UWorld Notes: Step 2 CK
destruction of property, deceitfulness or theft, or
malingering: intentional production of false
physical symptoms for secondary gain
factitious disorder: intentional production affects
physical or psychological signs or symptoms to
assume the sick role; no secondary gain
Hypochondriais: fear of disease and
preoccupation with the body, manifests through
multiple somatic complaints; at least six months
conversion disorder: unexplained serious
neurological symptoms preceded by an obvious
emotional trigger; symptoms are not artificially
produced, unexplained by any medical condition,
can cause social and functional impairment
----------------------------------------------------------------
prolonged hypotension from any cause can lead
to acute tubular necrosis. Hallmark findings on
urinalysis are muddy brown granulomatosis
consisting of renal tubular epithelial cells. Also
seen are serum BUN:creatinine ratio < 20:1,
urine osmolality 300 to 350 mOsm per liter
(never <300), urine sodium > 20 mEq per liter,
FE Na greater than 2%
broad casts are seen in chronic renal failure, due
to dilated tubules enlarged nephrons that have
undergone compensatory hypertrophy in
response to the reduced renal mass
waxy casts are shiny and translucent, also seen in
chronic renal disease
RBC casts are indicative of glomerular disease
or vasculitis; glomerulonephritis
WBC casts are evidence that urinary WBCs
originate in the kidney; seen in interstitial
nephritis and pyelonephritis
fatty casts: nephrotic syndrome
hyaline casts are composed of protein and pass
unchanged along the urinary tract; seen in
asymptomatics and prerenal azotemia
----------------------------------------------------------------
antisocial personality disorder is diagnosed at
age 18 years or older; often display evidence of
conduct disorder as minors
conduct disorder diagnosis requires at least three
symptoms from the following categories:
aggression towards people or animals: topical silver nitrate: prophylaxis against
penicillinase-producing strains of N. gonorrhea
a serious violation of rules (not available in the US)
borderline personality disorder called shortly nasolacrimal duct obstruction presents with
pattern of instability relationships, impulsive and unilateral tearing & minimal conjunctival
or reckless; have identity disturbance, recurrent injection; Rx massage nasolacrimal ducts
suicidal or self-mutilating behavior, feelings of ----------------------------------------------------------------
emptiness hypotension, tachycardia, flat neck veins,
histrionic personality disorder: excessively labile confusion, and cold extremities despite IV fluids
emotions and attention seeking behavior resuscitation: hypovolemic/hemorrhagic shock
---------------------------------------------------------------- cardiogenic shock: decreased cardiac output
causes elevated venous filling pressures and JVD
common etiologies of neonatal conjunctivitis loss of vascular tone occurs in septic &
Type Onse Findings Treatment neurogenic shock
t age ----------------------------------------------------------------
Chemical 24 Mild conjunctival Eye meniscal and ligamentous tears can both be a/w a
hours irritation/injectio lubricant popping sensation following a precipitating
n and tearing injury
after silver nitrate meniscal injuries cause gradual joint swelling
ophthalmic over 12 to 24 hours
prophylaxis ligamentous injuries (ACL) cause rapid joint
Gonococca 2 - 5 Eyelid swelling; IV or IM swelling due to hemarthrosis (ligaments have
l days profuse purulent ceftriaxone greater vascular supply than menisci, which rely
discharge; or on diffusion for nourishment)
corneal cefotaxime MRI provides definitive diagnosis
ulceration ----------------------------------------------------------------
Chlamydial 5 - eyelid swelling; oral Ulcerative colitis occurs more frequently in
14 chemosis; bloody erythromyci females, Ashkenazi Jews, with a peak incidence
days or mucopurulent n at ages 15 to 25
discharge UC is confined to the mucosal layer, while
Crohns disease is transmural
gonococcal conjunctivitis is the most destructive;
UC causes bloody diarrhea, tenesmus, cramping
resulting in corneal perforation and permanent
severe disease is marked by weight loss, fever,
blindness
anemia
ceftriaxone should be avoided in infants with
diagnosis is confirmed by friable mucosa on
hyperbilirubinemia has it results in displacement
colonoscopy and biopsy demonstrating mucosal
of bilirubin from albumin-binding sites,
inflammation
increasing the risk of kernicterus
extraintestinal compliations include sclerosing
oral erythromycin is the treatment of choice for
cholangitis, uveitis, erythema nodosum, and
both chlamydial conjunctivitis and pneumonia;
spondyloarthropathy
increased risk of infantile hypertrophic pyloric
severe complications include toxic megacolon
stenosis
and colorectal carcinoma
topical erythromycin: neonatal prophylaxis
routine surveillance with yearly colonoscopies is
against gonococcal conjunctivitis
recommended beginning 8 to 10 years after
 diagnosis for prevention and/or early detection of Hysterectomy no screening if no history of risk with ASA use, causing life-threatening
colon cancer without cervix high-grade lesions, cervical hepatic encephalopathy)
---------------------------------------------------------------- cancer, or exposure to DES complications: coronary artery aneurysms,
adjustment disorder: emotional or behavioral ---------------------------------------------------------------- leading to MI & ischemia
symptoms developing within 3 months of weight loss in obese patients is the most effective perform a baseline echocardiography in all
exposure to an identifiable stressor that rarely lifestyle intervention for reducing blood pressure suspected cases; repeat to monitor changes
lasts more than 6 months after the stressor ends DASH diet for is the next most effective ----------------------------------------------------------------
patient experiences marked distress in excess of approach in preventing and treating hypertension complication of untreated streptococcal
what would be expected from exposure to the especially in nonobese individuals, then exercise, pharyngitis: Scarlet fever
stressor dietary sodium, alcohol intake presents with tonsillar exudates, sandpaper-like
treatment of choice is cognitive or cigarette smoking causes a transient rise in BP rash that spares palms & soles
psychodynamic psychotherapy to develop coping ---------------------------------------------------------------- perform throat culture
mechanisms, response to and attitude about maternal risk factors for fetal macrosomia: Rx: amoxicillin
stressful situations advanced maternal age, obesity, diabetes,
SSRIs can be adjunctive therapy for depressive ----------------------------------------------------------------
multiparity Rheumatoid arthritis
symptoms African & Hispanic males are at increased risk
---------------------------------------------------------------- o morning stiffness >30 min, improves with
for fetal macrosomia, a risk factor for shoulder activity
atypical squamous cells, cannot rule out high-
dystocia o tenosynovitis of palms (trigger finger)
grade squamous epithelial lesion (ASC-H) is a/w
excessive traction on the neck during delivery o cervical joint involvement can lead to
premalignant lesions
can result in Erb-Duchenne palsy subluxation spinal cord compression
atypical squamous cells of undetermined
o involves 5th, 6th, 7th CN o positive anti-cyclic citrullinated peptide
significance (ASC-US) is the most common
o most infants recover arm function (anti-CCP)
cervical cytological abnormality, but the risk of
spontaneously within 3 months o CRP & ESR elevation correlate with disease
invasive cervical cancer is low
o Rx: gentle massage & PT to prevent o XR: soft-tissue swelling, joint space
ASC-US or LSIL for women age 21 24: repeat
contractures narrowing, bony erosions
pap smear in 1 year
---------------------------------------------------------------- greatest risk for osteoporosis
o colposcopy only if ASC on 3 consecutive
cephalohematoma: subperiosteal bleed, does not Rx: physical activity, optimize Ca++ & Vit D
paps or any ASC-H, atupical glandular cells,
or HSIL cross suture lines; resolves spontaneously intake, minimize corticosteroids, consider
---------------------------------------------------------------- bisphosphonates
ASC-US in women age 25: HPV testing
Kawasaki disease (mucocutaneous lymph node ----------------------------------------------------------------
o HPV positive = colposcopy
syndrome) is a clinical diagnosis avascular necrosis is common with systemic
o HPV negative = repeat pap & HPV in 3 yrs
o common in age < 5 corticosteroid therapy, heavy alcohol, SLE, or
o fever 5 days sickle cell disease
Cervical cancer screening
o irritability Paget disease of bone = osteitis deformans is due
Immunocompromised Onset of sexual
(HIV, SLE, organ o B/L non-exudative conjunctivitis to osteoclast overactivity, leading to replacement
intercourse
transplant on every six months x2 o cervical lymphadenopathy > 1.5 cm of lamellar bone with abnormal woven bone
immunosuppressants) o mucositis (injected/fissured lips or osteosarcoma risk factors: Paget disease,
than annually
strawberry toungue) radiation & chemotherapy exposure
Age 21 No screening
o polymorphous rash ----------------------------------------------------------------
21 to 29 cytology every 3 years
o coronary artery aneurysm Osteitis fibrosa cystica (Von Recklinghausen
30 to 65 cytology every 3 years
o swelling/erythema of palms/soles disease) presents with bony pain
OR cytology + HPV
Rx: ASA & IV immunoglobulin within 10 days excessive osteoclastic resorption, leads to
testing every 5 years
of fever to prevent cardiac complications, but replacement with fibrous tissue (brown tumors)
65 No screening if negative a/w parathyroid carcinoma
prior screens & not high-risk usually self-limited (caution: Reye syndrome
----------------------------------------------------------------
 Bronchiolitis: commonly caused by RSV avoid interventions that provoke vomiting (milk, ----------------------------------------------------------------
older children causes self-limited URI activated charcoal, vinegar, NG lavage) erythema chronicum migrans is hallmark of early
age < 2 involves lower respiratory tract ---------------------------------------------------------------- localized Lyme disease (Borrelia burgdorferi)
wheezing/crackles & respiratory distress with Pinworm infection can present with also a/w headache, malaise, fatigue, fever
waxing/waning peaking at 5-7 days erythematous vulvovaginitis in prepubertal early diagnosis is based on the trademark rash &
Rx: supportive care females; absence of vaginal discharge recent travel to Lyme-endemic areas
prophylaxis: Palivizumab for high risk cases recurrent episodes of nocturnal itching should be Rx: oral doxycycline (age > 8)
complications: apnea & respiratory failure; examined with the Scotch tape test Rx: oral amoxicillin (age < 8 & pregnancy) or
develops recurrent wheezing empiric Rx: mebendazole cefuroxime
increased risk of acute otitis media; rarely ---------------------------------------------------------------- ----------------------------------------------------------------
bacterial pneumonia or sepsis B/L, nontender, upper abdominal masses; chemotherapy-induced peripheral neuropathy
---------------------------------------------------------------- progressive renal insufficiency, early-onset HTN from vincristine (also cisplatin, paclitaxel)
alpha-1-antitrypsin counteracts neutrophil begins after several weeks, presents as
elastase ADPKD symmetric paresthesia in fingers/toes, spreads
AAT deficiency: uninhibited elastase causes symptoms most are asymptomatic proximally in stocking-glove pattern
bullous, panlobular emphysematous changes of hematuria early loss of ankle jerk reflexes, pain & temp
the lower lobes flank pain (due to renal calculi, cyst sensation, occasional motor neuropathy
centrilobular changes occur with smoking- rupture, hemorrhage, or upper UTI) ----------------------------------------------------------------
induced emphysema clinical signs early onset HTN sudden onset C/L lower extremity motor &
AAT deficiency can cause liver disease: b/l upper abd. masses sensory deficits with UMN signs: anterior
cirrhosis, neonatal hepatitis, or liver failure proteinuria cerebral artery occlusion
---------------------------------------------------------------- chronic kidney disease ----------------------------------------------------------------
Caustic ingestion extrarenal cerebral aneurysm Spinal cord compression
features hepatic/pancreatic cysts Causes spinal injury
Features Chemical burn or liquefaction
cardiac valve disorders (MVP, AR) malignancy
necrosis results in:
diverticulosis infection (epidural abscess)
hoarseness, stridor, orofacial
ventral/inguinal hernias Signs & gradual severe local back pain
inflammation (laryngeal damage)
diagnosis abdominal USS Symptoms pain worse when recumbent & at night
dysphagia, odynophagia
(esophageal damage) management monitor BP & renal Fx, potassium early: symmetric weakness, hypoactive/
epigastric pain, bleeding (gastric control cardiovascular risk factors absent DTRs
ACE-inhibitors for HTN late: B/L Babinski, decreased rectal
damage)
ESRD: dialysis, renal transplant tone, paraparesis with increased DTRs,
Management secure ABCs
sensory loss
remove contaminated clothing, Manage emergency MRI
central obesity, facial plethora, proximal muscle
irrigate exposed skin IV glucocorticoids
weakness, abdominal striae, ecchymosis:
CXR if respiratory symptoms
Cushings syndrome
upper endoscophy within 24 hr sensory ataxia, brief stabbing pains, Argyll-
headaches, palpitations, diaphoresis a/w
barium contrast (2-3 weeks) Robertson pupils (accommodate but do not
paroxysmal BP elevations: pheochromocytoma
Complication perforation measure urinary vanillylmandelic acid & react): Tabes dorsalis, a manifestation of late
s esophageal strictures metanephrines neurosyphilis
pyloric stenosis ---------------------------------------------------------------- ----------------------------------------------------------------
ulcers primary manifestations of Chagas disease: recent recurrent pneumonias in the same anatomic
cancer immigrant from Latin America with chronic region suggest bronchial obstruction;
megacolon/megaesophagus & cardiac disease bronchogenic carcinoma is most concerning with
(CHF: pedal edema, JVD, S3, cardiomegaly) a smoking history
 chest CT is indicated initially
o central masses or negative CT: bronchoscopy
o peripheral lesions: CT-guided biopsy
recurrent pneumonias in different regions:
o sinopulmonary disease (CF, immotile cilia)
o immunodeficiency (HIV, leukemia)
o vasculitis, bronchiolitis obliterans
recurrent aspiration, same lung region
o seizures
o ethanol/drug use
o GERD, dysphagia, achalasia
----------------------------------------------------------------
hypotension, tachycardia, poor skin turgor,
lethargy, confusion: hypovolemic hypernatremia
IV normal saline (0.9%) is preferred for
symptomatic hypovolemic hypernatremia until
euvolemic, then 5% dextrose
serum Na+ should be corrected by 0.5 mEq/dL/hr,
as cerebral edema can result if too rapid
high serum & low urine osmolality due to
inadequate ADH response is most likely due to
lithium-induced nephrogenic DI
Lithium induces ADH resistance, resulting in
acute-onset nocturia, polyuria, & polydipsia
Rx: discontinue lithium; or salt restriction &
diuretics (amiloride)
hemodialysis is indicated for serum lithium level
4 mEq/L or 2.5 mEq/L + signs of significant
toxicity or renal disease
----------------------------------------------------------------
secondary effects provoked by nitroglycerin like
increased contractility & reflex tachycardia are
due to changes in baroreceptor activity in
response to decrease BP from venodilation
----------------------------------------------------------------
polyarthralgia, tenosynovitis, and painless
vesiculopustular skin lesions suggest
disseminated gonococcal infection
lesions can number from 2 - 10 and appear
similar to furuncles or pimples
the person chills may be present
history of recent unprotected sex with a new
partner
all patients should undergo HIV screening
----------------------------------------------------------------
petechial rash, fever, headache, nausea\vomiting,
stiff, and photophobia: meningococcemia
fever, arthralgia, sore throat, lymphadenopathy,
mucocutaneous lesions, diarrhea, weight loss:
acute HIV infection
migratory arthritis of large joints, erythema
marginatum (raised ring-shaped lesions over
trunk and extremities), subcutaneous nodules,
carditis, Sydenham chorea: acute rheumatic fever
o an episodes of pharyngitis precedes the
onset of ARF by 2 - 4 weeks
----------------------------------------------------------------
best method of reducing maternal-fetal
transmission of HIV infection: triple HAART
therapy for the mother throughout pregnancy
HAART: dual NRTI + NNRTI or protease
inhibitor
test viral load monthly until undetectable, then
every 3 months
CD4 cell count every 3 months
avoid amniocentesis until viral load undetectable
mothers with undetectable viral loads at delivery
have 1% risk for transmission
intrapartum mother not on HAART: Zidovudine
intrapartum viral load > 1000 copies/mL:
Zidovudine + C-section
infants: Zidovudine for 6 wks & serial HIV
PCR testing
----------------------------------------------------------------
blunt abdominal trauma iscommonly caused by
MVAs; most common organs injured are the
liver and spleen
free peritoneal fluid should raise suspicion for
liver or splenic laceration
hemodynamically unstable patients with
evidence of free intraperitoneal fluid on
ultrasound need emergency laparotomy
splenic lacerations that are hemodynamically
stable with no evidence of other intra-abdominal
injuries may be managed nonoperatively
----------------------------------------------------------------
PDA-dependent congenital heart disease
Ductus arteriosus coarctation of the aorta
transposition of the great arteries
hypoplastic left lung syndrome
total anomalous pulmonary venous connection
tricuspid atresia
Normal ductus arteriosus constricts around day 3
of life
prostaglandin E1 is a vasodilator used to prevent
ductus arteriosus closure
inspired O2 stimulates PDA constriction
indomethacin is a potent prostaglandin inhibitor,
stimulating PDA closure
---------------------------------------------------------------
ventricular free wall rupture is a mechanical
complication occurring within 5 days to 2 weeks
after an acute MI (usually anterior); presents
with acute onset chest pain & profound shock,
with rapid progression to pulseless electrical
activity (PEA) and death
abrupt LV rupture leads to hemopericardium and
eventual cardiac tamponade
LV free wall rupture should be suspected in
patients with PEA after the recent first line no
signs of heart failure
----------------------------------------------------------------
acute peri-infarct pericarditis can occur within 1
to 3 days after an MI; pericardial friction rub
with or without chest pain
o self-limited, resolves with supportive care
posted-MI pericarditis occurring weeks to
months after an MI: Dressler syndrome
o improves with NSAIDs
----------------------------------------------------------------
interventricular septum rupture occurs 3 to 5
days after MI; causes a VSD, not pericardial
tamponade
sudden onset hypotension, CHF, holosystolic
murmur heard best at lower left sternal border
----------------------------------------------------------------
papillary muscle rupture occurs 3 to 5 days after
infarction, causing hypotension secondary to
severe acute mitral regurgitation and pulmonary
edema will
----------------------------------------------------------------
acute massive PE can cause hypotension
&syncope, leading to pulseless electrical activity
in some cases of
---------------------------------------------------------------- rupture days pain, effusion strabismus after age 4 months is abnormal and
ventricular aneurysm occurs as a late to 2 JVD, with requires treatment to prevent amblyopia (vision
complication (weeks to months) of acute STEMI wee distant tampon loss from disuse of deviated eye)
scarred or fibrotic myocardial wall resulting ks heart ade intermittent strabismus can be expected in
from healed transmural MI sounds infants < 4 months due to immaturity of
can present as heart failure, refractory angina, extraocular muscles; reassurance & observation
ventricular arrhythmias, or systemic arterial ---------------------------------------------------------------- esotropia beyond infancy must be treated to
embolism due to mural thrombus formation Sarcoidosis diagnosis is based on compatible Hx, prevent amblyopia
---------------------------------------------------------------- CXR: hilar adenopathy with/without first 5 years of life are critical to development of
hypotension or shock, JVD, clear lungs, reticulonodular infiltrates, & biopsy of visual acuity, a time of visual cortex maturity
Kussmaul sign: right ventricular infarction noncaseating granulomas; elevated serum ACE the deviated eye can be strengthened by patching
EKG: inferior MI &/or ST elevation in leads also supports the diagnosis the normal eye (occlusion therapy) or blurring
V4R V6R no definitive diagnostic test the normal eye with cycloplegic drops
---------------------------------------------------------------- presents with cough, dyspnea, erythema (penalization)
nodosum, anterior uveitis, acute polyarthritis new onset strabismus can be a sign of
Mechanical complications of acute MI asymptomatics are followed without treatment retinoblastoma if accompanied by white reflects
Tim Coron Clinical echo due to high rate of spontaneous remission acute onset strabismus can result from
e ary findings symptomatic disease Rx: systemic glucocorticoid intracranial hemorrhage, brain abscess, or
artery ---------------------------------------------------------------- encephalitis; performed brain MRI
involv Rx for SLE, malaria prophylaxis, acute malaria, ----------------------------------------------------------------
ed rheumatoid arthritis: hydroxychloroquine encephalopathy, ocular dysfunction, gait ataxia:
Right Acut RCA Hypotens Prokinet Rx for inflammatory bowel disease, ankylosing Wernicke encephalopathy
ventricular e ion ic RV spondylitis, rheumatoid arthritis: infliximab giving IV fluids containing glucose prior to
failure social (TNF-alpha blocker) thiamine can precipitate or worsen WE
lungs Rx for histoplasmosis: itraconazole thiamine should be given along with or before
Kussmau o sarcoidosis & histoplasmosis present with glucose
l sign similar symptoms & CXR; biopsy reveals ----------------------------------------------------------------
Papillary Acut RCA acute, Severe yeast forms in histoplasmosis flumazenil: competitive antagonists of
muscle e, 3 severe MR Rx for SLE with renal involvement: GABA/benzodiazepine receptor; Rx
rupture to 5 pulmonar with cyclophosphamide benzodiazepine overdose (slurred speech, ataxia,
days y edema flail ---------------------------------------------------------------- hypotension, depressed mental status)
new leaflet sudden onset abdominal pain a/w vaginal bleed, labetalol: Rx hypertensive encephalopathy (BP
holosysto fetal HR abnormalities, & loss of fetal station 180/120 mmHg, headache, N/V, confusion)
lic during active labor: uterine rupture ----------------------------------------------------------------
murmur o risk factors: pre-existing uterine scar, acute onset back pain after physical exertion,
Interventric Acut LAD Shock & left to abdominal trauma paravertebral tenderness, absence of radiation,
ular septum e, 3 apical chest right o prior low transverse c-section: < 1% risk negative straight leg raise test, normal
rupture/def to 5 RCA pain, shunt neurological exam: lumbosacral strain
o prior vertical c-section: as high as 9%
ect days basal holosysto o Rx: NSAIDs, early mobilization
HTN & cocaine use: risk for placental abruption
lic
sinusoidal fetal HR pattern: vasa previa acute intense pain, local spinal tenderness:
murmur,
fever, tender uterus, foul-smelling lochia, vertebral compression fracture
biventric
progression to sepsis: endometritis o risk factors: postmenopausal or senile
ular
failure ---------------------------------------------------------------- osteoporosis, steroid treatment
Ventricular first LAD Shock Pericard ----------------------------------------------------------------
free wall 5 and chest ial Cryptococcal meningoencephalitis
Features headache, fever, malaise, altered mental
status
develops over 2 weeks (subacute)
more acute & severe in HIV (CD4
100/ L
Diagnosis CSF features
high opening pressure
low glucose, high protein
WBC 50/L (mononuclear
predominant)
transparent capsule on India ink
cryptococcal antigen positive
culture on Sabouraud agar
Treatment Initial: amphotericin B with flucytosine
maintenance: fluconazole
serial lumbar puncture may be required to
reduce increased ICP
initiation of retroviral therapy for HIV in the
setting of acute infection is not recommended
due to risk of immune reconstitution syndrome
antiretroviral therapy should be deferred at least
2 weeks after completing induction antifungal
therapy for cryptococcal meningitis
itraconazole does not cross the BBB
sulfadiazinepyrimethamine: Rx cerebral
toxoplasmosis (headache, focal neurologic
deficits, &/or seizures); multiple ring-enhancing
brain lesions with edema
----------------------------------------------------------------
Baker cysts: excessive fluid production by an
inflamed synovium accumulates in popliteal
busa, results in a tender mass; common with
rheumatoid arthritis, osteoarthritis, cartilage tears
DDx: subcutaneous abscess, lymphedema
Baker cysts may burst and release contents into
the calf, presenting similar to DVT
----------------------------------------------------------------
prostaglandin-only oral contraceptives are
preferred for hormonal contraception for
lactating mothers
o does not affect volume or composition of
milk produced, or risk of venous thrombosis
a/w combination pills
lactation alone causes anovulation, thus some (preload
degree of contraception due to high prolactin )
levels which inhibit GnRH release, but not Cardiac 2-4
considered a reliable form of birth control index L/min/
---------------------------------------------------------------- (pump m2
Eikenella corrodens: G-negative anaerobe part of function
normal oral flora )
o infective endocarditis due to E. corrodens is Systemi
seen in poor dentition, periodontal infection, c
or manipulative dental procedures vascular
E. corrodens belongs to the HACEK group resistanc
congential heart lesions (bicuspid aortic valve, e
PDA, ToF, VSD) predisposes to risk of IE (afterloa
ulcerative colon lesions due to colonic neoplasia d)
or inflammatory bowel disease predisposes to IE Mixed
due to Strep gallolyticus (S. bovis type I) venous
S. aureus is the MCC of IE among IVDA O2
Enterococci (E. faecalis) commonly cause saturatio
n
endocarditis a/s nosocomial UTIs
----------------------------------------------------------------
acute pancreatitis can cause ARDS intravascular volume loss decreases LV
mechanical vent.: FiO2 improves oxygenation, preload decreased C.O. & systemic BP
increased HR & peripheral vasoconstriction
PEEP prevents alveolar collapse
(systemic vascular resistance)
arterial pO2 measures oxygenation, influenced
o pulmonary capillary wedge pressure
by FiO2 & PEEP
(PCWP) is a measure of LA pressure & LV
arterial pCO2 measures ventilation, affected by
end-diastolic pressure, are decreased
respiratory rate & tidal volume
cardiogenic shock leads to decreased C.O. & BP
initial ventilator management is decrease FiO2
increased HR & SVR maintains organ perfusion
to non-toxic values (< 60%); goal = paO2 60
increased PCWP due to heart failure
PEEP can be increased to maintain oxygenation
vasodilatory/distributive shock due to sepsis,
o decreasing PEEP lowers oxygenation by
anaphylaxis, SIRS, or CNS injury significant
decreasing availability of alveoli decease in SVR & BP, with compensatory HR &
---------------------------------------------------------------- C.O. increase
Hemodynamic measurements in shock o O2 saturation increases due to high flow rate
Normal Hypovole Cardioge Septic & decreased organ perfusion
mic shock nic shock shock o as sepsis progresses vasoconstriction with
RA 4 normal, rise in SVR & decline of C.O.
pressure mmHg or ----------------------------------------------------------------
(preload dizziness described as spinning sensation
)
accompanied by nausea: vertigo
Pulmona 9 normal,
vertigo classification: central or peripheral
ry mmHg or
o peripheral vertigo has a shorter interval
capillary
wedge o ear fullness suggests peripheral vertigo
pressure o CN VIII lesions lead to central vertigo
 vertigo with a sensation of ear fullness suggests transesophageal echo (TEE) is preferred over ----------------------------------------------------------------
Menieres disease, from abnormal accumulation chest CT with contrast in patients with kidney constrictive pericariditis is a complication of
of endolymph in the inner ear disease or contrast-induced nephropathy mediastinal irradiation (from Hodgkin lymphoma)
o may cause hearing loss & tinnitus patients should not receive antiplatelets (ASA, & cause of right heart failure (hepatomegaly,
---------------------------------------------------------------- clopidogrel) or anticoagulation without first progressive peripheral edema, JVD, ascites)
gaze abnormalities, limb ataxia, sensory loss, excluding aortic dissection can present 10 20 yrs after irradiation or
vertigo, Horners syndrome: Wallenberg ---------------------------------------------------------------- anthracycline therapy
syndrome (lateral medullary infarct) Lithium therapy results from scarring & inelastic pericardium
---------------------------------------------------------------- Indications mania due to bipolar CXR: pericardial calcifications
> 2 weeks of persistent, high-volume, non-bloody Contraindication chronic kidney disease echo confirms Dx: pericardial thickening,
watery diarrhea after recent travel; no fever, cardiovascular disease abnormal septal motion, bi-atrial enlargement
tenesmus or vomiting: Cryptosporidium parvum hyponatremia or diuretic use Rx: diuretics for temporary relief;
travel-associated diarrhea > 2 weeks: parasistic Baseline studies BUN/creatinine, U/A pericardiectomy for refractory symptoms
(cryptosporidium cystoisospora, microsporidia, Ca++
Giardia) Thyroid function Constrictive pericarditis
diarrhea < 1 week: viral or bacterial EKG if coronary risk factors Etiology idiopathic or viral
o rotavirus/norovirus: vomiting cardiac surgery
Adverse effects Acute
o ETEC/EPEC: contaminated food/water tremor, ataxia, weakness radiation therapy
o Campylobacter: abd pain, blood diarrhea, tuberculosis
polyuria, polydipsia
pseudoappendicitis Features fatigue, dyspnea on exertion
vomiting, diarrhea, weight gain
o Samonella: frequent fever peripheral edema, ascites
cognitive impairment
o Shigella: fever blood diarrhea, abd pain JVD, Kussmaul sign
Chronic hepatojugular reflux
Entamoeba histolytica causes amibiasis, nephrogenic DI
resulting in abdominal pain & bloody diarrhea pericardial knock (mid-diastolic sound)
thyroid dysfunction pulsus paradoxus
----------------------------------------------------------------
hyperparathyroidism with Diagnosi EKG: nonspecific, a-fib, or low voltage
extertional dyspnea, syncope, angina: aortic
hypercalcemia s QRS complexes
stenosis
o systolic ejection murmur radiating to apex & pericardial calcification & thickening
Lithium has a narrow therapeutic window, thus prominent x & y descents
carotid arteries
monitor every 6 12 months or 5 7 days after ----------------------------------------------------------------
o peripheral pulse: pulsus parvus et tardus
dose changes or possible drug interactions spontaneous esophageal rupture after severe
(rises gradually & delayed peak)
(diuretics, NSAIDs, SSRIs, ACE-I, phenytoin, retching/vomiting: Boerhaave syndrome
exaggerated decrease (> 10 mmHg) in systemic
carbamazepine) CXR: left-sided pleural effusion with/without
arterial BP with inspiration: pulsus paradoxus; during pregnancy may cause Ebsteins anomaly,
suggests cardiac tamponade pneumothorax, subcutaneous emphysema, &
polyhydramnios, DI, floppy infant syndrome widened mediastinum
pulmonary edema, a-fib, late diastolic murmur
no effect on liver function, lipids, or glucose pleural fluid: exudative, low pH, high amylase
with opening snap: mitral stenosis
---------------------------------------------------------------- (>2500 IU)
----------------------------------------------------------------
long-acting injectable antipsychotics (depot) are confirm Dx: CT or contrast esophagography with
sudden severe chest pain radiating to back,
useful for chroni noncompliance, but have Gastrografin
severe HTN, decrescendo diastolic murmur of
previously responded to oral antipsychotics Mallory-Weiss Boerhaave
aortic regurgitation: acute aortic dissection
o 1st & 2nd generations available as depot Etiology mucosal tear transmural tear
o also weak or absent peripheral pulses, &
o given as IM every 2 4 wks forceful forceful retching
systolic BP > 20 mmHg between arms
treatment-resistant schizophrenia: clozapine retching esophageal air/fluid
o heard better at right sternal border
o requires routine monitoring: CBC submucosal leakage
CXR & EKG to exclude other Dx
o risk of agranulocytosis arterial or
serum creatinine, contrast allergy?
 venule plexus o pain, tenderness, erythema in nasal vestibule
bleeding o potentially life-threatinging if spread to ----------------------------------------------------------------
Features vomiting, vomiting, retching cavernous sinus
retching chest/upper abd pain ----------------------------------------------------------------
epigastric pain odynophagia, fever, blunt abdominal trauma can cause splenic injury, ----------------------------------------------------------------
hematemesis dyspnea, or septic shock presenting as delayed onset hypotension, LUQ
subcutaneous emphysema pain radiating to left shoulder due to
Imaging confirm Dx CT or contrast diaphragmatic irritation (Kehr sign) ----------------------------------------------------------------
with EGD esophagography with Dx: abdominal CT with contrast if
Gastrografin hemodynamically stable
CXR: pneumomediastinum hemodynamic instability despite IV fluids ----------------------------------------------------------------
& pleural effusion requires laparotomy
pleural fluid: exudative, ----------------------------------------------------------------
low pH, high amylase hypotension, tachycardia, distended neck veins, ----------------------------------------------------------------
Treatment self-limited conservative: cervical electrical alternans: cardiac tamponade
endoscopic perforations ----------------------------------------------------------------
therapy as surgery: thoracic
stress fractures are common in the anterior ----------------------------------------------------------------
needed perforations middle third of the tibia in jumping sports &
posteromedial distal third of the tibia in runners
---------------------------------------------------------------- XR is typically normal initially
acute pancreatitis can cause unilateral, left-sided ----------------------------------------------------------------
Dx with MRI or bone scan
pleural effusion with high amylase concentration, ----------------------------------------------------------------
but not widened mediastinum
cephalohematoma: subperiosteal hemorrhage
cocaine use predisposes to aortic dissection with ----------------------------------------------------------------
limited to one cranial bone, presents several
wide mediastinum & unilateral pleural effusion, hours after birth; resorbs spontaneously
but not high amylase content
Caput succedaneum: diffuse, ecchymotic
aspiration pneumonia is common in the right ----------------------------------------------------------------
swelling of the scalp that crosses suture lines
lower lobe & unilateral pleural effusion due to
----------------------------------------------------------------
parapneumonic effusion or empyema infant with failure to thrive, B/L cataracts,
o pleural fluid shows elevated WBCs, protein, ----------------------------------------------------------------
jaundice, hypoglycemia: glactosemia
& LDH, but not amylase glactose-1-phosphate uridyl transferase deficiency
----------------------------------------------------------------
also vomiting, hepatomegaly, convulsions
complications following rhinoplasty: ----------------------------------------------------------------
increased risk for E.coli neonatal sepsis
dissatisfaction, nasal obstruction, epistaxis
early Dx & Rx: eliminating galactose from diet
nasal septum has poor blood supply &
complications: cirrhosis, mental retardation
regenerating capacity, thus trauma or surgery ----------------------------------------------------------------
may result in septal perforation ----------------------------------------------------------------

presents as a whistling during respiration due to galactokinase deficiency: cataracts only

a septal hematoma following rhinoplasty ----------------------------------------------------------------
----------------------------------------------------------------
---------------------------------------------------------------- solitary, painful, lytic long bone lesion with

allergic rhinitis: rhinnorhea, nasal pruritis, overlying tender swelling & hypercalcemia in a

cough; nasal mucosa is edematous & pale, child: Langerhans histiocytosis
locally destructive, but resolves spontaneously ----------------------------------------------------------------
polyps may be present
nasal furunculosis results from staphylococcal benign, Rx conservative

folliculitis due to nose-picking or hair plucking ----------------------------------------------------------------
11 ----------------------------------------------------------------
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