Internal Medicine Quick Tables
Internal Medicine Quick Tables
Internal Medicine Quick Tables
Obesity
Advanced age
Risk factors Varicose veins
History of DVT
Elevation
Management Compression stockings
Biliary stricture
Cholangitis or cholelithiasis
Complications Cholangiocarcinoma, colon cancer, biliary cancer
Cholestasis (eg, ↓ fat-soluble vitamins, osteoporosis)
Cryoglobulinemia
(immunoglobulins that precipitate at <37 C)
Type I Mixed = type II or III
Chronic viremia (eg, HCV,
Plasma cell dyscrasias
HIV)
Associated (eg, Waldenström, multiple
Autoimmunity (eg, SLE,
diseases myeloma)
Sjögren)
+ Cryocrit, normal
+ Cryocrit, ↓ C4
complement
+ RF autoantibodies
Laboratory ↑ Erythrocyte sedimentation
+ Viral or antinuclear
findings rate
antibodies
+ Monoclonal spike on SPEP
*Patients with AIDS (CD4 <200/mm3) & those on chronic glucocorticoid therapy generally
receive primary
prophylaxis against Pneumocystis pneumonia with trimethoprim-sulfamethoxazole.
Fat embolism syndrome
Fracture of marrow-containing bone (eg, femur)
Orthopedic surgery
Etiology
Pancreatitis
TURBT
Staging Upper urinary tract imaging (eg, IVP, MRI, CT)
Hypercalcemia
Metabolic alkalosis
Laboratory
Acute kidney injury
findings
Suppressed PTH
Fluoroquinolone
Inpatient OR
(non-ICU)
Beta-lactam + macrolide
Beta-lactam + macrolide
Inpatient OR
(ICU)
Beta-lactam + fluoroquinolone
ECG
Cardiac tests Echocardiography (optional)
Gottron sign/papules
Skin findings Heliotrope rash
Hyponatremia
Chest x-ray: lobar infiltrate
Diagnosis Sputum Gram stain: PMNs, few/no organisms
Urine Legionella antigen
*Antibiotics generally indicated if: (1) increased sputum purulence + ≥1 other cardinal
symptoms; or (2) patient requires hospitalization.
NIPPV = noninvasive positive pressure ventilation; VD = alveolar dead space ventilation; V/Q =
ventilation/perfusion ratio; WOB = work of breathing.
Meningococcal meningitis
Neisseria meningitidis
Epidemiology Most common in young children & young adults
Ceftriaxone
Treatment
Shock
Disseminated intravascular coagulation
Complications
Adrenal hemorrhage
Droplet precautions
Prevention Chemoprophylaxis* for close contacts
Direct visualization
Diagnosis Imaging (lateral neck x-ray)
Causes of gout
Primary gout (idiopathic)
Increased Myeloproliferative/lymphoproliferative disorders
Tumor lysis syndrome
urate production Hypoxanthine guanine phosphoribosyltransferase deficiency
Clinical Coma
examination Absent brainstem reflexes:
o Pupillary
o Corneal
o Oculocephalic, oculovestibular
o Jaw jerk
o Cough
o Gag
Absent brain-originating* motor responses (including decerebrate &
decorticate posturing)
Apnea test: no respiratory response to PaCO2 >60 mm Hg
*Movements originating from the spinal cord (eg, deep tendon reflexes) may still be present.
Nontreponemal
Quantitative (titers)
Possible negative result in early infection
(RPR, VDRL)
Decrease in titers confirms treatment
Recurrent aspiration
Same
lung lobe* Altered consciousness: seizure, sedatives, antipsychotics, alcohol,
illicit drugs
Primary hypogonadism
Increased long bone length
Clinical features Gynecomastia
Learning & socialization difficulties
↓ Testosterone
↑ LH & FSH (due to loss of feedback inhibition)
Laboratory findings
↑ Estradiol
Combined Hypercortisolism
Cirrhosis
(primary & secondary)
Toxic alcohol ingestion (methanol or ethylene glycol)
Methanol: windshield wiper fluid, contaminated homemade liquor
Ethylene glycol: automotive coolant/antifreeze, brake fluid
Typical sources Industrial solvents & deicing solutions may contain either toxic
alcohol
No preceding symptoms
Ventricular tachycardia Cardiomyopathy or previous MI
No preceding symptoms
Medications that prolong QT interval
Torsades de pointes
Hypokalemia or hypomagnesemia
Anticoagulation
Treatment
SLE = systemic lupus erythematosus.
Acute kidney injury
Prerenal Acute tubular necrosis
BUN/creatinine ratio Typically >20 Typically normal (~10-15)
Urine sodium <20 mEq/L >40 mEq/L
Fractional excretion of sodium <1% >2%
Urine osmolality >500 mOsm/kg ~300 mOsm/kg
Urine specific gravity >1.020 <1.020
Microscopy Bland Muddy brown casts
Indications for statin therapy in prevention of ASCVD
Established ASCVD
o Acute coronary syndrome
o Stable angina
Secondary prevention
o Arterial revascularization (eg, CABG)
o Stroke, TIA, PAD
Hyponatremia
Serum osmolality <275 mOsm/kg H2O (hypotonic)
Laboratory findings Urine osmolality >100 mOsm/kg H2O
Urine sodium >40 mEq/L
Age >50
Systemic signs & symptoms Elevated ESR, C-reactive
Stiffness > pain in shoulders, hip protein
Polymyalgia
girdle, neck Rapid improvement with
rheumatica
Association with giant cell glucocorticoids
(temporal) arteritis
Bland urinalysis
Very low urine Na+ (<10 mEq/L)
Diagnosis Exclusion of other causes of AKI
No improvement with trial of volume expansion
Electrocardiography
o Incomplete/complete right bundle branch block
o Right axis deviation, RV hypertrophy, RA enlargement
Echocardiography
Diagnostic o Pulmonary hypertension, RV dilation/dysfunction, tricuspid
evaluation regurgitation
Catheterization (gold standard)
o Elevated filling pressures, decreased cardiac output,
pulmonary hypertension
Usually asymptomatic
AKI ≤7 days of starting drug
Clinical presentation UA: Hematuria, pyuria & crystals
Increased risk with volume depletion, CKD
Rifampin
Prophylaxis Ceftriaxone
options Ciprofloxacin (adults only)
*Antibiotics generally indicated if: (1) increased sputum purulence + ≥1 other cardinal
symptoms; or (2) patient requires hospitalization.
NIPPV = noninvasive positive pressure ventilation; VD = alveolar dead space ventilation; V/Q =
ventilation/perfusion ratio; WOB = work of breathing.
Primary adrenal insufficiency
Etiology Autoimmune adrenalitis (most common)
Infection (eg, tuberculosis)
Metastatic infiltration
Hypercalcemia
Metabolic alkalosis
Laboratory
Acute kidney injury
findings
Suppressed PTH
(eg, sacubitril-valsartan)
OR
ACE inhibitor
Yes
(eg, lisinopril)
OR
(eg, losartan)
Beta blocker
Yes
(eg, metoprolol, carvedilol)
Mineralocorticoid receptor antagonist
Yes
(eg, spironolactone, eplerenone)
Sodium-glucose cotransporter-2 inhibitor
Yes
(eg, dapagliflozin, empagliflozin)
Diuretic
No*
(eg, furosemide, metolazone)
Digoxin No**
*Improves symptoms & reduces hospitalization.
**Reduces hospitalization.
Primary hyperparathyroidism
Parathyroid adenoma (most common), hyperplasia, carcinoma
Etiology Increased risk in MEN types 1 & 2A
Hypercalcemia
Elevated or inappropriately normal PTH
Diagnostic findings
Elevated 24-hour urinary calcium excretion
↑ TSH Levothyroxine
Inhibition of thyroid hormone
↓ T4
synthesis
↓ TSH Antithyroid drugs
↑ T3 & T4
AIT type 1
↓ RAIU
(iodine-induced increase
Increased vascularity on
in thyroid hormone synthesis)
ultrasound
↓ TSH Glucocorticoids
↑ T3 & T4
AIT type 2 Undetectable RAIU
(destructive thyroiditis) Decreased vascularity on
ultrasound
Neurologic disorders
Esophageal motility defects
Dysphagia Protracted vomiting
Gastroesophageal reflux
Tracheostomy
Pharyngeal or Intubation
glottal dysfunction Nasogastric feeding
Gingivitis
Dental issues Poor dental hygiene
Acute pericarditis
Viral or idiopathic
Autoimmune disease (eg, SLE)
Uremia (acute or chronic renal failure)
Etiology Post myocardial infarction
o Early: peri-infarction pericarditis
o Late: Dressler syndrome
Vibrio cholerae
Campylobacter jejuni Variable onset
Watery/bloody diarrhea
Bacterial epithelial invasion Nontyphoidal salmonella Fever
Systemic illness (Listeria)
Listeria monocytogenes
ETEC = enterotoxigenic Escherichia coli; STEC = Shiga toxin-producing E coli.
Cardiovascular effects of hyperthyroidism
Tachycardia/palpitations
Increased rate Atrial fibrillation
Anterior uveitis
Symptoms: ocular pain, photophobia, decreased acuity
Presentation Examination: ciliary flush, pupillary constriction, hypopyon
Slit-lamp examination
As indicated: HLA-B27, pelvis/spine x-ray, chest x-ray, HIV,
Evaluation/testing
syphilis serology
Classic triad
o Fever (~50%)
o Focal/severe back pain
Manifestations o Neurologic findings (eg, motor/sensory change, bowel/bladder
dysfunction, paralysis)
↑ Erythrocyte sedimentation rate
BP = blood pressure; HR = heart rate; LBBB = left bundle branch block; tHR = target HR.
Drugs for neuropathic pain
Drug Mechanism of action
Tricyclic antidepressants ↓ Reuptake of serotonin & norepinephrine
(eg, amitriptyline, nortriptyline) Inhibition of pain signals
SNRIs (eg, duloxetine)
Anticonvulsants Decreased depolarization of neurons in the CNS
(eg, gabapentin, pregabalin)
Activation of central opioid receptors
Opioids
Loss of membrane potential in nociceptive fibers
Capsaicin (topical)
Decreased depolarization of neurons in peripheral nerves
Lidocaine (topical)
SNRIs = serotonin-norepinephrine reuptake inhibitors.
Infective endocarditis with intravenous drug use
Injected particles cause microdamage to right-sided
valves before being filtered out by the lungs
Pathogenesis Microdamage facilitates bacterial attachment
Increased risk with HIV
Management of hypercalcemia
Short-term (immediate) treatment
Chronic
Idiopathic
lithium use
Antipsychotics Trauma
Hypercalcemia
(dry mouth) Pituitary
Hereditary
Etiology Psychiatric surgery
(AVPR2 &
conditions Ischemic
aquaporin 2
encephalopathy
mutations)
↑ MCHC
Negative Coombs test
Spherocytes on peripheral smear
Laboratory findings
↑ Osmotic fragility on acidified glycerol lysis test
Abnormal eosin-5-maleimide binding test
Metformin
Inhibits mitochondrial glycerophosphate dehydrogenase
Mechanism of action Upregulates AMP-activated protein kinase
Renal clearance
Pharmacokinetics No significant metabolites
Diarrhea
Lactic acidosis
Adverse effects
Vitamin B12 deficiency
Thyroiditis
Clinical features Diagnostic testing
Chronic autoimmune Predominant hypothyroid TPO antibody
thyroiditis features Variable radioiodine
Diffuse goiter uptake
(Hashimoto thyroiditis)
Variant of chronic autoimmune
Positive TPO
thyroiditis
antibody
Painless thyroiditis Mild, brief hyperthyroid phase
Low radioiodine
Small, nontender goiter
uptake
(silent thyroiditis) Spontaneous recovery
Subacute thyroiditis Likely postviral inflammatory Elevated ESR & CRP
(de Quervain thyroiditis) process
Prominent fever & hyperthyroid
symptoms Low radioiodine
Painful/tender goiter uptake
CRP = C-reactive protein; ESR = erythrocyte sedimentation rate; TPO = positive thyroid
peroxidase.
Wilson disease
Autosomal recessive mutation of ATP7B → hepatic copper accumulation
→ leak from damaged hepatocytes → deposits in tissues (eg, basal
Pathogenesis
ganglia, cornea)
Male predominance
Unilateral, trigeminal distribution with ipsilateral
autonomic symptoms
Cluster
Duration 15 min to 3 hr, circadian periodicity
Improves with oxygen therapy
Myasthenic crisis
Precipitating Infection or surgery
Pregnancy or childbirth
Tapering of immunosuppressive drugs
factors
Medications (eg, aminoglycosides, beta blockers)
ABG = arterial blood gas; AMS = altered mental status; ICU = intensive care unit; NIPPV =
noninvasive positive pressure ventilation; SaO2 = arterial saturation of oxygen; WOB = work of
breathing.
Clinical features of acute opioid intoxication
Substance abuse
Chronic opioid use
Risk factors Hospitalized patients (especially postoperative)
Hepatic or renal insufficiency
Somnolence, AMS
Pinpoint pupils (miosis)
Shallow breathing & ↓ respiratory rate
Clinical findings
Bradycardia, hypothermia, ↓ bowel sounds
Respiratory acidosis on ABG
Takayasu arteritis
Female
Asian
Risk factors
Age 10-40
Systemic glucocorticoids
Treatment
CRP = C-reactive protein; ESR = erythrocyte sedimentation rate.
Secondary causes of hypertension
Condition Clinical clues/features
Elevated creatinine level
Renal parenchymal disease Abnormal urinalysis (proteinuria, red blood cell casts)
Daytime somnolence
Obstructive sleep apnea Increased neck circumference
Anemia
Elevated venous lead level
Laboratory
Elevated serum zinc protoporphyrin level
findings
Basophilic stippling on peripheral smear
LAD = left anterior descending; MR = mitral regurgitation; RCA = right coronary artery.
Infectious keratitis
Pathogen Risk factors Clinical features*
Central, round ulcer
Improper contact lens use Stromal abscess
Bacteria (eg, Staphylococcus Corneal trauma, foreign Mucopurulent
aureus, Pseudomonas) body discharge
Acute presentation
Branched dendritic
ulcerations
Immunocompromised, HIV ↓ Corneal sensation
Herpes simplex virus
Watery discharge
Recurrent episodes
Ulcerations with
Immunocompromised with feathery margins &
corneal injury involving satellite lesions
Fungi (eg, Candida) contaminated soil (eg, Mucopurulent
gardening) discharge
Indolent course
*Eye pain/redness, blurred vision & photophobia are features of all infectious keratitis.
Jarisch-Herxheimer reaction
6-48 hours after initiating treatment for syphilis (most commonly
primary or secondary)
Epidemiology May also be seen with treatment of other spirochete diseases (eg,
Lyme disease, leptospirosis)
Subtypes
Squamous cell carcinoma
o Most commonly proximal and mid esophagus
Avoid sports for ≥3 weeks (contact sports ≥4 weeks) due to the risk of
Management splenic rupture
Sickle cell trait
Usually asymptomatic
Clinical features No change in overall life expectancy
CRP = C-reactive protein; ESR = erythrocyte sedimentation rate; TPO = thyroid peroxidase.
Waldenström macroglobulinemia Multiple myeloma
Hyperviscosity syndrome
Osteolytic lesions/fractures
Neuropathy
Anemia
Bleeding
Major manifestations Hypercalcemia
Hepatosplenomegaly
Renal insufficiency
Lymphadenopathy
*Theoretical risk due to unopposed alpha stimulation. Mixed alpha/beta blockers are sometimes
considered.
Osteoclast dysfunction
Pathogenesis Increased bone turnover
Bisphosphonates
Treatment
PINP = procollagen type I N-terminal propeptide.
Hemophilia A & B
X-linked recessive
Inheritance
Clinical Delayed/prolonged bleeding after mild trauma
features o Hemarthrosis, intramuscular hematomas
o Gastrointestinal or genitourinary tract bleeding
o Intracranial hemorrhage
Complications: hemophilic arthropathy
↑ Activated PTT
Normal platelet count & PT
Laboratory
Absent or ↓ factor VIII (hemophilia A) or factor IX
findings
(hemophilia B) activity
Factor replacement
Treatment Desmopressin for mild hemophilia A
*Theoretical risk due to unopposed alpha stimulation. Mixed alpha/beta blockers are sometimes
considered.
Hypercalcemia
Squamous cell carcinoma 20%-25% Central Necrosis & cavitation
Cushing syndrome
SIADH
Small cell carcinoma 10%-15% Central
Lambert-Eaton syndrome
Gynecomastia
Large cell carcinoma 5%-10% Peripheral Galactorrhea
Hematuria/proteinuria (glomerulonephritis)
Positive blood cultures
Diagnostic testing
TEE > TTE for detecting vegetation
Asymmetric oligoarthritis
Enthesitis
Musculoskeletal
Dactylitis
Reactive arthritis
Genitourinary infection: Chlamydia trachomatis
Enteritis: Salmonella, Shigella, Yersinia,
Preceding infection Campylobacter, Clostridioides (formerly Clostridium)
difficile
Asymmetric oligoarthritis
Enthesitis
Musculoskeletal
Dactylitis
Severe acute liver injury (ALT & AST often >1,000 U/L)
Signs of hepatic encephalopathy (eg, confusion, asterixis)
Diagnostic requirements
Synthetic liver dysfunction (INR ≥1.5)
Reverse/discontinue anticoagulants
Treatment Surgical evacuation of symptomatic or large bleeds
Sharp/stabbing pain
Pulmonary/pleuritic
Worse with inspiration
(pleurisy, pneumonia,
Pericarditis: worse when lying flat
pericarditis, PE)
Abrupt (maximal at onset), severe "tearing" pain
Aortic
May radiate to back
(dissection,
Hypertension and/or inherited aortopathy
intramural hematoma)
Substernal, may refer to neck
Associated with regurgitation
Esophageal Provoked by recumbent position
Nonexertional, relieved by antacids
Persistent pain
Chest wall/ Worse with movement or change in position
musculoskeletal Often follows repetitive activity
PE = pulmonary embolism.
Acute pericarditis
Etiology Viral or idiopathic
Autoimmune disease (eg, SLE)
Uremia (acute or chronic renal failure)
Post myocardial infarction
o Early: peri-infarction pericarditis
o Late: Dressler syndrome
Giardiasis
Contaminated food or water
Fecal incontinence & crowding (eg, day care, nursing home)
Risk factors
Immunodeficiency (eg, CVID, IgA deficiency, CF, HIV)
Ventriculoperitoneal shunting
Treatment
Common cognitive errors in medicine
Type of bias Definition Example
Anchoring Fixating on initial Burning throat pain
impressions to make a diagnosed as acid reflux
diagnosis despite weight loss
Related to confirmation Correct diagnosis is lung
bias & premature closure malignancy
Dyspnea diagnosed as
Allowing recently seen or influenza during peak
memorable (high-stakes) influenza season
Availability
cases to sway diagnosis Correct diagnosis is
pulmonary embolism
↓ Bone resorption
Calcitonin ↓ Renal calcium reabsorption
Rhabdomyolysis
Skeletal muscle lysis/necrosis due to:
ALT = alanine aminotransferase; AST = aspartate aminotransferase; RBCs = red blood cells.
Clinical features of pulmonary hypertension
Pulmonary arterial hypertension (WHO group 1)
Due to left heart disease (group 2)
Due to chronic lung disease or hypoxemia (eg, COPD, OSA)
Classification (group 3)
Due to chronic thromboembolic disease (group 4)
Due to other causes (eg, sarcoidosis) (group 5)
COPD = chronic obstructive pulmonary disease; JVD = jugular venous distension; OSA =
obstructive sleep apnea; PA = pulmonary artery; RV = right ventricular.
Clinical clues to renovascular disease
Resistant HTN (uncontrolled despite 3-drug regimen)
Malignant HTN (with end-organ damage)
HTN-related Onset of severe HTN (>180/120 mm Hg) after age 55
symptoms Severe HTN with diffuse atherosclerosis
Recurrent flash pulmonary edema with severe HTN
Physical examination
Laboratory results
Supportive evidence
Unexplained rise in serum creatinine (>30%) after starting ACE
inhibitors or ARBs
Imaging results
Usually empiric
Treatment Macrolide or respiratory fluoroquinolone
Disseminated gonococcal infection
Manifestations Purulent monoarthritis
OR
Hypoglycemia
Laboratory findings
Prolonged PR interval
ECG findings Bradycardia
Secure airway
GI decontamination
IV fluid boluses
Management
IV atropine
IV glucagon
GI = gastrointestinal; IV = intravenous.
Hodgkin lymphoma
Bimodal peak incidence: age 15-35 & >60
Epidemiology Association with EBV in immunosuppression
Painless lymphadenopathy
Mediastinal mass
Manifestations B symptoms (ie, fever, sweats, weight loss)
Pruritus
Age >50
Systemic signs & symptoms Elevated ESR, C-reactive
Stiffness > pain in shoulders, hip protein
Polymyalgia
girdle, neck Rapid improvement with
rheumatica
Association with giant cell glucocorticoids
(temporal) arteritis
Lung: acute & chronic pneumonia (usually mild to moderate but may be
severe)
Skin: wart-like lesions, violaceous nodules, skin ulcers
Clinical
Bone: osteomyelitis
features
Genitourinary: prostatitis, epididymoorchitis
CNS: meningitis, epidural or brain abscesses
Clinical
Muscle stage (up to 4 weeks after ingestion)
presentation
Myositis
Fever, subungual splinter hemorrhages
Periorbital edema
Eosinophilia (usually >20%) with possible elevated creatine kinase &
leukocytosis
↓ Platelets
Laboratory ↓ Sodium
findings ↑ AST & ALT
Rickettsia serology
Diagnosis Skin biopsy
Doxycycline
Treatment
ALT = alanine transaminase; AST = aspartate transaminase.
Overview of chronic pancreatitis
Alcohol use
Cystic fibrosis (common in children)
Ductal obstruction (eg, malignancy,
Etiology
stones)
Autoimmune
Pain management
Alcohol & smoking cessation
Treatment Frequent, small meals
Pancreatic enzyme supplements
Bland urinalysis
Very low urine Na+ (<10 mEq/L)
Diagnosis Exclusion of other causes of AKI
No improvement with trial of volume expansion
Upper body
o Well developed
o Hypertension (headaches, epistaxis)
Lower extremities
o Underdeveloped
Clinical features
o Claudication
Brachial-femoral pulse delay
Upper & lower extremity blood pressure differential
Left interscapular systolic or continuous murmur
*Begin at time of diagnosis for type 2 diabetes mellitus & 5 years after diagnosis for type 1.
BP = blood pressure.
Polycythemia vera
↑ Blood viscosity
o Hypertension
o Erythromelalgia (burning cyanosis in hands/feet)
o Transient visual disturbances
Manifestations
↑ RBC turnover (gouty arthritis)
Aquagenic pruritus
Bleeding
Elevated hemoglobin
Leukocytosis & thrombocytosis
Laboratory Low erythropoietin level
JAK2 mutation positive
findings
Thrombosis
Complications Myelofibrosis & acute leukemia
Phlebotomy
Treatment Hydroxyurea (if ↑ risk of thrombus)
Prerenal vasoconstriction
Pathophysiology Direct tubular cytotoxicity
Weight
Self-monitoring
Food intake
Exercise
Basal ganglia
Affected Subcortical white matter (eg, internal capsule, corona radiata)
areas Pons
Risk Hypertension
factor
Absence of cortical signs (eg, aphasia, agnosia, neglect, apraxia,
hemianopia), seizure, or mental status changes
Common syndromes:
Clinical o Pure motor hemiparesis (most frequent)
features o Pure sensory stroke
o Ataxic hemiparesis
o Dysarthria–clumsy hand syndrome
Anaphylaxis
Food (eg, nuts, shellfish)
Medications (eg, β-lactam antibiotics)
Triggers
Insect stings
Clinical Cardiovascular
o Vasodilation → hypotension & tissue edema
o Tachycardia
Respiratory
o Upper airway edema → stridor & hoarseness
o Bronchospasm → wheezing
manifestations
Cutaneous
o Urticarial rash, pruritus, flushing
Gastrointestinal
o Nausea, vomiting, abdominal pain
Intramuscular epinephrine
Airway management & volume resuscitation
Treatment
Adjunct therapy (eg, antihistamines, glucocorticoids)
Frequently asymptomatic
Mucocutaneous bleeding (eg, menorrhagia, epistaxis)
Manifestations Ecchymoses, petechiae, purpura
Severe hemorrhage is rare
Diagnosis of exclusion
Normal coagulation tests, platelet morphology (peripheral smear)
Diagnosis
HIV, HCV testing (commonly induces ITP)
OR
Manifestations
Triad of tenosynovitis, dermatitis, migratory polyarthralgia
Acute pancreatitis
Chronic alcohol use (~40%)
Gallstones (~40%)
Hypertriglyceridemia
Etiology Drugs (eg, azathioprine, valproic acid, thiazides)
Infection (eg, CMV, Legionella, Aspergillus)
Iatrogenic (post-ERCP, ischemic/atheroembolic)
Clinical presentation
Other findings
Trimethoprim-sulfamethoxazole
Alternate therapies:
Toxoplasma
<100/mm3 & positive IgG antibody Dapsone plus pyrimethamine
gondii
plus leucovorin
Atovaquone ± pyrimethamine
plus leucovorin
Fine-needle aspiration
Diagnosis Culture >14 days
Common Drugs
triggers
Allopurinol
Antibiotics (eg, sulfonamides)
Anticonvulsants (eg, carbamazepine, lamotrigine, phenytoin)
NSAIDs (eg, piroxicam)
Sulfasalazine
Other
Mycoplasma pneumoniae
Vaccination
Graft versus host disease
Intravenous fluids
Prophylaxis Xanthine oxidase inhibitor* or rasburicase
*Allopurinol or febuxostat.
Microscopic colitis
Watery, nonbloody diarrhea; fecal urgency & incontinence
Clinical
Abdominal pain, fatigue, weight loss, arthralgias
findings
Smoking, medications (eg, NSAIDs, PPIs, SSRIs)
Triggers
Colonoscopic biopsy with lymphocytic infiltration of lamina propria
o Collagenous: thickened subepithelial collagen band
Diagnosis
o Lymphocytic: high levels of intraepithelial lymphocytes
Gingival manipulation
Viridans streptococci Respiratory tract incision or biopsy
Prosthetic valves
Intravascular catheters
Staphylococcus epidermidis
Implanted devices
Stiffness of shoulders
& hips with restricted
motion
Polymyalgia Often coexists with
No Yes ↑ Normal
rheumatica GCA
Rapid improvement
with glucocorticoids
Multisystem
involvement (arthritis,
Polymyositis & Normal
Yes Uncommon ↑ rash, ILD)
dermatomyositis or ↑
↑ Malignancy risk
DTR = deep tendon reflex; ESR = erythrocyte sedimentation rate; GCA = giant cell arteritis;
ILD = interstitial lung disease.
Distinguishing features of fibromyalgia, polymyositis
& polymyalgia rheumatica
Clinical features Diagnosis
Young to middle-aged women
Chronic widespread pain ≥3 months of symptoms with
Fatigue, impaired concentration widespread pain index or
Fibromyalgia Tenderness at trigger points symptom severity score
(eg, midtrapezius, costochondral Normal laboratory studies
junction)
Age >50
Systemic signs & symptoms Elevated ESR, C-reactive
Stiffness > pain in shoulders, hip protein
Polymyalgia
girdle, neck Rapid improvement with
rheumatica
Association with giant cell glucocorticoids
(temporal) arteritis
Isoniazid
Tetracyclines
Antibiotics Metronidazole
Trimethoprim-sulfamethoxazole
Valproic acid
Antiepileptics Carbamazepine
Thiazides, furosemide
Antihypertensives Enalapril, losartan
Lamivudine
Antivirals Didanosine
Asparaginase
Others Estrogens
Mild-moderate
Headache, confusion
Malaise, dizziness, nausea
Manifestations
Severe
Pain management
Alcohol & smoking cessation
Treatment Frequent, small meals
Pancreatic enzyme supplements
NSAIDs = nonsteroidal anti-inflammatory drugs; RBCs = red blood cells; WBCs = white blood
cells.
Pheochromocytoma
Classic triad: episodic headache, sweating & tachycardia
Resistant HTN or HTN accompanied by unexplained ↑
glucose
Indications for testing
Family history or familial syndrome (eg, MEN2, NF1,
VHL)
Diuretics
Volume depletion SGLT-2 inhibitors
Beta blockers
Sympathetic blockade Clonidine
Sjögren syndrome
Keratoconjunctivitis sicca
Exocrine Dry mouth, salivary hypertrophy
features Xerosis
Raynaud phenomenon
Cutaneous vasculitis
Extraglandular Arthralgia/arthritis
features Interstitial lung disease
Non-Hodgkin lymphoma
Pseudomonas aeruginosa
Microbiology
Severe, unremitting ear pain (worse at night & with
chewing)
Deficits of lower cranial nerves (eg, facial
Clinical [CN VII], glossopharyngeal [CN IX], vagus
manifestations [CN X])
Granulation tissue in the external auditory canal
Elevated erythrocyte sedimentation rate
Complications of Graves disease treatment
Treatment Adverse effects
Agranulocytosis
Antithyroid drugs Methimazole: 1st-trimester teratogen, cholestasis
(thionamides) Propylthiouracil: hepatic failure, ANCA-associated vasculitis
Permanent hypothyroidism
Radioiodine Worsening of ophthalmopathy
ablation Possible radiation side effects
Permanent hypothyroidism
Risk for recurrent laryngeal nerve damage
Surgery
Risk for hypoparathyroidism
2nd-generation H1 antihistamines
Treatment & Add H2 antihistamines or systemic corticosteroids if severe
prognosis Two-thirds of cases self-resolve
Hepatitis A
Fecal-oral transmission
Transmission Poor sanitation/hygiene, travel to endemic areas
& risk factors Contaminated food & water
IV = intravenous; SQ = subcutaneous.
Obstructive sleep apnea
Relaxation of pharyngeal muscles, leading to closure of airway
Pathophysiology Loud snoring with periods of apnea
Daytime somnolence
Nonrestorative sleep with frequent awakenings
Symptoms Morning headaches
Affective & cognitive symptoms
Systemic hypertension
Sequelae Pulmonary hypertension & right-sided heart failure
Acute pericarditis
Viral or idiopathic
Autoimmune disease (eg, SLE)
Uremia (acute or chronic renal failure)
Etiology Post myocardial infarction
o Early: peri-infarction pericarditis
o Late: Dressler syndrome
Chronic cough
Clinical Prolonged fever
manifestations Weight loss, failure to thrive
Cryotherapy
Curettage
Reassurance
Treatment Topical therapy (eg, cantharidin,
podophyllotoxin)
ANA = antinuclear antibody; CCB = calcium channel blocker; ESR = erythrocyte sedimentation
rate.
Hepatic encephalopathy
Drugs (eg, sedatives, narcotics)
Hypovolemia (eg, diarrhea)
Electrolyte changes (eg, hypokalemia)
Precipitating factors ↑ Nitrogen load (eg, GI bleeding)
Infection (eg, pneumonia, UTI, SBP)
Portosystemic shunting (eg, TIPS)
Normocytic anemia
Renal insufficiency
Laboratory Hypercalcemia (constipation, muscle weakness)
Monoclonal paraproteinemia (M-spike)
Clinical presentation
Diagnosis Neuropsychological testing
Viral myocarditis
Relatively young adults (eg, age <55)
Viral prodrome (eg, fever, malaise, myalgias)
Clinical Heart failure (eg, dyspnea, orthopnea, edema)
presentation Chest pain
Sudden cardiac death
ECG: nonspecific
Echocardiography: 4-chamber dilation
Diagnosis Cardiac MRI: late enhancement of the epicardium
Biopsy: lymphocytic infiltration, viral DNA or RNA
Tricuspid regurgitation on
Exertional dyspnea
echocardiography
Signs of right-sided heart
Pulmonary ↑ Pulmonary arterial pressure
failure (eg, jugular venous
hypertension on right-sided heart
distension, edema)
catheterization
Disseminated histoplasmosis
Temperate regions worldwide
Soil contaminated by bird or bat droppings
Epidemiology
↑ Dose exposure or immunocompromised (eg, AIDS)
Laboratory findings:
o Pancytopenia
o Transaminase elevation
o ↑ LDH & ferritin
Diagnosis
Chest x-ray (reticulonodular or interstitial infiltrate)
Urine/serum histoplasma antigen (↑ sensitivity/rapid)
Serology
Culture (takes 4-6 weeks)
↓ ↓ ↓ ↓ Decreased
clearance
Misfolding Increased Increased Accumulation
mechanism production
production over time
↓
↓ ↓
↓ ↓
Amyloid
AL Aβ2M
fibril type
AA ATTR*
Cardiomyopathy,
Nephropathy, hepatosplenomegaly,
Clinical CTS, other Scapulohumeral
cardiomyopathy (AL > AA), peripheral
manifestations peripheral arthritis, CTS
neuropathy, macroglossia, skin bruising
neuropathy
Amyloid names begin with "A" followed by the precursor protein abbreviation.
Age >75
Obesity
Alcoholism
C-reactive protein >150 mg/dL at 48 hr after presentation
Associated with ↑ risk of
Rising blood urea nitrogen & creatinine in the first 48 hr
severe pancreatitis
Chest x-ray with pulmonary infiltrates or pleural effusion
CT scan/magnetic resonance cholangiopancreatography with
pancreatic necrosis & extra pancreatic inflammation
Pseudocyst
Peripancreatic fluid collection
Necrotizing pancreatitis
Complications Acute respiratory distress syndrome
Acute renal failure
Gastrointestinal bleeding
Intraarticular glucocorticoids
Nonsteroidal anti-inflammatory drugs
Treatment
Colchicine
**Cardiac index & SvO2 are usually decreased in neurogenic shock due to impaired sympathetic
reflexes.
Mostly asymptomatic
Metabolic syndrome
Clinical
AST/ALT ratio <1
features
Hyperechoic texture on ultrasound examination
Hepatic fibrosis associated with increased risk for cirrhosis & liver-
Prognosis related death
Fluid restriction
Fluid resuscitation
Preload & afterload
Avoid preload reduction
Management reduction
Reperfusion therapy
Reperfusion therapy
Nail pitting
Extradermal Conjunctivitis, uveitis
manifestations Psoriatic arthritis
Fatigue
Confusion
Neurologic Weakness
Color vision alterations
Clinical Acute
presentation
Back pain & decreased spinal mobility
Pain increasing with standing, walking, lying on
back
Referred pain to abdomen/flank
Spinal tenderness at affected level
Chronic/gradual
Painless
Progressive kyphosis
Loss of height
*Normal saline for the first hour regardless of sodium levels; fluid choice may change thereafter.
Heart failure with preserved ejection fraction
LV diastolic dysfunction due to impaired relaxation
Etiology
Chronic hypertension (concentric LV hypertrophy)
Obesity & sedentary lifestyle (myocardial interstitial fibrosis)
Risk factors
CAD & related risk factors (eg, diabetes mellitus)
Other findings:
Pleural effusion
Ileus
Complications Pancreatic pseudocyst/abscess/necrosis
Acute respiratory distress syndrome
Clinical
Low serum Na High serum Na Normal serum Na
features
ADH = antidiuretic hormone; DI = diabetes insipidus.
Kaposi sarcoma
Endothelial tumor caused by human herpesvirus 8
Most common malignancy in patients with untreated HIV
Etiology
Endemic in certain African & Mediterranean regions
Cutaneous lesions:
o Violaceous, red, or brown flat lesions grow into papules
o Most common along skin folds
o Pruritus, pain & friability are rare
Manifestations o Lymphedema distal to lesions
Visceral lesions:
o Lungs & gastrointestinal tract most common
o May cause life-threatening bleeding
KS = Kaposi sarcoma.
Diagnostic tests for pulmonary tuberculosis
Low cost & rapid (minutes to hours)
Low sensitivity because high burden (>10,000/mL) of organisms required
AFB smear
in sample
microscopy
Cannot differentiate TB from non-TB mycobacteria
Albendazole
Percutaneous therapy (>5 cm or septations)
Treatment
Surgery (if rupture)
Arthritis
Late Encephalitis
(months to years) Peripheral neuropathy
AV = atrioventricular.
Hyperosmolar hyperglycemic state
Type 2 diabetes mellitus
Patient
Older age
characteristics
Acute illness, trauma, infection
Inciting Insulin nonadherence
factors Medications: glucocorticoids, diuretics, atypical antipsychotics
Cerebrospinal fluid:
Septic embolism
Metastatic abscess
Distant (embolic) Mycotic aneurysm
Organ infarction
Normochromic anemia
Diagnostic Elevated ESR & CRP
tests Temporal artery biopsy
Systemic hypertension
Sequelae Pulmonary hypertension & right-sided heart failure
STEMI
*In patients with NSTEMI or unstable angina, P2Y12 inhibitor therapy is often held until after
coronary angiography in case the atherosclerotic coronary anatomy indicates the need for
coronary artery bypass grafting.
Chronic silicosis
Occupation: quarry work, stone cutting, glass & ceramic
manufacturing
Pathogenesis: respired silica crystals → inflammatory activation of
Risk factors &
alveolar macrophages
pathogenesis
Associations: lung cancer, mycobacterial disease, rheumatoid
arthritis
Asthma vs COPD
Asthma COPD Late-stage COPD
FVC Normal/↓ Normal/↓ ↓/↓↓
FEV1 ↓ ↓ ↓↓
FEV1/FVC ↓ ↓ ↓↓
Bronchodilator Partially reversible/ Usually
Reversible
response nonreversible nonreversible
Hyperinflation, loss
Chest x-ray Normal Normal
of lung markings
DLCO Normal/↑ Normal/↓ ↓
COPD = chronic obstructive pulmonary disease; DLCO = diffusion capacity of the lung for
carbon monoxide.
Hypersensitivity pneumonitis
Immunologic response to inhaled antigen (eg, mold, animal protein)
Etiology
Acute
BAL = bronchoalveolar lavage; DLCO = diffusion capacity of the lung for carbon monoxide;
PFT = pulmonary function testing.
Vasospastic angina
Hyperreactivity of coronary smooth muscle
Pathogenesis
Young patients (age <50)
Smoking (minimal other CAD risk factors)
Clinical Recurrent chest discomfort
presentation o Occurs at rest or during sleep
o Spontaneous resolution ≤15 min
Severe diarrhea
Lactic acidosis
Renal tubular acidosis
Diabetic ketoacidosis
Excess saline infusion
Renal failure (uremia)
Etiologies Intestinal or pancreatic
Methanol, ethylene glycol
fistula
Salicylate toxicity
CAI & MRA diuretics
Fistulae, abscesses
Intestinal Toxic megacolon
Strictures (bowel obstruction)
complications
RLQ = right lower quadrant.
Second-degree atrioventricular block:
distinguishing features of Mobitz types I & II
Mobitz type I Mobitz type II
Below AV node (eg, His
Level of block AV node
bundle)
Progressive prolongation of PR Constant PR interval with
ECG findings interval followed by dropped randomly dropped QRS
QRS complex complexes
QRS complexes Usually narrow Narrow or wide
Decreased vagal tone (eg,
Block improves Block worsens
exercise, atropine)
Increased vagal tone (eg,
Block worsens Block improves
carotid massage)
Risk of complete block Low High (indication for PPM)
AV = atrioventricular; PPM = permanent pacemaker.
Bacterial aspiration pneumonia
Oropharyngeal/gastric microbes aspirated into lungs → host
Pathophysiology defenses overwhelmed due to large inoculum size
Hilar/mediastinal lymphadenopathy
Mississippi/Ohio River Valley Hepatosplenomegaly
Histoplasmosis Pancytopenia
Central & South America Adrenal insufficiency
Skin lesions
Southern Arizona/California Lymph node involvement
Coccidioidomycosis Meningitis
Northern Mexico Osteoarticular infection
Laboratory evaluation of hypertension
Serum electrolytes (Na, K, Ca)
Serum creatinine
Renal function tests Urinalysis
Urine albumin/creatinine ratio (optional)
ECG
Cardiac tests Echocardiography (optional)
Sinus bradycardia
Sinus pauses (delayed P waves)
ECG findings
Sinoatrial nodal exit block (dropped P waves)
Pacemaker
Treatment +/- Rate-control medication (if tachyarrhythmias)
OR
Manifestations
Triad of tenosynovitis, dermatitis, migratory polyarthralgia
EEG = electroencephalography.
Frostbite
Superficial pallor & anesthesia
Clinical Blistering, eschar formation
findings Deep tissue necrosis & mummification
Rapid rewarming in water bath at 37-39 C (98.6-102.2 F)
Analgesia & wound care
Angiography or technetium-99m scan to assess for thrombosis if
Management
rewarming is unsuccessful
Thrombolysis in severe, limb-threatening cases
Fistulae, abscesses
Intestinal Toxic megacolon
Strictures (bowel obstruction)
complications
RLQ = right lower quadrant.
Advance directives
Legally binding instructions regarding patient's own health care
Considered determinative for giving consent/refusal for treatment
Definition
Takes priority over family's/friends' preferences
Gilbert syndrome
Most common inherited disorder of bilirubin metabolism
Epidemiology
↓ Hepatic UDP glucuronosyltransferase activity → ↓ conjugation of
Pathogenesis bilirubin
Recurrent episodes of mild jaundice
Provoked by stress (eg, febrile illness, fasting, dehydration, vigorous
Clinical findings
exercise, menstruation, surgery)
Anemia
Elevated venous lead level
Laboratory
Elevated serum zinc protoporphyrin level
findings
Basophilic stippling on peripheral smear
Hypersensitivity pneumonitis
Etiology Immunologic response to inhaled antigen (eg, mold, animal protein)
Acute
BAL = bronchoalveolar lavage; DLCO = diffusion capacity of the lung for carbon monoxide;
PFT = pulmonary function testing.
Classification of multiple endocrine neoplasia
Primary hyperparathyroidism (parathyroid adenomas or
hyperplasia)
Type 1 Pituitary tumors (prolactin, visual defects)
Pancreatic tumors (especially gastrinomas)
Hyponatremia
Serum osmolality <275 mOsm/kg H2O (hypotonic)
Laboratory findings Urine osmolality >100 mOsm/kg H2O
Urine sodium >40 mEq/L
Abdominal pain
Peripheral neuropathy most pronounced in the proximal upper
extremities
Autonomic dysfunction (eg, tachycardia, diaphoresis,
Manifestations
hypertension)
Neuropsychiatric (eg, hallucinations, anxiety, psychosis)
Red-tinged urine that oxidizes with light/air exposure
**Cardiac index & SvO2 are usually decreased in neurogenic shock due to impaired sympathetic
reflexes.
IV = intravenous.
Hyperosmolar hyperglycemic state
Type 2 diabetes mellitus
Patient
Older age
characteristics
Gradual hyperglycemic symptoms (eg, polyuria, polydipsia)
Clinical
Altered mentation (eg, coma, focal signs, seizures)
symptoms
Glucose >600 mg/dL (frequently >1,000 mg/dL)
Normal pH & bicarbonate
Laboratory Normal anion gap
studies Negative or small serum ketones
Serum osmolality >320 mOsm/kg
*Normal saline for the first hour regardless of sodium levels; fluid choice may change thereafter.
Systemic small-vessel vasculitides
Usual vasculitic patterns &
Laboratory & biopsy findings
associated findings
Primary
Palpable purpura, GN,
PN ANCA (PR3 or MPO)
ANCA-associated 3 types with variable Pauci-immune vasculitis (±
vasculitis lung, heart & sinus granulomas)
involvement
GN ± pulmonary
hemorrhage Serum anti-GBM antibodies
Anti-GBM disease No palpable purpura or Linear IgG on kidney biopsy
PN
Secondary
Palpable purpura, GN,
+Cryoglobulins, +rheumatoid
PN
factor, low complement
Cryoglobulinemic Hepatitis C, HIV,
+Viral or autoimmune
vasculitis (MCS) autoimmune disease*
serologies
(SLE, RA)
Clinical features
LAD = lymphadenopathy.
Chronic mesenteric ischemia
Atherosclerosis (smoking, dyslipidemia)
Etiology
Crampy, postprandial epigastric pain
Clinical features Food aversion & weight loss
Management of hypercalcemia
Short-term (immediate) treatment
Stiffness of shoulders
& hips with restricted
motion
Polymyalgia Often coexists with
No Yes ↑ Normal
rheumatica GCA
Rapid improvement
with glucocorticoids
Multisystem
involvement (arthritis,
Polymyositis & Normal
Yes Uncommon ↑ rash, ILD)
dermatomyositis or ↑
↑ Malignancy risk
DTR = deep tendon reflex; ESR = erythrocyte sedimentation rate; GCA = giant cell arteritis;
ILD = interstitial lung disease.
Pemphigus vulgaris vs bullous pemphigoid
Pemphigus vulgaris Bullous pemphigoid
40-60 >60
Age of onset
Painful
Flaccid bullae → Pruritic
erosions Tense bullae
Clinical features
Mucosal involvement Mucosal involvement rare
common
Outpatient: fluoroquinolones
Inpatient: ceftriaxone, piperacillin-tazobactam, carbapenems (eg,
Complicated imipenem)
UTI* Culture obtained prior to therapy, with adjustment of antibiotic as
needed
*Infection above the bladder (eg, pyelonephritis), pelvic pain in men, other signs or symptoms of
systemic illness.
CT scan or MR angiography
Diagnosis Renal venography
Anticoagulation
Treatment Local thrombolysis/thrombectomy (if AKI present)
TMP-SMX = trimethoprim-sulfamethoxazole.
IgA nephropathy APSGN
Several days after upper Weeks after group A
respiratory tract infection or Streptococcus infection (eg,
spontaneous pharyngitis, impetigo)
Onset
Most common in young Most common in school-aged
adults children
Diagnosis Clinical
Supportive findings
o Cerebrospinal fluid: ↑ protein, normal leukocytes
o Abnormal electromyography & nerve conduction
o MRI: normal or enhancement of anterior nerve roots/cauda
equina
Fluid restriction
Fluid resuscitation
Preload & afterload
Avoid preload reduction
Management reduction
Reperfusion therapy
Reperfusion therapy
ALT = alanine aminotransferase; AST = aspartate aminotransferase; RBCs = red blood cells.
AIDS-defining malignancies
Malignancy Viral association
Kaposi sarcoma Human herpesvirus 8
Invasive cervical carcinoma Human papillomavirus
Non-Hodgkin lymphoma Epstein-Barr virus
Primary CNS lymphoma Epstein-Barr virus
Often fatal
Treatment If HIV positive: antiretroviral therapy
TMP-SMX = trimethoprim-sulfamethoxazole.
Paget disease of bone
Most patients are asymptomatic
Bone pain & deformity
o Skull: headache, hearing loss
Clinical
o Spine: spinal stenosis, radiculopathy
features
o Long bones: bowing, fracture, arthritis of adjacent joints
Giant cell tumor, osteosarcoma
Bisphosphonates
Treatment
PINP = procollagen type I N-terminal propeptide.
Intravenous fluids
Prophylaxis Xanthine oxidase inhibitor* or rasburicase
*Allopurinol or febuxostat.
Benztropine, trihexyphenidyl
Antiparkinson
Ipratropium (bronchodilator)
Oxybutynin, darifenacin (overactive bladder)
Antimuscarinic Dicyclomine, hyoscyamine (antispasmodics)
Scopolamine (antiemetic)
Atropine, cyclopentolate
Mydriatics
Muscarinic mushroom species
Jimsonweed
Plant-based
Nightshade species
Thiamine deficiency
Pathophysiology
Encephalopathy
Oculomotor dysfunction (eg, horizontal nystagmus
Clinical features & bilateral abducens palsy)
Postural & gait ataxia
Purulent drainage
Folliculitis: infected hair follicle
MSSA
Furuncles: folliculitis → dermis →
Cellulitis (purulent) MRSA
abscess
Restrictive cardiomyopathy
Cardiac Conduction defects, low voltage
Hepatomegaly
Dysmotility, malabsorption
GI
GI bleeding due to vascular fragility
Anemia, thrombocytopenia
Heme
CNS = central nervous system; GI = gastrointestinal.
Overview of subarachnoid hemorrhage
Ruptured arterial saccular (berry) aneurysm (most common)
Severe headache at onset of neurologic symptoms
Clinical features Meningeal irritation (eg, neck stiffness)
Focal deficits can be present
**Right heart catheterization shows step up in O2 concentration from right atrium to right
ventricle.
LAD = left anterior descending; MR = mitral regurgitation; RCA = right coronary artery.
Acute pericarditis
Viral or idiopathic
Autoimmune disease (eg, SLE)
Uremia (acute or chronic renal failure)
Etiology Post myocardial infarction
o Early: peri-infarction pericarditis
o Late: Dressler syndrome
Hemangioblastomas
Clear cell renal carcinoma
von Hippel-Lindau syndrome
Pheochromocytoma
Parathyroid adenomas
Pituitary adenomas
Multiple endocrine neoplasia type 1
Pancreatic adenomas
Breast cancer
BRCA1 & BRCA2 Ovarian cancer
Bullous pemphigoid
Age >60
Pruritic, tense bullae
Clinical
Rare mucosal involvement
features
Prodrome of eczematous/urticaria-like rash
Dementia
Associated
Parkinson disease
Depression, bipolar disorder
disorders
Histology: subepidermal cleavage
Immunofluorescence: linear IgG/C3 deposition along basement membrane
Diagnosis
Serology: autoantibodies to bullous pemphigoid antigens (hemidesmosomes)
Drugs
Allopurinol
Antibiotics (eg, sulfonamides)
Anticonvulsants (eg, carbamazepine, lamotrigine, phenytoin)
NSAIDs (eg, piroxicam)
Common Sulfasalazine
triggers
Other
Mycoplasma pneumoniae
Vaccination
Graft versus host disease
Severe diarrhea
Renal tubular acidosis
Excess normal saline infusion
Thyrotoxicosis with normal or ↑
Thyrotoxicosis with ↓ RAIU
RAIU
Painless (silent) thyroiditis
Subacute (de Quervain) thyroiditis
Amiodarone-induced thyroiditis
Graves disease
Excessive dose (or surreptitious intake) of
Toxic multinodular goiter
levothyroxine
Toxic nodule
Struma ovarii
Iodine-induced
Extensive thyroid cancer metastasis
Acute
Jaundice, hepatic encephalopathy, variceal bleeding
o
Prolonged INR/PTT; elevated transaminases
o
Subacute/chronic
Manifestations
o Vague, progressive abdominal pain
o Hepatomegaly, splenomegaly, ascites
o Mild/moderate elevation in bilirubin, transaminases
Late signs
o ↓ Rectal tone
o ↑ Deep tendon reflexes, bilateral Babinski reflex
o Paralysis
Assess for:
o Stigmata of cirrhosis (eg, palmar erythema, spider
angiomata)
Physical
o Signs of malignancy (eg, lymph node enlargement)
examination
o Volume overload (eg, elevated jugular venous pressure)
o Visceral obesity (eg, truncal obesity)
Polycythemia vera
↑ Blood viscosity
o Hypertension
o Erythromelalgia (burning cyanosis in hands/feet)
o Transient visual disturbances
Manifestations
↑ RBC turnover (gouty arthritis)
Aquagenic pruritus
Bleeding
Elevated hemoglobin
Leukocytosis & thrombocytosis
Laboratory Low erythropoietin level
JAK2 mutation positive
findings
Thrombosis
Complications Myelofibrosis & acute leukemia
Phlebotomy
Treatment Hydroxyurea (if ↑ risk of thrombus)
Fundus with
retinal Observation ±
Blurred vision to hemorrhages & intravitreal
Central retinal
severe vision loss optic disc injection of VEGF
vein occlusion
edema ("blood inhibitors
& thunder")
↓ or absent red
Bed rest, HOB
reflex
Hazy vision ± elevation 30-45
RBCs/floating
red hue or vision degrees
Vitreous debris in
loss Photocoagulation
hemorrhage vitreous,
Floaters/shadows or vitrectomy in
obscured view
some cases
of fundus
PMNs >250/mm3
Positive culture, often gram-negative organisms (eg,
Diagnosis from ascitic Escherichia coli, Klebsiella)
fluid Protein <1 g/dL
SAAG >1.1 g/dL
Infectious mononucleosis
Epstein-Barr virus most common
Etiology
Fever
Tonsillitis/pharyngitis ± exudates
Posterior or diffuse cervical lymphadenopathy
Clinical features Significant fatigue
± Hepatosplenomegaly
± Rash after amoxicillin
Avoid sports for ≥3 weeks (contact sports ≥4 weeks) due to the risk of
Management splenic rupture
Mostly asymptomatic
Metabolic syndrome
Clinical
AST/ALT ratio <1
features
Hyperechoic texture on ultrasound examination
Hepatic fibrosis associated with increased risk for cirrhosis & liver-
Prognosis related death
Infection
Autoimmune hemolytic anemia
Complications
Secondary malignancies (eg, Richter syndrome)
Hypokalemia
Diuretic therapy (eg, thiazides)
Vomiting/diarrhea
Hypomagnesemia
Etiologies Hyperaldosteronism
Increased beta-adrenergic activity
(eg, albuterol)
*Simple aspergilloma (fungus ball in preexisting lung cavity) is a form of chronic pulmonary
aspergillosis but is usually quiescent with occasional hemoptysis.
Clinical features of alcoholic hepatitis
Jaundice, anorexia, fever
Right upper quadrant &/or epigastric pain
Abdominal distention due to ascites
Clinical presentation Proximal muscle weakness from muscle wasting (if
malnourished)
Possible hepatic encephalopathy
Clinical presentation
Other findings
Infection
Autoimmune hemolytic anemia
Complications
Secondary malignancies (eg, Richter syndrome)
Rhino-orbital-cerebral mucormycosis*
Diabetes mellitus (ketoacidosis)
Hematologic malignancy
Risk factors
Solid organ or stem cell transplant
Acute/aggressive
Fever, nasal congestion, purulent nasal discharge, headache, sinus pain
Manifestations
Necrotic invasion of palate, orbit, brain
CSF analysis:
o ↑ WBCs (↑ lymphocytes), ↑ RBCs
Diagnostic o ↑ Protein, normal glucose
findings o HSV DNA on PCR
Brain MRI: temporal lobe hemorrhage/edema
Intravenous acyclovir
Treatment
CSF = cerebrospinal fluid; WBCs = white blood cells; RBCs = red blood cells.
Clinical manifestations of hereditary hemochromatosis
Skin Hyperpigmentation (bronze diabetes)
Musculoskeletal Arthralgia, arthropathy & chondrocalcinosis
Elevated hepatic enzymes with hepatomegaly (early), cirrhosis (later) &
Gastrointestinal
increased risk of hepatocellular carcinoma
Endocrine Diabetes mellitus, secondary hypogonadism & hypothyroidism
Cardiac Restrictive or dilated cardiomyopathy & conduction abnormalities
Infections Increased susceptibility to Listeria, Vibrio vulnificus & Yersinia enterocolitica
Common causes of recurrent pneumonia
Bronchial obstruction
*Recurrent aspiration can lead to pneumonia in different dependent regions of the lung
depending on the position of the patient during the aspiration event.
Hypercalcemia/hypercalciuria
Laboratory Elevated serum ACE level
CO = cardiac output; DBP = diastolic blood pressure; LV = left ventricle; SBP = systolic blood
pressure; SV = stroke volume.
Multifocal atrial tachycardia
Exacerbation of pulmonary disease (eg, COPD)
Electrolyte disturbance (eg, hypokalemia)
Etiology
Catecholamine surge (eg, sepsis)
Typically asymptomatic
Rapid, irregular pulse
Clinical findings
ECG: >3 P-wave forms & atrial rate >100/min
Diagnosis Elevated plasma aldosterone & low plasma renin (ratio >20)
Absence of aldosterone suppression with oral saline load
CT scan of adrenal glands to determine bilateral hyperplasia vs
adenoma
*In some patients, the characteristic electrolyte abnormalities are apparent only after a thiazide
is initiated for blood pressure management.
Older individuals
Pain/stiffness worse with movement
Facet osteoarthritis
Relieved with rest
Young men
HLA-B27
Spondyloarthropathy Relieved with exercise
Prolonged morning stiffness
Constant pain
Worse at night
Spinal metastasis
Not responsive to position changes
Focal tenderness
Fevers & night sweats
Vertebral osteomyelitis
IVDU, immune compromise, or recent infection
Acute infection
o B19 IgM antibodies in immunocompetent patients
o NAAT for B19 DNA in immunocompromised patients
Diagnosis
Previous infection: B19 IgG antibodies (documents immunity)
Reactivation of previous infection: NAAT for B19 DNA
Decreased pulses
Normal pulses
Cool extremities
Frequently normal
Examination Decreased hair growth
examination
Pallor with leg elevation
Arthritis
Late Encephalitis
(months to years) Peripheral neuropathy
AV = atrioventricular.
Babesiosis
Babesia microti
Ixodes scapularis tick bite (Lyme disease & HGA)
Epidemiology
Northeastern United States
Atovaquone + azithromycin
Treatment Quinine + clindamycin (if severe)
Hepatotoxicity
Pyrimidine synthesis
Leflunomide inhibitor
Cytopenias
Infection
TNF inhibitors Demyelination
(eg, adalimumab, certolizumab, Congestive heart
etanercept, golimumab, failure
infliximab) Malignancy
Recumbency
Physical exertion
Precipitating Trigger foods (eg, alcohol,
Stress
factors coffee)
Rest
Alleviating Antacids
Nitroglycerin
factors
ACS = acute coronary syndrome; GERD = gastroesophageal reflux disease.
Bronchiectasis
Pathophysiology: airway insult (eg, infection, inhalation)
with impaired clearance (eg, mucostasis,
immunodeficiency)
Chronic: daily production of voluminous, thick ± blood-
Clinical features
tinged mucus
Acute exacerbations: recurrent infections with
mucopurulent sputum ± frank hemoptysis
Arthritis (sacroiliitis)
Reduced chest expansion & spinal mobility
Enthesitis (tenderness at tendon insertion sites)
Examination findings
Dactylitis (swelling of fingers & toes)
Uveitis
Osteoporosis/vertebral fractures
Aortic regurgitation
Complications
Cauda equina syndrome
Physical
Late signs
examination
o ↓ Rectal tone
o ↑ Deep tendon reflexes, bilateral Babinski reflex
o Paralysis
ARDS = acute respiratory distress syndrome; DLCO = diffusion capacity of lung for carbon
monoxide; Pplat = plateau pressure; SpO2 = oxygen saturation as measured by pulse oximetry;
VT = tidal volume.
Male hypogonadism
Primary Secondary
Congenital
Congenital
o Kallman syndrome
o Klinefelter syndrome
Gonadotropin suppression
o Varicocele
o Hyperprolactinemia
Acquired
o Glucocorticoids/opiates
o Radiation
Gonadotroph cell damage
o Infection (eg, mumps)
Causes o Benign/malignant
o Trauma
tumors
o Medications (eg,
o Pituitary apoplexy
alkylating agents,
o Infiltration (eg,
glucocorticoids)
hemochromatosis)
o Chronic disease
o Systemic disease
Karyotype Prolactin
Others based on clinical Transferrin
Evaluation
suspicion ± MRI
Pancreatic adenocarcinoma
Smoking
Hereditary pancreatitis
Risk factors Nonhereditary chronic pancreatitis
Obesity & lack of physical activity
Syphilis treatment
Stage First line Alternate
Primary (chancre) Penicillin G IM × 1 Doxycycline × 14 days
Secondary (diffuse rash)
Early latent (asymptomatic)*
Late latent (asymptomatic)*
Penicillin G IM × 3 Doxycycline × 28 days
Tertiary (eg, CV, gummata)
Neurosyphilis
Penicillin G IV × 10-14 days Ceftriaxone IV × 14 days**
(eg, meningitis, ocular)
*Early latent = asymptomatic with infection <1 year; Late latent = asymptomatic with unknown
duration of infection or infection >1 year.
Normal menstruation
Idiopathic hirsutism Normal serum androgens
Raynaud phenomenon*
Hand/finger swelling*
Arthritis/synovitis*
Inflammatory myopathy*
Clinical features
Pulmonary hypertension
Malar or discoid rash
Mild CNS &/or kidney disease
Anti–U1 ribonucleoprotein
Antinuclear antibody
Rheumatoid factor, anti–cyclic citrullinated peptide
Laboratory findings
Elevated creatine kinase
Anemia/cytopenia
*Diagnostic criteria.
Systemic sclerosis
Progressive tissue fibrosis
Pathogenesis
Vascular dysfunction
Antinuclear
Anti–topoisomerase type I (anti–Scl-70) (diffuse SSc)
Autoantibodies
Anticentromere (limited SSc)
Exposure to:
Low-risk contact
Urine, feces, nasal secretions, saliva, sweat, tears (with no
(prophylaxis not
visible blood)
recommended)
Initiate urgently, preferably in the first few hours
Timing Continue for 4 weeks
Bronchiectasis
Pathophysiology: airway insult (eg, infection, inhalation)
with impaired clearance (eg, mucostasis,
immunodeficiency)
Chronic: daily production of voluminous, thick ± blood-
Clinical features
tinged mucus
Acute exacerbations: recurrent infections with
mucopurulent sputum ± frank hemoptysis
Functional/idiopathic (75%)
Malignancy (eg, gastric, esophageal)
Etiology Peptic ulcer (eg, Helicobacter pylori infection, NSAIDs)
Drug-induced (eg, NSAIDs, bisphosphonate)
*GI bleeding, weight loss, iron deficiency anemia, lymphadenopathy, dysphagia, odynophagia,
persistent vomiting, palpable mass, family history of upper GI cancer.
May be asymptomatic
Bone pain & muscle weakness
Symptoms/signs Muscle cramps
Difficulty walking, waddling gait
Electrolyte disturbances
Hypo-/hyperglycemia
Endocrine (eg, hypo/hyperthyroid, pituitary, adrenal)
Metabolic Hypoxemia, hypercarbia
Nutritional (eg, thiamine, vitamin B12 deficiency)
Hepatic or renal failure
Leprosy
Epidemiology Mycobacterium leprae
Primarily developing world (eg, Asia, Africa, South America)
Respiratory droplets/nine banded armadillo
Low infectivity
Dapsone + rifampin
Treatment Add clofazimine if severe ("multibacillary")
Polymyalgia rheumatica
Clinical features Findings
Age >50
Bilateral pain & morning stiffness >1 month
Involvement of 2 of the following:
o Neck or torso
Symptoms
o Shoulders or proximal arms
o Proximal thigh or hip
o Constitutional (fever, malaise, weight loss)
Oral glucocorticoids
Treatment
CRP= C-reactive protein; ESR = erythrocyte sedimentation rate; ROM = range of motion.
Polymyalgia rheumatica
Clinical features Findings
Age >50
Bilateral pain & morning stiffness >1 month
Involvement of 2 of the following:
o Neck or torso
Symptoms
o Shoulders or proximal arms
o Proximal thigh or hip
o Constitutional (fever, malaise, weight loss)
Oral glucocorticoids
Treatment
CRP= C-reactive protein; ESR = erythrocyte sedimentation rate; ROM = range of motion.
Common skin infections
Infection Organism Manifestations
Superficial dermis & lymphatics
Streptococcus Raised, sharply demarcated edges
Erysipelas pyogenes Rapid spread & onset
Fever early in course
Purulent drainage
Folliculitis: infected hair follicle
MSSA
Furuncles: folliculitis → dermis →
Cellulitis (purulent) MRSA
abscess
Atovaquone-proguanil
Mefloquine
Chemoprophylaxis Doxycycline
Tafenoquine
Osteoclast dysfunction
Pathogenesis Increased bone turnover
Bisphosphonates
Treatment
PINP = procollagen type I N-terminal propeptide.
Common causes of diarrhea in patients with AIDS
Organism CD4 count Symptoms
Severe watery diarrhea
Low-grade fever
Cryptosporidium <180/mm3
Weight loss
Watery diarrhea
Crampy abdominal pain
Microsporidium/Isosporidium <100/mm3 Weight loss
Fever is rare
Watery diarrhea
High fever (>39 C [102.2 F])
Mycobacterium avium complex <50/mm3
Weight loss
Aneuploidy
Translocations/rearrangements
Chromosomal
Mosaicism
Ectopia lentis
Ocular
Cardiovascular Aortic dilation, regurgitation, or dissection
Mitral valve prolapse
*For patients with active sexually transmitted infection or those who request screening.
Chronic interstitial
pneumonitis (cough, fever,
Pulmonary dyspnea, pulmonary
infiltrates) most common
Hypothyroidism
Endocrine Hyperthyroidism
Elevated transaminases,
Gastrointestinal/
hepatitis
hepatic
Corneal microdeposits
Ocular Optic neuropathy
Diuretics
Removal of potassium Gastrointestinal cation exchangers
from body (slow acting) Hemodialysis
Malaria
Vector: female Anopheles mosquito
4 major species of Plasmodium: P falciparum, P
vivax, P ovale, P malariae
Epidemiology
Highest burden of disease is in Africa but is found
in most tropical/subtropical areas worldwide
Hydration
Analgesia
Acute pain crises
+/- Transfusion
Behçet disease
Young adults
Epidemiology Turkish, Middle Eastern, or Asian descent
Lifestyle measures
SGLT2 inhibitor
Glycemic control
GLP-1 agonist
**Atorvastatin 10-20 mg, rosuvastatin 5-10 mg, simvastatin 20-40 mg, pravastatin 40-80 mg,
lovastatin 40 mg, fluvastatin XL 80 mg, or pitavastatin 2-4 mg daily.
Paraneoplastic
Involved site Clinical features
syndrome
Fluctuating muscle weakness
o Ocular (ptosis, diplopia)
Acetylcholine receptor in o Bulbar (dysphagia,
Myasthenia gravis
postsynaptic membrane dysarthria)
o Facial, neck & limb muscles
*Uncommon. Typically only seen with prolonged (years) of high-dose ICS, superimposed oral
glucocorticoid use, or concurrent administration of potent cytochrome P-450 3A4 inhibitor.
Metronidazole or tinidazole
PLUS
Treatment
Intraluminal antibiotic (eg, paromomycin)
Watery diarrhea
Crampy abdominal pain
Microsporidium/Isosporidium <100/mm3 Weight loss
Fever is rare
Watery diarrhea
High fever (>39 C [102.2 F])
Mycobacterium avium complex <50/mm3
Weight loss
Dysuria
Manifestations Discharge
GU alone: ceftriaxone
GU + Chlamydia*: ceftriaxone +
doxycycline
Treatment
Chlamydia/Mycoplasma: azithromycin
Trichomonas: metronidazole
GU = gonococcal urethritis.
Autosomal dominant polycystic kidney disease
Clinical Most patients asymptomatic until age 30-40
presentation Flank pain, hematuria
Hypertension
Palpable abdominal masses (usually bilateral)
Chronic kidney disease (CKD)
Cerebral aneurysms
Hepatic & pancreatic cysts
Extrarenal Mitral valve prolapse, aortic regurgitation
features Colonic diverticulosis
Ventral & inguinal hernias
Sensory ataxia
Lancinating pains
Clinical findings Neurogenic urinary incontinence
Associated with Argyll Robertson pupils
Abnormally folded
proteins: beta-2
Light chains
Composition microglobulin,
of amyloid apolipoprotein or
(usually lambda)
transthyretin
AA amyloidosis = inflammatory amyloidosis; AL amyloidosis = amyloid
light-chain amyloidosis.
Lumbosacral strain
Strain of paraspinal muscles, tendons, intervertebral ligaments
Sudden or unbalanced muscle contraction (eg, lifting, twisting)
Causes Risk factors: obesity, spinal deformity or degeneration, muscle
weakness
Pain in lumbar area; may radiate to buttocks, hips, thighs (above knee)
Paraspinal tenderness
Clinical features
No neurologic deficits; negative straight-leg raising test
Moderate activity
Nonsteroidal anti-inflammatory drugs
Management
Nonbenzodiazepine muscle relaxants
Hyperthyroidism
Excessive alcohol use
Increased sympathetic tone
Triggers of increased o Acute illness (eg, sepsis, PE, MI)
automaticity o Cardiac surgery
Laboratory findings
Clinical evaluation
EMG
Diagnosis
MRI of brain & spinal cord (to exclude other causes)
Riluzole
Respiratory support (eg, NIPPV)
Treatment
Nutritional support (eg, PEG tube)
Fistulae, abscesses
Intestinal Toxic megacolon
Strictures (bowel obstruction)
complications
RLQ = right lower quadrant.
Internal validity External validity
Describes causality (ie, if change in Describes generalizability (ie, if
independent variable causes change in observed relationship applies to
dependent variable) situations or people outside study)
Characteristics ↑ As study becomes more tightly ↓ As study becomes more tightly
controlled controlled
↓ As study becomes more like the real ↑ As study becomes more like the real
world world
Threats to Bias due to: Bias due to:
validity
Confounding Artificial research
History
Maturation
Measurement environment
Regression toward the mean Measurement effects
Repeated testing Nonrepresentative sample
Selection
Acute pericarditis
Viral or idiopathic
Autoimmune disease (eg, SLE)
Uremia (acute or chronic renal failure)
Etiology Post myocardial infarction
o Early: peri-infarction pericarditis
o Late: Dressler syndrome
Treatment: supportive
Management & prognosis Survival: 10-20 years
Clinical presentation
Urinalysis: WBCs & WBC casts ± mild RBCs &
proteinuria
Diagnosis
Peripheral eosinophilia ± urine eosinophils
± Renal biopsy: tubulointerstitial inflammation & edema
Diagnosis Clinical:
o Impaired tandem walking/heel-knee-shin
o Preserved finger-nose testing
CT/MRI - cerebellar atrophy
Alcohol cessation
Nutritional supplements
Treatment
Ambulatory assistance devices (eg, walker)
Multiple myeloma
Plasma cell neoplasm produces monoclonal paraprotein
Pathophysiology (immunoglobulin)
Normocytic anemia
Renal insufficiency
Laboratory Hypercalcemia (constipation, muscle weakness)
Monoclonal paraproteinemia (M-spike)
Avascular necrosis
Etiology Steroid use
Alcohol abuse
Systemic lupus erythematosus
Antiphospholipid syndrome
Hemoglobinopathy (eg, sickle cell)
Infection (eg, osteomyelitis, HIV)
Kidney transplantation
Decompression sickness
High-output failure
Heart failure Exacerbation of preexisting low-output failure
Coronary vasospasm
Angina symptoms Preexisting coronary atherosclerosis
Viral myocarditis
Relatively young adults (eg, age <55)
Viral prodrome (eg, fever, malaise, myalgias)
Clinical Heart failure (eg, dyspnea, orthopnea, edema)
presentation Chest pain
Sudden cardiac death
ECG: nonspecific
Echocardiography: 4-chamber dilation
Diagnosis Cardiac MRI: late enhancement of the epicardium
Biopsy: lymphocytic infiltration, viral DNA or RNA
TMP-SMX = trimethoprim-sulfamethoxazole.
Prevention of calcium stone (calcium oxalate, calcium phosphate) recurrence
Intervention Mechanism
Dietary All calcium stones:
interventions ↑ Fluid (produce >2 L/day urine) ↑ Urine flow, ↓ solute concentration
↓ Sodium (<2,300 mg/day) ↑ Renal calcium reabsorption
↑ Citrate (fruits & vegetables) Binds urinary calcium to inhibit stone
formation
↑ Potassium ↑ Urinary citrate excretion
↓ Animal protein ↓ Urinary calcium excretion
Calcium oxalate stones:
Adequate calcium intake (1,200
↓ Oxalate absorption in GI tract
mg/day)
↓ Oxalate (spinach) ↓ Urinary oxalate excretion
Pharmacologic Thiazide diuretics ↑ Renal calcium reabsorption
interventions Potassium citrate ↑ Urinary citrate concentration
GI = gastrointestinal.
Nocardiosis
Gram-positive rod (beaded or branching)
Partially acid-fast
Microbiology
Aerobic
Endemic in soil
Disease from spore inhalation or traumatic inoculation into skin
Epidemiology
Immunocompromised or elderly patients
Trimethoprim-sulfamethoxazole
Treatment Surgical drainage of abscesses
Otitis externa
Water exposure
Trauma (eg, cotton swabs, ear candling)
Foreign material (eg, hearing aid, headphones)
Risk factors
Dermatologic conditions (eg, eczema, contact
dermatitis)
Pseudomonas aeruginosa
Microbiology Staphylococcus aureus
Treatment of rosacea
Avoidance of sun exposure, hot/spicy foods,
alcohol
General measures
Gentle cleansers & emollients
Topical brimonidine
Erythematotelangiectatic rosacea
Laser/intense pulsed light therapy
(flushing, erythema, telangiectasia)
First line: topical metronidazole, azelaic
Papulopustular rosacea acid, ivermectin
(small papules & pustules) Second line: oral tetracyclines
Oral isotretinoin
Phymatous rosacea
Laser therapy/surgery
(irregular thickening of skin)
Ocular rosacea Lid scrubs & ocular lubricants
(burning/foreign body sensations, Topical or systemic antibiotics (eg,
blepharitis, keratitis, conjunctivitis, corneal metronidazole, macrolides)
ulcers)
Myotonic dystrophy
Autosomal dominant CTG trinucleotide repeat expansion
Pathogenesis Longer repeat length correlating with earlier & more severe disease
Genetic testing
Diagnosis &
Supportive management
treatment
CTG = cytosine-thymine-guanine.
Hodgkin lymphoma
Bimodal peak incidence: age 15-35 & >60
Epidemiology Association with EBV in immunosuppression
Painless lymphadenopathy
Mediastinal mass
Manifestations B symptoms (ie, fever, sweats, weight loss)
Pruritus
Mild-moderate
Headache, confusion
Malaise, dizziness, nausea
Manifestations
Severe
Indolent or aggressive
Equatorial Africa
Endemic Visceral lesions can occur
Can be aggressive
Men who have sex with men Visceral lesions common
AIDS CD4 <200/mm3 Usually improves with antiretroviral
therapy
Hyponatremia
Hepatic dysfunction
Hematuria & proteinuria
Laboratory clues
Sputum Gram stain showing many neutrophils but
few or no microorganisms
Polyarteritis nodosa
Correlation with underlying hepatitis B/C (immune complexes)
Fibrinoid necrosis of arterial wall → luminal narrowing & thrombosis
→ tissue ischemia
Pathophysiology
Internal/external elastic lamina damage → microaneurysm formation
→ rupture & bleeding
OR
Change in
Inflammatory increase in membrane
hydrostatic or
Pathophysiology permeability
oncotic pressure
Heart failure
Infection (eg, pneumonia, TB)
Cirrhosis (hepatic
Malignancy
Common causes hydrothorax)
Rheumatologic disease
Nephrotic syndrome
Subacute/chronic manifestations
Inoculation → skin papule → ulceration → nonpurulent, odorless
drainage
Manifestations
Proximal lesions form along lymphatic chain
Distant spread & systemic symptoms are rare
SGLT-2 inhibitors*
Increased urinary glucose excretion (block proximal tubule
Mechanism of action glucose reabsorption)
Reduced progression of nephropathy & albuminuria
Reduced cardiovascular morbidity & mortality
Possible benefits Reduced hospitalizations for heart failure
Weight loss
Euglycemic ketoacidosis
Adverse effects Increased risk of genitourinary infections
Type 1 DM
History of DKA
Contraindications
Impaired renal function (eGFR <30-45 mL/min/1.73 m2)
Insulin resistance
Multiple skin tags Pregnancy
Crohn disease (perianal)
HIV infection
Severe seborrheic dermatitis
Parkinson disease
Chronic
Idiopathic
lithium use
Antipsychotics Trauma
Hypercalcemia
(dry mouth) Pituitary
Hereditary
Etiology Psychiatric surgery
(AVPR2 &
conditions Ischemic
aquaporin 2
encephalopathy
mutations)
Hepatitis C
HIV
Associated Excessive alcohol consumption
conditions Estrogen use
Smoking
↓↓ IgG, ↓ IgA/IgM
Diagnosis No response to vaccination
Pathogenesis
Vascular dysfunction
Antinuclear
Anti–topoisomerase type I (anti–Scl-70) (diffuse SSc)
Autoantibodies
Anticentromere (limited SSc)
Fatigue
Confusion
Neurologic Weakness
Color vision alterations
STEMI
*In patients with NSTEMI or unstable angina, P2Y12 inhibitor therapy is often held until after
coronary angiography in case the atherosclerotic coronary anatomy indicates the need for
coronary artery bypass grafting.
High fever
Tachycardia, hypertension, congestive heart failure, cardiac
arrhythmias (eg, atrial fibrillation)
Clinical
Agitation, delirium, seizure, coma
presentation
Goiter, lid lag, tremor
Nausea, vomiting, diarrhea, jaundice
Hyperosmolar hyperglycemic state
Type 2 diabetes mellitus
Patient
Older age
characteristics
Acute illness, trauma, infection
Inciting Insulin nonadherence
factors Medications: glucocorticoids, diuretics, atypical antipsychotics
Hypercalcemia of malignancy
Cause Tumor type Mechanism Diagnostic
Squamous cell
Renal & bladder ↓ PTH
PTH mimic
PTHrP* Breast & ↑ PTHrP
ovarian
↑ Calcium ↓ PTH
1,25-dihydroxyvitamin Lymphoma
absorption ↑ Vitamin D
D
*PTHrP causes approximately 80% of malignancy-associated hypercalcemia.
Cerebral aneurysms
Hepatic & pancreatic cysts
Extrarenal Mitral valve prolapse, aortic regurgitation
features Colonic diverticulosis
Ventral & inguinal hernias
Ultrasonography showing multiple renal cysts
Diagnosis
Aggressive control of risk factors for CV & CKD
ACE inhibitors preferred for hypertension
Management
Hemodialysis, renal transplant for ESRD
Subacute/chronic
Papuloulcerative lesion
Gardening or landscaping New lesions up lymphatic
Sporotrichosis
chain
No fever or purulence
Early signs
o Symmetric extremity weakness
o ↓ Deep tendon reflexes
Physical
Late signs
examination
o ↓ Rectal tone
o ↑ Deep tendon reflexes, bilateral Babinski reflex
o Paralysis
Headache, vomiting
Fever
Clinical findings Focal neurologic deficits, seizure
Ring-enhancing lesion on neuroimaging (CT, MRI)
Aspiration/surgical drainage
Treatment Prolonged antibiotic therapy
Dry skin
Chronic inflammation (eg, eczema, radiation therapy)
Breaches in
Chronic wounds (eg, pressure ulcer, venous ulcer)
skin barrier
Dermatophyte infection (eg, tinea pedis)
Obesity
Other
Features of constrictive pericarditis
Recurrent idiopathic or viral pericarditis
Cardiac surgery or radiation therapy
Etiology
Tuberculous pericarditis (where endemic)
Sometimes with:
Clinical features
Renal failure
Neurologic manifestations
Fever
Plasma exchange
Glucocorticoids
Management Rituximab
Caplacizumab
Thiamine deficiency
Pathophysiology
Encephalopathy
Oculomotor dysfunction (eg, horizontal nystagmus
Clinical features & bilateral abducens palsy)
Postural & gait ataxia
Female, HLA-DRB1
Environmental factors (United States, Europe, Australia)
Risk factors Low vitamin D levels
Epstein-Barr infection
Hypertrophic cardiomyopathy
Genetic mutations affecting cardiac sarcomere proteins
Autosomal dominant inheritance
Pathophysiology
Variable phenotypic penetrance
AV block
Cardiovascular Dilated or restrictive cardiomyopathy
Hepatosplenomegaly
Gastrointestinal Asymptomatic LFT abnormalities
Hypercalcemia
Peripheral lymphadenopathy
Parotid gland swelling
Other
Polyarthritis*
Constitutional symptoms (fever,* malaise)
ALT = alanine aminotransferase; AST = aspartate aminotransferase; RBCs = red blood cells.
Factors associated with poor outcome after witnessed out-of-hospital sudden cardiac arrest
Time elapsed prior to effective resuscitation (delayed bystander CPR, delayed
defibrillation)
Anorexia nervosa
Significantly low weight
Diagnostic
Fear of weight gain
criteria
Distorted views of body weight & shape
Complications Cardiovascular: myocardial atrophy, bradycardia, hypotension,
arrhythmias
Renal: poor urinary concentration, dehydration
Hematological: cytopenia
Diabetes mellitus
Impaired pulmonary Chronic obstructive pulmonary disease
function
Bronchiectasis/cystic fibrosis
Smoking
Substance/alcohol use disorder
Esophageal dysmotility
Acid suppressants
Medications Sedatives
Immunomodulatory agents
Acute vs chronic disseminated intravascular coagulation (DIC)
Acute DIC Chronic DIC
Sepsis
Obstetric complications
Coagulation studies Prolonged Often normal
Platelets Low Often normal
Fibrinogen Low Often normal
D-dimer High High
Bleeding risk Very high Mildly increased
Thromboembolism risk Mildly increased Very high
Causes of peripheral edema
Primary mechanism Clinical examples
Heart failure (left ventricular & cor pulmonale)
Increased capillary hydrostatic
Primary renal sodium retention (renal disease & drugs)
pressure
Venous obstruction (eg, cirrhosis & venous insufficiency)
Protein loss (eg, nephrotic syndrome & protein-losing
Decreased capillary oncotic enteropathy)
pressure (hypoalbuminemia)
Decreased albumin synthesis (eg, cirrhosis & malnutrition)
Increased capillary Burns, trauma & sepsis
permeability
Allergic reactions
Acute respiratory distress syndrome
Malignant ascites
Malignant ascites
Lymphatic
obstruction/increased Hypothyroidism
interstitial oncotic pressure
Lymph node dissection
Complications of Graves disease treatment
Treatment Adverse effects
Agranulocytosis
Antithyroid drugs
Methimazole: 1st-trimester teratogen, cholestasis
(thionamides)
Propylthiouracil: hepatic failure, ANCA-associated vasculitis
Permanent hypothyroidism
Radioiodine
Worsening of ophthalmopathy
ablation
Possible radiation side effects
Permanent hypothyroidism
Generalized, symmetric
Electroencephalography
Management
Antiepileptic medications
Hypoglycemia in patients without diabetes mellitus
Drugs: quinolones, quinine, beta blockers
Adrenal insufficiency
Insulinoma
Infection (granulocytopenia)
Hepatosplenomegaly/lymphadenopathy rare
Pain
Nonosmotic Hypotension
Hypovolemia
Hypoxia
Hypoglycemia
Actinic keratosis
Erythematous, scaly papules; rough plaques
Clinical
features
Sun-exposed areas
Clinical appearance
Diagnosis
Biopsy if features of possible SCC (eg, size ≥1 cm,
rapid growth, ulceration, tenderness)
Chronic/persistent
Spontaneous resolution
Isolated lesions: cryotherapy
Treatment
Diffuse lesions: topical fluorouracil, imiquimod,
tirbanibulin
SCC = squamous cell carcinoma.
Iron deficiency anemia & thalassemias
Iron
Alpha-thalassemia Beta-thalassemia
Parameter deficiency
minor minor
anemia
MCV ↓ ↓ ↓
RDW ↑ Normal Normal
RBCs ↓ Normal Normal
Peripheral Microcytosis,
Target cells Target cells
smear hypochromia
↓ Iron & ferritin
Serum iron Normal/↑ iron & ferritin Normal/↑ iron & ferritin
studies (RBC turnover) (RBC turnover)
↑ TIBC
Response to iron
↑ Hemoglobin No improvement No improvement
supplementation
Hemoglobin
Normal Normal ↑ Hemoglobin A2
electrophoresis
MCV = mean corpuscular volume; RBCs = red blood cells; RDW = red blood cell distribution
width; TIBC = total iron-binding capacity.
High-output heart failure
↓ SVR leads to ↑ cardiac output & ↑ venous
Pathophysiology
return
Morbid obesity (most common)
Intermittent self-catheterization
Clinical features of irritable bowel syndrome
Rome IV diagnostic Recurrent abdominal pain/discomfort ≥1 days/week for past 3 months
criteria & ≥2 of the following:
Gastrointestinal bleeding
Worsening pain
Uremia
Triggers
Medications (eg, fluoroquinolones, metronidazole)
↓ Ankle/Babinski reflexes
Treat underlying cause
Treatment
Pain management: gabapentinoid, tricyclic antidepressant, duloxetine &/or
capsaicin cream
Sjögren syndrome
Immune-mediated destruction of the lacrimal & salivary glands
Pathogenesis
Can occur as primary disease or secondary with other autoimmune
disorders (eg, SLE, RA)
Dry eyes (keratoconjunctivitis sicca)
Cutaneous vasculitis
Hyperventilation
Manifestations Hyperthermia
Metastatic cancers
Intrathoracic
neoplasms
Malignant mesothelioma
Lymphoma
Lung abscess
Empyema
Intrathoracic
Bronchiectasis
suppurative
diseases
Cystic fibrosis
Headache, confusion
Uremia
Diabetic ketoacidosis
Lactic acidosis
Salicylate (aspirin)
General manifestations of hyperthyroidism
Anxiety & insomnia
Palpitations
Increased perspiration
Hypertension
Lid lag
Atrial fibrillation
Clues to etiology of syncope
Trigger (eg, emotional stress, prolonged standing)
Vasovagal
Prodrome (eg, nausea, sweating, warmth)
Occurs with micturition, defecation, swallowing,
Reflex syncope Situational
or coughing
Tactile stimulation of carotid sinus while standing
Carotid
hypersensitivity
Advanced age, carotid atherosclerosis
Vasodilators (eg, alpha-1 blockers,
antihypertensives)
Medications
Inotropic/chronotropic blockade (eg, beta
Orthostatic blockers)
syncope
Hypovolemia History consistent with volume loss
Advanced age
Autonomic
dysfunction
Predisposing disease (eg, DM, Parkinson)
Syncope with exertion
LV outflow
obstruction
Systolic ejection murmur
No warning symptoms
Ventricular
Cardiomyopathy or ischemic HD (monomorphic)
Cardiac syncope tachycardia
QT-interval prolongation (polymorphic)
Preceding fatigue or light-headedness
Conduction
impairment* ECG abnormalities (eg, sinus pauses, dropped
QRS complexes)
*Sick sinus syndrome or advanced atrioventricular block.
Treatment Chemotherapy
Peaks in summer
Nonspecific fever, headache, myalgia, arthralgia
Heartburn
Manifestations
Odynophagia (often indicates reflux esophagitis)
Recurrent aspiration
Palpitations
Increased perspiration
Hypertension
Lid lag
Atrial fibrillation
Distinguishing hypertrophic cardiomyopathy from athlete's heart
Hypertrophic cardiomyopathy Athlete's heart
Family history Common Usually unremarkable
LVH criteria + depolarization &/or LVH criteria without other
ECG findings
repolarization abnormalities* abnormalities
Left atrial size Enlarged Normal
LV cavity size Usually decreased Slightly enlarged
LV wall
≥15 mm <15 mm
thickness
Focal septal Yes No
hypertrophy
LV diastolic
Impaired Normal
function
*Common depolarization abnormalities include prominent Q waves; common repolarization
abnormalities include T-wave inversions.
Often asymptomatic
Clinical
Fatigue, dyspnea, tachycardia
findings
Jaundice
Low-grade fever
Hemolytic anemia
Cytopenias
Hepatotoxicity
Pyrimidine synthesis
Leflunomide
inhibitor
Cytopenias
Hydroxychloroquine TNF & IL-1 suppressor Retinopathy
Hepatotoxicity
Hemolytic anemia
Infection
TNF inhibitors
Demyelination
(eg, adalimumab, certolizumab,
etanercept, golimumab,
Congestive heart failure
infliximab)
Malignancy
IL-1 = interleukin 1;TNF = tumor necrosis factor.
Transfusion reactions associated with hypotension
Reaction Onset* Cause Clinical features
Shock,
Seconds to Recipient anti-IgA
Anaphylaxis angioedema/urticaria
minutes antibodies
& respiratory distress
Respiratory distress &
noncardiogenic
Transfusion- Donor
Minutes to pulmonary edema
related acute lung antileukocyte
hours
injury antibodies
Bilateral pulmonary
infiltrates
Fever, flank pain,
Minutes to ABO
Acute hemolysis hemoglobinuria &
hours incompatibility
DIC
Bacterial
Minutes to Fever, chills, septic shock
Bacterial sepsis contamination of
hours & DIC
donor product
*Time after transfusion initiation.
Malignancy
Acute arm edema, heaviness, pain & erythema
Pulmonary embolism
Diagnosis Duplex or doppler ultrasonography
3 months of anticoagulation
Treatment
Thrombolysis (non–catheter-related)
Clinical features of chronic hepatitis C
Asymptomatic or nonspecific symptoms (eg, fatigue, anorexia,
arthralgia/myalgia)
Extrahepatic manifestations
Clinical
manifestations
Hematologic: mixed cryoglobulinemia, ITP, autoimmune hemolytic
anemia
Hips
Joint
involvement
Distal interphalangeal joints
Metastatic infiltration
Fatigue, weakness, anorexia/weight loss
Lymphadenopathy (epitrochlear)
Oral lesions
Hepatitis
Latent Asymptomatic
CNS (tabes dorsalis, dementia)
Cutaneous (gummas)
CNS = central nervous system.
ECG effects of antiarrhythmic drugs
PR interval
QRS duration QT interval
(prolonged via Ca2+
(prolonged via Na+ (prolonged via K+
channel inhibition or
channel inhibition) channel inhibition)
sympathetic blockade)
Class IA − ↑ ↑
(eg, procainamide)
Class IB
− − −
(eg, lidocaine)
Class IC
− ↑
(eg, flecainide)
Class II
↑ − −
(eg, metoprolol)
Amiodarone ↑ ↑ ↑
Sotalol ↑ − ↑
Other class III
− − ↑
(eg, dofetilide)
Class IV
↑ − −
(eg, verapamil)
Culture-positive infective endocarditis
Prosthetic valves
Intravascular catheters
Staphylococcus aureus
Implanted devices (eg, pacemaker/defibrillator)
Implanted devices
Enterococci Nosocomial urinary tract infections
Colon carcinoma
Streptococcus gallolyticus
(formerly S bovis)
Inflammatory bowel disease
Immunocompromised host
Fungi
Intravascular catheters
(eg, Candida)
Prolonged antibiotic therapy
Hyperosmolar hyperglycemic state
Type 2 diabetes mellitus
Patient
characteristics
Older age
Inciting Acute illness, trauma, infection
factors
Insulin nonadherence
Altered mentation
Clinical
features
Hyperglycemic symptoms (eg, polyuria)
Volume depletion
Glucose >600 mg/dL (33.3 mmol/L)
Stroke
Imaging: basilar meningeal enhancement & hydrocephalus
Chronic infection
Rheumatic disease
Common Etiologies
Obesity
Diabetes mellitus
Ethanol
Cocaine
Cocaine
Vasoconstrictive ischemia
Amphetamines
Ethanol
Prolonged immobilization
Opioids
(compression ischemia)
Benzodiazepines
Cor pulmonale
Right-sided heart failure due to primary pulmonary disorder
Pathophysiology
Absence of left-sided heart disease
Parenchymal disease/chronic hypoxia
Cystic fibrosis
Common
etiologies
Interstitial lung disease
Peripheral edema
Examination
Palpable RV heave, loud P2, tricuspid regurgitation murmur
Echocardiography
Asterixis
Correct precipitating causes (eg, fluids, antibiotics)
Treatment
↓ Blood ammonia concentration (eg, lactulose, rifaximin)
GI = gastrointestinal; SBP = spontaneous bacterial peritonitis; TIPS = transjugular intrahepatic
portosystemic shunt; UTI = urinary tract infection.
Pertussis
Microbiology Bordetella pertussis (gram-negative coccobacilli)
Catarrhal (weeks 1-2): mild cough, rhinitis
Weight loss
Examination Hard, bony enlargement of joints Soft/spongy, warm joints
Narrowed joint space
X-ray Periarticular erosions
Osteophytes
CMC = carpometacarpal; DIP = distal interphalangeal; MCP = metacarpophalangeal; PIP =
proximal interphalangeal.
Initial pharmacotherapy for acute asthma exacerbation
Class Medication Use
Bronchodilator
Short-acting ꞵ2-agonist Inhaled albuterol
Continuous (if severe) or
repeated dosing
Bronchodilator
Environmental exposures Direct contact with infected person, fomites, or public showers
Occlusive clothing
Obesity
**Right heart catheterization shows step up in O2 concentration from right atrium to right
ventricle.
LAD = left anterior descending; MR = mitral regurgitation; RCA = right coronary artery.
Cyanide poisoning
Common etiologies Structure fires (eg, combustion of plastics)
Occupational exposure (eg, mining)
Visceral lesions:
Endemic KS:
Pressure-treated wood
Manifestations Acute: garlic breath, vomiting, watery diarrhea, QTc prolongation
Chronic: hypo-/hyperpigmentation, hyperkeratosis, stocking-glove
neuropathy
Dimercaprol (British anti-Lewisite)
Treatment
DMSA (ie, meso-2,3-dimercaptosuccinic acid, succimer)
Hemodynamic measurements in shock
Distributive
Hypovolemic Cardiogenic Obstructive
Parameter
shock shock shock
shock
CVP
(right-sided ↓ ↑ ↑ ↓
preload)
PCWP
(left-sided ↓ ↑ ↓* ↓
preload)
Cardiac index
↓ ↓ ↓ ↑**
(LV output)
SVR
↑ ↑ ↑ ↓
(afterload)
SvO2 ↓ ↓ ↓ ↑**
*In tamponade, left-sided preload is decreased, but measured PCWP is paradoxically increased
due to external compression by pericardial fluid.
**Cardiac index & SvO2 are usually decreased in neurogenic shock due to impaired sympathetic
reflexes.
Underlying chronic medical illness (eg, chronic pulmonary, cardiovascular, renal, hepatic)
Immunosuppressed
Morbidly obese
Salicylate
Ingestion
Lithium
Encephalopathy
Uremia
Pericarditis
Bleeding
Red blood cell transfusion thresholds
Hemoglobin
Recommendation
(g/dL)
<7 Generally indicated
Cardiac surgery
Heart failure
Symptomatic anemia
Ongoing bleeding
8-10
Acute coronary syndrome
Noncardiac surgery
>10 Not generally indicated
Primary adrenal insufficiency
Etiology Autoimmune adrenalitis (most common)
Infection (eg, tuberculosis)
Metastatic infiltration
Fatigue, weakness, anorexia/weight loss
Financial difficulties
Chest pain
Reported
Epistaxis, rhinitis (intranasal use)
symptoms
Headaches
Hypertension, tachycardia
Examination
Dilated pupils
signs
Psychomotor agitation
Seizures
Intracranial hemorrhage
Organophosphate poisoning
Common Pesticide: farmer/field worker, pediatric ingestion, suicide attempt
exposures
Nerve agent: multiple patients presenting with similar symptoms
Muscarinic:
Diarrhea/diaphoresis
Urination
Miosis
Emesis
Lacrimation
Salivation
Fatigue
Fibrotic lung disease
Pleural effusions
Pulmonary
Lung nodules
Pulmonary hypertension
Atherosclerosis
Cardiovascular
Vasculitis
Musculoskeletal Osteopenia/osteoporosis
Dermatologic Rheumatoid nodules
Hematologic Anemia
Depression
Neuropsychiatric
Neuropathy
Sjögren syndrome
Scleritis, episcleritis
Management of pulmonary hypertension
Evaluate for autoimmune CTD, toxins (eg, amphetamines), HIV,
schistosomiasis, etc.
Group 1
PAH
Pulmonary vasodilator therapy, treat underlying (eg, autoimmune)
cause
Echocardiography (± RHC if diagnosis unclear)
Group 2
Left-sided
Optimize left ventricular function (eg, heart failure therapy), treat
heart disease
significant valve disease
Group 3 Pulmonary function tests, chest imaging, polysomnography
Lung disease &/or
chronic hypoxemia Treat underlying respiratory condition (eg, obstructive sleep apnea)
V/Q scan, pulmonary angiography
Group 4
CTEPH Pulmonary thromboendarterectomy surgery (curative),
anticoagulation
Refer to accredited PH center
Infective endocarditis
Etiology
Rheumatic heart disease
Trauma
**Cardiac index & SvO2 are usually decreased in neurogenic shock due to impaired sympathetic
reflexes.
CVP = central venous pressure; LV = left ventricular; PCWP = pulmonary capillary wedge
pressure; SvO2 = mixed venous oxygen saturation; SVR = systemic vascular resistance.
Management of hospital delirium
Reduce noise, improve room lighting, open window blinds during the day & avoid frequent
room changes
Reduce polypharmacy
Monitor & treat for metabolic disturbances, infections & drug toxicity
COPD = chronic obstructive pulmonary disease.
Localization of ST-segment elevation myocardial infarction
Involved Occluded
ST-segment elevation leads
myocardium vessel
Septal V1, V2 LAD
Anterior V3, V4 LAD
Lateral* V5, V6, I, aVL, V7 through V9 LAD or LCx
V1 through V3 (reciprocal ST-segment depression), V7
Posterior RCA or LCx
through V9 (ST-segment elevation)
Inferior II, III, aVF RCA or LCx
Right ventricle** II, III, aVF, V4R through V6R RCA
*Most lateral/posterolateral STEMIs are electrically silent due to poor coverage, usually
corresponding to LCx territory.
LAD = left anterior descending artery; LCx = left circumflex artery; RCA = right coronary
artery; STEMI = ST-segment elevation myocardial infarction.
Hospice model
Focus on quality of life, not cure or life prolongation
Milky: chylous
Color
Turbid: possible infection
Arterial or venous
Pregnancy morbidity
Stable angina
Arterial and venous thrombus - HIT antibodies activate platelets, resulting in platelet
aggregation and the release of procoagulant factors. The risk of thrombus is as high as
50% in untreated HIT.
Typically, type 2 HIT manifests with a >50% drop in platelets 5-10 days after the initiation of
heparin, but it may occur earlier (sometimes <1 day) in patients previously exposed. This
patient with end-stage renal disease likely receives heparin with hemodialysis. If HIT is
suspected, all heparin products should be discontinued immediately and anticoagulation should
be initiated with an alternate anticoagulant (eg, argatroban, fondaparinux).
Heparin works by binding antithrombin, which inactivates factor Xa; this prolongs activated
partial thromboplastin time.
Sometimes with:
Clinical features
Renal failure
Neurologic manifestations
Fever
Plasma exchange
Glucocorticoids
Management
Rituximab
Caplacizumab
LDH = lactate dehydrogenase; vWF = von Willebrand factor.
Differential diagnosis of polycythemia
Primary (↓ EPO) Secondary (normal/↑ EPO)
Hypoxemia
Cardiopulmonary disease
Androgen supplementation
EPO = erythropoietin.
Common variable immunodeficiency
Abnormal differentiation of B cells into plasma cells →
Pathophysiology
decreased immunoglobulin production
Symptom onset classically age 20-40, as early as puberty