1. Class I ICD indications:
- EF < 35, s/p at least 3 months of optimal medical management in NIDCM and 9 months in Ischemic DCM.
- Sustained v-tach + structural heart disease
- Syncopal episode of unknown origin + inducible v-tach or v-fib on EP testing
2. CI to spironolactone
- Cr < 2.5 in men, <2 in women
- K > 5
3. Osteoporosis:
- Defined as either fragility fracture (fracture with low impact, like falling from standing) or T-score <2.5 on bone mineral density. Osteopenia is T-score <1-2.5.
- Start bisphosphonae. Aledronate is poorly absorbed orally so it has to be taken on an empty stomach.
- Zaledronate is a long-acting injectable (can be given once a year as IV infusion)
- CI to aledronate: achalasia/stricture/dysphagia, can't remove upright for 30-60 minutes after taking, malabsorption (bad celiac's or IBD)
- Ca + vitamin D supplementation: 50,000 IU vitamin D every day for 1 week (loading), followed by 2,000 IU daily maintenance.
- Screen women at age 65, and at 60 if they are higher risk (weight < 70 kg/154lbs)
- Calcitonin is second line- effects on bone mass are modest and doesn't impact fracture rates
- Raloxifen is also second line- increases bone mass, prevents vertebral fractures but no data showing that it prevents hip fractures. Also carries the estrogen-agonist effects (DVTs, cardiovascular effects, etc)
- Teriparatide is an anabolic agent that stimulates osteoblasts and builds up bone mass and prevents vertebral and non-vertebral fractures. Limit use to 2 years in the most at risk people (T-score <3.0-2.5 with fragility fracture who can't take bisphosphonates). Daily subQ injections. Can increase risk of osteosarcoma so don't use in people with Paget's, history of bone cancer, history of radiation to bone.
4. Psoriatic arthritis: manage with NSAIDs, anti-TNF, methotrexate. Don't use systemic steroids.
5. Hypercalcemia of malignancy
- usually caused by PTHrP secretion, either systemically or locally (ie blood levels normal); PTH binds osteoblasts and increase expression of RANKL which activates RANK on osteoclasts and promotes growth/activity
- Tumors that can secret PTHrP (squamous cell cancer in general, h&n, breast, lung, renal + bladder, esophagus, ovarian and endometrial
- Some tumors also can secrete local cytokines that directly promote bone resorption by osteoclasts: multiple myeloma, lymphoma, breast, leukemia
6. Aortic dissection
- Manage with beta-blockers rather than vasodilators (ca-channel blockers, hydralazine), which can cause reflex tachycardia and worsen the shear forces on the aorta. Only use vasodilators if beta blockade is inadequate to lower BP
- Goal vitals: HR <60, BP <120 systolic {source:study in circulation showing tighter HR control lead to better outcomes}
7. Correcting hypernatremia:
- Euvolemic or Hypervolemic hypernatremia: D5W. Giving straight water may be an osmolar shock and cause red cell lysis-- hence the D5
- Hypovolemic hypernatremia: depending on how bad the hypernatremia is, either 0.9 NS or D5 half-normal.
8. Analgesic nephropathy: 
- Most common cause of drug-induced chronic renal failure.
- 3-5% of ESRD
- Usually females (peak 50-55) who use combined analgesics - aspirin and Naproxen for example.
- Typically occurs after cumulative ingestion of 2-3 kg of index drugs
- Papillary necrosis, tubulointerstitial nephritis
- Polyuria, sterile pyuria (WBC casts) seen early, with hematuria if papillary necrosis happens
- HTN, proteinuria, impaired ability to concentrate urine as disease progresses. May even seen nephrotic range proteinuria in advanced disease.
9. Other complications of chronic analgesia abuse: 
- Atherosclerotic disease
- Premature aging
- Urinary tract cancer
10. Cutoff BMI between anorexia and bullemia - 18.5

1. Milk/Soy protein enterocolitis: 
- Presents at age 2-8 weeks
- Often personal or family history of atopy (allergies, asthma, eczema)
- Pathogenesis: non-IgE mediated immune response to dairy and/or soy proteins => colorectal inflammation
- Sx: regurgitation of food/vomiting, bloody stools, eczema
- Treatment: if breastfeeding, mom has to also eliminate milk/soy from diet, if formula-fed, must move to hydrolyzed formula
- Visible bleeding will usually reduce by 3 days, with complete resolution in 2 weeks.
- Usually resolves spontaneously by 1 year of age.
2. DDx GI bleed in infants: 
- Milk/soy protein enterocolitis: vomiting, good appetite, no pain
- Bacterial colitis (fever, decreased appetite, irritability) - rare in breastfed infants due to lack of intake of contaminated food; C.diff is rare in infants due to lack of intestinal receptor to C.diff toxin until approx age 2 years
- Intussusception: intermittent, crampy pain
- Malro + volvulus: ill appearing, bilious vomiting, pain, poor appetite
- Meckel's: rarely presents in neonates
3. Head ultrasound requires open fontanelle - most useful in patients under 6 mos of age.
4. Drugs that cause hyperkalemia: 
- Dig: from inhibition of Na/K ATPase
- K sparing diuretics: ie spironolactone (anti-aldosterone) and triamterine/amiloride (ENaC inhibitor)
- Nonselective B-blockers: inhibit B-mediated cellular uptake of K
- ACE-I/ARB: anti-aldosterone effects
- NSAIDs: anti-aldosterone effects (from impaired local prostaglandin synthesis - prostaglandins cause renin release). Hyperkalemia may be amplified in patients with renal dysfunction (like... from NSAIDs...)
- In this 1985 paper where 50 patients were given indomethacin, 75% had <1mEq increase, 25% had >1mEq incresae
5. Pesudotumor: 
- Diagnosis: no focal deficits (other than a 6th nerve palsy), no evidence of other causes of hydrocephalus, normal CSF except for elevated OP
- Can be caused by tetracycline, isotretinoin.
- Treat with diamox, +/- lasix -- diamox inhibits choroid plexus carb anhyd, decreasing CSF production
- Encourage weight loss
- May need optic nerve sheatlh decompression or LP shunting if unresponsive to medical therapy
- May use steroids and repeated LPs to bridge to definitive treatment.
6. Post cholecystectomy syndrome:
- Persistent or recurrent pain months/years after chole (often same pain as before surgery)
- May be due to biliary (retained stone, sludging) or extrabiliary (PUD, pancreatitis) causes
- Workup with ERCP, EUS, or MR abdomen.    
7. Types of selection bias: 
- Sampling/Ascertainment: nonrandom selection
- Nonresponse rate: high % non-response*
- Attrition: high % loss to follow up*
- Berkson: study only contains inpatients
- Prevalence/Neyman: long lag time between exposure and disease - miss patients who died early or recovered
*: the missing data may represent a distinct group from retained subjects
8. Types of observational bias: 
- Recall: subjects reacall negative outcomes more than positiv
- Observer: observations influenced by bias
- Reporting: subjects lie about incidence of event for various reasons
9. AIN:
- B-lactams, PPIs
- Occurs 7-10 days after drug exposure; may be associated with rash, eosinophilia, pyuria.
10. RBC artifacts 
- Howell Jolly - asplenia
- Heinz - G6PD/thalassmia (denatured Hb) -> bite cells after splenic phagocytes remove them.

1. Risperidone is most likely to cause tardive dyskinesia, clozapine is the least likely (but may cause myocarditis, agranulocytosis, seizures...)
2. Blood cancers & smears
- Lymphoblastic leukemia: blasts in smears
- CLL: smudge cells, "overmatured" cells (hypercondensed nuclear chromatin). LAD + splenomegaly, then anemia and thrombocytopenia
- Early Hodgkins: normal periperipheral smears - reed-sternberg cells on LN biopsy
- CML - leukocytosis + left shift (myelomonocytes, neutrophils, basophilia) + marked splenomegaly
2. Types of aphasia: 
- Broca's: non fluent speech, impaired repetition, intact comprehension; may be associated with hemiparesis, eye deviation to affected side (i.e. MCA infarct)
- Wernicke's: fluent speech, impaired repetition, impaired comprehension; may be associated with contralateral superior quadrantanopia (meyer's loop)
- Conduction: fluent speech with some errors, impaired repetition, intact comprehension
3. Nondominant hemisphere strokes: 
- Temporal: can lead to sensory aprosodia (inability to comprehend emotional gestures), contralateral quadrantanospia (meyer's loop)
- Parietal: can lead to anosognosia - denial of one's disabilities, contralateral apraxia (can't carry out learned movements), contralateral inferior quadrantanopia (superior optic radiation).
- Frontal: can lead to motor aprosodia (inability to convey emotion through speech), contralateral weaknesss (motor strip), apraxia (pre-motor).
4. Dominant hemisphere strokes: 
- Temporal: wernicke's aphasia, may affect ability to speak nouns (anomic aphasia), may affect broca's if you take superior temporal gyrus, may affect arcuate fasciculus, meyer's loop.
- Parietal: may cause contralateral hemineglect, sensory losses (pain, vibration, agraphesthesia- can't recognize letter written on hand, asterognosis- can't ID object by touching it), contralateral inferior quandrantanopia.
- Frontal: Broca's, pre-motor, motor, frontal eye fields (eyes move towards side of lesion due to unopposed contralateral frontal eye field)
5. Cardiac drugs that interact with Digoxin: 
- Amio (D'oh! decreased dig by 25-50%)
- Verapamil
- Quinidine
- Propafenone (class Ic - also has beta-blockade activity)
6. Femoral head has 2 blood supply sources - ascending arteries and foveal artery (inside ligamentum teres) which is patent early in life but may become obliterated in older patients - this is why aseptic femoral head necrosis is rare in kids.
7. Complete spinal block is a complication of spinal/epidural anesthesia - when the anesthetic migrates all the way up to the cervical spine/medulla - hypotension, bradycardia, respiratory difficulty/apnea, may even lead to cardiopulmonary arrest, loss of consciousness.
8. Inheritance of bipolar disease
- General public: 1%
- First degree relative: 5-10%
- Both parents: 60%
- Monozygotic twin: 70%
9. TCA overdose.  
- Sodium bicarbonate can narrow the QRS, as well as facilitate clearance and correct acidosis.
- Manage seizures with benzos, and not dilantin, as it can increase frequency of ventricular arrhythmias
10. Trauma to the soft palate - may cause ICA dissection or compression of ICA that dislodges a thrombus and causes embolic stroke.

1. Disseminated gonococcal disease; 
- High fever
- Tenosynovitis
- Migratory polyarthraligas (may progress to supprative infectious arthritis)
- 5-40 cutaenous leaseions - pustular lesiosn with hemorrhagic component and occ central necrosis
2. Acute cholecystitis - lap chole performed within 72 hours of onset of symptoms reduces disease duration, duration of hospitalization, and mortality.
3. Trihexyphenidyl - useful in the treatment of parkinsons in younger patients where tremor is the predominant symptom.
4. Essential tremor - propanolol first line, benzos second line due to abuse potential. Primidone (anticonvulsant - metabolized to phenobarb) can also be used to treat, sometimes in combo with beta-blocker
5. Lupus anticoagulant
- 5-10% of lupus patients
- IgM or IgG that binds phospholipids used in various assays (PTT, VDRL)
- Will not correct if mixed in dilution with plasma
- Russell viper venom test designed specifically to test for lupus anticoagulant
6. Fetal drug exposures:
- Heroin/methadone: high pitched cry, tremors, seizures, sweating, sneezing, tachypnea, poor feeding, vomiting, diarrhea - withdrawal presents within 48 hrs of birth (heroin) and 48-72 hrs (methadone). Treat symptomatically - small frequent feeds, low stim environment, morphine PRN
- Cocaine - jitteriness, excessive sucking, hyperactive moro
- Alcohol - smooth philtrum, small palpebral fissures, thin upper lip, CNS abnormalities
7. Batteries in esophagus must be immediately removed - distal to that, 90% will pass uneventfully.
8. Disseminated blastomycosis 
- Can occur even in immunocompetent people
- Skin: violaceous nodules, wart-like, ulcers
- Bone: osteomyelitis
- Lung: acute/chronic pneumonia
- GU: prostatitis, epididymo-orchitis
- CNS: meningitis, epidural/brain abscesses.
- Treat with PO itraconazole, or amphotericin B if severe disease or immunocompromised person
9. Skin lesions in other disseminated fungal diseases:
- Coccidioides: erythema nodosum, erythema multiforme
- Histo: papular, crusting skin lesions-- generally only immunocompromised people will develop tho.
- Sporotrichosis: pustular, ulcerated - localized to wound/associated lymphatic channels
10. Treatment for HELLP: 
- >34 weeks gestation, unstable mom/baby, or mature fetal lungs: delivery
- Otherwise, can stabilize mom, give steroids to mature the baby's lungs, and wait for 34 weeks.

1. Risk factors for newborn respiratory distress 
- Prematurity
- Male sex
- Perinatal asphyxia
- Maternal DM - maternal hyperglycemia -> fetal hyperglycemia -> fetal hyperinsulinism -> insulin antagonizes cortisol and blocks maturation of sphingomyelin (component of surfactant)
- C-section without labor
- Prevent with antenatal steroids, treat with postnatal surfactant administration
2. Pill esophagitis: 
- Tetracyclines
- Bisphosphonates
- NSAIDs
- KCl
3. Platelet dysfunction: 
- Bernard Soulier: big platelets, mild thrombocytopenia, severe platelet dysfunction, bleeding out of proportion to thrombocytopenia
- Hypersplenism: platelets are usually > 30K, and patients don't have clinically significant bleeding
4. When to transfuse platelets: 
- <10K
- <30K if bleeding
- <50K if need surgery
- <100K if need neurosurgery***, DIC, intracranial bleed***
***these are the hematology guidelines... if someone is getting neurosurgery or bleeding into their head you should consult neurosurgery regarding platelet transfusion parameters***
5. ATN:
- Urine osm 300-350 (not <300)
- Urine Na>20 mEq/L
- FeNa > 2%
6. Renal casts: 
- Muddy brown : ATN
- RBC: nephritic
- WBC: pyelo, interstitial nephritis
- Fatty: nephrotic
- Broad/waxy: chronic renal failure
7. Grading of diabetic foot ulcers: 
- Grade 0: high risk foot, no ulcer
- Grade 1: full thickness skin ulcer
- Grade 2: ulcer penetrates to ligament/muscle, not not to bone, no abscess
- Grade 3: ulcer with abscess, osteo, or cellulitis
- Grade 4: local gangrene
- Grade 5: gangrene involving entire foot
8. Management of diabetic foot ulcers: 
- General principles: off-loading, debridement, wound dressings, antibiotics, revascularization, amputation
- Grade 1/2: wound care, debridement
- Grade 3: hospitalization, debridement, biopsy/cx of whatever tissue is affected, IV antibiotics,
- Grade 4/5: hospitalization, possible amputation.
9. HTN + hypokalemia = suspect primary aldosteronism
- First, measure plasma aldo:renin ratio; any ratio > 20:1 + plasma aldo > 15 = primary hyperaldo
- Then do adrenal suppression tests - if suppressible, image to find tumor.
- If imaging shows no tumor, adrenal venous sampling to differentiate adenoma (unilateral) from hyperplasia (bilateral)
- Adenoma gets surgery, hyperplasia gets medicine.
10. Lymphadenopathy: 
- <1cm, rubbery = non concerning, likely reaction to infection, no treatment
- >2cm, firm, immobile = work up for cancer vs granulomatous disease.

1. OCP side effects: 
- DVT/PE
- Hypertension
- Breakthrough bleeding
- Breast tenderness
- N/V
- Bloating
- Decreased risk of ovarian/endometrial cancer
- Increased risk cervical cancer
- Liver disorders (hepatic adenoma)
- Increased triglycerides (estrogen component)
- DO NOT cause weight gain despite the highly prevalent belief among users, not shown to pan out in controlled studies.
2. Uterine bleeding: 
- Abruption: only 25% visible on u/s - fetal vital signs will deteriorate as oxygen delivery is compromised.
- Accreta: less likely with fundal placenta (as most c-sections are done low tranverse, and accretion tends to happen at prior scar sites)
- Previa: placenta overlying os.
3. Epiglottitis: 
- Sudden onset fever, respiratory distress, dysphagia, drooling, inspiratory stridor, leaning forwards and hypertextending neck.
- If unstable vitals, go to OR for intubation- if that fails, then trach; should avoid crich in pre-pubescent kids, as they have increased risk of developing subglottic stenosis

vs peritonsilar abscess: has more subacute onset; unilateral tonsilar swelling with uvular deviation 

vs angioedema: history of allergen exposure 

4. Aspirin exacerbated respiratory disease: 

- asthma, chronic rhinosinusitis, nasal polyps, bronchospasm/nasal congestion following aspirin or NSAIDs 

- polyps tend to recur 

- vs juvenille nasal angiofibroma: tends to cause epistaxis, generally occurs teen males

- vs inverted papilloma: rarely presents in context of AERD 

5. Pregnant women have increased risk of pyogenic granulomas on anterior septum that result in epistaxis. 

6. Pneumonia vaccine: all adults >65 : 13-valent followed by 23-valent 6-12 mos later. 

23 valent alone for younger people who are smokers or have chronic diease 

7. HOCM - prevalence 1:500; Long QT syndrome - prevalence 1:2500

8. Varicella exposure: 

- In immune person (prior varicella or vaccine) - do nothing

- In immunocompetent person who is not immune - varicella vaccine - 70-100% effective in preventing infection if given within 3-5d of exposure 

- In immunocompromised person who is not immune - varicella Ig within 10d of exposure 

9. Ascending paralysis: 

- Tick: hours to days progression, no fever, normal sensation, no autonomic dysfunction; tick needs to feed for 4-7 days to release neurotoxin - meticulous search will often turn out with tick. Removal of tick => spont improvement in most. 

- Guillain Barre: days to weeks, sensation is usually mildly affected, autonomic dysfunction (tachy, urinary retention, arrhythmias) in 70%. Albuminocytologic diassoc on CSF (high protein, few cells) in 80-90% at 1 week. Tx: IVIg/plasmapharesis. 

10. SSRI should be continued for 6 months after symptom response in treatment of single episode of major depression. Multiple episodes = longer treatment. 

1. Friedreich's ataxia: 
- Most common type of spinocb ataxia, sx usually onset <22 years of age
- Neurological dysfunction (ataxia, dysarthria) - degen of spinal tracts (spinocb, posterior columns, pyramidal)
- Concentric hypertrophic cardiomyopathy - develops in up to 90%, most common cause of death
- DM
- Skeletal deformities (hammer toes, scoliosis)
- Median survival after disease onset <20 years
2. Raloxifene
- breast and vaginal tissue: antagonizes ER
- bones: agonises ER
- first line for osteoporosis tx.
- Does NOT increase risk of endometrial cancer like tamoxifen does.
- Does increase risk of DVT
3. Liver pathology stages: 
- first -- Fatty: short term EtOH
- then -- Alcoholic hepatitis: long term EtOH, mallory bodies, neutrophils, hepatocyte necrosis, perivenular inflammation
- then -- Fibrosis/cirrhosis: regenerative nodules (true cirrhosis - irrev at this point)
All of the above up to regenerative nodules is reversible (even early cirrhosis) with abstinence of alcohol.
4. Immunodeficiences: 
- IgA: respiratory infections, giardia
- Complement: C3 - pyogenic respiratory/sinus bacterial infections, C5-8: Neisseria, C1 esterase: hereditary angioedema.
- Phagocytosis: pyogenic (chediak higashi, job, CGD)
5. Untreated HIV with PCP pneumonia: 
- Bactrim + steroids (in severe PCP - ie PaO2<70, A-a gradient > 35)
- If cannot tolerate bactrim, can use pentamidine although less effective
- Restar/start HAART after the acute phase of illness has resolved
- PCP usually affects CD4<200 people
6. Scabies - often affects flexor wrist, lateral fingers, finger webs; diagnose with skin scrapings, treat with 5% permethrin cream, or PO ivermectin
7. Living will vs power of attorney: legally, the living well trumps, but if the two are in conflict should discuss with family first and consult ethics if can't find resolution.
8. Postop fever: 
- Immediate (hours) preop infection, trauma, transfusion reaction
- Acute (first week): infection, wound infection (GAS/clostridium), MI/DVT/PE
- Subacute (first month): wound infection, catheter infection, drug fever, DVT/PE
- Chronic (>1 month): viral, wound infection due to indolent organisms.
Wind, water, walking, wound, wonder
9. Liver diseases of pregnancy: 
- Intrahepatic cholestasis: intense pruritis, worse in palms/soles at night; treat with ursodeoxycholic acid, early delivery to avoid fetal complications. Jaundice rare -- presents warrants further w/u
- Acute fatty liver of pregnancy: rare; hepatitis symptoms (malasie, pain, n/v, jaundice), may progress to liver failure and the complications of liver failure.
- HELLP: pre-eclampsia symptoms; also the lab abnormalities of the acronym (hemolysis, etc)
10. Chlamydia is more common than gonorrhea; they cannot be distinguished clinically; PCR to diagnose. If you have both options on the exam guess the first because its more common.