USMLE Step 2 CK Quick Notes
Cardiology
Clinical features of Marfan syndrome
| Skeletal | arachnodactyly upper:lower body segment ratio arm:height ratio pectus deformity, scoliosis/kyphosis joint hypermobility |
| Ocular | ectopia lentis (lens subluxation) |
| Cardio | aortic dilation, regurgitation, dissection MVP |
| Pulmonary | spontaneous pneumothorax due to apical blebs |
Dermatology
| ▪ sunscreen: 30 min before exposure ▪ reapply every 2 hrs ➢ avoid sunscreen in infants < 6 months |
Emergency Medicine
Caustic ingestion
| features | chemical burn or liquefaction necros s results in: ▪ laryngeal damage: hoarseness, stridor, orofacial inflammation ▪ esophageal damage: dysphagia, odynophagia ▪ gastric damage: epigastric pain, GI bleeding |
| management | ▪ ABCs ▪ remove contaminated clothing, irrigate exposed skin ▪ upper GI XR with water-soluble contrast for suspected perforation ▪ CXR if respiratory symptoms ➢ upper endoscopy within 24 hr ▪ barium contrast (2 – 3 wks) |
| complications | ➢ esophageal strictures ➢ pyloric stenosis ▪ ulcers, perforation ▪ cancer |
| ▪ battery ingestion requires an XR ▪ batteries in the esophagus should be removed under endoscopic guidance to prevent mucosal damage & esophageal ulceration ▪ batteries distal to the esophagus need observation with stool exam or follow-up XR ▪ do not use NG tube or induce vomiting |
| ▪ avoid interventions that provoke vomiting (activated charcoal, milk, vinegar, NG lavage) ➢ in absence of perforation, upper endoscopy within 12 – 24 hr to assess damage & guide therapy |
| ▪ MCC blunt abdominal trauma: MVAs ▪ MC injured: liver & spleen o free peritoneal fluid should raise suspicion for liver or splenic laceration ▪ hemodynamically unstable & free intraperitoneal fluid on USS ◇ emergency laparotomy ▪ hemodynamically stable splenic lacerations & no evidence of other intra-abdominal injuries ◇ non-operative management |
| ▪ blunt abdominal trauma can cause splenic injury ▪ delayed onset hypotension, LUQ pain radiating to left shoulder 2/2 diaphragmatic irritation (Kehr sign) ▪ Dx: abdominal CT with contrast if hemodynamically stable ▪ hemodynamic instability despite IV fluids requires laparotomy |
| ▪ encephalopathy, ocular dysfunction, gait ataxia: Wernicke encephalopathy ▪ giving IV fluids containing glucose prior to thiamine can precipitate or worsen WE ➢ thiamine is given along with or before glucose |
Endocrine
| ▪ Diabetes Mellitus ➢ DM screening: sustained BP > 135/80 mmHg ▪ OGTT is preferred to screen glucose intolerance & DM Type II ▪ Dx: Type II DM ➢ 2 hr OGTT ≥ 200 mg/dL o fasting blood glucose > 126 o HbA1c ≥ 6.5% o random plasma glucose ≥ 200 |
| ➢ weight loss = most effective lifestyle intervention to reduce BP • DASH diet is the next most effective approach in prevent & treat HTN especially non-obese; then exercise, dietary sodium, alcohol intake • smoking causes a transient rise in BP |
Multiple endocrine neoplasia classification
| Type I | o Pituitary tumors o Primary hyperPTH (90%) o Pancreatic/GI tumors (gastrinoma) |
| Type 2A (Sipple’s) | o Medullary thyroid cancer (MTC) o Pheochromocytoma o Parathyroid hyperplasia |
| Type 2B | o MTC o Pheochromocytoma o Mucosal neuromas o marfanoid habitus |
| ▪ MEN1 pancreatic tumors: gastrinoma, insulinoma, glucagonoma, VIPoma o gastrinoma causes recurrent peptic ulcers |
| ▪ early-onset HTN, progressive renal insufficiency, gross hematuria, flank pain, B/L abdominal masses Dx ▪ central obesity, facial plethora, proximal weakness, abdominal striae, ecchymosis: Cushing’s ▪ headaches, palpitations, diaphoresis a/w paroxysmal BP elevations: pheochromocytoma o urinary vanillylmandelic acid, & metanephrines |
| ▪ high serum & low urine osmolality due to inadequate ADH response is most likely due to lithium-induced nephrogenic DI ▪ Lithium induces ADH resistance, resulting in acute-onset nocturia, polyuria, & polydipsia ▪ hypovolemic hypernatremia ▪ Rx: discontinue lithium; salt restriction & diuretics (amiloride: K+ sparing diuretic) ▪ Rx: hemodialysis for lithium level ˃ 4 mEq/L or ˃ 2.5 mEq/L + signs of toxicity or renal disease |
ENT
| ▪ allergic rhinitis: rhinorrhea, nasal pruritus, cough; nasal mucosa is edematous & pale; polyps ▪ nasal furunculosis: 2/2 staphylococcal folliculitis due to nose-picking or hair plucking o pain, tenderness, erythema in nasal vestibule o life-threatening if spreads to cavernous sinus |
GastroIntestinal
| ▪ Ulcerative colitis: MC in females, Ashkenazi Jew, peak @ age 15 – 25 ▪ MC site: rectum, confined to mucosal layer ▪ bloody diarrhea, tenesmus, pseudopolyps ▪ severe disease: weight loss, fever, or anemia ▪ +p-ANCA ▪ confirm Dx: friable mucosa on colonoscopy & biopsy with mucosal inflammation ▪ extraintestinal: erythema nodosum, uveitis, sclerosing cholangitis, spondyloarthropathy ▪ complications: toxic megacolon & colorectal ca ▪ surveillance: annual colonoscopies beginning at 8 – 10 yrs after Dx for colon cancer detection o colonic dysplasia is a/w progression to adenocarcinoma; Rx: total colectomy |
| ▪ chronic inflammatory diarrhea (< 4 wks): anemia, weight loss, ◇ ESR, acute phase reactants, reactive thrombocytosis, +occult blood/leukocyte stool |
| ▪ acute pancreatitis can cause unilateral, left-sided pleural effusion with high amylase concentration, but not widened mediastinum |
| ➢ young patient, aphthous ulcer, chronic diarrhea, abdominal pain, weight loss: Crohn’s ▪ non-caseating granulomas, “cobblestone”, transmural inflammation, skip lesions, creeping fat, non-lymphoid aggregates ▪ MC site: terminal ileum; rectum is spared ▪ chronic GERD with new dysphagia & symmetric LES narrowing: esophageal stricture ▪ body’s reparative response to chronic acid exposure ▪ other causes: radiation, systemic sclerosis, caustic ▪ Dx: endoscopic biopsy to r/o adenocarcinoma ▪ DDx: adenocarcinoma (asymmetric narrowing), hiatal hernia, achalasia (aperistalsis) |
| ▪ age > 60, dysphagia, regurgitation, halitosis, cough, variable neck mass: Zenker diverticulum ▪ most important pathogenic factor in development of Zenker: motor dysfunction ▪ develops above the upper esophageal sphincter, with posterior herniation between cricopharyngeal muscle fibers ▪ risk for aspiration pneumonia ▪ Dx: barium esophagram ▪ Rx: excision, cricopharyngeal myotomy |
| Mallory-Weiss | Boerhaave | |
| etiol. | mucosal tear 2/2 forceful retching; submucosal arterial or venule plexus bleeding | transmural tear 2/2 forceful retching; esophageal perforation with air/ fluid leakage |
| feat. | vomiting, retching epigastric pain hematemesis | vomiting, retching, retrosternal pain, WBC odynophagia, fever, dyspnea, or septic shock subcutaneous emphysema |
| Dx | EGD endoscopy | CT or contrast esophagography with Gastrografin CXR: pneumo- mediastinum & exudative pleural effusion (low pH, high amylase) |
| Rx | self-limited; endoscopic Rx as needed (clipping or coagulation) | cervical perforations: conservative measures thoracic perforations: surgery |
| ▪ spontaneous esophageal rupture after severe retching/vomiting: Boerhaave’s ▪ CXR: left-sided pleural effusion with/without pneumothorax, subcutaneous emphysema, & widened mediastinum ▪ exudative pleural fluid: low pH, high amylase (>2500 IU) ▪ Dx: CT or contrast esophagogram w/ Gastrografin (water-soluble contrast) |
Hematology
Microcytic/Hypochromic anemias
| Iron-def anemia | ferritin, TIBC |
| Thalassemias | normal/ serum iron & ferritin |
| Anemia of chronic disease | ferritin & transferrin, TIBC |
| Sideroblastic anemia | normal/ iron & ferritin, TIBC |
| ▪ iron deficiency: 2/2 ◇ intake or ◇ blood loss o ◇ RDW, ◇ reticulocyte count ▪ thalassemia or hemaglobinopathies: ◇ globin production & elevated HbA2 o ◇ reticulocyte count & total bilirubin 2/2 hemolysis ▪ anemia of chronic disease: defective utilization of storage iron, due to suppression of RBC production by inflammatory cytokines o ◇ ferritin = ongoing inflammation ▪ lead poisoning or sideroblastic anemia: reduced heme synthesis ▪ hemochromatosis: ◇ intestinal iron absorption & deposition o ◇ iron, ferritin, & transferrin, ◇ TIBC |
| ▪ RA, moderate anemia, low serum iron, low TIBC, ◇ transferrin: anemia of chronic disease ▪ a/w chronic inflammatory diseases (RA) ▪ iron trapping within macrophages, leads to poor iron availability for Hb synthesis ▪ low reticulocyte count ▪ Rx underlying cause can improve anemia |
| ▪ exertional dyspnea, fatigue, pale conjunctiva ▪ iron deficiency is MCC of microcytic anemia ▪ iron studies confirm Dx |
Infectious Diseases
Cryptococcal meningoencephalitis
| Features | develops over 2 weeks (subacute)… headache, fever, malaise, vomiting, altered mental status, B/L papilledema more acute & severe in HIV (CD4 ˂100) |
| Dx | CSF features… ➢ high opening pressure ▪ low glucose, high protein ▪ WBC ˂ 50/μL (mononuclear predominance) ▪ cryptococcal antigen positive ▪ transparent capsule on India ink ▪ culture on Sabouraud agar |
| Rx | initial: amphotericin B with flucytosine maintenance: fluconazole |
| ▪ serial LPs may be required to reduce ◇ ICP ▪ antiretroviral therapy should be deferred at least 2 weeks after completing induction antifungal therapy for cryptococcal meningitis o initiating retroviral therapy with acute infection ◇ risk of immune reconstitution syndrome ▪ itraconazole does not cross the BBB |
| ➢ best method of reducing maternal-fetal transmission of HIV infection: triple HAART therapy for the mother throughout pregnancy ▪ HAART: dual NRTI + NNRTI or protease inhibitor ▪ test viral load monthly until undetectable, then every 3 months; CD4 cell count every 3 months ➢ avoid amniocentesis until viral load undetectable ▪ mothers with undetectable viral loads at delivery have ˂ 1% risk for transmission ▪ intrapartum mother not on HAART: Zidovudine ▪ intrapartum viral load > 1000 copies/mL: Zidovudine + C-section ▪ infants: Zidovudine for ≥ 6 wks & serial HIV PCR testing |
| ▪ > 2 weeks of persistent, high-volume, non-bloody watery diarrhea after recent travel; no fever, tenesmus or vomiting: Cryptosporidium parvum ➢ travel-associated diarrhea > 2 weeks; parasitic o cryptosporidium cystoisospora, microsporidia, Giardia ▪ diarrhea < 1 week: viral or bacterial o rotavirus/norovirus: vomiting o ETEC/EPEC: contaminated food/water o Campylobacter: abdo pain, bloody diarrhea, “pseudoappendicitis” o Salmonella: frequent fever o Shigella: fever, bloody diarrhea, abd pain |
| ▪ Entamoeba histolytica causes amebiasis, resulting in abdo pain & bloody diarrhea |
| ▪ primary features of Chagas disease: recent immigrant from Latin America with chronic megacolon/megaesophagus & cardiac disease (CHF: pedal edema, JVD, S3, cardiomegaly) ▪ systolic & diastolic heart failure, RBBB ▪ Rx: benznidazole or nifurtimox |
| ▪ painless vesiculopustular rash, tenosynovitis, & migratory polyarthralgia: disseminated gonococcal infection ▪ 2 – 10 skin lesions similar to furuncles or pimples ▪ Hx of recent unprotected sex with a new partner ➢ all patients should undergo HIV screening |
| ➢ early Lyme disease: erythema chronicum migrans ▪ also a/w headache, malaise, fatigue, fever ▪ unilateral Bell’s palsy ▪ early Dx is based on trademark rash & recent travel ▪ MCC: B. burgdorferi (spirochete) ▪ Rx: oral doxycycline (age > 8) ➢ Rx: oral amoxicillin (age < 8, pregos, or lactating) or cefuroxime ▪ doxycycline A/E: permanent tooth discoloration & skeletal retardation in children & fetuses |
| ▪ Eikenella corrodens: G-negative anaerobe part of normal oral flora o infective endocarditis due to E. corrodens is seen in poor dentition, periodontal infection, or manipulative dental procedures o E. corrodens belongs to the HACEK group ▪ congenital heart lesions (bicuspid aortic valve, PDA, ToF, VSD) predisposes to risk of IE ▪ ulcerative colon lesions due to colonic neoplasia or inflammatory bowel disease predisposes to IE due to Strep gallolyticus (S. bovis type I) ▪ S. aureus is the MCC of IE among IVDA ➢ Enterococci (E. faecalis) MC endocarditis a/w nosocomial UTIs |
| ➢ bone marrow transplant recipient with lung & interstitial involvement: CMV pneumonitis ▪ develops 2 wks – 4 months post-transplant ▪ CXR: multi-focal, diffuse patchy infiltrates ▪ high-resolution CT: parenchymal opacification or multiple small nodules ▪ Dx: bronchoalveolar lavage |
| ▪ firm, flesh-colored, umbilicated, dome-shape plaques on trunk, limbs, anogenital areas; spares palms/soles: molluscum contagiosum (poxvirus) ▪ MCC due to sexual contact MC occur on genitalia, lower abdomen, inner thighs ▪ transmitted: skin-skin or fomites ▪ self-limited, localized infection ▪ linear pattern due to spread 2/2 scratching ▪ MC a/w cellular immunodeficiency (HIV), corticosteroid use, chemotherapy ▪ DDx: HSV-1 (vesicular eruption), HPV (verrucous papules), Staph (furuncles, carbuncles) |
| ▪ Pinworm infection: erythematous vulvovaginitis in prepubertal females; absence of vaginal discharge ▪ recurrent episodes of nocturnal itching should be examined with “Scotch tape” test ▪ empiric Rx: mebendazole |
| ▪ fever, headache, N/V, petechial rash, stiffness, & photophobia: meningococcemia ▪ fever, arthralgia, sore throat, lymphadenopathy, mucocutaneous lesions, diarrhea, weight loss: acute HIV infection ▪ migratory arthritis of large joints, carditis, erythema marginatum (raised ring-shaped lesions over trunk & extremities), subcutaneous nodules, Sydenham chorea: acute rheumatic fever o pharyngitis precedes onset by 2 – 4 wks |
| ▪ sulfadiazine–pyrimethamine: Rx cerebral toxo (headache, focal neurologic deficits, seizures); multiple ring-enhancing lesions with edema |
| ▪ CMV retinitis: MC when CD4 < 50 o yellow/white patches of retinal opacification & hemorrhages o Rx: ganciclovir or foscarnet |
| ▪ HSV encephalitis: cognitive & personality changes, focal neurologic deficits; temporal lobe hemorrhage |
| ▪ PML: JC virus detected on PCR of CSF, patchy areas of white matter due to demyelination o focal neurologic deficits; no mass effect o hemiparesis; speech, vision, & gait dysFx o no cure; 6 month survival |
| ▪ mononucleosis-like symptoms, atypical lymphocytes, negative Monospot: CMV mono ▪ absence of pharyngitis & lymphadenopathy ▪ large basophilic lymphocytes with a vacuolated appearance |
| ▪ +HIV, bloody diarrhea, normal stool: CMV colitis ▪ typically CD4 < 50 cells/μL ▪ Dx: colonoscopy multiple ulcers, mucosal erosions ▪ biopsy: large cells with eosinophilic intranuclear & basophilic intracytoplasmic inclusions ▪ Rx: ganciclovir (or Foscarnet) ▪ complications: toxic megacolon |
Duke Criteria for Infective Endocarditis
| Major Criteria | Minor Criteria |
| 2 positive blood culture for typical IE organisms (strep viridans or bovis, S. aureus, enterococcus HACEK) | Vascular phenomena: systemic arterial emboli, pulmonary infarcts, mycotic aneurysms, Janeway lesions, conju hemorrhages |
| Echocardiogram with oscillating intracardiac mass on valve | Immunologic phenomena: glomerulonephritis rheumatoid factor, Osler nodes, Roth spots |
| Dx : 2 Major, 0 Minor Dx : 1 Major, 3 Minor Dx : 0 Major, 5 Minor | predisposing heart condition or IVDA fever: > 38.0° C (100.4°) |
Endocarditis overview
| risk factors | poor dentition, congenital heart disease, valve abnormalities (MVP, MR), IVDA, intravascular catheters |
| features | subungal hemorrhages, petechiae,Janeway lesions, Osler’s nodes, Roth spots, splenomegaly, mitral valve disease (MVP, MR) |
| labs | positive blood cultures, WBCs, glomerulonephritis, septic emboli |
| Rx | vancomycin (initially), based on cultures |
| ▪ Staph aureus is MCC of healthcare-associated infective endocarditis (S. epidermidis) o prosthetic valves, indwelling catheters, IVDA, implanted devices (pacemakers, defibrillators) ▪ Streptococci is MCC of community-acquired IE o viridans strep: S. sanguinis, S. mutans o after dental procedures or procedures involving incision/biopsy of respiratory tract ▪ Enterococci: E. faecalis: a/w nosocomial UTIs ▪ Strep bovis: S. gallolyticus o colon cancer & inflammatory bowel disease risk factors |
| ▪ Janeway lesions: macular, erythematous, nontender lesions of palms/soles ▪ Osler’s nodes: painful, violaceous nodules on fingertips/toes ▪ Roth spots: edematous, hemorrhagic retinal lesions |
| ▪ blood cultures from 2 separate venipuncture sites for suspected IE prior to initiating ABX |
Acute rheumatic fever
| epidemiology | MC in females, age 5 – 15 yrs MCC: group A Strep pharyngitis precedes onset of ARF by 2 – 4 wks |
| Major criteria (“J♥NES”) | o Joints (migratory arthritis) o ♥ (carditis, mitral stenosis) o Nodules (subcutaneous) o Erythema marginatum o Sydenham chorea |
| Minor criteria | fever, arthralgias, elevated ESR/CRP prolonged PR interval |
| late features | mitral regurgitation/stenosis |
| prevention | PCN (regardless of +/- pharyngitis) |
| ➢ Dx: 2 major, or 1 major + 2 minor criteria ▪ supportive findings: ASO titer, Strep antigen test ▪ DDx: SLE, Henoch-Schonlein, Juvenile arthritis ▪ Hx of rheumatic fever increases risk of recurrence & progression of rheumatic heart disease ▪ Dx: continuous ABX prophylaxis to prevent recurrent group A Strep pharyngitis |
ABX prophylaxis for rheumatic fever (RF)
➢ IM benzathine PCN G every 4 wks
| RF without carditis | 5 yrs or until age 21 |
| RF with carditis, but no heart or valvular disease | 10 yrs or until age 21 |
| RF with carditis & persistent ♥ or valve dz | 10 yrs or until age 40 |
Neonatal conjunctivitis etiologies
| Onset | Features | Rx | |
| Chemical | ˂ 24 hrs | mild conjunctival irritation/ injection & tearing after silver nitrate ophthalmic prophylaxis | eye lubricant |
| Gonococcal | 2 – 5 days | eyelid swelling, purulent exudate, corneal ulceration | IV or IM ceftriaxone or cefotaxime |
| Chlamydia | 5 – 14 days | eyelid swelling; chemosis; watery or mucopurulent discharge | oral erythromycin |
| ➢ best way to prevent neonatal chlamydial & gonococcal conjunctivitis: screen, Dx, Rx pregos ▪ screen for chlamydia @ 1st & 3rd prenatal visit ▪ maternal infection may be asymptomatic |
| ▪ ceftriaxone should be avoided in infants with hyperbilirubinemia ◇ displacement of bilirubin from albumin-binding sites, ◇ risk of kernicterus ▪ oral erythromycin: Rx chlamydial conjunctivitis & pneumonia o risk of infantile hypertrophic pyloric stenosis ➢ topical erythromycin: prophylaxis for neonatal gonococcal conjunctivitis; regardless of screening ▪ topical silver nitrate: prophylaxis against penicillinase-producing strains of N. gonorrhea (not available in the US) ▪ nasolacrimal duct obstruction (dacryostenosis): unilateral chronic tearing & minimal conjunctival injection; Rx massage nasolacrimal ducts |
| ▪ neonatal gonococcal conjunctivitis: acquired through infected genital secretions ▪ prophylaxis: erythromycin ophthalmic ointment ▪ Rx: IV or IM ceftriaxone or cefotaxime ▪ complications: corneal ulcers, scarring, blindness |
Internal Medicine
Hemodynamic measurements in shock
| Normal mmHg | Hypovolemic shock | Cardiogenic shock | Septic shock | |
| RA pressure (preload) | 4 | nrml or | ||
| PCWP (preload) | 9 | nrml or | ||
| Cardiac index (pump function) | 2 – 4 L/m m^2 | |||
| SVR (afterload) | nrml or | |||
| Mixed venous O2 saturation |
| ▪ serum Na+ should be corrected by 0.5 mEq/dL/hr, as cerebral edema can result if too rapid |
| ▪ hypotension, tachycardia, flat neck veins, confusion, & cold extremities despite IV fluid resuscitation: hypovolemic/hemorrhagic shock ▪ cardiogenic shock: decreased C.O. causes ◇ SVR, ◇ PCWP, venous filling pressures & JVD ▪ loss of vascular tone occurs in septic & neurogenic shock with compensatory ◇ C.O./index o less blood return: ◇ PCWP & SVR |
| ▪ intravascular volume loss leads to ◇ LV preload ◇ ◇ C.O. & systemic BP ◇ ◇ HR & SVR o ◇ pulmonary capillary wedge pressure (PCWP) measures of LA & LVED pressure ▪ cardiogenic shock leads to ◇ C.O. & BP o ◇ PCWP due to heart failure o ◇ HR & SVR maintains organ perfusion ➢ ◇ C.O. decreases tissue perfusion, thus signals tissues to extract more O2 ▪ vasodilatory/distributive shock, MC due to sepsis, anaphylaxis, SIRS, or CNS injury o peripheral vasodilation ◇ ◇ SVR & BP, with compensatory ◇ HR & C.O. o hyperdynamic circulation, which decreases organ perfusion ◇ ◇ venous O2 saturation o as sepsis progresses ◇ vasoconstriction is a/w ◇ SVR & ◇ C.O. |
Neurology
Spinal Cord Compression
| causes | spinal injury (MVA), disk herniation, malignancy (lung, breast, pro M), infection (epidural abscess) |
| features | gradual, severe focal back pain; pain worse when recumbent & at night early: B/L LE weakness, absent DTRs, flaccid paraplegia late: B/L +Babinski, absent rectal tone, paraparesis with decrease DTRs, sensory loss, bladder dysfunction, urinary retention |
| manage | high-dose IV glucocorticoids, emergency spinal MRI, radiation-oncology, neurosurgery consult |
| ▪ chemotherapy-induced peripheral neuropathy from vincristine (also cisplatin, paclitaxel) begins after several weeks ▪ symmetric paresthesia in fingers/toes, spreads proximally in stocking-glove pattern ▪ loss of ankle jerk reflexes, pain/temp sensation, occasional motor neuropathy (B/L foot drop) |
| ▪ sudden onset C/L lower extremity motor & sensory deficits with UMN signs, urinary incontinence: anterior cerebral artery (ACA) occlusion ▪ MCC: ischemic stroke |
| ▪ pain worse on recumbent due to distension of epidural venous plexus |
| ▪ anterior spinal cord infarct: abrupt onset flaccid paralysis, loss of pain & temp sensation (anterior spinal artery), & autonomic dysfunction |
| ▪ normal aging: stage 4 sleep (deep sleep) becomes shorter & eventually disappear |
| ▪ dizziness, “spinning sensation” with nausea: vertigo ▪ vertigo classification: central or peripheral o peripheral vertigo has a shorter interval o ear fullness suggests peripheral vertigo o CN VIII lesions lead to central vertigo ▪ vertigo with a sensation of ear fullness suggests Meniere’s disease, from abnormal accumulation of endolymph in the inner ear ➢ tinnitus, vertigo, sensorineural hearing loss |
| ▪ child with severe headache of gradual onset a/w N/V, photophobia, visual aura: migraine ▪ most common form of headache < age 20 ▪ migraines in children are often bifrontal & shorter duration than adult migraines ▪ Rx in < age 12: supportive (dark, quiet room, & cool cloth on forehead), acetaminophen or NSAID (ibuprofen) ▪ alternative Rx: triptans |
| ▪ indications for neuroimaging in a child with headache: Hx of coordination difficulties, tingling, numbness, focal neurologic signs; headache that awakens from sleep, ◇ headache frequency |
OBGYN
| ➢ HPV vaccine for all girls/women age 9 – 26 (except pregos) regardless of HPV status or sexual activity (also immunocompromised) ➢ all boys/men age 9 – 21 ▪ routine HPV screening (Pap) should not begin prior to age 21, regardless of sexual activity ➢ **sexually active women age < 21 can be HPV+ & develop cervical dysplasia that is transient with regression within 2 yrs o thus no Pap smear ➢ age 21 – 29: cytology every 3 years ▪ routine HPV testing not for women age < 30 o HPV in most young women is transient, clearing within 2 years o age 30 – 65: cytology every 3 yrs, OR cytology + HPV testing every 5 yrs |
| ▪ hypotension, tachycardia, poor skin turgor, lethargy, confusion: hypovolemic hypernatremia o Rx: IV normal saline (0.9%) until euvolemic, then 5% dextrose |
| ▪ prostaglandin-only oral contraceptives are preferred for hormonal contraception for lactating mothers o does not affect volume or composition of milk produced, or risk of venous thrombosis a/w combination OCPs ▪ lactation causes anovulation, thus some degree of contraception due to high prolactin levels which inhibit GnRH release, but not reliable |
| ▪ atypical squamous cells of undetermined significance (ASC-US) is MC cervical cytological abnormality, but risk of invasive cervical cancer is low ▪ atypical squamous cells, cannot rule out high-grade squamous epithelial lesion (ASC-H) is a/w premalignant lesions ▪ ASC-US/LSIL in age 21 – 24: repeat pap in 1 yr o HPV infection is transient & malignant transformation is rare ➢ colposcopy only if ASC in 3 consecutive paps or ASC-H, atypical glandular cells, or HSIL • ASC-US in age ≥ 25: HPV testing o HPV positive ◇ colposcopy o HPV negative ◇ repeat pap & HPV in 3 yrs |
| ▪ sudden onset abdominal pain a/w vaginal bleed, fetal distress, loss of fetal station in active labor: uterine rupture o risk factors: pre-existing uterine scar, abdominal trauma, macrosomia o prior low transverse c-section: < 1% risk o prior vertical c-section: as high as 9% ▪ HTN & cocaine use: risk for placental abruption ▪ sinusoidal fetal HR tracing: vasa previa ▪ fever, tender uterus, foul-smelling lochia, progression to sepsis: endometritis o polymicrobial infection o Rx: IV clindamycin & gentamicin ▪ clindamycin for Gram+ & anaerobes ▪ gentamicin for Gram-negatives |
| High-grade squamous intraepithelial lesion (HSIL) ▪ age 21 – 24: colposcopy o if no CIN 2,3 ◇ repeat colposcopy & cytology @ 6-month intervals for 2 yrs ▪ age ≥ 25: LEEP (except postmenopause & pregos) ▪ pregos with HGSIL ◇ colposcopy o if colposcopy is negative ◇ repeat cytology & colposcopy @ 6 wks after delivery o 50% of HGSIL & CIN 2 or 3 regress spontaneously during pregnancy o no cervical biopsy or LEEP during pregnancy, unless colposcopy suggests invasive cancer |
Routine cervical cancer screening
| Immuno-compromised (HIV, SLE, organ transplant patients) | ▪ screen at onset of intercourse ▪ 6 months x2 then annual |
| Age ˂ 21 | No screening** |
| 21 to 29 | Pap (cytology) every 3 years |
| 30 to 65 | ▪ cytology every 3 years ▪ OR cytology + HPV test every 5 years |
| ≥ 65 | no screening if negative prior screens & not high-risk |
| Hysterectomy without cervix | no screening if no Hx of high-grade lesions, cervical cancer, or exposure to DES |
| ▪ amenorrhea > 3 months, hypoestrogenism, ◇ FSH, age < 40: premature ovarian failure ▪ may be secondary to accelerated follicle atresia or low number of primordial follicles ▪ MC is idiopathic; or a/w mumps, oophoritis, irradiation, chemotherapy, autoimmunity (Hashimoto’s, Addison’s, DM Type I, pernicious anemia) ▪ Dx: ◇ FSH/LH, hypo-estrogen o do not wait for 1 yr of amenorrhea for Dx ➢ early Dx prevents osteoporosis ▪ Rx: in vitro fertilization with donor oocytes |
| ▪ pulsatile GnRH agonists: induces ovulation ▪ progesterone: corrects luteal phase defect (failure of corpus luteum to produce progesterone to maintain the endometrium for implantation) |
| ▪ thin vaginal discharge, erythematous mucosa, motile pear-shaped organisms: trachomonal vaginitis ▪ Rx: metronidazole ▪ alcohol intake with metronidazole is a/w disulfiram-like reaction; acetaldehyde accumulates, causes flushing, N/V, hypotension |
| ▪ PCOS ▪ Dx for PCOS (≥ 2 criteria) o androgen excess (hirsutism, acne, alopecia) o olio- or anovulation o polycystic ovaries on USS o exclusion of other hyperandrogenic states ▪ Rx for PCOS ➢ weight loss ➢ combined OCPs: Rx hyperandrogenism & menstrual dysfunction, progestin ◇ risk of endometrial hyperplasia o clomiphene citrate: estrogen analog; induces ovulation with some ovulatory reserve o Metformin: promotes ovulation in PCOS prevented by insulin resistance; also for prevention or coexisting DM Type II ▪ Comorbidities of PCOS o obesity o insulin resistance/glucose intolerance/DM o dyslipidemia o OSA o endometrial ca risk 2/2 chronic anovulation |
| ▪ fetal distress (repetitive late decelerations) is an indication for emergent c-section |
Ophthalmology
| ▪ strabismus after age 4 months is abnormal & requires Rx to prevent amblyopia (vision loss from disuse of deviated eye) ▪ intermittent strabismus can be expected in infants < 4 months due to immaturity of extraocular muscles; reassurance & observation ➢ new onset strabismus can be a sign of retinoblastoma if accompanied by white reflex ▪ acute onset strabismus can result from intracranial hemorrhage, brain abscess, or encephalitis |
| ▪ first 5 years of life are critical to development of visual acuity, a time of visual cortex maturity ▪ esotropia beyond infancy must be treated to prevent amblyopia ▪ deviated eye can be strengthened by patching the normal eye (occlusion therapy) or blurring the normal eye with cycloplegic drops (penalization) |
Orthopedics
| ▪ avascular necrosis is a/w heavy alcohol use, SLE, chronic systemic corticosteroids, sickle cell disease |
| ▪ meniscal & ligamentous tears can both be a/w a popping sensation following precipitating injury ▪ meniscal injury: gradual joint swelling, 12 – 24 hr |
| ▪ ligamentous injury (ACL): rapid joint swelling & effusion due to hemarthrosis (ligaments have greater vascular supply than menisci, which rely on diffusion for nourishment) ▪ definitive Dx: MRI |
| ▪ Baker cysts: excess fluid produced by an inflamed synovium accumulates in popliteal bursa, results in a tender mass; a/w RA, osteoarthritis, cartilage tears ▪ Baker cyst rupture presents similar to DVT o cystic fluid leaks down the inner leg, results in a hematoma over medial malleolus (“crescent sign”) ▪ DDx: subcutaneous abscess, lymphedema |
| ▪ Osteitis fibrosa cystica (Von Recklinghausen disease of bone): due to hyperparathyroidism 2/2 parathyroid carcinoma ▪ excessive osteoclastic resorption, leads to replacement with fibrous tissue & bony pain ▪ XR: subperiosteal bone resorption, “salt-&-pepper” appearance of skull, bone cysts, & brown tumors of long bones |
| ▪ Paget’s disease of bone = osteitis deformans; due to osteoclast overactivity, leads to replacement of lamellar bone with abnormal woven bone |
| ▪ acute onset back pain after physical exertion, paravertebral tenderness, absence of radiation, negative straight leg raise test, normal neuro exam : lumbosacral strain o Rx: NSAIDs, early mobilization |
| ▪ acute back pain, local spinal tenderness, & decreased spinal mobility after minimal trauma, coughing, lifting: vertebral compression fracture ▪ worse with standing, walking, laying on back ➢ point tenderness, but normal neuro exam ▪ risk factors: postmenopausal or senile osteoporosis o also: steroid Rx, osteomalacia, osteomyelitis, trauma, bone mets, hyper-PTH, Paget’s o also: steroid Rx, osteomalacia, osteomyelitis, trauma, bone mets, hyper-PTH, Paget’s ▪ complications: risk of future fractures, hyperkyphosis (◇ respiratory capacity, risk of atelectasis, early satiety, weight loss) |
| ▪ stress fractures: MC in anterior middle third of the tibia in jumping sports & posteromedial distal third of the tibia in runners ▪ microfractures within cortical bone that coalesce ▪ risk factor: “female athlete triad” (◇ caloric intake, oligo-/amenorrhea, osteoporosis) ▪ MC site: 2nd metatarsal ▪ XR is normal initially, 6 wks ▪ Dx: MRI or bone scan ▪ Rx: rest & analgesia ▪ Rx: surgery for displaced fx or 5th metatarsal fx |
| Rhinoplasty ▪ complications following rhinoplasty: dissatisfaction, nasal obstruction, epistaxis ▪ nasal septum has poor blood supply & regenerating capacity, thus trauma or surgery may result in septal perforation ▪ presents as a whistling during respiration due to a septal hematoma following rhinoplasty |
Pediatrics
| PDA-dependent congenital heart disease |
| ▪ aortic coarctation ▪ transposition of great vessels ▪ hypoplastic left lung syndrome ▪ total anomalous pulmonary venous connection ▪ tricuspid atresia |
| ▪ normal ductus arteriosus constricts ~day 3 of life ▪ prostaglandin E1 keep ductus arteriosus open ➢ inspired O2 stimulates PDA constriction ▪ indomethacin is a potent prostaglandin inhibitor, stimulates PDA closure |
| • cephalohematoma: subperiosteal hemorrhage, does not cross suture lines; presents several hours after birth; resolves spontaneously ▪ Caput Succedaneum: diffuse, ecchymotic swelling of the scalp that Crosses Suture lines |
| ▪ child with a painful, solitary, lytic long bone lesion with overlying tender swelling & hypercalcemia: Langerhans histiocytosis ▪ locally destructive, but resolves spontaneously ▪ benign, Rx conservative |
| ▪ infant with failure to thrive, B/L cataracts, jaundice, hypoglycemia: galactosemia ▪ galactose-1-phosphate uridyl transferase deficiency ▪ also vomiting, hepatomegaly, convulsions ▪ ◇ risk for E.coli neonatal sepsis ▪ early Dx & Rx: eliminating galactose from diet o breastfeeding is C/I ▪ complications: cirrhosis, mental retardation |
| ▪ galactokinase deficiency: cataracts only |
| ▪ MCC of hip pain in children: transient synovitis ▪ boys age 3 – 10 yrs; after viral infection or trauma ▪ well-appearing, able to bear weight ▪ affected hip is flexed, slightly abducted & externally rotated which maximizes joint space ▪ Dx: XR to exclude bone lesions, fx, Legg-Calve ▪ Rx: ibuprofen & rest, F/U in 1 wk o recovery within 1 – 4 wks; no complications |
| ▪ Legg-Calve-Perthes: idiopathic avascular necrosis of femoral capital epiphysis ▪ MC in boys, age 5 – 7 yrs ▪ insidious hip, groin, or knee pain & antalgic gait (indication of pain with weight bearing) ▪ limited internal rotation & hip abduction ▪ Dx: high suspicion; early XR may be negative ▪ Rx: observation & bracing; surgery if severe ▪ DDx: SCFE, transient synovitis |
| obese boy with a limp, knee pain, decreased ROM, pain with hip internal rotation: slipped capital sis (SCFE) ▪ MC in obese boys, age 10 – 16 yrs ▪ insidious onset dull hip or referred knee pain, altered gait with no preceding trauma ➢ affected hip is held in passive external rotation ▪ a/w children with endocrinopathies (hypothyroidism, growth hormone deficiency) have B/L disease & present at an earlier age ▪ Dx: XR in frog-leg lateral view ▪ Rx: surgical screw fixation at current slippage ▪ complication: avascular necrosis |
Pharmaceuticals
| ▪ flumazenil: GABA/benzodiazepine Rc antagonist o Rx benzodiazepine overdose (slurred speech, ataxia, hypotension, depressed mental status) |
| ▪ labetalol: Rx hypertensive encephalopathy (BP ≥ 180/120 mmHg, headache, N/V, confusion) |
| ▪ nitroprusside: hypertensive emergency (BP > 220/120 with evidence of organ damage) |
Psychiatry
| ▪ malingering: intentional production of false physical symptoms for secondary gain |
| ▪ factitious disorder: intentional production of false physical or psychological signs or symptoms to assume a sick role; no secondary gain |
| ▪ hypochondriasis: fear of disease & preoccupation with the body, manifests as multiple somatic complaints; at least 6 months o prominent during psychological stress o inquire about current emotional stressors o Rx: refer for brief psychotherapy |
| ▪ conversion disorder: unexplained neuro symptoms preceded by an obvious emotional trigger; symptoms are not artificially produced, unexplained by any medical condition; cause social & functional impairment (la belle indifference) |
| ▪ bipolar disorder is an episodic illness; periods of severe irritability during discrete mood episodes ▪ strong genetic component ▪ bipolar disorder is at high risk of relapse after remission from an acute episode ➢ #1 maintenance Rx: atypical + lithium or valproate Guidelines for maintenance Rx of bipolar disorder ▪ first episode ◇ maintenance at least 1 yr ▪ 2 episodes ◇ long-term maintenance (years) if episodes were severe or +family Hx ▪ ≥ 3 relapses ◇ lifetime maintenance ▪ bipolar I: manic episodes with/without Hx of major depressive episodes o Dx can be made with a first manic episode ▪ bipolar II: hypomanic episodes (less severe, less functional impairment, no psychotic symptoms) o Hx of ≥ 1 depressive episodes required o never met criteria for a past manic episode ▪ cyclothymic disorder: ≥2 years of fluctuating, mild hypomania & mild depressive symptoms that do not meet criteria for hypomanic episodes nor major depressive episodes |
| Manic Episode | Hypomanic Episode |
| Symptoms more severe, one week (unless hospitalized) marked impairment in social or occupational functioning, psychotic features | Symptoms less severe, ≥ 4 consecutive days symptoms not severe enough to cause marked impairment or necessitate hospitalization, no psychotic features |
Lithium therapy
| Indications | mania due to bipolar |
| C/I | ▪ chronic kidney disease ▪ cardiovascular disease ▪ hyponatremia or diuretic use |
| Baseline studies | ▪ BUN/creatinine, U/A ▪ Ca++ ➢ Thyroid function ▪ EKG if coronary risk factors |
| A/E | Acute ▪ tremor, ataxia, weakness ▪ polyuria, polydipsia ▪ vomiting, diarrhea, weight gain ▪ cognitive impairment Chronic ▪ nephrogenic DI ▪ thyroid dysfunction ▪ hyperPTH with hyperCa++ |
| ▪ Lithium has a narrow therapeutic window, thus monitor every 6 – 12 months or 5 – 7 days after dose changes or drug interactions (diuretics, SSRIs, NSAIDs, ACE-I, phenytoin, carbamazepine) ▪ pregnancy: Ebstein’s anomaly, polyhydramnios, nephrogenic DI, floppy infant syndrome ▪ no effect on liver function, lipids, or glucose |
| ▪ conduct disorder: middle childhood/adolescent o Dx: at least 3 symptoms from the following categories: (1) aggression towards people or animals, (2) destruction of property, theft, deceitfulness, or (3) serious violation of rules ▪ oppositional defiant disorder: pattern of angry, irritable mood & argumentative toward authority o children; less severe vs. conduct disorder ▪ antisocial personality disorder: age 18 yrs or older; evidence of conduct disorder as minors |
| ▪ adjustment disorder: emotional or behavioral symptoms within 3 months of identifiable stressor; rarely > 6 months after the stressor ends ▪ marked distress in excess of expected from exposure to the stressor, with significant impairment ▪ Rx: cognitive or psychodynamic psychotherapy to develop coping mechanisms, response to & attitude about stressful situations ▪ SSRIs can be an adjunct for depressive symptoms |
| ▪ generalized anxiety disorder: excessive worry over many aspects of life, at least 6 months ▪ acute stress disorder: PTSD-like symptoms develop within 4 wks, last > 3 days, but < 1 month ▪ PTSD: anxiety symptoms > 1 month ▪ OCD: recognizes unreasonable nature of behavior o ego-dystonic beliefs ▪ altered levels of serotonin involved in OCD ▪ Rx: SSRI or clomipramine (TCA) ▪ OCPD: preoccupied with orderliness & perfection; does not see the behavior as a problem o ego-syntonic beliefs |
| ▪ borderline personality disorder: show a pattern of unstable relationships, impulsivity, reckless; identity disturbance, suicidal or self-mutilating behavior, feelings of emptiness; “splitting” ▪ histrionic personality disorder: excessively labile emotions & attention-seeking behavior; uses physical appearance to draw attention ▪ paranoid personality disorder: suspiciousness & distrust; negatively interpret actions, words & intentions of others; holds grudges ▪ dependent personality disorder: submissive & clingy; fear of separation, indecisive, does not take initiative; difficulty expressing disagreement ▪ avoidant personality disorder: shyness, feelings of inferiority with a desire for friends, but intense fear of embarrassment or rejection; low self-esteem |
| ▪ long-acting injectable antipsychotics (depot) Rx chronic noncompliance, who previously responded to oral antipsychotics o must assess tolerability of oral medication o 1st & 2nd generations available as depot o given as IM every 2 – 4 wks ▪ Rx-resistant schizophrenia: clozapine o fail to respond to ≥ 2 antipsychotics o risk of agranulocytosis o requires routine monitoring: CBC |
Pulmonology
| ▪ Bronchiolitis: MCC is RSV ▪ older children ◇ self-limited, mild URI ➢ age < 2 yrs involves the lower respiratory tract o wheezing/crackles & respiratory distress with waxing/waning; peaks @ days 5-7 ▪ Rx: supportive care ▪ prophylaxis: Palivizumab for high-risk cases ▪ complications: apnea & respiratory failure; develops recurrent wheezing through childhood o increased risk of acute otitis media; but rarely bacterial pneumonia or sepsis |
| ▪ ARDS: non-cardiogenic pulmonary edema caused by leaky alveolar capillaries ▪ mechanical vent.: FiO2 improves oxygenation, PEEP prevents alveolar collapse ▪ arterial pO2 measures oxygenation ◇ influenced by FiO2 & PEEP ▪ arterial pCO2 measures ventilation ◇ affected by respiratory rate & tidal volume ➢ initial ventilator management is decrease FiO2 to non-toxic values (< 60%); goal = paO2 ≥ 60 ▪ PEEP can be increased to maintain oxygenation o decreasing PEEP lowers oxygenation by decreasing availability of alveoli |
| ➢ hypoxemia is best treated by increasing PEEP ▪ PEEP complications: barotrauma, tension pneumoTx (resulting hypotension) |
| ▪ ARDS can develop in the setting of sepsis, severe bleeding, severe infection, toxic ingestion, burns, or acute pancreatitis ▪ inflammatory mediators are released locally or to distant tissues, damage the alveoli ▪ ◇ alveolar capillary permeability allows fluid to leak into alveoli, resulting in pulmonary edema ▪ excessive IV fluids ◇ hydrostatic pressure, thus can worsen pulmonary edema ▪ Rx: mechanical ventilation with low tidal volumes & PEEP to ◇ work of breathing & ◇ oxygenation |
| ▪ alpha-1-antitrypsin: protease inhibitor that protects from neutrophil elastase, which breaks down elastin ▪ AAT deficiency: uninhibited elastase cause bullous, panacinar emphysema of lower lobes (smoking-induced emphysema is centrilobular) ▪ also causes liver disease: cirrhosis, or HCC ▪ liver Bx: hepatocyte inclusion stain +PAS & resists digestion by diastase ▪ Rx: purified human AAT |
| ▪ ventilation = product of RR & tidal volume ▪ mechanically ventilated patients with respiratory alkalosis in the setting of appropriate tidal volume ◇ RR should be lowered o reducing tidal volume can trigger an ◇ RR ◇ worsens alkalosis o increasing tidal volume would ◇ ventilation ◇ worsens alkalosis |
| ▪ acute massive PE can present as hypotension & syncope, leading to PEA in some patients ▪ PE occluding part of pulmonary artery results in ◇ RA, RV, & pulmonary artery pressure ▪ compensatory hyperdynamic LV function: early ◇ cardiac index, but no effect on PCWP or SVR |
| ▪ recurrent pneumonia in the same anatomic region o bronchial obstruction or recurrent aspiration ▪ bronchogenic carcinoma obstruction is most concerning with a smoking history ➢ chest CT is indicated initially o central masses or negative CT: bronchoscopy o peripheral lesions: CT-guided biopsy ▪ recurrent aspiration, same lung region o seizures o ethanol/drug use o GERD, dysphagia, achalasia ▪ recurrent pneumonia in different regions o sinopulmonary disease (CF, immotile cilia) o immunodeficiency (HIV, leukemia) o vasculitis, bronchiolitis obliterans |
Pneumonia
| ▪ aspiration pneumonia is MC in right lower lobe & unilateral pleural effusion due to parapneumonic effusion or empyema o pleural fluid shows elevated WBCs, protein, & LDH, but not amylase |
Renal
| ▪ broad casts: a/w chronic renal failure o arise in dilated tubules of enlarged nephrons that undergone compensatory hypertrophy in response to the reduced renal mass ▪ waxy casts: chronic renal disease o shiny & translucent ▪ RBC casts: glomerulonephritis or vasculitis; o Wegener’s, SLE, Henoch-Schonlein ▪ WBC casts: interstitial nephritis & pyelonephritis o WBCs that originate in kidneys ▪ fatty casts: nephrotic syndrome ▪ hyaline casts: asymptomatics & prerenal azotemia o proteins that pass unchanged along urinary tract |
| ▪ prolonged hypotension from any cause can lead to acute tubular necrosis o U/A: muddy brown granular casts consist of renal tubular epithelial cells o serum BUN:Cr ratio < 20:1 o urine osmolality 300 – 350 mOsm/L o FENa > 2% |
| ▪ sore throat, skin infection, generalized edema, dark urine, HTN: post-strep glomerulonephritis |
ADPKD
| symptoms | most are asymptomatic hematuria, flank pain (due to renal calculi, cyst rupture, hemorrhage, or upper UTI) |
| clinical signs | early onset HTN B/L upper abdominal masses mild proteinuria, CKD |
| extra-renal manifestation | cerebral aneurysm hepatic/pancreatic cysts cardiac valves (MVP, AR) diverticulosis ventral/inguinal hernias |
| diagnosis | abdominal USS |
| management | monitor BP, renal Fx, & potassium control cardiovascular risk factors ACE-inhibitors for HTN ESRD: dialysis, renal transplant |
Rheumatology
| ▪ Rheumatoid arthritis o morning stiff >30 min, improves with activity o tenosynovitis of palms (“trigger finger”) o cervical joint involvement can lead to spinal subluxation ◇ cervical cord compression o positive anti-cyclic citrullinated peptide (anti-CCP) o ◇ CRP & ESR correlates with disease o XR: soft-tissue swelling, bony erosions, joint space narrowing ➢ greatest risk for osteoporosis ▪ Rx: physical activity, optimize Ca++ & Vit D intake, minimize corticosteroids, bisphosphonates |
| Systemic Lupus ▪ Rx for SLE, malaria prophylaxis, acute malaria, rheumatoid arthritis: hydroxychloroquine ▪ Rx for Crohn’s, ankylosing spondylitis, RA, psoriasis: infliximab (TNF-α-blocker) ▪ Rx for histoplasmosis: itraconazole ➢ Rx SLE with renal involvement: cyclophosphamide |
| ▪ chronic ankylosing spondylitis (> 20 yrs) are at ◇ risk for vertebral fractures with minimal trauma ▪ DDx: spinal root compression, bone mets |
