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Veryusefulmnemonics

Veryusefulmnemonics
CausesofacutePancreatitis
BADSHIT
Blackscorpionbite
Alcohol(orautoimmune:PAN)
Drugs(tetracycline,azothioprin,sulfa,diuretics)
Stones(gallstonesorsteroid)
Hyperlipidemia
Infection(mumps)
Trauma
SmallBowelObstruction
"SHAVIT"
SStone(gallstoneileus)
HHernia
AAdhesions
VVolvulus
IIntussusception
TTumor
NonGICausesofVomiting
ABC'sofNonGIcausesofvomiting
Acuterenalfailure
Brain(IncreasedICP)
Cardiac(InferiorMI)
DKA
Ears(labyrinthitis)
Foreignsubstances(Tylenol,theo,etc)
Glaucoma
HyperemesisGravidarum
Infections(pyelonephritis,meningitis)
ExtraintestinalmanifestationsofI.B.D.areAPIESAC
Aphthousulcers,Pyodermagangrenosum,Iritis,Erythemanodosum,Sclerosingcholangitis,Arthritis,
clubbing.
WhichI.B.D.hasCobblestonesonendoscopyCrohn's.
IfQRScomplexiswide,considerbundlebranchblock.LBBBcausesa"W"patterninV12anda"M"pattern
inV56.RBBBistheotherwayround.RememberasWiLLiaMMaRRoW.
BasalSystolicMurmur:AorticStenosis(AS)
ThemnemonickeyisArthurShawcross(AS),acannibalisticmurderer,akeywhichimmediatelyfollowsthe
symbol.
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Clinical:
Anginapectorisdespitenormalcoronaryarteries
ArthurShawcrossrepresentstheAngelofdeath[Angina].
Exertionalsyncope
HisvictimsSwooned[Syncope]withfearwhentheysawhim.
Exertionaldyspneaofcongestiveheartfailure
ArthurShawcrossclaimsheleftthecrimesceneswhistlingDixie[Dyspnea].
Suddencardiacdeath
ArthurShawcrosscausesSuddenDeath.
Physicalfindings
Loud,harsh,systolicejectionmurmurattheupperrightsternalborder,usually
associatedwithapalpablesystolicthrill.
ArthurShawcrossisaBase[Basal]Thrillmurderer[Thrill].
HeisaHarshHardenedcriminal,whoattributedhisgrotesqueactionsto
incestwithhisSister[Systolic].
S4gallopiscommonandrepresentsleftventricularhypertrophyandincreased
leftventricularpressure.
HisghoulishtalesreadliketheFour[S4]HorsemenoftheApocalypse.
S3whenleftventricularfailureispresent.
Asachild,ASdisplayedtheclassichomicidalTriad[S3]:animaltorture,
firesetting,andbedwetting.
Delayedupstrokeinthecarotidpulse.Parvusettarduscarotidpulse.
HislastvictimstillhadaSmallbutpalpablepulse.However,theambulancewas
Delayed[upstroke],and,itsoonbecametooLittle,tooLate[ParvusetTardus].
ParadoxicalsplittingofS2
ASsenthisvictimstoParadise[Paradoxical].
ApicalDiastolicMurmur:MitralStenosis(MS)
ThemnemonickeyisMicroSoft(MS),akeywhichimmediatelyfollowsthesymbol.
Physicalfindings:
Thethrillattheapexisthediastolicmurmur.
>>HopefulapplicantsattheApexoftheircareersareThrilledtobehiredby
MicroSoft.
Theleftventricle(LV)isofnormalpressureandsize,sothepointofmaximumimpulse
isnotdisplacedtotheleft.
>>MSownsaHealthyWindows[Vented:NormalLV]environment,andisNotwilling
tobeDisplacedfromitslocation.
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Highpitchedopeningsnap[OS]followingS2,heardbestbetweenthesecondto
fourthleftintercostalspace.
>>ThenewWindows98OperatingSystem[OS]soldataHighpitchedpace.
S1isloudandsnapping.
>>MicroSoft1soundisBillGates[S1],whobarksoutLoudSnappingorders.
Chestxray:
KerleyBlines(dilatedinterlobularseptaorseptaledema)arehorizontal,nonbranching
linesattheperipherallowerlungfields.
>>TheCurlyhaired[KerleyBlines]computergeek...
Thelargeleftatriumstraightenstheleftheartborderandissuggestedbyadouble
densityrightheartborder,bytheposteriordisplacementoftheesophagus,and
byanelevatedleftmainstembronchus.
>>...stoleDoubleDensity[CXR]diskettestobesoldinLosAngeles[largeLA].
Catheterization:
Theleftatrial(LA)pressurepulserevealsaprominent"awave(LAcontraction
againstthemitralvalve).
>>ThosetryingtoentertheranksofMShadtoshowProminentAgrades["awave]
attheApex[Apicaldiastolicmurmur]oftheirclass.

SymptomsofaorticstenosisareSADorASDSyncope,Angina,Dyspnea.
ForCausesofAFib/Flutter
H=cHf,othercardiomyopathies
E=Enlargementoftheatria
A=Alcoholbingedrinking
R=Rheumaticheartdisease
T=hyperThyroid
Asystole
"3Hypo's&3Hyper's"
Hypoxia
Hypothermia
Hypokalemia
Hyperkalemia
HyperH(Acidosis)
HyperRx(Drugs/OD)
SubmittedbyTagFilley,M.D.
Syncope
"HEAD,HEARTandVESS'LS"
Hhypoglycemiahypoxia
Eepilepsy
Aanxiety[the"swoon"]
Ddysfunctionofbrainstem[i.e.brainstemTIA]
Hheartattack
Eembolismofpulmonaryartery
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Aaorticobstruction[Aorticstenosis,myxoma,IHSS]
Rrhythmdisturbance
TtachycardiaespVT
Vvasovagal
Eectopici.e.hemorrhageobviousornot
Ssituational[micturation,defecation...]
Ssubclavialsteal
LlowSVR[eg:anaphalaxis]
Ssensitivecarotidsinus
ofM.I.isBOOMARBedrest,Oxygen,Opiate,Monitor,Anticoagulate,ReduceclotsizeProvenMI..shouldbe
metbyM.O.N.A.
M=morphine
O=oxygen
N=nitrates
A=aspirin
suspectedrightventricularMIsuspected..holdtheNitrates.submittedbyChris
Mnemonicforrememberingantiarrhythmics
ClassDrugMnemonicReadas:ProfessorQuackers"dissed"Lydia'spennyMexicantacos.Feeling
profaned,properBerthaButt(amiableBritishsocialite)virtuallydismembered'im.orProfessor
QuackersdissedLydia'sPennyMexicanTacos.Feelingprofaned,properBerthaButt,(amiableBritish
socialite),virtuallydismembered'im.*Note:"Dissed"isusedhereastheslangterm"dis"fromdismiss.
I.e.,"Don't'dis'me,man!"
ClassIAProcainamideProfessor
QuinidineQuackers
Disopyramide"dissed"*
ClassIBLidocaineLydia's
Phenytoinpenny
MexiletineMexican
TocainideTacos
ClassICFlecainidefeeling
Propafenoneprofaned
ClassIIPropranololproper
BetaBlockersBerthaButt
ClassIIIAmiodaroneamiable
BretyliumBritish
Solatolsocialite
ClassIVVerapamilvirtually
Diltiazemdismembered'im
Atropine
Adenosine

Endocarditis
"FAME"
FFEVER
AANEMIA
MMURMUR
EENDOCARDITIS
CausesofpericarditisareCARDIACRINDCollagenvasculardisease,Aorticaneurysm,Radiation,Drugseg.
hydralazine,Infections,Acuterenalfailure,Cardiacinfarction,Rheumaticfever,Injury,Neoplasms,
Dressler'ssyndrome.

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5T'sofearlycyanosisincongenitalheartdisease
Tetralogy,Transposition,Truncus,Totalanomalous,Tricuspidatresia
SumbittedbyBenHumphreys

95%ofhypertensionisprimary(idiopathic).5%issecondaryandcausesincludeCHAPSCushing's
syndrome,Hyperaldosteronism(Conn'ssyndrome),Aortacoarctation,Pheochromocytoma,Stenosisofthe
renalarteries.

Takayasu'sdiseaseisalsocalledpulselessdisease,thereforeIcan'tTak'aya'spulse.
HenochSchonleinPurpura
"JARS"
JJoints
AAbdominalpain
RRenal
SSkin
CompartmentSyndrome
"6p's"
pulselessness
pain
pallor
parasthesia
poikiolothermia
paralysis
PredisposingConditionsforPulmonaryEmbolismTOMSCHREPFER
Ttrauma
Oobesity
Mmalignancy
Ssurgery
Ccardiacdisease
Hhospitalization
Rrest(bedbound)
Eestrogen,pregnancy,postpartum
Ppasthx
Ffracture
Eelderly
Rroadtrip

(Cot)CaughtbySin:CottonBySSinosis
ShortnessofBreath
HAPISOCS
H:Historyofanypulmonarydisease
A:Activityatonset
P:Painuponinspiration
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I:Infectionsfever/chills
S:Smokeryears/packs
O:Orthopnea
C:Cough(Persistent)
S:SputumProductive/color

NonCardiogenicPulmonaryEdema
"PONS"
PPhosgene,paraquat,phenothiazines
OOpioids/organophosphates
NNitrousdioxide
SSalicylates
Treatmentofacutepulmonaryedema
AsEasyas'LMNOP':RememberthemnemonicLMNOPwhentreatingapatientwithacutepulmonaryedema
Lasix(furosemide)intravenous(IV),onetotwotimesthepatient'susualdose,or40mgifthepatient
doesnotusuallytakethedrug.
Morphinesulfate.Initialdose,4to8mgIV(subcutaneousadministrationiseffectiveinmildercases)may
repeatin2to4hours.Avoidrespiratorydepression.Morphineincreasesvenouscapacity,loweringleftatrial
pressure,andrelievesanxiety,whichreducestheefficiencyofventilation.
NitroglycerinIV,5to10ug/min.Increaseby5ug/minq3to5minutes.Reducesleftventricularpreload.
Caution:maycausehypotension.
Oxygen,100%giventoobtainanarterialPO2>60mmHg.
Positionpatientsittingupwithlegsdanglingoverthesideofthebed.Thisfacilitatesrespirationand
reducesvenousreturn.
Beta1receptorsareintheheart(youhave1heart)andbeta2receptorsareinthelungs(youhave2
lungs).
DecreasedPleuralfluidGlucose:"IRAN"
I=Infections
RA=Rheumatoidarthritis
N=Neoplasia
AnteriorMediastinalMass
"4T's"
TThymoma
TTeratoma
TThyroidtumor/goiter
TTerriblelymphoma
MiddleMediastinalMass
"Habit5"
HHhernia,hematoma
AAneurysm
BBronchogeniccyst/duplicationcyst
IInflammation(sarcoid,histo,coccidio,TB)
T5Tumors(lung,lymphoma,leukemia,leiomyoma,lymphnodehyperplasia)
BilateralHilarAdenopathy
"PleaseHelenLickMyPopsicleStick"
PPrimaryTB
HHistoplasmosis
LLymphoma
MMetastases
PPneumoconiosis
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SSarcoidosis
Sarcoidosis:
SARCOIDOSIS:GERMANACE"SCHAUMANN"BOEK
GGranulomas
EErythemanodosum
RRestrictivelungdefect(PFTs)
MMultiplesystemicmanifestations
AAsteroidbodies(inclusions)
NNoncaseatinggranuloma,NegativeTBtest
ACEAngiotensinconvertingenzymelevelsmonitordiseaseactivityandresponsetotherapy.
Schaumann'sbodies(inclusions)
BBell'spalsy,Bilateralhilarlymphadenopathy,BlackfemalesOOpticnervedysfunctionisacommon
manifestationofneurosarcoid.
EEyes:uveitis
KKveimskintest
RatPoisons
"RATSPANIC"I'msurethatyou'lleasilyrememberthisone!
RRedsquill
AArsenicals
TThallium
SStrychnine
PPNU/Phosphorus/znPhosphide
AAlphanaphthathiurea(ANTU)
NNorbormide
IIndanediones
CCoumadin/cholcalciferol
AnionGapAcidosis:
"Mudpiles"
MMethanol
UUremia
DDKA/AKA
PParaldehyde/phenformin
IIron/INH
LLacticacidosis
EEthyleneglycol
SSalicylates
NormalGapAcidosis
"HARDUP"
HHyperalimentation/hyperventilation
AAcetazolamide
RRTA
DDiarrhea
UUreteraldiversion
PPancreaticfistula/parenteralsaline
OsmolarGaps
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"MEDIE"
MMethanol
EEthanol
DDiuretics(mannitol,sorbitol,glycerol)
IIsopropanol
EEthyleneglycol
RespiratoryAlkalosis:AsthmaticSallypoisonedPOPE'sHEN
Asthma
Salicylatepoisoning
PO=PulmonaryOedema
PE=PulmonaryEmbolism
HEN=HepaticEncephalopathy
Hypoglycemia
"Reexplain"
Rrenalfailure
EXexogenous
Ppituitary
Lliverfailure
Aalcohol
Iinsulinoma/infection
Nneoplasm
Hypoglycemia[BySungKim]
HypoglycemiaHUNGER:BESTSAUCEISMSG
HHepaticfailure(advanced),Hypothermia
UUremia/renalfailure
NNausea,vomiting
GGrowthhormonedeficiency
EEthanolmetabolismbluntsgluconeogenesis
RReye'ssyndrome
BBetablockers
EEnzymedefects(glycogenstoragediseases)
SSepsis
TTumors:Isletbetacelltumors(pancreatic):Insulinomas
Nonisletcelltumors:Largemesenchymaltumors
SSulfonylureas
AAdrenalinsufficiency
UUnder0.3(insulin/glucoseratio)tomakethediagnosisCCpeptidemeasurementtoruleoutfactitious
hypoglycemia
EEndocrine:Epinephrine,glucagondeficiencies(counterregulatoryhormonedeficiencies)
IImmunediseasewithinsulinorinsulinreceptorantibodies
SSarcomas:largeretroperitonealsarcomas
MMaplesyrupurinedisease,severeMalaria
SSalicylatesinchildren
GGalactosemia(withmilkingestion),disordersofGluconeogenesis
Symptomsofhyperthyroidism
Rememberthefollowingmnemonicwhenevaluatingpatientsforhyperthyroidism:
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S:Sweating
T:TremororTachycardia
I:Intolerancetoheat,Irregularmenstruation,andIrritabilityN:NervousnessG:Goiterand
Gastrointestinal(loosestools/diarrhea).
CUSHING'S
DISEASEis
Dependenton(Pituitary)and
Depresses(Cortisol)on
DaddyDosesofDexa(HighdosesofDexamethasone).
Hypercalcemia
"SHAMPOODIRT"
SSarcoidosis
HHyperparathypoidism,Hyperthyroidism
AAlkalimilksyndrome
MMetastases,myeloma
PPagetdisease
OOsteogenesisimperfecta
OOsteoporosis
DVitaminintoxication
IImmobility
RRTA
TThiazides
HypercalcemiasymptomsareBones(pain),Stones(renal),abdominalGroans(pain)andpsychicmoans
(confusion).
Multipleendocrineneoplasia
MENIis3P's(Pituitary,Parathyroid,Pancreas).MENIIis2C's(Catecholaminesie.pheochromocytome,
carcinomaofmedullaofthyroid)andParathyroid(IIa)orMucocutaneousneuromas(IIb).
ThemostcommonthyroidcarcinomaisPapillary(Popular).ItalsohasPsammonabodiesonhistology.It
causesPalpablelymphnodes(lymphaticspread).
ThemostcommonsymptomsofPHEochromocytomabeginwiththefirst3lettersPalpitations,Headache,
Episodicdiaphoresis(sweating).
Tumorsthatgotobone
"KindsOfTumorsLeapingPrimarilyToBone"
KKidney
OOvarian
TTesticular
LLung
PProstate
TThyroid
BBreast
CausesofjointpainareSOFTERTISSUESepsis,Osteoarthritis,Fractures,Tendon/muscle,Epiphyseal,
Referred,Tumour,Ischaemia,Seropositivearthritides,Seronegativearthritides,Urate,Extraarticular
rheumatism(eg.polymyalgia).
Ossificationcentersoftheelbow
TherearetwothatIknowof(mostpeopleuse"CRITOE"):
CCapitellum
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RRadialhead
IInternal(medialepicondyle)
TTrochlea
OOlecranon
EExternal(lateralepicondyle)
Theseappearat2,4,6,8,10,and12yearsofageinorderandgoawaytwoyearslater.
TheothermnemonicIknowfortheossificationcentersis"ComeRubMyTreeOfLove"wherethe"M"is
medialepicondyleandthe"L"isthelateralepicondyle.
WristBones
"NeverLoosenTilliesPants,MotherMightComeHome"
Proximalrow:
NNavicular
LLunate
TTriquetrium
PPisiform
Distalrow:
MgreaterMultiangular(trapezium)
MlesserMultiangular(trapezoid)
CCapitate
HHamate
Also:"SomeLoversTryPositionsThatTheyCan'tHandle"
RotatorCuffMuscles
"SITS"
SSupraspinatus
IInfraspinatus
TTeresminor
SSubscapularis
TheSalterClassification:
"SALTR"
SSlipofphysis
AAbovephysis
LLowerthanphysis
TThroughphysis
RRammedphysis
NEPHROTICSYNDROME(NS)ischaracterizedbythefollowing:[ByShweta]
N=Na+waterretention
Thisoccursduetoseveralfactors,includingcompensatorysecretionofaldosteroneinresponseto
hypovolemiamediatedreleaseofADH.
E=Edema
Duetohypoproteinemia+Na,waterretention.Edemaissoft,pittingandstartsintheperiorbitalregion.
P=Proteinuria>3.5gm/1.74sq.ml/24hrs
H=Hypertension+hyperlipidemia(duetoincreasedlipoproteinsynthesisinliver,abnormaltransportof
circulatinglipoproteins,decreasedcatabolism.)
R=Renalveinthrombosis
O="Ovalfatbodies"intheurine.Lipiduriafollowshyperlipidemia.Albuminaswellaslipoproteinsarelost.
Lipoproteinsarereabsorbedbytubularepithelialcellsandtheyshedalongwithdegeneratedcellsthis
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appearsas"ovalfatbodies"inurine.
T=Thrombotic+thromboemboliccomplicationsowingtolossofanticoagulantfactors(eg.antithrombinIII
)
I=Infection.Thesepatientsarepronetoinfection,especiallywithstaphylococciandpneumococci.
Vulnerabilityisduetolossofimmunoglobulins.
C=hyperCoagulablestate
HenochSchonleinPurpura
"JARS"
JJoints
AAbdominalpain
RRenal
SSkin
Causesofhematuria
UsethemnemonicSITTTasanaidinevaluatingthecauseofhematuria:
S:Stone
I:Infection
T:Trauma
T:Tumor
T:Tuberculosis
Causesofsecondarynephroticsyndromeie.notofdirectrenaloriginareDAVIDDiabetesmellitus,
Amyloidosis,Vasculitis,Infections,Drugs.
CausesofacuteandreversibleformsofurinaryincontinenceThefollowingmnemonicaidsinremembering
thecausesofacuteandreversibleformsofurinaryincontinenceDRIP
D:Delirium
R:Restrictedmobility,retention
I:Infection,inflammation,impaction(fecal)
P:Polyuria,pharmaceuticals
Hereditarycysticdisorders:Polycystickidneydisease
Autosomaldominantpolycystickidneydisease(ADPKD)isassociatedwithcystsinthekidneysand,inmany
cases,inthebrain(berryaneurysms),liver,spleen,pancreas,andlungs.
HalleyBerryAKADorothy(Dandridge)PortrayedCarmenJones.
Halley?Hematuria:Grossandmicroscopic
BerryBerryaneurysms
AKA?ADPKD
DDominant(autosomal)inheritance
OObstructionoftheurinarytractbystones,bloodclotsRRenalfailure
OOxalate:calciumoxalateanduricacidstones
TrenalTubulardefects
HHemorrhagiccysts
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YYear1Mostcasesarediagnosedinthefirstyearoflife,presentingasbilateralabdominalmasses.
Portrayed?Polycystic:continuedenlargementofthecystsoftenleadstoprogressiverenalfailure.
Carmen?CTscanning:Enlargedkidneyswithmultiplebilateralcystsarediagnosedusingultrasound,IVP,
orCTscanning.
JonesJuvenilenephronophthisis(JN)andmedullarycysticdisease(MCD)areintheDDx.
Cardiacvalvulardisorders:Mostlymitralvalveprolapse(MVP)andaorticregurgitationSaltwasting
nephropathy,renaltubularacidosis(RTA)Chronicflankpainduetothemasseffectoftheenlargedkidneys
LustyCarmenJonespowderedhernose,usingherBivalve[MVP]mirrorcompact,thensheslowlyraised
herSaltrimmed[Saltwastingnephropathy]MargaRiTA[RTA],andseductively
placedherotherhandonherHip[Flankpain].
Hyperchloremicacidosis
Saltwastingnephropathycausinghyponatremia
ItwassaidthatDorothywasnotallowedtoswiminthehotelsChlorinatedpool[Hyperchloremicacidosis].
Whenshedefiantlyswaminthepool,theyDrainedit[Saltwastingnephropathy,Hyponatremia].
Hypertension
Endstagerenaldisease(ESRD)
Dorothywasforcedtoenterthroughthebackdoor,evenwhileshewascontractedtosingunderTheBig
Tent[Hypertension].
Dorothywasonly41whenshewasfoundDEAD[ESRD].
Review:
Dx:Positivefamilyhistory(autosomaldominantinheritance)
Grossandmicroscopichematuria
Ultrasound,IVP,orCTscanningdetecttheenlargedkidneyswithmultiplebilateralcysts

RenalPathologyBuzzwords
Lupus=wireLOOPlesion(LUPUS=LOOP)
goodPASTURE=apastureisFLATsoistheimmunoflouresenceforGP
MembraneousGN=spikeandDOMEappearance(thinkmembrane=dome)
(heldupbyspikes)
MembranoproliferativeGN=MPGN=TramTrack
thinkofMP's(militarypoliceridingonTrams)
PoststreptococcalGN=LumpyBumpy
thinkStrepaerobics
LumpypeopleBumping
arounddoingaerobics
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WBCCount
"NeverLetMomEatBeans"and"60,30,6,3,1"
Neutrophils60%
Lymphocytes30%
Monocytes6%
Eosinophils3%
Basophils1%
HemPT,PTT:
Toremembertheintrinsicandextrinsicpathwaysinrelationtowhatbloodtestisaffected:
PiTT(IforIntrinsicpathway)PiTTsburgh
PeT(EforExtrinsicpathway)
VitaminKdependentproteinsandwarfarinsodium[bySungKimandS.Levine,MD,PhD.]
WarfarinsodiumisavitaminKantagonist.
VitaminKdependentproteinsCandS.
VitaminKdependentclottingfactorsII,VII,IX,andXoftheextrinsicpathway.
>TheKorean[vitaminK]War[Warfarin]wasfoughtOutdoors[Extrinsic
>pathway].TheAmericanPTboats[PT,Protime,orprothrombintime],
>whoseaccesshadbeenlimited
bytheroughSeas[proteinC],quicklysentoutSOS[proteinS]messages.
MicrocyticAnemia
"TICS"
Thalasemia
Irondeficiency
Chronicdisease
Sideroblasticanemia
SubmittedbyJeffRodgersonM.D.
HCMCMedicalCenter
LotmoreareHidden:
[hide]Eosinophilia
"NAACP"
NNeoplasm
AAllergy
AAddison's
CCirrhosis,CVD
PParasite(viscerallarvamigrans),Periarteritisnodosa
SubmittedbyTagFilley,M.D.
ThalassemiamajoristhemostSeverethalassemia[BBetaBad].
MajorBADMAFIAguyshavethetypicalgangsterappearance:
Short[Microcytichypochromicanemia]and
Ugly[distortionoffacial,skull,andlongbones]
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BBasophilicstippling
AAnemia,Anisocytosis
DDeferoxamine
M?MCVislow
AHbAisdecreased
FHbFisincreased
IIneffectiveerythropoiesis
A?HbA2isincreased

Cooley'sanemia(betathalassemiamajor)isthehomozygousstate.
ThekeyisDentonA.Cooley,M.D.,TexasHeartInstitute(THI).

DDeferoxaminetherapytopreventhemochromatosis
AAnemiaInbetathalassemiamajororintermedia,anemiaisduetoacombinationofineffective
erythropoiesis
andhemolysisofcirculatingcells.CCongestiveheartfailureisacauseofdeathinthefirstyearsoflifeifthe
patientisnottransfused.

MMCVislowMicrocytichypochromicanemia
DDiagnosis,prenatal
TTowerskull(alsofrontalbossing,chipmunkfacies,anddistortionoflongbones)HHemolyticanemiawith
HepatosplenomegalyinthefirstyearofinfantlifeIIntermediaBetathalassemiaintermediapresentswith
abnormalitiessimilartothoseofthalassemiamajor.

Increasedsusceptibilitytoinfections
Peripheralbloodsmear:Basophilicstippling
Helmetcells
Nucleatedtargetcells
Anisocytosis(RBCsofdifferentsize/volume)
Xray:Haironendskull
Serumhemoglobinelectrophoresis:HbAisdecreased.
HbA2isincreased.
HbFisincreased
>Dr.CooleyperformedMajorsurgery[thalassemiaMajor]asa
>Cardiothoracicsurgeon[Cardiacfailure]live
ontheInternet[Infections].
>HisskilledhandscanperformMicrosurgery[Microcytichypochromic
>anemia]onFetuses[HbF].
>Hissurgicalcap[Helmetcells]fitlooselyoverhisCrewcut
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>[Haironendskull].
>HeproceededtomakeanincisionalongtheBlueStippledline
>[BasophilicStippling]drawnontheskin.
>Dr.Cooley'sTarget[Targetcells]academicscorehadalwaysbeenan
>A+[HbA2isincreased].
>HewouldNotacceptasimpleA[HbAisdecreased].
>Thesurgicalstaffisacloseknitcommunity,likeaBADMAFIA
>(seebelow),quicktodisposeofweak,
Ineffective[Ineffectiveerythropoiesis]residencycandidates.

Disseminatedintravascularcoagulation(DIC)

DISSEMINATED
DDx:Ddimer
IImmunecomplexes
SSnakebite,shock,heatstroke
SSLE
EEclampsia,HELLPsyndrome
MMassivetissuedamage
IInfections:viralandbacterial
NNeoplasms
AAcutepromyelocyticleukemia
TTumorproducts:TissueFactor(TF)andTFlikefactorsreleasedbycarcinomasofpancreas,prostate,
lung,
colon,stomach
EEndotoxins(bacterial)
DDeadfetus(retained)
CharacteristicfeaturesofmultiplemyelomaonXrayareABCDEAsymmetry,Borderirregular,Colour
irregular,Diameterusually>0.5cm,Elevationirregular.
9
Chroniclymphocyticleukemia(CLL)isamonoclonalmalignancy,usuallyofBlymphocytes.
Incidence:CLListhemostcommonadultleukemiaintheUnitedStates.
Males>Females
5070yearsofage
SongwriterPhilCoLLins[CLL]isMaleandprobablyover50yearsofage.Herecentlywonan
Oscarforhis"Tarzan"song.
Clinicalanddiagnosis
Lymphocytosis>15,000/mm3
Generalizedlymphadenopathy
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TarzancanspringfromLimb[Lymphocytosis]toLimb[Lymphadenopathy]abovethetree
tops
Splenomegaly,hepatomegaly
Lowserumimmunoglobulins(immunosuppression)
>wheretheSplendid[Splenomegaly]Moonlight[imMunosuppression]
>streamsthroughthe
branches.
Diffusebonemarrowinfiltrationandreplacementofcellularelementscause:
Anemia
Thrombocytopenia
Granulocytopenia
>WaltDisneyPicturesproducedtheAnimatedAnimal[Anemia]adventure
>"Tarzan".
>The"Tarzan"[Thrombocytopenia]songearnedCoLLinsanOscar[Osteo,
>bonemarrowfailure]
awardforthebestoriginalsong.
>TarzanhadLittleneedforPlates[Platelets<100,000/L]inthe
>jungle.
>PhilCoLLinsisaGrammy[Granulocytopenia]Awardwinningsingerand
>songwriter.
Occasionallyextravascularhemolysis:warmantibodyautoimmunehemolyticanemia(AHA)
>AnAfricanjungle[Autoimmuneextravascular]APE[AHA]hadWarmly
>[Warmantibody]
adoptedbabyTarzan.
Differentialdiagnosis
Malignantlymphoma
Infectiousmononucleosis
>TarzanisLord[Lymphoma]oftheJungleandfriendoftheMonkeys
>[Mononucleosis].PhilCoLLinswasborninLondon[Lymphoma].

Treatment
Chlorambucil(analkylatingagent),withorwithoutprednisone
Fludarabine
>SomemayimagineaRam[ChloRambucil]scramblingabout,butothers
>will
>recallthatClayton[Chlorambucil]isthevillainousjungleguide
>whowashiredby
Professor[Prednisone]Porter,notknowingthat
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>Clayton[Chlorambucil]hadhiscapturedPrey[Prednisone]
>immediatelyFlown
[Fludarabine]outforprofit.

References:
1.Harrison'sPrinciplesofInternalMedicine,14/eEdition,McGrawHill,NewYork,1998.2.Maximumaccess
todiagnosisandtherapy(MAXX),LippincottWilliams&Wilkins,NewYork,1999.3.ScientificAmerican
Medicine(SAMCD),ScientificAmericanInc,NewYork,1997.
Hodgkin'slyphomaclassificationA=Asymptomatic,B=Bad.
Riskofunderlyingmalignancywithdermatomyositisorpolymyositisis30%atage30,40%atage40etc.
MalignantMonoclonalGammopathies:Multiplemyeloma
Themnemonickeyformultiplemyeloma(MM)isMarilynMonroe(MM),akeywhichimmediatelyfollowsthe
>>symbol.
Clinical:
Weaknessandfatigueduetonormochromicnormocyticanemia.
>>MM'soriginalnamewasNorma[Normochromicnormocytic]Jean.
Bonepainandpathologicfractures:predominantlyosteolytictumorsandosteoporosis.
>>MM'snamewasilluminatedinmarqueeLights[osteoLytic],butshe
>>secretlylongedfor
anOscaraward[Osteoporosis].
Susceptibilitytobacterialinfections.
>>MMwasSusceptibletoToxic[infections]relationships.
Acuterenalfailure(ARF)duetotheeffectsoffilteredlightchainproteins,
hypercalcemia,andamyloiddepositsinthekidney.
>>MM'sLightlyChainedARFdogbarkedwhenMM'sdeathwassaidtobe
>>relatedtoher
JFKArmyLord[Amyloid].
Laboratory
Hypercalcemia
>>MMfluffedWhiteTalcum[hypercalcemia]powderonherdelicatewhite
>>skin...
Hypergammaglobulinemia
>>...toprotectitfromthemovieindustry'sLargehotCamera
>>lights[hyperGammaglob].
Serumelectrolytes:Lowaniongap
>>MMworegownswithLow[Lowaniongap]revealingnecklines.
Rouleauxonperipheralbloodsmear.
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OccasionallyCoombs(+)hemolyticanemia.
>>MMusedhairRollers[Rouleaux]andCombs[Coombs]tocreateher
>>famoushairdo.
Leukocytealkalinephosphatase(LAP)stainingreaction:HighLAPscore.
>>MMusedherGreatLAPtoheradvantagebecause....
NormallevelsofSerumAlkalinePhosphatase(SAP)
>>...shewasNotaSAP.

Antineoplasticagents&Adverseeffects

Maletesticulartumors:"SECsacTICS
SSeminoma:mostcommon
EEmbryonalcarcinoma
CChoriocarcinoma
SacYolksactumor(endodermalsinustumor)
TTeratoma,Teratocarcinoma
ICInterstitial(Leydig)celltumor
SSertolicelltumor
Paraneoplasticsyndromesandtheirassociatedcancers:
Yourdiagnosiscanbe"HighlySCRAMBLED."
HighlyHypercalcemia(squamouscellcarcinoma)
SSIADH,hyponatremia(SCLC)
CClubbing(adenocarcinomas)
RRetinalblindness(SCLC)
AACTH(SCLC)
MMyastheniagravis(thymoma)
BBonehyperosteoarthropathy(adenocarcinomas)
LLimbicencephalitis(SCLC)
EEatonLambertmyasthenicsyndrome(SCLC)
DDermatomyositis(cancerofthelung,ovary,breast,stomachNHL)

SIADH:Syndromeofinappropriateantidiuretichormonesecretion
SCLC:Smallcelllungcancer
NHL:nonHodgkin'slymphoma

Microbiology
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Thefirsttwomnemonicsaremodificationsofwellknownmnemonics.
Grampositive,sporeforming,rods:BacillusandClostridium
Somelovestayhomeformingspores:
BasicallyClaustrophilic(BacilliandClostridia)

Othergrampositiverods:
Otherslovetobelong:CLAN
CCorynebacterium
LListeria
AActinomyces
NNocardia

AllspecieswithintheEnterobacteriaceaefamilyaregramnegativeentericbacilliandarefacultative
anaerobesthatcanfermentglucosetoacid.
Whenmicroorganismscompetewithhumansforglucose,theyareNastyCURSESS."
NastyNeisseria(N.gonorrhoeaeandN.meningitides)
CCurved:VibrioandCCampylobacterspecies
URUreasepositive
SESerratia
SSSalmonella,Shigella
Urease(+):Y.enterocolitica,Y.pseudotuberculosis,P.mirabilis,P.vulgaris,M.morgani

ClinicallysignificantAnaerobes"AClosedBoxForPepsi."
AActinomycesG+
CClostridiaG+
BBacteroidesG
ForFusobacteriumG
PepsiPeptostreptococciG+
Bloodydiarrhea
Bloodydiarrheamaybecausedbyinvasivebacteriaorparasites,including:
Campylobacter,Shigella,Salmonella,Yersinia,andTrichuris(whipworm).
TheCuttingedgeoftheCampbell's[Campylobacter]soupcanwasBloody.
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TheShaggy[Shigella]surfacewasAbrasive[Bloody].
TheSalmon[Salmonella]scaleswereAbrasive[Bloody].
TheJersey[Yersinia]sweatshirtwasroughandAbrasive[Bloody].
TheBullwhip[Whipworm]drewBlood.

Bordetellapertussis:Whoopingcough
Bordetellapertussisistheetiologicagentofwhoopingcough.
Laboratory:
Absolutelymphocytosisinchildren(areportedlyrecentUSMLEStep2question).
>>ManycrossedtheBorder[Bordetella]fortheirGreen*cards[lymphocytosis].
*Inourcolorcodingschemeofmnemonics,greenwillrepresentlymphocytes.
BORDETELLA
BBordetGengouagarculturinganasopharyngealswabisthestandarddiagnostictestorderedduringthe
first2weeksofonset.
OwhOopingcough
RRod:B.pertussisisasmall,gramnegativepleomorphicrod
DDFADirectfluorescentantibodytestofnasopharyngealsecretionsresultsinfrequentfalsepositives.
EErythromycinfortherapyandprophylaxis.
TTrimethoprimsulfamethoxazoleisanalternativeantibioticchoice.
EELISAisthediagnostictestorderedafterthefirst2weeksofonset.
LLeukocytosis:10,00050,000cells/uLwith5075%maturelymphocytes
LLymphocytosisinchildren
AAdultlymphocytosisisrare.

OrganismsthatSpreadfromBloodtoUrine
CASHCML
Ccandida
Aaureusstaph
Ssalmonella
Hhistoplasma
Ccytomegalovirus
Mmycobacteria
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Lleptospira
SubmittedbyOusamaDabbaghM.D

Kawasaki's
"screamfever"
Ssausagefingers
Cconjunctivalredness
Rrash
Eextremityinvolvement
Aadenopathy
Mmucosalerythema
FEVERfever
Causesofpostopfever
Rememberthefollowingmnemonicwhendeterminingthepossiblecause(s)offeverinapatientwhohas
recentlyundergoneasurgicalprocedure:the5W's(or6W's)
Wind:thepulmonarysystemistheprimarysourceoffeverinthefirst48hours.(Atelectasis,pneumonia
ect.)
Wound:theremightbeaninfectionatthesurgicalsite.
Water:checkintravenousaccesssiteforsignsofphlebitis.
Walk:deepvenousthrombosisandpulmonayembolismcandevelopduetopelvicpoolingorrestricted
mobility
Whiz:aurinarytractinfectionispossibleifurinarycatheterizationwasrequired.
AlsoWonderdrugsdrugfevers.(addedbyCalvinLee)

Classificationofhypersensitivityreactions
"ACID"
TypeIAnaphylaxis
TypeIICytotoxicmediated
TypeIIIImmunecomplex
TypeIVDelayedhypersensitivity

CriteriaforLupus
SOAPBRAINMD
Serositis(pleuritis,pericarditis)
OralUlcers
Arthritis
Photosensitivity
Blood(allarelowanemia,leukopenia,thrombocytopenia)
Renal(protein)
ANA
Immunologic(DSDNAetc.)
Neurologic(psyc,seizures)
SubmittedbyMikeRitter,MDFAAEM,SanDiego,CA
Riskofunderlyingmalignancywithdermatomyositisorpolymyositisis30%atage30,40%atage40etc.
BlueSclera:"MIXED"
M=Marfans,
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I=Imperfecta(Osteogenesis)
XE=(pseudo)Xanthomaelasticum
ED=EhlersDanlos

AlteredMentalStatus
"AEIOUTIPS"
AAlcohol/drugs
EEndocrine
IInsulin
OOpiates
UUremia
TToxins/trauma
IInfections
PPsych/porhyria
SSAH,shock,stroke,seizure,spaceoccupyinglesion
MIDAS:Statestoexcludeascauseofcoma.
Meningitis
Intoxication
Diabetes
Airrespiratoryfailure
Subduralorsubarachnoidhemorrhage.
Levelofconsciousness
"AVPU"
Aalert
Vresondstoverbalstimuli
Prespondstopainfulstimuli
Uunconscious
Vertebral/BasilarIschemia
4Ds
dizziness(nystagmus)
diplopia(skewdeviation)
dysarthria
dysphagia
Submittedby:RonaldH.Miller,OD,TheOhioStateUniversity
CerebellarlesionsleadtoVANISHeDVertigo,Ataxia,Nystagmus,Intentiontremor,Slurredspeech,
Hypotonicreflexes,Dysdiadochokinesia.(orDementia)
MarcusGunnPupil
MarcusWelby,M.D."knows".RobertYoungwasalsoin"FatherKnowsBest".
DRKNOWS
DDeafferentationofthepupillarylightreflex
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RRetrobulbaropticneuritis
KKan'tkickinward:afferentlimbdefect
NNoconstrictiontodirectlightstimulation
OOpticnerve(CNII)damagedunilaterally
Wswingingflashlighttest
Sconsensualreflexintact

Subarachnoidhemorrhage(SAH):Ruptureofananeurysmreleasesblooddirectlyintothecerebrospinalfluid
(CSF)underarterialpressure.
Clinicalmanifestations:
CSF~FDR
FDR'sLastWords:O!CAN'TWHIP'EM
FFocalsigns:limbweakness,dysphagia,CNIIIpalsy
DDepressionofconsciousnesswithheadache
RRetinal(subhyaloid)hemorrhage
LastLuciditywithheadacheistheusualpatternofonset.
WordsWarningleaksignofimpendingrupture(controversialsign).
O(lookslikeeyes)CNIIIpalsy
Can'textendknees(Kernig'ssign)
WcircleofWillis
HHeadache:suddenonsetofsevereheadache("theworstheadacheofmylife")
IIncreasedICP
PPapilledema
EEpilepticseizures
MMeningismus

Subarachnoidhemorrhage:Rupturedberryaneurysm
AAdultpolycystickidneydisease,Anteriorcommunicatingartery
BBerryaneurysm
CCircleofWillis
DDanlosEhlersandMarfan'ssyndromes

CausesofSyncope:FADEOUT
FFaintsimplevasovagalfainting
AArrhythmiacausingcardiacsyncope
DDrugs:alcohol,illicitdrugs,nitrates,antihypertensives,sympatheticblockers
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EEyeballpressure
OOrthostatichypotension:dysautonomias
UUndiagnosedseizures
TTakayasu'sarteritis:reducedcerebralbloodflowduetoinvolvementofthecarotidandvertebralarteries.

CausesofVertigo:revolving,PIVOTINGMEN
PPetrositis,benignPositionalvertigo
IIschemicattacks:transientvertebrobasilarischemicattacks
VVestibularneuronitis
OOtherOtogeniccauses:Otosclerosis,herpeszosterOticus,Obstructedexternalauditorycanal
TTumorsofthemiddleear,labyrinth,pons,cerebellopontineangle,CNVIII
IInternalauditoryarteryocclusion
NNeuronitis:acutevestibularneuronitis
GGiantcellarteritisinternalauditoryarteryocclusion
MMeniere'sdisease
EEar:otitismedia,labyrinthitis,barotrauma
NNeuromas:acousticneuromas

Headache:STOICMP
SSentinelheadachethatprecedesamajorsubarachnoidhemorrhage(SAH)
TTemporomandibularjointdysfunction,Tensiontypeheadache,Tumors
OOther:pressure,traction,ordisplacementofextracerebralstructures.
IIndomethacinresponsiveheadache
CClusterheadache
MMeningitis,Migraineheadache
PPosttraumaticheadache,Paranasalsinuses
__________________________________________________
__________________________________________
Intracerebralhemorrhage:TIPUrHATtoMDs
TTrauma
IIdiopathic
PPenia?thrombocytopenia
UrVasculitis
HHypertension
AAmyloidangiopathy
TTumorsassociatedwithbleeding
MMalformations:AV
DbloodDyscrasias

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Subduralhemorrhage:subconsciouslydying
Elderly
Slowlydying
Alcohol
Braininjury
__________________________________________________
__________________________________________
CerebrovascularINFARCTS
IInfections:septicheartvalvevegetations
NNeoplasmsNonbacterialthromboticendocarditis
FFractureofthelongbone
AAtherosclerosis,Atrialfibrillationrelatedemboli
RReperfusion>infarct>hemorrhage
CCarotidatheromasormuralthrombi
TThromboticocclusions
SSylvanfissure:MCAisaparticularlycommonsite.

Lacunarinfarct:"Lacunar"fromtheLatinforGAPorDISPARITY
GdeepGraymatter:basalganglia
AAtherosclerosis
PhyPertension
DDysarthriaandacontralateralclumsyhandorarmduetoinfarctioninthebaseoftheponsorinthegenu
oftheinternalcapsule.(20%)
IInternalCapsule:LacunaeintheposteriorlimboftheInternalcapsulemaycausepuremotorhemiplegia
involvingtheface,arm,leg,foot.(60%)
SSubcortical,capsular,orthalamiclacunae
PPontinelesions
AAtaxichemiparesisduetoaninfarctinthebaseofthepons
RRare:LacunaeintheanteriorlimboftheInternalcapsulemaycauseseveredysarthriawithfacial
weakness.
IIpsilateralataxia(arm/leg)withlegweakness:Pontinelesion(rare)
TThalamus:LacunaeintheThalamusmaycausepuresensorystroke(10%)
yVVentrolateralThalamiclacunae

Anteriorcerebralartery(A*C*A)occlusion:
*C*ContralateralCrural(leg)monoplegia
*C*CrestofCerebralhemispheresandmedialhemisphericwallsrepresentthelegareaofthemotorstrip

Middlecerebralartery(MCA)occlusion:"DifficultywithABCsinMCA"
AApraxia
BBlindnessincorrespondinghalfofthevisualfield(contralateralhomonymoushemianopsia)
CContralateralClumsinessofarm,face.Legissomewhatspared.

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MMemorizationdifficulties
CCalculationdifficulties
AAphasiawithlanguagedominanthemispheralinvolvement.
Posteriorcerebralartery(PCA)occlusion:POST
PProximalflingmovements
OOccipitallobeinfarctionresultsincontralateralhomonymoushemianopsiawhichmaybecomplete
SSpeechandSpellingmaintained,butunabletoreadfluently
TThalamicsyndrome
__________________________________________________
__________________________________________
Awellknownmnemonicregardingocclusionofthevertebralbasilarcirculation:4D
Dizziness
Diplopia
Dysarthria
Dysphagia
__________________________________________________
__________________________________________
TypesofStroke
Stroke"HIT"you!
HHemorrhagic
IIschemic
TTIA(TransientIschemiaAttack)

T.I.A(TransientIschemicattack)
Patientsoftendescribeitasashadebeingpulledovertheireyes:SHADED
SSensorylossTIAmayheraldastroke
HHypertension,Hyperlipidemia
AAmaurosisfugax(transientmonocularblindness)

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