USMLE Step 2 CK Platinum Notes: The Complete Preparatory Guide Ashfaq UI Hassan
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Medicine1

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MINERAL-ASSOCIATED DISEASES
 
Zinc
 
Copper
 
Selenium
 
Chromium
 
Magnesium
 
Ultratrace Elements
 
5Cadmium
 
Deficiency of Minerals
  • Iron deficiency
  • Iodine
  • Zinc
  • Copper
  • Selenium
  • Chromium
  • Microcytic anemia
  • Goiter
  • Acrodermatitis enteropathica
  • Menkes disease
  • Cardiomyopathy
  • Impaired glucose tolerance
 
Arsenic-related Diseases
 
ACID-BASE/ELECTROLYTE DISORDERS
 
Medically Important Electrolyte Imbalances
Potassium Deficit and Hypokalemia
Potassium Excess and Hyperkalemia
  1. K depletion usually is due to excessive losses of K in the urine or stool
  2. Bartter's syndrome is characterized by sodium wasting, excessive production of renin and aldosterone, and normotension
Hyperkalemia (serum K > 5.5 mEq/L)
Must be distinguished from pseudohyperkalemia due to hemolysis of the blood sample, or the release of K from erythrocytes, leukocytes, and platelets during the clotting process in patients with marked leukocytosis (> 50,000/µL) or thrombocytosis (> 500,000/µL)
6
  1. Cushing's syndrome due to adrenal cancer or the ectopic ACTH syndrome and hyperaldosteronism
  2. In association with diuretics (e.g. thiazides, bumetanide, furosemide, ethacrynic acid, but not spironolactone or triamterene)
  3. Hypomagnesemia in osmotic diuresis (e.g. diabetic ketoacidosis); in renal tubular disease, such as type I or type II renal tubular acidosis, Fanconi's syndrome
  4. Excessive licorice ingestion and Liddle's syndrome
  5. Amphotericin B and with antipseudomonal penicillins (e.g. carbenicillin) or high-dose penicillin treatment
  6. Gastrointestinal losses usually are due to diarrhea, chronic laxative abuse or clay ingestion, vomiting or gastric suction (renal K wasting with developing metabolic alkalosis is of primary importance) and bowel diversion
  7. Villous adenoma of the colon is a rare cause of K loss from the GI tract
  8. Beta 2-Adrenergic agonists such as albuterol or terbutaline may produce hypokalemia due to cellular K uptake
  9. Cystic fibrosis
  10. Theophylline intoxication
  11. Cortisol
Hyperkalemia may occur when:
  1. Acidosis (due to accumulation of inorganic acids)
  2. Hyperglycemia (in the presence of insulin deficiency)
  3. Moderately heavy exercise (particularly in the presence of ß-blockade)
  4. Digitalis intoxication, Beta blockers
  5. Acute tumor lysis
  6. Acute intravascular hemolysis or
  7. Hyperkalemic familial periodic paralysis produces a shift of K out of cells into the ECF; or as a consequence of K excess
  8. Since the kidneys normally excrete K loads rapidly, sustained hyperkalemia usually implies diminished renal K excretion
  9. K excess is particularly common in acute oliguric states (especially acute renal failure) associated with severe crush injuries, burns, bleeding into soft tissue or the GI tract, or adrenal insufficiency
TREATMENT:
Acute emergency: Calcium gluconate, sodium bicarbonate, insulin, albuterol
Nonemergency: Furosemide, resins, hemodialysis, peritoneal dialysis
 
Hypokalemia
 
Hyperkalemia
The ECG Changes are:
USMLE Case Scenario
 
Hypomagnesemia
 
Hypermagnesemia
 
8Hypocalcemia
 
Symptoms and Signs: The clinical manifestations of hypocalcemia are primarily neurologic
 
9Causes of Hypercalcemia
Effective in treatment:
 
Simplest Explanation of Metabolic Disorders
CO2
pH
HCO3
Respiratory Acidosis
Respiratory Alkalosis
Metabolic Acidosis
No change
Metabolic Alkalosis
No change
USMLE Case Scenario
USMLE Case Scenario
 
Remember:
 
Anion Gap (AG)
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Conditions with decreased anion gap
 
11Lactic Acidosis
An increase in plasma L-lactate may be secondary to:
 
HYPOTHERMIA
 
Degrees of Hypothermia
Accidental hypothermia occurs when there is an unintentional drop in the body's core temperature below 35 °C (95 °F)
 
Causes
 
Hyper Thermic' Syndromes
 
RESPIRATORY MEDICINE
 
Importance of Different Presentations
 
Sputum
 
Differentiate between Obstructive and Restrictive Lung Disease
Obstructive lung disease
Restrictive lung disease
  • TLC↑
  • TLC↓
  • RV↑
  • RV↓
  • TV↓
  • TV↓
14
  • VC↓
  • VC↓
  • FEV1↓
  • FEV1↓
  • FVC↓
  • FVC↓
  • FEV1/FVC↓
  • FEV1/FVC↑
  • PaCO2
  • PaCO2 (N)or ↓
 
Carbon Monoxide Diffusion Capacity DLCO
Increased In
Decreased In
  • Alveolar hemorrhage
  • Congestive heart failure
  • Interstitial lung disease
  • Emphysema
  • Pulmonary embolism
  • Pulmonary hemorrhage
 
Respiratory Failure
 
Asthma
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Severe asthma
 
15Emphysema and Chronic Bronchitis
 
Bronchiectasis
Bronchiectasis describes a permanent dilatation of the airways secondary to chronic infection or inflammation.
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Bronchiectasis
 
16Causes
 
Primary Ciliary Dyskinesia
 
Cystic Fibrosis (CF)
 
Interstitial Lung Diseases
 
Pleural Effusion
Transudate
Exudate
  • Protein < 3 gm/100 ml
  • LDH < 200 IU
  • LDH Ratio < 0.6
  • Pleural fluid/serum protein < 0.5
    • CHF
    • Cirrhosis
    • Nephrotic syndrome
    • Meig's syndrome
    • Pulmonary embolism
  • Protein > 3 gm/100 ml
  • LDH > 200 IU
  • LDH Ratio > 0.6
  • Pleural fluid/serum protein > 0.5
    • Pneumoniae
    • Pulmonary infarction
    • Tuberculosis
    • Rheumatoid arthritis
    • Myxedema
    • Lupus erythematosus
    • Pulmonary embolism
    • Bronchogenic cancer
 
QUESTIONS ASKED
 
Pleural Fluid Characteristics
 
Pneumonias
 
Remember
USMLE Case Scenario
 
19‘Community-acquired ‘Atypical Pneumonia'
 
High-yield Points in Pneumonia
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Mycoplasma Pneumonia
 
Nosocomial Pneumonia
 
Aspiration Pneumonia and Anaerobic Lung Abscess
 
Aspiration of Solids
 
Mendelson's Syndrome
 
Paroxysmal (Nocturnal) Dyspnea
 
21Necrotizing Pneumonitis
 
FREQUENTLY ASKED
 
Differentiate
 
Allergic Angiitis and Granulomatosis of Churg and Strauss
 
The Hypereosinophilic Syndrome
 
22Remember: Hypersensitive Pneumonitis
  • Farmer's lung
Micropolyspora faeni
Moldy hay
  • Humidifier lung
Thermophilic actinomyces
Air conditioners
  • Bird Fancier's lung
Avian proteins
Bird excreta
  • Baggassosis
Thermoactinomyces sacchri
Sugar cane dust
  • Sequoisis
Graphium/aureobasidium
Sawdust
  • Suberosis
Pencillium frequentans
Cork dust
  • Mushroom Picker's Lung
Micropolysporafaeni
Moldy composite
 
ABPA (Allergic Bronchopulmonary Aspergillosis)
 
Nocardiosis
The clinical manifestations are nonspecific and include fever, cough, weight loss, and dyspnea. The range of pulmonary involvement extends from transient or inapparent infection to confluent bronchopneumonia with complete consolidation. Radiographic examination of the chest may reveal one or more of the following: fluffy infiltrates, multiple abscess formation with cavitation, bulging fissures, masses, nodules, and empyema.
 
23Pulmonary Tuberculosis
 
Primary Pulmonary Tuberculosis
 
Postprimary Disease
 
Pleural Tuberculosis
 
24Tuberculous Empyema
 
Cryptic Miliary Tuberculosis
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Tuberculocidal drugs
Isoniazid, Rifampin, Pyrazinamide, Streptomycin
Tuberculostatic drugs
Ethambutol, Thiacetazone, PAS, Ethionamide, Cycloserine
 
Important Points about TB in HIV-Positive Individuals
 
MAC Mycobacterium Avium Complex
 
Pneumocystis Carinii
 
Several Antimicrobials are Effective for PCP Infection
 
Sarcoidosis
Typical USMLE Case Scenario
 
Lymphangioleiomyomatosis (LAM)
 
Pulmonary Hypertension PPH
 
Guidelines for Treatment in PPH
 
Lung Cancer
 
Small Cell Carcinoma of Lung: Oat Cell Carcinoma
 
Lambert-Eaton Syndrome
 
Pulmonary Embolism
USMLE Case Scenario
 
Pneumothorax
 
Tension Pneumothorax
 
Remember
 
USMLE High Yield
The risk of a smoker with asbestos exposure developing lung cancer is about greater than the regular population. The patient has an increased risk for lung cancer and would greatly benefit from smoking cessation. Asbestosis can lead to an interstitial lung disease in patients with or without a smoking history. Even nonsmokers may present with dyspnea on exertion, cough, chest wall pain, and ultimately, end-stage lung disease. Patients with asbestosis are at increased risk for pleural or peritoneal mesotheliomas.
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X-ray presentations of asbestosis
 
ARDS Shock Lung/DAD (Diffuse Alveolar Damage)
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Features of ARDS
 
Respiratory Causes of Clubbing
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  • Most common cause of hemoptysis
  • Most common cause of hemoptysis in india
  • Most common cause of massive hemoptysis
  • Most common cause of massive hemoptysis in India
  • Most common presenting symptom of lung cancer
  • Most common site for bronchogenic cysts
  • Most common cause of stridor in children
  • Bronchitis
  • Tuberculosis
  • Bronchiectasis
  • Tuberculosis
  • Cough
  • Middle mediastinum
  • Foreign body
33
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CXR demonstrating COPD (Emphysematous Lung)
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CXR demonstrating miliary tuberculosis
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Rib-notching in coarctation of aorta
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CXR demonstrating a big right-sided pleural effusion
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CXR demonstrating atelectasis of right lung
(i) Homogenous density right hemithorax, (ii) Mediastinal shift to right, (iii) Right hemithorax smaller, (iv) Right heart and diaphragmatic silhouette are not identifiable
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CXR demonstrating bihilar adenopathy
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CXR of a squamous cell carcinoma of the left upper lobe of lung
 
34CARDIOVASCULAR MEDICINE
 
Different Types of Pulse
 
Waves in JVP
 
35Heart Sounds
Heart sounds
Cause
First
Closure of AV valves (Mitral Tricuspid)
High-pitched duration: 14 seconds
SOFT S1 is seen in:
  • MS (long-standing, calcified)
  • Obesity
  • MR
  • Pleural effusion
  • Loud S1 is heard in:
anemia, anxiety, fever, Thyrotoxicosis
ASD, PDA
MS (Polonged flow through AV valve)
Second
Closure of semilunar valves (aortic, pulmonary)
Wide split of S2 is seen in:
ASD, MR, PS
Reverse splitting of S2 is seen in:
LBBB, HTN, AS
 
S3
 
S4
Differentiating Different Types of Shock
  • Cardiogenic shock
↑PCWP
↓CO
  • Volume overload
↑PCWP
↑CO
  • Hypovolemic shock
↓PCWP
  • Noncardiogenic shock (ARDS)
n PCWP
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Parameters in shock
 
Recognizing Certain ECG Rhythms
 
37Conduction Abnormalities
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Normal ECG
 
Waves of Normal ECG
Wave/Segment
From – To
Cause
Duration (second)
P wave
_
Atrial depolarization
0.1
QRS complex
_
Ventricular depolarization
0.08 – 0.10
T wave
_
Ventricular repolarization
0.2
P–R interval
Onset of P wave to onset of Q wave
(0.12 to 0.2)
Q–T interval
Onset of Q wave and end of T wave
0.4 – 0.42
 
Prolonged
 
38Important Points to Note in ECG
 
‘Pacemaker' Syndrome
 
Relative Bradycardia
 
ECG: Axis Deviation
 
39ST Elevation is seen in
 
Torsades De Pointes
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Causes: Prolonged QT Syndrome
 
Wolff-Parkinson-White Syndrome
 
40Drugs and Arrhythmias
  • DOC for ventricular arrhythmias
Lidocaine
  • DOC for AF without heart failure
Beta blockers
  • DOC for Atrial flutter without heart failure
Beta blockers
  • DOC for AF with heart failure
Digoxin
  • DOC for Atrial flutter with heart failure
Digoxin
  • DOC for PSVT
Adenosine
  • DOC for WPWS
Procainamide
  • DOC for ventricular ectopics
Beta blockers
  • DOC for sinus bradycardia
Atropine
 
Sinus Bradycardia
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Heart rate: < 60 bpm, regular rhythm
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41Atrial Fibrillation
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Heart rate greater than 350, irregular rhythm, fibrillatory p wave
 
PVC
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Every third beat is a PVC
 
Ventricular Tachycardia
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42Ventricular Fibrillation
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VF: Here heart rate is greater than 300, irregular rhythm, absent P wave, fibrillatory base line
 
Myocardial Infarction
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Anteroseptal MI
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The QS complexes, resolving ST segment elevation and T wave inversions in V1-2 are evidence for a fully evolved anteroseptal MI
 
43Old Inferior MI
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Anteroseptal MI
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LVH with ‘Strain'
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44Left Atrial Enlargement
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LAE is best seen in V1 with a prominent negative (posterior) component measuring 1 mm wide and 1 mm deep hypothermia: J-waves or Osborn waves
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In hypothermia, a small extra wave is seen immediately after the QRS complex (best seen in Lead I in this example) This wave is called a J-wave, or Osborn wave. This wave disappears with the warming of body temperature
 
MURMURS: INNOCENT MURMUR FEATURES
 
7 Ss
 
Murmurs
Ejection systolic
Pan-systolic
Late systolic
Early diastolic
Mid-diastolic
  • Aortic stenosis
  • Pulmonary stenosis
  • HOCM
  • ASD
  • Fallot's
  • Mitral regurgitation
  • Tricuspid regurgitation
  • Mitral prolapse
  • VSD
  • HOCM
  • Mitral valve prolapse
  • Coarctation of aorta
  • Aortic regurgitation
  • Mitral stenosis
  • Austin-Flint murmur (severe aortic regurgitation)
 
45Continous murmur is seen in
 
REMEMBER
 
Coarctation of the aorta
 
Cyanotic Congenital Heart Diseases
 
Rheumatic Heart Disease
 
Rheumatic Heart Disease
 
Mitral Stenosis
Mitral stenosis: It is said that the causes of mitral stenosis are rheumatic fever, calcium deposits and narrowing of motral valve in Newborn babies. Rarer causes that may be seen include mucopolysaccharidoses, carcinoid and endocardial fibroelastosis
Features:
  • Mid-diastolic murmur (Best heard in expiration)
  • Loud S1, opening snap
  • Low volume pulse
  • Malar flush
  • Atrial fibrillation
  • Hemoptysis seen
  • Hoarseness of voice is seen in MS
  • Left atrial myxoma is an important differential diagnosis
  • Pulmonary hypertension occurs
Features of severe MS:
Length of murmur increases, opening snap becomes closer to S2
Echocardiography:
Most useful in MS is echocardiography
  • The normal cross-sectional area of the mitral valve is 4–6 sq cm
  • A ‘tight' mitral stenosis implies a cross-sectional area of < 1 sq cm
  • < 0.6 cms of mitral vavle area is incompatible with life.
USMLE Case Scenario
 
47Aortic Stenosis
 
Aortic Regurgitation
Signs seen in AR
  • Corrigan's sign
Dancing carotids
  • De Musset's sign
Head movements with cardiac pulse
  • Quincke's sign
Capillary pulsations
  • Traube's sign
Pistol shot sounds over femorals
  • Duroziez's murmur
Diastolic murmur over femorals
48
  • Hill's sign
Femoral-Brachial pulse gradient
  • Lighthouse sign
Blanching/flushing of forehead
  • Landolfi's sign
Alternate constriction/dilation of pupil
  • Muller's sign
Uvual pulsations
  • Rosenbach's sign
Liver pulsations
  • Gerhard's sign
Splenic pulsations
  • Lincoln's sign
Pulsating popliteals
  • Mayer's sign
Diastolic drop on raising arm
 
AR
 
MVP: Floppy Valve Syndrome/Mitral Valve Prolapse
 
CARDIOMYOPATHIES
 
HOCM
 
Dilated Cardiomyopathy
 
Restrictive Cardiomyopathy
 
50Infective Endocarditis
zoom view
 
Atherosclerosis
 
51ECG Changes seen in Acute Myocardial Infarction
 
ECG: Coronary Territories (Infarct areas)
 
Key Points for the Exam
Begins to rise
Peak value
Returns to normal
Myoglobin
1–2 hours
6–8 hours
1–2 days
CK-MB
2–6 hours
16–20 hours
1–2 days
CK
4–8 hours
16–24 hours
3–4 days
Trop T
4–6 hours
12–24 hours
7–10 days
AST
12–24 hours
36–48 hours
3–4 days
LDH
24–48 hours
72 hours
8–10 days
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Sequence of MI
 
52Wolff-Parkinson-White (WPW) Syndrome (ADDITIONAL)
 
53Mitral Valve Prolapse: (ADDITIONAL)
 
Digoxin Toxicity
 
Long QT Syndrome (ADDITIONAL)
 
Acute Pericarditis
 
Cardiac Tamponade
 
55Constrictive Pericarditis
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Heart failure
 
Pericardial Effusion
 
HEMATOLOGY
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Changes in reticulocyte count
 
Microcytic Anemia
Iron deficency
Thalassemia
Sideroblastic anemia
Chronic anemia
Sr Fe
n
n
TIBC
n
n
% Saturation
Ferritin
 
Paterson-Kelly Syndrome is Characterized
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57Megaloblastic Anemia
 
58Tongue in Megaloblastic Anemia
 
Folate Deficiency
USMLE Case Scenario
 
Hemolytic Anemias: By Site
 
Intravascular Hemolysis: Causes
 
Extravascular Hemolysis: Causes
 
59Features of Hemolytic Anemia
 
Features of Hemolysis
 
Sickle-cell Crises
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60Four Main Types of Crises are recognized
USMLE Case Scenario
USMLE Case Scenario
 
USMLE High Yield
 
Applications of Gene Therapy
 
Glucose 6 Phosphate Dehydrogenase Deficiency G6PD
 
Hereditary Spherocytosis
 
Structure of RBC Membrane
 
Paroxysmal Nocturnal Hemoglobinuria (PNH)
 
The LAP Score
 
Sideroblastic Anemia
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Pyridoxine response +ve
 
Pernicious Anemia
 
64Remember
  • Uremia
  • G6PD deficiency
  • Helmet cells
  • Burr cells are seen
  • Bite cells
  • Hemolytic Uremic Syndrome
  • Cirrhosis
  • Spur cells are seen
  • Iron depletion
  • Seen in iron-deficiency anemia, polycythemia vera
  • Thalassemia minor
  • Decreased osmolysis, microcytic hypochromic anemia, increased HbA2.
  • Sickle-cell anemia
  • Tactoids and sickling seen
  • Acquired spherocytosis
  • Schistocytes present, Coombs positive
  • Hereditary spherocytosis
  • Coombs negative
  • Aplastic anemia
  • Platelets maximum affected and last to recover, pancytopenia present
  • Pernicious anemia and folate deficiency anemia
  • Anisocytosis, poikilocytosis, fragmented RBCs, neutrophil lobes increased, platelets normal. Absolute reticulocyte count low.
  • Sideroblastic anemia
  • Ring sideroblasts present (These are iron granules in mitochondria around the nucleus), microcytic, hypochromic RBCs, macrocytic hypo- or normochromic RBCs
USMLE Case Scenario
 
Pan Cytopenia is seen in
 
Polycythemia Rubra Vera
USMLE Case Scenario
 
Myelophthisic Anemia
 
Tumors Associated with Polycythemia
 
Thrombocytopenia
 
Hemophilia
 
Coagulation Defects
  • Hemophilia A
Deficiency of factor VIII C
  • Hemophilia B (Christmas disease)
Deficiency of factor IX (X-linked)
  • Hemophilia C
Deficiency of factor XI (autosomal inherited defect)
  • Parahemophilia
Deficiency of factor V
  • von Willebrand's disease
Deficiency of v WF along with VIII C
 
von Willebrand's Disease
USMLE Case Scenario
 
Hemophilia
 
von Willebrand's Disease (NUTSHELL)
 
Factor V Leiden Mutation
 
Genetical Hypercoagulable States
 
Parameters in Different Disorders (Bleeding)
  • von Willebrand's disease
BT
PTT
  • Liver failure
PT
PTT
  • Heparin
PTT
  • Warfarin
PT
  • Scurvy
N
  • ITP
BT
Platelets
  • TTP
BT
Platelets
 
Antiphospholipid Syndrome
 
Leukemoid Reaction
USMLE Case Scenario
 
Chronic Lymphocytic Leukemia (CLL)
 
Blood Transfusion Complications
 
70Viruses Transmitted by Blood Transfusion
 
Thrombophilia
 
ITP (Idiopathic Thrombocytopenic Purpura)
 
DIFFERENTIATE ITP FROM TTP AND HUS
 
TTP (Thrombotic Thrombocytopenic Purpura)
 
71HUS: (Hemolytic Uremic Syndrome)
 
Some Specific Splenomegalic Syndromes
 
Common Translocations associated with Hematological Malignancies
 
72Hodgkin's Disease
 
Ann-Arbor Staging of Hodgkin's Lymphoma
 
Each Stage May be Subdivided into A or B
 
73Burkitt's lymphoma
 
Hairy Cell Leukemia
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74Mantle Cell Lymphoma
 
Blood Films: Typical Pictures
Hyposplenism, e.g. postsplenectomy
Iron-deficiency anemia
Myelofibrosis
Megaloblastic anemia
  • Target cells
  • Howell-Jolly bodies
  • Target cells
  • ‘Pencil' poikilocytes
  • ‘Tear-drop' poikilocytes
  • Hypersegmented neutrophils
  • Cabot's rings
  • Siderotic granules
  • Acanthocytes
  • Schizocytes
  • If combined with B12/folate deficiency, a ‘Dimorphic' film occurs with mixed microcytic and macrocytic cells
 
Leucocyte Alkaline Phosphatase (LAP)
Raised In
Low In
  • Myelofibrosis
  • Leukemoid reactions
  • Polycythemia rubra vera
  • Infections
  • Steroids, Cushing's syndrome
  • Pregnancy, oral contraceptive pill
  • Chronic myeloid leukemia
  • Pernicious anemia
  • Paroxysmal nocturnal hemoglobinuria
  • Infectious mononucleosis
 
Cat Scratch Disease
 
75Takayasu's Arteritis
 
Polyarteritis Nodosa and Microscopic Polyangiitis
 
Kawasaki Disease
 
Polymyositis/Dermatomyositis
 
Reiter's Syndrome (RS)
 
Temporal Arteritis
USMLE Case Scenario
 
Raynaud's Phenomenon and Disease
 
Erythromelalgia
 
Acrocyanosis
 
Systemic Lupus Erythematosus (SLE)
 
Lab Tests
 
Drug-induced Lupus
 
Progressive Systemic Sclerosis (PSS) (Scleroderma)
 
Sjogren's Syndrome
 
Behçet's Syndrome: Oro-oculo-genital Syndrome
USMLE Case Scenario
 
Henoch Schönlein Purpura
 
Differentiate
USMLE Case Scenario
 
Rocky Mountain Spotted Fever
USMLE Case Scenario
 
Paraneoplastic Syndromes (Endocrine Syndromes)
  • Hypercalcemia of malignancy
Hypercalcemia with cancer is classified as humoral hypercalcemia of malignancy (HHM), which is caused by circulating hormones, or local osteolytic hypercalcemia (LOH), which is caused by local paracrine factors secreted by cancers within the bone
Parathyroid hormone-related peptide (PTHrP) causes nearly all cases of HHM, while the mediators of LOH in bone are heterogenous
  • Hyponatremia of malignancy
Due to the inappropriate secretion of arginine vasopressin (AVP) and is termed as the syndrome of inappropriate antidiuretic hormone secretion (SIADH)
Small cell lung cancer is the malignancy chiefly responsible for producing ectopic AVP
  • Ectopic acth syndrome
Responsible for ~15% of all cases of Cushing's syndrome and for most cases of Cushing's syndrome that occur in cancer patients
Ectopic ACTH syndrome is most commonly due to small cell lung cancer (50% of cases), bronchial carcinoid tumors (10%), thymic carcinoid tumors or thymomas (10%), pancreatic islet cell tumors (10%), pheochromocytoma or other neural crest tumors (5%), or medullary carcinoma of the thyroid (5%).
  • Ectopic acromegaly
Ectopic production of growth hormone-releasing hormone (GHRH) is the predominant cause of ectopic acromegaly
The cancers associated with ectopic acromegaly include carcinoid tumors of the bronchus, pancreatic islet cell tumors, and cancers of the lung, breast, colon and adrenal glands.
  • Gynecomastia
Ectopic production of hCG is the most common cause of paraneoplastic gynecomastia; hepatoma or a germ cell tumor with choriocarcinoma elements contains aromatase enzyme activity that converts circulating androgens to estrogen. Other tumors rarely associated with ectopic gynecomastia include carcinoid tumors of the bronchus, intestine, and small cell lung cancer
About 5% of men with testicular choriocarcinoma present with an enlarging breast mass.
84
  • Non-islet cell tumor hypoglycemia
Can occur with large, slow-growing sarcomas, mesotheliomas, and hepatomas.
USMLE Case Scenario
 
Hematologic Syndromes
  • Erythrocytosis
Renal cell cancer, 10% of patients with hepatoma, and 15% of patients with cerebellar hemangioblastomas have erythrocytosis
  • Granulocytosis
Tumors and tumor cell lines from patients with lung, ovarian, and bladder cancers have been documented to produce granulocyte colony-stimulating factor (G-CSF), granulocyte-macrophage colony-stimulating factor (GM-CSF)
  • Thrombocytosis
Lung and gastrointestinal cancers, 20% of patients with breast, endometrial, and ovarian cancers, and 10% of patients with lymphoma
  • Eosinophilia
Eosinophilia is present in 10% of patients with lymphoma, 3% of patients with lung cancer, and occasional patients with cervical, gastrointestinal, renal, and breast cancer
  • Thrombophlebitis
Lung, pancreatic, gastrointestinal, breast, ovarian, and genitourinary cancers, lymphomas, and brain tumors
 
Medical Oncology
Cytotoxic
Mechanism of action
Adverse effects
  • Vincristine
Inhibits formation of microtubules
Peripheral neuropathy (reversible)
  • Cisplatin
Causes cross-linking in DNA
Ototoxicity, peripheral neuropathy
  • Bleomycin
Degrades preformed DNA
Lung fibrosis
  • Doxorubicin
Stabilizes DNA—topoisomerase II complex inhibits DNA and RNA synthesis
Cardiomyopathy
  • Methotrexate
Inhibits purine synthesis
Myelosuppression, mucositis
  • Cyclophosphamide
Alkylating agent—causes cross-linking in DNA
Hemorrhagic cystitis, myelosuppression
 
TREATMENT-RELATED ONCOLOGICAL EMERGENCIES
 
Tumor Lysis Syndrome
 
85Human Antibody Infusion Reactions
 
Hemolytic Uremic Syndrome
 
Neutropenia and Infection
 
Pulmonary Infiltrates
 
Typhlitis
 
Hemorrhagic Cystitis
 
MUSCLE DISORDERS
 
Toxic Myopathies
 
Polymyositis
 
Inclusion Body Myositis
USMLE Case Scenario
 
Duchenne's Muscular Dystrophy
 
Other Muscular Dystrophies
zoom view
Pattern of inheritance
 
Calcium Channel Disorders of Muscle
 
Sodium Channel Disorders of Muscle
 
CHLORIDE CHANNEL DISORDERS OF MUSCLE
 
Myotonia Congenita
 
Myasthenia Gravis (MG)
 
90GIT
  • Migratory glossitis
Geographic tongue
  • Atrophic glossitis
Iron deficiency
  • Leutic glossitis
Syphilis
 
Esophagitis
 
Plummer-Vinson Syndrome
 
Gastritis
 
Menetrier's Disease
 
Schindler's Disease
 
H. pylori
 
Causes
Duodenal Ulcer
Gastric Ulcer
  • More common
  • More associated with H. pylori
  • Early age of onset
  • Occur most often in the first portion of duodenum), with ~90% located within 3 cm of the pylorus
  • Usually < 1 cm in diameter
  • Less chances of malignancy
  • No loss of weight
  • Tenderness usually in R Hypochondrium
  • Night pain common
  • Less common
  • Associated with H. pylori
  • Later age of onset
  • Occur most often in the lesser curvature
  • More chances of malignancy
  • Loss of weight
  • Tenderness usually midline
  • Night pain uncommon
 
GI BLEEDING: CAUSES
 
ABCDEFGHI
 
MALABSORPTION
 
Tropical Sprue
 
Whipple's Disease
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94Celiac Disease
 
In Nutshell
 
Tests for GIT
Ulcerative Colitis
Crohn's disease
Involves rectum always
Involves ileum mostly
May cause ‘pancolitis'
Diffuse involvement
Nondiffuse involvement
Called ‘regional enteritis'
Retrograde spread to ileum is backwash ileitis
Disease of continuity
Skip lesions
Pseudopolyps present
Pseudopolyps absent
Limited to mucosa and submucosa
Transmural inflammation
Noncaseating granulomas not seen
Noncaseating granulomas seen
Creeping fat not seen
Creeping fat seen
Strictures, ulcerations, fistula less frequent
Strictures, ulcerations, fistula frequent
Toxic megacolon occurs
Rare
Malignant transformation +++
Malignant transformation +
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Mediators of inflammatory bowel diseases
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Extraintestinal manifestations of Crohn's disease
 
Verner-Morrison Syndrome
 
VIRAL HEPATITIS
 
Incubation period
 
HDV
 
Fitz-Hugh-Curtis Syndrome
 
98Budd-Chiari Syndrome: (5 Ps)
 
Wilson's Disease
 
99Disease of C (Wilson's Disease)
 
Hemochromatosis
 
Clinical Manifestations
Initial symptoms include weakness, lassitude, weight loss, change in skin color, abdominal pain, loss of libido, and symptoms of diabetes mellitus
 
Diagnosis
 
Primary Biliary Cirrhosis
 
Spontaneous Bacterial Peritonitis (SBP)
 
Carcinoid Syndrome
 
Hepatorenal Syndrome
 
Hypoxemia and Hepatopulmonary Syndrome
 
102Remember
 
RENAL SYSTEM
 
Significance of Casts
 
Recurrent Gross Hematuria is seen in
 
Prerenal Uremia-Kidneys hold on to sodium to preserve volume
Prerenal uremia
Acute tubular necrosis
Urine sodium
< 20 mmol/L
> 30 mmol/L
Fractional sodium excretion*
< 1%
> 1%
Fractional urea excretion**
< 35%
>35%
Urine: plasma osmolality
> 1.5
< 1.1
Urine: plasma urea
> 10:1
< 8:1
Specific gravity
> 1020
< 1010
Urine
‘bland' sediment
brown granular casts
Response to fluid challenge
Yes
No
 
Seen in CRF are
 
Diabetes Mellitus
Epidemiology
IDDM
NIDDM
Age at onset
Heredity
Autoimmunity
Clinical
treatment
Younger, lean patients
Usually < 25 years
HLA-DR 3 and/or DR 4 (95%)
30–50% concordance in identical twins
Presence of islet cell antibody, Insulin autoantibody. Association with other organ-specific autoimmune diseases
Insulin deficiency
May develop ketoacidosis
Insulin
Older, obese patients
Usually > 40 years
No HLA links
90% concordance in identical twins
None
Partial insulin deficiency, Insulin resistance
May develop nonketotic hyperosmolar state
Weight loss, drugs, insulin sometimes
 
Remember
 
Diabetic Nephropathy
 
Diabetic Nephropathy: Stages
 
Differences between Nephritic and Nephrotic Syndromes
Nephritic Syndrome
Nephrotic Syndrome
  1. Hematuria
  2. Hypertension
  3. Oliguria
  4. Proteinuria
  1. Severe proteinuria
  2. Hypoalbuminemia
  3. Hyperlipidemia
  4. Fibrinogen increased
  5. Lipoproteins increased
  6. Low serum calcium
  7. Platelet activation
  8. Decreased HDL
 
Acute Nephritic Syndrome
 
Kidney in HIV
 
Wegner's Granulomatosis
 
Goodpasture's Syndrome
 
Alport's Syndrome (Hereditary Nephritis)
 
Rhabdomyolysis
 
Liddle's Syndrome
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Differentiating features
 
Bartter's Syndrome
 
Renal Tubular Acidosis
 
Pheochromocytomas
 
110Polycystic Kidney Disease
 
Remember APKD: 11 B's
 
Tuberous Sclerosis
 
von Hippel-Lindau Disease
 
111Causes of Enlarged Kidneys: SHAPE
 
Diabetes Insipidus
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Differentiating diabetes insipidus
USMLE Case Scenario
 
Renal Vein Thrombosis (RVT)
 
Renal Artery Stenosis
 
113Dialysis
 
Hemodialysis is done for Poisoning in Blood From
 
For Dialysis, Properties Should be
 
Cushing's Syndrome
 
Tests
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Cushings disease
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Difference
 
115Thyroid Endocrinology
 
Drugs for Hyperthyroidism
 
Subacute Thyroiditis or De Quervain's Thyroiditis or Granulomatous Thyroiditis or Giant Cell Thyroiditis
 
Hypothyroidism
 
Primary Hyperparathyroidism
 
Hypoparathyroidism
 
Conn's Syndrome
 
Addison's Disease
 
Adrenal Insufficiency
 
Waterhouse-Friderichsen Syndrome
 
SIADH
 
119Polyglandular Autoimmune Syndrome Type I
 
Polyglandular Autoimmune Syndrome Type II
 
Insulinomas
 
Glucagonomas
 
Somatostatinoma Syndrome
 
VIPomas
 
Important Enzymes and Clinical Correlations
 
NEUROLOGY
 
Alzheimer's Disease
 
Frontotemporal Dementia and Pick's Disease
 
Diffuse Lewy Body Disease
 
Normal Pressure Hydrocephalus
 
Huntington's Disease
 
MS (Multiple Sclerosis)
 
Learn to Differentiate
 
Remember Epilepsy Syndromes Given Below
 
Progressive Multifocal Leukoencephalopathy
 
SSPE
 
Prion Diseases
 
Creutzfeldt-Jakob Disease
 
Guillain-Barré Syndrome
 
Miller-Fisher Syndrome
 
Friedreich's Ataxia
 
127Ataxia-telangiectasia
 
Newer Concepts
 
Diseases of the Cerebellum
 
Bacterial Meningitis
 
The Classic CSF Abnormalities in Bacterial Meningitis are
 
Commonest Causes of Meningitis
 
Viral Meningitis
 
Cryptococcus Neoformans Meningitis
 
Neuroimaging
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This is a normal sagittal MRI scan demonstrating the midline with the frontal lobe and parietal lobe and occipital lobe and cerebellum and genu of corpus callosum and splenium of corpus callosum and mammillary body and thalmus and midbrain and pons and medulla and cervical spinal cord and tongue and nasal cavity
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TCT scan without contrast demonstrating a large epidural hematoma with right to left shift and ventricular narrowing
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131MRI scan of the head in coronal view demonstrates a cysticercus cyst of the brain
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This computed tomographic (CT) scan of the head in transverse view demonstrates an area of hemorrhage arising in the basal ganglia on the left
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CT scan without contrast demonstrating a large subdural hematoma with left to right shift and ventricular narrowing
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132MRI scan in axial view here demonstrates a macroadenoma of the pituitary
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CT scan, there is a midline cerebellar mass in a child
 
Encephalitis
 
Progressive Rubella Panencephalitis
 
Benign Intracranial Hypertension
 
Pseudotumor Cerebri
 
Neuropathic Joint Disease
 
135Remember Here: Joint Erosions are seen in
 
Intracerebral Leukocytostasis
  • Putamen hemorrhage
Hemiparesis, hemisensory loss, homonymous hemianopia
  • Pontine hemorrhage
Pin-point pupils, reactive to light, no horizontal eye movements
  • Brainstem lesion
Sensory loss of half of face, contralateral half of body with cranial nerve lesions
  • Thalamic lesion
Sensory loss of half of face and ipsilateral half of body
  • Cerebellar involvement
Hypotonia, tremor, ataxia
 
Arterial Territories and Important Points in Blood Supply of Brain
 
Occlusion of the Anterior Spinal Artery May Cause
 
Occlusion of the Posterior Spinal Artery May Cause
 
Remember Lesions and their Locations
 
Parkinsonism
USMLE Case Scenario
 
Drugs Causing Parkinsonism
 
Remember
 
138Clinical Scenarios of Headache
  • A patient comes with severe, unilateral headaches several times a day with lacrimation, photophobia
  • Cluster headache
  • Periorbital
  • Male predominant
  • A person reports with severe, unilateral, throbbing headache with aura of scintilating scotomas
  • Migraine
  • Lateralized usually
  • Female predominant
  • Often preceded by aura, photopsia
  • Photophobia, nausea, vomiting
  • An elderly person reports scalp tenderness, intermittent throbbing and jaw claudication. ESR is↑.
  • Temporal arteritis
  • A person reports with prostrating headache associated with nausea and vomiting. The history will usually reveal that the headache started with severe eye pain. On physical examination, the eye is often red with a fixed, moderately dilated pupil
  • Glaucoma
  • A person reports with chronic head pain syndrome characterized by bilateral tight, band-like discomfort
  • Tension and headache
  • Tight band-like discomfort
  • Usually generalized with exacerbation by stress, fatigue
  • A patient reports with pain located at the jaw or neck, deep, dull, and aching, and it becomes pounding or throbbing. There are often superimposed sharp, ice pick-like jabs. Tenderness and prominent pulsations of the cervical carotid artery and soft tissue swelling
  • Caritodynia
  • A patient reports with vertigo, dysarthria, or diplopia, tinnitus, distal and perioral paresthesia, and occipital headache
  • Basila-migraine
  • A 56-year-old female presents with severe headache and neck stiffness of abrupt onset. She tells she never had such a headache before. She is nauseated and has photophobia
  • SAH
 
Subarachnoid Hemorrhage (SAH)
 
CRANIAL NERVE DISORDERS
 
Trigeminal Neuralgia
 
Glossopharyngeal Neuralgia
 
Facial Nerve Disorders: Bell's Palsy
 
PERIPHERAL NEUROPATHY
Peripheral neuropathy may be divided into conditions which predominately cause a motor or sensory loss.
 
Diseases with Predominately Motor Loss
 
Diseases with Predominately Sensory Loss
 
Vitamin B12 Deficiency
 
Amyotrophic Lateral Sclerosis
 
141Remember
 
Pearls about Brain Tumors
 
Brain Tumors are associated with
 
Fevers
Fever
Causative Organism
  • Sandfly fever
  • Arbovirus
  • Lassa fever
  • Arena virus
  • Glandular fever
  • Ebstein-barr virus
  • Boutonneuse fever
  • Rickettsiae conorii
  • Oroya fever
  • Bartonella
  • Pretibial fever
  • Leptospirosis
  • Canicola fever
  • Leptospirosis
  • Swamp fever
  • Leptospirosis
  • Seven-day fever
  • Leptospirosis
  • Haverhill fever
  • Streptobacillus moniliformis
  • Scarlet fever
  • Streptococci
  • Pontiac fever
  • Legionella
 
142Parasitic Diseases
Type of Schistosomiasis presenting predominantly with pulmonary hypertension
  • Schistosoma mansoni
Type of Schistosomiasis presenting predominantly with portal hypertension
  • Schistosoma japonicum
Type of Schistosomiasis presenting predominantly with hematuria
  • Schistosoma hematobonium
Parasitic disease in which pruritis ani is a feature
  • Pinworm infection
Parasitic disease in which rectal prolapse is a feature
  • Whipworm
Parasitic disease in which intestinal obstruction is a feature commonly
  • Roundworm
Parasitic disease in which megaloblastic anemia is a feature
  • Diphyllobathrium latum
Parasitic disease in which cholangitis or cholangiocarcinoma is a complication
  • Clonorchis sinesis
Parasitic disease in which megaesophagus is a feature
  • Chagas disease
Parasitic disease in which anchovy sauce expectoration is seen
  • Amebic abscess
Parasitic disease in which tennis racket-shaped organisms produce malabsorption
  • Giardiasis
Parasitic disease in which hemoptysis is a feature
  • Paragonimiasis
Parasitic disease in which elephantiasis occurs is a feature
  • Filariasis
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Antibody Target
Disease
  • Nicotinic acetyl choline receptor
  • Myasthenia gravis
  • Intrinsic factor
  • Pernicious anemia
  • Proteinase 3 (ANCA)
  • Wegner's granulomatosis
  • Alpha 3 chain of Collagen Type IV
  • Goodpasteur's syndrome
  • Thyroid peroxidase
  • Hashimoto's thyroiditi's
 
Enzyme Deficiencies in Porphyrias
  • Erythropoietic porphyria
  • Hereditary porphyria
  • Ferrochelatase
  • Coproporphynogen oxidase
  • Variegate porphyria
  • Acute Intermittent porphyria
  • Porphyria cutanea tarda
  • Congenital erythropoietic porphyria
  • Protoporphyrinogen oxidase
  • Porphobilinogen deaminase
  • URO decarboxylase
  • URO III CoA synthase
 
Eponym Spots in Medicine
  • Koplik spot
Measeles
  • Roth Spots
SABE
  • Bitot's Spots
Vitamin A deficiency
  • Herald Spot
Pitryriasis rosea
  • Café au lait spots
Peutz-jegher's syndrome
 
Important Eponyms
  • Hebra nose
Rhinoscleroma
  • Rubber man
Ehler-Danlos syndrome
  • Sailors skin
Solar elastosis
  • Petrified man
Myositis ossificans
Gamma heavy chain disease:
Franklin's disease
Alpha heavy chain disease:
Seligmann's disease
 
144Rare Syndromes
 
Important Triads and Pentads to be remembered
 
145Concept Clarifications
  • Hutchinson's freckle
  • Hutchinson's pupil
  • Hutchinson's sign
  • Hutchinson's teeth
  • Hutchinson's triad
  • Hutchinson's #
  • Hutchinson's book
Lentigo maligna (melanoma variant)
Blown pupil in uncal herniation
Herpes zoster ophthalmicus, vesicles at tip of nose
Small, widely spaced teeth in congenital syphilis
Interstitial keratitis, notched incisors, VIII nerve deafness
# radial styloid process
Book on medicine (not asked in exams)
  • Charcot's crystals
  • Charcot's disease
  • Charcot's joint
  • Charcot's triad
  • Charcot's aneurysm
In bronchial asthma
ALS
Neuropathic joints in leprosy, syphilis
Seen in multiple sclerosis, cholangitis
Brain aneurysm
 
CD Markers
  • Hairy cell leukemia
  • Mantle cell lymphoma
  • CLL
  • Apoptosis
CD 103+
CD 5+, CD 103
CD 23+
CD 95+
 
Remember
  • Nonenhancing lesion in AIDS
  • Solitary weakly ring-enhancing lesion
  • Multiple ring-enhancing lesions
PML
CNS lymphoma
Toxoplasmosis
USMLE Case Scenario
USMLE Case Scenario
 
Progressive Multifocal Leukoencephalopathy
  • Pott's puffy tumor
  • Cock's peculiar tumor
Osteomyelitis of skull
Complicated, infected sebaceous cyst
 
Cardiac Tamponade
 
147Constrictive Pericarditis
 
‘Quick wrap-up': Important Points Highlighted
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