1.

internal medicine

MEMORY AID FOR INTERNAL MEDICINE

Causes of acute Pancreatitis

BAD SHIT

Black scorpion bite

Alcohol ( or autoimmune : PAN )
Drugs ( tetracycline, azothioprin, sulfa, diuretics )

Stones ( gallstones or steroid )

Hyperlipidemia
Infection ( mumps )
Trauma

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Small Bowel Obstruction

"SHAVIT"
S - Stone (gallstone ileus)
H - Hernia
A - Adhesions
V - Volvulus
I - Intussusception
T - Tumor

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Non-GI Causes of Vomiting

ABC's of Non- GI causes of vomiting

Acute renal failure

Brain (Increased ICP)
Cardiac (Inferior MI)
DKA
Ears (labyrinthitis)
Foreign substances (Tylenol, theo, etc)
Glaucoma
Hyperemesis Gravidarum
Infections (pyelonephritis, meningitis)
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Extraintestinal manifestations of I. B. D. are A PIE SAC -

Aphthous ulcers, Pyoderma gangrenosum, Iritis, Erythema nodosum, Sclerosing cholangitis, Arthritis,
clubbing.

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Which I. B. D. has C-obblestones on endoscopy - C-rohn's.

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Acute Rheumatic Fever

There are several for the major criteria, I use "JONES"

J - Joints
O - Obvious (cardiac) - sorry, I know this is kinda weak
N - Nodules (subcutaneous nodules)
E - Erythema marginatum
S - Syndeham's Chorea

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Causes of ST Elevation

"ELEVATION"

E - Electrolytes
L - LBBB
E - Early Repolarization
V - Ventricular hypertrophy
A - Aneurysm
T - Treatment - Pericardiocentesis
I - Injury (AMI, contusion)
O - Osborne waves (hypothermia)
N - Non-occlusive vasospasm
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Hyperkalamia causes large T waves on the ECG, Hypokalaemia causes small ones - ie. large pot - lots of
tea, small pot - no tea.

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If QRS complex is wide, consider bundle branch block. LBBB causes a "W" pattern in V1-2 and a "M"
pattern in V5-6. RBBB is the other way round. Remember as WiLLiaM MaRRoW.

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Elevation of cardiac enzymes after a M.I. is CPK, then AST, then LDH. Remember as - C AST Le.

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Basal Systolic Murmur: Aortic Stenosis (AS)

-The mnemonic key is Arthur Shawcross (AS), a cannibalistic murderer, a key which immediately
follows the symbol.

-Clinical:

Angina pectoris despite normal coronary arteries

Arthur Shawcross represents the Angel of death [Angina].

Exertional syncope
His victims Swooned [Syncope] with fear when they saw him.

Exertional dyspnea of congestive heart failure

Arthur Shawcross claims he left the crime scenes whistling Dixie [Dyspnea].

Sudden cardiac death

Arthur Shawcross causes Sudden Death.

-Physical findings

Loud, harsh, systolic ejection murmur at the upper right sternal border, usually
associated with a palpable systolic thrill.
Arthur Shawcross is a Base [Basal] Thrill-murderer [Thrill].
He is a Harsh Hardened criminal, who attributed his grotesque actions to
incest with his Sister [Systolic].

S4 gallop is common and represents left ventricular hypertrophy and increased

left ventricular pressure.
His ghoulish tales read like the Four [S4] Horsemen of the Apocalypse.

S3 when left ventricular failure is present.

As a child, AS displayed the classic homicidal Triad [S3]: animal torture,
fire-setting, and bed-wetting.

Delayed upstroke in the carotid pulse. Parvus et tardus carotid pulse.

His last victim still had a Small but palpable pulse. However, the ambulance was
Delayed [upstroke], and, it soon became too Little, too Late [Parvus et Tardus].

Paradoxical splitting of S2
AS sent his victims to Paradise [Paradoxical].

References:
1. Harrison Principles of Internal Medicine, 14/e Edition, McGraw-Hill, New York, 1998.
2. Maximum access to diagnosis and therapy (MAXX), Lippincott Williams & Wilkins, New York, 1999

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Symptoms of aortic stenosis are SAD or ASD - Syncope, Angina, Dyspnea.

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For Causes of A-Fib/Flutter

H = cHf, other cardiomyopathies

E = Enlargement of the atria
A = Alcohol binge drinking
R = Rheumatic heart disease
T = hyperThyroid

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Asystole

"3 Hypo's & 3 Hyper's"

Hypoxia
Hypothermia
Hypokalemia

Hyperkalemia
Hyper H (Acidosis)
Hyper Rx (Drugs/OD)

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Syncope

"HEAD, HEART and VESS'LS"

H - hypoglycemia hypoxia
E - epilepsy
A - anxiety [the "swoon"]
D - dysfunction of brain stem [i.e. brain stem TIA]

H - heart attack
E - embolism of pulmonary artery
A - aortic obstruction [ Aortic stenosis, myxoma, IHSS ]
R - rhythm disturbance
T - tachycardia esp VT

V - vasovagal
E - ectopic i.e. hemorrhage obvious or not
S - situational [micturation, defecation...]
S - subclavial steal
L - low SVR [eg: anaphalaxis]
S - sensitive carotid sinus

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Basic management of M.I. is BOOMAR - Bed rest, Oxygen, Opiate, Monitor, Anticoagulate, Reduce clot
size

Proven MI.. should be met by M.O.N.A.

M = morphine
O = oxygen
N = nitrates
A = aspirin

suspected right ventricular MI suspected .. hold the Nitrates.

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Endocarditis

"FAME"

F - FEVER
A - ANEMIA
M - MURMUR

E - ENDOCARDITIS

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Causes of pericarditis are CARDIAC RIND - Collagen vascular disease, Aortic aneurysm, Radiation,
Drugs eg. hydralazine, Infections, Acute renal failure, Cardiac infarction, Rheumatic fever, Injury,
Neoplasms, Dressler's syndrome.

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5 T's of early cyanosis in congenital heart disease

Tetralogy, Transposition, Truncus, Total anomalous, Tricuspid atresia

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95% of hypertension is primary (idiopathic). 5% is secondary and causes include CHAPS - Cushing's
syndrome, Hyperaldosteronism (Conn's syndrome) , Aorta coarctation, Pheochromocytoma, Stenosis of
the renal arteries.
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Takayasu's disease is also called pulseless disease, therefore I can't Tak'a ya's pulse.

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Henoch-Schonlein Purpura

"JARS"

J - Joints
A - Abdominal pain
R - Renal
S - Skin

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Compartment Syndrome

"6 p's"

pulselessness
pain
pallor
parasthesia
poikiolothermia
paralysis

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Predisposing Conditions for Pulmonary Embolism TOM SCHREPFER

T--trauma
O--obesity
M--malignancy
S--surgery
C--cardiac disease
H--hospitalization
R--rest (bed-bound)
E--estrogen, pregnancy, post-partum
P--past hx
F--fracture
E--elderly
R--road trip

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Shortness of Breath

HAPISOCS

H: History of any pulmonary disease

A: Activity at onset
P: Pain upon inspiration
I: Infections fever/chills
S: Smoker years/packs
O: Orthopnea
C: Cough (Persistent)
S: Sputum Productive/color

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Non-Cardiogenic Pulmonary Edema

"PONS"

P - Phosgene, paraquat, phenothiazines

O - Opioids/organophosphates
N - Nitrous dioxide
S - Salicylates

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Treatment of acute pulmonary edema

As Easy as 'LMNOP' : Remember the mnemonic LMNOP when treating a patient with acute pulmonary
edema
Lasix¢ç (furosemide) intravenous (IV), one to two times the patient's usual dose, or 40 mg if the patient
does not usually take the drug.

Morphine sulfate. Initial dose, 4 to 8 mg IV (subcutaneous administration is effective in milder cases);

may repeat in 2 to 4 hours. Avoid respiratory depression. Morphine increases venous capacity, lowering
left atrial pressure, and relieves anxiety, which reduces the efficiency of ventilation.

Nitroglycerin IV, 5 to 10 ug/min. Increase by 5 ug/min q 3 to 5 minutes. Reduces left ventricular preload.
Caution: may cause hypotension.

Oxygen, 100% given to obtain an arterial PO2>60 mm Hg.

Position patient sitting up with legs dangling over the side of the bed. This facilitates respiration and
reduces venous return.

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Beta-1 receptors are in the heart (you have 1 heart) and beta-2 receptors are in the lungs (you have 2
lungs).

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Decreased Pleural fluid Glucose : "IRAN"

I=Infections
RA=Rheumatoid arthritis
N=Neoplasia

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Anterior Mediastinal Mass

"4 T's"

T - Thymoma
T - Teratoma
T - Thyroid tumor/goiter
T - Terrible lymphoma

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Middle Mediastinal Mass

"Habit5"

H - Hhernia, hematoma
A - Aneurysm
B - Bronchogenic cyst/duplication cyst
I - Inflammation (sarcoid, histo, coccidio, TB)
T5 - Tumors (lung, lymphoma, leukemia, leiomyoma, lymph node hyperplasia)

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Bilateral Hilar Adenopathy

"Please Helen Lick My Popsicle Stick"

P - Primary TB
H - Histoplasmosis
L - Lymphoma
M - Metastases
P - Pneumoconiosis
S - Sarcoidosis

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Sarcoidosis:

SARCOIDOSIS: G-E-R-M-A-N ACE "SCHAUMANN" B-O-E-K

G-Granulomas
E-Erythema nodosum
R-Restrictive lung defect (PFTs)
M-Multiple systemic manifestations
A-Asteroid bodies (inclusions)
N-Noncaseating granuloma, Negative TB test

ACE - Angiotensin converting enzyme levels monitor disease activity and response to therapy.

Schaumann's bodies (inclusions)

B-Bell's palsy, Bilateral hilar lymphadenopathy, Black females

O-Optic nerve dysfunction is a common manifestation of neurosarcoid.
E-Eyes: uveitis
K-Kveim skin test
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Rat Poisons

"RATS PANIC" I'm sure that you'll easily remember this one!

R - Red squill
A - Arsenicals
T - Thallium
S - Strychnine

P - PNU/Phosphorus/zn Phosphide
A - Alpha naphtha thiurea (ANTU)
N - Norbormide
I - Indanediones
C - Coumadin/cholcalciferol

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Anion Gap Acidosis:

"Mudpiles"

M - Methanol
U - Uremia
D - DKA/AKA
P - Paraldehyde/phenformin
I - Iron/INH
L - Lactic acidosis
E - Ethylene glycol
S - Salicylates

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Normal Gap Acidosis

"HARDUP"
H - Hyperalimentation/hyperventilation
A - Acetazolamide
R - RTA
D - Diarrhea
U - Ureteral diversion
P - Pancreatic fistula/parenteral saline

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Osmolar Gaps

"ME DIE"

M - Methanol
E - Ethanol

D - Diuretics (mannitol, sorbitol, glycerol)

I - Isopropanol
E - Ethylene glycol

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Respiratory Alkalosis: Asthmatic Sally poisoned POPE's HEN

Asthma
Salicylate poisoning
PO= Pulmonary Oedema
PE= Pulmonary Embolism
HEN= Hepatic Encephalopathy

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Hypoglycemia

"Reexplain"

R - renal failure
EX - exogenous
P - pituitary
L - liver failure
A - alcohol
I - insulinoma/infection
N - neoplasm

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Hypoglycemia

Hypoglycemia - H-U-N-G-E-R: B-E-S-T S-A-U-C-E I-S M-S-G

H-Hepatic failure (advanced), Hypothermia

U-Uremia/renal failure
N-Nausea, vomiting
G-Growth hormone deficiency
E-Ethanol metabolism blunts gluconeogenesis
R-Reye's syndrome

B-Beta blockers
E-Enzyme defects (glycogen storage diseases)
S-Sepsis
T-Tumors: Islet beta cell tumors (pancreatic): Insulinomas
Non-islet cell tumors: Large mesenchymal tumors

S-Sulfonylureas
A-Adrenal insufficiency
U-Under 0.3 (insulin/glucose ratio) to make the diagnosis
C-C-peptide measurement to rule out factitious hypoglycemia
E-Endocrine: Epinephrine, glucagon deficiencies (counterregulatory hormone deficiencies)

I-Immune disease with insulin or insulin receptor antibodies

S-Sarcomas: large retroperitoneal sarcomas

M-Maple syrup urine disease, severe Malaria

S-Salicylates in children
G-Galactosemia (with milk ingestion), disorders of Gluconeogenesis

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Symptoms of hyperthyroidism

Remember the following mnemonic when evaluating patients for hyperthyroidism:

S : Sweating
T : Tremor or Tachycardia
I : Intolerance to heat, Irregular menstruation, and Irritability
N : Nervousness
G : Goiter and Gastrointestinal (loose stools/diarrhea).
Submitted by Jed
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CUSHING'S

DISEASE is
Dependent on (Pituitary) and
Depresses ( Cortisol) on
Daddy Doses of Dexa(High doses of Dexamethasone).

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Hypercalcemia

"SHAMPOO DIRT"

S - Sarcoidosis
H - Hyperparathypoidism, Hyperthyroidism
A - Alkali-milk syndrome
M - Metastases, myeloma
P - Paget disease
O - Osteogenesis imperfecta
O - Osteoporosis

D - Vitamin intoxication
I - Immobility
R - RTA
T - Thiazides

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Hypercalcemia symptoms are Bones (pain), Stones (renal), abdominal Groans (pain) and psychic moans
(confusion).

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Multiple endocrine neoplasia

MEN I is 3 P's (Pituitary, Parathyroid, Pancreas). MEN II is 2 C's (Catecholamines ie. pheochromocytome,
carcinoma of medulla of thyroid) and Parathyroid (IIa) or Mucocutaneous neuromas (IIb).
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The most common thyroid carcinoma is P-apillary (P-opular). It also has P-sammona bodies on histology.
It causes P-alpable lymph nodes (lymphatic spread).

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The most common symptoms of PHEochromocytoma begin with the first 3 letters - Palpitations,
Headache, Episodic diaphoresis (sweating).

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Tumors that go to bone

"Kinds Of Tumors Leaping Primarily To Bone"

K - Kidney
O - Ovarian
T - Testicular
L - Lung
P - Prostate
T - Thyroid
B - Breast

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Causes of joint pain are SOFTER TISSUE - Sepsis, Osteoarthritis, Fractures, Tendon/muscle, Epiphyseal,
Referred, Tumour, Ischaemia, Seropositive arthritides, Seronegative arthritides, Urate, Extra-articular
rheumatism (eg. polymyalgia).

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Ossification centers of the elbow

There are two that I know of (most people use "CRITOE"):

C - Capitellum
R - Radial head
I - Internal (medial epicondyle)T - Trochlea
O - Olecranon
E - External (lateral epicondyle)

These appear at 2, 4, 6, 8, 10, and 12 years of age in order and go away two years later.
The other mnemonic I know for the ossification centers is "Come Rub My Tree Of Love" where the "M" is
medial epicondyle and the "L" is the lateral epicondyle.

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Wrist Bones

"Never Loosen Tillies Pants, Mother Might Come Home"

Proximal row:
N - Navicular
L - Lunate
T - Triquetrium
P - Pisiform

Distal row:
M - greater Multiangular (trapezium)
M - lesser Multiangular (trapezoid)
C - Capitate
H - Hamate

Also: "Some Lovers Try Positions That They Can't Handle"

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Rotator Cuff Muscles

"SITS"

S - Supraspinatus
I - Infraspinatus
T - Teres minor
S - Subscapularis

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The Salter Classification:

"SALTR"

S - Slip of physis
A - Above physis
L - Lower than physis
T - Through physis
R - Rammed physis

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NEPHROTIC SYNDROME (NS) is characterized by the following: [By Shweta]

N = Na + water retention
This occurs due to several factors, including compensatory secretion of aldosterone in response to
hypovolemia-mediated release of ADH.

E = Edema
Due to hypoproteinemia + Na, water retention. Edema is soft, pitting and starts in the periorbital region.

P = Proteinuria >3.5gm/1.74sq. ml/24hrs

H = Hypertension + hyperlipidemia (due to increased lipoprotein synthesis in liver, abnormal transport of

circulating lipoproteins, decreased catabolism.)

R = Renal vein thrombosis

O = "Oval fat bodies" in the urine. Lipiduria follows hyperlipidemia. Albumin as well as lipoproteins are
lost. Lipoproteins are reabsorbed by tubular epithelial cells and they shed along with degenerated cells-
this appears as "oval fat bodies" in urine.

T = Thrombotic + thromboembolic complications owing to loss of anticoagulant factors (eg. anti-

thrombin III )

I = Infection. These patients are prone to infection, especially with staphylococci and pneumococci.
Vulnerability is due to loss of immunoglobulins.

C = hyperCoagulable state

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Henoch-Schonlein Purpura

"JARS"

J - Joints
A - Abdominal pain
R - Renal
S - Skin

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Causes of hematuria

Use the mnemonic SITTT as an aid in evaluating the cause of hematuria:

S: Stone
I: Infection
T: Trauma
T: Tumor
T: Tuberculosis

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Causes of secondary nephrotic syndrome ie. not of direct renal origin are DAVID - Diabetes mellitus,
Amyloidosis, Vasculitis, Infections, Drugs.

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Causes of acute and reversible forms of urinary incontinence

The following mnemonic aids in remembering the causes of acute and reversible forms of urinary
incontinence - DRIP

D: Delirium
R: Restricted mobility, retention
I: Infection, inflammation, impaction (fecal)
P: Polyuria, pharmaceuticals

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Hereditary cystic disorders: Polycystic kidney disease

Autosomal dominant polycystic kidney disease (ADPKD) is associated with cysts in the kidneys and, in
many cases, in the brain (berry aneurysms), liver, spleen, pancreas, and lungs.

¡°Halley Berry AKA Dorothy (Dandridge) Portrayed Carmen Jones.¡±

Halley ?Hematuria: Gross and microscopic

Berry -Berry aneurysms

AKA ?ADPKD

D-Dominant (autosomal) inheritance

O-Obstruction of the urinary tract by stones, blood clots
R-Renal failure
O-Oxalate: calcium oxalate and uric acid stones
T-renal Tubular defects
H-Hemorrhagic cysts
Y-Year 1 - Most cases are diagnosed in the first year of life, presenting as bilateral abdominal masses.

Portrayed ?Polycystic: continued enlargement of the cysts often leads to progressive renal failure.

Carmen ?CT scanning: Enlarged kidneys with multiple bilateral cysts are diagnosed using ultrasound, IVP,
or CT scanning.
Jones - Juvenile nephronophthisis (JN) and medullary cystic disease (MCD) are in the DDx.

-Cardiac valvular disorders: Mostly mitral valve prolapse (MVP) and aortic regurgitation
-Salt-wasting nephropathy, renal tubular acidosis (RTA)
-Chronic flank pain due to the mass effect of the enlarged kidneys

Lusty Carmen Jones powdered her nose, using her Bivalve [MVP] mirror compact, ¡¦
-then she slowly raised her Salt-rimmed [Salt-wasting nephropathy] MargaRiTA [RTA], and seductively
placed her other hand on her Hip [Flank pain].

-Hyperchloremic acidosis
-Salt-wasting nephropathy causing hyponatremia

It was said that Dorothy was not allowed to swim in the hotels Chlorinated pool [Hyperchloremic
acidosis].
When she defiantly swam in the pool, they Drained it [Salt-wasting nephropathy, Hyponatremia].

-Hypertension
-End-stage renal disease (ESRD)

Dorothy was forced to enter through the back door, even while she was contracted to sing under The Big

Tent [Hypertension].
Dorothy was only 41 when she was found DEAD [ESRD].

Review:
Dx: Positive family history (autosomal dominant inheritance)
Gross and microscopic hematuria
Ultrasound, IVP, or CT scanning detect the enlarged kidneys with multiple bilateral cysts

References:

1. Harrison Principles of Internal Medicine, 14/e Edition, McGraw-Hill, New York, 1998.
2. Bennett WM and Rose BD. Polycystic kidney disease, UpToDate v8.2, (Rose, BD, ed), UpToDate, Inc,
Wellesley, MA, 2000.

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Renal Pathology Buzz words

Lupus = wire LOOP lesion (LUPUS=LOOP)

goodPASTURE = a pasture is FLAT so is the immunoflouresence for GP

Membraneous GN = spike and DOME appearance (think membrane = dome)

(held up by spikes)

Membranoproliferative GN = M P GN = Tram Track

think of MP's (military police riding on Trams)

Post streptococcal GN= Lumpy Bumpy

think Strep aerobics
Lumpy people Bumping around doing aerobics

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WBC Count

"Never Let Mom Eat Beans" and "60, 30, 6, 3, 1"

Neutrophils 60%
Lymphocytes 30%
Monocytes 6%
Eosinophils 3%
Basophils 1%

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Hem - PT, PTT: By M. Pereira (tufts.edu)

To remember the intrinsic and extrinsic pathways in relation to what blood test is affected:

PiTT (I for Intrinsic pathway) - PiTTsburgh

PeT (E for Extrinsic pathway)

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Vitamin K-dependent proteins and warfarin sodium [by Sung Kim and S. Levine, MD, PhD.]

Warfarin sodium is a vitamin K antagonist.

-Vitamin K-dependent proteins C and S.

-Vitamin K-dependent clotting factors II, VII, IX, and X of the extrinsic pathway.

--> The Korean [vitamin K] War [Warfarin] was fought Outdoors [Extrinsic pathway].
--> The American PT boats [PT, Protime, or prothrombin time], whose access had been limited
by the rough Seas [protein C], quickly sent out SOS [protein S] messages.

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Microcytic Anemia

"TICS"-

Thalasemia
Iron deficiency
Chronic disease
Sideroblastic anemia

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Eosinophilia

"NAACP"

N - Neoplasm
A - Allergy
A - Addison's
C - Cirrhosis, CVD
P - Parasite (visceral larva migrans), Periarteritis nodosa

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Thalassemia major is the most Severe (c)-thalassemia [B-Beta-Bad].

-Major B-A-D M-A-F-I-A guys have the typical gangster appearance:

Short [Microcytic hypochromic anemia] and
Ugly [distortion of facial, skull, and long bones]

B-Basophilic stippling
A-Anemia, Anisocytosis
D-Deferoxamine

M?MCV is low
A-HbA is decreased
F-HbF is increased
I-Ineffective erythropoiesis
A?HbA2 is increased

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Cooley's anemia (beta-thalassemia major) is the homozygous state.

-The key is Denton A. Cooley, M.D., Texas Heart Institute (THI).

D-Deferoxamine therapy to prevent hemochromatosis

A-Anemia - In beta-thalassemia major or intermedia, anemia is due to a combination of ineffective
erythropoiesis
and hemolysis of circulating cells.
C-Congestive heart failure is a cause of death in the first years of life if the patient is not transfused.

M-MCV is low; Microcytic hypochromic anemia

D-Diagnosis, prenatal

T-Tower skull (also frontal bossing, chipmunk facies, and distortion of long bones)
H-Hemolytic anemia with Hepatosplenomegaly in the first year of infant life
I-Intermedia - Beta-thalassemia intermedia presents with abnormalities similar to those of thalassemia
major.

Increased susceptibility to infections

Peripheral blood smear: Basophilic stippling
Helmet cells
Nucleated target cells
Anisocytosis (RBCs of different size/volume)

X-ray: Hair-on-end skull

Serum hemoglobin electrophoresis: HbA is decreased.

HbA2 is increased.
HbF is increased

--> Dr. Cooley performed Major surgery [thalassemia Major] as a Cardiothoracic surgeon [Cardiac failure]
live
on the Internet [Infections].

--> His skilled hands can perform Microsurgery [Microcytic hypochromic anemia] on Fetuses [HbF].

--> His surgical cap [Helmet cells] fit loosely over his Crew cut [Hair-on-end skull].

--> He proceeded to make an incision along the Blue Stippled line [Basophilic Stippling] drawn on the
skin.

--> Dr. Cooley's Target [Target cells] academic score had always been an A+ [HbA2 is increased].

--> He would Not accept a simple A [HbA is decreased].

--> The surgical staff is a close knit community, like a B-A-D M-A-F-I-A (see below), quick to dispose of
weak,
Ineffective [Ineffective erythropoiesis] residency candidates.

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Disseminated intravascular coagulation (DIC) <== Click !

D-I-S-S-E-M-I-N-A-T-E-D

D-Dx: D dimer
I-Immune complexes
S-Snakebite, shock, heatstroke
S-SLE
E-Eclampsia, HELLP syndrome
M-Massive tissue damage
I-Infections: viral and bacterial
N-Neoplasms
A-Acute promyelocytic leukemia
T-Tumor products: Tissue Factor (TF) and TF-like factors released by carcinomas of pancreas, prostate,
lung,
colon, stomach
E-Endotoxins (bacterial)
D-Dead fetus (retained)

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Characteristic features of multiple myeloma on X-ray are ABCDE - Asymmetry, Border irregular, Colour
irregular, Diameter usually > 0.5cm, Elevation irregular.

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Chronic lymphocytic leukemia (CLL) is a monoclonal malignancy, usually of B lymphocytes.

-Incidence: CLL is the most common adult leukemia in the United States.
Males>Females
50-70 years of age

Songwriter Phil CoLLins [CLL] is Male and probably over 50 years of age. He recently won an
Oscar for his "Tarzan" song.

Clinical and diagnosis

Lymphocytosis >15,000/mm3
Generalized lymphadenopathy

Tarzan can spring from Limb [Lymphocytosis] to Limb [Lymphadenopathy] above the tree
tops¡¦
Splenomegaly, hepatomegaly
Low serum immunoglobulins (immunosuppression)

--> where the Splendid [Splenomegaly] Moonlight [imMunosuppression] streams through the
branches.

Diffuse bone marrow infiltration and replacement of cellular elements cause:

Anemia
Thrombocytopenia
Granulocytopenia

--> Walt Disney Pictures produced the Animated Animal [Anemia] adventure "Tarzan".

--> The "Tarzan" [Thrombocytopenia] song earned CoLLins an Oscar [Osteo, bone marrow failure]
award for the best original song.

--> Tarzan had Little need for Plates [Platelets <100,000/¥ìL] in the jungle.

--> Phil CoLLins is a Grammy [Granulocytopenia] Award-winning singer and songwriter.

Occasionally extravascular hemolysis: warm-antibody autoimmune hemolytic anemia (AHA)

--> An African jungle [Autoimmune extravascular] APE [AHA] had Warmly [Warm-antibody]
adopted baby Tarzan.

Differential diagnosis

Malignant lymphoma
Infectious mononucleosis

--> Tarzan is Lord [Lymphoma] of the Jungle and friend of the Monkeys [Mononucleosis].

--> Phil CoLLins was born in London [Lymphoma].

Treatment

Chlorambucil (an alkylating agent), with or without prednisone

Fludarabine

--> Some may imagine a Ram [ChloRambucil] scrambling about, but others will¡¦

--> recall that Clayton [Chlorambucil] is the villainous jungle guide who was hired by
Professor [Prednisone] Porter, not knowing that¡¦

--> ¡¦Clayton [Chlorambucil] had his captured Prey [Prednisone] immediately Flown
[Fludarabine] out for profit.

References:
1. Harrison's Principles of Internal Medicine, 14/e Edition, McGraw-Hill, New York, 1998.
2. Maximum access to diagnosis and therapy (MAXX), Lippincott Williams & Wilkins, New York, 1999.
3. Scientific American Medicine (SAM-CD), Scientific American Inc, New York, 1997.

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Hodgkin's lyphoma classification - A = Asymptomatic, B = Bad.

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Risk of underlying malignancy with dermatomyositis or polymyositis is 30% at age 30, 40% at age 40
etc.

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Malignant Monoclonal Gammopathies: Multiple myeloma
-The mnemonic key for multiple myeloma (MM) is Marilyn Monroe (MM), a key which immediately follows
the >> symbol.

-Clinical:

Weakness and fatigue due to normochromic normocytic anemia.

>> MM's original name was Norma [Normochromic normocytic] Jean.

Bone pain and pathologic fractures: predominantly osteolytic tumors and osteoporosis.
>> MM's name was illuminated in marquee Lights [osteoLytic], but she secretly longed for
an Oscar award [Osteoporosis].

Susceptibility to bacterial infections.

>> MM was Susceptible to Toxic [infections] relationships.

Acute renal failure (ARF) due to the effects of filtered light-chain proteins,
hypercalcemia, and amyloid deposits in the kidney.
>> MM's Lightly-Chained ARF dog barked when MM's death was said to be related to her
JFK Army-Lord [Amyloid].

-Laboratory

Hypercalcemia

>> MM fluffed White Talcum [hypercalcemia] powder on her delicate white skin...

Hypergammaglobulinemia

>> ...to protect it from the movie industry's Large hot Camera lights[hyperGammaglob].

Serum electrolytes: Low anion gap

>> MM wore gowns with Low [Low anion gap] revealing necklines.

Rouleaux on peripheral blood smear.

Occasionally Coombs(+) hemolytic anemia.

>> MM used hair Rollers [Rouleaux] and Combs [Coombs] to create her famous hairdo.

Leukocyte alkaline phosphatase (LAP) staining reaction: High LAP score.

>> MM used her Great LAP to her advantage because....

Normal levels of Serum Alkaline Phosphatase (SAP)

>> ...she was Not a SAP.

References:
1. Harrison's Principles of Internal Medicine, 14/e Edition, McGraw-Hill, New York, 1998.
2. Maximum access to diagnosis and therapy (MAXX), Lippincott Williams & Wilkins, New York, 1999.
3. Scientific American Medicine (SAM-CD), Scientific American Inc, New York, 1997.
--------------------------------------------------------------------------------

Antineoplastic agents & Adverse effects

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Male testicular tumors: "S-E-C sac T-I-C-S¡±

S-Seminoma: most common

E-Embryonal carcinoma
C-Choriocarcinoma

Sac-Yolk sac tumor (endodermal sinus tumor)

T-Teratoma, Teratocarcinoma

I-C-Interstitial (Leydig) cell tumor

S-Sertoli cell tumor
__________________________________________________
__________________________________________

Paraneoplastic syndromes and their associated cancers:

Your diagnosis can be "Highly S-C-R-A-M-B-L-E-D."

Highly-Hypercalcemia (squamous cell carcinoma)

S-SIADH, hyponatremia (SCLC)

C-Clubbing (adenocarcinomas)
R-Retinal blindness (SCLC)
A-ACTH (SCLC)
M-Myasthenia gravis (thymoma)
B-Bone - hyperosteoarthropathy (adenocarcinomas)
L-Limbic encephalitis (SCLC)
E-Eaton-Lambert myasthenic syndrome (SCLC)
D-Dermatomyositis (cancer of the lung, ovary, breast, stomach; NHL)

SIADH: Syndrome of inappropriate antidiuretic hormone secretion

SCLC: Small cell lung cancer
NHL: non-Hodgkin's lymphoma

References:
1. UpToDate v8.2, (Rose, BD, ed), UpToDate, Inc, Wellesley, MA, 2000.
2. Scientific American Medicine (SAM-CD), Scientific American Inc, New York, 1997.

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Acute Rheumatic Fever

There are several for the major criteria, I use "JONES"

J - Joints
O - Obvious (cardiac) - sorry, I know this is kinda weak
N - Nodules (subcutaneous nodules)
E - Erythema marginatum
S - Syndeham's Chorea

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Kawasaki's

"scream fever"

S - sausage fingers
C - conjunctival redness
R - rash
E - extremity involvement
A - adenopathy
M - mucosal erythema
FEVER - fever

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Causes of post op fever

Remember the following mnemonic when determining the possible cause(s) of fever in a patient who has
recently undergone a surgical procedure: the 5 W's (or 6 W's)

Wind : the pulmonary system is the primary source of fever in the first 48 hours. ( Atelectasis,
pneumonia ect.)
Wound : there might be an infection at the surgical site.
Water : check intravenous access site for signs of phlebitis.
Walk : deep venous thrombosis and pulmonay embolism can develop due to pelvic pooling or restricted
mobility
Whiz : a urinary tract infection is possible if urinary catheterization was required.

Also Wonder drugs - drug fevers. (added by Calvin Lee)

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Classification of hypersensitivity reactions

"ACID"

Type I Anaphylaxis
Type II Cytotoxic - mediated
Type III Immune - complex
Type IV Delayed hypersensitivity

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Criteria for Lupus

SOAP BRAIN MD

Serositis (pleuritis, pericarditis)

Oral Ulcers
Arthritis
Photosensitivity

Blood (all are low - anemia, leukopenia, thrombocytopenia)

Renal (protein)
ANA
Immunologic (DS DNA etc.)
Neurologic (psyc, seizures)
--------------------------------------------------------------------------------

Risk of underlying malignancy with dermatomyositis or polymyositis is 30% at age 30, 40% at age 40
etc.

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Blue Sclera: "MIXED"

M = Marfans ,
I = Imperfecta ( Osteogenesis )
XE =(pseudo) Xanthoma elasticum
ED = Ehlers Danlos

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Altered Mental Status

"AEIOU TIPS"

A - Alcohol/drugs
E - Endocrine
I - Insulin
O - Opiates
U - Uremia

T - Toxins/trauma
I - Infections
P - Psych/porhyria
S - SAH, shock, stroke, seizure, space occupying lesion

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MIDAS : States to exclude as cause of coma.

Meningitis

Intoxication

Diabetes

Air - respiratory failure

Subdural or subarachnoid hemorrhage.

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Level of consciousness

"AVPU"

A - alert
V - resonds to verbal stimuli
P - responds to painful stimuli
U - unconscious

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Vertebral/Basilar Ischemia

4Ds

dizziness (nystagmus)
diplopia (skew deviation)
dysarthria
dysphagia

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Cerebellar lesions lead to VANISHeD - Vertigo, Ataxia, Nystagmus, Intention tremor, Slurred speech,
Hypotonic reflexes, Dysdiadochokinesia. ( or Dementia )

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Marcus Gunn Pupil

Marcus Welby, M.D. "knows". Robert Young was also in "Father Knows Best".

D-R K-N-O-W-S

D-Deafferentation of the pupillary light reflex

R-Retrobulbar optic neuritis

K-Kan't kick inward: afferent limb defect

N-No constriction to direct light stimulation
O-Optic nerve (CN II) damaged unilaterally
W-swinging flashlight test
S-consensual reflex intact

__________________________________________________
__________________________________________

Subarachnoid hemorrhage (SAH): Rupture of an aneurysm releases blood directly into the cerebrospinal
fluid (CSF) under arterial pressure.

Clinical manifestations:

CSF ~ FDR

F-D-R's Last Words: O! CAN'T W-H-I-P 'E-M

F-Focal signs: limb weakness, dysphagia, CN III palsy

D-Depression of consciousness with headache
R-Retinal (subhyaloid) hemorrhage

Last-Lucidity with headache is the usual pattern of onset.

Words-Warning leak sign of impending rupture (controversial sign).

O-(looks like eyes) CN III palsy

Can't extend knees (Kernig's sign)

W-circle of Willis
H-Headache: sudden onset of severe headache ("the worst headache of my life")
I-Increased ICP
P-Papilledema

E-Epileptic seizures
M-Meningismus

__________________________________________________
__________________________________________

Subarachnoid hemorrhage : Ruptured berry aneurysm

A-Adult polycystic kidney disease, Anterior communicating artery

B-Berry aneurysm
C-Circle of Willis
D-Danlos-Ehlers and Marfan's syndromes

__________________________________________________
__________________________________________
Causes of Syncope: F-A-D-E-O-U-T

F-Faint simple vasovagal fainting

A-Arrhythmia causing cardiac syncope
D-Drugs: alcohol, illicit drugs, nitrates, antihypertensives, sympathetic blockers
E-Eyeball pressure
O-Orthostatic hypotension: dysautonomias
U-Undiagnosed seizures
T-Takayasu's arteritis: reduced cerebral blood flow due to involvement of the carotid and vertebral
arteries.

__________________________________________________
__________________________________________

Causes of Vertigo: revolving, P-I-V-O-T-I-N-G M-E-N

P-Petrositis, benign Positional vertigo

I-Ischemic attacks: transient vertebrobasilar ischemic attacks
V-Vestibular neuronitis
O-Other Otogenic causes: Otosclerosis, herpes zoster Oticus, Obstructed external auditory canal
T-Tumors of the middle ear, labyrinth, pons, cerebellopontine angle, CN VIII
I-Internal auditory artery occlusion
N-Neuronitis: acute vestibular neuronitis
G-Giant cell arteritis - internal auditory artery occlusion

M-Meniere's disease
E-Ear: otitis media, labyrinthitis, barotrauma
N-Neuromas: acoustic neuromas

__________________________________________________
__________________________________________

Headache: S-T-O-I-C M-P

S-Sentinel headache that precedes a major subarachnoid hemorrhage (SAH)

T-Temporomandibular joint dysfunction, Tension-type headache, Tumors
O-Other: pressure, traction, or displacement of extracerebral structures.
I-Indomethacin-responsive headache
C-Cluster headache

M-Meningitis, Migraine headache

P-Posttraumatic headache, Paranasal sinuses

__________________________________________________
__________________________________________

Intracerebral hemorrhage: T-I-P Ur H-A-T to M-Ds

T-Trauma
I-Idiopathic
P-Penia ? thrombocytopenia
Ur-Vasculitis

H-Hypertension
A-Amyloid angiopathy
T-Tumors associated with bleeding

M-Malformations: AV
D-blood Dyscrasias

__________________________________________________
__________________________________________

Subdural hemorrhage: subconsciously dying¡±

-Elderly
-Slowly dying
-Alcohol
-Brain injury

__________________________________________________
__________________________________________

Cerebrovascular I-N-F-A-R-C-T-S

I-Infections: septic heart valve vegetations

N-Neoplasms; Nonbacterial thrombotic endocarditis
F-Fracture of the long bone
A-Atherosclerosis, Atrial fibrillation-related emboli
R-Reperfusion -> infarct -> hemorrhage
C-Carotid atheromas or mural thrombi
T-Thrombotic occlusions
S-Sylvan fissure: MCA is a particularly common site.

__________________________________________________
__________________________________________

Lacunar infarct: "Lacunar" from the Latin for G-A-P or- D-I-S-P-A-R-I-T-Y

G-deep Gray matter: basal ganglia

A-Atherosclerosis
P-hyPertension

D-Dysarthria and a contralateral clumsy hand or arm due to infarction in the base of the pons or in the
genu
of the internal capsule. (20%)
I-Internal Capsule: Lacunae in the posterior limb of the Internal capsule may cause pure motor
hemiplegia
involving the face, arm, leg, foot. (60%)
S-Subcortical, capsular, or thalamic lacunae
P-Pontine lesions
A-Ataxic hemiparesis due to an infarct in the base of the pons
R-Rare: Lacunae in the anterior limb of the Internal capsule may cause severe dysarthria with facial
weakness.
I-Ipsilateral ataxia (arm/leg) with leg weakness: Pontine lesion (rare)
T-Thalamus: Lacunae in the Thalamus may cause pure sensory stroke (10%)
y-V-Ventrolateral Thalamic lacunae

__________________________________________________
__________________________________________

Anterior cerebral artery (A*C*A) occlusion:

*C*-Contralateral Crural (leg) monoplegia

*C*-Crest of Cerebral hemispheres and medial hemispheric walls represent the leg area of the motor strip
__________________________________________________
__________________________________________

Middle cerebral artery (MCA) occlusion: "Difficulty with A-B-Cs in M-C-A"

A-Apraxia
B-Blindness in corresponding half of the visual field (contralateral homonymous hemianopsia)
C-Contralateral Clumsiness of arm, face. -- Leg is somewhat spared.

M-Memorization difficulties
C-Calculation difficulties
A-Aphasia with language-dominant hemispheral involvement

__________________________________________________
__________________________________________

Posterior cerebral artery (PCA) occlusion: P-O-S-T

P-Proximal fling movements

O-Occipital lobe infarction results in contralateral homonymous hemianopsia which may be complete
S-Speech and Spelling maintained, but unable to read fluently
T-Thalamic syndrome

__________________________________________________
__________________________________________

A well-known mnemonic regarding occlusion of the vertebral-basilar circulation: 4D

-Dizziness
-Diplopia
-Dysarthria
-Dysphagia

__________________________________________________
__________________________________________

Types of Stroke
Stroke "H-I-T" you!

H-Hemorrhagic
I-Ischemic
T-TIA (Transient Ischemia Attack)

__________________________________________________
__________________________________________

T.I.A (Transient Ischemic attack)

Patients often describe it as a shade being pulled over their eyes: S-H-A-D-E-D

S-Sensory loss; TIA may herald a stroke

H-Hypertension, Hyperlipidemia
A-Amaurosis fugax (transient monocular blindness)
D-DDx: seizures, neoplasms, migraine, vertigo
E-Extrinsic factor is monitored for warfarin administration; E-Endarterectomy
D-Diabetes

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Root values of reflexes are 1,2,3,4,5,6,7,8 - S1-2 ankle, L3-4 knee, C5-6 biceps/supinator, C7-8 triceps.

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Argyle Robertson Pupil

Accomodation Reflex Present - Pupillary Reflex Absent.

--------------------------------------------------------------------------------

Neurosyphilis

-Symptomatic Neurosyphilis: The small, irregular Argyll Robertson pupil reacts to accommodation but
not to light.
-Tabes dorsalis:
Argyl-Robertson Pupil (ARP) in syphlis - Accomodation Reflex Present (ARP)
but the light reflex is absent, so ARP=ARP.
-General paresis: P-A-R-E-S-I-S*
P-Personality
A-Affect
R-Reflexes are hyperactive
E-Eye: Argyll Robertson pupils
S-Sensorium: illusions, delusions, hallucinations
I-Intellect: decrease in recent memory, orientation, calculations
S-Speech

Reference:
*From Harrison Principles of Internal Medicine, 14/e Edition, McGraw-Hill, New York, 1998.

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Pattern of Weakness in UMN lesions

FLUE weakness FUELs Contractures

F=Flexion,L=Lower Limb,U=Upper Limb E= Extensors

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Normal Pressure Hydrocephalus

Demented (Memory Loss)

Dribbles (Urinary Incontinence)
Disbalanced (Gait disorder)

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TRAP to identify parkinson's disease

Tremor at rest (pill-rolling tremor)

Rigidity

Akinesia

Posture typical of a Parkinson's patient

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Radiopaque Ingestants

"Chipes"

C - Cocaine condoms/ chloral hydrate/ calcium

H - Heavy metals
I - Iron/ iodides
P - Psychotropics (TCA, phenothiazines)
E - Enteric coated/BA
S - Solvents (CCl4)

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Drugs that can go into an ET tube

"lane"

L - lidocaine
A - atropine
N - naloxone
E - epi

Some like NAVEL, which includes Valium. Others have commented that valium should not go in an ET
tube.

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Concretions:

"Big Mess"
B - Barbituates
I - Iron
G - Glutethemide
M - Meprobamate
E - Extended release theophylline
SS - Salicylates