High Yield Internal Medicine

Shelf Exam Review

Emma Holliday Ramahi
Cardiology
 A patient comes in with chest pain…
• Best 1st test = EKG
• If 2mm ST elevation or new LBBB (wide, flat QRS) STEMI
• ST elevation immediately, T wave inversion 6hrs- years, Q waves last
forever
Anterior LAD V1-V4
Lateral Circumflex I, avL, V4-V6
Inferior RCA II, III and aVF ***

R ventricular RCA V4 on R-sided EKG is 100% specific

• Emergency reperfusion- go to cath lab or *thrombolytics if no

(within 6h can use thrombolyrics)
contraindications CONTRAIND - if hx of hemorrhagic stroke, recent closed head trauma, recent ischemic attack, bleeding
• Right ventricular infarct- Sxs are hypotension, tachycardia, clear
lungs, JVD, and NO pulsus paradoxus. DON’T give nitro. Tx w/
vigorous fluid resuscitation.
the problem is with preload, need preload to be added, no nitro because that would vasodilate and decrease preload
• Next best test = cardiac enzymes
(to detect a trend
• If elevated  NSTEMI. Check enzymes q8hrs x 3.
Myoglobin Rises 1st Peaks in 2hrs, nl by 24 --> best for repeat ischemia
(goes up first and comes down first)
-- the rest can stay elevated for a
CKMB Rise 4-8hrs Peaks 24 hrs, nl by 72hs while from first ischemic episode

Troponin I Rise 3-5hrs Peaks 24-48hrs, nl by 7-10days

• Tx w/ morphine, oxygen, nitrates, aspirin/clopidogrel, and b-blocker

• Do CORONARY ANGIOGRAPHY w/in 48hrs to determine need for
intervention.
• PCI w/ stenting is standard.
• CABG if: L main dz, 3 vessel dz (2 vessel dz + DM), >70% occlusion,
pain despite maximum medical tx, or post-infarction angina
• Discharge meds = aspirin (+ clopidogrel for 9-12mo if stent placed)
• B-blocker
• ACE-inhibitor if CHF or LV-dysfxn
• Statin
• Short acting nitrates
• If no ST-elevation and normal cardiac enzymes x3…
• Diagnosis is unstable angina. (any new angina is unstable)

• Work up-
– Exercise EKG: avoid b-blockers and CCB before.
– Can’t do EKG stress test if old LBBB or baseline ST elevation
or on Digoxin. Do Exercise Echo instead.
– If pt can’t exercise- do chemical stress test w/ dobutamine
or adenosine.
– MUGA is nuclear medicine test that shows perfusion of
areas of the heart. Avoid caffeine or theophyline before
– Positive if chest pain is reproduced, ST depression, or
hypotension  on to coronary angiography
 Post-MI complications
• MC cause of death? Arrhythmias. V-fib
• New systolic murmur 5-7 Papillary muscle rupture
days s/p? (regurg mumur)

• Acute severe hypotension? Ventricular free wall rupture

• “step up” in O2 conc from Ventricular septal rupture
RA  RV?
• Persistent ST elevation Ventricular wall aneurysm
~1mo later + systolic MR
murmur? (flow in and around the aneurysm)

AV-dissociation. Either V-fib or 3rd

• “Cannon A-waves”? degree heart block
(look at them in the JVP) - bounding

• 5-10wks later pleuritic CP, Dressler’s syndrome. (probably)

low grade temp? autoimmune pericarditis. Tx w/
NSAIDs and aspirin.
A young, healthy patient comes in with chest pain…
• If worse w/ inspiration, better w/ leaning forwards, friction rub &
diffuse ST elevation  pericarditis (Tx - NSAIDs)

• If worse w/ palpation  costochondriasis

• If vague w/ hx of viral infxn and murmur  myocarditis
• If occurs at rest, worse at night, few CAD risk factors and
migraine headaches, w/ transient ST elevation during
episodes  Prinzmetal’s angina - worse early in the morning
– Dx w/ ergonovine stim test. Tx w/ CCB or nitrates
 EKG Buzzwords
“Progressive, prolongation of
the PR interval followed by a
dropped beat”
img.medscape.com/.../889392-890621-3206.jpg Winkebach/Mobitz Type I

Cannon-a waves on
physical exam.
“regular P-P interval
and regular R-R
interval”
3rd Degree Heart Block
-not a p before every QRS spaced regularly
http://www.ispub.com/ispub/ijpn/volume_4_number_1_43/an_unusual_cause_of_seizures_in_a_10_year_old/seizures-fig1.jpg

“varrying PR interval with 3 or

more morphologically distinct
P waves in the same lead”.
https://teach.lanecc.edu/brokawt/MAT4.jpg Seen in an old person w/
chronic lung dz in pending
respiratory failure
P-waves --> not afib. Different looking p-waves (at least 3)
MAT - multifactorial atrial tachy
www.emedu.org/ecg/images/wpw_3a.jpg

Ventricular tachycardia --> Tx: (if unstable, defib), (if stable, tx with lidocaine or amiodarone)

“Three or more consecutive beats w/ QRS <120ms @ a rate of >120bpm”

-delta wave --> WPW (Wolff Parkinson White) -- tx: procainamide, DO NOT GIVE b-blockers, digoxin, CCB (verapimil or
www.emedu.org/ecg/images/wpw_3a.jpg diltazem) --> anything that slows down AV node

“Short PR interval followed by QRS >120ms with a slurred initial deflection

representing early ventricular activation via the bundle of Kent”.

Atrial flutter (2:1 between vent:atr). Unstable - cardiovert, medically stable - give b-blockers and digoxin (like Afib)

“Regular rhythm with a ventricular rate of 125-150 bpm and atrial rate
of 250-300 bpm” Torsades de pointes -- look for low K or low Mg, TCA overdose (look for electrolyte abn)

“prolonged QT interval leading to

undulating rotation of the QRS
complex around the EKG baseline” In a
pt w/ low Mg and low K. Li or TCA OD
 “Regular rhythm w/ a
rate btwn 150-220bpm.”
Sudden onset of (onset/offset)
palpitations/dizziness.
www.ambulancetechnicianstudy.co.uk/images/SVT.gif
SVT - supraventricular tachycardia
1st line tx = CAROTID MASSAGE, shove face in ice water 2nd line = meds/adenosine (with tachycardia)

www.emedu.org/ecg/images/k_5.jpg

Renal failure patient/crush injury/burn victim w/ “peaked T-waves, widened QRS, short QT
and prolonged PR.” Hyperkalemia --> peaked T-waves

img.medscape.com/pi/emed/ckb/emergency_medici.. baseline undulating, low volume - TAMPONADE (electrical alternans)

“Alternate beat variation in direction, amplitude and duration of the QRS complex” in a
patient w/ pulsus paradoxus, hypotension, distant heart sounds, JVD
(AFIB - neither rate/rhythm that much better -- rhythm NOT more
can't see p-waves = undulating baseline effective so we do RATE CONTROL). Tx with beta-blockers or
AFIB -- too much synthroid, palpitations and SOB in elderly, digoxin
CHF with valve disease, hypothyroidism “Undulating baseline, no p-
waves appreciated, irregular R-R
interval” in a hyperthyroid pt, old
www.ambulancetechnicianstudy.co.uk/images/SVT.gif
pt w/ SOB/dizziness/palpitations
w/ CHF or valve dz
>Valsalva decreases preload --> less blood going thru stenotic Ao valve
>Squatting increases preload
>Handgrip increases afterload
Murmur Buzzwords

• SEM cresc/decresc, louder w/

Aortic Stenosis
squatting, softer w/ valsalva. + old calcific degeneration, congenital bicuspid Ao valve
>> tx: replace valve, only balloon to stabilize

parvus et tardus
• SEM louder w/ valsalva, softer HOCM
young pt in for sports physical - louder with valsalva
w/ squatting or handgrip.
• Late systolic murmur w/ click Mitral Valve Prolapse
"click" - younger patient
palpitations and syncope
louder w/ valsalva and
handgrip, softer w/ squatting
• Holosystolic murmur radiates Mitral Regurgitation
not an ejection mumur, it's holosystolic

to axilla w/ LAE
 More Murmurs

• Holosystolic murmur w/ late (most common congenital <3 defect)

VSD
diastolic rumble in kiddos
• Continuous machine like PDA
murmur-
• Wide fixed and split S2- ASD

• Rumbling diastolic murmur Mitral Stenosis

with an opening snap, LAE and
A-fib
• Blowing diastolic murmur with Aortic Regurgitation
widened pulse pressure and
-waterhammer pulse
eponym parade.
 A patient comes in with shortness of
breath… cardiac or pulmonary?
• If you suspect PE (history of cancer, surgery or lots of butt
sitting)  heparin! (giv heparin first if you REALLY suspect PE first)
• Check O2 sats  give O2 if <90%
• If signs/sxs of pneumonia  get a CXR (breath sounds, egophony)
• If murmur present or history of CHF  get echo to check
(compare to old echo)
ejection fraction
• For acute pulmonary edema  give nitrates, lasix and
morphine (acute pulm. edema - trifecta of meds)
• If young w/ sxs of CHF w/ prior hx of viral infx  consider
myocarditis (Coxsackie B). young, SOB
• If pt is young and no cardiomegaly on CXR  consider
primary pHTN primary pulmo HTN vs. CHF
– Right heart cath can tell CHF from pulmonary HTN (how?)
Right Heart Cath

-PCWP normal in pulm htn

-??? in CHF
 CHF
• Systolic- decreased EF (<55%)
– Ischemic, dilated
• Viral, ETOH, cocaine, Chagas, Idiopathic
• Alcoholic dilated cardiomyopathy is reversible if you stop the
booze.
• Diastolic- normal EF, heart can’t fill
– HTN, amyloidosis, hemachromatosis
• Hemachromatosis restrictive cardiomyopathy is reversible w/
phlebotomy. (diastolic dysfunction)
• Tx-
– ACE-I improve survival- prevent remodeling by aldo.
– B-blocker (metoprolol and carveldilol) improve survival-
prevent remodeling by epi/norepi
– Spironolactone- improves survival in NYHA class III and IV
– Furosemide- improves sxs (SOB, crackles, edema)
– Digoxin- decreases sxs and hospitalizations. NOT survival
Pulmonology
 lobar consolidation - pneumonia
CXR Buzzwords CHF - interstitial edema
COPD - air trapping

acutemed.co.uk hmc.psu.edu www.meddean.luc.edu/.../Heart/Dscn0008a.jpg

“Opacification, consolidation, “hyperlucent lung fields “heart > 50% AP

air bronchograms” with flattened diaphragms” diameter, cephalization,
Kerly B lines & interstitial
edema”

“Thickened peritracheal
stripe and splayed
carina bifurcation”
www.meddean.luc.edu -L. atrial enlargement (bad mitral
http://en.wikipedia.org/wiki/ stenosis) and mediastinal mass/
“Cavity containing an air- cancer

fluid level” “Upper lobe cavitation, consolidation

Lung abscess (staph and anerobes) +/- hilar adenopathy” TB
 Pleural Effusions
• Pleural Effusions  see fluid >1cm on lat decu
 thoracentesis! (know the difference between TRANSUDATIVE vs. EXUDATIVE)

– If transudative, likely CHF, nephrotic, cirrhotic (mpre liekly systemic)

• If low pleural glucose? Rheumatoid Arthritis

• If high lymphocytes? Tuburculosis
• If bloody? Malignant or Pulmonary Embolus
– If exudative, likely parapneumonic, cancer, etc. acidic, or bugs eating so
low gluc

– If complicated (+ gram or cx, pH < 7.2, glc < 60):

• Insert chest tube for drainage.
– Light’s Criteria  transudative if:
LDH < 200 (low)
All 3 need to be present for
TRANSUDATIVE
LDH eff/serum < 0.6
-otherwise, it's EXUDATIVE
Protein eff/serum < 0.5
ncbi.nlm.nih.gov
 Pulmonary Embolism
• High risk after surgery, long car ride, hyper
coagulable state (cancer, nephrotic) hypercoagulable state

– Sxs = pleuritic chest pain, hemoptysis, tachypnea

Decr pO2, tachycardia. wedge infarct, westermark's sign
download.imaging.consult.com/...
/gr1-midi.jpg

– Random signs = right heart strain on EKG, sinus tach,

decr vascular markings on CXR, wedge infarct, ABG w/
low CO2 and O2.
– If suspected, give heparin 1st! Then work up w/ V/Q
scan, then spiral CT. Pulmonary angiography is gold
standard. (but morbid procedure so we don't like to do it)

– Tx w/ heparin warfarin overlap. Use thrombolytics if

severe but NOT if s/p surgery or hemorrhagic stroke.
Surgical thrombectomy if life threatening. IVC filter if
contraindications to chronic coagulation.
 bilateral fluffy infiltrates

ARDS
• Pathophys: inflammation  impaired www.ispub.com/.../ards3_thumbnail.gif

gas xchange, inflam mediator release, hypoxemia

• Causes:
– Sepsis, gastric aspiration, trauma, low perfusion,
pancreatitis. -LPS from gram -VE staph

• Diagnosis:
1.) PaO2/FiO2 < 200 (<300 means acute lung injury)
2.) Bilateral alveolar infiltrates on CXR
3.) PCWP is <18 (means pulmonary edema is non
cardiogenic) (R/O cardiac causes - not problem with forward blood flow)

• Treatment: mechanical ventilation w/ PEEP

(used for ARDS)
 -obstructive vs. restrictive
look at FEV1/FVC ratio

PFTs
Obstructive Restrictive
Examples Asthma Interstitial lung dz (sarcoid,
COPD silicosis, asbestosis.
Emphysema Structural- super obese,
MG/ALS, phrenic nerve
paralysis, scoliosis
FVC ↓ <80% predicted ↓ <80% predicted
FEV1 ↓ <80% predicted ↓ <80% predicted
FEV1/FVC **** ↓ <80% predicted Normal
TLC ↑ >120% predicted ↓ <80% predicted
RV ↑ >120% predicted ↓ <80% predicted
Improves >12% with Asthma does Nope
bronchodilator COPD and Emphysema
Bronchodilator response - improvement of FEV1 with 12% don’t.
DLCO reduced Reduced in Emphysema Reduced in ILD due to
(diffusion) 2/2 alveolar destruction. fibrosis thickening distance
 COPD Acute exacerbation

• Criteria for diagnosis? Productive cough >3mo for >2 consecutive yrs Narrow TI, can cause
LABA LAAC

•
arrhthmias
Treatment? 1st line = ipratropium, tiotropium. 2nd Beta agonists. 3rd Theophylline
• Indications to start O2? PaO2 <55 or SpO2<88%. If cor pulmonale, <59
• Criteria for exacerbation? Change in sputum, increasing dyspnea
(amount, colour)

• Treatment for O2 to 90%, albuterol/ipratropium nebs, PO or IV

exacerbation? corticosteroids, FQ or macrolide ABX,
• Best prognostic indicator? FEV1 spirometry

• Shown to improve 1.) Quitting smoking (can decr rate of FEV1 decline
mortality? 2.) Continuous O2 therapy >18hrs/day

• Why is our goal for SpO2 COPDers are chronic CO2 retainers. Hypoxia is
94-95% instead of 100%? the only drive for respiration.
• Important vaccinations? Pneumococcus w/ a 5yr booster and yearly
influenza vaccine
 Your COPD patient comes with a 6
week history of this…

acute-onset clubbing
>>lung cancer
-get CXR

http://cancergrace.org/lung/files/2009/02/nail-clubbing.jpg

New Clubbing in a COPDer = Hypertrophic Osteoarthropathy

Next best step… get a CXR
Most likely cause is underlying lung malignancy
 Asthma
(mild intermittent -- just a rescue inhaler)

• If pt has sxs twice a week and PFTs are normal? Albuterol only
• If pt has sxs 4x a week, night cough 2x a month and
PFTs are normal? Albuterol + inhaled CS moderate --> mod-intermittent AND mod-
consistent

• If pt has sxs daily, night cough 2x a week and FEV1 is severe

60-80%? Albuterol + inhaled CS + long-acting beta-ag (salmeterol) (FEV1 < 60%)

• If pt has sxs daily, night cough 4x a week and FEV1 is

<60%? Albuterol + inhaled CS + salmeterol + montelukast and oral steroids
• Exacerbation  tx w/ inhaled albuterol and PO/IV normalizing PCO2 bad
sign --means that they

steroids. Watch peak flow rates and blood gas. PCO2 are getting tired -->
need to intubate

should be low. Normalizing PCO2 means impending

respiratory failure  INTUBATE.
• Complications  Allergic Brochopulmonary Aspergillus
look for specific antibiody
 Random Restrictive Lung Dz
• 1cm nodues in upper lobes w/ Silicosis. Get yearly TB test!.
eggshell calcifications. Give INH for 9mo if >10mm

• Reticulonodular process in Asbestosis. Most common cancer is

lower lobes w/ pleural broncogenic carcinoma, but incr risk
for mesothelioma
plaques.
• Patchy lower lobe infiltrates, Hypersensitivity Pneumonitis =
thermophilic actinomyces. “farmer’s lung” shovel hay

• Hilar lymphadenopathy, ↑ACE Sarcoidosis.

erythema nodosum. African american
Hyper Ca - high Vit D (macrophages in the granulomas produce a
vitamin D like substance)

– Hypercalcemia? 2/2 ↑ macrophages making vitD

– Important referral? Ophthalmology  uveitis conjunctivitis in 25%
– Dx/Treatment? Dx by biopsy. Tx w/ steroids EYES

(non-caseiting granuloma)
 So you found a pulmonary nodule…
• 1st step = look for an old CXR to compare!
• Characteristics of benign nodules:
– Popcorn calcification = hamartoma (most common)
– Concentric calcification = old granuloma
– Pt < 40, <3cm, well circumscribed
• Tx w/ CXR or CT scans q2mo to look for growth
• Characteristics of malignant nodules: http://emedicine.medscape.com/
article/356271-media

– If pt has risk factors (smoker, old), If >3cm, if eccentric

calcification
• Do open lung bx and remove the nodule

http://emedicine.medscape.com/ar
ticle/358433-media
 A patient presents with weight loss, cough,
dyspnea, hemoptysis, repeated pnia or lung
LUNG CANCER
collapse.
• MC cancer in non-smokers? Adenocarcinoma. Occurs in scars of old pnia
• Location and mets? Peripheral cancer. Mets to liver, bone, brain and adrenals
• Characteristics of effusion? Exudative with high hyaluronidase (GIVES a characteristic
pleural effusion)

• Patient with kidney stones, Squamous cell carcinoma. (hypercalcemia)

constipation and malaise low PTH +Paraneoplastic syndrome 2/2 secretion
central lung mass? of PTH-rP. Low PO4, High Ca
• Patient with shoulder pain, ptosis, Superior Sulcus Syndrome from Small
constricted pupil, and facial edema? cell carcinoma. Also a central cancer.
• Patient with ptosis better after 1 Lambert Eaton Syndrome from small
minute of upward gaze? cell carcinoma. Ab to pre-syn Ca chan
• Old smoker presenting w/ Na = 125, SIADH from small cell carcinoma.
moist mucus membranes, no JVD? Produces Euvolemic hyponatremia.
• CXR showing peripheral cavitation andFluid restrict +/- 3% saline in <112
quite metastatic
CT showing distant mets? Large Cell Carcinoma
Gastroenterology
 Inflammatory Bowel Disease
• Involves terminal ileum? Crohn’s. Mimics appendicitis. Fe deficiency.
• Continuous involving rectum? UC. Rarely ileal backwash but never higher
• Incr risk for Primary UC. PSC leads to higher risk of cholangioCA
Sclerosing Cholangitis?
• Fistulae likely? Crohn’s. Give metronidazole.
• Granulomas on biopsy? Crohn’s.
• Transmural inflammation? Crohn’s.
• Cured by colectomy? UC.
• Smokers have lower risk? UC. Smokers have higher risk for Crohn’s.
• Highest risk of colon cancer? UC. Another reason for colectomy.
• Associated w/ p-ANCA? UC.
Treatment = ASA, sulfasalzine to maintain remission. Corticosteroids to induce
remission. For CD, give metranidazole for ANY ulcer or abscess. Azathioprine,
6MP and methotrexate for severe dz.
IBD Images & Complications
*string sign -- on barium study --> more likely Crohn's

commons.wikimedia.org
medinfo.ufl.edu/~bms5191/gi/images/cd1a.jpg

Pyoderma gangrenosum
(no abx, no I and D, tx the disease)

http://www.ajronline.org/cgi/con
tent-nw/full/188/6/1604/FIG20

studenthealth.co.uk

toxic megacolon - pneumocystis intestinalis, widely dilated

(air in the wall of colon) Erythema nodosum (look like golf balls under skin)
also in sarcoid
 LFT/Lab Buzzwords
• AST>ALT (2x) + high GGT Alcoholic Hepatitis
• ALT>AST & in the 1000s Viral Hepatitis
• AST and ALT in the 1000s after Ischemic Hepatitis (“shock liver”)
surgery or hemorrhage --> don't have characteristic ALT>AST

• Elevated D-bili Obstructive (stone/cancer) or Dubin’s Johnsons, Rotor

• Elevated I-bili Hemolysis or Gilbert’s, Crigler Najjar
• Elevated alk phos and GGT Bile duct obstruction, if IBD  PSC
• Elevated alk phos, normal Paget’s disease (incr hat size, hearing loss,
GGT, normal Ca HA. Tx w/ bisphosphonates.
• Antimitochondrial Ab Primary Biliary Cirrhosis – tx w/ bile resins
• ANA + antismooth muscle Ab Autoimmune Hepatitis – tx w/ ‘roids
• High Fe, low ferritin, low Fe Hemachromatosis-
binding capacity hepatitis, DM, golden skin
• Low ceruloplasmin, high Wilson’s- hepatitis, psychiatric sxs
urinary Cu (BG), corneal deposits
Infectious Disease
 Meningitis
Strep Pneumo, H. Influenza, N. meningitidis
• Most Common bugs? (tx w/ Ceftriaxone and Vanco)
• In old and young? Add Lysteria. (tx w/ Ampicillin) -think about this in young and
old

• In ppl w/ brain surg? Add Staph (tx w/ Vanco)

• Randoms? TB (RIPE + ‘roids) and Lyme (IV ceftriazone)
meningitis
-RIPE tx for meningitis

• Best 1st step? Start empiric treatment (+ steroids if you think it

is bacterial), Exam for elevated ICP/CT, then LP
• Diagnostic test? +Gram stain, >1000WBC is diagnostic.
• Roommate of the kid High protein and low glucose support
bacterial
in the dorms who has
bacterial meningitis Rifampin!!
and petechial rash? (Neisseria Meningitides prophylaxis)
 Pneumonia
• Classic sxs… best 1st step? CXR!
• Most common bug all comers? Strep Pneumo. Tx w/ M, FQ, 3rd ceph
• Most common bug, healthy young Mycoplasma. Assoc w/ cold
(atypicals)

people? aggutinins. Tx w/ M, FQ or doxy

-macrolide 1st line

• Hospitalized w/in 3mo or in the Pseudomonas, Klebsiella, E. Coli, MRSA.

hospital >5-7d Tx w/ pip/tazo or imipenem+ Vanc
(hosp acquired pneum)

• Old smokers w/ COPD? H. influenzae. Tx w/ 2nd-3rd ceph

• Alcoholics w/ current jelly sputum? Klebsiella. Tx w/ 3rd ceph
• Old men w/ HA, confusion, diarrhea and (hang out in hot tubs) - pneumonia PLUS

abd pain? Legionella. Dx w/ urine antigen. Tx w/ M, FQ, doxy

-resp sx, GI and ALOC

• Just had the flu? MRSA. Tx w/ vanc

• Just delivered a baby cow and have Q-fever. Coxiella burnetti. Tx w/
vomiting and diarrhea? doxy
farmer
(Tularemia)
• Just skinned a rabbit? Franciella tularensis. Tx w/ streptamycin, gentamycin
 Tuberculosis
• If a patient is symptomatic  best test is CXR
• For screening 
– >15mm, >10mm if prison, healthcare, nursing home, DM, ETOH,
chronically ill, >5mm for AIDS, immune suppressed
– If + PPD  do CXR.
– If +CXR  do acid fast stain of sputum.
– If CXR negative, or +CXR & 3 negative sputums 
– If positive  tx w/ 4 drug RIPE Regimen for 6mo (12 for meningitis
and 9 if pregnant) 4 drug tx (which can be narrowed once you know the bug)

*Chemoprophylaxis (INH for 9mo) for kiddos <4 exposed to known TB.
• Drug Side Effects:
– Rifampin- body fluids turn orange/red, induces CYP450
– INH- peripheral neuropathy and sideroblastic anemia (prevent
by giving B6. Hepatitis w/ mild bump in LFTs
– Pyrazinamide- Benign hyperuricemia not enough to cause gout
– Ethambutol- optic neuritis, other color vision abnormalities.
 Endocarditis
Acute endocarditis- acute - staph
• most common bug? Staph aureus seeds native valves from bacteremia
Subacute Native valve endocarditis-
• Most common valve? Mitral Valve (MVP is MC predisposition)
• Most common bug? Viridens group strep (subacute - on native valve)

IVDU R. sided heart murmurs are worse with inspiration****

• Most common valve? Tricuspid Valve (murmur worse w/ inspiration)

• Most common bug? Staph Aureus
• Diagnosis? Blood cx, TTE then TEE. Major and Minor Criteria
• Complications? CHF #1 cause of death, septic emboli to lungs or brain
• Treatment? Strep Viridens = 4-6 wks PCN. Staph = Naf + gent or vanco
• Prophylaxis? if prosthetic valve, hx of EC, or uncorrected congenital lesion
• *What if you find strep bovis bacteremia?
Next step is colonoscopy!!
 When to suspect HIV…
• If a patient “travels a lot for work”  that means they
have sex with lots of strangers and are at risk for HIV
• Acute retroviral syndrome = 2-3 wks s/p exposure but
3wks before seroconversion.  ie, ELISA neg
– Fever, fatigue, lymphadenopathy, headache, pharyngitis,
n/v/d +/- aseptic meningitis
• A young patient with new/bilateral Bell’s Palsy.
• A young patient with unexplained thrombocytopenia
and fatigue.
• A young patient with unexplained weight loss >10%
• A young patient with thrush, Zoster, or Kaposi sarcoma
opportunistic type infxn
HSV, shingles
 When to start Tx/Post exposure
Prophylaxis
• Start HAART when CD4 < 350 or viral load
>55,000 (except preggos get tx >1,000 copies)
– GI, leukopenia, macrocytic anemia Zidovudine-
– Pancreatitis, peripheral neuropathy Didanosine-
– HS rash, fever, n/v, muscle aches, SOB in 1st 6wks. D/C
and never use again! Abacavir-
– Nephrolithiasis and hyperbilirubinemia Indinavir-
– Sleepy, confused, psycho Efavirenz- NNRI (bad psych symptoms)

• Post-exposure prophylaxis-
– If stuck w/ known HIV pt  AZT, lamivudine and
nelfinavir for 4wks
 HIV+ patient with DOE, dry cough, fever,
chest pain
Pneumocystis -- fluffy bilateral infiltrates

• Think PCP. CD4 prob <200.

• CXR shows “bilat diffuse
symmetric interstitial
infiltrates” www.learningradiology.com/.../cow43.jpg

• Can see elevated LDH.

• Best test? After CXR, do Bronchoscopy w/ BAL to visualize bug
• 1st line Treatment? Trim-sulfa
aerosolized
• 2nd line Treatment? Trim-dapsone or primaquine-clinda, or pentamidine
• When to add Steroids? When PaO2 < 70, A-a gradient >35
when it's really bad

• Prophylaxis? Start
st
when CD4 is <200. Can d/c is >200 for >6mo
nd
1 - Trim-sulfa 2 - Dapsone
3rd- Atovaquone 4th- Aerosolized pentamidine
(causes pancreatitis!)
 HIV+ patient with diarrhea
CD4 count

• CMV- (<50)
– Dx w/ colonoscopy/biopsy. Diarrhea can be bloody
– Tx w/ gancicylovir (neutropenia) or foscarnet (renal
tox)
• MAC- (<50) diagnosis of exclusion, no stool, ova parasites

– Diarrhea, wasting, fevers, night sweats.

– Tx w/ clarithromycin and ethambutol +/- rifampin
– Prophylax w/ azithromycin weekly
• Cryptosporidium- (<50)
– Transmitted via dog poo, swimming pools
– Watery diarrhea w/ mucus, Oocysts are acid fast **
 HIV+ patient with neurologic signs
• If multiple ring Think Toxo. Do empiric pyramethamine
sulfadiazine (+ folic acid) for 6wks. If no
enhancing lesions? improvement in 1wk, consider biopsy for
• If one ring enhancing CNS lymphoma. Assoc w/ EBV infxn of B-
lesion? cells. Tx w/ HAART.

• If seizure w/ de ja vu Think HSV encephalitis. (predisposed for

aura and 500 RBCs in temporal lobe). Give acyclovir as SOON as
CSF? suspected.

• If s/s of meningitis? Think Crypto. +India ink. Tx w/ ampho IV

for 2wks then fluconazole maintenance
• If hemisensory loss,
visual impairment, Think PML. JC polyomavirus demyelinates at
Babinski? grey-white jxn. Brain bx is gold standard dx

• If memory problems or Think AIDS-Dementia complex. Check

gait disturbanc? serum, CSF and MRI to r/o treatable
causes
 Neutropenic Fever
• Medical Emergency! can induce bactermia in these patients
by translocation of gut bacteria cross the

• NEVER do a DRE on a neutropenic patient!

wall

• Defined by a single temp > 101.3 or sustained temp

>100.4 for 1hr. ANC < 500.
• Mucositis 2/2 chemo causes bacteremia (usually from gut)
• MC bugs are pseudomonas or MRSA (if port present).
• Work up  1st get blood cx, then start 3rd or 4th gen
cephalosporin (ceftazidime or cefipime)
– Add vanc if line infxn suspected or if septic shock develops.
– Add amphoB if no improvement and no source found in 5
days.
 Random Infection Buzzwords
7
• Target rash, fever, VII palsy, Lyme! Tx w/ doxy (amox for <8). Heart or
meningitis, AV block CNS dz needs IV ceftriaxone
• Rash @ wrists & ankles (palms & Rickettsia! Tx w/ doxy.
soles), fever and HA.
• Tick bite, no rash, myalgia, fever, HA, Ehrlichiosis! Can dx w/ morulae
↓plts and WBC, ↑ALT intracell inclusion. Tx w/ doxy
• Immune suppressed, cavitary lung Nocardia! Tx w/ trim-sulfa
dz (purulent sputum)+ weight loss,
fever. Gram + aerobic branching
partially acid fast
• Neck or face infection w/ draining Actinomyces! Tx w/ high dose
yellow material (+sulfur granules). PCN for 6-12wks
Gram + anaerobic branching
Nephrology
 Electrolyte Abnormalities
• ↓Na = gain of water.
– Check osm, then check volume status.
• Hypervolemic hypoNa: CHF, nephrotic, cirrotic
• Hypovolemic hypoNa: diuretics or vomiting + free water
HYPONA • Euvolemic hypoNa: SIADH (check CXR if smoker), addisons,
hypothyroidism.
• Correct w/ NS if hypovolemic, 3% saline only if seizures or
[Na] < 120. Otherwise fluid restrict + diuretics.
• Don’t correct faster than 12-24mEq/day or else Central
Pontine Myelinolysis.
• ↑Na = loss of water.
– Replace water w/ D5W or other hypotonic fluid
• Don’t correct faster than 12-24mEq/day or else cerebral
edema.
 Other Electrolyte Abnormalities
• numbness, Chvostek or Troussaeu, prolonged
QT interval. ↓Ca Hypocalcemia

• bones, stones, groans, psycho. Shortened QT

interval. ↑Ca Hypercalcemia

• paralysis, ileus, ST depression, U waves. ↓K

Hypokalemia
– Tx w/ K (make sure pt can pee), max 40mEq/hr

• peaked T waves, prolonged PR and QRS, sine

waves. ↑K Hyperkalemia

Tx w/ Ca-gluconate then insulin + glc, kayexalate, albuterol and

sodium bicarb. Last resort = dialysis
 Acid Base Disorders
• Check pH  if <7.4 = acidotic. If >7.4 = alkalotic
– Check HCO3 and pCO2:
• If HCO3 is high and pCO2 is high  metabolic alkalosis
• Check urine chloride-
Saline-insensitive
» If [Cl] > 20 + hypertension  think hyperaldo (Conns). If
normotensive think Barter’s or Gittlemans.
Saline-sensitive » If [Cl] < 20  think vomiting/NG suction, antacids , diuretics
• If pCO2 is low and HCO3 is low  respiratory alkalosis
• Hyperventillation from anxiety, incr ICP, fever., pain, salicylates
• If HCO3 is low and pCO2 is low  metabolic acidosis
– Check anion gap (Na – [Cl + HCO3]), normal is 8-12
» Gap acidosis = MUDPILES
» Non-gap acidosis = diarrhea, diuretic, RTAs (I, II and IV)
• If pCO2 is high and HCO3 is high  respiratory acidosis
• Hypoventillation from opiate OD, brainstem injury, vent prob
"R" of HARDUP

Renal Tubular Acidoses

Cause NAGMA
Non Anion Gap Metabolic Acidosis

Cause Presentation/Dx Treatment

Type I Lithium/Ampho B Urine pH > 5.4
analgesics HypoK, Kidney stones Replete K
Distal
SLE, Sjogrens, sickle Problem? Cannot excrete H+ Oral bicarb
cell, hepatitis
Type II *Fanconi’s syndrome HypoK, Osteomalacia
Replete K
Myeloma, amyloid, Problem? Cannot reabsorb
Proximal Mild diuretic
vitD def, HCO3.
Bicarb won’t help
autoimmune dz
Type IV >50% caused by HyperK
diabetes! HyperCl
Hyperrenin Addisons, sickle cell, High urine [Na] even w/ salt Fludrocortisone
Hypoaldo any cause of aldo restriction
def.

*Fanconi’s anemia = hereditary or acquired prox tubule dysfxn where there is

defective transport of glc, AA, Na, K, PO4, uric acid and bicarb.
 Acute Renal Failure
• >25% or 0.5 rise in creatinine over baseline.
• Work up-
– BUN/Cr ratio  if >20/1 = prerenal
– Check urine Na and Cr  if FENA < 1% = prerenal
– If pt on diuretic measure FENurea  is <35% = prerenal
• Treatment-
– Prerenal causes = anything keeping the kidney from
being perfused.
– If prerenal, tx w/ fluids (& tx CHF, GN, cirhosis, renal
artery stenosis, etc)
 Intrinsic Causes
• Muddy brown casts in a pt w/ ATN. Tx w/ fluids, avoid
ampho, AG, cisplatin or nephrotox and dialysis if
prolonged ischemia? indicated.

• Protein, blood and Eos in the

AIN. Stop offending agent. Add
urine + fever and rash who steroids if no improvement.
took Trim-sulfa 1-2wks ago?
Rhabdomyolysis. 1st test is
• Army recruit or crush victim
check [K+] or EKG. Tx w/ bicarb
w/ CPK of 50K, +blood on dip to alkalinize urine to prevent
but no RBCs? precipitation
• Enveloped shaped crystals on Ethylene glycol intox. (AGMA). Tx w/
UA? MUDPILES dialysis or NaHCO3 if pH<7.2
• Bump in creatinine 48-72hrs Contrast nephropathy. Prevent by
s/p cardiac cath or CT scan? hydrating before or giving bicarb or NAC
 Indications for Emergent Dialysis
• A- Acidosis

• E- Electrolyte imbalance  particularly high K > 6.5

ethylene glycol

• I- Intoxication  particularly antifreeze, Li

Overload of volume  sxs of CHF or

• O- pulmonary edema

• U- Uremia  pericarditis, altered mental status

• NOT for high creatinine or oliguria alone!

 Chronic Kidney Disease
• #1 cause is DM, next is HTN
• #1 cause of death in CKD pt is cardiovascular
dz  so target LDL < 100.
• Complications =
– HTN (2/2 ↑aldo), fluid retention  CHF
– Normochromic normocytic anemia  loss of EPO
– ↑K, ↑PO4, ↓Ca (leads to 2ndary hyperPTH)
electrolyte abnormalities

– ↑PO4 leads to precip of Ca into tissues  renal

osteodystrophy and calciphylaxis (skin necrosis)
– Uremia  confusion, pericarditis, itchiness,
increased bleeding 2/2 platelet dysfxn
 So your patient is peeing blood…
• Best 1st test? Urinanalysis
• Painless hematuria? Bladder/Kidney cancer until proven otherwise
• “terminal hematuria” + tiny Bladder cancer or hemorrhagic cystitis
clots? (cyclophosphamide!)
• Dysmorphic RBCs or RBC Glomerular source RBCs look like mickey mouse ears
casts?
• Definition of nephritic Proteinuria (but <2g/24hrs), hematuria, edema
syndrome? and azotemia
• 1-2 days after runny nose, Berger’s Dz (IgA nephropathy). MC cause.
sore throat & cough?
• 1-2 weeks after sore throat Post-strep GN- smoky/cola urine, best 1st
or skin infxn? test is ASO titer. Subepithelial IgG humps
• Hematuria + Hemoptysis? Goodpasture’s Syndrome. Abs to collagen IV
• Hematuria + Deafness? Alport Syndrome. XLR mutation in collagen IV
• Kiddo s/p viral URI w/ Renal Henoch-Schonlein Purpura. IgA.
failure + abd pain, arthralgia Supportive tx +/- steroids
and purpura.
• Kiddo s/p hamburger and HUS. E.Coli O157H7 or shigella.
diarrhea w/ renal failure, Don’t tx w/ ABX (releases more
MAHA and petechiae. toxin)
• Cardiac patient s/p TTP. Tx w/ plasmapheresis.
ticlopidine w/ renal failure, DON’T give platelets.
MAHA, ↓plts, fever and Can tell from DIC b/c PT and PTT
AMS. are normal in HUS/TTP.
• c-ANCA, kidney, lung and Wegener’s Granuolmatosis. Most accurate test
sinus involvement. is bx. Tx w/ steroids or cyclophosphamide.
• p-ANCA, renal failure, Churg Strauss. Best test is lung bx. Tx w/
asthma and eosinophilia. cyclophosphamide.
• p-ANCA, NO lung Polyarteritis Nodosa. Affects small/med
involvment, Hep B. arteries of every organ except the lung! Tx w/
cyclophosphamide
 Kidney Stones
• Flank pain radiating to groin + hematuria.
• Best test? CT.
• Types-
– Most common type? Calcium Oxalate. Tx w/ HCTZ
– Kid w/ family hx of stones? Cysteine. Can’t resorb certain AA.
– Chronic indwelling foley and Mg/Al/PO4 = struvite. proteus,
alkaline pee? P-S-P-K staph, pseudomonas, klebsiella
– If leukemia being treated Uric Acid
w/ chemo? Tx by alkalinizing the urine + hydration
– If s/p bowel resection for volvulus? Pure oxylate stone. Ca not
• Treatment reabsorbed by gut (pooped out)
– Stones <5mm Will pass spontaneously. Just hydrate
– Stones >2cm Open or endoscopic surgical removal
– Stones 5mm-2cm Extracorporal shock wave lithotropsy break it up and let the
fragments pass
 So your patient is peeing protein…
• Best 1st test? Repeat test in 2 weeks, then quantify w/ 24hr urine
• Definition of nephrotic >3.5g protein/24hrs, hypoalbuminemia, edema,
syndrome? hyperlipidemia (fatty/waxy casts)
• MC in kiddos? Minimal change dz- fusion of foot processes, tx w/ ‘roids
• MC in adults? Membranous- thick cap walls w/ subepi spikes
• Assoc w/ heroin use and Focal-Segmental- mesangial IgM deposits.
HIV? Limited response to ‘roids.

• Assoc w/ chronic hepatitis Membranoprolif- tram-track BM w/

and low complement? subendo deposits
• If nephrotic patient Suspect renal vein thrombosis! 2/2 peeing
suddenly develops flank out ATIII, protein C and S. Do CT or U/S
stat!
pain?
Orthostatic, bence jones in MM, UTI,
• Other random causes? preggos, fever, CHF
Hematology/Oncology
 A patient walks in with microcytic
anemia… www.ezhemeonc.com/wp-content/uploads/2009/02

1.) MCV = 70, low 2.) MCV = 70, ↓Fe,

↓Fe, ↑TIBC, ↓TIBC, ↓retic, nl
↓retic, ↑RDW, ferritin. Anemia of chronic disease 4.) MCV = 70,
↓ferritin.
↑Fe, ↑ferritin,
Fe deficiency anemia
↓TIBC
Sideroblastic anemia
(INH can cause it! treatment for TB)

will see ring sideroblasts in the BM

-little variation, cause

3.) MCV = 60,
super low MCV, = Thalassemia
genetic deffect so all RBCs
are small ↓RDW
 A patient walks in with macrocytic
anemia… healthsystem.virginia.edu

hypersegmented neutrophil

acanthocyte

1.) MVC = 100, ↓retics, 3.) MVC = 100

↑homocysteine, FOLATE deficiecny
Liver disease = cause of macrocytic anemia

nl methylmelonic acid.

2.) MVC = 100, ↓retics,

↑homocysteine, B12 deficiency
+neurologic symptoms
↑methylmelonic acid
 Normal MCV, ↑LDH, ↑indirect bilirubin,
↓haptoglobin HEMOLYTIC ANEMIA
-hemolysis

• Sickle cell kid w/ sudden drop in Aplastic Crisis.

Sickle Crisis from hypoxia,
Hct? dehydration or acidosis
• Cyanosis of fingers, ears, nose + Cold Agglutinins. Destruction
occurs in the liver. IgM mediated.
recent Mycoplasma infx. (pneumonia)

• Sudden onset after PCN, ceph, Warm Agglutinins. Destruction in

spleen. IgG. Tx w/ steroids 1st, then
sulfas, rifampin or Cancer. splenectomy.
(drug rxn or malignancy)

• Splenomegaly, +FH, bilirubin Hereditary spherocytosis (AD loss

gallstones, ↑MCHC. of spectrin). Tx w/ splenectomy.

• Dark urine in AM, Budd-Chiari Paroxysmal Nocturnal Hemoglobinuria.

Defect in PIG-A. Lysis by complement.
syndrome. clots in the IVC?
Incr risk for aplastic anemia
• Sudden onset after primiquine, G6PDH def. Heinz bodies, Bite cells.
sulfas, fava beans Avoid oxidant stress.
 A patient walks in with thrombocytopenia
• 30 y/o F recurrent epistaxis, heavy ITP. Tx w/ prednisone 1st. Then
menses & petechiae. ↓plts only. splenectomy. IVIG if <10K. Rituximab
• 20 y/o F recurrent epistaxis, heavy VWD. DDAVP for bleeding or pre-op.
menses, petechiae, normal plts, ↑ Replace factor VIII (contains vWF) if
bleeding time and PTT. bleeding continues.
• 20 y/o M recurrent bruising, Hemophilia. If mild, tx w/ DDAVP,
hematuria, & hemarthroses, ↑ PTT otherwise, replace factors.
that corrected w/ mixing studies.
• 50y/o M “meat-a-tarian” just finished VitK def. ↓ II, VII, IX and X. Same
2wks of clinda has hemarthroses & for warfarin toxicity.
oozing at venipuncture sites. Tx w/ FFP acutely + vitK shot
• 50y/o M “beer-a-tarian” w/ severe Liver Disease. GI bleeding is MC
cirrhosis. 7
– 1st factor depleted? VII, so PT increases 1st
– 2 factors not depleted? VIII
8
and vWF b/c they are made by endothelial cells.
A patient walks in with thrombocytopenia
and this smear…

schistocytes

www.nejm.org/.../2005/20050804/images/s4.jpg

• If PT and PTT are ↑, fibrinogen DIC!

↓, D-dimer and fibrin split
products ↑? Sepsis, rhabdo, adenocarcinoma, heatstroke,
LPS Auer rodds for
aml tx

– Causes? pancreatitis, snake bites, OB stuff, *Tx of M3 AML*

– Treatment? FFP, platelet transfusion, correct underlying d/o
• If PT and PTT are nl? HUS or TTP
HUS
– Causes? O157H7, ticlopidine, quinine, cyclosporine, HIV, cancer,
– Treatment? Plasmapheresis. NO PLATELETS!
• 7 days post-op, a patient platelets low
pt develops clot

develops an arterial clot. Her

HIT!
platelets are found to be 50% (Heparin induced thrombocytoprnia)

less than pre-op.

– Mechanism? IgG to heparin bound to PF4
– Treatment? Stop heparin, reverse warfarin w/ vitK, start lepirudin
• What to look for in someone
w/ unprovoked thrombus?
– CANCER
– Lupus Anticoagulant ↑PTT, multiple SABs, false + VDRL
– Protein C/S deficiency Skin necrosis after warfarin is started
– Factor V Leiden MC inheritable pro-coag state. V is resistant to C
– AT III Deficiency Heparin won’t work. Clots on heparin.
– OCPs/HRT No Go for women >35 who smoke
– Nephrotic syndrome Pee out ATIII protein C and S preferentially.
Puts at risk for Renal Vein Thrombosis
Rheumatology/Dermatology
 A patient comes in w/ arthritis…

OA. RA.

www.yorkshirekneeclinic.co.uk/images/D3.jpg

www.hopkins-arthritis.org/.../radiology2.jpg

Knee pain, DIP involvement no

swelling or warmth, worse @ the PIP and wrists bilaterally, worse in
end of the day, crepetence. the AM, low grade fever.

• Symmetric, bilateral
arthritis, malar rash,
Psoriatic oral ulcers,
Arthritis. SLE.
proteinuria,
thrombocytopenia.
www.learningradiology.com/.../cow60.jpg Arthritis is not
erosive or have
DIP joint involvement, rash w/ silvery scale on lasting sequellae.
elbows and knees, pitting nails and swollen fingers.
 A patient comes in w/ acute swollen
painful joint…
• 1st best test? Tap it!
• WBCs >50K Septic arthritis
• 30 yr old who “travels a lot Gonococcal. Cx may be negative. Look
for work” also for tenosynovitis and arm pustules. Tx w/ ceftriaxone.
• 70 yr old nun Staph aureus. Tx w/ nafcillin or vanco.
• WBCs 5-50K Inflammatory. If no crystals, think RA, ank spon, SLE, Reiter’s
• Needle shaped, negatively Gout. Monosodium Urate.
birefringent crystals.
• Acute TX? Indomethacin + colchicine (steroids if kidneys suck).
• Chronic TX? Probenecid if undersecreter. Allopurinol if overproduc.
• Rhomboid shaped, positively Pseudogout. Calcium pyrophosphate.
birefringent crystals.
• WBCs 200-5K OA, hypertrophic osteoarthropathy, trauma
• WBCs <200 Normal.
 Antibodies to Know!
• If negative, rules out SLE? ANA – peripheral/rim staining.
• Most sensitive for SLE? Anti-dsDNA or Anti-Smith
• Drug induced lupus? Anti-histone
(hydralazine).
• Sjogren’s Syndrome? Anti-Ro (SSA) or Anti-La (SSB)
• CREST Syndrome? Anti-centromere
• Systemic Sclerosis? Anti-Scl-70, Anti-topoisomerase
• Mixed connective tissue Anti-RNP
disease?
• 2 tests for RA? RF (against Fc of IgG)
Anti-CCP (cyclic citrullinated peptide)
 Skin signs of systemic diseases:

http://www.clevelandclinicmeded.com/medicalpubs/
img.medscape.com/pi/emed/ckb/dermatology/1048

Sign of Leser Trelat Dermatomyositis Seborrheic Dermatitis

http://www.clevelandclinicmeded.com/medicalpubs/

http://www.clevelandclinicmeded.com/medicalpubs/
Dermatitis Herpetiformis
http://www.clevelandclinicmeded.com/medicalpubs/

Erythema Multiforme Acanthosis Nigricans

 Skin signs of systemic diseases part
deaux:

http://dermnetnz.org/systemic/necrolytic-erythema.html

http://www.clevelandclinicmeded.com/medicalpubs/
Necrolytic migratory
Porphyria Cutanea Tarda Erythema Nodosum erythema

http://bestpractice.bmj.com/best-practice/images/bp/376-
2_default.jpg
http://www.clevelandclinicmeded.com/medicalpubs/
http://www.clevelandclinicmeded.com/medicalpubs/
Pemphigus Vulgaris Behcet’s Syndrome
Bullous Pemphigoid
 Other Skin Randoms

http://dermnetnz.org/systemic/acrodermatitis-enteropathica.html

Acrodermatitis http://www.dermnetnz.org/systemic/pellagra.html

enteropathica (Zn Dermatitis of Pellagra secure.provlab.ab.ca

deficiency) Tinea Capitis

img.medscape.com/.../276262-279734-252.jpg
library.med.utah.edu

Actinic Keratosis Kaposi Sarcoma Bacillary

Angiomatosis
 Skin Cancer
• Basal Cell Carcinoma-
– Shave or punch bx then surgical removal (Mohs)
• Squamous Cell Carcinoma-
– AK is precursor lesion (tx w/ 5FU or excision) or http://emedicine.medscape.com/article/

keratoacanthoma. 276624-media

– Excisional bx at edge of lesion, then wide local excision.

– Can use rads for tough locations.
• Melanoma-
– Superficial spreading (best prog, most common)
– Nodular (poor prog) http://emedicine.medscape.com/article/1
101535-media

– Acrolintiginous (palms, soles, mucous membranes in darker

complected races).
– Lentigo Maligna (head and neck, good prog)
– Need full thickness biopsy b/c depth is #1 prog
– Tx w/ excision-1cm margin if <1mm thick,
2cm margin if 1-4mm thick, 3cm margin if >4mm
myhealth.ucsd.edu
– High dose IFN or IL2 may help
Endocrinology
 Common Endo Diseases
• MC pituitary adenoma? Prolactinoma. Consider in amenorrhea/hypoT
– Tx? Bromocriptine or cabergoline… even if macro (>10mm)
• Order of hormones lost in #1 FSH and LH #2 GR #3 TSH #4 ACTH
hypopituitarism?
• Polyuria, polydipsia, hyperNa, DI- lack of ADH (or non-fxnal)
hyperOsm, dilute urine. Do water deprivation test to tell if crazy
– Central- urine Osm still ↓ s/p water depriv. Urine Osm ↑ w/ ddAVP
– Nephrogenic- Urine Osm still ↓ s/p ddAVP. Tx w/ HCTZ/amiloride.
• See low TSH, high free T3/T4. Hyperthyroidism
Next best step? I123 RAIU scan. If ↑ = Graves. If ↓ = factitious or thyroiditis
– Tx? 1st = propranolol + PTU/MTZ. I131 ablation or surgery (preggos & kiddos)
– Tx of thyroid storm? PTU + Iodine (Lugol’s sol’n) + propranolol.
 Work up of a Thyroid Nodule
• 1st step? Check TSH
• If low? Do RAIU to find the “hot nodule”. Excise or radioactive I131
• If normal? FNA
• If benign? Leave it alone.
• If malignant? Surgically excise and check pathology
• If indeterminate? Re-biopsy or check RAIU
• If cold? Surgically excise and check pathology
– Papillary MC type, spreads via lymph, psammoma bodies
– Follicular Spreads via blood, must surgically excise whole thyroid!
– Medullary Assoc w/ MENII (look for pheo, hyperCa). Amyloid/calci
– Anaplastic 80% mortality in 1st year.
– Thyroid Lymphoma Hashimoto’s predisposes to it.
 Adrenal Issues
• Osteoporosis, central fat, DM, hirsutism Suspect Cushing’s.
– Best screening tests? 1mg ON dexa suppression test or 24hr urine cortisol
• If abnormal? Diagnoses Cushing’s Syndrome
– Next best test? 8mg ON dexa suppression test
• Suppression to <50% of control? Pituitary adenoma (Cushing’s dz)
• No suppression? Either adrenal neoplasia or ectopic ACTH
– Next best test? Plasma ACTH. Chest CT if smoker. Abdominal CT/DHEAS
• Weakness, hypotension, weight loss,
hyperpigmentation, ↑K, ↓Na, ↓pH Suspect Adrenal Insufficiency
– Best screening test? Cosyntropin stimulation test (60min after 250mcg)
• MC cause? Autoimmune (Addison’s dz)
– Treatment? NaCl resuc. Long term replacement of dexamethasone and
fludrocortisone.
 Work up of an Adrenal Nodule
• Best 1st step? Check functional status
Diagnosis Features Biochemical Tests
Pheochromocytoma High blood pressure, Urine- and plasma-free
catechol symptoms metanephrines
Primary aldosteronism High blood pressure, low Plasma aldosterone-to-
K+, low PRA* renin ratio
Adrenocortical carcinoma Virilization or feminization Urine 17-ketosteroids
Cushing or "silent" Cushing Cushing symptoms or Overnight 1-mg
syndrome normal examination results dexamethasone test

• #2- if <5cm and non-function 

• Observe w/ CT scans q6mo
If >6cm or functional 
Surgical excision
http://emedicine.medscape.com/article/116587-treatment
 Parathyroid Disease
Hypoparathryoidism
– Perioral numbness, Chvortek, Trousseau s/p
Thyroidectomy
– ↓*Ca+, ↑*PO4+, ↓*PTH+
Hyperparathyroidism
– Kidney stones, constipation/abd pain or psychiatric sxs
– ↑*Ca+, ↓*PO4+, ↑vitD, ↑*PTH]
Dx w/ FNA of suspicious nodules. Can use Sestamibi scan.
Tx w/ surgical removal of adenoma. If hyperplasia, remove all 4 glands and
implant 1 in forearm.
• MEN-
– MEN1- pituitary adenoma, parathyroid hyperplasia,
pancreatic islet cell tumor.
– MEN2a- parathryoid hyperplasia, medullary thyroid cancer,
pheochromocytoma
– MEN2b- medullary thyroid cancer, pheochromocytoma,
Marfanoid
 Diabetes
FBGL > 126 x 2, 2hr OGTT > 200, random glc >
• Diagnosis of Diabetes? 200 + sxs (polyuria, polydipsia, blurred vision)
• Nausea, vomiting, abdominal pain,
Kussmaul respirations, coma w/ BGL = 400? DKA
– Dx? Ketones in blood (&urine), AGMA, hyperkalemia
– Tx? High volume NS + insulin bolus & drip. Add K once peeing. Add glc <200
• Polyuria, polydipsia, profound dehydration, HHS
confusion and coma w/ BGL = 1000?
– Tx? High volume fluid & electrolytes. May require insulin.
• MC cause of death? Cardiovascular disease
• Important screening?
– Heart? LDL < 100, BP < 130/80,
– Kidney? Check for microalbuminemia (30-300 in 24hrs). Start ACE-I
– Eye? Annual screening for prolif retinopathy  Vitreous hemor/neovasc
– Nerves? Podiatric exam annually. Tx gastroparesis w/ metoclopramide or
erythromycin. May get ED. 3rd, 4th, 6th CN palsy.
Neurology
 Spinal cord compression

A 47 year old IVDU comes in requesting

hydromorphone for back pain. His pain is worse
w/ valsalva, and his L4 vertebra is TTP. His LE
have 4-/5 strength bilaterally, his has flaccid
rectal tone, and plantar response is upgoing.
• Next best step? MRI of the spine. 2nd choice is CT myelogram
• If same clinical picture in a patient w/ IV dexamethasone then MRI
hx of prostate ca… next best step? then radiation therapy.
• Pt s/p MVC w/ “whiplash” has loss of Syringomyelia. MRI to dx,
pain/temp on neck and arms & intact surgery to tx
sensation.
• Pt w/ high cholesterol presents w/ Anterior spinal artery
acute onset flaccid paralysis below the occlusion.
waist, loss of pain/temp w/ preserved Tx is supportive.
vibration of position.
 Stroke!
• Most common cause? 80% ischemic, 20% hemorrhagic
• Best 1st step? Non-contrast CT to r/o hemorrhage
• Most accurate test? Diffusion-weighted MRI best for ischemic. CT can be
• Treatment? neg 1st 48hrs.
If w/in 3 (4.5) hours? TPA
If later than that? Aspirin. Heparin only for those in a-fib, basilar clot
Contraindications to TPA? Stroke w/in 3mo, surg w/in 2wks, LP w/in 1wk
• If they had the stroke on Add dipyridamole or switch to clopidogrel.
aspirin? Don’t use ticlopidine! (why?)
• If they had a subarachnoid Nimodipine to reduce ischemic stroke
hemorrhage? from vc (MC cause of M&M)
• When to clip an aneurysm? W/in days or rupture or when <10mm
• When to do endarterectomy? When occlusion >70% and is
symptomatic. (>60% if <60y/o)
 Where’s the lesion?
• L hemiplegia/hemisensory loss, L homonomous R MCA stroke
hemianopsia w/ eyes deviated twoards the R +
apraxia.
• L hemiplegia/hemisensory loss in the leg>arm. R ACA stroke
Confusion, behavioral disturbance.
• L hemiplegia + R ptosis & eye deviated to the right R Webber’s
and down.
• Falling to the L + R ptosis & eye deviated to the right R Benedikt’s
and down.
• L hemisensory loss + Horners + R facial sensory loss.R Wallenburg (PICA)
• Vertigo, vomiting, nystagmus and clumsiness with Major R cerebellar
the right arm. arteries
• Total paralysis except for vertical eye movements. Paramedial
branches of the
basilar artery.
 Seizures
• Medical causes include hypoglycemia, hyponatremia,
hypocalcemia, structural (tumor, bleed, stroke), infection,
ETOH or benzo w/drawal.
• Status Epilepticus.
– Tx? Lorazepam + LD of phenytoin. Then phenobarbitol. Then anesthesia.
• Partial seizures begin focally. (Arm twitch, de-ja-vu,
burning rubber smell).
– They are simple if no LOC and complex if LOC (may have lip
smacking). Both can generalize.
– Tx? 1st line = carbamazepine or phenytoin. Then valproate or lamotrigine
• Generalized seizures begin from both hemispheres @
once.
– Either grand mal or absence (5-10sec unresponsiveness in
kiddos), myoclonic, atonic. Tx absence w/ ethosuximide
– Tx? 1st line = valproic acid, then lamotrigine, carbamezepine, phenytoin
 EEG Buzzwords
• 3 Hz spike-and- Absence Seizure. Tx w/ ethosuxamide
wave.
• Triphasic bursts Creutzfeldt Jakob. Dementia + myoclonus

• Diffuse Delirium. Contrast w/ psychosis that has no

background EEG changes
slowing.
• Hypsarrhythmia Infantile spasms. Tx w/ ACTH. Most are
associated w/ mental retardation.
 New Onset Severe Headache
Things to consider:
• “Worse headache of my life” Subarachnoid hemorrhage. Noncon CT 1st!
• + Fever and Nuchal rigidity Meningitis. Abx then CT then LP.
• Deep pain that wakes them up Consider brain tumor. Most important
at night. Worse w/ coughing or prognostic factor is grade (degree of
anaplasia).
bending forward.
• Unilateral pounding headache Temporal arteritis. Check ESR, then
w/ changes in vision and jaw give steroids, then do temporal artery
biopsy. Can lead to blindness.
claudication.
• Fat lady on minocycline or who Pseudotumor cerebri. Also assoc w/
takes isotreintoin w/ abducens OCPs. Normal CT, elevated pressure
on LP. Tx w/ weight loss, then
nerve palsy/diplopia.
acetazolamide, then shunt or optic
nerve sheath fenestration.
 Neuro reasons to go to the hospital…
• Diarrhea 3wks ago, now Guillain-Barre.
areflexia and ascending CSF shows albumino-cytologic dissociation
paralysis.
– Most likely bug? Campylobacter, HHV, CMV, EBV
– Best tx? IVIG or plasmapheresis. Monitor VC for intubation req.
• Nasal voice, ptosis, dysphagia, Myasthenia Gravis. 1st test is Ach-ab. Most
respiratory acidosis. accurate is EMG, decrease in muscle fiber contraction.
– Acute tx? IVIG or plasmapheresis. Monitor VC for intubation req.
– Chronic tx? Pyridostigmine, GCs/azathioprine, thymectomy (<60)
– Meds to avoid? Aminoglycosides & beta-blockers
• Urinary retention, Babinski on Multiple Sclerosis.
R. Episode of double vision Neuro-deficits separated by time and space
6mo ago.
– Best dx test? MRI of the brain. Incr T2 @ periventricular white matter
– Acute tx? Steroids. (3 days IV then 4wks oral). Plasma xchng is 2nd line
– Chronic tx? IFN-beta1a, beta1b, glatiramer reduce exacerbations
Gastroenterology Extra Slides
 A patient comes in with dysphagia…
• Best 1st test is a barium swallow
• Next best test is endoscopy (can be dx and
allow for bx of suspicious masses or tx in
dilation of peptic strictures or injecting botox
for achalasia).
• Manometry is the test of choice for achalasia.
• 24 pH monitoring is the test of choice for
GERD.
• If HIV+ (CD <100) or otherwise
immunocompromised- remember candida,
CMV and HSV esophagitis
• Bad breath & snacks in Zenker’s diverticulum.
the AM. Tx w/ surgery

• True or false? False. Only contains mucosa

• Dysphagia to liquids & solids. Dysphagia worse w/ hot &
Achalasia. cold liquids + chest pain that
Tx w/ CCB, nitrates, feels like MI w/ NO regurg
botox, or heller
sxs. Diffuse esphogeal spasm.
myotomy
Assoc w/ Chagas dz Tx w/ CCB or nitrates
jykang.co.uk
and esophageal
cancer.
ajronline.org

• Epigastric pain worse after GERD. Most sensitive test is 24-hr pH

eating or when laying down monitoring. Do endoscopy ifst“danger signs”
present. Tx w/ behav mod 1 , then antacids,
cough, wheeze, hoarse. H2 block, PPI.
• Indications for surgery? bleeding, stricture, Barrett’s, incompetent LES,
max dose PPI w/ still sxs, or no want meds.
If hematemesis (blood occurs If gross hematemesis If progressive
after vomiting, w/ subQ unprovoked in a cirrhotic dysphagia/wgt loss.
emphysema). Can see pleural w/ pHTN. Esophageal Carcinoma
effusion w/ ↑amylase Gastric Varices Squamous cell in
Boerhaave’s If in hypovolemic shock? smoker/drinkers in the
Esophageal Rupture middle 1/3.
do ABCs, NG lavage, Adeno in ppl with long
Next best test? medical tx w/ octreotide standing GERD in the
CXR, gastrograffin or SS. Balloon distal 1/3.
esophagram. NO tamponade only if you
edoscopy need to stablize for Best 1st test?
Tx? transport
barium swallow, then
surgical repair if full Tx of choice? endoscopy w/ bx, then
thickness staging CT.
Endoscopic
sclerotherapy or
banding
*Don’t prophylactically
band asymptomatic
varices. Give BB. img.medscape.com
/pi/emed/ckb/onco
logy/276262
 A patient comes in with MEG pain…
• #1 cause is non-ulcerative dyspepsia. Dx of
exclusion. Tx w/ H2 blocker and antacid.
• If GERD sxs predominate- tx empirically w/ PPI for
4 wks then re-evaluate.
• If biliary colic sxs predominate  RUQ sono
• If hx of stones or drinking, check amylase and
lipase and CT scan is best imaging for pancreas.
• Danger sxs warrant endoscopic work up-
– >50 y/o, hx of smoking and drinking, recent
unprovoked weight loss, odynophagia, Fe-def anemia
or melena.
• Gastric Ulcers- MEG pain worse w/ eating. H.pylori, NSAIDs, ‘roids
– Double-contrast barium swallow shows punched out lesion w/
regular margins. EGD w/ bx can tell H. pylori, malign, benign.
– Tx w/ sucralfate, H2-block, PPI. Surgery if ulcer remains s/p
12wks treatment.
• Duodenal Ulcers- MEG pain better w/ eating
– 95% assoc w/ H. pylori
– Healthy pts < 45y/o can do trial of H2 block or PPI
– Can do blood, stool or breath test for H. pylori but endoscopy
w/ biopsy (CLO test) is best b/c it can also exclude cancer.
– Tx H. pylori w/ PPI, clarithromycin & amoxicillin for 2wks. Breath
or stool test can be test of cure.
• Zollinger-Ellison Syndrome-
– Suspect it if MEG pain/ulcers don’t improve w/ eradication of H.
pylori, large, multiple or atypically located ulcers.
– Best test is secretin stim test (finding high gastrin)
– Tx w/ resection if localized, long term PPI if metastatic.
– Look for pituitary and parathyroid problems (MEN1)
• Acute Cholecystitis-
– RUQ pain  back, n/v, fever
(diff than sx-atic gall-stones)
worse after fatty food, +Murphy’s. med-ed.virginia.edu

– Best 1st test is U/S  thickened wall. HIDA shows non-

visualization of GB.
– Tx with cholecystectomy. If too unstable for surg, can place
a percutaneous cholecystostomy.
• Choledocothithiasis-
– Same sxs + obstructive jaundice, high bili, alk phos
– U/S will show stones. Do cholecystectomy or ERCP to
remove stone.
• Ascending Cholangitis-
– RUQ pain, fever, jaundice (+hypotension and AMS)
– Tx w/ fluids & broad spec abx. ERCP and stone removal.
• Cholangiocarcinoma- rare. RF are primary sclerosing
cholangitis (UC), liver flukes and thorothrast exposure. Tx w/
surgery.
• Acute Pancreatitis-
– Gallstones & ETOH most common etiologies
– MEG pain  back + n/v, Turner’s and Cullens signs
– Labs show incr amylase (>1000 means stone) &
lipase. Best imaging is CT scan. Tx w/ NG, NPO, IV.
Observe.
– Prognosis- worse if old, WBC>16K, Glc>200, LDH>350,
AST>250… drop in HCT, decr calcium, acidosis, hypox
– Complications- pseudocyst (no cells!), hemorrhage, abscess,
ARDs
• Chronic Pancreatitis-
– Chronic MEG pain, DM, malabsorption (steatorrhea)
– Can cause splenic vein thrombosis
• Adenocarcinoma-
– Usually don’t have sxs until advanced. If in head of pancreas 
Courvoisier’s sign (large, nontender GB, itching and jaundice).
Trousseau’s sign = migratory thrombophlebitis.
– Dx w/ EUS and FNA biopsy
– Tx w/ Whipple if: no mets outside abdomen, no extension into
SMA or portal vein, no liver mets, no peritoineal mets.
 A patient comes in with diarrhea…
• If hypotensive, tachycardic. Give NS first!
• Vial is #1 cause  rota in daycare kids, Norwalk on cruise
ships
• Check fecal leukocytes  tells invasion. Stool cx is best test
• If bloody diarrhea  consider EHEC, shigella, vibrio
parahaemolyticus, salmonella, entamoeba histolytica
• If hx of picnic  B. ceres, staph food poisoning. 1-6hrs
• If hx of abx use  check stool for c. diff toxin antigen
• If foul smelling, bulky, malnourished  consider Sprue,
chronic pancreatitis, Whipple’s dz, CF if young person.
• If accompanied by flushing, tachycardia/ hypotension 
consider carcinoid syndrome (metastatic).
– *Can cause niacin deficiency! (2/2 using all the tryptophan to
make 5HT) Dementia, Dermatitis, Diarrhea.
Oncology Extra Slides
 A patient presents w/ fatigue, petechiae,
infection bone pain and HSM…
• If >20% blasts? Defines Acute Leukemia on Biopsy

• CALLA or TdT? ALL. Most common cancer in kids.

• Auer Rods, AML. More common in adults. RF = rads

myeloperoxidase, exposure, Down’s, myeloprolif.
*M3 has Auer Rods and causes DIC upon tx.
esterase?
Hairy Cell Leukemia. See enlarged
• Tartate resistant acid spleen but no adenopathy.
phosphatase, Hairy Cells have numerous
cytoplasmic projections on smear.
↓monos & CD11 and Tx w/ cladribine 5-7day single course
CD22+?
Danorub, vincris, pred. Add intrathecal MTX for CNS
• Tx of ALL? recurrence. BM transplant after 1st remission.
• Tx of AML? Danorub + araC. If *M3  give all trans retinoic acid
CML- 9:22 transloc  tyrosine kinase CLL
• A patient presents w/ • Asymptomatic elevation
fatigue, night sweats, in WBCs found on routine
fever, splenomegaly and exam – 80% lymphs.
elevated WBCs w/ low
LAP and basophilia?

www.ncbi.nlm.nih.gov/bookshelf/picrender.fcgi...

If Lymphadenopathy
Stage 0 or 1 need no tx- 12 yrs
img.medscape.com/.../197800-199425-29.jpg
till death
If Splenomegaly
Tx w/ imantinib (Gleevec), inhibits Stage 2 tx w/ fludrabine
tyrosine kinase. 2nd line is bone
If Anemia
marrow transplant.
Cx = blast crisis. If Thrombocytopenia
Stage 3 or 4 tx w/ steroids
• Enlarged, painless, rubbery Think Lymphoma
lymph nodes
• Drenching night sweats, “B-symptoms” = poor prognosis along w/
fevers & 10% weight loss. >40, ↑ESR and LDH, large mediastinal LND
• Best initial test? Excisional lymph node biopsy
• Next best test? Staging Chest/Abdominal CT or MRI. If still unsure,
staging laparotomy is done. Bone marrow bx (esp for NHL

• Orderly, centripetal spread

Hodgkin’s Lymphoma
+ Reed Sternberg cells?
• Type w/ best prognosis? Lymphocyte predominant
• More likely to involve
Non-hodgkin’s Lymphoma
extranodal sites? (spleen,
BM)
I = 1 node group, II = 2 groups, same side of diaphragm,
• Staging? III = both sides of diaphragm, extension into organ. IV = BM or liver
• Treatment? I/II get rads
III/IV get ABVD chemo
 Other hematologic randoms…
• Bone pain, “punched out
Multiple Myeloma
lesions” on *x-ray*, hyper Ca
– Best 1st test- Serum protein elecrophoresis- IgG monoclonal spike
– Confirmatory test- Bone marrow bx showing >10% plasma cells.
– Tx- If young, BM transplant. If old, melphalan + prednisone. Hydration and
• Dizziness, HA, hearing/vision lasix then bisphosphonate for hyperCa
problems and monoclonal Waldenstrom Macroglobulinemia
IgM M-spike.
• No sxs, immunoglobulin MGUS
spike found on routine exam
• Older pt w/ generalized Polycythemia Vera
pruritis and flushing after
hot bath. Hct of 60%.
– Best 1st test- Check epo, make sure it isn’t secondary. (PSG, carboxy-Hb)
– Tx- Scheduled phlebotomy. Hydroxyurea can prevent thromboses