New Home of The Divine Intervention Step 2 Podcast Notes (2024)

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Divine Intervention Step 2 Podcasts Notes INFO DOC - Read Only File

Most Recent Update: August 14th 2022

New home of the Divine Intervention Step 2 Podcast Notes

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Due to the large size of our document, we have gone over 1.2 million characters and CANNOTkeep all the episodes in 1 google doc, and will NOT be adding more episodes to THIS document:

● Episodes 17-143: Divine Intervention Step 2CK Podcasts Notes ep. 17-143-Read Only

● Episodes 145-249: Divine Intervention Step 2 Podcasts Notes Episodes 145-249 - Read Only File

● Episodes 250-350: Divine Intervention Step 2CK Podcasts Notes ep. 250-350-Read Only ● ● Episodes 351-418 (current): Divine Intervention Step 2CK Podcasts Notes ep. 351-418-Read Only

● RR/HY/"Clutch" Podcasts: RR/HY/Clutch - DI Podcasts - READ ONLY

● Shelf Review Podcasts: Shelf Review - DI Podcasts - READ ONLY

● NBME/Misc. Podcasts: NBME/Misc. - DI Podcasts - READ ONLY ●_________________

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Official Errata

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Podcast checklists with episode lengths

Divine’s list of podcasts for Step 2 (grouped by specialty or “special topic”)

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How Divine Recommends to use his podcasts for Step 2CK and Shelf Exams_________________ For questions or feedback, use this Reddit thread or reach u/sn_sal and u/Lukaszdadamczyk on Reddit

DI Podcast Main Document 0 Table of ContentsEp. 29: Comprehensive Medicine Shelf Review Session 1 8

Ep. 30: Comprehensive Medicine Shelf Review Session 2. 21

Ep. 31: Comprehensive Medicine Shelf Review. Session 3. 49

Ep. 32: Comprehensive Medicine Shelf Review Session 4 86

Ep. 36: Ophthalmology 135

Ep. 37: Risk Factors 139

Ep. 41: Antibiotics Guide 142

Ep. 45: Neurology Clerkship Shelf Review Part 2 153

Ep. 46: Neurology Clerkship Shelf Review Part 3 159

Ep. 47: Neurology Clerkship Shelf Review Part 4 163

Ep. 48: Neurology Clerkship Shelf Review Part 5 165

Ep. 49: Neurology Clerkship Shelf Review Part 6 171

Ep. 58: Neurology Clerkship Shelf Review Part 7 179

Ep. 59: Neurology Clerkship Shelf Review Part 8 189

Ep. 65: Ventilator Physiology for the USMLEs 196

Ep. 94: Rapid Review, Series 1, Peds 197

Ep. 95: Rapid Review, Series 2, Peds 199

Ep. 97: The “Most Important” Podcast 201

Ep. 100: The "Clutch" Micro Podcast 203

Ep. 102: “The "Clutch” Cancer Podcast 218

Ep. 104: ACLS, Arrhythmias, and HY Cardiac Pharm 227

Ep. 111: The "Clutch" Pharmacology Podcast Round 1 230

Ep. 112: The "Clutch" Pharmacology Podcast Round 2 241

Ep. 118: Confusing Breast Pathologies 257

Ep. 119: Rapid Review Series 3 (IM) 258

DI Podcast Main Document 1 Ep. 120: Rapid Review Series 4 (IM / Peds) 260

Ep. 121: Rapid Review Series 5 (IM/Peds) 262

Ep. 123: Ethics I 264

Ep. 125: Rapid Review Series 6 (IM) 265

Ep. 126: Rapid Review Series 7 (IM) 267

Ep. 127: Rapid Review, Series 8 Ob/Gyn 269

Ep. 128: Rapid Review Series 9 (IM / Heme Malignancy / Random) 269

Ep. 129: Targeted Pulm Review 1 272

Ep. 130 : Rapid Review Series 10 (Peds) 281

Ep. 131: Rapid Review Series 11 (OB, Psych, IM, Neuro) 283

Ep 132: Weird topics of Social Sciences 286

Ep. 132: Weird topics of Social Sciences (Version 2) 290

Ep. 134: Rapid Review Series 12 (IM / Cardiology) 297

Ep. 135: The "Clutch" Electrolytes 299

Ep. 137: “Next Best Step In Management” Series 1 304

Ep. 138: The "Clutch" Genetic Disease 309

Ep. 141: Rapid Review Series 13 (IM) 315

Ep. 143: Biostats Review 320

Ep. 145: Rapid Review, Series 14, Surgery 331

Ep. 153: Rapid Review, Series 15, Surgery 333

Ep. 156: Rapid Review, Series 16, OB/GYN 335

Ep. 158: Rapid Review, Series 17, Surgery 335

Ep. 159: Rapid Review Series 18 (IM) 336

Ep. 161: The "Clutch" Antibody Podcast 339

Ep. 163: Rapid Review, Series 19, Surgery (Abdomen) 342

Ep. 164: The "Clutch" Toxicology Podcast (Drugs of abuse, overdose, withdrawal, toxidromes) 350

Ep. 166: Rapid Review Series 20 (Psych) 355

Ep 167: Rapid Review Series 21 Cardio 357

Ep. 169: The "Clutch" Nephrotic/Nephritic Syndrome 361 DI Podcast Main Document 2 Ep. 169: The "Clutch" Nephrotic/Nephritic Syndrome (Version 2) 363

Ep. 173: The "Clutch" Immunodeficiency Diseases Podcast 366

Ep. 174: Rapid Review Series 22 (IM) 370

Ep. 175: Rapid Review Series 23 (Psych) 372

Ep. 177: Rapid Review Series 24 (OGBYN) 375

Ep. 180: Hematology 377

Ep. 181: Comprehensive NBME Emergency Medicine Shelf Review Series 1 378

Ep. 182: Comprehensive NBME Emergency Medicine Shelf Review Series 2 392

Ep. 183: Comprehensive NBME Emergency Medicine Shelf Review Series 3 395

Ep. 187: Rapid Review Series 25 418

Ep. 189: Rapid Review Series 26 421

Ep. 195: Rapid Review Series 27 424

Ep. 196: Rapid Review Series 28 427

Ep. 197: Bias in Biostatistics 430

Ep. 198: The "Clutch" Hypertensive Integrations Podcast 432

Ep. 199: Rapid Review Series 29 435

Ep. 202: Rapid Review Series 30 438

Ep. 203: Leukemia and Lymphoma 442

Ep. 204: Military Part 1 444

Ep. 206: Family Medicine Shelf Review Series 1 445

Ep. 207: Geriatrics 450

Ep. 207: Geriatrics (Version 2) 451

Ep. 208: Transfusion Reactions 453

Ep. 209: Family Medicine Shelf Review Series 2 454

Ep. 210: Rapid Review Series 31 456

Ep. 211: Rapid Review Series 32 (Neuro) 458

Ep. 212: Family Medicine Shelf Review Series 3 (GI) 463

Ep. 213: Family Medicine Shelf Review Series 4 (GI) 476

Ep. 214: Family Medicine Shelf Review Series 5 - GI 478 DI Podcast Main Document 3 Ep. 214: Family Medicine Shelf Review Series 5 - GI (Version 2) 482

Ep. 215: Acetylcholine and The NBME 484

Ep. 217: Family Medicine Shelf Review Series 6 - Pulm (Version 2) 487

Ep. 217: Family Medicine Shelf Review Series 6 - Pulm (Version 2) 491

Ep. 219: Rapid Review Series 34 492

Ep. 220: Rapid Review Series 34 495

Ep. 221: Floridly HY Trauma / Ortho Podcast Part 1 (Step 2CK/3, Surgery/EMED Shelf) 499

Ep. 223: NBME Peds Shelf Add-On: The HY Newborn 501

Ep. 224: Genetic Diseases 2: Chromosomes 505

Ep. 225: Rapid Review Series 35 511

Ep. 226: Iron labs 512

Ep. 227: Rapid Review Series 36 (OBGYN + Others) 514

Ep. 228: CLEAN-SP 1 Palliative 516

Ep. 230: CLEAN-SP 2 Quality/Safety 516

Ep. 231: Military Part 2 518

Ep. 232: Vasculitis 520

Ep. 233: Shock 521

Ep. 233: Shock (Version 2) 524

Ep. 234: CLEAN-SP 2 Medication/Transition of Care 525

Ep. 237: HIV 527

Ep. 238: Rapid Review Series 37 528

Ep. 239: Ob/Gyn Risk Factors 531

Ep. 240: Rapid Review Series 38 (Ortho and OBGYN) 535

Ep. 242: Dermatology Part 1 of 3 537

Ep. 243: Water Soluble Vitamins 540

Ep. 244: Cardiac Valvular Disorders 543

Ep. 245: Rapid Review Series 39 548

Ep. 246: Dermatology Part 2 of 3 550

Ep. 247: Rapid Review Series 40 555 DI Podcast Main Document 4 Ep. 248: New Free 120 Q1-10 (2020) 558

Ep 249: Blood Oxygen Content and the USMLEs 561

Ep 250: HY Vaccines Podcast 564

Ep. 251: HY Thyroid Podcast 568

Ep. 252 Post Exposure Prophylaxis and the NBMEs 572

Ep. 253 Starling Forces and The NBMEs 574

Ep. 255 Legendary Step 2CK/3 Pharmacology 575

Ep. 256 Rapid Review Series 41 579

Ep. 257 The "Clutch" Bilirubin Podcast 581

Ep. 258 [Rapid Review Series 42] 584

Ep. 259 The "Clutch" Incontinence Podcast 587

Ep. 261 USMLE Derm Part 3 of 3 589

Ep. 262 The "Clutch" TB 592

Ep. 263 The "Clutch" CNS Infection 595

Ep. 264 The "Clutch" Comprehensive Heart Failure 598

Ep. 265 Male Reproductive Pathologies and the USMLEs 599

Ep. 267 USMLE and Normal Changes in the Elderly 601

Ep. 268 Clean SP 4 - (Palliative Care 2) 603

Ep. 269 NBME Ortho Series 1: Bone Tumors 606

Ep. 270 Rapid Review Series 43 608

Ep. 271 NBME and COPD 610

Ep. 272 Rapid Review Series 44 613

Ep. 273 NBME and High Output Heart Failure 615

Ep. 274 Rapid Review Series 45 618

Ep. 275 USMLE Nov 2020 Changes Series 5: Diagnostic Errors 620

Ep. 276 USMLE Nov 2020 Changes Series 6: Professionalism/Ethics 622

Ep. 277 USMLE Nov 2020 Changes Series 7: Infection Prevention and Control 624

Ep. 278 NBME and Amenorrhea 626

Ep. 279 NBME and Prostaglandins 629 DI Podcast Main Document 5 Ep. 281 Fat Soluble Vitamins and USMLE 631

Ep. 282 Combo Risk Factors/Prognostic Factors 634

Ep. 283 Combo Risk Factors/Prognostic Factors 2 635

Ep. 284 Rapid Review Series 48 (Bone Disorders) 637

Ep. 285 Rapid Review Series 49 640

Ep. 286 Ultra HY ARDS Podcast 642

Ep. 287 Ultra HY Urinalysis Podcast 643

Ep. 288 USMLEs and Stress Tests/TEEs 646

Ep. 289 Ultra HY Alcoholic Podcast 647

Ep. 290 Rapid Review Series 50 652

Ep. 291 Rapid Review Series 51 655

Ep. 292 NBME Endocarditis and Myocarditis 657

Ep 293 Gastroenterology Series 1 660

Ep. 293 Gastroenterology Series 1 Organized 664

Ep. 294 Gastroenterology Series 2 668

Ep. 295 Gastroenterology Series 3 670

Ep. 297 Rapid Review Series 52 671

Ep. 298 Gastroenterology Series 4 674

Ep. 299 Rapid Review Series 53 676

Ep. 300 Comprehensive COVID-19/Coronavirus 678

Ep. 325 Extremely HY Screening Guidelines 682

DI Podcast Main Document 6 ----------------------------------------------------------------------------------------------------------------------------

Ep. 29: Comprehensive Medicine Shelf Review Session 1 ● Opening snap + diastolic rumble at left 4th interspace + tall jugular venous A-waves. Murmur? tricuspid stenosis o Note: “Tall Jugular Venous A-waves” = JVD ▪ A-waves = atrial contraction ● Contraction against increased resistance = taller A waves

● What increases the intensity of tricuspid stenosis? Leg raise, IVF, Inspiration (increased preload)

● What decreases the intensity of tricuspid stenosis? (increased afterload; less blood flow across valve)

● Elevated AST/ALT + blistering lesions on dorsum of hands + hirsutism. → porphyria cutanea tarda o Deficiency enzyme? UROD (uroporphyrinogen decarboxylase) o Tx? Phlebotomy

● Hypoglycemia + hypoglycemia sxs + resolution w/ glucose administration. → Insulinoma o These 3 symptoms together = Whipple’s triad

● DDx 3 major etiologies of hypoglycemia o Insulinoma = ↑Insulin + ↑C-peptide + negative secretagogue screen

o Exogenous insulin = ↑Insulin + ↓C-peptide + negative secretagogue screen

o Sulfonylureas= ↑Insulin + ↑C-peptide + positive secretagogue screen

● Tx of acute hypoglycemia? juice/sugary drink (outpatient) or glucagon injection (inpatient; quickest way)

● Skin finding a/w glucagonoma → necrolytic migratory erythema

DI Podcast Main Document 7 Diarrhea

● Pork consumption or new puppy + diarrhea = Yersinia enterocolitica ● Undercooked shellfish + diarrhea = Vibrio parahaemolyticus or Vibrio vulnificus o Which has worse prognosis in pt’s with liver dz? Vibrio vulnificus ● Rice-water stools in developing country = Vibrio cholera o Tx? Oral rehydration + doxycycline ● Very small inoculum + bloody diarrhea = Shigella ● Eggs/poultry consumption + bloody diarrhea = Salmonella enteritidis ● Potato-salad consumption + watery diarrhea just hours later = Staph aureus ● Bloody diarrhea w/ low PLTs + unconjugated hyperbilirubinemia + SCr = E. coli O157:H7 or Shigella ● Diarrhea on return from Mexico → ETEC ● Foul-smelling watery diarrhea after recent abx treatment → C. diff o 1º Prevention? Hand washing o Tx? ▪ 1st line: Oral vancomycin or fidaxomicin ▪ Last resort: fecal transplant

● Crampy abdominal pain after eating home-canned veggies = Botulism(Clostridium botulinum) ● Bloody diarrhea w/ ascending paralysis in puppy owner = GBS 2/2 Campylobacter jejuni ● Watery diarrhea after eating rice at Chinese restaurant = Bacillus cereus(Cereulide toxin) ● Empiric ABX Tx of diarrhea? Fluoroquinolones(1 st-line) or macrolides

● 75 yo M + lives in home built in 1930s + Prussian blue stain shows basophilic inclusions around nucleus. Toxicity? Lead poisoning o Histo? Ringed sideroblasts o Labs? ↑Ferritin + ↓TIBC o Tx? ▪ Succimer aka Dimercaptosuccinic acid (DMSA) ▪ EDTA ▪ Dimercaprol aka British anti-Lewisite (BAL)

o What vitamin supplement to give in sideroblastic anemia? B6 ▪ ALAS (rate-limiting enzyme) uses B6 cofactor

● Febrile patient + taking high-dose immunosuppressants + CXR shows diffuse bilateral ground-glass infiltrates. → PCP pneumonia o Dx? BAL (broncho-alveolar lavage) o Relevant stain? Silver stain o Elevated marker from pulmonary fluid? LDH o PPx? TMP-SMX for CD4 < 200 ▪ Alternatives? Aerosolized pentamidine, dapsone, or atovaquone (clindamycin) o Tx? TMP-SMX ▪ When to add steroids? DI Podcast Main Document 8 ● O2 Sat < 92% aka PaO2 < 70 or ● A-a gradient > 35

● Flank pain + gross hematuria → nephrolithiasis o Envelope-shaped = calcium oxalate (X in oXalate for X-shape of folds of letter envelope) ▪ Etiologies? o Ethylene glycol ● Crohn’s Disease, i.e. increased reabsorption of oxalate o Coffin-shaped = struvite (magnesium-ammonium-phosphate) ▪ A/w which bug? Proteus mirabilis (Urease-positive → makes urine alkaline → precipitates stones) o Hexagonal-shaped = cysteine (“SIXtine stones”) ▪ Etiology? Cystinuria ● Pathophys? Defective COLA transporter → cannot reabsorb cysteine, ornithine, lysine, and arginine at PCT ▪ Tx? Acetazolamide ● MOA? Alkalinizes urine to solubilize the stones (cystine stones are acidic) o Radiolucent stones = uric acid stones (U in radiolUcent for U in Uric acid)

● What imaging to diagnose kidney stones? CT(1st line) o U/S if pregnant

● Tx for kidney stones? Fluids + tamsulosin (alpha-1 blocker) o For large stone? ESWL (extracorporeal shock wave lithotripsy) o For giant struvite stone? Nephrostomy tube to drain tube + surgery

● 24 yo M presents with painless, palpable bony mass on left knee. Knee XR reveals contiguous mushroom shaped mass. → osteochondroma o DDx ▪ osteosarcoma = kids ▪ osteoid osteoma= pain in legs at night + relieved with NSAIDs

● 66 yo F is found unconscious at home in December. PEx shows cherry-red appearance of skin. Toxicity? carbonic monoxide poisoning o Classic presentation? HA + AMS + cherry-red lips o A/w? Winter, space heaters, garage suicide o Pathophys? ▪ CO occupies binding sites on Hgb with 200x affinity than O2 → Leftward shift of oxyhemoglobin dissociation curve → prevents Hgb from releasing O2 o NBS for → Carboxyhemoglobin level o Tx? Hyperbaric O2 ▪ Mechanism? Reduces the half-life of CO binding to Hgb o Neuroimaging finding? Hyperintense lesions in globus pallidus

● Elevated creatinine 24 hrs after getting a CT scan. → Contrast nephropathy o Prevention? Hydration + N-acetylcysteine

● What are other uses of N-acetylcysteine?

DI Podcast Main Document 9 o APAP overdose o Inhalation tx for CF patients (breaks disulfide bonds) o Hemorrhagic cystitis 2/2 cyclophosphamide – however, mesna is first-line ▪ What virus causes hemorrhagic cystitis? adenovirus ▪ What microbe causes hemorrhagic cystitis in pt from Egypt? Schistosoma haematobium

● Skin fibrosis after getting a brain MRI. → nephrogenic systemic fibrosis o Exposure? Gadolinium

● What DM medication should be held before a CT scan? Metformin o Why? Risk of lactic acidosis with renal dysfunction (which could happen after contrast exposure)

● What common AE is a/w hydralazine and Ca2+ channel blockers? peripheral edema o Pathophys? Dilation of precapillary arterioles o Tx? ACE-I ▪ Mechanism? Dilation of post-capillary venule " decrease capillary hydrostatic pressure

● HIV patient with 3-day h/o fever + targetoid skin lesions + lip/mouth ulcers + visual impairment. PEx shows for skin sloughing (8% BSA). Positive Nikolsky sign. Started allopurinol 10 days ago for chronic gout. → SJS o NBS? Stop the drug o What Dx if there is > 30% BSA involvement? TEN

● 30 yo F presents with 3-day hx of polydipsia and polyuria. Blood glucose is 650 mg/dl, Bicarb is 21, pH is 7.35. → HHNS (Hyperglycaemic hyperosmolar non-ketotic syndrome) o A/w T2DM; normal pH; no ketosis ▪ Why no ketosis in HHS? B/c T2DM pt’s still make insulin, which inhibits glucagon and thus prevents DKA ▪ In contrast: DKA is a/w T1DM and causes low pH & ketosis o Tx? Fluids + insulin o Na+ balance? Hyperosmolar hyponatremia ▪ Na correction: add 1.6 for every extra 100 of glucose ● E.g. glucose of 900 → add 1.6*8 = 12.8 o K+ balance? ▪ Serum K+ high ▪ Total body K+ low

● Patient with HHNS receives rapid tx and becomes altered/comatose. What happened? Cerebral edema 2/2 rapid lowering of glucose

● 49 yo F presents with wheezing and flushing. PE is +ve for murmurs consistent with tricuspid regurgitation and pulmonic stenosis. → carcinoid syndrome o “Be FDR” = bronchospasm + flushing + diarrhea + R-sided heart lesions ▪ R-sided heart lesions = “TIPS” = tricuspid insufficiency + pulmonary stenosis o Why R-sided heart lesions? Lungs metabolize serotonin o Dx? urine 5-HIAA (metabolite of serotonin) ▪ NBSIM if positive 5-HIAA? Abdominal CT ▪ NBSIM if no tumor found on CT? octreotide scintigraphy o Tx? Can use octreotide to reduce sxs

DI Podcast Main Document 10 o Note: Only have symptoms if tumor metastasizes to liver (liver metabolizes serotonin) ▪ No symptoms if carcinoid tumor is localized to GI tract (e.g. appendix)

● Vit deficiency a/w carcinoid syndrome? Niacin (B3) deficiency → results in pellagra (diarrhea, dermatitis + dementia + death) o Pathophys? Tryptophan = precursor to serotonin and niacin. Carcinoid tumors use up tryptophan for production of serotonin → results in niacin deficiency

● Thyroid tumor that causes diarrhea? Medullary thyroid cancer (calcitonin causes diarrhea)

● 61 yo M + exertional dyspnea + Hct of 27%. NBSIM? Colonoscopy to r/o colon cancer o Iron studies? ↓Ferritin low + ↑TIBC + ↓Transferrin Saturation o When is transfusion indicated? Hgb < 7

● 61 yo M + exertional dyspnea + Hct of 27%. similar presentation + difficulty swallowing Plummer-Vinson syndrome ▪ Triad = IDA + esophageal webs + atrophic glossitis (smooth red tongue)

● 29 yo F with recent trip to India (ate local foods). Returned 2 weeks ago and initially had fevers for 1 week. Now has severe abdominal pain and distension. PEx is notable for salmon colored circular lesions on the trunk. → Typhoid fever o Bug? Salmonella typhi o Tx? Flouroquinolones

● Septic arthritis o NBSIM? Arthrocentesis ▪ WBC count in joint fluid? >50k o Tx? Joint washout + abx ▪ Tx for gonococcal arthritis? Ceftriaxone + doxy/azithro o MCC septic arthritis? Staph aureus o MCC sickle cell pt? Salmonella o MCC young F with purpuric skin lesions? NG

● Difference in Tx for Chamydia Trochomatis vs Neisseria Gonorrhoeae? o CT: only azithro or doxy o NG: ceftriaxone + azithro/doxy (treat empirically for Chlamydia)

● Pt with subconjunctival hemorrhage + nasty coughing episodes or post-tussive vomiting. → Pertussis o Tx? Macrolide o Ppx for close contacts? Macrolide o Lab findings? Elevated lymphocytes

● Pt recently started Ramipril for HTN and developed cough. NBSIM? Switch to ARB

● Uniformly prolonged PR interval without dropped QRS = 1st degree AV block o Tx? nothing!

● Progressive PR prolongation + dropped QRS = Wenckebachaka Type I 2º AV Block o “Longer longer longer drop → Wenckebach”

DI Podcast Main Document 11 o Tx? nothing!

● Fixed PR prolongation + dropped QRS → Type II 2º AV Block aka Mobitz II

● Constant P-P interval + constant R-R interval + no relation b/w P waves & QRS → 3º AV Block

● Which heart blocks that require a pacemaker? o Type II 2º AV Block o 3º AV Block

● Acute mgmt for decompensated pt w/ heart block? Transcutaneous or transvenous pacing + atropine

● Contraindicated medications in heart block? o Beta blockers o CCB (diltiazem/verapamil) o Digoxin (d/t muscarinic agonist activity)

● Reduced EF in patient with coarse facial features and enlarging fingers. → → acromegaly o Diagnostic algorithm? ▪ 1st step: check IGF-1 ▪ 2nd step: glucose suppression test ● Normal: glucose causes suppression of GH release ● Failure to suppress → acromegaly rd ▪ 3 step: MRI o Tx? Transsphenoidal surgery ▪ Differs from prolactinoma (usually managed medically) ▪ Tx prior to surgery? ● Octreotide ● dopamine agonist (bromocriptine/cabergoline) ● Pegvisomant (GH receptor antagonist) o MCC of death in acromegaly? HF

● Dysphagia to solids and liquids in patient with thick/thin blood smears (Giemsa stain) revealing motile parasites. → Achalasia 2/2 Chagas disease o Microbe? Trypanosoma cruzi o Dx? “BME” ▪ 1st step: Barium swallow ▪ 2nd step: Manometry ▪ 3rd step: Endoscopy o Imaging Finding? +Bird’s beak sign o Tx? ▪ Dihydropyridine CCB ▪ Botox injection ▪ Balloon dilation ● AE of balloon dilation? Esophageal rupture ▪ Heller myotomy (cut LES muscles) o Manifestations of T. cruzi ▪ Achalasia → megaesophagus ▪ Dilated cardiomyopathy

DI Podcast Main Document 12 ▪ Destruction of myenteric plexus → megacolon

● Reduced MCV in a patient with a long history of untreated rheumatoid arthritis. → anemia of chronic disease o Iron studies ▪ Ferritin high ▪ TIBC low ▪ Transferrin sat low (iron locked away in macrophages) o Pathophys? Hepcidin → ron sequestration by bone marrow macrophages & reduced iron export by enterocytes

● 25 yo M with nasal packing presents with a BP of 65/40, elevated Cr, respiratory distress, T of 104, and marginally elevated troponins. → Toxic shock syndrome o Pathophys? Superantigen production o Bugs? Staph aureus + Strep pyogenes o Tx? Fluids (+/- pressors) + abx

● Sequelae of CKD o Acid-base anomalies? Metabolic acidosis 2/2 H+ retention ▪ Recall there’s a H+ pump in the alpha-intercalated cell o Electrolyte anomalies? ▪ Hyperkalemia ● Pathophys? Kidneys not excreting K+ (normally happens via ROMK channel) ▪ Hypocalcemia ● Pathophys? Low 1-alpha hydroxylase → cannot make active Vit D → can’t absorb Ca+ and phos from the gut ▪ Hyperphosphatemia ● Pathophys? Hypocalcemia → 2ary hyper-PTH → BUT can’t excrete phos because the kidneys aren’t working ● Contrast with liver disease o Can’t make calcidiol → 2ary hyperparathyroidism → hypercalcemia & hypophosphatemia (kidneys functional) o Hematologic anomalies? ▪ Hgb low ● Pathophys? Kidneys not producing erythropoietin o Manifestations of uremia ▪ Pericarditis ▪ Platelet dysfunction ● Tx? Desmopressin o Note: Desmopressin = ADH analog → so, it can cause hyponatremia 2/2 SIADH ▪ AMS o Tx ▪ Hyperphosphatemia → phosphate binders (sevelamer) ▪ Hypocalcemia → calcitriol ● NOT calcidiol, because they can’t convert calcidiol to calcitriol o How is kidney function preserved in diabetic nephropathy? ACE-I o Indications for dialysis ▪ A = acidosis

DI Podcast Main Document 13 ▪ E = electrolyte problems ▪ I = ingestion ▪ O = overload (fluid) ▪ U = uremia

● Rb gene mutations, Paget’s disease, and Teriparatide (PTH analog) administration increase risk of what primary bone malignancy? Osteosarcoma o Associated radiological features? ▪ Codman’s triangle ▪ Sunburst pattern

●● Asthma step-up treatment o Albuterol o Albuterol + SABA o Albuterol + SABA + ICS o Albuterol + SABA + ICS + LABA (e.g. salmeterol)

DI Podcast Main Document 14 o Albuterol + SABA + ICS + LABA (e.g. salmeterol) + oral steroids

● Asthma + nasal polyps. → Aspirin Exacerbated Respiratory Disease o Pathophys? ▪ Arachidonic acid → prostaglandins (COX) + leukotrienes (LOX) ▪ Aspirin blocks COX → results in increased LOX pathway activity o Tx? ▪ Leukotriene receptor (CYSLTR1) blockers, e.g. montelukast ▪ LOX enzyme inhibitors, e.g. zileuton ● AE? Hepatotoxic

● DDx for nasal polyps? ▪ AERD ▪ Wegener’s = GPA ▪ CF

● Regular narrow-complex tachycardia. Arrythmia? SVT o Tx asymptomatic pt? ▪ Acute SVT ● Vagal maneuvers ● Adenosine ▪ Chronic SVT ● Beta blocker ● Verapamil/diltiazem o Tx HDUS pt? Synchronized cardioversion

● Indications for defibrillation aka unsynchronized cardioversion o Pulseless VTach o VFib

● MC EKG finding in pulmonary embolism? Sinus tachycardia

● 18 yo F with scaly, erythematous UE lesions. Long history of allergic rhinitis. → Atopic dermatitis/eczema o CBC finding? Elevated eosinophils o Tx? Topical steroids o What if these lesions also had umbilicated vesicles. → eczema herpeticum ▪ Pathophys? HSV superinfection ▪ Tx? Acyclovir

● A patient presents with classic “stones, bones, groans, and psychic overtones”. PE is notable for skin tenting. What is the first step in management? Fluids! o Bisphosphonates ▪ Indications? ● Osteoporosis o T-score cutoff? -2.5 ● Hypercalcemia of malignancy ● Paget’s disease

DI Podcast Main Document 15 ● Ppx if on oral steroids for >3 months ▪ AE? ● Esophageal irritation (prevent by sitting up for 30 minutes after taking pill) ● Osteonecrosis of the jaw

● H. Pylori infection o Dx? Urea breath test or stool Ag or EGD with bx o Tx? ▪ Triple xx = clarithromycin + amox + PPI ▪ Quad therapy = metronidazole + bismuth + tetracycline + PPI (“MBTP”) o RF for PUD? ▪ H. pylori infection ▪ Chronic NSAID use

● Alpha Thalassemia: o Mutation in 1 alpha gene = clinically silent o Mutation in 2 alpha genes = alpha-thalassemia trait (asymptomatic) o Mutation in 3 alpha genes = Hb H disease (tetramers of beta) ▪ Age at presentation? Birth (b/c alpha chains also required for HbF) o Mutation in 4 alpha genes = Hb Barts (tetramers of gamma)

● Beta Thalassemia: o Mutation in 1 beta gene = beta-thalassemia minor ▪ Electrophoresis findings? Elevated HbA2 ● HbA2 = alpha2-delta2 o Mutation in 2 beta genes = beta thalassemia ▪ Electrophoresis findings? Elevated HbA2 + elevated HbF ▪ Age at presentation? 6 months (b/c HbF persists until age of 6 months)

● Blood smear for thalassemias? Target cells

● Classic CBC findings in hemolytic anemias? Low haptoglobin + Indirect hyperbilirubinemia

● Classic “gallbladder” pathology for hemolytic anemia? Brown pigmented gallstones

● What microbe causes aplastic crisis in pt’s with hemolytic anemia? Parvovirus B19

● Do thalassemia’s cause microcytic, normocytic, or macrocytic anemia? Microcytic with normal RDW o In contrast: IDA causes microcytic anemia with high RDW

● 23 yo M with recent trip to Tucson + 2-week history of fever, ankle/knee pain, chest pain, and painful, erythematous pretibial lesion. Tx? coccidiomyocosis o Geographic association? Southwest U.S. o Derm finding? Erythema nodosum o Microscopy finding? Spherules o Tx? itraconazole

● Periorbital edema, hematuria, HTN in patient with recent cellulitis. BUN and Cr are elevated. → Post-infectious GN

DI Podcast Main Document 16 o Pathophys? Nephritic syndrome o Ab? Anti-streptolysin-O and anti-DNase B o Type of HSR? Type III HSR o Complications of… ▪ Strep pharyngitis? ● Rheumatic fever - abx decrease risk ● PSGN - abx have NO EFFECT on risk ▪ Strep skin infection? ● Only PSGN

● 11:22 translocation + XR shows “onion-skin-like” periosteal reaction + bone bx with histo shows small, round, blue cells. → Ewing’s sarcoma o Tx? Actinomycin D

● Parapneumonic effusion (PNE) = pleural effusion in setting of pneumonia

● Uncomplicated PNE ● Complicated PNE ● Empyema

● pH > 7.2 ● pH < 7.2 ● pH < 7.2● Glucose > 60 ● Glucose < 60 ● Glucose < 60● LDH < ⅔ ULN ● LDH > ⅔ ULN ● LDH > ⅔ ULN● NO bugs detected ● NO bugs detected ● YES bugs are isolated● Tx = ABX ● Tx = Abx + chest tube ● Tx = Abx + chest tube ● VATS surgery if refractory

● ● Arrythmia? V-Tach o How to describe the rhythm? Regular, wide-complex (“regular” b/c constant RR interval) o Tx algorithm for VTach ▪ Pulseless VTach = defibrillateaka unsynchronized cardioversion ▪ VTach + pulse + HDUS = synchronized cardioversion ▪ VTach + pulse HDS = amiodarone

● MCC of death in first 24h after MI? VFib

DI Podcast Main Document 17 o Tx V fib = defibrillation aka unsynchronized cardioversion

● 45y M + oral mucosal ulcerations + positive Nikolsky sign. → Pemphigus vulgaris o “Pemphigus vulgaris is vulgar b/c it exposes what’s your skin – hence it’s +Nikolsy sign” o Pathophys? Autoantibodies to desmosomes (anti-desmoglein-1/-3 Ab’s) o Type HSR? Type II HSR o Diagnostic skin bx? Immunofluorescence → intraepidermal immunofluorescence (net-like pattern) ▪ In contrast: IF of bullous pemphigoid shows a linear pattern o Tx? Oral steroids

● Labs in 1º hyperaldosteronism (Conn Syndrome)? ↑Aldosterone + ↓Renin + Plasma aldosterone:renin ratio >20 ▪ Dx? Plasma aldosterone:renin ratio >20 ▪ Tx? Aldosterone antagonists (spironolactone, eplerenone)

● Labs for 2º hyperaldosteronism? ↑Aldosterone high + ↑Renin o Clinical scenarios: ▪ Young F with abdominal bruits OR resistant HTN + AV nicking. → fibromuscular dysplasia ▪ Elderly man with abdominal bruits. → renal artery stenosis

● Young F with abdominal pain relieved on defecation. → IBS o Rome Criteria ▪ Recurrent abdominal pain associated with 2 of the 3 ● Related to defecation ● Change in stool form ● Change in BM frequency ▪ Are there lab abnormalities? NO ▪ IBS Classification ● IBS-C (constipation) → give stool softener ● IBS-D (diarrhea) → give antidiarrheal (e.g. loperamide)

● Cold vs Warm Agglutinins o Cold agglutinins = IgM ▪ A/w? Mycoplasma ▪ Tx? Cytotoxic drug (cyclosporine, azathioprine etc) o Warm agglutinins = IgG ▪ Tx? Splenectomy ● Why? IgG opsonizes things and splenic macrophages clear antibody-bound RBCs → so, need to get rid of spleen

● Labs in hemolytic anemia? ↑LDH + ↑Indirect bilirubin + ↓Haptoglobin ▪ Haptoglobin binds bilirubin

● 32 yo Egyptian immigrant with 2-week history of abdominal pain, hepatosplenomegaly, and hematuria. Swam in The Nile 2 months ago. → Schistosomiasis o Bug? Schistosoma haematobium o Transmission? Direct contact with water o CBC finding? Elevated eosinophils

DI Podcast Main Document 18 o Associated malignancy? Squamous cell carcinoma of bladder o Tx? Praziquantel

● Synpharyngitic glomerulonephritis aka IgA nephropathy o Presentation? 2-6 days after URI ▪ In contrast: PIGN occurs 2-6 weeks after URI ● Complement levels in PIGN? Low complement o Tx? steroids + ACEI

● Urine casts in nephritic syndromes? RBC casts

● Urine protein in nephritic syndrome ? < 3.5 g/24 hrs

● 70 yo M with leg pain worsened by back held in extension (better with back in flexion). → spinal stenosis o → MRI spine o Tx? Physical therapy + pain control ▪ If refractory, decompressive laminectomy

● Opening snap with diastolic rumble heard best at 4th intercostal space in midclavicular line. Valve Path? Mitral stenosis o #1 RF? Rheumatic fever o Dx? Echo o Tx? Valve replacement o MC arrhythmia a/w mitral stenosis? AFib

● Diagnostic test for all murmurs? Echo

● MC arrhythmia a/w Graves disease? AFib

● MC arrhythmia a/w hyperthyroidism? AFib

● MC comorbidity a/w AFib? Chronic HTN (Per UW 2021)

● No oral mucosal lesions + pruritus + tense blisters + negative Nikolsky sign. → Bullous pemphigoid o Pathophys? Hemidesmosome Ab’s o → Skin bx w/ immunofluorescence → linear subepidermal pattern (linear pattern) Tx? Topical steroids

● 69 yo M with fever + leukocytosis + LLQ pain. → diverticulitis o Pathophys? Inflammation of diverticula o Dx? CT abdomen o Contraindicated imaging? Colonoscopy is contraindicated!

● 2 Tx co*cktails for GI infections? o Cipro (GNRs) + metronidazole (anaerobes) o Metronidazole + amoxicillin + gentamicin (“MAG”) ▪ Note: Never choose Pip-Tazo for GI infections (too broad)

DI Podcast Main Document 19 ● Pt treated for diverticulitis presents with recurrent UTIs weeks later + UA shows air & fecal material. → Colovesical fistula o Dx? CT scan with oral and rectal contrast

Cross checked: Yes

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Ep. 30: Comprehensive Medicine Shelf Review Session 2. ● Primary adrenal insufficiency = problem at level of adrenal glands ○ Causes? Addison’s disease ○ Pathophys? Autoimmune destruction of the adrenal glands ○ Associated with hyperpigmentation ■ POMC is precursor to both ACTH and MSH ■ PAI → lack of negative feedback → high ACTH ○ Lab findings? ■ ACTH high ■ Aldosterone low ● Destruction of zona glomerulosa ■ Renin high ● Hypotension → RAAS activation ■ Electrolytes ● Na+ low, K+ high ■ CBC ● Eosinophils high ○ Pathophys? Glucocorticoids → eosinophil apoptosis. Lack of glucocorticoids cause eosinophilia. ○ Dx? Cosyntropin testing → no rise in cortisol ■ Adrenal glands aren’t working, so no response to ACTH. ○ Tx? prednisone/hydrocortisone/dexamethasone + fludrocortisone (mineralocorticoid) ■ Stress-dose steroids for surgery, serious illness, etc. ● Secondary adrenal insufficiency = problem at level of pituitary, reduced ACTH release ○ Causes? ■ MC is prolonged steroid use → ACTH suppression ■ Sheehan’s syndrome (infarction of pituitary) ■ Pituitary tumors (ACTH-producing tumor) ○ Lab findings? ■ ACTH low ● Anterior pituitary is being inhibited ■ Aldosterone normal ● Zona glomerulosa under control of RAAS system ■ Renin normal ■ Electrolytes ● Na+ & K+ unaffected (Aldosterone levels are normal) DI Podcast Main Document 20 ■ CBC ● Neutrophilia due to demargination (if pt was recently taking steroids) ○ Dx? Cosyntropin testing → rise in cortisol ■ Adrenal gland is functional ○ Tx? Glucocorticoids ■ Do not need to replace mineralocorticoids since adrenals are functional and aldosterone is under RAAS control ■ Stress-dose steroids for surgery, serious illness, etc.● AI with a history of nuchal rigidity and purpuric skin lesions → Waterhouse-Friedrichson syndrome ○ Pathophys? AI 2/2 hemorrhagic infarction of the adrenal glands in the context of Neisseria meningitidis infection● Adrenal synthesis enzymes ○ If the enzyme starts with 1 → HTN (high mineralocorticoids) ○ If the second # is 1 → virilization (high androgens) ○ E.g. 11-beta hydroxylase deficiency → HTN & virilization ○ E.g. 21 hydroxylase deficiency → virilization only ○ E.g. 17-alpha hydroxylase deficiency → HTN only

● B12 deficiency ○ Where does B12 come from? Animal products ○ Physiology ■ R factor in saliva binds to B12 and protects it from acidity in the stomach. R factor-B12 travels to the duodenum. ■ Parietal cells produce intrinsic factor, which travels to the duodenum. DI Podcast Main Document 21 ■ Pancreatic enzymes cleave B12 from R factor and B12 then binds IF. ■ B12-IF complex is reabsorbed in the terminal ileum ○ Reabsorption where? Terminal ileum ○ Causes of B12 deficiency ■ Extreme vegan ■ Pernicious anemia ■ Pancreatic enzyme deficiency ● Can’t cleave B12 from R factor ■ Crohn’s ● Affects terminal ileum ○ Lab markers ■ hom*ocysteine HIGH ■ MMA HIGH ○ Presentation? ■ Megaloblastic anemia ■ Subacute combined degeneration (of dorsal columns + lateral corticospinal tract) ■ Peripheral neuropathy ○ Dx of pernicious anemia? anti-IF Ab● Folate deficiency ○ Where does folate come from? Leafy things ○ Causes of folate deficiency ■ Poor diet (e.g. alcoholics, elderly) ■ Phenytoin ○ Lab markers ■ hom*ocysteine HIGH ■ MMA normal ○ Presentation? Megaloblastic anemia

● Prophylaxis in HIV+ patients ○ CD4 < 200 → PCP ■ TMP-SMX, inhaled pentamidine, dapsone, atovaquone ○ CD4 < 100 → Toxo ■ TMP-SMX ○ CD4 < 50 → MAC ■ Azithromycin ○ If live in endemic area, CD4 < 250 → Coccidioides Immitis ■ E.g. Arizona, Nevada, Texas, California ■ Itraconazole ○ If live in endemic area, CD4 < 150 → Histoplasma Capsulatum ■ E.g. Kentucky, Ohio, Missouri ■ Itraconazole

● Diabetes insipidus ○ Dx? Water deprivation test ■ Measure serum osmolality & urine osmolality DI Podcast Main Document 22 ■ Deprive pt of water ■ Remeasure serum osmolality & urine osmolality ● If urine osmolality doesn’t go up → suspect DI ○ Central DI → deficiency of ADH ■ Pathophys? Supraoptic nucleus not making enough ADH ■ Dx? Give desmopressin → urine osmolality increases significantly ○ Nephrogenic DI → kidneys are not responding to ADH ■ Dx? Give desmopressin → urine osmolality doesn’t change much ■ Tx? Hydrochlorothiazide ● Unless 2/2 lithium, use amiloride or triametere ■ Causes? ● Lithium ● SSRIs ● Carbamazepine ● Demeclocycline● Tx of normovolemic hypernatremia? D5W to correct free water deficit ○ Divine says NS, but most other resources I found said correct free water deficit● Tx of hypovolemic hypernatremia? Give NS first until normal volume, then give D5W● Consequence of correcting hypernatremia too rapidly? Cerebral edema

● Osteoarthritis ○ Presentation? Old person with joint pain that gets worse throughout the day ○ RF? obesity ○ Imaging findings? ■ Joint space narrowing ■ Subchondral sclerosis ■ Subchondral cysts ■ Osteophytes ○ Arthrocentesis findings? <2000 cells ○ Tx? ■ 1st line acetaminophen ■ 2nd line NSAID (e.g. naproxen) ■ 3rd line joint replacement surgery

● Returned from a business conference 1 week ago + Fever + Nonproductive cough + Abdominal pain + Hyponatremia → Legionella ○ Dx? Urine antigen ○ Tx? FQ or macrolide ■ MaCroLide mnemonic = Mycoplasma, Chlamydia, Legionella● What are the common causes of atypical PNA? Mycoplasma, Legionella, Chlamydia ○ MC cause? Mycoplasma ○ CXR findings? Interstitial infiltrates ○ HY associations ■ C. Psittaci → birds ■ C. Burnetii → cows, goats, sheet DI Podcast Main Document 23 ■ Mycoplasma → college student w/ walking pneumonia

● Midsystolic click heard best at the apex. → mitral valve prolapse ○ “Stenosnap & Proclick” ○ RF? Connective tissue disease ■ Marfarn ■ Ehlers-Danlos ■ ADPKD ○ Classic demographic? Young woman ○ Pathophys? Myxomatous degeneration ○ Exam maneuvers ■ Anything that increase amount of blood in LV → murmur softer ● Increase preload ● Increase afterload ■ Anything that decreases amount of blood in LV → murmur louder ○ Dx? Echo

● Scaly, itchy skin with yellowish crusting in the winter. → seborrheic dermatitis ○ Tx? Topical antifungals ■ e.g. ketoconazole or selenium sulfide shampoo ○ Classic disease distribution? ■ Hair → e.g. cradle cap ■ Eyebrows

● Episodic HTN + HA → pheochromocytoma ○ Genetic disease associations ■ MEN2A ■ MEN2B ■ VHL ■ NF-1 ○ Pathophys? Catecholamine-secreting tumor ○ Location? ■ Adrenal medulla ■ Posterior mediastinum ■ Organ of Zuckerkandl (chromaffin cells along the aorta) ○ Dx? ■ 1st step: urine metanephrines ● If elevated → CT abdomen ○ If nothing found on CT → MIBG scan ○ Tx? Alpha blocker (e.g. phenoxybenzamine, phenotaline) THEN beta blocker● Most common cause of a LGIB in the elderly → diverticulosis ○ Dx? Colonoscopy or barium enema ■ Recall that you acutely do a CT scan for diverticulitis, then 6 weeks later colonoscopy to r/o cancer ○ Ppx? Eat fiber DI Podcast Main Document 24 ● Megaloblastic anemias ○ Blood smear findings? ■ Hypersegmented neutrophils ■ MCV > 100 ○ Classic patient demographic with folate deficiency? ■ Alcoholics ■ Elderly person with poor nutrition ○ Folate synthesis inhibitors ■ Pt with molar pregnancy → methotrexate ● Pulmonary issue? Pulmonary fibrosis ■ HIV+ pt with ring-enhancing lesions → pyrimethamine-sulfadiazine ● Pyrimethamine inhibits DHFR ■ AIDS pt on ppx for toxo → TMP-SMX ● TMP inhibits DHFR ○ Use of leucovorin? Rescue bone marrow in setting of methotrexate toxicity ■ Mechanism? Folinic acid analog

● CMV presentations ○ Esophagitis → linear ulcers ○ Colitis → post-transplant pt ○ Retinitis → HIV pt with CD4 < 50 ○ Congenital CMV → periventricular calcifications + hearing loss ■ calcifications elsewhere → toxo● Histology? Owl’s eye intranuclear inclusions

●● Tx? Gancicyclovir ○ Resistance? UL97 kinase mutation ○ Tx for resistance? foscarnet

● CD4 < 200 + severe peripheral edema + frothy urine. → FSGS in HIV pt ○ Variant classic in HIV+ pts? Collapsing variant ○ Tx? Steroids + cyclophosphamide + ACE-I● Indinavir AE? Kidney stones● triad of fever, rash, and eosinophiluria → acute interstitial nephritis ○ Drugs cause? Penicillins

DI Podcast Main Document 25 ○ Tx? Stop the drug! ■ Can add steroids if severe

● Vitamin D metabolism ○ Liver converts Vit D to calcidiol (25OH-Vit D). Calcidiol goes to kidney. Alpha-1 hydroxylase converts calcidiol to calcitriol (1,25-OH Vit D). ○ Common causes of Vitamin D deficiency ■ CKD → 1-alpha hydroxyalse deficiency ■ Liver disease → can’t make calcidiol ■ CF → malabsorption ■ Crohn’s → malabsorption ○ Osteomalacia vs Rickets ■ Osteomalacia in adults ■ Rickets in kids ○ Tx? Calcium + vit D ○ Lab findings? ■ Ca++ low ■ Phos low ● Low in liver disease ● High in kidney disease (kidneys can’t get rid of phos) ■ PTH high (2ary hyperpara) ■ Alk phos

● Aspiration pneumonia ○ RF? ■ Alcoholism ■ Dementia ■ Neuromuscular problems (e.g. MG, ALS) ○ Bugs? ■ Anaerobes ● Bacteroides ● FUsobacterium ● Peptostreptococcus ■ Klebsiella → currant jelly sputum ○ Tx? Clindamycin● CURB-65 criteria ○ Purpose? Who to admit ○ Cutoff? 2+ → hospitalize ○ C = confusion ○ U = uremia (BUN > 20) ○ R = RR > 30 ○ B = BP < 90/60 ○ Age > 65● Drugs commonly used in PNA treatment ○ Ceftriaxone DI Podcast Main Document 26 ○ Levofloxacin ○ Macrolides - great for atypical PNA

● Pharmacological management of pulmonary arterial HTN ○ Endothelin antagonists ■ Bosentan ■ ambrisentan ○ PDE-5 inhibitors ■ Sildenafil ■ Tadalafil ○ Prostacyclin analogs ■ Iloprost ■ Epoprostenol ■ Treprostinil ● Causes? ○ Young female → idiopathic PAH ■ Mutation? BMPR2

● 55 yo F presents with a 5 week history of a rash on her forehead. PE reveals scaly macules with a sandpaper texture. → actinic keratosis ○ RF? Sun exposure ○ Tx? Topical 5-FU ○ Possible dangerous sequelae? Squamous cell carcinoma ○ Most likely disease sequelae? Resolution

1ary hyperparathyroidism 2ary hyperparathyroidism 3ary hyperparathyroidism

Autonomous PTH production Low Ca++ → PTH production PTH production despite normalized of Ca++ levelsCauses? Causes?Adenoma CKD Causes?Parathyroid hyperplasia CKD s/p transplant

PTH high PTH highCa++ high Ca++ low PTH highPhos low Phos high Ca++ high Phos low

DI Podcast Main Document 27 Tx? Parathyroidectomy (remove 3.5 glands) Cinacalcet (CSR modulator)

● Hypercalcemia ○ Presentation? bones, stones, groans, psychic overtones ○ Tx? ■ 1st step: NS ■ Hypercalcemia of malignancy → bisphosphonates ○ EKG finding? Shortened QT

● Periumbilical pain that migrates to the right lower quadrant. → appendicitis ○ PE findings? ■ McBurney’s point tenderness ■ Psoas sign ■ Obturator sign (pain with internal rotation of hip) ■ Rovsing’s sign (palpation of LLQ → pain in RLQ) ○ Dx? CT scan ■ Pregnant → US ■ Kid → US ○ Tx? Surgery

● Classic drug and viral causes of aplastic anemia. ○ Drugs? ■ Carbamazepine ■ Chloramphenicol ○ Viral? Parvovirus B19 (single stranded DNA virus)

● Fanconi anemia ○ Pathophys? Problems with DNA repair ○ Fanconi anemia vs Fanconi syndrome ■ Fanconi anemia → cytopenias + thumb anomalies + short stature + cafe-au-lait spots ■ Fanconi syndrome → type 2 RTA (proximal)

● CD4 count of 94 + MRI revealing ring enhancing lesions in the cortex → toxoplasmosis ○ Tx? Pyrimethamine-sulfadiazine ■ Rescue agent for pt who becomes leukopenic with treatment? leucovorin ○ Who should get steroids? Increased ICP ■ For PCP pneumonia: ● O2 sat < 92 ● PaO2 < 70 ● A-a gradient > 35 ○ Ppx? TMP-SMX for CD4 < 100

DI Podcast Main Document 28 ○ Congenital toxo ■ Hydrocephalus ■ Chorioretinitis ■ Intracranial calcifications ○ Classic methods of transmission? handling cat litter

● Lupus nephritis ○ Associated autoantibody? anti-dsDNA ○ Classic “immunologic” description? “Full house” pattern ○ Tx? Steroids + cyclophosphamide

● Osteoporosis ○ Screening population? women > 65 ○ Screening modality? DEXA scan ○ Dx? T-score < -2.5 ○ RF? ■ Postmenopauseal ■ Low BMI ■ Smoking ■ Alcohol ○ Preventive strategies? ■ Weight bearing exercise ■ Smoking cessation ■ Reduce alcohol consumption ○ Tx? ■ 1st line: bisphosphonates + Ca/Vit D supplementation ■ Raloxifene (SERM) ● Agonist in bone ● Antagonist in breast ○ Classic locations of osteoporotic fractures ■ Vertebral compression fracture ■ Hip fracture

● Name the PNA ○ Red currant jelly sputum. → Klebsiella ○ Rust colored sputum. → Strep pneumo ○ PNA in an alcoholic. → Klebsiella ○ Post viral PNA with a cavitary CXR lesion. → Staph aureus ○ PNA in a patient that has chronically been on a ventilator. → Pseudomonas ○ MC cause of CAP. → Strep pneumo● Pharmacological management of MRSA. ○ Vanc ○ Clinda ○ Linezolid ○ Ceftaroline (5th gen cephalosporin) DI Podcast Main Document 29 ○ Tigecycline● Pharmacological management of Pseudomonas. ○ Ceftazidime (only 3rd gen cephalosporin) ○ Cefepime (4th gen cephalosporin) ○ Pip-tazo ○ FQ ○ Carbapenems ○ Aztreonam ○ Aminoglycosides

● JVD and exercise intolerance in a patient with a recent history of an URI. → dilated cardiomyopathy 2/2 viral myocarditis ○ MC cause? Coxsackie B ○ Drug causes? ■ Clozapine ■ Anthracyclines ● Prevention? Dexrazoxane (iron chelator) ■ Trastuzumab ○ Classic cause in a patient with recent history of travel to S. America? Chagas ■ Potential sequelae? ● Achalasia ● Dilated cardiomyopathy ● Megacolon (2/2 degeneration of myenteric plexus)

● Massive skin sloughing (45% BSA) in a patient that was recently started on a gout medication? TEN ○ Dx? ■ <10% BSA → SJS ■ >30% BSA → TEN ○ Tx? STOP the drug ■ IVF ■ Topical abx to prevention infection

● Tetany and a prolonged QT interval in a patient with recent surgical treatment of follicular thyroid carcinoma. → hypocalcemia due to removal of parathyroids● Recurrent viral infections + QT prolongation + tetany → DiGeorge syndrome ○ Pathophys? Failure of development of 3rd/4th pharyngeal pouches● Trousseau and Chvostek signs. ○ Trousseau → inflation of BP cuff causes carpopedal spasm ○ Chvostek → taping on cheek causes facial muscle spasm● Hypocalcemia that is refractory to repletion → consider hypomagnesemia● Electrolyte/drug causes of prolonged QT intervals ○ Electrolytes? ■ Hypocalcemia ■ Hypomagnesemia ■ Hypokalemia DI Podcast Main Document 30 ○ Drugs? ■ Macrolides ■ FQ ■ Haloperidol ■ Ondensatron ■ Methadone● Hypoalbuminemia and Ca balance ○ Hypoalbumenia → decrease in total body Ca++, no change in ionized Ca++ ○ Drop of 1 in albumin → add 0.8 to Ca++

● Abdominal pain radiating to the back → acute pancreatitis ○ Causes? ■ #1 = Gallstones ■ #2 = Alcohol ■ Hypertriglyceridemia ■ Scorpion sting ■ Handlebar injuries ○ Lab markers? ■ Lipase - most sensitive ■ Amylase ○ Physical exam signs in pancreatitis. ■ Cullen’s sign = periumbilical ecchymosis ■ Grey Turner sign = flank ecchymosis ■ ○ Tx? NPO + IVF + pain control ■ Meperidine is a good agent because it doesn’t cause sphincter of Oddi spasms ○ Management of gallstone pancreatitis ■ Dx? US then ERCP ■ Tx? DELAYED cholecystectomy ○ What if the patient becomes severely hypoxic with a CXR revealing a “white out” lung? ARDS ■ PCWP? <18 mmHg

● 20 yo M with red urine in the morning + hepatic vein thrombosis + CBC findings of hemolytic anemia. → paroxysmal nocturnal hemoglobinuria ○ Pathophys? Defect in GPI anchors, which attach CD55 and CD59 to cell (they prevent complement from destroying RBC) ■ Sleep → hypoventilation → mild respiratory acidosis → activation of complement cascade ○ Gene mutation? PIGA ○ Dx? Flow cytometry ○ Tx? Eculizumab (terminal complement inhibitor) ■ Vaccine required? Neisseria meningitidis

● Chronic diarrhea and malabsorption in a HIV+ patient + detection of acid fast oocysts in stool. → cryptosporidium parvum ○ Acid-fast organisms DI Podcast Main Document 31 ■ Cryptosporidium ■ TB ■ MAC ■ Nocardia ○ Dx? Stool O&P ○ Tx? Nitazoxanide ○ Route of transmission? Contaminated water

● Muddy brown casts on urinalysis in a patient with recent CT contrast administration (or Gentamicin administration for a life threatening gram -ve infection) → ATN

● Woman with morning joint stiffness > 1 hr → RA. ○ Ab? ■ RF (IgM against IgG) ■ anti-CCP - more specific ○ HLA? DR4 ○ Pathophys? IgM constant region activates complement → inflammation → formation of pannus (hypertrophied synovium) → damage to cartilage and bone ○ Caplan syndrome = RA + pneumoconiosis ○ Felty syndrome = RA + neutropenia + splenomegaly (“RANS”) ○ Classic hand/finger findings/distribution? MCP & PIP joints of hands (DIP joints spared) ○ Imaging findings? ■ Symmetric joint space narrowing ○ Tx? Methotrexate (DMARDs) ■ If no response → TNF alpha inhibitor (e.g. infliximab) ○ Required testing prior to starting methotrexate? ■ PFTs ○ Required testing prior to starting infliximab? ■ TB ■ Hep B/Hep C

● Differentiating Strep pharyngitis from Infectious Mononucleosis ○ LND distribution ■ Anterior cervical → Strep ■ Posterior cervical → Mono ○ Disease onset ■ Acute → Strep ■ Over weeks → Mono ○ Organ involvement ■ Splenomegaly → Mono● Pt with sore throat takes amoxicillin and gets rash → mono ○ NOT allergic rxn!● CENTOR criteria ○ C = absence of Cough ○ E = tonsillar Exudates DI Podcast Main Document 32 ○ N = nodes/anterior cervical lymphadenopathy ○ T = temp (fever) ○ OR ■ <15 → +1 ■ >=45 → -1● Using CENTOR score ○ 0/1 → don’t test, don’t treat ○ 2/3 → rapid antigen test ■ Positive → treat ■ Negative → throat culture ○ 4/5 → treat empirically● Tx of Strep pharyngitis? ○ Amoxillcin ○ If PCN allergic → azithromycin● Potential sequelae of Strep pharyngitis ○ RF - preventable with abx ○ PSGN

● Endocarditis ○ MC cause of endocarditis? IVDU ■ Bug? Staph aureus ■ Valve? tricuspid ○ Prosthetic valve endocarditis ■ Bug? Staph epidermidis ○ Endocarditis after dental procedure? Viridans group streptococci ■ Strep viridans, Strep mitis, Strep mutans, Strep sanguineous ○ Patient with malar rash and echo showing vegetations on both sides of the mitral valve → Libman-Sacks endocarditis ○ Presentation? Fever + night sweats + new murmur ■ Splinter hemorrhages ■ Roth spots (retinal hemorrhages) ■ Painless Janeway lesions + painful Osler nodes (immune phenomenon) ○ Dx? ■ 1st step: blood cultures ■ TEE ○ Tx? Abx that include Staph aureus coverage (e.g. vancomycin) for WEEKS ○ Bugs implicated in culture negative endocarditis ■ HACEK ● H = haemophilus ● A = actinobacillus ● C = cardiobacterium ● E = eikenella ● K = kingella ■ Coxiella burnetii

DI Podcast Main Document 33 ○ Blood cultures in a patient with endocarditis reveal S. Bovis (or S. Gallolyticus bacteremia). NBS? Colonoscopy ○ Who needs antibiotic prophylaxis? ■ Hx endocarditis ■ Prosthetic valve ■ Unrepaired cyanotic congenital dz ■ Heart transplant with valve dysfunction

● Erythematous salmon colored patch with silvery scale on the elbows and knees. → psoriasis ○ Tx? Topical steroids ○ If this patient presents with joint pain (especially in the fingers)? Psoriatic arthritis ■ Imaging? Pencil-and-cup deformity ■ Tx? NSAIDs

● T of 104 + tachycardia + new onset Afib in a patient with a history of Graves disease. → thyroid storm ○ Lab findings? ■ TSH low ■ T3/T4 high ○ Tx? ■ 1st step: propranolol ■ 2nd step: PTU ■ Then: ● Prednisone ● Potassium iodide (Lugul’s solution) ○ Wolff-Chaikoff effect → large amounts of iodine inhibit thyroid hormone synthesis

● Biopsy revealing tennis racket shaped structures in cells of immune origin. → Langerhans cell histiocytosis ○ Electron microscopy? Birbeck granules (tennis rackets) ○ Marker? S100

● Small bowel obstruction in a HIV patient with purple macules on the face, arms, and lower extremities. → Kaposi’s sarcoma ○ Bug? HHV8 ○ Tx? HAART ○ Pathophys of vascular lesions? Overexpression of VEGF

● Fever + rash + eosinophiluria 10 days after a patient started an antistaphylococcal penicillin. → acute interstitial nephritis ○ Tx? STOP drug + steroids

● SLE ○ SOAP BRAIN MD ■ S = serositis DI Podcast Main Document 34 ■ O = oral ulcers ■ A = arthritis ■ P = photosensitivity ■ B = blood disorders (cytopenias) ■ R = renal ■ A = ANA/anti-dsDNA ■ I = immunologic ■ N = neurologic findings ■ M = malar rash ■ D = discoid rash ○ Type 2 vs 3 HSRs in lupus ■ Type 2 → cytopenias ■ Type 3 → all other manifestations ○ Lupus Ab? ■ ANA ■ anti-dsDNA ■ anti-Smith ○ Lupus nephritis → full house pattern on IF ○ Antiphospholipid antibody syndrome → recurrent pregnancy losses ■ Pathophys? Thrombosis of the uteroplacental arteries. ○ MC cause of death in lupus patients? ■ What I’ve read recently: CV disease ■ Per Divine: ● Treated → infection ● Untreated → renal dz ○ Also 40x risk MI ○ Endocarditis in lupus pt? Libman-Sacks endocarditis ○ Neonatal 3rd degree heart block → neonatal lupus ■ Maternal autoimmune dz? ● Sjogren’s ● SLE ■ Ab? ● anti-SSA/anti-Ro ● anti-SSB/anti-La ○ Tx? ■ Steroids ■ Cyclophosphamide ■ Hydroxychloroquine → good for skin lesions● Pulmonary abscesses ○ Bugs? ■ Staph ■ Anaerobes ■ Klebsiella ○ RF? ■ Alcoholism DI Podcast Main Document 35 ■ Elderly ■ Post-viral pneumonia ○ MC location of aspiration pneumonia? Superior segment of RLL

● Chest pain worsened by deep inspiration and relieved by sitting up in a patient with a recent MI or elevated creatinine or URI or RA/SLE. → pericarditis ○ EKG findings? Diffuse ST elevations + PR depression ○ PE finding? Friction rub (“scratchy sound on auscultation”) ○ A few days after MI → fibrinous pericarditis ○ Weeks after MI → Dressler’s ○ Tx? NSAIDS ■ Consider adding on colchicine

● Cardiac tamponade ○ Beck’s triad = hypotension + JVD + muffled heart sounds ○ EKG findings? Electrical alternans ○ Type of shock? Obstructive cardiogenic (Amboss) ■ CO low ■ SVR high ■ PCWP high ○ Tx? Pericardiocentesis

● Pearly lesion with telangiectasias on the ear in a farmer. → BCC ○ MC type skin cancer ○ Location? Upper lip ○ Dx? Biopsy ○ Tx? Mohs surgery

● Cold intolerance in a 35 yo white F → hypothyroidism ○ MC cause? Hashimoto’s ○ Histology? lymphoid follicles w/ active germinal centers ○ Lab findings? ■ TSH high ■ T3/T4 low ○ Ab? ■ anti-TPO ■ Anti-thyroglobulin ○ HLA? DR3/DR5 ○ Tx? Levothyroxine ○ Future complication? thyroid lymphoma

● Massive hematemesis in a patient with a history of chronic liver disease. → ruptured varices ○ Pathophys? L gastric vein has anastomosis with azygos veins. Increased portal pressure → backward flow from L gastric veins to azygous vein (which empties into SVC). ○ Acute tx? IVF + octreotide + ceftriaxone/cipro + EGD w/ ligation DI Podcast Main Document 36 ■ Do NOT give a beta blocker for acute tx ○ Ppx? Beta blocker + spironolactone ○ Other manifestations of elevated portal pressures ■ Caput medusa ■ Internal hemorrhoids ○ Tx for cirrhotic coagulopathies? FFP ■ If uremia → give desmopressin ● Note: Desmopressin = ADH analog → so, it can cause AE of hyponatremia 2/2 SIADH● Hemophilia A ○ Pathophys? deficiency of factor 8 ○ Inheritance? XLR ○ Coag labs? ■ Bleeding time normal ■ PTT HIGH ■ PT normal● Hemophilia B ○ Pathophys? deficiency of factor 9 ○ Inheritance? XLR ○ Coag labs? ■ Bleeding time normal ■ PTT HIGH ■ PT normal● Hemophilia C ○ Pathophys? deficiency of factor 11 ○ Inheritance? AR ○ Coag labs? ■ Bleeding time normal ■ PTT HIGH ■ PT normal● Bernard Soulier Syndrome ○ Pathophys? Deficiency of GpIb ○ Coag labs? ■ Bleeding time HIGH ■ PTT normal ■ PT normal● Glanzmann Thrombasthenia ○ Pathophys? Deficiency of GpIIbIIIa ○ Coag labs? ■ Bleeding time HIGH ■ PTT normal ■ PT normal● Von Willebrand’s disease ○ Pathophys? Deficiency of vWF ○ Inheritance? AD DI Podcast Main Document 37 ○ Coag labs? ■ Bleeding time HIGH ■ PTT HIGH ● vWF is a protecting group for factor 8 ■ PT normal● ITP ○ Pathophys? Ab against GpIIbIIIa ○ Classic pt? Pt with SLE ○ Tx? ■ Observation ■ Steroids ■ IVIG ■ Splenectomy● TTP ○ Pathophys? Deficiency in ADAMTS13 enzyme → cannot cleave vWF multimers → activation of platelets → thrombosis → thrombocytopenia ○ Presentation? microangiopathic hemolytic anemia + thrombocytopenia + renal failure + fever + neurologic problems ○ Tx? Plasma exchange transfusion ○● HUS ○ Bugs? Shigella or E. coli O157:H7 ○ Presentation? microangiopathic hemolytic anemia + thrombocytopenia + renal failure

● Platelet deficiency vs coagulation factor bleeds ○ Platelet deficiency → mucosal bleeds, petechiae, heavy menses ○ Coag factor deficiency bleeds → hemarthrosis

● Why do patients with CKD develop coagulopathy? Uremia → platelet dysfunction ○ Tx? Desmopressin ■ Note: Desmopressin = ADH analog → so, it can cause AE of hyponatremia 2/2 SIADH● Exercising caution with transfusion in patients with Bernard Soulier syndrome ○ Do NOT give transfusion that includes platelets ○ They can have an anaphylactic rxn to GpIb (since they don’t have GpIb)

● Oropharyngeal candidiasis. ○ RF? ■ HIV ■ Chronic ICS use ■ TNF inhibitor ○ Micro finding? Germ tubes at 37C ○ Tx oral candidiasis? Nystatin swish-and-swallow ○ Tx invasive candidiasis? Amphotericin B ■ Prevention of Amphotericin B toxicity? Liposomal formulation

DI Podcast Main Document 38 ● Pleural effusions ○ Light’s criteria (must meet all 3 to be considered transudative!) ■ LDH < 2/3 ULN ■ Pleural LDH/serum LDH < 0.6 ■ Pleural protein/serum protein < 0.5 ○ Causes of transudative effusion ■ CHF ■ Cirrhosis ■ Nephrotic syndrome ■ Note: Per UW 2021: Mechanism of transudate effusion? ● Decreased pulmonary artery oncotic pressure, e.g. hypoalbuminemia in nephrotic syndrome ● Increased pulmonary capillary hydrostatic pressure, e.g. volume overload in heart failure ○ Causes of exudative effusion ■ Malignancy ■ Parapneumonic effusion ■ Tb ■ Note: Per UW 2021: Mechanism of exudate effusion? Inflammatory increased in vascular permeability of membrane (increased flow of interstitial edema into pleural space) ○ Unique cause of both transudative & exudative effusions? PE ○ Classic PE findings? ■ Decreased breath sounds ■ Dullness to percussion ■ Decreased tactile fremitus ○ Tx? Chest tube● Chylothorax = lymph in the pleural space ○ Pathophys? Obstruction of thoracic duct or injury to the thoracic duct ○ Pleural fluid findings? High Triglycerides

● Holosystolic murmur heard best at the apex with radiation to the axilla in a patient with a recent MI. → mitral regurg 2/2 papillary muscle rupture ○ Dx? Echo ○ Why widely split S2? Aortic valve is closing earlier (LV is emptying into both aorta & LA) ○ Maneuvers that increase intensity ■ Increase preload (putting more blood in that can be regurgitated) ■ Increase afterload

● Decubitus ulcers ○ RF? ■ Elderly ■ Paraplegic ■ Fecal/urinary incontinence ■ Poor nutrition ○ Staging DI Podcast Main Document 39 ■ Stage 1 = non-blanchable erythema ● Tx? Repositioning q2hrs ■ Stage 2 = loss of epidermis + partial loss of dermis ● Tx? Occlusive dressing ■ Stage 3 = involves entire dermis, extending to subQ fat ● Does NOT extend past fascia ● Tx? Surgical debridement ■ Stage 4 = muscle/tendon/bose exposed ● Tx? Surgical debridement

○ General tx strategies? Repositioning + good nutritional support ○ Marjolin’s ulcer = non-healing wound that is actually squamous cell carcinoma

● T1DM ○ Pathophys? Autoimmune destruction of pancreas ○ Ab? ■ anti-GAD 65 (glutamic acid decarboxylase) ■ anti-IA2 (islet tyrosine phosphatase 2) ■ Islet cell autoantibodies ■ Insulin autoantibodies ○ Dx? ■ A1c > 6.5% (twice) ■ Fasting BG >= 126 (twice) ■ Oral glucose tolerance test >= 200 (twice) ■ Sxs of DM + random glucose > 200 ○ Tx? Long-acting insulin + mealtime insulin ■ Long-acting ● Glargine ● Detemir ■ Rapid-acting ● Lispro ● Aspart ● Glulisine ○ 3 HY complications ■ Nephropathy ■ Retinopathy & cataracts ■ Neuropathy ○ Chronic DM care ■ A1c q3 months ■ Foot exam annually ■ Eye exam annually ■ Microalbumin:Cr ratio annually ○ Nephroprotection in DM? ACE-I● GI bleed algorithm ○ 1st step: ABCs + 2 large-bore IVs + IVFs DI Podcast Main Document 40 ○ 2nd step: NG lavage ■ Clear fluid → go deeper ■ Blood → UGIB → upper endoscopy ■ Bilious fluid → have ruled out UGIB → proceed to colonoscopy ● See source → intervene as needed ● See nothing → ○ CT angiography for large bleed ○ Tagged RBC scan for smaller bleed

● Antiplatelet Pharmacology ○ Aspirin ■ Mechanism? Irreversibly inhibits COX-1 and COX-2 ○ Clopidogrel/ticlopidine = P2Y12 (ADP receptor) blockers ■ Mechanism? Inhibit platelet activation ○ Abciximab/eptifibatide/tirofiban = GpIIbIIIa receptor blockers ■ Mechanism? Inhibit platelet aggregation● Ristocetin cofactor assay ○ Issues with adhesion step → abnormal result ○ Abnormal ristocetin cofactor assays: ■ Von Willebrand disease ■ Bernard Soulier disease ○ Normal ristocetin cofactor assay: ■ Glanzmann Thrombasthenia● Von Willebrand disease effects on PTT? Increased ○ Pathophys? vWF is a protecting group for Factor 8.● Treatment of VWD? Desmopressin ○ Mechanism? Increases release of vWF from Weibel-Palade bodies of endothelial cells ○ Note: Desmopressin = ADH analog → so, it can cause AE of hyponatremia 2/2 SIADH

● HSV1 vs HSV2.

DI Podcast Main Document 41 ○ Oral herpes → HSV1 ○ Genital herpes → HSV2 ○ Dx? PCR (most up-to-date) ■ Tzanck smear (outdated, not very sensitive, nonspecific) → intranuclear inclusions ○ Brain area affected by HSV encephalitis? Temporal lobes ○ CSF findings in HSV encephalitis? RBCs ○ Tx herpes encephalitis? Acyclovir ■ AE? Crystal nephropathy

● Can’t see, can’t pee, can’t climb a tree. → reactive arthritis ○ HLA? B27 ○ Classic bug? Chlamydia ○ Tx? steroids ■ Need abx? Only if ongoing infection ● Can’t see, can’t pee, can’t hear a bee → Alport syndrome ○ Inheritance? X-linked dominant ○ ● Tx of NG & CT ○ NG → treat empirically for both → ceftriaxone + azithro/doxy ○ CT → azithro/doxy

Hypovolemic Septic Neurogenic Cardiogenic

CO low CO high CO low CO lowPCWP low PCWP normal PCWP highSVR high SVR low SVR low SVR high

Tx? norepi

● Tx anaphylactic shock? epinephrine

● Melanomas ○ ABCDE ■ A = asymmetry ■ B = irregular borders ■ C = color variation ■ D = diameter > 6 mm ■ E = evolving ○ Dx? Full-thickness biopsy ■ Excisional for small lesions ■ Punch for larger lesions ○ Most important prognostic factor → Breslow depth

● DM pharmacology DI Podcast Main Document 42 ○ Lactic acidosis → metformin ○ Decreases hepatic gluconeogenesis → metformin ○ Hold before CT w/ contrast → metformin ○ Weight gain → sulfonylureas & TZDs (-glitizones) ○ Diarrhea → acarbose & migliton ■ Inhibits disaccharidases (can’t reabsorb disaccharides) ○ Recurrent UTIs → SGLT-2 inhibitors ○ Weight loss → GLP-1 agonists (e.g. liraglutide, exenatide) & DPP4 inhibitors (-gliptins) ○ Contraindicated in pt with HF → TZDs ■ PPAR-gamma receptor found in kidney → water retention ○ Contraindication in pt with MTC → GLP-1 agonists ○ Biggest risk of hypoglycemia? Sulfonylureas

● RF esophageal adenocarcinoma ○ Barrett’s esophagus● RF esophageal squamous cell carcinoma ○ Smoking ○ Drinking ○ Achalasia● Location esophageal adenocarcinoma? Lower 1/3● Location esophageal squamous cell carcinoma? Upper 2/3● MC US? Adenocarcinoma● MC worldwide? Squamous cell carcinoma● Presentation? Dysphagia to solids → dysphagia to liquids● Dx? EGD● Staging? CT scan or esophageal US

● Factor V Leiden ○ Pathophys? Resistance to protein C ○ Dx? Activated Protein C resistance assay● Patient needs super large doses of heparin to record any changes in PTT → AT-III deficiency ○ Recall that heparin is a AT-III activator● 35 yo with a hypercoagulable disorder that does not correct with mixing studies. → antiphospholipid antibody disorder● Anaphylaxis in a patient with a long history of Hemophilia A → Ab against factor 8 that cause type 1 HSR with transfusion● Hx of hemophilia, diagnosed 5 years ago. Before you would give them factor 8 concentrate and PTT would normalize. Now they’re requirizing larger doses of factor 8 to normalize PTT. → inhibitor formation (antibodies against clotting factors)● Skin necrosis with Warfarin → protein C/S deficiency● Prothrombin G20210 mutation → overproduction of factor II

● Rash in dermatomal distribution → VZV infection ○ Contraindications to VZV vaccination? DI Podcast Main Document 43 ■ Pregnant woman ■ Kid < 1 year ■ Severe immunosuppression (e.g. HIV with CD4 < 200) ○ Tx? Acyclovir ■ If resistant, foscarnet ○ Tzanck smear findings? Intranuclear inclusions● Shingles vaccination guidelines? Adults over 60

● #1 cause of ESRD in the US → DM nephropathy ○ Histology? Kimmelsteil-Wilson nodules● #2 cause of ESRD in the US → hypertensive nephropathy● Pt with BP 240/150. How fast should you lower BP? 25% in first 24 hrs● Drugs for hypertensive emergencies? ○ Nicardipine ○ Clevidipine ○ Nitroprusside ■ AE? Cyanide poisoning ● Tx? Amyl nitrate + thiosulfate OR hydroxycobalamin ○ Labelol● Renal protective medications in patients with DKD or hypertensive nephropathy? ACE-I

● Anemia + Cranial Nerve deficits + Thick bones + Carbonic Anhydrase 2 deficiency + Increased TRAP + Increased Alkaline Phosphatase. → osteopetrosis ○ Pathophys? Carbonic anhydrase is defective → osteoclasts cannot produce acid to resorb bone ○ Tx? IFN-gamma ■ Osteoclasts are a specialized macrophage ■ IFN-gamma is an activator of macrophages

● Clinical diagnostic criteria for Chronic Bronchitis ○ Diagnostic criteria? ■ 2 years ■ 3 months/year of chronic cough ○ PFT findings ■ FEV1 low ■ FEV1/FVC ratio low ■ RV high ■ TLC high ○ Which PFT market can differentiate CB from emphysema? DLCO ■ DLCO normal → CB ■ DLCO low → emphysema ○ Tx acute exacerbation? Abx + bronchodilators + corticosteroids (“ABCs”) ○ Prevention? Stop smoking!

● Afib ○ #1 RF? Mitral stenosis DI Podcast Main Document 44 ■ #1 RF MS? Rheumatic fever ○ MC arrhythmia in hyperthyroidism → Afib ○ MC site of ectopic foci in Afib → pulmonary veins ○ EKG findings? “Irregularly irregular” + no P eaves ○ Location of emboli formation? LA appendage ○ Who should be cardioverted back to sinus rhythm? ■ New onset (<48 hrs) Afib ■ Anticoagulated for 3 weeks + TEE negative for clot ■ Afib that’s refractory to medical therapy ■ Afib & HDUS ○ Q on T phenomenon? Depolarization during T wave (repolarization) can cause QT prolongation → Torsades → death ■ Prevention? SYNCHRONIZED cardioversion ○ Tx? ■ Rate control ● Beta blockers ● ND-CCB (e.g. verapamil, diltiazem) ■ Rhythmic control ● Amiodarone ○ Reducing stroke risk in Afib? Anticoagulation for CHA2DS2VASc score >= 2 ○ Anticoagulation options ■ Valvular cause (e.g. MS) → warfarin ■ Any other cause → warfarin or NOAC ○ Reversal of AC ■ Warfarin → Vit K, four-factor PCC ■ Heparin → protamine sulfate ■ Dabigatran → idarucizumab

● Crusty, scaly, ulcerating lesion with heaped up borders → squamous cell carcinoma ○ Classic location? Lower lip ○ Precursor lesion? Actinic keratosis ○ What if it arises in a scar or chronic wound? Marjolin ulcer

DI Podcast Main Document 45 ● Hypothermia + hypercapnia + non pitting edema + hyponatremia + HR of 35 + hypotension in a patient with a history of papillary thyroid cancer → myxedema coma ○ Tx? Levothyroxine + steroids ○ Lab findings? ■ TSH high ■ T3/T4 low ■ LDL high

● Acute onset “dermatologic” breakout in a patient with a recent history of weight loss and epigastric pain. → Leser–Trélat sign associated with visceral malignancy ○ Lymph node associations ■ Supraclavicular → Virchow’s node ■ Periumbilical → Sister Mary Joseph ○ What are mets to the ovaries called? Kruckenberg tumor ○ Classic bug associated with gastric cancer? H. pylori (MALToma) ○ Classic histological finding in the diffuse type of gastric cancer? Signet ring cells

● RBCs without central pallor + elevated MCHC + anemia. → hereditary spherocytosis ○ Inheritance? AD ○ Pathophys? Deficiency of spectrin, ankyrin, or band 3.2 ○ Intravascular or extravascular hemolysis? Extravascular (RBCs bound by IgG, attacked by splenic macrophages) ○ Dx? ■ Osmotic fragility test ■ Eosin-5-maleimide ■ Acidified glycerol lysis test ○ Tx? Splenectomy ○ Post-splenectomy preventative care? ■ Strep pneumo ■ Hib vaccine ■ Neisseria

● Septic shock ○ Hemodynamic parameters ■ CO high ■ SVR low ■ PCWP normal ■ MvO2 high ○ Tx? IVF + norepi + broad-spectrum abx (cover MRSA + Pseudomonas) ■ E.g. vanc + pip-tazo ■ E.g. vanc + ceftriaxone ○ qSOFA criteria (need 1) ■ AMS ■ RR > 22 ■ SBP < 100 DI Podcast Main Document 46 ○ ● Acute kidney injuryPrerenal AKI Intrarenal AKI Postrenal AKI

● FeNA < 1% ● FeNA > 2% Variable ● BUN/Cr > 20 ● BUN/Cr < 20 Early → like prerenal ● Urinary Na < 20 ● Urinary Na > 40 Late → like intrarenal

● Cor Pulmonale ○ Pathophys? R heart failure from a pulmonary cause ● MC cause of right heart failure? L heart failure

● Papillary thyroid cancer ○ Histology? ■ Psammoma bodies ■ Orphan Annie eye nuclei ● Follicular thyroid cancer ○ Mode of spread? Hematogenous ● Medullary thyroid cancer ○ Tumor marker? Calcitonin ○ What accumulates in the thyroid? Amyloid ○ Histology? Apple green birefringence with congo red stain ○ Genetic disease associations? ■ MEN2A/B ● Mutation? RET ● Thyroid cancer with worst prognosis? anaplastic

● Diagnostic algorithm for suspected thyroid nodule/cancer ○ TSH ■ Very low → hot nodule (unlikely cancer) ● NBS? RAIU scan ○ Single hot nodule → toxic adenoma ○ Multiple hot spots → toxic multinodular goiter ○ Diffuse uptake → Grave’s ○ No uptake → exogenous thyroid hormone ■ Normal/high → cold nodule ● NBS? Thyroid US ○ Find something → FNA (can’t r/o follicular thyroid cancer!)

● Seizures after total thyroidectomy? Hypocalcemia 2/2 parathyroid gland removal

DI Podcast Main Document 47 -----------------------------------------------------------------------------------------------------------------------------

Ep. 31: Comprehensive Medicine Shelf Review. Session 3. ● Epigastric pain + Jaundice + Courvoisier’s sign + Conjugated hyperbilirubinemia in a long term smoker. → pancreatic cancer ○ Courvoisier’s sign = nontender palpable gallbladder + painless jaundice ○ Dx? CT abdomen ○ Tumor markers (pancreatic)? ■ CA19-9 ■ CEA ○ Migratory thrombophlebitis = eps of vessel inflammation due to blood clot (thrombophlebitis) that appear in different areas throughout the body ○ Relief of severe jaundice and pain in unresectable disease → ERCP to remove obstruction

● What is the one commonly tested vitamin that should be routinely replenished in patients with hemolytic anemia? Folate ○ Why? They are constantly undergoing RBC DNA synthesis

Nephritic Nephrotic

<3.5 g protein/24 hrs >3.5 g protein/24 hrs RBC casts Lipid casts HTN Hypoalbuminemia Anasarca

● Nephritic and nephrotic syndromes associations ○ Tram tracks → MPGN (membranoproliferative GN) ○ Subepithelial humps → PSGN ○ Kimmelstiel Wilson nodules → diabetic nephropathy ○ Subepithelial spike and dome → membranous nephropathy ○ Nephrotic Syndrome in a HIV+ patient → collapsing FSGS ○ Normal appearing glomeruli on light microscopy → minimal change ○ Apple Green Birefringence with Congo Red staining → amyloidosis

● 27 yo M was found down by his friend 13 hrs after they left a bar the night before. EKG is notable for peaked T waves. Creatinine is 4.5. → rhabdo ○ Pathophysiology? Rhabdo → K+ release from myocytes → hyperkalemia ○ Tx hyperkalemia? ■ 1st: calcium gluconate ■ Drive K+ inside cells ● insulin + glucose

DI Podcast Main Document 48 ● Albuterol ● Sodium bicarb ■ Reduce total body K+ ● Kayexalate ● Diuretic (e.g. loop or HCTZ)

● Life threatening sinusitis in a patient with a HbA1C of 9%. → mucormycosis ○ Bug? Mucor or rhizopus ○ Tx? Amphotericin B

● 25 yo F with a history of T1DM presents with a history of recurrent abscesses in the axillary and perineal region. → hidradenitis suppurativa ○ Pathophys? Inflammation of apocrine sweat glands

● MC cause of skin abscesses (bug)? Staph aureus ○ Tx? clinda

● Total and fT4 levels in pregnancy. ○ Total T4 increases ■ Why? thyroxine-binding globulin goes up ○ Free T4 normal● Best initial test in a diagnosis of hyperthyroidism? TSH● Graves disease ○ Pathophys? Autoantibodies against TSH receptor● RAIU results in Graves vs Toxic Adenoma vs Toxic Multinodular Goiter vs Surreptitious T4 intake. ○ Diffuse uptake → Graves ○ One spot → toxic adenoma ○ Multiple spots → toxic multinodular goiter ○ No uptake → exogenous T4 or Hash*toxicosis● Differentiating between surreptitious T4 use and other hyperthyroid states. ○ Hash*toxicosis → high thyroglobulin (thyroid hormone was produced by thyroid) ○ Exogenous T4 → low thyroglobulin ○ Thyroglobulin = C-peptide of thyroid● Antithyroid pharmacology ○ PTU & methimazole ■ Mechanism? Inhibit TPO

● Gradations in the neoplastic potential of colonic polyps ○ Villous > tubulovillous > tubular● Adenoma-Carcinoma sequence (AK-53) ○ APC → Kras → p53● Hyperpigmented macules on lip + GI tract hamartomas → Peutz-Jeghers syndrome ○ Associated malignancy? Colon, pancreatic, breast, gyn

● Sickle cell disease DI Podcast Main Document 49 ○ Pathophys? Mutated beta-globin ○ Mutation? Glu to val ○ Vaccines? Encapsulated organisms (SHiN) ■ Why? Sickle cell pts tend to auto-infarct spleen by age 5 ○ Osteomyelitis in a SS patient → Salmonella ○ Painless hematuria in a SS patient (or SS trait) → renal papillary necrosis ■ Other non-SS causes? Chronic NSAIDS ○ Aplastic crisis in a SS patient → parvovirus B19 ○ Classic peripheral smear findings ■ Sickle cells ■ Howell-Jolly bodies ● Why? Spleen normally removes nuclear material in RBCs ○ Tx? Hydroxyurea ■ Mechanism? Inhibits ribonucleotide reductase

● Worst headache of a patient’s life. PE is notable for palpable bilateral flank masses. → SAH in pt with ADPKD ○ Pathophys? Rupture of berry aneurysm ○ Mutation? PKD1/PKD2 ○ Associations ■ MVP ■ Berry aneurysm (circle of Willis) ● MC location? ACom ■ Liver cysts ■ Pancreatic cysts ○ Dx for SAH? Non-con head CT ■ If negative → LP (look for xanthochromia) ○ Prevention of post-SAH vasospam? nimodipine

CREST syndrome Diffuse scleroderma

C = calcinosis Ab? anti-Scl70, anti-topoisomerase R = Raynaud E = esophageal dysmotility S = sclerodactyly T = telangiectasias

Ab? anti-centromere

● Tx scleroderma renal crisis → ACE-I● Nephrogenic systemic sclerosis association? Gadolinium (MRI contrast)

● Sudden BP drop to 40/palpable in a patient who was recently placed on a ventilator with a PEEP of 15 cm H20. → tension pneumothorax ○ Tx? Thoracentesis (needle compression) 2nd intercostal space midclavicular line? DI Podcast Main Document 50 ● Basic ventilator strategies ○ Hypercarbia → increase ventilation → increase RR or tidal volume ○ Improving hypoxia → increase FiO2 or increase PEEP

● AV blocks ○ First degree/Mobitz 1 blocks generally require no treatment ■ Only treat if symptomatic ○ Mobitz 2/3rd degree blocks often require pacemaker placement. ○ In unstable patients with heart blocks, consider some sort of pacing.

● HY differences between cellulitis and erysipelas ○ Cellulitis ■ Involved layers? dermis + SQ fat ■ Bugs? Staph aureus + GAS ■ Tx? Clinda ○ Erysipelas

DI Podcast Main Document 51 ■ Involved layers? Superficial dermis + lymphatic vessels ■ Bug? GAS ■ Presentation? More acute + more fevers ■ Appearance? Well-circ*mscribed, elevated compared to surrounding skin

● G6PD deficiency ○ Pathophys? G6PD deficiency → problems with oxidative phase of the PPP → can’t produce NADPH ○ Classic triggers? ■ Stress ■ Infections ■ Fava beans ■ Drugs: primaquine, dapsone ○ Blood smear findings? ■ Heinz bodies ■ Bite cells ○ Dx? Assay for G6PD activity AFTER hemolytic episode has resolved ○ Inheritance? XLR

● Rash after getting amoxicillin for a URI in a 19 yo M with posterior cervical lymphadenopathy. → mononucleosis ○ Blood smear findings? Atypical lymphocytes (“Downey cells”) ○ Dx? Monospot test ■ What if its looks like mono but monospot is negative? CMV ○ Associated malignancies ■ Burkitt’s lymphoma t(8,14) ■ Primary CNS lymphoma ■ Nasopharyngeal carcinoma

● Heavy proteinuria + hyperlipidemia + hypoalbuminemia + EM revealing podocyte foot process effacement + normal glomeruli on LM. → minimal change disease ○ Malignancy associations? Hematologic malignancies

● Dry eyes + Dry mouth in a 40 yo F who delivered a child with congenital heart block. → Sjogren’s disease ○ Ab? ■ anti-SSA/anti-Ro ■ anti-SSB/anti-La ○ Bx findings? Lymphocytic infiltrate ○ Tx? Artificial tears + pilocarpine (muscarinic agonist)

● Panacinar emphysema + elevated LFTs in a 35 yo M. → alpha-1 antitrypsin deficiency ○ Pathophys? ■ Misfolded alpha-1 AT accumulates in hepatic cells. ■ Alpha-1 AT is a protease inhibitor, so lungs are more susceptible to proteases DI Podcast Main Document 52 ○ Inheritance? Autosomal codominant ■ PiZZ is worst● Liver bx finding? PAS-positive globules● Tx? Pooled alpha-1 antitrypsin● Prevention? NO SMOKING!

● Systolic crescendo-decrescendo murmur heard best at the right 2nd interspace with radiation to the carotids. → aortic stenosis ○ Pathophys? Calcification of the valve leaflets ○ Early onset? Bicuspid aortic valve ○ Prognostic indicators by severity? “ASH” (pt will become ashes) ■ Angina ■ Syncope ■ HF sxs - worst (death within 1 year) ○ Maneuvers that changes murmur intensity ■ Increase preload → murmur increases ■ Increase afterload → murmur decreases ○ Dx? Echo ○ Tx? Replace valve ○ Associated anemia? Shearing RBCs ■ Lab findings? ● LDH increased ● Haptoglobin decreased ● Indirect hyperbilirubinemia ○ Heyde’s syndrome = gastrointestinal bleeding from angiodysplasia in the setting of AS ■ Pathophy hypothesis? Calcified valve → cleavage of vWF multimers → issues with clotting

● Acne vulgaris ○ Pathophys? Inflammation of sebaceous glands ○ Bug? Propionibacterium acnes ○ Stepwise management ■ 1st: topical retinoids ■ 2nd: topical abx ■ 3rd: oral abx ■ 4th: isotretinoid (Vit A derivative) ● Pregnancy test before starting ● 2 forms of birth control ● AE? ○ Teratogen ○ Hepatotoxic ○ Skin dryness ○ Adjunct considerations in treatment? OCPs in woman ○ Treatment of acne in patients with PCOS? OCPs or spironolactone

DI Podcast Main Document 53 ● Congenital adrenal hyperplasia ○ 21-hydroxylase → virilization only ■ Female - virilization ■ Male - precocious puberty ○ 11-hydroxylase → HTN & virilization ○ 17-hydroxylase → HTN only ■ Hypokalemia ■ Only zona glomerulosa is working ○ Dx of 21-hydroxylase deficiency? Elevated 17-hydroxyprogesterone ○ Cosyntropin stimulation test → no rise in cortisol ○ Tx? Replace glucocorticoids & mineralocorticoids* (*if needed) ■ Don’t forget about stress dosing of steroids!

● Increased direct bilirubin + Increased urine bilirubin + decreased urine urobilinogen + elevated alkaline phosphatase → biliary obstruction ○ Increased urine bilirubin because D-bili is water soluble ○ Urobilinogen is decreased because GI flora convert D-bili to urobilinogen● Increased indirect bilirubin + No urine bilirubin + increased urine urobilinogen. → hemolysis ○ Urine bilirubin is NOT increased because I-bili in not water soluble ○ Urine urobilinogen increased because you are sending more bilirubin to the GI tract

● Common causes of direct and indirect hyperbilirubinemia. ○ Direct ■ Biliary atresia

DI Podcast Main Document 54 ■ Primary sclerosing cholangitis ● Pathophys? destruction of intrahepatic and extrahepatic bile ducts ● Association? Ulcerative colitis ● Marker? p-ANCA ● Imaging finding? Beads on a string ■ Primary biliary cholangitis ● Pathophys? Destruction of intrahepatic bile ducts ● Ab? Anti-mitochondrial ○ Indirect ■ Gilbert syndrome ■ Crigler-Najjar syndrome ■ Hemolysis

● High output heart failure in a patient with hemolytic anemia ○ Pathophys? Anemia → low O2 carrying capacity → have to increase CO to meet tissue O2 demand● Classic bone cause of high output heart failure? Paget’s disease ○ Pathophys? Hypervascular● Classic vascular cause of high output heart failure? AV fistula ○ E.g. from trauma ○ PE finding? Pulsatile mass

● Lyme disease. ○ Bug? Borrelia burgdorferi ■ Shape? spirochete ○ Vector? Ixodes tick ■ Other things carried? Babesia & Anaplasma ○ Classic skin presentation in early disease? Bullseye rash ○ Classic presentations in later stage disease ■ Arthritis ■ Bell’s palsy ■ Heart block ■ Meningitis ○ Dx? ELISA ■ Confirmatory test? Western blot ○ Tx? Doxy for > 8 yo ■ Pregnant → amoxicillin ■ Kid <8 yo → amoxicillin ○ Tx of Lyme-associated meningitis and heart block? Ceftriaxone

● Autoantibody associated with mixed connective tissue disease? anti-RNP (anti-U1-ribonucleoprotein)

● Chronic bronchiectasis + renal failure → secondary amyloidosis ○ Dx bronchiectasis? High-res CT scan ○ Common causes of bronchiectasis? DI Podcast Main Document 55 ■ CF ■ Kartagener’s syndrome (primary ciliary dyskinesia) ○ Obstructive or restrictive pattern on PFT? Obstructive ○ DDx bronchiectasis vs chronic bronchitis ■ Bronchiectasis = a/w chronic respiratory tract infections + chronic cough + daily copious mucopurulent sputum; sputum is foul-smelling ● Mechanism? Irreversible dilation and destruction of bronchi → results in chronic cough and inability to clear mucus ■ Chronic bronchitis = a/w cigarette smoking + white sputum ● Chronic productive cough for ≥ 3 months for 2 consecutive years

● Hypertensive urgency/emergency ○ BP cutoff? 180/120 ○ What defines hypertensive emergency? End-organ damage ○ Tx? ■ Nitroprusside ■ Labetalol ■ Clevidipine ■ Nicardipine ○ BP lowering goals? 25% in the first 24 hrs ○ Lactic acidosis and altered mental status in a patient on nitroprusside infusion → cyanide poisoning

● Painful, erythematous pretibial nodule. → erythema nodosum ○ Bug? coccidioides immitis ○ Autoimmune disease association? sarcoidosis

● Cushing’s syndrome ○ Pathophys? Overproduction of cortisol ○ Dx? ■ 1st step: confirm hypercortisolism ● 24-hr urinary cortisol ● Late night salivary cortisol (normally is low) ● Low-dose dexamethasone suppression test ■ 2nd step: check ACTH levels ● Low ACTH → adrenal adenoma ○ Overproduction by adrenal cortex → ACTH suppression ● High ACTH → Cushing’s disease, ectopic ACTH ■ 3rd step: high-dose dexamethasone test ● Suppression → pituitary lesion ● No suppression → ectopic ACTH (small cell lung cancer) ○ Interstitial infiltrates in a patient on long term steroids. → PCP pneumonia ○ Bone protection for pt on chronic steroids? Bisphosphonates ○ Small cell lung cancer paraneoplastic syndromes ■ SIADH DI Podcast Main Document 56 ■ LEMS ■ Ectopic ACTH

● Secretory vs Osmotic diarrhea ○ Secretory ■ Pathophys? Secreting electrolytes into GI tract and water follows ■ Examples: ● Cholera ● ETEC ● VIPoma ● Zollinger-Ellison syndrome ● Medullary thyroid cancer ○ Calcitonin increases electrolyte secretion in the GI tract ● Microscopic colitis ■ Stool osmotic gap < 50 ● Stool osmotic gap = 290 - 2(Na + K) ● Small gap means that electrolytes account for most of stool osmolality ○ Osmotic diarrhea ■ Pathophys? Something that is osmotically active (non-electrolyte) is in the GI tract and drawing in water ■ Examples? ● Lactose intolerance ● Celiac dz ● Osmotic laxatives (e.g. lactulose, PEG) ● Sugar alcohols (e.g., mannitol, sorbitol, xylitol) ● Alpha-glucosidase inhibitors (acarbose, miglitol) ■ Stool osmotic gap > 100 ● Stool osmotic gap = 290 - 2(Na + K) ● Large gap means that unmeasured non-electrolytes account for most of stool osmolality ○ Inflammatory diarrhea ■ Causes? ● UC ● Crohn’s ● Shigella ● EHEC ● Salmonella ● Campylobacter ● Entamoeba histolytica

● Reed Sternberg cells on lymph node biopsy → Hogkin’s lymphoma ○ Immune markers? CD15 & CD30 ○ What are the 4 types of this malignancy? ■ Lymphocyte predominant - best prognosis ■ Nodular sclerosing - MC type DI Podcast Main Document 57 ■ Mixed cellularity ■ Lymphocyte depleted - worst prognosis ○ What does an increased number of RS cells correlate with? Worse prognosis ○ Associated bug? EBV ○ Dx? LN biopsy ○ Staging? ■ 1 LN → stage 1 ■ >1 LN on same side of diaphragm → stage 2 ■ >1 LN on opposites side of diaphragm → stage 3

● Rheumatic fever ○ Diagnostic criteria ■ J = joints ■ O = heart ■ N = subcutaneous nodules ■ E = erythema marginatum ■ S = Sydeham’s chorea ○ Prevention? Abx for Strep pharyngitis ■ Abx do NOT prevent PSGN ○ Affect heart valve? “MAT” ■ MC = Mitral ■ 2nd MC = Aortic ■ 3rd MC = Tricuspid ○ Tx? penicillin/amoxicillin

● Membranous nephropathy ○ Associated bug? Hep B/C ○ Associated malignancy? hematologic ○ EM finding? Subepithelial spike-and-dome ○ Sudden onset severe flank pain in a patient with a history of membranous nephropathy → renal vein thrombosis ■ Pathophys? Loss of AT-III in urine → hypercoagulable state● Venous thrombosis sites ○ P. vera → hepatic vein thrombosis ○ Pt with pancreatitis → splenic vein thrombosis → gastric varices ○ Nephrotic syndrome → renal vein thrombosis

DI Podcast Main Document 58 Dermatomyositis Polymyositis

● Kids ● Adults ● CD4-mediated ● CD8-mediated damage ● Perimysial/perifascicular inflammation ● Endomysial inflammation

● Dermatomyositis and Polymyositis ○ Presentation? Proximal muscle weakness ○ Skin findings a/w dermatomyositis ■ Heliotrope rash ■ Gottron’s papules ■ Shawl sign ○ Associated malignancies? Lung cancer ○ Dx? ■ 1st step: check CK ● If CK elevated → MRI muscle ● If MRI equivocal → muscle biopsy & EMG ○ Ab? Not involved in diagnostic pathway ■ anti-Jo ■ anti-Mi 2 ■ anti-SRP ○ Tx? High-dose steroids

● Sarcoidosis. ○ Demographic? African American female ○ CXR findings? Bilateral hilar lymphadenopathy ○ Associations ■ Eye → anterior uveitis ■ Skin → erythema nodosum ○ Pattern of lung disease? Restrictive ○ Lab findings? ■ Elevated ACE DI Podcast Main Document 59 ■ Hypercalcemia ● Why? Macrophages produce 1-alpha-hydroxylase, which release in high calcitriol ○ Histology? Non-caseating granulomas ○ TB skin testing → false negative ○ Tx? Most people don’t require tx ■ Steroids if they need tx

● Systolic vs diastolic heart failure ○ Systolic HF ■ Reduced EF ■ Eccentric hypertrophy ■ Volume overload ○ Diastolic HF ■ Normal/high EF ■ Concentric hypertrophy ■ Pressure overload

● Heart failure ○ Signs from history? Dyspnea, orthopnea, PND ○ Dx? echo ○ Tx acute CHF exacerbation? LMNOP ■ L = Lasix (furosemide) ■ M = morphine ● Can dilates coronary vessels ■ N = nitrates ■ O = O2 ■ P = positioning ○ Drugs shown to improve survival in HF patients? ■ Beta blockers: carvedilol, bisoprolol, ER metoprolol ■ Spironolactone ■ ACE-I/ARB ■ BiDil (isosorbide dinitrate + hydralazine) ○ HY Inotropes ■ Digoxin (inhibits Na-K ATPase) ■ Milrinone (PDE-3 inhibitor)

● Targetoid skin lesions in a patient with Mycoplasma Pneumoniae (or HSV) → erythema multiforme ○ Classic drug association? ■ Beta-lactams ■ Sulfonamides ■ Phenytoin

Ectopic ACTH Cushing’s disease (anterior pituitary Iatrogenic Cushing’s overproducing ACTH) syndrome

DI Podcast Main Document 60 ● CRH low ● CRH low ● CRH low ● ACTH high ● ACTH high ● ACTH low ● Cortisol high ● Cortisol high ● Cortisol high

● Determining the cause of hypercortisolism with excessive ACTH secretion when the high dose dexamethasone suppression test is equivocal? Inferior petrosal sinus sampling ○ Elevated inferior petrosal ACTH → likely pituitary tumor● Tx of Cushing’s syndrome? Ketoconazole ○ Mechanism? Inhibits several enzymes in the steroid synthesis pathway

● Fever + RUQ pain radiating to shoulder → acute cholecystitis ○ Dx? US ■ If negative but high suspicion? HIDA scan ○ Tx? Antibiotics + cholecystectomy ■ Antibiotics ● Cipro + Metronidazole or ● MAG = metronidazole + amoxicillin + gentamicin

● Cholecystitis without stones in a very sick pt → acalculous cholecystitis ○ RF? ■ Prolonged ICU stay ■ Prolonged TPN ● GB isn’t contracting a lot ○ Tx? Percutaneous cholecystostomy ■ Do NOT do surgery!!

● Non-Hodgkin’s lymphoma ○ Follicular lymphoma ■ t(14, 18) ■ Pathophys? Overproduce BCL2 → reduced lymphocyte apoptosis ■ Biopsy findings? Lymphoid follicles ○ Burkitt’s Lymphoma ■ t(8,14) ■ Pathophys? C-myc overamplication ■ Biopsy findings? Starry sky pattern ■ Endemic presentation → jaw mass ■ Sporadic presentation → abdominal mass ○ Mantle cell lymphoma ■ t(11,14) ■ Pathophys? Overexpression of cyclin D1 → aberrant progression from G1 to S phase

● TB ○ TB induration guidelines

DI Podcast Main Document 61 ■ > 5 mm ● Immunosuppressed ● HIV+ ● TB exposure ■ > 10 mm ● Incarcerated ● Healthcare worker ■ > 15 mm ● Everyone ○ Dx? TST or IGRA ■ Positive skin test → CXR ● Nothing on CXR → latent TB ○ Tx active TB? ■ RIPE for 2 months ■ RI for 4 months ○ Tx latent TB? INH for 9 months ○ Vitamin supplementation? B6 ○ TB drug adverse effects ■ Red secretions + hepatotoxic → rifampin ■ Nephrotoxic + hepatotoxic → isoniazid ● Use “INH” as mnemonic ■ Sideroblastic anemia → isoniazid ■ Drug-induced Lupus → isoniazid ● Ab? Anti-histone ■ Ethambutol → color blindness ○ Where does TB love to reactivate? Upper lobes

● Bartter’s Syndrome ○ Location? Thick ascending limb of loop of Henle ○ Pathophys? Na-K-2Cl transporter defective (like taking a loop diuretic) ○ Inheritance? AR ○ Lab findings? ■ Hypocalcemia● Gitelman’s Syndrome ○ Location? DCT ○ Inheritance? AR ○ Pathophys? Na-Cl symporter is dysfunctional (like taking a thiazide diuretic) ○ Lab findings? ■ Hypercalcemia ○ Association? ■ CPPD

● Diastolic blowing murmur heard best at the left sternal border in the setting of a widened pulse pressure → aortic regurg ○ PE findings? DI Podcast Main Document 62 ■ Waterhamer pulse ■ Head bobbing● Wide pulse pressure in a kid → PDA● Next step in the management of the following scenarios ○ 2+ systolic murmur → nothing ○ 3+ systolic murmur → echo ○ symptomatic 1+ systolic murmur → echo ○ diastolic murmurs → echo

● General diagnostic strategy for cutaneous fungal infections → KOH prep● Tinea Versicolor ○ Bug? Malassezia furfur ○ Microscopy? Spaghetti & meatballs ○ Tx? Selenium sulfide topical● 3 common causes of dermatophyte infection ○ Trichophyton ○ Microsporum ○ Epidermophyton● Differences between the treatment strategies employed in tinea capitis vs tinea unguium vs tinea corporis ○ Tinea corporis → topicals ○ Tinea capitis / tinea unguium → oral (terbinafine or griseofulvin)● Painful red lesion under skin folds → intertrigo ○ Bug? Candida

● Beads on a string appearance with ERCP in a 30 yo M with a past history of chronic bloody diarrhea. → PSC in UC pt ○ Pathophys? Destruction or intrahepatic & extrahepatic bile ducts ○ Marker? p-ANCA ○ Tx? Liver transplant

● HY antineoplastic associations ○ Pulmonary fibrosis → methotrexate, bleomycin, busulfan ■ Which works in the G2 phase? bleomycin ■ Other drugs causing pulmonary fibrosis? Nitrofurantoin, amiodarone ○ Methotrexate toxicity rescue agent → leucovorin ○ Inhibits thymidylate synthase → 5-FU ■ Toxicity worsened by leucovorin ○ Toxicity with allopurinol/febuxostat→ 6-MP/Azathioprine ■ Why? Metabolized by xanthine oxidase ○ Antineoplastic for pediatric cancers → Actinomycin D ○ Irreversible dilated cardiomyopathy → Doxo/Daunorubicin ■ Prevention? Dexrazoxane (iron chelator) ○ Hemorrhagic cystitis→ cyclophosphamide ■ Metabolic? Acrolein DI Podcast Main Document 63 ■ Prevention? Mesna ○ Antineoplastic for brain cancer → nitrosoureas ○ Peripheral neuropathy → Vinca Alkaloids/Taxanes ○ Nephrotoxicity + ototoxicity → Cisplatin ■ Prevention of nephrotoxicity? Amifostine ○ Strongest association with n/v → Cisplatin ○ Inhibits ribonucleotide reductase → hydroxyurea ■ Indication? Sickle cell (increased HbF)

● Most common HIV treatment regimen? 2 NRTIs + protease inhibitor/integrase inhibitor● HY HIV drug side effects ○ Ritonavir → fat redistribution & CYP inhibition ○ Indinavir → nephrolithiasis ○ Other protease inhibitors → metabolic syndrome ○ Stavudine & didanosine → pancreatitis ○ AZT → bone marrow suppression ○ Abacavir → life-threatening HSR ■ Check which HLA? HLA B57 ○ NNRTIs like Efavirenz → teratogen & vivid dreams

● 55 yo M + hats don’t fit + mild deafness + high output heart failure → Paget’s disease ○ Lab findings? Elevated alk phos ○ Tx? Bisphosphates ○ Dx? Bone scan ○ Associated malignancy? Osteosarcoma ■ Genetic mutation that increases risk? Rb ■ Osteoporosis drug that increases risk? Teriparatide

● 50 yo F with a history of proximal shoulder pain + jaw pain with swallowing presents with a severe unilateral headache and eye pain. → temporal arteritis ○ NBS? Steroids ○ Dx? Temporal artery biopsy ■ AFTER giving steroids! ○ Classic demographic? Female > 50 ○ Lab findings? Elevated ESR

● Intense pruritus between the finger webs and toes in a patient with poor grooming and hygiene. → scabies ○ Tx? Permethrin ■ Lindane can cause seizures

● Type 1 diabetic with abdominal pain + ketones in urine → DKA ○ Presentation? ■ “DKA can cause Death Fast” ■ D = Delirium/altered mental status/psychosis DI Podcast Main Document 64 ■ K = Kussmaul respirations (rapid and deep breathing) ■ A = Abdominal pain/n/v ■ D = Dehydration ■ F= Fruity breath ○ Pathophys? Absolute insulin deficiency → can’t inhibit glucagon ○ Lab findings? ■ AG metabolic acidosis → low pH ■ Ketones in urine ○ Contrast K and Na balance ■ Low total body K+ (even if hyperkalemic) ■ Hyperosmolar hyponatremia ○ Tx? IVF + regular insulin infusion + potassium repletion ○ When do you stop an insulin infusion? Anion gap has closed ○ Discussion of the different kinds of insulin ■ Long acting = glargine + detemir ■ Intermediate acting = NPH ■ Rapid acting = regular ■ Ultra rapid acting = lispro + aspart + glulisine ○ Risk of reducing glucose too quickly? Cerebral edema

● Pruritus and RUQ pain in a 45 yo F with conjugated hyperbilirubinemia. → PBC ○ Pathophys? Destruction of intrahepatic bile ducts ○ Ab? Anti-mitochondrial ○ Tx? Ursodiol (improves survival) ■ Symptomatic tx of pruritus? Benadryl ○ Curative tx? Liver transplant

● “Moonshiner” with abdominal pain, cognitive deficits per family, and wrist drop → lead poisoning ○ Anemia associated with this disease? Sideroblastic ■ Pathophys? ALAD and ferrochelastase inhibition ○ Blood smear findings? ■ Ringed sideroblasts ■ Basophilic stippling ○ Dx? Lead level ○ Tx? ■ Lead level 45-69 → Succimer = DSMA ■ Lead level > 70 → EDTA or dimercaprol ○ Other RF? ■ Lives in old house ■ Drinks from foreign pottery

● Presentation of Shigella and EHEC diarrhea → bloody diarrhea ○ HUS triad = microangiopathic hemolytic anemia + thrombocytopenia + renal failure ○ Tx? Supportive ■ Do NOT give abx as this increases mortality! DI Podcast Main Document 65 ● Flank pain, palpable flank mass, hematuria, and polycythemia in a long term smoker → RCC ○ Associated hematologic phenomenon? Polycythemia 2/2 epo production ○ Potential testicular phenomenon? R-sided varicocele● Carpal Tunnel Syndrome ○ Affected nerve? Median nerve ○ Distribution? Radial 3.5 digits ○ RF? ■ Pregnancy ■ Hypothyroidism ■ RA ○ Pathophys? Compression of median nerve by flexor retinaculum ○ Dx testing prior to surgery? Nerve conduction study ○ Tx? ■ 1st step = wrist splint ■ 2nd step = corticosteroid injection ■ 3rd step = surgery ○ Provocative exam maneuvers ■ Tinnel’s sign = tapping on the wrist causes sxs ■ Phalen’s sign = wrist flexion for 1 min causes sxs

● Pulmonary embolism. ○ Virchow’s triad = stasis + hypercoaguability + endothelial injury ○ MC EKG anomaly? Sinus tachycardia ○ Classic EKG anomaly? S1Q3T3 ○ ABG findings ■ pH high (respiratory alkalosis 2/2 hyperventilation) ○ Dx? ■ Low risk pt → d-dimer ■ High risk pt → CTA ■ Pregnant pt → V/Q scan ○ Gold standard testing? Pulmonary angiography ○ Tx? ■ Stable → heparin ■ HDUS → tPA ■ HDUS with recent brain surgery → embolectomy ○ Anticoagulation review ■ Heparin ● Mechanism? Activates AT-III → inhibiting factor X and II ● Reversal? Protamine sulfate ■ Warfarin ● Mechanism? Inhibits Vit K epoxide reductase ● Reversal? Vit K + four-factor PCC ○ FFP if PCC is not an answer ■ Drop in platelets 5 days after starting heparin → STOP ALL heparin DI Podcast Main Document 66 ● Start direct thrombin inhibitor (e.g. dabigatran, argatroban) ● Dx? anti-PF4 (platelet factor 4) ○ Confirmatory test? Serotonin release assay● Pt with a big fracture that develops petechiae + respiratory distress → fat embolism syndrome

● Diagnosis based on EKG above? A-flutter ○ Classic EKG description? “Sawtooth” pattern ○ Acute Tx? ■ Stable → vagal maneuvers then adenosine ■ HDUS → synchronized cardioversion ○ Long-term Tx? ■ Beta blocker ■ ND-CCB

● 4 types of hypersensitivity reactions ○ Type 1 = IgE-mediated ■ Pathophys? Antigen → IgE cross-linking → mast cell degranulation ○ Type 2 = antibody mediated ■ Pathophys? Ab binds Ag → complement activation ■ Example? ● Grave’s disease ● Autoimmune hemolytic anemia ○ Type 3 = immune complex mediated ■ Example? ● PSGN ● Serum sickness ○ Type 4 = delayed ■ Example? ● TB skin testing

● Low urine osmolality + high serum osmolality in a patient with polyuria and polydipsia who recently started taking Li. → nephrogenic DI

DI Podcast Main Document 67 ○ Tx? ENaC blockers (e.g. amiloride, triamterene) ○ Other drug cause of nephrogenic DI? Demeclocycline ○ How is this disease differentiated from psychogenic polydipsia? ■ Psychogenic polydipsia has low serum osmolality

● CD10/19/20+ + History of Down’s Syndrome + Positivity for Terminal Deoxynucleotidyl Transferase + May present as an anterior mediastinal mass in a teenager (CD3/7+) → ALL ○ Good prognosis translocation? t(12,21) ○ Bad prognosis translocation? t(9,22)

● Watery or bloody diarrhea that lasts for a few days after consuming poultry/eggs or having exposure to turtles. → Salmonella enteritidis● High fevers in a 7 yo in a developing country + “Rose” spots on the abdomen. → Salmonella typhi● Salmonella antibiotic coverage strategies? FQ or macrolide

● 75 yo F presents with a 2 week history of neck pain and pain in her shoulders and hips bilaterally. ESR is markedly elevated. → polymyalgia rheumatica ○ How is this differentiated from fibromyalgia? Fibromyalgia has no lab abnormalities ○ Tx PMR? Low-dose steroids ○ Tx fibromyalgia? ■ TCAs ■ Duloxetine

● Recurrent pneumonia in the same anatomic distribution in a long term smoker. → lung cancer ○ RF? #1 is smoking ○ Dx central cancer? Endobronchial ultrasound ○ Dx peripheral cancer? VATS ○ Which lung cancer is NOT amenable to surgery? Small cell ○ Type by location ■ Central → small cell, squamous cell ■ Peripheral → adenocarcinoma, large cell ○ Edema of the face/arms + dilated veins on chest wall → SVC syndrome ○ Ptosis + miosis + anhidrosis → Pancoast tumor causing Horner’s syndrome. ■ Pathophys? Tumor involvement of the sympathetic chain ○ Testing before organ resection? FEV1 ■ Need to have enough pulmonary reserve to survive resection

DI Podcast Main Document 68 ● Diagnosis based on EKG above? Multifocal atrial tachycardia ○ Classic EKG findings? irregular rhythm with rate >100 bpm and at least 3 P wave morphologies ○ Classic “disease” and “electrolyte” associations ■ COPD ■ Hypokalemia ■ Hypomagnesemia ○ Tx? ND-CCB ○ Should propranolol be used in the treatment of this arrhythmia? NO (pt has reactive airway disease) ○ Should a patient with this arrhythmia be treated with electrical cardioversion or amiodarone? NO

● Skin lesion in the perineal region that shows up as a shiny papule with central umbilication in a patient with HIV. → molloscum contangiousum ○ Bug? Poxvirus ○ Tx? Salicylic acid ○ Transmission? contact

● Serum hypoosmolarity and urine hyperosmolarity in a patient on Carbamazepine. → SIADH ○ Common causes? ■ Drugs ● SSRIs ● Cyclophosphamide ● Chlorpropamide (1st gen sulfonylureas) ■ Small cell lung cancer ○ Tx? Fluid restriction ■ If resistant to fluid restriction? ● Demeclocycline ● ADH receptor antagonists (-vaptans) ○ When should hypertonic saline be administered? Seizures + Na < 120 ○ What happens when hyponatremia is corrected too quickly? Osmotic demyelination syndrome = central pontine myelinolysis

● Elevated serum markers in liver disease

DI Podcast Main Document 69 ○ hepatic pattern: AST/ALT ○ cholestatic pattern: alk phos● Which is more specific for liver disease (AST or ALT)? ALT● What is the classic AST/ALT ratio in alcoholic liver disease? >2:1● In addition to alkaline phosphatase, what is a unique marker for obstructive liver lesions? GGT● What is one HY serum marker that is somewhat unique to alcoholism? GGT

● Hemophilia A and B ○ Pathophys? Deficiency of factor 8 or 9 ○ Inheritance? XLR ○ Coagulation labs? ■ Normal bleeding time ■ Elevated PTT ■ Normal PT ○ Mixing studies? ■ PTT usually corrects with mixing study ■ If it doesn’t correct, inhibitor present ○ Tx? Factor concentrates ○ Contrast with lab findings in VWD ■ VWD will have elevated platelet time ○ Pattern of bleeding with platelet vs clotting factor deficiency. ■ Platelet issue → epistaxis, bleeding gums, heavy periods ■ Factor deficiency → hemarthrosis, muscle hematomas

● Rice water stools leading to circulatory collapse in a peace corps volunteer visiting some African or Asian country. ○ Bug? cholera ○ Diarrheal mechanism? Secretory diarrhea ○ Tx? Oral rehydration solution ■ Mechanism? Na-glucose symporter in GI tract● In general (rough approximation), what is the most accurate diagnostic test in gastroenteritis? Stool culture

● Renal mass in a patient with a history of cardiac rhabdomyomas and periventricular tubers. → angiomyolipoma in pt with tuberous sclerosis ○ Mutated proteins? Hamartin & tuberin

● Chondrocalcinosis observed on a knee XR in a patient with a genetic history of a C282Y mutation in the HFE gene. → CPPD in pt with hemochromatosis ○ Classic joint aspirate findings? Rhomboid-shaped, positively birefringent ■ Contrast with gout → needle-shaped, negatively birefringent ○ What is the renal disorder that has a strong association with this disease? Giletman syndrome ○ Tx? ■ 1st NSAIDs ■ 2nd steroids DI Podcast Main Document 70 ■ 3rd colchicine

● Fevers, dyspnea, and joint pain in a HIV+ patient that recently went on a cave expedition in Missouri. → Histoplasmosis ○ Bug? Histoplasma capsulatum ○ CXR findings? Interstitial infiltrates ○ Tx? ■ Milder → itraconazole ■ Disseminated → amphotericin B ○ Ppx? Itraconazole when CD4 < 150● Other prophylactic strategies in HIV+ patients. ○ Cocci → CD4 < 250 with itraconazole ○ PCP → CD4 < 20 with TMP-SMX, pentamidine, or atovaquone ○ Histo → CD4 < 150 with itraconazole ○ Toxo → CD < 100 with TMP-SMX ○ MAC → CD5 < 50 with azithro

● Diagnosis based on EKK above? V-fib ○ NBS? Defibrillation + high quality chest compressions ○ Meds? Epi + amiodarone● MC cause of death in the immediate period surrounding an MI? V fib● Should a person in PEA or asystole receive defibrillation? NO● Other rhythm that we should shock? Pulseless V tach

● 19 yo F presents with a large number of small, red macular lesions on the back arranged in a “Christmas tree” distribution. She had a similar but singular large lesion 1 week ago that cleared within a few days. → pityriasis rosea● 50 yo M presents with erectile dysfunction, gynecomastia, low libido, and loss of peripheral vision. → pituitary adenoma, like producing prolactin ○ Tx? Dopamine agonists (bromocriptine or cabergoline) ■ Surgery is NOT first-line● Other causes of hyperprolactinemia ○ Anti-psychotics (especially risperidone) DI Podcast Main Document 71 ○ Hypothyroidism ■ Pathophys? Lack of negative feedback → high TRH → TRH is a releasing factor for prolactin

● Ascites ○ Exam findings? ■ Shifting dullness at abdomen ○ SAAG gradient = serum albumin - ascites albumin ■ SAAG < 1.1 indicates absence of portal hypertension ● Etiologies: ○ Malignancy ○ Nephrotic syndrome ○ Pancreatitis (pancreatic ascites) ○ Tb ■ SAAG ≥ 1.1 indicates portal hypertension is present ● Etiologies: ○ Cirrhosis ○ Budd-Chiari ○ Right-sided HF (cardiac ascites) ■ Note: Per UW 2021 QID 4747, these are the correct answers ○ Tx? Paracentesis ■ Renal protection for large-volume paracentesis (ie > 5L of fluid drawn)? Give albumin

● Ascites with >250 neutrophils? SBP ○ NBS? Give abx (Ceftriaxone or FQ) ○ MC bug? E. coli ○ Ppx? FQ

● Tetanus ○ Pathophys? Tetanus toxic prevents release of GABA and glycine from Renshaw cells → spastic paralysis ○ Contrast with botulism, which will cause flaccid paralysis ○ Should a booster vaccination dose be given if the patient’s last booster was administered 12 years ago? YES - booster q10 years ○ Acute management of the tetanus? ■ NO abx ■ Tetanus immune globulin ■ Tetanus vaccine

DI Podcast Main Document 72 ● Recurrent pyelonephritis and nephrolithiasis in a patient with a low posterior hairline, breast underdevelopment, and a history of aortic coarctation. → Turner syndrome ○ Associations ■ Horseshoe kidney - stuck under IMA ■ Bicuspid aortic valve

● Pleural thickening on chest CT, recurrent hemorrhagic pleural effusions, weight loss, and severe dyspnea in a patient that spent 30 years working at a shipyard. → mesothelioma ○ Does smoking increase the risk of this malignancy? NO ○ Most common lung malignancy in this population? Bronchogenic carcinoma ■ Does smoking increase the risk of this common malignancy? YES

● Broad categorization and presentation of The Acute Coronary Syndromes. ○ Unstable angina ○ STEMI ○ NSTEMI

● HPV ○ Types ■ plantar warts → HPV 1,4 ■ genital warts → HPV 6,11 ■ cervical cancer → HPV 16, 18, 30s ○ Transmission? Direct contact ○ Tx? Liquid nitrogen ○ Gardasil covers? 6, 11, 16, 18

● What is true of total thyroid hormone and free thyroid hormone levels in the setting of OCP use? ○ Total → increase ○ Free → normal● Quick overview of thyroid physiology ○ Import iodine ○ Oxidize I- to I2 ○ Organification (iodide to tyrosine → MIT & DIT) ○ Coupling of MIT & DIT → T3 and T4● How can factitious hyperthyroidism be distinguished from the transient hyperthyroidism of Hashimoto’s thyroiditis (based on labs)? Thyroglobulin ○ High → Hash*toxicosis ○ Low → factitious hyperthyroidism

DI Podcast Main Document 73 ● Spontaneous bacterial peritonitis. ○ Bugs? ■ #1 = E. coli ■ Klebsiella ■ Strep pneumo ○ Dx? >250 PMNs on paracentesis ○ Tx? Ceftriaxone OR cipro ○ Ppx? FQ + albumin

● Microangiopathic hemolytic anemia + fever + thrombocytopenia + elevated creatinine + neurologic deficits. → TTP (thrombotic thrombocytopenic purpura) ○ Pathophys? ADAMTS13 deficiency ○ Tx? Plasma exchange

● Foul smelling diarrhea 1 week after treatment for a bacterial skin infection. → C. diff ○ Dx? Stool toxin assay ○ Tx? Oral vancomycin ■ Fidaxomicin ■ Fecal transplant ○ Prevention? Hand washing ○ A patient with the history described above deteriorates rapidly with severe abdominal pain and distension → toxic megacolon ■ NBS? surgery

● Can’t see + Can’t pee + Can’t hear a high C. → Alport syndrome ○ Pathophys? Defect in type 4 collagen ○ Mutated gene? COL4A5● Small cell lung cancer ○ Paraneoplastic syndrome? DI Podcast Main Document 74 ■ SIADH ■ LEMS ■ ACTH ○ Tx? Chemo ■ NOT surgical candidates● Squamous cell lung cancer ○ Paraneoplastic syndrome? ■ PTHrP● What are the 2 peripherally presenting lung malignancies? ○ Adenocarcinoma ○ Large cell● MC lung cancer in smokers? Squamous cell● Most likely lung ca in a 60 yo F with no history of smoking → adenocarcinoma● Pt with hx smoking starts to have joint pain & finger clubbing → hypertrophic osteoarthropathy (paraneoplastic syndrome associated with lung cancer)

● CP with exercise → stable angina ○ Dx? Stress test ○ Management? ■ Nitrates - decrease preload & myocardial O2 demand

● Kayser-Fleischer rings in the cornea + Parkinsonian symptoms + Liver dysfunction + Decreased serum ceruloplasmin. → Wilson’s disease ○ Inheritance? AR ○ Chromosome? 13 ○ Mutated gene? ATP7B ○ Tx? Penicillamine or triamterene

● Thrombocytopenia after heparin → HIT ○ Dx? anti-PF4 antibodies ○ Confirmatory test? Serotonin release assay ○ Tx? STOP heparin + give direct thrombin inhibitor ○ Is HIT a pro or an antithrombotic state? Prothrombotic

● Osteomyelitis ○ MC cause of osteomyelitis → Staph aureus ○ Osteomyelitis in a sickle cell patient → Salmonella ○ Osteomyelitis with recent history of a cat or dog bite → Pasteurella ○ Dx? MRI ○ Tx? Prolonged tx, often requires abx ■ How to determine abx sensitivity? Bone culture ○● Bonus! Is osteomyelitis in diabetics monomicrobial or polymicrobial? Polymicrobial ○ Note: Osteomyelitis = deep infection → deep foot wounds in diabetics are polymicrobial!

DI Podcast Main Document 75 ○ Note: In contrast, superficial foot wounds in diabetics are monomicrobial

● Bonus! Mechanism of spread of osteomyelitis in adults? Contiguous spread!

● Bonus! Mechanism of spread of osteomyelitis in children? Hematogenous

● Sinusitis (e.g. nasal polyps, saddle nose deformity) + hemoptysis + hematuria → Granulomatosis with polyangiitis (Wegener’s) ○ Marker? c-ANCA ○ Tx? Steroids + cyclophosphamide

● Nerve Lesions ○ Surgical neck fracture of the humerus OR anterior shoulder dislocation → axillary nerve ■ Muscle? deltoid ○ Humeral midshaft fracture with wrist drop and loss of dorsal hand sensation → radial nerve ○ Medial humeral epicondylar fracture with failed finger spread + failed MCP joint flexion and IP joint extension for digits 4-5 → ulnar nerve ■ Muscles? Dorsal interossei + lumbricals

● Stress test ○ Who should get a pharmacological stress test? Can’t exercise ○ Who should not get stress tests that involve EKG? Hx abnormal EKG ○ 2 pharmacological stress test methods ■ Dobutamine ■ Dipyridamole (coronary steal principle) ■ Regadenoson ○ Gold standard for CAD diagnosis → coronary angiogram (cardiac cath) ○ Principle behind stress echocardiograms? Looking for wall motion anomalies ○ Drugs to be held before stress testing? Beta blocker or ND-CCB

● Hypocalcemia + Elevated PTH + Hyperphosphatemia + Short Stature + Short 4th and 5th metacarpals + Mental retardation. → Albright hereditary osteodystrophy (pseudohypoparathyroidism) ○ Pathophys? symptoms of hypoparathyroidism despite normal or elevated PTH levels due to end-organ resistance to PTH ○ Gene? GNAS1 ○ Tx? Vit D + calcium

● Hepatitis virus matching game ○ Fecal oral transmission → Hep A & Hep E ○ Depends on Hep B for transmission → Hep D ○ Virulent in pregnancy → Hep E ○ Highest risk of a chronic carrier state → Hep C ○ Transmitted by blood → Hep B & Hep C & Hep D ○ Associated with chronic disease → Hep B & Hep C

DI Podcast Main Document 76 ● Hep B serologies ○ General rules ■ Core Ab → exposure to virus (“scar”) ■ Surface Ag → currently infected ■ Surface Ab → has immunity (vaccine-mediated or natural) ○ Scenarios: ■ Immunized: +surface Ab ■ Prior infection (recovered): +surface Ab, +core Ab IgG ■ Acute infection: +surface Ag, +core Ab IgM, +eAg (high infectivity) ■ Chronic infection: +surface Ag, +core Ab IgG ■ Window period: +core Ab ● Surface Ag is disappearing and surface Ab is appearing ○ Definition of chronic infection? Hep B surface Ag for > 6 months

● Recent viral infection or history of lupus + Isolated Thrombocytopenia. → ITP ○ Pathophys? Autoantibodies to GpIIbIIIa ○ Tx? ■ 1st line Steroids + IVIG ■ 2nd line spelectony ○ Should platelet transfusion ever be considered in these patients? NO ○ Drug that “replicates” the pathophysiology of the diagnosis? ■ Abciximab, eptifibatide, tirofiban ○ Deficiency that replicates the pathophysiology of the diagnosis? Glanzmann thrombasthenia ■ Ristocetin cofactor assay? normal

● 19 yo sexually active F with migratory arthritis + purpuric lesions on the lower extremities bilaterally. → disseminated gonococcal infection ○ Tx? Ceftriaxone + azithro/doxy

● Hyponatremia ○ Hyperosmolar hyponatremia ■ Pathophys? Some other osmole present ■ Causes? ● Hyperglycemia ○ Iso-osmolar hyponatremia ■ Causes? (lab error) ● Hypertriglyceridemia ● Hyperproteinemia ○ Hypoosmolar hyponatremia ■ Hypervolemic ● Causes? ○ CHF ○ Cirrhosis ○ Nephrotic syndrome ■ Euvolemic DI Podcast Main Document 77 ● SIADH ● Hyporthyroidism ● Psychogenic polydipsia ● Tea & toast/beer potomania ○ Pathophys? Low solute intake ■ Hypovolemic ● Intrarenal (urine Na > 10) ○ Diuretics ○ Barter’s/Gitelman’s ● Extrarenal ( ○ Dehydration 2/2 vomiting/diarrhea ○ Burns ○ Lab differentiation between intrarenal and extrarenal causes of hypovolemic hypoosmolar hyponatremia? ■ Urine Na > 10 → intrarenal ■ Urine Na < 10 → extrarenal ○ Distinguishing between SIADH and psychogenic polydipsia ■ Dilute urine (Uosm < 100) → psychogenic polydipsia ■ Concentrated urine (Uosm > 100) → SIADH ○ Risk of rapid Na+ correction? osmotic demyelination syndrome ○ Indications for hypertonic saline? Seizures AND Na < 120 ○ Correcting Na+ for hyperglycemia? Add 1.6 for every 100 glucose over 100 ■ Correction factor = 1.6 x (glucose - 100)/100

● Bamboo spine on XR + Stiffness relieved with exercise + HLA-B27 positive + 25 yo guy + Sacroiliitis + Anterior Uveitis. → ankylosing spondylitis ○ Tx? NSAIDs ■ 2nd line TNF inhibitor or methotrexate

DI Podcast Main Document 78 ● Central vs Obstructive Sleep Apnea ○ Central pathophys? Decreased respiratory drive ○ OSA pathophys? Blockage of upper airway ○ OSA RF? ■ Obesity ■ Large tonsils ○ Dx? Polysomnography ○ Tx? ■ OSA → CPAP + weight loss ■ CSA → acetazolamide ○ Surgical tx? uvulopalatopharyngoplasty ○ Complications/consequences ■ Pulmonary HTN ■ Hypoxia → Elevated Epo → Polycythemia● Obesity hypoventilation syndrome ○ Lab findings? ■ Elevated CO2 on ABG

● Athlete collapses suddenly on the field. → HOCM ○ Inheritance? AD ○ Mutations? Sarcomere proteins ■ beta myosin heavy chain ■ myosin binding protein C ○ Classic murmur presentation? Systolic crescendo-decrescendo murmur heard at LSB ■ What other murmur is heard here? AR ○ Maneuvers that increase and decrease murmur intensity ■ Anything that increases blood in LV → decrease intensity ● Increase preload ● Increase afterload ○ Tx? ■ Medical? Beta blocker to increase filling in diastole ■ Surgical? Septal myectomy ○ Associated GAA repeat AR disorder? Friedrich’s ataxia

● A 35 yo business man returns to the US from a trip to Mexico. He has felt unwell for the past 2 weeks with a primary presentation of flu like symptoms. Scleral icterus is observed on exam. AST/ALT is approximately 5K each. IgM antibodies specific to a single stranded picornavirus are detected in his serum. → Hep A ○ Tx? Supportive care

● Heavy menstrual bleeding + Normal PT + Elevated PTT + Increased bleeding time → Von Willebrand disease ○ Inheritance? AD ○ Pathophys? vWF deficiency ○ Why does PPT increase? vWF is a protecting group for factor 8 DI Podcast Main Document 79 ○ Ristocetin cofactor assay? Abnormal ○ Tx? Desmopressin ■ Mechanism? Increases release of vWF for Weibel-Palade bodies

● 25 yo F who went hiking in Oklahoma presents with a 6 day history of high fevers, headache, and myalgias. Has a rash that started on the extremities and spread inwards. Now has involvement of the palms and soles. CBC notable for low platelets. → Rocky mountain spotted fever ○ Bug? Rickettsia rickettsii ○ Tx? Doxy ■ Kids < 8 → doxy ■ Pregnancy → chloramphenicol ○ Disease with rash on palms/soles ■ Kawasaki ■ Coxsackie B ■ Rickettsia ■ Syphilis

● Acute onset exquisite pain/tenderness at the first MTP. → gout ○ Joint aspiration findings? Needle-shaped negatively bifrefringement crystals ○ Acute Tx? ■ 1st NSAID ● NOT aspirin (decreases excretion of uric acid) ■ 2nd Steroid ■ 3rd Colchicine ■ Do not start allopurinol, but continue it if they’re already on it ○ Chronic tx? ■ Xanthine oxidase inhibitors ● Allopurinol ● Febuxostat ■ Probenecid (increases uric acid excretion) ■ Converts uric acid to water-soluble allantoin ● Rasburicase ● Pegloticase ○ Tumor lysis syndrome ■ Prevention? Allopurinol ○ Drugs that increase azathioprine toxicity? Xanthine oxidase inhibitors

● 23 yo M smoker presents with a 6 month of history of mild dyspnea and productive cough. CT reveals cystonodular opacities in the upper and middle lung zones. A lung biopsy of one of the lesions is consistent with tennis shaped intracellular organelles. → Langerhans histiocytosis ○ EM findings? Birbeck granules

● Diastolic dysfunction in a patient with a history of sarcoidosis, amyloidosis, or hemochromatosis. → restrictive cardiomyopathy ○ Pathophys? Infiltration of cardiac muscle with various substances DI Podcast Main Document 80 ○ Dx? echo ■ Cardiac MRI ■ Endomyocardial biopsy

● A high school student shadowing at a local hospital is mistakenly stuck by a needle from a patient who is known to have chronic Hep B infection. Testing 2 weeks ago revealed that the student was negative for all Hep B markers. ○ NBS? Give Hep B vaccine + immune globulin ○ If pt has been vaccinated? Don’t need to do anything ○ Tx chronic Hep B infection? BELT ■ B = Hep B ■ E = emtricitabine ■ L = lamivudine ■ T = tenofovir

● Septic patient begins to bleed from IV Venipuncture sites. CBC is notable for elevations in PT and PTT. Fibrinogen levels and platelet count are low. A blood smear is positive for schistocytes. → DIC ○ Associated malignancy? APML ■ Histology? Aeur rods ■ Translocation? t(15,17)

● 21 yo presents with a 1 week history of fevers, fatigue, myalgias, and hemoglobinuria. She recently went hiking on a trail in Long Island, NY. Blood smear stained with Giemsa reveals “Maltese cross” shaped organisms within RBCs. → Babesia ○ Bug? Babesia microti ○ Vector? Ixodes tick ○ Tx? Atovaquone

● Differentiating between muscle strain, lumbar spinal stenosis, degenerative disk disease, and cauda equina syndrome (unique features of each) ○ Paraspinal tenderness → muscle strain ○ Pain better when leaning over → spinal stenosis ○ Sciatica + positive SLR → degenerative disk disease ○ Loss of bowel/bladder fxn + saddle anesthesia + progressive neurologic deficits → cauda equina● 65 yo M with no past history of smoking presents with a 6 mo history of dyspnea on exertion and fatigue. Lung auscultation reveals fine crackles. DLCO is markedly decreased. → idiopathic pulmonary fibrosis ○ Key PE finding? Fine crackles ○ Dx? high-CT chest ○ Imaging finding? honeycombing

● Kind of “dysfunction” associated with dilated cardiomyopathy. → systolic ○ Common causes of DCM ■ Coxsackie B ■ Chagas ■ Anthracyclines DI Podcast Main Document 81 ■ Trastuzumab ■ Alcohol (wet beriberi) ■ Postpartum cardiomyopathy ○ Extra heart sound associated with DCM? S3 ○ What is the bug that causes DCM, achalasia, and megacolonosis? T. cruzii ○ Dx? Echo ○ Tx? “BAD” ■ B = beta blocker ■ A = ACE-I ■ D = diuretics

● Palpable purpura on the skin + Hypocomplementemia + Monoclonal IgM expansion in the serum + History of Hep C infection. → mixed cryoglobulinemia ○ Dx? PCR ○ Risk chronic hepatitis? Hep C > Hep B ○ Tx Hep C? ■ ledipasvir/sofosbuvir (Harvoni) ■ Pegylated interferon-alpha ● Screen for what? depression ■ Ribavirin ○ MC cause of hepatocellular carcinoma in US? Hep C ○ Derm manifestation? Porphyria cutanea tarda ■ Pathophys? UROD

● Patient is rushed to the ED by ambulance from a restaurant after complaining of worsening respiratory difficulty and developing a diffuse rash. BP is 60/palpable. → anaphylaxis ○ NBS? IM Epinephrine ○ Type HSR? 1 ○ Pathophys? IgE crosslinking → mast cell degranulation ○ Mediating chemokine? histamine

● Prerenal AKI ○ Pathophys? Hypovolemia → hypoperfusion of kidney → decrease GFR ○ Lab findings? ■ FeNa < 1% ■ Urinary Na < 20

● Tx hypovolemic hypernatremia? NS until euvolemic then correct free water deficit● Tx hypovolemic hyponatremia? NS● Tx hypervolemic/euvolemic hyponatremia → fluid restriction

● Drug of choice in the management of hypercalcemia of malignancy? bisphosphonates● Bone met ○ Lytic ■ Multiple myeloma DI Podcast Main Document 82 ■ Lung ■ Thyroid ■ Kidney/RCC ■ Breast ○ Blastic ■ #1 prostate ■ Breast ○ Dx? Bone scan ○ Presentation? Point tenderness over spinous process

● Bilateral patchy infiltrates in a patient with a history of chronic treatment for symptomatic VTach. → amiodarone toxicity ○ Common drug causes of pulmonary fibrosis ■ Bleomycin ■ Busulfan ■ MTX ■ Nitrofurantoin ■ Amiodarone

● Classic bug cause of hypersensitivity pneumonitis in a patient that works in a barn. → thermophilic actinomyces

● Fevers + respiratory difficulty + negative sputum cultures + bilateral micronodular consolidations on CXR in a patient with a long history of rheumatoid arthritis. → bronchiolitis obliterans organizing pneumonia ○ Tx? steroids

● What is the most important modifiable risk factor for atherosclerosis related heart disease? smoking● Vitamin deficiencies associated with hyperhom*ocysteinemia ○ B12 ○ B9/Folate ○ B6● The 3 MEN syndromes ○ Inheritance? AD ○ Gene ■ MEN1 → MEN (menin protein) ■ MEN2 → RET ○ MEN 1 = “para pan pit” ■ Pituitary adenomas ■ Parathyroid hyperplasia ■ Pancreatic neuroendocrine tumors ● MC? Gastrinoma → Z-E syndrome ○ MEN2A ■ Parathyroid hyperplasia ■ MTC ■ Pheo DI Podcast Main Document 83 ○ MEN2B ■ Marfanoid habitus ● Ddx? Marfan’s, hyperhom*ocysteinemia ■ Mucosal neuromas ■ MTC ■ Pheo ○ Screening for family members? ■ MEN1 → no ■ MEN2 → YES ○ Prevention of MTC? Thyroidectomy ■ 100% rick of MTC in MEN2 ○ Tumor marker MTC? Calcitonin

● Esophageal varices ○ Ppx? Beta-blocker + spironolactone ● Tx of hepatic encephalopathy ○ Lactulose ■ Mechanism? ● Prevents NH3 reabsorption in the gut ● Lactulose metabolized by GI flora to lactic acid. Acidic environment favors NH4+, which is trapped in the colon and pooped out. ○ Rifaximin ■ Mechanism? Kills bugs that make ammonia ● What procedure increases the risk of hepatic encephalopathy? TIPS ● Spider angiomata association? Hyperestrogenism

● Pruritus after hot shower → polycythemia vera ○ Mutation? JAK2 ○ Lab findings? ■ EPO low ■ Hct high ■ O2 saturation normal ○ Differentiating PV from paraneoplastic EPO secretion ■ PV → low EPO ■ Paraneoplastic → high EPO ○ Complications ■ Budd Chiari syndrome = hepatic vein thrombosis ■ Gout ○ Tx? Phlebotomy until Hct < 45% + aspirin ■ For high-risk pts (age > 60, previous thrombosis): hydroxyurea

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DI Podcast Main Document 84 Ep. 32: Comprehensive Medicine Shelf Review Session 4 ● Fever + absolute neutrophil count < 1500 + chronic tx for Graves disease. Dx? Agranulocytosis 2/2 PTU or methimazole ○ Tx? STOP the drug ○ Tx for neutropenic fever? Broad-spectrum abx ■ Pip-tazo ■ Carbapenem ○ Drug a/w agranulocytosis? ■ PTU/methimazole ■ Clozapine (anti-psychotic) ■ Carbamazepine (anti-epileptic) ■ Chloramphenicol

● What 2 “big-picture” mechanisms result in hypokalemia? ○ Anything that makes you volume-down →which causes RAAS activation ○ Anything that causes afferent arteriole hypoperfusion (e.g. NSAIDs which cause afferent a. vasoconstriction)

● Which 2 RTA’s cause hypokalemia? ○ Type I RTA = defect in acid/H+ secretion at DCT ■ DCT unable to secrete H+ → therefore, H+/K+ antiporter at DCT cannot run → so, H+ builds up inside DCT cells while K+ remains in lumen → hypokalemia ○ Type II RTA = defect in bicarb reabsorption at PCT ■ 2 mechanisms ■ 1. PCT unable to reabsorb HCO3- → so, HCO3-/Na+ co-transporter at PCT cannot run → cannot take up Na+ or water → excess loss of Na+ and water from PCT to the tubular lumen → activation of RAAS ­→ ↑ALDO → Na+ and water are reabsorbed more distally in nephron while K+ is secreted ■ 2. Excess HCO3- in lumen combines with K+ in lumen ­→ so, even less K+ is available to be taken up by nephron!

DI Podcast Main Document 85 ● Which RTA causes hyperkalemia? Type IV RTA (hypoaldosteronism → K+ builds up → hyperkalemia)

● Hypokalemia + metabolic alkalosis + unrelenting HTN (refractory to tx) → Primary Hyperaldosteronism aka Conn syndrome ○ Pathophys? Aldosterone-secreting adrenal adenoma ■ HTN is 2/2 reabsorption of Na+ and water ■ Metabolic alkalosis is 2/2 aldosterone causing upregulation of H+-ATPase ○ What candy mimics Primary Hyperaldosteronism? Licorice (i.e. glycyrrhizic acid) ■ Mechanism? Inhibits 11-betaHSD-2 → so, cortisol cannot be inactivated into cortisone → excess cortisol acts like aldosterone → hypokalemia + metabolic acidosis

● Most diuretics cause hypokalemia + metabolic [blank]? hypokalemia + metabolic alkalosis…

● …However, which diuretic causes hypokalemia + metabolic acidosis? Acetazolamide ○ MOA? CAI (carbonic anhydrase inhibitor) → results in bicarb being dumped into urine

● Genetic renal etiologies of hypokalemia? ■ Barter’s syndrome – AR inheritance ■ Gitelman’s syndrome – AR inheritance ■ Liddle’s syndrome ■ Pathophys? Activating mutation in ENaC ■ Inheritance? AD

● EKG findings in hypokalemia? flat T-waves + U-waves

● 3 electrolyte imbalances that cause QT prolongation? Hypo[electrolyte]! ○ Hypokalemia

DI Podcast Main Document 86 ○ Hypocalcemia ○ Hypomagnesemia

● Tx for Torsade de Pointes? IV Mag

● NBSIM for hypokalemia refractory to K+ repletion? Replete magnesium!

Best route to replete K+? Oral

● 45 yo M lifting boxes + sudden-onset radicular pain. Straight leg raise is +ve. Achilles reflex cannot be elicited. → herniated disk ○ Most likely affected nerve root? S1 ○ Level of herniation? L5-S1 ○ Pathophys? Herniation of nucleus pulposus → nerve root compression ○ Tx? Physical Therapy + NSAIDs ■ Bedrest and surgery not recommended

● HY Nerve Roots and associated reflex ○ C5 = triceps reflex ○ C6 = brachioradialis reflex ○ C7 = triceps reflex ○ L4 = patellar reflex ○ S1 = Achilles reflex

● Pulmonary Arterial Hypertension ○ Dx? Right-heart catheterization ■ PA pressure cutoff? PA pressure > 25 mmHg ○ Classic heart sound? Loud S2 ○ Gene mutation? BMPR2 ○ MCC of PAH? COPD (older adults) ■ Pathophys? Hypoxic vasoconstriction → clamping of pulmonary vessels

DI Podcast Main Document 87 ● Demographic for idiopathic PAH? Young female ○ Tx of idiopathic PAH ■ Endothelin antagonists “—sentan” (e.g. bosentan, ambrisentan, atrasentan) ■ PDE-5 inhibitors (e.g. sildenafil) ■ Prostacyclin analogs (e.g. iloprostol, epoprostenol)

● Lipid Screening Guidelines for CVD (i.e. dyslipidemia screening guidelines) ○ High-risk individuals → 20 yo ○ Males → 35 yo ○ Females → 45 yo

● What 4 groups of patients get statins? ○ LDL > 190 ○ Existing ASCVD disease (i.e. MI, stroke, PAD) ○ 40-75 yo + ASCVD risk > 7.5% ○ 40-75 yo + DM

● Lipid-lowering drugs ○ Drug with AE of flushing → niacin ■ Tx? NSAIDs (or just wait it out) ○ Best drug to lower LDL → statins ■ Mechanism? inhibits HMG-CoA reductase ○ Best drug for lowering TGs → fibrates ■ Note: clinically, the best option is “fish oil” ○ Best drug to raise HDL → niacin ○ 2 drugs with AE’s of hepatotoxicity and myotoxicity → statins & fibrates (esp. if given together) ■ NBSIM before prescribing statins or fibrates? Check LFTs and CK ■ Only re-check LFTs or CK if pt has sxs ○ Drug with AE of diarrhea → bile acid resins (e.g. cholestyramine, colesevelam) ○ Which lipid-lowering drug inhibits reabsorption of cholesterol at GI tract? ezetimibe

DI Podcast Main Document 88 ● Liver abscess + bloody diarrhea in African immigrant. → Entamoeba histolytica ○ Tx? Metronidazole ■ NBSIM if imaging shows well-circ*mscribed liver lesion? inject iodoquinol

● Tx for hydatid cysts found on liver bx? Albendazole ○ Microbe? Echinococcus

● Microbe that causes cholangiocarcinoma? Clonorchis sinensis

STI’S WITH ULCERS ● Painless ulcer + indurated margins + non-tender inguinal LAD → syphilis

● Painless ulcer + beefy red base + slowly enlarges + irregular borders → granuloma inguinale ○ Microbe? Klebsiella granulomatis

● Painful purulent ulcer with soft, ragged edges → Haemophilus ducreyi

● Painful ulcer with surrounding vesicular lesions → genital herpes (HSV) ○ Tx: acyclovir (or foscarnet if resistant)

● Symptoms of syphilis ○ Primary syphilis = Painless chancre ○ Secondary syphilis = Rash on palms/soles ○ Tertiary syphilis = Argyll-Robertson pupil + Aortic regurgitation + Tabes dorsalis ■ Test to check posterior columns? Romberg test

● Dx for syphilis? ○ Screening test? RPR or VDRL (screening) ○ Confirmatory test? FTA-Abs or MHA-TP

DI Podcast Main Document 89 ○ Causes of false-positive screening test? Antiphospholipid syndrome

● Tx for syphilis? Penicillin G ○ Tx if penicillin-allergic? Doxy or macrolide ○ Tx if pregnant + PCN-allergic? Desensitize + Penicillin G ○ Tx if neurosyphilis + PCN-allergic? Desensitize + Penicillin G

● Hyperkalemia ○ Etiologies? ■ Potassium-sparing diuretics (“SEAT”) ■ Spironolactone or Eplerenone ■ Amiloride or Triamterene ■ ACE-I/ARBs ■ Addison’s disease aka Adrenal Insufficiency ■ Mechanism? Adrenal cortex destroyed ­→ cannot make ALDO → K+ accumulates ■ Tumor lysis syndrome ■ Mechanism? CTx kills cancer cells → intracellular K+ gets dumped into serum ■ Kidney stones a/w tumor lysis syndrome? Uric acid stones ■ Prevention of uric acid stones? Allopurinol or Rasburicase or Pegloticase ■ Rhabdomyolysis ○ Tx? ■ 1st step = calcium gluconate ■ Reduce serum K+ ■ Insulin + glucose (drives K+ into cells) ■ Albuterol (SABA; activates Na+/K+ ATPase on cells) ■ Sodium bicarb ■ Mechanism? Metabolic alkalosis draws H+ out of cell while driving K+ into cells via H+/K+-ATPase pump ■ Reduce total body K+ ■ Diuretics (non-potassium sparing!)

DI Podcast Main Document 90 ■ Kayexalate – AE: Bowel necrosis

● Pt has serum K+ of 8 with normal EKG → hemolyzed blood sample ○ Normal EKG, i.e. no peaked T-waves

● Chronology of EKG findings in hyperkalemia? Peaked T-waves → wide QRS → sine waves

● Wrist drop + humeral bone fracture. → radial nerve injury

● Tenderness over anatomical snuffbox. → scaphoid fracture ○ Complication? Avascular necrosis (2/2 compromised retrograde blood supply)

● Loss of lateral arm sensation + cannot abduct. → axillary nerve injury ○ 2 etiologies of axillary nerve injury? ■ Anterior shoulder dislocation ■ Surgical neck fracture

● COPD (emphysema; chronic bronchitis) ○ Mechanism of panacinar emphysema? alpha-1 antitrypsin deficiency ■ imbalance of anti-proteases vs. proteases (not enough anti-proteases) ■ alpha-1 antitrypsin is an anti-protease

○ PFT findings of COPD? ■ FEV1/FVC ratio < 70% ■ ↓ FEV1 ■ ↓ FVC ■ ↑ Lung volumes ■ ↑ TLC

○ DLCO in chronic bronchitis vs emphysema? ■ Normal DLCO → chronic bronchitis

DI Podcast Main Document 91 ■ Reduced DLCO → emphysema

○ Acid-base disturbance in COPD? respiratory acidosis with compensatory metabolic alkalosis ■ Mechanism? ↑CO2 (i.e. respiratory acidosis) → compensatory increase in bicarb (i.e. compensatory metabolic alkalosis)

○ CBC abnormality in COPD? Polycythemia ■ Pathophys? Hypoxia → ↑EPO production

○ What 2 interventions reduce mortality in COPD? ■ Smoking cessation ■ Home O2 supplementation

○ What are 4 indications for supplemental home O2 in COPD? ■ O2 Sat < 88% at rest ■ PaO2 < 55 ■ PAH (pulmonary hypertension) ■ Polycythemia

○ Tx for acute COPD exacerbation? “ABC-O’s” ■ ABX (azithro or levofloxacin) + Bronchodilators + Corticosteroids + supplemental O2

○ When to give Non-Invasive Positive Pressure Ventilation (NIPPV) in acute COPD exacerbation? Pt has COPD exacerbation with hypercapnia

○ Step-up Tx for COPD ■ Step 1: SAMA (ipratropium) or SABA or SAMA-SABA combination ■ GOLD Stage I or II, mild ■ Step 2: SAMA + LAMA (tiotropium) or SAMA + LABA ■ GOLD Stage I or II, severe ■ Step 3: SAMA + LAMA + ICS

DI Podcast Main Document 92 ■ GOLD Stage III or IV, mild ■ Step 4: SAMA + LAMA + ICS + PDE-4 inhibitor (roflumilast) ■ GOLD Stage III or IV, severe ■ MOA PDE-4 inhibitors? Smooth muscle relaxation → bronchial muscle relaxation ■ Step 5: SAMA + LAMA + ICS + PDE-4 inhibitor + oral steroids

○ Why is mechanical ventilation with SpO2 ~99% contraindicated in COPD? B/c COPD pt’s depend on hypoxic respiratory drive ■ Mechanism? COPD pt’s chronically retain high CO2 → so, respiratory drive switches from hypercapnia-driven respiratory drive to hypoxia-driven respiratory drive ­→ now COPD pt’s depend on hypoxia to drive respiration → if supplemental O2 causes COPD pt’s to reach high SpO2, the body no longer thinks it is in hypoxia → thus hypoxic respiratory drive is shut off → no more respiration ■ Note: In contrast, hypercapnia-driven respiratory drive is done non-COPD pt’s

● HTN ○ Dx? BP > 130/80 on TWO occasions ■ Gold standard Dx? 24h ambulatory monitoring ○ Lifestyle modifications for HTN (from most to least effective)? ■ Weight loss (most effective) >> DASH diet > exercise > Na+ restriction (least effective)

● Special anti-hypertensive indications ○ Tx for HTN + DM → ACE-I ○ Tx for HTN + CKD → ACE-I ○ Tx for HTN + HF or hx MI → ACE-I ○ Tx for HTN + hx kidney stones → thiazides ○ Tx for HTN + BPH → non-selective alpha-1 blocker (e.g. prazosin, not tamsulosin) ○ Tx for HTN in African-American with no other conditions → thiazides ○ Tx for HTN in African-American plus DM or HF or hx MI → ACE-I ○ Pregnant → hydralazine or labetalol or methyldopa or nifedipine

DI Podcast Main Document 93 ■ “He Likes My Neonate”

● 2 major contraindications to ACE-I’s ○ Anatomic contraindication to ACE-I → Bilateral renal artery stenosis ○ Enzyme contraindication to ACE-I ­→ C1 esterase inhibitor deficiency

● Fever + abdominal pain + left shoulder pain + pleural effusion on CXR + recent small bowel surgery. Dx? Subphrenic abscess ○ Pathophys? Phrenic nerve causes referred pain to left shoulder

● Antidotes for anti-coagulants ○ Heparin antidote → protamine sulfate ○ Dabigatran antidote → idarucizumab ○ Warfarin antidote → Vit K & 4-factor PCC

● Tx for heparin-induced thrombocytopenia (HIT)? Direct thrombin inhibitor (dabigatran) ○ Note: Do not give LWMH in HIT

● Which anticoag to give for valvular AFib? Warfarin ○ “VALerie WARring against AFib” ■ Note: Do not give dabigatran or bivalirudin in valvular AFib!

● Recurrent seizures + recent trip to South America + consumed pork → neurocysticercosis ○ Microbe? Taenia solium ○ Tx for neurocysticercosis? Anti-epileptic (phenytoin) + Albendazole + corticosteroids ■ Per UW and MedBullets ○ Tx for Taenia solium localized to GI tract? Praziquantel ■ Per UW and MedBullets

● Hypercalcemia ○ MCC of hypercalcemia? Primary hyperparathyroidism (parathyroid adenoma)

DI Podcast Main Document 94 ○ Other etiologies of hypercalcemia? ■ Drugs? Thiazides ■ General ilness? Malignancy ○ S/sx of hypercalcemia? “Stones, bones, groans, psychiciatric overtones” ○ EKG findings? Shortened QT ○ First step in management of symptomatic hypercalcemia? Fluids

● Urine Ca2+ in Primary Hyperparathyroidism vs FHH? ○ ↑ Urine Ca2+ = primary hyperparathyroidism ○ ↓ Urine Ca2+ = FHH

● Tx for hypercalcemia of malignancy? Bisphosphonates ○ 4 different criteria for parathyroidectomy in 1º hyperparathyroidism? ■ Symptomatic ■ Age < 50 yo ■ Ca2+ > 1 mg/dL over ULN ■ Renal dysfunction

DI Podcast Main Document 95 Primary Secondary Tertiary Familial Milk Alkali Hypercalcemia Liver Hyperparathyroidism Hyperparathyroidism Hyperparathyroidism Hypocalciuric Syndrome of Disease Hypercalcemia Malignancy ● ↑ PTH ● ↑ PTH ● ↑ PTH ● ↓ PTH 2+ 2+ 2+ ● ↑ PTH ● ↑ Ca ● ↓ Ca ● ↑ Ca ● ↑ PTH ● ↑Ca2+ ● ↑ PTH-rp ● ↓ Ca2+ ● ↓ PO43- ● ↑ PO43- ● ↓ PO43- ● ↑ Ca2+ ● ↓ PTH ● ↓ PO43- ● ↑Urine Ca2+ ● ↓ Urine Ca2+ ● ↑ Ca2+ ● ↓ PO43- Seen in Ca2+ ● ↓ PO43-Problem at PTH gland Seen in kidney failure Pt with kidney transplant toxicity Benign Tx = Note: Labs mirror bisphosphonates 1º HyperPTHism, but Note: Labs mirror vignette for 3º 1º HyperPTHism Note: PTH-rp acts HyperPTHism will state but the exactly like PTH, pt had a kidney distinguishing lab which is why there transplant is FHH causes ↓ is Urine Ca2+ ↓PO43-

● Acid-base disturbance for pH 7.25 + pCO2 65 + HCO3- 29? Respiratory acidosis + compensatory metabolic alkalosis ○ 2 associated drug overdoses? Opioids overdose and benzo overdose ○ Associated lung disease? COPD

● Pathophys of HTN in patient with Turner’s syndrome? coarctation of aorta

● HTN + hypokalemia + metabolic alkalosis + ↑ aldosterone:renin ratio. → Primary Hyperaldosteronism aka Conn syndrome ○ Tx? Spironolactone then surgery (give spironolactone before surgery)

● Episodic HTN + headaches. → pheochromocytoma

● HTN in 36 yo sexually active F. Drug association? OCPs

● HTN in patient on long-term NSAID tx for osteoarthritis. → RAAS activation (2/2 renal dysfunction)

DI Podcast Main Document 96 ○ Mechanism? NSAIDs cause afferent arteriole vasoconstriction → hypoperfusion of glomerulus → RAAS activation

● HTN in 25 yo F with abdominal bruit → fibromuscular dysplasia

● HTN in 70 yo M with abdominal bruit + AV nicking on fundoscopic exam → renal artery stenosis

● 70 yo F with Ca2+ of 12.9 + SCr of 3 + Hb of 8 + bone pain + lytic bone lesions on XR → multiple myeloma ○ Sxs of multiple myeloma? “CRAB” ■ hyperCalcemia ■ Renal failure (elevated SCr) ■ Anemia ■ Bone pain/bone lesions (lytic) ○ Dx? M-spike on SPEP or UPEP ■ Note: “M-spike” = ↑ in monoclonal Ig ■ There is an M-spike in MM, MGUS, and Waldenstrom Macroglobulinemia ○ Blood smear findings? Rouleaux formation ○ Bone marrow bx? > 10% plasma cells ○ Tx multiple myeloma? Bortezomib ■ MOA? Proteasome inhibitor → junk proteins accumulate → this kills MM cancer cells

● Plasma-cell levels in multiple myeloma vs MGUS? ○ MM → >10% plasma cells on bone marrow bx ○ MGUS → <10% plasma cells on bone marrow bx

● Does MGUS present with “CRAB” sxs? No! ○ Prognosis of MGUS? 1% of MGUS cases progress to MM every year

● How to DDx MGUS vs Waldenstrom Macroglobulinemia? ○ MGUS = small IgG monoclonal gammopathy

DI Podcast Main Document 97 ○ WaldenstroM MACROglobulineMia = IgMMM monoclonal gammopathy ■ WaldrenstroM MACROglobulineMia ← IgM is a pentamer, so it’s huge/macro! ■ Complications? Hyperviscosity syndrome

● Cyclical fevers + anemia + headaches + hepatosplenomegaly + recent trip to Africa. → Malaria ○ Microbe? Plasmodium species ■ Microbe that causes most severe form of malaria? Plasmodium falciparum ○ Vector? Anopheles mosquito (female mosquitoes) ○ Dx? Thick & thin blood smear on Giemsa Strain ■ Stain? Giemsa ○ Plasmodium species a/w hypnozoites? Plasmodium vivax and Plasmodium ovale ■ Tx for hypnozoite forms? Primaquine ○ Tx? ■ Chloroquine – high rates of resistance ■ Mefloquine – MC PPx ■ Primaquine – AE: hemolysis in G6PD deficiency ■ Atovaquone ■ Artemether/lumefantrine

● Prolonged QT + carpopedal spasms on manual BP checks after thyroidectomy for papillary thyroid cancer. → hypocalcemia 2/2 parathyroid removal

● Prolonged QT + carpopedal spasms on manual BP checks after receiving 9U of blood for severe hemorrhage → EDTA-induced chelation of Ca2+ (EDTA is found in packed RBCs)

● Hypocalcemia ○ EKG finding? QT prolongation ○ Tx? Calcium + Vit D ■ NBSIM when hypercalcemia is refractory to Ca2+ repletion? Give magnesium

● Serum Ca2+ and PO43- labs in CKD? hypocalcemia + high serum PO43-

DI Podcast Main Document 98 ○ Remember: CKD = 2º Hyperthyroidism!

● Serum Ca2+ and PO43- labs in Liver Disease? hypocalcemia + low serum PO43-.

● Serum Ca2+ and PO43- labs in Vit. D deficiency? hypocalcemia + low serum PO43-.

● Which causes hypocalcemia: metabolic acidosis or metabolic alkalosis? Metabolic alkalosis ○ “Metabolic alkaLOWsis” = LOW calcium ○ Mechanism? Metabolic alkalosis causes excess negative charges on albumin → albumin binds up more serum Ca2+

● Pt has hypercapnia + RR of 8 + multiple rib fractures. NBSIM? Pain control (e.g. nerve block) ○ Why? Pt’s with rib fx’s are hypo-ventilating to avoid pain on inspiration → nerve block will control pain to allow pt’s to breathe more comfortably

● Should rib fractures be casted? NO

● pH 7.52 + pCO2 31 + HCO3- 24. Acid-base disturbance? respiratory alkalosis ○ Etiology? Hyperventilation

● Acid-base disturbance in aspirin overdose? Respiratory alkalosis + metabolic acidosis ○ Hyperventilation → respiratory alkalosis ○ Aspirin aka Salicylic acid → AG metabolic acidosis

HYPONATREMIA

Hyper-Osmolar Hyponatremia ● MC Etiology? Hyperglycemia (e.g. DKA or HHNS) ● Pathophys? Excess glucose aka excess osmoles in serum → draws water out of cells and into extracellular space → serum sodium concentration becomes diluted ● Formula to calculate corrected Na+ in hyperglycemia? ○ Corrected Serum Na+ =

DI Podcast Main Document 99 ■ E.g. Serum Na+ of 120 and blood glucose of 1000 ■ Corrected Serum Na+ = [120] + [1.6 x [(1000 - 100)/100]) = 134

Iso-Osmolar Hyponatremia ● Etiologies? Hyperlipidemia and hyperproteinemia ○ Mechanism? Lab artifact (lab error)

Hypo-Osmolar Hyponatremia

Q: Next step after determining pt has hypo-osmolar hyponatremia?A: Assess volume status, i.e. hypervolemia vs euvolemic vs hypovolemic

● Hypervolemic Hyponatremia (Hypo-osmolar Hypervolemic Hyponatremia) ○ Mechanism? Activation of both RAAS and ADH → reabsorb way more water than Na+ ■ ADH only absorbs water → this is why more water is reabsorbed than Na+ ■ More details: ↓intravascular volume → hypoperfusion detected at afferent arteriole → activation of RAAS + ADH * → ↑Na+ uptake and ↑water uptake, but gain more water than Na+ b/c ADH only draws in water ■ *Non-osmotic release of ADH 2/2 hypovolemia ○ Etiologies? Anything that results in hypoperfusion at afferent arteriole ■ Cirrhosis – Urine Na+ < 10 ■ Right-sided heart failure – Urine Na+ < 10 ■ Nephrotic syndrome – Urine Na+ < 10 ■ Kidney failure – Urine Na+ > 10 ■ b/c kidneys unable to concentrate urine appropriately ○ Tx? Restrict fluids

● Euvolemic Hyponatremia (Hypo-osmolar Euvolemic Hyponatremia) ○ Pathophys? Pt only gaining water (pt originally had normal Na+ serum) ■ Why doesn’t the pt become hypovolemic? ↑Water intake → ↓ serum osmolality → water redistributes into cells, so serum volume remains stable ○ Etiologies?

DI Podcast Main Document 100 ■ SIADH – ↓Serum OsM + ↑ Urine Osm (> 100) ■ Psychogenic polydipsia (compulsive water drinker) – ↓Serum OsM + ↓ Urine Osm (< 100) ■ Hypothyroidism ■ Beer potomania/tea-and-toast diet

○ Tx? Fluid restriction

● Hypovolemic Hyponatremia (Hypo-osmolar Euvolemic Hyponatremia) ○ Mechanism? Pt loses more Na+ than water ■ Exacerbated by rehydrating with pure water ○ Etiologies? ■ Loop diuretics (i.e. due to Na+-dumping into urine) ■ Urine Na+ > 10 ■ Vomiting/diarrhea (loss of electrolyte-rich fluid) ■ Urine Na+ <10 ■ Addison disease ○ Tx? Normal Saline aka 0.9% NS

HYPERNATREMIA ● Hypervolemic Hypernatremia ○ Mechanism? Net gain of Na+ in excess of water ○ Etiologies? ■ Infusion of Na+-containing abx ■ Excess infusion of sodium bicarb ■ Excess ingestion of NaCl ■ Primary hyperaldosteronism ○ Tx? NS until euvolemic then D5W or 0.45% saline

● Hypovolemic Hypernatremia ○ Mechanism? Net loss of water in excess of loss of Na+ ○ Etiologies?

DI Podcast Main Document 101 ■ Osmotic diuresis (glucosuria, mannitol) ■ Sweating ■ Diarrhea, i.e. osmotic-laxative diarrhea, lactase deficiency) ■ Vomiting ○ Tx? NS until euvolemic then D5W or 0.45% saline● Euvolemic Hypernatremia ○ Mechanism? Net loss of only water, i.e. pure water loss (no loss of Na+) ○ Etiologies? ■ Fever (insensible water loss) ■ Diabetes insipidus ○ Tx? D5W

● CP at rest = unstable angina ○ Alternate presentation? CP with progressively less exertion ○ ST elevation preset? no ○ Troponin elevation present? no ○ DDx unstable angina vs NSTEMI? ■ NSTEMI causes elevated troponin ○ Tx unstable angina? Nitrates + statins + aspirin + beta blocker + ACE-I ■ O2 supplementation only if hypoxic ■ Are fibrinolytics ever indicated? NO! ■ How about for NSTEMI? In general, no

● Vitamin deficiencies and complications a/w chronic pancreatitis or other etiologies of fat malabsorption? ○ Vit A deficiency → blindness ○ Vit D deficiency → hypocalcemia, hypophosphatemia, secondary hyperparathyroidism ○ Vit E deficiency → hemolytic anemia, acanthocytosis, ataxia ○ Vit K deficiency → bleeding

● Genetic disease associated with skin necrosis with initiation of warfarin tx? Protein C/S deficiency

DI Podcast Main Document 102 ● Watery foul-smelling diarrhea + recent hiking/camping trip. → Giardia ○ Dx? Stool O&P ■ trophozoites or cysts in the stool ○ Tx? Metronidazole ○ Immunodeficiency a/w Giardiasis? IgA deficiency

● MCC of chronic hyperphosphatemia → CKD

● Tx for hyperphosphatemia? Sevelamer (mechanism: phosphate binder)

● Electrolytes that spill into the circulation with tumor lysis syndrome and rhabdomyolysis? ○ Hyperkalemia ■ EKG findings? Peaked T → wide QRS → sine wave → asystole ○ Hyperuricemia

● Most important electrolyte abnormality in refeeding syndrome? Hypophosphatemia

● Hypophosphatemia + muscle weakness + arrhythmias after re-introduction of nutrition in pt with chronic malnourishment → Refeeding syndrome ○ Chronically malnourished, e.g. pt with cancer!

● MC shoulder dislocation: anterior or posterior? Anterior shoulder dislocation ○ Affected nerve and artery? Axillary nerve and posterior humeral circumflex artery

● Etiologies of posterior shoulder dislocation? ■ Less common than anterior shoulder dislocations! ○ Seizures ○ Lightning strike

● MC hip dislocation: anterior or posterior? Posterior hip dislocation

DI Podcast Main Document 103 ○ “HP computers” = hip dislocates posterior

● Cystic fibrosis. ○ Mutated gene? CFTR ■ MC mutation? Delta F508 ○ Inheritance? AR ○ Pathophys? Thick secretions due to dysfunction of Cl- channel ■ In non-CF pt’s, water follows Cl-, which thins mucus secretions ○ Causes of pneumonia by age? ■ < 20 yo = Staph aureus ■ > 20 yo = Pseudomonas ○ Dx? Sweat chloride test ■ Serum trypsinogen (low due to obstruction of pancreatic ducts by thick secretions) ○ Tx? ■ N-acetylcysteine (breaks disulfide bonds → mucolytic) ■ DorNase Alfa (helps thin out mucus) ■ Nebulized tobramycin ■ Chest physiotherapy ■ Vit ADEK supplementation ■ Nutritional support (high calories!) ○ Associations ■ Nasal polyps ■ Rectal prolapse ■ Congenital absence of vas deferens

● 25 yo F smoker + severe chest pain at night + migraines. → Prinzmetal angina = variant angina ○ Pathophys? Vasospasm of coronary arteries ○ Dx? Provocative testing w/ ergotamine in the cath lab ■ If pt has ST elevations & elevated troponins → cath lab ○ Tx? CCB (per UTD, diltiazem or amlodipine)

DI Podcast Main Document 104 ○ Contraindicated drugs ■ Sumatriptan ■ Ergots ■ Non-selective beta blockers (e.g. propranolol) ■ b/c they exacerbate vasospasm

● Severe anal pruritus in child. Microbe? Enterobius vermicularis (pinworm) ○ Dx? Scotch tape test ○ Tx? Albendazole or pyrantel pamoate

● 65 yo F with signs of pancytopenia. Bone marrow bx shows > 20% blasts. Cells are positive for myeloperoxidase. Auer rods are found on biopsy. Dx? APML ○ Translocation? t(15,17) ○ Tx? ATRA (all- trans-retinoic acid) ○ Serious complication of APML? DIC ■ DIC labs? Normal PT + elevated PTT + elevated bleeding time + low platelets

● Protozoal a/w bloody diarrhea and liver abscesses? → entamoeba histolytica ○ Tx? metronidazole ■ If abscess? Inject iodoquinol

● Microbe that increases risk of cholangiocarcinoma? Clonorchis sinensis

● Hypoxemia with normal A-a gradient ○ Hypoventilation ○ High altitude

● Etiologies of hypoxemia with elevated A-a gradient? ○ Right-to-left cardiac shunt ○ V/Q mismatch (i.e. pulmonary embolism) ○ Diffusion issue (e.g. pulmonary fibrosis)

DI Podcast Main Document 105 ● EKG leads and associated MI and artery occlusion. ○ Leads II, III, avF = inferior MI + RCA occlusion ○ Leads I, aVL, V5, V6 = lateral MI + LCX occlusion ○ Leads V1-V4 = anterior MI + LAD occlusion

● Drug class contraindicated in right-sided MI? nitrates ○ These pts are preload dependent

● Most sensitive lab marker for MI? cTn (cardiac troponin)

● Most sensitive lab marker to diagnose reinfarction in setting of recent MI? CK-MB (short half-life)

● 75 yo M with recurrent infections. CBC shows lymphocytes of 109,000. PEx reveals anterior and posterior cervical lymphadenopathy. Blood shows smudge cells that are CD5/CD19/CD20/CD21 +ve. Dx? CLL ○ Prevention of tumor lysis syndrome? ■ Allopurinol ■ Rasburicase or pegloticase

● Watery diarrhea after eating oysters. Microbe? Vibrio parahaemolyticus or Vibrio vulnificus ○ Tx? Doxycycline ○ Demographic at risk of severe infection? Liver disease (Vibrio vulnificus, specifically) ○ Other sxs of Vibrio vulnificus infection? Severe cellulitis or necrotizing fasciitis

● Pt on eclampsia prophylaxis. Now has 2/5 patellar reflexes. Had 5/5 patellar reflexes a few hours ago. Toxicity? Magnesium toxicity ○ Sequence of sxs due to Mag toxicity? ■ Hyporeflexia → respiratory depression → arrhythmia ○ Tx? Calcium gluconate

● PTH levels depend on Magnesium levels

DI Podcast Main Document 106 ■ High Mag → low PTH (acts on CSR) ■ Low Mag → high PTH ■ Recall the hypomagnesemia-hypocalcemia association ■ Very low Mag → low PTH

● What 2 electrolyte abnormalities cannot be corrected if there is concurrent hypomagnesemia? Hypokalemia and hypocalcemia

● DDx cardiogenic pulmonary edema vs noncardiogenic pulmonary edema ○ Cardiogenic pulmonary edema ■ PCWP > 18 mmHg (elevated PCWP!) ■ Tx? Furosemide + inotrope (e.g. digoxin, dobutamine, milrinone) ○ Noncardiogenic pulmonary edema ■ PCWP < 18 mmHg (normal PCWP!) ■ Classic etiology? ARDS

● Pt has MI and the closet hospital where PCI can be done is 30 mins away. NBISM? Transport! ○ What if nearest hospital is > 2h away? tPA! ■ Contraindications to tPA? Recent ischemia stroke or recent brain surgery

● Always do PCI if nearest PCI-capable hospital is < 2h away ○ Give tPA if nearest PCI-capable hospital is >2h away

● Tx for left main coronary artery stenosis or 3-vessel disease? CABG

● Acute MI management ○ 1st step: Aspirin ○ Morphine ○ O2 supplementation if hypoxic ○ Beta-blockers ○ Nitrates

DI Podcast Main Document 107 ○ ACE-I ○ Statin ○ Heparin

● Brush border enzyme deficiency in Asian immigrant with abdominal pain and bloating after consuming cheese. → Lactose intolerance ○ Pathophys? lactase deficiency ○ Dx? Hydrogen breath test (↑ H+ ions)

● Abdominal discomfort + pancytopenia + dry tap on bone marrow bx + cells that stain +ve for Tartrate Resistant Acid Phosphatase + lymphoid cells with fine cytoplasmic projections on histology. → Hairy cell leukemia

● Watery diarrhea and severe vomiting for a 3 day period after consuming fried rice at a Korean restaurant. → Bacillus cereus

● Pt with history of HBV + asymmetric neurological deficits + weight loss + severe abdominal pain after meals + ANCA-negative + segmental transmural inflammation on renal angiography. Dx? polyarteritis nodosa ○ Note: lungs are unaffected in polyarteritis nodosa ○ Dx? Sural nerve biopsy

● Primary Spontaneous Pneumothorax vs Tension Pneumothorax. ○ Primary spontaneous pneumothorax ■ Classic demographics? ■ Tall skinny male ■ Emphysema ○ Tension pneumothorax ■ Classic demographics? ■ Trauma pt (e.g. chest stabbing) ■ Ventilated pt (2/2 barotrauma) ■ Central line placement, i.e. lung gets punctured

DI Podcast Main Document 108 ■ Auscultation? ■ Decreased breath sounds on affected side ■ Hyperresonant to percussion ○ Tx stable pt → O2 & observe ○ Tx unstable pt → needle thoracostomy then chest tube at 2nd mid-clavicular line at top of ICS ■ Where? 2nd intercostal space at midclavicular line ■ Bottom or top of intercostal space? Top (b/c intercostal nerve/vein/artery run along bottom of ribs)

● Emphysema ○ RF ■ Centriacinar emphysema = smoking ■ Panacinar emphysema = alpha-1 antitrypsin deficiency

o Imaging findings? ● Hyperinflation aka flattened diaphragms ● Bullae

o PFT’s? ● FEV1/FVC < 70% ● FEV1 decreased ● FVC decreased ● Lung volumes increased ● TLC increased ● DLCO? ● Normal DLCO → chronic bronchitis ● Decreased DLCO → emphysema

o What is GOLD staging? Staging used to categorize pulmonary function in COPD pt’s

■ GOLD staging dictates tx in COPD

o GOLD Stages DI Podcast Main Document 109 ● GOLD I = FEV1 > 80% ● GOLD II = FEV1 50-80% ● GOLD III = FEV1 30-50% ■ GOLD IV = FEV1 < 30%

○ Step-up of Tx in COPD based on GOLD staging ■ Step 1: SAMA (ipratropium) or SABA or SAMA-SABA combination ■ GOLD Stage I or II, mild ■ Step 2: SAMA + LAMA (tiotropium) or SAMA + LABA ■ GOLD Stage I or II, severe ■ Step 3: SAMA + LAMA + ICS ■ GOLD Stage III or IV, mild ■ Step 4: SAMA + LAMA + ICS + PDE-4 inhibitor (roflumilast) ■ GOLD Stage III or IV, severe

○ Interventions to decrease mortality in COPD? ■ Smoking cessation ■ Home O2

● Key difference b/w asthma vs emphysema Tx? ○ Asthma = first ICS then LABA ○ COPD = first LAMA/LABA then ICS

● 2 Interventions to increase survival in COPD? Smoking cessation and Home O2

● What is Cor Pulmonale? Right-heart failure 2/2 PAH ○ PAH is when PA pressure > 25 mmHg

● Pneumoconiosis ○ Are PFT’s obstructive or restrictive? Restrictive lung pattern ■ FEV1/FVC

DI Podcast Main Document 110 ○ MC pneumoconiosis? Asbestosis ■ Upper or lower lobes affected? Lower lobes ■ Note: all other pneumoconiosis affect upper lobes ■ “Roofs (asbestosis in roofs) affect lower lobes, ground affects upper” ■ Imaging findings? Pleural plaques ■ Histo? Ferruginous bodies ■ MC malignancy? Bronchogenic carcinoma ■ Thoracentesis presentation of mesothelioma? Hemorrhagic pleural effusion

● Pt has rheumatoid arthritis + pneumoconiosis. Dx? Caplan syndrome

● Which pneumoconiosis is a/w increased risk of Tb? Silicosis

● Interstitial infiltrates on CXR + sputum shows broad-based budding yeasts + hemoptysis/productive cough/SOB + resident of Wisconsin or Indiana + gray-colored skin lesions. → Blastomycosis ○ Tx for pulmonary blastomycosis? Itraconazole ■ Tx for disseminated Blastomycosis? Amphotericin B ○ Highest infection rate in Wisconsin!

DI Podcast Main Document 111 ● Hospitalized patient develops fever + diarrhea. → C. diff colitis

● Endocarditis in patient with prosthetic valves. → Staph epidermidis

● ICU pt has fever + history of alcoholism. → Klebsiella aspiration pneumonia

● Common causes of drug-induced fever? → ABX & heparin

● Classic imaging and LP findings in HSV encephalitis? ○ Imaging finding? Temporal lobe enhancement ○ LP? RBCs in 500’s (in the 100’s but less than 1000!)

● Drugs that cover MRSA ○ Vanc ○ Daptomycin ○ Clinda ○ Linezolid

DI Podcast Main Document 112 ○ Ceftaroline ○ Doxy ○ TMP-SMX

● Drugs that cover Pseudomonas ○ Ceftazidime ○ Cefepime ○ Pip-tazo ○ FQ ○ Carbapenems ○ Aztreonam ○ Aminoglycosides

● Tx for Neisseria infection? Ceftriaxone

● What 2 drug combinations for coverage of most abdominal infections? ○ Cipro + metro ○ Metro + amoxicillin + gentamicin

● Simple UTI management ○ Nitrofurantoin ○ TMP-SMX ○ Cipro

● Tx for pyelonephritis? Ceftriaxone

● Tx for Community acquired pneumonia? ○ Ceftriaxone ○ Azithromycin ○ Levofloxacin

DI Podcast Main Document 113 ● Tx for Rocky mountain spotted fever? Doxycycline (or chloramphenicol if pregnant)

● Tx for syphilis? Penicillin G ○ Desensitize if allergic!

● Tx for flu in first 48 hours of symptom onset? oseltamivir

● HY AEs of antibiotics ○ Vancomycin ■ Red man syndrome ■ Nephrotoxicity ■ Ototoxicity ○ Gentamicin ■ Nephrotoxicity ■ Ototoxicity ○ Penicillins ■ Hypersensitivity rxn ■ AIN

● AEs of HIV drugs ○ HIV drug with AE of fat redistribution or metabolic syndrome? ritonavir/protease inhibitors ○ HIV drug with AE of nephrolithiasis? indinivir ○ HIV drug with AE of pancreatitis? stavudine/didanosine ○ HIV drug with AE of HSR? abacavir ■ Check HLAB57 before starting abacavir

● Opportunistic infections in AIDS ○ Watery diarrhea → Cryptosporidium parvum ■ Diagnostic? Acid-fast oocytes ■ Tx? Nitazoxamide

DI Podcast Main Document 114 ○ Meningitis → Cryptococcus ■ Tx? Amphotericin + flucytosine ■ Maintenance? Fluconazole

○ Difficulty swallowing → Esophageal Candidiasis ■ Tx? itraconazole ■ DDx? CMV esophagitis and HSV esophagitis ■ CMG esophagitis = linear ulcers on EGD ■ HSV esophagitis = shallow round ulcers on EGD

○ Skin lesions → Kaposi’s sarcoma (HHV-8)

○ Ring-enhancing lesions on brain MRI (single vs multiple) ■ Single ring-enhancing lesion → primary CNS lymphoma ■ Virus? EBV ■ Multiple ring-enhancing lesions → Toxoplasmosis ■ Tx? Pyrimethamine-sulfadiazine

○ White non-scrapable oral lesions → oral hairy leukoplakia ■ Virus? EBV

● HIV PPx ○ CD4 < 250 + lives in Texas → itraconazole for Cocci ○ CD4 < 200 → TMP-SMX for PCP ○ CD4 <150 and lives in ohio → Itraconazole for Histoplasmosis ○ CD4 < 100 → TMP-SMX for Toxoplasmosis ○ CD4 < 50 → No PPx for MAC! ■ Note: azithromycin is no longer given as a PPx for MAC (i.e. no PPx given for MAC)

● CML ○ Translocation? t(9;22) ○ Dx? FISH DI Podcast Main Document 115 ○ CBC findings? Basophilia ○ Presentation? 45 yo M with fatigue + weight loss + splenomegaly ■ Think of “ML” in CML for “mid-life” -- presents in middle-aged pts :) ○ Tx? Imatinib (tyrosine kinase inhibitor) ○ Differentiating b/w CML vs leukemoid reaction ■ LAP high → leukemoid rxn ■ LAP low → CML

● Tx for neutropenic fever? Pip-Tazo or cefepime or carbapenem ○ Why? Need to cover Pseudomonas

● Tx for cancer-related cachexia? Megestrol acetate (progesterone analog)

● What 3 diseases result in high-output heart failure? ○ Bone → Paget’s disease of bone ○ Hematologic → Anemia ○ Vascular → AVM

● DDx for eosinophilia? “NAACP” ○ N = neoplasms ○ A = allergies/asthma ○ A = Addison’s disease ○ C = collagen vascular disease (e.g. SLE, scleroderma) ○ P = parasites

● HIV+ patient has acute-onset shortness of breath + productive cough + high fevers. CD4 count is 150. CXR shows lobar consolidation. → Strep pneumo ○ Note: In contrast, PCP pneumonia = interstitial infiltrates

● HIV complications and associated microbe ○ Retinitis → CMV

DI Podcast Main Document 116 ○ Esophagitis → Candida, CMV, or HSV ○ Meningitis → Cryptococcus ○ Diarrhea → Cryptosporidium ○ Bacillary angiomatosis → Bartonella henselae ■ Tx? doxycycline ○ Ataxia + motor deficits + diffuse hyperintense lesions → PML 2/2 JC virus ■ MS drug a/w PML? Natalizumab

● Etiologies of AG metabolic acidosis aka high anion-gap metabolic acidosis? “MUDPILES” ○ Methanol ○ Uremia ○ DKA ○ Propylene glycol/Paraldehyde ○ Iron/INH ○ Lactic acidosis (rhabdomyolysis) ○ Ethanol ○ Salicylic acid (aspirin)

● Etiologies of non-anion-gap metabolic acidosis? ○ RTAs ○ Diarrhea

SERUM ANION GAP, URINE ANION GAP, AND WINTERS FORMULA

● Serum AG = [Na+] – (Cl- + HCO3-) ○ Serum AG is calculated to DDx anion-gap metabolic acidosis vs NAGMA

● Urine AG = (Na + + K+) – [Cl-] ○ Urine anion gap is calculated to DDx if NAGMA is d/t RTA vs diarrhea ○ Negative Urine AG → diarrhea (“NeGUTive”)

DI Podcast Main Document 117 ■ Why? Large amt of unmeasured NH4+ is present in urine → this results in negative “#”○ Positive Urine AG → Type I or Type IV RTA ■ NBS? Check Serum K+

○ Use Serum K+ to DDx Type I vs Type II vs Type IV RTA ■ High Serum K+ → Type IV RTA (2/2 hypoaldosteronism) ■ Low Serum K+ → check urine pH ■ Urine pH > 5.5 → Type I RTA (unable to secrete acid/H+) ■ Urine pH < 5.5 → Type II RTA (unable to reabsorb bicarb → HCO3-/Na+ cotransporter at PCT does not run [cannot take up Na+] → excess loss of Na+ and water to lumen → activation of RAAS ­→ Na+ and water reabsorbed more distally and K+ secreted. Also, HCO3- in lumen combines with K+)

SUMMARY FOR NAGMA VIGNETTES: ● Step #1: You have determined pt has NAGMA ● Step #2: Check Urine AG ○ Negative urine AG = diarrhea – you’re done! ○ Positive urine AG = RTA ­ ● Step #3: If urine AG is positive, check K+ ○ ↑ K+ = Type IV RTA – you’re done! ○ ↓ K+ = Type I or Type II RTA ● Step #4: If serum K+ is low, check urine pH ○ Urine pH < 5.5 = Type II RTA ○ Urine pH > 5.5 = Type I RTA

○ When to use the Winter Formula? In metabolic acidosis to check if there is appropriate respiratory compensation ■ Winter’s Formula? [Expected pCO2] = (1.5 x bicarb) + 8 ± 2 ■ Example: bicarb = 16 and pCO2 = 20 ■ [Expected pCO2] = (1.5 x 16) + 8 ± 2 = 30-34

DI Podcast Main Document 118 ■ Conclusion? This pt has metabolic acidosis + respiratory alkalosis ■ Note: If pCO2 is ↑ than expected, there is a concurrent respiratory acidosis ■ Note: If pCO2 is ↓ than expected, there is a concurrent respiratory alkalosis

● Etiologies of metabolic alkalosis? ○ Drugs ■ Diuretics ○ Disease ■ Barter’s/Gitelman’s ■ Conn syndrome ○ Volume depletion

● Pt with hematuria + smoker OR Egyptian with chronic schistosomiasis OR history of nephrotic syndrome treated with cyclophosphamide. Dx? bladder cancer ○ Dx? cystoscopy ○ HY causes of hemorrhagic cystitis. ■ Cyclophosphamide ■ Adenovirus ■ Schistosoma haematobium

● How to prevent hemorrhagic cystitis 2/2 cyclophosphomide? Mesna!

● Type of bladder cancer caused by schistosomiasis? Squamous cell carcinoma of the bladder

● Indications for dialysis? “AEIOU” ○ A = Acidosis ○ E = Electrolyte imbalance ○ I = Ingestion ○ O = fluid Overload

DI Podcast Main Document 119 ○ U = Uremia

● Complications of uremia? Uremic pericarditis and platelet dysfunction ○ Tx for platelet dysfunction? Desmopressin

● Pt in his first-ever dialysis session then develops CP + back pain. Dx? First-use syndrome ○ Anaphylactic reaction to dialysis membrane or to materials used to sterilize dialysis machines

● Amyloidosis in patients on chronic dialysis. What protein involved? → β2 microglobulin

● Pt has abdominal pain + distension + fever + does peritoneal dialysis. → Spontaneous bacterial peritonitis (SBP)

● Pt has flank pain + CVA tenderness + high fevers + urgency/frequency/dysuria. Pyelonephritis ○ Dx? UA w/ culture ○ Urine Casts? WBC casts ○ Tx? Ceftriaxone or cipro ○ DDx outpatient treatment vs IV antibiotics ■ Admit pt’s who are vomiting or can’t tolerate PO ○ MCC pyelonephritis? E. coli

● FSGS – nephrotic syndrome ○ Classic demographic? ■ African Americans ■ HIV+ ■ Heroin use ■ Obesity patients ○ Variant of FSGS seen in HIV? Collapsing variant FSGS ○ EM findings? Effacement of foot processes ○ Tx? Steroids + ACE-I +/- cyclophosphamide

DI Podcast Main Document 120 ■ Note: Per Pathoma 2017: FSGS has poor response to steroids

Nephritic Syndromes

Note: This section includes all info. from the lecture, and add’l info. has been added to enhance learning

● What is Rapidly Progressive Glomerulonephritis? Group of nephritic syndromes that rapidly progress to renal failure in weeks to months!

● List the RPGNs based on IF findings ○ Linear IF = Goodpasture Syndrome ○ Granular IF (wire-loop appearance) = PSGN; Lupus nephritis (DPGN) ○ Negative IF (pauci-immune) = GPA; MPA; Churg-Strauss ■ Note: GPA, MPA, and Churg-Strauss are also considered vasculitides

● Goodpasture syndrome ○ Classic presentation? Young adult male + hemoptysis + hematuria ○ IF findings? Linear pattern ○ Ab? anti-GBM

● Post-Streptococcal glomerulonephritis ○ Classic presentation? Cola-colored urine with onset 2-6 weeks after Strep infection ○ IF findings? Granular pattern (2/2 immune-complex deposition) ○ EM findings? SubePithelial humps

● Lupus Nephritis aka Diffuse Proliferative Glomerulonephritis (DPGN) ○ IF findings? Pauci-immune ○ EM findings? Wire-loops (granular) ← “LOOPus = wire LOOPs” ○ MC renal disease in SLE

● IgA Nephropathy aka Berger Disease ○ Classic presentation? Hematuria 2-6 days after URI and a/w recurrent hematuria

DI Podcast Main Document 121 ● Alport Syndrome (note: included for completeness) o Presentation? Hematuria + hearing loss + ocular disturbances o Mechanism? Inherited Type IV collagen defect

VASCULITIDES ● Henoch-Schönlein Purpura ○ Classic presentation? Child + joint pain + abdominal pain + non-blanching palpable purpura on butt and LE’s + hematuria after an upper respiratory infection ○ Associated with what nephritic syndrome? IgA nephropathy ■ Hematuria in HSP is 2/2 IgA nephropathy

DI Podcast Main Document 122 ● Granulomatosis with Polyangiitis aka Wegeners disease ○ Classic presentation? Sinusitis + hemoptysis + hematuria + c-ANCA ■ Alternative nose sxs? nasopharyngeal ulcers ○ IF findings? Pauci-immune ○ Marker? c-ANCA

● Eosinophilic Granulomatosis with Polyangiitis (EGPA) aka Churg-Strauss disease ○ Classic Presentation? Asthma + eosinophilia + granulomas (lungs) + p-ANCA ○ Marker? p-ANCA

● Microscopic polyangiitis ○ Classic presentation? Hemoptysis + hematuria + p-ANCA ○ Marker? p-ANCA

● How to DDx EGPA vs MPA since both have p-ANCA? ○ EGPA has asthma + eosinophilia + lungs ■ MPA does not!

DI Podcast Main Document 123 ● Pt has JVD + hypotension + muffled heart sounds. Dx? Cardiac tamponade ○ Tx? pericardiocentesis

ATRIOVENTRICULAR RE-ENTRANT TACHYCARDIA (AVRT) ● Orthodromic AVRT – “ORTHOpods drive Down NARROW AVenues” ○ Conduction pathway? Down AV node then back up via accessory pathway ○ QRS finding? Narrow QRS ○ Acute Tx? ■ Orthodromic AVRT + HDUS → Synchronized cardioversion ■ Orthodromic AVRT + HDS ­→ Adenosine ○ Chronic Tx? Beta-blocker or ND-CCB ■ b/c want to slow down conduction through AV node → this slows the HR ○ Acute tx if HDUS? Synchronized cardioversion ○ Acute tx if stable? Adenosine

● Antidromic AVRT – “ANTI-people do everything opposite; that’s why they drive Down WIDE ACCESS Roads” ○ Conduction pathway? Down accessory pathway then back up to AV node ○ QRS finding? Wide QRS ○ Classic cause? WPW ■ EKG finding? Delta waves! ○ Tx? Procainamide ○ Contraindicated drugs? Beta-blocker or ND-CCB · EKG for TdP? Prolonged QT then sine waves o In contrast, EKG for VFib has sine waves without any preceding prolonged QT

● Prolonged QT interval ○ Drugs a/w prolonged QT? ■ Ondansetron ■ Haloperidol ■ Ziprasidone

DI Podcast Main Document 124 ■ Quinidine/disopyramide/procainamide ■ Amiodarone/Sotalol ■ FQ ■ Macrolides ○ Electrolytes abnormalities a/w prolonged QT? ■ Hypokalemia ■ Hypocalcemia ■ Hypomagnesemia ○ QT prolongation increases risk of what arrythmia? Torsade de Pointes ■ Tx TdP? IV Mag

● Physiologic or pharmacologic manipulation of cardiovascular parameters ○ Milrinone (“inodilator”) ■ CO? ↑CO ■ SBP? ↑ SBP ● Why is SBP increased? b/c CO and SBP move in tandem! ■ e.g. If CO increases, then SBP increases; vice versa ■ SVR? ↓SVR ■ Why is DBP decreased? b/c SVR and DBP move in tandem! ■ e.g. If SVR decreases, then DBP decreases; vice versa ■ DBP? ↓DBP ■ Pulse pressure? Widens ○ NE ○ Hydralazine ○ Nitrate

● Knife wound to arm + PEx reveals warm pulsating arm mass + LV EF of 75%. → high output HF 2/2 AV fistula

● Japanese female with abdominal pain and > 10 mmHg difference in SBPs between arms + 6 months of low-grade fevers + elevated ESR and CRP → Takayasu arteritis

DI Podcast Main Document 125 ○ Alternate presentation in arms? “weak or absent pulse in UE”

● Pericardial knock + JVP increase with inspiration + reduced EDV on echo. Dx? constrictive pericarditis ○ Note: JVP increase with inspiration aka “+Kussmaul sign”

● JVP Waveform to DDx cardiac tamponade vs constrictive pericarditis ○ Blunted (less steep) Y-descent on JVP waveform = cardiac tamponade ○ Steep Y-descent on JVP waveform = constrictive pericarditis

● Note: What is a normal JVP height (i.e. height above sternal angle)? < 4 cm!

DI Podcast Main Document 126 DI Podcast Main Document 127 DI Podcast Main Document 128 ● MCC of death in the first 24h after acute MI? V-Fib

● Pathophys of post-MI ventricular free wall rupture is similar to which heart path? Cardiac tamponade! ○ Mechanism? Blood spills out of heart via ventricular free wall rupture → free blood now surrounds and compresses the heart ○ Same sxs as cardiac tamponade! (JVD + hypotension + muffled heart sounds)

● Murmur in post-MI interventricular septal rupture? Harsh holosystolic murmur

● Murmur in post-MI papillary muscle rupture? Mitral regurgitation

● Tx for peri-infarction pericarditis? Aspirin

● Pericarditis weeks after MI. Dx? Dressler’s syndrome ○ Pathophys? Autoimmune

● Tx for post-MI? Aspirin + statin + ACE-I + beta-blocker

● Colon cancer screening guidelines ○ Start at? 50 yo ○ Screening options? ■ Colonoscopy q 10 years ■ Flex sigmoidoscopy q 5 years ■ FOBT q 1 year ■ NBSIM if FOBT test is positive? Colonoscopy ○ Age to screen pts who have 1st-degree relative diagnoses with colon cancer? ■ At 40 yo or 10 years before age of relative at time of dx -- whichever is earlier! ■ e.g. 1st-degree relative diagnosed at 52 yo → screen at 40 yo (not 42 yo!) ■ e.g. 1st- degree relative diagnosed at 48 yo → screen at 38 yo DI Podcast Main Document 129 ○ When to screen for colon cancer following ulcerative colitis dx? 8 years after UC diagnosis

● 22y M with multiple colon polyps. Dx? Familial Adenomatous Polyposis ○ Mutation? APC gene

● Multiple colon polyps + brain tumor. Dx? Turcot syndrome

● Multiple colon polyps + bone tumors + soft-tissue tumors. Dx? Gardner syndrome

● Early colon cancer arising from normal mucosa. Dx? HNPCC/Lynch syndrome ○ Mutation? MSH/MLH

● Hyperpigmented macules on lips + GI tract hamartomas. Dx? Peutz Jeghers Syndrome.

● Tx for GERD? PPIs ○ AEs of GERD? ■ Aspiration pneumonia ■ Osteoporosis ■ B12 deficiency ○ AE of cimetidine (PPI)? Gynecomastia (men)

● Tx for H. pylori ○ Triple therapy → PPI + amoxicillin + clarithromycin ○ Quad therapy → metro + bismuth + tetracycline + PPI (MBTP)

● 35 yo F with 15-year history of OCP use presents with RUQ pain. U/S reveals well-circ*mscribed hepatic mass. → hepatic adenoma

● 60 yo M has 7 weeks of bilateral knee pain + chronic diarrhea. Bx of intestinal mucosa is PAS+ macrophages + villous atrophy. PEx is notable for new murmur → Whipple’s disease ○ Microbe? Tropheryma whipplei

DI Podcast Main Document 130 ○ Tx? Ceftrixone (or penicillin G) for 2 weeks then TMP-SMX for 1 year

● PAS+ stain in liver. Dx?→ alpha-1 antitrypsin deficiency

● PAS+ stain in GI tract. Dx? → Whipple’s disease

● 60 yo M has halitosis + difficulty swallowing + palpable neck mass on swallow → Zenker diverticulum ○ Dx? Barium swallow ■ Do NOT do upper endoscopy (b/c it can perforate esophagus)

● Difficulty swallowing + chest pain radiating to jaw + relieved with nitrates → diffuse esophageal spasm ○ Dx? Manometry ○ Tx? CCBs or nitrates or TCAs

● 47 yo F with diabetes mellitus refractory to treatment + 1 week of necrotic, erythematous skin lesion. Dx? Glucagonoma ○ Associated syndrome? MEN1 ■ b/c glucagonoma is a pancreatic endocrine tumor ○ Tx? Surgery or octreotide

● Tx for diabetic gastroparesis? Metoclopramide or Erythromycin (motilin receptor agonist) ○ AE? Extrapyramidal symptoms (e.g. tardive dyskinesia) ○ Pathophys? Damage to enteric nervous system

● 60 yo pt with sepsis + severe abdominal pain and distension. Abdominal CT shows dilated colon with absence of obstruction. Dx? → Ogilvie syndrome aka acute colonic pseudo-obstruction ○ Tx? Neostigmine ■ AE? bradycardia

● Pt with elevated SCr + oliguria + history of ESLD. Dx? Hepatorenal syndrome

DI Podcast Main Document 131 ○ Pathophys? Cirrhosis causes splanchnic vasodilation → this steals blood away from kidneys → kidneys become hypo-perfused ■ Cirrhosis leads to production of nitric oxide → nitric oxide causes venodilation of splanchnic vessels → ↓SVR → hypoperfusion of kidneys ○ Urine labs are similar to what type of AKI? Similar to prerenal AKI! ■ FeNa < 1% ■ BUN/Cr > 20 ○ Tx? Liver transplant

● DDx hepatorenal syndrome vs prerenal azotemia based on fluid resuscitation? ○ No improvement with fluids → hepatorenal syndrome ○ Improvement with fluids → prerenal azotemia

● Pt with hypoxia on standing or walking + SpO2 improves on lying down + ESLD (end-stage liver disease). Dx? Platypnea-Orthodeoxia syndrome ○ Pathognomonic for what? Hepatopulmonary syndrome

● Diarrhea associations ○ Cruise ship gastroenteritis → norovirus ○ AIDS patient → Cryptosporidium parvum ○ 2 hrs after eating potato salad → Staph aureus ○ Daycare → rotavirus ○ Eating oysters → Vibrio parahaemolyticus ○ Eating fried rice → Bacillus cereus ○ Eating pork → Yersinia enterocolitica ○ Bloody diarrhea after eating poultry or eggs → Salmonella ○ Common cause of bloody diarrhea in the U.S. → Campylobacter

● MEN1 syndrome + jejunal ulcers + GERD refractory to tx. Dx? Zollinger-Ellison syndrome ○ Dx? Gastrin level ■ NBSIM if secretin is high but not “crazy high”? Secretin stimulation test

DI Podcast Main Document 132 ■ Increase in gastrin w/ secretin stimulation test = Z-E syndrome ○ Tx? ■ Medical? PPIs ■ Surgical? resection

● Ab’s in Type 1 and Type 2 Autoimmune Hepatitis? ○ Type 1 Autoimmune Hepatitis = anti-SM Ab’s (“anti-smooth muscle”) ○ Type 2 Autoimmune Hepatitis = anti-LKM Ab’s (“anti-liver kidney microsomal”)

● UC vs Crohn’s ○ UC ■ Bloody diarrhea + continuous lesions ■ a/w PSC (men) ○ Crohn’s ■ Skip lesions + non-caseating granulomas ■ Oxalate kidney stones ■ Pyoderma gangrenosum ■ Uveitis

● Joint disease associated with hemochromatosis? CPPD aka pseudogout ○ CCPD = calcium pyrophosphate deposition disease ○ Dx? Rhomboid-shaped with apple-green birefringence on Congo stain

● Dx for pancreatic cancer? CT scan

● Budd-Chiari syndrome = thrombosis of hepatic vein ○ Classic populations? ■ OCP users ■ Polycythemia vera ■ PNH

DI Podcast Main Document 133 ● Tx for APAP overdose? N-acetylcysteine ○ Mechanism of APAP toxicity? Elevated NAPQI levels

Cross Checked? Yes-------------------------------------------------------------------------------------------------------------------------------

Ep. 37: Risk Factors#1 RF = number one risk factorMCC = most common causeMCCOD = most common cause of death

1. #1 RF for suicide is prior suicide attempt 2. #1 RF for AFib → Mitral stenosis. 3. Most common arrhythmia in hyperthyroidism → A fib. 4. #1 RF for Mitral stenosis → Rheumatic fever 5 #1 RF for AAA development→ smoking 6. Screen AAA → men + 65-75yo + smoker. If >5.5 cm → surgery. Or >0.5cm/6 mos or 1 cm/yr growth 7. Greatest predisposing risk factor to rupture of AAA → diameter of aneurysm 8. Most important modifiable RF for CAD → smoking 9. #1 RF for stroke and aortic dissection → HTN 10. Biggest RF in iron deficiency anemia pt with h/o H.Pylori→ PUD 11. #1 RF for esophageal adenoCa → barrett’s esophagus which is caused by GERD 12. MCC CAP → Strep. Pneumo 13. MCC UTI→ E.coli 14. Common RF for osteoporosis → Low BMI. 15. Controlling blood glucose only decreases microvascular risks associated with retinopathy, neuro, and nephropathy, not macrovascular like CAD and stroke. 16. #1 RF for SCC → cumulative sun exposure 17. #1 RF for ovarian cancer → FHx of OCa. 18. #1 RF for prostate,breast Ca → Age 19. MCCOD in pt with kidney transplant → CV disease

DI Podcast Main Document 134 20. MCCOD in acromegaly → heart failure21. MCCOD (most common cause of death) in CKD → CVDisease./ arrhythmia followed by infection22. #1 RF for OSA → obesity23. #1 modifiable RF for knee OA → obesity24. MCCOD in ADPKD → CVDisease (not SAH!).25. MCCOD in SLE → ischemic heart disease26. #1 RF for pancreatic Ca → smoking27. MCC cancer a/w asbestos exposure → Bronchogenic carcinoma27.5) Mesothelioma has no relation to smoking28. Which pneumoconiosis increases risk of TB → Silicosis29. MCC of acute pancreatitis in America → Gallstones https://bit.ly/3CmHLvc30. MCC Chronic pancreatitis → alcoholism31. #1 RF for papillary thyroid cancer → prior chest/neck radiation32. Breast CA Screening → every year from 40 yo. USPSTF →every 2 years start at 50 until age 75,33. Cervical CA screen → every 3 years 21-30 regardless of sexual activity. >30 → HPV + pap every 5 years.34. Hyperlipidemia screen → men: every 5 year >35yo men women: every 5y > 45 yo35. Colon CA Screening Guidelines → Colonoscopy is gold standard Normally: Colonoscopy q 10 years from 50-75 yo. UC pt’s: staring 8 years after diagnosis then every 1-2 years after. If FHx colon cancer: 10 year prior to family member’s age at diagnosis. FAP pt’s: q 1 year starting at 10-15 yo36. All pregnant women 1st prenatal visit → screen syphilis, asymptomatic bacteriuria, HIV37. Rh immunoglobulin screen → 28-32 wks + within 72 hours of delivery. Determine dose → kleihauer-betke test38. Melanoma most likely determination of spread→ breslow depth39. #1 prevention of Hepato cellular carcinoma → Hep B vaccination40. #1 RF for ED → CVD41. MCCOD in cervical cancer → Renal failure esp ureters DI Podcast Main Document 135 42. Most important prognostic factor in cancer→ stage of tumor (TNM staging) 43. Lung CA → low dose CT, men and women, 55-80 who have >30pp smoking hx, who currently smoke + less than 15 yr since quitting. 44. #1 RF for endometritis → C-section 45. #1 RF for preeclampsia → prev hx of Preeclampsia/ nulliparity 46. #1 RF for uterine inversion → Prior inversion 47. #1 RF for chorioamnionitis → prolonged rupture of membranes 48. #1 RF for placenta previa → prior C-section 49. HY RF to preterm labor → bacterial vaginosis 50. #1 RF for endometrial cancer → unopposed estrogen> endometrial hyperplasia 51. #1 RF for ectopic pregnancy → hx of ectopic pregnancy and smoking (affects cilia) 52. #1 RF for Cervical incompetence → cervical conization procedure or LEEP 53. #1 RF for cervical cancer → HPV 54. #1 RF for fetal macrosomia → gestational diabetes or preexisting diabetes 55. #1 RF for shoulder dystocia → fetal macrosomia 56. MCC of placental abruption → trauma/cocaine 57. RF of urinary incontinence→ age and multiple vagin*l deliveries (stress incontinence), Diabetes→ overflow incontinence, MS→ urge incontinence 58. RF for Asherman’s syndrome→ history of uterine curettage 59. #1 RF for bladder cancer → smoking

Cross checked? Yes----------------------------------------------------------------------------------------------------------------------------

Ep. 41: Antibiotics Guide

Opening Pressure Cell Type Protein Glucose

Bacterial Meningitis ↑ PMNs ↑ ↓

DI Podcast Main Document 136 Fungal/Tb Meningitis ↑ Lymphocytes ↑ ↓

Viral Meningitis Normal or ↑ Lymphocytes Normal or ↑ Normal

● Neonate (newborn) with nuchal rigidity. → GBS meningitis ○ Microbe? Group B Strep (Strep agalactiae) ■ #1 cause bacterial meningitis in first 28 days of life ○ Tx? “CVA” for meningitis in first 28 days of life ■ Cefotaxime + Vancomycin + Ampicillin ■ Cefotaxime covers GBS/Strep pneumo/Neisseria ■ Vancomycin covers MRSA ■ Ampicillin covers Listeria ■ Listeria is ~100% fatal if untreated ■ Note: Do NOT use ceftriaxone in neonates b/c it causes biliary sludge ○ Alternate Tx? Ampicillin + gentamicin (not as common anymore)

● 65 yo M with nuchal rigidity + fever + headache. → Meningitis ○ Tx for meningitis in elderly pts ( > 50yo)? “CVA” ■ Ceftriaxone + Vancomycin + Ampicillin ■ Elderly pt’s need standard meningitis tx plus Listeria coverage

● 33 yo F with no relevant PMH has nuchal rigidity + headache + fever. → Strep pneumo Meningitis ○ Tx? Ceftriaxone + Vancomycin + Streoids (“CVS”)

● MCC meningitis in adults 18-65 yo? Strep pneumo

● Hospital-acquired or post-neurosurgical procedure bacterial meningitis. ○ Microbes a/w hospital-acquired infections? Pseudomonas and MRSA ○ Tx? Ceftazidime or cefepime + vancomycin ■ Ceftazidime = only 3rd gen ceph covering Pseudo) ■ Cefepime (4th gen ceph)

● Headache + nuchal rigidity + fever. LP shows gram-positive diplococci + neutrophil predominance. → Strep. pneumo meningitis ○ Histo? Gram+ diplococci aka gram+ cocci in pairs aka lancet-shaped Gram+ cocci in pairs ○ Tx? Ceftriaxone + Vancomycin + IV Steroids (“CVS”) ■ IV steoids reduces morbidity & mortality of Strep pneumo meningitis ■ Give IV dexamethasone before giving abx

● HIV pt has severe headache + nuchal rigidity + papilledema. → Cryptococcal meningitis DI Podcast Main Document 137 ○ Microbe? Cryptococcus ○ LP findings? ↑ WBC with lymphocyte predominance + ↓ glucose + ↑protein ○ LP opening pressure? ↑↑ significantly elevated opening pressure ■ Very high opening pressure = Cryptococcus (b/c Cryptococcus occludes CSF flow) ○ Dx? ■ CSF antigen test (highly sensitive and specific) ■ Latex agglutination assay or India ink stain ○ Tx? (Liposomal) Amphotericin B + flucytosine ■ Note: can also use Liposomal Amphotericin B b/c less likely to cause AE of nephrotoxicity) ■ MOA amphotericin B? binds ergosterol → makes holes in fungal membrane ■ MOA flucytosine? Inhibits thymidylate synthase ○ Maintenance Therapy? Fluconazole until symptoms resolve + CD4 >100 for >1yr

● Tx for bacterial meningitis in HIV+ patient? “CVA” -- Ceftriaxone + Vanc + Ampicillin ○ Same tx as elderly pt’s

● Opportunistic Infections in HIV

Coccidiomycosis P. jirovecii Histoplasmosis Toxoplasmosis gondii MAC Complex

· CD 4+ < 250 · CD4 < 200 · CD 4+ < · CD4 < 100 · CD4 < 50 + lives in AZ 150 + lives · PPx = TMP-SMX in KY · PPx = · PPx = none · PPx = or pentamidine TMP-SMX itraconazole (HY alternative) · PPx = · Tx = or dapsone (HY itraconazol · Tx = azithromycin alternative) e Sulfadiazine + + ethambutol or atovaquone pyrimethamine · Tx = IV o “It’s TOXic · Tx = TMP-SMX + liposomal to STeal dapsone amphoterici and Pyrate” nB

○ HIV + CD4 < 250 + lives in AZ → Coccidioidomycosis ■ PPx? Itraconazole ○ HIV + CD4 < 200 → Pneumocystis jirovecii ■ PPx? TMP-SMX or pentamidine (HY alternative) or dapsone (HY alternative) or atovaquone ■ MOA of TMP? inhibits dihydrofolate reductase ■ MOA of SMX? inhibits dihydrofolate synthetase ○ HIV + CD4 < 150 + lives in KY → Histoplasmosis ■ PPx? Itraconazole ○ HIV + CD4 < 100 → Toxoplasmosis gondii ■ PPx? TMP-SMX (which should be covered at CD4 < 200) ○ HIV + CD4 < 50 → Mycobacterium avium complex (MAC) ■ PPx? None ■ Per UW: PPx no longer given d/t low risk, abx resistance and cost DI Podcast Main Document 138 ■ Tx? Azithromycin + ethambutol ■ Rifabutin is 2nd line ■ Maintenance therapy? Continue tx for >1yr and CD4 >100 for > 6mo

● Pt on chemotherapy develops fever + WBC count is 2000. → Neutropenic fever ○ Microbes? Pseudomonas + MRSA ○ Tx? Ceftazidime (or Cefepime) + Vancomycin

● HIV + seizures + MRI shows multiple ring-enhancing lesions in brain. → Toxoplasmosis ○ Tx? Sulfadiazine + pyrimethamine (+ steroids if pt has papilledema or AMS) ■ “It’s TOXic to STeal and Pyrate” = Tx Toxo w/ Sulfadiazine + Pyrimethamine ■ MOA sulfadiazine? DHF synthetase inhibitor ■ MOA pyrimethamine? DHF reductase inhibitor ○ NBSIM for pt with toxoplasmosis + ↑ICP (e.g. papilledema or AMS)? Add steroids!

● Tx for pt with seizures due to neurocysticercosis? Phenytoin (i.e. anti-epileptics) ○ Do NOT give anti-helminth drugs b/c they will cause a fatal inflammatory response

● HIV + headache + nuchal rigidity. LP is positive for CSF with 500 RBCs. MRI reveals hyperintense lesions in the temporal lobe. → HSV encephalitis/meningitis ○ Tx? IV Acyclovir or foscarnet

● Pt has sudden-onset severe headache + nuchal rigidity + LP shows 4000-5000 RBCs. → Subarachnoid hemorrhage

● CSF findings of HSV encephalitis/meningitis vs subarachnoid hemorrhage o HSV encephalitis/meningitis = RBCs in hundreds but < 1000 o Subarachnoid hemorrhage = RBCs in thousands (4000-5000)

● HIV + headache + nuchal rigidity. LP shows lymphocytic pleocytosis. Imaging shows enhancement at base of brain (or in basilar cisterns”. → Tb Meningitis ○ Tx: “RIPE” ■ Rifampin – AE: red urine; MOA: RNA polymerase inhibitor ■ Isoniazid – AE: drug-induced lupus; supplement B6 to prevent neuropathy ■ Pyrazinamide ■ Ethambutol – AE: ocular/color blindness

● Pt has tender lesion on left lower extremity. PEx reveals blanching erythematous lesion on calf. Vital are normal. → Cellulitis ○ MCC of cellulitis? Staph aureus ○ Tx? Clindamycin or TMP-SMX or Cephalexin

● DDx Cellulitis vs Erysipelas vs Folliculitis ○ Cellulitis = blanching borders + on lower extremities + normal vitals DI Podcast Main Document 139 ○ Erysipelas = well-circ*mscribed + elevated + face + abnormal vitals ■ MCC of erysipelas? Strep pyogenes ○ Folliculitis = infection of hair follicles ■ MCC of folliculitis? Staph aureus ■ Recent hot-tub exposure = Pseudomonas folliculitis

● Empiric Tx for animal or human bites? Amox-Clav

● Empiric Tx for community-acquired PNA? “M or D (medical doctor)” ○ Macrolide (Azithromycin) or Doxycycline

● Empiric Tx of hospital-acquired PNA. “M or D-c (certified medical doctor)” ○ Macrolide (e.g. Azithromycin) or Doxycycline + Ceftriaxone

● Tx for HAP if pt is allergic to PCN? FQ monotherapy (e.g. moxifloxacin or levofloxacin)

● Microbe if pt has HAP + CXR shows cavitary infiltrate? MRSA! ○ Tx? Clindamycin or Vanc or Linezolid

LYME DISEASE – PT WILL BE FROM NORTHEAST!

● Tx for 7 yo M with bullseye rash? Amoxicillin ○ Always give amoxicillin in children < 8yo -- NO Doxycycline!

● Tx for 30 yo F with bullseye rash? Doxycycline

● Tx for 35 yo pregnant female with bullseye rash? Amoxicillin ○ Same tx as kids!

● Dx? ELISA then confirm with Western Blot (needed for early disseminated or late Lyme) ○ b/c Western blot sent without ELISA results in high false-positive rates

● Tx for pt with meningitis or chest pain or myocarditis + history of bullseye rash? IV ceftriaxone ○ IV ceftriaxone needed for advanced Lyme disease

● Pt from North Carolina has severe headache + T of 104. PEx shows rash on palms and soles. → Rocky Mountain Spotted Fever ○ Microbe? Rickettsia rickettsii (+ve Weil-Felix test) DI Podcast Main Document 140 ○ Tx? Doxycycline ■ Note: Do not be tricked! Any pt (even < 8 yo) who has RMSF and is not pregnant should be treated with doxycycline (d/t high mortality rate if untreated) ○ Tx in pregnant female? Chloramphenicol – essentially the only time it will be the right answer ■ AE? Gray-baby syndrome

● 23 yo non-pregnant woman has suprapubic pain + urinary frequency + urgency + burning on urination. → Cystitis (UTI) ○ MCC of UTIs? E. coli ○ Tx? Nitrofurantoin or ciprofloxacin or TMP-SMX or Fosfomycin

● Tx for UTI in pregnant woman? Nitrofurantoin or Fosfomycin ○ Do not give cipro or TMP-SMX d/t teratogenic effects

● Pt has CVA tenderness + dysuria. → Pyelonephritis ○ Tx? Ceftriaxone or fluoroquinolone 2nd best (note: do not give FQ to pregnant patient!)

● 31 yo F develops fever + uterine tenderness 2 days after having C-section. → Endometritis ○ Tx? Clindamycin + Gentamicin ■ “ECG” = Endometritis tx with Clindamycin + Gentamicin

● 33 yo F in active labor + T is 102 + fetal HR is 190 bpm. → Chorioamnionitis ○ Chorioamnionitis = Maternal fever + fetal tachycardia ○ Tx? Ampicillin (cover Listeria) + Gentamicin ■ “CAG” = Chorioamnionitis tx with Ampicillin + Gentamicin

● Tx for Latent TB? ○ Isoniazid for 9 months + B6; or ○ Rifampin for 4 months

● Tx for Active TB? RIPE + B6

● 21 yo sexually active F + vagin*l discharge OR cervical motion + adnexal tenderness + inconsistent condom use. → Pelvic Inflammatory Disease (PID) ○ Microbes? Chlamydia + Gonorrhea ○ Tx? Azithromycin (or Doxy) + Ceftriaxone ■ AZT or Doxy for Chlamydia ■ Ceftriaxone for Neisseria ○ Tx if only Chlamydia is detected? Azithromycin or Doxy ○ Tx if only Gonorrhea is detected? Azithromycin (or Doxy) + Ceftriaxone ■ Even if only Gonorrhea is detected, need to cover for both Chlamydia and Gonorrhea

DI Podcast Main Document 141 ● 21 yo F has RUQ pain + history of PID → Perihepatitis aka Fitz-Hugh-Curtis syndrome

● Female has off-white/gray vagin*l discharge with fishy odor → Gardnerella vaginosis ○ Labs? ■ pH > 4.5 (grows in vagin*l pH > 4.5) ■ Clue cells ○ Tx? Metronidazole or clindamycin

● Female has frothy yellow-green that is malodorous → Trichom*onas vaginosis ○ Labs? ■ pH > 4.5 ■ Motile trichom*onads ○ Tx? Metronidazole for patient + partner

● Female has thick cottage-cheese vagin*l discharge → Candida vaginosis ○ Labs? ■ pH < 4.5 ■ Pseudohyphae (grows as germ tubes at 37ºC) ○ Tx? “—azoles” (fluconazole)

● Tx for systemic Candidemia (blood infection)? Echinocandins (“—fungin”) or Ampho B ○ e.g. Caspofungin or mycofungin or andulafungin

● Tx for oral candidiasis? Nystatin swish-and-swallow

● Pt on CTx (i.e. ICH) + neutropenia + eosinophilia + cough + hemoptysis → Aspergillus

● Pt on CTx (i.e. ICH) + non-resolving PNA despite standard PNA treatment → Aspergillus ○ Histo? Acute angles of 45º ○ Tx? Voriconazole

● Pt with uncontrolled DM + glucose in hundreds + facial pain → Mucor or Rhizopus ○ Histo? Budding at 90º angles ○ Tx? Surgical debridement + liposomal Amp B

● Tx of allergic bronchopulmonary Aspergillosis? oral steroids (+ itraconazole if chronic/recurrent)

● Fungal Infections ○ Tx for Coccidioidomycosis? Itraconazole ○ Tx for Histoplasmosis? Itraconazole ○ Tx for Blastomycosis? Itraconazole ○ Tx of sporotrichosis (Sporothrix schenkii)? Itraconazole DI Podcast Main Document 142 ■ Class presentation? Rose gardener with lymphadenopathy along lymph node chain ○ Tx for tinea ■ Tinea corporis = topical antifungal (“—azole”) ■ Tinea capitis and tinea unguium = terbinafine or griseofulvin (oral anti-fungals) ■ Microbes a/w tinea? Trichophyton, Microsporum, Epidermophyton ○ Tx for all invasive aka systemic fungal infections? Amphotericin B

● General treatment for all stages of syphilis? Penicillin G IM

● Tx for syphilis in pt’s allergic to PCN? Macrolide (AZT) or doxycycline

● Tx for syphilis in pt with PCN allergy who is pregnant or has neurosyphilis? Desensitization then penicillin!

Primary Syphilis PCN G IM x1 dose Doxycycline x14d

Secondary Syphilis PCN G IM x1 dose Doxycycline x14d (same tx as primary)

Latent Syphilis (asx) PCN G IM x3 doses Doxycycline x28d

Tertiary Syphilis PCN G IM x14 days Ceftriaxone x14d

● Tx for GI infections (e.g. diverticulitis, appendicitis, cholecystitis)? ○ “MAG” = Metronidazole + Amoxicillin + Gentamicin ○ “MC” = Metronidazole + Cipro ■ “MAG-MC” (“Mad EmCee”)

● Tx of gastroenteritis (e.g. Salmonella or Shigella)? Fluoroquinolone or macrolide

● Tx options for malaria. ○ Chloroquine – but tons of resistance so don’t choose it ○ Mefloquine - most common PPx ○ Atovaquone + Proguanil ○ Artemether + lumefantrine ○ Primaquine = to kill hypnozoites, which cause latent malaria ■ NBSIM before prescribing primaquine? Test for G6PD deficiency ■ Microbes a/w hypnozoites? Plasmodium vivax and Plasmodium ovale

● MC PPx for malaria? Mefloquine

● High-yield AEs of HIV drugs. DI Podcast Main Document 143 ○ AE of pancreatitis → Didanosine or Zidovudine – think about pancreatitis ○ AE of fat lipodystrophy → Ritonavir/Protease inhibitors ■ fat lipodystrophy = redistribution of fat from extremities to central trunk ○ Bactrim with hemolytic anemia – G6PD ○ AE of vivid dreams and teratogens → Efavirenz and Delavirdine ○ AE of fatal hypersensitivity reaction → Abacavir ■ NSBIM before starting abacavir? Check for HLA*B5701 mutation (d/t ↑ risk of fatal hypersensitivity)

● HIV pt develops bacillary angiomatosis due to Bartonella henselae. Tx? Macrolide or doxycycline ○ Macrolide = azithromycin, clarithromycin, erythromycin) ○ Note: Add rifampin for severe Bartonella infections

EMPIRIC TREATMENT

● Post-antibiotic diarrhea → C. difficile ○ Prevention? Hand washing ○ Tx? Metronidazole or vancomycin or fidaxomicin ■ Note: Vancomycin is now first-line for C. diff but USMLE may not be updated to reflect this

● Bloody diarrhea + liver abscess → Entamoeba histolytica ○ Note: only HY protozoa a/w bloody diarrhea ○ Tx? Metronidazole

● Watery diarrhea in AIDS pt → Cryptosporidium parvum (acid-fast positive) ○ Tx? nitazoxanide

● Diarrhea in “post-transplant” pt → CMV colitis ○ Tx? Ganciclovir

● Kidney infection in post-kidney transplant patient → BK virus (polyomavirus)

● Mnemonic for microbes treated with metronidazole? “GET GAP” ○ Giardia -- foul-smelling diarrhea after drinking from a stream ○ Entamoeba -- bloody diarrhea + liver abscess ○ Trichom*onas -- malodorous yellow-green discharge + strawberry cervix ○ Gardnerella -- fishy-smelling gray discharge + clue cells ○ Anaerobes -- this is why metronidazole is used in GI infections! ○ Protozoa

DI Podcast Main Document 144 ● HIV + bilateral interstitial infiltrates on CXR → Pneumocystis jirovecii PNA ○ Tx? TMP-SMX or IV pentamidine

● HIV + bilateral interstitial infiltrates on CXR + A-a gradient >35 or PaO2 <70 or SaO2 <92% → Pneumocystis jirovecii PNA ○ Tx? TMP-SMX + steroids (or IV pentamidine + steroids) ○ Indications to add steroids to tx for PCP pneumonia? ■ A-a gradient >35 or ■ PaO2 <70 or ■ SaO2 <92% ■ Note: pt will have hypoxia + respiratory alkalosis :)

● What 3 populations at risk for PCP pneumonia? ○ HIV pt’s ○ Pt’s on chronic steroids (i.e. non-HIV pts) ○ Pt’s on immunosuppressants s/p solid organ transplant (e.g. kidney transplant)

● Influenza ○ Tx for sxs > 48h = supportive care ○ Tx for sxs < 48h = oseltamivir or zanamivir

● Post-partum woman + fever + unilateral breast tenderness → mastitis ○ Microbe? S. aureus ○ Tx? nafcillin or dicloxacillin

● Post-partum woman + fever + bilateral breast tenderness → breast engorgement ○ Tx? Continue breastfeeding

● General HIV regimen? 2 NRTIs + 1 other drug (i.e. integrase inhibitor or NNRTI or protease inhibitor) ○ Integrase inhibitor, e.g “—tegra—" ○ NNRTI, e.g. Delavirdine, Efavirenz, Nevirapine ○ Protease inhibitor, e.g. “—navir”

● Conjunctival injection after returning from Hawaii → Leptospirosis ○ Tx? doxycycline ■ Transmission? pee of animals in water

● RMSF – classically rash on palms and soles with thrombocytopenia ○ Thrombocytopenia – think ■ Anaplasmosis ■ Ehrlichiosis ■ Rickettsia rickettsii DI Podcast Main Document 145 ● Tx for Legionella? macrolide (azithro/clarithro/erythromycin) or fluoroquinolones

● Tx for H. pylori? ○ Triple therapy -- “CAP” = Clarithromycin + Amoxicillin + PPI ○ Quadruple therapy – “MBTP” = Metronidazole + Bismuth + Tetracycline + PPI

● Anthrax ○ Buzzword? Spore-forming rods in chains produces exotoxin with protective antigen, edema factor, lethal factor, and polypeptide capsule (poly-D-glutamate), colonies form “medusa head” with halo of projections; humans inhale the spores ○ Cutaneous form: Black eschar most common ○ Pulmonary form: (woolsorter’s disease – spores on animals) widened mediastinum, pulmonary infiltrates (nonspecific) ○ Treatment: doxycycline or fluoroquinolone ○ Think of this bug if given a government worker as it can be a bioweapon

● MC microbe in osteomyelitis? MRSA

● Drugs to tx MRSA? ○ Vancomycin ○ Daptomycin ○ Ceftaroline (5th gen cephalosporin) ○ TMP-SMX ○ Clindamycin (note: a/w C.diff colitis) ○ Linezolid (50S inhibitor; note: weak MAOI, so can trigger serotonin syndrome) ○ Streptogramins, e.g. dalfopristin/quinupristin

● Drugs to tx Pseudomonas? ○ Ceftazidime (3rd gen) ○ Cefepime (4th gen) ○ Cipro ○ Aminoglycosides ■ Note: CF pts > 20 yo receive inhaled tobramycin to cover chronic Pseudomonas infection :) ○ Carbapenems ■ Note: ertapenem does not cover Pseudomonas! ○ Aztreonam (monobactam) ○ Piperacillin-Tazobactam

● Microbe causing PNA in CF patient >20 yo? Pseudomonas ○ Tx? inhaled tobramycin (aminoglycoside, which from the above list, we know covers Pseudomonas ) DI Podcast Main Document 146 ● Microbe causing PNA in CT pt < 20 yo? Staph aureus

● Violent cough + PEx shos subconjunctival hemorrhage or post-tussive vomiting → Pertussis ○ Microbe? ○ Tx: Macrolides, e.g. erythromycin ■ Erythromycin can also be used for gastroparesis ○ PPx for close contacts? Macrolide

● PPx for close contacts of meningitis pt? Rifampin or Ceftriaxone or Cipro

● Tx for acute otitis media? Amoxicillin +/- Clavulanic acid or Cefuroxime ○ (Cefuroxime rarely comes up)

● Tx for acute otitis externa? Fluoroquinolone ear drop ○ Microbe? Pseudomonas

● Pt wears contacts + has conjunctivitis or corneal ulcer. Microbe? Pseudomonas ○ Tx? ■ Ceftazidime (3rd gen) ■ Cefepime (4th gen) ■ Cipro ■ Aminoglycosides ■ Note: CF pts > 20 yo receive inhaled tobramycin to cover chronic Pseudomonas infection ■ Carbapenems ■ Exception: Ertapenem does not cover Pseudomonas ■ Aztreonam (monobactam) ■ Piperacillin-Tazobactam

● Tx for Measles? Vitamin A supplementation

● Tx for CrouP? RaCemic ePinephrine ○ Microbe? Parainfluenzae (paramyxovirus)

CROSS CHECKED? yes

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Ep. 45: Neurology Clerkship Shelf Review Part 2

● CSF findings of meningitis DI Podcast Main Document 147 Opening Pressure Cell Type Protein Glucose

Bacterial Meningitis ↑ PMNs ↑ ↓

Fungal/Tb Meningitis ↑ Lymphocytes ↑ ↓

Viral Meningitis Normal or ↑ Lymphocytes Normal or ↑ Normal

● HSV meningitis and HSV encephalitis ○ CSF findings? ■ Elevated WBCs (lymphocytic predominance) ■ Lots of RBCs (but < 1000) ● Note: If 4000-5000 RBCs → think SAH instead ■ Elevated protein ■ Normal glucose ○ Location? Temporal lobe ○ Dx? HSV PCR of CSF ○ Tx? IV acyclovir

● Young adult patient + fever + headache + neurologic deficits + no nuchal rigidity→ brain abscess

● Headache + high fever + sudden-onset nuchal rigidity → bacterial meningitis ○ CSF findings? ■ Elevated WBCs (neutrophilic predominance) ● Note: in contrast, Tb meningitis is the only bacterial meningitis with lymphocytic pleocytosis ■ HIGH protein ■ LOW glucose

● #1 cause bacterial meningitis in children through middle-aged adults? Strep pneumo ○ Tx for bacterial meningitis? Ceftriaxone + vancomycin + steroids

● #1 cause bacterial meningitis in neonates? Group B Strep (Strep agalactiae) ○ Tx for neonatal meningitis? Cefotaxime + vancomycin + ampicillin ■ Cefotaxime covers GBS ■ Vancomycin covers Staph aureus & resistant Strep pneumo

DI Podcast Main Document 148 ■ Ampicillin covers Listeria

● Special bacterial cause of meningitis seen in neonates & elderly only? Listeria monocytogenes ○ Tx? Add ampicillin to standard bacterial meningitis tx

● What pathogen causes bacterial meningitis in young adult with sxs of skin petechiae? Neisseria meningitidis ■ Tx? Ceftriaxone ■ PPX for close contacts? Rifampin, ciprofloxacin, or ceftriaxone (“RCC”) ■ Prevention? Neisseria meningitidis vaccine

● Pt with Neisseria meningitidis meningitis becomes profoundly hypotensive + hypoglycemic + hyperkalemic + bleeding from mucosal sites. Dx? → Waterhouse-Friedrichson syndrome ○ Pathophys? adrenal hemorrhage → primary adrenal insufficiency ■ Cortisol production impaired → hypoglycemia & hypotension ■ Aldosterone production impaired → hyperkalemia & non-AG metabolic acidosis (can’t excrete H+) ■ Type 4 RTA

● Populations at risk for Neisseria meningitis? ○ Asplenic patients (e.g. sickle cell disease) ○ Terminal complement deficiency or eculizumab use (tx for paroxysmal nocturnal hematuria) ■ Terminal complement = C5-C9 ■ Eculizumab = C5 inhibitor

● 25 yo M is having generalized tonic-clonic seizures. Began intranasal desmopressin (ADH analog) 5 days ago after water deprivation test was conducted at local hospital. Dx? → hyponatremic seizures (i.e. due to increased water reabsorption) ○ Pathophys? Desmopressin = ADH analog → acts on V2 receptors of principal cells to cause increased water reabsorption → this causes dilutes serum Na+ ■ Note: Desmopressin = ADH analog → so, it can cause AE of hyponatremia 2/2 SIADH ○ Tx? Hypertonic saline ■ To raise serum Na+ levels ■ Note: cannot increase Na+ levels > 12 mEq over 24 hrs

● What neurological complication results if hyponatremia is corrected too quickly? Osmotic demyelination syndrome aka central pontine myelinolysis aka “locked in” syndrome

● What neurological complication results if hypernatremia is corrected too quickly? Cerebral edema → transtentorial herniation

● In general, do you use a slow or fast general management strategy to manage electrolyte imbalances? SLOW management strategy to correct electrolyte imbalances

DI Podcast Main Document 149 ● Bizarre dreams on awakening (hypnopompic hallucination) or on falling asleep (hypnagogic hallucination) + history of 3 major accidents from falling asleep while driving + sudden falls from LE weakness (cataplexy). Dx? → Narcolepsy ○ Diagnostic test? Polysomnography (will show decreased sleep latency, i.e. pt goes straight into REM sleep) ○ Tx? ■ Frequent naps ■ Modafinil (stimulant) ■ Sodium oxybate to treat cataplexy ○ CSF findings? Decreased hypocretin/orexin levels

● What drug is given to tx insomnia? Suvorexant ○ MOA? hypocretin receptor antagonist

● Severe headache + multiple extraocular muscle deficits + recent otitis media infection. → cavernous sinus thrombosis ○ Pathophys? CN III, IV, VI, V1, V2 go through cavernous sinus ■ Note: loss of CN VI function occurs first (lateral gaze palsy) ○ Ophthalmic veins anastomose with facial veins & veins that drain sinuses ○ MC organism? Staph aureus ○ Tx? IV abx + heparin

● Severe headache + necrotic sinusitis in patient with blood glucose of 300 + pH of 7.13 + HCO3- of 15. → mucormycosis in context of DKA ○ Tx? Debridement + amphotericin B

● Asymmetric resting tremor + cogwheel rigidity + bradykinesia/festinating gait + postural instability → Parkinson’s disease ○ Associated handwriting finding? Micrographia (small handwriting) ○ Associated BP finding? Orthostatic hypotension

DI Podcast Main Document 150 ○ Pathophys? Destruction of dopamine-producing cells in substantia nigra pars compacta (part of the midbrain) ○ Gross pathological finding? Loss of pigmentation of substantia nigra ○ Histology of Parkinson disease? Lewy bodies (eosinophilic inclusions made of alpha-synuclein) ○ Tx? ■ Start with: ● NMDA receptor antagonists (e.g. amantadine; increases dopamine release in CNS) OR ● Dopamine agonists (e.g. bromocriptine, ropinerole, cabergoline, pramipexole) OR ● MAO-B inhibitors (e.g. rasagiline, selegiline) OR ● COMT inhibitors (e.g. entacapone, tolcapone) ○ Entacapone = acts peripherally b/c does not cross BBB ○ Tolcapone = acts centrally b/c crosses BBB ■ Last line tx? Levodopa-carbidopa ● Why last line? b/c only works few years then becomes less effective due to on-off phenomenon

● What drugs or drug class cause drug-induced Parkinsonism? ○ Dopamine receptor antagonists ○ Metoclopramide ■ 2 indications for metochlopramide? antiemetic, gastroparesis

● What anticholinergic drug reduces tremors of Parkinson’s diseases? Benztropine (muscarinic receptor antagonist)

● Parkinsonism in a young patient that took a “drug” at a party? MPTP-contaminated heroin

● DDx Parkinson disease vs essential tremor ○ Parkinson’s disease tremor = asymmetric resting tremor + improves with activity ○ Essential tremor = symmetric + worsens with activity + responds to propranolol

● What 2 drugs tx acute dystonias caused by pt taking dopamine antagonists? Benztropine, diphenhydramine ○ Pathophys? Dopamine antagonists cause Ach-dopamine imbalance → results in unopposed Ach overactivity) ○ Note: diphendramine works to tx acute dystonias b/c it has significant anticholinergic activity

● Tx of focal dystonia? Botox injection

● Tx for psychosis in pt with Parkinson’s disease?

DI Podcast Main Document 151 ○ Reduce dose of carbidopa-levodopa ○ Quetiapine (atypical antipsychotic with weak dopamine receptor antagonist activity)● What Parkinson’s disease drug causes hypertensive crisis? MAO-B inhibitors ○ Tx? Phentolamine (alpha-1 blocker)

● 35 yo F + BMI of 35 + visual difficulty + intermittent severe headaches + being treated for acne vulgaris. → idiopathic intracranial hypertension ○ Risk factors? ■ Obese female ■ Vit A derivatives ■ Tetracyclines (can be used as acne tx, as in this pt) ○ Ocular finding? Papilledema ○ Diagnostic? CT scan plus LP ■ CT scan → normal ■ LP → elevated opening pressure (>250) ○ Tx? ■ Acetazolamide ■ Serial LPs

● 41 yo M with 1 year of forgetfulness + behavioral changes. His father had similar presentation before dying at 47 y.o. → Huntington’s disease ○ Pathophys? Atrophy of caudate (part of striatum) ○ Trinucleotide repeats? CAG ○ Chromosome? 4 ○ Inheritance? AD ■ With anticipation! ○ Tx? Anti-dopaminergic drugs ■ Haloperidol ■ Tetrabenazine (VMAT inhibitors)

● Worst headache of patient’s life + bilateral flank masses. → SAH in pt with ADPKD ○ Pathophys? Rupture of berry aneurysm in circle of Willis ○ MC aneurysm location? ACom aneurysm (anterior communicating artery) ○ Associate heart murmur? MVP ○ NBSIM? CT head non-contrast (because blood will show up as hyperdense) ■ If CT is negative → do LP (looking for xanthochromia) ○ Tx? Lower pt’s BP to 140/90 ○ What drug is given to prevent superimposed ischemia? nimodipine

● Cluster headache ○ Sxs? Unilateral tearing/conjunctival injection/rhinorrhea, occurs for several days ○ Tx? 100% O2 and triptans

● Tension headache ○ Sxs? Bilateral + high-stress environment + worse at end of day DI Podcast Main Document 152 ○ Tx? NSAIDs

● Migraine headache ○ Sxs? Unilateral + pulsatile + photophobia & phonophobia +/- aura ○ Abortive tx? ■ Sumatriptan (5-HT receptor agonist) ● Contraindications? variant angina aka Prinzmetal angina, CAD, CREST syndrome ○ Can trigger serotonin syndrome ● Ergotamine ○ PPx? ■ Propranolol ■ Topiramate ■ TCA ● Contraindications? Elderly pt’s, glaucoma pt’s ○ Avoid with glaucoma (anticholinergic mydriasis) ■ CCB’s

● Analgesic rebound headaches ○ Sxs: use of analgesics at least 8-10x in last month; headache returns once analgesic effects wear off ○ Tx? Wean off analgesics

● Headache + mental status changes in patient using fireplace to warm house in winter → CO poisoning ○ Diagnostic? Carboxyhemoglobin levels ■ Note: Pulse O2 cannot distinguish between oxyhemoglobin and carboxyhemoglobin ○ Tx? High-flow O2 / hyperbaric O2 ○ Imaging? Hyperintense lesions in globus pallidus on MRI

● 35 yo smoker + right-sided headache + occurs everyday at same time for past month + PEx notable for rhinorrhea & pupillary miosis on right → cluster headache

Cross checked: Yes----------------------------------------------------------------------------------------------------------------------------

Ep. 46: Neurology Clerkship Shelf Review Part 3 ● A child is not doing well in school. His teacher often observes him staring into space with no awareness of his surroundings. → absence seizures ○ EEG pattern? 3 Hz spike and wave ○ Tx? Ethosuximide (T-type Ca++ channel blocker)

DI Podcast Main Document 153 ● 55 yo F presents with a 6 mo history of feeling like the room is spinning around her that lasts for about 3 days at a time. She has also had difficulty hearing at home. She also complains of a “ringing sound” in her ear. → Menierre’s disease ○ Triad: vertigo + tinnitus + sensorineural hearing loss ○ Pathophys? Endolymphatic hydrops, poor reabsorption of endolymph in ear → high pressures ○ Tx? ■ Dietary Na+ reduction ■ For vertiginous sxs: ● scopolamine (anticholinergic) meclizine (antihistamine, anticholinergic) ● diphenhydramine (antihistamine, anticholinergic) ■ Diuretics ○ Definitive tx? Gentamicin injection to ablate CN8 ■ Causes of permanent sensorineural hearing loss● Vertigo triggered by changes in position, NO hearing loss → BPPV ○ Pathophys? otoconia/otoliths in semicircular canals ○ Dx? Dix-Hallpike maneuver ○ Tx? Epley maneuver● Recent viral URI + constant non-positional vertigo, lasts for days to weeks before spontaneous resolution, NO hearing loss → Vestibular neuritis● Recent viral URI + constant vertigo + hearing loss → Labrynthitis

● Hit in the head with a bat, passed out for < 30s, finished out the game, now presents with severe headache and somnolence. → epidural hematoma ○ Pathophys? Fracture of frontal bone → tearing of the middle meningeal artery ○ Dx? Non-con head CT → lens-shaped hematoma ■ Do NOT perform an LP because increased ICP will cause herniation ○ Tx? ■ Neurosurgical evacuation ■ Reduce ICP ● Elevate head of bed ● Hyperventilate pt (CO2 down → cerebral vasoconstriction) ● Mannitol ■ What is the quickest means of reducing ICP acutely? Hyperventilation

● Old person on warfarin with multiple falls, acting out-of-it recently OR alcoholic → subdural hematoma ○ Pathophys? Brains shrink with aging or alcoholism, stretches the bridging veins, causing greater susceptibility to shearing ○ Dx? Non-con head CT → crest-shaped● Brain bleed in shaken baby → subdural hematoma

● Super tense muscles and T of 105 after intubation. → malignant hyperthermia ○ Pathophys? Mutation in the ryanodine receptor → increased release of Ca++ from the sarcoplasmic reticulum → hypercontractile state that generates heat ○ Inheritance? AD DI Podcast Main Document 154 ○ Tx? Dantrolene (ryanodine receptor antagonist) ○ Electrolyte disturbance? hyperkalemia → peaked T waves → wide QRS → sinusoidal pattern ■ Tx? ● 1st calcium gluconate ● Then insulin/glucose, albuterol, or sodium bicarb ● Kayexalate (helps excrete K+) ● Furosemide (loop diuretic with hypokalemia as side effect) ○ Why elevated Cr? ■ Rhabdomyolysis → myoglobin release → damages kidney ■ Tx? IVF● If same presentation after starting fluphenazine (1st gen high-potency antipsychotic) → neuroleptic malignant syndrome ○ Tx? ■ Dantrolene ■ Dopamine agonist (e.g. bromocriptine/cabergoline, amantadine)● Hx of depression + Tx for S. Aureus bacteremia (or migraines) presents with high fevers, diarrhea, clonus → serotonin syndrome ○ Drugs that can trigger ■ Any antidepressant ■ Linezolid ■ Ondensatron ■ Triptans ■ MAO-B ■ MDMA/ecstasy ○ Tx? ■ Cyproheptadine (antihistamine with powerful serotonin receptor blocking activity) ■ Benzo

● Tremors 6 hrs after the successful completion of a AAA repair in a business executive. → alcohol withdrawal ○ Ppx? Long-acting benzo (e.g.chlordiazepoxide, diazepam)● Tremors after starting Indapamide (thiazide-like diuretic) in a patient with a history of “eps” where they spend tons of money/jump into severe depression. → lithium toxicity in pt with bipolar disorder ○ Pathophys? Diuretics can raise lithium levels → lithium toxicity, which manifests as tremors ○ Causes of lithium toxicity? anything that causes RAS activation (aldosterone acts on principal cell to increase Na+ reabsorption → Li+ can allow be reabsorbed through this channel)

● Child presents with bulging fontanelles and somnolence. What is the most likely region of stenosis responsible for the presenting hydrocephalus? Cerebral aqueduct of Sylvius

● 70 yo F that is forgetful. She staggers into the exam room. She has a history of recurrent perianal sores from urinary incontinence. → “wet wobbly wacky” → normal pressure hydrocephalus ○ Dx? Non-con head CT with enlarged ventricles ■ LP → normal opening pressure ○ Tx? VP shunt DI Podcast Main Document 155 ● Tuberous sclerosis ○ Inheritance? AD ○ Mutated genes? TCS1 & TCS2 (tumor suppressor genes) ○ Mutated proteins? Hamartin & tuberin ○ Brain findings? Subependymal tumors (usually calcified) ○ Renal findings? Angiomyolipoma ○ Cardiac findings? Rhabdomyoma ○ Skin findings ■ Hypopigmented = ash leaf spots ■ Hyperpigmented = Shagreen patch ○ Kind of infantile seizure? West syndrome = infantile spasms ■ EEG findings? hypsarrhythmia ■ Tx? ACTH or vigabatrin

● Mom has a history of inconsistent condom use. She delivers a stillborn fetus with no brain. → anencephaly 2/2 Zika ○ Pathophys? Anterior neuropore fails to close ■ Polyhydramnios because no swallowing center● Dimple or tuft on hair in lumbosacral area → Spina bifida occulta ○ Pathophys? Failure of the spinous processes to fuse around the spinal cord ○ Usually causes no problems● Meningocele ○ Pathophys? Failure of fusion of the posterior neural arch → herniation of meningeal tissue and CSF ○ Associated deficiency in mom? folate ○ Tx? Surgery ○ Good prognosis after surgery● Myelomeningocele ○ Pathophys? Failure of neural tube to close → herniation of meninges and spinal cord tissue through defect ○ Associated deficiency in mom? folate ○ Tx? Surgery ○ Worse prognosis ○ Associated dz? Chiari 2 malformation● Type 1 Chiari malformation ○ Pathophys? Cerebellar tonsils herniate through foramen magnum ○ Associated dz? Syringomyelia (“Syr1ngomyelia”)● Type 2 Chiari malformation ○ Pathophys? Cerebellar tonsils herniate through foramen magnum ○ Associated dz? Lumbosacral myelomeningocele● Serum marker for NTD/spinal dysraphism? Elevated maternal serum AFP ○ Also elevated ACh esterase ○ What if msAFP is decreased? Down syndrome

DI Podcast Main Document 156 ● Subacute combined degeneration of spinal cord ○ Vitamin deficiency? B12 ○ Loss of dorsal columns → loss of vibration, touch, proprioception ○ Loss of lateral corticospinal tract → UMN signs ○ Differentiate folate & B12 deficiency with serum markers ■ Megaloblastic anemia in both ■ hom*ocysteine high in both ■ MMA high in ONLY B12 deficiency

● Cafe au lait spots + brown “pigments” in the axilla + “tuber like” skin growths + episodic headache and severe HTN. → NF-1 ○ Eye malignancy? Optic nerve gliomas ○ Iris finding? Lisch nodules ○ Brain malignancy? Meningioma ○ Neuroendocrine malignancy? Pheo ○ Ear malignancy? Bilateral acoustic neuromas/vestibular Schwannomas in NF-2 ■ Location? Cerebellopontine angle ○ Inheritance? AD ○ Gene? ■ NF-1 → neurofibromin ■ NF-2 → merlin ○ Chromosome ■ NF-1 → 17 ■ NF-2 → 22

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Ep. 47: Neurology Clerkship Shelf Review Part 4 ● Student in a lab is unknowingly touching a lighted bunsen burner in the chemistry lab until his hand is pulled away by the TA. PE is notable for loss of pain and temperature sensation in the UEs bilaterally and mild hand muscle weakness. → syringomyelia ○ Pathophys? Obstruction in the central canal of the spinal cord → cystic expansion of central canal caudally → compression of anterior while commissure → knocks of spinothalamic tract ○ Tracts involved? ■ Spinothalamic → loss of pain + temperature bilaterally ■ If left untreated, will expand and affect the ventral horn → motor sxs (UE first because these tracts are most medium) ○ Dx? MRI

● Nuchal rigidity in a recent immigrant presenting with hemoptysis and high fevers. There is marked “enhancement” at the base of the brain. → TB meningitis ○ Dx? ■ LP DI Podcast Main Document 157 ○ CSF findings? ■ Lymphocytic predominance ■ Protein HIGH ■ Glucose LOW ■ High OP ○ Tx? RIPE regimen + Vit B6 ○ Differentiating meningitis from encephalitis ■ Encephalitis → more neuro deficits, may not have nuchal rigidity ■ Meningitis → nuchal rigidity

● Most common neurologic sequelae of meningitis in kids → hearing loss● Top 3 causes of meningitis in neonates ○ GBS ○ E. coli ○ Listeria● Empiric tx for neonatal meningitis? Cefoxamine + vanc + ampicillin ○ Ceftriaxone can cause intrahepatic cholestasis in neonates● CSF studies in bacterial, viral, and fungal meningitis. ○ Bacterial ■ Neutrophilic predominance ■ Protein HIGH ■ Glucose LOW ○ Fungal ■ Lymphocytic predominance ■ Protein HIGH ■ Glucose LOW ○ Viral ■ Lymphocytic predominance ■ Protein high ■ Glucose low/normal ○ Patient with symmetric ascending paralysis after a recent bloody diarrheal infection → GBS after Campylobacter infection ■ CSF finding? Albuminocytologic dissociation ● Usually WBC & protein go up together ● In this case, high protein but new WBCs ○ 30 yo F with an afferent pupillary defect and other neuro findings → MS ■ CSF finding? Oligoclonal bands ■ Dx? MRI ○ CSF with a ton of RBCs ■ HSV encephalitis ■ Xanthochromia 2/2 SAH

● General treatment co*cktail for bacterial meningitis. ○ Ceftriaxone + vancomycin + steroids (CVS)

DI Podcast Main Document 158 ● What should be added in the elderly, immunocompromised, or super young (infants/neonates)? ampicillin● CSF studies with normal glucose, slightly elevated protein, and a lymphocytic pleocytosis → viral meningitis● Classic imaging and CSF findings in HSV meningitis OR encephalitis → enhancement of temporal lobes

● 25 yo M presents with a T of 103, severe headache, and a 2 day history of profound LE muscle weakness. He was recently treated for Otitis Media. → brain abscess ○ Triad: fever + HA + neurologic deficit ■ No nuchal rigidity ○ Dx? MRI ○ Tx? Drain abscess + steroids to decrease swelling + abx ○ What is the bug that is classically associated with meningitis with MRI enhancement at “the base of the brain”? TB

● 35 yo zoologist is brought to the ED by ambulance after becoming unresponsive at home. He studies cave dwelling animals. Over the past 2 weeks he has resisted attempts by his parents to give him water or get him to the shower. → rabies ○ Prevention? Rabies immunoglobulin + vaccine (at two different sites) ○ Pathognomonic histologic finding? Negri bodies

● Bilateral acoustic neuromas → NF-2 ○ Inheritance? AD ○ Gene? Merlin ○ Chromosome? 22 ○ Involved cranial nerve? CN8 ○ Classic brainstem location? Cerebellopontine angle ○ Dx? MRI

● Port wine stain + glaucoma + seizures + ID + tram track CT calcifications → Sturge-Weber syndrome ○ Inheritance? Non-heritable! Sporadic! ○ Gene? GNAQ activating mutation

● Woman with trouble sleeping due to weird sensations in legs → restless legs syndrome ○ Associated dz? IDA ○ Tx? ■ pramipexole/ropinirole ■ primidone

● Pt that has paresthesias over palmar aspect of hand (+ thenar atrophy → carpal tunnel syndrome ○ Associations ■ RA ■ Pregnancy ■ Hypothyroidism ○ PE maneuvers DI Podcast Main Document 159 ■ Tinnel’s sign (tapping over carpal tunnel) ■ Phalen sign (flexed wrists) ○ Tx? ■ Wrist splint ■ NSAID ■ Inject steroids ■ Carpal tunnel release ○ What should be done to confirm the dx before pursuing surgery? Nerve conduction study!----------------------------------------------------------------------------------------------------------------------------

Ep. 48: Neurology Clerkship Shelf Review Part 5 ● 32 yo Asian M presents with severe R eye pain. PE reveals a “rock hard” unreactive pupil. → acute-angle glaucoma ○ Dx? Tonometry (eye pressures) ○ Tx? ■ Usually requires surgery: laser iridotomy ■ Medical management ● Mannitol (lows IOP by drawing water out of the vitreous humor of the eye and into the intravascular space) ● Acetazolamide (decreases aqueous humor production) ● Timolol (decreases aqueous humor production) ● Pilocarpine (muscarinic agonist, constricts pupil)

● A 3 yo F is brought to the ED by her dad. She has been using the potty continuously for the last 3 hrs. PE is notable for pupillary miosis and profuse sweating. She played in the farm this morning. → organophosphate poisoning ○ Pathophys? Organophosphates inhibit ACh esterase → ACh levels rise → parasympathetic overactivation ○ Tx? Atropine (blocks AChR) + pralidoxime (regenerated AChE)

● Flaccid paralysis after consuming home canned goods. → botulism ○ Pathophys? Botulinum toxin cleaves SNARE proteins → prevents release of ACh from presynaptic neuron ○ Tx? ■ Botulinum immune globulin ■ Intubate for respiratory support ○ Contrast to tetanus, which will have a spastic paralysis ■ Pathophys? tetanus toxin prevents the release of glycine & GABA (inhibitory NTs) from Renschaw cells → spastic paralysis ● Difficulty getting out of a chair in a patient with a 45 pack year smoking history that improves with muscle use. → LEMS ○ Pathophys? Ab to the presynaptic voltage-gated Ca++ channel ○ Increment in muscle contraction with repetitive nerve stimulation ○ Associated malignancy? Small cell lung cancer DI Podcast Main Document 160 ● Difficulty swallowing and droopy eyelids in a 35 yo F with an anterior mediastinal mass → myasthenia gravis in s/o thymoma ○ Pathophys? Ab against nicotinic AChR ○ Decrement in muscle contraction with repetitive nerve stimulation ○ Dx? anti-AChR antibodies ■ Not Tensilon test anymore ○ Tx? ■ AChE inhibitors (e.g. pyridostigmine) ■ Resection of thymoma ○ In addition to tx with AChE what is NBSM? Chest CT (look for thymoma) ○ How is this condition differentiated from ChAT deficiency? ■ ChAT = choline acetyltransferase ■ ChAT deficiency sxs will not improve with AChE therapy● Anticholinergic toxidrome = “hot as a desert, dry as a bone, red as a beet, blind as a bad, mad as a hatter” ○ Classic meds: ■ Diphenhydramine ■ TCAs ■ 1st gen low potency antipsychotics (e.g. chlorpromazine)

● Tongue fasciculations in a 6 mo. → SMA (spinal muscular atrophy) ○ Inheritance? AR ○ Pathophys? Pure LMN disease ○ Mutated gene? SMN1 ○ Chromosome? 5 ○ Viruses that affect anterior horn cells? ■ Polio ■ West nile● Tongue fasciculations in a 65 yo M with asymmetric weakness. → ALS ○ UMN + LMN problems ○ Pathophys? Destruction of the UMNs (corticospinal/corticobulbar tract), LMNs (anterior horn of spinal cord), and cranial nerves ○ Genetic mutation in familial cases? SOD1, C9orf72 ○ What is spared in ALS? Sensation, bowel/bladder function, extraocular muscles ○ EMG findings? Chronic denervation, fibrillation potentials ○ Tx that improves survival? ■ Riluzole (NMDA receptor antagonist, reduce glutamate excitotoxicity) ■ Bipap ○ Tx for spasticity? ■ Baclofen (GABA receptor agonist) ■ Tizanidine (alpha-2 agonist) ■ Botox injection

DI Podcast Main Document 161 Dermatomyositis Polymyositis

Kids AdultsCD4+ T-cells CD8+ T-cells (poly so it’s more)Perifascicular damage Endomysial damage

● Dermatomyositis/polymyositis ○ Ab? Anti-Jo1, anti-Mi-2, anti-SRP ○ Dx? ■ 1st muscle MRI ■ 2nd muscle biopsy ○ Lab findings? Elevated creatinine kinase ○ Associated malignancy? Lung cancer (especially small cell)

● Dysarthria + truncal, gait, and limb ataxia in a patient that is subsequently found to have lung cancer → paraneoplastic cerebellar degeneration ○ Associated malignancies? ■ Lung ■ Breast ○ Ab? Anti-Hu, anti-Yo ○ Pathophys? Tumors express cerebellar proteins, immune system tries to attack tumor but also mounts response against cerebellum

● Confusion, ophthalmoplegia, and ataxia in an alcoholic. → Wernicke’s syndrome ○ What if there’s also forgetfulness & confabulation → Korsakoff’s syndrome ○ Tx? IV thiamine (Vit B1) ● Pharmacological management of hepatic encephalopathy ○ Lactulose (convert ammonia to ammonium, which you poop out) ○ Rifaximin (a lot of ammonia comes from bacteria in GI tract)

● Simple partial seizures = focal seizure w/o loss of awareness ○ Is there a loss of consciousness? NO ○ 4 types: motor, sensory, autonomic, psychic ■ Rigidity or jerking of extremity → motor ■ Hissing sound or can’t see or smell burnt rubber → sensory ■ Sweating, mydriasis, rising sensation in abdomen → autonomic ○ Auras that localize to temporal lobe ■ Smelling burnt rubber ■ Deja vu ■ Rising sensation in abdomen

● Required imaging before recommending sports in a 12 yo with a history of Trisomy 21. Why? High risk of atlanto-axial instability/subluxation ○ Dx? Lateral neck XR ○ Another patient population at risk? DI Podcast Main Document 162 ■ RA ■ Ankylosing spondylitis

● 25 yo M goes into respiratory failure. He recently recovered from a 7 day ep of bloody diarrhea. PE is notable for pronounced areflexia in the LE bilaterally. His parents report that he had muscle weakness that “started in the legs and progressed upward”. He initially complained of leg tingling and numbness before his other sxs started. → GBS ○ Alternative term? AIDP (acute inflammatory demyelinating polyneuropathy) ○ Pathophys? Peripheral demyelinating disease ■ Cells affected? Schwann cells ○ Classically associated bug? Campylobacter jejuni ○ CSF findings? Albuminocytologic dissociation ○ Tx? ■ IVIG ■ Plasmapheresis● GBS-like presentation + nystagmus + ataxia? Miller-Fisher syndrome

● Pt that has syncope or neuro deficit when they use their arms → subclavian steal syndrome ○ Pathophys? Proximal subclavian stenosis → low pressure system distal to stenosis → reversal of blood flow in vertebral arteries → “stealing” blood from basilar → hypoperfusion to brainstem

DI Podcast Main Document 163 WEBER & RINNE TESTS ● Weber test compares bone conduction between ears

DI Podcast Main Document 164 ○ Normally, it should be the same in both ○ If Weber lateralized to the R ear, there are TWO possibilities: ■ Conductive hearing loss in R ear ■ Sensorineural hearing loss in L ear● Rinne test compares air conduction to bone conduction for each ear (single ear test) ○ Normally, air conduction is better than bone conduction ○ If bone conduction is better than air conduction, it implies conductive hearing loss

● Meningitis in a HIV+ patient → cryptococcus neoformans ○ How to ID? ■ India ink stain ■ Latex agglutination test ○ Tx? ■ Acutely: Amphotericin B + 5-flucytosine ■ Chronically: fluconazole

● Multiple ring enhancing lesions on MR imaging in a HIV+ patient → toxoplasmosis or primary CNS lymphoma ○ Toxoplasmosis ■ Tx? Pyrimethamine & sulfadiazine ■ Ppx for CD4 < 100? TMP-SMX ○ Primary CNS lymphoma - usually single lesion ■ Infectious association? EBV

● MMSE is 20/30 in a patient with a CD4 count of 25 and a high viral load. He last saw his PCP after an initial dx 21 yrs ago → HIV-associated dementia ○ Poor prognosis ○ Tx? ■ HAART ■ Alzheimer’s drugs (e.g. rivastigmine, galantamine, donepezil)

DI Podcast Main Document 165 ● HIV+ patient with neuro deficits and multiple areas of demyelination on MR imaging → progressive multifocal leukoencephalopathy ○ Infectious agent? JC virus ○ Cause of drug-induced PML? Natalizumab ■ Indication? MS ■ Mechanism? Alpha-4 integrin inhibitor

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Ep. 49: Neurology Clerkship Shelf Review Part 6 ● Multiple neuro deficits in a kid after getting the VZV vaccine or after an URI. → ADEM (acute disseminated encephalomyelitis) ○ Pathophys? Inflammatory demyelinating lesions in brain & spinal cord ○ Dx? MRI ○ Prognosis? Full recovery

● Multiple Sclerosis ○ Classic presentations? Female in her 30s with disparate neuro deficits ■ Uhthoff's phenomenon = sxs worse in heat ○ CN2 pathology? Optic neuritis ■ Presentation? Unilateral eye pain + decreased visual acuity (e.g. 20/200) + afferent pupillary defect ○ Associated Vit deficiency? Vit D ■ Higher prevalence in places farther from the equation ○ Dx? MRI brain & spinal cord ■ Multiple demyelinating lesions separated in space & time ○ LP findings? Oligoclonal bands ○ Exam findings? ■ APD ■ Lhermitte's sign = electric shock with neck flexion ○ Tx acute exacerbation? Very high-dose corticosteroids ○ Tx chronic/DMARDs? ■ Fingolimod ■ Natalizumab ● Mechanism ● AE? JC virus reactivation → PML ■ Glatiramer ■ Rituximab ■ Interferon-beta ○ Tx urge & overflow incontinence? ■ Urge → oxybutynin, trospium, darifenacin/solifenacin, tolterodine ● Detrusor muscles are hyperactive, so quiet them down with an antimuscarinic ■ Overflow → bethanechol, neostigmine DI Podcast Main Document 166 ● Alternative? Intermittent self-cath ● Destrusor hypotonia, so activate detrusor with muscarinic agonists or AChE-inhibitors ● High PVRs ○ Tx of spasticity? ■ Baclofen (GABA-B receptor agonist) ■ Tizanidine (alpha-2 agonist → decreases norepi release) ■ Dantrolene (CCB) ■ Benzos (GABA-A receptor agonist) ■ Botulinum toxin for localized spasticity

● Pt sees blood or has emotional stressor then passes out → vasovagal syncope ○ Dx? Tilt table test ○ Tx? Midodrine (alpha-1 agonist)

● Most common cause of death in patients with Factor 8/9 deficiencies? Hemorrhagic stroke ○ Pathophys? Defect of secondary hemostasis ○ Inheritance? X-linked recessive

● Stepwise diagnostic testing in stroke management. ○ 1st dx step? Non-con head CT ■ Why? Differentiate b/t hemorrhagic & ischemic stroke ○ If NCCT is negative? Diffusion-weighted MRI ○ Additional diagnostics? ■ Carotid artery duplex US of internal carotid arteries ■ Echo to look for LA appendage thrombus or PFO ○ Initial tx for ischemic stroke? ■ Aspirin ■ If aspirin isn’t an answer choice, choose another antiplatelet agent ● Clopidogrel ● Dipyridamole ■ Do NOT give anticoagulant unless A-fib ○ If high suspicion for SAH but NCCT negative? LP → look for xanthochromia ■ Tx for SAH? Lower BP + nimodipine

● Paralysis of ipsilateral upper and lower facial muscles, dry mouth, loss of lacrimation → LMN CN7 lesion ○ Pathway? ■ CNs (except CN2) are LMNs ■ UMNs comprise the corticobulbar tract (connect cerebral cortex to CNs) ● Decussate prior to synapsing with CNs ■ CN7 also carries parasympathetic fibers ○ Why ipsilateral? Decussation happens upstream to CN7● Paralysis of lower facial muscles, sparing of upper face→ contralateral corticobulbar tract lesion ○ Why contralateral? corticobulbar tract decussates BEFORE synapsing on CN7 nucleus

DI Podcast Main Document 167 ○ Why upper face sparing? Bilateral corticobulbar pathways that synapse on the CN7 nucleus (so you have to knock out both corticobulbar pathways to affect the upper face)

● Loss of facial sensation, jaw deviation to the ipsilateral side, impaired corneal reflex. → CN5 (trigeminal) ○ Pathways? ■ Facial sensation is carried by CN5 ■ Corneal reflex ● Afferent = CN5 ● Efferent = CN7 ■ CN5 provides motor innervation to muscles of mastication (e.g. masseter, pterygoids, temporalis)● Anosmia → CN1 ○ Associated syndrome? Kallman’s syndrome ■ Presentation? Anosmia + hypogonadotropic hypogonadism ■ Pathophys? Failure of GnRH neurons & olfactory neurons to migrate● Mydriasis with the eye deviated down and out. → CN3 (oculomotor) ○ Pathways? ■ CN3 innervates all muscles of eye except superior oblique (CN4 trochlear) & lateral rectus (CN6 abducens) ■ CN3 also carries parasympathetic fibers to go to pupillary constrictors ○ Why down & out? ■ Lateral rectus → abduction

DI Podcast Main Document 168 ■ Superior oblique → depression ○ Causes of CN3 lesions? ■ PCom aneurysm ■ Uncal herniation ○ For compression lesions, mydriasis often happens before eye deviation ■ Why? Parasympathetic fibers run on the outside of CN3 (so more susceptible to compression) ○ For ischemic lesions (e.g. due to DM), eye deviation will happen first

● Bitemporal hemianopsia (“tunnel vision”), afferent pupillary defect. → optic chiasm compression ○ Causes? ■ Pituitary adenoma ■ Craniopharyngioma ■● Contralateral lower facial weakness with forehead sparing and loss of taste sensation with the anterior ⅔ of the tongue. → UMN CN7 lesion ○ Pathways? ■ General sensation anterior ⅔ tongue → CN5 ■ Taste anterior ⅔ tongue → CN7● Horizontal diplopia with failed abduction on lateral conjugate gaze. → CN6 lesion● Vertical diplopia with the jaw tilted towards the side of the lesion + difficulty going down stairs. → CN4 (trochlear) lesion ○ Pathway? ■ Trochlear emerges dorsally & crosses to opposite side ■ It’s the only CN that decussates ○ Note that the head tilt if TOWARDS the side of the lesion

DI Podcast Main Document 169 ● Sensorineural hearing loss, vertigo, and abnormal caloric test results. → CN8 (vestibulocochlear nerve) ○ Caloric test results → COWS mnemonic (cold opposite, warm same)● Deviation of the protruded tongue to the ipsilateral side. → CN12 ○ Mnemonic “Lick your wounds” ○ Pathway? Innervates all intrinsic muscles of the tongue except palatoglossus (innervates by CN10)● Weakness in shoulder shrug + problems turning the head to the opposite side. → CN11 (spinal accessory nerve)

DI Podcast Main Document 170 ● Loss of taste sensation in the posterior ⅓ of the tongue + dysphagia + absent gag reflex. → CN9 or 10 ○ Pathways? ■ Taste posterior ⅓ of tongue → CN9 ■ General sensation posterior ⅓ of tongue → CN9 ■ Taste extreme posterior tongue → CN10 ■ General sensation extreme posterior tongue → CN10 ■ Gag reflex ● Afferent limb → CN9 ● Efferent limb → CN10● Innervates the superior oblique muscle → CN4 (trochlear)● Innervates the lateral rectus → CN6 (abducens) ○ Location? medially● Anosmia + hypogonadotropic hypogonadism → Kallmann syndrome● Differentiating between an afferent and efferent pupillary defect ○ Assume R-sided lesion ○ APD ■ Shine light into R eye → nothing ■ Shine light into L eye → bilateral constriction ○ EPD ■ Shine light into R eye → only L constriction ■ Shine light into L eye → only L constriction ■ Eye with the defect doesn’t constrict regardless

DI Podcast Main Document 171 ● Most common pediatric brain tumor → pilocytic astrocytoma ○ Location? Posterior fossa● Hemorrhagic lesion in the cerebellum with a path specimen revealing some kind of rosette (perivascular, Homer Wright) → medulloblastoma ○ 2nd MC pediatric brain tumor ○ Location? Cerebellum ○ Presentation? Ataxia + elevated ICP ○ Associated syndrome? Turcot syndrome (colon cancer + brain tumors)● Brain tumor that drains “motor oil fluid” and is calcified/could present with tunnel vision → craniopharyngioma ○ Presentation? Bitemporal hemianopsia 2/2 optic chiasm compression ○ Embryologic origin? Rathke’s pouch ○ Location? Sella turcica ○ Imaging? Calcified● Kid with abdominal mass that crosses midline with calcifications on imaging → neuroblastoma ○ Alternate location? Posterior mediastinum ○ Presentation? Opsoclonus myoclonus syndrome (“dancing eyes, dancing feet”)

● Neck pain radiating to the arm with specific dermatomes affected and multiple peripheral nerves involved → cervical radiculopathy ○ Pathophys? Problem with the nerve ROOT ■ Versus myelopathy, which is a problem with the spinal cord

● Complete paralysis of the face, arms, and legs with no sensory losses and contralateral “clumsiness” → internal capsule lesion (subcortical lesion) ○ Pathway? Motor fibers from the cortex condense and form the posterior limb of the internal capsule ○ Artery involved? Lenticulostriate arteries

● Inability to calculate + eyes looking towards the side of the lesion + facial paralysis contralateral to the side of the lesion + UMN signs → cortical stroke ○ Acalcula → dominant parietal lobe lesion ■ Contrast with nondominant parietal lobe (often R) lesion → L-sided hemineglect ○ Eyes looking toward side of the lesion → frontal eye field lesion ■ R front eye field → L PPRF→ controls L abducens and R oculomotor ■ R frontal eye field lesion → no communication to L PPRF → R PPRF unopposed → R deviation

● Complete sensory loss on the left + severe pain on the right → lesion of the thalamus (subcortical lesion)

● Ataxia, past pointing, impaired rapid alternating movements (dysdiadochokinesia), and intention tremor → ipsilateral cerebellar lesion

DI Podcast Main Document 172 ● Bowel/bladder dysfunction + UMN and LMN findings + sensory level → spinal cord compression ○ E.g. cauda equina syndrome ○ UMN findings below level of lesion ○ LMN findings at level of lesion

● Trouble swallowing + problems with eye adduction on conjugate gaze + sensory loss on the left face + sensory loss on the “right body” → lateral medullary syndrome (Wallenberg syndrome) ○ Pathophys? ■ Sensory loss L face → L spinal trigeminal nucleus ■ Sensory loss R body → L spinothalamic tract ■ Trouble swallowing → nucleus ambiguus lesion (supplies CN9/10) ○ Affected arteries? PICA

● Hemiballismus and bradykinesia → contralateral subthalamic nucleus lesion

● Stocking/glove distribution of sensory loss + LMN findings → peripheral nerve lesion

● Trouble rising from the seated position + Elevated CK → polymyositis/dermatomyositis ○ Pathophys? Problem at the level of the muscle

● Fatigable muscle weakness → neuromuscular junction issue (e.g. MG)

● 4 signs of a basilar skull fracture. ○ Bruising behind mastoid (“Battle's sign”) ○ Raccoon eyes ○ CSF rhinorrhea ○ CSF otorrhea

● peripheral neuropathy vs. radiculopathy ○ One nerve involved, stocking-glove distribution → peripheral neuropathy ○ Multiple nerves involved, dermatomal distribution → radiculopathy

● Weakness in shoulder abduction/deltoid paralysis. → axillary nerve lesion ○ Cause? ■ Anterior shoulder dislocation ■ Surgical neck fracture● Weakness in foot eversion and dorsiflexion → peroneal nerve lesion ○ DroPED → peroneal nerve lesion/eversion/dorsiflexion● Weakness in foot inversion and plantarflexion → tibial nerve lesion ○ TIP → tibial/inversion/plantarflexion● Weakness in wrist extension. → radial nerve lesion ○ Cause? Midshalf fracture of humerus ○ Reflex supplied by radial nerve? triceps● Problems with thumb abduction with sensory losses on the ventrolateral 3.5 digits. → medial nerve compression in CTS DI Podcast Main Document 173 ○ Pathophys? Compression of medial nerve by flexor retinaculum ○ Risk factors? ■ Pregnancy ■ RA ■ Hypothyroidism ● Problems with hip flexion → femoral nerve ○ F for Femoral and Flexion ● Problems with hip adduction. → obturator nerve ○ Also cannot internally rotation ○ Lots of AIR between thighs (AIR = adduction/internal rotation) ● Weakness with finger spread and problems with flexion at the MCPs and extension at the IP joints → ulnar nerve lesion ○ Pathophys? Ulnar nerve supplies the dorsal interossei, whose function is finger aBduction (spreading) + MCP flexion + IP joint extension ● Nerve roots controlling the following reflexes: ○ Biceps → C5/6 ○ Triceps → C7/8 (radial nerve) ○ Knee extension/patellar tendon reflex → L3/4 ○ plantarflexion/ankle jerk reflex → S1/2 ● Nerve roots associated with the following levels: ○ Nipple line → T4 ○ Xiphoid process → T7 ○ Umbilicus → T10

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Ep. 58: Neurology Clerkship Shelf Review Part 7

● Discussion of the pathway/information carried by the 3 HY spinal cord tracts: ○ DC-ML ■ Fine touch, vibration, proprioception ■ 1st order: ascends in the dorsal spinal cord → fasciculus gracilis/cuneatus → ascend ipsilaterally to caudal medulla → SYNAPSE ■ 2nd order: nucleus gracilis/cuneatus → decussates in medulla → ascend contralaterally as medial lemniscus → thalamus → SYNAPSE ■ 3rd order: thalamus → postcentral gyrus

○ Spinothalamic tract ■ Pain & temperature ■ 1st order: rises 1-2 levels → SYNAPSE ■ 2nd order: decussates via anterior white commissure → ascends contralaterally through lateral spinal cord & lateral brainstem → thalamus → SYNAPSE

DI Podcast Main Document 174 ■ 3rd: thalamus → postcentral gyrus

○ Corticospinal tract ■ Motor pathway ■ 1st order: precentral gyrus → travel medially in brainstem → pyramidal decussation (medulla) → ventral spinal cord → SYNAPSE ■ 2nd order: anterior horn motor neurons (LMN) → skeletal muscle

● Romberg test = close eyes while standing with feet together ○ Test of dorsal column function (proprioceptive ability) ○ Need ⅔ things to know where you are in space ■ Vision ■ Vestibular system ■ Dorsal columns ○ Examples where Romberg will be positive: ■ 3ary syphilis with tabes dorsalis

● Rapid alternating movement ○ Dysdiadochokinesia = inability to perform rapid alternating movements ○ Test for cerebellar ataxia

● Homunculus ○ Most medial: leg ○ In between: arm ○ Lateral: face

● Truncal ataxia is indicative of lesion in what location? Cerebellar vermis

DI Podcast Main Document 175 CIRCLE OF WILLIS & INFARCTION SYNDROMES

● Anterior spinal artery ○ Supplies medial medulla ○ Infarction → tongue deviation (CN12), contralateral hemiparesis (CST) ○ AAA repair: can infarct artery of Adamkowitz, which is precursor artery to ASA → anterior spinal cord syndrome ■ Lose everything in cord except for dorsal columns ● PICA ○ Supplies lateral medulla ○ Infarction → uvular deviation, swallowing issues, loss of gag reflex (CN9/10)

● AICA ○ Supplies lateral pons ○ Infarction → facial drop (CN7), CN8 dysfunction, Horner’s syndrome (hypothalamic-sympathetic tract), pain & temp (spinothalamic tract)

● Basilar ○ Supplies medial pons

DI Podcast Main Document 176 ○ Infarction → “locked in syndrome”

● Posterior cerebral artery ○ Supplies the midbrain & primary visual cortex (occipital lobe) ○ Infarction → cortical blindness (loss of vision everywhere except macula) ■ Macula has dual blood supply from PCA & MCA

● CN3 courses between the superior cerebellar artery & posterior cerebral artery

● PCom runs along CN3 ○ PCom aneurysm → compression of CN3 → parasympathetic fibers lie on the outside → loss of efferent limb of pupillary light reflex

● Most common location for aneurysms? ACom

● Anterior cerebral artery ○ Supply medial cerebral cortex ○ Infarction → LE paralysis

● Headache that is worse with sitting upright and better with lying down after a lumbar puncture → post-LP headache (“spinal headache”) ○ Pathophys? CSF leak after LP → lower intracranial/intraspinal pressures → loss of cushion ○ Tx? ■ Usually self-limited ■ Can do a blood patch ■ Caffeine for pain

CN3 LESIONS ● Isolated mydriasis with sparing of other CN3 functions. Down and out pupil without mydriasis → CN3 compression ○ Pathophys? Parasympathetic fibers are on the outside, so are most affected by compression ○ What aneurysm could cause this? PCom

● Down and out pupil without mydriasis ○ Pathophys? Ischemia of CN3 → infarction of deep vasculature that supplies motor fibers, but outer parasympathetic fibers are supplied by vessels on the surface of the nerve DI Podcast Main Document 177 ○ Associated condition? DM

● Down and out pupil + Mydriasis + weakness of other extraocular muscles + sensory loss over the forehead → CN3/4/6 + V1 affected → cavernous sinus thrombosis ○ Pathophys? CN3/4/5 + V1 + V2 run through the cavernous sinus

● Down and out pupil + Mydriasis + Contralateral motor paralysis → uncal herniation ○ Pathophys? Uncal herniation → CN3 compression + brainstem compression (contralateral motor deficits bc it occurs before decussation in the medulla)

CN7 LESIONS

● Recall: cranial nerves are the LMNs for the skeletal muscle in the head & neck ○ Derived from neural crest (except CN2, which is an outgrowth of the diencephalon so derived from neural tube) ○ Corticobulbar tract = UMN for cranial nerves ○ UMN cranial nerve lesion → contralateral deficit ○ LMN cranial nerve lesion → ipsilateral deficit ■ Go straight from nucleus to skeletal muscles ■ Exception: trochlear nerve (also decussates) ● UMN trochlear nerve lesion → ipsi deficit ● LMN trochlear nerve lesion → contra deficit

● UMN CN7 lesion → contralateral facial droop with forehead sparing ○ Pathophys? Cortical infarct ○ Why forehead sparing? Bilateral UMN innervation for forehead ○ Associated deficit? Hemiparesis on same side as facial droop

● LMN CN7 lesion → ipsilateral facial droop

● Bell’s palsy ○ Presentation? Can’t close mouth / can’t close eye on one side ○ Pathophys? LMN CN7 lesion ○ Causes? ■ Lyme disease ● Bug? Borrelia berdoferi ● Vector? Ixodes tick ■ HSV ■ MS ■ Sarcoid ○ Tx? ■ Eye drops for affected eye ■ Steroids ■ Acyclovir if presumed 2/2 HSV

DI Podcast Main Document 178 ● CN most susceptible to elevated ICP? CN6 (abducens nerve)

● 55 yo F presents with severe headache that is concentrated just over her right eye. History of jaw pain when chewing nuts and proximal shoulder pain relieved by low-dose prednisone → temporal arteritis ○ NBSM? High-dose steroids BEFORE biopsy ○ Dx? Temporal artery biopsy ■ If one side is negative, biopsy the other side! ○ Lab findings? ■ High ESR/CRP

● 39 yo F with PMH of MS presents with severe left eye pain + decreased vision. The right and left eye do not constrict when light is shone in the left eye. → APD 2/2 optic neuritis ○ Pupillary light reflex? CN2 afferents → pretectal nucleus → CN3 efferents ○ Dx? Slit-lamp exam ○ Tx? Steroids

● 65 yo M with a past history of DM and CAD presents with a 5 day hx of decreased vision/floaters in his right eye. Funduscopic exam reveals retinal venous engorgement and diffuse hemorrhage → retinal detachment ○ Dx? US eye or ophthalmoscopy ○ Tx? Retinal reattachment procedure

● Same patient presents with the sudden loss of vision in his R eye. Funduscopic exam is notable for optic disc pallor and a cherry red spot on the macula. → central retinal artery occlusion (CRAO) ○ Dx? ■ Usually a clinical dx, but can use fluorescein angiography if needed ■ Carotid US (usually embolic from carotid plaque) ○ Tx? ■ Ocular massage ■ intra-arterial tPA

● Transient loss of vision in the same patient with a return to baseline after 10 mins. He says that it felt like a “curtain coming down” → amaurosis fugax ○ Pathophys? TIA of the eye ○ Future complication? stroke ○ Dx? ■ Carotid US

● Ischemic strokes ○ Time window for TPA administration? Within 4.5 hrs ○ Medical therapy for most strokes? Antiplatelet agent ■ Aspirin ■ Clopidogrel

DI Podcast Main Document 179 ○ What is the only scenario that is amenable to a consideration of heparin/warfarin administration in a stroke setting? A-fib

A = optic nerve → loss of vision in one eyeB = optic chiasm → heteronymous hemianopsiaC = optic tract → hom*onymous hemianopsiaD = Meyer’s loop (lower fibers) → “pie in the sky”/superior quadrantanopiaE = visual cortex → hom*onymous hemianopsia with macular sparing

● Underlying mass in a child that presents with bitemporal hemianopsia? Craniopharyngioma ○ Imaging? Calcified suprasellar mass ○ Derived from? Rathke’s pouch

● Underlying mass in an adult that presents with bitemporal hemianopsia? Pituitary adenoma

● In a cerebral cortex stroke, how would the eyes deviate in conjugate gaze (vs a brainstem stroke)? Toward the side of the lesion ○ “Into the hole, away from the fire” ■ Same side in cortical strokes ■ Opposite side in seizures ○ R frontal eye field → decussates → L PPRF → controls L CN6 & R CN3 (connected by MLF) ○ Pathophys (R lesion)? Loss of R frontal eye field → L CN6 & R CN3 not working → R CN6 & L CN3 unopposed → R gaze ○ What side would have hemiparesis? Contralateral

DI Podcast Main Document 180 ● In a brainstem stroke, how would the eyes deviate in conjugate gaze? Away from the side of the lesion ○ Pathophys (R lesion)? Loss R PPRF → R CN6 & L CN3 not working → L CN6 & R CN3 unopposed → L gaze ○ What side would have hemiparesis? Contralateral ■ Lesion is before decussation of corticospinal tract in medulla

● A patient with a history of MS presents with a R abduction nystagmus and impaired L eye adduction when asked to look to the right. → INO ○ Pathophys? MLF lesion ipsilateral to the eye that can’t adduct ■ L MLF lesion → signal doesn’t get to L CN3 (can’t adduct L eye)

● Ptosis + miosis + anhidrosis → Horner’s syndrome ○ Locations: ■ Sympathetic trunk (Pancoast tumor) ■ Lateral brainstem stroke ○ Contract with cluster HA, which will have ptosis + miosis but NO anhidrosis

● 19 yo M visited a chiropractor for some neck massages 2 hrs ago. He was brought to the ED by ambulance after complaining of right sided neck pain. PE is notable for right sided pupillary ptosis and miosis. There are no left sided findings. → carotid artery dissection 2/2 neck trauma ○ Dx? CT/MR angiography

DI Podcast Main Document 181 DI Podcast Main Document 182 DI Podcast Main Document 183 ----------------------------------------------------------------------------------------------------------------------------

Ep. 59: Neurology Clerkship Shelf Review Part 8 ● Paresthesias in pt being treated for TB? INH toxicity

DI Podcast Main Document 184 ○ Prevention? Vit B6 (pyridoxine)

● Pt with hx of poorly treated Crohn’s disease now with paresthesias + loss of proprioception + lower extremity hyperreflexia → B12 deficiency ○ Pathophys: ■ Crohn’s destroys the terminal ileum, where B12-IF is absorbed ■ B12 deficiency → subacute combined degeneration of spinal cord ● Destroy dorsal columns → loss of proprioception, vibration, and fine touch ● Destroy lateral corticospinal tract → UMN signs (spasticity, hyperreflexia) ■ Dx? Macrocytic anemia on CBC + high MMA + high hom*ocysteine ■ Schilling’s test: inject B12 then give radiolabeled oral B12, everything is saturated so oral B12 should go to urine → if not, it indicates pernicious anemia or terminal ileum disease. ● Then give radiolabeled oral B12 + IF. ● If you see B12 in the urine now, the problem is pernicious anemia. ● If not, it’s probably a terminal ileum absorption issue ○ D-xylose test will be abnormal ■ Tx? Supplementation

● Ataxia and hemolytic anemia in a pt with hx abetalipoproteinemia. MRIb shows cerebellar atrophy. → Vit E deficiency ○ Pathophys? deficiency in microsomal triglyceride transfer protein which is necessary for creating beta-lipoproteins (ApoB48 & ApoB100), which transport fats, cholesterol, and fat-soluble vitamins from intestines to bloodstream ○ Peripheral blood smear finding? Acanthocytosis

● Mamillary body infarcts in a chronic alcoholic. → Wernecke’s syndrome ○ Pathophys? Thiamine (B1) deficiency

● Dermatitis and dementia in a patient with a long history of carcinoid syndrome. → pellagra → 2/2 niacin deficiency ○ Pathophys? All of the tryptophan is shunted towards serotonin production, so niacin cannot be produced ○ Dx of carcinoid? Urine 5-HIAA (serotonin metabolite) ○ Other causes of pellagra? ■ Hartnup disease ● Pathophys? Defect in neutral amino acid transporter

● Child with chronic abdominal pain and foot drop who over the past 6 mo has been performing poorly in school. → lead poisoning ○ Peripheral blood smear findings? ringed-sideroblast ○ Dx? Blood lead levels ■ Confirmatory test? Venous lead level ○ Tx? Lead chelator ■ EDTA ■ succimer DI Podcast Main Document 185 ● Weird lines on the fingers + garlic breath. → arsenic poisoning ○ Derm findings? Mees lines (horizontal white lines) on nails

● Child with declining grades and many staring eps → absence seizures ○ Seizure type? Generalized seizure ○ EEG findings? 3 Hz spike-and-wave ○ Tx? Ethosuximide (T-type CCB)● Seizures heralded by olfactory hallucinations and a rising sensation in the abdomen → temporal lobe epilepsy ○ Seizure type? Auras = simple partial seizure● Seizures associated with sensory/motor problems → parietal/frontal lobe seizures● Focal post-seizure paralysis and weakness → Todd’s paralysis ○ Will go away on is own in hours

● Focal seizures = partial seizures (activity localized to 1 hemisphere) ○ Focal seizure w/o loss of awareness = simple partial seizures ■ Examples: ● Focal muscle rigidity ● Bizarre sensations (e.g hearing hissing sound) ● Autonomic sxs ○ Focal seizure with loss of awareness = complex partial seizures ■ Can be a person who appears awake but is not aware of surroundings ■ Presentation? Automatisms (e.g. chewing, smacking lips)● Generalized seizures (activity in both hemispheres) ○ Absence ○ Generalized tonic-clonic ○ Atonic seizures (loss of muscle tone → pt drops to ground) ■ Also consider cataplexy in narcolepsy ○ Myoclonic seizures (jerking movements)

● Brain death = loss of all brain function, including the brainstem ○ Loss of vestibulo-ocular reflex (perform caloric testing) ○ Loss of pupillary light reflex ○ Apnea test → no spontaneous respiration after CO2 is allowed to rise ■ Hypercarbia normally stimulates respiratory center in medulla

● Reflex syncope ○ Syncope with sight of blood, emotional event, pain → vasovagal syncope ■ Dx? Tilt table test ○ Syncope after tightening tie → carotid sinus hypersensitivity ○ Pt trying to pee and they pass out → micturition syncope● Syncope w/o prodrome in pt with ASCVD risk factors → cardiogenic syncope

● Algorithm for the management of a patient in status epilepticus. DI Podcast Main Document 186 ○ 1st step: benzo (e.g. lorazepam) ○ 2nd step: IV phenytoin/fosphenytoin ○ 3rd step: sedate with phenobarbital

● AED with the strongest risk of neural tube defects → valproic acid ○ What if the patient is already pregnant and couldn’t be controlled on other agents but is now well-controlled on valproic acid? Continue valproic acid ○ Why? Seizures are very dangerous to the fetus

● Involuntary flailing movement of 1 arm → hemiballismus ○ Pathophys? Lesion in contralateral subthalamic nucleus

● Involuntary movements of the jaw with no other neuro deficits relieved with “gentle stroking” (geste antagoniste) → focal dystonia ○ Tx? Botulinum toxin injection ■ Mechanism? Cleaves SNARE proteins → no vesicle fusion → no ACh release

● Fever, headache, stiff neck → meningitis ○ NBS? Head CT, especially if signs of increased ICP on exam● Sudden onset severe headache and neck stiffness → SAH ○ NBS? Non-con head CT● Fever, headache, and FNDs → brain abscess ○ Dx? Brain MRI ○ Tx? Broad-spectrum abx + drainage by neurosurg● Recent history of otitis media with FNDs and papilledema on fundoscopic exam → brain abscess● IVDU with back pain + FNDs → spinal epidural abscess ○ Dx? MRI spine ○ Tx? Broad-spectrum abx + drainage by neurosurg

● Ataxia, urinary incontinence, and dementia → normal pressure hydrocephalus ○ “Wacky, wet, and wobbly” ○ Tx? Decrease ICP with VP shunt● Elderly patient with a MMSE of 20/30 with no past neurological history who took Benadryl last night → deliremia ○ Pathophys? Diphenhydramine has powerful anticholinergic activity ○ Anticholinergic drugs? ■ Drugs for urge incontinence (e.g. oxybutynin, trospium, darifenacin/solifenacin, tolterodine)

● MMSE 19/30 + difficulty speaking + inability to perform ADLs → Alzheimer’s disease ○ What do you need before formal AD dx? Brain MRI ○ Apo association? ■ ApoE4 → higher risk ■ ApoE2 → protective ○ Associated genetic dz? Down syndrome DI Podcast Main Document 187 ■ Pathophys? Amyloid precursor protein is on chromosome 21 ■ Presentation? AD in 40s ○ Pathology? ■ Senile plaques (extracellular deposits of amyloid) ■ Neurofibrillary tangles (intracellular aggregations of hyperphosphorylated tau protein) ○ Neuroanatomical association? Basal nucleus of Meynert (produces ACh) ○ Enzyme association? ChAT = choline acetyltransferase ○ Tx? ■ Three select AChE-inhibitors ● Galantamine ● Donepezil ● Rivastigmine ■ Memantine (NMDA receptor antagonist)

● Parkinsonian features + visual hallucinations + syncopal eps → Lewy body dementia

● Dementia + Choreiform movements → Huntington’s disease ○ Inheritance? AD ○ Repeat? CAG ○ Imaging? Atrophy of the caudate ○ Pathophys? Think of it as a high-dopamine disorders ○ Tx? Dopamine antagonist ■ Haloperidol ■ Tetrabenazine (VMAT inhibitor)

● Mild dementia + difficulty speaking + inappropriate behavior + Knife’s edge appearance on brain imaging → Pick’s disease = frontotemporal dementia

● “Stepwise” deterioration in cognitive function w/neuro deficits → vascular dementia ○ Presentation? 5 years ago pt started to be forgetful. 2 years ago this pt xyz. ○ RF? ■ HLD ■ CAD ■ Hx stroke ○ Tx? Cholinesterase inhibitors used in Alzheimer’s● Rapidly progressive dementia in a patient that got a corneal transplant a year ago with myoclonus → Creutzfeldt-Jakob disease ○ CSF findings? Elevated 14-3-3 protein● Mild dementia + Urinary incontinence + gait problems. → normal pressure hydrocephalus

● Inability to calculate + left to right disorientation. → dominant parietal lobe lesion (Gerstmann's syndrome) ○ Which side in most people? Left● Neglect of one side of the body. → nondominant parietal lobe lesion ○ Which side in most people? Right DI Podcast Main Document 188 ● HY AED side effects ○ Valproate ■ Highest risk of NTD ■ hepatotoxic ○ Carbamazepine ■ Agranulocytosis ■ SIADH ■ Teratogen ○ Phenytoin ■ Gingival hyperplasia ● Other drug? cyclosporin ■ Arrhythmias (class 1b antiarrhythmic) ■ Diplopia/visual issues ■ SJS ■ Drug-induced lupus ● Ab? anti-histone ■ Fetal hydantoin syndrome (microcephaly + flat nasal bridge + cleft lip/palate)

● 15 yo with jerky hand movements in the morning and occasional generalized tonic clonic seizures. → juvenile myoclonic epilepsy

● Recurrent seizures + contralateral hom*onymous hemianopia + problems understanding speech (or can talk but speech is not understandable) + recurrent nosebleeds + Positive FOBT → Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease) ○ Presentation? Lip telangiectasias ○ Pathophys? AVMs in multiple organs (e.g. brain, GI tract) ■ In this example, AVM in the temporal lobe ○ Imaging? Can have dystrophic calcifications ○ Inheritance? AD ○ Contrast with Peutz-Jeghers ■ Hyperpigmented macules on lips ■ multiple nonmalignant hamartomatous polyps in GI tract ■ Increased risk of colon, pancreatic, breast, gyn cancers

● Sudden onset of redness in the eye + “bulging eyes” + “humming sound” on auscultation of the skull + visual acuity 20/100 in the affected eye → carotid cavernous fistula ○ Pathophys? Essentially an AVM ○ PE finding? Bruit on auscultation of the skull ○ Dx? MRA ○ Tx? surgery

● 12 yo M that stands from a seated position by moving his hands over his legs → duch*enne muscular dystrophy ○ Inheritance? X-linked recessive DI Podcast Main Document 189 ○ Mutated protein? dystrophy ○ Pathophys? Defective cytoskeleton proteins ○ Prognosis? Death in teens to early 20s ○ Contrast with Becker muscular dystrophy ■ Inheritance? X-linked recessive ■ Pathophys? Mutated dystrophin still has some function ■ Prognosis? Live to 50s+

● Kid that is hypotonic at birth + pediatrician has trouble releasing grip from his mom during a 3 mo well child check OR 25 yo M with “severe balding” → myotonic dystrophy ○ Inheritance? AD ○ Repeat? CTG ○ Mutated gene? DMPK

● 18 yo M presents with a chief complaint of facial weakness and UE weakness that have progressively worsened over the past 18 months → facial-scapulo-humeral dystrophy ○ Presentation? Usually in teens ○ Inheritance? AD ■ Affects boys and girls!

● Polymyositis/Dermatomyositis ○ Presentation? Symmetric proximal muscle weakness ○ Pathophys? Inflammatory myopathies ○ Ab? anti-Jo1, anti-Mi2, anti-SRP ○ Derm findings in dermatomyositis? ■ Gottron's papules ■ Heliotrope rash ■ Shawl sign ○ Associated malignancy? Usually lung cancer or visceral malignancy ○ Dx? CK level ■ If elevated → MRI of muscle (no longer muscle bx) ○ Tx? Steroids ○ Which one can show up in kids? dermatomyositis

● Inclusion body myositis ○ Presentation? Asymmetric distal arm + proximal leg muscle weakness

● Toxidromes ○ Diarrhea + rhinorrhea + sweating + miosis → cholinergic ■ Causes? ● Nerve gases (e.g. sarin) ● Organophosphate poisoning ■ Tx? Atropine + pralidoxime ○ Mydriasis + constipation + flushing + hot skin + tachycardia → anticholinergic ■ Causes? DI Podcast Main Document 190 ● Jimson weed ○ Pt with psych hx with arrhythmia or wide QRS → TCAs ■ Tx? Sodium bicarb ○ Hypertension (possibly MI) + mydriasis + nasal septum perforation → cocaine ■ Tx? Benzos + alpha-1 blocker (e.g. phentolamine) ■ What drug is contraindicated? Beta blocker ○ AMS + rash near nose/mouth + nothing on Utox + type 1 RTA → Glue/Toluene ■ Pathophys? Glue sniffing causes hyperadrenergic response, which gives you the high. But this can also cause arrhythmias (often V-fib). ■ Electrolyte imbalance? Hypokalemia due to type 1 RTA ● No H+ excretion and K+ reabsorption in alpha-intercalated cells ○ Miosis + respiratory depression (RR = 6) → opioid overdose ■ Tx? naloxone ■ There is no tolerance to which effects of opioids? ● Miosis ● Constipation ○ Normal pupils + respiratory depression → benzodiazepines (could also be barbiturate) ■ Tx? Flumazenil for benzos or Z-drugs ○ Flashbacks + visual hallucinations + synesthesias → LSD ○ Pt that is acting like the hulk + nystagmus → PCP ○ Bad oral hygiene + sympathetic activation → Methamphetamine ○ Hyperthermia + hyponatremia + affectionate behavior → Ecstasy/MDMA ○ Someone who took drugs now with parkinsonism → MPTP-mediated destruction of substantia nigra

● Symmetric descending flaccid paralysis w/o sensory deficits → botulism ● Ascending paralysis w/o sensory deficits → GBS ○ CSF findings? Albuminocytologic dissociation

● Seizing patient with small cell lung cancer with a Na of 115 → hyponatremia 2/2 SIADH ○ NBS? Hypertonic saline ■ Only indication on NBMEs is seizing pt with Na+ < 120

● 2 HY electrolyte imbalances that could cause seizures in the infant of a diabetic mother? ○ Hypoglycemia ■ Pathophys? Hyperplasia of pancreatic islet cells → hypersecretion of insulin → hypoglycemia after delivery ○ Hypocalcemia ■ Associated syndrome? DiGeorge

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DI Podcast Main Document 191 Ep. 111: The "Clutch" Pharmacology Podcast Round 1 ● Nitrates ○ Indication? angina ○ AE? ■ HA (due to vasodilation) ● Statins ○ Mechanism? Inhibit HMG CoA-reductase ○ AE? ■ Hepatotoxic ■ Myotoxic ○ Interactions? ■ Fibrates ● Niacin ○ Raises HDL the best ● Cholestyramine ○ Mechanism? Prevent bile acid reabsorption ● Fibrates ○ Lower TGs ○ AE? ■ Hepatotoxic ■ Myotoxic ● Digoxin ○ Mechanism? Inhibits Na/K-ATPase so acts as positive inotrope + muscarinic agonist activity ○ Indications? ■ Afib ■ CHF - doesn’t improve survival ○ AE? ■ Hyperkalemia ○ What prediposes to digoxin toxicity? Hypokalemia ○ Sign of dig toxicity? PVCs, vision problems, abdominal pain ● Procainamide ○ Class Ia antiarrhythmic ○ Indication? WPW ○ AE? Drug-induced lupus ● Amiodarone ○ Class III antiarrhythmic ○ Mechanism? K+ channel blocker ○ AE? ■ Hypothyroidism/hyperthyroidism ■ Skin discoloration ■ Pulmonary fibrosis ● Beta blockers ○ A-M → selective DI Podcast Main Document 192 ○ N-Z → nonselective ■ Contraindication? Asthma ○ Indications? ■ Performance anxiety ■ Afib● Nondihydropyridine CCBs (e.g. verapamil, diltiazem) ○ Mechanism? Negative inotropes + slow conduction through AV node ○ Indication? ■ Afib ■ Prinzmetal angina● CCB indicated for pt with recent SAH? Nimodipine ○ Prevents post-SAH vasospasm and resultant ischemic stroke● DIhydropyridine CCBs ○ AE? Peripheral edema (dilation of precapillary arterioles → increase hydrostatic pressure in capillaries) ■ How to decrease this? Dilate post-cap venules with ACE-I● Nitroprusside ○ Indication? Hypertensive emergency ○ AE? Cyanide poisoning● Bisphosphonates ○ Indication? ■ Osteoporosis ■ Hypercalcemia of malignancy ○ AE? ■ Pill esophagitis (drink water, be upright for 30 mins after taking) ■ Osteonecrosis of jaw● Teriparatide ○ Mechanism? PTH analog ■ Continuous PTH → suppressed bone production ■ Pulsatile PTH → increases bone formation ○ AE? ■ Increased risk of osteosarcoma● Uses of Mg ○ Prevent seizures in pt with pre-eclampsia ○ Severe asthma attack● Dopamine agonist (e.g. bromocriptine/cabergoline) ○ Mechanism? Dopamine inhibits the release of prolactin (via tuberoinfundibular pathway) ○ Indication? prolactinoma● Typical antipsychotics? ○ High-potency: Haloperidol, fluphenazine, trifluoperazine ○ Low-potency: chlorpromazine, thioridazine ○ AE? ■ QT prolongation ■ Hyperprolactinemia ● Dopamine = “prolactin-inhibiting factor” DI Podcast Main Document 193 ■ EPS ● Acute dystonia ○ Tx? Benztropine, diphenhydramine ● Akinesthesia ○ Tx? Beta blocker ● Parkinsonian ● Tardive dyskinesia● Metoclopramide ○ Mechanism? Dopamine antagonist ○ Indication? Diabetic gastroparesis ○ AE? ■ EPS (e.g. drug-induced parkinsonism)● Atypical antipsychotics ○ Risperidone → hyperprolactinemia ○ Ziprasidone → QT prolongation ○ Quetiapine → cataracts ■ Special indication? Psychosis in the s/o of treatment for Parkinson’s ○ Olanzapine → metabolic syndrome ■ Indication aside from schizophrenia? OCD ● O = olanzapine ● C = clomipramine ● D = antidepressants (SSRIs) ○ Clozapine → agranulocytosis, myocarditis ■ Decreases risk of suicide ○ Aripiprazole → partial dopamine receptor agonist● Tricyclic antidepressants ○ AE? anti-HAM ■ Anti-histamine → sedation ■ Anti-alpha-1 → orthostatic hypotension ■ Antimuscarinic → urinary retention, constipation ○ Tx for toxicity? Sodium bicarb ○ Special indications? ■ OCD (clomipramine) ■ Nocturnal enuresis (imipramine) ● Other tx options? Desmopressin = ADH analog● MAO-Is ○ Isocarboxazid, phenelzine, tranylcypromine ○ MAO-B inhibitors: rasagiline, selegiline ■ Indication? Parkinson’s ○ AE? Hypertensive crisis with tyramine consumption● Serotonin syndrome ○ Presentation? High fevers + myoclonus ○ NBS? Supportive care + benzos ○ If not responding? cyproheptadine (anti-histamine with serotonin receptor-blocking activity)

DI Podcast Main Document 194 ● SSRIs ○ Indications? ■ 1st line for depression ■ 1st line for GAD ■ 1st line for PSTD ○ AE? ■ Sexual dysfunction ■ Weight gain● SNRIs (venlafaxine, duloxetine) ○ Indications? Neuropathic pain ○ AE? HTN● NDRIs (bupropion) ○ Benefits? No seuxal side effects, no weight gain, helps with smoking cessation ○ Contraindications? Anorexia & bulemia ■ Why? Lowers seizure threshold● Lithium ○ Decreases risk of suicide ○ AE? ■ Hypothyroidism ■ Nephrogenic DI ■ Tremors - sign of toxicity● -Vaptans (e.g. conivaptan, tolvaptan) ○ Mechanism? ADH receptor antagonists ○ Indications? SIADH● Darbepoetin ○ Mechanism? EPO analog ○ Indications? Anemia associated with CKD● Cinacalcet ○ Mechanism? CSR modulator → decreased PTH release ○ Indications?● Loop diuretics ○ Site of action? Na-K-2Cl transporter in the thick ascending limb of the loop of Henle ○ AE? ■ Hypokalemia ■ Hypocalcemia & hypercalciuria ■ Hypomagnesemia ○ Contraindication? Hx nephrolithiasis● Thiazide diuretics ○ Site of action? Na-Cl symporter in the DCT ○ Strongest association with ○ AE? hyper-GLUC ■ Hyperglycemia ■ Hyperlipidemia ■ Hyperuricemia ■ Hypercalcemia DI Podcast Main Document 195 ● Potassium-sparing diuretics ○ ENaC blockers (amiloride, triamterene) ■ Special indication? Nephrogenic DI associated with lithium ○ Aldosterone antagonists ■ Spironolactone ● AE? Gynecomastia (also blocks androgen receptors) ● Indications? ○ Conn’s syndrome ○ Hirsutism of PCOS (inhibits 5-alpha reductase in the skin) ○ Improves survival in HF ■ Eplerenone ○ Type of RTA? 4● Drugs that improve survival in HF ○ ACE-I ○ Beta blockers: bisoprolol, carvedilol (alpha-beta blocker), ER metoprolol ○ Spironolactone ○ Isosorbide dinitrate-hydralazine in African Americans● Acetazolamide ○ Mechanism? Carbonic anhydrase inhibitor ○ Electrolyte effects? Hypokalemia + metabolic acidosis ○ Indications? ■ Central sleep apnea (metabolic acidosis → compensatory resp alkalosis → hyperventilation → increases respiratory drive) ■ Idiopathic intracranial HTN ■ Glaucoma ■ Altitude sickness ○ Type of RTA? 2● Mannitol ○ Mechanism? Non-reabsorbable sugar ○ Indications? ■ Elevated ICP ■ Diuretic● Ethosuxamide ○ Mechanism? T-type CCB ○ Indications? Absence seizures● Carbamazepine ○ Indications? ■ Seizures (narrow spectrum) ■ Trigeminal neuralgia ○ AE? Agranulocytosis● Phenytoin ○ AE? ■ NTD in fetus ■ Drug-induced lupus● Valproic acid DI Podcast Main Document 196 ○ AE? ■ Most teratogenic antiepileptic ■ Hepatotoxic● Hyperthyroidism drugs ○ PTU ■ Better in pregnancy (1st trimester) ■ Can inhibit peripheral T4 → T3 conversion ■ Useful in the tx of thyroid storm ○ Methimazole ○ AE? Agranulocytosis● Tx of thyroid storm ○ 1st: propranolol ○ 2nd: PTU ○ Then steroids, Lugol’s solution, etc.● Abx that cover MRSA ○ Vancomycin ■ AE? ● Red man syndrome ○ Tx? Slow infusion, give antihistamine or NSAID before infusion ● Nephrotoxic ● Ototoxic ○ Daptomycin ■ Where can’t it be used? Lungs (inhibited by surfactant) AE? Myotoxicity ○ Linezolid ■ Mechanism? 50S inhibitor ■ AE? Serotonin syndrome ○ Rifampin ■ AE? Orange bodily fluids ○ Tigecycline

● Abx that cover Pseudomonas ○ Ceftazidime (only 3rd gen that covers) ○ Cefepime (4th gen) ○ Aztreonam ■ Little cross-reactivity with other penicillins ○ Aminoglycosides ■ AE? ● Nephrotoxicity → ATN ● Ototoxicity ○ FQ ■ AE? ● QT prolongation ● Achilles’ tendon rupture ■ Contraindications? DI Podcast Main Document 197 ● Pregnancy ● Children ○ Pip-tazo ○ Colistin/polymyxin E ■ Last-resort for serious GNR infections ■ VERY nephrotoxic

● TMP-SMX ○ Mechanism: ■ TMP → inhibits dihydrofolate reductase ■ SMX → inhibits dihydropteroate synthetase ○ Tx for resultant bone marrow suppression? Leucovorin ○ Ppx for PCP with CD4 < 200 ○ Ppx for toxo with CD4 < 100● Pyrimethamine-sulfadiazine ○ Pyrimethamine → inhibits dihydrofolate reductase ○ -Sulfadiazine → inhibits dihydropteroate synthetase ○ Indications? Tx of toxo● Macrolides ○ Indications? ■ Diabetic gastroparesis (macrolides are motilin receptor agonists) ■ Atypical pneumonia ● Mycoplasma ● Chlamydia ● Legionella ■ Triple therapy for H. pylori (azithromycin) ■ Ppx against MAC in AIDS pt with CD4 < 50 (azithromycin) ■ Pertussis tx & ppx for close contacts ○ AE? ■ Diarrhea ■ QT prolongation ■ Erythromycin → pyloric stenosis in NB● Ceftriaxone (3rd gen cephalosporin) ○ Indications? ■ Meningitis ■ Ppx of close contacts of pts with meningitis ● Rifampin is the preferred agent ○ AE? ■ Intrahepatic cholestasis in neonates ● Use cefotaxime (“baby ceftriaxone”)● Penicillins ○ Indications? ■ Syphilis ● Jarisch-Herxheimer reaction● Aminopenicillins (e.g. PO amoxicillin, IV ampicillin) DI Podcast Main Document 198 ○ Indications? ■ Ampicillin for Listeria infection ● #3 cause of serious infections in the neonate● Acyclovir ○ Indications? ■ Herpes ■ ZVZ ○ AE? Crystalline nephropathy ○ If resistant give what? Foscarnet● Ganciclovir ○ Indication? CMV ○ Mechanism of mutation? UL97 kinase mutation ○ If resistant give what? Foscarnet● Alpha-1 receptor blockers ○ Phenoxybenzamine (irreversible) ○ Phentolamine (reversible) ○ Indications? ■ Pheo (alpha block before beta block)● Alpha-beta blockers ○ Carvedilol ○ Labetalol● Alpha-1 agonist ○ Phenylephrine ■ Indications? ● Allergic rhinitis ● Hypotension ■ AE? Nasal septum perforation● Alpha-2 agonists (e.g. clonidine, guanfacine) ○ Indications? ■ Opioid withdrawal ■ Resistant HTN ■ Tourette’s ■ ADHD● Beta blockers ○ Indications? ■ Improve survival in HF (bisoprolol, carvedilol, metoprolol) ■ Thyroid storm (propranolol) ■ Glaucoma (timolol) ■ Performance anxiety ○ Contraindications? Cocaine intoxication (unopposed alpha → profound HTN) ○ Tx for toxicity? Glucagon ○ RAAS response? Decreased (beta-1 receptors on afferent arteriole)● PPIs ○ Mechanism? Irreversible inhibit Na-H antiporter on parietal cells → decrease acid in lumen of stomach DI Podcast Main Document 199 ○ Indications? ■ GERD ■ Barrett’s esophagus ■ Triple/quad therapy in H. pylori ● Hold PPI before testing to avoid false neg ○ AE? ■ CYP inhibition ■ Osteoporosis ■ Aspiration pneumonia● H2 receptor antagonists (e.g. cimetidine) ○ Indications? ■ GERD ■ PUD ○ AE? ■ CYP inhibition ■ Gynecomastia (cimetidine)● GnRH analogs (e.g. leuprolide) ○ Indication? ■ Shrink fibroid prior to surgery ■ Fertility tx (pulsatile) ■ Metastatic testicular cancer (continuous) ■ Metastatic prostate cancer (continuous) ● Alternatives? Androgen-receptor blockers (e.g. flutamide, bicalutamide)● Taxofimen ○ Mechanism? SERM ■ Antagonist in breast ■ Agonist in bone & uterus ○ AE? Increased risk of endometrial cancer● Raloxifene ○ Mechanism? SERM ■ Antagonist in breast ■ Agonist in bone ■ Doesn’t act in uterus● Pegvisomant ○ Mechanism? Growth hormone receptor antagonist ○ Indications? ■ Acromegaly● Dexamethasone → glucocorticoid● Hydrocortisone → glucocorticoid & mineralocorticoid● Fludracortisone → mineralocorticoid● PDE inhibitors (e.g. sildenafil, tadalafil) ○ Indications? ■ Erectile dysfunction ■ Pulmonary arterial HTN ○ Contraindications? DI Podcast Main Document 200 ■ Pts on other vasodilators● Aspirin ○ Mechanism? Irreversible inhibitor of COX-1 and COX-2 ○ Indications? ■ Chest pain 1st drug ○ AE? ■ PUD ● Prevention? Misoprostol (prostaglandin)● P2Y12 receptor blockers (e.g. clopidogrel, prasugrel, ticagrelor) ○ Indications? ■ Post-stroke ■ Post-MI● Dipyridamole ○ Mechanism? Increases cAMP → relaxes SM & increased cardiac contractility ○ Indications? ■ Stress test (uses coronary steal principle)● Cilostazol ○ Mechanism? Increases cAMP → relaxes SM ○ Indications? ■ Symptomatic relief of PAD● GpIIbIIIa receptor antagonists (e.g. abciximab, tirofiban, eptifibatide) ○ Mechanism? Prevents platelet aggregation● Heparin ○ Mechanism? Activates AT-III ○ Reversal agent? Protamine sulfate (for unfractionated heparin) ○ AE? HIT = heparin-induced thrombocytopenia ■ NBS? Give direct thrombin inhibitor (e.g. dabigatran, argatroban, bivalirudin) ● Reversal of dabigatran? Idarucizumab● Factor X inhibitors (e.g. apixaban, rivaroxaban)● Warfarin ○ Mechanism? Inhibitors VKOR → decreases gamma-carboxylation of factors 2,7, 9, 10, protein C &S ○ Bridge with heparin (avoid transient hypercoagulability) ○ Reversal agents? ■ Vit K ■ Four-factor PCC● Nitrofurantoin ○ Indication? Cystitis in females ○ AE? Pulmonary fibrosis● Drugs associated with pulmonary fibrosis ○ Busulfan ○ Bleomycin (G2 phase) ○ Amiodarone ○ Methotrexate ■ Mechanism? Dihydrofolate reductase inhibitor DI Podcast Main Document 201 ■ Rescue agent? Leucovorin ■ AE? Hepatotoxic ■ Indications? ● Autoimmune dz (e.g. RA) ● Choriocarcinoma ● Ectopic pregnancy● Cyclophosphamide ○ Mechanism? Alkylating agent ○ AE? ■ Hemorrhagic cystitis ● Prevention? mesna ■ Bladder cancer● Cisplatin ○ AE? ■ Ototoxicity ■ Nephrotoxic (causes ATN) ● Prevention? Amifostine● Vinc alkaloids (e.g. vincristine, vinblastine) ○ Mechanism? Prevent polymerization of microtubes ○ AE? Peripheral neuropathy● Taxanes ○ Mechanism? Prevent depolymerization of microtubules● TNF inhibitors (e.g. adalimumab, etanercept) ○ Check for latent TB before starting● ATRA ○ Indication? APML ■ t(15,17) ■ DIC risk● Imatinib ○ Indication? CML ■ t(9,22) ■ BCR-ABL fusion protein● Eculizumab ○ Mechanism? Monoclonal Ab against C5 ○ Indication? PNH ○ Vaccine against? Neisseria meningitidis● Adenosine ○ Indication? ■ Break SVT ■ Regadenoson for cardiac stress tests ○ What antagonizes its effects? ■ Caffeine ■ Theophylline● Octreotide ○ Indication? DI Podcast Main Document 202 ■ Variceal bleed ● Give spironolactone + propranolol to reduce recurrence risk ● Insulin ○ Ultra rapid-acting: lispro, aspart, glulisine ○ Rapid-acting: regular ○ Intermediate-acting: NPH ○ Long-acting: detemir & glargine ● Metformin ○ Weight neutral ○ Stop metformin before getting contrast. If contrast causes renal injury, they can have a life-threatening lactic acidosis ● Sulfonylureas ○ Mechanism? K+ channel blockers. Close ATP-dependent K+ channel which leads to insulin release ○ Weight gain (2/2 increased insulin release) ○ 2nd gen: glyburide, glipizide, glimepiride ● PPAR-gamma activation (e.g. pioglitazone, rosiglitazone) ○ Contraindication? CHF ○ Weight gain ● Alpha-glucosidase inhibitors (e.g. acarbose, miglitol) ○ AE? Diarrhea ● GLP-1 analogs (e.g. exenatide, liraglutide) ○ Contraindication? MTC ○ AE? Pancreatitis ○ Which can be prescribed as a weight loss drug? liraglutide ● DDP4-inhibitors (e.g. sitagliptin) ○ Contraindication? MTC ● SGLT-2 inhibitors (e.g. canagliflozin, dapagliflozin) ○ Contraindication? Renal failure ○ AE? UTIs

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Ep. 112: The "Clutch" Pharmacology Podcast Round 2 ● Alpha-1 agonists (e.g. phenylephrine, ephedrine) ○ Indication? Hypotension in the s/o anesthesia ● Alpha-1 antagonists ○ Phenoxybenzamine → irreversible ○ Phentolamine → reversible ○ Indication? pheo ● Other alpha-1 antagonists ○ Prazosin, doxazosin ■ Indication? Short-term tx of BPH DI Podcast Main Document 203 ● Long-term BPH tx? 5-alpha-reductase inhibitors (e.g. finasteride) ■ AE? Orthostatic hypotension ○ Tamsulosin (selective alpha-1a blocker) ■ NO orthostatic hypotension● Alpha-methyldopa ○ Indication? HTN in pregnancy ■ Other meds for HTN In pregnancy ● Hydralazine ○ AE? Reflex tachycardia & drug-induced lupus ● Labetalol ● Nifedipine ○ AE? Drug-induced lupus● Thyroid storm ○ 1st: propranolol ○ 2nd: PTU ■ AE? Agranulocytosis● Beta-2 agonists ○ SABA → albuterol ■ Indications: ● Asthma ● Hyperkalemia ○ LABA → salmeterol, formoterol ■ Never use LABA before ICS in asthma! ○ Terbutaline/ritodrine ■ Indication? Tocolytics● Asthma ladder ○ SABA ○ low-dose ICS ○ LABA or medium-dose ICS or leukotriene inhibitor ○ PO steroids● Epinephrine ○ Indication? ■ Anaphylaxis ■ ACLS● Norepinephrine ○ Indication? Septic shock● Inotropes ○ Indication? Cardiogenic shock ○ Dobutamine (beta-1 agonist) ○ Milrinone (PDE inhibitor)● Muscarinic agonists ○ Bethanechol/carbachol ■ Indications? ● Overflow incontinence ● Ogilvie syndrome aka acute colonic pseudo-obstruction DI Podcast Main Document 204 ○ Pilocarpine ■ Indication? ● Glaucoma ● Sjogren’s● Acetylcholinesterase inhibitors ○ Edrophonium ■ Very short acting ■ Indication? Diagnostic testing for MG (“Tensilon test”) ○ Neostigmine ■ Indication? Ileus ○ Pyridostigmine ■ Indication? MG ○ Physostigmine ■ Indication? Atropine overdose ■ Mechanism? ACh levels rise and can outcompete atropine (muscarinic antagonist) ○ Donepezil, galantamine, rivastigmine ■ Indication? Alzheimer’s● Organophosphates ○ Mechanism? irreversible AChE inhibitors → cholinergic toxidrome ○ Sweating, diarrhea, miosis, bradycardia ○ Tx? ■ Atropine ■ Pralidoxime (regenerates ACh)● Methacholine ○ Mechanism? Muscarinic receptor agonist → triggers bronchospasm ○ Indication? Provocative testing for asthma● Scopolamine ○ Mechanism? Anticholinergic ○ Indication? Motion sickness● Tx of urge incontinence/“overactive bladder”? ○ Muscarinic antagonists ■ “On The Darn Toilet” ● Oxybutynin, Trospium, Darifenacin/solifenacin, Tolterodine● Ipratropium/tiotropium ○ Mechanism? Muscarinic antagonist ○ Ipratropium → short-acting ○ Tiotropium → long-acting ○ Indication? COPD ■ SABA vs SAMA → choose SAMA● Midodrine ○ Mechanism? Alpha-1 agonist → vasoconstrictor ○ Indication? Orthostatic hypotension● Haloperidol (high-potency typical antipsychotic) ○ AE? ■ QT prolongation DI Podcast Main Document 205 ■ Hyperprolactinemia ■ EPS ■ NMS● Isoniazid ○ Indication? TB tx ○ AE? ■ B6 depletion ● Sideroblastic anemia (cofactor for ALAS) ● Seizures (cofactor for glutamate decarboxylase) ■ Drug-induced lupus ■ Hepatotoxic● Levodopa/carbidopa ○ Levodopa = dopamine precursor ○ Carbidopa = dopa decarboxylase inhibitor, prevents peripheral breakdown of levodopa ○ Indication? Parkinson’s● Entacapone/tolcapone ○ Mechanism? COMT inhibitors → prevent breakdown of dopamine ○ Indication? Parkinson’s● Selegiline/rasagiline ○ Mechanism? MOA-B inhibitors ○ Indication? Parkinson’s ○ AE? Tyramine hypertensive crisis● Amantadine ○ Indication? Parkinson’s● Pramipexole/ropinirole ○ Mechanism? Dopamine receptor agonists ○ Indication? ■ Restless leg syndrome ● Associated with IDA ● Other option? Primidone (barbiturate) ■ Parkinson’s● Bromocriptine/cabergoline ○ Mechanism? Dopamine agonists ○ Indication? Prolactinoma ■ Choose medical tx before transphenoidal resection● Halothane ○ Inhaled anesthetic ○ AE? Malignant hyperthermiaf ■ Tx? Dantrolene (CCB)● Succinylcholine ○ Mechanism? Depolarizing neuromuscular blocker ○ AE? Malignant hyperthermia ■ Tx? Dantrolene (CCB)● Cyproheptadine ○ Mechanism? Anti-histamine w/ serotonin receptor block activity DI Podcast Main Document 206 ○ Indication? Serotonin syndrome ■ Try benzo first● Benztropine/trihexyphenidyl ○ Mechanism? Muscarinic receptor antagonists ○ Indication? EPS (e.g. acute dystonia, parkinsonism)● Memantine ○ Mechanism? NMDA receptor antagonist (combats glutamate excitotoxicity) ○ Indication? ALS● Ketamine ○ Dissociative anesthetic, NMDA receptor blocking acting● Riluzole ○ Mechanism? NMDA receptor antagonist (combats glutamate excitotoxicity) ○ Indication? ALS● Ethosuximide ○ Mechanism? T-type CCB ○ Indication? Absence seizures● Phenytoin ○ AE? ■ Teratogen ● But if woman is already pregnant & well-controlled, continue it ■ Drug-induced lupus● Carbamazepine ○ Indication? Trigeminal neuralgia ○ AE? ■ Teratogen ■ Agranulocytosis● Valproic acid ○ Teratogen (causes NTD) ○ Hepatotoxic● Topiramate ○ AE? ■ Mental dullness ■ Nephrolithiasis ○ Indications ■ Epilepsy ■ Migraines● Lamotrigine ○ AE? SJS● Benzodiazepines ○ Mechanism? Increase frequency of GABA receptor (Cl- channel) opening ○ Indication? ■ Cocaine intoxication ■ Seizures ○ Benzos okay for liver dysfunction? LOT ■ L = lorazepam DI Podcast Main Document 207 ■ O = oxazepam ■ T = temazepam ○ Benzo for alcohol withdrawal? Chlordiazepoxide (very long-acting) ○ Reversal agent? Flumazenil● Barbiturates ○ Mechanism? Increase duration of GABA receptor (Cl- channel) opening● Gabapentin ○ Dose adjust in renal disease ○ Indication? Neuropathic pain● Propofol ○ Indications? ■ Induction & maintenance anesthesia ■ Sedation of mechanically ventilated pts ■ Procedural sedation ○ AE? ■ Respiratory depression ■ Hypotension ■ Propofol infusion syndrome = bradycardia + lactic acidosis ○ Contraindications? Familial hypertriglyceridemia ■ Propofil is suspended in lipid● Baclofen ○ Indication? Spasticity (e.g in cerebral palsy pt)● Naloxone ○ Indication? Opioid overdose● Naltrexone ○ Indication? Alcohol or opioid dependence● Triptans ○ Mechanism? Serotonin receptor agonists ○ Indication? Acute tx of migraines ○ Contraindications? Vasospastic disease ■ Prinzmetal angina ■ Raynaud’s ○ AE? Serotonin syndrome● Tx of cluster HA → 100% O2● tPA ○ Reversal agent? Aminocaproic acid● Drug to give after SAH? Nimodipine ○ Mechanism? Prevents post-SAH vasospasm● VEGF inhibitors (e.g. bevacizumab) ○ Indication? Wet age-related macular degeneration● Latanoprost ○ Mechanism? Prostaglandin analogs ○ Indication? Glaucoma● Acetazolamide ○ Mechanism? Carbonic anhydrase inhibitor DI Podcast Main Document 208 ○ Indications? ■ Central sleep apnea ■ Idiopathic intracranial hypertension ■ Elevated ICP ■ Glaucoma ■ Diuretic → metabolic acidosis + hypokalemia● Endogenous opioids ○ Beta-endorphin → mu ○ Dynorphin → kappa ○ Enkephalin → delta● MAO-Is (isocarboxazid, phenelzine, tranylcypromine) ○ 2 week taper when switching from SSRI to MAO-I ○ AE? Tyramine hypertensive crisis● TCAs ○ anti-HAM side effects ■ Sedation ■ Orthostatic hypotension ■ Urinary retention ○ Imipramine ■ Indication? Nocturnal enuresis ○ Clomipramine ■ Indication? OCD● SSRIs ○ Which has the longest half-life? Fluoxetine ■ Least associated with SSRI discontinuation syndrome● SNRIs (e.g. venlafaxine, duloxetine) ○ Which used to treat neuropathic pain? duloxetine ○ AE? hypertension● Trazodone ○ AE? ■ Priapism (due to alpha-1 blockade) ● Tx? Phenylephrine injection into penis● Mirtazapine ○ Mechanism? Alpha-2 antagonist → ultimately increases release of norepi ○ Indication? Depression in pts with anorexia or insomnia ○ AE? ■ Weight gain ■ Sedation● Bupropion ○ Mechanism? NDRI ○ Indication? ■ Smoking cessation ■ Depression ■ Weight loss ○ AE? Lowers seizure threshold DI Podcast Main Document 209 ○ Contraindication? ■ Anorexia/bulimia● Clozapine ○ Reduces risk of suicide ○ AE? ■ hypersalivation ■ Myocarditis ■ Agranulocytosis ● STOP drug if their white count falls● Atypical antipsychotics ○ Risperidone → hyperprolactinemia ○ ZIprasidone → QT prolongation ○ Quetiapine → cataracts ■ Special indication? Psychosis in s/o Parkinson’s ○ Olanzapine → metabolic syndrome ○ Aripiprazole → partial dopamine agonist● Lithium ○ Sign of toxicity? tremors ○ AE? ■ Tremors ■ Nephrogenic DI ■ Hypothyroidism● Z-drugs (e.g. zolpidem, zaleplon, eszopiclone) ○ Mechanism? GABA agonist ○ Indication? Insomnia ○ AE? Addictive potential ○ Reversal agent? Flumazenil● Ramelteon ○ Mechanism? Melatonin receptor agonist ○ Indication? Insomnia ○ NO addictive potential● Suvorexant ○ Mechanism? Orexin antagonist ■ Recall that pts with narcolepsy have low CSF orexin ○ Indication? Insomnia● Buspirone ○ Mechanism? Partial agonist at serotonin receptors ○ Indication? Anxiety● Drugs of abuse ○ PCP → very agitated ○ LSD → flashbacks ○ Marjuana → hunger + conjunctival injection● If a pt is getting an adenosine-based stress test, caffeine or theophylline (methylxanthines) will reverse the effects of adenosine● Varenicline DI Podcast Main Document 210 ○ Mechanism? Nicotinic receptor partial agonist ○ Indication? Smoking cessation● Methylphenidate ○ Mechanism? Stimulant ○ Indication? ADHD ○ AE? ■ Insomnia ■ Weight loss● Atomoxetine ○ Non-stimulant ○ Indication/ ADHD● Tx for alcohol withdrawal? Benzos● Aspirin ○ Mechanism? Irreversible inhibitor of COX-1 and COX-2 ○ Indications? ■ MI ■ Post-stent ■ Stroke ○ Signs of toxicity? Respiratory alkalosis + metabolic acidosis● Roflumilast ○ Mechanism? PDE-4 inhibitor ○ Severe COPD● Sildenafil ○ Mechanism? PDE-5 inhibitor ○ Indication? ■ Pulmonary arterial hypertension ■ Erectile dysfxn● Desmopressin ○ Mechanism? ■ Increases release of wVF from Weibel-Palade bodies ■ ADH analog → water reabsorption in the collecting duct ■ Note: Desmopressin = ADH analog → so, it can cause AE of hyponatremia 2/2 SIADH ○ Indication? ■ Von Willebrand disease ■ Central DI ■ Nocturnal enuresis ● Caution: it can cause hyponatremia → seizures● Heparin ○ Mechanism? Activates AT-III to inhibit factors X and II ○ Indication? Anticoagulant ○ AE? HIT ○ Reversal? Protamine● LMWH ○ Mechanism? Activates AT-III to inhibit factors X ○ Indication? Anticoagulant DI Podcast Main Document 211 ● Factor X inhibitors (e.g. rivaroxaban, apixaban)● Direct thrombin inhibitors (e.g. dabigatran, argatroban, bivalirudin) ○ Indication? HIT ○ Reversal? For dabigatran → idarucizumab● Warfarin ○ Reversal? Four-factor PCC (prothrombin● tPA (e.g. alteplase, tenecteplase) ○ Indication? Ischemic stroke within 3.5 hrs symptom onset ○ Reversal? ■ Aminocaproic acid ■ Tranexamic acid ● Other indication? Postpartum hemorrhage● Eculizumab ○ Mechanism? C5 inhibitor ○ Indication? Paroxysmal nocturnal hemoglobinuria ■ Pathophys? Defective GPI anchors ○ AE? Induced terminal complement deficiency ○ Ppx? Vaccinate against Neisseria meningitidis● Hydroxyurea ○ Mechanism? Inhibits ribonucleotide reductase → increased Hgb F ○ Indication? Sickle cell disease● Azathioprine & 6-mercaptopurine ○ Indication? Chemo ○ Metabolized by xanthine oxidase, so co-administration with xanthine oxidase inhibitors (e.g allopurinol) can cause toxicity● Methotrexate ○ Mechanism? Inhibits dihydrofolate reductase ○ Indications? ■ Autoimmune disorders ■ Molar pregnancy ■ Choriocarcinoma ○ AE? ■ Hepatotoxicity ■ Bone marrow suppression → rescue with leucovorin● Drugs that cause pulmonary fibrosis ○ Bleomycin (works in the G2 phase of the cell cycle) ○ Busulfan ○ Amiodarone ○ Methotrexate● 5-fluorouracil ○ Mechanism? Inhibits thymidylate synthase ○ Indication? Chemo ○ Leucovorin WORSENS toxicity ○ Flucytosine is metabolized into 5-FU● Cyclophosphamide DI Podcast Main Document 212 ○ Mechanism? Alkylating agent ○ AE? Hemorrhagic cystis ■ Prevention? mesna● Doxorubicin/daunorubicin (anthracyclines) ○ Indication? Breast cancer ○ AE? Irreversible dilated cardiomyopathy ■ Prevention? Dexrazoxane (iron chelator)● Trastuzumab ○ Mechanism? Monoclonal Ab against HER2 tyrosine kinase receptor ○ Indication? HER2+ Breast cancer ○ AE? Reversible dilated cardiomyopathy● actinomycin D ○ Indications? ■ Ewing sarcoma ■ Childhood cancer● Vincristine/vinblastine ○ Mechanism? Inhibit microtubule polymerization ○ Indication? chemo ○ AE? ■ Bone marrow suppression (vinblastine blasts the bone marrow) ■ Peripheral neuropathy● Taxanes (e.g. pacl*taxel) ○ Mechanism? Inhibit microtubule depolymerization● Platinum drugs (e.g. cisplatin) ○ Mechanism? Alkylating agents ○ AE? ■ Nephrotic ● Prevention? Amifostine ■ Ototoxic● 4 drugs that are nephrotoxic + ototoxic ○ Cisplatin ○ Vancomycin ○ Aminoglycosides ○ Loop diuretics● Topoisomerase inhibitors ○ Irinotecan/topotecan → inhibit topo-1 ○ Etoposide → inhibits topo-2● Imatinib ○ Mechanism? Tyrosine kinase inhibitor ○ Indication? CML● Rituximab ○ Mechanism? Monoclonal Ab against CD20 ○ Indication? B cell cancers● Tamoxifen ○ SERM DI Podcast Main Document 213 ■ Antagonist in breast ■ Agonist in bone ■ Agonist in uterus● Raloxifene ○ SERM ■ Antagonist in breast ■ Agonist in bone ■ No effect on uterus● What med is used for breast cancer chemoprophylaxis in ○ premenopausal women? tamoxifen ○ postmenopausal woman? Aromatase inhibitors (e.g. letrozole, anastrozole, exemestane) ■ AE? Osteoporosis● 5-alpha reductase inhibitors (e.g. finasteride, dutasteride) ○ Mechanism? Prevent formation of DHT ○ Indication? Long-term tx of BPH● EPO analogs (e.g. darbepoetin, erythropoietin) ○ Indication? Anemia in CKD● Filgrastim/sargramostim ○ Mechanism? G-CSF analogs ○ Indication? Profound bone marrow suppression in chemo pts● Ondansetron ○ Mechanism? Serotonin receptor antagonist ○ Indication? Chemo-induced vomiting● Aprepitant ○ Mechanism? NK-1 receptor antagonists ○ Indication? Chemo-induced vomiting● Metoclopramide ○ Mechanism? Dopamine antagonist ○ Indication? Diabetic gastroparesis ○ AE? EPS● ATRA ○ Indication? APML t(15,17)● Bortezomib ○ Mechanism? Proteasome inhibitor ○ Indication? Multiple myeloma● SGLT-2 inhibitors (e.g. canagliflozin) ○ Mechanism? Prevent renal reabsorption of glucose ○ Indication? DM ○ AE? UTIs ○ Contraindication? Renal insufficiency● Conivaptan/tolvaptan ○ Mechanism? ADH receptor antagonists ○ Indication? SIADH ○ Very expensive!● Mannitol DI Podcast Main Document 214 ○ Mechanism? Non-absorbable sugar ○ Indications ■ Elevated ICP ○ Contraindication ■ CHF - mannitol increases vascular oncotic pressure → increased intravascular volume● Loop diuretics ○ AE? ■ Nephrotoxicity & ototoxicity ● Especially ethacrynic acid ■ Hypocalcemia & hypercalciuria ■ Hypomagnesemia ■ Hypokalemia ○ Contraindication? ■ Hx nephrolithiasis (dump Ca++ in the urine) ■ Sulfa allergy (all except ethacrynic acid)● Thiazides (HCTZ, chlorthalidone, indapamide, metolazone) ○ AE? ■ Strongest association with hyponatremia ■ Hyper-GLUC (glucose, lipids, uric acid, calcium)● Probenecid ○ Mechanism? Uricosuric agent (increases excretion of uric acid) ○ Restricted use because pt must be a uric acid underexcretion ○ Contraindication? Nephrolithiasis from uric acid stones● Aldosterone receptor antagonists (e.g. spironolactone, eplerenone) ○ Indications? ■ CHF → prolongs survival ■ Conn’s syndrome ■ Hirsutism in PCOS ■ Chronic tx of elevated portal pressures & esophageal varices ○ AE? ■ Gynecomastia (only spironolactone)● ENaC channel blockers (e.g. amiloride, triamterene) ○ Indications? ■ Nephrogenic DI 2/2 lithium● Aliskren ○ Mechanism? Direct renin inhibitor● ACE-Is ○ Indication? ■ CHF → improves survival ■ Nephroprotection in DM ● Dilate efferent arteriole → reduce intraglomerular HTN ■ Peripheral edema associated with dihydropyridine CCBs ● Mechanism? ACE-Is dilate post-capillary venules ■ Scleroderma renal crisis ○ Contraindications? DI Podcast Main Document 215 ■ Bilateral renal artery stenosis ■ C1 esterase deficiency ○ Don’t start as first-line antihypertensive in African American pt unless that pt is diabetic ○ AE? ■ Dry cough● ARBs ○ Good for pts with hx dry cough from taking ACE-I● Ivabradine ○ Mechanism? Inhibits funny current channels ○ Indications? Symptomatic treatment of angina● Class 1a antiarrhythmics (procainamide, quinidine, disopyramide) ○ Procainamide → use for WPW, AE drug-induced lupus ○ Quinidine → AE cichinism ○ Increase AP duration, wider QRS & increased risk Torsades● Class 1b antiarrhythmics (e.g. lidocaine, mexiletine, tocainide) ○ Shorten AP duration● Class 1c antiarrhythmics (e.g. flecainide, propafenone)● Class 2 antiarrhythmics = beta blockers● Class 3 antiarrhythmics = K+ channel blockers (e.g. amiodarone, sotalol) ○ Sotalol also has beta-blocking activity ■ Prolongs PR interval● Class 4 antiarrhythmics = verapamil & diltiazem ○ Indications? ■ Afib rate control ■ Variant angina ■ Preventative tx for cluster HAs● Dihydropyridine CCBs ○ Clevidipine & nicardipine → hypertensive emergencies ○ Nifedipine → safe in pregnancy ○ Nimodipine → prevents post-SAH vasospasm● Digoxin ○ Mechanism? Inhibits Na-K ATPase ■ Positive inotrope ■ Muscarinic antagonist ○ Hypokalemia predisposes to toxicity ○ AE? Hyperkalemia ○ Tx of toxicity? Anti-dig Fab● Magnesium ○ Indications? ■ Severe asthma exacerbations ■ Eclamptic seizures● Atropine ○ Indications? ■ Organophosphate toxicity ■ Heart block DI Podcast Main Document 216 ■ Bradyarrhythmias in ACLS● Hydralazine ○ Mechanism? Arterial vasodilator → decreases afterload → increases CO ○ AE? ■ Reflex tachycardia ■ Peripheral edema● Nitroglycerin ○ Mechanism? Venodilator ○ Indication? angina ○ Contraindications? Pt taking PDE-inhibitor● Nitroprusside ○ Indication? Hypertensive emergency ○ AE? Cyanide poisoning ■ Tx? Amyl nitrate (oxidizing agent) + sodium thiosulfate● Minoxidil ○ Indication? Balding in men● Diazoxide ○ Mechanism? Opens K+ channel → prevents insulin release ○ Indication? insulinoma● Nesiritide ○ Mechanism? BNP analog ○ Indication? Severe CHF● Neprilysin inhibitors (e.g. sacubitril) ○ Mechanism? Neprilysin breaks down BNP, so neprilysin inhibitors prevent BNP breakdown ○ Indication? CHF● PCSK9 inhibitors (e.g. alirocumab, evolocumab) ○ Mechanism? PCSK9 breaks down LDL receptors. PCSK9 inhibition → less breakdown of LDL receptors → can clear more LDL from serum● Antistaphylococcal penicillins (e.g. nafcillin, dicloxacillin, oxacillin) ○ Cover MSSA ○ Indication? Mastitis ○ AE? Acute interstitial nephritis (fever + rash + eosinophils in blood or urine)● Cefazolin (1st gen cephalosporins) ○ Indication? Surgical ppx● Cefotetan/cefoxitin/cefuroxime (2nd gen cephalosporins)● Ceftriaxone (3rd gen cephalosporin) ○ Indication? Neisserial infections ○ Does NOT cover MRSA or Pseudomonas ○ AE? Intrahepatic cholestasis in neonates → give cefotaxime ○ 3rd cephalosporin that covers Pseudomonas? Ceftazidime● Cefepime (4th gen cephalosporin) ○ Covers Pseudomonas● Ceftaroline (5h gen cephalosporin) ○ Covers MRSA● Carbapenems (e.g. meropenem, imipenem, doripenem) DI Podcast Main Document 217 ○ Covers Pseudomonas, anaerobes, and much more ○ Ertapenem doesn’t cover Pseudomonas● Aztreonam (monobactam) ○ Covers Pseudomonas● Vancomycin ○ Mechanism? Binds to D-ala-D-ala, so transpeptidase cannot bind and create cross linkages ○ Resistance mechanism? Change D-ala-D-ala to D-ala-D-lac ○ Indications? ■ Covers Gram-positives including MRSA ■ Oral vanc → 1st line for C. diff ○ Does NOT cover Gram-negatives ○ AE? ■ Red man syndrome ● Prevention? Slow infusion rate or give NSAID beforehand ■ Nephrotoxic + ototoxic● Daptomycin ○ Mechanism? Disrupts cell membrane ○ Indications? ■ Covers Gram-positives including MRSA ○ AE? NMS● Aminoglycosides ○ Mechanism? Bactericidal 30s inhibitor ○ Indications? ■ Covers Gram-negatives ■ Inhaled tobramycin → prevent Pseudomonas in CF pt ○ Does NOT cover anaerobes (because it requires O2 to gain entry to cell) ○ AE? ■ Nephrotoxic + ototoxic ■ ATN → muddy brown cases● Tetracyclines ○ Mechanism? Bacteriostatic 30s inhibitor ○ Indications? ■ Zoonotic infections ● Lyme disease ○ Avoid doxy in kids < 8 yo ● RMSF ○ Give doxy to kids, give chloramphenicol in pregnancy ■ Cholera ■ Acne ■ Demeclocycline (causes nephrogenic DI) → SIADH ■ Tigecycline → covers MRSA ○ AE? ■ Photosensitivity ● “SAT for a photo” ○ S = Sulfonamides DI Podcast Main Document 218 ○ A = amiodarone ○ T = tetracyclines ■ Tooth dislocation ● Linezolid ○ Mechanism? Bactericidal 50s inhibitor ■ Prevents formation of the initiation complex for protein synthesis ○ Indication? ■ Covers MRSA ■ Covers VRE ○ AE? Serotonin syndrome (weak MAO-I activity)

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Ep. 118: Confusing Breast Pathologies

SUMMARY

● Unilateral vs Bilateral? o Bilateral process + breast-feeding = breast engorgement

● Unilateral: fever vs no fever? o Unilateral + no fever + breast-feeding = galactocele

● Unilateral + fever: mass vs no mass? o Unilateral + fever + no mass + breast-feeding = mastitis

● Unilateral + fever + mass: fluctuant mass vs mass in older pt? o Unilateral + fever + fluctuant breast mass + breast-feeding = breast abscess o Unilateral + fever + mass in older pt + progressive onset = inflammatory breast cancer ● Peau-d’orange appearance

● Unilateral erythema + tenderness + fever + recently gave birth = Mastitis

● Unilateral + painful + fluctuant mass + fever + recently gave birth = Breast Abscess

● Bilateral + fever + recently gave birth = Breast Engorgement

DI Podcast Main Document 219 ● Unilateral + tender + fluctuant mass + breast-feeding + NO FEVER = Galactocele

● Unilateral + older F (> 50 yo) + peau d’orange appearance = Inflammatory Breast Cancer

CROSS CHECKED? Yes

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Ep. 119: Rapid Review Series 3 (IM)

ep 119 notes were graciously provided by Divine Intervention from an anonymous contributor.

● Hypotensive, temp103, crackles at LLB, productive cough for 2-3 days: pneumonia sepsis o Tx: cover MRSA, pseudomonas ● MRSA: vancomycin (--| D-ALA), linezolid (--| 50S), daptomycin (--| gram+ by poking holes in cell membrane), ceftaroline (5th gen ceph), TMP-SMX, clindamycin (--| 50S), doxycycline ● Pseudomonas: ceftazidime (3rd gen ceph), cefepime (4th gen ceph), aztreonam (monobactam), fluoroquinolones, aminoglycosides (--| bactericidal 50S, *do not cover anaerobes), pip-tazo, carbapenems ● 2mos fatigue, hyponatremic, hyperkalemic, elevated eosinophils, 80/50: Addison's disease o RF: other autoimmune disease o Path: ● autoimmune destruction of adrenal cortex ▪ Zona glomerulosa: mineralocorticoids i.e. aldosterone ● Not affected by secondary adrenal insufficiency (failure of hypothalamus) ● Aldosterone is controlled by RAAS ▪ Zona fasciculata: cortisol ● --| eosinophils ● DDx of eosinophilia ▪ Zona reticularis: sex steroids ● Alpha intercalated cell pumps out protons into urine; aldosterone helps make this happen through excretion of K+. If no aldosterone --> non-anion gap metabolic acidosis (Type IV RTA) o Dx: ACTH/cosyntropin --> cortisol levels will not rise o Tx: fludrocortisone ● Dialysis a month ago, chest pain, difficulty breathing, bilateral/extremity edema, crackles: high-output heart failure o DDx: AV fistula (arteries-veins w/o capillary resistance), Paget's disease (bone marrow becomes hypervascular), AV malformation, severe anemia (CO increases to increase O2 delivery) ● Blood glucose 900, HCO3 15, Na 125: DKA o Vs. HHNS (not acidotic) ● Pathophys: insulin prevents release of glucagon --> decreased lipolysis, production of ketone bodies ● Skin hyperpigmentation, Hgb 15, blood glucose 300: hereditary hemochromatosis o Pathophys: C282Y mutation --> increased reabsorption of iron from gut ● "bronze diabetes" d/t iron-Fenten (free radical) reaction that leads to fibrosis of pancreas o Skin: @skin, gonads, heart (1. restrictive 2. dilated cardiomyopathy), calcium-pyrophosphate-deposition disease/CPPD/pseudogout ● CPPD ddx: hereditary hemochromatosis, Gitelman's syndrome (loss of ions @ tubules) DI Podcast Main Document 220 ▪ Positive birefringence, rhomboid crystals, chondrocalcinosis on imaging o Dx: ferritin o Tx: phlebotomy ● "menstrual cycles are monthly phlebotomy" --> delayed onset in women ● Pneumococcal pneumonia, 118 Na: SIADH o Pathophys: any lung or brain pathology! ● DDx: small-cell lung cancer (ACTH, SIADH, Lambert-Eaton) o Sx: euvolemic hyponatremia ● Urine is hyperosmolar o Tx: fluid restriction ● Vs. diabetes insipidus: not observing effects of ADH in body --> not reabsorbing water --> hyperosmolarity, hypernatremia, low urine osmolarity ● Dx: water deprivation, ADH analog (desmopressin) ● urine osmolarity shoots up: ADH deficiency @ supraoptic nucleus of hypothalamus = central DI ● Urine osmolarity does not change: nephrogenic DI ● RF: lithium (also suicide preventative), demeclocycline ● Vs. Psychogenic polydipsia: serum osmolarity goes down, urine osmolarity goes down (everything working fine)

Paraneoplastic phenomena Etiology PathophysHigh hematocrit polycythemia vera, hepatocellular carcinoma, renal cell carcinomaMoon facies, hypercortisolism small cell lung cancer Ectopic production that does not suppress with high dose dexamethasoneSmoker, pain in bones, finger lung cancer hypertrophic pulmonaryclubbing osteoarthropathyDermatomyositis, lung cancer polymyositisSudden-onset acanthosis GI cancer nigricans/Leser Trelat signHigh Ca (tx fluids, multiple myeloma, multiple myeloma (IL-1 =biphosphonates i.e zoledronic squamous-cell lung cancer, osteoclast-activating factor),acid) mets, sarcoidosis squamous-cell lung cancer (PTHrP), lytic mets (i.e. from thyroid/renal cancer), blastic mets (i.e. from prostate/breast cancer), sarcoidosis (non-caseating granulomas produce 1alpha-hydroxylase calcidiol --> calcitriol --> reabsorption of Ca/P in gut)

DI Podcast Main Document 221 ----------------------------------------------------------------------------------------------------------------------------

Ep. 120: Rapid Review Series 4 (IM / Peds)

ep 120 notes were graciously provided by Divine Intervention from an anonymous contributor.

● 80Y forgetful, impaired IADL, MMSE~20/30: Alzheimer's Disease ● Pathophys: low Ach (normally produced at basal nucleus of Meynert via ChAT enzyme) ● RF: Down syndrome (presenilin gene) ● Tx: ● AChE inhibitors = donepezil, rivastigmine, galantamine ● Kiddo w/ crying-->cyanosis, reverts back to normal after a while, heart = harsh holosystolic @ LLSB: Tetralogy of Fallot ● Pathophys: ● aorticopulmonary septum usually tries to meet up w muscular interventricular septum ● If aorticopulmonary septum descends to the right of muscular interventricular septum --> you're not dividing the heart too well ● R side of heart: too little space now! ● Sx: ● Pulmonic stenosis ● Right ventricular hypertrophy ● R-L shunt (cyanotic) ● Cry/squat --> compressing blood vessels --> increase SVR --> blood will prefer to go to pulmonic route --> L-R shunt ● Overriding aorta ● VSD RF Sx TxASD Wide-thick split of S2 Aortic stenosis Bicuspid +/- Syncopal eps, angina, Replace valve; high mortality Turner's delayed carotid, systolic once sx develop ("ASH" 1. syndrome, old age murmur @ RUSB angina 2. syncope 3. heart failure)Coarctation of Hypertension in UE, the aorta hypotension in LEAortic Bounding pulses, diastolic regurgitation murmur @ LLSBPDA Continuous machine-like murmur ● Turner's syndrome ● Sx: Hypergonadotropic hypogonadism, horseshoe kidney, bicuspid valve, coarctation of the aorta

DI Podcast Main Document 222 ● Wide pulse pressure? ● Adult: aortic regurgitation ● Kiddo: patent ductus arteriosus ● Marfan's syndrome ● Sx: mitral valve prolapse ("myxomatous degeneration of the valve), aortic dissection ("cystic medial necrosis") ● Aortic problems also a/w Ehlers Danlos, ankylosing spondylitis, syphilis ("vaso vasorum of the arch") ● Immigrant, diastolic murmur-opening snap: mitral stenosis ● RF: untreated GAS-rheumatic fever ● C/b AfibRF ● AAA: smoking ● Stroke, aortic dissection: HTN ● Afib: mitral stenosis

● Carcinoid syndrome ● Sx: ● 1. none if localized to bowel ● 2. mets to liver release serotonin ● 3. R-sided heart lesions ("TIPS" tricuspid insufficiency, pulmonic stenosis) ● Does not affect lungs bc lungs can metabolize serotonin ● Dx: elevated 5-HIAA ● *Depression: low levels of serotonin, NE, dopamine --> low levels of serotonin metabolites (5-HIAA)

● 5-hydroxytryptophan --> serotonin (5-HT) ● Not making niacin/B3 bc all diverted to serotonin! ● Sx: diarrhea, dermatitis, dementia, death ● Pt over last 3mos feeling very tired, skin hyperpigmentation, CBC looks terrible -- high eosinophil, sodium 123, potassium 6.5: addison's disease/primary adrenal insufficiency ● Pathophys: autoimmune destruction of adrenal cortex ● Sx: Adrenal cortex Hormone missing Sx Zona glomerulosa Aldosterone @ ENAC Hyponatremia, hyperkalemia, RTA 4/ non-anion gap metabolic acidosis (H+ pump) Zona fasciculata Cortisol Eosinophilia (lack of inhibition) Zona reticulata

● Increased ACTH bc lack of adrenal response: pro-opiomelanocortin/POMC --> ACTH --> melanocyte-stimulating hormone --> hyperpigmentation ● POMC = precursor to b-endorphin + ACTH + melanocytes ● ACTH --| Tuberous sclerosis: <1Y; seizure "infantile spasm"/West Syndrome ● Vs. secondary adrenal insufficiency (Sheehan syndrome, etc): low cortisol, no sodium/potassium problems (maintained by RAAS) ● Dx: ACTH stimulation --> cortisol levels do not rise ● Tx: replace hormones (fludrocortisone, glucocorticoid)

Eosinophilia DI Podcast Main Document 223 ● Drugs ● Neoplasm ● Addison's disease ● Acute interstitial nephritis ● Allergies ● Asthma ● Collagen vascular disease (lupus, scleroderma) ● Parasites

Cross checked? YES

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Ep. 121: Rapid Review Series 5 (IM/Peds)

ep 121 notes were graciously provided by Divine Intervention from an anonymous contributor.

● Chronic alcoholic, AMS, low-grade fever, vague abd pain w/ distension: spontaneous bacterial peritonitis o NBS: paracentesis (>250 WBC, bugs) o Tx: ceftriaxone, fluoroquinolone (gram+ & gram- coverage) o Ppx: fluoroquinolone o RF: ascites, peritoneal dialysis, VP shunt (h/o hydrocephalus) ● Infection few days ago, got a drug, now 101.5 fever w/ small rash on face and trunk, eosinophilia: acute interstitial nephritis o Sx: fever + rash + eosinophils (@blood or urine) ● DDx eosinophilia ● Drugs i.e. abx ● Neoplasms i.e. hematologic malignancies ● Asthma ● Addison's disease (hyperkalemia, skin hyperpig, hypotension, etc) ● AIN ● Collagen/vascular disease i.e. scleroderma ● Parasites o Dx: urine with elevated eosinophilsUrinalysis Dx EtEosinophils AIN DrugWBC casts Pyelonephritis pigmented muddy acute tubular necrosis intrarenal acute injurybrown castsreddish urine, but w/o Rhabdomyolysis/Myoglobinuria RF: alcoholics, older person fell downRBC on microscopy and couldn't get up, recent crush injury, combination of two myotoxic drugs (i.e. statins, fibrates, daptomycin)

DI Podcast Main Document 224 RBC casts nephritic syndrome lupus, IgA, PSGNfatty casts nephrotic syndrome (>3.5g/day) minimal change disease, hematologic malig, FSGS 2/2 HIV/AA, membranous nephropathy 2/2 solid malignancy, diabetic nephropathy @ Kimmelstein nodulesHyaline casts Dehydration Afferent arteriole underperfused --> RAAS --> Na absorbed in DCT, ADH release @ principal cell of nephron --> increased urine concentration ● Back pain o + lost sensation around buttocks, infertility: Leriche syndrome ● Et: severe PAD @ distal aorta + iliac arteries ● RF: smoking o + lifting heavy boxes, sudden-onset severe back pain, paravertebral muscle tenderness: muscle strain ● Tx: NSAIDs, activity modification o + osteoporosis, positive straight leg raise: herniated disk ● Et: nucleus pulposus herniation --> impingement on nerve roots ● Tx: rest + gradual return to activity for 6wks o + sudden-onset, severe abdominal pain, BP 100/50: ruptured AAA ● Dx: "draped aorta sign" = calcifications in front of vertebral bodies ● RF: smoking ● 6 mos kiddo with loss of motor milestones, fasciculations: spinomuscular atrophy o Vs. adult with fasciculations: ALS o Autosomal recessive @ chr5 SMN1 gene ● Kiddo with multiple bouts of pneumococcal sepsis, giardia, family members with multiple severe infections: Bruton's agammaglobulinemia o Et: X-linked mutation @ Bruton's tyrosine kinase (B-cell maturation) ● "humoral immunity defect/antibody defect" ● Vs. T cell @ PCP, viral, fungal infections o Sx: show up after 6mos because mom's Ab protects until then o Dx: low levels of every Ig o Tx: monthly IVIG ● Kiddo with recurrent infections, petechiae on skin, bleeds when mom tries to brush teeth, eczema: Wiskott Aldrich syndrome o Et: X-linked immunodeficiency o Sx: thrombocytopenia, eczema, recurrent infections ● Kiddo with recurrent abscesses with bacteria: CGD o Et: mutation in NADPH oxidase (oxidative burst) o Sx: infection with catalase positive organisms (i.e. Staph, Serratia) ● Kiddo with immunodeficiency, seizures, recurrent parainfluenza, prolonged QT interval: diGeorge syndrome o Et: failed development of 3rd/4th pouches (where T-cells reach puberty) ● T-cell deficiency --> infections ● Hypocalcemia --> prolonged QT, seizures ● DDx: infants of diabetic moms ● Sx: hypoglycemia 2/2 hyperinsulinemia developed in utero, VSD, HOCM

DI Podcast Main Document 225 ● Pediatric seizure, on desmopressin for nocturnal enuresis: hyponatremic seizure 2/2 ADH-analog over-secretion o DDx volume depleted kiddo: replenish with isotonic saline

Cross checked? YES

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Ep. 123: Ethics I

● 32 yo M s/p drug overdose in the ICU on a ventilator. No brainstem reflexes can be elicited. He is homeless and estranged from family. Girlfriend says that the pt wouldn’t want this. Family wants everything done. NBS? ○ Withdraw care ○ Principle: If you have an accurate, recent representation of a pt’s wishes, you should strongly consider following these wishes.

● Pt is septic with hallucinations and waxing-and-waning levels of consciousness. They don’t want you to place IV to administer fluids and antibiotics. They say “I don’t want any of those medications. Don’t give me any of those poisons.” ○ NBS? Administer abx and fluids against pt’s wishes ○ Principle: If the patient isn’t “with it” mentally, then their wishes don’t count. Instead, do what the “rational person” would decide to do.

● 4 week old infant was brought to ED with 2-3 days of bilious vomiting. He has a hypokalemic hypochloremic metabolic acidosis. Upper GI series shows malrotation with volvulus. You recommend immediate surgical intervention. Parents do not want surgery. NBS? ○ Proceed with surgery against the parents’ wishes ○ Principle: If something is life-threatening to a kid, perform the medically indicated intervention regardless of parents’ wishes ○ Another example: child of Jehovah’s witnesses that needs blood transfusion

● Adult with clear mentation has a life-threatening condition. You explain that they will die without treatment. They reiterate that they don’t want the intervention. NBS? ○ Do NOT give treatment ○ Principle: adults with clear mentation have autonomy

● Man with hx Alzheimer’s dementia is hospitalized. He has no written directives. Over the past several weeks, he’s been jaundiced and has lost 15 lbs. Imaging shows metastatic pancreatic cancer. A study states that similar pts there is no survival with xyz intervention. Family member wants xyz intervention to be done. NBS? ○ Comfort care measures ○ Do NOT do something that is not medically indicated even if the family wants it ○ Principle: if it’s not medically indicated, don’t do it

DI Podcast Main Document 226 ● 14 yo kid with a medical condition requiring surgery. The child is developmentally normal and clearly mentating. The child does not want the surgery. Parents want the surgery. NBS? ○ Proceed with the surgery ○ Principle: If pt is < 18 yo, their don’t matter (see exceptions below). ■ Exception: mental health ■ Exception: reproductive health (e.g. decisions regarding continuing pregnancy & abortion) ■ Exception: child married before age 18 ■ Exception: emancipated minor

● Pt comes in with diffuse lymphadenopathy & chronic diarrhea. He reports inconsistent condom use with multiple partners. He tests positive for HIV. He doesn’t want to tell his partner. NBS? ○ Inform the health department. The health department will perform partner notification. ○ Do NOT promise the patient that you won’t inform authorities or that partners won’t be told. ○ Similar to Tarasoff case (duty to warn when the pt expresses intention to harm another person)

● Pt says that he’s going to kill his wife. You call the wife. Option 1 = tell the wife to get away and go somewhere safe. Option 2 = tell the wife all the details of how he is going to attempt to kill her. ○ Option 1 is best. Only give enough information so the other person can get out of the unsafe situation.

● Pt that is depressed. Pt says “I don’t think I can take this anymore” and “I can’t continue like this much longer.” NBS? ○ Further screening for suicide OR hospitalization ○ Trick answer will be “give antidepressants.” They will take too long to go into effect and the person may already be dead.

● Pt expresses suicidal ideation. NBS? Option 1 = ask the pt how they feel about hospitalization. Option 2 = more forceful approach, where you tell the pt that they will be involuntarily admitted. ○ Option 1 is best. Try to convince the pt to voluntarily be admitted before pursuing involuntary admission.

● “Mental status exam is negative for evidence of suicidality” → you do NOT need to bring this pt into the hospital

—-------------------------------------------------------------------------------------------------------------------------------------------------Ep 132: Weird topics of Social Sciences

● Px lung CA, Terminal in Hospice care, cachectic: progestin analogs, cannabinoids, steroids. ○ These drugs do not increase longevity ● Px terminal CA, super depressed, hopeless feel guilty in hospice Tx: Methylphenidate. ○ NO SSRI. ● Px terminal CA, bad shortness of breath: you give opioids. ○ Give bowel regimen, as opioids cause constipation ● Px in Qx, nausea: Ondansetron (prolong Qt) ● Px terminal brain CA, feeling nausea with ICP: steroids, prednisone

DI Podcast Main Document 227 ● Px has neuropathic pain, burning tingling, neuropathy: TCAs, amitriptyline, Duloxetine, Pregabalin/gabapentin● Cancer pain hx of depression, and after Tx they have fever, myoclonus, hyperreflexia: serotonin sx and tramadol ○ Tramadol is usually the wrong answer for CA pain● Person with severe pain with mets to liver, kidney failure: Phentanyl, very safe in px with kidney disease. ○ Do not use morphine in liver injury or kidney failure ○ Another important with liver failure - lower the dose (?) of hydrocodone, oxycodone● Cancer pain, Px in tears, complaining of more pain with already opioids: give him MORE opioids: Increase the dose. The person is at the end of life, the best management is giving more opioids.● Cancer pain drug to avoid: meperidine → seizures● You smell EtOH in another physician : go to the people in charge; report it.● Conduct a person in severe illness go to palliative care: improve outcomes in patients, patients fits in this care because benefits of this treatment vs hospice ( <6 month of life) ○ Palliative care does not preclude you from getting therapy● Medical error with patient harmed : admit mistake to patient ○ Likely outcome is that you will not be sued as long as you disclose the error● Is physician assisted suicide: illegal in this country in every state● Px terminal cancer, super sick, he says I am no longer interested in another treatment: YOU respect wishes.● Px requests any intervention, if it is not medically indicated, you are not obligated to do that kind of treatment even if the patient wishes● Px disagrees with the physicians beliefs/practices/ethical principles: you transfer the px.● Old person, senile, not taking the medication: appoint to a legal guardian, because these person need someone to take care of them.● Less than 18 year, living with parents, not marry, not in the army, under the age of 18 yr : parents decision matters, patients do not have choice● Capacity and competence ○ Capacity: you can determine as a physician, by decision making capacity. ■ Classic scenarios: If the person is under influence of a substance, delirium, or altered, this person does not have decision making capacity, you do not respect this decision. ■ Things you want to check: if the person understands what’s going on, understands the risk and benefits of the therapy, alternative therapy and in clear terms communicates to the provider. ○ Competence: best left for the legal system. ■ When NBME give you a scenario: Person with power attorney, surrogate decision maker: ■ Decision makes by that surrogate example: You have a 23 years person in opioids overdose, comatose not responsive, they call the next of care, and this person say to withdraw the life support, because this person knows the patient and think what he would wish: Is a principle where the surrogate Thinks like the person who is comatose = Substituted judgment standard ■ Surrogate decision maker, trying to decide on a comatose patient, two different treatment options available, physician shows data related to survival with each therapy; the surrogate goes with the therapy that has data as a better option = Best interest standard ● The thing that you feel is best for the patient ● Physician is acting as a surrogate decision maker● If the person has an advanced care directive, designates a health care power attorney, makes decisions for that person, and another terms like living will (specific instruction what you want or what you refuse) ○ Advance Directive: Living will + power attorney DI Podcast Main Document 228 ○ But if the person does not have this designation (in order): spouse, children (+18), parents, adult siblings● When can you violate HIPAA ○ Keep the px from harm ○ Protect public from harm ○ Trying to obey the law● Px hand off: key things ○ Face to face when possible ○ Provide key pieces of information: in Standardized fashion. Use a lot of “If...then…” statements, meds the patient has, meds that need to be changed● Medical error occurs: Quality improvement ○ you want to analyze an error: Fish bone diagram: Head of the fish is the error and then you ask questions: Identifying factors like the spines of a fish. ○ If you want to FIX that Error: PDSA Cycle: process improvement model to test changes in real clinical setting. Impact in px ■ Plan: define problem and solution ■ Do: test the new process ■ Study the result ■ Act: integrate new process into regular workflow● Kinds of errors: when you try to make diagnostics decisions ○ Availability error: physician has seen a px with cough, dyspnea, chest pain, dx as pneumonia, therefore this new patient with the same symptoms has pneumonia too ○ Anchoring error: Px certain symptoms that they had a previous hospitalization, patient comes in again with the sames symptoms, you don’t make differentials on the second visit ○ Blind obedience bias: a resident comes to his shift and then the attending presents a px and this resident says everything exactly like the attending. Blindly believes everything that the attending says. ○ Premature Closure Bias: consider just a diagnostic because it comes in a common way; pts present in a common way with a common symptoms; make sure to consider everything and make a differential● Analytics tools ○ Screening methods in detecting partner violence: three words ■ HITS; hurts you, insults you, threatens you, screams at you ■ HARK: humiliated you, afraid of you, raped you, kick you ■ STAT: slapped, threatened, thrown around ○ Screen for alcohol abuse (2 but one is better) ■ CAGE ■ AUDIT-C (better test) ● Make sure to quantify their drinking before the questionnaire, and then administer the questionnaire ■ Female >7 drinks/week or >3 drinks/sitting → at risk drinking ■ Male > 14 drinks/week or >6 drinks/sitting → at risk drinking● If a pt is withdrawing from EtOH → do not give antipsychotic → increase risk of seizure ○ Best treated with benzodiazepines ○ Treat EtOH chronic with thiamine before glucose etc.● Addicted to opioids: give buprenorphine and naloxone to help with opioid dependence ○ If opioid withdrawal → clonidine● Pt trying quit smoking: ○ Nicotine replacement therapy ○ Bupropion - if comorbid depression DI Podcast Main Document 229 ○ Varenicline - works on nicotine receptors (partial agonist) - most effective ○ Smoking cessation is almost always the correct answer, never E-cigarettes● Screening guideline for AAA: abd US between 65-75 if they ever smoked ○ Only applies to men● Osteoporosis, screens women, >65, T < 2.5 → bisphosphonate● If <65, triggering conditions (chronic steroids, anorexia nervosa) → screen for osteoporosis ○ FRAX > 9.3% risk of osteoporosis● HPV ○ Age 21 - 65 screen every 3 years ○ Age 30 - 65 can do co-testing for every 5 ○ Immunodeficient: screen every year with pap ○ If she had hysterectomy for benign reason → can stop pap ○ If pt had surgery for endometrial cancer/hyperplasia → must do pap of vagin*l cuff● Colon cancer: start at 50, every 10 years if colonoscopy ○ FOBT every year ○ FIT every year ○ Flex sig = every 5 ○ Flex sig + FIT q1yr = flex sig every 10 years ○ If FHx, screen 10 years earlier ○ Family member at 53 dx w/Colon Ca when do you start? ■ Screen at 10 years earlier or at 40 ← whichever one comes earlier● Lung Ca: if pt has 30pack history, quit <15 years ○ Low dose CT every● Prostate cancer: discussion between physician and patient (not recommend past the age of 70)● Breast Ca ○ If >40, you can screen for breast Ca, mammography q2yr (NBME exam specific)● STI screening, if they sexually active ○ If <21, no pap test● Vaccines ○ If healthcare worker → get HBV ○ Influenza → q1yr, in the fall ○ Tdap → Td every 10 years ■ If pregnant women, she needs 1 Tdap for every pregnancy at 27-36 wks ○ Varicella → do not give <1yr ○ HPV → women can start at age 9, men start at 11 ■ Men having sex with other men, can give up to age 26 ○ College student → meningococcal vaccine ○ Asplenic → vaccinate against encapsulated organisms ○ Implazumab (against C5) → high risk of neisseria therefore vaccinate against ○ Egg allergy is not a C/I for the flu vax ○ Kids <1yr, pregnant women: do not give live vaccine (Varicella, MMR, yellow fever, herpes zoster, intranasal influenza) ○ Pneumococcal vaccine ■ >65 y/o need the pneumococcal (lower number should always come first PCV-13, 1 yr later give the PPSV-23) ■ <65 and immunocompromised (nephrotic syndrome is considered immunodeficient?) → need PCV-13 and PPSV23 ■ <65 and chronic disease/DM/smoke a lot/heavy alcohol → only give PPSV-23 ■ If got original PPSV-23 before the age of 65, get a second dose of PPSV-23 5 years after the first DI Podcast Main Document 230 ○ Know live-attenuated vs inactivated vaccines

Cross Checked: First half yeah, Second half no-------------------------------------------------------------------------------------------------------------------------------Ep. 132: Weird topics of Social Sciences (Version 2)

● Pt with terminal lung cancer in hospice that’s not really eating. What meds can you give them? ○ Megestrol (progestin analog) ○ dronabinol (cannabinoid) ○ corticosteroids ○ don’t improve survival or reduce morbidity

● Pt with terminal lung cancer in hospice with depression. What meds would you try? ○ Stimulants: methylphenidate ○ If super anxious, consider benzo ○ SSRIs will take too long to act

● Pt with metastatic malignancy complains of SOB. What meds would you try? ○ Opioids (e.g. morphine) + bowel regimen

● Pt on chemo with severe n/v. What meds would you try? ○ Ondansetron (serotonin receptor antagonist) ■ Adverse effect? QT prolongation

● Pt with terminal GBM. Days to week to live. Feels nauseous in the context of increased ICP. NBS? ○ Glucocorticoids to reduce ICP

● Pt with burning & tingling in extremities (neuropathic pain). What meds would you try? ○ TCAs ○ SNRI (e.g. duloxetine) ○ Gabapentin/pregabalin

● Pt with cancer pain & hx of depression on treatment. Pt was started on pain med and started to have fevers + myoclonus → serotonin syndrome 2/2 tramadol ○ Tramadol is usually not a good choice for cancer pain because it’s not that strong and has lots of interactions

● Pt with widely metastatic cancer to liver & kidneys presents with severe pain. What pain med would you consider? Fentanyl patch ○ Avoid morphine in liver & kidney disease

● Pt with bad cancer pain. Morphine dose was increased at last visit. Pt returns and is still in severe pain. NBS? Increase dose or frequency of their opioid regimen

● Pt with metastatic malignancy in hospice complains of pain. What drug should be avoided? Meperidine DI Podcast Main Document 231 ○ Why? Can cause seizures● Physician that smells of alcohol. NBS? ○ Report it to higher authority (e.g. the supervisor, ethics committee, medical board)

● Pt is being treated for cancer with intent to cure. Can they receive palliative care? YES ○ Palliative care does NOT preclude life-prolonging therapy ○ Contrast with hospice care (physician must determine that pt has less than 6 months to live before they can start hospice)

● Medical error was made. NBS? ○ Admit error to pt ○ Data suggests that the most likely outcome is the physician NOT getting sued

● Physician-assisted suicide ○ Illegal in every state

● 60-70s yo pt that is very ill. Some medical therapies remain but the pt is not interested. NBS? ○ Respect the pt’s wishes as the pt ■ Understands the situation ■ Understands the risks & benefits ■ Communicates their choice clearly

● Pt requests a therapy that is not standard of care and won’t affect outcomes. NBS? ○ No obligation to administer futile therapy

● Pt requests abortion. Physician doesn’t feel comfortable performing the procedure. NBS? ○ Transfer care of the pt to another physician who can perform the procedure

● Old senile person that isn’t taking meds as prescribed. Keeps getting admitted for problems that result from inability to take care of himself/herself. NBS? ○ Appoint legal guardian

● Adolescent < 18 yo → parents make decisions regarding medical care ○ Exceptions: ■ Substance abuse ■ Mental health ■ Reproductive health

● Capacity vs. competence ○ Capacity ■ Criteria: understands the situation, understands the risks & benefits, clearly communicates a decision to provider ■ Determined by physician ■ Examples of when pts lack decision-making capacity: ● Delirium/AMS DI Podcast Main Document 232 ● Under the influence of drugs ○ Competence ■ Determined by legal system

● 23 yo M that overdosed on opioids, now comatose in the hospital. Next-of-kin decides to withdraw care because pt said “I don’t want to be on life support.” What principle was followed? ○ Substituted judgment

● Pt is comatose. Surrogate decision maker is deciding between treatment option A and option B. They choose option A because the physician provides that data that it produces better outcomes in some regard. What principle was followed? ○ Best interest standard ○ What they

● The physician treating unresponsive trauma pt John Doe does what is medically indicated in the situation. What principle was followed? ○ Best interest standard

● Pt previously designated someone as their healthcare POA. They will make decisions on the pt’s behalf if the pt can’t make decisions for himself.

● What is a living will? ○ Document where pt outlines certain interventions that they would/would not want

● What is the surrogate decision-maker order if there is no healthcare POA designated ○ Spouse → adult children → parent → adult sibling

● Following HIPPA laws ○ Don’t disclose pt’s information to family members without their authorization ○ Exceptions: ■ Protecting pt (e.g. protect pt from killing themselves) ■ Protecting general public (e.g. homicidal ideation) ■ Following the law

● Resident is finishing shift and is getting ready to handoff to night team. ○ Handoff should happen in person ○ Provide key pieces of information in a standardized fashion ■ Use if-then statements ■ Key active problems ■ Key medications ■ Labs to f/u

● If a medical error occurs, what is the first thing that should happen? Analyze the error! ○ Fishbone/Ishikawa diagram ■ Keep identifying factors that contributed to the error DI Podcast Main Document 233 ● Core principle of QI? PDSA cycle ○ P = plan (planning the intervention) ○ D = do (putting the intervention into practice) ○ S = study (study the results) ○ A = act (refine the intervention)

● Diagnostic errors ○ Pt was cough + dyspnea + CP. Physician that has seen that presentation before and previous pt ended up having pneumonia. Physician assumes that this pt must also have pneumonia. → availability bias ○ Pt presents with certain set of sxs. They were previously hospitalized for the same sxs and a diagnosis of PNH was made. Resident assumes that sxs are again due to PNH → anchoring bias ■ Depending too heavily on an initial piece of information or the first idea that came to mind ○ Resident coming onto nightshift is assigned a pt that was just admitted by the attending. The resident doesn’t question the diagnosis or think of other possibilities. → blind obedience bias ○ Pt presents with cough + fever + CP. CXR shows consolidation. Resident says “this must be pneumonia” and doesn’t consider other things → premature closure

● Pt is undergoing IPV at home. What screening method could be employed to detect IPV? ○ HITS (does your partner hurt, insult, threaten, or scream at you?) ○ HARK (humilitation, afraid of partner, rape, kick) ○ STAB (slapped, threatened,

● Screening tools for alcohol abuse ○ FIRST quantify their drinking ○ Definition of “at risk drinking” ■ Woman OR >65 yo: >7 drinks/week or >3 drinks/one sitting ■ Man : >14 drinks/week or >4 drinks/one sitting ○ THEN employ formal screen ■ CAGE ● Cut Down ● Annoyed ● Guilt ● Eye opened ■ AUDIT-C is better than CAGE ○ Clues that suggest alcoholism on NBMEs: ■ Megaloblastic anemia (MCV > 100) ■ High GGT ■ AST/ALT > 2:1 ○ Signs/sxs of alcohol withdrawal → give benzons ■ E.g. alcoholic hallucinosis, DTs ○ Remember thiamine before glucose if alcoholic comes to ED ■ This avoids precipitating Wernicke-Korsakoff syndrome DI Podcast Main Document 234 ○ If person is delirious because they are withdrawing from EtOH ■ Don’t give antipsychotic (anti-dopaminergic agent) because this can cause seizures ■ Tx? Benzos

● Pt addicted to opioids ○ Tx? Suboxone (buprenorphine/naloxone)● Pt going through opiate withdrawal ○ Tx? Clonidine

● Pt that is trying to quit smoking. What tx would you consider? ○ Nicotine replacement therapy ○ Bupropion (NDRI) ■ Contraindications: eating disorder ○ Varenicline (nicotinic receptor partial agonist) ○ Most effective? Combination > varenicline > bupropion > NRT ○ Never choose e-cigarette on NBME

● Screening for AAA? ○ US for men age 65-76 if they’ve ever smoked or have a family hx

● Screening for osteoporosis? ○ Women > 65 yo ○ Women < 65 yo with risk factor (e.g. anorexia, prolonged steroid use) ○ FRAX > 9.3 ○ T < -2.5 → bisphosphonate

● Screening for cervical cancer ○ Age <21 → NO Pap ○ Age 21-29 → Pap q3y ○ Age 30+ → + cotesting Pap q5y ○ HIV or immunodeficiency → yearly Pap ○ Hysterectomy for benign reasons → no screening ○ Hysterectomy for endometrial hyperplasia/cancer→ Pap of vagin*l cuff

● Screening for colon cancer ○ Methods ■ Colonoscopy every 10 years ■ Flex sig every 5 years ■ Flex sig every 10 years + annual FIT ■ Annual FIT ■ Annual FOB ○ Age ■ No family hx → age 50 ■ Family hx → age 40 OR 10 years before dx of relative (whichever is earlier) ● E.g. mother had colon cancer at age 53 → start at age 40 DI Podcast Main Document 235 ● Screening for lung cancer ○ Annual low dose CT scan ○ Criteria: ■ Age 55-80 ■ Current smoker OR quit < 15 years ago ■ 30 pack-year smoking hx

● Screening for prostate cancer ○ Shared decision-making ○ > age 70 → NOT recommended

● Screening for breast cancer ○ USPSTF: start at age 50, do it every 2 years ○ ACS: start at age 40, do it every year ○● Vaccines ○ Healthcare workers should get Hep B ○ Influenza every year in the fall ○ 1 dose Tdap + Td booster every 10 years ■ Tdap in every pregnancy at 27-36 weeks ○ Varicella can’t be given to infants < 1 year old ○ HPV: ■ Girls age 9-26 ■ Boys 11-21 ■ MSM 11-26 ○ Meningococcal vaccine ■ Teens going to college ■ Military recruits ○ Asplenic or functionally asplenic → vaccinate against encapsulated organisms ■ Strep pneumo ■ H. flu ■ Neisseria meningitidis ○ Pt on eculizumab (monoclonal Ab against C5) or terminal complement deficiency → vaccinate against Neisseria meningitidis ○ Can pt with egg allergy can influenza vaccine? YES ○ Live attenuated vaccines ■ Varicella ■ Zostavax Herpes zoster ■ MMR ■ Yellow fever ■ Intranasal influenza ■ Oral polio ○ Who shouldn’t get live attenuated vaccines? ■ Babies < 1 year DI Podcast Main Document 236 ■ Pregnant women ■ HIV with low CD4 (<200)○ Inactivated vaccines ■ Hep A/B ■ Tdap → toxoid ■ Pneumococcal ■ Meningococcal ■ Influenza (injection) ■ Polio (injection) ■ Shingrix Herpes zoster○ Pneumococcal vaccine ■ https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf ■ >65 yo → just PPSV23 OR PCV13 then after 1 year PPSV23 ■ <65 yo with certain conditions → PCV13 then after 8 weeks PPSV23 ● Asplenic* ● Sickle cell (functionally asplenic)* ● Immunocompromised* ○ HIV ○ CKD ○ Nephrotic syndrome ○ Transplant ○ Hematologic malignancy ● Cochlear implant or CSF leak ● *get second dose of PPSV23 5 years later ■ <65 yo with chronic disease → just PPSV23 ● DM ● Heart disease ● Liver disease ● Lung disease ● Smoking ● Alcoholism

DI Podcast Main Document 237 -------------------------------------------------------------------------------------------------------------------------------

Ep. 134: Rapid Review Series 12 (IM / Cardiology)ep 134 notes were graciously provided by Divine Intervention from an anonymous contributor.

Recent MI ● Pt with recent MI + 12h later becomes suddenly unresponsive then dies. Cause of death? Vfib o VFib = MCC death in first 24h after MI

DI Podcast Main Document 238 o Tx: chest compressions, defibrillation, epinephrine + amiodarone (see ACLS podcast) ● Epinephrine: used to tx arrhythmias, and anaphylactic shock ● Note: Defibrillation aka unsynchronized cardioversion is only used in 2 arrhythmias, i.e. Vfib and Pulseless VTachycardia● Pt with recent MI + bilateral crackles + profoundly hypotensive. Dx? Cardiogenic shock o MI = death of cardiac myocytes --> inadequate contractility o Left ventricle heart volume is high bc it can't pump blood out o What are the hemodynamic parameters for cardiogenic shock?

LV End-Diastolic Volume increased LV End-Diastolic Pressure increased Stroke volume decreased LV End-systolic volume increased SBP Decreased CO Decreased LA pressure (surrogate for PCWP) Increased SVR Increased CV pressure (surrogate for RA) Increased ● Note: cardiogenic shock leads to pulmonary edema ● In contrast: ARDS (increased pulmonary permeability): has normal PCWP (< 18 mmHg)

● Pt with recent MI + flash mitral regurgitation d/t papillary muscle rupture --> florid backflow of blood

● Pt with recent MI + holosystolic murmur @ LLSB: intraventricular septal rupture

● Pt with recent MI + severe abdominal pain: acute mesenteric ischemia o "heart is quivering and not contracting appropriately, causing/flicking off a clot" o Vs chronic mesenteric ischemia: pain after eating, "angina of the bowel"

● Pt with recent MI + severe leg pain: acute limb ischemia o Vs chronic = peripheral arterial disease

● Pt with recent MI a few days ago, BP 80/50, JVD, tall + tiny QRS (Beck's triad): ventricular free wall rupture o Blood pools in pericardial space causing cardiac tamponade ● Sx: distant heart sounds, electrical alternans (heart "dancing" in some kind of fluid -- recorded when comes close to chest wall), low-voltage EKG (also seen in deposition i.e. amyloid)

● Pt with recent MI + revascularization, chest pain: reinfarction? --> dx with CK-MB

● Pt with recent MI + PCI, rising Cr, "blue-toe syndrome", mat-like rash "livedo reticularis" on LE? Cholesterol embolization

● Pt with recent MI + few days, chest pain (worse in supine position), scratchy sound in systole + diastole? Post-infarction pericarditis o Widespread ST elevation, PR depression

● Pt with recent MI + weeks, chest pain, scratchy sound in systole + diastole? Dressler's syndrome (autoimmune pericarditis) o Ddx of pericarditis: recent viral syndrome (MCC), renal failure/uremia, radiation therapy to chest (also a huge RF for thyroid CA!) DI Podcast Main Document 239 ● Pt with recent MI + chest pain radiating to jaw, nitroglycerin leading to hypotension: RCA infarct (pre-load dependent!) o EKG: II, III, AVF o Tx: fluids ● *steroids are not generally helpful in MI bc they prevent wound healing*

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Ep. 135: The "Clutch" Electrolytesep 135 notes were graciously provided by Divine Intervention from an anonymous contributor.

Calcium ● Hypocalcemia o Sx: Chvostek sign @ jaw, Trousseau sign @ upper extremities ● Hypercalcemia|-- 1. fluids 2. calcitonin o Pathophys: high Ca messes with signaling cascade of ADH --> ~ nephrogenic DI ~ --> low volume o @hospital: think about malignancy! o @outpt: think about primary hyperparathyroid! ● Pt placed on ACEi o Sx, dx: high renin, high K, metabolic acidosis ● ACEi --> decreased conversion of AT1-AT2 --> low aldosterone --> volume down --> positive feedback on RAAS ● --| Aldosterone --> H+ pump ● Hypercalcemia o Short QT interval o DDx ● Primary hyperparathyroidism ▪ Parathyroid adenoma: PTH secretion --> osteoclasts --> reabsorb bone ● Vs parathyroid hyperplasia (MEN) ▪ NBS ● Check ionized Ca, PTH ● Tch-99 sestamibi scan ● Sx/dx ▪ High Ca, low PO4 (PTH trashes phosphate) ▪ High urine Ca ● Tx: parathyroidectomy ● "CHIMPANZEES" ● Familial hypocalciuric hypercalcemia o Pathophys: calcium-sensing receptor does not respond to right signals o Sx/dx: high PTH, high Ca, low PO4, low urine Ca ● Receptor does not function well --> reabsorb tons of Ca from urine o Tx: benign! ● Chronic kidney disease o Pathophys: no activity of 1-alpha-hydroxylase --> impaired conversion of calcidiol to calcitriol (active VitD) --> cannot reabsorb Ca, PO4 in gut o Sx ● High PTH ● High Ca, high PO4 (cannot excrete through kidneys) DI Podcast Main Document 240 o Tx: sevalamer = binds PO4 o What if they get a transplant? ● Glands of parathyroid undergo hyperplasia due to CKD (they're "always on!") --> no longer response to normal signals --> ● Sx/dx: high PTH, high Ca, low PO4 (new kidneys) = tertiary hyperparathyroidism ▪ Bad habits are hard to break. True. ▪ Tx: resect 3.5 parathyroid glands, re-implant 0.5 gland; cinacalcet (if poor sgy candidate)● Chronic liver disease o Pathophys: no calcidiol (comes from the liver) --> decreased calcitriol --> cannot reabsorb Ca, PO4 o Sx/dx ● High PTH ● High Ca, low PO4 (kidneys are still functioning!)● AA with bilateral hilar adenopathy: sarcoidosis o Pathophys: noncaseating granulomas --> 1-alpha-hydroxylase --> calcidiol conversion to calcitriol --> reabsorption in gut --> high Ca --> low PTH● Heavy smoker, cavitary lesion in lungs, hypercalcemia: lung squamous cell carcinoma o Pathophys: paraneoplastic PTHrP --> high PTH --> high Ca, low PO4 --> low PTH o Sx: central mass, cavitary lesions o Dx: "keratin pearls" on histology● H/o MEN syndrome, diarrhea, prolonged QT interval: MEN2B o Sx: medullary thyroid cancer, Marfanoid habitus, mucosal neuromas, pheochromo ● Vs, MEN2A primary hyperparathyroid, pheo, MTC ● Vs. MEN1 primary hyperpara, pituitary adenoma, pancreatic neuroendocrine (VIPoma, insulinoma, glucagonoma, gastrinoma) ▪ Tx: insulinoma - diazoxide (open K channels to prevent insulin secretion) o Dx: calcitonin --> tones down calcium! Low Ca o Ppx: resect thyroids● Large volume blood transfusion, carpopedal spasms, seizures: EDTA o = ~anticoag that chelates Ca --> hypocalcemia o Sx: dilutional thrombocytopenia --> bleeding o Tx: calcium gluconate ● Also used for hypermagnesemia (i.e. PEC), hyperkalemia● Rhabdomyolysis o Sx/dx: low Ca ● Necrosed skeletal muscle fibers sequester Ca● Pancreatitis o Sx/dx: low Ca ● Saponification reaction by fatty acids● Infants of diabetic mothers o Sx/dx: low Ca, low glucose● Congenital heart disease, hypocalcemia: diGeorge syndrome o Pathophys: failure of 3rd/4th pharyngeal pouches o Sx: low Ca, recurrent infections, hypocalcemic seizures● Hypervitaminosis D o Sx/dx: high Ca, variable PO4, low PTH ● Increased reabsorption of Ca, PO4 in gut● Hypercalcemia of malignancy o Tx: biphosphonates● Multiple myeloma --> hypercalcemia o Pathophys: plasma cells secrete IL-1 (osteoclast-activating factor) --> reabsorbs bone --> high Ca DI Podcast Main Document 241 ● Mg x Ca o High Mg --| PTH --> low Ca o Low Mg --> PTH --> high Ca o Very low Mg --| PTH --> low Ca ● Won't respond to Ca (or K) depletion w/o Mg repletion! ● Thiazide diuretics o Sx/dx: high Ca, low urine Ca o Pathophys: --| Na/Ca exchanger @ DCT ● Good for kidney stones, osteoporosis! ● Loop diuretics o Sx/Dx: low Ca, high urine Ca o Pathophys: --| NKCC transporter @loop of Henle --> no extrusion of K --> no reabsorption of Ca o C/i: kidney stones ● Nephrotic syndrome, Menetrier's disease (protein-losing gastropathy): low albumin --> low Ca, normal ionized Ca Zinc ● Low zinc o Sx: impaired taste, impaired wound healing, loss of hair o DDx ● Nutritional ● Trientene = zinc chelator ▪ @ Wilson's dz txMagnesium ● Low Mg o Sx/dx: prolonged QT interval ● "hypo___" causes prolonged QT interval! o DDx ● Alcoholics: hypomagnesemia, folate deficiency, B1/thiamine deficiency ● Refeeding syndrome ▪ *Hypophosphatemia is the killer in refeeding syndrome! o Tx: Mg ● High Mg o Sx/dx: 1. decreased DTR 2. respiratory depression 3. CV collapse o DDx ● PEC with Mg infusion o Tx: calcium gluconate ● Tx for premature labor, preterm infantPotassium 1. Hypoperfusion @ JG cells 2. Renin released 3. AT1 converted to AT2 @ ACE receptor in lung capillaries 4. AT2 a. Vasoconstrictor @ type1 receptors b. Stimulates production of aldosterone from zona glomerulosa c. Stimulates release of ADH from supraoptic nucleus of hypothalamus d. Efferent arteriolar constriction to maintain GFR ● Low K DI Podcast Main Document 242 o Sx: flat T waves, U waves, prolonged QT interval o DDx: anything that increases RAAS activity! ● Hypovolemic ▪ Pathophys: decreased perfusion of afferent arteriole --> JG cells see this --> renin --> AT1 --> AT2 --> aldosterone --> principal cell of collecting duct --> reabsorb Na, dump K ● Conn syndrome ▪ Sx: resistant hypertension, metabolic alkalosis ▪ Pathophys: adrenal adenoma making aldosterone --> reabsorb Na, waste H, waste K --> volume expansion, metabolic alkalosis ● Hyperperfusion --| renin ▪ Dx: increased plasma aldosterone:renin ratio ● Vs: renal artery stenosis/FMD/NSAID = hypoperfusion of afferent arteriole --> RAAS --> low K, high Na, metabolic alkalosis, normal aldosterone:renin ratio ● Diuretic --> decreased volume --> hypoperfusion --> RAAS ● Sx/dx: low K, metabolic alkalosis (proton pumps @ alpha-intercalated cells) ● *low K does not always mean alkalosis -- see below! ● Acetazolamide, dorzalamide ● Pathophys: --| carbonic anhydrase --| reabsorption of HCO3 --> dumping HCO3 in urine, water follows --> non-anion gap metabolic acidosis (Type 2 RTA) with volume depletion/diuresis --> RAAS ● Sx/dx: low K, metabolic acidosis, volume depletion ● Uses ▪ Volume overload ▪ Central sleep apnea: encourages ventilation ▪ Idiopathic intracranial hypertension/pseudotumor cerebri: inhibition of CSF production ▪ Glaucoma: inhibition of aqueous humor production ▪ Altitude sickness ● Hyperventilation o Pathophys: respiratory alkalosis --> ● pulls H+ from cells --> potassium enters cells ● Binds up positive charges in the body i.e. Ca --> low Ca● High K o Sx: ​peaked T waves ​widened QRS o Can also be caused by TCA! ​sinusoidal EKG ​flat line/asystole ​death o Tx: ​calcium gluconate ​insulin (activate Na/K pump) + glucose ​albuterol/beta agonist (activate Na/K pump) ​sodium bicarb (induce alkalosis) ​kayexalate, loop diuretic o Addison's disease ​Sx: orthostatic hypotension for a while, low Na, high K, non anion-gap metabolic acidosis (Type IV RTA, positive urine AG), eosinophilia ▪ Vs. diarrhea non anion-gap: urine AG (negative/"neGUTive") ​Pathophys: autoimmune destruction of adrenal glands DI Podcast Main Document 243 ▪ Decreased perfusion --> RAAS --X--> cannot produce aldosterone --| reabsorption of Na … o Rhabdomyolsis ​Pathophys: muscle cells are dying --> release of K ​Ppx: telemetry to track fatal arrythmia ​Tx: hydration, monitor EKG o Tumor lysis syndrome ​Pathophys: lymphoma/leukemia cells dying --> release of K o Potassium sparing diuretics ​spironolactone/eplerenone (--| aldosterone receptor) ​amiloride/triamterene (--| ENAC) ▪ Can treat nephrogenic DI 2/2 lithiumSodium ● Low Na o Serum osmolarity = 2(Na) + glucose/18 + BUN/2.8 ● ^Na is the greatest contributor o + Low serum osmolarity (280-290) ● + Low volume ▪ DDx: ● diuretics (--| NKCC, losing more Na than water bc of power of diuretic) ● Forcing a kidney to work outside its normal physiology! High urine Na ● vomiting (loss of electrolyte-rich fluid) ● Low volume --> RAAS --> reabsorb Na, low urine Na ▪ Tx: fluids ● + Normal volume ▪ DDx: ● Small-cell lung cancer: SIADH ● Also seen with early gen sulfonylurea, clozapine, SSRI ● ADH --> keep reabsorbing water in the blood --> low serum osmolarity, high urine osmolarity ● Tx: fluid restriction, ADH antagonist (-vaptan) ● Hypothyroidism ● Psychogenic polydipsia ● Also seen in MDMA ● Excess water intake --> dilution of plasma --> low osmolarity --> decreased ADH --> pee out all the water you just drank --> low serum osmolarity, low urine osmolarity 4. Tea and toast diet ● + High volume ▪ DDx: cirrhosis, nephrotic syndrome, renal failure ● Low oncotic pressure --> not much fluid in vasculature --> not perfusing vasculature -->--> RAAS ▪ DDx: CHF ● Effective blood volume is low i.e. not perfusing kidneys well (cannot pump forward) --> RAAS ● High aldosterone: increase Na + H2O ● High ADH: increase H2O ● Dx: low urine Na (*high urine Na in renal failure) d/ t aldosterone ● Tx: restrict fluid ● High Na DI Podcast Main Document 244 o DDx: diabetes insipidus ● Not enough ADH activity! Cannot retain water --> peeing out a ton --> high serum osmolarity, low urine osmolarity ● DDx ● Central: closed head injury ● Nephrogenic: lithium, demeclocycline, hypocalcemia ● Dx: ▪ water deprivation test ● Urine osmolarity goes up: normal ● Barely increases: DI! ▪ Desmopressin ● Urine osmolarity goes up? Central DI ● Barely increases: nephrogenic DI ● Also used for: central DI, vWD (increased release of vWF from WP bodies), mild hemophilia A, nocturnal enuresis, kidney-assoc coagulopathy (uremia prevents degranulation of platelets)) ● Vs. coagulopathy of liver disease (tx: FFP) ● Ae: hyponatremic seizure o Tx: ● Normal saline ● D5W ● High --> low: cerebral edema! o *Think about this in overtly rapid correction of glucose in DKA, HHNK ● Low --> high: pons will die!

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Ep. 137: “Next Best Step In Management” Series 1

● 55 yo M with unilateral vision loss, sxs resolved within 5 mins → TIA ○ NBSDx? Carotid ultrasound ○ NBSM? Antiplatelet agent (e.g. aspirin, clopidogrel) ■ NOT anticoagulant unless obviously has A-fib ● 55 yo M with WHOL, started 30 mins ago + nuchal rigidity + fever 100.9F → SAH ○ NBSDx? NCCT ■ If negative, do LP → xanthochromia ○ NBSM? ■ Labetalol (control BP) ■ Nimodipine (prevent ischemic stroke) ● 50 yo F with unilateral HA + pain with chewing 2 weeks ago → temporal arteritis ○ NBS? High-dose corticosteroids ○ Temporal artery biopsy later ○ Polymyalgia rheumatica ■ Proximal shoulder pain & stiffness ■ NBS? Low-dose corticosteroids

DI Podcast Main Document 245 ■ Temporal artery biopsy later● 60 yo M w/ AMS for past 24 hrs + temp 102F + nuchal rigidity → meningitis ○ If signs of elevated ICP → give abx ○ Otherwise, obtain LP then immediately afterward give abx ○ Antibiotics: ■ Neonate or over 50 → ceftriaxone + vancomycin + ampicillin ■ Otherwise → ceftriaxone + vancomycin● Red, hot, swollen, painful knee + temp 102F → possible septic joint ○ NBS? Arthrocentesis ■ <2k WBC → OA ■ 2-50k → RA ■ >50k → septic arthritis ● Potentially crystalline arthropathy ■ Yellow needle-shaped, negatively birefringent crystals → gout ■ Blue rhomboid, positively birefringent crystals → CPPD● Lifelong smoker + 40 lbs weight loss + nodule in LUL on CXR + large L-sided pleural effusion → lung cancer ○ NBS? Thoracentesis ○ Malignant cells in pleural fluid → stage 4 → not surgical candidate● Alcoholic M with AMS for past few days + spider angiomas/gynecomastia + asterixis + fever 100.9F + mild diffuse abdominal tenderness + shifting dullness & fluid wave → SBP ○ NBS? paracentesis ■ >250 PMNs → SBP ○ Tx? Ceftriaxone (+ FQ prophylaxis after recovered) ○ Associations? ■ Peritoneal dialysis ■ VP shunts ■ Budd Chiari syndrome● 50 yo M with MI 3 days ago or hx A-fib + severe, sudden onset leg pain + cold, mottled leg → ALI ○ NBS? ■ 1st: IV heparin ■ 2nd? Vascular surgery consultation● 50 yo M with MI 3 days ago or hx A-fib + severe abdominal pain → acute mesenteric ischemia ○ NBS? Angiography to find vessel ■ Most likely vessel? SMA● Lifelong smoker with severe bilateral leg pain → peripheral arterial disease ○ NBS? ABI ■ < 0.9 → PAD ■ 0.9-1.0 → borderline ■ 1-1.4 → normal ■ > 1.4 → Mönckeberg medial calcific sclerosis ● NBS for ABI > 1.4? Toe-brachial index ○ Tx? ■ 1st: Supervised walking program ■ 2nd: Cilostazol (PDE inhibitor, helps improve sxs) DI Podcast Main Document 246 ■ 3rd: Bypass ● But arteriography first! ○ Note: PAD causes painful ulcers on the tips of digits + cool pale skin with dermal atropy + decreased pulses!● Pt with hx hearing voices + multiple hospitalizations + improves on antipsychotics in hospital, then stops taking them → schizophrenia ○ NBSIM? Monthly haloperidol decanoate injections● Pt on antipsychotic with head “stuck” → acute dystonia ○ NBS? Give diphenhydramine or benztropine● Pt on antipsychotic feeling restless, pacing in exam room → akathisia ○ NBS? ■ 1st line: beta blocker ■ 2nd line: benzodiazepine● Pt with hx schizophrenia with resting tremor + bradykinesia → parkinsonian ○ NBS? ■ 1st line: benztropine or trihexyphenidyl ■ 2nd line: dopamine agonists● Pt been on antipsychotic for a while, now with weird tongue movements → tardive dyskinesia ○ NBS? Stop drug ■ Switch to atypical antipsychotic

● 35 yo F with BMI 40 with morning HAs + blurry vision for last 3 weeks → IIH ○ NBS? LP ○ Tx? ■ Acetazolamide ■ serial therapeutic LPs ○ Stop potential offending meds ■ Vit A analogs ■ Doxycycline● 35 yo M with daily pulsatile headaches for past 3 months, feels better resting in dark room → migraines ○ NBS? Chronic migraine medication ■ Beta blockers ■ Topiramate ● Adverse effect? nephrolithiasis ■ TCA ● Signs of toxicity? Wide QRS● 35 yo M hx of migraines, having severe HA right now ○ NBS? Abortive therapy ■ Sumatriptan ■ Ergo derivative● 35 yo M with severe unilateral headache + rhinorrhea + conjunctival injection → cluster HAs ○ NBS? 100% O2● 30 yo M hx of tx-resistance schizophrenia, started on new med 2 weeks ago, over last 24 hrs has had fever to 103F + WBC 2k with 20% neutrophils → neutropenic fever 2/2 agranulocytosis 2/2 clozapine tx ○ NBS? Stop clozapine DI Podcast Main Document 247 ○ Tx? ■ Antipseudomonal agent: e.g. meropenem, imipenem ○ Similar presentation to pt on chemo or pt with Graves’ on methimazole● Lifelong smoker presents with 7 days of SOB + increased sputum production → COPD exacerbation ○ NBS? IV corticosteroids + bronchodilators (e.g. Duoneb) + azithromycin ■ Azithromycin is used for its anti-inflammatory properties● 60 yo M with hx AR presents with 3 days of profound SOB + orthopnea + S3 heart sound → CHF exacerbation ○ NBS? IV furosemide (loop diuretic) ■ Can also gives nitrates to relieve dyspnea 2/2 pulmonary edema● Pt with terminal cancer with dyspnea ○ NBS? Morphine● 75 yo M lifelong smoker presents with 6 weeks of joint pain (fingers, legs) not improved with NSAIDs + finger clubbing on exam → Hypertrophic pulmonary osteopathy ○ NBS? CXR● 57 yo F with insomnia due to “crawling sensation in leg” → restless leg syndrome ○ NBS? Dopamine agonist (e.g. pramipexol, ropinirole) ■ Alternatively, primidone ○ Association? IDA● 30 yo M with 6 months of diffuse worries → GAD ○ NBS? Consider SSRI or buspirone (partial serotonin receptor agonist)● 25 yo F with hx depression + placed on SSRI/SNRI 4 weeks ago + want to stop drug due to sexual side effects ○ NBS? Switch to bupropion (no sexual side effects) ■ Other indications: smoking cessation, weight loss ■ Contraindication: anorexia & bulimia, hx seizures● 50 yo F with 2 months of guilt + loss of interest + hypersomnia + low energy + HR 49 → pseudodepression 2/2 hypothyroidism ○ NBS? TSH● 45 yo M with 2 weeks palpitations + 10 lb weight loss + BP 180/90 + HR 190, then suddenly becomes somnolent → thyroid storm ○ NBS? Propranolol then PTU then Lugol’s solution (supersaturated solution of KI)● 75 yo M over past year forgets to turn off stove, forgets longtime friends → Alzheimer’s disease ○ NBS? Brain MRI ○ Tx? AChE inhibitor ■ Donapozel ■ Galamine ■ Rivastigmine● 35 yo M alcoholic presents with 2 days severe mid abdominal pain, radiates to back → alcoholic pancreatitis ○ NBS? IVF & NPO ○ DX? Lipase (more specific than amylase)● 40 yo F with Grave’s on methimazole presents with 2 hrs palpitations + HR 220 + pulse irregular, then appears confused & BP drops 70/40 → A-fib with RVR, now HDUS ○ NBS? Synchronized cardioversion = DC cardioversion DI Podcast Main Document 248 ■ Because pt is hemodynamically unstable ○ What if the patient was HDS? ■ Beta blocker ■ CCB (verapamil, diltiazem) ● Verapamil associated with hyperprolactinemia ○ Rate control strategy: beta blocker, non-dihydropyridine CCB, digoxin ○ Rhythm controls strategy: amiodarone● 25 yo M with palpitations + HR 250 + irregularly irregular + hx WPW ○ NBS? Procainamide ■ Do NOT use AV nodal blocking agent (BB, CCB, digoxin, adenosine) because this enhances use of accessory tract → V-fib likely● 30 yo F presents with 3 months severe abdominal pain + globular, boggy uterus → adenomyosis ○ NBS? Hormonal IUD● 40 yo F presents with 3 months severe abdominal pain + globular, boggy uterus, doesn’t want any more children, fed up with pain → adenomyosis ○ NBS? Hysterectomy ○ Dx? Uterine MRI ○ Gold-standard test for adenomyosis? Diagnostic laparoscopy● 45 yo F with BMI 40 + severe pain RUQ + temp 101F + WBC 12k? ○ NBS? RUQUS ■ If equivocal → HIDA scan ● “Non-visualization of GB after 4 hrs” = positive for cholecystitis ○ Tx? Proceed with cholecystectomy● Pt severely ill in hospital for 2 weeks now with RUQ pain + fever + leukocytosis + RUQUS showing GB wall thickening & pericholecystic fluid but NO cystic duct dilation or obstructing stones → acalculous cholecystitis ○ NBSM? Percutaneous cholecystostomy ■ Do NOT perform cholecystectomy (high mortality!)● 17 yo M with BMI = 40 with morning HAs + RR 8 + PCO2 60 → OSA/OHS ○ NBS? Polysomnogram● 6 month old with 2 weeks of frequent GTCs + hypopigmented macules on exam ○ NBSM? ACTH ■ Alternative = vigabatrin ○ EEG findings? Hypsarrhythmia ○ Association? Tuberous sclerosis● 33 yo M with BMI = 18 with 3 days of severe blood diarrhea + severe distention, rebound, guarding on exam → toxic megacolon 2/2 UC ○ NBS? Ex-lap● Ex-lap is NBSM ○ Toxic megacolon (2/2 C. diff, UC, Chagas) ○ Penetrating trauma to abdomen ○ Free air under diaphragm● Nurse stuck by needle from Hep B positive pt, had Hep B vaccine 2 years ago with confirmed immunity ○ NBS? No further action ○ If non-immune? Hep B vaccine + Hep B immune globulin DI Podcast Main Document 249 ● HIV pt on HAART, CD4 = 600 ○ NBS? ■ In fall, give influenza vaccine ■ Pneumococcal vaccine ● Adults <65 yo if smoker, CKD, DM, or immunocompromised ● All adults >65 yo ● 22 yo G2P1 F at 18 weeks, has elevated AFP, decides to undergo amniocentesis ○ NBS? Give Rhogam ● 37 yo F with 3 months of heavy menstrual bleeding, BMI = 35, menses every 70 days ○ NBS? OCPs ○ Endometrial biopsy may also be the right choice due to high risk of endometrial hyperplasia/carcinoma ● 25 yo M with high # partners and inconsistent use of condoms. Painless lesion with heaped up borders on penis ○ NBS? RPR or VDRL ○ After RPR/VDRL, do a treponemal test (e.g. FTA Abs) ○ Tx? Penicillin G ● 35 yo M going for eye surgery, 20 minutes after induction has stiffness in extremities and fever 105F → malignant hyperthermia ○ Pathophys? Abnormal ryanodine receptors permits tons of Ca++ to be released from SR → muscle contraction ○ NBS? Administer dantrolene ■ Blocks ryanodine receptor (which is a Ca++ channel that enables Ca++ release from the sarcoplasmic reticulum) ○ Inheritance? AD ○ Gene? Ryanodine receptor gene

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Ep. 138: The "Clutch" Genetic Diseaseep 138 notes were graciously provided by Divine Intervention from an anonymous contributor.

Chromosomal/trisomy ● Newborn w/ flat face, epicanthal folds, Brushfield spots on iris, single palmar crease: Down syndrome ● Et: Trisomy 21 ● Pathophys: 1. Maternal nondisjunction (MCC) 2. Robertsonian translocation = 1 part of one chromosome goes to another --> teeny-tiny chromosome + big boy chromosome ● Dx: elevated bHCG + inhibin, low AFP + estriol, karyotyping ● Sx (mostly from neural crest issues): ● Endocardial cushion defects w septa + valves --> atria and ventricles not separated properly ● Duodenal atresia --| recanalization DI Podcast Main Document 250 ▪ Vs. jejunal atresia d/t vascular insult in utero ● Hirschsprung disease --| Auerbach/Meissner plexi ▪ Sx: meconium ileus ● C/b ALL, Alzheimers (amyloid-precursor protein on chr21) ● RF: advanced maternal age = less eggs to fertilize, higher likelihood of fertilizing nondisjunction egg● Second most common trisomy: Edwards Syndrome ● Et: Trisomy eighteen ● RF: advanced maternal age ● Sx: prominent occiput, micrognathia, overlapping digits, rocker-bottom feet, death by age1-2● Least common trisomy: Patau syndrome ● Et: Trisomy 13 ● RF: advanced maternal age ● Sx: microcephaly, micropthalmia, holoprosencephaly, multiple digits, cleft lip/palate, rocker-bottom feet, death <1Y● Cat-like cry: cri-du-chat syndrome ● Et: chr5 defect ● Sx: microcephaly, high-pitched cat-like cry● 6mo losing motor milestones, fasciculations: spinomuscular atrophy ● Et: chr5 @ SMR1 gene ● Pathophys: destruction of anterior horn cells in spinal cord● White reflex/leukocoria: retinoblastoma ● Et: chr15 Rb tumor suppressor deletion ● C/b osteosarcoma● Visual problems (no iris), flank mass, posterior urethral valves, ID: WAGR ● Sx: Wilms tumor + aniridia + genitourinary + mental retardation ● Et: chr11 gene deletion● Beckwith-Wiedemann Syndrome ● Sx: Wilms tumor, macroglossia, hemihypertrophy, hepatoblastoma ● Seizures at birth d/t hypoglycemia <-- overgrowth of pancreatic islet beta cells (insulin)● 25M infertility, 6', breast tissue, micropenis: Klinefelter syndrome ● Et: 47XXY ● Pathophys: gonads do not work --> no inhibition @ pituitary --> elevated FSH/LH (hypergonadotropic hypogonadism) ● Sx: no sperm, female distribution of hair● Female w short stature, short posterior hairline: Turner Syndrome ● Et: 45XO ● Pathophys: second X chromosome is necessary for forming ovaries! Therefore they have streak ovaries --> no estrogen --> defect in secondary sexual characteristics ● Sx: ● cubitus valgus (elbow turned inward) ● short stature, ● low posterior hairline ● congenital lymphedema (cystic hygromas, webbed neck) ● primary amenorrhea ● coarctation of the aorta ▪ Delayed radial-femoral pulse ▪ d/t stenosis past the subclavian ● Bicuspid aortic valve --> early onset aortic stenosis ▪ *MCC of aortic stenosis <70Y! (afterwards: senile calcification) ● Horseshoe kidney DI Podcast Main Document 251 ● Later in life, abdominal mass: streak ovary --> gonadoblastoma ● hypergonadotropic hypogonadism ▪ Vs: athlete that works out a ton --> shut down HPG axis --> hypogonadotropic hypogonadism ▪ Vs. Hypothyroidism --> elevated TSH --> prolactin --| GnRH, FSH, LH ▪ Vs. Kallmann syndrome --| GnRH cells ● Genomic imprinting disorders or uniparental disomy ● Obesity, hypotonia, deletion of paternal chr15: Prader-Willi ● Inappropriate laughter, deletion of maternal chr15: AngelmanAutosomal recessive: enzyme defects, earlier sx, need 2 bad copies of allele ● 5th percentile weight, 10th percentile weight, recurrent infections: cystic fibrosis ● Et: chr7 deltaF508 @ CFTR channel ● Pathophys: Cl does not leave the cell --> attracts extracellular sodium --> water follows --> thick secretions of exocrine, sweat glands ● Sx: ● Pancreas: fat malabsorption ADEK (night blindness, secondary hyperpara, cerebellar ataxia, acanthocytosis, bleeding), ● Recurrent sinus infections d/t impaired mucus clearance ● Inflammatory response --> "cystic" dilation of airways = bronchiectasis + fibrotic damage ● Pneumonia 1) Staph aureus 2) Pseudomonas ▪ Burkholderia cepacia --> TERRIBLE pulm infection --> sudden death 2/2 pneumonia ● Plugging of seminiferous tubules, agenesis of vas deferens --> infertility ● Meconium ileus ● Secondary primary biliary cholangitis d/t thick secretions of bile canaliculi ● Tx: Ivacaftor ● Dx: sweat chloride test, conductance of nasal epithelium, low serum trypsinogen (pancreas), DNA testing ● Child w/ musty odor, ID: phenylketonuria ● Et: deficiency of phenylalanine hydroxylase ● BH4 cofactor; mutation in tetrahydropterine reductase could cause similar sx ● Pathophys: buildup of phenylalanine ● Sx ● Toxicity @ neurons ● Musty odor (phenyl = benzene ring = aromatic compound) ● Albinism d/t deficiency of tyrosine (--> melanin) ● Tx: no phenylalanine in diet, avoid aspartame (artificial sweeteners) ● Dx: newborn screen ● Ppx: mom has PKU --> needs to be placed on careful diet during pregnancy; phenylalanine can cross placenta --> sx in baby ● 25Y, osteoarthritis, black joints on synovial analysis, discoloration of ears/nose: alkaptonuria/ochronosis ● Et: deficiency of hom*ogentisic acid oxidase ● Sx: "cartilage fetish" ● Albinism ● Et: deficiency in tyrosinase ● tyrosine --tyrosinase--> melanin ● Sx: oculocutaneous albinism ● C/b basal cell/squamous cell carcinoma (melanin helps absorb some of the bad UV) ● Cherry-red spot on macula, loss of motor milestones, no HSM: Tay-Sachs disease ● Lysosome = "waste basket of the cell" ● Et: deficiency of hexosaminidase A --> buildup of GM2 ganglioside (@CNS)

DI Podcast Main Document 252 ● Sx: hyperreflexia, ID, cherry-red (ganglion cells in retina enlarge, engorge/compress blood vessels), death <2Y ● RF: Ashkenazi-Jewish heritage ● Niemann-Pick Disease ● Et: deficiency of sphingomyelinase --> buildup of sphingomyelin in macrophages (@ reticuloendothelial system = liver, spleen, bone marrow + @CNS) ● Sx: cherry-red spot on macula, hyperreflexia, ID, hepatosplenomegaly (c/b thrombocytopenia) ● Pancytopenia, macrophages on bone marrow biopsy w/ crumpled paper appearance: Gaucher disease ● Et: deficiency of glucocerebrosidase @ macrophages in reticuloendothelial system ● Sx: ineffective erythropoiesis, joint problems ^^^ ● Corneal clouding, coarse facial features: Hurler syndrome ● Et: mutation in alpha-L-iduronidase --> buildup of heparin + dermatan sulfate ● Sx: ● Vs. Hunter syndrome (X-linked recessive): mutation in alpha-iduronate sulfatase ● Pathophys: buildup of heparin + dermatan sulfate ● Sx: no corneal clouding or coarse facial features ● Von Gierke disease (Type 1 GSD) ● Et: deficiency of glucose-6-phosphatase (glycogen-->glucose) --> buildup of G6P in liver ● --> hepatic cells expand, explode! ● Sx: hypoglycemia between meals d/t lack of gluconeogenesis ● Pompe disease (Type 2 GSD) ● Et: deficiency of alpha-1,4-glucosidase/acid maltase ● Sx: heart failure ● Cori disease (Type 3 GSD) ● Et: deficiency of debranching enzyme/alpha-1,6-glucosidase (@muscle, liver) ● Sx: hepatosplenomegaly, muscle sx ● McArdle's disease (Type 5 GSD) ● Et: deficiency of glycogen (myo)phosphorylase @muscle ● Sx: muscle cramping w/ exercise ● I-cell disease: --| phosphotransferase --> cannot put mannose-phosphate on things, so things are improperly transported ● FA oxidation disorders ● Medium chain, long chain FA: metabolized @ mitochondria ● MCAD/LCAD --| beta-oxidation --> impaired FA oxidation --> elevated acylcarnitine ▪ Vs. carnitine deficiency: low acylcarnitine ● Very long chains: metabolized @ peroxisome ● Adrenoleukodystrophy: demyelination, cerebellar ataxia, death <2Y ● Hemophilia C --| Factor 11 ● African missionary with oxidizing drug --> hemolytic anemia: G6PD ● Sx: heinz bodies, bite cells ● Dx: G6PD assay weeks after epX-linked recessive (sx @ boys) ● Immunodeficiencies! ● Recurrent infections, hypopigmented skin (eczema), low platelets: Wiskott Aldrich syndrome ● Chronic Granulomatous Disease ● Et: deficiency in NADPH oxidase ● Sx: recurrent infections w Staph aureus (abscesses) ● Dx: tetrazolium, dihydrorhodamine test ● Tx: interferon-gamma

DI Podcast Main Document 253 ▪ Vs. ● Interferon alpha --| HepC ● Interferon beta --| MS ● Kiddo w/ gout, chews off fingers/toes: Lesch-Nyhan syndrome ● Et: deficiency of HGPRT (purine salvage pathway) ● Sx: hyperuricemia --> toxicity @ neurons, self-mutilation ● Bruton's agammaglobulinemia ● Et: mutation in Bruton's tyrosine kinase (B-cells) ● Sx: small tonsils, bacterial infections ● Tx: IVIG ● Hemophilia A --| Factor 8 ● Sx: elevated PTT ● Dx: correct w mixing studies (but sometime create Ab-factor8) ● Hemophilia B --| Factor 9 ● Sx: elevated PTT ● Dx: correct w mixing studies (but sometime create Ab-factor9) ● Meinke's disease/kinky hair disease ● Et: ATP7A mutation (copper metabolism) ● Vs. ATP7B Wilson's disease (copper @ basal ganglia, liver dz, psych, Kayser, c/I copper IUD, tx penicillamine/trientine) ▪ *penicillamine/trientine = chelators; ae: zinc deficiency (also chelated) ● Sx: death <2YAutosomal dominant: structural protein or receptor defect, later sx ● If two copies of bad dominant allele: death in utero i.e. lethal form of osteogenesis imperfecta ● 19Y, father died from MI @30Y, severe chest pain, STEMI, xanthelasma/xanthomas: familial hypercholesterolemia ● Et: mutation in LDL receptor --> will not clear cholesterol ● Type 1: No LDL receptor ● Type 2: LDL receptors do not reach surface of the cell (--| exocytosis pathway) ● Type 3: LDL has trouble binding to LDL receptor; MCC ● Type 4: LDL binds to LDL receptor but not endocytosed ● Type 5: --| recycling LDL receptor ● Sx: accelerated atherosclerotic dz ● Tx: statin, PCSK9 inhibitors (-cumab) ● 6'5", hyperextensible joints, displacement of lens, tearing chest pain radiating to back: Marfan's syndrome ● Et: mutation on chr15 fibrillin gene/FBN1 (maintains integrity of elastic fibers) ● Sx: ● Mitral valve prolapse/myxomatous degeneration ● Impaired elasticity of arteries (@intima) --> dilation without collapse --> aneurysm --> ascending aortic dissection (highest pressure vs. abdominal aorta) --> pull leaflets apart --> aortic regurgitation ● Circle of willis aneurysm --> subarachnoid hemorrhage ● Lens subluxation/ectopia lentis: up and out Marfan's syndrome hom*ocystinuria Aut dom Aut rec Fibrillin mutation Cystathionine beta-synthase deficiency Lens up and out Lens down and out

DI Podcast Main Document 254 Normal intelligence ID *B6/B9/B12 elevate hom*ocysteine* ● Problems w/ wound healing, hyperextensible joints: Ehlers-Danlos syndrome ● Et: mutation in Type 3 collagen ● Sx: aortic dissection, thoracic aortic aneurysm, wound dehiscence, rupture of colon (thicker fecal material d/t water absorption --> wall of colon w type3 collagen struggles) ● Kiddo w blue sclera, fractures, short: osteogenesis imperfecta ● Et: defect in Type 1 collagen (COL1) ● Kiddo w hematuria, hearing problems, cataracts: Alport syndrome ● Et: defect in Type 4 collagen COL4A5 (@eye, ear, kidney) ● *X-linked dominant ● Vs. Goodpasture syndrome: Ab-Type4collagen ● Kiddo w short stature, dwarf, problems w long bone growth: achondroplasia ● Et: mutation in fibroblast-growth-factor3 ● Café au lait spots, growths on body: NF1 ● Et: chr17 @ neurofibromin = tumor suppressor of p21 (RAS cascade) ● Sx: neurofibromas, meningiomas, pheochromo, Lisch nodules (hamartomas @ iris) ● NF2 ● Et: chr22 @ merlin = tumor suppressor that tells cells when they're too close (contact inhibition) ● Sx: bilateral acoustic neuromas ● Posterior fossa mass, hematocrit 60%: VHL ● Et: chr3 @ VHL gene = ubiquitination of proteins that cause growth/proliferation ● Sx: hemangioblastoma (esp @cerebellum, inhibited downregulation of HIF1 vascularization), EPO production, cysts @ liver/pancreas, bilateral renal cell carcinoma ● Multiple polyps in colon: FAP ● Ppx: colonoscopies <20Y ● + medulloblastoma = Turcot syndrome ● + soft tissue osteoma = Gardner syndrome ● Hgb 8, paternal relatives have blood disorders: hereditary spherocytosis ● Et: mutation in ankyrin, spectrin, band3.2 ● Tx: splenectomy ● F with heavy menstrual bleeding: Von Willebrand Disease ● Et: deficiency of VWF ● Dx: normal plt, elevated PTT Trinucleotide repeat ● Autosomal dominant ● Myotonic dystrophy ● Et: CTG @ DMPK1 ● Sx: trouble releasing grip, early balding ● Huntington's ● Et: CAG @ chr4 ▪ w/ anticipation! ● Sx: choreiform movements, dementia, inappropriate behavior ▪ DDx choreiform movements: ● Huntington's ● Sydenham chorea 2/2 rheumatic fever ● Lesion @ subthalamic nucleus = contralateral hemiballismus

DI Podcast Main Document 255 ● PANDAS = pediatric autoimmune neuropsych disorder 2/2 GAS ● Vs. myoclonus ● Neuroblastoma (flank mass, posterior mediastinum, calcified, crosses midline): "opsoclonus-myoclonus syndrome" ● Crutzfeld-Jakob disease: elevated 14-3-3, prion ● Serotonin syndrome ● Tx: haloperidol, tetrabenazine ● X-linked dominant (only 2 = Fragile X + Alport!) ● Big ears, testicl*s, long face, ADHD/autism: Fragile X syndrome ● Et: CGG repeat ● Autosomal recessive ● Friedrich ataxia ● Et: GAA repeatMitochondrial disorders: from mom! ● Leber optic neuropathy ● MELAS = mitochondrial dz "ragged red fibers" --> encephalopathy, lactic acidosis, strokeMultifactorial inheritance ● Neural tube defects ● Congenital heart disease ● T2DM

-------------------------------------------------------------------------------------------------------------------------------Ep. 141: Rapid Review Series 13 (IM)

● 40 yo F, BMI = 40, presents with pain in upper abdomen + fever 102F + positive Murphy’s sign → acute cholecystitis ○ Dx? RUQUS w/ GB wall thickening + pericholecystic fluid ■ If negative, HIDA scan ● Don’t see gallbladder at 90 mins → acute cholecystitis ○ Tx? Lap chole ● Pt on TPN or in ICU, RUQUS shows characteristic findings but no stones → acalculous cholecystitis ○ Tx? Percutaneous cholecystostomy ■ Do NOT perform cholecystectomy (increased mortality) ● Pt with stone in cystic duct + dilation of intrahepatic bile ducts → Mirizzi syndrome ● RUQ pain + fever + AMS + scleral icterus + BP 80/48 → ascending cholangitis ○ Charcot triad = RUQ pain, fever, jaundice ○ Reynolds pentad = Charcot triad + AMS + hypotension ○ Dx? ERCP ○ Tx? ERCP + abx ● Pt s/p spleen repair for traumatic injury, now with referred pain to L shoulder & fevers → subphrenic abscess ○ Tx? Drain abscess

DI Podcast Main Document 256 ● Pt recently treated for acute pancreatitis, isolated gastric varices found on imaging or endoscopy → splenic venous thrombosis ○ Weird thromboses: ■ Renal vein thrombosis ● Association: nephrotic syndromes (esp membranous nephropathy) ■ Hepatic vein thrombosis = Budd Chiari syndrome ● Associations: OCPs, polycythemia vera● Pt with hx OA presenting with epigastric pain → peptic ulcer disease● Alcoholic pt with pain radiating to back → acute pancreatitis ○ Drug that cause pancreatitis: ■ Didanosine ■ Stavudine ■ GLP-1 agonists (e.g. exenatide, liraglutide) ■ DPP4-inhibitors (e.g. sitagliptin) ○ Associations: ■ Alcoholism ■ Gallstones ■ Sickle cell ■ IgG4-related dz ● RP fibrosis ● Pancreas looks like a sausage on imaging● Periumbilical pain progressing to RLQ → acute appendicitis● Flank pain radiating to groin + hematuria → nephrolithiasis● 23 yo F with severe RLQ pain + inconsistent condom use → ectopic pregnancy● 15 yo F with 5 cm simple ovarian cyst, now with sudden-onset severe abdominal pain → ovarian torsion ○ Contrast with ruptured cyst: will have free fluid in peritoneal cavity on USMLEs● Cervical motion tenderness + vagin*l discharge → PID ○ Fitz-Hugh-Curtis syndrome = involvement of hepatic capsule ○ Bugs? CT & NG ○ Tx? Ceftriaxone + azithro/doxy ○ Don’t give IUD recently after PID ep● 80 yo F with LLQ pain + fever → diverticulitis ○ Dx? CT w/ contrast ○ Colonoscopy weeks later to r/o CRC● 80 yo F with LLQ pain + pneumaturia or fecal matter in urine → colovesical fistula 2/2 diverticulitis● Pt on chemo with thickened cecum → typhlitis ○ Pathophys: severe inflammation of cecum (similar to necrotizing enterocolitis)

● MAHA + thrombocytopenia + renal failure → Hemolytic uremic syndrome ○ Bugs? O157H7 E. coli or Shigella ○ Platelet count low ○ Bleeding time high ○ PT/PTT normal● Hemophilia A/B ○ Platelet count normal DI Podcast Main Document 257 ○ Bleeding time normal ○ PT normal ○ PTT high ○ Inheritance? X-linked recessive ○ Factors? ■ Hemophilia A → factor VIII ■ Hemophilia B → factor IX● Von Willebrand disease ○ Platelet count normal ○ Bleeding time prolonged ○ PT normal ○ PTT high ■ Pathophys: factor VIII is bound to vWF in circulation, vWF helps prevent its degradation● Risocetin test used to assess 1st step in primary hemostasis (integrity of Gp1b-vWF interaction) ○ Abnormal in VWD & Bernard–Soulier syndrome● DIC ○ Platelet count low (consumption) → prolonged bleeding time ○ Coagulation factors being consumed → PT & PTT high● Warfarin ○ Platelet count normal ○ Bleeding time normal ○ PT & PTT both high (affects factors 2, 7, 9 10) ○ Reversal? ■ Vit K ■ Four-factor PCC (prothrombin complex concentrate)● Heparin ○ Platelet count normal ○ Bleeding time normal ○ PT & PTT both high (affects factors 2 & 10 in common pathway) ○ Reversal? Protamine sulfate● Aspirin ○ Platelet count normal ○ Bleeding time prolonged ■ Pathophys: irreversibly inhibits COX → impairs platelet function ○ PT & PTT normal● Liver ○ PT & PTT elevated due low factor production● Splenomegaly ○ Platelet count low (due to sequestration)

● 45 yo F with hx HIV at annual visit, with bilateral pedal & periorbital edema on exam, decreased breath sounds + dullness to percussion lower lung fields + UA with 4+ protein + CXR with bilateral blunting of costophrenic angles → transudative effusion 2/2 FSGS ○ Pathophys: loss of protein in urine → decreased oncotic pressure → transudative effusions ○ Causes of transudative effusions DI Podcast Main Document 258 ■ CHF ■ Cirrhosis (low albumin) ■ Nephrotic syndromes ■ Menetrier disease (protein-losing enteropathy) ■ PE **can cause both ○ Causes of exudative effusions ■ Malignancy ■ PE ○ Light’s criteria ■ Pleural protein/serum protein < 0.5 ■ Pleural LDH/serum LDH < 0.6 ■ Effusion LDH < ⅔ ULN serum LDH

● 55 yo M s/p type A aortic dissection 2 days ago, has developed progressive dyspnea + pH 7.47 / pCO2 44 / PaO2 58 + CVP 8 + PCWP 14 + BNP 97 + bilateral crackles + CXR with pulmonary edema (“batwing appearance”) → ARDS ○ Pathophys? Increased pulmonary vascular permeability ○ PCWP must be < 18 to make ARDS diagnosis! ■ Indicates that it’s a non-cardiogenic pulmonary edema ○ ARDS diagnostic criteria? ■ PaO2/FiO2 < 300 ■ CXR with bilateral infiltrates ■ PCWP < 18 ○ Tx? Ventilation with high PEEP & low tidal volumes

DIARRHEA EXTRAVAGANZA ● Pt with recent travel to Mexico, now watery diarrhea → ETEC ● Pt with rice-water stools → Vibrio cholerae ○ Tx? ■ Rehydration with OHS (salt & sugar) ■ Macrolide or tetracycline ● Watery diarrhea in hiker/camper, pt with IgA deficiency or Bruton’s agammaglobulinemia → Giardia ● Watery diarrhea on cruise ship → norovirus ● Watery diarrhea in infant → rotavirus ○ Vaccine can’t be given if hx of intussusception, Meckel’s, HSP ● Watery diarrhea in AIDS pt → cryptosporidium ○ Special stain? Acid-fast oocysts ○ Tx? ■ Paromomycin ■ Nitazoxanide ● Bloody diarrhea after beef consumption → EHEC, Shigella, Campylobacter ○ Campylobacter is most common cause of bloody diarrhea in US ○ Campylobacter associated with GBS ■ Dx? Albuminocytologic dissociation in CSF ■ Tx? Plasmapheresis or IVIG DI Podcast Main Document 259 ● Diarrhea after abx → C. diff ○ Tx? Oral vancomycin ● Bloody diarrhea + RLQ pain + hx pork consumption → Yersinia enterocolitica ○ “Pseudoappendicitis” ● Bloody diarrhea + liver abscess → Entamoeba histolytica ○ Tx? ■ Metronidazole ■ Inject iodoquinol into abscess ● Blood diarrhea + low Hgb + low platelets + elevated Cr → HUS ○ Bugs? Shigella or EHEC ■ Shigella has very low microbe requirements for infection ● Diarrhea after oyster/seafood consumption → Vibrio parahaemolyticus ● Pt with liver dz, consumes oysters, now severely ill → Vibrio vulnificus ● Pt swam in freshwater then died soon thereafter → Naegleria fowleri ● Diarrhea & vomiting after eating fried rice → Bacillus cereus ● Vomiting 2 hrs after consuming potato salad → Staph aureus

POISONING ● 44 yo M brings 4 yo son to ED, 4 hr history of profuse sweating + drooling + watery diarrhea, BP 89/58 + HR 33 + T99.1 + RR 8, PE with diffuse wheezing + bilateral pupillary constriction, mother with myasthenia gravis → AChE inhibitor poisoning ○ Similar presentation to organophosphate poisoning ■ Organophosphates inhibit AChE ○ Tx? Atropine (anticholinergic, blocks muscarinic receptors) ○ Other overdose tx ■ Physostigmine (cholinesterase inhibitor) ● Jimson weed (anticholinergic properties) ● atropine overdose ■ Flumazenil ● Benzos overdose ● Zolpidem, zaleplon, eszopiclone ■ Naloxone ● Opioid overdose

IRRITABLE BOWEL SYNDROME TX ● IBS will not have any PE or lab abnormalities ● IBS-D treatment ○ Loperamide (synthetic opioid) ○ TCA (anticholinergic activity) ● IBS-C ○ Stool softener ○ Lubiprostone (chloride channel activator → secretory diarrhea)

DI Podcast Main Document 260 -------------------------------------------------------------------------------------------------------------------------------

Ep. 143: Biostats ReviewFYI: Here’s a copy of the powerpoint slides found on the Divine Intervention website formatted to a worddocument. This is NOT the audio transcribed.

Q1A new serum test is created to screen for peripheral arterial disease. The sensitivity of the test is 80%. Themost accurate interpretation of thisstatement is? a. Patients with positive test results have an 80% chance of having the disease. b. In patients with negative test results, 80% do not have the disease. c. In patients who have the disease, 20% will have a negative test result. d. Patients with negative test results have an 80% chance of not having the disease.

Q1 Key-The best answer here is C.-In my experience, answering NBME questions rarely depends solely on doing math. Understanding isthe way to go!-Sensitivity essentially answers the Q-Of all the population with a given disease, what % have +ve testresults? That’s it!-The other % that you don’t detect that TRULY have disease are the false negatives. The 2nd word is “negative”but the word in front of it is “false” so you know that they are in fact +ve. I use this 2nd-1st word mantra tokeep things straight. Highly seNsitive tests have a low fNr.

Q2A study is done on 1000 patients with a history of glioblastoma (GBM). A new serum test (ST) is done to screenfor recurrent GBM. 100 patients have a positive ST test and 900 have a negative ST test. Brain imaging withbiopsy is done on all these patients and 30 recurrences of GBM are found. 10 patients with positive ST testshave GBM and 20 patients with negative ST tests have GBM. Which of the following best represents thesensitivity of ST tests? a. 92% b. 35% DI Podcast Main Document 261 c. 75% d. 50%

Q2 Key-The best answer here is B. The sensitivity is 33%. This is the closest # to 35%. The NBME occasionally playsthis trick where inexact answers are posted. When this occurs, pick the answer that is closest to your math.-The Q here sounds nebulous but simple math based on understanding will save the day.-Sensitivity essentially answers the Q-Of all the population with a given disease, what % have +ve testresults?-The total diseased population is 30 people. The # with +ve test results were 10. So sensitivity = 10/30 =33%. You’re welcome to test a 2 by 2 table.

Q3A new serum test for glioblastoma (GBM) has a specificity of 90%. The most accurate interpretation of thisstatement is? a. 90% of patients with GBM have positive test results. b. 10% of patients with GBM are missed by this test. c. 10% of patients without GBM have positive test results. d. 90% of patients without GBM have positive test results.

Q3 Key-The best answer here is C.-Again, simple math + understanding = The "Clutch" on this Q.-Specificity essentially answers the Q-Of all the population without a given disease, what % have -ve testresults? That’s it!-The specificity of this test is 90%. So of the people w/o GBM, 90% test -ve. So 10% that should have tested-ve, ultimately end up testing +ve (aka false +ve’s).-A highly sPecific test has a low fPr.

Sidebar 1-SPin and SNout principle-If a test is highly sensitive, people with disease should have a +ve test result.-If the test is -ve, then disease should be absent (aka a low FNR). A -ve test should rule OUT disease.-If a test is highly specific, people w/o disease should have a -ve test result.-If the test is +ve, then disease should be present (aka a low FPR). A +ve test should rule IN disease.

Sidebar 2-Screening and Confirmatory Tests-In tests with high sensitivity, people with disease should have +ve test results.-High sensitivity tests make good “screening” tests so you don’t inadvertently miss out on people withdisease. For example, you’d hate to miss out on people with HIV. This is why you use the ELISA test.-In tests with high specificity, people w/o disease should have -ve test results.-High specificity tests make good “confirmatory” tests so you don’t inadvertently label people w/o diseaseas having a disease. Tests that are highly specific are very good at labeling people w/o disease so if the test is+ve (and by definition, high specificity tests have a low FPR), you very likely have disease. This is why Western DI Podcast Main Document 262 Blots are undertaken after a +ve ELISA so you don’t tell a patient they have HIV based on a +ve ELISA whenthey don’t!-Note however, that the WB is no longer done in most places as a confirmatory test.

Q4Which of the following points best represents the region of the graph with the highest positive predictive value(PPV) for the detection of Type 2 Diabetes Mellitus (T2DM)?

Q4 Key-The best answer here is C.-These Q’s have a high tendency to be annoying. To beat them, remember the following;The highest PPV region on a graph, corresponds to the region with the highest sPecificity, which correspondsto the region that DOES NOT miss anyone w/o disease. If you remember this, you’re golden.-Said another way, the highest PPV is achieved if the test when +ve, only includes people that have thedisease.-PPV simply means the % of people with +ve tests who have disease.

Sidebar-Do not mix this up!Sensitivity of a test represents the % of people with disease who have +ve test results.PPV of a test represents the % of people with +ve test results who have disease.DO NOT MIX THIS UP! If you switch the words before and after “who have”, you should be able to keep thingsstraight. Learn one side and remember that the other one is the other one.

Q5Which of the following points best represents the region of the graph with the highest negative predictive value(NPV) for the detection of Type 2 Diabetes Mellitus (T2DM)?

DI Podcast Main Document 263 Q5 Key-The best answer here is B.-These Q’s have a high tendency to be annoying. To beat them, remember the following;The highest NPV region on a graph, corresponds to the region with the highest seNsitivity, which correspondsto the region that DOES NOT miss anyone with disease. If you remember this, you’re golden.-Said another way, the highest NPV is achieved if the test when -ve, only includes people that don’t havethe disease.-NPV simply means the % of people with -ve tests who don’t have disease.

Sidebar-Do not mix this up!Specificity of a test represents the % of people w/o disease who have -ve test results.NPV of a test represents the % of people with -ve test results who don’t have disease.DO NOT MIX THIS UP! If you switch the words before and after “who have”, you should be able to keep thingsstraight. Learn one side and remember that the other one is the other one.

Q6A clinical trial is conducted to measure the effectiveness of the IM test as a screening tool for the detection oftesticular cancer. 500 IM tests are obtained. 20 men have positive IM tests and are found by testicular biopsy tohave testicular cancer. 180 men have positive IM tests and are negative for testicular cancer by biopsy. 290men have negative IM tests and are negative for testicular cancer by biopsy. 10 men have negative IM tests andare found to be testicular cancer positive by biopsy. What is the NPV of this test for the detection of testicularcancer? a. 97% b. 10% c. 33% d. 40% e. 90%Q6 Key-The best answer here is A.No need to panic on these questions with tons of numbers. Simply define the qty that is being tested AND thenabstract the #s you need. Many times the #s given are not useful. DI Podcast Main Document 264 -NPV of a test represents the % of people with -ve test results who don’t have disease.-There are 300 people with -ve IM test results. Of these people, 290 DO NOT have testicular cancer. So theNPV is basically 290/300 which is 97%.

Q7If the cutoff for a positive IM test result for the detection of testicular cancer (TC) is 5, which of the following bestrepresents the outcome of adjusting the test cutoff value to 1? a. PPV would increase but NPV would decrease. b. Specificity would decrease but sensitivity would increase. c. PPV and NPV would both increase. d. Sensitivity and specificity would both increase.

Q7 Key-The best answer here is B.-The name of the game with biostats Q’s is to first define what is being tested (doing your analysis first) beforepicking out an answer. When you look at the answers first, your mind is swayed in -ve directions.-The prior cutoff is 5 (above 5, you have TC). If you bring it down to 1, you vastly increase your chances ofcatching every single person with TC. In other words, you don’t miss anyone.-This increases the sensitivity of a test. Whenever seNsitivity goes up, Npv goes up.sPecificity and Ppv also go in the same direction.

Q8A medical student at Johns Hopkins invents a drug that improves survival in patients with GlioblastomaMultiforme (GBM) by 7 years. Which of the following changes would be seen a few years after drug FDAapproval? a. The sensitivity of screening tests for detecting GBM would decrease. b. The prevalence of GBM would increase in the population. c. The PPV of GBM detection tests would decrease. d. The incidence of GBM would increase in the population. e. The specificity of screening tests for detecting GBM would increase. f. The NPV of GBM detection tests would increase

Q8 Key-The best answer here is B.-By having this awesome Hopkins invented drug, we would keep more peoplewho have already been diagnosed with GBM alive, which is great, so the # of people with GBM in thepopulation would increase.-Therefore, prevalence increases. As Prevalence goes up, Ppv should increase, hence C is wrong. NPVwould decrease, so F is wrong (look at next slide).-Changes in prevalence do nothing to test sensitivity and specificity so A and DI Podcast Main Document 265 E are wrong. The only things that change these qties are changes in the actual test (like modifying thecutoff values).-We will likely still be diagnosing GBM at the same rate, so incidence stays the same.

Sidebar 1-Why does PPV increase with prevalence?Think of this, if a person comes to the ED in December with fevers, rhinorrhea, and myalgias, they likely havethe flu. If you got a -ve flu swab result, would you believe this?The prevalence of the flu goes up in December so NPV goes down, but PPV goes up. You are less likelyto believe the results of a -ve test during this “high prevalence” period.Stated another way, you are a lot more likely to believe the results of a +ve test if the disease is common!

Sidebar 2-Incidence vs Prevalence-Incidence represents the # of new cases of a disease that have been diagnosed within a specific time period.-Prevalence is the # of people that are alive AT a given time period.

Q9An M2 (2nd year med student) researcher at The Gifted Medical Students Institute plans to study the effects ofconsuming high amounts of kale on the development of pheochromocytoma. He plans to publish the results ofhis study prior to graduation. Which of the following study designs presents the most appropriate means ofcompleting the study? a. Randomized control trial. b. Prospective cohort study. c. Crossover study. d. Case-control study. e. Case report.

Q9 Key-The best answer here is D.-The phenomenon the researcher is trying to measure here is exceedingly rare and he has a limited timeframe.-Approaching this by way of a prospective cohort study/RCT would literally take as much time as a 60+ yearmedical career.-To study rare phenomena, case-control studies are typically the best option on NBME exams.-Results generated from the CCS can then be used to formulate research Q’s that can be examined in a cohortstudy/RCT.

Sidebar-Case-Control Studies-In a CCS, you need 2 groups of people with similar characteristics.-Group 1 have the disease in Q (pheo), Group 2 do not have the disease in Q (no pheo).-You then ask about exposures they may have had back in the day. You should already imagine that recallbias may be a prominent issue with CCS.-It is HY to know that CCSs give rise to data pertaining to odds ratios. DI Podcast Main Document 266 Q10A professor and 2 medical students undertake a case control study over the course of a year and publish theirresults in a high impact journal. Which of the following best represents an example of a possible conclusionfrom their study? a. Duloxetine decreases pain scores in patients with fibromyalgia. b. A combination of Sofosbuvir and Ledipasvir cures hepatitis C with high fidelity. c. Asbestos exposure causes mesothelioma. d. Ursodiol administration improves survival in patients with primary biliary cholangitis.

Q10 Key-The best answer here is C.-In option C, the researchers essentially looked at people with mesothelioma and compared them to people w/omesothelioma. They likely determined that a good # of people with mesothelioma had prior exposure toasbestos.-Option A, B, and D are wrong because they involve “interventions” which are things you’d ordinarily do in aRCT.-As is evident with this Q, you can’t just memorize facts and do well on these USMLE exams. You actually needto understand concepts. This is the central principle behind doing well regardless of Q difficulty on theseexams.-CCS/Cohort studies deal with exposures, RCTs deal with interventions. DETOUR

Q11The average normal CD4 count is 1000 per mm3 of blood with a standard deviation of 100/mm3. Which of thefollowing best represents the normal percentage of individuals who would be measured to have a CD4 count >1200/mm3 of blood? a. 2.51% b. 95% c. 5% d. 16% e. 68.2%

Q11 Key-The best answer here is A.-The key principle to realize here is that 95% of the population will fall within 2 SDs (2*100 = 200) of themean-from 800-1200.-So 5% must fall “outside” this range on “either side”. Either side here means < 800 or > 1200.-Therefore, half of this 5% must have a CD4 count that is < 800/mm3 and the other half must have a CD4 countthat is > 1200/mm3. DI Podcast Main Document 267 -So the best answer is 2.51%. Make sure you know this for the USMLEs!

Sidebar-P Values (Statistical Significance)-P values are used to express the probability that the results of a study occur from chance events.-The lower the number, the more confident we are in the results of that test. In other words, a P value of 0.05(5% probability of obtaining results by chance or 1 in 20) is worse than a P value of 0.01 (1% probability ofobtaining results by chance or 1 in 100).-Unless you’re told otherwise, use a P value of 0.05 in every NBME question.

Q124 separate drug trials are conducted to test the relative effectiveness of 4 different 3-beta hydroxysteroiddehydrogenase agonists in raising libido. The mean “libido” levels in the study (with confidence intervals) aregraphed below. Which of the following statements are true?

Q12 contd. (multiple answers may be correct) a. Drug 1 is more effective than Drug 2. b. Drugs 3 and 4 are similar in effectiveness. c. Drug 4 is more effective than Drug 2. d. Drugs 1 and 4 show similar effectiveness.

Q12 Key-Statements A, B, and D are all true.-The general principle is that when 2 confidence intervals cross each other (lines overlap), there is nodifference b/w those treatments.-These scenarios are unfortunately very common on the USMLEs.-Another critical way this can be tested is to give you confidence intervals (CI) of epidemiological quantitiesthat are ratios or differences;A ratio driven qty (like relative risk) will have non-significant results if the CI crosses 1. A difference drivenqty (like absolute risk reduction) will have non-significant results if the CI crosses 0. Why???

Q13A study is done to assess the relationship between vaping in college and the future need for lung transplant.The study yielded a relative risk of 3.5 with a p value < 0.05. Which of the following represents a possible 95%confidence interval from this study? a. 0.5-3.5 b. 2-4.5 c. 3.5-6.0 d. 3.9-7.1 e. 0.71-3.68

DI Podcast Main Document 268 Q13 Key-The best answer here is B.-A and E are wrong b/c the CI includes 1 but this study is measuring a relative risk (which is a ratio), soyou cannot have significant results and have the CI cross 1.-A and C are wrong b/c the RR derived from the study either begins or ends the CI. This is not possible.Results obtained from a study have to be WITHIN the CI, they cannot BEGIN or END the CI.-D is wrong b/c it does not include the value obtained from the study.-Pls be absolutely sure you understand this.

Q14A study is done to assess the effectiveness of a new drug (D) for the treatment of GBM. All patients enrolled inthe study received the current standard of care (SOC). In addition to receiving SOC, Group A received drug D;Group B received SOC and a sham drug (Y). Of the 40 patients receiving D, 8 die over the course of the study.Of the 40 patients receiving Y, 20 die over the course of the study. What is the NNT for drugD? a. 2.7 b. 3.3 c. 13.3 d. 5.0 e. 15.5

Q14 Key-The best answer here is B.-To calculate the NNT, you need to find the difference in risk b/w patients exposed to D and the patientsexposed to Y (placebo). You then divide the answer obtained into 1. That’s it!-Stated another way, NNT is 1/Absolute Risk Reduction.-40 people got D, 8 died (20%). 40 people got Y, 20 died (50%). The difference here is 30% (or 0.3).-Dividing this into 1 gives (1/0.3) which yields 3.3.-The NNH is a qty that has a similar calculation but follows the mantra that the rate of harm in the“exposed/treatment” group exceeds that in the placebo group.-To make things even easier (and only remember 1 formula), take 1/the difference in risk b/w any 2 groupsgiven. Just always write the higher risk # first in the difference.

Sidebar-Relative Risk-To calculate relative risk, take the risk in the exposed population and divide it by the risk in theunexposed population.-For example, if a cohort study comparing smokers and non-smokers is done with 100 of 500 people in thesmoking group developing lung cancer and only 50 of 500 people in the non-smoking group developing lungcancer. The RR is 20%/10% (risk of LC in smokers/risk of LC in non-smokers) which is 2. DI Podcast Main Document 269 -The smokers have a 2-fold increased risk of LC compared to non-smokers.

Q15If the presence of dysmorphic erythrocytes in the urine has a sensitivity of 90% and a specificity of 45% for thedetection of IgA nephropathy, what is the likelihood ratio of having IgA nephropathy if the patient hasdysmorphic erythrocytes detected on urinalysis? a. 1.35 b. 0.45 c. 4.55 d. 2.33 e. 1.67

Q15 Key-The best answer here is E.-Likelihood ratios occasionally pop up on the USMLEs. The classic worry of many students is to decipherwhen to use the +ve LR formula (Sensitivity/1-specificity) vs the -ve LR formula(1-sensitivity/specificity).

Here’s the rule;If the patient has a +ve test result, use the +ve LR formula.If the patient has a -ve test result, use the -ve LR formula.In this Q, we need to use the +ve LR (0.9/1-0.45) = 1.67

Sidebar-Likelihood Ratios-When calculated, +ve LRs tell you how much more likely a phenomenon is given a +ve test result.-When calculated, -ve LRs tell you how much less likely a phenomenon is given a -ve test result.

Q16In a study examining the relationship b/w exposure to ketamine and the subsequentdevelopment of neutropenia, medical records of 300 children were reviewed. 100 children who were exposed toketamine were found to have neutropenia, 50 childrenwho were exposed to ketamine were found to not have neutropenia, 80 children whowere not exposed to ketamine were found to not have neutropenia, and 70 children whowere not exposed to ketamine were found to have neutropenia. What is the odds ratio for this study? a. 3.29 b. 2.29 c. 5.67 d. 2.23 e. 7.16 DI Podcast Main Document 270 Q16 Key-The best answer here is B.-Odds ratios compare the odds of a person with disease being exposed to a risk factor (RF) to the odds ofcontrols being exposed to the same RF.-To calculate OR, take the logical people product (LGP)/weird people product (WPP).-LGP = (exposed and affected, unexposed and unaffected)/WPP(exposed and unaffected, unexposed andaffected).-In this case our OR = 100 * 80/70*50 = 8000/3500 = 2.29.

Q17The mean blood glucose level of a group of 81 medical students was 170 mg/dL with a SD of 15 mg/dL.Calculate the 95% CI and in words interpret your results.

Q17 KeyMean = 170 mg/dL. Std error of the mean = 15/sq.rt of 81 = 1.67 mg/dL.Z-score for the 95% CI = 2 (1.96 is more accurate but doesn’t matter).Therefore, CI = 170 +/- (2*1.67) = 170 +/- 3.34 = 166.66-173.34You can say with 95% confidence that the real mean BP of the medical student population falls between166.66 and 173.34 mg/dL.Alternatively, you can say that the mean BP of any randomly selected group of 81 medical students willfall b/w 166.66 and 173.34 mg/dL 95% of the time if the same experiment is repeated on multipleoccasions.HY to know the calculation and the interpretation in words!

Other HY Concepts-For ROC curves, the best test (highest combined sensitivity and specificity) lies at the upper left corner of thegraph.-Cohort studies essentially involve looking at 2 groups of people with differential exposures and following theminto the future for the development of some outcome.They could be prospective or retrospective.-68%, 95%, and 99.7% of a normal population lie b/w 1, 2, and 3 SDs of the mean respectively.

Other HY Concepts contd.-To compare means of 2 groups, use the T test. For > 2 groups, use the ANOVA (or F) test.-When you incorrectly reject the null, you are committing a Type 1 error (alpha error). When youincorrectly accept the null, you’re committing a Type 2 error (beta error). Remember that power = 1-beta.

DI Podcast Main Document 271 -Tighter CIs tell you that a study is more precise. However, you should be a lot less confident in theresults of the study as the CIs are too narrow (less room for error).

Other HY Concepts contd-Increasing powerTo increase the power of a study;-Recruit more people for a study (more closely approximates the population).-Have a large difference b/w 2 qties you’re trying to measure (aka larger effectsize). The power of a study comparing people with test scores of 99 and 100 as a means of comparingintelligence has less power than one comparing test scores of 25 and 100.-Have a lot of your data for a measured qty cluster around 1 value. Increasing theprecision of your measurements also increases the power of a study.-Stated another way, a study that uses a P value of 0.01 has more power than oneusing a P value of 0.05.

Other HY Concepts contd.-The fact that something is statistically significant does not mean that it is clinically significant. A BPdrug that lowers BP by 1 mm Hg from baseline even at a p value < 0.01 is a useless drug.-Mean is the average. Median represents the middle # (if you have an odd # set of data) OR the mean of the 2middle #s (if you have an odd # set of data). Mode represents the most frequent qty in the data set. Arrangethese in order before making these determinations. The mean is affected by extreme values.

Other HY Concepts contd.-For a normal distribution, mean = median = modeRemember that mean precedes median which precedes mode when taken in alphabetical order.-This should help you remember that in a -vely skewed curve (flat portion at left), mean < median < mode.-In a +vely skewed curve (flat portion at right), mean > median > mode.-HY bimodal distributions to be aware of include the distro for Hodgkin’s lymphoma and slow/fast acetylatorsin the metabolism of some drugs.

Other HY Concepts contd.-Lead time bias involves erroneously thinking that survival has been improved when in fact the “apparentsurvival improval” arose primarily from detecting a disease early.

Cross checked: No-------------------------------------------------------------------------------------------------------------------------------Ep. 145: Rapid Review, Series 14, Surgery ● Kid w/mild RLQ pain guaiac positive stool → Meckel’s ○ Failure of obliteration of the vitelline duct/omphalomesenteric duct ○ Tech-99/Pertechnetate scan for diagnosis ○ Gastric mucosa secretes acid that erodes the GI tract and causes bleeding ■ Not in most cases, just symptomatic cases ○ Treated with resection

DI Podcast Main Document 272 ● Pt w/ hx of Crohn’s has n/v and no bowel mvmts → small bowel obstruction ○ Obstructed d/t strictures (GERD can also cause strictures)● Pt w/ hx of UC has severe abdominal pain, distended, transverse colon → toxic megacolon ○ Next best step = ex lap ○ Other things that can cause toxic megacolon: c.diff, chagas ○ Screening colonoscopies 8 yrs after diagnosis and every 1-2 yrs after ○ PSC and UC diagnosed at the same time → screening colonoscopy at time of diagnosis● Pt w/ 3 mos of fatigue, low mood, bradycardic, carpal tunnel → hashimoto’s thyroiditis ○ Most common cause of hypothyroid in US: hashimoto’s w/ anti TPO abs ○ Most common cause in newborn: thyroid dysgenesis ○ Radioactive iodine uptake: minimal to none ○ Other causes of hypothyroid: ■ de Quervain's thyroiditis (painful, tender thyroid, hx of recent viral URI, decreased radioactive uptake) (can also cause hyperthyroid in early thyrotoxic phase) ■ Factitious hyperthyroid → low TSH, low radioactive uptake, low thyroglobulin ○ Grave’s → autoab’s against TSH receptor, diffusely increased uptake on radioactive scan ○ Struma ovarii → elevated T3/T4, low TSH, decreased uptake on radioactive scan ○ Toxic adenoma → only 1 hotspot on radioactive scan ○ Multinodular goiter → multiple hotspots interspersed w/cold spots ○ Papillary thyroid cancer is popular aka most common ■ Psammoma bodies and orphan Annie eye nuclei ○ Follicular thyroid cancer spread hematogenously● 80 yo pt w/profound wt loss and enlarging thyroid → anaplastic thyroid cancer● Pt had multiple kidney stones, recurrent ab pain, enlarging thyroid → medullary thyroid cancer ○ MEN2A- hypercalcemia ○ Calcitonin tumor marker → can cause prolonged QT ○ Apple green birefringence on congo red b/c it becomes amyloid● Rock hard thyroid gland → Reidel’s thyroiditis (Fibrosis of the thyroid) ○ Associated w/ IgG4 related dz → Autoimmune pancreatitis (sausage shape), retroperitoneal fibrosis (BL hydronephrosis), autoimmune gallbladder dz● Psammoma bodies: papillary thyroid cancer, meningiomas (parasagittal, dural tail), mesothelioma (ferruginous bodies)● Pt w/ n/v, coffee bean sign w/head toward RUQ → sigmoid volvulus ○ Coffee bean sign w/head toward LUQ → cecal volvulus● Pt w/ heavy smoker, wt loss, dullness to percussion, decreased breath sounds, larger pleural effusion, coin lesion ○ Next best step = thoracentesis w/cytology (Malignant cells → stage 4 cancer)● #1 cause of lung cancer → adenocarcinoma● Squamous cell carcinoma → keratin pearls, hypercalcemia (PTHrP)● Small cell lung cancer → SIADH (hypoosmolar serum, hyperosmolar urine), Lambert Eaton (Ab against presynaptic Ca channels → proximal muscle weakness improves w/use), and Cushing’s (ACTH does not suppress w/dexamethasone) ○ Neuroendocrine origin, already metastatic at diagnosis● Lung cancer complications: SVC Syndrome (next best step is radiation), pancoast tumor (Horner’s syndrome), hypertrophic pulmonary osteopathy (get imaging)● Partial Horner’s syndrome (ptosis and miosis) → cluster headache● Xanthochromia → subarachnoid hemorrhage ○ Worth HA of pt life, often mimics meningitis but is sudden onset ○ Next best step = non contrast head CT → LP ○ Give nimodipine to prevent superimposed ischemic stroke● Herpes encephalitis/meningitis → hyperintense signalling in temporal regions on MRI DI Podcast Main Document 273 ○ RBCs in CSF → cover w/IV acyclovir (only give IV if admitting pt) ● 6 wk period of memory, myoclonus, and proprioception loss → CJD ○ Elevated protein 14.3 3 ● Narcolepsy → low levels of orexin/hypocretin in CSF ○ Diagnose w/ sleep study, treat w/scheduled naps, stimulants (modafinil), sodium oxybete (for cataplexy)These are my personal notes from when I originally listened to the podcast. I apologize for anything Ioverlooked or any mistakes!

Cross Checked: No

-------------------------------------------------------------------------------------------------------------------------------Ep. 153: Rapid Review, Series 15, Surgery

● Long term smoker in ED b/c on increased urine, ab pain, low BP → squamous cell cancer ○ PTHrP → hypercalcemia causes stones, bones, groans, psychiatric overtones ○ First step = give IV normal saline then loop diuretic to decrease Ca, can also give calcitonin (tones down calcium) ○ Hypercalcemia causes short QT interval ● small cell lung cancer: euvolemic hypoNa, SIADH, ACTH, hypercortisolism not suppressed with high dose dexamethasone. ● smoker for long time, trouble standing from chair, proximal muscle weakness that gets better with repetitive nerve stimulation – lambert Eaton ○ autoantibodies against presynaptic VG Ca channels ● lung cancer and pleural effusion thoracentesis and if malignant cells found, drain fluid or pleurodesis. bad sign :/ ● Polymyositis and dermatomyositis can be paraneoplastic syndromes for lung cancer ● smoker and 4-5 weeks, severe arthritis in LE hypertrophic pulmonary osteoarthropathy. no tx, treat cancer ● loss of sensation below nipple line (T4) prostate cancer with mets ● How to diagnose prostate cancer bone mets → ○ Gets there by Batson’s plexus ○ If causing spinal cord compression → high dose dexamethasone and MRI ● Pt w/hx of lupus and 7 days of nosebleeds and heavy menstrual bleeding → ITP ○ Can be idiopathic but is often d/t autoimmune hx ○ Abs against Gp2b3 (low platelets, high megakaryocytes) ○ Mild → no treatment Severe → steroids, IVIG, rituximab, splenectomy (cure) ● Deficiency of Gp2b3 → Glanzman’s ○ Normal ristocetin assay ● Bernard-soulier → Gp139, increased bleeding time, normal PTT ○ Abnormal ristocetin assay ● VWD → increased bleeding time and PTT (less production of Factor 8) ○ Abnormal ristocetin assay DI Podcast Main Document 274 ● Esophageal rupture ○ few hours ago pt got pneumatic dilation for achalasia OR pt came in with dysphagia, losing weight, so EGD with biopsy was done, now is sick, hypotensive. ○ Next best step = gastrografin enema aka water soluble contrast enema ● Pt recently started dialysis and now is volume overloaded, SOB → high output HF ○ Mechanism → new AV fistula decreases time in capillaries and venules ● Peritoneal dialysis complications → SBP (ab pain, low grade fever) ○ Next best step = paracentesis (>250 neutrophils → start 3rd gen ceph) ● ESRD patient on dialysis uremia, coagulopathy. Tx desmopressin ● Other causes of high output HF: paget dz, severe anemia, trauma AV fistula (pulsatile mass at region of stab wound), hereditary hemorrhagic telangiectasia, osler-weber-rendu dz ● Pt had recent ERCP w/biopsy and now has severe ab pain with high lipase → acute pancreatitis ○ Tx: NPO, IV fluids, pain management (opioids) ○ Can also have hypocalcemia 2/2 saponification (prolonged QT) ● Pt had parathyroidectomy then has seizures and spasms → hypocalcemia ○ Tx: IV calcium gluconate (also used for symptomatic hyperkalemia and hypermagnesemia) ○ PS. if it’s a kid consider DiGeorge syndrome (murmur, seizures, 34rd/4th pharyngeal pouch not developed, no thymus → fungal, bacterial infections ○ Infants of diabetic mothers (seizures due to hypocalcemia or hypoglycemia) ○ Hypocalcemia also seen in rhabdo ● Transplant rejection: ○ Hyperacute → rejection in OR, Ab mediated ○ Acute → rejecting days to weeks later, MHC2 to CD4 T cells ○ Chronic → years later ● Woman with bulge in inguinal canal → femoral hernia ● Hx of MEN1 w/ potassium of 2.5 and diarrhea → VIPoma (watery diarrhea, hypokalemia, achlorhydria) ○ Pancreatic tumors can be neuroendocrine (gastrinoma = jejunal ulcers, ZES lots of acid) ○ Whipple triad → symptomatic hypoglycemia relieved w/glucose administration (insulinoma – high insulin, high C peptide levels) ○ new onset diabetes, new rash = necrolytic migratory erythema from glucagonoma ● Insulin and c peptide are elevated with sulfonylurea use ○ Differentiated using secretagogue screen – positive with overdose of sulfonylurea use ○ Same is true for meglitinides b/c they both block K dependent insulin channels ○ PS Don’t give B-blockers to diabetics b/c it masks symptoms of hypoglycemia

These are my personal notes from when I originally listened to the podcast. I apologize for anything Ioverlooked or any mistakes!

Cross Checked: YES (added missed text in different font)

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DI Podcast Main Document 275 Ep. 156: Rapid Review, Series 16, OB/GYN ● 52 yo woman with breast mass → mammogram ○ <30 yo → ultrasound ○ Risk factors: fam hx, personal hx, BRCA1/2, extra estrogen ○ Mets to bone and brain ● Acceptable contraceptives w/breast cancer hx: ○ NO ESTROGEN OR PROGESTIN ○ Copper IUD ● Eczematoid rash of breast → Paget’s Dz of Nipple ○ Next step = mammogram w/core needle biopsy ○ Sign of underlying DCIS (rarely LCIS) ● Most worrisome mammographic features → spiculated, irregular borders, microcalcifications ● How often for mammos → 40 yo or 50 yo q2 years or pt preference ● When to get a breast MRI in addition to mammo: ○ BRCA mutations, 1st deg. Relative ● Old lady was assaulted w/breast trauma and mass → fat necrosis ○ Next step = mammogram w/biopsy (just in case) ● FNA: ○ Serous fluid → cytology ○ Blood fluid → mammo ● Tamoxifen is not appropriate in women > 50 yo (give aromatase inhibitor ex. anastrozole) ○ If not in menopause aromatase inhibitor will start menopause ● Her2 positive and triple negative breast cancers have poor prognosis ○ Prior to starting trastuzumab get an echo! ● Suspect metastatic breast cancer to bone then next step = bone scan (sensitive but not specific) ● LCIS tx = lumpectomy with radiation (equivalent of mastectomy) ○ Increases risk of local recurrence of cancer ○ Cannot repeat lumpectomy if it recurs d/t fibrosis → mastectomy ● Pt had radiation for breast cancer, rapidly growing neck mass, cervical lymphadenopathy → papillary thyroid cancer ● Positive sentinel lymph node biopsy → proceed to axillary node dissection ○ At increased risk for lymphangiosarcomaCross checked: No

-------------------------------------------------------------------------------------------------------------------------------Ep. 158: Rapid Review, Series 17, Surgery ● Most likely complication of axillary lymph node dissection → lymphedema ○ Now the limbs are large (usually upper limb) and they’re losing wt → lymphangiosarcoma ○ Most common cause of lymphedema → filariasis ○ Congenital lymphedema is found in Turner syndrome (cystic hygroma) ○ Most common cause of lymphedema in US → lymph node dissection/removal ● Pt w/leg pain that gets worse by end of day w/ ulcer on medial malleolus → varicose veins ○ Risk factors: prolonged standing, combined OCPs, pregnancy, obesity ○ Stasis dermatitis and painless ulcers above medial malleolus ○ First step in management = compression stockings ○ Refractory therapy = sclerotherapy ■ Diagnostic test prior to sx → venous doppler ultrasound of lower extremity ○ Arises from incompetent valves DI Podcast Main Document 276 ● Mini NBME Pathophysiology Buzzwords Review ○ Chronic venous insufficiency: incompetence of the valves in the lower extremity ○ Aortic stenosis: calcification of valves ○ Mitral Valve Prolapse: myxedematous degeneration ○ Aortic Dissection: cystic medial necrosis ○ Duodenal atresia: failure of recanalization ○ Jejunal atresia: vascular assault in utero ● Pt loses vision for 5 min and it comes back → amaurosis fugax ○ Next best step dx = carotid duplex ultrasound (Embolus usually arises from carotids) ○ Next best step tx = antiplatelet agent (e.g., clopidogrel) ● Who gets an anticoagulant if they have carotid artery disease as well? → A. Fib ● When to do carotid endarterectomy → >70% stenosis and symptomatic (never acute!) ● Pt w/severe chest pain and large pleural effusion, hx of uncontrolled HTN → aortic dissection ○ Dx: CT angio or TTE (TransThoracic Echocardiogram) if unstable ○ Type A → involves the ascending aorta ■ Tx: B-blocker, nitroprusside, surgery ○ Type B → limited to descending aorta ■ Tx: B-blocker (first line), nitroprusside (consider, but not first line) ○ Cause is cystic medial degeneration ● Genetic dz w/aortic dissection → Marfan syndrome ○ Mutation in chr 15 fibrillin dz, AD inheritance ○ Could also be Ehlers Danlos syndrome but EDS is less common ● AAA ○ Male >65-74 yo with ANY hx of smoking → get 1x screening ab ultrasound (or CT) ○ Male >50 yo with any fam hx of AAA → get 1x screening ab ultrasound (or CT) ○ Most commonly located in the infrarenal aorta ○ Draped aorta sign → aorta is hanging around the posterior vertebrae ○ Tx: open surgical vs endovascular repair ■ Complications of endovascular repair → ● endoleak (leakage around the graft) ● paraplegia b/c of artery of adamkiewicz ● fatigue/heme pos stools/microcytic anemia: aortoenteric fistula

These are my personal notes from when I originally listened to the podcast. I apologize for anything Ioverlooked or any mistakes!

Cross checked: YES

-------------------------------------------------------------------------------------------------------------------------------Ep. 159: Rapid Review Series 18 (IM) ● 65 yo M with 2 weeks of hematuria + recent 20 lb weight loss. Worked as a plumber. PMH of EGPA. Non-smoker. UA with hematuria, no dysmorphic RBCs. → Bladder cancer ○ RF in this case? Meds (likely cyclophosphamide for EGPA) ○ Cyclophosphamide ■ Adverse effects? Hemorrhagic cystitis, bladder cancer ■ Prevention? Mesna

DI Podcast Main Document 277 ○ Dx? Cystoscopy w/ bx ○ RF for bladder cancer ■ Smoking ■ Schistosoma haematobium ■ Aniline dyes● Flank mass + hematuria + new-onset varicocele in longtime smoker → RCC ○ Most common type? Clear cell ○ Dx? Do NOT biopsy ○ Tx? Nephrectomy ○ Paraneoplastic syndrome? Polycythemia 2/2 epo production

● 23 yo F, roommates note behavior change, working on multiple projects to cure poverty, sleeps less than 2 hrs but lots of energy, med student can’t get word in during interview, urine tox is negative → bipolar disorder ○ Tx? ■ Lithium ● Ebstein’s anomaly ■ Valproic acid ● Liver toxicity ● Teratogen

● ACE-I contraindications ○ Bilateral renal artery stenosis ■ Already low GFR ■ Pathophys? ATII constricts efferent arteriole. ACE-I → low ATII → efferent arteriole constricts → possible renal failure ○ Hereditary angioedema ■ Pathophys? C1 esterase inhibitor deficiency. C1 esterase and ACE both breakdown bradykinin. Block ACE → can’t break down bradykinin ○ Pregnancy

● 50 yo F with large breast mass, nipple retraction, skin changes. Hx of depression on paroxetine, currently well-controlled. Says that she is not interested in knowing diagnosis. NBS? Ask pt why she doesn’t want to know diagnosis ○ Always explore the patient’s mental model!● 45 yo F Crohn’s on etanercept. Comes to ED with dyspnea + nonproductive cough + fever + 12 days malaise. Na 131. PaO2 = 57. CXR with “diffuse ground glass interstitial infiltrates.” PPD 3 years ago was negative. No sick contacts. → PCP pneumonia ○ Many brain or lung pathologies can cause SIADH ○ Labs? Elevated serum LDH ○ Dx? BAL w/ silver-stain positive organisms ○ RF? ■ HIV ■ TNF inhibitors ○ Before you start a TNF inhibitor, screen for what? DI Podcast Main Document 278 ■ TB ■ Hep B ○ Contrast with Strep pneumo → more rapid onset, severe sxs, lobar consolidation ○ Contrast Legionella → pneumonia + diarrhea/abdominal pain + hyponatremia + exposure to water source (e.g. hotel, fountain, air conditioning) → Legionella ○ Contrast with TB → fever + night sweats + hemoptysis + cavitary lesion (not interstitial infiltrates)

● 33 yo F with fatigue + loss of interest + 10 lb weight gain + bilateral LE edema + missed last 2 periods → Hashimoto’s thyroiditis ○ Dx? TSH ○ Ab? anti-TPO ○ Histology? Lymphocytic infiltrate of thyroid gland ○ Associations? Other immune diseases ■ Vitiligo ■ Pernicious anemia ○ Complications ■ Initial thyrotoxic phase ● Pathophys: release of preformed thyroid hormone ■ Hx Hashimoto's + rapidly enlarging thyroid → thyroid lymphoma ○ Why the missed periods? ■ Low T3/T4 → TRH release → TSH & prolactin release → suppresses HPG axis● Low TSH + low T3/T4 → secondary hypothyroidism ○ Causes? ■ Craniopharyngioma ● Derived from? Rathke’s pouch ■ Sheehan’s syndrome● Painful thyroid + hx viral URI → De Quervain’s subacute thyroiditis ○ Hypothyroid or hyperthyroid (2/2 release of preformed hormone) ○ RAIU? Low uptake (not producing thyroid hormone)● ICU pt + mildly low T3/T4 + mildly low TSH → euthyroid sick syndrome● High estrogen → increases TBG → higher total T4 but free T3 normal → clinically euthyroid● Thyroid cancer ○ Labs? Elevated TSH (thyroid cancers tend by hypofunctional) ○ Dx? US with biopsy ○ #1 RF? Radiation to head & neck ○ Papillary ■ Most common type ■ Spread? lymphatic ■ Histology? Psammoma bodies + Orphan Annie eyes ○ Follicular ■ Spread? Hematogenous ○ Medullary ■ Tumor marker? Calcitonin ● Calcitonin → hypocalcemia → prolonged QT ■ Association? MEN2A/2B DI Podcast Main Document 279 ● Mutation? RET gene ● Inheritance? AD ● Prevention? Prophylactic thyroidectomy (risk = 100%) ■ Histology? Apple green birefringence on congo red stain

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Ep. 161: The "Clutch" Antibody Podcastep 161 notes were graciously provided by Divine Intervention from an anonymous contributor.

Sx Dx Specific

Morning stiffness, Rheumatoid arthritis Anti-RF (sensitive), Anti-CCP better w exercise, (specific) ulnar deviation

Malar rash Lupus ANA (sensitive), Anti-smith, Ab can cause 3rd degree anti-dsDNA (specific) heart block by crossing placenta

Autoimmune Lupus hemolytic anemia

Pregnant woman w Antiphospholipid Anti-phospholipid, size less than dates, antibody syndrome anti-cardiolipin, lupus recurrent pregnancy anticoag, losses anti-beta2-glycoprotein

Marital problems Sjogren's Anti-ro (SSA), anti-la (SSB) Ab can cause 3rd degree d/t pain w sexual heart block by crossing intercourse, dry placenta! mouth

Wegner's c-ANCA

Ulcerative colitis, PSC, p-ANCA polyarteritis nodosa, Churg-Strauss/EGPA, microscopic polyangiitis

Prox muscle, Polymyositis, Anti-Jo1 (--| tRNA synthetase), shoulder weakness; dermatomyositis anti-mi 2, anti-SRP elevated CK

DI Podcast Main Document 280 Bleeding gums, plt ITP Anti-Gp2b3a Vs. Glanzmann>20,000 (complete deficiency of Gp2b3a)

45F, jaundice, Primary biliary Anti-mitochondrialpruritus, conjugated cholangitishyperbili

Systemic scleroderma Anti-Scl 70/topoisomerase

CREST Anti-centromere calcinosis + Raynaud + esophageal + sclerodactyly + telangiectasia

TB tx with new Drug-induced lupus Anti-histone Sulfonamides,malar rash etanercept, procainamide, hydralazine, isoniazid

Mixed-connective Anti-U1RNP tissue disease

Post-infectious Antistreptolysin O, anti-DNAse glomerulonephritis B

17Y w/ diabetes T1DM Anti-islet cell antibodies = GAD, IA2

Hypothyroidism Hashimoto's Anti-thyroglobulin, anti-TPO *MCC of hypothyroidism in US

Hyperthyroid Graves Thyroid-stimulating immunoglobulin

40F, Droopy eyes Myasthenia gravis Anti-nicotinic ach receptor

Hemolytic disease of Anti-Rh, anti-Kell newborn

Encephalitis, post Autoimmune Anti-NMDAURI/vaccine/VZV encephalitis

H/o breast cancer, Limbic encephalitis Anti-Hu, anti-Yoataxia

DI Podcast Main Document 281 Autoimmune hepatitis Type 1: anti-smooth muscle; "lupoid-hepatitis" Type 2: anti-liver/kidney/microsomal

Painful vision loss Neuromyelitis Anti-NMO MS-variantthat resolves after optica/Devic's diseasefew weeks, lose allsensation belowT4/T10

Hematuria, Goodpasture Anti-GBMhemoptysis syndrome

Pemphigus vulgaris Anti-desmoglein (desmosomes)

Bullous pemphigoid Anti-hemi-desmosomes Less dangerous than pemphigus, nikolsky-negative

Fat malabsorption, Celiac disease Anti-gliadin, anti-TTG,low weight, rash on anti-endomysialextensor surfaces ofupper/lowerextremities w/osilver scale

Smoked for long Lambert-Eaton Anti-presynaptic voltage gatedtime, trouble rising syndrome Ca channelfrom a char

Loss of LE vibratory B12 deficiency 2/2 Anti-IF (parietal cells)sensation, pernicious anemiaBabinski+, (UMN +LMN sx)

Sx Dx HLA

Seronegative HLA-B27 spondyloarthropathy

Recent HIV tx, profound Abacavir-anaphylaxis HLA-B57anaphylaxis + death!

DI Podcast Main Document 282 Iran, painful sores on buccal Behcet's disease HLA-B51 Dx: pathergy test mucosa

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Ep. 163: Rapid Review, Series 19, Surgery (Abdomen)

● NBSIM for penetrating trauma to the abdomen → ex lap

● NBSIM for blunt trauma to abdomen + rebound and guarding (signs of peritonitis) → ex lap

● NBSIM for blunt trauma to abdomen + stable + no rebound or guarding → CT abdomen

● NBSIM for blunt trauma to abdomen + unstable → FAST scan (then DPL if FAST is equivocal/negative)

● Cardiac cath and hours later patient has back pain, hypotensive, unstable → Dx is retroperitoneal hematoma/hemorrhage → get emboli angiogram for NBSIM

● Pt involved in MVC + has minimal urine output. PEx shows suprapubic tenderness or fullness. ○ Dx? Urinary retention or cauda equina syndrome. ○ NBSIM? urinary cath ○ Mets cancer with hx of prostate cancer? suprapubic fullness, breast cancer, prostate cancer, spinal cord compression → give IV dexamethasone ○ Tx for female with breast cancer + subrapubic tenderness? IV dexamethasone

● Bladder rupture ○ NBSIM for intraperitoneal rupture (dome) with diffuse pain + signs of peritonitis → straight to urology surgery ○ NBSIM Extraperitonal rupture of neck of bladder/trigone → conservative treatment

● Pt involved in MCV + left shoulder pain → Spleen rupture (+Kehr sign)

DI Podcast Main Document 283 ○ Vaccinate these patients for SHiN organisms

● Pt involved in MVC gets blunt abdominal trauma + right shoulder pain → liver laceration with diaphragmatic rupture on left side typically (abdominal contents in thoracic cavity)

● Recent abdominal surgery + fever + abdominal pain for days → Subphrenic abscess

● Newborn with abdominal folds/contents in thoracic cavity → Diaphragmatic hernia ○ Embryo: diaphragmatic hernia arises from pleural peritoneum membrane

● Injury or MVC or child with epigastric pain due to handlebar injury + ↑amylase/lipase → traumatic pancreatitis

● Kid with handlebar injury + epigastric pain or back pain + pulsatile mass + bilious vomit + low Hb → Duodenal hematoma

● Pt started on warfarin + has epigastric pain + low Hb → Duodenal hematoma

● Peptic ulcer disease + sudden hypotension + low Hb + severe abdominal pain → Perforation of peptic ulcer due to gastroduodenal artery laceration (this can bleed like crazy!) ○ NBSIM? EGD

● Massive GI Bleeds management ○ 2 large IV bore needles ○ IV fluids, blood products ○ Consider surgery

● Acute-onset RLQ pain + fever + leukocytosis + +Psoas sign → acute appendicitis ○ NBSIM? Ex lap (or laparoscopic appendectomy) ○ Pathophys? Fecolith that obstructs appendiceal lumen. ○ NBSIM for perforated appendicitis → rapid appendectomy! DI Podcast Main Document 284 ○ NBSIM for appendiceal abscess → abx, drain + appendectomy weeks later

● Pt with 7-9 days of gradually worsening RLQ pain + fever + leukocytosis → Psoas abscess ○ Dx? CT contrast ○ Tx? ciprofloxacin + metronidazole or cefazolin ○ Note: Psoas abscess has similar presentation to appendicitis but psoas abscess presents with DAYS of symptoms ■ In contrast: appendicitis presents ACUTELY!

● PEx findings for appendicitis ○ Psoas sign ○ Obturator sign ○ Rovsing sign ○ Mcburney point

● Young adult female with RLQ pain + high fever + leukocytosis + b-HCG positive → Ruptured ectopic pregnancy

● Pt with hx of recent MI, irregularly irregular interval. ○ Dx? Acute mesenteric ischemia - superior mesenteric artery is messed up ○ Get angio ○ May need to resect bowel

● LUQ pain with eating + weight loss + systemic hypotension = Chronic mesenteric ischemia

● Hx of ulcerative colitis + severe abdominal pain with rebound and guarding + abd distention + massive dilation of colon → Toxic megacolon. ○ NBSIM? IV steroids (hydrocortisone, dexamethasone) followed by surgery (if no response to medical management) ○ Other etiologies of toxic megacolon? ■ C diff colitis (2/2 abx use) DI Podcast Main Document 285 ■ Trypanosoma cruzi (pt from South America)

● Female has severe lower abdominal pain + bilateral adnexal tenderness → Pelvic inflammatory disease ○ Tx? ceftriaxone + doxycycline/azithromycin

● Female with hx of PID + now pt ℅ RUQ pain → Peri-hepatitis aka Fitz-Hugh-Curtis syndrome ○ Pathophys? Inflammation of the hepatic capsule

● NBSIM for Appendicitis? Go straight to surgery ○ But if NBME wants you to pick imaging: CT for adults; or U/S for children or pregnant females

● NBSIM for stable pt with hx of diabetic who has abdominal pain and needs CT with contrast? ○ Discontinue metformin ■ Because metformin causes lactic acidosis in pt’s with CKD or AKI, esp. if pt has profound hypotension with pre-renal AKI

● Smoker + severe mid-abdominal pain or back pain + profound hypotension + pulsatile mass on abdominal exam → Ruptured AAA ○ Calcifications anterior to vertebral body = ruptured or impending AAA ○ NBSIM? immediate surgery (can get abdominal US if NBME asks for imaging)

● AAA Surgery Options: Open Surgical Repair or EVAR

● Complications of AAA Repair: ○ Aorto-enteric fistula ■ Presentation? Microcytic anemia weeks to months after AAA repair ■ Pathophys? fistula between aorta and GI tract -> slow leak of blood into GI tract. ■ Note: Colon cancer will be an incorrect answer choice.

○ Anterior Spinal Artery Syndrome

DI Podcast Main Document 286 ■ Presentation? Multiple episodes of profound hypotension during surgery + paraplegic + cauda equina style symptoms or urinary retention after surgery ■ Pathophys? Ischemia to Artery of Adamkiewicz → damage to anterior 2/3 of spinal cord ○ Acute Tubular Necrosis or Prerenal AKI: Rising SCr after AAA repair ■ Pathophys? Ischemia of kidneys during surgery

○ Endoleak ■ Presentation? Pt had AAA repair + Hb is slowly dropping + microcytic anemia + contrast going beyond margins of excluded aneurysm on CT angiogram

● #1 RF for AAA? smoking

● Screen for AAA in: ○ male smokers b/w age 65-75yo ○ male smokers or nonsmokers > 50 yo with first-degree relative who had AAA rupture

● NBSIM based on imaging findings of AAA Screening: ○ AAA > 5.5cm or AAA >0.5 cm/6 months → repair asap ○ Prior u/s shows 3-4 cm AAA → repeat U/S in 2 years ○ Prior u/s shows 4-5 cm AAA → repeat U/S in 1 year ○ Prior u/s shows 5-5.5 cm AAA → repeat U/S in 6 months

● Young female + sudden-onset abdominal pain + cyst found weeks earlier on imaging → ovarian torsion ○ Tx? urgent surgery ○ Risk factors: ■ PCOS ■ Fermoid cyst ■ Teratoma ■ Prior ovarian cyst ○ Note: If “free fluid in peritoneum” mentioned in vignette → pick ruptured ovarian cyst

DI Podcast Main Document 287 ○ Note: If “free fluid in peritoneum” is not mentioned in vignette → pick ovarian torsion

● Pt has bulging abdominal mass for a long time + mass is not reducible + severe abd pain → strangulated hernia ○ Tx? surgery

● Pt has RUQ pain + shoulder pain + fever + leukocytosis → acute cholecystitis. ○ Dx? RUQ U/S (then HIDA scan if U/S is equivocal) ○ Imaging findings? Thickened gallbladder wall + pericholecystic fluid ○ Tx? laparoscopic cholecystectomy + abx ○ NBSIM if RUQ US is equivocal? get HIDA scan ■ Negative HIDA scan = GB fills with contrast → this r/o acute cholecystitis!

● Elderly or critically ill pt + RUQ pain + fever + leukocytosis + no gallstones on imaging → acalculous cholecystitis. ○ NBSIM? Percutaneous cholecystostomy (NOT cholecystectomy) ○ These patients are very sick, e.g. on ventilators, ICU level care, etc

● RUQ pain + fever + leukocytosis + profound jaundice with signs of ascending cholangitis. Common bile duct is not distended on imaging → Mirizzi syndrome ○ Pathophys? obstructing stone in cystic duct → cystic duct dilation bulges to press on common hepatic duct → direct hyperbilirubinemia ○ Cholecystocholedochal fistula = complication of Mirizzi syndrome ■ fistula between cystic duct and common hepatic duct ○ Dx? RUQ U/S or MRCP

● RUQ pain + fever + leukocytosis + jaundice + hypotension → ascending cholangitis. ○ NBSIM? ERCP (diagnostic and therapeutic) ○ Ascending cholangitis is an emergency!

● RUQ pain + no fever + dilation of common bile duct → choledocliathsis ○ Dx? RUQ U/S (or MRCP if equivocal) ○ Pt’s with choledocholithasis are not as sick patients as pts with ascending cholangitis!

DI Podcast Main Document 288 ● NBSIM for blunt trauma to abdomen involving kidney → Non-operative management ○ Do not do nephrectomy!

● Kidney transplant - new kidney in the pelvic fossa and bad kidney is not removed

● Pt has hx of peritoneal dialysis + mild fever (100.7) + acting crazy (AMS) + low-grade abdominal pain. ○ Dx? Spontaneous bacterial peritonitis ○ NBSIM? Paracentesis (>250 PMNs) ○ Tx? Ceftriaxone or cefotaxime. ○ PPx for pts with ascites but no fever? Fluoroquinolone

● Peritoneal dialysis vs hemodialysis - no difference in outcome ○ Peritoneal dialysis = Insert cath at least 1 month prior ○ Hemodialysis = Insert AV fistula at least 2 months prior

● Pt with recent AV fistula placed for hemodialysis + chest pain + hypotension + crackles in lungs with heart failure symptoms + Echo shows EF 75% → High output heart failure ○ Etiologies of high-output heart failure? ■ AV Fistula ■ Anemia ■ Paget disease of bone (d/t hypervascularization of bone marrow)

● Tx for acute pancreatitis? NPO + IVF + pain control ○ #1 MCC acute pancreatitis? Alcoholic pancreatitis ○ #2 MCC acute pancreatitis? Gallstone pancreatitis ■ Gallstone pancreatitis = RUQ pain + ↑amylase/lipase + gallstones + ALT ≥ 150

● Pt has abdominal pain + epigastric tenderness and fullness + hx of pancreatitis weeks ago → Pancreatic pseudocyst

● Chronic epigastric pain + fat malabsorption + white dots in the walls of pancreas on imaging → Chronic pancreatitis

DI Podcast Main Document 289 ○ #1 RF = EtOH abuse

● Elderly pt with LLQ pain + fever + leukocytosis → Diverticulitis ○ NSBIM? CT with contrast ○ Tx? abx ○ What imaging is needed weeks later? Colonoscopy (to r/o colon cancer as source of bleed)

● Pt has hx of diverticulitis + now has poop or air in urine --> Colovesical fistula

● Severe abdominal pain + coffee-bean sign with head of coffee-bean sign is oriented to RUQ → sigmoid volvulus

● Severe abdominal pain + coffee-bean sign with head of coffee-bean sign is oriented to LUQ → cecal volvulus

● Elderly man + abdominal pain + severely distended abdomen + not passing BM or gas + distended colon but no obstruction on CT + non-dilated small intestines on CT → Ogilvie syndrome aka colonic pseudo-obstruction ■ S/sx of colon obstruction but no actual obstruction on imaging! ○ Tx? NPO + nasogastric tube decompression + rectal tube decompression ■ If refractory (> 48h) → neostigmine (AChE inhibitor) ○ Etiologies: ■ Electrolyte abnormalities (vignette will mention days of watery diarrhea + diuretic use for HTN) ■ Neurologic disorders ● Pt has abdominal pain + bilious voming + not passing gas + hx of Appendectomy or C-section → small bowel obstruction ■ This pt has SBO 2/2 adhesions! ○ Etiologies of SBO? ■ #1 MCC = adhesions (i.e. hx of surgery!) ■ #2 = Hernias ■ #3 = malignancy

CROSS CHECKED? Yes

DI Podcast Main Document 290 --------------------------------------------------------------------------------------------------------------------------

Ep. 164: The "Clutch" Toxicology Podcast (Drugs of abuse, overdose, withdrawal,toxidromes)

● Pt with a hx of DM found unresponsive → likely hypoglycemia ○ NBSM? Administer dextrose solution OR give glucagon injection

● Pt found unresponsive with RR = 4 and bilateral pupillary miosis. ABG with pH 7.21, PaO2 55, CO2 70 → opioid overdose ○ NBSM? Naloxone ■ NOT naltrexone

● Pt with hx of multiple eps of acute pancreatitis or calcified pancreas on imaging. Pt comes to ED with nystagmus and trouble walking. → Wernicke’s encephalopathy ○ NBSM? IV thiamine (B1) ○ Triad = confusion + ophthalmoplegia + ataxia ○ What if there is amnesia + confabulation? Korsakoff’s psychosis ○ Neuroanatomical association? Hemorrhagic infarction of mamillary bodies ○ Pathophys? Lack of B1 cofactor → dysfunction of transketolase enzyme (rate-limiting enzyme of nonoxidative phase of pentose phosphate pathway) ○ Patient population ■ Alcoholics ■ Anorexic ■ Hyperemesis gravidarum ■ Chronic malnutrition

● Pt on nitroprusside drip that develops metabolic acidosis with pH 7.19 and bicarb 10 → cyanide poisoning ○ Pathophys? Lactic acidosis 2/2 anaerobic metabolism ○ NBSM? Hydroxocobalamin OR amyl nitrate + sodium thiosulfate ■ CN- binds to Fe3+ (oxidized state). Amyl nitrate oxidizes hemoglobin so CN- binds. Sodium thiosulfate converts the CN- to thiocyanate, which can be excreted.

● Pt that consumes antifreeze, now complaining of flank pain radiating to the groin → oxalate nephrolithiasis 2/2 ethylene glycol poisoning ○ Other population that gets oxalate nephrolithiasis? Crohn’s ○ NBSM? Fomepizole ■ Mechanism? Alcohol dehydrogenase inhibitor ■ Indications: methanol, ethanol, or ethylene glycol poisoning ○ Lactic acidosis + visual difficulty → methanol poisoning

● Respiratory depression + no pupillary findings +/- psych disorder? benzodiazepine overdose ○ NBSM? Flumazenil DI Podcast Main Document 291 ■ Mechanism? GABA receptor antagonist ■ Indications: ● Benzo overdose ● Z drug overdose (zolpidem, zaleplon, eszopiclone)

● Body temp 103F + dilated pupils + dry red skin + suprapubic fullness → anticholinergic toxicity ○ Causes ■ Atropine ■ TCAs (also look for wide QRS on EKG, give sodium bicarb) ■ 1st gen antihistamines (e.g. diphenhydramine) ■ 1st gen low potency antipsychotics ■ Clozapine ■ Belladonna plants/Jimson weed ○ Tx? physostigmine ■ Mechanism? AChE inhibitor

● Diarrhea + miosis + sweating + lacrimation + bronchospasm → cholinergic toxidrome ○ Causes? ■ Child that takes AChE pills ■ Organophosphate poisoning ● E.g. terrorist attack with nerve gas ○ Tx? Atropine (1st) + pralidoxime (2nd) ■ Atropine - block muscarinic receptors ■ Pralidoxime - helps regenerate AChE

● Hx of DM with gastroparesis. Pt is having muscle rigidity + temp 105F → NMS 2/2 metoclopramide ○ Tx? ■ Benzodiazepine ■ Dopamine agonist (e.g. cabergoline, bromocriptine) ○ NBSM

● Pt that was on an SSRI for a while switched to MAOI. Now with fever + myoclonus + diarrhea → serotonin syndrome 2/2 inadequate washout time ○ Causes? ■ SSRI / SNRI / TCA / MAOI ■ Trazodone ■ St. John’s wort ■ Linezolid ■ Ondansetron ■ Triptans ■ Ergots ■ Tramadol ■ Ecstasy/MDMA ○ Which SSRI has the longest half life? Fluoxetine ○ Tx? DI Podcast Main Document 292 ■ Benzo ■ Cyproheptadine (antihistamine with antiserotonergic properties) ○ Why diarrhea? Oversecretion of serotonin causes diarrhea ■ Recall carcinoid syndrome mnemonic (mnemonic “Be FDR”) ● Bronchospasm ● Flushing ● Diarrhea ● Right-sided heart lesions

● Pt recently started on psych drug is at dinner and starts to have HA and vision changes. BP is 240/120 → hypertensive crisis 2/2 tyramine consumption while on MAOI ○ Tx? Phentolamine (reversible alpha-1 antagonist) ○ General tx for hypertensive urgency/emergency ■ Nitroprusside ■ Nicardipine ■ Clevidipine ■ Labetalol ■ Fenoldopam ○ Do NOT use hydralazine for hypertensive emergency

● Pt with diabetic gastroparesis has rigid UE → acute dystonia ○ Pathophys? Dysfunction of nigrostriatal pathway (extrapyramidal symptom) ○ Tx? ■ Diphenhydramine ■ Benztropine (anticholinergic)● Pt started on antipsychotic feels really restless → akinesthesia ○ Tx? Beta blocker● Pt started on antipsychotic now has cogwheel rigidity, trouble walking at normal pace ○ Tx? ■ Dopamine agonist (e.g. bromocriptine, cabergoline) ■ Benztropine● Pt that’s been on a psych drug for a while now has repetitive movements of the tongue → tardive dyskinesia ○ NBS? STOP the drug ○ Switch to an atypical antipsychotic

● Pt was a hx of Parkinson’s. Carbidopa/levodopa dose was recently increased. Now they’re having psychosis. NBS? ○ NBS? reduce dose of carbidopa/levodopa ■ If they don’t tolerate dose reduction → quetiapine ● Why? Quetiapine has weaker antidopaminergic activity ● Adverse effect? Cataracts● Pt with HTN + tachycardia + mydriasis → sympathomimetic toxidrome ○ Causes? ■ If nasal septum perforation → cocaine toxicity DI Podcast Main Document 293 ● Tx for HTN? ○ Alpha-1 blocker (phentolamine) ○ Alpha-beta blocker (carvedilol) ○ Benzodiazepine ■ Amphetamines ■ Benzo/alcohol withdrawal ■ Hyperthyroidism

● Pt found down at home in the winter, now with bad lactic acidosis → CO poisoning ○ Causes? Space heater use ○ Tx? Hyperbaric oxygen

● Pt going to developing country and taking malaria ppx, now hypoxic with cyanosis → methemoglobinemia ○ Pathophys? Fe2+ in Hgb is converted to Fe3+. O2 can’t bind to Fe3+ ○ Common drug causes ■ Dapsone ■ Primaquine ■ TMP-SMX ■ Lidocaine/benzocaine ■ Nitrates & nitrites ○ Tx? Methylene blue ○ When do we induce methemoglobinemia? To treat cyanide poisoning

● Pt with mitral stenosis and A-fib presents with bloody BMs → warfarin toxicity ○ Manifestations ■ GI bleeds: duodenal hematomas/rectus sheath hematomas ○ NBSM? Give four-factor PCC (prothrombin complex concentrate) ○ Tx for other cases ■ High INR but no sxs → stop warfarin + give oral Vit K

● Pt with psych disorder tried to overdose on something. Now LFTs are high and Cr is rising → acetaminophen poisoning ○ Pathophys? Production of NAPQI, which is toxic to hepatocytes ○ Tx? N-acetylcysteine to prevent hepatic damage ■ If within minutes → give activated charcoal ○ Other weird presentations ■ Hypoglycemia ■ Metabolic acidosis (mitochondrial poisoning → lactic acidosis) ■ Encephalopathy● Pt that tried to overdose on something. RR = 30 and PaCO2 = 20, pH 7.51, bicarb 13 → aspirin toxicity ○ Pathophys? Respiratory alkalosis + metabolic acidosis ○ Tx? Sodium bicarb ■ Mechanism? Alkaline the urine and increases excretion of aspirin ○ Tx if very severe? dialysis DI Podcast Main Document 294 ● Profound bradycardia + hypotension in pt on an antihypertensive drug → beta blocker overdose ○ Tx? Glucagon

● Pt that overdoses on a CCB. NBS? Calcium-containing agent (e.g. calcium chloride, calcium gluconate)

● Hyporeflexia + slow RR → Mg toxicity ○ NBS? calcium gluconate

● Pt is admitted for CHF exacerbation and is put on a loop diuretic. Now they’re having a lot of ventricular arrhythmias → digoxin toxicity ○ Pathophys? Hypokalemia predisposes to digoxin toxicity ○ Tx? anti-digoxin Fab fragments ○ Other adverse effects of digoxin ■ Yellow vision ■ Hyperkalemia

● Reversal agents ○ Dabigatran → idarucizumab ○ Unfractionated heparin → protamine sulfate ■ Does NOT tx LMWH toxicity ○ Warfarin → Vit K or PCC

● Pt found down, unresponsive. Hx of T2DM and not being treated with insulin. → hypoglycemia ○ Oral agent with the highest risk of hypoglycemia? Glyburide (sulfonylureas) ○ Tx? ■ Give glucose (best choice) ■ Glucagon ■ Octreotide

● Pt was partying at a club and took a drug. Now with hyperkalemia + hypocalcemia + rising Cr. → MDMA (Ecstasy) use & rhabdomyolysis ○ Other problems with Ecstasy use ■ Serotonin syndrome ■ Heat exhaustion ■ Psychogenic polydipsia

● Pt is undergoing surgery and gets rigid and febrile → malignant hyperthermia ○ NBS? Dantrolene (CCB) ■ Mechanism? Ryanodine receptor antagonist ○ Inheritance? AD ○ Pathophys? Ryanodine receptor mutation → excessive Ca++ released from the sarcoplasmic reticulum

● Pt that has been on a ventilator for a while gets pancreatitis → propofol DI Podcast Main Document 295 ○ Pathophys? Propofol contains a ton of lipid → hypertriglyceridemia ○ Contraindications ■ Familial hypertriglyceridemia

● Pt with Parkinson’s disease presents with myoclonus + hyperthermia → MAO-B inhibitors ● Pt on a cancer drug that starts having blood clots in urine → hemorrhagic cystitis 2/2 cyclophosphamide ○ Pathophys? Acrolein metabolites ○ Prevention? Mesna

● Pt on a cancer drug with rising Cr and hearing difficulties → cisplatin ○ Prevention of renal toxicity? Amifostine ○ Renal + ototoxicity drugs ■ Aminoglycosides ■ Vancomycin ■ Ethacrynic acid

● Pt with breast cancer that now has SOB or PND → irreversible dilated cardiomyopathy 2/2 anthracyclines (doxorubicin, daunorubicin) ○ Prevention? Destrozame (iron chelator) ○ What if the pt has HER2-positive breast cancer? reversible dilated cardiomyopathy 2/2 trastuzumab

● Megaloblastic anemia in pt with alcoholism → folate deficiency ○ NOT B12 deficiency ○ Folate stores don’t last as long as B12 stores

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Ep. 166: Rapid Review Series 20 (Psych)

● Pt thinks they are president, has slept 1 hr/day for past 2 weeks, feels like superman → bipolar I disorder ○ Manic eps ■ D = distractibility ■ I = indiscretion/impulsivity ■ G = grandiosity ■ F = flight of ideas ■ A = increased goal-directed activity ■ S = decreased need for sleep ■ T = talkativeness ○ Depressive eps ○ After ONE manic ep → can make diagnosis! Even w/o depressive ep! ■ ep must last at least 1 week ■ Exception: if sxs are so severe they are hospitalized

DI Podcast Main Document 296 ○ Tx if acutely manic? Antipsychotic & start lithium ○ 1st line maintenance tx? Lithium ■ Decreased risk of suicide! ■ Adverse effects? ● Hypothyroidism ● Nephrogenic DI (high serum osmolarity, low urine osmolarity) ○ Gains entry to principal cell via ENaC channel ○ Tx? ENaC blockers, e.g. amiloride, triamterene ○ Thiazide will worsen lithium toxicity by causing RAAS activation and increasing ENaC activity ● Tremors ● Ebstein’s anomaly = downward displacement of tricuspid valve, “atrialization of LV” ■ If a woman is well-controlled on lithium and gets pregnant, NBS? Continue lithium! ■ If a woman is diagnosed with bipolar disorder in pregnant, NBS? ● Start haloperidol ○ Person with bipolar disorder, sxs not controlled on lithium, NBS? Add atypical antipsychotic (e.g. quetiapine)

● Pt with HTN is also on a psych drug. Which drug? SNRI (especially venlafaxine)● Pt with low libido, recently started on psych med. Which drug? SSRI ○ Adverse effects? ■ Sexual dysfunction ■ Weight gain ○ Indications? ■ MDD ■ GAD ■ PMDD ■ PTSD● How to make GAD diagnosis? Need sxs for 6 months● How to make MDD diagnosis? 5/9 of SIGECAPS + low mood for at least 2 weeks ○ S = sleep ○ I = loss of interest ○ G = guilt ○ E = low energy ○ C = poor concentration ○ A = appetite ○ P = psychom*otor ○ S = suicidal ideation● What if they don’t meet 5/9 or 2 week criteria for MDD? adjustment disorder with depressed mood

● How long must sxs by present to make PTSD diagnosis? 1 month ○ What’s the diagnosis if they have sxs for < 1 month → acute stress disorder ○ Tx for PTSD nightmares? Prazosin

DI Podcast Main Document 297 ● Pt with an eating disorder is taking a psych med and had a seizure? Bupropion (NDRI) ○ Indications? ■ MDD, if patient has been sexual side effects with SSRI ■ Weight loss ■ Smoking cessation ● Varenicline is more effective (partial agonist at nicotinic receptors) ● Nicotine patch + variclean is MOST effective ○ Contraindications ■ Anorexia ■ Bulimia ■ Seizure disorder

● How to distinguish between anorexia, bulimia, binge eating? ○ BMI < 18.5 → anorexia ○ Binge eat & compensatory behavior → bulimia ○ Binge eat & NO compensatory behavior → binge eating disorder

-------------------------------------------------------------------------------------------------------------------------------Ep 167: Rapid Review Series 21 Cardio

● Elderly pt passes out while mowing lawn. Valve path? aortic stenosis o NBSIM? Echocardiogram (dx) ▪ Note: NBSIM for any suspected valve path = Echo! o S/Sx: Systolic ejection murmur (SEM) + radiates to carotids o Where to auscultate? RUSB at 2nd intercostal space o Pathophys: "calcification of valve" ▪ Note: Aortic stenosis in young pt’s = bicuspid aortic valve

● Pathophys of MVP? "myxomatous degeneration"

● Pathophys of Aortic Dissection? "cystic medial degeneration/necrosis"

Aortic Stenosis HOCM Age Elderly Young adult Where to auscultate? RUSB LLSB

Murmur SEM + radiates to carotids SEM

Pulse Pulsus parves et tardus ("late") d/t Pulses bisferiens d/t mitral valve trouble getting blood out of ventricle moving towards LVOT mid-systole (PMI…carotid) ("bifid carotid pulse") = 1. small 2. big carotid pulse

DI Podcast Main Document 298 Maneuvers that ▪ Rapid Squatting (↑venous return, ▪ Valsalva (phase II) (↓preload) increase intensity? ↑preload, ↑afterload) ▪ Standing up (↓preload)

Maneuvers that ▪ Valsalva (phase II) (↓preload) ▪ Rapid squatting (↑venous return, decrease intensity? ↑preload, ↑afterload) ▪ Standing up (↓preload) ▪ Handgrip (↑afterload)

Note: both increased preload and increased afterload decrease intensity of HOCM ☺ Tx Valve replacement ▪ Defibrillator ▪ Beta-blockers (slow HR → more time for LV to fill with blood)

● Diastolic murmur at apex? mitral stenosis o RF: Rheumatic fever o MC complication: AFib (LA contracts against increased resistance d/t stenotic mitral valve → dilation of LA → disrupts electrical conduction pathways of LA) o Upper GI complication? Dysphagia (mitral stenosis causes dilation of LA, which compresses esophagus)

● Holosystolic murmur at apex + radiates to axilla? mitral regurgitation

● Mid-systolic murmur at apex with opening snap/click? mitral valve prolapse o RF? ADPKD, Marfan syndrome, Ehlers-Danlos syndrome

Mitral Regurgitation Mitral Valve Prolapse Maneuvers that ▪ Handgrip (↑afterload) ▪ Valsalva (phase II) (↓preload) increase intensity? ▪ Standing up (↓preload)

Note: earlier onset of opening snap/click

Maneuvers that ▪ Valsalva (phase II) (↓preload) ▪ Rapid squatting (↑venous return, decrease intensity? ↑preload, ↑afterload) ▪ Standing up (↓preload) ▪ Handgrip (↑afterload)

Note: later onset of opening snap/click

● Diastolic blowing murmur heard at RUSB? Aortic regurgitation o RF? Takayasu, tertiary syphilis (@vasa vasorum of aortic arch), connective tissue disorder, retrograde aortic dissection, Marfan syndrome, Ehlers-Danlos syndrome o Effect on Pulse Pressure? Widened pulse pressure ▪ Note: wide pulse pressure in adults = aortic regurge DI Podcast Main Document 299 ▪ Note: wide pulse pressure in kids = PDA

● Type of LV Hypertrophy in AR? Eccentric hypertrophy (sarcomeres in series) o Eccentric hypertrophy is a/w HFrEF ▪ Mechanism? Chronic volume overload of LV → eccentric hypertrophy → dilation of LV →systolic dysfunction → HFrEF

● Type of LV Hypertrophy in AS? Concentric hypertrophy (sarcomeres in parallel) o Concentric hypertrophy is a/w HFpEF ▪ Mechanism? Pressure overload → concentric hypertrophy (sarcomeres in parallel) → result in decreased size of lumen of LV → diastolic dysfunction

● Severe sudden onset chest pain with radiation to back. Dx? Aortic dissection o RF? HTN o S/Sx: >10 mmHg difference in BP in between arms, mediastinal widening, unilateral pleural effusion + chest pain, elevated BP o Dx? ▪ Aortic dissection + stable pt = CTA ● Note: contraindicated in renal insufficiency) ▪ Aortic dissection + unstable pt = TTE o Tx ▪ Stanford Type A = ascending aorta → surgery ▪ Stanford Type B = does *not* involve ascending aorta → Propranolol ● Do not give use hydralazine b/c it causes reflex tachycardia (causes vasodilation → results in reflex baroreceptor activation) ● Must avoid increased heart rate b/c ↑HR = ↑shear stress on aortic valve = ↑risk of worsening aortic dissection

● IVDU + fevers + 10lb weight loss + murmur at LLSB. Dx? tricuspid valve endocarditis o NBSIM: blood culture o Dx: echocardiogram o Tx: IV abx for 6wks o Etiology: Staph aureus (MCC IVDU endocarditis) into bloodstream, veins drain to R side of heart (tricuspid valve) ▪ Vs. recent dental procedure: Strep viridans --> subacute endocarditis ● Increased risk with valvular issues ● Ppx: oral amoxicillin after dental procedures ▪ Vs. culture-negative: Coxiella Burnetti ▪ Vs. + hemolytic anemia, malar rash on face: SLE Libman-Sacks endocarditis ▪ Vs. Strep bovis. NBSIM? Colonoscopy (Strep bovis bacteremia indicates colon cancer) ▪ Vs. Weeks-months after valve replacement: Staph epidermidis (biofilm on valve) ▪ Vs. recent immigration, URT w/o treatment: GAS Rheumatic fever

● 70Y, heavy smoker, severe BLE pain when walking: PAD o NBSIM: ABI – ABI <0.9 indicates PAD! ▪ Vs. ABI > 1.1: Monckeberg arteriosclerosis 2/2 T2DM (calcified blood vessels) ● NBSIM with ABI > 1.1?: toe brachial index o Tx: supervised walking program, cilostazol (PDE inhibitor leading to increased cAMP, smooth muscle relaxation), arteriography --> bypass o Occlusion @ Location DI Podcast Main Document 300 ▪Femoral artery occlusion: pain @ thigh ▪Popliteal artery occlusion: pain @ leg ▪Leriche syndrome d/t occlusion of internal+external iliac branches of aorta + impotence, buttock pain #rip o RF: smoking

● Long-term smoker, past 30min severe back/abdominal pain, pulsatile abdominal mass, hypotensive: ruptured AAA o RF: smoking o Dx: bedside ultrasound or CTA

● NBSIM for 65-75yo M with h/o smoking or FMHx AAA? abd ultrasound (one-time screening) ▪ >5.5 cm, growing >0.5 cm/6mo or >1cm/yr, symptomatic --> surgery

● Complications of AAA surgery: ▪ AKI d/t transient hypoperfusion of kidneys ● AAA @ Infrarenal aorta near renal artery ▪ Anterior spinal artery syndrome d/t infarction of Artery of Adamkiewitz ● Sx: paraplegic/quadriplegic; all of spinal cord knocked out except dorsal columns (vibration/fine touch) ▪ Endo-leak = did not properly exclude aneurysm --> contrast going past contours of aneurysm stent ▪ Aortoenteric fistula ● Sx: dropping Hgb s/p weeks or months, heme-occult positive stools

● Bed-bound hospitalized patient, severe unilateral leg pain/tenderness: DVT o RF: Virchow's triad = stasis, hypercoagulability, endothelial dysfunction o NBS and Dx: duplex scan of LE o Tx: heparin or IVC filter (prevent PE)

● Bonus! Young male athlete who is either a pitcher or weight-lifter + sudden-onset arm swelling + arm heaviness + arm pain → Spontaneous upper extremity DVT o Tx? Throbolysis and/or 3 months of anti-coagulation

● Chest pain, ST elevations on EKG, radiation to jaw: STEMI

● Acute Coronary Syndrome STEMI NSTEMI Unstable Angina Chest pain + + + Troponin + + ST elevation +

▪ Note: stable angina is not an “acute coronary syndrome”

● MI (STEMI and NSTEMI) o MCC death s/p 48h: VFib

DI Podcast Main Document 301 ● Recent MI + diffuse STE + chest pain + worsened with inspiration or lying down + relieved sitting up and leaning forward. Dx? Pericarditis o Post-myocardial pericarditis = days after MI o Dressler myocarditis aka auto-immune pericarditis = weeks after MI o Tx? ▪ NSAIDs; colchicine; steroids ▪ Do not give NSAIDs or colchicine in renal failure

● NBSIM for Unstable angina? Coronary angiography

● NBSIM for Stable angina? Echo stress test o Echo stress test if known cardiac anomaly o Exercise stress test preferred vs pharmacological stress test ▪ Pharm stress test = adenosine/dipyridamole/dobutamine for obese pts ▪ Adenosine contraindicated in asthma or COPD ▪ Dobutamine contraindicated in arrhythmias

● Short PR segment + wide QRS, palpitations. Arrhythmia? WPW o Pathophys: Direct communication from atria to ventricles via bundle of Kent o Tx: procainamide

● Severe leg pain worse at end of day + painless ulcer above medial malleolus. Dx? chronic venous insufficiency o Dx: Duplex U/S of LE o Pathophys: "incompetence of venous valves" o Sx: painless ulcer, stasis dermatitis (d/t blood pooling) o Tx: leg compression (Unna boots), leg elevation

● Wide-complex regular tachyarrhythmia. Arrhythmia? VTach o Tx ▪ Pulseless VTach → defibrillation aka unsynchronized cardioversion ▪ VTach + HDUS → synchronized cardioversion ▪ VTach + HDS → amiodarone

Cross checked: Yes---------------------------------------------------------------------------------------------------------------------------------------

Ep. 169: The "Clutch" Nephrotic/Nephritic Syndrome

● Nephrotic → protein excretion more than 3.5 in 24 hrs ○ Urine protein to creatinine ratio, low albumin, edema, hyperlipidemia, maltese cross bodies ○ Systemic diseases: DM, sarcoidosis ○ Lost antithrombin III = hypercoagulable ○ Tx: statins, anticoagulate, loop diuretics ○ FSGS ■ Risk factors: A. american, IV drug users, HIV (collapsing), obesity, NPHS1 and NPHS2 mutations ■ Dx: biopsy w/podocyte effacement

DI Podcast Main Document 302 ■ Tx: steroids or cyclosporine ■ Less than 50% effected and not continuous ■ More than 50% progress to renal failure in 5 yrs ○ Membranous glomerulopathy ■ White person with ab against phospholipase A2 receptor ■ Subepithelial spike and dome ■ Risk factors: solid cancers, HBV, HCV, malaria, lupus, NSAIDs ■ Can develop renal vein thrombosis → hypercoagulable ■ Dx: biopsy ■ Tx: steroids + cyclophosphamide or cyclosporine, treat coexisting HBV (emcitabine, lamivudine, tenofovir) ○ Minimal change dz ■ Usually in kids w/podocyte effacement ■ Risk factors: URI, NSAIDs, liquid cancers ■ Tx: steroids ○ Diabetic nephropathy ■ Microalbuminuria in pt with longstanding DM, clinical diagnosis ■ Tx: ACE/ARB ■ Check kidney function at time of diagnosis for type 2 and 5 years after diagnosis for type 1● Nephritic → protein excretion less than 3.5 ○ Dysmorphic erythrocytes, periorbital edema, HTN, RBC casts ○ Goodpasture aka anti-GBM dz ■ Auto ab against a3 chain of type IV collagen → young male with hematuria and hemoptysis ■ Linear pattern rather than granular ■ Type 2 hypersensitivity rxn ■ Tx: steroids and cyclophosphamide ○ Wegener’s aka GPA ■ Triad of hematuria, hemoptysis, and sinusitis ● Might have mastoiditis, eustation tube, or otitis media ■ c-ANCA (antiproteinase 3 abs) - only c-ANCA dx ■ Normal complement levels ○ Churg Strauss aka EGPA ■ Asthma hx w/eosinophilia and hematuria ■ Normal complement levels ○ Microscopic polyangiitis ■ >60 yo, hematuria, fevers, weight loss - nonspecific sx so likely will not ask to dx ■ p-ANCA (myeloperoxidase abs) ○ RPGN → progress to bad renal function over days to weeks ■ Histo: crescents b/c of leakage into bowman’s space ○ IgA nephropathy ■ Hematuria 1-2 days after URI or GI infection ■ Dx: biopsy w/ Ag-Ab complexes Tx: don't need to treat ■ Normal complement, HSP ○ MPGN ■ Subendothelial tram tracks ■ Associated with lupus, HBV and HCV ■ Low complement → low C3 with normal C4 ■ DDD → dense deposits around BM, C3 nephritic factor, super low C3 ○ Post infectious GN ■ Subepithelial humps, granular pattern DI Podcast Main Document 303 ■ Low complement, different strains than what cause RF ■ 1-6 wks after strep infection ■ Titers for ASO and anti DNAseB ■ 40% of adults gets RPGN vs 10% of kids (diff in incidence) ○ DPGN ■ Low complement, associated with lupus ■ Anti smith abs, ANA abs ○ Alport ■ XLD, can’t see, can’t pee, can’t hear a bee (sensorineural) ■ Mutations in a2 chain of type IV collagen ■ COL4A5 mutationThese are my personal notes that I took while listening to the podcast a while ago. I apologize for any errors!

Cross Checked: No

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Ep. 169: The "Clutch" Nephrotic/Nephritic Syndrome (Version 2)ep 169 (Version 2) notes were graciously provided by Divine Intervention from an anonymous contributor.

Nephrotic syndrome Nephritic syndromeDx >3500mg proteinuria (or protein:Cr) in <3500mg proteinuria in 24h 24hPathophys Low levels of albumin and Inflammation of glomerulus anti-thrombinIII (--|factor 2, 10)Sx Edema, hyperlipidemia (liver tries to Periorbital edema, hypertension compensate for decreased oncotic pressure)Systemic etiologies Diabetes, amyloidosis General tx statins, anticoagulants, loop diuretic Urinalysis "Maltese cross" pattern, oval fat bodies RBC casts/dysmorphic erythrocytes ● Nephrotic syndrome o Focal segmental glomerulosclerosis/FSGS ● Path: <50% of glomeruli affected + only small segment affected ● RF: African American, IV drug user, HIV (w/ bad prognosis "collapsing" FSGS), obesity, NPHS1/2 mutation ● Dx: renal biopsy, "podocyte foot process effacement" ● Tx: steroids, cyclophosphamide ● C/b chronic renal failure (50% of FSGS pts) DI Podcast Main Document 304 ▪ *Tip lesion form has good prognosis o Membranous nephropathy/glomerulonephropathy ● MCC nephrotic syndrome in adults ● RF: White, Ab-phospholipaseA2, solid malignancies, HepB/HepC, malaria, lupus ▪ Vs. minimal change disease RF: heme malignancies ● Path: Ab complement region activates complement cascade --> "everything goes haywire" ● Sx: renal vein thromboses (d/t anti-thrombinIII deficiency --> sudden onset flank pain + fevers) ● Dx: biopsy, "subepithelial spike and dome" ● Tx: cyclophosphamide +/- steroids ▪ Also treat underlying disease i.e. HepB (|-- emtricitabine, lamivudine, tenofovir "HepBELT") o Minimal change disease ● RF: kiddos, also found less commonly in adults, URI, heme malignancy ● Dx: "podocyte foot process effacement" ▪ --> loss of negative charges @ foot processes --> albumin leaks through ▪ Tx: steroids ● Good response, rarely progress to renal failure o Diabetic nephropathy ● Dx: clinical, microalbuminuria ● Ppx: @ time of DM diagnosis --> measure albumin:Cr ratio ▪ If not done at time of diagnosis, start 5y after dx is made ● Tx: ACEi/ARB, glucose + BP control● Nephritic syndrome o Goodpasture's syndrome/anti-GBM disease ● Path: Ab-alpha 3 chain of Type4 collagen = T2HS ● Sx: hematuria, hemoptysis ● Dx: linear pattern of Ig deposition ● Tx: plasmapheresis, steroids o Pauci-immune: Wegeners/GPA, microscopic polyangiitis, Churg-Strauss/EGPA ● Sx: rapidly progressive glomerulonephritis = normal renal function --> failure over days-weeks ▪ Wegener's: hematuria, hemoptysis, sinusitis/mastoiditis, otitis media, eustachian tube dysf(x) ● Path: c-ANCA (Ab-proteinase3) ▪ Microscopic polyangiitis: >60Y, fever, hematuria, p-ANCA (Ab-myeloperoxidase) ▪ Churg-Strauss/EGPA: asthma/allergies, tons of eosinophils, hematuria, p-ANCA ● Dx: crescent-shaped = monocytes leak through GBM into Bowman's space and proliferate ▪ Complement levels are normal ● Tx: steroids, cyclophosphamide, rituximab o IgA nephropathy/synpharyngitic nephropathy ● RF: recent URI ● Pathophys: Ab against glycosylated-IgA (from N-acetylgalactosamine on bugs) --> deposits in mesangium of kidneys --> inflammation ● Systemic manifestation = HSP (purpura x abdominal pain x hematuria) ● Sx: hematuria ● Dx: biopsy, complement levels are normal ● Tx: supportive o Lupus nephritis ● Sx: malar rash, anti-Sm Ab, anti-dsDNA, low complement levels ("full-house pattern") ● Subtypes ▪ Diffuse proliferative glomerulonephritis o Post-infectious glomerulonephritis/PSGN

DI Podcast Main Document 305 ● RF: URI, Strep infection (nephritogenic strains) ▪ --> abx for Strep throat do not decrease chance of PSGN ● Pathophys: Ab against GAS cross react with antigens in glomerulus --> complement "destroys everything in its wake" ● Sx: 1-6wks post-URI, hematuria, low complement ● Dx: anti-DNAseB, anti-streptolysinO, anti-hyaluronidase, "granular pattern" ● C/b: chronic renal failure (kids 1% vs adults 40%) o Membranoproliferative glomerulonephritis (MPGN) ● RF: lupus, HepB/C ● Dx: low C3, "subendothelial tram tracks" ● Subtype: dense-deposit disease ("ribbon-shaped" deposits around basem*nt membrane of glomerulus, C3 nephritic factor = C3 convertase --> low C3) o Alport syndrome ● Sx: "can't pee, can't see, can't hear a bee" = cataracts/dislocation of lens, nephritic syndrome, sensorineural hearing loss ● Path: X-linked dominant mutation in alpha2* chain of Type4 collagen/COL4A5 ▪ *A comes before G[oodpasture] in the alphabet! ▪ (same inheritance as Fragile X syndrome)Disease Light microscopy findingsMinimal change disease Podocyte effacementFSGS Podocyte effacementPSGN Subepithelial humps, granularMembranous nephropathy Subepithelial spike and domeMembranoproliferative glomerulonephritis subendothelial tram tracksLupus nephritis wire-loop appearanceGoodpasture's syndrome/anti-GBM disease Linear pattern of IgG depositionIgA nephropathy Mesangial proliferation, IgA deposits

Complement levels DiseaseLow PSGN, lupus, membranoproliferative (C3)Normal IgA nephropathy, pauci-immune entitiesHigh

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DI Podcast Main Document 306 Ep. 173: The "Clutch" Immunodeficiency Diseases Podcast ● 3 yo M with multiple Strep pneumo pneumonia + giardia infections → Bruton’s agammaglobulinemia ○ Recurrent infections after 6 months old (when antibodies from mom wane) ○ Cell affected? B-cells ○ Pathophys? Mutation in tyrosine kinase that allows for B cell differentiation → no mature B cells → issues with antibody production / humoral immunity ○ Classic organisms? Encapsulated organisms (Strep pneumo, H. flu) ○ Inheritance? X-linked dominant ○ Mutated gene? BTK ○ PE findings? ■ Poorly developed tonsils ■ Tiny spleen ■ No lymphadenopathy with infections ○ Lab findings? ■ NO B cells on peripheral smear ■ Low levels of immunoglobulin ○ Tx? Monthly IVIG

● Similar presentation to Bruton’s? CVID ○ Inheritance? AR or AD ○ Pathophys? Issues with B cell differentiation → low levels of immunoglobulins ○ Presentation? Boy or girl that has recurrent respiratory or GI infections after age 10 ○ Alternate presentation? Pt gets pneumococcal vaccine, but still gets multiple pneumococcal infections. Check titers and they’re not immune. ○ Associated problems: ■ Skin disease (e.g. alopecia, vitiligo) ■ Autoimmune dz (e.g. ITP, autoimmune hemolytic anemia, RA) ■ Lymphoma ○ Lab findings? ■ B cells on peripheral smear ○ Tx? IVIG

● Pt getting blood transfusion that becomes hypoxia, has stridor/wheezing → IgA deficiency ○ Presentation? Recurrent respiratory and GI infections ○ Pathophys? ■ Failure of differentiation of IgA-producing B cells. Recall that IgA is the “guardian of the mucosa” ■ Since they are deficient in IgA, they can form Ab to IgA. ○ Associated problems ■ Food allergy ■ Atopic disorders ○ Lab findings? ■ Normal WBC count DI Podcast Main Document 307 ■ Low IgA levels, other Ig normal ○ Tx? ■ Keep treating recurrent infections ■ Washing of blood transfusions (to remove plasma)

● Girl with progressive neurologic impaired + problems walking + telangiectasias in the skin or eye + mild ID → Ataxia-telangiectasia ○ Classic presentation? ataxia w/ negative Romberg → age 3-6 telangiectasias on skin & eye → then recurrent sinopulmonary infections ■ Freidrich’s ataxia tends to have positive Romberg ■ Use name of the disease to remember order ○ Inheritance? AR ○ Pathophys? ATM gene regulates response to ds DNA breaks → sensitivity to ionizing radiation ○ Mutated gene? ATM ○ Chromosome? 11 ○ Lab testing? ■ Low WBC count ■ Low IgA level ○ Associated problems? ■ Increased risk of cancer, especially hematologic cancers

● SCID ○ Presentation? Bad infections since birth ○ Pathophys? ■ Common cause: deficiency of adenosine deaminase → apoptosis of lymphocytes ■ Another cause: Mutation in IL-2 receptor ○ Cells affected? B-cells & T-cells ○ Classic organisms? ALL (bacterial, fungal, viral) ○ Inheritance? Can vary (AR, X-linked) ○ Lad findings? ■ Low WBC count ■ Low immunoglobulins ○ Imaging? Absent thymic shadow on CXR ■ Also seen in DiGeorge ○ Histology? Hypoplasia of the paracortex (T-cell zone) of lymph node ○ Tx? ■ Abx ■ Bone marrow transplant ○ Vaccination restrictions? NO live-attenuated vaccines

DI Podcast Main Document 308 ● Boy with petechiae on skin + platelet count 30k + eczematous lesions + recurrent infections → Wiskott-Aldrich syndrome ○ Inheritance? X-linked recessive ○ Mutated gene? WASP ○ Pathophys? WASP gene mutation → issues with signaling cascade allowing for the appropriate movement of actin filaments ○ Lab findings? ■ Thrombocytopenia ■ Tiny platelets ■ High IgE → eczema ■ High IgA ■ Low IgM ○ Associated problems? ■ Autoimmune disease

● Skin infections w/o pus + delayed separation of umbilical cord → leukocyte adhesion deficiency ○ Pathophys? Neutrophils cannot adhere to endothelium & exit the bloodstream ○ Mutated proteins? Integrins (e.g. CD-18), E-selectin, sialyl Lewis X ○ Lab findings? ■ Leukocytosis w/o signs of infection (large % leukocytes are in a demarginated state) ○ Dx? Flow cytometry

DI Podcast Main Document 309 ● Pt with lymphadenopathy + recurrent Staph aureus abscesses → CGD ○ Inheritance? X-linked recessive ○ Cells affected? Neutrophils ○ Pathophys? NADPH oxidase deficiency → neutrophils cannot generate oxidative burst ○ Classic organisms? Catalase-positive ■ Staph aureus ■ E. coli ■ Candida ○ Dx? ■ Dihydrorhodamine test (DHR) ■ Nitroblue tetrazolium test (NBT)--OLD! ○ Tx? Interferon-gamma

● Recurrent infections + albinism (“diffuse skin hypopigmentation”) w/ blond hair & blue eyes + intellectual disability → Chediak-Higashi disease ○ Inheritance? AR ○ Cells affected? Neutrophils ○ Mutated gene? LYST or CHS1 ○ Pathophys? Problems with intracellular protein transport → problems with transporting secretory granules to appropriate place ■ Issues with melanin granule transport → albinism ■ Issues with neutrophil granules → can’t use them to kill bacteria ○ Associated problems? ■ Hematologic malignancies ○ Lab findings? ■ Peripheral smear with giant granules in neutrophils DI Podcast Main Document 310 ● Recurrent infections + no thymic shadow on CXR + hypocalcemia → DiGeorge ○ Pathophys? Failure of the 3rd and 4th pharyngeal pouches to develop ■ No thymus → T cells can’t mature ■ No parathyroids → hypocalcemia → prolonged QT & seizures ○ Gene? 22q11 deletion ○ Chromosome? 22 ○ Dx? FISH ○ CATCH-22 ■ C = cardiac issues (e.g. tetralogy, truncus arteriosus, VSD) ■ A = abnormal facies ■ T = thymic aplasia ■ C = cleft palate ■ H = hypoparathyroidism ■ 22 = chromosome 22 ○ Most common cause of death? Heart disease ○ Velocardiofacial syndrome vs. DiGeorge ■ Doesn’t have the hypoparathyroidism

● Terminal complement deficiency (C5-C9) makes you susceptible to what bug? Neisseria meningitidis ○ Prevention? Neisseria meningitidis vaccine

-------------------------------------------------------------------------------------------------------------------------------Ep. 197: Bias in Biostatistics ● Selection bias = the people in the study are a bad representation of the population ○ Can I generalize the results of this study to the rest of the world? ○ Examples: ■ Berkson's bias = using a hospital population from the study (will be sicker than non-hospitalized pts) ■ Attrition bias = differences in loss to follow up among study groups (pts who drop out of study may be different from pts who complete the study) ● Solution? Intention-to-treat analysis ■ Selecting participants from a particular geographic area ■ Volunteer bias = people who respond to surveys or participate in studies likely have different characteristics than those who don’t

● Measurement bias = the way you obtain data distorts information that you get from the study ○ The researcher has bias of his own! ○ Examples: ■ Hawthorne effect = people act differently when they know they’re being observed ■ Pygmalion effect = a researcher's cognitive bias causes them to subconsciously influence the participants of an experiment

DI Podcast Main Document 311 ● e.g. investigator inadvertently conveys his high expectations to subjects, who then produce the expected result ● Also called “observer-expectancy bias” ○ Solutions? ■ Blinding

● Lead-time bias = confusing early detection with increased survival ○ Example: Cancer X causes death 10 years after the first mutation. If we detect it at year 5, the person will live for 5 years after diagnosis. If we detect it at year 3, the person will live for 7 years after diagnosis BUT patients will still die 10 years after the first mutation. ■ If we detect it at year 3 and give tx, then the person lives for 17 years, this is true benefit NOT lead-time bias

● Length-time bias = late-look bias = you never come in contact with the worst cases of a given disease ○ People with really severe disease die before screening test. Those who are screened have more indolent disease, so it looks like screening saves lives. ○ Example: Collecting data on people with brain cancer. You notice that patients just have headache and no neuro deficits, still completing ADLs. You don’t come into contact with pts with very aggressive disease, like rapidly fatal GBMs. ○ Solution? ■ Stratify by disease severity● Recall bias ○ Especially relevant to case-control studies ○ Example: Mothers of children with birth defects are likely to remember drugs they took during pregnancy than mother of normal infants ○ Ways to mitigate? ■ Reduce length of time between exposure & recall ■ Corroborate the information the pt gives

● Confounding ○ You want everything to be the same between groups except the intervention, so that any difference will be likely due to the intervention ○ Confounder = anything beside the intervention that accounts for the difference between the control & intervention groups ■ A third factor that is either positively or negatively associated with both the exposure and outcome ○ Example: sunburn is associated with increased ice cream consumption (confounder = summertime sun exposure) ○ Example: BP drug is being compared to placebo. Intervention group BP went down by 20 points, control group BP went down by 5 points. However, there is a much higher % of obesity than in the control group. When you stratify by BMI, there is no difference in BP reduction. → obesity is a confounding factor ○ If stratification eliminates difference → confounder

● Effect modification DI Podcast Main Document 312 ○ If stratification doesn’t erase effects → effect modification ○ Example: When you stratify by BMI, the difference in BP reduction is still present. Implies that there’s something about obesity that makes the drug more effective in that population. ○ Example: The increased risk of cancer in smokers is even higher among those who also drink heavily.-------------------------------------------------------------------------------------------------------------------------------Ep. 204: Military Part 1Classify TBI (traumatic brain injury) by severity using GCS → ≥13 mild TBI, 9-12 moderate, ≤8 severe TBI.Pathognomonic → diffuse axonal injuryAnterior temporal lobes + orbital frontal cortex most susceptible to damage in TBI.

1. N-Acetyl Cysteine → to TBI pts to prevent complications 2. Tranexamic acid within first 3 hrs to pts of TBI (traumatic brain injury) 3. Hyperventilation is the fastest measure to lower ICP but can only be used for short term 4. Mannitol can be used as well to lower ICP, but is contraindicated in CHF. Hypertonic saline is another option but risks hypernatremia. 5. NEVER give steroids in traumatic brain injury 6. Keep TBI patients normothermic 7. Central diabetes insipidus can occur after TBI 8. Most common cognitive impairment after TBI- memory loss 9. After discharge from hospital for TBI → send pt to rehab 10. Post concussive syndrome → neuropsych symptoms in a post TBI (mild) pt → headache, dizziness, inc sensitivity to light and sound, anxiety, depression 11. Second impact syndrome → a second ep of TBI after a mild TBI → persistently vegetative or die 12. PTSD (post traumatic stress disorder)→ alcohol abuse is very common post PTSD, Rx SSRIs (sertraline, fluoxetine, paroxetine), venlafaxine; pts tend to have distress, autonomic hyperactivity on re experiencing triggers; it usually arises from an interpersonal trauma vs natural disaster (eg. rape vs earthquake) 13. 4 months pharm Rx does NOT apply to ASD (acute stress disorder, where symptoms last <1 month) 14. CBT (cognitive behavioral therapy) of choice for PTSD, OCD, specific phobias→ exposure therapy 15. eye movement therapy ? (asked us to look up on google) 16. Do not give benzodiazepines to PTSD especially in veterans (coz it worsens it) 17. small volume of hippocampus seen in → PTSD 18. exaggerated response to dexamethasone suppression test seen in → PTSD pts 19. PTSD pts → abnormal low cortisol and high catecholamines in urine due to a maladaptive hyperadrenergic response 20. Don’t pick debriefing (a meeting to question someone, typically a soldier or spy, about a completed mission or undertaking) as a treatment for PTSD 21. military sexual trauma W >> M→ is the biggest risk factor for PTSD among servicemen/women

DI Podcast Main Document 313 22. Poor mental heath in family, behavorial disorders in children, high risk of suicide, divorce etc in families of deployed servicemen/women; better outcomes w/ pre-deployment planning (medical insurance etc.), communication with family while deployed 23. homelessness is very common in veterans 24. MC comorbidity in veteran is substance use disorder (commonly alcohol) 25. Highest risk can be decades after service 26. For PTSD nightmares use prazosin

CROSS CHECKED? YES, yes

-------------------------------------------------------------------------------------------------------------------------------Ep. 206: Family Medicine Shelf Review Series 1

Thyroid Disorders

● Able to palpate pt’s thyroid nodule on physical exam. ○ NBS? order TSH level ○ Low TSH = hot nodule = low risk of thyroid cancer ■ NBS? RAIU scan ● Single hot spot = toxic adenoma ● Multiple hot spots = toxic multinodular goiter ● Diffusely increased uptake → Grave’s disease ○ Normal TSH or high TSH = cold nodule ■ Usually benign (70-75% cases are colloid cysts), but some are malignant ■ NBS? Thyroid US w/ FNA to check for thyroid cancer

● Papillary thyroid carcinoma ○ Histology? Psammoma bodies, Orphan Annie eye nuclei ○ #1 RF? Hx of head/neck radiation ○ Spread? Lymphatic spread ○ Best prognosis ○ ● Follicular thyroid carcinoma ○ Spread? Hematogenous

● Medullary thyroid carcinoma ○ Histology? Amyloid, apple green birefringence on Congo red stain ○ Poor prognosis ○ Paraneoplastic syndrome? Hypocalcemia 2/2 increased calcitonin levels produced by tumor ■ EKG finding? prolonged QT interval ○ Clinical picture: Pt with neck mass + multiple relatives diagnoses with thyroid cancer → medullary thyroid carcinoma 2/2 MEN2A or MEN2B syndrome ■ This pt’s relatives have medullary thyroid carcinoma DI Podcast Main Document 314 ● Thyroid biopsy is full of lymphoid follicles → Hashimoto’s thyroiditis ○ Also known as? Lymphocytic thyroiditis ○ #1 cause of hypothyroidism in United States ■ Sxs: Bradycardia + fatigue + weight gain + hair loss + high cholesterol ■ Note: initially causes increased T3/T4 but eventually causes decreased T3/T4 ○ Progresses to what cancer? thyroid lymphoma ■ Sxs: pt with hx of Hashimoto thyroiditis has enlarging thyroid mass

● Hypothyroidism sxs = bradycardia + fatigue + weight gain + hair loss + high cholesterol

● Hyperthyroidism sxs = tachycardia + weight loss + heat intolerance + insomnia + irritability

● Pt with hyperthyroid sxs + low TSH + low uptake on RAIU scan → factitious hyperthyroidism (i.e. pt taking exogenous thyroid hormone) ○ Pathophys? Excess exogenous T3/T4 levels suppress endogenous TSH production

● Pt with tender/painful thyroid + low TSH + low uptake on RAUI scan → Subacute/deQuervain’s thyroiditis ○ Pathophys? Diffuse inflammatory process at thyroid glands causes release of preformed thyroid hormone into circulation

● How to DDx Subacute Thyroiditis vs. factitious hyperthyroidism (excessive exogenous thyroid intake)? ■ Subacute/DeQuervain's thyroiditis = high thyroglobulin levels ■ Exogenous thyroid hormone = low thyroglobulin levels ■ Thyroglobulin is the “c-peptide” of the thyroid (i.e. akin to how C-peptide is measured to check for exogenous insulin use)

● Newborn with umbilical hernia + macroglossia → congenital hypothyroidism ○ MC cause? Thyroid dysgenesis

● MEN 1 = “3 P’s”: pituitary adenoma + pancreatic endocrine tumor + hyperparathyroidism ○ Pituitary adenoma, e.g.: ■ Prolactinoma → gynecomastia (in men), galactorrhea (in women), infertility ■ GH-secreting pituitary adenoma → acromegaly (enlarging head/hands/feet in adult) ○ Pancreatic neuroendocrine tumors, e.g.: ■ Insulinoma ■ Glucagonoma → new-onset DM + rash (necrolytic migratory erythema) ■ Gastrinoma → Zollinger-Ellison syndrome → jejunal ulcers ■ VIPoma → WDHA syndrome (watery diarrhea + hypokalemia + achlorhydria) ○ Primary hyperparathyroidism

● MEN2A – “2 P’s”: primary hyperparathyroidism + pheochromocytoma + medullary thyroid carcinoma ○ Primary hyperparathyroidism ○ Pheochromocytoma → episodic HA + HTN DI Podcast Main Document 315 ■ Dx? Increased urine metanephrines ● NBSIM? CT abdomen or MIBG scan ○ Medullary thyroid carcinoma

● MEN2B – “1 P”: pheochromocytoma + medullary thyroid carcinoma + mucosal neuroma + marfanoid habitus ○ Pheochromocytoma ○ Medullary thyroid cancer ○ Mucosal neuromas ○ Marafanoid habitus

● 4 indications for statin tx: 1. LDL ≥ 190 2. Hx of ASCVD (e.g. MI, CAD, stroke, PAD) ■ ASCVD = atherosclerotic cardiovascular disease + 3. 40 y.o. + diabetes mellitus + LDL >70 4. 40+ y.o. + ASCVD risk > 7.5%

● Which 2 statins are “high-intensity statins”? Atorvastatin, Rosuvastatin ○ High-intensity statins given in specific dosing and reduce LDL by ≥ 50% ■ Atorvastatin (40 or 80 mg qday) ■ Rosuvastatin (20 or 40 mg qday)

Vitamin & Mineral Deficiencies:

● Vitamin B1 aka thiamine deficiency = Wernicke-Korsakoff syndrome or wet beri-beri ○ Wernicke-Korsakoff syndrome ■ Pathophys? Depletion of Vit. B1 → issues with transketolase in TCA cycle and pentose phosphate pathway ● Transketolase enzyme uses Vit. B1 as cofactor ■ Triad: confusion + ataxia + ophthalmoplegia → Wernicke encephalopathy ● Tx? IV thiamine then glucose ● Reversible ● Note: “ophthalmoplegia” can be any eye problem, e.g. nystagmus, lateral gaze palsy, etc. ■ Confusion + ataxia + ophthalmoplegia + amnesia + confabulation → Korsakoff syndrome ● Complication of untreated Wernicke encephalopathy ● Irreversible ■ Populations at risk? ● Alcoholics ● Pregnant woman with hyperemesis gravidarum ○ Hypokalemic hypochloremic metabolic alkalosis ○ Pathophys? Vomiting triggers RAS activation → H+ & K+ excretion

DI Podcast Main Document 316 ■ Neuroanatomical association/pathology? Hemorrhagic infarction of mammillary bodies

○ Wet beri-beri = dilated cardiomyopathy

● Vitamin B2 = riboflavin

● Vitamin B3 aka niacin deficiency ○ Pellagra = diarrhea, dermatitis, dementia, death ■ Dermatitis on hands + around neck (necklace-like rash) ■ Etiologies: ● Dietary deficiency ● Carcinoid syndrome ○ Pathophys? Carcinoid tumor produces excess serotonin → shunts tryptophan to serotonin production instead of niacin production ■ Note: tryptophan = precursor for serotonin and niacin ● Hartnup disease ○ Pathophys? Defect in neutral amino acid transporter in PCT → cannot reabsorb neutral amino acids (tryptophan is a neutral a.a.)

● Vitamin B6 aka pyridoxine deficiency ○ What drug causes Vit B6 deficiency? Isoniazid treatment for Tb ○ What 3 pathologies result from Vit B6 deficiency? Sideroblastic anemia, seizures, abnormal LFT’s ■ Sideroblastic anemia ● Pathophys? ALAS enzyme rxn cannot run → heme production halted ○ ALAS = rate-limiting enzyme for heme synthesis and requires Vit B6 as cofactor ■ Seizures ● Pathophys? GABA deficiency, i.e. lack of inhibitory n.t’s → unopposed excitatory n.t. activity ○ Normally: glutamate decarboxylase requires Vit B6 as a cofactor to convert glutamate to GABA ○ Glutamate decarboxylase cannot run In Vit B6 deficiency → GABA deficiency ■ Abnormal LFTs ● Pathophys? Transaminases unable to function properly (b/c transaminases normally use Vit B6 as cofactor) ● Results in AST/ALT > 2 ○ Note: same finding as LFTs seen in alcoholics b/c alcoholics often have Vit. B6 deficiency ☺

● Vitamin Vit B9 aka folate deficiency ○ What 2 pathologies result from Vit B9 deficiency? Megaloblastic anemia, neural tube defects ■ Megaloblastic anemia DI Podcast Main Document 317 ● High hom*ocysteine, normal MMA ■ Neural tube defects ● Folate is in prenatal vitamins to prevent NTD’s ○ Populations at risk? ■ Tea & toast diet/malnutrition ■ Alcoholics ■ Pts on anti-seizure drugs, esp. valproate

● Vitamin B12 aka cobalamin deficiency ○ What 2 pathologies result from Vit B12 deficiency? Megaloblastic anemia, subacute combined degeneration ■ Megaloblastic anemia ● Labs show? Elevated hom*ocysteine + elevated methylmalonic acid ● In odd-chain fatty acid pathway, methylmalonyl-CoA mutase converts methylmalonyl-CoA to succinyl-CoA by using B12 as a cofactor ○ So, MMA build ups up in Vit. B12 deficiency ■ Subacute combined degeneration of spinal cord ● Loss of dorsal columns → loss of vibration, proprioception, light touch ● Loss of corticospinal tract → UMN lesion signs (e.g. hyperreflexia) ○ Populations at risk? ■ Vegans (B12 comes from animal products)

● Dysgeusia + alopecia → zinc deficiency ○ Etiologies? ■ TPN use (total parenteral nutrition) ■ Wilson’s disease tx’ed with trientine ● Trientine chelates copper and zinc

● Mucosal bleeds + fatigue/weakness + muscle aches → Vit C deficiency (scurvy) ○ Pathophys? Body unable to do collagen synthesis (specifically, unable to do hydroxylation of proline & lysine)

● Night blindness → Vit A deficiency

● Osteoporosis + secondary hyperparathyroidism → Vit D deficiency ○ Pathophys? Decreased Vit. D causes decreased Ca2+ absorption from intestines → increased PTH levels in response to low serum Ca2+ levels

● Acanthocytosis on blood smear + ataxia → Vit E deficiency ○ Pathophys? Demyelination of spinocerebellar tracts ■ Myelination of spinocerebellar tracts requires Vit E● Bleeding problems → Vit K deficiency

● Fat malabsorption causes deficiency of fat-soluble vitamins (Vitamins ADEK) ○ Etiologies? DI Podcast Main Document 318 ■ Crohn’s, esp. if terminal ileum is resected ■ Cystic Fibrosis → pancreatic insufficiency ■ Celiac disease ■ Chronic pancreatitis

Cross checked: Yes-------------------------------------------------------------------------------------------------------------------------------

Ep. 207: Geriatrics 1. Check vision, hearing, fall risk, ur. incontinence 2. Polypharmacy- review meds 3. BEERS criteria 4. Look out for Elderly abuse 5. Assess functional ability- assess ADLs 6. Basic and instrumental ADLs (things that you need to live independently vs things that you need to interact w/ society) 7. MMSE to evaluate cognitive functioning ( abN <24) 8. Mini-Cog--> tell pt a series of words then draw a clock then recall the words 9. Check TSH, B12, meds, S. Na, BNP if they have cognitive dysfunction 10. MCC of hearing loss in elderly → presbycusis (high freq hearing loss first) 11. Best screening test to determine hearing loss-> take history then whispered voice test then audiometry 12. Access for Presbyopia, macular degeneration, cataracts 13. Rule out depression in the elderly esp in CKD, stroke, CAD pts; older pts have a greater risk of suicide than younger 14. We don’t always use SIGECAPS for elderly; instead ask have you felt depressed/sad/low and ask have you lost interest in the past 2 wks? 15. SSRI is D.O.C. do NOT pick TCA (coz of S/E profile) 16. Fall risk assessment→ ask for h/o problems w/ gait or balance, do a get up and go test (normal is 10-11sec, abN is >20 sec) 17. Interventions that dec fall risk-> exercise, physiotherapy, Vit D supplementation 18. Urge incont./ overactive bladder (hypertonic detrusor)-> bladder training is the best Tx, biofeedback, oxybutynin, tolterodine (best avoided in elderly) 19. Elderly women, G6P6 (multiple deliveries)-> Keigel’s exercise, sling procedure 20. Overflow incont. (hypotonic detrusor)-> self catheterization, timed voiding 21. Functional incont. (cognitive problems or arthritis where they can’t move fast enough)--> need caregiver 22. Living will aka Advanced Directive 23. Health care proxy (DPOA) 24. POLST forms--> a health care provider has to be present when pt is signing this 25. Palliative care < 6 mos prognosis--> initiate Hospice care DI Podcast Main Document 319 26. Elderly pt driving h/o mild dementia or is taking benzo, TCA or h/o vision problems or h/o falls, ambulation issues, degenerative dz who can have trouble moving neck side to side-> report to DMV 27. Pressure ulcer--> old pt, sensory issues, chrn illness, stool or ur incontinence, vascular dz all RF for developing Pressure/ Decubitus Ulcer. To prevent it, reduce pressure points by using air beds, reduce friction, reduce shearing forces; 4 stages: stage 1- erythema on skin, non blanchable; stage 2- lose partial thickness of skin epi and dermis; stage 3- subcut tissue is exposed but no involvement of fascia/bone/musc/tendon; stage 4 – involvement of fascia, muscle, tendon or bone; give them as much nutrition as possible, consider debridement for stage 3 and 4 ulcer, apply occlusive dressings 28. Surrogate decision maker--> use next of kin (spouse then adult children then parents then siblings then other relatives)

Cross checked? NO

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Ep. 212: Family Medicine Shelf Review Series 3 (GI)

Hepatocellular Pattern Cholestatic Pattern of Liver Injury of Liver Injury Labs ● ↑↑ AST/ALT >> AP/GGT ● ↑↑ALKP/GGT >>AST/ALT ● Direct hyperbilirubinemia

Note: In hepatocellular pattern, Note: In cholestatic pattern, AST/ALT is disproportionately ALKP/GGT is disproportionately elevated compared to ALKP/GGT elevated compared to AST/ALT

Etiologies ● APAP toxicity ● Biliary tree pathology ● Alcoholic hepatitis ● Hemolytic anemia ● HAV ● Gilbert syndrome

Tx ● Liver transplant if MELD ● N/A score >18 or Marjorie score > 32

● Alcoholic + AST:ALT ratio > 2:1 + ↑PTT and ↑PT/INR → Alcoholic Liver Disease ○ Tx? steroids (and liver transplant if needed) ■ Steroids preserve liver function

DI Podcast Main Document 320 ● Criteria to get liver transplant? MELD score 18+ or Marjorie score 32+

● Jaundice + ↑ ALKP/↑GGT + recent illness/surgery/fasting → Gilbert Syndrome ○ Indirect hyperbilirubinemia ○ Benign → supportive tx only

VIRAL HEPATITIS ● Very acute-onset + RUQ pain + jaundice + ↑ AST/ALT (in 1000’s) + trip to Mexico = HAV ○ NBSIM? Check Anti-HAV IgM ■ Remember: IgM = acute infection ○ Tx? supportive ○ Prevention? HAV vaccine for those with RF’s ○ Risk Factors? ■ Travel to endemic area (Mexico) ■ IVDU ■ Cirrhosis ■ Hemophilia ■ MSM ● HBV ○ Transmission? blood (needle stick), birthing, bonking ○ HBV Serologies

SUMMARY OF HBV SEROLOGIES

● HBsAg + anti-HBc IgM = acute infection ● HBeAg + anti-HBc IgM = window period ● HBsAg + anti-HBc IgG = chronic infection ● Anti-HBs + anti-HBc IgG = resolved infection ● Anti-HBs Ab only = vaccinated

DI Podcast Main Document 321 Type of HBV Infection HBsAg Anti-HBs Ab HBeAg Anti-HBe Ab Class of HBc Ig

Acute HBV + - + - IgM

Window Period - - + - or + IgM

Chronic HBV + - + - IgG(high infectivity/active)

Chronic HBV + - - + IgG(low infectivity/inactive)

Resolved Infection - + - - IgG

Vaccinated (immunized) - + - - -

○ General Rules for HBV Serology ■ +HBsAg = current infection ■ How to DDx acute vs chronic infection? Check whether anti-HBc is IgM vs IgG ■ HBsAg + anti-HBc IgM = acute infection ■ HBsAg + anti-HBc IgG = chronic infection ■ +anti-HBs Ab = vaccinated or recovered ■ How to DDx if vaccinated vs recovered? Check for anti-HBc Ab ■ Anti-HBs Ab + anti-HBc Ab = recovered ■ Anti-core Ab only obtained from actual infection ■ +HBeAg + anti-HBc IgM = window period ○ Tx: ■ Needle-stick + unvaccinated → HBV vaccine + IVIG ■ Needle-stick + vaccinated → nothing (no post-exposure PPx needed!) ■ Adults → supportive tx only (most people clear infection) ■ Chronic HBV → entecavir (or tenofovir) or pegylated IFN-alpha ■ Entecavir or tenofovir are c/i in pregnancy

DI Podcast Main Document 322 ■ Pegylated-IFN-alpha is c/i in MDD, cirrhosis with many complications, cytopenias (e.g. neutropenia, leukopenia, thrombocytopenia, anemia) ■ HIV pt’s → emtricitabine + tenofovir ○ Prevention? Vaccine at childbirth (3-series) ■ Note: babies who contract HBV develop chronic HBV ○ Classic associations in which vignette says “pt has a history of HBV” in order to help you diagnose an associated disease ■ Polyarteritis Nodosa (PAN) ■ PAN = chronic abd. pain + asymmetric neuro deficits + ANCA-negative + segmental transmural inflammation on renal angiography + history of HBV ■ Membranous Nephropathy ■ Membranous Nephropathy = nephrotic syndrome● HCV ○ Dx? Anti-HCV Ab then HCV RNA (Type 1 in US) ■ Anti-HCV Ab plus positive HCV RNA = active viral replication → so Tx! ■ If pt only has Anti-HCV Ab but no positive HCV RNA, then they once had an HCV infection but cleared it ○ Tx: sofosbuvir or simeprevir ■ NBSIM before starting anti-HCV drugs? Check for HBV infection before starting anti-HCV drugs ○ RF ■ Born in 1945-1965 ■ Blood transfusions ■ IVDU ■ Mixed cryoglobulinemia (Raynaud’s phenomenon + cold agglutinins) ■ Porphyria cutanea tarda (UROD enzyme deficiency) ○ Sequelae: ■ Leukocytoplastic vasculitis (h/o HCV + palpable purpura on feet) ■ HCC ■ NBSIM? U/S q 6 months to screen for HCC ■ HBV superinfection

DI Podcast Main Document 323 ● RUQ pain + ↑ AST/ALT + ANA+ + h/o autoimmune disease → Autoimmune hepatitis ○ RF: other autoimmune disease (e.g. Hashimoto) ○ Dx? ■ Type 1 Autoimmune Hepatitis = anti-Sm Ab’s ■ Type 2 Autoimmune Hepatitis = anti-LKM Ab’s ○ Tx? steroids or azathioprine

● ↑ IgG4 + sausage-shaped pancreas → autoimmune pancreatitis

● 65 yo M + erectile dysfunction + skin hyperpigmentation + new-onset DM + pseudogout + arthritis in shoulders/elbows/ankles → hemochromatosis ○ Pathophys? iron deposition in various organs → oxidation of iron causes destruction ○ Dx? Transferrin saturation ○ Tx? Phlebotomy (also the tx for polycythemia and porphyria cutanea tarda) ○ Inheritance? AD ○ Mutations? HFE gene (hom*ozygous C282Y mutation; or heterozygous C282Y-H63D mutation)

● Very obese + mildly ↑ AST/ALT + T2DM or HLD → NAFLD (non-alcoholic fatty liver disease) ○ RF: diabetes; HLD ○ Tx: tx underlying etiology/risk factor (e.g. tx T2DM or HLD)

● PBC and PSC

Primary Biliary Cirrhosis Primary Sclerosing Cholangitis

Demographic ● women 40-60 yo ● young men with ulcerative colitis

Location ● Intrahepatic bile ducts ● Intrahepatic + Extrahepatic bile ducts

Labs ● ↑ ALKP + ↑GGT ● ↑ ALKP + ↑GGT ● (cholestatic pattern) ● (cholestatic pattern) ● anti-mitochondrial Ab

DI Podcast Main Document 324 Diagnostic ● U/S ● Step #1: U/S Imaging o If biliary tree dilated, do MRCP or ERCP ● Step #2: MRCP or ERCP to diagnose and treat! annually o Imaging findings? "string of beads" (areas of dilation and strictures)

Tx ● Ursodiol aka ● Liver transplant (curative) ursodeoxycholic acid ● MRCP or ERCP to dilate strictures ● Replete Vit. ADEK as needed (a/w fat-soluble vitamin deficiency)

Follow-up ● N/A ● U/S q 6 months to screen for HCC ● Colonoscopy at time of PSC diagnosis then q 1-2y ● U/S to screen for cholangiocarcinoma

COMPLICATIONS OF CIRRHOSIS

Note: For all cirrhosis patients, get U/S every 6 months to screen for HCC!

Note: Skip to 00:28:35 – this section is based on order starting from 00:29:04

● Hepatosplenomegaly (2/2 portal HTN) ○ Labs? ↓ plt’s

● Excess bleeding (2/2 inability of liver to synthesize clotting factors )

● Cirrhosis + comatose or AMS ­→ hepatic encephalopathy

DI Podcast Main Document 325 ○ Pathophys? 2/2 NH4+ accumulation ○ Triggers of hepatic encephalopathy? Infection, GI bleed ■ What surgery also ↑ risk of hepatic encephalopathy? TIPS procedure ○ Tx? lactulose or rifaximin

● Cirrhosis + SOB + high A-a gradient → hepatopulmonary syndrome ○ Dx? echo

● Cirrhosis + SOB + high RV pressure → portal-pulmonary hypertension ○ Dx? Echo

● Cirrhosis + ↑ SCr → hepatorenal syndrome ○ Pathophys? Cirrhosis causes splanchnic vasodilation → this steals blood away from kidneys → kidneys become hypo-perfused ■ Cirrhosis leads to production of nitric oxide → nitric oxide causes venodilation of splanchnic vessels → ↓SVR → hypoperfusion of kidneys ○ Urine labs are same as what type of AKI? Pre-renal azotemia ■ FENa < 1% ■ BUN/Cr > 20

● Ca2+ , PO4-, and PTH levels in cirrhosis? ↓Ca2+ + ↓ PO4- + ↑ PTH ○ Pathophys? Liver unable to synthesize inactive 25-hydroxy-vit-D ○ Tx: calcitriol, bisphosphonate ○ Sequelae: osteopenia, osteoporosis, "secondary hyperpara"

● GI Bleed Management ○ Note: Tx is same for all major GI bleeds (whether upper or lower) ○ Tx? ■ Step #1: 2 large-bores IV’s

DI Podcast Main Document 326 ■ Step 2: Fluids (+ blood if Hb < 7) ■ Step 3: EGD – if you do not find bleed, go to step 4! ■ Step 4: Colonoscopy – if you do not find bleed, go to step 5! ■ Step 5: Tagged RBC scan ■ What meds do you also give in addition to the above steps? IV octreotide + PPIs ○ Summary of Tx for all major GI bleeds? 2 large-bore IV’s + fluids + IV octreotide + PPIs + imaging (EGD then colonoscopy then tagged RBC scan)

● Cirrhosis + low-grade fever + abdominal pain + ascites + strange behavior → Spontaneous bacterial peritonitis ○ Dx? Paracentesis with > 250 PMNs ○ Tx: albumin + ceftriazone (or cefotaxime) ■ PPx: FQ (in pt’s with ascites but not signs of infection)

● SAAG = [serum albumin] – [ascites fluid albumin] …Therefore, SAAG is only calculated if ascites is present! ○ SAAG < 1.1 indicates absence of portal hypertension ■ Etiologies: ● Malignancy ● Nephrotic syndrome ● Pancreatitis (pancreatic ascites) ● Tb ■ SAAG ≥ 1.1 indicates portal hypertension is present ● Etiologies: ○ Cirrhosis ○ Budd-Chiari syndrome ○ Right-sided HF (cardiac ascites) ○ Note: Per UW 2021 QID 4747, these are the correct answers

DI Podcast Main Document 327 ● HCC → so, monitor with U/S q 6 months

● Varices ○ Complication? Variceal Hemorrhage

● Ascites (2/2 ↓ albumin) ○ Tx: furosemide or serial paracenteses (give albumin if > 5L fluids drawn)

DI Podcast Main Document 328 ● Very abrupt increase in AST/ALT + comatose or altered mental status + APAP overdose → Acute liver injury ○ Dx? abrupt increase AST/ALT + known insult ○ Etiologies of acute livery injury? ■ APAP ■ Acute viral hepatitis ■ Amanita mushrooms ■ Systemic hypotension (i.e. "shock liver") ○ Tx? ■ APAP overdose → N-acetylcystein ■ Amanita mushroom poisoning → Penicillin G

● ↑ AST/ALT + psych sxs + Parkinsonism + Kayser-Fleisher rings → Wilson's disease ■ Parkinsonism = choreiform movements ○ Dx? ↓ serum ceruloplasmin ○ Tx: ■ Penicillamine ■ Trientine ■ AE? Zinc deficiency (chelates both copper and Zinc)

PREGNANCY-RELATED GI PATHOLOGIES

● 1st trimester of pregnancy + severe vomiting + ↑AST/ALT → Hyperemesis gravidarum ○ Tx: ■ Inpatient: hydration + anti-emetics + IV thiamine ■ Why thiamine? b/c at risk for Wernicke encephalopathy ■ Outpatient: B6 + doxylamine o Sequelae: Wernicke's encephalopathy

● 2nd or 3rd trimester of pregnancy + pruritus + ↑ ↑ ALT + ↑ ↑ AP → Intrahepatic cholestasis

● 3rd trimester of pregnancy + BP > 140/90 mmHg + proteinuria → pre-eclampsia DI Podcast Main Document 329 ○ Tx? Deliver baby + IV Mag (seizure PPx)

● 3rd trimester of pregnancy + hemolysis (indirect hyperbilirubinemia) + elevated liver enzymes + low platelets → HELLP syndrome ○ Note: hemolysis always causes indirect hyperbilirubinemia

● 3rd trimester of pregnancy + rapid-onset + many abnormal liver labs + coma or encephalopathy → acute fatty liver of pregnancy ○ Abnormal liver lab include: indirect bili, ↑AST/ALT, ↑PTT, ↑PT/INR

● How to DDx HELLP syndrome vs. acute fatty liver of pregnancy? ○ Acute fatty liver of pregnancy causes coma and encephalopathy ■ HELLP syndrome does not!

OTHER GI PATHOLOGY

● RUQ pain + ↑ AST/ALT + fever + no jaundice + U/S shows thickened gallbladder wall with pericholecystic fluid → Cholecystitis ○ Dx? U/S ○ Tx? cholecystectomy

● Intermittent RUQ pain + no stones on U/S abdomen → biliary sludge

● RUQ pain + jaundice + 104º fever + low BP → ascending cholangitis ○ Tx: emergent ERCP + broad-spectrum abx ○ Demographic? ICU patients

● Critically-ill + RUQ pain + fever + gallbladder wall thickening and pericholecystic fluid without gallstones on imaging studies → acalculous cholecystitis ○ Demographics? ■ Elderly

DI Podcast Main Document 330 ■ TPN nutrition ■ S/p surgery ■ ICU patients ○ Dx? U/S ○ Tx: cholecystostomy · Epigastric pain that radiates to back + ↑ amylase/lipase (3-4x ULN) → acute pancreatitis o Tx? NPO + pain control + IVF o RANSOM Criteria

● RUQ pain + purulent vagin*l discharge + adnexal tenderness → Peri-hepatitis aka Fitz-Hugh-Curtis syndrome o Tx: ceftriaxone + azithromycin (or doxy)

● Jaundice + dilated common hepatic duct + stone in cystic duct → Merizzi syndrome ○ Dx? U/S ○ Imaging finding? Stone in cystic duct plus common hepatic duct dilation ○ Note: In contrast, acute cholecystitis = cystic stone but no jaundice

DI Podcast Main Document 331 ● Intermittent vomiting + hyperactive bowel sounds + dilated loops of bowel + pneumobilia → gallstone ileus aka cholecysto-enteric fistula ■ Pneumobilia = air in biliary tree ■ Gallstone ileus = hepatobiliary cause of small bowel obstruction ○ Pathophys? Gallstone blocks ileum; pneumobilia is d/t air from ileum going into biliary tree

● Elderly + painless large-volume blood on defecation + light-headed + HDUS → diverticulosis o Dx? Barium study or CT scan

● 65+ yo + anemia + positive FOBT = colon cancer o Dx? Colonoscopy

● Pt w/ AFib + sudden-onset severe abdominal pain → acute mesenteric ischemia ● Pt w/ aortic stenosis + microcytic anemia + bloody stools → Heyde Syndrome ○ Pathophys? vWF multimers are cleaved by stenotic aortic valve → prevents 1º hemostasis → results in GI bleed

● Pt w/ telangiectasias + recurrent epistaxis + skin discoloration + AV malformations + GI bleeding + hematuria → HHT o Telangiectasias commonly on lips

o CROSS CHECKED: Yes

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Ep. 213: Family Medicine Shelf Review Series 4 (GI)ep 213 notes were graciously provided by Divine Intervention from an anonymous contributor. ● Difficulty swallowing, lost weight NBS: EGD o Alarm symptoms: lost weight, dysphagia, odynophagia, max medical therapy w/o improvement, >50Y ● Difficulty initiating swallowing NBS: video fluoroscopy ~ barium swallow o Dx: Oropharyngeal dysphagia (assoc w neuromuscular dz) ● Regurgitation of undigested food, halitosis: Zenker's diverticulum o Et: cricopharyngeal muscle dysfx o Dx: Barium swallow o c/I EGD d/t r/o perforation ● Dysphagia to solids and liquids (decreased peristalsis): achalasia = esophageal motility disorder o RF: Chagas disease ("traveled to S America") o Dx: barium swallow ("birds-beak sign") 2. esophageal manometry 3. EGD (r/o pseudo-achalasia!) ● c/b SCC of esophagus ^^

DI Podcast Main Document 332 ● c/I pneumatic dilation --> perforation of esophagus! o Tx: CCB, botox, surgical myotomy + PPI● Heartburn, cough worsened in morning, hoarseness, asthma-like sx: GERD o NBS/Tx (if no alarm sx): PPI ● *GERD + ANY other sx --> EGD o Dx: 1. EGD 2. Esophageal pH monitor o c/b: Barrett's esophagus ● Tx: endoscopic resection + ablation, PPI ● F/u: routine EGD q6-12mo● Esophageal adenocarcinoma o RF: ● 1. Barrett's esophagus ● 2. GERD ● *pick the answer most directly related to question at hand! o Alcohol, smoking, long-standing GERD in a man --> screening EGD● Odynophagia, HIV: Candidal esophagitis o *may not always present with thrush o Tx: -azole lozenges, nystatin swish 'n swallow o MCC esophagitis! ● Candida ● CMV ● TX: ganciclovir, foscarnet ● HSV ● Tx: acyclovir/valacyclovir, foscarnet● Bisphosphonates, tetracycline, ibuprofen, NSAIDs, potassium, iron tablets: pill-induced esophagitis o Tx: drink lots of water/supportive care● Young pt with dysphagia, GERD: eosinophilic esophagitis o Dx: EGD "crap ton of eosinophils" o Tx: corticosteroid therapy● Bloating, burning, gnawing in epigastrium, feel full early (!): peptic ulcer disease o Et: H. pylori, NSAIDs ● Dx: urea breath test, stool antigen test, (antibody test suboptimal) ● Tx: "CAP" or "MBTP" o NBS: test for H. pylori o C/b: perforation, hemoptysis (esp if ulcer erodes gastroduodenal artery yikes!) o + alarm sx! --> EGD● Chronic steroid therapy? Requires bisphosphonates + PPI ppx o Et: steroids --> gastric acid production --> ulcers o Et: steroids --> avascular necrosis● Diabetic, early satiety: gastroparesis o Other causes: hypothyroidism, scleroderma, chronic opioid therapy, daily diphenhydramine o Tx: erythromycin (motilin-receptor agonist), metoclopramide (dop-antagonist ae: parkinsonism) ● -LOL this is why macrolides cause diarrhea-● Weight loss surgery, cramping pain, nauseous, sweating, light-headed: dumping syndrome o Tx: smaller meals more frequently, low-carb (prevent hyper-insulinemia)● Sudden-onset pain in epigastrium going to back: pancreatitis! o RF: EtOH, gallstones (4 F's), familial hypertriglyceridemia (>1000), stavudine, didanosine, valproic acid, CF, hypercalcemia, GLP-1 agonist o Dx: 2/3 severe abd pain, lipase 3x normal, CT o Tx: pain control, IVF DI Podcast Main Document 333 o F/u: Ranson's criteria (CA HOBBES)

● o C/b: pancreatic pseudocyst, chronic pancreatitis (tx: supplementation of fat-soluble vitamins + enzymes), peri-pancreatic abscess ● Hypothyroidism, Graves disease, vitiligo, Addison's///autoimmune "crap" with recurrent epigastric pain: autoimmune pancreatitis o Et: IgG4 = pancreatitis, cholecystitis, retroperitoneal fibrosis o Dx: CT scan "sausage-shaped pancreas" o Tx: corticosteroids

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Ep. 214: Family Medicine Shelf Review Series 5 - GI ● Pt with 1 week of bloody diarrhea + RLQ pain → Yersinia enterocolitica ○ Can cause an pseudoappendicitis

● AIDS pt with chronic watery diarrhea → cryptosporidium ○ Histology? Acid-fast oocysts in stool

● Diarrhea in pt with recent abx, recent hospitalization, lives in nursing room → C. diff

● MC cause of diarrhea? Viral (norovirus)

● Pt who is avid hiker or has IgA deficiency, now with foul-smelling watery diarrhea → Giardia ○ Dx? Stool antigen testing ○ Tx? metronidazole

● Pt from developing country with blood diarrhea + liver abscess → Entamoeba histolytica ○ Tx? Metronidazole

● EHEC ○ Strain? O157:H7 ○ Tx? No abx!

● Do not give antidiarrheals (e.g. loperamide) for pt’s with blood diarrhea! ○ Loperamide causes increases risk of HUS in pt’s with EHEC DI Podcast Main Document 334 ○ Loperamide causes increases risk of toxic megacolon in pt’s with C. diff

● Chronic diarrhea + fat malabsorption → consider Crohn’s

● Stool osmotic gap = 290 - 2*(Na+K) ○ Low (<50) stool osmotic gap → lots of electrolytes in the stool → secretory diarrhea ■ Carcinoid syndrome ● Presentation? Flushing + watery diarrhea ● Dx? Urine 5-HIAA ■ VIPoma ■ Cholera ○ High (>100) stool osmotic gap → osmotic diarrhea ■ Lactase deficiency● Pt with low BMI, body-image issues. Stool osmolarity < 250 → laxative use

● Pt with recurrent bouts of pneumonia/sinusitis + chronic diarrhea 2/2 giardia → IgA deficiency, CVID, or CF ○ CF - sxs from birth ○ IgA deficiency - sxs can start in 20s/30s

● Pt eating lots of sugar-free candy has bloating + diarrheal eps → diarrhea 2/2 artificial sweeteners (osmotic agents)

● Pt who has bloating & diarrhea after eating. No alarm sxs. → consider lactase deficiency

● Young pt with bloating/dyspepsia + sxs improve with defecation + changes in BMs. No weight loss. No lab abnormalities → IBS ○ IBS-C tx ■ Lubiprostone ■ Linaclotide ○ IBS-D tx ■ TCA (e.g. imipramine) ■ Loperamide ■ Alosetron ● Serotonin antagonist ● Effective, but associated with ischemic colitis

● Middle-aged women with chronic diarrhea. No association with food. Colonoscopy normal. → microscopic colitis ○ Associated meds? ■ NSAIDS ■ PPIs ○ Tx? ■ Oral budesonide ■ Loperamide DI Podcast Main Document 335 ● 25 yo pt with chronic diarrhea + fat malabsorption + microcytic anemia → celiac disease ○ Pathophys? Autoimmune attack → damaged villi → impaired absorption of iron in the duodenum ○ Ab? ■ anti-tTG ■ anti-gliadin ■ anti-endomysial ○ Dx? tTG IgA ■ If positive, EGD with bx ■ If negative, get tTG IgG (IgA deficiency is common in pts with celiac) ○ Tx? Gluten-free diet ■ MC cause of failure to respond to therapy? Non-adherence ■ Decreases the risk of small bowel lymphoma! ○ Skin finding? Dermatitis herpetiformis (vesicular rash on extensor surfaces) ■ Tx? Dapsone ○ MSK complication? Osteoporosis ■ Pathophys? Can’t absorb Vit D and calcium ■ Dx? DEXA ○ Neoplastic complication? small bowel lymphoma, i.e. EATL (enteropathy-associated T-cell lymphoma) ○ Other comorbid autoimmune diseases? ■ T1DM ■ Hashimoto’s ● Presentation? Pt taking Synthroid but isn’t getting better because it’s not getting absorbed well ○ Ileum involvement → fat-soluble vitamin deficiencies ■ Vit A deficiency → night blindness ■ Vit D deficiency → Rickets/osteomalacia ■ Vit E deficiency → acanthocytosis, ataxia ■ Vit K deficiency → bleeding issues

● Pt with heavy alcohol use hx. Stopped drinking 3 years ago. High blood glucose. → chronic pancreatitis / pancreatic insufficiency ○ Dx? Check stool for fat content ○ Imaging? Calcifications in pancreas on imaging ○ Tx? Pancreatic enzyme replacement

● Pt has macrocytic anemia + hx bowel resection / scleroderma / DM gastroparesis → consider small intestinal bacterial overgrowth (SIBO)

● Middle-aged man with diarrhea/abdominal pain/weight loss + joint pain + cardiac problems + eye problems → Whipple’s disease ○ Dx? EGD w/ bx ○ Tx? 1 year of abx

DI Podcast Main Document 336 ● Pt travels to Puerto Rico and returns. Has been having chronic diarrhea + fatty stools + weight loss → tropical sprue ○ Tx? ■ Abx? Bactrim or tetracyclines ■ Folate

● Young person with bloody diarrhea. Sxs improves with smoking → Ulcerative colitis ○ Histology? Crypt abscesses ○ Affected areas? Colon + rectum ○ Dx? Colonoscopy ○ Colonoscopy findings? ■ Pseudopolyps ■ Continuous areas of inflammation ○ Tx? ■ Acute flare: steroids ■ Maintenance: salicylates (e.g. sulfasalazine, mesalamine) ■ If medical management fails? Proctocolectomy (remove colon and rectum) ○ Associated hepatobiliary disorder? PSC ■ Pathophys? Affected intrahepatic & extrahepatic bile ducts ■ Lab findings? Direct hyperbilirubinemia, alk phos high, GGT high ■ Marker? p-ANCA

● Pt with watery diarrhea + abdominal pain + fevers + fistulas (stool coming out of skin; stool in urine) → Crohn disease ○ Dx? Colonoscopy ■ Which study is contraindicated? Barium swallow ○ Tx? ■ Acute flare: steroids ■ Maintenance (step up approach): ● salicylates ● immunomodulators (e.g. azathioprine, 6-mercaptopurine, methotrexate) ○ AZA & 6-MP are metabolized by xanthine oxidase (which is inhibited by gout drugs, like allopurinol) ○ Check TPMT activity because deficiency is common ● TNF inhibitors (e.g. infliximab, adalimumab) ○ Test for TB & Hep B before starting these ○ Histology? Non-caseating granulomas ○ Colonoscopy findings? ■ Skip lesions ■ Cobblestoning ■ Strictures ○ Depth of colonic mural involvement? Transmural ○ Affected areas? MC is terminal ileum, but anywhere from mouth to anus ○ Skin findings? erythema nodosum & pyoderma gangrenosum ○ Mucosal findings? Aphthous ulcers DI Podcast Main Document 337 ○ Eye findings? Uveitis ○ Associated rheumatic disorder? ankylosing spondylitis

● Pt with hx chronic diarrhea + colonoscopy shows black mucosa → melanosis coli (benign; 2/2 laxative use)

● Old person with LLQ pain + fevers → Diverticulitis ○ Dx? CT with IV contrast ○ Tx? ■ Clear liquid diet ■ Cipro + metronidazole ○ Colonoscopy? NO during acute ep ■ Perform 6 weeks later to r/o colon cancer ○ When is surgery appropriate? After 2nd ep

● Pt with hx of AFib or recent MI + sudden-onset, severe abdominal pain → acute mesenteric ischemia ○ Dx? CT angiography ■ Catheter angiography is gold-standard, but is more invasive ○ Tx? Bowel resection if necrotic bowel

● Pt with hx of CAD or PAD + abdominal pain that is worse with eating → chronic mesenteric ischemia ○ Dx? CT/MR angiography

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Ep. 214: Family Medicine Shelf Review Series 5 - GI (Version 2)ep 214 (Version 2) notes were graciously provided by Divine Intervention from an anonymous contributor.

Diarrhea ● + Bloody, RLQ pain "pseudo-appendicitis": Yersinia enterocolitica o Tx: supportive care, >1 wk --> abx ● + Chronic watery, AIDS: cryptosporidium "acid-fast oocysts" ● + Recent abx, nursing home, hospitalization: C. diff ● + Hiking, IgA deficiency, chronic: Giardia lamblia o Dx: stool antigen o Tx: metronidazole ● + Bloody, liver abscess: Entamoeba histolytica o Tx: metronidazole ● EHEC O157:H7: NO ABX (increased risk of HUS) ● *loperamide generally c/I ● + Chronic, malabsorption: Crohn's disease ● Osmotic gap o = 290 - 2(stool Na + K) o Lots of electrolytes, low osmotic gap <50: secretory diarrhea

DI Podcast Main Document 338 o "other nasty stuff", high osmotic gap >100: osmotic diarrhea i.e. lactase deficiency/malabsorption ● Sx: improves with fasting ● + Flushing sx: carcinoid syndrome o Dx: 5-HIAA ● + Low BMI, self-conscious: laxative abuse o Dx: stool osmolarity < 250 ● + black colon: melanosis coli o No tx needed ● + recurrent pneumonia, sinusitis, Giardial diarrhea: Selective IgA deficiency o Ddx: CVID (all Ig low) ● + pancreatic insufficiency, diarrhea from birth: Cystic fibrosis ● + sugar-free, sour candies, cough drops, bloating: artificial sweetener-diarrhea! ● + bloating, w/o alarm symptoms: lactase deficiency ● + bloating, better sx with bowel movement: IBS o Tx: TCA, serotonin-agonists (alosetron ae: ischemic colitis), loperamide, rifaximin ● + 45-60Y, chronic, no temporal assoc, NSAIDs, normal scope: microscopic colitis o Tx: oral budesonide, laxative ● + fat malabsorption, microcytic anemia, dermatitis herpetiformis (extensors), osteoporosis (NBS: DEXA): Celiac disease o Dx: 1. anti-TTG 2. EGD w/ biopsy ● Can also see anti-gliadin or anti-endomysial Ab o Tx: gluten-free diet, dapsone for dermatitis ● F/u non-adherence to diet, ADEK deficiency o Assoc with Hashimoto's, T1DM, IgA deficiency, small-bowel lymphoma ● Ex. Thyroid replacement therapy not working d/t lack of absorption in small bowel ● + EtOH, hyperglycemia: chronic pancreatitis o Dx: stool fat, white streaks on imaging o Tx: pancreatic enzyme replacement ● + resected bowel, scleroderma, diabetic gastroparesis, macrocytic anemia: bacterial overgrowth o Et: bacteria <3 B12, folate! (@diphyllo) ● + middle aged man w joint pain, uveitis, neuro sx, cardiac sx: Whipples disease o Dx: biopsy of small intestine o Tx: abx for 1 year ● + international travel, chronic diarrhea, weight loss, fatty stools: tropical sprue o Tx: bactrim, tetracycline, folateIBD ● + chronic, better w smoking: Ulcerative colitis o Tx: proctocolectomy (@rectum) o Assoc PSC (high AP/GGT) ● + watery, abd pain, chronic fevers, fistulas: Crohn's ● c/b: seronegative spondyloarthropathy, uveitis, erythema nodosum, pyoderma gangrenosum ● Dx: colonoscopy o NEVER get a barium swallow! --> triggers toxic mega ● Tx acute flare: steroids ● Tx chronic: aspirin-derivatives (ASA to colon)/TNF inhibitors, PCV23 o 6-MP and azathioprine inhibited by gout drugs (xanthine oxidase, allopurinol) ● Check TPMT! ▪ If no metabolic activity, you have high risk of toxicity

DI Podcast Main Document 339 ----------------------------------------------------------------------------------------------------Ep. 215: Acetylcholine and The NBME ● Alpha motor neurons innervate muscle ○ Where is their cell body? Anterior horn of spinal cord ● Anterior horn pathologies: ○ Polio ○ West nile (usually transient) ○ Spinal muscular atrophy (Werdnig-Hoffman disease) ● Child of immigrant or anti-vaxxer that presents with bilateral muscle weakness & atrophy → polio ● 6-month old with muscle fasciculations & loss of motor milestones → SMA ○ Mutated gene? SMN1 ○ Inheritance? AR ○ Chromosome? 5

● Resting membrane potential = -70 mV ○ Arises because cell is more permeable to K+ than any other ion (due to K+ leak channels) ● Depolarization → opening of voltage-gated Na+ channels → at positive voltages, Na+ channels are inactivated & K+ channels open → repolarization ● Depolarization spreads down the neuron via “saltatory conduction” at the nodes of Ranvier ● At the end of the neuron, depolarization → activates voltage-gated Ca++ channels → SNARE proteins bring vesicles to the synapse → release of ACh ● ACh binds to AChR (ligand-gated Na+ channel) ○ Na+ enters myocyte, causing depolarization ○ depolarization travels down the T-tubules ○ dihydropyridine receptor on T-tubule opens ○ Dihydropyridine receptor is coupled to ryanodine receptor, so ryanodine receptor also opens ○ ryanodine receptor is Ca++ channel and allows Ca++ release from sarcoplasmic reticulum ● How does ACh leave the synaptic cleft? ○ ACh esterase breaks down ACh to choline + acetate ○ Reabsorption into alpha motor neuron via transporter ■ Inhibited by hemicholinium ● How is ACh made? ○ CHAT = choline acetyltransferase is the rate-limiting enzyme

● Floppy baby (MG-like presentation) but no improvement for ACh esterases. Can also have Alzheimer’s-like phenotype → congenital myasthenic syndrome ○ Pathophys? CHAT deficiency → no production of ACh

● ACh & Alzheimer’s ○ Neuroanatomical association? Basal nucleus of Meynert destroyed in AD ○ Tx? ACh esterase inhibitors ■ Donepezil ■ Galantamine DI Podcast Main Document 340 ■ Rivastigmine

● Ptosis & bulbar sxs. Gets worse with use → Myasthenia gravis ○ Pathophys? Production of autoantibodies to AChR. ○ Dx? anti-AChR antibody testing ○ Old dx test? Edrophonium (Tensilon test) ○ EMG results? Decremental response with repetitive nerve stimulation ○ Muscles most affected? Bulbar muscles + diaphragm ○ Associated tumor? Thymoma ■ Dx? CT chest ○ Tx? Pyridostigmine (ACh esterase inhibitor)

● Pt with substantial smoking hx with difficulty rising from seated position and climbing stairs. They can get up more easily with repetition. → LEMS ○ Associated malignancy? Small cell lung cancer ○ Pathophys? Production of autoantibodies against the synaptic voltage-gated Ca++ channel ■ Sxs improve with use because you recruit more calcium ○ EMG results? Incremental response with repetitive nerve stimulation ○ Muscles more affected? Proximal limb muscles

● Pt that consumed canned vegetables, now with muscle weakness → botulism ○ Bug? Clostridium botulinum ○ Transmission in infants? Ingest spores (e.g. from honey), which grow into bacteria in the GI tract ■ In adults, other GI flora will outcompete C. botulinum ○ Transmission in adults? Ingestion of preformed toxin ○ Pathophys? Botulinum toxin cleaves SNARE proteins → can’t release ACh-containing vesicles

● Tetanus ○ Pathophys? Cleavage of SNARE proteins in Renshaw cells (inhibitory neurons that release glycine & GABA) → no release of inhibitory NTs → tonic contraction → spastic paralysis

● Child of a farmer that has diarrhea + urinary incontinence + sweating + miosis + bradycardia → organophosphate poisoning ○ Pathophys? Organophosphates inhibit ACh esterases → cholinergic toxidrome ○ Tx? Atropine + pralidoxime ■ Atropine to reverse parasympathetic sxs ■ Pralidoxime helps regenerate ACh esterase

● Paralysis for intubation ○ First, induce with propofol ○ Then paralyze with neuromuscular-blocking agent ■ Depolarizing = succinylcholine ● Mechanism? ○ Hyperstimulation of AChR ○ Continued depolarization prevents further contraction DI Podcast Main Document 341 ● Degradation? Pseudocholinesterase ● Some pts have low pseudocholinesterase → prolonged blockade ■ Non-depolarizing = vecuronium, rocuronium, pancuronium, atracurium ● Mechanism of non-depolarizing agents? ○ Competitive antagonists at AChR ● Degradation? ACh esterase ● Reversal? ACh esterase inhibitor (increases levels of ACh, which can outcompete the competitive inhibitors)

● Pt that gets succinylcholine then 1 hr into surgery T if 105F, WBC 18K, creatinine kinase 10k → malignant hyperthermia ○ Inheritance? AD ○ Mutated protein? Ryanodine receptor ○ Pathophys? Mutated ryanodine receptors allow for excessive release of Ca++ ○ Tx? Dantrolene (Ca++ channel blocker) ■ Other indications for dantrolene? NMS ○ Complications ■ Arrhythmias 2/2 hyperkalemia ● Dying muscles release K+ ■ AKI ● Due to release of myoglobin that is toxic to kidneys

● How do local anesthetics (e.g. lidocaine) work? ○ Blockage of voltage-gated Na+ channels → prevents depolarization ○ Recall that lidocaine is a Class 1b antiarrhythmic

DI Podcast Main Document 342 ---------------------------------------------------------------------------------------------------Ep. 217: Family Medicine Shelf Review Series 6 - Pulm (Version 2) ● Spirometry review ○ Indications? Suspected asthma or COPD ○ Obstructive pattern ■ FEV1/FVC < 0.7 ● Increases by > 12% after bronchodilator → asthma ■ Increased lung volumes ○ Restrictive pattern ■ FEV1/FVC > 0.8 ■ Decreased lung volumes ○ DLCO - measures how effectively the lungs allow for the diffusion of O2 ■ DLCO inversely proportional to thickness ● Pulmonary fibrosis / interstitial lung disease → decreased DLCO ■ DLCO directly proportional to surface area ● Emphysema → destruction of alveoli → decreased DLCO ■ Causes of increased DLCO? Increased pulmonary blood flow ● Polycythemia DI Podcast Main Document 343 ● Pulmonary hemorrhage

● Restrictive lung disease with normal DLCO → mechanical ventilation problem ○ Diaphragmatic weakness: MG, ALS, GBS ○ Obesity ○ Anatomic problem: scoliosis, kyphosis, pectus excavatum

● CO poisoning ○ PaO2 normal ○ SatO2 decreased (but pulse ox will be normal) ■ Order CO-oximetry instead

● You suspect asthma in a pt but spirometry is normal. NBSM? Methacholine challenge ○ Mechanism? Methacholine is a muscarinic agonist that can cause bronchospasm. Dilute amounts won’t affect people with normal airways, but will cause bronchoconstriction in asthmatics.

● Asthma + nasal polyps → aspirin-exacerbated respiratory disease (AERD) ○ Pathophys? Arachidonic acid can go down the prostaglandin pathway (via COX) or the leukotriene pathway (via LOX). Aspirin/NSAIDs inhibit COX so increase flux through the LOX pathway. Increased leukotrienes increase vascular permeability & cause bronchoconstriction. ○ Tx? ■ Leukotriene receptor antagonists (e.g. montelukast) ■ Lipoxygenase inhibitors (e.g. zileuton) ● BUT it’s hepatotoxic

● Asthma + renal problems → EGPA / Churg-Strauss● Asthma sxs + really high IgE + infiltrates in upper lobes → ABPA ○ Dx? Skin-testing for Aspergillus

● Asthma treatment ladder ○ Mild intermittent ■ Daytime sxs twice/week or less ■ Nighttime sxs twice/month or less ■ Tx? SABA ○ Mild persistent ■ Daytime sxs >2x/week but not every day ■ Nighttime sxs 3-4x/month ■ Sxs not well-controlled on SABA ■ Tx? SABA + low-dose ICS ○ Moderate persistent ■ Daytime sxs every day ■ Nighttime sxs more than once/week (but not nightly) ■ Tx? ● SABA + low-dose ICS + LABA DI Podcast Main Document 344 ● SABA + low-dose ICS + leukotriene antagonist ● SABA + medium-dose ICS ○ Severe persistent ■ Sxs throughout the day ■ Nighttime sxs every night ■ Extreme limited in physical activity ■ Tx? Oral corticosteroids

● Drugs that can trigger asthma sxs? non-selective beta-blocker (e.g. propranolol, timolol)● Asthma pt with high IgE levels. Which drug can help prevent attacks? Omalizumab (monoclonal Ab against IgE)● Vaccines indicated for asthma pts? ○ Influenza ○ Pneumococcal● Asthma pt on ICS now with dysphagia/odynophagia/white patches in mouth → thrush ○ Prevention? Wash out mouth after ICS● Asthma pt on chronic oral corticosteroids. What other meds may help mitigate adverse effects? ○ PPIs to prevent peptic ulcer disease ○ Calcium & vitamin D supplementation +/- bisphonsates to prevent osteoporosis● What should NOT be used as monotherapy in asthma? LABA ○ Increase mortality● Asthma/COPD pt on theophylline. What other drugs should be avoided? ○ Macrolides (can reduce theophylline clearance) ○ Fluoroquinolones (can reduce theophylline clearance)

● Management for acute asthma exacerbation in the ER? ○ Albuterol/ipratropium neb (DuoNeb) + IV steroids ○ If severe: add IV Mg ○ Discharge with 3-4 days oral corticosteroids ○ What is a sign of decompensation in asthma exacerbation? normalization of PaCO2 (During asthma attack, pt is hyperventilating so PCO2 should be low. Rising CO2 suggests respiratory muscle fatigue.) ■ NBS? intubate

● Pt < age 45 with COPD + multiple family members with COPD. Consider what disease? Alpha-1 antitrypsin deficiency ○ Tx? IV pooled alpha-1 antitrypsin

● COPD treatment ladder ○ Start with SAMA or SABA ■ Choose SAMA if you have to choose ○ Add LAMA (e.g. tiotropium) or LABA (e.g. salmeterol, formoterol) ■ Don’t give SAMA + LAMA together ○ LAMA + LABA OR LABA + ICS ○ Oral steroids DI Podcast Main Document 345 ● Indications for home O2 ○ PaO2 < 55 ○ O2 sat < 88 ○ Polycythemia ○ Pulmonary hypertension

● Things that improve survival in COPD ○ Smoking cessation ○ Home O2 therapy● Management for COPD exacerbation ○ DuoNebs (ipratropium-albuterol) ○ BiPAP (NIPPV = non-invasive positive-pressure ventilation) ○ IV corticosteroids ○ Azithromycin ■ Anti-inflammatory effects ○ Discharge on 3-5 days oral corticosteroids

● SOB in pts with terminal COPD? Opiate

● Low weight + nasal polyps + recurrent sinusitis + finger clubbing + fat malabsorption → CF ○ MC cause of bronchiectasis in the US ○ If sudden-onset severe abdominal pain? Intussusception ○ Tx? ■ Pancreatic enzymes + fat soluble vitamins ■ Chest physiotherapy ■ Inhaled dornase alfa or N-acetylcysteine ■ Inhaled tobramycin ppx ○ Dx? Sweat chloride testing

● Pt with lots of chronic coughing & sputum production. Linear streaks of CXR → bronchiectasis ○ Dx? High-resolution CT scan → tram-track pattern ○ MC cause in the US? CF ■ Causes restrictive lung disease ■ Pneumonia in CF pt < 20 → Staph aureus ● Tx? Cover MRSA (e.g. vanc, linezolid, ceftaroline, tigecycline) ■ Pneumonia in CF pt > 20 → Pseudomonas or Burkholderia cepacia ● Tx? Ceftazidime, cefepime, carbapenems (except ertapenem), aztreonam, fluoroquinolones, aminoglycosides ● Many CF pts take inhaled tobramycin for ppx

DI Podcast Main Document 346 Ep. 217: Family Medicine Shelf Review Series 6 - Pulm (Version 2)ep 217 (Version 2) notes were graciously provided by Divine Intervention from an anonymous contributor.

● NBS: spirometry ● DLCO: how good are your lungs at allowing O2 to diffuse? o Increased: polycythemia, hemorrhage in lungs ● CO or CN poisoning --| Hb; paO2 is nl, SaO2 abnlObstructive lung disease ● FEV1/FVC ratio <0.7 o Increased lung volumes ● Improves after bronchodilator (>200cc)? Asthma o Dx: 1. spirometry 2. methacholine (muscarinic agonist) challenge test o Sx: o + nasal polyps, worsened with aspirin: aspirin-intolerant asthma ● Inhibited COX --> shunting to leukotriene pathway --> bronchospasm ● Tx: leukotriene inhibitors (CYSLT1 receptor) i.e. montelukast > zafirlukast o + kidney issues, + p-ANCA: Churg-Strauss syndrome o + chronic, high IgE, past TB or infiltrates in upper lungs: ABPAspergillosis ● Tx: omalizumab (anti-IgE) o Tx ladder Daytime Night Tx Mild-intermitt <2x/week <2x/mo SABA ent Mild-persiste >2x/week >2x/mo + inhaled ICS nt Moderate-per Almost daily Almost daily + LABA or med-ICS or sistent montelukast Severe-persist Daily Daily + oral ICS ent ● Exacerbation: nebulizer, albuterol, muscarinic antagonist (ipratropium), IV steroids, 3-4d oral corticosteroids, [IV mag] ▪ pCO2 should be low (hyperventilation), but if it starts to normalize --> status asthmaticus RIP pls intubate ● Adverse effects/c/I ▪ Bronchospasm, worsened glaucoma ● Can use selective alpha: atenolol, metoprolol ▪ Thrush: candidal esophagitis ● Tx: drink water to decrease concentration ▪ LABA cannot be used as monotherapy! ▪ Fluoroquinolones c/I theophylline --> arrythmias ● Vaccines: PCV23, annual flu ● Ppx: bisphosphonates + PPI ● COPD DI Podcast Main Document 347 o RF: smoker ● If <45 w/ same symptoms or strong FMHx: AAT deficiency ▪ Tx: IV AAT o Tx ladder Tx I SAMA > SABA II + LAMA/LABA III + inhaled ICS IV + oral ICS ● *don't give SAMA and LAMA at same time! ● Home O2 therapy: PaO2 <55, O2 sat < 88%, polycythemia, pHTN, R-CHF ● Exacerbation: SAMA + IV steroids + NIPPV + 3-5d oral steroids + azithromycin (macrolides have anti-inflammatory properties), opioid (advanced COPD w SOB) ● Vaccines: influenza, PCV23 o Emphysema: proteases chomp down alveolar membranes --> decreased surface area ● Decreased DLCO ● Bronchiectasis o Sx: lots of sputum production, hemoptysis, linear streaks on x-ray o Dx: CT scan "tram-track" o RF: 1. CF (restrictive +/- obstructive) 2. Kartagener's/primary ciliary dys ● CF ▪ Sx: finger clubbing, pancreatic insufficiency (fat malabsorption, diabetes), recurrent pneumonia (1. staph 2. pseudomonas 3. Burkholderia cepacia), intussusception ▪ Dx: sweat chloride testing ▪ Tx: abx for infections, fat soluble vitamin supplementation, enzyme replacement, BiPAP, N-acetylcysteine (--| disulfide bonds in secretions) o Normal DLCORestrictive lung disease ● FEV1/FVC ratio >0.7 ● Decreased DLCO: pneumoconiosis, pulmonary fibrosis, o Diffusion equation: directly proportional to surface area, inversely proportional to thickness ● Normal DLCO: neuromuscular dz (GBS, MG, ALS), obesity

-------------------------------------------------------------------------------------------------------------------------------Ep. 226: Iron labsep 226 notes were graciously provided by Divine Intervention from an anonymous contributor.

Ferritin = iron stores ● Increased ● Anemia of chronic disease: bacteria need iron to reproduce --> body tries to "starve out" the bacteria = hepcidin puts iron on bone marrow macrophages (storage) --> can barely see iron around the body ● Lead poisoning --| ferrochelatase (iron-protoporphyrin --> heme), --| ALAD ● Iron is building up in the bone marrow, around mitochondria because it cannot be conjugated ● = "iron-overload" syndrome ● Hereditary hemochromatosis: C2A2Y2/HFE gene mutation DI Podcast Main Document 348 ● Decreased ● Iron deficiency anemia: lacking iron all together, so not savingTIBC = total iron binding capacity ● Opposite of ferritin: if you have lots of iron stored away, you will not go out and seek ironTransferrin saturation = %sat of protein that moves iron around in the bloodstream ● Increased ● Lead poisoning: iron overload state; tons of iron on board ● 1. mitochondria bone marrow ● 2. bloodstream ● Decreased ● Anemia of chronic disease: body is trying to sequester iron away from bacteria! "doesn't make sense for iron to run around willy-nilly, your body isn't stupid” ● *does not spill into bloodstream ^^^ because hepcidin 1) locks up iron in macrophages 2) prevents reabsorption of iron in GI tract (duodenum) ● Iron deficiency anemiaMCHC = mean corpuscular hemoglobin concentration ● Concentration = mass/volume ● Increased ● Hereditary spherocytosis: aut dom mutation in RBC membrane ● Pathophys: mutation in spectrin, ankyrin, band3.2 (RBC membrane proteins) --> too little membrane --> volume decreased ● Increased MCHC ● Dx: eosin-5-maleimide test, osmotic fragility ● Tx: splenectomy ● Decreased ● Iron deficiency anemia ● Iron + protoporphyrin = heme + globin = hemoglobin ● Hemoglobin contributes to mass of RBC ● decreased massFree erythrocyte protoporphyrin = binds with iron to create heme ● Increased ● Iron deficiency anemia: "if iron doesn't show up, protoporphyrin is left at the altar" ● Decreased ● Porphyria cutanea tarda --| UROD ● Intermittent porphyria --| PB deaminase ● Lead poisoningReticulocyte count ● RBC lifespan = 4mos ● If RBCs go into "live fast die young" phase --> lifespan = 30d ● ~ companies have had to ramp up production to meet N95 demand ● Implicates that you have enough raw materials for production: iron, B12, folate ● Increased ● Tend to run out of folate/raw materials quickly ● No quality control d/t rapid production ● Hemolytic anemia ● Sickle cell disease ● Hereditary spherocytosis ● Decreased

DI Podcast Main Document 349 ● Iron deficiency anemia ● B12/folate deficiency ● Aplastic crisisRDW ● Increased ● Iron deficiency anemia ● *Your body cares more about the concentration vs amount i.e. hemoglobin* ▪ i.e. Iron deficiency anemia: mass decreased --> body tries to keep up concentration by decreasing volume (MCV) ▪ Big <--> small, as body keeps trying to compensate for concentration

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Ep. 227: Rapid Review Series 36 (OBGYN + Others) ● URI/UTI/diarrhea 2 weeks ago, now with trouble walking, beginning to complain of SOB → Guillain Barre syndrome ○ Classic presentation: bloody diarrhea secondary to Campylobacter jejuni then symmetric ascending paralysis ○ Monitoring? FEV1 (track pulmonary status) ■ If FEV1 drops → intubate ○ Tx? Plasmapheresis = plasma exchange ■ 2nd line: IVIG ○ CSF finding? Albuminocytologic dissociation ■ High protein, but low WBCs ● IVIG used to treat: ○ Bruton’s agammaglobulinemia ○ CVID ○ IgA deficiency ○ ITP (2nd line tx, 1st line is steroids) ● 1st prenatal visit (~10 weeks) to-dos: ○ UA ■ If bacteria present → treat & repeat UA as test of cure ■ In non-pregnant females, don’t treat asymptomatic bacteriuria ○ Screen for syphilis, HIV, NG, CT ○ Cell-free DNA ■ If positive, NBS? CVS or amnio ○ If indicated for genetic testing, CVS at10-13 weeks ● 15-20 weeks: ○ Quad screen (15-22 weeks) ■ If elevated AFP on quad screen, NBS? ultrasound! ● Do this BEFORE amnio ■ Down syndrome: beta-hCG & inhibit INCREASED ■ Edward syndrome (trisomy 18): low beta-hCB, estriol, AFP ○ If indicated for genetic testing, amniocentesis + Rhogam DI Podcast Main Document 350 ○ 18-week anatomy scan● 24-28 weeks: ○ Screen for gestational DM ■ Tx: insulin (according to NBME) ■ Size > dates due to polyhydramnios ■ Glucose from mom → baby hyperglycemic → making lots of urine → lots of amniotic fluid → polyhydramnios ○ Rhogam if Rh-● 32-34 weeks: ○ If high-risk: re-screen for syphilis, HIV, NG, CT● If PTL before 32 weeks, NBS? ○ Betamethasone (2 doses over 24 hrs) + Mg (neuroprotection, decrease CP risk)● If PTL before 32w1d-34 weeks, NBS? ○ Betamethasone● 35-37 weeks: ○ Test for GBS ■ If positive → give ampicillin during labor● If at 41 weeks, at no labor? induce

● Causes of polyhydramnios: ○ Gestational DM ○ TE fistula ■ Baby can’t swallow ○ Anencephaly ■ Rostral neuropore fails to close → no swallowing center● Causes of oligohydramnios: ○ Posterior urethral valves ○ AR polycystic kidney disease ○ Bilateral renal agenesis ○ Renal issues → Potter sequence

● Newborn should receive which vaccine before they leave the hospital? Hep B● When do you give mom Rhogam? ○ 24-28 weeks ○ After any invasive procedure (e.g. amnio) ○ After delivery (use Kleihauer-Betke test) to determine dose● HIV-positive mom delivery baby. Baby has IgG to p24 antigen. Do they have HIV? Not necessarily! ○ IgG can cross the placenta ○ If they have IgM, that’s concerning because IgM does not cross the placenta. NBS? HIV RNA testing

● CO is a surrogate for SBP. SVR is a surrogate for DBP. ○ Causes of widened pulse pressure? ■ Aortic regurg ■ PDA DI Podcast Main Document 351 ■ Milrinone (PDE inhibitor) ● Increases cAMP → ○ Increases contraction of cardiac muscle ○ Relaxation of vascular SM muscle → decrease SVR ■ Septic shock ● Inflammatory mediators → vasodilation → decrease SVR ● CO increases (easier for blood to flow out of heart)

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Ep. 228: CLEAN-SP 1 Palliative

● #1 cause of death in the US? Heart disease ○ But incidence is decreasing ● #2 cause of death in the US? Cancer ○ Trend is increasing ● Most healthcare spending goes to chronic disease ○ Most goes toward the last few years of a person’s life ○ Increasing trend of hospitalizations & ICU admissions near end of life (e.g. last 30-60 days) ● Terminal illness = reasonable medical expectation that person won’t survive beyond the next 6 months

● Palliative care is part of comprehensive care for chronic disease ● Principles of palliative care ○ Manage sxs ○ Avoid invasive diagnostic testing & exams ○ Goals of care discussions on a regular basis

● Why don’t physicians initiate goals of care discussions? ○ Fear of bringing up death ○ Time constraints ● Communication skills for goals of care discussion ○ Normalize: this is a discussion I have with all my pts, I have these discussions so pts can maintain their autonomy in their care even if they become incapacitated ○ Start open-ended

● How to break bad news to pt ○ P = prepare for discussion ○ S = setting ○ P = patient’s perception (assessing pt’s understanding) ○ I = information (how much would you like to know?) ○ K = knowledge ○ E = empathy & acknowledge emotions ○ S = sharing next steps & summarize

DI Podcast Main Document 352 ● Advanced directives ○ Living will → patient complete while coherent, details specific wishes for various scenarios ○ Healthcare proxy / durable POA → person that the pt designates to make healthcare decisions if they cannot

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Ep. 230: CLEAN-SP 2 Quality/Safety

● Quality Control ○ Example: resident checks EVERY med student note to make sure if has all the required components

● Quality Assurance ○ Periodic audit ○ Example: resident does weekly checks of med student notes to make sure they’re up to par

● Quality improvement ○ You’ve identified a problem then designed an intervention to improve things

● Hawthorne Effect = people act differently when they know they’re being observed

● Weber Effect = if you are tracking adverse events, the incidence of that adverse event will go down (for the first year)

● Safety Champion = person in charge of quality & safety

● High value care ○ Value = service x quality / cost ○ Example: residents are a high value resource because they provide a lot of services that are pretty high quality at a low cost

● PDSA Cycle is used for Quality Improvement ○ P = plan ○ D = do ○ S = study ○ A = act

● Lean model = find inefficiencies in a process then eliminate them ○ Goal = reduce waste

● Data-driven improvement model = “DMAIC” ○ D = define ○ M = measure

DI Podcast Main Document 353 ○ A = analyze ○ I = improve ○ C = control

● Six Sigma Model = no more than 3 defects per million products (this is 6 standard devs) ○ High-fidelity process ○ Goal = eliminate defects

● FMEA = failure mode & effects analysis ○ “What are the different ways in which something might fail?” ○ “What are the consequences of these failures?” ○ PROSPECTIVE TOOL ○ Find the different ways this thing can fail and rank them, then focus on the biggest error

● Root cause analysis ○ Like FMEA but RETROSPECTIVE TOOL

● Swiss cheese model ○ Multiple steps in a process need to fail (holes in the cheese align) in order to cause the error ○ When you design a process, you want to create multiple safeguards to error ○ Example: ordering the wrong dose (off by a zero) ■ the EMR flags the order ■ the pharmacist sees that the dose is not reasonable

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Ep. 231: Military Part 2

1. Vaccines/protection for military personnel: I. MMRV, Tdap, typhoid, influenza, polio, hep A + depending on location may give (yellow fever, anthrax, smallpox). II. DEET on skin and permethrin on clothes III. If medic→ Hep B IV. Sexually active→ Hep B V. Outbreak of meningitis→ N. meningitidis, use ceftriaxone or ciprofloxacin for treatment and rifampinppx for all close contacts. 2. Returning service member (RSM) returning from Egypt with hematuria or portal hypertension: Schistosomiasis (hematuria→ haematobium) or (Portal htn. → mansoni) 3. MCC of diarrhea in military → Norovirus 4. Peace keeping mission in Africa with bleeding, petechiae, contact with WILD ANIMALS, or dead bodies→ Ebola or Marburg viruses, spread via fomites or body fluids. No Rx.

DI Podcast Main Document 354 5. RSM from Russia, China, Korea, or stationed at Utah, New Mexico, Arizona, Colorado, had contact with mice (deer mouse, “worked in barn”) presenting with high fever, myalgias/flu-like symptoms, bilateral INTERSTITIAL pulmonary edema→ Hantavirus (can have hemorrhage as well). No known treatment.6. RSM from Hawaii or navy has conjunctival injection, jaundice → Leptospirosis. a. Particularly bad form = WEIL’s Disease (anemia, very high creatinine, jaundice) → attacks the liver and kidneys. Use doxycycline from prevention7. RSM with Hemoptysis, widened mediastinum ± necrotic ulcer on neck→ Anthrax (poly d glutamate capsule). Can present as Hemorrhagic mediastinitis → widened mediastinum on CXR. Rx with doxycycline or fluoroquinolone. There is a vaccine available for service members.8. Malaria PPX (asia, Africa, ME) → atovaquone + proguanil, or mefloquine, primaquine (for vivax and ovale- tertian fever, have hypnozoite form), or chloroquine (high resistance), or doxycycline. a. P. malariae = quartan fever b. P. falciparum = fever at odd intervals (most severe manifestations → cerebral malaria, pulmonary edema, renal failure)9. RSM with exposure to animal or animal products or unpasteurized milk, undulant fevers and PROFUSE SWEATING→ Brucellosis, requires very low dose to get infected, tends to recur after treatment. Rx with doxy and rifampin, if recurring give aminoglycosides10. Contact with dogs/cats/pigs and one of the most common causes of bloody diarrhea→ Campylobacter jejuni (Keep in mind, association with Gullian barre syndrome and Reiter's syndrome)11. Cattle or sheep birth, pneumonia or chest pain (due to culture -ve endocarditis) → Q fever due to Coxiella Burnetii. Do not confuse Q fever with brucellosis (pneumonia is unique to Q fever)!12. RSM from Mexico, ME, North/East Africa, South America, Asia (“tropical areas”) has fevers, weight loss pancytopenia, hepatosplenomegaly, DARK SKIN LESIONS → Leishmaniasis (visceral form due to donovani), carried by sandflies, may see amastigotes on microscopy from tissue biopsy. Rx with sodium stibogluconate or amphotericin B.13. RSM with fever, neck rigidity, headache, myalgia, LP → Opening pressure is not high, WBC not high (but + lymphocytes), protein is not high, not high glucose → West nile virus.14. RSM with trouble swallowing (achalasia), chronic constipation (megacolon or hirschsprung), S3 heart sound (dilated cardiomyopathy)→ Chagas disease, spread by reduviid bug, specific→ periorbital edema (Romana sign) a. Rx: nifurtimox, benznidazole.15. RSM→ worked with turtles or pets, or lots of eggs or poultry and presents with bloody diarrhea, increased WBC (mostly neutrophils)→Nontyphoidal or enteritidis salmonella→DON’T TREAT IT.16. RSM→ don’t forget TB. Presents with chronic cough, fever, hemoptysis, night sweats right upper lobe infiltrate/cavitary lesion on CXR. Treatment = RIPE regimen for 2 months then drop 2 and continue with rifampin and isoniazid. DON’T forget B6 vitamin.17. Before primaquine treatment for p vivax or ovale, check those patients (men, X-linked inheritance) for G6PD deficiency.18. Patient going to a place with a high incidence of leptospirosis → give doxycycline as prophylaxis19. RSM with very high fevers, rash, bad myalgias (bone break fevers), bleeding (FOBT + stools, epistaxis, petechiae, hematuria, gingival bleeding), positive tourniquet test (petechiae below blood pressure cuff), ALT elevated maybe AST, usually in a south American country, thrombocytopenia→ Dengue hemorrhagic fever (aedes mosquito) a. Bug causes increased capillary permeability

DI Podcast Main Document 355 20. Chikungunya fever does not cause hemorrhage; identical to dengue but without the hemorrhage. Do not confuse Dengue and Chikungunya. 21. Zika usually in a woman with a child who has microcephaly and intracranial calcifications. 22. Yellow fever → jaundice, hepatomegaly not present in dengue. Re-hydrate these patients give supportive care.

CROSS CHECKED? YES

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Ep. 232: Vasculitisep 232 notes were graciously provided by Divine Intervention from an anonymous contributor.

Vasculitis = inflammation of vessel ● Inflammation = rubor, dolor, tumor 1. Large vessels = elastic arteries o Trigger primary/secondary hemostasis --> thrombosis --> occlusion of vessels --> "stroke" of the organ o 35F (<50Y) Japanese, hands hurt, BP LUE =/= RUE, transient blindness: Takayasu arteritis ● @ aorta, branches of subclavian, carotid artery ● Dx: string of beads on aortic branches ● Tx: corticosteroids o >50F, pain w chewing (jaw claudication), polymyalgia rheumatica, mildly elevated CPK, unilateral HA, elevated ESR: Giant cell arteritis ● Tx: corticosteroids *before* temporal artery biopsy ▪ (low dose for PMR) 2. Medium vessels = muscular arteries o 40Y man with hematuria (rapidly progressive glomerulonephritis), "sinusitis"/nasal polyps/stridor/mastoiditis, hemoptysis, RBC casts, 2+ proteinuria: Wegener's/Granulomatosis with Polyangiitis ● Dx: c-ANCA: anti-proteinase 3 ● Tx: corticosteroids o p-ANCA: anti-MPO ● Churg-Strauss/Eosinophilic granulomatosis with polyangiitis ▪ RF: personal or FMHx of allergies ▪ Sx: hematuria ▪ Epi: >50Y, recently stopped corticosteroids ▪ Tx: corticosteroids ● Microscopic polyangiitis ▪ Strong a/w p-ANCA ● Primary sclerosing cholangitis o Commercial sex worker, high fevers for last 3wks, severe abd pain (d/t infarction of vessels), blood in her stools, HepB surface antigen+, HepB core antigen+: polyarteritis nodosa ● "infarction, bleeding from organs" ▪ No involvement of lungs ● RF: HepB infection

DI Podcast Main Document 356 ●Dx: inflammatory markers, CTA "string of pearls" appearance, biopsy of vessel that is involved ●Tx: steroids, cyclophosphamide o 4y/o boy with 105 degree fevers, unilateral cervical LAD, red tongue, rash/edema/kelosis on palms/soles: Kawasaki disease ● @Asian boys ● C/b MI, gallbladder hydrops ("swelling of gb") ● Dx: thrombocytosis! Plts >10000000 ● Tx: aspirin, IVIG o 30M, Ashkenazi Jewish, severe pain in BLE, R great toe has autoamputated, 2ppd smoker: Buerger's disease/thromboangiitis obliterans ● LE always involved ● Tx: stop smoking!!! "otherwise your lower extremities will disappear" YIKE Raynaud's disease Raynaud phenomenon Epi Young woman + lupus, CREST, scleroderma Sx "steps out in cold, palms turn white --> blue --> red" Et Medium-vessel vasculitis Tx Protect from cold (i.e. gloves), Dihydro CCB (--| L-type dihydro CCB Ca2+ channel)3. Small vessels = capillaries, arterioles, venules o "tumor" component of blood vessels = "purpura" ● Vs. "petechiae" d/t low platelets, collagen dysfx o Goodpasture syndrome ● Pathophys: antibodies against Type IV collagen GBM ▪ Linear immunofluorescence of C5a binding ● C5a = chemotactic for neutrophils o Child with palpable purpura under buttocks, joint pain, abdominal pain: Henoch-Schoenlein Purpura ● Tx: supportive/reassurance, check renal labs, *severe sx --> corticosteroids* ● c/I rotavirus ssDNA vaccine (also c/I w intuss, Meckel's) ● T3HS reaction (deposition of complement-antibody complexes): Iga-Ab --> activation of neutrophils --> damage to kidneys, skin, abdomen● Pt from NC, migrating rash from palms/soles to inwards: Rocky Mountain Spotted Fever o Lesions on palms and soles = vasculitis! ● Rickettsia rickettsii (carried by dog tick) invades endothelial cells --> inflammatory response o Tx: doxycycline (even if under 8 years old!) ● *pregnant women get chloramphenicol● Meningitis, purpura: Meningococcal meningitis o Neisseria penetrates blood vessels --> purpura o C/b adrenal insufficiency: Waterhouse-Friedrichsen syndrome ● Tx: replace mineralocorticoids, glucocorticoids (prednisone, dexamethasone, etc) o Tx: ceftriaxone● Female, HepC, renal-like sx, stroke, moved to colder climate: Mixed cryoglobulinemia o RF: HepC, Sjogrens, SLE ● HepC also a/w membranoproliferative glomerulonephritis, porphyria tarda o Pathophys: IgMs agglutinate at cold temperatures o Sx: palpable purpura, sx better in warmth o Tx: tx underlying disease, cyclophosphamide

DI Podcast Main Document 357 -----------------------------------------------------------------------------------------------------------------------

Ep. 234: CLEAN-SP 2 Medication/Transition of Care ● Medication error = any error that occurs between the clinician prescribing the medication and the medication arriving to the pt

● Adverse drug event = any type of harm that is experienced by a pt as a result of taking a drug

● RF for adverse drug event ○ #1 = polypharmacy ○ Elderly pt ○ Pediatric pt (weight-based dosing can be confusing) ○ Low health literacy ○ Drugs that look alike ■ Similar tablets ■ Similar names

● Screening tools for inappropriate rx in the elderly ○ BEERS criteria ○ STOPP criteria

● 4 drugs responsible for 50% adverse drug events ○ Insulin ○ Warfarin ○ Antiplatelets ○ Opioids

● Drugs NOT to prescribe ○ Benzos in the elderly ○ Opioids for dental procedures or small surgical procedures

● Pathway from clinician to pt & ways to prevent error ○ Clinician orders ■ Prescribe conservatively (reduce # of rxs) ■ Computerized order entry systems w/ clinical decision support system (e.g. “This pt has valvular Afib dx in EHR. NOAC may not be appropriate”) ■ Medication reconciliation ○ Pharmacist transcribes ■ EHR has helped eliminate transcribing errors due to poor handwriting ○ Pharmacist dispenses ■ Pharmacist must oversee the process ■ Tall man lettering (helps distinguish drugs with similar names)

DI Podcast Main Document 358 ■ Automated dispensing cabinets ○ Nurse/caregiver administers ■ 5 Rights Rule ● Right med ● Right dose ● Right time ● Right route ● Right pt ■ Barcode scanners help ensure you’re giving right med to right pt ■ Minimize interruptions in the process of med administration ■ Use a smart infusion pump for IV meds ■ Use a multicompartment medication device when pt is discharged on lots of meds● IV meds are more prone to error than oral meds due to more calculations required for dosing● MC type of medication error? Administering med at the wrong time

● Opioid safety ○ Biggest issue is overprescribing ○ Appropriate for: ■ Acute traumatic pain ■ Cancer-related pain ■ SOB in c/o cancer (morphine) ○ Use prescription monitoring program ○ Use short course of opioids ○ Use only when it’s clinically warranted

● Transition of care = moving of pt from one healthcare setting to another ○ E.g. ward → ICU ○ E.g. hospital → LTAC● Two mostly likely complications of poor transition of care ○ Readmission ○ Adverse drug events● Measures to improve transition of care ○ Clearly written discharge instructions ○ Explain instructions to pt & use teach back ○ Give detailed records to rehab facility/nursing home ○ Medication reconciliation ○ Arrange definitive f/u (get them an appt!) ○ Discharge checklist

● Reduce error in pt handoffs ○ Well-written instructions for the other team ○ Done in an environment free of interruptions ○ Use I-PASS method ■ I = illness severity ■ P = pt summary DI Podcast Main Document 359 ■ A = action list (to-dos for the night team) ■ S = situation awareness (if-then statements) ■ S = synthesis by receiver (teach back from new team)

● SBARR method for nurse-physician or physician-physician communication ○ S = situation (e.g. this pt’s BP is going down) ○ B = background (e.g. hx of MIs, recurrent V-tach eps) ○ A = assessment (e.g. I see ST elevations. I think he’s having another MI) ○ R = recommendation (e.g. please put the pt on O2. I’m coming down) ○ R = response----------------------------------------------------------------------------------------------------------------------------Ep. 239: Ob/Gyn Risk Factors

● #1 RF for postpartum depression → hx of depression

● Most reliable indicator of successful labor induction → Bishop score

● MCC of infertility → ovulatory dysfunction (PCOS)

● MC late-onset adverse effect of pelvic radiation → vagin*l stenosis

● #1 RF for uterine sarcoma → pelvic radiation

● #1 RF for squamous cell carcinoma of vagin* → HPV

● #1 RF for clear cell carcinoma → in-utero exposure to DES

○ DES results in t-shaped uteruses and 2nd trimester losses

● #1 RF for vulvar carcinoma → HPV

DI Podcast Main Document 360 ○ Note: If “HPV” is not listed, choose “lichen sclerosus”

○ NBSIM? Punch bx

● #1 RF for post-partum endometritis → recent C-section

● #1 RF for pelvic septic thrombophlebitis → hx of post-partum endometritis

● #1 Prognostic Factor for breast cancer→ involvement of axillary lymph nodes

● What 3 prognostic factors indicate worse outcomes for gestational trophoblastic disease?

○ Mets to liver or brain

○ ↑↑↑ b-HCG

○ More time between pregnancy and gestational trophoblastic disease

● #1 Prognostic Factor for vulvar cancer → lymph nodes mets then lesion size

● #1 Prognostic Factor for endometrial cancer ­→ stage

● MC presenting complaint is vagin*l bleeding

● #1 RF for endometriosis → family history of endometriosis

● MCC of DIC during pregnancy → placental abruption

DI Podcast Main Document 361 ● #1 RF for placenta previa → previous C-section

● #1 RF for placental abruption → hx of placental abruption or hypertension

● #1 RF for preterm labor → hx of preterm labor, Ureaplasma or Gardnerella vagin*lis

● #1 RF for cervical incompetence → LEEP or conization

● #1 intervention prevent: NEC; intraventricular hemorrhage; and NRDS → betamethasone

● Preventive measure in PPROM to prevent infection → decreasing cervical exam numbers

● #1 RF for IUGR → hx of IUGR gestations

● #1 RF for fetal macrosomia → maternal diabetes

● #1 RF for fetal tachycardia → maternal fever

● #1 RF for post-partum hemorrhage → uterine atony

● PDA → premature

● #1 RF for ectopic pregnancy → hx of ectopic pregnancy

DI Podcast Main Document 362 ● #1 RF for uterine rupture → uterine scar d/t previous C-section

● #1 RF for breast cancer → increasing age

● #1 RF for pre-eclampsia → hx of pre-eclampsia

● #1 RF for uterine inversion → hx of uterine inversion

● #1 RF for chorioamnionitis → PROM

○ NBSIM? GBS PPx if > 18h

● What are 2 RF’s for gestational trophoblastic disease?

○ Nulliparity

○ Extremes of age (really young or really old)

● Indications to administer intrapartum penicillin as GBS PPx?

○ Child with GBS sepsis regardless of culture

○ +Urine culture at any point in pregnancy

○ If unknown status

○ Woman with ruptured membranes for ≥ 18h

○ Intrapartum fever

● Indications to give Rhogam?

○ At 28 wks

DI Podcast Main Document 363 ○ During any procedure

○ Within 3 days post-partum

○ During uterine cerclage

○ During ectopic pregnancy

○ Pregnant pt involved in MVA

○ Any other event that can cause maternal-fetal blood mixing

CROSS CHECKED? YES------------------------------------------------------------------------------------------------------------------------Ep. 252 Post Exposure Prophylaxis and the NBMEs ● Post exposure prophylaxis ○ Immunoglobulins, vaccines etc to prevent... ● Hepatitis B ○ Pt is a newborn to a mom with HepBs+. What to give the baby? ■ Hep B Vaccine AND HepB Immunoglobulin ● Should give given in separate arms. ○ Healthcare worker with needlestick exposure. Unsure of HepB vaccination? ■ Give HepB immunoglobulin and Hep B vaccine ○ Pt has been given a HepB vaccine in the past (and had an adequate antibody response) and becomes exposed now? ○ Do NOT give anything. ● Hepatitis C ○ Pt is Exposed to HepC? ■ Not a lot you can do. ■ Good thing is that are medications to help: ● Sofosbuvir, NS-B inhibitors ● Hepatitis A ○ Pt is Exposed to HepA? ■ Never vaccinated? ● HepA vaccine ○ Exposed to Hep A but the patient is immunocompromised (HIV, IgA deficiency, DiGeorge, Chediak-Higashi, CGD, etc)? ■ Hep A immunoglobulin AND vaccine ● HIV ○ Pt is exposed to HIV? ■ Two regimens (TE-LZ) both for about 4 weeks ● T+E ○ Tenofovir

DI Podcast Main Document 364 ■ AND ○ Emtricitabine ● L+Z ○ Lamivudine ■ AND ● Zidovudine● Varicella Zoster ○ Pt is exposed to VZV? ○ For example, newborn born to mom with active shingles, varicella infection etc? ■ Varicella Zoster immunoglobulin ● CANNOT give vaccine (it’s live ○ Pt is pregnant or HIV with CD < 200. ■ Varicella Zoster immunoglobulin ○ Pt is healthy? ■ Can give Varicella vaccine● Rabies ○ Pt has been exposed to Rabies? ■ Rabies immunoglobulin + vaccine ○ Where do you give the rabies immunoglobulin? ■ Want to give AROUND the round ● Infiltrated and bind toxin.● N. meningitidis ○ Pt exposed to someone with N. meningitidis ■ Four options ● Ciprofloxacin ● Rifampin ○ Preferred ● Ceftriaxone ● Azithromycin ■ Pt is pregnant? ● Ceftriaxone ● Azithromycin● Pertussis ○ Pt exposed to someone that has pertussis? ■ Macrolide ● Clarithromycin ● Erythromycin ■ If a patient has a long QT interval or person has ventricular arrhythmia history or macrolides aren’t an option? ● TMP-SMX● Tuberculosis ○ Pt is exposed to someone with Tuberculosis? ■ Test person with TB Skin Test or Interferon Gamma Assay ■ Induration cutoff for someone with exposure? ● 5mm or more DI Podcast Main Document 365 ○ Give them latent TB regimen (INH for 9 months + Vitamin B6 ■ Pyridoxal phosphate given to prevent peripheral neuropathy ● Tetanus ○ Two groups of patients ■ Group A ● Types of patients: ○ Unsure of hx of vaccines/ immunization status? or ○ Hx of last tetanus vaccine more than 10 years ago? ● Treatment ○ Nasty wound? ■ Tdap Vaccine + Tetanus Immunoglobulin ○ Small wound? ■ Give Tdap vaccine only ■ Group B ● Types of patients: ○ Tetanus vaccine within the last 5 years? ● Treatment ○ Do nothing! (Regardless of type of wound) ● Necrotizing fasciitis ○ Exposed to necrotizing fasciitis? ■ Some kind of antibiotic ● Azithromycin ● Clindamycin ● Rifampin + Penicillin ● General topics ○ Transmission ■ Rotavirus, C. diff (spores) ● Improper handwashing ■ Staph Aureus gastroenteritis? ● Did not refrigerate food properly

----------------------------------------------------------------------------------------------------------------------------Ep. 253 Starling Forces and The NBMEs ● Pt started on enalapril for HTN. Notice a few days / weeks their creatinine elevates from 1.2 -> 3 after starting medication. ○ ACE inhibitor normally elevate Cr a little bit ■ Prevent conversion of angiotensin I to angiotensin II ● Angiotensin II is a potent constrictor of efferent arteriole ● Effect of medication? ○ Dilate efferent arteriole ■ Blood will not pool in glomerular capillaries ● Will drain away

DI Podcast Main Document 366 ■ Hydrostatic pressure goes down in glomerular capillaries. This does NOT favor filtration. ■ GFR goes down. Creatinine goes up.● With Renal Artery Stenosis, the RAAS system is activated. Increased renin-->Angiotensin 2 constricts efferent arteriole, raising hydrostatic pressure in glomerular capillaries hence favoring filtration.● Hydrostatic pressure favors fluids going out of the vessel (fluid extravasation). Oncotic pressure favors fluid staying in the vessel.● If you take ACEi/ARB, the RAAS system is no longer activated and the opposite occurs. Blood is no longer flowing to afferent capillaries due to ischemia in the setting of Renal Artery stenosis. The addition of ACEi/ARB causes a dilation of efferent arteriole (instead of vasoconstriction as in RAAS activation in the setting of unilateral Renal Artery Stenosis). This decreases GFR, and increases Cr. ○ Summary: ACEi in the setting of unilateral RAS, dilates efferent arterioles, thus decreasing GFR, and ultimately increasing Cr. This is why ACEi/ARB are contraindicated in bilateral Renal Artery Stenosis.● Kidneys have a portal system.● Why does ACEi slow down the rate of diabetic nephropathy? In diabetic nephropathy, there is non enzymatic glycosylation of efferent which is the same as constricting the efferent arterioles, which leads to increased hydrostatic pressure, this increases GFR. GFR is increased (sounds like a good idea, analogous to working out (exercising), but if you overwork yourself (exercising 20 hours a day), your body will die because at some point your heart will give out), if GFR is chronically elevated, over time the capillaries will be injured (known as hyperfiltration injury). ○ If you give ACEi in the setting of diabetes, efferent arterioles will be dilated, decreased GFR, decreasing hydrostatic pressure and intraglomerular hypertension.● BPH patient: If you have obstruction out of the uterers, this create a backup of fluid, increasing hydrostatic pressure surrounding the glomerular capillaries, hence more fluids will go into the glomerular capillaries, will not favor filtration, Creatine will not rise.● Hydrostatic pressure always favors fluid movement out of a compartment. Oncotic pressure favors keeping fluids within a compartment.● Calcium Channel Blockers (ex: amlodipine): Lowers BP. Amlodipine is a direct arteriolar dilator. This will send more fluids to the capillaries, increasing hydrostatic pressure, causing extravasation of fluid. Hence the peripheral edema. ○ How do you treat the peripheral edema? Lower hydrostatic pressure via ACEi/ARBs ■ What drug can dilate post capillary venules (efferent arterioles)? ACEi/ARBs● In ARDS (as in the setting of COVID-19): cytokines increase vascular permeability, causing more fluid to drain into the interstitium of lungs, impairing gas exchange leading to non-cardiogenic pulmonary edema. PCWP<18. ○ Burns patients have the same mechanism.● Patient with heart failure secondary to left ventricular failure, there will be fluid backup in the left atrium, pulmonary veins, and finally pulmonary capillaries causing an increase in hydrostatic pressure resulting in a cardiogenic pulmonary edema. PCWP>18.● Nephrotic syndrome: urinating albumin (excretion), decreased oncotic pressure (cannot keep fluids within compartment), resulting in extravasation aka edema/periorbital edema/anasarca. ○ Liver disease similar pathway: cirrhosis ○ Menetrier disease: protein losing gastropathy aka nephrohitic disease of the stomach, pooping out albumin DI Podcast Main Document 367 ○ Protein Malnutrition: Kwashiorkor.----------------------------------------------------------------------------------------------------------------------------Ep. 255 Legendary Step 2CK/3 Pharmacology ● Blood drugs ○ antiplatelet/ anticoagulants ○ Anti-platelet ■ Who? ● Stroke or carotid stenosis (TIA) ○ 1st line drug? ■ Aspirin ○ 2nd drug ■ Clopidogrel ○ 3rd drug ■ Dipyridamole ● Peripheral Arterial disease ○ Aspirin for life ● Percutaneous coronary intervention (MI) ○ Dual antiplatelet agents for a few months after the stent is placed ● Acute MI / Chest pain ○ 1st line drug? ■ Aspirin ● Kawasaki ○ Aspirin + IVIG ● Preeclampsia in previous pregnancy and prevent in future pregnancy ○ Aspirin prophylaxis ● Woman with cervical insufficiency. How to prevent insufficiency in future pregnancy? ○ Progestin suppository ● Primary Hemostasis ○ Adhesion step ■ GP1B - VWF binding ● Begin to eject ADP from platelet ○ ADP binds to ADP receptor (P2Y12) ■ GPCR triggers signaling cascade ○ Aggregation step ■ GpIIb/IIIa binds to other GpIIb/IIIa ○ Formation of platelet plug ● What does aspirin do? ○ Irreversible COX-1 and COX-2 inhibitor ■ Can’t make TXA2 (helps with platelet aggregation) so you can’t aggregate ● GpIIb/IIIa inhibitors ○ Abciximab, eptifinabie, terafibine ■ Prevent GpIIb/IIIa from binding to another GpIIb/IIIa can’t form platelet plug ● ADP receptor antagonists (P2Y12 receptor blockers) DI Podcast Main Document 368 ○ clopidogrel , ■ Block receptor ADP won’t bind to it and can’t activate the receptor.● PD3 inhibitors ○ Cilostazol, dipyridamole ○ Increase cAMP ■ Increase cAMP in platelet INHIBIT signaling cascade downstream of p2y2 receptor ■ P2Y2 is inhibitory GPCR. less camp = more platelet activation. So if you inhibit PD3 leads to more cAMP and decreased platelet activation. ○ When cAMP is high it causes smooth muscle? ■ To Relax! ● Vasodilation ○ Cilostazol and NBME? ■ Give after trying a supervised exercise program in patients with Peripheral Arterial Disease. ○ Dipyridamole ■ Pharmacological stress test ■ Boosts levels of adenosine ● Adenosine deaminase inhibitor ○ Causes vasodilation ● Theophylline antagonizes Adenosine

■ ~12 mins ○ Warfarin ■ Prosthetic Heart Valve indication ● Target INR 2.5 - 3.5 ● INR 6 and 7 ○ Stop the Warfarin, give oral vitamin K ○ Bleeding Out? Reverse with 4FPCC ○ Reverse Heparin with Protamine Sulfate ■ A. Fib from valvular cause i.e. MS cause ■ Risks ● Don’t give to pregnant woman ● Duodenal hematoma (SBO), rectus sheath hematoma, intracranial bleed ● Don't’ give tPA with warfarin (they’ll bleed out and die)

■ Inhibits Vitamin K Epoxide Reductase ● Can’t gamma carboxylate 2,7,9, 10, Protein C, S ● Protein C and S are anticoagulation ● 2,7,9,10 are coagulants

■ Bridge with Heparin First! ● Activates antithrombin III ○ Can inhibit factors 10 and 2 ● Protein C and S have a shorter half life ○ Fall out of circulation first DI Podcast Main Document 369 ○ 2,7,9,10 are left for temporary coagulation ○ So there is a temporary hypercoagulable state in patients with Warfarin, that’s why they need that heparin bridge ● Low Molecular Weight Heparin ○ Also activates antithrombin III BUT only inhibits Factor 10 ○ Factor 10 Inhibitors ■ All have Xa in their name ○ Factor 2 inhibitors ■ Argatroban, Dabigatron, Bivalirudin ■ Pt. presentation ● Platelets drop post giving heparin ○ Stop Heparin, don’t give LMWH ○ Start them on Factor 2 inhibitors ○ Dabigatran is reversible by Idarucizumab● Cardio Drugs ○ ACE inhibitors (-pril) ■ Site of action → pulmonary capillaries, endothelial cells ■ Used in hypertensive diabetic patients ■ Improves survival in HF patients (also beta-blockers and potassium sparing diuretics) ■ Contraindicated in patients with bilateral renal artery stenosis (Significant rise in creatinine after ACE inhibitor → renal angiography) ■ Hyperkalemia counteracts the Hypokalemia caused by loop diuretics ■ Scleroderma renal crisis (steroids are never the right answer for scleroderma) ■ Teratogenic → renal dysgenesis, oligohydramnios ○ Cardiac resynchronization therapy ■ EF < 35% + maximal medical therapy ■ Can improve survival ○ Spironolactone ■ Treat Hirsutism associated with PCOS ■ Used to decrease portal HTN in ascites along with Furosemide for chronic use ■ Conn syndrome, bilateral adrenal hyperplasia ■ Improves survival in HF ○ Beta-blockers ■ HCOM, improved survival in HF, migraines, akathisia ■ Initial DOC for thyroid storm is Propanol (peripheral conversion of Thyroid) ■ Labetalol (mixed alpha and beta blocker) ■ Hypertensive moms love Nifedipine ● H = Hydraline, M= alpha methyldopa, L = Labetalol, N = Nifedipine ● Pregnant anti-HTN drugs ■ Don’t give to patients with acute cocaine intoxication ■ Can be used to treat glaucoma (Timolol, etc) ■ Overdose → Atropine then Glucagon ■ Class II antiarrhythmic ○ Alpha-1 blockers ■ Prazosin - PTSD for nightmares (first-line is SSRI and psychotherapy) DI Podcast Main Document 370 ■ Useful for BPH ■ Side effect → orthostatic hypotension ■ Tamsulosin (Blocks specifically alpha-1 receptors in bladder) ○ Alpha-2 blockers: Mirtazapine -> used for depression ○ Alpha-2 agonists : Clonidine (leads to rebound HTN) ■ Third-line for ADHD ■ Tourette’s ■ Can be used in opioid withdrawal ○ Loop diuretics ■ Peripheral edema, nephrotic syndrome, CHF ■ Loops lose Calcium → hypocalcemia, hypercalciuria (risk factor for nephrolithiasis) ■ NKCl(x2) transporter in thick ascending loop of Henle ■ Ototoxic (other ones are Cisplatin, Vanc, Aminoglycosides - Gentamicin) ■ Taking these is like having Bartter Syndrome ○ Thiazide ■ Hypercalcemia with HYPOcalciuria ■ Stronger association with hyponatremia ■ Metolazone is an example ■ Taking these is like having Gitelman Syndrome ○ Amiodarone ■ V Tach ■ Class III - K channel blocker ○ Antiarrhythmics ■ Procainamide - Class Ia, used for WPW, can cause drug-induced lupus ○ Verapamil → can cause hyperprolactinemia ○ Nimodipine → post-stroke vasospasm ○ Digoxin ■ Na-K ATPase blocker ■ Normal job - 3 NA leaves cell, 2 K in → hyperkalemia side effect ■ If patient is hypokalemic, more susceptible to Digoxin toxicity ■ Abdominal pain, yellow vision, diarrhea, etc ■ Contraindicated in WPW ○ Causes of dilated cardiomyopathy ■ Trastuzumab ■ Doxorubicin ■ Clozapine → Myocarditis

----------------------------------------------------------------------------------------------------------------------------Ep. 265 Male Reproductive Pathologies and the USMLEs - Newborn not urinated since they are born, dorsal surface groove = Epispadias (associated with bladder exstrophy = bladder outside of body like gastroschisis or omphalocele of body) - Don’t circumcision as you need foreskin to fix the prob - Hypospadia = urethra coming out of to ventral of urethra

DI Podcast Main Document 371 - cause UTI, problem with ejacul*tion - can have cryptorchidism- Biggest RF = Penile cancer - HPV 16,18, & 30s, smoking, uncircumcised - Squamous cell kind, person has penile malignancy, biopsy show keratinization - Malignant cell limited by basem*nt membrane = Bowen disease (squamous cell carcinoma in situ) - outcome = resolution but 10% -> progress to invasive cancer - any SCC can present with PTH-rp paraneoplastic syndrome = hypercalcemia- Cryptorchidism = testis didn't descend (androgen causes descent in 3rd trimester) - seen in androgen insensitivity syndrome - If testis kept in pelvic cavity = cant maintain blood body temp = cant make sperm (but scrotum has <2degree can make it) - Most common location for cryptorchidism is the inguinal canal - following associated reproductive anomalies = inguinal hernia = common in kids with cryptorchidism - increase risk of testicular cancer = even after descent of 1 testis - if stuck = testicl* go atrophy hence get them down quickly as possible- Bilateral testicular atrophy is associated with = klinefelter syndrome 47 XXY- Testicular enlargement is associated with Fragile X syndrome (CGG repeats, have ADHD and intellectual disability), alport syndrome, mumps (25-35% = inflammation = orchitis)- 19 y/o M, sexually active, does not use condom consistently, pain & tenderness along the rim of scrotum (pain linear band, extended out of scrotum, radiating to groin) = epididymitis - cause = N. Gonorrhea or Chlamydia (young adults) = tx with ceftriaxone or doxycycline/azithromycin, old people = E.coli (tx with bactrim, ciprofloxacin)- Newborn comes for 2 wk visit, accumulation of fluid in testicl*/small palpable mass = Hydrocele - fluid accumulates because tunic vaginilis didnt close/failed obliteration/transudate accumulation - Differentiate it from testicular cancer = transillumination = hydrocele does but testicular cancer doesn't- 20-30s y/o M, infertile, trying to have kids, have sex many times a week, wife has kid from previous husband - cause = varicocele (bag of worm = physical exam = palpate pt’s ball) - dilation of the pampiniform plexus → pooling of blood → impaired heat exchange → scrotum and testes temperature rises → sperm production decreases- Young guy, was studying for exam, has sudden onset groin/testicular pain, rushed to hospital = testicular torsion (dx testing not done) = don't do U/S → move straight to exploratory surgery - Epididymitis will usually have systemic sx if caused by STI whereas testicular torsion will not - spermatic cord twists suddenly = stops venous drainage = just like central retinal occlusion - The problem is not really with arterial blood flow - if testicl* doesn't drain = testicl* die = infertility - surgical explore testicl* = detorsion & bilateral orchiopexy (fix testicl* to the wall of scrotum) = reduce risk of future ep - most likely finding on U/S = decrease blood flow - has decrease cremaster reflex (normally testicl* elevates with stroke of inner thigh) DI Podcast Main Document 372 - severe pain along upper pole, nodular blue discoloration (torsion of appendix testis, slightly different from testicular torsion, this is torsion of a vestigial structure) - In testicular torsion if no Tx within 6 hours testis die from hemorrhagic infarction (remember lack of venous drainage)- Some guy, playing game was hit in balls by bat, felt like mass & comes to clinic weeks later - dx = germ cell tumor (95% of testicular cancer) - testicular or ovarian cancer tx = cut out the whole thing no need to do biopsy then send it for analysis - Androgen insensitivity syndrome 46 XY, male genotype, female phenotype = has high risk of seminoma- Seminoma = no real tumor marker (no afb, b-hCG), human placental lactogen (diabetogenic hormone = leads to insulin resistance in pregnancy, but marker for placental site gestational trophoblastic disease and seminomas) - Seminoma = radiation & chemo = good prog - if spread = orchiectomy then chemo & radiation- Other testicular cancers - 2nd most common testicular tumor = embryonal carcinoma - bad prognosis - Yolk sac (endodermal sinus tumor) - biopsy = schiller duval bodies (glomeruloid bodies) - Serum biomarker = AFP - Choriocarcinoma - biopsy = syncytiotrophoblast - Serum biomarker = b-hcg- Leydig cell tumor - presents in kid with precocious puberty (because the tumor produces excess androgen) - histologically = rinkie crystals (intracytoplasmic rod shaped)- BPH - acutely -> alpha-1 blocker (prazosin also help with nightmares in PTSD, doxazosin) - AE? systemic vasodilation = decrease SVR = reflex tachycardia, - Avoid systemic vasodilation by giving tamsulosin i.e flomax (blocks alpha-1 receptor found on prostatic urethra) - DHT = grows prostate, comes from testosterone via 5 alpha reductase (blocked by finasteride/long term = shrink size of prostate) - if nothing works use Transurethral resection of the prostate (TERP)- Chronic prostatitis = few months, has urinary symptoms (ex dysuria), tons of WBC but no bacteria, back or perineum pain - if sx only for few days + bacteria + prostate tender = acute prostatitis- Prostate cancer - BPH does NOT increase your risk for prostate cancer - age = biggest risk factor - blastic metastasis - Most common metastatic location = vertebral bodies

DI Podcast Main Document 373 ----------------------------------------------------------------------------------------------------------------------------Ep. 267 USMLE and Normal Changes in the ElderlyTop to the bottom of the individual:

Brain:Gets smaller as we get older (ie they are susceptible to subdural hematomas and stretch the bridging veins andcan shear)Cerebral blood flow also goes downNon-specific white matter changes → normal (as long as they don’t have symptoms)MSSE: mild defects, doesn’t mean AlzWorking memory goes downADL’s or missing on way back from store → that’s NOT normal, must work up

Nervous system:

some mild opacification of lens is normal if pretty good visual acuity, which also goes down, but this isn’tcataractsAnosmia is normal in old peopleHigh frequency sounds goes downVestibular system gets worse as you get older (knowing where you are in space)

CV:

Pulse pressure widens (spread between systolic and diastolic) systolic BP goes UP and diastolic goes DOWN,so wider pulse pressureHR goes down as you get older (fibrosis of conducting system), so CO goes down as wellBaroreflex also stops working as wellHY: blood vessels become less compliant, less elastic → inc in systolic BP as they get olderHeart gets smaller, so if you see a big heart that is NOT normal (number of cardiac myocytes goes down andsmaller)

Lungs:

Pulmonary reserve goes downFEV1 goes downSmoking accelerates this obviously, if they stop, FEV1 will decline less harshly but never normal as if they neversmokedLungs are not as good at recoiling when they are oldMucus is hard to clear

GI:

DI Podcast Main Document 374 Mild malabsorption because vili atrophyGERD because esophagus isn’t as good at peristalsisLiver mass goes down, so unable to deal with toxic chemicals and alcohol and drugsDecreased bone marrowdensityAnemiaLess able to absorb calcium and iron in gut → bigger incidence of fractures and osteoporosisMild proteinuria is normal

GU:

Increased urinary frequency and incontinence → bladder holds lessHY: Cr should go up little by little, because Cr clearance isn’t as robust

Bone marrow density goes down → Decreased activity of 1a-hydroxylase in kidney cells

Androgen levels go down → libido goes down (Atrophy of testicl*s and ovaries which house the theca-luteincells which produce androgens)

Estrogen also goes down from the ovarian atrophy → more osteoporosis, painful sex

Men → sperm count goes down

Should not be able to palpate ovaries in old woman → think cancer if palpable

PTH goes up, leach your bone of calcium → MORE osteoporosis

Insulin secretion goes up

NE and vasopressin go up

Thyroid hormone and ACTH go down → metabolic rate goes down

Skin:

Thickness of epidermis and dermis goes down (thin) → due to decreased activity of fibroblasts → less collagen

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Ep. 268 Clean SP 4 - (Palliative Care 2) ● Palliative care → for seriously ill patients ● Not only for the wellbeing of the patients - but it’s also for the well being of their families ● Misconception: doing it just because the person is sick or doing it just because you think the person is going to die. NO!! → you do palliative care at any stage of the illness (even if the treatment intention is curative). DI Podcast Main Document 375 ● There is no age to be qualified for palliative care

PALLIATIVE CARE DOCUMENTS COMMONLY TESTED ON EXAMS

Before giving the patient a bunch of papers to fill, find out what are the patient’s values/preferences “What doesthe patient want?” ● Living will: patient directions - ie, talk about the extent of life-sustaining treatment (especially if they become very ill or go into a vegetative state), is the patient saying what saving measures to take or not to take in the case he/she becomes incapacitated and unable to make decisions. ● Durable health care power of attorney (POA): a legal document where you designate someone to make healthcare decisions for you. ○ The difference from a living will is that a living will focus on interventions that either deal with withholding care or withhold life-sustaining intervention ○ POA: have a lot more power, they have much broader scopes in the kind of decisions that they can make ● *If there is a patient in the ICU, and the physician tries to create an order sets - the physician asks the patient or it POA, “what would you like us to do if x or y happened?” → this is called POLST ○ Physician orders of life-sustaining treatment ○ It deals with how the patient is currently doing right now, not like in a hypothetical situation in the future ● If a patient has a living will or a POA, or has gone over a POLST, BUT the patient is still lucid and is still able to make their own decisions, the patient’s own decision supersede this other stuff.

When a person is going through palliative care there are some key classic sx of end of life that you would haveto manage: ● For a patient that is going through a lot of pain, keep in mind (especially if it is a terminal illness) there is something that was released by WHO, to manage pain is the 3 stage analgesic ladder ○ Measures pain with VAS, so from VAS 1-3 use step 1, from VAS 4-6 use step 2 & from VAS >7 use step 3

DI Podcast Main Document 376 ○ (Source: https://assessment-module.yale.edu/im-palliative/pharmacologic-approaches-pain-management) ○ Classic NBME scenario → When a patient has pain from metastasis disease (severe pain/severe sx), and opioids are not enough you can increase the dose, titrate it so the patient does not have the side effects from the opioids, or increase the frequency (this are rescue doses)● Patient with metastatic disease to the bone and they’re getting a lot of fractures from those bone mets, to help these people with the pain (and they don’t give opioids as a choice), give bisphosphonates or calcitonin is IDEAL!● Patient with a malignancy that has metastasized to the bowel or primary bowel malignancy (like primary colon cancer that is obstructing the bowel, or primary gastric malignancy that is obstructing the stomach; even melanomas like to metastasize to the small bowel) - any malignancy that is obstructing the GI tract, these patients will benefit from an anticholinergic agent - glycopyrrolate → muscarinic receptor antagonist; it can mess up with GI motility (use it cautiously!), so it makes your bowel “not work”, so your bowel won’t be contracting and it won’t contract against that resistance (the obstruction)● Neuropathic pain → gabapentin, pregabalin● Pain from a tumor that is infiltrating nerves or compressing the spinal cord → STEROIDS (ie, Pancoast tumor that is beginning to infiltrate the brachial plexus)● SOB (dyspnea) associated with cancer → DOC opioids (especially morphine). ○ Normally opioids depress respiration → oxygen consumption ↓, so if your short of breath it means you’re gasping for oxygen, so with opioids you decrease the person “need for oxygen”, so they won’t be gasping as much ○ Opioids dilate pulmonary vessels and can ↑ oxygen delivery in the body ○ When a person is hypoxic, the body response is to hyperventilate, CO2 begins to build up or they become hypoxic (O2 goes down), opioids “numb” that response, they make you hyporesponsive to hypoxia or hypercapnia.● Patient with lung cancer that is obstructing the airway (ie, bronchus), if they asking for ways to treat their dyspnea → Stent this patient airway (insert a stent to widen the airway so they can breath better)

DI Podcast Main Document 377 ● Patient with mesothelioma that is producing a massive pleural effusion → THORACENTESIS (to consistently drain it) ● Patient with pancreatic cancer and is obstructing the pancreatic duct producing severe pain → Stent the pancreatic duct, it helps with the pain, the itching. it does not change their prognosis/survival but it does improve the QUALITY of life! ● Nausea (especially if due to chemotherapy): the DOC is ONDANSETRON (serotonin receptor antagonist); alternatives metoclopramide (dopamine receptor antagonist - very good prokinetic agent; be careful with EPS!) & Aprepitant (antagonist of neurokinin-1 receptors - very powerful antiemetic in palliative care). [OMA] ○ If they give a scenario of a patient who is receiving tx for nausea induced by chemo and now they have leukocytosis, high fever, muscle rigidity → NMS ■ Dantrolene is the DOC, is a ryanodine receptor blocker, works like a CCB ■ If they ask what is the most common/adverse renal complication of NMS: rhabdomyolysis (intrarenal AKI → acute tubular necrosis!); remember you’ll see a lot of blood in UA but in urine microscopy, there won’t be a lot of RBCs. ● Patient with nausea due to bowel obstruction from a GI mass → Steroids, because they can ↓ edema which can relieve obstruction ● Cancer patient with a lot of pain, who is on a lot of opioids → constipation ○ Prophylaxis against constipation: give a stimulant laxative like Senna ○ Tx against constipation: give agents that make the stool bulky like methylcellulose, psyllium - remember you need to be taking a lot of fluid for these agents to work; you can also use PEG (not reabsorbable in the GI tract - is an osmotic laxative); lactulose (non-absorbable sugar); methylnaltrexone is a mu receptor antagonist, which reverse the effects of opioids in the GI tract. ● REMEMBER in a patient who has a high-grade bowel obstruction you CAN’T give any of these medications for constipation → you can induce peritonitis! or can produce a bowel perforation!!. ○ You can also use mechanical means: so if it is a small bowel obstruction you use an NGT connected to wall suction; if it is a large bowel obstruction (ie, sigmoid volvulus) you can do a sigmoidoscopy and place a rectal tube and attached it to wall suction. ● Anorexia & cachexia: ○ Patients are losing a lot of skeletal muscle mass and won’t gain weight even if you give them a lot of nutritional support. ○ This is due to: TNF-alpha (proinflammatory CK) and also because when people reach near the end of life they’re having abnormal metabolism of energy products. ○ Tx: progestin analog, like megestrol or medroxyprogesterone, these are very powerful appetite stimulants! If you don’t see them in the answer choice, choose steroids. Also Dronabinol (synthetic cannabinoid)

HOSPICE ● When life expectancy is less than 6 months ● It can be done at home or at a nursing facility ● The goal here is not curative, is to make the person more comfortable at the end of their life. It is to manage their sx.

DI Podcast Main Document 378 REMEMBER: you don’t give palliative care to a person who is going to die in the near future, you can give it topatients that are being treated with a curative goal. YOU GET PALLIATIVE CARE BECAUSE YOU HAVE ASERIOUS ILLNESS, NOT BECAUSE YOU’RE GOING TO DIE.

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Ep. 275 USMLE Nov 2020 Changes Series 5: Diagnostic ErrorsDiagnostic error = cannot provide the correct diagnosis at all or in a timely manner

Radiologist reads an image and finds pulmonary embolism => must call the clinician rather than just putting it inyour notes. If you don't this is a diagnostic error.

MCC of malpractice claims? Diagnostic error, esp in internal medicine.

Most diagnostic errors are due to cognitive issues. What are some buzzwords for these cognitive errors? ● Premature closure = comes to a diagnosis and ends workup prematurely. Example: an alcoholic patient with vomiting and abdo pain. You dx them with AP without running further tests. You may harm the pt if you miss out the real dx because of premature closure. ● Diagnostic momentum = you consider a particular diagnosis earlier on, you work up the patient but although the results do not point to your initial diagnosis, you keep doing more tests that could confirm that initial diagnosis. Example: patient presents with a pic similar to alcoholic pancreatitis, lipase is normal, you still think pancreatitis and work up further to prove this. ● Confirmation bias = you make a diagnosis but overlook evidence that points to another diagnosis. Always consider other diagnoses and document these too!! This bias is present with people with premature closure & diagnostic momentum. ● Faulty application of knowledge = you know how asthma should be treated but you fail to apply it properly somehow.

To prevent diagnostic errors -> have the concept of heuristic in your mind.

Heuristics: ● Availability heuristic = your current diagnostics are affected by previous experiences. Example: alcoholic patient presents with abdominal pain, which is later diagnosed as DKA. As a result, the first thing that comes to mind is DKA rather than alcoholic pancreatitis, which is more common. ● Anchoring heuristic = settling on a diagnosis early, through initial impressions. ● Representativeness heuristic = you’ve seen alcoholic patients with epigastric pain and you diagnosed them correctly with AP. Seeing this consistent pattern repeatedly leads to making this dx in all patients presenting similarly and not considering other dx. Similar to availability heuristic but anchoring occurs with a specific, memorable event in which you see a classic presentation + rare disease. Representativeness is classic presentation + classic disease. So epigastric pain + DKA vs epigastric pain + AP in an alcoholic presenting with epigastric pain.

Other ways to reduce diagnostic errors on NBME exams?

DI Podcast Main Document 379 ● Diagnostic time out -> take a timeout to re-consider the diagnosis every now and then. It allows a fresh set of eyes. Especially if the patient is not responding very well to tx. ● Always admit your mistakes! ● Worst case scenario medicine also helps. ○ Used a lot in emergency medicine. Consider the worst diagnosis first, this allows you to safeguard against missing the most life threatening diagnoses & documents that you considered. ○ Does not mean that you have to test but at least consider & document why you considered & why you didn't pursue further testing. ● Being systematic in approaching common problems & having thorough checklists also reduces errors and missing out. ● Ask why! What may have caused this patient’s problem? Pathophys based thinking. ○ Smoker comes with increasing cough and dyspnea => dx with COPD exacerbation. But still ask what caused the exacerbation! ○ This also helps with lowering cost of healthcare -> more tests ordered if not thinking about causes ● Employ Bayes theorem -> good clinical decision making. ○ Whenever you are ordering a test -> always ask if pt is low-interm-high risk for this problem. ○ Ask about pretest & posttest probability for the patient. ○ Example: fit, athletic, young patient with SOB and chest pain. Pretest probability of having PE for this patient is LOW -> so D-dimer test over CTPA. ■ Vs 37 yo female, smoker, OCPs, just flew in from somewhere distant -> high risk for PE -> CTPA. D-dimer being negative will not rule out PE in this patient because she is not at the same level of risk as the athlete. ○ Bayes theorem guides algorithms. ● Ask what features of the presentation may not fit the diagnosis.

Systems based factors that can contribute to diagnostic errors -> pressure of performance. ● Example: high volume and turnover of patients in EMED. ○ Leads to diagnostic errors ○ High volume of tests being ordered -> not high value of care. This increases cost of healthcare

----------------------------------------------------------------------------------------------------------------------------Ep. 276 USMLE Nov 2020 Changes Series 6: Professionalism/Ethics4 principles: beneficence (act in best interest), nonmaleficence (no harm), autonomy, justice (equitableregardless of SES and access to care)

Patient makes a choice, must respect that choice!! Informed consent allows this. Informed consent = Risks +benefits of treatment, alternatives, etc

Patient with covid 19, PPE is available. Can a physician refuse to give care because they are worried aboutcontracting the disease? No because there is PPE!! But if there was no PPE, physician can ethically refuse

DI Podcast Main Document 380 providing care. You can implement this to the context of HIV, hep B, hep C, MDR organisms like tb. As long asyou are taking appropriate measures, ethically bound to take care of these patients.

Close family member/friend needs care, can you take care of them? No! Because you may not be impartial.

Sexual relations with a current patient? Absolutely not!! If you really want to, the appropriate thing will be to talkto a colleague + break the therapeutic relationship first + wait for 6 mo. (But never ever if you are a psychiatrist!!- addition from Conrad.) Having sexual relationships with relatives/cousins of a current patient is inappropriate.

Patient comes in for a disability evaluation and patient is trying to coach you on how to fill in the disability claimforms. Just do whatever is medically appropriate, never assist a patient in getting fraudulent disability benefits.Legally culpable if you do so.

Patient is from another country, 89 yo F with terminal cancer. Family members ask you not to disclose the dx tothe grandma. First line response? Ask the patient how much they want to know!! Then, do as they say. Mostright answers encourage more convo between patient and physician. If patient wants only the family to knowand not themselves, this is known as authorized delegation.

Difficult patient, quarrels with you, is not compliant - can you sever your relatioship with these patients? ● If serious illness or not medically stable = cannot sever relationship!! Patient has to be medically stable to sever relationship. ○ Severing a relationship when pt is medically unstable = physician abandonment ● Patient is medically stable and things are not working out, best answer = try to repair the relationship. ○ If nothing has worked out, to end the relationship = ending relationship should be mutual + give written notice 60 days in advance + provide info on other physicians who may take care of pt ○ Eventually, before transferring their medical records to the other physician MUST GET APPROVAL FROM THE PATIENT!!

You are a resident and you notice an attending is impaired. There is clear evidence of impairment and they aretrying to take care of pts. First step? Immediately remove from patient care. If they are doing a surgery, removefrom surgery. Then, report to appropriate authority. Chief of division -> head of department -> medical board.Note: but never report heresy. Only report smt that you yourself observed.

If you make an error as a physician, always disclose. You give too much insulin but patient’s glucose is ok. Nextsteps? 1. Disclose the error to patient 2. Apologize for the error 3. Tell what you plan to do to prevent similar errors in the futureEven if no harm occurs, must disclose errors.

Patient came to see a physician, gets blood tests. But the patient does not pay and still requests their results.NBS? Must tell the pt their results!! They have full rights to own info regardless of payment.

Patient confidentiality, when can it be violated? ● Transmissible disease (e.g. hep B) + HCW, food prep industry -> must disclose to employer DI Podcast Main Document 381 ● Bad communicable illness (tb, meningitis) but patient wants to leave and keep working -> hold pt against will if need be until not infectious! ● STI (e.g. HIV, trich) -> first pick the choice that encourages pt to tell the partner. Even if pt says they will inform the partner you need objective evidence. Regardless of what the pt says, also let the health department know. They will reach out to close contacts of the patient. ● Person has severe arrhythmias, uncontrolled seizures -> report this to DMV, you would be legally culpable if this patient drove and got involved in an MVC ● Person < 18 -> most times have to disclose health info to parents even if the child doesn’t want. On the flipside, if parents don’t want the dx to be disclosed to child, NBS? Encourage the parents to tell the child or ask the child what have you parents said. So, gathering info is the answer! But you cant tell the dx to the child. ● Person < 18 + health issue concerns sexual health, substance abuse, mental health -> do not disclose to parents if child does not want them to know!!

Do not refer patients to facilities where you have some kind of financial interest in!! Or do not pay anotherphysician to refer patients to you.

As a physician, you do not accept gifts from insurance companies or pharma companies to recommend aspecific product.

Physicians selling stuff in their office = unethical! Cannot sell cosmetics or herbal products as a physicianbecause these are not medically proven. Living in a rural area + selling health equipment that patients mayneed but can’t find in that area.

Physicians cannot become the face of a non medically approved product, eg a supplement not approved byFDA or has evidence.

Perfectly fine for a physician to be an expert witness in a legal case!! But should not accept money to become awitness.

Research study for super expensive drugs, you cannot deny access to this study based on SES!

Patient has a living will you have to follow the living will! Not the family’s orders. Living will will always hold up.What if the patient does not have a living will? Next step: gather more info about the patient's wishes from thefamily members, do not directly acquiesce to what family members say.

Patient has something that will kill them like PE, but the patient wants to go home and they are completely lucid.NBS? In real life leaving against medical advice form. Then they can go home. We can override this only whenthey are a danger to others, like communicable illness or they will drive but it will not be safe.

Patient is on a ventilator, they are lucid and wants the ventilator removed. Do not pick the answer choice thatinvolves boom you pull the plug. Try to gather more info like why do you want to do this? Talk to family, etc. if ptis persistent after all this then you can pull it.

DI Podcast Main Document 382 Patient diagnosed with a really bad genetic disease but refuses to tell wife. NBS? Encourage them to tell thespouse. If they still refuse it, tell them because if they have a child with them the baby will be at risk.

----------------------------------------------------------------------------------------------------------------------------Ep. 277 USMLE Nov 2020 Changes Series 7: Infection Prevention and Control a. Droplet i. Gown+glove+regular surgical mask b. Airborne i. Gown+ glove+ RESPIRATOR/N95 mask c. Contact i. Gown + glove

2. Will tell you about a C diff outbreak in an ICU. What measure would have prevented this? a. Handwashing - Can’t use hand sanitizer b. C diff pts need to be in CONTACT isolation means you can get it by TOUCHING A SURFACE c. Need to wear gown & gloves when taking care of pt (but NO MASK needed) i. Others that have contact isolation 1. HUS – from EHEC or Shigella

3. COVID 19 pts = under AIRBORNE precautions a. GOWN+GLOVES+ RESPIRATOR/N95 mask b. Patient also needs to be wearing mask BUT it can be ANY KIND OF MASK c. Also- SARS, Smallpox, TB d. N95 b/c filters out 95% of particles i. N100 -filter out 99% of particles

4. TB a. When available🡪 need to be in negative pressure room

5. Pt on ventilator b/c they have ARDS. What can you do to improve survival? a. If on ventilator🡪 most likely in ICU b. Do lung protective strategies i. LOW tidal volumes ii. HIGH PEEP c. Need to be place PRONE position (not supine) – belly down

6. Droplet Precautions a. N. meningitis, Pertussis (Whooping Cough), Influenza b. Also Walking pneumonias-eg. Mycoplasma, Legionella

7. If pt has some plastic in bodies (catheter/IV line/central line/etc), the moment they can be without it: a. TAKE IT OUT

8. When should you wean a person off a ventilator? a. If pt has very good oxygen saturation (good O2 tension)- FiO2 30-35 %or less and they’re using VERY LOW PEEP (< 5) DI Podcast Main Document 383 9. Central lines (Central Venous Catheter) a. You have to clean surrounding skin with CHLORHEXADINE b. When putting it in🡪 you need to be completely sterile- need to drape you AND pt i. Surgical mask, cap, gown, STERILE gloves c. Always try to AVOID a femoral central line🡪 VERY HIGH risk of infection or CLABSI i. Go for jugular or subclavian d. Give TPN through central line i. Most likely complication pt will have from getting TPN= central line assoc blood stream infxn (CLABSI) 1. Way higher chance of getting CLABSI than acalculous cholecystitis

10. Pre-op ABX prophylaxis a. 30-60 min before surgery b. Cefazolin (ANCEF)

11. Needlestick injury a. Clean off wound as much as possible b. Start PEP as quickly as possible c. Test needed after PEP treatment to make sure person never develops infection d. HEP B i. Pt is HepB positive and you (healthcare worker) are HbsAb positive (hepB immune via vaccine) 1. NBS🡪 do NOTHING ii. Pt is HepB positive and you (HCW) are not immune 1. You get PEP🡪 HepB vaccine + HepB Ig- but give in separate arms (so Ig does not bind up the vaccine) e. HepC i. Don’t worry about this for NBME exams f. HIV i. PEP= tenofovir +imcitrabine + raltegravir for 4-6 weeks to prevent from seroconverting and getting HIV

g. Pt has all the diseases. If HCW gets needlestick injury, which does he have greatest risk of seroconverting to which disease? i. HEP B (have 25% chance of getting it if not immune) – 1 in 3 chance 1. Hep C- 1 in 30 chance 2. HIV risk is very low- 1 in 300 chance

12. What are some healthcare systems and preventions that you can improve to prevent needlestick injuries? a. Use PPE (glove/gown/mask/etc) b. Put needles in Sharps containers as soon as done c. Safe needles (blunt tips/capped/syringes over them)

13. What’s the most effective ways in reducing transmission of HEPB in HCW? a. HCW getting hepB vaccine DI Podcast Main Document 384 ----------------------------------------------------------------------------------------------------------------------------

Ep. 286 Ultra HY ARDS PodcastARDS (Acute Respiratory Distress Syndrome): Respiratory failure that happens acutely, Many different causes ofARDS Most Common Causes: Sepsis, Pancreatitis, COVID-19, Aspiration (stomach contents), Motor Vehicle Accident (pulmonary contusion), DrowningPresentation: Tachypnea (rapid breathing), super cyanoticDx: Chest X-ray --> Bilateral opacities on imaging (white out on BOTH sides of the lungs)40% of patients with ARDS will die (best medical efforts, mechanical ventilation, etc..) More severe --> more likely to die

Pathophysiology of ARDS 1st event (Injury in lungs) --> inflammation (due to recruitment of neutrophils, T-cells) --> inflammatorymediators released (histamine, bradykinin) --> decrease capillary permeability, increase vascular permeability--> fluid leaks into lungs (alveoli) --> begin to form hyaline membrane (diffuse alveolar damage) --> increasedistance/thickness O2 must travel to perform gas-exchange (diffusion ability decreases) --> Oxygen tensioninside alveoli lower than in pulmonary capillaries

Mechanism of Hypoxemia in ARDS: Increased thickness of alveolar membrane and increased diffusion distance Intrapulmonary Shunt (no gas exchange occurring due to hyaline membranes and edema) --> blood flows through artery to vein and is NOT oxygenated

Pulmonary Values:DLCO (in ARDS): DECREASEDA-a Gradient (in ARDS): INCREASED

Ptx presents with 3-month history of Shortness of Breath, chronic epistaxis, serpiginous tracts on buccalmucosa: Hereditary Hemorrhagic Telangiectasia (Osler-Weber-Rendau Syndrome) Pathophysiology: Excessive number of AV malformations (AVMs) --> pulmonary AVMs leads toDECREASED gas exchange --> hypoxemia (intrapulmonary shunts) --> High Output Heart Failure

High Output Heart Failure: Type of Dilated Heart Failure (due to overwork of heart muscle)

Diagnosis of ARDS: BERLIN CRITERIA Acute onset of symptoms Bilateral opacities on imaging (chest x-ray/chest CT) Pulmonary Edema (confirm it is NOT due to heart failure; measure PCWP < 18) DI Podcast Main Document 385 PaO2: FiO2 ratio 350-450 (normal); Mild: 201-249; Moderate: 101-200; Severe < 100PEEP for ARDS patient: < 5

PCWP > 18: Cardiogenic Cause of Pulmonary Edema

Treatment: Aggressive (ICU) Endotracheal Intubation & Mechanical Ventilator Mechanical ventilation: PEEP > 5 cm H2O (Minimum), monitor Mean Airway Pressure, Plateau Pressure (pressure applied during inspiration) < 30 cm H2O, Low Tidal Volume (6 ml H2O/kg using ideal body weight), PCO2 increases

3 types of alveoli:perfectly normal----middle ground; partially filled with fluid ----destroyed/damaged alveoli PEEP helps recruit “middle ground” alveoli to work better

3 measures to increase survival in ARDS: Low Tidal Volumes on mechanical ventilators, ECMO (extra-corporalmembrane oxygenation), Placing people in Prone position (laying on belly)

IF plateau Pressure HIGH --> LUNGS CAN EXPLODE

Ptx with carbon monoxide poisoning, carboxyhemoglobin levels elevated initially Tx: Hyperbaric ChamberPtx removed from hyperbaric chamber --> hypoxia, shortness of breath, CXR: Pneumothorax (black on one sidewhere lung is supposed to be) Too much oxygen and high pressures --> Pop Lung

Nitric oxide doesn’t do anything (trick on tests)

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Ep. 287 Ultra HY Urinalysis PodcastUrinalysis Vignettes/Scenarios

Person with SIADH (syndrome of inappropriate Anti-diuretic Hormone) Causes: Paraneoplastic Syndrome, SSRI user, Pneumonia, Brain process (cryptococcal meningitis) Urinalysis: Urine Osmolality HIGH (relative to serum osmolality); Specific Gravity > 1.012

Specific Gravity 1.012 (normal) (less than 1.012 = dilute; greater than 1.012 = concentrated)

Causes of Increased Specific Gravity:

DI Podcast Main Document 386 SIADH, Volume depleted (prerenal azotemia), Dehydration, Urine SUPER hypertonic (i.e Diabetic crisis,DKA/HHS; Contrast for imaging procedure),Cyclosporine use (hypoperfusion of afferent arterioles), chronic NSAID use (excess prostaglandins leads tohypoperfusion of afferent arterioles)

Causes of Decreased Specific Gravity:Excess hydration (psychogenic polydipsia), Diabetes Insipidus (Central=low ADH production/Peripheral=noresponse to ADH secretion), Sickle Cell Disease (nephropathy --> cannot concentrate urine),Intrarenal/Postrenal AKI (dead tubular cells --> cannot concentrate urine)

Cannot take metformin if going to get procedure requiring contrast dye Destroy kidneys from contrast & taking metformin can cause life-threatening acidosis

RAAS activation due to hypoperfusion of afferent arterioles --> JGA release renin --> activate RAAS --> ADHsecretion & Mineralocorticoids (i.e. aldosterone) from zona glomerulosa

CHF: Effective Arteriole blood flow REDUCED --> hypoperfusion of Kidneys --> activation of RAAS --> netconstriction of vessels in body --> INCREASE SVR

How to determine WHICH RTA (renal tubular acidosis) Is potassium high? YES --> Type IV RTA (low aldosterone state --> hyperkalemia) Is potassium low? Yes; Look at Urine pH Urine pH > 5.5 --> Distal RTA (Type I RTA) Urine pH < 5.5 --> Proximal RTA (Type II RTA)

Causes of Type IV RTA (normal anion gap metabolic acidosis):Spironolactone/Eplerenone use, Addison’s Disease (destroyed adrenal cortex), Waterhouse-FriedrichsenSyndrome (Due to N. Meningitidis), CAH (21-Hydroxylase deficiency)

Which CAH associated with LOW levels of aldosterone with NO Type IV RTA: 11-β Hydroxylase deficiency

RTA Type I: Alpha-intercalated cells do not function properly

vagin*l pH: Trichom*onas pH > 4.5 Candida pH < 4.5 Gardnerella vagin*lis pH > 4.5

Low urine pH (overabundance of protons): Increased risk of “acidic” kidney stones Cysteine Stones; Uric Acid stones

DI Podcast Main Document 387 High urine pH (≅ 7): Struvite stones (ammonium-Magnesium-Phosphate) Stones, Calcium Oxalate stones

Basic Urine: Nephrolithiasis

Basic urine: Urease + bugs: Proteus Mirabilis (staghorn calculi; swarming motility); Staph Saprophyticus (#2cause of UTIs, E. Coli #1), Ureaplasma Uryliticum (high urine pH)

Looking for Blood in Ptx urine:If 3+/4+ blood on urinalysis --> 30-50 RBC per HPF (hemoglobinuria) Nephrolithiasis, Kidney Injury, Nephritic Syndrome (dysmorphic Erythrocytes), Renal Cell Carcinoma/Bladder Cancer (RBCs in urine), Wilm’s Tumor (hematuria), IgA nephropathy (child with URI 2-6 days ago), PSGN (child with URI 2-4 weeks ago)

If 3+/4+ blood on urinalysis --> 0-5 RBC per HPF (Rhabdomyolysis) Processes that cause muscle breakdown

Glucose in Urine: Plasma glucose high (>180 mg/dL) Fanconi Syndrome (type II RTA, glucosuria), Diabetes MellitusGlucosuria a RF for: Candida infection, Necrotizing fasciitis of perineum (Foney’s Gangrene), SGLT-2 inhibitor

Nitrite Negative urine + Symptoms of a UTI --> Treat for UTI (nitrites NOT specific)

Squamous cells in patient’s urine --> Contaminated specimen

Hyaline casts in patient’s urine --> Urine concentrated

Pigmented “muddy-brown” granular casts --> ATN/Intrarenal AKI

RBC casts --> Nephritic syndrome

WBC casts --> Pyelonephritis

Eosinophils in urine --> Acute Interstitial Nephritis

Urine Crystal shapes Calcium oxalate stones (Crohn’s disease --> increased reabsorption of oxalate; ethylene glycol poisoning) --> ENVELOPE SHAPED/DUMBBELL SHAPED stones Calcium Phosphate stones (Type I RTA) --> Star shaped/Needle Shaped/Prism shaped

DI Podcast Main Document 388 Uric Acid Stones (Tumor Lysis syndrome (treated with chemotherapy for cancer --> cells die --> uric acid overproduction)) --> Rhomboid Shape Struvite Stones (Urease + bugs; PUS (Proteus mirabilis, Ureaplasma Uryliticum, Staph Saprophyticus) --> coffin-lid shaped Cysteine Stones (COLA transporter defect) --> Hexagonal shaped

Tx of Tumor Lysis Syndrome: Rasburicase, Allopurinol/Febuxostat

Microalbuminuria in a Diabetic: >30 mg/24 hr to 300 mg/g in 24 hrs (Spot test)Macro albuminuria in a Diabetic: >300 mg/24 hr

Proteinuria: 1+, 2+, 3+ --> nephritic Syndrome (usually)Proteinuria: 4+ 5+ --> Nephrotic Syndrome-----------------------------------------------------------------------------------------------------------------------

Ep. 300 Comprehensive COVID-19/CoronavirusCOVID-19

Patient with recent travel history or a Patient who works in a place with lots of foot traffic (store, mall). Patientover the past 24 hours has been crashing and burning. Profound shortness of breath, productive/dry cough,high fevers. O2 sats very low. Dx: CORONAVIRUS Enveloped, Linear, ssRNA virus with a helical capsule

Person gets coronavirus. Symptomatic few days after exposure. Usually infectious for approximately 14 days.

RF for severe symptoms of coronavirus Older Age (>60) Chronic conditions (Asthma, Diabetes, COPD, HTN) Immunocompromised (immunosuppressive therapy, HIV, immunodeficiency)

Transmission: Respiratory route Aerosols, Respiratory Droplets, Contact (least likely)

RF of receiving illness from someone who is sick Close interaction (attempt to social distance) Long interaction (do not stand/talk next to a sick contact for long period of time) Aerosol-generating procedures in healthcare workers (i.e intubation, nebulized treatment, Bronchoscopy, CPAP/BiPAP

Diagnosis of Coronavirus: Nasopharyngeal swab

DI Podcast Main Document 389 RT-PCR for the swab (RNA virus)DO NOT DO CHEST CT as diagnostic tool

Chest CT: Sensitive, so will pick up a lot of false positives MUST confirm with a RT-PCRWill find bilateral ground-glass opacities, typically slightly asymmetric, peripheral, subpleural Do NOT have pleural effusions

Most patients with coronavirus die of ARDS

Prevent the spread of coronavirus Public Health measures: Physical and social distancing (6 feet apart), quarantine IF exposed to someone who has coronavirus (14 day self-isolation), Hand-washing (destroys the viral capsule), Hand-sanitizer (minimum 60% alcohol), Mask-wearing, Vaccination, Increase ventilation indoors, No hand/nose/mouth touching Do NOT wear a mask with exhalation valves (N95) IF you are sick Respirator (healthcare provider working with COVID patients; N95)

N-Not resistant to OilR-Resistant to Oil (Single use)P- oil-ProofMasks: 95- 95% effective filtering liquid droplets from getting into the airway

P100- Very cheap respirators, very effective, but have an exhalation valve (excellent for healthcare workers)

Vitamin D deficiency --> increases risk of severe infection with COVID-19

Dark Skinned patient, Radiologist (no light exposure), living in colder/further towards the poles and receivingless sunlight SUPPLEMENT vitamin D

COVID-19 virus has 4 key proteins (MENS)M-glycoprotein (Protein that helps in bringing nutrients into the virus)EnvelopeNuclear capsid proteinSpike protein

How people get COVID-192 types of pneumocytes Type I: Simple squamous epithelium (air exchange)

DI Podcast Main Document 390 Type II: Cuboidal, Surfactant (store in lamellar bodies), undergo metaplasia to Type IAngiotensin I --> Angiotensin II under ACE Type II cells have ACE-II receptorsACE receptors on Type II pneumocytes bind Spike protein of Coronavirus Spike protein has 2 subunits (S1 and S2) S1 subunit is the receptor binding domain for ACE-II receptor (antigen for many mRNA vaccines) S2 subunit mediates fusion of virus with type II pneumocytesType II pneumocytes help people regenerate lung tissue Post-COVID difficult to regenerate lung tissue

ACE II receptors found in heart, duodenal epithelium, rectum COVID-related myocardial injury, COVID-related intestinal injury

When virus infects, massive increase in inflammatory markers (CRP, ferritin, LDH) Increased vascular permeability: Can cause septic shock, fluid buildup in lungs (noncardiogenic pulmonary edema), torch kidneys (AKI)

ARDS: noncardiogenic pulmonary edema (PCWP less than 18)

Histology: Diffuse Alveolar damage (due to massive inflammation)

Vaccines (4 major categories) RNA vaccines (Pfizer, Moderna) mechanism 1: Giving an individual mRNA --> cell utilizes its ownmachinery to make it into a foreign protein (make antigen in your own body)--> proteasomes break down theprotein --> TAP proteins (TAP I and TAP II) get them into the endoplasmic reticulum --> load the protein ontoMHC class I --> Create cell-mediated humoral immunityRNA vaccines (Pfizer, Moderna) mechanism 2: Giving an individual mRNA --> cell utilizes its own machinery tomake it into a foreign protein (make antigen in your own body)--> picked up by dendritic cells --> present onMHC class II --> create humoral immunity Inactivated/killed virus vaccines (humoral immunity ONLY) Viral Vector vaccines (Astra-Zeneca, J&J) --> NO integration into own DNA Protein subunit vaccines

Store mRNA at VERY LOW TEMP (mRNA easily degrades)mRNA vaccines have a low likelihood of creating infection (just giving genetic info, no live organism)mRNA vaccines CAN be given to immunocompromised, pregnant, HIV patients (cannot give live-attenuatedvaccines to this populationmRNA cannot go into our genome (not giving DNA, cannot integrate into genome) NOT given with a viral primer (therefore cannot go into nucleus and by reverse transcriptase begin to integrate into DNA)

DI Podcast Main Document 391 Live attenuated vaccine: Cell-mediated & humoral immunity Vaccine with an organism that is NOT dead (attenuated ability of organism to cause disease, still caninfect cells --> becomes an endogenous antigen --> cell-mediated immunity) Exogenous antigen (antigen outside cell, brought in by phagocytosis, presented to MHC class II) Endogenous antigen (antigen within the cell, presented to MHC class I, can present cell-mediated immunity)Inactivated/killed vaccine: Humoral immunity only i.e. Salk polio vaccine (cannot infect cells, become exogenous antigens, presented to MHC class II -->binds to CD4+ helper T-cells --> produce cytokines and substances for class-switching)

Ebola vaccine: modified virus vector vaccine

How to manage people with COVID-19?Supportive Care (NSAIDs) If Hypoxia present --> Steroids (dexamethasone), 100% O2 (oxygen chain) by nasal cannula (If this fails, either give high flow nasal cannula OR BiPAP (noninvasive PEEP) if those fail --> intubation; if intubation fails --> ECMOHigh Flow nasal cannula preferred to BiPAP Reduces need for intubationRemdesivir (for patients caught early in disease that do not require intubation) Not super effective, shortens time to potential recovery; no mortality benefitO2 therapy: do not allow the O2 saturation above 95% Too much oxygen --> metabolic toxin --> damage (hyperoxia) via free radical damageIf a patient goes into shock with COVID-19? Usually septic shock/distributive shock (CO up, SVR down; PCWP and CVP down; MVO2 high) Blood flows very quickly through tissues --> inadequate oxygen extraction --> oxygen tension of blood is higher than normal Antibiotic therapy usually for septic shock (not for COVID), use Norepinephrine (1st line pressor), Vasopressin (2nd line pressor), Epinephrine (3rd line pressor); FLUIDS (normal saline or LR) NVE MAP goal: 60-65 mmHg Severe Respiratory failure --> Ventilator (LOW tidal volumes (6 ml/kg) and High PEEP due to having an ARDS) and put in a prone position (lie on chest and belly; reduces shunt-fraction), low plateau pressures (<30 mmHg) Do not want patients to suffer barotrauma (Ventilator-Induced Lung Injury)

In Kids: Disease related to COVID-19 Pediatric multisystem inflammatory syndrome Can cause deathChildren with COVID-19 have much lower mortality rate

DI Podcast Main Document 392 Case fatality rate for patients with COVID-19 is 2.2% (As of April 1st 2021)

Bleomycin sensitizes the lung to oxygen free-radical damage --> pulmonary fibrosis

NRDS children developing retinopathy of prematurity, interventricular hemorrhage, bronchopulmonarydysplasia Due to hyperoxia (oxygen free radical damage)

Oxygen is NOT always the fix for hypoxia

Patients on Normal Saline can develop a hypochloremic metabolic acidosis --> switch to Lactated Ringers

Prone position: Optimizing pressures to decrease shunt fractions in Zone 1/2/3 of lungs Shunt: regions of lung being perfused but NOT oxygenated----------------------------------------------------------------------------------------------------------------------------

Ep. 325 Extremely HY Screening GuidelinesIn pregnancyFirst Appointment ScreeningGestational Diabetes · Start screening at 24 weeks with 1 hour glucose test and a. If positive follow with 3-hour glucose tolerance testHIV · At first prenatal visit · Retest for HIV in the Third Trimester.HBV · At first prenatal visit o Hep B Surface Antigen.Syphilis · At first visitAsymptomatic bacteria: Increase risk of preterm labor and delivery. (Nonpregnant asymptomatic not treated) · Treated with nitrofurantoin o or 1st/2nd gen cephalosporin · Test of cureGroup B STREP35-37 weeks anal and vagin*l

Women’s RH status and antibody status (BY INDIRECT COOMBS TEST ) · Rhogam at 28 weeks and second dose within 3 days postpartum

Smokers · Screen for AAA (Abdominal aortic aneurysm)

DI Podcast Main Document 393 o Between ages 65-75 o Only men!!! o If you have smoked as a male or have a family history of AAA o With an ultrasound o If more than 5.5 cm you need intervention (endovascular repair of some sort) · Screen for Osteoporosis o Screen in woman o Normally you start screening with DEXA scan at age 65 for general population. o But in smokers you can start screening for osteoporosis at younger age o You can also screen for osteoporosis at less than 65 if: § Very thin like with Anorexia Nervosa § Premature ovarian failure · Lung Cancer o You need to be between ages 50-80 o Have a 20 or more pack-year history o Currently smoking or have quit less than 15 years ago. o Screen with a low dose CT scan and you only do it 3 times every year § If you screen 3 times year after year and it is negative you can stop

Special Genetic DiseasesFamilial Hypercholesterolemia · People get MI at age 25 · People have LDL receptor mutation generally · Remember rule of 3 o Start checking LDL cholesterol at age of 3, 9 and 18 o You will continue to screen but not tested on NBME

Inflammatory Bowel Disease (Both of them) · You start screening for colon cancer 8 years after making initial diagnosis. o Continue screening every 1-3 years after that · You have a small exception of rule: o If they are diagnosed with primary sclerosing cholangitis they need to be screened for colon cancer at the time of diagnosis. § Then you continue screening every 1-2 years

Lynch SyndromePx tend to have microsatellite instability problems · Start colon cancer screening at age of 20 o Continue every 1-2 years o Make sure you go straight to COLONOSCOPY o You can give aspirin as a prophylaxis!!! · They have other cancers as well o Start screening endometrial cancer at age 30 DI Podcast Main Document 394 § Continue every 1-2 years § Endometrial biopsy or sampling § You offer a prophylactic (THBSO) total hysterectomy with bilateral salpingo-oophorectomy after child bearing due to astronomic risk of endometrial cancer and ovarian cancerPatients with MEN 2A or 2B · Its not a matter of if but when will you get a medullary thyroid cancer · You offer a prophylactic thyroidectomy !!!Familial Adenomatous PolyposisAPC gene mutation-> Polyps -> Kras mutation-> p53 mutation-> Adenocarcinoma · Start colon cancer screening at age 10 years · Continue every yearBRCA MutationsBreast cancer screening guidelines · Between ages 25-29 you deserve an annual breast mammogram · If you are over the age of 30 you deserve o Annual breast MRI and annual mammography

Risky Sexual Group · Individuals with HIV · Men that have sex with men · Sex workers · IV drug usersScreening guidelines · If you are between ages 15-64 · You deserve annual HIV · Screen for syphilis every three months · Screen for Chlamydia and gonorrhea o You only screen women, DO NOT SCREEN MEN! o You screen higher risk patients annually no matter the age o ALL patients (not only high risk) younger than 24 need annual testing o Non risky patients don’t need to be screened for these two annually after age of 24 · Screen for Hep B surface antigen every year o Also screen the antivaxxers every year for hep b

Metabolic DiseasesHypertension · Screening is started at age 18 through 40 every 3-5 years · After age 40 you screen every 1-2 years DI Podcast Main Document 395 o Prevalence and incidence increases dramatically over age 40 o Guideline will change due to increase of burden of cardiovascular diseaseDiabetes · Obese individuals between age 40-70 years old o Screen every 6 months o Fasting blood glucose o Oral glucose tolerance test o HbA1c · Hypertension over 135/80 and over age 45 o Needs screening every 6 months!!!!Osteoporosis · Screening at age 65 · We only screen Women · DEXA scan looking at t score o -2.5 or less o Needs treatmentHyperlipidemiaThere are three screening guidelines separated into groups:Everyone gets initial screening at age 20For metabolic disease the screening guidelines gets more frequent the older you become. · Men o Ages 20-45: Every 5 years o Ages 45-65: Every 1 to 2 years o Over age 65: Every single year · Women o Risk increases more after menopause o Ages 20-55 every 5 years o Ages 55-65: Every 1-2 years o Older than 65: Every years · Diabetics o You screen every year, the end! o If LDL is 70mg/dl or higher they will be placed on a high intensity statin like rosuvostatin or atorvastatin.

Cancer ScreeningColon Cancer · Start screening at age 50 · Age 45 or 75 or higher might need colon cancer screening o Screening has been started at an earlier age now so lets say its age 45 to 75. · Many ways to screen: o Colonoscopy every 10 years DI Podcast Main Document 396 o Flexible sigmoidoscopy every 5 years o Flexible sigmoidoscopy every 10 years if you do a Fecal immune test every year o Fecal Immunotest or fecal occult blood test every year. o CT colonography every 5 years will start to be implemented. § CT scan that has certain protocols that make it highly sensitive for detecting colon cancer. · If any of the tests other than colonoscopy show an alteration, the next best step is to DO A COLONOSCOPY WITH BIOPSY!!!

Breast CancerThe problem is NBME uses ACS so know both of them, the question stem will probably give you enough information toknow both of themAmerican Cancer Society · Mammogram Start at age 40 and then do it every yearUSPSTF guidelines · Mammogram: Ages 50-75 then every 2 years

Cervical Cancer · Screen ages 21-29 with pap smear every three years · If you are 30 to 65 years old o Preferred modality: Pap smear + HPV contesting every 5 years o Pap smears every three years o HPV testing every 5 years · Special Cervical Screening guidelines o HIV or immunodeficiencies: § They get pap smears every year!!! § Especially T cell deficiencies like DiGeorge · Hysterectomy and pap smears: o If it was done do to benign conditions like leiomyomas: You do NOT NEED TO DUE A PAP! o If it was done due to malignant reason (cervical or endometrial cancer): Pap smear of the vagin*l cuff. o If hysterectomy was done due to cervical cancer you will continue doing pap smears until 20 years after the surgery · Stop screening at 65: o No history of cervical cancer o No history or severe Pap smear HSIL OR CIN 3 § If they did then you need to have 3 negatives in a row § Or 2 pap smears plus HPV contesting in a row

ChildrenPatients with Language difficulties: · Screening hearing with audiometryAll kids between ages 3-5 years old

DI Podcast Main Document 397 · Screen for amblyopia-> Lazy eye

MiscellaneousWomen Less than 24 years old: Screen annually for gonorrhea and chlamydia ONLY IN womenWho needs to be screened for Hep B?Need to be screened every year · Patients who receive multiple blood transfusions or are constantly on dialysis · Long term chemotherapy or long-term immunosuppressive therapy due to transplant. · With hepatitis b surface antigenAll people between ages Hep C 18-79 onceScreening for depression · Easy questionnaire: o PHQ-9 o Beck depression inventory-----------------------------------------------------------------------------------------------------------------------

ALL FURTHER EPISODES WILL BE INTHE SMALLER DOCUMENTS

DI Podcast Main Document 398