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Important points:

1. Hyperkalemia may be caused by a hemolyzed blood sample or rbabdomyolysis (due to high intracellular potassium concentration).

2. Hyponatremia may be caused by hyperglycemia, hyperproteinemia, or hyperlipidemia; these forms of secondary hyponatremia will correct with correction of the glucose, lipid, or protein levels,

3. Correcting hyponatremia aggressively (especially with hypertonic saline [3%]) may cause brainstem damage (central pontine rnyclinolysis).

4. Alkalosis may cause hypokalemia and symptoms of hypocalcemia (perioral numbness, tetany) due to cellular shift; acidosis may* cause hyperkalemia by the same mechanism.

5. High levels of amylase and lipase may be due to sources other than the pancreas (salivary glands, GI tract, renal failure, ruptured tubal pregnancy), but elevation of both in the same patient usually is due to pancreatitis.

6. Alkaline phosphatase can be elevated by biliary disease, bone disease, or pregnancy. If the elevation is due to biliary disease, gamma glutamyl transpeptidase (GGT) and/or 5 -nucleotidase (5-NT) also should be elevated.

1. Hypothyroidism can cause elevated cholesterol.

8. Elevated creatine kinase (CK) may be due to muscle injury (striated or myocardial), drugs (HMG-CoA reductase inhibitors) or burns (CK-MB is more specific for cardiac muscle).

3. Hypokalemia and/or hypocalcemia may be due to hypomagnesemia. You cannot correct the hypokalemia until you correct the hypomagnesemia.

10. Watch for hypophosphatemia in diabetic ketoacidosis.

11. Blood urea nitrogen:creatinine ratio > 15 usually implies dehydration.

12. Positive results on the rapid plasma reagin or Venereal Disease Research Laboratory test for syphilis may be due to systemic lupus erythematosus.

13. In patients with isosthenuria and hyposthenuria—the inability to concentrate urine

think of diabetes insipidus or sickle cell disea.se/li-ait.

14. The erythrocyte sedimentation rate (ESR) is a worthless test in pregnancy; IiSR is ele vated by pregnancy itself. A high -normal blood urea nitrogemcreatinine ratio may mean renal disease in pregnancy.

Important points:

1. Do not force adult Jehovah's witness patients to accept bfood products.

Z If a child has a life-threatening condition and the parents refuse a simple, curative treatment (antibiotics for meningitis), first try to persuade the parents to change their mind. If you cannot, your second option is to get a court order to give the treatment. But do not give the treatment until you talk to the courts if you can avoid it.

3. Let competent people die if they want to do so. Never force treatments on adults of sound mind. Respect wishes for passive euthanasia, but avoid active euthanasia.

4. Do not tell anyone how your patient is doing unless he or she is directly involved with care and needs to know or is an authorized family member. If a colleague asks about a friend who happens to be your patient, refuse to answer.

5. Break confidentiality only in the following situations: m The patient asks you to do so.

■ Child abuse is suspecied. »The courts mandate you to tell.

■You have a duty to protect life. (If the patient says that he or she is going to kill someone or him- or herself, you have to tell the intended victim, the authorities, or both.)

■ The patient has a reportable disease. You must report to authorities, let them deal with it.

«a The patient is a danger to others. If the patient is blind or has seizures, let the proper authorities know so that they can Lake away the patient's license to drive. If the patient is an airplane pilot and a paranoid, hallucinating schizophrenic, authorities need to know.

6. Informed consent involves giving the patient information about the diagnosis (his or her condition and what it means), the prognosis (the natural course of the condition without treatment), the proposed treatment (description of the procedure and what the patient will experience), the ri.sk/bcncfits of the treatment, and the alternative treatments. The patient is then allowed to make his or her own choice. The documents seen on hospital wards that pa tients are made to sign are neither required nor sufficient for informed consent; they are used for medicolegal purposes (i.e., lawsuit paranoia).

7. When the patient is incompetent, a guardian (surrogate decision maker or health care power of attorney) should be appointed by the court.

8. living wills and. do-not-resuscitate orders should be respected and followed if done correctly. For example, if in a living will the patient says that a ventilator should not be used if he or she is unable to breathe independently, do not put the patient on a ventilator, even if the spouse, son, or daughter makes the request.

9. Depression always should be evaluated as a reason lor the patient's "incompetence." Patients who are suicidal may refuse all treatment; this decision should not be respected until the depression is treated.,

10. Patients can be hospitalized against their will in psychiatry (if they are a danger to self or others) for a limited time. After 1-3 days, patients usually get a hearing to determine whether they have to remain in custody. This practice is based on the principle of beneficence (a principle of doing good for the patient and avoiding harm).

11. Restraints can be. used on an incompetent or violent patient (delirious, psychotic) if needed, but their use should be brief and reevaluated often .

12. Patients under 18 do not require parental consent in the following situations:

h If they are emancipated (married, living on their own arid financially independent, parents of children, serving in the armed forces)

■ If they have a sexually transmitted disease, want contraception, or are pregnant.

b If they want drug treatment or counseling.

Some states have exceptions to these rules, but for boards let such minors make their own decisions.

13. If a patient is comatose and no surrogate decision maker has been appointed, the wishes of the family generally should be respected. If there is a family disagreement or ulterior motives are evident, talk to your hospital ethics committee. Use courts as a last, resort.

14. In a pediatric emergency when parents are not available, treat the patient as you see frt.

15. Do not hide a diagnosis from patients (including pediatric patients) if they want to know the diagnosis—even if the family asks you do so. Do not lie to any patient because the family asks you to do so. Tire flip side also applies: do not force patients to receive information against their will. If they don't want to know ihe diagnosis, don't tell them.

16. If a patient cannot communicate, give any required, emergency care unless you know that the patient, does not want it,

17. Withdrawing and withholding care are no different in a legal sense. Just because the patient is on a respirator does not mean that you cannot stop it.

18. In terminally ill patients, give enough, medication to relieve paixr. Opioids are commonly used.

Although some questions with photos can be figured out without looking at the photo, this is not always the case. You should be able to recognize the entities listed below. The Color Atlas and Text of Clinical Medicine by Forbes and Jackson is a. great source. For other good atlases, see your librarian.

Blood smears:

hi Howell-Jolly bodies (asplenia/splenic dysfunction) « Basophilic stippling (lead poisoning, thalassemia) a Malaria

■ Spherocytosis a Target cells (thalassemia, severe liver disease) a Heinz -bodies/ "bite cells" (G6PD deficiency)

* Schistocytes/helmet cells (disseminated intravascular coagulation, thrombotic thrombocytopenic purpura, microangiopathic hemolysis)

* Multiple myeloma

■ Acute lymphoblastic leukemia, chronic lymphocytic leukemia

■ Auer rods (acute myeloid leukemia)

■ Chronic myelocytic leukemia a Acanthocytes (abetalipoproteinemia) a Teardrop cells (myelofibrosis, myelodysplasia) a Iron deficiency anemia

■ Sideroblastic anemia

■ Folate/B|2 anemia (macrocytic, hypersegmented neutrophils) « Sickle cell disease

» Reticulocytes h Aplastic anemia ("dry" bone marrow tap)

■ Chediak-Higashi cell

» I'eed Sternberg cell (Hodgkiu's lymphoma)

■ Dohle bodies (toxic lymphocytes; for boards, think of Epstein-Barr virus)

■ Hairy cell leukemia

Ophthalmology;

a Kayser-Fleischer ring (Wilson's disease) s» Bacterial conjunctivitis (especially in neonates)

■ Glaucoma (closed -angle attack or acute)

■ Graves' disease (exophthalmos)

■ Diabetic fundus

■ Hypertensive fundus

■ Central retinal artery occlusion (fundus) a Central retinal vein occlusion (fundus)

* Papilledema a Retinoblastoma (white reflex instead of red) a Xanthelasma

« Corneal arcus (in patients < 50, a marker for hypercholesterolemia) a Roth spots (think of endocarditis)

a Herpes simplex keratitis (dendritic ulcer seen with fluorescein; avoid steroids)

■ Cataracts (bad enough to notice with the naked eye)

■ Orbiial cellulitis

Dermatology/skin findings:

■ Pityriasis rosea

« Neisseria sp. septicemia (severe purpura)

■ Lyme disease (erythema chronicurn migrans) » Tinea capi tis a Scabies

■ Psoriasis (skin findings and nail pitting)

■ Cheilitis/stomatitis (think of B vitamin deficiencies)

■ Toxic shock syndrome, scalded skin syndrome a Abdominal striae (Gushing's syndrome)

■ Erythema marginatum (rheumatic fever)

■ Janeway and Osier lesions (endocarditis)

m Acanthosis nigricans (marker for visceral malignancy) a Syphilis (chancre, condyloma lata, secondary syphilis rash)

a Varicella zoster virus (chiekenpox, shingles, trigeminal and ophthalmic involvement) h Henoch' Schonlein purpura (rash)

■ Erythema multiforme (target lesion) a Malar rash (lupus)

m Heliotrope rash (dcrmatomyositis)

■ Oral hairy leukoplakia (caused by lipstein-Barr virus; seen in HIV-positive patients) a Basal cell cancer a Squamous eel! cancer

■ Melanoma a Actinic keratosis

■ Stasis dermatitis/venous insufficiency (skin changes, ulcers) « Arterial insufficiency (skin changes)

■ Diabetic foot ulcers (similar in appearance to arterial insufficiency ulcers but usually jMinless) h Vitiligo (associated with pernicious anemia and hypothyroidism)

«Impetigo

■ Raynaud's phenomenon (finger autoamputation; often seen in scleroderma)

■ Temporal arteritis (tortuous-looking temporal artery) * (Tubbing of the fingers

■ Adenoma sebaceum (tuberous sclerosis)

■ Condyloma acuminata

■ Molluscum contagiosurn

» Bitot's spots (vitamin A deficiency)

■ Cafe-au-lait patches (neurofibromatosis in patients with normal IQ, McCune-Albright syndrome with mental retardation)

i® Varicose veins

■ Grey-Turner sign

■ Erythema infectiosum (slapped, cheek rash with fever resolution just before rash appears) » Sturge-Weber syndrome (hemangioma; port-wine stain on one side of face)

a Cavernous hemangiomas (in children, most lesions resolve on (heir own) »Hirsutism, (know conditions associated with it) a Rocky Mountain spotted fever rash

■ Pyoderma gangrenosum (think of inflammatory bowel disease)

■ Erythema nodosum (think of inflammatory bowel disease, infections [the classic example is Coccidioides ¡minilis or tuberculosis], or sarcoidosis)

■ Pretibial myxedema (Graves' disease) s» Neurofibromatosis (skin)

■ Keloids (usually in blacks)

■ Allergic contact dermatitis

« Tinea corporis and tinea cruris

Microsc opic findings:

■ Gram stain (gram negative = red, gram- positive - blue) plus clustering tendencies e» Caseating granulomas (tuberculosis, fungi)

m Noncaseat ing granulomas (sarcoidosis)

■ Goodpasture's disease (linear immunofluorescence in kidney)

« Gout (needle-shaped crystals from a joint with no birefringence)

m Pseudogout (needle -shaped crystals wi th positive birefringence) » TiicflOJllOlMIS Sp.

■ Clue cells (G<irdfaerella sp. vagin itis) m Giardia sp.

m Koilocytosis (think of human papillomavirus or cytomegalovirus)

Radiologic findings:

a Lobar pneumonia

■ Sinusitis (maxillary or frontal sinus opacification)

■ Sarcoidosis

■ Osteoarthritis (osteophytes, inter phalangeal joint changes)

■ Multiple myeloma (punched-out skull x- rays) w Osteosarcoma (sunray or sunburst pattern)

h Duodenal and jejunal atresia ("double-bubble" sign)

■ Esophageal atresia (barium x-ray) m Pleural effusion

* Congestive heart failure on chest x-ray

» Small bowel obstruction (air-fluid levels)

■ Toxic megacolon (Hirschsprung's disease or inflammatory bowel disease, infection)

■ Pneumothorax b Grossly abnormal ventilation-perfusion scan

* Classic chest x-ray of tuberculosis

■ Chest x-ray findings of asbestosis (plaques) » Abdominal aortic aneurysm on angiogram a Achalasia (esophagus on barium enema)

h Volvulus on barium enema (bird's beak)

■ Appearance of a major cerebrovascular accident (stroke) on CT/MRJ « Berry aneurysms on angiogram

« Slipped capital femoral epiphysis (x-ray)

■ Nephrolithiasis 011. abdominal x-ray (radiopaque)

■ Coarctation of aorta (on angiogram) « Multiple sclerosis (plaques on MRI)

■ Pancoast tumor on chest x-ray (know associated Horner's syndrome)

■ Lung abscess on chest x-ray (air-fluid level)

a Bossing of the skull on x-ray (think of hemolytic anemias, especially thalassemias and sickle cell disease, and. in elderly patients Paget:'s disease)

W Colon cancer on barium enema (apple core and napkin-ring lesions)

m Liver tumors on CT (metastasis 20 limes more likely than primary tumor)

■ Severe carotid artery stenosis on angiogram » Shoulder separation on x-ray a Lytic lesions of bone on x-ray (think of malignancy) Other photos:

■ Rheumatoid arthritis (swan-neck, deformity, boutonnière deformity, ulnar deviation, rheumatoid nodules)

■ Osteoarthritis (Heberdens and Bouchard's nodes) a Gout (podagra, tophi)

h Dactylitis (sickle cell disease)

■ Down syndrome (fades, simian crease)

« Turner's syndrome (body habitus, widely spaced nipples, webbed neck, cubitus valgus) « Horner's syndrome (unilateral ptosis and miosis and history of hemianhydrosis) s Bell's palsy (facial asymmetry) « Gushing's syndrome (fades, striae) » Graves' disease (exophthalmos) » Acromegaly (facies)

■ Peutz-Jeghers syndrome (freckling pattern on face)

■ Achondroplasia (overall appearance; usually autosomal dominant) a Candidal infection (vaginal, thrush)

a Gonorrhea (yellowish discharge) w Erb's palsy (waiter's tip) m Polycystic kidneys (gross appearance)

• Fetal alcohol syndrome (facies)

a Decubitus ulcers (best preven tion is frequent turning of patient)

a Pseudohermaphrotidism (picture of ambiguous genitalia; look for 7.1 -hydroxylase deficiency)

h Tanner stages (male and female)

a Congenital syphilis (Hutchinson's teeth, saddle nose deformity)

■ Osteomyelitis extending to the skin (think of Staphylococcus or Salmonella sp. in sickle cell disease)

h Scleroderma (late-stage facies)

■ Spina bifida (gross appearance; encephalocele, meningoceleocele, meningomyelocele, occulta/patch of hair)

« Strawberry tongue (scarlet fever and Kawasaki's disease)

a Acute tonsillitis (Streptococcus sp. or Epstein-Barr virus; rarely diphtheria in unimmunized patient)

■ Acute pharyngitis (viral or streptococcal)

■ Gynecomastia (normal finding in pubertal males)

• Tenosynovitis (think of gonorrhea if the patient is sexually active) h Hypertrophy of the heart (gross specimen; severe disease)

■ Dilated cardiomyopathy (gross specimen; severe disease)

■ Karyotype showing Down (trisomy 21),Turner's (XO), or Klinefelter's (XXY) syndrome

■ Fetal, heart strips (normal, short--term, and. long-term variability; early, variable, and late decelerations)

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