IM

Terms / Facts
DDx: Abdominal pain of gastroduodenal origing

(3)
!
DDx: Abdominal pain of

intestinal origin (6)
DDx: Abdominal pain of urinary

tract origin (4)
Acute cholecystitis Chronic cholecystitis

Cholangitis
DDx: Abdominal pain of pancreatic

origin (3)
DDx: Abdominal pain of

gynecological origin (6)
Acute pancreatitis Chronic pancreatitis

Malignancy
Cystitis Acute retention of urine Acute

pyelonephritis Ureteric colic
Rupture of extopic pregnancy Rupture/Torsion of

ovarian cyst Salpingitis Endometriosis Mittelschmerz
Severe dysmenorrhea
!
DDx: Abdominal pain of vascular origin (2)

DDx: Abdominal pain of peritoneal origin
(2)
DDx: Abdominal pain referred from
other locations (3)
!
DDx: Abdominal swelling in

the RUQ (4)
!
DDx: Abdominal
swelling in the LUQ (6)
DDx: Abdominal swelling in

the umbilical region (5)
!
DDx: Abdominal swelling in the

suprapubic region (4)
Primary periotonitis Secondary

peritonitis
Myocardial infarction Pericarditis

Testicular torsion
Right kidney carcinoma Right colonic carcinoma

Feces Diverticular mass
Lipoma Epigastric hernia Carcinoma of the

transverse colon Feces Diverticular mass
Paraumbilical/umbilical hernia Malignancy

Carcinoma Feces Diverticular mass
Appendix mass/abscess Carcinoma of the cecum

Carcinoma of the ascending colon Feces Crohn's disease

LLQ (3)
DDx: Acute anorectal

pain (4)
Aortic aneurysm Mesenteric embolus
Splenomegaly Gastric carcinoma Left kidney carcinoma

Feces Diverticular mass Pancreatic pseudocyst

epigastrium (5)
DDx: Abdominal swelling

in the RLQ (5)
Peptic ulcer Gastritis

Malignancy
Appendicitis Obstruction Diverticulitis Gastroenteritis

Mesenteric adenitis Strangulated hernia
DDx: Abdominal pain of hepatobiliary

origin (3)
Carcinoma of the sigmoid colon Diverticular

mass Feces
!
Acute/chronic bladder retention Pregnancy

Fibroids Diverticular mass
Fissure-in-ano Perianal hematoma Thrombosed
1!
Terms / Facts
hemorrhoids Perianal abscess
DDx: Chronic anorectal pain
(3)
DDx: Arm
pain (5)
Fistula-in-ano Anorectal malignancy Chronic perianal

spesis
Disc lesion Cervical spondylosis Myocardial ischemia Repetitive

strain injury Carpal tunnel syndrome
!
DDx: Arm swellings (2)

DDx: Ascites
(5)
Trauma Infection (cellulitis, lymphangitis)
Cirrhosis Cardiac failure Nephrotic syndrome Carcinomatosis

Abdominal/pelvic tumor
DDx: Axillary swellings

(5)
Acute abscess Sebaceous cyst Lipoma Lymphadenopathy

Breast lump
!
DDx: Backache (congenital) (3)

!
DDx: Backache of traumatic

origin (4)
Kyphoscoliosis Spina bifida Spndylolithesis

Vertebral fractures Ligamentous injury Joint strain
Muscle tears
!
DDx: Backache of inflammatory

origin (2)
Ankylosing spondylitis Rheumatologic

disorder
!
DDx: Backache of neoplastic origin (2)

DDx: Backache of degenerative origin (2)
Osteoarthritis Intervertebral disc lesions

!
DDx: Backache of metabolic origin (2)

DDx: Backpain of gynecological origin
(2)
DDx: Backpain of renal origin (2)
DDx: Breast lumps
(discrete) (5)
DDx: Chest
pain (5)
Pelvic inflammatory disease

Endometrosis
Renal calculus Renal carcinoma
Breast carcinoma Fibroadenoma Cyst (cystic mastitis) Duct

ectasia Sebaceous cyst
!
Pregnancy Lactation Puberty

Mastitis
Non-/Cyclical mastalgia Duct ectasia Breast abscess Pregnancy

Lactation
Angina/Myocardial infarction GERD Pneumonia/Pneumothorax
Chest wall injury Depression
How does one quickly calculate heart rate when

rhythm is normal with an EKG?
How does one calculate heart rate
Osteoporosis Osteomalacia
DDx: Breast lumps due to generalized swelling

(4)
DDx: Breast
pain
Metastases Primary tumors
300/ # large boxes between 2

QRS complexes
Count the number ofo complexes that occur in
2!
Terms / Facts
from an EKG if the rhythm is
irregular?
What rule determines whether the
rhythm is sinus on an EKG?
a 6-second interval (30 boxes) and multiply by

10 to get a rate
!
If p waves are present in all leads and upright

in leads I and aVF, then the rhythm is sinus
!
What kind of rhythm is indicated by an EKG where each QRS

wave is preceded by a p wave?
What EKG findings indicate a normal
axis?
I and aVF are both upright and positive

!
I is upright and aVF is upside

down
I is upside down and aVF is

upright
I and aVF are both upside down or

negative
What EKG findings indicate a left axis

deviation?
What EKG findings indicate right axis
deviation?
What EKG findings indicate extreme right axis
deviation?
Normal sinus
rhythm
What is the time range of a normal PR interval?

What disease is a short PR interval associated
with?
0.12 to 0.20 seconds
Wolff-Parkinson-White
syndrome
What kind of EKG appearance characterizes Wolff-Parkinson-White ! Delta wave

syndrome?
! PR > 0.2 seconds
What PR interval indicates a first-degree block?
!
What is the length of a normal QRS complex?

!
What R wave width on lead I indicates LVH?
R I > 15 mm
!
What R wave width on lead II indicates LVH?

What R wave width on lead aVF indicates LVH?
What R wave width on lead aVl indicates LVH?
What R wave width on lead V5 indicates LVH?
What R wave width on lead V6 indicates LVH?
0.12 s
> 20 mm
> 20 mm
> 11 mm
> 26 mm
> 26 mm
! LVH
If the sum of the widths of R I and S III is > 25 mm, what cardiac
pathology is indicated?
! Tall or peaked p waves in limb or
What EKG morphology indicates right atrial
precordial leads
hypertrophy?
What EKG morphology indicates left atrial

hypertrophy?
Broad or notched p waves in limb

leads
3!
Terms / Facts
!
The presence of a Q wave indicates what cardiac pathology?

!
What mechanical event does the QRS complex

represent?
What electrical event does the ST segment

represent?
The horizontal segment of baseline that
follows the QRS complex is known as the
[...] segment.
What electrical event does the T wave
represent?
Ventricular depolarization
Plateau phase of venricular

repolarization
The horizontal segment of baseline that

follows the QRS complex is known as
the ST segment.
The rapid phase of ventricular

repolarization
!
What are the boundaries of the ST

segment?
!
What parts of the EKG represent

ventricular systole?
Ventricular contraction
(initiation)
!
What electrical event does the QRS complex

represent?
Old infarction
End of the S to the beginning of the T
Beginning of the QRS complex to the end

of the T wave
!
What are the boundaries of the QT interval?

What cardiac event does it represent?
!
What is a simple rule of thumb for

determining whether a QT interval is
normal?
Begininng of the Q to the end of

the T; ventricular systole
A QT interval should be less than half
of the R-to-R interval at normal rates
!
What ion is responsible for conduction in the AV node?

!
What is deflection with respect to an EKG?

!
Positive deflections are [...] on the

EKG.
Negative deflections are [...] on the
EKG.
What kind of electrical activity
produces a positive deflection on an
EKG?
The direction of a wave on an EKG
Positive deflections are upward on the EKG.

Negative deflections are downward on the
EKG.
Movement of positive charges

(depolarization) toward a positive skin
electrode
!
How much time is represented by a small square on an EKG?

!
How many leads does a standard EKG have?

In the aVR lead, what limb electrode is positive?
In the aVL lead, what limb electrode is considered positive?

In the aVF lead, what limb electrode is considered positive?
Ca2+
0.04 s
12 leads
Right arm positive

!
Left arm positive

!
Foot (left)
4!
Terms / Facts
!
What are the lateral leads?

Why are leads AVL and I called
the lateral leads?
Leads I and AVL
These leads have a positive electrode positioned

laterally at the left arm
!
What are the inferior leads? (3)

Why are leads II, III and AVF called
inferior leads?
Leads II, III and AVF
They have positive electrodes positioned

inferiorly on the left foot
!
What is the charge of the chest electrodes?
Positive
!
Through what part of the heart are the chest leads oriented?
What is the orientation of electrode V2?
Front to back of the patient

!
What is the deflection of V1 and V2 normally?

!
What is the deflection of V6 normally?

What part of the heart are the V3 and V4 leads oriented
over?
What plane do the six limb leads lie in?
What plane do the six chest leads lie in?
What is the normal heart rate range?

What is the heart's normal pacemaker?
Negative
Positive
Interventricular septum
Frontal plane
Horizontal plane
60-100 bpm
!
SA node
!
What is the inherent rate of the AV junctional automaticity focus?

What is the inherent rate of the atrial automaticity focus?
What is coronary
ischemia?
What causes stable angina

pectoris?
60-80 bpm
Stable angina occurs when oxygen demand exceeds

available blood supply.
!
Due to fixed atherosclerotic lesions that narrow the

major coronary arteries.
!
What are the possible clinical

presentations of coronary
artery disease? (5)
40-60 bpm
An imbalance between blood supply and oxygen demand,

leading to inadequate perfusion.
When does stable angina

occur?
What are the risk

factors for stable
angina pectoris? (8)
AV node
When thinking CAD, ASSUMe the following

presentations: Asymptomatic Stable angina pectoris
Sudden cardiac death Unstable angina pectoris
Myocardial infarction e
Don't get LASHeD by Stable Angina Pectoris Low HDL

Age (m>45, w>55) Smoking Hyperlipidemia, Hypertension,
5!
Terms / Facts
Homocysteine, History (family) Diabetes mellitus
!
What is the normal left ventricular ejection fraction (%)?

!
What is the clinical presentation of

stable angina pectoris? (3)
Crushing retrosternal chest pain Exertional

dyspnea Radiation of pain to left side
!
Left main coronary artery

because it serves nearly 2/3 of
the heart.
Involvement of what coronary artery has the

worst prognosis for stable angina pectoris? Why?
What ejection fraction is associated with increased mortality in stable

angina pectoris?
In what situations is
stress ECG used?
(3)
!
!
Are there normally any abnormalities on an ECG

in a patient with stable angina pectoris?
!
EF <
50%
Rest Nitroglycerin
Not usually, unless a prior
cardiac pathology is present
Test that involves recording ECG before, during and after

excerise on a treadmill.
What condition must be met to make a

stress ECG most sensitive?
Patient must be able to achieve 85% of

maximum predicted heart rate for age.
How does excerise-induced ischemia present on a stress ECG in

a patient with stable angina pectoris?
What is the course of treatment for a patient with
a positive stress test?
What is the course of treatment for a patient with a

positive stress echocardiograph?
What criteria make a stress
test positive? (4)
ST-segment
depression
!
!
Stress echocardiography
Cardiac catherization
should be performed.
Any of the following: ST segment depression Chest

pain Hypotension Significant arrhythmias
!
Why is stress echocardiography

preferred to stress ECG?
Cardiac catheritization should be

performed
What is the preferred test for assessing stable angina

pectoris?
Stress echo is more sensitive, can assess LV

size and function, and can diagnose vascular
disease.
What procedure is almost always performed

concurrently with cardiac catherization? Why?
Coronary angiography for

visualization
What is the most accurate method of identifying the presence !
Confirmation of diagnosis of angina Evaluation of response to

therapy in CAD Indentification of patients with CAD with high
risk for acute coronary events
What relieves stable angina pectoris? (2)
What is a stress
ECG?
> 50%
Coronary
6!
Terms / Facts
and severity of CAD?
arteriography
!
What stress test should be used if a patient cant'

exercise?
!
What drugs are used in a pharmacologic

stress test? (3)
!
What is the mechanism by

which IV adenosine and
dipyramidole work in
pharmacologic stress
testing?
Explain how myocardial
perfusion scintigraphy
works.
IV adenosine IV dipyramidole IV
dobutamine
Adenosine/dipyramidole are vasodilators; because

diseased coronary arteries are already maximally dilated
at rest to increase blood flow, they received relatively
less blood flow when the entire coronary system is
dilated pharmacologically.
Viable myocardial cells extract the radioisotope (thallium
201) during exercise; no radioisotope uptake means no
blood flow to an area of the myocardium.
!
What is the mechanism by which

dobutamine works in pharmacologic stress
testing.
Dobutamine myocardial O2
demand HR/BP/Contractility
!
What diagnostic tool is used to detect silent

ischemia?
Holter monitoring (ambulatory

ECG)
By how much is the risk of coronary heart disease reduced

with smoking cessation? In what time frame?
!
What pharmacological agents are used for

treatment of stable angina pectoris? (4)
How do -blockers work in the
treatment of stable angina
pectoris?
50% reduction 1 year

after cessation
Blockage of sympathetic stimulation

HR/BP/contractility cardiac work (O2
consumption)
What is the net therapeutic effect of -blockers on

stable angina pectoris?
What is the mechanism by which nitrates
treat stable angina pectoris?
!
Aspirin -blockers Nitrates

Calcium-channel blockers
What is the net therapeutic effect of aspirin on stable

angina pectoris?
What are the side effects of

nitrates? (4)
Pharmacologic stress test
morbidity - reduces risk

of MI
Reduces the frequency of

coronary events
Generalized vasodilation preload

cardiac work angina
Nitrates make you feel SHOT S yncope H eadache O

rthostatic hypotension T olerance
What drug can prevent angina if taken before exertion?
Nitrates
! Vasodilation and afterload reduction

What is the mechanism by which calcium
decreased work angina
channel blockers treat stable angina
pectoris?
Are calcium channel blockers primary or secondary treatment ! Secondary
7!
Terms / Facts
agents for stable angina pectoris?
What are the methods of
revascularization? (2)
treatment
PTCA (Percutaneous transluminal coronary
angioplasty) CABG (Coronary artery bypass graft)
!
What is the effect of revascularization on

incidence of MI?
Does not reduce incidence; improves

symptoms, however.
What management decisions are indicated for all patients

with stable angina pectoris? (2)
!
What management decisions are indicated in

patients with mild stable angina pectoris? (3)
!
What are the criteria for mild stable

angina? (3)
What management decisions are indicated in

patients with moderate stable angina
pectoris? (4)
What are the criteria for severe stable
Risk factor
modification Aspirin
Nitrates -blockers. Calciumchannel blockers if needed.
Normal EF Mild angina Single-vessel

disease
What are the criteria for moderate stable

angina? (3)
Normal EF Moderate angina Twovessel disease

!
Nitrates -blockers Calcium-channel

blockers CABG/PTCA if above don't
work.
Decreased EF Severe angina Threevessel/left main/LAD disease
What management decision is indicated for patients

with severe stable angina pectoris?
What is the most significant complication of PTCA?
What is the risk and in what time frame?
Coronary angiography and

consider for CABG
!
Restenosis; up to 40%
within first 6 months
What intervention helps reduced the rate of restenosis in PTCA?

What patients should be considered
for PTCA?
Stents
Patients with one- or two-vessel stable

angina pectoris.
! CABG
What is the treatment of choice in patients with high-risk stable angina
pectoris?
! Left main disease Three-vessel disease with
What are the indications for
reduced LV function Two-vessel disease with
CABG in patients with stable
proximal LAD stenosis Severe ischemia
What kind of lesions are most responsive to PTCA?

!
How does the pathophysiology of

unstable angina pectoris differ from that
of stable angina pectoris?
Proximal lesions
With unstable angina, oxygen demand is

unchanged; in stable angina, there is
increased demand, which precipitates the
angina.
8!
Terms / Facts
!
What is the pathophysiology of

unstable angina pectoris?
Why is unstable angina
pectoris significant?
Reduced resting coronary blood flow &rarr

with no change in O2 demand angina
It indicates stenosis that has enlarged via thrombosis,

hemorrhage, or plaque rupture.
Patients with angina at rest Patients with new-onset

angina that is severe and worsening Patients with
chronic angina with increasing frequency, duration
or intensity of pain.
Patients with what

presentations are said to have
unstable angina pectoris? (3)
What does acute coronary syndrome refer to? (2)

What precautions should be taken before
stress testing patients with unstable angina
pectoris?
Patients should be medically managed

or should undergo cardiac
cathertization initially.
!
How is non-ST elevation MI differentiated from

unstable angina pectoris diagnostically?
!
What was the key finding of the

ESSENCE trial?
In non-ST elevation MI,

cardiac enzymes are elevated.
Enoxaparin is the drug of choice for treatment of

unstable angina pectoris.
How does one treat unstable medical angina

upon hospital admission? (2)
What pharmacogical interventions
are indicated for unstable angina
pectoris? (5)
Unstable angina or acute MI
Establish IV access Give

supplemental oxygen
Aspirin -blockers LMWH or unfractionated

heparin (Enoxaparin) Nitrate (first-line)
Glycoprotein IIb/IIIa inhibitors (second line)
For how long should LMWH/unfractionated heparin therapy be given

for unstable angina pectoris?
What target value of PTT should be maintained with unfractionated
heparin administration in unstable angina pectoris?
At least 2
days
2 to 2.5x
normal
Should PTT be followed with LMWH treatment in unstable angina pectoris?

!
What is catecholaminergic
polymorphic ventricular
tachycardia?
!
What is the pathogenesis of

myocardial infarction?
No
An unstable rhythm with a continuously varying

QRS complex in any recorded ECG lead in a
patient without any structural heart disease.
Rupture of atheromatous plaque acute coronary

thrombosis interruption of blood supply necrosis
of myocardium
!
What is the most common cause of myocardial

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

diaphoreis strongly suggests acute MI
(disease).
What is the classic clinical presentation

of myocardial infarction? (3)
'Crushing' retrosternal chest pain Radiation

of pain to left side Diaphoresis
!
In what patient groups are myocardial infarctions

often asymptomatic? (4)
right ventricular infarct? (5)
Post-op patients Elderly

Diabetics Women
Inferior EKG changes Hypotension Elevated

JVP Hepatomegaly Clear lungs
What does S-T segment elevation indicate?

What can it be diagnostic for?
What are Q waves indicative of?
Transmural injury; diagnostic of

an acute infarct
Evidence of necrosis
!
When are Q waves seen in the course of an MI?
Usually seen late; not acute

!
What is an S-T segment depression indicative of?
Subendocardial injury
!
When in the course of an MI are peaked T waves observed on an

EKG?
!
ST segment elevation infarct (STEMI)

Non-ST segment elevation infarct
(NSTEMI)
What are the categories of infarct in

terms of EKG morphologies? (2)
How much of the heart wall is affected by STEMI?

How much of the heart wall is affected by
NSTEMI?
Transmural; entire thickness
Subendocardial; partial involvement of

heart wall
!
What diagnostic test is used to differentiate

NSTEMI from unstable angina pectoris?
Cardiac enzymes are present in

NSTEMI but not USA
!
What test is the diagnostic gold standard for myocardial

injury?
When does CK-MB increase after myocardial injury?
When is the peak reached?
At what interval should total CK and CK-MB be measured
after admission? For how long?
What are the most important cardiac enzymes to order?
When do troponins I and T increase after a
myocardial infarction? When do they peak?
Occur very
early
Cardiac enzymes
4 to 8 hours; peak at
24 hours
!
Every 8 hours for

24 hours
Troponins I and T
Increase within 3 to 5 hours

Reach a peak in 24 to 48 hours
10!
Terms / Facts
When do troponins return to normal after myocardial infarction?
Why are troponins preferred to CK-MB for diagnosis of
myocardial infarction?
When should cardiac enzymes be
drawn?
Greater sensitivity and

specificity
Troponin I can be falsely elevated in

patients with r enal failure (disease).
!
What are the only three agents shown to reduce

mortality in MI?
!
Aspirin ACE inhibitors blockers
Antiplatlet activity reduces coronary reoccclusion

by inhibiting platelet aggregation on top of the
thrombus
What is the rationale for using -blockers in a

patient with acute MI?
!
When should ACE inhibitors be

administered to a patient with acute MI?
What was the key finding of the
CAPRICORN trial?
HR, contractility and afterload

mortality
Within hours of hospitalization if there

are no contraindications.
Showed that carvedilol reduces risk of death in

patients with post-MI LV dysfunction
Myocardial infarction in the anterior region of the

heart has what EKG morphologies? (2)
!
Myocardial infarction in the posterior

region of the heart has what EKG
morphologies? (3)
ST segement elevation in
V1-V4 Q waves in V1-V4
Large R wave in V1 and V2 ST segment

depression in V1 and V2 Upright and
prominent T wave in V1 and V2
!
Myocardial infarction in the lateral region of the heart has

what EKG morphologies? (1)
Myocardial infarction in the inferior region of the heart has
what EKG morphologies? (1)
What is the rational for using statins in
mainenance therapy of MI?
What pharmacologic agents are
indicated in patients with MI? (7)
What is the rationale for using
nitrates in patients with acute
MI? (3)
What did the
HOPE trial find?
5 to 14 days
At admission and every 8 hours until three

samples are obtained
Troponin I can be falsely elevated in

patients with r [...] (disease).
What is the rationale for using

aspirin in a patient with acute
MI?
Q waves in leads I
and aVL
Q waves in leads II,
III and aVF
Stabilizes plaques and lowers cholesterol

risk of further coronary events
Oxygen Nitroglycerin -blockers Aspirin

Morphine ACE inhibitors IV Heparin
Dilate coronary arteries (increase supply)

Venodilation (decrease preload and demand)
Reduce chest pain
ACE inhibitor ramipril reduces mortaliti, MI, stroke and renal
11!
Terms / Facts
disease in patients with high-risk cardiovascular disease
What did the GUSTO
trial find?
t-PA plus heparin gives the greatest mortality benefit in

patients with acute MI
What are the two types of revascularization used in acute MI

patients?
What is the most important criterion for effectiveness of
revascularization in acute MI patients?
!
What is the rationale for giving heparin to

patients with acute MI?
PTCA
Thrombolysis
Timing; must be
given early
Prevention of progression of
thrombus formation.
! CHF
What is the most common cause of in-hospital mortality related to acute
MI?
! Acute MI is a RAMP to lots of complications R
What are the classes of
ecurrent infarction A rrhthymias M echanical
complications related to acute
complications P ump failure (CHF)
MI? (4)
What is cardiac
rehabilitation?
Physician-supervised regimen of exercise and risk factor

reduction after MI
!
What treatment does premature ventricular

contractions call for in a patient post acute MI?
Observation; no need for

antiarrhythmics
!
What treatment does ventricular tachycardia call for in the

context of hemodynamic instability?
What treatment does ventricular tachycardia call for
in the context of hemodynamic stability.
!
What treatment does ventricular

fibrillation call for?
What treatment does asytole call
for?
Electrical defribillation followed transcutaneous

pacing
What treatment does 2nd- or 3rd-degree AV block

call for in the setting of anterior MI?
What is the initial treatment for 2nd- or 3rddegree AV block in the setting of inferior
MI?
Antiarrhythmic therapy (IV

amiodarone)
Immediate unsynchronized defibrillation

and CPR
In what setting does a second- or third-degree AV block

have a dire prognosis?
What is a recurrent
infarction?
Electrical
cardioversion
In the setting of an
anterior MI
Emergent placement of a
temporary pacemaker
IV atropine followed by temporary

pacemaker if conduction is not
restored
Extension of existing infarction or reinfarction of a

new area.
12!
Terms / Facts
What cardiac enzyme is best for assessing
recurrent infarction? Why?
CK-MB because it returns to normal

faster so a re-elevation is detectable.
When does CK-MB return to normal after an acute MI?

!
What is the treatment for

recurrent infarction?
48 to 72 hours
Repeat thrombolysis or urgent cardiac catheterization

and PTCA followed by standard medical therapy for MI
!
What EKG finding suggests reinfarction

after an acute MI?
!
What is a free wall rupture?

When does it occur most
commonly?
Repeat ST segment elevation within

first 24 hours
Catastrophic, usually fatal event that occurs during

the first 2 weeks after MI (most common 1 to 4
days)
!
What is the mortality rate of a free wall rupture?
90%
What is the result of free wall rupture? ! Hemopericardium and cardiac temponade
(2)
! You need to fix HIS free rupture Hemodynamic
stabilization Immediate pericardiocentesis Surgical
What is the treatment for
repair
free wall rupture? (3)
!
How does ejection fraction post-MI relate to

the risk for stroke? In what time range?
The lower the EF, the greater the

risk for stroke in the next 5 years.
In what time range post-MI does rupture of the interventricular

septum occur?
10 days postMI
! Mitral regurgitation
What cardiac pathology results from papillary muscle
rupture?
! Emergent surgery (mitral valve
What is the treatment for mitral
replacement) Afterload reduction with
regurgitation secondary to papillary
nitrprusside or intra-aortic baloon pump
muscle rupture? (2)
!
What is a ventricular
pseudoaneurysm?
Incomplete free wall rupture (myocardial rupture is

contained by pericardium)
!
What is the treatment for a ventricular

pseudoaneurysm? Why?
Ventricul aneursym is associated
with a high incidence of [...] .
Emergent surgery because VP can

become free wall rupture.
Ventricul aneursym is associated with a high

incidence of ventricular tachyarrhythmias .
What is the treatment for acute pericarditis secondary to MI?

What drugs are contraindicated in acute
pericarditis secondary to MI? Why?
What is Dressler's
syndrome?
Aspirin
NSAIDs and corticosteroids; may

hinder myocardial scar formation
Immunologically based syndrome occurring weeks to
13!
Terms / Facts
months after MI
What is the clinical presentation of Dressler's
syndrome? (5)
Fever Malaise Pericarditis

Leukocytosis Pleuritis
What is the most effective therapy for Dressler's syndrome?

!
DDx: Chest pain due to heart,

pericardium or vascular causes. (4)
Wheezing Cough Dyspnea

!
In what manner do the symptoms of asthma

usually appear?
What are the triggers of asthma? (3)
What breath sounds are heard in asthma? (2)
Frequency Duration Required

treatment Severity
Wheezing Prolonged expiratory
What external signs are observed with physical exam in

asthma? (3)
DDx:
Asthma (6)
Nasal polyps Rhinitis

Rash
Asthma exams have HARD, Paradoxical

Pulses HR Accessory muscle use RR
Diaphoresis Pulsus paradoxis
Hyperventilation Panic attacks Upper airway obstructor or inhaled

foreign body COPD Bronchiectasis CHF
What is the triad of atopic asthma?
Asthma + allergic rhinitis + atopic dermatitis

!
What is the triad of ASA-sensitive

asthma?
What are the 'reliever'

medications used to quickly
relieve the sx of asthma? (2)
What is the clinical triad of ChurgStrauss?
What are the controller
medications used for
asthma? (6)
Asthma + ASA sensitivity + nasal polyps

!
What is the clinical triad of allergic

bronchopulmonary aspergillosis?
Asthma + pulmonary infiltrates +

allergic rxn to Aspergillus
Short-acting inhaled 2 -agonists: albuterol,

levoalbuterol. Inhaled anticholinergics
(ipratropium; bronchodilation)
!
Asthma + eosinophilia + granulomatous

vasculitis
Inhaled corticosteroids (fluticasone, beclamethasone) Long

acting 2 -agonists (salmeterol) Nedocromil/cromolyn
Theophylline Leukotriene modifiers Anti-IgE
What should long-acting 2 agonists always !
Chronic with episodic

exacerbation
Viral infection Environmental allergens Drugs
What information should one note about

asthma exacerbations? (4)
What physical exam findings does

one observe in asthma with
exacerbation? (5)
Aspirin
Angina (stable, unstable, variant) MI

Pericarditis Aortic dissectoin
!
What is the classic triad of asthma?
Always use with inhaled
14!
Terms / Facts
corticosteroids; mortality without.
be used with in asthma? Why?
What test can be used to predict response to

leukotriene modifiers in asthma?
What is the goal of asthma therapy?

What does that goal consist of? (3)
To achieve complete control = daily sx

2/week, nocturnal sx, reliever med 2/wk
What happens to FEV 1 , FEV 1 /FVC, RV and

TLC and flow volume loops in asthma?
!
What are the distinct pathologic

features in the sputum samples of
patients with asthma? (2)
sx and # of exacerbations (but no

change in FEV 1 )
What benefit does bronchial thermoplasty

offer patients with asthma?
Check transcription of genes for

5-lipoxygenase
FEV 1 FEV 1 /FVC RV and

TLC coved flow-volume loop
Curschmann's spirals (mucus casts of distal

airways) Charcot-Leyden crystals (eosinophil
lysophospholipase)
What PEF (peak expiratory flow) findings

suggest asthma? (2)
60 L/min after bronchodilation

20% diurnal variation
What is the treatment for Step 2 in asthma stepwise therapy?

!
What is the treatment for Step 3 in asthma stepwise

therapy?
!
What is the treatment for Step 4 in asthma stepwise

therapy?
What suspicions should prompt a CXR in an asthma

patient with exacerbation? (2)
What are the precipitants of

DKA? (4)
Low-dose ICS + LABA
Oral steroids
Previous need for

intubation
Suspicion of pneumothorax
or pneumonia
Insulin deficiency Infection or inflammation Ischemia

or infarction Intoxication
!
What type diabetes does DKA occur in mostly?

What happens to acid-base status with DKA?
What is the value for the corrected serum [Na+]

in the context of DKA-related hyperglycermia?
What happens to serum [K+] with
DKA? Why?
T1D and ketosis-prone T2D

anion gap metabolic acidosis
!
What is the predominant ketone in DKA?
Low-dose ICS
Med/high dose ICS +

LABA
What is the treatment for Step 5 in asthma stepwise therapy?

What is a good predictor of risk of death with asthma
exacerbation?
-hydroxybutyrate
Corrected Na = measured Na +
[2.4 x (measured glucose100)/100]
Hyperkalemia due to exchange with H+
15!
Terms / Facts
(acidosis) from ICF
!
What happens to total body K+ with DKA?

!
What happens to the CBC with DKA?
Leukocytosis
!
What happens to total body phosphorous with DKA?

What pancreatic enzyme is elevated with DKA?
!
What is the general treatment

strategy for DKA?
What does fluid
management consist of in
DKA?
What does electrolyte

management consist of in
DKA? Explain.
DDx:
DKA (5)
amylase
Rule out possible precipitants Aggresive hydration

Insulin Electrolyte repletion
(1) 10 U IV push of insuin followed by 0.1 U/kg/h;

continue insulin until AG normal (2) When AG is
normal, give subcutaneous insulin.
Replace K+ (20-40 mEq/L) if < 4.5 (within 1 to 2
hours of starting insulin); insulin shift of K+ into
cells hypokalemia. Replace PO 4 if < 1
Cerebral edema (if glucose levels decrease too rapidly)

Hyperchloremic nongap metabolic acidosis (due to
rapid infusion of a large amount of saline)
Alcoholic ketoacidosis Hyperosmolar hyperglycemic nonketotic syndrome

(HHNS) Hypoglycemia Sepsis Intoxication
What lab tests should be

ordered if a patient presents
with DKA? (10)
What is acute bacterial meningitis?
Arterial blood gas Blood glucose/BUN

CBC/Creatinine/CXR/Cultures Electrolytes/ECG
UA
!
List the bacteria that cause adult

meningitis in descending order? (4)
Bacterial infection of the subarachnoid space

!
What are the clinical manifestations of acute

bacterial meningitis? (6)
S.pneumoniae N. meningitidis H.
influenzae L. monocytogenes
!
Fever Headache Stiff neck

Photosensitivity AMS Seizures
What is the atypical presentation of acute bacterial meningitis that

may occur in the elderly and immunosuppressed?
!
What physical exam signs are present in

acute bacterial meningitis? (5)
Decreases
Aggresive (10-14 mL/kg/h) hydration with normal saline

(add 5% glucose once blood glucose reached 250 mg/dL
to prevent hypoglycemia)
What does insulin treatment

consist of in the management
of DKA?
What are the complications

of DKA treatment? Explain.
(2)
K+
Lethargy w/o
fever
Nuchal rigidity Kernig's sign

Brudzinski's sign Focal neuro findings
Rash
16!
Terms / Facts
!
What are the possible causes of recurrent

bacterial meningitis?
Blood culutres should be taken [...]
antibiotic therapy in bacterial meningitis
CSF leak Dermal sinus

Congenital/acquired defects
Blood culutres should be taken before
antibiotic therapy in bacterial meningitis
!
What is the WBC count in bacterial meningitis?
What test should be performed if meningitis is suspected?

!
Empiric antibiotic therapy should be

initiated immediately [...] LP is
performed.
!
What are the Rule of 2s

(bacterial meningitis)?
> 10,000 WBC

Lumbar puncture
Empiric antibiotic therapy should be

initiated immediately after LP is
performed.
CSF WBC > 2k glc <20 TP > 200 > 98%

specificity for bacterial meningitis
!
What is the appearance of CSF in bacterial meningitis?
Cloudy
!
What is the opening pressure of CSF in bacterial meningitis? (cm H20)

!
What range of WBCs is found in the CSF with bacterial

meningitis? What is the predominant type?
What is the empiric abx treatment for a normal adult

with meningitis?
What is the empiric abx treatment for an adult
> 50 y/o?
!
What other treatment may be initiated in

bacterial meningitis? What is the
indication? When should it be
administered?
What are the most common viral etiologies of

aseptic meningitis? (4)
What CSF findings suggest viral
meningitis? (3)
Tx: TB meningitis
Tx: Fungal meningitis
< 45
Ceftriaxone +
Vancomycin
Ceftriaxone + Vancoymcin +
Ampicillin
Dexamethasone if cerebral edema is

suspected. Must be administered before
or w/ 1st dose of abx.
What prophylaxis should be given to the contacts of a patient

with bacterial meningitis?
What is the definition of aseptic meningitis?
100-10,000
PMNs
!
What is the glucose level in CSF in bacterial meningitis?
18-30
Rifampin or
ceftriaxone
Negative bacterial microbiologic data

!
Enterovirus HIV HSV (type 2

>1) VZV
Cell count < 500 w/ > 50% lymphs TP < 80-100

mg/dL Normal glucose
Antimycobacterial Rx + dexamethasone
!
Amphotericin B + 5-FU
17!
Terms / Facts
!
What anatomic regions are affected in lower urinary tract

infections? (2)
!
What anatomic regions are affected in upper urinary

tract infections?
!
What is an
uncomplicated UTI?
What is a
complicated UTI?
(4)
Urethra Urinary
bladder
Kidneys (pyelonephritis)
Prostate
Cystitis in immunocompetent nonpregant women w/o

underlying structural or neurologic disease
Upper tract infection in women UTI in men UTI in pregnant

women UTI with underlying structural disease or
immunosuppression
!
What is the number one culprit in uncomplicated UTIs?

!
What microbes are responsible for

complicated UTIs? (4)
E.coli
E. coli Enterococci Pseudomonas S.

epidermidis
What organisms are the most frequent causes of catheter-associated ! Yeast E.coli
UTIs? (2)
! Dysuria Urgency Frequency
What are the clinical manifestations of cystitis? (3)
!
How does the clinical presentation of urethritis differ

from that of cystitis?
!
What is the clinical presentation of acute

prostatitis? (3)
pyelonephritis? (3)
Perineal pain Fever Tenderness on

prostate exam
Fever w/ shaking chills Flank/back pain

Nausea/vomiting
How does the clinical presentation of a renal abscess

differ from that of pyelonephritis?
What are the urinalysis findings of
UTIs? (4)
Persistent fever despite

appropriate antibiotics
Pyuria + Bacteriuria +/- hematuria +/nitrites

!
What is the definition of pyuria?

What is the definition of bacteriuria?
Urethral discharge may be

present
> 8 WBC/HPF
> 1 organism per oil-immersion field.
What is the criterion for a UTI based on urine culture for an

asymptomatic woman?
What is the criterion for a UTI based on urine culture in a
symptomatic woman?
What is the criterion for a UTI based on urine culture in a man?
What does the presence of squamous cells in a
urinalysis indicate?
10 5
CFU/ml
100
CFU/ml
1000 CFU/ml
Vulvar or urethral
18!
Terms / Facts
contamination
!
What is the empiric treatment for uncomplicated

cystitis? (2)
!
What is the empiric treatment for complicated

cystitis? (2)
!
What is the empiric treatment for

pregnant women with UTI? (3).
FQ or TMP-SMX PO x 1014 d
Ampicillin Amoxicillin Oral

cephalosporins x 7 to 10 days
!
What is the empiric treatment for UTIs in

men?
What is the empiric treatment for urethritis?
(2) What is the indication for each part of
this treatment?
FQ or TMP-SMX x 3
day
Treat as in women, except for 7

days
Ceftriaxone 125 mg IM x 1
(Neisseria) Doxy 100 mg PO bid x 7
d (Chlamydia)
What is the empiric treatment and duration for

acute prostatitis?
What is the treatment with duration for chronic
prostatitis?
FQ or TMP-SMX Po x 14-28
d (acute)
FQ or TMP-SMX Po x 6-12
weeks
! Ceftriaxone IV x 14 d
What is the inpatient treatment with duration for
pyelonephritis?
! Drainage + antibiotics for pyelonephritis
What is the treatment for a renal
abscess?
! CT to r/o
What test should be conducted in patients with pyelonephritis who
abscess
fail to defervesce within 72 hours? Why?

rheumatoid arthritis?
Pain Swelling Impaired function of joints

Morning stiffness
!
How many joints are involved in the majority of cases of

rheumatoid arthritis?
!
What is the precursor lesion to almost all cases of CRC?

What is the most specific and sensitive test for CRC?
Adenomas
Colonoscopy
!
What test is used to complement flexible sigmoidoscopy in

evaluating CRC?
Barium enema
!
What is the most common site of distant spread of CRC?

What age group is at increased risk for CRC?
Polyarticular
Liver
> 50 y/o
What kind of adenoma has the highest malignant potential for ! Villous adenomas
CRC?
! CT scan of abdomen and CXR
How is staging performed for CRC?
What other gastrointestinal diseases increase the risk !
Ulcerative colitis Crohn's
19!
Terms / Facts
for CRC? (2)
disease
!
What does Stage A colorectal cancer

mean?
!
What does Stage B1 CRC mean?
Limited to submucosa/muscularis propria

!

Limited to muscualris mucosa; T1-2, N0,

M0
Through the entire bowel wall
Through bowel wall and into adjacent structures

!
What does Stage C CRC mean?
Positive regional lymph nodes

!
What does Stage D CRC mean?
Distant metastases
!
What is the recommended treatment for familial

adenomatous polyposis?
Prophylactic
colectomy
!
At what age is the risk of CRC 100% with Gardner's Syndrome?

What is the clinical presentation of Turcot's
syndrome? (2)
What is Lynch I
syndrome?
What is Lynch syndrome
II?
Polyps + cerebellar medulloblastoma

or GBM
Early onset CRC with an absence of antecendent multiple

polyposis
!
Lynch syndrome I features + early occurence of other

cancers
!
What is the clinical presentation of CRC?

Which symptom is most common? (4)
Abdominal pain Weight loss Blood

in stool Colonic perforation
What is the most common cause of large bowel obstruction in adults?

!
What is the clinical presentation of right-sided

CRCs? (3)
CRCs on what side of the colon present with
melena? And with hematochezia?
Why is obstruction unusual with right-sided CRCs?

What is a common symptom of leftsided CRC?
What is the surgical treatment

for CRC?
What blood marker should be
CRC
Anemia Weakness RLQ

mass
Melena: right side
Hematochezia: left side
!
Large luminal diameter
Changes in bowel habits secondary to bowel

obstruction
What is the most common symptom of rectal cancer?
Age 40
Hematochezia
Resection of tumor-containing bowel as well as the

regional lymphatics
!
CEA; levels are checked periodically every 3
20!
Terms / Facts
obtained before surgical resection of
CRC? Why?
to 6 months. Elevations strongly suggest

recurrence.
!
What is the adjuvant therapy for Dukes'

C colon cancer?
Postoperative chemotherapy:5-FU and

leucovorin
What is the adjuvant therapy for Dukes' B2 or C

rectal cancer?
!
What follow-up studies are used s/p

CRC resection?
5-FU + radiation therapy

postoperatively
Stool guaiac Annual CT of abdomen/pelvis

CEA levels
In what time frame do the majority of recurrences take place

for CRC s/p resection?
!
[...] therapy is not indicated in the

treatment of colon cancer.
What is a completed stroke?

Why are symptoms transient
in a TIA?
Within 3 years of
surgery
Radiation therapy is not indicated in the

treatment of colon cancer.
!
What is the leading cause of neurologic disability?

What is an evolving stroke?
Ischemic stroke
Stroke that is worsening
One in which the maximal deficit has occurred.
Reperfusion occurs due to collateral circulation or

embolus break up.
!
What is the usual cause of a TIA?

!
What is the association between TIA and

stroke risk?
Embolism
TIA = high risk of stroke in subsequent

months.
!
What is the 5-year stroke risk with a TIA?

!
What are the most important risk factors for TIA? (2)
What are the types of strokes? (2)
Age HTN
Ischemic strokes Hemorrhagic strokes
What is the most common source of emboli in ischemic

stroke?
What are the major
causes of stroke? (3)
30%
Heart (mural
thrombus)
Ischemia due to atherosclerosis Atrial fibrillation with clot

emboli to the brain Septic embolic from endocarditis
In what vessels does thrombotic stroke

occur most frequently? (2)
Bifurcation of the common carotid artery

Middle cerebral artery
! Hypertension
What predisposing factor is found in nearly all cases of lacuanr
stroke?
What is the pathogenesis ! Narrowing of the arterial lumen by thickening of the
of lacunar strokes?
vessel wall (hyaline arteriolosclerosis) microinfarcts
21!
Terms / Facts
result (lacunes)
!
What is the classic presentation of a

thrombotic stroke?
What are the two causes of a
carotid bruit?
Patient awakens from sleep with

neurologic deficits
Murmur referred from the heart Turbulence in the

internal cartoid artery
Describe the onset and severity of symptoms with

embolic stroke.
!
Clinical
manifestations: MCA
stroke (5)
Very rapid with maximal

deficits initially
MCA stroke can cause CHANGes Contralateral

paresis/sensory loss in face and arm Homonymous
hemianopia Aphasia (dominant) Neglect (nondominant) Gaze
preference toward the side of the lesion
Where is the location of a lesion with pure motor lacunar stroke?
Internal capsule
Where is the location of a lesion with pure sensory lacunar stroke?

!
What is ataxic hemiparesis?
What is pectus carinatum?
How should one assess thoracic

expansion?
Risk factors:
COPD (4)
Contralateral lower extremity and face

weakness and sensory loss
Many small breaths from a position of

relative inspiration but without very deep
breaths.
Place hands on lateral chest wall from the

posterior view
Inward inspiratory movements alternating with normal outward

inspiratory movements due to diaphragmatic weakness.
!
Definition:
Emphysema
Pons
Sternum protrudes from the narrowed thorax
How do people with small airways

disease breath when dyspneic or
tachypneic?
Definition: Chronic
bronchitis
The term subclavian steal has been used to describe retrograde

blood flow in the vertebral artery associated with proximal
ipsilateral subclavian artery stenosis or occlusion
What is subclavian
steal syndrome?
What is respiratory
alternans?
Thalamus
Incoordination ipsilaterally
With clumsy hand dysarthria, where is the lesion?

What kind of deficit and occurs with
anterior cerebral artery stroke? Where?
Chronic cough productive of sputum for at least 3 months per

year for at least 2 consecutive years
Permanent enlargement of air spaces distal to the terminal

bronchioles due to destruction of the alveolar walls
Tobacco smoke 1 -antitrypsin deficiency Environmental factors
22!
Terms / Facts
(second hand smoke) Chronic asthma
!
Below what value is the FEV1/FEV in COPD?

!
What happens to the forced expiratory time in

COPD?
Greater than or equal to 6

secs
What is the definitive diagnostic test for COPD/
Pulmonary function testing
What happens to FEV1/FVC in COPD?

What percent reduction in FEV1 compared to the predicted
value is indicative of mild disease? And severe disease?
!
What happens to TLC in COPD?
!
!
!
What happens to vital capacity in COPD?
What are the radiographic featuers of

COPD on CXR? (3)
Decrease
Mild: 70%
Severe: 50%
Increased RV
Increased FRC
Decreased vital capacity
What disease is predominant in COPD of pink puffers?

!
What disease is predominant in COPD of blue

bloaters?
Increased TLC
What happens to residual volume in COPD?

What happens to FRC in COPD?
< 0.75-0.80
Predominant emphysema
Predominant chronic
bronchitis
Hyperinflation Diminished vascular

markings Flattened diaphragm
What is a good screening test for pulmonary

obstruction? What value should prompt PF
testing?
Peak expiratory flow for

screening; < 350 L/min should
prompt PFT
! Smoking cessation
What is the most important intervention for COPD
treatment?
! Serial FEV1 measurements Pulse
What does clinical monitoring of COPD
oximetry Exercise tolerance
patients entail? (3)
Within what time range do respiratory symptoms improve in COPD after

cessation of smoking?
What happens to the FEV1 of a COPD
patient after smoking cessation?
Tx: COPD
(4)
1
year
Decline of FEV1 returns to the rate of

someone who has never smoked
Corticosteroids Oxygen Prevention (smoking cessation, pneumococcal

vaccine) Dilators (beta agonists, anticholinergics)
What are the criteria for continous or

!
intermittent long-term oxygen therapy
in COPD? (3)
PaO2 55 mm Hg OR O2 saturation < 88%

OR PaO2 55-59 mm Hg + polycythemia or
23!
Terms / Facts
evidence of cor pulmonale
!
1st line: metered-dose inhaler of bronchodilator 2nd:

inhaled glucocorticoids can be used as well; start w/ low
dose
Tx guidelines for mild to

moderate COPD? (2)
!
Tx guidelines for severe

COPD? (3)
Bronchodilators Continuous oxygen therapy Pulmonary

rehabilitation
!
Definition: Acute COPD

exacerbation
CXR 2 -agonist systemic corticosteroids

antibiotics supplemental oxygen non-invasive positive
pressure ventilation
Tx: acute
exacerbations of
COPD (6)
Persistent increase in dyspnea (not relieved w/

bronchodilators)
What antibiotics should be used in acute exacerbations of

COPD? (2)
What are the complications of
COPD? (4)
!
What is
bronchiectasis?
azithromycin
levofloxacin
Acute exacerbations Secondary polycythemia

Pulmonary HTN and cor pulmonale
Permanent, abnormal dilation and destruction of bronchial

walls.
!
What is the most common cause of bronchiectasis?

!
Clinical presentation:
bronchiectasis (4)
!
Dx: Bronchiectasis (3)

Tx: Bronchiectasis
(2)
Chronic cough Dyspnea Hemoptysis Recurrent or

persistent pneumonia
High-resolution CT scan PFTs Bronchoscopy
Abx for acute exacerbations Bronchial hygiene (hydration, chest

physiotherapy, inhaled bronchodilators)
What are the two pathologic subtypes

of lung cancer?
Risk factors: Lung cancer
(5)
Small cell lung cancer (25%) Non-small cell

lung cancer (75%)
Cigarette smoke COPD Radon Asbestos Passive

smoke
How is non-small cell lung cancer staged?

How is small cell
lung cancer staged?
(2)
TNM system
Limited - confined to chest plus supraclavicular nodes, but not

cervical or axillary nodes Extensive - outside of chest and
supraclavicular nodes
What cancer is most commonly associated with superior vena

cava syndrome?
Cystic Fibrosis
Small cell lung

cancer
24!
Terms / Facts
What type of neoplasm is Pancoast's tumor generally?
!
Diagnosis: lung cancer (3)
Squamous cell carcinoma
CXR CT scan Tissue biopsy

!
Cytologic examination of sputum detects lung neoplasms

from wht location?
!
Tx: non-small cell lung cancer
Central but not

peripheral
Surgery w/ radiation therapy as adjunct

!
What is the 5-year survival rate for lung cancer patients?

!
Tx: small cell lung cancer

For what stage of small cell lung cancer is
radiation therapy a useful adjunct? When not?
Is surgery a useful treatment in small cell lung
cancer? Explain.
14%
chemotherapy
radiation is useful in limited stage
disease but not extensive
!
No; tumors are usually

unresectable
! Metastatic cancer
What is the most comon cause of mediastinal mass in older
patients?
! Thyroid Teratogenic tumors Thymoma Terrible
Ddx: anterior mediastinal mass
lymphoma
(4)
!
Ddx: middle mediastinal mass

(5)
!
Ddx: posterior mediastinal

mass (5)
cyst lung cancer lymphoma aneurysm morgani

hernia
Neurogenic tumor Esophageal mass Enteric cyst

Aneurysms Bochdalek's hernia
!
What is the test of choice for diagnosing a mediastinal mass?

What is the most common presentation of a mediastinal mass?
What are the clinical
manifestations of a mediastinal
mass? (5)
!
What is oropharyngeal
dysphagia?
!
What is esophageal
dysphagia?
Etiology: achalasia
(3)
Sx: achalasia (3)
Dx: achalasia
CT scan
Asymptomatic
SVC syndrome Dysphagia Nerve compression

(hoarseness, horner's, diaphragmatic paralysis)
Chest pain Dyspnea
Oropharyngeal: inability to propel food from mouth

through UES into esophagus
Esophageal: difficulty swallowing & passing food from
esophagus into stomach
idiotpathic (most common) pseudoachalasia (due to GE jxn

tumor) chagas disease
dysphagia (solid and liquid) chest pain regurgitation
!
barium swallow
25!
Terms / Facts
What radiologic finding is associated with barium
swallow in achalasia?
!
Tx: achalasia (3)
congenital GVHD Fe-deficiency anemia
Excessive transient relaxations of lower esophageal sphincter

(LES) or incompetent LES Mucosal damage (esophagitis) due
to prolonged contact w/ acid can evolve to stricture
Pathophysiology:
GERD
Risk factors: GERD

(4)
!
hiatal hernia obesity hypersecretory states delayed emptying

supine position fatty foods caffeine alcohol cigarettes CCB
pregnancy
!
Clinical manifestations
(esophageal): GERD (5)
heartburn atypical chest pain regurgitation

dysphagia water brash
!
Clinical manifestations (extraesophageal):

GERD (4)
!
Dx: GERD (2)
Failure to respond to PPI Alarm features (dysphagia,

odynophagia, vomiting, wt loss, palpable mass, age
> 55 y)
What diagnostic study is indicated for uncertain

dx of GERD w/ a normal EGD?
!
cough asthma laryngitis dental

erosions
Hx and Empiric trial of PPI
When is EGD indicated for

diagnosis of suspected GERD?
(2)
Tx (lifestyle): GERD
(4)
dilated esophagus w/ distal

'bird's beak'
Heller myotomy Balloon dilation Botulinum toxin
Etiologies: esophageal webs (3)
Precipitants: GERD
(7)
high res manometry w/ 24-h

esophageal pH monitoring
avoid precipitants lose weight avoid large and late meals

elevate head of bed
!
Tx (medical): GERD
!
Tx (surgical): GERD
Complications: GERD (2)
PPI
fundoplication
Barrett esophagus Esophageal adenocarcinoma
How does one manage the complications of GERD?
surveillance EGD w/ biopsy

!
How frequently should one perform EGD w/ bx surveillance if a patient has

Barrett's esophagus w/ no dysplasia?
How frequently should one perform EGD w/ bx surveillance if a patient
has Barrett's esophagus w/ low grade dysplasia?
How does one manage Barrett's
esophagus w/ high grade dysplasia?
q3
y
q6
mos
Endoscopic mucosal resection to r/o cancer,

then RFA or other ablative Rx
26!
Terms / Facts
!
Definition:
dyspepsia
upper abdominal sx (discomfort, pain, fullness, bloating,

burning)
!
Etiology (functional):
dyspepsia (2)
visceral afferent hypersensitivity abnormal gastric

motility
!
Etiology (organic): dyspepsia (3)

!
Tx: functional dyspepsia (2)

What are the cardiac causes of
chest pain? (4)
!
Sx: unstable
angina (4)
GERD PUD Gastric cancer

H. pylori eradication PPI
Pericarditis/myopericarditis Unstable angina MI

Aortic dissection
Substernal pressure that radiates into the neck, jaw and L arm
Dyspnea Diaphoresis N/V
What exacerbates unstable angina? And improves?

(2)
Dx: unstable angina
(2)
w/ exertion w/ NTG or
rest
EKG Stress test (make sure to stabilize with medical

management beforehand)
What kind of EKG changes are seen in unstable angina? ! / ST T-wave inversion
(2)
! Substernal pressure that radiates into the neck, jaw and L arm
Sx: myocardial
Dyspnea Diaphoresis N/V
infarction
Dx: myocardial infarction
(3)
!
Sx: pericarditis
(2)
EKG changes (/ ST, T-wave inversion) tropinin I/T

CK-MB
Sharp pain that radiates into the trapezius pericardial friction rub
pericardial effusion
What kind of EKG changes are associated with

pericarditis? (2)
!
Sx: myocarditis
(5)
Diffuse ST segment elevation

PR interval
EKG changes troponin
abrupt onset severe tearing, knifelike pain radiating anteriorly or to

the posterior mid-scapular region HTN or HoTN Weak pulses Focal
neurological deficits Aortic insufficiency
What are the radiologic findings of aortic

dissection? (2)
What are the pulmonary causes !
Sharp pain that radiates into the trapezius pericardial friction rub
pericardial effusion EF +/- s/s CHF
Dx: myocarditis (2)

Sx: aortic
dissection (5)
w/ respiration w/ sitting forward
What exacerbates pericarditis? and

improves?
Widened mediastinum on CXR False

lumen on CT
Pneumonia Pleuritis Pneumothorax Pulmonary
27!
Terms / Facts
of chest pain? (5)
Sx: pneumonia (6)
embolism Pulmonary hypertension

Pleuritic pain dyspnea fever cough w/ sputum RR crackles
CXR: pneumonia
!
Sx: pleuritis (2)

Sx: pneumothorax
(3)
pulmonary infiltrate
sharp, pleuritic pain friction rub
sudden onset, sharp, pleuritic pain hyperressonance breath

sounds
CXR: pneumothorax
Sx: pulmonary emobolism
(4)
air in the pleural space
sudden onset pleuritic pain RR &HR S a O 2 EKG

changes
What imaging study should be ordered for suspected pulmonary

embolism?
!
Sx: pulmonary hypertension (3)
Exertional pressure dyspnea SaO2

!
Auscultation: pulmonary hypertension (2)

What are the GI causes
of chest pain? (7)
Loud P2 right sided S3 and/or S4
Esophageal reflux Esophospasm Mallory-Weiss tears

Boerhaave syndrome PUD Biliary disorder Pancreatitis
!
Sx: esophageal spasm
intense substernal pain

!
Aggravating/alleviating factors:
esophageal spasm (1/2)
swallowing nitroglycerin and

calcium-channel blockers
!
Dx: esophageal spasm
manometry
!
Precipitating factors: Mallory-Weiss tears

!
Dx: mallory weiss tears

Sx: Boerhaave syndrome
Vomiting
EGD
Severe pain Palpable subcutaneous emphysema

!
Aggravating factor: Boerhaave syndrome
Radiologic finding: Boerhaave syndrome

Sx: biliary disorders (2)
Aggravating factor: biliary disorder
w/ swallowing
!
Precipitating factor: Boerhaave syndrome
CT
angiogram
vomiting
mediastinal air on chest CT

RUQ pain N/V
!
fatty foods
28!
Terms / Facts
!
Dx: biliary disorder (2)

!
Sx: pancreatitis
Epigastric/back discomfort
amylase lipase abd CT
Dx: pancreatitis (3)
What are the miscellaneous causes of chest

pain? (3)
Sx: herpes zoster (2)
Intense unilateral pain dermatomal rash w/ sensory findings

!
What is the initial approach to a

patient presenting with chest pain (5)
Definition:
Diabetes
Mellitus
Chostochondritis Herpes Zoster

Anxiety
Localized sharp pain that w/ movement and is reproduced by

palpation
Sx:
chostochondritis
RUQ U/S LFTs
Focused hx Targeted exam 12 lead EKG

cardiac biomarker (CK-MB and Tn) CXR
Fasting glucose >/= 126 mg/dL x 2 Random glc >/= 200 mg/dL x 2
(or 1 if severe hyperglycemia w/ acute metabolic decompensation)
75 g OGTT w/ 2-h glc >/= 200 mg/dL
!
What percentage of the US population has pre-Diabetes?

!
Definition: Impaired fasting glucose

!
Definition: Impaired glucose tolerance
100-124 mg/dL
140-199 mg/dL 2h after 75 g OGTT
What inteventions can be used to prevent progression

of pre-diabetes to frank DM? Give them in order of
risk reduction.
TZD (60%) >

Diet/exercise (58%) >
metformin (31%)
!
HbA1c above what level is sufficient to diagnose DM?

Pathogenesis: Type 1 DM
>/= 6.5%
islet cell destruction absolute insulin deficiency

!
What autoantibodies are found in type I

DM?(3)
!
Risk factors: type II DM (3)

Clinical manifestations: Diabetes
Mellitus
anti-GAD anti-islet cell anti-insulin
FHx Obesity Sedentary lifestyle

Polyuria Polydipsia Polyphagia w/ unexplained
weight loss
What is the first line therapy for T2DM w/ HbA1c >/=

7%
Metformin + lifestyle mod

!
By how much does metformin reduce HbA1c?

Contraindications: metformin (2)
What complications does DM cause to the eye?
~40%
~ 1.5%
Renal (Cr> 1.5) or liver failure

!
Retinopathy
29!
Terms / Facts
How does one treat proliferative retinopathy 2/2 DM?
photocoagulation surgery
! retinopathy
With what other diabetic complication does diabetic nephropathy
present?
! strict BP control using ACE inhibitors or ARBs
Tx: diabetic nephropathy
!
Sx: symmetric diabetic

neuropathy (3)
Sx: autonomic diabetic
neuropathy (5)
symmetric distal sensory loss paresthesias +/motor loss
gastroparesis constipation neurogenic bladder erectile

dysfunction orthostasis
Sx: diabetic mononeuropathy

Complications (dermatologic):
Diabetes Mellitus (3)
sudden onset peripheral or CN deficit
Necrobiosis lipoidica diabeticorum

Lipodystrophy Acanthosis nigricans
!
What criteria are used to classify hypertension?

!
Definition (JNC VII): Normal

pressure
Definition (JNC VII): Pre-HTN
Definition (JNC VII): Stage 1

HTN
Systolic < 120 mm Hg Diastolic < 80 mm

Hg
Systolic: 120-139 mm Hg Diastolic: 80-89 mm Hg

!
Systolic: 140-159 mm Hg Diastolic: 90-99 mm

Hg
!
Definition (JNC VII): Stage 2 HTN
Systolic: 160 mmHg Diastolic 100 mmHg

!
When is the onset of essential HTN?

!
What are the etiologies of HTN? (2)

!
What infections are diabetics

more susceptible to? (5)
Definition:
Heart failure
UTI Candidiasis Osteomyelitis of foot

Mucormycosis Necrotizing extern otitis
!
q3-6 mo;
(1) failure of the heart to pump blood forward at sufficient rate to

meet metabolic demands of peripheral tissues or (2) ability to do so
only at abnormally high cardiac filling pressures
Sx: low output heart failure (4)

Sx: congestive heart failure (left
sided) (3)
Sx: congestive heart failure (right
sided) (4)
25-55 yr
Essential Secondary
How often should HbA1c be checked? What is the target goal?

!
JNC VII
anorexia fatigue exercise intolerance weakenss

!
dyspnea orthopnea paroxysmal nocturnal

dyspnea
peripheral edema RUQ discomfort bloating

satiety
30!
Terms / Facts
!
Definition: class I heart failure (NYHA)

Definition: class II heart failure (NYHA)
Definition: class III heart failure (NYHA)
no sx w/ ordinary activity
!
sx w/ ordinary activity
sx w/ minimal activity
!
Definition: class IV heart failure (NYHA)

!
Precipitants: acute heart

failure (5)
Tx: acute decompensated
heart failure (5)
Goals of
workup: HTN
(3)
sx @ rest
MI renal failure hypertensive crisis drugs worsening

aortic stenosis
Lasix w/ monitoring of UOP Morphine Nitrates
Oxygen Position (sitting up & legs danging over bed)
(1) identify CV risk factors or other diseases that would modify

prognosis or rx (2) reveal 2 causes of HTN (3) assess for target
organ damage
What are renal causes of 2

HTN? (2)
renal parenchymal renovascular (atherosclerosis, FMD,

PAN, scleroderma)
!
What findings are suggestive of

renovascular 2 HTN? (4)
ARF induced by ACEI/ARB recurrent flash

pulm edema renal bruit hypokalemia
!
What is the most common cause of new cases of blindness among

working-age people?
What is the most common cause of end stage renal disease?
!
What are the primary headache syndromes? (3)

!
Sx: cluster
headache (4)
What warning signs should

prompt neuroimaging w/
headache? (5)
Headache diary Stress

reduction
worst ever, worsening over days, wakes from sleep

vomiting, aggravated by exertion or Valsalva age
> 50 y fever abnl neuro exam
POUNDing P ulsatile duration 4-72 h O urs U nilateral N

ausea/vomiting D isabling LR= 3 if 3 critera are met, LR=24 if 4 or
more
What doex prophylactic treatment of

migraine consist of? (5)
Definition: complicated
migraine
tension Migraine cluster
oxygen triptans CCB
What does non-pharmacologic treatment of headache

consist of? (2)
Diabetes
periodic, paroxysmal brief, sharp orbital headache lacrimation

rhinorrhea unilateral horner's syndrome
Tx (acute): cluster headache (3)
Sx:
migraine (5)
Diabetes
TCA Beta-blockers CCB Valproic

acid Topiramate
accompanied by stereotypical neurologic deficit tha
31!
Terms / Facts
tmay last hours
Definition: common migraine
Definition: classical migraine
!
What does abortive therapy

of migraine consist of? (4)
HA w/o aura
HA w/o aura
Triptans ASA/acetaminophen/high-dose NSAIDs

Metoclopramide IV Prochlorperazine IV/IM
!
What is the most common cause of peptic ulcer disease?

!
Sx: PUD
H. pylori
Epigastric abdominal pain

!
Complications: PUD (3)
UGIB Perforation & penetration Gastric outlet obstruction
What drug class is responsible for almost half of gastric and duodenal ! NSAIDs
erosions?
! Stool antigen test
What diagnostic test is used to confirm eradication of H.pylori
What diagnostic test is required to make definitive diagnosis of PUD?
Why is a serologic test not used to confirm
eradication of H. pylori in PUD?
!
Tx: H. pylori-related
PUD
What is Dieulafoy's
lesion?
Etiologies: Lower GI
bleed (5)
Serology can stay (+) for

weeks to years
Gastric acid suppression w/ PPI Lifestyle changes
What drugs can be given in conjunction with

NSAID/ASA to prevent PUD in susceptible persons? (2)
Etiologies: upper
GI bleed (6)
Misoprostol H2-receptor
antagonist
Peptic ulcer (50%) Varices (10-30%)

Gastritis/gastropathy/duodenitis (15%) Mallory-weiss tear (10%)
Vascular lesions (5%)
!
lesion of superficial ectatic artery usually in cardia ->

sudden, massive UGIB
!
Clinical manifetations: UGIB

(5)
Diverticular hemorrhage Neoplastic disease Colitis

Angiodysplasia Anorectal
!
N/V Hematemesis Coffee-grind emesis Epigastric

pain Melena
Clinical manifestations: LGIB (4)

What does initial management of GI
bleeding consist of? (5)
diarrhea tenesmus hematochezia brbpr

!
Assess severity Resuscitation Transfuse

Reverse coagulopathy Triage
Tachycardia in a patient with GI bleeding indicates approximately !
EGD
Sequential Rx (PPI + abx x 5d -> PPI + 2 different abx x 5

d)
Tx: H. pylori-negative PUD
10% volume
32!
Terms / Facts
how much blood loss?
loss
!
Orthostatic hypotension in a patient with GI bleeding suggests how much

volume loss?
!
Shock in a patient with GI bleeding suggests how much volume loss?

If a patient presents with monoarticular joint pain, what is the first
problem to rule out?
Definition:
Gout
20%
30%
Infected
joint
monosodium urate (MSU) crystal deposition in joints and other

tissues
What is the ratio of prevalence of gout in men to women?
9:1 men to women
What is the most common cause of inflammatory arthritis in men over 30 ! Gout
y?
! serum uric acid related to metabolic syndrome HTN CKD
Risk factors:
intake of meat, seafood, EtOH
gout (4)
!
Etiologies: gout (2)

!
Clinical
manifestations: gout
(5)
Dx: gout
(5)
primary hyperuricemia secondary hyperuricemia

Gout is for BRATS Bursitis Renal sx (urate stones, urate
nephropathy) Asymptomatic hyperuricemia Tophi Sudden
onset, painful monoarticular arthritis
I SWEAR it's gout serum UA, WBC, ESR, athrocentesis (definitive

diagnosis has negative birefringent crystals), radiographs
!
What are the ARA diagnostic

criteria for rheumatoid arthritis?
(7) How many must be fulfilled
for diagnosis of RA?
!
What joint is classically involved

in gout?
!
Tx (acute): gout (3)

Tx (chronic):
gout (3)
Metatarsophalangeal joint of the first toe (big toe podagra)
NSAIDs Colchicine Corticosteroids
The pt HAD gout, but no longer hydration antihyperuricemic therapy

(allopurinol, febuxostat, probenecid) dietary changes
!
Definition:
chondrocalcinosis
Etiologies (metabolic):
CPPD (3)
calcification of cartilage visible on radiographs, resulting

from CPPD deposition in articular cartilage, fibrocartilage or
menisci
!
3 H's Hemochromatosis Hypothyroidism

Hyperparathyroidism
Clinical manifestations: CPPD (3)
4 criteria must be fulfilled Morning stiffness

Involvemnet of 3+ joints Involvement of hand
joints Symmetric arthritis Presence of
rheumatoid nodules Positive rheumatoid factor
Radiologic changes
Pseudogout Pseudo-RA Premature OA
33!
Terms / Facts
!
Pathogenesis:
CPPD
(1) synovial & joint fluid levels of inorganic pyrophosphate

produced by articular chondrocytes from ATP hydrolysis in response
to various insults or inherited defects favors CPPD crystallogenesis
and deposition in the cartilage matrix (2) Crystals activate cryopyrin
inflammasome IL-1 inflammation
!
Clinical manifestations:
pseudogout
acute mono- or asymmetric oligoarticular

arthritis
!
What joints are affected by pseudogout? (3)

Definition: pseudo-RA
Dx: CPPD (3)
knees wrists MCP joints
chronic polyarticular arthritis w/ morning stiffness +/- RF
arthrocentesis radiographs CMP

!
What are the findings on

athrocentesis w/ CPPD? (2)
!
Tx (acute): CPPD (3)

Clincial manifestations
(MSK): rheumatoid
arthritis (5)
(pulmonary): rheumatoid
arthritis (3)
rhomboid-shaped, weakly positively birefringent

crystals WBC 2000-100,000/mm3, > 50% polys
NSAIDs colchicine corticosteroids
morning stiffness polyarthritis > monoarthtiris joint

deformities (ulnar deviation, swan neck, boutonierre,
cock up toes) C1-C2 instability rheumatoid nodules
ILD (COP, fibrosis, nodules, Caplan's syndrome)
pleural disease (pleuritis, pleural effusions) airway
disease (bronchiolitis, bronchiectasis, cricoarytenoid
arthritis)
! pericarditis myocarditis
Clinical manifestations (cardiac): rheumatoid arthritis
(2)
! glomerulonephritis nephrotic
clinical manifestations (renal): rheumatoid
syndrome
arthritis (2)
clinical manifestations (heme): rheumatoid

arthritis (3)
anemia of chronic disease leukemia

lymphoma
!
clinical manifestations (constitutional): rheumatoid

arthritis (2)
clinical manifestations (ocular): rheumatoid
arthritis (3)
scleritis episcleritis
keratoconjunctivitis sicca
!
What are the major diagnoses that have to be

considered in a nontraumatic swollen joint? (4)
Dx (studies): rheumatoid
arthritis (4)
Tx: rheumatoid
arthritis (3)
fever weight loss

malaise
gout infectious arthritis

osteoarthritis rheumatoid
arthritis
Rheumatoid factor ACPA or anti-CPP ESR and CRP

radiographs of hands and wrists
nonselective NSAIDs glucocorticoids DMARD (disease-
34!
Terms / Facts
modifying anti-rheumatic drugs) w/in 3 mo
!
What laboratory studies are included in the workup of GI

bleeding? (3)
!
Diagnostic study: UGIB

!
Diagnostic study: LGIB
arteriography tagged RBC

scan
octreotide w/ Abx (ceftriaxone/norfloxicin)

prophylaxis
!
Tx (non-pharamcologic): GI varices
!
Tx: Mallory-Weiss tear
endoscopic band ligation (> 90% success)

usually stops spontaneously
!
Tx: bleeding 2/2 esophagitis/gastritis (2)

!
Tx: bleeding 2/2 PUD

Tx: bleeding 2/2 diverticular
disease
Tx: bleeding 2/2
angiodysplasia
!
Definition: Obscure GIB

!
Etiologies: Obscure
GIB (5)
Dx: obscure
GIB (2)
PPI H2RA
PPI + endoscopic therapy
usually stops spontaneously (75%) endoscopic rx if

doesn't stop
usually stops spontaneously Endo Rx if doesn't stop
continued bleeding despite (-) EGD & colonoscopy
Dieulafoy's lesion Small bowel angiodysplasia CRC Crohn's

disease Meckel's diverticulum
repeat EGD w/ push enteroscopy/colonoscopy (perform when bleeding

is active) video capsule Tc-99m pertechnetate scan (meckel's scan)
What is a reliable sign of anemia in the elderly?

Sx: anemia (3)
Signs: anemia (3)
Conjunctival pallor
pallor tachycardia orthostatic hypotension

!
CBC w/ measurement of RBC indices Peripheral

blood smear Reticulocyte count
Clinical manifestations: iron deficiency

anemia (4)
Tx: iron deficiency
anemia
fatigue exertional dyspnea angina (if CAD)
What should initial workup of

anemia consist of? (3)
EGD
First ru/o UGIB then colonoscopy
What studies should be used to assess recurrent or

unstable GI bleeding? (2)
Tx (pharmacologic): GI
varices
Hct/plt PT/PTT
LFTs
angular cheilosis atrophic glossitis pica

koilonychia
oral Fe tid (6 wks to correct anemia, 6 mo to replete Fe

stores)
35!
Terms / Facts
!
Signs: HbH disease (3)

Tx: thalassemias
(3)
severe anemia hemolysis splenomegaly
transfusions + deferoxamine, deferasirox splenectomy HSCT in

children w/ -thal major
!
What are Papenheimer bodies?
Fe-inclusion bodies seen in sideroblastic anemia

!
What is the MCV/RBC in the thalassemias?
MCV/RBC < 13
!
What hemoglobin increases in -thalassemia minor?

!
What are the "warning signs"

of diarrhea? (6)
!
PEx findings: acute

diarrhea (5)
Imaging: acute
diarrhea (2)
!
Ddx: acute
diarrhea (4)
fever significant abd pain blood or pus in stools

severe dehydration > 6 stools/d
vol depletion (VS, UOP, axillae, skin turgor, MS) fever

abd tenderness ileus rash
!
Labs: acute diarrhea (5)
Fecal WBC Stool cx BCx Electrolytes Stoop O&P

CT/KUB if suspected toxic megacolon sig/colo if
immunosupp or cx (-)
Infectious Preformed toxin Med-induced Initial presentation of

chronic diarrhea
!
Tx: acute diarrhea w/ no warning

signs (3)
oral hydration loperamide bismuth

subsalicylate
!
Tx: acute diarrhea w/ moderate

dehydration
50-200 mL/kg/d of oral solution (gatorade,

etc)
!
Prophylaxis: traveler's diarrhea
bismuth or rifaximin
Why should abx therapy be avoided if E. coli O157:H7 is

suspected?
What is the empiric abx treatment for non-hospital acquired

inflammatory diarrhea?
!
Dx: c.difficile-associated diarrhea (2)

Tx: mild c.difficile-associated diarrhea
Tx: severe c.difficile-associated diarrhea

Complications: celiac disease (2)
May increase risk of

HUS
!
FQ x 57d
Stool ELISA Stool cytotoxin assay
Metronidazole 500 mg PO tid x 10-14 d

!
Tx: moderate c.difficile-associated

diarrhea
Tx: whipple's
HbA2
vancomycin 125-500 mg PO qid x 10-14

d
!
vancomycin PO + metronidazole IV
T-cell lymphoma Small bowel adenocarcinoma
PCN + streptomycin of 3rd-gen cephalosporin x 10-14d
36!
Terms / Facts
disease
bactrim for 1+ year

!
What are the lab findings of inflammatory

chronic diarrhea? (4)
+ fecal WBC + lactoferrin +

caloptectin + FOB
!
What lab test does one perform to assess for malabsorption?

Tx: constipation
bulk laxatives osmotic laxatives stimulant laxative
What drug is used for opiod-induced constipation?

!
Dx: constipation
Etiologies (medication): constipation
(5)
Etiologies (obstruction):
constipation (4)
opioids anticholinergics CCB diuretics

NSAIDs
Parkinson's Hirschsprung's Amyloid MS Spinal

injury Autonomic neuropathy
Electrolyte imbalance ( Ca, K, Mg) DM
hypothyroidism uremia pregnancy panhypopit
porphyria
loss of intestinal peristalsis in absence of mechanical

obstruction
acute colonic adynamic ileus in presence of competent

ileocecal valve
intra-abdominal process (surgery, pancreatitis, peritonitis)

severe medical illness intestinal ischemia meds electrolyte
abnl
Precipitants:
adynamic ileus (5)
!
NPO Mobilize decompression erythromycin neostigmine
clinical manifestations: adynamic

ileus (5)
Dx: adynamic ileus
H&P w/ DRE
Definition: Ogilvie's
disease
Methylnaltrexone
The CARS can't move through the bowel cancer anal

stenosis rectocele stricture
Etiologies (metabolic/endo):
constipation (7)
Definition: adynamic
ileus
Etiologies (neurological):
constipation (6)
Tx: adynamic ileus (5)
+ fecal fat
abd. discomfort N/V abd. distention or absent

bowel sounds hiccups
supine & upright KUB vs. CT
Describe the workup algorithm for chronic diarrhea.
Pathophysiology: CHF
Definition: Systolic Heart Failure
Definition: Diastolic Heart Failure
Inability to expel sufficient blood

!
Failure to relax and fill normally
37!
Terms / Facts
Dx: Heart Failure
(6)
CXR BNP Echo PA Catheterization EKG Coronary

angiography
What are the CXR findings

with HF? (4)
Pulm edema Pleural effusions +/- cardiomegaly

Cephalization Kerley B lines
In HF, what findings suggest perfusion to vital

organs? (4)
Echo findings: systolic dysfunction (HF)

!
PA Cath findings: HF (3)

!
Tx: Mild CHF

(NYHA Class I to II)
(3)
Tx: Moderate to Severe CHF

(NYHA Class III to IV) (2)
!
s/s: RHF
(6)
EF chamber size
PCWP CO SVR
Mild restriction of sodium intake (< 4 g/day) Start loop diuretic

if volume overload or pulmonary congestion present ACE
inhibitor as first-line
Tx: Mild to Moderate CHF (NYHA

Class II to III) (2)
Signs: Heart
Failure (5)
BUN Cr serum Na
Abnormal LFTs
Start loop diuretic and an ACE inhibitor Add

-blocker if moderate disease
Add Digoxin (to loop diuretic and ACE inhibitor)

Add spironolactone if still symptomatic
Displaced PMI pathologic S3 pathologic S4 rales/crackles

dullness to percussion
Peripheral pitting edema Nocturia JVD Hepatomegaly Ascites RV heave

!
What is the initial test of choice for CHF workup?

What BNP level is strongly associated with the presence of
decompensated CHF?
What EF level is the cutoff for systolic dysfunction?
What was the major finding of
the RALES trial?
What did the COMET

trial find?
BNP > 100

pg/ml
EF < 40%
Diuretic + ACE
inhibitor
ACE inhibitors reduce mortality, prolong

survival and alleviate sx in CHF
Carvedilol led to significant improvement in survival

compared to metoprolol in HF
What are the indications for digoxin in HF?

(3)
EF < 30% Severe CHF Severe a-fib
What is the overall 5-year mortality for all patients with CHF?
Spironolacton reduces morbidity and mortality in

patients with class III/IV HF
What should be the initial treatment in most symptomatic

patients with HF?
What did the CONSENSUS and
SOLVD studies find?
Echocardiogram
50%
38!
Terms / Facts
What is the 6040-20 rule?
Total body water = 60% of body weight ICF = 40% of body weight
(2/3 TBW) ECF = 20% of body weight (1/3 TBW)
!
What percentage of ECF is interstitial fluid?

!
What fraction of ECF is plasma?

!
What is the normal output range of urine/day?

!
Definition:
Syncope
Vasovagal syncope
sympathetic tone vigorous contraction of LV

mechanoreceptors in LV trigger vagal tone (hyperactive
Bezold-Jarisch reflex) HR and/or BP
Pathophysiology:
vasovagal syncope
What study can reproduce the symptoms of vasovagal syncope?

!
What are the premonitory sx of vasovagal

syncope? (4)
!
Tx: vasovagal syncope (4)
Tilt-table study
Pallor Diaphoresis Lightheadedness

N/V
emotional stress pain fear extreme fatigue
Hypovolemia Diuretics Vasodilators Autonomic neuropathy

(DM, PD, Shy-Drager, Lewy Body Dementia, Amyloidosis)
Tx: syncope 2/2 orthostatic hypotension

What is a common cerebrovascular cause of
syncope?
!
What is the main goal of

diagnosis of syncope?
!
!
increase sodium intake and fluids

TIA involving the vertebrobasilar
circulation
Differentiate between cardiac and noncardiac etiologies

because prognosis is poorest for those with underlying
heart disease
H&P EKG (all patients) Tilt-table testing Echocardiogram (if there is

evidence of structural heart disease or abnormal EKG)
How long does one treat nosocomial pneumonia?

Definition: hospital-acquired
pneumonia
midodrine fludrocortisone disopyramide SSRI
Precipitants: vasovagal syncope (4)
800 to 1500 mL
Arrhythmias (SSS, VT, AV block, RSVT) Obstruction of

flow (AS, hypertrophic CMP, pulmonary HTN, etc.)
Massive MI
What is the most common cause of syncope?
Dx:
syncope
1/3 ECF
transient loss of consciousness/postural tone 2/2 acute decrease in

cerebral blood flow
Etiologies
(cardiogenic): syncope
(3)
Etiologies: orthostatic
hypotension (4)
2/3 ECF
8 days
pneumonia acquiried withing 3 months of a

hospital admission
39!
Terms / Facts
!
What are premature atrial

complexes?
!
Etiologies: premature atrial

complexes (5)
Definition: premature
ventricular complex
Adrenergic excess EtOH/tobacco Electrolyte

imbalances Ischemia infection
!
EKG finding: premture atrial

complexes
Early beats arising within the atria, firing on its

own
early P waves that differ in morphology from the

normal sinus P wave
early beat that fires on its own from a focus in the

ventricle and then spreads to the other ventricle
EKG finding: premature ventricular complexes

Patients with frequent, repetitive
PVCs and underlying heart disease
are at increased risk for [...]
Definition: atrial
fibrillation
Patients with frequent, repetitive PVCs and

underlying heart disease are at increased risk
for SCD due to cardiac arrhythmia
paroxysmal (self-terminating) vs. persistent (sustained > 7 d)

vs. permanent (typically > 1 y when cardioversion has failed)
Valvular vs. nonvalvular Lone AF
!
Etiologies (cardiac): atrial

fibrillation (5)
CHF myo/pericarditis ischemia/MI hypertensive

crisis cardiac surgery
!
Etiologies (pulmonary): atrial

fibrillation (2)
!
Etiologies (metabolic): atrial

fibrillation (2)
Etiologies (drugs): atrial

fibrillation (5)
Pathophysiology: atrial
fibrillation (3)
!
acute pulmonary disease (COPD flare,

pneumonia) PE
high catecholamine states (stress, infection, postop,

pheo), thyrotoxicosis
alcohol (holiday heart) cocaine amphetamines
theophylline caffeine
Etiologies (neurogenic): atrial fibrillation

(2)
subarachnoid hemorrhage ischemic

stroke
Ectopic foci chaotic, uncoordinated beating loss of

atrial contraction HF; LA stasis thromboemboli;
tachycardia CMP
fatigue exertional dyspnea palpitations dizziness angina
syncope
!
Dx: atrial fibrillation

EKG findings: atrial fibrillation
wide QRS complexes
chaotic, uncordinated firing of multi foci of automaticity in the

atria leading to rapid ventricular beating
Classification: atrial
fibrillation (6)
Sx: atrial fibrillation

(6)
EKG
irregularly irregular rhythm
40!
Terms / Facts
!
Tx: acute atrial fibrillation in a

hemodynamically unstable patient
Rate control anticoagulation

cardioversion
What are the general treatment goals of

atrial fibrillation? (3)
immediate electrical cardioversion

to sinus rhythm
What is the target rate for rate control in a-fib?
60 to 100 bpm
! CCBs (preferred) Beta-blockers (alternative)

What drugs are used to
Digoxin/amiodarone (LV systolic dysfunction)
achieve rate control in AFib?
(3)
! Electrical (preferred) Pharmacological
How is cardioversion achieved in afib tx?
(2)
! Ibutilide Procainamide Flecainide
What drugs can be used for pharmacological
Sotalol Amiodarone
cardioversion in AFib? (5)
If a patient has been in

AFib > 48 hrs, how
should one treat?
Obtain TEE to image left atrium. If no thrombus is present,

start IV heparin and perform cardioversion within 24 hours.
Anticoagulation required for 4 weeks after cardioversion
!
What drugs are used for rate control with chronic AFib? (2)
!
Tx: chronic AFib
chronic anticoagulation (warfarin(

!
Which leads are the inferior leads? (3)

!
Which leads are left lateral? (4)
Leads I and AVL, V5, V6

!
Angle of Lead II?
60
Angle of Lead III?
120
!
Angle of Lead AVF?

Angle of Lead I?
Angle of Lead AVL?
-30
!
!
Which precordial leads overlie the interventricular septum?
What causes the Q wave?

!
Leads V1 and V2
Leads V5 and V6
!
Leads V3 and V4
!
Which leads are the anterior group?
-150
Which precordial leads lie over the right ventricle?

Which precordial leads overlie the left ventricle?
90
Angle of Lead AVR?
What is R-wave
Beta blocker CCB
V1-V4
Septal depolarization
pattern of progressively increasing R-wave amplitude moving
41!
Terms / Facts
progression?
right to left in the precordial leads is called R-wave progression
What does the QT interval

encompass?
time from the beginning of ventricular depolarization to

the end of ventricular repolarization
!
The duration of the QT interval is

proportionate to the [...]
!
What are the five basic

types of arrhythmias?
Arrhythmias of sinus origin Ectopic rhythms Reentrant

arrhythmias Conduction blocks Preecitation syndromes
!
What is sinus arrest?

!
What is asystole?
The duration of the QT interval is

proportionate to the heart rate
Sinus node stops firing
Prolonged electrical inactivity

!
What is the intrinsic rate of atrial pacemakers?

What is the intrinsic rate of junctional pacemakers?
What is the intrinsic rate of ventricular pacemakers?
!
What is the intrinsic rate of the SA node?

!
What does a junctional escape look like on

EKG?
!
What does a wide QRS

usually imply?
40-60 bpm
30-45 bpm
60-100 bpm
Origin of ventricular depolarization is within the

ventricles themselves
!
From AV node or ventricles;

from below atria
Are normal P waves present? Are the QRS complexes

narrow or wide? What is the relationship between P waves
and QRS complexes? Is the rhythm regular or irregular?
What are the five types of

sustained supraventricular
arrhythmias?
Paroxysmal superventricular tachycardia (PSVT)

Atrial flutter Atrial fibrillation Multifocal atrial
tachycardia Paroxysmal atrial tachycardia
What is the most common mechanism

driving PSVT?
Reentrant circuit looping within the

AV node
What is the appearance of atrial flutter on EKG?

What is the usual mechanism of
atrial flutter?
What is the appearance of atrial !
Saw-toothed pattern
reentrant circuit that runs largely around the

annulus of the tricuspid valve
What ratio AV block is common with atrial flutter?
P wave inversion in leads II and

AVR
If no p waves are present, what does that say about

the origin of an arrhythmia?
What four questions
should one ask to assess
rhythm?
60-75 bpm
2:1 block
Irregularly irregular appearance of QRS
42!
Terms / Facts
fibrillation on EKG?
complexes in the absence of discrete p waves

!
Thrombolytic therapy within what time frame gives

the best results in acute MI?
!
Indications:
thrombolytic therapy
(MI)
first 6 hours, but up to 24 hrs

from onset of pain
ST elevation in two contiguous EKG leads in patients with

onset within 6 hours who have been refractory to
nitroglycerin
What is the first line thrombolytic medication in most medical centers?

!
What did the PAMI trial show?
PTCA reduces mortality more than t-PA
What are the only agents shown to reduce

mortality in MI? (3)
!
Severe headache Visual disturbances

Altered mentation
reduce MAP by 25% in 1 to 2 hrs If severe (diastolic > 130) or if

HTN encephalopathy is present, lower BP with IV agents
(nitroprusside/labetalol)
Tx: hypertensive urgencies

What are the effects of
metabolic acidosis? (5)
Elevated BP levels alone without end-organ

damage
Step 1: lower BP with antihypertensive agent Step 2:

order CT scan of the head to r/o intracranial bleeding
Step 3: If CT negative, proceed to LP
Clinical presentation: hypertensive

emergency (3)
Tx: hypertensive
emergencies (2)
Maintenance therapy; reduce risk of further

coronary events
Noncompliance with antihypertensive tx/dialysis Cushing's

syndrome Drugs (cocaine, LSD, methamphetamines)
Hyperalodosteronism Eclampsia Vasculitis Pheochromocytoma
Approach to a patient with

severe headache and
markedly elevated BP? (3)
Aspirin Beta-blocker ACE

inhibitors
BP > 220 and/or diastolic BP > 120 in addition to

end-organ damage
!
Definition: Hypertensive
urgency
Etiologies:
Hypertensive
emergency (7)
Oxygen Nitroglycerin Beta-blocker Aspirin Morphine

ACE inhibitor IV heparin
How do statins figure into the

therapy of MI? Why?
emergency
t-PA
Trauma (head or traumatic CPR) Recent invasive

procedure/surgery Acute PUD Previous stroke
Uncontrolled HTN (>180/110) Dissecting aortic
aneurysm
Contraindications:
thrombolytic therapy (MI)
(6)
Tx (acute): myocardial
infarction (7)
BP should be lowered within 24 hours using oral agents

!
CNS depression Pulmonary Blood Flow Arrhythmias
43!
Terms / Facts
Impared myocardial function Hyperkalemia
What are the effects of alkalosis?
(3)
Definition: anion gap
cerebral blood flow arrhythmias

tetany/seizures
AG (mEq/L) = [Na+] - ([Cl-]+[HCO3-])

!
What is the normal range for angion gap?

!
Give the five

step analysis of
acid-base
disorders.
8 to 15 mEq/L
Step 1: Acidemia (pH < 7.38) or alkalemia (pH>7.42) Step 2:

Primary or metabolic disturbance (Look at PCO2 on ABG or HCO3
on metabolic panel) Step 3: Is there appropriate compensation? Step
4: Is there anion gap metabolic acidosis? Step 5: If there is
metabolic acidosis, is there another concomitant metabolic
disturbance?
How does one determine if there is acidemia

or alkalemia?
Look at pH. < 7.38 = acidemia > 7.42

=alkalemia
How does one determine if an acid-base

disturbance is primary respiratory or metabolic?
Look at HCO3 or PCO2 on

Chem 7 or ABG respectively
! PCO2 = [1.5x(serum
What formula is used to determine if appropriate
HCO3)] +8 (+/-2)
compensation has occured with primary metbaolic
acidosis?
! Metabolic acidosis
With what acid-base disorder does Kussmaul breathing
occcur?
! Decreased CO and tissue perfusion by diminishing the
How does acidosis affect
responsiveness of the myocardium to catecholamines
cardiac output? Explain.
What equation gives the compensation for acute

respiratory acidosis?
What equation gives the compensation for acute
respiratory alkalosis?
What equation gives the compensation for chronic
respiratory acidosis?
What equation gives the compensation for chronic
respiratory alkalosis?
PaCO2 = 0.75 x
HCO3
What equation gives the predicted respiratory compensation

for a metabolic alkalosis?
!
HCO3= 0.1 x
PaCO2
HCO3 = 0.2 x
PaCO2
HCO3 = 0.4 x
PaCO2
HCO3 = 0.4 x
PaCO2
If PaCO2 is too low by prediction, what other acid-base disorder is

concomitantly occurring?
If PaCO2 is too high by prediction, what other acid-base disorder is
1 resp.
alkalosis
1 resp.
acidosis
44!
Terms / Facts
If HCO3 is too low by prediction, what other acid-base disorder is
If HCO3 is too high by prediction, what other acid-base disorder is
1 met.
acidosis
1 met.
alkalosis
One irritable automaticity focus in the atria fires at about 250

to 350 bpm, giving rise to regular atrial contractions;
ventricular rate is one-half to one-third of atrial rate because
only every two or three flutter waves conduct to the ventricles
COPD (most common) Heart disease: RHD, CAD, CHF

Atrial Septal Disease
Patholophysiology:
atrial flutter
Etiologies: atrial
flutter (3)
EKG findings: atrial

flutter
EKG: saw-tooth baselines with QRS every second or third

wave
!
Tx: atrial flutter
similar to AFib
Patients with what other disease usually display

multifocal atrial tachycardia?
Severe pulmonary disease

(COPD)
! Paroxysmal SVT
What is the most common cause of supraventricular
tachyarrhythmia?
! All automaticity foci pace with a regular
All automaticity foci pace with a
rhythm
regular [...]
Definition: sinus
arrhythmia
normal (but minimal) increase in HR during inspiration and

minimal decrease in HR during expiration
!
Where are the automaticity foci in

the AV node?
Which bundle branch depolarizes the
interventricular septum? Why?
!
What does a U wave

represent?
!
Definition: overdrive
suppression
Distal (junctional). No automaticity foci in the

proximal AV node
!
Final phase of Purkinje repolarization following a T

wave
The mechanism whereby the automaticity focus with the

highest pacing rate suppresses all slower automaticity foci in
the heart
!
Rhythms that lack a constant duration

between paced cycles are said to be [...]
What does it mean for an
automaticity focus to be
parasystolic? Explain.
Definition: wandering !
Left bundle branch; has terminal fibers in

the septum. Right bundle branch does not.
Rhythms that lack a constant duration

between paced cycles are said to be
irregular
The focus paces but can't be overdrive

suppressed because of an entrance block (due to
a structural pathology or hypoxia)
Irregular rhythm produced by the pacemaker activity
45!
Terms / Facts
pacemaker
wandering from the SA node to nearby atrial automaticity foci

!
What does the P' wave

represent?
Atrial depolarization by an automaticity focus as opposed to

the normal Sinus-paced P waves
!
What is the HR of wandering pacemaker?

!
Describe the ventricular rhythm of a wandering

pacemaker?
!
Why does multifocal atrial

tachycardia occur?
What kind of waveform can't be discerned

in AFib?
!
Definition: escape
beat
Irregular ventricular
rhythm
Atrial automaticity foci are damaged, showing early

signs of parasystole resistance to overdrive
suppression
!
Describe the ventricular rhythm of MAT.
Definition: escape
rhythm
Irregular ventricular rhythm
No discernbible P' waves; chaotic atrial

spikes
An automaticity focus escapes overdrive suppression to pace

at its inherent rate
An automaticity focus transienty escapes overdrive suppression
to emit one beat
!
Definition: sinus arrest
Very sick SA node ceases pacemaking completly

!
Definition: idiojunctional
rhythm
Heart rhythm determined by the pacing of the junctional

automaticity foci
What abnormality in the SA node gives rise to en escape rhythm?

What abnormality in the SA node gives rise to en escape beat?
What automaticity focus can produce retrograde atrial
depolarization?
EKG finding: retrograde atrial depolarization
!
What conditions can give

rise to a ventricular escape
rhythm? (2)
!
Definition: StokesAdams syndrome

Explain how ventricular
escape beats happen most
commonly.
< 100 bpm
!
!
Sinus arrest
Sinus block
Junctional automaticity
focus
inverted p' wave with upright QRS
(1) Complete conduction block high in the ventricular

conduction system (2) Total failure of SA node and all
automamticity foci above the ventricles
When pacing from a ventricular focus is so slow that blood

flow to the brain is significantly reduced to the point of
syncope
!
Burst of cardiac parasympathetic innervation depresses

the SA node, atrial and junctional foci but not the
ventricular foci, leading to a ventricular escape beat
46!
Terms / Facts
Definition: premature beat
an irritable focus spontaneously fires a single stimulus
! Ventricular automaticity foci

Which automaticity foci are most sensitive to O2
status?
! Digitalis Adrenergic excess/sympathetic stimulation
What are the causes of atrial
Stimulants (caffeine, cocaine, amphetamines)
and junctional foci
Hyperthyroidism Stretch
irrititability? (5)
What is the effect of a premature stimulus on the other

automaticity centers?
Explain the mechanism of a
premature atrial beat with
aberrant ventricular
conduction.
Premature P' with no QRS response followed

by reset sinus rhythm
Coupling of a PAB to end of each normal cycle

!
Definition: atrial trigeminy
When a PAB fires after two normal cycles
With a junctional escape rhythm with no retrograde atrial

depolarization, what does the EKG look like?
Definition:
premature
junctional beat
Definition: junctional
bigeminy
Definition: junctional
trigeminy
Lone QRS complexes

without P waves
When a premature junctional beat is coupled to a normal

(SA-node generated) cycle
When a premature junctional beat is coupled with two
consecutive normal cycles
Definition: premature
ventricular contraction
Why is the QRS of a PVC

wider than a normal QRS?
Low O2 Low K+ Structural pathology (MP,

myocarditis, stretch)
Premature ventricular beat produced by an irritable

ventricular automaticity focus
(1) Great width and enormous amplitude QRS

complex early in cycle (2) QRS opposite polarity of
the normal QRS
The wave of depolarization originating in the left

ventricle spreads unopposed to the right ventricle
EKG finding: premature

ventricular contraction (2)
Irrititable junctional focus within the AV node fires suddently,

conducting a premature stimulus to the ventricles, and
sometimes, retrograde to the atria
What are the causes of ventricular

focus irritability? (3)
What EKG
!
feature follows the
PVC? Why?
Resets the automaticity

center
Premature atrial impulse reaches one of the bundle

branches while it is still refractory (and the other is
not). This causes asynchronous depolarization of the
ventricles, leading to a widened QRS
EKG finding: non-conducted

premature atrial beat
Definition: atrial begeminy
Compensatory pause; the PVC doesn't depolarize the SA so the

SA discharges on schedule, but the ventricles are refractory and
47!
Terms / Facts
the SA-generated impulse can't progress
!
What number of PVC's is considered pathological?

!
Definition: ventricular bigeminy

!
Definition: ventricular trigeminy

Definition:
ventricular
parasystole
adrenal insufficiency (8)
!
PVC coupled to a normal beat

PVC coupled to two normal cycles
Ventricular automaticity focus that suffers from entrance block

and is not vulnerable to overdrive suppression; paces at its
inherent rate in the background of dominant sinus rhythm
!
Etiologies:
primary adrenal
insufficiency (4)
Weakness Weight loss Hyperpigmentation Hyponatremia

Anorexia Nausea Orthostatic hypotension Abdominal
pain
Idiopathic (autoimmune) Infectious

(tuberculosis/fungal/cryptococcus/toxoplasmosis) Iatrogenic
(bilateral adrenalectomy) Metastatic disease
Etiologies: secondary adrenal insufficiency

(2)
long-term steroid therapy

hypopituitarism
!
Etiologies: Tertiary adrenal insufficiency

Dx: adrenal
insufficiency (3)
hypothalamic disease
cortisol levels (am) cosyntropin stimulation test MRI if

secondary/tertiary suspected
What is the normal repsonse to a cosyntropin stimulation

test?
!
Tx (acute): adrenal
insufficiency
Tx (chronic): adrenal
insufficiency (2)
6 PVC's per minute
18 ug/ml within 60
mins
volume resusication w/ normal saline +

hydrocortisone IV
Hydrocortisone or prednisone Fludrocortisone (not

needed in secondary insufficiency)
Why is hyponatremia seen in primary

adrenal insufficiency?
Why is hyponatremia seen in
secondary adrenal insufficiency?
Mineralcorticoids are decreased as well as

glucocorticoids
Aldosterone is normal but decreased cortisol

removes suppresion on ADH SIADH
!
Give the stepwise workup of adrenal insufficiency.

!
In lead V1, what is the polarity of the QRS complex normally?
In lead V6, what is the polarity of the QRS complex normally?

Over what part of the heart do leads V3 and V4 lie?
Negative
Positive
Septum
48!
Terms / Facts
!
What condition produces multifocal PVCs?

!
What is the R on T
phenomenon?
Severe cardiac hypoxia
When a PVC falls on a T wave; vulnerable period.

Dangerous arrhythmias may result.
!
Paroxysmal atrial tachyarrhythmia

is usually a sign of [...]
!
EKG findings: PAT with block
two p' waves for each QRS response on EKG
Definition: paroxysmal atrial

tachycardia
Paroxysmal atrial tachyarrhythmia is usually a

sign of digitalis excess or toxicity
sudden, rapid firing of a very irritable atrial

automaticity focus
!
Rate: paroxysmal atrial tachycardia

!
Definition: paroxysmal
junctional tachycardia
tachyarrhythmia caused by the sudden rapid pacing of a

very irritable automaticity focus in the AV junction
EKG findings: paroxysmal junctional

tachycardia (PJT)
QRS complexes with either (1) no p' wave

or (2) retrograde p waves
!
Definition: supraventricular tachycardia

!
Definition: paroxysmal
ventricular tachycardia
What is a capture
beat on the EKG of
VT?
either PAT or PJT
tachyarrhythmia produced by a very irritable

ventricular automaticity focus
!
Rate: VTach
What is a fusion beat on
the EKG of VT?
150-250 bpm
150-250 bpm
When a sinus pased depolarization stimulus meets a

depolarization progressing from a ventricular focus
A normal appearing QRS in the midst of ventricular tachycardia

produced by a sinus-paced depolarization that is able to pass
normally through the AV node
Ventricular tachycardia often

indicates [...]
Ventricular tachycardia often indicates coronary

insufficiency
!
What width range do QRS complexes in VT fall in?

Definition: torsades de
pointes
form of very rapid VT caused by low K+, meds that block

K+ channels or Long QT syndrome
!
Rate: torsades de pointes

Rate: atrial flutter
250 to 350 bpm
250 to 350 bpm

!
EKG findings: ventricular flutter

Rate: ventricular flutter
0.14 sec or greater
Sine wave pattern

250-350 bpm
49!
Terms / Facts
!
What is
fibrillation?
totally erratic rhythm caused by continuous, rapid rate discharges

from numerous automaticity foci in either the atria or in the
ventricles
Why do atrial foci all pace at once in AFib?

!
What causes
ventricular
fibrillation?
The irritable atrial foci are parasystolic
Rapid-rate discharges from many irritable, parasystolic

ventricular automaticity foci, producing an erratic, rapid
twitching of the ventricles
!
EKG findings: ventricular

fibrillation
totally erratic appearance and lack of any identifiable

waves on EKG
!
What does ventricular flutter usually evolve into?

!
Rate: ventricular fibrillation

!
Rate: atrial fibrillation

!
Ventricular fibrillation is a type of

cardiac [...]
!
Delta wave
(1) rapid conduction: SVTs may be rapidly

conducted 1:1 through accesory pathway (2)some
Kent bundles may have automaticity foci that can
initiate a paroxysmal tachycardia (3) re-entry
through Kent bundle (circus re-entry loop)
Give the mechanisms by which

Wolff-Parkinson-White
syndrome can produce a
paroxysmal tachycardia.(3)
AV node is bypassed by an extension of the anterior internodal

tract (James); with no conduction delay, the James bundle can
conduct atrial depolarizations directly to the His Bundle without
delay, which can cause rapid ventricular arrhythmias
!
EKG findings: Lown-GanongLevine syndrome (3)
Definition: First degree AV

block
Definition: second degree AV
block
Definition: third degree AV
block
Shortened PR interval (<0.12 s) QRS complex is

not widened No delta waves
!
EKG findings: sinus block
350-450 bpm
Ventricular fibrillation is a type of cardiac

arrest
EKG findings: Wolff-Parkinson-White syndrome
Mechanism: LownGanong-Levine
Syndrome
350-450 bpm
a cardiac arrest situation in which a heart rhythm is observed

on the electrocardiogram that should be producing a pulse, but
is not.
Definition: pulseless
electrical activity
Ventricular fibrillation
Missed cycle (with no p wave)
Lengthens delay between atrial and ventricular

depolarizations
Intermittent block between atrial and ventricular

depolarizations
Complete block of conduction of atrial stimuli to the
50!
Terms / Facts
ventricles
!
What is the normal duration of the PR interval?

!
EKG finding: 1st degree

AV block
PR interval > 0.2 s consistently, and P-QRS-T is normal

in every cycle
Wenckebach blocks correspond to what part of the conduction system?

!
Mobitz blocks correspond to what part of the

conducting system?
!
What happens in a
Mobitz AV block?
What is the
CHADS2 score?
His Bundle and Bundle

Branches
Successively proloned PR intervals followed by a

completely dropped QRS
Clinical prediction rule for estimating the risk of stroke in

patients with non-rheumatic atrial fibrillation
!
CHF = 1 Hypertension =1 Age > 75 years=1 Diabetes

Mellitus=1 Stroke (prior) or TIA=2
Give the risk stratification designations for

CHADS2 scores and the corresponding
anticoagulation therapy
!
Tx: Wolff-Parkinson-White
Syndrome
What types of drugs should
one avoid in WFW?
!
0 = low risk = none or aspirin 1 =

moderate = aspirin or warfarin 2+ =
moderate or high = warfarin
Radiofrequency ablation of one arm of reentrant

loop
Drugs active on the AV node (digoxin) because they

accelerate conduction through the accessory pathway
CAD with prior MI (most common) Hypotension Active

ischemia Prolonged QT syndrome Cardiomyopathies
Congenital defects Drug toxicity
!
What is the most common cause of cardiac arrest?

!
Definition: sustained VT
!
Why should patients with nonsustained

VT have a through cardiac workup?
Clinical presentation: ventricular
AV node
(1) Initial dose of prednisone 40-60 mg (2) Taper down to 10

mg/day over by 10% decrements every 1-2 weeks (3) Slow taper
in 1 mg decrements over 9 months to 1 year (4) Low dose aspiring
What are the criteria in the

CHADS2 score?
Etiologies:
Ventricular
tachycardia (7)
Total block of several (2 or more) pace atrial depolarizations

(P waves) before conduction to the ventricles is successful
What happens in a
Wenckebach block?
Tx: temporal
(giant cell)
arteritis (4)
< 0.2 s
VFib/VT
VT > 30 s
VT is an independent risk factor for sudden

death when CAD and LV dysfunction are
present
Palpitations Angina Lightheadedness Impaired
51!
Terms / Facts
tachycardia (5)
consciousness Dyspnea
!
Physical exam: ventricular

tachycardia (2)
!
Tx: sustained VT in
hemodynamically stable patient
(SBP > 90)
!
Tx: sustained VT in
hemodynamically unstable
patient (3)
Tx:
nonsustained
VT
Pharmacological cardioversion w/ IV
amiodarone, IV procainamide, or IV sotalol IDC
placement
Immediate synchronous DC cardioversion Follow
with IV amiodarone to maintain sinus rhythm IDC
placement
No treatment if no underlying heart disease If underlying cardiac

disease, order an echo; if inducible, sustained VT found, ICD
placement recommended
!
What are the causes

of prolonged QT?
Cannon a waves in the neck S1 that varies in

intensity
QT: Prolonged QT syndrome W: WPW I: Infarction D: Drugs

T: Torsades H: Hypokalemia, hypocalcemia,
hypomagnesemia
!
What do the QRS complexes in a bundle branch block

look like?
!
Explain the appearance of the

wide QRS complex in a bundle
branch block EKG.
Wide QRS with R and

R'
Non-simulataneous depolarization of the right

and left ventricles due to the slow conduction
down one blocked bundle branch
!
How wide should a QRS be in order to diagnose BBB?

In what leads should one look for a RBBB?
In what leads should one look for a LBBB?
!
What does an inverted T wave indicate?
3 squares (> 0.12 s)

!
V1-V2
V5-V6
Area of ischemia
!
In what leads should one look for an inverted T wave?

What does ST-segment elevation signify?
!
EKG findings: Brugada syndrome

EKG findings: pericarditis (2)
That the myocardial infarction is acute
RBBB pattern QRS w/ ST elevation in V1-V3
ST segment elevation T wave elevation (sometimes)

!
What drug can cause ST segment depression?

!
What do significant Q waves signify?

How wide and tall are significant Q
aves?
V1-V6
Digitalis
Necrosis due to MI
1 small square wide or 1/3 of QRS

amplitude
52!
Terms / Facts
!
Explain how Q waves are formed

in the setting of MI.
Positive electrode sees through the necrotic void

and produces negative deflection
What is the recurrence rate of VFib that is not associated with ! 30% within 1 year
MI?
! Ischemic heart disease (most common) Antiarrhythmic drugs
Etiologies:
(prolonged QT) AFib with rapid ventricular rate in WFW
VFib (3)
!
VFib (2)
Tx: VFib
Cannot measure BP; absent heart sounds and pulse

Patient is unconscious
Immediate defibrillation and CPR
If VFib persists despite defribillation, what

pharmacological interventions are called
for? (2)
Definition: Sinus bradycardia

!
Etiologies: sinus bradycardia

(3)
Definition: sick sinus
syndrome
Sinus node dysfunction characterized by persistent

spontaneous sinus bradycardia
Tx: sick sinus syndrome

Tx: Mobitz type II block
Dizziness Confusion Fatigue CHF
Pacemaker implantation
Pacemaker implantation
!
Tx: 3rd-degree heart block

!
Sinus rate < 60 bpm
ischemia increased vagal tone antiarrhythmic drugs
Clinical presentation: sick sinus syndrome (4)
Tx: Dilated
Cardiomyopathy (3)
Epinephrine (1 mg IV bolus and then

every 3 to 5 mins) IV amiodarone
followed by shock
pacemaker implantation
Digoxin, diuretics, vasodilators and cardiac transplantation

Remove offending agent if possible Anticoagulation
Clinical presentation: hypertrophic cardiomyopathy

(3)
!
Physical exam: hypertrophic

cardiomyopathy (4)
Etiologies: restrictive
cardiomyopathy (6)
restrictive cardiomyopathy
Dyspnea Angina
Arrhythmias
Sustained PMI Loud S4 Systolic ejection murmur

Rapidly increasing carotid pulse with two upstrokes
Dx: hypertrophic cardiomyopathy (3)

Tx: hypertrophic
cardiomyopathy (4)
CXR Echo EKG
-blockers CCBs Treat AFib if present

Myomectomy (90% cure rate)
idiopathic scleroderma carcinoid syndrome
amyloidosis sarcoidosis hemochromatosis
right sided>left sided heart failure w/ peripheral edema
diuretic refractoriness thromboembolic events poorly
53!
Terms / Facts
(4)
tolerated tachyarrhythmias
!
JVP +/- Kussmaul's sign S3/S4 Congestive

hepatomegaly +/- ascites and jaundice
Treat underlying disease Gentle diuresis

Anticoagulation
Physical exam: restrictive

cardiomyopathy (3)
Tx: restrictive cardiomyopathy
(3)
Why shouldn't digoxin be given to someone with

amyloidosis
!
Etiologies: acute
pericarditis (5)
Infectious Neoplastic (metastatic cancer) Autoimmune (SLE,

RA, scleroderma, drug induced lupus) Uremia Dressler's
syndrome
!
Clinical presentation: acute

pericarditis (3)
Physical exam: acute
pericarditis
Chest pain (pleuritic, positional) Fever

Pericardial effusions
pericardial friction rub best heard at LLSB w/ diaphragm

[sound:rub2.mp3]
!
EKG findings: acute pericarditis
Diffuse ST elevation and PR depression

!
Dx: acute pericarditis (3)

!
Tx: acute pericarditis (2)
EKG CXR Echo
NSAIDs +/- colchicine glucocorticoids

!
Clinical presentation: constrictive pericarditis

!
Physical exam: constrictive

pericarditis (5)
What should cardiac catheterization show

in constrictive pericarditis? (2)
!
EKG findings: constrictive

pericarditis (2)
Tx: constrictive
pericarditis
Physical exam: pericardial
effusion (4)
EKG CXR Echo Cardiac cath

!
Elevated and equal diastolic pressures

in all chambers square root sign
Low QRS voltages Generalized T wave

flattening or invesion
Complete resection of the pericardium is definitive

therapy
!
Muffled heart sounds Soft PMI Dullness at left lung

base Pericardial fricction rub
!
Echocardiogram CXR
What is the imaging study of choice for pericardial effusion?
RHF > LHF
JVD Kussmaul's sign Pericardial knock Ascites

dependent edema
Dx: constrictive pericarditis (4)
Dx: pericardial effusion
Can precipitate
arrhythmias
Echocardiogram
54!
Terms / Facts
!
EKG findings: pericardial effusion (2)

!
Tx: pericardial
effusion (2)
!
pericardiocentesis (if cardiac tamponade suspected)

observation (if minor)
penetrating trauma to the thorax iatrogenic (central line,
pacemaker, pericardiocentesis( pericarditis post-MI with free
wall rupture
Etiologies: cardiac
tamponade (4)
Physical exam: cardiac

tamponade
Elevated JVP most common finding Narrowed pulse

pressure Pulsus paradoxus
!
Clinical presentation: cardiac

tamponade (2)
!
Dx: cardiac tamponade (4)

Tx: cardiac
tamponade (2)
Echocardiogram CXR EKG Cardiac cath
Rheumatic heart disease Mitral annular calcification
Clinical manifestations: mitral stenosis (3)

!
Etiologies: demand
ischemia (6)
Coronary artery spasm Coronary embolism Anemia

Arrhythmias Hyper/hypotension
!
Etiologies: hospital-acquired
pneumonia
Sx: "typical"
pneumonia (4)
S. pneumoniae H. flu Klebsiella and other

GNR S. aureus
GNR bugs including pseudomonas, klebsiella, e.coli,

enterobacter MRSA
acute onset fever cough w/ purulent sputum dyspnea

pleuritis chest pain
!
"atypical" pneumonia (4)
Physical exam: "typical"
Dyspnea Pulmonary edema AFib
mismatch between myocardial oxygen demand and

supply
Etiologies: community acquired

pneumonia (6)
Definition: COPD
exaccerbation (GOLD
criteria)
Loud S1 Opening snap following S2 Low-pitched middiastolic rumble at apex [sound:ms.mp3]
Definition: demand
ischemia
cardiogenic shock w/o pulmonary edema

dyspnea
pericardiocentesis (nonhemorrhagic) emergent surgery w/

pericardiocentesis as temporizing measure (hemorrhagic)
Etiologies: mitral stenosis (2)
Physical exam:
mitral stenosis
Low QRS voltages T wave flattening
insidious onset dry cough extrapulm sx (N/V, diarrhea,

headache, myalgias, sore throat) patchy interstitial
pattern on CXR
Cough increases in frequency and severity Sputum
production increases in volume and/or changes
character Dyspnea increases
!
Tachycardia/tachypnea Late inspiratory crackles
55!
Terms / Facts
community-acquired
pneumonia (4)
Pleurla friction rub Dullness to percussion

!
CXR: community acquired pneumonia

!
What is the classic clinical

presentation of atypical pneumonia?
!
Physical exam: atypical

pneumonia (4)
CXR: atypical pneumonia
(2)
!
Sore throat and headache followed by a

nonproductive cough and dyspnea
Mycoplasma pneumoniae C. pneumoniae C. psittaci Coxiella

burnetti Legionella spp. Viruses (influenza, adenoviruses, RSV,
parainfluenza)
Etiologies: atypical
pneumonia (6)
Dx: pneumonia
(4)
Pulse-temperature dissociation (normal pulse in the setting

of high fever) Wheezing Rhonchi Crackles
!
diffuse reticulonodular infiltrates absent/minimal

consolidation
sputum gram stain sputum bacterial culture blood cultures (before

abx) CXR
Tx (empiric): communityacquired pneumonia,

hospitalized (2)
Tx (empiric): communityacquired pneumonia,

outpatient (2)
3rd-generation cephalosporin (ceftriaxone) + macrolide

(azithromycin) New generation FQs
(moxifloxacin/levofloxacin)
!
No recent abx: macrolide or doxycycline Recent

abx: macrolide + high-dose augmentin or 2nd.
generation ceph.
Tx (empiric): hospital-acquired pneumonia

Definition:
CURB-65
lobar consolidation
Vancomycin + Zosyn + FQ
Clinical prediction rule for mortality in community-acquired

pneumonia Confusion Uremia RR 30 BP < 90/60 Age 65
!
What CURB-65 score warrants inpatient admission?

Complications: pneumonia (3)
Workup/tx
sequence:
pneumonia (6)
Pleural effusion Pleural empyema ARDS
CXR Lab tests - CBC w/ diff, BUN, creatinine, glucose,

electrolytes O2 saturation Pretreatment cultures (2) Gram stain
and sputum culture Abx therapy (empiric)
!
In what leads are Q waves seen with a lateral infarct?
In what leads are Q waves seen with an inferior infarct?

EKG findings: posterior infarct in
left ventricle
Leads I and AVL

!
In what leads are Q waves seen with an anterior infarct?
Score of 2
Leads V1-V4
Large R wave in V1-V2 ST segment

depression in V1-V2
56!
Terms / Facts
!
EKG findings: anerior infarct (2)
ST elevation and Q waves in V1-V2 Q waves

!
Left bundle branch; Q wave would

occur in the middle of QRS
complex
In what circumstance is it nearly impossible to

diagnose an infarction from EKG? Why?
! Right coronary artery

A posterior infarct is usually caused by occlusion of wht
vessel?
! blocks of either the anterior or posterior division of the left
Definition:
bundle branch
hemiblock
EKG findings: anterior hemiblock
Q waves in lead I Wide/deep S wave in lead III
What happens to the axis in anterior hemiblock?

What happens to the axis with posterior hemiblocks?
EKG findings: posterior hemiblock (2)
!
EKG findings: pulmonary

embolus (3)
EKG findings: COPD
Right axis deviation
Deep or wide S in lead I Q wave in lead III
QRS complexes of small amplitude in all leads

!
Peak T waves Wide, flat P waves QRS widening

!
EKG findings: Hypokalemia
T wave flattening U waves

!
EKG findings: Hypercalcemia

!
EKG findings: hypocalcemia

EKG findings: Digitalis effect
!
Short QT
Prolonged QT
curved ST segment depression
Wide, notched P wave Wide QRS Depressed ST

segment Prolonged QT interval
What happens to the mean QRS vector in

hypertrophy?
What tends to happen to the mean QRS vector

(axis) of the heart with an infarct? Why?
Deviation toward the ventricle that is

hypertrophied
!
Points away from infarct due to

unopposed depolarization
A negative QRS in lead I indicates deviation of the axis to

what side?
What does a negative QRS in lead AVF say
about mean QRS vector?
Right axis
deviation
Points into the negative sphere

(away from AVF)
A normal axis has positive QRS complexes in which leads?
Left axis deviation
Large Q wave and T wave inversion V1-V4 Transient

Right BBB Wide S in Lead I
EKG findings: Hyperkalemia (3)
EKG findings: Quinidine

effects (4)
Leads I and AVF
57!
Terms / Facts
!
How does one find left axis

deviation? (2)
Positive QRS in lead I Negative QRS in lead

AVF
How does one find right axis

deviation? (2)
Negative QRS in lead I Positive QRS in lead

AVF
!
What is the normal sign of QRS complex

in V2? Why?
Negative; the thick left ventricle is

mostly posterior
!
Which precordial leads are usually isoelectric?

EKG findings: leftward axis rotation
isoelectric (transitional) QRS in leads V5-V6
EKG findings: rightward axis

rotation
Isoelectric (transitional) QRS in leads V1-V2
What EKG lead gives the most accurate information about the atria?
What is a diphasic wave?
If the initial portion of the diphasic P wave

is the larger of the two phases, then there
is [...] atrial enlargment
Lead V1
Atrial enlargement
If the initial portion of the diphasic P

wave is the larger of the two phases,
then there is right atrial enlargment
Small initial component and larger terminal

component in diphasic P wave
!
What does V1 look like with right ventricular hypertrophy?

!
What is the normal appearance of QRS in lead V1?

!
What does V1 look like with left ventricular hypertrophy?

What does V5 look like with left ventricular hypertrophy?
!
How does one check an EKG for left ventricular

hypertrophy?
!
What do T waves look like in the left

chest leads with LVH?
What does left ventricular strain look like? In

what lead?
The characteristic EKG sign of
ischemia is an [...]
Large R wave
Deep S wave
Really deep S wave

Very tall R wave in V5
mm of S in V1 + mm of R in V5
> 35 = LVH
Inverted T wave with a gradual downslope

and very steep return
What does right ventricular strain look like? In

what lead?
A wave that has both positive and negative portions
What is a diphasic P wave characteristic of?
EKG findings: left atrial

enlargement
V3-V4
Depressed and humped ST

segment in V1
Depressed and humped ST segment

in V5
The characteristic EKG sign of ischemia is an

inverted T wave
58!
Terms / Facts
!
In which leads are T wave inversion most common in ischemia?

!
Marked T wave inversion in leads V2-V3 is

indicative of what syndrome?
!
What EKG sign is indicative of acute myocardial

injury?
Physical exam:
COPD (6)
V1-V6
Wellens syndrome; stenosis

of the LAD
ST segment
elevation/depression
AP diameter hyperressonance diaphragmatic excursion

breath sounds expiratory phase rhonchi wheezes
!
Clinical manifestations: COPD (3)

!
Exacerbation triggers:
COPD (2)
Chronic cough Sputum production Dyspnea
Infxn (S. pneumoniae, H. influenzae, M. catarrhalis)

Cardiopulmonary disease, incl. PE
!
What are the criteria for continous or

intermitten long-term oxygen therapy in
COPD? (2)
PaO2 55 mg or O2 sat < 88% PaO2 55 to

59 plus polycythemia or evidence of cor
pulmonale
Definition (GOLD): COPD Stage I (mild)

Tx: Stage I (GOLD) COPD
FEV1/FVC <70% FEV1 80%
Bronchodilator prn
Definition (GOLD): Stage II (moderate) COPD ! FEV1/FVC < 70% FEV1 50-80%
(2)
! Standing LA dilator (tiotropium > Beta agonist)
Tx: Stage II (GOLD) COPD
Rehabilitation
(2)
Definition (GOLD): Stage III COPD (severe) (2)
!
Tx: Stage III (GOLD)

COPD
Fev1/FVC < 70% Fev1 30-50%
Standing LA dilator + inh. steroid if increased

exacervations
!
Tx: Stage IV (GOLD) COPD (3)
Standing LA dilator + inh. steroids + O2

!
Definition: Stage IV (GOLD) COPD
Fev/FVC < 70% FEV1 < 30%
What is the most common location for diverticulosis?

!
diverticulosis (2)
!
!
Tx: diverticulosis (2)

Complications: diverticulosis (2)
Sigmoid colon
Usually asymptomatic; incidentally found by barium

enema or colonoscopy Vague, LLQ discomfort, bloating,
constipation/diarrhea
Dx: diverticulosis
Pathophysiology:
Barium enema
High-fiber foods Psyllium

!
Painless rectal bleeding Diverticulitis
Impaction of food and bacteria in diverticulum fecalith
59!
Terms / Facts
formation obstruction compromise of the diverticulum's
blood supply, infection, perforation
diverticulutis
Dx: diverticulitis
(2)
Abdominal/pelvic CT w/w/o oral contrast (test of choice) Abd

radiograph
!
Which diagnostic tests are contraindicated

in diverticulutis? Why?
!
diverticulutis (3)
DDx: diverticulutis
(6)
LLQ abdominal pain Fever

Nausea/Vomiting/Constipation
IBD Infectious colitis PID Tubal pregnancy Cystitis Colorectal

cancer
!
Tx: diverticulutis (mild) (2)

Tx: diverticulitis (severe)
(2)
Metronidazole + FQ 7-10d Liquid diet
Inpatient - NPO, IV fluids, NG tube IV abx amp/gent/MNZ or zosyn

!
When is surgery indicated for tx of

diverticulitis?
!
Definition: angiodysplasia of the

colon
If medical management doesn't work or if

there are 2+ episodes
Tortuous, dilated veins in the submucosa of the

colon wall
Complication: angiodysplasia of the colon
Tx: angiodysplasia of the

colon
!
acute mesenteric ischemia
(5)
Lower GI bleeding (low grade usually)

Colonoscopy
self-resolving colonoscopic coagulopathy if

persistent
SMA embolism Nonocculusive mesenteric ischemia SMA

thrombosis Venous thrombosis Focal segmental ischemia of
the small bowel
!
Sudden onset abd pain out of proportion to the abd

tenderness on examv (occlusive) Abd distension & pain
(nonocclusive) N/V Hematochezia Intestinal angina
Physical exam: acute mesenteric

ischemia (2)
Dx (studies): acute mesenteric
ischemia (2)
Peritoneal signs Abd distention (FOBT ~ 75% pts)

May be unremarkable
Mesenteric angiography (definitive) CT

angiogram (test of choice)
Lab findings: acute mesenteric ischemia

(4)
Dx: angiodysplasia of the colon
Etiologies: acute
mesenteric ischemia
(5)
Barium enema and colonscopy due to

acute risk of perforation
WBC amylase LDH acidosis w/

lactate
60!
Terms / Facts
!
Tx: acute mesenteric ischemia

(3)
IV fluids Broad-spectrum abx Resection if necrotic

!
Tx: acute mesenteric ischemia due to SMA

embolism (2)
When is intra-arterial infusion of papaverine

indicated in acute mesenteric ischemia?
!
Tx: acute mesenteric ischemia due to SMA

thrombosis
When SMA spasm

(nonocclusive) is suspected
percutaneous or sugical
revascularization
What is the strongest predictor of survival of acute

intestinal ischemia?
Signs: intestinal infarction (5)
Fibrinolytics Surgical
embolectomy
Dx prior to infarction of
bowel
Hypotension Tachypnea Fever AMS Lactic acidosis
How do clincial presentations of an

embolic vs thrombotic acute mesenteric
ischemia differ?
Embolic: sx are more sudden and painful

Thrombotic: sx are more grandual and
less severe
! Vasopressors
What drug class should be avoided acute mesenteric ischemia is
occurring?
! Atherosclertoic occlusive disease of main
Etiology: chronic mesenteric
mesenteric vessels
ischemia
!
Clinical presentation: chronic

mesenteric ischemia (2)
Abdominal angina (postprandially) Significant

weight loss due to abdominal angina
!
Dx: chronic mesenteric ischemia

!
Tx: chronic mesenteric ischemia

!
Definition: Ogilvie's
syndrome
Etiologies: Ogilvie's syndrome

(3)
Tx: Ogilvie's
syndrome (3)
surgical revascularization (definitive)
s/s of large bowel obstruction w/o mechanical

obstruction
!
recent surgery/trauma serious medical illness

medications
Stop offending agent Supportive measures (IV fluids, electrolyte

repletion) Decompression with gentle enemas or NG suction
Complications:
pseudomembranous colitis (3)
pseudomembranous colitis (3)
Definition: colonic
volvulus
Toxic megacolon Colonic perforation

Anasarca/electrolyte imbalances
!
Profuse, watery diarrhea Crampy abdominal

pain Toxic megacolon w/ risk of perforation
Twisting of a loop intestine about its mesenteric

attachment site
What are the most common sites of colonic
Mesenteric arteriography
Sigmoid colon (75%) Cecal volvulus
61!
Terms / Facts
volvulus? (2)
(25%)
Clinical manifestations: colonic

volvulus (4)
!
Dx: colonic volvulus

(3)
Tx: sigmoid volvulus
Acute onset colicky abdominal pain Obstipation,

abdominal distention Anorexia N/V
Plain films Sigmoidoscopy (dx and tx for sigmoid volvulus)

Barium enema
!
nonoperative reduction (decompression vs sigmoidoscopy)

!
What is Reynold's
pentad?
Fever Severe jaundice RUQ pain Confusion Hypotension

!
What is Charcot's triad? In what disease

is it seen?
!
Definition:
cholangitis
Infection of the biliary tract 2/2 obstruction biliary stasis &

bacterial overgrowth
Etiologies: cholangitis (3)
Tx:cholangitis
(3)
BD stone (85%) Malignant or benign stricture Flukes

!
Workup/approach:
cholangitis (4)
Dx: cholangitis
(3)
Cholangitis: Fever Severe Jaundice

RUQ pain
Blood cultures IV fluids IV abx after cultures

Decompress CBD when patient stable
RUQ U/S Labs (CBC, LFTs, amylase) ERCP (don't perform during
acute phase)
IV abx IV fluids ERCP (patients who dont' respond to abx and

supportive care)
What vaccinations should all patients with

HCV receive?
!
What are the most important

causes of thyrotoxicosis w/ low
radioactive iodine uptake? (5)
Pulmonary embolism (4)
HBV and HAV vaccinations, if not

already immune
Subacute painless thyroiditis Subacute

granulomatous thyroiditis Iodine-induced
thyroid toxicosis Levothyroxine overdose
Struma ovarii
Dyspnea Tachycardia Sudden-onset pleuritic
chest pain Cough Hemoptysis
!
What kind of lesion does positive pronator drift

indicate?
Upper motor neuron lesion

!
What laboratory value in a parapneumonic effusion is most

indicative of empyema?
A low pH (<7.2) in a parapneumonic effusion is an indication for
what intervention?
Tube
thoracostomy
!
What is the ideal tidal volume on a ventilator?

What is the ideal FIO2 for a patient on ventilation?
Low pH <
7.2
6 ml/kg
<40%; avoid oxygen
62!
Terms / Facts
Why?
toxicity
Clinical presentation: choledochal cyst (adult)

Clinical presentation: choledochal
cyst (child) (3)
Vague epigastric or RUQ pain
Abdominal pain Jaundice Attacks of

rucurrent panccreatitis
!
Complications: choledochal cyst (2)
Cholangiosarcoma Cholangitis
!
What is the initial investigation of choice for a

choledochal cyst?
What is the definitive test for diagnosis of bronchiectasis?
!
How does the cough of

bronchiectasis differ from
that of chronic bronchitis?
!
Definition:
Cirrhosis
!
High-resolution CT
Bronchiectasis: mucopurulent expectoration and

occasional episode of hemoptysis Chronic bronchitis:
nonpurulent expectoration
Fibrosis and nodualr regeneration resulting from hepatocellular

injury
Alcohol (60-70%) Viral hepatitis Autoimmune hepatitis Metabolic

disease (hemochromatosis, Wilson's disease, a1-antitrypsin) Biliary
tract diseases (primary biliary cirrhosis, PSC) Vascular diseases (Buddchiari, RHF, constrictive pericarditis) NAFLD
Etiologies:
cirrhosis (7)
chronic liver disease (8)
Ascites Varices Gynecomastia Palmar erythema

Spider angiomas Hemorrhoids Caput medusae
Testicular atrophy
!
Lab findings: cirrhosis (3)

CBC findings: cirrhosis (3)
!
Workup:
cirrhosis (3)
Tx: ascites (2)
Complications:
liver failure (11)
Anemia Thrombocytopenia Neutropenia
Transjugular intrahepatic portal-systemic shunt to lower portal

pressure
Clinical manifestations: varices (2)
Tx: refractory
ascites (2)
bilirubin albumin PT
Abdominal U/S w/ dopller Assess fibrosis (FibroSURE biomarkers)

Determine etiology (hepatitis serologies, autoimmune serologies) +/liver bx
Tx: portal
hypertension
U/S followed by
CT/MRI
massive hematemesis melena
Na intake (1-2 g/d) diuretics
Large-volume paracentesis (1st line because of TIPS

complications( transjugular intrahepatic portosytemic shunts
AC, 9H Ascites coagulopathy Hypoalbuminemia Portal
Hypertension Hepatic encephalopathy Hepatorenal syndrome
Hypoglycemia Hyperbilirubinemia/jaundice Hyperestrinism
63!
Terms / Facts
Hepatocellular carcinoma
! Cirrhosis
In what disease is spontaneous bacterial peritonitis a common
complication?
! E. coli Klebsiella S. pneumo
Etiologies: spontaneous bacterial peritonitis (3)
Clinical manifestations: spontaneous bacterial

peritonitis (4)
!
Dx: spontaneous bacterial peritonitis

Tx: spontaneous bacterial peritonitis (2)
Clinical manifestations: hepatic
encephalopathy (4)
Tx: hepatic encephalopathy (3)
!
Tx: bleeding 2/2

esophageal/gastric varice
rupture (4)
Definition: Child's
classification (B)
IV cefotaxime IV albumin
AMS Asterixis Rigidity/hyperreflexia Fetor

hepaticus (musty breath odor)
Lactulose Neomycin Limited-protein diet
octreotide + midodrine + albumin
Albumin: > 3.5 Bili: < 2.0 Encephalopathy: None

Ascites: none Nutritional status: Excellent
Albumin: 3.0-3.5 Bili: 2.0-2.5 Encephalopathy: minimal
Ascites: controlled Nutritional status: good
Definition: Child's
classification (C)
paracenntesis and exam of ascitic fluid
!
!
Abd pain Fever Vomiting Rebound

tenderness
Hemodynamic stabilization (IV fluids) Emergent upper

GI endoscopy IV octreotide infusion emergently Betablockers long term therapy to prevent rebleeding
Tx: hepatorenal syndrome

Definition: Child's
classification (A)
Albumin: < 3.0 Bili: > 3.0 Encephalopathy: Severe

Ascites: uncontrolled Nutritional status: Poor
At what Child's score should a cirrhotic patient be evaluated for

transplant?
What serum ascites albumin gradient indicates portal HTN?
!
!
!
Dx: hemochromatosis
(2)
> 1.1 g/dL
Fatigue Arthralgias Bronze skin Hypogonadism DM

Labs (serum iron, ferritin, iron sat. TIBC) Liver bx required
for dx
Lab findings: hemochromatosis (4)

Tx: hemochromatosis
(4)
Child class B
Order period labs (LFTs 3-4 months) Perform endoscopy

to determine presence of esophageal varices CT-guided
biopsy if HCC suspected
How does one monitor a

patient w/ cirrhosis? (3)
Sx: hemochromatosis (5)
serum iron serum ferritin Fe sat TIBC
Repeated phlebotomies Deferoxamine Treat complications

Consider liver transplant
64!
Terms / Facts
Tx: Wilson's
disease (2)
24-hr urine Cu serum ceruloplasmin penicillamine

challenge with urine Cu excretion
Lab findings: Wilson's

disease (3)
Cheltion therapy w/ penicillamine + pyridoxine Zinc (decreases

intestinal uptake of copper)
What are the two pathologic types of

HCC? (2)
!
HCC (6)
Dx: HCC (3)
abdominal pain weight loss anorexia fatigue s/s of chronic

liver disease paraneoplastic syndromes
Liver biopsy Labs (hep B/C, LFTs, PT/PTT, tumor markers) Imaging
!
Tx: HCC (2)
Liver resection Liver transplantation

!
Definition: hemobilia
Blood draining into the duodenum via CBD

!
Tx: amebic liver abscess

!
Etiologies: liver abscess (2)
Tx: hydatid liver cyst (2)

!
Definition:
Budd-Chiari
Dx: Budd-Chiari (2)

!
IV metronidazole
Biliary tract obstruction GI infection

Surgical resection Mebendazole
Liver disease caused by occlusion of hepatic venous outflow, which

leads to hepatic congestion and subsequent microvascular ischemia
Etiologies: BuddChiari (4)
Tx: BuddChiari (3)
Nonfibrolamellar (hep B/C associated)

Fibrolamellar
Myeloproliferatie disorder Hypercoagulable state Tumor

invasion Pregnancy
Hepatic venography Serum ascites albumin gradient > 1.1 g/dl
Medical therapy - anticoagulation, thrombolytics, diuretics Surgery

(balloon angioplasty w/ stent, TIPS) Liver transplantation
What are the signs of a conjugated hyperbilirubinemia? (2)

!
Definition: cholelithiasis
!
cholelithiasis (3)
Definition: Boas' sign

!
Complications:
cholelithiasis (5)
Pale stools Dark urine
Stones in the gallbladder
Biliary colic = episodic RUQ or epigastric abd painn

Radiation of painn to scapula Nausea
!
Dx: cholelithiasis
RUQ U/S
Referred right subscapular pain w/ biliary colic
Cholecystitis w/ prolonged obstruction of cystic duct

Choledocholithiasis Gallstone ileus Malignancy Mirizzi's
syndrome: common hepatic duct compression by cystic duct
stone
65!
Terms / Facts
!
Cholecystectomy (laparoscopic) Ursodeoxycholic acid (rare)

for cholesterol stones if poor surgical candidate or
uncomplicated biliary pain
Tx: symptomatic
cholelithiasis (2)
What is the best indicator of the severity of TCA overdose?

Tx:
prolactinoma
(2)
First line: dopaminergic agents (cabergolin/bromocriptine) Second

line: surgery only if impaired vision does not improve with drug
treatment
A normal/high pCO2 in the context of an acute

asthma exacerbation is indicative of what?
!
What are the types of pleural effusions? (2)

!
Decompensation - intubation
may be required
Inhaled B2 agonist (first-line) via nebulizer/MDI

Corticosteroids (IV or PO) Oxygen (titrate to achieve
>90% SaO2)
Tx: acute severe asthma

exacerbation (3)
Exudative Transudative
Rapid decline in renal function, with an increase in serum

creatinine level (relative increase of 50% or absolute of 0.5-1.0
mg/dL)
Definition: Acute
renal failure
What are the most common clinical manifestations of acute

renal failure? (2)
Workup: acute renal

failure
Clinical manifestations: prerenal ARF (5)

!
Dry mucous membranes Hypotension Tachycardia

Decreased tissue turgor Oliguria/anuria
Oliguria BUN:Cr > 20:1 Urine osmolality > 500 FeNa < 1%
Bland urine/hyaline casts
Etiologies: acute tubular necrosis
Daily weights, I/Os BP Serum electrolytes Hb/Hct

for anemia Watch for infection
Infection
H&P Urine evaulation Renal U/S Serologies (if

indicated)
Categories: ARF (3)
Lab findings: ATN

(4)
Weight gain
Edema
Hypovolemia CHF Peripheral vasodilation (sepsis, etc.)

Cirrhosis/hepatorenal syndrome Drugs (NSAIDs, ACE inhibitors,
cyclosporin)
How does one monitor a

patient with ARF? (5)
Lab findings: prerenal ARF
What is the most common cause of death with ARF?

Etiologies:
prerenal failure
(5)
EKG w/ wide QRS
Prerenal Intrinsic Postrenal

!
Ischemia Toxins
BUN:Cr < 20 FeNa > 2% Urine osmolality < 350 mOsm/kg

Brown muddy casts
66!
Terms / Facts
Etiologies:
postrenal ARF (5)
urethral obstruction 2/2 BPH nephrolithiasis obstruction of

solitary kidney retroperitoneal fibrosis obstructing neoplasms
!
Urinalysis Urine chemistry Serum

electrolytes Bladder cath (dx and tx) Renal
U/S
What tests/procedures should be

ordered for any patient with ARF? (5)
In the early phase of ARF, what are the most

common mortal complications? (2)
!
Tx: acute renal

failure (general)
(5)
Hyperkalemic cardiac arrest

Pulmonary edema
Avoid meds that decrease renal blood flow Correct fluid

imbalance Correct electrolyte imbalances Optimize cardiac output
Order dialysis if symptomatic uremia
!
WBC casts suggest what etiologies of renal

failure?
Pyelonephritis Acute interstitial

nephritis
!
RBCs and RBC casts suggest what etiology of ARF?

!
Tx: prerenal
ARF (3)
Tx: intrinsic ARF
(2)
treat underlying disorder give NS to maintain euvolemia and restore

BP Eliminate offending agents
!
Supportive therapy for ATN Furosemide trial if patient is

oliguric
!
Tx: postrenal ARF
bladder catherization to decompress urinary tract

!
Definition: chronic kidney disease

Etiologies: CKD (5)
3 mos of reduced GFR (
Diabetes (most common) HTN Chronic GN AIN PKD

!
Definition: Stage I CKD
Definition: Stage 2 CKD
GFR > 90 ml/min

GFR 60-89 ml/min

Definition:
uremia
30-59 ml/min
15-29 ml/min
GFR < 15 ml/min or dialysis
Signs and symptoms associated with accumulation of nitrogenous

wastes due to impaired renal function
Clinical manifestations (general):

uremia (5)
Clinical manifestations (skin): uremia (4)
N/V anorexia malaise fetor uremicus

metallic taste
!
Uremic frost Pruritis Calciphylaxis NSF
Clinical manifestations (cardiovascular): uremia

(3)
Glomerular disease
pericarditis hypertension CHF
67!
Terms / Facts
Clinical manifestations (neurologic):
uremia (4)
Encephalopathy seizures Neuropathy

restless legs
!
Clinical manifestations (Hematologic): uremia (2)

!
(metabolic): uremia (5)
!
Dx: CKD (4)
anemia bleeding
Hyperkalemia Hyperphosphatemia Acidosis

Hypocalcemia 2 hyperparathyroidism/osteodystrophy
Urinalysis Chem 7 CBC Renal US

!
ACE inhibitors are first line Goal 130/80
Low protein Low salt Restrict K+
Tx (BP control): CKD

Tx (diet): CKD (3)
Tx (anemia): CKD
Tx (metabolic acidosis): CKD
Treat with erythropoietin
Oral bicarb or sodium citrate if HCO3 < 22
Tx (electrolytes): CKD (2)

!
Indications (absolute):
dialysis (5)
calcium citrate/acetate vitamin D/calcium
Acidosis Electrolyte imblances Intoxications/ingestions

Overload Uremia
What are the two major methods for dialysis?
Hemodialysis Peritoneal dialysis

!
What is the preferred access route for hemodialysis?

!
Definition: proteinuria
> 150 mg protein/24hr
What are the classifications of proteinuria?

!
nephrotic syndrome (5)
!
Etiologies: nephrotic
syndrome (6)
Dx: nephrotic syndrome
(3)
Tx: nephrotic
syndrome (5)
Definition: hematuria
Glomerular Tubular Overflow
Urine protein > 3.5g/24hr Hypoalbuminemia

Hyperlipidemia Hypercoagulable state Edema
Primary glomerular disease Systemic disease Drugs/toxins

Infection Multiple myeloma Malignant HTN
!
Urine dipstick Urinalysis renal biopsy (if other methods

don't help)
Treat underlying disease ACE inhibitors (decreases protein loss)

Diuretics Treat HL Vaccinate against influenza and pneumococcus
!
What is the general etiology of

microscopic hematuria? And gross
hematuria?
> 3 erythrocytes/HPF on urinalysis

!
Microscopic: glomerular Gross:

nonglomerular or urologic
What diseases should be suspected with gross painless

hematuria? (2)
AV fistula
Bladder cancer Kidney

cancer
68!
Terms / Facts
! Nephrolithiasis Neoplasms Foley trauma BPH
Etiologies (extrarenal): hematuria
(4)
! Vascular (renal thrombosis, infarcts, etc) Glomerular
Etiologies (intrarenal):
disease PKD Nephrolithiasis Neoplasms Trauma/exercise
hematuria (6)
!
Dx: hematuria (4)
Urine dipstick Urinalysis Cytology Renal bx
Tx: hematuria (2)
treat underlying disease maintain urine volume

!
Clinical manifestsion:
Goodpasture's syndrome (6)
Tx: ANCA+/Anti-GBM GN
Tx: SLE nephritis
Definition: Acute Interstitial
Nephritis
!
Etiologies: AIN
(3)
steroids ASAP + cyclophosphamide + plasmapheresis
IV cyclophosphamide + steroids
Inflammation involving interstitium that surrounds

glomeruli and tubules
Fever Eosinophilia Acute renal insufficiency Rash

FEAR AIN
Renal function tests (BUN/Cr) Urinalysis (eos strongly suggestive)

!
Tx: AIN (2)
Toxins (most common) Infection Collagen vascular diseases (e.g.

sarcoidosis)
Clinical manifestations: AIN

(4)
Dx: AIN (2)
Fever Myalgia Rapidly progessive renal failure

Hemoptysis Cough Dyspnea
Remove offending agent Treat infection if present
What is the definitive diagnosis for AIN?

!
Renal bx
Slowly progressive form of interstitial nephritis that can lead

to progressive scarring of the interstium, renal failure and
ESRD over time
Definition: Chronic
interstitial nephritis
!
Etiologies: chronic
interstitial nephritis (5)
urinary tract obstruction reflux nephropathy heavy

analgesic use heavy metal exposure arteriolar
nephrosclerosis w/ HTN
! Nephrocalcinosis/nephrolithiasis
What are the sequelae of RTA I that leads to
symptom manifestations?
! MM Autoimmune diseases Meds (analgesics)
Etiologies: RTA I (3)
!
Tx: RTA I (2)
correct acidosis w/ sodium bicarb administer phosphate salts
Etiologies: Type II RTA

(4)
Tx: RTA II
(2)
Fanconi's syndrome Cystinosis Wilson's Paraprotein (MM,

amyloid)
Na restriction (increases bicarb reabsorption) Don't give bicarb to

correct acidosis
69!
Terms / Facts
!
Clinical manifestations: PKD (4)
Hematuria Abd pain HTN Palpable kidneys

!
Dx: PKD
Tx: PKD (3)
U/S
Drain cysts if symptomatic Treat infection w/ abx Control HTN

!
Dx: medullary sponge kidney disease

!
Clinical manifestations: renal artery stenosis (2)
Physical exam: renal artery stenosis

!
Dx: renal artery stenosis (2)

Tx: renal artery
stenosis (2)
IVP
HTN Renal insufficiency

Abdominal bruit
Renal arteriogram (w/o contrast if possible) MRA
Revascularizaztion w/ PRTA Conservative medical therapy

(ACEi, CCBs) if PRTA or surgery contraindicated
Nephrosclerosis
Systemic HTN increases capillary hydrostatic pressure

in the glomeruli, leading to benign or malignant sclerosis
What common antihypertensive is contraindicated in renovascular HTN?
ACEi
! Hematuria Flank pain N/V Dysuria UTI

Clinical manifestations: nephrolithiasis
(5)
! Noncrast helic CT scan Strain urine for stone 24-h urine
Workup: nephrolithiasis
x2
(3)
!
Analgesia Aggresive PO/IV hydration Abx if UTI

Lithotripsy/percutaneous nephrolithotomy if ongoing
obstruction
Tx (acute):
nephrolithiasis (4)
Tx (chronic):
nephrolithiasis
Increase fluid intake (> 2 L/d) Limit Ca+ intake Thiazide

diuretics Allopurinol (uric acid stones)
What diuretics should be used in renal insufficiency? (2)

!
What diuretics should be used for CHF? (2)

What diuretics should be used with cirrhosis?
(2)
Loop diuretic + thiazide
Lasix + spironolactone (1:2.5

ratio)
What diuretic should be used with severe metabolic alkalosis?

Clinical manifestations: urinary
tract obstruction (5)
Dx: urinary tract obstruction (3)

Tx: lower urinary tract obstruction (2)
Loop diuretic + thiazide
Acetazolamide
Renal colic/pain oliguria recurrent UTIs

hematuria/proteinuria renal failure
!
renal U/S initial test IVP Urinalysis

!
urethral catheter prostatectomy (if BPH)
70!
Terms / Facts
!
Tx: upper urinary tract obstruction (2)

Definition: Solitary
Pulmonary Nodule
nephrostomy tube drainage ureteral stent
Single, well circumscribed nodule seen on CXR with no

associated mediastrinal or hilar lymph node involvement
!
What does the initial evaluation of SPN consist of?

Dx: SPN (3)
PET Transthoracic needle biopsy Video assisted thorascopic surgery

!
Management: low risk SPN
Serial CT q3mo
!
Management: medium-risk SPN

!
Management: high risk SPN

Etiologies: pleural effusion
(4)
Physical exam: pleural

effusion (3)
VATS w/ lobectomy if malignant
Exterional dyspnea Peripheral edema

Orthopnea
Dullness to percussion Decreased breath sounds over

effusion Decreased tactile fremitus
!
Dx: pleural effusion (2)

Tx: transudative effusions
(3)
PET or bx
CHF Pneumonia Malignancies (lung/breast/lymphoma)

PE
Clinical manifestations: pleural

effusion
CXR Thoracentesis
Diuretics Na restriction Therapeutic thoracentesis (if

massive)
!
Tx: parapneumonic effusions (2)
Abx Chest tube drainage if complicated

!
Classic ECG finding in atrial flutter.

Definition of unstable angina.
Sawtooth P waves
Angina is new, is worsening, or occurs at rest
Antihypertensive for a diabetic patient with proteinuria.

!
Beck's triad for cardiac tamponade.
ACEI
?-blockers, digoxin, calcium channel

blockers
Hypercholesterolemia treatment that ? flushing and pruritus.

Treatment for atrial fibrillation.
Hypotension, distant heart sounds, and JVD

!
Drugs that slow AV node

transmission.
Niacin
Anticoagulation, rate control, cardioversion

!
Treatment for ventricular fibrillation.

Autoimmune complication occurring 2-4
weeks post-MI.
CT scan + Hx
Immediate cardioversion
Dressler's syndrome: fever,

pericarditis, ? ESR
71!
Terms / Facts
IV drug use with JVD and holosystolic murmur
at the left sternal border. Treatment?
!
Diagnostic test for hypertrophic

cardiomyopathy.
Classic ECG findings in pericarditis.

!
!
Eight surgically
correctable causes of
hypertension.
Treat existing heart failure and

replace the tricuspid valve
Echocardiogram (showing thickened left

ventricular wall and outflow obstruction)
!
A fall in systolic BP of > 10 mmHg with

inspiration.
Definition of
hypertension.
Pulsus paradoxus (seen in cardiac

tamponade)
Low-voltage, diffuse ST-segment elevation
BP > 140/90 on three separate occasions two weeks apart
Renal artery stenosis, coarctation of the aorta,

pheochromocytoma, Conn's syndrome, Cushing's syndrome,
unilateral renal parenchymal disease, hyperthyroidism,
hyperparathyroidism
!
Evaluation of a pulsatile abdominal mass and

bruit.
Indications for surgical repair of abdominal
aortic aneurysm.
Treatment for acute coronary
syndrome.
Abdominal ultrasound and CT
> 5.5 cm, rapidly enlarging,

symptomatic, or ruptured
Morphine, O2, sublingual nitroglycerin, ASA, IV ?blockers, heparin
! Abdominal obesity, high triglycerides, low HDL, hypertension,

What is the
insulin resistance, prothrombotic or proinflammatory states
metabolic
syndrome?
! Exercise stress
Appropriate diagnostic test? ? A 50-year-old male with
treadmill with ECG
angina can exercise to 85% of maximum predicted heart
rate.
Appropriate diagnostic test? ? A 65-year-old woman ! Pharmacologic stress test
(e.g., dobutamine echo)
with left bundle branch block and severe
osteoarthritis has unstable angina.
! Angina, ST-segment changes on ECG, or
Signs of active ischemia during stress
? BP
testing.
ECG findings
suggesting MI.
ST-segment elevation (depression means ischemia), flattened

T waves, and Q waves
A young patient has angina at rest with ST-segment elevation.

Cardiac enzymes are normal.
Common symptoms associated with silent
MIs.
CHF, shock, and altered mental

status
!
The diagnostic test for pulmonary embolism.

An agent that reverses the effects of heparin.
Prinzmetal's
angina
V/Q scan
Protamine
72!
Terms / Facts
!
The coagulation parameter affected by warfarin.

!
A young patient with a family history of sudden death

collapses and dies while exercising.
!
Endocarditis
prophylaxis regimens.
Hypertrophic
cardiomyopathy
Oral surgeryamoxicillin; GI or GU procedures

ampicillin and gentamicin before and amoxicillin after
!
The 6 P's of ischemia due to

peripheral vascular disease.
Virchow's triad.
Pain, pallor, pulselessness, paralysis,

paresthesia, poikilothermia
Stasis, hypercoagulability, endothelial damage

!
The most common cause of hypertension in young women.

!
The most common cause of hypertension in young men.

!
Stuck-on appearance.
Seborrheic keratosis
!
The most common type of skin cancer; the lesion is a pearly-colored

papule with a translucent surface and telangiectasias.
!
Honey-crusted lesions.
Psoriasis
Basal cell
carcinoma
Impetigo
A febrile patient with a history of diabetes presents with a red, swollen, !

painful lower extremity.
! Pemphigus vulgaris
+ Nikolsky's sign.
!
Acanthosis nigricans. Check fasting

blood sugar to rule out diabetes
!
Dermatomal distribution.
!
Flat-topped papules.
!
Varicella zoster
Lichen planus
Erythema multiforme
!
A lesion characteristically occurring in a linear pattern in areas

where skin comes into contact with clothing or jewelry.
!
Presents with a herald patch, Christmas-tree pattern.

A 16-year-old presents with an annular patch of
alopecia with broken-off, stubby hairs.
Contact
dermatitis
Pityriasis rosea
Alopecia areata
(autoimmune process)
Pinkish, scaling, flat lesions on the chest and back. KOH prep has
!
a "spaghetti-and-meatballs" appearance.
Cellulitis
Bullous pemphigoid
A 55-year-old obese patient presents with

dirty, velvety patches on the back of the
neck.
Iris-like target lesions.
OCPs
Excessive EtOH
Red plaques with silvery-white scales and sharp margins.
- Nikolsky's sign.
PT
Pityriasis
73!
Terms / Facts
versicolor
!
Four characteristics of a nevus

suggestive of melanoma.
Asymmetry, border irregularity, color

variation, large diameter
!
Premalignant lesion from sun exposure that can ? squamous cell

carcinoma.
!
Dewdrop on a rose petal.

Cradle cap.
Actinic
keratosis
Lesions of 1 varicella
Seborrheic dermatitis. Treat with antifungals
Associated with Propionibacterium acnes and changes in androgen ! Acne vulgaris

levels.
! Herpes simplex
A painful, recurrent vesicular eruption of mucocutaneous
surfaces.
! Lichen
Inflammation and epithelial thinning of the anogenital area,
sclerosus
predominantly in postmenopausal women.
!
Exophytic nodules on the skin with varying degrees of scaling

or ulceration; the second most common type of skin cancer.
The most common cause of hypothyroidism.
!
Lab findings in Hashimoto's

thyroiditis.
Hashimoto's thyroiditis
High TSH, low T4, antimicrosomal

antibodies
!
Exophthalmos, pretibial myxedema, and ? TSH.

The most common cause of
Cushing's syndrome.
Squamous cell
carcinoma
Graves' disease
Iatrogenic steroid administration. The second most

common cause is Cushing's disease
! Hypoparathyroidism
A patient presents with signs of hypocalcemia, high
phosphorus, and low PTH.
! Signs and symptoms of hypercalcemia
Stones, bones, groans, psychiatric
overtones.
! 1 hyperaldosteronism (due to
A patient complains of headache, weakness, and
Conn's syndrome or bilateral
polyuria; exam reveals hypertension and tetany.
adrenal hyperplasia)
Labs reveals hypernatremia, hypokalemia, and
metabolic alkalosis.
A patient presents with tachycardia, wild swings in BP,
! Pheochromocytoma
headache, diaphoresis, altered mental status, and a sense of
panic.
! ?-antagonists (phentolamine and
Should ?- or ?-antagonists be used first in
phenoxybenzamine)
treating pheochromocytoma?
A patient with a history of lithium use presents with

copious amounts of dilute urine.
Treatment of central
!
DI.
Nephrogenic diabetes
insipidus (DI)
Administration of DDAVP ? serum osmolality and free water
74!
Terms / Facts
restriction
A postoperative patient with significant pain presents with
hyponatremia and normal volume status.
An antidiabetic agent associated with lactic acidosis.
A patient presents with weakness, nausea,
vomiting, weight loss, and new skin
pigmentation. Labs show hyponatremia and
hyperkalemia. Treatment?
SIADH due to
stress
Metformin
1 adrenal insufficiency (Addison's

disease). Treat with replacement
glucocorticoids, mineralocorticoids,
and IV fluids
!
Goal hemoglobin A1c for a patient with DM.

Treatment of
DKA.
<6.5
Fluids, insulin, and aggressive replacement of electrolytes (e.g.,

K+)
Why are ?-blockers contraindicated in

diabetics?
They can mask symptoms of

hypoglycemia
!
Bias introduced into a study when a clinician is aware of the

patient's treatment type.
Observational
bias
!
Bias introduced when screening detects a disease earlier and thus

lengthens the time from diagnosis to death.
Lead-time
bias
If you want to know if race affects infant mortality rate but most ! Confounding
variable
of the variation in infant mortality is predicted by socioeconomic
status, then socioeconomic status is a _____.
The number of true positives divided by the number of patients with ! Sensitivity
the disease is _____.
! Out
Sensitive tests have few false negatives and are used to rule _____ a disease.
PPD reactivity is used as a screening test because most people with
TB (except those who are anergic) will have a +PPD. Highly
sensitive or specific?
Chronic diseases such as SLEhigher prevalence or
incidence?
Epidemics such as influenzahigher prevalence or incidence?
Describe a test that consistently gives identical results, but

the results are wrong.
Higher prevalence
Higher incidence
Prevalence
Incidence and prevalence

!
Case-control studyincidence or prevalence?
Difference between a
Highly
sensitive for
TB
Cross-sectional surveyincidence or prevalence?

Cohort studyincidence or prevalence?
Neither
High reliability, low

validity
Cohort studies can be used to calculate relative risk (RR),
75!
Terms / Facts
cohort and a case-control
study.
!
Attributable
risk?
!
Relative
risk?
Odds
ratio?
incidence, and/or odds ratio (OR). Case-control studies

can be used to calculate an OR
The incidence rate (IR) of a disease in exposed ? the IR of a disease

in unexposed
The IR of a disease in a population exposed to a particular factor the

IR of those not exposed
The likelihood of a disease among individuals exposed to a risk factor
compared to those who have not been exposed
!
Number needed to treat?

!
1 (rate in untreated group ? rate in treated group)

Patients with IBD; those with familial adenomatous
polyposis (FAP)/hereditary nonpolyposis colorectal cancer
(HNPCC); and those who have first-degree relatives with
adenomatous polyps (
In which patients do you

initiate colorectal cancer
screening early?
The most common cancer in men and the

most common cause of death from cancer
in men.
Prostate cancer is the most common

cancer in men, but lung cancer causes
more deaths
The percentage of cases within one SD of the mean? Two SDs?

Three SDs?
!
Birth rate?
Number of live births per 1000 women 15-44 years of age

!
Mortality rate?
Neonatal mortality?
Postnatal
mortality?
Infant
mortality?
Fetal
mortality?
Perinatal
mortality?
Maternal
mortality?
Number of deaths per 1000 population
Number of deaths from birth to 28 days per 1000 live births
Number of deaths from 28 days to one year per 1000 live births
Number of deaths from birth to one year of age per 1000 live births
(neonatal + postnatal mortality)
Number of deaths from 20 weeks' gestation to birth per 1000 total

births
!
Number of deaths from 20 weeks' gestation to one month of life

per 1000 total births
Number of deaths during pregnancy to 90 days postpartum per

100,000 live births
True or false: Once patients

sign a statement giving
consent, they must continue
68%, 95.5%,
99.7%
Number of live births per 1000 population
Fertility rate?
False. Patients may change their minds at any time.

Exceptions to the requirement of informed consent
include emergency situations and patients without
76!
Terms / Facts
treatment.
decision-making capacity
!
A 15-year-old pregnant girl requires

hospitalization for preeclampsia. Should her
parents be informed?
No. Parental consent is not

necessary for the medical
treatment of pregnant minors
A doctor refers a patient for an MRI at a facility he/she owns.

Involuntary psychiatric hospitalization
can be undertaken for which three
reasons?
False. Withdrawing and withholding

life are the same from an ethical
standpoint
When there is no rationale for treatment, maximal

intervention is failing, a given intervention has
already failed, and treatment will not achieve the
goals of care
When can a physician refuse to

continue treating a patient on
the grounds of futility?
An eight-year-old child is in a serious accident. She

requires emergent transfusion, but her parents are
not present.
Conditions in which
confidentiality must be
overridden.
Conflict of interest
The patient is a danger to self, a danger to

others, or gravely disabled (unable to
provide for basic needs)
True or false: Withdrawing life-sustaining

care is ethically distinct from withholding
sustaining care.
!
Treat immediately. Consent is

implied in emergency
situations
Real threat of harm to third parties; suicidal

intentions; certain contagious diseases; elder and
child abuse
Involuntary commitment or isolation for

medical treatment may be undertaken for
what reason?
When treatment noncompliance

represents a serious danger to public
health (e.g., active TB)
!
A 10-year-old child presents in status

epilepticus, but her parents refuse
treatment on religious grounds.
!
A son asks that his mother not be told

about her recently discovered cancer.
Treat because the disease represents an

immediate threat to the child's life.
Then seek a court order
A patient's family cannot require that a

doctor withhold information from the
patient
! Emergent laparotomy to
Patient presents with sudden onset of severe, diffuse
repair perforated viscus,
abdominal pain. Exam reveals peritoneal signs and
likely stomach
AXR reveals free air under the diaphragm.
Management?
! Diverticulosis
The most likely cause of acute lower GI bleed in patients > 40
years old.
! HIDA scan
Diagnostic modality used when ultrasound is equivocal for
cholecystitis.
! Acute pancreatitis
Sentinel loop on AXR.
77!
Terms / Facts
!
Risk factors for cholelithiasis.
Fat, female, fertile, forty, flatulent
Inspiratory arrest during palpation of the

RUQ.
Murphy's sign, seen in acute

cholecystitis
!
Identify key organisms causing diarrhea: ? Most common

organism
Identify key organisms causing diarrhea: ? Recent antibiotic !
use
Campylobacter
Clostridium difficile
!
Identify key organisms causing diarrhea: ? Camping
Giardia
!
Identify key organisms causing diarrhea: ? Traveler's diarrhea

!
Identify key organisms causing diarrhea: ? Church picnics/mayonnaise

!
Identify key organisms causing diarrhea: ? Uncooked

hamburgers
Identify key organisms causing diarrhea: ? Fried rice
Identify key organisms causing

diarrhea: ? AIDS
Inflammatory disease of the colon with ? risk of colon cancer.
Medical treatment for

IBD.
Yersinia
Crohn's
disease
Ulcerative colitis
Mallory-Weisssuperficial tear in the esophageal

mucosa Boerhaavefull-thickness esophageal
rupture
RUQ pain, jaundice, and fever/chills in the setting of ascending

cholangitis
Charcot's triad plus shock and mental status changes, with

suppurative ascending cholangitis
Medical treatment for hepatic

encephalopathy.
Uveitis, ankylosing spondylitis, pyoderma gangrenosum,

erythema nodosum, 1 sclerosing cholangitis
Reynolds'
pentad.
Vibrio, HAV
5-aminosalicylic acid +/? sulfasalazine and steroids during

acute exacerbations
Difference between MalloryWeiss and Boerhaave tears.

Charcot's
triad.
Salmonella
Isospora, Cryptosporidium, Mycobacterium

avium complex (MAC)
A 25-year-old Jewish male presents with pain and watery diarrhea

after meals. Exam shows fistulas between the bowel and skin and
nodular lesions on his tibias.
E. coli O157:H7
Identify key organisms causing diarrhea: ? Pseudoappendicitis
Extraintestinal
manifestations of IBD.
S. aureus
Bacillus cereus
Identify key organisms causing diarrhea: ? Poultry/eggs

Identify key organisms causing diarrhea: ? Raw seafood
ETEC
? protein intake, lactulose, neomycin
78!
Terms / Facts
!
First step in the management of a patient with acute GI

bleed.
!
A four-year-old child presents with oliguria,

petechiae, and jaundice following an illness with
bloody diarrhea. Most likely diagnosis and cause?
!
Post-HBV exposure treatment.

!
Classic causes of druginduced hepatitis.
Establish the ABCs
Hemolytic-uremic
syndrome (HUS) due to E.
coli O157:H7
HBV immunoglobulin
TB medications (INH, rifampin, pyrazinamide),

acetaminophen, and tetracycline
A 40-year-old obese female with elevated alkaline phosphatase,

elevated bilirubin, pruritus, dark urine, and clay-colored stools.
Biliary tract
obstruction
! Femoral hernia
Hernia with highest risk of incarcerationindirect, direct, or
femoral?
! Confirm the diagnosis of acute
pancreatitis with elevated amylase and
A 50-year-old man with a history of alcohol
lipase. Make patient NPO and give IV
abuse presents with boring epigastric pain
fluids, O2, analgesia, and "tincture of
that radiates to the back and is relieved by
time"
sitting forward. Management?
Four causes of
microcytic anemia.
TICSThalassemia, Iron deficiency, anemia of Chronic

disease, and Sideroblastic anemia
!
An elderly male with hypochromic, microcytic

anemia is asymptomatic. Diagnostic tests?
Precipitants of hemolytic crisis in patients with
G6PD deficiency.
Fecal occult blood test and

sigmoidoscopy; suspect colorectal
cancer
Sulfonamides, antimalarial drugs,
fava beans
!
The most common inherited cause of

hypercoagulability.
The most common inherited hemolytic anemia.
Diagnostic test for hereditary spherocytosis.
!
Pure RBC aplasia.
Factor V Leiden mutation
Hereditary spherocytosis
!
Osmotic fragility test
Diamond-Blackfan anemia
! Fanconi's
Anemia associated with absent radii and thumbs, diffuse
anemia
hyperpigmentation, caf-au-lait spots, microcephaly, and
pancytopenia.
! Chloramphenicol, sulfonamides, radiation, HIV,
chemotherapeutic agents, hepatitis, parvovirus B19,
Medications and viruses
EBV
that ? aplastic anemia.
How to distinguish
polycythemia vera from 2
polycythemia.
Both have ? hematocrit and RBC mass, but

polycythemia vera should have normal O2 saturation
and low erythropoietin levels
79!
Terms / Facts
!
Pentad of TTP"FAT RN":Fever, Anemia,

Thrombocytopenia, Renal dysfunction, Neurologic
abnormalities
Thrombotic thrombocytopenic
purpura (TTP) pentad?
HUS triad?
Treatment for
TTP.
Anemia, thrombocytopenia, and acute renal failure

!
Emergent large-volume plasmapheresis, corticosteroids,

antiplatelet drugs
!
Treatment for idiopathic

thrombocytopenic purpura (ITP) in
children.
Usually resolves spontaneously; may

require IVIG and/or corticosteroids
Which of the following are ? in DIC: fibrin

split products, D-dimer, fibrinogen, platelets,
and hematocrit.
An eight-year-old boy presents with
hemarthrosis and ? PTT with normal PT
and bleeding time. Diagnosis? Treatment?
Fibrin split products and D-dimer are

elevated; platelets, fibrinogen, and
hematocrit are ?.
Hemophilia A or B; consider
desmopressin (for hemophilia A) or
factor VIII or IX supplements
! von Willebrand's disease;

A 14-year-old girl presents with prolonged bleeding
treat with desmopressin,
after dental surgery and with menses, normal PT,
FFP, or cryoprecipitate
normal or ? PTT, and ? bleeding time. Diagnosis?
Treatment?
! Monoclonal gammopathy, Bence Jones
A 60-year-old African-American male
proteinuria, "punched-out" lesions on x-ray
presents with bone pain. Workup for
of the skull and long bones
multiple myeloma might reveal?
!
Reed-Sternberg cells
Hodgkin's lymphoma
A 10-year-old boy presents with fever, weight loss, and night

sweats. Examination shows anterior mediastinal mass. Suspected
diagnosis?
!
Microcytic anemia with ? serum iron, ? total iron-binding

capacity (TIBC), and normal or ? ferritin.
Microcytic anemia with ? serum iron, ? ferritin, and ?
TIBC.
An 80-year-old man presents with fatigue, lymphadenopathy,

splenomegaly, and isolated lymphocytosis. Suspected
diagnosis?
A late, life-threatening complication of chronic
myelogenous leukemia (CML).
Auer rods on blood smear.
Non-Hodgkin's
lymphoma
Anemia of chronic
disease
Iron deficiency anemia

!
Chronic
lymphocytic
leukemia (CLL)
Blast crisis (fever, bone pain,

splenomegaly, pancytopenia)
Acute myelogenous leukemia (AML)

!
AML subtype associated with DIC.

Electrolyte changes in tumor lysis
syndrome.
M3
? Ca2+ , ? K? , ? phosphate, ? uric acid
80!
Terms / Facts
!
Treatment for AML M3.
Retinoic acid
! CML
A 50-year-old male presents with early satiety, splenomegaly, and
bleeding. Cytogenetics show t(9,22). Diagnosis?
! Intracellular inclusions seen in thalassemia, G6PD deficiency, and
Heinz
postsplenectomy
bodies?
!
An autosomal-recessive disorder with a defect in the

GPIIbIIIa platelet receptor and ? platelet aggregation.
Glanzmann's
thrombasthenia
Virus associated with aplastic anemia in patients with sickle cell ! Parvovirus B19
anemia.
! O2, analgesia, hydration,
A 25-year-old African-American male with sickle cell
and, if severe,
anemia has sudden onset of bone pain. Management of
transfusion
pain crisis?
!
A significant cause of morbidity in thalassemia

patients. Treatment?
The three most common causes of fever of
unknown origin (FUO).
!
Four signs and symptoms of

streptococcal pharyngitis.
Infection, cancer, and

autoimmune disease
Fever, pharyngeal erythema, tonsillar

exudate, lack of cough
A nonsuppurative complication of streptococcal infection

that is not altered by treatment of 1 infection.
!
Asplenic patients are particularly

susceptible to these organisms.
Iron overload; use

deferoxamine
Postinfectious
glomerulonephritis
Encapsulated organisms--pneumococcus,
meningococcus, Haemophilus influenzae,
Klebsiella
The number of bacterial culture on a clean-catch specimen to

diagnose a UTI.
!
Which healthy population is

susceptible to UTIs?
105
bacteria/mL
Pregnant women. Treat this group aggressively

because of potential complications
A patient from California or Arizona presents with

fever, malaise, cough, and night sweats. Diagnosis?
Treatment?
!
Nonpainful chancre.
Coccidioidomycosis.
Amphotericin B
1 syphilis
! Rubella
A "blueberry muffin" rash is characteristic of what congenital
infection?
! Group B strep, E. coli, Listeria. Treat with
Meningitis in neonates. Causes?
gentamicin and ampicillin
Treatment?
Meningitis in infants.
Causes? Treatment?
Pneumococcus, meningococcus, H. influenzae. Treat

with cefotaxime and vancomycin
81!
Terms / Facts
!
What should always be done prior to LP?
Check for ? ICP; look for papilledema
CSF findings: ? Low glucose, PMN predominance

CSF findings: ? Normal glucose, lymphocytic
predominance
!
CSF findings: ? Numerous RBCs in serial CSF

samples
Bacterial meningitis
Aseptic (viral)
meningitis
Subarachnoid hemorrhage
(SAH)
!
CSF findings: ? ? gamma globulins

!
Initially presents with a pruritic papule with regional

lymphadenopathy and evolves into a black eschar after
7-10 days. Treatment?
Findings in 3
syphilis.
MS
Cutaneous anthrax. Treat

with penicillin G or
ciprofloxacin
Tabes dorsalis, general paresis, gummas, Argyll Robertson pupil,

aortitis, aortic root aneurysms
Characteristics of 2 Lyme
disease.
Arthralgias, migratory polyarthropathies, Bell's palsy,

myocarditis
!
Cold agglutinins.
Mycoplasma
A 24-year-old male presents with soft white

plaques on his tongue and the back of his
throat. Diagnosis? Workup? Treatment?
Candidal thrush. Workup should

include an HIV test. Treat with
nystatin oral suspension
Begin Pneumocystis carinii pneumonia (PCP) ! ? 200 for PCP (with TMP); ? 50-100
for MAI (with
prophylaxis in an HIV-positive patient at
clarithromycin/azithromycin)
what CD4 count? Mycobacterium aviumintracellulare (MAI) prophylaxis?
! Pregnancy, vesicoureteral reflux, anatomic anomalies,
Risk factors for
indwelling catheters, kidney stones
pyelonephritis.
!
Neutropenic nadir postchemotherapy.

!
Erythema migrans.
Classic physical findings for
endocarditis.
Lesion of 1 Lyme disease
Fever, heart murmur, Osler's nodes, splinter

hemorrhages, Janeway lesions, Roth's spots
!
Aplastic crisis in sickle cell disease.

Ring-enhancing brain lesion on CT with seizures
Name the organism: ? Painful chancroid.
Parvovirus B19
Taenia solium (cysticercosis)
Name the organism: ? Branching rods in oral infection.
7-10 days
Actinomyces israelii
Haemophilus ducreyi
82!
Terms / Facts
!
Name the organism: ? Dog or cat bite.

!
Name the organism: ? Gardener.
Pasteurella multocida
Sporothrix schenckii
!
Name the organism: ? Pregnant women with pets.

!
Name the organism: ? Meningitis in adults.

!
Name the organism: ? Meningitis in elderly.
Toxoplasma gondii
Neisseria meningitidis
Streptococcus pneumoniae
!
Name the organism: ? Alcoholic with pneumonia.
Klebsiella
Name the organism: ? "Currant jelly" sputum.

!
Name the organism: ? Infection in burn victims.
Klebsiella
Pseudomonas
!
Name the organism: ? Osteomyelitis from foot wound puncture.
Pseudomonas
Name the organism: ? Osteomyelitis in a sickle cell patient.
Salmonella
A 55-year-old man who is a smoker and a heavy drinker presents

! Legionella
with a new cough and flulike symptoms. Gram stain shows no
pneumonia
organisms; silver stain of sputum shows gram-negative rods. What
is the diagnosis?
! Lyme disease,
A middle-aged man presents with acute-onset monoarticular
Ixodes tick,
joint pain and bilateral Bell's palsy. What is the likely
doxycycline
diagnosis, and how did he get it? Treatment?
A patient develops endocarditis three weeks after receiving a
prosthetic heart valve. What organism is suspected?
A patient presents with pain on passive movement,
pallor, poikilothermia, paresthesias, paralysis, and
pulselessness. Treatment?
All-compartment fasciotomy
for suspected compartment
syndrome
Back pain that is exacerbated by standing and walking and relieved

with sitting and hyperflexion of the hips.
Joints in the hand affected in rheumatoid
arthritis.
S. aureus or S.
epidermidis.
Spinal
stenosis
MCP and PIP joints; DIP joints are

spared
Joint pain and stiffness that worsen over the course of the day and ! Osteoarthritis
are relieved by rest.
! Osteogenesis
Genetic disorder associated with multiple fractures and
imperfecta
commonly mistaken for child abuse.
Hip and back pain along with stiffness that improves
with activity over the course of the day and worsens at
rest. Diagnostic test?
Arthritis, conjunctivitis, and
Suspect ankylosing
spondylitis. Check HLAB27
Reactive (Reiter's) arthritis. Associated with
83!
Terms / Facts
urethritis in young men. Associated
organisms?
Campylobacter, Shigella, Salmonella,

Chlamydia, and Ureaplasma
A 55-year-old man has sudden, excruciating

first MTP joint pain after a night of
drinking red wine. Diagnosis, workup, and
chronic treatment?
Gout. Needle-shaped, negatively

birefringent crystals are seen on joint
fluid aspirate. Chronic treatment with
allopurinol or probenecid
! Pseudogout
Rhomboid-shaped, positively birefringent crystals on joint fluid
aspirate.
! Polymyalgia
An elderly female presents with pain and stiffness of the
rheumatica
shoulders and hips; she cannot lift her arms above her head.
Labs show anemia and ? ESR.
! Osgood-Schlatter
An active 13-year-old boy has anterior knee pain.
disease
Diagnosis?
!
Bone is fractured in fall on outstretched hand.

Complication of scaphoid fracture.
Signs suggesting radial nerve damage with
humeral fracture.
Distal radius (Colles' fracture)

!
Avascular necrosis
Wrist drop, loss of thumb

abduction
!
A young child presents with proximal muscle weakness,

waddling gait, and pronounced calf muscles.
A first-born female who was born in breech
position is found to have asymmetric skin
folds on her newborn exam. Diagnosis?
Treatment?
An 11-year-old obese, African-American boy

presents with sudden onset of limp. Diagnosis?
Workup?
Developmental dysplasia of the hip.

If severe, consider a Pavlik harness
to maintain abduction
!
Slipped capital femoral

epiphyses. AP and frog-leg
lateral view
!
The most common 1 malignant tumor of bone.
The most common pituitary tumor.

Treatment?
Cluster
headache
?-blockers, Ca2+ channel blockers, TCAs
Prolactinoma. Dopamine agonists (e.g.,

bromocriptine)
A 55-year-old patient presents with acute "broken

speech." What type of aphasia? What lobe and vascular
distribution?
The most common cause of
SAH.
Multiple myeloma
!
Unilateral, severe periorbital headache with tearing and

conjunctival erythema.
Prophylactic treatment for migraine.
Duchenne muscular
dystrophy
Broca's aphasia. Frontal

lobe, left MCA
distribution
Trauma; the second most common is berry

aneurysm
84!
Terms / Facts
A crescent-shaped hyperdensity on CT that does
not cross the midline.
Subdural hematomabridging
veins torn
Epidural hematoma. Middle

meningeal artery.
Neurosurgical evacuation
A history significant for initial altered mental

status with an intervening lucid interval.
Diagnosis? Most likely etiology? Treatment?
!
CSF findings with SAH.

Albuminocytologic
dissociation.
Elevated ICP, RBCs, xanthochromia
Guillain-Barr (? protein in CSF with only a modest ?

in cell count)
! Normal
Cold water is flushed into a patient's ear, and the fast phase of the
nystagmus is toward the opposite side. Normal or pathological?
! Lung, breast, skin (melanoma),
The most common 1 sources of metastases
kidney, GI tract
to the brain.
!
May be seen in children who are accused of inattention in class

and confused with ADHD.
The most frequent presentation of intracranial neoplasm.

!
The most common cause of seizures in

children (2-10 years).
Trauma, alcohol withdrawal,

brain tumor
!
First-line medication for status epilepticus.

!
IV benzodiazepine
Wernicke's encephalopathy due to a

deficiency of thiamine
!
What % lesion is an indication for carotid

endarterectomy?
The most common causes of dementia.
Seventy percent if the stenosis is

symptomatic
Alzheimer's and multi-infarct

!
Combined UMN and LMN disorder.

Rigidity and stiffness with resting tremor and masked facies.
!
The mainstay of Parkinson's therapy.
Treatment for Guillain-Barr syndrome.
ALS
Parkinson's disease
Levodopa/carbidopa
IVIG or plasmapheresis
Rigidity and stiffness that progress to choreiform movements,

accompanied by moodiness and altered behavior.
A six-year-old girl presents with a port-wine
stain in the V2 distribution as well as with
Headache
Infection, febrile seizures, trauma,

idiopathic
The most common cause of seizures in young

adults (18-35 years).
Confusion, confabulation,
ophthalmoplegia, ataxia.
Absence
seizures
Huntington's
disease
Sturge-Weber syndrome. Treat

symptomatically. Possible focal
85!
Terms / Facts
mental retardation, seizures, and
leptomeningeal angioma.
cerebral resection of affected lobe

!
Caf-au-lait spots on skin.
Neurofibromatosis 1
!
Hyperphagia, hypersexuality, hyperorality, and

hyperdocility.
Klver-Bucy syndrome
(amygdala)
! Edrophonium
Administer to a symptomatic patient to diagnose myasthenia
gravis.
! Placental abruption and placenta previa
1 causes of third-trimester bleeding.
!
Classic ultrasound and gross

appearance of complete hydatidiform
mole.
Snowstorm on ultrasound. "Cluster-ofgrapes" appearance on gross examination

!
Chromosomal pattern of a complete mole.

!
Molar pregnancy containing fetal tissue.

!
Symptoms of placental abruption.

Symptoms of placenta previa.
46,XX
Partial mole
Continuous, painful vaginal bleeding
Self-limited, painless vaginal bleeding
! Never
When should a vaginal exam be performed with suspected placenta
previa?
! Tetracycline, fluoroquinolones, aminoglycosides,
Antibiotics with teratogenic
sulfonamides
effects.
Shortest AP diameter
of the pelvis.
Obstetric conjugate: between the sacral promontory and

the midpoint of the symphysis pubis
!
Medication given to accelerate fetal lung

maturity.
Betamethasone or dexamethasone 48
hours
!
The most common cause of postpartum hemorrhage.

Treatment for postpartum
hemorrhage.
Uterine massage; if that fails, give oxytocin
Typical antibiotics for group B streptococcus (GBS)

prophylaxis.
A patient fails to lactate after an emergency Csection with marked blood loss.
IV penicillin or
ampicillin
Sheehan's syndrome (postpartum

pituitary necrosis)
!
Uterine bleeding at 18 weeks' gestation; no products expelled;

membranes ruptured; cervical os open.
Uterine bleeding at 18 weeks' gestation; no products expelled;
cervical os closed.
The first test to perform when a woman
presents with amenorrhea.
Uterine atony
Inevitable
abortion
Threatened
abortion
?-hCG; the most common cause of
86!
Terms / Facts
amenorrhea is pregnancy
!
Term for heavy bleeding during and between menstrual

periods.
Cause of amenorrhea with normal prolactin, no response to

estrogen-progesterone challenge, and a history of D&C.
Therapy for polycystic ovarian syndrome.
Medication used to induce ovulation.
Medical options for endometriosis.
Weight loss and OCPs
Clomiphene citrate
!
OCPs, danazol, GnRH agonists

!
Chocolate cysts, powder burns

!
The most common location for an ectopic pregnancy.
Ampulla of the oviduct

!
How to diagnose and follow a leiomyoma.

!
Contraceptive methods that protect against PID.
A patient presents with recent PID with RUQ

pain.
Intraductal papilloma
OCP and barrier contraception
Endometrial or estrogen receptorbreast cancer

!
Consider Fitz-Hugh-Curtis
syndrome
Breast malignancy presenting as itching, burning, and erosion of

the nipple.
Annual screening for women with a strong family
history of ovarian cancer.
A 50-year-old woman leaks urine when laughing
or coughing. Nonsurgical options?
Trichomonas
vaginitis
Oral or topical metronidazole
The most common cause of bloody nipple discharge.
Unopposed estrogen is contraindicated in

which cancers?
Ultrasound
Regresses after menopause
A patient has ? vaginal discharge and petechial patches in the

upper vagina and cervix.
Treatment for bacterial vaginosis.
Endometrial
biopsy
Stable, unruptured ectopic pregnancy of < 3.5

cm at < 6 weeks' gestation
Laparoscopic findings in endometriosis.
Natural history of a leiomyoma.
Asherman's
syndrome
Diagnostic step required in a postmenopausal woman who

presents with vaginal bleeding.
Indications for medical treatment of
ectopic pregnancy.
Menometrorrhagia
Paget's
disease
CA-125 and transvaginal

ultrasound
Kegel exercises, estrogen,

pessaries for stress incontinence
87!
Terms / Facts
A 30-year-old woman has unpredictable
urine loss. Examination is normal.
Medical options?
Anticholinergics (oxybutynin) or ?adrenergics (metaproterenol) for urge

incontinence.
!
Lab values suggestive of menopause.
? serum FSH
!
The most common cause of female infertility.

!
Two consecutive findings of atypical squamous cells of

undetermined significance (ASCUS) on Pap smear.
Follow-up evaluation?
Colposcopy and
endocervical curettage
!
Breast cancer type that ? the future risk of invasive

carcinoma in both breasts.
Endometriosis
Lobular carcinoma in
situ
! Neuroblastoma
Nontender abdominal mass associated with elevated VMA and
HVA.
! Esophageal atresia with distal TEF
The most common type of
(85%). Unable to pass NG tube
tracheoesophageal fistula (TEF).
Diagnosis?
! Mild illness and/or low-grade fever, current antibiotic
Not contraindications to
therapy, and prematurity
vaccination.
!
Tests to rule out shaken baby syndrome.

!
A neonate has meconium ileus.
Ophthalmologic exam, CT, and MRI

CF or Hirschsprung's disease
!
Bilious emesis within hours after the first feeding.

A two-month-old presents with nonbilious
projectile emesis. What are the appropriate
steps in management?
Correct metabolic abnormalities.

Then correct pyloric stenosis with
pyloromyotomy
!
The most common 1 immunodeficiency.
Selective IgA deficiency

!
An infant has a high fever and onset of rash as fever

breaks. What is he at risk for?
Acute-phase treatment for
Kawasaki disease.
Febrile seizures (roseola

infantum)
High-dose aspirin for inflammation and fever; IVIG to

prevent coronary artery aneurysms
Treatment for mild and severe unconjugated

hyperbilirubinemia.
Phototherapy (mild) or exchange

transfusion (severe)
Sudden onset of mental status changes, emesis, and liver

dysfunction after taking aspirin.
!
A child has loss of red light reflex. Diagnosis?

Vaccinations at a six-month well-child visit.
Duodenal atresia
Reye's
syndrome
Suspect retinoblastoma
HBV, DTaP, Hib, IPV, PCV
88!
Terms / Facts
!
Tanner stage 3 in a six-year-old female.
Precocious puberty
Infection of small airways with epidemics in winter and spring.

Cause of neonatal RDS.
Surfactant deficiency
!
Chronic
granulomatous
disease
What is the immunodeficiency? ? A boy has chronic

respiratory infections. Nitroblue tetrazolium test is +.
!
What is the immunodeficiency? ? A child has eczema,

thrombocytopenia, and high levels of IgA.
!
What is the immunodeficiency? ? A four-month-old

boy has life-threatening Pseudomonas infection.
!
!
A congenital heart disease that cause 2 hypertension.

!
First-line treatment for otitis media.
Coarctation of the aorta
Parainfluenza virus type 1

!
A homeless child is small for his age and has peeling

skin and a swollen belly.
!
Intussusception
Amoxicillin 10 days
!
The most common pathogen causing croup.
Wiskott-Aldrich
syndrome
Bruton's X-linked
agammaglobulinemia
A condition associated with red "currant-jelly" stools.
Defect in an X-linked syndrome with

mental retardation,
RSV bronchiolitis
Kwashiorkor (protein
malnutrition)
Lesch-Nyhan syndrome (purine salvage

problem with
gout, self-mutilation, and choreoathetosis.
A newborn female has continuous "machinery

murmur."
HGPRTase deficiency)
!
Patent ductus arteriosus

(PDA)
!
First-line pharmacotherapy for depression.
Antidepressants associated with hypertensive crisis.

Galactorrhea, impotence, menstrual dysfunction, and
? libido.
SSRIs
MAOIs
Patient on dopamine
antagonist
A 17-year-old female has left arm paralysis after her boyfriend

dies in a car crash. No medical cause is found.
Conversion
disorder
! Displacement
Name the defense mechanism: ? A mother who is angry at her
husband yells at her child.
! Reaction formation
Name the defense mechanism: ? A pedophile enters a
monastery.
! Isolation
Name the defense mechanism: ? A woman calmly describes a grisly
murder.
89!
Terms / Facts
Name the defense mechanism: ? A hospitalized 10-year-old begins to ! Regression
wet his bed.
! Neuroleptic malignant
Life-threatening muscle rigidity, fever, and
syndrome
rhabdomyolysis.
!
Amenorrhea, bradycardia, and abnormal body image in a young

female.
!
A 35-year-old male has recurrent episodes of palpitations,

diaphoresis, and fear of going crazy.
!
The most serious side effect of clozapine.

!
A 21-year-old male has three months of

social withdrawal, worsening grades,
flattened affect, and concrete thinking.
Key side effects of atypical
antipsychotics.
Anorexia
Panic
disorder
Agranulocytosis
Schizophreniform disorder (diagnosis

of schizophrenia requires ? 6 months of
symptoms)
Weight gain, type 2 DM, QT prolongation
A young weight lifter receives IV haloperidol

and complains that his eyes are deviated
sideways. Diagnosis? Treatment?
Acute dystonia (oculogyric crisis).

Treat with benztropine or
diphenhydramine
Medication to avoid in patients with a history of alcohol withdrawal !

seizures.
!
A 13-year-old male has a history of theft, vandalism, and violence

toward family pets.
Conduct
disorder
!
A five-month-old girl has ? head growth, truncal dyscoordination,

and ? social interaction.
A patient hasn't slept for days, lost $20,000 gambling, is
agitated, and has pressured speech. Diagnosis?
Treatment?
Neuroleptics
Rett's
disorder
Acute mania. Start a

mood stabilizer (e.g.,
lithium)
! Malingering
After a minor fender bender, a man wears a neck brace and
requests permanent disability.
! Factitious disorder
A nurse presents with severe hypoglycemia; blood
(Munchausen syndrome)
analysis reveals no elevation in C peptide.
A patient continues to use cocaine after being in jail, losing his job,
and not paying child support.
A violent patient has vertical and
horizontal nystagmus.
Substance
abuse
Phencyclidine hydrochloride (PCP)

intoxication
A woman who was abused as a child frequently feels

outside of or detached from her body.
A man has repeated, intense urges to rub his body against
unsuspecting passengers on a bus.
Depersonalization
disorder
!
Frotteurism (a
paraphilia)
90!
Terms / Facts
!
Tardive dyskinesia. ? or discontinue

haloperidol and consider another
antipsychotic (e.g., risperidone,
clozapine)
A schizophrenic patient takes haloperidol for

one year and develops uncontrollable tongue
movements. Diagnosis? Treatment?
A man unexpectedly flies across the country, takes a new name,

and has no memory of his prior life.
!
Risk factors for

DVT.
Dissociative
fugue
Stasis, endothelial injury and hypercoagulability (Virchow's

triad)
!
Criteria for exudative

effusion.
Causes of
exudative effusion.
Pleural/serum protein > 0.5; pleural/serum LDH >

0.6
Think of leaky capillaries. Malignancy, TB, bacterial or viral

infection, pulmonary embolism with infarct, and pancreatitis
Causes of transudative
effusion.
Think of intact capillaries. CHF, liver or kidney disease,

and protein-losing enteropathy
!
Normalizing PCO2 in a patient having an asthma

exacerbation may indicate?
Fatigue and impending

respiratory failure
! Sarcoidosis
Dyspnea, lateral hilar lymphodenopathy on CXR, noncaseating
granulomas, increased ACE, and hypercalcemia.
! Obstructive pulmonary disease (e.g., asthma)
PFT showing ? FEV1/FVC.
!
Honeycomb pattern on CXR.

Diagnosis? Treatment?
Diffuse interstitial pulmonary fibrosis.

Supportive care. Steroids may help
!
Treatment for SVC syndrome.

!
Treatment for mild, persistent

asthma.
Inhaled ?-agonists and inhaled corticosteroids

!
Acid-base disorder in pulmonary embolism.

Non-small cell lung cancer (NSCLC) associated with
hypercalcemia.
!
Lung cancer associated with SIADH.
Treatment of tension pneumothorax.

Characteristics favoring
carcinoma in an isolated
Hypoxia and hypocarbia

!
Squamous cell
carcinoma
Small cell lung cancer (SCLC)
Lung cancer highly related to cigarette exposure.

A tall white male presents with acute
shortness of breath. Diagnosis?
Treatment?
Radiation
SCLC
Spontaneous pneumothorax. Spontaneous

regression. Supplemental O2 may be
helpful
!
Immediate needle thoracostomy
Age > 45-50 years; lesions new or larger in

comparison to old films; absence of calcification or
91!
Terms / Facts
pulmonary nodule.
irregular calcification; size > 2 cm; irregular

margins
! ARDS
Hypoxemia and pulmonary edema with normal pulmonary capillary
wedge pressure.
! Mycobacterium tuberculosis
? risk of what infection with silicosis?
Causes of
hypoxemia.
Right-to-left shunt, hypoventilation, low inspired O2 tension,

diffusion defect, V/Q mismatch
!
Classic CXR findings

for pulmonary edema.
Cardiomegaly, prominent pulmonary vessels, Kerley B lines,

"bat's-wing" appearance of hilar shadows, and perivascular
and peribronchial cuffing
!
Renal tubular acidosis (RTA) associated with abnormal H+

secretion and nephrolithiasis.
!
RTA associated with abnormal HCO3 ? and rickets.

!
RTA associated with aldosterone defect.

Doughy skin.
Type II (proximal) RTA
Type IV (distal) RTA
Hypernatremia
!
Differential of hypervolemic hyponatremia.
Cirrhosis, CHF, nephritic syndrome

!
Chvostek's and Trousseau's signs.

The most common causes of hypercalcemia.
Hypokalemia
!
Peaked T waves and widened QRS.

First-line treatment for moderate
hypercalcemia.
Hypocalcemia
Malignancy and hyperparathyroidism
T-wave flattening and U waves.
Hyperkalemia
IV hydration and loop diuretics

(furosemide)
!
Type of ARF in a patient with FeNa
The most common type of nephrolithiasis.
A 20-year-old man presents with a palpable flank mass and

hematuria. Ultrasound shows bilateral enlarged kidneys with
cysts. Associated brain anomaly?
Hematuria, hypertension, and oliguria.
Proteinuria, hypoalbuminemia, hyperlipidemia,
hyperlipiduria, edema.
Prerenal
!
A 49-year-old male presents with acute-onset flank pain and

hematuria.
Type I (distal)
RTA
Nephrolithiasis
Calcium oxalate
!
Cerebral berry
aneurysms (AD
PCKD)
Nephritic syndrome
!
Nephrotic
syndrome
92!
Terms / Facts
!
The most common form of nephritic syndrome.

The most common form of glomerulonephritis.
IgA nephropathy (Berger's disease)

!
Glomerulonephritis with deafness.

!
Glomerulonephritis with
hemoptysis.
Membranous glomerulonephritis
Alport's syndrome
Wegener's granulomatosis and Goodpasture's

syndrome
!
Presence of red cell casts in urine

sediment.
Glomerulonephritis/nephritic syndrome
Eosinophils in urine sediment.
Allergic interstitial nephritis

!
Waxy casts in urine sediment and Maltese crosses (seen with

lipiduria).
Drowsiness, asterixis, nausea, and a
pericardial friction rub.
Nephrotic
syndrome
Uremic syndrome seen in patients

with renal failure
Wait, surgical resection, radiation

and/or androgen suppression
A 55-year-old man is diagnosed with

prostate cancer. Treatment options?
Low urine specific gravity in the presence of high serum osmolality.

Treatment of SIADH?
Renal cell carcinoma (RCC)

!
Testicular cancer associated with ?-hCG, AFP.

The most common type of testicular cancer.
Transitional cell carcinoma

!
Complication of overly rapid correction of

hyponatremia.
!
Choriocarcinoma
Seminomaa type of germ cell tumor
The most common histology of bladder cancer.
Central pontine
myelinolysis
Anion gap acidosis and 1 respiratory alkalosis

due to central respiratory stimulation
Acid-base disturbance commonly seen in pregnant women.

!
Three systemic diseases ? nephrotic syndrome.

Elevated erythropoietin level, elevated
hematocrit, and normal O2 saturation
suggest?
A 55-year-old man presents with irritative
!
and obstructive urinary symptoms.
Treatment options?
DI
Fluid restriction, demeclocycline
Hematuria, flank pain, and palpable flank mass.
Salicylate ingestion ? in what type

of acid-base disorder?
Respiratory alkalosis
DM, SLE, and amyloidosis
RCC or other erythropoietinproducing tumor; evaluate with CT

scan
Likely BPH. Options include no

treatment, terazosin, finasteride, or
93!
Terms / Facts
surgical intervention (TURP)
! Antipsychotics (neuroleptic
Class of drugs that may cause syndrome of muscle
malignant syndrome)
rigidity, hyperthermia, autonomic instability, and
extrapyramidal symptoms.
! Acute mania, immunosuppression, thin skin, osteoporosis,
Side effects of
easy bruising, myopathies
corticosteroids.
!
Treatment for DTs.
Benzodiazepines
!
Treatment for acetaminophen overdose.
N-acetylcysteine
!
Treatment for opioid overdose.
Treatment for benzodiazepine overdose.

!
Treatment for neuroleptic malignant syndrome.
Nitroprusside
Rate control, rhythm conversion, and anticoagulation

!
Treatment of supraventricular
tachycardia (SVT).
!
Causes of drug-induced SLE.
Rate control with carotid massasge or other

vagal stimulation
INH, penicillamine, hydralazine, procainamide
Macrocytic, megaloblastic anemia with neurologic symptoms.
Test to rule out urethral injury.

Radiographic evidence of
aortic disruption or
dissection.
Radiographic indications for
surgery in patients with acute
abdomen.
B12 deficiency
Folate deficiency
Treat CO poisoning with

100% O2 or with hyperbaric
O2 if severe poisoning or
pregnant
A burn patient presents with cherry-red flushed

skin and coma. SaO2 is normal, but
carboxyhemoglobin is elevated. Treatment?
Blood in the urethral meatus or high-riding
prostate.
!
!
Macrocytic, megaloblastic anemia without neurologic

symptoms.
Bladder rupture or urethral

injury
Retrograde cystourethrogram
Widened mediastinum (> 8 cm), loss of aortic knob,

pleural cap, tracheal deviation to the right, depression
of left main stem bronchus
!
Free air under the diaphragm, extravasation of

contrast, severe bowl distention, space-occupying
lesion (CT), mesenteric occlusion (angiography)
The most common organism in burn-related infections.
Flumazenil
Dantrolene or bromocriptine
Treatment for malignant hypertension.

Treatment of AF.
Naloxone
Pseudomonas
94!
Terms / Facts
Method of calculating fluid repletion in burn patients.
Parkland formula
!
50 cc/hour
30 cc/hour
Acceptable urine output in a trauma patient.

Acceptable urine output in a stable patient.
!
Cannon "a" waves.
Third-degree heart block

!
Signs of neurogenic shock.

!
Signs of ? ICP (Cushing's

triad).
Hypotension and bradycardia
Hypertension, bradycardia, and abnormal

respirations
? CO, ? pulmonary capillary wedge pressure (PCWP), ?

peripheral vascular resistance (PVR).
? CO, ? PCWP, ? PVR.
Treatment of septic shock.
!
Treatment of cardiogenic shock.
Etiologies:
CHF
Cardiogenic shock
Fluids and antibiotics
Diphenhydramine or epinephrine 1:1000

!
Continuous positive airway pressure
A patient with chest trauma who was previously stable

suddenly dies
!
Trauma series.
Identify cause; fluid and blood repletion
Supportive treatment for ARDS.

Signs of air
embolism.
AP chest, AP/lateral C-spine, AP pelvis
HTN Endocrine Anemia Rheumatic heart disease Toxins Failure to take

meds Arrhythmia Infection Lung (PE) Electrolytes Diet (excess Na+)
Definition: parapneumonic effusion

Definition: pneumothorax
Pleural effusio in the presence of pneumonia
Air in the normally airless pleural space

!
Categories: pneumothorax (2)
Spontaneous Traumatic
What is the usual cause of traumatic pneumothoraces?

After what procedures should
CXR always be obtained?
Why? (3)
Pneumothorax (3)
Physical exam:
Hypovolemic
shock
Identify cause; pressors (e.g., dobutamine)
Treatment of hypovolemic shock.

Treatment of anaphylactic shock.
Iatrogenic
Pneumothorax: Transthoracic needle aspiration

Thoracentesis Central line placement
!
Ipsilateral chest pain, sudden onset Dyspnea

Cough
Decreased breath sounds over affected side Hyperresonance
95!
Terms / Facts
Pneumothorax (4)
over the chest Decreased or absent tactile fremitus on affected

side Mediastinal shift toward side of pneumothorax
Tx: primary
spontaneous
pneumothorax
Small/asymptomatic:observation Large/symptomatic: O2
administration, chest tube insertion
!
Tx: secondary spontaneous pneumothorax

!
accumulation of air within the pleural space such that tissues

surrounding the opening into the pleural space act as valves,
allowing air to enter but not to escape
Definition: tension
pneumothorax
Etiologies: tension
pneumothorax (3)
!
Physical exam: tension

pneumothorax (4)
!
Tx: tension
pneumothorax (2)
!
Definition:
Interstitial Lung
Disease
ILD
Physical exam: ILD
(3)
Dx: ILD
(6)
chest tube drainage
mechanical ventilation w/ associated barotrauma

CPR Trauma
hypotension distended neck veins trachael shift away

from pneumothorax decreased breath diminished breath
sounds
medical emergency (1) chest compression with a large-bore
needle (2) chest tube placement
Inflammatory process involving the alveolar wall that can lead

to irreversible fibrosis, distortion of lung architecture and
impair gas exchange
!
Dyspnea (first with exertion, then with rest) Cough

(nonproductive) Fatigue
Rales at base Digital clubbing Cyanosis/pulmonary HTN in

advanced disease
CXR High resolution CT PFTs Bronchoalveolar lavage Tissue Bx

Serologies
Clinical manifestion (skin): sarcoidosis (2)
erythema nodusum lupus pernio

!
Clinical manifestations (eyes): sarcoidosis

Clinical manifestations (cardiac): sarcoidosis
(3)
Clinical manifestations (MSK): sarcoidosis (2)
arrhythmias heart block sudden

death
!
What is the most common cause of death with sarcoidosis?

!
Dx: sarcoidosis
(4)
Tx: sarcoidosis
Uveitis (anterior)
arthalgias bone lesions

!
Cardiac disease
CXR - bilateral hilar lymphadenopathy ACE levels Lung biopsy

PFTs
systemic corticosteroids methotrexate for refractory disease
96!
Terms / Facts
!
What is the typical patient presenting with histiocytosis X?

!
Etiologies:
ILD (6)
young male smoker
Sarcoidosis Iatrogenic Environmental/occupational exposure Collagen

vascular disease Hypersensitivity disease Alveolar filling disease
!
Clinical presentation: asbestosis (2)
Exertional dyspnea Cough w/ sputum
Clinical presentation: hypersensitivity pneumonitis ! Fever Chills Cough Dyspnea

(4)
! removal of offending agent glucocorticoids
Tx: hypersensitivity pneumonitis (2)
!
Clinical presentation: eosinophilic pneumonia
acute hypoxic febrile illness

!
Tx: eosinophilic pneumonia
Clinical presentation: goodpasture syndrome

!
Tx: goodpasture syndrome (3)
inflammatory lung disease w/ similar clinical and

radiographic features to infectious pneumonia
!
Clinical manifestations: cryptogenic organizing

pneumonitis
Tx: cryptogenic organizing pneumonitis
Criteria:
ARDS
steroids - relapses common after cessation
Hypoxemic respiratory failure

Hypercarbic (ventilatory)
What are the major pathophysiologic mechanism of

hypoxemic respiratory failure? (2)
What is
intrapulomonary
shunting?
V/Q mismatch
Intrapulmonary shunting
Little or no ventilation in perfused areas (due to collapsed or

fluid-filled alveoli); venous blood is shunted into the arterial
circulation w/o being oxygenated
Hypoxia due to what cause is responsive to

O2? And not?
Clinical presentation: respiratory failure (2)
cough dyspnea flu-like

symptoms
Acute onset (< 24hr) Bilateral patchy airspace disease Noncsardiogenic

pulmonary edema (PCWP < 18) Severe hypoxemia (PaO2/FiO2 200)
What are the two major types of acute

respiratory failure?
Physical exam:
lung lavage GM-CSF
supplemental O2 corticosteroids w or w/o

cyclophosphamide lung transplantation
!
Definition: cryptogenic
organizing pneumonitis
DAH + RPGN
plasmapheresis cyclophosphamide corticosteroids
Tx: pulmonary alveolar proteinosis (2)

Tx: idiopathic pulmonary
fibrosis (3)
steroids
V/Q mismatch responsive to O2 Shunt not responsive

!
dyspnea cough +/-
inability to speak in complete sentences tachypnea
97!
Terms / Facts
respiratory failure (5)
tachycardia cyanosis impaired mentation
What is the effect of severe

hypercapnia on cerebral
vasculature?
Vasodilation of cerebral vessels (with increased

intracranial pressure and papilledema, headache,
impaired consciousness)
!
What parameter is used to monitor ventilation?

What parameters are used to monitor oxygenation? (2)
What techniques are used to
improve tissue oxygenation?
(4)
PaCO2
O2 saturation PaO2
Increase FIO2 Increase PEEP Extend inspiratory

time fraction Decrease O2 requirements (work of
breathing, fever, agitation)
What are the forms of noninvasive positive pressure ventilation?

!
What is the primary indication for BIPAP use?
BIPAP/CPAP
Hypoventilation
Provide an algorithm for evaluating a patient with hypoexemia.

!
Dx: respiratory failure (3)

!
Tx: respiratory
failure (3)
ABG CXR or chest CT CBC and CMP
Treat underlying disease Provide supplemental O2 if patient is

hypoxemic NPPV or intubation w/ mechanical ventilation if
condition worsens
!
Only for conscious patients with possible impending

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

candidates for NPPV?
Why are high concentrations of supplemental

O2 contraindicated in hypercarbic (e.g. COPD)
patients?
Pathophysiology: ARDS
(3)
!
Etiologies:
ARDS (8)
Tx: ARDS
(4)
O2 can decrease respiratory drive

by decreasing hypoxia, worsening
hypercapnia
intrapulmonary shunt hypoxemia dead space

fraction compliance
Dyspnea Tachypnea Tachycardia Unresponsive to

O2
CXR - diffuse bilateral pulmonary infiltrates ABG Pulmonary artery

catheter Bronchoscopy w/ BAL
Oxygenation (> 90%) Mechanical ventilation w/ PEEP Fluid

management Treat underlying disease
Complications:
Sepsis (most common) Pneumonia Aspiration of gastric contents

Severe trauma/fractures Acute pancreatitis Cardiopulmonary bypass
Intracranial HTN Drug overdose
Clinical presentation: ARDS

(4)
Dx: ARDS
(4)
permanent lung injury ventilator induced lung injury line
98!
Terms / Facts
ARDS (4)
associated infections renal failure

!
Definition: pulmonary
HTN
!
PA mean pressure > 25 mm Hg at rest or 30 mm Hg w/

exertion
Pulmonary arterial HTN Left heart disease Lung

disease/chronic hypoxemia Chronic thrombotic/embolic disease
Miscellaneous (sarcoid, histiocytosis X, lymphangiomatosis)
Classification:
pulmonary HTN (5)
pulmonary HTN (4)
Dyspnea Exertional syncope (hypoxia, decreaed CO)

Exertional chest pain (RV ischemia) RHF sx
Physical exam: pulmonary HTN (3)

!
Dx: pulmonary HTN (5)

!
Tx: pulmonary
HTN (2)
pulmonary HTN in the absence of diseases of the

heart or lung
RVH w/ eventual RV failure resulting from pulmonary HTN

2/2 pulmonary disease
!
COPD (most common) other lung diseases (PE, ILD, asthma,

CF, etc.)
Clinical manifestations: cor

pulmonale (5)
pulmonary vasodilators (IV prostacycline, CCBs, bosentan,

etc.) Anticogulation w/ warfarin lung transplantation
Etiologies: cor
pulmonale
Tx: cor
pulmonale (4)
EKG PFTs ABG Echo Cardiac cath
Tx: primary
pulmonary HTN (3)
Dx: cor pulmonale

(3)
prominent P2 R-sided S4 RV heave
prevent and reverse vasoactive substance imbalance and vascular

remodeling (O2, vasodilators, anticoags,etc) prevent RV failure
(diuretics, digoxin)
Definition: primary pulmonary

HTN
Definition: cor
pulmonale
Decrease in exercise tolerance Cyanosis and digital

clubbing s/s RHF parasternal lift polycythemia
CXR (enlargement of the RA, RV and pulmonary arteries)

EKG Echo
Treat underlying pulmonary disorder diuretic therapy O2 therapy

long term Digoxin if coexistent LV failure
Clinical presentation: Barrter

syndrome (3)
Polydipsia Polyuria Growth/mental

retardation
In a patient with viral hepatitis, what does PT and

transaminases reflect?
What is the single most important test to assess function of

the liver?
How can pregnancy
Progression to fulminant
hepatitis
!
Prothrombin time
(PT)
Accumulation of fluid in the carpal tunnel can cause CTS,
99!
Terms / Facts
cause CTS?
especially in the third trimester
What is the mechanism by which acromegaly

causes carpal tunnel syndrome?
!
What are the dietary

recommendatiosn for patients with
renal calculi? (4)
Synovial tendon hyperplasia causes

median nerve compression
Decreased protein and oxalate Decreased

sodium intake Increased fluid intake
Decreased dietary calcium
!
A systolic-diastolic abdominal bruit is strongly suggestive of

what disease?
!
Dx: squamous cell carcinoma of the skin

!
Risk factors: squamous cell

carcinoma of the skin (4)
How do diuretics
promote gout attacks?
Hyperuricemic effect resulting from hypovolemia-associated

enhancement of uric acid absorption in the PCT
!
Diarrhea Dermatitis Dementia
What kind of surveillance is necessary in patients

with giant-cell arteritis? Why?
!
polycythemia vera (4)
Tense bullae Urticarial plaques Pruritus
Hyperviscosity (HA, dizziness, tinnitus, blurred vision)

Thrombosis (DVT, MI, stroke, budd-chiari, amaurosis
fugax) Pruritus Bleeding (epistaxis, GI bleed)
Physical exam: polycythemia vera

(4)
plethora splenomegaly HTN engorged retinal

veins
phlebotomy low-dose ASA hydroxyurea supportive:

allopurinol (gout), H2-blockers (pruritus)
Dx: polycythemia vera (3)

What will a BM bx in polycythemia vera
show?
CBC Epo level BM bx
Hypercellular w/ megakaryocytic
hyperplasia
What will EPO levels show in polycythemia vera?
Serial chest x-rays to look for

aortic aneurysms
Determine whether a pleural effusion is transudative or

exudative
Physical exam: bullous pemphigoid (3)
Definition:
Fluid protein/serum protein > 0.5 Fluid LDH/serum LDH > 0.6 Fluid
LDH > 2/3 ULN serum LDH
What are Light's criteria

used for?
Tx: polycythemia
vera (4)
Punch biopsy
SHIT can lead to SCC Sun exposure H/o of burns

Immunosuppression Tar derivatives
Clinical presentation: pellagra (3)
Light's
criteria (3)
Renal artery
stenosis
EPO
in RBC mass +/- granulocytes and platelets in the absence
100!
Terms / Facts
polycythemia vera
!
Dx: TTP-HUS (2)

Tx: TTP (3)
of physiologic stimulus
CBC (thrombocytopenia) Peripheral smear (w/ schistocytes)
Plasmapheresis Corticosteroids FFP if delay to plasma exchange

!
What kind of saline solution

should be used to correct acute
hyponatremia? Why?
Hypertonic saline (3%) because equiilbration

has not occurred yet and thus the risk of CPM is
low; correction can happen more rapidly
!
Clinical manifestations: chronic

venous insufficiency (3)
Swelling of the lower leg Skin changes (thin,

scaly, atrophic) Venous ulcers
What is the most common cause of chronic venous insufficiency?

!
Pathophysiology: chronic
venous insufficiency
!
Tx: chronic venous

insufficiency (3)
Incompetence of venous valves in the deep venous

system ambulatory HTN edema
Memory loss Apraxia Aphasia Personality changes

and impaired judgment (later)
acinar injury via direct or indirect toxicity release or

impaired secretion of enzymes autodigestion fat necrosis
profound acute inflammatory response
What are the most common etiologies of

pancreatitis? (2)
!
pancreatitis (3)
!
Ddx:
pancreatitis (7)
Tx:
pancreatitis (4)
Complications:
pancreatitis (5)
Ranson's criteria
(admission) (5)
Gallstones (40%) Alcohol

(30%)
Epigastric abdominal pain, constant, radiating to back,

some relief w/ leaning forward N/V
acute cholecystitis perforated viscus intestinal obstruction

mesenteric ischemia IMI AAA ruptured ectopic pregnancy
Physical exam:
pancreatitis (5)
Dx: pancreatitis (2)
Prior h/o DVT
Leg elevation Avoiding long periods of sitting or

standing Compression stockings
Alzheimer's Disease (4)
Pathophysiology:
pancreatitis
abdominal tenderness and guarding fever tachycardia

hypotension bowel sounds
serum amylase and lipase levels Abd CT (test of choice)
Fluid resuscitation Nutrition (enteral vs TPN) Analgesia (IV

meperidine/morphine) Prophylatic systemic abx (imipenem)
!
ARDS Pseudocyst Necrosis (sterile vs. infected) Acute

fluid collection Infection
!
Glucose > 200 mg/dl Age > 55 yrs LDH > 350 AST >
250 WBC > 16000
101!
Terms / Facts
Ranson's criteria
(48 hours) (6)
C alcium < 8 mg/dl H ct > 10% Pa O 2 8 mg/dl BUN increase

> 8 mg/dl B ase deficit > 4 mg/dl Fluid S equestration > 6 L
Etiologies: chronic pancreatitis (3)
Alcoholism (80%) Hereditary Autoimmune

!
Clinical manifestation: chronic

pancreatitis (3)
!
Dx: chronic pancreatitis

(2)
Epigastric pain N/V Steatorrhea and wt loss

over time
CT scan - calcifications ERCP (gold standard but not done

much)
!
Tx: chronic pancreatitis (2)
low fat diet enzyme replacement
Clinical presentation (adult):

parvovirus B19
acute onset polyarticular and symmetric

arthritis
Acute onset Lack of elevated

inflammatory markers Resolution within 2
months
What features distinguish viral arthritis

from other causes of arthritis? (3)
Explain the mechanism of a febrile
transfusion reaction. What procedure can
reduce risk of this from happening?
Tx: myasthenia
crisis
Antibodies in the patient's plasma react

with donor leukocytes; washing the
cells depletes leukocytes
Endotracheal intubation Withdrawal of anticholinesterases for

several days
Tx: amebic abscess

Clinical presentation: amebic abscess
(4)
Oral metronidazole
RUQ pain Diarrhea Leukocytosis Elevated

ALP
!
Tx: first-degree heart block

What is the most important cause of morbidity
and mortality in subarachnoid hemorrhage?
!
Clinical presentation: carbon monoxide

poisoning (4)
Clinical presentation: subarachnoid
hemorrhage (4)
Etiologies: subarachnoid
hemorrhage (3)
Vasospasm with symptomatic

ischemia and infarction
Headache Nausea Dizziness Exposure

to CO
Thunderclap headache Transient LOC N/V

Meningismus
Ruptured berry aneurysm (most common) Trauma

AV malformation
Non-contrast CT LP if CT is unrevealing and clinical

suspicion is high Cerebral angiogram (once SAH is
diagnosed)
Vasospasm (50%) Rerupture Hydrocephalus Seizures
Dx: subarachnoid
hemorrhage (3)
Complications: SAH
None; observation
102!
Terms / Facts
(5)
SIADH
Tx: SAH
(5)
Reverse anticoagulation HTN control Surgery (berry aneurysm) Nimodipine

(for vasospasm) Phenytoin (seziure prophylaxis)
!
What is the initial test of choice for back pain?

!
Sore throat and

lymphadenopathy are
uncommon
How does the presentation of CMV mononucleosis

differ from that of EBV mononucleosis?
!
Clinical manifestations: infectious

mononucleosis (5)
!
Physical exam: infectious

mononucleosis (5)
!
Dx: infectious
mononucleosis (3)
Monospot test Peripheral blood smear (atypical

lymphocytes) Throat culture (r/o strep pharyngitis)
Transmission: enterobiasis
Tx: enterobiasis
Enterobius vermicularis (roundworm)
Fecal oral (usually self transmission in children)

!
Clinical presentation: enterobiasis

!
Fever Sore throat Malaise Myalgias

Weakness
Lymphadenopathy Pharyngeal erythema/exudate

Splenomegaly Maculopapular rash Hepatomegaly
What is the causative agent in enterobiasis?
Dx: enterobiasis
Perianal pruritus, worse at night
Tape test; see eggs on tape after it is placed near anus

Albendazole/mebendazole; pyrantel pamoate is alternative
What is the most common helminthic infection in the US?

Describe the lesions of molluscum
contagiosum
Definition: leukemoid
reaction
!
spinal cord compression
(4)
What conditions predispose to

molloscum contagiosum? (3)
Enterobiasis
Firm, flesh color, dome shaped umbilicated

papules
Cellular immunodeficiency (AIDS)
Corticosteroids Chemotherapy
Marked increase in leukocytes due to a severe infection or

inflammation
Flacid paraparesis and absent reflexes (acute) vs. spastic
paraparesis and hyperactive reflexes (chronic) Sensory loss
below lesion Bilateral prominent Babinski signs Posterior
column dysfunction in legs
!
Dx: spinal cord compression

What is the localization of cauda equina
syndrome?
Plain film x-ray
STAT MRI
Nerve roots (LMN) and

Unilateral
103!
Terms / Facts
!
Describe the pain in cauda equina syndrome
Severe, radicular > back

!
What is the pattern of sensory loss in cauda equina

syndrome?
!
What is the pattern of motor dysfunction in cauda

equina syndrome?
What happens to bowel/bladder function in cauda
equina syndrome? (2)
What is
coronary steal?
EKG findings: variant angina

!
Tx: variant angina (2)

!
Tx: symptomatic
cholelithiasis
!
Clinical
presentation:
osteoarthritis (4)
Loss of rectal tone Urinary

incontinence
transient ST elevations on EKG
Cholecystectomy is indicated for all patients with

symptomatic gallstones
Joint pain (often monoarticular) that worsens with activity and

improves with rest Stiffness in the morning or after a period of
inactivity Limited range of movement Lack of systemic
symptoms
!
Radiographic findings:
osteoarthritis (4)
!
In the night (midnight to 8

am)
CCBs/nitrates avoidance of triggers
Dx: osteoarthritis
!
Plain film x-ray
Joint space narrowing Osteophytes Subchondral

sclerosis Subchondral cysts
Lifestyle changes Acetaminophen/NSAIDs Intrarticular injections

(steroids) Surgery for serious debility
Clinical presentation: opioid

intoxication (4)
Respiratory depression Hypotension Decreased

bowel sounds Miosis (sometimes)
Clincial manifestations: obesity hypoventilation

syndrome (3)
Physical exam: obesity hypoventilation
syndrome (3)
ABG findings: obesity hypoventilation
syndrome (3)
Tx: obesity hypoventilation
syndrome (4)
Marked asymmetric
weakness
Redistribution of coronary blood flow to 'non-diseased' segments

induced by pharmacological vasodilation (dipyridamole)
When do episodes of variant angina occur most

frequently?
Tx: osteoarthritis
(4)
Assymetric saddle/leg
hypersomnolence fatigue
exertional SOB
Extreme obesity Thick neck

Hypoventilation
hypercapnia hypoxemia respiratory

acidosis
weight loss ventilator support O2 therapy

progestins
104!
Terms / Facts
!
Surveillance: women
treated for CIN II/III
Pap smears q6 mos until 3 negative tests obtained, then

resume age appropriate screening (annually)
!
Clinical presentation: acute angle

closure glaucoma (3)
!
Verrucous lesions (papulopustular, then

progressively crusted, warty and violaceous)
Ulcerative
Describe the cutaneous lesions

of blastomycosis. (2)
Clinical presentation: disseminated

gonococcal infection (3)
What neurotransmitter is implicated in
restless leg syndrome?
Clinical presentation: essential
tremor
unilateral, severe eye pain redness dilated

pupil w/ poor light response
Polyarthralgia Tenosynovitis Painless

vesiculopustular skin lesions
!
Abnormalities in dopaminergic
transmission; dopamine agonists used
Tremor that is increased at the end of goaldirected activities

!
Tx: essential tremors

!
anserine bursitis
!
Physical exam:
anserine bursitis (2)
Sharply localized pain over the anteromedial part of the

tibial plateau just below the joint line of the knee
Well defined area of tenderness over the medial tibial plateau

just below the joint line Valgus stress test does not aggravate
the pain
!
Tx: anserine bursitis

Bilirubin in the urine is
indicative of what
condition? Why?
propranolol
Corticosteroid injections into the bursa

Conjugated (direct) hyperbilirubinemia; only the
conjugated bili is water soluble and unbound to albumin,
and so it is filtered in the urine
What causes the pleuritic pain associated with PE?

Etiologies: hypovolemic
hyponatremia (2)
Pulmonary infarction
GI losses (vomiting, diarrhea) Renal losses

(diuretics)
What is the primary hormone that regulates total body sodium?
Aldosterone
! ADH
What is the primary hormone that regulates total body sodium
concentration?
! excess of water relative to sodium; almost always due
Pathophysiology:
to ADH
hyponatremia
What are the three classes of hypotonic

hyponatremia?
Etiologies: euvolemic
!
hypotonic hyponatremia (5)
Hypovolemic Euvolemic
Hypervolemic
SIADH Glucocorticoid deficiency Hypothyroidism

Psychogenic polydipsia Low solute (beer potomania,
105!
Terms / Facts
tea&toast)
!
Etiologies: hypervolemic hypotonic

hyponatremia (4)
!
Tx: hypovolemic hyponatremia

Tx: SIADH
(4)
volume repletion w/ normal saline
volume restrict treat underlying cause hypertonic saline (if sx or

restriction doesn't help) conivaptan if refractory SIADH
!
Tx: hypervolemic hyponatremia (2)

Workup:
hyponatremia
CHF Cirrhosis Nephrotic syndrome

Advanced renal failure
free water restrict aquaresis (conivaptan)
Measure plasma osmolality determine tonicity for

hypotonic determine volume status measure U osm
What labs should be ordered on all patients with

suspected BPH? (2)
Urinalysis Serum
creatinien
!
What serum ascites albumin gradient level indicates that portal

hypertension is the cause of ascites?
!
What antibody is positive in ulcerative colitis?
SAAG > 1.1

g/dl
p-ANCA
! Anoscopy/proctoscopy
What is the initial diagnostic procedure in patients < 50
y/o who present with BRBPR?
! Pruritic, elevated, serpiginous lesions in the skin;
infection often acquired through contact w/ sand
cuteaneous larva migrans
!
What are the 5 P's of embolic

occlusion?
Tx: acute limb
ischemia (2)
Pain Pulselessness Paresthesia Poikilothermia

Pallor
IV heparin (immediately) Surgical embolectomy or intraarterial/mechanical embolectomy
What is a common side effect of the dihydropyridine Ca-channel

antagonists?
!
What is the most common source of

pulmonary emboli?
Definition:
emphysematous
cholecystitis
Initial thyrotoxicosis due to destruction

of follicular cells
Form of acute cholecystitis that arises due to secondary

infection of the gallbladder wall with gas-forming
bacteria
emphysematous cholecystitis (5)
RUQ pain Nausea Vomiting Low grade fever

Crepitus in abdominal wall adjacent to GB
Radiographic findings: emphysematous !
Peripheral
edema
Proximal deep leg veins (iliac, femoral and

popliteal veins)
!
What is the initial effect of radioactive

iodine on the thyroid?
Air fluid levels in GB by plain film US w/
106!
Terms / Facts
cholecystitis (2)
curvilinear gas in GB
stone impaction in cystic duct inflammation behind
obstruction GB swelling secondary infection of
biliary fluid (50%)
Pathogenesis: acute
calculous cholecystitis
What are the indications for asymptomatic

patients with cholelithiasis to receive
cholecystectomy? (4)
!
Definition: cholecystoenteric
fistula
Definition: gallstone ileus
!
!
When a GB stone erodes through the GB into the

bowel
RUQ/epigastric pain N/V Fever +/- radiation to R

shoulder/back
!
Physical exam: cholecystitis (2)
Tx: cholecystitis
(4)
Mucosal GB calcification GB
polyps > 10 mm Native American
Stone > 3 cm
SBO due to stone in intestine that passed through fistula
cholecystitis (4)
Dx: cholecystitis (2)
RUQ tenderness Murphy's sign
RUQ U/S HIDA scan (most sensitive)
NPO IV fluids Abx (zosyn, ceftriaxone, or FQ) Cholecystectomy

!
Definition: choledocholithiasis
!
choledocholithiasis
Gallstone lodged in bile duct
Asymptomatic (50%) RUQ/epigastric pain due to

obstruction of bile flow
bilirubin ALP
Lab findings: choledocholithiasis (2)
What does a spike in amlyase or ALT in the context of

choledocholithiasis indicate?
Tx: choledocholithiasis
(2)
Passage of the
stone
ERCP & papillotomy w/ stone extraction CCY w/in 6

weeks
! cholangitis cholecystitis pancreatitis strictures

Complications: choledocholithiasis
(4)
! Weak urinary stream Urgency Frequency Sensation of
incomplete voiding
BPH (4)
!
What is the most important initial step in patients who

present with acute renal failure?
What diagnostic test is most useful in
distinguishing asthma from COPD?
When should screening for CRC begin in high risk

patients (e.g. with first degree relative w/ CRC)?
Placement of a Foley
catheter
FEV1 measurement with and

without a bronchodilator
!
10 years before the age the

relative was diagnosed
107!
Terms / Facts
!
Clinical manifestation: tinea

corporis
Tx: tinea
corporis
Ring-shaped scaly patches with central clearing and

distinct borders
2% antifungal lotions (e.g. terbinafine) or griseofulvin for extensive

disease
!
Account for the increased

bruisability of patients with
amyloidosis.
Binding of amyloid fibrils to the liver can inhibit

the synthesis of coagulation factors, resulting in
increased bruisability
!
What is the most common cause of back pain?

!
What bacterial infections are patients with

hemochromatosis more susceptible to? (3)
!
Lumbosacral strain
L. monocytogenes Yersinia
enterolitica V. vulnificus
Back pain that radiates to buttoms and thigh Worse

during walking and lumbar extension Alleviated by
flexion
Clincal presentation: lumbar

spinal stenosis (3)
What is the most common congenital cause of aplastic anemia?

!
Clinical manifestations (bone marrow):

Fanconi anemia
!
Clinical manifestations (skin):

Fanconi anemia (3)
Apalstic anemia and progressive bone

marrow failure
Short stature Microcephaly Abnormal

thumbs Hypogonadism
What are the eye/ear abnormalities that patients

with Fanconi anemia present with? (3)
When is the peak incidene of ventricular free wall
rupture s/p MI?
!
Complications: ventricular free wall

rupture (2)
!
Clinical manifestations: tonsillitis (4)

!
Strabismus Low-set ears

Middle ear abnormalities
!
3-7 days s/p anterior wall

MI
Acute decompensation PEA 2/2

tamponade
fever sore throat dysphagia headache
swollen, hyperemic red tonsils +/- exudate unilateral cervical

lymphadenopathy
Definition: peritonsillar
abscess
acute bacterial infection next to the tonsils and

pharynx
What disease precudes peritonsillar abscess?

Tx: peritonsillar abscess (2)
Fanconi anemia
hypopigmented/hyperpigmented areas cafe au lait

spots large freckles
Describe the appearance of patients with

Fanconi anemia (4)
Physical exam:
tonsillitis (2)
Acute tonsillitis
Incision and drainage IV abx
108!
Terms / Facts
Clinical manifestations: peritonsillar abscess
(4)
!
Physical exam: peritonsillar

abscess (2)
Muffled voice Fever Chills Sore

throat
uvula deviation prominent unilateral

lymphadenopathy
! Acute erosive gastritis

Massive doses od NSAIDs can cause what problem
acutely?
! Acute onset severe eye pain Blurred
Clincial manifestations: acute angle
vision Nausea Vomiting
!
Arises when the peripheral iris occludes the anterior

chamber angle, blocking aqueous outflow and causing a
sudden increase in IOP
Mechanism: acute angle

closure glaucoma
Tx: acute angle closure

glaucoma (2)
intravenous acetazolamide laser peripheral iridotomy

(definitive)
!
Physical exam: acute angle

red eye w/ steamy cornea moderately dialted pupil

that is not reactive to light
What vaccinations should patietns with chronic hepatitis C receive? !

(2)
! ribavirin + interferon-alfa
Tx: chronic hepatitis C
What vascular problem should all cirrhotic patients be
screened for? How?
Esophageal varices by
endoscopy
What does primary prophylaxis for esophageal varices 2/2 cirrhosis

consist of?
What is the most common thyroid cancer?
Risk factors: thyroid
cancer (3)
Beta
blockers
Papillary thyroid cancer
Digitalis toxicity Increased vagal tone Inferior

wall MI
Definition: hyperglycemic hyperosmolar

non-ketotic syndrome
Mechanism: hyperglycemic
hyperosmolar non-ketotic syndrom
Lab findings: HHNK syndrome (3)

!
Extreme hyperglycemia w/o ketoacidosis

+ hyperosmolarity + AMS
Hyperglycemia osmotic diuresis vol

depletion pre-renal azotemia glc, etc.
Clinical manifestations: HHNK syndrome (2)
Head/neck irradiation during childhood Positive family

history Female sex
Etiologies: Wenkebach heart

block (3)
Tx: HHNK syndrome (2)
Hep A Hep B
Volume depletion AMS
serum glc, serum osmolality, BUN/Cr
aggresive hydration (initially NS then 1/2 NS) Insulin
109!
Terms / Facts
A wedge-shaped pulmonary infarct is virtually pathognomonic
for what problem?
!
What are the criteria for a massive

pulmonary embolism? (2)
JVP R-sided S 3 Graham Steel murmur
When does surveillance for CRC begin in a patient

with IBD? What does it consist of?
Definition:
osteomyelitis
Hypotension PEA
Infections cause systemic release of insulin

counterregulatory hormones like catecholatimes and
cortisol
Explain why infections are

precipitants for DKA.
Tx: hereditary spherocytosis

(2)
Pulmonary
embolism
Right atrial pressure > 10 Pulmonary

artery systolic pressure > 40
Clinical manifestations: massive PE (2)

Physical exam: massive PE (3)
8-10 years after diagnosis;

yearly colonoscopy
folate (all patients) splenectomy for moderate/severe

HS
infection ofbone due to hematogenous seeding or direct spread

from contiguous focus
What bacteria are most commonly responsible for osteomyelitis by

hematogenous spread?
What bacteria are most commonly responsible for osteomyelitis
by spread from a contiguous focus? (2)
Clinical manifestations: osteomyelitis (4)
Physical exam: vertebral
osteomyelitis
S.
aureus
S. aureus S.
epidermidis
fever chills malaise focal pain
tenderness to gentle percussion over the spine
What is the most common site of osteomyelitis in IV drug users?

Dx: osteomyelitis
(5)
Spine
Data from tissue cultures Blood cultures ESR (> 70 greatly

increases likelihood of OM) Needle aspiration MRI
What is the preferred imaging modality for osteomyelitis?

MRI
Tx: osteomyelitis
Antibiotics based on culture data x 4-6 wks Surgery if indicated
(2)
(treatment resistant, chronic, vertebral)
What is the typical pattern of
distal symmetrical sensorimotor
neuropathy in DM?
polyneuropathy
Sudden onset of mucocutaneous lesions over two
Stevens Johnson syndrome
sides (oral and conjunctival) Targetoid lesions Fever
(5)
Tachycardia Hypotension AMS
Definition: dacryocystitis
Infection of lacrimal sac
sudden onset of pain and redness in the medial
dacryocystitis
canthal region
What are the common infecting organisms in
S. aureus beta-hemolytic
dacryocystitis? (2)
strep
110!
Terms / Facts
What parameter is added to mechanical ventilation in
PEEP; prevent alveolar
ARDS? Why?
collapse
What is the most common site of metastasis of colorectal cancer?
Liver
What skeletal diseases are patients with RA more at risk
Osteopenia
of developing? (2)
Osteoporosis
What is the cause of senile
Perivascular connective tissue atrophy due to
purpura?
age
What vitamin can cause pseudotumor cerebri?
Vitamin A/isotretinoin
What are the characteristic histological
Yellow-white patches of retinal
findings of CMV retinitis?
opacification and hemorrhages
What is the characteristic histological finding of herpes simlpex
Dendritic
keratitis?
ulcer
What is the characteristic
Necrosis of the inner layers of the retina,
histological findings of ocular
which appears as white, fluffy lesions
toxoplasmosis?
surrounded by retinal edema and vitritis
Physical exam: rosacea
rosy hue with telangiectasia over the cheeks, nose and chin
Precipitants: rosacea (4)
hot drinks heat emotion rapid body temp changes
Tx: rosacea (2)
initial: metronidazole telangiectasias require laser surgery
Clinical manifestations: primary
Mononucleosis-like syndrome (fever, nigh
HIV infection
sweats, LAD, arthralgias, diarrhea)
What is the most common causative organism in UTI with alkaline
P.
urine?
mirabilis
What is the most common causative agent of esophagitis in an
Candida
HIV patient?
albicans
Tx: candida esophagitis in
(1) 3-5 day course of fluconazole (2) if unresponsive,
HIV patient (2)
esophagoscopy with cytology is warranted
Antidote: anti-histamine overdose
Physostigmine
Clinical manifestations: Meniere's disease
Vertigo Ear fullness Tinnitus Hearing
(4)
loss
Tx: Meniere's
Dietary modification (low-salt diet) - first-line Medical therapy
disease (2)
(diuretics, antihistamines, anticholingergics)
Definition: epidural abscess
enclosed infections in the epidural space
Clinical manifestations: epidural
Back pain Fever Chills Focal neurological
abscess (4)
deficits 2/2 cord compression
Dx: epidural abscess (3)
MRI Blood cultures Aspiration of abscess fluid
Lab findings: epidural abscess
Leukocytosis
Tx: epidural
Antibiotics +/- surgery (decompressive laminectomy and
abscess
debridement)
In most cases of inferior MI, what vessel is occluded?
Right coronary artery
Eye examinations due to risk
What routine screening is necessary in patients
of retinopathy and corneal
with SLE taking hydroxychloroquine? Why?
damage
What drug is commonly used for SLE with isolated skin
and joint involvement?

Hydroxychloroquine
How is a cold (hypothermic) extremity best
Rapid re-warming with warm
treated?
water
Definition:
Whitish patch or plaque that cannot be clinically or
leukoplakia
pathologically characterized
Saddle anesthesia Bowel/bladder dysfunction Low
cauda equina syndrome (4)
back pain Lower extremity weakness/reflex
111!
Terms / Facts
abnormalities
Etiologies: cauda equina
Trauma Lumbar disk disease Malignancy
syndrome (4)
Abscesses
What is the cause of cauda equina
Comrpession of the nerves of the cauda
syndrome?
equina
Tx: sphincter of Oddi dysfunction
ERCP w/ sphincterotomy
Etiologies: post-cholecystectomy
Functional pain Sphincter of Oddi dysfunction
pain (3)
CBD stones
What arrhythmia is most specific for digitalis
Atrial tachycardia w/ AV
toxicity?
block
What are the most common
Peripheral neuropathy L5 radiculopathy
etiologies of foot drop? (3)
Trauma to the common peroneal n.
What is the most common cause of excessive daytime
Obstructive sleep
sleepiness?
apnea
Give the stepwise approach to
1. Sodium and water restriction 2. Spironolactone
the treatment of ascites. (4)
3. Loop diuretic 4. Frequent abdominal paracenteses
What electrolyte abnormality may result from immobilization?
Hypercalcemia
Tx: hypercalcemia of immobilization
bisphosphonates
What diagnostic method is used in suspected PCP when
BAL (90%
sputum induction does not confirm the diagnosis?
sensitivity)
What is the best way to monitor respiratory function in
serial bedside vital
GBS?
capacity
What is the treatment for symptomatic
Ursodeoxycholic acid +
cholelithiasis in patients who are poor surgical
avoidance of fatty foods
candidates?
Tx: toxic
Bowel rest IV fluids IV abx IV corticosteroids Emergency
megacolon (5)
surgery (subtotal colectomy w/ end ileostomy) if severe
What is the most sensitive test for diagnosing disseminated
Urine antigen
histoplasmosis?
detection
Clinical manifestations: cerebellar
Vertigo Vomiting Occipital headache
hemorrhage (4)
Abducens nerve palsy
A history of diarrhea, weight loss, bloating and
Malabsorption 2/2
flatulence in a patient with past abdominal surgery is
bacterial overgrowth
likely due to what?
Clinical manifestations: central
Sudden, unilateral visual impairment that is
retinal vein occlusion
usually noted upon waking in the morning
Disc swelling Venous dilation and
What does opthalmoscopy reveal in
tortuosity Retinal hemorrhages Cotton wool
central retinal vein occlusion? (4)
spots
Clinical manifestations: macular
Distorted vision and central
degeneration
scotoma
Clinical manifestations: retinal
Unilateral blurred vision that progressively
detachment (3)
worsens Floaters Photopsia
What does opthalmoscopy reveal in open angle
Pathological cupping of the
glaucoma?
optic disc
Tx: diabetic retinopathy
Argon laser photocoagulation
Antidote: -blocker overdose (2)
1. Atropine and IV fluids 2. Glucagon
What underlying pathology is suggested by initial hematuria?
Urethral damage
What underlying pathology is suggested by terminal
Bladder or prostatic
hematuria?
damage
112!
Terms / Facts
What underlying pathology is suggested by total
Damage to the kidney or
hematuria?
ureters
True or false: clots are not usually seen with
True; more likely a bladder
renal causes of hematuria
pathology (cancer perhaps)
Clinical manifestations: acute
severe, tearing pain w/ radiation to the back
aortic dissection
that is maximal at onset
Physical exam: acute aortic
Hypo/Hyper-tension Difference in BP of > 30 mm
dissection (3)
Hg between arms AI murmur
Risk factors: aortic
HTN (most common) Male sex Connective tissue disease
dissection (6)
Congenital aortic anomaly Aortitis Pregnancy Trauma
What are the diagnostic studies of choice in suspected aortic
TEE or chest
dissection? (2)
CT
Definition: classic aortic
intimal tear leading to extravasation of blood into
dissection
the aortic media
Definition: incomplete
intimomedial tear w/o significant intramural
dissection
extravasation
Definition: intramural
vasa vasorum rupture leading to medial
hematoma
hemorrhage
Definition: penetrating ulcer
Ulceration of plaque penetrating intima leading
(aortic dissection)
to medial hemorrhage
-blockers first to blunt reflex HR & inotropy that will occur
Tx (medical):
in response to vasodilators SBP w/ IV vasodilators
aortic dissection
(nitroprusside)
Tx: descending aortic
medical management (beta blockers,
dissection
vasodilators)
Tx: ascending (proximal) aortic dissections
root replacement (surgery)
Complications: aortic
Rupture pericardial tamponade Obstruction of branch
dissection (3)
artery (MI, CVA, bowel ischemia, etc) Aortic insufficiency
Tx: external hordeolum
Warm compression (first-line) I&D if resolution does
(stye) (2)
not begin in 48 hours
What is the normal response to a
Urinary excretion > 4.5 grams in 5 hours after
D-xylose test?
a 25 gram ingestion
How does one distinguish between
bacterial overgrowth: normal Dmalabsorption due to bacterial
xylose response after abx Celiac:
overgrowth vs. celiac disease using the Dabnormal D-xylose despite abx
xylose test?
What type of glomerular disease is especially
Membranous nephropathy
common in patients with HBV?
(glomerulopathy)
What type of glomerular disease is especially
Membranoproliferative
common in patients with HCV?
glomerulonephritis type I
Fasting plasma glucose 126 mg/dl or 2-hour plasma glucose
Criteria: diabetes
level of 200 mg/dl Casual plasma glucose 200 mg/dl if
mellitus (3)
symptomatic
2-hour glucose levels of 140-199 mg/dl during an oral
Criteria: Prediabetic
glucose tolerance test Fasting glucose level of 100-125
glycemic states (2)
mg/dl
What is the insulin regimen
0.5 units of insulin per kg body weight with 40 to
for the average patient w/
50% delivered as long-acting basal insulin; the
type I DM?
remainder is short-acting (lispro) meal boluses
What are the ideal postprandial glucose
30-50 mg/dl above premeal
excursions in a diabetic?
glucose levels
113!
Terms / Facts
What is the next step in treating a patient
Add another class of drug, i.e.
with type 2 DM who is failing
adding metformin to an existing
pharmacological monotherapy?
sulfonylurea regimen
True or false: increasing sulfonylurea doses beyond half the maximal
dosing range has minimal further benefits on treating hyperglycemia.

True
Contraindication:
Contraindicated in patients with asthma because of risk
zanamavir
of bronchospasm
Persistent rhinitis symptoms in the
Persistent rhinitis symptoms in the setting
setting of nasal decongestant spray
of nasal decongestant spray overuse suggest
overuse suggest [...]
rhinitis medicamentosa.
Criteria: acute
Duration of sx > 1 week Worsening sx after initial
bacterial rhinosinusitis
improvement Maxillary tenderness Purulent drainage Poor
(5)
response to decongestants
Tx: acute bacterial rhinosinusitis (3)
Abx: amoxicillin, TMP-SMX, doxycycline
What oral abx can be used for outpatient treatment of
Levofloxaxin x 7pyelonephritis?
14 d
Dysphagia Dysarthria Dysphonia Diplopia
botulism (5)
Descending paralysis
Weakness Fatigue Muscle cramps
hypokalemia
Arrhythmia/tetany/flaccid paralysis when < 2.5 mEq/ml
Thrombocytopenia and
Thrombocytopenia and hypercoagulation
hypercoagulation within days of
within days of initiating anticoagulant
initiating anticoagulant therapy are
therapy are most likely cause by
most likely cause by [...]
unfractionated heparin
What is the most common type of lung cancer?
Adenocarcinoma of the lung
Tx: febrile neutropenia
IV cefipime to cover gram positives and
(abx)
pseudomonas
Clinical manifestations: nasal
Epistaxis Nasal obstruction Visible
angiofibroma (3)
nasal mass
How long after splenectomy are patients with hereditary
Up to 30
spherocytosis susceptible to sepsis?
years
What are the major risk factors for lacunar infarcts? (2)
Diabetes Hypertension
Definition: transient ischemic
neurological deficit that lasts from a few minutes
attack (TIA)
to no more than 24 hours
Clincial manifestations: ACA
Hemiplegia (leg > arm) Confusion Abulia Urinary
stroke (5)
incontinence Primitive reflexes
Contralateral hemisensory disturbance MacularPCA stroke (3)
sparing homonymous hemianopia Aphasia
What are the 4 "deadly D's" of posterior
Diplopia Dizziness Dysphagia
circulation strokes?
Dysarthria
Pinpoint pupils Long tract signs (Quadriplegia/sensory
basilar stroke (4)
loss) Cranial nerve palsies Cerebellar dysfunction
numbness of ipsilateral face and contralateral limbs
vertebral stroke (4)
Diplopia Dysarthria Ipsilateral horners
Clinical manifestations: lacunar stroke (internal
Pure motor
capsule)
hemiparesis
Clinical manifestations: lacunar strok (pons) (2)
Dysarthria Clumy hand
Clinical manifestations: lacunar stroke (thalamus)
Pure sensory deficit
Posterior limb of the internal capsule
What are the possible locations for
Ventral pons Corona radiata Cerebral
pure motor hemiparesis strokes? (4)
peduncle
114!
Terms / Facts
Dx: stroke (4)
Noncontrast CT EKG CMP CTA (after noncontrast)
Tx:
Heparin IV with bridge to warfarin Antiplatelet therapy: ASA, clopidogrel
TIA (3)
or ASA + dipyridamole Carotid revascularization if > 70% stenosis
ABCD2: Age 60 y; BP 140/90 Clinical
What scoring system is used
features: unilateral weakness or speech impairment
to predict risk of progression
w/o weakness, Duration 60 mins or 10-59 min;
of TIA to stroke?
Diabetes
Tx: ischemic
Supportive treatment Thrombolytic therapy (t-PA) if administered
stroke (3)
within 4.5h of onset Antiplatelet therapy: ASA, dipyridamole + ASA
SAMPLE STAGES Stroke or head trauma within the last
3 monts Anticoagulation w/ INR > 1.7 MI (recent) Prior
Contraindications: t-PA
intracranial hemorrhage Low platelet count (< 100K)
therapy s/p ischemic
Elevated BP: SBP > 185 Surgery in past 14 days Age < 18
stroke (12)
GI or urinary bleeding in past 21 days Elevated blood
glucose Seizures at onset of stroke
Etiologies: hemorrhagic stroke (2)
Intracerebral (90%) Subarachnoid (10%)
Clinical manifestations: hemorrhagic stroke (3)
AMS Vomiting Headache
Etiologies:
HTN (most common) AVM Amyloid angiopathy (lobar)
intracerebral stroke (5)
Anticoagulation/thromblysis Tumors
Dx: hemorrhagic
CT scan CT angiography LP to check for xanthrochromia if
stroke (3)
no evidence of hemorrhage on CT or suspicious for SAH
Tx: hemorrhagic
Admission to ICU ABCs BP reduction (gradual) with
stroke (3)
nitroprusside w/ goal of SBP < 140
What conditions makes
Marfan's syndrome Aortic coarctation Kidney
subarachnoid hemorrhage
disease (PKD) Ehlers-Danlos syndrome Sickle cell
more likely? (7)
anemia Atherosclerosis History (familial)
Tx: cerebral vein thrombosis
angicoagulation w/ IV heparin
Optimize preload (IV fluids; don't give nitrates) contractility
Tx: RV
(dobutamine) reperfusion mechnical support pulmonary vasodilators
infarct (5)
(inhaled NO)
What is the single most important intervention for
Adequate pre-CT
preventing contrast nephropathy?
intravenous hydration
What is the histopathological criterion for
Demonstration of invasion
differentiating thyroid follicular adenomas from
of the capsule and blood
follicular carcinomas?
vessels
What is the drug of choice for chemoprophylaxis against P.
falciparum malaria?
Mefloquine
How does the clinical presentation of EHEC differ from that of
EHEC
other bacteria that cause bloody diarrhea?
lacks fever
What electrolyte abnormality makes a
Hypomagnesemia makes
concurrent hypokalemia refractory to
hypokalemia refractory
treatment?
Tx: symptomatic hypercalcemia
Vigorous hydration with IV normal saline
What neuromuscular blocker should be used in
Atracurium; degraded
patients with renal or hepatic insufficiency? Why?
independent of kidneys or liver
Definition: malignant otitis
severe pseudomonal infection of the external
externa
auditory canal
Clinical manfiestations: malignant otitis externa
Severe ear pain w/ drainage
(2)
Fever
Otoscopic finding: malignant otitis
granulation tissue in the external auditory
externa
canal
115!
Terms / Facts
What is the drug of choice for malignant otitis externa?
Ciprofloxacin
If suspicion for an intraocular foreign body is high, what
Fluorescein
test should be performed?
examination
What agents most quickly reduce serum
Calcium gluconate Insulin Beta
potassium levels? (3)
agonists
Tx: sinus bradycardia
IV atropine Permanent pacemaker if bradycardia doesn't
(2)
resolve
Complications
Cryoglobulinemia B-cell lymphomas Plasmacytomas
(extrahepatic): Hepatitis
Autoimmune disease (Sjogren's, thyroiditis) Lichen planus
C (7)
Porphyria cutanea tarda ITP
What type of contrast agent is the least nephrotoxic?
Non-ionic contrast agent
Definition: presbycusis
Sensorineural hearing loss that occurs with aging
Clinical manifestation:
High-frequency, bilateral hearing loss Difficulty
presbycusis (2)
hearing in noisy, crowded environments
What is the test of choice for diagnosisng renal cancer?
CT abdomen
What positioning makes the
Lying supine and turning to the left brings the
patient more aware of aortic
heart closer to the chest wall and makes the
regurgitation? Why?
patient more aware of the forceful heartbeat
What is the most common middle ear pathology in patients
Serous otitis
with HIV?
media
Definition: serous otitis
Presence of middle ear effusions without the evidence of
media
acute infection
Tx (pharmacological): hepatitis B (2)
intereron lamivudine
How does the clinical presentation of
CMV retinitis is typically painless and
CMV retinitis in and AIDS patient
does not cause initial conjunctivitis or
differ from that of HSV/VZV?
keratitis (in contrast to HSV/VZV)
What are common middle
Bronchogenic cysts Tracheal tumors Lymphomas
mediastinal masses? (5)
Aortic arch aneurysms Pericardial cysts
What are anterior mediastial
Thymoma Teratoma "Terrible" lymphoma
masses? (4)
Retrosternal thyroid
Tx: uncomplicated
IV abx in first 48-72 h Transition to oral abx (e.g.
pyelonephritis (2)
TMP-SMX) if responsiv to parenteral abx
Dx: diffuse esophageal spasm
Manometry
Account for the metabolic acidosis
Lactic acidosis due to accelerated production
that follows a grand-mal seizure.
of lactic acid and reduced hepatic lactate uptake
How does one manage post-ictal lactic
Observation; resolves without tx in 60acidosis?
90 mins
Tx: ventricular
Loading w/ lidocaine or amiodarone (drug of choice)
tachycardia (2)
Cardioversion if hemodynamically unstable
HIV patients with what CD4 count warrant pneumococcal
CD4 > 200
vaccination?
cells/uL
Tx: bleeding 2/2 coagulopathy
Fresh frozen plasma administration and IV fluids
When should colonoscopic surveillance begin in a patient
8 years after diagnosis
with ulcerative colitis? How frequently should it be
and then q1-2y
conducted thereafter?
thereafter.
Definition:
A cyst in the eyelid caused by inflammation of a blocked
chalazion
meibomian gland, usually in the upper eyelid
Painful swelling that progresses to a nodular
chalazion
rubbery lesion
What is the usual cause of persistent or recurrent
Meibomian gland
116!
Terms / Facts
chalazion?
carcinoma
What diagnostic test should be
Histopathological examination to r/o
performed on recurrent
malignancy (meibomian gland carcindoma or
chalazion?
BCC)
DOPAMINE RASH Discoid rash Oral ulcers Photosensitivity Arthritis
Criteria:
Malar rash Immunologic critera (anti-Sm, anti-dsDNA, anti-Ro/La)
SLE (11)
Neurologic changes ESR increased Renal disease ANA+ Serositis
Hematologic disease (hemolytic anemia, thrombocytopenia, leukopenia)
Is the arthritis of SLE deforming or non-deforming?
Non-deforming
What are the most common side effects of digoxin
GI distress: N/V,
toxicity?
anorexia
Diffuse erythema that starts on the trunk Strawberry
tongue Conjunctival hyperemia Desquamation (1-2
toxic shock syndrome (4)
weeks later)
What animals are the definitive hosts for E. granulosis?
Dogs
What is the preferred test for HIV screening?
ELISA for gp120
Dx: prostatitis
1. Mid-stream urine sample 2. Blood culture 3. CBC 4. Prostatic
(4)
massage
[...] should always be considered in a
Hypothyroidism should always be
patient with an unexplained elevation
considered in a patient with an unexplained
of serum CK and myopathy.
elevation of serum CK and myopathy.
Complications: central lines
Venous thrombosis (subclavian in particular)
(2)
Infection
Tx: venous thrombosis 2/2
First: catheter removal Second: carotid duplex
central lines (3)
Third: anticoagulation
Indications: cardioversion (4)
AFib Atrial flutter VT w/ pulse SVT
Indications: defibrillation (2)
VFib VT w/o pulse
Clinical manifestations: atrial
Fatigue Exertional dyspnea Palpitations
fibrillation (6)
Dizziness Angina Syncope
What is the most common cause of atrial flutter?
COPD
EKG findings: multifocal
variable P wave morphology and variable PR and RR
tachycardia
intervals (at least 3 different ones for dx)
EKG findings: PSVT
narrow QRS complexes w/ no discernible P waves
Pathophysiology: paroxysmal
(1) AV nodal reentry due to circuit within
supraventricular tachycardia (2
AV node (2) orthodromic AV reentry via
mechanisms)
accessory pathway
Tx: PSVT (2)
Vagal maneuvers IV adenosine (agent of choice)
What drug is used for prevention of PSVT?
Digoxin
Tx: Wolff-Parkinson-White
Radiofrequency ablation of one arm of
syndrome
reentrant loop
Tx: hemodynamically stable
pharmacological therapy: IV amiodarone,
VT (3)
procainamide or sotalol
Tx: hemodynamically
immediate synchronous cardioversion Follow w/ IV
unstable VT (2)
amiodarone to maintain sinus rhythm
What is the imaging study of choice for pericardial effusion or
tamponade?
Echocardiogram
Tx (medical): mitral
Diuretics for pulmonary edema Infective endocarditis
stenosis (3)
prophylaxis Chronic anticoagulation (warfarin)
Clinical manifestations: aortic stenosis (3)
Angina Syncope HF sx
Physical exam:
1. harsh crescendo-decrescendo systolic murmur in right 2nd
117!
Terms / Facts
aortic stenosis
intercostal space w/ radiation to carotids 2. precordial thrill 3.
(5)
sustained PMI 4. S4 5. Carotid pulses parvus et tardus
Tx: aortic
AV replacement is tx of choice; indicated in all symptomatic
stenosis
patients
Dx: aortic stenosis
CXR EKG Echocardiogram Cardiac catheterization
(4)
(definitive)
Exertional dyspnea PND Orthopnea Palpitations
aortic regurgitation (6)
Angina Cyanosis/shock in acute aortic regurgitation
Physical exam: aortic
Widened pulse pressure Diastolic decrescendo murmur at
regurgitation (4)
LSB Austin-Flint murmur Head-bobbing/uvula bobbing
What compensatory structural changes does the heart
LV dilation and
make in response to aortic regurgitation?
hypertrophy
What is the definitive treatment for aortic regurgitation?
AV replacement
Tx: acute aortic
Medical emergency - perform emergent aortic valve
regurgitation
replacement
Tx: unruptured
If aneursym > 5 cm in diameter or symptomatic,
abdominal aortic
surgical resection w/ synthetic graft placement is
aneurysm
recommended
Tx: ruptured abdominal aortic aneurysm
emergent surgical repair
Clinical triad: ruptured
abdominal pain hypotension palpable pulsatile
AAA
abdominal mass
Definition: peripheral vascular
occlusive atherosclerotic disease of the lower
disease
extremities
Clinical manifestations: PVD
Intermittent claudication Rest pain, prominent at
(2)
night
Physical exam:
Dimished/absent pulses Muscular atrophy Decreased hair growth
PVD (5)
Ischemic ulcertation Thick toenails
Dx: peripheral vascular
Ankle-to-brachial index < 1.0 Pulse volume recordings
disease (3)
Arteriography (gold standard)
Tx (medical): peripheral
Smoking cessation Graduated exercise program
vascular disease (4)
Atherosclerotic risk factor reduction Aspirin
Tx (surgical): peripheral vascular disease
Surgical bypass grafting
(2)
Angioplasty
Dx: acute arterial occlusion
Ateriogram
Classification: Shock (4)
Hypovolemic Cardiogenic Septic Neurogenic
When shouldn't IV fluids be used in
If LV pressures are elevated, IV fluids
cardiogenic shock?
are likely to be harmful
Tx: cardiogenic
ABCs Identify and treat underlying cause Vasopressors
shock (4)
(dopamine/dobutamine) IABP
What are the recommendations for screening
One-time screening of all
with DEXA scans for osteoporisis?
women who are 65 and older
Tx: acute acalculous
Percutaneous drainage followed by
cholecystitis
cholecystectomy
Dx: biliary dyskinesia
HIDA scan
Motor dysfunction of the sphincter of Oddi which leads to
Definition:
recurrent episodes of biliary colic w/o evidence of gallstones on
biliary dyskinesia
diagnostic imaging studies
Tx: biliary dyskinesia
Laparoscopic cholecystectomy Endoscopic
(2)
sphincterectomy
Tx: appendicitis
Appendectomy (laparoscopic)
118!
Terms / Facts
What is the best test for evaluating a patient with epigastric
Upper GI
pain?
endoscopy
What is the test of choice for initial evaluation of a thyroid
Fine-needle
nodule?
biopsy
Tx: normal pressure
Large volume serial LPs followed by
hydrocephalus
ventriculoperitoneal shunting
Tx: central diabetes insipidus
Intranasal desmopressin acetate
Clinical presentation: ventricular
CHF sx MR Ventricular arrhythmias
aneurysm 2/2 MI (4)
Thrombus formation
Tx: uric acid stones
Urine alkalinazation w/ oral potassium citrate/bicarobinate
What is the appropriate tx for the management of bone pain in
Radiation
patients with prostate cancer who have undergone orchiectomy?
therapy
Tx (acute): MS exacerbation
IV steroids
Clinical presentation: phenytoin
Horizontal nystagmus Cerebellar ataxia
toxicity (3)
Confusion
What class of drugs is first-line for diabetic neuropathy?
TCAs
Contraindications: anticoagulation
Recent surgery Hemorrhagic stroke Bleeding
therapy (4)
diathesis Active bleeding
Tx (pharmacological): fibromyalgia (2)
TCAs (amitriptyline) Cyclobenzaprine
Dx: lupus
Renal biopsy is required in all patients with new onset lupus
nephritis
nephritis
Etiologies:
Sickle cell disease Perineal or genital trauma Neurogenic lesions
priapism (4)
(spinal cord injury) Medications (trazadone, prazosin)
Tx: S. viridans endocarditis (2)
IV penicillin G or IV cefriaxone
Tx (pharmacologic): diabetic
Metaclopramide (drug of choice) before meals
gastroparesis (3)
Bethanechol Cisapride
Side effects: ACE
Cough Angioedema Proteinuria Taste changes hypOtension
inhibitors (9)
Pregnany problems Rash Increased renin Lower angiotensin II
What is the initial DMARD of choice for RA?
Methotrexate
What is the prophylactic treatment for a
Five day course of
cat bite?
amoxicillin/claulanate
Hyperactive deep tendon reflexes in a
Due to hypocalcemia from multiple
post-op patient is usually caused by
blood transfusions and citrate chelating
what?
calcium
What is the most common manifestation of hemophilia?
Hemarthrosis
Clinical presentation: cavernous
Headache Low-grade fever Periorbital
sinus thrombosis (4)
edema Cranial nerve palsies
What is the most common
Most cases are secondary to an infection located in
etiology of cavernous sinus
the medial aspect of the face around the eyes and
thrombosis?
nose; sinus infections can be causes too.
Dx: cavernous venous thrombosis
MRI/CT w/ contrast
When should therapy for PE be initiated
If suspicion is high, start treatment
with respect to diagnostic testing if clinical
immediately, then do dx tests; stop
suspicion is high?
heparin if negative
What is the major toxicity of mycophenolate?
Bone marrow suppression
What are the major toxicities of azathioprine?
Diarrhea Leukopenia
(3)
Hepatotoxicity
Tx: Legionnaire's disease (2)
Azithryomycin Levofloxacin
Side effects: erythropoietin (3)
Wordening of hypertension Headaches Flu-like sx
Describe the progression of
Patients tend to present initially with
119!
Terms / Facts
hypertensive intraparenchymal
hemorrhages
focal sx but can rapidly progress to signs of

elevated ICP
(1) inappropriate secretion of vasopressin, which
Pathophysiology: cerebral
causes water retention (2) increased secretion of
salt-wasting syndrome (2)
ANP/BNP, which causes naturesis
What class of drug can be used as monotherapy in
Antiemetics such as
migraine headaches that present with vomiting
prochlorperazine or
and photophobia?
metoclopramide
Tx: opiod withdrawal
methadone
Suspect [...] in patients with
Suspect tropical sprue in patients with
malabsorption along with a history of
malabsorption along with a history of
living in tropical areas for more than
living in tropical areas for more than one
one month
month
What cause of hypoxemia presents with an elevated PCO2 and
normal A-a gradient?

Hypoventilation
Describe the PaCO2 and A-a gradient in hypoxemia
Normal PaCO2 Normal Acaused by low FIO2.
a gradient
Describe the PaCO2 and A-a gradient in V/Q
PaCO2 normal A-a gradient
mismatch
increased
Describe the PaCO2 and A-a
Normal PaCO2 Increased A-a gradient that
gradient in shunting
is refractory to O2
Complications: high PEEP
alveolar damage tension pneumothorax
ventilation (3)
hypotension
What is the classic antibody associated with dermatomyositis?
anti-Mi-2
What other disease is more common in patients
Internal malignancies such as
with dermatomyositis compared to the normal
ovarian cancer; 10% of DM
population?
patients
What are the ways in which potassium can be
Dialysis Cation-exchange resins
removed from the body? (3)
(kayexalate) Diuretics
Tx: primary biliary cirrhosis (2)
Ursodeoxycholic acid Cholestyramine
Tx: comedonal
topical retinoids (first line) topical abx (mild-moderate) oral
acne
abx (severe)
Tx: nodulocystic acne
oral isotretinoin
What is appropriate blood product to administer for
Packed red blood
anemia?
cells
Indications: platelet transfusion
platelet count < 10K
Indications: thyroid
Hyperlipidemia Unexplained hyponatremia Elevated
function testing (4)
serum muscle enzymes Anemia
[...] is likely in a postoperative
Massive pulmonary embolism is likely in a
patient with JVP and new-onset
postoperative patient with JVP and new-onset
RBBB
RBBB
Recurrent pneumonia in the same
Recurrent pneumonia in the same
anatomic location is a red flag for lung
anatomic location is a red flag for [...]
cancer
Clinical presentation: charcot joints
Functional limitation Deformity
(neurogenic arthropathy) (3)
Degenerative joint disease
Tx (pharmacological): WFW w/
Pharmacological (procainamide, e.g.) or
Afib and RVR
electrical cardioversion; avoid AV nodal blockers
At what time point s/p acetaminophen ingestion does the Rumack 4
Matthew nomogram start?
hours
Within what time frame should N-acetylcysteine be administered
Within 8
120!
Terms / Facts
s/p acetaminophen ingestion?
hours
If a patient presents with acetaminophen toxicity, what
Activated charcoal
is the first step in treatment?
administration
Definition: eczema
Form of primary herpes simplex virus infection
herpeticum
associated w/ atopic dermatitis
Tx: eczema herpticum
Acyclovir immediately (in infants)
A copious amount of purulent eye
A copious amount of purulent drainage in
drainage in newborns who are two to
newborns who are two to five days old is
five days old is most consistent with
most consistent with gonococcal
[...]
conjunctivitis.
New clubbing in patients with COPD
New clubbing in patients with COPD
often indicates the development of lung
often indicates the development of [...]
cancer
What is the treatment of choice
IM benzathine pencillin; single oral dose of
for primary syphilis? What are
azithromycin or two-week course of doxycycline
the alternatives?
for penicilli-allergic patients
What classes of diuretic most commonly causes
Aminoglycosides Loop
ototoxicity? (2)
diuretics
Tx (acute): ischemic stroke in a sickle cell patient
Exchange transfusion
Prophylaxis: human bite
Augmentin
What is the most common nephropathy associated with
Minimal change
Hodgkin's lymphoma?
disease
What is the most common nephropathy associated with
Membranous
carcinomas?
nephropathy
What is the most sensitive test to diagnose pancreatic exocrine
Fecal elastase
failure?
study
An alcoholic patient preenting with
An alcoholic patient preenting with
chronic abdominal pain and diarrhea
chronic abdominal pain and diarrhea is
is classic for [...]
classic for chronic pancreatitis
In what situations is the medial meniscus
Forceful torsion of the knee w/ the
injured?
foot planted
Physical exam:
Localized tenderness on medial side of knee Locking of the knee
medial
joint on extension McMurray's sign (palpable or audidible snap
meniscus tear
occurring while slowly extending the leg at the knee from full
(3)
flexion while simultaneously applying tibial torsion)
Where do the majority of clavicular fractures occur?
Middle third of the bone
What is the classic event leading to
Fall on an outstreched arm or direct
clavicular fracture?
blow to shoulder
Pain and immobility of the affected arm Contralateral hand
is used to support weight of the affected arm Shoulder on
clavicular fracture (3)
affected side is displaced inferiorly or posterioly
Why must a careful neuromuscular exam be
Rule out damage to underlying
performed on patients with suspected clavicular
brachial plexus and subclavian
fracture?
artery
If a bruit is heard just below the clavicle (fractured), what
diagnostic study is indicated?

Angiogram
Clinical manifestations: acute
Abdominal pain (McBurney's to RLQ
appendicitis (3)
progression) Fever N/V
If a patient waits more than 48 hours to seek medical
High incidence of
attention w/ sx of appendicitis, what complications can
rupture w/ abscess
occcur?
formation
121!
Terms / Facts
Tx: suspected perforation 2/2 appendicitis
exploratory laparotomy
If a patient w/ suspected psoas abscess (2/2
IV hydration Abx Bowel rest
appendicitis) and is stable, what is the treatment?
Interval appendectomy
(4)
What carpal bone is most commonly injured in acute injury of
Scaphoid
the wrist?
bone
What injury usually leads to scaphoid
Fall on outstreched hand w/
fracture?
dorsiflexion
What are scaphoid fractures of particular
Risk of avascular necrosis due to
concern in acute wrist injury?
tenuous blood supply
Pain on the radial aspect of the anatomic snuffbox
Physical exam:
Minimally decreased range of motion Decreased grip strength
scaphoid fracture (4)
Swelling
Dx: scaphoid fracture
Plainn film x-rays
Tx: scaphoid fracture
thumb spica cast for 7-10 days followed by repeat x-rays
Risk factors: developmental
Caucasian race First-born infants Breech
dysplasia of the hip (4)
position Family history
Dx: developmental dysplasia of the hip
Hip ultrasound (< 4 mo) Plain films (> 4
(2)
mo)
Tx: developmental dysplasia of the hip (2)
Hip harness Spica cast
What organs are most commonly injured with blunt
Spleen > liver >
abdominal trauma? (3)
intestines
Definition: Kehr
Ipsilateral shoulder pain referred from the abdomen due to
sign
irritation the phrenic nerve and diaphragm
Dx: blunt abdominal
(1) FAST (2) CT w/ IV contrast (if FAST negative but
trauma (2)
suspicion high)
What radiographic sign on CXR indicates
free air in the peritoneal cavity
perforation of a hollow viscus?
(usually under the diaphragm)
What diagnostic test should be used to confirm proper placement of a
Chest xcentral venous catheter?
ray
Definition: Leriche
Bilateral hip/buttock/thigh claudication Impotence
syndrome
Symmetric atrophy of bilateral extremities
Pathophysiology: Leriche
Atherosclerosis at the bifurcation of the aorta into
syndrome
the common iliac arteries
On what side of the body is diaphragmatic
Left side because right side is
rupture more common? Why?
protected by the liver
What is the most commonly injured ligament of the knee?
MCL
What kind of insult causes
Forceful abduction of the knee, often with a
MCL injury?
torsional component of motion
Physical exam: MCL tear
Swollen knee due to effusion Positive valgus stress
(2)
test
Dx: MCL tear
MRI
Tx: MCL tear
bracing and early ambulation
What are the components of the
Motor response (6) Verbal response (5)
Glasgow Coma Score?
Eye opening (4)
At what GCS level does one intubate?
GCS of 8 = intubate
What is the most common site for metatarsal stress fracture?
Second metatarsal
Tx: stress fracture (metatarsal)
Rest, analgesia, hard-soled shoe
Tx: sharp, penetrating abdominal trauma in a
Exploratory
hemodynamically unstable patient
laparotomy
122!
Terms / Facts
Tx: sharp, penetrating abdominal trauma in a
exploratory
hemodynamically stable patient
laparoscopy
Definition:
Subluxation of head of radius at elbow joint; due commonly
nursemaid elbow
to swinging children by the arm
Tx: nursemaid
Closed reduction by gentle passive elbow flexion and forearm
elbow
supination
Selective damage to central spinal cord due to hyperextension
Definition: central
injuries in elderly patients w/ degenerative changes in the
cord syndrome
cervical spine
Clinical manifestations: central cord
Upper extremity > lower extremity
syndrome
weakness
Clinical manifestations: anterior cord syndrome
bilateral spastic motor paresis
What is the most common etiology of anterior cord
Occlusion of the vertebral
syndrome?
artery
What features distinguish
Unilateral infiltrate (usually bilateral in ARDS)
pulmonary contusion from
Onset: usually within 24-48 hrs in ARDS vs within
ARDS? (2)
first 24 hours for contusion
What does treatment of asymptomatic patients
Asymptomatic: no treatment
with Paget's disease of bone consist of? And of
Symptomatic: bisphosphonates
symptomatic patients?
Stones (nephrolithiasis/nephrocalcinosis) Bone (bone aches/pains,
Sx:
osteitis fibrosa cystica) Groans (muscle pain, abdominal pain, gout,
hypercalcemia
constipation) Psychiatric overtones (depression, fatigue, anorexia,
(4)
lethargy, etc.)
Etiologies: primary
Adenoma (80%) Hyperplasia (15-20%)
hyperparathyroidism (3)
Carcinoma (< 1% cases)
BMP (Ca++ levels ) PTH levels normal or
Lab studies & findings: primary
elevated Urine cAMP elevated
Chloride/phosphorous ratio > 33
Radiographic findings: primary
Subperiosteal bone resoprtion
Osteopenia
What imaging study is obtained before surgical treatment of
Sestamibi
primary hyperparathyroidism?
scan
Serum calcium at least 1 mg/dl
What are the indications for
above ULN Young (< 50 y/o) BMD
parathyroidectomy in asymptomatic patients
less than T -2.5 at any site Reduced
with primary hyperparathyroidism? (4)
renal function
If a sestamibi scan in a patient with primary
Bilateral neck
hyperparathyroidism is negative but shows many
exploration w/
abnormal glands, what kind of surgery is indicated?
intraoperative PTH level
What is the most common mechanism of atrial
Re-entrant rhythm in within the
flutter?
atria
Progesterone respiratory rate via stimulation
Pathophysiology: respiratory
of dorsal respiratory group chronic compensated
alkalosis of pregnancy
respiratory alkalosis
Tx: congenital prolonged QT syndrome (Jervell-Lange-Nielson
beta
syndrome or Romano-Ward)
blockers
Clinical manifestations: Jervell-Lange Syncopal episodes w/o following
Nielson syndrome (2)
disorientation Hearing impairment
What is the most common form of drug-induced chronic
Analgesic
renal failure?
nephropathy
123!
Terms / Facts
What is the best initial screening test for
Cosyntropin stimulation test w/
adrenal insufficiency?
cortisol and ACTH levels
What is the most common cause of ductopenia in
Primary biliary
adults?
cirrhosis
What is the only drug FDA approved for ALS treatment?
Riluzole; glutamate
What is its mechanism?
inhibitor
What kind of immunological response is induced by the
T-cell-independent B23-valent pneumococcal vaccine?
cell response
Chest CT to look for
What diagnostic study is required whenever a new
thymoma (present in 15% of
diagnosis of myasthenia gravis is made? Why?
cases)
Hypocalcemia with concordant
Hypocalcemia with concordant changes
changes of serum calcium and
of serum calcium and phosphate levels are
phosphate levels are usually caused by
usually caused by vitamin D deficiency
[...]
Clinical manifestations: primary
painless chancre that resolves in 3-6
syphilis
weeks
truncal rash that extends to the periphery, including
secondary syphilis (2)
palms and soles generalized lymphadenopathy
What type of urethral injury is most commonly associated
Posterior urethral
with pelvic fractures?
injury
Clinical manifestations: posterior
Suprapubic pain Inability to void
urethral injury (2)
following major trauma
Physical exam:
blood at the urethral meatus high-riding prostate due to
posterior urethral
displacement of the prostate by a pelvic hematoma scrotal
injury (3)
hematoma
Tx: Carbon monoxide poisoning
100% oxygen via nonrebreather facemask
If a patient with suspected PVD has normal ABIs, what further
Exercise
testing should be pursued?
ABIs
What injury is most commonly associated with anterior
Burst fracture of the
cord syndrome?
vertebra
What is the next step in a patient with a gunshot wound below
Exploratory
the nipple who is hemodynamically unstable?
laparotomy
What are the first compensatory physiological
Tachycardia Peripheral
changes to hemorrhage? (2)
vasoconstriction
Clinical manifestations: retroperitoneal abscess
Fever Chills Deep abdominal
(3)
pain
Tx: pancreatic
Immediate placement of a percutaneous drainage catheter with
abscess
culture of the drained fluid and surgical debridement
Tx: mastitis
antibiotics (dicloxacillin or cephalosporins) Analgesics Continuation
(3)
of breast-feeding from the affected breast
What is the radiologic finding for blunt aortic injury?
Widened mediastinum
What is the most common cause of spinal
Thoracic and thoracoabdominal aortic
cord ischemia and infarction?
aneurysm repair surgeries
Flaccid paralysis Bowel/bladder Incontinence
Clinical presentation: anterior
Sexual dysfunction Hypotension Loss of tendon
spinal artery syndrome (5)
reflexes
Dx: esophageal perforation
Water-soluble contrast esophagram
Where do diabetic foot ulcers
Plantar surface of the foot under points of
classicaly occur?
greatest pressure
What surgery commonly causes early dumping syndrome?
Partial gastrectomy
124!
Terms / Facts
Clinical manifestations: early
postprandial abdominal cramps weakness
dumping syndrome (4)
light-headedness diaphoresis
What imaging modalities is can detect uric acid stones? (2)
CT abdomen IVP
Parotid surgery involving the deep lobe
Parotid surgery involving the deep lobe
of the parotid gland carries a
of the parotid gland carries a significant
significant risk of [...] palsy
risk of facial nerve palsy
What is the most common bone in the body to be affected by stress
fractures?
Tibia
Where do tibial stress fractures classically
Anterior part of the middle third of
occur?
the tibia
What are the best diagnostic modalities for tibial stress
MRI Bone
fractures? (2)
scan
What are the most common
Arnold-Chiari malformation Prior spinal cord
causes of syringomyelia? (2)
injuries (classically, whiplash from MVA)
Definition: Ludwig
rapidly progressive bilateral cellulitis of the submandibular
angina
and sublingual spaces
What is the classic etiology of Ludwig
Infector second or third mandibular
angina?
molar
Clinical manifestations: Ludwig angina
Fever Dysphagia Odynophagia
(4)
Drooling
What is the most common cause of death with Ludwig angina?
asphyxiation
Tx: Ludwig angina (2)
Antibiotics Removal of infected molar
Definition: Legg-Calve-Perthes
Idiopathic avascular necrosis of the femoral
disease
capital epiphysis
Tx: Legg-Calve Observation and bracing Surgery if the femoral head is not
Perthes disease (2)
well contained within the acetabulum
What is the typical course of a congenital
Spontaneous resolution by 12
hydrocele?
months
If a congenital hydrocele does not disappear within a
Surgical repair due to the
year, what treatment may be indicated? Why?
risk of inguinal hernia
GI sx followed by triad of:Periorbital edema
trichinellosis (4)
Myositis Eosinophilia
Tx: severe symptomatic hyponatremia (< 120
hypertonic saline (3%)
meq/L)
infusion
What type of catherization is best for minimizing
Intermittent
UTIs?
catheterization
abdominal pain w/ diarrhea and/or constipation pain
relief with bowel movements bloating sense of
irritable bowel syndrome (4)
incomplete emptying
Prophylaxis: M. avium complex in HIV patient
Azithromycin or
(2)
clarithromycin
What is the mechanism by which
Disrupts thermoregulation and the
fluphenazine (antipsychotic) causes
body's shivering mechanism
hypothermia?
All sexually active women < 24 y/o and other
What are the routine screening
asymptomatic women at increased risk for
guidelines for C. trachomtis?
infection
What is the best initial diagnostic test for
Panendoscopy (esophagoscopy,
squamous cell carcinoma of the head/neck?
bronchoscopy, laryngoscopy)
Describe the following parameters in
Calcium: decreased Phosphate:
tumor lysis syndrome: calcium,
Increased Potassium: increased Uric acid:
125!
Terms / Facts
phosphate, potassium, uric acid
increased
What is the most significant cause of morbidity in patients with
Diffuse axonal
traumatic brain injury?
injury
In cases of suspected child abuse, what test should be
Complete skeletal
ordered?
survey
What is the leading complication of
Bacterial infection leading to sepsis
surface body burns?
and septic shock
acute-onset severe substernal pain subcutaneous
esophageal perforation (2)
emphysema in the neck/mediastinal emphysema
Clinical presentation: acute
Fever Chest pain leukocytossis sternal wound
mediastinitis (5)
drainage mediastinal widening on chest x-ray
Tx: acute mediastinitis
Drainage Surgical debridement Prolonged antibiotic
(3)
therapy
Conservative medical therapy initially CT guided
Tx algorithm:
percutaneous drainage (if > 3 cm); if < 3 cm, IV abx and
diverticulitis
observation If unresolved after drainage, surgery for drainage
complicated by abscess
and debridement
Sigmoid resection; fistulas, perforation
What surgery should be performed for
with peritonitis, obstruction and recurrent
diverticulitis? What are the indications?
attacks
What is the only region of the bladder covered by
Dome of the
peritoneum?
bladder
Definition: Volkmann's
Final end point of compartment syndrome in which
ischemic contracture
the dead muscle has been replaced by fibrous tissue
What is the immediate management of splenic
IV fluids first, then: Stable:
trauma in a hemodynamically stable patient? And
CT abdomen Unstable:
hemodynamically unstable?
exploratory lapartomy
Definition: torus
benign bony growth (exostosis) located on the midline
palatinus
suture of the hard palate
After blunt trauma to the chest, if
After blunt trauma to the chest, if an x-ray
an x-ray shows a deviated
shows a deviated mediastinum with a mass in
mediastinum with a mass in the left
the left lower chest, one should suspect a
lower chest, one should suspect a
diaphragmatic hernia w/ herniation of
[...]
abdominal viscera
Dx: diaphragmatic hernia (2)
Barium swallow or CT scan w/ oral contrast
What can happen to the extremities upon
Ischemia-reperfusion injury leading
reperfusion after ischemia (4-6 hours)?
to compartment syndrome
Tx: compartment syndrome
emergent fasciotomy
Tx: cardiac
immediate decompression by pericardiocentesis or surgical
tamponade
pericardiotomy
Radiologic findings: acute cardiac
normal cardiac silhouette w/o tension
tamponade
pneumothorax
[...] is the preferred way to
Orotracheal intubation with rapid sequence
establish an airway in an apneic
intubation is the preferred way to establish an
patient with a cervical spine
airway in an apneic patient with a cervical spine
injury
injury
What are the best methods for
preoperative intensive active breathing
prevention of post-operative
exercises incentive spirometry forced
atelectasis? (3)
expiration techniques
Tx: penile
emergent surgery to evacuate penile hematoma and mend torn
fracture
tunica albuginea
126!
Terms / Facts
Dx: penile fracture
emergent urethrogram to assess for urethral injury
What is the most common cause of penile
Sexual intercourse with the woman
fracture?
on top
Acute pain and swelling of the midline
Acute pain and swelling of the midline
sacrococcygeal skin and subcutaneous
sacrococcygeal skin and subcutaneous
tissues are most commonly due to pilonidal
tissues are most commonly due to [...]
disease
Tx: pilonidal disease
drainage of abscesses and excision of sinus tracts
If a FAST exam is inconclusive, what is the test of choice for
diagnostic
detecting intraperitoneal hemorrhage in an unstable trauma
peritoneal lavage
patient?
Diangose: patient with anterior chest trauma w/ elevated
myocardial
CVP/PCWP and unrepsonsive hypotension after bolus of IV
contusion
fluid
Clinical presentation: flail chest
respiratory distress tachypnea w/ shallow
(2)
breaths
Clinical manifestations: gastric
early satiety w/ postprandial pain nausea
outlet syndrome (4)
nonbilious vomiting weight loss
Physical exam: gastric outlet syndrome
abdominal succussion splash
Definition: Mohs
Microscopic shaving of basal cell cancer such that 1-2 mm of
surgery
clear margins are achieved
Indications: Mohs surgery for
Patients with high risk features Lesions in
BCC (2)
functionally critical areas
Tx (pharmacological): condylomata
TCA Podophyllin 5-Fu epi gel
acuminata (5)
Imiquimod Interferon alpha
What is the glucose concentration
Low glucose (< 30 mg/dl) because of
exudative pleural effusion? Why?
high leukocyte metabolic activity
Drug of choice: dermatitis herpetiformis
Dapsone
What physical exam sign excludes the diagnosis of a
Absence of forehead
central facial paresis?
furrows
Tx (pharmacological):
alpha blockers (phentolamine,
pheochromocytoma
phenoxybenzamine) before beta-blockers
In what order should adrenergic
alpha before beta blockers; if beta blockers
blockers be given in
given first, there will be unopposed alpha
pheochromocytoma? Why?
receptor stimulation, resulting in hypertension
Tx (pharmacological): aortic
afterload reduction w/ CCBs or ACE
regurgitation
inhibitors
Tx: heat stroke
Induction of evaporative cooling to reverse hyperthermia
What is the initial effect of radioactive
Initial thyrotoxicosis due to dying
iodine treatment on thyroid levels in the
follicular cells; can exacerbate the
hyperthyroid patient?
hyperthyroid state
What are the two ways in which
(1) Asymmetric polyarthritis (associated with
Gonoccocal septic arthritis may
tenosynovitis and skin rash) (2) isolated
present?
purulent arthritis
Diagnostic
Serum osmolality < 270 Urine osmolaltiy > Serum osmolality
criteria: SIADH
Urine sodium > 20 mEq/L Absence of hypovolemia Normal renal,
(5)
adrenal and thyroid function
How is toxic epidermal necrolysis distinguished
TEN > 30% of body Stevens
from Stevens Johnson syndrome?
John up to 10% of body
Clinical presentation: vitreous hemorrhage
Sudden loss of vision Onset of
(2)
floaters
127!
Terms / Facts
What is the most common etiology of vitreous
Diabetic
hemorrhage?
retinopathy
What is the most feared complication
Spread of infection into the mediastinum,
of a retropharyngeal abscess?
leading to acute necrotizing mediastinitis
Describe the G6PD levels in patients with G6PD deficiency
G6PD levels are
suffering a hemolytic episode.
often normal
What is the first line medical treatment for idiopathic benign
intracranial hypertension?
Acetazolamide
What organism is commonly responsible for nosocomial
P.
pneumonia in intubated patients?
aeruginosa
What nasal cytology finding is characteristic of allergic
nasal
rhinitis?
eosinophilia
What is the appropriate first-line diagnostic test if the cause of
Nasal
rhinitis is not clear?
cytology
Definition:
asymptomatic elevation of monoclonal protein detected on
MGUS
protein electrophoresis
How is MGUS distinguished
Absence of MM sx: renal insufficiency,
from multiple myeloma?
hypercalcemia, anemia and lytic bone lesions
Definition: sympathetic
Damage of one eye (the sympathetic eye) after a
opthalmia
penetrating injury to the other eye
Mechanism:
Injury to eye unveiling of previously "hidden
sympathetic opthalmia
antigens" immunologic response in sympathetic eye
What event usually precedes the development of HUS?
Diarrheal illness
Tx: solitary brain metastasis
surgical resection followed by whole brain radiation
What are the earliest side effects of
Hallucinations Dizziness
levodopa/carbidopa therapy in PD? (4)
Headache Agitation
Tx: torsades de pointes (2)
remove offending agent IV magnesium sulfate
What CBC finding is the presenting sign in HIV in about
10% of cases?
Thrombocytopenia
What is the most specific test available for GERD?
24 hour pH recording
What imaging modality is the gold standard for avascular necrosis of the
hip?
MRI
What breathing maneuver is used on a ventilator to
End-inspiratory hold
determine the lung compliance?
maneuver
follicular conjunctivitis pannus (neovascularization)
Trachoma (2)
in the cornea
In what patient populations is FSGS the most
African Americans Obese
common cause of nephrotic syndrome in adults?
patients Heroin users HIV
(4)
patients
Pathophysiology: isolated
decreased elasticity of the arterial wall with aging
systolic hypertension
systolic BP w/o change to diastolic pressure
What cytochemical test is used to detect acute
Alpha-naphthyl esterase
monocytic leukemia?
(positive)
What is the treatment of choice for iron deficiency in
IV iron (iron
dialysis patients?
dextran)
What is the first-line therapy for reactive arthritis?
NSAIDs
What is the most common cause of blood-tinged sputum in
acute
young patients?
bronchitis
True or false: fever is usually present in acute bronchitis
false; usually afebrile
!
128!

IM

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

IM

Uploaded by

Copyright:

Available Formats

Terms / Facts

DDx: Abdominal pain of gastroduodenal origing

DDx: Abdominal pain of

DDx: Abdominal pain of urinary

Acute cholecystitis Chronic cholecystitis

DDx: Abdominal pain of pancreatic

DDx: Abdominal pain of

Acute pancreatitis Chronic pancreatitis

Cystitis Acute retention of urine Acute

Rupture of extopic pregnancy Rupture/Torsion of

DDx: Abdominal pain of vascular origin (2)

DDx: Abdominal swelling in

DDx: Abdominal swelling in

DDx: Abdominal swelling in the

Primary periotonitis Secondary

Myocardial infarction Pericarditis

Right kidney carcinoma Right colonic carcinoma

Lipoma Epigastric hernia Carcinoma of the

Paraumbilical/umbilical hernia Malignancy

Appendix mass/abscess Carcinoma of the cecum

DDx: Abdominal swelling in the

DDx: Acute anorectal

Aortic aneurysm Mesenteric embolus

Splenomegaly Gastric carcinoma Left kidney carcinoma

DDx: Abdominal swelling in the

DDx: Abdominal swelling

Peptic ulcer Gastritis

Appendicitis Obstruction Diverticulitis Gastroenteritis

DDx: Abdominal pain of hepatobiliary

Carcinoma of the sigmoid colon Diverticular

Acute/chronic bladder retention Pregnancy

Fissure-in-ano Perianal hematoma Thrombosed

Fistula-in-ano Anorectal malignancy Chronic perianal

Disc lesion Cervical spondylosis Myocardial ischemia Repetitive

DDx: Arm swellings (2)

Trauma Infection (cellulitis, lymphangitis)

Cirrhosis Cardiac failure Nephrotic syndrome Carcinomatosis

DDx: Axillary swellings

Acute abscess Sebaceous cyst Lipoma Lymphadenopathy

DDx: Backache (congenital) (3)

DDx: Backache of traumatic

Kyphoscoliosis Spina bifida Spndylolithesis

DDx: Backache of inflammatory

Ankylosing spondylitis Rheumatologic

DDx: Backache of neoplastic origin (2)

Osteoarthritis Intervertebral disc lesions

DDx: Backache of metabolic origin (2)

Pelvic inflammatory disease

Renal calculus Renal carcinoma

Breast carcinoma Fibroadenoma Cyst (cystic mastitis) Duct

Pregnancy Lactation Puberty

Non-/Cyclical mastalgia Duct ectasia Breast abscess Pregnancy

How does one quickly calculate heart rate when

DDx: Breast lumps due to generalized swelling

Metastases Primary tumors

300/ # large boxes between 2

Count the number ofo complexes that occur in

a 6-second interval (30 boxes) and multiply by

If p waves are present in all leads and upright

What kind of rhythm is indicated by an EKG where each QRS

I and aVF are both upright and positive

I is upright and aVF is upside

I is upside down and aVF is