UWstep 2 - Medicine PDF

QID Subject System Category Topic Objective
Heart failure with preserved ejection fraction is characterized by progressive stiffening of the left ventricle resulting in impaired diastolic filling and reduced cardiac output. In addition
23078 Medicine Cardiovascular
Heart
System
Failure AndChronic
Shock Heart Failure
to chronic hypertension, systemic inflammation from a sedentary lifestyle and/or obesity plays a significant role.
Root cause analysis (event analysis) is a comprehensive, retrospective error analysis tool. The objective is to identify all underlying causes of error, including both latent (i.e. system
22581 Medicine Social Sciences
System
(Ethics/Legal/Professional)
Based-Practice
PatientAnd
Safety
Qualitylevel)
Improvement
and active (i.e. personnel level) factors.
Oral hairy leukoplakia typically presents as multiple white lesions on the lateral tongue with a distinct corrugated appearance. Because it occurs almost exclusively in patients with
22474 Medicine Ear, Nose & Throat
Disorders
(ENT)
Of The Leukoplakia
Ear, Nose, And Throat
significant immunodeficiency, HIV testing should be performed, especially in patients with signs of systemic illness.
22431 Medicine Biostatistics &Probability
Epidemiology
And Principles
P-Value And
Of Testing
Confidence
A confidence
Interval
interval (CI) always contains the sample value at the center of the interval. A CI that excludes a null value (i.e. difference in percentages = 0) is statistically significant.
Vaccine efficacy is calculated by estimating the risk of disease in a group of vaccinated individuals and in a group of unvaccinated individuals (i.e. control group) and then
22396 Medicine Biostatistics &Study
Epidemiology
Design AndStudy
Interpretation
Designs determining the percentage reduction among vaccinated individuals relative to unvaccinated individuals.
Internal validity refers to the ability of a research design to provide evidence of a causal relationship between a treatment and an outcome. Blinding increases the internal validity of a
Epidemiology
Design AndValidity
Interpretation
And Reliability
study.
A C% confidence interval is a range of plausible values calculated from sample data that captures the true population value with a C% confidence level. An interval may be used to
Epidemiology
Design AndP-Value
Interpretation
And Confidence
evaluateInterval
claims about population values.
Accurate quality measurement includes measures that assess organizational capacity (structural measures), compliance of health care workers with specified processes (process
System
Based-Practice
Healthcare
And Quality
Qualitymeasures),
Improvement
health status indicators (outcome measures), and counterbalancing costs (balancing measures).
Berkson bias occurs when controls are chosen from among hospitalized patients only, resulting in a potential bias (e.g. hospitalized controls may have an exposure related to the
Epidemiology
Design AndBias
Interpretation outcome of interest) and limiting generalizability.
A case series is a descriptive observational study in which a (generally small) group of patients with a similar diagnosis or treatment is described at a point in time or followed over a
certain period. This study design includes no comparison group, so it cannot compare the effectiveness of different treatments and does not provide enough evidence to affect clinical
Epidemiology
Design AndStudy
Interpretation
Designs decisions (e.g. treating patients with new drugs or therapies).
Patient safety in the operative setting can be promoted through time-out procedures, which apply teamwork and redundancy to confirm patient identity and operative site and side.
Preoperative site and identity verification should involve the patient (or surrogate(s)) and be performed by at least 2 providers; an additional final time-out should be performed in the
Patient
Safety Patient Safety operating room immediately prior to incision and involve the entire surgical team.
Initial management of acute urticaria includes a second-generation H1 blocker (e.g. cetirizine). No additional evaluation is needed for a single episode of urticaria, although laboratory
22180 Medicine Allergy & Immunology
Anaphylaxis And Allergic
UrticariaReactionsevaluation and biopsy are recommended for episodes that are unresponsive to therapy, that exhibit atypical features, or that are accompanied by systemic symptoms.
Patients who encounter difficulties during initial attempts at lifestyle modification (e.g. diet, activity changes) are more likely to prematurely abandon efforts. Physicians can increase
Communication
And
Physician
Interpersonal
PatientSkills
the
Communication
likelihood of success by counseling patients regarding SMART (i.e. specific, measurable, attainable, relevant, and time-bound) goals.
Vitamin D deficiency in patients who have had Roux-en-Y gastric bypass surgery (and other malabsorptive conditions) can lead to osteomalacia, presenting with diffuse
21996 Medicine Rheumatology/Orthopedics
Metabolic Bone&Disorders
Sports
Vitamin D Deficiency
musculoskeletal pain and an elevated alkaline phosphatase level. The diagnosis is confirmed by measuring serum 25-hydroxyvitamin D.
Epidemiology
Design AndP-Value
Interpretation
And Confidence
Statistical
Interval
significance is reflected by a p-value less than a given significance level (e.g. p < 0.05).
21830 Medicine Pulmonary & Critical
Critical Care
Care And Trauma
Organ Donation
Medicine To maximize organ donation rates, federal guidelines require hospitals to notify the regional organ procurement organization of all imminent deaths.
Epidemiology
Design AndStudy
Interpretation
Designs Case-control studies can consider only 1 outcome (i.e. disease) per study but can evaluate exposure to > 1 risk factors.
Epidemiology
Design AndStudy
Interpretation
Designs Nonrandom treatment assignment may lead to selection bias because study participants may have an unequal chance of receiving the treatments of interest.
Epidemiology
Design AndStudy
Interpretation
Designs Differential loss to follow-up is a subtype of selection bias and represents a threat to the internal validity of a study.
Positive predictive value is the probability that an individual has a disease given a positive test result. Negative predictive value is the probability that an individual does not have a
Epidemiology
Design AndSensitivity,
Interpretation
Specificity,
diseaseNPV,
given
PPVa negative test result.
Pay-for-performance programs, which are used in accountable care organizations, link financial incentives to predefined quality metrics (e.g. percentage of patients completing
Healthcare
PolicyHealth
And Economics
Insurance cancer screening). They optimize resource use (e.g. avoiding unnecessary treatment) while promoting timely, evidence-based health care.
Insurance plans may deny coverage of medications that are less cost-effective or carry higher risk than the preferred medication choices. When a treating physician believes a
System
Based-Practice
HealthAnd
Insurance
Qualitydenied
Improvement
medication is appropriate therapy for a patient, the physician should request escalated review (e.g. prior authorization) for coverage by the plan.
Physicians have an ethical and legal duty to treat patients with life-threatening conditions, regardless of the patients’ behavior. The Emergency Medical Treatment and Active Labor
Medical
Ethics And
Ethical
Jurisprudence
Principles Act
In Healthcare
requires providers (e.g. physicians) to appropriately screen, treat, and stabilize patients arriving to the emergency department.
When a patient is unable to make decisions regarding medical care and has not designated a surrogate decision-maker, decision-making falls to the next of kin default surrogate.
Communication
And
Patient
Interpersonal
Confidentiality
Skills
Patients who wish not to inform family members of their medical information should designate an alternate surrogate decision-maker.
Review of medications should be prioritized in evaluating new-onset or worsening cognitive impairment. Medications with anticholinergic properties are strongly associated with risk
21721 Medicine Nervous System
Miscellaneous Mild Cognitive Impairment
of cognitive impairment, particularly in the elderly.
To avoid patient misidentification, clinical personnel should confirm a patient’s identity using at least 2 separate, reliable patient identifiers (e.g. full name, date of birth, medical record
Patient
Safety Patient Safety number), ideally involving the patient, prior to performing any service or treatment.
Epidemiology
Design AndStudy
Interpretation
Designs A cohort study begins by identifying individuals as exposed or nonexposed to 1 risk factor and ends by comparing the incidence of > 1 outcomes (i.e. disease) between the 2 groups.
A cross-sectional study is an observational study commonly used to estimate the prevalence of > 1 disease. It may also be used to examine associations between potential risk
Epidemiology
Design AndBias
Interpretation factors and disease. However, this study design may be affected by late-look (Neyman) bias.
Epidemiology
Design AndStudy
Interpretation
Designs Case-control studies can consider only 1 outcome (i.e. disease) per study but can evaluate exposure to > 1 risk factors.
Epidemiology
Design AndSensitivity,
Interpretation
Specificity,
Predictive
NPV, values
PPV depend on disease prevalence. As disease prevalence increases, the positive predictive value increases and the negative predictive value decreases.
Epidemiology
And Principles
HypothesisOf Testing
Testing
Studies with larger sample sizes have greater statistical power, and consequently a lower probability of a type II error, than studies with smaller sample sizes.
Predictive values change depending on the disease prevalence in a study population. As disease prevalence increases, the positive predictive value increases and the negative
21648 Medicine Biostatistics &Measures
Epidemiology
And Distribution
Sensitivity,
OfSpecificity,
Data predictive
NPV, value
PPV decreases, and vice versa.
Epidemiology
And Distribution
SensitivityOf
And
Data
Specificity
More sensitive diagnostic tests have lower false negative rates than less sensitive tests. More specific diagnostic tests have lower false positive rates than less specific tests.
No Escalation of Treatment (NEOT) orders are predetermined limits of care that are not to be exceeded regardless of clinical status. When a patient’s family members are reluctant
Medical
Ethics And
Medical
Jurisprudence
Futility to withdraw care, NEOT orders can promote agreement with the care team, minimize futility, and lessen feelings of guilt for hastening the patient’s death.
Distractions (e.g. interruptions) are unavoidable in health care, and they increase cognitive overload and risk of error. Wherever possible (e.g. non-emergency situations), physicians
Communication
And
Patient
Interpersonal
Safety Skills
should manage interruptions in a way that minimizes unnecessary task-switching and multitasking.
Classic vasovagal syncope involves a brief loss of consciousness preceded by a trigger (e.g. emotional distress) and a vagal prodrome (e.g. diaphoresis, warmth). No further workup
Miscellaneous
System Syncope or intervention is indicated when there are no physical examination or ECG findings to suggest other etiologies (e.g. cardiac, orthostatic).
The correlation coefficient r describes the direction (negative or positive) and the strength (values closer to -1 or 1 indicate stronger relationships) of the linear relationship between 2
Epidemiology
Design AndCorrelation
Interpretation
Coefficient
quantitative variables. It does not necessarily imply causality.
A confidence interval (CI) with a greater confidence level is always wider than a CI with a lower confidence level for the same data. A CI for a difference in means is significant if the
Epidemiology
And Principles
P-Value And
Of Testing
Confidence
interval Interval
excludes the null value (i.e. 0), and it is not significant if the interval includes the null value.
Obstructive sleep apnea (OSA) likely encourages the development and persistence of atrial fibrillation, possibly via nocturnal right atrial dilation and chronically elevated levels of
Cardiac
System
Arrhythmias
Atrial
AndFibrillation
Syncope sympathetic tone. The diagnosis of OSA is important in patients with atrial fibrillation as treatment of OSA may assist in management of arrhythmia.
Per-protocol analysis includes only those participants who strictly adhered to and completed the study protocol (i.e. nondropouts). This approach tends to provide an estimate of the
Epidemiology
Design AndPer-Treatment
Interpretation Analysis
true effect of an intervention for a perfect scenario, but it can overestimate the effect of the intervention in a practical clinical setting.
The null value of a confidence interval (CI) for a difference (percent change or mean change) between 2 groups is always 0, indicating that there is no difference between the groups.
Epidemiology
Design AndStatistical
Interpretation
Vs Clinical
A CISignificance
that includes the null value (i.e. 0) is not statistically significant, and a CI that excludes the null value is statistically significant.
Voluntarily Stopping of Eating and Drinking is a decision by patients with terminal illness to cease all food and fluid intake, often as a symbolic acceptance of death. Physicians
should verify that the patient has decision-making capacity and is acting voluntarily, provide counseling regarding potential consequences (e.g. discomfort), and record preferences
Medical
Ethics And
End
Jurisprudence
Of Life Care for comfort (e.g. oral swabbing) in case of thirst-induced cognitive impairment (e.g. delirium).
Verbal handoffs during transfers of care necessitate exchanging a large volume of information in limited time. To minimize communication error, handoff discussion should prioritize
System
Based-Practice
PatientAnd
Safety
Qualitypatients
Improvement
with highest medical acuity, promote accurate comprehension of critical information (e.g. selective read-back), and adopt a structured and interactive approach.
Facial nerve palsy can be the presenting symptom of early disseminated Lyme disease especially in patients with exposure to an endemic area and following systemic flu-like
Disorders Of Peripheral
Bell Palsy
Nerves Andsymptoms.
Muscles
Bell palsy, an idiopathic peripheral neuropathy involving the facial nerve (CN VII), presents with acute, progressive, unilateral facial weakness. Although it is a diagnosis of exclusion,
Bell Palsy
Nerves Andmany
Muscles
other causes of facial weakness can be eliminated through a thorough history and physical examination.
Bell Palsy
Nerves AndSlowly
Muscles
progressive facial weakness associated with hearing loss and facial twitching is concerning for a tumor at the cerebellopontine angle (e.g. acoustic neuroma).
The odds ratio is a measure of association used in case-control studies to compare odds of exposure in cases (i.e. individuals with a condition) relative to controls (i.e. individuals
Epidemiology
Design AndCase
Interpretation
Control Studies
without a condition).
Cardiac
System
Arrhythmias
Atrial
AndFibrillation
Syncope Chronic hypertension is the most common comorbidity associated with atrial fibrillation and is likely one of the strongest contributors to the predisposing atrial remodeling.
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, and affected patients usually have underlying heart disease (e.g. hypertension, coronary artery disease) and
Cardiac
System
Arrhythmias
Atrial
AndFibrillation
Syncope left atrial enlargement. The prevalence of AF increases dramatically with age; approximately 70% of those affected are age > 65.
A regression analysis is a statistical technique used to describe the effect of > 1 quantitative or qualitative independent (i.e. explanatory) variables on 1 quantitative dependent (i.e.
Epidemiology
And Principles
StatisticalOfTests
Testingoutcome) variable.
Implicit bias, or subconscious attitudes toward specific groups (e.g. ethnicity), is highly prevalent and can perpetuate health disparities. Organizations can address implicit bias by
System
Based-Practice
Principles
AndOf
Quality
Public
assessing
Improvement
Health for its presence, encouraging individual and group awareness (e.g. small group debriefing), and promoting metacognition (i.e. self-monitoring thought processes).
The applicability of study results beyond the specific population studied depends on whether particular patients are similar to those studied. Compliance to treatments can be an
Epidemiology
Design AndEvidence-Based
Interpretation Clinical
importantRecommendations
factor.
Epidemiology
Interpretation
Vs Clinical
Statistically
Significance
significant changes are reflected by a p-value less than a given significance level (e.g. p < 0.01).
Delirium is characterized by acute-onset, fluctuating consciousness, most frequently seen in elderly hospitalized patients. It usually resolves with treatment. However, cognitive
Miscellaneous Delirium dysfunction can be persistent, and a single episode of delirium increases the risk of further cognitive decline.
The number needed to treat (NNT) is the number of patients who need to receive a treatment to prevent 1 additional negative event. NNT is the inverse of the absolute risk reduction.
Epidemiology
Design AndNumber
Interpretation
Needed To
TheTreat
lower the NNT, the more effective the treatment because fewer patients need to be treated to prevent 1 additional negative event.
Epidemiology
Design AndMeasures
Interpretation
Of Association
Hazard ratio (HR) measures the effect of an intervention on an outcome over time. A confidence interval for the HR that excludes the null value (HR = 1.0) is statistically significant.
Cross-cultural care improves health outcomes and communication in diverse populations. It involves components of high-value care common to all populations, including patient-
Communication
And
Cultural
Interpersonal
Considerations
Skills
centeredness (i.e. exploring an individual patient’s beliefs), avoidance of stereotyping, and cultural sensitivity (responding to a patient’s sociocultural paradigm).
Confounding bias occurs when an extraneous (i.e. confounding) variable masks the relationship between an independent variable (e.g. risk factor, treatment) and a dependent
variable (i.e. outcome, disease of interest). It may lead to false conclusions (i.e. statistically significant results that are truly invalid). Failure to adjust for potential confounding factors
Epidemiology
Design AndConfounding,
InterpretationEffect
mayModification,
lead to residual
Bias,confounding
Errors and a distortion of the true relationship between variables.
The odds ratio (OR) is a measure of association between an exposure and an outcome. Confidence intervals that contain the null value (i.e. OR = 1.0) indicate that the association is
Epidemiology
Design AndP-Value
Interpretation
And Confidence
not statistically
Interval significant. Adjusted ORs minimize confounding and provide better estimates of associations.
Cross-cultural care is patient-centered (reflects patient values) and culturally sensitive (responding to a patient’s sociocultural paradigm). It involves first exploring individual health
Communication
And
Physician
Interpersonal
PatientSkills
perceptions
Communication
(e.g. cancer causes), allowing tailoring of further counseling (e.g. cancer screening).
A single cerebral infarct may lead to vascular dementia (VaD) if it damages key areas involved in cognition (e.g. frontal lobes). Patients with VaD due to a strategic infarction typically
Cerebrovascular Disease
Vascular Dementia
experience an abrupt decline in cognitive functioning.
Patients with syncope not clearly attributable to a benign etiology (e.g. reflex or orthostatic syncope) should undergo further cardiac workup (e.g. ambulatory ECG) to determine
Cardiac
System
Arrhythmias
Syncope
And Syncope whether a cardiac etiology is present. Syncope that occurs while supine or sitting, at rest, and without warning symptoms suggests an arrhythmic etiology.
Gilbert syndrome is characterized by intermittent jaundice and indirect (unconjugated) hyperbilirubinemia in the absence of other laboratory abnormalities. Jaundice is often triggered
21154 Medicine Gastrointestinal
Hepatic
& Nutrition
DisordersHereditary Hyperbilirubinemias
by periods of stress, such as febrile illness, dehydration, fasting, vigorous exercise, menses, and surgery.
Nickel can cause chronic allergic contact dermatitis (type IV hypersensitivity) that is typically triggered by belt buckles, jewelry, or watches. Chronic, low-level nickel exposure can
21149 Medicine Dermatology Inflammatory Dermatoses
Contact Dermatitis
And Bullous
leadDiseases
to itching and lichenification. Treatment includes topical corticosteroids and allergen avoidance.
Patients with terminal illness can benefit from reframing personal goals in more realistic, attainable ways. To assist, physicians can help patients clarify their priorities and values and
Communication
And
EndInterpersonal
Of Life Care Skills
encourage the patient (pt) to fulfill their goals by alternate means or revised timing.
The hospice model of care is designed to optimize comfort and quality-of-life for patients with terminal illness. Patients enrolling in hospice services may continue treatments that are
System
Based-Practice
End OfAnd
LifeQuality
Care intended
Improvement
for relief of symptoms (e.g. palliative radiotherapy), but not those that are curative or intended to prolong life.
Opioids are used to relieve pain and dyspnea at the end of life. In actively dying patients with comfort-oriented goals of care, opioids may be used to promote comfort despite
Critical Care
Care And Trauma
Acute Respiratory
Medicine hastening
Failure the dying process.
Dialysis-related amyloidosis results from inadequate clearance of β2-microglobulin despite dialysis, and the prevalence increases with age and dialysis duration. It has a predilection
21041 Medicine Renal, Urinary
Chronic
Systems
Kidney
& Electrolytes
Disease
Amyloidosis for osteoarticular structures presenting as scapulohumeral periarthritis (shoulder pain/hypertrophy), carpal tunnel syndrome, and bone cysts.
Hepatitis C has a high mutation rate, and lifelong immunity does not occur. Patients who have experienced spontaneous hepatitis C viral clearance, as well as those successfully
Hepatic
& Nutrition
DisordersHepatitis C treated with antiviral therapy, remain at risk for reinfection.
2:1 atrioventricular block is a unique type of second-degree block in which Mobitz type I and Mobitz type II block cannot be differentiated based on ECG alone. Vagal maneuvers may
Cardiac
System
Arrhythmias
Heart
And
Block
Syncope help in differentiation.
Hypertension
System Primary Hypertension
Medication nonadherence is common in young patients with hypertension and can lead to persistent blood pressure elevation despite an appropriate drug regimen.
Hypertension is a major risk factor for chronic kidney disease and, conversely, kidney disease can cause secondary hypertension. Therefore, patients with hypertension should have
Hypertension
their renal function (including serum creatinine, electrolytes, and urinalysis) assessed at the time of diagnosis.
First-line antihypertensive medications include ACE inhibitors, angiotensin receptor blockers, calcium channel blockers, and thiazide diuretics; the choice of drug is largely
determined by comorbid conditions, concurrent medications, and side-effect profile. Thiazide diuretics reduce renal calcium wasting and slow the rate of bone loss and are therefore
Hypertension
preferred in patients with osteoporosis.
Losartan is an angiotensin II receptor blocker (ARB) that has a mild uricosuric effect and is the preferred first-line antihypertensive drug for patients with gout. Other options include
Hypertension
other ARBs, ACE inhibitors, and calcium channel blockers. Thiazide diuretics can raise circulating uric acid levels and should be avoided.
Allergic contact dermatitis is a delayed-type hypersensitivity reaction caused by activation of memory T-cells. The acute rash is characterized by intense pruritus, erythema, edema,
Contact Dermatitis
And Bullous
and Diseases
vesicles/bullae.
Creutzfeldt-Jakob disease, a fatal prion disease, presents with rapidly progressive dementia, myoclonus, and mood symptoms. Routine cerebrospinal fluid analysis is often normal,
Neurodegenerative
Prion
Disorders
Disease
And Dementias
but more detailed evaluation usually shows elevated 14-3-3 protein titers and a positive real-time quaking-induced conversion.
Creutzfeldt-Jakob disease is a fatal prion disease that presents with rapidly progressive dementia, often accompanied by personality changes, visual cortex dysfunction,
hypersomnia, and myoclonus. A positive real-time quaking-induced conversion test demonstrating prion-induced conformational changes in fluorescent-labeled proteins is the most
Neurodegenerative
Prion
Disorders
Disease
And Dementias
sensitive and specific diagnostic test.
Cocaine can induce acute long toxicity in the form of diffuse alveolar hemorrhage (DAH). DAH presents with rapid onset of dyspnea; diffuse, bilateral airspace opacities; and
20900 Medicine Pulmonary & Miscellaneous
Critical Care Cocaine hypoxemia soon after inhaled cocaine exposure.
Patients with severe hypertension or evidence of end-organ damage should be prescribed antihypertensive therapy immediately. For those with only mild blood pressure elevations,
Hypertension
the diagnosis should first be confirmed outside of a healthcare setting with ambulatory blood pressure monitoring or home measurement.
An odds ratio (OR) < 1 indicates that the exposure (e.g. caffeine) is associated with a decrease in odds of an outcome (e.g. fecundability). A confidence interval that excludes the null
Epidemiology
Design AndMeasures
Interpretation
Of Association
value (i.e. OR = 1) is statistically significant.
Effect modification occurs when the magnitude or direction of the effect of the independent variable on the dependent variable (outcome) varies depending on the level of a third
Epidemiology
variable
Modification,
(effect modifier).
Bias, Errors
Separate (stratified) analyses should be conducted for each level of the effect modifier.
Polyarticular septic arthritis and vertebral osteomyelitis can be musculoskeletal manifestations of endocarditis. Intravenous drug use is a risk factor for this clinical presentation.
Arthritis And Spondyloarthropathies
& Sports
Septic Arthritis Synovial fluid leukocyte count is typically > 50,000/mm3, which helps distinguish between septic and inflammatory arthritis.
Lacerations crossing the vermilion border must be repaired precisely for optimal cosmesis. Local infiltration of anesthetics into the wound edges should be avoided and regional
20791 Medicine Dermatology Miscellaneous Wound Healing nerve block should be performed instead. Wound repair should start at the vermilion border to ensure proper alignment.
Lidocaine, a common local anesthetic, is typically buffered with sodium bicarbonate; this raises the solution’s pH, reducing the pain associated with injection and increasing the onset
Anesthesia/Pharmacotherapy
Anesthesia of analgesia. In contrast, addition of epinephrine causes vasoconstriction, decreased bleeding, reduced systemic absorption of lidocaine, and prolonged analgesic effect.
An association between a risk factor and an outcome is more likely to be causal if its strength increases as the exposure level increases (i.e. dose-response relationship or biological
Epidemiology
Design AndCausality
Interpretation gradient). Although a dose-response relationship is a highly important factor of causality, it is not necessary to infer causation.
Comparisons between groups are important to determine the full impact of an exposure (e.g. treatment, intervention) on an outcome. Different measures of effect (e.g. relative risk,
Epidemiology
Design AndP-Value
Interpretation
And Confidence
mean difference
Interval between groups) may be used in a single study to evaluate different aspects of the effect on an exposure.
Management of Tourette syndrome depends on the degree of functional impairment and distress. When symptoms are mild and do not interfere with activities, the appropriate first
Miscellaneous Tourette Syndrome
step is counseling and watchful waiting.
Pharmacotherapy of Tourette syndrome consists of vesicular monoamine transporter type 2 (VMAT2) inhibitors, antipsychotic medications, and α2-adrenergic receptor agonists.
Miscellaneous Tourette Syndrome
VMAT2 inhibitors are increasingly preferred as initial treatment over antipsychotics due to a more favorable adverse effect profile.
Acute paronychia (i.e. inflammation of the nail fold) can occur following minor trauma and can be complicated by abscess formation that may track to the pulp space of the finger (i.e.
20758 Medicine Dermatology Disorders Of Epidermal
Paronychia
Appendages
felon). Incision and drainage are necessary whenever an abscess is present.
The p-value is the probability of obtaining a result by chance alone when a null hypothesis H0 is assumed to be true. Its magnitude is compared to a predetermined significance level
α (usually set at 5% or 1%) to determine statistical significance. A p-value less than the significance level α indicates that results will occur by chance less than α% when H0 is
Epidemiology
Interpretation
Vs Clinical
assumed
Significance
to be true.
A confidence interval (CI) with a greater confidence level is always wider than a CI with a lower confidence level for the same data, and the sample value (e.g. mean) is always the
Epidemiology
And Principles
P-Value And
Of Testing
Confidence
midpointInterval
of the interval.
Atrioventricular nodal re-entrant tachycardia is the most common type of paroxysmal supraventricular tachycardia, resulting from abnormal conduction through 2 distinct
Cardiac
System
Arrhythmias
Supraventricular
And Syncope Tachycardia
atrioventricular nodal pathways. ECG typically demonstrates a narrow QRS complex tachycardia with a regular rhythm and buried (not visible) P waves.
Epidemiology
Interpretation
Vs Clinical
GivenSignificance
different disease manifestations, the same treatment may lead to significantly different clinical outcomes.
The null value of a confidence interval (CI) for a difference in rates (proportions or percentages) is always 0, indicating that there is no difference between the rates. A CI that includes
Epidemiology
Interpretation
Vs Clinical
the null
Significance
value (i.e. 0) is not statistically significant, and a CI that excludes the null value is statistically significant.
Epidemiology
Design AndRisk
Interpretation When comparing the relative risk (RR) of the same outcome in 2 cohorts: RR = rate of outcome in cohort 1 / rate of outcome of cohort 2.
Run charts enable systematic assessment of an intervention’s effect on process performance (e.g. no-show rate). Presence of a desired trend (i.e. consistent directional change for 5
or more data points in a row) post-intervention suggests potential effectiveness; persistent underperformance or excessive variation suggests the intervention only partially addresses
System
Based-Practice
Healthcare
And Quality
Qualityfactors
Improvement
influencing performance.
A run chart is a quality improvement tool that graphs a process performance outcome (e.g. no-show rate) over time (e.g. before and after a quality improvement intervention). Run
System
Based-Practice
Healthcare
And Quality
Qualitycharts
Improvement
allow visualization of trends (> 5 consecutive points with consistent directional change) and systematically determines effectiveness of a quality improvement intervention.
Patients with limited English proficiency are at increased risk of experiencing serious errors during medication reconciliation (process of verifying new and existing prescriptions). To
reduce errors, physicians should use a qualified interpreter, communicate directly with the patient (rather than only addressing the interpreter), and apply teach-back (e.g. asking
Communication
And
Interpreters
Interpersonal Skills
patients to repeat their understanding of new information, such as new medication instructions).
Providers should use qualified interpreters when communicating with patients with limited English proficiency, even when encounters are limited to physical examination. Ad hoc
interpretation (e.g. by unqualified medical staff or team members), even by conversationally fluent staff, is not recommended in nonemergency situations (e.g. consenting patient for
Communication
And
Interpreters
breast examination) due to potential bias and miscommunication.
The odds ratio (OR) is a measure of association calculated as follows: OR = (odds of exposure in cases) / (odds of exposure in controls). For a contingency table in the standard
Epidemiology
And Principles
Measures OfOf
Testing
Association
format: OR = ad / bc.
The odds ratio (OR) is a measure of association calculated as: OR = (odds of exposure in cases) / (odds of exposure in controls). For a correctly formatted contingency table: OR =
Epidemiology
Design AndMeasures
Interpretation
Of Association
ad / bc (or other mathematically equivalent equations).
Syphilis is diagnosed when nontreponemal and treponemal serology is positive. Negative nontreponemal and positive treponemal serology is seen with appropriately treated
infection, late untreated syphilis, and early primary syphilis (e.g. chancre). Positive nontreponemal and negative treponemal serology is often linked to pregnancy, intravenous drug
20553 Medicine Infectious Diseases
HIV And Sexually Syphilis
Transmitted Infections
use, liver disease, HIV, and autoimmune conditions.
In the United States, genital ulcers are most often due to herpes simplex virus or syphilis. In developing regions, ulcers can also be caused by chancroid or lymphogranuloma
venereum. Painless ulcers with indurated borders and a clean base are most often due to primary syphilis (chancre); although most cases are marked by a single chancre, multiple
chancres can occur, particularly in those with HIV.
The paired t-test compares the mean of 2 related groups. The test requires that a quantitative dependent variable (i.e. outcome) be evaluated in 2 related (i.e. matched, paired)
Epidemiology
And Principles
StatisticalOfTests
Testinggroups.
The accuracy of a diagnostic test is the probability that an individual is correctly classified by the test: Accuracy = ( True positives + True negatives ) / Total number of individuals
Epidemiology
And Principles
Sensitivity
OfAnd
Testing
Specificity
tested.
A percentile is the value in a normal distribution that has a specified percentage of observations below it (i.e. area under the curve to the left of the specific value). It is possible to use
Epidemiology
And Distribution
Normal Distribution
Of Data the 68-95-99.7 rule to identify the percentiles that correspond to values that are 1, 2, or 3 standard deviations from the mean.
In a clinical setting, the pretest probability of disease is equal to the prevalence of disease in the population of interest; it is used to calculate the pretest odds of disease as follows:
Epidemiology
And Principles
Pretest Probability
Of TestingPretest
And Odds
odds of disease = Pretest probability / (1 - Pretest probability)
Benign prostatic hypertrophy can cause an obstructive uropathy presenting as a slowly rising creatinine level. A renal ultrasound, which should be obtained in all patients being
Acute
Systems
Kidney
& Electrolytes
Injury
Benign Prostatic Hyperplasia
evaluated for creatinine elevation or chronic kidney disease, typically reveals hydronephrosis and may help assess the extent and reversibility of kidney injury.
Occupational asthma (OA) is induced by workplace antigen exposure (e.g. animal proteins, flours, isocyanates). Chronic OA may result in persistent airway inflammation that abates
20535 Medicine Pulmonary & Obstructive
Critical CareAnd Restrictive
Asthma Lung Disease
only after prolonged absence. OA is diagnosed by demonstrating workplace-specific declines in airway physiology, such as impaired peak expiratory flow rate.
Blinding is the concealment of intervention assignments from individuals involved in a clinical research study. The optimal strategy to maximize unbiased ascertainment of outcomes
Epidemiology
Design AndBias
Interpretation is to blind as many individuals as possible in a clinical study, especially those collecting and analyzing the data.
Intimate partner violence can present with chronic, nonspecific somatic symptoms (e.g. headaches, abdominal pain) and a normal physical examination. Evaluation for contributing
Patient
Safety Intimate Partner Violence
psychosocial factors and a high degree of clinical suspicion is required.
Ad hoc (i.e. informal) interpretation by nonqualified individuals (e.g. family members, medical staff, providers) may be necessary in limited situations, including when a patient has an
Communication
And
Interpreters
urgent medical need, interpreter services are not reasonably accessible, and delaying care to access interpreter services could cause patient harm.
Transgender patients experience significant health disparities, including communication errors (e.g. addressed as incorrect name/pronoun), that increase emotional distress and
reluctance to seek care. Such errors can be prevented by human factors engineering strategies incorporating physical changes (e.g. visibility of patient preferred name/gender in the
System
Based-Practice
Physician
AndPatient
Qualitychart)
Communication
Improvement
and simplification, which reduce the effort needed for correct action.
Epidemiology
Design AndBias
Interpretation Observer bias occurs when observers (e.g. researchers, physicians) misclassify data (e.g. treatment outcomes) due to preconceived expectations regarding the treatment.
In ecological studies, the unit of observation is the population. Disease rates and exposures are measured in each of a series of populations, and their association is determined.
Epidemiology
Design AndStudy
Interpretation
Designs Therefore, results about associations at the population level may not translate to the subject level.
In ecological studies, the unit of observation is the population, not the individual. Disease rates and exposures are measured in each of a series of populations and their associations
Epidemiology
Design AndStudy
Interpretation
Designs determined. Results about associations at the population level may not translate to the individual level.
Many common medicaftions (e.g. scopolamine, antimuscarinics for overactive bladder) can cause anticholinergic toxicity, especially in the elderly or when used together. Agitated
Miscellaneous Anticholinergics delirium due to anticholinergic toxicity is treated with benzodiazepines; in refractory cases, physostigmine may be beneficial.
Central herniation occurs when the diencephalon and midbrain are displaced caudally due to increased intracranial pressure (e.g. intracranial hemorrhage). This causes damage to
Traumatic Brain Injuries
Brain Herniation the brainstem, which results in Cushing triad, unconsciousness, mid-sized and fixed pupils, and abnormal posturing (decorticate vs. decerebrate).
Restless legs syndrome is characterized by an urge to move the legs with discomfort that is temporarily relieved by movement. Dopamine agonists (e.g. pramipexole) are often
Sleep Disorders Restless Legs Syndrome
effective.
Restless legs syndrome can occur during pregnancy and is characterized by an urge to move the legs accompanied by dysesthesia that is worsened by inactivity and improved with
movement. Symptoms are worse in the evening or at night and may impair sleep.
Restless legs syndrome (RLS) is a neurologic condition that can interfere with the quality and duration of sleep. It is characterized by an urge to move the legs and discomfort that is
temporarily relieved by movement. Although RLS is diagnosed clinically, serum iron studies should be obtained; supplementation should be started in patients with low or low-normal
ferritin levels.
Right ventricular myocardial infarction commonly presents with epigastric pain and nausea and is commonly associated with hypotension and bradycardia. A right-sided precordial
Coronary
SystemHeart Disease
Myocardial Infarction
ECG should be obtained to confirm the diagnosis.
Right ventricular myocardial infarction is confirmed by ST-segment elevation in the right-sided precordial ECG lead (e.g. V4R). Increased right ventricular preload, decreased left
Coronary
SystemHeart Disease
ventricular preload, and reduced cardiac output with hypotension and a compensatory increase in systemic vascular resistance are expected.
Daily long-acting muscarinic antagonists are the best initial therapy for stable chronic obstructive pulmonary disease with higher symptom burden (i.e. dyspnea on light exertion)
20468 Medicine Pulmonary & Pulmonary
Critical Care
Infections
COPD and/or disease risk (history of exacerbations and hospitalizations).
The odds ratio (OR) is a measure of association used in case-control studies. It quantifies the relationship between an exposure and a disease; its null value (i.e. null hypothesis) is
Epidemiology
Design AndCase
Interpretation
Control Studies
always 1 (i.e. OR = 1).
Analysis of variance (ANOVA) is used to compare the means of independent groups; it determines only whether at least 2 group means differ. Group comparisons are follow-up tests
used to determine which group means differ. A confidence interval for the difference in group means that includes 0 indicates no significant difference in group means, and vice
Epidemiology
And Principles
ANOVA Of Testingversa.
Per-protocol analysis includes only those participants who strictly adhered (i.e. non-dropouts) to the study protocol. This approach tends to provide an estimate of the true effect of an
Epidemiology
Design AndRandomized
InterpretationControl
intervention
Trials for a perfect scenario, but it overestimates the effect of the intervention in a practical clinical setting.
Although acromegaly typically presents with characteristic changes in facial and limb bones, it should also be suspected in patients with constellations of less specific findings, such
20453 Medicine Endocrine, Diabetes
Hypothalamus
& Metabolism
And
Acromegaly
Pituitary Disorders
as macroglossia, thyromegaly, thickening of skinfolds, and obstructive sleep apnea. The initial test for acromegaly is a serum insulin-like growth factor-1 level.
Patients suspected of anticholinergic toxicity (e.g. altered mental status, tachycardia, dry skin, mydriasis, urinary retention) should have an electrocardiogram performed early in their
20444 Medicine Poisoning & Environmental
Toxicology Exposure
Anticholinergics evaluation because medications with anticholinergic properties (e.g. tricyclic antidepressants) may also cause QRS interval or QTc prolongation, and other arrhythmias.
Patients treated with multiple anticholinergic medications (e.g. elderly psychiatric patients) are at risk for chronic anticholinergic toxicity, which often presents with subtle and
Miscellaneous Anticholinergics nonspecific findings not typical of acute anticholinergic toxicity. Removal of the anticholinergic medication leads to resolution of symptoms.
Predictive values change depending on the disease prevalence in a study population. As disease prevalence increases, the positive predictive value increases and the negative
Epidemiology
And Principles
Sensitivity,
Of Specificity,
Testingpredictive
NPV, value
PPV decreases, and vice versa.
A cohort study begins by identifying individuals as exposed or unexposed to a risk factor and ends by comparing outcome (i.e. disease) rates between the 2 groups. In a prospective
Epidemiology
Design AndStudy
Interpretation
Designs cohort design, the study begins before the outcome has occurred, whereas in a retrospective cohort design the study begins after the outcome has occurred.
Patient-centered care incorporates patient preferences and values, with emphasis on measuring and monitoring outcomes prioritized by patients (e.g. pain level, functional status).
Shared decision-making optimizes care in chronic conditions featuring multiple reasonable management strategies (e.g. pain management, cancer treatment), promoting selection of
Communication
And
Healthcare
Interpersonal
Quality
Skills
treatments aligned with patient priorities.
Home health care, a form of care coordination (e.g. safe transition of care), provides home-based, interdisciplinary health services (e.g. physical therapy, home safety assessment,
management of complex medication regimen) by skilled professionals (e.g. nurses, social workers). It improves safety (e.g. reducing fall risk in the elderly) and health care quality
System
Based-Practice
Healthcare
And Quality
Qualitywhile
Improvement
maintaining patient independence, autonomy, and engagement.
Attributable risk percentage (ARP) describes the percentage of disease in an exposed group that can be attributed to the exposure. It is calculated as the difference in risk of disease
Epidemiology
Design AndMeasures
Interpretation
Of Association
between the exposed and unexposed groups divided by the risk of disease in the exposed group: ARP = [(Risk[exposed] - Risk[unexposed]) / Risk[exposed]] x 100.
Relative risk reduction (RRR) measures how much a treatment reduces the risk (i.e. rate) of an unfavorable outcome. RRR may be calculated using absolute risk reduction (ARR) or
Epidemiology
Design AndRisk
Interpretation relative risk (RR) as follows: RRR = ARR / Rate[control] = (Rate[control] - Rate[treatment]) / Rate[control]; RRR = 1 - RR.
A case-control study is an observational study design. It begins with individuals who have the outcome (i.e. cases) and compares them with individuals who do not have the outcome
Epidemiology
Design AndStudy
Interpretation
Designs (i.e. controls), according to a history of exposure to > 1 risk factors.
Oral isotretinoin is indicated for severe nodulocystic acne or milder acne that is producing scars or has failed less aggressive treatments. Liver function tests, lipid panel, and
20422 Medicine Dermatology Skin And Soft Tissue
AcneInfections
Vulgaris pregnancy test (if female) should be obtained prior to and during treatment.
Relative risk (RR) is a measure of association between an exposure and an outcome. Confidence intervals that contain the null value (i.e. RR = 1.0) indicate that the association is
Epidemiology
Design AndMeasures
Interpretation
Of Association
not statistically significant. Adjusted RRs minimize confounding and provide better estimates of associations.
Methotrexate (MTX) pneumonitis is an idiosyncratic lung toxicity sharing similar pathogenesis to hypersensitivity pneumonitis. Evaluation for pulmonary infection is obligatory. MTX
20412 Medicine Pulmonary & Interstitial
Critical Care
Pulmonary
Interstitial
And OtherLungSystemic
Disease
cessation
Disorders
is both diagnostic and therapeutic.
Critical Care
Pulmonary
Interstitial
Disease
In patients
Disorders
with suspected early interstitial lung disease, initial workup includes high-resolution computed tomography scanning and full pulmonary function testing.
Hydrofluoric acid is a highly corrosive substance that can cause local tissue destruction with life-threatening arrhythmias. It is a medical emergency that requires rapid treatment with
Environmental Exposure
Exposure
Thermal Burn copious irrigation and the application of topical calcium gluconate gel.
The interpretation of the number needed to treat (NNT) should always include information about the comparison group, the specific outcome, and the period of observation for the
Epidemiology
And Principles
Number Of Needed
Testing
To
outcome.
Treat NNT values for the same intervention or treatment will vary depending on the outcome, the period of observation, and the comparison group used.
The number needed to harm (NNH) is the number of people who must be exposed to a treatment to cause harm to 1 person who otherwise would not have been harmed. To
Epidemiology
And Principles
Number Of Needed
Testing
To
calculate
Harm the NNH, the absolute risk increase (ARI) between the treatment and control group must be known: NNH = 1 / ARI.
Celiac disease can present with a diverse array of symptoms related to malabsorption (e.g. diarrhea, microcytic anemia, vitamin D deficiency) or autoimmune inflammation (e.g.
Disorders
& Nutrition
Of Nutrition
Celiac Disease peripheral neuropathy, atrophic glossitis).
Melanosis coli is an abnormal brown pigmentation of the colon due to excessive use of anthraquinone (e.g. senna) laxatives. Factitious disorder imposed on another is characterized
by the causation or falsification of illness in another person, typically a family member, to obtain psychologic validation or facilitation of the sick/caregiver role. The victim must be
Miscellaneous
& Nutrition Factitious Disorder
protected by notifying protective services.
Celiac disease, an immune-mediated disorder triggered by gluten, causes inflammatory changes that decrease the small bowel’s ability to absorb nutrients. Vitamin D deficiency is
Disorders
& Nutrition
Of Nutrition
Celiac Disease common, which increases the risk for osteoporosis. DXA can be used to screen for osteoporosis in patients with celiac disease.
Epidemiology
Design AndStudy
Interpretation
Designs A cohort study is an analytical study design that estimates and compares the risk of developing disease between exposed and nonexposed groups.
Confounding bias occurs when an extraneous (i.e. confounding) variable masks the relationship between an independent variable (e.g. risk factor, treatment) and a dependent
Epidemiology
Design AndStudy
Interpretation
Designs variable (i.e. outcome, disease of interest). It may lead to false conclusions (i.e. statistically significant results that are truly invalid).
Decompression sickness in divers is caused by rapid ascent to the surface that leads to formation of nitrogen bubbles in the tissues and bloodstream. It is diagnosed clinically, and
Exposure
Decompression Sickness
the definitive treatment is hyperbaric oxygen therapy.
The Kaplan-Meier survival curve is a commonly used graphic representation of the probabilities that subjects survive in a study without an event of interest. The event-free survival
Epidemiology
Design AndLife
Interpretation
Expectancy And
rates
Survival
of > 2 study
Statistics
groups can be compared; they are statistically different only if the p-value is less than 0.05.
The external validity (or generalizability) of a study is the applicability of study results beyond the specific population studied. Results from a randomized controlled trial conducted in
Epidemiology
Design AndValidity
Interpretation
And Reliability
a very specific population of patients are generalizable only to that specific subgroup of the population.
Health behaviors (e.g. diet, physical activity), a leading modifiable cause of chronic disease risk, are shaped by environmental factors, including social determinants of health (e.g.
System
Based-Practice
Principles
AndOf
Quality
Public
access
Improvement
Health
to healthy food, physical activity opportunities). Inequities in social determinants create health disparities.
A randomized controlled trial is used to estimate and compare the incidence of an outcome in groups of individuals randomly assigned to one of several treatments or placebo. A
Epidemiology
Design AndStudy
Interpretation
Designs common measure of association is relative risk.
The correlation coefficient (r) describes the direction (i.e. positive, negative) and strength of the linear relationship between 2 quantitative variables. It does not necessarily imply
Epidemiology
And Principles
StatisticalOfTests
Testingcausality.
A central venous catheter (CVC) is used in critically ill patients who need multiple medications or vasopressors. Accidental arterial cannulation is a potential complication of CVC
placement and may be recognized by bright red, brisk-flowing blood; resistance to catheter flushing; and blood gas analysis consistent with arterial blood. Ultrasound guidance helps
Critical Care Central Venous Catheter
ensure successful CVC placement and minimizes complications.
Postpartum thyroiditis is an autoimmune disorder characterized by lymphocytic inflammation of the thyroid and disruption of thyroid follicles occurring < 12 months after parturition. It
can cause a self-limited hyperthyroid phase due to release of preformed thyroid hormone. Management includes a β blocker to attenuate adrenergic symptoms, but specific
Thyroid &DisordersHyperthyroidism
Metabolism antithyroid therapy is not usually needed.
Positive pressure ventilation (PPV) is a mainstay lifesaving treatment for acute cardiogenic pulmonary edema. PPV lowers left ventricle (LV) preload and afterload to promote LV
Critical Care
Care And Trauma
Acute Heart
Medicine
Failure
diastolic filling and systolic ejection, decreasing pulmonary congestion and enhancing oxygen delivery.
A chi-square test evaluates the relationship between 2 categorical variables. It requires a categorical independent variable (e.g. exposure or intervention) that is used to divide study
Epidemiology
And Principles
StatisticalOfTests
Testingparticipants into 2 groups and a categorical dependent variable (e.g. outcome).
Alert fatigue occurs after exposure to frequent, clinically significant alarms and alerts (e.g. low-risk patient movement, minor drug interaction). Alarm effectiveness decreases because
providers become desensitized to all alerts, including those indicating true adverse events. Alert fatigue (and alarm effectiveness) can be improved by adjusting sensitivity of alarm
System
Based-Practice
PatientAnd
Safety
Qualitysettings
Improvement
to lower overall alarm frequency and false alarm likelihood.
Epidemiology
Design AndStudy
Interpretation
Designs The case-control study is the most appropriate analytical design to study uncommon (rare) diseases and diseases with a long latent period.
A cross-sectional study is an observational study commonly used to estimate the prevalence of disease, but it may also be used to examine associations between potential risk
Epidemiology
Design AndStudy
Interpretation
Designs factors and disease. However, exposure to risk factors and disease status are measured simultaneously at a particular point in time (i.e. snapshot).
A case-control study is used to compare the exposure status of people with a disease (i.e. cases) to the exposure status of people without the disease (i.e. controls). The main
Epidemiology
Design AndStudy
Interpretation
Designs measure of association is the odds ratio.
Interpretation of cognitive screening tests should take educational level into account. Individuals with high educational levels may score in the unimpaired range despite experiencing
Neurodegenerative
Alzheimer
Disorders
Disease
And Dementias
clinically significant cognitive decline.
Aspiration of fluid during drowning can cause bronchospasm, alveolar collapse, and pulmonary edema, leading to impaired ventilation and hypoxemia. Pulmonary complications of
Critical Care
Care And Trauma
Drowning
Medicine drowning are managed with supportive care, which may include supplemental oxygen, bronchodilators, and ventilatory support.
Diarrhea that is not explained after extensive evaluation suggests possible factitious diarrhea. Helpful studies include stool osmolality (hypo-osmolality suggests addition of water or
dilute fluid; hyperosmolality suggests addition of concentrated fluid (e.g. urine)), stool electrolytes (elevated magnesium or phosphate suggests use of saline osmotic laxatives), and
20233 Medicine Psychiatric/Behavioral
Intestinal And
& Substance
Colorectal
Factitious
Abuse
Disorders
Disorder
stool osmotic gap (osmotic laxatives cause a high osmotic gap diarrhea).
Pay-for-performance programs link financial incentives to provider actions (e.g. completing cancer screening). They can promote clinicians’ delivery of evidence-based care and high-
Healthcare
PolicyHealthcare
And Economics
Qualityvalue health care (i.e. care that optimizes patient outcomes and quality while avoiding unnecessary treatment).
Hospital readmissions are used as a quality metric because they are often preventable through improved patient communication and follow-up. Telephone-based outreach shortly
after discharge reduces readmissions rates by preventing loss to follow-up, increasing patient engagement (proactively identifying and addressing potentially serious concerns) and
System
Based-Practice
Healthcare
And Quality
Qualitycare
Improvement
coordination (effective transition between inpatient and outpatient care).
Health insurance coverage increases access to and affordability of health care while promoting diagnosis and recommended management (e.g. assessment, ongoing medical
treatment, laboratory monitoring) of chronic conditions. Medicaid is a public health insurance program funded by federal and state governments that covers low-income individuals
Healthcare
PolicyHealth
And Economics
Insurance and families living (including children and pregnant women) and those with disabilities.
A relative risk (RR) < 1.0 indicates a lower risk for the outcome in the treatment group; a RR = 1.0 indicates no association between treatment and outcome; and a RR > 1.0 indicates
a greater risk for the outcome in the treatment group. A confidence interval (CI) that includes the null value for RR (i.e. RR = 1.0) is not statistically significant, and a CI that excludes
Epidemiology
Design AndMeasures
Interpretation
Of Association
the null value (i.e. RR = 1.0) is statistically significant.
Acute mountain sickness can progress to high-altitude cerebral edema (HACE), a life-threatening condition characterized by ataxia and declining mental function that can occur after
Exposure
High Altitude Illness
rapid ascent to high altitude. Early treatment of HACE with dexamethasone can improve symptoms; definitive treatment requires immediate descent.
Pes anserine bursitis presents as a swelling over the upper medial tibial region. It is typically caused by overuse and poor knee mechanics. Treatment includes quadriceps and
& Sports
Bursitis hamstring strengthening exercises to optimize strength, flexibility, and stability of the knees.
Negative predictive value (NPV) is the probability that an individual does not have a disease given a negative test result. It is calculated as NPV = true negative / (true negative +
Epidemiology
And Principles
Sensitivity,
Of Specificity,
Testingfalse NPV,
negative).
PPV
Osteoarthritis of the hands presents with hard, periarticular enlargement of the joints; crepitus with range of motion; and mild tenderness. It most commonly involves the first
& Sports
Osteoarthritis carpometacarpal joint and distal and proximal interphalangeal joints. X-ray reveals decreased joint space, subchondral sclerosis, and periarticular osteophytes.
Initial management of hand osteoarthritis includes stretching and strengthening exercises. Topical nonsteroidal anti-inflammatory drugs (NSAIDS) (e.g. diclofenac) are beneficial for
& Sports
Osteoarthritis most patients; oral NSAIDs are also effective but carry greater risk for toxicity (e.g. peptic ulcer).
Hematuria in a setting of urinary tract infection should not be solely attributed to the infection. A repeat urinalysis should be performed in 6 weeks to confirm resolution of hematuria; if
Urinary
Systems
Incontinence/Retention,
& Electrolytes
Hematuria GUhematuria
Infection is still present, a workup is indicated.
Physicians have an ethical duty toward resource stewardship (i.e. responsible use of health care resources) by following evidence-based guidelines and avoiding unnecessary
medical treatment (i.e. delivering high-value care). Overutilization of imaging studies for acute, uncomplicated low back pain is associated with increased health care spending and
System
Based-Practice
Healthcare
And Quality
Qualitysuboptimal
Improvement
patient outcomes.
Excessive medical treatment (overuse of resources) lowers quality of care and may cause patient harm. Physicians are ethically obligated to promote resource stewardship
System
Based-Practice
Healthcare
And Quality
Quality(responsible
Improvementhealth care resource use) by following standards of evidence-based, medically necessary care.
Administration of naltrexone, an opioid μ-receptor antagonist, along with opioids causes the blockade of opioid-induced effects and inadequate pain control. This error can result from
incorrect medication reconciliation during transfers of care (e.g. discharge from the hospital to another facility) and can be prevented through interdisciplinary (e.g. pharmacist)
Miscellaneous
& Substance
Patient
Abuse
Safety involvement and enhanced interprovider communication.
Capnography is the measurement of carbon dioxide concentration over time. It can provide valuable information about ventilation/perfusion and metabolic status and is the most
Critical Care
Care And Trauma
Emergent
Medicine
Airway reliable
Management
method for verifying endotracheal tube (ETT) placement. Patients with abnormal waveforms should be assessed for proper ETT placement.
The odds ratio (OR) is a measure of association between an exposure and a disease. For OR < 1.0, the exposure decreases the odds of disease (i.e. protective factor). For OR =
1.0, there is no association between exposure and disease. For OR > 1.0, the exposure increases the odds of disease (i.e. risk factor). Confidence intervals that contain the null
Epidemiology
Design AndMeasures
Interpretation
Of Association
value (i.e. OR = 1.0) indicate that the association is not statistically significant.
Bites from imported fire ants cause sterile pustules that should be left intact to prevent secondary infections. Pustules and small local reactions require no treatment. Large local
Exposure
Insect Bites And Stings
reactions can be treated successfully with antihistamines and topical steroids.
Confounding bias occurs when an extraneous (i.e. confounding) variable masks the association between an independent variable (e.g. risk factor, treatment) and a dependent
Epidemiology
Design AndBias
Interpretation variable (i.e. outcome, disease of interest). It may lead to false conclusions about the association (i.e. statistically significant associations that are truly invalid).
Olecranon bursitis presents with localized swelling over the posterior elbow, usually due to repetitive pressure, overuse, or other microtrauma to the bursa. Treatment includes
activity modification, nonsteroidal anti-inflammatory drugs, and elbow padding. However, redness, warmth, or significant pain suggests an infectious or inflammatory etiology and
Bone, Joint, And
& Sports
Soft
Bursitis
Tissue Injurieswarrants
And Infections
bursal fluid aspiration.
Childhood cancer survivors treated with abdominopelvic radiation, patients with inherited colon cancer syndromes, and patients with a history of inflammatory bowel disease are all at
Tumors
& Nutrition
Of The GIColorectal
Tract Canceran
Screening
increased risk for developing colorectal adenocarcinoma and should start colon cancer screening at an earlier age than the general population.
Fracture of a bone containing abundant marrow (e.g. pelvis) can release fat into the venous circulation, resulting in fat embolism syndrome. Diagnosis is made based on clinical signs
Bone, Joint, And
& Sports
Soft
Fat Embolism
Tissue Injuries(e.g.
Andrespiratory
Infections distress, neurologic dysfunction, petechial rash), and management is supportive (e.g. supplemental oxygen).
The independent samples t-test compares the mean of 2 independent groups. The test requires that a quantitative dependent variable (e.g. outcome) be evaluated in 2 independent
Epidemiology
And Principles
StatisticalOfTests
Testinggroups.
The analysis of variance test compares the mean of > 3 groups. The test requires a quantitative dependent variable (e.g. outcome) and a categorical independent variable (e.g.
Epidemiology
And Principles
StatisticalOfTests
Testingexposure, risk factor).
Phase III trials evaluate the efficacy, risks, and benefits of a new treatment compared to current standard treatments (or placebo) in a large sample of affected patients (i.e. patients
Epidemiology
Design AndClinical
Interpretation
Trials with the disease of interest). Most phase III trials are randomized, blind, and compare > 2 treatments.
Absolute risk reduction (ARR) describes the difference in the rate (or risk) of an unfavorable outcome between control and treatment groups. It is calculated as follows: ARR = (Rate
Epidemiology
Design AndRisk,
Interpretation
Rate, Prevalence
[control]
And - Rate
Incidence
[treatment]). The rate of an unfavorable outcome is equal to the number of unfavorable outcomes in a group divided by the sample size of that group.
The number needed to treat (NNT) is the number of patients who need to receive a treatment to prevent 1 additional negative event. NNT is the inverse of the absolute risk reduction.
Epidemiology
And Principles
Number Of Needed
Testing
To
TheTreat
lower the NNT, the more effective the treatment because fewer patients need to be treated to prevent 1 additional negative event.
Patients with chronic kidney disease taking renin-angiotensin system inhibitors often develop chronic mild or moderate hyperkalemia. This is typically managed with a low-potassium
Fluid,
Systems
Electrolytes,
& Electrolytes
Hyperkalemia
And Acid-Base diet and an oral cation exchange agent (e.g. patiromer, zirconium cyclosilicate), which binds to potassium in the colon and is subsequently excreted in feces.
Relative risk reduction (RRR) measures how much a treatment reduces the risk of an unfavorable outcome. RRR may be calculated using the absolute risk reduction (ARR) or the
Epidemiology
Design AndRisk,
Interpretation
Rate, Prevalence
relative
And
riskIncidence
(RR): RRR = ARR / Risk[control] = (Risk[control] - Risk[treatment]) / Risk[control]; RRR = 1 - RR.
Epidemiology
Design AndPower
Interpretation
And Sample
Studies
Size with larger sample sizes have greater power (i.e. a false H0 is rejected) and therefore lower probability of a type II error than do studies with smaller sample sizes.
A regression analysis is a statistical technique used to describe the effect of > 1 independent variables (e.g. exposures, risk factors), which may be quantitative or qualitative, on 1
Epidemiology
And Principles
StatisticalOfTests
Testingquantitative dependent variable (i.e. outcome).
Recurrent sinopulmonary infections and evidence of chronic lung disease (e.g. bronchiectasis, fibrosis/scarring) in a young adult are suspicious for an underlying immunoglobulin
Immune Deficiencies
Common Variabledeficiency
Immunodeficiency
such as common variable immunodeficiency.
Coronary
SystemHeart Disease
Because elderly patients with acute myocardial infarctions frequently report atypical symptoms, an ECG is often indicated on arrival to the emergency department.
Volunteer bias (a subtype of selection bias) results when a sample of volunteers (e.g. nonrandom sample method) misrepresents its target population and threatens the
Epidemiology
Design AndBias
Interpretation generalizability (i.e. external validity) and utility of findings in a clinical setting.
Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor lowers morbidity and mortality rates in patients with non-ST-segment elevation myocardial infarction. It should be
Coronary
SystemHeart Disease
administered early to all patients in the absence of contraindications.
ST-segment elevation myocardial infarction (STEMI) can present with atypical symptoms in elderly patients. Criteria for diagnosing STEMI include ST-segment elevation in 2
Coronary
SystemHeart Disease
contiguous leads. Patients with STEMI should undergo emergency cardiac catheterization and percutaneous coronary intervention.
Hyperkalemic emergency causes characteristic, progressive changes on ECG (e.g. peaked T waves → loss of P waves → widened QRS → sine wave pattern → asystole). Patients
with hyperkalemia-induced ECG changes should be urgently treated with calcium gluconate to stabilize the cardiac membrane and insulin plus glucose to move potassium into cells.
Cardiac
System
Arrhythmias
Hyperkalemia
And Syncope Longer-acting therapies to remove potassium from the body can then be administered.
Bronchial carcinoid is the most common lung cancer in adolescents and young adults. It typically presents with proximal airway obstruction, leading to dyspnea, wheezing, and
19924 Medicine Pulmonary & Cancer
Critical And
CarePulmonary/Mediastinal
Carcinoid Tumorsrecurrent
Masses pneumonia in the same lobe of the lung. Carcinoid syndrome is much less common than with gastrointestinal carcinoid tumors.
Group A Streptococcus (GAS) pharyngitis is characterized by exudative pharyngitis, fever, tender anterior cervical lymphadenopathy, and absence of cough, features that are less
Miscellaneous Pharyngitis common in viral pharyngitis. Patients at low risk for GAS pharyngitis based on these clinical criteria do not require rapid antigen testing or empiric antibiotic treatment.
Loss to follow-up after hospital discharge can lead to adverse outcomes. High-quality patient counseling that encourages early (< 4 weeks) primary care follow-up increases the
Patient
Safety Patient Safety likelihood of patient attendance, completion of pending items (e.g. imaging studies), and management of patient health status (e.g. new diagnoses).
A spinal epidural abscess can occur due to trauma, especially in immunocompromised patients. Manifestations include progressive worsening of pain, neurologic deficits, and
Spinal Cord Disorders
Epidural Abscess systemic inflammatory signs (e.g. fever, leukocytosis).
Patients who remain unresponsive after generalized convulsive status epilepticus require electroencephalography to differentiate between sedation due to benzodiazepines and
Seizures And Epilepsy
Seizures persistent nonconvulsive status epilepticus.
Carbon monoxide poisoning disrupts oxygen delivery and usage, which can cause clinical manifestations of myocardial ischemia. Elevated carboxyhemoglobin levels confirm the
Myopericardial
System Diseases
Carbon Monoxidediagnosis.
PoisoningSevere cases require hyperbaric oxygen therapy.
Plantar fasciitis is caused by degeneration of the plantar aponeurosis at its insertion on the calcaneus due to overuse. The diagnosis is made clinically. Imaging is not required unless
Bone, Joint, And
& Sports
Soft
Plantar
Tissue
Fasciitis
Injuriesa And
secondary
Infections
pathology (e.g. fracture) is suspected or if the pain does not improve after treatment.
Patients with severe immunosuppression (e.g. AIDS, solid-organ transplantation, immunosuppressant medications) are at increased risk for cryptococcal meningitis. Most cases are
marked by subacute, progressive headache, vomiting, fever, and nuchal rigidity. Cerebrospinal fluid typically shows lymphocytosis with a mildly elevated white blood cell count, mild
CNS Infections Cryptococcal Infections
protein elevation, and low glucose.
Cryptococcal meningitis is an AIDS-defining illness that primarily affects patients with CD4 counts < 100/mm3. Three phases of treatment are required to ensure eradication and
prevent relapse: induction with amphotericin B and flucytosine for ~2 weeks, consolidation with high-dose oral fluconazole for ~8 weeks, and maintenance with low-dose oral
Fungal Infections Cryptococcal Infections
fluconazole until CD4 counts recover to > 100/mm3 for > 3 months on antiretroviral treatment.
Guillain-Barré syndrome presents with rapidly progressive ascending motor weakness due to immune-mediated demyelination of peripheral nerve fibers. Because it primarily affects
Guillain-Barré
Nerves And
Syndrome
peripheral
Muscles nerves, MRI of the spinal cord is often normal.
Following hand hygiene recommendations (e.g. cleansing hands using antiseptic hand rub or soap and water) can substantially reduce health care-associated infections, but provider
compliance in health care settings is typically low. Physical environmental reengineering (e.g. improving number and placement of hand hygiene stations) is a systems approach that
System
Based-Practice
PatientAnd
Safety
Qualityincreases
Improvement
provider likelihood of hand hygiene compliance.
Adverse drug events (ADEs) frequently affect elderly patients and often involve antidiabetic and sound-alike medications. Patient-centered medication counseling reduces ADE risk
and improves health literacy and adherence; best practices include plain-language communication and interactive methods such as teach-back (i.e. having patients describe their
Patient
Safety Patient Safety understanding of new information or changes in treatment plans).
Preventable adverse drug events (ADEs) are a major patient safety concern; risk increases with vague prescription instructions (e.g. ‘as directed’). Plain-language medication
Patient
Safety Patient Safety teaching improves patient health literacy and reduces ADE risk.
Diagnostic errors commonly result from cognitive bias, unconscious mental heuristics (shortcuts) distorting clinical judgement. Cognitive bias and associated diagnostic errors can be
Patient
Safety Patient Safety reduced by applying metacognition (i.e. understanding and reflecting on one’s own thought patterns and biases).
Lactose intolerance is caused by deficiency of intestinal lactase and presents with postprandial abdominal pain, bloating, and nausea. It may be precipitated by inflammatory
disorders that affect the intestinal brush border (e.g. infectious gastroenteritis, celiac disease, Crohn disease). Lactose breath testing, which detects hydrogen released from a
Disorders
& Nutrition
Of Nutrition
Lactose Intolerance
standardized dose of oral lactose, can be diagnostic.
Achilles tendinopathy (AT) presents with ankle pain and tenderness in the tendon proximal to its insertion on the calcaneus. It is most common in patients who abruptly increase
athletic activity. Management of acute AT includes activity modification, cold compresses/icing, and nonsteroidal anti-inflammatory drugs. For chronic symptoms, a rehabilitation
Bone, Joint, And
& Sports
Soft
Achilles
Tissue
Tendinopathy
Injuriesprogram
And Infections
emphasizing eccentric resistance exercises is recommended.
Lateral epicondylitis is a tendinopathy of the wrist extensors at the lateral epicondyle origin. The pain is most severe 1 cm distal to the lateral epicondyle and is elicited by resisted
wrist extension. Initial treatment includes activity modification and use of an elbow counterforce brace. NSAIDs are of limited value, given that the underlying pathology is chronic
Bone, Joint, And
& Sports
Soft
Lateral
Tissue
Epicondylitis
Injuriestendinosis
And Infections
rather than inflammation.
Meralgia paresthetica is caused by compression of the lateral femoral cutaneous nerve under the inguinal ligament and presents with localized pain and paresthesia in the lateral
Spinal/Peripheral
& Sports
Meralgia
Nerve Disorders
Paraesthetica
And
thighBack
without
Painweakness. Patients are usually treated conservatively with weight loss and avoidance of tight garments.
Euthyroid sick syndrome (ESS) is a common pattern of thyroid function markers seen in acutely ill and hospitalized patients. Initial findings include a low T3 level; however, as the
underlying illness continues, T4 and TSH levels may also decrease. ESS may represent a mild transient central hypothyroid state, which functions to minimize catabolism in severe
Thyroid &DisordersEuthyroid
Metabolism Sick Syndrome
illness.
Major risk factors for severe, life-threatening asthma include a history of prior intubation and recent poor asthma control. Impending respiratory failure should be considered in
Asthma Lung Disease
patients with accessory muscle use, hypoxia, tachypnea, and hypercarbia.
Transverse myelitis is an immune-mediated disorder that causes a rapidly progressive myelopathy characterized by motor weakness (with upper and/or lower motor neuron signs),
Transverse Myelitis
sensory disturbances (characterized by a distinct sensory level), and autonomic dysfunction (including bowel or bladder dysfunction).
Transverse myelitis is an immune-mediated, rapidly progressive myelopathy that typically causes motor and sensory deficits, a distinct sensory level, and focal T2 hyperintensity of
Transverse Myelitis
the spinal cord on MRI. First-line management is the administration of high-dose intravenous glucocorticoids.
Patients with mild snake bite envenomation should be observed closely for 12-24 hours following the event. Repeat wound examinations and laboratory evaluation are important.
Exposure
Snake Bite Most medically significant snakebites in North America can be treated appropriately with antivenom if symptoms progress.
Peri-infarction pericarditis (PIP) results from localized inflammation triggered by myocardial necrosis and can occur 2-4 days following transmural myocardial infarction. PIP is best
Myopericardial
System Diseases
Acute Pericarditisprevented by early coronary reperfusion therapy to minimize the extent of myocardial necrosis.
Sickle cell disease patients are at high risk of delayed hemolytic transfusion reactions due to alloimmunization from frequent transfusions. Reactions develop > 24 hours after
19721 Medicine Hematology &Red
Oncology
Blood Cell Disorders
Sickle Cell transfusion and can cause hemolytic anemia. Diagnosis is confirmed with a newly positive Coombs test.
Secondary iron overload usually occurs in patients who require repeated blood transfusions due to chronic anemia (e.g. sickle cell disease, thalassemia). Common manifestations
Oncology
Sickle Cell include hepatic dysfunction and cardiac disease (e.g. heart failure). Elevated serum ferritin and transferrin saturation are characteristic.
Asthma Lung Disease
Intermittent asthma is caused by leukocyte-induced acute and reversible bronchoconstriction.
Normal physiologic changes in pregnancy include a progesterone-induced sensation of dyspnea and an increase in minute ventilation that is driven mostly by increased tidal volume.
19704 Medicine Pulmonary & Normal
Critical Care
Pulmonary
Dyspnea
Structure
OfAnd
Pregnancy
Function
Basilar lung compression by the gravid uterus decreases residual volume and functional residual capacity. Vital capacity and FEV1 are unchanged from normal levels.
Hepatitis A causes fever, vomiting, jaundice, hepatomegaly, and severe elevations in hepatic transaminases (e.g. aminotransferase levels > 1,000 U/L). Unvaccinated individuals are
Hepatic
& Nutrition
DisordersHepatitis A at increased risk, as are day care workers, homeless shelter residents, international travelers, and men who have sex with men.
The risk of pulmonary hypertension is increased in patients with sickle cell disease due to chronic intravascular hemolysis causing pulmonary vascular remodeling. Symptoms include
Critical Care
Vascular
Sickle
AndCell
Cardiopulmonary
exertional
Disease
dyspnea and signs of right-sided heart failure (e.g. hepatomegaly, edema).
Amyotrophic lateral sclerosis often causes weakness of the muscles of respiration, resulting in a restrictive pattern on spirometry (i.e. reduced vital capacity, forced expiratory volume
in 1 second [FEV1], forced vital capacity [FVC] with a normal or increased FEV1/FVC ratio), with reduced maximal inspiratory and expiratory pressure. The diffusion capacity for
Critical Care
Pulmonary
Diaphragmatic
And Other Systemic
Paralysis
carbon Disorders
monoxide, a measurement of alveolar gas exchange, is preserved.
Antipsychotic agents (e.g. haloperidol) can cause QT-interval prolongation; therefore, an ECG should be obtained prior to administering these agents to avoid causing a life-
Cardiac
System
Arrhythmias
Antipsychotics
And Syncope threatening arrhythmia (e.g. torsade de pointes).
Communication breakdowns, a leading cause of medical error, are at increased risk of occurring when providers use abbreviations, verbal orders, or third parties to relay messages.
System
Based-Practice
PatientAnd
Safety
QualityClosed-loop
Improvementcommunication increases accuracy of information relay and interpretation between providers and reduces risk of medical error.
Acute chest syndrome (ACS) is a potentially fatal vaso-occlusive complication of sickle cell disease that presents with a new pulmonary infiltrate in addition to fever, hypoxia, or
respiratory symptoms. Management includes antibiotics (e.g. ceftriaxone and azithromycin) because pneumonia is clinically indistinguishable from ACS and may be the underlying
Critical Care
Vascular
Sickle
AndCell
Cardiopulmonary
trigger. Disease
Characteristics of acute and chronic salicylate toxicity include vomiting, tinnitus, pulmonary edema, hyperthermia, tachypnea, and an anion gap metabolic acidosis. Hemodialysis is
Toxicology Exposure
Salicylate Poisoning
indicated in patients with altered mental status, pulmonary edema, renal failure, and persistent acidosis.
Congestive heart failure (CHF) frequently causes bilateral pulmonary infiltrates on chest x-ray. In contrast to bacterial or viral pneumonia, which causes prolonged chest x-ray
Critical Care
Infections
Community Acquired
findings,
Pneumonia
patients with CHF can have rapid resolution of chest x-ray findings following diuretic administration.
Patients with community-acquired pneumonia usually have a pulmonary infiltrate on initial chest x-ray. However, those who are immunosuppressed may have normal pulmonary
imaging despite signs and symptoms that localize the infection to the lungs. These patients should undergo additional pulmonary imaging with high-resolution CT scan of the chest to
Critical Care
Infections
Community Acquired
identify
Pneumonia
pulmonary infiltrate.
Handwriting tasks can help distinguish between essential tremor (ET) and Parkinson disease (PD). Patients with ET often show consistent fluctuations (e.g. waviness) in writing.
Miscellaneous Tremor Handwriting in PD is characterized by decrementing micrographia.
Hereditary hemochromatosis (HH) arthropathy often resembles osteoarthritis but differs in age at onset (< 40); predilection for the second and third metacarpophalangeal joints and
wrists; and presence of chondrocalcinosis. Management is primarily symptomatic (e.g. acetaminophen, nonsteroidal anti-inflammatory drugs), but therapeutic phlebotomy is
Autoimmune Disorders
& Sports
Hemochromatosis
And Vasculitides
necessary to minimize other systemic complications of HH (e.g. liver disease).
Hereditary hemochromatosis can cause secondary hypogonadism due to iron deposition in the pituitary with deficient production of gonadotropins. Initial assessment should include
Reproductive
& Metabolism
Endocrinology
Hemochromatosisserum iron, serum ferritin, and transferrin saturation. The diagnosis is confirmed with HFE genetic testing. Treatment includes therapeutic phlebotomy.
Hereditary hemochromatosis is characterized by increased intestinal iron absorption, tissue iron deposition, and multisystem end-organ damage (e.g. hepatotoxicity). The diagnosis
is confirmed by testing for HFE genetic mutations, but patients with extreme hyperferritinemia (e.g. serum ferritin > 1,000 ng/mL) should receive urgent therapeutic phlebotomy
Hepatic
& Nutrition
DisordersHemochromatosiswithout waiting for genetic testing results.
Pyogenic granulomas are small vascular tumors composed of abnormal capillaries and granulation tissue. They typically present as friable, dome-shaped nodules on the hands,
19584 Medicine Dermatology Skin Tumors And Pyogenic
Tumor-Like
Granuloma
Lesions
trunk, or oral mucosa/gingiva. Pyogenic granulomas are common in pregnancy and usually regress postpartum.
Power describes a study’s ability to detect an effect (e.g. difference between groups) when one truly exists. Power is influenced by 4 factors, as follows: ↑ sample size ↑ power; ↓
Epidemiology
And Distribution
Power And OfSample
Data outcome
Size variability ↑ power; ↑ effect size ↑ power; ↑ significance level ↑ power.
Failure mode and effects analysis (FMEA) is a prospective, systematic, team-based approach that consists of identifying steps in a process and finding solutions to any problems that
System
Based-Practice
PatientAnd
Safety
Qualitymay
Improvement
arise, with the goal of ensuring safe outcomes. FMEA can be performed before any problems are identified.
An enhanced physiologic tremor is typically a fine, fast, symmetric action tremor of the hands that increases with sympathetic activity. Certain medications (e.g. selective serotonin
Tremor reuptake inhibitors, β-agonists) can cause enhanced physiologic tremor, which generally improves with dose reduction or medication cessation.
Essential tremor most often presents as an action tremor of the hands that is not associated with other neurologic symptoms. First-line treatment includes propranolol, which exerts
Tremor its effects due to peripheral β-adrenergic receptor blockade, and primidone, a centrally acting anticonvulsant.
High-output heart failure is caused by decreased systemic vascular resistance that leads to an increase in stroke volume, cardiac output, and venous return and is recognized by a
Heart
System
Failure AndAcute
ShockHeart Failure
wide pulse pressure and prominent point of maximal impulse. Hyperthyroidism is a common cause of high-output heart failure.
Anterior uveitis often occurs in association with systemic inflammatory disorders, in particular spondyloarthritis (e.g. ankylosing spondylitis). Patients with uveitis and features
19495 Medicine Ophthalmology
Disorders Of The Ankylosing
Eye And Associated
Spondylitis
suggesting
Structures
ankylosing spondylitis (e.g. chronic back pain, enthesitis) should undergo x-ray of the pelvis/sacroiliac joints (and maybe human lymphocyte antigen B27 typing).
Guillain-Barré syndrome (GBS), an immune-mediated polyneuropathy, can be associated with early HIV infection. The clinical presentation and diagnostic workup of HIV-associated
Guillain-Barré
Nerves And
Syndrome
GBS
Muscles
is the same as non-HIV-associated GBS; nerve conduction studies (e.g. showing demyelination) can help confirm the diagnosis.
Evaluating older drivers requires a careful evaluation of the patient’s functional capacity to drive and balancing patient autonomy and confidentiality with public safety. In addition to
Miscellaneous
& Substance
Driving
Abuse the performance of a history and physical examination, an on-road driving evaluation is recommended in complex cases.
Patients with a family history of Alzheimer disease are at increased risk of developing the disease but can mitigate risk by addressing modifiable risk factors. Aggressive treatment of
Neurodegenerative
Alzheimer
Disorders
Disease
And Dementias
cardiovascular risk factors (e.g. hypertension, diabetes, obesity/physical inactivity), especially in mid-life, can help reduce risk.
Interferon-γ release assay measures lymphocyte response to tuberculous antigens. An indeterminate result can occur when patients have high background interferon-γ levels due to
ongoing inflammation or concurrent infection; it can also occur when there is minimal response to control mitogens due to lymphocyte suppression from HIV or immunomodulatory
Bacterial Infections
Tuberculosis medications (e.g. glucocorticoids).
Mycobacterium tuberculosis takes several weeks to grow in culture. In order to reduce the risk of transmission and progression, patients with a high pretest probability of pulmonary
tuberculosis require empiric 4-drug treatment with isoniazid, rifampin, pyrazinamide, and ethambutol while awaiting culture results. Although rapid testing (e.g. acid-fast bacilli stain)
Tuberculosis supports the diagnosis, several samples are required to achieve adequate sensitivity.
Tuberculous meningitis is typically marked by subacute symptoms of meningeal irritation (e.g. vomiting, headache, nuchal rigidity) and imaging findings of basilar meningeal
CNS Infections Tuberculosis enhancement, hydrocephalus, and stroke due to vasculitis. Risk is increased with immunocompromise (e.g. HIV).
Tuberculous meningitis is generally marked by subacute symptoms of meningeal irritation with or without cranial nerve palsy and stroke. Cerebrospinal fluid analysis generally
CNS Infections Tuberculosis reveals lymphocytosis, moderate increase in white blood cells, mildly elevated protein, low glucose, and elevated adenosine deaminase.
Pulmonary tuberculosis is common in older individuals with comorbidities (e.g. renal failure) due to waning cell-mediated immunity. Older patients often have fatigue, weight loss, and
Tuberculosis anorexia; cavitation is seen less often on chest x-ray.
Primary pulmonary tuberculosis typically presents with several weeks of fever, cough, and pleurisy. Imaging usually shows a lobar infiltrate, significant hilar lymphadenopathy, and
(sometimes) pleural effusion. Suspicion should be raised in those who reside in high-risk settings or have impaired immunity, particularly when treatment for common pulmonary
Critical Care
Infections
Tuberculosis diseases (e.g. pneumonia) does not improve symptoms.
Impetigo is a superficial skin infection that commonly presents with honey-crusted papules and pustules on the face and extremities. Pre-existing trauma to the skin, infection (e.g.
Skin And Soft Tissue
varicella,
Infections
herpes simplex, scabies), and inflammation (e.g. eczema) are risk factors.
L5 radiculopathy often presents with low back pain that radiates down the leg associated with sensory loss over the lateral thigh, calf, and dorsal foot, and weakness of great toe
Radiculopathy extension and foot dorsiflexion, inversion, and eversion.
Radiculopathies result in deficits that affect part of an extremity and follow a dermatomal/myotomal pattern; lancinating pains are common. C8 nerve root compression results in
Radiculopathy sensory deficits from the forearm to the fourth and fifth fingers, and weakness of the fingers and thumb.
Progressive sensory loss in a distal, symmetric, stocking-glove distribution is characteristic of a length-dependent axonal polyneuropathy. If it occurs acutely, it is likely to be related
Peripheral
Nerves
Neuropathy
AndtoMuscles
a toxin or medication such as metronidazole.
Hypersensitivity pneumonitis is an exaggerated immunologic response to an inhaled antigen (e.g. Mycobacterium avium complex from hot tub exposure). Chronic disease presents
with gradually progressive dyspnea, cough, weight loss, and fatigue over several months, and lung biopsy demonstrates lymphocytic infiltrate, non-necrotizing granulomas, and
Critical Care
Pulmonary
Hypersensitivity
And Other Systemic
Pneumonitis
interstitial
Disorders
inflammation or fibrosis.
Amyotrophic lateral sclerosis can present with bulbar symptoms (e.g. dysphagia, dysarthria) with examination revealing both upper motor neuron signs (e.g. pathologic jaw jerk
Amyotrophic
NervesLateral
Andreflex)
Muscles
Sclerosis
and lower motor neuron signs (e.g. tongue fasciculations and atrophy).
Acute hypersensitivity pneumonitis classically presents with recurrent episodes of abrupt-onset fever, dyspnea, nonproductive cough, and fatigue that coincide with intermittent
Critical Care
Pulmonary
Hypersensitivity
And Other Systemic
Pneumonitis
exposure
Disorders
to an inhaled antigen. The condition is often mistaken for bacterial pneumonia but self-resolves within a few days after removal of antigen exposure.
Severe hypoglycemia can cause confusion, seizure, loss of consciousness, and death. Even mild hypoglycemia can be distressing due to the associated autonomic activation (e.g.
anxiety, palpitations, sweating). Frequent or severe hypoglycemia can encourage behavioral changes to prevent recurrence, such as increased caloric intake or less rigorous insulin
Diabetes& Mellitus
Metabolism
Physician Patient management,
Communication which may impair glycemic control.
Hypoglycemia normally prompts a catecholamine (e.g. epinephrine) surge, which increases hepatic glucose production and triggers hypoglycemic symptoms. Recurrent
hypoglycemia in patients with long-standing diabetes reduces the glucose-raising effects of epinephrine and suppresses the symptoms related to the catecholamine surge, increasing
Diabetes& Mellitus
Metabolism
Hypoglycemia the risk for progressively worsening hypoglycemic episodes.
Chronic pancreatitis or pancreatic resection can cause loss of insulin-producing β cells, leading to pancreatogenic diabetes; exogenous insulin is required. Patients typically also lose
Normal &Structure
Metabolism
Hypoglycemia
And Function Of Endocrine
glucagon-secreting
Glands α cells and are at risk for rapid and severe hypoglycemia.
Hypoglycemia can occur in patients with critical illness due to increased use of glucose in the tissues and suppression of gluconeogenesis in the liver. The risk is higher in patients
Miscellaneous
& Metabolism
Hypoglycemia with renal insufficiency, likely due to decreased renal gluconeogenesis and reduced clearance of endogenous insulin.
Frequent hypoglycemia is uncommon in patients with type 2 diabetes who are not treated with insulin or sulfonylureas. It should raise suspicion for factitious disorder, which is
characterized by intentional falsification of illness in the absence of external reward. Laboratory testing (e.g. insulin/C-peptide levels, sulfonylurea screen) or close observation in a
Miscellaneous
& Metabolism
Hypoglycemia controlled environment (e.g. hospital) may confirm the abnormal behaviors.
Amyotrophic lateral sclerosis leads to degeneration of cells in the anterior horn of the spinal cord. It is characterized by often asymmetric weakness with upper and lower motor
Neurodegenerative
Amyotrophic
Disorders And
Lateral
Dementias
neuron
Sclerosis
signs. Electrodiagnostic studies often show characteristics of both acute and chronic denervation.
Amyotrophic lateral sclerosis can cause respiratory insufficiency due to respiratory muscle weakness. Noninvasive positive-pressure ventilation prolongs survival and improves
Neurodegenerative
Amyotrophic
Disorders And
Lateral
Dementias
quality
Sclerosis
of life.
β blocker overdose presents within 6 hours of ingestion with bradycardia, hypotension, cardiogenic shock, bronchospasm, altered mental status, and seizures. Hypoglycemia is often
Toxicology Exposure
β Blocker Poisoning
seen. Treatment consists of airway management, gastric decontamination, intravenous fluids, intravenous atropine, and intravenous glucagon.
Low-grade atrioventricular block, including first degree and Mobitz type I second degree, are common findings on resting ECG in highly trained endurance athletes because of their
Cardiac
System
Arrhythmias
Heart
And
Block
Syncope high levels of resting vagal tone. These findings are benign and require no intervention.
Gonococcal proctitis typically occurs in adolescents or young adults practicing unprotected sexual intercourse. Rectal infection can occur via receptive anal intercourse or proximal
Intestinal
& Nutrition
And Colorectal
Gonococcal
Disorders
Infection
spread from the vagina. Manifestations include tenesmus, mucopurulent anal discharge, and pruritus; rectal fullness, bleeding, anorectal pain, and constipation may also occur.
Anemia with reticulocytosis suggests that the bone marrow is responding appropriately to the anemia by generating new erythrocytes and that sufficient levels of folate, vitamin B12,
and iron are available for erythrocytosis. Anemia with reticulocytosis is commonly seen in acute bleeding conditions and hemolysis. Chronic lymphocytic leukemia is associated with
Oncology
Hemolytic Anemiawarm autoimmune hemolytic anemia.
Proctalgia fugax is a functional anorectal disorder characterized by recurrent episodes of rectal pain unrelated to defecation. Attacks may be precipitated by stress, sexual
intercourse, and/or sitting but often occur without an obvious stimulus. Proctalgia fugax is a diagnosis of exclusion; physical examination (e.g. digital rectal, prostate, pelvic) and
Intestinal
& Nutrition
And Colorectal
Proctalgia
Disorders
Fugax laboratory analysis are normal.
Exercise-associated postural hypotension occurs in conditioned athletes and is caused by the sudden decrease in venous return after cessation of exercise, which fails to meet
Exposure
Heat Related Illness
increased cardiac demand. It is characterized by collapse (with no loss of consciousness) immediately after completion of exercise.
High-altitude pulmonary edema results from unevenly distributed hypoxic pulmonary vasoconstriction that leads to patchy areas of high pulmonary capillary perfusion pressure and
Critical Care
Vascular
HighAnd
Altitude
Cardiopulmonary
Illness
alveolar-capillary
Disease membrane disruption. Treatment involves prompt reduction of pulmonary arterial pressure, typically with either supplemental oxygen or descent to lower altitude.
High-altitude pulmonary edema (HAPE) typically presents with shortness of breath, cough, hypoxemia, and bilateral lung crackles. Characteristics that favor HAPE over multifocal
Critical Care High Altitude Illness
pneumonia include recent ascent to high altitude, the absence of leukocytes > 15,000/mm3, and rapid improvement with supplemental oxygen.
High-altitude pulmonary edema (HAPE) typically presents with shortness of breath, cough, hypoxemia, and bilateral lung infiltrates. Characteristics that favor HAPE over multifocal
pneumonia include recent ascent to high altitude, normal procalcitonin with no more than mild leukocytosis, and rapid improvement of hypoxemia with supplemental oxygen.
Celiac disease causes small bowel villous atrophy, leading to malabsorption of iron and iron deficiency anemia. Vitamin D deficiency can also occur, leading to hypocalcemia,
19037 Medicine Hematology &Miscellaneous
Oncology Celiac Disease secondary hyperparathyroidism, and premature osteoporosis. Initial screening for celiac disease can be performed with tissue transglutaminase autoantibody testing.
MedianNerves
Nerve And
Injury
Because
Musclesthe median nerve lies directly adjacent to the brachial artery in the distal upper arm, it can be injured (e.g. laceration, compression) as a result of brachial artery cannulation.
Acetazolamide helps prevent and treat high altitude illness by increasing renal HCO3 excretion to reduce blood pH and alleviate central chemoreceptor inhibition of the hypoxic
ventilatory response.
Salicylate toxicity is generally marked by nausea/vomiting, anion gap metabolic acidosis, elevated lactate level, hyperthermia, and tachypnea. Diagnosis is made with serum
Toxicology Exposure
Salicylate Poisoning
salicylate level.
Hyperventilation syndrome presents with acute onset of deep breathing and/or tachypnea often accompanied by neurologic symptoms. Lung examination is normal. Initial treatment
Critical Care Respiratory Alkalosis
is reassurance with breathing retraining.
Diaphragmatic
Nerves And
Paralysis
Botulism
Musclespresents with symmetric, descending motor paresis that can progress to involve the diaphragm, causing hypoventilation and respiratory acidosis.
Critical Care
Care And Trauma
Respiratory
Medicine
Acidosis
Acute benzodiazepine intoxication causes decreased central respiratory drive, leading to hypoventilation and respiratory acidosis.
Critical Care
Care And Trauma
Respiratory
Medicine
Acidosis
Acute opioid intoxication causes decreased central respiratory drive, leading to hypoventilation and respiratory acidosis.
Renal tubular acidosis (RTA) involves a net loss of HCO3 and is a common cause of nonanion gap metabolic acidosis. Type 1 RTA results from impaired H excretion in the distal
Fluid,
Systems
Electrolytes,
& Electrolytes
Renal
And Acid-Base
Tubular Acidosis
tubule and can be recognized by abnormally high urine pH (e.g. > 5.5) in the setting of acidosis.
Refeeding syndrome occurs after the reintroduction of carbohydrates in patients with chronic malnourishment. Clinical manifestations include hypophosphatemia and other electrolyte
Fluid,
Systems
Electrolytes,
& Electrolytes
Hypophosphatemia
And Acid-Base abnormalities, muscle weakness, hyporeflexia, arrhythmias, and/or congestive heart failure.
Diagnostic errors are commonly caused by cognitive bias, including framing, anchoring, and confirmation bias. Framing bias occurs when contextual information (e.g. previous
System
Based-Practice
Cognitive
AndError
Qualitydiagnosis)
Improvement
influences a provider’s judgment, resulting in failure to consider alternate diagnoses.
Anchoring bias occurs when a diagnosis is prematurely swayed by immediate impressions (i.e. an anchor). This bias can preclude thoroughly evaluating a differential diagnosis. An
System
Based-Practice
Cognitive
AndError
Qualityexample
Improvement
of anchoring bias is prematurely assigning a non-cardiac diagnosis to chest pain associated with mental stress.
Counseling a patient in the setting of clinical uncertainty should convey the potential seriousness of the situation and include an individualized discussion of differential diagnosis
based on known facts of the case. The degree of uncertainty should be acknowledged. The discussion should also explain the need for further evaluation, include a clear plan for
Communication
And
Physician
Interpersonal
PatientSkills
follow-up,
Communication
and allow the patient an opportunity to ask questions.
Several communication strategies can reduce antibiotic use in acute bronchitis. The clinician should express awareness of patients’ symptoms and concern for their well-being and
probe their understanding of the illness and the self-limited nature of the infection. Referring to the illness as a ‘chest cold’ may alleviate patients’ anxiety that their infection requires
Communication
And
Physician
Interpersonal
PatientSkills
antibiotics.
Communication
The clinician should also discuss the risks and adverse effects of antibiotics.
Post-thrombotic syndrome occurs in > 50% of patients with a history of acute deep venous thrombosis and is marked by the development of chronic venous insufficiency distal to the
Miscellaneous
System Venous Thromboembolism
site of thrombus. It usually presents with leg pain, edema, fatigue, superficial venous dilation, and/or ulcer. Treatment includes exercise and compression.
Patients who undergo initial cytotoxic chemotherapy or immunotherapy for hematologic malignancies with high tumor burden or rapid division rate are at risk for tumor lysis syndrome
due to the massive release of intracellular tumor products into the circulation. Major manifestations include electrolyte abnormalities and renal insufficiency due to the precipitation of
18770 Medicine Hematology &Principles
OncologyOf Oncology
Tumor Lysis Syndrome
uric acid and calcium-phosphate. Renal injury can often be prevented with intravenous fluids to flush the kidneys and uric acid inhibitors to reduce serum uric acid levels.
Clinical decision support systems (CDSS) assist providers in achieving reliability (minimizing harmful variations of care) and adhering to evidence-based guidelines in diagnostic and
System
Based-Practice
PatientAnd
Safety
Qualitytherapeutic
Improvement processes. CDSS can potentially reduce medication errors (e.g. mathematical errors resulting from incorrect conversion of opioid equivalents).
Root cause analysis is a systematic approach that identifies fundamental, system-level factors causing error, in lieu of assigning individual blame. Interprofessional rounds (i.e.
System
Based-Practice
PatientAnd
Safety
Qualityinvolving
Improvement
a team of professionals from different disciplines) improve teamwork, communication, and oversight, reducing the risk of sentinel events such as wrong-patient error.
To prevent serious adverse events (e.g. wrong-surgery error), safety measures should address both latent errors, describing system-level safety vulnerabilities (e.g. operating room
Patient
Safety Patient Safety scheduling), and active errors, describing frontline personnel’s actions.
Hepatitis A presents acutely with fever, malaise, anorexia, nausea, hepatomegaly, and, sometimes, jaundice. Severe elevations in hepatic transaminases (> 1,000 U/L) occur early in
the disease process, whereas bilirubin and alkaline phosphatase levels may increase several days later. The virus has fecal-oral transmission, and outbreaks have been linked to
Hepatic
& Nutrition
DisordersHepatitis A contaminated water or food, as well as to overcrowded homeless shelters.
When a patient chooses to prematurely discontinue treatment (e.g. leaving a hospital against medical advice), the provider should clearly inform the patient of the risks of doing so. If
the patient insists on discontinuing treatment, the provider should continue to act in the patient’s best interest, including offering appropriate (even if less effective) alternate treatment
Medical
Ethics And
Against
Jurisprudence
Medical Advice
options.
Discharge
Autoimmune hepatitis is characterized by a hepatocellular pattern of liver injury (elevations in aspartate aminotransferase and alanine aminotransferase with normal alkaline
phosphatase and bilirubin), as well as high levels of autoantibodies, resulting in elevated serum globulins and a γ gap. Positive serology (e.g. anti-smooth muscle, anti-liver/kidney
Hepatic
& Nutrition
DisordersAutoimmune Hepatitis
microsomal type 1, antinuclear antibodies) or hypergammaglobulinemia confirms the diagnosis.
Polymyalgia rheumatica is an inflammatory disorder that occurs in patients age > 50; it is characterized by aching pain and stiffness in the hip girdle, shoulders, and/or neck. The
diagnosis is suggested by the presence of elevated acute-phase inflammatory markers (e.g. erythrocyte sedimentation rate, C-reactive protein), and the condition responds rapidly to
& Sports
Polymyalgia
And Vasculitides
Rheumatica
low-dose glucocorticoid therapy.
Open-angle glaucoma can be treated with topical agents that lower intraocular pressure. The first-line agent for most patients is a topical prostaglandin (e.g. latanoprost,
Disorders Of The Glaucoma
Eye And Associated
bimatoprost),
Structures which increases drainage of aqueous humor in the anterior chamber. If prostaglandins are ineffective, topical β blockers (e.g. timolol) can be added.
Successful weight loss can be enhanced by incorporating behavioral strategies into the overall program. Detailed self-monitoring of dietary intake, exercise, and daily weight is
Communication
And
Obesity
associated with increased success rates. Self-monitoring is also associated with greater long-term maintenance of weight loss.
Provider counseling that reflects patient readiness can increase the likelihood of successful lifestyle change. One such approach is the stages of change model. In the contemplation
phase (i.e. the patient understands the need for change but has not committed to a specific plan), the clinician should probe the patient’s level of understanding and provide a
Obesity &And
Metabolism
Dyslipidemia
Obesity scientifically valid assessment of the pros and cons of the proposed change.
Polyarteritis nodosa often causes mononeuritis multiplex, a neuropathy of > 2 noncontiguous peripheral nerves. Patients also frequently have skin, renal, and gastrointestinal
Polyarteritis
Nerves Nodosa
Andmanifestations;
Muscles the lungs are generally spared.
Meningococcal meningitis is a potentially fatal infection that presents with rapidly progressive symptoms (e.g. fever, headache, nuchal rigidity, petechiae) over 12-24 hours. If clinical
Meningitis suspicion is high, empiric vancomycin and ceftriaxone should be administered as soon as possible; lumbar puncture should not delay treatment.
Early meningococcal infection is often nonspecific (e.g. fever, pharyngitis) but should be suspected in a patient with rapidly progressive illness, severe myalgias (e.g. leg pain), and
Meningococci poor perfusion (e.g. mottled skin, cold hands/feet). Positive cerebrospinal fluid culture obtained via lumbar puncture is diagnostic.
Early meningococcal meningitis presents with nonspecific symptoms that rapidly progress over 12-24 hours and may include a petechial/purpuric rash, nuchal rigidity, and altered
Meningococci mental status. Signs of poor perfusion and severe myalgias should prompt a lumbar puncture to evaluate for Neisseria meningitidis infection.
Giant cell arteritis is characterized by new headache and elevated inflammatory markers in patients age > 50; complications include permanent vision loss. Definitive diagnosis can
Giant Cell Arteritisbe obtained with temporal artery biopsy; however, to reduce the risk of blindness, treatment with systemic glucocorticoids should not be delayed while awaiting biopsy results.
Subarachnoid hemorrhage classically presents with a sudden-onset, severe headache. Lumbar puncture is warranted if clinical suspicion remains high despite a normal CT scan of
Subarachnoid Hemorrhage
the head. Characteristic findings include an elevated opening pressure, xanthochromia, and an elevated red blood cell count that does not decline with successive samples.
In cases in which a patient declines a recommended service based on inaccurate or incomplete information, the clinician should provide a balanced assessment of the recommended
Communication
And
Influenza
intervention, including the likely benefits, risks, and limitations. Giving a more accurate and thorough explanation can reinforce patient autonomy and improve decision-making.
Chemotherapy-related diarrhea often presents with voluminous, watery, brown stool that persists despite periods of fasting (e.g. nocturnal diarrhea). Evaluation includes complete
blood count, serum chemistry, and stool studies (e.g. Clostridioides difficile, fecal occult blood) to rule out other etiologies. First-line therapy is oral hydration and antidiarrheal
Disorders
& Nutrition
Of Nutrition
Chemotherapy medications (e.g. loperamide).
Autonomic dysfunction is common with Parkinson disease and can lead to neurogenic orthostatic hypotension, with patients experiencing lightheadedness or syncope on standing.
Neurodegenerative
Parkinson
Disorders
Disease
And Dementias
The disorder is typically recognized by a > 20 mm Hg drop in systolic blood pressure with standing and an absence of the expected increase in heart rate.
Chronic lithium therapy is commonly associated with nephrogenic diabetes insipidus (DI), presenting with polyuria and persistently dilute urine. Lithium-induced nephrogenic DI
Diabetes
SystemsInsipidus
& Electrolytes
Diabetes Insipidusresults from lithium accumulation in the renal collecting ducts, which leads to antidiuretic hormone resistance and impaired renal water reabsorption.
Isolated cranial nerve palsies can be suggestive of a ruptured or enlarging saccular aneurysm with active or impending subarachnoid hemorrhage. Isolated oculomotor nerve palsy
can indicate an aneurysm of the posterior communicating artery.
HIV neuropathy is a distal, symmetrical polyneuropathy that typically begins with numbness/tingling/pain in the feet and progresses proximally. Older patients with long-standing,
Peripheral
Nerves
Neuropathy
Andpoorly
Muscles
controlled HIV are at greatest risk. Antiretroviral treatment reduces the risk of progression. Gabapentin is first-line for symptomatic management.
Temporomandibular joint disorder can present with headaches, muscle spasms, jaw fatigue, and facial pain. Physical examination can reveal tenderness of the muscles of
Headache Temporomandibular
mastication,
Disordersas well as pain, crepitus, and/or audible clicks from the joint.
Cervical radiculopathy is usually caused by compression of the nerve root due to disk herniation or spondylosis; manifestations depend on the involved nerve root but typically
include neck pain, shoulder/arm pain, weakness, paresthesia, and diminished reflexes. Improvement of radicular symptoms when the hand is placed on the top of the head is both
Radiculopathy diagnostic and therapeutic.
An annual low-dose CT scan of the chest is recommended for patients with a > 30-pack-year smoking history to reduce morbidity and mortality from lung cancer. Screening should
Critical And
Lung Cancer generally
Masses begin at age 55 and continue to age 80 or until > 15 years of smoking cessation.
Subarachnoid hemorrhage (SAH) results in sudden-onset, severe headache; nausea/vomiting, brief loss of consciousness, and meningismus are common. Patients should undergo
an urgent noncontrast CT scan of the head; if results are negative and a high suspicion for SAH still exists, lumbar puncture should be performed.
Suprascapular nerve entrapment presents with shoulder pain and weakness of shoulder abduction and external rotation. It can be caused by external compression of the nerve at the
Bone, Joint, And
& Sports
Soft
Rotator
Tissue
CuffInjuriessuprascapular
And Infectionsnotch (e.g. use of a heavy backpack), a direct blow, or repetitive motion at the shoulder.
Concussions are characterized by a transient neurologic disturbance (e.g. disorientation, amnesia) that results from mild traumatic brain injury (TBI); headache, dizziness, slurred or
delayed speech, and incoordination are also common. After a concussion, average-risk adults should rest for > 24 hours before gradually increasing activity level each 24-hour period
Concussion they remain asymptomatic, potentially returning to full contact sports in 1 week.
Diuretics, especially in combination with proton pump inhibitors, can cause hypomagnesemia and other electrolyte abnormalities. Patients taking these medications should have
Cardiovascular
System Drugs
Hypomagnesemiaelectrolyte levels checked routinely, and whenever muscle cramping, weakness, or ECG changes are present.
Crossed signs (i.e. cranial nerve dysfunction with contralateral limb weakness; e.g. ptosis, impaired pupil constriction, down-and-out eye) raise suspicion for a brainstem stroke. A
midbrain infarction due to occlusion of the posterior cerebral artery results in Weber syndrome, which is characterized by ipsilateral oculomotor nerve (CN III) dysfunction
Ischemic Stroke accompanied by contralateral hemiparesis.
Patients with alcohol use disorder are at risk for alcohol withdrawal with alcohol reduction/cessation. Manifestations begin within 6-24 hours and include anxiety, agitation, tremor,
diaphoresis, and nausea. More severe cases are marked by delirium tremens (e.g. autonomic instability, delirium), hallucinations, and/or seizures. The primary treatment is with
Miscellaneous Alcohol Withdrawal
benzodiazepines, which dampen CNS excitation.
Urine osmolality and specific gravity can be used to narrow the cause of suspected polyuria. Low urine osmolality and low urine specific gravity (e.g. < 1.006) suggest dilute urine, as
Hypothalamus
& Metabolism
And
Diabetes
PituitaryInsipidus
Disorders
seen in diabetes insipidus. High urine osmolality and high urine specific gravity suggest osmotic diuresis from conditions such as diabetes mellitus.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line drug therapy for acute, uncomplicated low back pain. If NSAIDs are ineffective, a short course of a nonbenzodiazepine
Spinal/Peripheral
& Sports
Back
NervePain
Disorders And
muscle
Back
relaxant
Pain (e.g. cyclobenzaprine, tizanidine) can provide additional pain relief.
In hyperosmolar hyperglycemic state, severely elevated glucose (> 600 mg/dL) and plasma osmolality are present, causing altered mentation and focal neurological signs. Due to
osmotic diuresis and insulin deficiency, total body potassium is often depleted despite normal or slightly elevated serum potassium values. Therefore, in addition to insulin and
Diabetes& Mellitus
Metabolism
Diabetic Ketoacidosis
intravenous fluids, potassium repletion should be given when serum potassium is < 5.3 mEq/L.
Irritable bowel syndrome is characterized by recurrent abdominal pain related to defecation and changes in stool frequency or form. Management includes reassurance, dietary
Intestinal
& Nutrition
And Colorectal
IrritableDisorders
Bowel Syndrome
modification, and fiber supplementation (in constipation-predominant disease) or antidiarrheal agents (in diarrhea-predominant disease).
Organophosphates inhibit acetylcholinesterase, leading to symptoms of muscarinic (mnemonic: DUMBELS) and nicotinic (neuromuscular dysfunction) cholinergic hyperstimulation.
Management includes atropine, a competitive inhibitor of acetylcholine at the muscarinic receptor (reverses muscarinic symptoms), followed by pralidoxime, a cholinesterase-
Exposure
Organophosphatereactivating
Poisoning agent that has both nicotinic and muscarinic activity (reverses neurotoxicity).
Organophosphates inhibit cholinesterase in both the muscarinic and nicotinic cholinergic synapses, leading to increased visceral smooth muscle tone and glandular secretions
(mnemonic: DUMBELS) as well as muscle fasciculations, weakness, and paralysis. Organophosphate poisoning can be confirmed with the measurement of red blood cell
Exposure
Organophosphateacetylcholinesterase
Poisoning activity.
Adrenal insufficiency results in gastrointestinal symptoms and loss of vascular tone (e.g. orthostatic hypotension); hyponatremia is common due to the syndrome of inappropriate
antidiuretic hormone. Unlike patients with primary adrenal insufficiency (e.g. Addison disease), patients with central (secondary or tertiary) adrenal insufficiency do not develop
Adrenal&Disorders
Metabolism
Adrenal Insufficiency
hyperkalemia or skin hyperpigmentation.
In patients with alcoholic cirrhosis, cessation of alcohol use can reduce liver inflammation, fibrogenesis, and portal pressure, which can lead to the resolution of ascites and,
Hepatic
& Nutrition
DisordersCirrhosis ultimately, improved survival. Alcohol abstinence should be recommended in all patients with cirrhosis.
Obstructive sleep apnea (OSA) is a common cause of secondary hypertension due to the production of catecholamines during apneic episodes. The hypertension is often resistant to
medications, but treatment of the underlying OSA (e.g. nocturnal continuous positive airway pressure) often leads to resolution. Other cardiovascular complications of OSA include
Hypertension
System Secondary Hypertension
pulmonary hypertension, right-sided heart failure, coronary heart disease, and arrhythmias.
Ascites in cirrhosis develops from hemodynamic changes related to portal hypertension. Splanchnic vasodilation decreases the systemic vascular resistance, which causes activation
of the renin-angiotensin-aldosterone system and promotes sodium and water retention. Hyperdynamic circulation and resistance to flow promote third spacing of fluids into the
Hepatic
& Nutrition
DisordersAscites abdominal cavity while low oncotic pressure (i.e. hypoalbuminemia due to impaired synthetic function) reduces fluid resorption from the interstitium.
All patients with new-onset ascites require diagnostic paracentesis. Ascitic fluid cell count and differential should be performed to rule out spontaneous bacterial peritonitis, whereas
Hepatic
& Nutrition
DisordersAscites fluid color assessment and measurement of albumin and total protein are needed to determine the underlying etiology.
The evaluation of reduced bone density is aimed at ruling out secondary causes of bone loss. Bone loss associated with anemia, renal insufficiency, and hypercalcemia suggests
Sports
Osteoporosis multiple myeloma.
Oral lichen planus (LP) presents with white papules and plaques on the oral mucosa; variants may also show erythematous mucosal atrophy or ulceration. It is often associated with
Lichen Planus
And Bullous
hepatitis
Diseases
C. Treatment includes topical high-potency glucocorticoids. Unlike cutaneous LP, which is self-limited, oral LP often has a prolonged course with relapses over many years.
Stress-induced (Takotsubo) cardiomyopathy most commonly affects postmenopausal women and is believed to result from a catecholamine surge brought on by acute physical or
Myopericardial
System Diseases
Stress Cardiomyopathy
emotional stress. It is characterized by left ventricular mid- and apical segment hypokinesis and basilar segment hyperkinesis and typically resolves on its own within several weeks.
Bisphosphonates (e.g. alendronate, risedronate) are the first-line treatment for most women with postmenopausal osteoporosis. After initiation, bone density is typically remeasured
Miscellaneous
& Metabolism
Osteoporosis after 2 years to assess response to therapy. Treatment is usually discontinued after 5 years due to a risk of atypical fracture with prolonged use.
Peri-infarction pericarditis (PIP) results from local inflammation following myocardial infarction (MI) and typically presents with pleuritic chest pain within 4 days of MI. All patients with
suspected PIP should undergo echocardiography to characterize the presence and severity of any associated pericardial effusion and to rule out other post-MI complications (e.g.
Myopericardial
System Diseases
Acute Pericarditisfree wall rupture).
High-intensity statin therapy can reduce the risk of myocardial infarction and ischemic stroke in patients with atherosclerotic cardiovascular disease. For patients who are intolerant of
Cardiovascular
System Drugs
Statins one high-intensity statin, switching to a different high-intensity or a moderate-intensity statin should be considered.
Chronic inflammatory demyelinating polyneuropathy causes immune-mediated destruction of myelin in a non-length dependent manner; this results in progressive weakness of both
ChronicNerves
Inflammatory
Andproximal
Muscles
Demyelinating
and distal muscles,
Polyneuropathy
sometimes with distal sensory loss.
Lichen planus most commonly occurs as pruritic, purple/pink, polygonal papules and plaques on the skin of the extremities and trunk, but lesions may also appear on the genitalia or
oral mucosa. The diagnosis is based primarily on examination, but biopsy can be performed for confirmation. Treatment includes topical high-potency glucocorticoids. The disorder is
17493 Medicine Male Reproductive
Disorders
System
Of The Lichen
Male Reproductive
Planus self-limited
System and typically resolves within 2 years.
Vertigo accompanied by loss of sensation over the ipsilateral face and contralateral body is concerning for a posterior circulation stroke that can be precipitated by vertebral artery
Ischemic Stroke dissection after minor neck trauma.
Migraine is an episodic neurological disorder that results in severe, unilateral, throbbing headaches often associated with photophobia, phonophobia, and nausea/vomiting; they may
be accompanied by aura (focal, reversible neurologic symptoms that precede or accompany the headache). Estrogen-containing contraceptives are contraindicated in patients with
Headache Migraine migraine with aura due to the increased risk of ischemic stroke.
Patients with primary adrenal insufficiency have glucocorticoid and mineralocorticoid deficiency. Most patients require replacement of both glucocorticoid (e.g. hydrocortisone) and
Adrenal&Disorders
Metabolism
mineralocorticoid (e.g. fludrocortisone) activity.
Anemia of chronic disease is caused by long-term elevation in inflammatory cytokines. It is primarily mediated by hepcidin, a small peptide produced by the liver that destroys iron
channels on enterocytes and reticuloendothelial macrophages. This limits iron availability for erythropoiesis, which causes a normocytic or slightly microcytic anemia with a low
Oncology
Anemia Of Inflammation
reticulocyte response.
Diabetic nephropathy (DN) is characterized by persistent albuminuria (> 30 mg/g) and/or decreased glomerular filtration rate. In the absence of signs suggestive of another etiology,
the diagnosis can be presumed in patients with renal dysfunction and either a prolonged history of diabetes (> 5 years for type 1 diabetes) or proliferative diabetic retinopathy, which
Diabetes& Mellitus
Metabolism
Diabetes Mellitus correlates with the presence of DN.
Patients with type 2 diabetes should be screened annually for moderately increased albuminuria. Patients with hypertension and moderately increased albuminuria should be treated
with ACE inhibitors (ACEIs) for secondary prevention of overt nephropathy. However, ACEIs are not indicated for primary prevention in patients with diabetes who are normotensive
Diabetes& Mellitus
Metabolism
Diabetes Mellitus and have normal albumin excretion.
Organophosphates are acetylcholinesterase inhibitors that are commonly used as agricultural pesticides. Toxicity is characterized by signs of cholinergic excess (e.g. miosis,
Exposure
Organophosphatebronchospasm,
Poisoning muscle fasciculations/weakness, diarrhea, vomiting, lacrimation). First-line therapy is atropine, a competitive inhibitor of acetylcholine at the muscarinic receptor.
Rocky Mountain spotted fever is a tick-borne illness that presents with fever, headache, and a maculopapular or petechial rash on the wrists and ankles that spreads centrally.
Rocky Mountain Spotted
Thrombocytopenia
Fever and hyponatremia are characteristic laboratory findings. Prompt treatment with doxycycline decreases the risk of progressive disease and death.
HIV And Sexually HIV
Patients with HIV should be started on antiretroviral therapy regardless of CD4 count to reduce HIV-related morbidity and death.
Secondary hypogonadism in men presents with low libido, erectile dysfunction, a low serum testosterone level, and a low or inappropriately normal LH. Secondary hypogonadism is a
Reproductive
& Metabolism
Endocrinology
Male Sexual Dysfunction
common adverse effect of opioids, which suppress GnRH and LH secretion, leading to reduced Leydig cell testosterone synthesis.
Klinefelter syndrome is a common cause of primary hypogonadism and is associated with an elevated estrogen/androgen ratio. This causes gynecomastia and an increased risk of
breast cancer. Invasive ductal carcinoma is the most common histologic type, and most tumors are hormone receptor-positive. The initial evaluation of suspected breast cancer
Reproductive
& Metabolism
Endocrinology
Klinefelter Syndrome
should include mammography.
Sjögren syndrome is characterized by inflammation of the exocrine glands, commonly presenting with dry eyes (keratoconjunctivitis sicca) and dry mouth (xerostomia). Decreased
tear volume leads to a hyperosmolar state on the surface of the eye, resulting in irritative symptoms and promoting an inflammatory response. Complications include decreased
Disorders Of The Sjögren
Eye AndSyndrome
Associated
visual
Structures
acuity, infection, corneal ulceration, and corneal perforation.
Female pattern hair loss (FPHL) usually presents with gradual thinning of the hair at the vertex and midline and is characterized by replacement of terminal hairs by smaller vellus
hairs (follicular miniaturization). Hair loss can be seen in women with hyperandrogenic states, but androgen levels in most women with FPHL are normal. The first-line treatment is
Hair Loss
Appendages
topical minoxidil.
Many chemotherapeutic agents preferentially target rapidly dividing cells, including hair follicle cells in the anagen phase. Impaired cellular reproduction in the anagen phase can lead
Hair Loss
Appendages
to temporary, reversible cessation of hair growth and rapid shedding of hair shafts (anagen effluvium).
Alopecia areata is characterized by patchy, nonscarring hair loss. It is an autoimmune disorder and is often associated with other autoimmune conditions. Treatment includes topical
Hair Loss
Appendages
or intralesional corticosteroids. A recurring course is common, but most patients have regrowth over time.
Bacterial conjunctivitis should be suspected in patients with conjunctival erythema and thick, purulent eye discharge that reaccumulates within a few minutes after wiping. Most cases
Conjunctivitis occur after direct contact with an infected individual, and one or both eyes may be affected. S. aureus is the most common etiology in adults.
Blepharitis presents with burning or itching of the lids, discharge, and often a foreign body sensation in the eye. Examination shows redness, swelling, and scaling at the lid margin,
and the adjacent conjunctiva may also be inflamed. Common contributors include seborrheic dermatitis, rosacea, allergic disorders, bacterial infection, viral infection, and Demodex
Disorders Of The Blepharitis
Eye And Associated
miteStructures
infestation.
The adrenal glands are a common site of metastatic cancer spread, and extensive metastatic involvement can lead to primary adrenal insufficiency (PAI). Clinical manifestations of
Oncology Adrenal Insufficiency
PAI include hypotension/orthostasis, hyponatremia, hyperkalemia, and hypoglycemia. Diagnosis is made by cosyntropin stimulation testing.
Scleroderma renal crisis is characterized by the acute onset of hypertension and acute kidney injury in patients with systemic sclerosis. The mainstay of treatment is ACE inhibitors
& Sports
Systemic
AndSclerosis
Vasculitides
(typically captopril), which reduce renin-angiotensin-aldosterone system hyperactivity, improve renal function, and normalize blood pressure.
AL amyloidosis most commonly presents as nephrotic syndrome. Hepatomegaly and restrictive cardiomyopathy are frequent manifestations. Periorbital purpura is a rare but highly
17140 Medicine Dermatology Miscellaneous Amyloidosis characteristic skin finding.
Dystonias are involuntary muscle contractions that often involve the small muscles of the head and neck; oculogyric crisis results in a forced upward gaze deviation. Dystonias
typically occur as extrapyramidal symptoms of a high-potency, first-generation antipsychotic (e.g. haloperidol, fluphenazine). Management includes benztropine and
Dystonia diphenhydramine.
Psoriasis is characterized by erythematous, scaly plaques. It is classically found on the extensor surfaces of the knees and elbows (large plaque) but can also occur on the scalp,
Psoriasis
Appendages
hands, and trunk (e.g. gluteal cleft) as small plaques. When psoriasis occurs on the hands, it is typically found on the dorsal surface, likely due to frequent minor trauma.
Chronic silicosis is a fibrotic occupational lung disease that occurs in high-risk workers (e.g. stone cutters) exposed to respirable silica dust. It is caused by silica-induced,
Critical Care
Pulmonary
Occupational
And OtherLung
Systemic
macrophage-driven
Disease
Disorders inflammation and is characterized by upper lobe fibrosis and calcified hilar adenopathy.
Anaphylaxis is a life-threatening, multisystem disorder that commonly involves the skin or mucosa in association with the cardiovascular or respiratory system. Other common
17054.1 Medicine Cardiovascular
Heart
System
Failure AndAnaphylaxis
Shock manifestations include gastrointestinal, neurologic, and ocular symptoms. Management includes the prompt administration of intramuscular epinephrine.
Anaphylaxis is a rapid-onset, life-threatening, multisystem disorder that commonly involves the skin/mucosa with cardiovascular, respiratory, and gastrointestinal symptoms.
Heart
System
Failure AndAnaphylaxis
Shock Anaphylaxis should be considered in any patient with symptoms in > 2 organ systems after exposure to a likely allergen.
Vascular air embolism can occur due to decompression sickness following deep underwater diving. Venous air embolism can cause skin cyanosis, respiratory distress, and
Miscellaneous Air Embolism obstructive shock, whereas arterial air embolism can cause confusion, gait ataxia, dysarthria, and stroke.
Continuous positive airway pressure (CPAP) predisposes users to recurrent epistaxis because of its drying effect on the nasal mucosa. Humidification is often effective in preventing
Disorders
(ENT)
Of The Epistaxis
CPAP-associated epistaxis.
Milk-alkali syndrome is characterized by hypercalcemia, acute kidney injury, and metabolic alkalosis. It is caused by excessive intake of calcium and absorbable alkali, usually in the
Normal &Structure
Metabolism
Milk
And Alkali
Function
Syndrome
Of Endocrine
form of calcium
Glandscarbonate taken for heartburn or osteoporosis.
Tinea versicolor is a superficial fungal skin infection characterized by hyperpigmented, hypopigmented, or salmon-colored macules on the upper trunk and the extremities. It is often
worse during the summer months. The diagnosis can be confirmed with potassium hydroxide preparation of skin scrapings. Treatment includes topical selenium sulfide or
Tinea
Infections
Versicolor ketoconazole.
Large-volume atelectasis can result from airway obstruction (e.g. mucus plug) and lead to mediastinal displacement toward the side of alveolar collapse. Dullness to percussion and
AtelectasisLung Disease
decreased or absent breath sounds are expected over the area of atelectasis.
A syphilitic chancre (nonexudative, painless genital ulcer) can result from direct sexual contact with an infectious lesion in an exposed area despite condom use (e.g. base of penile
shaft). Penicillin is the first-line treatment.
Onychomycosis is a chronic dermatophyte infection of the nails most commonly caused by Trichophyton rubrum and similar fungi. It is characterized by thickening, roughness, and
Onychomycosis
Appendages
discoloration of the nails. The diagnosis is confirmed by potassium hydroxide microscopy of nail scrapings.
Autoimmune atrophic gastritis is an autoimmune disorder resulting in the formation of antibodies toward parietal cells (resulting in hypochlorhydria and unchecked gastrin production)
Gastroesophageal
& Nutrition Atrophic
Disorders
Gastritis and intrinsic factor (resulting in B12 deficiency). Common manifestations include postprandial abdominal pain, bloating, elevated serum gastrin levels, and macrocytic anemia.
Tinea corporis is a superficial dermatophyte infection characterized by a slowly expanding, pruritic rash with a raised border and central clearing. The fungi are transmitted by skin-to-
skin contact, contact with animals, or via fomites. The diagnosis is generally apparent on inspection but can be confirmed with potassium hydroxide examination of skin scrapings.
Tinea
Infections First-line treatment is a topical antifungal (e.g. terbinafine, miconazole).
Follicular lymphoma is a common form of non-Hodgkin lymphoma. It generally presents in an older patient with months or years of waxing and waning lymphadenopathy. B
16854 Medicine Hematology &White
Oncology
Non-Hodgkin Lymphoma
symptoms and laboratory abnormalities are rare, but mediastinal/hilar lymphadenopathy is sometimes seen.
Epidermolysis bullosa is a group of inherited disorders characterized by epithelial fragility (e.g. bullae, erosions, ulcers) triggered by minor trauma. These conditions are caused by
mutations of proteins involved in intraepidermal and dermoepidermal adhesion complexes in the basement membrane zone. Diagnosis is based on biopsy with immunofluorescence
Epidermolysis
And Bullous
Bullosa
microscopy
Diseases
and genetic testing. Treatment is supportive.
Pseudofolliculitis barbae presents with small, painful papules in the beard area. It is caused by penetration of the hair shaft into interfollicular skin, often due to shaving of tightly
curled hair. Complications include hyperpigmentation, secondary bacterial infection, and keloid formation. Management includes discontinuation of shaving or use of alternative
Pseudofolliculitis
And BullousBarbae
shaving
Diseases
techniques.
Nummular eczema is an idiopathic inflammatory disorder that presents with round, pruritic, scaly plaques, most commonly on the extremities. It is often associated with dry skin. The
NummularAnd
Eczema
Bullous
diagnosis
Diseases
is based primarily on clinical findings. Treatment includes topical glucocorticoids, emollients, and avoidance of harsh soaps.
Dyshidrotic eczema (acute palmoplantar eczema) is characterized by a recurrent, pruritic, vesicular rash that primarily affects the palms, soles, and sides of the digits. The diagnosis
Dyshidrotic
AndEczema
Bullous
is based
Diseases
on clinical features, and treatment includes high- and super high-potency topical corticosteroids.
Discoid lupus erythematosus presents with scaly, erythematous plaques, leading to atrophy, hypopigmentation, and scarring. It most commonly affects sun-exposed areas of the
Discoid Lupus
And Bullous
Erythematosus
headDiseases
and neck.
Recurrent tinea cruris is common and suggests re-exposure to an external source or autoinfection from a concurrent dermatophyte infection elsewhere on the body (e.g. tinea pedis,
Tinea
Infections tinea corporis, onychomycosis). Patients should have a thorough skin inspection, and any other sites of infection should be treated.
Tinea cruris (i.e. jock itch) presents as pruritic, annular plaques with a raised, scaly border. It occurs in the groin but usually spares the scrotum. The diagnosis is often apparent
Tinea
Infections based on clinical findings and can be confirmed with potassium hydroxide preparation of skin scrapings. Topical antifungals (e.g. clotrimazole, tolnaftate) are usually effective.
Patients with tinea corporis are at risk for developing additional foci of infection elsewhere on the body, toes, groin, or nails due to autoinoculation. Patients with compromised
Tinea
Infections immunity due to diabetes mellitus, systemic glucocorticoid therapy, or HIV infection can develop extensive, widespread involvement.
Tinea pedis most commonly involves the skin between the toes but can extend to involve the soles and sides of the feet (moccasin pattern), often with significant hyperkeratosis and
flaking. A potassium hydroxide preparation of skin scrapings showing branched, segmented hyphae is diagnostic. Treatment includes topical antifungals (e.g. miconazole,
Tinea
Infections terbinafine, tolnaftate).
Cellulitis occurs when gram-positive skin flora gain access to the subcutaneous space via breaks in the skin. Tinea pedis, one of the most common risk factors for lower extremity
Fungal Infections Tinea cellulitis, causes fissuring, erosions, and ulceration that allow bacterial entry into the tissue.
Myotonic dystrophy is an autosomal dominant disorder caused by the expansion of cytosine-thymine-guanine trinucleotides. The disease typically presents in late adolescence or
early adulthood with facial and distal muscle weakness and myotonia (delayed muscle relaxation after contraction); cataracts, testicular atrophy, and sleep disturbances are also
Myotonic
Nerves
Dystrophy
Andcommon.
Muscles
Patients with chronic autoimmune diseases are at increased risk for lymphoproliferative disorders such as non-Hodgkin lymphoma (NHL) due to chronic B-cell stimulation, immune
Oncology
dysregulation, and use of immunosuppressive agents. NHL often presents with painless lymphadenopathy and B symptoms.
Patients with HIV are at significantly increased risk of malignancy due to immune dysregulation and reactivation of oncogenic viruses. One of the most common malignancies is non-
Oncology
Hodgkin lymphoma, which is due to the reactivation of the Epstein-Barr virus in B-lymphocytes. Patients generally present with diffuse lymphadenopathy and B symptoms.
Paradoxical vocal cord movement is an episodic, inappropriate closing of the vocal cords during inspiration, which results in laryngeal obstruction and inspiratory stridor. It can
Airway Emergency
Lung Disease
present in elite athletes and often mimics exercise-induced asthma.
Stress ulceration is common in patients in the intensive care unit and can cause occult or gross gastrointestinal bleeding. Risk factors include shock, sepsis, coagulopathy,
Gastroesophageal
& Nutrition Stress
Disorders
Gastric Ulcer
mechanical ventilation, traumatic spinal cord/brain injury, burns, and high-dose corticosteroids.
Squamous cell carcinoma (SCC) in situ of the skin (Bowen disease) presents as a slowly enlarging, scaly, erythematous patch or plaque. It most commonly occurs on sun-exposed
16708 Medicine Dermatology Skin Tumors And Nonmelanoma
Tumor-Like Lesions
Skin
skin
Cancer
and is usually not associated with pain or itching. Because SCC in situ can develop foci of invasive SCC, biopsy is recommended for confirmation.
Screening for hepatitis C virus (HCV) begins with antibody testing. Those with positive antibody screens require HCV RNA PCR testing for confirmation of chronic infection. Those
with positive HCV RNA have chronic HCV infection and should be referred for treatment. Negative HCV RNA indicates no current infection; these individuals have resolved infection
Viral Infections Hepatitis C or false-positive HCV antibody testing.
Hodgkin lymphoma is generally treated with combination chemotherapy and radiation therapy. Although > 75% of patients are cured, treatment can lead to long-term complications,
Oncology
Hodgkin Lymphoma
most notably secondary malignancy (e.g. solid organ, hematologic) and cardiovascular disease.
Hodgkin lymphoma is a common cause of mediastinal mass. It often presents with cough, shortness of breath, or retrosternal chest pain due to compression of adjacent structures.
Peripheral lymphadenopathy, B symptoms, pruritus, and worsened pain with exposure to alcohol may be present. Laboratory evaluation often reveals elevated serum lactate
Oncology
Hodgkin Lymphoma
dehydrogenase and eosinophilia.
Hodgkin lymphoma often presents with painless peripheral lymphadenopathy (LAD) in the cervical and/or supraclavicular chains. Patients may also have mediastinal LAD, B
Oncology
Hodgkin Lymphoma
symptoms, and pruritus. Diagnosis is usually made with excisional lymph node biopsy (Reed-Sternberg cells).
Benign paroxysmal positional vertigo causes brief (< 1 min) episodes of vertigo triggered by changes in head position. Triggering an episode by using provocative head positioning
BenignNerves
Paroxysmal
Andmaneuvers
Muscles
Positional(e.g.
Vertigo
Dix-Hallpike) is diagnostic.
Pulmonary function tests in patients with sarcoidosis-associated lung disease typically follow a restrictive pattern: normal or reduced FEV1, normal or reduced FVC, normal or
Critical Care
Pulmonary
Sarcoidosis
And Other Systemic
increased
Disorders
FEV1/FVC ratio, reduced total lung capacity, and decreased diffusion capacity for carbon monoxide.
Sarcoidosis is characterized by multisystem inflammatory noncaseating granuloma formation. Subclinical (asymptomatic) hepatic involvement is common, and liver function tests
Hepatic
& Nutrition
DisordersSarcoidosis demonstrate a mixed cholestatic and hepatocellular pattern.
Small intestinal bacterial overgrowth presents with bloating, diarrhea, and mild abdominal pain. It can develop in patients with altered small bowel motility (e.g. uncontrolled diabetes,
Intestinal
& Nutrition
And Colorectal
Small Intestinal
DisordersBacterial
chronic Overgrowth
opiate use) and is diagnosed with carbohydrate breath testing. Treatment is with antibiotics (e.g. rifaximin, neomycin).
Hyperventilation during panic attacks results in respiratory alkalosis (elevated pH, low pCO2). Ionized calcium competes with hydrogen ions to bind to albumin; elevated pH causes
Fluid,
Systems
Electrolytes,
& Electrolytes
Respiratory
And Acid-Base
Alkalosis
dissociation of hydrogen ions from albumin, allowing for increased calcium binding and a decrease in serum ionized (free) calcium.
Add-on therapy in type 2 diabetes mellitus for patients with established cardiovascular disease includes glucagon-like peptide-1 (GLP-1) receptor agonists and sodium-glucose
cotransporter 2 (SGLT-2) inhibitors, which reduce cardiovascular mortality and morbidity. Both agents are associated with weight loss, an effect not seen with insulin, sulfonylureas,
Diabetes& Mellitus
Metabolism
Diabetes Mellitus and thiazolidinediones.
Calcineurin inhibitors (e.g. tacrolimus, cyclosporine) have vasoconstrictive properties that are responsible for much of their toxicity. Acute calcineurin inhibitor toxicity is often
Acute
Systems
Kidney
& Electrolytes
Injury
Kidney Transplantation
triggered by impaired hepatic clearance of the drug and presents with hypertension and prerenal acute kidney injury.
Transverse myelitis is an immune-mediated disorder characterized by the infiltration of inflammatory cells into a segment of the spinal cord. Inflammation localizes to > 1 contiguous
spinal cord segments, leading to a rapidly progressive myelopathy characterized by motor weakness, autonomic dysfunction (e.g. bowel/bladder dysfunction), and sensory deficits
Transverse Myelitis
with a distinct sensory level.
Sarcoidosis is a systemic granulomatous disorder that can involve the nervous system, presenting as facial nerve palsy. Other common extrapulmonary manifestations of sarcoidosis
Sarcoidosis
Nerves Andinclude
Muscles
lymphadenopathy, hypercalcemia, and parotid gland swelling.
Patients with an acute exacerbation of chronic obstructive pulmonary disease are at risk for symptomatic hypercapnia. Clinical manifestations are predominantly neurologic and
include headache and hypersomnolence with mild to moderate hypercapnia; higher levels of hypercapnia (e.g. PaCO2 > 75-80 mm Hg) can cause delirium, confusion, lethargy, and
COPD Lung Disease
eventually coma (CO2 narcosis) or seizures.
Drug-induced lichen planus (lichenoid drug reaction) is associated with a number of medications, including ACE inhibitors, thiazide diuretics, β blockers, and hydroxychloroquine.
Whereas idiopathic lichen planus occurs most commonly at the wrists and ankles, drug-induced lichen planus can have a more diffuse presentation. Treatment includes topical
Lichen Planus
And Bullous
glucocorticoids
Diseases and discontinuation of the suspected medication.
Lichen planus presents with pruritic, purple/pink, polygonal papules and plaques on the flexural surfaces of the wrists and ankles. Lesions may also occur on the oral mucosa, nails,
Lichen Planus
And Bullous
and Diseases
genitalia. Lichen planus is often associated with hepatitis C. The disorder is self-limited; treatment includes topical glucocorticoids.
Active smoking increases the risk of postoperative pulmonary complications (e.g. pneumonia, respiratory failure requiring mechanical ventilation), especially in patients with
underlying lung disease (e.g. chronic obstructive pulmonary disease). Smoking cessation is recommended > 4-8 weeks prior to elective surgery as it has been shown to reduce the
Critical Care Perioperative Medical
risk of
Management
postoperative pulmonary complications.
Clostridium septicum bacteremia is strongly associated with underlying colon cancer. Therefore, patients with C. septicum bacteremia require screening colonoscopy. Bacteremia
Intestinal
& Nutrition
And Colorectal
Clostridium
Disorders
Septicum
with Infection
group D streptococci, particularly Streptococcus bovis, is also strongly linked to colon cancer.
A photosensitive rash, along with multisystemic symptoms (e.g. arthralgias, pancytopenia, splenomegaly), raises concern for systemic lupus erythematosus (SLE). The antinuclear
& Sports
SLE And Vasculitides
antibody assay is highly sensitive for SLE.
Lupus nephritis is caused by deposition of anti-double-stranded DNA immune complexes in the glomerulus, which leads to glomerulonephritis (e.g. hematuria, proteinuria, renal
Glomerular
Systems &Diseases,
Electrolytes
SLE Nephrotic/Nephritic
insufficiency,
Syndrome
hypertension, peripheral edema) or nephrotic syndrome. Serum anti-double-stranded DNA antibody titers correlate with risk of nephritis.
Alcohol bingeing can lead to acute alcohol myopathy and rhabdomyolysis, especially when combined with cocaine abuse. Patients with rhabdomyolysis are at risk of developing
Acute
Systems
Kidney
& Electrolytes
Injury
Rhabdomyolysis acute kidney injury due to both intravascular volume depletion and pigment-induced nephropathy.
Some drugs (e.g. statins, colchicine) are directly myotoxic and may cause rhabdomyolysis, especially when used in combination. Rhabdomyolysis is suggested by dark urine, blood
Nephrolithiasis,
Systems & Electrolytes
Hematuria,
Rhabdomyolysis
And Urinary
on urinalysis
Tract Obstruction
in the absence of red blood cells on urine microscopy, and acute kidney injury.
Anorexia nervosa (AN) is characterized by low body weight, distorted body image, and avoidance of weight gain. Because patients with AN often try to hide their disorder, associated
Intestinal
& Nutrition
And Colorectal
AnorexiaDisorders
Nervosasigns and symptoms (e.g. constipation, cold intolerance, bradycardia, hypotension) are important diagnostic clues.
Manifestations of renal infarction include flank pain, nausea, and vomiting; urinalysis demonstrates hematuria and proteinuria without casts. A wedge-shaped cortical infarction on CT
Neoplasms
Systems &And
Electrolytes
Trauma
Renal Infarction
Of The Kidneys
scan is
Anddiagnostic.
Urinary Tract
Renal infarctions can occur as a sequela of infectious endocarditis, which typically presents with recurrent fever, cardiac murmurs, and leukocytosis.
Long-term (> 5 years) metformin therapy can cause vitamin B12 deficiency due to alterations in calcium homeostasis, leading to impaired absorption of vitamin B12 in the terminal
VitaminNerves
B12 Deficiency
Andileum.
Muscles
Although megaloblastic anemia is often seen, a minority of patients have isolated neurologic findings (e.g. paresthesias, sensory ataxia, neuropsychiatric changes).
AA amyloidosis occurs in the setting of chronic inflammation and is most commonly seen in patients with long-standing rheumatoid arthritis. The most common manifestation is renal
disease characterized by proteinuria and nephrotic syndrome; cardiac and gastrointestinal disease may also occur. The diagnosis is confirmed with biopsy demonstrating amorphous
Chronic
Systems
Kidney
& Electrolytes
Disease
Amyloidosis hyaline material that stains with Congo red.
Phenytoin is highly protein-bound and metabolized hepatically by the cytochrome P450 system; medications that inhibit cytochrome P450 (e.g. trimethoprim-sulfamethoxazole,
fluconazole) or that displace phenytoin from plasma proteins (e.g. valproic acid) increase the risk of drug toxicity. Common symptoms of acute phenytoin toxicity include horizontal
Antiepileptics nystagmus, ataxia, and nausea/vomiting, and significant toxicity can result in altered mental status, coma, and death.
Splenic infarction usually occurs in the setting of splenic artery (or sub-branch) occlusion due to hypercoagulable states, embolic disease, or hemoglobinopathy (e.g. sickle cell
disease or trait). Although patients with sickle cell trait are generally asymptomatic, they occasionally develop splenic infarction and intravascular hemolysis in the setting of certain
Oncology
Sickle Cell stressors such as air travel or dehydration. Diagnosis of most hemoglobinopathies is made by hemoglobin electrophoresis.
Gout initially causes an episodic monoarthritis typically affecting the first metatarsophalangeal joints and knees. Persistent hyperuricemia can lead to tophaceous gout, which is
characterized by excessive monosodium urate deposition, leading to chronic inflammation and nodular deformity. Tophi commonly involve the joints of the hands and feet; soft tissue
& Sports
Gout involvement may also occur.
Roux-en-Y gastric bypass induces weight loss by restricting food intake and promoting malabsorption. Stomal stenosis is a potential complication that results from a narrowing of the
gastrojejunal anastomosis, leading to symptoms of nausea, postprandial vomiting, gastroesophageal reflux, and dysphagia. Esophagogastroduodenoscopy is used for both diagnosis
Disorders
& Nutrition
Of Nutrition
Bariatric Surgery and treatment.
Myoclonus is characterized by sudden, involuntary muscle contraction or relaxation that results in movement of limbs or joints. Posthypoxic myoclonus is often seen after cardiac
arrest; the acute form (myoclonus status epilepticus [MSE]) occurs while patients are still unconscious and is characterized by generalized (often symmetric) myoclonus that involves
Anoxic Brain Injury
the axial, limb, and facial muscles. Prolonged MSE is a marker of poor prognosis.
Splenic infarction usually presents with acute pain and tenderness in the left upper quadrant. Most cases arise in those with hypercoagulable states (e.g. systemic lupus
Miscellaneous
& Nutrition Splenic Infarct erythematosus (SLE), malignancy), embolic disease, or hemoglobinopathy.
Chronic pancreatitis is characterized by intermittent epigastric pain that radiates to the back and worsens after meals. In more advanced cases, patients develop pancreatic exocrine
insufficiency with associated abdominal pain from pancreatic hyperstimulation. Pancreatic enzyme supplementation (i.e. lipase, protease, amylase) is used to treat both exocrine
Pancreatic
& Nutrition
Disorders
Chronic Pancreatitis
insufficiency and pain.
Rheumatoid arthritis can cause exudative pleural effusions characterized by low glucose, very high lactate dehydrogenase, and (often) low pH and is associated with interstitial lung
& Sports
Rheumatoid
And Vasculitides
Arthritis
disease.
Rheumatoid arthritis (RA) causes a chronic, symmetric polyarthritis predominantly affecting the small joints of the hands. Rheumatoid factor (low specificity) and cyclic citrullinated
peptide antibodies (high specificity) are the primary serologic markers for RA. Patients who have negative assays for both markers (seronegative RA) may have a more favorable
& Sports
Rheumatoid
And Vasculitides
Arthritis
prognosis.
Blepharospasm is a form of focal dystonia characterized by recurrent forceful contraction of the eyelid muscles. Bright lights may trigger symptoms, whereas touching or brushing the
Dystonia skin around the eye may terminate the spasm. Mild cases may be managed with trigger avoidance, but botulinum toxin injection may be needed for more significant symptoms.
Most cases of acute pancreatitis are related to gallstones or alcohol abuse, and hypertriglyceridemia is the third most common cause. Drug-induced pancreatitis should be
Pancreatic
& Nutrition
Disorders
Acute Pancreatitisconsidered once these more common etiologies are ruled out, especially in patients taking a known offending agent (e.g. furosemide, hydrochlorothiazide).
Microscopic colitis disproportionately affects women age > 60 and is characterized by chronic, watery diarrhea that may occur during periods of fasting and/or at night. Colonoscopy
reveals grossly normal-appearing colonic mucosa; however, biopsy demonstrates a mononuclear infiltrate within the lamina propria, and a subepithelial collagen band may be
Intestinal
& Nutrition
And Colorectal
Microscopic
Disorders
Colitis
present. Risk factors include concurrent autoimmune conditions, cigarette smoking, and certain medications (e.g. nonsteroidal anti-inflammatory drugs).
Irritable bowel syndrome is characterized by recurrent abdominal pain and altered bowel habits (e.g. diarrhea, constipation) and symptoms that worsen (or improve) with bowel
movements. Further workup is not typically required unless alarm features are present, which include older age of onset, gastrointestinal bleeding, nocturnal diarrhea, unintended
Intestinal
& Nutrition
And Colorectal
IrritableDisorders
Bowel Syndrome
weight loss, iron deficiency anemia, elevated inflammatory markers, or a family history of early colon cancer.
The management of irritable bowel syndrome includes limited testing (e.g. complete blood count, serologies for celiac disease, inflammatory markers) and reassurance. However, the
presence of alarm features requires further workup; these include older age of onset (> 50 years), nocturnal diarrhea, gastrointestinal bleeding, worsening pain, unintended weight
Intestinal
& Nutrition
And Colorectal
IrritableDisorders
Bowel Syndrome
loss, abnormal laboratory tests (e.g. iron deficiency anemia, elevated inflammatory markers), or a family history of inflammatory bowel disease or early colon cancer.
Postherpetic neuralgia is characterized by burning pain and hyperesthesia lasting > 4 months following acute zoster. The risk is greatest in those with advanced age, severe initial
CNS Infections Herpes Zoster pain, or severe rash. First-line treatment includes anticonvulsants (e.g. gabapentin) and tricyclic antidepressants (e.g. amitriptyline).
Complex regional pain syndrome typically follows local trauma or surgery and is characterized by severe burning or tingling pain in a regional (not dermatomal) distribution. It is often
Spinal/Peripheral
& Sports
Complex
Nerve Disorders
RegionalAnd
associated
Pain
Back
Syndrome
Pain
with edema, erythema, and trophic skin, hair, or nail changes. X-ray may show patchy demineralization.
Alcoholic neuropathy is a toxic neuropathy that typically results in a symmetric distal polyneuropathy (i.e. stocking and glove pattern) characterized by paresthesia, burning pain, and
Peripheral
Nerves
Neuropathy
Andataxia.
MusclesLoss of distal deep tendon reflexes (e.g. ankle) and light touch and vibratory sense are common.
Miller-Fisher syndrome (MFS) is a variant of Guillain-Barré syndrome, a group of immune-mediated polyneuropathies that are caused by molecular mimicry. MFS is characterized by
Guillain-Barré
Nerves And
Syndrome
ophthalmoplegia,
Muscles ataxia, and areflexia; strength is often preserved. It is highly associated with anti-GQ1b antibody.
Eosinophilic esophagitis commonly affects young men and is frequently associated with other atopic disorders. It can present with intermittent solid food dysphagia and refractory
Gastroesophageal
& Nutrition Esophagitis
Disorders heartburn. More than 50% of patients have a history of food impaction. The diagnosis is confirmed with biopsies demonstrating eosinophilic infiltration of the esophageal mucosa.
Methotrexate therapy for rheumatoid arthritis is associated with hepatotoxicity. Serum liver studies should be checked prior to initiation and periodically thereafter. Much of the toxicity
& Sports
Rheumatoid
And Vasculitides
Arthritis
of methotrexate, including hepatotoxicity, can be mitigated by concurrent administration of folic acid, which does not reduce the effectiveness of the drug.
Clinical findings that favor the diagnosis of rheumatoid arthritis (RA) over osteoarthritis include prolonged morning stiffness, systemic symptoms, and soft tissue swelling. Other
characteristic findings in RA include periarticular erosions on x-ray, elevated inflammatory markers, and positive cyclic citrullinated peptide antibodies or rheumatoid factor. Disease-
& Sports
Rheumatoid
And Vasculitides
Arthritis
modifying antirheumatic drugs (e.g. methotrexate) slow disease progression and should be initiated on diagnosis.
Carpal tunnel syndrome is a common manifestation of rheumatoid arthritis involving the wrist. Initial evaluation of rheumatoid arthritis should include inflammatory markers (e.g.
& Sports
Rheumatoid Arthritis
erythrocyte sedimentation rate, C-reactive protein), serologic studies (e.g. rheumatoid factor, cyclic citrullinated peptide antibodies), and x-rays of the symptomatic joints.
Internal carotid artery dissection is a common cause of stroke in young patients and can occur spontaneously or after mild trauma or illness. It is typically characterized by partial
Cervical Artery Dissection
Horner syndrome (ptosis and miosis without anhidrosis), unilateral headache and neck pain, and cerebral ischemia (transient ischemic attack, stroke).
Acute cholangitis leads to right upper quadrant pain, fever, and jaundice (e.g. direct hyperbilirubinemia); hypotension and altered mental status can occur with severe disease. An
Biliary
& Nutrition
Tract Disorders
Cholangitis anion gap metabolic acidosis may be present due to lactic acidosis in severe sepsis. Common bile duct dilation is typically visible on right upper quadrant abdominal ultrasound.
Psoriatic arthritis is common in those with long-standing psoriatic skin disease and usually presents with asymmetric oligoarthritis or symmetric polyarthritis (resembling rheumatoid
& Sports
Psoriasis
And Vasculitides
arthritis). Important diagnostic clues are the involvement of the distal interphalangeal joints (present in ~50%) and characteristic nail changes such as pitting (present in > 90%).
Cryptococcal meningoencephalitis is common in patients with advanced AIDS and generally manifests with signs of elevated intracranial pressure (ICP), including progressive
headaches, nausea/vomiting, and confusion. In a minority of patients, elevated ICP compresses the 6th cranial nerve and results in diplopia and lateral gaze palsy. The diagnosis is
CNS Infections Cryptococcal Infections
generally made using lumbar puncture with CSF analysis and India ink stain or capsular polysaccharide antigen testing.
Non-pupil-sparing oculomotor nerve (CN III) palsies are concerning for aneurysmal compression. MR or CT angiography should be performed immediately. Pupil-sparing CN III
Cranial Nerve Palsy
palsies are most commonly caused by microvascular ischemia associated with diabetes mellitus, hypertension, and hyperlipidemia.
Alcohol, opioids, and benzodiazepines can all cause central respiratory depression, and intoxication can lead to hypoventilation and acute hypercapnic respiratory failure. Arterial
blood gas findings will show a primary respiratory acidosis. Correction of the hypercapnia requires increased ventilation, which can be accomplished via increased respiratory rate or
Critical Care
Care And Trauma
Acute Respiratory
Medicine tidal
Failure
volume.
The initial criteria for extubation readiness include pH > 7.25, adequate oxygenation on minimal ventilator settings, and sufficient mental alertness to protect the airway. Patients who
Critical Care
Care And Trauma
Mechanical
Medicine
Ventilation
meet these criteria should undergo a spontaneous breathing trial to help confirm candidacy for successful extubation.
Myasthenia gravis is characterized by autoimmune disruption of the neuromuscular junction. A myasthenic crisis occurs when increased disease activity causes significant muscle
weakness, resulting in diaphragmatic impairment and respiratory failure; bulbar weakness may also be a prominent feature. Precipitants include infection, medications, surgery, and
Critical Care
Care And Trauma
Acute Respiratory
Medicine pregnancy
Failure or childbirth. Elective intubation should be performed in patients with evidence of impending respiratory failure.
Clostridioides difficile infection should be suspected in recently hospitalized patients who develop voluminous watery diarrhea, low-grade fever, and leukocytosis. Stool testing for C.
Intestinal
& Nutrition
And Colorectal
Clostridium
Disorders
Difficile
difficile
Infection
toxin is generally diagnostic. Other established risk factors include antibiotic use, severe comorbid illness (e.g. inflammatory bowel disease), and advanced age.
Pulmonary embolism (PE) is the most common, life-threatening cause of pleuritic chest pain and should be strongly considered in patients with risk factors (e.g. prolonged
immobilization) and suggestive clinical features (e.g. dyspnea, tachycardia, tachypnea, unilateral lower extremity edema). Patients with high pretest probability of PE are best
Coronary
SystemHeart Disease
Pulmonary Embolism
evaluated with CT pulmonary angiography.
Fecal impaction is common in older patients with impaired mobility, chronic constipation, or decreased sensation of stool in the rectal vault. Obstruction of fecal flow in the rectum can
Intestinal
& Nutrition
And Colorectal
Fecal Impaction
Disorders cause backup of stool; passage of liquid stool around the impaction can lead to incontinence. Initial management includes manual disimpaction and enemas to clear the rectal vault.
Spinal epidural abscess, a bacterial infection of the epidural space, typically arises in the setting of bacteremia from intravenous drug use or distant infection. Manifestations include
Epidural Abscess fever, malaise, focal back pain, and progressive neurologic findings (e.g. sensory, motor, reflex deficits).
The initial workup of suspected dementia should include neuropsychological testing (e.g. Montreal Cognitive Assessment), selected laboratory testing (complete blood count,
Neurodegenerative
Alzheimer
Disorders
Disease
And Dementias
complete metabolic panel, TSH, vitamin B12), and neuroimaging (e.g. MRI). Patients in specific risk groups may warrant additional targeted testing.
Descending (type B) aortic dissections can be associated with interruption of blood flow to the anterior spinal cord, leading to anterior spinal cord ischemia (particularly in the lower
thoracic levels). Patients generally develop acute bladder paralysis, lower extremity paresis, crude touch/pain sensation loss, and diminished reflexes (initially). Vibrioception and
Anterior Cord Syndrome
deep touch sensation are generally preserved because these are carried in the posterior columns and receive some blood flow from the intact posterior spinal arteries.
Acute tubular necrosis results in limited resorptive capacity, leading to high urine sodium (> 40 mEq/L) and a normal blood urea nitrogen/creatinine ratio (~10-15:1). Usually, renal
Acute
Systems
Kidney
& Electrolytes
Injury
Multiple Myelomainjury results in hypocalcemia; the presence of hypercalcemia suggests multiple myeloma cast nephropathy.
The elderly are especially vulnerable to the cumulative adverse effect burden of polypharmacy. In particular, medications with anticholinergic properties are strongly associated with
the risk for cognitive impairment, which may produce a medication-induced syndrome that mimics dementia. Review of medications is an important first step in evaluating a patient
Neurodegenerative
Alzheimer
Disorders
Disease
And Dementias
on a complex medication regimen with new-onset or worsening cognitive impairment.
Epileptic seizure can present similarly to a number of other conditions and can be especially difficult to differentiate from syncope. Tongue biting, especially of the lateral tongue, is
Cardiac
System
Arrhythmias
Seizures
And Syncope highly specific for epileptic seizure and can be helpful in confirming the diagnosis.
Otitis externa is characterized by pain, erythema, edema, and discharge. Loss of cerumen, trauma, and foreign materials in the ear canal increase the risk. The most common
Disorders
(ENT)
Of The Otitis
Ear, Nose,
Externa
And Throat
pathogen is Pseudomonas aeruginosa.
Acute otitis externa (‘swimmer’s ear’) presents with pain, erythema, and discharge from the ear. It often occurs after disruption of the skin barrier and when conditions cause moisture
Disorders
(ENT)
Of The Otitis
Ear, Nose,
Externa
And Throat
retention in the external auditory canal. Pseudomonas aeruginosa is the most common pathogen.
For hypertensive patients with a systolic BP < 20 mmHg and/or diastolic BP < 10 mmHg above target, 1-drug antihypertensive therapy is often adequate to reach the goal. However,
Hypertension
a single agent is unlikely to be adequate for those with a baseline BP > 20/> 10 mmHg above target; in such cases, 2-drug therapy is likely to be required.
Onset of hypertension at a young age (i.e. age < 30) should raise suspicion for a secondary cause. In addition to hypertension, features suggesting intranasal cocaine use include
Hypertension
epistaxis and tremor. A urine drug screen should be considered in a young patient with unexplained hypertension.
Conventional β blockers (e.g. metoprolol, atenolol, propranolol) are associated with impaired glucose control and increased weight gain, likely via effects on skeletal muscle that lead
Cardiovascular
System Drugs
β Blockers to reduced insulin sensitivity. Therefore, these drugs are an unfavorable option for hypertension management in patients with, or at high risk for, type 2 diabetes mellitus.
The initial evaluation of hypertension focuses on identifying complications or comorbid conditions that might influence management. Assessment should include a serum chemistry
panel, hemoglobin/hematocrit, and urinalysis. In addition, patients should be screened for major atherosclerotic risk factors with a lipid panel and either fasting serum glucose or
Hypertension
hemoglobin A1c.
Certain medications can disrupt the normal baroreceptor response and cause or contribute to orthostatic syncope. Medications with α1 receptor blocking properties (e.g. quetiapine)
are particularly common precipitants of orthostatic symptoms, and patients taking concomitant exacerbating medications (e.g. other vasodilators) are at greater risk of experiencing
Cardiovascular
System Drugs
Syncope symptoms.
Normal pressure hydrocephalus is a potentially reversible cause of dementia characterized by cognitive decline, gait impairment, and urinary incontinence. Neuroimaging
Neurodegenerative
Normal
Disorders
Pressure
And Dementias
demonstrates
Hydrocephalusventriculomegaly out of proportion to the sulci.
Acute bacterial prostatitis usually manifests with a flu-like illness and lower urinary symptoms. The diagnosis is generally confirmed when digital rectal exam reveals exquisite
Disorders
System
Of The Prostatitis
Male Reproductive
prostatic
Systemtenderness and swelling.
Gonococcal urethritis in men typically presents with dysuria and a purulent urethral discharge. The diagnosis is confirmed with urethral culture or with nucleic acid amplification
testing of a urethral swab or urine sample. The recommended treatment includes a single dose of ceftriaxone and azithromycin, and empiric treatment of sexual contacts is also
15915.1 Medicine Infectious Diseases
HIV And Sexually Urethritis
recommended.
Patients with Neisseria gonorrhoeae infection are at risk for coinfection with other sexually transmitted pathogens, including Chlamydia trachomatis, HIV, and Treponema pallidum
(syphilis). Patients should be screened for these infections, counseled on safe sexual practices, and given appropriate antibiotics.
Elderly, depressed patients can have significant cognitive impairment that may be mistaken for a dementing syndrome. However, unlike most dementias, depression-related
Mood Disorders
& Substance
Depression
Abuse cognitive impairment is reversible with treatment of the underlying depression.
Cognitive errors involve heuristics (mental shortcuts) incorrectly influencing clinical decision-making, resulting in diagnostic error. Availability bias describes the tendency for recent or
System
Based-Practice
Cognitive
AndError
Qualitynotable
Improvement
clinical experiences to bias subsequent clinical judgment, and often causes excessive diagnostic workup.
Prosthetic valve thrombosis (PVT) is a potential complication of both mechanical and bioprosthetic valves. Patients can have a new murmur, heart failure due to valvular obstruction
Mechanical Valve(stenosis) or regurgitation, or a thromboembolic event (e.g. transient ischemic attack). Suspected PVT should be promptly evaluated with echocardiography.
Huntington disease is an autosomal dominant disease of CAG trinucleotide repeat expansion characterized by psychiatric symptoms, cognitive impairment, and chorea. It is
Neurodegenerative
Huntington
DisordersDisease
And Dementias
associated with preferential degeneration of GABA-producing neurons in the caudate nucleus and putamen.
Vascular dementia (VaD) is caused by large or small artery ischemia or infarction and presents with executive dysfunction and focal neurologic findings. Patients with suspected VaD
Neurodegenerative
Vascular
Disorders
Dementia
And Dementias
should undergo neuroimaging to evaluate for cerebrovascular disease.
Decompensated heart failure is a common cause of secondary (functional) mitral regurgitation. Increased left ventricular end-diastolic volume (LVEDV) causes impaired valve closure
due to dilation of the mitral valve annulus and lateral papillary muscle displacement with restricted movement of the chordae tendineae. The mitral regurgitation resolves with
Valvular
SystemHeart Diseases
Mitral Regurgitation
reduction in LVEDV, resulting in disappearance of the associated murmur.
Valvular
Patients with severe mitral regurgitation develop left ventricular volume overload and an S3 gallop due to the large volume of regurgitant flow re-entering the ventricle during diastole.
Patients with prior myocardial infarction complicated by left ventricular systolic dysfunction with ejection fraction < 30% are at an increased risk of sudden cardiac death due to
ventricular arrhythmia (i.e. ventricular tachycardia, ventricular fibrillation). Following a trial of optimal medical therapy, primary prevention with placement of an implantable
Cardiac
System
Arrhythmias
Ventricular
And Syncope
Tachycardia
cardioverter-defibrillator is indicated in these patients.
The jugular venous pulsation waveform is representative of right atrial hemodynamics throughout the cardiac cycle. Cannon A waves are intermittent, prominent A waves caused by
the surge in jugular venous pressure that occurs due to right atrial contraction against a closed tricuspid valve. These waves are indicative of a cardiac arrhythmia involving
Cardiac
System
Arrhythmias
Ventricular
And Syncope
Tachycardia
atrioventricular dissociation (e.g. ventricular tachycardia, complete atrioventricular block).
Aortic stenosis (AS) is a common cause of angina, syncope, and heart failure; however, such symptoms are rare until the AS becomes severe (usually indicated by valve area < 1
Valvular
Aortic Stenosis cm2). In patients with mild to moderate AS, anginal symptoms are likely due to another cause, most commonly obstructive coronary artery disease.
In severe, chronic aortic regurgitation, the left ventricle responds to volume overload with eccentric hypertrophy to increase both left ventricular compliance and contractility, allowing
for an increase in stroke volume to maintain cardiac output. This allows for a temporary asymptomatic period. However, overwhelming wall stress eventually leads to symptomatic,
Valvular
Aortic Regurgitation
decompensated heart failure.
Osteoarthritis is common in patients with prior joint injury (especially anterior cruciate ligament injury) or surgery. Other secondary causes of osteoarthritis include infection,
& Sports
Osteoarthritis inflammatory disorders, bony deformities, and neuromuscular weakness.
A positron emission tomography scan using a radiolabeled glucose analog can identify areas of enhanced metabolic activity (e.g. cancer, infection). However, the tracer will also pool
OncologyOf Oncology
PET Scan in healthy organs with high glucose requirements such as the brain, liver, and kidneys; uptake will also be seen in the urinary collecting system due to radiotracer excretion.
Drug-induced lupus erythematosus should be suspected in patients developing acute onset of fever, arthralgia, and serositis after initiation of causative medications. Hydralazine is
& Sports
strongly associated with drug-induced lupus erythematosus. Treatment includes cessation of the causative medication and symptom management.
Multiple sclerosis is an immune-mediated demyelinating disease of the central nervous system. The disease is most common in Caucasian women age < 50. Risk factors include
Demyelinating Diseases
Multiple Sclerosisvitamin D deficiency, geographic location, genetic predispositions (HLA-DRB1), and smoking.
Acne mechanica is an acneiform eruption caused by pressure-related damage to pilosebaceous follicles. It can result from pressure from crutches, bra straps, turtlenecks, sports
Acne Vulgaris
And Bullous
padding,
Diseases
helmets, and heavy backpacks.
Calciphylaxis (calcific uremic arteriolopathy) is characterized by systemic arteriolar calcification and soft-tissue calcium deposition with local ischemia and necrosis. It is primarily
seen in patients with longstanding end-stage renal disease. Risk factors include hyperparathyroidism, hyperphosphatemia, and hypercalcemia, although serum calcium is often
Chronic
Systems
Kidney
& Electrolytes
Disease
Chronic Kidney Disease
normal.
Erythema nodosum is a delayed hypersensitivity reaction characterized by 2- to 3-cm, tender, erythematous nodules, most often on the shins. Common triggers include infection,
ErythemaAnd
Nodosum
Bullous
inflammatory
Diseases bowel disease, sarcoidosis, and malignancy. It can also be triggered by medications, such as penicillins, sulfonamides, and oral contraceptives.
Claw toe and hammer toe deformities reflect an imbalance in strength and flexibility between the flexor and extensor muscle groups. In a patient with longstanding diabetes, these
deformities may suggest underlying diabetic peripheral neuropathy. Other complications of diabetic neuropathy include callusing, ulceration, joint subluxation, and Charcot
Bone, Joint, And
& Sports
Soft
Diabetic
Tissue
Neuropathy
Injuriesarthropathy.
And Infections
REM sleep behavior disorder (RBD) is characterized by dream enactment during REM sleep atonia. Most patients with idiopathic RBD eventually develop a disorder of α-synuclein
Sleep Disorders REM Sleep Behavior
neurodegeneration,
Disorder most commonly Parkinson disease.
Patients with antiphospholipid antibodies (e.g. lupus anticoagulant) have prolonged PTT that fail to correct with a mixing test (combination with normal plasma). Most patients with
15112 Medicine Hematology &Hemostasis
Oncology And Thrombosis
Antiphospholipid Syndrome
antiphospholipid antibodies are asymptomatic, but a minority develop antiphospholipid-antibody syndrome (thromboembolism, fetal loss).
Pheochromocytoma should be suspected in patients with resistant hypertension, especially in the presence of other suggestive features (e.g. episodic anxiety, headaches, sweating,
Endocrine
& Metabolism
TumorsPheochromocytoma
tachycardia). Measurement of urine or plasma metanephrine levels is the initial step in evaluation.
Somatoform& Substance
Disorders
IllnessAbuse
And
Anxiety
SleepDisorder
Disorders
Illness anxiety disorder is characterized by excessive concern about having a serious, undiagnosed disease despite minimal or no somatic symptoms.
Anorexia nervosa is characterized by a distorted body image and fear of weight gain despite an abnormally low BMI. Medical complications due to malnutrition include bradycardia,
Miscellaneous
& Metabolism
Anorexia Nervosahypotension, edema, gastroparesis, cardiac atrophy, and decreased bone mineral density.
Anti-NMDA receptor encephalitis is an autoimmune encephalitis syndrome characterized by psychiatric symptoms (e.g. anxiety, psychosis), cognitive dysfunction (e.g. memory
impairment), seizure, autonomic instability, dystonia, and rigidity. It occurs most commonly in young women (median age of 21) and is associated with ovarian teratoma in > 50% of
Miscellaneous
& Substance
Psychotic
AbuseDisorder
cases.
Due To Another Medical Condition
Chronic pancreatitis is a progressive inflammatory disease that leads to pancreatic fibrosis; destruction of pancreatic islet and acinar cells results in endocrine (i.e. diabetes) and
exocrine insufficiency. Pancreatic exocrine insufficiency is characterized by protein and fat malabsorption, steatorrhea, weight loss, and fat-soluble vitamin deficiencies; low fecal
Pancreatic
& Nutrition
Disorders
elastase is diagnostic. Treatment involves pancreatic enzyme replacement.
Herpes zoster oticus (Ramsay Hunt syndrome) is caused by the reactivation of varicella zoster virus in the geniculate ganglion, disrupting cranial nerve VII motor fibers, with
Disorders
(ENT)
Of The Herpes
Ear, Nose,
Zoster
And Throat
subsequent spread to cranial nerve VIII. Primary manifestations include a painful, erythematous, vesicular rash on the auditory canal or auricle and ipsilateral facial paralysis.
Acute nitrofurantoin-induced pulmonary injury is due to a hypersensitivity that can present with fevers, shortness of breath, dry cough, and erythematous rash. Symptoms usually
Critical Care
Pulmonary
Interstitial
Disease
begin 3-9
Disorders
days from medication initiation. Bilateral basilar opacities and pleural effusions are common. Treatment involves cessation of nitrofurantoin.
Cervical spondylotic myelopathy is common in older adults and generally presents with progressive neck pain, gait disturbances, lower motor neuron signs in the upper extremities
Cervical Myelopathy
(e.g. weakness, diminished reflexes), and upper motor neuron signs in the lower extremities (e.g. increased reflexes, spasticity).
Medication overuse headache is characterized by chronic, near-daily headache in the setting of regular use of acute headache medications in patients with a pre-existing headache
disorder. Common features include headache that is present upon awakening and brief symptom relief followed by rebound pain. Management involves cessation of the culprit
Headache Medication Overuse
medication.
Headache
Generalized convulsive status epilepticus is defined as a seizure lasting > 5 minutes or > 2 seizure events in which the patient does not completely regain consciousness.
Intravenous benzodiazepines (e.g. lorazepam, diazepam) should be administered for seizure termination. In addition, a nonbenzodiazepine antiepileptic medication should be
Seizures administered to prevent seizure recurrence; recommended medications include fosphenytoin, phenytoin, levetiracetam, or valproic acid.
Wernicke encephalopathy is a neurologic complication of thiamine deficiency; it classically manifests as the triad of ataxia, encephalopathy, and oculomotor dysfunction. It is usually
associated with long-standing alcohol abuse; however, it may be caused by any disorder that causes chronic malnourishment (e.g. short-gut syndrome). Treatment is with
Miscellaneous Wernicke-Korsakoff
intravenous
Syndromethiamine.
Bell palsy is a peripheral neuropathy of the facial nerve (cranial nerve VII) characterized by facial weakness that involves both the upper and lower face. It is thought to be caused by
Bell Palsy
Nerves Andreactivation
Muscles of neurotrophic viruses (e.g. herpes simplex virus), resulting in inflammation, edema, and degeneration of the myelin sheath.
Amyotrophic lateral sclerosis leads to degeneration of the upper motor neurons (e.g. motor nuclei in the precentral gyrus and their projections in the corticospinal and corticobulbar
tracts) and lower motor neurons (e.g. cranial nerves, spinal nerves). Because any motor neuron can be involved, patients may have a variety of symptoms, including bulbar muscle
Neurodegenerative
Amyotrophic
Disorders And
Lateral
Dementias
weakness.
SclerosisExamination shows both upper motor neuron and lower motor neuron signs.
Acute carbon monoxide poisoning can occur due to inhalation of car exhaust in a closed space, often performed intentionally in a suicide attempt. Toxicity results from impaired
delivery and usage of oxygen, leading to clinical manifestations of cerebral hypoxia (e.g. headache, confusion, seizure, coma). Laboratory results may demonstrate lactic acidosis,
Miscellaneous Carbon Monoxideand
Poisoning
permanent hypoxic brain injury can occur.
Tuberous sclerosis is an autosomal dominant neurocutaneous disorder characterized by typical skin (e.g. angiofibromas, ash-leaf spots) and neurologic (e.g. seizures,
14193 Medicine Dermatology Skin Tumors And Tuberous
Tumor-Like
Sclerosis
Lesions
behavioral/cognitive disorders) findings.
Bell palsy (cranial nerve VII palsy) presents with acute-onset, progressive, unilateral facial weakness involving the upper and lower face. A prodrome of auricular pain may be
Bell Palsy
Nerves Andpresent.
MusclesTherapy is with glucocorticoids, and some studies recommend the addition of acyclovir or valacyclovir.
Methacholine bronchoprovocation testing is the first step in the diagnostic approach of patients who have respiratory symptoms suspicious for asthma and are currently
Asthma Lung Disease
asymptomatic with normal baseline spirometry values. A negative challenge should prompt further workup for alternate diagnoses.
Pertussis often occurs in adolescents and adults. It generally manifests as a stepwise illness that begins with 1-2 weeks of nonspecific symptoms and then progresses to several
Pertussis weeks of the classic paroxysmal cough. Adults often do not have the classic post-tussive emesis. Most cases resolve within 3 months.
Hypothyroidism disrupts the hypothalamic-pituitary-ovarian axis. Low circulating thyroxine levels increase the excretion of hypothalamic thyrotropin-releasing hormone, which in turn
Thyroid &DisordersHypothyroidism
Metabolism stimulates anterior pituitary production of both TSH and prolactin. The resulting hyperprolactinemia suppresses ovulation, leading to abnormal uterine bleeding (e.g. oligomenorrhea).
Carotid sinus hypersensitivity involves an exaggerated vagal response that is often triggered by tactile stimulation. The exaggerated response causes a > 3 second ventricular pause
Cardiac
System
Arrhythmias
Syncope
And Syncope and > 50 mm Hg drop in systolic blood pressure, leading to a transient reduction in cerebral perfusion that manifests as syncope or presyncope.
Disorders
(ENT)
Of The Rhinitis
Over-the-counter decongestant sprays can cause rhinitis medicamentosa after only a few days. Cessation of the medication is the most important step in management.
Obesity hypoventilation syndrome is driven by a combination of disturbances in central ventilatory control and weight-related extrapulmonary restriction. It is a diagnosis of exclusion,
Obesity Hypoventilation
Lung Disease
definedSyndrome
as chronic daytime hypoventilation that cannot be explained by other causes. Treatment is focused on weight loss and correction of comorbid sleep apnea.
New-onset asthma can present as an acute exacerbation with cough, wheezing, and shortness of breath. Treatment includes albuterol (inhaled short-acting β-agonist) for
Asthma Lung Disease
bronchodilation and a systemic glucocorticoid (e.g. prednisone) to reduce airway inflammation.
Prerenal acute kidney injury (AKI) can occur in volume overloaded states. That occurring in an acute heart failure exacerbation is most likely due to cardiorenal syndrome, which
Acute
Systems
Kidney
& Electrolytes
Injury
Acute Kidney Injury
involves elevated central venous pressure leading to a reduction in renal perfusion. Decreased renal perfusion due to reduced cardiac output also plays a role.
Cervical radiculopathy is common in older individuals and usually arises after physical activity or trauma puts stress on the neck and leads to disc herniation or nerve root
compression from underlying cervical spondylosis. Patients usually have pain in the neck radiating to the shoulder/arm, weakness in an upper extremity myotome, and sensory loss
Cervical Spondylosis
in an upper extremity dermatome. MRI of the cervical spine is the first test of choice.
Older patients with a history of chronic antacid use are at risk for vitamin B12 deficiency due to achlorhydria. These patients frequently have subtle neurologic findings, including
lower extremity paresthesias and signs of dorsal column injury (e.g. diminished light touch/vibration sensation). A serum vitamin B12 test is usually diagnostic, but methylmalonic acid
Disorders
& Nutrition
Of Nutrition
Vitamin B12 Deficiency
or homocysteine testing may be required for confirmation in inconclusive cases.
Sarcoidosis is a multisystem, granulomatous disorder that can manifest with skin findings, including papular lesions and erythema nodosum. Hypercalcemia in sarcoidosis occurs
due to extrarenal calcitriol production in the lungs and lymph nodes and is independent of parathyroid hormone (PTH). It is associated with high serum calcitriol, low PTH, and
Fluid,
Systems
Electrolytes,
& Electrolytes
Sarcoidosis
And Acid-Base increased urinary calcium.
Treatment of an acute asthma exacerbation includes a short-acting β-agonist (e.g. albuterol) to manage immediate bronchoconstriction and a glucocorticoid (e.g. prednisone) to
Asthma Lung Disease
control late-phase inflammation and prevent symptom relapse.
Chronic, excessive noise exposure can lead to sensorineural hearing loss due to the irreversible death of hair cells in the cochlea. Hearing screening programs are often mandated in
Normal Structure Hearing
And Function
Loss Of The
high-risk
Nervous
occupations
System (e.g. manufacturing, transportation).
Contemplation is a stage of behavior change in which a patient is willing to consider changes to maladaptive behaviors but has not yet decided to pursue specific action. Patients
Communication
And
Physician
Interpersonal
PatientSkills
considering
Communication
behavioral change should be assessed for conviction (understanding importance of change) and confidence (self-perceived ability to change).
Telogen effluvium causes acute, diffuse, noninflammatory hair loss. It is often triggered by a stressful event, such as weight loss, pregnancy, major illness or surgery, or psychiatric
Hair Loss
Appendages
trauma. Patients have widespread thinning of hair but the scalp and hair shafts appear normal. It is a self-limited disorder but may take up to a year to resolve completely.
HIV-associated neurocognitive disorder is due to replication of HIV in the CNS and is characterized by a chronic decline in multiple cognitive domains. Mood and behavior
Neurodevelopmental
& Substance
HIVAnd
Abuse
Neurocognitive
disturbances
Disorders
are common. The risk increases with duration of HIV infection and is greatest in patients age and those with CD4 counts < 200/mm3.
Anterior uveitis (iritis and iridocyclitis) is characterized by a painful, red eye with tearing and decreased visual acuity. Examination findings include ciliary flush, pupillary constriction, a
hazy ‘flare’ in the aqueous humor, and hypopyon. Anterior uveitis is most often idiopathic or traumatic but can be associated with systemic inflammatory diseases such as certain
Disorders Of The Uveitis
Eye And Associated
infections,
Structures
sarcoidosis, spondyloarthritis, and inflammatory bowel disease.
Epidemiology
Design AndBias
Interpretation Reporting bias may occur if subjects over- or under-report exposure history due to perceived social stigmatization.
Cross-sectional studies are examples of observational studies. They are often relatively quick and easy to perform, are useful in determining prevalence of an outcome, and can
Epidemiology
Design AndStudy
Interpretation
Designs serve to generate hypotheses.
Epidemiology
Design AndInterpretation
InterpretationAndStratification
Use Of Evidence-Based
can help clarify
Datathe(Including
association
Individualization,
between 2 variables.
Risk-Benefit Analysis, Synthesis Of Concepts With Real Data)
The number needed to treat is the reciprocal of the absolute risk reduction rate from an intervention. This number is used by some clinicians to present probabilities regarding
Epidemiology
Design AndNumber
Interpretation
Needed To
outcomes
Treat to patients.
Estimated atherosclerotic cardiovascular disease (ASCVD) risk can be calculated using the Pooled Cohort Equations cardiovascular risk calculator. Initiation of statin therapy is
Cardiovascular
System Drugs
Dyslipidemia recommended for primary prevention in patients with a 10-year ASCVD risk > 7.5%-10%.
Masked hypertension describes normal blood pressure readings in clinic but elevated average blood pressure throughout the day. The diagnosis is made by ambulatory blood
Hypertension
pressure monitoring in patients with clinical evidence of hypertension (e.g. left ventricular hypertrophy) despite normal clinic blood pressure readings.
Chronic lymphedema is most commonly caused by an acquired disruption of the lymphatic system (e.g. chronic inflammation, malignancy) and typically presents with pain and
12527 Medicine General Principles
Miscellaneous Lymphedema swelling in one or more extremities. Patients usually have pitting edema that later progresses to nonpitting edema accompanied by firm, thickened skin.
Patients with hypertriglyceridemia should be evaluated for secondary causes and initially managed with exercise, weight loss, low-fat/carbohydrate diet, and reduction or cessation of
alcohol intake. In patients with mild hypertriglyceridemia (i.e. 150-500 mg/dL) who have known or are at high risk for atherosclerotic cardiovascular disease, statins are the first-line
Coronary
SystemHeart Disease
Dyslipidemia pharmacologic therapy. Fibrates and niacin reduce triglyceride levels but have not been shown to improve cardiovascular outcomes.
Dobutamine is a potent inotropic agent with a strong affinity for β1 receptors and a weak affinity for β2 and α1 receptors. Dobutamine stimulates increased myocardial contractility
Heart
System
Failure AndAcute
ShockHeart Failure
leading to improved ejection fraction, reduced left ventricular end-systolic volume, and symptomatic improvement of decompensated heart failure.
Gastroesophageal
& Nutrition Esophageal
Disorders Varices
Non-selective β blockers such as propranolol or nadolol and endoscopic variceal ligation are the mainstays of primary prophylaxis for esophageal variceal hemorrhage.
Patients with cirrhosis should undergo screening endoscopy to exclude varices, indicate the risk of variceal hemorrhage, and determine strategies for primary prevention of variceal
Hepatic
& Nutrition
DisordersCirrhosis hemorrhage.
Opioid intoxication is commonly characterized by mental status changes, respiratory depression, and miosis. Hypotension, bradycardia, hypothermia, and decreased bowel sounds
Toxicology Exposure
Opioids may also be present.
Vasovagal syncope is typically preceded by a prodrome (e.g. nausea, diaphoresis, pallor, lightheadedness) and usually occurs due to a cardioinhibitory response from increased
Cardiac
System
Arrhythmias
Syncope
And Syncope parasympathetic activity. Cardiac monitoring immediately preceding the syncope typically shows sinus bradycardia and asystole due to sinus arrest.
Major depressive disorder may occur in up to 20% of patients with Parkinson disease (PD). Although the diagnosis of major depression may be difficult due to overlapping symptoms
Neurodegenerative
Parkinson
Disorders
Disease
And Dementias
with PD, the presence of depressed mood, anhedonia, hopelessness, and/or suicidality often suggests major depression.
Waldenström macroglobulinemia is a B-cell neoplasm associated with elevated monoclonal IgM. High levels of IgM may cause hyperviscosity syndrome (vision changes, headaches,
Oncology Waldenström Macroglobulinemia
vertigo, dizziness, ataxia), peripheral neuropathy, cryoglobulinemia, and/or renal insufficiency. Diagnosis requires serum protein electrophoresis and bone marrow biopsy.
The Jarisch-Herxheimer reaction is an acute, febrile reaction that commonly occurs < 12 hours after initial treatment of early syphilis. Symptoms include fever, headache, myalgias,
rigors, sweating, hypotension, and worsening of syphilitic rash (if present). Manifestations are self-limited and typically resolve spontaneously within 48 hours.
Haemophilus ducreyi is a gram-negative rod that causes sexually transmitted infections (chancroid) primarily in developing countries. Cases in the United States are uncommon but
outbreaks have occurred in those who trade sex for drugs or money. Manifestations include the development of > 1 painful papules that convert to pustules and then to ulcers
HIV And Sexually Chancroid
(painful, erythematous base, well-demarcated borders, purulent exudate). Inguinal lymphadenitis is common.
Acute promyelocytic leukemia (APL), a unique form of acute myelogenous leukemia, generally presents with symptoms related to pancytopenia. Individuals with APL are at
extremely high risk for catastrophic hemorrhage due to tumor-induced consumptive coagulopathy. Therefore, patients require urgent treatment with all-trans retinoic acid, which
Oncology
Acute Promyelocytic
differentiates
Leukemia the abnormal promyelocytes into mature myelocytes and rapidly reduces bleeding risk.
Von Willebrand disease is a genetic disorder associated with impaired activity/quantity of von Willebrand factor, leading to poor platelet-endothelial binding and reduced factor VIII
Von Willebrand Disease
levels. Patients are usually asymptomatic but may have prolonged mucocutaneous bleeding, easy bruising, and prolonged PTT.
Idiopathic pulmonary fibrosis is characterized by slowly progressive dyspnea, dry cough, and fine crackles and commonly occurs in patients age 50-70. It is associated with a
Critical Care
Pulmonary
Interstitial
Disease
restrictive
Disorders
profile and reduced diffusion capacity on pulmonary function testing.
Vestibular neuritis is a self-limited disorder of the vestibulocochlear nerve (CN VIII) that sometimes follows a viral upper respiratory infection. Vestibular neuritis with unilateral hearing
Disorders
(ENT)
Of The Vestibular
Ear, Nose,Neuritis/Labyrinthitis
And Throat
loss is termed labyrinthitis.
Pharyngitis, fever, and lower abdominal pain in a sexually active patient are caused by gonococcal pharyngitis and associated pelvic inflammatory disease. Gonococcal pharyngitis is
HIV And Sexually Gonococcal
Transmitted Infection
Infections
due to orogenital contact.
Neisseria gonorrhoeae is a common sexually transmitted infection that can cause pharyngitis due to orogenital contact and pelvic inflammatory disease due to ascending infection
Infections
from the lower to the upper genital tract.
Acute myeloid leukemia (AML) is the most common acute leukemia in adults and is typically associated with fatigue and symptoms related to > 1 cytopenias. Acute promyelocytic
Oncology
Acute Myeloid Leukemia
leukemia is a unique form of AML that often presents with life-threatening coagulopathy due to disseminated intravascular coagulation.
Lactose is processed into glucose and galactose by intestinal lactase that is present on the brush border of the duodenum. Lactase enzyme deficiency commonly causes lactose
Disorders
& Nutrition
Of Nutrition
Lactose Intolerance
intolerance, which is characterized by chronic, crampy, postprandial abdominal pain, bloating, and watery diarrhea.
Prostate cancer may initially present with symptoms related to metastatic disease. Spread to the axial skeleton is common, and manifestations typically include slowly progressive
lower back pain or functional impairment (e.g. motor weakness, incontinence). Prostate cancer usually causes osteoblastic bone lesions with normal or low calcium, elevated alkaline
OncologyOf Oncology
Prostate Cancer phosphatase, and radiographic evidence of focal, sclerotic lesions.
Radioiodine therapy for Graves disease leads to resolution of hyperthyroidism in 6-18 weeks, but the dose needed for treatment gradually leads to permanent hypothyroidism in most
Thyroid &DisordersRadioactive
Metabolism Iodinepatients. This therapy can also acutely worsen Graves ophthalmopathy due to increased titers of thyroid-stimulating autoantibodies.
Arsenic toxicity should be suspected in a patient with possible environmental exposure (e.g. pressure-treated wood, pesticides) who has painful sensorimotor polyneuropathy, skin
Exposure
Arsenic Poisoninglesions (hypo- and hyperpigmented, hyperkeratotic), pancytopenia, and mild transaminase elevation. Diagnosis is confirmed with elevated urine arsenic levels.
Chronic lead toxicity presents in adults with neuropsychiatric, gastrointestinal, and general symptoms, including peripheral sensorimotor neuropathy, fatigue, abdominal pain, and
constipation. It can lead to hypertension, nephropathy, hyperuricemia, and microcytic anemia with basophilic stippling seen on peripheral smear. Treatment for symptomatic patients
Miscellaneous Lead Poisoning involves chelation therapy with an agent such as calcium disodium EDTA.
Chronic lead toxicity in adults presents with neuropsychiatric, gastrointestinal, and general symptoms including peripheral sensorimotor neuropathy, fatigue, abdominal pain, and
constipation. It can lead to hypertension, nephropathy, hyperuricemia, and microcytic anemia with basophilic stippling seen on the peripheral smear. Diagnosis hinges on a thorough
Miscellaneous Lead Poisoning history including potential sources of lead exposure.
Aplastic anemia is an acquired deficiency of pluripotent stem cells that can result from certain exposures, viral infections, or autoimmune conditions. The manifestations, including
Oncology
Aplastic Anemia fatigue, infection, and mucocutaneous bleeding, are due to pancytopenia. Cellular morphology is normal and splenomegaly is absent.
Subclavian steal syndrome occurs due to stenosis or occlusion of the proximal subclavian artery, leading to reversal of blood flow in the ipsilateral vertebral artery. Patients are often
asymptomatic but may have symptoms of upper extremity ischemia (e.g. pain, fatigue, paresthesias) or vertebrobasilar insufficiency (e.g. dizziness, ataxia, dysequilibrium) that are
Subclavian Steal Syndrome
worsened by upper extremity exercise.
Klinefelter syndrome (47,XXY) is characterized by a eunuchoid habitus, gynecomastia, small testes, and decreased virilization. It can lead to infertility due to testicular fibrosis with
Disorders
System
Of The Klinefelter
Male Reproductive
Syndrome
seminiferous
System tubule dysgenesis, azoospermia, hypogonadism, and elevated FSH and LH levels.
Patients with acute viral (or idiopathic) pericarditis should be initially treated with a combination of nonsteroidal anti-inflammatory drugs (e.g. ibuprofen) and colchicine, as colchicine
Myopericardial
System Diseases
Acute Pericarditislowers the rate of recurrent pericarditis. Corticosteroids (e.g. prednisone) are second-line therapy for these patients.
Pericarditis is the most common cardiac manifestation of systemic lupus erythematosus (SLE). Patients typically have pleuritic chest pain, a pericardial friction rub, and diffuse ECG
Myopericardial
System Diseases
Acute Pericarditischanges accompanied by other manifestations of active SLE (e.g. joint pain, cytopenia).
Patients with diabetes mellitus who have an elevated hemoglobin A1c despite normal fasting glucose levels may have postprandial hyperglycemia. A combined regimen including a
Diabetes& Mellitus
Metabolism
Diabetes Mellitus long-acting basal insulin (to control fasting glucose) and a rapid-acting mealtime insulin (to control postprandial glucose) can improve glycemic control.
Erythema multiforme is an acute inflammatory disorder characterized by erythematous, round papules that evolve into target lesions, although the appearance can vary. It is
ErythemaAnd
Multiforme
Bullous
associated
Diseases
with certain infections (especially herpes simplex) as well as medications, malignancies, and connective tissue diseases.
Rupture of the interventricular septum typically occurs 3-5 days after an acute myocardial infarction and presents with sudden-onset cardiogenic shock with hypotension, biventricular
Congenital
System Heart Ventricular
Disease Septalfailure,
Defect and a new harsh holosystolic murmur with palpable thrill at the left sternal border.
Factors that can lead to worsening of psoriasis include local skin trauma (Koebner phenomenon), withdrawal from systemic glucocorticoids, and certain medications (e.g.
antimalarials, indomethacin, propranolol). In addition, certain infections, especially HIV and streptococcal pharyngitis (which can also trigger guttate psoriasis), are associated with
PsoriasisAnd Bullous
psoriasis.
Diseases
Psoriasis presents with chronic, erythematous plaques with a white or silver scale, primarily located on the extensor surfaces (e.g. knees, elbows). Initial treatment for limited plaque
psoriasis includes topical high-potency glucocorticoids (e.g. betamethasone, fluocinonide) or vitamin D derivatives (e.g. calcipotriene). Patients with moderate to severe disease may
PsoriasisAnd Bullous
require
Diseases
phototherapy or systemic treatment.
Ecthyma gangrenosum is a rapidly progressive cutaneous disorder seen most commonly in immunocompromised patients with Pseudomonas aeruginosa bacteremia/sepsis. Lesions
begin as painless red macules, quickly progress to pustules/bullae, and then form ‘punched-out’ gangrenous ulcers. Patients are usually febrile and ill. Blood cultures and empiric,
Pseudomonas intravenous antibiotics are required.
Chlamydia trachomatis is a common sexually transmitted infection that is often asymptomatic but may cause urethritis in men. Symptoms include mucoid discharge and dysuria.
Treatment with a one-time dose of azithromycin is almost always curative; however, current sexual partners must receive testing and treatment to prevent reinfection.
Disseminated gonococcal infection causes purulent monoarthritis or the triad of tenosynovitis, polyarthralgia, and pustular lesions. Blood, synovial, and skin cultures are often
negative due to the fastidious nature of Neisseria gonorrhoeae, but urogenital mucosa testing (e.g. nucleic acid amplification) is typically positive even in the absence of urogenital
symptoms.
Amitriptyline is commonly used for depression, insomnia, and pain disorders but is frequently associated with side effects including orthostatic hypotension, lethargy, and
Miscellaneous Tricyclic Antidepressants
anticholinergic symptoms (e.g. dry mouth, constipation, urinary retention). Discontinuing the medication usually resolves these symptoms.
Hypovolemia stimulates the renin-angiotensin system, which helps improve intravascular volume, glomerular filtration rate, and blood pressure via vasoconstriction and kidney-
Acute
Systems
Kidney
& Electrolytes
Injury
Prerenal Azotemiamediated sodium and water reabsorption.
Age-related sicca syndrome is due to a decrease in exocrine output from the lacrimal and salivary glands. Decreased blink rates, oxidative damage, and use of anticholinergic
medications can also contribute. Sjögren syndrome is an autoimmune disorder of the exocrine glands that can also present with dry eyes and dry mouth but occurs in younger
& Sports
SjögrenAnd
Syndrome
Vasculitides
patients and is associated with a positive antinuclear antibody assay.
Tetanus is a presynaptic neuromuscular junction disorder caused by the Clostridium tetani toxin, which blocks the release of the inhibitory neurotransmitters glycine and GABA
TetanusNerves Andacross
Muscles
the synaptic cleft, leading to fever, painful muscle spasms, and trismus (lockjaw). It is usually seen only in those who are unvaccinated or incompletely immunized.
Delirium is a reversible disorder characterized by agitation and confusion, most frequently seen in the elderly or those with underlying dementia. Determining the underlying cause,
avoiding unnecessary medications, treating infections and metabolic disturbances, and encouraging regular activity during the day while minimizing disturbances at night can help
Miscellaneous Delirium patients recover more quickly.
Alcoholic cerebellar degeneration is caused by damage to the Purkinje cells of the cerebellar vermis. Manifestations typically include the slowly progressive onset of ambulation
Neurodegenerative
Cerebellar
DisordersDegeneration
And Dementias
difficulties, including wide-based gait and postural instability. Truncal coordination (e.g. tandem gait) is impaired, but limb coordination (e.g. finger-nose test) is relatively intact.
Neurodegenerative
Alzheimer
Disorders
Disease
And Dementias
Neurocognitive testing should be obtained in patients with cognitive impairment to establish a diagnosis.
Common fibular neuropathy is typically the result of leg immobilization, leg crossing, or protracted squatting. Manifestations are usually transient (lasting hours) and include foot drop
and sensory changes over the dorsal foot and lateral shin. Physical examination shows impaired ankle dorsiflexion and great toe extension with preserved plantar flexion and
Footdrop
Nerves Andreflexes.
Muscles
Tension-type headaches can occur due to stress and are usually bilateral, dull, and nonthrobbing without associated symptoms (e.g. nausea, vomiting). When infrequent, they can be
Headache Tension Headache
treated with analgesics (e.g. ibuprofen), but when more disabling, prophylactic medication (e.g. amitriptyline) should be considered.
The most common cause of community-acquired bacterial meningitis is Streptococcus pneumoniae. Most patients have > 2 symptoms of headache, fever, nuchal rigidity, and altered
Meningitis mental status. Concurrent pneumococcal pneumonia may or may not be present.
Headaches that are new or differ in character from prior, that are present on awakening, and that are associated with frequent nausea and vomiting as well as blurry vision are
Headache Increased Intracranial
concerning
Pressure
for a pathological cause. These patients should be evaluated early with an MRI of the brain.
Exercise-associated hyponatremia occurs due to a combination of excessive fluid intake and nonosmotically mediated release of inappropriately high levels of antidiuretic hormone.
Fluid,
Systems
Electrolytes,
& Electrolytes
Hyponatremia
And Acid-Base In severe cases, patients may experience seizures, profound confusion, and even death.
Central vertigo presents with nonfatigable nystagmus, which cannot be suppressed by visual fixation. Head imaging should be performed to evaluate for cerebellar stroke or
Vertigo hemorrhage in patients who have persistent, new-onset central vertigo and vascular risk factors, neurologic signs/symptoms, or accompanying headache.
Patients with large or embolic ischemic strokes and those treated with thrombolytics are at high risk for hemorrhagic transformation. This condition usually occurs within 48 hours of
Hemorrhagic Stroke
the stroke and often manifests with deteriorating mental status. Diagnosis requires emergent noncontrast CT scan of the head.
Neurological deficits related to an acute demyelinating plaque of multiple sclerosis usually last for days to weeks whereas transient ischemic attack (TIA) symptoms usually last for <
Transient Ischemic
24Attack
hours. The initial treatment of TIA is modifying risk factors, starting aspirin and statin, and improving blood pressure control.
Peptic ulcer disease can be complicated by perforation, which typically causes acute-onset, severe pain; a systemic inflammatory response (e.g. fever, tachycardia); and peritonitis.
Gastroesophageal
& Nutrition Perforated
DisordersViscusUpright x-ray of the chest and abdomen can confirm the diagnosis of perforation by revealing subdiaphragmatic free air.
A complication of Crohn disease is perianal disease (e.g. abscess, fissure, fistula), including rectovaginal fistula, due to transmural inflammation of the gastrointestinal tract. Patients
12137 Medicine Female Reproductive
Miscellaneous
System &Rectovaginal
Breast Fistula
with a rectovaginal fistula typically have a malodorous, tan vaginal discharge; passage of flatus through the vagina; and a posterior vaginal lesion.
Pulmonary arterial hypertension (PAH) is a common manifestation of systemic sclerosis that results from intimal hyperplasia of the pulmonary arteries. Absence of alveolar airspace
Critical Care
Vascular
Systemic
And Cardiopulmonary
Sclerosis
disease Disease
and normal FEV1 and FEV1/FVC ratio help differentiate PAH from pulmonary hypertension due to lung disease or left-sided heart failure.
Pulmonary arterial hypertension is a common manifestation of systemic sclerosis that typically presents with progressive dyspnea and often leads to right ventricular enlargement
Critical Care
Vascular
Systemic
And Cardiopulmonary
Sclerosis
and right-sided
Diseaseheart failure.
Late neurosyphilis can manifest years after untreated Treponema pallidum infection with tabes dorsalis (sensory ataxia, lancinating pains, reduced/absent deep tendon reflexes) and
CNS Infections Syphilis Argyll-Robertson pupils (normal pupillary constriction with accommodation but not with light). Intravenous penicillin is the treatment of choice.
Glucocorticoid nasal sprays are the most effective single agent for allergic rhinitis, although maximal benefits may require continuous treatment for several days or weeks. Oral
Disorders
(ENT)
Of The Rhinitis
antihistamines, antihistamine or cromolyn nasal sprays, and leukotriene modifiers can be considered based on the patient’s symptoms and drug tolerances.
Foodborne botulism is a potentially life-threatening illness caused by the ingestion of food (e.g. improperly canned fruits/vegetables, cured fish) contaminated with botulinum toxin.
Botulism
Nerves AndSymptoms
Muscles typically occur within 36 hours of ingestion and begin with bilateral cranial neuropathies followed by symmetric descending muscle weakness.
Peripartum cardiomyopathy is an uncommon cause of dilated cardiomyopathy characterized by the development of heart failure during the last month of pregnancy or within 5
Myopericardial
System Diseases
Peripartum Cardiomyopathy
months following delivery.
Postexposure prophylaxis with either hepatitis A vaccine or hepatitis A immune globulin should be considered in a number of groups, including those with close personal contact (e.g.
Viral Infections Hepatitis A sexual contacts, household contacts) with infected patients.
Acute bronchitis is a self-limited illness usually caused by a viral infection. Treatment is supportive, although patients with associated wheezing due to underlying asthma may benefit
Critical Care
Infections
Acute Bronchitis from an inhaled bronchodilator (e.g. albuterol). Antibiotics are not helpful and should be avoided.
Management of chronic back pain should include an exercise program emphasizing stretching and strengthening of the back muscles and aerobic conditioning. Acetaminophen or
nonsteroidal anti-inflammatory drugs can be used intermittently. Some patients may benefit from tricyclic antidepressants or duloxetine, but opioids, benzodiazepines, and muscle
Spinal/Peripheral
& Sports
Back
NervePain
Disorders And
relaxants
Back are
Painnot advised.
Takayasu arteritis is a large artery vasculitis that is most common in young Asian women. Initial symptoms include fever, arthralgias, and weight loss. Later features include arterio-
occlusive symptoms, blood pressure discrepancies, and pulse deficits. CT and MRI can reveal aneurysm formation or narrowing of the arterial lumen. Treatment includes systemic
& Sports
Takayasu
And Arteritis
Vasculitides
glucocorticoids.
Phenytoin is an antiepileptic drug with known teratogenic effects (e.g. fetal hydantoin syndrome). Women of childbearing age who have a low risk of seizure recurrence may safely
Seizures discontinue phenytoin if considering becoming pregnant; however, the medication should be slowly tapered as rapid withdrawal may result in seizure recurrence.
First-line treatment for urgency urinary incontinence includes bladder training and pelvic floor muscle (Kegel) exercises. Patients whose condition does not respond to these therapies
Urinary
Systems
& Electrolytes
Urinary Incontinence
GUare
Infection
treated with antimuscarinic medications (e.g. oxybutynin) to decrease detrusor contractions and reduce the sense of urgency.
The diagnosis of myasthenia gravis can be supported with the bedside ice pack test. In this test, an ice pack is applied over the eyelids for several minutes, leading to an
Myasthenia
Nerves
Gravis
Andimprovement
Muscles in ptosis. Patients with positive test results should undergo confirmatory testing for acetylcholine receptor antibodies (highly specific).
Normal Structure Hearing
And Function
Loss Of The
Presbycusis
Nervous is
System
common in the elderly and presents with bilateral, symmetric, sensorineural hearing loss.
The initial treatment of ankylosing spondylitis includes regular exercise and nonsteroidal anti-inflammatory drugs. Tumor necrosis factor inhibitors and IL-17 inhibitors are used in
& Sports
Ankylosing Spondylitis
patients whose conditions do not respond to less aggressive treatment.
Antinuclear antibody (ANA) is a very sensitive, but nonspecific, marker for systemic lupus erythematosus. If ANA titers are elevated, more specific autoantibodies (e.g. anti-double-
& Sports
stranded DNA) can confirm the diagnosis.
The initial diagnostic workup of a first-time seizure in an adult should include basic blood tests (e.g. serum electrolytes, glucose, calcium, magnesium, complete blood count, renal
Seizures and liver function tests) and a toxicology screen to evaluate for metabolic and toxic causes. Unprovoked seizures generally require further evaluation with neuroimaging and EEG.
Felty syndrome is a complication of seropositive rheumatoid arthritis (RA) characterized by neutropenia and splenomegaly. Most patients have high-titer rheumatoid factor and anti-
& Sports
Rheumatoid
And Vasculitides
Arthritis
citrullinated peptide antibodies (both of which are usually elevated in RA). Risk of recurrent bacterial infection is significantly increased due to neutropenia.
Fibrocystic breast changes are a common cause of cyclic breast pain in women of reproductive age. Classic clinical findings are diffusely nodular breasts with non-focal tenderness
Breast Disorders
System &Fibrocystic
Breast Breastand
Changes
no nipple discharge or lymphadenopathy.
Heberden and Bouchard nodes represent bony enlargement at the distal and proximal interphalangeal joints and are pathognomonic for osteoarthritis. Osteoarthritis of the hands is
& Sports
Osteoarthritis primarily a clinical diagnosis; imaging (e.g. x-ray) is less sensitive than examination findings and is usually unnecessary for diagnosis or management.
Accepting gifts from interested third parties can influence a physician’s practice in subtle or subconscious ways. Only nonmonetary gifts that are of minimal value and that directly
Communication
And
Professional
Interpersonal
Conduct
Skills
benefit the patient, such as unbiased educational material or drug samples, should be considered.
Synthetic cathinones (‘bath salts’) have amphetamine-like properties that can cause severe agitation, combativeness, psychosis, delirium, myoclonus, and, rarely, seizures.
Tachycardia and increased blood pressure are often present. In contrast to other stimulants and hallucinogens, which have a much shorter duration of effect, the effects of synthetic
Substance& Use
Substance
Disorders
Substance
AbuseUse Disorders
cathinone intoxication may take up to a week to subside.
Prolonged infusion of sodium nitroprusside at high rates can lead to cyanide toxicity, especially in patients with chronic kidney disease. Typical findings include headache, confusion,
Fluid,
Systems
Electrolytes,
& Electrolytes
Cyanide
And Acid-Base
Poisoning
arrhythmias, flushing, and respiratory depression.
Traumatic brain injury (TBI) of any severity can lead to (a few hours to days later) postconcussive syndrome, which is clinically described by the following constellation of symptoms:
headache, confusion, amnesia, difficulty concentrating or with multitasking, vertigo, mood alteration, sleep disturbance, and anxiety. These symptoms typically resolve with
Post-Concussion symptomatic
Syndrome treatment within a few weeks to months following TBI; however, some patients may have persistent symptoms lasting > 6 months.
Endurance athletes are at risk for thermal illness, both hyper- and hypothermia. Mild hypothermia is generally managed with passive rewarming. More severe hypothermia requires
Exposure
Accidental Hypothermia
aggressive treatment, including active external (heated blankets) and internal (heated peritoneal irrigation) rewarming.
Primary therapy for moderate hypothermia includes active external rewarming and warmed intravenous fluids. Bradycardia associated with hypothermia is often refractory to
Exposure
treatment with atropine and cardiac pacing, but it usually improves with correction of hypothermia.
In patients with diabetes mellitus, intensive blood glucose control with insulin decreases the risk of microvascular complications (e.g. retinopathy, nephropathy) but has an uncertain
effect on macrovascular outcomes (e.g. stroke, myocardial infarction) and mortality. Very strict glycemic control (e.g. goal A1c < 6.5%) is associated with increased risk of
Diabetes& Mellitus
Metabolism
Diabetic Retinopathy
hypoglycemia and increased cardiovascular mortality. Therefore, the recommended target hemoglobin A1c for most nonelderly patients is 7.0%.
Thyroid storm is a life-threatening thyrotoxicosis usually triggered by a specific event (e.g. surgery, trauma, infection, iodine contrast, childbirth) in patients with undiagnosed or
Metabolism inadequately treated hyperthyroidism. Patients can develop fever, hemodynamic instability, cardiac arrhythmias, and congestive heart failure.
Postpartum adrenal insufficiency (AI) may be due to adrenal (primary AI) or pituitary (secondary AI) disease. Hyperpigmentation and signs of mineralocorticoid deficiency suggest
Adrenal&Disorders
Metabolism
primary rather than secondary AI.
Adhesive capsulitis is characterized by pain and loss of distensibility of the glenohumeral joint capsule due to chronic inflammation, fibrosis, and contracture. It is often seen in
patients with diabetes mellitus, thyroid disorders, chronic immobility, rotator cuff tendinopathy, and fracture of the proximal humerus. Examination shows decreased active and
Bone, Joint, And
& Sports
Soft
Adhesive
TissueCapsulitis
Injuriespassive
And Infections
range of motion in multiple planes. X-ray findings are normal.
Left ventricular systolic or diastolic dysfunction is a common cause of pulmonary hypertension. Initial management includes loop diuretics and ACE inhibitors (or angiotensin II
Hypertension
System Pulmonary Arterialreceptor
Hypertension
blockers).
Chikungunya fever is a mosquito-borne viral illness that typically presents with flulike illness, symmetric polyarthralgias, macular or maculopapular rash on the limbs and trunk,
Viral Infections Chikungunya Fever
peripheral edema, and cervical lymphadenopathy.
Irritant contact dermatitis can be triggered by a variety of chemicals, solvents, cleaning products, or acidic/alkaline solutions. It is nonimmunologically mediated but can resemble
Contact Dermatitis
And Bullous
allergic
Diseases
contact dermatitis with pruritus, erythema, local swelling, and vesicles. Chronic symptoms include excoriations, hyperkeratosis, and fissuring of skin.
Gastroesophageal reflux disease (GERD) and esophageal motility disorders are common causes of non-cardiac chest pain. Features suggestive of an esophageal origin of chest
Miscellaneous
System Gastroesophagealpain
Reflux
include
Disease
prolonged episodes lasting more than an hour, postprandial symptoms, associated heartburn or dysphagia, and relief of pain by antireflux therapy.
HIV-associated Kaposi sarcoma (KS) is an AIDS-defining malignancy due to human herpesvirus 8. Cutaneous KS develops most commonly on the lower extremities, face, oral
Viral Infections Kaposi Sarcoma mucosa, and genitalia. The lesions usually appear as multiple violaceous papules. Diagnosis is made clinically but may require biopsy.
Clostridium difficile is a common cause of nosocomial and outpatient infectious diarrhea. Major risk factors include recent antibiotic use, age > 65, and gastric acid suppression (e.g.
Intestinal
& Nutrition
And Colorectal
Clostridium
Disorders
Difficile
proton-pump
Infection inhibitors). Diagnosis is typically made with stool assay for C. difficile exotoxin genes via polymerase chain reaction.
Acute urinary incontinence in elderly patients may have atypical presentations. Consider reversible etiologies first, especially if new onset (remember: DIAPPERS). Fever may not
Genitourinary
System
Tract
&Urinary
Breast
Infections
Incontinence
present with urinary tract infections limited to the lower urinary tract. Initial evaluation should include urinalysis with culture.
Asthma may present with chronic cough that is predominantly nocturnal. These patients should be evaluated with spirometry to assess bronchodilator response. Other common
Chronic Cough
Lung Disease
causes of chronic cough include upper airway cough syndrome, gastroesophageal reflux disease, and ACE inhibitors.
Intravenous antibiotics decrease the risk of septic embolic events in patients with native valve infective endocarditis. Surgery can be considered in some patients with stroke,
Ischemic Stroke significant valvular dysfunction, persistent/difficult to treat infection, or recurrent embolism.
Meningococcal vaccination should be provided to all adolescents at age 11-12, with a booster recommended at age 16. Meningococcal vaccination is especially important for
patients with complement deficiency or asplenia, military recruits, college students living in dormitories, and travelers to sub-Saharan Africa. Live-attenuated vaccines should be
Immunizations avoided in patients receiving tumor necrosis factor antagonists.
Asterixis is a flapping movement of the hands that occurs when the wrist is extended with the arms outstretched. Common causes include hepatic encephalopathy, uremic
Miscellaneous Acute Kidney Injury
encephalopathy, and hypercapnia. Treating the underlying cause will improve neurological status and resolve asterixis.
Scleroderma renal crisis typically presents with acute renal failure (without previous kidney disease) and malignant hypertension (e.g. headache, blurry vision, nausea). Urinalysis
Oncology
Systemic Sclerosis
may show mild proteinuria. Peripheral blood smear can show microangiopathic hemolytic anemia with fragmented red blood cells (e.g. schistocytes) and thrombocytopenia.
Constrictive pericarditis is an important cause of right heart failure and is characterized by progressive peripheral edema, ascites, elevated jugular venous pressure, pericardial knock
Myopericardial
System Diseases
Constrictive Pericarditis
(mid-diastolic sound), and pericardial calcifications on chest radiograph.
Cyanide toxicity can occur in patients treated with nitroprusside who receive prolonged infusions, higher doses, or have underlying renal insufficiency. It presents with altered mental
Cardiovascular
System Drugs
Cyanide Poisoning
status, lactic acidosis, seizures, and coma.
Patient
Safety Patient Safety Checklists are an important tool to prevent undesired medical outcomes that result from physician communication failures during the patient handoff process.
Patient
Safety Patient Safety Communication failures between physicians during patient handoffs are a large contributor to medical errors and adverse patient outcomes.
Vitamin B12 deficiency is common in those with chronic malabsorption (e.g. Crohn disease) and often presents with macrocytic anemia and neurologic findings (e.g. paresthesia,
subacute combined degeneration). A vitamin B12 level is the initial test of choice, but serum methylmalonic acid and homocysteine testing should be ordered in borderline or
VitaminNerves
B12 Deficiency
Andinconclusive
Muscles cases.
Plantar warts are due to human papillomavirus (HPV) infection and most commonly occur in young adults and immunocompromised individuals. The lesions appear as hyperkeratotic
Warts Appendages
papules on the sole of the foot that can be painful when walking or standing.
Chemotherapy-induced peripheral neuropathy typically presents as a symmetric, distal, sensory neuropathy that progresses in a stocking-glove pattern. Common causative agents
Peripheral
Nerves
Neuropathy
Andinclude
Muscles
platinum-based medications, taxanes, and vinca alkaloids.
Vascular dementia presents as a sudden or stepwise decline in executive function after stroke, which interferes with activities of daily living. Patients typically have abnormal
Neurodegenerative
Vascular
Disorders
Dementia
And Dementias
neurologic findings on examination (e.g. hemiparesis, pronator drift, Romberg sign).
Dermatofibromas are nontender, firm, hyperpigmented nodules that are usually < 1 cm in diameter. They are due to fibroblast proliferation and most commonly occur on the lower
10402 Medicine Dermatology Skin Tumors And Dermatofibroma
Tumor-Like Lesions
extremities. The lesions have a fibrous component that causes the central area to dimple when pinched.
Vascular dementia typically presents as a sudden or stepwise decline in executive function with mild memory loss early in the disease. Patients can have focal neurologic deficits on
Neurodegenerative
Vascular
Disorders
Dementia
And Dementias
examination, and neuroimaging classically demonstrates a cerebral infarction and/or deep white matter changes from chronic ischemia.
Acute urticaria (< 6 weeks) can be due to infections (viral, bacterial, or parasitic), nonsteroidal anti-inflammatory drugs, and IgE mediated (e.g. antibiotics, insect bites, latex, food) or
direct (e.g. narcotics, radiocontrast medium) mast cell activation. Nearly 50% of patients have idiopathic urticaria. Patients usually develop well-circumscribed and raised
10298.1 Medicine Dermatology Miscellaneous Urticaria erythematous plaques with a central pallor, along with intense pruritus and resolution of individual skin lesions within 24 hours.
Acute urticaria presents with intensely pruritic, well-circumscribed erythematous plaques (i.e. wheals). Individual lesions resolve within 24 hours, but additional lesions may erupt for
10298 Medicine Dermatology Miscellaneous Urticaria up to 6 weeks. Angioedema sometimes accompanies urticaria.
Hematuria (gross or microscopic) can be due to glomerular or non-glomerular causes. The source of hematuria is more likely to be glomerular if the urine studies reveal proteinuria,
Glomerular
Systems &Diseases,
Electrolytes
Glomerular
Nephrotic/Nephritic
Disorders
dysmorphic
Syndrome
red blood cells (RBCs) or RBC casts.
Peripheral edema is a common side effect of dihydropyridine calcium channel blockers (CCBs). Addition of a renin-angiotensin system antagonist (angiotensin-converting enzyme
Cardiovascular
System Drugs
Calcium Channel inhibitor
Blocker or angiotensin receptor blocker) can reduce CCB-associated peripheral edema.
To prevent cardiorespiratory arrest and permanent neurologic disability, victims of smoke inhalation injury should be treated empirically for cyanide toxicity with an antidote, such as
Exposure
Cyanide Poisoning
hydroxocobalamin or sodium thiosulfate, or with nitrites to induce methemoglobinemia.
Cyanide binds to ferric iron in cytochrome oxidase a3 in the mitochondrial electron transport chain. This activity blocks oxidative phosphorylation and promotes anaerobic
Exposure
Cyanide Poisoning
metabolism, causing lactic acidosis.
Raynaud phenomenon (RP) is abnormal vasoconstriction of digital arteries in response to cold or emotional stress. It may be primary, or may occur in association with systemic
& Sports
RaynaudAndPhenomenon
Vasculitides
disease, especially autoimmune disorders. Patients with suspected secondary RP should be tested for autoantibodies and inflammatory markers.
Primary Raynaud phenomenon is an increased vascular response to cold temperature or emotional stress. It is usually found in women age < 30 with symptoms of symmetrical
episodic attacks without evidence of peripheral vascular disease, tissue injury, or abnormal nailfold capillary examination. Treatment involves mainly calcium channel blockers (e.g.
& Sports
RaynaudAndPhenomenon
Vasculitides
nifedipine, amlodipine) and avoiding aggravating factors.
Patients with HIV who have subacute-onset of low-grade fever, headache, and signs of increased intracranial pressure should be evaluated for cryptococcal meningitis. Diagnosis is
Fungal Infections Meningitis established by detection of the cryptococcal antigen or isolation of the organism in cerebrospinal fluid.
Single photon emission CT scan is a useful tool to evaluate for coronary artery disease and indicates inducible ischemia when a reversible defect is noted on stress and rest images.
Coronary
SystemHeart Disease
Coronary Artery Disease
Antiplatelet therapy is the preferred treatment to prevent coronary artery disease in these patients.
Continuity of care for medications at the time of transitions of care, between inpatient and outpatient facilities and within inpatient facilities, is a potential source of medical error.
9634 Medicine Biostatistics &Epidemiology
EpidemiologyAndAdverse
Population
Event
Health
Interventions that target pharmacy personnel and high-risk patients appear to be the most effective in improving the quality of patient care.
Infectious esophagitis is a common complication seen in patients with advanced HIV disease. Patients with oral thrush most likely have Candida esophagitis, with viral causes (e.g.
herpes simplex, cytomegalovirus) being more likely in the setting of severe odynophagia without dysphagia or thrush. The diagnosis is confirmed with upper gastrointestinal
Viral Infections Esophagitis endoscopy.
According to ethical guidelines, permission must be obtained from the family (or from the patient prior to death) before procedures can be performed on a newly deceased patient for
Medical
Ethics And
Informed
Jurisprudence
Consenttraining purposes.
Absent sperm concentration with normal FSH, LH, and testosterone suggests infertility due to obstructive azoospermia. Congenital absence of the bilateral vas deferens, a cause of
Disorders
System
Of The Infertility
Male Reproductive
obstructive
System azoospermia, is highly associated with cystic fibrosis and may be the only feature in mild, atypical disease.
Hospice is a palliative, interdisciplinary model of care for patients with a prognosis of < 6 months. The focus is on symptom control; quality of life; and psychosocial, spiritual, and
Patient
Safety End Of Life Care bereavement care.
Acute gout presents as an acute monoarthritis, usually in the first metatarsophalangeal joint or knee. Synovial fluid analysis shows leukocytosis (2,000-100,000/mm3 with > 50%
& Sports
Gout neutrophils) and monosodium urate crystals, which are needle-shaped and negatively birefringent.
A supervised exercise program should be recommended as a part of an initial treatment regimen in all patients with intermittent claudication. Pharmacologic therapy with cilostazol
Aortic
System
And Peripheral
Peripheral
Artery Diseases
Vascular
andDisease
percutaneous or surgical revascularization should be reserved for those with persistent symptoms despite adequate supervised exercise therapy.
Cardiovascular disease is the major cause of morbidity and mortality in patients with peripheral artery disease (PAD). Patients with PAD and intermittent claudication have an
estimated 20% 5-year risk of nonfatal myocardial infarction and stroke and a 15%-30% risk of death due to cardiovascular causes. Only 1%-2% of patients with PAD progress to
Aortic
System
And Peripheral
Peripheral
Artery Diseases
Vascular
develop
Disease
critical limb ischemia with risk of limb amputation.
Contact lens-associated infectious keratitis is a medical emergency that causes a painful, red eye and opacification and ulceration of the cornea. Most cases are due to Gram-
Disorders Of The Infectious
Eye And Associated
Keratitisnegative
Structures
organisms but can also be due to Gram-positive organisms as well as certain fungi and amoebas. Most cases require topical broad-spectrum antibiotics.
Viral conjunctivitis is a self-limited condition associated with adenovirus and other viral upper respiratory illnesses. It is common in sporadic outbreaks, especially among children and
Disorders Of The Conjunctivitis
Eye And Associated
caregivers
Structures
in late summer and early fall. No specific treatment is needed, although some patients may develop a bacterial superinfection which requires topical antibiotics.
Hypopituitarism with a mild to moderate increase in prolactin suggests a nonfunctioning (gonadotroph) adenoma. Patients may develop symptomatic hypogonadism or
Hypothalamus
& Metabolism
And
Hypopituitarism
Pituitary Disorders
hypothyroidism but are frequently asymptomatic until the adenoma becomes very large and causes a mass effect on surrounding tissues.
Although asthma is usually diagnosed in childhood or early adulthood, in some cases it presents for the first time in late adulthood. The diagnosis is confirmed on pulmonary function
Asthma Lung Disease
testing. Reversible airway obstruction (> 12% increase in FEV1) with normal diffusion capacity for carbon monoxide suggests asthma regardless of age.
Chronic gastrointestinal disease (e.g. steatorrhea, celiac disease) can cause vitamin D deficiency due to malabsorption. Patients usually develop hypocalcemia, low phosphorus, and
Miscellaneous
& Metabolism
elevated parathyroid hormone. Patients can be asymptomatic or complain of bone pain or tenderness, muscle weakness or cramps, and gait abnormalities.
Primary hyperaldosteronism is characterized by hypertension, mild hypernatremia, metabolic alkalosis, and suppressed plasma renin activity. Hypokalemia is not always present at
Adrenal&Disorders
Metabolism
Hyperaldosteronism
baseline but can be severe with diuretic use. Clinically significant hypernatremia and edema are not seen due to aldosterone escape.
Preconception counseling and testing identifies couples at risk for autosomal recessive hemoglobinopathies that might affect their offspring. Patients with microcytic anemia and
normal iron studies require further testing with hemoglobin electrophoresis. Based on these results, patients may be offered genetic counseling, hematology consultation, and fetal
Oncology
Thalassemia diagnostic testing.
Patellofemoral pain syndrome is a common cause of chronic anterior knee pain in women. Diagnosis is based on clinical findings; symptoms are typically reproducible with isometric
Bone, Joint, And
& Sports
Soft
Patellofemoral
Tissue Injuries
Syndrome
quadriceps
And Infections
contraction (e.g. squatting). Treatment includes strengthening the quadriceps and hip abductors.
Development of atrioventricular block in a patient with infective endocarditis should raise suspicion for perivalvular abscess extending into the adjacent cardiac conduction tissues.
Valvular
Endocarditis Aortic valve endocarditis is associated with increased risk of periannular extension of endocarditis.
Vitamin D deficiency can lead to hypocalcemia with an elevated parathyroid hormone level. Causes include inadequate dietary intake of vitamin D, inadequate sunlight exposure, or
Miscellaneous
& Metabolism
Hypocalcemia malabsorptive disorders. Evaluation includes measuring the serum 25-hydroxyvitamin D level.
Fluoroquinolone use is associated with tendinopathy and tendon rupture (Achilles most common). Patients can develop tendon pain within 24 hours with a median of 8 days after
starting the drug. Patients should stop the drug at onset of symptoms, avoid exercise and/or use of the affected area, and seek medical care for symptom evaluation and changing to
Bone, Joint, And
& Sports
Soft
Achilles
Tissue
Tendinopathy
Injuriesa And
non-fluoroquinolone
Infections antibiotic.
Delayed sleep-wake phase disorder is a circadian rhythm disorder characterized by the inability to fall asleep at traditional bedtimes, resulting in sleep-onset insomnia and excessive
Disorders
Insomnia
Abuse
And Sleep Disorders
daytime sleepiness. Patients sleep normally if allowed to follow their internal circadian rhythm and sleep until late morning.
Poor sleep hygiene is a common cause of insomnia. Strategies to improve sleep hygiene include maintaining a regular sleep schedule and a quiet, dark, and comfortably cool
Disorders
Insomnia
Abuse
And Sleep Disorders
bedroom; avoiding late afternoon naps and exposure to electronic devices before bedtime; and avoiding nicotine, caffeine, alcohol, and heavy meals in the evening.
Acanthosis nigricans is characterized by symmetrical, hyperpigmented, velvety plaques in the axilla, groin, and neck. It is associated with insulin resistance states (e.g. diabetes
8821 Medicine Dermatology Miscellaneous Acanthosis Nigricans
mellitus, polycystic ovarian syndrome) in younger patients and gastrointestinal malignancy in older individuals.
Coarctation of the aorta is a potential cause of secondary hypertension in young adults. Patients should be initially evaluated with simultaneous palpation of the brachial and femoral
Congenital
System Heart Aortic
DiseaseCoarctationpulses to assess for brachial-femoral delay, and bilateral upper and lower extremity blood pressure measurement to assess for blood pressure differential.
Pleural effusion insulates sound and vibration originating within the lung parenchyma. Physical examination of patients with a pleural effusion typically shows decreased breath
8818 Medicine Pulmonary & Normal
Critical Care
Pulmonary
Pleural
Structure
Effusion
And Function
sounds, decreased tactile fremitus, and dullness to percussion over the effusion.
Postnasal drip, gastroesophageal reflux disease, and asthma account for > 90% of chronic cough in nonsmokers who do not have pulmonary disease. For patients with cough
following upper respiratory infection, initial empiric treatment includes oral first-generation antihistamine (e.g. chlorpheniramine) or combined antihistamine-decongestant (e.g.
Critical Care
Pulmonary
Chronic
And Cough
Other Systemic
brompheniramine
Disorders and pseudoephedrine).
Atrial fibrillation is most commonly caused by ectopic foci within the pulmonary veins. Atrial flutter commonly involves a re-entrant circuit around the tricuspid annulus. Atrioventricular
Cardiac
System
Arrhythmias
Atrial
AndFibrillation
Syncope nodal re-entry tachycardia results from a re-entrant circuit formed by 2 separate conducting pathways within the AV node.
Trimethoprim can cause hyperkalemia due to blockade of the epithelial sodium channel in the collecting tubule. Trimethoprim also competitively inhibits renal tubular creatinine
Fluid,
Systems
Electrolytes,
& Electrolytes
Hyperkalemia
And Acid-Base secretion and may cause an artificial increase in serum creatinine without affecting the glomerular filtration rate.
Hypovolemic hyponatremia occurs due to nonosmotic stimulation of antidiuretic hormone (ADH) secretion in response to hypovolemia, hypotension, and decreased renal perfusion
Fluid,
Systems
Electrolytes,
& Electrolytes
Hyponatremia
And Acid-Base (via angiotensin II). Restoration of blood volume shuts off nonosmotic stimulation of ADH and corrects the hyponatremia.
Changing the cutoff value of a test in a way that alters the proportion of true-positive and false-negative results will change the sensitivity. Likewise, a change in the test that modifies
the proportion of false-positive and true-negative results will change the specificity. Alterations in test sensitivity and specificity, as well as changes in disease prevalence, will affect
Epidemiology
Design AndSensitivity
Interpretation
And Specificity
the positive and negative predictive values.
A shift in the receiver operating characteristic curve upward for a given cutoff indicates increased sensitivity. A shift of the curve to the right for a given cutoff point indicates a
Epidemiology
Design AndColorectal
Interpretation
Polypsdecrease
And Cancer in specificity.
The number needed to treat (NNT) is defined as the number of people that need to receive a treatment to prevent 1 additional adverse event. It is calculated as the inverse of the
Epidemiology
Design AndNumber
Interpretation
Needed To
absolute
Treat risk reduction (ARR).
Epidemiology
InterpretationAndWhen
Use Of
comparing
Evidence-Based
the effects
Dataof (Including
a treatmentIndividualization,
on a composite Risk-Benefit
outcome, it isAnalysis,
importantSynthesis
to note any
Of Concepts
differences
With
between
Real Data)
the individual endpoints.
When the treatment regimen selected for a patient depends on the severity of the patient’s condition, a form of selection bias known as susceptibility bias (confounding by indication)
can result. To avoid selection bias in studies, patients are randomly assigned to treatments to minimize potential confounding variables. Many studies also perform an intention-to-
Epidemiology
Design AndBias
Interpretation treat analysis, which compares the initial randomized treatment groups (the original intention) regardless of the eventual treatment.
Hazard ratios are the ratio of an event rate occurring in the treatment group versus the non-treatment group. Ratios < 1 indicate that the treatment group had a lower event rate and
Epidemiology
Design AndStudy
Interpretation
Designs ratios > 1 indicate that the treatment group had a higher event rate.
Epidemiology
Factorial
Trials design studies involve randomization to different interventions with additional study of 2 or more variables.
Hazard ratios are the ratio of an event rate occurring in the treatment arm versus the non-treatment arm. Ratios less than 1 indicate that the treatment arm had a lower event rate
Epidemiology
whileTrials
ratios higher than one indicate the treatment arm had a higher rate of events.
Successful randomization in a clinical trial allows a study to eliminate bias in treatment assignments. An ideal randomization process minimizes selection bias, results in near-equal
Epidemiology
treatment
Trials and control group sizes, and achieves a low probability of confounding variables.
Hazard ratios are proportions that indicate the chance of an event occurring in the treatment group compared to the chance of the event occurring in the control group. When
Epidemiology
reviewing
Trials a drug advertisement, it is important to critically read all the presented information.
Patients with psychotic illness do not necessarily lack decision-making capacity. If a patient’s psychotic symptoms do not interfere with understanding or ability to communicate a
Medical
Ethics And
Decision
Jurisprudence
Making Capacity
choice regarding medical treatment, the patient has the right to refuse treatment, even if it would be lifesaving.
Infections are common in patients who undergo liver transplantation. Likely etiology can be discerned based on the length of time since transplantation. Most infections within the first
Transplant Medicine
Liver Abscess month are due to bacterial causes; infections during months 1-6 are usually caused by opportunistic pathogens (in the setting of high-dose immunosuppression).
Mild facial flushing and sensitivity due to rosacea can often be managed with simple behavioral measures (e.g. avoidance of sun exposure, hot/spicy foods, or alcohol). However,
patients with papulopustular rosacea (i.e. papules and pustules on the central face) typically require pharmacologic treatment. First-line options include topical metronidazole, azelaic
RosaceaAnd Bullous
acid,Diseases
and ivermectin.
Patients taking exogenous insulin for diabetes are vulnerable to exercise-induced hypoglycemia because insulin continues to be released from the injection site despite falling
Diabetes& Mellitus
Metabolism
Hypoglycemia glucose levels. Patients with chronic kidney disease are at increased risk due to delayed clearance of insulin by the kidneys.
& Sports
Systemic lupus erythematosus is a multisystem inflammatory disease that can present with central nervous system findings such as a generalized tonic-clonic seizure.
Renal vein thrombosis, which can present with hematuria, flank pain, and scrotal edema (in men), is an important complication of nephrotic syndrome. Nephrotic syndrome, and
Glomerular
Systems &Diseases,
Electrolytes
Glomerular
Nephrotic/Nephritic
Disorders
membranous
Syndrome
nephropathy in particular, is associated with the urinary loss of several endogenous anticoagulant proteins, resulting in hypercoagulability.
The initial therapy of patients with pulmonary edema and hypoxemia due to acute decompensated heart failure includes aggressive intravenous diuresis, oxygen supplementation,
Heart
System
Failure AndAcute
ShockHeart Failure
and possibly assisted ventilation.
Early septic shock is associated with a hyperdynamic cardiovascular state that occurs in response to peripheral vasodilation with capillary leak and intravascular hypovolemia. This
Critical Care
Care And Trauma
Sepsis Medicine leads to an increase in stroke volume, heart rate, and pulse pressure, which results in bounding peripheral pulses.
Acute intermittent porphyria is a disorder of the heme synthesis pathway that results in reduced activity of porphobilinogen deaminase. Patients experience discrete attacks of
abdominal pain, peripheral neuropathy with proximal muscle weakness, autonomic dysfunction, and neuropsychiatric manifestations. Urobilinogen levels are typically elevated, and
Acute Intermittent
Nerves Andelevated
Porphyria
Musclesurinary porphyrin levels confirm the diagnosis.
Salvage therapy is defined as treatment for a disease when standard therapy fails, such as radiation therapy for prostate-specific antigen recurrence after radical prostatectomy for
OncologyOf Oncology
Chemotherapy prostate cancer.
Amphotericin B is required in patients with HIV who develop progressive disseminated histoplasmosis (PDH). After 1-2 weeks of clinical improvement, patients are often transitioned
to oral itraconazole for > 1 year of maintenance therapy. Antiretroviral therapy should be initiated in all patients with HIV who develop PDH (usually 2 weeks after antifungal
Fungal Infections Histoplasmosis treatment).
Histoplasma capsulatum rarely causes illness in immunocompetent patients; however, in patients with advanced HIV (CD4 < 100/mm3), progressive disseminated histoplasmosis
Fungal Infections Histoplasmosis (PDH) is the norm (> 90%). Urine or serum Histoplasma antigen assay is a rapid, sensitive test for diagnosing PDH.
Pill esophagitis is due to a direct effect of certain medications on esophageal mucosa. Tetracyclines, potassium chloride, bisphosphonates, and nonsteroidal anti-inflammatory drugs
Gastroesophageal
& Nutrition Esophagitis
Disorders are common causes. Patients experience sudden-onset odynophagia and retrosternal pain that can sometimes cause difficulty swallowing.
Morton neuroma is a mechanically induced degenerative neuropathy that causes numbness, aching, and burning in the distal forefoot from the metatarsal heads to the third and
fourth toes. The pain is often reproduced by lateral compression of the metatarsal heads, and palpation of the third metatarsal interspace during compression may reveal crepitus
Spinal/Peripheral
& Sports
Morton
Nerve Disorders
Neuroma And
(Mulder
Backsign).
PainTreatment is conservative with metatarsal support or padded shoe inserts.
Both low-dose aspirin and statin therapy are indicated for secondary prevention of cardiovascular events in all patients with known atherosclerotic cardiovascular disease (ASCVD).
Peripheral artery disease is a manifestation of ASCVD, as is myocardial infarction, stable or unstable angina, coronary or other arterial revascularization, and stroke or transient
Aortic
System
And Peripheral
Peripheral
Artery Diseases
Vascular
ischemic
Disease
attack.
Patients with upper gastrointestinal bleeding who have a depressed level of consciousness and ongoing hematemesis should be intubated to protect the airway as a part of initial
Gastroesophageal
& Nutrition Gastrointestinal
Disorders Hemorrhage
stabilization and resuscitation. Prompt endoscopic treatment with ligation or sclerotherapy should then be performed to stop the bleeding.
Epidural hematoma is most common in young adults and occurs as a result of traumatic head injury, which leads to tearing of the middle meningeal artery and bleeding between the
dura mater and skull. CT scan of the head typically reveals a hyperdense biconvex lesion that does not cross suture lines. Symptomatic patients require emergent neurosurgical
Epidural Hematoma
hematoma evacuation.
Use dependence refers to enhanced pharmacologic effects of a drug during faster heart rates and is seen with class I (especially IC) and class IV (calcium channel blockers)
Cardiac
System
Arrhythmias
Atrial
AndFibrillation
Syncope antiarrhythmic agents. Class IC agents cause a progressive decrease in impulse conduction with faster heart rates, leading to an increase in the QRS complex duration.
Embolic strokes usually have sudden onset with maximal symptoms at the beginning. They occur more commonly in patients with a history of structural cardiac disease (e.g. atrial
Ischemic Stroke fibrillation, endocarditis). Patients with atrial fibrillation PLUS existing structural heart disease have an increased risk of cardioembolic strokes.
Intravenous adenosine is useful in the initial diagnosis and management of patients with narrow-QRS-complex tachycardia. It slows the sinus rate, increases atrioventricular (AV)
nodal conduction delay, or can cause a transient block in AV node conduction. Intravenous adenosine can be useful in identifying P waves to clarify diagnosis of atrial flutter or atrial
Cardiac
System
Arrhythmias
Supraventricular
tachycardia. It can also terminate paroxysmal supraventricular tachycardias by interrupting the AV nodal re-entry circuit.
TremorNerves AndFirst-line
Musclestreatment for essential tremor is propranolol, especially if the patient is also hypertensive. Alternate medications include primidone and topiramate.
Essential tremor is characterized by a fine tremor that is typically suppressed at rest and exacerbated at the end of goal-directed movements. It is most common in the upper
TremorNerves Andextremities
Muscles but is highly variable and may affect any part of the body. It is usually not associated with other neurologic symptoms.
Mitral regurgitation classically results in a holosystolic murmur heard best at the apex with radiation to the axilla. Common clinical features of MR include exertional dyspnea, fatigue,
Valvular
atrial fibrillation, and signs of heart failure.
Aortic regurgitation produces an early diastolic murmur and can be associated with several physical signs caused by a hyperdynamic pulse, including bounding or ‘water hammer’
Valvular
peripheral pulses.
The fourth heart sound (S4) is a low frequency sound heard at the end of diastole just before S1 that is commonly associated with left ventricular hypertrophy from prolonged
Heart
System
Failure AndChronic
Shock Heart Failure
hypertension.
The third heart sound (S3) is a low frequency diastolic sound heard just after S2 that is associated with left ventricular failure. Intravenous diuretics provide symptomatic benefits to
Heart
System
Failure AndAcute
ShockHeart Failure
patients with decompensated heart failure.
Crohn disease can involve any component of the gastrointestinal tract from the mouth to the anus, such as aphthous ulcers and perianal skin tags and fistulas. Biopsy typically
Intestinal
& Nutrition
And Colorectal
Inflammatory
Disorders
Bowel
reveals
Disease
focal ulcerations with transmural inflammation.
Macular degeneration is the most common cause of blindness in industrialized nations. Activities that require fine visual acuity are usually the first affected, and patients with this
Disorders Of The Macular
Eye AndDegeneration
Associated
condition
Structures
may report that straight grid lines appear curved.
Papilledema is caused by increased intracranial pressure and presents with transient vision loss lasting a few seconds with changes in head position. It requires urgent diagnostic
Headache Idiopathic Intracranial
evaluation
Hypertension
(e.g. ophthalmologic examination, neuroimaging, and/or lumbar puncture) as persistent papilledema can lead to vision loss.
Wolff-Parkinson-White (WPW) pattern refers to the characteristic ECG findings of a short PR interval (< 120 msec), slurred initial upstroke of the QRS complex (δ wave), and
Cardiac
System
Arrhythmias
Wolff-Parkinson-White
And Syncope widening
Syndrome
of the QRS complex with ST/T wave changes. WPW is due to an accessory pathway that bypasses the atrioventricular node and directly connects the atria to the ventricles.
Secondary bacterial pneumonia is the most common complication of influenza and should be suspected in any patient who develops worsening fever or pulmonary symptoms after
initial improvement. Streptococcus pneumoniae and Staphylococcus aureus are the most common etiologic organisms. S. aureus pneumonia tends to cause rapid-onset, severe,
Community Acquired
necrotizing
Pneumonia
pneumonia with high risk of death.
The pathogenesis of metabolic alkalosis requires generating excess bicarbonate (generation phase) and preventing excretion of excess bicarbonate (maintenance phase). Treatment
Fluid,
Systems
Electrolytes,
& Electrolytes
Metabolic
And Acid-Base
Alkalosis
involves addressing the underlying cause and promoting urinary bicarbonate excretion.
Pulmonary airway disease (e.g. chronic bronchitis, bronchogenic carcinoma, bronchiectasis) is the most common cause of hemoptysis in adults. Chronic bronchitis is defined as a
Critical Care
Infections
Hemoptysis chronic productive cough for > 3 months in 2 successive years, with cigarette smoking as the leading cause.
Interstitial lung disease (ILD) is a disease of progressive pulmonary fibrosis characterized by restrictive physiology on pulmonary function testing (decreased FEV1 and FVC with a
normal or an increased FEV1/FVC ratio). The diffusion capacity of the lung for carbon monoxide is decreased in ILD but remains normal in extrinsic causes of restrictive pulmonary
Critical Care
Pulmonary
Interstitial
Disease
physiology.
Disorders
Lead toxicity is usually due to lead exposure at work or home. Patients may present with nonspecific (e.g. fatigue, irritability, insomnia), neuropsychiatric (e.g. neurocognitive deficits,
Exposure
Lead Poisoning peripheral neuropathy), or gastrointestinal manifestations.
Hemophilias Hemophilia is an X-linked recessive bleeding disorder that can present with recurrent hemarthrosis and skeletal muscle hematoma after minor trauma.
Idiopathic thrombocytopenia purpura is usually diagnosed after excluding other possible causes of thrombocytopenia. These patients should be tested for hepatitis C and HIV as
4860 Medicine Hematology &Platelet
OncologyDisordersThrombocytopenia
thrombocytopenia may be the initial presentation of HIV infection (up to 5%-10% of patients). Treatment of the underlying infection can affect the platelet count.
Heparin-induced thrombocytopenia (HIT) is an immune-mediated process that causes thrombocytopenia several days after initiation of heparin therapy. HIT is highly thrombogenic
Heparin Induced Thrombocytopenia
and patients must be placed on alternate forms of anticoagulation due to the risk for arterial and venous clots.
Drug-induced acne is a common side effect of systemic glucocorticoids and is characterized by monomorphic papules without associated comedones, cysts, or nodules. Drug-
4812 Medicine Dermatology Miscellaneous Steroid Acne induced acne does not respond to typical acne treatment but improves rapidly on discontinuation of the offending agent.
An acute massive pulmonary embolism can present initially with syncope and shock. Right heart catheterization will show elevated right atrial and pulmonary artery pressures along
Critical Care
Vascular
Pulmonary
And Cardiopulmonary
Embolism
with normal
Disease
pulmonary capillary wedge pressure.
Pulsus paradoxus is defined as an exaggerated fall in systemic blood pressure > 10 mm Hg during inspiration. It is a frequent finding in cardiac tamponade but can also occur in
Miscellaneous
System Pulsus Paradoxusconditions without pericardial effusion such as severe asthma or chronic obstructive pulmonary disease.
Alveolar consolidation in pneumonia causes hypoxemia due to right-to-left intrapulmonary shunting. Positional changes that make the consolidation more gravity dependent worsen
Critical Care
Infections
Acute Respiratoryventilation/perfusion
Failure mismatch, increase intrapulmonary shunting, and lead to worsened hypoxemia.
Hypokalemia may be caused by increased intracellular entry of potassium (e.g. with insulin, β-adrenergic agents, hematopoiesis), gastrointestinal losses, and renal potassium
Fluid,
Systems
Electrolytes,
& Electrolytes
Hypokalemia
And Acid-Base wasting (e.g. hyperaldosteronism, diuretics).
Critical Care
Infections
Pleural Effusion Empyemas are exudative effusions with a low glucose concentration due to the high metabolic activity of leukocytes and bacteria within the pleural fluid.
Hepatorenal syndrome is characterized by a decrease in glomerular filtration in the absence of other causes of renal dysfunction, minimal hematuria, and lack of improvement with
Acute
Systems
Kidney
& Electrolytes
Injury
Hepatorenal Syndrome
volume resuscitation. It occurs due to splanchnic arterial dilation, decreased vascular resistance, and local renal vasoconstriction with decreased perfusion.
Initial hematuria suggests urethral damage, terminal hematuria indicates bladder or prostatic damage, and total hematuria reflects damage anywhere in the urinary tract. Clots are
Neoplasms
Systems &And
Electrolytes
Trauma
Hematuria
Of The Kidneys
not usually
And Urinary
seen with
Tract
renal causes of hematuria (e.g. glomerular diseases).
Diabetic nephropathy is characterized by glomerular hyperfiltration, basement membrane thickening, and mesangial nodules. Persistent proteinuria in a patient with long-standing
Glomerular
Systems &Diseases,
Electrolytes
Diabetic
Nephrotic/Nephritic
Nephropathy
diabetesSyndrome
and poorly controlled hypertension should raise suspicion for this diagnosis.
Nephrolithiasis,
Hematuria,
Renal Calculi
And Urinary
Obstructive
Tract Obstruction
uropathy presents with flank pain, low-volume voids with or without occasional high-volume voids, and, if bilateral, renal dysfunction.
In evaluating ascites, a serum-to-ascites albumin gradient (SAAG) > 1.1 g/dL indicates portal hypertensive etiologies (e.g. cardiac ascites, cirrhosis) while a SAAG < 1.1 suggests
Hepatic
& Nutrition
DisordersAscites non-portal hypertensive etiologies (e.g. malignancy, pancreatitis, nephrotic syndrome, tuberculosis).
Aspirin and β blockers are common medications that can trigger bronchoconstriction in patients with asthma. Short-term use of cardioselective β blockers is usually safe in patients
Cardiovascular
System Drugs
Asthma with mild-to-moderate asthma, but all β blockers should be used with caution.
The primary anti-ischemic and antianginal effects of nitrates are due to systemic vasodilation rather than coronary vasodilation. Systemic venodilation lowers preload and left
Coronary
SystemHeart Disease
ventricular end-diastolic volume, reducing wall stress and myocardial oxygen demand.
Acute mitral regurgitation (MR) can occur due to papillary muscle displacement in patients with acute myocardial infarction. It leads to abrupt and excessive volume overload, causing
elevated left atrial and ventricular filling pressures and acute pulmonary edema. Unlike chronic MR, acute MR does not cause any significant change in left atrial or ventricular size
Valvular
and/or compliance.
Fluid,
Systems
Electrolytes,
& Electrolytes
Respiratory
And Acid-Base
Alkalosis
The kidney compensates for respiratory alkalosis by preferentially excreting bicarbonate in the urine. The result is an alkalinized urine (increased urine pH).
Anticoagulants Warfarin is an anticoagulant agent that functions by inhibiting the synthesis of vitamin K-dependent factors II, VII, IX, and X, protein C, and protein S.
First-generation H1-antihistamines have potent anticholinergic effects and may cause eye and oropharyngeal dryness as well as urinary retention. Due to a high prevalence of benign
Urinary
Systems
& Electrolytes
Urinary Retention
GUprostatic
Infectionhyperplasia, elderly men are at increased risk of urinary retention due to anticholinergic activity.
Toxicodendron plants (poison ivy/oak/sumac) are a frequent cause of allergic contact dermatitis. The erythematous, vesicular rash involves exposed skin and can form linear streaks
Contact Dermatitis
And Bullous
where
Diseases
skin has brushed against the plant leaves.
All patients with acute exacerbation of chronic obstructive pulmonary disease should receive inhaled bronchodilators (β2-agonists and anticholinergics) and systemic glucocorticoids.
COPD Lung Disease
In addition, supplemental oxygen, antibiotics, and ventilatory support should be administered when indicated.
Progressively decreasing baroreceptor sensitivity and defects in the myocardial response to this reflex are the main reasons for the increased incidence of orthostatic hypotension in
Miscellaneous
System Aging the elderly.
Pulseless electrical activity (PEA) or asystole should be managed with uninterrupted cardiopulmonary resuscitation along with vasopressor therapy to maintain adequate cerebral
and coronary perfusion. Potentially reversible causes of PEA should also be investigated. Defibrillation or synchronized cardioversion has no role in the management of these
Coronary
SystemHeart Disease
Cardiac Arrest patients.
Hyperparathyroidism is a cause of secondary hypertension and should be suspected in patients who have hypertension associated with hypercalcemia, renal stones, abdominal pain,
Hypertension
or neuropsychiatric symptoms. Other cardiovascular manifestations of hyperparathyroidism include left ventricular hypertrophy, arrhythmias, and vascular and valvular calcification.
Cushing syndrome is characterized by hypertension, hyperglycemia, and weight gain. Common causes include excess glucocorticoid intake, ACTH-producing pituitary adenoma, and
Adrenal&Disorders
Metabolism
Cushing Syndrome
ectopic ACTH production.
Ascending aortic dissection can propagate proximally from the site of intimal tear to involve the aortic valve, causing acute aortic regurgitation and heart failure. Cardiac tamponade is
Aortic
System
And Peripheral
Aortic
Artery
Dissection
Diseases
another potential complication of ascending aortic dissection that can be differentiated from acute aortic regurgitation by an absence of pulmonary edema.
Despite advances in therapy, the overall survival rate for patients with sudden cardiac arrest remains quite poor. The most important factors in improving patient survival are prompt
effective resuscitation with adequate bystander cardiopulmonary resuscitation, prompt rhythm analysis, and defibrillation in patients found to be in a shockable rhythm (e.g.
Cardiac
System
Arrhythmias
Ventricular
And Syncope
Fibrillation
ventricular fibrillation).
Supplemental oxygen in patients with advanced chronic obstructive pulmonary disease can worsen hypercapnia due to a combination of increased dead space perfusion causing
COPD Lung Disease
ventilation-perfusion mismatch, decreased affinity of oxyhemoglobin for CO2, and reduced alveolar ventilation. The goal oxyhemoglobin saturation in these patients is 90%-93%.
Pneumonia causes hypoxemia due to right-to-left intrapulmonary shunting, an extreme form of ventilation/perfusion mismatch. Depending on how much of the lungs are affected by
Critical Care
Infections
Community Acquired
intrapulmonary
Pneumonia shunting, the resulting hypoxemia may be difficult to correct with an increase in the fraction of inspired oxygen.
Patients with massive pulmonary embolism usually present with signs of low arterial perfusion (e.g. hypotension, syncope) and acute dyspnea, pleuritic chest pain, and tachycardia.
Critical Care
Vascular
Pulmonary
And Cardiopulmonary
Embolism
The thrombus
Diseaseincreases pulmonary vascular resistance and right ventricular pressure, causing right ventricular hypokinesis and dilation and hypotension.
Peak airway pressure is the sum of airway resistance and plateau pressure. The plateau pressure is the sum of the elastic pressure and positive end-expiratory pressure (PEEP) and
Critical Care
Care And Trauma
Mechanical
Medicine
Ventilation
is calculated by performing the end-inspiratory hold maneuver. PEEP is calculated with the end-expiratory hold maneuver.
Cardiac
System
Arrhythmias
Supraventricular
Patients with persistent tachyarrhythmia (narrow- or wide-complex) causing hemodynamic instability should be managed with immediate synchronized cardioversion.
The symptoms of intracranial hypertension include headache (worse at night), nausea/vomiting, and mental status changes. Papilledema and focal neurologic deficits may be seen
Headache Increased Intracranial
on examination.
Pressure Cushing reflex (hypertension, bradycardia, respiratory depression) is a worrisome finding suggestive of brainstem compression.
Patients with heart failure with preserved ejection fraction, often due to hypertensive heart disease, have typical manifestations of congestive heart failure with a normal left
ventricular (LV) ejection fraction and objective evidence of diastolic dysfunction. Impaired myocardial relaxation and/or increased LV wall stiffness leads to an increase in LV end-
Heart
System
Failure AndChronic
Shock Heart Failure
diastolic pressure.
Patients with severe asthma exacerbation should receive inhaled short-acting β2-agonists, inhaled ipratropium, and systemic corticosteroids. Elevated or even normal partial
Asthma Lung Disease
pressure of carbon dioxide suggests failure of medical therapy and impending respiratory collapse. These patients require endotracheal intubation and mechanical ventilation.
Heat stroke is characterized by core temperature > 40 C (104 F) with CNS dysfunction (e.g. altered mental status). It occurs most commonly in those exposed to hot/humid
Miscellaneous Heat Related Illness
environments while performing extreme activities. Complications include rhabdomyolysis, disseminated intravascular coagulation, and end-organ dysfunction.
In patients with suspected stroke, noncontrast CT scan of the head is the initial diagnostic test of choice as it is critical for guiding further management. Hemorrhagic strokes appear
immediately on noncontrast CT as white hyperdense regions in the brain parenchyma, whereas many ischemic strokes do not become evident (hypodense) until > 24 hours after the
Hemorrhagic Stroke
event.
Wernicke encephalopathy is due to thiamine (vitamin B1) deficiency and is most commonly seen in malnourished patients with underlying alcoholism. Features include
Miscellaneous Delirium encephalopathy, ocular dysfunction, and gait ataxia. Patients should be treated empirically with thiamine prior to or along with glucose administration.
Gastroesophageal reflux disease (GERD) predisposes to Barrett esophagus, erosive esophagitis, and esophageal (peptic) stricture formation. Peptic strictures cause symmetric and
circumferential narrowing of the involved esophagus with dysphagia for solids but typically no weight loss. Other causes of peptic strictures include radiation, systemic sclerosis, and
Gastroesophageal
& Nutrition Gastroesophageal
Disorders caustic
Refluxingestions.
Disease
Herpes zoster is a painful reactivation of the varicella zoster virus that causes a vesicular rash in a dermatomal distribution. Acyclovir and other antivirals may be used to decrease
Herpes
Infections
Zoster the duration of disease and the incidence of postherpetic neuralgia.
Neoplastic epidural spinal cord compression presents with worsening focal back pain, bilateral lower-extremity weakness, sensory loss, and gait ataxia. Bowel/bladder disturbances
Spinal Cord Compression
are late findings. In the acute phase of spinal cord injury, patients can develop spinal shock with absence of reflexes and flaccid paraplegia as a result.
Pulmonary emboli classically present with sudden-onset pleuritic chest pain, cough, and dyspnea. Hemoptysis can occur as a result of pulmonary infarction. Chest CT scan showing
Critical Care
Vascular
Pulmonary
And Cardiopulmonary
Embolism
a wedge-shaped
Disease infarction is virtually pathognomonic for pulmonary embolism.
Patients with Hodgkin lymphoma who are treated with chemotherapy and radiation are at high risk for secondary malignancy later in life (generally > 10 years after therapy). Solid
Critical And
Lung Cancer tumors
Massesin the lung (especially in smokers), breast, and gastrointestinal system (e.g. colorectal, esophageal, gastric tumors) are most common.
Restless legs syndrome is characterized by an urge to move the legs and is accompanied by dysesthesias that are worsened by inactivity and improved with movement. Symptoms
are worse in the evening/night. Treatment includes iron supplementation for iron deficiency, conservative measures, and pharmacotherapy with dopamine agonists (e.g. pramipexole)
Restless
Nerves
Legs And
Syndrome
orMuscles
α-2-δ calcium channel ligands (e.g. gabapentin).
A cohort study design is best for determining the incidence of a disease. Comparing the incidence of the disease in 2 populations, with and without a given risk factor, allows for
Epidemiology
Design AndRisk,
Interpretation
Rate, Prevalence
calculation
And Incidence
of relative risk.
Molluscum contagiosum is characterized by firm, flesh-colored, dome-shaped, umbilicated papules. Patients with impaired cellular immunity (e.g. HIV disease) are at risk for more
Molluscum
Infections
Contagiosum
severe, widespread disease.
Rhabdomyolysis can result from prolonged immobilization with ischemic compression of skeletal muscle, a scenario that may occur following ingestion of a CNS depressant (e.g.
opioids). Affected patients commonly develop acute kidney injury due to decreased renal perfusion and direct renal tubular toxicity of heme pigment, which is contained in the
Nephrolithiasis,
Hematuria,
Rhabdomyolysis
And Urinary
myoglobin
Tract Obstruction
protein released from lysed skeletal muscle cells.
Renovascular hypertension is the most common and correctable cause of secondary hypertension and should be suspected in patients with diffuse atherosclerosis and resistant
Hypertension
System Renal Artery Stenosis
hypertension. The presence of a systolic-diastolic abdominal bruit has high specificity for the presence of renal artery stenosis.
The renin-angiotensin-aldosterone system is integrally involved in the pathophysiology and treatment of hypertension. Numerous antihypertensives, including angiotensin receptor
Cardiovascular
System Drugs
ACE Inhibitors blockers, angiotensin-converting enzyme inhibitors, and direct renin inhibitors, affect this system.
Most patients with autosomal dominant polycystic kidney disease are asymptomatic until age 30-40, when renal cysts become large and numerous. Bilateral upper abdominal
Hypertension
System Polycystic Kidneymasses
Diseaseare typically palpable on physical examination, and hypertension is an early disease manifestation that typically precedes a progressive decline in renal function.
An abnormal fourth heart sound (atrial gallop) can often be heard during the acute phase of myocardial infarction due to left ventricular stiffening and dysfunction induced by
Coronary
SystemHeart Disease
myocardial ischemia.
Acidosis accompanied by hypercarbia and a normal or elevated serum bicarbonate is diagnostic of a respiratory acidosis. Hypoventilation is a major cause of respiratory acidosis and
Critical Care
Care And Trauma
Respiratory
Medicine
Acidosis
may occur in the postictal state.
Atrial fibrillation (AF) presents with electrocardiogram findings such as irregularly irregular rhythm, varying R-R intervals, and no clearly discernible P waves. Patients with new-onset
Cardiac
System
Arrhythmias
Atrial
AndFibrillation
Syncope AF should have TSH and free T4 levels measured to screen for occult hyperthyroidism as an underlying cause.
Syncope in a young patient with a crescendo-decrescendo murmur at the lower left sternal border is most likely due to hypertrophic obstructive cardiomyopathy (HOCM). Syncope in
Myopericardial
System Diseases
Hypertrophic Cardiomyopathy
HOCM is often multifactorial and can be due to outflow obstruction, arrhythmia, ischemia, and a ventricular baroreceptor response that inappropriately causes vasodilation.
Anaphylactic transfusion reaction is characterized by a rapid onset (seconds to minutes) of respiratory distress and hypotension, which quickly progresses to respiratory failure and
4672 Medicine Hematology &Transfusion
Oncology Medicine
Blood Transfusionshock. Acute management includes immediate transfusion cessation and administration of epinephrine. IgA-deficient patients are at increased risk.
Miliary tuberculosis typically presents with subacute or chronic fevers, weight loss, fatigue, and pulmonary symptoms. Chest x-ray classically reveals a diffuse reticulonodular pattern
Tuberculosis (millet seed). The most common behavioral risk factor for tuberculosis in the United States is substance abuse.
Infective endocarditis can cause acute, subacute, or chronic symptoms. Manifestations are often nonspecific (e.g. fever, fatigue, myalgia, arthralgia), cardiac (e.g. dyspnea),
Endocarditis immunologic (e.g. glomerulonephritis, Osler node), and embolic. Laboratory studies usually show normocytic anemia and dramatic elevations in erythrocyte sedimentation rate.
Inhaled antimuscarinic agents such as ipratropium are the mainstay of symptom management in COPD. These anticholinergic medications may be combined with short-acting β-
COPD Lung Disease
adrenergic agonists for greater symptom relief.
Decreased alveolar elasticity in chronic obstructive pulmonary disease causes lung hyperinflation, which results in increased total lung capacity, functional residual capacity, and
COPD Lung Disease
residual volume, as well as diaphragmatic flattening. The flattened diaphragm has more difficulty contracting to expand the thoracic cavity, resulting in increased work of breathing.
COPD Lung Disease
The body compensates for chronic hypercapnia by increasing renal bicarbonate retention and creating a compensatory metabolic alkalosis.
Patients with combined obesity hypoventilation syndrome and obstructive sleep apnea can develop chronic hypoxia and hypercapnia (with a compensatory metabolic alkalosis),
Lung Disease
secondary
Syndrome
erythrocytosis, pulmonary hypertension, and cor pulmonale.
In Mobitz type I atrioventricular block, there is progressive prolongation of PR interval leading to a non-conducted P wave and a ‘dropped’ QRS complex. The PR interval
Cardiac
System
Arrhythmias
Heart
And
Block
Syncope prolongation is best appreciated by measuring PR intervals just before and after the ‘dropped’ QRS complexes.
Paget disease of bone is characterized by osteoclast dysfunction with a focal increase in bone turnover. Most patients are asymptomatic, but symptoms may include skeletal
Sports
Paget Disease Ofdeformities,
Bone bone pain, and fractures. Involvement of cranial bones may lead to headaches and hearing loss.
Thrombolytic therapy (e.g. intravenous alteplase) improves neurologic outcomes in patients with acute ischemic stroke when given within 4.5 hours of symptom onset. Before
thrombolytics are administered, a noncontrast head CT should be performed to rule out hemorrhagic stroke, and the patient should be screened for other contraindications to
Ischemic Stroke therapy.
Secondary syphilis is characterized by systemic symptoms (fever, malaise), widespread lymphadenopathy (particularly epitrochlear), and a diffuse maculopapular rash that begins on
the trunk and extends to the extremities, including the palms and soles. Diagnosis is made with serology (using both a treponemal and a nontreponemal test). One intramuscular
dose of penicillin G benzathine is the standard treatment.
Chronic hepatitis C virus (HCV) infection is associated with many extrahepatic manifestations, including fatigue, arthralgias, and porphyria cutanea tarda (PCT). PCT presents with
4654 Medicine Dermatology Miscellaneous Hepatitis C fragile, photosensitive skin that develops vesicles and bullae with trauma or sun exposure. All patients with PCT should be screened for HCV.
Normal pressure hydrocephalus is characterized by gait abnormalities, cognitive impairment, and urinary incontinence that often presents as urgency in early disease. It is thought to
Neurodegenerative
Normal
Disorders
Pressure
And Dementias
result
Hydrocephalus
from decreased CSF absorption with increased ventricular compliance, allowing for ventricular enlargement without chronically increasing intracranial pressure.
Costochondritis presents with tenderness of > 1 costochondral or sternochondral joints and is the most common cause of musculoskeletal chest pain. Patients typically have sharp,
Miscellaneous
System Costochondritis localized chest pain that is reproducible with palpation. Treatment involves reassurance and symptomatic pain management.
Anticoagulation agents, such as non-vitamin K antagonist oral anticoagulants (e.g. apixaban) and warfarin, should be used to reduce the risk of systemic thromboembolism in
Cardiac
System
Arrhythmias
Acute
AndLimb
Syncope
Ischemia
patients with atrial fibrillation and a high risk of thromboembolic events (i.e. CHA2DS2-VASc score > 2).
Ischemic hepatic injury occurs in the setting of hypotension and manifests as acute, massive increases in the transaminases with milder associated increases in the total bilirubin and
Hepatic
& Nutrition
DisordersIschemic Hepatitisalkaline phosphatase. In patients who survive the inciting condition (e.g. hypotension), liver enzymes typically return to normal within a few weeks.
Oral direct factor Xa inhibitors (e.g. rivaroxaban, apixaban) have similar efficacy to warfarin in the treatment of acute venous thromboembolism and do not increase the risk of
bleeding complications. These drugs do not require laboratory monitoring or overlap therapy with heparin and are becoming preferred agents for the treatment of acute venous
Venous Thromboembolism
thromboembolism.
Patients with hypertension should stop smoking, get regular aerobic exercises, avoid excessive alcohol intake, and follow a dietary program proven to lower blood pressure. In
addition, patients who are overweight or obese should be advised to lose weight. Obesity is the single greatest contributing lifestyle risk factor for hypertension, and weight loss is the
Hypertension
most effective non-pharmacologic intervention for lowering blood pressure.
COPD is characterized by progressive expiratory airflow limitation which causes air trapping, decreased VC and increased total lung capacity. FEV1 is disproportionately decreased
COPD Lung Disease
as compared to VC.
Delirium is an acute confusional state characterized by a reduced or fluctuating level of consciousness, along with inability to sustain attention, anxiety, agitation, and/or
hallucinations. Common precipitating causes of delirium include infections (e.g. urinary tract infection), polypharmacy, medication side effects, volume depletion, and electrolyte or
Miscellaneous Delirium metabolic disturbances.
Pulmonary pathology may lead to the syndrome of inappropriate antidiuretic hormone secretion (SIADH), which is characterized by hypotonic hyponatremia in a euvolemic patient.
Critical And
SIADH Infusion
Massesof normal saline may worsen hyponatremia in patients with SIADH.
Acute exacerbations of multiple sclerosis should be treated with high-dose intravenous glucocorticoids. Plasma exchange is reserved for patients who do not respond to high-dose
Multiple Sclerosisglucocorticoids.
Cirrhosis can cause hypogonadism due to primary gonadal injury or hypothalamic-pituitary dysfunction. Cirrhosis is also associated with elevated circulating levels of estradiol due to
Reproductive
& Metabolism
Endocrinology
increased conversion from androgens.
Patients with asplenia are at risk for fulminant infection with encapsulated bacteria (e.g. Streptococcus pneumoniae, Haemophilus influenzae) due to deficits in antibody response
Oncology
Splenectomy and antibody-mediated phagocytosis/complement activation.
Right mainstem bronchus intubation is a relatively common complication of endotracheal intubation. It causes asymmetric chest expansion during inspiration and markedly
decreased or absent breath sounds on the left side on auscultation. Repositioning the endotracheal tube by pulling back slightly will move the tip between the carina and vocal cords
Critical Care
Care And Trauma
Acute Respiratory
Medicine and
Failure
solve the problem.
Parapneumonic effusions result from an inflammatory increase in membrane permeability and are exudative by Light criteria. They should be differentiated as uncomplicated or
complicated. Uncomplicated parapneumonic effusions involve increased flow of sterile exudate into the pleural space and demonstrate pH and glucose levels near those of serum,
Critical Care
Infections
Parapneumonic Effusion
as well as
& Empyema
relatively low leukocyte and lactate dehydrogenase levels.
Upper Airway
Lung
Obstruction
Disease
A fixed upper-airway obstruction will decrease the airflow rate during inspiration and expiration, flattening both the top and bottom of the flow-volume loop.
For anticoagulation, unfractionated heparin is preferred over low-molecular-weight heparin, fondaparinux, and rivaroxaban in patients with severe renal insufficiency (estimated
Critical Care
Vascular
Pulmonary
And Cardiopulmonary
Embolism
glomerular
Disease
filtration rate < 30 mL/min/1.73 m2) as reduced renal clearance increases anti-Xa activity levels and bleeding risk.
A normal D-dimer result is useful in excluding pulmonary venous thromboembolism (VTE) in patients with unlikely pretest probability. However, a normal D-dimer result is not useful
Critical Care
Vascular
Pulmonary
And Cardiopulmonary
Embolism
in patients
Disease
with likely pretest probability. An elevated D-dimer result in any patient is not diagnostic of VTE and must be followed by more specific studies.
Management of chronic liver disease involves both treatment of the underlying cause and strategies to prevent further liver damage (e.g. alcohol avoidance, hepatitis A and hepatitis
Hepatic
& Nutrition
DisordersHepatitis C B vaccination).
Treatment of hepatic encephalopathy involves identifying the underlying precipitant and lowering serum ammonia. Nonabsorbable disaccharides (e.g. lactulose, lactitol) are preferred
Hepatic
& Nutrition
DisordersHepatic Encephalopathy
for lowering serum ammonia.
Peptic ulcer disease (PUD) may present with epigastric pain, nausea, and/or early satiety in association with food. Symptoms of duodenal ulcer classically occur in the absence of a
food buffer (e.g. 2-5 hours after meals, on an empty stomach, or at night). Melena is a manifestation of upper gastrointestinal bleeding, with PUD being one of the most common
Gastroesophageal
& Nutrition Peptic
Disorders
Ulcer Disease
causes.
Toxic-metabolic and infectious etiologies are the most common causes of delirium in a hospitalized patient. Patients with dementia have an increased risk of developing agitated
delirium in the hospital. Typical and atypical antipsychotics are useful for treating acute agitation in elderly patients with dementia. Benzodiazepines are typically not recommended in
Miscellaneous Delirium this setting.
Alzheimer disease, the most common type of dementia in the United States, is characterized by early and prominent memory impairment. The differential includes dementia with
Neurodegenerative
Alzheimer
Disorders
Disease
And Dementias
Lewy bodies, frontotemporal dementia, and vascular dementia, as well as nondementing syndromes such as normal pressure hydrocephalus.
Neurodegenerative
Dementia
Disorders
With
AndLewy
Dementias
Dementia
Bodieswith Lewy bodies causes cognitive fluctuations, visual hallucinations, and parkinsonism. Cognitive symptoms may precede, or appear along with, parkinsonian features.
Cerebellar dysfunction is common among chronic alcohol abusers. Symptoms include gait instability, truncal ataxia, difficulty with rapid alternating movements, hypotonia, and
Neurodegenerative
Cerebellar
DisordersDegeneration
And Dementias
intention tremor.
Mild persistent asthma is characterized by symptoms > 2 days per week or 3-4 nightly awakenings per month. Patients with mild persistent asthma require a daily controller
Asthma Lung Disease
medication (e.g. inhaled corticosteroid) in addition to an as-needed short-acting β2-agonist (e.g. albuterol).
Heparin-induced thrombocytopenia should be suspected in patients receiving heparin anticoagulation who have thrombocytopenia, thrombosis (arterial or venous), or a > 50% drop
in the platelet count from baseline 5-10 days after the initiation of treatment.
Most cases of active tuberculosis in the United States occur in foreign-born individuals who have recently emigrated from endemic areas (especially Mexico, the Philippines, China,
Critical Care
Infections
Tuberculosis Vietnam, India, Dominican Republic, and Haiti), with the highest rates for those arriving in the last 5 years.
Sudden-onset dyspnea, chest pain, and tachycardia with no consolidation on chest imaging suggests a pulmonary embolism (PE). PE can cause pleural effusions (typically small,
Critical Care
Vascular
Pleural
And Cardiopulmonary
Effusion exudative,
Disease
and bloody).
Toxoplasmosis is a common opportunistic infection in patients with AIDS who have CD4 counts < 100/mm3. Primary prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMX)
prevents active infection; TMP-SMX is generally given to patients with AIDS who have CD4 counts < 100/mm3 and positive Toxoplasma gondii IgG serology. TMP-SMX is also
Parasitic And Helminthic
Toxoplasmosis
Infections effective in preventing Pneumocystis pneumonia.
Acute pancreatitis complicated by hypotension is thought to arise from intravascular volume loss secondary to local and systemic vascular endothelial injury. This causes
Pancreatic
& Nutrition
Disorders
Acute Pancreatitisvasodilation, increased vascular permeability, and plasma leak into the retroperitoneum, resulting in systemic hypotension.
Ascites presents with increased abdominal girth and findings of shifting dullness and fluid wave. It is most commonly caused by cirrhosis due to chronic alcohol misuse, nonalcoholic
steatohepatitis, or hepatitis C. In the setting of cirrhosis, stigmata of chronic liver disease (e.g. spider angiomas, palmar erythema, asterixis, jaundice) and hepatosplenomegaly are
Hepatic
& Nutrition
DisordersAscites also common.
Evaluation of a solitary pulmonary nodule detected on chest x-ray includes comparison with old imaging studies, if available, followed usually by chest computed tomography. The
Critical And
Lung Nodule decision
Masses to observe, biopsy, or surgically resect the nodule is based on its size and characteristics as well as the patient’s age and smoking history.
Irritable bowel syndrome is a functional disorder of the gastrointestinal tract characterized by chronic abdominal pain with diarrhea and/or constipation. Patients with symptoms
Miscellaneous
& Nutrition Irritable Bowel Syndrome
consistent with the ROME III criteria and no alarm features do not require extensive workup for diagnosis.
Decompensated heart failure involves the activation of compensatory mechanisms in the form of the sympathetic nervous system and renin-angiotensin-aldosterone system. These
systems stimulate vasoconstriction and sodium retention to maintain organ and tissue perfusion in the setting of reduced cardiac output. The compensatory mechanisms are
Heart
System
Failure AndAcute
ShockHeart Failure
ultimately maladaptive as they further decrease cardiac output and perpetuate a downward spiral of clinical decompensation.
Cor pulmonale is impaired function of the right ventricle due to pulmonary hypertension that usually occurs due to chronic lung disease. Signs of right ventricular failure include:
Elevated jugular venous pressure; Right ventricular 3rd heart sound; Tricuspid regurgitation murmur; Hepatomegaly with pulsatile liver; Lower-extremity edema, ascites, and/or
Myopericardial
System Diseases
Cor Pulmonale pleural effusions. Echocardiogram will show signs of increased right heart pressures, and right heart catheterization will show pulmonary systolic pressure > 25 mm Hg.
Chronic venous insufficiency is a common cause of lower extremity edema that may be accompanied by varicose veins, skin discoloration, and medial skin ulceration. Initial
Miscellaneous
System Chronic Venous Insufficiency
treatment includes conservative measures with leg elevation, exercise, and compression therapy.
Nephritic glomerulonephritis usually presents with urinary sediment containing red blood cells, occasional white blood cells, and red cell or mixed cellular casts. Edema in these
Glomerular
Systems &Diseases,
Electrolytes
Glomerular
Nephrotic/Nephritic
Disorders
patientsSyndrome
is due primarily to decreased glomerular filtration rate and retention of sodium and water by the kidneys.
& Sports
Gonococcal Infection
Disseminated gonococcal infection often presents with a triad of polyarthralgias, tenosynovitis, and vesiculopustular skin lesions.
In hyperthyroidism, increased radioactive iodine uptake (RAIU) suggests de novo thyroid hormone synthesis, whereas decreased RAIU suggests release of preformed hormone or
Metabolism exogenous hormone intake. Thyrotoxicosis due to exogenous thyroid hormone is characterized by low serum thyroglobulin levels.
Osteoarthritis causes chronic joint pain and is most common with advanced age, obesity, and prior joint injury. Examination findings include bony enlargement and tenderness,
& Sports
Osteoarthritis crepitus with movement, and painful or decreased range of motion.
Secondary amyloidosis is a complication of a chronic inflammatory condition (e.g. chronic infections, inflammatory bowel disease, rheumatoid arthritis) resulting in extracellular tissue
deposition of fibrils into tissues and organs. Patients can develop multi-organ dysfunction (e.g. kidneys, liver, gastrointestinal tract). Treatment usually involves treating the underlying
& Sports
Amyloidosis
And Vasculitides
inflammatory disease.
Pseudogout is an acute inflammatory arthritis caused by calcium pyrophosphate crystals. It often occurs in the setting of surgery or medical illness. Pseudogout is diagnosed with
& Sports
Pseudogout synovial fluid showing rhomboid-shaped, positively birefringent crystals and radiographic evidence of chondrocalcinosis (calcified articular cartilage).
Psoriatic arthritis occurs in 5%-30% of patients with psoriasis. The classic presentation involves the distal interphalangeal joints. Morning stiffness, deformity, dactylitis (‘sausage
digit’), and nail involvement are common. Current treatment options for psoriatic arthritis include nonsteroidal anti-inflammatory agents, methotrexate, and anti-tumor necrosis factor
& Sports
Psoriasis
And Vasculitides
agents.
Fibromyalgia presents commonly in young to middle-aged women with widespread pain, fatigue, and cognitive/mood disturbances. Diagnosis is made clinically using the widespread
Miscellaneous & Sports
Fibromyalgia pain index and symptom severity score, which emphasize cognitive problems, fatigue, and severity of somatic symptoms.
The self-limited arthritis of parvovirus B19 may resemble early rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE), and may be associated with a weakly positive
rheumatoid factor or antinuclear antibody titer. However, RA and SLE are significantly less common, typically produce more obvious synovitis, and usually follow a chronic, protracted
& Sports
Parvovirus course.
Patients with long-standing ankylosing spondylitis can develop bone loss due to increased osteoclast activity in the setting of chronic inflammation. In addition, spinal rigidity in these
& Sports
patients can increase the risk of vertebral fracture, which often results from minimal trauma.
Reactive arthritis is a seronegative spondyloarthropathy resulting from enteric or genitourinary infection. Findings in reactive arthritis may include urethritis, conjunctivitis,
& Sports
Reactive Arthritis mucocutaneous lesions, enthesitis and asymmetric oligoarthritis. Not all extra-articular manifestations need be present to suspect the diagnosis. NSAIDs are the first line therapy.
Enthesitis is characterized by inflammation and pain at sites of tendon and ligament attachment to bone. It is a common finding in ankylosing spondylitis and other
& Sports
spondyloarthropathies.
Patients with ankylosing spondylitis can develop restrictive lung disease due to diminished chest wall and spinal mobility. Pulmonary function tests show a mildly restrictive pattern
Critical Care Ankylosing Spondylitis
with reduced vital capacity and total lung capacity but normal FEV1/FVC.
Rheumatoid arthritis is characterized by synovial inflammation and progressive joint damage. It most commonly affects the peripheral joints, especially the metacarpophalangeal and
proximal interphalangeal joints of the fingers, metatarsophalangeal joints of the toes, and the wrists. Involvement of the cervical spine can lead to atlantoaxial subluxation and spinal
& Sports
Rheumatoid
And Vasculitides
Arthritis
cord compression.
Methotrexate is a disease-modifying antirheumatic drug used in treatment of rheumatoid arthritis. Its effects are mediated largely by inhibition of dihydrofolate reductase, which
causes folate depletion and leads to impaired DNA synthesis. Side effects include oral ulcers, macrocytic anemia, and hepatotoxicity. Much of the toxicity of methotrexate can be
& Sports
Rheumatoid
And Vasculitides
Arthritis
mitigated by the administration of folic acid, which does not reduce the effectiveness of the drug.
Patients with rheumatoid arthritis are at increased risk of developing osteopenia, osteoporosis, and bone fractures. Management includes adequate physical activity, optimization of
& Sports
Rheumatoid
And Vasculitides
Arthritis
calcium and vitamin D intake, minimization of glucocorticoid therapy, and bisphosphonate treatment.
Septic arthritis is characterized by acute monoarthritis, often with fever and restricted range of motion. It is more common in patients with underlying joint disease. Synovial fluid
& Sports
Septic Arthritis analysis should be performed promptly to confirm the diagnosis.
Congestive heart failure exacerbation can cause tachypnea as left ventricular dysfunction allows fluid to pool in the lungs, causing a pleural effusion and hypoxemia due to reduced
ventilation. Tachypnea causes hypocapnia and respiratory alkalosis. Examination typically shows signs of fluid overload, S3 and S4 gallops, cardiomegaly, and bibasilar crackles in
Critical Care Acute Heart Failure
the lungs.
Acute exacerbation of chronic obstructive pulmonary disease (COPD), characterized by an acute worsening of symptoms in a patient with COPD, is commonly triggered by an upper
COPD Lung Disease
respiratory infection. Examination often reveals wheezes, tachypnea, prolonged expiration, and use of accessory muscles.
The elderly can be especially susceptible to intravascular volume depletion leading to prerenal acute kidney injury. There is often a history of poor oral intake or excessive volume
Acute
Systems
Kidney
& Electrolytes
Injury
Prerenal Azotemialoss (e.g. diarrhea). Laboratory results typically demonstrate a blood urea nitrogen/creatinine ratio > 20:1 and an unremarkable urine sediment.
Acute bronchitis is a common cause of cough that may be productive of purulent, blood-tinged sputum. Upper respiratory viral infection is the typical etiology, and symptoms are
Critical Care
Infections
Acute Bronchitis usually self-limiting. Symptomatic treatment and close clinical follow-up are the best management strategies.
Osteoarthritis presents in adults age > 40 with progressive pain that is worsened by activity and relieved by rest. The pain is typically felt in the groin, buttock, or lateral hip
& Sports
Osteoarthritis (trochanteric) region and can radiate to the lower thigh or knee. The joint is not tender, and systemic symptoms are absent.
The 3 cardinal signs of Parkinson disease are rest tremor, rigidity, and bradykinesia. The presence of at least 2 of these 3 on physical examination is grounds for a clinical diagnosis
Neurodegenerative
Parkinson
Disorders
Disease
And Dementias
of this disease.
Oxygenation in mechanically ventilated patients may be improved by increasing the fraction of inspired oxygen (FiO2) or increasing positive end-expiratory pressure (PEEP). If high
Critical Care
Care And Trauma
ARDS Medicine levels (> 60%) of FiO2 are required to maintain oxygenation, PEEP levels should be increased to allow for reductions in the FiO2 as oxygenation improves.
Because hepatitis C virus may spontaneously clear in up to half of affected patients, the diagnosis of chronic infection is a 2-step process that requires both a positive serologic
Viral Infections Hepatitis C antibody test and a confirmatory molecular test for the presence of circulating hepatitis C virus RNA.
Mechanical ventilation improves oxygenation by providing an increased fraction of inspired oxygen (FiO2) and positive end-expiratory pressure (PEEP). FiO2 should be reduced as
Critical Care
Care And Trauma
ARDS Medicine soon as possible below levels that predispose to oxygen toxicity (e.g. < 60%). PEEP may need to be increased to maintain adequate oxygenation.
Respiratory compensation for the marked acidemia that occurs with profound metabolic acidosis (e.g. septic shock, severe acute renal failure) creates high ventilatory demand that
some patients are unable to meet. Respiratory muscle fatigue leads to acute respiratory failure, recognized by higher-than-expected PaCO2 (i.e. mixed primary metabolic acidosis
Critical Care
Care And Trauma
Respiratory
Medicine
Acidosis
and respiratory acidosis).
The primary risk factors for abdominal aortic aneurysm include male gender, smoking history, and age > 65. The US Preventive Services Task Force recommends screening for this
Aortic
System
And Peripheral
Aortic
Artery
Aneurysm
Diseases
condition with a one-time abdominal ultrasound in men age 65-75 who ever smoked.
Constrictive pericarditis is a complication of mediastinal irradiation and an important cause of right heart failure. It should be suspected in patients with progressive peripheral edema,
elevated jugular venous pressure, hepatomegaly, and ascites. Other findings include the presence of hepatojugular reflux, Kussmaul sign (lack of decrease or increase in jugular
Myopericardial
System Diseases
venous pressure on inspiration), and a pericardial knock (mid-diastolic sound).
Anaphylaxis is commonly characterized by an acute illness involving the skin/mucosa and either respiratory or cardiovascular compromise. Risk factors include immune disorders
Critical Care
Care And Trauma
Anaphylaxis
Medicine such as asthma. Medications such as nonsteroidal anti-inflammatory drugs can worsen anaphylaxis by resulting in nonimmunologic mast cell activation.
Lung malignancies, cystic fibrosis, and right-to-left cardiac shunts are the most common causes of secondary digital clubbing. Chronic obstructive pulmonary disease (with or without
hypoxemia) does not cause digital clubbing, and the presence of clubbing should prompt a search for occult malignancy. Hypertrophic osteoarthropathy refers to digital clubbing
Critical And
Lung Cancer along
Masses
with painful joint enlargement, periostosis of long bones, and synovial effusions.
The 3 most common causes of chronic cough are upper airway cough syndrome (postnasal drip), asthma, and gastroesophageal reflux disease. The diagnosis of upper airway
Critical Care
Pulmonary
Chronic
And Cough
Other Systemic
cough syndrome
Disorders is confirmed by the elimination of nasal discharge and cough with the use of H1 histamine receptor antagonists.
Elevated brain natriuretic peptide levels and an audible third heart sound are signs of increased cardiac filling pressures and are noted in patients with congestive heart failure due to
Heart
System
Failure AndAcute
ShockHeart Failure
left ventricular systolic dysfunction.
Secondary bacterial pneumonia is the most common influenza complication and should be suspected when fever and pulmonary symptoms worsen after initial improvement. Most
cases occur in patients age > 65, but community-acquired methicillin-resistant Staphylococcus aureus has a predilection for young patients with recent influenza. This pathogen
Community Acquired
causes
Pneumonia
rapidly progressive, necrotizing pneumonia with high fever, productive cough (often with hemoptysis), leukopenia, and multilobar cavitary infiltrates.
Hyperosmolar hyperglycemic state in type 2 diabetes mellitus is characterized by severe hyperglycemia and hyperosmolality without significant ketoacidosis. Altered sensorium is
Diabetes& Mellitus
Metabolism
Hyperglycemic Hyperosmolar
due to high plasma
Nonketotic
osmolality.
Syndrome
Common precipitating factors include infection, medications (e.g. glucocorticoids), interruption of insulin therapy, trauma, and acute illness.
Diabetic nephropathy, a microangiopathic glomerular process suggested by persistent proteinuria, is more likely to occur in the setting of long-standing diabetes, suboptimal glycemic
Glomerular
Systems &Diseases,
Electrolytes
Diabetic
Nephrotic/Nephritic
Nephropathy
and blood
Syndrome
pressure control, and other systemic microvascular damage (e.g. retinopathy). It is associated with increased risk of cardiovascular mortality.
A single brain abscess usually results from direct extension of an adjacent infection (e.g. otitis media, sinusitis, dental infection). Viridans streptococcus and Staphylococcus aureus
are the 2 most commonly isolated organisms. Headache, fever, focal neurologic deficits, and seizure may be present. Brain imaging (CT scan, MRI) typically reveals a single ring-
CNS Infections Brain Abscess enhancing lesion with central necrosis.
Ethylene glycol is associated with hypocalcemia and calcium oxalate deposition in the kidneys. This leads to flank pain, hematuria, oliguria, acute kidney injury, and anion gap
metabolic acidosis. Treatment involves administration of fomepizole or ethanol to inhibit alcohol dehydrogenase, sodium bicarbonate to alleviate the acidosis, and hemodialysis in
Toxicology Exposure
Toxic Alcohols cases of severe acidosis and/or end-organ damage.
Decreased respiratory rate is the most reliable and predictive sign of opioid intoxication, which also frequently presents with altered mental status, hypothermia, and miosis (which
Toxicology Exposure
Opioids may be absent due to co-ingestions). Management should focus on airway protection, improving ventilation, and prompt administration of naloxone.
Common symptoms of opioid withdrawal include nausea, cramps, diarrhea, restlessness, rhinorrhea, lacrimation, myalgias, and arthralgias. Examination can show hypertension,
Toxicology Exposure
Opioids tachycardia, mydriasis, piloerection, and hyperactive bowel sounds. Low-dose methadone with adjunctive medications is the treatment of choice.
Neoplasms
Systems &And
Electrolytes
Trauma
BladderOfCancer
The Kidneys
Bladder
Andtumors
Urinary
areTract
a common cause of painless hematuria in older adults, particularly in those who have used tobacco.
Patients at average risk of developing colon cancer should begin screening at age 50 with high-sensitivity stool-based testing or direct visualization techniques (e.g. colonoscopy
Tumors
& Nutrition
Of The GIColorectal
Tract Cancerevery
Screening
10 years). Patients with an affected first-degree relative should begin screening at age 40 or 10 years before the age of the relative’s diagnosis (whichever comes first).
The risk of bladder cancer is greatest in those with chronic exposure to chemical carcinogens in tobacco smoke, the workplace, or drinking water; family history can also indicate
increased risk. However, screening for bladder cancer (e.g. urinalysis, urine cytology, tumor markers) has not been shown to conclusively improve outcomes, so it is not
Neoplasms
Systems &And
Electrolytes
Trauma
BladderOfCancer
The Kidneys
recommended.
And Urinary Tract
Ulcerative colitis (UC) presents with bloody diarrhea, often with weight loss and fever. UC invariably involves the rectosigmoid but can have continuous involvement of the entire
Intestinal
& Nutrition
And Colorectal
Inflammatory
Disorders
Bowel
colon.
Disease
Biopsy shows mucosal inflammation and crypt abscesses. The risk of colorectal cancer is elevated in UC, and surveillance colonoscopy is advised.
Contrast-induced nephropathy is characterized by an acute rise in creatinine after radiologic contrast administration followed by a gradual return to baseline. Patients with chronic
kidney disease are at increased risk. Preventive measures include avoidance of nonsteroidal anti-inflammatory drugs, periprocedural saline hydration, and using the smallest
Acute
Systems
Kidney
& Electrolytes
Injury
Contrast Nephropathy
possible volume of contrast media.
Obesity hypoventilation syndrome is defined by obesity (BMI > 30 kg/m2), daytime hypercapnia (PaCO2 > 45 mm Hg), and alveolar hypoventilation. Arterial blood gas will show
Lung Disease
hypercapnia,
Syndrome
hypoxemia, and respiratory acidosis as a result of altered lung mechanics due to obesity and hypoventilation.
Patients with Neisseria gonorrhoeae are at high risk of simultaneous coinfection with several other sexually transmitted pathogens, including Chlamydia trachomatis, HIV, Treponema
pallidum (syphilis), and hepatitis B virus. Patients should be screened for these infections in addition to receiving appropriate antibiotics (usually ceftriaxone plus azithromycin) and
counseling on safe sexual practices.
Chlamydia trachomatis infection is often asymptomatic but may cause dysuria and mucoid discharge, particularly in men. Treatment with a one-time dose of azithromycin or 7 days of
doxycycline is usually curative; however, current and recent sexual partners must receive testing and treatment to prevent reinfection.
Tricyclic antidepressant (TCA) overdose is characterized by central nervous system depression, hypotension, and other anticholinergic effects including dilated pupils, hyperthermia,
and intestinal ileus. It can also cause QRS prolongation, increasing the risk of ventricular arrhythmias. Management of patients suspected of TCA overdose should start with securing
the airway, breathing, and circulation; in patients with evidence of cardiac toxicity, sodium bicarbonate should then be administered to improve blood pressure, narrow the QRS
Toxicology Exposure
Tricyclic Antidepressants
interval, and prevent arrhythmia.
Aortic root disease is the predominant cause of morbidity and mortality in patients with Marfan syndrome. Most patients have aneurysmal aortic root dilation that can progress to
cause chronic aortic regurgitation or type A aortic dissection. If dissection occurs it is usually prior to age 40; it is a surgical emergency that may be complicated by acute aortic
Aortic
System
And Peripheral
Aortic
Artery
Dissection
Diseases
regurgitation.
Infective endocarditis should be suspected in intravenous drug users presenting with fever and a cardiac murmur. Patients can develop septic emboli due to dislodgement of infected
vegetations, leading to cerebral ischemic infarction, cerebral abscess, and/or bacterial meningitis. Renal injury may also occur due to embolic infarction or immune complex-mediated
CNS Infections Septic Emboli glomerulonephritis.
Lacunar strokes occur due to microatheroma formation and lipohyalinosis in the small penetrating arteries of the brain. They often affect the internal capsule and result in pure motor
Ischemic Stroke hemiparesis. Hypertension, hyperlipidemia, diabetes, and smoking are major risk factors.
All adults should receive annual vaccination for influenza, as well as a single dose of tetanus-diphtheria-acellular pertussis, with revaccination for tetanus and diphtheria every 10
years. In addition, all patients with HIV should receive vaccinations for hepatitis A, hepatitis B, and zoster (unless they have documented immunity); immunization for Meningococcus
and Streptococcus pneumoniae should also be given.
Patients with chronic liver disease require the same immunizations as the general population and additional disease-specific vaccines, including hepatitis A and B vaccines as well as
Miscellaneous Immunizations the 23-valent pneumococcal polysaccharide vaccine.
The clinical manifestations of autosomal dominant polycystic kidney disease generally correlate with the progression of cystic structural degeneration of the kidneys and include
Cystic
Systems
Kidney
& Electrolytes
Diseases
Polycystic Kidneyhypertension,
Disease polyuria, flank pain, and renal dysfunction. Extrarenal manifestations include liver cysts and cerebral aneurysms.
Warfarin is a vitamin K antagonist that prolongs INR. Its anticoagulant effects are influenced by medications that affect the gut microbiome/cytochrome P450 system and the dietary
Cardiovascular
System Drugs
Anticoagulants intake of green leafy vegetables. Acetaminophen use commonly prolongs INR in those on warfarin due to interruption of vitamin K recycling in the liver.
Metabolism Hypothyroidism is an important cause of reversible changes in memory and mentation. It will be accompanied by systemic changes such as weight gain, fatigue, and constipation.
Tuberculin skin testing is used to identify patients with latent tuberculosis (TB) infection and a high risk of reactivation TB. In the United States, an induration size of < 15 mm is
Tuberculosis considered negative (i.e. > 15 mm is considered positive) in healthy patients with a low likelihood of TB infection.
Warfarin or target-specific oral anticoagulants (e.g. rivaroxaban, apixaban, dabigatran) should be used to reduce the risk of systemic thromboembolism in patients with atrial
fibrillation (AF) and moderate to high risk of thromboembolic events (CHA2DS2-VASc score > 2). Patients with lone AF (score 0) are at low risk of systemic embolization and
Cardiac
System
Arrhythmias
Atrial
AndFibrillation
Syncope anticoagulant therapy is not indicated.
Transudative effusions are commonly caused by decreased intrapleural or plasma oncotic pressures or elevated hydrostatic pressure. Exudative effusions are often the result of
Critical Care
Infections
Pleural Effusion increased capillary or pleural membrane permeability or disruptions to lymphatic outflow.
Patients with multiple myeloma are at increased risk for infection due to bone marrow infiltration by neoplastic cells, which alters the normal leukocyte population and causes
4466 Medicine Hematology &Plasma
Oncology
Cell Disorders
Multiple Myelomahypogammaglobulinemia.
Guillain-Barré syndrome is an acute or subacute ascending flaccid paralysis. Cerebrospinal fluid analysis shows an elevated protein level with normal cell count (albuminocytologic
Guillain-Barré
Nerves And
Syndrome
dissociation).
Muscles
Neuromuscular junction disorders are generally characterized by muscle weakness in the absence of upper or lower motor neuron signs. Myasthenia gravis is a neuromuscular
disease that typically presents with fluctuating and fatigable extraocular (e.g. diplopia, ptosis) and bulbar (e.g. dysarthria, dysphagia) muscle weakness as well as symmetrical
Myasthenia
Nerves
Gravis
Andproximal
Musclesweakness of the neck and extremities (upper more than lower).
Amiodarone can increase the serum levels of digoxin and cause toxicity in a patient on a stable digoxin regimen. Acute digoxin toxicity typically presents with gastrointestinal
symptoms (e.g. anorexia, nausea, vomiting, abdominal pain). Chronic digoxin toxicity presents with less pronounced gastrointestinal symptoms but more significant neurologic and
Cardiovascular
System Drugs
Digoxin visual symptoms (e.g. changes in color vision, scotomas, blindness).
Common causes of corneal abrasion include trauma, foreign body lodging under the lid, and contact lens use leading to a corneal epithelial defect. Abrasions can also occur without
obvious corneal trauma. Patients typically develop severe eye pain, photophobia with reluctance to open the eye, and a sensation of a foreign body in the eye. Absence of eye pain
CNS Infections Infectious Keratitissuggests trigeminal nerve dysfunction as the ophthalmic branch (V1) of the trigeminal nerve (cranial nerve V) controls corneal sensation.
& Sports
Giant And
Cell Arteritis
Vasculitides
Aortic aneurysms can occur in patients with giant cell (temporal) arteritis due to the involvement of the branches of the aorta.
High-output heart failure usually results from increased cardiac output in response to a reduction in systemic vascular resistance (e.g. arteriovenous fistula). It involves hyperdynamic
Heart
System
Failure AndChronic
Shock Heart Failure
circulation (evidenced by widened pulse pressure and brisk carotid upstroke) and increased cardiac venous return leading to peripheral and pulmonary edema.
Benign paroxysmal positional vertigo causes brief (< 1 min) episodes of vertigo triggered by changes in head position. Dizziness related to cardiovascular causes (e.g. aortic
BenignNerves
Paroxysmal
Andstenosis,
Muscles
Positional
intermittent
Vertigo arrhythmia) is usually due to global cerebral hypoperfusion and presents as lightheadedness or near-syncope rather than true vertigo.
ECG is useful in identifying cardiogenic syncope and should be obtained in all patients with unexplained syncope. ECG findings suggesting an arrhythmia as the cause of syncope
Cardiac
System
Arrhythmias
Syncope
And Syncope include sinus bradycardia, sinus pauses, atrioventricular block, and prolonged QTc interval.
Aortic stenosis can present with decreased exercise tolerance, exertional dyspnea, angina, or syncope. Physical examination typically reveals a delayed and diminished carotid
Valvular
Aortic Stenosis pulse, soft second heart sound, and mid- to late-peaking systolic murmur with maximal intensity at the second right intercostal space and radiation to the carotids.
Digoxin has a narrow therapeutic window and toxicity is common in elderly patients as they are susceptible to acute renal dysfunction with decreased clearance of the drug.
Symptoms of toxicity include gastrointestinal disturbances (e.g. anorexia, nausea, vomiting), neurologic disturbances (e.g. confusion, changes in color vision), and cardiac
Heart
System
Failure AndChronic
Shock Heart Failure
arrhythmias.
Amiodarone causes thyroid dysfunction due to its iodine content and effects on thyroid metabolism. It impairs synthesis of thyroid hormone and decreases peripheral conversion of
T4 to T3. It also can increase synthesis of thyroid hormone in patients with nodular thyroid disease or latent Graves disease and can cause destructive thyroiditis with release of
Cardiovascular
System Drugs
Hypothyroidism preformed hormone.
Anticoagulation (e.g. warfarin, direct oral anticoagulants) has been shown to significantly reduce the risk of embolization in patients at moderate to high risk of thromboembolic
Cardiac
System
Arrhythmias
Atrial
AndFibrillation
Syncope events. CHA2DS2-VASc score is recommended for assessment of stroke risk in patients with nonvalvular atrial fibrillation.
Acute decompensated heart failure (systolic or diastolic dysfunction) can present with acute pulmonary edema. Treatment for patients with acute decompensated heart failure and
pulmonary edema who have normal or elevated blood pressure includes supplemental oxygen, assisted ventilation as needed, aggressive intravenous diuresis, and possible
Heart
System
Failure AndAcute
ShockHeart Failure
vasodilator therapy (e.g. nitroglycerin, nitroprusside).
Atrioventricular nodal re-entrant tachycardia (AVNRT) is the most common form of paroxysmal supraventricular tachycardia and is caused by a re-entry mechanism due to the
presence of a dual electrical pathway (slow and fast pathway) in the AV node. Vagal maneuvers increase parasympathetic tone and result in a temporary slowing of conduction in the
Cardiac
System
Arrhythmias
Supraventricular
AV node and an increase in the AV node refractory period, leading to termination of AVNRT.
& Sports
Gout Gout is a common complication of myeloproliferative disorders due to excessive turnover of purines and the resulting increase in uric acid production.
Obstructive sleep apnea (OSA) can present without symptoms of snoring or witnessed apneic events. OSA causes transient periods of hypoxemia. The kidneys respond by
Oncology
Obstructive Sleepincreasing
Apnea erythropoietin, which can result in erythrocytosis.
Patients with hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome) can develop pulmonary arteriovenous malformations associated with hemoptysis and right-to-left
Oncology
Hereditary Hemorrhagic
shunt physiology.
Telangiectasia
This diagnosis must be entertained in a patient with recurrent nose bleeds and oral lesions.
Oncology
Polycythemia Carbon monoxide poisoning should be considered in patients with environmental risk factors who present with headache, nausea, and dizziness.
Glucocorticoid-induced myopathy is a complication of chronic corticosteroid use. It is characterized by painless proximal muscle weakness, which is more prominent in the lower
extremities. There is no muscle inflammation or tenderness, and creatine kinase level and erythrocyte sedimentation rate are normal. Glucocorticoid-induced myopathy slowly
Giant Cell Arteritisimproves once the offending medication is discontinued.
Thalassemia minor is usually asymptomatic and no treatment is required. Patients typically have mild anemia, low mean corpuscular volume (55-75 µm3), target cells on peripheral
Oncology
Thalassemia smear, and disproportionately high red blood cell (RBC) count. Iron deficiency anemia is associated with low RBC count and no microcytosis until hemoglobin is < 10 g/dL.
Drug-induced hemolytic anemia is often triggered by penicillin and cephalosporin medications. It is marked by evidence of extravascular hemolytic anemia such as fatigue,
weakness, splenomegaly, dark urine, and jaundice. Discontinuation of the offending drug usually results in complete resolution of symptoms within days. No additional workup is
Oncology
Hemolytic Anemiagenerally required.
Patients with chronic obstructive pulmonary disease often have chronic CO2 retention, resulting in respiratory acidosis and compensatory metabolic alkalosis. Diuretics are often
administered to treat cor pulmonale symptoms but must be used cautiously as they can lead to a reduction in cardiac output and subsequent development of prerenal acute renal
Acute
Systems
Kidney
& Electrolytes
Injury
Prerenal Azotemiainjury.
Herpes zoster (shingles) is due to reactivation of varicella zoster virus from a dorsal root ganglion. Patients experience pain and a vesicular rash in a dermatomal distribution. The
Miscellaneous
& Nutrition Herpes Zoster pain may precede the rash by several days, during which the diagnosis may not be apparent.
Acute, symptomatic hyponatremia (impaired mental status/seizures) is a medical emergency. It requires a prompt increase in the serum sodium concentration with 3% or hypertonic
Fluid,
Systems
Electrolytes,
& Electrolytes
Central
And Acid-Base
Pontine Myelinolysis
saline at a rate of no more than 0.5 mEq/L/hr to avoid causing central nervous system osmotic demyelination syndrome.
Unilateral foot drop is characterized by a ‘steppage’ gait: exaggerated hip and knee flexion while walking. Common causes include L5 radiculopathy and compression peroneal
Peroneal
Nerves
Neuropathy
Andneuropathy.
Muscles
Diabetes
SystemsInsipidus
& Electrolytes
Diabetes InsipidusLithium is a common cause of nephrogenic diabetes insipidus (DI). Lithium-induced nephrogenic DI is treated with salt restriction and discontinuation of lithium.
Patients with chronic alcoholism often present with multiple electrolyte abnormalities (e.g. hypokalemia, hypomagnesemia, hypophosphatemia). Hypomagnesemia can lead to
refractory hypokalemia due to removal of inhibition of renal potassium excretion and should be suspected in patients with hypokalemia that is difficult to correct with potassium
Fluid,
Systems
Electrolytes,
& Electrolytes
Hypokalemia
And Acid-Base replacement.
Hyperkalemic emergency is marked by ECG changes, cardiac arrhythmia, and/or sudden or dramatic rise in serum potassium. Urgent treatment with calcium gluconate to stabilize
the cardiac membrane and insulin plus glucose to shift serum potassium into cells is indicated. Definitive removal of potassium via the stool (e.g. patiromer), kidneys (e.g.
Fluid,
Systems
Electrolytes,
& Electrolytes
Hyperkalemia
And Acid-Base furosemide), and/or blood (e.g. hemodialysis) should then be initiated.
Chronic primary adrenal insufficiency presents with weight loss, fatigue, and gastrointestinal symptoms. Volume depletion and reduced vascular tone can cause hypotension and
syncope. Most patients have hyponatremia due to renal sodium loss and increased secretion of antidiuretic hormone. Hyperkalemia is also common due to renal potassium retention
Adrenal&Disorders
Metabolism
in the setting of aldosterone deficiency.
Cushing syndrome is characterized by weight gain, muscle weakness, and hypertension. Patients can experience easy bruisability, dermal atrophy, and striae due to the catabolic
Adrenal&Disorders
Metabolism
Cushing Syndrome
effects of cortisol on connective tissue. Women can have features of hyperandrogenism due to co-secretion of adrenal androgens with cortisol.
Influenza is usually a self-limited infection marked by < 1 week of systemic (fever, malaise, myalgias, headache) and respiratory (rhinorrhea, sore throat, nonproductive cough)
Viral Infections Influenza symptoms. Complications (e.g. pneumonia) are common in patients with advanced age and chronic illness.
Nocardia is a filamentous, aerobic, gram-positive bacteria that is partially acid-fast. It causes pulmonary or disseminated disease (particularly to the brain) in immunocompromised
Nocardiosis hosts. The treatment of choice is trimethoprim-sulfamethoxazole.
Pancytopenia (decreased red blood cells, white blood cells, and platelets) is common in patients with systemic lupus erythematosus. It usually indicates concurrent peripheral,
OncologyDisordersSLE immune-mediated destruction of all 3 cell lines.
Graves ophthalmopathy is due to the effects of activated T cells and thyrotropin receptor antibodies (TRAB) on TSH receptors on retro-orbital fibroblasts and adipocytes. Radioactive
Metabolism iodine (RAI) treatment can raise titers of TRAB and worsen the ophthalmopathy. Glucocorticoids and antithyroid drugs can be used to minimize the effects of RAI.
Obstructive sleep apnea is caused by episodic obstruction of the upper airway due to laxity of pharyngeal tissue, resulting in nocturnal hypoventilation. Common manifestations
4413 Medicine Pulmonary & Sleep
CriticalDisorders
Care Obstructive Sleepinclude
Apnea daytime sleepiness, snoring, and a choking or gagging sensation while sleeping.
Antiphospholipid-antibody syndrome is common in patients with systemic lupus erythematosus. It generally presents with thromboembolism and/or recurrent fetal loss. Positive
testing for lupus anticoagulant (LA), anticardiolipin antibody, and/or β2-glycoprotein-I antibody is diagnostic. Those with LA have prolonged PTT that does not improve with 1:1
Antiphospholipid Syndrome
dilution with normal serum (mixing test).
Actinic keratosis is characterized by scaly papules or plaques on the scalp, face, lateral neck, and dorsal surface of the hands. Chronic sun exposure is the major risk factor. Actinic
4410 Medicine Dermatology Skin Tumors And Actinic
Tumor-Like
Keratoses
Lesions
keratosis can progress to squamous cell carcinoma, but the likelihood of malignant progression of an individual lesion is low.
Ischemic oculomotor (CN III) palsy is commonly associated with poorly controlled diabetes mellitus and is characterized by damage to the inner somatic nerve fibers while sparing
Cranial Nerve Palsy
the more peripheral parasympathetic fibers. This manifests with ptosis, ‘down-and-out’ gaze, diplopia, and normal pupillary response.
Schistocytes (helmet cells) are fragmented erythrocytes. They occur in microangiopathic hemolytic anemia (e.g. disseminated intravascular coagulation, hemolytic-uremic syndrome,
thrombotic thrombocytopenic purpura) and due to erythrocyte destruction by prosthetic cardiac valves. Hemolytic anemias are characterized by a decreased serum haptoglobin level
Oncology
Mechanical Valveas well as an increased lactate dehydrogenase and bilirubin.
Achalasia commonly presents with chronic dysphagia to both solids and liquids, regurgitation, difficulty belching, and weight loss. Achalasia is caused by impaired peristalsis of the
Gastroesophageal
& Nutrition Achalasia
Disorders distal esophagus and failure of the lower esophageal sphincter to relax when food boluses reach it. Manometry is key to diagnosis.
4403 Medicine Dermatology Skin Tumors And Cherry
Tumor-Like
Angioma
Lesions
Cherry hemangiomas are small, red, cutaneous papules common in aging adults. They do not regress spontaneously, but they are benign and generally do not require treatment.
Patients who have received the equivalent of more than one blood volume of blood transfusions or packed red blood cells over 24 hours may develop elevated plasma levels of
Oncology Medicine
Hypocalcemia citrate (a substance added to stored blood). Citrate chelates calcium and magnesium and may reduce their plasma levels, causing paresthesias.
Acute angle-closure glaucoma (ACG) is a vision-threatening condition that may be associated with certain medications (e.g. anticholinergics for Parkinson disease) or arise
spontaneously. Manifestations include the sudden onset of severe eye pain, nausea, vomiting, unilateral conjunctival injection, and a dilated pupil with poor light response. Untreated,
Neurodegenerative
Parkinson
Disorders
Disease
And Dementias
patients with acute ACG can develop permanent vision loss within 2-5 hours of symptom onset. Urgent ophthalmologic consultation is required.
Resting tremor is often the presenting symptom of Parkinson disease. It is usually a ‘pill-rolling’ tremor that starts in one hand and can progress to involve other extremities, jaw, face,
Neurodegenerative
Parkinson
Disorders
Disease
And Dementias
tongue, and lips.
Torticollis is a common form of focal dystonia involving the sternocleidomastoid muscle. It can occur idiopathically but is very often medication-related. Discontinuation of the
Dystonia
Nerves Andcausative
Muscles agent(s) may improve symptoms.
Intravenous drug users are at increased risk for bacterial endocarditis involving the right-sided heart valves. Tricuspid regurgitation is commonly present in patients with tricuspid
Valvular
Endocarditis valve endocarditis and can be distinguished from other murmurs by augmentation of intensity of holosystolic murmur with inspiration.
Vasovagal (neurocardiogenic) syncope occurs due to excessive vagal tone that can be triggered by emotional stress, pain, or prolonged standing. Episodes typically involve a
SyncopeNerves Andprodrome
Muscles of nausea, diaphoresis, and pallor.
The most common signs and symptoms of pulmonary embolism include dyspnea, pleuritic chest pain, tachypnea, and tachycardia. Chest radiograph is frequently abnormal but has
Cardiac
System
Arrhythmias
Pulmonary
And Syncope
Embolism
poor sensitivity and specificity for pulmonary embolism, and may be normal.
Diagnostic testing for coronary artery disease (CAD) should not be performed routinely in low-risk patients as they frequently can have false-positive test results. Patients with
intermediate probability of CAD should receive appropriate stress testing based on ECG findings and their ability to exercise. High-risk patients should be started on appropriate
Coronary
SystemHeart Disease
medical therapy, with expert evaluation to consider coronary angiography.
Elderly patients are at higher risk for subdural hematoma due to increased fall risk and cerebral atrophy. Chronic subdural hematoma often presents insidiously weeks after the initial
Subdural Hematoma
injury with headache, somnolence, confusion, and focal neurologic deficits.
Hypokalemia is a common electrolyte abnormality that causes weakness, fatigue, and muscle cramps. When severe, it can lead to paralysis and arrhythmia. The ECG may show U
Hypokalemia
Nerves Andwaves,
Muscles
flat and broad T waves, and premature ventricular beats.
Cauda equina syndrome is a disorder marked by compression of > 2 spinal nerve roots in the lumbar cistern. Most cases are caused by large, central lumbar disc herniation, but
some are due to epidural tumor or abscess or inflammation in the region. Suspicion should be raised when a patient has severe, radicular lower back pain plus impaired
Cauda Equina Syndrome
motor/sensory/reflex activity in the lower extremities, bowel/bladder/sexual dysfunction, and/or saddle anesthesia.
Spinal cord compression is characterized by signs and symptoms of upper motor neuron dysfunction distal to the site of compression. These include weakness, hyperreflexia, and an
extensor plantar response. Cord compression is a medical emergency requiring prompt diagnosis by spinal MRI.
Electrical alternans with sinus tachycardia is a highly specific sign for large pericardial effusion. This is due to the swinging motion of the heart in the pericardial cavity causing a beat-
Myopericardial
System Diseases
Pericardial Effusion
to-beat variation in QRS axis and amplitude. Patients with cardiac tamponade and hemodynamic compromise should have emergency pericardiocentesis.
The most common site of colon cancer metastasis is the liver. Liver metastases manifest as right upper quadrant pain, mildly elevated liver enzymes, and firm hepatomegaly. The
Tumors
& Nutrition
Of The GIMetastatic
Tract Liver Disease
diagnosis is confirmed by CT of the abdomen.
Intravenous drug users are more prone to developing tricuspid endocarditis caused by Staphylococcus aureus. Fragments of the vegetation can embolize to the lungs, causing the
Endocarditis characteristic nodular infiltrate with cavitation.
Critical Care
Infections
Community Acquired
LungPneumonia
consolidation (e.g. lobar pneumonia) presents with dullness to percussion, increased intensity of breath sounds, and increased tactile fremitus.
Treatment of actively bleeding esophageal varices involves hemodynamic support, pharmacologic treatment (e.g. octreotide), endoscopic therapy, and prophylactic antibiotics.
Gastroesophageal
Disorders Varices
Coagulopathy, anemia, and thrombocytopenia are common complications and may also require correction.
Packed red blood cell transfusions are recommended in acute gastrointestinal bleeding for patients with hemoglobin < 7 g/dL. A higher threshold of hemoglobin < 9 g/dL is
Gastroesophageal
considered for unstable patients with acute coronary syndrome or with active bleeding and hypovolemia.
Vitamin B6, folate, and vitamin B12 are involved in the metabolism of homocysteine. Vitamin B6 lowers homocysteine levels by acting as a cofactor for the enzyme cystathionine β-
synthase, which metabolizes homocysteine into cystathionine.
Immune thrombocytopenia is an autoimmune disorder with increased platelet destruction and inhibition of platelet production due to IgG autoantibodies against platelet membrane
OncologyDisordersITP glycoproteins. Patients may have mucocutaneous bleeding with isolated thrombocytopenia and no hepatosplenomegaly.
Chronic hyperthyroid myopathy is characterized by proximal muscle weakness in the setting of clinical features of hyperthyroidism. Objective findings may include muscle atrophy.
Metabolism Treatment of hyperthyroidism usually improves the myopathy.
Pronator drift is a relatively sensitive and specific sign for upper motor neuron or pyramidal tract disease affecting the upper extremities. It is performed by having the patient
Multiple Sclerosisoutstretch the arms with the palms up and eyes closed. In patients with pyramidal lesions, the affected arm drifts downward and the palm turns (pronates) toward the floor.
Aminoglycosides are antibiotics used to treat serious gram-negative infections. They are potentially nephrotoxic and drugs levels and renal function must be monitored closely during
Acute
Systems
Kidney
& Electrolytes
Injury
Acute Kidney Injury
therapy.
Cardiac
System
Arrhythmias
Syncope
And Syncope Orthostatic hypotension is characterized by a drop in blood pressure after standing and is typically preceded by a lightheaded or presyncopal sensation.
Competitive athletes using exogenous androgens, autologous blood transfusions, or erythropoietin to enhance athletic performance can develop an elevated hematocrit. Clinical
Oncology
Polycythemia findings suggesting exogenous androgens include gynecomastia, testicular atrophy, mood disturbances, and hepatotoxicity.
Bartonella henselae and Bartonella quintana can cause bacillary angiomatosis in immunocompromised individuals (e.g. advanced HIV). Patients develop vascular cutaneous lesions,
systemic symptoms, and sometimes organ involvement (liver, central nervous system, bone). Treatment requires antimicrobials (e.g. doxycycline, erythromycin) and antiretroviral
Bartonella initiation.
Spinal epidural abscess may present with fever, focal back pain, and neurologic dysfunction. Evaluation includes urgent MRI of the spine. Most patients require treatment with broad-
Epidural Abscess spectrum intravenous antibiotics and prompt drainage/surgery.
Inflammatory back pain is characterized by the gradual onset of pain and stiffness that begins at a young age (< 40), worsens with rest (e.g. at night), and improves with activity. It
Spinal/Peripheral
& Sports
Back
NervePain
Disorders And
typically
Backsuggests
Pain spondyloarthropathy (e.g. ankylosing spondylitis, psoriatic arthritis, reactive arthritis, arthritis associated with inflammatory bowel disease).
Lumbar spinal stenosis is a common cause of back pain in patients age > 60. It is characterized by back pain radiating to the thighs that is worse with lumbar extension and persists
Spinal/Peripheral
& Sports
Spinal
Nerve Stenosis
Disorders And
whileBack
standing
Pain still. Vascular claudication is exertion-dependent and resolves with standing still.
Although spinal imaging is not recommended for uncomplicated acute low back pain, imaging is warranted for patients with suspected malignancy, infection, or bony abnormalities.
X-ray and inflammatory markers (e.g. erythrocyte sedimentation rate) are recommended for patients with suspected malignant pain. MRI is indicated for patients with abnormal
Spinal/Peripheral
& Sports
Back
NervePain
Disorders And
findings
BackonPain
initial tests, significant neurologic deficits, or cauda equina syndrome.
Angle-closure glaucoma is characterized by narrowing of the anterior chamber angle leading to decreased aqueous outflow and elevated intraocular pressure. It presents with
headache, eye pain, nausea, and decreased visual acuity. Examination findings include conjunctival injection, corneal edema, palpable firmness of the eyeball, and a fixed, mid-
Headache Glaucoma dilated pupil. The diagnosis is confirmed by gonioscopy and/or tonometry.
The antiemetics metoclopramide and prochlorperazine are dopamine antagonists, which, along with most antipsychotics, can cause extrapyramidal symptoms such as acute
Miscellaneous
& Substance
Dystonia
Abuse dystonia, akathisia, and parkinsonism.
Duodenal ulcer (DU) is characterized by epigastric pain that improves with eating. The majority of DUs are caused by Helicobacter pylori or nonsteroidal anti-inflammatory drugs.
Gastroesophageal
& Nutrition Peptic
Disorders
Ulcer Disease
Management of H. pylori-associated ulcer requires acid suppression and antibiotic eradication therapy.
Chronic pancreatitis is a progressive inflammatory disorder of the pancreas characterized by recurrent bouts of upper abdominal pain, diarrhea/steatorrhea, and weight loss.
Pancreatic
& Nutrition
Disorders
Diagnosis is established by the presence of pancreatic calcifications on CT scan or plain film.
Ureteral calculi may cause flank or abdominal pain radiating to the perineum, often with nausea and vomiting. Ultrasonography or a noncontrast spiral CT scan of the abdomen and
Nephrolithiasis,
Hematuria,
Renal Calculi
And Urinary
pelvisTract
are the
Obstruction
imaging modalities of choice to confirm the diagnosis. Ultrasonography is preferred in pregnant patients to reduce radiation exposure.
Anemia of chronic disease is a disorder of iron utilization that most commonly occurs in the setting of chronic inflammation. It is characterized by a normocytic anemia with decreased
serum iron, decreased total iron-binding capacity, decreased iron saturation, and normal/elevated serum ferritin. Treating the underlying inflammatory disorder will often improve the
Oncology
Anemia Of Inflammation
anemia.
Vitamin B12 deficiency often presents with macrocytic anemia and/or neurologic manifestations (e.g. paresthesia, subacute combined degeneration). Most cases are seen in older
individuals with pernicious anemia, marked by antibody-mediated destruction of intrinsic factor and gastric parietal cells. Damage to the stomach results in gastric atrophy and
Oncology
increases the risk of gastric cancer.
Senile purpura usually presents with ecchymoses in elderly patients in areas exposed to repeated minor trauma (e.g. extensor surfaces of the hands and forearms). It is due to age-
4355 Medicine Dermatology Normal Structure Senile
And Function
PurpuraOf Skin
related loss of elastic fibers in perivascular connective tissue. Senile purpura is not dangerous and requires no further evaluation.
Viral Infections Infectious Mononucleosis
Infectious mononucleosis causes prolonged fever, pharyngitis, fatigue, and lymphadenopathy and is diagnosed by the heterophile antibody (Monospot) test.
Vitamin B12 deficiency is common after a total or partial gastrectomy. Vitamin B12 is a necessary cofactor in purine synthesis, and its deficiency causes defective DNA synthesis.
Oncology
This results in ineffective erythropoiesis, presenting as megaloblastic anemia.
Anemia of chronic kidney disease is due to erythropoietin deficiency; treatment is with erythropoiesis-stimulating agents (ESAs) (e.g. erythropoietin, darbepoetin). Iron deficiency is
Oncology
the most common cause of inadequate response to ESAs in patients on dialysis.
Oncology
Iron Deficiency Anemia
Pica is an appetite for non-nutritive substances such as ice, clay, dirt, and paper products. Pica, especially for ice, can be indicative of iron deficiency.
Glucose-6-phosphate dehydrogenase deficiency causes hemolytic anemia due to oxidative injury to red blood cells. Hemolytic episodes can be precipitated by infection or
Oncology
G6PD Deficiency medications, especially dapsone, antimalarials, and nitrofurantoin.
Chest pain due to gastroesophageal reflux disease (GERD) can mimic anginal chest pain. Prolonged episodes of chest pain that occur at rest or after meals, and associated
laryngopharyngeal irritation (e.g. cough, hoarseness) are suggestive of GERD. Appropriate treatment combines lifestyle changes with a histamine 2 receptor antagonist or proton-
Miscellaneous
System Gastroesophagealpump
Reflux
inhibitor
Disease (e.g. omeprazole).
Patients with cardiac tamponade usually have clinical features of Beck triad: hypotension, distended neck veins, and muffled heart sounds. These symptoms are due to an
Myopericardial
System Diseases
Cardiac Tamponade
exaggerated shift of the interventricular septum toward the left ventricular cavity, which reduces left ventricular preload, stroke volume, and cardiac output.
Pulmonary embolism typically presents with dyspnea, tachypnea and tachycardia. Occlusion of a peripheral pulmonary artery by thrombus may cause pulmonary infarction with
Critical Care
Vascular
Pulmonary
And Cardiopulmonary
Embolism
pleuritic Disease
pain and hemoptysis.
The 2 most common causes of microcytic anemia, iron deficiency and thalassemia, are differentiated by iron studies. Thalassemia is a hemoglobin defect caused by alterations to > 1
Oncology
Thalassemia of the hemoglobin globin subunits. Thalassemia minor is minimally symptomatic.
Thrombotic thrombocytopenic purpura (TTP) is caused by autoantibodies to plasma protease ADAMTS13 and is marked by microangiopathic hemolytic anemia and
OncologyDisordersThrombotic Thrombocytopenic
thrombocytopenia.
Purpura
TTP is life threatening and requires emergent treatment with plasma exchange.
Thrombotic thrombocytopenic purpura should be suspected in patients with laboratory evidence of thrombocytopenia and intravascular hemolytic anemia. Neurologic changes and
OncologyDisordersThrombotic Thrombocytopenic
renal failure are
Purpura
often present at diagnosis. Peripheral blood smear is crucial in the diagnostic workup, demonstrating signs of intravascular hemolysis (e.g. schistocytes).
Acute
Systems
Kidney
& Electrolytes
Injury
Acute Kidney Injury
Metformin should not be given to acutely ill patients with acute renal failure, liver failure, or sepsis as these conditions increase the risk of lactic acidosis.
Obesity &And
Metabolism
Dyslipidemia
Dyslipidemia Statin therapy is indicated for the primary prevention of atherosclerotic cardiovascular disease in all patients age > 40 with diabetes mellitus, regardless of LDL level.
Comorbid gastroesophageal reflux disease (GERD) is common in patients with asthma and can worsen asthma symptoms as a result of microaspiration. In asthma patients with
Asthma Lung Disease
signs and/or symptoms suggestive of comorbid GERD, proton-pump inhibitor therapy has shown benefit in improving asthma symptoms and peak expiratory flow rate.
Patients presenting to the emergency department with chest pain and suspected acute coronary syndrome (ACS) should be administered aspirin as soon as possible. Early
Coronary
SystemHeart Disease
antiplatelet therapy with aspirin reduces the rate of myocardial infarction and overall mortality in patients with ACS.
Hereditary spherocytosis is an inherited defect in the red blood cell membrane that presents with hemolytic anemia, jaundice, and splenomegaly. Acute cholecystitis from pigmented
Oncology
Hereditary Spherocytosis
gallstones is a common complication.
Glucose-6-phosphate dehydrogenase deficiency is an X-linked disorder commonly seen in African American men. It is characterized by episodic hemolysis in response to oxidants,
Oncology
G6PD Deficiency drugs, infections, or certain foods (e.g. fava beans). Heinz bodies and bite cells are characteristically seen on peripheral blood smear.
Folate and cobalamin deficiency both result in megaloblastic, macrocytic anemia. Folate supplementation can improve the anemia of either disorder but will not improve the
Oncology
neurologic changes of cobalamin deficiency. It is important to distinguish between the two prior to initiating therapy.
Anemia can be due to decreased red blood cell (RBC) production, increased RBC destruction, and frank blood loss. The anemia of lymphoproliferative disorders is due to bone
Oncology
Chronic Myeloid Leukemia
marrow infiltration with cancerous cells.
Systemic sclerosis can cause atrophy and fibrosis of the smooth muscle in the lower esophagus. This leads to decreased peristalsis and decreased tone in the lower esophageal
& Sports
Systemic
AndSclerosis
Vasculitides
sphincter. Typical symptoms include heartburn and dysphagia.
Hypovolemic shock is characterized by low cardiac output and a compensatory elevation in systemic vascular resistance. Central venous pressure and pulmonary capillary wedge
Heart
System
Failure AndHypovolemia
Shock pressure are low due to decreased intravascular blood volume.
Chronic use of exogenous glucocorticoids can cause secondary (central) adrenal insufficiency (AI) due to disruption of the hypothalamic-pituitary axis. Laboratory studies show low
ACTH and cortisol levels and a normal aldosterone level. In contrast, patients with primary Al have elevated ACTH, low aldosterone and cortisol, and significant electrolyte
Hypothalamus
& Metabolism
And
Hypopituitarism
Pituitary Disorders
abnormalities (e.g. hyperkalemia, hyponatremia).
TSH-secreting pituitary adenomas cause hyperthyroidism with elevated thyroid hormone and elevated or inappropriately normal TSH levels. Most TSH-secreting tumors are
Metabolism macroadenomas and can be associated with mass effect symptoms including headache, visual field defects, and impaired function of surrounding pituitary tissue.
Acromegaly is caused by excessive secretion of growth hormone (GH), usually due to a pituitary somatotroph adenoma. Insulin-like growth factor-1 mediates most of the effects of
GH and is the preferred initial test in suspected acromegaly. GH is not as sensitive due to wide fluctuations in circulating levels. Initial treatment for most patients includes
Hypothalamus
& Metabolism
And
Acromegaly
Pituitary Disorders
transsphenoidal resection of the pituitary adenoma.
Parkinsonism is caused by overactivity of cholinergic neurons and underactivity of dopaminergic neurons in the substantia nigra. A shuffling gait (i.e., the patient appears as if he was
Neurodegenerative
Parkinson
Disorders
Disease
And Dementias
chasing his center of gravity) is characteristic of the disease.
Nonalcoholic fatty liver disease resembles alcohol-induced liver disease but occurs in patients with minimal or no alcohol history. It is associated with insulin resistance. Severity can
Hepatic
& Nutrition
DisordersNonalcoholic Fattyrange
Liverfrom
Disease
bland steatosis to steatohepatitis to fibrosis and cirrhosis.
Hyperthyroidism from toxic adenoma is due to autonomous production of thyroid hormones from the hyperplastic thyroid follicular cells. The radioactive iodine uptake scan reveals
Metabolism uptake only in the hyperactive nodule, with suppression of uptake in the rest of the gland.
In type 2 heparin-induced thrombocytopenia (HIT), heparin induces a conformational change in a platelet surface protein which exposes a neoantigen. Antibodies are formed and
bind to the surface of platelets, resulting in platelet activation, thrombocytopenia, and a prothrombotic state. Type 2 HIT typically occurs 5-10 days after heparin initiation but may
occur sooner in patients previously exposed to heparin.
Epidemiology
InterpretationAndScatter
Use Ofplots
Evidence-Based
are useful forData
crude
(Including
analysisIndividualization,
of data. They canRisk-Benefit
demonstrate Analysis,
the typeSynthesis
of association
Of Concepts
(i.e. linear,
Withnon-linear),
Real Data) if any is present.
The porphyrias are disorders of heme synthesis. Porphyria cutanea tarda, the most common porphyria, is due to deficiency of uroporphyrinogen decarboxylase. It can be triggered by
4314 Medicine Dermatology Normal Structure Porphyria
And Function
Cutanea
Of Skin
the
Tarda
ingestion of ethanol or estrogens and is frequently associated with hepatitis C. Manifestations include photosensitivity with blisters and skin fragility.
Patients with an intracranial mass often have headache associated with nausea and vomiting and/or focal neurologic deficits. Symptoms are often worse at night and with body
Tumors Of The Nervous
Brain Tumors
System positioning that increases intracranial pressure. An MRI of the brain is usually diagnostic.
Humoral hypercalcemia of malignancy is the most common cause of parathyroid hormone (PTH)-independent hypercalcemia and frequently presents with very high, symptomatic
calcium levels. It is due to secretion of PTH-related protein by malignant cells. Other mechanisms of tumor-related hypercalcemia include osteolytic bone metastasis, increased
Miscellaneous
& Metabolism
Hypercalcemia production of 1,25-dihydroxyvitamin D, and increased interleukin-6 levels.
Untreated hyperthyroid patients are at risk for rapid bone loss from increased osteoclastic activity in the bone cells. Untreated hyperthyroid patients are also at risk for cardiac
Metabolism tachyarrhythmias, including atrial fibrillation.
Autoimmune adrenalitis is the most common cause of primary adrenal insufficiency (PAI) in developed countries. The key differentiating features of PAI from central adrenal
Adrenal&Disorders
Metabolism
insufficiency are the hyperpigmentation and hyperkalemia seen in PAI.
Primary adrenal insufficiency most commonly results from an autoimmune response against the bilateral adrenal cortex and often occurs in conjunction with other autoimmune
disease (e.g. primary hypothyroidism, vitiligo). Clinical manifestations result from deficiency of mineralocorticoids, glucocorticoids, and androgens and include fatigue, weight loss,
Adrenal&Disorders
Metabolism
hypotension, and hyperpigmentation of the skin and mucous membranes.
Primary hyperparathyroidism is characterized by autonomous secretion of parathyroid hormone from parathyroid adenomas or parathyroid hyperplasia. Most patients have mild,
Miscellaneous
& Metabolism
Hyperparathyroidism
asymptomatic hypercalcemia, but potential clinical features include nephrolithiasis, osteoporosis, nausea, constipation, and neuropsychiatric symptoms.
Patients with upper gastrointestinal bleeding often have an elevated blood urea nitrogen (BUN) and elevated BUN/creatinine ratio, possibly due to increased urea production (from
Gastroesophageal
intestinal breakdown of hemoglobin) and increased urea reabsorption (due to hypovolemia).
Recurrent bacterial infections in an adult should raise suspicion for common variable immunodeficiency. Quantitative measurement of serum immunoglobulin levels is needed to
Immune Deficiencies
Common Variableestablish
Immunodeficiency
the diagnosis.
Dual antiplatelet therapy (aspirin and a P2Y12 receptor blocker) leads to a reduction in recurrent myocardial infarction (MI) and cardiovascular death compared to aspirin alone in
Coronary
SystemHeart Disease
patients with non-ST elevation MI. It also reduces the risk of stent thrombosis and is recommended in all patients for at least 12 months following drug-eluting stent placement.
Cor pulmonale refers to isolated right-sided heart failure (RHF) from pulmonary hypertension, most commonly due to chronic obstructive pulmonary disease. Signs of RHF include
jugular venous distension, increased intensity of P2 (pulmonic component of the 2nd heart sound), right ventricular heave, hepatomegaly, dependent pitting edema, and possible
Critical Care
Vascular
CorAnd
Pulmonale
Cardiopulmonary
ascites. Disease
Vitiligo is an autoimmune condition characterized by areas of depigmentation due to destruction of melanocytes. It can be associated with other autoimmune conditions, such as
4296 Medicine Dermatology Normal Structure Vitiligo
And Function Of Skin
pernicious anemia, autoimmune thyroid disease, type 1 diabetes mellitus, primary adrenal insufficiency, hypopituitarism, and alopecia areata.
Methotrexate is a disease-modifying antirheumatic drug used for rheumatoid arthritis. Macrocytic anemia and hepatotoxicity are common adverse effects. The toxicity of methotrexate
& Sports
Rheumatoid
And Vasculitides
Arthritis
(including hepatotoxicity) can be mitigated by the administration of folic acid, which does not reduce the effectiveness of the drug.
Counseling for nonpharmacologic therapy (lifestyle modification) should be part of the overall management of hypertension at every office visit. All patients should be encouraged to
Hypertension
restrict dietary salt intake; have a diet rich in fruit, vegetables, and low-fat dairy products; engage in regular aerobic exercise; lose weight; and limit alcohol intake.
The most common causes of hyperkalemia include acute or chronic kidney disease, medications, or disorders impairing the renin-angiotensin axis. Common offending medications
include nonselective β-adrenergic blockers, potassium-sparing diuretics (e.g. amiloride), angiotensin-converting-enzyme inhibitors, angiotensin II receptor blockers, and nonsteroidal
Fluid,
Systems
Electrolytes,
& Electrolytes
Hyperkalemia
And Acid-Base anti-inflammatory drugs.
Initial interventions for all patients with carotid artery stenosis should include intensive medical management (i.e. aspirin, statin, blood pressure control) and counseling on lifestyle
changes. Symptomatic patients (i.e. transient ischemic attack or ischemic stroke in the distribution of the affected vessel) with high-grade carotid stenosis (70%-99%) should be
Carotid Artery Stenosis
considered for carotid endarterectomy to reduce future stroke risk.
Painless thyroiditis is a variant of chronic lymphocytic (Hashimoto) thyroiditis. It is characterized by a self-limited hyperthyroid phase due to release of preformed thyroid hormone,
followed by a hypothyroid phase or return to a euthyroid state. It does not require specific therapy, but a β blocker may be prescribed to control symptoms due to hyperthyroidism (e.
Metabolism g. palpitations, tremulousness).
Patients with influenza abruptly develop systemic (fever, malaise, myalgia, headache) and upper/lower respiratory (rhinorrhea, sore throat, nonproductive cough) symptoms. In the
Viral Infections Influenza absence of risk factors (e.g. age > 65, chronic medical conditions) for influenza complications, most adults do not require testing and are treated symptomatically.
Necrotizing (malignant) otitis externa is a severe infection of the external auditory canal that extends to the skull base and is usually caused by Pseudomonas aeruginosa. It is seen
Disorders
(ENT)
Of The Otitis
Ear, Nose,
Externa
And Throat
most frequently in elderly patients with diabetes mellitus. Intravenous ciprofloxacin is the first-line therapy.
Alcoholic hepatitis (AH) is most commonly seen in patients with a history of chronic heavy alcohol use. AH is characterized by fever, jaundice, anorexia, and tender hepatomegaly
Hepatic
& Nutrition
DisordersAlcoholic Liver Disease
with laboratory results showing an aspartate aminotransferase to alanine aminotransferase ratio of > 2:1.
Patients with severe aortic stenosis can have angina, syncope/presyncope, and heart failure symptoms. Physical examination typically reveals diminished and delayed carotid
Valvular
Aortic Stenosis pulses, a soft and single S2, and a late-peaking, crescendo-decrescendo systolic murmur best heard at the right upper sternal border.
Hemisection of the spinal cord can cause Brown-Séquard syndrome, which is characterized by the following: Ipsilateral hemiparesis and diminished proprioception, vibratory
Brown-Séquard Hemicord
sensation,
Syndrome
and light touch at the level of the spinal cord injury and below; Contralateral diminished pain and temperature sensation 1-2 levels distal to the cord injury and below.
Elevated plasma brain natriuretic peptide levels have high sensitivity for the diagnosis of congestive heart failure. In contrast, clinical signs of congestive heart failure (e.g. bilateral
Heart
System
Failure AndAcute
ShockHeart Failure
lung crackles, elevated jugular venous pressure, lower extremity edema, third heart sound) have high specificity but low sensitivity for the diagnosis.
Lateral medullary infarct (Wallenberg syndrome) occurs due to occlusion of the posterior inferior cerebellar or vertebral artery. Patients develop loss of pain and temperature over the
ipsilateral face and contralateral body, ipsilateral bulbar muscle weakness, vestibulocerebellar impairment (e.g. vertigo, nystagmus), and Horner syndrome. Motor function of the face
Ischemic Stroke and body is typically spared.
Acute unilateral motor weakness without sensory deficits or higher cortical dysfunction (pure motor hemiparesis) is suggestive of a lacunar stroke affecting the posterior limb of the
internal capsule. Lacunar infarcts are most commonly associated with chronic hypertension, which leads to arteriolar sclerosis and occlusion of deep penetrating branches of the
Ischemic Stroke major cerebral arteries.
Drug-induced type 1 hypersensitivity reactions are immediate in onset and mediated by IgE and mast cells/basophils. Mild manifestations of a drug allergy (e.g. urticaria and pruritus
4267 Medicine Dermatology Miscellaneous Drug Allergy without systemic symptoms) are usually treated with antihistamines and discontinuation of the offending drug.
Nephrotic syndrome is a hypercoagulable condition which manifests as venous or arterial thrombosis, and even pulmonary embolism. Renal vein thrombosis is the most frequent
manifestation. Complications of nephrotic syndrome include: protein malnutrition, iron-resistant microcytic hypochromic anemia, increased susceptibility to infection, and vitamin D
Glomerular
Systems &Diseases,
Electrolytes
Glomerular
Nephrotic/Nephritic
Disorders
deficiency.
Syndrome
Critical Care Chronic Cough Chronic nonproductive cough is a common side effect of ACE inhibitors that is likely due to increased circulating levels of kinins, substance P, prostaglandins, and thromboxane.
The receiver operating characteristic curve of a quantitative diagnostic test demonstrates the trade-off between the test’s sensitivity and specificity at various cutoff points. Changing
Epidemiology
And Principles
ReceiverOfOperating
TestingtheCharacteristic
cutoff point to increase the true-positive rate (directly proportional to sensitivity) will also increase the false-positive rate (inversely proportional to specificity).
Lifestyle modifications, including alcohol cessation and weight loss, are recommended to prevent recurrent gout attacks. Medications for lowering serum urate are indicated for
& Sports
Gout patients with repeated attacks of gouty arthritis or complicated disease (e.g. tophi, uric acid kidney stones).
PituitarySystem
Tumors Craniopharyngiomas are benign suprasellar tumors that present with visual defects, headache, and symptoms of pituitary hormonal deficiencies.
Hypoparathyroidism (parathyroid hormone deficiency) is characterized by hypocalcemia and hyperphosphatemia in the presence of normal renal function. Causes of
Miscellaneous
& Metabolism
Hypocalcemia hypoparathyroidism include postsurgical, autoimmune and nonautoimmune parathyroid destruction, and defective calcium-sensing receptor.
Cluster headaches usually present with acute, unilateral, severe retro-orbital pain that awakens patients from sleep. These headaches may be accompanied by redness and tearing,
Headache Cluster Headacherhinorrhea, and ipsilateral ptosis and miosis.
Diabetic ketoacidosis causes osmotic diuresis and secondary hyperaldosteronism, leading to urinary potassium loss and a total body potassium deficit. However, laboratory
potassium values are often normal or elevated. This finding is due to hyperosmolarity, which draws water and potassium into the extracellular space, and insulin deficiency, which
Diabetes& Mellitus
Metabolism
impairs cellular uptake of potassium.
Congestive heart failure due to left ventricular systolic dysfunction is characterized by decreased cardiac output/index, increased systemic vascular resistance (SVR), and an
Heart
System
Failure AndChronic
Shock Heart Failure
increase in left ventricular end-diastolic volume (LVEDV).
Tachycardia-mediated cardiomyopathy can develop in patients who have persistent or recurrent tachyarrhythmia with prolonged periods of rapid ventricular rate. Initial treatment is
Cardiac
System
Arrhythmias
Atrial
AndFibrillation
Syncope aimed at restoration of sinus rhythm or aggressive control of ventricular rate and can lead to significant improvement in left ventricular function.
Septic shock leads to a decrease in systemic vascular resistance (cardiac afterload) due to overall peripheral vasodilation. Hemodynamic monitoring in these patients reveals a low
Heart
System
Failure AndSepsis
Shock normal or decreased pulmonary capillary wedge pressure, low systemic vascular resistance, increased cardiac output (at least initially), and high mixed venous oxygen saturation.
Gastric contents are rich in hydrogen, chloride, and potassium. Therefore, vomiting causes hypochloremic metabolic alkalosis and hypokalemia. Bicarbonate levels rise as a result of
Fluid,
Systems
Electrolytes,
& Electrolytes
Metabolic
And Acid-Base
Alkalosis
hydrogen loss and activation of the renin-angiotensin system.
Myocardial infarction can lead to cardiogenic shock (e.g. hypotension, poor organ perfusion) due to impaired left ventricular contractility. Cardiac index is reduced, and pulmonary
Heart
System
Failure AndCardiogenic
Shock Shock
capillary wedge pressure (estimate of left atrial pressure) is elevated due to failure of forward blood flow.
Anaphylaxis is an IgE-mediated hypersensitivity reaction that can result from exposure to latex (e.g. surgical gloves, Foley catheter). Patients typically present with hypotension,
Anaphylaxis
Reactionstachycardia, urticarial rash, and wheezing, and they may develop life-threatening upper airway edema.
Legionnaires’ disease can present similarly to other atypical community-acquired pneumonias. However, concurrent gastrointestinal and central nervous system symptoms may
Legionella suggest Legionnaires’. Diagnosis can be confirmed with urine antigen testing in combination with culture.
Benign prostatic hyperplasia causes slow voiding, postvoid dribbling, hesitancy, urgency, or nocturia; complications include bladder outlet obstruction with acute urinary retention.
Management of acute retention includes bladder decompression with urethral or suprapubic catheterization; definitive treatment includes α blockers (e.g. terazosin, tamsulosin), 5-α
Disorders
System
Of The Urinary
Male Reproductive
Retentionreductase
System inhibitors (e.g. finasteride), and possibly surgery.
Diabetic autonomic neuropathy can affect the genitourinary tract to cause a neurogenic bladder with urinary retention and distended bladder. Patients can then develop overflow
Urinary
Systems
& Electrolytes
Urinary Incontinence
GUincontinence
Infection (e.g. dribbling, poor urinary stream) with a high post-void residual volume.
Statins inhibit intracellular HMG-CoA reductase enzyme, prevent conversion of HMG-CoA to mevalonic acid, and increase the number of cell membrane LDL receptors. Statins also
Cardiovascular
System Drugs
Drug Induced Myopathy
decrease coenzyme Q10 synthesis, which is involved in muscle cell energy production and possibly contributes to statin-induced myopathy.
Diffuse esophageal spasm is characterized by uncoordinated contractions of the esophagus and presents with chest pain and dysphagia. Esophageal manometry reveals multiple
Gastroesophageal
& Nutrition Diffuse
Disorders
Esophageal
simultaneous
Spasm contractions of the middle and lower esophagus. Esophagram may show a ‘corkscrew’ pattern. First-line treatment includes calcium channel blockers.
Living-donor renal transplantation provides the best survival benefit for patients with end-stage renal disease (ESRD). Both living-donor and deceased-donor transplantation provide
significant survival benefit over any form of chronic dialysis. Further benefits of renal transplantation over dialysis include better quality of life and improvement in ESRD-associated
Chronic
Systems
Kidney
& Electrolytes
Disease
complications (e.g. anemia, impaired bone metabolism).
Chronic pulmonary aspergillosis manifests with > 3 months of weight loss, cough, hemoptysis, and fatigue in patients with a history of underlying lung disease. Imaging usually
reveals > 1 apical cavitary lesions with or without an aspergilloma. Diagnosis is made with Aspergillus IgG serology in the setting of characteristic symptoms and radiographic
Critical Care
Infections
Aspergillosis findings.
Obesity and malignancy are important risk factors for deep venous thrombosis and pulmonary embolism (PE). Wheezing can occur in acute PE. An elevated alveolar-arterial oxygen
Critical Care
Vascular
Pulmonary
And Cardiopulmonary
Embolism
gradientDisease
is commonly seen in patients with PE.
Hemineglect syndrome is characterized by ignoring one side of a space (the left side in right-handed individuals) and involves the nondominant parietal lobe (the right lobe in right-
Ischemic Stroke handed individuals).
Cervical radiculopathy often arises in older individuals due to underlying cervical spondylosis. Manifestations generally include neck pain that radiates to the shoulder/arm and
unilateral upper extremity sensory, motor, and/or reflex abnormalities in a dermatomal distribution. Spine imaging generally shows abnormal facet joints, including the presence of
Cervical Spondylosis
sclerosis and osteophytes.
Lacunar stroke of the posterolateral thalamus typically presents with sudden-onset contralateral sensory loss involving all sensory modalities (i.e. pure sensory stroke). Weeks to
Ischemic Stroke months later, patients can develop thalamic pain syndrome, characterized by severe paroxysmal burning pain over the affected area that is exacerbated by light touch (allodynia).
Nonallergic rhinitis usually presents with one of the chronic rhinitis symptoms (nasal congestion, rhinorrhea, sneezing, and postnasal drainage) without a specific etiology. Routine
allergy testing is not necessary prior to initiating empiric treatment. Depending on the severity of the symptoms, patients should be treated with an intranasal antihistamine, intranasal
Disorders
(ENT)
Of The Rhinitis
glucocorticoids, or combination therapy.
Sarcoidosis typically affects young adults and is more common in African Americans. It is often discovered incidentally on routine chest x-ray by the presence of bilateral hilar
Critical Care
Pulmonary
Sarcoidosis
And Other Systemic
adenopathy.
Disorders
The underlying histopathologic lesion is noncaseating granulomas on tissue biopsy.
First-line treatment for erectile dysfunction in diabetic patients consists of phosphodiesterase-5 inhibitors (e.g. sildenafil). However, these medications can cause hypotension,
Disorders
System
Of The Male Sexual
Reproductive
Dysfunction
especially
System in patients who are taking α blockers or nitrates.
Hyponatremia in patients with congestive heart failure parallels the severity of heart failure and is an independent predictor of adverse clinical outcomes. It is caused by increased
Heart
System
Failure AndAcute
ShockHeart Failure
levels of renin, norepinephrine and antidiuretic hormone. Treatment involves fluid restriction, angiotensin-converting enzyme inhibitors, and loop diuretics.
Epidemiology
And Principles
Sensitivity,
Of Specificity,
TestingIf a test
NPV,result
PPVis negative, the probability of having the disease is 1 - negative predictive value.
NPV is the probability of being free of a disease if the test result is negative. Remember: the NPV will vary with the pretest probability of a disease. A patient with a high probability of
Epidemiology
And Principles
Sensitivity,
Of Specificity,
TestinghavingNPV,
a disease
PPV will have a low NPV, and a patient with a low probability of having a disease will have a high NPV.
Matching is frequently used in case-control studies because it is an efficient method to control confounding. Remember: matching variables should always be the potential
confounders of the study (e.g., age, race). Cases and controls are then selected based on the matching variables, such that both groups have a similar distribution in accordance
Epidemiology
with
Modification,
the variables.
Bias, Errors
Essential tremor most often presents as a tremor of the hands that is suppressed at rest, exacerbated by outstretched arms, and more pronounced at the end of goal-directed
Miscellaneous Tremor movements. It is often hereditary and can be associated with a head tremor, but it is not associated with other neurologic symptoms. The diagnosis is clinical.
Loss to follow-up in prospective studies creates a potential for attrition bias, a subtype of selection bias. When a substantial number of subjects are lost to follow-up, the study may
Epidemiology
Design AndBias
Interpretation overestimate or underestimate the association between the exposure and the disease. Investigators try to achieve high rates of follow-up to reduce the potential for attrition bias.
Primary pulmonary hypertension can be seen in middle-aged patients, and it presents with exertional breathlessness. Lungs are generally clear to auscultation. Chest x-ray would
Critical Care
Vascular
Pulmonary
And Cardiopulmonary
Arterialshow
Hypertension
enlargement
Disease of the pulmonary arteries with rapid tapering of the distal vessels (pruning) and enlargement of the right ventricle.
Compression of the median nerve at the wrist causes carpal tunnel syndrome, which is characterized by pain and paresthesia in the first 3 digits and the radial half of the fourth. The
Spinal/Peripheral
& Sports
Carpal
Nerve Disorders
Tunnel Syndrome
And
diagnosis
Back Pain
is usually made on clinical grounds, but nerve conduction studies can confirm the diagnosis.
An increasing prevalence but stable incidence of a disease can be attributed to factors that prolong the duration of the disease (e.g. improved quality of care and disease
EpidemiologyAndPrevalence
PopulationAnd
Health
Incidence
management).
Unfavorable metabolic side effects of thiazide diuretics include hyperglycemia, increased LDL cholesterol and plasma triglycerides, and hyperuricemia. Electrolyte abnormalities that
Fluid,
Systems
Electrolytes,
& Electrolytes
Primary
And Acid-Base
Hypertension
can be induced by thiazide diuretics include hyponatremia, hypokalemia, hypomagnesemia, and hypercalcemia.
The ulnar nerve is vulnerable to injury where it runs posterior to the medial epicondyle at the elbow. Features include decreased sensation in the medial hand, decreased grip
Ulnar Nerve
Nerves
Neuropathy
Andstrength,
Musclesand weakness of intrinsic hand muscles.
Patients with pyelonephritis who are vomiting, of older age, or septic or who have certain comorbidities (e.g. diabetes mellitus, urinary obstruction) typically require hospitalization and
Urinary Tract Infection
intravenous therapy. Most hospitalized patients can be transitioned to culture-guided oral antibiotics if symptoms are improved at 48 hours.
Streptococcus pneumoniae is the most common cause of community-acquired pneumonia. Manifestations tend to begin abruptly and include fever, chills, productive cough,
Critical Care
Infections
Community Acquired
leukocytosis,
Pneumonia and chest x-ray evidence of a lobar infiltrate.
Insulin resistance typical for patients with central-type obesity is the key pathogenic factor in the development of type-2 diabetes mellitus and associated abnormalities (hypertension,
Diabetes& Mellitus
Metabolism
Metabolic Syndrome
dyslipidemia). *Extremely high yield question for the USMLE!!!
Endocarditis Mitral valve disease, usually mitral valve prolapse with coexisting mitral regurgitation, is the most common valvular abnormality detected in patients with infective endocarditis.
Erectile dysfunction is common in patients with cardiovascular disease. First-line treatment includes phosphodiesterase-5 (PDE-5) inhibitors (e.g. sildenafil). PDE-5 inhibitors are
Disorders
System
Of The Male Sexual
Reproductive
Dysfunction
contraindicated
System in patients taking nitrates or α blockers as concomitant use can cause severe hypotension.
Febrile non-hemolytic transfusion reaction (FNHTR) is the most common adverse reaction and is caused by release of cytokines from leukocytes in the stored blood product.
Oncology Medicine
Blood TransfusionSymptoms develop within 1-6 hours and include transient fever, chills, and malaise. Leukoreduction of donor blood helps prevent FNHTR.
Brain death is a clinical diagnosis. The characteristic findings are absent cortical and brain stem functions. The spinal cord may still be functioning; therefore, deep tendon reflexes
Brain Death may be present.
ARP represents the excess risk in the exposed population that can be attributed to the risk factor. It can be easily derived from the relative risk using the following formula: ARP =
EpidemiologyAndRisk
Population Health
(RR - 1) / RR.
Oral estrogen preparations increase levels of thyroxine-binding globulin (TBG). Patients on thyroid replacement may need a higher dose to saturate the increased number of TBG
Reproductive
& Metabolism
Endocrinology
Menopausal Hormone
binding
Therapy
sites.
Acute renal allograft rejection is predominantly T-cell mediated and usually occurs within the first 6 months following transplant. Affected patients typically experience an
asymptomatic rise in serum creatinine. The diagnosis is confirmed by renal biopsy showing lymphocytic infiltration of the intima, and treatment is with high-dose intravenous
Acute
Systems
Kidney
& Electrolytes
Injury
Transplant Rejection
glucocorticoids.
GVHD is caused by recognition of host major and minor HLA-antigens by donor T-cells and consequent cell-mediated immune response. The organs that are typically affected
OncologyOf Oncology
Graft Versus Hostinclude
Diseasethe skin, intestine, and liver.
Secretory diarrhea is characterized by watery diarrhea that occurs even during fasting or sleep. Common etiologies include toxins (e.g. produced by Vibrio cholerae), hormones (e.g.
produced by VIPomas), congenital disorders of ion transport (e.g. cystic fibrosis), or unabsorbed bile acids (e.g. due to postsurgical changes). A low stool osmotic gap (< 50
Intestinal
& Nutrition
And Colorectal
ChronicDisorders
Diarrhea mOsm/kg) is typical.
Phenytoin commonly causes megaloblastic anemia and gingival hyperplasia due to impaired folic acid absorption in the jejunum. Supplementation with folic acid prevents these
Oncology
Folic Acid Deficiency
adverse effects. Calcium and vitamin D supplementation are also usually given to counter alterations in bone mineral metabolism that impair bone density.
Herpes simplex virus (HSV) encephalitis mainly affects the temporal lobe of the brain and may present acutely (< 1 week duration) with focal neurological findings. The characteristic
cerebrospinal fluid findings are lymphocytic pleocytosis, an increased number of erythrocytes, and elevated protein. HSV polymerase chain reaction analysis is the gold standard for
CNS Infections HSV Infection diagnosis.
Humoral hypercalcemia of malignancy is characterized by severe, symptomatic hypercalcemia. It is due to the release of parathyroid hormone-related protein by tumor cells, leading
Miscellaneous
& Metabolism
Hypercalcemia to increased bone resorption and reabsorption of calcium in the distal renal tubule.
Hepatojugular reflux is a useful clinical tool that can differentiate between cardiac- and liver disease-related causes of lower-extremity edema. Patients with peripheral edema due to
heart failure have elevated jugular venous pressure and positive hepatojugular reflux. Those with peripheral edema from primary hepatic disease and cirrhosis have reduced or
Heart
System
Failure AndChronic
Shock Heart Failure
normal jugular venous pressure and negative hepatojugular reflux.
Estrogen increases the level of T4-binding globulin. This effect is seen in pregnancy and in patients on oral contraceptives or menopausal estrogen replacement. Total thyroid
Metabolism hormone levels are elevated, but patients with normal hypothalamic-pituitary-thyroid function maintain a euthyroid state and normal TSH level.
Patients with chronic obstructive pulmonary disease who have resting arterial oxygen tension (PaO2) < 55 mm Hg or pulse oxygen saturation (SaO2) < 88% are candidates for long-
COPD Lung Disease
term home oxygen treatment. Those with signs of right heart failure or hematocrit > 55% should be started on home oxygen if PaO2 < 59 mm Hg or SaO2 < 89%.
Neurodegenerative
Multiple
Disorders
System
AndAtrophy
Dementias
Always consider multiple system atrophy when a patient with Parkinsonism experiences orthostatic hypotension, impotence, incontinence, or other autonomic symptoms.
Most thoracic aortic aneurysms are due to age-related degenerative changes that lead to disruption of the aortic medial layer, resulting in loss of elasticity and consequent aortic
Aortic
System
And Peripheral
Aortic
Artery
Aneurysm
Diseases
dilation. Chest x-ray often demonstrates a widened mediastinum, enlarged aortic knob, and tracheal deviation.
β blockers are first-line therapy for alleviating symptoms and improving exercise tolerance in patients with stable angina. They help prevent angina by decreasing exertional heart rate
Coronary
SystemHeart Disease
and myocardial contractility, leading to a reduction in myocardial oxygen demand. Calcium channel blockers and long-acting nitrates are also used.
Several systemic and cardiac manifestations of hyperthyroidism are due to an increase in sympathetic activity. β blockers are recommended as initial therapy for atrial fibrillation due
Cardiovascular
System Drugs
Hyperthyroidism to hyperthyroidism and should be continued until the patient becomes euthyroid with thionamides, radioiodine, and/or surgery.
Dermatomyositis is an idiopathic inflammatory myopathy with immune-mediated muscle injury that can be due to a paraneoplastic syndrome in malignancy. Patients typically have
Polymyositis And symmetrical
Dermatomyositis
proximal muscle weakness and erythematous rash over the dorsum of the fingers (Gottron sign) and/or upper eyelids (heliotrope eruption).
Epidemiology
In clinical
Trials trials, randomization is said to be successful when a similarity of baseline characteristics of the patients in the treatment and placebo groups is seen.
Vertebral osteomyelitis usually presents with fever, back pain, and focal spinal tenderness. Evaluation includes blood cultures and inflammatory markers (erythrocyte sedimentation
Osteomyelitis rate and C-reactive protein). Magnetic resonance imaging is the modality of choice for diagnosis, followed by computed tomography-guided bone biopsy.
Critical Care
Infections
Aspiration Pneumonia
Patients with impaired consciousness, advanced dementia, and other neurologic disorders are predisposed to aspiration pneumonia due to impaired swallowing and cough reflex.
Risk factors for aspiration pneumonia include altered consciousness due to excessive alcohol intake, neurologic dysphagia, or mechanical disruption of glottic closure. Patients
Critical Care
Infections
usually present with indolent symptoms, foul-smelling sputum, and concurrent periodontal disease.
Chronic obstructive pulmonary disease (COPD) is a disease of progressive airflow limitation characterized by a decreased FEV1/FVC ratio on pulmonary function testing. The
diffusion capacity of the lung for carbon monoxide (DLCO) is normal in chronic bronchitis-predominant COPD and decreased in emphysema-predominant COPD. Interstitial lung
COPD Lung Disease
disease is also marked by a decreased DLCO, but the FEV1/FVC ratio is normal.
Pneumocystis jirovecii is an opportunistic pathogen that typically infects those with advanced AIDS or individuals receiving chronic glucocorticoid therapy. Indolent manifestations
usually develop in patients with AIDS, but acute respiratory failure usually develops in those receiving chronic immunosuppressive therapy. Bilateral, diffuse interstitial infiltrates are
Fungal Infections Pneumocystis Pneumonia
common on chest x-ray.
Histoplasma capsulatum is prevalent in the central, midwestern, and northeastern United States. Inoculation typically occurs when patients are exposed to soil contaminated by bird
or bat droppings. Infections are usually subclinical in immunocompetent hosts; however, some patients (especially with high-dose (HD) exposure) may have subacute pulmonary
Critical Care
Infections
Histoplasmosis illness.
Epidemiology
Design AndRisk
Interpretation In a case-control study, if the outcome is uncommon in the population, the odds ratio is a close approximation of the relative risk (‘rare disease assumption’).
Right coronary artery occlusion can cause acute inferior and posterior wall myocardial infarctions (MIs). Inferior wall MI presents with ST-segment elevations in the inferior leads (II,
III, and aVF). ST-segment depression in leads V1 and V2 in this setting usually suggests a posterior wall MI. Inferior MI is also associated with hypotension, bradycardia, and
Coronary
SystemHeart Disease
atrioventricular block.
Epidemiology
And Distribution
Accuracy OfAnd
Data
Precision
Precision is the measure of random error. The tighter the confidence interval, the more precise the result. Increasing the sample size increases precision.
Patients with an acute asthma exacerbation usually have respiratory alkalosis with a low PaCO2 due to hyperventilation. A normal or elevated PaCO2 is an alarming and extremely
Asthma Lung Disease
important finding that suggests impending respiratory failure.
Diastolic and continuous murmurs are usually due to an underlying pathologic cause, and their presence should prompt further evaluation with a transthoracic echocardiogram.
Valvular
Midsystolic murmurs in otherwise young, asymptomatic adults are usually benign and do not require further evaluation.
Epidemiology
A confounder
Modification,
is Bias,
an extraneous
Errors factor that has properties linking it with both the exposure and the outcome of interest.
In HIV patients, both HSV and VZV can cause severe, acute retinal necrosis associated with pain, keratitis, uveitis, and funduscopic findings of peripheral pale lesions and central
retinal necrosis. In contrast, CMV retinitis is painless, not usually associated with keratitis or conjunctivitis, and characterized by funduscopic findings of hemorrhages and fluffy or
Disorders Of The HSV
Eye And
Infection
Associated
granular
Structures
lesions around the retinal vessels.
The diagnosis of community-acquired pneumonia requires the presence of a lobar, interstitial, or cavitary infiltrate on chest imaging (e.g. chest x-ray). Sputum and blood cultures are
Critical Care
Infections
Community Acquired
typically
Pneumonia
not required in the outpatient setting as empiric oral antibiotics are almost always curative.
Risk is the probability of getting a disease over a certain period of time. To calculate the risk, divide the number of diseased subjects by the total number of subjects at risk (i.e. all the
Epidemiology
Design AndRisk
Interpretation people at risk).
Re-entrant ventricular arrhythmias (e.g. ventricular fibrillation) are the most common cause of sudden cardiac arrest in the immediate post-infarction period in patients with acute
Coronary
SystemHeart Disease
myocardial infarction.
Inflammatory acne is treated with topical retinoids and benzoyl peroxide. Moderate and moderate-to-severe cases will benefit from the addition of topical antibiotics. Oral antibiotics
AcneInfections
Vulgaris and isotretinoin are usually reserved for severe or recalcitrant acne.
Recent studies have suggested that a brain that has seized for > 5 minutes (status epilepticus) is at increased risk of developing permanent injury due to excitatory cytotoxicity.
Seizures Cortical laminar necrosis is the hallmark of prolonged seizures and can lead to persistent neurologic deficits and recurrent seizures.
Critical And
Pleural Effusion Undiagnosed
Masses pleural effusion is best evaluated with thoracentesis, except in patients with clear-cut evidence of congestive heart failure. *Extremely high yield question for USMLE!!!
Diverticulosis is associated with chronic constipation. It is usually asymptomatic, but potential complications include hemorrhage and diverticulitis. The risk of complications is lower
Intestinal
& Nutrition
And Colorectal
Diverticular
Disorders
Disease
with increased intake of fruit and vegetable fiber; it is higher with heavy meat consumption, aspirin or nonsteroidal anti-inflammatory drug use, obesity, and smoking.
Angiodysplasia is characterized by dilated submucosal veins and arteriovenous malformations. It is a common cause of recurrent, painless gastrointestinal bleeding. Diagnosis is
Gastroesophageal
made on colonoscopy, although it is frequently missed. Asymptomatic patients do not require treatment. Those with anemia or bleeding can be treated with cautery.
Carbon monoxide poisoning can occur due to faulty indoor heating systems during the winter months. Both oxygen delivery and usage are disrupted, causing clinical manifestations
of cerebral hypoxia (e.g. headache, confusion, seizure, coma, death). Diagnosis is made by co-oximetry of arterial blood gas showing an elevated carboxyhemoglobin level, and
Exposure
Carbon Monoxidetreatment
Poisoningis with 100% oxygen.
A vertebral compression fracture is a common complication of advanced osteoporosis. Patients with osteoporosis can develop a compression fracture with acute back pain following
Spinal/Peripheral
& Sports
Vertebral
Nerve Disorders
Compression
And
minimal
Back
Fracture
trauma
Pain (e.g. bending, coughing, lifting). Examination may show localized/point tenderness, although neurological examination is typically normal.
Hypomagnesemia is an important cause of hypocalcemia, particularly in alcoholics. Hypomagnesemia causes decreased release of parathyroid hormone (PTH) and PTH resistance.
Normal &Structure
Metabolism
Hypocalcemia
Hypoparathyroidism
Glands induced by low magnesium is not associated with elevated phosphorus levels (as seen with other causes of hypoparathyroidism).
Gastrointestinal blood loss is the most common occult cause of iron deficiency anemia, especially in patients age > 50. Referral to a gastroenterologist for endoscopy is usually
Oncology
required.
Epidemiology
Interpretation
Tests The chi-square test is used to compare proportions. A 2 x 2 table may be used to compare the observed values with the expected values.
Lumbosacral strain is the most common cause of acute back pain. It is often triggered by twisting, lifting, or physical exertion. The pain and tenderness are localized primarily to the
Spinal/Peripheral
& Sports
Back
NervePain
Disorders And
lumbar
Back
paraspinal
Pain area, but pain may radiate to the buttocks, hips, and thighs. Straight-leg raising test and neurologic examination are typically normal.
Topical retinoids are first-line treatment for noninflammatory (comedonal) acne with the addition of organic acid preparations (e.g. salicylic, azelaic, or glycolic acid) if initial therapy
AcneInfections
Vulgaris fails. Benzoyl peroxide, an antibacterial agent, may be used for comedonal acne, but is preferred for inflammatory acne.
A number of features are helpful in differentiating ulcerative colitis (UC) and Crohn disease (CD), including involvement of multiple portions of the gastrointestinal tract, rectal sparing,
Intestinal
& Nutrition
And Colorectal
Inflammatory
Disorders
Bowel
presence
Disease
of noncaseating granulomas, and fistula formation, all of which are more suggestive of CD than UC.
Surgical resection is recommended for solitary brain metastasis in patients with good performance status and stable extracranial disease. In patients with multiple brain metastases,
Brain Tumors
System whole brain radiation therapy is typically used.
Iron studies are indicated in patients who present with microcytic/hypochromic anemia. These are useful in confirming the diagnosis of iron deficiency anemia, which is the usual
Oncology
cause of microcytic/hypochromic anemia, and in ruling out other causes.
When dealing with an angry patient, the most appropriate response is to remain non-defensive, acknowledge that the patient is upset, and begin the discussion with an open-ended
Communication
And
Professional
Interpersonal
Conduct
Skills
question.
Aspirin-exacerbated respiratory disease (AERD) is a non-IgE-mediated reaction that results from aspirin-induced prostaglandin/leukotriene misbalance. It is most often seen in
patients with a history of asthma or chronic rhinosinusitis with nasal polyposis. AERD is characterized by bronchospasm and nasal congestion following aspirin ingestion. Treatment
Asthma Lung Disease
includes avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs), desensitization if NSAIDs are required, and the use of leukotriene receptor antagonists (e.g. montelukast).
Viral myocarditis is a potential cause of dilated cardiomyopathy in relatively young adults (e.g. age < 55). Patients usually present with decompensated heart failure that is often
Myopericardial
System Diseases
Dilated Cardiomyopathy
preceded by a viral prodrome. Echocardiography typically shows biventricular enlargement with diffuse ventricular wall hypokinesis.
Depression-related cognitive impairment may be so severe in elderly patients that they appear to have dementia. Psychotherapy and/or antidepressant medications are the treatment
Neurodegenerative
Depression
Disorders And Dementias
of choice for elderly patients with depression and frequently result in reversal of cognitive deficits.
Measures to prevent urinary calcium stone formation include increasing fluid intake, following a low-sodium, low-protein diet, maintaining moderate calcium intake, and taking thiazide
Nephrolithiasis,
Hematuria,
Renal Calculi
And Urinary
diuretics
TracttoObstruction
lower urinary calcium excretion.
Pharmacologic vasodilator stress testing (e.g. adenosine) causes a marked increase in blood flow in normal coronary arteries and a relatively small increase in blood flow in stenotic
Coronary
SystemHeart Disease
coronary arteries. The difference in blood flow allows for diagnosis of obstructive coronary artery disease due to reduced uptake of radioactive isotope in ischemic myocardium.
Congestive heart failure commonly causes transudative effusions (bilateral 61%, unilateral right-sided 27%, and unilateral left-sided 12%). Normal pleural fluid pH is 7.60.
Critical Care
Vascular
Pleural
And Cardiopulmonary
Effusion Transudative
Disease
fluid usually has a pleural fluid pH of 7.4-7.55.
Theophylline toxicity can manifest as central nervous system stimulation (e.g. headache, insomnia, seizures), gastrointestinal disturbances (e.g. nausea, vomiting), and cardiac
COPD Lung Disease
toxicity (arrhythmia). Inhibition of the cytochrome oxidase system by other medications, diet, or underlying disease can alter its narrow therapeutic window.
Osteonecrosis is a common complication of systemic lupus erythematosus, and the risk is increased with chronic glucocorticoid use. It causes pain in the groin, thigh, or buttock that
Bone, Joint, And
& Sports
Soft
Osteonecrosis
Tissue InjuriesisAnd
worsened
Infections
by activity. Early examination findings and x-rays may be normal, and MRI is a more sensitive test.
Patients with cocaine-associated chest pain should be treated initially with intravenous benzodiazepines. These improve the symptoms of psychomotor agitation, reduce myocardial
oxygen demand, and alleviate cardiovascular symptoms. Aspirin, nitroglycerin, and calcium channel blockers are also effective in the initial management of cocaine-associated chest
Coronary
SystemHeart Disease
Cocaine pain. β blockers are contraindicated.
The use of noninvasive positive-pressure ventilation (NPPV) in patients with acute exacerbation of chronic obstructive pulmonary disease has been shown to decrease mortality, rate
COPD Lung Disease
of intubation, hospital length of stay, and incidence of nosocomial infections. Endotracheal intubation with mechanical ventilation is recommended for patients who fail a trial of NPPV.
Antibiotics are indicated for treatment of acute exacerbation of chronic obstructive pulmonary disease (COPD) in patients with moderate to severe exacerbation and those needing
COPD Lung Disease
mechanical ventilation. Antibiotics are not indicated in patients with mild COPD exacerbation.
Sideroblastic anemia usually manifests as microcytic/hypochromic anemia simulating iron deficiency anemia, but iron studies reveal elevated serum iron level and normal or
decreased total iron binding capacity. In patients with an identifiable cause of vitamin B6 deficiency (alcohol, medications), the administration of pyridoxine can easily correct the
Oncology
Sideroblastic Anemia
problem.
Leukocytosis
Lung Disease
Glucocorticoids cause a leukocytosis mainly through mobilization of marginated neutrophils and an increase in the number of circulating neutrophils.
Tricyclic antidepressant overdose can present with central nervous system, cardiac, and anticholinergic findings. Sodium bicarbonate is used to treat cardiac toxicity, which is
Toxicology Exposure
characterized by prolonged QRS duration (> 100 msec) and ventricular arrhythmias (e.g. ventricular tachycardia, ventricular fibrillation).
Sepsis leads to hypotension and intravascular volume depletion and is a common cause of prerenal acute kidney injury (AKI). Prerenal AKI is characterized by low urinary sodium (<
Acute
Systems
Kidney
& Electrolytes
Injury
Prerenal Azotemia20 mEq/L), low fractional excretion of sodium (< 1%), and elevated blood urea nitrogen/creatine ratio (> 20:1). Urine sediment is bland.
Uric acid stones are often radiolucent but may be seen on renal ultrasound or CT scan. They are highly soluble in alkaline urine; alkalization of the urine to pH 6.0-6.5 with oral
Nephrolithiasis,
Hematuria,
Renal Calculi
And Urinary
potassium
Tract Obstruction
citrate is the treatment of choice.
Cardiovascular disease is the most common cause of death in patients with end-stage renal disease (ESRD) and accounts for approximately 50% of all deaths in this population.
This is likely due to an increased prevalence of traditional cardiovascular risk factors (e.g. hypertension, advanced age) and ESRD-related risks (e.g. anemia of chronic kidney
Chronic
Systems
Kidney
& Electrolytes
Disease
disease, oxidative stress related to dialysis).
Treatment for community-acquired pneumonia (CAP) is dependent on the required level of care (e.g. outpatient, medical floor, intensive care). Common tools for risk stratification
include the pneumonia severity index and CURB-65 criteria. Patients with CAP who are hospitalized on the medical floor require treatment with a β-lactam plus macrolide (e.g.
ceftriaxone plus azithromycin) or fluoroquinolone (e.g. moxifloxacin). Fluoroquinolones should generally be avoided in elderly patients (when possible) due to the risk of Clostridium
Critical Care
Infections
Community Acquired
difficile
Pneumonia
infection, tendon rupture, and aortic dissection.
A detailed history and neurologic examination of a patient with a stroke can often localize the region of brain dysfunction and the involved vasculature. An anterior cerebral artery
stroke is characterized by contralateral motor or sensory deficits, which are more pronounced in the lower limb than the upper limb. Urinary incontinence can also be seen
Ischemic Stroke occasionally.
The power of a study represents its ability to detect a difference between 2 groups (e.g. exposed versus unexposed) when there truly is a difference. Increasing the sample size
increases the power of a study and consequently narrows the confidence interval surrounding the point estimate. Confidence intervals express statistical significance and are
Epidemiology
Design AndP-Value
Interpretation
And Confidence
interrelated
Interval
with p-values.
Spirometry before and after administration of a bronchodilator is the most effective way to differentiate asthma from chronic obstructive pulmonary disease (COPD). Reversal of
airway obstruction by the bronchodilator suggests asthma. Patients with COPD may have a partial bronchodilator response, but normal airflow after bronchodilator administration
Asthma Lung Disease
rules COPD out.
Systemic sclerosis (SS) is divided into diffuse cutaneous and limited cutaneous subtypes. Although there is considerable overlap in disease manifestations between the 2 subtypes,
& Sports
Systemic
AndSclerosis
Vasculitides
internal organ involvement (e.g. interstitial lung disease) is more common and more extensive in diffuse cutaneous SS, leading to a worse prognosis.
Hypercalcemia is common in patients with multiple myeloma. It is caused by osteolytic bone destruction. Fatigue, constipation, and depression are common symptoms of mild
Oncology
Cell Disorders
Multiple Myelomahypercalcemia.
Nocardia most commonly causes pulmonary disease in an immunocompromised host, with or without extrapulmonary manifestations (e.g. skin, central nervous system). Nocardiosis
Nocardiosis is diagnosed by culture and the presence of filamentous, gram-positive, weakly acid-fast rods on Gram stain. Trimethoprim-sulfamethoxazole is the treatment of choice.
Herpetic whitlow is a viral infection of the hand caused by herpes simplex virus. Most adult infections are acquired from contact with genital herpetic lesions or infected orotracheal
4011 Medicine Dermatology Skin Tumors And HSV
Tumor-Like
Infection
Lesions
secretions. Spontaneous resolution is the norm but recurrences are common.
Analgesic nephropathy is the most common form of drug-induced chronic renal failure. Papillary necrosis and chronic tubulointerstitial nephritis are the most common pathologies
Acute
Systems
Kidney
& Electrolytes
Injury
Acute Interstitial Nephritis
seen. Patients with chronic analgesic abuse are also more likely to develop premature aging, atherosclerotic vascular disease, and urinary tract cancer.
Nephrolithiasis,
Hematuria,
HematuriaAnd Urinary
Rifampin
Tractcauses
Obstruction
red to orange discoloration of body fluids. ‘Red urine’ in a patient taking rifampin is usually a benign drug effect.
Long-term analgesic use with 1 or more analgesics (e.g. nonsteroidal anti-inflammatory drug such as aspirin) can cause chronic kidney disease due to tubulointerstitial nephritis and
Acute
Systems
Kidney
& Electrolytes
Injury
hematuria due to papillary necrosis.
Age-dependent idiopathic sclerocalcific changes are the most frequent cause of isolated aortic stenosis in elderly patients. These changes are common and usually have minimal
Valvular
Aortic Stenosis hemodynamic significance, but sometimes may be severe.
An outlier is defined as an extreme and unusual value observed in a dataset. The mean is very sensitive to outliers and easily shifts toward them. The median and mode are more
Epidemiology
And Distribution
Central Tendency
Of Data resistant
(Mean, Median,
to outliers.
Mode, Outliers)
Epidemiology
Randomization
Modification, is
Bias,
usedErrors
to control for confounders during the design stage of a study. It helps to control for known, unknown, and difficult-to-measure confounders.
Lumbosacral radiculopathy (sciatica) is due to nerve root compression, usually by a herniated disc or lumbar spondylosis. Most patients experience spontaneous resolution. Initial
Spinal/Peripheral
& Sports
Back
NervePain
Disorders And
management
Back Painis focused primarily on short-term relief of symptoms with nonsteroidal anti-inflammatory drugs or acetaminophen.
Factor V Leiden is the most commonly inherited hypercoagulable disorder in the Caucasian population, leading to increased risk of thrombosis. Testing should be considered for an
Inherited Thrombophilia
unprovoked first-time thrombus in young (age < 45) patients or those with an unusual site of thrombus.
Epidemiology
And Principles
StatisticalOfTests
TestingThe two-sample t-test is a statistical method that is commonly employed to compare the means of two groups of subjects.
Rheumatoid arthritis predisposes to amyloidosis. Renal involvement is characterized by nephrotic syndrome. The class pathologic finding is amyloid deposits that stain with Congo
red and demonstrate apple-green birefringence under polarized light. Multiple myeloma is the most common cause of AL amyloidosis, and rheumatoid arthritis is the most common
Chronic
Systems
Kidney
& Electrolytes
Disease
Amyloidosis cause of AA amyloidosis.
Polycystic ovary syndrome may present with irregular menses and signs of hyperandrogenism (e.g. hirsutism). Treatment involves weight loss and oral contraceptives containing
Reproductive
& Metabolism
Endocrinology
Polycystic Ovary Disease
estrogen and progestin to regulate menstrual cycles.
Isolated systolic hypertension, an important cause of hypertension in elderly patients, is caused by increased stiffness or decreased elasticity of the arterial wall. It is associated with
Hypertension
an increase in cardiovascular morbidity and mortality, and management should be similar to that of primary hypertension, with lifestyle modifications and pharmacologic therapy.
Epidemiology
And Distribution
Normal Distribution
Of Data A normal distribution is symmetric and bell-shaped. All its measures of central tendency are equal: mean = median = mode.
Epidemiology
Design AndCorrelation
Interpretation
Coefficient
The correlation coefficient (r) shows the strength and direction (positive, negative) of linear association between 2 variables. It does not necessarily imply causality.
High-dose intravenous acyclovir can cause crystalluria with renal tubular obstruction. Administering intravenous fluids concurrently with the drug can help reduce the risk of acute
Acute
Systems
Kidney
& Electrolytes
Injury
Acute Kidney Injury
kidney injury.
The early stages of diabetic nephropathy (DN) involve a period of glomerular hyperfiltration, which is primarily driven by an increase in hormonal mediators that lead to renal afferent
arteriole vasodilation and efferent arteriole vasoconstriction. The consequent increase in glomerular hydrostatic pressure stimulates glomerular capillary sclerosis and facilitates the
gradual progression of DN. ACE inhibitors and angiotensin II receptor blockers decrease renal efferent arteriole vasoconstriction, reducing glomerular hydrostatic pressure and
Chronic
Systems
Kidney
& Electrolytes
Disease
Diabetic Nephropathy
slowing the rate of DN progression.
HIV-associated nephropathy is thought to be caused by direct infection of the renal epithelial cells by HIV and typically presents with heavy proteinuria, rapidly progressive renal
Glomerular
Systems &Diseases,
Electrolytes
FSGS Nephrotic/Nephritic
failure, Syndrome
and edema. It is most common in patients of sub-Saharan African descent with advanced HIV infection.
Epidemiology
And Distribution
Central Tendency
Of Data The
(Mean,
median
Median,
is theMode,
valueOutliers)
that is located in the middle of a dataset. It divides the right half of the data from the left half.
Miscellaneous
& Metabolism
Hypocalcemia, hyperphosphatemia, and increased parathyroid hormone levels are characteristic biochemical abnormalities of secondary hyperparathyroidism in chronic renal failure.
Calcineurin inhibitors (e.g. tacrolimus, cyclosporine) have a wide range of adverse effects, including nephrotoxicity, hypertension, neurotoxicity (e.g. tremor), and impaired glucose
Transplant Medicine
Calcineurin Inhibitors
control.
Uremic pericarditis (UP) occurs in 6%-10% of renal failure patients, typically those with blood urea nitrogen levels > 60 mg/dL. Most UP patients do not present with the classic
electrocardiogram changes of pericarditis (e.g. diffuse ST-segment elevations). Hemodialysis leads to rapid resolution of chest pain and reduces the size of any associated
Miscellaneous
System Chronic Kidney Disease
pericardial effusion.
Erythropoietin is the treatment of choice for anemia related to chronic kidney disease. Hypertension is a common side effect of erythropoietin; patients who receive large doses or
Oncology
experience a rapid rise in hemoglobin concentration are at highest risk.
High-dose niacin therapy to treat lipid abnormalities frequently produces cutaneous flushing and pruritus. This side effect is explained by prostaglandin-induced peripheral
Cardiovascular
System Drugs
Dyslipidemia vasodilatation and can be reduced by low-dose aspirin.
Patients with sickle cell trait, a carrier mutation, do not typically have specific symptoms of sickle cell disease; however, sickling can occur in the setting of physiologic stress (e.g. low
Nephrolithiasis,
Hematuria,
Sickle CellAnd Urinary
oxygen
Tract
tension,
Obstruction
dehydration, acidosis), leading to renal papillary necrosis with hematuria and possibly flank pain.
Vasovagal syncope is a type of reflex syncope preceded by a trigger (e.g. strong emotion) and a prodrome (e.g. pallor, light-headedness). A neurally mediated reflex response
SyncopeNerves And(cardioinhibitory
Muscles and vasodepressor) leads to brief (e.g. < 1-2 min) loss of consciousness, followed by rapid and complete recovery.
General treatment measures in patients with vasovagal syncope include reassurance and education about the benign nature of the condition. Patients should be advised to avoid
Cardiac
System
Arrhythmias
Syncope
And Syncope triggers and to use physical counterpressure maneuvers during the prodromal phase in order to abort or delay an episode of syncope.
Epidemiology
Design AndHypothesis
Interpretation
Testing
The null hypothesis is the statement of no relationship between the exposure and the outcome. To state the null hypothesis correctly, the study design should be considered.
Generalizability or external validity pertains to the applicability of study results to other populations (e.g. the results of a study in middle-aged women would not be expected to be
Epidemiology
Design AndValidity
Interpretation
And Reliability
applicable to elderly men).
Hypovolemia is a common cause of orthostatic hypotension and orthostatic syncope, especially in elderly patients. Due to decreased renal perfusion and activation of the renin-
Critical Care
Care And Trauma
Hypovolemia
Medicine angiotensin-aldosterone system, decreased urine sodium is usually present in patients with hypovolemia.
Transesophageal echocardiogram has excellent sensitivity and specificity for the diagnosis of aortic dissection and is the preferred diagnostic study in patients with hemodynamic
Aortic
System
And Peripheral
Aortic
Artery
Dissection
Diseases
instability or renal insufficiency. CT angiography and MR angiography should be avoided in patients with moderate to severe kidney disease.
Muddy brown granular cast - Acute tubular necrosis; Red blood cell casts - Glomerulonephritis; White blood cell casts - Interstitial nephritis and pyelonephritis; Fatty casts - Nephrotic
Acute
Systems
Kidney
& Electrolytes
Injury
Acute Kidney Injury
syndrome; Broad and waxy casts - Chronic renal failure; *Extremely high yield question for the USMLE!!!
Huntington disease (HD) presents with psychiatric symptoms (e.g. depression, irritability), cognitive impairment, and chorea. HD is an autosomal dominant CAG trinucleotide repeat
Congenital And Developmental
Huntington Disease
Anomalies
expansion disorder with no known disease-modifying treatment.
Metabolism Systolic hypertension in thyrotoxicosis is caused by hyperdynamic circulation resulting from increased myocardial contractility and heart rate.
Platelet dysfunction is the most common cause of abnormal hemostasis in patients with chronic kidney disease. PT, PTT, and platelet count are normal. Bleeding time is prolonged.
DDAVP is usually the treatment of choice, if needed. DDAVP increases the release of factor VIII:von Willebrand factor multimers from endothelial storage sites. Platelet transfusion is
Chronic
Systems
Kidney
& Electrolytes
Disease
not indicated because the transfused platelets quickly become inactive. *Extremely high yield question for USMLE!!!
Cholesterol embolization should be suspected in patients with multisystem involvement with acute or subacute renal failure, typical skin manifestations (e.g. livedo reticularis, blue toe
Coronary
SystemHeart Disease
Atheroembolism syndrome), cerebral or intestinal ischemia, and Hollenhorst plaques after recent arteriography or cardiac catheterization.
Effect modification results when an external variable positively or negatively impacts the effect of a risk factor on the disease of interest. Stratified analysis helps determine whether a
Epidemiology
variable
Modification,
is a confounder
Bias, Errors
or an effect modifier.
Glomerular
Systems &Diseases,
Electrolytes
MPGN Nephrotic/Nephritic
Membranoproliferative
Syndrome glomerulonephritis, type 2, is a unique glomerulopathy that is caused by persistent activation of the alternative complement pathway.
Sublingual nitroglycerin is used as a first-line agent for rapid relief of symptoms in patients with angina pectoris. The anti-ischemic effect of nitrates is mediated by systemic
Coronary
SystemHeart Disease
vasodilation with a decrease in left ventricular end-diastolic volume and wall stress resulting in decreased myocardial oxygen demand.
Critical Care Chronic Cough ACE inhibitors commonly cause chronic cough and should be considered in the differential diagnosis in all patients taking the medication.
Multiple myeloma is a plasma cell neoplasm. It is characterized by the excessive production of monoclonal protein that can accumulate in the kidneys and cause renal insufficiency.
Oncology
Cell Disorders
Multiple MyelomaApproximately 50% of patients with multiple myeloma have renal insufficiency at diagnosis.
Hypertensive nephrosclerosis develops in patients with chronically uncontrolled hypertension and is characterized by hyaline arteriolosclerosis and ischemic glomerulosclerosis.
Chronic
Systems
Kidney
& Electrolytes
Disease
Hypertensive Nephropathy
Clinical features include progressive, irreversible renal insufficiency with mild proteinuria and small, atrophic kidneys.
The concept of a latency period can be applied to both disease pathogenesis and exposure to risk modifiers. Exposure to risk factors and the initial steps in disease pathogenesis
sometimes occur years before clinical manifestations are evident. In addition, exposure to risk modifiers may need to be continuous over a certain period before influencing the
Epidemiology
Design AndBias
Interpretation outcome.
Autosomal dominant polycystic kidney disease is commonly associated with cerebral aneurysms that may rupture and lead to intracranial bleeding. This association is likely related
Cystic
Systems
Kidney
& Electrolytes
Diseases
Polycystic Kidneyto
Disease
both impaired vascular integrity caused by the underlying PKD gene mutation as well as the hypertension that is typically present with the disease.
Manifestations of Pneumocystis pneumonia (PCP) in patients with HIV are usually indolent and include nonproductive cough, exertional dyspnea, fever, hypoxia, elevated lactate
dehydrogenase, and bilateral interstitial infiltrates. Trimethoprim-sulfamethoxazole is the first-line treatment. Concomitant corticosteroids are administered for those with PaO2 < 70
mm Hg, alveolar-arterial gradient > 35 mm Hg, or pulse oximetry < 92% on room air to reduce risk of respiratory decompensation.
Nonsteroidal anti-inflammatory drugs are a common cause of iron deficiency anemia, often through chronic blood loss from the gastrointestinal tract. Iron deficiency anemia should
prompt a thorough evaluation for the cause as early low-grade bleeding can herald later catastrophic hemorrhage. Elderly patients often have a low-grade chronic anemia at baseline
Miscellaneous
& Nutrition Iron Deficiency Anemia
and may not tolerate additional blood loss.
Headache Cluster HeadacheProviding 100% oxygen by facemask is an effective and rapid method used to abort an acute cluster headache without major side effects.
The p-value is the probability of observing a given (or more extreme) result due to chance alone, assuming the null hypothesis is true. A result is generally considered statistically
Epidemiology
Design AndP-Value
Interpretation
And Confidence
significant
Interval
when p < 0.05.
Renovascular hypertension should be suspected in all patients with resistant hypertension and diffuse atherosclerosis, asymmetric kidney size, recurrent flash pulmonary edema, or
elevation in serum creatinine > 30% from baseline after starting an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker. The presence of a continuous abdominal
Hypertension
bruit has a high specificity for the presence of renovascular hypertension.
A precise tool is one that consistently provides a very similar or identical value when measuring a fixed quantity. An accurate tool is one that provides a measurement similar to the
Epidemiology
And Principles
AccuracyOfAnd
Testing
Precision
actual value or within a specified range of a reference value (as reflected by a gold-standard measurement).
A case-control study is used to compare the exposure of people with the disease (cases) to the exposure of the people without the disease (controls). The main measure of
Epidemiology
Design AndOdds
Interpretation
Ratio association is the exposure odds ratio.
Oncology
Heavy alcohol use is a common cause of nutritional folate deficiency in the United States and would cause megaloblastic anemia.
Viridans group streptococci colonize the oral mucosa and can cause infective endocarditis of a structurally abnormal heart valve following dental procedures. Patients typically have a
Endocarditis subacute presentation with several weeks of fatigue and low-grade fever.
Coarctation of the aorta is a narrowing of the descending aorta that leads to a proximal arterial pressure load. Patients typically present with upper extremity hypertension and
diminished femoral pulses with brachial-femoral delay. Chest x-ray usually demonstrates inferior notching of the third to eighth ribs due to pressure-induced enlargement of the
Congenital
System Heart Aortic
DiseaseCoarctationintercostal arteries.
Normal pressure hydrocephalus is characterized by the symptom triad of gait disturbance, dementia, and urinary incontinence; upper motor neuron signs may also occur.
Neurodegenerative
Normal
Disorders
Pressure
And Dementias
Neuroimaging
Hydrocephalusdemonstrates enlargement of the ventricles out of proportion to the sulci.
In a cross-sectional study, risk factor and outcome are measured simultaneously at a particular point in time (snapshot study). In other study designs, a certain period separates the
Epidemiology
Design AndStudy
Interpretation
Designs exposure from the outcome.
Situational syncope is a form of vasovagal (neurally mediated) syncope associated with specific triggers (e.g. micturition, defecation, cough). These triggers cause an alteration in the
Cardiac
System
Arrhythmias
Syncope
And Syncope autonomic response and can precipitate a predominant cardioinhibitory, vasodepressor, or mixed response.
Dihydropyridine calcium channel blockers can cause peripheral edema and should always be considered in the differential diagnosis of this condition, along with other causes, such
Cardiovascular
System Drugs
Calcium Channel as
Blocker
heart failure, renal disease, and venous insufficiency.
In older patients, cognitive impairment caused by depression often mimics other neurocognitive disorders, such as Alzheimer disease. However, it is accompanied by other
Neurodegenerative
Depression
Disorders And Dementias
symptoms of depression and usually improves with treatment of the underlying depressive disorder.
Adenomatous polyps carry increased malignant potential and warrant enhanced colonoscopic surveillance. Large polyps (> 1 cm) and adenomas with high-grade dysplasia or villous
Intestinal
& Nutrition
And Colorectal
Colorectal
Disorders
Polypsfeatures
And Cancer
carry an even greater malignant potential.
Patients with AIDS who have CD4 counts < 50/mm3 are at high risk for infectious colitis with opportunistic bacterial, viral, and protozoal pathogens. Cytomegalovirus colitis should be
suspected in those with frequent, small-volume, bloody stools and abdominal pain. Diagnosis is confirmed by colonoscopy with biopsy. Any patient with HIV who has active CMV
Viral Infections Cytomegalovirus disease requires ocular examination to rule out concurrent retinitis.
Priapism refers to an unwanted, persistent, and often painful erection that constitutes a medical emergency. Certain medications (e.g. trazodone, prazosin) and medical conditions (e.
Disorders
System
Of The Priapism
Male Reproductive
g. System
sickle cell disease, perineal trauma) may precipitate priapism.
Epidemiology
Design AndBias
Interpretation Observer bias occurs when the investigator’s decision is adversely affected by knowledge of the exposure status.
Confidence intervals and p values are interrelated and express the statistical significance of a study. In a statistically significant study, p should be < 0.05. This corresponds to a 95%
Epidemiology
Design AndRisk
Interpretation confidence interval that does not include the null value.
In a normal (bell-shaped) distribution: 68% of all values are within 1 standard deviation from the mean; 95% of all values are within 2 standard deviations from the mean; 99.7% of all
Epidemiology
And Distribution
Standard OfDeviation
Data values are within 3 standard deviations from the mean.
Moderately increased albuminuria (urine albumin-creatinine ratio of 30-300 mg/g) is an early sign of diabetic nephropathy and should prompt therapy with ACE inhibitors or
Diabetes& Mellitus
Metabolism
angiotensin-receptor blockers. These agents reduce glomerular hydrostatic pressure and are clinically proven to prevent progression of proteinuria and nephropathy.
Polyuria in nonhospitalized patients can be due to primary polydipsia or diabetes insipidus (DI). Primary polydipsia is due to increased water intake that leads to a dilute urine (urine
osmolality < 1/2 plasma osmolality) and hyponatremia (sodium < 137 mEq/L). Serum Na > 145 mEq/L with dilute urine excludes primary polydipsia and favors DI. DI can be central
Hypothalamus
& Metabolism
And
Diabetes
PituitaryInsipidus
Disorders
(decreased antidiuretic hormone [ADH] release from pituitary) or nephrogenic (normal ADH level but with renal ADH resistance).
Systemic lupus erythematosus is an autoimmune disorder affecting multiple organ systems. Renal involvement may present with nephritic syndrome with low serum C3 and C4
Glomerular
Systems &Diseases,
Electrolytes
SLE Nephrotic/Nephritic
levels. Nephrotic
Syndromesyndrome may also occur.
Know the difference between incidence and prevalence. Incidence is the measure of new cases, the rapidity with which they are diagnosed. Prevalence is the measure of the total
EpidemiologyAndPrevalence
PopulationAnd
Health
Incidence
number of cases at a particular point in time.
Nephrolithiasis,
Hematuria,
Renal Calculi
And Urinary
The dietary
Tract Obstruction
recommendations for patients with renal calculi are: 1. Increased fluid intake; 2. Decreased sodium intake; 3. Normal dietary calcium intake.
ACE inhibitors or angiotensin receptor blockers are indicated for initial therapy in patients with renovascular hypertension (due to renal artery stenosis). Renal artery stenting or
Chronic
Systems
Kidney
& Electrolytes
Disease
Renal Artery Stenosis
surgical revascularization is reserved for patients with resistant hypertension or recurrent flash pulmonary edema and/or refractory heart failure due to severe hypertension.
Myasthenia gravis is caused by autoantibody-mediated degradation of acetylcholine receptors at the neuromuscular junction, which often leads to fatigable ocular and bulbar muscle
weakness. Most patients with acetylcholine receptor antibodies have thymic abnormalities (e.g. thymoma, thymic hyperplasia), which appear as an anterior mediastinal mass on
Myasthenia
Nerves
Gravis
Andchest
Muscles
imaging.
Hereditary hemochromatosis should be considered in patients who have elevated liver enzymes, diabetes mellitus, and skin hyperpigmentation. It can progress to cirrhosis and is
OncologyOf Oncology
Hemochromatosisassociated with a significantly increased risk for hepatocellular carcinoma.
Vaccination for hepatitis A is recommended for adults who are at increased risk of contracting the virus such as men who have sex with men and travelers to countries where
hepatitis A is prevalent. It is also recommended for adults who have chronic liver disease.
Giardiasis is characterized by persistent diarrhea and abdominal cramps, and is most commonly transmitted via water in rural areas and developing countries. The preferred
Intestinal
& Nutrition
And Colorectal
Giardia Disorders diagnostic test is a stool antigen assay. Metronidazole is the first-line treatment.
Both the positive predictive value (PPV) and negative predictive value (NPV) of a test depend on the prevalence of the disease of interest in the population in which the test is
Epidemiology
And Principles
Sensitivity,
Of Specificity,
Testingapplied.
NPV,
PPV
PPVincreases and NPV decreases with an increase in prevalence.
Know the concept of confounding. Distinguish between crude and adjusted measures of association. Confounding refers to the bias that can result when the exposure-disease
Epidemiology
relationship
Modification,
is mixed
Bias,with
Errors
the effect of extraneous factors (i.e., confounders).
The increased incidence of urinary tract infections in women is due to the shorter length of the female urethra compared to males. Other predisposing factors for UTIs include sexual
Urinary
Systems
& Electrolytes
GUintercourse,
Infection recent antibiotic use, the use of spermicidal contraceptives, and a close proximity of the urethra to the anus.
Patients with an arrhythmic cause of syncope usually have underlying structural heart disease and may not have any prodromal symptoms prior to the syncopal episode. In contrast,
those with vasovagal or neurocardiogenic syncope frequently experience a prodrome with nausea, pallor, diaphoresis, and generalized sense of warmth prior to the syncopal
Cardiac
System
Arrhythmias
Syncope
And Syncope episode.
Understand the concept of lead-time bias in screening tests. The typical example of lead-time bias is prolongation of apparent survival in patients to whom a test is applied, without
Epidemiology
Design AndBias
Interpretation changing the prognosis of the disease.
Ischemic Stroke Hypertension increases the risk of stroke more than any other risk factor including hypercholesterolemia, diabetes mellitus, smoking, and sedentary lifestyle.
Hypothyroid myopathy is characterized by myalgias, proximal muscle weakness, and an elevated serum creatine kinase level. Patients often have additional features of
Metabolism hypothyroidism (e.g. fatigue, delayed reflexes). Initial diagnostic testing includes TSH and free T4 levels.
Initial management of frostbite is based on rapid rewarming of affected tissues in a 37-39 C (98.6-102.2 F) water bath. Hot air rewarming is not recommended, and rewarming should
Exposure
not be attempted if there is a possibility of refreezing before definitive care can be provided.
Mitral stenosis usually occurs in the setting of rheumatic heart disease and presents with exertional dyspnea, cough, and orthopnea. Left atrial dilation is typical and may be
recognized by elevation of the left mainstem bronchus on chest x-ray. Atrial fibrillation is a common complication and can precipitate acute decompensated heart failure in previously
Critical Care
Vascular
Mitral
AndStenosis
Cardiopulmonary
well-compensated
Disease patients.
The varicella vaccine is a live-attenuated virus that causes a low virulence infection after inoculation. Patients with HIV with CD4 counts < 200/mm3 may have difficulty clearing the
attenuated virus and should not receive vaccination. Those with CD4 counts > 200/mm3 who have low titers should receive the varicella vaccine.
The US Preventive Services Task Force recommends biennial (every 2 years) screening mammography for women age 50-74. Screening at age 40-49 and age > 75 is not routinely
3863 Medicine General Principles
Miscellaneous Breast Cancer recommended but can be considered on an individual basis.
Persistence of nocturnal and early-morning penile erections helps differentiate psychogenic from organic causes of male erectile dysfunction. Normal nocturnal erections indicate
Disorders
System
Of The Male Sexual
Reproductive
Dysfunction
intact
System
vascular and nerve function in the penis.
Minimal rectal bleeding is usually due to hemorrhoids or other benign conditions. Evaluation depends on the patient’s presentation and risk factors. Patients age > 50 or with clinical
Intestinal
& Nutrition
And Colorectal
Gastrointestinal
DisordersHemorrhage
features suggesting malignancy should undergo colonoscopy. For younger patients (age < 40) and no other risk factors, office-based anoscopy may be performed first.
A caustic ingestion causes injury to the upper aerodigestive tract and most commonly presents with pain, dysphagia, and oropharyngeal erythema and ulcerations. It does not cause
Toxicology Exposure
Caustic Ingestion alterations in consciousness.
Asthma Lung Disease
The most common adverse effect of inhaled corticosteroid therapy is oropharyngeal thrush (oral candidiasis).
General management of somatic symptom disorder includes regularly scheduled visits and avoiding unnecessary diagnostic testing and specialist referrals. Patients who do not
respond to general measures may benefit from pharmacotherapy with antidepressants and cognitive-behavioral therapy. Selective serotonin reuptake inhibitors are generally used as
Disorders
Somatic
Abuse
AndSymptom
Sleep Disorders
first-line
Disorder treatment.
Lambert-Eaton myasthenic syndrome is frequently associated with an underlying malignancy (e.g. small cell lung cancer). It is caused by autoantibodies directed against the voltage-
Lambert-Eaton
Nerves And
Myasthenic
gated
Muscles
calcium
Syndrome
channels in the presynaptic motor nerve terminal leading to symmetric proximal muscle weakness with depressed deep tendon reflexes.
Acute pancreatitis is most often due to alcohol use, gallstones, or medications. Commonly implicated drugs include diuretics, antiseizure drugs (e.g. valproic acid), and antibiotics (e.
g. metronidazole). An abdominal CT scan can reveal diffuse or focal parenchymal changes, edema, necrosis, or liquefaction. Drug-induced pancreatitis is usually mild and resolves
Pancreatic
& Nutrition
Disorders
Acute Pancreatitiswith supportive care.
The ratio of plasma aldosterone concentration to plasma renin activity is the preferred initial screening test for primary hyperaldosteronism. Adrenal suppression testing can confirm
the diagnosis, and positive tests require further adrenal imaging. Adrenal venous sampling is the most sensitive test for differentiating adrenal adenoma and bilateral adrenal
Adrenal&Disorders
Metabolism
Hyperaldosteronism
hyperplasia in patients without discrete unilateral adrenal mass on imaging.
Condylomata acuminata (anogenital warts) are verrucous papilliform lesions located in the anogenital region. These lesions are caused by human papillomavirus, which is the most
common sexually transmitted disease in the United States. Certain serotypes (especially 16 and 18) are associated with squamous cell carcinoma of the anus, genital organs, and
3831 Medicine Dermatology Skin Tumors And Warts
Tumor-Like Lesions
throat.
Primary percutaneous coronary intervention (PCI) is recommended within 90 minutes for acute, ST-segment elevation myocardial infarction (STEMI). Additional stabilization
measures include oxygen, full-dose aspirin, platelet P2Y12 receptor blockers, nitroglycerin, β blockers, and anticoagulation. Fibrinolysis may be administered within 12 hours of
symptom onset for STEMI patients who cannot undergo PCI but is associated with higher rates of recurrent myocardial infarction, intracranial hemorrhage, and mortality compared to
Coronary
SystemHeart Disease
PCI.
There is a strong association between infections with Streptococcus gallolyticus (S. bovis biotype I) and colonic neoplasms, and all such patients should have further evaluation with
Endocarditis colonoscopy to look for underlying occult malignancy.
Statin therapy is indicated for primary prevention of atherosclerotic cardiovascular disease (ASCVD) in patients with an estimated 10-year ASCVD risk > 7.5%-10% based on the
Coronary
SystemHeart Disease
Dyslipidemia Pooled Cohort Equations cardiovascular risk calculator.
Lipid-lowering therapy with a statin is recommended for patients with type 2 diabetes mellitus age > 40 and for those age < 40 with established atherosclerotic cardiovascular disease
(ASCVD). In general, moderate-intensity statin therapy is recommended for patients without known ASCVD, whereas high-intensity therapy is recommended for those with
Cardiovascular
System Drugs
Dyslipidemia established cardiovascular disease.
Entamoeba histolytica infection should be considered in patients with a liver abscess who have lived or traveled in a developing country; abscesses may occur following an episode
of dysentery (i.e. amebic colitis). Patients typically develop fever, right upper quadrant pain, anorexia, elevated liver enzymes, and leukocytosis. Treatment includes a tissue agent (i.
Liver Abscess
Infections e. metronidazole, tinidazole) followed by paromomycin to eradicate intestinal colonization.
Behçet syndrome is a multisystem inflammatory condition characterized by recurrent oral and genital ulcers. Skin and ocular involvement is common. Thrombosis is a major cause of
& Sports
BehçetAnd
Disease
Vasculitides
morbidity. It is most common in patients of Turkish, Middle Eastern, and Asian descent. The diagnosis is made based on clinical features.
Nickel allergy is a type IV hypersensitivity reaction that is typically caused by jewelry or clothing fasteners. Chronic, low-level nickel exposure can lead to itching, scaling, and
Contact Dermatitis
And Bullous
lichenification.
Diseases Most patients respond to low- or mid-potency topical corticosteroids.
Myasthenic crisis is a life-threatening complication of myasthenia gravis that is characterized by severe respiratory muscle weakness leading to respiratory failure. Symptoms are
Myasthenia
Nerves
Gravis
Andoften
Muscles
preceded by increasing generalized or bulbar muscle weakness. The condition may be precipitated by infection, surgery, and certain medications (e.g. fluoroquinolones).
Taenia solium is a pork tapeworm whose eggs cause neurocysticercosis. Most infections are asymptomatic, but patients can develop seizure (without other symptoms) or signs of
increased intracranial pressure (vomiting, headaches, papilledema) months or years after inoculation. Diagnosis is made largely by clinical and radiographic findings (> 1 cyst often
Neurocysticercosis
Infections with enhancement/edema on brain MRI).
Patients with hypertension should be screened for diabetes mellitus with either fasting blood glucose or hemoglobin A1c. Even in the absence of hypertension, screening for diabetes
Diabetes& Mellitus
Metabolism
Diabetes Mellitus is advised for patients age 40-70 with a BMI > 25.
Communication
And
Professional
Interpersonal
Conduct
Skills
When dealing with difficult patients, the physician must maintain professional conduct and responsibilities while addressing their medical and psychological needs.
Management options for acute pain (including opioids) will be similar for all patients regardless of substance use history, although those with a history of opioid addiction who are
Acute Pain given opioid analgesics may need close follow-up care to avoid relapse.
Initial treatment options for painful diabetic neuropathy include tricyclic antidepressants, dual serotonin norepinephrine reuptake inhibitors, and anticonvulsants. Pregabalin decreases
Diabetes& Mellitus
Metabolism
Diabetic Neuropathy
pain by inhibiting the release of excitatory neurotransmitters.
Diabetic gastroparesis (i.e. delayed gastric emptying) presents with anorexia, nausea, vomiting, early satiety, postprandial fullness, and impaired glycemic control. Metoclopramide is
Diabetes& Mellitus
Metabolism
Gastroparesis a prokinetic agent that can relieve gastroparesis symptoms but is associated with a small risk of extrapyramidal side effects and tardive dyskinesia.
Sensorimotor polyneuropathy in diabetes is characterized by length-dependent axonopathy. Small fiber involvement causes pain, paresthesia, and allodynia, whereas large fiber
Diabetes& Mellitus
Metabolism
Diabetic Neuropathy
injury causes numbness, loss of proprioception and vibration sense, and diminished ankle reflexes.
Patients who are victims of suspected physical abuse should be approached with empathic interviewing techniques. The physician should ask open-ended questions to allow patients
to describe their situation on their own terms. The first priorities are to obtain an accurate and thorough understanding of the abuse and take any necessary action to ensure patient
Patient
Safety Intimate Partner Violence
safety. Additional steps may then be needed to address concurrent emotional symptoms and satisfy legal reporting requirements.
Risk factors for diabetic foot ulcers include diabetic neuropathy, previous foot ulceration, vascular disease, and foot deformity. Diabetic neuropathy is the most important contributing
Diabetes& Mellitus
Metabolism
Diabetic Neuropathy
factor and is found in > 80% of patients with ulcers. Monofilament testing predicts the risk of future ulcers.
Disorders Of The Subconjunctival
Eye And Associated
Hemorrhage
Spontaneous
Structures subconjunctival hemorrhage is a benign finding, and does not require any treatment.
& Sports
Gout In chronic tophaceous gout, urate crystals can be deposited in the skin, resulting in the formation of tumors with a chalky white appearance.
Vasopressors (e.g. norepinephrine), which cause profound vasoconstriction, can also cause ischemia of peripheral structures such as the distal digits. The resulting digital tissue
Critical Care
Care And Trauma
Acute Limb
Medicine
Ischemia
necrosis is usually bilateral and symmetric.
Superior pulmonary sulcus (Pancoast) tumors arise in the apical pleuropulmonary groove and typically present with shoulder pain, Horner syndrome, or neurologic manifestations in
Critical And
Lung Cancer the
Masses
arm due to invasion of adjacent structures (e.g. brachial plexus, paravertebral sympathetic chain).
Amyotrophic lateral sclerosis presents with both upper and lower motor neuron signs; sensation is typically normal. Medical management includes riluzole (a glutamate inhibitor) and
Neurodegenerative
Amyotrophic
Disorders And
Lateral
Dementias
edaravone
Sclerosis(an antioxidant), which improves survival and slows disease progression.
Pulmonary toxicity is a serious adverse effect of long-term amiodarone use and can occur months to several years after the initiation of therapy. Interstitial pneumonitis due to
Cardiovascular
System Drugs
Interstitial Lung Disease
amiodarone presents with progressive dyspnea, nonproductive cough, and new reticular or ground-glass opacities on chest radiograph.
Complete heart block is characterized by temporal dissociation of P waves and QRS complexes (atrioventricular [AV] dissociation). Patients with symptomatic third-degree AV block
should be managed with temporary pacemaker insertion while undergoing further evaluation to identify and correct reversible causes. A permanent pacemaker is indicated if no
Cardiac
System
Arrhythmias
Heart
And
Block
Syncope reversible causes of heart block are found.
Degeneration of the sinus node and replacement with fibrous tissue is the most common cause of sick sinus syndrome. Elderly patients are typically affected and have bradycardia,
Cardiac
System
Arrhythmias
SickAnd
Sinus
Syncope
Syndrome
leading to fatigue, dyspnea on exertion, lightheadedness, confusion, and syncope or presyncope. ECG demonstrates sinus bradycardia with delayed or dropped P waves.
Mobitz type I atrioventricular block has progressive prolongation of the PR interval leading to a nonconducted P wave and a ‘dropped’ QRS complex. It is a benign and transient
Cardiac
System
Arrhythmias
Heart
And
Block
Syncope arrhythmia. Treatment usually involves observation in asymptomatic patients and correction of reversible causes (e.g. holding medications that affect AV node conduction).
Most cases of first-degree atrioventricular (AV) block with normal QRS duration are due to delayed AV nodal conduction and require no further evaluation. Patients with first-degree
Cardiac
System
Arrhythmias
Heart
And
Block
Syncope AV block and prolonged QRS duration likely have a conduction delay below the AV node and should have electrophysiology testing to determine its nature.
Stable patients with wide-complex tachycardia can be initially managed with antiarrhythmic drugs (e.g. amiodarone, procainamide, sotalol, lidocaine). Synchronized electrical
cardioversion is indicated for patients with persistent tachyarrhythmia who are severely symptomatic (altered mental status, acute heart failure or pulmonary edema, ischemic chest
Cardiac
System
Arrhythmias
Ventricular
And Syncope
Tachycardia
pain) or hemodynamically unstable (hypotension, signs of shock).
The initial response to patients suggesting complementary and alternative medicine is to explore their reasons for requesting such treatment. Physicians must be prepared to discuss
Communication
And
Complementary
InterpersonalAnd
Skills
the Alternative
risks and benefits
Medicine
of complementary and alternative approaches to treatment and be open to integrating modalities with proven safety and efficacy.
Dominant frontal lobe lesions can cause expressive (Broca) aphasia, contralateral hemiparesis due to involvement of the primary motor cortex, and contralateral apraxia due to
Ischemic Stroke involvement of the supplementary motor cortex.
Patients who develop serious bleeding (e.g. intracerebral hemorrhage) due to excess anticoagulation with warfarin should have their anticoagulation immediately reversed with
Acute Intracerebral
intravenous
Hemorrhage
vitamin K and prothrombin complex concentrate to reduce the risk of death and permanent disability.
A water deprivation test can distinguish between central and nephrogenic diabetes insipidus (DI) and also definitively exclude primary polydipsia. Administration of desmopressin
after water deprivation can distinguish between central and nephrogenic DI. Patients with central DI increase their urine osmolality by at least 50% following the administration of
Hypothalamus
& Metabolism
And
Diabetes
PituitaryInsipidus
Disorders
desmopressin acetate tablets; patients with nephrogenic DI will not show much change. Desmopressin (intranasal form preferred) is the first-line treatment for central DI.
The basal ganglia (putamen) is a common site of hypertensive intraparenchymal brain hemorrhage. The internal capsule that lies adjacent to the putamen is almost always involved,
Hemorrhagic Stroke
leading to contralateral hemiparesis, contralateral sensory loss, and conjugate gaze deviation toward the side of the lesion.
The management of myasthenic crisis with respiratory failure consists of endotracheal intubation followed by treatment with plasmapheresis (or intravenous immunoglobulins) and
Myasthenia
Nerves
Gravis
Andcorticosteroids.
Muscles
Spontaneous cerebellar hemorrhage is typically caused by poorly controlled hypertension and presents with occipital headache, neck stiffness, nausea/vomiting, nystagmus, and
ipsilateral hemiataxia. There is usually no hemiparesis or sensory loss. Early diagnosis with noncontrast head CT scan is important as emergency surgical decompression may be
Acute Cerebellar Ataxia
life-saving.
Syringomyelia is a disorder in which a fluid-filled cavity forms within the spinal cord (usually within the cervical and/or thoracic spine). Patients typically have dissociated sensory loss
(i.e. loss of pain/temperature sensation but not vibratory/proprioceptive sensation), often in a ‘cape’ distribution, and may develop weakness that disproportionately affects the upper
Syringomyelia extremities.
Intracranial hemorrhage classically presents with acute focal neurologic deficits that gradually worsen over minutes to hours and can be associated with symptoms of elevated
Hemorrhagic Stroke
intracranial pressure (e.g. headache, vomiting, altered mental status). Patients with suspected acute stroke should initially receive a head CT without contrast to rule out hemorrhage.
Myasthenia gravis is characterized by fluctuating, fatigable weakness that is most prominent in the ocular (e.g. ptosis, diplopia), bulbar (e.g. dysphagia, dysarthria), facial (e.g.
myasthenic sneer), and proximal (e.g. difficulty holding up the head or lifting the arms) muscles. Pyridostigmine, a long-acting oral acetylcholinesterase inhibitor, is the initial drug of
Myasthenia
Nerves
Gravis
Andchoice.
Muscles
Parkinson disease (PD) should be suspected in patients with a resting tremor of 5-7 Hz that is asymmetric and associated with rigidity. Tremor is often the presenting symptom of
Neurodegenerative
Parkinson
Disorders
Disease
And Dementias
PD. Trihexyphenidyl is an anticholinergic medication sometimes used in the treatment of PD, generally in younger patients where tremor is the primary symptom.
Early and effective anticoagulation decreases the mortality risk of acute pulmonary embolism (PE) and should be initiated prior to pursuing confirmatory diagnostic testing in patients
Critical Care
Vascular
Pulmonary
And Cardiopulmonary
Embolism
with likely
Disease
probability of acute PE, especially those in moderate to severe distress.
COPD Lung Disease
Smoking cessation is associated with a mortality benefit and reduced progression of disease in patients with chronic obstructive pulmonary disease.
Neurodegenerative
Parkinson
Disorders
Disease
And Dementias
Medications used in the treatment of Parkinson disease may cause hallucinations. Dopamine agonists and, to a lesser extent, levodopa are associated with this adverse effect.
Aspirin is the only antiplatelet agent that is effective in reducing the risk of early recurrence of ischemic stroke. It should be given within 24 hours to all patients presenting with
Ischemic Stroke ischemic stroke. Aspirin plus dipyridamole OR clopidogrel is recommended for patients who have recurrent stroke on aspirin therapy.
Epidemiology
And Principles
Risk Of TestingKnow how to interpret the strength of association and dose-response relationship from a study.
Acute erosive gastropathy is characterized by the development of hemorrhagic lesions after ischemia or the exposure of gastric mucosa to various injurious agents (e.g. alcohol,
Gastroesophageal
& Nutrition Peptic
Disorders
Ulcer Disease
aspirin, cocaine).
Immediate synchronized cardioversion is the initial treatment of choice in patients with persistent tachyarrhythmia (narrow or wide complex) associated with clinical or hemodynamic
Cardiac
System
Arrhythmias
Atrial
AndFibrillation
Syncope instability (hypotension, cardiogenic shock, signs of ischemia, acute heart failure).
Patients with ventricular fibrillation or pulseless ventricular tachycardia (VT) should be managed with immediate defibrillation. In contrast, patients with hemodynamic instability due to
Cardiac
System
Arrhythmias
Ventricular
And Syncope
Fibrillation
a narrow or wide QRS complex tachyarrhythmia (e.g. atrial fibrillation, atrial flutter, VT with a pulse) should be managed with synchronized cardioversion.
In atrial fibrillation (AF) with rapid ventricular response, rate control should be attempted initially with β blockers or calcium channel blockers. Immediate synchronized electrical
Cardiac
System
Arrhythmias
Atrial
AndFibrillation
Syncope cardioversion is indicated in hemodynamically unstable patients with rapid AF.
Dipsticks are commercially available kits that detect the presence of leukocyte esterase and nitrite in the urine of patients with suspected UTI. Positive leukocyte esterase signifies
Urinary
Systems
& Electrolytes
GUsignificant
Infection pyuria and positive nitrites indicate the presence of Enterobacteriaceae.
Exertional heat stroke is characterized by temperature > 40 C (104 F) and CNS dysfunction (e.g. altered mental status, seizure). First-line treatment is rapid cooling with ice water
Exposure
immersion.
Nonexertional heat stroke is a life-threatening multisystem disorder characterized by body temperature > 40 C (104 F) associated with CNS dysfunction (e.g. seizure). It occurs due
Exposure
to failure of normal neural thermoregulatory mechanisms.
Nonexertional (classic) heat stroke most commonly affects elderly patients and is characterized by body temperature > 40 C (104 F) with CNS dysfunction (e.g. encephalopathy).
Exposure
Other common manifestations include tachycardia, tachypnea, hypotension, and end-organ dysfunction (e.g. diffuse intravascular coagulopathy, pulmonary edema).
Malaria is a very common cause of fever in the returning traveler. Classic findings include cyclical fever with nonspecific constitutional and gastrointestinal manifestations, anemia,
MalariaInfections and thrombocytopenia.
Cutaneous larva migrans is a creeping cutaneous eruption due to dog (Ancylostoma caninum) or cat (A. braziliense) hookworm larvae. Most infections arise from walking barefoot on
contaminated sand or soil. Symptoms include a pruritic, papular lesion at the portal of entry and intensely pruritic, migrating, serpiginous reddish-brown tracks. Ivermectin is typically
Cutaneous
Infections
Larva given
Migrans
to speed resolution and clearance.
Epidemiology
Design AndBias
Interpretation Consider the natural history of a disease when evaluating the effectiveness of a drug in a trial.
The critical distinction between case-control and retrospective cohort studies is the order in which outcomes and risk factors are assessed. Case-control studies determine the
Epidemiology
Design AndStudy
Interpretation
Designs outcome first and then look for associated risk factors; retrospective cohort studies first ascertain risk factor exposure and then determine the outcome.
Rapid treatment with calcium gluconate is necessary in patients with hyperkalemia who develop significant ECG changes. Temporary (e.g. intravenous insulin) and definitive (e.g.
Fluid,
Systems
Electrolytes,
& Electrolytes
Hyperkalemia
And Acid-Base cation exchange resin, dialysis) measures to reduce serum potassium should follow calcium administration.
Know the different kinds of bias, which can decrease the validity of study results. Hawthorne effect is the tendency of the study population to affect the outcome since they are aware
Epidemiology
Design AndBias
Interpretation that they are being studied.
When multiple sclerosis is suspected but clinical examination or MRI is not classic, a lumbar puncture should be performed for cerebrospinal fluid analysis; this analysis shows
Multiple Sclerosisoligoclonal bands in 85%-95% of patients. Opening pressure, protein, and cell count are generally normal.
Acute exacerbations of multiple sclerosis with disabling neurologic symptoms are typically treated with glucocorticoids (e.g. intravenous methylprednisolone). Plasmapheresis should
be considered in patients who are refractory to corticosteroids. Interferon β or glatiramer acetate can be used as chronic maintenance therapy in patients with relapsing-remitting or
Multiple Sclerosissecondary, progressive forms of multiple sclerosis.
Acetazolamide +/- furosemide is the first-line medical treatment for idiopathic intracranial hypertension. Optic nerve sheath decompression or lumboperitoneal shunting is
recommended for patients refractory to medical therapy. Corticosteroids and serial lumbar punctures are not recommended as long-term primary treatments. However, they may be
usedHypertension
as bridging therapies for patients awaiting definitive surgical treatment.
Multiple erythema migrans are pathognomonic for early disseminated Lyme disease, even without a known history of a tick bite. Systemic symptoms (e.g. malaise, headache, fever)
Lyme Disease may be present. Doxycycline is the treatment of choice.
Constrictive pericarditis is caused by pericardial scarring and thickening that result in diastolic heart dysfunction. Patients present with signs of decreased cardiac output and venous
overload. Common etiologies in the United States include viruses, cardiac surgery, chest radiation, and idiopathic causes. Tuberculosis is the most common cause in developing
Myopericardial
System Diseases
countries and endemic areas such as Africa, India, and China.
Acromegaly causes concentric myocardial hypertrophy, diastolic dysfunction, left ventricular dilation, and global hypokinesis. This cardiomyopathy is often worsened by concurrent
Hypothalamus
& Metabolism
And
Acromegaly
Pituitary Disorders
hypertension, obstructive sleep apnea, and valvular heart disease. Complications include heart failure and arrhythmias.
Huntington disease (HD) presents with psychiatric symptoms, cognitive impairment, and chorea. HD is an autosomal dominant CAG trinucleotide repeat expansion disease that is
Neurodegenerative
Huntington
DisordersDisease
And Dementias
associated with preferential atrophy of the caudate nucleus and putamen.
Epidemiology
And Principles
Sensitivity
OfAnd
Testing
Specificity
Know how to calculate the sensitivity and specificity of a test.
Epidemiology
And Principles
Sensitivity,
Of Specificity,
TestingKnowNPV,
how PPV
to calculate the predictive values of a test.
Patients have the right to refuse treatment except when doing so poses a serious threat to public health. In these cases, the physician is justified in restricting individual liberties until
Medical
Ethics And
Refusal
Jurisprudence
Of Treatment
the public’s health is no longer at risk.
Nontraumatic subarachnoid hemorrhage is most commonly due to ruptured saccular (berry) aneurysm and typically presents with thunderclap headache and symptoms of meningeal
irritation (e.g. nuchal rigidity, photophobia, nausea). Noncontrast CT scan usually reveals acute bleeding around the brainstem and basal cisterns.
Migraine should be suspected in patients with unilateral headaches with a pulsing or throbbing quality, particularly if accompanied by nausea/vomiting and photophobia. Patients who
have frequent attacks or disabling symptoms that do not respond to abortive treatment should be considered for prophylactic treatment, including topiramate, β blockers, or
Headache Migraine amitriptyline.
Medical
Ethics And
Decision
Jurisprudence
Making Capacity
When a patient refuses potentially life-saving treatment, it is important to fully discuss the specific reasons for the decision before honoring it.
Medical
Ethics And
Advance
Jurisprudence
Directive/Surrogate
In the absence
Decision
of an advance
Maker directive, a life-saving blood transfusion can be given to a Jehovah’s Witness who lacks decision-making capacity.
Patients have the right to know their diagnoses. If family members request that the diagnosis not be revealed to the patient, the underlying reasons should be explored before
Medical
Ethics And
Patient
Jurisprudence
Confidentiality
deciding how to proceed.
The Health Insurance Portability and Accountability Act protects health information by requiring verbal or written authorization for release of information. Hospitals and physicians’
offices frequently have additional policies requiring written forms for release of information and procedures to verify the identity of phone callers. It is important that health care
Medical
Ethics And
Patient
Jurisprudence
Confidentiality
providers be familiar with these rules and disclose only the minimum necessary information.
Patients who receive a solid organ transplant are at risk for opportunistic infections, most notably Pneumocystis pneumonia and cytomegalovirus (CMV). In the absence of
Viral Infections Cytomegalovirus prophylaxis, patients who present with a systemic illness involving multiple organ systems (e.g. pneumonitis, hepatitis, gastroenteritis) should be tested for CMV.
A mechanical or severely calcified aortic valve can cause hemolytic anemia due to erythrocyte shearing. Patients also frequently have mildly low platelets due to concurrent
Oncology
Hemolytic Anemiamechanical platelet injury. An echocardiogram should be performed to assess the valvular function.
Glucose-6-phosphate dehydrogenase (G6PD) deficiency causes episodic hemolytic anemia after oxidative insults (e.g. sulfa drugs, primaquine, infection, fava beans). Laboratory
studies show hemolytic anemia (e.g. elevated lactate dehydrogenase/bilirubin, low haptoglobin), and peripheral blood smear typically demonstrates bite cells and Heinz bodies.
Oncology
G6PD Deficiency Diagnosis is made by G6PD activity level, but sensitivity is low in acute hemolytic crises; therefore, this test cannot be relied on to rule out the condition in the acute setting.
Lactose intolerance is characterized by a positive hydrogen breath test, positive stool test for reducing substances, low stool pH and increased stool osmotic gap. There is no
Disorders
& Nutrition
Of Nutrition
Lactose Intolerance
steatorrhea.
Celiac disease should be suspected in any patient with malabsorption and iron deficiency anemia. IgA anti-endomysial and anti-tissue transglutaminase antibodies are highly
Disorders
& Nutrition
Of Nutrition
Celiac Disease predictive of celiac disease but may be absent if there is concurrent selective IgA deficiency.
Rapidly progressive hirsutism with virilization suggests very high androgen levels due to an androgen-producing neoplasm. Elevated dehydroepiandrosterone sulfate levels are seen
Reproductive
& Metabolism
Endocrinology
Hirsutism in androgen-producing adrenal tumors.
The proximal deep leg veins are the most common source of symptomatic pulmonary embolism. Other less common sources of emboli include the calf veins, renal veins, pelvic
veins, upper extremity veins, and right heart.
Noninvasive evaluation with compression ultrasonography is recommended as an initial test in patients with moderate or high probability of deep venous thrombosis.
Secondary hypogonadism can be due to mass lesions in the hypothalamus or pituitary, hyperprolactinemia, long-term use of glucocorticoids or opiates, or severe systemic illness.
Patients should have measurement of serum prolactin and screening for other pituitary hormone deficiencies. Pituitary imaging is indicated for patients with elevated prolactin, mass-
Reproductive
& Metabolism
Endocrinology
effect symptoms, very low testosterone levels, or disruptions in other pituitary hormones.
Laxative abuse is characterized by frequent, watery, nocturnal diarrhea. The diagnosis is suggested by a positive laxative screen or colonoscopy with characteristic findings of
Disorders
& Nutrition
Of Nutrition
Laxative Abuse melanosis coli (dark brown discoloration with pale patches of lymph follicles).
ChronicInfections
Diarrhea Cryptosporidium parvum is a major cause of chronic diarrhea in patients with HIV who have CD4 counts < 180/mm3.
Helicobacter pylori is a urease-producing organism that can cause peptic ulcer disease. Symptoms of peptic ulcers include dyspepsia, postprandial fullness and nausea, and
Gastroesophageal
& Nutrition Dyspepsia
Disorders gastrointestinal bleeding; worsening pain during fasting and nocturnal pain can also occur.
Pancreatic cancer should be suspected in patients with a history of chronic pancreatitis who develop abdominal pain and weight loss. Patients with jaundice should undergo
abdominal ultrasound to rule out cancer in the head of the pancreas. Patients without jaundice are likely to have cancer in the body and tail of the pancreas, and should undergo
Pancreatic
& Nutrition
Disorders
abdominal CT scan.
Acute HIV infection often causes a mononucleosis-like syndrome consisting of fever, night sweats, lymphadenopathy, arthralgias, and diarrhea. Important diagnostic clues include
oral ulcerations and a transient rash (oval, red, macular lesions). Providers should have a low threshold for HIV testing even when traditional HIV risk factors are absent.
Whipple disease is a multi-systemic illness characterized by arthralgias, weight loss, fever, diarrhea, and abdominal pain. PAS-positive material in the lamina propria of the small
Intestinal
& Nutrition
And Colorectal
WhippleDisorders
Disease intestine is a classical biopsy finding of Whipple disease.
Granulomatosis with polyangiitis is a vasculitis affecting small- and medium-sized blood vessels and is characterized by upper and lower respiratory tract disease and
Critical Care
Vascular
Granulomatosis
And Cardiopulmonary
With
glomerulonephritis.
Polyangiitis
Disease Diagnosis is made by antineutrophil cytoplasmic antibody positivity and tissue biopsy.
Anti-glomerular basement membrane disease affects the lungs (causing cough, dyspnea, and hemoptysis) and kidneys (causing nephritic range proteinuria, acute renal failure, and
dysmorphic red cells/red cell casts on urinalysis). Systemic symptoms are uncommon. Diagnosis is made by renal biopsy showing linear IgG antibodies along the glomerular
Critical Care
Vascular
Anti-GBM
And Cardiopulmonary
DiseasebasementDisease
membrane.
Lateral epicondylitis (tennis elbow) is painful noninflammatory angiofibroblastic tendinosis at the common extensor origin caused by repetitive, forceful wrist extension. Examination
Bone, Joint, And
& Sports
Soft
Lateral
Tissue
Epicondylitis
Injuriesreveals
And Infections
tenderness at the lateral epicondyle and pain with passive flexion or resisted extension at the wrist.
Actinomyces is part of the normal oral flora but may cause an invasive infection in patients who have dental infections or trauma (especially in those with weakened immunity).
Symptoms include a chronic, slow-growing, nontender mass at or near the mandible. Multiple sinus tracts to the skin may drain purulent fluid with sulfur granules (discrete, yellow
Actinomycosis granules). Penicillin is the preferred therapy; surgery is sometimes required for severe cases.
Acute spinal cord compression can present with loss of motor and sensory function, loss of rectal tone, and urinary retention. Management includes emergency surgical consultation,
neuroimaging, and possibly intravenous glucocorticoids.
Cerebral amyloid angiopathy is the most common cause of spontaneous lobar (e.g. parietal, occipital) hemorrhage, particularly in the elderly. It occurs due to β-amyloid deposition in
Hemorrhagic Stroke
the walls of small- to medium-size cerebral arteries and is associated with Alzheimer dementia.
All patients with carotid artery stenosis should receive medical therapy with antiplatelet agents and statins. Some evidence suggests benefit of carotid endarterectomy in
Aortic
System
And Peripheral
Carotid
Artery
Artery
Diseases
Stenosis
asymptomatic patients with high-grade (80%-99%) stenosis. However, asymptomatic patients with lower-grade (< 80%) lesions are managed medically.
Amaurosis fugax is characterized by painless, rapid, and transient monocular vision loss. The description of a curtain descending over the visual field is highly suggestive of this
diagnosis. The most common etiology is retinal ischemia due to atherosclerotic emboli originating from the ipsilateral carotid artery; therefore, patients with vascular risk factors
Amaurosis Fugaxshould receive a duplex ultrasound of the neck.
Acute limb ischemia after myocardial infarction suggests embolization of a left ventricular (LV) thrombus. Transthoracic echocardiography should be performed to screen for LV
Coronary
SystemHeart Disease
Acute Limb Ischemia
aneurysm and/or residual LV thrombus.
Post-cardiac injury syndrome (Dressler syndrome) presents weeks after a myocardial infarction with chest pain that is improved by leaning forward. Nonsteroidal anti-inflammatory
Coronary
SystemHeart Disease
drugs are the treatment of choice and are usually administered with colchicine. Anticoagulation should be avoided to prevent development of a hemorrhagic pericardial effusion.
Medullary thyroid cancer (MTC) is a calcitonin-producing tumor of the thyroid parafollicular C cells. It often occurs as a component of multiple endocrine neoplasia types 2A and 2B,
which are also associated with pheochromocytoma. Patients with MTC should be screened for pheochromocytoma prior to thyroidectomy with a plasma fractionated metanephrine
Endocrine
& Metabolism
TumorsMultiple Endocrineassay.
Neoplasia
Patients with symptomatic Paget disease of bone and those with involvement of high-risk skeletal structures (e.g. skull, weight-bearing long bones) should be treated to reduce pain
Sports
Paget Disease Ofand
Bone
decrease the risk of complications. Bisphosphonates inhibit osteoclasts and suppress bone turnover and are the preferred therapy.
Paget disease of bone is characterized by disordered osteoclastic bone resorption. Serum alkaline phosphatase and urine hydroxyproline levels are increased due to increased bone
Sports
Paget Disease Ofturnover.
Bone Serum calcium will usually be normal in the absence of other complicating factors.
Malignancy is the most common cause of SVC syndrome. Lung cancer (particularly small cell lung cancer) and NHL are often implicated. Other possible causes include fibrosing
mediastinitis (secondary to histoplasmosis or Tb infection) or thrombosis secondary to indwelling central venous devices. When the history and physical examination are suggestive,
OncologyOf Oncology
Superior Vena Cava
chest
Syndrome
x-ray is warranted.
Pulmonary toxicity is a serious adverse effect of long-term amiodarone use that can occur months to several years after the initiation of amiodarone therapy. A baseline chest
Cardiac
System
Arrhythmias
Atrial
AndFibrillation
Syncope radiograph and pulmonary function testing should obtained prior to initiating therapy with amiodarone.
Antithyroid peroxidase (anti-TPO) antibodies are present in > 90% of patients with Hashimoto thyroiditis, and high titers of anti-TPO are associated with an increased risk of
Metabolism progression to overt hypothyroidism. High titers of anti-TPO are also associated with increased risk of miscarriage in both euthyroid and hypothyroid women.
Type 2B multiple endocrine neoplasia (MEN-2B) is characterized by medullary thyroid cancer (MTC), pheochromocytoma, marfanoid habitus, and mucosal neuromas. MTC
Miscellaneous
& Metabolism
Multiple Endocrineassociated
Neoplasiawith MEN-2B is often very aggressive, and thyroidectomy is often recommended in infancy.
Prolactin-producing lactotroph adenoma (prolactinoma) is the most common primary pituitary tumor. Serum prolactin levels correlate with the size of prolactinoma, and levels > 200
Endocrine
& Metabolism
TumorsHyperprolactinemia
ng/mL are essentially diagnostic.
Patients with a macroprolactinoma (> 1 cm) or a symptomatic prolactinoma should be treated with dopaminergic agonists (e.g. cabergoline, bromocriptine), which can lower prolactin
Endocrine
& Metabolism
TumorsHyperprolactinemia
levels and reduce tumor size.
Osteomalacia is due to defective mineralization of the organic bone matrix. It is most commonly due to severe vitamin D deficiency, which leads to decreased intestinal calcium and
Miscellaneous
& Metabolism
phosphorus absorption with resultant secondary hyperparathyroidism. Typical laboratory findings include hypophosphatemia, hypocalcemia, and elevated alkaline phosphatase.
Intestinal malabsorption with chronic vitamin D deficiency can lead to osteomalacia, which is characterized by reduced mineralization of osteoid. Symptoms include bone pain and
muscle weakness. Laboratory findings include hypocalcemia, hypophosphatemia, increased parathyroid hormone, and elevated alkaline phosphatase. X-ray findings include cortical
Miscellaneous
& Metabolism
thinning, concave vertebral bodies, and pseudofractures.
Subacute (de Quervain) thyroiditis is characterized by fever, neck pain, and a tender goiter following an upper respiratory illness. Patients have a self-limited thyrotoxic phase
Metabolism followed by hypothyroidism and eventual recovery of thyroid function. Treatment is symptomatic with β blockers and nonsteroidal anti-inflammatory drugs.
Graves disease can be treated with antithyroid drugs, radioactive iodine therapy, or thyroidectomy. The most serious side effect of antithyroid drugs is agranulocytosis (0.3% of
Metabolism patients). Patients developing sore throat and fever should stop the drug and see a physician to check their white blood cell count.
Euthyroid sick syndrome is characterized by low T3 levels with normal TSH and T4 in patients with acute illness. It is due primarily to decreased peripheral conversion of T4 to T3.
Metabolism Treatment is generally not recommended unless abnormal thyroid function persists after the patient has returned to baseline health.
Thyroid &DisordersThyroid
Metabolism Nodules Thyroid nodules should be evaluated by serum TSH and ultrasound. A radionuclide scan is indicated only for patients with low TSH.
Hypothyroidism can cause elevated levels of total cholesterol, LDL, and triglycerides and is associated with an increased risk of coronary atherosclerosis. Treatment of
Metabolism hypothyroidism with levothyroxine can improve lipid levels, although normalization may take several months.
Patients with lower urinary tract symptoms (e.g. urinary frequency, nocturia, hesitancy) should have a urinalysis to evaluate for hematuria and infection. Prostate-specific antigen
Disorders
System
Of The Benign
Male Reproductive
Prostatic Hyperplasia
should
System
also be obtained in symptomatic patients to assess the risk for prostate cancer unless predicted life expectancy is <10 years.
The preferred initial treatment for uncomplicated benign prostatic hyperplasia includes α1 blockers, which can provide rapid relief of symptoms. 5-α-reductase inhibitors can be used
Disorders
System
Of The Benign
Male Reproductive
Prostatic Hyperplasia
asSystem
an alternative or in addition to α blockers but have a much slower onset of action.
Acute pyelonephritis can result in Gram-negative sepsis. Urine (and blood) cultures should be obtained routinely before administration of empiric antibiotics. Urological imaging is
typically reserved for patients with persistent clinical symptoms despite 48-72 hours of therapy, history of nephrolithiasis, complicated pyelonephritis, or unusual urinary findings (e.g.
gross hematuria, suspicion for urinary obstruction).
Impaired immune defense contributes to the development of bronchiectasis. Impaired mucociliary clearance in cystic fibrosis typically leads to bronchiectasis located predominantly
Critical Care
Infections
Bronchiectasis in the upper lobe.
Trigeminal neuralgia is characterized by recurrent and sudden-onset severe, stabbing pain along the V2 (maxillary) and V3 (mandibular) branches of the trigeminal nerve. Multiple
Multiple Sclerosissclerosis should be suspected when trigeminal neuralgia presents bilaterally.
Trigeminal Neuralgia
Carbamazepine can be used to treat trigeminal neuralgia. It is an anticonvulsant that can cause nausea and vomiting as well as leukopenia.
Trigeminal neuralgia is characterized by recurrent severe pain usually along the V2 (maxillary) and V3 (mandibular) branches of the trigeminal nerve (CN V), often triggered by minor
Trigeminal
Nerves
Neuralgia
Andstimuli.
Muscles This condition is usually treated with carbamazepine.
Stasis dermatitis is characterized by scaling, weeping, superficial erosions, and pitting edema. Chronic findings include red/brown discoloration, woody induration, fibrosis, and
Miscellaneous
System Chronic Venous Insufficiency
chronic ulcers. The diagnosis is primarily based on clinical findings, although duplex ultrasonography can confirm venous hypertension and reflux.
The first step in evaluation of solitary pulmonary nodules is to obtain any previous radiographic lung images. Absence of growth over 2-3 years rules out malignancy. If previous films
Critical And
Lung Nodule are
Masses
not available, a CT should be performed to further characterize the lesion.
Ménière disease is a disorder of the inner ear characterized by increased volume and/or pressure of endolymph (endolymphatic hydrops). Clinical features include episodic vertigo,
Disorders
(ENT)
Of The Ménière
Ear, Nose,
Disease
And Throat
sensorineural hearing loss, and tinnitus or aural fullness.
When multiple sclerosis is suspected, magnetic resonance imaging should be performed to support the diagnosis. T2-weighted imaging usually demonstrates multifocal, ovoid,
Multiple Sclerosissubcortical white matter lesions located in periventricular, juxtacortical, infratentorial, or spinal cord areas.
The management of acute respiratory distress syndrome (ARDS) involves avoiding complications of mechanical ventilation by using lung protective strategies such as low tidal
Critical Care
Care And Trauma
ARDS Medicine volume ventilation (LTVV). LTVV results in lower pulmonary pressures, decreasing the likelihood of overdistending alveoli. In addition, it improves mortality in patients with ARDS.
Multiple sclerosis should be suspected in young women with neurologic deficits disseminated in space and time. Common presentations include optic neuritis (e.g. monocular
Multiple Sclerosisblindness, painful eye movement) and transverse myelitis (e.g. motor and sensory loss below the level of the lesion, incontinence).
Acute angle-closure glaucoma is characterized by acute eye pain, headache, and nausea. Signs include conjunctival erythema, corneal opacification, and a mid-dilated pupil.
Eye And Associated
Gonioscopy
Structuresis the gold standard for diagnosis. Ocular tonometry can be helpful if urgent ophthalmologic consultation is unavailable.
Leprosy is a chronic granulomatous disease of the skin and peripheral nerves that is found primarily in developing regions. Symptoms include chronic, anesthetic, hypopigmented
lesions with peripheral nerve involvement (nodular/painful nerve deformations with diminished sensory/motor activity). Diagnosis usually requires a biopsy from the active edge of the
Leprosy lesion.
Herpes zoster causes a dermatomal rash characterized by small papules that evolve into vesicles or bullae with ulceration and crusting. It is caused by reactivation of varicella zoster
Viral Infections Herpes Zoster virus; decreased cell-mediated immunity (e.g. older age, HIV) increases the risk. It is treated with antiviral agents (e.g. acyclovir, famciclovir, valacyclovir).
Anaphylaxis is a widespread, IgE-mediated response to an allergen (e.g. medication). Rapid administration of intramuscular epinephrine is the best treatment to minimize the
Critical Care
Care And Trauma
Anaphylaxis
Medicine development of life-threatening complications (e.g. hypotension, upper airway edema).
Medical
Ethics And
Advance
Jurisprudence
Directive/Surrogate
A living will communicates
Decision Makerthe patient’s own wishes if he or she becomes incapacitated, and it overrules the wishes of the family.
Creutzfeldt-Jakob disease is characterized by rapidly progressive dementia, myoclonus, and sharp, triphasic, synchronous discharges on electroencephalogram. This spongiform
Neurodegenerative
Prion
Disorders
Disease
And Dementias
encephalopathy is caused by a prion. Most patients die within one year of symptom onset.
Cholinesterase inhibitors such as donepezil, rivastigmine, and galantamine may provide moderate symptomatic relief of cognitive symptoms and temporarily improve functioning in
Neurodegenerative
Alzheimer
Disorders
Disease
And Dementias
Alzheimer disease; however, these medications have not been shown to alter the disease course.
Disorders
System
Of The Androgenic
Male Reproductive
Steroids
Anabolic
Systemsteroid use by a man can produce infertility by suppressing the production of GnRH, LH, and FSH.
Patients with severe bladder outlet obstruction due to benign prostatic hyperplasia can develop acute kidney injury. A renal ultrasound is advised for assessment of hydronephrosis in
Acute
Systems
Kidney
& Electrolytes
Injury
Acute Kidney Injury
those with worsening kidney function.
Presbyopia is a common age-related decrease in lens elasticity that leads to difficulty with near vision. A history of a middle-aged individual who has to hold books at an arm’s length
Disorders Of The Presbyopia
Eye And Associated
to read
Structures
is classic.
The 3 main categories of diabetic retinopathy are background or simple (microaneurysms, hemorrhages, exudates, retinal edema), pre-proliferative (cotton wool spots), and
proliferative or malignant (neovascularization). Visual impairment occurs with the development of macular edema. Argon laser photocoagulation is performed for the prevention of
Disorders Of The Diabetic
Eye And Retinopathy
Associated
complications.
Structures
Central retinal vein occlusion presents with acute or subacute painless monocular visual loss. Funduscopic examination shows a ‘blood and thunder’ appearance consisting of optic
Disorders Of The Central
Eye AndRetinal
Associated
Vein
diskOcclusion
Structures
swelling, retinal hemorrhages, dilated veins, and cotton wool spots.
Because the facial/ophthalmic venous system is valveless, uncontrolled infection of the skin can result in cavernous sinus thrombosis. Red-flag symptoms include severe headache;
Cavernous Sinus bilateral
Thrombosisperiorbital edema; and cranial nerve III, IV, V, and VI deficits.
Patients with significant puncture wounds who have not received revaccination for tetanus within 5 years should be vaccinated. In addition, tetanus immune globulin should be given
Tetanus to patients with significant or dirty wounds who have not previously received at least 3 doses of tetanus vaccine or whose vaccine status is uncertain.
Mixed connective tissue disease is characterized by clinical features of systemic lupus erythematosus, systemic sclerosis, and polymyositis, which appear sequentially. Important
manifestations include Raynaud phenomenon, swelling of the fingers and hands, inflammatory arthritis, and myositis. Autoantibodies for U1 ribonucleoprotein have high sensitivity
& Sports
MixedAnd
Connective
Vasculitides
and
Tissue
specificity.
Disease
Systemic sclerosis is characterized by connective tissue thickening due to fibroblast dysfunction. Cutaneous features include thickening of the skin with dermal sclerosis and vascular
dysfunction (e.g. Raynaud phenomenon). Extradermal manifestations include esophageal dysmotility, interstitial lung disease, and hypertension. Anti-topoisomerase I (anti-Scl-70) is
& Sports
Systemic
AndSclerosis
Vasculitides
a specific serologic marker and is associated with extensive disease.
The diagnosis of Sjögren syndrome requires evidence of dry mouth and eyes (e.g. positive Schirmer test result for decreased lacrimation) with either histologic evidence of
& Sports
SjögrenAnd
Syndrome
Vasculitides
lymphocytic infiltration of the salivary glands or serum autoantibodies against SSA (Ro) and/or SSB (La).
Disseminated gonococcal infection causes high fever, chills, tenosynovitis, polyarthralgia, and pustular lesions on the trunk and extremities. Disseminated gonococcal infection
should be considered when risk factors for gonococcal infection are present. Routine blood and pustule cultures can be negative due to the fastidious nature of Neisseria
Infections
gonorrhoeae.
Infectious urethritis in young men is usually due to sexually transmitted infection. Nucleic acid amplification testing provides confirmation, but patients with suspected infection should
be treated at the time of care. When the organism is unknown, ceftriaxone plus doxycycline is recommended to cover Neisseria gonorrhoeae and Chlamydia trachomatis, the 2 most
Infections
common organisms.
All rheumatoid arthritis (RA) patients should receive disease-modifying antirheumatic drugs (DMARDs) as early as possible in the disease course. Methotrexate is the initial DMARD
of choice in most patients with active RA. Nonsteroidal anti-inflammatory drugs or glucocorticoids should be used for initial temporary symptomatic relief while awaiting response to
& Sports
Rheumatoid
And Vasculitides
Arthritis
DMARD therapy.
Polymyalgia rheumatica (PMR) affects patients age > 50 and is characterized by pain and stiffness in the neck, shoulders, and pelvic girdle, along with an elevated erythrocyte
& Sports
Polymyalgia
And Vasculitides
Rheumatica
sedimentation rate. The treatment of choice for uncomplicated PMR is low-dose prednisone, which results in rapid relief of symptoms.
Inflammatory bowel disease is frequently complicated by arthritis, which occurs in up to 45% of patients and can involve axial or peripheral joints. Treatment with nonsteroidal anti-
& Sports
Inflammatory
And Vasculitides
Bowelinflammatory
Disease drugs may exacerbate the underlying disease.
Whipple disease is a multisystem disorder with a varied presentation caused by infection with the gram-positive bacillus Tropheryma whippelii. Chronic malabsorptive diarrhea,
& Sports
Whipple Disease weight loss, migratory non-deforming arthritis, lymphadenopathy and a low-grade fever are the most common presenting symptoms.
The most common cause of an asymptomatic elevation of alkaline phosphatase in an elderly patient is Paget disease of bone, which is frequently discovered incidentally on routine
Sports
Paget Disease Ofblood
Bone tests. X-rays will show osteolytic or mixed lytic-sclerotic lesions, and radionuclide bone scan can fully stage the disease.
Pes anserinus pain syndrome presents with localized pain and tenderness over the medial tibial condyle. It is often associated with overuse; risk factors include obesity, diabetes
mellitus, knee osteoarthritis, and angular deformity of the knee. The diagnosis is based on clinical features, although x-ray can exclude concurrent osteoarthritis. Management
Bone, Joint, And
& Sports
Soft
Bursitis
Tissue Injuriesincludes
And Infections
quadriceps strengthening exercises and nonsteroidal anti-inflammatory drugs.
Anterior cord syndrome usually occurs when there is injury to the anterior spinal artery from trauma. It is characterized by bilateral motor function loss at and below the level of the
injury with diminished pain and temperature sensation bilaterally that begins 1-2 levels below the cord injury, whereas proprioception, vibratory sensation, and light touch are
Anterior Cord Syndrome
unaffected.
3299.1 Medicine Nervous System
Traumatic Brain Injury
CT scan of a diffuse axonal injury shows numerous minute punctate hemorrhages with blurring of the gray-white interface.
Diffuse axonal injury (DAI) often causes severe neurologic impairment in the absence of major CT scan findings. MRI is more sensitive for DAI and may reveal minute punctate
Traumatic Brain Injury
hemorrhages in the white matter and blurring of the gray-white interface.
Trichinellosis typically presents with gastrointestinal complaints (e.g. abdominal pain, nausea, vomiting) followed by the characteristic triad of periorbital edema, myositis, and
Trichinellosis
Infections eosinophilia (hallmark of the disease). Other findings include fever, subungual splinter hemorrhages, and conjunctival or retinal hemorrhages.
Bacillus cereus enterotoxin forms in starch products (e.g. rice) that have been left at room temperature for extended periods or reheated. Symptoms begin rapidly after ingestion,
Foodborne Illnessusually within 1-6 hours. Vomiting is the primary manifestation.
Erysipelas is a superficial skin infection that manifests with the acute onset of systemic symptoms (fever, chills), regional lymphadenitis, and a warm, tender, erythematous rash with
Skin And Soft Tissue
raised,
Infections
sharply demarcated borders. The majority of erysipelas cases are caused by group A Streptococcus.
Proteus mirabilis is a urease-producing bacterium that commonly causes urinary tract infections. Urease generates ammonium, resulting in urine alkalinization (pH > 8). This
decreases the solubility of phosphate, dramatically increasing the risk of urinary calculi with struvite stones (magnesium ammonium phosphate).
Lyme disease is caused by the spirochete Borrelia burgdorferi and is endemic to the northeastern United States. Patients often develop clinical illness without knowledge of a
previous tick bite. Early disease typically manifests with erythema migrans (EM), but patients may also present with multiple EM lesions, carditis, and/or neurologic manifestations.
Lyme Disease Lyme carditis most commonly causes atrioventricular block.
Malaria chemoprophylaxis is recommended for most travelers who visit malaria endemic countries. In areas with high rates of chloroquine resistance, patients typically receive
MalariaInfections atovaquone-proguanil, doxycycline, or mefloquine. Measures for avoiding mosquito bites (e.g. protective clothing, insecticide, insecticide-treated bed nets) are also recommended.
Lyme Disease Pregnant patients with early localized Lyme disease are typically treated with amoxicillin. This treatment is generally curative and does not pose a risk to the fetus.
A single dose of intramuscular benzathine penicillin G is the treatment of choice for early syphilis. Patients with severe penicillin allergy should receive doxycycline. All patients with
syphilis should have pretreatment serology with a nontreponemal test (e.g. rapid plasma reagin) to quantitate antibody titers. A 4-fold decrease in antibody titers at 6-12 months
indicates treatment success.
Cryptococcal meningoencephalitis usually develops in patients with advanced HIV disease (CD4 cell count < 100/µL). Induction therapy includes amphotericin B plus flucytosine
followed by fluconazole for consolidation and maintenance therapy. Serial lumbar punctures may be required to reduce increased intracranial pressure. Antiretroviral therapy should
Fungal Infections Cryptococcal Infections
be deferred for at least 2 weeks after antifungal therapy is started.
Kaposi sarcoma (KS) is a vascular tumor due to human herpesvirus 8 that typically occurs in advanced HIV disease. Typical lesions appear as violet papules, nodules, or plaques.
Viral Infections Kaposi Sarcoma KS will often regress if the underlying HIV disease is treated with highly active antiretroviral therapy.
HIV patients with CD4 counts < 200 cells/mm3 require primary prophylaxis with trimethoprim-sulfamethoxazole to prevent Pneumocystis pneumonia. This medication is also used for
primary prophylaxis against toxoplasmosis in those with positive serology and CD4 counts < 100/mm3. Primary prophylaxis against Mycobacterium avium complex (azithromycin) is
no longer required. No other primary prophylaxis is routinely given; however, patients in Histoplasma-endemic areas with CD4 counts < 150/mm3 are sometimes given prophylactic
itraconazole.
Postexposure HIV prophylaxis with 3-drug antiretroviral therapy for 4 weeks is recommended following high-risk occupational exposure to blood or body fluids from an HIV-infected
individual. Therapy should be started as soon as possible, preferably in the first few hours.
Travelers’ diarrhea that is prolonged, profuse, and watery is often due to a parasitic pathogen such as Cryptosporidium parvum. C. parvum infections may be transiently severe but
Cryptosporidiosis
Infections are typically self-limited in otherwise healthy individuals (resolving spontaneously in 10-14 days). Patients who are immunocompromised (e.g. AIDS) are at risk for chronic infection.
Enterohemorrhagic Escherichia coli (EHEC) is a food-borne pathogen that causes acute watery to bloody diarrhea. Diagnosis can be confirmed with a stool assay for Shiga toxin. If
Acute Diarrhea EHEC is suspected, empiric antibiotic therapy should be avoided as it may increase the risk of hemolytic uremic syndrome.
Ehrlichiosis should be suspected in a patient from an endemic region with a history of tick bite, febrile illness with systemic symptoms, leukopenia and/or thrombocytopenia, and
Ehrlichiosis
Infections
& Anaplasmosis
elevated aminotransferases. Rash is uncommon, and the drug of choice is doxycycline.
Patients with newly diagnosed HIV should be screened for latent tuberculosis infection (LTBI) with a tuberculin skin testing (TST) or interferon-γ release assay. A TST with induration
> 5 mm is considered positive in this population. In the absence of active TB manifestations (positive chest x-ray, fever, night sweats, cough), treatment of LTBI with 9 months of daily
Tuberculosis isoniazid and pyridoxine or 12 weeks of weekly rifapentine, high-dose isoniazid, and pyridoxine is curative.
Empiric antibiotics must not be delayed while awaiting results of CT scan or performing lumbar puncture to diagnose bacterial meningitis. Cefepime plus vancomycin plus ampicillin is
the regimen of choice for immunocompromised patients with suspected bacterial meningitis. Corticosteroids should be started at the same time as antibiotics and discontinued if
Antimicrobial Drugs
Meningitis cultures show an organism other than Streptococcus pneumoniae.
Early localized Lyme disease should be suspected in individuals in Lyme-endemic areas who develop a flat, annular rash with or without central clearing. The diagnosis is made
Lyme Disease clinically because serology is negative in early disease; doxycycline is usually curative.
Communication
And
Patient
Interpersonal
Safety Skills
A physician has a moral responsibility to act in the patient’s best interests. When a physician’s mistake is discovered, the facts should be clarified and the truth told to the patient.
Confidential patient information should be disclosed only to fellow health care workers who are directly involved in the patient’s care. Physicians should avoid discussing a patient’s
medical condition in public areas where comments might be overheard. Inappropriate inquiries from colleagues curious about a patient’s medical condition should be politely but
Medical
Ethics And
Patient
Jurisprudence
Confidentiality
firmly rebuffed.
Communication
And
Professional
Interpersonal
Conduct
Skills
Physicians should respond politely but firmly to inappropriate patient requests. Maintaining professional boundaries is an important component of the physician-patient relationship.
Medical
Ethics And
Patient
Jurisprudence
Confidentiality
Medical information should be shared with family members only with the patient’s permission.
Primary hyperaldosteronism is usually due to an adrenal adenoma or bilateral adrenal hyperplasia. Surgery is preferred for unilateral adrenal adenoma. Medical therapy with
aldosterone antagonists (e.g. spironolactone, eplerenone) is recommended for patients with bilateral adrenal hyperplasia or with unilateral adrenal adenoma who either refuse
Adrenal&Disorders
Metabolism
Hyperaldosteronism
surgery or are poor surgical candidates.
Adrenal&Disorders
Metabolism
Hyperaldosteronism
Patients with mild primary hyperaldosteronism may not have spontaneous hypokalemia, but they are prone to developing diuretic-induced hypokalemia.
Always suspect surreptitious vomiting as a cause of hypokalemic alkalosis in a normotensive patient, and be able to distinguish it from other entities (e.g. diuretic abuse, Bartter
Fluid,
Systems
Electrolytes,
& Electrolytes
Hypokalemia
And Acid-Base syndrome) using the urine chloride concentration.
All patients with smoke inhalation should be suspected to have acute carbon monoxide (CO) poisoning and treated with 100% oxygen via a nonrebreather facemask. Early
Exposure
Carbon Monoxidesymptoms
Poisoning of CO poisoning are typically neurological and include agitation, confusion, and somnolence.
Vertebral metastasis should be suspected in patients with back pain who have a history of cancer, pain worse at night and unrelieved with rest, and focal vertebral tenderness. Other
features may include neurologic deficits, unexpected weight loss, and hypercalcemia. The most common cancers associated with vertebral metastasis include prostate, breast,
Spinal/Peripheral
& Sports
Back
NervePain
Disorders And
kidney,
Backthyroid,
Pain and non-small cell lung cancer, as well as non-Hodgkin lymphoma.
Polymyositis is characterized by chronic proximal weakness. Muscle enzymes (e.g. creatine kinase) are elevated, and autoantibodies (e.g. antinuclear antibodies, anti-Jo-1
& Sports
Polymyositis
And Vasculitides
And antibodies)
Dermatomyositis
are present in most cases. Muscle biopsy is the most definitive test and shows a mononuclear infiltrate surrounding necrotic and regenerating muscle fibers.
Dermatomyositis is characterized by classic cutaneous findings accompanied by proximal muscle weakness. Over 15% of adult patients will have or develop an internal malignancy,
& Sports
Polymyositis
And Vasculitides
And most
Dermatomyositis
commonly ovarian, lung, pancreatic, stomach, or colorectal cancers, or non-Hodgkin lymphoma. Regular, age-appropriate cancer screening is essential in these patients.
Fibromyalgia is a pain syndrome that occurs most commonly in young to middle-aged women and is characterized by fatigue, widespread pain, and cognitive/mood disturbances.
Fibromyalgia Amitriptyline is an effective initial therapy. Pregabalin, duloxetine, and milnacipran are alternate therapies for patients not responding to tricyclic antidepressants.
Carpal tunnel syndrome is caused by compression of the median nerve at the wrist. It initially has an intermittent course, but with progression the symptoms may become more
Carpal Tunnel Syndrome
persistent and associated with motor features. Pain may radiate to the forearm or upper arm, but sensory loss in these areas is not seen.
Fibromyalgia most commonly presents in young to middle-aged women with widespread pain, fatigue, and cognitive/mood disturbances. Patients have point muscle tenderness in
areas such as the mid trapezius, lateral epicondyle, costochondral junction in the chest, and greater trochanter. Exercise is the foundation of management, with medications (e.g.
Fibromyalgia duloxetine, tricyclic antidepressants) reserved for patients who fail initial measures.
Cocaine acts as a sympathomimetic agent that leads to hypertension, tachycardia, pupillary dilation, and psychomotor agitation; causes coronary vasoconstriction; promotes
Coronary
SystemHeart Disease
Cocaine thrombus formation; and increases the risk of myocardial ischemia and infarction.
Sarcoidosis is diagnosed in the setting of a compatible history, chest x-ray findings of hilar adenopathy with or without reticulonodular infiltrates, and noncaseating granulomas on
& Sports
Sarcoidosis
And Vasculitides
biopsy. Hypercalcemia can be present due to granulomatous production of 1,25-dihydroxyvitamin D. Symptomatic disease is treated with systemic glucocorticoids.
Hydroxychloroquine is used for patients with active systemic lupus erythematosus. However, it can cause retinal toxicity with prolonged use. Patients treated with hydroxychloroquine
& Sports
should have a baseline ophthalmologic evaluation and periodic reassessment.
Parvovirus B19 can cause an acute symmetric arthritis of the hands (metacarpophalangeal, proximal interphalangeal, and wrist), knees, and ankle joints. The diagnosis can be
Viral Infections Parvovirus confirmed with anti-parvovirus B19 IgM. The syndrome is usually self-limited and does not require specific treatment.
Viral arthritis due to parvovirus B19 is characterized by acute, symmetric, small-joint arthralgias, mild joint swelling, and a benign, self-limited course. It is usually seen in adults,
& Sports
Parvovirus whereas erythema infectiosum due to parvovirus B19 is more common in children.
& Sports
BladderAnd
Cancer
Vasculitides
Long-term CYC use is associated with the increased incidence of acute hemorrhagic cystitis and bladder carcinoma.
Ankylosing spondylitis (AS) is characterized by chronic inflammatory back pain and stiffness, lumbosacral tenderness, and reduced spinal range of motion. In young patients with
characteristic pain, plain x-rays showing sacroiliitis can confirm the diagnosis. AS is strongly associated with HLA-B27, but HLA-B27 is not specific for AS and not necessary for
& Sports
diagnosis.
First-line treatment options for ankylosing spondylitis include nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors, which provide substantial relief of symptoms and
& Sports
may inhibit progression of the disease for long periods.
Giant cell arteritis (GCA, or temporal arteritis) presents with headache and systemic symptoms (e.g. fatigue, fever) in patients age > 50. Potential complications include anterior
Giant Cell Arteritisischemic optic neuropathy, which can lead to blindness. Threatened (e.g. vision change) or confirmed vision loss in GCA requires high-dose intravenous glucocorticoids.
Idiopathic intracranial hypertension typically presents in young, obese women with headache, vision changes, papilledema, and abducens nerve (CN VI) palsy. Diagnosis is
confirmed
Hypertension
by lumbar puncture showing elevated opening pressure and normal cell counts.
The most severe consequences of methanol intoxication are vision loss and coma. Physical examination in methanol intoxication reveals optic disc hyperemia while laboratory
Toxicology Exposure
Toxic Alcohols studies reveal anion gap metabolic acidosis. An increased osmolar gap is often seen as well.
Lumbar spinal stenosis is most commonly caused by degenerative changes in the spine and presents with low back and leg pain. The leg pain of neurogenic claudication is position-
Spinal/Peripheral
& Sports
Spinal
Nerve Stenosis
Disorders And
dependent
Back Pain
(exacerbated by lumbar extension) and persists even while standing still. Vascular claudication is exertion-dependent and resolves with standing still.
Initial management of osteoarthritis of the knee should include regular, moderate activity and weight loss, particularly in overweight and obese patients. Weight loss decreases the
& Sports
Osteoarthritis inflammation and joint loading that promote degeneration of the articular cartilage and is associated with decreased pain and functional impairment.
Disseminated gonococcal infection may present with asymmetric polyarthralgias (often with tenosynovitis and rash) or isolated septic arthritis. Neisseria gonorrhoeae is the most
common cause of septic arthritis in young, sexually active patients. Diagnosis is confirmed by Gram stain of the synovial fluid, blood cultures, and genital/pharyngeal nucleic acid
& Sports
Gonococcal Infection
amplification tests.
Hyperparathyroidism with chronic hypercalcemia can cause pseudogout, presenting as acute, painful monoarthritis. Diagnostic findings include calcification of the articular cartilage
& Sports
Pseudogout (chondrocalcinosis) on x-ray and rhomboid-shaped, positively birefringent calcium pyrophosphate crystals in synovial fluid.
Gout typically presents as an acute monoarticular arthritis that quickly progresses to maximum intensity within 12-24 hours. Triggers include alcohol use, surgery/trauma,
& Sports
Gout dehydration, and certain medications (e.g. diuretics).
Synovial fluid should be obtained urgently for cell count, Gram stain, and culture in any patient with possible septic arthritis. Pre-existing joint disorders can increase the risk for
secondary infection of the joint. In patients with crystal-induced arthritis (e.g. gout), the presence of crystals in the synovial fluid does not rule out septic arthritis as these will be
& Sports
Gout present between attacks.
Physical examination in osteoarthritis shows crepitus, periarticular bony enlargement, and painful or decreased range of motion. X-ray findings include a narrowed joint space,
& Sports
Osteoarthritis osteophytes, and subchondral sclerosis/cysts. Patients can also have a bland synovial effusion (no organisms, < 2,000 white blood cells/mm3).
Tricyclic antidepressant overdose can present with central nervous system, cardiac, and anticholinergic findings. Sodium bicarbonate is used to treat cardiac toxicity, which is
characterized by prolonged QRS duration (> 100 msec) and ventricular arrhythmias. Sodium bicarbonate increases serum pH and extracellular sodium, thereby alleviating the cardio-
Toxicology Exposure
depressant action on sodium channels.
For patients who present soon after a single, potentially toxic ingestion (> 7.5 g) of acetaminophen, the first step in management is gastric decontamination and measurement of
Toxicology Exposure
Acetaminophen Poisoning
acetaminophen levels. Patients can be asymptomatic during the first 24 hours after ingestion.
Infectious mononucleosis typically presents with prolonged fever, malaise, exudative pharyngitis, splenomegaly, and generalized lymphadenopathy. Patients may develop
autoimmune hemolytic anemia and thrombocytopenia up to 2-3 weeks after the onset of initial symptoms.
Clinical features of marijuana intoxication include increased appetite, tachycardia, tachypnea, dry mouth, and conjunctival injection. Marijuana use slows reaction time; impairs
Toxicology Exposure
Substance Use Disorders
attention, concentration, and coordination; and can increase the risk of motor vehicle collisions.
Bartonella Bright red, firm, friable, exophytic nodules in an HIV infected patient are most likely bacillary angiomatosis.
Oral trimethoprim-sulfamethoxazole is the primary agent used for prophylaxis for Pneumocystis pneumonia in patients who have had solid organ transplantation. Many patients also
require cytomegalovirus prophylaxis with ganciclovir or valganciclovir.
Babesiosis is a tick-borne protozoal illness found primarily in the northeastern United States. Transmission occurs via Ixodes scapularis, and coinfection with other microbes (e.g.
Borrelia burgdorferi, Anaplasma phagocytophilum) is possible. Symptoms are often flu-like (fever, chills, malaise), and laboratory studies usually show anemia with signs of
Babesiosis
Infections intravascular hemolysis and thrombocytopenia. Diagnosis is made primarily by identifying organisms on peripheral blood smear (‘Maltese cross’).
Patients with AIDS who have odynophagia and visible oral thrush likely have candidal esophagitis and should receive 1-2 weeks of empiric oral fluconazole therapy. If symptoms
persist and/or no thrush is apparent, endoscopy with biopsy is generally performed. Cytomegalovirus esophagitis is characterized by large, linear ulcers and
intranuclear/intracytoplasmic inclusions; it is treated with ganciclovir. Herpes simplex esophagitis is characterized by small, well-circumscribed, round/ovoid ulcers and intranuclear
Viral Infections Cytomegalovirus inclusions; it is treated with acyclovir.
Causes of hypercalcemia should be categorized on the basis of parathyroid hormone (PTH) levels. PTH-independent hypercalcemia (suppressed PTH) is usually due to malignancy.
Miscellaneous
& Metabolism
Hypercalcemia PTH-dependent hypercalcemia (elevated or inappropriately normal PTH) is usually due to primary hyperparathyroidism.
Normal &Structure
Metabolism
Hypocalcemia
Patients with
Glands
hypoalbuminemia can have decreased total serum calcium. However, ionized calcium (physiologically active form) is hormonally regulated and remains stable.
Increased extracellular pH (e.g. respiratory alkalosis) causes dissociation of hydrogen ions from albumin, allowing increased binding of calcium and a drop in unbound (ionized)
Normal &Structure
Metabolism
Hypocalcemia
calcium. Ionized
Glandscalcium is the physiologically active form, and decreased levels can result in clinical manifestations of hypocalcemia.
Digitalis toxicity causes increased ectopy and increased vagal tone. Atrial tachycardia with AV block occurs from the combination of these two digitalis effects, and is relatively
Cardiac
System
Arrhythmias
Chronic
And Syncope
Heart Failure
specific for digitalis toxicity.
Lifestyle modification should be the first-line intervention for newly diagnosed stage I hypertension. The most effective lifestyle intervention for reducing blood pressure is weight loss
in obese patients. All patients should be encouraged to follow the DASH diet (rich in fruits, vegetables, and low-fat dairy products), restrict dietary salt intake, engage in regular
Hypertension
aerobic exercise to maintain normal body weight, and limit alcohol intake.
Congenital bicuspid aortic valve is the most common cause of aortic regurgitation (AR) in developed countries, with patients typically diagnosed in their 30s or 40s. The AR is usually
Valvular
valvular but can also be due to aortic root dilation.
Aortic regurgitation leads to increased left ventricular (LV) end-diastolic volume due to leakage of blood from the aorta back into the left ventricle. Features of aortic regurgitation
include a wide pulse pressure, ‘water hammer’ pulse, and LV enlargement. The left lateral decubitus position brings the enlarged left ventricle closer to the chest wall and causes a
Valvular
pounding sensation and increased awareness of the heartbeat.
Patients with aortic outflow obstruction from supravalvular aortic stenosis develop left ventricular hypertrophy and can have exertional angina due to subendocardial ischemia with
Valvular
Aortic Stenosis increased myocardial oxygen demand during exercise.
Pellagra is due to niacin deficiency and is characterized by the ‘3 D’s’: dermatitis, diarrhea, and dementia. Prolonged isoniazid therapy can interfere with niacin metabolism and
Disorders
& Nutrition
Of Nutrition
Niacin Deficiency occasionally cause pellagra.
Body stores of folate are minimal, and deficiency may occur quickly in the setting of significant alcohol abuse. Folate and cobalamin (vitamin B12) deficiencies both result in
Disorders
& Nutrition
Of Nutrition
megaloblastic anemia with insufficiency reticulocytosis, but folate deficiency is associated with normal (not high) methylmalonic acid levels.
Diuretic abuse leads to increased excretion of water and electrolytes by the kidneys, resulting in dehydration, weight loss, orthostatic hypotension, hyponatremia, and hypokalemia.
Fluid,
Systems
Electrolytes,
& Electrolytes
Hypovolemia
And Acid-Base Urinary sodium and potassium will be elevated. Patients sometimes abuse diuretics to induce weight loss.
Milk-alkali syndrome is caused by excessive intake of calcium and absorbable alkali. It can be seen in patients taking calcium bicarbonate for osteoporosis. Clinical findings include
Miscellaneous
& Metabolism
Hypercalcemia symptomatic hypercalcemia, metabolic alkalosis, and acute kidney injury.
Thiamine deficiency can cause Wernicke encephalopathy, which is characterized by encephalopathy, oculomotor dysfunction, and gait ataxia. This is generally seen in malnourished
Miscellaneous Wernicke-Korsakoff
patients
Syndrome
(e.g. anorexia, chronic alcohol use) and may be induced iatrogenically by the administration of glucose without thiamine.
Cellulitis is a skin infection of the deep dermis and subcutaneous fat that is usually caused by β hemolytic Streptococcus (nonpurulent) or Staphylococcus aureus (purulent). Patients
SkinInfections
And Soft Tissue
typically
Infections
develop a slowly spreading rash that is warm, erythematous, and painful with flat, indistinct borders.
Epidemiology
And Principles
Sensitivity
OfAnd
Testing
Specificity
False negatives will increase when the cut-off level of a diagnostic test is raised.
Alzheimer disease, the most common cause of dementia, is characterized by insidious memory loss followed by behavioral changes. Psychotic symptoms (delusions, hallucinations)
Neurodegenerative
Alzheimer
Disorders
Disease
And Dementias
may develop later in the course of the disease.
Patients with Wolff-Parkinson-White syndrome who develop atrial fibrillation with a rapid ventricular rate should be treated with cardioversion or antiarrhythmics such as
procainamide. Atrioventricular nodal blockers such as β blockers, calcium channel blockers, digoxin, and adenosine should be avoided as they can cause increased conduction
Cardiac
System
Arrhythmias
Wolff-Parkinson-White
And Syncope through
Syndrome
the accessory pathway.
Endocarditis Enterococci, especially Enterococcus faecalis, are a common cause of endocarditis associated with nosocomial urinary tract infections.
Pernicious anemia, an autoimmune condition associated with antibodies against intrinsic factor, is the most common cause of vitamin B12 deficiency. It occurs most often in older
adults with other autoimmune conditions. Patients generally have megaloblastic anemia, atrophic glossitis (smooth, shiny tongue), and/or neurologic abnormalities (e.g. lower
Oncology
extremity paresthesia, subacute combined degeneration).
Vitamin B12 deficiency should be suspected in strict vegetarians with anemia and neurologic complications. Folic acid supplementation may correct the anemia in these patients, but
Oncology
it leads to rapid progression of neurologic complications.
Chagas disease is a chronic disease that can cause megaesophagus, megacolon, and/or cardiac dysfunction. The protozoan Trypanosoma cruzi, endemic to Latin America, is
Heart
System
Failure AndChagas
Shock Disease responsible.
Hereditary spherocytosis is usually an autosomal dominant disorder characterized by hemolytic anemia, jaundice, splenomegaly, and spherocytes on peripheral blood smear. Mean
Oncology
Hereditary Spherocytosis
corpuscular hemoglobin concentration is elevated due to red blood cell dehydration and membrane loss. Pigment gallstones are a common complication.
Drug-induced interstitial nephritis is usually caused by antibiotics (e.g. penicillins, cephalosporins, trimethoprim, rifampin), nonsteroidal anti-inflammatory drugs, and diuretics.
Acute
Systems
Kidney
& Electrolytes
Injury
Patients present with a fever, maculopapular rash, and renal failure. Urinalysis may reveal white blood cell casts and, less frequently, eosinophils.
Hypertensive intracerebral hemorrhages occur most commonly in the basal ganglia, thalamus, pons, and cerebellum. Patients tend to present initially with focal symptoms but can
Hemorrhagic Stroke
rapidly progress to signs of elevated intracranial pressure. Brain CT confirms hemorrhage and excludes other causes.
Polymyositis is characterized by proximal muscle weakness and elevated creatine kinase. Initial treatment includes systemic glucocorticoids (e.g. prednisone), and most patients also
& Sports
Polymyositis
And Vasculitides
And receive
Dermatomyositis
a glucocorticoid-sparing agent (e.g. methotrexate, azathioprine) to minimize the adverse effects of treatment.
Alzheimer disease initially presents with memory impairment. Neuroimaging generally demonstrates temporal lobe atrophy, which is most prominent in the hippocampi and
Neurodegenerative
Alzheimer
Disorders
Disease
And Dementias
surrounding medial temporal lobes.
Intravenous β blockers (e.g. labetalol, esmolol) are the treatment of choice for the initial medical management of patients with acute aortic dissection, as they lower heart rate and
Aortic
System
And Peripheral
Aortic
Artery
Dissection
Diseases
blood pressure and reduce left ventricular contractility.
Legionella pneumophila is an intracellular, gram-negative organism commonly spread by aerosols or droplets from contaminated water supplies. A history of recent travel is common.
Legionella Extrapulmonary symptoms such as confusion, ataxia, or diarrhea are suggestive of Legionnaires’ disease. Treatment options include macrolides or fluoroquinolones.
Multifocal atrial tachycardia is a supraventricular tachyarrhythmia characterized by distinct P waves with > 3 different morphologies, atrial rate > 100/min, and an irregular rhythm. It is
Critical Care
Vascular
Multifocal
And Cardiopulmonary
Atrial Tachycardia
usually precipitated
Disease by acute respiratory illness in patients with underlying lung disease. Treatment should be directed at correcting the underlying inciting disturbance.
Short-acting β-adrenergic agonists administered 10-20 minutes before exercise are the first-line treatment for exercise-induced bronchoconstriction if required only a few times a
Asthma Lung Disease
week (less than daily). Inhaled corticosteroids or antileukotriene agents can be used in patients who exercise daily.
Granulomatosis with polyangiitis is a systemic vasculitis characterized by upper and lower respiratory tract granulomatous inflammation and glomerulonephritis that can be rapidly
Critical Care
Vascular
Granulomatosis
And Cardiopulmonary
With
progressive.
Polyangiitis
Disease
Ventilation is defined as the product of the respiratory rate and the tidal volume. Respiratory alkalosis results from hyperventilation. In mechanically ventilated patients with respiratory
Critical Care
Care And Trauma
Respiratory
Medicine
Alkalosis
alkalosis in the setting of an appropriate tidal volume, the respiratory rate should be lowered.
Cardiac sarcoidosis is a disease of noncaseating granuloma infiltration of the myocardium and can result in serious arrhythmia, cardiomyopathy, heart failure, and sudden cardiac
Cardiac
System
Arrhythmias
Sarcoidosis
And Syncope death.
Idiopathic pulmonary fibrosis is due to excessive collagen deposition in peri-alveolar tissues. This leads to decreased lung volumes (low total lung capacity, functional residual
capacity, and residual volume) with preserved or increased forced expiratory volume in 1 second/forced vital capacity ratio. Patients have impaired gas exchange resulting in reduced
Critical Care
Pulmonary
Interstitial
Disease
diffusion
Disorders
capacity of carbon monoxide and increased alveolar-arterial gradient.
Suspect idiopathic intracranial hypertension (pseudotumor cerebri) in a young woman with obesity who comes with a headache that is suggestive of a brain tumor, but with normal
neuroimaging and elevated CSF pressure. The treatment includes weight reduction and acetazolamide. Shunting or optic nerve sheath fenestration may be performed to prevent
blindness.
Hypertension
COPD Lung Disease
Long-term supplemental oxygen therapy has been proven to prolong survival in patients with chronic obstructive pulmonary disease and significant chronic hypoxemia.
Bronchiectasis is a disease of bronchial thickening and dilation due to recurrent infection and inflammation. Cough with large-volume mucopurulent sputum production, hemoptysis,
Critical Care
Infections
Bronchiectasis and dyspnea are common. The diagnosis is made using a high-resolution CT scan of the chest.
Blastomycosis is a pulmonary fungal infection endemic to the Great Lakes, and Mississippi and Ohio River basins. Systemic blastomycosis may cause skin and bone lesions in
addition to pulmonary manifestations. Broad-based budding yeast grown from the sputum confirm the diagnosis. Itraconazole or amphotericin B may be used to treat symptomatic
Fungal Infections Blastomycosis disease.
Patients involved in motor vehicle collisions due to drowsy driving should be evaluated for high-risk behaviors, use of sedating medications, and sleep disorders. Obstructive sleep
3033 Medicine Pulmonary & Sleep
CriticalDisorders
Care Obstructive Sleepapnea
Apneais frequently implicated in drowsy driving motor vehicle collisions; nocturnal polysomnography should be ordered to confirm the diagnosis.
α1 antitrypsin (AAT) deficiency should be considered in patients who lack typical risk factors for chronic obstructive pulmonary disease (e.g. age < 45) or those with atypical features
3031 Medicine Pulmonary & Congenital
Critical Care
And Developmental
α1 Antitrypsin Anomalies
Deficiency
(e.g. basilar-predominant disease). Diagnosis is confirmed by measuring serum AAT levels.
Lung malignancy is a potential cause of localized airway obstruction and may present with episodes of recurrent pneumonia. CT scan of the chest should be used to evaluate
Critical Care
Infections
Community Acquired
patients
Pneumonia
in whom there is suspicion for lung malignancy.
Intermittent asthma is characterized by symptoms < 2 days per week, nighttime awakenings < 2 times per month, normal FEV1 and FEV1/FVC ratio, and no limitation on daily
activity. Patients with intermittent asthma are managed with an as-needed short-acting β2-agonist (e.g. albuterol) and do not require daily controller medication (e.g. inhaled
Asthma Lung Disease
corticosteroid).
High-dose (HD)s of β2-agonists used in asthma treatment (e.g. albuterol) can cause hypokalemia, which may present with muscle weakness, hyporeflexia, and life-threatening
Asthma Lung Disease
arrhythmias.
Asbestosis is a pneumoconiosis resulting from inhalation of particles involved in many industrial processes. Progressive dyspnea, clubbing, and end-inspiratory crackles are typical
signs and symptoms. Pulmonary function tests show a restrictive lung disease pattern with decreased lung volume, decreased diffusion lung capacity, and a normal FEV1/FVC ratio.
Critical Care
Pulmonary
Asbestos
And Other Systemic
Pleural Disorders
plaques on imaging are the hallmark of asbestosis.
Asbestos exposure increases the risk of pulmonary fibrosis and malignancy. Bronchogenic carcinoma is the most common malignancy diagnosed in patients exposed to asbestos.
Critical And
Asbestos Smoking
Masses acts synergistically with asbestos to further increase the risk of lung cancer.
Acute respiratory distress syndrome is associated with hypoxemia and bilateral alveolar infiltrates not fully explained by volume overload. It results in impaired gas exchange,
Critical Care
Care And Trauma
ARDS Medicine decreased lung compliance, and pulmonary hypertension.
Hypersensitivity pneumonitis (HP) is inflammation of the lung parenchyma caused by antigen exposure. Acute episodes present with cough, breathlessness, fever and malaise that
occur within 4-6 hours of antigenic exposure. Chronic exposure may cause weight loss, clubbing, and honeycombing of the lung. The cornerstone of HP management is avoidance of
Critical Care
Pulmonary
Hypersensitivity
And Other Systemic
Pneumonitis
the responsible
Disordersantigen.
Staphylococcal infection is the most common cause of healthcare-associated infective endocarditis (IE); streptococcal infection is a common cause of community-acquired IE. IE with
viridans group streptococci is commonly encountered after dental procedures involving manipulation of the gingival tissue or oral mucosa and with procedures involving incision and
Endocarditis biopsy of the respiratory tract.
Right-sided endocarditis should be considered in patients with presumed history of intravenous drug use. Empiric antibiotic treatment of native-valve endocarditis should be geared
Endocarditis toward methicillin-resistant Staphylococcus aureus, streptococci, and enterococci. Vancomycin is the most appropriate empiric antibiotic for these patients.
Endocarditis Blood cultures from separate venipuncture sites should be obtained over a specified period in all patients with suspected infective endocarditis prior to initiating antibiotic therapy.
Viral encephalitis can present with cerebrospinal fluid findings of elevated white blood cell count with a lymphocytic predominance, elevated red blood cell count, normal glucose, and
normal to slightly elevated protein concentration. Early empiric therapy with intravenous acyclovir should be initiated as soon as possible for suspected herpes simplex virus
Viral Infections HSV Infection encephalitis until confirmatory tests return.
Rabies postexposure prophylaxis (PEP) for mammalian bites includes rabies vaccine and rabies immune globulin. PEP is indicated when the animal is unavailable or symptomatic.
Viral Infections Rabies Available, asymptomatic animals can either be observed (pets, for 10 days) or tested (wild animals) to determine the need for PEP.
Sporothrix schenckii is a dimorphic fungus found in decaying plant matter and soil and primarily infects gardeners and landscapers (direct cutaneous inoculation). Typically, a papule
forms at the inoculation site, which may ulcerate and drain nonpurulent, odorless fluid. Additional, proximal papular lesions may form along lines of lymphatic drainage. Deeper
Fungal Infections Sporotrichosis tissues and lymph nodes are usually spared, and systemic spread is rare.
Blastomycosis is a fungal infection endemic to the central United States. It usually causes a mild pulmonary illness, but disseminated infection may occur even in immunocompetent
Fungal Infections Blastomycosis individuals. Cutaneous blastomycosis manifests as well-circumscribed verrucous nodules and plaques that progress to microabscesses.
Coccidioides is an endemic mycosis of the desert southwest that causes community-acquired pneumonia (fever, chest pain, cough, lobar infiltrate) often accompanied by arthralgias,
erythema nodosum, and erythema multiforme. Symptoms may last weeks to months. Most otherwise healthy patients do not require antifungal therapy. Patients who are at high risk
Fungal Infections Coccidioidomycosis
(e.g. immunocompromised) for dissemination are often given ketoconazole or fluconazole.
Invasive aspergillosis primarily affects immunocompromised patients and typically causes the triad of fever, pleuritic chest pain, and hemoptysis. CT scan often reveals pulmonary
Critical Care
Infections
Aspergillosis nodules with surrounding ground-glass opacities (‘halo sign’). Treatment usually requires a combination of voriconazole and an echinocandin (e.g. caspofungin).
Histoplasmosis closely mimics the presentation of sarcoidosis and should be considered when a patient with suspected sarcoidosis deteriorates after immunosuppressive therapy. In
Fungal Infections Histoplasmosis endemic regions, dimorphic fungi (e.g. Histoplasma, Blastomyces, Coccidioides) should be excluded before immunosuppression is initiated.
Mucormycosis is an invasive fungal infection most commonly seen in patients with poorly controlled diabetes mellitus (especially in ketoacidosis). Treatment involves surgical
Fungal Infections Mucormycosis debridement, antifungal medication (e.g. liposomal amphotericin B), and the elimination of promoting factors (e.g. hyperglycemia, ketoacidosis).
Mucormycosis is an invasive fungal infection that most commonly manifests as rhino-orbital-cerebral disease in patients with immunocompromise (particularly poorly controlled
diabetes mellitus). Symptoms include acute fever, nasal congestion, purulent nasal discharge, headache, and sinus pain. Local, necrotic spread is common. Diagnosis requires sinus
Fungal Infections Mucormycosis endoscopy with tissue sampling. Rhizopus is the most common cause.
Creutzfeldt-Jakob disease should be suspected in older adult patients (age 50-70) with rapidly progressive dementia, myoclonus, periodic sharp-wave complexes on
Neurodegenerative
Prion
Disorders
Disease
And Dementias
electroencephalogram, and/or elevated 14-3-3 proteins in cerebrospinal fluid.
Budd-Chiari syndrome, a condition marked by obstruction of hepatic venous outflow, often presents with subacute manifestations such as vague, progressive abdominal pain,
ascites, and hepatosplenomegaly. Polycythemia vera, a chronic myeloproliferative neoplasm associated with increased red blood cell mass, is particularly likely to cause Budd-Chiari
Oncology
Polycythemia syndrome.
Survival without liver transplantation is low in patients with acute liver failure and indications that the disease is worsening or failing to improve. When appropriate, these patients
Hepatic
& Nutrition
DisordersAcute Liver Failure
should undergo early consideration for liver transplantation.
Cholesterol embolism can occur after a vascular procedure (e.g. cardiac catheterization) and may lead to skin (e.g. livedo reticularis, blue toe) or gastrointestinal (e.g. mesenteric
ischemia, acute pancreatitis) complications. Acute pancreatitis from uncorrectable causes (e.g. ischemia, atheroembolism) can be conservatively managed with analgesics and
Pancreatic
& Nutrition
Disorders
Acute Pancreatitisintravenous fluids.
Approximately 10%-20% of patients on isoniazid will develop mild aminotransferase elevation within first few weeks of treatment. This hepatic injury is typically self-limited and will
Tuberculosis resolve without intervention.
Fever, jaundice, and right upper quadrant abdominal pain (Charcot triad) are consistent with acute cholangitis. Ultrasound or CT scan most commonly shows common bile duct
dilation. In addition to leukocytosis with left shift, laboratory studies reflect biliary stasis and demonstrate direct hyperbilirubinemia, elevated alkaline phosphatase, and mildly elevated
Biliary
& Nutrition
Tract Disorders
Cholangitis aminotransferases.
Dubin-Johnson syndrome is a benign, hereditary condition resulting in chronic or fluctuating conjugated hyperbilirubinemia and intermittent jaundice due to a defect in hepatic
Hepatic
& Nutrition
DisordersJaundice excretion of conjugated bilirubin.
Elevated serum alkaline phosphatase levels are indicative of cholestasis. These patients (with or without hyperbilirubinemia) should be evaluated with right upper quadrant
Biliary
& Nutrition
Tract Disorders
Gallstone Diseaseultrasound to assess for intrahepatic or extrahepatic causes of biliary obstruction.
Hepatic hydrothorax generally results in transudative pleural effusions and is thought to occur due to small defects in the diaphragm. Diagnosis involves documentation of the
Hepatic
& Nutrition
DisordersCirrhosis effusion and testing to exclude other causes.
Acute pancreatitis is most commonly due to chronic alcohol use and gallstones. Marked hypertriglyceridemia (> 1,000 mg/dL) can lead to acute pancreatitis and can cause eruptive
Pancreatic
& Nutrition
Disorders
Acute Pancreatitisxanthomas. The diagnosis can be confirmed with a fasting serum lipid profile.
Among healthy adults, acute hepatitis B virus infection is self-limited in > 95% of cases. In the recovery phase, serology typically demonstrates hepatitis B surface antibody (which
Viral Infections Hepatitis B provides immunity), IgG hepatitis B core antibody, and hepatitis B e antigen antibody.
Mixed cryoglobulinemia syndrome is an immune complex deposition disorder commonly associated with chronic hepatitis C. It presents with fatigue, palpable purpura, arthralgias,
renal disease, and peripheral neuropathies. Laboratory studies show serum cryoglobulins, hypocomplementemia, positive rheumatoid factor, elevated transaminases, and kidney
& Sports
Cryoglobulinemia
And Vasculitides
injury.
Patients with hepatic encephalopathy on diuretics can develop low intravascular volume despite having total volume overload, leading to a metabolic alkalosis with associated
Hepatic
& Nutrition
DisordersHepatic Encephalopathy
hypokalemia. Treatment includes volume resuscitation and repletion of hypokalemia in addition to serum ammonia-lowering medications (e.g. lactulose).
Ursodeoxycholic acid (UDCA) is the drug of choice in primary biliary cholangitis (PBC). It delays histologic progression and may improve symptoms and possibly survival. Therefore,
Biliary
& Nutrition
Tract Disorders
Primary Biliary Cholangitis
UDCA should be initiated as soon as the diagnosis of PBC is made. Patients with advanced disease require liver transplantation.
Wilson disease presents with hepatic, neurologic, and psychiatric symptoms. The diagnosis is supported by low serum ceruloplasmin, increased urinary copper, and Kayser-
Congenital And Developmental
Wilson Disease
Anomalies
Fleischer rings on slit-lamp examination.
In evaluating the asymptomatic elevation of aminotransferases, the first step is to take a thorough history to rule out the more common hepatitis risk factors (e.g. alcohol or drug use,
Hepatic
& Nutrition
DisordersAbnormal LFTs travel outside of the country, blood transfusions, high-risk sexual practices).
Uncomplicated patients with acute onset of severe epigastric pain radiating to the back and increased amylase or lipase (> 3 times normal) do not need confirmatory imaging for
diagnosing acute pancreatitis. Contrast-enhanced computed tomography scan of the abdomen may be performed in patients with unclear diagnosis or those who fail to improve with
Pancreatic
& Nutrition
Disorders
Acute Pancreatitisconservative management. Abdominal ultrasound may identify gallstones as the cause of pancreatitis.
Active hepatitis B (HB) infection typically presents with positive HB surface antigen, positive Be antigen, and absent surface antibody. Health care workers exposed to blood from HB
patients (ocular, mucous membrane, or skin) should receive postexposure prophylaxis. Unvaccinated individuals should receive both the HB vaccine and HB immune globulin as
Viral Infections Hepatitis B soon as possible.
Individuals with resolved hepatitis B infection are positive for anti-HBs and anti-HBc but negative for HBsAg. Individuals who are immunized with the hepatitis B vaccine are positive
Hepatic
& Nutrition
DisordersHepatitis B for anti-HBs but negative for HBsAg and anti-HBc.
Gilbert syndrome is caused by reduced bilirubin glucuronidation and results in intermittent jaundice due to a mild, unconjugated hyperbilirubinemia. Jaundice may be triggered by
Biliary
& Nutrition
Tract Disorders
Hereditary Hyperbilirubinemias
fasting or consumption of a fat-free diet, physical exertion, febrile illness, stress, or menstruation. Management involves reassurance and supportive care.
In most patients with nonbleeding varices, prophylactic treatment with nonselective β blockers (e.g. propranolol, nadolol) is recommended to reduce the likelihood of progression to
large varices as well as the risk of variceal hemorrhage. Endoscopic variceal ligation can be used as an alternate primary preventive therapy in patients with contraindications to β
Gastroesophageal
Disorders Varices
blocker therapy.
Primary sclerosing cholangitis is often asymptomatic but may present with fatigue and pruritus, and laboratory studies usually reveal cholestasis. It is strongly associated with
ulcerative colitis. The diagnosis is confirmed with magnetic resonance cholangiopancreatography demonstrating multifocal bile duct strictures alternating with segments of ductal
Hepatic
& Nutrition
DisordersPrimary Sclerosing
dilation
Cholangitis
(e.g. beaded appearance).
α1 antitrypsin deficiency is a genetic disease that results in symptoms of chronic obstructive pulmonary disease (COPD) and liver disease. It should be considered in patients who
α1 Antitrypsin
LungDeficiency
Disease
have COPD but lack typical risk factors or who have a family history of emphysema or liver disease.
Hepatic
& Nutrition
DisordersDrug Induced Liver
Isoniazid
Injury causes idiosyncratic liver injury with histological features similar to those seen in patients with viral hepatitis.
Acute liver failure (ALF) is characterized by elevated aminotransferases, encephalopathy, and INR > 1.5. Acetaminophen toxicity is a common cause of ALF that may be potentiated
Hepatic
& Nutrition
by chronic alcohol use.
HBsAg and anti-HBc are the most appropriate diagnostic tests for acute hepatitis B (HBV) infection as they are both elevated during initial infection and anti-HBc will remain elevated
Hepatic
& Nutrition
DisordersHepatitis B during the window period.
Alcoholic hepatitis is generally characterized by a ratio of aspartate aminotransferase (AST) to alanine aminotransferase (ALT) > 2, elevated γ-glutamyltransferase, and elevated
Hepatic
& Nutrition
DisordersAlcoholic Liver Disease
ferritin. The absolute values of AST and ALT are almost always < 500 IU/L in alcoholic liver disease.
Nonalcoholic fatty liver disease is characterized by hepatomegaly, with mild elevations in liver transaminase levels in the absence of other causes of secondary hepatic fat
Hepatic
& Nutrition
DisordersNonalcoholic Fattyaccumulation
Liver Disease(e.g. alcohol). It is most common in patients with obesity and diabetes. Management includes weight loss and control of metabolic risk factors.
Workup of ascites includes ultrasonography and a diagnostic paracentesis (i.e. serum-ascites albumin gradient, cell count and differential, total protein) to determine the underlying
etiology and rule out spontaneous bacterial peritonitis. Initial management of ascites from cirrhosis includes spironolactone and furosemide, sodium restriction, and alcohol
Hepatic
& Nutrition
DisordersCirrhosis abstinence.
Cirrhosis should be suspected in any patient with evidence of chronic liver disease (e.g. ascites, spider angiomata, gynecomastia, splenomegaly). Viral hepatitis, chronic alcohol
Hepatic
& Nutrition
DisordersCirrhosis abuse, nonalcoholic fatty liver disease, and hemochromatosis are the most common causes of cirrhosis in the United States.
Hepatitis A virus infection commonly presents with fever, nausea, vomiting, and abdominal pain followed by jaundice and pruritus. Physical examination and laboratory analysis
Viral Infections Hepatitis A reveal tender hepatomegaly and significant elevations in transaminases, bilirubin, and alkaline phosphatase. Most patients completely recover in 3-6 weeks.
Spontaneous bacterial peritonitis (SBP) should be suspected in any patient with cirrhosis and ascites who presents with low-grade fever, abdominal discomfort, or altered mental
Hepatic
& Nutrition
DisordersSpontaneous Bacterial
status.Peritonitis
The Reitan trail test, a timed connect-the-numbers test, helps detect subtle mental status changes sometimes present in patients with SBP.
Acute liver failure is defined as acute onset of severe liver injury with encephalopathy and impaired synthetic function (defined as INR > 1.5) in a patient without cirrhosis or
Hepatic
& Nutrition
underlying liver disease. Drug toxicity and acute viral hepatitis are the most common causes.
Hepatic
& Nutrition
DisordersCirrhosis Hyperestrinism in cirrhosis leads to gynecomastia, testicular atrophy, decreased body hair, spider angiomas, and palmar erythema.
Primary biliary cholangitis (previously termed primary biliary cirrhosis) is a chronic liver disease characterized by intrahepatic cholestasis due to autoimmune destruction of small bile
ducts. It presents in middle-aged women with fatigue, pruritus, hepatomegaly, and elevated alkaline phosphatase. The diagnosis is confirmed with serum antimitochondrial antibody
Biliary
& Nutrition
Tract Disorders
titers.
Wilson disease is characterized by the combination of liver disease and neuropsychiatric symptoms that present in patients age 5-35. Liver dysfunction ranges from asymptomatic
Hepatic
& Nutrition
DisordersWilson Disease liver function abnormalities to cirrhosis. Neuropsychiatric symptoms include parkinsonism, dysarthria, choreoathetosis, ataxia, personality changes, and depression.
Chronic myeloid leukemia (CML) is driven by a reciprocal translocation of chromosomes 9 and 22 forming the BCR-ABL fusion gene. This gene creates a constitutively active
Oncology
tyrosine kinase. Tyrosine kinase inhibitors such as imatinib are a key therapy in the treatment of CML.
Bone pain is a common presenting symptom in multiple myeloma (MM). In an elderly patient with evidence of osteolytic lesions on x-ray, MM should always be suspected. The
Oncology
Cell Disorders
Multiple Myelomascreening tests of choice for MM are serum protein electrophoresis, urine protein electrophoresis, and free light chain analysis. Diagnosis can be confirmed with bone marrow biopsy.
Oncology
Chronic Lymphocytic
Infections
Leukemia
are a common complication of chronic lymphocytic leukemia (CLL). CLL is diagnosed by flow cytometry (clonality of mature B cells).
Leukemoid reaction (LR) occurs as a response to severe infection and is marked by leukocyte counts > 50,000/mm3. Compared to chronic myeloid leukemia, LR is characterized by
Oncology
Leukemoid Reaction
the presence of a high alkaline phosphatase score, a greater proportion of late neutrophil precursors (metamyelocytes, bands), and a lack of absolute basophilia.
Chronic myeloid leukemia (CML) is marked by dramatic leukocytosis, absolute basophilia, and a shift towards very early neutrophil precursor cells (promyelocytes, myelocytes). In
Oncology
CML, the leukocyte alkaline phosphatase score, a marker of neutrophil activity, typically is low.
Polycythemia vera is a myeloproliferative disorder marked by erythrocytosis. It is a form of primary polycythemia, almost always caused by a mutation of JAK2 in a myeloid precursor
Oncology
Polycythemia cell. Erythropoietin levels tend to be low (unlike most causes of secondary polycythemia).
Polycythemia vera is a myeloproliferative disorder characterized by erythrocytosis. It often presents with hypertension, transient vision disturbances, aquagenic pruritus, or
thrombosis. Facial plethora and splenomegaly are common on physical examination. Treatment is primarily serial phlebotomy; bone marrow suppressive drugs (e.g. hydroxyurea)
Oncology
Polycythemia may sometimes be added if there is a high risk of thrombosis.
Hereditary hemochromatosis is commonly associated with calcium pyrophosphate dihydrate crystal deposition in joints, leading to chondrocalcinosis, pseudogout, and chronic
& Sports
Hemochromatosis
And Vasculitides
arthropathy. Patients commonly also have diabetes and liver disease. Diagnosis is suggested by iron overload on serum iron studies and can be confirmed by genetic tests.
The most common causes of microcytic anemia include iron deficiency, anemia of chronic disease, and thalassemia. Iron studies can be used to differentiate among these etiologies.
Iron deficiency anemia usually demonstrates a low serum iron, low ferritin, elevated total iron-binding capacity (TIBC), and low transferrin saturation (i.e. iron/TIBC). Iron deficiency in
Oncology
men is usually due to chronic gastrointestinal blood loss.
Macrocytic anemia can be due to megaloblastic (e.g. impaired DNA synthesis due to B12 or folate deficiency) or nonmegaloblastic (e.g. alcohol use, hypothyroidism, drugs, liver
Oncology
disease) etiologies. Peripheral smear, reticulocyte count, and B12 and folate levels can aid diagnosis and distinguish between B12 and folate deficiency.
Clinical manifestations of infectious mononucleosis include fatigue, sore throat, fever, lymphadenopathy, and splenomegaly. Atypical lymphocytes on peripheral smear are
characteristic; heterophile antibodies, while specific for Epstein-Barr virus infection, may be negative early in the illness.
Hairy cell leukemia is a chronic B-cell neoplasm that infiltrates the bone marrow, spleen, and peripheral blood, resulting in cytopenias, splenomegaly, and peripheral smear evidence
Oncology
Hairy Cell Leukemia
of atypical lymphocytes with ‘hairy’ cytoplasmic projections. Hepatomegaly, lymphadenopathy, and B symptoms are uncommon. Diagnosis is made with bone marrow biopsy.
Oncology
Chronic Lymphocytic
Chronic
Leukemia
lymphocytic leukemia is seen almost exclusively in elderly patients. Peripheral smear is characterized by a marked leukocytosis with mature lymphocytes and smudge cells.
Multiple myeloma (MM) is a plasma cell neoplasm that infiltrates the bone marrow and may cause a monoclonal protein elevation (M-spike). MM is associated with hypercalcemia,
Oncology
Cell Disorders
Multiple Myelomaanemia, renal insufficiency, and an elevated protein gap (> 4 g/dL).
Disorders Of The Diabetic
Eye And Retinopathy
Associated
Vitreous
Structures
hemorrhage typically presents as a sudden loss of vision and onset of floaters. Vitreous hemorrhage occurs in patients with diabetic retinopathy.
Disorders Of The Retinal
Eye AndDetachment
Associated
Retinal
Structures
detachment usually presents with a sudden onset of photopsia and floaters.
Retinal Artery Occlusion
Central retinal artery occlusion is a monocular painless acute vision loss most commonly caused by an embolized atherosclerotic plaque from the ipsilateral carotid artery.
Disorders Of The Infectious
Eye And Associated
KeratitisHerpes
Structures
simplex keratitis is characterized by corneal vesicles and dendritic ulcers.
Disorders Of The Dacryostenosis
Eye And Associated
&Dacryocystitis
Dacryocystitis
Structures presents with inflammatory changes in the medial canthal region of the eye. Staphylococcus aureus and β-hemolytic Streptococcus are the usual infecting organisms.
Optic neuritis is usually characterized by the acute onset of monocular vision loss with central scotoma, afferent pupillary defect, changes in color perception, and pain with eye
Optic Neuritis movement. There is a strong association between optic neuritis and multiple sclerosis.
Cytomegalovirus (CMV) retinitis is the most common end-organ complication of CMV in those with advanced AIDS. It typically presents with blurred vision, floaters, and photopsia
(sensation of flashing lights). The major complications are vision loss (including blindness) and retinal detachment. Treatment necessitates antiviral medication (e.g. valganciclovir)
Disorders Of The Cytomegalovirus
Eye And Associated
and,
Structures
in severe cases, intravitreal injections. All patients should also be started on antiretroviral treatment to prevent recurrence and progression.
Disorders Of The Herpes
Eye AndZoster
Associated
Herpes
Structures
zoster ophthalmicus is characterized by dendriform corneal ulcers and a vesicular rash in the trigeminal distribution.
Open-angle glaucoma (OAG) is a type of optic neuropathy characterized by loss of peripheral vision associated with an enlarged optic cup and an increased cup/disc ratio (i.e.
‘cupping’). It is typically associated with increased intraocular pressure, but this finding is not highly sensitive or specific. OAG usually has an insidious course, and patients frequently
Eye And Associated
areStructures
asymptomatic until the condition is advanced.
Angle closure glaucoma occurs predominantly in people aged 55-70 years. It presents with an acute onset of severe eye pain and blurred vision associated with nausea and
Eye And Associated
vomiting.
Structures
Examination reveals a red eye with steamy cornea and moderately dilated pupil that is nonreactive to light.
Allergic conjunctivitis is an acute hypersensitivity reaction caused by environmental exposure to allergens. It is characterized by intense itching, hyperemia, tearing, and edema of the
Disorders Of The Conjunctivitis
Eye And Associated
conjunctiva
Structures
and eyelids.
Oral leukoplakia presents as white patches or plaques over the oral mucosa that usually cannot be scraped off. The risk factors for development of leukoplakia are similar to those for
Disorders
(ENT)
Of The Leukoplakia
squamous cell carcinoma (tobacco and alcohol use). Development of areas with induration and/or ulceration should prompt biopsy to rule out malignant transformation of the lesion.
Aspirin-exacerbated respiratory disease is a clinical condition defined by the triad of asthma, bronchospasm or nasal congestion following the ingestion of aspirin or nonsteroidal anti-
Disorders
(ENT)
Of The Nasal
Ear, Nose,
Polyps
And Throat
inflammatory drugs, and chronic rhinosinusitis with nasal polyposis.
Loop diuretics can cause hearing loss that may be either temporary or permanent. Ototoxicity is more common in patients taking high-dose (HD)s of loop diuretics, those with
Disorders
(ENT)
Of The Hearing
Ear, Nose,
Loss
And Throat
coexistent renal failure, or those also being treated with other known ototoxic medications (e.g. aminoglycosides).
Miscellaneous Aminoglycoside Aminoglycosides can be ototoxic to both the cochlea (resulting in sensorineural hearing loss) and the vestibular system (resulting in imbalance).
Sensorineural hearing loss that occurs with aging is called presbycusis. It presents with bilateral, high-frequency hearing loss and is related to damage to sensorineural structures in
Disorders
(ENT)
Of The Hearing
Ear, Nose,
Loss
And Throat
the inner ear.
Necrotizing (malignant) otitis externa represents osteomyelitis of the skull base and is most commonly caused by Pseudomonas aeruginosa. The characteristic presentation consists
Disorders
(ENT)
Of The Otitis
Ear, Nose,
Externa
And Throat
of severe ear pain and ear drainage; granulation tissue may be seen in the ear canal. Progression of the infection may lead to cranial neuropathies.
Loop diuretics are frequently administered to cirrhotic patients with volume overload and ascites. Potential side effects include hypokalemia, metabolic alkalosis, and prerenal kidney
Fluid,
Systems
Electrolytes,
& Electrolytes
Metabolic
And Acid-Base
Alkalosis
injury.
Postictal lactic acidosis commonly occurs following a tonic-clonic seizure. It is a transient anion gap metabolic acidosis that resolves without treatment within 90 minutes following
Fluid,
Systems
Electrolytes,
& Electrolytes
Metabolic
And Acid-Base
Acidosisresolution of seizure activity.
Chloride is essential for renal excretion of HCO3- and total body chloride depletion often plays an important role in metabolic alkalosis. Etiologies of metabolic alkalosis characterized
by chloride depletion include severe vomiting and diuretic overuse. These etiologies demonstrate low urine chloride (< 20 mEq/L), and the alkalosis corrects with Cl- repletion (saline
Fluid,
Systems
Electrolytes,
& Electrolytes
Metabolic
And Acid-Base
Alkalosis
responsive).
Primary adrenal insufficiency (PAI) is a potential complication of miliary tuberculosis. Signs and symptoms of aldosterone deficiency (e.g. hypovolemia, hyperkalemia) are present in
Critical Care
Infections
PAI and can help differentiate PAI from secondary adrenal insufficiency.
Recurrent vomiting causes depletion of fluid, acid, and sodium chloride, leading to metabolic alkalosis, activation of the renin-angiotensin-aldosterone system, and increased urinary
Fluid,
Systems
Electrolytes,
& Electrolytes
Metabolic
And Acid-Base
Alkalosis
potassium loss. Volume resuscitation with normal saline corrects contraction alkalosis. Hypokalemia should be treated as well.
Type 4 renal tubular acidosis (hyperkalemic renal tubular acidosis) is characterized by non-anion gap metabolic acidosis, persistent hyperkalemia, and mild-to-moderate renal
Fluid,
Systems
Electrolytes,
& Electrolytes
Renal
And Acid-Base
Tubular Acidosis
insufficiency. It commonly occurs in patients with poorly controlled diabetes.
Acute salicylate intoxication should be suspected in patients with the triad of tinnitus, fever, and tachypnea. It usually causes a mixed primary respiratory alkalosis and primary
Fluid,
Systems
Electrolytes,
& Electrolytes
Salicylate
And Acid-Base
Poisoning
metabolic acidosis with arterial pH often within the normal range.
Ethylene glycol and methanol intoxication cause metabolic acidosis with both an anion gap and an osmolal gap. Calcium oxalate crystals (square, envelope-shaped) are seen in
Acute
Systems
Kidney
& Electrolytes
Injury
Toxic Alcohols patients with ethylene glycol (antifreeze) poisoning. Ethylene glycol intoxication can result in renal failure; methanol intoxication can cause blindness.
Fluid,
Systems
Electrolytes,
& Electrolytes
Metabolic
And Acid-Base
AcidosisThe anion gap must always be calculated in patients with metabolic acidosis in order to narrow the differential diagnosis.
Diabetic ketoacidosis commonly occurs as a presenting symptom of type 1 diabetes mellitus. It generates anion gap metabolic acidosis (low pH, low bicarbonate) and can be
accompanied by compensatory respiratory alkalosis (signified by increased respiratory rate and deep breathing) leading to decreased PaCO2. The pH can be restored to near-
Fluid,
Systems
Electrolytes,
& Electrolytes
Metabolic
And Acid-Base
Acidosisnormal levels but never fully corrects.
The anion gap (AG) represents the concentration of unmeasured serum anions. In anion gap metabolic acidosis, the AG is increased by the abnormal presence of non-chlorinated
Fluid,
Systems
Electrolytes,
& Electrolytes
Metabolic
And Acid-Base
Acidosisacids in the serum.
Mixed acid-base disorders involve > 2 primary disturbances and can be recognized by inappropriate compensation for the initial primary disturbance. Sepsis with respiratory failure is
Fluid,
Systems
Electrolytes,
& Electrolytes
Metabolic
And Acid-Base
Acidosisa common cause of mixed metabolic and respiratory acidosis.
In any patient, the pH and PaCO2 are the two lab values that provide the best picture of acid-base status; the HCO3 can be calculated from these values using the Henderson-
Fluid,
Systems
Electrolytes,
& Electrolytes
Physiological
And Acid-Base
Buffers
Hasselbalch equation.
Pneumonia triggers hyperventilation that can lead to primary respiratory alkalosis, which is indicated by high pH and low PaCO2. Serum HCO3 remains near normal in the acute
Fluid,
Systems
Electrolytes,
& Electrolytes
Respiratory
And Acid-Base
Alkalosis
setting because full renal compensation requires several days to complete.
Stevens-Johnson syndrome is an inflammatory reaction to drugs or certain infections and is characterized by coalescing erythematous macules, bullae, desquamation, and
2780 Medicine Dermatology Skin Tumors And Stevens-Johnson
Tumor-Like Lesions
mucositis.
SyndromeSystemic signs include fever, hemodynamic instability, and altered level of consciousness.
Vitiligo is caused by regional destruction of melanocytes, most likely due to an autoimmune etiology. It is often associated with other autoimmune conditions and is usually slowly
2779 Medicine Dermatology Normal Structure Vitiligo
And Function Of Skin
progressive. The diagnosis is made on clinical grounds, and topical or systemic corticosteroids are the most common first-line intervention.
Toxic epidermal necrolysis (TEN) is a severe syndrome characterized by the sudden onset of mucocutaneous lesions and systemic signs of toxicity. Typical features include an
erythematous eruption that rapidly evolves into exfoliation of the skin. It is most often caused by medications (e.g. antibiotics, anticonvulsants, allopurinol). TEN and Stevens-Johnson
syndrome (SJS) are similar disorders distinguished by the percentage of involved skin: SJS involves < 10% of the body surface area, TEN involves > 30, and SJS/TEN overlap
Toxic Epidermal
And Bullous
Necrolysis
syndrome
Diseases
involves 10-30%.
Erythematotelangiectatic rosacea causes erythema involving the central face, facial flushing, telangiectasias, and burning discomfort. Symptoms are typically precipitated by hot
RosaceaAnd Bullous
drinks,
Diseases
alcohol, heat, emotion, and other causes of rapid body temperature changes. The episodes are usually intermittent but can lead to permanently flushed skin.
Pemphigus vulgaris is a mucocutaneous blistering disease characterized by flaccid bullae and mucosal erosions. It is caused by autoantibodies against desmogleins, which are
Pemphigus
AndVulgaris
Bullous
involved
Diseases
in adherence between epidermal keratinocytes. Biopsy shows intraepidermal cleavage, and immunofluorescence studies show intercellular IgG deposits in the epidermis.
Dermatitis herpetiformis is an autoimmune dermal reaction due to dietary gluten and is commonly associated with celiac disease. It presents with clusters of pruritic papules and
Dermatitis
And
Herpetiformis
Bullous
vesicles
Diseases
on the elbows, knees, back, and buttocks. Management includes dapsone and a gluten-free diet.
Tetracyclines are an important cause of phototoxic drug eruptions. These eruptions manifest as exaggerated sunburn reactions with erythema, edema, and vesicles in sun-exposed
2771 Medicine Dermatology Miscellaneous Adverse Drug Reaction
areas.
ACE inhibitors are the most common cause of acquired angioedema. It is important to note that angioedema from ACE inhibitors can occur at ANYTIME, not just within weeks of
ACE Inhibitors
Reactionsstarting the medication. Other adverse effects of ACE inhibitors are cough, hyperkalemia, and precipitation of acute renal failure in patients with bilateral renal artery stenosis.
Malignant melanoma may occur wherever there are pigmented cells. Sunlight exposure, hereditary factors, fair skin, and a history of pre-existent dysplastic nevi are important risk
2765 Medicine Dermatology Skin Tumors And Melanoma
Tumor-Like Lesions
factors. Findings that suggest melanoma include asymmetric shape, irregular border, variability of color, diameter > 6 mm, and evolution of size and appearance over time.
Seborrheic keratosis is a benign epidermal tumor that presents in middle-aged or elderly individuals as a tan or brown, round lesion with a well-demarcated border and ‘stuck-on’
2764 Medicine Dermatology Skin Tumors And Seborrheic
Tumor-Like Keratosis
Lesions
appearance. Diagnosis is based primarily on clinical appearance, and treatment is usually not required.
Basal cell carcinoma is the most common skin malignancy in the United States. It typically presents as a slow-growing nodule with pearly, rolled borders. Although it only rarely
2762 Medicine Dermatology Skin Tumors And Nonmelanoma
Tumor-Like Lesions
Skin
metastasizes,
Cancer it may invade local tissues and should be removed.
Molluscum contagiosum is a benign condition characterized by small papules with central umbilication. First-line therapy in adults includes cryotherapy with liquid nitrogen, curettage,
Molluscum
Infections
Contagiosum
or topical therapies (e.g. cantharidin).
Primary biliary cholangitis is a progressive autoimmune disease characterized by destruction of intrahepatic bile ducts. It can be associated with severe hyperlipidemia, leading to
Biliary
& Nutrition
Tract Disorders
xanthelasmas. Other complications include malabsorption, metabolic bone disease (e.g. osteoporosis, osteomalacia), and hepatocellular carcinoma.
Seborrheic dermatitis causes pruritic, erythematous plaques with a greasy scale that predominantly affect the scalp and face. It is most common in the first year of life and in middle
Seborrheic
AndDermatitis
Bullous
age Diseases
and can be associated with Parkinson disease and HIV. Topical antifungal agents are effective treatment.
Ichthyosis vulgaris is a chronic, inherited skin disorder characterized by diffuse dermal scaling. The skin appears dry and rough with horny plates resembling fish or reptile scales.
Ichthyoses
And Bullous
Treatment
Diseases
options include emollients, keratolytics, and topical retinoids.
Bullous pemphigoid is an autoimmune disorder characterized by pruritus and tense bullae. A pre-bullous prodrome can present as urticarial or eczematous lesions. The diagnosis is
Bullous Pemphigoid
And Bullous
confirmed
Diseases
with skin biopsy. First-line treatment is a high-potency topical glucocorticoid, which is effective for even extensive disease.
Scabies is due to infestation by Sarcoptes scabiei mites and causes a pruritic rash in the flexor surfaces of the wrist, lateral surfaces of the fingers, and the finger webs. Patients
usually have excoriations and crusted, red papules in the affected areas. Diagnosis is confirmed by light microscopy of skin scrapings. Topical permethrin or oral ivermectin is the
Scabies
Infections preferred treatment in adults.
Tinea versicolor is a superficial nondermatophyte fungal skin infection caused by Malassezia species and characterized by salmon-colored, hyper- or hypopigmented macules. The
Tinea
Infections
Versicolor diagnosis is confirmed with potassium hydroxide preparation of skin scrapings, and treatment is with topical antifungals.
Tinea corporis is a cutaneous dermatophyte infection that causes a pruritic rash with a scaly, erythematous border and central clearing. Patients often have concurrent infection
Tinea
Infections elsewhere on the body, hands, groin, or feet. Those with immunocompromising conditions (e.g. HIV, diabetes mellitus) can have severe or widespread disease.
Prompt recognition and restoration of coronary blood flow with primary percutaneous intervention or fibrinolysis improves cardiovascular and overall long-term mortality in patients
Coronary
SystemHeart Disease
with ST-elevation myocardial infarction.
Cardiac
System
Arrhythmias
Atrial
AndPremature
Syncope Beats
Tobacco and alcohol are reversible risk factors for premature atrial contractions. β blockers are often helpful in symptomatic patients.
Diuretics are recommended for acute pulmonary edema (acute myocardial infarction). β blockers are a standard therapy in myocardial infarction but should be avoided in patients
Coronary
SystemHeart Disease
with decompensated congestive heart failure or bradycardia.
Coronary
SystemHeart Disease
Exercise stress ECG is recommended as an initial test for diagnosis and risk stratification in most patients with suspected stable ischemic heart disease.
Viral myocarditis is a common cause of dilated cardiomyopathy in relatively young adults. Patients typically present with signs and symptoms of decompensated heart failure (e.g.
Myopericardial
System Diseases
dyspnea, orthopnea, peripheral edema).
The medications shown to improve long-term survival in patients with left ventricular systolic dysfunction include β blockers, ACE inhibitors, angiotensin II receptor blockers, and
Heart
System
Failure AndChronic
Shock Heart Failure
mineralocorticoid receptor antagonists.
Electrical alternans is when the amplitudes of the QRS complexes vary from beat to beat. It is fairly specific for pericardial effusion. Enlargement of the cardiac silhouette can often be
Myopericardial
System Diseases
Cardiac Tamponade
seen on chest x-ray as well. Echocardiogram can more definitely demonstrate a pericardial effusion.
Acute coronary syndrome due to unstable angina or non-ST elevation myocardial infarction is managed with antiplatelet and antithrombotic agents, β blockers, nitrates, and high-
Coronary
SystemHeart Disease
intensity statins. Fibrinolytic therapy is not used in patients with non-ST elevation acute coronary syndrome.
Not taking dual antiplatelet therapy (DAPT) is the most common cause of intracoronary stent thrombosis. Patients receiving an intracoronary stent should be counseled regarding the
Coronary
SystemHeart Disease
importance of taking DAPT, both at the time of stent placement and in follow-up.
Systemic hypertension is the most important risk factor for aortic dissection, especially in older patients (age > 60). Marfan syndrome is common in young patients (age < 40) with
Aortic
System
And Peripheral
Aortic
Artery
Dissection
Diseases
aortic dissection, but it is rare in older patients with dissection.
Following myocardial infarction (MI), deleterious cardiac remodeling is mostly driven by neurohormonal mechanisms. ACE inhibitors (e.g. enalapril, lisinopril), cardioselective β
Coronary
SystemHeart Disease
blockers (e.g. metoprolol), and aldosterone antagonists (e.g. spironolactone) improve survival following MI, likely due to inhibition of neurohormonal-mediated cardiac remodeling.
Ventricular aneurysm occurs as a late complication of acute ST-segment elevation or transmural myocardial infarction. ECG often shows persistent ST-segment elevation along with
Coronary
SystemHeart Disease
deep Q waves. Progressive left ventricular enlargement can cause heart failure, refractory angina, ventricular arrhythmias, functional mitral regurgitation, or mural thrombus.
Patients with peri-infarction pericarditis typically have pleuritic chest pain, a pericardial friction rub, and diffuse ST-segment elevations on ECG < 4 days following myocardial
Myopericardial
System Diseases
Acute Pericarditisinfarction. Treatment is usually supportive.
Right ventricular myocardial infarction is due to occlusion of the proximal right coronary artery, and is seen in 30%-50% of patients with acute inferior wall MI. Patients typically have
hypotension, jugular vein distension, and clear lung fields. Such patients are preload dependent and should be treated with intravenous fluids; preload-reducing medications such as
Coronary
SystemHeart Disease
nitrates and diuretics should be avoided.
Primary hyperaldosteronism (Conn syndrome) causes hypertension, mild hypernatremia, hypokalemia, and metabolic alkalosis. The diagnosis of Conn syndrome is suggested by low
Adrenal&Disorders
Metabolism
Hyperaldosteronism
renin and elevated aldosterone levels.
Vasospastic angina results from hyperreactivity of intimal smooth muscle, leading to intermittent coronary artery vasospasm. Calcium channel blockers (e.g. diltiazem, amlodipine)
Coronary
SystemHeart Disease
cause coronary artery vasodilation and are the preferred pharmacologic treatment.
Vasospastic angina is characterized by recurrent chest discomfort resulting from hyperreactivity of vascular smooth muscle, leading to intermittent coronary artery vasospasm.
Coronary
SystemHeart Disease
Raynaud phenomenon mainly affects the digital arteries and occurs through a similar mechanism.
The primary mitral valve abnormality in patients with hypertrophic cardiomyopathy is the presence of systolic anterior motion of the mitral valve, leading to anterior motion of mitral
Myopericardial
System Diseases
valve leaflets toward the interventricular septum. Contact between the mitral valve and the thickened septum during systole leads to left ventricular outflow tract obstruction.
Amyloidosis is a disease involving deposition of insoluble protein fibrils in various organs and tissues throughout the body. Cardiac involvement is common, typically manifesting as
restrictive cardiomyopathy that may later progress to dilated cardiomyopathy. Other commonly affected organs include the liver, kidneys, skin, and nervous system. The diagnosis is
Heart
System
Failure AndAmyloidosis
Shock confirmed by tissue biopsy (e.g. abdominal fat pad).
Findings of acute respiratory distress syndrome (ARDS) include respiratory distress, diffuse crackles on lung examination, severe hypoxemia, and bilateral alveolar infiltrates on
Critical Care
Care And Trauma
ARDS Medicine chest imaging, all of which are not completely explained by volume overload. ARDS risk factors include infections, trauma, and other causes (e.g. massive transfusion).
Mitral stenosis leads to an increase in pulmonary pressures and pulmonary vascular congestion, manifesting as dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and
Valvular
Mitral Stenosis hemoptysis. It also causes left atrial enlargement, predisposing to atrial fibrillation and systemic thromboembolic complications (e.g. stroke).
Mitral stenosis (MS) is recognized by a mid-diastolic murmur preceded by an opening snap. Atrial fibrillation is common in MS and results from an increase in left atrial pressure with
consequent left atrial stretching. In the setting of MS, atrial fibrillation can trigger decompensated heart failure and also carries a higher thrombogenic risk than nonvalvular atrial
Valvular
Mitral Stenosis fibrillation.
Amyloid cardiomyopathy should be suspected in patients with unexplained congestive heart failure, proteinuria, and left ventricular hypertrophy in the absence of a history of
Miscellaneous
System Amyloidosis hypertension.
The 3 most common causes of aortic stenosis in the general population are senile calcific aortic stenosis, bicuspid aortic valve, and rheumatic heart disease. A bicuspid aortic valve
Valvular
Aortic Stenosis is the cause of aortic stenosis in the majority of patients age < 70.
Cardiac auscultation in patients with mitral valve prolapse typically shows a systolic click and/or mid-to-late systolic murmurs of mitral regurgitation. Squatting from a standing position
Valvular
Mitral Valve Prolapse
increases preload and left ventricular volume, decreasing the intensity of the murmur.
Mitral valve prolapse is the most common cause of mitral regurgitation (MR) in developed countries. It usually causes mild MR with mid-systolic click and mid-to-late systolic murmur.
Patients with severe leaflet dysfunction and prolapse can develop severe MR and holosystolic murmur on physical examination. Chronic severe MR causes left atrial and ventricular
Valvular
Mitral Valve Prolapse
enlargement leading to atrial fibrillation, left ventricular dysfunction, and congestive heart failure.
Complete cessation of alcohol consumption is the mainstay of therapy in patients with alcoholic cardiomyopathy and is associated with improvement or normalization of left
Myopericardial
System Diseases
ventricular function over time.
Hypertrophic cardiomyopathy (HCM) is an autosomal dominant genetic disorder caused by mutation in one of the several genes encoding the myocardial contractile proteins of the
cardiac sarcomere. Mutations in the cardiac myosin binding protein C gene and cardiac β-myosin heavy chain gene are responsible for about 70% of identifiable mutations in patients
Myopericardial
System Diseases
with HCM.
Negative inotropic agents (e.g. β blockers, verapamil, disopyramide) are recommended for the pharmacological management of symptomatic patients with hypertrophic
Cardiovascular
System Drugs
cardiomyopathy. β blockers are preferred for initial therapy, and verapamil or disopyramide can be used as additional therapy in patients with persistent symptoms.
Diabetic neuropathy is a distal, symmetric polyneuropathy that can cause a ‘stocking and glove’ pattern of sensory loss, impaired proprioception and vibratory sense, and diminished
ankle reflexes; motor findings may be a late manifestation in severe disease. Hyperactive reflexes and an upgoing plantar reflex are inconsistent with diabetic neuropathy and are
suggestive of an upper motor neuron process.
Vasospasm is the major cause of delayed morbidity and mortality in subarachnoid hemorrhage and can result in cerebral infarction. Vasospasm can best be prevented with initiation
of nimodipine.
Multiple SclerosisA multiple sclerosis plaque in the upper thoracic spinal cord can result in paraplegia, bladder incontinence, and absent sensation below the level of the lesion.
Neurodegenerative
Amyotrophic
Disorders And
Lateral
Dementias
Amyotrophic
Sclerosis lateral sclerosis (ALS) is characterized by the presence of both upper (e.g. spasticity, hyperreflexia) and lower (e.g. fasciculations, atrophy) motor neuron lesions.
The upper face receives input from bilateral motor cortices. Lesions in the central nervous system typically cause unilateral lower facial weakness that spares the forehead whereas
peripheral lesions (e.g. Bell palsy) cause weakness that affects the entire side of the face. Bell palsy may also result in decreased eye lacrimation, hyperacusis, and reduced taste
Bell Palsy
Nerves Andsensation
Muscles over the anterior tongue.
Spontaneous deep intracerebral hemorrhage is typically caused by hypertensive vasculopathy involving the penetrating branches of the major cerebral arteries. Common locations
include the basal ganglia (putamen), cerebellar nuclei, thalamus, and pons. Putaminal hemorrhage often produces contralateral hemiparesis and contralateral sensory loss due to
Hemorrhagic Stroke
injury of the adjacent internal capsule.
Computed tomography (CT) scan of the brain without contrast is the initial imaging study of choice in patients with unprovoked first seizure to exclude acute neurologic problems (e.g.
intracranial or subarachnoid bleed) that might require urgent intervention. Magnetic resonance imaging is more sensitive than CT in identifying most structural causes of epilepsy and
Seizures is the neuroimaging modality of choice in elective situations.
Myasthenia gravis is characterized by fluctuating, fatigable muscle weakness that worsens with repetitive motions and improves with rest. Common symptoms include weakness of
the proximal (e.g. difficulty rising from sitting), ocular (e.g. diplopia, ptosis), and bulbar (e.g. dysarthria, dysphagia) muscles. Pregnant and postpartum patients are at increased risk
Myasthenia
Nerves
Gravis
Andfor
Muscles
developing the disease.
Slurred speech, unsteady gait, and drowsiness can be seen in the overdose of multiple drugs. Benzodiazepine overdose can be distinguished from opioid overdose by the lack of
Toxicology Exposure
Benzodiazepines severe respiratory depression and the lack of pupillary constriction.
β blocker overdose presents with bradycardia, hypotension, wheezing, hypoglycemia, delirium, seizures, and cardiogenic shock. Intravenous fluids and atropine are the first-line
Cardiovascular
System Drugs
β Blocker Poisoning
treatment options. Intravenous glucagon should be administered in patients with profound or refractory hypotension.
Anticholinergic toxicity can cause confusion, mydriasis (e.g. blurry vision), hyperthermia, dry mucous membranes, and urinary retention due to widespread, competitive blockade of
2662.1 Medicine Poisoning & Environmental
Toxicology Exposure
Anticholinergics muscarinic acetylcholine receptors. This can occur from overdose of common medications (e.g. diphenhydramine) that have anticholinergic properties.
Diphenhydramine overdose leads to antihistaminic (e.g. drowsiness, confusion) and anticholinergic (e.g. dry mouth, dilated pupils, blurred vision, reduced bowel sounds, urinary
Toxicology Exposure
Anticholinergics retention) effects. Physostigmine, a cholinesterase inhibitor, can counteract these anticholinergic effects.
Alcoholic hallucinosis usually presents in the first 24 hours after the last drink and is typically associated with other symptoms of alcohol withdrawal (e.g. tremor, anxiety, diaphoresis,
Substance& Use
Substance
Disorders
Alcohol
Abuse
Withdrawal
autonomic hyperactivity). Treatment consists of benzodiazepines to control agitation and prevent progression of withdrawal.
Torsades de pointes (TdP) refers to polymorphic ventricular tachycardia that occurs in the setting of a congenital or acquired prolonged QT interval. Immediate defibrillation is
Cardiac
System
Arrhythmias
Ventricular
And Syncope
Tachycardia
indicated in hemodynamically unstable patients with TdP, while intravenous magnesium is the first-line therapy for stable patients with recurrent episodes of TdP.
Warfarin-induced skin necrosis typically occurs within the first few days of warfarin therapy. It is caused by a rapid decline in protein C levels, usually in patients with underlying
Anticoagulants hereditary protein C deficiency. Treatment involves immediate warfarin cessation and administration of protein C concentrate.
Causes of hyponatremia include syndrome of inappropriate antidiuretic hormone secretion and primary polydipsia. Primary polydipsia is more common in patients with psychiatric
conditions (e.g. schizophrenia), possibly due to a central defect in thirst regulation. Patients typically develop hyponatremia and dilute urine with urine osmolality < 100 mOsm/kg.
Fluid,
Systems
Electrolytes,
& Electrolytes
Primary
And Acid-Base
Polydipsia
Those with significant hyponatremia can develop confusion, lethargy, psychosis, and seizures.
VIPoma is a rare tumor affecting the pancreatic cells that produce vasoactive intestinal peptide (VIP). Most patients develop VIPoma syndrome (pancreatic cholera) with watery
diarrhea, muscle weakness/cramps (due to hypokalemia), and hypo- or achlorhydria (due to decreased gastric acid secretion). Stool studies are consistent with secretory diarrhea; a
Endocrine
& Metabolism
TumorsVIPoma VIP level > 75 pg/mL confirms VIPoma diagnosis.
Progesterone analogues (megestrol acetate and medroxyprogesterone acetate) and corticosteroids have been shown to increase appetite and weight gain in patients with cancer-
OncologyOf Oncology
Cancer Anorexia Cachexia
related anorexia/cachexia
Syndrome syndrome. Progesterone analogues are preferred over corticosteroids due to their decreased incidence of side effects.
Glucagonomas frequently cause necrolytic migratory erythema, characterized by painful/pruritic papules that coalesce to form large plaques on the face, groin, and extremities. Other
manifestations include diabetes mellitus, weight loss, diarrhea, and anemia. A serum glucagon level > 500 pg/mL confirms the diagnosis, and abdominal imaging can localize the
Endocrine
& Metabolism
TumorsGlucagonoma tumor and evaluate for metastases.
Patients with aggressive hematologic malignancies are at risk of tumor lysis syndrome when initiated on cytotoxic chemotherapy or immunotherapy. Intracellular contents are
released into the serum, leading to hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia (due to calcium phosphate binding in the renal tubules). Major
complications include acute renal injury (uric acid/calcium phosphate tubular injury) and cardiac arrhythmia. Prophylaxis with intravenous fluids and uric acid inhibitors reduces the
OncologyOf Oncology
Tumor Lysis Syndrome
risk of kidney injury.
Hyponatremia due to the syndrome of inappropriate antidiuretic hormone secretion is a common complication of small cell lung cancer. Fluid restriction is the initial treatment of
Critical And
SIADH choice
Massesin asymptomatic or mildly symptomatic patients.
Individuals with features of myasthenia gravis (e.g. fluctuating and fatigable ocular/bulbar weakness) should undergo confirmatory testing with acetylcholine receptor antibodies,
which are highly specific. Those with an established diagnosis should subsequently undergo chest imaging (e.g. CT scan, MRI) to evaluate for thymoma and for possible surgical
Myasthenia
Nerves
Gravis
Andplanning,
Muscles as thymectomy is associated with long-term clinical improvement in both patients with and without thymoma.
Severe hypercalcemia can cause weakness, gastrointestinal distress, and neuropsychiatric symptoms. Patients are typically volume-depleted due to polyuria and decreased oral
intake. Initial treatment includes saline hydration to restore intravascular volume and calcitonin to inhibit bone resorption. Bisphosphonates further reduce calcium levels and are
Fluid,
Systems
Electrolytes,
& Electrolytes
Hypercalcemia
And Acid-Base given after initial administration of saline.
Type 1 multiple endocrine neoplasia is characterized by primary hyperparathyroidism, pituitary tumors, and gastrointestinal/pancreatic endocrine tumors (e.g. gastrinomas). Common
Endocrine
& Metabolism
TumorsMultiple Endocrinecomplications
Neoplasia include symptomatic hypercalcemia and recurrent peptic ulcer.
Carcinoid syndrome typically presents with episodic flushing, secretory diarrhea, wheezing, and murmur of tricuspid regurgitation. Elevated 24-hour urinary 5-hydroxyindoleacetic
Intestinal
& Nutrition
And Colorectal
Carcinoid
Disorders
Tumorsacid can confirm the diagnosis in most patients.
OncologyOf Oncology
Chemotherapy Serotonin (5HT) antagonists that block 5HT3 receptors are the drugs of choice for treating and preventing chemotherapy-induced nausea and vomiting.
Mild to moderate cancer-related pain can usually be managed with nonopioid analgesics. However, if initial interventions are not effective, intermittent doses of short-acting opioids
Miscellaneous Chronic Pain should be offered. If the pain requires frequent dosing or if bedtime dosing does not provide relief through the night, a long-acting opioid may be added.
Lung cancer is the most common neoplasm to metastasize to the brain and may present with headache, focal neurologic dysfunction, cognitive change, or seizure. An MRI of the
Brain Tumors
System brain typically reveals multiple, well-circumscribed lesions with vasogenic edema at the gray and white matter junction.
Patients with febrile neutropenia should be started on empiric broad-spectrum antibiotics as soon as possible after blood cultures are obtained. Empiric monotherapy with an
Antimicrobial Drugs
Febrile Neutropenia
antipseudomonal agent (e.g. cefepime, meropenem, piperacillin-tazobactam) is recommended for initial management.
Smoking is the single greatest risk factor for lung cancer in all patient populations. However, ~50% of women who develop lung cancer have no history of smoking. Women who have
Critical And
Lung Cancer never
Masses
smoked most often develop adenocarcinoma, which usually arises in the lung periphery.
Trastuzumab is used for the treatment of patients with human epidermal growth receptor 2-positive breast carcinoma and is associated with a risk of cardiotoxicity. Cardiac function
Breast Disorders
System &Breast
BreastCancer should be assessed with echocardiography at baseline and at regular intervals in patients treated with trastuzumab.
Breast Disorders
System &Breast
BreastCancer Tumor burden is the single most important prognostic consideration in the treatment of patients with breast cancer. It is based on TNM staging.
OncologyOf Oncology
Bone Metastasis Bisphosphonates (e.g. zoledronic acid, pamidronate) are the drugs of choice for stabilizing bony metastatic lesions to prevent hypercalcemia of malignancy and pathologic fractures.
Waldenström macroglobulinemia (WM) is a lymphoplasmacytic neoplasm characterized by excessive monoclonal IgM, end-organ damage, and > 10% clonal lymphocytes by bone
Oncology Waldenström Macroglobulinemia
marrow biopsy. Hyperviscosity syndrome, neuropathy, and cryoglobulinemia are common consequences of elevated serum IgM in patients with WM.
Helicobacter pylori infection plays a critical role in the pathogenesis of extranodal marginal zone B cell lymphomas (low-grade B cell lymphoma of mucosa-associated lymphoid tissue
(MALT)) of the stomach. All patients with MALT lymphomas should be tested for H. pylori infection, and those with a positive result and early-stage MALT lymphoma should undergo
Tumors
& Nutrition
Of The GIMALT
Tract LymphomaH. pylori eradication therapy (e.g. quadruple therapy).
The initial step in the evaluation of Cushing syndrome is to confirm hypercortisolism with a late-night salivary cortisol assay, 24-hour urine free cortisol measurement, and/or
Adrenal&Disorders
Metabolism
Cushing Syndrome
overnight low-dose dexamethasone test. If hypercortisolism is confirmed, ACTH levels are measured to differentiate ACTH-dependent from ACTH-independent causes.
Patients with familial adenomatous polyposis have a significantly increased risk of colorectal cancer. Consequently, frequent colonoscopic screening starting in childhood and
Tumors
& Nutrition
Of The GIFamilial
Tract Adenomatous
elective
Polyposis
proctocolectomy are the standard of care.
Lynch syndrome causes colorectal cancer and imparts an extremely high risk of endometrial carcinoma for female carriers. An annual endometrial biopsy, as well as prophylactic
Tumors
& Nutrition
Of The GILynch
Tract Syndrome hysterectomy, is recommended to prevent endometrial cancer.
Patients with ulcerative colitis are at increased risk for colorectal cancer. Screening colonoscopy with mucosal sampling should be offered to patients with ulcerative colitis beginning
Intestinal
& Nutrition
And Colorectal
Inflammatory
Disorders
Bowel
8 years
Disease
after the initial diagnosis and repeated every 1-3 years thereafter.
There appears to be a bimodal distribution of ulcerative colitis with a second peak at age 50-80. Patients commonly experience abdominal pain, bloody diarrhea, tenesmus, and fecal
Intestinal
& Nutrition
And Colorectal
Inflammatory
Disorders
Bowel
incontinence.
Disease Endoscopy demonstrates continuous involvement with erythematous and friable mucosa and ulcers.
Antiphospholipid syndrome is characterized by a thrombotic event or pregnancy morbidity in the setting of a positive autoantibody to 1 of 3 phospholipids - anticardiolipin antibody,
& Sports
Antiphospholipid
And Vasculitides
Syndrome
anti-β2-glycoprotein-I antibody, or lupus anticoagulant. It is very common in patients with systemic lupus erythematosus.
Polycystic ovary syndrome (PCOS) may present with androgenic alopecia (male-pattern hair loss), irregular menses, and obesity. Patients with PCOS are at increased risk of
Reproductive
& Metabolism
Endocrinology
Polycystic Ovary Disease
developing type 2 diabetes mellitus and should be screened with an oral glucose tolerance test.
Screening for osteoporosis with dual-energy x-ray absorptiometry is recommended in all women age > 65 and for younger women who have an equivalent risk of osteoporotic
Sports
Osteoporosis fracture.
Caustic alkali ingestion causes immediate esophageal injury with liquefactive necrosis. In stable patients with no evidence of perforation, endoscopy should be performed within the
Toxicology Exposure
Caustic Ingestion first 24 hours to assess the severity of the injury and guide further management.
Disorders Of The Macular
Eye AndDegeneration
Associated
Age-related
Structures
macular degeneration is usually seen in patients age > 50. It presents with progressive and bilateral loss of central vision. Navigational vision is preserved.
An external hordeolum is an acute inflammatory disorder of the eyelash follicle or tear gland and presents as an erythematous, tender nodule at the lid margin. It is often due to
Disorders Of The Hordeolum
Eye And Associated
infection
Structures
with Staphylococcus aureus but can be sterile. Initial treatment includes warm compresses.
Diverticulosis is the most common cause of gross lower gastrointestinal bleeding in adults. Bleeding is typically painless but may be associated with lightheadedness and
Intestinal
& Nutrition
And Colorectal
Gastrointestinal
DisordersHemorrhage
hemodynamic instability. Diverticular hemorrhage usually resolves spontaneously but occasionally requires endoscopic or surgical intervention.
Stress fractures are common in patients who suddenly increase their physical activity, especially in female runners with the female athlete triad (oligomenorrhea, osteoporosis, and
Bone, Joint, And
& Sports
Soft
Stress
Tissue
Fractures
Injuriesdecreased
And Infections
caloric intake). Typical symptoms include localized pain to palpation and possible swelling.
Erythema nodosum (EN) is a condition of painful, red or violaceous, subcutaneous nodules. It can be a sign of a more serious disease process. Even in the absence of respiratory
& Sports
Sarcoidosis
And Vasculitides
symptoms, chest x-ray should be performed in patients with EN to assess for findings consistent with sarcoidosis.
Lumbar spinal stenosis is most commonly caused by degenerative joint disease. The term ‘neuropathic claudication’ is often used to describe lumbar stenosis. This refers to the
exacerbation of leg symptoms with walking (similar to peripheral vascular disease [PVD]). However, unlike PVD, the symptoms are positional and remain while standing still. Pain is
Spinal Stenosis relieved by flexion of the spine. Diagnosis is made based on clinical history and classic findings on spinal MRI.
Systemic lupus erythematosus is a multisystem, inflammatory disease that often presents with arthritis and arthralgias. Joint involvement tends to be symmetric, migratory, and
& Sports
nonerosive with brief morning stiffness. The knees, carpal joints, and joints of the fingers are most commonly affected.
The finding of chondrocalcinosis in a joint with a typical acute inflammatory arthritis establishes a diagnosis of probable calcium pyrophosphate dihydrate (CPPD) crystal arthritis
& Sports
Pseudogout (pseudogout). Synovial fluid analysis will show an inflammatory effusion and rhomboid-shaped, weakly positively birefringent CPPD crystals.
Atheroembolism (cholesterol embolism) is a complication of cardiac catheterization and other vascular procedures. It is characterized by cutaneous findings (e.g. ‘blue toe syndrome’,
livedo reticularis), cerebral or intestinal ischemia, acute kidney injury, and Hollenhorst plaques. Treatment is supportive and includes statin therapy for risk factor reduction and
Coronary
SystemHeart Disease
Atheroembolism prevention of recurrent cholesterol embolism.
The initial management of osteoarthritis should emphasize nonpharmacologic measures, including exercise, weight loss, and activity modification. Nonsteroidal anti-inflammatory
& Sports
Osteoarthritis drugs are the medication of choice for pain relief.
Pneumocystis pneumonia is a common opportunistic infection in patients taking immunosuppressant medication after solid organ transplantation. Diagnosis requires the identification
of Pneumocystis jirovecii organisms in respiratory secretions using microscopy with specialized stains. Samples are obtained using induced sputum or, if this is unrevealing,
bronchoscopy with bronchoalveolar lavage.
The manifestations of pulmonary embolism are nonspecific and variable. The diagnosis should be suspected in any patient who presents with some combination of sudden-onset
Critical Care
Vascular
Pulmonary
And Cardiopulmonary
Embolism
shortness
Disease
of breath, pleuritic chest pain, low-grade fever, and hemoptysis. Tachypnea, tachycardia, and hypoxemia are common examination findings.
The development of clubbing and sudden-onset joint arthropathy in a chronic smoker is suggestive of hypertrophic osteoarthropathy. This condition is often associated with lung
Critical And
Hypertrophic Osteoarthropathy
cancer,
Massesand therefore a chest x-ray is indicated to rule out malignancy and/or other lung pathology.
Know the complications of positive-pressure ventilation: Alveolar damage, pneumothorax, and hypotension. Pneumothorax presents with sudden-onset shortness of breath,
Critical Care
Care And Trauma
Pneumothorax
Medicine hypotension, tachycardia, tracheal deviation, and unilateral absence of breath sounds.
Mycoplasma pneumoniae causes atypical pneumonia with indolent symptoms of headache, malaise, low-grade fever, incessant cough, and nonexudative pharyngitis. Chest x-ray
Community Acquired
oftenPneumonia
reveals interstitial infiltrate with or without a small, serous pleural effusion. Empiric oral antibiotics (e.g. azithromycin) usually resolve the infection completely.
Patients with HIV have a much higher risk of reactivation tuberculosis than the general population. Patients typically have subacute or chronic symptoms (e.g. fever, fatigue, cough,
Tuberculosis weight loss, night sweats). Upper lobe cavitary lesions are common on chest x-ray.
In patients with fever and a cough productive of foul-smelling sputum after instrumentation of the upper airway or esophagus, an anaerobic lung infection should be suspected.
Antimicrobial Drugs
Common antibiotic options for anaerobic coverage include metronidazole with amoxicillin, amoxicillin-clavulanate, and clindamycin.
Guillain-Barré syndrome (GBS) is characterized by ascending weakness, bulbar symptoms (e.g. dysarthria) and respiratory compromise after antecedent illness such as respiratory
or gastrointestinal infection (especially Campylobacter jejuni). Cerebrospinal fluid analysis shows albuminocytologic dissociation. Treatment of GBS includes intravenous
Guillain-Barré
Nerves And
Syndrome
immunoglobulin
Muscles or plasmapheresis.
Tick-borne paralysis is characterized by rapidly progressive ascending paralysis (which may be asymmetrical), absence of fever and sensory abnormalities, and normal CSF
CNS Infections Tick Paralysis examination. Ticks must feed for 4-7 days and are typically found on patients after meticulous searching. Removal of the tick results in spontaneous improvement in most patients.
Internuclear ophthalmoplegia is a disorder of conjugate horizontal gaze that results from damage to the medial longitudinal fasciculus (MLF). The affected eye (ipsilateral to the
lesion) is unable to adduct and the contralateral eye abducts with nystagmus. Unilateral MLF lesions can occur with lacunar stroke in the pontine artery distribution; however, bilateral
Multiple Sclerosislesions are classically seen in multiple sclerosis.
The behavioral variant of frontotemporal dementia (FTD) is characterized by early personality changes, compulsive behaviors, and executive dysfunction; memory difficulties tend to
Neurodegenerative
Frontotemporal
Disorders AndDementia
Dementias
develop later in the disease course. FTD has an early age of onset (i.e. 50s-60s) and a strong hereditary component.
Progressive multifocal leukoencephalopathy is caused by JC virus reactivation and occurs primarily in patients with advanced HIV (CD4 count < 200/mm3). Manifestations include
Progressive Multifocal
subacute
Leukoencephalopathy
neurologic changes (e.g. mental status change, motor deficits, ataxia) and imaging evidence of multiple nonenhancing brain lesions with no mass effect (edema).
Patients with advanced AIDS are at increased risk for malignancy. Primary CNS lymphoma is an AIDS-defining malignancy associated with the expression of Epstein-Barr virus
CNS Lymphoma
System oncogenes, which can often be identified in the cerebrospinal fluid. MRI of the brain generally shows a solitary, irregular, nonhomogenous ring-enhancing mass.
Patients with AIDS are at high risk for infectious esophagitis with Candida albicans (most common), herpes simplex virus, and cytomegalovirus. Patients with concurrent oral thrush
are generally treated with empiric oral fluconazole. Those who do not respond to fluconazole or have no evidence of thrush often require further evaluation with upper endoscopy and
Fungal Infections Esophagitis biopsy to clarify the diagnosis.
Pneumocystis pneumonia is common in patients with advanced AIDS (CD4 counts < 200/mm3). Trimethoprim-sulfamethoxazole is the first-line treatment; concomitant
corticosteroids are added for those with pulse oximetry < 92%, PaO2 < 70 mm Hg, or alveolar-arterial gradient > 35 mm Hg on room air to reduce risk of worsened hypoxia with
treatment initiation.
Cytomegalovirus (CMV) mononucleosis is marked by persistent fever, malaise, and fatigue with absolute lymphocytosis on complete blood count and atypical lymphocytes on
peripheral blood smear. Unlike Epstein-Barr virus, CMV usually causes mild pharyngitis, lymphadenopathy, and splenomegaly (or these symptoms may be absent). In patients with
Viral Infections Cytomegalovirus CMV, the heterophile antibody test is negative, and CMV IgM serology is positive.
HIV-associated diarrhea has many potential causes. CD4 count, chronicity, and the presence or absence of symptoms of colitis help narrow the differential diagnoses. Work-up
HIV And Sexually Acute
Transmitted
Diarrhea
Infections
typically involves sending the stool for several tests including culture, ova and parasites, acid-fast stain, and Clostridium difficile antigen.
Mycobacterium avium complex is seen primarily in patients with advanced AIDS (CD4 < 50/mm3). It is caused by the nontuberculous Mycobacterium, M. avium or Mycobacterium
intracellulare. Patients usually have nonspecific symptoms (e.g. diarrhea, weight loss), an elevated alkaline phosphatase level, and lymphadenopathy. Diagnosis is typically made
with blood culture or bone marrow aspirate; treatment with macrolide-based combination therapy is curative, but antiretroviral therapy should be initiated to prevent future infection.
Community Acquired
Patients
Pneumonia
with HIV are at increased risk of community-acquired pneumonia. Streptococcus pneumoniae is the most commonly implicated organism.
Primary syphilis is characterized by the formation of a chancre (painless, genital ulcer) in the setting of high-risk sexual behavior (e.g. multiple sexual partners, new sexual partners).
Syphilis is diagnosed with a combination of nontreponemal and treponemal serologic testing. Treponemal tests (e.g. fluorescent treponemal antibody absorption) have higher
sensitivity (> 97%) in patients with primary syphilis.
Toxoplasmosis causes headache, fever, focal neurologic deficits, and altered mental status in patients with advanced AIDS (CD4 count < 100/mm3). An MRI of the brain reveals
Toxoplasmosis
Infections multiple ring-enhancing lesions. Treatment is with sulfadiazine and pyrimethamine.
Rocky Mountain spotted fever is a tick-borne illness caused by Rickettsia rickettsii. Classic symptoms include a few days of fever and headache, followed by a maculopapular or
Rocky Mountain Spotted
petechial
Fever
rash that may involve the palms/soles. Without empiric antibiotic treatment (e.g. doxycycline), noncardiogenic pulmonary edema and shock can occur.
Patients with malnutrition, pregnancy, or certain comorbid conditions (e.g. diabetes mellitus) should be started on pyridoxine supplementation when treated for latent or active
Tuberculosis tuberculosis with isoniazid (INH). This helps prevent INH-induced peripheral neuropathy, which is due to INH-mediated pyridoxine deficiency.
Paroxysmal nocturnal hemoglobinuria should be suspected in patients who have a combination of hemolytic anemia, cytopenias, and hypercoagulable state (intra-abdominal or
Oncology
Paroxysmal Nocturnal
cerebral
Hemoglobinuria
venous thrombosis). Flow cytometry tests are used to confirm the diagnosis by assessing for absence of the CD55 and CD59 proteins on the surface of red blood cells.
Immune thrombocytopenia (ITP) is an autoimmune disorder associated with isolated thrombocytopenia. Although most cases are primary, a minority of individuals have ITP due to
an underlying condition (e.g. HIV, hepatitis C). Testing for HIV and hepatitis C virus is recommended for all patients with ITP; additional testing is needed when signs and symptoms
OncologyDisordersITP of other disorders (e.g. systemic lupus erythematosus) are present.
Autoimmune hemolytic anemia (AIHA) and hereditary spherocytosis (HS) can cause extravascular hemolytic anemia. A negative family history and positive Coombs test suggest
Oncology
Hemolytic AnemiaAIHA; a positive family history and negative Coombs test suggest HS. The peripheral blood smear in both conditions may show spherocytes without central pallor.
Acute bacterial prostatitis often presents with lower urinary symptoms similar to a urinary tract infection. However, it is typically distinguished by the presence of perineal pain,
pronounced systemic symptoms (e.g. fever, chills, acute illness), and a tender, swollen prostate on digital rectal examination. Urine culture is required to establish the underlying
Disorders
System
Of The Prostatitis
Male Reproductive
pathogen.
System
Patients with nephrotic syndrome have increased risk for atherosclerosis (due to hyperlipidemia) and arteriovenous thrombosis (due to loss of antithrombin III). Atherosclerosis and
Glomerular
Systems &Diseases,
Electrolytes
Glomerular
Nephrotic/Nephritic
Disorders
hypercoagulability
Syndrome increase the risk for stroke and myocardial infarction.
Glomerular
Systems &Diseases,
Electrolytes
RenalNephrotic/Nephritic
Vein Thrombosis
Renal vein
Syndrome
thrombosis is an important complication of all causes of nephrotic syndrome. However, it is most commonly associated with membranous glomerulopathy.
70% of cases with interstitial nephritis are caused by drugs such as cephalosporins, penicillins, sulfonamides, sulfonamide containing diuretics, NSAIDs, rifampin, phenytoin, and
Acute
Systems
Kidney
& Electrolytes
Injury
allopurinol. Discontinuing the offending agent is the treatment of drug-induced interstitial nephritis.
Acute epididymitis typically manifests with unilateral testicular pain and epididymal swelling. Those age > 35 usually develop epididymitis due to bacteriuria from bladder outlet
obstruction; ascending coliform organisms such as Escherichia coli are the most likely pathogens. Patients age < 35 are far more likely to have epididymitis due to sexually
Epididymitis transmitted infections with Chlamydia trachomatis or Neisseria gonorrhoeae.
Chronic prostatitis/chronic pelvic pain syndrome is a common disorder of uncertain etiology, characterized by irritative voiding symptoms (e.g. frequency, urgency, hesitancy);
Disorders
System
Of The Prostatitis
Male Reproductive
perineal
Systemor genital pain; and pain or blood on ejaculation. Urine culture is sterile. Treatment includes antibiotics, α blockers, and 5-α-reductase inhibitors.
In the absence of identifiable bacteria on culture or Gram stain, a mucopurulent urethral discharge in a patient who is sexually active suggests chlamydial urethritis. Nucleic acid
amplification testing confirms the diagnosis.
Uncomplicated cystitis commonly occurs in otherwise healthy patients and has a low risk of treatment failure. Urinalysis confirms the diagnosis. Patients can be treated without a
Urinary
Systems
& Electrolytes
GUurine
Infection
culture, which may be done later in those who fail initial therapy. Oral trimethoprim/sulfamethoxazole, nitrofurantoin, and fosfomycin are effective first-line treatment options.
Mixed cryoglobulinemia is a small-vessel vasculitis that commonly presents with palpable purpura (leukocytoclastic vasculitis), arthralgias, fatigue, peripheral neuropathy, liver
involvement, and renal disease. It is strongly associated with hepatitis C infection, and characteristic laboratory abnormalities include hypocomplementemia, polyclonal IgG, and
Glomerular
Systems &Diseases,
Electrolytes
Cryoglobulinemia
Nephrotic/Nephritic
rheumatoid
Syndrome
factor.
IgA nephropathy is the most common cause of glomerulonephritis in adults. Patients have recurrent episodes of gross hematuria, usually within 5 days after an upper respiratory tract
infection (synpharyngitic presentation). IgA nephropathy is differentiated from postinfectious glomerulonephritis based on earlier onset of upper respiratory tract infection-related
Glomerular
Systems &Diseases,
Electrolytes
IgA Nephropathy
Nephrotic/Nephritic
glomerulonephritis
Syndrome and normal serum complement levels. Kidney biopsy can also help differentiate these 2 processes.
Skeletal muscle overexertion (e.g. due to tonic-clonic seizure) is a potential cause of rhabdomyolysis, which involves the release of myoglobin into the bloodstream and may cause
heme-induced acute renal insufficiency. Because urinalysis blood testing detects heme rather than actual red blood cells (RBCs), rhabdomyolysis is often suggested by positive
Nephrolithiasis,
Hematuria,
Rhabdomyolysis
And Urinary
bloodTract
on urinalysis
Obstruction
in the absence of RBCs on urine microscopy.
Calcium oxalate stones are the most common type of kidney stone; patients may also have stones composed of a mixture of calcium oxalate and calcium phosphate. Risk factors
Nephrolithiasis,
Hematuria,
Renal Calculi
And Urinary
include
Tract
dehydration,
Obstruction
excess sodium or oxalate in the diet, obesity, hyperparathyroidism, and malabsorptive disorders. Calcium-containing stones are radiopaque.
Uremic pericarditis results from inflammation of the visceral and parietal layers of the pericardium. Patients have advanced renal failure (blood urea nitrogen > 60 mg/dL) and typically
Myopericardial
System Diseases
Acute Pericarditispresent with pleuritic chest pain and a pericardial friction rub. The classic ECG finding of diffuse ST elevation is typically absent due to lack of myocardial inflammation.
Nephrotic syndrome is defined as heavy proteinuria (> 3.5 g/24 hr) with hypoalbuminemia and edema. Focal segmental glomerulosclerosis (FSGS) and membranous nephropathy
are the most common causes of nephrotic syndrome in adults in the absence of a systemic disease. FSGS is more common in African American patients and in those with obesity,
Glomerular
Systems &Diseases,
Electrolytes
FSGS Nephrotic/Nephritic
heroin use,
Syndrome
and HIV.
Unilateral varicoceles that fail to empty when a patient is recumbent raise suspicion for an underlying mass pathology, such as renal cell carcinoma (RCC), that obstructs venous
Neoplasms
Systems &And
Electrolytes
Trauma
Renal Cell
Of The
Carcinoma
Kidneys
flow. CT
Andscan
Urinary
of the
Tract
abdomen is the most sensitive and specific test for diagnosing RCC.
Carcinoid tumors are rare neuroendocrine tumors that cause episodic flushing, secretory diarrhea, bronchospasm, and cardiac valvular abnormalities. Carcinoid cells cause
Endocrine
& Metabolism
TumorsCarcinoid Tumorsincreased production of serotonin from tryptophan (required for niacin synthesis), resulting in niacin deficiency (i.e. pellagra, with dermatitis, diarrhea, and dementia).
Hepatorenal syndrome is seen in patients with severe liver cirrhosis secondary to systemic and renal hypoperfusion. Patients have acute renal failure (creatinine > 1.5 mg/dL) with a
Acute
Systems
Kidney
& Electrolytes
Injury
Hepatorenal Syndrome
very low urine sodium level, typically < 10 mEq/L, and an absence of blood, casts, or protein in urine. Renal function does not improve with intravenous fluid resuscitation.
Spontaneous bacterial peritonitis can have a subtle presentation and should be considered in any patient with cirrhosis and ascites accompanied by either fever or a change in
Hepatic
& Nutrition
DisordersSpontaneous Bacterial
mentalPeritonitis
status. Paracentesis is the test of choice, with the main diagnostic criteria being a positive ascites fluid culture and neutrophil count of > 250/mm3.
Episodes of dysphagia, regurgitation, and/or chest pain precipitated by emotional stress should raise the suspicion for esophageal motility disorder such as diffuse esophageal
Gastroesophageal
& Nutrition Diffuse
Disorders
Esophageal
spasm.
Spasm
Manometry establishes the diagnosis of diffuse esophageal spasm.
Oropharyngeal dysphagia presents as difficulty initiating swallowing associated with coughing, choking, aspiration, or nasal regurgitation. Typically, patients are evaluated initially
Disorders
& Nutrition
Of Nutrition
with videofluoroscopic modified barium swallow to evaluate swallowing mechanics, degree of dysfunction, and severity of aspiration.
The most common cause of iron deficiency anemia in the elderly is gastrointestinal blood loss. The next step in evaluation would be colonoscopy and endoscopy. A single negative
Miscellaneous
& Nutrition Iron Deficiency Anemia
occult blood test does not exclude the possibility of gastrointestinal bleeding.
Acquired risk factors for venous thromboembolism (VTE) include immobilization, surgery, malignancy, and medications. Recommended testing for occult malignancy includes age-
appropriate screening (e.g. colonoscopy, mammogram) and chest x-ray in most patients with a first episode of unprovoked VTE. More detailed testing is indicated for patients with
findings concerning for malignancy or for recurrent or multiple-site (e.g. cerebral, hepatic vein) VTE.
Crohn disease is characterized by chronic abdominal pain, diarrhea, weight loss, and evidence of inflammation (e.g. anemia, elevated inflammatory markers). It can involve any part
Intestinal
& Nutrition
And Colorectal
Inflammatory
Disorders
Bowel
of the
Disease
gastrointestinal tract from mouth to anus.
Clostridioides (formerly Clostridium) difficile colitis should be suspected in any patient who has been on antibiotics and has diarrhea and/or abdominal pain. Stool studies for C.
difficile toxin should be sent to confirm the diagnosis. Treatment options for the initial episode include oral vancomycin or oral fidaxomicin. Patients with fulminant disease (e.g.
Intestinal
& Nutrition
And Colorectal
Clostridium
Disorders
Difficile
hypotension,
Infection ileus, megacolon) should be treated with high-dose oral vancomycin and intravenous metronidazole; if ileus is present, vancomycin may be given rectally.
Patients with typical gastroesophageal reflux symptoms require an upper gastrointestinal (GI) endoscopy if they have alarm symptoms (dysphagia, odynophagia, weight loss,
anemia, GI bleeding, or recurrent vomiting) or are men age > 50 with chronic (> 5 years) symptoms and cancer risk factors (e.g. tobacco use). All other patients can receive an
Gastroesophageal
& Nutrition Gastroesophageal
Disorders empiric
Refluxtrial
Disease
of proton-pump inhibitor therapy and further evaluation if refractory to therapy.
Pseudoachalasia, which is due to narrowing of the distal esophagus secondary to causes other than denervation (e.g. esophageal cancer), can closely mimic achalasia. Clues
pointing to pseudoachalasia include significant weight loss, rapid symptom onset, and presentation at age > 60. Consequently, endoscopy is recommended to exclude malignancy in
Gastroesophageal
& Nutrition Achalasia
Disorders all patients with suspected achalasia.
D-xylose is a monosaccharide that is absorbed in the proximal small intestine without degradation by pancreatic or brush border enzymes. Patients with small intestinal mucosal
Disorders
& Nutrition
Of Nutrition
Celiac Disease disease will have impaired absorption of D-xylose. Patients with malabsorption due to enzyme deficiencies will have normal absorption of D-xylose.
When delivering potentially bad news, a physician should first assess the patient’s comprehension, fears, and desire for information to deliver the news in an empathetic yet
Communication
And
Physician
Interpersonal
PatientSkills
comprehensible
Communication manner.
Disorders
(ENT)
Of The Temporomandibular
Temporomandibular
Disorders joint disorder can result in referred pain to the ear that is worse with chewing. Patients typically have a history of nocturnal teeth grinding.
Metformin is the recommended first-line medication for most patients with type 2 diabetes mellitus. Options for add-on therapy in patients with established cardiovascular disease
include glucagon-like peptide-1 (GLP-1) agonists and sodium-glucose cotransporter 2 inhibitors. GLP-1 agonists can induce significant weight loss and are associated with
Diabetes& Mellitus
Metabolism
Diabetes Mellitus decreased mortality in patients with cardiovascular disease.
Painless thyroiditis (silent thyroiditis) is characterized by acute thyrotoxicosis with mild thyroid enlargement and suppressed TSH. Thyroid scintigraphy shows decreased radioiodine
Metabolism uptake.
Strict blood pressure control, particularly using ACE inhibitors or angiotensin II receptor blockers, can reduce the progression of diabetic nephropathy (DN). Tight glycemic control
Diabetes& Mellitus
Metabolism
with a target hemoglobin A1c < 7% also can prevent progression of DN; further lowering is associated with an increased risk of hypoglycemia and possibly cardiac events.
The most accurate markers indicating resolution of diabetic ketoacidosis are the serum anion gap and serum β-hydroxybutyrate levels. The anion gap estimates the unmeasured
Diabetes& Mellitus
Metabolism
anion concentration in the blood and returns to normal with the disappearance of ketoacid anions.
Hypoglycemia is associated with multiple differential diagnoses. Helpful tests used in the evaluation of hypoglycemic patients are measurements of C-peptide, proinsulin and
Endocrine
& Metabolism
TumorsHypoglycemia sulfonylurea levels. Hypoglycemia secondary to insulinoma is associated with elevated insulin, C-peptide and proinsulin levels.
Hyperosmolar hyperglycemic state is characterized by severe hyperglycemia and hyperosmolarity, mental status changes, and normal anion gap. Osmotic diuresis leads to marked
Diabetes& Mellitus
Metabolism
deficits in total
Nonketotic
body water;
Syndrome
therefore, treatment should begin with immediate intravenous fluid resuscitation with normal saline.
Patients with hyperosmolar hyperglycemic state or diabetic ketoacidosis have a total body potassium deficit due to excessive urinary loss caused by glucosuria-induced osmotic
diuresis. However, serum potassium levels may be normal or mildly elevated due to the shift of potassium out of cells into the extracellular space. Insulin in these patients can rapidly
Diabetes& Mellitus
Metabolism
lower potassium
Nonketotic
levels, Syndrome
leading to hypokalemia.
Essential measures in diabetic ketoacidosis include: 1. Hydration to restore intravascular volume, with 0.9% (normal) saline recommended in the first 1-2 hours; 2. Correction of
Diabetes& Mellitus
Metabolism
hyperglycemia and ketosis with intravenous regular insulin; 3. Serial assessment of electrolytes, especially potassium; 4. Treatment of the underlying precipitating factors.
Diabetic nephropathy, a microvascular complication of diabetes mellitus, is associated with abnormal (moderately increased) albuminuria. Random urine albumin-to-creatinine ratio
testing is the most sensitive test to detect early elevations in albumin excretion. This test should be performed at least annually in patients with type 2 diabetes mellitus starting at
Glomerular
Systems &Diseases,
Electrolytes
Diabetic
Nephrotic/Nephritic
Nephropathy
diagnosis.
Syndrome
Patients with the syndrome of inappropriate antidiuretic hormone secretion who are asymptomatic or have mild symptoms usually respond to fluid restriction. Patients with severe
Fluid,
Systems
Electrolytes,
& Electrolytes
SIADH
And Acid-Base symptoms require treatment with hypertonic (3%) saline.
The syndrome of inappropriate antidiuretic hormone secretion is characterized by hypotonic hyponatremia and euvolemia. Low serum osmolality (< 275 mOsm/kg), high urine
Fluid,
Systems
Electrolytes,
& Electrolytes
SIADH
And Acid-Base osmolality (> 100 mOsm/kg), and an elevated urine sodium concentration (> 40 mEq/L) strongly suggest the diagnosis.
Graves disease can be treated with antithyroid drugs, radioactive iodine, or thyroidectomy. Antithyroid drugs are used for patients with mild disease who are likely to have a
Metabolism permanent remission. They are also used in preparation for treatment with radioactive iodine in patients with significant hyperthyroidism or who are at increased risk of complications.
Fever and sore throat in any patient taking antithyroid drugs suggests agranulocytosis. Antithyroid drugs should be stopped and WBC count checked. Routine WBC count
Metabolism measurement in patients taking antithyroid drugs is not cost effective.
Hypopituitarism is characterized by glucocorticoid deficiency, hypogonadism, and hypothyroidism. Typical features include fatigue, cold intolerance, hypoglycemia, anorexia, and low
Hypothalamus
& Metabolism
And
Hypopituitarism
Pituitary Disorders
libido. In contrast to primary adrenal insufficiency, aldosterone is normal in central adrenal insufficiency due to hypopituitarism.
The evaluation of adrenal insufficiency should include an 8 AM serum cortisol and plasma ACTH. In addition, an ACTH stimulation test (cosyntropin test) can identify patients with
Adrenal&Disorders
Metabolism
primary adrenal insufficiency (and most patients with central adrenal insufficiency) and should be performed in the initial evaluation.
Myopathy in Cushing syndrome is characterized by progressive painless muscle weakness predominantly involving the proximal muscles. It is due to the direct catabolic effects of
Adrenal&Disorders
Metabolism
Cushing Syndrome
cortisol on skeletal muscle, leading to muscle atrophy.
Fibromuscular dysplasia is a noninflammatory and nonatherosclerotic condition that presents most commonly in women age 15-50. The condition affects primarily the renal arteries
and causes hypertension. Involvement of the cerebrovascular arteries (e.g. carotid, vertebral) can cause symptoms of brain ischemia (e.g. transient ischemic attack, amaurosis
Hypertension
fugax, stroke) or nonspecific symptoms (e.g. headache, pulsatile tinnitus, dizziness).
Diabetic ketoacidosis can be the initial manifestation of type 1 diabetes mellitus. Typical symptoms include acute onset of weight loss, polydipsia, abdominal pain, hyperventilation,
Diabetes& Mellitus
Metabolism
and altered mentation. Fingerstick blood glucose can rapidly provide a presumptive diagnosis, and treatment should begin immediately with intravenous fluids and insulin.
Rapid-onset hyperandrogenism, particularly with virilization, suggests an androgen-secreting ovarian or adrenal neoplasm. Serum testosterone and DHEAS levels are used to
Reproductive
& Metabolism
Endocrinology
Hirsutism delineate the site of androgen production. Elevated testosterone with normal DHEAS suggests an ovarian source, whereas elevated DHEAS suggests an adrenal source.
Severe hypercalcemia can cause weakness, gastrointestinal distress, and neuropsychiatric symptoms. Patients are typically volume-depleted due to polyuria and decreased oral
intake. Initial treatment includes saline hydration to restore intravascular volume and calcitonin to inhibit bone resorption. Bisphosphonates further reduce calcium levels and are
Fluid,
Systems
Electrolytes,
& Electrolytes
Hypercalcemia
And Acid-Base given after initial administration of saline.
The most common causes of hyperkalemia include acute or chronic kidney disease, medications, or disorders impairing the renin-angiotensin axis. Common offending medications
include nonselective β-adrenergic blockers, potassium-sparing diuretics (e.g. triamterene), angiotensin-converting-enzyme inhibitors, angiotensin II receptor blockers, and
Fluid,
Systems
Electrolytes,
& Electrolytes
Hyperkalemia
And Acid-Base nonsteroidal anti-inflammatory drugs.
Familial hypocalciuric hypercalcemia is caused by a mutation in the calcium-sensing receptor. It is a benign disorder characterized by asymptomatic hypercalcemia, elevated or
inappropriately normal parathyroid hormone levels, and low urinary calcium excretion. It can be differentiated from primary hyperparathyroidism, which has increased urinary calcium
Fluid,
Systems
Electrolytes,
& Electrolytes
Hypercalcemia
And Acid-Base excretion, by the urine calcium/creatinine clearance ratio.
Cardiac
System
Arrhythmias
Ventricular
And Syncope
Tachycardia
Loop diuretics cause hypokalemia and hypomagnesemia. These electrolyte abnormalities can cause ventricular tachycardia, and also potentiate the side effects of digoxin.
The initial evaluation of hypertension focuses on identifying complications or comorbid conditions that might influence management. Assessment should include a serum chemistry
panel, hemoglobin/hematocrit, and urinalysis. In addition, patients should be screened for major atherosclerotic risk factors with a lipid panel and either fasting serum glucose or
Hypertension
hemoglobin A1c.
Patients with right ventricular myocardial infarction can experience profound hypotension due to inadequate right ventricular preload. These patients should be managed initially with
Heart
System
Failure AndCardiogenic
Shock Shock
intravenous saline bolus to increase right ventricular preload and improve cardiac output.
An echocardiogram should be obtained in all patients with syncope due to suspected structural heart disease. Neurological workup (e.g. brain CT scan) has low yield in most patients
Valvular
Aortic Stenosis without specific neurological symptoms.
Response bias occurs when participants purposely give desirable responses to questions about topics perceived to be sensitive (e.g. health behaviors). This practice results in
Epidemiology
Design AndBias
Interpretation responses that are inaccurate and may lead to incorrect conclusions (e.g. lower than expected prevalence of disease or frequency of risk factors).
The diagnosis of chronic mesenteric ischemia should be suspected in patients with unexplained chronic abdominal pain, weight loss, and food aversion. Most cases are due to
Intestinal
& Nutrition
And Colorectal
Mesenteric
Disorders
Ischemia
atherosclerotic changes of the celiac or superior mesenteric arteries.
Coronary
SystemHeart Disease
Abdominal pain and nausea/vomiting are atypical presentations of acute coronary syndrome. In select patients, cardiac causes must be excluded prior to pursuing other etiologies.
Paget disease can cause focal enlargement, weakness, or fracture of bone. Bowing of long bones, bone pain, and arthritis in adjacent joints are common. Involvement of cranial
Sports
Paget Disease Ofbones
Bone may cause frontal bossing, headaches, cranial nerve dysfunction, and hearing loss.
Patients with symptomatic sinus bradycardia should be treated initially with intravenous atropine. In patients with inadequate response, further treatment options include intravenous
Cardiac
System
Arrhythmias
Bradycardia
And Syncope epinephrine or dopamine, or transcutaneous pacing.
Changing the cutoff point of a quantitative diagnostic test will inversely affect its sensitivity and specificity. Typically, lowering the cutoff value will increase sensitivity (fewer false
Epidemiology
And Principles
Sensitivity
OfAnd
Testing
Specificity
negatives) and decrease specificity (more false positives). Screening tests need high sensitivity, and confirmatory tests need high specificity.
Changing the cutoff point of a quantitative diagnostic test will inversely affect its sensitivity and specificity. Typically, raising the cutoff value will increase specificity (fewer false
Epidemiology
And Principles
Sensitivity
OfAnd
Testing
Specificity
positives) and decrease sensitivity (more false negatives). Screening tests need high sensitivity; confirmatory tests need high specificity.
Unlike sensitivity and specificity, positive and negative predictive values depend on the prevalence of disease in the population being tested. A change in a test cutoff point that
Epidemiology
And Principles
Sensitivity,
Of Specificity,
TestingcausesNPV,
an PPV
increase in the number of false positives and true positives will decrease positive predictive value.
Epidemiology
And Principles
Sensitivity,
Of Specificity,
TestingRaising
NPV,
thePPV
cut-off point (e.g. increasing the inclusion criteria) of a screening test results in an increase in specificity and decrease in sensitivity.

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