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

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Ultratrace Elements
Deficiency of Minerals
  • Iron deficiency
  • Iodine
  • Zinc
  • Copper
  • Selenium
  • Chromium
  • Microcytic anemia
  • Goiter
  • Acrodermatitis enteropathica
  • Menkes disease
  • Cardiomyopathy
  • Impaired glucose tolerance
Arsenic-related Diseases
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)
  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
Acute emergency: Calcium gluconate, sodium bicarbonate, insulin, albuterol
Nonemergency: Furosemide, resins, hemodialysis, peritoneal dialysis
The ECG Changes are:
USMLE Case Scenario
Symptoms and Signs: The clinical manifestations of hypocalcemia are primarily neurologic
9Causes of Hypercalcemia
Effective in treatment:
Simplest Explanation of Metabolic Disorders
Respiratory Acidosis
Respiratory Alkalosis
Metabolic Acidosis
No change
Metabolic Alkalosis
No change
USMLE Case Scenario
USMLE Case Scenario
Anion Gap (AG)
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Conditions with decreased anion gap
11Lactic Acidosis
An increase in plasma L-lactate may be secondary to:
Degrees of Hypothermia
Accidental hypothermia occurs when there is an unintentional drop in the body's core temperature below 35 °C (95 °F)
Hyper Thermic' Syndromes
Importance of Different Presentations
Differentiate between Obstructive and Restrictive Lung Disease
Obstructive lung disease
Restrictive lung disease
  • TLC↑
  • TLC↓
  • RV↑
  • RV↓
  • TV↓
  • TV↓
  • 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
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Severe asthma
15Emphysema and Chronic Bronchitis
Bronchiectasis describes a permanent dilatation of the airways secondary to chronic infection or inflammation.
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Primary Ciliary Dyskinesia
Cystic Fibrosis (CF)
Interstitial Lung Diseases
Pleural Effusion
  • 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
Pleural Fluid Characteristics
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
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
  • Suberosis
Pencillium frequentans
Cork dust
  • Mushroom Picker's Lung
Moldy composite
ABPA (Allergic Bronchopulmonary Aspergillosis)
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
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
Tension Pneumothorax
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
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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
Different Types of Pulse
Waves in JVP
35Heart Sounds
Heart sounds
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
MS (Polonged flow through AV valve)
Closure of semilunar valves (aortic, pulmonary)
Wide split of S2 is seen in:
Reverse splitting of S2 is seen in:
Differentiating Different Types of Shock
  • Cardiogenic shock
  • Volume overload
  • Hypovolemic shock
  • Noncardiogenic shock (ARDS)
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Parameters in shock
Recognizing Certain ECG Rhythms
37Conduction Abnormalities
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Normal ECG
Waves of Normal ECG
From – To
Duration (second)
P wave
Atrial depolarization
QRS complex
Ventricular depolarization
0.08 – 0.10
T wave
Ventricular repolarization
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
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
  • DOC for AF without heart failure
Beta blockers
  • DOC for Atrial flutter without heart failure
Beta blockers
  • DOC for AF with heart failure
  • DOC for Atrial flutter with heart failure
  • DOC for PSVT
  • DOC for WPWS
  • DOC for ventricular ectopics
Beta blockers
  • DOC for sinus bradycardia
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
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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
7 Ss
Ejection systolic
Late systolic
Early 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
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
  • 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
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
  • 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
MVP: Floppy Valve Syndrome/Mitral Valve Prolapse
Dilated Cardiomyopathy
Restrictive Cardiomyopathy
50Infective Endocarditis
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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
1–2 hours
6–8 hours
1–2 days
2–6 hours
16–20 hours
1–2 days
4–8 hours
16–24 hours
3–4 days
Trop T
4–6 hours
12–24 hours
7–10 days
12–24 hours
36–48 hours
3–4 days
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
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Changes in reticulocyte count
Microcytic Anemia
Iron deficency
Sideroblastic anemia
Chronic anemia
Sr Fe
% Saturation
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
  • 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
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
von Willebrand's Disease (NUTSHELL)
Factor V Leiden Mutation
Genetical Hypercoagulable States
Parameters in Different Disorders (Bleeding)
  • von Willebrand's disease
  • Liver failure
  • Heparin
  • Warfarin
  • Scurvy
  • ITP
  • TTP
Antiphospholipid Syndrome
Leukemoid Reaction
USMLE Case Scenario
Chronic Lymphocytic Leukemia (CLL)
Blood Transfusion Complications
70Viruses Transmitted by Blood Transfusion
ITP (Idiopathic Thrombocytopenic Purpura)
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
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
Reiter's Syndrome (RS)
Temporal Arteritis
USMLE Case Scenario
Raynaud's Phenomenon and Disease
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
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.
  • 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
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
  • Methotrexate
Inhibits purine synthesis
Myelosuppression, mucositis
  • Cyclophosphamide
Alkylating agent—causes cross-linking in DNA
Hemorrhagic cystitis, myelosuppression
Tumor Lysis Syndrome
85Human Antibody Infusion Reactions
Hemolytic Uremic Syndrome
Neutropenia and Infection
Pulmonary Infiltrates
Hemorrhagic Cystitis
Toxic Myopathies
Inclusion Body Myositis
USMLE Case Scenario
Duchenne's Muscular Dystrophy
Other Muscular Dystrophies
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Pattern of inheritance
Calcium Channel Disorders of Muscle
Sodium Channel Disorders of Muscle
Myotonia Congenita
Myasthenia Gravis (MG)
  • Migratory glossitis
Geographic tongue
  • Atrophic glossitis
Iron deficiency
  • Leutic glossitis
Plummer-Vinson Syndrome
Menetrier's Disease
Schindler's Disease
H. pylori
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
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
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
Incubation period
Fitz-Hugh-Curtis Syndrome
98Budd-Chiari Syndrome: (5 Ps)
Wilson's Disease
99Disease of C (Wilson's Disease)
Clinical Manifestations
Initial symptoms include weakness, lassitude, weight loss, change in skin color, abdominal pain, loss of libido, and symptoms of diabetes mellitus
Primary Biliary Cirrhosis
Spontaneous Bacterial Peritonitis (SBP)
Carcinoid Syndrome
Hepatorenal Syndrome
Hypoxemia and Hepatopulmonary Syndrome
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%
Urine: plasma osmolality
> 1.5
< 1.1
Urine: plasma urea
> 10:1
< 8:1
Specific gravity
> 1020
< 1010
‘bland' sediment
brown granular casts
Response to fluid challenge
Seen in CRF are
Diabetes Mellitus
Age at onset
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
Older, obese patients
Usually > 40 years
No HLA links
90% concordance in identical twins
Partial insulin deficiency, Insulin resistance
May develop nonketotic hyperosmolar state
Weight loss, drugs, insulin sometimes
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)
Liddle's Syndrome
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Differentiating features
Bartter's Syndrome
Renal Tubular Acidosis
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
Hemodialysis is done for Poisoning in Blood From
For Dialysis, Properties Should be
Cushing's Syndrome
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Cushings disease
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115Thyroid Endocrinology
Drugs for Hyperthyroidism
Subacute Thyroiditis or De Quervain's Thyroiditis or Granulomatous Thyroiditis or Giant Cell Thyroiditis
Primary Hyperparathyroidism
Conn's Syndrome
Addison's Disease
Adrenal Insufficiency
Waterhouse-Friderichsen Syndrome
119Polyglandular Autoimmune Syndrome Type I
Polyglandular Autoimmune Syndrome Type II
Somatostatinoma Syndrome
Important Enzymes and Clinical Correlations
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
Prion Diseases
Creutzfeldt-Jakob Disease
Guillain-Barré Syndrome
Miller-Fisher Syndrome
Friedreich's Ataxia
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
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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
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
USMLE Case Scenario
Drugs Causing Parkinsonism
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)
Trigeminal Neuralgia
Glossopharyngeal Neuralgia
Facial Nerve Disorders: Bell's Palsy
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
Pearls about Brain Tumors
Brain Tumors are associated with
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
  • 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
  • Roth Spots
  • Bitot's Spots
Vitamin A deficiency
  • Herald Spot
Pitryriasis rosea
  • Café au lait spots
Peutz-jegher's syndrome
Important Eponyms
  • Hebra nose
  • 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
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+
  • Nonenhancing lesion in AIDS
  • Solitary weakly ring-enhancing lesion
  • Multiple ring-enhancing lesions
CNS lymphoma
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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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