USMLE Step 2CK Notes With Additions

Dr Jamal’s USMLE
Notes for Step2 CK

This file contains notes for USMLE step 2CK. All topics have
been included but some topics have been more emphasized
than other.
To best use this guide, read it before you start solving the
Qbanks. A lot of the question ideas have been summarized in an
easy way and significantly enhances your recall.
You will notice that once you start solving questions, you will
save time reading explanations and thus you can use it to solve
other question banks or revising the questions that you have
already done.
Qbanks recommended uWorld, Kaplan and NBME. If you have

very short time to study, uWorld is enough. If you have more
time, do NBMEs.
I also provide notes Step1 and “The Ultimate Match Guide”,

check www.drjamalusmle.com
All the information in this file are written genuinely by me and

are not copied, but are taken from many references. I hold no
responsibility for your score achievements.
My notes are color coded:

 Single color per line like yellow and green(except red): Normal Info
which is easy to remember
 Red: Hard info, mainly not found in conventional books
 Yellow & green: 2 contrasting info for two different contrasting ideas
which students have difficulty differentiating
 Different colors: info from same category
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Copyright © 2018
By Dr Jamal
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Contents
Nephrology ......................................................................................................................... 4
Gastroenterology ................................................................................................................. 8
Endocrinology ................................................................................................................... 15
Respiratory ........................................................................................................................ 26
Rheumatology ................................................................................................................... 30
Infectious Diseases............................................................................................................ 33
Cardiology......................................................................................................................... 42
Neurology ......................................................................................................................... 52
GYNEcology-OBStetrics .................................................................................................. 59
Pediatrics ........................................................................................................................... 66
Psychiatry.......................................................................................................................... 81
Dermatology ..................................................................................................................... 83
Surgery .............................................................................................................................. 86
Preventative medicine ....................................................................................................... 95
Hematology Oncology ...................................................................................................... 96
Biostatistics ....................................................................................................................... 98
Ophthalmology ............................................................................................................... 100
Subspecialty .................................................................................................................... 102
Miscellanuous ................................................................................................................. 103
Nephrology
Side effects of cyclosporine include: hirsutism, gum hypertrophy, diabetes mellitus, renal
vasoconstriction with sodium retention and hypertension, nephrotoxicity with
hyperkalemia, hypomagnesemia, hypophosphatemia, malignancy (squamous cell
carcinoma of the skin and lymphoproliferative disease), and GI upset. Tacrolimus has
same spectrum of side effects as cyclosporine except gum hypertrophy and hirsutism.
For metabolic alkalosis, urine chloride has to be checked to determine if it is chloride

sensitive or chloride resistant:
Chloride Sensitive Metabolic alkalosis: urinary chloride is less than 20 and there is
volume depletion, it is mostly associated with volume depletion and contraction like
diuretics and vomiting. The reason why chloride is low is due to mineralocorticoid
secretion that tries to maintain volume by reabsorbing NaCl. Treat by infusion of normal
saline
Chloride-Resistant: urinary chloride > 20 and volume is expanded. Causes include
primary hyperaldosteronism, barter, gitelman and licorice ingestion. These are NOT
corrected with saline infusion
Trimethoprim causes hyperkalemia due to sodium tubule channel blockade
Azathioprine side effects include dose related diarrhea, leucopenia and liver toxicity
Most common cause of nephrotic syndrome in lymphoma patients is minimal change

disease
Chlamydia causes muccopurulent urethral discharge and negative colonies while

GOnococcal urtheritis cause purulent discharge with positive colonies
To determine if alkalosis is due to diuretic use is by checking chloride in serum and

urine. Diuretics dump chloride in urine and try to reabsorb all bicarbs. This leads to low
serum chloride and high urine chloride. If diuretic alkalosis happens, stop the diuretic and
give acetazolamide as it will dump bicarbs and fix the alkalosis
Good pasture syndrome= Lower repiratory (hemoptysis) + hematuria, often there is a

history of recent URTI. Anti glomerular basement membrane is pathognomonic.
Wegner Granulomatosis= Upper respiratory (sinusitis) + lower respiratory (Hemoptysis)

+ renal involvement (hematuria), obtain c-ANCA
Autosomal polycystic kidney disease has two mutations ( PKD1: on chromosome 16 and
worse, PKD2 on chromosome 4 and better prognosis) , the earlier presentation the worse
To diagnose Alport syndrome, do skin biopsy first to look for Alpha-5 chain of type IV
collagen. If not found then patient has alport. IF result is equivocal, then do renal biopsy
APSGN shows proliferative pattern with infiltration of neutrophils. IF shows electron
deposits in the subepithelial region that are hump like ( along the glomerular capillary
wall), c3 and c4 are low
Severe hypocalcemia after Parathyroidectomy by one week is due to Hungry Bone

disease as bone will be taking in all the calcium in the blood and reminieralization. This
syndrome happens after hyperparathyroidectomy in 20% of patients
Best thing to do for hypercalcemia is IV fluids, as patients are usually volume depleted
and calcium itself leads to NDI. This therapy is followed by bisphosphonates and
calcitonin
The most important thing for a urinary stone is pain medication. Stones less than 1cm
have a high rate of passing spontaneously. If stones are small, do not subject patients to
unnecessary procedures.
IgA nephropathy is hematuria with concomitant URTI (Synpahryngitic). Treat with

ACEI or ARBS. Biopsy is gold standard and shows diffuse mesangial proliferation on
light microscope and granular deposits in the messangium and glomerular capillary wall
on electron microscope.
TTP has predominantly neurologic symptoms and lesser renal symptoms. HUS presents
with renal failure and few neurologic symptoms, HUS presents with a Hx of hemorrhagic
colitis. Treat both with plasmapherisis
Treatment of Proven Uric acid stones in the ureter include Oral fluids, NSAIDS and
Potassium Citrate or Potassium Carbonate. DO not Give Sodium carbonate as it will
increase sodium content leading to volume expansion and probably hypercalciuria
forming calcium stones. Potassium citrate and Potassium carbonate would alkalinize the
urine
The treatment of Barter syndrome is aimed at minimizing the effects of excessive

prostaglandins and aldosterone seen with this disorder. NSAID and spironolactone are
first line treatments
First line treatment for HTN with APKD is lisinopril
Minimal change is seen with Hodgkin disease, HIV infection and drug induced interstitial
nephritis. Patients respond to oral steroids. Half of patients enter remission following 8
weeks of high dose steroids.
Extrarenal complications of APKD are: Cardiac valve disease (30%), Hepatic cysts
(10%), Cerebral aneurysms (8%), colonic diverticula, abdominal and inguinal hernias
Traumatic hemolysis from repetitive sports can be differentiated from Rhabdomyolysis

where the traumatic hemolysis doesn’t have an increase in CK
Needle shaped monohydrate crystals are calcium oxalate
Autosomoal polycystic kidney disease is due to defect in epithelial cell differentiation

and or extracellular matrix functioning
Toxicity of mycophenolate is bone marrow suppression
If BPH is suspected, do abdominal ultrasound to assess for hydronephrosis
Renal amyloidosis is revealed with deposits under polarized light
Do US if there is no improvement with ABx for UTI. Look for compression, obstruction
or abscesses.
Unilateral varicocele that fails to empty suggests renal malignancy. Order CT. RCC is
associated with thrombocytosis and polycythemia and hypercalcemia and cachexia and
FEVER
Emergency plasmapherisis is required in management of good pasture’s disease. SLE

nephritis does not benefit for plasmapherisis.
Focal segmental is associated with African American, obesity, heroin and HIV.
Membranoproliefrative glomerulonephritis type 2 is unique glomerulopathy that is

caused by persistent activation of the alternative pathway caused by IgG antibodies
(called c3 nephritic factor) that is directed against c3 convertase leading to compliment
activation
Balkan endemic nephropathy are at increased risk for transitional cell carcinomas of
the renal pelvis, ureters, and bladder. Due to chronic Aristolochic acid exposure (herbal
therapy, used to lose weight). Also can cause extensive fibrosis of the urinary system.
Acute GlomeruloNephritis → get urgent renal biopsy unless the cause is very benign
(post infectious). Very important to know type of GN.
Infection-related glomerulonephritis (IRGN): it is the wide name for (PSGN but to any
infection) happens 7-10 days after infection. immune complex–mediated, nephritic urine
sediment (erythrocytes, erythrocyte casts, and proteinuria), low C3 and NL C4
(alternative complement pathway). Management: continue ABx to treat infection that
caused it. No need for biopsy
IgG4-related disease: infiltration of different organs by lymphoplasmacytic infiltrates of

IgG4-positive plasma cells with resultant fibrosis associated with elevated serum IgG4
levels. Seen in Autoimmune pancreatitis and nephritis
Orlistat: blocks fat uptake from bowel → fats stay in lumen and forms calcium soaps
production in the small bowel → decreased free Ca → decreased oxalate-calcium binding
→ increased free oxalate and increase intestinal uptake of oxalate into blood → increase
renal oxalate excretion. Can cause AKI in patients with volume depletion or CKD.
PPI & NSAID: can cause chronic tubulointerstitial disease (mild leukocytosis on
urinalysis and subnephrotic-range proteinuria
Nephrotic + thromboembolic events: think about Membranous Glomerulopathy. Very

common. Anticoagulation when albumin ≤2.8 g/dL.
FSGS: could be due to obesity → weight loss and ACEI improve proteinuria
HIV → collapsing form of FSGS
Refeeding syndrome: Pt presenting with Alcohol intoxication and was not eating well→
IV dextrose fluids can exacerbate hypophosphatemia by stimulating insulin release →
increase phosphate uptake by the cells.
Tumor lysis syndrome: prevention by allopurinol & IV fluids. Once happened

allopurinol can’t help→ start Rasburicase (converts uric acid to allantoin, 10 times more
soluble and excreted by the kidney.
Hypokalemic periodic paralysis: often associated with thyrotoxicosis. Generalized

flaccid weakness from a sudden intracellular potassium shift precipitated by strenuous
exercise or a high carbohydrate meal
Initial hematurea indicates urethral injury. Terminal hematurea indicates bladder or

prostatic damage. Total hematurea indicates damage to kidneys or ureters. Clots are not
seen with renal damage, clots are seen in bladder pathology.
Cardiovascular disease is the most common cause of death for dialysis patients.
Recommendations for patients with renal calculi:

Increased fluid intake
Increased dietary calcium
Decreased Proteins
Decreased oxalate
Decreased sodium
70-90% of renal stones are calcium oxalate, it is also found in malabsorption syndromes.
Calcium phosphate are found in hyperparathyroidism.
Simple renal cysts are always benign and have thin walls, without any solid component
and do not enhance. Reassurance and observation is enough.
The treatment of choice for fibromuscular dysplasia of Renal artery is by percutaneous

angioplasty
Acute epididymitis can be either sexually transmitted or non-STD
Prazocin and trazodone cause priapism
Patients who are oligouric post-surgery is mostly due to anesthetics and urinary retention.
First thing to do is to put foley’s catheter
Hexagonal crystals in cysteinurea
Kidney changes in diabetes: glomerular hyperfiltration > thickening of basement

membrane >mesangial expansion > glomerulosclerosis
Intimal thickening of renal arterioles and luminal narrowing of arteries is seen in

Hypertension.
Sudden onset of flank pain, hematuria and fever in nephrotic syndrome is highly due to
Renal Vein thrombosis. The most common nephrotic syndrome that does so is
membranous glomerulonephritis.
Gastroenterology
Ursodeoxycolic acid is the treatment of choice for Primary Biliary cirrhosis.
Glucocorticoids are ineffective
Dubin-Johnson and rotor syndrome are a cause of direct hyperbilirubinemia.

Dubin-Johnson is due to error in bile secretion into the ducts leading to its
storage in hepatocytes, giving the characteristic Black colour of the liver.
Rotor syndrome is due to inability to store bile in the hepatocyte leaking it
into the plasma without having the black colour. In both, liver function is
normal. Liver steatosis due to OCP, will have elevated Bilirubin but also
high liver enzymes.
Rifaximin is an antibiotic that kills ammonia forming bacteria in the gut. It is

used to treat hepatic encephalopathy
Presence of bilirubin in dipstick urine is indicative of conjugated

hyperbilirubinemia. Unconjugated is water insoluble and is bound to
proteins and is not filtered in the glomeruli. Hemolytic anemias, thalassemia,
gilber, PNH are all causes of unconjugated hyperbili
Hepatic adenoma might be induced from OCP, androgen use, glycogen

storage disease, pregnancy and diabetes. Abnormal hepatic architecture
without septa or porta or biliary tracts. Complications include growth,
rupture, bleeding and malignant transformation.
Spontaneous bacterial peritonitis: Antibiotics, third generation cephalosporin. Also, give

IV albumin if Cr >1.0, Bilirubin > 40, BUN > 30.
AKI and hepatic encephalopathy: before making diagnosis of Hepatorenal, IV fluid

challenge and IV Albumin to check for response. If failed -> cont with the Dx criteria
(elevated Cr > 1.5, failure to respond to Albumin, no other reason could find).
Empiric treatment for H. pylori is not appropriate because the diagnosis of H. pylori
should be made before initiating treatment. Empiric therapy for H. pylori is expensive
and carries the potential harm of medication side effects; therefore, it would not be
indicated without first confirming active infection
Gallbladder polyp larger than 1 cm is an indication for cholecystectomy, even if the

patient is asymptomatic
Gallbladder polyp smaller than 1 cm can be followed with serial ultrasound examinations
unless the patient is symptomatic or has primary sclerosing cholangitis.
Chronic diarrhea: Giardiasis should be considered in patients with exposure to young

children or potentially contaminated water such as lakes and streams. Infection is
asymptomatic in more than 50% of patients, and the protozoa clear spontaneously.
Patients with hypogammaglobulinemia are at increased risk of developing severe or
chronic infection
Autoimmune pancreatitis (AIP): Rx is by steroids. Dx criteria of Type 1:

○ Imaging features (focal pancreatic enlargement with a featureless rim and a nondilated
pancreatic duct),
○ increased serum IgG4 level,
○ Extrapancreatic organ involvement (sclerosing cholangitis or IgG4-associated
cholangitis).
Irritable bowel syndrome with constipation: try OTC laxative. If not improved >
Linaclotide / lubiprostone as both are FDA approved.
Acute peripancreatic fluid collections (APFCs): Symptomatic pt can be treated
medically with bowel rest, jejunal feeding, pancreatic enzymes, octreotide, and rarely
pancreatic duct stenting. Rarely, APFCs persist beyond 4 weeks, when they become
encapsulated and are labeled a pancreatic pseudocyst. Pseudocysts are amenable to
drainage if clinically indicated based on persistent pain despite medical therapy, infected
pseudocyst, or obstruction of the gastric outlet or biliary tract.
IBS-D should undergo screening for celiac disease with serum tissue transglutaminase
testing, as celiac disease has greater prevalence in patients with IBS-D than in the general
population.
HCV genotype 2: Rx with sofosbuvir and ribavirin
Microscopic colitis: has 2 subtypes; Lymphocytic colitis (intraepithelial lymphocytosis)

and collagenous colitis (subepithelial collagen band). Distinguishable only by histology
Acalculous cholecystitis: 50% of these high-risk patients will develop cholangitis,

empyema, gangrene, or gallbladder perforation during their hospitalization. The mortality
rate is 10-50%. Cholecystectomy is preferred but may be contraindicated in severely ill
patients. In this case, perform decompression by percutaneous cholecystostomy.
Focal Nodular hyperplasia of the liver is not related to OCP use
Asymptomatic gallstones should not be treated unless if at increased risk for

carcinoma or complications.
For monitoring of acute hepatitis, decreasing levels of liver enzyme means

either recovery from injury or that there are fewer hepatic cells (cells are
dying so less number of cells). Next lab test to be ordered is PT which
estimates the function. If there is increase in PT, it means that less
coagulation factors are made confirming the diagnosis of acute fulminant
hepatitis. If PT decreases, then goes with recovery
Trest criggler najjar 1 with Phototherapy or plasma pheresis, though ultimate

cure is with transplant. Phenobarbital is not helpful in Criggler 1. criggler
najjar 2 is a milder form and IV Phenobarbital is used to decrease the level
of bilirubin. Both types have normal liver enzymes.
Mallory bodies are indication of alcoholic hepatitis. It is reversible if alcohol

intake is stopped. Frank cirrhosis is irreversible. Mallory might be seen in
Wilson disease.
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In order for hypertriglyceridemia to cause pancreatitis, levels shall be above
1000. Look for other things like eruptive xanthomas.
Risk factor for non-alcoholic steatohepatitis is Obesity, DM and

hyperlipidemia. Histologic features are indistinguishable from Alcoholic
steatohepatitis. Both have macrovesicular steatosis.
Non-caseating granulomas are characteristic of Crohn and not UC.

Pseudopolyps are typically seen in UC but also can be seen in Crohns
Most common presenting symptom of sigmoid masses is obstruction
Hepatic adenomas do not take sulfur technetium scan as they don’t have kupfer cells.
Malignant transformation happens in 15%. US is sensitive but not specific.
Drugs that cause pancreatitis: furosmide, thiazide, sulfadiazine, 5-ASA, azathioprine,

VALPROIC acid, Didanosine and pentamidine in HIV patients, metronidazole,
tetracycline.
Eggshell calcification of liver cyst is Echinococcus granulosus. It is unilocular.
Treatment of acute ascending cholangitis starts with Intravenous antibiotics. If

complicated, do ERCP. Surgical treatment is not recommended anymore
All patients with Hepatitis C should be evaluated for antiviral therapy. Liver biopsy
should be offered as it offers the best clinical predictor of response to therapy and also
rules out other pathologies. Patients with moderate to severe have the best response to
therapy.
Absence of peristaltic waves in lower third of esophageus and significant decrease in

LES tone is seen in scleroderma. GERD has low LES tone but the peristaltic waves are
normal.
Gastrointestinal bleeding is associated with increased BUN/Cr ratio because blood in

broken down by bowel bacteria into nitrogen compounds that will be absorbed by the
bowel.
Abnormal taste, pustular eruptions on skin and alopecia is seen in zine deficiency
Positive hydrogen breath test is useful for dignosing lactose intolerance
Angiodysplasia is seen in patients with aortic stenosis or end stage renal failure
Rubber band ligation is for internal hemorrhoids only. For thrombosed external
hemorrhoids, intervention is best the first three days, afterwards only conservative
treatment as the disease will resolve on its own
Zenker diverticulum is a flase diverticulum located above the cricopharyngeus muscle

(above the upper sphincter not below), less than 0.5% turn malignant. It is due to
weakness in a skeletal muscle not smooth muscle.
Hepatorenal syndrome is due to renal vasoconstriction and thus patients present with
secondary hyperaldosteronism and low urine sodium. Managed only by hepatic transplant
Carriers of Salmonella typhi may have increased risk of Gallbladder Cancer. Patients
infected with Clonorchis Sinensis (Chinese liver fluke) is implicated in the development
of Cholangiocarcinoma
Think of bacterial overgrowth in scleroderma with intestinal dysmotility as small bowel

dilation might lead to stasis and secondary bacterial overgrowth leading to decreased
carbohydrate absorption and subsequent diarrhea. Give antibiotics
Scope the patient that has achalasia with malignancy signs (weight loss)
Sphincter of oddi dysnfunction is failure of sphincter to relax resulting in biliary pain or

pancreatitis. Gold standard is ERCP with sphincter manometry. Tests would show normal
lab results and normal gallbladder on US
Melanosis coli seen on colonoscopy is dark brown to black pigmentation of colonic

mucosa due to laxative chronic use or abuse. Macrophages come up the mucosal surfaces
ingesting the dead debris and lipofuscin pigment causeing the dark colour. Milanosis thus
is a misnomer. Condition is benign and doesn’t demand treatment
Predisposing factors that lower esophageal sphincter tone: alcohol, smoking, fatty food,
peppermint, chocolate, pregnancy and some medications. Modification of risk factors can
decrease symptoms and should be attempted before medications are started.
Whenever porcelain gall bladder is found on imagine, go for prophylactic laprascopic

cholecystectomy as it has 20% risk of developing into Carcinoma
GERD can be treated with a trial of PPI not H2 blockers but it doesn’t cofirm the Dx. TO
confirm Diagnoses, do 24-Hr pH monitoring.
Mid-esophageal varcies = Superior vena caval obstruction

Distal esophagous or Gastric = portal vein
In ascending cholangitis due to stone, put patient on Antibiotics and IV fluids and
observe till patient is stable with no fever. Schedule the patient for elective
sphincterotomy usually after 72 hours after the start of antibiotics and while patient is
stabilized. If the patient fails to improve within 24 hours, then urgent ERCP. Typical
antibiotics are Ceftriaxone and metronidazole
Do endoscopy when achalasia is suspected as esophageal cancer can mimic

achalasia.
Gastric ulcer in the absence of NSAID use is mostly due to H.Pylori colonization rather
than invasion.
For Hydatid cyst, do not attempt to needle it as these cysts are under high pressure and
needling might cause rupture and anaphylaxis or intraperitoneal seeding. This patient
should be taken to the theatre and drained and injected with alcohol or 20% saline (if the
fluid is clear)
Benign postoperative cholestasis occurs 2-10 days after prolonged surgery and is
multifactorial with anesthesia, TPN, pigment load and hepatic hypoxia. No treatment is
necessary and resolves on its own.
Even in the absence of occult-positive stool, a total colonoscopy is indicated in patients

above 50 as part of recommended screening guidelines
The pathophysiology of Diverticulitis is micro or macroperforation of diverticuli leading

to transmural abscess formation.
Chronic atrophic gastritis caused by pernicious anemia is associated with markedly

elecated serum gastrin levels, because the normal acid inhibition of G cells is lost.
Cancer cachexia is commonly present in metastatic brain malignancy rather than Primary
CNS malignancy.
Anti-smooth muscle antibody is found in autoimmune hepatitis. Antimitochondiral

antibodies are found in Primary biliary cirrhosis.
Measuring serum Antigliadin antibody is no longer used routinely for the diagnosis of
celiac disease because of its lower specificity and sensitivity as compared with
AntiEndomesial antibody and Anti-tissue transglutaminase
Liver abscesses of Ameba should be treated with metronidazole. Do not drain them as
you cannot culture it from pus and because treatment is sufficient.
Tangier disease is a rare codominant familial disease characterized by alpha lipoprotein

deficiency leading to low levels of HDL. Clinical manifestations include polyneuropathy,
lymphadenopathy, hepatosplenomegaly, and orange yellow tonsillar hyperplasia
Multiple angiokeratomas on the lower half of the body suggests Fabry disease
Grey brown pigmentation of the forehead, hands and pretibial region suggests Gaucher
disease
Pingueculae are yellow orange pigmented spots in the eyes that are made up of
degenerated subepithelial tissue and their presence suggests Gaucher disease.
Liver enzymes are not prognostic in Hepatitis. Encephalopathy and coagulopathy hold
the worst prognosis in hepatitis
Ascites in Portal Hypertension has SAAG >1.1 , while SBP has a SAAG <1.1 ( if
infected there will be proteins in the fluid and so there is no difference between blood and
ascetic fluid)
Once polyps are identified in a patient who has a high risk of being FAP, no need to keep
monitoring with colonoscopy, do proctocolectomy as next step
Splenic vein thrombosis can ensue after chronic pancreatitis and pseudocyst formation.
This will lead to gastric varices and bleeding
Rotor syndrome is defect in storing bilirubin leading to high conjugated

hyperbilirubinemia and high urinary coproporphyrins. Dubin-Johnson is inability to
secrete bilirubin in the canaliculi which leads to high conjugated hyperbilirubinemia with
NORMAL urinary Coproporphyrins
Chronic pancreatitis is tested by secretin stimulation test. A normal patient should secrete
large amounts of Bicarbonates upon this test if normal but a patient with chronic
pancreatitis will not do so.
Inflammatory bowel disease has bimodal age distribution with the second
one at age 60. Look for elevated inflammatory markers and neutrophilia.
Neutrophilic cryptitis is seen. It is very hard to distinguish between them
Patients below 55 and without alarming signs with Dyspepsia, serology

testing for H. Pylori should be done and treated accordingly. If h pylori is
negative, give PPI and re evaluate
Smoking is most significant risk factor for pancreatic cancer
Tea and toast diet is associated with folic acid deficiency. Folic acid is very
sensitive to cooking. Think of it when there are no neurologic symptoms
with macrocytosis.
Benign strictures of the distal esophagous complicate long standing GERD
in 15-20%
Hemorrhage is the most common complication of PUD
Verapamil decreases the renal clearance of Digoxin leading to side effects of

digoxin which are mostly GI
D-xylose is a monosaccharide and doesn’t need any enzymes for absorption.

Low urinary xylose after oral intake means malabsorption
Abdominal CT is the best initial diagnostic modality for pancreatic

pathology
Cryptosporidium parvum is a major cause of chronic watery diarrhea in HIV

infected with less than 180 CD4 count
Stepwise approach for treatment of ascites:

1) sodium and water restriction
2) spironolactone
3) Furosemide not more than one liter per day
4) Frequent abdominal paracentesis (2-4 L/day as long as renal function
is okai)
Suspected variceal bleeding: fluid resuscitation, antibiotics and then

Octreotide
Finding of pancreatic calcifications on CT establishes the diagnosis of

chronic pancreatitis
Endocrinology
Sick euthyroid happens in a patient seriously ill with low t4 and
low t3 but normal TSH level. They do not have clinical
hypothyroidism
The cause of diabetic ulcers has been shown to be due to hypoxia
Benign looking hyofunctional adrenal nodules should be left alone. Reassure patient and
no further serial imaging studies is needed.
Skin changes is very specific for Graves disease
IN pseudohypoparathyroidism, the PTH level is high, calcium is low and phosphate is

high because the cells are not responding to PTH so parathyroid cells secrete more PTH.
While primary hypoparathyroid has low PTH
Metabolic X syndrome:
1. Abdominal obesity: >102 cm for men and >88 cm for women
2. TG: >150 or drug ttt for TGs
3. HDL: <40 for men and <50 for women or drug ttt for low HDL
4. BP: >130/85 or drug ttt for HTN
5. Fasting Glucose >100 or ttt for high glucose
Patient presenting with suspected Osteoporosis, Order DEXA scan and meanwhile advise
for exercise and Vit D and Calcium Supplementation. After the confirmation of
Osteoporosis, Bisphosphonates are the treatment of choice. Remember that Osteoporosis
have normal lab Values.
Hypothyroidism: start L-Thyroxin when TSH > 10. If the pt is symptomatic & TSH 5-
10, repeat in 3 months and then start L-thyroxin if sustained.
Toxic nodule: TSH is low > then do radioactive iodine (123I) thyroid uptake and scan
(not FNA), to identify whether one or more of the nodules is responsible for thyroid
function abnormalities.
Macroprolactinoma with mild mass effect: ALWAYS start with dopamine agonist
(eg:cabergoline), that will shrink the mass to less than 50% of it’s size, and will
normalize the prolactin level in 90% of the pts.
Hypocalcemia should promote parathyroid hormone (PTH) secretion to help correct the
hypocalcemia. If PTH is low/NL, then think about Hypomagnesemia (impairs release of
PTH). Magnesium is essential in production of PTH.
Incidentally noted adrenal mass: Always check plasma free & urine metanephrines!!
Also, perform low-dose dexamethasone suppression test to evaluate for subclinical
Cushing syndrome.
Obese persons (BMI >35) with type 2 DM and associated complications > consider
bariatric surgery.
Primary thyroid lymphoma most often occurs in elderly women with underlying
hypothyroidism; the typical presentation includes rapidly enlarging goiter, weight loss,
and night sweats, and imaging reveals a diffusely enlarged thyroid.
In ESRD: don't use HgbA1C to guide the therapy for DM, as it is not accurate > use
fasting blood glucose and pre/post prandial sugar.
Adrenal vein sampling is performed to evaluate for a bilateral versus unilateral adrenal
cause of primary hyperaldosteronism.
Hyperglycemia caused by chronic pancreatitis is an acquired form of diabetes mellitus

and should be treated with insulin, because the cells secreting insulin are destroyed,
usually by excessive alcohol.
In patients with hyperprolactinemia and hypothyroidism, the hypothyroidism should

be treated first, then the patient should be reevaluated to ensure that the
hyperprolactinemia resolves (do not get MRI yet! Start thyroxin and recheck).
Congenital bilateral absence of the vas deferens is a common cause of obstructive

azoospermia and is frequently associated with cystic fibrosis.
Cortisol replacement therapy should be initiated immediately in persons with confirmed

adrenal insufficiency (am cortisol < 3 μg/dL).
In patients with nondiagnostic basal cortisol values (4-12 μg/dL), stimulation testing with
cosyntropin (synthetic ACTH) is indicated to Dx Adrenal insufficiency.
Cushing disease has increased risk of DVT
Granulomatous disease have increased secretions of vitamin D leading to hypercalcemia
Immobilization leads to hypercalcemia due to bone resorption thus leads to high

phosphate and low PTH
The recommendations of screening for diabetes include all adults with BMI above 25 and
for all adults older the 45 years. People with frank diabetes are at increased risk for macro
and microvascular disease. People with impaired glucose tolerance are at increased risk
for macrovascular disease.
To test for Gastrinoma, patients should be off PPI for one week and then tested for
gastrin level. To confirm, do secretin stimulation test, secretin stimulates gastrinoma cells
to secrete gastrin but it suppresses gastrin release in normal cells. Secretin stimulation is
not affected by PPI and patients are not asked to stop it before the test. In order to
localize the tumor, do somatostatin receptor scintigraphy.
IF you see bone pain, skeletal deformity, pathologic fractures with cranial nerve deficits
and diminished hearing secondary to expansion of the calvarium, high output cardiac
failure and evidence of valve calcification, think of Paget disease. Bisphosphonates are
first line treatment.
Amiodarone might cause hypothyroidism. In a patient with

uncontrolled arrhythmias who presents with hypothyroidism, give
Levothyroxine to fix hypothyroidism, do not stop amiodarone.
Spot urine protein to Cr is the best method for screening for

diabetic nephropathy. Normal is less than 30. Between 30 and 300
is micro. Urine dipstick is not very sensitive as it only detects
marcoalbuminura
Pituitary acidophils include somatotroph and lactotroph, NOT ACTH secreting!
Remember to measure calcium in a patient with pernicious anemia for predisposition to

hypoparathyroidism (olyglandular autoimmunesyndrome type 1)
Tumor lysis syndrome presents with HYperphosphatemia and hypocalemia
Hypothyroidism has high BP due to decrease in HR which is compensated by higher BP
In diabetic ketoacidosis, start potassium therapy when potassium gets below 5meq/L as it
will be decreased more after insulin therapy.
Goal of hypercholesterolemia therapy should depend firstly on LDL level ( most

important) and are more predictive of future events
In HHS, first do Blous of Normal saline until u get lab electrolytes. If potassium is less
than 5.3 mEq then add IV potassium with Half Saline (Not Normal Saline as you will
increase the osmolarity) then insulin. If K is less than 3.3 then leave the insulin till the
end and give 30 mEq K. If K is more than 3.3 then give K and Half saline with Insulin. If
K is more than 5.3 then start Insulin first and recheck K.
Metformin might precipitate lactic acidosis if Cr is more than 1.4
Make sure to give 4 hour interval between viagara and doxazocin.

Viagara is contraindicated in Nitrates
In Paget’s disease, alkaline phosphatase is high while Calcium and
phosphorus are normal. Look for hearing loss and change in hat
size.
For monitoring of DKA, use anion gap or PH as they are reliable.

Serum or urine ketones usually lag behind the PH change
IN osteoporosis, bone pain is only found if there is fracture, no

muscle weakness is seen. While is osteomalacia (vitamin D
deficiency), there is diffuse bone pain and muscle weakness
Patients with Hashimoto are at increased risk for thyroid

lymphoma
Resistance to thyroid hormone presents with symptoms of

hypothyroidism with Elevated levels of thyroid hormone.
Exophthalmos in graves is due to lymphocytic infiltration leading

to fibroblast proliferation and hyaluronic acid deposition, edema
and fibrosis.
Prokinetic agents like metoclopromide and erythromycin are used

in diabetic gastroparesis where patients present with nausea,
bloating, fullness, and post prandial hypoglycemia and early
satiety.
Every 1% increase in HbA1c is equivalent to an increase of

35mg/dl glucose from the mean level.
Parathyroidectomy is indicated for those with aymptomatic

hypercalcemia if they have one of the following:
1) calcium more than 1 unit above normal
2) young <50 years
3) bone mineral density of T<2.5
4) reduced renal function GFR<60
Familial hypocalciuric hypercalcemia have 24 Hr urinary calcium
as less than 100 mg. In Hyperparathyroidism, the urinary calcium
would be higher than 250, although calcium is being absorbed.
For hypernatremia, asses Volume:

1) IF euvolemic , give free water suplmentation.
2) IF hypovolemic and patient is asymptomatic, give 5%
dextrose
3) IF hypovolemic and patient is symptomatic, give 0.9% Saline
then 5% dextrose when patient euvolemic
5% dextrose is preferred over 0.45%Saline for free water
supplementation once the patient is euvolemic.
Patients with HHS or DKA may present with hyperkalemia but

they are in fact potassium depleted because the high sugar level
will induce diuresis and potassium will follow leading to a deficit
of 3-5mg/Kg
Anyone without DM risk factors shall be screened for DM at the

age of 45. IF with risk factors, screening shall be done at earier
age.
Do genetic testing for suspected MEN2a. Calcitonin test is not

reliable
Hyperthyroid patients who are untreated may present with

proximal myopathy with atrophy.
Normal saline is for the acute treatment of hypercalcemia.

Bisphosphonates for the long term
Hyperthyroidism causes hypertension due to hyperdynamic state

rather than systemic resistance. This hypertension is predominantly
systolic. In Hypothyroidism, the hypertension is usually diastolic
and due to high vascular resistance.
PTU is preferred in treatment of Hyperthyroidism in pregnancy.

Methimazole is overall preferred because of the acute liver injury
with PTU
Radioactive iodine is the preferred therapy for Graves disease as it

solves it with one shot. Contraindications to radioactive iodine
include pregnancy and Severe ophthalmology as it might increase
it. The incidence of thyroid cancer is not increased in those who
receive the treatment.
HRT for menopause are used to treat hot flashes and vaginal
atrophy. They are associated with increased risk for breast cancer,
heart attack, stroke and venous thrombosis.
Hereditary hypophosphatemic rickets (vitamin-D resistant rickets)

is an Xlinked disorder with hypophophatemia, slow growth,
rickets. Urinary excretion of phosphate is very high. They have
normal calcium levels, normal to high PTH, high Alkaline
phosphatase with normal to low levels for calcitriol.
Sertoli cell tumor doesn’t present with endocrine abnormalities.

Leydig cell tumor presents with gynecomastia as the excess
androgen is converted peripherally to estrogen
Hypercalcemia due to malignancies other than parathyroid glands

is due to PTH-related peptide.
PTU andmethimazole are used to treat but not cure

hyperthyroidism. The definitive treatment is with Radioactive
iodine ablation. PTU is preferred in pregnancy, otherwise
methimazole is preferred because of its longer duration of action.
Checking serum for Anti-Intrinsic factor antibodies and Antiparietal cell antibodies.
Schilling test is not available everywhere due to difficulties and certification issues
For CML, make sure to test for BCR-ABL protein before giving Imatinib
Bone marrow biopsy is needed to confirm the suspicion of Multiple myeloma and
differentiate it from MGUS
Anemia of chronic disease is characterized by low HB and HCT and Reticulocyte count,
low TIBC and IRON but High Ferritin. IF disease is RA, then control the disease with
DMARDS like methotrexate. If you have a suspicion of neoplastic disorder, then bone
marrow biopsy
ALL patients must undergo prophylaxis of the central nervous system and the best agent
is intrathecal methotrexate
Glanzman thrombasthenia is normal ristocetin reaction but abnormal adenosine and

epinephrine reaction. Bernard solier has abnormal ristocetin but normal ADP and
epinephrine reaction. Both have Normal PT and PTT but prolonged bleeding time
Primary polycythemia has low erythropoietin level and elevated leukocyte alkaline
phosphate.
Erythropoeitin induced hypertension is a common side effect and is seen in 33% of

patients on Hemodialysis with hormone replacement.
Afebrile Neutropenia after chemotherapy does not require treatment other than
observation. Neutropenia is calculated by multiplying the leukocyte count by the
neutrophils percentage, if less than 55 then neutropenia. Neutropenia has to be managed
if the temperature increases pointing to an infection.
Heparin Induced thrombocytopenia has two types:

 Type I: happens within the first 48 hours of therapy, fall in platelet count but less
severe than type II, not immune mediated, no risk for thrombosis, treat by
continuing heparin and observation.
 Type II: happens 5-10 days after administration, severe fall in platelet count,
immune mediated, associated with thrombosis, confirm diagnosis by serotonin
release essay, switch to argatroban or lepirudin if anticoagulation is required.
A finding of a hypocellular marrow with loss or precuros cells, predominanted by fat and
stroma is diagnostic of aplastic anemia
Vitamin B12 is associated with increased LDH and bilirubin due to hemolysis within the
bone marrow. Look for low reticulocyte count. Low reticulocyte count is against
hemolytic anemia.
Iron deficiency anemia starts as Microcytic Normochromic anema and then progresses to
Microcytic hypochromic. At the beginning, MCHC may be normal confirming the
normochromic but size is decreased from the beginning. Iron deficiency in adults is
almost always caused by blood loss from the body through menstruation of
gastrointestinal bleeding.
Hairy cell leukemia express CD11c and CD22
TTT of CLL: stages (0-1)> no TTT is needed, Stages (2,3,4)> fludaribine, or

(chlorambucil as palliative for those who cannot tolerate fludaribine). Prednisone is used
to decrease the autoimmune hemolysis.
Hydroxyurea is used in Polycythemia vera patients who are above 60 and have had a
previous thrombotic event
Anagrelide is used for thrombocytosis that is refractory to other treatments. It produces

orthostatic hypotension and heart failure
aPTT is elevated in HIT due to consumption of thrombin because of

thrombosis.
Offer proctocolectomy at the time of diagnosius of FAP
For testicular tumors, kill first (radical orchidectomy) and then investigate
later
Tumor burden is the most important prognostic factor. It is based on TNM

staging.
For typical fibrocystic disease, aspirate the fluid. If the fluid is bloody, send
for cytology. If the fluid is clear, observe for 4 weeks.
In chronic renal failure, patients are put of erythropoietin to increase RBC

production. This will cause a surge in production and use up of iron stores.
Thus, iron stores shall be checked before injections and iron
supplementation with IV iron dextran may be indicated to make sure that
stores are replenished.
For cachectic patients, use progesterone analogues (megestrol or

medroxyprogesterone acetate) or corticosteroids to increase weight gain and
appetite. Progesterone analogues are preferred over steroids.
Hyposthenuria is seen in sickle cell anemia and sickle cell trait and is failure
to concentrate urine leading to nocturia.
In PCV, the ESR is normal or low but not elevated
Consider carbon monoxide poisoning in patients presenting with headaches,

dizziness and nausea with environmental risk factors like working in closed
spaces and parking lots and traffic
For acute cancer pain, give short acting morphines. Transdermal fentanyl
patches take 8 hours to work. After dosge of morphine is adjusted, use long
acting and then use short acting for rescue if needed.
The presence of thrombocytopenia is a poor prognostic factor for CLL
Alcohol inhibits folic acid enteropathic cycle leading to deficiency
Tumor lysis syndrome causes hyperphosphatemia, hyperuricemia and

hyperkalemia but HUPOcalcemia due to phosphate binding it.
Heterophile antibody testing maybe negative early in the disease and do not
rule out.
Offer colonoscopy for UC patients after 8 years of onset of disease and

repeat colonoscopy on yearly basis. The patient should be informed that
colectomy will be done if dysplasia occurs.
Mets to brain usually due to lung > breast >unknown > melanoma > colon.
Solitary mets are usually breast, colon and renal cell carcinoma. Multiple
mets are usually lung and melanoma
TTP-HUS is due to deficiency or Autobody against Von willebrand cleaving

protease leading to formation of platelet multimers and platelet aggregation.
Plasmapherisis (Plasma exchange) is the treatment of choice as it clears
away these antibodies and replaces the deficient enzyme
Steroids should be given ASAP to patients with Epidural spinal cord

compression to decrease the vasogenic edema. Suspect this with patients
with history of cancer with focal acute back pain. This pain is worse with
recumbent position ( unlike degenerative bone disease where they get
relieved with recumbency). Bone scan identifies mets but doesn’t provide
information about thecal sac compression and is not used for this. MRI is the
gold standard after giving steroids.
Suspected HIT should be managed with stopping all heparin formulations

including LMWH, followed by confirmation with serotonin release essay
and switching to direct thrombin inhibitors (argatroban or fondaparinux)
Solitary brain mets are surgically treated followed by whole brain radiation.
Multiple brain mets are palliatevly treated with whole brain irradiation.
Focal radiation can be used for those who can’t undergo full brain radiation.
Transferrin saturation is defined as Serum iron / Total iron binding capacity.

In IDA, serum iron is low and the total iron binding capacity is high giving a
low transferring saturation
Pernicious anemia patients are at least at double risk for gastric cancer than
the rest of the population
Isolated thrombocytopenia is ITP and can be seen in up to 10% of chronic

AIDS patients. Test for HIV and HepC
Tartarate-Resistant Acid-phosphatase reaction is a strong reaction of

leukocytes to acid phosphatase which is not inhibited by Tartaric acid.
Normally this reaction is inhibited by Tartaric acid. IN hairy cell leukemia,
this reaction is not inhibited and is called TRAP. This type of leukemia has a
relatively specific marker (CD11c)
Seminomas may cause an elevated B-HCG but AFP is almost always

normal. Non-seminoatous germ cell tumors often have elevated AFP and
considerable number has elevated B-HCG
Mechanism of polycythemia is OSA is due to renal sensation of low oxygen

level and the production of more Erythropoeitin.
PNH should be suspected in patients presenting with hemolytic anemia,

venous thrombosis and anemia or thrombocytopenia.
Respiratory
Peak airway pressure is the sum of airway resistance and plateau pressure. Plateau
pressure is the sum of the elastic pressure and PEEP and is calculated by performing the
end inspiratory hold maneuver. PEEP is measured by the end expiratory hold maneuver.
Echocardiography is useful to look for right heart strain and hypokinesis which points to
PE
Platypnea and orthodeoxia are signs of HepatoPulmonary syndrome
In chronic patients with COPD, expect them to have normal PH with increased CO2 and
compensated respiratory acidosis.
When pleural fluid PH is less than 7.2, it is an indication for empyema and thoracic tube
insertion.
Treatment of Invasive asperigellosis is now by Voriconazole. It used to be amphotercin

but not recommended due to high adverse effects of nephrotoxicity and as it showed no
decrease in mortality. Amphotercin may be used as salvage if voriconazole didn’t work.
Lung adenocarcinoma is most common form of lung cancer. Occurs also in NON-
SMOKERS, is typically peripheral airising from scar tissue in the lung
Acute exacerbation of chronic bronchitis is usually from Strep. Pneumo and Moraxella
catarrhalis and should be treated with AMoxiclav (Drug of choice), others like
macrolides, clarithromycin, second or third generation or the newer fluoroquinolones can
be used
If a patient has minimal smoking history and is presenting with severe emphysema, think
of Alpha-1 anti trypsin deficiency. Look for other cues like family history and elevated
liver enzymes.
Amiodarone leads to pulmonary fibrosis ( restrictive disease)
Acute eosinophilic pneumonia is diagnosed by acute febrile illness of less than one week
with hypoxemic respiratory failure and diffuse pulmonary infiltrates on CXR, more than
25% eosinophils on BAL and absence of know causes of eosinophilic pneumonia (drugs,
infections, asthma, and atopic disease). Treat with corticosteroids.
Radiation pneumonitis: CT shows hazy opacities with ground-glass attenuation in the

field of radiation, 6 weeks after the exposure, resolve within 6 months but can progress
to demarcated fibrosis. Usually the area affected is within one line that crosses the body
where the radiation was applied.
Omalizumab (Anti-IgE) is used in moderate to severe persistent asthma with (all):
■ inadequately controlled with inhaled glucocorticoids
■ Evidence of allergies to perennial aeroallergens, and
■ IgE 30-700 U/mL (normal range, 0-90 U/mL).
Allergic bronchopulmonary aspergillosis: dark brown mucous. IgE > 1000. Treatment
with steroids.
Methanol and ethylene glycol ingestion are characterized by encephalopathy, an

increased anion gap acidosis, and an elevated osmolal gap (both gaps).
Isopropyl alcohol: elevated osmolal gap, with NO anion gap acidosis
Pt presenting with profound hypoxia despite high flow O2 → think about Rt to Lt

intrapulmonary shunt. Patient who just got out of surgery, patient who is immobile or
sleepy, atelectasis and lung collapse. Body will try to shift the blood to go to other
aerated areas and so raising FiO2 will not help (physiologic shunt)
Hot Potato voice: epiglottitis
Bronchospasm, diarrhea, flushing! There is some material that is doing this! Carcinoid!
Ship builder or worked in insulation! Remember Asbetosis
Sandblasting workers, mines! Think Silicosis
Anyone who has worked in Aerospace centers and electrical plants! Think about
Beryllium
Hypersensitivity pneumonitis shoud be suspected in those with high occupational

exposure to antigens, including farmers, lab workers and construction workers. The most
important step in management is to avoud exposure to antigens.
For intubation, the tidal volume is according to the disease. Asthma <8ml/Kg. COPD 5-
7ml/Kg. ARDS 6ml/kg. Increasing the tidal volume in patients with COPD leads to
alveolar distention and barotraumas and may even lead to pneumothorax
CURB65 Severity score for admission of pneumonia: Confusion, RR>30, BP<90/60

either one, Age>65. A zero score goes with home treatment, more than this means
admission.
For PE, if the patient is stable, give Unfractionated heparin or LMWH. If the patient is
unstable, give thrombolytics, if any contraindication for thrombolytics, go go surgical
embiolectomy
Exercise induced asthma is due to histamine release from mast cells. Can be treated by
prophylactic beta-2-agnoists 15 minutes before exercise or by using inhaled
cromoglycates or inhaled steroids. Once bronchoconstriction has occured, these
treatments become less effective so they are better done before exercise
Suspected cases of Empyema should be CT scanned as treatment differs for uniloculated

versus multiloculated masses. Do it whenever there is aspiration of pus
Chronic cough causes: GERD, Asthma and Post nasal drip
Emphysema: irreversible permanent dilation or air spaces impairing diffusion
ABPA can happen with marijuana abuse. Treat ABPA with oral glucocorticoids (not
inhalants) and itraconazole
For TB screening: IF there is a family member with TB, all family members should be
PPD and they are very high risk, so any value above 5mm is significant. Very High risk
group include HIV positive, chronic steroid, Transplant patients and Close contact with
TB. IF the person is a health worker, prisoner and immigrant, they are High risk group
and a PPD more than 10mm is significant. IF there is no risk and from general
population, a PPD of more than 15mm is significant.
Pulsus paradoxus is an indication for very severe asthmatic attack (also use of intercostals
muscles). This is due to the fact that the hyperinflated lungs are compressing the hearts
impairing filling process. This patient should be intubated and mechanically ventilated
Pulmonary nodule in a patient less than 35Years, no smoking history and calcified with
less than one cm is classified as low risk and demands only serial CT scans every 3
months for two years. Lesions more than one cm are classified as Intermediate risk and
demand biopsy. If lesion is non calcified, or has stippled eccentric calcification or is more
than 4 cm or has increased in size from the previous X-ray, then it is classified as high-
risk and demands excision. Popcorn calcification is usually benign.
For community acquired pneumonia: Use either 1) Fluoroquinolones alone or 2)

BetaLactam plus macrolide (but not erythromycin due to Qt prolongation or 3)
betalactam plus doxycycline
ARDS: PO2 / FiO2 < 200
Low molecular weight heparin is preferred in Hemodynamically stable PE. Do not use
low molecular heparin in Kidney failure and GFR<10 . Unfractionated heparin or
Thrombolytics are preferred in Hemodynamically unstable patients.
Fat embolism presents with respiratory complications rather than hypovolemic shock
INR for DVT 2-3. INR for metallic valve 2.5-3.5
Enoxaparin, fondaparinux, rivaroxaban cannot be used in patients with GFR

< 30. Use unfractionated heparin as it can be monitored with aPTT
Mobile cavitary mass with intermittent hemoptysis points to the diagnosis of

aspergilloma
Low glucose in pleural fluid is due to high metabolic activity of WBC
Bronchogenic cysts are found in middle mediastinum. Thymomas in anterior

mediastinum. Neurogenic in the posterior mediastinum
Non-seminomatous germ cell tumors produce both HCG and AFP.

Seminimatous only produce HCG
Bronchoalveolar lavage is used for maliugnancies and opportunistic

infections. It is of less diagnostic importance in the diagnosis of intersticial
lung diseases, connective tissue diseases.
Recurrent albuterol inhaler might lead to hypokalemia and muscle weakness.
For Pulmonary effusion, exudative effusion is diagnosed if one or more

imply:
1) Pleural protein / serum protein >0.5
2) Pleural LDH / Serum LDH > 0.6
3) Pleural LDH is greater than two-thirds the upper border of serum
LDH
Exudative effusion differential include: Malignancy, infection, tuberculosis,
Pulmonary embolus(can cause transudative or exudative), Connective tissue
disease and Iatrogenic causes.
Remember, Wisconsin, lytic bone lesions and skin lesions with night sweats,
weight loss and cough is suggestive of Blastomycosis
Pulmonary hypertension is defined as >25 mmHg or >30mmHg with

exercise
Rheumatology
Patients with rheumatoid arthritis with jjoint destruction are at a higher risk
of developing septic arthritis. Look for monoarthropathy with chills and
associated inflammation. Treat with antibiotics.
Watch out for tophaceous gout in patients with Hx of Gout. These tophi might go around
tendon shealths, soft tissues and in a periarticular distribution. Treat with allopurinol.
These nodules do not illuminate, on the other hand, ganglions and epidermal inclusion
cyst contain fluids and transilluminate
Viral arthritis secondary to parvo b19 virus presents with acute onset of symmetric
polyarthritis that resolves within tow months. ESR is not elevated. Stiffness less than 30
minutes. No swelling or tenderness.
Give steroids for sarcoidosis.
Bone Mets pain presents with with constant pain that is worse at night. Always put in
differential in a person with a previous malignancy even if previous tests show complete
resolution as there is always high chance of recurrence
Anterior uveitis is seen with Ankylosing spondylitis. On the other hand, episcleritis is
seen in RA and IBD
Think of disseminated gonococcal infection in patients presenting with pustular lesions

and migratory polyarthralgias.
Typical sites of enthesis are heels, tibial tuberosities and iliac crests.
Good prognosis in sarcoidosis: Erythema nodosum, hilar adenopathy and acutearthritis.

Poor prognosis: Lung consolidation, black race and extrapulmonary sarcoidosis
Pegloticase has the capacity to lower serum urate levels through enzymatic digestion of
urate; however, it is immunogenic and approved only for treatment-failure gout. Very
expensive
Eosinophilic fasciitis is characterized by woody induration of the extremities sparing the

hands and face in the absence of Raynaud's phenomenon. Skin biopsy: lymphocytes,
plasma cells, and eosinophils infiltrating the deep fascia
Familial Mediterranean fever is characterized by recurrent 12- to 72-hour episodes of

fever with serositis (abdominal or pleural), synovitis, and erysipeloid rash.
Adult-onset Still disease: fever, rash, and joint pain, and serositis (usually pleuritis or
pericarditis). However, fever associated with AOSD is quotidian (everyday), lasts less
than 4 hours, and peaks in the early evening; rash is evanescent, salmon-colored, not
painful, and appears on the trunk and proximal extremities. Abdominal pain is rare.
Markedly elevated serum ferritin level occurs in most patients with AOSD.
In patients with isolated anterior uveitis of unknown cause, a chest radiograph is

recommended to evaluate for the presence of sarcoidosis.
Empty Can test > Rotator cuff Tear
Pain out proportion in a muscle! Think compartment syndrome
Keep INR between 2 and 3 for patients with APS
Lofgren syndrome is an acute, self limiting form of sarcoidosis characterized by fever,

hilar lymphadenopathy, erythema nodosum, anterior uveitis and severe symmetric
polyarthritis. It has good prognosis nd remission in 90%
For ankylosing spondylitis, NSAIDS are started first (indomethacin) then TNF-a
antagonists are used for severe disease. Oral predinisone is not proven to be effective
First thing to do for Raynauds phenomenon is to distinguish between primary and

secondary. If HX doesn’t lead to secondary then do Nail fold microscopy. If negative for
distortion or enlarged capillary loops, then just observe.
Dequervian tenosynovitis is due to inflammation of the tendons of Abductor pollicis

longus and extensor pollicis brevis
First ttt of choice for fibromyalgia is TCA
Felty syndrome is RA, Neutropenia and splenomegaly
Anserine bursitis is found on the ateriomedial part of the tibia.
High dose steroids for giant cell arteritis. Low dose steroids for polymyalgia
rheumatica
Don’t use systemic steroids for psoraiatic arthritis
Neer test is a test where lidocaine is injected in the shoulder joint. If the
shoulder can be moved, then it is rotator cuff tendinitis. If the shoulder can’t
move then it is either rotator cuff tear or frozen shoulder (adhesive
capsulitis)
Gonococcal septic arthritis may present in two ways:

1) asymmetric polyarthritis that is often associated with tenosynovitis
and rash
2) Isolated purulent arthritis of one or more joints.
Viral arthritis presents with small joints polyarthritis that resolves within two
months. Lab may have positive RF and ANA. Treatment may not be
necessary as it would resolve on its own.
Patients with RA are at increased risk for Osteoporosis and osteopenia
Remember that anyone on steroids is at increased risk for osteoporosis and

any small trauma might lead to compression fracture of the vertebra which
might have point tenderness of the vertebrae
Fever and leukocytosis are not reliable signs of osteomyelitis. Point

tenderness is a very reliable sign
Vanishing bile duct syndrome is loss of bil ducts (ductopenia). Most

common cause is primary biliary cirrhosis.
Elevated hepatic enzymes more than 1000 is usually due to acute viral
hepatitis, medication toxicity or hypotensive hepatic injury
Patients with acute mechanical back pain shall be started on analgesics,

muscle relaxants and early mobilization. Bed rest and physical therapy has
not shown to be effective.
Ethanol is metabolized to lactate which competes with uric acid for

excretion
CTS is hypothyroid is due to muccopolysaccharide deposition
Tenderness upon flexion and internal rotation of shoulder is due to

subacromial bursitis.
Infectious Diseases
Babesia is a tick borne illness, found in northwestern USA, hemolysis,
jaundice, without skin rash, treat with quinine-clindamycin or azithromycin-
atovaquone
Serous otitis media is defined as middle ear infection without the presence of
active infection. Patient presents with dull tympanic membrance that is
hypomobile. Patients with HIV usually present with this due to austachian
tube lymphadenopathy or obstructing lymphomas.
Epiglottitis is caused by haemophilus influenza and strep pyogens
Treat CMV disseminated with Ganciclovir plus/minus foscarnet. Treat HSV with
acyclovir. Treat Cryptococcal with amphotercin B. Treat oral and esophageal candidiasis
with Fluconazole, If only oral then consider nystatin. Treat toxoplasmosis with
pyrimethamine and sulfadiazine.
Nocardia is a gram positive aerobe, weekly acid fast bacilli that forms granulomatous-
supparative lesions that can become widely disseminated. Starts with a pulmonary
infectionand is associated with multiple metastatic brain abscesses in one third of
patients. Treat with sulfadiazine or TMP-SMX for months
HIV associated diarrhea: Cryptosporidium (Normal colonoscopy and negative stool

studies), CMV (colonoscopy reveals mucosal ulceration and biopsy shows giant cells)
Prophylaxis for Neisseria meningitides: 1) Rifampin 600 mg, 2X2 for 2 days. 2)
Ciprofloxacin 500mg Single dose 3) Ceftriaxone 250 mg IM
Rash in lyme is called erythema chronicum migrans which has bull’s eye appearance
Following treatment of HIV toxoplasmosis, patients should be put on chronic

suppressive therapy of lower doses of sulfadiazine and pyrimethamine
Empirical therapy for Meningitis is Ceftriaxone and Vancomycin. Add Ampicillin if

there is a suspicion for Listeria. If cultures come back with sensitivity of the organisms to
ceftriaxone, then vancomycin can be discontinued. Strep pneumonia is unlikely to be
sensitive and is usually resistant to ceftriaxone and that’s why we add vancomycin
Hospitalized patients who have Cap should receive a repiratory quinolone as
monotherapy as first line. Ciprofloxacin is not a respiratory quinolone. As second line
treatment, use combination of Third Generation Cephalosporin combined with Macrolide
or Doxycyline.
HIV patients with less than 50 CD4 presents with CMV proctocolitis with tenesmus,
urgency and bloody diarrhea. Teart with Ganciclovir and HAART if the patient is not on
them
Immune reconstitution inflammatory syndrome (IRIS): immune response after

starting HIV management, as the body will start fighting coexisting infections prior to
antiretroviral therapy. (Unmasking of preexisting infection). Look for CD4 BEFORE
starting HAART, correlate with the clinical picture to identify the organism.
CMV in AIDS: usually presents with focal organ involvement, esophagitis/colitis or

retinitis
HIV exposure: post exposure PPx (someone who gets exposed to HIV through sexual
contact or blood) will get three-drug regimen of tenofovir-emtricitabine and raltegravir
Brain abscess from a likely odontogenic source: empiric therapy with IV penicillin and
metronidazole
West Nile virus: Fever, headache, and focal limb weakness following outdoor activities.
Check for CSF Ab.
CMV post-transplant: PPx Ganciclovir is indicated for 3 months if the donor or the
recipient is seropositive. Classic presentation is Colitis (diarrhea/abd pain) or esophagitis.
Even if the Pt received PPX, he can get CMV infection reactivation after a while.
Dengue fever: sudden high fever, frontal headache and retro-orbital pain, myalgias and
arthralgias, severe lower back pain, and rash that appears as the fever abates. Leukopenia
with relative lymphocytosis, thrombocytopenia, and elevation of hepatocellular enzymes
Coccidioidomycosis; southwest US, Mexico, and South and Central America
Herpes simplex encephalitis: necrotizing infection of the temporal lobes (could be

localized to b/l temporal lobes), appear on MRI/CT. Initial CSF PCR could be falsely
negative, repeat 3-7 days later if highly suspecting. Start Acyclovir empirically
Creutzfeldt-Jakob disease: elderly, cognitive impairment, ataxia/spasticity, myoclonus,

and elevated 14-3-3 protein in the CSF
Mycobacterium fortuitum furunculosis is a well-described skin infection in patients

who obtain pedicures at nail salons that use contaminated whirlpool footbaths
NMDA-Receptor encephalitis: autoimmune. AMS, psychiatric symptoms, seizures,
autonomic instability, and choreoathetoid movements. Check for CSF anti-NMDAR
antibodies. May be common and misdiagnosed as viral encephalitis
Middle East respiratory syndrome: caused by a novel β-coronavirus (MERS-CoV)

travel Hx to Saudi Arabia. AKI, viral syndrome, PNA, GI manifestation.
A patient who had a negative PPD at first and the PPD was repeated 2-3 weeks later that
shows an increase in induration is said to be positive while the first test is said to be false-
Negative. This is called Booster effect that happens with people in whom TB infection
happened many years before and whose hypersensitivity has decreased and in patients
with history of BCG vaccination. If a patient is not infected, the second PPD should
remain normal!
With CD4 Levels below:

 200: start prophylaxis against PJP with TMP-SMX
 100: start prophylaxis for Toxoplasmosis with TMP-SMX
 50: start MAC prophylaxis with Weekly azithromycin
Strep pneumo is the most common cause of pneumonia in nursing homes
Measles doesn’t have arthralgias. Adults who get rubella especially girls
may complain of join pain
Treat baciallary angiomatosis with erythromycin. They are vascular lesions

on the skin
The fastest way to diagnose disseminated histoplasma is with serum or urine

antigen. Treat histoplasmosis with Itraconazole
If a dog has rabies, he will die in ten days, that’s why if someone is bitter by
a dog, the dog should be observed without patient PEP
If a patient has hemochromatosis, they will be more susceptible to iron

loving bacteria like Listeria, Yersinia and Vibrio vulnificus
Patients with STDs are at increased risk for other STDs, do RPR, HIV, Pap
smear, hepatitis B surface antigen. If there is a history of drug abuse, do
HepC.
Cutaneous larva migrans is common in travelers to tropical areas and

characterized by pruritic, elevated, serpiginous lesions on the skin. In fection
is often contracted by direct contact with sand that hosts ancylostoma
braziliense
Didanosine: pancreatitis
Abacavir: hypersensitivity
NRTI: Lactic acidosis
NNRTI: Steven Johnson
Nevirapine: liver failure
Indinavir: crystals in urine
Arizona and California: coccidiomycosis
Sudden onset of sharp well demarcated red and tender skin lesion with
raised borders and fever suggests erysipelas (a specific type of cellulitis) and
the most common organism causing it is strep pyogens
Think of vibrio parahemolyticus in ingestion of seafood like shrimps and

crabs and oysters. Patient presents with bloody or watery diarrhea
Current guidelines for treatment of influenza: if there is confirmation of

diagnosis or suspected influenza that presents within 2 days, treat with
oseltamivir and zanamivir. If patients have high risk of complications,
treatment can be started after 2 days.
HIV patient with esophagitis:

1) with Oral thrush: candida
2) without oral thrush: viral (HSV or CMV)
Alkaline urine: proteus mirabilis
Steroids are given empirically for meningitis. If the culture shows strep
pneumo, keep steroids. If no strep pneumo, discontinue steroids.
TMP-SMX is treatment of choice for nocardia
Most commonly detecting mitral valve regurgitation in a patient with IE
Remember Toxic shock syndrome by staph aureus with

hypotension, high fever, vomiting, watery diarrhea, sore throat,
myalgias, macular erythematous rash and conjunctivitis. It might
happen after a break in the skin.
Diagnosis of leprosy is by finding acid fast bacilli in a skin biopsy
Ehrlichia presents with leucopenia and thrombocytopenia with elevated liver

enzymes and without rash. Treat with doxycycline while awaiting for
diagnosis. Found in south eastern and south central USA. Reservoir is deer.
Erythema migrans is pathognomonic for Lyme disease. Start doxycycline

without waiting for lab test. IF patient is pregnant or child less than 8 years,
give amoxicillin. Ceftriaxone is reserved for late Lyme with carditis and
encephalopathy
Vertebral osteomyelitis in its early stages may not have leukocytosis and
may not be shown on Plain X-ray. If the patient has focal tenderness with
High ESR, then go further with MRI
Suspect trichinellosis in a patient who presents with GI complaints followed

by a triad of periorbital edema, myositis and eosinophilia. Other clues might
include subungal splinter hemorrhages, and conjunctival and retinal
hemorrhages.
Rhizopus mucormycosis should be aggressively treated with surgical

debridment and Amphotercin (it is the only antibiotic that is effective)
IE in UTI patients in usually due to Enterococci. Suspected IE in drug

abusers is usually due to staph aureus (treat with Vancomycin, not oxacillin
due to high resistance).
Post exposure prophylaxis for HIV needle stick is with 2 or 3 antiretrovirals

with frequent HIV testing.
CMV mononucleosis presents with fatigue without pharyngitis and without

lymphadenopathy. EBV mononucleosis presents with all these.
Disseminated histoplasmosis presents with palatal ulcers, pancytopenia and

hepatosplenomegaly.
Nocardia can cause lung infection showing gram positive, partially acid fast
filamentous aerobe. TTT with TMP-SMX
Actinomycosis is treated with 12 weeks of penicillin or clindamycin
For PCP give TMP-SMX. IF patient PaO2 is less tan 70mHg, give steroids
with antibiotics as it has shown to decrease mortality
Atovaquone-proguanil is a drug for malaria prophylaxis given that Cr clearance is more

than 30 ml/min. Chloroquine is the first agent used in chloroquine-sensitive areas (which
are Costa Rica, Mexico, Salvador, Argentina, Caribbean, and Paraguay). Africa and
Brazil are choloroquine resistant areas. Use mefloquine or Doxycycline instead of
atovaquone-Proguanil. Don’t use mefloquine (contraindication) in patients with cardiac
conduction abnormalities, neuropsychiatric symptoms or seizures
Give TMP-SMX for kidney transplant patients to prevent PCP pneumonia.
For injuries administer Tdap with TIG if dirty and no hx of previous vaccination.
Any patient with active TB, or Herpes zoster in a young patient or seborrheic dermatitis
in a young patient, demands testing for HIV
For IMN, the best next appropriate is CBC with heterophile test (monospot). BUT the
most sensitive and specific is testing for IgM against VCA
According to CDC, chloroquine, atovaquone/proguanil or doxycycline are recommended

drugs for malaria propylaxis for those travelling to choloroquine sensitive areas. These
areas include countries of Central America (Mexico, El Salvador, and Costa Rica),
Argentina, Paraguay and the carribean. Mefloquine or doxycycline is recommended for
malaria prophylaxis in choloquine resistant malaria endemic areas
For bacterial conjunctivitis: use either erythromycin ointment or Sulfa ophthalmic drops.
The ointment would lead to blurring of vision
Start HIV prophylaxis for MAC at cd4<50 and for Pneumocystis jerovici at cd4<200.
Varicella vaccine can be given for cd4>200, but it is not indicated
Epidemic Typhus by Ricketssia Prowazaki: macular rash on trunk and extremities

sparing palms and soles, by lice. Endemic typhus by ricketssia typhi: gradual onset and
spread by Rat Flea, rash on trunk and fades rapidly. Rocky Mountain spotted fever:
Rickettsia Rikettsii: tick bite, 2-14 days after bite, Rash starts on extremities including
palms and soles and wrists and ankles and then spreads centrally, myalgia and irritability
In AIDS, bloody diarrhea is more with CMV, while Cryptosporidium causes cholera-like
diarrhea
Live attenuated influenza vaccine is made from chicken eggs and so contraindicated if
allergy is present
Inactivated Influenza vaccine is indicated for pregnant women.
For Uncopmlicated pyelonephritis, oral management can be used. Admission for

Pyeloneophritis for the following: severe illness, not tolerating oral, uncertain diagnosis,
old age, other medical illness, pregnancy. Admit for IV antibiotics until no fever for 48
hours and then discharge on oral antibiotics without the need for followup
No treatment of HIV during preganacy: vertical transmission of 25%. With TTT only:
8%. With ttt and cesarian section < 3%
Acute prostatitis is caused by E.coli or Chlamydia infection. Treat with Fluoroquinolone

(Ciprofloxacin or Ofloxacin) for 4-6 weeks to ensure adequate AB level
If pyelnephritis is the infection, if you don’t know the culture and

suspect enetrococcus, give IV gentamycin and Ampicillin. But if
the bacteria are known to be gram negative, give IV ciprofloxacin.
Best initial differentiating test for meningitis is White blood count

in CSF with differentials.
Suspect clostridium infection in IV drug users of Black tar heroin

as its preparation has clostridium spores in it. Look for Crepitus.
Treatment of PCP is IV SMX-TMP. IF patient has PaO2 of less

than 70 or an A-a gradient of more than 35, then give steroids to
decrease the need for mechanical ventilation.
Frontal lobe abscess can be from sinus infection, tooth abscess,

otitis media, mastoiditis. The incriminating organism is usually
Alpha-hemolytic strep and mixed anaerobes (which are the flora of
the mouth)
Vibrio parahemolyticus is a frequent cause of seafood associated

disrrheal illness but only rarely causes septicemia or wound
infection. It may present with bloody diarrhea. On the other side,
Vibrio vulnificus is a fatal organism that can spread from a wound
and it causes dark coloured bullous lesions or from eating
contaminated food. It doesn’t present with diarrhea.
Rememeber neurocysticercosis in adult onset seizure in endemic

countries. Do CT scan. Treat with albendazole and surgical
removal
The risk factor for reactivation of VZV is advanced age, recent

trauma or surgery to the affected site, immunosuppression. Contact
with a child with Varicella is not a risk, it might be a protective
factor indeed.
Cavernous sinus thrombosis occurs because of a septic thrombosis

that can complicate chronis bacterial sinusitis.
Leprosy is by Mycobacterium leprae. Skin biopsy is the glod

standard for diagnosis. Two types: tuberculoid and lepromatous.
Tuberculoid type has vigorous cell mediated immune response and
a week humoral response. Lepromatous form is more disfiguring
and more insidious and progressive that is associated with minimal
or absent immunologic response. Two drugs are needed to treat
leprosy: dapsone, rifabutin and clofazamine. Tuberculoid has
positive skin lepromatous testing while lepromatous has negative
test. NL SPEP for Tuberculoid while Lepromatous has polyclonal
gammopathy. Antibody testing is positive in 50% of patients with
Tuberculoid type and more than 90% of lepromatous type.
HIV vacuolar myopathy is a diagnosis of exclusion and happens

when cd4 counts are too low. It looks like vitamin b12 deficiency.
It is a pathologic process with degeneration of the spinal tracts in
the posterior and lateral columns and have a vacuolated
microscopic appearance.
Patients with Membranous nephropathy are at a greater risk of
renal vein thrombosis more than any other nephritic syndrome.
Presentation includes pain and hematuria. Diagnosis by CT
angiogram.
The most important thing in necrotizing fasciitis is surgical

debridement of the necrotic tissue.
Immdeiately after a needlestick injury with a known HIV-Positive

patient, an HIV test must be done for baseline, followed by post
exposure prophylaxis with 3 antiretroviral drugs for 4 weeks.
Repeat testing at 6 weeks, 12 weeks and 6 months.
Remember Atriventricular block with Lyme disease.
UTI in men require 7 day AB course while they require 3 day

course in women.
Creuzvelt-jakob disease is a rapidfly progressive dementia with

myoclonic jerking movements and most common cause is sporadic
mutations in the prion protein gene.
Skin popping which is injecting drugs intradermally puts one at

risk for secondary amyloidosis. Amyloidosis can cause nephritic
syndrome by amyloid nephropathy
IF a patient is suspected to have Isoniazid-resistant TB, start 4 drug

regimen including Isoniazid until sensitivity and culture comes
back.
Cardiology
Pulsatile mass over groin after cardian catheterization and cool foot with loss of distal
pulses point to Femoral pseudoaneurysms.
Prehypertension needs only lifestyle modification unless patient has other morbidities.
Frank hypertension needs lifestyle modification and oral medication. Diabetics have a
less threshold than normal patients
Sublingual nitrate is indicated in ACS but not in Hypertensive emergencies
Handgrip is used to differentiate between aortic stenosis and mitral regurgitation. It

decreases aortic stenosis, but increases regurgitation.
Situational syncopes include micturition syncope and syncopes after coughing fits.
The arrhythmia that happens due to digoxin toxicity is atrial tachycardia with AV block
and this arrhythmia is quite specific.
Ventricular aneurysms shows ST segment elevation with depp Q waves in the same leads
as in the MI. VA can also present with mitral regurgitation with the progressive increase
in LV size. The way to differentiate between it and papillary muscle rupture, is that it has
ECG changes, wile papillary rupture doesn’t.
If a patient on OCP and has HTN, then stop OCP
For IE, don’t give oral antibiotics. You should continue IV antibiotics for 4 weeks.
Highest rate of AAA expansion is with current smoking. Hypertension has a weak
association with AAA, though BP has to be controlled for overall cardiovascular risk.
Congenital bicuspid aortic valve is the most common cause of Aortic regurgitation in
Developed countries.
Alcohol is an underestimated cause of hypertension which should be addressed firstly if

found without the use of durgs.
Pericardial knock is heard shortly after S2 which is the due to the cessation of ventricular
filling due to pericardial constrition. The knock is heard in 50% of patients with
pericardial contriction
Free wall rupture is a complication 7day post-MI! Presentation as Tamponade that needs
emergent pericardiocentesis
In patients with an intermediate risk of cardiovascular disease (calculated 10-year

CHD risk of 5-7.5%) the measurement of high-sensitivity C-reactive protein has been
proved to be useful for guiding primary prevention strategies, with as many as 30% of
patients being reclassified as either low risk or high risk based on the hsCRP
measurement. Other choice is Coronary artery calcium scoring but make sure patient
has no previous stents or previous hx of CAD.
Patients with hsCRP measurement below 1.0 mg/L are considered at a low relative risk
for coronary heart disease and those with levels of 3.0 mg/L or higher are considered at a
high relative risk. For values of (1-3) testing should be repeated in 2 weeks to assess for
persistent elevation.
Uncomplicated type B acute aortic injury is best treated medically, initially with β-
blockade followed by a parenteral arterial vasodilator (nitroprusside) to control blood
pressure.
Influenza vaccine should be administered to patients with established cardiovascular

disease to reduce the risk of future cardiovascular events
CABG is recommended for patients who remain symptomatic with optimal medical
therapy and have specific angiographic findings (either left main disease or multivessel
disease with involvement of the proximal LAD), concomitant HFrEF, or DM.
AAA repair when: >5.5 cm in men and 5.0 cm in women. Do not get confused with
ASCENDING Aortic ANEURYSM DIMENSIONS
Symptomatic PVCs > 10% (burden) → Try BB or CCBs → if no improvement and

monomorphic → ablation. Avoid Amiodarone in long term due to side effects.
Cilostazol: add to medical management of PAD before going for surgery.

Contraindicated with CKD and CHF.
Wide complex Arrhythmia after MI revascularization → Accelerated idioventricular

rhythm: always less than 120/min and usually less than 100/min. → BB. No need for
amiodarone
Cardiac resynchronization therapy: EF < 35%, NYHA III-IV, and LBBB with QRS >
150 ms.
Severe pulmonary valve stenosis, valve intervention is recommended regardless of the

presence or absence of symptoms
The presence of a conduction block is an indication for surgical therapy in patients with
native valve infective endocarditis (likely developing abscess) → to Dx get TEE even if
the pt is improving. (not TTE or CT. MRI is ok). It is very important to make sure you do
not miss an abscess!
Pt with STEMI failed tPA trial → immediately transferred for rescue PCI
Brugada pattern with symptoms (episodes of syncope) → Brugada syndrome → ICD

implantation
Cardiotoxicity due to Anthracyclines, such as doxorubicin → stop it immediately (do

not decrease the dose).
Pt s/p AFib ablation presenting with unexplained dyspnea → likely Pulmonary vein
stenosis, even with NL examination.
In patients with suspected CAD with baseline ECG abnormalities (preexcitation, LBBB,
paced rhythm, ST depression > 1 mm) → get Vasodilator + imaging stress test.
Exercise stress test will be abnormal in LBBB as the perfusion will be delayed and the
isotope will reach that area late → use Vasodilator to overcome the delay.
For STEMI and NSTEMI: dual antiplatelet therapy for 1 year regardless of initial
treatment approach.
Pt with an ICD going for surgery where electrical cautery will be used → make sure to
deactivate the shock, and switch the mode to asynchronous pacing. The ICD will be
miss-reading the cautery as if it is ventricular tachycardia and then patient will be
inappropriately shocked.
Pt presenting with rapidly worsening heart failure (within weeks) → check TSH. The
most wrong answer is Endomyocardial biopsy!!
HCM: screen All first-degree relatives with a physical examination, EKG, and echo:
 < 12 y → screen when (1) presence of symptoms; (2) family Hx of VT; (3) athlete/intense
training; or (4) clinical suspicion of early LVH.
 12-21 y → Echo every 12-18 months
 > 21 y → Echo every 5 year and whenever develop symptoms.
If shown an ECG and you see more P waves than QRS > third degree hear block
Wide mediastinum on CXR > think about aortic dissection
NL capillary wedge pressure <18
Life style modifications in hypertension: weight loss (up to 20mmHg) > DASH ( up to 15
mmHg)> Limiting alcohol consumption ( up to 4 mmHg)
Asynchronous defibrillation is indicated in Ventricular fibrillation and Pulseless Vtach.

The rest of arrhythmias need synchronous cardioversion
Any symptomatic adult with aortic stenosis requires valve replacement because of high
risk mortality when symptoms develp. Balloon valvuloplasty is reserved for those who
are poor surgical candidates.
Pulmonary veins are the foci for atrial fibrillation. Atrial flutter involves re-entrant circuit
around tricuspid annulus.
Multiple PVCs after MI is frequent and treating them has been shown to worsen survival.
No treatment is indicated if patient is asymptomatic. If patient is symptomatic, start with
b-blockers, second line is amiodarone.
Causes of constrictive pericarditis include radiation therapy, viral pericarditis and heart
surgery
Hepatojugular reflex is used to differentiate between cariac and hepatic cause of ascites.
If there is elevation of more than 3 cm during compression, this signifies positive test and
cardiac cause. The compression would increase venous return but a failing heart cannot
accommodate and thus elevated JVP.
It is difficult to palpate the point of maximal impulse in pericardial effusion
Prior to exercise testing, CCB, BB and nitrates should be withheld for 48 hours before the
test as they reduce the severity and extent of ischemia.
Prominent x and y descent seen in constrictive pericarditis
Hypertrophic cardiac myopathy murmur is best hear at left sternal border while murmur
of aortic stenosis is best hear at right second intercostal space
Lidocaine increases the risk of asystole
Cause of aortic stenosis in less than 70 years is bicuspid aortic valve. Above 70 years is
caused by senile calcific aortic stenosis.
Vasovagal syncope is diagnosed by history. If a test is needed, do upright tilt table which
puts the patient in an upright state for 20 minutes and BP and telemetry is noted.
Using dypiridamole in perfusion scanning uses the steal phenomenon to check for
ischemic areas as blood is shunted from the diseased atherosclerotic that cannot further
dilate into the healthy vessels
Restrictive heart disease is usually irreversible but can be reversible in hemochromatosis
with repeated phlebotomies
Tricuspid endocarditis is caused by IV drug abuse and usually presents with tricuspid
regurgitation rather than stenosis. Conduction defects are not seen in typical endocarditis
but is seen in perivalvular extension into the cardiac tissue.
Premature atrial beats area benign and do not require any diagnosis or treatment
Hypertrophic cardiomyopathy is autosomal dominant
Niacin produces profuse itching through prostaglandin related reaction. Give aspirin to
counteract
The level of BNP correlates with the severity of heart failure. A low level argues against
heart failure and has a high negative predictive value.
Reentrant ventricular arrhythmia is the physiology of Ventricular fibrillation after MI and

is the most common cause of death post MI. Increased automaticity is the mechanism in
glycoside intoxication.
Myocarditis is different than pericarditis by the fact that myocarditis can lead to heart
failure and patient presents with symptoms of failure like pleural effusions, edema, third
heart sounds.
Hypertensive emergency can be divided into Malignant Hypertension and Hypertensive

encephalopathy. Both have BP more than 180/120 but malignant hypertension has retinal
hemorrhages, exudates and papilledema, while hypertensive encephalopathy has cerebral
edema with non localizing neurological symptoms.
Door to balloon less than 90 minutes, door to needle less than 30 minutes
Abstinence of Alcohol is the mainstay treatment of alcohol induced dilated

cardiomyopathy. If this patient is cathed, the study would not show any evidence of
stenosis or decreased perfusion. Look for thrombocytopenias, high mcv, high LFTs.
Free wall rupture happens within 5days to 2weeks post MI
Type A and B aortic dissections require BP lowering and HR lowering with intravenous
Labetalol. Type A then requires surgical intervention.
Uremic pericarditis do not usually present with the ECG for pericarditis. Look for BUN
more than 60. Hemodialysis will lead to fast recovery from chest pain.
Basic tests for hypertensive patients include UA, chemistry panel, Lipid profile and
baseline ECG.
The most important factors in improving survival rate is sudden cardiac arrest is
performing bystander CPR, prompt rhythm analysis and defibrillation.
Mitral valve prolapse is the most common cause of MR in developed countries.
Use CT with contrast to diagnose Aortic dissection if Normal Cr and kidney function. If
abnormal kidney function, do Treansesophageal Echocardiography. Transthoracic echo
has poor visualization of the thoracic aorta.
Indications for aortic valve replacement:

All symptomatic patients with AS
Patients with severe AS undergoing CABG
Asymptomatic patient with severe AS and either poor LV function, LV hypertrophy more
than 15 mm, valve area less than 0.6 cm2 or abnormal response to exercise.
Mixed venous oxygen saturation is high in septic shock because of inability of the tissues
to extract oxygen
Prinzmetal angina has ST elevations while other anginas have ST depression.
Management of diastolic dysfunction incldeas decreasing heart rate with BBlockers or

with CCB, as this will give time for the ventricle to fill.
ECG is the most useful test for the diagnosis of acute pericarditis. Echo is often normal in
acute pericarditis and useful only to rule out coexisting effusion or tamponade
IF WPW shows up in the board exam and you have procainamide and amiodarone, the
answer is procainemaide.
ACEI are first line therapy for HTN in pts with scleroderma, which delays the
progression of kidney disease
Shortness of breath is the most common presentation of HOCM
After doing TTE (not TEE) for HOCM, do holter monitoring for fatal arrhythmias.
In patients whom diagnosis of myocardian infarction is difficult due to a nonspecific or

non diagnostic ECG change, the next step should be to confirm the diagnosis with either
cardiac enzymes or to perform echocardiography in the emergency room is readily
available. Digoxin interrupts the interpretation of the ECG whether there is st elevation of
not as it obscures these readings.
Criteria for Implantable cardiac defibrillator who have HOCM: history of survival of
cardiac arrest or sustained VT in good prognosis patients. Also, high risk patients who fit
2 or more of the following: family history of Sudden cardiac death, syncope,
asymptomatic nonsustained VT, abnormal BP in response to exercise or massive
ventricular hypertrophy.
ABPI is highly sensitive for peripheral vascular disease with normal ABI measurement
more than 1. This test is also best for confirmation of diagnosis. CT angiogram is
reserved for those who want to go for surgery after being confirmed by ABPI
The presence of elevated JVP that increases with respiration (kussmaul sign) is sensitive
and specific for RV in acute inferior MI.
IF a patient is presenting with acute pulmonary edema that hasn’t responded to IV

furosemide, nitrates and morphine, will be given dobutamine which is a positive inotrope
but also dcreases afterload. Dobutamine can cause severe hypotension due to its effect on
afterload. If this happens, give dopamine as it has a pressor effect and it will increase
afterload thus reversing the effect of dobutamine.
Changes in MI: Hyperacute T wave > ST elevation > inversion of T wave > return of ST
to normal > development of Q waves
Recommendations for perfoming angiography is patients with stable angina: Continual

anginal symptoms despite maximal medical therapy, high risk patients who may not
tolerate noninvasive testing, survivors of cardiac arrest or serious ventricular arrhythmias,
patients who have CHF and strong suspicion of severe coronary artery disease. Maximal
medical therapy for stable angina is: aspirin, statin, metoprolol with HR less than 60. If
heart rate is more than 60, then the dose of metoprolol should be increased.
ACEI are not currently recommended for stable angina. They have been shown benefit is
reducing mortality in patients who have ventricular failure as in low ejection fraction.
High BP without symptoms of organ damage (high ICP (blurry vision), renal failure
(bloody tinged urine)) is called hypertensive urgency that is treated with Oral anti
Hypertensives. High BP with end organ damage is called hypertensive emergency that
requires immediate decrease of blood pressure by 25% of the presenting blood pressure
within the first 2 hours by IV medication. The agent of choice is sodium Nitroprusside,
then nitroglycrine, labetalol, hydralazine, esmolol, enalapril and others.
Abrupt sesation of Clonidine can lead to rebound hypertension that is greater than the
patients range of BP. If the doctors wants to discontinue clonidine, the dose should be
tapered down slowly to avoid this phenomenon.
The most important step in the management of cold leg and acute ischemia of the lower
limb is immediate vascular surgery consultation for embolectomy. Irreversible damage
occurs after 6 hours.
Acute anemia oftenly by GI bleeding can result in decreased oxygen delivery to the heart
and myocardial ischemia. ECG will show ST depressions suggestive of Myocardial
ischemia. The best initial treatment is blood transfusion to increase hematocrit and relieve
cardiac ischemia. Remember not to give Aspirin for someone who is acutely bleeding!
Presentation of variant angina: young women, at night, hyperentialation from exercise,

worsened with agents like cocaine and sumatriptan, occurs at any distribution but usually
right coronary artery, look for raynauds phenomena. Changes during the chest pain
episode would show ST elevation in the inferior leads.
Myocardial speckling on Echo is specific for Amyloidosis Resrictive cardiomyopathy.

Hemochromatosis causes restrictive Cardiomyopathy but without Speckling. Alcohol and
Viral myocarditis causes Dilated Cardiomyopathy
Betablockers are the drug of choice for the management of HOCM, as they slow HR and
thus increasing the ventricular filling time. Do not give ACEI, diuretics or nitrates as they
decrease afterload, decrease LV volume and aggravate the outflow obstruction.
The goal of therapy for Diastolic dysfunction is to prolong diastole with negative
inotropic agents like Betablockers or Calcium channel blockers. Also, reduce after load
with ACEI and sartans. Diastolic dysfunction is usually due to uncontrolled high BP that
causes concentric hypertrophy that prevents the heart from relaxing and the usual
accompanied tachycardia which leaves less time for the heart to be filled.
Acute papillary muscle rupture is an acute complication most commonly presenting 3-5
days post-MI. The mortality rate is high and emergent surgical intervention remains the
treatment of choice.
Adenosine stress test may cause bronchospasms and is contraindicated for patients with
AStma or COPD
Any form of bradycardia with signs of hypoperfusion (hypotension, near-syncope,

syncope, lightheadedness) should be initially treated with Atropine. Ultimatley, should be
treated with a permanent transvenous pacemakers if Mobits 2 or complete heart block.
If patient with HOCM who is not responding to medical treatment and with high EF
(meaning that the heart is doing maximal effort to overcome the thickened septum) can
be sent for surgical myectomy.
Sick sinus syndrome is chronic state of SA nodal dysfunction with SOB, palpitations and
angina. Manifestations include alternating bradycardia with supraventricular tachycardia
commonly with AF or atrial flutter. The treatment is by terminating the bradycardia-
tachycardia syndrome by ventricular pacing.
IE prophylaxis is no longer indicated for rheumatic valve or for any other acquired
valvular dysfunction
Coarctation of aorta is associated with Bicuspid aortic valve, VSD and Hypoplastic left
ventricle.
For any presenting pulmonary edema, ECG must be done first to rule out any arrhythmias
that caused this decompensation.
For estimating EF, the most accurate is MUGA not echocardiography. Echo is quick,
inexpensive, non invasive.
WPW is called pre-excitation syndrome and caused by an aberrant connection between

the atria and the ventricles. Medications like digoixin, CCB, BBLockers block
conduction in the normal pathway increasing aberrant conduction that can lead to VT!
Handgrip increases afterload which decreases the intensity of the murmur of HOCM
BBLockers have been shown to improve survival after MI by decreasing oxygen demand.
They are good for both high and low EF less than 40%. For patients with LOW EF, ACEI
have been shown to increase survival. For Normal ejection, BBLocker is better.
The first finding for hyperkalemia is T-wave Preaking > P-wave flattening >
prolongation of PR interval > Widening of QRS > Shortening of QT interval
Prominent U waves are signs of hypokalemia.
Patients who suffered ACS must undergo Submaximal Stress test performed 5-7 post MI
to reach 70% of target heart rate. After 2-weeks post-MI a patient may undergo for
Maximal stress test by reaching 80% of target HR. Any positive tests of these should go
for coronary angiogram.
ADRS is a complication of pancreatitis because of the release of phospholipase which

circulates through the blood stream and damages the alveolar capillary membranes in the
lungs.
Hypothyroidism may lead to hypertension because of increased TPR.
Treatment of hyperkalemia according to best next step:

1) Hyperkalemia with ECG changes: calcium gluconate to stabilize cardiac
membrance, drugs to lower potassium shall be given afterward
2) Hyperkalemia with hyperglycemia: Insulin
3) Hyperkalemia with metabolic acidosis: Bicarbonate.
IN pregnant patients with symptomatic mitral stenosis who fail medical management,
balloon valvuloplasty is the most effective therapy to preserve the life of the mother.
Emergent mitral valve replacement during pregnancy poses excessive risk to both mother
and child. Though, valve replacement may prove necessary following delivery.
The idea behind managing mitral regurgitation is to decrease preload by diuretics,

decrease afterload by ACEI and to push forward cardiac output by giving digoxin.
The most common signs of PE are Sinus tachycardia and Nonspecific ST-Twave
abnormalities. The other classical findings are right axis deviation, atrial fibrillation, right
bundle branch block and S1Q3T3 and are all as much likely as the others.
TEE is better in visualizing Atrial thromi but is not the best initial test. Use TTE in
emergency
Hypotension, tachycardia and rales on auscultation points to Cardiac failure rather than
tamponade. Tamponade have clear lung
Stable anginal symptoms not controlled by maximal doses of BBlockers, aspirin statin
and nitrates indicate coronary angiography and next step is picked up from there
Cholesteroal embolism is treated supportively and carries poor prognosis
For impending aortic dissection, Give Labetolol as it is a B and A antagonist, inhibits

tachycardia and gets BP down. Do not give Nitroprusside as it will cause tachycardia
with enhanced ventricular contraction which might aggrevate the situation
RTA1 is due to decreased Tubular acid excretion. Urine pH is more than 5.5 and there is
low serum potassium. Develops with autoimmune diseases, amphotercin, lithium,
analgesics, ifosfamide, nephrocalcinosis, sickle cell , chronic infection and chronic
hepatitis. Nephrocalcinosis and nephrolithiasis are distinguishing features.
Amiodarone inhibts the metabolism of Warfarin, so warfarin dose should be decreased to

avoid elevations in INR. Amiodarone also inhibts the metabolism of Digoxin which
demands decreased Digoxin dose too.
Best modality to prevent contrast nephropathy is by rehydration with Normal Saline 24

hours before the angiography. Other modalities have been tried but are not proven right
all the time (Bicarbs and N-acetylcystiene)
For SVT, do vagal maneuvers (Valsalva, carotid massage or rectal stimulation), all are
the same. But watch out Carotid massage in a patient with carotid stenosis. After these
maneuvers are done, if they fail do drug therapy
90 minutes is the maximum delay allowed to choose PCI over thrombolytics. For
example if the cath lab is two hours away, start thrombolytics immediately. The time
between patient encounter and thrombolytics administration should be less than 30
minutes
Remember side effectos of digoxin. Draw blood for digoxin levels if patient comes in
with symptoms and is on digoxin. Look for scooping of ST segment. It includes nausea,
diarrhea, fatigue, yellow colour. Drugs like quinidine, amiodarone, spironolactone and
verapamil may increase digoxin levels.
For right sided endocarditis look for multiple cavitations and nodules on chest graph
For suspscion of Subclavian steal syndrome, check BP in both arms
Aortic stenosis is treated by decreasing afterload with ACEI. Diuretics will decrease
preload which will diminish cardiac output. Aortic valve replacement is indicated when
the valve area is less than 1 cm and the gradient is above 50 mmHg
Neurology
In SIADH, there is high intravascular volume and high urine sodium. High urine sodium
is due to the kidney’s effort to normalize the intravascular volume
Patients with excruciating pain should receive adequate analgesia regardless of their IV
drug abuse history. Pain undermedication leads to dis-satisfaction and longer hospital
stay
If a patient has hyponatremia (110): treat with hypertonic saline if seizing,

treat with normal saline if not seizing. In both cases, the increase should not
be more than 12 meq/L/ day
Suspect PML in AIDS patient that presents with multiple non-enhancing lesions.
CNS lymphomas in HIV patients are solitary and weekly enhancing, check for EBV
Suspect Multiple sclerosis in a patient that presents with bilateral trigeminal neuralgia.
15% of myasthenia present with a thymomas
Migraine: brain MRI may show several punctate hyperintensities in the bilateral
subcortical white matter, specifically in the posterior circulation and particularly in
women.
Primary progressive aphasia: loss of language function with relative sparing of cognitive
function. Start with speech therapy. Associated with frontotemporal dementia, also
comes with Alzheimer.
Topiramate: kidney stones
Oxcarbazepine is associated with hyponatremia in 20% to 30%
Suspect nonepileptic seizure in patient with prolonged seizure duration despite multiple
AED. Basically seizures are not real and are sometimes called psychogenic. Risk factor:
PTSD, trauma, psychiatric disorders.
Reversible cerebral vasoconstriction syndrome: thunderclap headache, spontaneously or

triggered by bathing, exertion, or Valsalva maneuvers. May complicated by focal
neurologic deficits. Triggered by exposure to certain medications (sympathomimetic
agents, ergots, triptans) or blood products (transfused erythrocytes, immune globulin), or
catecholamine-secreting tumors.
Carpal tunnel syndrome: immediate decompression surgery if muscle weakness,

atrophy, EMG showed active denervation. Otherwise, splint, NSAID, exercise … etc.
First-line therapy for convulsive status epilepticus is intravenous (IV) lorazepam (not
diazepam) followed by IV phenytoin or fosphenytoin (not keppra).
Deep brain stimulation is the appropriate treatment of patients with advanced Parkinson
disease who continue to benefit from dopaminergic medications but experience
medication-related complications (could not increase the dose). Add entacapone, then
deep brain stimulator.
Worsening neuro exam in patient getting tPA is worrisome for complication of

intracranial bleeding, get CT head without contrast stat.
Metastatic brain tumors and with seizures > HAVE to give AED. Use meds that does not
induce hepatic enzymes (as Pt will get chemo). Use Valproic acid, lacosamide,
lamotrigine, levetiracetam
Someone who is getting crazy at hospital or ICU, think of delirium. High risk if old age
and infected and hx of dementia
Always consider multiple system atrophy when a patient with Parkinsonism presents with
autonomic dysfunction (orthostatic hypotension, erectile dysfunction and incontinence).
It is also called shy-drager syndrome and treated with volume expansion as anti
Parkinson drugs are ineffective
Spinal muscular atrophy shows perineural denervation. Positive SMN gene in blood
Hyponatremia is one of the complications of subarachnoid hemorrhage due to increased
secretion of ANP/BNP which leads to salt wasting
Cavernous sinus thrombosis presents with severe headache and bilateral periorbital
edema and cranial nerve defects (3,4,5,6)
Tick borne paralysis is characterized by rapidly progressing ascending paralysis with

absence of fever and sensory abnormalities and normal CSF examination. In order for
this to happen, ticks should be feeding for 4-7 days and are typically found on patients’
bodies after careful search. Removal of the tick usually improves the situation.
Intracerebral hemorrhage is of slow onset, while intra cerebellar is usually fast onset.
Surgical evacuation is required for Intra cerebellar hematomas before herniation occurs,
unlike intracerebral
The occlusion of anterior spinal artery may present with flaccid paralysis,
loss of bowel and bladder function and loss of pain and temperature
sensation.
Do CSF analysis with SAH as the test increases in sensitivity after 12 hr. CT
decreasers iun sensitivity after 12 hours
Crainiopharyngioma have heavy calcification with unilocular or multilocular

cysts and a viscious yellow fluid content. Benign.
For Guillain barre, mechanical ventilation is required in 30% of patients.

The patient’s tachypnea and SOB indicated impending respiratory failure.
Increased likelihood of intubation: time of onset of symptoms to admission
less than 7 days (Fast progression), inability to cogh, inability to stand,
inability to lift elbows, inability to lift head and high liver enzymes.
All anaerobic infections in the CNS (Bacteroides fragilis) should be treated with IV
metronidazole. Steroids can be added if there is substantial mass effect.
Herpes encephalitis is usually due to reactivation. Immediate IV acyclovir is indicated as

it has a poor prognosis and immediate treatment is indicated. Look for olfacatory
hallucinations as it hits the temporal lobes
For Growth hormone secreting pituitary tumor, first line is surgery. Medical treatment is
used in patients who don’t tolerate surgeries or if the tumor is less than 1 cm (Octerotide>
pegvisomant(GH antagonist> bromocriptine and cabergoline)
HIV encephalitis after excluding other diagnoses by CSF analysis and MRI
Meningiomas are extra axial, well circumscribed and cause adjacent skeletal thickening
CT scan shall be done before LP in an adult with suspected meningitis is the patients has
the following risk factors: Papilledema, Immunocompremised stste, new onset seizure,
history of CNS disease (mass lesion, stroke), abnormal level of consciousness, focal
neurologic deficit.
The frequent site of Brain mets is at the junction of the grey matter and white matter in
the cortex at the watershed area between the middle and posterior cerebral perfusion
zones. Lung cancer is the most common cause of mets to the brain.
Intracranial hypertension is more than 20 mmHg. Presents with headache, nausea, blurry
vision that is worse when leaning forward
Optic neuritis is several days of loss of vision, eye pain with movements, central
scotoma, loss of colour vision, afferent papillary defect and inflammation of optic nerve
with flame hemorrhages
Laser photocoagulation may halt the progression of Wet Age related macular
degeneration as it is due to neovascularization
Status epilepticus: Lorazepam or diazepam or medazolam >>> Phenytoin >>

Phenobarbital >>> Propofol >>> inhaled anesthetics
TB meningitis presents as Lymphocytosis in CSF with high protein and low glucose.
Treat with 4 TB medications with steroids. There will be no gram stain
Treatment of Cryptococcal meningitis includes induction phase with Amphotercin B and

flucytosine for 2 weeks followed by a maintenance phase of HAART with fluconazole
for about two months until cd4 count is more than 100
Cryptococcal India ink is 50-70% sensitive, while Cryptococcal CSF antigen is more than
95% sensitive
Meniere disease: hearing loss, episodic vertigo, tinnitus and feeling of ear fullness
Guillain-Barre syndrome can happen in campylobacter and HIV. Look for albumino-
cytologic dissociation
Symptoms of acute brain stem infarction are best evaluated with angiography as it will
evaluate the source of bleeding, thrombus or stenosis.
Best way to monitor respiratory condition in GBS is with bed side serial Vital Capacity
measuring
Hyperactive reflexes and upgoing plantar response is incompatible with Diabetic
neuropathy. Look for upper motor neuron lesion
If CN3 is ischemic, only somatic symptoms. IF CN3 is compressed both autonomic and
somatic are affected. This is because the somatic and the autonomic nerves are supplied
by separate blood supply
Primidone and propranolol are given for essential tremors. Primidone is broken up to
Phenobarbital and might cause acute intermittent porphyria which manifests as
abdominal pain, headaches, confusion, hallucinations and dizziness
Deep tendon reflexes may be still found in brain dead patients
For agitation in elderly, use small dose antipsychotics like haloperidol. For agitation in
younger patients, use benzodiazepines.
Carotid end arterectomy is beneficial in asymptomatic patients with more than 60%
stenosis. Carotid stent placement wasn’t proven to be better in asymptomatic patients
Status epilepticus may lead to excitatory cytotoxicity causing cortical laminar necrosis.
Treatment of restless leg syndrome is with dopamine agonists (pramipexole) or

gabapentin
In MS, CSF protein and pressure and cell count are normal. Look for oligolonal bands
Anaerobic organisms are the cause of brain abscesses
Major distinguishing features between aging and dementia is impairment of daily

functioning.
Gait problems in NPH is the most prominent feature, appears early and is broad based
and shuffling. In alzheimers, gait problems come as a late finding.
Anticholinergics like trihexylphenidyl might precipitate acute angle closure glaucoma

with retroorbital pain and blurry vision. Look for other anticholinergic symptoms like
constipation and urinary retention, hyperthermia due to impaired sweating.
Common causes of delirium in elderly patients include polypharmacy, UTI, electrolyte

imbalances.
Pendular reflexes (swinging more than 4 times) is not brisk and is considered in
cerebellar lesions.
Cerebral lobe strokes cause eye deviation
Complex rehional pain syndorome is characterized by severe hyperesthesia weeks to
months following trauma. Initial symptoms include swelling, edema, and redness. Later
in the course, atrophy, cyanosis or pallor or contracture.
The most common initial side effects of levodopa/carbidopa are nausea, hallucinations,
dizziness, somnolensce and headache. After 5-10 years, there might be a side effect of
involuntary movements (dyskinesia)
Craniopharyngioma has two age peaks, children and adults between 55-65 years of age.
Multiple cysts with oily fluid. They are benign tumors. They present in adults with
hypopituitarism, sexual dysfunction, and headache and bitemporal hemianopsia.
Treatment of myasthenia crisis is with intubation and withdrawal of anticholinesterases.
Acute limb ischemia should be immediately anticoagulated with Heparin and given then
continuous infusion of heparin and the referral to vascular surgeon for
thromboembolectomy, thrombolysis, revascularization or amputation if severe
The empiric treatment of confusion is with Thiamine, dextrose, oxygen and naloxone.
Treatment should be directed at the reversible causes even if the history in non-
conclusive until the diagnosis is known.
Hypertension is known to be the most important risk factor for all types of strokes with a
risk of 4 compared to non-hypertensives.
Interferon-Beta is used as a long term management to decrease the frequency of relapses

in MS. Immunosuppressants (cyclosporine, methotrexate, mitoxantrone) can be
employed in the progressive form of MS which is recognized by downhill without clear
cut remissions, it can halt the progression temporarily but doesn’t offer an acceptable
long term solution.
Heat stroke is due to thermoregulation failure. Patients present with >40 degress. If
patient is more than 41 degrees, rhabdomyloysis may ensue with blood in urine. The
body loses its ability to dissipate heat in an effective manner when humidity is more than
75% and when the temperature is highly elevated. Best modality to treat heat stroke is
with IV fluids and applying lukewarm water over the body and running fans to circulate
air that will produce evaporative cooling.
Suspect primary CNS lymphoma in an HIV patient with altered mental status, EBV DNA
in CSF, solitary, weakly ring enhancing lesion in the periventricular area. Even though
toxoplasmosis serology might be positive, it doesn’t mean that it is toxo, as the positive
serology is a common finding in the US. Toxoplasmosis are usually multiple, ring
enhancing lesions in the basal ganglia.
Criteria for brain death:

1) clinical or radiologic CNS catastrophe
2) absent cranial nerves
3) Fixed dialted pupils
4) No spontaneous breathing for 10 minutes
5) Absent gag, corneal, oculovestibular reflex
6) Agreement of two physicians
Patients with trigeminal neuralgia who fail medical therapy may benefit from
microvascular decompression to relivee pressure.
Pseudoclaudication is seen in Lumbar spinal stenosis.
Irreversible tissue damage in a limb signs include complete paraesthesia, complete

paralysis and no audible arterial or venous pulses. Primary amputation is required to
prevent sepsis. No need for arteriography
Nerve conduction studies may be used to show demyelination in GuillainBarreS
HIV patients with presumed Toxoplasmosis with failure of treatment must receive lesion
biopsy to rule out CNS B-cell lymphoma.
Surgical treatment of NPH with CSF shunting may improve cognitive and gait
impairment and that’s why it is very important to diagnose it.
Urinary incontininece is not associated with dementia of lewy bodies.
“Get up and Go” test is an important part of PE for elderly with frequent falls where the
patient is asked to stand up from a chair, go forward, turn and then come backward. This
enables the physician to establish the problem the elderly is facing. This helps to identify
deficits in leg strength, balance, vestibular dysfunction and gait.
In patients with known epilepsy and controlled with medication, a common cause of
breakthrough seizures is subtherapeutic drug levels with may be caused by
noncompliance
HYpopigmented lesions in a baby might point to ash leaf macules in Tuberous sclerosis
that become more visible with Woods lamp. Common presentation with TS include
infantile spasms (sometimes flexion of the body with crying that is often confused with
colic pain and GERD) where EEG will show hypsarrhythmias. Treat with ACTH.
Most common cause of neonatal seizure is hypoxic-ischemic encephalopathy (birth

asphyxia)
First line therapy for trigeminal neuralgia is Carbamazepine. Second line drugs include
phenytoin, gabapentin and lamotrigine
Otosclerosis is autosomal dominant disease in which new immature bone with vascular
channels cause ankylosing of the stapedial foot plate leading to conductive and
sometimes sensory hearing loss which becomes evident in late teens and early twenties.
Pregnancy or OCP use may cause the condition to progress more rapidly.
GYNEcology-OBStetrics
For infertility, if first semen analysis is abnormal, repeat after ten days due to high
variability
IF a pregnant lady had a hx of gestational diabetes, then check her after delivery as 50%
of them go into DM. Do 75g of glucose oral glucose tolerance test and is diagnostic.
Check sugar level after two hours, if level is more than 200 then DM
Gonorrhea and Chlamydia are usually asymptomatic in women. Do PCR of endocervical

specimen for high risk patients with multiple partners, unsafe sex. PCR has replaced
culture or Giemsa.
Down syndrome have high HCG and Inhibin A but low estriol and MSFAP
Adnexal torsion presents with nausea and vomiting. Ruptured cyst doesn’t present with
nausea and vomiting. DO Color US to see blood flow. Torsion mostly happens on the
right side more due to longer utero-ovarian ligament. Management is with emergent
laprascopic detorsion.
For precocious puberty, do GnRH stimulation test. Administer GnRH and check for LH
level. If central cause, LH will rise after GnRH test. If peripheral cause (estrogen
secreting tumor), LH will be low
Intersticial cystitis (painful bladder syndrome) presents with urinary frequency and
urgency and dysparenuea. Pain is eacerbated by sex, filling of bladder, exercise, spicy
food and certain beverages. Other diseases should be ruled out. On cystoscopy shows
submucosal petechiae or ulceration.
Endometriosis presents with 3Ds (dyspareunea, dysmennorhea, dyschezia)
If nucleic acid amplification is used to diagnose cervical discharge, then the results have
high sensitivity and a negative result rules out. For an asymptomatic woman that has only
positive Chlamydia, treat her only for Chlamydia and do not treat her for gonococcus as
negative nucleic acid test rules out the infection. This is not the same when doing cervical
discharge smear and microscopy, as the test is not very sensitive.
Cigarette smoking is the most common preventable cause of Fetal growth restriction
Age related ovarian reserve is a common cause of infertility for women aged more than
35. The reserve is not just by quantity, but also by quality of the oocytes. One in 5
women is infertile in her fourth decade, though she might be having regular menstrual
cycles.
An autopsy should be done after the first child demise (loss of baby after 20 weeks)
Routine testing for HPV is not indicated for women below 30. Give vaccine without
testing if woman less than 26 unless if they are pregnant and give vaccine regardless of
sexual activity.
Absolute contraindications to OCPs include preganancy, recent Hx or increased risk of

thrombotic events (DVT, PE, SLE, and CVA), smoking in patients above 35 years,
undiagnosed vaginal bleeding and estrogen dependent neoplasms. SLE is a
contraindication
Do Pap Smear for all girls at age of 21 regardless of when they started sex. A 14 year old
who started sex last year should be offered Pap smear at the age of 21.
Postpartum, low grade fever and leukocytosis and vaginal discharge are common
findings. The lochia is first bloddy (lochia rubra), after three days becomes pale (lochia
serosa) and then changes to white yellow (lochia alba). Unlike endometritis, the lochia is
not associated with pain or foul smell.
DES is associated with Vaginal and cervical clear cell adenocarcinoma
Before confirmation of PMS, do menstrual diary.
Risk factors that increase the risk of osteoporosis: alcohol, smoking, advanced age, thin
habitus, steroids, malnutrition, menopause and Fx.
OCP use is NOT associated with weight gain.
Uterine rupture is more likely to cause hypovolemia than abruption placenta
Elective abortion is very controversial issue and the law permits that the doctor can refuse
giving abortion for personal or professional reasons. No need to give other excuses. Just
say “I can refer you to a physician who can perform this procedure”
In false labor, there are no cervical changes
For androgen insensitivity syndrome, gonadectomy shall be performed after puberty has
finished
Asymptomatic bacteriruea may progress to pyelonephritis in 30% of cases
Physiologic leucorrhea is copious amount of vaginal discharge that is white or yellow in
colour without any smell and without pruritis or erythema.
If a woman presents on 28th week for preterm premature labor, on US you find a
significant congenital anomaly that is incompatible with life; then labor should be
allowed to proceed without any intervention. Such anomalies include bilateral renal
agenesis.
Granulosa cell tumors secrete estrogens. Sertoli leydig cell tumors secrete androgens
The presence of Renal failure, hypoglycemia, hyperbilirubinema and coagulopathy points

to Acute fatty liver of pregnancy rather than HELP syndrome.
INtrahepatic cholestasis of pregnancy is seen in second or third trimester pregnancy.

Although it is benign for the mother, it carries significant risks for the fetus. Delivery is
recommended as soon as possible when cholestasis is severe.
New onset exudative ascites in a female more than 50 years of age with no risk factors
for liver disease and lack of physical findings for an alternative diagnosis such as CHF
and normal liver functions with SAAG<1.1 should raise the suspicion for primary
ovarian malignancy. Go for pelvic ultrasound or pelvic CT scan.
Postpartum thyroiditis develops within a few weeks to 1 year after delivery or abortion. It
is autoimmune in nature and does not cause thyroid enlargement or tenderness. It usually
resolvces by one year post partum but may progress to permanent hypothyroidism.
Raloxifene is used to increase bone density. It doesn’t increase the risk for breat or
endometrial cancer. Decreases LDL concentration without increasing TGs and TC. It
doesn’t increase HDL level as estrogen does. It should not be used in potients with
previous TE diseases. It doesn’t relieve menopausal symptoms, it might actually worsen
it.
Even if fetal heart tracing shows deceleration and cesarian is scheduled, you cannot
confirm that the fetus is in distress because some fetuses might have no distress while
having some decelerations. So, it is better said that the cesarian was scheduled due to
non-reassuring fetal tracing
A radiation dose of 5 rads or less has not been proven to have any increased risk of
abortion.
Normal folic acid supplementation before pregnancy is 0.4 mg/day. If the mother has had
a previous NTD-affected pregnancy, then 4mg/day is required.
Abdominal Bloating is the most common symptom in PMS (90%) , breast tenderness
(85%), headaches (60%), labile mood (80%), food craving and increased appetite (75%)
For urge incontinence offer pelvic excercises first and frequent voiding every two hours,
then prescribe antimuscarinics
Vaginal secretion and bleeding in a child , Rule out foreign body
Melasmas persist indefinitely, even if OCPs are discontinued, it will be aggrevated by

further pregnancies
Clavicular fracture with shoulder dystocia in Gestational diabetes is the most common
chomplication
Hypotension after spinal anesthesia can be treated with vasocontrictors
Mentum anterior can be delivered vaginally
Evaluation of primary amenorrhea should start at age 13 if there is no breast development

or at 15 if there is breast development
Check for Von Willebrand disease in girls coming with menorrhagia from the start of
menstruation with normal regular cycle
Compound presentation of vertex and arm shall go vaginal delivery
Progestasert is a preogesterone containing IUD that should be replaced annually. Mirena

is a levonorgestrel containing IUD that should be replaced every 5 years. Copper
containing IUD should be replaced every 10 years
Physical trauma (RTA) for a pregnant lady necessitates Close observation with Fetal
monitoring for at least 24 Hours is indicated even if the primary US is assuring with
FHT. This is due to the fact that abruption might happen at any time. Also, normal
observation is not the right answer.
A booster of tetanus toxoid is indicated in 2nd term of pregnancy if not received within 12
years
Pap smear for non high risk previous pap is screening every three years. If previous pap
is suspicious; screening shall be done in a year
In pregnancy: pyridoxine also has shown to decrease nausea. Pyrodoxine-Doxylamine

combination decreases nausea and vomiting, Promethazine on its own decreases nausea
and vomiting . Ondansetron can decrease vomiting but is very expensive. These drugs are
given after Ruling out thyroid disease.
Hyperemisis gravidarum is the low of 5% of pre-pregnancy weight
Granuloma inguinale (Donovanosis) is painless
Trichomonas has pruritis and inflammation. There is no inflammation or pruritis in

bacterial vaginosis.
Metronidazole was thought to be teratogenic but metaanalysis failed to show this. Use in
pregnant and non-pregnant females with Bacterial vaginosis for a dose of 500mg by 2 for
seven days
IN help above 34 weeks, deliver immediately.
Breast engorgement is a common problem post partum due to milk accumulation.

Presents with bilateral tenderness and swelling without fever, starts first day till third day,
peaks 3-5, resolves spontaneously. Use cool compresses, acetaminophen, NSAID for
symptoms control
Endometriosis presents with Dyschezia and dyspareunia and dysnmenorrhea. Laprascopy

is method for diagnosis.
There is no place for medication for lactation suppression. They used to give
bromocriptine but now it is not FDA approved. Pateints are asked to wear a fitted bra
with ice packs and analgesics. Frequent emptying of the breast would lead to more
lactaction.
ABO incompatibility causes mild hemolytic anemia.
Endometritis is caused by polymicrobial organisms and is given gentamycin and

clindamycin imperically.
Levonorgestrel can be used for emergency contraception for up to 120 hours.
Pregnancy is associated with increased total T3 and T4 with normal levels of free T3 and
T4, TSH is normal too.
The mucus at ovulation gains stretching ability of about 6 cm becoming less thick and
clear.
Transvaginal US is the gold standard for evaluation of cervics for incompetency.
Septic abortion needs to be treated with antibiotics and suction curettage
IF patient is allergic to penicillin and has GBS, give vancomycin if erythromycin

sensitivity is not known
Aminocentesis is associated with mid second trimester abortion.
CVS is associated with Limb defects
OCP use for at least 3 years has been shown to decrease the risk of endometrial cancer by
50%. OCP with breast cancer is not yet clear.
Give antacids before epidural placement to prevent aspiration. DO not give meals!
Lochia is the normal shedding of endometrium after delivery of the placenta and may last
up to 8 weeks in some patients. Normal progression is bright-red (lochia rubra) then
pinkish-brown(lochia serosa) then white-yellow(lochia alba)
Benign cystic teratomas might be complicated with torsion in up to 16% and rupture in
4%
The first sign of puberty in girls is thelarche (breast development). The first sign in boys
is testicular growth followed by penile growth and then adrenarche.
Lichen sclerosis is a chronic inflammatory skin disease classified as a vulvar dystrophy.

Symptoms include vulvar itching burning and pain and dyspareunia. Lichen sclerosis is
ass with squammous cell in 5% of cases. Treatment is with High potency topical steroids
like CLobetasol or halobetasol.
Killed intramuscular influenza vaccine should given to any pregnancy regardless of the
trimester if they have significant medical problems as the sequalae of influenza
pneumonia and superinfection with Staph is very bad.
MMR and varicella vaccines are contraindicated in preganancy as they are live
attenuated.
Remove cerclage at 36-38 weeks of preganancy
The treatment of breast cancer in a pregnant woman should be the same as that in a
nonpregnant woman except for two restrictions: No chemotherapy during the first
trimester, No radiation during whole pregnancy.
High levels of LH in PCOS lead to increased androgen which lead to a decrease in

hepatic secretion of SHBG and thus increased free testosterone level and thus hirsutism.
Treatment of symptomatic bacterial vaginosis in pregnancy is indicated for symptomatic

relief and to decrease the risk of preterm labor. Treatment is with oral metronidazole.
IF a women has history of cervical incompetency and she refused prophylactic cerclage,
she should have regular examinations for the cervix at week 16 and so on
Uterine hyperstimulation is more than 5 contractions in ten minutes, contractions lasting
more than 2 minutes or contractions of normal duration occurring within one minute of
each other and a nonreassuring fetal heart rate tracing. Discontinue oxytocin.
Risks for GTN: Advanced Maternal Age and previous Hx of molar pregnancy. At 12
weeks postpartum, the uterus is expected to be fully contracted (actually before that
time). B-HCG should decrease to zero within 2 to 4 weeks post partum. If this doesn’t
happen, RO GTN
Prgenant women with more than 2 episodes of documented UTI, more than 2 episodes of
Asymptomatic bacteriuria or more than one episode of Pyelonephritis should receive
prophylactic Abs for the remainder of pregnancy. Drug of choice is once daily
nitrofurantoin or sulfisoxazole. After the treatment of any infection, do a culture after 10
days.
Test for syphilis at first prenatal visit and should be repeated during the third trimester.
For eclampsia, your first step is to prevent further seizures by magnesium sulfate and
then deliver.
Perform external cephalic version after the 36th week as doing it before so has a high rate
of spontaneous reversion.
Patients with Gastric retention, Urinary retention and Narrow-Angle glaucoma should not
take tolterodine (antimuscarinic) for urinary urgency.
For any pregnant lady who had trauma or accident, admit for observation for 24 hours
with continuous fetal monitoring as she is at risk anytime for abruption.
Up to 5 to 20% of patients who do not receive prophylaxis after elective abortion go into
endometritis. The endometrium would be more than 10mm thick if there are retained
products after abortion which necessitates D&C.
OCP is not a treatment of choice for fibroids. Do myectomy if the woman wants fertility.
For a stable DUB, compbined oral high dose of estrogen and progesterone is given to
stop the bleeding. IF unstable, give IV estrogen.
Pseudocyesis is a rare disorder where the woman has signs and symptoms of pregnancy
including breast tenderness, abdominal enlargement, contractions, nausea and vomiting
and last up to few weeks to 9 months. Failure to prove preganancy with US and HCG.
Happens in women who have an inherent desire to have children.
Treatment of Mastitis is with dicloxacillin with continuing breastfeeding. Staph aureus is

resistant to penicillin and do not give levofloxacin to lactating.
Treat endometritis with CLindamycin and Gentamycin.
Treatment of Vulvovaginal candidiasis is best orally except if woman is

preganancy where topical treatment to prevent embryopathies.
For suspected fetomaternal hemorrhage during delivery:

1) Screening test with Rosette test which shows either positive or
negative:
2) IF negative, then administer the standard 300ug dose of RHoGAM.
3) IF positive, then do kleihaure-Betke stain to quantify hemorrhage.
LEEP is indicated for the therapeutic removal and histologic examination of

cervical lesions including HGSIL and cervical intraepithelial neoplasia grade
2 and 3. It is an outpatient procedure that can be performed with local
anesthesia. Immediate complications include minor bleeding and infection.
Long term complications include cervical stenosis and cervical
incompetence.
Deliver by cesarian if active herpes infection at labor presentation. If the

lady comes in with a history of activation in pregnancy, offer her acyclovir
prophylaxis which will decrease recurrence rate and thus decreasing cesarian
risk. 400 Mg by 3 from week 36 onwards
For treatment of DIC, look for the cause and correct hemodynamic
instability by giving blood products and fresh frozen plasma (antithrombotic
will be consumed fast)
For magnesium toxicity, stop magnesium and administer Calcium gluconate.

Adjust dose for renal patients. Contraindicated for myasthenia gravis as it
can precipitate a serve crisis.
For pregnant ladies with suspected hypertension, do not start medication

unless their diastolic BP is more than 90
Pediatrics
Ataxis-telangectasia show low IgA and IgE
Lead poisoning: without encephalopathy give EDTA and (DMSA or BAL). With
encephalopathy give EDTA and BAL
Bedwetting is normal before the age of 5. Don’t rush and don’t do anything, just reassure.
Transient synovitis of the hip joint is the most common cause of pain in hip joint.
Happens after URTI. Treated with rest and ibuprofen. Child is well appearing and is able
to bear weight, though there is limping. NO fever, no leukocytosis, no high ESR or CRP
as in septic arthritis.
Finger prick testing for lead might have high false positive, do confirmatory venous level.
OCD has been seen in patients with a recent infection of strep pharyngitis and has been
known as “pediatric autoimmune neuropsychiatric disorders associated with strep
pharyngitis” “PANDAS”
Acidified glycerol lysis test for hereditary spherocytosis or do eosine–5-maleimide

binding test
Eczema herpeticum is a form of primary herpes simplex infection on top of atopic

dermatitis. Submandibular adenopathy is present. Acyclovir should be initiated
immediately as it is a life threatening infection
Batteries dislodged in esophageus should be removed immediately while batteries that

have passed the esophagous should be left to pass out
Pinealomas cause parinaud syndrome with impaired vertical gaze. Some are germinomas
secreting HCG stimulating leydig cells and causing early puberty in a male
For suspicion of DDH, do US if less than 6 months. X-ray is done if patient is more than
4 months of age.
Vitamin A decreases morbidity and mortality with measles
Extensive fatty vacuolation of liver cells is seen in Reye’s syndrome. Mortality up to

30%
Pink stains or brick dust on diaper is common and are uric acid crystals.
Trachoma presents with follicular conjunctivitis and neovascularization of the cornea

(pannus formation). Treat with topical tetracycline or oral zithromycin
Fetal alcohol syndrome is characterized by small palpebral fissures, short philtrum, and
thin vermilion border
Atopic dermatitis in infants is seen on face, chest, scalp and extensor surfaces. Diaper
region is spared!
Surgery is indicated for umbilical hernia if persists after 3-4 years, more than 2 cm in
diameter, causes symptoms, becomes strangulated, enlarges after the age of 1-2 years.
Thrombocytopenia in wiskott-aldrich syndrome is due to decreased platelet production

and the platelets are usually small
Mothers that are not vaccinated with tetanus can present with baby umbilical stump
infection and swelling
Presence of calcified parasellar cystic lesion on MRI is almost diagnostic of

crainopharyngioma
Symmetric swelling of hands and feet are seen in sickle cell patients between the age of
6months and 2 years. (dactylitis). The pathophysiology includes vascular necrosis of the
metacarpals and metatarsals.
Think of DM1 in a child who had already been toilet trained but presents with secondary
enurisis with diaper cadidal rash
CF patients less than 20 years are more prone for staph pneumonia. CF patients more
than 20 years are more prone for Pseudomonas.
Recurrent episodes of vomiting and nausea in children without any apparent cause
suggests the diagnosis of cyclical vomiting. Its incidence is high in children whose
parents have migraine.
Hep B and Hep C are not contraindications for breastfeeding except if nipple is cracked
or bleeding.
First febrile UTI in a child less than 2 years is an indication for renal and bladder
ultrasound.
Vascular rings around trachea and esophagous present with stridor that is relieved with
neck extension., this stridor doesn’t respond to steroids or epinephrine.
Laryngotracheomalacia presents with stridor that is worse on supine position and better in
prone.
Both arnol chiari I and II are associated with syringomyelia
Best Treatment for Gaucher disease (deficiency of Gluccerebrosidase) is an Enzyme

therapy replacement with a recombinant enzyme called imiglucerase. This drug costs
400000 Dollars per year. Allogenic bone marrow transplant can be done but is associated
with higher risk of morbidity and mortality
Palivizumab immunoprophylaxis for RSV is indicated for children less than 2 years of
age with Bronchopulmonary dysplasia
Observe and prescribe analgesics for herpetic whitlow. Don’t incise or drain as it will
spread it
In term infants, delayed closure of ductus arteriosus is diagnosed if it is still patent after
6-8 weeks of delivery
Doubling of length by 4 years. Tripling of Weight by 1 Year
Innocent murmur: 30% of children from 3-7, systolic musical murmur, not more than 2/6,
left lower sternal, heard during states of increased output (fever and infection) , reassure
and recheck
Apgar of 8-10 reflects good ventilation and oxygenation so no need for active
resuscitation.
Inability to extend the neck and widened prevertebral space suggests retropharyngeal
abscess
Sleeping babies in supine position has decreased the incidence of SIDS dramatically.
Smoking parents are at increased risk, but smoking cessation has not shown to be
effective.
Up to 80% of patients with erb-duchene palsy correct within 3 months without any
intervention
Laryngeomalacia presents at 4-8 months of age with inspiratory stridor and noisy
breathing. Diagnosis is made by flexible laryngoscopy. Self resolves by 18 months
If anyone contracts pertussis, all close contacts should be taking prophylactic

erythromycin for 14 days because this disease is highly contagious regardless of
immunization status. About 75% of close contacts will have symptoms when exposed
Blood stained eye discharge is highly characteristic of chlamydial conjunctivitis
Myotonic dystrophy is autosomal dominant
Sun protection should be aopplied 30 minutes before exposure to sun for the formation of
a protective film to occur. Repeat every 2 hours.
Nikolsky sign is positive in SSSS and pathology is due to toxin against desmoglein 1. for
impetigo, nikolsky sign is negative.
Rectal diazepam is only incdicated if febrile seizures stay for more than 5 mins
Most common predisposing factor for acute bacterial sinusitis is Upper viral respiratory
infection
Regression of milestones can be seen as a complication of meningitis.
Thyroid dysgenesis comprises 85% of cases of congenital hypothyroidism.
Prematurity is the leading risk factor for the development of Cerebral Palsy
Best prevention from chlamydial conjunctivitis is to test mother before delivery.

Prophylactic Erythromycin ointment is not effective in preventing the chlamydial
conjunctivitis.
Cat bites should be treated prophylactically with amoxiclav for 5 days
Hyperventilation will trigger an absence seizure but not a complex partial seizure.
Absence seizure patients do not have post-ictal state.
Treat local impetigo with topical mupirocin or erythromycin.
Internal carotid artery embolism is a cause of stroke in children usually after trauma to
soft palate with a foreign body
Remember to give Pneumovax for sickle cell patients as they can die with pneumococcal
sepsis.
Post ictal paralysis (Todd’s paralysis) is seen after generalized or focal seizures. Motor
deficits ensure for less than 24Hr and the patient regains control afterwards. It is an
indication that a structural abnormality underlying the seizure is present.
Nieman pick presents with hepatosplenomegaly but taysachs doesn’t!
Muscle biopsy is to confirm the Dx of DMD
Fanconi anemia is an autosomal recessive disorder with congenital marrow failure with
poor growth and morphologic abnormalities with macrocytic anemia. Treat with bone
marrow transplantation.
Beckwith-weidemann should be followed up closely for the development of wilms tumor

and hepatoblastoma. FU with Abdominal US
Lymphedema in turner is due to dysgenisis of the lymphatic network and in non-pitting,

unlike in CHF.
Hepatitis B is associated with nephrotic syndrome due to membranous
glomerulonephritis. Usually associated with positive HBeAg
For Lyme disease, treat with doxycycline if above 8 years, treat with amoxicillin or
cefuroxime if less than 8 years.
Even with surgical correction of cryptorchidism, the sperm count remains below
standard. Testicular torsion complication is eliminated as the testis is held to the scrotal
wall.
IF UA shows proteinurea without other things like blood, there is 10% risk that it would
be positive in children. So, do at least 2 other specimen for proteinura, or else it would be
transient proteinurea. IF other specimens confirm proteinura, go for 24 Hr collection
Down syndrome patients can present with Atlanto-Axial join instability in about 10%.
Patient presents with UMN signs with urinary incontinence, torticollis, and behavioral
changes. If there is hypotonia, this is due to the fact that normal down are usually
hypotonic.
Hearing impairment should be investigated before diagnosing ADHD. ADHD doesn’t

have any language problems.
Breast milk jaundice is unconjugated, may rise as 10-30mg/dl, and appears in the second
week of life, treatment by stopping breast feeding for two days and substitution with
formula milk.
Acute lymphoblastic leukemic cells contain aggregates of PAS positive material. Also
immunostaining for TdT is positive in more than 95%
For alkaline intoxication, first thing ABC, then Endoscopy in order to assess damage and
do further management. Nasogastric lavage and neutralization with an acid are not
recommended
TOF presentation mainly depends on the degree of RVOT obstruction. This causes harsh
systolic murmur in the 2nd left sternal border. Poor pulmonary flow results in Single S2
Clubfoot is initially managed with manipulation, stretching and serial plaster casts, if no
improvement, surgical management can be done between 3 and 6 months of age.
Suspect midgut volvulus in an infant less than one month with bilious vomiting, blood
stained stools and abdominal distension
Spondylolisthesis is devolepmental disorder characterized by a forward slip of vertebrae

that manifests in preadolescent children. Look for back pain, neurologic symptoms and a
palpable step-off at the lumbosacral area.
Gastric reflux can occur in newborns. If the patient Is gaining weight and is otherwise
normal (happy spitter), no need for management, only education by decreasing the
amount and increasing frequency and holding the baby up for 30 minutes. If the baby has
significant irritability and has failure to thrive, then this is pathologic GERD. Treat
pathologic GERD with thickened feeds and antacid therapy. Prone positioning can
decrease reflux but if patient is going to sleep, should be supine.
Breath holding spells area self limited and have no long term sequale, it is associated with
iron deficiency anemia.
Albendazole for enterobius vermecularis.
There was a vaccine for Lyme disease but it was withdrawn in 2002 due to low demand.
The way to prevent the disease is by wearing long sleeves and trousers, insect repelant
and showering if bitten by insect.
Polycythemia in a newborn is defined as Hct more than 65% and is due to delayed
clamping of the umbilical cord that results in excessive transfer of placental blood to the
baby. The baby can present with lethargy, irritability, jitteriness, seizures, respiratory
distress, tachypnea and cyanosis by the high viscosity of blood.
Constipation in children should be treated immediately with laxative until stools are
softened. Sorbitol containing juices may work but not as good as laxatives.
Postviral synovitis may occur 1 to 2 weeks aftar a respiratory infection or Rubella

vaccine. It may represent either a viral infection of the join capsule or an immune
mediated phenomenon. It resolves after a few days, Relieved by Ibuprofen.
Varicella pneumonia is a very bad prognosis in patients with immunocompremised state.
Meperidine during labour might cause repiratory depression in the newborn infant if born
within 2 to 3 hours of drug administration. Neonatal resuscitation must always start with
ABC’s regardless of the cause of the reparatory depression.
For recurrent UTI in a child, do US and Voiding cystourethrogram.
Rocky Mountain spotted fever is a severe disease with potentially fatal outcome (9%
mortality) because of DIC. The Treatment of choice is doxycycline and it is administered
to children even if they are younger than 8 years. If it is not possible, give
chloramphenicol. The side effects of tetracyclines are dose dependent.
If a baby is given oxygen and he becomes tachypneic, this goes with the diagnosis of
hypoplastic left heart syndrome. The pulmonary venous blood goes through foramen
ovale and then to the dilated right ventricle that acts as a systemic pump. The systemic
circulation receives blood through ductus arteriosus. If the duct closes, inadequate blood
goes to the body. Even if the duct remains open, giving oxygen while further dilate the
pulmonary circulation and blood will preferentially flow to the lower pressure system,
depriving the systemic circulation. The infant will have a hyperdynamic precordium
because the right ventricle is contracting against systemic pressure. Loud S2
In patients who have genetic short stature (Familial short stature), the chronological age
is equal to bone age
Apnea of prematurity is cessation of airflow for more than 20 seconds and it often
associated with bradycardia and hypoxemia. First line treatment with Methylxanthines
(caffeine and theophylline)
Give varciella vaccine at 12 months of age
First step in management for CDH is nasogastric suction for bowel decompression to
prevent further lung compression.
For rheumatic fever, give penicillin for the infection and aspirin for the arthralgia.
Normal serum amylase level might be seen in one third of all patients with pancreatitis.
The most feared complication of Juvenile rheumatoid rthritis is asymptomatic

iridocyclitis which can cause blindness if untreated. It may present in all subtypes of JRA
but is particular to pauciarticular disease of early childhood, in which 30% develop the
complication. So slit examination is mandated because it is asymptomatic
Adrenoleukodystrophy is an X-linked disease that results in a peroxisomal membrane

protein defect which causes accumulation of abnormal very long chain fatty acids in
affected organs and present with Neurologic deficits (weakness, spaciticity, dementia,
blindness and quadriparesis), adrenal insufficiency (hyponatremia, postural hypotension,
hyperkalemia, lack of response to cosyntropin stimulation test). mRI is abnormal.
Adrenal disease is detected before neurological.
Indications for surgery for VUR:

1) Anybreak through infection while on prophylaxis
2) New renal scars of renal scan
3) Faiure of VUR to resolve
4) Bilateral and young age
Look for IE in a person who had a murmur months ago (rheumatic fever) and now
presenting with chills for a couple of days after a dental procedure.
Prevalence of celiac in Type 1 DM is 3-6% so it is good to screen them with serum

Tissue transglutaminase antibody in conjunction with a measurement of IgA. If positive,
do colonoscopy and confirm by biopsy. Compliance can be documented by the return of
TTG after 6 to 12 months. Anti-Gliadin has poor specificity and not used for screening
Hexagonal crystals are cystine stones seen in Cystinuria. Radioopaque because of Sulfur
content and seen on X-ray. To confirm do 24-Hr urine for cystine.
Suspect Osteogenesis imperfecta in patients with bone fragility with any of the following:
short stature, scoliosis, basiall skull deformities, blue sclera, hearing loss, increased
laxity, easy bruisability.
Infantile hepatic hemangiomas are self limited and begin involuting at 18 months. Most
of them are asymptomatic but they can have some complications like: High output
cardiac failure, destructions of platelets and coagulopathy, bleeding. Treat with steroids,
if no response, give interferon. If a vacular thing continues to grow during adolescence,
then it is not hemangioma and mostly is vascular malformation.
Ristocetin test is for VWF disease. Ristocetin agglutinates platlets by binding to its GP1b
Most common organisms causing neonatal meningitis (first 3 months of life) include
GBS, Listeria and E.coli
Cerebral Palsy is characterized by non-progressive motor impairment and accompanied

by cognitive disability, mental retardation, visual impairments, skeletal deformities,
seizures, poor oral function, poor growth and development and constipation.
Steven-Johnson manifests with erythematous macules with purpuric centers, the lesions
may be targetoid and there must be involvement of at least two mucosal surfaces (eyes,
mouth, upper airway, GIT and anogenital area). Sloughing is limited to less than 10% of
body surface. Tenderness is minimal but pain from mucosal ulceration is severe. Eye
involvement is conjunctival injection that can be accompanied by anterior uveitis, corneal
ulceration and panophthalmitis. Causes: mycoplasma pneumo, HSV, M,tuberculosis,
HBV, EBV, Enterovirus, leukemia, lymphoma, penicillin, sulfonamides, isoniazid,
tetracycline, cephalosporins, quinolones, phenytoin, Phenobarbital, carbamazepine,
valproic acid, lamotrigene, radiation, captopril, azithromycin, ibuprofen, nsaid,
acetaminophen, sunlight, pregnancy , allopurinol.
Epidermolysis bullosa is a wide variety of hereditary blistering disorders that are

characterized by trauma induced blistering in warm weather too. Lesions heal without
scarring. Usually present at birth
In TAPVR, the heart size is normal with pulmonary edema. Or sometimes there is a
shadow in the supracardiac area forming Snowman appearance.
Pediatric patiens under age of 5 who have exposure to suspected or confirmed cases of
TB are at increased risk of latent infection and should start empiric treatment for latent
tuberculosis with Isoniazid regardless of their initial tuberculin test. If the test is negative,
repeat after 8 to 12 weeks to verify if they have latent or not. If negative, then discontinue
INH.
SIDS is unexplained death of an infant less than one year. Autopsy shows diffuse
intrathoracic petechiae. Risk factors include: respiratory pattern, chemoreceptor
sensitivity, arousal responses, temperature regulation, and cardiac control. Peak
incidence: 2-3 months of age, midnight to 9am, winter more than summer, prematurity,
lack of prenatal care, maternal smoking suring pregnancy, lower SEC, prone and side
sleep position. Siblings of infants who died with SIDS are 6 times risk for SIDS.
Neuroblastoma tends to encase abdominal structures, Mets to liver and bone, increased
uptake on MIBG scan. Wilms tumor (NEPHROBLASTOMA) tends to displace
structures, mets to lungs, doesn’t take MIBG.
If you see anemia with low reticulocyte count after an apparent viral infection, this might
be Transient Erythoblasopenia of Childhood (TEC). This disorder is the most commonly
acquired pure red cell aplasia of childhood. It occurs between 6mo and 3 years of age.
MCV is normal, HBf is normal for age, ADA is normal (unlike diamond-blackfan anemia
where ADA is elevated, congenital hypoplastic anemia). Children recover spontaneously
in 2 months. Manage by following up Hb until resolution of the problem. Transfusion
may be necessary with severe anemia and a longer than normal course.
HSP presents with lower limb petechiae without thrombocytopenias. If peteichae are
found in the setting of thrombocytopenias and leukopenias, think of infiltration of organs
with Leukemic cells.
Adams test (forward bending) is best screening test for scoliosis
Nevus sebaceous is a congenital lesion that occurs at the scalp and surrounded by an area
of alopecia or at the neck, small well demarcated and typically oval plaque that is yellow
orange in colour and is slightly raised. By time this lesion will be come nodular and
warty in adolescence
Signs of neonatal sepsis are nonspecific like grunting, tachypnea, cyanosis, poor feeding,
irritability, apnea, bradycardia, jitters, tremors, seizures. Newborns do not always develop
fever and they might present with hypothermia. Large bulging anterior fontanelle may be
palpated but rarely nucal rigidity.
Delayed resorption of fetal lung fluid describes transient tachypnea of the newborn.
Respiratory distress from birth that improves rapidly with Oxygen administration and
resolves in 2 days. On Xray, there is perihilar streaking (engorged lymphatic system with
retained lung fluid) and there is fluid in the fissures.
For Kawasaki, give 80-100mg/kg/day of aspirin in divided doses PLUS IVIG in high
doses.
For parents who had a child with Down syndrome, they have a 1% increase in risk in
getting another child with down plus the age-related risk of the mother.
Treat SSSS with IV oxacillin. The bullae are non-contagious and sterile, unlike bullous
impetigo.
Mainstay treatment for atopic dermatitis is to hydrate the skin with emollients. Acute
flares show in flexural areas while chronic form is seen on extensor areas.
HIV status is not a reason for exclusion from school or child-care. HIV is transmitted
with blood exposure, vaginal secretions, semen, and breast milk but NOT by saliva. So
even if the child is aggressive with biting and scratching, he should not be excluded from
school.
All complications of streptococcus pharyngitis can be preventable with early antibiotic

treatment except Glomerulonephritis.
The sisters of male children who have fragile X syndrome should receive cytogenic
testing. Heterozygous females may have similar behavios and developmental problems as
those with children who have ADHD.
Newborns with Vitamin K deficiency present between 2 and 7 days with bleeding from
umbilical stump, melena, and large cephalhematoma and after circumcision. PT and PTT
are elevated.
Renovascular disease is the most common of hypertension in children (65%)
The most common cardiac abnormality in infants of diabetic mothers is asymmetric

septal hypertrophy with significant obstruction to left ventricular outflow. There will be
decreased perfusion as evident with weak pulses, decreased blood pressure and prolonged
capillary refill.
Most common cause of congenital hypothryroidism is thryroid dysgenesis. Newborn

presents with coarse facial features, enlarged fontanelles, poor feeding, somnolence, large
tongue, constipation, dry skin and umbilical hernia.
Jervell-Lange-Nielsen syndrome is an autosomall recessive condition with QT

prolongation and Neural deafness. Romano-ward syndrome is autosomal dominant
condition with QT prolongation WITHOUT deafness
Otner syndrome is recurrent laryngeal nerve palse caused by a large left atrium due to
mitral stenosis.
Make sure that coagulation studies are normal before you report to child protection
services.
Serum antibodies are present in 92% of patients at the time of liver abscess by ameba.
Treatment of invasive and extraintestinal ameba is paromomycin, iodoquinol or
diloxanide furoate. Fecal microscopy is not an accurate test for liver ameba abscesses.
Fetal alcohol syndrome with microcephaly, short palpebral fissures, midfacial hypoplasia,
cardiac defects.
Both SSSS and Bullos impetigo are caused by production of exfoliative toxins. Toxin B
is from Staph while Bullos impetigo is caused by toxin A from strep. These deases spare
the mucosa. Positive nikolsky sign. These toxins cleave desmoglein-1
Total Anomalous pulmonary venous return is when all the pulmonary vein drain back in
the systemic venous circulation mixing venous with oxygenated blood. The child presents
with mild cyanosis early and heart failure later. X-ray will show a supracardain shadow
above an enlarged heart with increased pulmonary blood flow and EKG will show right
heart enlargement
For male infants presenting with absent urination and suspicion of posteror urethral
valves. First thing to do is to place a urethral catheter to protect the kidneys. Next thing
for diagnosis is to do VCUG. Retrograde urethrogram is not helpful at all as the dye can
go into the bladder in PUV, but urine can’t leave the bladder.
Ebstein anomaly is associated with WPW
ABx regimens for CF patients:

1) Tobramycin plus ticarcillin
2) Tobramycin plus 3rd generation (ceftazidime and cefepime)
3) Tobramycin and Imipenem or meropenem
IF there is family history of CAH, family counciling includes the administration of

Dexamethasone to the mother no later than 6th week of pregnancy. Then perform CVS at
10-12 weeks of gestation. Dexamethasone will cross the placenta and will inhibit the
secretion of ACTH which will lead to masculanization in a female. IF CVS confirms
male gender, dexa can be stopped. IF female, then dexa has to be given until birth.
Citrobacter koseri is implicated in brain abscess formation. Use third generation

cepahlosporins and aminoglycosides for 4 to 6 weeks and drain it
Suspect Reye syndrome in a child who presents with features of encephalopathy after a
viral infection. A history of aspirin use may not be given in the question.
There is NO evidence that breast feeding transmits Hepatitis C virus and breast feeding is
not contraindicated.
Risk factors of DDH include female sex, breech presentation, family Hx of DDH, and
limited fetal mobility
Diaper dermatitis is a form of irritant contact dermatitis. Treatment involves regular
diaper change and application of zinc oxide barrier ointment or low steroids in severe
cases. Examination shows erythematous scaly patches on the buttocks but sparing the
inguinal skin folds. Candida causes well demarcated red plaques, satellite papules and
superficial pustules and commonly involve the skin folds
Patient who suffer from conditions that cause rapid erythrocyte turnover will experience
symptomatic anemia with B19 like hereditary spherocytosis, sickle cell anemia, and
autoimmune hemolytic anemia.
Remember diastolic decrescendo murmur at the sternal border is aortic regurgitation and
is associated with Marfan Syndrome.
Transposition of great arteries has narrow mediastinum, narrow heart base and absence of
pulmonary artery (because the aorta is coming out of the right ventricle and will
completely cover the pulmonary trunk)
In coarctation of the aorta you can see rib notching on the posterior ribs not Anterior,
because the posterior intercostal arteries are the arteries that are found in the cost groove
Scabies: thin grey, red or brown line, with small erythematous papule, excoriated and
crusted with blood. Look for them in the webs of fingers, extensor elbows, posterior feet,
nipples, genitalia, knees, buttocks. Treat all the family with permethrin cream, overnight
application, repeated once in seven days
Very low birth weight infants are at risks of: Intracranial hemorrhage (32%) > PDA
(30%) > RDS (23%) > Necrotizing enterocolitis (10%)
Give mebendazole for enterobius vermicularis, one dose and then a second dose two
weeks later. Treat family.
For Suspected GH deficiency, obtain IGF-1 and IFG-BP3 level, then do a confirmation
with GH stimulation test.
If a woman of child bearing age is suspected for rubella, make sure to test for pregnancy.
Diagnose Lyme by ELISA then confirm by Western Blot. Treat children less than 8 years
with Amoxicillin and older children with Doxycycline.
Inspiratory obstruction that presents within two months of life and increases when infant
is supine, crying or agitated or during URTI, think of Laryngomalacia.
Bilateral choanal atresia is cyanosis relieved by crying
Viral croup presents in children less than 3 years and has barking symptoms and
inspiratory stridor oftenly after URTI. Absence of cough rules out croup
Red diaper syndrome: infants less than 6 months presenting with red colour due to
physiologic high excretion of Uric acid in Urine.
NEC, if mild without perforation it treated with abdominal decompression, fluids and
electrolyte repletion. If signs of perforation: free air under diaphragm or on lateral
decubitus, fixed dilated on serial x-rays, abdominal wall cellulitis or progressive clinical
deterioration; then go for surgical resection and anastomosis after 6 weeks.
For hYpernatremic hypertonic dehydration; Give the maintenance and solute deficit over
the first 24 Hours, also give with it Half the free water deficit. For the next day, give
maintenance and the other half of the free water deficit over the 24 hours. Hypertonic
dehydration shall be corrected slowly over 48 hours.
For hyopnatremic or isotonic dehydration, give maintenance over 24 hours, half the
deficit over 8 hours, the other half of deficit over 16 hours.
Decreased libido in hyperprolactinemia is due to decreased androgen from the

suppression of LH. Androgen level decrease leads to decreased energy, low libido, loss of
axillary and pubic hair and amenorrhea.
Chile with hypotonia, almond shaped palpebral fissures and hypogonadism (small penis),
do genetic testing for Prader-Willi syndrome
24Hr urine protein should be obtained in all patients presenting with nephrOtic syndrome
(Minimal change) and some hematuria for confirmation of the diagnosis. Give prednisone
as first step in management.
For a patient presenting with Acute Otitis Media with Effusion, send for Audiometry. If
there is no hearing loss, then give antibiotics and follow up for the next month until 6
months. If there is hearing loss then myringotomy and insertion of tympanostomy tube is
indicated to clear the fluid. If the OME has been present for 6 months then immediate
myringotomy is indicated.
Chlamydia trachomatis presents with staccato cough which is short abrupt bursts of
coughing and presents with low or no fever
For patients with VP shunt presenting with meningitis, think of infection of VP shunt.
Remove the shunt and give IV Vancomycin. Most common due to coagulase negative
Staph epidermidis (60%), Next by Staph Aureus.
Positive ANA is of great prognosis in Juvenile rheumatoid arthritis
Treatment of Choice for Strep Pharyngitis is Oral Penicillin V for 10 days. If non-
compliant, single dose Benzathine Penicillin G is appropriate as it is a long acting
penicillin. Intramuscular Procaine penicillin is a short acting penicillin. One shot of
ceftriaxone does not effectively eradicate streptococcal infection.
For acute otitis media, Oral penicillin is the drug of choice for 10 days. Then comes
azithromycin. Make sure that you see the patient in three days to make sure they are
improving.
Teeth eruption: Start at 6 months with Mandibular central incisors >>> Maxillary central
incisors >>> Mandibullar lateral incisors >>> maxillary lateral incisors >>> maxillary
first molars
Fever may be absent in children with osteomyelitis
Congenital torticollis regresses over 4 to 8 months on its own, more than 80% resolve
completely without treatment. Physical therapy with passive movement of the neck is
recommended to prevent further future restrictions. Usually happens with first borns
Suspicion of HD: screening with Anometry and then confirmation with Full thickness
rectal biopsy
Steatorrhea in an infant is due to a very small pool of bile acids compared to adults. So
they lose a lot of bile in their stools leading to fat malabsorption. Treat by substituting
LCT with MCT as MCT do not need bile for absorption.
Growing pains are most commonly bilateral, involving the lower leg and knees, deep
pain during rest and at bedtime, relieved by massaging and analgesics. Positive familial
predisposition.
Scaphoid abdomen in duodenal atresia. 30% of duodenal atresia have Down syndrome.
US is used to detect this anomal during the prenatal period with polyhydraminios.
Infants of mothers with cocain abuse are small for gestational age and sometimes have
microcepahly and neurodevelopmental abnormalities, newborns are irritable and
inconsolable and have high pitched cry, excessive suck.
Disseminated amebiasis can result in abscess formation in the liver which demands US
screening. Liver function is usually normal as the abscess doesn’t destroy the cells.
Diagnosing lysch-Nyhan syndrome is by measurement of HPRT enzyme in blood
Ulcerative colitis has P-ANCA positive in 50-80% of patients.
Trichomonas vaginalis has punctuate hemorrhages of the cervix (strawberry)
Gaucher disease: painless hepatosplenomegaly with elecvated transaminases,
thrombocytopenia and ansemia, pain crisis, avascular necrosis, osteoporosis fractures and
abnormal modeling and widening of distal femur. Deficiency of Glucocerebrosidase.
Think of small left colon in infants of diabetic mothers.
If someone has been bitten by a dog:

1) If the dog is wild; kill it and examine the brain for rabies.
2) Provoked attack of a pet: the dog should be observed for behavioral changes
suggestive of rabies. Dogs with rabies usually die within ten days.
3) IF the animal that attacked is not available for testing, then post exposure
prophylaxis with Vaccine and Rabies immunoglobulin should be administered.
Psychiatry
During the assessment of trichotillomania, it is important to look for other behavioral
disorders like OCD.
Survivors of sexual assaults are at high risk for PSTD, depression and suicidality
Alcoholic halucinosis is a type of alcohol withdrawal that happens 12-24 hours after last
drink, presents with hallucination but without any vital signs change (unlike delirium
tremens)
Adjustment disorder is development of depression symptoms after a certain stressor

within 3 months.
Give SSRI and propranolol for social phobia
Cotard syndrome: nihilistic delusions
Treatment of choice for Paranoia and agitation is Demented patients is low dose of
atypical anti-psychotics
Typical Antipshycotics and Resperidone (atypical) can cause elevations in Prolactin
Varenicline may cause suicidal ideation and is contraindicated in patients with

depression.
Bupropion for smoking sessaion works within two weeks
TTT for acute cocain abuse: Aspirin, Nitrates and Diazepam
Ziprasidone is the only anti-psychotic that is weight neutral. Olanzapine is directly

connected with weight gain
TTT of TCA intoxication is IV resuscitation for hypotension and Sodium bicarbonate for
QRS elongation >100
Vaginismus is treated first by kegel exercises and dilators.
Patients with somatization benefit from regular scheduled appointments
Tourette is associated with ADHD and OCD
Schizophrenia has enlargement of cerebral ventricles. OCD has abnormalities in the

orbitofrontal cortex. Panic disorder has decrease in amygdale volume
Treat manic episode with mood stabilizers and Atypical antipsychotics. Typical
antipsychotics can be used but are not preferred due to movement disorder side effects
Clozapine is reserved for treatment resistant schizophrenia but it causes high risk of
agranulocytosis
Patients who are jehova’s witnesses that do not have this info written and the patient is
unconscious, should be given Blood products if in an emergency situation.
Cocaine presents with erythema of turbinates and septum
Second generation anti-psychotics cause metabolic deranges. Test for FBS and lipid
For bipolar, a son of a parent with bipolar has 10% risk, a son of parents with both eing
bipolar is 60%, monozygotic twin has 70% risk.
Symptoms of hypochondriasis flare up during stress and patients should be asked to

mention their stressors to be referred for psychotherapy.
For TCA poisoning, fast sodium channels inhibition cause QRS prolongation. Use
sodium bicarbonate to reverse this effect.
Fluphenazine “long acting typical antipsychotic” is a major cause of hypothermia by

inhibiting the body’s shivering mechanism and autonomic thermoregulation.
Methanol damages the eye and causes optic disc hyperemia. Ethylene glycol damages the
kidneys
For acetaminophen poisoning, obtain serum level after 4 hours of ingestion. Getting
values before that time is not helpful at all. Use N-acetyle cysteine within 8 hours
The treatment of uncomplicated first episode of Major depressive disorder is for 6
months of antidepressants until remission. Then the drug may be tapered. For any patient
who had two major episodes, the drug has to be continued indefinitely
For depression with severe insomnia, use trazodone
Competence is a legal, not a medical issue. Only courts can decide competence. So if a
psychiatrist is consulted, he should not mention anything related to competency to his
report, he should only mention if there are any changes in judjement, understanding and
mental examination, and psychotic, suicidal.
Cognitive behavioral therapy incorporates exposing the patient to disturbing stimuli in an

attempt to develop coping mechanisms in response to stimuli
Conflicts within family members can be common when having to make the decision of
withdrawingf life support. Even with the existence of an advance directived, it is always
better to do so after reaching an agreement with all the family members.
Dermatology
Herpes can be reactivated after infliximab use. Treat with valcyclovir
For diagnosis of melanoma, do excisional biopsy first with narrow margins, then after
diagnosis is confirmed do wide margins
Treat frost bite with immersion in warm water rapidly
Management of black hairy tongue consists of tongue brushing as part of aggressive oral
hygiene.
Pitted keratolysis: superficial bacterial infection, with small indented pits on a

background of hyperkeratosis and results from increased sweating or perspiration
(hyperhidrosis) of the feet. Increasing odor and wetness involving both feet during the
summer months. First-line treatment is clindamycin lotion or erythromycin lotion in
conjunction with keeping the feet dry.
Dermatomyositis is associated with an increased risk of which lung disease? Interstitial

lung disease.
IBD with colostomy developed peristomal pyoderma gangrenosum (persisting skin

ulceration despite ski hygiene and protector) → Glucocorticoids (oral, topical,
intralesional) are first-line therapy (clobetasol is topical steroid).
Bedbug bites can be recognized by their characteristic grouping in a linear series
pattern; the lesions are painless, pruritic, urticaria-like papules.
DRESS (drug reaction with eosinophilia and systemic symptoms) = drug

hypersensitivity syndrome. Severe and potentially life-threatening type IV
hypersensitivity reaction. 10 days to several weeks after the start of the causative
medication. New rash and flu-like symptoms, lymphadenopathy, and, in severe reactions,
hypotension. Should have a complete blood count with differential to evaluate for
eosinophilia or atypical lymphocytosis and kidney/ liver chemistry tests to assess for
evidence of systemic organ involvement. The treatment is to stop the suspected
medication, and systemic glucocorticoids.
Sweet syndrome: The lesions in Sweet syndrome are “juicy” red papules, plaques, or
nodules with sharp borders, appearing on the upper trunk and proximal extremities in
the setting of fevers. Most commonly seen in patients with hematologic malignancies.
May also occur as a reaction to certain medications, particularly granulocyte colony-
stimulating factors.
Acne in pregnancy: Azelaic acid cream is rated FDA pregnancy category B and is safe
to use for mild comedonal and inflammatory acne during pregnancy. Don’t prescribe
tretinoids even topical
Treatment of Tinea capitis: Oral Griseofulvin for 6-12 weeks>> Oral terbinafine or
Itraconazole. Shampooing with selenium is an adjunct to decrease shedding of spores.
Topical clotrimazole is a common cause of TTT failure
Gross examination for herpes or zoster is better than microscopic examination for
Diagnosis. No further diagnostic tools are needed other than the physical examination.
Palpable purpuric papules on lower extremities: leukocytoclastic vasculitis (HSP and

HepC). Intensely pruritic vesicles on elbows and knees: dermatitis herpitiformis. Edema
and brownish dyspigmentation of the medial lower extremities: chronic venous
insufficiency
Junctional nevi have melanocytes at the dermal-epidermal junction.

Comound nevus has clusters of melanocytes both at the junction and in the
dermis. Intradermal nevus has clusters within the dermis only.
Immunosuppression after solid organ transplantation raises the risk for

developing cutaneous squammous cell carcinoma.
Sebaceous cell carcinoma is a rare cancer of the upper lids of females over
50. A nodle that originally resembles a chalazion and then causes loss of
lashes as well as destruction of the meibomian gland orifices. Biopsy it!
Herpes zoster with postherpetic neuralgia is best treated with acyclovir (also famciclovir,
valacyclovir) and a tricyclic antidepressant. Prednisolone is not used.
Fixed drug eruptions are typically solitary erythematous or violaceous

patches or plaques that occur in an identitcal location with each exposure to
an offending drug. Offending drugs include sulfonamides, anticonvulsants,
NSAIDS, pseudoephedrine and tetracyclines
Pyogenic granuloma is a misnomer. They are best referred as lobular

capillary hemangionas which is a proliferation of small blood vessels in a
fibrous stroma.
Erythrasma is asuperficial bacterial infection of the skin caused by

corynebacterium minutissimum and it affects the intertriginous sites and
digital webspace of the 4th and 5th toe with well demarcated red brown
poatches and macerated plaques. Wood light examination is diagnostic with
Coral Red fluorescence. Treat with oral erythromycin, topical clindamycin
and benzoyl peroxide.
Hyperlinear palms and soles is characteristic finding for Icthyosis vulgaris.
Achrochordon is the medical term given for Skin tag which are cutaneous
polys that do not require treatment unless they are symptomatic or for
cosmetic reasons. They appear pedunculated, small, fleshy lesions in areas
of chronic in fection. There is familial predisposition and an association
between acrochordons and obesity and insulin resistance.
Seborrheic dermatitis that is resistant to treatment > check for AIDS
In atopic dermatitis, treatment includes keeping the skin moist and inhibiting the loss of
water by using bland emollients. Also, advice patient to use less soap as it takes away the
insulating lipids on skin.
Malessezia furfur produces azelic acid which inhibits tyrosinase enzyme in melanocytes
causing hypopigmentation
Familial melanoma syndrome: germline mutation of cyclin-dependent kinase inhibitor
2A (CDKN21) also known as p16INK4/p14ARF. History of pancreatic cancer. This gene
codes for tumor suppressor and loss of heterozygosity leads to cancer
Surgery
Pelvic fractures can easily put a patient into hemovolemic shock. If a patient is not
getting better on IV fluids and has a trauma to pelvis then do External fixation by
wrapping a patient with bedsheet or commercial binders that will cause tamponade effect
and decrease further bleeding of veins. Open fixation will inhibit the effect of tamponade
and increase bleeding.
Acute cardiac tamponade may present with a normal cardiac shadow
Pulmonary contusions generally develop within 24 hours of blunt chest trauma. Irregular
nonlobular opacification of the pulmonary parenchyma on CXR si the diagnostic finding.
The indications for admission is hypoxia and pulmonary contusion findings, give pain
control and pulmonary toilet.
Penile fracture requires urethral imaging before surgical repair
Remember Febrile nonhemolytic transfusion reaction that happens between 1-6 hours
after blood transfusion and is due to the cytokines released from residual plasma or
leukocytes in RBC concentrate
Torus platinus is a congenital boiny outgrowth (exostosis) on the midline suture of hard
palate.
Nondisplaced scaphoid fratures should be immobilized for 6-10 weeks.
For blunt abdominal traumas:

1) If there are clear signs of peritoneal irritation, the diagnosis of acute abdomen is
made and patient should undergo immediate exploratory laparotomy in the
theatre.
2) If there is concern for internal bleeding in an Unstable patient, investigate further
with emergent US or diagnostic peritoneal lavage (No acute abdomen but patient
is still unstable means that there is some bleeding going on but not overt to go for
surgery)
3) Only stable patients should be transported to the CT scanner
Bone scan is for monitoring bony metastasis in prostate cancer
IF a node looks malignant by examination, go for biopsy rather than FNA.
Piriformis syndrome is caused by compression of sciatic nerve as it exits the greater
sciatic formaen below the piriformis muscles. Pain is exacerbated by pressure placed on
the buttocks and sitting.
For a neck mass that looks suspicious ( smoking and drinking, hard, big mass) is mostly a
metastatic squammous carcinoma from a primary carcinoma in the aerodigestive tract.
Perform Panendoscoy (triple: direct laryngoscopy, bronchoscopy and esophagouscopy)
looking for primary tumor with multiple mucosal biopsies
Follicular carcinoma has to be treated with total thyroidectomy and radioactive iodine
ablation therapy. Why total? Because tumor cells do not compete well with normal cells
for iodine uptake, that’s why if you take the thyroid out, tumor cells would be the only
cells taking in the iodine, making sure to destroy any metastatic disease.
Patient on anticoagulants that show neurologic signs should be CT scanned to determine

the etiology of the defect ( Bleeding VS clotting)
Ventilator associated pneumonia happens after 48 hours of tube insertion. Hospital

associated pneumonia happens after 3days of inpatient
Relieve of pain on testicular support (Prehn’s sign): Epididymitis
Asymoptomatic hematochezia for a patient under 45 without family history of colon

cancer should receive anoscopy and flexible sigmoidoscopy; because the majority of
lesions are located distally. Anoscopy alone would miss many lesions. Any patient above
50 or family history of colon cancer should receive colonoscopy.
Adenoid cystic carcinoma is a malignant cancer of the glands like lacrimal
Indications for intubation of a burn patient are dyspnea, hoarsness, wheezing or cough,
stridor or burn or soot inside the mouth or nose. Intubate before edema insues
Neck veins have negative pressure so if they are injured, instead of bleeding, they will
suck air and a hissing sound is heard, leading to sudden death
For suspected stable Pneumothroax, if the site of injury shows “sucking of air” then put
Vaseline gauze and x ray. If no air sucking, then regular dressing and x-ray
For patients with Brain Mets use whole brain irradiation (surgery is less feasible and
chemotherapy is not better)
Morton neuroma is an enlarged nerve located in the foot’s third interspace between the
third and fourth toe. Diagnosis by eliciting pain on palpation of that area. Avoid high
heels. Surgical intervention bny separation of the metatarsals, infiltrations and removal of
the neuroma.
Anterior scalene muscle hypertrophy in excessive weight lifters might lead to Thoracic
outlet syndrome and venous obstruction leading to edema of the arm
IF an inoperable tumor presents, give chemotherapy to decrease the size of the tumor to
do palliative surgery
IN abdominal trauma settings, aggressive fluid replacement might lead to abdominal

compartment syndrome with increase abdominal pressure compressing the lungs, inferior
vena cava and abdominal sutures after laparatomy. That’s why, don’t close the skin
primarily, put a temporary plastic coverage or absorbable mesh as the sutures will blow
off if put and cause skin damage.
If there is bullet injury and there is no exit way for the bullet then use x-ray to identify the
location before admission for surgery
Transrectal US is to detect masses that are not palpable by rectal examination. Transrectal
biopsy is needed for pathology and for Gleason score (sum of two numbers indicating the
prevalence of histological variant, out of 10, the higher the worst)
Postoperative ileus: air in both colon and small intestine, while Obstruction would have a
cut off point. For postoperative ileus, treat by NPO and NG tube for decompression
The only thing that causes air under diaphragm is a perforated viscus. Perforated ulcer
would have an increase in amylase. Pancreatitis and Cholecystitis would not cause air
under diaphragm. Treat a perforated viscus by immediate lapratomy
Rectal inflammation of UC: give aminosalicylate supp.

Pancolitis of UC: give oral aminosalicylate
Post-operative confusion: the most dangerous is hypoxia which is treated by

supplemental oxygen as should be done as the best next step. Stopping medications or
taking blood tests would need a longer duration.
Renal US can be done at time of UTI, while VCUG should not be doen as it include
contrast and might damage the kidney during the infection. DO VCUG after the end of
the UTI
For intermittent claudication, do: ABI >>> Pulse volume recordings with Doppler>>
Angiography (best is angiogram, CTA and MRA can be done)
IF guaiac test is positive in a person who eats red meat, it might be falsely positive. You
have to check if this is bleeding or not by measuring hematocrit as chronic blood loss in
tumors would decrease the hematocrit while if the blood was due to red meat eating then
Hct would be normal.
Mass in parotid: go for partial or total parotidectomy. Don’t risk doing incision or core
biopsies as you might damage the facial nerve. Also, enucleation is not effective if the
tumor turns out malignant
MRI and Triphasic nuclear bone scan tests for osteomyelitis which shows increased
uptake in all three phases. Use triphasic nuclear bone scan when MRI is contraindicated
Cushing triad (hypertension and bradycardia and respiratory depression) is thought to be

due to brainstem compression
Whenever there is a suspicion of urethral injury, do retrograde urethrogram to avoid

further damage before inserting a foley’s catheter
Osgood shlatter disease: microscopic avulsion fractures in teenagers. Give ice and rest,
exercise is not contraindicated and is actually encouraged
Untreated ulcer can do a fistula. Gastrocolic fistula might present with halitosis as fecal
contents go to the stomach and also with diarrhea
Bimalleolar fracture is an unstable fracture and demands emergent splinting (not casting)
and when edema decreases, the case should be openly reduced and internally fixated
For estrogen positive breast cancer, if premenopausal give tamoxifen, if post menopausal
give astrazole. But if the post menopausal women has history of osteoporosis, do not give
anastrazole, give tamoxifen as anastrazole aggrevates osteoporosis.
There might be a formation of hematoma after femoral artery cath. If the puncture was
done above the inguinal ligament, there might be an extension of bleeding into
retroperitoneal space causing significant bleeding with hypotension and tachycardia.
Obtain CT scan without contrast to confirm diagnosis and treatment is mainly supportive.
IF patient is hemodynamically unstable, the patient may need reversal of anticoagulation.
If patient has any neurological deficits of the limb, then surgical decompression is
mandated.
Pelvic abscesses usually present after acute appendicitis with pain, malaise, fever, tender
pelvic mass on PR.
For suspected meniscal injury with popping, do MRI. MRI is preferred over arthroscopy.
After confirmation, do Arthroscopy or open surgery to fix the injury
Diffuse axonal injury is seen on CT scan as numerous minute punctuate hemorrhages

with blurring of grey white interface
Corticosteroid deficiency might present with eosinophilia.
IF lung is bleeding, put it in dependent position and do bronchoscopic procedures.
Chest X ray shall be done after putting central line before administering any drugs
Blunt trauma to the pancreas may be missed in CT the first six hours, follow up by serial
CTscan.
For any fall for more than 10 feet, flunt aortic injury should be ruled out, widening of the
mediastinum is most sensitive
Always remember fast reversal of warfarin effect if emergent lapratomy is needed for
abdominal trauma.
Lung nodules shall be evaluated with CT after CXR. According to their malignancy risk.
If low malignancy risk, serial CT monitoring. IF high risk, go for biopsy.
Knee injury and hemarthrosis = anterior cruciate ligament injury.
Morton neuroma is mechanically induced degenerative neuropathy seen in runners and

presents with pain between the third and fourth toes reproducible with palpation.
Fat necrosis of the breast has mammographic appearance same as a cancer with
speculated calcifications and the mass appears solid in US and may cause nipple
retraction. Biopsy is used to differentiate with the appearance of fat globules and foamy
histiocytes. Standard follow up is sufficient. Only half of the patients admit a history of
Trauma.
In traumatic amputations, the organ should be covered with sterile gauzes filled with
saline and then put in a plastic bag. This plastic bag is put above a bed of ice. This
prolongs viability up to 24 Hr. Ice should not be put directly on tissues as it will freeze
the vessels and make it harder for repair.
Volkman’s contracture is the final result of compartment syndrome where dead muscle is
replaced by fibrous tissue.
Falling on outstretched hands followed by the inability of the patient to adduct his arms
slowly after being passively lifted to more than 90 degrees is diagnosed as rotator cuff
injury.
AAA may rupture and blood fills the retroperitonium and may create an aortocaval fistula
leading to venous congestion of the organs like bladder. Congested veins in the bladder
may rupture leading to hematurea
Anterior cord syndrome is seen in burst fracture of the vertebrae and presents with
paralysis and loss of pain and temperature sensation below the lesion with sparing of
proprioception.
Central cord syndrome is burning pain and paralysis in the upper extremities with relative
sparing of the lower limbs. Seen in elderly with hyperextension of the neck
Tearing ligaments produce hemarthrosis. But tearing of meniscus leads to swelling which
is gradual but not bloody as cartilage is not vascular as ligaments.
Hypoxemia after chest trauma that is worsened with IV fluid administration is pulmonary
contusion. Findings include tachypnea, dyspnea, and chest pain with patchy irregular
pulmonary infiltrates on x-ray
Uretric stone may be associated with ileus due to vagal reaction.
Acute limb ischemia that is reperfused may be subject to reperfusion injury with swelling
and compartment syndrome. Presents with pain out of proportion to the physical
examination findings.
Wound classification: clean (1%), clean-contaminated (3-5%), contaminated (10-15%),

dirty (30-35%)
Seminoma has raised Placental Alkaline phosphatase, Choriocarcinoma has elevated B-

HCG, Yolk sac tumor has elevated AFP, and Embryonal carcinoma has elevated AFP.
CT scan has become the favored study when there is suspicion of Mechanical intestival
Obstruction of Small bowel
Bell’s palsy: associated with Herpes simplex, varicella, EBV and Lyme disease
The drug of choice for aspiration pneumonia is clindamycin.
Colonic pseudo-obstruction or Ogilvie syndrome is characteriozed by abdominal pain and

distention, nausea, constipation typically in the post operative period. X-ray will show
dilated large bowel. Once an obstruction is rules out, give IV neostigmine 2mg slowly.
If hemorrhoids are thrombosed acutely, incise them and remove the clot followed by
compression of the area.
Legg-Calve-Perthes disease is a form of avascular necrosis that presents in boys aged 4-

12 as a painless limp with limited abduction and internal rotation that can proceed to
painful libm worsened by activity and relieved by rest. Diagnosis is with X-ray by
finding of flattened femoral head which later becomes spherical. Management ranges
from observation to physical therapy, rarely surgical as the disease is self limited in two
years. Patients are usually not Overweight (unlike slipped capital), patient has painless
gait with persistently externally rotated femur.
Slipped capital femoral epiphysis presents in adolescent boys as PAINFUL gait
abnormality with externally rotated lower extremity, patients tend to be obese, family Hx,
a little older than Calves disease
Nonocclusive mesenteric ischemia is seen in elderly who have diffuse atherosclerotic

disease in the setting of acute hypoperfusion of vasoconstriction. CT scan demonstrates
small bowel thickening and foci of intramural gas. Angiography would show irregular
ireas of narrowing and dilation of arterial branches.
Posterior dislocation of the shoulder needs axillary view X-ray to be seen. Normal views
would be normal. Anterior dislocation is easily seen on normal views.
Dupuytren contracture is a disease of the palmar fascia that results in shortening and
thickening of fibropus bands in the handfs and fgingers and palpable nodules (Very
characteristic). Insidious onset of joint stiffness and loss of full extension of the digits
which happens over decades. Patients of Scandinavian descent are at very high risk! This
disease belongs to a group of fibromatosis including plantar fibromatosis, penile
fibromatosis (peyronie), fibromatosis of the dorsal interphalangeal joints.
Congenital megaureter is the dilation of the distal ureter without evidence of obstruction.
It results from aperistalisis of the involved area and may remain asymptomatic for long
time or it may lead for the development of hydronephrosis and renal failure. Males are
more commonly affected than females. The majority is unilateral. Bilateral in 25%
Smoking and drinking alcohol are risk factor for esophageal squamous carcinoma. Long
standing GERD is a risk for esophageal adenocarcinoma
Normal systemic vascular resistance is between 1000 and 1300 Dynes.sec/cm5. For cases
where there is high vascular resistance but low BP, a diagnosis of cardiogenic shock can
be made and Dobutamine can be given as first line therapy. Epinephrine is used as last
resort
Malodorous discharge from the nose of a child with blood and unilateral involvement
point to foreign body.
In the presence of normal perfusion pressure, only mechanical problems can suddenly
drive the urine output from normal to zero, like Kinking of the foley catheter. Biologic
problems only happen at a gradual decline.
Visceral artery aneurysms most often involve the splenic artery and have a tendancy to
rupture during pregnancy. Look for a pregnant lady without labor pain. Any artery can be
affected
Bariatric surgical procedure is indicated in the following: motivated patient, BMI>40,

BMI>35 with comorbidity, reasonable surgical risk, failure of previous weight loss
regimens
Penetrating injuries such as gunshot or motor vehicle accident can lead to AVF
classically presenting with a bruit, palpable thrill and tachycardia. In longstanding cases,
this leads to venous hypertension resulting in edema. Most commonly involves groin,
limbs and neck vessels.
Manegment of acute diverticulitis is determined acooring to whether the acute

presentation is complicated or uncomplicated. Complicated is presence of perforation,
abscess, and fistula. Treat with ABx, fluids and urgent surgical exploration and probably
removal of the sigmoid. For uncomplicated cases, admit patient, IVF, ABx, NPO and
probably CT guided drainage of abscess if the patient is stable.
Sonogram can show the disruption of achiles tendon rupture. Do Thompson test by
squeezing the gastrocnemius
For breast mases, Lumpectomy is only done when the mass is less than 4 cm.
Lumpectomy with axillary sampling and postoperative radiation is done for a mass less
than 4 cm in a large breast. If the mass is more than 4 cm, do mastectomy and axillary
sampling. Radical mastectomy is not performed anymore.
Penile cancer is the appearance of a painless, exophytic growth, an ulcerated nodule or a

flat ulcer that doe not heal but keeps on enlarging progressively. Directly related with
absence of circumcision. Look for metastatic lymph nodes in the inguinal area, they are
the strongest prognostic factors. Risk factors include HPV, smoking, smegma, phimosis,
AIDS
Reflex sympathetic dystrophy (Causalgia) is described as an intense burning pain that

occurs after an injury. Early aggressive approach is preffewred because it usually
progresses. Pain management with analgesics and if fails, do sympathectomy.
IF suspicion for Ascending cholangitis, then common bile duct has to be decompressed
from the pus and stones. Stones cannot be seen by US and so we depend on Charcot’s
triad and Reynolds Pentad. Decompression is best with ERCP but also can be done by
percutaneous transhepatic cholangiography or by open surgery.
Patients with CHF should be treated before they undergo major elective surgery. Do not
transfuse blood for them as it will aggrevate the CHF. Treatment includes, ACEI, beta
blockers and diuretics.
Waiting for up to 6 months is advised before noncardiac surgery is performed after an

MI.
Oropharyngeal carcinoma SCC is associated with Alcohol and tobacco and HPV
oncogenic strains.
CT without IV contrast for Nephrolithiasis
GI fluids have a sodium concentration very close to that of plasma. If they are lost, they
should be replaced with isotonic fluids. This DOESN’T happen at home, as patients
usually drink water, sugary drinks, and tea, but they do not eat solid food (that contain
sodium), thus resulting in dilutional hyponatermia.
Ischemic colitis is a known complication of AAA repair secondary to occlusion of IMA.

Prompt recognition and diagnosis with colonoscopy allows for timely resection with a
colostomy to prevent sepsis and death. Things that point to this are Bloody diarrhea,
leukocytosis
Normal colonic mucosa should not bleed in response to anticoagulation. Thus further
tests are needed to detect the abnormality of the mucosa
Epidydymitis occurs as sexually transmitted (young males), or non-sexually transmitted

as UTI. Elevation of the testicle alleviates the pain. In sexually transmitted, there is
purulent discharge and urethral involvement, partners need to be treated.
In patients whom fail medical therapy for GERD, do nissen fundoplication. Do not
remove part of esophagous unless there is high grade dysplasia or Cancer
In patients with hypothyroidism who want to undergo for surgery, their adrenal glands
are also “slow”, patients need to get steroids before getting their Thyroid function up. As
fixing thyroid without addressing the steroid would lead to worsening state.
Normal Prostate mass is 20 to 25 Grams. Patients with BPH who do not have much
improvement on Alpha-1-antagonists and with a prostate of more than 40 Grams can be
given finasteride as it has shown to decrease the size due to the decrease in DHT
Fractures can lead to vascular injury. Diminished or absent distal pulses in the presence
of normal compartment pressure indicates arterial injury where fracture has to be splinted
and CT angiography should be done to assess the damage. Normal compartment pressure
is less than 30 mmHg.
Hernias:
1) IF the patient had no fever, normal white count, Tender abdomen = he could be
obstructed (incarcerated) without strangulation
2) Fever, high WBC and tender abdomen= small bowel has been incarcerated and
lack of blood supply (strangulation), this needs urgent surgery
A complication of Acute pancreatitis is the formation of pancreatic abscess about 10 to

14 days after the episode. Patient presents with high grade fever and leukocytosis. Next
step should be CT scan to locate the abscess for drainage.
A gunshot wound to the abdomen in a patient who has hemodynamic instability mandates
surgical exploration. The pringle maneuver which is clamping the portal triad temporarily
will stop the blood flow if injury is due to any of the vessels in the hepatoduodenal
ligament (portal vein, hepatic artery). If blood continues to flow after this maneuver, then
the vessel injured is hepatic vein or inferior vena cava
The presence of metabolites of both epinephrine and norepinephrine implies that the
adrenal gland is the location of Pheochromocytome, this has to be confirmed by MRI.
Acute GI bleeding after clear fluid aspirate by NGT, perform the following:
1) If bleeding is more than 2ml/min then an angiogram is indicated.
2) If bleeding is less than 0.5ml/min, wait until bleeding stops and then do
colonoscopy.
3) For cases between 0.5 and 2 ml/min, do a tagged RBC
Colonoscopy might not be a good modality at the event of acute non-stop bleeding as the
blood will be obstructing the view.
The only single lesion that can lead to bleeding and obstruction of the biliary tract is
cancer of ampulla of Vater. These cancers are very small and demand endoscopic
examination of the duodenum. CT scan might not detect these small lesions.
FNA results are valuable only when they are positive for malignancy. A negative FNA
does not rule out cancer. Go for tissue biopsy
First thing to do after spinal injury is to give steroids. Better be done within 8 hours.
Surgical decompression can be done afterwards but discussed according to case
In liver transplantation, technical problems with biliary and vascular anastomosis are the
most common cause of early functional deterioration and have to be excluded first.
Antigenic reaction are less common than in other solid organ transplants. If no technical
problems arise and checked, then appropriate liver biopsies are needed to confirm the
diagnosis of organ rejection.
Remember the unique timeline for metastatic melanoma: it is the only malignant tumor
tat once removed, can metastasize 20 years later. Maliganant melanoma goes to all the
usual places and also to weird places (muscle of left ventricle, duodenum, anywhere).
The classic picture is a patient who has mets with a missing toe or a missing eye.
The two tumors that might need eye enucleation are Melanoma and Retinoblastoma
Preventative medicine
HAV vaccine is recommended to all children, as well as for high risk adults
(chronic liver disease, sewers, drug abusers, food handlers, homosexuals,
travelling to endemic areas)
Chronic liver disease patients should receive HAV, HBV, Influenza
inactivated, TDap and pneumococcal vaccine.
Immunity to pertussis may wane overtime, so a single shot of TDap is

recommended after the age of 18 and then TD boosters required every ten
years.
Chlamydial screening in all sexually active women less than 24 years of age
and in any other asymptomatic woman at risk for this infection
Contraindiactions to Rota Virus (Live):

1) Anaphylaxis to vaccine components
2) Personal Hx of Intussusceptions
3) Hx of uncorrected congenital malformations of GIT (meckels)
4) SCID
Animals that can be infected with rabies: dog, bats, raccoons, skunks and
foxes. Other animals like rabbits and rats do not carry rabies.
Women who take rubella vaccine by mistake while being pregnancy should
be reassured as the vaccine trait of rubella has not been associated with fatal
adverse effects
All vaccines should be given according to chronological age rather than

gestational age. The exception is that hepatitis B vaccine should be given
when weight is more than 2 Kgs
Hematology Oncology
Febrile neutropenia is neutropenia with a sustained temperature of more than
38 degrees. Neutropenia is defined as ANC<1500. All require antibiotics but
have to be stratified into oral or people that should be admitted for IV
antibiotics. Management is with Blood cultures and empiric ABx covering
gram positive and negative, including anti-pseudomonal:
pipperacillin/tazobactam or cefipime or meropenem. Add vancomycin if
there is suspected catheter related infection. Colony stimulating factor has
not be proven to be beneficial in these patients. If patient is stable give oral
ciprofloxacin with amoxiclav
For stroke in sickle cell patients, do exchange transfusion.
Hereditary telengectasia (Osler weber) presents with epistaxis, widespread

AV malformation, especially from right heart to left heart having chronic
hypoxia and nail clubbing. Pulmonary AVM can present with hemoptysis.
Serotonin antagonists are first line therapy for Chemotherapy induced

vomiting. Other medications like antidopamine do not work
Over expression of HER2/NEU is seen with FISH
For polycythemia vera acute presentation, give Aspirin or Clopidogrel if intolerant. Then,
phlebotomy until Hct is <45% in males and <42% in females. Add HYdroxyurea if the
patient is above 70 years or if he had a previous thrombosis, platelets more than 1.5
millions or if he has cardiovascular risk factors
Hyper-IgM syndrome is due to CD40L deficiency and inability to class switch
First line for hyperphosphatemia is to give phosphate binders like calcium acetate to
prevent life threatening hypocalcemia. High phosphate level would lead to binding to
calcium and decreasing its blood level. Dialysis is not a first line treatment
Livedo reticularis is a common manifestation of Antiphospholipid syndrome, look for

prolonged aPTT
Patient on warfarin with major bleeding: start 4-factor prothrombin complex concentrate
in addition to intravenous vitamin K. 4f-PCC is superior to FFP. It is expensive and
not everywhere available but this is the target treatment.
Chronic thromboembolic pulmonary hypertension (CTEPH) in patients with a history of

PE and persistent or progressive dyspnea -> get VQ scan (CT angio would be normal in
chronic perfusion defect). If the V/Q scan suggests CTEPH, confirm with right heart
catheterization.
Transfusion: immunocompromised Pt gets: Leukoreduced and irradiated erythrocytes
Persons with hereditary hemochromatosis: advised to avoid Raw or undercooked seafood

(risk for Vibrio infection) with subsequent sepsis and death. As excess iron decreases the
immunity for vibrio.
Iron malabsorption is usually caused by generalized malabsorption conditions such as

celiac disease, achlorhydria, or Helicobacter pylori infection.
Patients with amyloidosis should undergo amyloid typing (immunoglobulin light chain
[AL], hereditary, or secondary [AA] amyloidosis) as the treatment is different for each.
Diffuse large B-cell lymphoma: ttt regardless stage or prognosis, is Rituximab plus
CHOP.
Metastatic melanoma: check BRAF mutation. As it has poor prognosis, treatment with a
BRAF inhibitor (Vemurafenib and dabrafenib).
Patients with small cell lung cancer who had chemotherapy or combined chemotherapy
and radiation therapy should be offered prophylactic brain irradiation to reduce the
incidence of brain metastases and improve overall survival.
Prostate cancer: persistently elevated PSA immediately following surgery, likely have
distant metastatic disease and should be started on androgen deprivation therapy
Burkitt lymphoma: aggressive therapy with combination chemotherapy and aggressive

intravenous hydration, urine alkalinization, and administration of allopurinol or
rasburicase
Cancer of unknown primary site in female presenting as abdominal carcinomatosis

and ascites should be treated as if they have ovarian cancer (Cytoreductive surgery
followed by systemic chemotherapy
Hodgkin diease have CD15 and CD30 cells, CXR would show mediastinal
Lynphadenopathy
Before giving Intramuscular B12 injections, make sure that the person has pernicious
anemia by
Biostatistics
Improved quality of care increases prevalence
Remember latency bias in drug side effects or effects especially for chronic
diseases or its effect on survival.
Successful randomization = baseline characteristics
The tighter the confidence interval = the more precise
Chisquare to compare proportions of categories
NNT= 1/ARR (absolute risk reduction)
Interventions that target the pharmacy personel appear to be the most

effective in raising the quality of healthcare while transitions of care
Matching is the solution to confounding bias
ODDs ratio from Case control Studies. Incidecne cannot be calculated from
Case control studies.
Prospective cohort studies can calculate incidence and Relative risk
Ascertainment is the same as observer bias
Reliability and reproducibility is a measure of random error
Generalizability or external validity is the measure whether the results are

applicable to other populations. Ex: a study made on middle aged women
would not be expected to be applicable for elderly men
In case control, only exposure odds ratio can be calculated. Relative risk
cannot be calculated, but if the disease has very low prevalence and is rare,
Odds ratio is very close to relative risk.
P value correlated with a random error or an error due to chance. IT is not

related to Bias which is a systematic error.
Think of lead-time bias when you see a new screening test for a poor
prognosis pathology
Correlation coefficient shows the strength of association and doesn’t

necessarily imply causality
PPV is related to prevalence of a disease. A patient tested positive in an area

with high prevalence would mostly have the disease.
Ophthalmology
For suspected corneal abrasion and the eye cannot be well examined,
administer topical tetracaine to anesthetise the area and allow good fluorecin
slit lamp testing
Hordeolum is an abscess over the upper or lower eye lid caused by staph
aureus and has localized swelling, pain and tenderness. Chalzion presents as
lid discomfort and is a chronic granulomatous inflammation of meibomian
gland and appears as had painless nodule.
Think of optic gliomas in patients with NF1. Patients present with

dyschromatopsia, slight exophthalmous and pallor of optic discs.
Sympathetic ophthalmia is damage of one eye after a penetrating injury to

the other eye that uncovers hidden antigen where immunological reactions
start happening destroying the sympathetic eye.
Central retinal artery occlusion has been emergently treated with ocular
massage and high flow oxygen administration.
In HIV patients, both HSV and VZV can cause severe acute retinal necrosis
with keratitis (corneal inflammation). But also, HIV patients would go
through CMR retinitis which causes only isolated retinitis with fluffy or
granular retinal lesions near the vessels.
Amaurosis fugax is a vision loss that is monooccular and transient and feels
like a curtain falling down and shows whitened zones of edematous retina
following the distribution of retinal artery as is it caused by retinal emboli
Central retinal artery occlusion presents with sudden painless unilateral loss
of vision with noted patients with hypertension that shows pallor of the optic
disc on fundoscopy with cherry red fovea.
On the other hand, central retinal vein occlusion presents with sudden onset
of painless unilateral loss of vision that is also seen in hypertensives but the
signs are different with disc swelling, venous dilation tortuosity, retinal
hemorrhages and cotton wool spots.
Floaters in eye field with difficulty in visualizing the fundus is due to
vitreous hemorrhage that is most commnly seen with diabetics.
Don’t MRI someone who might have a foreign body in his eye as MRI
might dislodge it!
Subconjunctival hemorrhage is a benign finding and doesn’t need any

referral and disappears within 48 hours.
Corneal ulcer may develop as a result of infection by bacteria, fungi or

viruses or from non infections causes like wearing contact lenses and corneal
trauma. Patients with pain, tearing, photophobia. The ulcer needs to be
scraped for gram stain, culture and sensitivity.
Secondary acute angle closure glaucoma can happen with anterior uveitis.
Treatment of gonococcal ophthalmia is by systemic Ceftriaxone. Topical

silver nitrate is only for prophylaxis
Blowout fracture of the orbit is an ophthalmologic emergency and surgical

intervention is needed to prevent damage.
For iridocyclitis consult ophthalmology immediately as the patient needs to

be treated with steroids.
Suspect allergic conjunctivitis is patient with atopy and allergic rhinitis.

Treat this patient with topical combination of anti-H1 and mast cell stabilizer
like Ketotifen drops.
One of the dreaded complications of CMV retinitis is retinal detachment,

which requires surgical correction. Thus most important step in evaluating a
patient with CMV retinitis is to do fundoscopic examinal.
Orbital pseudotumour is an immune mediated disorder of the orbit caused by

a diffuse granulomatous infiltrate of lymphocytes and plasma cells in the
orbital fat and external ocular muscles. It is suggested by CT scan and
diffuse lesion with fat stranding. Biopsy confirms diagnosis.
An intracranial aneurysm can compress the third cranial nerve with drooping eyelid and
dilated pupil and inability to adduct. The severe migraine before this attack is probably a
sentinel or warning headache
Ethambutol is a common cause of optic neuritis which presents with a central scotoma
and pain worse with movement of the affected eye.
If pterygium goes over the visual access, then remove surgically. If not, then reassurance
without intervention is best
Subspecialty
Suspect peritonsillar abscess in a patient presenting with a severe sore throat and fever
and hot potato muffled voice with swelling and deviation of uvula to the opposite side
and cervical adenopathy.
If acetaminophen toxic ingestion was very recent, give activated charcoal

and measure acetaminophen level after 4 hours. The level of acetaminophen
would be the guide for the administration of NAC. Measuring
acetaminophin level at the time of ingestion is of no benefit.
Treatment of hypercalcemia is IV fluid with furosmide
Rigid bronchoscope is used to remove foreign objects in pediatrics. Flexible

bronchoscope is the treatment of choice for foreign body in adults
Acute presentation of complete cardiac block, do transcutaneous pacing then

arrange permenant pacemaker
Any gunshot below the nipples and above the pubis is considered to involve
the abdomen. Penetrating abdominal wounds are an absolute indication for
an exploratory laparotomy.
If chest trauma and chest tube is done and the lung is not reexapnding, then
think of an injury to a major bronchus
For animal bites mostly are caused by areoes and anaerobes. Pasteurella is
the most common. Initial treatment is vigorous cleaning and irrigation and
debridement. Suturing should not occur for these bites. Drug of choice:
amoxiclav. For allergic, second line is clindamycin plus doxycycline, a
fluoroquinolone or TMP-SMX. Pastuerella is resistant to clindamycin.
Second line therapy must include clindamycin with sth else.
In diabetic ketoacidosis, give Insulin IV, then switch to subcutaneous with the closure of
anion gap.
Corticosteroid induced myopathy doesn’t usually cause an increase in muscle enzymes

and EMG is normal. Diagnosis is confirmed by the improvement in strength after 4
weeks of decreasing the dose of steroids.
To identify if liquid is CSF, do Beta-t-transferrin test
Miscellanuous
Bursal fluid aspiration should be performed for both therapeutic and diagnostic purposes
in all patients who present with prepatellar bursitis.
Anchoring bias: is a diagnostic cognitive error that results from locking onto features of a
patient's initial presentation despite the appearance of new clinical information.
Morphine should be avoided in the setting of kidney failure. Dilaudid is metabolized by

the LIVER
In patients with usual symptoms of benign prostatic hyperplasia (BPH), a careful history
and physical examination can usually render the diagnosis; a urinalysis is also indicated
(before starting Rx) in evaluating BPH to exclude infection, malignancy, or
postobstructive nephropathy.
Treatment of cerumen impaction is indicated only in symptomatic patients or if the

tympanic membrane needs to be visualized.
Bird’s beak in Achalasia on Xray
Alcoholic comes in with hematemesis either think about Mallory weis tear or variceal
bleeding if cirrhotic
Severe C dif may end up with megacolon and is a catastrophe!

USMLE Step 2CK Notes With Additions

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USMLE Step 2CK Notes With Additions

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Dr Jamal’s USMLE

Notes for Step2 CK

Qbanks recommended uWorld, Kaplan and NBME. If you have

I also provide notes Step1 and “The Ultimate Match Guide”,

All the information in this file are written genuinely by me and

My notes are color coded:

For metabolic alkalosis, urine chloride has to be checked to determine if it is chloride

Trimethoprim causes hyperkalemia due to sodium tubule channel blockade

Most common cause of nephrotic syndrome in lymphoma patients is minimal change

Chlamydia causes muccopurulent urethral discharge and negative colonies while

To determine if alkalosis is due to diuretic use is by checking chloride in serum and

Good pasture syndrome= Lower repiratory (hemoptysis) + hematuria, often there is a

Wegner Granulomatosis= Upper respiratory (sinusitis) + lower respiratory (Hemoptysis)

Severe hypocalcemia after Parathyroidectomy by one week is due to Hungry Bone

IgA nephropathy is hematuria with concomitant URTI (Synpahryngitic). Treat with

The treatment of Barter syndrome is aimed at minimizing the effects of excessive

First line treatment for HTN with APKD is lisinopril

Traumatic hemolysis from repetitive sports can be differentiated from Rhabdomyolysis

Autosomoal polycystic kidney disease is due to defect in epithelial cell differentiation

Toxicity of mycophenolate is bone marrow suppression

If BPH is suspected, do abdominal ultrasound to assess for hydronephrosis

Renal amyloidosis is revealed with deposits under polarized light

Emergency plasmapherisis is required in management of good pasture’s disease. SLE

Membranoproliefrative glomerulonephritis type 2 is unique glomerulopathy that is

IgG4-related disease: infiltration of different organs by lymphoplasmacytic infiltrates of

Nephrotic + thromboembolic events: think about Membranous Glomerulopathy. Very

HIV → collapsing form of FSGS

Tumor lysis syndrome: prevention by allopurinol & IV fluids. Once happened

Hypokalemic periodic paralysis: often associated with thyrotoxicosis. Generalized

Initial hematurea indicates urethral injury. Terminal hematurea indicates bladder or

Recommendations for patients with renal calculi:

The treatment of choice for fibromuscular dysplasia of Renal artery is by percutaneous

Acute epididymitis can be either sexually transmitted or non-STD

Prazocin and trazodone cause priapism

Hexagonal crystals in cysteinurea

Kidney changes in diabetes: glomerular hyperfiltration > thickening of basement

Intimal thickening of renal arterioles and luminal narrowing of arteries is seen in

Dubin-Johnson and rotor syndrome are a cause of direct hyperbilirubinemia.

Rifaximin is an antibiotic that kills ammonia forming bacteria in the gut. It is

Presence of bilirubin in dipstick urine is indicative of conjugated

Hepatic adenoma might be induced from OCP, androgen use, glycogen

Spontaneous bacterial peritonitis: Antibiotics, third generation cephalosporin. Also, give

AKI and hepatic encephalopathy: before making diagnosis of Hepatorenal, IV fluid

Gallbladder polyp larger than 1 cm is an indication for cholecystectomy, even if the

Chronic diarrhea: Giardiasis should be considered in patients with exposure to young

Autoimmune pancreatitis (AIP): Rx is by steroids. Dx criteria of Type 1:

HCV genotype 2: Rx with sofosbuvir and ribavirin

Microscopic colitis: has 2 subtypes; Lymphocytic colitis (intraepithelial lymphocytosis)

Acalculous cholecystitis: 50% of these high-risk patients will develop cholangitis,

Focal Nodular hyperplasia of the liver is not related to OCP use

Asymptomatic gallstones should not be treated unless if at increased risk for

For monitoring of acute hepatitis, decreasing levels of liver enzyme means

Trest criggler najjar 1 with Phototherapy or plasma pheresis, though ultimate

Mallory bodies are indication of alcoholic hepatitis. It is reversible if alcohol

Risk factor for non-alcoholic steatohepatitis is Obesity, DM and

Non-caseating granulomas are characteristic of Crohn and not UC.

Drugs that cause pancreatitis: furosmide, thiazide, sulfadiazine, 5-ASA, azathioprine,

Eggshell calcification of liver cyst is Echinococcus granulosus. It is unilocular.

Treatment of acute ascending cholangitis starts with Intravenous antibiotics. If

Absence of peristaltic waves in lower third of esophageus and significant decrease in

Gastrointestinal bleeding is associated with increased BUN/Cr ratio because blood in

Positive hydrogen breath test is useful for dignosing lactose intolerance

Zenker diverticulum is a flase diverticulum located above the cricopharyngeus muscle

Think of bacterial overgrowth in scleroderma with intestinal dysmotility as small bowel