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DIP Episode 31 - Comprehensive Medicine Shelf Review. Session 3

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Topic

G6PD deficiency, Nephrotic Syndrome; Cardiac Murmurs/Heart Failure; Endocrine Disorders (Cushing's, Adrenal Insufficiency)...

Key Takeaway

The comprehensive shelf review emphasizes the critical differentiation of systemic diseases based on specific clinical presentations and diagnostic findings—for example, distinguishing between various types of nephrotic syndrome, identifying the characteristic physical exam signs of valvular heart disease, and correctly interpreting hormonal axis testing in adrenal disorders.

Runtime: — min

Published: 2018-05-20

Completed audio: Yes

Completed notes: Yes

Anki made: Yes

Section: INTERNAL MEDICINE

Open Notion notes Episode source

Episode Notes

Source / episode info

Episode: 31
Title: Divine Intervention Episode 31 – Comprehensive Medicine Shelf Review. Session 3.
Published: 2018-05-20
Source: Episode page

One-liner

This session covers a vast array of high-yield topics including G6 PD deficiency management, differentiating nephrotic syndromes, recognizing classic cardiac murmurs (Aortic Stenosis), managing Cushing's syndrome and adrenal insufficiency, diagnosing vasculitides like GPA, understanding the pathophysiology of various diarrheas, and reviewing complex pharmacology principles.

High-yield summary

G6 PD Deficiency: Acute hemolysis is triggered by oxidative stress, especially fava beans or certain drugs (e.g., sulfa antibiotics). The diagnosis requires quantitative enzyme assay confirmation after a positive smear finding.
Aortic Stenosis (AS): Classic murmur is a systolic crescendo-decrescendo heard best at the right upper sternal border radiating to the carotids; associated with Pulsus Parvus et Tardus and potential for syncope/pre-syncope due to fixed outflow obstruction.
Cushing's Syndrome Workup: The key is determining if ACTH excess (pituitary or ectopic) or cortisol excess is present. High dose dexamethasone suppression test failure suggests ACTH-dependent Cushing's (e.g., pituitary adenoma).
Vasculitis (GPA): Granulomatosis with polyangiitis classically involves the upper respiratory tract, lungs, and kidneys; associated with ANCA (c-ANCA) and requires aggressive immunosuppression.
GI Bleeding: The "Beads on a string" appearance in ERCP suggests Crohn's disease due to skip lesions/inflammation of the terminal ileum.
Electrolyte Imbalances: In hyponatremia, rapid correction (over 24 hours) risks Osmotic Demyelination Syndrome (ODS).

Learning objectives

Differentiate between various types of nephrotic syndrome and their associated primary pathologies.
Master the clinical presentation, diagnosis, and management strategies for common valvular heart diseases.
Apply knowledge of endocrine axis testing (ACTH/Cortisol) to distinguish causes of hypercortisolism.
Recognize the classic signs and symptoms of systemic vasculitides (e.g., GPA).
Understand the pathophysiology and differential diagnosis of various types of diarrhea (secretory vs osmotic).

Board exam buzzwords

Condition	Key Finding	Association	Board Exam Tip
G6 PD Deficiency	Hemolysis after oxidative stress	Fava beans, Sulfa drugs	Always consider G6 PD deficiency in acute hemolysis following drug exposure.
Aortic Stenosis	Pulsus Parvus et Tardus	Right upper sternal border murmur	The "parvus" (small) and "tardus" (slow) pulse are classic signs of fixed outflow obstruction.
Cushing's Syndrome	High dose dexamethasone suppression test failure	Pituitary adenoma (ACTH-dependent)	If the high dose fails to suppress cortisol, it suggests ACTH excess is driving the problem.
GPA (Wegener's)	Upper respiratory tract/Lungs/Kidneys triad	ANCA (c-ANCA)	Remember the classic "trilogy" of involvement for GPA.

Rapid review table

Topic	Key Point	Context	Exam Relevance
Nephrotic Syndrome	Minimal Change Disease (MCD)	Most common cause in children; EM shows foot process effacement.	Must differentiate MCD from primary glomerular diseases like FSGS or Membranous Nephropathy.
Aortic Stenosis	Fixed outflow obstruction	Causes syncope/pre-syncope due to inability to increase cardiac output.	High yield for physical exam and hemodynamic stability assessment.
Cushing's Syndrome	ACTH levels guide diagnosis	Low dose dexamethasone suppression test is the initial screening tool.	Know the difference between pituitary (mildly suppressed) vs ectopic (no suppression).
Crohn's Disease	"Beads on a string" appearance	Inflammation/skip lesions, typically in the terminal ileum.	Helps localize inflammation and differentiate from other enteritis causes.

Board-speak -> diagnosis

Board-speak / Vignette phrase	Diagnosis / Concept	Why it fits
A systolic crescendo-decrescendo murmur heard best at the right upper sternal border radiating to the carotids, associated with syncope.	Aortic Stenosis	The classic location and radiation pattern point directly to outflow tract obstruction; syncope is due to fixed cardiac output limitation.
A 40 yo F presents with dry eyes/mouth and a child with congenital heart block.	Sjögren's Syndrome	This triad (sicca symptoms + autoimmune association) strongly suggests Sjögren's, which can affect multiple systems including the heart.
Elevated LF Ts and panacinar emphysema in a young male smoker.	Alpha-1 Antitrypsin Deficiency	The combination of lung disease (emphysema) and liver injury is highly characteristic; deficiency leads to accumulation in the liver/lung.
A patient with chronic bloody diarrhea and "beads on a string" appearance on ERCP.	Crohn's Disease	This finding represents skip lesions, which are pathognomonic for Crohn's inflammation affecting the terminal ileum.
Skin lesion in the perineal region that shows up as a shiny papule with central umbilication in an HIV+ patient.	Condyloma Acuminatum (Acanthosis Nigricans)	While technically not umbilicated, this description points to common HPV lesions, and the location/context suggests chronic genital infection management.
A high-output heart failure secondary to hemolytic anemia.	High Output Heart Failure	The increased cardiac demand from peripheral shunts or systemic conditions (like severe anemia) overwhelms the myocardium.

Differential diagnosis / distinguishing features

Diarrhea Types

Key Features	Distinguishing Findings	Next Step
Secretory Diarrhea	High stool osmolality gap (osmolar gap > 10 mOsm/kg); often associated with toxins or hormones.	Identify the causative agent (e.g., Cholera toxin, bile acid malabsorption).
Osmotic Diarrhea	Low stool osmolality gap; caused by non-absorbable solutes in the gut lumen.	Dietary modification and identifying the offending solute (e.g., lactose intolerance).
Inflammatory Diarrhea	Bloody stools, abdominal pain; often associated with immune response/colitis.	Stool culture, fecal calprotectin, endoscopy to rule out IBD or infectious colitis.

Hyperbilirubinemia Patterns

Key Features	Distinguishing Findings	Next Step
Increased Direct Bilirubin + Decreased Urobilinogen	Suggests biliary obstruction (e.g., choledocholithiasis).	Imaging (ultrasound/MRCP) to visualize the biliary tree and identify the blockage.
Increased Indirect Bilirubin + Normal Urine Bilirubin	Suggests pre-hepatic or excessive hemolysis (overload of unconjugated bilirubin).	Check for hemolytic causes (e.g., G6 PD deficiency, autoimmune hemolysis).

Management pearls

Aortic Stenosis: The primary goal is to prevent syncope/pre-syncope by optimizing cardiac output; consideration of valve replacement or palliation may be necessary if symptoms are severe.
Cushing's Syndrome: If the cause is ACTH excess, treatment involves pituitary surgery (transsphenoidal) or medication targeting cortisol synthesis (e.g., ketoconazole).
Hyponatremia Correction: Never correct sodium rapidly; use a slow rate of correction (e.g., < 8 mEq/L in 24 hours) to prevent ODS.
GI Bleeding (Crohn's): Management is often immunosuppressive or biologic agents, targeting the underlying inflammatory process rather than just treating the bleeding site.

Don't miss

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The classic triad of dry eyes, dry mouth, and a systemic autoimmune condition strongly suggests Sjögren's Syndrome.

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Aortic Stenosis causes fixed outflow obstruction, leading to symptoms (syncope) when cardiac output cannot increase sufficiently during exertion.

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In the workup of hypercortisolism, failure of suppression with high dose dexamethasone points toward an ACTH-dependent source.

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The "Christmas tree" pattern of macular lesions is highly suggestive of a viral exanthem or drug reaction (e.g., certain antibiotics).

Integration & clinical reasoning

Cardiology/Endocrinology: Both Aortic Stenosis and Cushing's Syndrome can lead to cardiac complications; AS requires managing fixed output, while hypercortisolism causes hypertension and cardiomyopathy.
GI/Nephrology: Chronic inflammation (Crohn's) can lead to secondary nephrocalcinosis or kidney injury, linking GI pathology to renal failure.
Pharmacology/Endocrinology: The management of adrenal insufficiency requires replacement therapy for all deficient hormones (glucocorticoids, mineralocorticoids, and sometimes sex steroids).

OMM / COMLEX integration

🦴

For COMLEX: know these viscerosomatics / Chapman points, but don't let OMM distract from emergent diagnosis and management.

Viscerosomatics: The association between autoimmune conditions (like Sjögren's) and systemic organ involvement (heart block, etc.) is a key concept for understanding how one system affects another.
Clinical Integration: When managing chronic GI inflammation (Crohn's), the risk of secondary renal or vascular complications must be considered.

Concept connections / cross-references

Episode 12 : Autoantibody associated with mixed connective tissue disease (Anti-Sm, Anti-RNP).
Episode 34 : HIV drug side effects (Protease inhibitors, NRT Is).
Episode 56 : Hemophilia A/B management and coagulation factor deficiencies.

High-yield association table

Condition	Association	Mechanism	Clinical Significance
G6 PD Deficiency	Oxidative stress	Breakdown of red blood cells due to inability to regenerate NADPH.	Requires avoidance of specific drugs (e.g., sulfa, primaquine) and fava beans.
Aortic Stenosis	Fixed outflow obstruction	Limits the ability of cardiac output to increase during exercise or stress.	Leads to syncope/pre-syncope; requires careful assessment of hemodynamic stability.
Cushing's Syndrome	High dose dexamethasone failure	Indicates ACTH excess (pituitary adenoma) that is not suppressed by high doses of steroids.	Guides the diagnosis between pituitary and ectopic sources of ACTH.
GPA (Wegener's)	ANCA positivity	Autoantibodies targeting neutrophil cytoplasmic antigens, leading to vasculitis.	Requires aggressive immunosuppression (e.g., cyclophosphamide) for organ preservation.

Key terms glossary

Term	Definition	Context	Example
Pulsus Parvus et Tardus	A slow and small pulse wave amplitude.	Found in severe outflow tract obstruction, such as Aortic Stenosis.	Indicates that the heart cannot generate sufficient pressure or volume to overcome the fixed resistance.
Osmotic Demyelination Syndrome (ODS)	Neurological complication from rapid correction of chronic hyponatremia.	Occurs when serum sodium is corrected too quickly over a short period.	Requires slow, controlled administration of hypertonic saline or careful fluid restriction.
ANCA	Anti-Neutrophil Cytoplasmic Antibodies.	Associated with small vessel vasculitides like GPA and Polyarteritis Nodosa (PAN).	Positive testing supports the diagnosis but is not definitive; requires clinical correlation.
SAAG Gradient	Serum Albumin minus Albumine in Urine ({S}_{{A}}{AG} = {Serum Alb}-{Urine Alb}).	Used to differentiate causes of ascites (portal hypertension vs. infection).	A low gradient (< 1.1 g/dL) suggests a non-portal hypertensive cause, like peritoneal carcinomatosis.

Study optimization

Topic	Study Approach	Priority	Resources
Cardiology	Focus on murmurs and hemodynamic consequences.	High	Review the relationship between outflow obstruction (AS) and cardiac output limitation.
Endocrinology/Metabolic	Master the axis testing logic (ACTH, Cortisol).	High	Create flowcharts for Cushing's workup and adrenal insufficiency management.
Nephrology/GI	Differentiate patterns of injury (e.g., nephrotic vs. inflammatory; secretory vs. osmotic diarrhea).	Medium-High	Use mnemonic devices to recall associated bugs or antibodies (e.g., GPA -> ANCA).

Question pattern recognition

The "Classic Triad" Pattern: Identifying the three key components that define a syndrome (e.g., Nephrotic Syndrome: proteinuria, hypoalbuminemia, edema).
Differential Diagnosis by Mechanism: Comparing conditions based on how they fail (e.g., AS failure due to fixed outflow vs. CHF failure due to pump failure).
The "Red Flag" Association: Recognizing a specific finding that mandates immediate investigation for a serious underlying condition (e.g., elevated ALP + decreased urine urobilinogen -> obstruction).

Test yourself

Common mistakes to avoid

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Confusing the differential diagnosis between various types of diarrhea (e.g., osmotic vs. secretory).

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Misinterpreting which specific test failure points to ACTH excess in Cushing's workup.

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Forgetting that Aortic Stenosis causes fixed outflow obstruction, leading to syncope on exertion.

Common traps

⚠️

Assuming all hyperbilirubinemia is due to hemolysis (remember biliary obstruction can cause indirect/direct issues).

⚠️

Believing that the diagnosis of vasculitis only requires ANCA positivity; clinical triad and biopsy are essential.

⚠️

Overlooking the critical difference between pituitary vs. ectopic ACTH sources in Cushing's syndrome.

Original transcript with highlights

Medicine Keywords B Some MS4

1 G6 PD deficiency. Pathophysiology. Classic triggers. Diagnostic testing (smear findings, confirmatory testing). Method of inheritance. 2 Rash after getting amoxicillin for a URI in a 19 yo M with posterior cervical lymphadenopathy. Diagnosis? Classic blood smear finding? Diagnostic testing? What should be considered if diagnostic testing is negative? Associated malignancies -> 8:14 translocation, HIV patients, nasopharyngeal ca. 3 Heavy proteinuria + hyperlipidemia + hypoalbuminemia + EM revealing podocyte foot process effacement + normal glomeruli on LM. Diagnosis? Malignancy associations? 4 Dry eyes + Dry mouth in a 40 yo F who delivered a child with congenital heart block. Diagnosis? Associated autoantibodies? Biopsy finding in exocrine glands? General treatment strategy. 5 Panacinar emphysema + elevated LF Ts in a 35 yo M. Diagnosis? Pathophysiology? Mechanism of inheritance? Classic biopsy finding? Treatment. 6 Systolic crescendo-decrescendo murmur heard best at the right 2nd interspace with radiation to the carotids. Diagnosis? HY Pathophysiology? Early onset? Prognostic indicators by severity? Preload/Afterload changes and murmur intensity. Diagnostic testing. Pulsus Parvus et Tardus. Heyde’s syndrome. Anemia. Tx 7 Acne vulgaris. What is it? Classic bug association. Stepwise management (3 steps). The side effects of Isotretinoin. Adjunct considerations in treatment. Treatment of acne in patients with PCOS.

8 Differentiating between 21-hydroxylase, 11-hydroxylase, and 17-hydroxylase deficiency (by clinical presentation in males/females, what is deficient, HTN or no HTN, what is overproduced, Na/K balance). Cosyntropin stimulation test. What do we look for in the serum in patients with the first 2? Treatment strategies. Stress dosing. 9-Localize the lesion (and why) Increased direct bilirubin + Increased urine bilirubin + decreased urine urobilinogen + elevated alkaline phosphatase vs Increased I. Bilirubin + No urine bilirubin + increased urine urobilinogen. Common causes of direct and indirect hyperbilirubinemia. Quick review of bilirubin metabolism. 10 High output heart failure in a patient with hemolytic anemia. Pathophysiology. Bone and Vascular causes of high output heart failure. 11 Lyme disease. Bug? Classic skin presentation in early disease. Classic presentations in later stage disease. Diagnostic testing. Treatment strategies by population (pregnant/< 8 yo, vs nonpregnant/> 8 yo). Treatment of lyme associated meningitis and heart block. What are other bugs carried by the Ixodes tick? 12 Autoantibody associated with mixed connective tissue disease. 13 Chronic bronchiectasis + renal failure (on an NBME). Diagnosis? Common causes of bronchiectasis. Diagnostic testing. Obstructive or restrictive pattern on PFT? Differentiating bronchiectasis from chronic bronchitis. 14 Differences between hypertensive urgency and hypertensive emergency.

Pharmacological management. BP lowering goals and thresholds. Lactic acidosis and altered mental status in a patient on nitroprusside infusion. 15 Painful, erythematous pretibial nodule. Diagnosis? Classic dimorphic fungi association? Classic autoimmune disease association? 16 Cushing’s syndrome. Classic features of hypercortisolism. Sequential biochemical testing (checking cortisol levels, determining ACTH levels, further dexamethasone testing). Interstitial infiltrates in a patient on long term steroids. Bone protective pharmacology with long term steroid use. Small cell lung cancer paraneoplastic syndromes. 17 Secretory vs Osmotic diarrhea (+ differences with respect to the stool osmolar gap). Common bug/endocrine disorder causes of secretory diarrhea. Common causes of osmotic diarrhea. Common causes of an inflammatory diarrhea. Common bug causes of watery and bloody diarrhea (with scenarios). 18 Reed Sternberg cells on lymph node biopsy. Diagnosis? Immune markers? What are the 4 types of this malignancy (by prognosis)? What does an increased number of RS cells correlate with? What is the classic bug associated with this malignancy? Basics of disease staging. Diagnostic testing. 19 Diagnostic criteria for Rheumatic Fever. Can RF be prevented with antibiotics (same Q but for PSGN?). Commonly affected heart valves. Treatment strategies. 20 Common bug associations with membranous nephropathy.

Is membranous nephropathy associated with hematologic or solid malignancies? What is the classic finding on electron microscopy? Sudden onset severe flank pain in a patient with a history of membranous nephropathy. 21 Dermato vs Polymyositis (immune mediators, classic findings on muscle biopsy). Skin findings associated with dermatomyositis. Associated malignancies. Classic “muscle” complaint. Sequential diagnostic testing. Associated autoantibodies. Treatment strategies. 22 Sarcoidosis. Classic NBME demographic and imaging finding. Further diagnostic testing. Associated disease findings (skin, eyes). Pattern of lung disease. Common lab findings in patients with sarcoidosis. Granuloma pattern. TB skin testing. General treatment strategies. 23 Discussion of the subtleties of systolic vs diastolic heart failure (HF). Signs of heart failure. Diagnostic testing. The Renin Angiotensin response. Treatment of an acute CHF exacerbation (LMNOP). Drugs shown to improve survival in HF patients. Cardiovascular parameters in systolic HF. HY Inotropes. 24 Targetoid skin lesions in a patient with Mycoplasma Pneumoniae (or HSV). Diagnosis? Classic drug association? 25 Comparison of CRH, ACTH, and Cortisol levels in ectopic ACTH production vs Cushing’s disease vs iatrogenic Cushing’s syndrome. Determining the cause of hypercortisolism with excessive ACTH secretion when the high dose dexamethasone suppression test is equivocal.

Pharmacological management of Cushing’s syndrome. 26 Classic presentation of acute cholecystitis. Diagnostic pathway. Treatment options (antibiotic regimens + surgical options). Acalculous cholecystitis. Classic NBME risk factors for acalculous cholecystitis. Contrasting the treatment of acute and acalculous cholecystitis. 27 Non-Hodgkin’s lymphoma. Follicular lymphoma (translocation, pathophysiology, biopsy findings). Burkitt’s Lymphoma (translocation, pathophysiology, biopsy findings, endemic vs sporadic). Mantle cell lymphoma (translocation, pathophysiology, biopsy findings). 28 TB induration guidelines. Interferon Gamma Release Assay. The RIPE regimen for active TB (mechanism of action, common side effects). Vitamin supplementation. Treatment of latent TB. Where does TB love to reactivate? 29 Bartter’s Syndrome, Gitelman’s Syndrome. Pathophysiology. Mechanism of inheritance. Comparing Bartter’s and Gitelman’s syndrome with lab values (especially Calcium). 30 Diastolic blowing murmur heard best at the left sternal border in the setting of a widened pulse pressure. Diagnosis? Classic PE findings. Next step in the management of the following scenarios -> 2+ systolic murmur, 3+ systolic murmur, diastolic murmurs, symptomatic 1+ systolic murmur. 31 General diagnostic strategy for cutaneous fungal infections. Tinea Versicolor (causative bug, classic description on microscopy, treatment). 3 common causes of dermatophyte infection.

Differences between the treatment strategies employed in tinea capitis vs tinea unguium vs tinea corporis. Painful red lesion under skin folds (diagnosis, bug)? 32 Beads on a string appearance with ERCP in a 30 yo M with a past history of chronic bloody diarrhea. Diagnosis? Pathophysiology? Associations (including ANCA)? Treatment strategies. 33 Basic pharmacology and HY side effects of antineoplastics. Methotrexate, Leucovorin, 5-FU, 6-MP and Azathioprine, Cytarabine, Dactinomycin, Doxo/Daunorubicin, Dexrazoxane, Bleomycin, Busulfan, Cyclophosphamide, Mesna, Nitrosoureas, Vinca Alkaloids, Taxanes, Cisplatin, Hydroxyurea. 34 Most common HIV treatment regimen. HY HIV drug side effects (Ritonavir, Indinavir, and other protease inhibitors, NRT Is like Stavudine, Didanosine, AZT, and Abacavir, NNRT Is like Efavirenz). 35 55 yo M + hats don’t fit + mild deafness + high output heart failure. Diagnosis? Treatment? What is the only NBME lab anomaly in this disease? Best diagnostic test? Future malignant risk (+ genetic mutation, + Ca drug that also increases this risk)? 36 50 yo F with a history of proximal shoulder pain + jaw pain with swallowing presents with a severe unilateral headache and eye pain. Diagnosis? What is the next best step in management? Pathophysiology? Classic patient demographic? Diagnostic testing? 37 Intense pruritus between the finger webs and toes in a patient with poor grooming and hygiene. Diagnosis? Treatment? 38 DKA.

Pathophysiology and classic association. Contrast K and Na balance. Classic lab anomalies (glucose, pH). Management strategies. Reducing glucose too quickly. When do you stop an insulin infusion? Discussion of the different kinds of insulin. 39 Pruritus and RUQ pain in a 45 yo F with conjugated hyperbilirubinemia. Diagnosis? Associated autoantibody? Pathophysiology? Pharmacological management (+ pruritus)? Curative treatment? 40 “Moonshiner” with abdominal pain, cognitive deficits per family, and wrist drop. Diagnosis? What is the classic form of anemia associated with this disease (+ pathophysiology)? What are the 2 HY blood smear findings associated with this disease? Diagnostic testing? Treatment strategies. Other NBME demographics. 41 Presentation of Shigella and EHEC diarrhea. Hemolytic Uremic Syndrome. Diagnostic testing. Treatment strategies. 42 Flank pain, palpable flank mass, hematuria, and polycythemia in a long term smoker. Diagnosis? Associated hematologic phenomenon? Potential testicular phenomenon? 43 Carpal Tunnel Syndrome. Classic presentation/hand distribution. Risk factors. Unusual disease associations. Pathophysiology. Diagnostic testing (Nerve Conduction Study or EMG)? Stepwise treatment (3 or 4)? Provocative exam maneuvers. 44 Pulmonary embolism. Virchow’s triad. Most common EKG anomaly (+ classic anomaly). Blood gas/pH anomalies. Diagnostic testing considerations (by risk and population). Gold standard testing.

Treatment strategies (stable, hemodynamic compromise, hemodynamic compromise with recent brain surgery). Quick overview of anticoagulant mechanism of action, side effect profiles (especially HIT), and reversal strategies. Classic presentation of the fat embolism syndrome. Relates To The Next Keyword

45 Based on what you have on the previous slide, what is your diagnosis? What is the classic EKG description? How is this disease managed in patients that are hemodynamically unstable vs patients that are stable? 46 Quick discussion of the 4 types of hypersensitivity reactions. 47 Low urine osmolality + high serum osmolality in a patient with polyuria and polydipsia who recently started taking Li. Diagnosis? What are the 2 kinds of this disease? The water deprivation test (and sequential steps). Classic causes of this disease. Treatment options available. How is this disease differentiated from psychogenic polydipsia? 48 CD10/19/20+ + History of Down’s Syndrome + Positivity for Terminal Deoxynucleotidyl Transferase + May present as an anterior mediastinal mass in a teenager (CD3/7+). Diagnosis? Good prognosis translocation? Bad prognosis translocation? 49 Watery or bloody diarrhea that lasts for a few days after consuming poultry/eggs or having exposure to turtles. Bug? High fevers in a 7 yo in a developing country + “Rose” spots on the abdomen. Bug? General antibiotic coverage strategies. 50 75 yo F presents with a 2 week history of neck pain and pain in her shoulders and hips bilaterally. ESR is markedly elevated. What is your diagnosis? How is this differentiated from fibromyalgia? How is this disease treated (vs fibromyalgia)? What is one HY association to watch out for in this disease? 51 Recurrent pneumonia in the same anatomic distribution in a long term smoker. Risk factors (including most important). Diagnostic testing (including tissue sampling). Treatment by kind of malignancy (amenable to surgery or not?). SVC Syndrome. Pancoast lesions and Horner’s syndrome. Testing before organ resection. For The Next Keyword

52 Diagnosis? Classic EKG findings? Classic “disease” and “electrolyte” associations. Management strategies. Should propranolol be used in the treatment of this arrhythmia? Should a patient with this arrhythmia be treated with electrical cardioversion or amiodarone? 53 Skin lesion in the perineal region that shows up as a shiny papule with central umbilication in a patient with HIV. Diagnosis? Bug? General management strategies. Method of transmission. 54 Serum hypoosmolarity and urine hyperosmolarity in a patient on Carbamazepine. Diagnosis? Pathophysiology. Common labs. Common causes (3 C drugs, other causes). Treatment strategies (pharmacology). When should hypertonic saline be administered? What happens when hyponatremia is corrected too quickly? 55 Elevated serum markers in liver disease (hepatic vs cholestatic pattern). Which is more specific for liver disease (AST or ALT)? What is the classic AST/ALT ratio in alcoholic liver disease. In addition to alkaline phosphatase, what is a unique marker for obstructive liver lesions? What is one HY serum marker that is somewhat unique to alcoholism? 56 Hemophilia A and B. Pathophysiology? Mechanism of inheritance? Coagulation labs. Treatment options. Mixing studies in hemophilia (correctable and pathophysiology of uncorrectables). Coagulation lab differences between the hemophilias and VWD. Pattern of bleeding with platelet vs clotting factor deficiency.

57 Rice water stools leading to circulatory collapse in a peace corps volunteer visiting some African or Asian country. Bug? Diarrheal mechanism? Treatment strategies? Mechanism of rehydration with a “sugar-salt” solution. In general (rough approximation), what is the most accurate diagnostic test in gastroenteritis? 58 Renal mass in a patient with a history of cardiac rhabdomyomas and periventricular tubers. Diagnosis? 59 Chondrocalcinosis observed on a knee XR in a patient with a genetic history of a C282 Y mutation in the HFE gene. Diagnosis? Deposits? Classic joint aspirate findings (shape, presentation in polarized light). Treatment strategies. What is the renal disorder that has a strong association with this disease (super low yield but who knows??)? 60 Fevers, dyspnea, and joint pain in a HIV+ patient that recently went on a cave expedition in Missouri. Bug? Treatment? Classic CXR appearance? When should a HIV+ patient living in a susceptible area receive prophylaxis against this bug? Other prophylactic strategies in HIV+ patients. For The Next Keyword

61 Diagnosis? Most common cause of death in the immediate period surrounding an MI. Management strategies (shock or not?). Pharmacological agents employed in management. Should a person in PEA or asystole receive defibrillation? 62 19 yo F presents with a large number of small, red macular lesions on the back arranged in a “Christmas tree” distribution. She had a similar but singular large lesion 1 week ago that cleared within a few days. Diagnosis? 63 50 yo M presents with erectile dysfunction, gynecomastia, low libido, and loss of peripheral vision. Diagnosis? Treatment strategies? Other common causes of this patient’s diagnosis. 64 Classic presentation of ascites. The SAAG gradient. Causes of ascites associated with a SAAG gradient < 1.1 g/dL vs > 1.1 g/dL. Pharmacological and Procedural management of ascites. 65 Mechanism of action of the tetanus toxin. Contrast with the paralysis observed in botulism. Should a booster vaccination dose be given if the patient’s last booster was administered 12 years ago? Acute management of the tetanus toxidrome. 66 Recurrent pyelonephritis and nephrolithiasis in a patient with a low posterior hairline, breast underdevelopment, and a history of aortic coarctation. Diagnosis? Pathophysiology/anatomic correlations. 67 Pleural thickening on chest CT, recurrent hemorrhagic pleural effusions, weight loss, and severe dyspnea in a patient that spent 30 years working at a shipyard. Diagnosis?

Does smoking increase the risk of this malignancy? Most common lung malignancy in this population? Does smoking increase the risk of this common malignancy? 68 Broad categorization and presentation of The Acute Coronary Syndromes. 69 HPV causes of plantar warts, genital warts, cervical cancer. Method of spread. General treatment strategies for anogenital warts. The HPV vaccine. 70 What is true of total thyroid hormone and free thyroid hormone levels in the setting of OCP use? Quick overview of thyroid physiology. How can factitious hyperthyroidism be distinguished from the transient hyperthyroidism of Hashimoto’s thyroiditis (based on labs?) 71 Spontaneous bacterial peritonitis. Pathophysiology. Classic presentation. Common bug associations. Diagnostic testing (+criteria). Treatment. Renal protection in SBP. SBP prophylactic strategies (2 options). 72 Microangiopathic hemolytic anemia + fever + thrombocytopenia + elevated creatinine + neurologic deficits. Diagnosis? Common bug association? ADAMTS13 deficiency. Treatment strategy (unusual but very HY). 73 Foul smelling diarrhea 1 week after treatment for a bacterial skin infection. Bug? Diagnostic testing? Stepwise pharmacological management. How can the spread of this bug be reduced in a healthcare setting? A patient with the history described above deteriorates rapidly with severe abdominal pain and distension, what is the next best step in mgt? 74 Can’t see + Can’t pee + Can’t hear a high C. Diagnosis?

Pathophysiology (gene, protein product)? 75 Paraneoplastic phenomena + Treatment of Small cell lung ca. Paraneoplastic phenomena + Treatment + Classic presentation of Squamous cell lung ca. What are the 2 peripherally presenting lung malignancies? What is the lung ca that has the strongest smoking association? Most likely lung ca in a 60 yo F with no history of smoking. Hypertrophic Osteoarthropathy. 76 Classic presentation of stable angina. Classic exercise stress test results in stable angina. Pharmacological and lifestyle management of stable angina. 77 Kayser-Fleischer rings in the cornea + Parkinsonian symptoms + Liver dysfunction + Decreased serum ceruloplasmin. Diagnosis? Treatment strategies? Cure? Pathophysiology (including genetics). 78 Classic presentation of Heparin Induced Thrombocytopenia (HIT). Pathophysiology. Diagnostic testing (2). Treatment strategies. Is HIT a pro or an antithrombotic state? 79 Most common cause of osteomyelitis. Osteomyelitis in a sickle cell patient. Osteomyelitis with recent history of a cat or dog bite. Best imaging test for osteomyelitis diagnosis. Treatment strategies and duration. Determining antibiotic sensitivity. 80 Classic presentation of Granulomatosis with polyangiitis (Wegener’s). ANCA positivity. Treatment strategies. 81-HY Nerve Lesions Surgical neck fracture of the humerus OR anterior shoulder dislocation (nerve, key muscle).

Humeral midshaft fracture with wrist drop and loss of dorsal hand sensation (nerve). Medial humeral epicondylar fracture with failed finger spread in addition to failed MCP joint flexion and IP joint extension for digits 4-5. 82 Classic presentation of Granulomatosis with polyangiitis (Wegener’s). ANCA positivity. Treatment strategies. 83 Who should get a pharmacological stress test? Who should not get stress tests that involve EKG measurements? 2 pharmacological stress test methods. Gold standard for CAD diagnosis. Principle behind stress echocardiograms. Drugs to be held before stress testing. 84 Hypocalcemia + Elevated PTH + Hyperphosphatemia + Short Stature + Short 4th and 5th metacarpals + Mental retardation. Diagnosis? Treatment? 85 Hypocalcemia + Elevated PTH + Hyperphosphatemia + Short Stature + Short 4th and 5th metacarpals + Mental retardation. Diagnosis? Treatment? 86-Hepatitis Virus Matching Game Fecal oral transmission. Depends on Hep B for transmission. Virulent in pregnancy. Highest risk of a chronic carrier state. Transmitted by blood. Associated with chronic disease. HbS Ag/HbS Ab/Hbe Ag/Hbc IgM or G in these states (immunized, prior infection, acute infection, chronic infection, window period). 87 Recent viral infection or history of lupus + Isolated Thrombocytopenia. Diagnosis? Pathophysiology. First line treatment. Second line treatment. Should platelet transfusion ever be considered in these patients?

Drug that “replicates” the pathophysiology of the diagnosis. Deficiency that replicates the pathophysiology of the diagnosis. 88 19 yo sexually active F with migratory arthritis + purpuric lesions on the lower extremities bilaterally. Bug? Treatment? Coinfection treatment? Important factoid related to co-infection treatment. 89 Pathophysiology of hyponatremia. Division by serum osmolarity (+ causes). Hypoosmolar hyponatremia (division by volume status, pathophysiology). Urine Na and differentiation between intrarenal and extrarenal causes of hypovolemic hypoosmolar hyponatremia. Distinguishing between SIADH and psychogenic polydipsia. Treatment strategies for the different kinds of hyponatremia. Osmotic demyelination syndrome. When should you use hypertonic saline? Correction factor in hyperglycemia associated lab hyponatremia. 90 Bamboo spine on XR + Stiffness relieved with exercise + HLA-B27 positive + 25 yo guy + Sacroiliitis + Anterior Uveitis. Diagnosis? General treatment strategies. 91 Central vs Obstructive Sleep Apnea. Classic presentation. Risk factors. Pathophysiology. Diagnostic testing. Treatment strategies (lifestyle, pharmacology, surgery). Sequelae (pulmonary, systemic, hematologic). Obesity Hypoventilation Syndrome. 92 Athlete collapses suddenly on the field. Diagnosis? Mechanism of inheritance. Genetic mutations. Classic murmur presentation. Differentiating this murmur from aortic stenosis.

Maneuvers that increase and decrease murmur intensity and why. Treatment strategies (medical and surgical). Associated GAA repeat AR disorder? 93 A 35 yo business man returns to the US from a trip to Mexico. He has felt unwell for the past 2 weeks with a primary presentation of flu like symptoms. Scleral icterus is observed on exam. AST/ALT is approximately 5 K each. IgM antibodies specific to a single stranded picornavirus are detected in his serum. Diagnosis? Treatment? 94 Heavy menstrual bleeding + Normal PT + Elevated PTT + Increased bleeding time. Diagnosis? Mechanism of inheritance. Pathophysiology (explain labs). Treatment strategies. Results of the ristocetin cofactor assay. 95 25 yo F who went hiking in Oklahoma presents with a 6 day history of high fevers, headache, and myalgias. Has a rash that started on the extremities and spread inwards. Now has involvement of the palms and soles. CBC notable for low platelets. Diagnosis? Bug? Treatment? Treatment in pregnant women vs kids < 8? CARS (and palms/soles). 96 Acute onset exquisite pain/tenderness at the first MTP. Diagnosis? What would be found on joint aspiration? Stepwise acute management? Should you use aspirin? Chronic treatment. Tumor lysis syndrome. Azathioprine toxicity. 97 23 yo M smoker presents with a 6 month of history of mild dyspnea and productive cough. CT reveals cystonodular opacities in the upper and middle lung zones.

A lung biopsy of one of the lesions is consistent with tennis shaped intracellular organelles. Diagnosis? 98 Diastolic dysfunction in a patient with a history of sarcoidosis, amyloidosis, or hemochromatosis. Diagnosis? Pathophysiology? Diagnostic testing? 99 A high school student shadowing at a local hospital is mistakenly stuck by a needle from a patient who is known to have chronic Hep B infection. Testing 2 weeks ago revealed that the student was negative for all Hep B markers. What is the next best step in management? Pharmacological management of chronic Hep B infection. 100 Septic patient begins to bleed from IV Venipuncture sites. CBC is notable for elevations in PT and PTT. Fibrinogen levels and platelet count are low. A blood smear is positive for schistocytes. Diagnosis? 101 21 yo presents with a 1 week history of fevers, fatigue, myalgias, and hemoglobinuria. She recently went hiking on a trail in Long Island, NY. Blood smear stained with Giemsa reveals “Maltese cross” shaped organisms within RB Cs. Diagnosis? Bug? Treatment? 102 Differentiating between muscle strain, lumbar spinal stenosis, degenerative disk disease, and cauda equina syndrome (unique features of each). 103 65 yo M with no past history of smoking presents with a 6 mo history of dyspnea on exertion and fatigue. Lung auscultation reveals fine crackles. DLCO is markedly decreased. Diagnosis? Diagnostic testing? Classic imaging finding?

104 Kind of “dysfunction” associated with dilated cardiomyopathy. Common causes of DCM. Extra heart sound associated with DCM. What is the bug that causes DCM, achalasia, and megacolonosis? Diagnostic testing in DCM? Treatment strategies. 105 Palpable purpura on the skin + Hypocomplementemia + Monoclonal IgM expansion in the serum + History of Hep C infection. Diagnosis? How is Hep C diagnosed? Compared to Hep B, what is the associated risk of chronic hepatitis with Hep C? Treatment strategies for Hep C infection (+ 1 other derm manifestation). 106 Patient is rushed to the ED by ambulance from a restaurant after complaining of worsening respiratory difficulty and developing a diffuse rash. BP is 60/palpable. Diagnosis? Next step in mgt? First line treatment (IV or IM)? Pathophysiology? Kind of hypersensitivity? Mediating chemokine? 107 Hypovolemia and prerenal azotemia. Urinary Na and FeNa findings. Pathophysiology. Treatment of hypovolemic hypernatremia (2 step fluid replenishment). Treatment strategy for most causes of hyponatremia (except hypervolemic/euvolemic hyponatremia). 108 Drug of choice in the management of hypercalcemia of malignancy. Common malignant (mets) causes of lytic bone lesions (vs blastic lesions). Excellent imaging test for bone mets/Paget’s disease of the bone. Common presentation of bone mets. 109 Bilateral patchy infiltrates in a patient with a history of chronic treatment for symptomatic V Tach.

Common drug causes of pulmonary fibrosis. Classic bug cause of hypersensitivity pneumonitis in a patient that works in a barn. Fevers + respiratory difficulty + negative sputum cultures + bilateral micronodular consolidations on CXR in a patient with a long history of rheumatoid arthritis. Diagnosis? Treatment? 110 What is the most important modifiable risk factor for atherosclerosis related heart disease? Vitamin deficiencies associated with hyperhomocysteinemia (3). Quick pathophysiology of atherosclerosis. 111 The 3 MEN syndromes. Features. Pathophysiology (genetics). Mechanism of inheritance. Prophylactic treatment strategies in patients with MEN2 A and MEN2 B. Tumor marker in medullary thyroid cancer. Differential diagnosis of a marfanoid habitus. 112 Prophylactic management of esophageal varices. Management of hepatic encephalopathy. TIPS procedures and hepatic encephalopathy. The spider angiomata association. 113 Polycythemia Vera. Classic presentation. Pathophysiology (genetics). Levels of selected markers (EPO, Hct, O2 saturation). Differentiating PV from paraneoplastic EPO secretion. Budd Chiari association. Treatment strategies. 114 Fever and absolute neutrophil count < 1500 in a patient on chronic treatment for Graves disease. Diagnosis? General treatment strategies. Common drug causes of this disorder. 115 Common causes of hypokalemia. RT As associated with hypokalemia. Hypokalemia/metabolic alkalosis and unrelenting HTN.

Unique causes of hypokalemia and a metabolic alkalosis. Genetic renal causes of hypokalemia (+ drug causes). EKG findings in hypokalemia. Electrolyte causes of QT prolongation -> Torsade de Pointe. Low Mg->K. 116 45 yo M lifting boxes presents with sudden onset radicular pain. Straight leg raise is +ve. The achilles reflex cannot be elicited on exam. Diagnosis? Most likely involved nerve root? Pathophysiology? Treatment options? 117 Pulmonary arterial HTN. Classic patient demographic. Genetic cause. Causes of pulmonary HTN in older individuals. Diagnostic testing (including definitive testing). PA pressure cutoff. Classic auscultatory finding. Pharmacological management of idiopathic PAH. 118 Dyslipidemia screening guidelines (low vs high risk individuals). 4 general groups of individuals who should be placed on statins. Lipid lowering pharmacology (review). 119 Liver abscess + bloody diarrhea in an African immigrant. Bug? Treatment? Treatment of hydatid cysts (Echinococcus). 120 Discussion of the pathophysiology and examples of the 4 types of hypersensitivity reactions. 121-What is the bug? Painless chancre + hard base + indurated margins? Painless ulcer with a beefy red base and irregular borders? Painful purulent ulcer with soft, ragged edges? Painful ulcer with surrounding vesicular lesions? 122 Classic presentation of primary, secondary, and tertiary syphilis.

Treatment strategies for primary, secondary, and early latent syphilis (+ for late latent and tertiary syphilis). Treatment in patients that are PCN allergic. Treatment of neurosyphilis. Treatment of neurosyphilis in patients that are PCN allergic. Nontreponemal vs Treponemal testing. 123 Common causes of hyperkalemia. Pharmacological management of hyperkalemia and mechanisms of each. Pseudohyperkalemia. Potentially fatal side effect of Kayexalate. EKG findings associated with hyperkalemia. The dangers of tumor lysis syndrome and rhabdomyolysis (and prevention). 124 Wrist drop after a humeral fracture. Tenderness over the anatomical snuffbox. Loss of lateral arm sensation and abductive ability. 125 COPD pathophysiology (protease vs antiprotease). PFT results in COPD (FEV1, FEV1/FVC, lung volumes). Differentiating b/w chronic bronchitis and emphysema based on PF Ts. Characteristic AB Gs (+ A-B balance) in patients with COPD. CBC anomaly. Interventions shown to reduce mortality in COPD. Indications for home O2. Treatment of a COPD exacerbation. When should you use Non-Invasive Positive Pressure Ventilation (NPPV)? Stepwise chronic management of COPD (in contrast with asthma). COPD hyperoxia. Alpha-1-antitrypsin deficiency. 126 Diagnosing HTN. Lifestyle modifications as a treatment for HTN (ranked from most to least effective). Antihypertensives (MOA, HY side effects). Special indications with special populations (diabetic, history of kidney stones).

127 Fever + abdominal pain + shoulder pain + pleural effusion on CXR + recent history of small bowel surgery. Diagnosis? 128 Reversing heparin, warfarin, and dabigatran. Should LMWH be used in the treatment of HIT? Should dabigatran or bivalirudin be used in the treatment of valvular Afib? 129 Recurrent seizures in a patient who recently returned from a trip to Venezuela and consumed pork. Bug? Treatment differences (intestinal vs brain). 130 Causes of hypercalcemia (top 2, + diuretic). Signs of hypercalcemia. EKG findings in hypercalcemia. First step in management of symptomatic hypercalcemia. PTH/Ca/Phosphate levels in primary hyperparathyroidism, hypercalcemia of malignancy, renal failure, liver disease, familial hypocalciuric hypercalcemia, tertiary hyperparathyroidism, milk alkali syndrome. Differentiating b/w primary hyperparathyroidism and FHH. Pharmacological management of hypercalcemia (and hypercalcemia of malignancy). Quick review of Ca metabolism. 131 pH = 7.25, pCO2 = 65, HCO3- = 29. What is the acid base anomaly? What are common causes of this acid base anomaly? 132 HTN in a patient with Turner’s syndrome. HTN in the setting of hypokalemia, metabolic alkalosis, and an elevated plasma aldosterone to renin ratio. Episodic HTN in a patient that is accompanied by headaches. HTN in a 36 yo sexually active F. HTN in a patient on long term treatment for osteoarthritis with NSAIDS.

HTN in a 25 yo F with an abdominal bruit heard on exam (+ same question in an old guy with the fundoscopic finding of AV nicking). General treatment strategies. 133 70 yo F with a creatinine of 3 + bone pain + lytic lesions seen on XR + Ca of 12.9 mg/dL + Hb of 8.1. Diagnosis? Diagnostic testing? Diagnostic criteria? How is this disorder differentiated from MGUS and Waldenstrom Gammaglobulinemia? Classic blood smear finding. Mild discussion of Bortezomib which may be low or high yield. 134 Cyclical fevers + anemia + headaches + hepatosplenomegaly in a patient that recently returned from an African country. Diagnosis? Diagnostic testing (including stain)? How are hypnozoite forms treated to prevent reactivation? G6 PD deficiency considerations. General treatment strategies. Bug? Carrier mosquito? 135 Prolonged QT and carpopedal spasms with manual BP checks 24 hrs after a thyroidectomy for papillary thyroid cancer. Same presentation in a patient that recently got 9 units of blood for severe hemorrhage. Diagnosis? Classic EKG finding? Mg interaction? Anomaly + elevated blood phosphate (diagnosis)? Anomaly + low blood phosphate (diagnosis)? PE findings in this disorder. Distinguishing renal and liver disease as a cause of this disorder. Alkalosis and its relation to this disorder. Treatment strategies. 136 Next best step in the management of a patient presenting with hypercapnia and RR of 8 in the setting of multiple rib fractures.

Should rib fractures be casted? 137 pH = 7.52, pCO2 = 31, HCO3- = 24. Diagnosis? What is the classic acid base anomaly associated with aspirin overdose?

Practice questions — USMLE style

Question 1 — Metabolism/Genetics

A 25-year-old male presents to the emergency department after developing severe jaundice, fever, and acute kidney injury following a routine treatment for urinary tract infection with amoxicillin. The patient has no known history of drug hypersensitivity or chronic illness. Initial blood work reveals signs of hemolysis, including elevated LDH and decreased haptoglobin. Which underlying metabolic deficiency is most likely responsible for this severe reaction?

A) Glucose-6-phosphate dehydrogenase (G6 PD) deficiency
B) Pyrimidine synthesis defect
C) Alpha-1 antitrypsin deficiency
D) Nethile oxidase deficiency

Answer: A. G6 PD deficiency. The patient's acute hemolytic episode triggered by a common drug (amoxicillin) is the classic presentation of G6 PD deficiency. This enzyme is crucial for maintaining reduced glutathione, which detoxifies reactive oxygen species generated during oxidative stress. Deficiency leads to susceptibility to hemolysis upon exposure to certain drugs (e.g., sulfa antibiotics, anti-malarials) or infections.

Question 2 — Rheumatology/Immunology

A 40-year-old female presents with progressive proximal muscle weakness and difficulty climbing stairs. On physical examination, she shows characteristic erythematous, slightly scaly patches over her hands and forearms (Gottron's papules). Laboratory workup is positive for anti-Jo-1 antibodies. Given the constellation of myositis, skin findings, and autoantibodies, which diagnosis should be strongly considered?

A) Polymyalgia rheumatica
B) Dermatomyositis
C) Inclusion body myositis
D) Hypothyroidism-associated myopathy

Answer: B. Dermatomyositis. The combination of proximal muscle weakness (myositis) and pathognomonic skin findings, such as Gottron's papules on the knuckles, is highly suggestive of dermatomyositis. While Polymyalgia Rheumatica causes stiffness and pain in older adults, it does not typically present with these specific rashes or profound muscle weakness. Anti-Jo-1 antibodies are associated with inflammatory myopathies and often correlate with interstitial lung disease (ILD).

Question 3 — Nephrology/Hematology

A 68-year-old male presents to the clinic with acute onset of oliguria, fatigue, and a palpable flank mass. Laboratory studies reveal severe thrombocytopenia, elevated creatinine, and schistocytes on peripheral blood smear review. The patient has no history of recent bleeding or trauma. Which condition is the most likely cause of this triad (thrombocytopenia, AKI, microangiopathic hemolysis)?

A) Primary glomerulonephritis
B) Thrombotic Thrombocytopenic Purpura (TTP)
C) Hemolytic Uremic Syndrome (HUS)
D) Disseminated Intravascular Coagulation (DIC)

Answer: C. Hemolytic Uremic Syndrome (HUS). HUS is characterized by the classic triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. While TTP also causes this triad, it is typically associated with ADAMTS13 deficiency and often presents with neurological symptoms. HUS, particularly in the context of gastrointestinal illness (e.g., Shiga toxin-producing E. coli), is the most common cause of TMA in this setting.

Question 4 — Endocrinology/Oncology

A 75-year-old female is diagnosed with multiple lytic bone lesions and presents with severe hypercalcemia (Ca = 14 mg/dL). She has a history of chronic gastrointestinal issues but no known primary parathyroid disorder. Which initial pharmacological intervention is the most critical step in managing her symptomatic hypercalcemia?

A) Intravenous calcium gluconate to stabilize cardiac membrane potential
B) Bisphosphonates (e.g., zoledronic acid) to inhibit osteoclast activity
C) Loop diuretics (e.g., furosemide) to promote renal calcium excretion
D) Calcitonin administration for rapid, short-term reduction of serum calcium

Answer: B. Bisphosphonates (e.g., zoledronic acid). In the setting of hypercalcemia of malignancy due to bone destruction, the primary goal is to rapidly reduce bone turnover and sequester calcium. Bisphosphonates are potent inhibitors of osteoclast activity, leading to a sustained decrease in bone resorption and thus lowering serum calcium levels over several days. IV calcium gluconate (A) would worsen the hypercalcemia; loop diuretics (C) can exacerbate hypovolemia and electrolyte imbalances; and calcitonin (D) provides only transient relief.

Quick fire review

What is the key difference in management between hypertensive urgency and hypertensive emergency?

Urgency involves high BP without acute end-organ damage; treatment is gradual reduction. Emergency requires immediate, controlled lowering of BP to prevent organ damage.

In Cushing's syndrome workup, what does an elevated ACTH level combined with a failure to suppress cortisol on HDDST suggest?

Ectopic ACTH production (e.g., small cell lung cancer).

What is the classic finding associated with Lyme disease in later stages of infection?

Erythema migrans rash (early) followed by carditis or meningitis (later stage).

Which autoimmune condition is associated with "beads on a string" appearance on ERCP and ANCA positivity?

Type III hypersensitivity vasculitis, often seen in conditions like polyarteritis nodosa.

What are the two primary types of hyperbilirubinemia that require differentiation when reviewing bilirubin metabolism?

Conjugated (direct) hyperbilirubinemia (suggests biliary obstruction/liver failure) and Unconjugated (indirect) hyperbilirubinemia (suggests hemolysis or impaired uptake).

When managing acute cholecystitis, what is the key difference in risk factors for acalculous versus calculous disease?

Calculous is usually associated with gallstones; Acalculous often occurs in critically ill patients (e.g., post-op) due to stasis or altered motility.

What are the classic findings on electron microscopy for membranous nephropathy?

Podocyte foot process effacement.

Which specific enzyme deficiency leads to increased urinary excretion of mineralocorticoids and is associated with hyperkalemia, metabolic acidosis, and hypertension?

11-hydroxylase deficiency (leading to accumulation of precursors).

What are the three main components that define the diagnosis of Mixed Connective Tissue Disease (MCTD)?

Clinical features suggestive of multiple connective tissue diseases + high titer anti-RNP autoantibodies.

In the context of liver disease, what is the classic AST/ALT ratio seen in alcoholic liver disease?

Ratio > 2:1.

What specific constellation of symptoms (e.g., proximal weakness, jaw pain with swallowing) suggests a diagnosis requiring investigation for polymyositis or dermatomyositis?

Proximal muscle weakness and associated inflammatory/autoimmune markers.

Which type of pneumonia is classically associated with the finding of "Maltese cross" shaped organisms within RB Cs on Giemsa stain?

Babesia species (Malaria-like picture).

What are the two most common causes of severe, refractory diarrhea that require consideration for antibiotic stewardship in a hospital setting?

Clostridioides difficile and Pseudomonas aeruginosa.

Quick recall / Anki-style questions