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Sub Division Notes

Id Division
Ovarian / Adrenal Tumors: If there is a
precipitous rise in the manliness of a female
patient (<6 mos) that occurs in a middle
aged woman rather than a young one, or in
Endocrine, Diabetes &
2170 Medicine a woman who's not fat enough to have
Metabolism
PCOS, think of ovarian / adrenal masses
first. Check DHEAS (adrenal) and
Testosterone (ovarian) before checking LH /
FSH
Cushing's Syndrome: Painless muscle
weakness associated with wt gain, bone
loss, htn, hirsutism.
Endocrine, Diabetes & -myopathy caused by weakness in proximal
2173 Medicine
Metabolism muscles (catabolic effects of cortisol on
skeletal muscles --> muscle atrophy)
-be suspicious of this if the patient has bone
demineralization and hirsutism as well.
Graves Disease
-Hyperthyroidism with diffuse RAI uptake
Endocrine, Diabetes &
2179 Medicine -use anti-thyroid drugs like methimazole and
Metabolism
propanolol as a bridge to thyroidectomy if pt
has increased r of complications
Hypovolemic Hypernatremia:
-pt gets NS until euvolemic, then give 5%
Renal, Urinary Systems & dextrose
2182 Medicine
Electrolytes -finally can switch to free watch when pt is
not shocky
-correct slowly or else cerebral edema
Pancreatic cancer:
-mostly in head of pancreas
-compress panc duct and common bile
2209 Medicine Gastrointestinal & Nutrition
duct...painless jaundice! "double duct sign"
-intra and extra hepatic biliary duct dilation,
distended gallbladder (courvoisier's sign)
Hepatorenal syndrome: splancnic
vasodilation --> blood gets diverted away
Renal, Urinary Systems &
2219 Medicine from the kidneys; any insult that would
Electrolytes
decrease intravascular volume flow can
precipitate hepatorenal syndrome
 Uremic Pericarditis:
-high BUN -> pericardial inflammation
-Look for in pts with CKD who present with
2224 Medicine Cardiovascular System pleuritic CP that improves with siting up +/-
pericardial friction rub
-nonspecific T wave changes
-tx with dialysis +/- rule out tamponade
GBS
-albuminocytologic dissociation: high protein
2290 Medicine Nervous System
with nl WBC
-tx = supportive, IVIG, plasmapharesis
Pseudogout
->65, monoarticular arthritis,
chondrocalcinosis
-MC knees and ankles
-occurs in the setting of trauma, overuse, or
medical illness
Rheumatology/Orthopedics
2314 Medicine -inflammatory effusion + rhomboid shaped
& Sports
positively birefringent cyrstals
-tx with rest, corticosteroids, and
arthocentesis

*key difference vs. urate gout is the

chondrocalcinosis!*
lower GI bleeding MC due to diverticulosis
-mc in sigmoid colon
-painless, large-volume (+/-
lightheadedness, hemodynamic instability)
2341 Medicine Gastrointestinal & Nutrition
-most will relieve spontaneously
-confirm on colonoscopy
-AVMs less common than diverticulosis.
ALso they don't cause large volume bleeds
neutropenic fever: start broad-spectrum
pip/tazo. Add vanc if there is an indication:
2616 Medicine Infectious Diseases known colonization with mrsa, ivda, catheter
related infection, skin/tissue infection; pna,
or hemodynamic instability
BB overdose: bradycardia, AV block,
hypotension, *diffuse wheezing* (specific to
BBs vs. CCBs)
2663 Medicine Cardiovascular System
-tx with glucagon: increases intracellular
cAMP. Also could give epinephrine, iv lipid
emulsion therapy
 Unprovoked First Seizure
-Do a CT or MRI as part of a work-up for all
unprovoked seizures!
-can exclude bleeds that require urgent
2671 Medicine Nervous System
intervention.
-noncontrast
-only do LP after you have excluded bleeds
with CT
Amyloidosis:
-cardiac (restrictive cardiomyopathy) CHF +
ECHO findings of constrictive LV
hypertrophy with predominant RHF sx
2699 Medicine Cardiovascular System
-asymptomatic proteinuria, nephrotic
syndrome, waxy skin, anemia, bruising,
hepatomegaly, subq nodules, enlarged
tongue, peripheral/autonomic neuropathy.
Prinzmetal Angina
-Tx with Diltiazem or nitrates
2723 Medicine Cardiovascular System
-young females, RF = smoking; seen with
transient ST elevations on EKG.
1* Adrenal Insufficiency (Addison's)
Renal, Urinary Systems & -low cortisol, low adrenal sex hormone, and
2817 Medicine
Electrolytes aldosterone secretion
-high K, low Na --- NL AG met acidosis
Aspirin
1. AG metabolic acidosis due to decreased
Renal, Urinary Systems &
2820 Medicine elimination of organic acids (lactic, keto)
Electrolytes
2. Medullary resp centers of the brain -
tachypnea and resp alkalosis
MC INFECTION IN AIDS
-Serous otitis media
-2/2 HIV lymphadenopathy leading to
2839 Medicine Ear, Nose & Throat (ENT) auditory tube dysfxn;
-sx = conductive hearing loss
-dull tympanic membrane hypomobile on
pneumatic otoscopy
Nasal Polyps
-NSAIDs + rhinitis + post-nasal drip =
aspirin exacerbated respiratory disease
2842 Medicine Ear, Nose & Throat (ENT)
(leads to nasal polyps)
-food can taste bland, rec nasal
discharge/block
 ALT more specific for hepatic injury
AST all over body including liver heart
kidney muscle
2937 Medicine Gastrointestinal & Nutrition -asx elevation can be caused by the
following meds: NSAIDs, antibiotics,
hmg-coa inhibitors, anti-epileptic drugs,
antituberculous drugs, herbal preparations)
Acute cholangitis: tx with
2978 Medicine Gastrointestinal & Nutrition beta-lactam+lactamase; 3rd gen
cephalosporin + metronidazole
Blastomycosis:
-pneumonia, wartlike/violaceious lesions +
2999 Medicine Infectious Diseases ulcers, osteomyelitis, prostatitis/orchitis,
abscesses/meningitis
-itraconazole +/- amphotericin B if IC
3011 Medicine Infectious Diseases Amox-Clav for polymicrobial skin infections
granulomatosis with polyangiitis
-wegeners
-whites 30-50yo
-chronic rhinosinusitis, tracheal narrowing
with ulceration****, cavitation in the lung,
3049 Medicine Pulmonary & Critical Care
anemia of chronic disease, renal
involvement (fast worsening, very common -
high creatinine, high rr of ESRD)
-check ANCA, tx with steroids
-definitive dx by bx
AIN: bactrim, cephalosporins, nsaids,
occasionally mycoplasma
Renal, Urinary Systems &
3061 Medicine -maculopapular rash, fever, arthralgias
Electrolytes
-AKI, wbc casts, urinary eosinophils, edema
-tx glucocorticoids
Pellagra = niacin deficiency
-diarrhea, dementia, dermatitis
-3rd world people who have corn based
diets only
3087 Medicine Gastrointestinal & Nutrition -1st world in Etoh, chronic illness; carcinoid
syndrome
-hartnup disease
-prolonged isoniazid therapy can mess with
tryptophan metabolism and lead to pellagra
 Digoxin toxicity: Heart manifestations
include increased ectopy and increased
heart block, so you get a very unique EKG
3096 Medicine Cardiovascular System
finding: atrial tachycardia with AV block.
atrial speed is less than what you'd see in
flutter (250 instead of 350)
TCA OD --> give NaHCO3 --> helps bc
increase sodium to increase serum pH and
extraceulluar sodium. this decreases drug
affinity for sodium channels.
Poisoning & Environmental
3138 Medicine -TCA usually bind to fast Na channels in the
Exposure
his-purkinje system and myocardium -->
decreased conduction velocity; more
repolarization; --> hypoten, qrs prolongation;
ventricular arrythmias.
Dermatomyositis:
-prox, symmetric muscle weakness
-heliotrope rash + grotton's papules
-ILD, dysphagia, myocarditis
-Dx with high CPK, aldolase, LDH, anti Jo1
mi2
Rheumatology/Orthopedics -Do an EMG or bx if you are suspicious
3208 Medicine
& Sports -tx with high dose steroids AND a
glucocortidoid-sparing agent.
-SCREEN FOR MALIGNANCY

*15% inc risk for ovarian, lung, panc,

stomach, colorectal cancers; NHL.

Paget's Dz of Bone (AKA osteitis

deformans)
-Isolated elevated of Alk Phos in the 400s
that is asx
Rheumatology/Orthopedics -Alk phos found in the hepatobiliary tree and
3304 Medicine
& Sports the bones
-caused by osteoclast dysfunction -->
defective osteoid formation
-osteolytic/sclerotic mixed lesions
everywhere
Dressler's Syndrome
-fever, high ESR, malaise, pleuritic CP that
3521 Medicine Cardiovascular System
improves with leaning forward
-tx with nsaids
 Hand tremor in parkinson's disease
-tx with trihexyphenydyl anti cholinergic
-aka it occurs at rest and improves with
activity (vs. essential tremor, which is the
3718 Medicine Nervous System
opposite)
-usually presents asymetrically (one hand
before other)
-
In a wide complex tachycardia, look for
fusion beats (diagnostic!) of sustained
3763 Medicine Cardiovascular System monomorphic ventricular tachycardia.
-increased R for V. arrythmias, VT, and VF.
-if stable, IV amiodarone
Acute Pancreatitis
-2/2 to valproic acid use
3833 Medicine Gastrointestinal & Nutrition -furosemide, thiazides, sulfasalazine, 5-asa,
azathioprine, HIV drugs, metronidazole,
tetracyclines
Minimal BRBPR: <40: anoscopy, 40-49:
sigmoidoscopy; 50+ colonoscopy. Has to do
with risks for cancer vs. hemorrhoids
3857 Medicine Gastrointestinal & Nutrition
(benign). If there are changes in bowel
habits, IDA, abd pain, wt loss, or FH of
colon ca, then go straight to the colonoscopy
stroke risk
-htn strongest association with stroke
3879 Medicine Nervous System
-etoh consumption has a protective effect
(higher HDL)
Chronic giardiasis is a thing. Pts with
nonbloody diarrhea for a long time after
travel to an endemic location should be w/u
3887 Medicine Gastrointestinal & Nutrition
for giardiasis. tx with metronidazole.
Confirm first with stool microscopy or a
nucleic acid amplification assay.
Calcium Oxalate stone prevention
-low Na diet -> decreases Ca excretion ->
prevent stones
Renal, Urinary Systems &
3895 Medicine -also consider HCTZ
Electrolytes
-fructose may worsen calciuria
-high vit C increases oxaluria (restrict
chocolate, tea, peanuts)
 ACE-i
Endocrine, Diabetes &
3902 Medicine -reduces urinary albumin
Metabolism
-decreases intraglomerular pressure
Pheochromocytoma
Endocrine, Diabetes & -severe htn can be precipitated by surgical
3976 Medicine
Metabolism procedures, use of bb, induction of
anesthesia, and serveral other medications.
EPO deficiency:
-common in ESRD.
-SE include: worse HTN (mechanism
3978 Medicine Hematology & Oncology
unknown)
also headaches, flu-like sx; red cell aplasia
(rare)
Fluorescein examination = after a wood's
lamp or slip lamp examination to assess for
4015 Medicine Ophthalmology
intraocular foreign objects following
high-velocity injuries
URIC ACID STONES = tx with potassium
Renal, Urinary Systems & citrate to alkalinize urine
4027 Medicine
Electrolytes CALCIUM OXALATE STONES = tx with
HCTZ to re-absorb calcium
SCC is the most common malignancy in pts
on immunosuppressive therapy for a history
4033 Medicine Dermatology of organ transplantation
-more aggressive, higher risk of recurrence
and regional metastasis
-Mg Sulfate used for severe life threatening
asthma exacerbations
-Only check sputum cultures if there are risk
4039 Medicine Pulmonary & Critical Care factors for pseudomonas infection
-Roflumilast = PDE inhibitor that decreases
inflammation and mucociliary malfunction.
Maintenance therapy for COPD.
Cocaine MI Tx
-Supp O2, IV Benzos to decrease
4042 Medicine Cardiovascular System sympathetic outflow, reduce BP, HR, CV sx
-Aspirin, nitrates, CCBs to decrease
thrombus formation
Transudate has higher pH (7.4) than
4053 Medicine Pulmonary & Critical Care
exudate (<7.3)
 Phenytoin causes folic acid deficiency
-also primidone, phenobarbital
4147 Medicine Hematology & Oncology
-less absorption in the small intestine
-also bactrim, methotrexate
Alcoholic Hepatitis
-fever, jaundice, anorexia, tender
hepatomegaly, and mild elevation of
AST:ALT 2:1; macrocytic anemia; and
thrombocytopenia and high INR.
-Clinical dx; no need for RUQ U/S or
4278 Medicine Gastrointestinal & Nutrition
anything
-radiograph reveals fatty liver dz, cirrhosis,
ascites
-tx with abstinence, hydration, nutritional
support, and acid suppression +/- biopsy if
there is dx uncertainty
Thyroid disease: If you do a radioactive
iodine uptake test (RAIU) and you see lots
of stuff lighting up then it's graves dz or a
toxic nodular goiter (tx methimazole). If
Endocrine, Diabetes & there is decreased uptake, then consider
4286 Medicine
Metabolism subacute thyroiditis or painless thyroiditis,
where the sx are a result of released of
preformed hormones from the thyroid (tx
propanolol). CHeck peroxidase abs also for
hashimotos.
1* Adrenal Insufficiency
-50% of people with autoimmune adrenalitis
have other autoimmune conditions involving
the endocrine glands (thyroid, parathyroid,
ovaries)
Endocrine, Diabetes & -Also common are pernicious anemia and
4305 Medicine
Metabolism vitiligo
-Presents with hypotension, pigmentation,
hyponatremia, hyperkalemia, esinophilia,
HIGH ACTH, low serum cortisol levels)
-1* = autoantibodies vs. adrenal
steroidogenic hormones
 Anemia:
-loss of RBC production, increase RBC
production, or blood loss
4329 Medicine Hematology & Oncology
loss of production = lymphoproliferative
cancer (leukemia, lymphoma)
ESRD Anemia
-low EPO --> normochromic,
4349 Medicine Hematology & Oncology hypoproliferative, normocytic anemia
-replete Fe with EPO because increase Hgb
will deplete iron stores
Eval of LBP: 1. radiograph + ESR. 2. MRI if
1. is abnormal or if there are neurological
deficits. 3. bone scan if MRI is not feasible.
Only do #1 if there are alarm symptoms.
Rheumatology/Orthopedics
4368 Medicine Otherwise the LBP doesn't need imaging.
& Sports
Alarm sxs: >50yo, history of ca, fever, wt
loss, nocturnal pain, no response to pain tx,
neuro deficits
DVT + high homocysteine
-high homocys = predisposed to
4384 Medicine Hematology & Oncology
thrombosis. tx with pyridoxine *(vitamin B6),
and potentially B12 if it is found to be low.
Infective Endocarditis in IV Drug Users
-Staph most common
-HIV increases IE risk
-Tricuspid valve involvement more common
than aortic valve
-septic embolus common *to the pulmonary
4398 Medicine Cardiovascular System
circuit, which is why pts have multiple round
peripheral opacities in their lungs
-fewer peripheral manifestations of IE (no
splinter hemorrhages, janeway lesions)
-HF rare with tricuspid disease
-present with cough, CP, hemoptysis
4427 Medicine Nervous System Review common causes of gait disorders!
COPD exacerbation tx: Be careful with
Renal, Urinary Systems & using diuretics to alleviate sx of cor
4435 Medicine
Electrolytes pulmonale as they can lead to AKI
*(prerenal)
 Guillain-Barre
-URI or diarrheal illness precedes it
-CSF shows high protein 2/2 inc
4465 Medicine Nervous System permeability of the BBB. Albumin and other
things are normal (albuminocytlogic
dissociation); Tx = IVIG or plasmapheresis.
-monitor for resp failure
obesity hypoventilation syndrome:
-chronic r acidosis
-high bicarb
-can't breathe bc weight and altered lung
4489 Medicine Pulmonary & Critical Care
mechanics
-won't breathe becuase of decreased
chemosensitivty to hypercapnia from
persistent nocturnal hypoventilation
Rupture of Alveolar Bleb
-COPD with acute SOB, hypoxia, with dec
breath sounds on one side == 2* spont.
pneumothorax. Rupture of a large sac of air
4520 Medicine Pulmonary & Critical Care
(alveolar bleb) can rupture and lead to leak
of air into the pleural splace.
-Dx CXR, no tracheal dev
-tx with supp O2, consider tube thoracotomy
Pts on ventilators need to have FiO2 < .6
4536 Medicine Pulmonary & Critical Care
(60%) to prevent O2 toxicity
ARDS Management
-resp distress + bilateral opacities +
hypoxemia
-Look for hypoxemia if pt is on ventilator
PaCO2 <60mmHg == poor oxygenation.
4562 Medicine Pulmonary & Critical Care
Increase FiO2 or increase PEEP
(preventing alveolar collapse, allowing for
greater recruitment). We don't want FiO2 to
be too high in the patient (<60% pref) bc of
risk of O2 toxicity - free radical formation.
Edema in nephritic syndrome is usually 2/2
Renal, Urinary Systems &
4591 Medicine decreased GFR and retention of water and
Electrolytes
sodium by kidneys
 Alcoholic Cerebellar Degeneration
-gait dysfunction, truncal ataxia, nystagmus,
intention tremor/dysmetria, impaired rapid
4618 Medicine Nervous System alternating movements (dysdiadocokinesia),
hypotonia, pendular knee reflex (persistent
swinging movements of the libs after liciting
the deep tendon reflxes)
Fixed upper-airway obstruction
-limits air flow during in and out, which
causes flattening of the Flow-Vol loop.
4630 Medicine Pulmonary & Critical Care
-Usually 2/2 laryngeal edema from a food
allergy (tx with epinephrine, systemic
corticosteroids, and antihistamines)
Lyme Ticks
-tick must be attached for >36h or be
engorged
4662 Medicine Infectious Diseases
-no CI to doxy
-local inf rate >20% (must be endemic)
-prophy started within 72 of tick removal
HOCM: The classic HOCM murmur is a
crescendo-decsecendo murmur in the L
4673 Medicine Cardiovascular System sternal border that does not radiate to the
carotids. Also will be seen in younger more
athletic male patients
Cancers of the spine:
-breast, lung, renal, prostate, and multiple
myeloma
4691 Medicine Nervous System -thoracic 2x vs. lumbar
-progressive back pain worse with
recumbency, point tenderness, 3+ DTRs,
upgoing plantar reflexes
Pneumonia mechanisms
-Causes R to L shunting 2/2 V/Q mismatch
-perfusion of lung tissue without alveolar
ventilation (the alveoli get filled with
4717 Medicine Pulmonary & Critical Care
inflammatory exudate, preventing effective
air flow)
-cannot correct hypoxemia with more FiO2.
-
 Pulseless electrical activity:
-very different from pulseless lack of
electrical activity (in which case you shock)
-if there is any sort of rhythm that is
4725 Medicine Cardiovascular System
appreciable on the cardiac monitor, do CPR
+ give epinephrine uninterrupted. There is
no role for cardioversion or defibrillation in
this case
Urinary Retention in H1s given to elderly
Renal, Urinary Systems & -detrusor muscle contraction is impaired;
4733 Medicine
Electrolytes poor voiding ability
-inc risk in males bc BPH
In veterans with amnesia, nightmares, sleep
Psychiatric/Behavioral & disturbances, irritability, numbness, and
11811 Medicine
Substance Abuse hypervigilance, increased startle response,
think of PTSD