USMLE Step 2 CK Quick Notes


Clinical features of Marfan syndrome

 upper:lower body segment ratio
 arm:height ratio
pectus deformity, scoliosis/kyphosis
joint hypermobility
Ocularectopia lentis (lens subluxation)
Cardioaortic dilation, regurgitation,
dissection MVP
Pulmonaryspontaneous pneumothorax due to
apical blebs


▪ sunscreen: 30 min before exposure
▪ reapply every 2 hrs
➢ avoid sunscreen in infants < 6 months

Emergency Medicine

Caustic ingestion

featureschemical burn or liquefaction necros s
results in:
▪ laryngeal damage: hoarseness, stridor, orofacial inflammation
▪ esophageal damage: dysphagia,
▪ 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


▪ 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 Io Pituitary tumors
o Primary hyperPTH (90%)
o Pancreatic/GI tumors (gastrinoma)
Type 2A
o Medullary thyroid cancer (MTC)
o Pheochromocytoma
o Parathyroid hyperplasia
Type 2Bo 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
▪ 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


▪ 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


▪ 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

etiol.mucosal tear
2/2 forceful retching;
arterial or
tear 2/2
with air/
fluid leakage
pain,  WBC
dyspnea, or
septic shock
subcutaneous emphysema
CT or contrast
& exudative
pleural effusion
(low pH, high
Rx as needed
(clipping or
▪ 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)


Microcytic/Hypochromic anemias

Iron-def anemia ferritin,  TIBC
Thalassemiasnormal/ serum iron & ferritin
Anemia of
chronic disease
 ferritin & transferrin,
normal/ iron & ferritin,
▪ 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

Featuresdevelops over 2 weeks (subacute)…
headache, fever, malaise, vomiting,
altered mental status, B/L papilledema
more acute & severe in HIV (CD4 ˂100)
DxCSF 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
Rxinitial: 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
➢ 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
▪ 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 CriteriaMinor Criteria
2 positive blood culture for typical IE organisms (strep viridans or bovis,
S. aureus, enterococcus
Vascular phenomena:
systemic arterial emboli, pulmonary infarcts, mycotic aneurysms, Janeway lesions, conju
Echocardiogram with oscillating intracardiac mass on valveImmunologic phenomena:
rheumatoid factor,
Osler nodes, Roth spots
Dx : 2 Major, 0 Minor
Dx : 1 Major, 3 Minor
Dx : 0 Major, 5 Minor
predisposing heart condition

fever: > 38.0° C (100.4°)

Endocarditis overview

poor dentition,
congenital heart
disease, valve
intravascular catheters
featuressubungal hemorrhages, petechiae,Janeway
lesions, Osler’s
nodes, Roth spots,
mitral valve disease
labspositive blood cultures,
 WBCs,
septic emboli
Rxvancomycin (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

epidemiologyMC in females, age 5 – 15 yrs
MCC: group A Strep pharyngitis
precedes onset of ARF by 2 – 4 wks
o Joints (migratory arthritis)
o ♥ (carditis, mitral stenosis)
o Nodules (subcutaneous)
o Erythema marginatum
o Sydenham chorea
fever, arthralgias, elevated ESR/CRP
prolonged PR interval
late featuresmitral regurgitation/stenosis
preventionPCN (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 carditis5 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

Chemical˂ 24 hrsmild conjunctival
& tearing after
silver nitrate
eye lubricant
Gonococcal2 – 5 dayseyelid swelling,
purulent exudate,
corneal ulceration
IV or IM
ceftriaxone or
Chlamydia5 – 14 dayseyelid swelling;
chemosis; watery
or mucopurulent
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
▪ 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

4nrml or
9nrml or
2 – 4
nrml or
▪ 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.


Spinal Cord Compression

causesspinal injury (MVA),
disk herniation,
malignancy (lung,
breast, pro M), infection
(epidural abscess)
featuresgradual, severe focal
back pain; pain worse
when recumbent & at
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
managehigh-dose IV
emergency spinal MRI,
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


➢ 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

(HIV, SLE, organ transplant patients)
▪ screen at onset of intercourse
▪ 6 months x2 then annual
Age ˂ 21No screening**
21 to 29Pap (cytology) every 3 years
30 to 65▪ cytology every 3 years
▪ OR cytology + HPV test every 5 years
≥ 65no screening if negative
prior screens & not high-risk
Hysterectomy without cervixno 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
▪ 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
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 endometrial ca risk 2/2 chronic anovulation
▪ fetal distress
(repetitive late decelerations) is an
indication for emergent c-section


▪ 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
▪ 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)


▪ 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
▪ 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
▪ 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


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


▪ 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)


▪ 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
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
no psychotic features

Lithium therapy

Indicationsmania due to bipolar
C/I▪ chronic kidney disease
▪ cardiovascular disease
▪ hyponatremia or diuretic use
▪ BUN/creatinine, U/A
▪ Ca++
➢ Thyroid function
▪ EKG if coronary risk factors
▪ tremor, ataxia, weakness
▪ polyuria, polydipsia
▪ vomiting, diarrhea, weight gain
▪ cognitive impairment

▪ 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)
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


▪ Bronchiolitis:
▪ 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


▪ 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


▪ 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


symptomsmost are asymptomatic
hematuria, flank pain (due to renal calculi, cyst rupture, hemorrhage, or upper UTI)
clinical signsearly onset HTN
B/L upper abdominal masses
mild proteinuria, CKD
cerebral aneurysm
hepatic/pancreatic cysts
cardiac valves (MVP, AR)
ventral/inguinal hernias
diagnosisabdominal USS
managementmonitor BP, renal Fx, & potassium
control cardiovascular risk factors
ACE-inhibitors for HTN
ESRD: dialysis, renal transplant


▪ 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,
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