Cardiology

Systolic/ mid-systolic murmur at the cardiac apex that shortens with squatting = MVP

MPV can also present with a MR murmur. MVP can also present with non-specific symptoms such as
atypical chest, SOB, etc just reassure the patient.

Squat includes the initial act of squatting which increases pre-load/and remaining squatting which
increases afterload. Squatting will decrease the sound of HOCM and also cause MVP to be shorter and
have a later click.

Handgrip increases afterload which will decrease the sound of HOCM and make MVP shorter with an
later click. Squat/Handgrip by increase afterload increase the sound of regurgitant murmurs: AR/MR

Valsalva decreases preload which will increase the sound of HOCM and make MVP longer with an earlier
click.

Standing decrease preload which will increase the sound of HOCM and make MVP longer with an earlier
click.

Associated with posterior Wall MI, Marfans/Ehlers danlos, and rheumatic disease

Continous machine-like murmur = PDA

Associated with rubella/prematurity.

Loud, harsh, holosytolic murmur with maximal intensity in the lower left intercostal space (3rd/4th) = VSD

Mid to late diastolic murmur with an opening snap and mid-diastolic rumble at cardiac apex = MS

Holosystolic, blowing murmur at the cardiac apex in a patient with endocarditis = MR

Pt with AKI and BUN of 68 px with sharp, pleuritic chest pain, that improves with sitting up worsens in
supine position, and a squeakyrub sound on auscultation at left sternal border = Pericarditis 2/2
uremia

Pt can have acute or chronic renal failure which triggers the uremia.
Differs from Autoimmune/postmyocardial pericarditis (where px with DIFFUSE ST elevation and PR
depression) in that uremic pericarditis may have not show classic DIFFUSE ST and PR depression.

Dx: 1) EKG to r/o acute MI 2) Echocardiography to r/o cardiac tamponade.

Tx: of Uremic is dialysis

Pt with hx of A-fib px with severe lower extremity pain, with mottled skin appearance, coolness to
touch, and non-palpable pulses = Acute arterial occlusion 2/2 to A-fib What should they have been on
to prevent this?

Px Acute Limb ischemia: pain, paresthesia, pallor, pulselessness, poikothermia

Prevention: They should have been on anti-coagulant such as WF or oral anticoagulants such as
Apixaban, rivaroxaban, dabigatran based on the CHADS-VASc 2 score.

Note, Cilostazol is used to treat intermittent claudication in patients with Peripheral Vascular Disease. It
does not treat Acute Limb Ischemia.

A pt aged 72 has HTN, DM, peripheral artery disease. What is the CHADS-VASc 2 score?

Elderly pt px with 6 month hx of periodic, substernal chest pain worsened with exertion but improves
with rest = Stable Angina What meds can be used to treat the condition?

Stable angina can be treated with LONG-acting nitrates + BB (1st line) or CCB if BB is ctx,. If refractory to
those treatments give Ranolazine.

Ranolazine works by inhibiting Na/Ca2+ influx exchanger into myocytes and thereby reduces Ca2+.
Ranolazine is used to refractory angina.

CCB treat angina by increasing coronary blood flow (increase O2 delivery) and decrease contractility by
decreasing Ca.

Nitrates work by reducing preload.

Pt px with syncope, angina, dyspnea as a RECENT change from baseline with a systolic murmur best
heard in R upper sternal border and slow rising, delayed carotid pulses = Aortic Stenosis

Early peaking AS = milder disease. Late peaking AS = more severe disease.

Px classic findings for AS include 1) mid to late-peaking systolic murmur, 2) pulsus parvus et tardus: weak
(slow rising) and delayed pulses, 3) soft and single second heart sound 2/2 to stenotic valve being unable
to close as strongly. Also, single and not split because there is a delay in A2 closing so it closes at same
time as P2.

Pt px with depression, mood swings, muscle weakness, and recurrent kidney stones and found to be
HTN and have Ca2+ of 11.7 = Hypercalcemia 2/2 to PTH

Stones (recurrent kidney stones), Bones (muscle weakness), Groans, Thrones, and psychiatric overtones
(depression).

Primary hyparathyroidism classic presentation is Hypercalcemia causing polyuria, polydipsia, and kidney
stones and Neuropsychiatric complaints: confusion, depression, psychosis.

You should know that PRIMARY hyperparathyroidism can cause HTN. HTN with HPTH may indicated
MEN2 syndrome with a Pheo and should be investigated.

Differentiate renal parenchymal disease can cause 2 HTN but you would also see elevated Cr and
abnormal urinalysis. KEY POINT when you think answer to a question relates to the kidney look for
evidence of kidney dysfunction.

Hypothyroidism can cause HTN but would expect to see other signs of hypothyroidism including weight
gain, fatigue, bradycardia, and dry skin.

55+ woman px severe HTN (Systolic > 180/120s), abdominal bruit on auscultation, and episodes of flash
pulmonary edema with HF, with an elevated Cr = Renal Artery Stenosis

The giveaways are severe HTN, abd bruit, and elevated Cr.

Pt px with headaches, epistaxis, blurred vision, elevated BP in upper extremities, notching in the ribs, to
and fro machinery murmur, and brachial-femoral pulse delay = Coarctation of the Aorta

Giveaways: elevated BP in UE, notching in the ribs indicating collateral circulation, and brachial-femoral
pulse delay.

Hypothyroidism can cause HTN.

Pt with cardiomyopathy on digoxin, furosemide, and lisinopril is started on amiodarone after developing
A-fib. Soon after, develops anorexia, abd pain, nausea, weakness, and confusion = ? Drug interaction aka
Digoxin toxicity due to Amiodarone.

The hallmark sign of digoxin toxicity is YELLOW vision aka Xanthopsia and other vision problems: loss of
color vision, scotoma, blindness. It would be too easy for it to be in the stem.

But think GI disturbances, Neurologic disturbance, and vison changes.

Acute toxicity is more GI symptoms, Chronic toxicity is more neurology and visual disturbances.

Recall that other anti-arrhythmics such as Amiodarone and verapamil can increase serum levels of
digoxin. When you start a patient on digoxin with Amiodarone, you should decrease their digoxin dose
by 25-50%

Pt with hypertriglyceridemia is prescribed a new medication to treat his condition. Few days later he
presents to ED with flushing, generalized itching, and sensation of warmth. What med is he on? How do
you treat?

Niacin is used to treat hyperltriglceridemia can cause flushing and itching due to vasodilation from
prostaglandin production. This is managed by pre-treating patient with NSAIDS 30 mins before
administering the drug.

Niacin can cause elevated LFTs, hyperglycemia, and hyperuricemia.

If you ever choose cancer or occult malignancy as an answer choice, the patient must have weight loss,
fatigue, night sweats etc (at least one of them).

Always pay attention to medication changes in questions stems. Especially giving new medications, they
are often related to the answer. ! HIGH YIELD
Pt px with exertional dyspnea, dry cough, fatigue and a holosytolic murmur best heard in apex = MR

Pt px with exertional dyspnea, JVD, pulsatile hepatomegaly, and fluid overload with hx of recurrent
pericarditis and pericardial knock on auscultation = Constrictive Pericarditis

An EKG with narrow QRS < 3 small boxes, PR interval > 5 small boxes, and a dropped beat = 2nd degree
AV block. If PR interval increases = Mobitz Type 1. If PR interval constant = Mobitz type 2.

HY: Dropped beat

Look at the PR interval before the dropped beat and after the dropped beat.

An EKG with, a narrow QRS < 3 small boxes, unclear/no p waves, fuzzy baseline, and irregular QRS
intervals in an elderly patient = Afib

HY = Irregular QRS intervals on an EKG

Baseline is measured from the end of the T wave to the beginning of the p wave.

An EKG with p waves of differing morphology, narrow QRS < 3 small boxes, irregular QRS intervals with
early p waves and QRS = Premature Atrial Contraction

HY: p wave of differing morphology and irregular QRS interval all have p waves as opposed to A fib
where there are no p waves.

An EKG with normal p wave, wide QRS complex > 3 small boxes, short PR interval < 3 small boxes, and
slurred upstroke of QRS complex = WPW syndrome

HY: Wide QRS complex + Delta wave and Short PR interval

Sick sinus syndrome is 2/2 to impaired SA node automaticity. Pt px with fatigue, lightheadedness,
palpipations, pre-syncope/syncope and bradycardia with sinus pauses/arrest or alternating bradycardia
with atrial tachyarrhythmias.
GI

Pt px with severe periumbilical abd pain that is out of proportion to exam findings = Mesenteric
ischemia

Pt px with severe epigastric pain that radiates to the back, improves with leaning forward, n, v, = Acute
Pancreatitis

Look for elevated Lipase or Amylase.

Pt px with fatigue, SOB after a recent URI. She is hypotensive, JVD, and slightly tachycardic. Lungs are
clear to auscultation and cardiomegaly on CXR = Pericardial effusion/cardiac tamponade 2/2 to
pericarditis from URI.

Dx of JVD + hypotension = Cardiac tamponade or PTX

Since lungs are clear to auscultation, no severe breathing issues, and no CXR findings R/O PTX.

Cardiomegaly water bottle heart shape with clear lung fields (no lung findings) = pericardial
effusion/cardiac tamponade

Pericardial effusion also px with an inability to palpate API and reduced heart sounds. Compare this to
Cardiac tamponade where you would have muffled heart sounds.

Differentiate from viral myocarditis which causes congestive heart failure so the patient would have
WET lungs and crackles or other pulmonary symptoms on exam.

Px after a recent URI infection with fatigue, dyspnea, JVD, and cardiomegaly with wet lungs on CXR,
bibasilar crackles on physical exam, and S3 = Viral myocarditis causing dilated cardiomyopathy.

S4 is heard in peeps with HTN heart disease, aortic stenosis, and hypertrophic cardiomyopathy.

ASD presents with an enlarged RA and RV on CXR with prominent hilar and pulmonary arterial
vasculature.

Pulsus bisifirens (biphasic pulse) is defined as 2 strong systolic peaks of aortic pulse separated by a mid-
systolic dip aka double pulse and is associated with Aortic Regurg with or w/o AS and HOCM. 1st pulse is
systole, 2nd pulse is large regurg of blood back into heart from AR.

Pulsus alternans is defined as alternating strong and weak pulses and indicates left-sided heart failure
and has a poor prognosis.

Pt px with left atrial enlargement represented as straightening of the left heart border on CXR = MS.
MG 2/2 to thymoma would present as a mediastinal/retrosternal mass on a LATERAL CXR.

Infectious Diseases

Warm tender, erythematous superficial skin rash with raised, sharply demarcated edges and regional
lymphadenopathy + systemic signs (fever, chills) = Erysipelas caused by Streptococus pyogenes

Tx: IV abx or oral meds.

Path infection from minor trauma, inflammation or edema.

Differentiate from non purulent Cellulitis which causes deep infection, with flat edges and poor
demarcation, and is more localized. Non-purulent cellulitis can be caused by S pyogenes or MSSA.

Differentiate from purulent cellulitis which has purulent drainage and may involve follicles; caused by
MSSA and MRSA.

Young sexually active pt who px with Gonorrhea infection should also be screened for Chlamydia, HIV,
Syphillis, and Hep B.

IV drug users or patients HIV should be screened for hepatitis C.

We do not screen for genital herpes. Only treat people with an active infection.

Motor weakness, paresthesias, encephalitis that progress to coma and death after a bite from a
mammal = Rabies

Most cases of rabies in US are from wild animals: bats, raccoons, foxes, skunks. Most cases in
developing countries are form dogs.

Patients exposed to high-risk wild animals: raccoons, bat, fox, coyote should receive PEP if you cant
catch and test the animal. If the animal can be tested, hold PEP until you euthanize the animal look at its
brain.

Patients bitten by domestic animals do not need PEP if the animal is available for testing. Hold PEP and
quarantine the animal for 10 days and see if it shows signs of rabies.

Patients bitten by low risk animals (chipmunk and squirrels) do not need PEP.

Staph Aureus and Pseudomonas Aeruginosa are the most common cause of deep infections eg
osteomyelitis from puncture wounds. P Aeruo notoriously causes osteomyelitis in puncture wounds
through a sole of a shoe.
Dx Osteomyelitis with CXR 2 weeks after the puncture wound. Then perform blood cx and bone bx to
find organism

Tx IV abx and surgical debridement.

C tetani does not cause osteomyelitis.

Systemic signs: fever, chills, tachy, leukocytosis, PNA + headache, neck rigidity, AMS, in an adult =
Meningitis caused Strep Pneumo

Differentiate from SIRS, headache, neck rigidity, AMS in an elderly patient who may have eaten cheese
= Listeria

Strep-Pneumo is the #1 cause of MOPS in adults. The meningitis may or may not be accompanied with
PNA.

Tx: Ceftriaxone, macrolide

Dx of Meningitis = Need 2 or more of Neck Rigidity, Headache, Fever, and AMS

1st Consider Head CT to rule out intracranial mass before LP in patients with FND, seizures,
papilledema, AMS, or immunocompromised

2nd dx step is lumbar puncture showing high opening pressure (> 350) , low glucose (< 40), high protein (
> 200), neutrophilic leukocytosis (> 200)

Tx: Ceftriaxone, Vancomyin, and dexamethasone(steroids)

Pruritic, ulcerating lesions with non-purulent, odorless discharge, ascending up through the arm in a
patient who works as landscaper/gardener w decaying/plant soil = Sporothrix

Path: sporothrix is a dimporphic fungus found in decaying plants and soil (rose) spreads along the
lymphatic chain but it DOES not cause lymphadenopathy.

Dx Culture w bx

Tx 3-6 months of itraconazole

Differentiate from Cat scratch disease caused by Bartonella which presents with cutaneous lesions with
regional lymphadenopathy in Immunocompetent patients and disseminated bacillary angiomatosis in
immunocompromised patients.

Immunocompromised patient with lung nodules, indurated skin rash, brain abscess and B-symptoms
with culture showing gram positive, partially acid fast, aerobic filamentous rods = Nocardia

Nocardia is similar to TB so it causes B symptoms

Tx: Bactrim, (TMP-SMX)

Differentiate from TB which would present similarly but is an ACID FAST rod that does not Gram Stain.

Differentiate from Actinomyces which is also a gram +, branching filamentous rod but is ANAEROBIC and
not acid fast. Actinomyces causes sulfur granules, cervio-facial, lung, and GI/Gu infections.

RUQ pain, intrahepatic cyst with thick wall/eggshell calcifications on CT, in contact with dogs = Hydatid
Cyst from Echinococcus granulosus

Eggshell calcifications = Hydatid Cyst

Path: Tapeform human get disease from intimate contact with dogs.

Tx: surgical resection with albendazole.

Differentiate from Amebic liver abscess 2/2 entamoeba hystolytica which presents with fever and RUQ
pain but would NOT see eggshell calcifications

Differentiate from Cysticercosis 2/2 Taenia solium which causes cysts in brain and muscle.

Differentiate from Pyogenic Liver abscess which develop after surgery, GI infection, or appendicitis. Pat
would have severe pain, high fevers, and leukocytosis.

Differentiate from Simple hepatic cysts which cause dull RUQ pain, abd bloating, and early satiety but
NO eggshell calcifications.

Man develops maculopapular rash that begins in trunk and spreads to entire body, diffuse widespread
lymphadenopathy including an epitrochlear node, and has had 3 new sexual partners = 2nd stage
Syphillis

Why syphilis, the rashes spreads to his entire body ie it doesnt spare the hands and feet + he is sexually
active.
Differentiate 2nd stage from Rickettsial disease where rash begins in Arms and feet (including palm and
soles) and then spreads to the body. Rickettsial disease presents with high fever, headache malaise after
a tick bite in the outdoors.

Dx: Screen: VDRL or RPR Confirm: FTA-Ab

Tx: Penicillin G

Adequate treatment of syphilis = 4-fold decrease in serologic titers at 6 12 months

Patient with cirrhosis has not been vaccinated against Hep A and Hep B and has not received Tdap.

Young patient underwent a dental procedure develops fever, malaise, splinter hemorrhage, hematuria
and new diastolic murmur = Sub-acute endocarditis from Strep Viridans

Dx 1) 1st step is obtain 3 serial Blood cx before giving abx (to know what the organism is)

2) If patient is stable and has mild symptoms collect blood cultures over several hours and wait for
results before starting abx. If patient is severe/unstable collect all 3 blood cx in 1 hour and immediately
start broad spec abx.

Use TTE or TEE if patient is suspected to have vegetation.

Patient after a dental procedure develops MR = Subacute endocarditis from Strep Viridans

Strep Viridans namely Strep Sanguinis is the most common cause of endocarditis after any procedure
that involves the mouth. Strep mutans more commonly associated with dental caries.

HIV patient with CD4 count of 500, viral load of 42,000, and not on Anti-Retroviral needs Varicella
vaccine. Should you give it?

If CD4 > 200 can give varicella vaccine and they do not have to be on ART.

HIV patients with a CD4 > 200 can receive all the live attenuated vaccines (MMRV) (Measles, Mumps,
Rubella, Varicella)

HIV patient with CD4 count of 50 wants influenza and TdaP vaccine. Should you give it to them?

Yes, all HIV patients should get influenza, and TdAP because they are inactivated viruses. There are
concerns for live-attenuated vaccines in HIV patients. If CD4 > 200 then yes can give MMRV.
Transplant patient px with fever, HA, confusion (AMS), leukocytosis, and neck stiffness = Meningitis 2/2
S pneumo, N meningitidis, Listeria

What broad spec abx should he be given? Vanc, Cefepime, + Ampicillin What else?

All patients with meningitis get Steroids empirically (for potential S. pneumo) but if S pneumo is r/o then
stop steroids.

Newly diagnosed HIV patient has an 8 mm induration at 48 hours with tuberculin skin testing? Do they
need further testing or treatment?

Yes, peform CXR to rule out active TB and screen for B symptoms. If neg, then start Isoniazid + Pyroxine
for 9 months for latent TB.

If a patient has HIV, transplant, or is immunosuppressed PPD of 5 or more mm is an indication to treat.

If a patient is a child, immigrant, in prison, or hospital employee, has a PPD 10 mm or more, treat.

If a patient is normal PPD > 15 or more, treat.

An elderly man px with fever, chills, cough, SOB and symptoms initially improved but then symptoms
worsened and is now found to have infiltrates on CXR and crackles on auscultation = Secondary Bacterial
Superinfection after Influenza 2/2 Staph Aureus or S pneumo.

RF Old patients ( > 65), fat patients, sick patients (COPD, CKD, immunosuppressed), and pregnant
patients are increased risk for complications from influenza.

S. Pneumo and S. aureus are the 2 most common causes of 2 bacterial superinfection.

S aureus causes a more severe, necrotizing, and rapidly progress PNA. High fever, cxr shows lobar or
multilobar infiltrates w or w/o cavitation.

Tx: ICU and Broad spec abx( Vanc, Zosyn( Pip-tazo), and Levo)

Pulmonary symptoms, putrid sputum, and infiltrates in lower lung fields in an alcoholic diabetic who
may have aspirated = Klebsiella PNA.

Klebsiella PNA occurs in (Alcoholics, Aspiration, Abscess, and diAbetics ) Px with putrid sputum and
infiltrates in dependent lung fields.

Pulmonary symptoms with interstitial infiltrates, GI symptoms: n/v, diarrhea, Headache/confusion,

Hyponatremia, and high fever and recent travel to a hotel/cruise = Legionella
Fever, chills, cough, SOB, in patient who was recently hospitalized = Pseudomonas Aeru PNA (Noscomial
infection)

Patient with poorly controlled diabetes develops DKA and px with fever, facial pain and found to have
foul-smelling discharge and a necrotic nasal turbinate = Mucormycosis

RF: Diabetic patients, patients with hematologic malignancies, and transplant patients

Px occurs acutely with fever, nasal congestion, and local necrotic spread.
Dx. Sinus endoscopy with bx and culture

Tx: Surgical debridement + Amphotericin B

Pt px with headache,myalgia (muscle aches), high fever, severe hypotension, resistance to neck flexion,
petechiae, and CSF results of low glucose, high proteins and PMNs = N mengitidis Meningitis

Px: symptoms develop suddenly, with rapid progression. Often start with the fever, headache, vomiting,
and SEVERe myalgias. Then develop neck stiffness, petechial rash, and then SHOCK. Think of
waterhouse-Friedrickson Syndrome.

Key symptoms for N. meningitidis are Meningitis + myalgias, petechiae, and shock.

Tx: Ceftriaxone + Vanc + Steroids are not helpful but given empirically until S pneumo is ruled out

Close contacts are prophylaxed with Rifampin

Differentiate from Rocky Mountain spotted fever which px with fever, headache, and petechial rash that
spreads from the hands and feet (palms and soles) to the body. It would have CSF findings of a viral
meningitis (high glucose, and mostly lymphocytes).

Differentiate from Pneumococcal meningitis which does not have petechiae, and shock.

Acute lyme disease which presents with erythema migrans, migratory polyarthritis, and headaches.

Patient with active TB is being treated with RIPE therapy and presents with tingling sensation in the
hands and feet (glove and stocking), problem with proprioception (rombert test +) vibration, and
temperature sensation = Pyridoxine Vitamin B6 deficiency 2/2 to Isoniazid.

Patients with malnutrition, pregnancy, and DM are at increased risk of developing B6 deficiency.

B6 is important for synthesis of neurotransmitters hence why it causes the glove-and stocking
neuropathy.
Differentiate from Vitamin B12 which would presented similarly but also have Ataxia and muscle
weakness.

Differentiate from GBS which would cause ascending weakness and numbness and tingling.

Differentiate from ALS where they are no sensory symptoms.

Man px with acute (< 2 weeks) copious watery diarrhea after traveling to Eastern Europe where he hiked
and swam in lakes = Cryptosporidium

Crypto is a parasite found in contaminated drinking water and causes profuse, watery diarrhea, with
mild abd pain and low grade fever. Symptoms usually resolved in 2 weeks. AIDS patients at increased
risk of chronic infection.

Dx with microscopy showing partially acid-fast on stool O and P.

Differentiate from Shigella and other causes of BLOODY diarrhea.

Differentiate from Entamoeba histolytica which causes bloody diarrhea and RUQ pain

Differentiate from Strongyloides which also cause GI pain and pulmonary symptoms and would take
YEARS to manifest.

Differentiate from C.diff which causes watery diarrhea (w mucous) in setting of recent abx usage. May
have occult blood BUT diarrhea from C. diff is not bloody.

_____________________________________________________________________________________

Pt px with a painless penile ulcer after recent sexual activity with a sex worker. He develops severe rash
and oropharyngeal swelling to penicillin. What does he have and how do you treat?

= 1 Syphillis Remember primary syphillis is painLiss

If a normal patient has a SEVERE, potentially life-threatening reaction to penicillin treat with oral
doxycline.

The exceptions to this where you still desensitize the patient and still treat with penicillin are 1)
Pregnant woman (high risk of transmission to baby) and 2) Neurosyphllis (argyle Robinson, neurologic
symptoms; need to achieve adequate CNS penetration.

Signs of adequate treatment are 4 fold decrease in titers by 6-12 months.

Pt with 3 syphillis with gummas has a severe allergy to penicillin (severe rash, and oropharyngeal
edema). What do you treat them with?

Ceftriaxone. For all other stages of syphilis, if a patient has a severe penicillin allergy you give
Doxycycline. Tertiary syphilis is the only one treated with Ceftriaxone.
Pt px with cough, confusion, high fever, hypotensive, tachypnea, tachy, with dullness and crackles on
pulm exam. He has a hx of multiple gunshot wounds in the abd? What is the dx and what is the most
likely organisms? Septic pneumonia 2/2 S. Pneumo

Pt likely had a splenectomy from the multiple gunshot wounds, which increases his risk of infection by
encapsulated organisms: S. pnuemo, H flu, and Nessieria meningitis, and Salmonella (SHiNS) Recall,
spleen not only helps to clear bacteria from blood but also produces opsonizing antibodies against the
polysaccharide capsule of these organisms. Recall in sketchy that they all have sickles

Patients with a hx of splenectomy (surg of sickle cell) should be given the pneumococca, meningococcal,
and H.flu type B vaccines.

Recall S.pneumo is described as gram+ lancet shaped diplococci.

Complement deficiency can also predisposes to infection with encapsulated organisms, namely
Neisseria but is a less common cause than splenectomy.

Pt presents with delayed separation of the umbilical cord, recurrent bacterial infections of skin and
mucosa with no pus (non-pyogenic), and Neutrophilic Leukocytosis. Dx?

LAD Leukocyte Adhesion Deficiency due to lack of CD-18 (remember LADS).

Neutrophilic leukocytosis because there is no marginal pool. Neutrophils cant travel to umbilical cord to
cause separation and they cant travel to sites of infection to generate pus.

Pt px with recurrent infections, thrombocytopenia, and eczema. Dx? Wiskott Aldrich Syndrome

Recall WATER- Wiskott Aldrich Thrombocytopenia, Eczema, Recurrent infections. Also might see
elevated IgE and IgA levels.

Pt presents with recurrent bacterial and fungal infections namely: S aureus, and Aspergillus? What test
would you use to diagnose?

Chronic Granulomatous deficiency

Nitroblue tetrazolium in which the test remains colorless indicating the patient has CGD 2/2 to
defective NADPH ie no oxidative killing.
Pediatric pt px with recurrent Fungal and viral infections, hypocalcemia, cleft-palate, heart defects, and
an absent thymic shadow on CXR? -- > DiGeorge Syndrome

In Di-George, 3rd and 4th pharyngeal pouches dont develop, no thymus so no T cells to kill the fungus
and viruses and no parathyroid glands and heart problems.

Recall B cells kill bacteria and parasites.

Pediatric pt px with recurrent fungal, viral, parasitic, and bacterial infections and chronic diarrhea ,
failure to thrive? Severe combined immunodeficiency

Key point: baby is susceptible to both Fungi/Virus (T cells) and Bacteria/Parasites (B cells). Hence
combined. + failure to thrive.

Pt px with recurrent pus-filled infections, neutropenia, easy bleeding, skin issues (albinism) and
tingling/pain in hands and feet? = Chediak Higashi Syndrome

The Chediak Hiagashi Railroad aka microtubule is defective which causes impaired phagolysosome
fusion.

neutroPenia because neutrophils cant fuse phagosomes with lysosomes, Platelet dysfunction, Partial
albinism, and Peripheral neuropathy.

Pt px with fever, malaise, new right-sided murmur, and has hx of IV drug use? Endocarditis 2/2 to S
Aureus

S. Aureus is the number 1 cause of endocarditis in drug users. Drug users tend to develop more right-
sided murmurs than left-side.

Pt px with fever, holosytolic murmur at apex, blood cultures grow Eikenella? Dx? Endocarditis from a
HACEK organism. (Haemophilus, Aggrregativacter, Cardiobacterium, Eiknella and Kingella)

HACEK organisms usually cause CULTURE NEGATIVE endocarditis.

Eikenella is associated with endocarditis from poor dentition/periodontal infection and dental
procedures. 2nd to Strep Viridans of course.

Pt who is hospitalized develops a UTI and is being treated. 2 days later she develops fever, malaise, and
a new murmur. Dx. Endocarditis 2/2 to Enterococcus

Enterococcus is a common cause of endocarditis in patients with nosocomial UTIs.

Pt with longstanding Ulcerative colitis for 11 years px with weight loss, fever, malaise, and a new
murmur. Dx?

Endocarditis 2/2 to Strep Bovis.

Ulcerative colitis increases the risk of colon cancer, particularly after having it for 10 years.

Colon cancer patients that develop endocarditis are infected by Strep Bovis.

Pt with poorly controlled T2DM and PVD, px with fever and pain in foot. He notes that he developed a
small ulcer on his foot a few weeks ago that has not healed and has an elevated ESR? Osteomyelitis 2/2
to polymicrobial infection with Pseudomonas Aeruginosa, Staph aureus, and Strep pyogenes.

X-ray would show cortical erosion.

Foot infections are common in diabetic patients. Typically px with localized skin erythema, warm,
tenderness and edema. Suspect osteomyelitis if pt has systemic signs such as fever/chills, elevated ESR,
and if the ulcer is large > 2 cm and is long-standing (> 1 week).

Osteomyelitis from an overlying would is caused by contiguous spread not hematogenously.

Hematogenous osteomyelitis is more common in children as opposed to adults.

In adults usually occurs from open-wound trauma. Hematogenous osteo affects the vertebrae, pelvis,
and hips.

GI

55 yo pt with a chronic hx of constipating and straining, px with gross blood in stool. Dx? He asks how
can he prevent this?

Diverticulosis is associated with increasing Age, chronic constipation, diet low in fiber, and high in fat.

The best thing this pt can do is increase intake of fiber rich foods: ie fruits and vegetables, avoid meat,
and increase physical activity.

Things that increase of complications are eating meat, NSAIDS use (bleeding), obese, and smoking.
35 yo pt px with a 6 month hx of hand shaking and involuntary jerky movements. He has a hx of
depression treated with Fluoxetine. He is a non-drinker. On exam his liver is enlarged but nontender.
Labs notable for slightly elevated AST/ALT. Dx?

Wilson disease aka hepatolenticular degeneration

The combination of liver dysfunction findings, psychiatric complains, and basal ganglia neurologic
symptoms (hand shaking, and jerky movements) supports Wilson disease.

The only additional finding you needed was Kayser-Fleischer rings: golden brown or greenish rings
around the iris.

Liver dysfunction in Wilson can range from asymptomatic to cirrhosis. The psychiatric problems include
parkinsonism, dysarthria, choreoasteotosis, depression etc. Symptoms start from age 5 to 35.

Dx. Decreased Ceruloplasmin, increased urinary copper 2/2 to decreased ceruloplasmin (cant hold
copper and so much copper builds up in the blood that it gets filtered into urine), or Kayer-Fleischer
rings.

Tx: 1st line: D Pencillamine and trientine which are copper chelators. Oral zinc can be used for
maintenance therapy. If the patient has cirrhosis, transplant is the only cure.

In younger patients liver disease symptoms dominates while in older patients the neurologic symptoms
dominate.

Differentiate from hemochromatosis which would have skin findings: hyperpigmentation, diabetes,
arthropathy, heart involvement BUT would not have any Psychiatric symptoms.

Differentiate from Huntingtons disease which could cause some of psychiatric symptoms: tremor and
jerky movements but would not explain liver dysfunction.

Renal

Pt px with fever, tinnitus, tachypnea, and has a PaCO2 of 20, bicarb of 10 and pH of 7.4 after ODing on
one of her meds 2 hours ago? Aspirin Overdose

Acute aspirin toxicity initially causes a mixed-acid base disorder: Resp Alkalosis that is later balanced by
an anion-gap metabolic acidosis.

The resp alkalosis causes the low PaCO2 (<40). The metabolic acidosis cause the low bicarb (<24).
Acutely at least the combination gives a close to normal pH (7.4).

Tinnitus is also a big giveaway for Aspirin toxicity.

Tx: bicarb or dialysis since this is an acidosis.

Pt px with muscle cramps and weakness. Vitals notable for BP of 150/96 and labs for slight
hypernatremia and hypokalemia? CONN syndrome aka Primary Hyperaldosteronism.
Muscle weakness and cramps are explained by the hypokalemia.

In a patient presenting with HTN, slight hypernatremia, and hypokalemia you should think of CONN
syndrome. Also, be on the lookout for a HTN patient who after taking diuretics develops severe
hypokalemia.

Dx:

1 A plasma Aldosterone/Renin activity ratio > 20 is strongly suggestive of CONN syndrome.

2 Confirm by salt-loading the patient to see if they fail to suppress aldosterone. (This is called adrenal
suppression testing); failure to suppress aldo supports CONN.

3. F/U with CT imaging to look for bilateral adrenal hyperplasia or discrete aldosterone secreting
adenoma. If inconclusive ie no discrete mass, perform adrenal vein sampling to differentiate hyperplasia
from adenoma.

Tx: Surgery for adenoma. Medical therapy for hyperplasia.

65 year with a 40 ppy hx of smoking px with progressive proximal weakness that improves after activity,
dry mouth, ptosis and is hyponatremic? Lambert-Eaton syndrome and SIADH 2/2 to Lung Cancer (small
cell).

Lambert Eaton presents with progressively worsening proximal muscle weakness that improves with
sustained activity, weakness, fatigue, ptosis, and autonomic dysfunction.

18 pt px with low grade fever, generalized, diffuse maculopapular skin rash, malaise, and muscle pain
after being treated with Bactrim for a UTI 1 week ago. Cr is 2.0 and u/a shows numerous WBC casts. Dx?

Acute interstitial nephritis 2/2 to allergy to sulfa.

These patients have renal failure represented by elevated Cr.

May also see WBC casts and urinary Eosinophils aka eosinophilluria and other signs of AKI such as
oliguria.

Remember that the Ps can cause interstitial nephritis. Pain (analgesics NSAIDS), Penicillins
(cephalo,Bactrim), Pee (diuretics), and rifampin.

Differentiate from Lupus which causes a malar and discoid rash, not a maculopapular rash.

13 y/o boy px with hematuria with RBC casts, and HTN. On exam, also noted to have swelling around his
eyes. No significant PMH but he had a skin infection 2 weeks earlier? Post-infectious
Glomerulonephritis (PIGN)

Classical px as coke colored urine with periorbital edema 2 weeks after a throat or skin Strep infection.
Tx is supportive.

26 yo px with severe left-sided colicky pain that radiates to the groin. Dx? What is the most likely
etiology?

Nephroliathsis 2/2 to calcium oxalate.

Most kidney stones (90%) are caused by calcium oxalate stones.

Calcium oxalate stones are radiopaque and described as enveloped shaped.

Small bowel disease, surgical resection, or chronic diarrhea can cause malabsorption of fatty acids and
bile which increases risk of calcium oxalate stones. Recall that calcium stones are actually caused by too
much oxalate and that Ca normally clears oxalate from the GI tract. In the above conditions,
malabsorption of fatty acids lets those fatty acids complex with calcium, allowing oxalate to be absorbed
into the blood.

Tx with thiazides, citrate (binds to Ca2+ in kidneys before oxalate can) (decrease Ca2+ excretion),
hydration, and low salt diet.

Differentiate from uric acid kidney stones which are more commonly associated with dehydration, gout,
Myeloproliferative disorder, and leukemia ie there is increased cell turnover.

Differentiate from Cysteine kidney stones which occur in children with Cystinuria. Px as recurrent
staghorn calculi. Look for a family hx of kidney stones.

Differentiate from Struvite stones which are formed from the alkaline env caused by urease producing
bacteria such as Proteus Mirabilis. Recall, that the staghorn calculi would cause RECURRENT UTIs.

Endo cont.

37 yo pt px with 3 month hx of HTN. He also complains of episodic headache, sweating, palpitations and
is tachycardic on exam. Dx? Pheochromocytoma

Recall that the symptoms of Pheochromocytom are spells or episodes of Palpitation, Perspiration, Pain
(headache), Pressure (hytension), and Pallor.

Dx: Urine metanephrines

Tx: Phenoxybenzamine before surgery.

Woman px with weight gain recently, especially in the abdominal area and thinning of her arms and legs.
Also reports developing easy bruising and amenorrhea Dx?

Cushing syndrome aka Pituitary ACTH tumor

Cushing syndrome classically presents with central obesity, proximal muscle wasting, purple striae,
glucose intolerance, amenorrhea, osteoporosis, and HTN.

Recall the mnemonic: Cushing is that Gunner med student who is always breaking down: (catabolism in
proximal muscles and insulin resistance), under a lot of pressure (HTN), emotionally fragile (purple
striae, osteoporosis), and is always sick (immunosuppression), and is likely sick (psychiatric problems).

Lab findings show: hyperglycemia, leukocytosis, lymphocytopenia, and hypokalemia.

Dx with dexamethasone suppression test. Will respond to suppression by high dose dexamethasone.

Neuro

A young pt who is stable on Phenytoin after an unproved seizure 5 years ago, comes in and says she
plans to become pregnant. What should you do?

Gradually taper of the Phenytoin due to teratogenic effects = fetal hydantoin syndrome. It is generally
ok to stop seizure meds in patients who are seizure free for at least 2 years. You do not want to just
discontinue without a taper as this can trigger a seizure recurrence.

A pregnant woman stable on 2 anti-convulsant therapies is pregnant has IUGR and delivers a baby with a
small head, cleft palate, nail/digit hypoplasia, limb deformities, and cardiac defects. What were her
meds? And what is the diagnosis? Fetal Hydantoin Syndrome which can be caused by CBZ or Phenytoin.

A pregnant women with seizures stabilized on anticonvulsants delivers a baby with a neural tube defect
and facial defects? What was she taking? Valproic Acid

Endo

Middle age woman px with headaches, palpitations, weight loss, amenorrhea, and visual problems? Dx?

Hyperthyroidism? Testing shows an enlarged thyroid with an elevated TSH (> 5) with elevated T3 (>190
ng) and T4 (>12 ug). What is the etiology?

Hyperthyroidism 2/2 to a TSH secreting pituitary adenoma.

TSH pit adenoma can cause headache and Visual problems (evidence pointing to pituitary tumor) and an
enlarged thyroid.

A TSH adenoma would not cause infiltrative ophthalmopathy (exophthalmos: bug eyes) or pretibial
myxedema which are seen in Graves Disease.

All the other symptoms go with Hyperthyroidism.

Differentiate from Graves disease which is an autoimmune disorder when ab bind to the TSH receptor
stimulating uncontrolled release of T3/T4. Would see an enlarged thryroid but because T3/T4 are
elevated, TSH levels would be down. Also, would see bug eyes and myxedema.

Differentiate from exogenous Levothyroixine intake as again TSH levels would be down and thyroid
would not be enlarged.

Differentiate from Thyroid hormone resistance where pt presents with elevated T3/T4 and normal to
elevated TSH with a goiter. In this condition, the pituitary/other organs of the body are what has
resistance to thyroid hormone. Pit can sense it has enough T3/T4 so TSH remains high. Patients
present as euthyroid or hypothyroid.

Pt with a known hx of hyperthyroidism undergoes surgery after a bad infection. On day 2 suddenly
become febrile, tachy, agitated, delirius, and has diarrhea? DDx

Thyroid storm 2/2 to acute stress from the infection of surgery.

Symptoms of thyroid storm: TADD Fever: tachyarrhytmia, agitation, delirium, diarrhea

Hyperthyroidism worsens with HITS: infection, trauma, surgery

Patients often develop Tachy-arrhythmias.

Tx would be the 4Ps: Propanolol, Potassium iodide, Propylthiouracil, and Prednisone.

Pt px with palpitations, tremor, nervousness, and headache and found to have blood glucose of 30.
Serum insulin and c-peptide levels are both above normal limits. Dx. Insulinoma aka Beta cell tumor

Non-specific findings are sympathetic surge/response to the profound hypoglycemia.

The two main causes of profound hypoglycemia are 1) Insulinoma or 2) surreptitious use of
insulin/sulfonylureas.

A high serum insulin with an appropriate C-peptide levels, and elevated pro-insulin level (> 5) suggest
Insulinoma over surreptious insulin.

Differentiate from non-beta cell tumors aka Nonislet tumor which produce IGF-2 which acts similarly to
insulin and can cause hypoglycemia. However, Insulin levels and C-peptide levels are suppressed.

Differentiate from Sulfonylurea induced hypoglycemia which presents similarly in that both serum
insulin and C-peptide levels will be elevated. Recall, that sulfonylureas induced endogenous release of
insulin. The key differentiator is that pro-insulin levels should be low in Sulfonylurea induced
hypoglycemia.

Pt px with a pain, necrotic erythematous rash in his arms and feet. Incidentally, has elevated glucose
levels and has been losing weight? Glucagonoma causing Necrotic Migratory Erythema.

Tx with Octreotide/surgery
Pulm

Young, african-american woman px with dry cough and malaise for 2 months. She is a non-smoker and
has no allergies. CXR shows prominent hilar markings. Dx?

Sarcoidosis

Classic presentation of Sarcodosis is: Uveitis, skin problems: erythema nodosum, msk problems:
polyarthritis, pulmonary symptoms: dyspnea, Cough with prominent hilar lymph nodes on CXR in an
AFRICAN-AMERICAN female.

May also see Hypercalcemia 2/2 to hypervitaminosis D from M-phages in the non-caseating granulomas.

Watch out for cardiac symptoms: restrictive or dilated CM, and CNS problems: neurosarcoid.

Dx: biopsy from lung, lymph nodes, or skin lesions showing noncaseating granulomas.

Tx: usually self-limited and resolves spontaneously, can tx with steroids.

Recall GUE SACS mnemonic

40 yo nonsmoker px with progressive development of dyspnea, dry cough, and is jaundiced, with spider
angiomata and palmar erythema. CXR shows hyperinflated lungs. Dx? A1AAT

Key points here: Relatively young patient with no smoking history develops COPD and is found to have
signs of liver dysfunction.

A1AT causes cirrhosis: (jaundice, spider angiomata, palmar erythema) and early-onset emphysema. CXR
would show hyperinflation.

A1AT classically presents with COPD, liver dysfunction, and skin disease. They can develop symptoms
without smoking, but smoking will accelerate their symptoms.

The best way to reduce mortality in COPD patients is smoking cessation. Long-term supplemental O2
and lung reduction surgery may also help in some patients.

Steroids decrease number of COPD exacerbation but have no effect on mortality.

21 yo px with stuffy nose, nasal breathing and dry cough. She has no inciting factors and denies itching,
wheezing, or skin rash. Dx?
Non-allergic vasomotor rhinitis

Dx Clinical

Tx: Mild symptoms: intransal antihistamine or glucorticoid; Moderate to severe: combination of

antihistamine + glucocorticoid

Non-allergic vasomotor rhinitis can be differentiated from Allergic rhinitis in that it is mostly nasal
congestion symptoms: stuffiness, post-nasal drip, cough and has no identifiable triggers. Serum IgE
normal.

Patients with allergic rhinitis have nasal congestion symptoms + eye symptoms, itching, and sneezing
with an identifiable trigger. Also with allergic rhinigits, serum IGE levels would be elevated.

COPD results in increased work of breathing due to hyperinflation which flattens the diaphragm making
breathing less efficient.

COPD eg emphysema actually increases lung compliance while restrictive diseases decrease lung
compliance (but increase elastance). Think how easy is it to blow up a balloon.

Elderly man with a 40 year hx of smoking px with CXR of elongated and narrow heart shadow, barrel-
shaped chest with an increased A-P diameter, and a flatten diaphragm. What are these findings?

CXR findings of Hyperinflation from COPD.

Optho

Pt who recently had a mild cold develops sudden-onset eye pain, headache, and as non-reactive, mid
dilated pupil with redness. Dx? Acute angle-closure glaucoma 2/2 to decongestant use. What is best
next step to evaluate his condition?

Key to understand that this could occur spontaneously but will more classically be associated with drug
use: decongestants, antiemetics, and anticholingeric drugs.

Key findings are: sudden onset eye pain, non-reactive dilated pupil with redness and corneal
opacification.

Dx: gonioscopy with slit lamp/tonometry to measure IOP

Tx: urgent ophthalmologic evaluation.

Differentiate from amarosis fugax which is due to embolization of plaque from carotid to the ophthalmic
artery which can cause temporary vision loss. Dx with duplex study of carotids.

Differentiate from corneal abrasion or herpes keratitis which would be dx with fluorescein slit lamp.
Rheumatology

38 y/o px with back pain for 3 months. The back pain improves with exercise but does not improve with
rest. He often wakes up at night due to the pain. He also is found to have diastolic murmur. Dx?
Ankylosing Spondylitis

For the record, nocturnal back pain is back pain that become worse when a patient lies down or goes to
sleep.

The patients young age, nocturnal back pain that improves with exercise, and AR are classic signs for
Ankylosing spondylitis.

Important to note they are at increased risk for vertebral fracture as pt with long-standing disease
develop osteopenia/osteoporosis 2/2 to increased osteoclast activity from chronic inflammation.

42 yo with long-standing hx of ankylosing spondylitis had a mild fall and now has spinal tenderness with
limited ROM. Dx?

Vertebral fractures. Pt with long-standing ankylosing spondylitis have osteoporosis and at increased risk
for vertebral fracture even after mild trauma.

Differentiate from metastatic cancer which could also increase the risk of fracture from minimal trauma
but the pt has no risk factors: no weight loss, nocturnal pain, or hx of malignancy.

Elderly pt with low back pain that radiates to the leg and numbness in the same leg and traumatic fall on
his back. Dx? Acute lumbosacral radiculopathy 2/2 herniated disc.

This presentation is also consistent with degenerative spinal stenosis causing root compression but the
fall supports a herniated disc.

Pt presents with swelling in his hands and has morning stiffness. DIP joints are particularly swollen and
has diffuse swelling of all his fingers. He has pitting and other deformity in his nails. Dx?

Psoriatic arthritis Sausage Digits

Prolonged morning stiffness is a sign of inflammatory process and differentiates osteoarthritis from all
the other inflammatory arthritis.

Also look for a description of psoriasis. It would have been too easy to include hx of red plaques with
silver scales.

Differentiate the red plaques and silver scales of psoriasis from the gotrrons papule(violaceous plaques)
in dermatomyositis.

Differentiate from osteoarthritis which also affects the DIP joints but there would be no nail findings or
diffuse swelling of the fingers.

Differentiate from Rheumatoid arthritits who can also present with morning stiffness BUT would not
affect DIP. It affects PIP recall mother swan stays Proximal to her kids. ~ swan neck deformity seen in RA.

PT with Crohns disease develops arthritis symptoms in his LE and sacroiliac joints that wax and wane
with IBD flare ups. Dx?

Enteropathic arthritis. One of the extra-intestinal manifestations of IBD: Crohns and UC. Think of the
PAIR mnemonic.

Heme/Onc

18 African-American male px with worsening fatigue and exertional dyspnea after an URI treated with
amoxicillin 2 weeks ago. On exam spleen is enlarged and scleral icterus is present. Labs notable for
normocytic anemia of 8 and Retic of 10%. Dx? Warm autoimmune hemolytic anemia 2/2 to abx
therapy.

Despite the stem saying African-American, the fact that the patient is an adult and has splenomegaly
rules out Sickle cell disease. (if he had SS he would have had autosplenectomy already). Furthermore,
there was no description of prior hx of crisis or a current pain crisis.

The key thing is the only they gave you here was treatment with abx led to the patient developing a
hemolytic anemia with splenomegaly and anemia.

Warm autoimmune hemolytic anemia is associated with 1) Lupus, 2) CLL, and 3) Drugs: pencillins and
cephalosporins.

Buzz words for AHA are spherocytes and agglutination on peripheral smear. Since, ab bind to RBC
surfaces they are nibbled down to spherocytes in the spleen (extravascular hemolysis).

Dx with a direct coombs test which would show IgG antibodies bound to RBCs.

Tx. High dose glucocorticoids.