(1)Hi
gh
Yi
el
d In
ternal
Medi
ci
ne
Shel
f Ex
am R
evi
ew
Emm
a Hol
lida
y
Ramahi
ƉĂ
ƚŝ
ĞŶ
ƚ
ĐŽŵĞ
Ɛŝ
Ŷǁŝ
ƚŚ
ĐŚĞƐ
ƚƉĂŝ
Ŷ͙
Bes
t 1
st tes
t
=
EK
G
If 2m
m
ST el
ev
ati
on o
r ne
w
LBB
B
(
wi
de, fl
at QR
S)
Æ
STE
M
I
ST e
le
va
ti
on
imme
di
at
el
y,
T
w
av
e i
n
ver
si
o
n
6hr
s-‐
year
s,
Q
w
av
es
las
t
fo
re
ver
Eme
rg
enc
y
reperfusi
o
n
-‐
go
t
o
c
ath
lab or *
thr
o
mbol
yti
cs
if
no
co
n
tr
ai
ndi
ca
ti
ons
Ri
gh
t v
en
tri
cul
ar i
n
far
ct
-‐
Sx
s
ar
e
h
ypot
ensi
on, t
ach
yc
ar
di
a,
cl
ear
lungs,
JVD
, and NO
pul
sus
par
ado
xus
͘KE͛
d
Őŝ
ǀĞŶŝ
ƚƌ
Ž
͘Tx
w/
vi
go
ro
us
fl
ui
d r
esus
ci
ta
ti
on.
An
terio
r
LAD
V1
-‐V4
La
te
ral
Ci
rc
um
fl
ex
I,
avL
, V4
-‐V6
In
fe
rior
R
CA
II,
III
and
aVF
R
ve
n
tricu
lar
R
CA
V4 on
R
-‐si
ded
EK
G
is
100%
sp
eci
fi
c
Ne
xt bes
t t
es
t =
cardi
ac
enzym
es
If el
ev
at
ed
Æ
NS
TEM
I.
Check
enz
ymes
q8hr
s
x 3
.
Tx
w/
morphi
ne,
o
xy
gen,
ni
tr
at
es,
as
pi
ri
n/
cl
opi
dogr
el
, and b
-‐bl
ock
er
Do
C
OR
ON
A
R
Y
ANG
IOG
RA
PH
Y
w/i
n 48hr
s
to
de
termi
ne
nee
d
for
in
ter
ven
ti
on.
PC
I w/
st
en
ti
ng
is s
tandar
d.
CAB
G
if:
L
mai
n
dz
, 3 v
ess
el
dz
(2 v
ess
el
dz
+
DM),
>70%
o
cc
lusi
o
n,
pai
n
despi
te
ma
xi
mu
m
medi
cal
tx
, o
r pos
t-‐
in
far
ct
ion angi
na
Di
scharge
meds
= a
spi
ri
n
(+
cl
opi
dogr
el
fo
r
9
-‐12mo
if s
ten
t
pl
aced)
B
-‐bl
ock
er
A
CE
-‐i
nhi
bi
to
r
if
CHF
o
r L
V
-‐dy
sfxn
St
ati
n
Shor
t
acti
ng
ni
tr
at
es
My
oglo
b
in
Ri
se
s
1
st
Pea
ks
in
2hr
s,
nl
by
24
C
KMB
R
ise
4
-‐8hr
s
Peak
s
24
hr
s,
nl
b
y
72hs
Tr
op
on
in
I
Ri
se
3
-‐5hr
s
Pea
ks
24
-‐48hr
s,
nl
b
y 7
-‐10da
ys
If
no
ST
-‐Ğů
Ğǀ
Ăƚŝ
ŽŶ
ĂŶĚ
ŶŽƌ
ŵĂů
Đ
Ăƌ
Ěŝ
ĂĐ
ĞŶnj
LJŵ
ĞƐ
džϯ͙
Di
agnosi
s
is uns
tabl
e
angi
na.
W
ork up
-‐
±
Ex
er
ci
se
EK
G:
av
oi
d b
-‐bl
ock
er
s
and CC
B
be
for
e.
±
ĂŶ͛ƚ
ĚŽ
<
'Ɛ
ƚƌ
ĞƐƐƚ
ĞƐ
ƚ
ŝĨŽ
ůĚ>
Žƌ
ďĂƐĞů
ŝŶĞ^
d
Ğů
Ğǀ
Ăƚŝ
Ž
Ŷ
or
on Di
go
xi
n.
Do Ex
er
ci
se
Echo
ins
tea
d.
±
/Ĩ
Ɖ
ƚĐ
ĂŶ͛ƚ
Ğdž
Ğƌ
Đŝ
ƐĞ
-‐
do chemi
cal
s
tr
ess t
es
t
w/
dobut
ami
ne
or
adenosi
ne.
±
MUG
A
is nucl
ea
r
medi
ci
ne
tes
t
tha
t
sho
w
s
per
fusi
on
of
ar
ea
s
of the heart.
A
voi
d c
af
fei
ne
o
r theoph
yl
ine
be
for
e
±
Pos
iti
ve
if ches
t
pai
n i
s r
epr
od
uced, S
T
depr
essi
o
n, or
h
ypot
ensi
on
Æ
on t
o c
or
onar
y
angi
ogr
aph
y
Pos
t-‐
MI
compl
ic
ati
ons
MC c
ause
of
dea
th?
Ne
w
sy
st
ol
ic
mur
mur
5
-‐7
da
ys
s/p?
Acut
e
se
ver
e
h
ypot
ensi
on?
͞Ɛ
ƚĞƉ
ƵƉ͟ŝ
Ŷ
KϮ
conc
fr
om
RA
Æ
R
V?
Per
si
st
en
t
ST el
ev
ati
on
~1mo
la
ter
+ s
ys
tol
ic
MR
murmur
?
͞ĂŶŶŽŶ
-‐ǁ
Ăǀ
ĞƐ͍͟
5
-‐10wk
s
la
ter
pl
eur
iti
c
CP
,
low
gr
ade t
emp?
Arrh
ythmi
as
. V
-‐fi
b
Papi
llar
y
muscl
e
rup
tur
e
V
en
tri
cu
lar
fr
ee w
al
l rup
tur
e
V
en
tri
cu
lar
sep
tal
rup
tur
e
V
en
tri
cu
la
r w
al
l aneu
ry
sm
AV
-‐di
ss
oci
ati
on.
Ei
ther V
-‐fi
b
or 3
rd
deg
ree
heart b
lock
ƌ
ĞƐƐ
ůĞ
ƌ͛
Ɛ
ƐLJŶ
Ěƌ
ŽŵĞ
͘;Ɖ
ƌŽďĂď
ůLJͿ
aut
oi
m
mune
peri
car
di
ti
s.
Tx
w/
NS
AID
s
and
aspi
ri
n.
LJŽƵŶŐ
͕ŚĞĂů
ƚŚ
LJ
ƉĂ
ƚŝ
ĞŶ
ƚ
ĐŽŵĞƐ
ŝŶ
ǁŝ
ƚŚ
ĐŚĞƐ
ƚ
ƉĂŝ
Ŷ
͙
If w
o
rse
w/
inspi
ra
ti
on,
be
tt
er
w/
leani
ng
fo
rw
ar
ds,
fri
cti
o
n rub
&
di
ffus
e S
T
el
ev
ati
on
Æ
peri
car
di
ti
s
If
w
or
se w/
pal
pa
ti
on
Æ
cos
tochondri
asi
s
If
vague
w/
hx
of v
ir
al
in
fxn
and murmur
Æ
m
yoc
ar
di
ti
s
If
occur
s
at
res
t, w
or
se
at
ni
gh
t, f
ew
CA
D
ri
sk
fac
tor
s
and
mi
gr
ai
ne
headac
hes, w/
tr
ansi
en
t
ST
el
ev
ati
o
n duri
ng
epi
sodes
Æ
Wƌŝ
ŶnjŵĞ
ƚĂů
͛Ɛ
angi
na
±
Dx
w/
er
gono
vi
ne
sti
m
tes
t.
Tx
w/ CCB
or ni
tr
at
es
(8)EK
G
Buzz
w
or
ds
im
g.m
ed
sc
ap
e.c
o
m
/...
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392
-‐8
90
621
-‐3
20
6.j
p
g
ht
tp://w
ww.
isp
ub
.c
o
m
/i
sp
ub
/i
jpn
/vo
lum
e_
4_
nu
m
be
r_
1_
43/an_
u
nu
su
al
_c
au
se
_
o
f_
se
iz
ur
e
s_
in_
a_
10_
ye
ar
_o
ld/s
ei
zur
es
-‐f
ig
1.jpg
ht
tps
://
te
ac
h.l
an
ec
c.e
du
/br
o
kawt
/MAT
4.jpg
͞Wƌ
ŽŐƌ
ĞƐ
Ɛŝ
ǀĞ͕
Ɖƌ
Žů
ŽŶŐ
Ăƚŝ
ŽŶ
ŽĨ
the PR
in
ter
val
f
ol
lo
w
ed
b
y
a
Ěƌ
ŽƉƉĞ
Ěď
ĞĂ
ƚ͟
Can
non
-‐a w
av
es
on
ph
ysi
cal
e
xam.
͞ƌ
ĞŐ
Ƶů
Ăƌ
W
-‐P
in
ter
val
and
r
eg
ul
ar R
-‐R
ŝŶ
ƚĞƌ
ǀĂů
͟
͞ǀ
ĂƌƌLJ
ŝŶŐ
W
Z
ŝŶ
ƚĞƌ
ǀĂů
ǁŝ
ƚŚ
ϯ
Žƌ
mor
e
morphol
ogi
cal
ly
di
sti
nct
W
ǁ
Ăǀ
ĞƐ
ŝŶ
ƚŚĞ
ƐĂ
ŵĞ
ůĞĂ
Ě͟
͘
See
n
in
an
ol
d
per
son w/
chr
oni
c
lun
g
dz
in
pe
nd
ing
res
pi
ra
tor
y
fai
lur
e
www
.e
m
edu
.or
g/e
cg
/i
m
ag
es/wpw_
3a.jpg
www
.e
m
edu
.or
g/e
cg
/i
m
ag
es/wpw_
3a.jpg
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ĞĞ
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Ğ
ĐŽŶƐ
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Z
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ǀĂů
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ǁ
ĞĚ
ď
LJYZ
^
хϭϮϬŵƐ
ǁŝ
ƚŚ
Ă
Ɛů
Ƶƌƌ
ĞĚ
ŝŶŝ
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ĚĞ
Ĩů
ĞĐƚ
ŝŽŶ
ƌĞƉ
ƌĞƐ
ĞŶ
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LJ
ǀĞŶ
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ĞŶ
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͘
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ĞŐ
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Ăƌƌ
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LJƚŚŵǁŝ
ƚŚ
Ă
ǀĞŶ
ƚƌ
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Ƶů
Ăƌƌ
Ăƚ
Ğ
ŽĨϭϮϱ
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bp
m an
d
atr
ial
r
at
e
of
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ŵ͟
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ƌŽů
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ĞĚ
Y
dŝ
Ŷ
ƚĞƌ
ǀĂů
ůĞĂ
Ěŝ
ŶŐ
ƚŽ
un
du
la
ti
ng
r
ot
ati
on
of the
QR
S
ĐŽŵƉů
Ğdž
Ăƌ
ŽƵŶĚ
ƚŚĞ
<
'
ďĂƐ
Ğů
ŝŶĞ
͟/
ŶĂ
p
t w/
lo
w
Mg
and
lo
w
K. Li
or
TCA OD
im
g.m
eds
cap
e.c
o
m
/pi
/e
m
ed/c
kb/e
m
er
ge
nc
y_
m
edi
ci
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m
edu
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g/e
cg
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m
ag
es/k
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www
.am
bu
lan
ce
te
chn
ic
ian
st
ud
y.c
o
.uk
/i
m
ag
es/SVT
.g
if
www
.am
bu
lan
ce
te
chn
ic
ian
st
ud
y.c
o
.uk
/i
m
ag
es/SVT
.g
if
͞Z
ĞŐ
Ƶů
Ăƌƌ
Ś
LJƚŚŵǁͬ
Ă
ra
te
b
tw
n
150
-‐ϮϮϬďƉŵ
͘͟
Sud
de
n on
set
of
pal
pi
ta
ti
ons
/di
zz
ine
ss
.
Z
ĞŶĂů
Ĩ
Ăŝ
ůƵƌ
Ğ
ƉĂ
ƚŝ
ĞŶ
ƚͬ
ĐƌƵƐŚ
ŝŶũƵƌ
LJͬďƵƌŶ
ǀŝ
Đƚŝ
ŵ
ǁͬ
͞ƉĞ
ĂŬ
ĞĚd
-‐w
av
es
, wi
den
ed
QR
S,
short
Q
T
ĂŶĚ
Ɖƌ
Žů
ŽŶŐ
ĞĚ
W
Z
͘͟
͞ů
ƚĞƌŶĂ
ƚĞďĞ
Ăƚǀ
Ăƌŝ
Ăƚŝ
ŽŶŝ
Ŷ
Ěŝ
ƌĞĐƚ
ŝŽŶ͕
ĂŵƉů
ŝƚƵĚĞ
ĂŶĚ
ĚƵƌ
Ăƚŝ
ŽŶ
ŽĨƚŚĞ
YZ
^Đ
ŽŵƉů
Ğdž
͟ŝ
Ŷ
Ă
pa
ti
en
t
w/
pu
lsu
s
par
ado
xus
, h
ypot
en
si
on,
di
st
an
t hea
rt
sou
nd
s, JVD
͞hŶĚƵů
Ăƚŝ
ŶŐ
ďĂƐ
Ğů
ŝŶĞ͕
ŶŽƉ
-‐
w
av
es
app
reci
at
ed
, i
rr
eg
ul
ar
R
-‐R
ŝŶ
ƚĞƌ
ǀĂů
͟ŝ
Ŷ
ĂŚ
LJƉĞ
ƌƚ
Ś
LJƌ
Žŝ
Ě
Ɖ
ƚ͕
Žů
Ě
p
t w/
SOB/d
izz
ine
ss
/pa
lpi
ta
ti
ons
w/ CHF
or
val
ve
dz
Murmur Buzz
w
or
ds
SEM
cr
esc
/decr
esc
, l
ouder
w/
squa
tti
ng
, sof
ter
w/
val
sa
lv
a.
+
par
vus
et
tar
dus
SEM
louder
w/
val
sal
va
, soft
er
w/
squa
tti
ng
or handgri
p.
La
te
sy
st
ol
ic
murmur
w/ cl
ick
louder
w/
val
sa
lv
a
and
handgri
p,
sof
ter
w/ sq
ua
tti
ng
Hol
o
sy
st
ol
ic
murmur
r
adi
at
es
to a
xi
lla
w/ LAE
Aorti
c
St
enosi
s
HOCM Mi
tr
al
V
al
ve Pr
ol
ap
se
Mi
tr
al
R
egur
gi
ta
ti
o
n
Mor
e
Murmur
s
Hol
os
ys
tol
ic
mur
mur
w/
la
te
di
as
tol
ic
rumbl
e
in ki
ddos
Con
ti
nuous
machi
ne
lik
e
mur
mur
-‐
Wi
de
fi
xed and
spl
it S2
-‐
Rumbl
ing d
ias
tol
ic
murmur
wi
th
an
openi
ng snap,
LAE and
A
-‐fi
b
Bl
o
wi
ng
di
as
tol
ic
murmur
wi
th
wi
dened
pul
se
pr
essur
e
and
epon
ym
par
ade.
V
SD
PD
A
ASD
Mi
tr
al
St
enos
is
Aorti
c
R
egur
gi
ta
ti
o
n
A
pa
ti
en
t
comes i
n wi
th short
ness of
ďƌ
ĞĂ
ƚŚ͙
car
di
ac
or
pul
monar
y
?
If
y
ou sus
pect
PE (hi
st
or
y
of c
ancer
, sur
ger
y
or
lot
s
of but
t
si
tti
ng)
Æ
hepari
n!
Check
O2
sa
ts
Æ
gi
ve O
2
if
<90%
If
si
gns
/sx
s
of pneumoni
a
Æ
get a
CXR
If
mu
rmur
pr
esen
t
or h
is
tor
y of
CHF
Æ
ge
t
echo
to
check
ej
ect
ion
fr
act
ion
For
acut
e
pul
monar
y
ede
ma
Æ
gi
ve
ni
tr
at
es,
lasi
x
and
morphi
ne
If
y
oung
w/
sx
s
of CHF
w/ pri
o
r
hx
of vi
ral
in
fx
Æ
consi
der
m
yoc
ar
di
ti
s
(Co
xsacki
e
B).
If
p
t
is y
oung and
no
car
di
omeg
al
y
on CXR
Æ
consi
der
pri
mar
y
pHTN
±
Ri
gh
t heart
ca
th
can
tel
l CHF
fr
om
pul
monar
y
HTN (ho
w?)
CHF
Sy
st
ol
ic
-‐
decr
eased
EF (<55%)
±
Is
che
mi
c,
di
la
ted
Vi
ral
, E
TOH,
c
oc
ai
ne,
Chag
as
, Idi
opa
thi
c
Al
cohol
ic
di
la
ted
car
di
om
yopa
th
y
is
r
ev
er
si
bl
e
if y
ou
st
op
the
boo
ze.
Di
as
tol
ic
-‐
ŶŽƌŵĂů
&
͕ŚĞĂƌƚ
Đ
ĂŶ͛ƚĨŝ
ůů
±
HTN, am
yl
oi
dos
is,
hem
ac
hr
oma
tosi
s
Hem
ach
roma
tosi
s
res
tri
cti
ve
car
di
om
yopa
th
y
is
r
ev
er
si
bl
e
w/
ph
le
bot
om
y.
Tx
-‐
±
A
CE
-‐I
impr
o
ve
sur
vi
val
-‐
pr
ev
en
t
rem
odel
ing b
y
al
do
.
±
B
-‐bl
ock
er
(met
opr
ol
o
land
car
vel
di
lol
)
impr
o
ve sur
vi
val
-‐
pr
ev
en
t r
em
odel
ing
b
y
epi
/nor
epi
±
Spi
ron
ol
act
on
e
-‐
impr
o
ves su
rvi
val
in N
YHA cl
ass
III
and I
V
±
Fur
osemi
de
-‐
impr
o
ves
sx
s
(S
OB
, cr
ac
kl
es,
ede
ma)
±
Di
go
xi
n
-‐
dec
rea
ses
sx
s
and hospi
tal
iz
ati
ons.
NO
T sur
vi
val
CXR Buz
zw
or
ds
ac
ut
em
ed.c
o
.uk
͞KƉĂĐŝ
Ĩŝ
ĐĂ
ƚŝ
ŽŶ͕
ĐŽŶƐ
Žů
ŝĚĂ
ƚŝ
ŽŶ͕
Ăŝ
ƌďƌ
ŽŶĐ
ŚŽŐƌ
ĂŵƐ͟
͞Ś
LJƉĞ
ƌů
ƵĐĞŶ
ƚů
ƵŶ
Ő
Ĩŝ
Ğů
ĚƐ
ǁŝ
ƚŚĨů
Ăƚ
ƚĞŶĞ
Ě
Ěŝ
ĂƉŚƌ
ĂŐŵƐ
͟
h
m
c.p
su
.e
d
u
www
.m
edd
ean
.luc
.e
du
/.
..
/H
ear
t/Ds
cn0008a.jp
g
͞Ś
ĞĂ
ƌƚ
хϱϬй
W
di
ame
ter
, c
ep
hal
iz
ati
on,
K
erl
y B
li
ne
s
&
in
ter
sti
ti
al
ĞĚ
ĞŵĂ
͟
www
.m
edd
ean
.luc
.e
du
͞Ă
ǀŝ
ƚLJ
ĐŽŶ
ƚĂŝ
Ŷŝ
ŶŐ
ĂŶ
Ăŝ
ƌ-‐
Ĩů
Ƶŝ
Ěů
Ğǀ
Ğů
͟
h
tt
p
://e
n
.wi
ki
p
ed
ia.o
rg
/wi
ki
/
͞hƉƉ
Ğƌ
ůŽďĞ
Đ
Ăǀŝ
ƚĂ
ƚŝ
ŽŶ͕
ĐŽŶƐ
Žů
ŝĚĂ
ƚŝ
ŽŶ
+/
-‐
Śŝ
ůĂƌ
ĂĚĞ
ŶŽƉĂƚ
Ś
LJ͟
͞dŚŝ
ĐŬ
ĞŶ
ĞĚ
ƉĞ
ƌŝ
ƚƌ
ĂĐŚĞĂů
str
ipe
an
d s
pl
ay
ed
ĐĂƌŝ
ŶĂ
ďŝ
ĨƵƌ
ĐĂ
ƚŝ
ŽŶ͟
Pl
eur
al
E
ffusi
on
s
Pl
eu
ral
E
ffusi
ons
Æ
see
fl
ui
d >
1cm on
la
t
de
cu
Æ
thor
acen
tesi
s!
±
If
tr
ansuda
ti
ve
, l
ik
el
y
CHF
, nephr
oti
c,
ci
rr
hoti
c
If l
o
w pl
eu
ral
gl
uc
o
se?
If h
igh
lym
phocy
tes?
If bl
oo
dy?
±
If
ex
uda
ti
ve,
lik
el
y
par
apneumoni
c,
cancer
, e
tc.
±
If
com
pl
ic
at
ed
(+ gr
am
or cx,
pH <
7.2,
gl
c
< 60):
Insert c
hes
t tube
fo
r dr
ai
nag
e.
±
>ŝ
ŐŚ
ƚ͛
Ɛ
ƌŝ
ƚĞƌŝ
Ă
Æ
tran
suda
ti
ve
if:
nc
bi
.nl
m
.ni
h.g
o
v
LDH
<
20
0
LDH
ef
f/
ser
um < 0
.6
Pr
ot
ei
n e
ff/
se
rum
< 0.5
Rh
euma
toi
d
Arthri
ti
s
Tubu
rcul
osi
s
Mal
ignan
t
or
Pul
m
onar
y
Embol
us
Pul
mon
ar
y
Embol
ism
Hi
gh
ri
sk a
ft
er
sur
gery
, l
ong c
ar
ri
de
, h
ype
r
coagul
abl
e
st
at
e
(c
ancer
, ne
phr
oti
c)
±
Sxs
=
pl
euri
ti
c
ches
t
pai
n, hemo
p
ty
si
s,
tach
ypnea
Dec
r
pO2,
tach
yc
ar
di
a.
±
Random
si
gns
= ri
gh
t heart
s
tr
ai
n
on EK
G,
si
nus
tach
,
decr
vascul
ar
marki
ngs
on CXR,
w
edg
e
in
far
ct,
ABG
w/
lo
w C
O2
and
O2.
±
If
suspect
ed,
gi
ve
hepari
n
1
st
!
Then
w
ork up
w/ V
/Q
sc
an,
then
spi
ral
C
T.
Pul
mo
nar
y
angi
ogr
aph
y
is
gol
d
st
andar
d.
±
Tx
w/ hepari
n
w
arf
ari
n o
verl
ap.
Use
thr
om
bol
yt
ics
if
se
ver
e
but
NO
T
if
s/p
sur
ger
y
or hemorrhagi
c
str
ok
e.
Sur
gi
cal
thr
om
bect
om
y
if
lif
e
thr
ea
teni
ng.
IV
C
fi
lt
er
if
con
tr
ai
ndi
ca
ti
ons
to c
hr
oni
c
coagul
ati
on.
do
wnl
o
ad
.im
ag
ing
.c
o
ns
ul
t.c
o
m
/.
..
/g
r1
-‐m
idi
.jpg
ARDS
Pa
thoph
ys
: i
n
fl
amma
ti
on
Æ
imp
ai
red
gas
xchang
e,
in
fl
am
medi
at
or r
el
ease,
h
ypo
xemi
a
Causes:
±
Sep
si
s,
gas
tri
c
aspi
ra
ti
on,
tr
auma,
lo
w perfusi
on,
pancr
ea
ti
ti
s.
Di
agnosi
s:
Tr
ea
tmen
t:
www
.isp
ub
.c
o
m
/.
..
/ar
ds
3_
thu
m
bn
ai
l.g
if
1.)
PaO2/
Fi
O2
< 200
(<30
0
m
eans
acut
e l
ung
injur
y)
2.)
Bi
la
ter
al
al
veol
ar
in
fi
ltr
at
es
on CXR
3.)
PCWP
is
<18 (means pul
monar
y
edema i
s
non
car
di
og
eni
c) m
echani
cal
v
en
ti
la
ti
o
n
w
/ P
EE
P
PFT
s
Ob
structi
ve
R
e
strictiv
e
Ex
amp
les
As
thma
C
OP
D
Emph
yse
ma
In
ter
sti
ti
al
lun
g
dz
(sa
rc
oi
d
,
si
lic
osi
s, asb
es
tosi
s.
Str
uct
ur
al
-‐
su
pe
r obes
e,
MG/
ALS, phr
en
ic
ne
rv
e
par
al
ysi
s,
sc
ol
iosi
s
FV
C
љ
<80%
pr
ed
ic
ted
љ
<80%
pr
ed
ic
ted
FEV1
љ
<80%
pr
ed
ic
ted
љ
<80%
pr
ed
ic
ted
FEV1/FV
C
љ
<80%
pr
ed
ic
ted
Normal
TL
C
ј
хϭϮϬй
Ɖƌ
ĞĚ
ŝĐ
ƚĞĚ
љ
<80%
pr
ed
ic
ted
RV
ј
хϭϮϬй
pr
ed
ic
ted
љ
<80%
pr
ed
ic
ted
Imp
ro
ves
>12% wi
th
br
onchodi
la
tor
As
thma
doe
s
C
OP
D
and
Emph
yse
ma
ĚŽŶ͛ƚ͘
Nope
DL
C
O
red
uced
R
ed
uced
in
Emph
yse
ma
2/2 al
veol
ar
de
str
uct
ion.
R
ed
uced
in
ILD
du
e
to
fi
br
osi
s
thi
ck
en
ing
di
st
ance
C
OPD
Cri
ter
ia f
or di
agnos
is?
Tr
ea
tmen
t?
Indi
ca
ti
ons
to s
tart
O2?
Cri
ter
ia f
or e
xacerba
ti
on?
Tr
ea
tmen
t
for
ex
acerba
ti
on?
Bes
t
pr
ognos
ti
c i
ndi
ca
tor?
Shown
t
o
impr
o
ve
mort
al
ity?
Wh
y i
s our g
oal
f
or SpO2
94
-‐95%
ins
tead
of 1
00%?
Import
an
t
vacci
na
ti
ons?
P
roducti
ve c
oug
h
>3mo f
or >2
cons
ecuti
ve
yr
s
1
st line
=
ipr
atr
opi
um,
ti
ot
ropi
um.
2
nd
Be
ta ag
oni
sts. 3
rd
Theoph
yl
line
PaO2
<55
or SpO2<88%. If
c
or
pu
lmona
le,
<59
Cha
nge
in
sp
utum,
incr
ea
si
ng
dy
sp
ne
a
O2
to 90%,
al
but
er
ol
/i
pr
atr
opi
um
ne
b
s,
P
O or
IV
cort
ic
os
ter
oi
ds
, F
Q or macr
ol
ide
AB
X,
FEV1
1.) Qui
tti
ng
sm
oki
ng
(c
an
de
cr
ra
te
of F
EV1
de
cl
ine
2.) Con
ti
nu
ous
O2 t
he
rap
y
>18hr
s/d
ay
C
OP
Der
s ar
e chr
oni
c
C
O2
r
et
ai
ner
s.
H
ypo
xi
a
is
the on
ly dri
ve
for r
es
pi
ra
ti
on.
P
ne
umoc
oc
cus
w/
a 5yr boos
ter
and
y
ea
rl
y
in
fl
uen
za v
acc
ine
Your C
OPD pa
ti
en
t
comes
wi
th a 6
ǁ
ĞĞŬŚŝ
Ɛƚ
Žƌ
LJŽĨ
ƚŚŝ
Ɛ͙
Ne
w
Cl
ubbi
ng
in a
C
OP
Der
= Hy
per
tr
ophi
c
Os
teoarthr
opa
th
y
EĞ
džƚ
ďĞƐ
ƚ
Ɛƚ
ĞƉ͙Ő
Ğƚ
Ă
y
Z
Mos
t
lik
el
y
cause i
s underl
yi
ng
lung mal
ignancy
ht
tp://ca
nc
er
gr
ac
e.or
g/l
un
g/f
ile
s/2009/
02/nai
l-‐
cl
ub
bi
ng
.jpg
As
thma
If
p
t has
sx
s twi
ce
a w
eek
and
PFT
s ar
e
normal
?
If
p
t has
sx
s 4x a
w
eek
, ni
gh
t c
ough
2x
a
mon
th
and
PFT
s
ar
e
normal
?
If
p
t has
sx
s dai
ly
, ni
gh
t c
ough 2
x
a w
eek
and
FEV1 i
s
60
-‐80%?
If
p
t has
sx
s dai
ly
, ni
gh
t c
ough 4
x
a w
eek
and
FEV1 i
s
<60%?
Ex
acerba
ti
on
Æ
tx
w/ i
nhal
ed
al
but
er
ol
and
PO/IV
st
er
oi
ds.
W
at
ch
peak fl
o
w rat
es
an
d bl
oo
d
ga
s. P
C
O2
shoul
d
be l
ow
. N
ormal
izi
ng P
C
O2 means
impendi
ng
respi
ra
tor
y
fai
lur
e
Æ
INTUB
ATE.
Com
pl
ic
ati
ons
Æ
Al
ler
gi
c Br
ochopul
m
onar
y
Asper
gi
llus
Al
but
er
ol
onl
y
Al
but
er
ol
+
inh
al
ed
CS
Al
but
er
ol
+
inh
al
ed
CS
+ l
ong
-‐act
ing
be
ta
-‐ag
(sal
me
ter
ol
)
Al
but
er
ol
+
inh
al
ed
CS +
sa
lme
ter
ol
+
mon
tel
uk
as
t and
or
al
s
ter
oi
ds
Rando
m
R
es
tri
cti
ve Lung D
z
1cm
nodues
in
up
per l
obes
w/
eg
gshel
l c
al
ci
fi
ca
ti
ons.
R
eti
cul
onodul
ar
pr
ocess
in
lo
wer
lobes
w/ p
leur
al
pl
aques.
Pa
tch
y
lo
wer l
obe
in
fi
ltr
at
es,
ther
mophi
lic
acti
nom
yces.
,ŝ
ůĂƌ
ůLJŵƉŚĂĚĞŶŽƉĂ
ƚŚ
LJ͕
ј
ery
thema
nodosum
.
±
Hyp
er
cal
cemi
a?
±
Im
port
an
t
re
ferr
al
?
±
Dx/T
rea
tm
en
t?
Silic
os
is
. Ge
t y
earl
y T
B
tes
t!.
G
iv
e INH
for
9mo
if >
10mm
Asbes
tos
is
. Mos
t com
mon
canc
er
is
br
oncog
eni
c
car
ci
noma,
bu
t
incr ri
sk
for
m
es
othel
io
m
a
Hy
per
sen
sitivity
Pneu
mon
itis
=
͞Ĩ
Ăƌŵ
Ğƌ
͛Ɛů
ƵŶŐ
͟
Sar
coido
sis
.
Ϯͬ
Ϯ
ј
ŵ
ĂĐƌ
ŽƉŚĂŐ
ĞƐ
ŵ
ĂŬŝ
ŶŐ
ǀŝ
ƚ
Op
h
thal
mol
ogy
Æ
uv
ei
ti
s
conju
nc
ti
vi
ti
s
in
25
%
Dx
b
y bi
op
sy
. T
x
w/
st
er
oi
ds
1
st
st
ep
=
look
for an
ol
d CXR t
o
compar
e!
Char
act
er
is
ti
cs
of beni
gn nodul
es:
±
Popc
orn
cal
ci
fi
ca
ti
on =
hamart
om
a
(mos
t
com
mo
n)
±
Concen
tri
c
cal
ci
fi
ca
ti
on
=
ol
d g
ranul
om
a
±
Pt
< 40,
<3cm,
w
el
l ci
rcumscri
b
ed
Tx
w/
CXR
o
r
C
T s
cans
q2mo
to
loo
k f
o
r gr
owt
h
Char
act
er
is
ti
cs
of mal
ign
an
t nod
ul
es:
±
If
pt
has
ri
sk
f
act
or
s
(smok
er
, ol
d), If
>3cm,
if eccen
tri
c
cal
ci
fi
ca
ti
on
Do
open l
ung
bx
and r
em
ov
e
th
e no
dul
e
ht
tp://e
m
edi
ci
ne
.m
eds
cap
e.c
o
m
/
ar
ti
cl
e/356
271
-‐m
edi
a
ht
tp://e
m
edi
ci
ne
.m
eds
cap
e.c
o
m
/ar
ti
cl
e/358
433
-‐m
edi
a
^ŽLJ
ŽƵ
ĨŽƵŶĚ
ĂƉ
Ƶů
ŵŽŶĂƌ
LJ
ŶŽĚƵ
ůĞ͙
A
pa
ti
en
t pr
esen
ts
wi
th
w
ei
gh
t l
oss, c
ough,
dy
spn
ea, hem
op
ty
si
s, r
epea
ted
pni
a
or
lun
g
col
lap
se.
MC
canc
er
in
non
-‐smok
er
s?
Loc
ati
on
and
mets
?
Cha
rac
teri
sti
cs
of e
ffusi
on?
Pa
ti
en
t
wi
th
ki
dne
y
st
ones,
cons
ti
pa
ti
on
and mal
ai
se
lo
w P
TH
+
cen
tra
ll
ung mass?
Pa
ti
en
t
wi
th
sho
ul
der
pai
n, p
tos
is,
cons
tri
ct
ed
pupi
l, and f
ac
ial
ede
ma?
Pa
ti
en
t
wi
th
p
tosi
s be
tt
er
aft
er 1
mi
nut
e
of
up
w
ar
d g
az
e?
Ol
d
smok
er
pr
ese
n
ti
ng w/
Na = 12
5,
moi
st
muc
us
mem
br
ane
s,
no J
VD?
CX
R
sho
wi
ng
pe
ri
ph
er
al
ca
vi
ta
ti
on
and
C
T
sho
wi
ng di
st
an
t
mets
?
Adeno
car
cino
ma
. Oc
cu
rs
in sc
ar
s of
ol
d pn
ia
Per
ipher
al
c
ancer
. Me
ts t
o l
iv
er
, bone,
br
ai
n
and a
dr
enal
s
Ex
ud
ati
ve
wi
th
hi
gh
h
yal
ur
oni
dase
Sq
u
amou
s
cell
car
cin
om
a.
Par
an
eop
las
ti
c
syn
d
rome
2
/2
secr
eti
on
of
P
TH
-‐rP
. Lo
w
PO4
, Hi
gh
Ca
Su
peri
or
Su
lcus
Syn
dr
ome
fr
om
Small
cell
car
cino
ma
. Al
so a
cen
tr
al
c
anc
er
.
Lambert
Ea
ton
S
yn
d
rome
fr
om smal
l
cel
l c
ar
ci
no
ma.
A
b
t
o p
re
-‐s
yn
Ca
ch
an
SIADH
fr
om
sm
al
l cel
l c
ar
ci
nom
a.
Pr
odu
ces
Euv
ol
emi
c
h
yp
ona
tr
em
ia.
Fl
ui
d
res
tri
ct
+/
-‐
3%
sal
ine
in
<112
Lar
ge Cell
Ca
rcino
ma
In
fl
amma
tor
y
Bow
el
Di
seas
e
Tr
ea
tme
n
t
= A
SA
, sul
fas
al
zi
ne
to
mai
n
tai
n r
emi
ssi
o
n. Cor
ti
co
st
er
o
ids
to
induc
e
remi
ssi
o
n.
Fo
r CD
, gi
ve me
tr
ani
daz
o
le
fo
r ANY
ul
cer or ab
scess
. Az
athi
opri
ne,
6MP
and me
thotr
ex
at
e
fo
r se
ver
e
dz.
In
vol
ves
ter
mi
nal
il
e
um?
Con
ti
nuous
in
vol
vi
ng
rectum?
Incr ri
sk f
or
Pri
mar
y
Scl
er
osi
ng
Chol
angi
ti
s?
Fi
stul
ae
li
kel
y?
Gr
anul
oma
s on
bi
op
sy?
Tr
ansmur
al
in
fl
amma
ti
o
n?
Cur
ed b
y
col
e
ct
om
y?
Smo
ker
s ha
ve l
o
w
er
ri
sk?
Hi
ghe
st
ri
sk o
f c
ol
o
n
cancer
?
As
soci
at
ed w/ p
-‐AN
CA
?
ƌ
ŽŚŶ
͛Ɛ͘
Dŝ
ŵ
ŝĐƐ
ĂƉƉ
ĞŶĚŝ
Đŝ
ƚŝ
Ɛ͘&
ĞĚĞ
Ĩŝ
Đŝ
ĞŶĐ
LJ͘
UC.
Rar
el
y i
le
al
bac
kw
ash
bu
t
ne
ver
hi
gh
er
UC.
PSC l
eads t
o h
igher
ri
sk
of
ch
ol
angi
oCA
ƌ
ŽŚŶ͛
Ɛ͘
'
ŝǀ
Ğ
ŵ
Ğƚƌ
ŽŶŝ
ĚĂnj
Žů
Ğ͘
ƌ
ŽŚŶ͛
Ɛ͘
ƌ
ŽŚŶ
͛Ɛ͘
UC.
h͘
^ŵŽŬ
Ğƌ
Ɛ
ŚĂ
ǀĞŚŝ
ŐŚ
Ğƌ
ƌŝ
ƐŬ
ĨŽƌ
ƌ
ŽŚŶ
͛Ɛ͘
UC.
An
other
reason f
or
col
ect
om
y.
UC.
IBD Imag
es
& Co
mpl
ic
ati
ons
ht
tp://w
ww.
ajr
o
nl
ine
.or
g/c
gi
/c
o
n
te
nt
-‐nw/f
ul
l/188
/6/
1604/
FIG2
0
m
edi
nf
o
.uf
l.e
du
/~
bm
s5191/g
i/i
m
ag
es/c
d1a
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co
m
m
o
ns
.w
ik
im
edi
a.o
rg
st
ud
ent
he
al
th.c
o
.uk
LFT
/Lab
Buzz
w
or
ds
AS
T>AL
T (2
x)
+ hi
gh
GG
T
AL
T>AS
T & i
n the 100
0s
AS
T
and
AL
T
in the 100
0s
a
ft
er
sur
ger
y
or
hemor
rhag
e
El
ev
at
ed
D
-‐bi
li
El
ev
at
ed
I-‐
bi
li
El
ev
at
ed
al
k
phos
and GG
T
El
ev
at
ed
al
k
phos
, norma
l
GG
T,
normal
Ca
An
ti
mi
tochondri
al
Ab
AN
A +
an
ti
smoo
th
mus
cl
e
Ab
Hi
gh F
e, l
ow f
er
ri
ti
n, l
ow
Fe
bi
nd
ing c
apaci
ty
Lo
w
cer
ul
opl
asmi
n
, hi
gh
uri
nar
y Cu
Al
cohol
ic
Hepa
ti
ti
s
Vi
ral
Hepa
ti
ti
s
/ƐĐŚĞŵŝ
Đ,Ğ
ƉĂ
ƚŝ
ƚŝ
Ɛ
;͞
ƐŚŽĐŬů
ŝǀ
Ğƌ
͟Ϳ
KďƐ
ƚƌƵĐƚ
ŝǀ
Ğ;Ɛ
ƚŽŶĞͬ
ĐĂŶĐ
ĞƌͿ
ŽƌƵ
ďŝ
Ŷ͛
Ɛ
:ŽŚŶƐŽŶƐ͕
Z
Žƚ
Žƌ
,Ğŵ
Žů
LJƐŝ
Ɛ
Žƌ
'ŝ
ůďĞƌ
ƚ͛
Ɛ͕
ƌŝ
Őů
Ğƌ
EĂũũ
Ăƌ
Bi
le duc
t
ob
structi
on,
if IBD
Æ
PSC
WĂŐ
Ğƚ
͛Ɛ
Ěŝ
ƐĞ
ĂƐĞ
;ŝ
ŶĐ
ƌ
ŚĂ
ƚƐŝ
njĞ͕
ŚĞĂƌŝ
ŶŐ
ůŽƐ
Ɛ͕
HA
. T
x
w/
bi
sphosph
ona
tes.
Pr
im
ar
y
Bi
liary
Ci
rr
hosi
s
ʹ
tx
w/
bi
le
r
esi
ns
Au
toi
m
mune
Hepa
ti
ti
s
ʹ
ƚdž
ǁͬ
͚ƌ
Žŝ
ĚƐ
Hem
achr
om
at
osi
s-‐
hepa
ti
ti
s, D
M,
gol
den
ski
n
tŝ
ůƐŽŶ͛
Ɛ-‐
hepa
ti
ti
s,
p
sy
chi
atri
c s
xs
(B
G),
corneal
deposi
ts
Meni
n
gi
ti
s
Mos
t C
ommon
bugs?
In ol
d and
young?
In
ppl
w/ br
ai
n
sur
g?
Random
s?
Bes
t
1
st
st
ep?
Di
agnos
ti
c
tes
t?
R
oomma
te
of t
he ki
d
in
the dorms
who has
bact
eri
al
m
eni
ngi
ti
s
and pet
echi
al
r
ash?
Str
ep
Pneumo
, H
. In
fl
uenz
a,
N.
me
ni
ng
iti
di
s
(tx
w/
Ce
ftri
ax
one an
d V
anco)
Ad
d
Ly
st
eri
a.
(tx w/
Ampi
ci
lli
n)
Ad
d
St
aph
(tx w/
V
anco)
d
;Z
/W
н
͚ƌ
Žŝ
ĚƐͿĂŶ
Ě
>LJŵĞ
;/sĐĞ
Ĩƚƌŝ
Ănj
ŽŶĞͿ
St
art em
pi
ri
c
tr
ea
tme
n
t
(+
st
er
oi
ds
if y
ou
thi
nk i
t
is
b
act
eri
al
),
Ex
am
for
el
ev
at
ed
ICP
/C
T,
then
LP
+G
ram
s
tai
n,
>1000
WBC
is
di
agnos
ti
c.
Hi
gh
pr
ot
ei
n
and
lo
w
gl
ucos
e
supp
ort
bac
teri
al
Ri
fam
pi
n!
!
Pneu
moni
a
Cl
assi
c
sx
s͙ďĞƐ
ƚ
ϭ
st
st
ep?
Mos
t
comm
on bug al
l c
omer
s?
Mos
t
commo
n bug
, heal
th
y
young
peopl
e?
Hospi
tal
iz
ed
w/i
n 3mo
or i
n the
hospi
tal
>5
-‐7d
Ol
d
smo
ker
s
w/ C
OPD?
Al
coho
lics
w/ c
urr
en
t
jel
ly
sputum?
Ol
d
men
w/
HA
, c
on
fusi
on,
di
arr
hea
and
abd
pai
n?
Jus
t
had
the fl
u?
Jus
t
del
iv
er
ed
a
bab
y
co
w
and
ha
ve
vomi
ti
ng
and
di
arr
hea?
Jus
t
ski
nned
a r
abbi
t?
CXR
! Str
ep
Pneumo.
Tx
w/
M, F
Q
, 3
rd
cep
h
My
copl
asm
a.
Assoc w/ c
ol
d
ag
guti
ni
ns.
T
x
w
/ M,
FQ
or do
xy
Pseudomonas,
Kl
eb
si
el
la,
E.
Col
i, MR
SA
.
Tx
w/
pi
p/
taz
o
or
im
ipenem
+
V
anc
H.
in
fl
uenz
ae. T
x
w/
2
nd -‐3
rd
cep
h
Kl
eb
si
el
la.
Tx
w/
3
rd
cep
h
Legi
onel
la.
Dx
w/
uri
ne an
ti
gen.
Tx w/
M, F
Q
, do
xy
MR
SA
. T
x
w/
vanc
Q
-‐f
ev
er
. Co
xi
el
la
bu
rne
tti
. T
x
w/
do
xy
Fr
anc
ie
lla tu
lar
ensi
s.
Tx
w/
str
ep
tam
yci
n,
ge
n
tam
yci
n
Tube
rcul
os
is
If
a pa
ti
e
n
t
is s
ymp
toma
ti
c
Æ
bes
t t
es
t i
s CXR
For
scr
ee
ni
ng
Æ
±
>15mm
, >10mm
if p
ri
so
n, h
eal
th
car
e, n
ur
si
ng
home,
DM, E
TOH,
chr
o
ni
cal
ly
ill
, >5mm
f
o
r AIDS,
immu
ne
suppr
ess
ed
±
If + P
PD
Æ
do C
XR
.
±
If +CXR
Æ
do aci
d f
as
t s
tai
n of
sputum
.
±
If CXR
neg
ati
ve,
or +CXR
&
3 ne
ga
ti
ve
sputum
s
Æ
±
If pos
iti
ve
Æ
tx
w/
4 drug RIPE R
egi
m
en
fo
r
6mo
(12 f
o
r me
ni
ngi
ti
s
and
9 i
f
pr
egnan
t)
*
Chemoproph
yl
ax
is
(IN
H
f
or
9mo) f
or
ki
ddos
<4 e
xposed
to k
no
w
n
TB.
Drug
Si
de E
ff
ect
s:
±
Ri
fampi
n
-‐
±
INH
-‐
±
P
yr
azi
nami
de
-‐
±
Ethambut
o
l
-‐
body
fl
ui
ds turn o
rang
e/r
ed, i
nduc
es CYP4
50
per
ipher
al
neur
opa
th
y and si
der
obl
as
ti
c
ane
mi
a
(pr
ev
en
t
b
y
gi
vi
ng
B6.
Hepa
ti
ti
s
w/
mi
ld
bump i
n
LFT
s
op
ti
c
neur
iti
s, o
ther
c
ol
o
r vi
si
on a
bnormal
iti
es.
Be
ni
gn
h
ype
ruri
cem
ia
Endo
car
di
ti
s
Acut
e
endoc
ar
di
ti
s-‐
mos
t
comm
on bug?
Subacut
e
Na
ti
ve
val
ve
endoc
ar
di
ti
s-‐
Mos
t
comm
on v
al
ve?
Mos
t
comm
on bug?
IV
DU
Mos
t
comm
on v
al
ve?
Mos
t
comm
on bug?
Di
agnosi
s?
Com
pl
ic
ati
ons?
Tr
ea
tmen
t?
Pr
oph
yl
axi
s?
*Wha
t
if
you f
ind s
tr
ep
bo
vi
s
bact
er
emi
a?
St
aph
aur
eus see
ds
na
ti
ve
val
ves
fr
om bac
ter
em
ia
Mi
tr
al
V
al
ve (M
VP i
s MC
pr
edi
sposi
ti
on)
Vi
ri
dens g
roup
s
tr
ep
Tri
cu
spi
d
V
al
ve (murmur w
or
se
w/
inspi
ra
ti
on)
St
aph
Au
reus
Bl
ood
cx, T
TE th
en
TEE
. Major
and
Mi
nor
Cri
teri
a
CHF
#1
cause
of
dea
th,
se
p
ti
c em
bol
i t
o
lungs
or
br
ai
n
Str
ep Vi
ri
dens = 4
-‐6 w
ks PCN.
St
aph
= Na
f
+ g
en
t
or
vanco
if
pr
os
the
ti
c
val
ve, h
x
of
EC
, o
r
un
corr
ect
ed
conge
ni
tal
le
si
on
Ne
xt
st
ep
is
col
onosc
op
y!!
tŚĞ
Ŷ
ƚŽ
ƐƵƐ
ƉĞĐƚ,/s͙
/Ĩ
Ă
ƉĂ
ƚŝ
ĞŶ
ƚ
͞ƚƌ
Ăǀ
Ğů
Ɛ
Ăů
Ž
ƚ
ĨŽƌǁ
ŽƌŬ
͟
Æ
tha
t
means
the
y
ha
ve
se
x
wi
th
lots o
f s
tr
ang
er
s
and
ar
e
at
ri
sk f
or HIV
Acut
e
re
tr
ovi
ral
s
yndr
ome
=
2
-‐3
wk
s
s/p
exposur
e
but
3wk
s
be
for
e
ser
oc
on
ver
si
on
.
Æ
ie
, ELIS
A
neg
±
Fev
er
, f
ati
gue, l
ympha
denopa
th
y,
hea
dac
he,
phar
yngi
ti
s,
n/v
/d +/
-‐
asep
ti
c
meni
ngi
ti
s
LJŽƵŶŐƉĂ
ƚŝ
ĞŶ
ƚ
ǁŝ
ƚŚŶĞ
ǁͬďŝ
ůĂ
ƚĞƌ
Ăů
Ğů
ů͛Ɛ
WĂů
ƐLJ
͘
A
young pa
ti
en
t
wi
th une
xpl
ai
ned
thr
ombo
cy
topeni
a
and
fa
ti
gue.
A
young pa
ti
en
t
wi
th une
xpl
ai
ned
w
ei
gh
t
los
s
>10%
A
young pa
ti
en
t
wi
th thr
ush,
Zos
ter
, or K
aposi
sar
coma
When t
o s
tart
Tx
/P
os
t
exposur
e
Pr
op
h
yl
axi
s
St
art
HAAR
T
whe
n CD4 < 350
or vi
ral
load
>5
5,000 (e
xcep
t
pr
eg
gos
ge
t
tx
>1
,000 c
opi
es)
±
GI,
leuk
openi
a,
macr
ocyt
ic
anemi
a
±
Pancr
ea
ti
ti
s,
peri
pher
al
neur
opa
th
y
±
HS
rash,
fe
ver
, n/v
, muscl
e
aches,
SO
B i
n
1
st
6wk
s. D/C
and
ne
ver
use
ag
ai
n!
±
N
ephr
ol
ithi
asi
s
and
h
yperbi
liru
bi
ne
mi
a
±
Sl
eep
y,
con
fused,
p
sy
cho
Pos
t-‐
exposur
e
pr
oph
yl
axi
s-‐
±
If
stuck
w/
kno
wn HIV
pt
Æ
AZ
T,
lami
vudi
ne
and
nel
fi
na
vi
r
for 4wk
s
Zi
do
vudi
ne
-‐
Di
dano
si
ne
-‐
Abac
avi
r
-‐
Indi
na
vi
r
-‐
Ef
avi
ren
z
-‐
HIV
+
pa
ti
en
t wi
th
DOE
, dry
cough
, f
ev
er
,
che
st
pai
n
Thi
nk
PCP
. CD4 pr
ob <2
00.
yZ
ƐŚŽ
ǁ
Ɛ
͞ďŝ
ůĂ
ƚ
Ěŝ
ĨĨƵƐĞ
symmet
ri
c
in
ter
sti
ti
al
ŝŶ
Ĩŝ
ůƚƌ
Ăƚ
ĞƐ͟
Can se
e
el
evat
ed LDH
.
Bes
t
tes
t?
1
st
line T
rea
tmen
t?
2
nd
line T
rea
tmen
t?
When
to add
St
er
oi
ds?
Pr
oph
yl
axi
s?
www
.le
ar
ni
ng
rad
io
lo
gy
.c
o
m
/.
..
/c
o
w43.
jpg
Aft
er CXR,
do Br
onc
hosc
op
y
w/
B
AL
to
vi
sual
iz
e
bu
g
Tri
m
-‐sul
fa
Tri
m
-‐daps
one
or
pri
m
aqu
ine
-‐cl
inda,
or
pen
tami
di
ne
Wh
en
PaO2
< 70
, A
-‐a g
radi
en
t
>35
St
art when
CD
4
is
<2
0
0
. Can
d
/c
is
>2
0
0
f
or
>6
mo
1
st -‐
Tri
m
-‐sul
fa
2
nd -‐
Daps
on
e
3
rd -‐
A
to
vaq
u
on
e
4
th -‐
A
er
osol
iz
ed
p
en
tami
d
ine
(causes
p
an
cr
ea
ti
ti
s!
)
HIV+ pa
ti
en
t
wi
th di
arrhe
a
CMV
-‐
(<
50)
±
Dx
w/ c
ol
o
nosc
op
y/bi
o
p
sy
. Di
arr
hea
can
be
bl
oo
dy
±
Tx
w/
ganci
cyl
o
vi
r
(neutr
openi
a)
or
fosc
arne
t
(r
enal
to
x)
MA
C
-‐
(<50
)
±
Di
arrhea,
w
as
ti
ng
, f
ev
er
s,
ni
gh
t
sw
ea
ts.
±
Tx
w/ cl
ar
ithr
om
yci
n
and
ethambut
ol
+/
-‐
ri
fampi
n
±
Pr
oph
yl
ax
w/ azi
thr
om
yci
n
w
eekl
y
Cryp
tospori
di
um
-‐
(<
50)
±
Tr
ansmi
tt
ed
vi
a do
g po
o
, swi
m
mi
ng
poo
ls
±
W
at
er
y
di
arr
hea
w/
mucus,
Oocy
sts
ar
e
aci
d f
as
t
HIV+ pa
ti
en
t
wi
th
neu
rol
o
gi
c si
gn
s
If
mul
ti
pl
e ri
ng
en
hanci
ng
le
si
ons?
If
one ri
ng enhanci
ng
le
si
on?
If
sei
zur
e
w/
de
ja
vu
aur
a
and 50
0 R
BCs i
n
CSF?
If
s/
s of men
in
gi
ti
s?
If
he
mi
sen
sor
y
loss,
vi
sual
impai
rmen
t,
Babi
nski
?
If
memor
y
pr
obl
ems
or
gai
t
di
sturbanc
?
Thi
nk
To
xo.
Do
em
pi
ri
c
p
yr
ame
thami
ne
sul
fadi
azi
ne
(+ f
ol
ic
aci
d)
f
or
6wk
s. If
no
im
pr
o
vem
en
t
in
1wk,
consi
der
bi
op
sy
for
CNS
lymphoma.
Assoc
w/
EB
V
in
fxn
of
B
-‐
cel
ls. T
x
w/
HAA
R
T.
Thi
nk
HS
V
enc
ephal
iti
s.
(p
redi
sposed
for
tem
por
al
lobe).
Gi
ve
acy
cl
o
vi
r as SO
ON
as
suspect
ed.
Thi
nk
Cr
ypt
o.
+Indi
a
ink. T
x
w/
ampho
IV
for
2wk
s then fl
uconaz
ol
e
mai
n
tenanc
e
Thi
n
k
PML.
JC p
ol
yoma
vi
rus
d
em
yel
in
at
es
at
gr
ey
-‐whi
te
jxn.
Br
ai
n
b
x
is
gol
d
s
tan
d
ar
d
d
x
Thi
nk
AID
S-‐
Demen
ti
a c
ompl
ex.
Chec
k
ser
um,
CSF
and
MR
I t
o
r/
o
tr
ea
tabl
e
causes
Neutr
op
eni
c
Fe
ver
Medi
cal
Emer
gency!
NEVER
do
a
DR
E
on a
neut
ropeni
c
pa
ti
en
t!
De
fi
ned
b
y a si
ngl
e
temp
>
101.3
or sus
tai
ned
temp
>100.4
for 1hr
. ANC < 500.
Muc
osi
ti
s
2/2
chemo c
auses
bact
er
emi
a
(usual
ly fr
om
gut)
MC bugs
ar
e
p
seudomo
nas
or MR
SA
(i
f po
rt
pr
esen
t).
W
ork
up
Æ
1
st
ge
t bl
oo
d
cx,
then
s
tart
3
rd
or 4
th
gen
cephal
ospo
ri
n
(ce
ft
azi
di
me
or
ce
fi
pi
me
)
±
Add
vanc
if l
ine
in
fxn
suspect
ed or i
f s
ep
ti
c
sho
ck
de
vel
op
s.
±
Add
amphoB
if no
impr
o
vem
en
t
and no sour
ce
f
ound i
n 5
da
ys.
Rando
m
In
fecti
on Buzz
w
or
ds
Tar
get
rash, f
ev
er
, VII
pal
sy
,
meni
ngi
ti
s, A
V
bl
ock
Rash @ wri
sts & ank
les (pal
ms
&
sol
e
s),
fev
er
and HA
.
Ti
ck
bi
te, no r
ash, m
yal
gi
a,
fev
er
, HA
,
љ
pl
ts
ĂŶĚt
͕ј
>d
Imm
une
sup
pr
essed,
ca
vi
tar
y
lung
dz
(purul
en
t
spu
tum)+
w
ei
gh
t l
o
ss
,
fe
ver
. Gr
am
+ ae
robi
c br
anchi
ng
part
ial
ly
aci
d
fas
t
Neck o
r f
ace
in
fect
ion w/ dr
ai
ni
ng
yel
low ma
ter
ial
(+
su
lfu
r
gr
anul
es).
Gr
am
+ a
naer
obi
c
br
anchi
ng
Lyme!
Tx
w/ do
xy
(amo
x
for
<8
). Hear
t
or
CN
S
d
z
n
eed
s IV ce
ftri
ax
on
e
Ri
ck
et
tsi
a! T
x w/
do
xy
.
Eh
rl
ichi
o
si
s!
Can
dx
w
/
m
orul
ae
in
tr
acel
l i
ncl
usi
on.
Tx
w/
do
xy
Noc
ar
di
a!
T
x w/
tri
m
-‐sul
fa
Ac
ti
nom
yces!
T
x
w/
hi
gh
dose
PCN
for
6
-‐12
wk
s
