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An anorectal fistula can present with perirectal pain, purulent discharge, an
inflammatory papule/pustule with a palpable fistula tract. Management includes
assessing extent of fistula with gentle probe or imaging and surgical correction
(fistulotomy). Anorectal fistulas are most often due to rupture of a perianal abscess with
formation of a residual sinus tract. They can also occur due to Crohn’s radiation
proctitis, and atypical infections (lymphogranuloma venereum) or trauma.
Tumors in bladder have painless hematuria THROUGHOUT micturition whereas tumors
in the bladder neck only have terminal hematuria.
Chemotherapy related diarrhea is due to direct cytotoxic effect of medications on
intestinal mucosa, which results in voluminous, watery, and persistent diarrhea despite
periods of fasting (nocturnal diarrhea). Management of Chemo diarrhea includes oral
hydration and antidiarrheal therapy with loperamide or diphenoxylate-atropine
Patients with a large anterior STEMI from occlusion of LAD are at highest risk of LV
aneurysm formation, which can lead to LV thrombi that can embolize.
Arterial blockage will cause cold, mottled extremity lacking pulses while venous
blockage will cause swelling and warmth. SO acute limb ischemia after an
MI suggests embolization from LV thrombus. TTE should be performed to screen for LV
aneurysm and/or residual LV thrombus.
Focal nodular hyperplasia nodules in the liver show evidence of increased arterial blood
flow and sometimes a central scar.
Neck pain/stiffness and low-grade fever are common in SAH due to blood-induced
meningeal irritation. Xanthochromia (pink/yellow tint to CSF) is caused by hemoglobin
degradation products and it appears in CSF as soon as 2 hours after SAH and persists for
weeks.
Nontreponemal tests (abs to cardiolipin-cholesterol-lecithin like RPR, VDRL) can possibly
come back negative in early syphilis infection; a decrease in their titers confirms tx.
Treponemal tests (abs to treponemal antigens like FTA-ABS, TP-EIA) have greater
sensitivity in early infection and come back positive even after treatment. // A pathergy
test is useful for diagnosing Behcet syndrome (recurrent oral ulcers and multiple painful
genital ulcers
Patient presents with hypokalemia, alkalosis, and normotension, suspect surreptitious
vomiting, diuretic abuse, Barter syndrome, Gitelman’s syndrome.
Central retinal artery occlusion can have a whitened retina (due to edema) and cherry
red macula. Patients also usually have a defect in the afferent pupil reflex. Patients with
hypertensive retinopathy typically DO NOT have an acute loss of vision. Central retinal
vein occlusion has “blood and thunder appearance” (looks REALLY bad)
COPD hyperinflation is due to “air stacking.” In COPD, the diaphragmatic flattening and
muscular shortening caused by hyperinflation result in more difficulty in decreasing
intrathoracic pressure during inspiration and therefor increase the work of breathing.
Decreased alveolar elasticity in COPD causes lung hyperinflation, increased TLC, FRC, RV,
and diaphragmatic flattening.
Females lose hair at vertex, center of scalp, sparing the hairline. Tx is with minoxidil.
Female pattern hair loss is characterized by the replacement of terminal hairs by smaller
vellus hairs (follicular miniaturization). Androgen levels are normal in women with FPHL.
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Cardiotoxicity causes most deaths in TCA overdose. TCAs inhibit fast sodium channels
which decreases conduction velocity which results in hypotension, QRS widening, and
ventricular arrhythmias. QRS >100 msec in the setting of TCA overdose is an indication
for sodium bicarb therapy which increases serum pH and extracellular sodium The
increased pH decreases drug affinity for sodium channels and elevated Na concentration
increases the electrochemical gradient across cardiac cells.
Urine alkalinization is the mechanism responsible for increasing salicylate excretion in
aspirin overdose.
Postherpetic neuralgia is characterized by burning pain and hyperesthesia lasting >4
months following acute zoster. Tx is with gabapentin or TCAs
Smoking induces centriacinar emphysema and MC affects upper lobes of the lungs
whereas the A1AT deficiency causes panacinar emphysema and mostly affects the lower
lobes. A1AT deficiency should be considered in patients with COPD at young age
(<45yo), COPD with minimal to no smoking hx, basilar- predominant COPD, or a history
of unexplained liver disease. Tx is IV supplementation with pooled human A1AT.
Patients with chronic hyperkalemia may be asx until the potassium gradually rises >7
(Give calcium gluconate above 7)
Attributable risk percentage represents the excess risk in the exposed population that
can be attributed to the risk factor. It can be calculated as ARP=(RR-1)/RR // Monospot
test has 25% false negative rate during 1st week of illness.
In some patients, a stab wound may violate the peritoneum but miss important
intraabdominal organs. When this is suspected (eg small wound with otherwise benign
abdominal examination, normal VS, nonconcerning imaging) serial abdominal
examinations may be performed to r/o progression of an occult injury.
Drug induced acne (aka steroid folliculitis or steroid acne) appears as monomorphic
papules or pustules without comedones, cysts, or nodules. It typically occurs on the
upper back, shoulders, and upper arms. This type of acne can occur due to systemic
steroids, topical steroids, steroid sparing agents (azathioprine, cyclosporine),
anticonvulsants, TB drugs.
Hiradenitis suppurativa (acne inversa) is MC in intertriginous areas (axilla, inguinal,
perineal areas). It is due to chronic inflammatory occlusion of follicles. It presents as
solitary, painful, inflamed nodules that can regress or progress to abscesses. Most
patients have a relapsing/remitting course. Complications include sinus tracts,
comedones, and scarring. Severe scarring can lead to dense, rope-like bands with
strictures and lymphedema. Intertrigo is well defined erythematous plaques with
satellite vesicles.
Acute mesenteric ischemia can result from gradual atherosclerosis, an embolic source or
hypercoagulable disorders. Labs will show leukocytosis, elevated amylase and
phosphate, and met acidosis with elevated lactate. Dx with CT (preferred) or MRA, using
mesenteric angiography if unclear.
Bowel sounds are typically INCREASED in opioid withdrawal. // Steroids decrease
peripheral T4àT3 conversion.
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Malignant hyperthermia usually presents with hypercarbia, sinus tachycardia, muscle
rigidity, elevated CK, hyperkalemia, and hyperthermia. vs thyroid storm which presents
with tachycardia, cardiac arrhythmias, high fever, tremor, AMS, lid lag.
Acute mitral regurgitation results in sudden onset large volume backflow of blood from
the LV to the LA. Neither chamber has time for compensatory dilation, leading to a rapid
increase in LV end diastolic BP and LA pressure, resulting in pulmonary edema. Although
forward blood flow is reduced, LVEF is normal to increased due to a large amount of
stroke volume flowing backward into the LA.
Waldenstrom macroglobulinemia has hyperviscosity, neuropathy, bleeding,
cryoglobulinemia, hepatosplenomegaly, lymphadenopathy, IgM spike, Rouleaux
formation. Hyperviscosity can present with diplopia, tinnitus, headache,
dilated/segmented funduscopic findings, electric sensation. WM also has anemia, and
thromboMM has osteolytic lesions, anemia, hypercalcemia, renal insufficiency with IgG
spike.
Classic reactive arthritis consists of a triad of nongonococcal urethritis, assymetric
oligoarthritis, and conjunctivitis. In addition to the triad, mucocutaneous lesions and
enthesitis (Achilles tendon pain) are common findings. NSAIDs are best tx for reactive
arthritis.
Many patients suffering from osteoarthritis take chondroitin sulfate, a component of
the ground substance that composes cartilage to improve their condition and sx.
The liver can normally store a 30 day supply of Vit K but an acutely ill person with
underlying liver disease can become Vit K deficient in as little as 7-10 days. Giving Vit K
can replenish stores in 8-10 hours and FFP much faster. // Hypersplenism (splenic
sequestration) leads to thrombocytopenia and does not affect PT or PTT.
Dyshidrotic eczma (pompholyx) is a recurrent, pruritic rash with deep vesicles that affect
the palms, soles, and sides of the digits. Tx is with topical high potency steroids.//
Nummular eczema has chronic ROUND COIN shaped scaly plaques in regions of dry skin.
Pressure (decubitus) ulcers are MC over bony prominences, prevent with repositioning.
vs DM ulcers which are MC on soles of the feet under metatarsal heads or on the tops of
toes.
Clean intermittent catheterization is an effective measure for reducing the risk of
catheter associated UTI in patients with neurogenic bladder.
REM sleep behavior disorder has dream enactment and it has a very strong association
with the future development of alpha-synuclein neurodegenerative disorders
(Parkinson’s, Lewy Body dementia)
Staph aureus is the MCC of IE in IVDU.
Fever occurring immediately (within a few hours) post op is typically associated with
prior infection/trauma, inflammation due to surgery, malignant hyperthermia,
anesthetic meds, or blood products. Nonhemolytic transfusion reaction causes fever
secondary to stored blood cytokines and occurs within 1-6 hours of transfusion.
SGLT2 inhibitors (flozins) reduce progression of nephropathy and albuminuria, reduce
cardiovascular morbidity and mortality, reduce HF hospitalizations, and increase weight
loss. They can cause euglycemic ketoacidosis and increase the risk of genitourinary
infections. Contraindicated in DMT1, History of DKA, and impaired renal function
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(GFR<30) // GLP receptor agonists (glutides) suppress glucagon secretion and increase
insulin release. They decrease CVD mortality and increase weight loss as well but can
cause GI SE’s and pancreatitis. // Sulfonyureas (glipizides) increase insulin secretion but
do not affect cardiovascular health. // Thiazolidinediones (glitazones) decrease
gluconeogenesis and increase insulin sensitivity; they are associated with weight gain
and fluid retention and actually increase the risk of HF. // DP4 inhibitors (gliptins) are
not cardio protective and are weight neutral. SO add on therapy in DMT2 patients with
established CVD includes glucagon like peptide 1 agonists (GLP1) and flozins which
reduce CVD morbidity and mortality; both agents are associated with weight loss, an
effect not seen with insulin, sulfonylureas or thiazolidinediones.
The presence of a single vertebral fracture (especially cervical) in a patient with BAT is
an indication to image the entire spine because the risk of a second, noncontiguous
vertebral fracture is as high as 20%
Most cases of obstructive shock result from prepulmonary obstruction with
hemodynamic parameters showing high central venous pressure, low to normal PCWP,
and low CO. Post pulmonary obstructive shock (aortic dissection or severe AS) has high
Central venous pressure, high PCWP, and low CO.
Fat necrosis can mimic breast cancer as it appears as a fixed mass with skin or nipple
retraction and gives the appearance of calcifications on mammography, U/S will show
hyperechoic mass and biopsy will show fat globules and foamy histiocytes.
Pilonidal disease most frequently occurs in young, obese mails with sedentary lifestyles.
They most commonly present with a painful, fluctuant mass 4-5 cm cephalad to anus in
the intergluteal region with associated mucoid, purulent, or bloody drainage. PD
develops when an edematous, infected hair follicle becomes occluded. The infection
spreads and forms an abscess that can create a pilonidal sinus tract. Tx is drainage and
excision of sinus tracts.
Pupillary light reaction and oculovestibular reaction are absent in patients with brain
death. The HR fails to accelerate after atropine injection because vagal control of the
heart is lost. Brain death is a clinical diagnosis BUT it is important to note that the SC
may still be functioning with intact DTR’s.
Invasive pulmonary aspergillosis is characterized by triad of fever, pleuritic chest pain,
and hemoptysis. CT will show nodules with surrounding ground glass opacities (halo
sign)
Mammography is the first line imagining study for women > 30yo with a palpable mass.
// Rewarm someone with hypothermia at rate of 1-2 degrees C/hr
Wilson disease has copper deposition in the liver, basal ganglia, and cornea. Wilson
disease can lead to Mallory bodies (damaged intermediate filaments) and Mallory
bodies are MORE COMMON in Wilson than in alcoholic liver disease. Wilson disease has
a low ceruloplasmin level. // A1AT deficiency has hepatocytes that are diastase
resistant.
Right sided colon cancer presents with anemia while left sided colon cancer presents
with bowel obstruction.
Acute angle closure glaucoma is associated with nausea and vomiting. The anterior
chamber will be shallow with inflammatory chances (steamy cornea). IV acetazolamide
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can help lower the pressure. Permanent cure is laser peripheral iridotomy. Open angle
glaucoma has loss of peripheral vision. Conjunctivitis has NORMAL vision while uveitis
has blurry vision.
Primary sclerosing cholangitis can be asx, have fatigue and pruritis, and is MC associated
with UC. Labs show elevated alk phos and GGT with multifocal structuring/dilation of
intrahepatic and/or extrahepatic bile ducts. Liver biopsy will show fibrous obliteration of
small bile ducts with concentric replacement by connective tissue in onion skin pattern.
Complications include biliary stricture, cholangitis, gallstones, cholangiocarcinoma,
colon cancer, biliary cancer, cholestasis. Patients with PSC and IBD should have annual
colonoscopies because they are at 5x risk of colon caner.
Exfoliative dermatitis (erythroderma) is a widespread, scaly eruption of the skin.
Digoxin toxicity has life threatening arrhythmias, anorexia, N/V, abdominal pain, fatigue,
confusion, weakness, color vision alterations. Amiodarone, verapamil, quinidine, and
propafenone can all increase digoxin levels by interfering with its metabolism. It is
recommended that digoxin dose be decreased by 25-50% when starting amiodarone.
Hypothyroidism is associated with lipid abnormalities that can lead to increased CAD.
Hypothyroidism causes increased total cholesterol and LDL as well as
hypertriglyceridemia. // Increased androgen use causes increased cholesterol levels but
NOT hypertriglyceridemia.
Upper face involvement distinguishes Bell palsy from UMN disorders which spare the
upper face. Bell palsy is associated with decreased ipsilateral eye lacrimation,
hyperacusis and decreased sensation of taste over the anterior 2/3 of the ipsilateral
tongue. The weakness of bell palsy often occurs at night and patients may awaken with
significant facial droop. Usually it resolves after 3-6 months. Bell palsy is reactivation of
HSV (affects CN 7 myelin sheath)
Fluoroquinolones are first line therapy for prostatitis because they achieve high
concentration in the prostate.
Spinal epidural hematoma is a potential complication of neuraxial anesthesia (epidural
block) LP, or spinal surgery and is MC in older adults taking antithrombotic meds (even if
they stop them prior to surgery). Get urgent MRI and decompress.
Second metatarsal is MC bone injured in stress fractures. Fractures of the 2nd, 3rd, and
4th metatarsals are managed conservatively with rest and analgesics as the bones
around them basically form a biologic splint (give acetaminophen not NSAIDS). Stress
fractures of the 5th metatarsal are at increased risk of nonunion and are usually
managed with casting or internal fixation.
Sensation of objects moving is called oscillopsia. Aminoglycosides are ototoxic and can
cause hearing loss, imbalance, oscillopsia, and a positive head thrust test (inability to
maintain visual fixation during forced rapid head movement) evaluating the vestibular
ocular reflex.
Post fracture avascular necrosis is MC in areas of bone with limited blood supply such as
the scaphoid, femoral head, or 5th metatarsal. A salter-Harris type 3 (juvenile tillaux
fracture) has a fracture of distal epiphysis and lateral physis (growth plate) and can lead
to lim-length discrepancy, physeal bars, arthritis.