Buzz words and core concepts for review

Pulmonary5 gm deoxygenated Hgb to have central cyanosis – you cannot be both anemic and cyanotic; you can look fine with cyanosis if you are polycythemic

carbon monoxide – co-oximetry, pulse ox normal

bronchiolitis – RSVbad bronchiolitis – preemies, congenital lung/heart diseaseribavarin – RSV with congenital heart/lung defects

bad asthma – ER visit 1 mo, more than 2 inhalers, 1 ICU/intubation, 2 hospitalization in 12 mo, 3 ER visits in 12 mo

Aa gradient (quick): 140-PCO2 –PO2

NL max Aa gradient – (10+age)/10

asthma deaths – inspissated secretions – mucus plugs

RSI in asthma - ketamine

intubated asthma – think barotraumas if worse; permissive hypercapnia

nasal polyps, RAD, NSAID’s combo (also atopic dermatitis)

methemoglobin – co-oximetry; sats are low but look fine- dapsone, pyridium, well water, nitrites/nitrates/ peds with GI

ARDS – aka NCPE – NL PCWP (<18), PO2<60 mmHg with FiO2>50%, bilateral alveolar infiltrates, normal heart sizeARDS TV 6 cc/kg (NL 10 cc/kg)

PNA- strep pneumo – most common, rusty sputum, rigor - Klebsiella – currant jelly sputum, ethanol- Legionella – older people, AMS, elevated LFTs, hyponatremia, cooling

towers, GI stuff, relative bradycardia - Staph aureus – post influenza, cavitation, empyema- Chlamydia – staccato cough, intracellular- Mycoplasma – extrapulm (GBS, encephalitis, EM, agglutinins)- PCP – HIV <200 CD4, butterfly pattern, low sats, elevated LDH

o Pentamidine – hyponatremia, hypotensiono Dapsone - methemoglobinemia

- Miliary TB – millet seed- TB – upper lobe- Pscitacossis – birds- Histoplasma – Mississipi River, Ohio river valley- Coccidioidomycosis – SW area- Blastomycosis – SE USA- Q fever – sheep, cow, abbatoir worker- Anthrax – G pos rods, mediastinal nodes- Hantavirus – SW USA, rodents

Amp and gent for < 1 month (no ceftriaxone for newborns!)Doxycycline works for all exotic/bioterror stuff

TB drugs side effectsINH – neuropathiesEthambutol –gout, red-green color blindness

PPD15 mm if no risk factors10 mm if IVDA, recent immigrants from high-risk location5 mm HIV

FB aspiration – expiration X rays best, lat decubs also good

L sided effusion – PNA, dissection, Boerhaave’s, pancreatitis

Cavitation – Staph, TB, pseudomona, klebsiella, aspergillus

Anterior mediastinal mass – T’s (thymoma, teratoma, thyroid, T cell lymphoma, terrible bronchogenic CA)

Tension pneumo – hypotension, JVD, absent breath sounds (also tracheal deviation)

Massive hemoptysis - >200 ml in 24 hrsBad side down (if you can ID)Embolization is best tx

Pneumomediastimun – Hamman’s crunch

Pleural effusionTransudate (liquid)– CHF, renal failure (nephrotic), CLDExudates (have stuff)– PNA, inflammatory, neoplastic

Virchow’s triad – stasis, endothelial damage, hypercoagulable

PE ECG – nonspecific STT changes, TWI ant-inf leads, RAD, new RBBB, pulmonary P, S1Q3T3

CXR – elevated hemidiaphragm, Hampton’s hump (pleural based wedge infarct), Westermark sign (oligemia in proximal vessel)

D-dimer – must be ELISA, not latex agglutination

Testing in PECT angio in PE – very specific, good sensitivityVQ scan – very sensitive but not very specificPulm angio – gold standard

TPA in PE – in shock only (clinically, and probably on echo)

RSIPreparation, preoxygenation, premedication, performance, post-procedure

Angioedema – C1 esterase deficiency, ACEI

Pediatrics

Colic – crying 3 hrs/d, 3 d/wk, x 3 weeks

Hypoglycemia, metabolic acidosis combo – inborn errors of metabolism

Bilious vomiting – malrotation of gut

HPS – first born males, olive mass, projectile vomiting, hypochloremic/hypokalemic metabolic alkalosis

Bloody diarrhea and febrile seizure = shigella

Intussusception – colicky pain, currant jelly stool. Most common pedi surgical emergency in <2 y/o, US (dx) or air contrast enema (dx and tx)

Jaundice admissionBased on time and amt

ALTE – scares people, apnea, color change (cyanosis/pallor), (tone) limp, coughing/gagging

SIDS most common cause of death from 1 mo to 1 yr

Bronchiolitis – wheezing/tachypnea/dyspnea. RSV (50-70%)

Nebulized epi

Pertussis – paroxysmal cough, post-tussive emesisTDaP used now due to resurgence (added acellular pertussis to diphtheria

and tetanus)

Simple febrile sz – GTC, <10 min, short/no post-ictal, 6 mo-6 yrs, neuro intact before or after, First 24 hrs illness, runs in families, fever usually >102

Hydrocephalus – large head, large scalp veins, bulging fontanelle, decreased upward gaze, decreased mental status, vomiting, increased LE tone

Most commonly involved CN eye deficit – 6th (lat rectus) – due to long tract

Idiopathic intracranial HTN – (pseudotumor) – HA, white/overweight females, tunnel vision

TOF: Cyanosis not relieved by oxygen, “tet spells”, blood flowing from R to L, squatting increases PVR and increases lung blood flow, boot shaped heart

Other cyanosis: tricuspid atresia, truncus arteriosus, transposition, TAPVR

Cystic fibrosis: most common genetic disorder in whites

Sickle cell: most common genetic disorder in blacks

HSP: rash(purpura), abd pain, arthritis. Intussusception, renal involvement (hematuria)

HUS (think TTP in peds): micronagiopathic hemolytic anemia, uremia, thrombocytopenia, neuro stuff, GI stuff. E. coli assoc. No abx.

Meningitis<2 months: think Listeria (ampicillin) 2 months: usual stuff – Strep, Neisseria, H flu steroids – H flu

Most common cause of pedi hip pain – toxic synovitis

SCFE- rapid growth ages, boys, overweight, often bilateral. Referred knee pain. Slipped snowcone

AVN – think sickle cell

NEC X ray – pneumatosis intestinalis

ITP – most common platelet disorder of childhood

Pedi dehydrationMild: 50 cc/kg downModerate: 100 cc/kg downSevere: 150 cc/kg down

Maintenance (per 24 hrs):100cc/kg x first 10 kg50 cc/kg for second 10 kg20 cc/kg thereafter

PALS pearls2J/kg defib0.5Jkg for sync CVETT size (uncuffed): (age/4)+4, subtract 0.5 – 1 for cuffed Uncuffed tube until age 8Asystole most common arrest rhythm; brady 2ndNo cric until age 10Bolus 20 cc/kgEpi 0.01 mg/kgAtropine 0.02 mg/kg (min 0.1mg)

ENTAir conduction>bone conductionPinna hematomas: cauliflower ear if not treated

Perichondritis/chondritis – cover pseudomonas

Otic barotraumas: pain, hemorrhage, decreased hearing

Otitis externa – pseudomonasMalignant otitis externa – elderly, diabetics

Otitis media – 1/3 viral; strep pneumo, H flu, M. catarrhalisBullous Myringitis – used to be Mycoplasma, now S. pneumoSerous OM – sterile, decreased hearing (affects learning and speech)Cholesteatoma – squamous epithelium mass

Central vertigo Peripheral vertigoOnset Slower onset Rapid onsetNystagmus Horiz/vertical nystagmus

Not fatigableTorsional or horizontal nystagmusFatigable with fixation

Symptoms Not that severe Severe

No N/V/diaphoresis Worse with movementN/V, diaphoresis

Deficits Other CN deficitsNo hearing loss

No other CN deficitsHearing loss

BPPV – most common cause of peripheral vertigo, otoliths, Dix-Hallpike, worse with head movement

Vestibular neuronitis: nystagmus, sudden onset, no hearing loss (different from labyrinthitis)

Labyrinthitis – infection, decreased hearing, and tinnitus

Meniere’s – vertigo, tinnitus and decreased hearing, can last week to years

SinusitisComplications of sinusitis – orbital cellulitis, brain abscess/meningitis, cavernous sinus thrombosis, skul osteoPott’s puffy tumor – skull osteoSame bugs as OM – Strep pneumo, H flu, M. catarrhalis

Orbital cellulitis – pain with eye movement

Kiesselbach’s plexus –most common source of anterior nosebleedPosterior packing risk – hypoxemia, hypercarbia, coronary ischemia, bradycardia, sinusitis, OMPosterior epistaxis – 5%, atherosclerosis

Septal hematoma – saddlenose deformity if not drained

CSF leaks – ring sign, glucose >30 mg/dl

LeFort1 – maxilla2 – maxilla and nose3 – maxilla, nose, orbit, and zygoma (craniofacial dissociation)

Cavernous sinus thrombosis – fever, toxic looking, proptosis, chemosis, CN deficits (3,4,6)Salivary glands – mumps (viral), Staph (bacterial)

Luwig’s angina – bilateral cellulitis of submandibular space; brawny edema, mixed aerobes and anaerobes

ANUG (trench mouth) – gum problems – swollen, red, tender, foul odor. Flagyl and PCN

Gum hyperplasia – dilantin, leukemia

PTA – most common deep ENT infection

Retropharyngeal abscess – most common deep ENT infection in peds; duck like voice; won’t look up; duck-like voice

Diphtheria – pseudomembrane, bull neck, systemic symptoms (neuro, liver, heart, kidney). Antitoxin

Bacterial tracheitis – look sick, airway obstruction, stridor

Epiglottitis – pain with movement of thyroid cartilage, thumb sign on X ray

Croup – laryngotracheitis, barking seal cough, stipple sign, viral. Rx steroids and epi

Madible fx – neck (1), angle (2), body(3)

Herpangina (coxsackie) – sore throat, fever, HA. many vesicles that spare buccal mucosa/gingival/lips

Pericoronitis – third molar

Alveolar osteitis – dry socket; severe pain 2-5 days post-extraction

Avulsed teeth – 1% survival per minute out

Ellis classificationI – enamelII – dentinIII – pulpIV – alveolar bone

Thyroglossal duct cyst – centralBrachial duct cyst – lateral

Central vs peripheral VII palsy – forehead does not work on peripheral lesions

Ramsay-Hunt syndrome: herpes zoster oticus, worse prognosis than Bell’sHutchinson sign – herpes zoster ophthalmicus. Nasociliary branch of trigeminal nerve

Trigeminal neuralgia – electric shock facial pain. Rx tegretol

Scarlet fever – strawberry tongue and sandpaper rash, skin lines

Nasal FB – unilateral foul smelling discharge

Esophageal FBs – coronal plane

Neuropsych

Nerve levelsReflexes: Biceps – C6Triceps – C7Sacral nerves –rectal toneKnee – L4Ankle – S1

Sensory:C4- clavicleHand – C6 1st finger (OK): C7 MF, C8 - last 2 fingersT4 – nipple lineT10 – belly buttonL1 – inguinal ligament (IL)

AMS – DON’T mnemonic – dextrose, oxygen, naloxone, thiamine

Cold calorics “COWS” – cold opposite, warm same (for the nystagmus part, which is a cortical function). The tonic deviation is cold same, hot opposite, which is a brainstem function.

Doll’s eyes – eyes should stay ML when moving head L and R. brainstem reflex

8th nerve lesions – CPA tumor. Hearing loss/tinnitus, dizzy, ataxia/cerebellar.

INO – palsy of medial gaze on affected eye, the other one has nystagmus, dx = MS

Corneal reflex – 5 sensation and 7 for blink

HeadachesTrigeminal neuralgia – shooting facial pain Migraine – with/without aura

Preventive therapy: BB’s, TCAD’sAbortive therapy: ergot (alpha constrictors), triptans (also alpha), antiemetics, narcotics +/-

Clusters – minutes, in groups, ocular findings, males. Rx 100% oxygenTension HA – tight

Toxic metabolic – fever, hypoxia, ethanol, COPost-concussive – follows trauma, more in pedsPost-LP HA – 2-3 days after LP, worse when sitting up. Correlates: size of needle, number of attempts. Tx: caffeine, hydration, analgesia, blood patch (definitive, diagnostic and therapeutic)SAH – sentinel HA, “worst HA of life”, sudden onset (thunderclap), LP with xanthochromia. LP better early, LP better later, CT > 90% sensitive if within 12 hours

Pseudotumor cerebri – young females, overweight. Papilledema. Slit-like ventricles. High OPHydrocephalus ex vacuo – from cerebral atrophyNPH – triad of ataxia, incontinence, dementia

SDH – more common than EDH, bridging veins. Assoc with brain parenchymal injury (worse outcome), crescent shaped. Does not cross ML.EDH – lucid interval, arterial bleed (middle meningeal artery), lens shaped. Does not cross suture linesMass – HA worse in am or valsalvaToxo – most common brain infection in AIDS

MeningitisHA, fever, AMS, stiff neckKids: irritability, poor feeding, bulging fontanelleMeningitis and rash – meningococcemia

Ages:< 1 month – GB strep, E coli, Listeria (add ampicillin + gent/cefotaxime)1 mo-3 yrs – adults plus H. flu>3 yrs– pneumococcus, neisseria meningitidis (3rd gen cephalosporin and vanc)

add vancomycin for bacterial meningitis (resistant strep)

steroids: needed for bacterial meningitides, esp pneumococcus (NNT 5 for morbidity of hearing loss)

needs CP prior to LP: >age 60, immunocompromised, hx prior CNS dz, recent sz, abnormal neuro exam

LGB (Guillain-Barre) – ascending arreflexic paralysis.MS: optic neuritis (aching visual loss, color or saturation loss). Young females. Pathognomonic: bilateral INO. Dx MRI. LP: oligoclonal bands (IgG)

Periodic paralysis – post exercise, assoc with high or low K, thyroid, pure motor.

MG - antibody against Ach receptor. Bulbar muscles first. Fatigue with use. Thymoma association. Tensilon test.

Myasthenic crisis – MG poor controlCholinergic crisis – too much physo

Lambert Eaton syndrome - antibodies against presynaptic Ach receptor. Think with distal weakness in cancer.

Other pure motor paralysis: tick paralysis, botulism, Eaton Lambert

Wernicke’s encephalopathy: AMS, ataxia, EOM palsy or nystagmus. B1 deficiencyKorsakoff – add confabulation

West Nile virus – birds. Can give pure motor problems.

Seizures:Todd’s paralysis: focal weakness after szGeneralized – T/C or absence. Both hemispheresPartial: simple (preserved mentation) or complex (affects mentation or behavior)Seizure tx: BDZ, phenytoin, phenobarb sequence for most

Status – more than 2 sz without return to normal in betweenStatus: think INH (use B6 – pyridoxine 5 gm or gm/gm ingested)

UMN: spasticity, NL muscle mass, increased DTR’sLMN: atrophy, fasciculations, no DTR’sALS (Lou Gehrig’s) – both UMN and LMN signs, sensation intact

Cauda equina: LMN. Weakness, incontinence, saddle anesthesia. Think HNP. Urinary retention most sensitive finding > 90% sensitivity Conus medullaris – same symptoms, but no recovery

Epidural abscess: back pain, +/- fever, weakness/paralysis. anything that causes bacteremia. Get MRI. Neurosurgical emergency.

Syringomyelia – collection of fluid in center of cord. IO weakness, decreased pain/temp to fingers. Position vibration (post horns are normal)

StrokeIschemic most commonCortex – contralateral weakness to face and body

ACA – more leg than arm weaknessMCA: more arm than leg, Broca’s aphasia with dominant hemisphere, homonymous hemianopsia, hemineglect with non-dominantPCA – homonymous hemianopsia, cortical blindness when bilateral

Brainstem – ipsilateral face and contralateral body

Pons – coma and pinpoint pupils but NL respirationCerebellar – balance, N/V, nystagmus. Can herniated quick.Vertebrobasilar – coma, “locked in” (can blink and vertical gaze)Lacunes – small vessels. Small defects.

Wallenberg syndrome – decreased P/T one side, ipsilateral horner, ipsilateral face and contralateral body

TPA: ischemic, measurable neuro deficit, not rapidly improving, time from onset 3 hrs, no contraindications

Uncal herniation – ipsilateral blown pupil, contralateral weakness

Cushing reflex – HTN (response to maintaining CPP) and bradycardia (carotid body response to HTN)

Gardner wells tongs – 5lbs per vertebral level

Myopathy – more prox weaknessNeuropathy – more distal weakness

RSD – pain, skin changes. Sympathetic problems to extremity

Psych

Functional – gradual onset, younger, clear sensorium, oriented, visual hallucinationsOrganic – age extremes, acute onset, disoriented, abnormal vitals, auditory/tactile hallucinations.

Transient global amnesia – no recent or immediate memory

Personality disorderAntisocial personality – impulsive behavior, no remorseBorderline – emotional lability, difficulty with relationshipsHistrionic – attention seekingNarcissistic – center of attention

Anxiety disorders:PTSD: stress after traumatic eventPanic attack – impending doomOCD – repetitive ritualistic behaviors

Mood disordersBipolar – mood changes, flamboyant, pressured speech

Eating disorders – anorexia and bulimia (purge)

Catatonia – waxy flexibility

Munchausen – fake illness/create illness. Want test/procedures/admissionMalingering – fake illness, have secondary gain or external incentives

NMS – lead pipe rigiditySerot syndrome – AMS, autonomic instability, motor irritabilityDystonia – sustained contractionAkathisia – inner restlessnessParkinsonism – cogwheeling, shuffling gait, masked facies

Suicide – recently widowed men at greatest risk. Men succeed more; females attempt more

Tarasoff – duty to protect potential victims supersedes confidentiality duty.

Tourette’s – vocal/motor tics

Night terror – 15 mins, “awake”, incoherent, amnesia

Environmental

Drowning – suffocation from immersionNear drowning – recoverSecondary drowning – dies of complications laterImmersion syndrome – immediate death from coldDry (85%) vs wet drowning

Shock and drowning – think trauma (spinal cord)

Drowning survival: duration of immersion (#1), age, water temp, water contamination, bystander CPR, assoc trauma, assoc dysbarism

DivingBoyle’s law – the volume of the gas is inversely proportional to the pressure applied to it. Squeeze syndromesHenry’s law – the partial pressure of a gas in a liquid is proportional to the partial pressure of that gas in contact with the surface of the liquid. Decompression sickness. Champagne bottle example.Dalton’s law – total pressure of a mixture of gases is equal to the sum of the partial pressure of each gas in the mixture. Nitrogen narcosis.

Middle ear barotraumas – ear squeeze. Blocked Eustachian tubesExternal ear barotraumas – cerumen plugs

Inner ear barotraumas – vertigo and hearing lossBarosinusitis – from URI’sFace barotraumas – mask squeeze

AGE: rapid ascent, immediate symptoms. AMS. Dive immediatelyNitrogen narcosis – euphoria, confusion, disorientation. Occurs at depthDecompression sickness (“the bends”). Depend on length and depth of dive. Delayed presentation.

Type 1 – Caisson’s disease. Musculoskeletal. Cutis marmorata – skin bendsType 2 – CNS and spinal cord. Inner ear (“The staggers”), pulmonary (“the chokes”)

POPS – from ascent with mouth closed. PTX, pneumomediastinum.

Blast 1. Pressure wave. Top 4 organs – ears, lungs, GI, CNS2. Shrapnel3. Flying human4. Other stuff – toxic chemicals, etc

high altitudehypoxemia leading to vasodilatation and vascular leakagefactors_ rate of ascent, ultimate altitude, duration at altitude (esp sleeping at altitude)Even 1K descent is useful

brain:acute mountain sickness - >8K feet. HA/nausea/fatigue/insomnia. Rx acetazolamide (not to sulfa allergics), descent/oxygen/steroidsHACE – ataxia/confusion/sz/coma. Rx descent, steroids, mannitol, HBO

LungHAPE – 2nd day. Leading cause of high altitude deaths. Steroids, HBO, nifedipine, descent.

HypothermiaRadiation – most of heat loss (head)Conduction – increased 30-50x when wetEvaporation – important in hot environmentsConvection – windchill

Hunter’s response – Cold-induced vasodilatationCold diuresisParadoxical core afterdrop – when rewarming, periphery vasodilates, cold lactate rich blood returns to core, both central pH and temp drop.

Frostbite is irreversible, frostnip is reversibleFrostbite – refreezing is very bad. Leave blisters intact. Conservative surgical managementECG in hypothermia – slow afib and Osborn J waves. Myocardial irritability

Heat related illnessMinor (cramps, edema, syncope, prickly heat) – NL core tempModerate: exhaustion (slight core temp elevation). Dehydrated but sweaty.Severe: heat stroke. No/little sweat. Core temp >41

Classic – epidemic, non-exertional. High death rateExertional – isolated, more complication, less deaths

Target organs – brain (AMS), liver, blood (DIC) Treatment: fans with mist (convection), immersionDemerol and thorazine, IV BDZ – stop shivering thermogenesis

Burns1st - 2nd

3rd

4th – muscle, fascia4 cc/kg x BSA of LR – ½ in first 8 hrs. UOP 1 cc/kg/hr

burn admits – 2nd degree >15% adults and 12% peds, 3rd 2-5%; inhalational; hand/perineum/face/feet/joints; co-morbid disease

escharotomy – arterial insufficiency with circumferential burns; inadequate ventilation in chest burns

current more important than voltage; AC (hold) worse than DC (thrown)low voltage< 1000V

oral commissure burn – delayed labial artery (day 5)

lightning – massive DC shock. 30% mortality. Asystole 1st, ST, motor paralysis, then VF

keraunoparalysis – transient spinal cord dysfunctionLichtenberg figure – fern like rash

HF acid burns – throbbing pain out of proportion. Rx calcium

RadiationIonizing radiationAlpha – least penetrationBeta – 8mm burnsGamma – deep penetration

2Gy – probable survivalmedial lethal dose 4.5Gy8Gy – no survivalEarlier/more severe symptoms – worse outcome

ALC at 48 hrs most important>1200 – good<300 lethal

Biological weaponsDoxy covers all organisms hereAnthrax – black eschar, mediastinitis. Rx cipro or doxyPlague – pneumonic and bubonic, sepsisCholera – rice water stoolsSmallpox – all lesions in same phase

Ricin – castor beanBotulism – bulbar findingsStrychnine – seizures while awake

Nerve agentsG agents – cholinesterase inhibitors. SLUDGE. Rx atropine and pralidoximeVX – same, liquidCN,CS, capsicum – irritatingPhosgene – delayed pulm edema, fresh mown hayMustard gas/lewisite – blistering

Mammalian bitesAll Rx AugmentinDog bite – Pasteurella, not that badHuman bite – Eikenella corrodens, worstCat bite – Pasteurella, very bad

Rabies – negri bodies. Bats, raccoon, skunk, foxActive – 0,3,7,14,21 (HDCV)20 IU/kg (50% at wound, HRIG)

paralytic vs furious rabies

snakesseasnakes – neurotoxiccoral – neurotoxic, red on yellowcrotalidae – hemotoxic>>neurotoxic

Wyeth – 5-10 vials, anaphylaxis, serum sicknessCroFAB 4-6 vials, may need repeat doses

SpidersBlack widow – red hourglass, mimics acute abdomen. Analgesia, BDZ. Has antivenomBrown recluse – dark violin top, necrotic lesion (delayed). Dapsone, HBO, surgery

ScorpionsCenturoides- fasciculation, salivation, delirium. Have antivenom

Hymenoptera (bees, ants, wasps, hornets)Anaphylaxis>10 stings can have toxic systemic reaction (DIC, renal failure)

Tickborne diseases: hyponatremia, fever, tick bite. Hand and feet solesTick paralysis – camperTularemia – rabbitsDengue – breakbone fever, retroorbital painLyme disease – Bell’s palsy, target lesionsVibrio vulnificus – seawater, 3rd gen ceph + doxyVibrio cholera – rice water stool

Marine envenomationsMost are heat labile – immerse in hot water, vinegarBox jellyfish – most deadly. Has antivenomNematocysts – will deploy and make things worseFish: zebra, lion, scorpion, stone (admit this, has antivenom)Cone snail – paralysisPufferfish (fugu)- paralysis

Endocrine

Epinephrine and glucagon are counter-regulatory hormones

C peptide differentiates too much endogenous vs exogenous insulin

GlucoseD50W adultsD25W kidsD10W neonates

Octreotide – antidote for sulfonylurea. Blocks insulin release from pancreas

Diabetes agentsSulfonylureas - end in “ide”. Long half lives.RepiglanideMetformin – no hypoglycemia. Metabolic acidosisAlpha glucosidase inhibitors – block hydrolysis of carbohydrates

Thiazolidenediones – “glitazones”; no hypoglycemia

Glucagon will not help in those with low glycogen stores (kids, alcoholics, malnourished, etc

DKA – dehydration, free ketoacids, glycosuria, total body K deficitTX: fluids, insulin, treat precipitant, KBicarb may increase risk of cerebral edema in peds. Also hypokalemia, hypernatremia, paradoxical spinal acidosis, decreased O2 offload to tissues

Na correction – decreased 1.6 for each 100 of glucose >100

Alcoholic ketoacidosisToo little insulin and too many counter-regulatory hormonesTx: D5W saline

Non-ketotic Hyperosmolar state (HONK)Glucose very high, profound dehydration, AMS, scant/no ketones, slow onsetTx – fluids (slow), tx precipitant, +/- insulin

ThyroidThyroid problems are generally primary

HyperthyroidismGrave’s disease #1 – antibodies to thyroid glandThyroid storm – neurologic dysfunctionRX – supportive (ASA displaces thyroid hormone from thyroglobulin), steroids (decreased conversions T4 to T3); peripheral blockade (beta blockers); blockade of hormone synthesis (PTU, methimazole); blockade of thyroid hormone release (Iodine after PTU or methimazole); tx precipitating events

HypothyroidismPost-Grave’s #1 and Hashimoto’s #2Symptoms – myxedema, slowed DTR’s, “myxedema madness”Myxedema coma – most severe form

Rx - supportive, steroids, IV T4 (thyroxine).

AdrenalsMost problems are from the pituitary (secondary) and hypothalamus (tertiary – from exogenous steroids)

Glucocorticoids (cortisol) and mineralocorticoids (aldosterone – retain Na and pee K)Waterhouse Friderichsen syndrome – B adrenal hemorrhage post meningococcemia or traumaAddison – primary adrenal insuficiency (hyperpigmentation from too much ACTH). Cosyntropin stimulation abnormal

Hallmark – low Na (most common) and high K. Also fever and hypotension

Tx: fluids, hydrocortisone

Cushing’s syndrome – from too much steroid, pituitary adenomaTruncal obesity (moon facies, buffalo hump, purple striae), HTN,

hirsutism, glycosuria

SIADHADH = vasopressin – posterior pituitaryToo much ADH when I don’t need it – dilution of serum and concentrated urineTo solve problem – brain, lung, drugs (chlorpropamide, etc)

Diabetes insipidus (the opposite of ADH)Pee too much, dilute urine too much and serum too concentratedCentral (CNS not making ADH), nephrogenic (kidney not responsive to ADH, lithium)

Pheochromocytoma – too much epi release from adrenal medulla. P’s – pressure, pain, perspiration, palpitations, pallor, paroxysmsDX ; 24 hr urine for VMA

Carcinoid syndrome – tumor secretes serotonin (flushed, diarrhea, vasodilation, wheezing)

SodiumHyponatremia: Symptoms depend on level and how fast it got there

Hypovolemic_ V/D, diuretics (lost both Na and water). Rx salineEuvolemic – SIADH, psychogenic polydypsia. Rx water restrictionHypervolemic - IV volume is low so more ADH (CHF, cirrhosis, nephritic). Na and water restriction, +/- diuretics

Pseudohyponatremia – glucose, lipids, proteins

Central pontine myelinolysis – confusion, locked in. Restrict correction to 0.5-1mEq/hrHypernatremia

Most commonly from free water loss (GI, renal, skin) or decreased intake (CVA, kids, elderly)Tx – restore IV volume;Correct slow (0.5mEq/hr) to prevent cerebral edemaTotal water deficit: TBW (70% weight) – 1(desired Na/actual Na)

PotassiumMajor intracellular cationHypokalemia = weakness. ECG U waves

Oral replacement best; 10MEq/hr when using IVNeed normal magnesium to replace

Hyperkalemia = arrhythmias, weaknessRemember – kidney failure, digoxin toxicity, hemolysis, succ, acidosisECG progression– peaked Ts, decreased PR, flat Ps, wide QRS, sine waveRx – calcium gluconate (fast but short lived), albuterol, insulin/glucose, bicarb, kayexalate, HD

Calcium

PTH – increases Ca and lowers Phosphorus via kidneysVitD – kidney plus sunlight. Increases intestinal absorption of calcium

Hypercalcemia (PAM P SCHMIDT)– hyperpara, MM, Paget’s, Cancer, milk alkali, excess vitamin D, thiazides.Stones, bones, moans, and psychic undertonesECG – short QTcTx: volume and then diuretics

Hypocalcemia Causes – post – parathyroidectomy, kidney failure, pancreatitisChvostek and TrousseauECG – long QTcTx – calcium

MagnesiumHypermagnesemia – rare. Renal failure, iatrogenic. Tx with calcium. HyporrelexiaHypomagnesemia – think in malnourished

PhosphateHigh phosphate – low PTH, renal failure. Rx phosphate binding gel or HD

Low phosphate – weakness. Rx with oral vs IV phosphate

Anion gapHAG – MUDPILES. Na- (Cl + Bicarb)Low anion gap – decreased unmeasured anions (proteins) or increased unmeasured cations (lithium, high calcium, high magnesium). Bromide is measured as chlorideNormal anion gap – HARDUP. Think renal (RTA) or GIMetabolic alkalosis – GI loss of acid or to much base intake

OsmolarityNormal: 285-295, NL gap up to 10 (Na) + glucose /18 + BUN/2.8 + ethanol /4.6

Dermatology and ID

Eczema (atopic dermatitis) – related to hay fever or asthma. AC/pop fossa; infants in face. Rx steroidsContact dermatitis – immediate or delayed (allergic)Exfoliative dermatitis (erythroderma)– red skin all over. Drugs or malignancyPsoriasis – thick white/silver scales. Nail pitting. Arthritis assoc.Seborrheic dermatitis – yellow waxy scales. Scalp and face. Seborrhea shampooPityriasis rosea – herald patch. Christmas tree distribution. SupportivePetechia (<3mm) and purpura (>3mm): nonpalpable (superficial – low platelets), palpable (deep, vasculitis)

Urticaria – hives, wheals. Superficial epidermis. IgEAngioedema – deeper dermis. Bradykinin mediated.

Erysipelas – cellulitis from Group B strep. Shiny red. Well demarcated borderErythema nodosum – vasculitis of fat. Painful red/viotel nodules. Pretibial region classicDrug eruptions – think in all acute symmetric rashes

Erythema multiforme/Stevens Johnson (<10%)/TEN(>30%) – target lesions, Nikolsky, mucosal involvement. Rx like burnsSSSS – Nikolsky positive, assoc with Staph. Exotoxin. Young kidsPemphigus vulgaris – flaccid bullae. Autoimmune. Worst oneBullous pemphigoid – tense/thick bullae. Autoimmune. Better of two

Basal cell – most common cell malignancy. Pearly rolled borders. Slow growing

Malignant melanoma – worst one. #1 skin cancer cell. Sun exposed areas. Irregular (shape, color)Squamous – 2nd most common skin malignancy. Indurated raised borders, central ulcer. Face/ear/tongue/hands

Dermatophytes (tineas)Capitis, barbae, pedis, crurisHair loss in areas with hairKerion – inflammatory reaction Topical antifungals – may need oral in hair or nailsVersicolor – malassezia furfur, like seborrhea. Shampoo

Gonococcemia – fever and arthritis (large joints), tenosynovitis. Aspiration often negative, but blood cultures positive

SpirochetesAll Doxy susceptibleLeptospirosis – Weil’s disease (worst: fever, DIC, hepatitis, nephritis)Lyme’s – Ioxdes tick, erythema chronicum migrans (stage 1), Bell’s or myo/pericarditis/heart block or meningitis (stage 2), arthritis (stage 3)Syphilis – painless chancre (1st stage), rash palms and soles, condyloma lata (2nd stage), neuro and CV (third stage).

Jarisch Herxheimer rxn – due to abx treatment

TORCHS infections – cause congenital transmissionToxo, rubella, CMV, herpes, syphilis

Meningococcemia – fever, HA, rashPurpura fulminans – bad outcomeWaterhouse Friderichsen syndrome - adrenal hemorrhages

from this

Necrotizing soft tissue infectionsNec fasc – pain out of proportion. Fournier’s gangrene – scrotum or vulva.

MRSACA-MRSA: purulent skin and soft tissue infections. Rx doxy, bactrim or clinda; vanco or linezolid for serious

Toxic shock syndrome – tampons. Staph exotoxin

TicksRMSF – SE USA, centripetal rash, palms and soles. Thrombocytopenia and hyponatremia. Tetracycline

Ehrlichiosis – like RMSF with no rash and affects WBC’sBabesiosis – NE USA. like malaria, affects RBC’s. Milder than malaria.

Herpes virusCMV – congenital very bad, also bad in AIDS. Rx gancyclovir or foscarnet. One of TORCHSHerpes 1 – oral; herpes 2 – genital. Grouped vesicles. Rx acyclovir

Herpetic whitlowTzank smear – multinucleated giant cellsHerpes encephalitis – temporal lobe, blood in CSFHerpes zoster (varicella) – dermatomal distribution, very painfulHutchinson sign – eye involvementRamsay Hunt – CN 7 involvementDisseminated zoster – admit

AIDSPCP is most frequent opportunistic infectionCrypto meningitis – most common CNS fungal infectionToxo – most common cause of encephalitis. Ring enhancing lesionsOral candida – most common GI infectionKaposi’s – purple painless plaques

Molluscum – umbilicated papules

Mononucleosis – EBV. LAD, exudative pharyngitis, atypical lymphocytes. Splenic rupture. Dx with Monospot. NO abx (rash), no sports

OccupationalNeedlesticks:Hep B surface antigen- infectious. Surface antibody – immunized. E antigen – highly infectious. 2% risk infection with surface antigen and 25-30% with E antigenAntibody >10 probably good for life. Can rx with immuneglobulin +/- vaccine.

Hep C – 2% risk for exposures. No tx available

HIV risk from needlestick 0.3%. increased risk – visible blood contamination; deep injury, hollow needle, source with heavy viral load. Rx – start 1-2 hrs; multi-drug regimens (2-3 meds) x4 weeks.

Malaria – most important travel-related illness. Falciparum – most severe disease, lots of resistance. Tx = quinidine + doxy in chloroquine resistant areas (i.e. Africa)Black water fever – severe hemolysisThick and thin smears

Pedi rashes –Erythema infectiosum (5th disease)– Parvo B19, slapped cheeks, lacy rash. Keep away from SCD and pregnant patients (aplastic crisis with parvo, hydrops in pregnancy)

Hand foot mouth – Coxsackie. Painful oral lesions to anterior mouth; fever; gray vesicles to palms and soles. Supportive

Herpangina – oral ulcers on back of OP.

HSP – vasculitis. Abd pain (GIB, intussusception), renal (hematuria), joints, and the vasculitic rash (buttocks and legs)

Kawasaki – MCLNS. Vasculitis. Coronary artery aneurysms. Criteria – 5 days of fever and 4 of these – conjunctivitis, oral changes, extremity changes, rash, adenopathy. Tx ASA, IV IG

Impetigo – honey colored crusts. Bullous impetigo – staph

Rubella (German Measles) – 3day measles. adenopathy (posterior), rash goes head down. TORCHS

Rubeola (measles) – bad one – 3C’s – cough, coryza and conjunctivitis, Koplik’s spots.

Roseola (exanthema subitum)– herpes. Fever/febrile sz. Fever stops and the rash

Scarlet fever – strawberry tongue, exudative pharyngitis, sandpaper rash. While lines in skin folds. Desquamation. ASO titer. Tx PCN

Varicella (chicken pox) – different stages (dew drop on a rose petal). Complications – PNA, encephalitis. Can rx acyclovir. Vaccine (live)

Salycilate – Reye’s syndrome

Lice – Scabies (burrows; thin skin areas), crabs, etc. rx Kwell, Nix, RID, Elimite, etc

Norwegian scabies – high mite burden

Heme onc

Central cyanosis – 5 gm deoxygenated Hgb. Look in tonguemetHgb – 1.5 grams deoxygenated hgb. Fe+3. Local anesthetics, nitrates, aniline

dyes. O2 sat 85% regardless on O2 administration. Rx methylene blue COhgb – “chery red”, but more like don’t turn blueSulfhgb – 0.5 grams for cyanosis. Irreversible.95% oxygen carried in Hgb, not dissolved

cyanosis unresponsive to O2 – abnormal Hgb or R to L shunt

coombs positive – antibodies to RBC’sG6PD – most common enzyme deficiency

PRBC – each until increases Hgb 1 gramsCitrate – chelates Ca – hypocalcemiaHyperK, worse with older bloodInfuse with NSS (LR has calcium)

Blood content – 70 cc/kg or 5L in manMassive transfusion – early transfusion of other products – platelets and FFP

Transfusion rxnsAcute hemolytic transfusion rxn - Wrong blood type. Fever, back pain, SOB. Stop, hydrate, send blood to lab – free Hgb, haptoglobin, Coombs.

Febrile non-hemolytic – rxn to protein antigens. like the hemolytic one. Labs above are negative.

Allergic transfusion rxns – Not dose related. hives, wheezing, can be anaphylactic. Can continue depending on severity

Infections – HIV 1:2million, Hep C 3:10K

Other – vol overload, hypothermia, hyperK, hypoCa

Type O - universal donor. Rh negative for women of child bearing age.Type AB – universal recipient

Platelets – 5 day storage. Donated by apheresis. 1 unit of platelet raises by 10K (50-60 K if apheresis unit)spont bleeding with platelets <10K; 50K for procedures/traumadysfunctional platelets – ASA (irreversible inhibition), kidney failurelow platelets – ethanol, aplastic marrow, large spleen

ITP – immune rxn to platelets. low platelets. Stop immune system first and then give platelets if bleeding. Tx = steroids splenectomy

TTP – systemic endothelial damage, release of vWF, platelet aggregation, microangipathic hemolytic anemia

HUS – like TTP but kids and more kidney involvement

FFP - what remains after RBC and platelets removed – give 1 per each 5U PRBC’s

Cryo – subproduct of FFP. Pooled (more risk of infection)

Hemostasis testBleeding time now done by platelet function testVon Willebrand factor – released from vessels, tells platelets to aggregate if not in vessel lumen. It also carries factor 8Protime - measures extrinsic system and common pathway (5, 7, 9). WarfarinPTT – measures intrinsic and common. Heparin

DIC – can either cause ischemia (consumption coagulopathy) or bleeding. Low platelets, low fibrinogen, increased FSP, high dimmer, fragmented RBC’s. Prolonged PT!! Rx – give FFP if bleeding, consider heparin if thrombosis

Heparin – does not cross placenta. HIT complication, antidote: protamineLMWH - smaller molecule, no monitoring. Less freq dosing.Warfarin – inhibits 2,7,9,10, C, S (Vit K dependent). Rx with vit K and PCC (FFP if no

PCC)

Contraindications to thrombolysis – BP >185/100, active bleeding or recent <14d bleeding, recent spine or brain surgery (2 weeks), brain tumor or malformations, recent CVA (2-6 mo) or hemorrhagic CVA, bleeding diathesis, on anticoagulants, pregnancy, suspected aortic dissection or pericarditis.

Sickle cell anemia – anemia, high retic count, pain, functional aspleniaPain crisis – from cell sludgingChest syndrome – leading cause of death in sicklers. Pulm infarction. Tx = abx, exchange transfusionSplenic sequestration – kids with shock. 2nd most common cause of deathAplastic crisisCNS crisis – strokesHand foot syndrome – kids with swollen hands and feet.Priapism

Salmonella – it thrives on iron rich tissues

Hemophilia – blood bad to cartilage

A – 85% of cases. factor 8 def. Give DDAVP and then factor 8 concentrate (FFP if not available). Treat before studies.B – factor 9 def

Von Willebrand disease – Most common inherited coagulation disorder. “guides” platelets and carries factor 8. Rx same as hemophilia

HIV related emergenciesLactic acidosis – mitochondrial damage. Medication reactionImmune reconstitution syndrome – when HAART reactivates immune system, exaggerated immune responseKidney stones – indinavir. RadiolucentHypoglycemia – pentamidinemetHgb - dapsoneCMV and varicella – eye complicationsPCP – single cell fungus. CD4<200. Disproportionate dyspnea and hypoxemia. Steroids before abx if hypoxic (PaO2<70 or A-a gradient >35, Bactrim 1st line, atovaquone or pentamidine 2nd lineToxo (ring enhancing lesion) and criptococcus (most common systemic fungus, India ink)– CD4<50. Thrush

Oncology

Cord compression –lung, breast, prostate. Thoracic back painAirway obstruction – voice changes, stridorPericardial effusions – lung and breast, melanoma. Beck’s triad – JVD, hypotension,

muffled heart sounds. ECG – low voltages, electrical alternansSVC syndrome – Lung cancer. egress of blood from head is obstructed. Neck veins,

plethora, face swelling, HAHypercalcemia – PTH hormone-like substance secretion. Also from mets. Lung,

renal, MM, breast. ECG short QTc. Stones, bones, moans, and psychic undertones. Rx fluids and diuretics. Biphosphonates etc later.Calcium x phosphorus product =40

Hyperventilation causes functional hypocalcemia (twitchy etc)SIADH – tumor secrete ADH. Hyponatremia and concentrated urine.Hyperviscosity syndrome – proteins (MM) or WBCs (leukemia). Roulleaux

formationAdrenal insufficiency – consider with fever, dehydration, resistant shock.

Hyponatremia/hyperkalemia/eosinophilia/hypoglycemiaTumor lysis – post chemo. hyperK, hyperphos, low calcium. High uric acid. Rx fluids,

lower phosphorus, alkalinize urine, lower uric acid (allopurinol – inhibits xanthine oxidase; or rasburicase – recombinant urate oxidase)

Neutropenic fever – 50% have occult infection

Rheumatology

Joint fluidsSeptic arthritis –low glucose, WBC >75K, low viscosity, very turbid. Staph (most common overall), salmonella in SCDGonococcal – rash (necrotic pustules), girls, menses

Inflammatory - <50K WBC’s, NL glucose, can have crystalsGout – needle like. Negative birefringence. Podagra – big toe (75%). Rx NSAIDs and colchicinePseudogout – calcium pyrophosphate, rhomboid. Positive birefringence. Rx as gout.

Lyme – rash (ECM, central clearing), neuro (CN 7th), heart (arrhythmias, heart block)

SLEAntiphospholipid syndrome – excessive clotting. recurrent fetal lossButterfly rash (malar), or discoid lesions (scars)Renal – nephritic, nephriticcerebritisRx steroids

Seronegative spondyloarthropathies (rheumatoid factor negative) – symmetric, sacral involvement of joints and tendon/ligament insertions

Ankylosing spondylitis – bamboo spine, uveitis (most common extra articular finding)Reiter’s – arthritis, urethritis, conjunctivitis. Heel preference (“lover’s heel”)Psoriatic arthritis IBD arthritis – both UC and Crohn’s

Rheumatic fever – Jones criteria (CASES); GABHS infection2 major, or 1 major and 2 minor

OB/Gyn

STD’sUlcerative lesions increase risk for HIVNon-ulcerative lesions have discharge

Chlamydia - #1 STD. related to PID. Can be asymptomatic. Nuclear amplification test. Rx doxyPID – cause of infertility and ectopics. Fever, discharge, CMT, abd pain, and adnexal tenderness – treat empiricallyTOA – Admit.Fitz-Hugh-Curtis – perihepatitis from PID. Admit

LGV – C. trachomatis also. Buboes (groove sign) with no genital lesion. Rx doxy x 3 weeks

GC – #2 STD. related to PID. gram neg diplococci. Copious purulent discharge. Rx cephalosporin. Gonococcemia (dermatitis arthritis syndrome). Eye emergency (melts cornea)

Syphilis – painless chancre. Rash, condyloma latum (2ry); CNS – psychosis/neuropathies/tabes dorsalis – no propioception, and heart-aortitis (3ry). Rx PCN LA 2.4 million units

Chancroid – painful ulcer and bubo at same time.Herpes – type 2. Painful vesicles in crops. Recurrent Trichomonas - strawberry cervix. Grey yellow malodorous frothy discharge.

pH>4.5. rx flagyl Genital warts – HPV, assoc with cervical CA.BV – Polymicrobial. copious vaginal discharge, fishy odor. Clue cells. pH>4.5. rx

flagylCandida – white cottage cheese, KOH with hyphae. Rx fluconazole

Bartholin gland abscess – lower aspect of introitus at 5 and 7 o’clock. Drain and insert Word catheter x weeks

Mittleschmerz – ovulation 14 days before menstrual cycle. Pain with ovulationOvarian cyst – usually in luteal phase. Ruptured look like ectopic. Can torse if bigger

(>4 cms) (like torsed testicle, dx with US).Ovarian masses – can also torse, esp dermoids. Ovarian CA – 2nd most common gyn

malignancy. Meig’s syndrome (ascites and pleural effusion)Endometriosis – chocolate cysts. Can be anywhere. Catamenial PTX. Assoc with

infertility.Uterine fibroids – excessive bleedingUterine CA – consider in AUB in perimenopausal women; painless uterine

enlargement.Cervical CA – HPV assoc. is an AIDS defining illness

AUB: irregular excessive bleedingDo pregnancy testDUB – anovulatory bleeding. No luteal phase

OB stuffFundus at umbilicus at 20 wksHCG doubles every 2-3 days for 1st 7-8 weeksPositive within days of ovulation, stays positive x 2-3 weeks

MiscarriageThreatened – bleeding, closed osInevitable – open os, bleedingIncomplete – bleeding pain, products at osComplete – bleeding decreased, sono negative (empty uterus)

Missed – retained productsSeptic abortion – infection, rare

Ectopic pregnancy – positive preg test, abd pain, bleeding. Discriminatory zone: 2K for transvag and 65K for transabdominalBeware of heterotopic in assisted reproduction patients.

RhoGam: passive immunization to all Rh negative moms. 50 mcg if <12 weeks and 300 mcg after that

Molar pregnancy – very high HCG’s, snowstorm appearance on US; passing “grape like stuff”

Abruptio placentae – risks – cocaine/trauma. Uterine tetany, fetal distress. Painful 3rd trimester with dark blood

Placenta previa – reliably seen in US, bright red painless bleeding. NO pelvic exam!

Pregnancy-induced HTN – unknown cause>20 weeks, >140/90pre-eclampsia – HTN, edema, proteinuriaHELLP – Hemolytic anemia, elevated LFTs, low platelets, NL clottingEclampsia – pre-eclampsia plus seizures. RX magnesium and hydralazine/labetalol

Hypermagnesemia – rx calciumAppendicitis – most common surgical emergency in females. Do same w/up. Same

risk as non-pregnant, but more dx delays and more complicationsDrugs to avoid in pregnancy – Coumadin, tetracycline, quinolones, live vaccines,

erythromycin estolate, sulfa (3rd trim), ASA (3rd trim), flagyl (1st trimester)

TraumaMaternal stabilization is 1stDisplace uterus in hypotension third trimesterKB test for fetomaternal hemorrhageAPGAR – appearance, pulse, appearance, grimace, respiration

PROM – ferning test, nitrazine paper – high pH. Sterile exam.

Umbilical cord prolapse – knee chest position, arrest delivery, emergent C-section

Amniotic fluid embolism – CV collapse soon after delivery. Supportive. 50-80% mortality

Fetal distress – late decelerations, also marked tachycardia and bradycardiaMonitor after 26 weeks after trauma

Post partum hemorrhage - #1 cause is uterine atony

Perimortem C section – within 5 minutes of CPR

Endometritis – foul smelling lochia

Mastitis – staph, analgesia, warm compress, abx (dicloxacillin)

Renal/urology

Nephrotic syndrome – protein in urine; hypercoagulable (urinates antithrombin 3), high lipids (lose lipid transporting proteins)

Nephritic syndrome (active sediment – casts, red cells); HTN, volume up

Test taking strategies

Note key word and red flagsEliminate obviously wrong answersOK to guessDo questions!Avoid controversial answers, stay with gold standardPictorial – read the question and try to answer before you see the pictureDon’t get stuck on calculations – waste of time and increases frustrationB most common correct answer; D after that – for numerical questions. Written choices are randomized by first letter of answer, and most verbs start with vowels, which tends to randomize most to ABCStem – question partFoil –wrong answer

4 types of questionsFact questions often have a destabilizer – a rarely know fact. Often not the answer. Can be a “red herring” if in the stem – nothing do to with the case.

2 part question – present a disease and then ask about management or complications. Look at the answers then go back and make the dx

long question with lots of info (camouflage)– look at the answers first and then read the statement again

research questions – similar questions throughout the exam. They are looking at correlation with scores (“test questions”)