DR.

HIGH YIELD – INTERNAL MEDICINE

CRITERIAS
• CHA2DS2VAS – score used for Atrial Fibrillation
o CHF (1)
o HTN (1)
o Age >75 (2)
o DM (1)
o Stroke/TIA/Thrombo-embolism (2)
o Vascular disease (prior MI, PAD, Aortic disease) (1)
o Age 65-74 (1)
o Sex (female) (1)
o Maximum Score (9) – cant count age twice
▪ >2 Warfarin (Xa blockers or direct thrombin
inhibitors)
▪ <2 Aspirin
• Centor Score (Modified/McIsaac) for Strep Pharyngitis
o Cough (NONE)
o Exudates
o Nodes (Anterior cervical LN)
o Temperature >38
o OR
▪ Age 3-14 (+1)
▪ Age 15-44 (0)
▪ Age 44+ (-1)
o Score:
▪ 4+ treat with penicillin
▪ 2-3 rapid strep test
▪ NOTE: In children you always do
rapid strep
• POUND criteria for migraine headache
o Pulsatile
o Duration between 4-72 hOurs
o Unilateral
o Nausea or vomiting
o Disabling intensity
• CURB-65 for pneumonia
o Confusion
o BUN > 7 mmol/l
o Respiratory rate >30
o SBP < 90, DBP < 60
>2: hospitalize
Inpatient DOC: Fluoroquinolone
• Outpatient DOC:
• Atypical Azithromycin
• Typical: Amoxicillin
 o Age >65
• SEPSIS
o SIRS – Systemic Inflammatory Response
Syndrome
▪ Two or more of the following
• Body temp: >38 or <36
• HR: >90
• RR: >20 or PaCO2 <32
• WBC: >12,000 or <4000 or
>10% left shift
o Sepsis= SIRS + Source of infection
o Severe sepsis = SIRS + Source of infection +
End organ damage + Hypotension of SBP L90
+ Lactate > 4
o Septic shock = Severe sepsis that is unresponsive to fluids
• Light’s criteria for pleural effusion
o Protein: Pleural protein/Serum protein >.5 = exudate
o LDH:
▪ Pleural LDH/Serum LDH >.6 = exudate
▪ Pleural LDH < 2/3 Upper normal = Trans
▪ Pleural LDH > 2/3 Upper normal = Exudate

• Well’s Criteria PE
o >4 do CTA
o <4 do d-dimer
• COPD
o If O2 Sat < 88 or PaO2 < 55 = Be on long term oxygen therapy at home
• Glascow coma
o <8 you intubate (endotracheal intubation)

• Ascites
o 250+ neutrophils = infection = SBP
o Seen in patients who are cirrhotic and have chronic ascites
o Next step: Paracentesis
• SAAG
o Serum to Ascites Albumin Gradient (Serum – Ascites)
o Ascites is either made in the liver sinusoid (hepatic lymph) or not
▪ Hepatic sinusoids keep albumin in blood
▪ Diseased sinusoids become less likely to allow albumin to escape blood into the
hepatic lymph
▪ HIGH SAAG >1.1 in a diseased liver and PORTAL HTN
• Meaning SERUM > Ascites because the albumin stays in serum
▪ In LOW SAAG <1.1
• Ascites albumin is close to plasma because the ascites is plasma
• Ascites not made from the liver
• Extrahepatic source:
o Biliary leak, nephrotic syndrome, malignancy, malnutrition,
protein losing enteropathy, tuberculosis
 • TIMI risk score: The thrombolysis in myocardial infarction (TIMI) risk score
o >0 – 2 = Stress test
o 3 or more= Cath lab

CARDIO

• Coronary Artery Disease

Outpatient Cath Lab

Asx CAD Stable Angina Unstable Angina NSTEMI STEMI
Pain No pain Exertional At rest , worsening At rest At rest
Relieved by NOTHING Rest, NTG Rest NOTHING NOTHING

Troponin I None None None ↑ +/- Depends on how

*what separates soon you find MI.
NSTEMI from -this is why you admit
unstable angina is overnight to monitor
rise in troponin. the level
What separates
NSTEMI from STEMI
is absence of ST
elevations
ST ↑ NO NO NO NO YES
Pathology Stenosis with Stenosis with THROMBUS THROMBUS THROMBUS
atherosclerotic atherosclerotic plaque < 100% Occlusion < 100% Occlusion 100% Occlusion
plaque < 70% > 70% Transmural Infarct Transmural Infarct Transmural Infarct

• Stable Angina
o Substernal chest pain that occurs with exercise/exertion
o Relieved by rest
o Dx: Stress test (pharmacologic or exercise)
▪ EKG (ST depression)
• If abnormal EKG then do echo or nuclear perfusion
 ▪ Echo (abnormal wall motion)
▪ Nuclear perfusion (decreased uptake nuclear isotope)
o Definitive way of diagnosing CAD is by Angiography (invasive) so you must do stress test
first
o Tx: Nitrates, Aspirin, Beta blockers
• Unstable Angina
o Occurs at rest
o Tx
▪ MONACBASH
▪ Always give aspirin first
o **Becomes NSTEMI when there are elevated troponins**
o **Becomes STEMI with elevated troponins and ST elevations**

–Morphine sulfate 2 to 4 mg IV PRN for severe pain. May repeat dose of 2 to 8 mg at 5 to 15-
minute intervals.
–Oxygen via nasal cannula to keep SaO2 > 92%
–Nitroglycerin (NTG) 0.3-0.6 mg SL q5min PRN chest pain. Max: 3 doses within 15 minutes.
–Aspirin. The first tab is 325 (chew), then 81mg QD after that. Avoid enteric coated Aspirin.
–Clopidogrel
–Beta-blocker. Metoprolol tartrate 25mg po q6h
–ACE. Watch BP. May wait to see BB work if concerned about BP or start low dose, e.g. Lisinopril
5mg po BID
–Statin. High-intensity statin for all patients with ACS – atorvastatin 80mg po Qbedtime or
rosuvastatin 20-40 mg daily.
–Heparin. For all patients with non-ST elevation ACS, start anticoagulation ASAP after you’ve
made the diagnosis. Will start heparin instead of Lovenox. Heparin is easily reversible if needed.
60 U/kg IVB (max 4000 U); 12 U/kg/hr (max 1000 U/hr initially).

• Chest pain:
o Want to rule out acute coronary syndromes: Unstable angina, NSTEMI, STEMI
o Do:
▪ EKG (1mm elevation in 2 contiguous leads or a new LBBB + CP = stemi)
• STRAIGHT TO CATH
▪ Cardiac Enzymes
▪ Want to do serial troponins or EKG to see if evolving or changing
• CABG
o 3-vessel disease
o Proximal left anterior descending disease with 70% stenosis
• Prinzmental angina
o Coronary vasospasm
o ST elevations DURING episodes
o Tx: CCB or Nitrates
• TPA in MI
 o No access to PCI center
• Inferior MI II,III, avF
o Do not give nitrates because they have a RV MI, the heart is already having problem
pumping blood to left side → EXACERBATE HYPOTENSION
o RCA supplies SA node → bradycardia can cause cardiogenic shock
▪ First Line is dobutamine which is B1 agonist, but in case of Inf Wall MI you give
atropine for bradycardia
o Tx: Fluids
• Decrease mortality in MI
o Aspirin
o BB
o ACEi
• Nitrates
o Decreases preload as venodilator and decreases stress on myocardium
o Dilates coronary arteries
• AV Blocks
o First degree: No tx
o Mobitz I: No tx
o Mobilitz II: Pacemaker
o Complete AV block: Pacemaker
• Pericarditits after MI= Aspirin (Dressler syndrome)
• Restrictive cardiomyopathy
o -Osis
o Diastolic HF
o Hemochromatotis (bronze diabetes, ↑ ferritin ↓ TIBC ↑ serum FE
o Amyloidosis (protein deposits in heart, kidney, joint, proteinuria)
o Sarcoidosis (heart and lung, bilateral hilar LAD, dry cough)
• CHF decrease mortality
o ACEi
o BB
o Spironolactone
• Metformin
o Contraindicated:
▪ Renal disease and CHF
▪ Can cause metabolic acidosis
• CHF
o Acute decompensation of CHF
▪ Tx: NO LIP
• Nitrates
• Oxygen
• Loop diuretics
• Inotropes
• Positioning (elevating head of bed)
• SVT vs Ventricular tachycardia
 o SVT
▪ Narrow QRS
▪ QRS-T, QRS-T
▪ Stable: Vagal
maneuver (carotid massage) then Adenosine
▪ Unstable: Cardioversion
o Ventricular tachycardia
▪ Wide QRS
▪ Stable: Amiodarone
▪ Unstable: Cardioversion
o V-fib and pulseless V tach
▪ Tx: Defibrillation
o Asystole, Pulseless electrical activity
▪ Tx: CPR
o Torsades de pointes
▪ Can lead to v-fib
▪ Tx: IV mag
• Constrictive pericarditis
o Imaging (CXR) *calcifications*
• Acute pericarditits
o Coxsackie
▪ NSAID
o Dressler
▪ ASPIRIN
• Cardiac Tamponade
o Becks triad
▪ Hypotension
▪ JVD
▪ Muffled heart sounds
o Pulsus parodoxus
▪ Inspiration causes >10 drop in SBP
o Electric alternans
• Mitral stenosis
o RF
• HTN or aortic stenosis
o Angina because of decreased perfusion to coronary artery
o Syncope decreased perfusion of brain
o LV hypertrophy – increased afterload
o Dialated CM- chronicity
o Soft S2
• Aortic stenosis:
o Catheter to measure valve diameter
▪ <1 sq cm
▪ Angina, syncope, CHF – valve replacement
• Tricuspid valve
o IVDU
o Carcinoid syndrome – too much serotonin – bronchospasm, flushing, R Heart mumur
• Infective endocarditis
o Fever, leukocytosis, new onset murmur
o Tx empirically with vancomycin + aminoglycoside
▪ Then adjust to blood culture
• 180/120 + end organ damage = HTN emergency
o Tx:
▪ IV hydralazine
▪ Nitroprusside
▪ Labetalol
o *Evidence of end organ damage*
o Urgency: has no evidence of end organ damage
• 180/120 = HTN urgency
o Tx:
▪ Oral medications
• Subarachnoid hemorrhage
o 1st: CT w/o contrast
o 2nd: LP (xanthochromia)
• Aortic dissection
o Type A – proximal to L subclavian
▪ Tx: surgery right away
o Type B – distal to L subclavian
▪ Tx: BB
o Diagnosis: CT angio (anyone with kidney disease cannot have CT w/ contrast) or TE echo
o

• Peripheral artery disease

o Ankle brachial index
▪ ABI= LE SBP/brachial SBP
▪ Index <0.9= disease
▪ <0.4 severe disease which will have pain at rest
 ▪ Claudication in legs while walking
• Leriche syndrome
o Atherosclerosis proximal to aortic bifurcation
o Bilateral leg pain
o Impotence
o Butt pain
• IVC filters are placed if CI to heparin or warfarin or failed previous therapy
• If suspect PE in patient
o Acute sudden onset tachypnea, tachycardia, HYPOXEMIA (<02 sat)
o Give heparin before CT angio
o HEPARIN NEXT BEST STEP
• LMWH = CI in renal disease
• Venous insufficiency look for medial malleolus ulcer
• Cardiogenic shock
o Dobutamine
• Septic shock
o IV abx + IV fluids + pressors
• Neurogenic shock
o Everything is down
o Tx: IV fluids

PULMONARY

• COPD
o *SMOKERS*
o Alpha 1-antitrypsin
o Chronic bronchitis
▪ Excess mucous
▪ Mucous gland hypertrophy
o Emphysema
▪ Destruction of alveoli
o Physical Exam:
▪ Hyperresonance because alveoli are destroyed
▪ Decreased breath sounds (harder to exhale)
▪ Crackles (mucous)
o Decrease mortality in COPD:
▪ Smoking cessation
▪ Home oxygen
o Stages of COPD: FEV1
▪ Mild: >80% - albuterol
▪ Moderate: 50-80 % -albuterol + ipratropium
▪ Severe: 30-50% albuterol + ipratropium + inhaled steroid
▪ Very severe: <30% albuterol + ipratropium + inhaled steroid + long term oxygen
• 2 indications for home oxygen
o PaO2 <55 or O2 sat < 88
• COPD exacerbation
o COPD who has change in sputum production or color
o CXR to rule of PNA
o ADD IV STEROIDS + ABX (fluoroquinolone or azithromycin)
o Positive Pressure ventilation, do not want to exceed 93%
• COPD + PNA
o Zosyn (pipercillin, tazobactam)
o Cefepime
o PSEUDOMONAS
• Acute exacerbation with asthma in respiratory distress should have respiratory alkalosis, so if
someone with normal PCO2 is normal or elevated you must;
o INTUBATE
• 4 stages of asthma
o Intermittent <2 week
▪ Albuterol
o Mild persistent 3-7x week
▪ Albuterol _ low dose steroid
o Moderate persistent every day
▪ Albuterol + med dose steroid
o Severe persistent multiple times a day
▪ Albuterol + high dose steroid
• Bronchiectasis
o Dilation of bronchi
o A LOT Of MUCUS
o Buckets of mucus
o Cystic fibrosis is most common cause
o Dx: High res CT
o Tx: Bronchodilators
o Tx of Exacerbations: Abx
• Cystic fibrosis
o All secretions are thick
o AR
o <20: Staph aureus
o >20: pseudomonas
o Tx: pancreatic enzymes, ADEK, inhaled dornas alfa
• Pancoast tumors
o Horner syndrome – FPAM
o SVC syndrome
o Phrenic nerve palsy – one diaphragm higher than other
o Brachial plexus
o Recurrent laryngeal palsy – hoarseness
• Smokers: central lung tumors
o SqCC – PTHrP – hypercalcemia, hypophosphatemia, low PTH
o Small cell carcinoma – SIADH, ACTH, Lambert Eaton
• Adenocarcinoma
o Nonsmokers
o Peripheral
• Nodule on chest XRAY
o BEST NEXT STEP – previous chest Xray to compare
o If changed or no old imaging → CT
• Pneumothorax
o One sided decrease breath sounds, HYPERresonance, decreased fremitus
o Tx: Chest tube
• Tension
o Tracheal deviation
o Hypotension due to compression of IVC
o Tx: 1st needle thoracentesis then chest tube
• Interstitial lung disease
o CXR:
▪ Reticulonodular, Ground glass
▪ Honeycombing
o Asbestosis
▪ Pleural plaques
▪ Mesothelioma
▪ BASE of lung
▪ Shipyard, roofing,
o Berylliosis
▪ Aerospace
▪ upper lobe
o Coal
▪ upper lobe
o Silicosis
▪ Egg shell calcifications in upper lobe
▪ Sandblasting, foundries, mines
o Sarcoidosis
▪ Bilateral Hilar LAD
▪ Uveitis
▪ Hyper vitamin D
▪ ↑ ACE and HYPERCALCEMIA
▪ Restrictive cardiomyopathy
▪ Tx: Steroids
• UPPER LOBE:
o TB
o Silicosis
o Aspergillus
• Mechanical ventilation (PCO2, PaO2)
o Tidal volume – alters PCO2
▪ Increase tidal volume will lower pco2
 o RR – alters PCO2
▪ Increase RR will lower pco2
o FiO2
▪ Increase FiO2, higher PaO2
o PEEP
▪ Increase PEEP, higher PaO2
•

• ARDS
o Pyelonephritis
o Pancreatitis
o HIGH PEEP, LOW TIDAL
• Pulmonary HTN
o Pulm artery > 25
• Lactate
o <1 normal
o >1 lactid acidosis
• Aspiration PNA
o Mechanical Ventilation
o Alcoholics, dementia, seizures, stroke patients
o Right Lower Lobe PNA or Abscess
o Tx: Clindamycin
• Pneumocystis jirovecii
o Opportunistic infection
o Tmp-SMX prophylactic and tx
o Steroids? If PaO2 < 70 or A-a gradient is > 35
o AIDS- prophylaxis at CD4 <200
o Sx: Fever, nonproductive cough, bilateral interstitial infiltrates

GASTROINTESTINAL

o Most cancer after you dx → next thing to do? Staging with CT

o Ovarian, colon, lung cancer
o Diverticulosis
o Lots of blood in toilet (PAINLESS BRBPR)
o Dx with barium enema
o Diverticulitis
o LLQ pain, fever, constipation, leukocytosis
o Dx with CT angiogram
o Mesenteric ischemia
o Pain out of proportion!
▪ Extreme abd pain but PE not impressive
o Atherosclerotic RF: HTN, HLD, diabetes, smoking
o Associated with AFIB!!!! (emboli form in the LAA!)
o Dx with angiography
▪ “MI of the mesenteric arteries dt emboli or thrombosis”
o Ogilvie’s syndrome
o Colonic pseudo-obstruction
o Acute dilation of the colon in the absence of an anatomic lesion that obstruct the flow
of intestinal contents
o Abd xray: distended colon, but normal small intestine
o **seen in older person post-op**
▪ Vs post-op ileus
• Here the small bowel and colon are BOTH distended and there are
DECREASED bowel sounds!
o Sigmoid volvulus
o Tx: sigmoidoscopy
o Abd Xray: omega/bean sign
o Varices
o Dt cirrhosis
o 1st line med: octreotide (+sphlanchnic vasoconstriction → decreases portal venous
blood supply)
o Prophylaxis: beta blocker
o SBP
o Cirrhosis + chronic ascites + fever & abd pain
o Dx: paracentesis & PMN > 250
o Tx: ceftriaxone
o Young female taking OCP → hepatic adenoma!
o Only resect if > 5 cm
o Liver abscess/cysts
o Eichinococcus = hyatidid cyst
▪ Latin america, close contact with dogs.
▪ RUQ US: round cyst full of smaller rund cysts
▪ Tx: mebendazole
o Pyogenic liver abscess
▪ Complication of ascending cholangitis
• Ascending colangitis is complication of cholecholidothethiasis (infx of
CBD w/ E coli) that travels up to liver
▪ Tx: I&D plus abx
• FATAL if untreated
 o Amebic (Entamebic histolytica) liver abscess
▪ Fever, RUQ pain, DIARRHEA, eosinophilia
▪ Tx: metronidazole
o Physiologic jaundice of newborn
o Occurs after a few days of life
o Immature conjugation system
o Causes indirect hyperbilirubinemia (unconjugated)
o Pathological jaundice of newborn
o Occurs right at birth
o Best next step = coombs test
o Crigler-Naajer
o Deficiency of glucuronyl transferase → unconjugated hyperbilirubinemia
o Gilbert disease
o CN “light” = not complete def of glucuronyl transferase → unconjugated
hyperbilirubinemia
▪ Only apparent when sick/stressed → jaundice
o Dubin-Johnson syndrome
o Hepatocytes can conjugate biliriubin, but they cannot release it → BLACK LIVER
o Rotor syndrome
o DJ “light” → no black liver tho
o Causes of elevated AST & ALT
o Mnemonic = ABCDEFGHI
▪ A = autoimmune
▪ B = hep B
▪ C = hep C
▪ D = drugs
▪ E = ethanol
▪ F = fatty liver
▪ G = growth of tumors
▪ H = hemodynamic instability → shock liver
▪ I = iron overload (hemochromatosis)
o Suspect cholecystitis:
o Next best step?
▪ RUQ US
• Positive (need 2/3 present) = GB wall thickening (>3 mm), gall stones,
pericholcystic fluid
• If non-diagnostic → all sx of cholecystitis (RUQ pain, fever, leukocytosis,
+murphy sign) without +RUQ US
o Next step = HIDA scan
▪ Dye that lights up entire biliary tree
• If the GB does not light up then you know there
is gallstone blocking it
o Choledocholithiasis
o Presence of gall stone lodged in CBD
 ▪ Can cause infection (asc cholangitis) if left untreated
• Charcot’s triad = RUQ pain, fever, jaundice
o Reynolds pentad = AMS & HoTN
▪ Can obstruct pancreatic duct → gallstone pancreatitis
• Someone who has pancreatitis (elevated lipase amylase)
o What is the best next step in imaging?
▪ RUQ US!!!!
• Don’t need CT bc the lipase & amylase is
already elevated so don’t need a CT to dx
pancreatitis, you can use the RUQ US to dx the
cause of pancreatitis → GALLSTONES!
(gallstones & EtOH are the MCC of pancreatitis)
• If gallstones are seen on RUQ US, pt needs
cholecystectomy during this same hospital visit,
or else this will happen again!
▪ Can erode thru the gallbladder and the adjacent small intestine and then block
the terminal ileum → gallstone ileus
• Air in gallbladder wall
• Sx of small bowel obstruction
o Distention of small bowel proximal to obstruction
o Air fluid level
o Hypoactive bowel sounds
o Nausea and bilious vomiting
o Obstipation = constipation + l/o flatulence
o Diffuse abdomen pain
▪ ICU pt can get predisposed to acalculus cholecystitis
• Bc they are on TPN
o Underactive GB (does not contract a lot) → increased risk for
bacterial colonization
• Prolonged ischemia → ischemia of GB
• RUQ US
o NO STONES!
• Tx: percutaneous cholecystoscopy to drain the GB
o Cholangitis
o MCC = E Coli
▪ If ascends → pyogenic liver abscess
o Tx: IVF, IV abx & ERCP!
▪ ERCP: retrieve gallstone
o PSC = primary sclerosing cholangitis
o “beading of biliary tree”
o Highly assoc w/ UC
o Intra & extra-hepatic bile ducts
o PBC = primary biliary cirrhosis (cholangitis)
o Anti-mitochondrial Ab
 o Extreme pruritis
o Tx: ursodiol
o Appendicitis
o Dx: clinically (N/V, periumbilical → RLQ pain, +Mcburney’s point, +Psoas, +Rovsing,
+rebound tenderness, fever, leukocytosis)
▪ Best next step:
• Appendectomy
• Only do CT if diagnosis is not clear cut (RLQ pain and negative psoas
sign)
o Carcinoid tumor = BFDR (Bronchospasm, Flushing, Diarrhea, Right sided heart valve
abnormality)
o Secretes 5HT
o MC found in appendix & sm bowel
o Increased risk for niacin def (vit B3) = diarrhea, dementia, death
▪ Tryptophan makes 5HT, melatonin & niacin
• If pt has carcinoid tumor they are using up all tryptophan to make 5HT
→ no niacin or melatonin left
o Pancreatic pseudocyst
o Occurs ~3 wks after acute pancreatitis
o Early satiety, distended abdomen, vague abd pain
o CT abd = cyst
o Tx: observe, unless > 5cm → drain
o Chronic pancreatitis
o CALCIFICATIONS!
o Aortic surgery
o Common complication
▪ Aortic entero fistula → hole erodes from aorta into intestine → bleeding from
aorta into GI system → BRBPR
o Achalasia = failure of LES to relax
o Problems swallowing = dysphagia
▪ 1st line imaging = barium swallow
• Zenkers vs esophageal spasm vs cancer vs stricture vs CREST vs achalasia
o Zenker = old man, food stuck in back of throat & halitosis
o Achalasia = bird beak sign!
▪ UNLESS they have alarm symptoms (> 55 yo w/ problems swallowing, wt loss &
iron def anemia)
o GERD (gastric reflux)
o Increased risk for esophageal stricture → difficulty swallowing food/liquids
o MCC peptic ulcer disease (gastric/duodenal ulcers)
o NSAIDS or H pylori
o Anyone who comes in w/ gastritis, sx heartburn or GERD
o Young & from N. America → 1st line tx = PPI & come back
o Asia → 1st line tx = offer H pylori urease breath test or H pylori fecal Ag test
o Alarm sx (microcytic anemia, wt loss, elderly (55+ yo)) → 1st line = endoscopy
 o Anyone who is > 50 yo who has microcytic anemia = colon cancer until proven otherwise
o Better get a colonoscopy
▪ Colonoscopy screening when ppl turn 50 then q 10 yrs
▪ Unless pt had family member dx w/ colon cancer < 60 yo then do colonoscopy
either @ 40 yo or 10 years younger than when family member was dx (whatever
age is younger)
o IBD
o Crohn disease
▪ Skip lesions
▪ Oral ulcers
▪ Strictures & fistulas
▪ Transmural
o Ulcerative colitis
▪ Always include rectum
▪ Mucosal only
▪ Continuous
▪ Assoc w/ PSC
o Tx w/ sulfasalazine
o Acute flares tx w/ steroids
o Cutaneous manifestation = pyoderma gangrenosum = STERILE WOUND! (tx w/ steroids
NOT abx!)

ENDOCRINE

o New thyroid nodule

o Check TSH & do thyroid U/S
▪ Hyperthyroid vs euthyroid?
• Hyperthyroid = usually NOT malignant
o Next best step = radioactive iodine uptake!

▪ Diffuse = graves
▪ One nodule = toxic adenoma
▪ Multinodular = plummer disease
 ▪ Hyperthyroid w/ 0 radioactive iodine uptake
• This means that the pt has a burst gland /
inflamed gland that is leaking out preformed
thyroid gland → not actively making new
thyroid gland
o Post partum
o De Quervain (subacute) painful
thyroiditis
o Hashimoto thyroiditis hyperthyroid
phase
• Most malignant nodules are Euthyroid
o Next best step:
▪ > 1 cm → bx
▪ < 1 cm → wait and f/u in a few wks bc less likely to be
malignant

▪ U/S
• Size
o > 1 cm
o < 1 cm
• Cystic, Multiloculated = cancerous
o Extra estrogen (pregnant or OCP)
o High thyroglobulin → attaches to thyroid hormone
▪ Hypothyroid pts
• Increase TBG → cannot make more thyroid H → even more deficient…
these pts need to increase their levothyroxine doses
o Hashimoto’s thyroiditis = Chronic lymphocytic thyroiditis
o Assoc w/ lupus, pernicious anemia or Sjogren
o Assoc w/ thyroid lymphoma
o De Quervain subacute thyroiditis
o PAINFUL
o Recently had URT infection
o Caused by leakage of excess thyroid hormone → NO radioactive uptake
o Tx: NSAID or aspirin
o Medullary thyroid cancer
o Arises from parafollicular C cells
▪ Make calcitonin
• Decrease Ca2+ to normal (tone down Ca2+)
o Vs PTH made by parathyroid gland that increases Ca2+ levels
o Next best step after dx is to check for PHEOCHROMOCYTOMA!!! (urine metanephrines)
▪ Bc medullary thyroid cancer is assoc w/ MEN2a = PPM & MEN2b = PMM
• PPM: Pheochromocytoma, hyperParathyroidism, Medullary thyroid ca
• PMM: Pheochromocytoma, Medullary, Mucosal neuroma/Marfanoid
habitus
▪ After that then you can do surgical RESECTION!
o Acromegaly
o Excess GH from ant pit
o First diagnostic test = IGF-1 (released from liver)
▪ More reliable than GH bc levels are consistently high
o SIADH
o 1st line tx = H2O restriction
o Cushing syndrome symptoms
o BAMCUSHINGOID
▪ B = Buffalo hump
▪ A = Amenorrhea
▪ M = Moon facies
▪ C = Crazy
▪ U = Ulcers
▪ S = Skin changes
▪ H = HTN
▪ I = Infection
▪ N = Necrosis of femoral head
▪ G = Glaucoma
▪ O = Osteoporosis
▪ I = Immunosuppressed
▪ D = Diabetes
o 1 test = low dose dexamethasone suppression test, 24 hr Urine cortisol level or late
st

night salivary cortisol level

o Adrenal insufficiency
o 1st test = Urine cortisol or ACTH stimulation
▪ If ACTH stimulation boosts up cortisol levels → secondary adrenal insuff caused
by pituitary problem
 ▪ If ACTH stimulation does not increase cortisol levels → primary adrenal insuff =
Addison’s disease (MCC = autoimmune!)
o HTN + hypernatremia + hypokalemia
o 1st step = renin:aldosterone
▪ Bc want to determine if hyperaldosterone is caused by adrenal gland issue or
underperfusion of kidney
• High aldo & low renin → Conn syndrome
• High aldo & high renin → renal a stenosis or fibromuscular dysplasia
o Decreased perfusion to JG cells → increase renin → +RAAS →
increase aldosterone
o Renal a stenosis = older person w/ hx of HTN that has been
taking meds, but now HTN is refractory. & murmur on renal a
on abd ausculation
o Fibromuscular dysplasia = young female with abdominal bruit
with unexplained HTN and subauricular bruit (bruit behind ear)
o Diabetes Mellitus
o Diagnosed 3 ways
▪ 2 fasting MBG > 126
▪ Random MBG > 200 w/ sx polyphagia, polyuria, polydipsia, dehydration, wt loss
▪ HbA1c > 6.5%
o Metformin CI in CHF & kidney failure
▪ Exacerbates lactic acidosis
▪ CI when creatinine > 1.5
o Effects of metformin
• Enhances insulin sensitivity
• Decreases GI absorption
• Decreases hepatic gluconeogenesis
o Metformin is the 1st line tx of T2DM
o MCC death in T2DM = MI dt accelerated atherosclerosis
▪ ****this is the same for rheumatoid arthritis!!!!****
o DKA vs HHS
o DKA: increased AG met acidosis (pH < 7.35), glucose levels ~ 300
▪ Usually T1DM that is not making insulin; abd pain, N/V, Kussmaul breathing
(deep tachypnea w/ large TV = resp compensation to try to “blow off” acid)
▪ Tx: IV insulin, dextrose, IVF, K replacement (want to keep K > 5.2 when pt in
DKA)
• STOP GIVING INSULIN WHEN AG CLOSES
o HHS: NO increased AG (pH 7.35 – 7.45), glucose levels ~ 1000
▪ Tx: IV insulin & IVF
o Zollinger-Ellison
o Multiple duodenal ulcers w/ diarrhea
o Dx: elevated gastrin levels (> 1000) then secretin challenge
▪ Normally secretin will decrease gastrin, but in ZE it doesn’t
o Tx: PPI or surgery
 o Glucagonoma
o Hyperglycemia PLUS necrotizing migratory erythema
o Beta blocker OD → tx w/ glucagon!

CT & JOINTS

o Fetus w/ congenital heart block → assoc w/ neonatal lupus

o Treatment regimens for rheumatoid arthritis and lupus
o Rheumatoid arthritis
▪ Mild: NSAID
▪ DMARD: MTX
▪ Flare: steroids
o Lupus
▪ Mild: NSAID
▪ DMARD: hydroxychloroquine
▪ Flare: steroids
o Diagnosis:
o RA based on clinical findings – BL symmetric metacarpohalangeal and proximal
interphalangeal joint stiffness and erythema that is worse in AM and better throughout
day. Spares DIP. Elevated ANA, RF & specific = elevated anti-CCP
o Lupus – mnemonic = SOAPBRAINMD (4 out of these 11)
▪ S = Serositis (pleuritis, pericarditis)
▪ O = Oral ulcers
▪ A = Arthralgias
▪ P = Photosensitivity
▪ B = Blood (pancytopenia)
▪ R = Renal (lupus nephritic syndrome)
▪ A = ANA
▪ I = Immunoglobulin (anti-dsDNA, anti-smith)
▪ N = Neuro
▪ M = Malar rash
▪ D = Discoid lupus
o Antiphospholipid syndrome
o Recurrent miscarriages & random thrombotic episodes (DVT or PE)
o Prolonged PTT & PT (not corrected w/ mixing studies)
o False elevated VDRL (false syphillis +)
o HYPERCOAGULABLE
o Gout
o Sudden o/s super painful red, warm, swollen joint
▪ Metatarsalphalangeal joint = base of big toe
o Next best step = arthrocentesis
▪ Synovial fluid analysis = negatively birefringent crystals (yellow needle shaped)
• If the crystals are rhomboid shaped and posively birefringent (blue) =
pseudogout = calcium pyrophosphate disease = CPPD
 o Assoc w/ chondrocalcinosis (calcifications seen in the joint on
Xray)
o Tx of gout = NSAIDs & colchicine
▪ CI: kidney disease
• Can give intraarticular steroids
o Polymyositis vs polymyalgia rheumatica vs fibromyalgia
o Polymyalgia rheumatica = STIFFNESS
▪ Elderly patient w/ stiffness, pain in hip & shoulders
▪ Elevated ESR and normal CPK
▪ Assoc w/ giant cell temporal arteritis (can lead to blindness!)
• This is to be treated with HIGH DOSE STEROIDS
▪ Tx: low dose steroids
• Pts are VERY responsive to steroids and will feel very good after
treatment
o Polymyositis (& dermatomyositis) = WEAKNESS
▪ Symmetric proximal muscle weakness
▪ Elevated CPK (dt ms breakdown)
▪ Dermatomyositis can have cutaneous features = heliotrope rash (around eyes)
& gottron papules (red papules on knuckles)
▪ Usually associated with underlying malignancy!!!
▪ Tx: steroids
o Fibromyalgia = PAIN
▪ Trigger points – symmetric: neck, shoulders, back, butt
▪ Constant, aching pain
▪ Assoc w/ mood or somatic disorders
▪ Tx: TCA or SNRI (venlafaxine)
o Sudden o/s psoriasis or molluscum contagiosum → assoc w/ HIV
o Best next step = test for HIV!

RENAL

o WBC in urine
o Acute interstitial nephritis
o Pyelonephritis
o Uremia (high uremia levels)
o 4 manifestations of uremia that indicate need for hemodialysis
▪ HUS = MAHA – plts clumping and RBC shear → thrombocytopenia & anemia
• Usually caused by EHEC or shigella, but can also be caused by UREMIA!
▪ Uremic pericarditis
▪ Plt dysfunction → prolong bleeding time
▪ AMS and asterixis
o Top 2 causes of CKD = HTN & DM
o Indications for emergent hemodialysis = AEIOU
o A = Acidosis
o E = Electrolytes (K > 6.5)
 o I = Intoxication
▪ MALE
• M = Methanol
• A = Aspirin
• L = Lithium
• E = Ethylene glycol
o O = Overload (fluid)
o U = Uremia
o AIN = Acute Interstitial Nephritis
o Recently took drugs, now has hematuria and WBC casts (only see WBC casts in AIN &
pyelonephritis), plus a rash
o Caused by NSAIDs, diuretics, Abx
o FEAR
▪ F = Fever
▪ E = Eosinophilia
▪ A = Azotemia (kidney injury)
▪ R = Rash
o ATN = Acute Tubular Necrosis
o Someone went into shock and then had acute kidney injury
o Hypoxia (underperfusion to kidneys = prerenal azotemia = BUN:Cr > 20) or toxins
o MUDDY BROWN CASTS
o Tx: IVF
o 2 MCC of NAGMA
o Diarrhea = diarrhea bc you poop out all the bicarb
o RTA
▪ RTA = renal tubular acidosis
• RTA 1 → think of 1 letter; H! & think of stONEs!
o Unable to secrete H making you acidotic
o Assoc w/ kidney stONEs
• RTA 2 → think of Bicarb
o Unable to absorb bicarb – lose too much bicarb making you
acidotic
• RTA 4 → think of 4 letter A L D O
o Hypoaldosterone → hyponatremia, hyperkalemia
▪ Normal Aldosterone functions: reabsorb Na thru ENac
and secrete K. also secretes H thru alpha-intercalated
cells
• So in HYPOaldosteronism → not absorbing Na
→ hyponatremia. Not secreting K →
HYPERkalemia. Not secreting H → ACIDOTIC
o ONLY ONE WITH HYPERKALEMIA
o Metabolic alkalosis
o Next best step → check urine chloride
▪ If high → kidneys cannot absorb chloride: kidney problem
 ▪ If low → then probs GI problem (vomiting)
o Steatorrhea
o Fatty stools
▪ When the fat reaches terminal ileum it can bind up Ca2+ (saponification) → this
is an issue bc oxalate & Ca2+ usually bind at terminal ileum, but if the fat is
stealing and binding all the Ca2+ the oxalate has nothing to bind to to be
excreted properly so the oxalate is reabsorbed and then goes to the kidneys and
finds Ca2+ in tubule there to bind to and then this forms calcium oxalate stones
• Eating high fat foods predisposes to calcium oxalate kidney stones
• If you have calcium oxalate stones → you can eat a high calcium, low
salt, low fat, high water diet
o Elderly male that smokes a lot presents with painless gross hematuria
o Ddx:
▪ Renal Cell Carcinoma (RCC)
• Pt wil also have flank pain & abdominal mass
• Next best step = CT abdomen
• Tx: nephrectomy
▪ Bladder cancer (usually transitional cell carcinoma from the carcinogens in
cigarette smoke)
• Next best step = cystoscopy
o Young male with irregularly shaped testicle and painless mass in testicle
o Next best step = scrotal U/S
▪ If there is a mass, it could potentially be cancer
• Next best step = inguinal orchiectomy (DO NOT BIOPSY DT POTENTIAL
SEEDING)
o Testicular torsion vs epidydimitis
o Testicular torsion
▪ Twisting around spermatic cord → cuts off blood supply to testicle
▪ Acute o/s severe testicular pain & NON-TENDER spermatic cord
▪ Pain is WORSE with elevation of scrotum
▪ Absent cremasteric reflex
▪ Next best step =
• Not super clear cut whether it is testicular torsion vs epidydimitis (e.g.
no cremasteric reflex, plus fever, plus relieve when scrotum is elevated)
o Scrotal U/S to check for blood flow
• Yes clear cut this is testicular torsion
o BL orchiopexy (bc CL side will most likely torsion in near future)
o Epidydimitis
▪ Cremasteric reflex is present (stroke medial thigh → scrotum will rise)
▪ An infection; fever and tender spermatic cord
▪ Pain is RELIEVED with elevation of scrotum
▪ Vs orchitis vs prostatitis (all are inflammation!!)
• Young vs old
o Young (< 35 yo) = gonorrhea & chlamydia
 ▪ Tx: ceftriaxone & azithromycin
o Old (> 35 yo) = E coli
▪ Tx: FQ (ciprofloxacin)

FLUIDS/ELECTROLYTES

o Hyponatremia algorithm
o First thing you wanna do – check osmolarity normal btw 275-295
▪ Serum osmolality = 2Na + (glucose/18) + (BUN/2.8)
▪ > 295 = hyperosmolar hyponatremia → dt glucose
▪ 275-295 = isoosmolar hyponatremia → dt protein or lipids
▪ < 275 = hypoosmolar hyponatremia
• Next best step = check volume status w/ BP, mucosal membranes
o Hyper-, eu-, hypo- volemic
▪ Hypervolemic: CHF, cirrhosis, nephrotic syndrome
▪ Euvolemic: SIADH & primary polydipsia
▪ Hypovolemic: diarrhea, vomiting, diuretics
• THEN you determine Urine Sodium (indirect way to see how good
kidneys are at absorbing Na)
o > 20 → intrinsic kidney disease, kidneys cannot reabsorb Na
▪ E.g. hypovolemic, hypotonic, hyponatremia with high
urine sodium → MCC = diuretics
▪ E.g. euvolemic, hypotonic, hyponatremia with high
urine sodium → MCC = SIADH
▪ E.g. hypervolemic, hypotonic, hyponatremia with high
urine sodium → MCC = CKD or acute kidney injury
(ATN)
o < 20 → kidneys are good at absorbing Na, issue is elsewhere
▪ E.g. hypovolemic, hypotonic, hyponatremia with low
urine sodium → MCC = diarrhea or vomiting
▪ E.g. euvolemic, hypotonic, hyponatremia with high
urine sodium → MCC = primary polydipsia
▪ E.g. hypervolemic, hypotonic, hyponatremia with high
urine sodium → MCC = CHF, cirrhosis or nephrotic
syndrome (remember, the renal tubules are intact in
nephrotic syndrome… it is the glomerular BM that is
screwed up)
o Hyponatremia TREATMENT
▪ Hypervolemic or euvolemic w/o symptoms
• fluid restrict
▪ Hypovolemic w/o symptoms
• 0.9% NS
▪ Hypovolemic w/ symptoms (lethargy, coma, AMS)
• 3% hypertonic saline
 o Do not overcorrect too fast! (low to high → pons will die –
central pontine myelinolysis)
o Hypernatremia TREATMENT (go slowly: high to low, brain will blow = cerebral edema)
o Hypervolemic & euvolemic w/o symptoms
▪ Free water
o Hypovolemic w/o symptoms
▪ D5 ½ NS (0.45%)
o Hypovolemic w/ symptoms
▪ 0.9% NS → this will give the “most room” to add the most fluid as possible
o Blood transfusions can cause hypocalcemia dt citrate binding up calcium
o Tx of hypercalcemia = IVF
o Tx of hyperkalemia
o 1st step – look at EKG → if there are changes
▪ Give calcium gluconate to stabilize myocardial membranes & prevent
arrhythmias
▪ Can also give insulin that pushes K into the cells, but make sure you give glucose
with it to maintain MBG levels
▪ Can also give kayexalate → promote K+ excretion through GI tract
o Hypermagnesemia
o 1st sign = l/o deep tendon reflexes
o Tx: IV calcium gluconate to stabilize myocardial membranes
o Parathyroid hormone
o MAIN ACTIONS → high Ca2+ & low phosphate
o PTH has 3 actions
▪ Works on bones directly → increased Ca2+ & phosphate released from bone
▪ Works on kidney tubules → increase Ca2+ absorption & promote phosphate
excretion
▪ Works on converting calcidiol to calcitriol (activated vitamin D3) via +1a-
hydroxylase
• Calcitriol can then go to gut and increase Ca2+ & phosphate uptake
o Primary hyperparathyroidism
▪ Increase PTH
▪ Tx: parathyroidectomy
o PTH axis
▪ Negative feedback (shuts off PTH)
• High Ca2+ & high vit D3
o Hypoparathyroidism
▪ Low PTH → low Ca2+ & high phosphate
o Kidney failure → elevated PTH with LOW Ca2+ & HIGH phosphate
▪ Cannot convert calcidiol to calcitriol (dt no alpha 1 hydroxylase) → cannot
absorb Ca2+ & phsophate from gut. Also cannot absorb Ca2+ and cannot
secrete phosphate from kidney.
o Vit D deficiency
▪ Isolated – nutritional/malabsorption
 • Low vit D3 → cannot absorb Ca2+ & phosphate from gut → low Ca2+,
low phosphate, high PTH
o Squamous cell Ca of lung → makes PTHrP → acts like PTH
▪ Causes high Ca2+, low phosphate → low PTH
o Mechanical ventilation
o PCO2 controlled by TV & RR
▪ If PCO2 too high = hypoventilation
• Want to increase TV and/or RR
o PaO2 controlled by FiO2 & PEEP
▪ If PaO2 too low = hypoxemia
• Want to increase FiO2 and/or PEEP
o Acid/Base
o First thing – check pH!
▪ Low (< 7.35) = acidosis
▪ High (> 7.45) = alkalosis
o Second step – look at CO2 & bicarb
▪ Normal CO2 = 35-45
• High = acid
• Low = alk
▪ Normal Bicarb = 22-28
• High = alk
• Low = acid
o E.g. metabolic acidosis; pH < 7.35, bicarb < 22
▪ Next best step = calculate AG
• Na – HCO3 – Cl
o If > 16 → AG met acid
o If < 16 → NAGMA = RTA vs diarrhea
▪ How can you tell RTA vs diarrhea
• Calculate urine AG = Na + K – Cl
o If neGUTive = GI loss
o If positive = renal loss = RTA
o E.g. metabolic alkalosis; pH > 7.45, bicarb > 28
▪ Next best step = check the urine chloride
• If high (> 20) → renal issue
• If low (< 20) → GI issue

HEME/ONC

o Next best step to narrow down differential = Reticulocyte count & MCV
o Increased reticulocyte count (>2%) to replenish RBC that have been dying
▪ Hemolysis or splenic sequestration
o MCV
▪ Microcytic (< 90)
• FAST
o F = Fe deficiency anemia
 ▪ Low ferritin, low serum iron, high TIBC (transferrin)
▪ High RDW
o A = Anemia of chronic disease
▪ Hepcidin is hidin iron in hepatic MO
• High ferritin, low serum iron, low TIBC
o Recall TIBC & ferritin opposite
▪ Cytokines suppress EPO
▪ Tx: treat underlying disease
hemochromatosis o S = Sideroblastic anemia
AD, excessive iron absorption thru gut. ▪ High ferritin, high serum Fe, low TIBC
High ferritin, high serum Fe, low TIBC. • Iron in RBC bursting out dt B6 (pyridoxine) def,
Bronzed diabetes & elevated LFTs
lead poisoning or INH → dt defective heme
Tx: phlebotomy
(porphyrin) synthesis
o T = Thalassemia
▪ Alpha: asians
▪ Beta: crew cut skull, Mediterranean people. Elevated
HbA2
▪ Normocytic
• Hereditary spherocytosis (AR)
Spherocytes can also be see in autoimmune o Defective ankyrin, spectrin, band 4.2
hemolytic anemia bc the Ab pluck off membrane o Spherocytes get lodged in spleen
blebs → diminish redundant plasma membrane ▪ Tx: splenectomy
so you cannot make the biconcanve disc anymore
o High MCHC
▪ Macrocytic (>100)
• Folate def
o Increased homocysteine
o Megaloblastic anemia = hypersegmented PMN
• B12 (cyanocobalamin) def
o Neuro deficits (subacute decombined degen)
o Increased methylmalonic acid, increased homocysteine
o Megaloblastic anemia = hypersegmented PMN
• Other macrocytic anemias that are NOT also megaloblastic anemia
o Alcoholic
o Fanconi: hypoplastic thumb & pancytopenia
o Diamond Blackfin: triphalangeal thumb w/ anemia
o RBC transfusion reactions
o 30 sec – anaphylaxis
▪ IgA deficiency
▪ Prevent via washing blood
o 30 min – acute hemolytic reaction
▪ ABO incompatibility
▪ HoTN & flank pain
▪ Tx: IVF
o 3 hr – cytokine release
 ▪ Febrile reaction
▪ Prevent w/ leukoreduction
o 3 days – delayed hemolytic reaction
▪ Jaundice
▪ Tx: self-limited
o Aplastic crisis = RBC only
o Can be caused by parvovirus B19
▪ Parvovirus B19 in mother can cause hydrops fetalis in fetus
o Aplastic anemia = pancytopenia!
o Autoimmune hemolytic anemia
o Warm
▪ Is Great – IgG against RBC
• Causes: “Luke warm” = leukemia, lymphoma, lupus
• IgG is opsonin → splenic sequestration → splenomegaly
▪ Tx: steroids
o Cold
▪ Is Miserable – IgM against RBC
• Mycoplasma or Mononucleosis
▪ Tx: avoid the cold
o TTP = thrombotic thrombocytopenic purpura
o Deficient ADAMST13 (protease) → cannot cleave vWF → excessive plt adhesion (vWF
on endothelium attaches to plt GP1b to promote adhesion) and cause little thrombus
speed bump that RBC shear on → shistocyte/hemolytic anemia
o Sx: FAT RN
▪ F = Fever
▪ A = Anemia
▪ T = Thrombocytopenia
▪ R = Renal
▪ N = Neuro
o HUS = hemolytic uremic syndrome
o Causes
▪ EHEC (O157H7)
▪ Shigella
▪ Uremia
o Can lead to microangiopathic hemolytic anemia
▪ Hematuria, anemia, thrombocytopenia
o Tx: dialysis
o HIT = heparin induced thrombocytopenia
o Plt drops by ~50% within 3 days of starting heparin
▪ Next best step
• STOP heparin
o Start on agatroban/dabagatran (direct thrombin inhibitor)
▪ Bc the plts are prothrombotic so the pts are at
increased risk for DVT/PE
 o If pt has +PF4, when you give heparin, the Ab will start to bind to the heparin on the plts
▪ Testing: +Antiplatelet factor 4 Ab & +serotonin release assay
o vWD: von Willebrand disease
o deficient vWF
o reduced ristocetin activity (no coagulation)
▪ lab test that induces vWF from binding to GP1b to plts → increases coagulation
o can see elevated bleeding time (measure of plt activity) and elevated PTT (intrinsic
pathway)
▪ bc vWF protects factor VIII & bc plts cannot stick without the vWF
o clinical signs = epistaxis, ginigival bleeding, menorrhagia
o tx: desmopressin (ddAVP: promotes release of vWF from endothelial cells)
o DIC = disseminated intravascular coagulation
o Most extreme microangiopathic hemolytic anemia
o Thrombocytopenia (plt consumption), anemia (shistocytes)
o Consumption of coagulation factors
▪ Elevated PT, PTT, BT, D-dimer
▪ Decreased fibrinogen
o Clinically: spontaneously bleeding from IV access sites & shock
o Tx: treat underlying cause, FFP, vitamin K
o Oncological emergencies
o Hypercalemia: tx w/ IVF
o Spinal cord compression from metastasis: tx w/ IVF
o Cardiac tamponade: tx w/ pericardiocentesis
o Tumor lysis syndrome: tx w/ IVF
o Hodgkin lymphoma vs NHL; both can have B symptoms: fever, night sweat, wt loss
o Hodgkin
▪ RS cells (CD15 & 30+)
▪ LN cluster in chains
▪ MC = nodular sclerosing > lymphocyte depleted
o NHL
▪ Diffuse LAD
▪ Burkitt, follicular & HIV lymphoma
o Any LN that is > 1cm, not assoc w/ infx, not painful & been there for > 1mon should be
biopsed!
o Acute leukemia: > 20% blasts, pancytopenia
o Chronic leukemia
o Myelogenous = anything other than lymphocytes (basophils, eosinophils, neutrophils)
o Lymphocytic = lymphocytes
o AML → auer rods
o M3 APL → increased risk of DIC. Tx w/ ATRA
o CML → Ph+ 9;22 mutation, elevated basophils, low LAP score
o Tx: imatinib (tyr-kinase inhibitor bcr-abl)
o CLL → smudge cells
o Polycythemia vera → JAK2 mutation
 o High Hgb, high WBC & plts
o Aquagenic pruritis
o Next best step → check EPO levels
▪ If low: PCV
▪ If high: secondary polycythemia
• Hypoxemia causing kidneys to be underperfused: smoking

INFECTIOUS DISEASES

o PNA
o Typical: lobar consolidation
▪ Strep pneumo
▪ H influenza
▪ Moraxella catarrhalis
o Atypical: interstitial infiltrates
▪ Mycoplasma
▪ Legionella
▪ Chlamydia
o Hospital/nosocomial acquired: predispose to aspiration PNA (MC in RLL) → abscess
formation; can be seen as air fluid level on CXR
▪ Pseudomonas
▪ E coli
▪ Staph aureus
o Abx treatment of PNA
o Outpatient
▪ Typical
• Amoxicillin
▪ Atypical
• Azithromycin
o Inpatient
▪ MC prescribed = FQ
▪ If aspiration PNA
• Clindamycin to cover anaerobes
▪ If hospital acquired; want to cover pseudomonas
• Pip-tazo or cefepime
o PPD = TB screening test
o > 15 mm: healthy
o > 10 mm: incacerated, healthcare worker, foreigner
o > 5 mm: HIV, close contact with known TB+
o If positive, next step →
▪ CXR
• If positive (cavitations in upper lobe, fever, night sweats, hemoptysis) →
tx w/ RIPE for 2 mon then RI for 4 mon
o Rifampin
▪ AE: orange bodily secretions
 o INH w/ vit B6 (w/o B6 → neuropathy & sideroblastic anemia)
o Pyrazinamide
▪ AE: gout
o Ethambutol
▪ AE: eye problems
• If negative → tx w/ INH & vit B6 for 9 mon
o Still have to do this if the pt had BCG vaccine
o Note* all TB meds can cause hepatotoxicity… only stop if LFTs are > than 3x upper limit
of normal
o Meningitis
o Meningitis sx: headache, fever, nuchal rigidity, photophobia, +Brudzinksi sign
o Bugs/treatments based on age groups:
▪ < 3 mon (BEL)
• GBS (Strep agalactiae)
• E coli
• Listeria
• Empiric tx:
o Vancomycin: strep
o Ceftriaxone: E coli
o Add Ampicillin: Listeria
▪ Everyone in btw
• Strep pneumo
• H influenzae
• N meningitis
o RASH
• Empiric tx:
o Vancomycin: strep
o Ceftriaxone: neisseria
▪ > 50 yo/IC
• Cryptococcal meningitis in AIDS pt
o India ink stain
o Pigeon poop
o Tx: amphotericin
• Empiric tx:
o Vancomycin: strep
o Ceftriaxone: E coli
o Add Ampicillin: Listeria
o CSF findings
▪ Viral (herpes = temporal lobe encephalitis → seizures, echovirus, enterovirus)
• Increased WBC (LYMPHOCYTE)
• Increased protein
• Normal glucose
▪ Bacteria
• Increased WBC (NEUTROPHIL)
 • Increased protein
• Decreased glucose
▪ Fungal (IC pts) [TB is a bacteria by CSF findings looks like fungal. It does infect
the base of the brain.]
• Increased WBC (LYMPHOCYTE)
• Increased protein
• Decreased glucose
o UTI
o Uncomplicated UTI → usually treated empirically w/o UA
• 1st line: TMP-SMX, nitrofurantoin, FQ
o Unless pregnant; then use nitrofurantoin, amoxicillin or
cephalosporin
▪ NO FQ dt tendinopathy
▪ NO TMP-SMX dt NTD
o Complicated UTI occurs in 4 demographics
▪ Diabetics
▪ Pregnant
▪ Male UTI
▪ Immunosuppressed
o If someone has > 2 UTIs/year then they should take TMP-SMX prophylactically (either
daily or post-coital)
o Prostatitis vs epidydimitis vs orchitis
o Depends on age:
▪ Young (< 35) → N. gonorrhea or chlamydia
• Tx: ceftriaxone & azithromycin
▪ Old (> 35) → E coli
• Tx: ciprofloxacin (FQ)
o HIV Stuff
o HIV viral count > 1000 → must do C section
o HIV is CI to breastfeeding
o HIV prodrome is similar to mono
▪ Malaise, fever, LAD and RASH and maybe DIARRHEA
o HIV prophylaxis
▪ CD4 < 200 → TMP SMX: prevents PCP PNA
▪ CD4 < 50 → azithromycin: prevents MAC (fever, diarrhea, wt loss)
o CMV & AIDS
▪ CMV → colitis (bloody diarrhea), retinitis (“Sight”-o-megalovirus), esophagitis
(shallow, linear ulcer)
o HIV & diarrhea
▪ Cryptosporidium parvum = watery
• Acid fast oocysts
▪ CMV = bloody
▪ MAC = fever + diarrhea
o HIV pts need 2 vaccines: influenza, pneumovax & Hep B
o Chlamydia
o LGV (lymphogranuloma venereum) L1-3
▪ Painless genital ulcers & inguinal LAD
• Buboes (big, hard painful inguinal LN)
o Granuloma inguinale = donovanosis
o Klebsiella granulomatosis
▪ Painless genital ulcers & inguinal LAD
• Inguinal LAD ulcerate and turn into granulomas
o Syphillis
o Primary: painless genital chancre
o Secondary: rash on palms & condyloma lata on genitals
o Tetiary: gummas (granulomas), tabes dorsalis, syphillitic aortitis
o Cellulitis
o MCC = strep pyogenes
o Erysipelas
o Rapid o/s, sharply defined borders
o MCC = strep pyogenes
o Abscess = staph aureus
o Necrotizing fasciitis
o 2 MCC = strep pyogenes & clostridium perfringens
o Pain out of proportion
o Gas gangrene → C. perfringens
o Tetanus algorithm
o Clostridium tetani
o Greater than 3 vaccines in their life?
o Is wound clean or dirty?

o If pt does have tetany → can give diazepam to help reduce ms spasms

o Septic arthritis & osteomyelitis
o Know common bugs (they are the same for both^^!) →
▪ Normal person = staph aureus
▪ Sickle cell anemia = salmonella
▪ IVDU = pseudomonas
o Sx septic arthritis: fever, leukocytosis, inability to bear weight on joint
o Swollen red joint
 ▪ Next best step? → aspirate or arthrocentesis to r/o septic arthritis
• > 50 WBC = + diagnosis for septic arthritis
o Lyme disease
o Borrelia burgdorferi ixodes tick
o Starts with target rash (erythema migrans)
o First step → what treatment?
▪ > 8 yo: doxycycline
▪ < 8 yo: amoxicillin
• Bc tetracycline can cause teeth discoloration/bone deformities
o Malaria
o Usually will have a recent travel history to india or africa
o Can tell the difference btw species based on cyclical fever cycles:
▪ P falciparum: CONSTANT fevers
▪ P vivax/ovale: fever q48 hr (2 days)
• Also have hypnozoites that go dormant in liver!
▪ P malariae: fever q72 hr (3 days)
o Pt will have evidence of RBC hemolysis
o Tx: mefloquine
▪ Need to add primaquine to kill off liver hypnozoites in P vivax & ovale
o Treatment of rabies
o Irrigate wound, give Ab & vaccine
o Presents w/ hydrophobia, encephalopathy → at this stage it is too late and probably
fatal
o MCC = bat bite!
o Cat scratch disease (Bartonella hensalae)
o Presentation: distal cat scratch with proximal lymphadenitis
o Tx: macrolide or doxycycline
o Aspergillus
o ABPA
▪ Asthma + eosinophilia
o Aspergilloma
▪ Hemoptysis + chronic cough
▪ Fungus ball on upper lobe
o Invasive aspergillus
▪ Systemic disease
• Fever, leukocytosis, hemoptysis
▪ Classic “halo” sign = pulmonary nodule w/ surrounding ground glass opacity on
CT scan
▪ Tx: amphotericin
o Dimorphic fungi
o “His Coc Blasts Spores”
▪ Histoplasma
• Bats & caves
• BL hilar adenopathy
 ▪ Coccidiodes
• West coast
• UL hilar LAD
▪ Blastomyces
• Midwest
• Purple skin lesions w/ PNA
▪ Sporothrix
• Rose gardener
• Lymph chain of lymphadenitis
• Tx: atraconazole or KI
o Hookworms = in thru feet walking on SANd → lungs → cough, swallow → GIT
o Eosinophilia! (MBP help lyse worms)
▪ Strongyloides
▪ Ancylostoma
▪ Necator
o Enterobius vermicularis
o Anal pinworm, young kid with itchy butthole. Scotch tape test
o Tx: abendazole
o Tapeworm
o Taenia solium → pork
o Taenia sagina → beef
o D. latum → fish
o Tx: praziquantal
o Schistosoma haematobium: SNAIL!
o Middle eastern person with hematuria (worm deposits eggs in bladder wall) and
eosinophilia
o TSS = toxic shick syndrome
o Shock & nosebleed (with plug) or tampon
o Desquamation
o Staph aureus exotoxin = super Ag → cytokine storm
o Tx: IVF & vancomycin
o Neutropenia = ANC < 1500
o Neutropenic fever treat empirically for pseudomonas until proven otherwise with pip-
tazo
o Gastroenteritis
o Watery: rotavirus, norovirus, ETEC (recent travel to S. America)
o Bloody: EHEC, campylobacter, salmonella, shigella, yersinia
▪ Febrile
▪ Best next step? Stool analysis for WBC
• +WBC
o Next best step? Stool culture
o Diarrhea is really only treated symptomatically. You only treat if they are really young,
really old or IC pt.
▪ Inflammatory diarrhea abx = FQ
 ▪ NEVER GIVE PT ABX FOR EHEC → PREDISPOSES THEM TO DEVELOPING HUS!
o Pt taking abx then gets diarrhea → C diff colitis
o Best next step = C diff toxin

DERMATOLOGY

o Acne is treated in tiers

o 1st line: topical benzoyl peroxide or topical retinoid
o 2nd line: topical abx
o 3rd line: oral abx
o 4th line: accutane (isotretinoin) → pt MUST be on 2 forms of contraceptive

o Rosacea
o Middle age woman w/ flushed red face that kinda looks like sunburn + acne/malar rash
o Tx: metronidazole
o Assoc w/ ocular problems
o Keratoacanthoma
o Grows really fast, pt gets concerned. What do you do?
▪ Reassure bc it will go away on own
o Seborrheic dermatitis
o Scales, greasy, flakey skin over nasal/labial folds or on hairline
o Tx: selenium sulfide shampoo or -azoles
o Assoc w/ HIV & parkinsons!
o Contact dermatitis
o T4HS reaction
▪ Latex allergy, poison ivy
▪ Itchy
o Tx: topical steroids
o Pityriasis rosea
o Starts w/ herald patch, then you get christmas tree pattern of macules/papules
o Not contagious
o Tx: antihistamines
o Erythema muliforme
 o On spectrum of TEN & SJS
o TARGET LESIONS
o Caused by sulfa drugs/HSV
o SJS lesions cover < 30 % BSA
o Causes = APPLE PCS
▪ A = Allopurinol
▪ P = Phenytoin
▪ P = Phenobarbitol
▪ L = Lamotrigine
▪ E = Ethosuximide
▪ P = Penicillin
▪ C = Carbamazepine
▪ S = Sulfas
o **called TEN if lesions cover > 30% BSA**
o Bullous pemphigoid vs Pemphigus vulgaris
o Pemphigus vulgaris
▪ Ab against desmisomes
▪ Open blisters, oral mucosal lesions
o Bullous pemphigoid
▪ Ab against hemidesmosomes
▪ Tense blisters
o Tx both with PO steroids
o 65 yo → get zoster vaccine to prevent herpes zoster reactivation within the DRG (shingles)
o Dermatophytes
o Tinea capitus, cruris, corporis, pedis
▪ Capitus → tx ORAL griseofulvin
▪ Rest of tineas → tx topical -azoles
o Scabies
o Contact – people living together
o SUPER itchy; worse at night
o Burrows/tracts under the skin. Common in btw finger webs.
o Tx: topical permethrin for everyone in the family and then wash all the laundry!
o Actinic keratosis
o Elderly person who worked outside for their whole life
o Scaly lesion on the head or arms
o Tx: topical 5-FU
o Need to bx, dt increased risk of transforming to SCC
o Basal cell Ca vs Squamous cell Ca
o Basal cell Ca
▪ Pearly telangiectasias!
o Marjolin ulcer
o Chronic, nonhealing wound (diabetic)
▪ Over decades
o Can progress to SCC
AMBULATORY/BONUS

o Anaphylaxis
o Wheezing, hives, SOB, HoTN
o Best next step? IM epinephrine
o Retinal artery occlusion: cherry red macula

o Retinal vein occlusion: blood & thunder retina

o Pediatriac cherry red macula: tay sachs (hexosaminadase A) & niemann pick (sphingomyelinase)
o Niemann pick also has hepatomegaly!
o CKD or DM w/ proteinuria → 1st line = ACEi
o Angiotensin (constrict eff arteriole → increase glomerular filtration)
▪ By blocking Ang → decrease GFR → decrease protein filtered thru glomerulus
o Best at lowering TG = fibrates!
o Only want to use fibrates when TG > 1000
o Also, hypertriglyceridemia can cause pancreatitis
o Best at increasing HDL = niacin
o First line for HLD = statin
o 4 groups of people get statins:

o First line for cluster headache (UL eye pain & weeping, UL runny nose) = oxygen
o Prophylaxis = CCB (verapamil)
o Treatment for tension headache (BL, bandlike MSK issue) = supportive
o Migraine (UL, pounding, N/V, aura)
o The aura might look like a stroke
▪ Key sign = age!
• Young → probs migraine
 o Treatment: severe/refractory migraine
▪ Sumatriptan (5HT agonist)
o Prophylaxis: BB or TCA
o Post-nasal drip
o Can cause upper airway reactive syndrome
▪ Cough
• 1st line = antihistamine
o Allergic rhinitis: constant runny nose
o 1st line = intranasal steroids
o Bloody stools + fever
o Next step?
▪ Stool WBC
• If +
o Stool culture
• If –
o Symptomatic treatment
o If you suspect C diff
o Next best step?
▪ C diff toxin
o Bowel obstruction
o Next best step?
▪ Abdominal Xray
• **anything acute going on with abdomen, want to get Xray to give you
more info & more importantly, to r/o pneumoperitoneum (free air
under diaphragm = surgical emergency)
o IBS = alternating constipation & diarrhea that is alleviated with defectation
o Interstitial cystitis
o All sx of UTI = dysuria, increased urgency/frequency
o UA negative &/or Abx didn’t work
o BUT, sx improve with urination…
o Disc herniation vs spinal stenosis
o Position!
▪ Flexion
• Worse for disc herniation
• Better for spinal stenosis
▪ Extension
• Better for disc herniation
• Worse for spinal stenosis
o Disc herniation best next step = supportive therapy
▪ Physiotherapy & analgesic treatments
▪ Don’t do MRI yet bc disc herniation sx can resolve
• BUT, if the sx continue for 6+ weeks or pt develops scary neurological sx
like incontinence, then you order the MRI
o Indications for MRI of spine
 o Cauda equina syndrome
▪ LMN deficits = hyporeflexia, flaccid paralysis, incontinence, fasiculations,
decreased anal sphincter tone, saddle paresthesia
o Epidural abscess dt seeding from infection
▪ Fever, point tenderness & neurological tenderness
o Metastatic cancer back pain
o Point tenderness, back pain very bad at night
o 1st line = Xray!
o Tx: opioids & radiation
o Osteoarthritis
o RISK FACTOR = OBESITY! (BMI > 30)
o Worse w/ use
▪ Vs RA (improves throughout day)
o Tx: analgesics & lose weight
o Osteoporosis
o DEXA scan @ age 65
▪ T score < -2.5 = osteoporosis
• 1st line = bisphosphonates
• Vit D, Ca2+ supplements & weight-bearing exercise
▪ T score -1 to -2.5 = osteopenia
o Open angle glaucoma
o Closed angle glaucoma
o DANGEROUS = acute closed angle glaucoma
▪ Presents w/ a “ROCK HARD EYE”
• Non-reactive pupils
• Very painful red eye
• Pt can only see halos
o MIOSIS HELPS!
▪ Stretch out iris, opens trabecular meshwork allowing for aq humor outflow
▪ Pilocarpine (muscarinic agonist)
o Can also give BB (decrease aq humor production, specifically B2)
o Blepharitis
o Inflammation of eyelid
o Crusting over eyelid in AM
o Peds
o MCC = staph aureus
o Tx: clean eye w/ warm water in morning and using warm compress
o Bacterial conjunctivitis
o Purulent discharge from eye
o MCC – staph aureus
o Tx: abx (macrolide for pus! = erythromycin)
o 1st line tx for obesity = lifestyle modification
o If this does not work; 2nd line = orlistat (pancreatic lipase inhibitor)
o Indications for bariatric surgery
o INCONTINENCE
o Stress: multiple pregnancies, older age
▪ Dt internal urethral sphincter falling below pelvic diaphragm muscles
• Increased pressure (w/ valsalva = cough, sneeze) → pee bc bladder
compresses but the internal urethral sphincter is no longer above the
pelivc diaphragm to also be compressed
▪ Urethral hypermobility with Q tip test

▪ 1st line = kegel

▪ 2nd line = pessary

▪ 3rd line: mid-urethral sling

o Overflow: neurogenic bladder
▪ Seen in diabetic pts, spinal cord injury, recent surgery and bladder stunning
▪ 1st line: intermittent self cath
▪ 2nd: bethanechol: muscarinic agonist
o Urge: random spasms of the bladder
▪ 1st line: bladder training exercise
▪ 2nd line: meds to relax detrusor ms
• Oxybutyrin: muscarinic antag
o Alcoholism
o Treatment:
▪ Naltrexone
▪ Acamprosate
o Smoking cessation
o 1st line: nicotine gum/patch
o Varenicline (Chantix): partial nicotinic Ach-R agonist. AE: suicide ideations
o Bupropion (Wellbutrin) CI: bulemia, alcoholics dt decreased seizure threshold
o Colon cancer screening (colonoscopy)
o Starts @ age 50, q 10 yrs. Stop @ age 75
o If you find polyp, repeat screen in 3 yrs
▪ Worst polyp = villous adenoma
o If family member had colon cancer at age < 60 yo, need first colonoscopy at age 40 or 10
years prior to when family member was diagnosed (whatever comes first)
o Pap smears
o Start at age 21, end at age 65
o Occur q 3 yr
o HIV testing occurs in sexually active people ages 15-65
o Mammograms start at age 40 and you get one every year
o DEXA scan starts at 65 yo
o AAA screening starts 65 yo in male that ever smoked cigarettes
o 60 yo = pneumovax & zoster vaccine
o Lung cancer screening: 55 yo in anyone that had 30 PPY hx within last 15 yrs or who currently
smokes
o Chlamydia and gonorrhea screening in all women < 24 yo who are sexually active
o Hep A & B vaccine in MSM, IDVU, hep C or chronic liver disease bc hep A or B infections
superimposed on pre-existing liver disease is super bad
o Having a cold or fever is not CI for getting vaccine
o Breastfeeding is ok if you got vaccine
o But don’t breastfeed if you have HIV, getting chemo or are a drug user
o All military or college people should get the meningococcal vaccine
o Cephalosporins are LAME. They cannot treat
o Listeria
o Atypical PNA
o MRSA
o Enterococcus
o Metronidazole treats: “GET GAP on the Metro”