1. internal medicine

MEMORY AID FOR INTERNAL MEDICINE

Causes of acute Pancreatitis

BAD SHIT

Black scorpion biteAlcohol ( or autoimmune : PAN )Drugs ( tetracycline, azothioprin, sulfa, diuretics )

Stones ( gallstones or steroid )HyperlipidemiaInfection ( mumps )Trauma

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Small Bowel Obstruction

"SHAVIT" S - Stone (gallstone ileus)H - HerniaA - AdhesionsV - VolvulusI - IntussusceptionT - Tumor

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Non-GI Causes of Vomiting

ABC's of Non- GI causes of vomiting

Acute renal failureBrain (Increased ICP)Cardiac (Inferior MI)DKAEars (labyrinthitis)Foreign substances (Tylenol, theo, etc)GlaucomaHyperemesis GravidarumInfections (pyelonephritis, meningitis)

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Extraintestinal manifestations of I. B. D. are A PIE SAC -

Aphthous ulcers, Pyoderma gangrenosum, Iritis, Erythema nodosum, Sclerosing cholangitis, Arthritis, clubbing.

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Which I. B. D. has C-obblestones on endoscopy - C-rohn's.

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Acute Rheumatic Fever

There are several for the major criteria, I use "JONES"

J - JointsO - Obvious (cardiac) - sorry, I know this is kinda weakN - Nodules (subcutaneous nodules)E - Erythema marginatumS - Syndeham's Chorea

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Causes of ST Elevation

"ELEVATION"

E - ElectrolytesL - LBBBE - Early RepolarizationV - Ventricular hypertrophyA - AneurysmT - Treatment - PericardiocentesisI - Injury (AMI, contusion)O - Osborne waves (hypothermia)N - Non-occlusive vasospasm

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Hyperkalamia causes large T waves on the ECG, Hypokalaemia causes small ones - ie. large pot - lots of tea, small pot - no tea.

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If QRS complex is wide, consider bundle branch block. LBBB causes a "W" pattern in V1-2 and a "M" pattern in V5-6. RBBB is the other way round. Remember as WiLLiaM MaRRoW.

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Elevation of cardiac enzymes after a M.I. is CPK, then AST, then LDH. Remember as - C AST Le.

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Basal Systolic Murmur: Aortic Stenosis (AS)

-The mnemonic key is Arthur Shawcross (AS), a cannibalistic murderer, a key which immediatelyfollows the symbol.

-Clinical:

Angina pectoris despite normal coronary arteriesArthur Shawcross represents the Angel of death [Angina].

Exertional syncope His victims Swooned [Syncope] with fear when they saw him.

Exertional dyspnea of congestive heart failureArthur Shawcross claims he left the crime scenes whistling Dixie [Dyspnea].

Sudden cardiac death Arthur Shawcross causes Sudden Death.

-Physical findings

Loud, harsh, systolic ejection murmur at the upper right sternal border, usually associated with a palpable systolic thrill.

Arthur Shawcross is a Base [Basal] Thrill-murderer [Thrill]. He is a Harsh Hardened criminal, who attributed his grotesque actions to incest with his Sister [Systolic].

S4 gallop is common and represents left ventricular hypertrophy and increasedleft ventricular pressure.His ghoulish tales read like the Four [S4] Horsemen of the Apocalypse.

S3 when left ventricular failure is present.As a child, AS displayed the classic homicidal Triad [S3]: animal torture, fire-setting, and bed-wetting.

Delayed upstroke in the carotid pulse. Parvus et tardus carotid pulse.His last victim still had a Small but palpable pulse. However, the ambulance wasDelayed [upstroke], and, it soon became too Little, too Late [Parvus et Tardus].

Paradoxical splitting of S2AS sent his victims to Paradise [Paradoxical].

References:1. Harrison Principles of Internal Medicine, 14/e Edition, McGraw-Hill, New York, 1998.2. Maximum access to diagnosis and therapy (MAXX), Lippincott Williams & Wilkins, New York, 1999

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Symptoms of aortic stenosis are SAD or ASD - Syncope, Angina, Dyspnea.

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For Causes of A-Fib/Flutter

H = cHf, other cardiomyopathiesE = Enlargement of the atriaA = Alcohol binge drinkingR = Rheumatic heart diseaseT = hyperThyroid

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Asystole

"3 Hypo's & 3 Hyper's"

Hypoxia

HypothermiaHypokalemia

HyperkalemiaHyper H (Acidosis)Hyper Rx (Drugs/OD)

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Syncope

"HEAD, HEART and VESS'LS"

H - hypoglycemia hypoxiaE - epilepsyA - anxiety [the "swoon"]D - dysfunction of brain stem [i.e. brain stem TIA]

H - heart attackE - embolism of pulmonary arteryA - aortic obstruction [ Aortic stenosis, myxoma, IHSS ]R - rhythm disturbanceT - tachycardia esp VT

V - vasovagalE - ectopic i.e. hemorrhage obvious or notS - situational [micturation, defecation...]S - subclavial stealL - low SVR [eg: anaphalaxis]S - sensitive carotid sinus

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Basic management of M.I. is BOOMAR - Bed rest, Oxygen, Opiate, Monitor, Anticoagulate, Reduce clot size

Proven MI.. should be met by M.O.N.A.

M = morphineO = oxygenN = nitratesA = aspirin

suspected right ventricular MI suspected .. hold the Nitrates.

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Endocarditis

"FAME"

F - FEVERA - ANEMIAM - MURMUR

E - ENDOCARDITIS

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Causes of pericarditis are CARDIAC RIND - Collagen vascular disease, Aortic aneurysm, Radiation, Drugs eg. hydralazine, Infections, Acute renal failure, Cardiac infarction, Rheumatic fever, Injury, Neoplasms, Dressler's syndrome.

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5 T's of early cyanosis in congenital heart disease

Tetralogy, Transposition, Truncus, Total anomalous, Tricuspid atresia

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95% of hypertension is primary (idiopathic). 5% is secondary and causes include CHAPS - Cushing's syndrome, Hyperaldosteronism (Conn's syndrome) , Aorta coarctation, Pheochromocytoma, Stenosis of the renal arteries.

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Takayasu's disease is also called pulseless disease, therefore I can't Tak'a ya's pulse.

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Henoch-Schonlein Purpura

"JARS"

J - JointsA - Abdominal painR - RenalS - Skin

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Compartment Syndrome

"6 p's"

pulselessnesspainpallorparasthesiapoikiolothermiaparalysis

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Predisposing Conditions for Pulmonary Embolism TOM SCHREPFER

T--trauma O--obesity M--malignancy S--surgery C--cardiac disease H--hospitalization R--rest (bed-bound) E--estrogen, pregnancy, post-partum P--past hx F--fracture E--elderly R--road trip

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Shortness of Breath

HAPISOCS

H: History of any pulmonary diseaseA: Activity at onsetP: Pain upon inspirationI: Infections fever/chillsS: Smoker years/packsO: OrthopneaC: Cough (Persistent)S: Sputum Productive/color

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Non-Cardiogenic Pulmonary Edema

"PONS"

P - Phosgene, paraquat, phenothiazinesO - Opioids/organophosphatesN - Nitrous dioxideS - Salicylates

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Treatment of acute pulmonary edema

As Easy as 'LMNOP' : Remember the mnemonic LMNOP when treating a patient with acute pulmonary edema

Lasix¢ç (furosemide) intravenous (IV), one to two times the patient's usual dose, or 40 mg if the patient does not usually take the drug.

Morphine sulfate. Initial dose, 4 to 8 mg IV (subcutaneous administration is effective in milder cases); may repeat in 2 to 4 hours. Avoid respiratory depression. Morphine increases venous capacity, lowering left atrial pressure, and relieves anxiety, which reduces the efficiency of ventilation.

Nitroglycerin IV, 5 to 10 ug/min. Increase by 5 ug/min q 3 to 5 minutes. Reduces left ventricular preload. Caution: may cause hypotension.

Oxygen, 100% given to obtain an arterial PO2>60 mm Hg.

Position patient sitting up with legs dangling over the side of the bed. This facilitates respiration and reduces venous return.

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Beta-1 receptors are in the heart (you have 1 heart) and beta-2 receptors are in the lungs (you have 2 lungs).

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Decreased Pleural fluid Glucose : "IRAN"

I=Infections RA=Rheumatoid arthritis N=Neoplasia

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Anterior Mediastinal Mass

"4 T's"

T - ThymomaT - TeratomaT - Thyroid tumor/goiterT - Terrible lymphoma

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Middle Mediastinal Mass

"Habit5"

H - Hhernia, hematomaA - AneurysmB - Bronchogenic cyst/duplication cystI - Inflammation (sarcoid, histo, coccidio, TB)T5 - Tumors (lung, lymphoma, leukemia, leiomyoma, lymph node hyperplasia)

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Bilateral Hilar Adenopathy

"Please Helen Lick My Popsicle Stick"

P - Primary TBH - HistoplasmosisL - LymphomaM - MetastasesP - PneumoconiosisS - Sarcoidosis

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Sarcoidosis:

SARCOIDOSIS: G-E-R-M-A-N ACE "SCHAUMANN" B-O-E-K

G-GranulomasE-Erythema nodosumR-Restrictive lung defect (PFTs)M-Multiple systemic manifestationsA-Asteroid bodies (inclusions)N-Noncaseating granuloma, Negative TB test

ACE - Angiotensin converting enzyme levels monitor disease activity and response to therapy.

Schaumann's bodies (inclusions)

B-Bell's palsy, Bilateral hilar lymphadenopathy, Black femalesO-Optic nerve dysfunction is a common manifestation of neurosarcoid.E-Eyes: uveitisK-Kveim skin test

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Rat Poisons

"RATS PANIC" I'm sure that you'll easily remember this one!

R - Red squillA - Arsenicals

T - ThalliumS - Strychnine

P - PNU/Phosphorus/zn PhosphideA - Alpha naphtha thiurea (ANTU)N - NorbormideI - IndanedionesC - Coumadin/cholcalciferol

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Anion Gap Acidosis:

"Mudpiles"

M - MethanolU - UremiaD - DKA/AKAP - Paraldehyde/phenforminI - Iron/INHL - Lactic acidosisE - Ethylene glycolS - Salicylates

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Normal Gap Acidosis

"HARDUP"

H - Hyperalimentation/hyperventilationA - AcetazolamideR - RTAD - DiarrheaU - Ureteral diversionP - Pancreatic fistula/parenteral saline

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Osmolar Gaps

"ME DIE"

M - Methanol

E - Ethanol

D - Diuretics (mannitol, sorbitol, glycerol)I - IsopropanolE - Ethylene glycol

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Respiratory Alkalosis: Asthmatic Sally poisoned POPE's HEN

Asthma Salicylate poisoning PO= Pulmonary Oedema PE= Pulmonary Embolism HEN= Hepatic Encephalopathy

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Hypoglycemia

"Reexplain"

R - renal failureEX - exogenousP - pituitaryL - liver failureA - alcoholI - insulinoma/infectionN - neoplasm

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Hypoglycemia

Hypoglycemia - H-U-N-G-E-R: B-E-S-T S-A-U-C-E I-S M-S-G

H-Hepatic failure (advanced), HypothermiaU-Uremia/renal failureN-Nausea, vomitingG-Growth hormone deficiencyE-Ethanol metabolism blunts gluconeogenesisR-Reye's syndrome

B-Beta blockers E-Enzyme defects (glycogen storage diseases)

S-SepsisT-Tumors: Islet beta cell tumors (pancreatic): InsulinomasNon-islet cell tumors: Large mesenchymal tumors

S-SulfonylureasA-Adrenal insufficiencyU-Under 0.3 (insulin/glucose ratio) to make the diagnosisC-C-peptide measurement to rule out factitious hypoglycemiaE-Endocrine: Epinephrine, glucagon deficiencies (counterregulatory hormone deficiencies)

I-Immune disease with insulin or insulin receptor antibodiesS-Sarcomas: large retroperitoneal sarcomas

M-Maple syrup urine disease, severe MalariaS-Salicylates in childrenG-Galactosemia (with milk ingestion), disorders of Gluconeogenesis

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Symptoms of hyperthyroidism

Remember the following mnemonic when evaluating patients for hyperthyroidism: S : SweatingT : Tremor or TachycardiaI : Intolerance to heat, Irregular menstruation, and IrritabilityN : NervousnessG : Goiter and Gastrointestinal (loose stools/diarrhea). Submitted by Jed

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CUSHING'S

DISEASE is Dependent on (Pituitary) and Depresses ( Cortisol) on Daddy Doses of Dexa(High doses of Dexamethasone).

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Hypercalcemia

"SHAMPOO DIRT"

S - SarcoidosisH - Hyperparathypoidism, HyperthyroidismA - Alkali-milk syndromeM - Metastases, myelomaP - Paget diseaseO - Osteogenesis imperfectaO - Osteoporosis

D - Vitamin intoxicationI - ImmobilityR - RTAT - Thiazides

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Hypercalcemia symptoms are Bones (pain), Stones (renal), abdominal Groans (pain) and psychic moans (confusion).

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Multiple endocrine neoplasia

MEN I is 3 P's (Pituitary, Parathyroid, Pancreas). MEN II is 2 C's (Catecholamines ie. pheochromocytome, carcinoma of medulla of thyroid) and Parathyroid (IIa) or Mucocutaneous neuromas (IIb).

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The most common thyroid carcinoma is P-apillary (P-opular). It also has P-sammona bodies on histology. It causes P-alpable lymph nodes (lymphatic spread).

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The most common symptoms of PHEochromocytoma begin with the first 3 letters - Palpitations, Headache, Episodic diaphoresis (sweating).

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Tumors that go to bone

"Kinds Of Tumors Leaping Primarily To Bone"

K - KidneyO - OvarianT - TesticularL - LungP - ProstateT - ThyroidB - Breast

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Causes of joint pain are SOFTER TISSUE - Sepsis, Osteoarthritis, Fractures, Tendon/muscle, Epiphyseal, Referred, Tumour, Ischaemia, Seropositive arthritides, Seronegative arthritides, Urate, Extra-articular rheumatism (eg. polymyalgia).

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Ossification centers of the elbow

There are two that I know of (most people use "CRITOE"):

C - CapitellumR - Radial headI - Internal (medial epicondyle)T - TrochleaO - OlecranonE - External (lateral epicondyle)

These appear at 2, 4, 6, 8, 10, and 12 years of age in order and go away two years later. The other mnemonic I know for the ossification centers is "Come Rub My Tree Of Love" where the "M" is medial epicondyle and the "L" is the lateral epicondyle.

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Wrist Bones

"Never Loosen Tillies Pants, Mother Might Come Home"

Proximal row:N - NavicularL - LunateT - TriquetriumP - Pisiform

Distal row:M - greater Multiangular (trapezium)M - lesser Multiangular (trapezoid)C - CapitateH - Hamate

Also: "Some Lovers Try Positions That They Can't Handle"

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Rotator Cuff Muscles

"SITS"

S - SupraspinatusI - InfraspinatusT - Teres minorS - Subscapularis

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The Salter Classification:

"SALTR"

S - Slip of physisA - Above physisL - Lower than physisT - Through physisR - Rammed physis

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NEPHROTIC SYNDROME (NS) is characterized by the following: [By Shweta]

N = Na + water retention This occurs due to several factors, including compensatory secretion of aldosterone in response to hypovolemia-mediated release of ADH.

E = EdemaDue to hypoproteinemia + Na, water retention. Edema is soft, pitting and starts in the

periorbital region.

P = Proteinuria >3.5gm/1.74sq. ml/24hrs

H = Hypertension + hyperlipidemia (due to increased lipoprotein synthesis in liver, abnormal transport of circulating lipoproteins, decreased catabolism.)

R = Renal vein thrombosis

O = "Oval fat bodies" in the urine. Lipiduria follows hyperlipidemia. Albumin as well as lipoproteins are lost. Lipoproteins are reabsorbed by tubular epithelial cells and they shed along with degenerated cells- this appears as "oval fat bodies" in urine.

T = Thrombotic + thromboembolic complications owing to loss of anticoagulant factors (eg. anti-thrombin III )

I = Infection. These patients are prone to infection, especially with staphylococci and pneumococci. Vulnerability is due to loss of immunoglobulins.

C = hyperCoagulable state

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Henoch-Schonlein Purpura

"JARS"

J - JointsA - Abdominal painR - RenalS - Skin

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Causes of hematuria

Use the mnemonic SITTT as an aid in evaluating the cause of hematuria:

S: StoneI: InfectionT: TraumaT: TumorT: Tuberculosis

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Causes of secondary nephrotic syndrome ie. not of direct renal origin are DAVID - Diabetes mellitus, Amyloidosis, Vasculitis, Infections, Drugs.

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Causes of acute and reversible forms of urinary incontinence

The following mnemonic aids in remembering the causes of acute and reversible forms of urinary incontinence - DRIP

D: DeliriumR: Restricted mobility, retentionI: Infection, inflammation, impaction (fecal)P: Polyuria, pharmaceuticals

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Hereditary cystic disorders: Polycystic kidney disease

Autosomal dominant polycystic kidney disease (ADPKD) is associated with cysts in the kidneys and, in many cases, in the brain (berry aneurysms), liver, spleen, pancreas, and lungs.

¡°Halley Berry AKA Dorothy (Dandridge) Portrayed Carmen Jones.¡±

Halley ?Hematuria: Gross and microscopicBerry -Berry aneurysms

AKA ?ADPKD

D-Dominant (autosomal) inheritanceO-Obstruction of the urinary tract by stones, blood clotsR-Renal failureO-Oxalate: calcium oxalate and uric acid stonesT-renal Tubular defectsH-Hemorrhagic cystsY-Year 1 - Most cases are diagnosed in the first year of life, presenting as bilateral abdominal masses.

Portrayed ?Polycystic: continued enlargement of the cysts often leads to progressive renal failure.

Carmen ?CT scanning: Enlarged kidneys with multiple bilateral cysts are diagnosed using ultrasound, IVP,

or CT scanning.Jones - Juvenile nephronophthisis (JN) and medullary cystic disease (MCD) are in the DDx.

-Cardiac valvular disorders: Mostly mitral valve prolapse (MVP) and aortic regurgitation-Salt-wasting nephropathy, renal tubular acidosis (RTA)-Chronic flank pain due to the mass effect of the enlarged kidneys

Lusty Carmen Jones powdered her nose, using her Bivalve [MVP] mirror compact, ¡¦-then she slowly raised her Salt-rimmed [Salt-wasting nephropathy] MargaRiTA [RTA], and seductively placed her other hand on her Hip [Flank pain].

-Hyperchloremic acidosis-Salt-wasting nephropathy causing hyponatremia

It was said that Dorothy was not allowed to swim in the hotels Chlorinated pool [Hyperchloremic acidosis]. When she defiantly swam in the pool, they Drained it [Salt-wasting nephropathy, Hyponatremia].

-Hypertension-End-stage renal disease (ESRD)

Dorothy was forced to enter through the back door, even while she was contracted to sing under The Big Tent [Hypertension].Dorothy was only 41 when she was found DEAD [ESRD].

Review:

Dx: Positive family history (autosomal dominant inheritance)Gross and microscopic hematuriaUltrasound, IVP, or CT scanning detect the enlarged kidneys with multiple bilateral cysts

References:

1. Harrison Principles of Internal Medicine, 14/e Edition, McGraw-Hill, New York, 1998.2. Bennett WM and Rose BD. Polycystic kidney disease, UpToDate v8.2, (Rose, BD, ed), UpToDate, Inc, Wellesley, MA, 2000.

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Renal Pathology Buzz words

Lupus = wire LOOP lesion (LUPUS=LOOP)

goodPASTURE = a pasture is FLAT so is the immunoflouresence for GP

Membraneous GN = spike and DOME appearance (think membrane = dome)(held up by spikes)

Membranoproliferative GN = M P GN = Tram Trackthink of MP's (military police riding on Trams)

Post streptococcal GN= Lumpy Bumpythink Strep aerobicsLumpy people Bumping around doing aerobics

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WBC Count

"Never Let Mom Eat Beans" and "60, 30, 6, 3, 1"

Neutrophils 60% Lymphocytes 30% Monocytes 6% Eosinophils 3% Basophils 1%

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Hem - PT, PTT: By M. Pereira (tufts.edu)

To remember the intrinsic and extrinsic pathways in relation to what blood test is affected:

PiTT (I for Intrinsic pathway) - PiTTsburghPeT (E for Extrinsic pathway)

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Vitamin K-dependent proteins and warfarin sodium [by Sung Kim and S. Levine, MD, PhD.]

Warfarin sodium is a vitamin K antagonist.

-Vitamin K-dependent proteins C and S.-Vitamin K-dependent clotting factors II, VII, IX, and X of the extrinsic pathway.

--> The Korean [vitamin K] War [Warfarin] was fought Outdoors [Extrinsic pathway].--> The American PT boats [PT, Protime, or prothrombin time], whose access had been limitedby the rough Seas [protein C], quickly sent out SOS [protein S] messages.

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Microcytic Anemia

"TICS"-

ThalasemiaIron deficiencyChronic diseaseSideroblastic anemia

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Eosinophilia

"NAACP"

N - NeoplasmA - AllergyA - Addison'sC - Cirrhosis, CVDP - Parasite (visceral larva migrans), Periarteritis nodosa

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Thalassemia major is the most Severe (c)-thalassemia [B-Beta-Bad].

-Major B-A-D M-A-F-I-A guys have the typical gangster appearance: Short [Microcytic hypochromic anemia] and Ugly [distortion of facial, skull, and long bones]

B-Basophilic stipplingA-Anemia, AnisocytosisD-Deferoxamine

M?MCV is lowA-HbA is decreasedF-HbF is increasedI-Ineffective erythropoiesisA?HbA2 is increased

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Cooley's anemia (beta-thalassemia major) is the homozygous state.

-The key is Denton A. Cooley, M.D., Texas Heart Institute (THI).

D-Deferoxamine therapy to prevent hemochromatosisA-Anemia - In beta-thalassemia major or intermedia, anemia is due to a combination of ineffective erythropoiesis and hemolysis of circulating cells.C-Congestive heart failure is a cause of death in the first years of life if the patient is not transfused.

M-MCV is low; Microcytic hypochromic anemiaD-Diagnosis, prenatal

T-Tower skull (also frontal bossing, chipmunk facies, and distortion of long bones)H-Hemolytic anemia with Hepatosplenomegaly in the first year of infant lifeI-Intermedia - Beta-thalassemia intermedia presents with abnormalities similar to those of thalassemia major.

Increased susceptibility to infections

Peripheral blood smear: Basophilic stippling Helmet cells Nucleated target cells Anisocytosis (RBCs of different size/volume)

X-ray: Hair-on-end skull

Serum hemoglobin electrophoresis: HbA is decreased.HbA2 is increased.HbF is increased

--> Dr. Cooley performed Major surgery [thalassemia Major] as a Cardiothoracic surgeon [Cardiac failure] live on the Internet [Infections].

--> His skilled hands can perform Microsurgery [Microcytic hypochromic anemia] on Fetuses [HbF].

--> His surgical cap [Helmet cells] fit loosely over his Crew cut [Hair-on-end skull].

--> He proceeded to make an incision along the Blue Stippled line [Basophilic Stippling] drawn on the skin.

--> Dr. Cooley's Target [Target cells] academic score had always been an A+ [HbA2 is increased].

--> He would Not accept a simple A [HbA is decreased].

--> The surgical staff is a close knit community, like a B-A-D M-A-F-I-A (see below), quick to

dispose of weak, Ineffective [Ineffective erythropoiesis] residency candidates.

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Disseminated intravascular coagulation (DIC) <== Click !

D-I-S-S-E-M-I-N-A-T-E-D

D-Dx: D dimerI-Immune complexes S-Snakebite, shock, heatstrokeS-SLEE-Eclampsia, HELLP syndromeM-Massive tissue damageI-Infections: viral and bacterialN-NeoplasmsA-Acute promyelocytic leukemiaT-Tumor products: Tissue Factor (TF) and TF-like factors released by carcinomas of pancreas, prostate, lung, colon, stomachE-Endotoxins (bacterial)D-Dead fetus (retained)

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Characteristic features of multiple myeloma on X-ray are ABCDE - Asymmetry, Border irregular, Colour irregular, Diameter usually > 0.5cm, Elevation irregular.

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Chronic lymphocytic leukemia (CLL) is a monoclonal malignancy, usually of B lymphocytes.

-Incidence: CLL is the most common adult leukemia in the United States.Males>Females50-70 years of age

Songwriter Phil CoLLins [CLL] is Male and probably over 50 years of age. He recently won anOscar for his "Tarzan" song.

Clinical and diagnosis

Lymphocytosis >15,000/mm3

Generalized lymphadenopathy

Tarzan can spring from Limb [Lymphocytosis] to Limb [Lymphadenopathy] above the tree tops¡¦Splenomegaly, hepatomegalyLow serum immunoglobulins (immunosuppression)

--> where the Splendid [Splenomegaly] Moonlight [imMunosuppression] streams through thebranches.

Diffuse bone marrow infiltration and replacement of cellular elements cause: AnemiaThrombocytopeniaGranulocytopenia

--> Walt Disney Pictures produced the Animated Animal [Anemia] adventure "Tarzan".

--> The "Tarzan" [Thrombocytopenia] song earned CoLLins an Oscar [Osteo, bone marrow failure]award for the best original song.

--> Tarzan had Little need for Plates [Platelets <100,000/¥ìL] in the jungle.

--> Phil CoLLins is a Grammy [Granulocytopenia] Award-winning singer and songwriter.

Occasionally extravascular hemolysis: warm-antibody autoimmune hemolytic anemia (AHA)

--> An African jungle [Autoimmune extravascular] APE [AHA] had Warmly [Warm-antibody]adopted baby Tarzan.

Differential diagnosis

Malignant lymphomaInfectious mononucleosis

--> Tarzan is Lord [Lymphoma] of the Jungle and friend of the Monkeys [Mononucleosis].

--> Phil CoLLins was born in London [Lymphoma].

Treatment

Chlorambucil (an alkylating agent), with or without prednisoneFludarabine

--> Some may imagine a Ram [ChloRambucil] scrambling about, but others will¡¦

--> recall that Clayton [Chlorambucil] is the villainous jungle guide who was hired byProfessor [Prednisone] Porter, not knowing that¡¦

--> ¡¦Clayton [Chlorambucil] had his captured Prey [Prednisone] immediately Flown[Fludarabine] out for profit.

References:

1. Harrison's Principles of Internal Medicine, 14/e Edition, McGraw-Hill, New York, 1998.2. Maximum access to diagnosis and therapy (MAXX), Lippincott Williams & Wilkins, New York, 1999.3. Scientific American Medicine (SAM-CD), Scientific American Inc, New York, 1997.

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Hodgkin's lyphoma classification - A = Asymptomatic, B = Bad.

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Risk of underlying malignancy with dermatomyositis or polymyositis is 30% at age 30, 40% at age 40 etc.

--------------------------------------------------------------------------------Malignant Monoclonal Gammopathies: Multiple myeloma

-The mnemonic key for multiple myeloma (MM) is Marilyn Monroe (MM), a key which immediately followsthe >> symbol.

-Clinical:

Weakness and fatigue due to normochromic normocytic anemia. >> MM's original name was Norma [Normochromic normocytic] Jean.

Bone pain and pathologic fractures: predominantly osteolytic tumors and osteoporosis.>> MM's name was illuminated in marquee Lights [osteoLytic], but she secretly longed foran Oscar award [Osteoporosis].

Susceptibility to bacterial infections.>> MM was Susceptible to Toxic [infections] relationships.

Acute renal failure (ARF) due to the effects of filtered light-chain proteins, hypercalcemia, and amyloid deposits in the kidney. >> MM's Lightly-Chained ARF dog barked when MM's death was said to be related to her JFK Army-Lord [Amyloid].

-Laboratory

Hypercalcemia

>> MM fluffed White Talcum [hypercalcemia] powder on her delicate white skin...

Hypergammaglobulinemia

>> ...to protect it from the movie industry's Large hot Camera lights[hyperGammaglob].

Serum electrolytes: Low anion gap>> MM wore gowns with Low [Low anion gap] revealing necklines.

Rouleaux on peripheral blood smear. Occasionally Coombs(+) hemolytic anemia.

>> MM used hair Rollers [Rouleaux] and Combs [Coombs] to create her famous hairdo.

Leukocyte alkaline phosphatase (LAP) staining reaction: High LAP score.

>> MM used her Great LAP to her advantage because....

Normal levels of Serum Alkaline Phosphatase (SAP)

>> ...she was Not a SAP.

References:1. Harrison's Principles of Internal Medicine, 14/e Edition, McGraw-Hill, New York, 1998.2. Maximum access to diagnosis and therapy (MAXX), Lippincott Williams & Wilkins, New York, 1999.3. Scientific American Medicine (SAM-CD), Scientific American Inc, New York, 1997.

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Antineoplastic agents & Adverse effects

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Male testicular tumors: "S-E-C sac T-I-C-S¡±

S-Seminoma: most commonE-Embryonal carcinomaC-Choriocarcinoma

Sac-Yolk sac tumor (endodermal sinus tumor)

T-Teratoma, Teratocarcinoma

I-C-Interstitial (Leydig) cell tumorS-Sertoli cell tumor__________________________________________________ __________________________________________

Paraneoplastic syndromes and their associated cancers:

Your diagnosis can be "Highly S-C-R-A-M-B-L-E-D."

Highly-Hypercalcemia (squamous cell carcinoma)

S-SIADH, hyponatremia (SCLC)C-Clubbing (adenocarcinomas)R-Retinal blindness (SCLC)A-ACTH (SCLC)M-Myasthenia gravis (thymoma)B-Bone - hyperosteoarthropathy (adenocarcinomas) L-Limbic encephalitis (SCLC)E-Eaton-Lambert myasthenic syndrome (SCLC)D-Dermatomyositis (cancer of the lung, ovary, breast, stomach; NHL)

SIADH: Syndrome of inappropriate antidiuretic hormone secretionSCLC: Small cell lung cancerNHL: non-Hodgkin's lymphoma

References:1. UpToDate v8.2, (Rose, BD, ed), UpToDate, Inc, Wellesley, MA, 2000.2. Scientific American Medicine (SAM-CD), Scientific American Inc, New York, 1997.

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Acute Rheumatic Fever

There are several for the major criteria, I use "JONES"

J - JointsO - Obvious (cardiac) - sorry, I know this is kinda weakN - Nodules (subcutaneous nodules)E - Erythema marginatumS - Syndeham's Chorea

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Kawasaki's

"scream fever"

S - sausage fingersC - conjunctival rednessR - rashE - extremity involvementA - adenopathyM - mucosal erythemaFEVER - fever

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Causes of post op fever

Remember the following mnemonic when determining the possible cause(s) of fever in a patient who has recently undergone a surgical procedure: the 5 W's (or 6 W's)

Wind : the pulmonary system is the primary source of fever in the first 48 hours. ( Atelectasis, pneumonia ect.)Wound : there might be an infection at the surgical site.Water : check intravenous access site for signs of phlebitis. Walk : deep venous thrombosis and pulmonay embolism can develop due to pelvic pooling or restricted mobility Whiz : a urinary tract infection is possible if urinary catheterization was required.

Also Wonder drugs - drug fevers. (added by Calvin Lee)

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Classification of hypersensitivity reactions

"ACID"

Type I AnaphylaxisType II Cytotoxic - mediatedType III Immune - complexType IV Delayed hypersensitivity

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Criteria for Lupus

SOAP BRAIN MD

Serositis (pleuritis, pericarditis)Oral UlcersArthritisPhotosensitivity

Blood (all are low - anemia, leukopenia, thrombocytopenia)Renal (protein)ANAImmunologic (DS DNA etc.)Neurologic (psyc, seizures)

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Risk of underlying malignancy with dermatomyositis or polymyositis is 30% at age 30, 40% at age 40 etc.

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Blue Sclera: "MIXED"

M = Marfans , I = Imperfecta ( Osteogenesis ) XE =(pseudo) Xanthoma elasticum ED = Ehlers Danlos

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Altered Mental Status

"AEIOU TIPS"

A - Alcohol/drugsE - EndocrineI - InsulinO - OpiatesU - Uremia

T - Toxins/traumaI - InfectionsP - Psych/porhyriaS - SAH, shock, stroke, seizure, space occupying lesion

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MIDAS : States to exclude as cause of coma.

Meningitis

Intoxication

Diabetes

Air - respiratory failure

Subdural or subarachnoid hemorrhage.

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Level of consciousness

"AVPU"

A - alertV - resonds to verbal stimuliP - responds to painful stimuliU - unconscious

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Vertebral/Basilar Ischemia

4Ds

dizziness (nystagmus)diplopia (skew deviation)dysarthriadysphagia

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Cerebellar lesions lead to VANISHeD - Vertigo, Ataxia, Nystagmus, Intention tremor, Slurred speech, Hypotonic reflexes, Dysdiadochokinesia. ( or Dementia )

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Marcus Gunn Pupil

Marcus Welby, M.D. "knows". Robert Young was also in "Father Knows Best".

D-R K-N-O-W-S

D-Deafferentation of the pupillary light reflexR-Retrobulbar optic neuritis

K-Kan't kick inward: afferent limb defectN-No constriction to direct light stimulationO-Optic nerve (CN II) damaged unilaterallyW-swinging flashlight testS-consensual reflex intact

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Subarachnoid hemorrhage (SAH): Rupture of an aneurysm releases blood directly into the cerebrospinal fluid (CSF) under arterial pressure.

Clinical manifestations:

CSF ~ FDR

F-D-R's Last Words: O! CAN'T W-H-I-P 'E-M

F-Focal signs: limb weakness, dysphagia, CN III palsyD-Depression of consciousness with headacheR-Retinal (subhyaloid) hemorrhage

Last-Lucidity with headache is the usual pattern of onset.

Words-Warning leak sign of impending rupture (controversial sign).

O-(looks like eyes) CN III palsy

Can't extend knees (Kernig's sign)

W-circle of WillisH-Headache: sudden onset of severe headache ("the worst headache of my life")I-Increased ICPP-Papilledema

E-Epileptic seizuresM-Meningismus

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Subarachnoid hemorrhage : Ruptured berry aneurysm

A-Adult polycystic kidney disease, Anterior communicating arteryB-Berry aneurysmC-Circle of WillisD-Danlos-Ehlers and Marfan's syndromes

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Causes of Syncope: F-A-D-E-O-U-T

F-Faint simple vasovagal faintingA-Arrhythmia causing cardiac syncopeD-Drugs: alcohol, illicit drugs, nitrates, antihypertensives, sympathetic blockersE-Eyeball pressureO-Orthostatic hypotension: dysautonomiasU-Undiagnosed seizuresT-Takayasu's arteritis: reduced cerebral blood flow due to involvement of the carotid and vertebral arteries.

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Causes of Vertigo: revolving, P-I-V-O-T-I-N-G M-E-N

P-Petrositis, benign Positional vertigoI-Ischemic attacks: transient vertebrobasilar ischemic attacksV-Vestibular neuronitisO-Other Otogenic causes: Otosclerosis, herpes zoster Oticus, Obstructed external auditory canalT-Tumors of the middle ear, labyrinth, pons, cerebellopontine angle, CN VIIII-Internal auditory artery occlusionN-Neuronitis: acute vestibular neuronitisG-Giant cell arteritis - internal auditory artery occlusion

M-Meniere's diseaseE-Ear: otitis media, labyrinthitis, barotraumaN-Neuromas: acoustic neuromas

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Headache: S-T-O-I-C M-P

S-Sentinel headache that precedes a major subarachnoid hemorrhage (SAH)T-Temporomandibular joint dysfunction, Tension-type headache, TumorsO-Other: pressure, traction, or displacement of extracerebral structures.I-Indomethacin-responsive headacheC-Cluster headache

M-Meningitis, Migraine headacheP-Posttraumatic headache, Paranasal sinuses

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Intracerebral hemorrhage: T-I-P Ur H-A-T to M-Ds

T-TraumaI-IdiopathicP-Penia ? thrombocytopenia

Ur-Vasculitis

H-HypertensionA-Amyloid angiopathyT-Tumors associated with bleeding

M-Malformations: AVD-blood Dyscrasias

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Subdural hemorrhage: subconsciously dying¡±-Elderly-Slowly dying-Alcohol-Brain injury

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Cerebrovascular I-N-F-A-R-C-T-S

I-Infections: septic heart valve vegetationsN-Neoplasms; Nonbacterial thrombotic endocarditisF-Fracture of the long boneA-Atherosclerosis, Atrial fibrillation-related emboli R-Reperfusion -> infarct -> hemorrhageC-Carotid atheromas or mural thrombiT-Thrombotic occlusionsS-Sylvan fissure: MCA is a particularly common site.

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Lacunar infarct: "Lacunar" from the Latin for G-A-P or- D-I-S-P-A-R-I-T-Y

G-deep Gray matter: basal gangliaA-AtherosclerosisP-hyPertension

D-Dysarthria and a contralateral clumsy hand or arm due to infarction in the base of the pons or in the genuof the internal capsule. (20%)I-Internal Capsule: Lacunae in the posterior limb of the Internal capsule may cause pure motor hemiplegia involving the face, arm, leg, foot. (60%)S-Subcortical, capsular, or thalamic lacunaeP-Pontine lesionsA-Ataxic hemiparesis due to an infarct in the base of the ponsR-Rare: Lacunae in the anterior limb of the Internal capsule may cause severe dysarthria

with facial weakness.I-Ipsilateral ataxia (arm/leg) with leg weakness: Pontine lesion (rare)T-Thalamus: Lacunae in the Thalamus may cause pure sensory stroke (10%)y-V-Ventrolateral Thalamic lacunae

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Anterior cerebral artery (A*C*A) occlusion:

*C*-Contralateral Crural (leg) monoplegia*C*-Crest of Cerebral hemispheres and medial hemispheric walls represent the leg area of the motor strip__________________________________________________ __________________________________________

Middle cerebral artery (MCA) occlusion: "Difficulty with A-B-Cs in M-C-A"

A-ApraxiaB-Blindness in corresponding half of the visual field (contralateral homonymous hemianopsia)C-Contralateral Clumsiness of arm, face. -- Leg is somewhat spared.

M-Memorization difficultiesC-Calculation difficultiesA-Aphasia with language-dominant hemispheral involvement

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Posterior cerebral artery (PCA) occlusion: P-O-S-T

P-Proximal fling movementsO-Occipital lobe infarction results in contralateral homonymous hemianopsia which may be completeS-Speech and Spelling maintained, but unable to read fluentlyT-Thalamic syndrome

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A well-known mnemonic regarding occlusion of the vertebral-basilar circulation: 4D

-Dizziness-Diplopia-Dysarthria-Dysphagia

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Types of Stroke

Stroke "H-I-T" you!

H-HemorrhagicI-Ischemic

T-TIA (Transient Ischemia Attack)

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T.I.A (Transient Ischemic attack)

Patients often describe it as a shade being pulled over their eyes: S-H-A-D-E-D

S-Sensory loss; TIA may herald a strokeH-Hypertension, HyperlipidemiaA-Amaurosis fugax (transient monocular blindness)D-DDx: seizures, neoplasms, migraine, vertigoE-Extrinsic factor is monitored for warfarin administration; E-EndarterectomyD-Diabetes

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Root values of reflexes are 1,2,3,4,5,6,7,8 - S1-2 ankle, L3-4 knee, C5-6 biceps/supinator, C7-8 triceps.

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Argyle Robertson Pupil

Accomodation Reflex Present - Pupillary Reflex Absent.

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Neurosyphilis

-Symptomatic Neurosyphilis: The small, irregular Argyll Robertson pupil reacts to accommodation butnot to light. -Tabes dorsalis:Argyl-Robertson Pupil (ARP) in syphlis - Accomodation Reflex Present (ARP)but the light reflex is absent, so ARP=ARP.-General paresis: P-A-R-E-S-I-S*P-PersonalityA-AffectR-Reflexes are hyperactiveE-Eye: Argyll Robertson pupilsS-Sensorium: illusions, delusions, hallucinations I-Intellect: decrease in recent memory, orientation, calculationsS-Speech

Reference:

*From Harrison Principles of Internal Medicine, 14/e Edition, McGraw-Hill, New York, 1998.

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Pattern of Weakness in UMN lesions

FLUE weakness FUELs Contractures F=Flexion,L=Lower Limb,U=Upper Limb E= Extensors

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Normal Pressure Hydrocephalus

Demented (Memory Loss) Dribbles (Urinary Incontinence) Disbalanced (Gait disorder)

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TRAP to identify parkinson's disease

Tremor at rest (pill-rolling tremor)

Rigidity

Akinesia

Posture typical of a Parkinson's patient

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Radiopaque Ingestants

"Chipes"

C - Cocaine condoms/ chloral hydrate/ calciumH - Heavy metalsI - Iron/ iodidesP - Psychotropics (TCA, phenothiazines)E - Enteric coated/BAS - Solvents (CCl4)

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Drugs that can go into an ET tube

"lane"

L - lidocaineA - atropineN - naloxoneE - epi

Some like NAVEL, which includes Valium. Others have commented that valium should not go in an ET tube.

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Concretions:

"Big Mess" B - BarbituatesI - IronG - Glutethemide M - MeprobamateE - Extended release theophyllineSS - Salicylates