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1000 Cards in this Set

  • Front
  • Back
What is the first step in the diagnosis of a suspect hematopoietic problem (aka anemia)?
CBC to Dx: white & red blood cells + platelets
What are the 4 main diseases/body states that have a direct influence on the red cell system & can result in anemia?
1) pregnancy
2) inflammation
3) renal insufficiency
4) hypothyroidism
What is anemia?
a significant reduction in the RBC mass resulting in a corresponding decrease in the oxygen carrying capacity of the blood
A reduction in 2 of 3 lab values indicate that the presence of anemia. Name these 3 parameters.
1) RBC (red blood cell count / unit of the whole blood volume)
2) HGB (mass of hemoglobin / unit of the whole blood volume = hemoglobin concentration)
3) HCT (volume of the red cells / unit of whole blood volume)
What are 2 cases of 'pseudoanemia' (due only to expanded blood volume) that can result in decreased RBC, HGB, or HCT?
pregnancy
CHF
Regarding the CBC, what does "RBC" stand for?
RBC = red blood cell count / unit of the whole blood volume
Regarding the CBC, what does "HGB" stand for?
HGB = mass of hemoglobin / unit of the whole blood volume = hemoglobin concentration
Regarding the CBC, what does "HCT" stand for?
HCT = volume of the red cells / unit of whole blood volume
What is the early RBC, HGB, & HCT values for iron defficiency anemia?
RBC = normal
HGB = decreased
HCT = decreased
What is the normal RBC range (in T/L) for women? for men?
Women = 4.0 - 5.5
Men = 4.5 - 6.0
What is the normal HGB for women (in g/dL) ? for men?
Women = 12-16
Men = 14-18
What is the normal HCT (in %) for woman? for men?
Women = .37 - .47
Men = .40 - .54
What is the normal range for MCV (mean corpuscular volume)?
80-100
What is the normal range for RDW (Red Blood Cell Distribution Width)?
11.5-14.5 (<15) %
What is the normal range for MCH (Mean Corpuscular Hemoglobin)?
27-32 pg (x10^-12g)
What is the normal range for MCHC (Mean Corpuscular Hemoglobin Concentration)?
32-37 g/dL
What is the normal range for relative Reticulocyte count (% or RBCs)
0.5- - 1.5
What is the normal range for absolute Reticulocyte count (x10^9/L or G/L)
30-70
What is the normal WBC count (x10^9/L or G/L)?
4.0 - 10
What % of WBCs are band neutrophils?
1 - 5
What % of WBCs are segmented neutrophils?
40-70
What % of WBCs are lymphocytes?
20-45
What % of WBCs are monocytes?
3 - 8
What % of WBCs are eosinophils?
1 -5
What % of WBCs are basophils?
0 -1
What is the normal PLT (x 10^9/L or G/L) count?
140-400
What are the 3 main initial steps in the Dx of anemia?
1) Is the patient really anemic (must check RBC, HGB, HCT)?
2) If yes, what is the morphological type?
- MCV = miro, normo, macrocytic
- RDW = anisocytic or not
- MCH+MCHC = hypo, normo, hyperchromic
3) Is the pathology affecting any other part of the blood?
- WBC + % of different WBC populations
- PLT
What are the 3 aspects of the RBC that can be altered to result in microcytic anemia (MCV < 80)?
1) IRON (Deficiency or chronic disease)
2) Heme (Sideroblastic anemia due to congenital or enzyme dysfunction)
3) Globin (Thalassemia: impaired globin chain synthesis)
What test is done to DDx microcytic anemia?
1) Serum IRON
2) TIBC
What Iron-panel results indicate iron-deficiency anemia?
- Serum Iron = decreased
- Ferritin = decreased
- TIBC = INCREASED
What Iron-panel results indicate anemia of chronic disease (ACD)?
- Serum Iron = decreased
- Ferritin = INCREASED
- TIBC = decreased
What Iron-panel results indicate sideroblastic anemia?
- Serum Iron = Increased
- Ferritin = increased
- TIBC = DECREASED
What Iron-panel results indicate Thalassemia anemia?
- Serum Iron = increased/normal
- Ferritin = increased/normal
- TIBC = increased/normal
What is the 2-step Dx for normocytic anemia (MCV = 80-100)?
1) Reticulocyte count (is the bone marrow reasponding by increasing erythropoietic activity)?
2) Bone marrow exam or Blood smear
In what cases would a Bone marrow exam be needed in a case of normocytic anemia?
2 conditions must be met:
1) Reticulocyte = normal/decreased
2) Associated leukocyte & platelet abnormalities
What are the 5 main types of Bone marrow diseases that can result in normocytic anemia?
1) aplasia
2) fibrosis
3) malignancy
4) infiltration
5) myelodysplasia
If a patient has normocytic anemia, a decreased reticulocyte count, and NO associated leukocyte/platelet disfunction, what is the likely cause?
SYSTEM disease:
1) DECREASED erythropoiesis activators:
- Uremia
- Hypothyroidism
2) INCREASED erythropoiesis inhibitors:
- Anemia of chronic disease
What is the next step in evaluating normocytic anemia with an elevated reticulocyte count?
Check for hemolysis:
- ACUTE: find source of blood loss
- CHRONIC: blood smear
What is the first step in the Dx of macrocytic anemia (MCV > 100 fl)?
Blood Smear
What are the causes of non-megaloblastic (aka, 2ndary macrocytic) anemia?
- alcohol, drugs
- liver disease
- hypothyroidism
- reticulocytosis
If the blood smear suggests macrocytic anemia, what's the next step?
Bone marrow exam
What are the 2 main causes of megaloblastic anemia?
1) B12 deficiency
2) Folate deficiency
What are the 3 main causes of macrocytic anemia that is NOT caused by a B12 or folate deficiency?
1) drug induced
2) inborn metabolic errors
3) myelodysplastic syndrome
What is primary hemostasis?
formation of platelet plug
- platelets
- plasma coagulation factors
What is secondary hemostasis?
Reinforcement of the platelet plug with a meshwork of fibrin strands
How is primary hemostasis regulated?
Prevention of platlet response extension beyond vascular damage by:
1) Structure:
- negative charge of glycocalyx
2) Function: (via endothelial-derived substances)
- prostacyclin, NO, ADPase
How is 2ndary hemostasis regulated?
Prevention of fibrin clot formation beyond the sites of vascular damage by endothelial-derived or activated substances:
- TFPI (Tissue Factor Pathway Inhibitior)
- SERPINs (Serine Protease Inhibitors)
- Protein C system
- Fibrinolytic System
What are the 2 main general processes that lead to a hypocoagulable state & a BLEEDING disorder?
1) Decreased procoagulant activity (e.g. deficiency of coagulation factors)
2) Increased regulatory activity (e.g. fibrinolytic syndrome)
What are the 2 main general processes that lead to a hypercoagulable state & a THROMBOTIC disorder?
1) Decreased regulatory activity (e.g. deficiency of natural anticoagulants)
2) Increased procoagulant activity (disruption of Virchow's triad)
What are the 3 usual types of causes of symptomatic bleeding patients (with bleeding diathesis)?
1) Generalized bleeding from multiple sites: bruising, purpura
2) Inappropriate local bleeding without obvious mechanical cause
3) Past history of inappropriate bleeding (e.g. after dental extraction or trauma)
What are the 3 main causes of a bleeding disorder in asymptomatic patients?
1) Family History
2) Underlying Clinical disease
3) Incidental lab abnormalities detected in the course of other investigations
What are the main underlying clinical diseases that can present as a bleeding disorder without hemorrhagic diathesis?
1) Primary disorders of the hematopoietic system
2) liver or kidney disease
3) hypercortisolism
4) anticoagulant or antiplatelet drugs
5) vit. K or C deficiency
What type of bleeding signs indicate a primary hemostasis defect?
SUPERFICIAL BLEEDING:
1) Skin: petechiae, bruises
2) Mucose membranes (nose, GI, GU, menorrhagia after aspirin)
3) IMMEDIATELY after trauma
What type of bleeding signs indicate a secondary hemostasis defect?
DEEPER BLEEDING (+/- mucocutaneous findings):
1) Hematomas in retroperitoneum
2) Hemarthroses (joints)
3) Pseudotumors (muscles
4) DELAYED (hours/days) after trauma
What are the 3 steps used to Dx a primary hemostasis disorder?
- 1st: BT (bleeding time) & PLT (platelet count in CBC)
- 2nd: Blood smear (OPTIONAL)
- 3rd: Platelet functional tests
What are the 3 steps used to Dx a secondary hemostasis disorder?
- 1st: APTT (activated partial thromboplastin time) & PT (Prothrombin time)
- 2nd: Fibrinogen & Thrombin Time + APTT/PT Mixing study
- 3rd: Factor assay or inhibitor study
In what type of state are BT, APTT & PT prolonged?
hypocoagulable states
What bleeding disorders will NOT be Dx with BT, APTT & PT?
Hypercoagulable states (b/c these values will remain NORMAL)
For what reason are PT & APTT monitored in thrombotic disorders?
Therapeutic: to monitor anticoagulant treatment
What are the 3 interactions that occur upon vascular disruption?
1) Platelet - Vascular Interaction
2) Intrinsic Coagulation Pathway
3) Extrinsic Coagulation Pathway
What initiates platelet-vascular interaction and what does it form? What lab test evaluates this?
- Initiation: Platelets adhere to exposed subendothelial tissue
- Result: Platelet plug
- Test: BT
What initiates the Intrinsic coagulation pathway and what does it form? What lab test evaluates this?
- Initiation: contract group factors (XII, XI, HMWK, PK) bind to negatively charged surface of collagen & activated platelets
- Result: Thrombin, which then converts fibrinogen to fibrin
- Test: APTT
- NB: ALL components from circulating blood
What initiates the Extrinsic coagulation pathway and what does it form? What lab test evaluates this?
- Initiation: Tissue Factor (TF), a membrane glycoprotein from subendothelial or surrounding tissue
- Result: Thrombin, which converts fibrinogen to fibrin
- NB: requires TF, which is NOT usually in circulating blood
- Test: PT
What type of bleeding disorder is von Willebrand's disease?
Congenital, primary (evaluate with BT)
What type of bleeding disease is Thrombocytopenia?
Acquired, primary (evaluate with BT)
What type of bleeding disorder is Hemophilia?
Secondary
What type of bleeding disorder is caused by liver disease or vitamin K deficiency?
Secondary, acquired
What is the first A or the platelet response to vascular injury?
Adhesion: GPIb receptor on platelet adheres to vonWillebrandt factor on subendothelial tissue
What is the second A or the platelet response to vascular injury?
Activation: (result of vWF stimulation by GPIb)
1) Change of platelet shape into puzzle-like
2) Production of TXA2 & secreation of mediations (e.g. ADP)
3) Changes in platelet membrane
- Activation of GPIIb/IIa (fibrinogen receptors)
- Phospholipid movement making its surface attractive for plasma coagulation factors (PF3)
What is the third A or the platelet response to vascular injury?
Aggregation:
- Platelet to platelet interaction augmented by cross-linking of fibrinogen
Give an example of a quantitative platelet deficit.
Thrombocytopenia
Give an example of a qualitative platelet deficit.
hereditary or acquired platelet dysfunction
Give an example of a disease which results in the failure of platelet plug formation at the level of Adhesion?
von Willebrand's disease
Give an example of a disease which results in the failure of platelet plug formation at the level of Activation?
NSAID or antiplatelet drug
Give an example of a disease which results in the failure of platelet plug formation at the level of Aggregation?
Severe hypo- or dysfibrinogenemia
What is the only coagulation factor deficiency that can result in the prolongation of BT?
ONLY a deficiency in fibrinogen!!
What are the 2 steps of secondary hemostasis?
1) Formation of Thrombin (procoagulant enzyme) via the Coagulation cascade
2) Conversion of fibrinogen (soluable protein) into fibrin (insoluble gel) meshwork
What element of the extrinsic coagulation pathway facilitates the course of the intrinsic pathway?
TF: activates V, VIII, XI
What inhibits disseminated coagulation from the extrinsic pathway?
TFPI = inhibits the extrinsic pathway (& intrinsic pathway continues)
What elements of coagulation are serine proteases?
Factors XII, XI,
Vit. K-Dependent Factors: X, IX, VII, II
What factor is a transglutimase that stabilizes the fibrin clot?
Factor XIII
What are the 4 main cofactors of the coagulation cascade?
- HMWK (High Molecular Weight Kininogen)
- PK (Prekalkrein)
- PF3 (phospholipids on activated platelets' surface)
- Factors VIII, V, & IV (Ca)
What are the following factors in the coagulation cascade: Factor III, Factor I?
Factor I: Fibrinogen
Factor III: Tissue Factor
What must be added to plasma to test secondary hemostasis?
1) Citrate chloride, and Ca
2) Specific pathway activator analogues
What is used to test the intrinsic coagulation pathway?
APTT (activated partial thromboplastin time) Test:
1) Citrated plasma
2) CaCl2
3) Activators: negatively-charged surface (kaolin) or phosopholipids (cephalin)
What diseases can cause an increase in APTT?
1) Deficiency of XII, PK, HMWK, XI, IX, VIII, (or common factors: X, V, II, I):
- hemophilia, liver dysfunction, DIC

2) Decreased factor activity:
- vWD (decreased VIII)
- presence of an inhibitor, such as: heparin, lupus anticoagulant, oral anticoagulants
What diseases can cause an increase in PT?
1) Deficiency of factors VII (or common factors: X, V, II, I): liver dysfunction, DIC

2) Decreased factor activity: vitamin K deficiency
- presence of inhibitor such as heparin, lupus anticoagulant, oral anticoagulants
What is used to test the extrinsic coagulation pathway?
1) citrated plasma
2) CaCl2
3) Activator: full thromboplastin tissue extract (e.g. from the brain) = TF + phsopholipids
What disease is characterized by the deficiency of coagulation factor IX?
hemophilia B
What disease is characterized by the deficiency of coagulation factor XI?
hemophilia C
How does heparin treatment affect the coagulation cascade?
Activates ATIII to inhibit factors: IIa, Xa, IXa, Xia, XIIa
- Result: elevated PT
How does early stage of liver disease treatment affect the coagulation cascade?
- Decreased synthesis of factor VII first
- Result: elevated PT
How does warfarin treatment affect the coagulation cascade?
- Decrease in factors IX, X, VII, II, & proteins C&S
- Result: elevated PTT
- ALSO: intermediate stage liver disease
How does advanced liver disease or DIC affect the coagulation cascade?
Elevated PT & PTT
Which of the following are affected by thrombocytopenia? (BT, PLT, APTT, PT, Fibrinogen)
BT = elevated
PLT = decreased
APTT = OK
PT = OK
Fibrinogen = OK
Which of the following are affected by thrombocytopathy (e.g. Glanzmann thrombastenia)? (BT, PLT, APTT, PT, Fibrinogen)
BT = elevated
PLT = OK
APTT =OK
PT = OK
Fibrinogen = OK
Which of the following are affected by wonWillebrand's disease? (BT, PLT, APTT, PT, Fibrinogen)
BT = elevated
PLT = OK
APTT = OK/increased
PT = OK
Fibrinogen = OK
Which of the following are affected by hemophilia? (BT, PLT, APTT, PT, Fibrinogen)
BT = OK
PLT = OK
APTT = ELEVATED
PT = OK
Fibrinogen = OK
Which of the following are affected by heparin treatment? (BT, PLT, APTT, PT, Fibrinogen)
BT = OK
PLT = OK
APTT = ELEVATED
PT = mildly elevated
Fibrinogen = OK
Which of the following are affected by warfarin treatment? (BT, PLT, APTT, PT, Fibrinogen)
BT = OK
PLT = OK
APTT = mildly increased
PT = INCREASED
Fibrinogen = OK
Which of the following are affected by advanced liver disease treatment? (BT, PLT, APTT, PT, Fibrinogen) ORDER the Changes
BT = Increased
PLT = Decreased
APTT = Increased
PT = Increased
Fibrinogen = Decreased
Which of the following are affected by advanced stage DIC? (BT, PLT, APTT, PT, Fibrinogen)
BT = Increased
PLT = Decreased
APTT = Increased
PT = Increased
Fibrinogen = Decreased
What are the 5 steps in evaluating acid-base disturbances?
1) Determine pH status (alkalemia or academia)
2) Determine whether the process is respiratory, metabolic, or both
3) Calculate the anion gap
4) Check for compensation
What lab value indicates respiratory alkalosis?
if pCO2 is less than 35 mmHg
What lab value indicates metabolic alkalosis?
bicarbonate greater than 26 mmol/L
What lab value indicates respiratory acidosis?
pCO2 greater than 45 mmHg
What lab value indicates metabolic acidosis?
bicarbonate less than 22 mmol/L
What is the formula used to calculate the serum anion gap?
Sodium - (Bicarbonate + Chloride)
What anion gap indicates metabolic acidosis?
> 10 mEq/L = MAYBE
> 20 mEq/L = ALWAYS acidosis
What change in blood components necessitates a revision of the anion gap?
Add 2.5 to the calculated anion gap for every 1 g/dL of albumin below normal
In a case of metabolic acidosis, how is respiratory compensation assessed?
1) Calculated pCO2: pCO2 = 1.5x(HCO3-) +8 +/-2
2) pCO2 falls by 1-1.3 mmHg for each mEq/L fall in HCO3-
3) Last 2 digits of pH = pCO2 (e.g. if pCO2 = 28, pH = 7.28
In a case of metabolic alkalosis, how is respiratory compensation assessed?
- pCO2 increases 6mmHg for every 10mEq/L rise in HCO3-
- HCO3 + 15 = pCO2
In a case of respiratory acidosis, how is metabolic compensation assessed?
ACUTE: HCO3- increases 1 mEq/L for each 10 mmHg rise in pCO2

CHRONIC: HCO3 increases by 4 mEq/L for each 10mmHg rise in pCO2
In a case of respiratory alkalosis, how is metabolic compensation assessed?
ACUTE: HCO3 falls by 2mEq/L for each 10mmHg fall in pCO2

CHRONIC: HCO3 falls by 4mEq/L for each 10mmHg fall in pCO2
What is the normal anion gap?
3 - 12 mEq/L
What is the normal body pH range?
7.35 - 7.45
What is the normal range for pO2?
8.7 - 12.7 kPa (65-95 mmHg)
What is the normal range for pCO2?
4.8 - 6.0 kPa (35-45 mmHg)
What is the normal range for HCO3 in blood gas?
22 - 26 mmol/L
What is the normal range for BE?
+/- 2.5 mmol/L
What is the normal range for plasma Na+?
135-145 mmol/L
What is the normal range for plasma K+?
3.5 - 5.0 mmol/L
What is the normal range for plasma Cl-?
98-107 mmol/L
What is the normal range for plasma HCO3-?
22 - 26 mmol/L
What is the normal range for plasma Ca?
2.12 - 2.62 mmol/L
What is the normal range for plasma Ca2+?
0.98 - 1.13 mmol/L
What is the normal range for plasma Mg2+?
0.8 - 1.0 mmol/L (1.9-2.5 mg/dL)
What is the normal range for plasma PO42-?
0.97-1.45 mmol/l (3.0-4.5 mg/dL)
What is the normal urine daily excretion of Na+?
80 - 240 mmol/24 Hr
What is the normal urine daily excretion of K+?
25 - 80 mmol/24 Hr
What is the normal urine daily excretion of Cl-?
110 - 260 mmol/24 Hr
What is the normal urine daily excretion of albumin?
35-50 g/L
What acid/base disorder is characterized by pH <7.35 & pCO2 <35?
Metabolic acidosis
What acid/base disorder is characterized by pH <7.35 & pCO2 >45?
Respiratory acidosis
What acid/base disorder is characterized by pH >7.45 & pCO2 <35?
Respiratory alkalosis
What acid/base disorder is characterized by pH >7.45 & pCO2 <40?
Metabolic alkalosis
What is the primary change in metabolic acidosis & what is the compensation?
1) Decreased pH & decreased HCO3-
2) Compensation = decreased pCO2
What is the primary change in metabolic alkalosis & what is the compensation?
1) Increased pH & increased HCO3-
2) Compensation = increased pCO2
What is the primary change in respiratory acidosis & what is the compensation?
1) Decreased pH & Increased pCO2
2) Compensation = increased HCO3-
What is the primary change in respiratory alkalosis & what is the compensation?
1) Increased pH & decreased pCO2
2) Compensation = decreased HCO3-
What are the main causes of metabolic acidosis (pH < 7.35 & pCO2 < 35) with an anion gap > 12?
1) Renal failure
2) Lactic acidosis: shock, seizures, pulmonary edema
3) Diabetic ketoacidosis
4) Toxins: methanol, ethylene glycol, salicylate
What are the main causes of metabolic acidosis (pH < 7.35 & pCO2 < 35) without an ion gap & serum K+ <3.5?
1) Diarrhea
2) Acetazolamide
3) Type 1 RTA
4) Ureteroenteric anastomosis
5) Toluene intoxication
What are the main causes of metabolic acidosis (pH < 7.35 & pCO2 < 35) without an ion gap & serum K+ >5.5?
1) NSAIDS
2) Type 4 RTA
3) K+- sparing diuretics
4) Addison's disease
For metabolic acidosis, when is alkali indicated?
1 or more of these 2:
1) pH less than 7.2
2) Serum bicarbonate is 12mEq/L or less
How can bicarbonate required for acidosis correction be calculated? What is the rate of the administration?
HCO3- deficit = [24 mEq/L - measured HCO3-] x 0.5 x body weight

- 1/2 of calculated deficit may be replaced in 3-4 hours in concentration of 50-150 mEq/L
What are the main causes of chloride-depletion metabolic acidosis WITH hypokaliemia (pH > 7.35 & pCO2 > 40) with urine [Cl-] <15mmol/L)?
- Vomiting or upper GI drainage
- Diuretic therapy
- Cl--loosing diarrhea
What are the main causes of chloride-depletion metabolic acidosis WITHOUT hypokaliemia (pH > 7.35 & pCO2 > 40) with urine [Cl-] <15mmol/L)?
- Corticosteroid excess
- Milk-alkali syndrome (Na-HCO3 ingestion)
What are the 3 major causes of corticosteroid excess?
1) Primary hyperaldosteronism
2) Cushing syndrome (including ACTH-secreting tumors)
3) Bartter's syndrome
What are the bronchopulmonary causes of acute respiratory acidosis?
- Pulmonary edema
- Severe asthma
- ARDS
- Airway
- Obstruction
- Pneumothorax
What are the CNS causes of acute respiratory acidosis?
- Opiate OD
- Guillain-Barre syndrome
What are the neuromuscular causes of acute respiratory acidosis?
- Myasthenia gravis crisis
- Severe potassium or phosphate disorder
What are the bronchopulmonary causes of chronic respiratory acidosis?
- COPD
- Kyphoscoliosis
What are the CNS causes of chronic respiratory acidosis?
- MS (multiple sclerosis)
- Myxedema
- Pickwickian syndrome
- Severe obesity
- Amyotrophic lateral sclerosis
What can cause a respiratory alkalosis with A-a O2 gradient > 15-20 & sO2>90 (pH >7.45, pCO2 <35mmHg)?
Bronchopulmonary disorders:
- Ashtma
- Pneumonia
- Pulmonary embolus
- Early pulmonary edema
- Pulmonary fibrosis
What can cause a respiratory alkalosis with A-a O2 gradient < 15-20 & sO2>90 (pH >7.45, pCO2 <35mmHg)?
- Fever due to sepsis
- Pregnancy
- Cerebrovascular accident
- Severe anemia
- Liver disease
- Salicylate intoxication
- Hysteria
- Mechanical hyperventilation
What can cause a mixed acid-base disorder with pCO2 <<35 mmHg?
Metabolic acidosis & respiratory alkalosis due to:
- Sepsis
- Liver disease
- Salicylate intoxication
What can cause a mixed acid-base disorder with pCO2 35-45 mmHg?
Metabolic acidosis & alkalosis due to:
- AG 6-12 = diarrhea + vomiting
- AB >12 = DKA + vomiting, AKA + vomiting, Lactic acidosis + diuretics, Renal disease + vomiting
What can cause a mixed acid-base disorder with pCO2 >>45 mmHg?
Metabolic alkalosis + respiratory acidosis:
- Chronic lung disease + diuretics
What is the normal range for total serum protein?
60-80 g/L
What is the normal range for total serum albumin?
35-50 g/L
What is the normal range for total serum glucose?
65-110 mg/dl
What are the Na+, Cl-, and mOsm/L contents of a 0.45% saline solution?
Na+ = 77
Cl- = 77
mOsm/L = 154
What are the Na+, Cl-, and mOsm/L contents of a 0.9% saline solution?
Na+ = 154
Cl- = 154
mOsm/L = 308
What are the Na+, Cl-, and mOsm/L contents of a 3% saline solution?
Na+ = 513
Cl- = 513
mOsm/L = 1026
What is the mOsm/L contents of a 5% Dextrose in Water solution?
253
What is the mOsm/L contents of a 10% Dextrose in Water solution?
505
What is the mOsm/L contents of a 20% Dextrose in Water solution?
1010
What is the mOsm/L contents of a 40% Dextrose in Water solution?
2526
What is the mOsm/L contents of a 70% Dextrose in Water solution?
3536
What are the Na+, Cl-, and mOsm/L contents of a 5% in 0.22% Dextrose in saline solution solution?
Na+ = 38
Cl- = 38
mOsm/L = 330
What are the Na+, Cl-, and mOsm/L contents of a 5% in 0.22% Dextrose in saline solution solution?
Na+ = 77
Cl- = 77
mOsm/L = 406
What are the Na+, Cl-, and mOsm/L contents of a 5% in 0.22% Dextrose in saline solution solution?
Na+ = 154
Cl- = 154
mOsm/L = 559
What is the ion concentrations in Ringer's lactated solution (Na+, K+, Ca2+, Cl-, HCO3- precursor)?
Na+ = 147
K+ = 4
Ca2+ 5
Cl- = 156
HCO3- precursor = NA
What is the ion concentrations in Hartmann's solution (Na+, K+, Ca2+, Cl-, HCO3- precursor)?
Na+ = 130
K+ = 4
Ca2+ 3
Cl- = 109
HCO3- precursor = 28
How much potassium is in 1 mL of potassium chloride?
1-3 mEq/mL
How much potassium is in 1 mL of potassium acetate?
2-4 mEq/mL
How much potassium is in 1 mL of potassium phosphate?
2 mEq/mL
What are the concentrations of Na+ & HCO3- in a solution of sodium bicarbonate 1.96%?
Na+ = 150
HCO3- = 150
What are the concentrations of Na+ & HCO3- in a solution of sodium bicarbonate 8.4%?
Na+ = 1000
HCO3- = 1000
What is the normal [Na] in the ECF?
135-145 mmol/L
What is the normal plasma osmolality?
285-295 mOsm/kgH20
What lab values indicate hyponatremia & hypoosmolaity due to water excess?
Na < 135 mmol/L
Plasma Osm <285 mOsm/kgH20
What lab values indicate hypernatremia & hyperosmolaity due to water depletion?
Na > 145 mmol/L
Plasma Osm >295 mOsm/kgH20
What results from Na retention?
Concomitant H20 retention = Edema
What results from Na depletion?
Concomitant H20 loss = hypovolemia
What are the symptoms of hypernatremia?
- Disorientation
- Lethargy that progresses to coma
- Increased deep tendon reflexes
- Muscle weakness
- Tremor
- Myoclonus
- Convulsions
What are the symptoms of hyponatremia?
- Weakness
- Hyporeflexia hyperreflexia
- Anorexia
- Muscular twitches
- Exhaustion
- General rigidity
- Headache
- Convulsions
- Disorientation
- Nausea
- Lethargy
- Vomiting
- Confusion
- Light-headedness
What are the symptoms of hypovolemia (low extracellular fluid volume)?
- Dry mucous membranes
- Decreased skin turgor
- Soft/contracted eyes
- Flattened neck veins
- low Bp
- Postural changes in Bp
- Increased HR
- Low central venous pressure
- Dry/shrunken tongue with deep furrows
What are the symptoms of overhydration (expanded extracellular volume)?
- Neck vein distention
- Increased CVP
- Edema
- Ascites
- CHF
- Basal crepitations
What diseases lead to normatremia with expanded ECF (edema)?
- CHF
- Cirrhosis of the liver
- Nephrotic Syndrome
- Administration of Na+-containing isotonic fluids (in excess)
What lab tests should be used to work up normonatremia with expanded ECF?
- Blood: plasma [Na], plasma osmolaity, BUN, plasma [creatinine], CBC
- Urine: [Na], osmolaity, output
What are the most common causes of normonatremia with decreased ECF?
bleeding
diarrhea
When there is an effective arterial plasma volume decrease (which results in baro & volumo receptor stimulation), what is activated to increase GFR & Na+ reabsorption?
- Sympathetic nervous system
- ANP secretion INHIBITION
When there is an effective arterial plasma volume decrease (which results in baro & volumo receptor stimulation), what is activated to increase Na+ reabsorption ONLY?
RAA activation
When there is an effective arterial plasma volume decrease (which results in baro & volumo receptor stimulation), what is activated to increase H20 reabsorption ONLY?
ADH secretion
When there is an osmolaity increase (which results in osmoreceptor stimulation), what happens to increase body H20?
- ADH secretion stimulation
- Thirst increases
What are the most common causes of hypernatremia with decreased ECF (Na+ > 145 & Plasma Osm > 295)?
1) Extrarenal water loss:
- Osmotic diarrheas (lactulose, sorbitol, malabsorption of carb), vomiting, sweating, burns
2) Renal water loss:
- Osmotic diuresis (glucose, mannitol, urea), diuretics
What lab tests are indicated for hypernatremia with decreased ECF (Na+ > 145 & Plasma Osm > 295)?
- Blood: Plasma [Na], plasma osmolaity, BUN, plasma [creatinine], Ht, plasma [protein]
- Urine: [Na], osmolaity, output
What are the most common causes of hypernatremia with normal ECF?
1) Extrarenal H20 loss: increased insensible water loss due to fever, hot/dry environment, thyrotoxicosis, hyperventilation
2) Renal H20 loss: central or nephrogenic diabetes insipidus
What are the most common causes of hypothalamic diabetes insipidus?
- Head trauma
- Post surgical (hypophysectomy)
- Infections
- Granulomatous disease
- Cerebrovascular disease
- Idiopathic (sporadic, familial)
What are the most common tumor causing of hypothalamic diabetes insipidus?
- Craniopharyngioma
- Pinealoma
- Meningioma
- Germinoma
- Glioma
- Benign cysts
- Leukemia/lymphoma
- Metastatic
What are the most common Graunlomatous causes of hypothalamic diabetes insipidus?
- Sarcoidosis
- Histiocytosis X / eosinophylic granuloma
- Wegener's
What are the most common cerebrovasular causes of hypothalamic diabetes insipidus?
- Aneurysms
- Cavernous sinus thrombosis
- Sheehan's syndrome
- CVA
What are the most common congenital causes of nephrogenic diabetes insipidus?
1) Vassopressin V2 - receptor mutations
2) Aquaporin - 2 water cannel mutations
What are the most common acquired causes of nephrogenic diabetes insipidus?
1) Meds
2) Obstructive uropathy
3) Chronic tubulointerstitial diseases
4) Electrolyte disoders
What are the most common medications which cause of nephrogenic diabetes insipidus?
Lithium
Amphotericin B
Demeclocycline
Methoxyflurane
What are the most common tubulointerstitial diseases which cause of nephrogenic diabetes insipidus?
- Analgesic abuse nephropathy
- Sickle cell nephropathy
- Multiple myeloma
- Amyloidosis
- Sarcoidosis
- Sjogren's
- Policystic kidney disease
- Medullary cystic disease
What are the most common electrolyte diseases which cause of nephrogenic diabetes insipidus?
- Hypercalcemia
- Potassium depletion
What are the most common causes of hypernatremia with an expanded ECF (Na > 145; Plasma mOsm/kgH20 > 295)?
1) Administration of concentrated sodium bicarbonate
2) Ingestion of sea water
3) Salt inadvertently used instead of sugar
What are the 3 types of hypernatremia?
1) Hypovolemic = Loss of H20 > Na+ loss
2) Isovolemic = Loss of H2)
3) Hypervolemic = Gain of H20 & Na+
In a case of hypovolemia hypernatremia, what is the cause if urine Na+ is >40 mEq/L? Tx?
Renal Loss:
- Diuretic
- Glycosuria
- Renal Failure

Tx: Saline, then hypotonic solution
In a case of hypovolemia hypernatremia, what is the cause if urine Na+ is <20 mEq/L? Tx?
Extrarenal Loss:
- GI-vomiting
- GI-diarrhea
- Excess sweating
- Respiratory Loss

Tx: Saline, then hypotonic solution
In a case of isovolemic hypernatremia, what is the cause if urine Na+ is >40 mEq/L? Tx?
Renal Loss:
- Diabetes insipidus
- Central/Nephrogenic

Tx: Water replacement, Dextrose +/- vasopressin for central DI
In a case of isovolemic hypernatremia, what is the cause if urine Na+ is <20 mEq/L? Tx?
Extrarenal loss:
- insensible losses
- Skin
- respiration

Tx: Water replacement, Dextrose +/- vasopressin for central DI
In a case of hypervolemic hypernatremia, what is the cause if urine Na+ is >40 mEq/L? Tx?
Iatrogenic
- Hypertonic NaHCO3-, NaCl tablets, Hypertonic solutions

Mineralocorticoid:
- primary hyperaldosteronism, Cushing's disease, Adrenal

Hypertonic dialysis:
- Hemo or peritoneal dialysis

Tx: diuretics +/- dialysis
How do you calculated the body's free water deficit?
0.5 x body weight x [(plasma sodium/140)] - 1]
What is the method of water replacement in hypernatremia?
1) 1/2 of cacluated water deficit can be replaced during the 1st 12 hours (so that plasma [Na] decreases by 1 - 2 mmol/L/hr)
2) The remainder of fluid should be added over the ensuing 24 - 48 hours
What is the maximum safe rate @ which plasma [Na] can be lowered in hypernatremia?
0.5 mmol/L/hour or 12 mmol/L per day
What solution is given orally or IV to patients with hypernatremia due to pure water loss?
dextrose in water
What solution is used for dehydration when Na+ depletion is with concurrent vomiting, diarrhea or diuretic use?
quarter-isotonic saline
What symptom requires temporary discontinuation of water replacement?
deterioration in neurologic symptoms after initial improvement (due to cerebral edema)
When patients have hypernatremia secondary to solute administration, what is administered?
water & solute (aka sodium) removal (loop diuretic)
How does hyponatremia develop?
hoponatremia & hypoosmolaity develop as a result of water retention
What are the most common causes of hyponatremia & expanded ECF?
- Congestive heart failure (low ejection fraction)
- Cirrhosis of the liver (hypoproteinemia)
- Nephrotic syndrome (hypoproteinemia)

ALL 3 lead to ADH secretion
How can a patient by hyponatremia with normal ECF?
- Water is retained enough to cause [Na] decrease but Na is excreted property via the kidney & thus edema does not develop
- If enhanced water ingestion takes place, acute water intox can develop (b/c ADH is in excess)
What is the most common cause of acute hyponatremia (acute water intox) with normal ECF?
Rapid administration of H20 +:

- Acute hypovolemia (e.g. haemorrhage)
- Post-Op (early)
- Labor & delivery
- Schizophrenia
- In the presence of a chronic cause of impaired water exertion
What is the most common cause of chronic hyponatremia (acute water intox) with normal ECF?
- Primary polydipsia
- Decreased solute intake (beel potomania)
- Antidiuretic drug administration
- SIADH
- AVP release due to pain, nausea, drugs
- Glucocorticoid deficiency
- Anterior hypopituarism
- Abrupt withdrawal of glucocorticoid drug therapy
- Severe hypotheyroidism
- Chronic renal insufficiency
What are the symptoms of acute hyponatremia when Na < 125 mmol/L?
Weakness
Exhaustion
What are the symptoms of acute hyponatremia when Na < 120 mmol/L?
- Headache
- Nausea
- Vomiting
- Anorexia
- Disorientation
- Lethargy
- Pathological deep tendon reflexes
What are the symptoms of acute hyponatremia when Na < 110 mmol/L?
- Papilledema & other manifestations of increased intracranial pressure
- Seizures
- Coma
What are the 6 diagnostic criteria for SIADH?
1) hypotonic hyponatremia
2) Urine osmolaity > 100 mOsm/kgH20
3) Urine [Na] > 40 mmol/L
4) Absence of ECF depletion or expansion
5) Normal thyroid & adrenal function
6) Normal cardiac, hepatic, & renal function
What are the 6 main causes of SIADH?
1) Postop State (30%)
2) Other (22%)
3) Intracranial disease (17%)
4) Cancer (17%)
5) Medication (9%)
6) Pneumonia (5%)
What are the most common causes of hyponatremia with low ECF?
- Extensive sweating, burns
- GI loss: vomiting, tube drainage, fistula, obstruction, diarrhoea
- Renal loss: diuretics, osmotic diuresis, hypoaldosteronism, salt-wasting nephropathy, postobstructive diuresis
How can improper treatment of hypovolemia result in hyponatremia with low ECF?
- When a patient is loosing isotonic or hypotonic fluid, they need electrolytes & water.
- If pure water is given, then most of the volume will move to the ICF & only 1/3 will remain in the ECF = hypovolemia remains
What are the causes of isoosmotic hyponatremai (285-295 mOsm/kg)?
1) Pseudohyponatremia: hyperlipidemia, hyperproteinemia
2) Isotonic infusions: mannitol, sorbitol, glycine, ethanol
What are the causes of hyperosmotic hyponatremia (>295 mOsm/kg)?
1) Hyperglycemia
2) Hypertonic infusions: glucose, glycerol, mannitol, sorbitol, glycine, ethanol
What is the main cause of hyoosmotic (true) hyponatremia (<285 mOsm/kg) with a Urine osmolality of <100 mOsm/kg?
Polidypsia (extensive water intake)
If a patient is truely hyposomotic hyponatremic (<285 mOsm/kg) & has impaired renal water excretion (urine osmolity >100 mOsm/kg), then what is the next step?
Check for extracellular fluid volume state by checking Urine Na+:
LOW ECF:
1) <20 mEq/L = extrarenal
2) >40 mEq/L = Renal
NORMAL ECF:
3) <20 mEq/L = H20 intoxication
4) >40 mEq/L = many causes
EXPANDED ECF:
5) <20 mEq/L = cirrhosis, hear or renal failure
6) >40 mEq/L = Acute/Chronic renal failure
If a patient is truely hyposomotic hyponatremic (<285 mOsm/kg) & has impaired renal water excretion (urine osmolity >100 mOsm/kg), what is the cause if they have a Low ECF volume & urine Na+ of <20 mEq/L?
Extrarenal:
- GI: vomiting
- GI: diarrhea
- Pancreatitis
- Skin or Lung loss
If a patient is truely hyposomotic hyponatremic (<285 mOsm/kg) & has impaired renal water excretion (urine osmolity >100 mOsm/kg), what is the cause if they have a Low ECF volume & urine Na+ of >40 mEq/L?
Renal:
- diuretic
- obstruction
- renal damage
- renal tubular acidosis
- adrenal insufficiency
If a patient is truely hyposomotic hyponatremic (<285 mOsm/kg) & has impaired renal water excretion (urine osmolity >100 mOsm/kg), what is the cause if they have a normal ECF volume & urine Na+ of <20 mEq/L?
H20 Intox
If a patient is truely hyposomotic hyponatremic (<285 mOsm/kg) & has impaired renal water excretion (urine osmolity >100 mOsm/kg), what is the cause if they have a normal ECF volume & urine Na+ of >40 mEq/L?
- Renal failure
- Hypothyroid
- Pain
- SIADH
- Emotion
- Adrenal insufficiency
If a patient is truely hyposomotic hyponatremic (<285 mOsm/kg) & has impaired renal water excretion (urine osmolity >100 mOsm/kg), what is the cause if they have a an expanded ECF volume & urine Na+ of <20 mEq/L?
- Cirrhosis
- Heart Failure
- Renal Failure
If a patient is truely hyposomotic hyponatremic (<285 mOsm/kg) & has impaired renal water excretion (urine osmolity >100 mOsm/kg), what is the cause if they have a an expanded ECF volume & urine Na+ of >40 mEq/L?
Acute or Chronic renal failure
How is acute hypotonic hyponatremia (Na<120 mmol/L) with hypovolemia treated?
- 0.9% NaCl
- Rapid correction: 1-2 mmol/L/h during the 1st 6-8 hours & subsequently 0.5 mmol/L/h
How is acute hypotonic hyponatremia (Na<120 mmol/L) with euvolemia?
3% NaCl
- Rapid correction: 1-2 mmol/L/h during the 1st 12 hours & subsequently 0.5 mmol/L/h
- Furosemide
- monitor serum [Na] hourly
How is acute hypotonic hyponatremia (Na<120 mmol/L) with edema?
Hemodialisis with utrafiltration or hemofiltration
How is chronic hypotonic hyponatremia (Na<120 mmol/L) with hypovolemia?
- 0.9% NaCl
- Slow correction: 0.5 mmol/L/h
- Potassium supplementation
How is chronic hypotonic hyponatremia (Na<120 mmol/L) with euvolemia?
- H20 restriction
- SIADH = demeclocycline
- Potassium supplementation
How is chronic hypotonic hyponatremia (Na<120 mmol/L) with edema?
- H20 & Na restriction
- Furosemide
- ACE inhibitors
- Potassium supplementation
What form of hyponatremia does not require aggressive treatment?
Asymptomatic or >= 120 mmol/L hyponatremia
In acute hyponatremia, what is the idea Na rise during the 1st 24-hr period?
Less than 20 mmol/L (best = 10-12 mmol/24 hrs)
In chronic hyponatremia, what is the idea Na rise during the 1st 24-hr period?
10-12 mmol/L
How is sodium deficit calculated?
0.6 x body weight x (125 - Plasma Na)
In treatment of severe hypotonic hyponatremia, what is the target [Na] within the 1st 24 hours?
120-125 mmol/L
What 2 types of decreased intake can cause hypokalemia?
- Starvation
- Clay ingestion
What causes hypokalemia due to redistribution into cells?
- Metabolic alkalosis
- Insulin adminstration
- Beta2 adrenergic agonists (endogenous or exogenous)
- Alpha-adrenergic antagonists
- Vit. B12 or folic acid (RBC production)
- Granulocyte-macrophage colony stimulating factor (WBC production)
What causes hypokalemia due to increased loss?
Nonrenal:
- GI loss: diarrhea, vomiting
- Integumentary loss: sweat
Renal:
- Increased distal flow: diuretics, osmotic diuresis, salt-wasting nephropathies
- Increase Potassium secretion: minceralocorticoid excess (primary hyperaldosteronism, 2ndary hyperaldosteronism)
What are the symptoms of hypokalemia on physical exam?
- Muscle weakness
- Muscle cramps
- Paresthesias
- Muscular pains
- Lethargy
- Drowsiness
- Confusion
- Irritability
- Postural hypotension
- Anorexia
- Nausea to vomiting
- Abd. cramps
What are the symptoms of hypokalemia on ECG?
- ST depression
- T Wave: flattening or inversion
- U Wave elevation
- P-wave: increased amplitude
- PR interval prolongation
- QRS prolongation by 0.1 to 0.3 s (in severe cases)
- Arrhythmias
What can cause hypokalemia without redistribution?
- Alkalosis
- Insulin
- Periodic paralysis
- Barium poisoning
- Vitamin B12 therapy
What causes Hypokalemia due to extrarenal K loss?
- Biliary loss
- Lower GI loss
- Fistulla
- Skin Loss

K < 20 mEq/day
Na > 100mEq/day
What causes hypokalemia due to renal K loss, with high Bp, & high plasma renin?
- Malignant HTN
- Renovascular disease
- Renin-secreting tumor
What causes hypokalemia due to renal K loss, with high Bp, low plasma renin, & high aldosterone?
- hyperaldosteronism
- bilateral hyperplasia
What causes hypokalemia due to renal K loss, with high Bp, low plasma renin, & low aldosterone?
- Mineralocorticoid ingestion
- Adrenal hyperplasia (congenital)
- Cushing's syndrome
What causes hypokalemia due to renal K loss, with low/normal Bp, and low pH?
RTA
What causes hypokalemia due to renal K loss, with low/normal Bp, high pH, & Urine chloride <10 mEq/day?
vomiting
What causes hypokalemia due to renal K loss, with low/normal Bp, high pH, & Urine chloride >10 mEq/day?
- Bartter's syndrome
- Diuretic
- Magnesium deficiency
What is required to raise the serum K by 1 mEq/L if serum K is less than 3 mEq/L?
200-400 mEq infusion
What is required to raise the serum K by 1 mEq/L if serum K is between 3 & 4.5 mEq/L?
100-200 mEq/L
What is the maximum concentration of administered K?
40 mEq/L via peripheral vein or 60 mEq/L via central vein
What is the maximum rate of infusion of K?
20 mEq/h
Under what should K be infused at rates up to 40 mEq/h and concentration of 60 mEq/L?
- Serum K less than 2.0 mEq/L
- Abnormal electrocardiogram
- Paralysis

- Up to 400 mEq KCL can be administered IV per day
- reduce rate to 10 mEq/hr & solution to 30 mEq/L with [K] reaches 2.5 mEq/L
When administering K, what needs to be checked?
serium creatinine levels to ***** adequacy of renal function
When does K infusion require ECG monitoring?
- K @ rate of 120 mEq/day or 20 mEq/h for more than 2 hours
- Also, measure serum K with every 50-100 mEq infused
What solution should be used to infuse K in severe hypokalemia?
saline
What are the causes of hyperkalemia due to redistribution OUT of cells?
- Metabolic acidosis
- Insulin deficiency (diabetic ketoacidosis)
- Hyperosmolaity (hyperglycemia)
- Beta2 adrenergic antagonists (beta blockade)
- Alpha-adrenergic antagonists
- Cell damage (lysis)
- Periodic paralysis
- Succinylocholine
- Digoxin toxicity
What can cause hyperkalemia due to decreased K secretion?
- Renal failure
- primary hypoaldosteronism: adrenal insufficiency, adrenal enzyme deficiency
- Secondary hypoaldosteronism: hyporeninemia, drugs (ACE inhibitors, NSAIDS)
- Resistance to aldosterone: pseudohypoaldosteronism, tubointestitial disease, drugs (K-sparing diuretics)
What are the symptoms of hyperkalemia on physical exam?
- Usually asymptomatic
- Muscular weakness
- Tremor
- Paresthesias
What are the symptoms of hyperkalemia on ECG?
- T wave peak
- PR interval prolongation
- P wave disappearance
- QRS prolongation & decomposition
- Ventricular fibrillation
What are spruious causes of hyperkalemia?
Leaky RBCs
- hemolysis
- thrombocytosis
- leukocytosis
- mononucleosis
What causes hyperkalemia due to increased intake or tissue release?
- IV/oral intake
- Hemolysis
- Rhabdomyolysis
- Tumor lysis
- Stored Blood
What can cause hyperkalemia due to renal function with a GFR <20 ml/min?
Acute or chronic renal failure
What can cause hyperkalemia due to renal function with a GFR >20 ml/min and Aldosterone deficient?
- Addison's disease
- Hereditary
- Adrenal defects
- Drugs: Heparin, NSAIDS, Cyclosporine, Spironolactone, Trimethoprim, Pentamidine
What can cause hyperkalemia due to renal function with a GFR >20 ml/min without Aldosterone deficient?
1) Acquired: obstruction, renal transplants, SLE, Amyloidosis, Sickle cell
2) Drugs: K-sparing diuretics
In what tissues is ALT (alanine aminotransferase) found?
LIVER (also in kidney, heart, liver)
- EXCLUSIVELY cytoplasmic
In what tissues is AST (aspartate aminotransferase) found?
- Heart, liver, skeletal muscle, kidney, RBCs
- Mitochondrial (60-80%) & cytoplasmic (20-40%), 80% of AST in hepatocytes is in mitochondrial membrane
What aminotransferase is 15% higher in black men?
AST
What aminotransferases directly relate to BMI?
AST & ALT (40-50% higher with a high BMI)
What aminotranserase varies 45% during the day and is highest in the afternoon & lowest at night?
ALT
What aminotransferase varies 5-10% from one day to the next?
AST
What aminotransferase varies 10-30% from one day to the next?
ALT
What aminotransferase shows a 3x increase with strenuous exercise?
AST
What aminotransferase shows a 20% reduction in those who exercise at USUAL levels when compared to those who exercise more strenuously or not at all?
ALT
- Usually in men
- In women, <10% & usually with strength training
What aminotransferase is significantly increased with hemolysis, hemolytic anemia, and muscle injury?
AST
- In muscle injury, this increase is related to the amount of increase in CK
- In hemolysis: usually severalfold lower increase than LDH increase
What aminotransferase is significantly decreased with renal failure?
AST, ALT
What aminotransferase is moderately increased with increased with hemolysis, hemolytic anemia, and muscle injury?
ALT
What are ALT levels used for?
Confirm liver origin of an AST increase
What is more specific for detecting liver disease in nonalcoholic, asymptomatic patients?
ALT
What vitamin deficiency in alcholics causes decreased hepatic ALT activity?
pyridoxine
What aminotransferase is used to monitor therapy with potentially hepatoxic drugs?
AST
In chronic alcoholics, what aminotransferase is chronically elevated and drops 50% upon abstinence for 1 week?
AST
What disease process results in a 10x increase in ALT & AST?
Acute viral hepatitis
What can cause chronic elevation of ALT/AST in asymptomatic patients?
- alcohol or medication use
- chronic viral hepatitis
- primary hemochromatosis
- nonalcoholic fatty liver disease
Under what conditions is an AT/ALT >1? (HINT: in all other forms of hepatocellular injury, AST/ALT ratio <1)
alcoholic liver injury/cirrhosis
Where is the bulk of serum ALP found?
liver & bone
Where are less amounts of ALP (alkaline phosphatase) found?
placenta, ileal mucosa, kidney
What is ALP a marker for?
biliary dysfunction
What stimulates synthesis of ALP & release from cell membranes?
cholestasis
What 3 liver conditions result in ALP elevation?
1) extrahepatic (CBD) biliary tract obstruction
2) Intrahepatic biliary tract obstruction due to acute liver injury
3) Liver space-occupying lesions (e.g. tumor, abscess, granuloma)
What are the most common causes of persistent ALP elevation more than 3x the upper reference limit?
- CBD obstruction
- Metastatic tumor to the liver
- Primary biliary cirrhosis
What change in ALP levels is seen in pregnancy?
2-3x increase in 3rd trimester
What change in ALP levels is seen day to day?
4-10%
What change in ALP levels is seen in food ingestion?
increases by as much as 30 IU/L
What change in ALP levels is seen in black men and women?
10-15% increase
What change in ALP levels is seen in higher BMI?
25% higher with increased BMI
What change in ALP levels is seen in smokers?
10% higher
What change in ALP levels is seen in oral contraceptive users?
20% lower
What marker do bone disease show?
Elevated ALP (+ ALP differentiation & normal GGT to rule out liver cause)
Where is Gamma-glutamyl transferase located?
Liver cell membrane
What is affected by both acute liver cell damae & biliary tract obstruction?
GGT
What can GGT be used to confirm?
Liver source of elevated ALP (but does NOT rule out bone disease coexisting)
What is the GGT change in cholestasis?
Increase 10-12x
How much is GGT increased in alcoholics?
70-80%
When acetaminophen is taken in high concentrations, what can be elevated?
GGT
What is the daily variation in GGT?
10-15%
What is the affect of race on GGT?
2x higher in African Americans
What is the affect of BMI on GGT?
25% higher with mild increase in BMI; 50% higher with BMI > 30
What is the affect of food ingestion on GGT?
Decreases after meals
What is the affect of drugs on GGT?
Increased 2x by:
- Furosemide
- Heparin
- Methotrexate
- Phenobarbital
- Penytoin (5x increase)
- Carbamazepine
- Oral contraceptives
What is the affect of smoking on GGT?
10% higher with 1 pack/day
2x higher with heavy smoking
What is the affect of DM, hyperthyroidism, rheumatoid arthritis, & COPD on GGT?
Increased activity
What is the affect of alcoholism on GGT?
direct: can remain increased for weeks after cessation of chronic alcohol intake
Where is lactate dehydrogenase 5 found?
liver & skeletal muscle
What does increase of total Ld to 500 IU/L (+) with ALP to levels above 250 IU/L indicate?
Space-occupying lesions of the liver (METASTATIC carcinoma)
Where is lipoprotein LpX found?
bile
What does the presence of LpX in serum indicate?
obstructive biliary disease
What are the 3 general types of unconjugated jaundice?
1) Overproduction
2) Decreased hepatic uptake
3) Decreased conjugation
What are the overproduction causes of unconjugated jaundice?
- Hemolysis (intra & extravascular)
- Ineffective erythopoesis
What are the decreased hepatic uptake causes of unconjugated jaundice?
- Gilber's syndrome
- Drugs (e.g. novobiocin, rifampin)
What are the decreased conjugation causes of unconjugated jaundice?
- Gilbert's syndrome
- Neonatal jaundice
- Hepatocellular disease
- Crigle-Najjar syndrome (type 1 & 2)
- Drugs (e.g. Chloramphenicol)
What are the 2 general types of conjugated jaundice?
- Impaired hepatic excretion
- Extrahepatic biliary obstruction (mechanical)
What causes conjugated jaundice due to impaired hepatic excretion?
- Dubin-Johnson, Rotor
- Drugs: chloramphenicol, metylotestosterone, oral contraceptives
- 3rd trimester pregnancy
- benign recurrent intrahepatic cholestasis
- primary biliary cirrhosis
- sepsis
- post op
What causes conjugated jaundice due to extrahepatic biliary obstruction (mechanical)?
- Gallstones
- Tumors
- Stricture of the bile duct (e.g. post-cholecystectomy, primary sclerosing cholangitis)
What are the best markers for hepatocellular injury?
- AST & ALT
- bilirubin in serum
- urobilinogen in urine
- serum albumin
- prothrombin time
- GGT
- LDH
- Viral Ab/Ag
What are the best markers for biliary obstruction?
- ALT
- GGT
- bilirubin in serum
- bilirubin in urine
- LpX
- 5'-Nucleotidase
What are the best markers for toxic liver injury?
AST
GGT
Wwhat is hemosiderosis?
Increase in the quantity of iron stored in the body
- Can be due to alcoholic liver disaes, chronic HCV, non-alcoholic statohepatitis
What is hemochromatosis?
an increase in total body iron stores with iron deposition in parenchymal tissues that ultimately leads to functional impairment of most severely affected organs:
1) Liver = cirrhosis
2) Pancreas = diabetes mellitus
3) Heart = cardiomyopathy
4) Joints = arthritis
What are the two types of hemochromatosis?
Acquired
Hereditary/Primary
What is acquired hemochromatosis due to?
- Excessive dietary iron ingestion
- Repeated blood transfusions
What is primary hemochromatosis?
- Genetic disorder (1/200- 1/400)
- Most frequent metabolic liver disease with multisystem involvement
What is the 1st line screening test & definitive test for hemochromatosis?
- Screening: % transferrin saturation & serum [ferritin]
- Dx: genetic (look for C282Y mutation on HFE gene, AR), liver biopsy, MRI
What is the plasma iron value for symptomatic hemochromatosis?
180-300 (vs. normal = 50-150)
What is the plasma TIBC (ug/dL) value for symptomatic hemochromatosis?
200-300 (vs. normal = 250-375)
What is the plasma % transferrin saturation value for symptomatic hemochromatosis?
50-100 (vs. normal = 20-40)
What is the serum ferritin (ng/mL) value for symptomatic hemochromatosis?
400-6000 (vs. normal 10-200)
What is the urinary iron after 0.5 gm desferrioxamine value for symptomatic hemochromatosis?
9-23 (vs. normal 0-2)
What is the Liver iron (ug/100mg dry weight) for symptomatic hemochromatosis?
600-1800 (vs. normal 30-140)
What are the chemicals that can indicate plaque instability?
- sCD40L (soluable CD40 ligand)
- PAPP-A: prenancy associated plasma protein A
- MPO: myeloperoxidase
- ICAM: intercellular adhesion moleucle
- VCAM: vascular adhesion molecule
What is the acute phase reactant that can be used to manage/Dx heart diseases?
hsCRP
What can IMA, FFAu, & Choline be used to Dx/manage?
ischemia
What can cTNI, cTNT, CK-MB, mioglobina, h-FABP be used to measure?
Necrosis of heart tissue
What can BNP, NT-proBNP be used to measure?
Myocardial dysfunction
What are the early markers of myocardial necrosis?
CK-MB mass
mioglobin
h-FABP
What are the early markers of heart tissue ischemia?
IMA
uFFA
choline
What lab values are used for risk stratifcation in heart diesease?
Tn
hsCRP
BNP, NT-pro BNP
sCD401
What lab markers are used to make Tx strategies in heart diseases?
Tn
hsCRP
BNP, NT-proBNP
sCD401
What are the 2 subunits of creatine kinase (CK)?
B (brain)
M (muscle)
What are the locations of the following CKs? CK-BB, CK-MB, CK-MM
CK-BB (CK1) = brain, prostate, intestine, lungs

CK-MB (CK2) = heart, skeletal muscle

CK-MM (CK3) = skeletal muscle, heart
What CK isoenzyme is localized in mitochondria?
CK-Mt
What CK has been identified as the CK-BB linked with IgG?
makro CK-type 1
What CK has been identified as the CK-Mt oligomer?
makro CK-type 2
What are the serum isoforms of CK?
CK-3(sub2)
CK-3(sub1)
CK-2(sub1)
What are the tissue isoforms of CK?
CK-3(sub3)
CK-2(sub2)
Which CK subunit may be hydrolyzed by carboxypeptidase in blood?
M subunit
What are the 4 other cases in which Ck is elevated?
1) Skeletal muscle disorders (damage 2ndary to trauma, intramuscular injections, prolongs immobilization, surgery)

2) After physical effort

3) After electric cardioversion, cardiac catheterization

4) Hypothyreosis
Give the time for CK-MB activity: onset, peak value, decrease to normal range?
- Onset: 4-8 hours
- Peak Value: 12-24 hours
- Decrease to normal: 2-3(4) days
What are the 4 cases in which CK-MB is elevated?
1) Skeletal muscle disorders
2) Renal failure
3) Some neoplasms
4) Liver cirrhosis
What is the CK-MB index used to increase the specificity for myocardium?
(CK-MB act / CK act) x 100%
What is the Dx sensitivity of CK-MB in the 4th hour from the 1st symptoms?
30%
What is the CK-MB mass times for onset, peak value, & decrease to normal range?
Onset = 5 (3.5-5.5) hrs
Peak = 14 (11.5-15.5) hrs
Decrease to Normal = 87 (68-96) hrs
When is CK-MB mass NOT useful?
after 30 hours (i.e. not useful in late-stage MI)
Besides cardiovascular disease, in what other condition is CK-MB mass increased?
skeletal muscle diseases
What is the Dx sensitivity for CK-MB mass after an MI: 4th hour, 6th hour, 8th hour?
4th = 50%
6th = 75%
8th = 90%
What lab markers for an MI has the great effectiveness for excluding an MI?
CK-MB: if there is NO increase of CK-MB within the first 8 hours for the 2st symptoms, an MI is excluded up to 93-95%

myoglobin: if there is NO increase of myoglobin within the first 4 hours for the 2st symptoms, an MI is excluded up to 90-100%
What lab value is useful in the evaluation of fibrinolytic therapy?
CK-MB mass
What is the 1st serum cardiac marker that rises above the normal range after an MI?
myoglobin
What is the post MI myoglobin times for onset, peak value, & decrease to normal range?
Onset = 3.3 (2.5 - 4.3) hr
Peak = 6.0 (4.0 - 8.5) hr
Decrease to Normal = 20 (15.5 - 39.9) hour
When is myoglobin levels NOT useful?
late stage MI: increase only lasts for 12-15 hours
Besides MIs in what cases will myoglobin concentration be increased?
1) Skeletal muscle diseases & injury
2) Renal failure
3) After physical effort
What is the Dx sensitivity for myoglobin after an MI?
- 2.5 hours after symptoms: 30%
- 4 hours after MI: 50%
What does h-FABP stand for?
heart type fatty acid binding protein
What are the advantages of h-FABPR?
- High early sensitivity
- Sufficient cardioselectivity
- Early Dx in ER: "poly-marker" strategy, high + & - predictive value
Where is troponin found?
thin filament of striated muscles
What are the 3 isotypes of troponin?
- T (TnT)
- I (TnI)
- C (TnC)
What is the function of TnT (tropnin T)?
Binds the troponin complex to tropomyosin
What is the function of TnI (tropnin I)?
Inhibits actomyosin ATP-ase
What is the function of TnC (tropnin C)?
Regulates TnI activity by binding calcium
Which tropnins have diagnostic value in an MI?
TnI & TnT
What are the 3 isoforms for TnI & TnT?
- Cardiac isoforms (cTnI & cTnT)
- Fast myofibril
- Slow myofibril
Which troponin has an absolute specificity for the myocardium?
- cTnI: absolute; 100%
- cTnT: high, but not 100%
Give the time for TnI activity: onset, peak value, decrease to normal range?
Onset: 4.5 (4 - 6.5) hr
Peak: 19.0 (12.8 - 29.8) hr
Decrease: 168.0 (105 - 168) hr
Give the time for TnT activity: onset, peak value, decrease to normal range?
Onset: 5.0 (3.5 - 8.1) hr
Peak: 18.0 (12.8 - 75.0) hr
Decrease: 172 (147 - 296) hr
When, other than an MI, is cTnT increased?
- Chronic renal failure
- Muscular dystrophy
- Polymyositis
What is the diagnostic sensitivity of troponins for 4 and 6 hours after an MI?
4 hr: 50%
6 hr: 70%
What are BNP & NT-proBNP?
- BNP = Brain natriuretic peptide

- NT-proBNP = N-terminal pro-B-type natriuretic peptide

- Produced within the heart ventricles due to increased pressure & diastolic overload
What are the 3 main effects of BNP & NT-proBNP?
1) Reduction of Bp by arterial & venous vasodilation
2) Natriuretic & diuretic effects by increasing GFR & decreasing Na reabsorption within the neprons
3) Inhibition of sympathetic system & renin-angiotension-aldosterone system
DTAS
Digital Terminal Automation System
What is the diagnostic value of BNP & NT-proBNP in acute coronary syndromes?
Ischaemia induces BNP & N-proBNP release but it is not yet used as a marker
What is the prognostic value of BNP & NT-proBNP in acute coronary syndromes?
- Higher levels associated with increased early/late mortality & progression of heart failure independently of troponin & CRP evaluation
- Linear correlation observes in NSTEMI (no threshold though)
What is the therapeutic value of BNP & NT-proBNP in acute coronary syndromes?
High NT-proBNP levels may indicate beneficial effects of invasive methods
What is the normal urine (in ml) per day?
1000 - 1500 ml
What is oliguria?
<500 ml of urine per day
- When urine flow rate is less than the minimum required to allow excretion of daily solute load
What is anuria?
<100 ml of urine per day or the complete absence of urine flow
- Causes are usually the same as for acute renal failure
What is polyuria?
Passage of large volume of urine (but does not necessarily indicate a pathological process
What are the causes of polyuria?
- Psychosychogenic polydipsia (excessive water intake)
- Diabetes mellitus (osmotic diuresis)
- Chronic kidney disease (urea)
- Abnormal tubular water handling
What is the noraml urine pH?
6.2 (4.6-8.0)
What are the 7 main causes of alkaline urine?
1) Vegetarian diet
2) Alkali ingestions (Na-bicarb, K-citrate)
3) Urea-splitting organism infection
4) Metabolic alkalosis
5) Respiratory alkalosis (acute)
6) Renal tubular acidosis (type 1)
7) Water diuresis
What are the 8 main causes of alkaline urine?
1) High protein diet
2) Acid ingestion (ascorbic acid, ammonium chloride)
3) K-depletion
4) Metabolic acidosis
5) Respiratory alkalosis (acute)
6) Hyperaldosteronism
7) Water deprivation
8) Intox with methyl alcohol
What is the normal color of urine?
Pale, straw yellow
- Due to pigment urochrome

Normal urine can also be deep amber or colorless
What are the 5 main causes of orange urine?
1) Bile pigments
2) Nitrofurantoin
3) Phenothiasines
4) Rhubarb
5) Carrot
6) Senna
What are the 5 main causes of yellow urine?
1) Bile pigments
2) Nitrofurantoin
3) Penacetin
4) Rhubarb
5) Carrot
What are the 4 main causes of green urine?
1) Biliwerdin
2) Methylene blue
3) Nitrofurans
4) Vitamin B complex
What are the 2 main causes of blue-green or blue urine?
1) Nitrofurans
2) Methylen blue
What are the 8 main causes of red urine?
1) RBC
2) Myoglobin
3) Hemoglobin
4) Porphyrins
5) Bromsulfophtalein
6) Phenytoin
7) Senna
8) Beetroots
What are the 6 main causes of brown or black urine?
1) Biliary pigments
2) Hematin
3) Myoglobin
4) Iron salts
5) Nitrofurans
6) Sulpha drugs
What causes urine to have an ammonia odor?
break-down of urea in the urine
What causes urine to have a pungent odor?
- UTI
- high ammonia concentration
- failure to deliver the specimen to the lab in a fresh state
What 3 metabolic diseases result in characteristic urine odors?
1) Maple syrip urine disease
2) Phenylketonuria
3) Isovaleric acidemia
What 4 states result in turbid urine?
1) phosphates
2) leukocyturia
3) bacteriuria
4) chyluria
What is the normal range of urine specific gravity?
1.003 - 1.040
What should the specific gravity of the 1st specimen of the day be?
> 1.015
What does a very high urine specific gravity usually indicate?
glucose or protein in the urine
What are the 4 main causes of dilute urine?
1) high fluid intake
2) tubular disorders
3) diuretic administration
4) early glomerular disease
What are the 3 main causes of very dilute urine (1.001 - 1.005 specific gravity)?
1) Extremely high fluid intake
2) Diuretics
3) Diabetes insipidus
What is orthostatic proteinuria?
- Protein excretion rate is generally increased in the up-right posture
- Avoid by taking an early-morning urine sample
What is the normal urine protein level?
</= 150 mg/day
What amount of protein in the urine (mg/day) causes mild proteinuria?
500 mg/day
What amount of protein in the urine (mg/day) causes moderate proteinuria?
up to 3 g/day
What amount of protein in the urine (mg/day) causes heavy proteinuria?
more than 3g/day
What are the 7 main causes of mild proteinuria?
1) Fever
2) Benign hypertensive nephrosclerosis
3) Renal tumour
4) Obstructive nephropathy
5) Chronic pyelonepritis
6) Early diabetic nephropathy
7) Orthostatic proteinuria
What are the 7 main causes of moderate proteinuria?
1) UTI
2) Chronic pyelonephritis
3) Acute tubular necrosis
4) Acute/Chronic glomerulonephritis
5) Obstructive nephropathy
6) Accelerated phase hypertension
7) Orthostatic proteinuria
What are the 7 main causes of heavy proteinuria?
1) Pre-eclampsia
2) Myeloma
3) Acute/Chronic glomerulonephritis
4) Diabetic nephropathy
5) ALL causes of nephrotic syndrome
What are the 6 categories of proteinuria?
1) prerenal
2) glomerular
3) tubular
4) mixed
5) lower urinary tract
6) asymptomatic
What are the 2 types of prerenal proteinuria?
1) Abnormal low molecular weight protein easily passes through the glomerulus into the urine
2) Change in hydrostatic pressure in the kidney glomerulus
What are the 2 stages of glomerular proteinuria?
1) Early: glomerular damage is SELECTIVE & urinary proteins are the lowest molecular weight proteins found the bloodstream
2) Advanced: NON-SELECTIVE proteinuria, all proteins in the blood are found in the urine
What causes tubular proteinuria (mild, low molecular weight)?
- tubular damage
- heavy metal intoxication
- vitamin D intoxication
- galactosemia
- pyelonephritis
- acute tubular necrosis
- PCOS
What causes mixed proteinuria and what is mainly excreted?
- glomerular & tubular damage
- Beta-2 microglobulin
What causes lower urinary tract proteinuria?
- 2ndary to a UTI
- Exudation of protein through the mucosal layer of the lower urinary tract
What causes asymptomatic proteinuria?
orthostatic
What is the albumin level in normal urine?
- Excretion is less than 30 mg/24h
- Urine concentration is less than 20 mg/l
What is the albumin level in microalbuminuria?
- Excretion rate from 30-300 mg/24h
- Urine conenctration ranges from 20-200 mg/l
- Predicts the later development of clinical diabetic nephropathy
What level of albumin is needed for macroalbuminuria?
- Excretion rate >300 mg/24h
- Urine albumin concentration >200 mg/l
What level of plasma glucose (mmol/l) exceeds the reabsorptive capacity of the tubules?
10 mmol/l
What 2 states of increased fat metabolism leads to ketoacidosis?
1) Starvation
2) Insulin-deprivation
What are the 3 causes of hemoglobinuria?
1) Intravascular hemolysis
2) Glomerular disease
3) Bleeding from the lower urinary tract
What is the mechanism of hemoglobinuria in intravascular hemolysis?
When the capacity of haptoglobin or hemopexin to bind & remove haemoglobin is exceeded, free haemoglobin passes through the glomerulus into the urine
What is the type of hemoglobinuria found in glomerular disease?
presence of red cells and red-cell casts in the urine
What type of hemoglobinuria is found in bleeding from the lower urinary tract?
red cells but NEVER red-cell casts
In orthopedics, what are the important aspects of history taking regarding identification?
- Occupation, hobbies, hand dominace
- Chief complaint
- Past ortho history
- Past surg, med. illness, allergies, meds
What does OPQRST stand for?
Onset
Provoking/Alleviating factors
Quality
Radiation
Site
Timing
Regarding pain, what are the 3 main questions?
- OPQRST
- Muscular, bony or joint
- # of joints involves & symmetry of involvement
In orthopedics, what are inflammatory symptoms?
Morning stiffness (>30 minutes)
Tenderness
Swelling
Redness
Warmth
In orthopedics, what are mechanical/degenerative symptoms?
- Increased with activity, decreases with rest
- Locking, giving way
- Instability
In orthopedics, what are the symptoms of neoplasm or infections?
- Constant pain, night pain
- Fever, night sweats
- Anorexia, fatigue, weakness, weight loss
- METS (PT Barnum Loves Kids): Prostate, Thyroid, Breast, Lungs, Kidney
What are the 4 main types of orthopedically-relevant referred pain symptoms?
- Shoulder pain from the heart or diaphragm
- Arm pain from the neck
- Leg pain from the back
- Back pain from the kidney, aortic aneurysm, duodenal ulcer, pancreatitis
In orthopedics, What does SEADS stand for?
Swelling
Erythema
Atrophy
Deformity
Skin changes
What is the 99Tc (Technetium) bone scan used for?
- Osteoblastic activity or inflammatory reaction
- Positive with fractures, tumors, local reation
What is a gallium scan used for?
- Reflects hypervascularity, taken up by leukocytes
- Positive with infection
- Positive when uptake on gallium is greater than on 99Tc
What blood tests should be taken for a painful, swollen joint?
CBC
ESR
Rheumatoid Factor (RF)
ANA
C-reactive protein (CRP)
What are the 3 main processes that lead to fractures?
- Traumatic
- Pathologic: tumore, metabolic bone disease, infection, osteopenia
- Stress: repetitive mechanical loading
What are the 5 clinical features of fractures?
1) Pain & Tenderness
2) Loss of Function
3) Deformity
4) Abnormal mobility & creptius (avoid)
5) Altered neurovascular status (DOCUMENT)
Regarding fractures, what are the initial steps in management?
1) ABCDEs
2) limb: attend to neurovascular status (above & below)
3) Rule out other fractures/injuries
4) AMPLE history: Allergies, Medications, Past medical history, Last meal
5) Events surrounding the injury
6) Analgesia
7) Analgesia
8) Splint fracture: makes patient more comfortable, decresses progression of soft tissue injury, decreases blood loss
9) Imaging
What is the radiographic description of fractures in the rule of 2s?
2 Sides
2 Views: AP & Lateral
2 Joints: above & below the site of injury
2 Times: before & after reduction
What identifies an open fracture radiographically?
gas in the soft tissue
How is a fracture site identified radiographically?
- Which bone
- If Diaphyseal describe by 1/3s: proximal/middle/distal
- extra-articular: diaphysis/metaphysis
- intra-articular
What are the 4 types of fractures?
1) Spiral: rotational force, low energy (# line >2x bone width)
2) Oblique: angular & rotational force
3) Transverse: direct force, high energy
4) Commuted (>2 pieces): direct force, high energy
When describing fractures, what are three things to look for in the soft tissue?
- Calcification
- Gas
- Foreign Bodies
In fractures, what are the 4 types of displacement (position of distal fragment with respect to the proximal one)?
1) Apposition/Translation: describes what % of surfaces remain in contact
2) Angulation: describes which way the apex is facing
3) Rotation: distal fragment compared to proximal fragment
4) Shortened: due to overlap or impaction
What are the 3 types of fractures that may not need reduction?
- Clavical
- Fibula
- Vertebral compression fractures
What does NO CAST stand for regarding open reductions?
Non-union
Open fracture
neurovascular Compromise
intra-Articular fractures
Salter Harris III, IV, V
polyTrauma
What are the other, not NO CAST, indications for an open reduction?
- Failure to reduce a closed fracture
- Cannot cast or apply traction due to site (e.g. hip fracture)
- Pathologic fractures
- Fractures in paraplegics for nursing access
- Potential for improved function via internal fixation (ORIF)
What are the complications of open reductions?
Infection
Non-union
New fracture through screw holes
Implant failure
What are the aspects of post-stabilization rehab for fractures?
Goal:
- Avoid joint stiffness
- Isometric exercises to avoid muscle atrophy
- ROM for adjacent joints
- Evaluate bone healing (clinical, x-ray)
What are the 3 classifications of open fractures?
1) <1 cm; minimal soft tissue injury; use ancef
2) >1 cm; moderate soft tissue injury; use ancef
3) >1cm; esctensive muscle damage due to gunshot, MVC, barnyard injury; use ancef, gentamycin, flagyl
What are the 5 steps of initial managment of open fractures?
1) ONLY reduce if NV compromise from fracture site
2) Remove gross debris
3) Obtain culture & cover wound with sterile dressing
4) Tetunus vaccine/booster
5) Antibiotics
6) split
NPO & prepare for OR
What is the time limit of getting an open fracture to the OR?
Arrive within 6 hours to reduce risk of infection
For adults, when is a Td (0.5 mL adsorbed tetanus toxoid) for an open fracture required?
- Clean wound if tetanus history is unknown or <3 Td
- Dirty wound (also add TIG = 250 units tetanus immune globulin)
What are the 5 complications of open fractures?
- Osteomyelitis
- Soft tissue damage
- Neurovascular injury
- Blood loss
- Nonunion
What is the normal bone healing stages of fractures: 0-3 weeks, 3-6 weeks, 6-12 weeks, 6-12 months, 1-2 years?
- 0-3 weeks: hematoma, macrophages surround fracture site
- 3-6 weeks: osteoclasts remove sharp edges, callus forms within hematoma
- 6-12 weeks: bone forms within the callus, bridging fragments
- 6-12 months: cortical gap is bridged by bone
- 1-2 years: normal architecture is achieved through remodelling
What is the clinical test of a fracture union (healing)?
no longer tender to palpation or angulation stress
What is the x-ray evidence of a fracture union (healing)?
trabeculae cross fracture site, visible callus bridging site
What are the 5 early, local complications of fractures?
- Neurovascular injury
- Infection
- Compartment syndrome
- Implant failure
- Fracture blisters
What are the 7 late, local complications of fractures?
- Malunion
- Nonunion
- Osteonecrosis
- Osteomyelitis
- Heterotopic ossification
- Post-traumatic arthritis
- Reflex sympathetic dystrophy (RSD)
What are the 5 early, systemic complications of fractures?
- Sepsis
- DVT & PE
- Fat embolus
- ARDS
- Hemorrhagic shock
What 2 compartments are most susceptible to compartment syndrome?
- Forearm (classically, flexor compartment)
- Calf (classically, the tibial compartment)

b/c their fibro-osseous compartment has little room for expansion
What intracompartmental pressure over 30mmHG requires intervention (i.e. due to compartment syndrome)?
30 mmHg
What is the pathogenesis of compartment syndrome?
1) Increased pressure from blood & swelling
2) Decreased venous & lymph drainage
3) pressure in compartment > perfusion pressure
4) Muscle & nerve anoxia (acidosis)
5) Muscle & nerve necrosis
6) Leaky BM (basement membrane)
7) transudation itno tissue surrounding compartment
What are the possible etiologies of compartment syndrome?
- Fracture, Dislocation
- Soft tissue damage & muscle swelling
- Crush injury
- Arterial compromise
- Muscle anoxia
- Venous obstruction
- Increased venous pressue
- Constrictive dressing, cast, splint
What are the early clinical S/S of compartment syndrome?
Pain:
- greater than expected for injuy
- not relieved by analgesics
- increased with passive stretch of compartment muscles
Pallor:
- Palpable tense, swollen compartment
What are the late clinical S/S of compartment syndrome?
- Paralysis (inability to move limb)
- PULSES
- Paresthesias
What are the mmHg measurements found in compartment syndrome?
- 0 mmHg = normal tissue pressure
- 10-30 mmHg = diastolic Bp is inadequate for perfusion &/or ischemia results
- 40-45 mmHg = fasciotomy
When there is a tibial fracture, what are the weakness points, pain upon movement & sensory indications that are signs of compartment syndrome?
Weakness = Toe during foot extension
Pain = Toe during foot flexion
Sensory = 1st dorsal web space
When there is a supracondylar (humerus) fracture, what are the weakness points, pain upon movement & sensory indications that are signs of compartment syndrome?
Weakness = finger upon wrist flexion
Pain = finger upon wrist extension
Sensory = volar aspect of fingers
What are the causes of avascular necrosis (AVN)?
- Steroid use (for disease Tx)
- Alcohol
- Post-traumatic fracture/dislocation
- Septic arthritis
- Sickle cell
- Gaucher's disease
- Caisson's disease
What are the clinical & x-ray features of stage 1 AVN?
Clinical: pre-clinical; no pain

X-ray: No x-ray abnormality; may be detectable on MRI
What are the clinical & x-ray features of stage 2 AVN?
Clinical: painful

X-ray: fragment appears dense; normal bone contour
What are the clinical & x-ray features of stage 3 AVN?
Clinical: painful

X-ray: abnormal bone contour
What are the clinical & x-ray features of stage 4 AVN?
Clinical: very painful

X-ray: collapse of articular surface & signs of arthritis on both sides of the joint
What is the mechanism of AVN?
- Disruption of blood supply to bone
- Pathological changes: resorption, subchondral fractures & loss of cartilage
What bones are most susceptible to AVN?
Bones extensively covered in cartilage which rely on intra-osseous blood supply & distal to proximal blood supply:
- Head of femur
- Proximal pole of scaphoid
- Body of talus
What are the 4 joints of the shoulder?
- Glenohumeral
- Acromioclavicular (AC) joint
- Scapulothoracic joint
- Sternoclavicular joint
What area of the spine refers pain to the shoulder?
C-spine
What change in the shoulder is more common that Osteoarthritis?
Rotator cuff & tendon degeneration
What is the passive ROM for shoulder abduction?
180 degrees
What is the passive ROM for shoulder adduction?
45 degrees
What is the passive ROM for shoulder flexion?
180 degrees
What is the passive ROM for shoulder extension?
45 degrees
What is the passive ROM for shoulder internal rotation?
Level of T4
What is the passive ROM for shoulder external rotation?
40-45 degrees
What 3 views are necessary for proper shoulder evaluation?
1) AP
2) Trans-scapular
3) axillary
What is the Mercedes Benz sign?
In the trans-scapular radiograph, look for the humeral head overlapping the glenoid:
- Left line is acromion
- Right line is coracoid
- Vertical line is scapula
What is usually injured in a fall onto the shoulder with an adducted arm?
AC joint (acromioclavicular)
What are the 2 main ligments that attache the clavical to the scapula?
- AC ligament (acromioclavicular)
- CC ligament (coracoclavicular)
What are the characteristics of a Type 1 acromioclavicular sprain?
- Partial injury
- No instability
- No displacement (sprain of AC lig)
- CC is intact

Tx: ice, immobilization, early ROM & strengthening
What are the characteristics of a Type 2 acromioclavicular sprain?
- Disrupted AC ligament
- Sprain of CC ligament

Tx: ice, immobilization, early ROM & strengthening
What are the characteristics of a Type 3 acromioclavicular sprain?
Disrupted AC & CC ligaments with superior clavicle displacement (shoulder displaced inferiorly)

Tx: ice, immobilization, early ROM & strengthening OR operative repair if skin compromise is imminent
What are the characteristics of a Type 4 acromioclavicular sprain?
Clavicle displaces superiorly & posteriorly through trapezius
What are the characteristics of a Type 5 acromioclavicular sprain?
Clavicle displaces inferior to acromion or coracoid (beware of brachial plexus injury)

Tx: operative repair = excision of lateral clavical with reconstruction of CC & AC ligament
What are the findings on physical exam that indicate an acromioclavicular (AC) joint sprain?
- Palpable step between distal clavical & acromion
- Pain with adduction

Tx: operative repair = excision of lateral clavical with reconstruction of CC & AC ligament
What is the MOA of clavicular fracture?
Fall on the shoulder or onto outstretched hand
What shoulder injury presents as pain & tenting of skin?
clavicular fracture
What % of clavicular fractures result in brachial plexus & arterial injuries?
10%
What is the Tx for proximal & middle 1/2 clavicular fractures?
- Closed reduction with figure 8 brace or sling for 1-2 weeks
- Early ROM & strengthening
What is the Tx for a distal 1/3 clavicular fracture?
This fracture is unstable & may require ORIF
What are the characteristics of an involuntary, anterior shoulder dislocation?
traumatic
unidirectional
Bankart lesions
RESPOND to surgery
What are the characteristics of an voluntary, anterior shoulder dislocation?
Atraumatic
multidirectional
bilateral
reahab
surgery is last resort
What is a Hill-Sachs lesion?
Indentation of humeral head after impaction on glenoid rim (can happen during anterior shoulder dislocations)
What is a Bankart lesion?
- Avulsion of capsule when shoulder dislocates
- Occurs in 85% of all anterior shoulder dislocations
What nerves are at risk due to an anterior shoulder dislocation?
Axillary
Musculocutaneous
What additional injuries can be found in the elderly along with an anterior shoulder dislocation?
Vascular
Fracture of the greater tuberosity
WHat are the 4 main spinal anesthesia agents?
"Little Boys Prefer Toys":
1) Lidocaine
2) Bupivicaine
3) Procaine
4) Tetracaine
Xylocaine, where not to use with epinephrine?
"Nose, Hose, Fingers and Toes"
- Vasoconstrictive effects of xylocaine with epinephrine are helpful in providing hemostasis while suturing.
- However, may cause local ischemic necrosis in distal structures such as the digits, tip of nose, penis, ears.
What patients are susceptible to respiratory complications from anesthesia?
COUPLES:
1) COPD
2) Obese
3) Upper abdominal surgery
4) Prolonged bed rest
5) Long surgery
6) Elderly
7) Smokers
What are the most common causes of failed intubation?
INTUBATION:
- Infections of larynx
- Neck mobility abnormalities
- Teeth abnormalites (eg poor dentifom, loose and protuberant teeth)
- Upper airway abnormalities, strictures, or swellings
- Bullsneck deformities
- Ankylosing spondylitis
- Trauma/Tumour
- Inexperience
- Oedema of upper airway
- Narrowing of lower airway
What are the top causes of poor bilateral breath sounds after intubation?
DOPE:
- Displaced (usually right mainstem, pyreform fossa, etc.)
- Obstruction (kinked or bitten tube, mucuous plug, etc.)
- Pneumothorax (collapsed lung)
- Esophagus
List the main inhalational (volitile) anesthetics.
SHINE:
Sevoflurane
Halothane
Isoflurane
Nitrous oxide
Enflurane
What is the manner/order of disappearance of sensation after depositing local anesthetics?
Manner/Order of Disappearance After Depositing Local Anesthetics
1. Pain
2. Changes in Temperature
3. Pressure
4. Skeletal Muscle Tone
What is the manner/order of reappearance of sensation after depositing local anesthetics?
1. Skeletal Muscle Tone
2. Pressure
3. Changes in Temperature
4. Pain
What are the PaO2 & PaCO2 disturbances that characterize ARF?
PaO2 < 60 mmHg @ rest

PaCO2 = elevated, normal or low
What are the 4 mechanisms of abnormal gas exchange?
1) Hypoventilation
2) Ventilation-Perfusion mismatching
3) Shunting
4) Diffusion Impairment
What are the 2 types of diseases that can lead to inadequate chest movements and t/f hypoventilation?
1) Depressed CNS function
2) Neuromuscular or skeletal diseases
What changes in PaCO2 & PaO2 will show hypoventilation?
Both will change from the normal values by the same amount. For example, 40 mmHg decrease in PaO2 with a 40 mmHg increase in PaCO2
What is the the normal range in young adults & other adults (up to 75 years old) for P(A-a)O2?
Young Adults: 8 mmHg
Other Adults: 16mmHg
What P(A-a)O2 measurement is evidence of a problem additional to hypoventilation?
>20mmHg
What is the treatment for a mild V/Q mismatch?
Increase inspired O2 concentration (FiO2)
What is the response of a severe V/Q mismatch to increasing the FiO2?
Curvilinear (NOT linear) increase of PaO2 in response to increasing FiO2
What is the effect of increases FiO2 when a patient has a very severe V/Q mismatch?
Effect of increasing FiO2 becomes similar to a shunt situation
What is the major cause of hypoxemia in patients with acute lung injury?
Right to left shunting of mixed venous blood through the lungs
What are the 4 main types of acute lung injury?
- Cardiogenic pulmonary oedema
- Noncardiogenic pulmonary edema
- Pulmonary embolism
What is the normal % of blood shunted through the lungs (right to left)?
2-3%
What vessels are involved in a right to left shunt due to acute lung injury?
Blood from bronchial, mediastinal veins goes directly into the left ventricle
What is a diffusion impairment?
Failure of equilibration of pulmonary capillary blood with the alveolar gas
What % must diffusing capacity fall before any change in PaO2 is seen?
20%
How does the lung compensate for diffusion problems?
Recruits additional pulmonary capillaries
What 3 systems regulate the acid-base balance in the body?
1) Lungs
2) Kidneys
3) Buffers: carbonic acid, phosphates, proteins, & intra/extra cellular ion shifts
What is regulated in terms of acid/base?
Ph: 7.4
PaCO2: 40 mmHg
Bicarb: 24mmol/L
What 3 systems are necessary for adequate systemic O2 delivery?
1) Cardiovascular: Cardiac Output (Q)
2) Hematologic: hemoglobin
3) Respiratory: saturation
How much O2 is in 100ml of arterial blood?
20 ml
What is the normal resting cardiac output?
6L/minute
What is the normal resting O2 consumption?
300 ml/min
What is the normal CvO2?
900 ml
How much O2 does 1 g of hemoglobin carry?
1.34 ml of O2
What temperature & acid/base disturbance shifts the oxyhemoglobin curve to the left?
Hypothermia & alkalemia
What temperature & acid/base disturbance shifts the oxyhemoglobin curve to the right?
Fever & Acidemia
What level of PvO2 shows that there is inadequate O2 delivery?
PvO2 < 30mmHg

- Indicates anaerobic cellular metabolism with lactic acid production
What type of ARF is caused by acute lung injury or ARDS?
Type 1: abnormally low PaO2 with low or normal capnia
What type of ARF is caused by alveolar ventilatory failure?
Type 2:
- Decrease in minute ventilation & increase in total dead space
- Causes: depression of CNS control of ventilation or exacerbation of COPD
What is the normal breaths/minute for the following ages:
<1
1-5
5-12
>12
>1 = 30-40
1-5 = 20-30
5-12 = 15-20
>12 = 12-16
What causes respiratory grunting?
- Decreased lower airway compliance
- NB: can disappear in a fatigued child
What are the physiologic (aka lab) signs of ARDS?
- PaO2 < 50 mmHg with FiO2 > 6.0
- Overall compliance < 50 ml/cm, usually 20-30 ml/cm
- Increased shunt fractions QS/QT & dead space ventilation VD/VT
What is the 1st radiographic sign of ARDS?
Reticular infiltrates = perivascular fluid accumulation & interstitial edema
- Occurs 12-24 hours after onset
What is the signs of respiratory insufficiency due to ARDS?
- Snow storm Xray: 5-lobed alveolar & interstitial infiltrate
- Tachypnoe, crackles
- Severe reduction in PaO2 even with high O2 concentration
What are the signs of the terminal phases of ARDS?
- Persistent severe hypoxemia despite 100% O2 administration
- High CO2 retention
-MODS: multiorgan dysfunction syndrome
What's the formula foe mechanical ventilation?
5-6 ml/kg body weight
What are the 2 barbiturates used in anesthesiology?
Thiopentone (5-18hrs)
Methohexitone (2-6hrs)
What is the affect on the CNS when a barbituate (like thiopentone & methohexitone) is used for anesthesia?
- Dose dependent hypnosis with depression of EEG activity
- Significant brain protection (reduced cerebral blood flow & CMRO2)
- Hyperalgesic effect in subanesthetic doses
What is the affect on the cardiovascular system when a barbituate (like thiopentone & methohexitone) is used for anesthesia?
- Cardiovascular depression due to venodilation & impairment of myocardial contractility
- Increased heart rate
What is the affect on the respiratory system when a barbituate (like thiopentone & methohexitone) is used for anesthesia?
- Transient central respiratory depression after induction does
- Laryngeal & tracheal reflexes remain intact
What are the main benefits of a barbituate (like thiopentone & methohexitone) when used for anesthesia?
- Anticonvusants - facilitates action of GABA & increase threshold of normal brain structures (thiopentone)
- Brain protection: use after head trauma (especially in peds patients)
What are the postop sequelae when a barbituate (like thiopentone & methohexitone) is used for anesthesia?
- Thrombosis & phlebitis
- Nausea & vomiting
- Paralysis & death in patients with acute intermittent porphyria (via induction of delta-aminolevulinic acid synthetase)
Where is etomidate metabolized & excreted?
- liver (via ester hydrolysis)
- kidney
What is the elimination 1/2 time of etomidate?
3-5 hrs.
What is the affect on the CNS when etomidate is used for anesthesia?
- Hypnosis in 1 arm-brain circulation time
- Some brain protection (reduction in cerebral blood flow & CMR02)
- High incidence of myoclonic movement
What is the affect on the cardiovascular system when etomidate is used for anesthesia?
- Minimal
- INDUCTION agent of choice in compromised patients
What is the affect on the respiratory system when etomidate is used for anesthesia?
- Minimal effect on ventilation
What is the affect on the endocrine effects when etomidate is used for anesthesia?
- Adrenocortical suppression followed by induction dose is not significant
What is the clinical situations when etomidate is used for anesthesia?
- Induction of general anesthesia (0.2-0.6 mg/kg IV)
- Maintenance of general anaesthesia (10 ug/kg/min)
What is the elimination 1/2 time of diazepam?
20-50 hrs.
Where is diazepam metabolized?
- Oxidative hepatic microsomal pathway (to oxazepam)
- Then to glucuronide conjugation
What is the affect on the CNS when diazepam is used for anesthesia?
- Dose related (from mild sedation to deep coma)
- NO analgesic or antianalgetic effect
- Antegrade amnesia
- Some cerebral protection
- Tolerance with long-term therapy
What is the affect on the respiratory system when diazepam is used for anesthesia?
- Modest depression
- Additive effects with opioids & other hypnotics
What are the clinical uses for diazepam in anesthesia?
- Relief of anxiety
- Supplementation of regional anesthesia
- Induction & maintenance of anesthesia
- Control of grand mal seizures
Where is midazolam metabolized?
oxidative hepatic microsomal pathway or glucuronide conjugation
What is the elimination 1/2 time of midazolam?
2-4 hours
What is the affect on the CNS when midazolam is used for anesthesia?
- Dose related effect on cerebral metabolism & blood flow
- Some brain protection against hypoxic events
- Increases seizure threshold
- Cerebral blood flow
What is the affect on the cardiovascular system when midazolam is used for anesthesia?
hypotension when used in large doses
What is the affect on the CNS when midazolam is used for anesthesia?
- Central depression of the respiratory drive
- Additive effects with opioids
What is the clinical uses of midazolam as an anesthesia?
- Premedication
- Supplimentation of regional anaesthesia
- Induction & maintenance of anaesthesia
- Relief of postop anxiety
- Sedation in ICU
What is the elimination 1/2 time of ketamine?
2-3 hours, water soluble metabolites excreted by the kidneys
What is the affect on the CNS when ketamine is used for anesthesia?
- Dose related hypnosis & analgesia
- State of dissociative anaesthesia due to depression of thalmoneocortical projection system & stimulation of parts of the limbic system
- Unpleasant emergence reaction
- Rise of ICP & CMRO2
What is the affect on the cardiovascular system when ketamine is used for anesthesia?
- Stimulation = systemic hypertension & tachycardia
What is the affect on the respiratory when ketamine is used for anesthesia?
- Minimal effect on ventilation
- Bronchial smooth muscle relaxant
What is clinical indication for ketamine for anesthesia?
- Induction (0,5-2,0 mg/kg iv)
- Maintenance (15-45 ug/kg/min iv)
- Sedation & analgesia (0.2=0.8 mg/kg iv)
What is clinical contraindications for ketamine for anesthesia?
Increased ICP
Ischemic heart disease
What is clinical indication for propofol for anesthesia?
- Induction (1-2.5 mg/kg iv)
- Maintenance (50-150 ug/kg/min iv)
- Sedation in ICU (25-75 ug/kg/min iv)
What is the affect on the CNS when propofol is used as an anesthetic?
- Hypnosis in 1 arm-brain circulation time
- Some brain protection (reduction in cerebral blood flow & CMRO2)
- Tolerance possible with repeat anesthesia
What is the affect on the Cardiovascular system when propofol is used as an anesthetic?
- Decrease in Bp after induction dose
What is the affect on the respiratory system when propofol is used as an anesthetic?
- 30% incidence of apnea
- Decrease in tidal volume & respiratory frequency
What fiber types are the most sensitive to local anesthetic nerve blockade?
1) NO MYELIN: Type C, dorsal root pain fibers and sympathetic post ganglionic fibers
2) LIGHT MYELIN: Type B, preganglionic autonomic fibers
What fiber types have medium sensitivity to local anesthetic nerve blockade?
All are HEAVILY MYELINATED
1) Delta, pain & temperature fibers
2) Gamma, muscle spindle fibers
3) Beta, touch & pressure fibers
What fiber types have the least sensitivity to local anesthetic nerve blockade?
Type A, Alpha proprioception motor fibers
ALL are HEAVILY MYELINATED
What are the signs of cocaine toxicity?
Inhibits norepinephrine uptake by peripheral nerves and CNS:
- Tremors
- Seizures
- Tachycardia
- Vasoconstriction
- Elevated body temperature
What are the symptoms of blood toxicity of a local anasthetic?
- Numb tongue & circumoral area
- Restlessness
- Blurred Speech
- Visual Disturbances
- Muscular Twitching -> seizures
- CNS: coma & apnea
What is the Tx for blood toxicity from local anesthetic?
- Supplimental O2 to prevent hypoxia
- Diazepam to control twitching & seizures
- Thiopental for seizures
- suxamethonium in severe seizures
What is the Tx for cocaine OD?
Alpha & beta-adrenergic antagonists to reduce excess sympathetic stimulation
What is the effect on the cardiovascular system of a blood toxic level of local anesthetics?
- Hypotension due to relaxation of arteriolar smooth muscle
- Direct myocardial depression due to blockade of cardiac sodium channels
What are the adverse cardiac changes if bupivacaine reaches toxic levels in the blood?
- Circulatory collapse after direct cardiovascular depression & acidosis due to the period of apnea
- This drug is highly lipid soluable and VERY slowly dissociates from cardiac Na-channels
What is the treatment to prevent cardiac collapse after a toxic blood level of a local anesthetic?
- Massive fluid resuscitation IV
- Vasopressors (dopamine, adrenaline)
- Tx of ventricular arrhythmia (cardioversion, bretylium)
What does Entamoeba Histolytica cause?
- Bloddy diarrhrea (amebic dysentery)
- Also: liver & pulmonary abcess
- Tx: metronidazole or Iodoquinol
How is Entamoeba Histolytica identified?
STOOL:
- Trophozoites with sinble nucleus
- Cysts have 4 small nuclei
How is entomoeba histolytica transmitted? What public health measure can prevent transmission?
- Fecal/Oral (NO animal reservoir)
- BOILING water (not cleared by chlorination)
What does Giardia lamblia cause?
Nonbloody diarrhea:
- Foul smelling diarrhea
- Nausea, anorexia
- flatulence, ab cramping
What types of places have Giardiasis outbreaks?
daycare, mental hospitals
How is Giardia lamblia diagnosed?
STOOL:
- pear shaped trophozoite: 2 nuclei, 4 pairs flagella, suction disk
- thick-walled oval cyst with 4 nuclei
What 2 parasites are particularly easy to transmit via homosexual contact?
- Entamoeba Histolytica
- Giardia lamblia
what is the pathogenesis of Giardiosis?
Excyst in duodenum
- ATTACHES (NO invasion)
- Causes: inflammation, malabsorption of proteins/fats
What is the Dx procedure for giardiosis?
STOOL
- trophozoites/cysts
String Test
Serology
What are the public health measures to prevent Giardiosis?
Removal of cysts by:
- filtration
Kill cysts by:
- boiling
- iodine
- NOT chlorination
What does cryptosporidium cause?
Nonbloody diarrhea:
- Fluid loss
- Malnutrition
DANGER for IMMUNOcompromised
What is the transmission route for cryptosporidium?
fecal oral (oocysts) from human/animals
What is the Dx procedure for cryptosporidium?
STOOL:
- ID kinyoun acid fast oocytes in smear = RED
What's the Tx for cryptosporidium?
- No effective therapy
- TRY azithromycin
What does Trichomonas vaginalis cause?
- WOMEN: vaginal itching with watery foul smelling, green vaginal discharge
- MEN: asymptomatic
What % of sexually active women are infected with Trichomonas vaginalis?
25-50%
What is the Tx from Trichomonas vaginalis?
Metroniadazole (both partners)
When post-bite do malaria symptoms start?
2 weeks
Why does malaria cause splenic sequestration?
damaged RBCs are sequestered there
Which species of malaria cause the benign form?
P. ovale
P. vivax
What form of malaria has 72 hour fever peaks?
P. malariae
What is the Tx for malaria?
- Acute form: chloroquine
- Chloroquine-resistant P. falciparum: mefloquine
- P. ovale & P. vivax: primaquine
What 2 drugs are used as prophylaxis for malaria?
chloroquine
mefloquine
What protozoa causes heterophil antibody-negative infectious mononulceosis?
Toxoplasma gondii
What are the symptoms of transplacental transmission of toxoplasmosis?
- Encephalitis
- Retinitis
- Microcephaly
- Mental retardation
How are humans infected with Toxoplasma gondii?
Humans eat cycst in meat or cat feces
What is the pathogenesis of Toxoplasma gondii?
- cysts rupture & invade gut mucosa
- ingested by macrophases
- differentiate into tachyzoites & disseminate to BRAIN & MUSCLE
What is the Tx for Toxoplasmosis?
Sulfadiazine & Pyrimethamine
What are the 3 forms of Chagas disease?
- Acute: edematous nodule (Chagoma) @ bite site, fever lymphdenopathy, H/Smegaly
- Indeterminate: low-level parasitemia
- Chronic: myocarditis, megacolon, megaesophagus
What is the COD from Chagas?
Arrythmia does to arrythmia, dilated cardiomyopathy, CHF
What is the pathogenesis of Chagas disease?
- Reduviid bug bites
- Trypomastigotes invade skin
- Amastigoes proliferate inside macrophages & myocardium
What is the Dx for Chagas disease?
- Thick & think blood smears for trypomastigotes
- Serology
- Muscle biopsy for amastigoes
- Xenodiagnosis
What is the Tx for Chagas disease?
Nifurtimox (for all forms except chronic)
What are the symptoms of Trypanosoma gambiense?
African Sleeping sickness:
- Chancre at bite site
- Cylical fever
- Lymphadenopathy
- Demyelinating encephalitis
- HA
- Insomnia
- Slurred speech
- Ataxia
- Mood changes
- Somnolence
- COMA
What is the Dx procedure for Trypanosoma gambiense?
Blood Smear, LN, or CSF:
ID trypomastigotes
What is the Tx for African sleeping sickness caused by Trypanosoma gambiense/rhodesiense?
- Pre-encephalitis stage: Suramin
- CNS involvement: Melarsoprol
What is Kala-azar?
Visceral leishmaniasis:
- RES involvement
- Chronic low grade fever, anorexia, weight loss
- skin HYPERpigmentation
- Bone marrow = anemia, leukopenia, thrombocytopenia, 2ndary infections, coagulopathies, massive splenomegaly
What is the pathogenesis of Leishmania donovani?
promastigotes invade human macrophages & differentiate back into amastigotes
What is the Dx procedure for Kala-azar caused by Leishmania donovani?
- ID amastigotes in spleen, LN, BM biopsy
What is the Tx for Kala-azar (Leishmania donovani infection)?
Sodium stibogluconate
What 2 parasites cause cutaneous Leishmania?
- Old World: L. tropica
- New World: L. mexicana
What parasite causes mucocutaneous Leishmania?
L. braziliensis
What is the Dx procedure for Leishmania in the cutaneous or mucocutaneous forms?
ID amastigotes in skin lesions
What does PCP (Pneumocystis carinii) cause?
- Pneumonia: acute fever, nonproductive cough, dyspnea, tachypnea
- FATAL if untreated
What is the Dx process for PCP (pneumocystis carinii)?
- Silver stained induced sputum specimen
- Blonchoalveolar lavage fluid
- Bronchial tissue biopsy for pneumocystis
At what CD4 count do you give prophylaxis for PCP?
<200
What is the Tx for Pneumocystis carinii infection?
TMP-SMZ Pentamidine
What is the treatment for Taenia (pork or beef tapeworm) infection?
Niclosamide
Praziquantel
For headache, what are the key elements of the physical exam which must be included?
- Vital Signs
- Inspection/Palpation of entire head
- ENT inspection
- Complete Neurological Exam
- Fundoscopic Exam
Give the Key differential for the following case:

21yo F with several episodes of throbbing left temporal pain that lasts 2-3 hours. Prior to its onset, she sees flashes of light in her right visual field & feels weakness & numbness on the right side of her body for a few minutes. Headaches are often associated with nausea & vomiting. She has a family history of migraine.
- Migraine (complicated)
- Tension headache
- Cluster headache
- Pseudotumor cerebri
- Trigeminal neuralgia
- CNS vasculitis
- Partial Seisure
- Intracranial Neoplasm
Give the Key workup for the following case:

21yo F with several episodes of throbbing left temporal pain that lasts 2-3 hours. Prior to its onset, she sees flashes of light in her right visual field & feels weakness & numbness on the right side of her body for a few minutes. Headaches are often associated with nausea & vomiting. She has a family history of migraine.
- CBC
- ESR
- CT - head
- MRI - brain
- LP
Give the Key differential for the following case:

26yo M presents with severe right temporal headaches associated with ipsilateral rhinorrhea, eye tearing, and redness. Episodes have occurred at the same time every night for the past week & last for 45 minutes.
- Cluster headache
- Migraine
- Tension headache
- Sinusitis
- Pseudotumor cerebri
- Intracranial neoplasm
Give the Key workup for the following case:

26yo M presents with severe right temporal headaches associated with ipsilateral rhinorrhea, eye tearing, and redness. Episodes have occurred at the same time every night for the past week & last for 45 minutes.
- CBC
- ESR
- CT - head
- MRI - brain
- LP
Give the Key differential for the following case:

65 yo F presents with severe intermittent right temporal headache, fever, blurred vision in her right eye, & pain in her jaw when chewing.
- Temporal (Giant cell) arteritis
- Migraine
- Cluster headache
- Tension headache
- Meningitis
- Carotid artery dissection
- Pseudotumor cerebri
- Trigeminal neuralgia
- Intracranial neoplasm
Give the Key workup for the following case:

65 yo F presents with severe intermittent right temporal headache, fever, blurred vision in her right eye, & pain in her jaw when chewing.
- CBC
- ESR
- CRP
- Temporal artery biopsy
- Doppler U/S - carotid
- MRI - brain
Give the Key differential for the following case:

30 yo F presents with frontal headache, fever and nasal discharge. There is pain on palpation of the frontal & maxilary sinuses. She has a history of sinusitis.
- Sinusitis
- Migraine
- Tension Headache
- Meningitis
- Intracranial neoplasm
Give the Key workup for the following case:

30 yo F presents with frontal headache, fever and nasal discharge. There is pain on palpation of the frontal & maxilary sinuses. She has a history of sinusitis.
- CBC
- XR - sinus
- CT - sinus
- LP
Give the Key differential for the following case:

50 yo F presents with recurrent episodes of bilateral squeezing headaches that occur 3-4 times per week, typically toward the end of her work day. She is experiencing significant stress in her life.
- Tension headache
- Migraine
- Depression
- Caffeine or analgesic withdrawal
- Hypertension
- Cluster headache
- Pseudotumor cerebri
- Intracranial neoplasm
Give the Key workup for the following case:

50 yo F presents with recurrent episodes of bilateral squeezing headaches that occur 3-4 times per week, typically toward the end of her work day. She is experiencing significant stress in her life.
- CBC
- Electrolytes
- ESR
- CT - head
- LP
Give the Key differential for the following case:

35yo M presents with sudden severe headache, vomiting, confusion, left hemiplegia, & nuchal rigidity.
- Subarachnoid hemorrhade
- Migraine
- Menigitis/encephalitis
- Intracranial hemorrhage
- Vertebral artery dissection
- Intracranial venous thrombosis
- Acute hypertension
- Intracranial neoplasm
Give the Key workup for the following case:

35yo M presents with sudden severe headache, vomiting, confusion, left hemiplegia, & nuchal rigidity.
- CT without contrast - head
- LP
- CBC
- PT/PTT
- MRI/MRA - brain
Give the Key differential for the following case:

25 yo M presents with high fever, severe headache, confusion, photophobia, & nuchal rigidity. Kernig's & Brudzinski's signs are positive.
- Meningitits
- Migraine
- Subarachnoid hemorrhage
- Sinusitis/encephalitis
- Intracranial or epidural abscess
Give the Key workup for the following case:

25 yo M presents with high fever, severe headache, confusion, photophobia, & nuchal rigidity. Kernig's & Brudzinski's signs are positive.
- CBC
- CT - head
- MRI - brain
- LP - CSF analysis (cell count, protein, glucose, gram stain, PCR for antigens, culture)
Give the Key differential for the following case:

18 yo obese F presents with a pulsatile headache, vomiting, & blurred vision for the past 2-3 weeks. She is taking OCPs.
- Pseudotumor cerebri
- Tension headache
- Migraine
- Cluster headache
- Meningitis
- Intracranial venous thrombosis
- Intracranial neoplasm
Give the Key workup for the following case:

18 yo obese F presents with a pulsatile headache, vomiting, & blurred vision for the past 2-3 weeks. She is taking OCPs.
- Urine hCG
- CBC
- CT - head
- LP - opening pressure & CSF analysis
Give the Key differential for the following case:

57 yo M c/o daily pain in the right cheek over the past month. The pain is electric & stabbing in character & occurs while he is shaving. Each episode lasts 2-4 minutes.
- Trigeminal neuralgia
- Tension headache
- Migraine
- Cluster headache
- TMJ dysfunction
- Intracranial neoplasm
Give the Key workup for the following case:

57 yo M c/o daily pain in the right cheek over the past month. The pain is electric & stabbing in character & occurs while he is shaving. Each episode lasts 2-4 minutes.
- CBC
- ESR
- MRI - brain
When the presentation is headache, what are the key elements of the history which must be asked?
- LOCATION (unilateral vs. bilateral)
- Quality, Intensity, Duration, Timing (sleep disturbance?)
- Associated neurological: paresthesias, visual stigmata, weakness, numbness, ataxia, photophobia, dizziness, auras, neck stiffness
- Nausea/vomiting
- Jaw claudication
- Recent trauma, dental surgery
- Sinusitis symptoms
- Exacerbating: stress, fatigue, menses, exercise, food
- Alleviating: rest, meds
- Past history of headache
- Family history of migraines
When the presentation is confusion/memory loss, what are the key elements of the history which must be asked?
- HISTORY from family member/caregiver
- Detailed time course of cognitive deficits: acute vs. chronic/gradual onset
- Associated symptoms: constitutional, incontinence, ataxia, hypothyroid symptoms, depression
- Screen for delirium: waxing/waning level of alertness
- Falls
- Medications / med changes
- History of stroke or atherosclerotic vascular disease
- Syphilis
- HIV risk factors
- Alcohol use or B12 deficiency
- Family history of Alzheimer's disease
When the presentation is confusion/memory loss, what are the key elements of the physical which must be performed?
- Vital signs
- Complete neurologic exam
- Mini mental status & gait
- general physical exam
- ENT
- Heart/lungs, abdomen, extremities
What are the key differentials given the following presentation:

81 yo M presents with progressive confusion over the past several years together with forgetfulness & clumsiness. He has a history of hypertension, diabetes mellitus, & 2 strokes with residual left hemiparesis. His mental status has clearly worsened after each stroke (stepwise decline in cognitive function)
- Vascular (multi-infarct) demntia
- Alzheimer's disease
- Normal pressure hydrocephalus
- Chronic subdural hematoma
- Intracranial tumor
- Depression
- B12 deficiency
- Neurosyphilis
- Hypothyroidism
What is the key workup given the following presentation:

81 yo M presents with progressive confusion over the past several years together with forgetfulness & clumsiness. He has a history of hypertension, diabetes mellitus, & 2 strokes with residual left hemiparesis. His mental status has clearly worsened after each stroke (stepwise decline in cognitive function)
- CBC
- VDRL/RPR
- Serum B12
- TSH
- MRI - brain
- CT - head
- LP - CSF analysis (rare)
What are the key differentials given the following presentation:

84 yo F brought by her son c/o forgetfulness (e.g. forgets phone numbers, loses her way back home) along with difficulty performing some of her daily activities (e.g. bathing, dressing, managing money, using the phone). The problem has gradually progressed over the past few years.
- Alzheimer's disease
- Vascular dementia
- Depression
- Hypothyroidism
- Chronic subdural hematoma
- Normal pressure hydrocephalus
- Intracranial neoplasm
- B12 Deficiency
- Neurosyphilis
What is the key workup given the following presentation:

84 yo F brought by her son c/o forgetfulness (e.g. forgets phone numbers, loses her way back home) along with difficulty performing some of her daily activities (e.g. bathing, dressing, managing money, using the phone). The problem has gradually progressed over the past few years.
- CBC
- VDRL/RPR
- Serum B12
- TSH
- MRI - brain (preferred)
- CT - head
- LP - CSF analysis (rare)
What are the key differentials given the following presentation:

72yo M presents with memory loss, gait disturbance, & urinary incontinence for the past 6 months.
- Normal pressure hydrocephalus
- Alzheimer's disease
- Vascular dementia
- Chronic subdural hematoma
- Intracranial neoplasm
- Depression
- B12 deficiency
- Neurosyphilis
- Hypothyroidism
What is the key workup given the following presentation:

72yo M presents with memory loss, gait disturbance, & urinary incontinence for the past 6 months.
- CT head
- LP - opening pressure & CSF analysis
- Serum B12
- VDRL/RPR
- TSH
What are the key differentials given the following presentation:

55yo M presents with a rapidly progressive change in mental status, inability to concentrate, & memory impairment for the past 2 months. His symptoms are associated with myoclonus & ataxia.
- Creutzfeldt-Jakob disease
- Vascular dementia
- Lewy body dementia
- Wernicke's encephalopathy
- Normal pressure hydrocephalus
- Chronic subdural hematoma
- Depression
- Delirium
- B12 deficiency
- Neurosyphilis
What is the key workup given the following presentation:

55yo M presents with a rapidly progressive change in mental status, inability to concentrate, & memory impairment for the past 2 months. His symptoms are associated with myoclonus & ataxia.
- CBC, electrolytes, calcium
- Serum B12
- VDRL/RPR
- MRI - brain (preferred)
- CT - head
- EEG
- LP - CSF analysis
- Brain biopsy
What are the key differentials given the following presentation:

70yo insulin-dependent diabetic M presents with episodes of confusion, dizziness, palpitation, diaphoresis, & weakness
- Hypoglycemia
- Transient ischemic attack
- Arrhythmia
- Delirium
- Angina
What is the key workup given the following presentation:

70yo insulin-dependent diabetic M presents with episodes of confusion, dizziness, palpitation, diaphoresis, & weakness
- Glucoase
- CBC, electrolytes
- Echocardiography
- ECG
- MRI - brain
- Doppler U/S - carotid
What are the key differentials given the following presentation:

55yo F presents with gradual altered mental status & headache. 2 weeks ago she slipped, hit her head on the ground, & lost consciousness for 2 minutes.
- Subdural hematoma
- SIADH (causing hyponatremia)
- Creutzfeldt-Jakob disease
- Intracranial neoplasm
What is the key workup given the following presentation:

55yo F presents with gradual altered mental status & headache. 2 weeks ago she slipped, hit her head on the ground, & lost consciousness for 2 minutes.
- Electrolytes
- CT - head
- MRI - brain
- LP
What are the key differentials given the following presentation:

68yo M presents with a two-month history of crying spells, excessive sleep, poor hygiene, & a 7-kg weight loss, all following his wife's death. He cannot enjoy time with his grandchildren & reluctantly admits to thinking he has seen his dead wife in line at the supermarket or standing in the kitchen making dinner.
- Normal bereavement
- Adjustment disorder with depressed mood
- Major depressive disorder with psychotic features
- Schizoaffective disorder
- Depressive disorder not otherwise specified (NOS)
What is the key workup given the following presentation:

68yo M presents with a two-month history of crying spells, excessive sleep, poor hygiene, & a 7-kg weight loss, all following his wife's death. He cannot enjoy time with his grandchildren & reluctantly admits to thinking he has seen his dead wife in line at the supermarket or standing in the kitchen making dinner.
- Physical Exam
- Mental status exam
- TSH
- CBC
- Urine Toxicology
What are the key differentials given the following presentation:

42yo M presents with a 4-month history of excessive fatigue, insomnia, and anhedonia. She states that she thinks constantly about death. She has suffered 5 similar episodes in the pst, the first in her 20s, and has made 2 previous suicide attempts. She further admits to increased alcohol use in the past month.
- Major depressive disorder
- Substance-induced mood disorder
- Dysthymic disorder
What is the key workup given the following presentation:

42yo M presents with a 4-month history of excessive fatigue, insomnia, and anhedonia. She states that she thinks constantly about death. She has suffered 5 similar episodes in the pst, the first in her 20s, and has made 2 previous suicide attempts. She further admits to increased alcohol use in the past month.
- Physical exam
- Mental Status exam
- Blood alcohol level
- TSH
- CBC
- Urine toxicology
What are the key elements of the history when a patient presents with depressed mood?
- Onset & Duration
- Sleep patterns
- Appetite & Weight change
- Drug & alchohol use
- Life stresses
- Excessive guilt
- Suicidality
- Social function
- Decreased interest (anhedonia)
- decreased energy
- decreased concentration
- psychomotor agitation/retardation
- family history of mood disorders
- Prior episodes
- Medications
What are the key elements of the physical exam which must be performed when a patient presents with depressed mood?
- Vital signs
- head & neck
- neurologic exam
- mental status exam
- Documentation of appearance, behavior, speech, mood, affect, thought process, thought content, cognition (30-point mini mental status exam), insight & judgement
What are the key differentials given the following presentation:

26yo F presents with a 3-kg weight loss over the past 2 months, accompanied by early-morning awakening, excessive guilt, and psychomotor retardation. She does not identify a trigger for the depressive episode but reports several weeks of increased energy, sexual promiscuity, irresponsible spending, and racing thoughts approximately six months before her presentation.
- Bipolar I disorder
- Bipolar 2 disorder
- Cyclothymic disorder
- Major depressive disorder
- Schizoaffective disorder
What is the key workup given the following presentation:

26yo F presents with a 3-kg weight loss over the past 2 months, accompanied by early-morning awakening, excessive guilt, and psychomotor retardation. She does not identify a trigger for the depressive episode but reports several weeks of increased energy, sexual promiscuity, irresponsible spending, and racing thoughts approximately six months before her presentation.
- Physical Exam
- Mental status exam
- Urine toxicology
What are the key elements of the medical history in a patient that presents with psychosis?
- Positive symptoms (delusions, hallucinations, disorganized thoughts, disorganized or catatomic behavior)
- Negative symptoms: blunted affect, socal withdrawal, decreased motivation, decreased speech/thought
- cognitive symptoms: disorganized speech or thought patterns, paranoia
- Age of first symptoms &/or hospitalizations
- Previous psychiatric meds
- Alcohol/substance use
What are the key elements of the physical which must be performed when a patient presents with psychosis?
- Vital signs
- Mental status exam
What are the key differentials given the following presentation:

19yo M c/o receiving messages from his TV. He reports that he did not have many friends in high school. In college, he started to suspect his roommate of bugging the phone. In the same time frame, he stopped going to classes b/c he felt that his professors were saying horrible things about him that no one else noticed. He rarely showered or left his room & has recently been hearing a voice from his TV telling him to "guard against the evil empire".
- Schizophrenia
- Schizoid or schizotypal personality disorder
- Schizophreniform disorder
- Psychotic disorder due to a general medical condition
- Substance- induced psychosis
- Depression with psychotic features
What is the key workup given the following presentation:

19yo M c/o receiving messages from his TV. He reports that he did not have many friends in high school. In college, he started to suspect his roommate of bugging the phone. In the same time frame, he stopped going to classes b/c he felt that his professors were saying horrible things about him that no one else noticed. He rarely showered or left his room & has recently been hearing a voice from his TV telling him to "guard against the evil empire".
- Mental Status Exam
- Urine toxicology
- TSH
- CBC
- Electrolytes
What are the key differentials given the following presentation:

28yo F c/o seeing bugs crawling on her bed over the past 2 days & reports hearing loud voices when she is alone in her room. She has never experienced symptoms such as these in the past. She recently ingested an unknown substance.
- Substance-induced psychosis
- Brief psychotic disorder
- Schizophreniform disorder
- Schizophrenia
- Psychotic disorder due to a general medical condition
What is the key workup given the following presentation:

28yo F c/o seeing bugs crawling on her bed over the past 2 days & reports hearing loud voices when she is alone in her room. She has never experienced symptoms such as these in the past. She recently ingested an unknown substance.
- Urine toxicology
- Mental status exam
- TSH
- CBC
- Electrolytes, BUN/Cr, AST/ALT
What are the key differentials given the following presentation:

48yo F presents with a 1-week history of auditory hallucinations, stating, "I am worthless" and "I should kill myself". She also reports a 2-week history of weight loss, early-morning awakening, decreased motivation, and overwhelming feelings of guilt.
- Schizoaffective disorder
- Mood disorder with psychotic features
- Schizophrenia
- Schizophreniform disorder
- Psychotic disorder due to a general medical condition
What is the key workup given the following presentation:

48yo F presents with a 1-week history of auditory hallucinations, stating, "I am worthless" and "I should kill myself". She also reports a 2-week history of weight loss, early-morning awakening, decreased motivation, and overwhelming feelings of guilt
- Mental status exam
- Beck depression inventory
- TSH
- CBC
- Electrolytes
What are the key history elements when a patient presents with dizziness?
- Lightheadedness vs. vertigo
- +/- auditory symptoms: hearling loss, tinnitus
- Duration of episodes
- Context: positioning, following head trauma
- Other associated symptoms: visual disturbance, URI, nausea
- Neck pain/injury
- Medications
- History of atherosclerotic vascular disease
What are the key elements of the physical exam to include when a patient presents with dizziness?
- Vital signs
- Complete neurological exam including Romberg test
- Nystagmus
- Tilt test (e.g. Dix-Hallpike maneuver)
- Gait
- Hearing
- Weber & Rinne tests
- Head/neck exam
- Cardiovascular exam
What are the key differentials given the following presentation:

35yo F presents with intermittent episodes of vertigo, tinnitus, nausea, and hearing loss over the past week.
- Meniere's disease
- Vestibular neuronitis
- Labyrinthitis
- Benign positional vertigo
- Acoustic neuroma
What is the key workup given the following presentation:

35yo F presents with intermittent episodes of vertigo, tinnitus, nausea, and hearing loss over the past week.
- CBC
- VDRL/RPR (syphilis can cause Meniere's disease)
- MRI - brain
What are the key differentials given the following presentation:

55 yo F c/o dizziness for the past day. She feels faint and has severe diarrhea that started 2 days ago. She take furosemide for her hypertension.
- Orthostatic hypotension due to dehydration (diarrhea, diuretic use)
- Vestibular neuronitis
- Labyrinthitis
- Benign positional vertigo
- Vertebrobasilar insufficiency
What are the key differentials given the following presentation:

55 yo F c/o dizziness for the past day. She feels faint and has severe diarrhea that started 2 days ago. She take furosemide for her hypertension.
- Orthostatic vital signs
- CBC
- Electrolytes
- Stool exam (occult blood, fecal leukocytes)
What are the key differentials given the following presentation:

65yo M presents with postural dizziness & unsteadiness. He has hypertension and was started on hydrochlorothiazide 2 days ago.
- Drug-induced orthostatic hypotension
- Vestibular neuronitis
- Labyrinthitis
- Benign positional vertigo
- Brain stem or cerebellar tumor
- Acute renal failure
What is the key workup given the following presentation:

65yo M presents with postural dizziness & unsteadiness. He has hypertension and was started on hydrochlorothiazide 2 days ago.
- Orthostatic vital signs
- CBC
- Electrolytes
- BUN/Cr
- MRI - brain
What are the key differentials given the following presentation:

44yo F c/o dizziness on movign her head to the left. She feels that the room is spinning around her head. Tilt test results in nystagmus & nausea.
- Benign positional vertigo
- Vestibular neuronitis
- Labyrinthitis
- Meniere's disease
What is the key workup given the following presentation:

44yo F c/o dizziness on movign her head to the left. She feels that the room is spinning around her head. Tilt test results in nystagmus & nausea.
- MRI - brain
- Audiogram
What is the key differential when a patient presents with:

55 yo F c/o dizziness that started this morning. She is nauseated and vomited once in the past day. She had a URI two days ago & has experienced no hearing loss.
- Vestibular neuronitis
- Labyrinthitis
- Meniere's disease
- Benign positional vertigo
- Vertigo associated with cervical spine disease/injury
- Vertebrobasilar insufficiency
What is the key workup when a patient presents with:

55 yo F c/o dizziness that started this morning. She is nauseated and vomited once in the past day. She had a URI two days ago & has experienced no hearing loss.
- CBC
- Electrolytes
- Electronystagmography
- MRI/MRA - brain
What is the key differential when a patient presents with:

55yo F c/o dizziness that started this morning and of "not hearing well". She feels nauseated and has vomited once in the past day. She had a URI two days ago.
- Labyrinthitis
- Vestibular neuronitis
- Meniere's disease
- Acoustic neuroma
- Vertebrobasilar insufficiency
What is the key workup when a patient presents with:

55yo F c/o dizziness that started this morning and of "not hearing well". She feels nauseated and has vomited once in the past day. She had a URI two days ago.
- Audiogram
- Electronystagmography
- MRI/MRA - brain
What is the key elements of history that must be collected when a patient presents after having experienced a loss of consciousness.
- Presence/absence of preceding symptoms: nausea, diaphoresis, palpitation, pallor, lightheadedness
- Context: exertional, postural, traumatic, stressful, painful, or claustrophobic experience, dehydration
- Associated tongue biting, incontinence, tonic-clonic movements, prolonged confusion
- Dyspnea or pulmonary embolism risk factors
- History of heart disease
- Arrhythmia
- Hypertension or diabetes
- Alcohol or drug use
What are the key elements of the physical exam when a patient presents after experiencing a loss of consciousness.
- Vital signs, including orthostatics
- Complete neurologic exam
- Carotid & cardiac exam
- Lung exam
- Exam of the lower extremities
What is the key differential when a patient presents with:

26yo M presents after falling and losing consciousness at work. He had rhythmic movements of the limbs, bit his tongue, and lost control of his bladder. He was subsequently confused (as witnessed by his colleagues).
- Seizure, grand mal (i.e. complex tonic-clonic seizure)
- Convulsive syncope
- Substance abuse/overdose
- Malingering
- Hypoglycemia
What is the key workup when a patient presents with:

26yo M presents after falling and losing consciousness at work. He had rhythmic movements of the limbs, bit his tongue, and lost control of his bladder. He was subsequently confused (as witnessed by his colleagues).
- CBC, electrolytes, glucose
- Urine toxicology
- EEG
- MRI - brain
- CT - head
- LP - CSF analysis
- ECG
What is the key differential when a patient presents with:

55yo M c/o falling after feeling dizzy and unsteady. He has hypertension and is on numerous antihypertensive drugs
- Drug-induced orthostatic hypotension (causing syncope)
- Cardiac arrhythmia
- Syncope (vasovagal, other causes)
- Stroke
- MI
- Pulmonary embolism
What is the key workup when a patient presents with:

55yo M c/o falling after feeling dizzy and unsteady. He has hypertension and is on numerous antihypertensive drugs
- Orthostatic vital signs
- CBC
- Electrolytes
- CT - head
- ECG
- V/Q scan
- CT - chest with IV contrast
What is the key differential when a patient presents with:

65yo M presents after falling & losing consciousness for a few seconds. He had no warning prior to passing out but recently had palpitations. His pas history includes coronary artery bypass grafting (CABG).
- Cardiac arrhythmia (causing syncope)
- Severe aortic stenosis
- Syncope (other causes)
- Seizure
- Pulmonary embolism
What is the key workup when a patient presents with:

65yo M presents after falling & losing consciousness for a few seconds. He had no warning prior to passing out but recently had palpitations. His pas history includes coronary artery bypass grafting (CABG).
- ECG
- Holter monitoring
- CBC, electrolytes
- Glucose
- Echocardiography
- CT - head
What are the key history topics that most be covered in a patient that presents with numbness/weakness?
- Distribution: unilateral, bilateral, proximal, distal
- Duration
- +/- progressive
- Pain (esp. headache, neck or back pain)
- Constitutional symptoms
- Other neurological symptoms
- History of diabetes
- Alcoholism
- Atherosclerotic vascular disease
What are the key physical exam areas that most be covered in a patient that presents with numbness/weakness?
- Vital signs
- Neurologic/musculoskeletal exams
- Relevant vascular exam
What is the key differential when a patient presents with:

68 yo M presents following a 20-minute episode of slurred speech, right facial drooping and numbness, & right hand weakness. His symptoms had totally resolved by the time he got to the the ER. He has a history of hypertension, diabetes mellitus, and heavy smoking.
- Transient ischemic attack (TIA)
- Hypoglycemia
- Seizure
- Stroke
- Facial nerve palsy
What is the key workup when a patient presents with:

68 yo M presents following a 20-minute episode of slurred speech, right facial drooping and numbness, & right hand weakness. His symptoms had totally resolved by the time he got to the the ER. He has a history of hypertension, diabetes mellitus, and heavy smoking.
- CBC
- Glucose
- Electrolytes
- ECG
- CT - head
- MRI - brain
- Doppler U/S - carotid
- Echocardiography
- EEG
What is the key differential when a patient presents with:

68yo M presents with slurred speech, right facial drooping and numbness, and right hand weakness. Babinski's sign is present on the right. He has a history of hypertension, diabetes mellitus, and heavy smoking.
- Stroke
- TIA
- Seizure
- Intracranial neoplasm
- Subdural or epidural hematoma
What is the key workup when a patient presents with:

68yo M presents with slurred speech, right facial drooping and numbness, and right hand weakness. Babinski's sign is present on the right. He has a history of hypertension, diabetes mellitus, and heavy smoking.
- CBC, electrolytes
- PT/PTT
- CT - head
- MRI - brain (preferred)
- Doppler U/S - carotid echocardiography
What is the differential when a patients presents with:

- 33yo F presents with ascending loss of strength in her lower legs over the past 2 weeks. She had a recent URI.
- Guillain-Barre syndrome
- Multiple Sclerosis
- Polymyositis
- Myasthenia gravis
- Peripheral neuropathy
- Tumor in the vertebral canal
What is the workup when a patients presents with:

- 33yo F presents with ascending loss of strength in her lower legs over the past 2 weeks. She had a recent URI.
- CBC, electrolytes
- CPK
- LP - CSF analysis
- MRI - spine
- EMG/nerve conduction study
- Tensilon Test
- Serum B12
What is the differential when a patients presents with:

30yo F presents with weakness, loss of sensation, and tingling in her left leg that started this morning. She is also experiencing right eye pain, decreased vision, and double vision. She reports feeling 'electric shocks down her spine upon flexing her head.
- Multiple sclerosis
- Stroke
- Conversion disorder
- Malingering
- CNS tumor
- Neurosyphilis
- Syringomyelia
- CNS vasculitis
What is the workup when a patients presents with:

30yo F presents with weakness, loss of sensation, and tingling in her left leg that started this morning. She is also experiencing right eye pain, decreased vision, and double vision. She reports feeling 'electric shocks down her spine upon flexing her head.
- CBC, ESR
- VDRL/RPR
- MRI - brain
- LP - CSF analysis
- Retinal evoked potentials
What is the key differential when a patient presents with:

55yo M presents with tingling and numbness in the hand and feet (glove & stocking distribution) over the past 2 months. He has a history of diabetes mellitus, hypertension, and alcoholism. There is decreased soft touch, vibratory, and position sense in the feet.
- Diabetic peripheral neuropathy
- Alcoholic peripheral neuropathy
- B12 deficiency
- Hypocalcemia
- Hyperventilation
- Paraproteinemia/myeloma
What is the key workup when a patient presents with:

55yo M presents with tingling and numbness in the hand and feet (glove & stocking distribution) over the past 2 months. He has a history of diabetes mellitus, hypertension, and alcoholism. There is decreased soft touch, vibratory, and position sense in the feet.
- HbA1C
- ESR
- Calcium
- Serum B12
- Serum & Urine protein electrophoresis
What is the key differential when a patient presents with:

40yo F presents with occasional double vision and droopy eyelids at night with normalization by morning.
- Myasthenia gravis
- Horner's syndrome
- Multiple sclerosis
- Intracranial tumor compressing CN III, IV, VI
- Amyotrophic lateral sclerosis
What is the key workup when a patient presents with:

40yo F presents with occasional double vision and droopy eyelids at night with normalization by morning.
- Tensilon Test
- ACh receptor antibodies (in serum)
- CXR
- CT - chest
- MRI - brain
- EMG
What is the key differential when a patient presents with:

25yo M presents with hemiparesis (after a tonic-clonic seizure) that resolves over a few hours.
- Todd's paralysis
- TIA
- Stroke
- Complicated migraine
- Malingering
What is the key workup when a patient presents with:

25yo M presents with hemiparesis (after a tonic-clonic seizure) that resolves over a few hours.
- CBC, electrolytes
- EEG
- MRI - brain
- Doppler U/S - carotid
What are the key history topics that most be covered in a patient that presents with fatigue & sleepiness?
- Duration
- Sleep hygiene
- Snoring
- Waking up choking/gasping
- Witness apnea
- Overexertion
- Stress, depression or other emotional problems
- Symptoms of thyroid disease
- History of bleeding or anemia
- Medications
- Drugs &/or alcohol use
What are the key parts of the physical exam in a patient that presents with fatigue & sleepiness?
- Vital signs
- Head & neck exam: conjunctival pallor, orophyarynx/palate, lymphadenopathy, thyroid exam
- Heart & lungs
- Abdominal
- Neurologic exam
- Rectal & Occult blood testing
What is the key differential when a patient presents with:

40yo F c/o feeling tired, hopeless, and worthless and of having suicidal thoughts. She recently discovered that her husband is homosexual.
- Depression
- Adjustment disorder
- Hypothyroidism
- Anemia
What is the key workup when a patient presents with:
- CBC
- TSH
- HIV/STD testing (b/c of husband's behavior as a risk factor)
What is the key differential when a patient presents with:

44yo M presents with fatigue, insomnia, and nightmares about a murder that he witnessed in a mall one year ago. Since then, he has avoided that mall & has not gone out at night.
- PTSD (post-traumatic stress disorder)
- Depression
- Generalized anxiety disorder
- Psychotic or delusional disorder
- Hypothyroidism
What is the key workup when a patient presents with:

44yo M presents with fatigue, insomnia, and nightmares about a murder that he witnessed in a mall one year ago. Since then, he has avoided that mall & has not gone out at night.
- CBC
- TSH
- Calcium
- Urine toxicology
What is the key differential when a patient presents with:

55yo M presents with fatigue, weight loss, and constipation. He has a family history of colon cancer.
- Colon cancer
- Hypothyroidism
- Renal failure
- Hypercalcemia
- Depression
What is the key workup when a patient presents with:

55yo M presents with fatigue, weight loss, and constipation. He has a family history of colon cancer.
- Rectal exam, stool for occult blood
- CBC, electrolytes, calcium, BUN/Cr, AST/ALT, TSH
- Colonoscopy
- Barium enema
What is the key differential when a patient presents with:

40 yo F presents with fatigue, weight gain, sleepiness, cold intolerance, constipation, and dry skin.
- Hypothyroidism
- Depression
- Diabetes
- Anemia
What is the key workup when a patient presents with:

40 yo F presents with fatigue, weight gain, sleepiness, cold intolerance, constipation, and dry skin.
- TSH, FT3, FT4
- CBC
- Glucose, HbA1C
What is the key differential when a patient presents with:

50yo obese F presents with fatigue and daytime sleepiness. She snores heavily and naps 3-4 times per day but never feels refreshed. She also has hypertension.
- Obstructive sleep apnea
- Hypothyroidism
- Chronic fatigue syndrome
- Narcolepsy
What is the key workup when a patient presents with:


50yo obese F presents with fatigue and daytime sleepiness. She snores heavily and naps 3-4 times per day but never feels refreshed. She also has hypertension.
- CBC
- TSH
- Nocturnal pulse oximetry
- Polysomnography
- ECG
What is the key differential when a patient presents with:

20 yo M presents with fatigue, thirst, increased appetite, and polyuria.
- Diabetes mellitus
- Atypical depression
- Primary polydipsia
- Diabetes insipidus
What is the key workup when a patient presents with:

20 yo M presents with fatigue, thirst, increased appetite, and polyuria.
- Glucose tolerance test, HbA1C
- UA
- CBC, electrolytes, glucose
- BUN/Cr
What is the key differential when a patient presents with:

35yo M policeman c/o feeling tired and sleepy during the day. He changes to the night shift last week.
- Sleep deprivation
- Sleep apnea
- Depression
- Anemia
What is the key workup when a patient presents with:

35yo M policeman c/o feeling tired and sleepy during the day. He changes to the night shift last week.
- CBC
- Noctural pulse oximetry
- Polysomnography
What are the key elements of the patient history when a patient presents with night sweats?
- Onset, duration, severity, frequency, timing, patters
- Recent URIs, associated cough, hemoptysis, pleuritic chest pain
- Lymphadenopathy, fever, rash, malaise, weight loss, itching
- Diarrhea, nausea/vomiting, early satiety, anorexia
- Alcohol history, sexual exposure, sick contacts, exposure to high-risk populations
- Menstrual history, perimenopause
What are the key elements of the patient physical when a patient presents with night sweats?
- Vital signs
- HEENT
- Throat inspection for lymphadenopathy
- Heart & Lungs
- Abdominal for hepatosplenomegaly
- skin exam
- Musculoskeletal exam for joint pain
What is the key differential when a patient presents with:

30yo M presents with night, sweats, cough, and swollen glands of one month's duration.
- Tuberculosis
- Acute HIV infection
- Lymphoma
- Leukemia
- Hyperthyroidism
What is the key workup when a patient presents with:

30yo M presents with night, sweats, cough, and swollen glands of one month's duration.
- PPD
- CBC
- CXR
- Sputum Gram stain, acid-fast stain, & culture
- HIV antibody
- TSH, FT4
What are the key elements of the patient history when a patient presents with insomnia?
- Primary vs. secondary
- Duration
- Description: trouble falling asleep vs. multiple awakenings vs. early-morning awakening
- Daytime sleepiness
- Other medical problems that keeps patients awake at night: arthritis (pain), or diabetes (polyuria)
- Associated symptoms: loud snoring, nightmares, depression
- Caffeine use, Recreational drug use
- Work or lifestyle changes: jet lag or shift work
- Stressors
- Sleep hygeine
What are the key elements of the patient physical when a patient presents with insomnia?
- Vital signs
- Mental Status exam
What is the key differential when a patient presents with:

25yo F presents with a 3-week history of difficulty falling aspleep. She sleeps 7 hrs. per night without nightmares or snoring. She recently began college and is having trouble with her boyfriend. She drinks 3-4 cups of coffee per day.
- Stress-Induced insomnia
- Caffeine-induced insomnia
- Insomnia with circadian rhythm sleep disorder
- Insomnia related to a major depressive disorder
What is the key workup when a patient presents with:

25yo F presents with a 3-week history of difficulty falling aspleep. She sleeps 7 hrs. per night without nightmares or snoring. She recently began college and is having trouble with her boyfriend. She drinks 3-4 cups of coffee per day.
- Polysomnography
- Mental status exam
- Urine toxicology
- CBC
- TSH
What is the key differential when a patient presents with:

55yo obese M presents with several months of poor sleep & daytime fatigue. His wife reports that he snores loudly.
- Obstructive sleep apnea
- Daytime fatigue in primary hypersomnia
- Insomnia with circadian rhythm sleep disorder
- Insomnia related to major depressive disorder
What is the key workup when a patient presents with:

55yo obese M presents with several months of poor sleep & daytime fatigue. His wife reports that he snores loudly.
- Mental status exam
- TSH
- CBC
- Polysomnography
What is the key differential when a patient presents with:

33 yo F c/o 3 weeks of fatigue and trouble sleeping. She states that she falls asleep easily but wakes up at 3 AM and cannot return to sleep. She also reports an unintentional weight loss of 3.5 kg along with an inability to enjoy the things she once liked to do.
- Insomnia related to major depressive disorder
- Primary hypersomnia
- Insomnia with circadian rhythm sleep disorder.
What is the key workup when a patient presents with:

33 yo F c/o 3 weeks of fatigue and trouble sleeping. She states that she falls asleep easily but wakes up at 3 AM and cannot return to sleep. She also reports an unintentional weight loss of 3.5 kg along with an inability to enjoy the things she once liked to do.
- Mental status exam
- TSH
- CBC
- Polysomnography
What are the key elements of the patient history when a patient presents with cough/shortness of breath?
- Acute vs. Chronic
- Presence/description of sputum
- Associated syptoms: constitutional, URI, postnasal drip, dyspnea, wheezing, chest pain, heartburn, other
- Exacerbating/alleviating factors
- Timing, Exposures
- Smoking History
- History of lung disease
- Allergies
- Medications, esp. ACE inhibitors
What are the key elements of the patient physical when a patient presents with cough/shortness of breath?
- Vital signs +/- pulse oximetry
- Exam of nasal mucosa
- Oropharynx
- Heart & Lungs
- Lymph nodes
- Extremities: clubbing, cyanosis, edema
What are the key elements of the patient history when a patient presents with a sore throat?
- Duration
- Fever
- Other ENT symptosm: ear pain, URI
- Odynophagia
- Swollen glands +/- cough
- Rash
- Sick contacts
- HIV risk factors
What are the key elements of the patient physical when a patient presents with a sore throat?
- Vital signs
- ENT exam including oral thrush, tonsillar exudate & lymphadenopathy
- Lungs
- Abdominal
- Skin exam
What is the key differential when a patient presents with:

26yo F presents with soar throat, fever, severe fatigue, and loss of appetite for the past week. She also reports epigastric and LUQ discomfort. She has cervical lymphadenopathy & a rash. Her boyfriend recently experience similar symptoms.
- Infectious mononucleosis
- Hepatitis
- Viral or bacterial pharyngitis
- Acute HIV infection
- Secondary syphilis
What is the key workup when a patient presents with:

26yo F presents with soar throat, fever, severe fatigue, and loss of appetite for the past week. She also reports epigastric and LUQ discomfort. She has cervical lymphadenopathy & a rash. Her boyfriend recently experience similar symptoms.
- CBC, peripheral smear
- Monospot test
- Throat culture
- AST/ALT/Bilirubin/Alkaline phosphate
- HIV antibody & viral load
- Anti-EBV antibodies
- VDRL/RPR
What is the key differential when a patient presents with:

26yo M presents with sore throat, fever, rash, & weight loss. He has a history of IV drug abuse and sharing needles.
- HIV (acute retroviral syndrome)
- Infectious Mononucleosis
- Hepatitis
- Viral pharyngitis
- Stretococcal tonsillitis/scarlet fever
- Secondary syphilis
What is the key workup when a patient presents with:

26yo M presents with sore throat, fever, rash, & weight loss. He has a history of IV drug abuse and sharing needles.
- CBC
- Peripheral smear
- HIV antibody & viral load
- CD4 count
- Monospot test
- Throat culture
- VDRL/RPR
- AST/ALT/bilirubin/alkaline phosphatase
What is the key differential when a patient presents with:

46 yo F presents with fever and sore throat.
- Pharyngitis (bac or viral)
- Mycoplasma pneumonia
- HIV acute infections
- Infectious mononucleosis
What is the key workup when a patient presents with:

What is the key workup when a patient presents with:
- Throat swab for culture & rapid streptococcal antigen
- Monospot test
- CBC
- HIV antibody & viral load
What is the key differential when a patient presents with:

30 yo M presents with shortness of breath, cough, and wheezing that worsen in cold air. He has had several such episodes over the past 4 months.
- Asthma
- GERD
- Bronchitis
- Pneumonitis
- Foreign Body
What is the key workup when a patient presents with:

30 yo M presents with shortness of breath, cough, and wheezing that worsen in cold air. He has had several such episodes over the past 4 months.
- CBC
- CXR
- Peak flow measurement
- PFTs
- Methacholine challenge test
What is the key differential when a patient presents with:

56yo F presents with SOB as well as with productive cough that has occurred over the past 2 years for at least 3 months each year. She is a heavy smoker.
- COPD - chronic bronchitis
- Bronchiectasis
- Lung Cancer
- Tuberculosis
What is the key workup when a patient presents with:

56yo F presents with SOB as well as with productive cough that has occurred over the past 2 years for at least 3 months each year. She is a heavy smoker.
- CBC
- Sputum Gram stain & culture
- CXR
- PFTs
- CT - chest
- PPD
What is the key differential when a patient presents with:

58yo M presents with pleuritic chest pain, fever, chills, and cough with purulent yellow sputum. He is a heavy smoker with COPD.
- Pneumonia
- Bronchitis
- Lung abscess
- Lung cancer
- Tuberculosis
- Pericarditis
What is the key workup when a patient presents with:

58yo M presents with pleuritic chest pain, fever, chills, and cough with purulent yellow sputum. He is a heavy smoker with COPD.
- CBC
- Sputum Gram stain & culture
- CXR
- CT - chest
- ECG
- PPD
What is the key differential when a patient presents with:

25yo F presents with 2 weeks of a nonproductive cough. 3 weeks ago she had a sore throat and a runny nose.
- Atypical pneumonia
- Reactive airway disease
- URI-associated ("postinfectious")
- Postnasal drip
- GERD
What is the key workup when a patient presents with:

25yo F presents with 2 weeks of a nonproductive cough. 3 weeks ago she had a sore throat and a runny nose.
- CBC
- Induced sputum Gram stain & culture
- CXR
- IgM detection for Mycoplasma pneumoniae
- Urine Legionella antigen
What is the key differential when a patient presents with:

65yo M presents with worsening cough over the past 6 months together with hemoptysis, dyspnea, weakness, and weight loss. He is a heavy smoker.
- Lung cancer
- Tuberculosis
- Lung abscess
- COPD
- Vasculitis (i.e. Wegener's)
- Interstitial lung disease
- CHF
What is the key workup when a patient presents with:

65yo M presents with worsening cough over the past 6 months together with hemoptysis, dyspnea, weakness, and weight loss. He is a heavy smoker.
- CBC
- Sputum Gram stain, culture, & cytology
What is the key differential when a patient presents with:

55yo M presents with increased dyspnea & sputum production over the past 3 days. He has COPD & stopped using his inhalers last week. He also stopped smoking two days ago.
- COPD exacerbation (bronchitis)
- Lung cancer
- Pneumonia
- URI
- CHF
What is the key workup when a patient presents with:

55yo M presents with increased dyspnea & sputum production over the past 3 days. He has COPD & stopped using his inhalers last week. He also stopped smoking two days ago.
- CBC
- CXR
- PFTs
- Sputum Gram stain & culture
- CT - chest
What is the key differential when a patient presents with:

34yo F nurse presents with worsening cough for 6 weeks duration together with weight loss, fatigue, night sweats, and fever. She has a history of contact with tuberculosis patients at work.
- Tuberculosis
- Pneumonia
- Lung Abscess
- Vasculitis
- Lymphoma
- Metastatic cancer
- HIV/AIDS
- Sarcoidosis
What is the key workup when a patient presents with:

34yo F nurse presents with worsening cough for 6 weeks duration together with weight loss, fatigue, night sweats, and fever. She has a history of contact with tuberculosis patients at work.
- CBC
- PPD
- Sputum Gram stain, acid-fast stain, and culture
- CXR
- CT - chest
- Bronchoscopy
- HIV antibody
What is the key differential when a patient presents with:

35yo M presents with SOB and cough. He has had unprotected sex with multiple sexual partners and was recently exposed to a patient with active tuberculosis.
- Tuberculosis
- Pneumonia (including Pneumocystis jiroveci)
- Bronchitis
- CHF (cardiomyopathy)
- Asthma
- Acute HIV infection
What is the key workup when a patient presents with:

35yo M presents with SOB and cough. He has had unprotected sex with multiple sexual partners and was recently exposed to a patient with active tuberculosis.
- CBC
- PPD
- Sputum Gram stain, acid-fast stain, silver stain, & culture
- CXR
- HIV antibody
What is the key differential when a patient presents with:

50yo Male presents with a cough that is exacerbated by lying down at night and improved by propping up on 3 pillows. He also reports exertional dyspnea.
- CHF
- Cardiac valvular disease
- GERD
- Pulmonary fibrosis
- COPD
- Postnasal drip
What is the key workup when a patient presents with:

50yo Male presents with a cough that is exacerbated by lying down at night and improved by propping up on 3 pillows. He also reports exertional dyspnea.
- CBC
- CXR
- ECG
- Echocardiography
- PFTs
- BNP
What are the key history elements of patient history which must be elicited from a patient who presents with chest pain?
- Location, quality, severity, radiation, duration
- Context: exertion, postprandial, positional, cocaine use, trauma
- Associated symptoms: sweating, nausea, dyspnea, palpitation, sense of doom
- Exacerbating & alleviating factors: esp. medications
- Prior history of similar symptoms
- Known heart or lung disease or history of diagnostic testing
- Cardiac risk factors: hypertension, hyperlipidemia, smoking, family history of early MI
- Pulmonary embolism risk factors: History of DVT, coagulopathy, malignancy, recent immobilization
What are the key physical exam elements must be performed when a patient presents with chest pain?
- Vital signs +/- BP in both arms
- Complete cardiovascular exam: JVD, PMI, Chest wall tenderness, heart sounds, pulses, edema
- Lungs
- Abdominal Exam
What is the key differential when a patient presents with:

60yo M presents with sudden onset of substernal heavy chest pain that has lasted for 30 minutes and radiates to the left arm. The pain is accompanied by dyspnea, diaphoresis, and nausea. He has a history of hypertension, hyperlipidemia, and smoking.
- Myocardial infarction (MI)
- GERD
- Angina
- Costochondritis
- Aortic dissection
- Pericarditis
- Pulmonary Embolism
- Pneumothorax
What is the key workup when a patient presents with:

60yo M presents with sudden onset of substernal heavy chest pain that has lasted for 30 minutes and radiates to the left arm. The pain is accompanied by dyspnea, diaphoresis, and nausea. He has a history of hypertension, hyperlipidemia, and smoking.
- ECG
- CPK-MB, troponin
- CXR
- CBC, electrolytes
- Echocardiography
- Cardiac catheterization
What is the key differential when a patient presents with:

20yo African-American F presents with acute onset of severe chest pain. She has a history of sickle cell disease & multiple previous hospitalizations for pain & anemia management.
- Sickle cell disease - pulmonary infarction
- Pneumonia
- Pulmonary embolism
- MI
- Pneumothorax
- Aortic dissection
What is the key differential when a patient presents with:

20yo African-American F presents with acute onset of severe chest pain. She has a history of sickle cell disease & multiple previous hospitalizations for pain & anemia management.
- CBC, reticulocyte count, LDH, Peripheral smear
- ABG
- CXR
- CPK-MB, troponin
- ECG
- CT - chest with IV contrast
What is the key differential when a patient presents with:

45yo F presents with a retrosternal burning sensation that occurs after heavy meals and when lying down. Her symptoms are relieved by antacids
- GERD
- Esophagitis
- Peptic ulcer disease
- Esophageal spasm
- MI
- Angina
What is the key workup when a patient presents with:

45yo F presents with a retrosternal burning sensation that occurs after heavy meals and when lying down. Her symptoms are relieved by antacids
- ECG
- Barium swallow
- Upper endoscopy
- Esophageal pH monitoring
What is the key differential when a patient presents with:

55yo M presents with retrosternal squeezing pain that lasts for 2 minutes and occurs with exercise. It is relieved by rest & is not related to food intake.
- Angina
- Esophageal spasm
- Esophagitis
What is the key workup when a patient presents with:

55yo M presents with retrosternal squeezing pain that lasts for 2 minutes and occurs with exercise. It is relieved by rest & is not related to food intake.
- ECG
- CPK-MB, troponin
- CXR
- CBC, electrolytes
- Exercise stress test
- Upper dndoscopy/pH monitor
- Cardiac catheterization
What is the key differential when a patient presents with:

34yo F presents with retrosternal stabbing chest pain that improves when she leans forward and worsens with deep inspiration. She had a URI 1 week ago.
- Pericarditis
- Aortic dissection
- MI
- Costochondritis
- GERD
- Esophgeal rupture
What is the key workup when a patient presents with:

34yo F presents with retrosternal stabbing chest pain that improves when she leans forward and worsens with deep inspiration. She had a URI 1 week ago.
- ECG
- CPK-MB, troponin
- CXR
- Echocardiography
- CBC
- Upper endoscopy
What is the key differential when a patient presents with:

34yo F presents with stabbing chest pain that worsens with deep inspiration and is relieved by aspirin. She had a WRI one week ago. Chest wall tenderness is noted.
- Costochondritis
- Pneumonia
- MI
- Pulmonary embolism
- Pericarditis
- Muscle strain
What is the key workup when a patient presents with:

34yo F presents with stabbing chest pain that worsens with deep inspiration and is relieved by aspirin. She had a WRI one week ago. Chest wall tenderness is noted.
- ECG
- CPK-MB, troponin
- CXR
- CBC
What is the key differential when a patient presents with:

70yo F presents with acute onset of SOB at rest and pleuritic chest pain. She also presents with tachycardia, hypotension, tachypnea, and mild fever. She is recovering from hip replacement surgery.
- Pulmonary embolism
- Pneumonia
- Costochondritis
- MI
- CHF
- Aortic dissection
What is the key workup when a patient presents with:

70yo F presents with acute onset of SOB at rest and pleuritic chest pain. She also presents with tachycardia, hypotension, tachypnea, and mild fever. She is recovering from hip replacement surgery.
- ECG
- CXR
- ABG
- CPK-MB, troponin
- CBC, electrolytes
- CT - chest with IV contrast
- Doppler U/S - legs
- D-dimer
What is the key differential when a patient presents with:

55yo M presents with sudden onset of severe chest pain that radiates to the back. He has a history of uncontrolled hypertension.
- Aortic dissection
- MI
- Pericarditis
- Esophageal rupture
- Esophageal spasm
- GERD
- Pancreatitis
- Fat embolism
What is the key workup when a patient presents with:

55yo M presents with sudden onset of severe chest pain that radiates to the back. He has a history of uncontrolled hypertension.
- ECG, CPK-MB, Troponin
- CXR
- CBC, amylase, lipase
- Transesophageal echocardiography (TEE), MRI/MRA - aorta
- Aortic angiography
- Upper endoscopy
What are the key history elements of patient history which must be elicited from a patient who presents with palpitations?
- Gradual vs. acute onset/offset
- Context: exertion, caffeine, anxiety
- Associated symptoms: ligthheadedness, chest pain, dyspnea
- Hyperthyroid symptoms
- History of bleeding or anemic
- History of heart disease
What are the key elements of patient physical which must be performed for a patient who presents with palpitations?
- Vital Signs
- Endocrine/Thyroid exam
- Exophthalmos
- Lid retraction, Lid lag, Gland size, bruit, and tremor
- Complete cardiovascular exam
What is the key differential when a patient presents with:

70yo diabetic M presents with episodes of palpitations and diaphoresis. His is on insulin
- Hypoglycemia
- Cardiac arrhythmias
- Angina
- Hyperthyroidism
- Hyperventilation episodes
- Panic attacks
- Pheochromocytoma
- Carcinoid
What is the key workup when a patient presents with:

70yo diabetic M presents with episodes of palpitations and diaphoresis. His is on insulin
- Glucose
- CBC, electrolytes
- TSH
- BUN/Cr
- ECG
- Holter monitor
What are the key parts of the patient history which must be asked in a patient who complains of weight loss?
- Amount
- Duration
- +/- intentional
- Diet history
- Body image, anxiety, or depression
- Constitutional Symptoms: palpitation, tremor, diarrhea
- Family history of thyroid disease
- HIV risk factors
- Alcohol & drug use
- Medications
- History of cancer
What are the key parts of the patient physical which must be performed in a patient who complains of weight loss?
- Vital signs
- COMPLETE physical
What is the differential when a patient presents with:

42yo F presents with a 7-kg weight loss over the past 2 months. She has a fine tremor, and her pulse is 112.
- Hyperthyroidism
- Cancer
- HIV infection
- Dieting/diet drugs
- Anorexia nervosa
- Malabsorption
What is the workup when a patient presents with:

42yo F presents with a 7-kg weight loss over the past 2 months. She has a fine tremor, and her pulse is 112.
- TSH, FT4
- CBC, electrolytes
- HIV antibody
- Urine toxicology
What are the key history items what must be asked in a patient who complains chiefly of weight gain?
- Amount
- Duration
- Timing: relation to medication changes, smoking cessation, depression
- Diet history
- Hypothyroid symptoms: fatigue, constipation, skin/hair/nail changes
- Menstrual irregularity
- Past medical history
- Alcohol & drug use
What are the key physical items what must be performed in a patient who complains chiefly of weight gain?
- Vital signs
- Complete exam
- Signs of Cushing's syndrome: hypertension, central obesity, moon face, buffalo hump, supraclavicular fat pads, purple abdominal striae
What is the key differential in patients who present with:

44yo F presents with weight gain of >11kg over the past 2 months. She quit smoking 3 months ago & is on amitriptyline for depression. She also reports cold intolerance and constipation.
- Smoking cessation
- Drug side effect
- Hypothyroidism
- Cushing's syndrome
- Polycystic ovary syndrome
- Diabetes Mellitus
- Atypical depression
What is the key workup in patients who present with:

44yo F presents with weight gain of >11kg over the past 2 months. She quit smoking 3 months ago & is on amitriptyline for depression. She also reports cold intolerance and constipation.
- CBC, electrolytes, glucose
- TSH
- 24-hr urine free cortisol
- Dexamethasome suppression test
What are the key history items what must be asked in a patient who complains chiefly of dysphagia?
- Solids vs. both solids & liquids
- +/- progressive
- Constitutional symptoms, esp. weight loss
- Drooling, regurgitation, odynophagia
- GERD symptoms
- Medications
- HIV risk factors
- History of smoking
- History of Raynaud's phenomenon
What are the key elements of the physical exam which must be performed in a patient who complains chiefly of dysphagia?
- Vital signs
- Head & neck exam
- Heart & Lungs
- Abdominal
- Skin exam for signs of scleroderma/CREST
What is the key differential when a patient presents with:

75yo M presents with dysphagia that started with solids and progressed to liquids. He is an alcoholic and a heavy smoker. He has had an unintentional weight loss of 7kg over the past 4 months.
- Esophageal cancer
- Achalasia
- Esophagitis
- Systemic Sclerosis
- Esophageal stricture
- Amyotrophic lateral sclerosis
What is the key workup when a patient presents with:

75yo M presents with dysphagia that started with solids and progressed to liquids. He is an alcoholic and a heavy smoker. He has had an unintentional weight loss of 7kg over the past 4 months.
- CBC
- CXR
- Endoscopy with biopsy
- CT - chest
What is the key differential for a patient who presents with:

45yo F presents with dysphagia for 2 weeks together with fatigue and a craving for ice and clay.
- Plummer-Vinson syndrome
- Esophageal cancer
- Esophagitis
- Achalasia
- Systemic sclerosis
- Mitral valve stenosis
What is the key workup for a patient who presents with:

45yo F presents with dysphagia for 2 weeks together with fatigue and a craving for ice and clay.
- CBC
- Serum iron, ferritin, TIBC
- Barium swallow
- Endoscopy
What is the key differential for a patient who presents with:

48yo F presents with dysphagia for both solid and liquid foods that has slowly progressed in severity over the past year. It is associated with regurgitation of undigested food, especially at night.
- Achalasia
- Plummer-Vinson syndrome
- Esophageal cancer
- Esophagitis
- Systemic sclerosis
- Mitral valve stenosis
- Esophageal Stricture
- Zenker's diverticulum
What is the key workup for a patient who presents with:

48yo F presents with dysphagia for both solid and liquid foods that has slowly progressed in severity over the past year. It is associated with regurgitation of undigested food, especially at night.
- CXR
- Endoscopy
- Barium swallow
- Esophageal manometry
What is the key differential for a patient who presents with:

38yo M presents with dysphagia and pain on swallowing solids more than liquids. Exam reveals oral thrush.
- Esophagitis (CMV, HSV, pill-induced)
- Systemic sclerosis
- GERD
- Esophageal stricture
- Zenker's diverticulum
What is the key workup for a patient who presents with:

38yo M presents with dysphagia and pain on swallowing solids more than liquids. Exam reveals oral thrush.
- CBC
- Endoscopy
- Barium swallow
- HIV antibody
- CD4 count
What are the key elements of the patient history when a patient presents with nausea/vomiting?
- Acuity of onset
- +/- abdominal pain
- Relation to meals, sick contacts, possible food poisonings, possible pregnancy
- Neurologic symptoms: headache, stiff neck, vertigo, focal numbness or weakness
- Other associated symptoms: GI, chest pain
- Exacerbating & alleviating factors
- Medications
What are the key elements of the patient physical when a patient presents with nausea/vomiting?
- Vital signs
- ENT
- Funduscopic exam: increased ICP
- Complete abdominal
- Heart & Lung
- Rectal
What is the key differential when a patient presents with:

20yo F presents with nausea, vomiting (especially in the morning), fatigue, and polyuria. Her last menstrual period was 6 weeks ago,a nd her breasts are full and tender. She is sexually active with her boyfriend, & they use condoms for contraception.
- Pregnancy
- Gastritis
- Hypercalcemia
- Diabetes mellitus
- UTI
- Depression
What is the key workup when a patient presents with:

20yo F presents with nausea, vomiting (especially in the morning), fatigue, and polyuria. Her last menstrual period was 6 weeks ago,a nd her breasts are full and tender. She is sexually active with her boyfriend, & they use condoms for contraception.
- Urine hCG
- Pelvic exam
- U/S - pelvis
- CBC, electrolytes, calcium, glucose
- UA, urine culture
- Baseline Pap smear, cervical cultures, rubella antibody, HIV antibody, hepatitis B surface antigen, VDRL/RPR
What are the key elements of the patient history when a patient presents with abdominal pain?
- Location, quality, intensity, duration, radiation, timing (relation to meals)
- Associated symptoms: constitutional, GI, cardiac, pulmonary, renal, pelvic, other
- Exacerbating & alleviating factors
- Prior history of similar symptoms
- History of abdominal surgeries, gallstones, renal stones, atherosclerotic vascular disease
- Medications
- Alcohol & drug use
- Domestic violence
What are the key elements of the patient physical when a patient presents with abdominal pain?
- Vital signs
- heart & lung
- abdominal exam including guarding, rebound, Murphy's sign, and CVA palpation
- Rectal exam
- Pelvic exam in women
What is the key differential when a patient presents with:

45yo M presents with sudden onset of colicky right-sided flank pain that radiates to the testicles, accompanied by nausea, vomiting, hematuria, and CVA tenderness.
- Nephrolithiasis
- Renal cell carcinoma
- Pyelonephritis
- GI etiology (e.g. appendicitis)
What is the key differential when a patient presents with:

45yo M presents with sudden onset of colicky right-sided flank pain that radiates to the testicles, accompanied by nausea, vomiting, hematuria, and CVA tenderness.
- Rectal exam
- UA
- Urine culture & sensitivity
- BUN/Cr
- CT - abdomen
- U/S - renal
- IVP
What with the key differential when a patient presents with:

60yo M presents with dull epigastric pain that radiates to the back, together with weight loss, dark urine, and clay-colored stool. He is a heavy drinker and smoker.
- Pancreatic cancer
- Acute viral hepatitis
- Chronic pancreatitis
- Cholecystitis/Choledocholitiasis
- Abdominal aortic aneurysm
- Peptic ulcer disease
What with the key workup when a patient presents with:

60yo M presents with dull epigastric pain that radiates to the back, together with weight loss, dark urine, and clay-colored stool. He is a heavy drinker and smoker.
- Rectal exam
- CBC, electrolytes
- Amylase & lipase
- AST/ALT/bilirubin/alkaline phosphatase
- U/S - abdomen
- CT - abdomen
- Upper endoscopy
- ECG
What is the key differential when a patient presents with:

56yo M presents with severe midepigastric abdominal pain that radiates to the back & improves when he leans forward. He also reports anorexia, nausea, and vomiting. He is an alcoholic and has spent the past three days binge drinking.
- Acute pancreatitis
- Peptic ulcer disease
- Cholecystitis/Choledocholithiasis
- Gastritis
- Abdominal aortic aneurysm
- Mesenteric ischemia
- Alcoholic hepatitis
- Mallory-Weiss tear
What is the key workup when a patient presents with:

56yo M presents with severe midepigastric abdominal pain that radiates to the back & improves when he leans forward. He also reports anorexia, nausea, and vomiting. He is an alcoholic and has spent the past three days binge drinking.
- Rectal exam
- CBC, electrolytes, BUN/Cr, amylase, lipase, AST/ALT/Bilirubin/Alkaline phosphatase
- U/S - abdomen
- CT - abdomen
- Upper endoscopy
- ECG
What is the key differential when a patient presents with:

41yo obese F presents with RUQ abdominal paint hat radiates to the right scapula and is associated with nausea, vomiting, and a fever of 101.5F. The pain started after she had eaten fatty food. She has had a similar but less intense episodes that lasted a few hours. Exam reveals positive Murphy's sign.
- Acute cholecystitis
- Hepatitis
- Choledocholithiasis
- Ascending cholangitis
- Peptic ulcer disease
- Fritz-Hugh-Curtis syndrome
What is the key workup when a patient presents with:

41yo obese F presents with RUQ abdominal paint hat radiates to the right scapula and is associated with nausea, vomiting, and a fever of 101.5F. The pain started after she had eaten fatty food. She has had a similar but less intense episodes that lasted a few hours. Exam reveals positive Murphy's sign.
- Rectal exam
- CBC
- AST/ALT/bilirubin/alkaline phosphatase
- U/S - abdomen
- HIDA scan
What is the key differential when a patient presents with:

43yo obese F presents with RUQ abdominal pain, fever, and jaundice. She was diagnosed with asymptomatic gallstones 1 year ago.
- Ascending cholangitis
- Acute cholecystitis
- Hepatitis
- Choledocholithiasis
- Sclerosing cholangitis
- Fitz-Hugh-Curtis syndrome
What is the key workup when a patient presents with:

43yo obese F presents with RUQ abdominal pain, fever, and jaundice. She was diagnosed with asymptomatic gallstones 1 year ago.
- Rectal exam
- CBC
- AST/ALT/bilirubin/alkaline phosphatase
- Viral hepatitis serologies
- U/S - abdomen
- MRCP
- ERCP
What is the key differential when a patient presents with:

25yo M presents with RUQ pain, fever, anorexia, nausea, and vomiting. He has dark urine and clay-colored stool.
- Acute hepatitis
- Acute cholecystitis
- Ascending cholangitis
- Choledocholithiasis
- Pancreatitis
- Acute glomerulonephritis
What is the key workup when a patient presents with:

25yo M presents with RUQ pain, fever, anorexia, nausea, and vomiting. He has dark urine and clay-colored stool.
- Rectal exam
- CBC, amylase, lipase
- AST/ALT/bilirubin/alkaline phosphatase
- UA
- Viral hepatitis serologies
- U/S - abdomen
What is the key differential when a patient presents with:

35yo M presents with burning epigastric pain that starts 2-3 hours after meals. The pain is relieved by food and antacids.
- Peptic ulcer disease
- Gastritis
- GERD
- Cholecystitis
- Chronic pancreatitis
- Mesenteric ischemia
What is the key workup when a patient presents with:

35yo M presents with burning epigastric pain that starts 2-3 hours after meals. The pain is relieved by food and antacids.
- Rectal exam
- Amylase, lipase, lactate
- AST/ALT/bilirubin/alkaline phosphatase
- Endoscopy (including H. pylori testing)
- Upper GI series
What is the key differential when a patient presents with:

37yo M presents with severe epigastric pain, nausea, vomiting, and mild fever. He appears toxic. He has a history of intermittent epigastric pain that is relieved by foods and antacids. He also smokes heavily & takes aspirin on a regular basis.
- Peptic ulcer perforation
- Acute pancreatitis
- Hepatitis
- Cholecystitis
- Choledocholithiasis
- Mesenteric ischemia
What is the key workup when a patient presents with:

37yo M presents with severe epigastric pain, nausea, vomiting, and mild fever. He appears toxic. He has a history of intermittent epigastric pain that is relieved by foods and antacids. He also smokes heavily & takes aspirin on a regular basis.
- Rectal exam
- CBC, electrolytes, amylase, lipase, lactate
- AST/ALT/bilirubin/alkaline phosphatase
- AXR
- Upright CXR
- Endoscopy: including H. pylori testing
What is the key differential when a patient presents with:

18yo M boxer presents with severe LUQ abdominal pain that radiates to the left scapula. He had infectious mononucleosis 3 weeks ago.
- Splenic rupture
- Kidney stone
- Rib fracture
- Pneumonia
- Perforated peptic ulcer
- Splenic infarct
What is the key workup when a patient presents with:

18yo M boxer presents with severe LUQ abdominal pain that radiates to the left scapula. He had infectious mononucleosis 3 weeks ago.
- Rectal exam
- CBC, electrolytes
- CXR
- CT- abdomen
- U/S - abdomen
What is the key differential when a patient presents with:

40yo M presents with crampy abdominal pain, vomiting, abdominal distention, and inability to pass flatus or stool. He has a history of multiple abdominal surgeries.
- Intestinal obstruction
- Small bowel or colon cancer
- Volvulus of the bowel
- Gastroenteritis
- Food poisoning
- Ileus
- Hernia
What is the key workup when a patient presents with:

40yo M presents with crampy abdominal pain, vomiting, abdominal distention, and inability to pass flatus or stool. He has a history of multiple abdominal surgeries.
- Rectal exam
- CBC, electrolytes
- AXR
- CT - abdomen/pelvis
- CXR
What is the key differential when a patient presents with:

70yo F presents with acute onset of severe, crampy abdominal pain. She recently vomited and has a massive dark bowel movement. She has a history of CHF and atrial fibrillation, for which she has received digitalis. Her pain is out of proportion to the exam.
- Mesenteric ischemia/infarction
- Diverticulitis
- Peptic ulcer disease
- Gastroenteritis
- Acute pancreatitis
- Cholecystitis/Choledocholithiasis
- MI
What is the key workup when a patient presents with:

70yo F presents with acute onset of severe, crampy abdominal pain. She recently vomited and has a massive dark bowel movement. She has a history of CHF and atrial fibrillation, for which she has received digitalis. Her pain is out of proportion to the exam.
- Rectal exam
- CBC, amylase, lipase, lactate
- ECG, CPK-MB, troponin
- AXR
- CT - abdomen
- Mesenteric angiography
- Barium enema
What is the key differential when a patient presents with:

21yo F presents with acute onset of severe RLQ pain, nausea, vomiting. She has no fever, urinary symptoms, or vaginal bleeding and has never taken OCPs. Her last menstrual period was regular, and she has no history of STDs.
- Ovarian torsion
- Appendicits
- Nephrolithiasis
- Ectopic pregnancy
- Ruptured ovarian cyst
- PID
- Bowel infarction or perforation
What is the key workup when a patient presents with:

21yo F presents with acute onset of severe RLQ pain, nausea, vomiting. She has no fever, urinary symptoms, or vaginal bleeding and has never taken OCPs. Her last menstrual period was regular, and she has no history of STDs.
- Pelvic exam
- Rectal exam
- Urine hCG
- UA
- CBC
- Doppler U/S - pelvis
- CT - abdomen
- Laparoscopy
What is the key differential when a patient presents with:

68yo M presents with LLQ abdominal pain, fever, and chills for the past 3 days. He also reports recent onset of alternating diarrhea and constipation. He consumes a low-fiber, high-fat diet.
- Diverticulities
- Crohn's disease
- Ulcerative colitis
- Gastroenteritis
- Abscess
What is the key workup when a patient presents with:

68yo M presents with LLQ abdominal pain, fever, and chills for the past 3 days. He also reports recent onset of alternating diarrhea and constipation. He consumes a low-fiber, high-fat diet.
- Rectal exam
- CBC, electrolytes
- AXR
- CT - abdomen
- U/S - abdomen
What is the key differential when a patient presents with:

20yo M presents with severe RLQ abdominal pain, nausea, and vomiting. His discomfort started yesterday as a vague pain aroundthe umbilicus. As the pain worsened, it became sharp and migrated to the RLQ. McBurney's and psoas signs are positive.
- Acute appendicitis
- Gastroenteritis
- Diverticulitis
- Crohn's disease
- Nephrolithiasis
- Volvulus or other intestinal obstruction/perforation
What is the key workup when a patient presents with:

20yo M presents with severe RLQ abdominal pain, nausea, and vomiting. His discomfort started yesterday as a vague pain aroundthe umbilicus. As the pain worsened, it became sharp and migrated to the RLQ. McBurney's and psoas signs are positive.
- Rectal exam
- CBC, electrolytes
- AXR
- CT - abdomen
- U/S - abdomen
What is the key differential when a patient presents with:

30yo F presents with periumbilical pain for 6 months. The pain never awakens her from sleep. It is relieved by defecation and worsens when she is upset. She has alternating constipation and diarrhea but no nausea, vomiting, weight loss or anorexia.
- Irritable bowel syndrome
- Crohn's disease
- Celiac disease
- Chronic pancreatitis
- GI parasitic infection: amebiasis, giardiasis
- Endometriosis
What is the key workup when a patient presents with:

30yo F presents with periumbilical pain for 6 months. The pain never awakens her from sleep. It is relieved by defecation and worsens when she is upset. She has alternating constipation and diarrhea but no nausea, vomiting, weight loss or anorexia.
- Rectal exam, stool for occult blood
- Pelvic exam
- Urine hCG
- CBC
- Electrolytes
- CT - abdomen/pelvis
- Stool for ova & parasitology, Entamoeba histolytica antigen
What is the key differential when a patient presents with:

24yo F presents with bilateral lowe rabdominal pain that started with the 1st day of her menstrual period. The pain is associated with fever and a thick, greenish-yellow vaginal discharge. She has had unprotected sex with multiple sexual partners.
- PID
- Endometriosis
- Dysmenorrhea
- Vaginitis
- Cystitis
- Spontaneous abortion
- Pyelonephritis
What is the key workup when a patient presents with:

24yo F presents with bilateral lowe rabdominal pain that started with the 1st day of her menstrual period. The pain is associated with fever and a thick, greenish-yellow vaginal discharge. She has had unprotected sex with multiple sexual partners.
- Pelvic exam
- Rectal exam
- Urine hCG
- Cervical cultures
- CBC/ESR
- UA, urine culture
- U/S - pelvis
What are the key elements of the patient history when a patient complains of constipation or diarrhea?
- Frequency & volume of stools
- Duration of change in bowel habits
- Associated symptoms: constitutional, abdominal pain, bloating, sense of incomplete evacuation, melena or hematochezia
- Thyroid disease symptoms
- Diet: expecially fiber & fluid intake
- Medication: including recent antibiotics
- Sick contacts
- Travel, camping, HIV risk factors
- History of abdominal surgeries, diabetes, pancreatitis
- Alcohol & Drug use
- Family history of colon cancer
What are the key elements of the patient physical when a patient complains of constipation or diarrhea?
- Vital signs
- Relevant thyroid/endocrine exam
- Abdominal & Rectal exam
- +/- female pelvic exam
What is the key workup when a patient presents with:

67yo M presents with alternating diarrhea and constipation, decreased stool caliber, and blood in the stool for the past 8 months. He also reports unintentional weight loss. His is on a low-fiber diet and has a family history of colon cancer.
- Rectal exam
- CBC
- AST/ALT/bilibrubin/alkaline phosphatase
- Colonoscopy
- Barium enema
- CT - abdomen/pelvis
What is the key differential when a patient presents with:

67yo M presents with alternating diarrhea and constipation, decreased stool caliber, and blood in the stool for the past 8 months. He also reports unintentional weight loss. His is on a low-fiber diet and has a family history of colon cancer.
- Colorectal cancer
- Irritable bowel syndrome
- Diverticulosis
- GI parasitic infection: ascariasis, giardiasis
- Inflammatory bowel disease
- Angiodysplasia
What is the key differential when a patient presents with:

28yo M presents with constipation (very hard stool) for the last 3 weeks. Since his mother died 2 months ago, he and his father have eaten only junk food.
- Low-fiber diet
- Irritable bowel syndrome
- Substance abuse (e.g. heroin)
- Depression
- Hypothyroidism
What is the key workup when a patient presents with:

28yo M presents with constipation (very hard stool) for the last 3 weeks. Since his mother died 2 months ago, he and his father have eaten only junk food.
- Rectal exam
- TSH
- Electrolytes
- Urine toxicology
What is the key differential when a patient presents with:

30yo F presents with alternating constipation & diarrhea & abdominal pain that is relieved by defecation. She has no nausea, vomiting, weight loss, or blood in her stool.
- Irritable bowel syndrome
- Inflammatory bowel disease
- Celiac disease
- Chronic pancreatitis
- GI parasitic infection (ascariasis, giardiasis)
What is the key workup when a patient presents with:

30yo F presents with alternating constipation & diarrhea & abdominal pain that is relieved by defecation. She has no nausea, vomiting, weight loss, or blood in her stool.
- Rectal exam, stool for occult blood
- CBC
- Electroytes
- Stool for ova & parasitology
- AXR
- CT - abdomen/pelvis
What is the key differential when a patient presents with:

33yo M presents with watery diarrhea, vomiting, and diffuse, abdominal pain that began yesterday. He also reports feeling hot. Several of his coworkers are also ill.
- Infectious diarrhea (gastroenteritis): bacterial, viral, parasitic, protozoal
- Food poisoning
- Inflammatory bowel disease
What is the key workup when a patient presents with:

33yo M presents with watery diarrhea, vomiting, and diffuse, abdominal pain that began yesterday. He also reports feeling hot. Several of his coworkers are also ill.
- Rectal exam, stool for occult blood
- Stool leukocytes & culture
- CBC
- Electrolytes
- CT - abdomen/pelvis
What is the key differential when a patient presents with:

40yo F presents with watery diarrhea and abdominal cramps. Last week she was on antibiotics for a UTI.
- Pseudomembranous (Clostridium difficile) colitis
- Gastroenteritis
- Cryptosporidiosis
- Food poisoning
- Inflammatory bowel disease
What is the key workup when a patient presents with:

40yo F presents with watery diarrhea and abdominal cramps. Last week she was on antibiotics for a UTI.
- Rectal exam
- Stool leukocytes, culture, occult blood
- C. difficile toxin in stool
- Electrolytes
What is the key differential when a patient presents with:

25yo M presents with watery diarrhea and abdominal cramps. He was recently in Mexico.
- Traveler's diarrhea
- Giardiasis
- Amebiasis
- Food poisoning
- Hepatitis A
What is the key workup when a patient presents with:

25yo M presents with watery diarrhea and abdominal cramps. He was recently in Mexico.
- Rectal exam
- Stool leukocytes, culture, Giardia antigen, Entamoeba histolytica antigen
- Electrolytes
- AST/ALT/bilibrubin/alkaline phosphatase
- Viral hepatitis serology
What is the key differential when a patient presents with:

30yo F presents with watery diarrhea and abdominal cramping and bloating. Her symptoms are aggravated by milk ingestion and are relieved by fasting.
- Lactose intolerance
- Gastroenteritis
- Inflammatory bowel disease
- Irritable bowel syndrome
- Hyperthyroidism
What is the key workup when a patient presents with:

30yo F presents with watery diarrhea and abdominal cramping and bloating. Her symptoms are aggravated by milk ingestion and are relieved by fasting.
- Rectal exam
- Stool exam
- Hydrogen breath test
- TSH
What is the key differential when a patient presents with:

33yo M presents with watery diarrhea, diffuse abdominal pain, and weight loss over the past 3 weeks. He has not responded to antibiotics.
- Crohn's disease
- Gastroenteritis
- Ulcerative colitis
- Celiac disease
- Pseudomembranous colitis
- Hyperthyroidism
- Small bowel lymphoma
- Carcinoid
What is the key workup when a patient presents with:

33yo M presents with watery diarrhea, diffuse abdominal pain, and weight loss over the past 3 weeks. He has not responded to antibiotics.
- Rectal exam
- Stool exam & culture
- CBC, electrolytes
- TSH
- CT - abdomen
- Colonoscopy
- Small bowel series
- Urinary 5-HIAA
What are the key elements of the patient history for a patient who presents with Upper GI bleeding?
- Amount
- Duration
- Context: after severe vomiting, alcohol ingestion, nosebleed
- Associated symptoms: constitutional, nausea, abdominal pain, dyspepsia
- Medications: esp. warfarin, NSAIDs
- History of peptic ulcer disease, liver disease, abdominal aortic aneurysm repair, easy bleeding.
What are the key elements of the patient physical for a patient who presents with Upper GI bleeding?
- Vital signs, including orthostatics
- ENT
- Heart & Lung
- Abdominal & Rectal
What is the key differential when a patient presents with:

45yo F presents with coffee-ground emesis for the last 3 days. Her stool is dark & tarry. She has a history of intermittent epigastric pain that is relieved by food and antacids.
- Bleeding peptic ulcer
- Gastritis
- Gastric cancer
- Esophageal varices
What is the key workup when a patient presents with:

45yo F presents with coffee-ground emesis for the last 3 days. Her stool is dark & tarry. She has a history of intermittent epigastric pain that is relieved by food and antacids.
- Rectal exam
- CBC, electrolytes
- AST/ALT/bilirubin/alkaline phosphatase
- Endoscopy: including H. pylori testing if ulcer is confirmed
What is the key differential when a patient presents with:

40yo F presents with epigastric pain and coffee-ground emesis. She has a history of rheumatoid arthritis that has been treated with aspirin. She is an alcoholic.
- Gastritis
- Bleeding peptic ulcer
- Gastric cancer
- Esophageal varices
- Mallory-Weiss tear
What is the key workup when a patient presents with:

40yo F presents with epigastric pain and coffee-ground emesis. She has a history of rheumatoid arthritis that has been treated with aspirin. She is an alcoholic.
- Rectal exam
- CBC, electrolytes
- AST/ALT/bilirubin/alkaline phosphatase
- Barium swallow
- Endoscopy
What are the key elements of patient history when a patient presents with blood in stool?
- Melina vs. bright blood
- Amount, duration
- Associated symptoms: constitutional, abdominal or rectal pain, tenesmus, constipation/diarrhea
- Trauma
- Prior history of similar symptoms
- Prior colonoscopy
- Medications: especially warfarin
- History of easy bleeding or atherosclerotic vascular disease
What are the key elements of patient physical when a patient presents with blood in stool?
- Vital signs
- +/- orthostatics
- Rectal exams
What is the key differential when a patient presents with:

67yo M presents with blood in his stool, weight loss, and constipation. He has a family history of colon cancer.
- Colorectal cancer
- Anal fissure
- Hemorrhoids
- Diverticulosis
- Ischemic bowel disease
- Angiodysplasia
- Upper GI bleeding
- Inflammatory bowel disease
What is the key workup when a patient presents with:

67yo M presents with blood in his stool, weight loss, and constipation. He has a family history of colon cancer.
- Rectal exam
- CBC, PT/PTT
- AST/ALT/bilirubin/alkaline phosphatase
- CEA
- Colonoscopy
- CT - abdomen/pelvis
- Barium enema
What is the key differential when a patient presents with:

33yo F presents with rectal bleeding and diarrhea for the past week. She has had lower abdominal pain and tensmus for several months.
- Ulcerative colitis
- Crohn's disease
- Proctitis
- Anal fissure
- Hemorrhoids
- Diverticulosis
- Dysentery
What is the key workup when a patient presents with:

33yo F presents with rectal bleeding and diarrhea for the past week. She has had lower abdominal pain and tensmus for several months.
- Rectal exam
- CBC, PT/PTT
- AXR
- Colonoscopy
- CT - abdomen/pelvis
- Barium enema
What is the key differential when a patient presents with:

58yo M presents with bright red blood per rectum and chronic constipation. he consumes a low-fiber diet.
- Diverticulosis
- Anal fissure
- Hemorrhoids
- Angiodysplasia
- Colorectal cancer
What is the key workup when a patient presents with:

58yo M presents with bright red blood per rectum and chronic constipation. he consumes a low-fiber diet.
- Rectal exam
- CBC, PT/PTT
- Electrolytes
- Colonoscopy
- CT - abdomen/pelvis
What are the key elements of the patient history when a patient presents with hematuria?
- Amount, duration
- +/- Clots
- Associated symptoms: constitutional, renal colic, dysuria, irritative voiding symptoms
- Medications
- History of vigorous exercise, trauma, smoking, stones, cancer, or easy bleeding
What are the key elements of the patient physical when a patient presents with hematuria?
- Vital signs
- Lymph nodes
- Abdominal exam
- Genitourinary & Rectal exams
- Extremities
What is the key differential when a patient presents with:

65yo M presents with painless hematuria. He is a heavy smoker and works as a painter.
- Bladder cancer
- Renal cell carcinoma
- Nephrolithiasis
- Acute glomerulonephritis
- Prostate cancer
- Coagulation disorder (i.e. factor VIII antibodies)
- Polycystic kidney disease
What is the key workup when a patient presents with:

65yo M presents with painless hematuria. He is a heavy smoker and works as a painter.
- Genitourinary exam
- UA, urine cytology
- BUN/Cr, PSA, CBC, PT/PTT
- Cystoscopy
- U/S - renal/bladder
- CT - abdomen/pelvis
- IVP
What is the key differential when a patient presents with:

35yo M presents with painless hematuria. He has a family history of kidney problems.
- Polycystic kidney disease
- Nephrolithiasis
- Acute glomerulonephritis (e.g. IgA nephropathy)
- UTI
- Coagulation disorder
- Bladder cancer
What is the key workup when a patient presents with:

35yo M presents with painless hematuria. He has a family history of kidney problems.
- Genitourinary exam
- UA
- BUN/Cr, PSA, CBC, PT/PTT
- U/S - renal
- CT - abdomen/pelvis
- IVP
What is the key differential when a patient presents with:

55yo M presents with flank pain & blood in his urine without dysuria. He has experienced weight loss & fever over the past 2 months.
- Renal cell carcinoma
- Bladder cancer
- Nephrolithiasis
- Acute glomerulonephritis
- Pyelonepritis
- Prostate Cancer
What is the key workup when a patient presents with:

55yo M presents with flank pain & blood in his urine without dysuria. He has experienced weight loss & fever over the past 2 months.
- Genitourinary, rectal exam
- UA, urine cytology, BUN/Cr, PSA, CBC, PT/PTT
- U/S - renal
- CT - abdomen/pelvis
- IVP
What are the key elements of the patient history when a patient presents with general urinary symptoms?
- Duration
- Obstructive symptoms: hesitancy, diminished stream, sense of incomplete bladder emptying, straining, postvoid dribbling
- Irritative symptoms: urgency, frequency, nocturia
- Constitutional symptoms
- Bone pain
- Medications
- History of UTIs, urethral stricture, or urinary tract instrumentation
- Stones, diabetes, alcoholism
What are the key elements of the patient physical when a patient presents with general urinary symptoms?
- Vital signs
- Abdominal exam: including suprapubic percussion to assess for a distended bladder
- Genital & Rectal exams
- Focused neurologic exam
What is the key differential when a patient presents with:

60yo M presents with nocturia, urgency, weak stream, and terminal dribbling. He denies any weight loss, fatigue, or bone pain. He has two episodes of urinary retention that required catheterization.
- Benign prostatic hyperplasia (BPH)
- Prostate cancer
- UTI
- Bladder stones
What is the key workup when a patient presents with:

60yo M presents with nocturia, urgency, weak stream, and terminal dribbling. He denies any weight loss, fatigue, or bone pain. He has two episodes of urinary retention that required catheterization.
- Rectal exam
- UA
- CBC, BUN/Cr, PSA
- U/S - prostate (transrectal)
What is the key differential when a patient presents with:

71yo M presents with nocturia, urgency, weak stream, terminal dribbling, hematuria, and lower back pain over the past 4 months. He also experienced wight loss & fatigue.
- Prostate cancer
- BPH
- Renal cell carcinoma
- UTI
- Bladder stones
What is the key workup when a patient presents with:

71yo M presents with nocturia, urgency, weak stream, terminal dribbling, hematuria, and lower back pain over the past 4 months. He also experienced wight loss & fatigue.
- Rectal exam
- UA
- CBC, BUN/Cr, PSA
- U/S - prostate (transrectal)
- CT - pelvis
- IVP
What is the key differential when a patient presents with:

18 yo M presents with a burning sensation during urination and urethral discharge. He recently had unprotected sex with a new partner.
- Urethritis
- Cystitis
- Prostatitis
What is the key workup when a patient presents with:

18 yo M presents with a burning sensation during urination and urethral discharge. He recently had unprotected sex with a new partner.
- Genital +/- rectal exam
- UA
- Urine culture
- Gram stain & culture of urethral discharge
- Chlamydia & gonorrhea PCR
What is the key differential when a patient presents with:

45yo diabetic F presents with dysuria, urinary frequency, fever, chills, & nausea over the past 3 days. There is left CVA tenderness on exam.
- Acute pyelonephritis
- Nephrolithiasis
- Renal cell carcinoma
- Lower UTI (cystitis, urethritis)
What are the key elements of the patient history when a patient presents with erectile dysfunction?
- Duration, severity
- +/- nocturnal erections
- Libido
- Stress or depression
- Trauma
- Associated incontinence
- Medications & recent med changes
- Past medical history: hypertension, diabetes, high cholesterol, known atherosclerotic vascular disease, prior prostate surgery
- Smoking, alcohol & drug use
What are the key elements of the patient physical when a patient presents with erectile dysfunction?
- Vital signs
- Cardiovascular exam
- Genital & rectal exams
What is the key differential when a patient presents with:

47yo M presents with impotence that started 3 months ago. He has hypertension and was started on atenolol 4 months ago. He also has diabetes & is on insulin.
- Drug-related ED
- ED cause by hypertension
- ED caused by diabetes mellitus
- Psychogenic ED
- Peyronie's disease
What is the key workup when a patient presents with:

47yo M presents with impotence that started 3 months ago. He has hypertension and was started on atenolol 4 months ago. He also has diabetes & is on insulin.
- Genital exam
- Rectal exam
- Glucose
- CBC
What are the key elements of the patient history when a patient presents with amenorrhea?
- Primary vs. Secondary
- Duration
- Possible pregnancy
- Associated symptoms: headache, decreased peripheral vision, galactorrhea, hirsutism, virilization, hot flashes, vaginal dryness, symptoms of thyroid disease
- history of anorexia nervose
- excessive dieting
- Vigorous exercise
- Pregnancies
- D&C
- Uterine infections
- Drug use
- Medications
What are the key elements of the patient physical when a patient presents with amenorrhea?
- Vital signs
- Breast exam
- Complete pelvic exam
What is the key differential when a patient presents with:

40yo F presents with amenorrhea, morning nausea and vomiting, fatigue, and polyuria. Her last menstrual period was 6 weeks ago, and her breasts are full and tender. She uses the rhythm method for contraception.
- Pregnancy
- Anovulatory cycle
- Hyperprolactinemia
- UTI
- Thyroid disease
What is the key workup when a patient presents with:

40yo F presents with amenorrhea, morning nausea and vomiting, fatigue, and polyuria. Her last menstrual period was 6 weeks ago, and her breasts are full and tender. She uses the rhythm method for contraception.
- Pelvic exam
- Urine hCG
- U/S - pelvis
- CBC, electrolytes
- UA, urine culture
- Prolactin, TSH
- Baseline Pap smear, cervical cultures, rubella antibody, HIV antibody, hepatitis B surface antigen, & VDRL/RPR
What is the key differential when a patient presents with:

23yo obese F presents with amenorrhea for 6 months, facial hair, and infertility for the past 3 years.
- Polycystic ovary syndrome
- Thyroid disease
- Hyperprolactinemia
- Pregnancy
- Ovarian or adrenal malignancy
- Premature ovarian failure
What is the key workup when a patient presents with:

23yo obese F presents with amenorrhea for 6 months, facial hair, and infertility for the past 3 years.
- Pelvic exam
- Urine hCG
- U/S - pelvis
- LH/FSH, TSH, prolactin
- Testosterone, DHEAS
What is the key differential when a patient presents with:

35yo F presents with amenorrhea, galactorrhea, visual field defects, and headaches for the past 6 months.
- Amenorrhea secondary to prolactinoma
- Pregnancy
- Thyroid disease
- Premature ovarian failure
- Pituitary tumor
What is the key differential when a patient presents with:

35yo F presents with amenorrhea, galactorrhea, visual field defects, and headaches for the past 6 months.
- Pelvic & Breast exam
- Urine hCG
- LH/FSH, TSH, prolactin, testosterone, DHEAS
- CBC
- MRI - brain
What is the key differential when a patient presents with:

35yo F presents with amenorrhea, cold intolerance, coarse hair, weight loss, and fatigue. She has a history of abruptio placentae followed by hypovolemic shock & failure of lactation 2 years ago.
- Sheehan's syndrome
- Premature ovarian failure
- Pituitary tumor
- Thyroid disease
- Asherman's syndrome
What is the key workup when a patient presents with:

35yo F presents with amenorrhea, cold intolerance, coarse hair, weight loss, and fatigue. She has a history of abruptio placentae followed by hypovolemic shock & failure of lactation 2 years ago.
- Pelvic exam
- Urine hCG
- CBC
- LH/FSH, prolactin
- TSH, FT4
- ACTH
- MRI - brain
- Hysteroscopy
What is the key differential when a patient presents with:

18yo F presents with amenorrhea for the past 4 months. She has lost 95 pounds & has a history of vigorous exercise & cold intolerance.
- Anorexia nervosa
What is the key workup when a patient presents with:

18yo F presents with amenorrhea for the past 4 months. She has lost 95 pounds & has a history of vigorous exercise & cold intolerance.
- CBC
- TSH
- FT4
- ACTH
- FSH
- LH
What is the key differential when a patient presents with:

29yo F presents with amenorrhea for the past 6 months. She has a history of occasional palpitations and dizziness. She lost her fiance in a car accident.
Anxiety-induced amenorrhea
What is the key workup when a patient presents with:

29yo F presents with amenorrhea for the past 6 months. She has a history of occasional palpitations and dizziness. She lost her fiance in a car accident.
- CBC
- TSH
- FT4
- ACTH
- Urine cortisol level
- Progesterone challenge test
- FSH/LH/Estradiol levels
What is the key patient history for a patient that presents with vaginal bleeding?
- Pre vs. postmenopausal
- Duration, amount
- Menstrual history & relation to last menstrual period
- Associated discharge
- Pelvic or abdominal pain
- Urinary symptoms
- Trauma
- Medications: esp. warfarin, contraceptives
- History of easy bleeding or bruising
- History of abnormal Pap smear
What is the key patient physical for a patient that presents with vaginal bleeding?
- Vital signs
- Abdominal exam
- Complete pelvic exam
What is the key differential when a patient presents with:

17yo F presents with prolonged, excessive menstrual bleeding occurring irregularly over the past 6 months.
- Dysfunctional uterine bleeding
- Coagulation disorders (e.g. vonWillebrand's disease, hemophilia)
- Cervical cancer
- Molar pregnancy
- Hypothyroidism
- Diabetes mellitus
What is the key workup when a patient presents with:

17yo F presents with prolonged, excessive menstrual bleeding occurring irregularly over the past 6 months.
- Pelvic exam
- Urine hCG
- Cervical cultures, Pap smear
- CBC, ESR, glucose
- PT, PTT
- Prolactin, LH/FSH
- TSH
- U/S - pelvis
What is the key differential when a patient presents with:

61yo obese F presents with profuse vaginal bleeding over the past month. Her last menstrual period was 10 years ago. She has a history of hypertension and diabetes mellitus. She is nulliparous.
- Endometrial cancer
- Cervical cancer
- Atropic endometrium
- Endometrial hyperplasia
- Endometrial polyps
- Atrophic vaginitis
What is the key workup when a patient presents with:

61yo obese F presents with profuse vaginal bleeding over the past month. Her last menstrual period was 10 years ago. She has a history of hypertension and diabetes mellitus. She is nulliparous.
- Pelvic exam
- Pap smear
- Endometrial biopsy
- U/S - pelvis
- Endometrial curettage
- Colposcopy
- Hysteroscopy
What is the key differential when a patient presents with:

45yo G5P5 F presents with postcoital bleeding. She is a cigarette smoker and takes OCPs.
- Cervical cancer
- Cervical polyp
- Cervicits
- Trauma (e.g. cervical laceration)
What is the key workup when a patient presents with:

45yo G5P5 F presents with postcoital bleeding. She is a cigarette smoker and takes OCPs.
- Pelvic exam
- Pap smear
- Colposcopy & biopsy
What is the key differential when a patient presents with:

28yo F who is 8 weeks pregnant presents with lower abdominal pain & vaginal bleeding.
- Spontaneous abortion
- Ectopic pregnancy
- Molar pregnancy
What is the key workup when a patient presents with:

28yo F who is 8 weeks pregnant presents with lower abdominal pain & vaginal bleeding.
- Pelvic exam
- Urine hCG
- U/S - pelvis
- CBC, PT/PTT
- Quantitative serum hCG
What is the key differential when a patient presents with:

32yo F presents with sudden onset of left lower abdominal pain that radiates to the scapula and back and is associated with vaginal bleeding. Her last menstrual period was 5 weeks ago. She has a history of PID and unprotected intercourse.
- Ectopic pregnancy
- Ruptured ovarian cyst
- Ovarian torsion
- PID
What is the key workup when a patient presents with:

32yo F presents with sudden onset of left lower abdominal pain that radiates to the scapula and back and is associated with vaginal bleeding. Her last menstrual period was 5 weeks ago. She has a history of PID and unprotected intercourse.
- Pelvic exam
- Urine hCG
- Cervical cultures
- U/S - pelvis
- Quantitative serum hCG
What are the key elements of the patient history when a patient presents with vaginal discharge?
- Amount, color consistency, odor, duration
- Associated vaginal burning, pain or pruritus
- Recent sexual activity
- Onset of last menstrual period
- Use of contraceptives, tampons, & douches
- History of similar symptoms
- History of STDs
What are the key elements of the patient physical when a patient presents with vaginal discharge?
- Vital signs
- Abdominal exam
- Complete pelvic exam
What is the key differential when a patient presents with:

28yo F presents with a thin, grayish-white, foul-smelling vaginal discharge.
- Bacterial vaginosis
- Vaginitis - candidal
- Vaginitis - trichomonal
- Cervicitis - chlamydia, gonorrhea
What is the key workup when a patient presents with:

28yo F presents with a thin, grayish-white, foul-smelling vaginal discharge.
- Pelvic exam
- Wet mount
- Cervical cultures
- KOH prep ("whiff test")
What is the key differential when a patient presents with:

30yo F presents with a thick, white, cottage cheese-like odorless vaginal discharge and vaginal itching.
- Vaginitis - candidal
- Bacterial vaginosis
- Vaginitis - trichomonal
What is the key workup when a patient presents with:

30yo F presents with a thick, white, cottage cheese-like odorless vaginal discharge and vaginal itching.
- Pelvic exam
- KOH prep ("whiff test")
- Wet mount
- Cervical cultures
- pH of vaginal fluid
What is the key differential in a patient who presents with:

35yo F presents with malodorous, profuse, frothy, greenish vaginal discharge with intense vaginal itching and discomfort.
- Vaginitis - trichomonal
- Vaginitis - candidal
- Bacterial vaginosis
- Cervicitis: chlamydia, gonorrhea
What is the key workup in a patient who presents with:

35yo F presents with malodorous, profuse, frothy, greenish vaginal discharge with intense vaginal itching and discomfort.
- Pelvic exam
- Wet mount
- Cervical cultures
- pH of vaginal fluid
- KOH prep ("whiff test")
What are the key elements of the patient history when a patient presents with dyspareunia?
- Duration, timing
- Associated symptoms: vaginal discharge, rash, painful menses, GI symptoms, hot flashes
- Adequacy of lubrication
- Libido
- Sexual history
- History of sexual trauma or domestic violence
- History of endometriosis, PID or prior abdominal/pelvic surgeries
What are the key elements of the patient physical when a patient presents with dyspareunia?
- Vital signs
- Abdominal exam
- Complete pelvic exam
What is the key differential when a patient presents with:

54yo F c/o painful intercourse. Her last menstrual period was 9 months ago. She has hot flashes.
- Atrophic vaginitis
- Endometriosis
- Cervicitis
- Depression
- Domestic abuse
What is the key workup when a patient presents with:

54yo F c/o painful intercourse. Her last menstrual period was 9 months ago. She has hot flashes.
- Pelvic exam
- Wet mount, KOH prep, cervical cultures
- U/S - pelvis
What is the key differential when a patient presents with:

37yo F presents with dyspareunia, inability to conceive, and dysmenorrhea.
- Endometriosis
- Cervicitis
- Vaginismus
- Vulvodynia
- PID
- Depression
- Domestic violence
What is the key workup when a patient presents with:

37yo F presents with dyspareunia, inability to conceive, and dysmenorrhea.
- Pelvic exam
- Wet mount, KOH prep, cervical cultures
- U/S - pelvis
- Laparoscopy
What is the key differential when a patient presents with:

28yo F c/o multiple facial and bodily injuries. She claims that she fell on the stairs. She was hospitalized for some physical injuries seven months ago. She presents with her husband.
- Domestic violence
- Osteogenesis imperfecta
- Substance abuse
- Consensual violent sexual behavior
What is the key workup when a patient presents with:

28yo F c/o multiple facial and bodily injuries. She claims that she fell on the stairs. She was hospitalized for some physical injuries seven months ago. She presents with her husband.
- XR - skeletal survey
- CT - maxillofacial
- Urine toxicology
- CBC
What is the key differential when a patient presents with:

30 yo F presents with multiple facial and physical injuries. She was attacked and raped by two men.
Rape
What is the key differential when a patient presents with:

30 yo F presents with multiple facial and physical injuries. She was attacked and raped by two men.
- Pelvic exam
- Urine hCG
- Wet mount, KOH prep, cervical cultures
- XR - skeletal survey
- CBC
- HIV antibody
- Viral hepatitis serologies
What are the key elements of the patient history when a patient presents with joint/limb pain?
- Location
- Quality, intensity, duration
- Pattern: small vs. large joints, # of joints involved, swelling, redness, warmth
- Associated symptoms: constitutional, red eye, oral or genital ulceration, diarrhea, dysuria, rash, focal numbness/weakness
- Exacerbating/Alleviating factors: trauma (including vigorous exercise)
- Medications
- DVT risk factors
- Alcohol & drug use
- Family history of rheumatic disease
What are the key elements of the patient physical when a patient presents with joint/limb pain?
- Vital signs, HEENT & musculoskeletal exams
- Relevant neurovascular exam
What is the key differential when a patient presents with:

30yo F presents with wrist pain and a black eye after tripping, falling, and hitting her head on the edge of a table. She looks anxious and give an inconsistent story
- Domestic violence
- Factitious Disorder
- Substance abuse