Peds

● Fragile X - large set ears

○ Diagnose w/ FMR1 DNA analysis
● Down syndrome - can present with atlantoaxial instability
○ → can cause compression of spinal cord → hyperreflexia, ataxic gait,
urinary incontinence, weakness
■ Diagnosed with lateral XR
● Kawasaki disease
○ CRASH and BURN
○ C - conjuntivitis
○ R - rash (polymorphous/desquamating)
○ A - adenopathy
○ S - strawberry tongue / serositis (injected pharynx)
○ H - hand, foot changes (edema, erythema, perianal!))
○ BURN - fever
○ ALSO - VENTRICULAR DYSFUNCTION (lymphocytic myocarditis)
○ Diaphoresis between feeds

● Tracheoesophageal fistula with esophageal atresia

○ If you can’t pass NGT into stomach/resistance at upper esophagus
○ Need to check for VACTERL anomalies → renal u/s + echo
● Scarlet fever - pharyngitis + skin peeling (later) + rash (trunk → axilla, groin folds)
+ fever
● Eosinophilic esophagitis - failure to progress to solids (solid food refusal), poor
appetite, poor weight gain
○ Will have normal swallow study
○ Diagnose: endoscopy w/ esophageal biopsy
○ Treatment: avoid trigger foods

Platelet disorder Ecchymosis, mucosal bleeding

(epistaxis), and petechiae

Clotting defect Ecchymosis, hemarthrosis (bleeding into

joint) Ex: factor 8 deficiency
● Joint custody child - only ONE parent needs to consent for treatment, especially if life
saving/in child’s best interest
● Parents cannot refuse life saving treatment for a child (ex: chemotherapy)
○ If this happens (ex: both parents say no to chemo) → must obtain court
order and ADVOCATE for the child

● Tetralogy of fallot - can present shortly after birth or LATER as toddler (ex: 3 years old)
w/ cyanotic tet spells
○ Will have VSD - systolic murmur at mid/upper L sternal border
○ Cyanosis Improves with squatting → increase afterload → shifts L
to R through VSD
○ (versus HOCM - systolic murmur at LLSB)
● HOCM - midsystolic or crescendo-decrescendo murmur heard at cardiac apex or left
sternal border
○ Decreased preload (Valsalva)→ worsens LVOT obstruction → increases
intensity of murmur
●

● Anemia v thalassemia
○ Anemia → decreased erythrocyte count , can have thrombocytosis (400+)
○ Check iron studies first
○ Correction of iron deficiency anemia is necessary before evaluation for
hemoglobin electrophoresis second (iron deficiency anemia can mask
thalassemia)
● Drug induced hemolytic anemia - can occur with cephalorsporins or penicillins
○ Ex: After taking CTX, develop anemia, elevated bilirubin, dark urine.
○ Diagnose: Coombs test
 ● Neuroblastoma - bruising around eyes, irregular firm abdominal mass, opsoclonus-
myoclonus (dancing eyes dancing feet) aka rapid eye movements

● Tretinoin can cause idiopathic intracranial hypertension - headaches, vomiting, visual

changes

● Otitis media - 1st line amoxicillin, if penicillin allergy, then azithromycin

● Congenital hypothyroidism - due to thyroid dysgenesis. Low T4, high TSH

○ Asymptomatic at birth
○ Symptoms begin a few weeks after as maternal T4 wanes
○ Macroglossia, hoarse cry, umbilical hernia, jaundice

● Transfusion associated circulatory overload (TACO) - children <3 yo with iron

deficiency anemia 2/2 to drinking a lot of cows milk are susceptible
○ After transfusion → develop pulmonary edema, increased HR and BP
(S3 gallop, crackles, think circulatory overload similar to heart failure)
○ → give diuretics + respiratory support

● Common variable immunodeficiency - infection by strep, giardia.

○ Treatment: IVIG (intravenous immunoglobulin)

● Sudden infant death syndrome - risk with baby sleeping on side or prone
○ Make sure babys on back
○ Pacifier actually decreases risk

● Campylobacter gastroenteritis - treat with supportive care UNLESS high fever, bloody
stools, pregnant, elderly, lasting longer than > 7 days,
○ Can be mucoid or bloody
○ Can cause PSEUDOAPPENDICITIS! (periumbilical → RLQ pain)

● Neonatal with hyperbilirubinemia - most common cause is biliary atresia, 2nd possibility
if also with subhepatic mass is biliary cyst

● CMV - microcephaly, periventricular calcifications

versus
● Toxo - macrocephaly/hydrocephalus, diffuse intracranial calcifications
○ Also chorioretinitis

● MMR - 1 and 4 years

○ Rash starts on face → spreads to abdomen + extremities
○ Low grade fever
○ Post auricular LAD
● Myositis ossificans - aka heterotrophic bone formation
○ Ex: get kicked in thigh, contusion → 1-2 weeks later painful, firm,
mobile mass

● Enterobius vermicularis - itchy anus

○ Scotch tape test
○ Treatment: pyrantel pamoate or albendazole

● Meconium ileus - no bowel movement and bilious vomiting (green vomit) →

intestinal obstruction by inspissated stool
○ → do water contrast enema
●
● If strep pneumo - on abx for 48 hours and still fevering → repeat CXR
○ Likely parapneumonic effusion → unresponsive pneumonia
● Todd paralysis - kid has seizure with postictal period, then has hemiplegia (ex:
can’t move arms or legs)

● Galactosemia - galactose cannot get reduced to glucose → reducing

substances in UA → hyperbilirubinemia (indirect/direct,
hepatomegaly), jaundice, hypotonia, hypoglycemia, seizures

● Hemophilia - deposition of hemosiderin into joints!

● Polymorphous rash after taking penicillin (with diffuse cervical LAD, enlarged
tonsils with exudates…) → EBV
○ Develops a few days later
○ Not immediately after which would be → allergy reaction
● Rubella - born with sensorineural hearing loss
○ + hepatomegaly
○ + growth restriction

● Chronic suppurative otitis media - bugs are pseudomonas and STAPH AUREUS
○ Don’t fall for epidermidis

● If air conduction is better than bone conduction in both ears →

congenital CMV infection
○ Can be delayed onset → show up at 5 years old

● VZV rash - can occur 1-3 weeks after varicella vaccine. Can be mild and itchy,
NOT PAINFUL, with maculopapular lesions
 ○ Due to strain replicating
● Henoch sholein purpura/IgA vasculitis
○ Hinge pain
○ Stomach pain (assoc w/ intussusception)
○ Palpable purpura (petechiae)
○ Only 2 or more is required to diagnose
● Physiologic jaundice - first few days of like. Causes indirect hyperbilirubinemia
○ Decreased UGT activity for first 2 weeks, especially in Asian children
○ → decreased hepatic bilirubin clearance (can’t clear bilirubin if it
is not conjugated)
● Wilms tumor / nephroblastoma - can present with hematuria and a non tender
palpable abdominal mass
○ Typically diagnosed at 2-5 years old. Often asymptomatic with large mass
○ TYPICALLY UNILATERAL
○ Must get US, then CT. also CT chest for pulm mets
● Pneumatosis intestinalis (air in bowel wall) - from necrotizing
enterocolitis (necrosis of small/large bowel → perforation → introduces
gas-forming bacteria)
○ In infants
○ Tx: blood cultures and abx
○ Don’t need to do ex lap! Bc might have stable vital signs
○ Typically LOW BIRTH WEIGHT receiving ENTERAL FEEDS
● Droplet precautions - Neisseria meningitidis, H flu, Mycoplasma
● Staph - get sick 6 hours later
● Norovirus - most common cause of gastroenteritis. Get sick 36 hours later
● Post strep glomerulonephritis - treat supportively → give diuretics if
volume overloaded

MUCOSAL NEUROMA!!!!!!!!!!!!!! → THINK MEN2B (marfanoid habitus +

mucosal neuroma + medullary thyroid cancer)
 ● If baby is more than 6 months old and their testes has NOT descended →
must go to surgery
○ UNLIKELY to descend if it hasn't yet
○ No imaging necessary
● Leukocyte adhesion deficiency
○ Think skin and mucous infections like [cellulitis, oral ulcers, periodontitis],
typically staph and strep
○ You see leukocytosis
● Lidocaine induced methemoglobinemia - topical anesthetic can cause
methemoglobinemia
○ Will have normal PaO2 with cyanosis
○ Fails to increase pulse ox after 100% oxygen delivery
● croup/aka laryngotracheitis - edema and narrowing of the proximal trachea
○ Inspiratory stridor and seal bark cough
○ Treatment: corticosteroids + nebulized epinephrine
○ If patient has NO STRIDOR AT REST → d/c home with 1 dose oral
glucocorticoids (no epinephrine)
○ If patient has STRIDOR AT REST → nebulized epinephrine
Versus
● Epiglottis - edema of the epiglottis and folds
● Non bullous impetigo - honey crusted lesions!!!
○ Aka yellow crusting
○ pustules/papules
○ Spreads easily! Can also be painful
○ Must give topical mupirocin
● Pertussis -
○ 1st week: mild cough, rhinitis
○ 2nd week: whooping cough (“harsh”), posttussive emesis , cyanosis,
apnea
○ Treat with azithromycin!
● Foreign body aspiration
○ Kid that comes in with WHEEZES and albuterol does not improve
symptoms
○ Might also present with hyperresonance and decreased breath sounds
■ Also mediastinal shift
● SCD - aplastic crisis: just anemia (parvo)
○ Vs. aplastic anemia is PANCYTOPENIA
 ● Measles
○ Fever, cough, coryza, conjunctivitis, koplik spots
○ Airborne precautions - airborne respiratory particles
● Nicotine poisoning
○ Can present with myoclonus
○ And cholinergic symptoms - vomiting, diarrhea. Drooling, wheezing
○ Tx: supportive unless bradycardic (tx atropine)

Surgery

● Congenital ASD: may not manifest until adulthood

○ Such as pregnancy → Left to R shunting increased → R heart
overload/ R ventricle dilated → R bundle branch block →
arrhythmias → R heart failure → (way down line, Eisenmenger
syndrome)
○ Wide fixed split
● Anterior STEMI → LAD infarction → LV thrombus → DVT/acute limb
ischemia
○ Need to obtain an echo! To r/o LV aneurysm
● Slipped cap femoral epiphysis - might see trendelenburg sign (pelvis tilts when
standing on 1 leg)
○ If you see this must get → bilateral hip XRs
○ Typically obese children but can also happen with low BMI!!!! (ex: atrophy
of quad muscles)
○ Tx: surgical pinning?
● Spinal epidural abscess - ex: 10 days after receiving epidural
○ Presents with fever + back pain + tingling/numbness in LE
○ → requires urgent MRI because can lead to paralysis
● Adhesive capsulitis - limited active and passive range of motion
○ Pain and stiffness
○ Unilateral
○ Tx → range of motion exercises
versus
● Polymyositis - focused on WEAKNESS, not pain/stiffness, also BILATERAL
Ob/gyn
● Invasive ductal carcinoma - skin retraction/dimpling + firm/palpable mass +
bloody discharge
versus
● Intraductal papilloma - would NOT present with palpable mass. + blood discharge

● Ileus - NO air fluid levels, NO FLATUS, all intestines dilated, no transition point
○ Treat: bowel rest and serial examinations
versus
● SBO - air fluid levels, acute abdomen, dilated proximal bowel, collapsed distal
bowel
● Peptic ulcer disease - NSAID use, (ex migraines), postprandial nausea/upper
abdominal pain
○ If stool guaiac positive → check for perforation
○ Do an upright XR of chest and abdomen
○ Not gallbladder related! Cholecystitis would NOT cause blood in stool
● Biliary colic - temp, leukocyte, and liver tests are NORMAL
○ Can cause RUQ, epigastric + pain radiating to back
○ DIAGNOSE WITH ABDOMINAL ULTRASOUND
Versus
● Pancreatitis - can also cause pain radiating to back
○ Would present with systemic signs like weight loss
● Alcohol withdrawal - would not see focal deficits or hypoxia!
○ If after femur fracture → cerebral embolism
■ Can be microemboli → small enough to pass through
pulmonary circulation
● EXTERNAL HEMORRHOIDS are the ones that
HURT
○ Think “my ex hurt me” lol
● Blunt cardiac injury → if traumatic event OR hemodynamically unstable
get 3 things:
○ EKG → because can cause wall rupture/tamponade → will see on
EKG
○ FAST
○ CT scan
● Mass near anal orifice with fluctuation → infected of occluded anal crypt
gland
○ We would NOT see induration/fluctuation with hemorrhoid
○ We also would NOT SEE fever with hemorrhoid
If you see this → emergent surgery
●
● Blunt chest trauma that causes hypovolemic shock → intercostal vessel
injury
● First line for opioid induced constipation - stimulant laxatives (Miralax, senna)
○ 2nd line: methylnaltrexone
● Fat embolism syndrome - typically 24+ hours later, presents with petechial rash
and change in neurologic function
● Pulmonary contusion - can present with rales, dyspnea, tachypnea, ground-glass
opacities.
● Sickle cell trait - Young guy that has evidence of intravascular hemolysis
(indirect bilirubin, elevated reticulocytes) and splenic infarction →
sickle cell trait
○ Get a HEMOGLOBIN ELECTROPHORESIS
● Posterior urethral valves - cause oligohydramnios, weight gain in the days after
birth instead of expected weight loss, decreased urine output
○ Remember oligohydramnios → lung hypoplasia → diminished
lung volumes → Respiratory distress
● Lethal triad - acidosis, coagulopathy, hypothermia
○ Large volume crystalloid can worsen this
○ Instead of JUST giving normal saline, you need to give blood products too
○ Room temp fluids are COLDER than our body temp fluids →
hypothermia
 ○ Fluids can cause hyperchloremic metabolic acidosis

● If in car accident, and have decreased femoral pulses, tachycardic →

get CT angiography for aortic rupture
○ Can cause pseudocoarctation → HIGH blood pressure in upper
extremities, then DECREASED femoral pulses
○ Also can cause a hoarse voice
● Watershed areas (aka more prone to ischemia)
○ Splenic flexure
○ Rectosigmoid junction
○ Ex: abdominal pain and bloody diarrhea after surgery → ischemic
colitis
■ Colonoscopy will show ulcers
● Hidradenitis suppurativa - give antibiotics FIRST, then SURGICAL excision
last
 ● Young person, self resolving, no systemic symptoms, just ONE PART of colon
dilated. + abdominal pain, distension
Verus
● Toxic megacolon - whole colon dilated, fever, bloody diarrhea

● Ratio >20:1 = PRERENAL INJURY

○ → decreased renal perfusion/volume depletion → give
isotonic fluids
● Non anion gap metabolic acidosis
○ HARDASS !
○ Can happen from pancreatic fluid leak → pancreatic fluid is HIGH
in BICARB
● Post MI - if presenting with POSITIONAL chest pain, i.e. IMPROVES WHEN
SITTING UP/LEANING FORWARD → think peri-infarction pericarditis!!
○ Next step: get EKG! → will see ST elevation and PR depression
● Abdominal aortic aneurysm - can present as sudden onset, unprovoked
back pain
○ Risk factors: men, 60+, smokers
○ Can present with prevertebral calcification on XR
 ○ Next step: Get an abdominal CT
● Gilbert syndrome
○ Decreased activity of UGT
○ Ex: patient after surgery with new onset jaundice + elevated
indirect bilirubin
■ But ALL OTHER LABS ARE NORMAL (normal ALP,
AST/ALT)
■ (also NORMAL CBC, blood smear, retic)
From Divine’s surgery:
- Contralateral motor loss = lenticulostriate artery
- s/p AAA surgery, now blood loss in stool = aortoenteric fistula
- Back pain with erectile dysfunction = PAD/aortoiliac occlusion
- Shiny, hairless = PAD
- Enoxaparin = heparin
- Warfarin = shuts off 2, 7, 9, 10, c, S
- Diverticulitis = cipro + metro, or MAG
- A, c,v wave pulsations = JVD
- Low voltage EKG = electrical alternans = tamponade
- Boerhaave syndrome = gastrografin (water soluble) swallow next step
- Intussusception = air/contrast enema 1st
- Intussusception / meckel = no rotavirus
- Plop sound = myxoma
- Cholecystitis = 1st RUQ US, if neg = HIDA scan 2nd
- SBO = adhesions, hernias, cancer
- GI bleed elderly = diverticulosis = barium enema
- Newborn drooling, choking, respiratory distress w/ 1st feed =
tracheoesophageal fistula
- Baby nonbilious vomiting = pyloric stenosis
- Pyloric stenosis = fix electrolytes first, surgery 2nd
- Newborn failed to pass meconium, down syndrome = hirschsprung
- Newborn failed to pass meconium, elevated sweat Cl- = CF
- ogilvie / pseudo colonic obstruction = neostigmine, rectal tube
- Periumbilical / flank eccymosis = pancreatitis
- Reynolds pentad: fever, RUQ pain, jaundice, AMS, hypotension =
ascending cholangitis
- Ascending cholangitis = ERCP 1st
- “Thumbprint sign” = bowel ischemia
 - Burn patients = PPIs
- Hernias: MDs LIE
- Femoral hernia = always surgery
- Increased ICP = hyperventilation
- Anterior spinal artery syndrome = s/p AAA repair
- Petechiae s/p surgery = fat embolism
- Septic shock = epinephrine
- Anterior knee pain over tibial tubercle = osgood schlatter
- Overweight male with hip pain = SCFE = ice cream
- Japanese guy with severe eye pain = acute angle closure glaucoma =
laser/pilocarpine/musc agonist/ B blocker
- Carcinoid syndrome = (pellagra - 3Ds), urine HIAA,
- Flushing
- diarrhea
- R sided murmur
- Calcified lesion, falx cerebri = meningioma
- Motor oil fluid = craniopharyngioma

OB/GYN for real

● Postpartum endometritis - occurs within > 24 hr postpartum, typically after
C-section
○ 2 out of 3 criteria: > 24 hrs postpartum, purulent/malodorous lochia,
uterine tenderness/soft
○ Additional testing NOT required - no imaging, abx, cx, etc
○ If NO improvement after abx:
■ Get pelvic ultrasound to evaluate for retained products of
conception
■ Might need d&c but this is not 1st step; get pelvic u/s first
● Peripartum cardiomyopathy
○ Only 36+ weeks !!!!!
○ Not likely to cause A fib
● Patients with rheumatic mitral stenosis can be asx until pregnancy
○ Can lead to a fib with RVR
● The greatest risk factor for epithelial ovarian cancer “epithelial
carcinoma of the ovary” is a family history of ovarian cancer
 ● Adenocarcinoma of cervix ~ HPV
● Vomiting in pregnancy
●

→ 1st line give: B6 and H1 antihistamine like doxylamine sulfate

Medicine
● Cirrhosis
○ Managing hypervolemia
■ Diuretics – >furosemide and spironolactone (do not give
HCTZ; can worsen hyponatremia)
 ○ Managing hyponatremia
■ NO TREATMENT NEEDED unless seizures, AMS
■ Discontinue antihypertensive meds (so ADH decreases)
● Non small cell lung cancer → NOT sensitive to chemo
○ Must RESECT
○ EVEN IF METS TO BRAIN → SURGICAL RESECTION
● Glucose control
○ Basal coverage - sufficient if fasting glucose is good range
○ If postprandial hyperglycemia → inadequate rapid acting
insulin coverage
● If DVT with no provoked factors → check age appropriate cancer
screening for malignancy
● Stroke - if <4.5 hrs can give thrombolytic (altepase, tPA)
○ If < 24 hours can follow with mechanical thrombectomy to restore
blood flow to area
● Diabetic nephropathy (advanced disease can present with proteinuria and
nephrotic syndrome)
○ Target A1c: <7%
○ Target BP: <130/90 (ACEis or ARBs) to lower risk of
progression
○ Also smoking cessation and lipid management (however lipid
lowering therapy has NOT been shown to reduce the progression of
nephropathy)
○ Low protein diet not advised given protein wasting
● Nephrotic syndrome
○ Increases risk for accelerated atherosclerosis
○ Due to decreased clearance of LDL
○ And increased lipoprotein synthesis
○ Membranous nephropathy -
■ Diffuse granular deposits of IgG and C3
■ If no primary causes (SLE, anti phospholipase A2 receptor Ab)
■ Check for malignancy → CT Chest
● For suspected occupational asthma there is a 2 step process:
○ 1. PFTs before and after albuterol to confirm asthma
○ 2. Peak expiratory flow measurements at work AND at home
● Aspirin exacerbated respiratory disease:
○ Asthma
 ○ bronchospasm/nasal congestion/wheezing after taking aspirin or
NSAIDs
○ chronic rhinosinusitis/nasal congestion/stuffy nose with nasal
polyps!
● Pt taking oral contraceptives with isolated HTN:
○ 1. Switch to different birth control (OCPs can cause HTN)
○ 2. Try diuretic
○ 3. Last if no improvement can consider CT angiogram of abdomen
● Alcohol and benzo overdose:
○ Will have respiratory and CNS depression due to the addition of
alcohol
■ Benzo overdose by themselves will have NORMAL vital signs
○ Will have hypotension (from alcohol)
○ Normal pupils
○ Normal bowel sounds (vs. DECREASED WITH OPIOIDS)
○ Naloxone with no effect
● R ventricle MI (RCA, II, III, aVF)
○ RV fails → no blood pumped through heart → hypotension,
JVD (increased RV preload), clear lungs
○ Best practice: give normal saline bolus to increased preload to the
heart
■ Do not consider dopamine unless saline bolus does not
improve BP
● Glucagonoma: 6Ds
○ Diarrhea, dermatitis (necrolytic migratory erythema/ painful plaques),
depression, declining weight, DVT, diabetes
● Trauma to penis:
○ If hematuria → do retrograde urethrography to diagnose urethral
injury
○ If that is normal → d/c with analgesics
○ Do NOT foley cath
● Anterior vs posterior shoulder dislocation
○ Anterior: abducted and externally rotated
■ Fall, direct blow
○ Posterior dislocation: adducted and internally rotated
■ Seizure
● Migraine prophylaxis - B blockers, TCAs, antiepileptics (topiramate)
● Polycythemia vera - EPO is LOW
○ Because the erythropoiesis is driven by JAK2 mutation instead
○ Iron and ESR also low
● TTP - thrombotic thrombocytopenic purpura
○ Pentad:
■ AKI
■ Thrombocytopenia
■ MAHA
■ Fever
■ Neurological sx
■ Tx: plasma exchange (need to remove antibodies against
ADAMTS13) so that platelets aren’t getting trapped/activated
by uncontrolled vWF
● HIV associated nephropathy
○ Can cause nephrotic syndrome: focal segmental glomerulosclerosis
■ Proteinuria >3g / day
■ Fatty cases in UA
■ With advanced HIV (low CD4, high viral load)
● Vs. crystal induced tubular dysfunction
○ With protease inhibitors
■ Would present with crystals on UA + hematuria and pyuria
● Polymyositis - for diagnosis do A MUSCLE BIOPSY
○ Don’t fall for EMG, that is not specific
● Paget disease of bone
○ Old person that is ASYMPTOMATIC
○ Might ONLY present with increased ALP
○ Diagnose with radionuclide bone scan - look for osteolytic or mixed
lytic-sclerotic lesions
● OA - Heberden and Bouchard nodes in PIP and DIP
○ Uniform across joints UNLIKE tophaceous gout
○ If suspect OA in hands, no additional testing needed
● Seborrheic keratosis = stuck on dark guy
● Cyclopentolate can cause anticholinergic toxicity in kids
● Lumbosacral strain
○ Elicits “achy pain” with straight leg test
○ Vs. lumbar radiculopathy - burning/shooting pain
● In patients diagnosed with HIV:
 ○ Get an interferon gamma release assay to screen for latent TB
○ **Testing for latent TB is recommended for all patients with
newly diagnosed HIV
○ CXR not recommended as initial screen
● Salicylate toxicity/aspirin overdose: -tinnitus, fever, tachypnea
○ Mixed acid base disturbance:
■ AG metabolic acidosis (low HCO3-)
■ AND respiratory alkalosis (stimulates respiratory centers; low
PaCO2)
■ → NORMAL PH
● In patient with HTN 150-160+/90-100+
○ Start on lifestyle mods + 2 drug antihypertensive therapy
○ Non pharm measures are not gonna cut it
● If patient with new BPH and slowly rising creatinine level:
○ Get renal ultrasound to evaluate for obstructive uropathy
○ Expect to see hydronephrosis
○ Renal ultrasound should be done in everyone with rising Cr
● ACEi bump in Cr
○ Occurs within 3-5 days of taking
○ Not over 12 months (long term)
● Raynaud syndrome
○ In young patients → primary
○ In older patients → secondary to something else
■ r/o SLE/scleroderma/CREST syndrome: get ANA antibodies
● Nephrolithiasis
○ If patient has no AKI, UTI, complete obstruction, intractable pain
■ Send them home with analgesics and instructions to drink 2L water
■ IV fluids are not proved superior to oral hydration
● If patient with popliteal aneurysm
○ → get abdominal u/s and contralateral leg
● Diffuse alveolar hemorrhage
○ Can be cocaine induced
○ Respiratory sx within 24h - hypoxemia, crackles
○ See diffuse pulmonary airspace opacities on CXR, could be ground
glass
○ Will also see normal EKG, normal BNP and normal troponin, and
normal cardiomediastinal silhouette!
■ Vs if cardiogenic edema - would see enlarged heart and labs
showing heart injury
● Boerhaave syndrome - aka esophageal perforation
○ Presents due to forceful retching
○ Crepitus, crunching sound on exam (pneumomediastinum)
○ fever
○ Also chest/abdominal pain
● Vs mallory weiss tear
○ Also retching but associated with hematemesis instead
● Vs subpleural bleb
○ Could cause subcutaneous emphysema but would present with
decreased breath sounds
○ No fever
● Atelectasis
○ Can result from asthma/mucus plug in airways → causes that
part of lung to collapse → mediastinal/trachea shift TOWARD SAME
SIDE OF ATELECTASIS
○ Also decreased breath sounds, dullness to percussion
● Vs. pleural effusion - would have mediastinal shift AWAY from side
● Untreated rheumatoid arthritis - common cause of secondary amyloidosis
○ Serum amyloid A is an acute phase reactant → increases with
chronic inflammation → commonly manifests as renal disease
(nephrotic syndrome)
○ Look for amorphous hyaline material that stains congo red
● Cardiac tamponade triad
○ Hypotension
○ Muffled heart sounds
○ JVD
● For elevated CHADSVASC - GIVE
ANTICOAGULATION - Xa inhibitor (Apixaban)
○ Aspirin is NOT anticoagulation
● A negative TST does NOT rule out active TB infection
● For pneumonia:
○ 1st step: get chest x-ray FIRST
○ 2nd step: if PNA, treat with ceftriaxone and azithro
● If after ETT, no breath sounds on L side → reposition the ETT tube!
○ Likely went too far, into R mainstem bronchus
● Oral hairy leukoplakia
○ If suspect: get HIV testing first
● If someone on dialysis is getting EPO but still has signs of iron deficiency anemia
○ → give them iron!
poisonings
Arsenic Acute: garlic breath, diarrhea
- Fence worker Chronic: stocking/glove neuropathy,
- Skin changes hyper/hypopigmentation,
hyperkeratosis
Pancytopenia, hepatitis

Tx: DMSA or Dimercaprol

Lead Also anemia and stocking/glove

- GI symptoms neuropathy
+ diarrhea/GI
No skin changes

Tx: Dimercaprol, EDTA, succimer

Acute salicylate/acetaminophen toxicity give activated charcoal within 2 hours

IV bicarb also option
● If chronic toxicity, or
presenting with confusion/AMS
→ hemodialysis
Causes hyperthermia + epigastric pain

● Oral contraceptives
○ Can cause hyperthyroidism via estrogen increasing levels of T4 binding
globulin
■ See elevated total thyroid hormone but normal TSH/euthyroid state
● SCFE
○ No fever
● Osteomyelitis: fever, point tenderness over affected bone, refusal to bear weight
● Small cell lung cancer
○ SIADH - if mild sx, 1st step: fluid restriction
○ If severe symptoms, Hypertonic saline
● Uremic pericarditis- hemodialysis
○ Vs acute pericarditis - colchicine + prednisone
● Women childbearing with nonspecific abdominal pain - screen for intimate
partner violence
● Anion gap = serum osmolal gap measurement
● Blunt ocular trauma
○ → hyphema (collection of blood) → intraocular hypertension →
optic nerve injury
 ○ Different from a subconjunctival hemorrhage which is PAINLESS
● Acute pancreatitis
○ If acute onset of abdominal pain radiating to back → get serum
amylase/lipase!
○ Imaging not required unless diagnosis is unclear
● Autoimmune adrenalitis -
○ Most common cause of adrenal insufficiency in developed county
○ Presents with hyperpigmentation and hyperkalemia
○ Vs. exogenous glucocorticoids do NOT present with skin/potassium
changes
● Hemoptysis (severe >600ml)
○ 1st step: respiratory isolation
○ 2nd step: intubate
○ 3rd step: bronchoscopy
○ 4th step: pulmonary arteriography
○ 5th step: thoracotomy if bronchoscopy and arteriography fails
● Heparin induced thromboctypenia
○ Causes thrombocytopenia AND thrombosis
● Exogenous steroids
○ Causes LOW LH and small testes
○ Vs klinefelter: causes HIGH FSH AND LH
● Acute diverticulitis
○ Does NOT have hematochezia
○ Usually presents with constipated (vs diarrhea)
● For atrial fibrillation:
○ Can give beta blockers for Non dihydropyridine CCD
■ Aka verpamil or diltiazem!!!!!!!!!!
○ If unstable, HR > 150, hypotensive, do synchronized cardioversion
○ Biggest contributor: chronic hypertension! (LA dilates via concentric
hypertrophy)
■ And age
■ CAD not contributor
● Cushing syndrome
○ If suspect: get dexamethasone suppression test, urinary cortisol, or late
night salivary cortisol FIRST
■ Then 2nd: get ACTH levels
● Organophosphate poisoning (cholingergic toxicity)
○ 1st step: remove clothing and irrigate skin
○ 2nd step Atropine, then pyridostigmine
 ○ Do not worry about ECG/sodium bicarb for prolonged QTc with cholinergic
(vs anticholinergic toxicity)
● Intubation
○ If 1st attempt is with a video intubation and fails
■ → must obtain surgical airway (cricothyrotomy)!!!
■ Do NOT attempt intubation again because this delays oxygenation
○ If 1st attempt is ETT without video
■ 2nd step is ETT with video
● High altitude
○ Once symptoms develop (crackles, hypoxia)
■ → due to pulmonary hypoxic vasoconstriction
■ → we want to decreased the pulmonary hypertension
causing the HAPE
● For shoulder dislocation
○ If NO fracture → Can do closed reduction
○ If FRACTURE is present → do open reduction!
● Ventricular tachycardia
○ Can cause sudden death
○ No warning sign → can present with passing out and
jerking/myoclonus
○ Can be triggered by infection/fever
■ NOT a febrile seizure in an adult - only kids have those
● Chronic mesenteric ischemia
○ Food aversion and WEIGHT LOSS
○ PAIN IN EPIGASTRIC REGION/postprandially
○ Not related to pancreatitis/pancreatic cancer
● A fib
○ Can be caused by obstructive sleep apnea
■ → causes atrial remodeling !
● If you hit flank
○ And have tenderness/bruising → get a CT
○ Even if no hematuria/normal UA
● If bit by a snake
○ Even if stable vitals → observe in hospital for 12-24 hours for
delayed toxicity
○ If unstable vitals → given antivenom
● Inflammatory diarrhea
○ Recognize triad!
 ■ Bloody diarrhea, thrombocytosis, normocytic
anemia
● → Crohns, UC
● Also ischemic colitis
● Also C. diff
● Abdominal aortic aneurysm
○ → for any MAN 65-75 who has ever smoked (any lifetime exposure), get
abdominal ultrasound
● Acute nitrofurantoin lung injury
○ Hypersensitivity reaction
○ 3-9 days later
○ Presents with bilateral opacities in lungs
● COPD
○ If severe (dyspnea with light housework) → do LAMA and LABA
○ If mild → SAMA and SABA
● Opioid induced hypogonadism
○ Reduces LH and testosterone
● End stage renal disease → increases risk of cardiovascular disease !
● Cirrhosis
○ If dilutional hyponatremia → don’t need to do anything (aka
hypervolemic hypernatremia)
● Treat hydrofluoric acid with calcium gluconate gel
● Stone in ureter AND fever/chills → urgent urology consultation!
● Viral myocarditis
○ Causes dilated cardiomyopathy !
○ → dilated ventricles with diffuse hypokinesis

Meds:
● For thiazide diuretics Causes everything to be HIGH except
for potassium, sodium, and
magnesium
■ So hyperglycemia,
hypercalcemia,
hyperuricemia

Lambert Eaton MG Dermatomyositis

- Presynaptic - Postsynaptic - Proximal muscle
- Presents with - Ptosis, diplopia weakness
proximal muscle - Worse with use - Gottron’s papules
weakness (red rash on finger
- AND autonomic knuckles!!!)
dysfunction (dry - Also upper eyelids
mouth, erectile (heliotrope)
dysfunction) - Presents with occult
- Improves with use malignancy
-

● Avascular necrosis
○ SLE!!!
○ Steroids!!!!
○ Both increase risk
○ Next step: get MRI!
● Supraventricular tachycardia
○ Most common form in young patients: AV node reentrant tachycardia
■ Aka 2 distinct conduction pathways in AV node
● Vs ventricular tachycardia
○ Abnormal automaticity in ventricular conduction system
● Metclopramide - not JUST antinausea; also PRO gut motility
○ Good for gastric paresis
● Diabetes
○ If uncontrolled → can cause gastric paresis (neuropathy)
○ Can treat with metclopramide
○ EGD might show partially digested food, also post-prandial vomiting
● Radioiodine for hyperthyroidism
○ Causes necrosis of thyroid follicular cells
■ → leading to hypothyroidism over weeks to months
● If severe pain radiating to groin with nausea/vomiting → Get abdominal

US to r/o ureteral lithiasis

○ US is lower radiation
○ Spiral CT can also be done
○ Also NON contrast CT
○ Be careful when answers say CT “with contrast” → hint that this
is not the right answer; we don’t need contrast to see stones
● Orbital trauma rules:
○ If decreased visual acuity
○ Or pain with EOM
○ → GET CT ORBIT
● Dog/Cat bite rules:
○ Must give Augmentin if
■ Puncture wound → ALL cat bites warrant antibiotic
prophylaxis
■ On hand/face/joint
■ Patient is immunocompromised
● Celiac disease
○ Anemia
○ Weight loss, fatigue
 ○ Remember: foul/bulky stools because they can’t absorb fat soluble
vitamins
■ → No ADEK
■ Therefore; if low Vit D → low Ca2+ → secondary hyperPTH !
● Malabsorption issues + bone pain !
● For patients with suspected acute coronary syndrome (ex: retrosternal CP
radiating down arm, thrombotic risk factors)
○ → give ASA as soon as possible
○ Do NOT give heparin unless confirmed MI or HIGH suspicion of PE (Wells
score)
● Warfarin associated intracerebral hemorrhage
○ See increased INR (normal 0.8-1.1)
○ Acetaminophen INCREASES warfarin’s anticoagulation effects
○ → administer prothrombin complex concentrate to reverse warfarin
● Decompression sickness/”the bends”
○ muscle/joint pain
○ Forms nitrogen bubbles
○ → treat with hyperbaric oxygen
● Subarachnoid hemorrhage
○ Thunderclap headache
○ Blood can irritate the meninges → causes pain with neck flexion,
neck stiffness
○ 1st step: get non contrast CT
○ 2nd step: LP (if CT is not conclusive)
● Hsv encephalitis
○ Usually does NOT present with nuchal rigidity
● Strokes

● Strokes:
○ Ex: women suddenly drops fork at dinner, shows signs of stroke
 ■ Then 1 hour later vomiting
■ Even later, becomes stuprous
● → tells us it is HEMORRHAGIC
● Think intracerebral hemorrhage

BUGS
● Fusobacterium necrophorum
○ Internal jugular vein thrombosis ( lemierre syndrome)
○ Tonsillitis
○ Neck swelling/SCM tenderness
■ Apparently can also cause cavitations
■ Can arise from dental work
● Klebsiella
○ Current jelly sputum
● Lyme disease
○ 1st line: doxycycline
○ If pregnant: give amoxicillin
● Trichinosis - triad of
○ Periorbital edema
○ Myositis
○ Eosinophilia
○ Can also see splinter hemorrhages!
○ + nausea/vomiting/diarrhea
○ Think ~after eating pork in Mexico~
○ Don’t confuse with trichinella :’)
● Parvovirus B19
○ Slapped cheek in kids
○ In adults: elementary school teachers, arthritis, resembles RA
■ Will now from acute onset
■ Also presents with loose stools and non-specific rash
■ *** think: woman that works at a day care/school and develops
joint pain
● ESR might be normal
● Acute, symmetric, small joint swelling (hands)
● Babeiosis
○ Also ixodes tick! So northeastern US (like lyme disease)
○ But protozoa
○ Worse in ASPLENIC PATIENTS
 ○ Causes: anemia, intravascular hemolysis (increased bilirubin, LFTS,
LDH), thrombocytopenia
○ Diagnose with blood smear
○ Maltese cross
● Shigella
○ Men who have sex with men are more at risk
○ Presents with watery → inflammatory/bloody diarrhea
○ Also more at risk for E. histolytica and Giardia
● TB
○ If someone has high pretest probability → respiratory isolation
○ Start on empiric FOUR DRUG THERAPY: RIPE for 2 months
■ THEN 2 months of 2 drug therapy
■ Must start with 4 to make sure no resistance develops
● CMV
○ Causes bloody diarrhea in HIV patients
● E histolytica
○ Can cause bloody diarrhea but is NOT an opportunistic pathogen
■ Acquired during international travel in countries with poor sanitation
● Blastomycosis
○ WISCONSIN
○ Ohio river valley
○ Can present with verrucous ulcers
○ Also upper lobe consolidation and lytic lesions on ribs
○ + fever, weight loss, night sweats, cough
● HIV
○ Severe pain swallowing = VIRAL esophagitis
○ Vs oral thrush = candida
● First step in evaluating difficulties initiating swallowing
○ Get a videofluoroscopic modified barium swallow
■ This will evaluate swallowing mechanics, degree of dysfunction,
and severity of aspiration
■ Ex: pt with prior stroke, now food “gets stuck” in his throat when
swallowing
● Infective endocarditis/perivalvular abscess
○ If patient has “poor dentition” and early diastolic murmur (aortic
regurgitation) and AV block
■ → likely perivalvular abscess
■ Vs Lyme disease does not affect valves
● Peptic ulcer vs. duodenal ulcer
○ Duodenal ulcer feels BETTER with food
○ Likely do to H pylori or NSAIDS
■ 1st line: antibiotics and PPI
 ● Recurrent pregnancy loss
○ Can result from hypothyroidism
○ Need to test for Hashimotos (most common in women of childbearing age)
■ Test for thyroid peroxidase antibodies

DERM:
Gram negative bacteremia with pseudomonas
○ Can happen with chemotherapy patients
○ Manifests as gangrenous ulcers + red macules + fever
○ Called ecthyma gangrenosum
○ → get bcx
○ Vs. pyoderma gangrenosum - associated with IBD and
spondyloarthropathies
■ No fever
● Erythema nodosum
○ Work up: CXR (sarcoidosis) even if no respiratory sx, antistreptolysin O,
TB
● Lymphedema
○ → Disruption of lymphatic system
○ Can occur with repeated episodes of cellulitis
○ Presents with firm edema
●