Menomnics

Rheumatology/MSK

Rheumatoid Arthritis

Using the 2010 ACR/EULAR classification criteria for RA, classification as definite RA is based upon the presence of synovitis in at least one joint, the absence of an alternative diagnosis that better explains the synovitis, and the achievement of a total score of at least 6 (of a possible 10) from the individual scores in four domains.  The highest score achieved in a given domain is used for this calculation. These domains and their values are:

●Number and site of involved joints

•2 to 10 large joints (from among shoulders, elbows, hips, knees, and ankles) = 1 point

•1 to 3 small joints (from among the metacarpophalangeal joints, proximal interphalangeal joints, second through fifth metatarsophalangeal joints, thumb interphalangeal joints, and wrists) = 2 points

•4 to 10 small joints = 3 points

•Greater than 10 joints (including at least 1 small joint) = 5 points

●Serological abnormality (rheumatoid factor or anti-citrullinated peptide/protein antibody)

•Low positive (above the upper limit of normal [ULN]) = 2 points

•High positive (greater than three times the ULN) = 3 points

●Elevated acute phase response (erythrocyte sedimentation rate [ESR] or C-reactive protein [CRP]) above the ULN = 1 point

●Symptom duration at least six weeks = 1 point

In addition to those with the criteria above, which are best suited to patients with newly presenting disease, the following patients are classified as having RA:

●Patients with erosive disease typical of RA with a history compatible with prior fulfillment of the criteria above

●Patients with longstanding disease, including those whose disease is inactive (with or without treatment) who have previously fulfilled the criteria above based upon retrospectively available data

RA: Repeat As: Arthritis, antibodies, acute phase reactants, age of symptoms

Impingement testing:

Neer’s test (near face is elicited when the patient's rotator cuff tendons are pinched under the coracoacromial arch). The test is performed by placing the arm in forced flexion while the arm is fully pronated. The scapula should be stabilized during the maneuver to prevent scapulothoracic motion.

Hawkin’s test (flap like a hawk) is another commonly performed assessment of impingement. It is performed by elevating the patient's arm forward to 90 degrees while forcibly internally rotating the shoulder. Pain with this maneuver suggests subacromial impingement or rotator cuff tendonitis.

Cartilage types: I (osteogenesis imperfecta)- bone, tendon, skin dentin (#1 is most strong, 1=bONE).

II- cartilage (cartwolage)

III (Ehlers Danlos)- granulation tissue, blood vessels, skin

IV- basement membrane (IV under the floor in the basement)

TNF alpha blockers: A, C, E, G,I.  Adalimumab (SQ, human mAb so lower risk of Ab formation), Certolizumab pegol (SQ, no Fc portion so no complement activation), Etanercept (SQ, binds TNF receptors, can’t use for IBD),  Golimumab (SQ & rarely IV, human mAb),  Infliximab (IV, chimeric mAb against TNF so increased risk of antibody formation)

Test for knee effusion medially. (checking for fluid INSIDE the knee).

If immunocompromised or CKD, do prevnar (13-valent) 8 weeks before pneumovax (23-valent).  (Prevnar should have been done previously, otherwise have to wait 6-12 months after pneumovax to do prevnar).

For Lupus dx you need four of MD SOAP CHAIR criteria.  Four for diagnosis.

MCTD has components of systemic sclerosis, lupus, and polymyositis (don’t slp and forget it)

Losartan slightly lowers uric acid (low).

Osteoporosis treatment: ibandronate, risedronate, alendronate, zoledronic acid, teraperatide (CI if radiation hx or Paget’s), denosumab.  I rise and zest the day.

Leflunomide is teratogenic and it’s metabolites can last for up to 2 years.  If need to get rid of drug, use cholestyramine.  (Leflunomide left behind for a long time).

Gout vs. pseudogout: crystal lab findings

P seduogout crystals are:
P ositive birefringent
P olygon shaped
Gout therefore is the negative needle shaped crystals. Also, gout classically strikes great Toe, and its hallmark is Tophi.
ABCs/123s of antiphospholipid antibody syndrome antibodies.  For diagnosis you need one clinic symptoms (thrombosis or pregnancy morbidity) plus one or more antibodies at least 12 weeks apart.  1+2=3, three possible antibodies (lupus Anticoagulant, Beta2glycoprotein, and antiCardiolipin, with antibodies needing to be IgM or IgG).

Hem-Onc

CA 19-9 is pancreatic tumor marker, 9 looks like backwards P

Platelet lifespan about 8 days, same as number of letters.

Microcytic anemia (A SLIT): anemia of chronic disease, sideroblastic anemia, lead poisoning, iron def, thalassemia.

Macrocytic anemia (FLAHBe): folate def, liver disease, alcoholism, hypothyroidism, B12 def, eliminate E

Anemia (normocytic): causes

ABCD:

Acute blood loss

Bone marrow failure

Chronic disease

Destruction (hemolysis)

Mets to brain: Lots of Bad Stuff Kills Glia: lung, breast, skin (melamona), kidney, GI (colon)

Sx of lead poisoning A-G: anemia, basophilic stippling, colicky abdominal pain, diarrhea, encephalopathy, foot drop, gums with lead lines

G6PD results in Heinz cells (oxidized iron) and bite cells on smear. (Heinz 57 varieties and G6PD both have numbers).

Anterior mediastinal masses

4 T's:
Teratoma
Thymoma
Testicular-type
T-cell / Hodgkin's lymphoma

GI/Nutrition

B12 absorption: in stomach, B12 binds R protein, which prevents degredation.  R factor protein comes off due to pancreatic secretions in duodenum and intrinsic factor binds.  Together B12 and intrinsic factor absorbed in ileum.  R protein (R looks like B) Instrinsic factor (I) together (2)=(B12).

B vitamins: The rich never pan pyrite filled creeks. Thiamine (B1), riboflavin (B2), niacin (B3), pantothenic acid (B5), pyridoxine (B6), folate (B9), cobalamin (B12).

Essential Amino Acids: PVT TIM HALL (all needed in diet): phenylalamine, valine, threonine, tryptophan, isoleucine, methionine, histidine, arginine, leucine, and lysin.

Branch chain amino acids (increased in maple syrup urine disease): Isoleucine, Leucine, Valine. I Love Vermont maple syrup.

Iron rule of 3s: iron def anemia tx 325mg up to TID, should normalize after about 3 months, take with OJ.

Primary biliary cirrhosis: usually women >35, anti-mitochondrial Abs (Prim Bill and Sir Mit with the ladies) and increased IgM, intrahepatic lesions (cirrhosis), so often get liver biopsy.

Primary sclerosing cholangitis usually males, often associated with ulcerative colitis (-itis) and cholangiocarcinoma (cholang), often ANCA+. Dx: beading of intra and extra hepatic bile ducts.

Both likely autoimmune and result in increased conjugated bilirubin, increased alk phos, increase cholesterol along with pruritus, jaundice, dark urine, light stools, hepatomegaly.  Can often treat with ursodiol or liver transplant.

Child-Pugh score determines prognosis of chronic liver disease, necessity of liver transplant, and mortality during surgery.  Score based on PT/INR, albumin, total bili, ascites, encephalopathy of hepatic origin.  Pour Another Beer At Eleven.

Small bowel obstruction causes: ABD so adhesions, bulge (hernia), and cancer (often external tumors.

Large bowel obstruction causes: CDE so cancer, diverticular disease, and entwinement (volvulus).

Cards

MAP=COxTPR so P=QxR.

TIMI risk score for UA/NSTEMI for mortality:

1.       >1mm ST change up or down

2.       >2 episodes of CP in 24 hours

3.       >3 CAD risk factors

4.       Cardiac markers 4 damage

5.       > 50% known stenosis

6.       >65 years of age

7.       ASA within the last 7 days

BB proven for CHF mortality: Metop ER, Bisoprolol, Carvedilol.  Carve the Bishop’s Mets in the ER.

Class 1 antiarrythmics:

1 A length AP: disopyramide, quinidine, procainamide

1 B shorten AP: lidocaine, tocainide, mexilitine

1 C no change in AP: flecainide, propafenone

Double quarter pounder,  lettuce/tomatoe/mayo, fries please

Venous ulcers usually above medial malleolus, arterial ulcers usually on lateral malleolus or bony prominenece. VMAL

Hyperkalemia EKG changes: first peaked T wave, then loss of P wave, then wide QRS.  Go up, then down, then sideways.

Aortic Stenosis

                Aortic jet velocity             Valve area           Mean gradient

Nl            <2 m/s                                  3-4 cm sqr           <5mmHg                              (2, 3 4, 5)

Severe  >4                                           <1.0                       >40

Easily missed bad EKGs:

Wellen syndrome- proximal LAD occlusion, high risk for MI in days-weeks.  EKG shows deep inverted or biphasic T waves in V2, V3 (fall into a deep well).  Tx: don’t stress as it can cause death, do a cath.

Brugada syndrome- AD, Na channel mutation, risk of sudden cardiac death. EKG shows coved/biphasic ST elevated in V1-V3, like RBBB but no prolonged S wave in 1,V6.  Tx: Need ICD

JVD (1,2,3) assess at 45 degree angle (4,5).  5 cm at sternal notch plus whatever is measure above and if >4cm then elevated.  With the abdominojugular reflex if greater than 4 cm elevation then elevated.

Endocrine

Old oral DM drugs that end in –ide can cause hypoglycemia so sulfonylureas (glipizide, glyburide) and meglitinides (repaglinide, neteglinide).

Grave’s disease in pregnancy: first trimester: PTU (pregnancy trimester uno). Second/Third trimester: methimazole.

Pulmonology

ARDS dx: Acute onset within 7 days of event, Ratio of PaO2/FiO2 < 300 (200-300=mild, 100-200=moderate, <100=severe), Diffuse (bilateral) infiltrates on CXR or CT, Signs/symptoms not fully explained by cardiac failure or volume overload.

COPD FEV1:FVC ratio < .70 (< looks like 7) or less than 10% predicted normal.  Stage 1: FEV1>80, Stage 2: FEV1=50-79, Stage 3= 30-49, Stage 4 <30 or severe symptoms (home O2, etc).  So 30+50=80.

COPD exacerbation: Cough, OverProduction sputum, Dyspnea increase (need at least one)

Neurology/Psych

Parkinson’s tremor is better with movement, opposite of essential tremor.  Think of Parkinsons’s pill rolling tremor being prominent at rest and improving with activity.

Quetiapine (Seroquel) is very sedating atypical antipsychotic so good for making people quiet.

Aripiprazole (Abilify) has least QT prolongation of antipsychotics (rip up EKG, best ability).

Major reflexes and nerve root: Go from bottom to top and count up.

Ankle plantarflexion/Achilles reflex: S1/S2.

Knee extension/patellar reflex: L3/L4.

Elbow flexion/biceps reflex: C5/C6.

Elbow extension/triceps reflex: C7/C8.

ID

Common UTI pathogens: SEEK PP

Staph saprophyticus (gram positive)

E. Coli (lactose fermenter)

Enterobacter (lactose fermenter)

Klebsiella (lactose fermenter)

Proteus (non-lactose fermenter, urease enzyme causes alkalinization of urine)

Pseudomonas (often immunocompromised or hospitalized)

(A positive nitrite indicates an Enterobacteriaceae so includes proteus, enterobacter, serratia, citrobacter, salmonella, yersinia, klebsiella, shigella and others)

Encapsulated bacteria (+quelling rxn, increased susceptibility if no spleen): GBS Kapsules Shield SHINS. Group B strep, Klebsiella pneumonia, Salmonella, Strep pneumon, Haemophilus influenzae, Neisseria meningitidis.

Pseudomonas aeruginosa – think water and air. Blue-green pigment production, obligate aerobe, found in moist environments ex. hot tub folliculitis, CF pneumonia, external otitis media, burn pts, etc.

Gram + rods (blue bacilli): rod’s blue Corn Clusters Back Listerine. Corynebacterium, Clostridium, Bacillus, Listeria.

Live viral vaccines: Mr. Sabin is a Small, Yellow, Rotating, Chicken. MMR, sabin oral polio and nasal flu, smallpox, yellow fever, rotavirus, varicella zoster and herpes zoster.

Jones criteria for acute rheumatic fever: 2-4 wks after GAS pharyngitis. Major criteria=JONES. J=joints (migratory arthritis). O looks like heart (carditis/valvulitis). N= nodules, subQ. E=erythema marginatum (expanding annular lesions on trunk with return of normal skin in center). S=sydenham chorea.  Minor criteria: arthralgia, fever, elevated ESR/CRP, inc PR interval.  Need 2 major or 1 major and 2 minor or can dx if documented infx and chorea or if only indolent carditis.

As and Cs of antipseudomonal coverage. A: aztreonam, anti-pseudomonal PCNs, aminoglycosides. C: carbapenems (ertapenem an exception), ceftaz/cefipime, cipro (not other fluoroquinolones).

Outpatient skin infx abx:

	MSSA	MRSA	Strep pyogenes
amox	-	-	+
amox-clav	+	-	+
keflex/ancef	+	-	+
clindamycin	+	+	+
bactrim	+	+	-
doxy	+	+	-

Clindamycin broad as it covers MSSA, MRSA, Strep pyogenes, and anaerobic infx

HAART common SE:

Anemia- ziodvudine

HLD, HTN- protease inhibitors

Peripheral neuropathy, pancreatitis- stavudine, didanosine (stab Dan in the pancreas and nerves)

Kidney stones/crystals- indinavir (indentation in kidney)

Few SE: lamivudine (harmless lamb)

Teratogenic: efavirenze and delavirdine (if ever can deliver, don’t use).

Bell’s palsy: Lovely Bell Had An STD. Lyme, Herpes, AIDS, Sarcoidosis, Tumor, DM.

Consider double coverage abx for SPACE organisms: serratia, pseudomonas, acinetobacter, citrobacter, enterobacter

250 neutrophils needed for SBP. Lasix to Spironolactone ratio: 2:5 (looks like cursive L and S).

Erythema Nodosum causes SORE SHINS: streptococci, OCPs, Rickettsia, Eponymous (Behcet), Sulfa drugs, Hansen’s (leprosy), IBD, NHL, Sarcoidosis

Cephalosporins don’t have activity against LAME: Listeria, atypicals, MRSA, enterococci. 1^st gen cephs starts with ceph such as cephalexin(keflex) except for cefazolin (anceph).  As you increase generation, you increase gram negative activity.

TB treatment: RIPE for 2 months, RI for 4 more months.  If outside of lungs do longer treatment.

MRSA tx besides vanc: linezolid (lean on this, basically PO verson of vanc, can cause thrombocytopenia or other cell line depression), daptomycin (trapped by lung surfactant so no lung coverage, typically used for skin or endocarditis), ceftaroline (5^th gen ceph, very broad spec), tigecycline (it’s a tiger against MRSA).

In vaginal discharge, nl pH is 4-4.5. If pH >4.5 then malodorous (trich, BV). Candidiasis has pH 4-4.5.

Dermatology

For skin cancer, cumulative sun exposure is biggest risk for squamous cell carcinoma while sunburns are biggest risk for BCC and melanoma.  SCC= sun cumulates cancer.

UVA light causes acceleration of skin damage and acceleration of skin cancer growth.  UVB light is bad because it causes skin cancer and is blocked by window light, also needed for vitamin D production.

Nephrology

Triple phosphate crystals in urine seen with magnesium, ammonium phosphate (struvite) stones, look like coffin lid.  A split (urea-splitting) stag(horn) gets a crystal coffine.

Hyperkalemia tx: C A BIG K Drop.  Calcium gluconate 1g, albuterol neb, 1 amp bicarb, insulin reg 10 u plus 1 amp D50, kayexalate,  diuretics or dialysis.

TTP=penTad of thrombocytopenia, microangiopathic hemolytic anemia, kidney failure, fever, neuro sxs.  HUS=Hemolytic anemia, Uremia (AKI), Small amt of plt (thrombocytopenia).

Ca correction for low albumin is +0.8 for 1 gram albumin below 4.  Clotting factor 8 only one not made in liver (8 hates liver).  Liver often cause of low albumin. When correcting for anion gap, add 2.5 for every 1 gram albumin below 4.

Other

Infant development milestones:

3 month: smile (looks like 3 sideways), hold head up (3 holding head up)

6 month: sites without support (6), teeth (6 with tooth at top), babbles (6abbles), stranger anxiety

12 month: starting to walk, separation anxiety (walk away)

2 years: parallel play (two parallel lines), 2 word sentences

3 years: toilet training (pee at 3), tricycle riding

4 years: past tense (b4), grooms self

Pap smear: 21-30 pap Q 3 years.  30-65 pap Q5 years if with HPV testing.

Cyanide causes almond scented breath (almond shaped pills). Arsenic causes garlic scented breath (bad arse farting from garlic).

Phimosis comes from Greek word for muzzle and indicates inability to retract the foreskin.  Paraphimosis ccurs when foreskin is retracted then cannot be returned to normal position and is a urological emergency as it can cut off blood-flow (think of paratrooper being unable to drop down).

At age 65, if male do AAA screening if smoking hx and if female do DEXA scan.

Pulmonary HTN can be seen in Raynaud’s alone.  However, Pulm HTN more common with limited SS, while ILD more common in diffuse SS (more diffuse means more fibrosis).

Comparing AST and ALT, ALT more specific to Liver.

Posaconazole mainly for Pulmonary fungal infections.

Coronary artery anatomy: RCA has acute marginal come off.  LAD has diagonal and septal branches.  LCx has obtuse marginal come off.  (Marginals come off laterally, A before O).

Severe c diff= WBC >15k or Cr inc 1.5 x nl.  (1.5=1&2 so liquid diarrhea) Tx with PO vanc.

PAH groups (2-4 in middle, run from L to R):

Type 1- idiopathic, heritable, or disease related to small arterioles (CTD, HIV, etc.)

Type 2- Left heart disease

Type 3- Lung disease or hypoxemia

Type 4- Chronic thromboembolic disease

Type 5- Due to unclear mechanisms

The lone star tick Amblyomma americanum (American cowboys amble), bit can cause STARI.  Rash is often similar to Lyme’s erythema migrans but smaller and less severe, can have HA, muscle pains, fever, but no progression to arthritis, neuro sxs, or systemic sxs.  Tx: Doxy

Treat pneumonia for 5-7 days  (P looks like a 7).

Uvea= iris, ciliary boy, and choroid.  ICC (I see see).  Anterior uveitis is most common (in front), is painful, often due to seronegative sponyloarthropathies or JRA.  Sarcoidosis and TB or syphilis can cause any type of uveitis.  Typically treat with corticosteroid drops.

ADLs of self care: DEATH- dressing, eating, ambulating, toileting, hygiene.

IADLs of self care: SHAFT – shopping, housekeeping, accounting, food preparation/meds, telephone/transportation.

Med that increase TSH: VIALS- valproic acid, iodine, amiodarone, lithium, sertraline.

Delirum: ACC (acute and fluctuating course, consciousness disturbed with poor attention, cognition change not attributable to dementia).  Also should not be due to underlying medical issue or dementia.

CYP inducers: Queen barb steals phen-phen and refuses greasy carbs chronically.  Quinidine, barbituates, st. john’s wort, phenobarbital, phenytoin, rifampin, griseofulvin, carbamazepine, chronic alcohol usage.

CYP inhibitors: Alcohol from KEG makes you SICC. Acute alcohol, ketoconazole, erythromycin, grapefruit, sulfonamides, isoniazid, cimetidine, chloramphenicol.  Can also think slowed down robot with errorythromycin, locked down without keytoconazole, sinking in iceoniazide in shoes filled with cementidine.

Iliac crest is at L4.  L4 is top (crest) area for (4) lumbar (lumbar spine) puncture.

ABCs of the aorta: Aorta, then Brachiocephalic trunk, then left Common carotid, then left Subclavian

AAA is >3 cm in size (3 letters for 3 cm).  If 6 months with >0.5cm growth or >5.5 cm in size then repair.  Do a one-time screening for any males >65 who ever smoked.  All numbers either 3, 6, or 5 so remember 365 days a year, if ever smoked one of those days then do AAA screening.

In Gout, uric acid level goal <6 (G looks like 6).

PSA controversial, as general rule <4.0 ng/ml is around normal.  Increased risk of cancer if ratio of free/total is <1/4.  Remember, DRE 4 free.

In urolithiasis, can multiply diameter in mm by 10 and subtract from 100 to get a rough idea of percentage chance of passing stone.

Weber test and Rinne’s test done for sensorineural hearing loss.  Weber is a complicated web, as lateralization can mean conductive (weber lateralizes to affected ear) or sensorineural (weber lateralizes to normal ear).  Rinne’s test is for Conductive hearing loss and is simple like RC cola, so if BC>AC then conductive hearing loss and normal/sensorineural is AC>BC.

All females should get biannual mammograms started at age 50, possibly earlier.  All patient’s should start getting colonoscopies every 10 years, possibly more often, starting at age 50.

Increased floaters in vision can indicated retinal detachment (think floating retina) especially if flashing of lights.  Can also indicated posterior vitreous detachment (floating posterior vitreous)  which is less serious and typically does not need tx.  However, majority of cases are due to aging and vitreous humor changes.

Amblyopia is impaired vision without organic deficit and due to developmental deficit.  Strabismus is misaligned eyes “cross eyed” and can cause amblyopia.  With amblyopia think needing to amble slowly because of impaired vision and with strabismus think strife because of crossed eyes.

In vision testing, then numerator is the distance at which the exam took place (ND) and denominator is the smaller sized letter the patient could read (numerator over denominator).  OD is right eye and OS is left eye (OD=right).  Myopia is nearsighted so cannot see far away, my vision problem and needs negative correction.

Methimazole is typically used to treat Grave’s disease, often with BB to achieve euthyroid state before ablation or just continue with drug.  Exception is during first trimester when propylthiouracil is used (PTU-pregnancy trimester uno).

Hepatitis B serology

·         HBsAg-carrier of Hep B, if chronic carrier then won’t develop HBsAb

·         HBsAb- immunity (previous vaccine or clearance)

·         HBcAb- past or present infection, only one positive in window period (cAB window)

·         HBeAg- if high then high enfectivity

Purpura- extravasation of RBC from cutaneous vessels into skin or mucous membranes resulting in reddish-purple lesions.  Erythema (from capillary dilation) blanches while purpura does not.  Purpura lacks blanco (Spanish for white).

Cryoglobulinema (often seen in MM, hep C, SLE, RA) has abnormal proteins (cryoglobulins) that precipitate in cold temperature and block blood flow.  Cold agglutinins disease (seen with CLL, mycoplasma infection) is an autoimmune hemolytic anemia with antibodies that bind RBC at low temperatures and cause clumping of RBC.  Cryglobulins=immunoglobulins.  Cold agglutinins=antibodies cause agglutination of RBC.

Hordeolum or “stye” is red and tender mass on lid due to abscess formation (hording bacteria and stye often due to staph)  While chalazion is a subcutaneous mass on eyelid, nonred/nontender, due to granulomatous formation (lazy so less inflamed and more chronic and concealed).

MEN1- parathyroid, pancreatic endocrine, and pituitary (3Ps).

MEN2a-parathyoroid, pheochromocytoma, and medullary thyroid carcinoma (2Ps).

MEN2b-pheochromocytoma, medullary thyroid carcinoma, and mucosal neuromas/marfinoid habitus (1Ps).

MCC of cough in adults: GERD, asthma, postnasal drip, asthma, also drugs.  GAPS.

Modified centor criteria: Cough abscent, Exudate on tonsils, Nodes/tender cervical adenopathy, temperature/fever, Old >44 subtract one point, Reduced age of <15 add one point.  If <1 then usually don’t have to test, if 4 or greater than can just treat.

For osteopenia, check FRAX and do antiosteoporotic therapy for persons whose risk of major osteoporotic fracture over the next 10 years is 20% or greater or whose risk of hip fracture over the next 10 years is 3% or greater.  So 1 (10 years), 2 (20%), and 3 (3%).

May need to consider intubation if PCO2 >50 (if not chronic) or PO2 <50.

Hypoxia causes: hypoventilation (high PCO2, nl A-a gradient), V/Q mismatch, R to L shunt, diffusion limitation, reduced inspired O2 content (nl A-a gradient). So main ones are VDRL-V/Q mismatch, Diffusion limitation, R to L shunt, low O2 content.

Circumferential speech wanders off topic but comes back to point eventually (circles back so think circumference).  Tangential speech wanders off and nevers gets back to the point (off on a tangent).

Warfarin FAB-4 drug interactions: fluconazole, amiodarone, Bactrim, flagyl.

Isopropyl alcohol- rubbing alcohol, no acidosis but has ketosis (I so rub you).

Ethylene glycol- antifreeze, anion gap acidosis tx: fomepizole or EtOH

Methanol- wood alcohol, anion gap acidosis same tx as ethylene glycol

Propylene glycol is a surfactant used in some medications like Ativan, valium (not versed), phenytoin and causes anion gap acidosis.

All alcohols cause osmolar gap. 

Acute (minutes to hours) infarct on MRI: DWI- da white infarct.  ADC- a dark correlate.

Temporal arteritis has age >50 and ESR>50.  Tx with around 50mg prednisone QD unless visual loss then do solumedrol 1 gram QD.

Common dialyzable intoxicants: MEAL methanol, ethylene glycol (other alcohols), ASA, lithium

Dialysis indications: AEIOU so intractable acidosis, electrolyte abnormality, intoxicants (SLIME-salicylates, lithium, isopropyl alcohol, methanol, ethylene glycol), overload of fluid, uremic sxs (pericarditis, N/V/AMS, bleeding).

Paroxysmal SVT can be AV nodal reentrant tachycardia (P wave often in QRS) or AV reentrant tachycardia (typically WFW syndrome but won’t see delta wave when tachycardic).  AV reentrant tachycardia can be orthodromic (ortho=straight) so AV node to ventricles to accessory AV pathway retrograde to atrium so narrow QRS.  Or it can to antidromic accessory pathway to ventricle then retrograde up AV accessory pathway to atrium so wide QRS. 

Common mets to spine: BLT Kosher Pickle (breast, lung, thyroid, kidney, prostate)

Mets to brain: Lots of Bad Stuff Kills Glia.  Lung, Breast, Skin (melanoma), Kidney, GI (colon cancer)

Most common brain tumors in adults: MGM Studies so Mets, Glioblastoma Multiforme, Meningioma, Schwannoma

Aggitation tx: B52 bomber so 50 benadryl IM, 5 haldol IM, 2 ativan IM.

QT prolonging meds (among others): FOAMS so fluoroquinolones, ondansetron, antipsychotics, macrolides, SSRIs, also methadone etc.

Factor 8 is only clotting factor not made in the liver (H8s liver).

Erysipelas and cellulitis overlap and often present together.  Both infection in dermis but erysipelas has clear margin so can be “etched” out and more superficial while cellulitis is a deeper cellular level and less clear border.

RCRI for pre-op cardiac complication assessment: DR C4: DM with insulin, risk of surgery high (vascular but not CEA, intraperitoneal, intrathoracic), CVA, CHF, CAD, CKD (Cr >2).

Erythema nodosum is inflammation of fat cells under skin.  SORE SHINS so streptococci, OCPs or pregnancy, Rickettsial disease, eponyms (Bechet’s), sulfa drugs, Hansen’s disease (leprosy), IBD, NHL, Sarcoidosis.

Babesiosis similar sxs to malaria (babe=hot=malaria) and similar treatment to chloroquine resistant malaria by treating with atovoquone plus azithro or clindamycin.

Antiarhythmics type 1:

1A Disopyramide, Quinidine, Procainamide          Disco Queen Proclaims

1B Tocaimide, Lidocaine, Mexilitene                        Toking Little Mexicans

1C Flucainide, Moricizine, Propafenone                 Fleece Most Preppies.

Total body water 60,40,20

60% of total body weight is total body water. 40% of total body weight is intracellular fluid and 20% of total body weight is extracellular fluid.

Kernig’s sign is painful knee extension when hips are flexed. Brudzinski sign is neck flexion causes hip and knee flexion (ski position).

Spinothalamic decussates at the ventral white commissure (not on same side as it ascends).  Corticospinal and dorsal column don’t decussate until the medulla.  Tabes dorsalis (tertiary syphilis) affects dorsal columns while syringomyelia affects spinothalamic at ventral white commissure.  Vitamin deficiencies, most commonly B12, cause subacute combined degeneration so affect dorsal column and corticospinal tract. 

Huntington’s Disease think C.  Crazy, chorea, CAG repeat on chromosome cuatro (4) and remember Caudate loses Ach and Gaba, cuarento (40) is average age of onset.

CN locations in the brain:

1-Cortex

2-retinal ganglion cells

3,4-midbrain

5,6,7,8-pons

9,10,11,12-medulla

Depression 5 symptoms for 2+ weeks SIG E CAPS +depressed mood (counts as one of the 5). Suicidality, interest loss/anhedonia, guilt/worthlessness, energy decrease/fatigue, concentration problems, appetite change, psychomotor retardation, sleep change.

Mania episode criteria is at least 3 symptoms for 1 week: DIG FAST. Distractability, irresponsibility, grandiosity, flight of ideas, activity increase, sleep decrease, talkative.

Factitious disorder (Munchausen syndrome) is primary gain (facts are number 1) while malingering is secondary gain.

Posterior shoulder dislocation is usually due to electrocution or seizure (think POST-ictal).

Monteggia fracture- proximal ulnar fracture with anterior dislocation of the radial head.  Galeazzi fracture is radial fracture with distal dislocation of ulnar-radial joint.  MUGR.

Foot sensation is L5 by the big toe (5^th biggest toe) and S1 by small toe (smallest # is also smallest toe).

PTH causes increased Ca and decreased phosphate (Phosphate trashing hormone).

Minimal change disease selectively loses albumin and is most common nephrotic syndrome in kids, response to steroids.  Kids are very picky.

Anakinra- IL-1 R blocker, immune suppressant (you only have 1 family).

Lichen planus (Ps): pruritic, purple, polygonal, papules and plaques. Tx: prednisone.

Pemphigus vulgaris has oral lesions (vulgar mouth) and antidesmosome antibodies in epidermis.  Bullous pemphigoid has antihemidesmosome antibodies to dermal-epidermal junction so bullow with tense bulla.

Lancunar strokes:

Pure motor hemiparesis: posterior limb of the internal capsule

Pure sensory: contralateral ventroposterolateral nucleus of thalamus (VPL- valued perception loss)

Dysarthria clumsy hand syndrome: basis pontis

Absence seizure DOC: ethosuximide (absence of ethos)

Bell’s Palsy (upper and lower facial paralysis unlike stroke that spares upper): Lovely Bell Had An STD. Lyme disease, Herpe Zoster, AIDS, Sarcoidosis, Tumor, DM.

Calcium citrate has less GI SE that Ca carbonate (Ca citrate has a lower sit rate than carbs).

RA=21% 2, each L NC increases by about 4%, max 6L so around 44% O2.  Air four nose.

Strep pneumo vaccine at 65, flip 65 and looks like SP.  Also do prevnar first at 65 then pneumovax 6 months later.

Spironolactone:Lasix ratio in ascites do 50:20 with max of 400:160. 5:2 looks like S : L

Levofloxacin has action against UTI and pneumonia (levo means left so think both sides covered)

E>I and I>E.  Flow volume loop for variable intra-thoracic and extra-thoracic obstruction.  Variable extra-thoracic.  Variable extrathoracic obstruction has flattening of curve with inspiration as intrathoracic airway has negative pressure and extrathoracic has 1 atm, so decrease lumen of extrathoracic, ex include laryngomalacia, upper tracheomalacia, vocal cord paralysis.  Variable intrathoracic obstruction has flattening of curve during expiration as when you expire intrathoracic pressure is positive so obstruction accentuated, ex include tracheomalacia, bronchogenic cyst, other tracheal lesions.  Basically, whenever air going from one side to another (high to low air pressure), if obstruction on side with higher air pressure then will have evidence of obstruction.

Steven Johnson syndrome has <10% BSA while Toxic Epidermal Necrolysis (TEN) has >30% BSA.

Shingles vaccine at sixty.

Ground glass on CT indicates an opacification but can still see underlying vasculature and architecture, sort of like a veil, seen with lots of diseases including acute (PCP, viral pneumonia, acute interstitial pneumonia, acute eosinophilic pneumonia, hypersensitivity pneumonitis, early interstitial lung disease) and chronic (hypersensitivity pneumonitis, interstitial lung diseases such as NSIP and DIP, bronchoalveolar carcinoma, alveolar proteinosis, sarcoidosis)

Restrictive lung disease can be due to extrinsic causes such as AS or intrinsic causes, classifie as ILD/DFLD.  Intersitial lung disease (aka diffuse parenchymal lung disease) is a group of diseases that affects the tissue and space around the alveoli and the alveoli themselves of the lungs, used to distinguish these diseases from obstructive airway disease as these all have a restrictive pattern.  When no cause for the DPLD can be found, it is then a type of idiopathic interstitial pneumonia.  UIP is the histological findings seen in IPF, as IPF can be diagnosed based on CT with a characteristic pattern of peripheral (subpleural), bibasilar reticular opacities associated with architectural distortion, including honeycomb changes and traction bronchiectasis.  NSIP presents similar to other IIPs but doesn’t have specific histological findings.  Most ILDs: SHIT FACED: Sarcoidosis, Histiocytosis X, Idiopathic pulmonary fibrosis, tuberculosis/tumor, fungal infection, asbestosis/alveolar proteinosis, collagen vascular disease, environmental, drugs.

If EF <35% then consider AICD and AICD costs approximately 35k.

Alpha thalassemia.  If 4 abnormal genes then Hb Barts (gamma 4) so never born (Bart should have been aborted).  If 3 abnormal genes then HbH (B4) and H looks like B, pt will be anemic, microcytic with high retic count, low Mentzer index (MCV/RBC count).

Turner’s syndrome XO think CLOWNS: coarctation of the aorta, lymphedema, ovaries underdeveloped, webbed neck, nipples widely spaced, short.  Noonan syndrome has similar features, can occur in males are females due to different AD defect (no one turned away).

Glomerular disease: nephritic (inflammatory) while nephrotic (>3.5 grams protein per day, also hypercoagulable and increased lipids.  Tx both with steroids, ACEI, statins.

Nephritic syndrome with low complement: Wolf cries at the end of the post crescentic mood-phase.  Lupus nephritis, cryoglobulinemia, endocarditis, post-strep glomerulonephritis, crescentic (depends on etiology), membrano-proliferative.

RTA: Stones (1), Bones (2), and No Aldosterone (4).

Type 1: Distal, impaired H secretion in distal tubule so can’t correct in tubule so urine pH >5.3, often kidney stones

Type 2: Proximal, impaired HCO3 reabsorption along with phosphate wasting so get osteomalacia/rickets and lytic bone lesions. 

Type 4: aldosterone deficiency or resistance, only one with hyperkalemia

Hypercalcemia symptoms: Bones (bone pain, frx), stones (nephrolithiasis), abdominal groans (N/V/C), psychiatric overtones (altered mental status).

Urine casts

Hyaline-normal (normal to say hi to lynne)

Granular- generally indicate chronic renal disease (old granny).  A subtype is muddy brown casts which indicates ATN (think muddy ATV).

If electrolyte in urine >20 then not being conserved.

Papillary thyroid carcinoma is most common thyroid CA (Papa bear).

Sitagliptin (Januvia) and saxagliptin (onglyza) inhibit DPP-IV.  Normally DPP-IV inactivates GLP-1 and GLP-1 stimulates insulin release, decreases glucacon release, and delays gastric emptying.  They sit on DPPIV and inhibit it.

Knuckle, knuckle, dimple, dimple is short 4 and 5 metatarsal seen in pseduohypoparathyroidism (2 sets of parathyroids so 4 total and 2 dimples).  Knuckle, knuckle, dimple, knuckle seen in Turner’s (turned back to knuckle).

ASA inhibit COX enzyme so prevents platelets from producing TxA2.  On Scrubs, Dr. Cox is and ass when tx patients.

Basophilic stippling seen on RBC (remnants of RNA).  Baste ox TAIL. Thalassemia, anemia of chronic disease, iron deficiency anemia, lead poisoning.

RBC target cell: THAL. Thalassemia, HbC, Asplenia, Liver disease

Alpha thal prevalent in Asia and Africa while Beta thal prevalent in Mediterranean.

MCHC reflects central color so increased in hereditary spherocytosis, HbS, HbC, and decreased in anemia.  Mean Corpuscular Hemoglobin Concentration (Middle Color Hb Concentration).

Acute intermittent porphyria (defect in heme synthesis leading to accumulation of heme precurors). 5 Ps: painful abdomen with nl CT, pink/red urine that turns purple in light (porphyria means purple), polyneuropathy, psych sxs, precipitated by drugs or alcohol often.

Most common inherited hypercoagulability is Factor V Leiden (AD) so a big factor.  Most common inherited bleeding disorder is vW disease (very widespread disease).

Leukemia common age groups: 0-14 ALL, 15-39 AML, 40-59 AML or CML, 60+ CLL

Direct coombs test looks for Abs already directly on RBC while indirect coombs test checks serum for Abs.

Eosinophilia ddx: DA NAACP so drugs (NSAIDs, PCN), AIN, Neoplasm, Addison’s, Allergies/Asthma (Churg Strauss)/Aspergillosis, collagen vascular disease (PAN, Dermatomyositis), parasites (invasive helminths), etc.

Candidiasis can be scraped off while oral hairy leukoplakia and dry mucosa can’t.  Thrush brushes off, candidiasis can be brushed off.

RILE- right sided murmurs increase on inspiration, L sided increase on expiration.

Wenckebach= Mobitz type 1 (one-ckeback or wink with one eye open) so have progressive lengthening of PR until dropped.

Pitting edema usually indicates transudative so CHF, kidney failure while non-pitting edema usually indicates exudative so inflammation, myxedema, lymphedema

Pulsus paradoxus >10mmg HG drop on systolic BP on inspiration, due to impaired LV filling seen in cardiac tamponade (too much fluid so use tampon).  Kussmaul’s sign is JVD on inspiration, due to impaired RV filling and seen in constrictive pericarditis.  Pulse determined by L side of heart while cursing determined by R side of heart.

Kawasaki disease CRASH and Burn (need 4  plus fever): conjunctivitis, rash, adenopathy, strawberry tongue, hands/feet desquamation, fever >5 D.

Antihypertensives used in pregnancy: Hypertensive Mothers Love Nifedipine: hydralazine, methyldopa, labetalol, nifedipine.

Want <90 minute door to balloon time for PCI (3 letters to 30 minutes each).

CHF exacerbation: LMNOP so Lasix, morphine if breathless, nitrates, O2, positive and if needed pushers (ionotropes).

Endocarditis symptoms: FROM JANE so fever, Roth’s spots, osler’s nodes, murmur, Janeway lesions, anemia, nail/splinter hemorrhages, emboli

Duke Endocarditis criteria: END PIVOT, need 2 major or 1 major+3 minor or 5 minor

Major: echo with evidence, new valvular regurg, double (serial, at least 2) blood cx positive for endocarditis orgs (strep viridans, strep bovis, HACEK, straph a, enterococci)

Minor: Predisposing heart condition, immunological phenomena, vascular phenomena, other orgs on culture, temp/fever.

Crohn’s: Ask a (often ASCA+) fat (creeping fat on GI serosa) granny (granuloma on biopsies) Crone (Crohn’s) skipping (skip lesions) to end (perianal fistuals and fissues) of cobblestones (cobblestone mucosa).  UC often PANCA positive.

Drug-induced lupus: HIPP so hydralazine, isoniazide, penicillamine, procainamide

Itraconazole is DOC for histo/blasto (hit and blast it).

Atypical pneumonias:

Klebsiella- currant jelly sputum, alcoholics/aspiration

Mycoplasma- most common, +cold agglutinins (IgM)

Others include legionella, chlamydia, etc

Indirect inguinal hernia go through internal (deep) inguinal ring, external/superficial ring, and into scrotum; it starts lateral to inferior epigastric A and occurs usually in infants due to failure of processus vaginalis to close.  Direct inguinal hernia is through external ring only and occurs in Hasselbach’s triangle.

Acute pancreatitis: GET SMASHED: gallstones, ethanol, trauma, steroids, mumps, autoimmune, scorpion sting, hypercalcemia/hypertriglyceridemia, ERCP, drugs (sulfa, statins, etc.)

H pylori tx: PPI, clarithromycin, amoxicillin (metronidazole if PCN allergy).  Please Clear Ache.

Ranson’s criteria for acute pancreatitis on admission: GA LAW: glucose >200, AST >250, LDH >350, Age >55, WBC >16,000.  48 hours after admission: Calvin and HOBBeS: Ca <8, Hct >10% decrease, O2 <60 PaO2, Base deficit >4, BUN inc >5, Sequestration of fluids >6L.  Amylase/lipase are diagnostic but not prognostic.

Primary Biliary Cirrhosis has anti-mitochondrial Abs, Prim Bill and Sir Mit, typically seen in middle-age females with pruritis treat with ursodeoxycholic acid.  Primayr sclerosing cholangitis typically seen in patients with ulcerative colitis, have multifocal strictures, segmental dilations on biliary imaging, typically need transplant.  Both can have pruritus, elevated alk phs.

Normal anion gap acidosis is 8-12.  Correct anion gap by adding 2.5 for every 1 gram albumin below 4.  DDx: RAGE: RTA, acetazolamide, GI (diarrhea, fistula), endocrine (Addison’s, spironolactone, amiloride/triamterene).  If nl anion gap then get urine anion gap (Urine Na + Urine K – Urine Cl) and if positive then renal bicarb loss to RTA and if negative then extra-renal loss so usually GI (negutive). 

Jugular venous waveform. Upward slope letters correspond to action.

• "A" wave: atrial contraction (ABSENT in atrial fibrillation)
• "C" wave: ventricular contraction (tricuspid bulges). YOU WON'T SEE THIS
• "X" descent: atrial relaxation
• "V" wave: atrial venous filling (occurs at same of time of ventricular contraction)
• "Y" descent: ventricular filling (tricuspid opens)

Clotrimazole covers both candida and tinea (clots off fungus).

Acroosteolysis is resorption of the distal bony phalanges. A mnemonic commonly used for acro-osteolysis is PINCHFO. Pyknodysostosis, Psoriasis, Injury (thermal burn, frostbite), Neuropathy (diabetes), Collagen vascular disease (scleroderma, Raynaud's), Hyperparathyroidism, Familial (Hadju-Cheney, progeria), Occupational (polyvinyl exposure).
Very Old malaria= Vivax and Ovale