diagnostic test if the cause of • Nasal
rhinitis is not clear? cytology
Definition: • asymptomatic elevation of monoclonal protein detected on
MGUS protein electrophoresis
How is MGUS distinguished • Absence of MM sx: renal insufficiency,
from multiple myeloma? hypercalcemia, anemia and lytic bone lesions
Definition: sympathetic • Damage of one eye (the sympathetic eye) after a
opthalmia penetrating injury to the other eye
Mechanism: • Injury to eye → unveiling of previously "hidden
sympathetic opthalmia antigens" → immunologic response in sympathetic eye
What event usually precedes the development of HUS? • Diarrheal illness
Tx: solitary brain metastasis • surgical resection followed by whole brain radiation
What are the earliest side effects of • Hallucinations Dizziness
levodopa/carbidopa therapy in PD? (4) Headache Agitation
Tx: torsades de pointes (2) • remove offending agent IV magnesium sulfate
What CBC finding is the presenting sign in HIV in about •
10% of cases? Thrombocytopenia
What is the most specific test available for GERD? • 24 hour pH recording
What imaging modality is the gold standard for avascular necrosis of the •
hip? MRI
What breathing maneuver is used on a ventilator to • End-inspiratory hold
determine the lung compliance? maneuver
Clinical presentation: • follicular conjunctivitis pannus (neovascularization)
Trachoma (2) in the cornea
In what patient populations is FSGS the most • African Americans Obese
common cause of nephrotic syndrome in adults? patients Heroin users HIV
(4) patients
Pathophysiology: isolated • decreased elasticity of the arterial wall with aging → ↑
systolic hypertension systolic BP w/o change to diastolic pressure
What cytochemical test is used to detect acute • Alpha-naphthyl esterase
monocytic leukemia? (positive)
What is the treatment of choice for iron deficiency in • IV iron (iron
dialysis patients? dextran)
What is the first-line therapy for reactive arthritis? • NSAIDs
What is the most common cause of blood-tinged sputum in • acute
young patients? bronchitis
True or false: fever is usually present in acute bronchitis • false; usually afebrile
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