Step 2 UWORLD Sub Division

Question Main
Sub Division Notes

Id Division
PPSV23 - capsular material from 23 serotypes
that are responsible for majority of pneumococcal
infxns. Polysaccharides alone cant be presented
to T cells - vaccine induces T-cell-independent
B-cell response that is less effective in kids and
2386 Medicine Allergy & Immunology elderly
PCV13 - capsular polysaccharide from 13 MC
serotypes covalently attached to inactivated
diphtheria toxin. This induces a T-cell-dependent
B-cell response, high immunogenicity d/t
higher-affinity antibodies and memory cells
Angiotensin Converting Enzyme is AKA Kininase; it
fxns to degrade bradykinin. ACEI increase levels
of bradykinin, thereby leading to angioedema.
2770 Medicine Allergy & Immunology
Bradykinin promotes edema, inflammation &
sensation of pain. Angioedema from ACEI can
occur at ANYTIME.
Cyclosporine & tacrolimus have the same MOA
(calcineurin-inhibitors. The major S/E of
cyclosporine include nephrotoxicity, hyperkalemia,
hypertension, gum hypertrophy, hirsutism, and
tremor. Tacrolimus has similar toxicities, except
for hirsutism and gum hypertrophy.
Major toxicity of azathioprine is dose-related
diarrhea, leukopenia, and hepatotoxicity
Major toxicity of mycophenolate is bone marrow
suppression.
Traveling to North Africa - need HAV, HBV, polio
booster, and typhoid vaccines . MC
vaccine-preventable infectious dz is HAV. Risk of
contracting hep A is significant for those traveling
to dvlopin countries. Mortality of hepA inc w age
and approaches 3% in adults over 55ya. Most
Asian and African countries are high-risk zones.
Single dose of Hep A vaccine provids enough
protection for young immunocompetent adult. 2nd
dose admin for long-term immunity.
Rubella
Congenital dz: Sensorineural hearing loss,
intellectual disability, cardiac anomalies, cataracts,
glaucoma
Children: low-grade fever, conjunctivitis, coryza,
cervical LAD, Forschheimer spots, cephalocaudal
Obstetrics
spread of blanching erythematous maculopapular
4734 & Allergy & Immunology
rash
Gynecology
Adolescents/Adults: Same as children +
arthralgias/arthritis
Dx. PCR, acute & convalescent serology for
anti-rubella IgM & IgG
Ppx. Live attenuated rubella vaccine
Tx. Supportive
X-linked agammaglobulinemia -> Defect in tyrosine
kinase that prevents development of mature B
cells. Low B cell concentrations lead to small or
absent lymphoid tissue (tonsils, adenoids) on phys
exam and low or absent serum Ig concentrations.
2134 Pediatrics Allergy & Immunology
Infants w XLA get sinopulmonary (H influ, S
pneumo) and GI infxns (absence of IgA). Tx is all
about restoring IG by giving IVIG. Abx for infxns
and ppx if IVIG alone is unsuccessful. Live vacc
are contraindicated & other vacc don't work
Hereditary angioedema
- Rapid onset of:
Noninflammatory edema of the face, limbs &
genitalia
Laryngeal edema - can be life-threatening
Edema of the intestines resulting in colicky abd
pain
- No evidence of urticaria
Hereditary vs. Aquired. Deficiency, dysfxn, or
destruction of C1 inhibitor leads to elevated levels
of edema-producing factors C2b & bradykinin.
MCC of aquired angioedema is ACEI use.
Hereditary presents in late childhood following
infxn, dental procedure, trauma.
Bruton's agammaglobulinemia = XLA .. recessive
d/o characterized by a defect in tyrosine kinase in
B cells. This defect results in failed development
of bone marrow pre-B cells into mature circulating
B cells, which also leads to low IG production.
When maternal IgGs wane at 3-6 mnths, pts w
XLA develp recurrent sinopulmonary and GI infxns
that can be severe or chronic. Exam in older kids
shows underdeveloped lymphoid tissue (tonsils,
lymph nodes). Tx -IVIG & PPx Abx
Low serum IgA IgG + markedly elevated IgM -
Hyper-IgM syndrome (HIM) - Defective class
switching - X-linked genetic defect in the CD40
ligand - Absence of CD40 ligand prevents class
switching leading to elevated IgM levels and a
deficiency of all other Ig types.
SevereCombinedImmunoDeficiency
Etiology - Gene defect leading to failure of T cell
development, B cell dysfxn d/t absent T cells
Inheritance - X-linked recessive, Autosomal
3197 Pediatrics Allergy & Immunology recessive (adenosine deaminase)
Clinical features - Recurrent, severe, viral, fungal,
or opportunistic (ie, Pneumocystis) infxns, Failure
to thrive, Chronic diarrhea
Tx - Stem cell transplant
Recurrent bacterial infxns, severe periodontitis,
and marked leukocytosis is consistent w leukocyte
adhesion deficiency. LAD - defective integrins on
the leukocyte surface, normally allows neutrophils
to adhere to vascular endothelium, exit the
vasculature, and migrate to areas of infxn.
Recurrent skin, mucosal infxns & poor wound
healing. Exam shows notable lack of purulence.
Biopsy of infected tissue is w/o neutrophils. Serum
- leukocytosis + neutrophilia esp during infxn.
Contraindications to DTaP
Diphtheria/tetanus - anaphylaxis to vaccine
ingredients - moderate or severe acute illness +/-
fever, GBS w/in 6 weeks of tetanus
toxoid-containing vaccine, Arthus-type HSR
following diphtheria- or tetanus toxoid-containing
vaccine
Pertussis - Anaphylaxis to vaccine ingredients,
Progressive neurologic d/o (epilepsy, spasms),
encephalopathy w/in a week of previous vaccine
dose - Moderate or severe acute illness +/- fever,
Rxns to previous doses
Standard pediatric immunizations
Inactivated (killed)
Polio, HAV
Toxoid (inactivated)
Diphtheria, Tetanus
Subunit/conjugate
HBV, Pertussis, HiB, Pneumococcal,
Meningococcal, HPV, influenza (injection)
Live attenuated
Rotavirus, Measles, Mumps, Rubella, Varicella,
Influenza(intranasal)
CGD
Majority are XLR
Recurrent pulmonary & cutaneous infxns
4495 Pediatrics Allergy & Immunology Catalase-positive organisms (S aureus, Serratia,
Burkholderia, Aspergillus)
Dx - Neutrophil fxn testing (Dihydrorhodamine 123
test, Nitroblue tetrazolium test)
Severe infxns, failure to thrive, & lymphopenia
(CD19+ = B cells, CD3+ = T Cells) - Consistent w
SCID. Infxn, failure to thrive, and chronic diarrhea
in infancy are typical. Stem cell transplant is the
only definitive therapy and should be performed as
early as possible.
Contraindications to rotavirus vaccine
Anapylaxis to vaccine ingredients
Hx of intussusception
Hx of uncorrected congenital malformation of the
GI tract (eg, Meckel's diverticulum)
SCID
Tetanus-diphtheria toxoid should be given to
individuals w severe or dirty wounds who received
a booster >5 years AND those w minor clean
3325 Surgery Allergy & Immunology wounds who received a booster >10 years ago.
Tetanus immune globulin should be given to any
individual w a severe or dirty wound and an
unclear or incomplete immunization history.
Carefully read the question. Don't lose focus. Have
Biostatistics & time to lose focus after the test. Carefully think out
2135 Medicine
Epidemiology each answer choice. Fully follow through all
thoughts.
In a normal (bell-shaped) distribution:
Biostatistics &
3904 Medicine 68% of all values are w/in 1 SD from the mean.
Epidemiology
95% in 2 SDs and 99.7% in 3 SDs
Cross-sectional study AKA prevalence study -
simultaneous measurement of exposure and
Biostatistics & outcome - snapshot study frequently used for
3922 Medicine
Epidemiology surveys - cheap and easy to perform - It's major
limitation is that temporal relationship b/t exposure
and outcome is not always clear.
Effect modification results when an external
variable positively or negatively impacts the effect
of a risk factor on the dz of interest. It can be
Biostatistics & distinguished from confounding by performing a
3947 Medicine
Epidemiology stratified analysis centered on the variable of
interest. Effect modification is not a bias, but
rather is a natural phenomenon that is important to
recognize.
In a positively skewed distribution (tail on the
Biostatistics & right), the mean > median > mode. In a negatively
3992 Medicine
Epidemiology skewed distribution (tail on the left), the mean <
median < mode.
Attributable risk percent (ARP) or etiologic fraction
is an impt measure of the impact of a risk factor
being studied. ARP represents the excess risk in a
Biostatistics & pop that can be explained by the exposure to a
4157 Medicine
Epidemiology risk factor. It is calculated by subracting teh risk in
the unexposed population (baseline risk) from teh
risk in the exposed population and dividing by the
risk in the exposed population. ARP = (RR -1)/RR.
Selection biases - Inappropriate selection or poor
retention of study subjects: Ascertainment
(sampling) bias, nonresponsive bias, Berkson
Biostatistics & bias, Prevalence (Neyman) bias, Attrition bias
4178 Medicine
Epidemiology Observational biases - Inaccurate measurement
or classification of dz, exposure, or other variable:
Recall bias, Observer bias, Reporting bias,
Surveillance (detection) bias
Hazard ratios are proportions that indicate the
Biostatistics & chance of an event occuring in the tx group
7686 Medicine
Epidemiology compared to the chance of the event occuring in
the control group.
Hazard ratio is the ratio of an event rate occurring
in the treatment group compared to an event rate
Biostatistics &
7688 Medicine occuring in the non-treatment group. Ratio<1
Epidemiology
indicates treatment group had a lower rate event,
and >1 indicates higher rate event.
Factorial design studies involve randomization to
different interventions with additional study of 2 or
more variables. A factorial design involves 2 or
Biostatistics & more experimental interventions, each with 2 or
7689 Medicine
Epidemiology more variables that are studied independently. 3
interventions (metoprolol, ramipril, amlodipine) 2
different BP endpoints, and which causes
hyperkalemia w greatest frequency.
Continuity of care for medications at the time of
transitions of care, between inpatient and
outpatient facilities and w/in inpatient facilities, is a
Biostatistics &
9634 Medicine potential source of medical error. Interventions
Epidemiology
that target pharmacy personnel and high-risk
patient appear to be the most effective in
improving the quality of patient care.
Pts w symptomatic sinus bradycardia should be tx
initially w IV atropine. In pts w inadequate
2141 Medicine Cardiovascular System
response, further tx options include IV epi or
dopamine, or transcutaneous pacing
Aortic Stenosis - Exertional symps (chest pain,
dyspnea, dizziness, syncope), Delayed and
diminished carotid pulse (pulsus parvus et tardus),
single and soft S2, audible S4, Harsh ejection
2153 Medicine Cardiovascular System (crescendo-decresendo) systolic murmur in the
2nd right intercostal space w radiation to carotids.
TTE should be obtained in all pts w syncope d/t
suspected structural heart disease to confirm dx
and plan tx. Severe AS - AV replacement
Right ventricular myocardial infarction (RVMI)
presents w hypotension, eleved JVP, and clear
lung fields in the setting of acute inferior MI.
2156 Medicine Cardiovascular System Affected patients require increased RV preload to
maintain cardiac output and may need IV fluid
support. Nitrates, diuretics, and opioids can
reduce RV preload and should be avoided.
Pts dx w htn should have a detailed hx and
physical. Urinalysis for occult hematuria and urine
protein/cr ratio. Chemistry panel. Lipid profile.
Baseline EKG.
When a pt experiences recurrent VT, the 1st thing
to do after stabilizing the pt is to search for an
underlying cuase. Electrolyte imbalance d/t
diuretics is common. Furosemide causes
hypokalemia and hypomagnesemia. If
uncorrected, this can lead to VT. Furthermore,
hypokalemia potentiates S/E of digoxin, which
include arrhythmias such as VT. Therefore
ordering serum electrolytes and digoxin level is
first approach.
Fibromuscular Dysplasia (FMD) - abnormal cell
development in the arterial wall that can lead to
vessel stenosis, aneurysm, or dissection. MC
involves renal(hypertension), carotid(TIA,
2172 Medicine Cardiovascular System amaurosis fugax, stroke), and vertebral arteries.
MC in women age 15-50. Dx noninvasive imaging -
CTA of abdomen or duplex USG. If inconclusive
then - catheter-based digital subtraction
arteriography.
Indications for urgent dialysis (AEIOU)
Acidosis - metabolic acidosis (pH <7.1)
Electrolytes - Symptomatic hyperkalemia (EKG
changes or ventricular arrhythmias), severe
hyperkalemia (K>6.5)
Ingestion - Toxic alcohols, Salicylate, Lithium,
Valproate,Carbamazepine
Overload - Volume overload refractory to diuretics
Uremia - Symptomatic: Encephalopathy,
pericarditis (typical EKG findings of pericarditis
are not seen d/t lack of involvement of
epicardium), bleeding
Cholesterol embolism - recent cardiac cath -
atherosclerotic plaque is disrupted and cholesterol
crystals and debris are showered into circulation.
Clinical mnfsts can be immediate or delayed
(>30days). Atherosclerotic plaques can embolize
to the brain and cause cerebral infarction. Diffuse
emboli - periph circ can cause intestinal ischemia,
GI bleed, pancreatits, AKI. Skin mnfsts "blue toe
syndrome" cyanotic toes intact pulses, livedo
reticularis. Retina - Hollenhorst plaque
Torsades de pointes (TdP) refers to polymorphic
ventricular tachycardia that occurs in the setting of
a congenital or acquired prolonged QT interval.
2659 Medicine Cardiovascular System Immediate defibrillation is indicated in
hemodynamically unstable pts, while IV
magnesium is the first-line therapy for stable pts w
recurrent episodes of TdP.
Bradycardia, AV block, hypotension, diffuse
wheezing - Beta blocker OD. Intox w CCBs,
digoxin, and cholinergic agents looks similar, but
wheezing is more specific for Beta blocker toxicity.
MC presentation is bradycardia and hypotension
2663 Medicine Cardiovascular System leading to cardiogenic shock. Mgmt - secure
airway, give isotonic fluid, IV atropic to tx
hypotens and bradycard. Next give IV glucagon
(inc cAMP). Also can give IV Ca2+, pressors,
high-dose insulin and glucose, and IV lipid
emulsion therapy
Pts w acute arterial occlusion (limb ischemia)
clasically present w the 5 Ps (pain pallor
pulselessness paresthesia and paralysis).
Immediate anticoag and referral for emergency
vasc surgery eval should be performed in those w
2666 Medicine Cardiovascular System suspected limb ischemia. Pts w limb ischemia
should be tx immediately w IV heparin bolus
followed by cont hep infusion. Next step is referral
for emergency vasc surgery. Intra-arterial
thrombolysis, revasc, thromboembolectomy, or
amputation.
HCM - 15-25% of pts report syncope as a
symptom. AD. Systolic murmur at the left sternal
border vs aortic stenosis which at the right upper
sternal border. Worsens with decreased preload -
smaller ventricular volume leads to higher degree
of obstruction. Hypertrophied myocardium ->
primary diastolic heart failure. Beta blockers are
one of tx of choice - slow the heart and prolong
diastole - more time for heart to fill, less outflow
obstruction. CCB like diltiazem works too.
HCM - AD - mutation in one of the several genes
encoding the myocardial contractile proteins of the
cardiac sarcomere. Mutations in the cardiac
myosin binding protein C gene and cardiac
beta-myosin heavy chain gene are responsible for
about 70% of identifiable mutations in pts w HCM.
Thrombocytopenia, macrocytosis, elevated
transaminases - alcoholism -> dilated
cardiomyopathy. Total abstinence from alcohol is
the mainstay of alcoholic cardiomyopathy mgmt
and it may reverse this condition if it is employed
early in the course of disease.
MVP- myxomatous degneration of the mitral valve
leaflets and chordae and causes a mid-systolic
click followed by a mid-to-late systolic murmur-
the MCC of MR in developed countries. Usually
causes mild MR w mid-systolic click and
mid-to-late systolic murmur. Pts w severe leaflet
dysfxn and prolapse can develop severe MR and
holosystolic murmur on phys exam. Chronic MR
causes left atrial and ventricular enlargement
leading to Afib, LV dysfxn, and CHF.
Cardiac auscultation in pts w MVP typically show
a systolic click and/or mid to late systolic murmurs
2696 Medicine Cardiovascular System of MR. Squatting from a standing position
increases preload and LV volume, decreasing the
intensity of the murmur.
The 3 MCC of aortic stenosis in the general
population are senile calcific aortic stenosis,
2698 Medicine Cardiovascular System bicuspid aortic valve, and rheumatic heart disease.
A bicuspid aortic valve is the cause of aortic
stenosis in majority of patients under 70.
Restrictive cardiomyopathy (RCM) - infiltrative
diseases (sarcoidosis, amyloidosis), storage
diseases (hemochromatosis), endomyocardial
fibrosis, or idiopathic. Diastolic dysfxn. LV volume
2699 Medicine Cardiovascular System is normal. HCM - interventricular septum is
thickest. RCM - symmetric thickening. RSHF -
JVD, ankle edema, tender hepatomegaly. RCM
can cause sxs of LSHF as well. Hemochromatosis
if dx/tx early is reversible cause of RCM.
Rheumatic fever - MC in developing countries -
Mitral stenosis - increase in left atrial pressure -
transmitted to pulmonary vascular bed (->
pulmonary congestion - exertional dyspnea,
nocturnal cough, hemoptysis<-highly suspicious) -
High risk for developing Afib d/t left atrial dilation
(palpitations and irregular heartbeats) - incr risk of
developing thrombi in atria that can embolize
Cardiac amyloidosis should be suspected in pts w
unexplained CHF (predominantly diastolic dysfxn),
low voltage on EKG, and echo showing increased
wall thickness w normal left ventricular cavity
2707 Medicine Cardiovascular System dimensions (esp in pts w/o hypertension). Pts may
develop syncope or presyncope d/t conduction
abnormalities. Tissue biopsy (abd fat pad, bone
marrow, rectum, kidney, endomyocardial) can
confirm dx by showing amyloid deposits.
The outflow obstruction in HCM is d/t both a
hypertrophied interventricular septum and an
abnormality in the motion of the mitral valve
2711 Medicine Cardiovascular System leaflets referred to as systolic anterior motion
(SAM). SAM results in increased outflow
obstruction, and in some pts may be of greater
clinical consequence than septal hypertrophy.
Myxomas are the MC benign primary cardiac
tumor w approx 80% located in left atrium. Pts
typically develop consititutional symps (due to inc
prod of IL-6 - fatigue, low-grade fever, weight
2713 Medicine Cardiovascular System loss, raynaud phenom), systemic embolization
(TIA, ischemic stroke, acute embolic arterial
occlusion), and CV symps simulating MV disease
(dyspnea, orthopnea, cough, pulmonary edema,
hemoptysis)
AAA - pulsatile abdominal mass. Rupture is life
threatening; therefore all discovered require close
F/U. Imaging modality of choice for dx and f/u is
abdominal USG - nearly 100% sensi and speci,
facilitates measurement of size, and shows
presence of any assoc thrombus.
Variant angina - prinzmetal angina - temporary
spasm of coronary arteries - young women -
smoking is greatest risk factor - absence of CV
risk factors - assoc w other vasospastic d/o -
Raynaud's phenomenon and migraine headaches -
episodes occur in middle of night - exercise,
hyperventilation, emotional stress, cold exposure
or cocaine use - transient ST elevations w return
of ST segments at end of episode - CCBs or
Nitrates.
Variant angina - chest pain by coronary
vasospasm. Occurs in young females and
greatest risk factor is smoking. Affected pts
usually lack other CV risk factors. Episodes occur
at night and asssoc w transient ST elevations. Tx -
elimination of risk factors and CCBs or nitrates.
These promote vasodilation and prevent
vasoconstriction.
RVMI is d/t occlusion of proximal right coronary
artery, and seen in 30-50% of pts w acute IWMI.
Pts have hypotension, JVD, and clear lung fields.
Such pts are preload dependent and should be tx
2726 Medicine Cardiovascular System w IVF; preload-reducing meds such as nitrates
and diuretics should be avoided. STEMI in inferior
leads II, III, and aVF and kussmaul's sign (Inc JVD
w inspiration). RVMI confirmed w > or = 1mm ST
elevation in right sided precordial leads V4R-V6R.
LV free wall rupture is a mechanical complication
of transmural MI that usu occurs w/in 5days -
2weeks after MI. Majority of free wall ruptures
occur after anterior MI. Abrupt LV rupture leads to
hemopericardium and eventual cardiac
2728 Medicine Cardiovascular System tamponade. Blood in pericardial compresses the
LV. Severe compromise results in pulseless
electrical activity (PEA) w ECG showing low
voltage. LV rupture suspected in pts w PEA after
recent MI. Dx w echo, supportive care,
pericardiocentesis.
Acute pericarditis typically occurs in the first
several days after MI. Characterized by sharp,
pleuritic pain that is worse in the supine position
and improved by sitting up and leaning forward.
Diffuse ST elevations, esp w PR depressions, are
typical ECG findings. Ventricular free wall rupture
occurs 3-7 days after AWMI. Ventricular
aneurysm is a complicatoin of AWMI that occurs
days to months after initial MI - Akinesis of
involved wall, Varrhythmias, systemic embolization
Ventricular aneurysm occurs as a late
complication of acute STEMI. EKG often shows
persistent ST-segment elevation along w deep Q
2731 Medicine Cardiovascular System waves in the same leads. Progressive left
ventricular enlargement causing heart failure may
occur in addition to refractory angina, ventricular
arrhythmias or mural thrombus.
Ventricular remodeling occurs in the weeks to
months following an MI. ACE inhibitors have been
2732 Medicine Cardiovascular System shown to limit ventricular remodeling. ACE inhibitor
should be initiated w/in 24 horus after MI in all pts
w/o a contraindication.
CK-MB is the most useful lab test in assessing for
coronary re-occlusion after an MI bc it typically
returns to normal levels w/in 1-2 days. While
2737 Medicine Cardiovascular System troponin T is generally a more sensitive marker for
cardiac injury, it takes up to 10 days to return to
normal after an MI, making elevations difficult to
interpret.
Upper respiratory infection w bilat pleural effusions
and an enlarged cardiac silhouette - probs viral
pericarditis.. Electrical alternans describes QRS
complexes whose amplitudes vary from beat to
2739 Medicine Cardiovascular System beat on EKG. Result of the heart swinging back
and forth w increased quantity of pericardial fluid.
JVD, muffled heart sounds, and borderline BP
indicate developing cardiac tamponade. Echo can
confirm presence of pericardial effusion.
In otherwise young healthy patients who develop
CHF, myocarditis should be considered high on
2741 Medicine Cardiovascular System the differential. Viral infxn, esp w Coxsackie B
virus is the MCC. Patients often, THOUGH NOT
ALWAYS, have preceding viral-type symptoms.
Epigastric burning pain not relieved by antacids
but brought on by heavy lifting points to ischemic
2742 Medicine Cardiovascular System heart disease. EKG should be obtained at rest
and exercise. SLE and chronic steroid use are risk
factors for accelerated coronary atherosclerosis.
AWMI - Ischemic heart failure - Acute pulmonary
edema ("flash pulmonary edema"). Loop diuretic ie
furosemide is doc in this setting. Lasix rapidly
2743 Medicine Cardiovascular System relieves pulmonary edema by dec cardiac preload,
thereby decreasing pulmonary capillary pressure.
It also causes venodilation, which further
decreases preload.
Atrial premature beats occur when there is
premature activation of the atria originating from
tha site other than the SA node. EKG shows an
early P wave. PACs -singly or bigeminy. May be a
2744 Medicine Cardiovascular System manifest of underly heart dz. PACs usually
asymptomatic, can cause palpations. Can cause
supraventricular or vent arrhythmias. Tx required
when sxs cause distress. tobacco, alcohol,
caffeine, should be identified and avoided.
Beta-blockade is the most appropriate initial
intervention for acute aortic dissection. Type A
dissections involve the ascending aorta and are
treated w medical therapy and surgery, while
Type B dissections involve only the descending
aorta and are usually tx w medical therapy alone.
Chagas disease - T. cruzi -
megacolon/megaesophagus and cardiac disease.
Megacolon or megaesophagus (focal GI
dilatation) occur secondary to destruction of
nerves controlling GI smooth muscle. Pedal
edema, JVD, S3, cardiomegaly all point to CHF.
Can be caused by prolonged myocarditis
secondary to protozoal infection.
Pt's w WPW syndrome who develop Afib w a
rapid ventricular rate should be tx w cardioversion
or antiarrhythmics such as procainamide. AV nodal
3069 Medicine Cardiovascular System blockers such as beta blockers, CCBs, digoxin,
and adenosine should be avoided as they can
cause inc conduction through the accessory
pathway.
Exertional chest pain improves w rest - angina.
Aortic stenosis - usually from congenital bicuspid
valve - often enlarged left ventricular mass which
then requires more O2. Increased myocardial O2
demand can cause anginal pain. Accompanying
prolonged myocardial contraction and impaired
diastole, both of which reduce blood flow through
the coronary arteries
Aortic Regurg leads to inc LVEDV d/t leakage of
blood from the aorta back into the left ventricle.
Feats of AR include a wide pulse pressure, "water
hammer" pulse, and LV enlargement. The left
3092 Medicine Cardiovascular System lateral decubitus position brings the enlarged left
ventricle closer to the chest wall and causes a
pounding sensation and increased awareness of
the heartbeat. MCC in developed countries is
aortic root dilation or congenital bicuspid valve.
The murmur or aortic regurgitation is best heard
along the left sternal border at the 3rd and 4th
interspaces. It may be heard in some pts only by
applying firm pressure w the diaphragm of the
3093 Medicine Cardiovascular System stethoscope while the pt is sitting up, leaning
forward, and holding the breath in full expiration.
Congenital bicuspid aortic valve is the MCC of AR
in young adults in developed countries. Rheumatic
heart disease is MCC in developing countries.
Dietary Approaches to Stop Hypertension (DASH)
diet - rich in fruits, veggies and low-fat dairy
products. All pts w newly dx stage I htn should be
recommended to modify lifestyle. Most effective
intervention is weight loss. DASH diet, exercise,
reduce salt intake, and limit EtOH intake.
Atrial tachycardia w AV block is the arrhythmia
most specific for digitalis toxicity. Digitalis can
increase ectopy in atria or ventricles which can
lead to Atach. Atach is diff from Aflutter by its
somewhat slower rate (150-250 bpm vs 250-350
bpm). P waves are presnt but appear different
from P waves normally seen when conduction
originates in the SA node. Closer the ectopic focus
is to SA node the more normal the P wave.
Digitalis toxicity also causes AV block.
Statin s/e - Muscle injury (elevated CPK, BUN, Cr)
3158 Medicine Cardiovascular System liver injury (elevated transaminases). First step is
to DC the statin
CXR should be obtained in all patients who
undergo central venous catheterization to confirm
3504 Medicine Cardiovascular System proper placement of the catheter tip and absence
of complications before administering drugs or
other agents through the catheter.
Pulmonary toxicity is a serious adverse effect of
long-term amiodarone use that can occur months
to several years after the initiation of amiodarone
therapy. A baseline chest radiograph and PFT
shoul dbe obtained prior to initiating therapy w
amiodarone.
Pericarditis after MI - worse w deep inspiration,
improved on leaning forward, diffuse ST elevation
w exception of reciprocal depression in aVR.
Post-MI acute pericarditis occurs in the first
several days postinfarction. Dressler's syndrome -
immunologic phenomena. Malaise and s/t fever.
ESR is elevated. NSAIDs are mainstay of therapy.
Steroids can be used in refractory cases.
Acute limb ischemia - cardiac emboli, thrombosis
(vasc stents, hypercoagulable states), trauma -
sources of emboli: LV thrombus, Afib thrombus,
aortic atherosclerosis - Pts w large anterior
STEMI are at highest risk of LV thrombus and
anteroapical aneurysm formation. High risk for
systemic embolization (stroke, peripheral arterial
occlusion) and require immediate anticoag and
vasc surgery. TTE w echo must be performed to
screen for LV thrombus.
Carotid endarterectomy (CEA) is indicated in pts
w symptomatic carotid artery stenosis 70-99%.
Men w asymptomatic carotid artery stenosis of
60-99% may also benefit from CEA compared to
medical mgmt alone. All pts w cerebrovascular
disease should be started on antiplatelet agents
and statins w optimization of risk factors (smoking
cessation, glucose control, BP control).
Contrictive pericarditis is caused by pericardial
scarring and thickening that result in diastolic heart
dysfxn. Pts present w signs of decreased CO and
venous overload. Common etiologies in the US
include viruses, cardiac surgery, chest radiation,
and idiopathic causes. TB is the MCC in
developing countries and endemic areas, Africa,
India, China.
Exertional heat stroke is defined as a body temp >
40 (104F) w CNS dysfxn (encephalopathy). It is
commonly induced by strenuous exercise during
hot and humid weather. Dehydration, hypotension,
and tachycardia are common. Systemic effects
such as seizures, ARDS, DIC, and hepatic/renal
failure may also occur. Tx - rapid cooling and
supportive managment
Irregularly irregular rhythm w/ narrow-complex
tachycardia and no organized P waves consistent
w afib w rapid ventricular response. AF is a
supraventricular tachyarrhythmia w unorganized
3697 Medicine Cardiovascular System atrial activity. AF w RVR can present w ventricular
rates up to 150bpm, and symps are d/t the rate.
Hemodynamically stable pts - medical therapy -
beta blockers, diltiazem, digoxin. Unstable pts -
emergencycardioversion
Vfib and sustained Vtach are feared complications
of MI, occurring in up to 10% of cases. VF may
occur in the setting of electrolyte imbalances,
myocarditis, cardiomyopathy, and as a drug side
3698 Medicine Cardiovascular System effect. Time to defibrillation is strongly correlated
with survival. In unwitnessed arrests or witnessed
arrests occurring >5mins before arrival of
defibrillator, a cycle of CPR should precede
defibrillation.
Afib is a cardiac arrhythmia characterized by lack
of organized atrial activity. Common complication
of CABG, occurring in up to 40% of pts. In CABG
w aortic valve replacement, the incidence jumps to
over 50%. In pts who are hemodynamically
unstable - immediate cardioversion is indicated.
Premature atrial beats - P waves that are
premature relative to sinus cycle length and differ
in morphology from sinus P waves. Atrail
premature beats frequently reset the sinus node,
3700 Medicine Cardiovascular System producing pauses. QRS is normal. Premature
atrial beats may be completely normal or d/t
anxiety, CHF, hypoxia, caffeine or electrolyte
abnormalities. They never require tx and are
completely benign.
Electrical cardioversion is indicated for Sustained
Monomorphic Ventricular Tachycardia patients
who are hemodynamically unstable, pulseless, or
3763 Medicine Cardiovascular System severly symptomatic. Hemodynamically stable
patient can first be given antiarrhythmics (IV
amiodarone) as these may lead to sinus rhythm
and avoidance of the need for cardioversion.
Most cases of first-degree AV block w normal
QRS duration are d/t delayed AV nodal conduction
and require no further evaluation. Patients w
3765 Medicine Cardiovascular System first-degree AV block and prolonged QRS duration
likely have a conduction delay below the AV node
and should have electrophysiology testing to
determine its nature.
Mobitz type 1 AV block has a progressive
prolongation of the PR interval leading to a
non-conducted P wave and a "dropped" QRS
complex. It is a benign and transient arrhythmia.
Tx usually involves observation in asymptomatic
3766 Medicine Cardiovascular System patients and correction of the reversible causes
(eg, holding meds that affect AV node
conduction). Type 2 is d/t a block in His-Purkinje
system below AV node. Episodic and
unpredictable absence of conduction bt atria and
vent. II can progress to III
Complete heart block is characterized by temporal
dissociation of P waves and QRS complexes (AV
dissociation). Patients w symptomatic 3rd-degree
AV block should be managed w temporary
pacemaker insertion while undergoing futher
evaluation to identify and correct reversible
causes. A permanet pacemaker is indicated if no
reversible causes of heart block are found.
Amiodarone s/e
Pulmonary Tox: time dependent - longer term of
use increases chances of pulmonary fibrosis
developing. Not conc dependent.
Thyroid tox: Hypothyroidism (85%),
Hyperthyroidism (15%). TSH should be checked
Hepatotox: Up to 25% exp elevated
aminotransferase levels.
Cornea: Corneal deposits are common as
amiodarone is secreted by the lacrimal gland.
Vision is not affected. Don't need to stop drug.
Skin: Blue-gray skin discoloration, mostly on face
Pressors such as norepi can cause ischemia of
the distal fingers and toes secondary to
3777 Medicine Cardiovascular System vasospasm. Dx is suggested by symmetric
duskiness and coolness of all fingertips. Norepi is
a potent alpha-1 agonist.
Diabetic pts age 40-75 should be tx w statin
therapy in addition to lifestyle modification and
glucose control. Those w 10-year risk of
3822 Medicine Cardiovascular System atherosclerotic CV dz <7.5% should receive
moderate-intensity statin therapy, and those w a
risk > or = 7.5% should receive high-intensity
statin therapy. Risk calculated using ASCVD
Lipid-lowering therapy w statins is recommended
3823 Medicine Cardiovascular System for primary prevention in pts age 40-75 w a
10-year risk of ASCVD > or = 7.5%
PCI is recommended w/in 90 minutes for acute
STEMI. Additional stabilization measures - O2, full
dose aspirin, platelet P2Y12 receptor blockers
(clopidogrel), Nitroglycerin, Beta blockers,
3826 Medicine Cardiovascular System Anticoagulation. Fibrinolysis may be administered
w/in 12 hours of symptom onset for STEMI
patients who cannot undergo PCI but is assoc w
higher rates of recurrent MI, intracranial
hemorrhage, and mortality compared to PCI.
Premature Ventricular Complexes (PVCs) -
identified by wide QRS (>120msec), bizarre
morphology, and compensatory pause. Can be
seen in normal ppl, but MC in pts w cardiac
pathology. They often occur w inc frequency post-
MI. Numerous PVCs may indicate a worse
prognosis, suppressing PVCs w antiarrhythmic
meds has been shown to worsen survival. No tx
indicated if pt is asymptomatic. Beta-blockers are
first line for symptomatic pts.
Syncope:
-Arrhythmia - sudden onset, no warning signs -
presence of structural heart dz (post MI scar and
MR) - frequent ectopic beats - presence of
3881 Medicine Cardiovascular System thiazide diuretic
-Vasovagal - preceded by dizziness, weakness,
and nausea - precipitated by emotional reaction
-Autonomic dysfxn - orthostatic - usu drug induced
postural hypotension - occurs while standing
Dihydropyridine CCBs can cause peripheral
edema and should always be considered in the
3920 Medicine Cardiovascular System Ddx of this condition, along w other causes, such
as heart failure, renal disease and venous
insufficiency
Situational syncopy should be considered in the
ddx of syncopal episodes. The typical scenario
would include a middle age or older male, who
loses his consciousness immediately after
urination, or a man who loses his consciousness
during coughing fits.
Renovascular htn should be suspected in all pts w
resistant htn and diffuse atherosclerosis,
asymmetric kidney size, recurrent flash pulmonary
edema, or elevation in serum Cr >30% from
baseline after starting an ACE inihibitor or ARB.
Presence of a continous abdominal bruit has a
high specificity for the presence of renovascular
hypertension.
Resistant htn is persistent htn despite using >/= 3
antihypertensive agents. All pts w resistent htn
should be evaluated for secondary causes. Renal
artery stenosis is present in 1% of pts w mild htn,
45% of white pts w severe htn, and in 23-35% of
pts w PAD. Continous abd bruit (up to 99%
specific but only 40% sensitive), is highly
suggestive of renovascular disease.
Atheroembolism
RF - HLD, HTN, DM2. Cardiac cath or vascular
procedure
CF - Dematologic: livedo reticularis, ulcers,
gangrene, blue toe syndrome. Renal: acute or
subacute kidney injury. CNS: stroke, amaurosis
fugax. Ocular involvement: Hollenhorst plaques.
GI: intestinal ischemia, pancreatitis
Dx - Lab findings: Elevated Cr, eosinophilia,
hypocomplementemia. UA: benign w few cells, or
casts, may have eosinophiluria. Skin or renal bpx:
Biconvex, needle-shaped clefts in vessels
Systemic atheroembolism from disruption of
atherosclerotic aortic plaques (cholesterol crystal
embolism. Aortic atherosclerotic plaques occur in
patients w risk factors for atherosclerosis and can
3950 Medicine Cardiovascular System lead to systemic emboli. Embolism can happen
spontaneously but more commonly during vascular
procedures - angiography, guidewire or catheter
manipulations during cardiac cath, and intraaortic
balloon pump insertion.
Acute aortic dissection has a high mortality rate
and requires rapid dx. Effective and less invasive
modalities for rapid dx include TEE and CT of
chest w contrast. TEE is preferred over CT d/t
risk of contrast-induced nephropathy (esp in
kidney dz ppl).
Postural or orthostatic hypotension is a common
cause of syncope in elderly patients d/t impaired
baroreceptor sensitivity (autonomic failure) or
volume depletion. BUN/Cr ratio increases w
increasing severity of hypovolemia and is a
sensitive (but not specific) indicator of hypovolemia
Vasovagal syncompe is usually CLx and needs no
further testing if H&P pt strongly towards Dx and
ECG is norm. In uncertain cases can do Upright
Tilt Table Test - pt lies down strapped on an exam
3962 Medicine Cardiovascular System table. Continuous ECG and BP monitoring are
used. Exam table passively moves the pts from
supine to head-up position between
60-90degrees. Pt is held in this for 20-45 mins. If
signs of syncope the test is positive.
High-dose niacin therapy to tx lipid abnormalities
frequently produces cutaneous flushing and
pruritis. This S/E is explained by
prostaglandin-inducedperipheralvasodilatation
3973 Medicine Cardiovascular System and can be reduced by low-dose aspirin. The role
of prostaglandins is confirmed by the fact that
low-dose aspirin can greatly reduce or prevent
cutaneous flushing and pruritis if taken 30 mins
before niacin.
Hypertensive emergency is defined as marked,
sever hypertension assoc w malignant
hypertension or hypertensive encephalopathy.
Malignant hypertension is defined as the presence
of sever hypertension (>180/120mmHg) assoc w
retinal hemorrhages, exudates, and/or
papilledema. Hypertensive encephalopathy is
assoc w cerebral edema
Uremic pericarditis (UP) occurs in 6-10% of renal
failure pts, typically those w BUN >60 mg/dL.
Most UP pts do not present with the classic EKG
3979 Medicine Cardiovascular System changes of pericarditis (diffuse ST-elevations).
Hemodialysis leads to rapid resolution of chest
pain and reduces the size of any associated
pericardial effusion.
ISH is an important cause of htn in elderly pts, and
is caused by decreased elasticity of the arterial
wall. ISH should always be tx d/t it's association w
an incr risk for CV events. Initial Tx involves
monotherapy w a low dose thiazide, an ACEI, or a
long-acting CCB.
Isolated systolic hypertension - decreased
elasticity of the arterial wall - increase in SBP w/o
significant change in DBP. Heart ejects blood at
slightly higher pressure than peak systolic
measured in the aorta. Elastic properties of aorta
and major arteries dampen some of the pressure
and convert it into stored elastic energy. Elastic
recoil of the arterial walls is used to maintain DBP
when the heart relaxes. When a person ages the
elastic properties diminish.
Aortic stenosis - increased intensity of apical
impulse, narrow pulse pressure,
crescendo-decrescendo systolic murmur).
Age-dependant idiopathic sclerocalcific changes
are the MCC of isolated aortic stenosis in elderly
pts. Bicuspid aortic valve is a congenital valve that
leads to aortic stenosis but this presents in the
50s.
Pts w cocaine-associated chest pain should be tx
initially w IV benzos. These improve the symps of
psychomotor agitation, reduce myocardial O2
demand, and alleviate cardiovascular symps.
Aspirin, nitroglycerin, and CCBs are also effective
in initial mgmt. Beta-blockers are contraindicated.
Dipyridamole can be used during myocardial
perfusion scanning to reveal the areas of
restricted myocardial perfusion. The redistribution
of the coronary blood flow to 'non-diseased'
segments induced by this drug is called coronary
stealphenomenon
Dilated cardiomyopathy can be seen following viral
myocarditis, particularly after a Coxsackievirus B
infxn. Dx is made by echo, which shows dilated
ventricles and diffuse hypokinesia resulting in
systolic dysfxn (low EF). Tx is largely supportive,
involving mainly the management of CHF symps.
Vfib is the MC underlying arrhythmia responsible
for SUDDEN CARDIAC ARREST in the setting of
acute MI; >50% occur w/in the first hour of
symptom onset. Reentry is the predominant
mechanism responsible for ventricular arrhythmias
in the immediate post-infarction period. Immediate
or phase 1a - Arrhythmias occuring w/in 10 mins
of coronary occlusion - reentrant arrhythmia
Delayed (phase 1b) - 10-60 minutes after MI
abnormal automaticity
Diastolic and continuous murmurs as well as loud
systolic murmurs revealed on cardiac auscultation
should always be investigated using Doppler
echocardiography. Midsystolic soft murmurs
(grade I-II/VI) in an asymptomatic young pt are
usually benign and need no further work-up.
Anterior MI - LAD - Some or all of leads V1-V6
Inferior MI - RCA or LCX - ST elevation in leads II,
III & aVF
Posterior MI - RCA or LCX - ST depression in
V1-V3, ST elevation in I & aVL (LCX), ST
4108 Medicine Cardiovascular System depression in leads I & aVL (RCA)
Lateral MI - LCX, diagonal - ST elevation in leads
I, aVL, V5 & V6, ST depression in leads II, III &
aVF
Right Ventricle MI (occurs in 1/2 of inferior MI) -
RCA - ST elevation in leads V4-V6R
Atrial fibrillation w rapid ventricular response is the
most common arrhythmia in hyperthyroidsim
occuring in 5-15% of patients. Thyroid hormones
increase beta receptor expression which leads to
4126 Medicine Cardiovascular System increase in sympathetic activity. Beta blockers are
the recommended initial therapy to control HR and
hyperadrenergic symps. Propanolol decreases
peripheral conversion of T4 to T3. Should be given
ASAP.
Beta blockers are recommended as first-line
therapy for controlling symps and improving
exercise tolerance in pt w stable angina pectoris.
CCBs or long-acting nitrates are used if beta
blockers are contraindicated, poorly tolerated d/t
S/E, and/or in combinaion w beta blockers when
initial therapy w beta blockers alone is not
effective.
Ascending aortic aneurysms are most often due to
Cystic Medial Necrosis or connective tissue
disorders. Descending aortic aneurysms are
4129 Medicine Cardiovascular System usually due to atherosclerosis. CXR can suggest
thoracic aortic aneurysm by showing a widened
mediastinal silhoutte, increased aortic knob, and
tracheal deviation.
Hepatojugular reflux is a clinical tool that can
differentiate b/t cardiac and liver dieases-related
causes of lower-extremity edema. Pts w
peripheral edema d/t heart failure have elevated
JVP and positive hepatojugular reflux. Those w
peripheral edema from primary hepatic disease
and cirrhosis have reduced or normal JVP and
negative hepatojugular reflux.
Hyponatremia in pts w CHF parallels the severity
of heart failure and is an independent predictor of
4190 Medicine Cardiovascular System adverse clinical outcomes. It is caused by
increased renin, norepi, and ADH. Tx involves fluid
restriction, ACEI, and loop diuretics.
Pts w DM have high risk for ED, risk inc w age
and duration of DM. First-line tx for ED -> PDE-5
inhibitors. PDE5i should be used w caution bc of
4191 Medicine Cardiovascular System risk of drug interactions. Sildenafil + alpha blocker
(doxazosin) can cause severe hypotension. Pts
should be prescribed the lowest effective doses of
both meds w careful dose titration.
Statins inhibit HMG-CoA reductase - rate-limiting
enzyme in the intracellular synthesis of cholesterol
that converts HMG-CoA to mevalonate. Decr
hepatic cholesterol activates signals to increase
LDL receptors on liver cell membranes. LDL-R
pick up circulating LDL and bring it into liver cells.
Minority of pts can develop hepatic dysfxn.
Myalgia occurs in 2-10% of pts but significant
myositis w elevated Cr kinase is uncommon.
Statins decr coQ10 synthesis - involved in energy.
Basic underlying pathophys in septic shock is the
decrease in SVR d/t overall peripheral
4237 Medicine Cardiovascular System vasodilation. Hemodynamic monitoring is these pts
shows a low PCWP, low SVR, incr CO, and high
mixed venous O2 saturation.
Progressive dyspnea, decreased exercise
tolerance, AFib w rapid ventricular response and
LV systolic dysfxn - Tachycardia-mediated
Cardiomyopathy(TMCM). Various
tachyarrhythmias w prolonged rapid ventricular
4238 Medicine Cardiovascular System rates can lead to TMCM. Afib, flutter, Vtach,
junctional tach, AV nodal reentrant tach. Chronic
tach causes structural changes in the heart
including LV dilatation and myocardial dysfxn. Dx-
EKG, echo, and assesment for other causes of LV
dysfxn. AVnod blockers, antiarrhy
CHF - dyspnea, orthopnea, pulmonary and
peripheral edema, hx of MI
After MI - LV remodeling - mitral annulus
enlargement with LV dilatation and/or papillary
muscle displacement - mitral regurgitation.
4243 Medicine Cardiovascular System Ischemic caridiomyopathy -> decr CO d/t impaired
myocardial contractility. Compensatory rise in
RAA increase in SVR keeps BP high and vital
organs perfused. Increased blood volume d/t renal
sodium and water retention -> inc preload -> inc
LVEDV -> inc SV
Indications for aortic valve replacement:
1. all symptomatic pts w AS
2. pts w severe AS undergoing CABG or other
4277 Medicine Cardiovascular System valvular surgery
3. asymptomatic pts w severe AS and either poor
LV systolic fxn, LV hypertrophy > 15mm, valve
area <0.6cm^2 or abnormal response to exercise
ASA (75-325mg/day), beta blockers, ACE
inhibitors, Statins - Drugs shown to have a
mortality benefit. Clopidogrel should prescribed to
al pts w unstable angina/non-ST elevation MI, as
4298 Medicine Cardiovascular System well as patients who are post PCI. Clopidogrel,
ticlopidine - Thienopyridines. Anti-platelet effect -
antagonize ADP. Clopidogrel is an appropriate
alternative to ASA. Clopidogrel + Aspirin is more
effective than ASA alone.
Beta blockers, CCBs, and nitrates are antianginal
agents that should be withheld for at least 48
hours prior to cardiac stress testing. However,
4300 Medicine Cardiovascular System these meds should be continued in patients w
known coronary artery disease undergoing stress
testing to assess the efficacy of antianginal
therapy.
10-30% of people w 1 mm depression will not
have significant coronary disease
Orthostatic hypotension bcomes more common in
elderly people. Prolonged recumbence increases
the risk. Ppl will often note a pre-syncopal
lightheaded sensation. Classic scenario - older
person who experiences syncope upon standing
after a period of bed rest.
Electrical alternans w sinus tachycardia is a highly
specific sign for large pericardial effusion. This is
d/t the swinging motion of the heart in the
4390 Medicine Cardiovascular System pericardial cavity causing a beat-to-beat variation
in QRS axis and amplitude. Pts w cardiac
tamponade and hemodynamic compromise should
have emergency pericardiocentesis.
Diagnostic testing for CAD should not be
performed routinely in low-risk patients as they
frequently can have false-positive test results.
Patients w intermediate probability of CAD should
4395 Medicine Cardiovascular System receive appropriate stress testing based on ECG
findings and their ability to exercise. High-risk
patient should be started on appropriate medical
therapy, w expert evaluation to consider coronary
angiography.
Pleuritic chest pain, dyspnea, tachypnea, and
tachycardia in a long-distance truck driver - PE.
Other signs of PE - cough, hemoptysis, and/or
lower extremity pain or swelling (DVT). Some pts
may be asymptomatic or have other non-specific
4396 Medicine Cardiovascular System symps. CXRs - atelectasis, infiltrates, pleural
effusions, Westermark's sign (peripheral
hyperlucency d/t oligemia), Hampton's
hump(peripheral wedge of lung opacity d/t
pulmonary infarction), and Fleischner
sign(enlarged pulmonary artery).
IVDA increased risk for bacterial endocarditis
involving right-sided heart valves. Tricuspid regurg
is a common complication and typically causes a
holosystolic murmur that increases in intensity w
inspiration. Augmentation of intensity w inspiration
was shown to have 100% sensi and 88% specif in
differentiating right-sided systolic murmurs from all
others.
Pericardial effusion appears as an enlarged
"water bottle"- shaped cardiac silhouette on CXR.
Phys exam findings of effusion w/o cardiac
tamponade include diminished heart sounds on
auscultation and a maximal apical that is difficult to
palpate.
PSVT - MC paroxysmal tachycardia in people w/o
structural heart disease. Attacks begin abruptly w
HRs between 160-200/min. MC mechanism is
re-entry into AV node. Mechanical and medial
therapy for PSVT decrease AV node conductivity.
Vagal maneuvars - Valsalve, carotide sinus
massage, immersion in cold water - increase
vagal tone and decr conduction through AV node.
This slows the HR and can break the rhythm.
Adenosine can be used as well.
Acute decompensated heart failure (systolic or
diastolic dysfxn) can present w acute pulmonary
edema. Tx for pts w acute decompensated heart
failure and pulmonary edema who have normal or
elevated BP includes supplemental O2, assisted
ventilation as needed, aggressive IV diuresis, and
possible vasodilator therapy (nitroglycerine,
nitroprusside).
Worsening fatigue w irregularly irregular HR -
Atrial Fibrillation (AF). 2 major tx issues inlclude
choice between rate or rhythm contorl strategy
and risk stratification for prevention of systemic
4452 Medicine Cardiovascular System embolization. Systemic thromboemboilsm is a
major cause of morbidity in pts w AF; tx w
warfarin has been shown to significantly reduce
this risk in pts at moderate to high risk of
thromboembolic events.
Amiodarone
Cardiac - Sinus bradycardia, heart block, risk of
proarrhythmias - QT prolongation, torsades de
pointes
Pulmonary - Chronic interstitial pneumonitis
(cough, fever, dyspnea, pulmonary infiltrates)
most common
Endocrine - Hypo-, hyperparathyroidism
GI/Hepatic - Elevated transaminases, hepatitis
Ocular - Corneal microdeposits, optic neuropathy
Dermatologic - Blue-gray skin discoloration
Neurologic - Peripheral neuropathy
Digoxin is a cardiac glycoside used to tx Afib and
heart failure and is renally cleared w a narrow
therapeutic index. Toxicity presents w nausea,
vomiting, decreased appetite, confusion, and
4454 Medicine Cardiovascular System weakness. Scotomata, blurry vision, changes in
color or blindness. Viral illness or diuretic use can
lead to volume depletion that concentrates digoxin
level. Hypokalemia assoc w loop diuretics inc risk
of toxic effects.
Exertional syncope - Vtach & LV outflow
obstruction (aortic stenosis or HOCM). AS
becomes symptomatic when it is severe w valve
area <1.0 cm^2. Pts w AS have a systolic murmur
typically heard best at the right 2nd intercostal
space. Murmur begins after S1 and terminates
before S2. Classically radiates to the carotids.
Pulsus parvus et tardus - pulse that rises gradually
and has a delayed peak. Prolonged cardiac
impulse palpated at the apex.
An initial EKG should be obtained in all patients
presenting with unexplained syncope. EKG
findings suggesting an arrhythmia as the cause of
syncope include inappropriate sinus bradycardia,
sinatrial block, sinus pauses, AV block,
nonsustained ventricular arrhythmias, and short or
prolonged QTc interval. Prolonged PR interval and
QRS duration suggest bradyarrhythmia or high
grade AV block. Since it can be intermittent a
normal HR doesn't R/O
Congenital AVF - PDA, Angiomas, Pulmonary
AFV, CNS AVF,
Acquired AVF - Trauma, Iatrogenic (eg. femoral
cath), Atherosclerosis (e.g aortocaval fistula),
Cancer
4459 Medicine Cardiovascular System AVF decreases SVR, incr preload, and incr CO.
Widened pulse pressure, strong peripheral arterial
pulsation (brisk carotid upstroke), systolic flow
murmur, tachycard, flushed extremities. LVH and
pt of max impulse gets displaced to the left. ECG
shows LCH.
CYP450 Inhibitors - Acetaminophen, NSAIDs,
Abx/antifungals, amiodarone, cimetidine, cranberry
juice, gingkobiloba, Vit E, omeprazole, thyroid
hormone, SSRIs. Will inc [warfarin] d/t less
metabolism.
CYP450 Inducers - Carbamazepine, Ginseng,
Green veggies, OCPs, Phenobarbital, Rifampin,
St. John's wort
Marfan Syndrome
Skeletal - arachnodactyly, low upper:lower body
ratio, high arm:height ratio, pectus deformity,
scoliosis, kyphosis, jt hypermobility
4484 Medicine Cardiovascular System Ocular - Ectopia lentis
CV - Aortic dilation, regurg, or dissection, MVP
Pulmonary - Spontaneous pneumothorax from
apical blebs
Skin - Recurrent or incisional hernia, skin striae
Elevated pro-brain natriuretic peptide (proBNP)
level indicates CHF. BNP released in response to
ventricular stretch and wall tension when cardiac
filling pressures are elevated. The level of BNP
correlates w the severity of LV filling pressure
elevation as well as w mortality. low BNP argues
against acute heart failure w a high NPV. S3 - soft
diastolic sound produced by tensing of the
papillary chordal apparatus when rapid influx of
blood into the ventricle in early diastole
Constrictive pericarditis -scarring and loss of
normal elasticity of pericardial sac -> prevents
venous return to heart and causes RHF. Potential
late complication of radation therapy. Survivors of
Hodgkin lymphoma are at increased risk for
cardiac disease which can present 10-20 years or
more after medistinal irradiation and/or
anthracycline therapy. Complications - acute or
delayed pericardial disease, MI, RCM, CHF,
valvular abnormalities, conduction defects.
USPSTF has identified men aged 65-75 who have
smoked cigarettes as having the greatest benefit
from screening, and recommends a one-time
abdominal USG. Screening and surgical repair of
AAAs (5.5cm or greater) have been found to decr
4532 Medicine Cardiovascular System AAA-specific mortality in this population. USG is
the recommended screening modality d/t it's lower
cost, non-invasive nature, and lack of ionizing
radiation. No recommendations for or against
screening men aged 65-75 who have never
smoked.
Peripheral edema d/t venous insufficiency -
bilateral lower-extremity pitting edema, varicose
veins, and venous ulcer. Leg discomfort, pain, or
swelling that worsens w prolonged standing and
improves after walking or limb elevation. Exam
may show abnormal venous dilation
(telangiectasia, varicose veins), pitting edema,
skin discoloration, dermatitis,
lipodermatosclerosis, ulcers. Tx Elevation,
exercise, compression stockings.
Cor pulmonale is impaired fxn of the RV d/t
pulmonary htn that usually occurs d/t chronic lung
disease. Signs of RV failure include:
Elevated JVP
RV 3rd heart sound
Tricuspid regurgitation murmur
Hepatomegaly w pulsatile liver
Lower-extremity edema, ascites, and/or pleural
effusions
Echocardiogram will show signs of increased right
heart pressures, and right heart cath will show
pulmonary systolic pressure >25 mm Hg.
In patients w CHF, activation of RAAS and
production of angiotensin II causes preferential
4594 Medicine Cardiovascular System vasoconstriction of efferent renal arterioles, which
increases intraglomerular pressure in order to
maintain adequate GFR.
Most significant nonpharmacologic intervention to
decrease blood pressure is weight loss.
Antithrombotic therapy w warfarin (or other
anticoags such as dabigatran, rivaroxaban, and
apixaban) is the most effective way to reduce the
risk of systemic embolization in pts w nonvalvular
4649 Medicine Cardiovascular System atrial fib. Risk stratification w the CHADS2 (risk
for stroke) scoring system should be used in all
AF pts to assess the need for long-term anticoag.
CHADS2 score 0 - no anticoags. 1 - anticoag or
aspirin. 2-6 - anticoags.
Costochondritis - pain syndrome characterized by
tenderness of the costochondral or costosternal
4650 Medicine Cardiovascular System jxns. Pain is sharp, focal, lasts for hours, worsens
w inspiraiton and movemement. Tenderness is
reproducible w palpation.
Look for P waves. Look at PR intervals. Pay
4660 Medicine Cardiovascular System attention to the Q wave. Look at P-P interval. R-R
interval. Group beating.
IE can present with several nonspecific symptoms
and physical exam findings due to immunologic
and/or vascular phenomena. Early recognition is
4668 Medicine Cardiovascular System important to avoid a missed or late diagnosis in
such patients. Definitive diagnosis is based on
Duke criteria and requires a more comprehenisve
evaluation.
Syncope in a young pt w a
crescendo-decrescendo murmur at the lower left
sternal border is most likely d/t HOCM. Syncope
4673 Medicine Cardiovascular System in HOCM is multifactorial and can be d/t outflow
obstruction, arrhythmia, ischemia, and a
ventricular baroceptor response that
inappropriately causes vasodilation
EKG ischemia findings - Q waves, ST changes,
T-wave inversions.
Afib w rapid ventricular response- Irregularly
irregular rhythm, varying R-R intervals, no
discernible P waves, and narrow complex
tachycardia. Patients w new-onset AF should have
TSH and free T4 levels measured to screen for
occult hyperthyroidism
Substernal discomfort, left-sided neck pain,
diaphoresis, and dyspnea = acute coronary
syndrome. Acute myocardial ischemia or infarction
causes myocardial dysfxn and stiffening of the LV
myocardium and can lead to changes in normal
heart sounds. An abnormal S4 (atrial gallop) can
be heard in most patients during the acute phase
of myocardial infarction d/t ischemia induced
myocardial dysfxn. S4 is also frequently heard in
ppl w dec LV compliance.
Pts w ADPKD usually present w hypertension,
hematuria, proteinuria, palpable renal masses, or
progressive renal insufficiency. They may also
4680 Medicine Cardiovascular System have flank pain due to renal calculi, cyst rupture or
hemorrhage, or upper UTIs. Hypertension is a
common early finding in pts w ADPKD and usually
precedes the decline in renal fxn.
Abdominal bruits are foundin up to 85% of ppl w
RAS. Systolic-diastolic bruits are seen in approx
40% of pts w renal artery stenosis but <1% of pts
w/o renal artery stenosis. Differential in BP
between right and left arms; in aortic dissection,
it's accompanied by chest pain; in coarctation, it's
greater in the right arm than left; in RAS it may be
d/t subclavian atherosclerotic disease.
Heart failure w presevered LV EF - AKA Diastolic
dysfxn. Impaired filling of the left or ventricle,
either bc of impair myocardial relaxation or a
stiff-non compliant ventricle. EF may remain
normal but diastolic pressures are elevated,
4707 Medicine Cardiovascular System consequencly reducing cardiac output. Leads to
typical findings of CHF. Systemic HTN is the
classic cause of diastolic dysfxn. Chronically
elevated LV diastolic press cause left atrial
dilatation, which leads to afib. tx diuretics and BP
contr
Patients with persistent tachyarrhythmia (narrow-
or wide-complex) causing hemodynamic instability
should be managed w immediate synchornized DC
cardioversion. Pts who have minimal symptoms
and remain hemodynamically stable during an
episode of regular, narrow-complex SVT can be
managed initially w a trial of vagal maneuvers
and/or adenosine.
Most critical factor determining overall patient
survival after sudden cardiac arrest is elapsed
time to effective resuscitation. This includes
effective bystander CPR, prompt rhythm analysis,
and early defibrillation for patients found to be in
Vfib. Vfib almost never terminates spontaneously.
Hyperparathyroidism - 80% d/t parathyroid
adenoma - muscle weakness, recurrent
nephrolithiasis,neuropsychiatric symptoms,
hypercalcemia. Hypercalcemia d/t increased
calcium resporption, GI calcium absorption, and
bone resporption. Bones, Stones, Abdominal
moans, and psychiatric overtones (depression).
Significant HTN w PHPT - MEN 2.
Pulseless Electrical Activity (PEA) is the presence
of an organized rhythm on cardiac monitoring w/o
a measurable BP or palpable pulse in a cardiac
arrest patient. Guidelines recommend managing
4725 Medicine Cardiovascular System PEA w CPR and vasopressor thearpy to acheieve
adequate cerebral and coronary perfusion. CPR
should be continued uninterrupted while attempts
are made to identify and tx the reversible causes
of PEA.
Empiric abx for IE - vanco. If penicillin sensitive
then IV aqeous penicillin G (every 4-6 hrs or 24 hr
4727 Medicine Cardiovascular System continuous infusion) or IV ceftriaxone (once daily)
for 4 weeks. Oral abx NOT recmnded as initial
thearpy in IE. Parenteral abx are preferred.
Progressively decreasing baroreceptor sensitivity
and defects in the myocardial response to this
reflex are the main reasons for the increased
4728 Medicine Cardiovascular System incidence of orthostatic hypotension in the elderly.
Orthostatic hypotension - postural decrease in BP
by 20mmHg systolic or 10mmHg diastolic that
occurs on standing.
Strongest predictors of AAA expansion and
rupture are large aneurysm diameter, rapid rate of
expansion, and current cig smoking. Current
indications for operative or endovascular repair
include aneurysm size >5.5cm, rapid rate of
aneurysm expansion (>0.5cm in 6 months or >1cm
per year), and presence of sxs (ab, back, or flank
pain; limb ischemia) regardless of aneurysm size.
Acute Mitral Regurg can occur due to papillary
muscle displacement in pts w AMI. It leads to
abrupt and excessive volume overload, causing
4740 Medicine Cardiovascular System elvated left atrial and ventricular filling pressures
and acute pulmonary edema. Unline chronic MR,
acute MR does not cause an significant change in
left atrial or ventricular size and/or compliance.
Nitroglycerin -> systemic venodilation -> lowers
preload and LVEDV and reduces myocardial O2
4741 Medicine Cardiovascular System demand by reducing wall stress. Nitrates also
cause arterial and arteriolar vasodilation to a
lesser degree but can decrease SVR and BP.
WPW - accessory pathway between atrium &
ventricle resulting in preexcitation and increased
risk for tachyarrhythmias. EKG shows a shortened
PR interval, delta waves, and widening of the QRS.
S3 is a low frequency diastolic sound heard just
after S2 that is assoc w left ventricular failure. It's
believed to result when inflow from the left atrium
strikes blood that is already in the left ventricle,
causing reverberation of blood between the left
ventricular walls. IV diuretics provide symptomatic
benefits to patients w decompensated heart
failure.
The presence of a 4th heart sound produces a
rhythm that is often referred to as "TEN-nes-see,"
with S4 corresponding to the first syllable. In
adults, the S4 is an indicator of stiff left ventricle
(restrictive cardiomyopathy or LVH from prolonged
hypertension). S4 corresponds w atrial contraction
and is believed to result from teh sound of blood
striking a stiffened left ventricle.
Early diastolic murmur - AR - Varies w degree of
regurgitation. Mild AR - early diastolic murmur.
Severe AR - holodiastolic murmur. Bounding or
"water hammer" pulse - Increased stroke volume
creates high SBP following low DBP bc blood
regurgitated back into the LV.
Exertional dyspnea, dry cough, and holosystolic
murmur on auscultation - Mitral Regurgitation. Dry
cough may relate to pulmonary congestion and
4911 Medicine Cardiovascular System edema (an indicator of more severe disease that
has resulted in left ventricular dysfxn). Murmur of
MR is holosystolic heard best over the apex w
radiation to the axilla.
PSVTs are SVTs w abrupt onsent and offset; they
include AV Nodal Reentrant Tachycardia
(AVNRT), AVRT, atrial tachycardia, and jxnal
tachycardia. In hemodynamically stbale pts, next
step is to evaluate the type of SVT w use of vagal
maneuvars or IV adenosine (slow AV node
conduction and aid in the dx by unmasking
"hidden" P waves in pts w atrial flutter or Atach.
They can also cause a transient AV nodal block
and terminate AVNRTs and AVRTs
Use dependence refers to enhanced
pharmacologic effects of a drug during faster HR
and is seen w class I (esp IC) and class IV
(CCBs) antiarrhythmics. Class IC agents cause a
progressive decr in impulse conduction w faster
HR, leading to inc in QRS complex duration.
A supervise graded exercise program is the most
useful intervention to improve fxnal capacity and
reduce symptomatic claudication in patient w PAD.
Antiplatelet agents (eg, aspirin, clopidogrel)
reduce overall cardiovascular mortality.
Lipid-lowering therapy w statins should also be
given to all patients w clinically significant
atherosclerotic cardiovascular disease (ASCVD).
Afib - absent P waves replaced by tiny chaotic
fibrillatory waves, irregularly irregular R-R
intervals, and narrow QRS complexes. Pulmonary
veins are the MC location of the ectopic foci that
cause AF. Cardiac tissue extends into the PVs
and normally fxns like a sphincter to reduce reflux
of blood into PVs during atrial systole. This tissue
has different electrical props than the surrounding
atrial myocytes and is prone to ectopic electrical
foci and/or aberrant conduction.
Aortic regurg - early diastolic murmur. When due
to valvular disease - the early diastolic murmur is
best heard along the left sternal border (3rd and
4th intercostal spaces). When AR is due to aortic
root disease - it is best heard along the right
sternal border. Perivalvular abscess is seen in
approx 30-40% of pts w IE at time of surgery or
autopsy.
Studies have shown that intermittent claudication
is a strong predictor of future risk cardiovascular
M&M. Pts w PAD and intermittent claudication
have a 20% 5 year risk of MI and stroke and
15-30% 5 year risk of death d/t CV causes. Risk
rises exponentially w progression of PAD, w
estimated 25% 1 year risk of CV mortality in pts w
critical limb ischemia.
PAD is a CAD risk equivalent and medical therapy
is aggressive risk factor modification w counseling
for smoking cessation, lipid-lowering therapy, and
evaluation and tx for htn and DM. Start on
low-dose ASA and statins. Then enroll in a
supervised exercise program. Exercise for 12
weeks w 30-45 mins of exercise 3x a week.
Cilostazol and revascularization is reserved for ppl
w persistent symps despite supervised exercise
therapy.
Tc-99m is injected then single photon emission CT
(SPECT) scan is used to visualize perfusion of
myocardium. Decreased tracer uptake w stress
but normal at rest (reversible defect) indicates
inducible ischemia and likely CAD. Guidelines
recommend antiplatelet therapy (aspiring) for
prevention of MI, beta blockers, and risk factor
modifications (smoking, exercise, diet, weight loss)
Peripheral edema is a common s/e of CCBs w a
reported incidence of 25% after 6 months of
therapy. Edema is likely related to preferential
dilation of precapillary vessels (arteriolar dilation)
-> increased capillary hydrostatic pressure and
fluid extravasation into the interstitium.
Dihydropyridine CCBs (i.e. amlodipine, nifedipine)
are potent arteriolar dilators and cause more
peripheral edema than non-DHPs. Headache,
flushing dizziness are other common s/e.
Cyanide toxicity can occur in patients treated with
nitroprusside who receieve prolonged infusions,
higher doses, or have underlying renal
10763 Medicine Cardiovascular System insufficiency. It presents with altered mental
status, lactic acidosis, seizures, and coma.
Symptoms of alcohol withdrawal occur within
12-48 hours.
Constrictive pericarditis is an important caue of
RHF and is characterized by progressive
10764 Medicine Cardiovascular System peripheral edema, ascites, elevated JVP,
pericardial knock (middiastolic sound), and
pericardial calcifications on CXR.
Scleroderma renal crisis typically presents w
acute renal failure (w/o previous kidney disease)
and malignant htn (headache, blurry vision,
10767 Medicine Cardiovascular System nausea). Urinalysis may show mild proteinuria.
Peripheral blood smear can show
microangiopathic hemolytic anemia w fragmented
RBCs (schistocytes) and thrombocytopenia.
Acute type A aortic dissection can extend into the
pericardial space, causing hemopericardium and
11104 Medicine Cardiovascular System rapidly progressing to cardiac tamponade and
cardiogenic shock. Bedside TEE is typically
performed in the ED for rapid dx and early tx.
First-line agents for management of essential
Obstetrics hypertension during pregnancy are labetalol and
2400 & Cardiovascular System methyldopa. CCBs and hydralazine are acceptable
Gynecology alternate therapies. ACEI and ARBs are
contraindicated in pregnancy.
When evaluating hypertension, one should look for
secondary causes (eg. medications). OCPs can
cause mild elevations in BP & lead to overt htn
(~5% of chronic OCP users). Women who devlop
Obstetrics
htn during pregnancy or have family hx are more
3914 & Cardiovascular System
likely to get htn from OCPs. D/T
Gynecology
estrogen-mediated increase in hepatic
angiotensinogen synthesis or other effects on RA
system. Stopping OCPs can correct it over 2-12
months
Trisomy 18 - Edwards - Micrognathia,
microcephaly, rocker bottom feet, overlapping
fingers, & absent palmar creases. Congenital
heart disease occurs in >50% of affected pts;
VSD is the MC. 80% of affected children die in the
2468 Pediatrics Cardiovascular System first month, 90% in the first year and the remaining
are mentally retarded. Supravalvular aortic
stenosis is assoc w Williams' Syndrome.
Congenital heart block is assoc w Lupus.
Conotruncal abnlties - CATCH-22 syndromes
(DiGeorge & velocardiofacial)
HCM d/t asymmetrical LVH leading to left
ventricular outflow tract obstruction. More
common in African Americans. AD inheritance.
Asymptomatic or present w dyspnea, chest pain,
palpitations, or presyncope/syncope. Phys exam
2691 Pediatrics Cardiovascular System
can show a carotid pulse w dual upstroke d/t
midsystolic obstruction during cardiac contraction.
HCM w significant LVOT obstrxn causes a systolic
ejection murmur along the left sternal border w a
strong apical impulse.
Pts w a hx of rheumatic fever have an incr risk of
recurrent episodes and progression of rheumatic
heart disease w repeated infxn w GAS
pharyngitis. All such patients should receive
continuous abx ppx to prevent recurrent GAS
pharyngitis and limit the progression of rheumatic
heart disease
IM PCN G Q4weeks
RF w/o carditis - 5 years or until 21 (whichever is
longer)
RF w carditis w/o valvular issues - 10 years or
until 21
RF w carditis & valvular disease - 10 years or until
40
Kawasaki disease
Dx criteria
Fever >/= 5 days + >/=4 criteria:
Bilateralnonexudativeconjunctivitis
Mucositis (injected or fissured lips, injected
pharynx, or strawberry tongue)
3079 Pediatrics Cardiovascular System Cervical ladpy w at least 1 lymph node being >1.5
cm in diameter
Erythematous polymorphous rash
Extremity changes (edema & erythema)
Tx ASA + IVIG
Complications - Coronary artery aneurysms, MI &
ischemia
Complete AV septal defect is MC congenital heart
defect in pts w Down syndrome. Failure of
endocardial cushions to merge results in both VSD
& ASD as well as a common AV valve d/t poor MV
& TV development. Loud S2 d/t pulmonary htn,
systolic ejection murmur from increased flow
across the pulmonary valve from the left to right
shung across the ASD. Holosystolic murmur of
VSD that may be soft or absent if the defect is
large.
Turner syndrome - MC sex-chromosome
abnormality caused by complete or partial loss of
an X chromosome. 4 extremity blood pressures
and echo should be performed on all pts w 45, X
karyotype d/t increased prevalence of CV
abnormalities. MC anomalies - Bicuspid aortic
valve (20-30%), coarctation of the aorta (3-10%),
aortic root dialtion w inc risk of aortic dissection
Benign murmur
Hx: Normal appetite, energy, activities & growth.
No significant family hx.
Murmur feat: Early or mid systolic. Grade I or II
3546 Pediatrics Cardiovascular System intensity that decr on standing & valsalva
maneuver. Low-pitched, musical, puroe or
squeaky tone at LLSB (Still's murmur) or high
pitched at LUSB (pulmonary flow murmur)
No workup indicated
Fibromuscular dysplasia can present as new onset
htn in children (MCC of secondary htn in children).
Bimodal incidence, children and premenopausal
women (<50). Bruit or venous hum may be heard
at the CVA. Angiogram reveals the "string of
beads" sign.
Inherited prolonged QT syndromes
Jervell-Lange-Nielsen (autosomal recessive)
Romano-Ward (autosomal dominant)
De- and repolarization of the ventricles occurs
3910 Pediatrics Cardiovascular System during the QT interval. Duration of which varies by
HR but is normally <440ms in males and <460ms
in females. Prolonged QT intervals are MC
aquired. Symptomatic ppl w inherited type require
a beta blocker + long-term pacemaker placement.
Coarctation of the Aorta - congenital defect
characterized by stenosis of the aorta near the
ductus arteriosus - HTN in upper part of body -
Relative hypoperfusion in lower part of body -
3924 Pediatrics Cardiovascular System Prevalence in Turner's is 7% - Occasional
headaches, incr BP in both arms, leg muscle
fatigability while climbing stairs - mild continuous
murmur heard all over chest - Rib notching caused
by dilation of collateral chest wall vessels
Holosystolic murmur at lower left sternal border -
VSD - MCC (25%) of congential heart disease.
Presence of a harshe and loud murmur w normal
EKG & absence of concerning symps
(tachycardia, tachypnea, failure to thrive, right
3990 Pediatrics Cardiovascular System ventricular heave) make a small VSD most likely.
Echo shoul dbe done to determine siza & location.
Small VSDs close spontanously in 75% of children
by age 2 w no long term issues. Large defects
have softer murmurs. High-volume shunting ->
pulm htn, CHF..
Tricuspid valve atresia should be suspected in a
cyanotic infant w left axis deviation & small or
absent R waves in precordial leads. Lack of
communication bt right heart chambers results in
hypoplastic right ventricle w diminsihed RV forces
on EKG. Lack of blood flow to RV and pulm
outflow tract results in underdevelopment of
pulmonary valve and/or artery.
Transposition of great vessels
Exam: Single S2, +/- VSD murmur
Xray: egg-on-a-string heart
TOF
Exam: Harsh pulmonic stenosis & VSD murmurs
Xray: Boot-shaped heart (RVH)
Tricuspid Atresia
Exam: Single S2, VSD murmur
4260 Pediatrics Cardiovascular System Xray: Minimal pulmonary blood flow
Truncusarteriosus
Exam: Single S2, Systolic ejection murmur (incr
flow thru truncal valve)
Xray: Incr pulm blood flow, edema
TAPVR
Exam: severe cyanosis, resp distress
Xray: Pulm edema, snowman sign (enlarged
supracardiac veins)
Vascular rings, which can encircle both the
trachea and esophagus are caused by abnl
development of the aortic arch and present w
respiratory (stridor, wheezing, cough) and
4497 Pediatrics Cardiovascular System esophageal (dysphagia) symptoms. Stridor
typically improves w neck extension. Symptoms
do not improve w corticosteroids, racemic epi, or
bronchodilators. Dx rquires a high index of
suspicion.
Holosystolic murmur - left lower sternal border -
VSD - Apical diastolic rumble may be heard d/t
relatively increased flow across the mitral valve.
Echo should be performed to evaluated location &
4705 Pediatrics Cardiovascular System size of the defect. Tx depends on size of defect
and severity of symps but is generally a
combination of meds (diuretics) & transcatheter or
surgical closure, ideally well before development
of Eisenmenger syndrome.
Pericardial effusion can occur w/in days or months
after cardiac surgery and is referred to as
postpericardiotomy syndrome. Inflammation from
surgical intervention can lead to reactive
4826 Pediatrics Cardiovascular System pericarditis, pericardial effusion, or even cardiac
tamponade. Life-threatening fluid accumulation is
characterized by distant heart sounds,
hypotension, and distended jugular veins (scalp
veins in infants) and requires drainage.
The degree of right ventricular outflow tract
obstruction can fluctuate in TOF. Pts w mild
obstruciton can develop a dramatic spasm
resulting in "hypercyanotic" or "tet" spells.
Placement of pts in a knee-chest position during a
hypercyanotic spell increases SVR, increases
pulmonary blood flow, and improves symptoms
and cyanosis.
Pediatric viral myocarditis
Cause: Coxsackie B virus, Adenovirus
Clinical: Viral prodrome
Heart failure: dyspnea, syncope, tachycardia,
nausea, vomiting, HSM
CXR: cardiomegaly, pulm edema
EKG: sinus tachycardia
Echo: decr EF, diffuse hypokinesis
Endomyocardial biopsy (gold standard):
inflammatory infiltrate of myocardium w myocyte
necrosis
Prognosis: Mortality Newborns ~75%, older
infnts/children ~25%
Outcome
Full recovery w/in 2-3 mnths ~66%
DCM/Chronic HF ~33%
On CXR infants <1 yr should have a transverse
Cardiothoracic ratio of </= 60%. Children >1 year
and adults should have a CT ratio of </= 50%.
Pulmonary edema can s/t be seen on cxr. EKG
shows tachycard & nonspecific T-wave changes.
Echo is the best means of evaluating myocardial
fxn (shows global hypokinesis). Cardiac enzymes,
inflammation markers can help indicate. Gold
standard is myocardial bpx, tx should be started
based on clinical suspicion. Diuretics & inotropes
Coarctation of the aorta
Thickening of the tunica media of aortic arch near
ductus arteriosus
Clnical: Htn in extremities
Decr perfusion to lower extremities
Decr post-ductal O2 sat
Decr Femoral pulses
Lower-ext claudication (adults)
Heart failure (irritability, poor feeding,
diaphroesis); cardiogenic shock (infants)
Palpable pulsations of intercostal vessels (adults)
Tx. Surgical repair
Acute medistinitis can occur following cardiac
surgery and present w fever, chest pain,
leukocytosis, and mediastinial widening on CXR. It
is a serious condition that requires drainage,
2337 Surgery Cardiovascular System surgical debridement, and prolonged abx therapy.
Complicates 5% of sternotomies. Dx is made
when pus is noted in the mediastinum. Acute
medistinitis has a mortality rate of 10-50% even w
appropriate tx.
Acute aortic dissection - severe hyt - sudden
onset of severe, persistent and tearing chest pain
radiating to back, abdomen, or neck. Catastrophic
illness w mortality of 1-2% per hour after symp
2734 Surgery Cardiovascular System onset w complications depending on involved
structures. Dx suggested by mediastinal widening
on CXR but not always present. Dx confirmed w
contrast chest CT or Transesophageal
echocardiogram
Edema, stasis dermatitis and venous ulcerations
result from lower extremity venous insufficiency
3455 Surgery Cardiovascular System due to valve incompetence. Such dz clasically
occurs on the medial leg superior to the medial
malleolus.
AAA - severe back pain, syncope, hypotension.
AA normally 1-3cm in diameter. >3cm considered
aneurysm. AAA in people >60 and higher rate in
smokers, men, ppl w CAD. Pulsatile abdominal
3551 Surgery Cardiovascular System mass at the level of the umbilicus. Only 50% of pts
survive a rupture long enough to come to hospital.
Rupture can create aortocaval fistula.. venous
congestion in retroperitoneal structures.. fragile
and distended veins can rupture (hematuria).
Peripheral artery aneurysm manfsts as pulsatile
mass that can compress adjacent structures
(nerves, veins) and can result in thrombosis and
ischemia. Popliteal and femoral artery aneurysms
(FAA) are the MC peripheral artery aneurysms.
4241 Surgery Cardiovascular System
Frequently assoc w AAA. FAA-pulsatile mass
below inguinal ligament. Ant thigh pain due to
compression of femoral nerve that runs lateral to
the artery. Femoral is 2nd MC after popliteal
artery aneurysm.
ABI is a noninvasive test that is highly sensitive
and specific for PAD in symptomatic pts. It is the
preferred first step to confirm the dx in most
cases.
Retroperitoneal hematoma can occur as a local
vascular complication of cardiac cath, and often
presents w sudden hemodynamic instability and
ipsilateral flank or back pain. Dx is confirmed w
non-contrast CT scan of abdomen and pelvis or
abdominal USG. Tx is usu supportive w bed rest,
intensive monitoring, and IV fluids and/or blood
transfusion
Arterial occlusion in the lower extremity may arise
due to 1 of 3 major causes: embolus, thrombosis,
or trauma. All forms of occlusion cause pain,
diminished pulses, pallor, neurologic deficits and
muscle dysfxn in the affected extremity. Embolic
arterial occlusion, the pain is sudden and severe.
Majority of emboli originate from the heart
following MI or from atria in Afib.
Arterial occlusion at the bifurcation of the aorta
into the common iliac arteries (aortoiliac occlusion,
Leriche syndrome). Triad of bilat hip, thigh, and
buttock claudication, impotennce and symmetric
atrophy of the bilat lower extremities due to
chronic ischemia. Impotence is almost always
present in men w this condition. Absence of
impotence another dx should be sought.
Rapid deceleration blunt chest trauma - aortic
injury. Blunt trauma -> aortic transection ->
circulatory collapse -> death. Some have
incomplete or contained rupture. Hypotension,
external evidence of trauma, and altered mental
4527 Surgery Cardiovascular System status common. Stabilize ABCs, then assess w
xray. Widened mediastinum, large left-sided
hemothorax, deviaton of mediastinum to the right,
and disruption of normal aortic contour. Dx
confirmed via CT. Mgmt - AntiHTN and operative
repair
All patient w hypotension/shock after a MVA
should be presumed to have hypovolemic shock
from hemorrhage. Elevated PCWP at baseline
should raise the suspicion of myocardial dysfxn d/t
cardiac contusion and prompt an urgent
echocardiogram.
hypotension unresponsive to IV fluids, tachycardia,
JVD, after blunt thoracic trauma consistent w
acute cardiac tamponade. Occurs accutely in
trauma bc of bleeding into a stiff pericardium that
4556 Surgery Cardiovascular System has no elasticity. ONly 100-200mL of blood is
needed to cause a sudden rise in intrapericardial
pressure that compresses the cardiac chambers
and both venous return and CO. CXR can appear
normal. pericardiocentisis, pericardiotomy.
Tinea corporis - ring-shaped scaly patches w
central clearing and distinct borders - Trichophyton
rubrum is the most frequent culprit. Most
predominant symptom is itching - dx confirmed w
microscopic exam using KOH which revelas
2746 Medicine Dermatology
hyphae. Topical tx w 2% antifungal lotions and
creams (terbinafine) or systemic tx w griseofulvin
offers good relief. Pts w extensive disease should
be investigated for underlying d/o that cause
immunosuppression (DM, HIV...)
Tinea versicolor (pityriasis versicolor)
Pathogenesis - Malassezia globosa skin flora
grows in exposure to hot & humid weather
Clinical feats
Hypopigmented, hyperpigmented, or mildly
erythematous lesions (face in children, trunk &
upper extremities in adolescents & adults)
2747 Medicine Dermatology +/- Fine scale
+/- Pruritis
Dx
KOH prep shows hyphae & yeast cells in a
"spaghetti & meatballs" pattern
Tx
Topical ketoconazole, terbinafine, or selenium
sulfide
Scabies is a highly contagious disease d/t
infestation by the Sarcoptes scabiei mite that
presents w an intensely pruritic rash in the flexor
surfaces of the wrist, lat surfaces of the fingers,
and finger webs. Pts usu have excoriationes w
small, crusted, red papules scattered around the
affected areas. Dx is confirmed by skin scrapings
from excoriated lesions. Topical permethrin 5%
cream or oral ivermectin is the preferred tx in
adults.
Bullous pemphigoid - autoimmune blistering d/o.
Triggered by culprit meds - furosemide, NSAIDs,
captopril, penicillamine, various abx. Look for
elderly individual on many meds. Tense bullae &
2751 Medicine Dermatology urticarial plaques. Pruritis is common. Anitbody
binding activates complement and inflammatory
mediators resulting in subepidermal blister
formation. Dx - skin biopsy & DIF - IgG & C3
deposits linearly along the BM.
Normal skin at birth, gradual progression to dry
scaly skin - typical of ichthyosis. Hereditary or
acquired. Skin is usually dry and rogh w horny
plates over the extensor surfaces of the limbs. In
children, there may be relative sparing of the face
and diaper area. The condition worsens in the
winter bc of increased dryness, and is sometimes
referred to as "lizard skin."
Seborrheic dermatitis - pruritic, erythematous
plaques w greasy scale that predominantly affect
the scalp & faec. MC in the first year of life and in
middle age and can be associated w Parkinson
disease and HIV. Topical antifungal agents are
effective tx.
Basal Cell CA - MC skin malignancy in the US. It
typically presents as a slow-growing papule w
pearly rolled borders. Although BCC only rarely
metastasizes, it may invade local tissues and
should be removed. SCC is must less common
and faster growing. Often arises from a precursor
lesion, such as actinic keratosis, and typically has
overlying hyperkeratosis.
Seborrheic Keratosis (SK) - become more
common w advancing age w/o sex predilection.
MC asymptomatic but can be pruritis or tender
esp in locations that come into contact w clothing
or jewelry. Benign growths that can occur in many
2764 Medicine Dermatology locations on the body but favor the face & trunk.
Not on palms and soles. Waxy, warty "stuck on,"
and well-circumscribed appearance. Some are
flat. Color varies from pink/white to pale brown to
dark brown or black. Slow enlargement w inc
thickness
Excisional biopsy w narrow margins is the
preferred study for the dx of melanoma. If the
depth of the lesion is less than 1mm, the
2767 Medicine Dermatology melanoma can be excised w a 1cm tumor free
margin and they have a 99% 5-year survival.
Tumors greater than 1mm in depth should have a
sentinal lymph node study.
After initial VZV infection, latent infection is
established in the sensory dorsal root ganglia.
Shingles is reactivation of the latent infxn. MC in
older individuals, immunosuppressed pts or during
periods of stress. Pain usually precedes the
vesicular eruption by 48 hrs or more. Eruption is
most commonly unilateral and occurs in a
band-like fashion along the affected dermatome.
Disseminated dz can occur in severely
immunocomp pts.
Tetracyclines are an important cause of phototoxic
drug eruptions. These eruptions manifest as
exaggerated sunburn rxns w erythema, edema,
and vesicles over sun-exposed areas.
Warfarin-induced skin necrosis - assoc w protein
C deficiency - Females MC affected - MC
breasts, buttocks, thighs, and abdomen - pain
followed by bullae and skin necrosis - w/in weeks
2772 Medicine Dermatology after starting therapy - Vit K should be promptly
administered in early stages of lesion and warfarin
DCd if lesion progresses. Heparin should be used
to maintain AC until the necrotic lesions heal - Few
pts rquire skin grafting
Dermatitis Herpetiformis is assoc w
gluten-sensitive enteropathy (celiac dz). In addition
to a gluten-free diet, dapson is the tx of choice for
DH. Subsequent improvement of the lesions after
2774 Medicine Dermatology starting dapsone is considered a dx feature of the
condition. MOA of dapsone on DH is not clear but
is thought to be d/t the drug's anti-inflammatory
and immunomodulatory effects. Pruritis and
lesions improve within hours after starting the drug.
Suspect rosacea in 30- to 60-year old pts w
telangiectasia over the cheeks, nose, and chin.
Flushing of these areas is typically precipitated by
2776 Medicine Dermatology hot drinks, heat, emotion, and other causes of
rapid body temp changes. Topical antibiotic such
as metronidazole is MC prescribed initial therapy.
Telangiectasias require laser surgery.
<10% of skin: SJS
10-30%: SJS/TEN overlap
>30%: TEN
4-28 days after exposure to trigger (2 days after
repeat exposure), acute influenza like prodrome,
rapid onset erythematous macules, vesicles,
bullae, necrosis & sloughing of epidermis, mucosal
involvement
Drugs - allopurinol, sulfonamides, anticonvulsants,
NSAIDs,Sulfasalazine
Other - M. pneumoniae, vaccination, graft vs host
disease
Erysipelas - S pyogenes - Fiery, red, tender,
painful plaque w sharply demarcated edges
Cellulitis - S aureus - Folliculitis: purulence in hair
follicle, usu in areas w heavy friction/perspiration;
Furuncles: folliculitis extending into dermis, leading
to abscess; Carbuncle: more severe infxn caused
by aggregation of mult furuncles
Cellulitis (non-purulent) - Strep - Erythema, edema
& tenderness; Flat lesion w less demarcation than
in erysipelas; May include lymphangitis
Poison ivy and nickel jewelry can cause allergic
contact dermatitis - type IV HSR. Initial
sensitization occurs w/in 10-14 days of contact w
the causative substnce. On re-exposure, the
antigen is presented to sensitized lymphocytes
3811 Medicine Dermatology which release cytokines, thereby causing
inflammation within 12-48 hrs. Pts generally
present an intensely pruritic rash at area of
contact. Tx - avoiding trigger, calamine lotion,
topical antihistamines, topical steroids, oral
steroids in severe c
Condyloma acuminata (anogenital warts) caused
by HPV.. MC STD in US. Characteristic lesions
are verrucous, papilliform, and either pink or
skin-colored. Lesions are asymptomatic but may
have mild itching or burning. HPV 16, 18, 31, 33
are assoc w inc risk for SCC. HIV screening
should be offered w newly dx HPV. Tx Chemical
or physical agents (trichloroacetic acid,
podophyllin), Immune therapy (imiquimod),
Surgery (cryosurgery, excision, laser tx).
For frostbite injuries, the best tx is rapid
re-warming w warm water. Whenever frostbite or
3876 Medicine Dermatology cold injuries are dx, no attempt should be mae to
debride any tissue initially. Rapid re-warming w
dry heat (like a fan) is not effective for frostbite.
Herpetic whitlow - common viral infxn of the hand -
direct inoculation of herpes through broken skin -
HSV 1 or 2 - MC seen in women w genital herpes
or kids w herpetic gingivostomatitis - healthcare
workers are also at inc risk of this infxn d/t contact
w infected serum or saliva - ~14% of adults w
herpetic whitlow are health care workers. Pts
present w throbbing pain in the distal pulp space -
swollen, soft, tender. Lat nailfold can be affected.
Tzanck smear +.
Topical retinoids are 1st-line tx for
noninflammatory (comedonal) acne. Inflammatory
acne is tx w topical retinoids and benzoyl
4076 Medicine Dermatology peroxide. Moderate and moderate-to-severe
inflammatory acne benefits from the addition of
topical abx. Oral abx and isotretinoin are usually
reserved for severe or recalcitrant acne.
Inflammatory acne is tx w topical retinoids and
benzoyl peroxide. Moderate and
moderate-to-severe cases will benefit from the
addition of topical abx. Oral abx and isotretinoin
are usually reserved for severe or recalcitrant
acne.
Acute Graft-Versus-Host Disease (GVHD) -
common after bone marrow transplant. Up to 50%
of pts w bone marrow transplant from matched
siblings develop the disease. Target organs for
GVHD are skin (maculopapular rash involving
palms, soles, and face), intestine (blood-positive
diarrhea), liver (abnl LFTs and jaundice). Basic
pathophys is recognition of host major and minor
HLA-antigens by donor T-cells and consequent
cell-mediated immune response.
Porphyria cutanea tarda - deficiency of
uroporphyrinogen decarboxylase - painless
blisters, increased skin fragility on the dorsal
surfaces of the hands, facial hypertrichosis, and
4314 Medicine Dermatology hyperpigmentation - can be triggered by ingestion
of substances (ethanol, estrogens) that should be
DCd immediately. Dx - elevated urinary porphyrin.
Tx - Phlebotomy or hydroxychloroquine or IFN-a in
pts w HCV
Solitary ulcer not healed over 3 months located in
the keratinized epithelium of the vermillion zone of
the lower lip. Could be malignant, chronic
infectious, or chronic autoimmune. Most likely dx is
squamous cell carcinoma - characterized by
invasive cords of squamous cells w keratin perals.
Location and hx of occupational sun exposure
make SCC most likely.
Senile purpura - noninflammatory d/o that is MC in
the elderly but can also be seen in middle-aged
pts w extensive sunlight exposure. Caused by loss
of elastic fibers in the perivascular connective
tissue. Minor abrasions that would merely stretch
the skin in younger pts can rupture superficial
blood vessels in the elderly. Pts can have residual
brownish discoloration from hemosiderin
deposition. Incidence & severity increased in pts
taking ACs, steroids, and NSAIDS.
Cherry hemangiomas are small, red, cutaneous
papules common in aging adults. They do not
regress spontaneously, but they are benign and
generally do no require tx.
Actinic keratoses develop in predisposed
individuals on chronically sun-exposed areas of the
skin. The lesions consist of erythematous papules
w a central scale and a "sandpaper-like" texture.
Actinic keratoses can convert to SCC in ~1% of
cases.
Stage 1 Ulcer - Intact skin, non-blanchable w
localized redness
Stage 2 Ulcer - Shallow, open ulcer, red-pink
wound w no sloughing, possible intact or ruptured
blister
Stage 3 Ulcer - Full-thickness skin loss w possible
4610 Medicine Dermatology visible subq fat, no exposed bone, tendon, or
muscles
Stage 4 Ulcer - Full-thickness skin loss, Exposed
bone, tendon, or muscle
Unstageable - Full-thickness skin loss, Ulcer base
covered by slough and/or eschar that needs
removal to stage
Molluscum contagiosum is characterized by firm,
flesh-colored, dome-shaped, umbilicated papules.
Pts w impaired cellular immunity (HIV) are at risk
for more severe, widespread disease.
Topical 5-FU is used to tx skin conditions caused
by rapid cell division (actinic keratoses, superficial
basal cell carcinoma). These lesions are hyper
4693 Medicine Dermatology keratotic. VZV causes vesicular rash in a
dermatomal distribution. Acyclovir and other
antivirals may be used to dec both the duration of
disease and incidence of post-herpetic neuralgia.
Suppurative hidradenitis - chronic follicular
occlusive dz MC affecting intertriginous skin,
including axilla, groin, and inframammary regions -
painful inflamm nodules and draining sinus tracts
that can last weeks or longer. Allergic contact
dermatitis - inflamm skin condition caused by
allergens: poison sumac, cosmetics, and nickel.
Prsents days to weeks after exposure w intensely
pruritic erythematous rash w vesicles. Secondary
infxn as a resllt of excessive scratching-pus
Steroid-induced folliculitis - steroid acne -
monomorphous pink papules and absence of
comedones. Systemic and topical corticosteroids
can induce an acneiform eruption characterized by
monomorphos, erythematous follicular papules
distributed on the face, trunk and extremities.
Pyoderma gangrenosum - IBD
Acute multiple seborrheic keratoses - GI
malignancy
Severe seborrheic dermatitis - HIV, Parkinson
Sudden-onset severe psoriasis, recurrent herpes
8821 Medicine Dermatology zoster, molluscum contagiosum - HIV
Dermatitis herpetiformis - Celiac disease
Mult skin tags - Insulin resistance, pregnancy,
Crohn disease (perianal)
Acanthosis nigricans - Insulin resistance, GI
malignancy
Hidradenitis suppurativa (AKA acne inversa) -
chronic inflammatory occlusion of skin follicles -
MC occurs in intertriginous skin areas (axilla,
inguinal, genital, perianal, and perineum) - can
occur in any hair-bearing skin area. Most likely d/t
follicular occlusion and inability of keratinocytes to
properly shed. RF - fam hx, smoking, obesity,
mechanical stress. Initial solitary lesion that lasts
days-months. Can progress to abscess. Severe
scarring. Dx made clinically
Acute urticaria (<6 weeks) can be d/t infxns (viral,
bacterial, or parasitic), NSAIDS, and IgE mediated
(Abx, insect bites, latex, food) or direct (narcotics,
radiocontrast medium) mast cell activation. Nearly
10298 Medicine Dermatology 50% of pts have idiopathic urticaria. Pts usually
develop well-circumscribed and raised
erythematous plaques w a central pallor, along w
intense pruritus and resolution of individual skin
lesions w/in 24 hrs.
Dermatofibromas are nontender, firm,
hyperpigmented nodules that are usually <1cm in
diameter. They are d/t fibroblast proliferation and
MC occur on the lower extremities. The lesions
10402 Medicine Dermatology have a fibrous component that causes the central
area to dimple when pinched. Dx - appearance of
lesion. Tx - cryosurgery or shave excision. Tx for
cosmetic reasons or bc of recurrent cuts when
shaving legs.
Plantar warts are due to hpv infxn andbare MC
found in young adults and immunocomp ppl. The
10485 Medicine Dermatology lesions appear as hyperkeratotic papules on the
sole of the foot that can be painful when walking
or standing.
Epidermal inclusion cyst (EIC) - discrete benign
nodule containing normal epidermis that produces
keratin. EIC often occurs when epidermis
becomes lodged into the dermis d/t trauma or
comedones - although many pts have no hx of
10670 Medicine Dermatology trauma or acne. EIC can occur anywhere on body.
Lesion can grow or stay stable. Some pts develop
inflammation w rupture. Dx - clinical showing
dome-shaped, firm, and freely movable cyst or
nodule w a central punctum. I&D only for infected
lesions
Contact dermatitis - allergic rxn or direct chemical
effect of an irritant. Clinical feats - pruritis,
erythema, local swelling, and occasionally
vesicles. Continued exposure -> dry, scaly skin.
Initial mgmt - emollients and topical
glucoccorticoids. Topical tacrolimus is an alternate
therapy for areas in which glucocorticoids are
contraindicated (the face). Dx of contact
dermatitis is based on clinical findings - if initial
measures do not clear the rash, skin biopsy is req
SSSS is caused by exfoliative toxin-producing
strains of S aureus. Starts w a prodrome of fever,
irritability, & skin tenderness, which is followed by
generalized erythema and superficial flaccid
blisters w a + nikolsky sign. Scaling &
2778 Pediatrics Dermatology
desquamation follow, before resolution of disease
process. SSSS usually affects kids <10yo, but
adults w kidney dz or immune compromise may
also be affected. Tx - abx for exposed areas +
wound care.
Erythema toxicum neonatorum (benign and
evanescent): Asymptomatic, scattered
erythematous macules, papules & pustules
throughout the body - can occur any part of body
in first 2 weeks of life - no tx
Neonatal HSV: 3 patterns: Vesicular clusters on
skin, eyes & mucous membranes. CNS infxn. Or
fulminant, disseminated multi-organ dz - Tx
Acyclovir
Neonatal varicella: Fever; ranges from vesicular
clusters on skin to fulminant disease. Tx Acyclovir
Staph Scalded Skin syndrome
Congenital dermal melanocytosis (Mongolian
spot): Benign, flat, blue-grey patches usually
present over the lower back and buttocks but can
also be seen in other parts of the body. Most
infants of Africa, Asian, Hispanic, and Native
American ethnicity have Mongolian spots at birth,
and the hyperpigmentation fades spontaneously
during the first decade of life.
Impetigo - S aureus, S pyogenes - painful,
non-pruritic pustules w honey-crusted adherent
coating
Eczema herpeticum - HSV 1 - Painful vesicular
rash w "punched-out" erosions & hemorrhagic
4104 Pediatrics Dermatology crusting
Molluscum contagiosum - Poxvirus - Flesh-colored
papules w central umbilication
Tinea corporis - trichophyton rubrum - pruritic
circular patch w central clearing & raised, scaly
border
Sunburn
Prevention
Remain indoors 10am-4pm
Wear protective clothing (hats, pants,
long-sleeved shirts, tightly woven, thick, or dark
fabrics)
Apply sunscreen 30 mins before sun exposure
Avoid tanning beds
Tx
4313 Pediatrics Dermatology Mild-moderate:
Topical: cool compresses, calamine lotion, aloe
vera
Oral: NSAIDs
Severe:Hospitalization
IVF & analgesia
Wound care
Complications
Cancer: melanoma, BCC, SCC
Photoaging
Superficial infantile hemangiomas (strawberry
hemangiomas) are benign capillary tumors of
childhood. They appear during the first weeks of
life, initially grow rapidly, and typically regress
spontaneously. Some lesions may require tx w
beta blockers
Tinea corporis (ring worm)
RF - Athletes who have skin-to-skin contact.
Humid environment. Contact w infected animals
(rodents)
Presentation - Scaly, erythematous, pruritic patch
4704 Pediatrics Dermatology w centrifugal spread. Subsequent central clearing
w raised annular border
Tx - First line/localized: Topical antifungals (eg,
clotrimazole, terbinafine)
Second line/extensive: Oral antifungals
(terbinafine, griseofulvin)
Seborrheic dermatitis
Peaks in infancy & adulthood
Erythematous patches and plaques &/or yellow,
oily scales
Mild pruritis might be present
Located on scalp, face (eg, eyebrows/eyelids,
4711 Pediatrics Dermatology posterior ears, nasolabial folds), umbilicus, diaper
area
Tx
Spontaneous resolution is common
First line: Emollients, nonmedicated shampoos
Second line: Topical antifungals or low-potency
glucocorticoids
Henoch-Schonlein purpura
IgA-mediated leukoclastic vasculitis
Palpable purpura
Arthritis/arthralgia
Abd pain, intussusceptions
Renal dz similar to IgA nephropathy
Nl plt ct & coag studies
Nl to inc Cr
Hematuria +/- RBC casts +/- proteinuria
Supportive (hydration & NSAIDs) for most pts

Hospitalization & systemic glucocorticoids in pts w
severe symps
Tinea capitis
Clinical features
Scaly erythematous patch on scalp
Hair loss w residual black dot
Possiblepainful lymphadenopathy
Predominant in African Americans
Human-to-human or fomite (eg shared combs)
10553 Pediatrics Dermatology transmission
Management
KOH exam of hair shaft to document spores
Tx. Oral griseofulvin (1st line), terbinafine,
itraconazole, or fluconazole
Superficial dermatophytosis occurs MC in children.
Scaly erythematous patch that can progress to
alopecia, s/t w inflammation, & LAD
When a wound fails to heal after a prolonged
period, biopsies should be obtained to ensure the
3456 Surgery Dermatology ulcer has not degenerated into a SCC. When SCC
arises within a burn wound, these ulcers are
known as Marjolin ulcers.
In patients w significant body surface area burns,
the major cause of M&M is hypovolemic shock. In
the setting of adequate initial fluid resuscitation,
bacterial infection (usually bronchopneumonia or
burn wound infxn) leading to sepsis and septic
4550 Surgery Dermatology
shock is the leading complication. Leading causes
are pneumonia and wound infxns from S aureus
and p aeruginosa. Sepsis - worsening
hyperglycemia, leukocytosis, thrombocytopenia,
mild hypothermia, tachypnea, and tachycardia.
TMJ dysfxn - Nocturnal teeth grinding, pts think
the pain is coming from the ear. Pain is worsened
w chewing. Audible clicks or crepitus w TMJ
movement but not always present. Radiologic
2194 Medicine Ear, Nose & Throat (ENT)
imaging of TMJ is limited. Inital tx is conservative
w a nighttime bite guard, but surgical intervention
is sometimes necessary. Ramsay Hunt is VSV
that causes Bell's palsy.
A muffled voice shouuld make one consider a dx
other than uncomplicated pharyngitis or tonsillitis.
A peritonsillar abscess is a potential complication
2195 Medicine Ear, Nose & Throat (ENT) of tonsillitis and requires both IV Abx & urgent
drainage of the abscess. Deviation of the uvual
and unilateral ladpy can be helpful in distinguishing
a peritonsillar abscess from epiglottitis.
MOE - serious infxn of the ear in elderly pts w
poorly controlled DM, MCC by P aeruginosa.
Characteristic presentation consists of ear pain &
2828 Medicine Ear, Nose & Throat (ENT) ear drainage, and granulation tissue may be seen
w/in the ear canal on exam. Progression of the
infxn can lead to osteomyelitis of the skull base
and destruction of the facial nerve.
Presbycusis - sensorineural hearing loss that
occurs w aging. Typically first noted in the 6th
decade of life - characteristically symmetrical,
high-frequency hearing impairment. Pts often
complain of difficulty hearing in crowded or noisy
environments. Medications, genetics, hx of
infection, exposure to loud noise are all
contributing factors to the onset of presbycusis.
Aminoglycosides, CTX agents, aspirin, and loop
diuretics cause medication-induced ototoxicity ->
sensorineural hearing loss. Loop diuretics are
assoc w reversible or permanent hearing
impairment, reversible deafness, and/or tinnitus.
Risk is higher in ppl taking higher doses but ppl w
coexistent renal failure may experience hearing
loss or deafness at lower doses.
Serous otitis media is the MC middle ear
pathology in pts w AIDS. D/t auditory tube dysfxn
arising from HIV ladpy or obstructing lymphomas.
Serous otitis media is characterized by presence
2839 Medicine Ear, Nose & Throat (ENT) of a middle ear effusion w/o evidence of an acute
infxn. Conductive hearing loss the MC symptom
experienced by pts w serous otitis media, and
exam reveals a dull TM that is hypomobile on
pneumatic otoscopy.
Aspirin exacerbated respiratory disease (AERD)
consists of: asthma, chronic rhinosinusitis w nasal
polyposis, and bronchospasm or nasal congestion
following ingestion of aspirin or NSAIDs. Dx is
made clinically when all 3 conditions are met. Pts
complain of bland tasting food (2ndary to
anosmia), recurrent nasal DC/congestion, exam
reveals bilateral, grey, glistening mucoid masses.
Dizziness can be classified as vertigo (vs.
presyncope vs. disequilibrium) if the pt describes a
sensation of spinning accompanied by nausea.
3449 Medicine Ear, Nose & Throat (ENT) Meniere's dz is the likely cause of vertigo if the pt
also has a sensation of ear fullness. Meniere's dz
is a d/o of unclear etiology in which there is an
abnl accumulation of endolymph w/in the inner ear.
MOE - Pseudomonas aeruginosa. Tx - Abx.
Ticarcillin, Piperacillin
Ceftazidime, Cefepime
4282 Medicine Ear, Nose & Throat (ENT) Amikacin, Gentamicin, tobramycin
Ciprofloxacin(IV is empiric tx), Levofloxacin
Aztreonam
Imipenem, Meropenem
Meniere's - d/o resulting from distension of
endolymphatic compartment of inner ear. Classic
presentation consists of episodes of vertigo lasting
20 mins - 24 hrs + low-frequency, sensorineural
hearing loss & tinnitus. Vomiting & postural
instability. Triggers include EtOH, caffeine,
nicotine, foods high in salt. Strict, salt-restricted
diet is initial therapy.
Otosclerosis - common cause of conductive
hearing loss in 20-30yo ppl. Abnormal remodeling
of otic capsule thought to b a possible autoimmune
process in genetically susceptible ppl. Stapes
4902 Medicine Ear, Nose & Throat (ENT) footplate becomes fixed to the oval window. AKA
otospongiosis as CT scan may show a lucent as
opposed to sclerotic focus in the temporal bone
near oval window. Tx stapedectomy or hearing
amplification
Crohn's disease can involve any component of the
GI tract from the mouth to anus, and
characteristically has skip areas of involvement.
Although nonspecific, aphthous ulcers in the mouth
can be seen in CD. Granulomas are identified
pathologically in up to 30% of CD patients.
Sialadenosis - benign, noninflammatory, nontender
swelling of the salivary glands. Common finding in
pts w advanced liver dz (alcoholic & nonalcoholic
cirrhosis) and malnutrition (DM, bulimia). It is
11906 Medicine Ear, Nose & Throat (ENT) assoc w abnl autonomic innervation of the glands
w accumulation of secretory granules in the acinar
cells. Ddx: Sialadenitis (focal tenderness,
erythema, fever), Salivary gland stones, and
malignancy.
Laryngomalacia
Pathophys - Incr laxity of supraglottic structures
Clinical - Inspiratory stridor - worsens when
supine, crying or feeding. Improves when prone. -
Begins in neonatal period, peaks @ age 4-8
mnths, resolves by 12-18 months
2432 Pediatrics Ear, Nose & Throat (ENT)
Dx - Flexible laryngoscopy showing collapse of
supraglottic structures w inspiratoin &
omega-shaped epiglottis
Mgmt - Reassurance for most cases,
Supraglottoplasty for severe symps (poor weight
gain, apnea, cyanosis, rapidly worsening stridor)
Nasal obstruction, visible nasal mass, & frequent
nosebleeds - Juvenile angiofibroma, unless proven
otherwise. Typically found in the back of the nose
or upper throat (nasopharynx) of adolescent boys.
It is a benign growth, but is capable of eroding
and locally invading. JNAs deemed dangerous bc
they're made of BVs that can bleed a lot. Areas of
occurence are difficult to access surgically. Tx
(surger) only required if causing symptoms.
Difficult tumor to tx. High recurrence.
DDx of otalgia
AOM - middle ear effusion + acute eardrum
inflammation (bulging, fever)
Otitis media w effusion - Middle ear effusion w/o
acuteinflammation
Bullous myringitis - Serous liquid-filled blisters on
the typanic membrane
Cerumen impaction - Liquid or hard wax in
auditory canal obstructing eardrum visualization
Hemotympanum - Purple or red eardrum +/-
bulging
Otitis externa - Pain w tragal traction,
erythematous & swollen external auditory canal +/-
otorrhea
Cholesteatomas in children can either be
congenital or acquired secondary to chronic
middle ear disease. New-onset hearing loss or
chronic ear drainage despite abx therapy are
typical presenting symptoms of cholesteatomas,
and granulation tissue & skin debris may be seen
w retraction pockets of the tympanic membrane
on otoscopy.
Acute bacterial rhinosinusitis
Persistent symptoms >/= 10 days w/o
improvement
OR
3285 Pediatrics Ear, Nose & Throat (ENT) Severe symptoms, fever >/= 39 C (102 F),
purulent nasal discharge, or face pain >/= 3 days
OR
Worsening symptoms >/= 5 days after initially
improving viral URIs
Acute otitis media is a common infxn in infants &
young children, esp w cig smoke exposure, recent
or concurrent URTI, day care attendance, and
3972 Pediatrics Ear, Nose & Throat (ENT) formula intake. MCC S pneumo, non-typeable H
influenzae, & Moraxella catarrhalis. Oral amoxillin
should be administered to prevent complications
(eg, mastoiditis).
Hearing impairment in children can be hereditary
or acquired. MCC is conductive hearing loss d/t
repeated ear infxns. Undetected hearing
impairment can lead to poor language
development & social skills. Often, these children
suffer from poor self-esteem & isolate themselves
as a results. Apparent inattentiveness, difficulty
following directions, & refusal to listen can be a
result of undetected hearing impairment. Thorough
evaluation is required to make a definitive dx.
In a young individual who presents w a fleshy
immobile mass on the midline hard palate, the
most likely dx is torus palatinus. No medical or
3427 Surgery Ear, Nose & Throat (ENT)
surgical therapy is reqd unless the growth
becomes symptomatic or interferes w speech or
eating.
If a patient develops a whistling noise during
respiration following rhinoplasy, one should
suspect nasal septal perforation likely resulting
from a septal hematoma. Nasal furunculosis
results from staph folliculitis following nose picking
or nasal hair plucking. Potentially life threatening
as it can spread to the cavernous sinus. Pain,
tenderness, erythema in nasal vestibule.
Nasopharyngeal Carcinoma is highly associated
with Epstein-Barr Virus.
Rapidly developing hyperandrogenism w virilization
is highly suggestive of an androgen-secreting
neoplasm of the ovary or adrenal. Serum
testosterone and DHEAS levels are very helpful in
Endocrine, Diabetes & delineating the site of excess androgen
2170 Medicine
Metabolism production. Elevated testosterone levels w normal
DHEAS levels indicate and ovarian source,
whereas elevated DHEAS levels w relatively
normal testosterone levels indicate an adrenal
source. DHEAS from ovary, DHEA from adrenals
Best initial screening tests for pts w suspected
adrenal insufficiency are early-morning cortisol,
ACTH, and cosyntropin (analogue of ACTH)
Endocrine, Diabetes & stimulation. An increase in serum cortisol levels
2174 Medicine
Metabolism >20 microgram/dL 30-60 mins after the
administration of 250microgram cosyntropin
virtually r/o primary adrenocortical insufficiency
(addison's disease).
Panhypopituitarism
Glucocorticoid deficiency (low ACTH, low cortisol)
- fatigue, loss of appetite, hypoglycemia,
hyponatremia, eosinophilia
Endocrine, Diabetes &
2175 Medicine Testosterone deficiency (low/normal FSH and LH,
Metabolism
low testosterone) - low libido, erectile dysfxn
Hypothyroidism (low or inappropriately normal
TSH, low free T4) - cold intolerance, constipation,
bradycardia
Parathyroidectomy for primary
hyperparathyroidism is recommended for pts who
have any of the following clinical feats:
2176 Medicine Serum calcium >1 above the upper limit of normal
Metabolism
Young age
Bone mineral density T-score < -2.5 at any site
Reduced renal fxn (eGFR <60mL/min)
Antithyroid drugs PTU and MMI are associated w
agranulocytosis (seen in 0.3% of pts). Caused by
immune destruction of granulocytes, and most
cases occur w/in 90 days of tx. Routine monitoring
Endocrine, Diabetes & of granulocyte count is no effective nor advocated.
2178 Medicine
Metabolism Recommendations state once the pt shas fever
and sore throat the meds should be stopped
ASAp and WBC ct measured. WBC<1000 -
permanent discontinuation. WBC >1500 drug
toxicity is unlikely cause of sore throat and fever.
Radioactive iodine ablative therapy is the
preferred treatment for most patients with
hyperthyroidism, including Graves' disease. A
Endocrine, Diabetes & large number of patients acheieve euthyroidism w
2179 Medicine
Metabolism a single dose of radioactive iodine. 10-30% of pts
develop hypothyroidism during the first 2 years of
tx and 5% per year thereafter. Contraindications
are pregnancy and very severe ophthalmopathy
Management of DKA:
1. Restoration of intravascular volume w normal
saline
2. Correction of hyperglycemia (IV regular insulin),
electrolyte imbalances (K+ correction is crucial),
2184 Medicine and acidosis
Metabolism
3. Treatment of the precipitating cause, infections
- abx
The most appropriate initial management is rapid
IV administration of normal saline and regular
insulin.
Hyperosmolar hyperglycemic state
-Type 2 DM, older age
-More pronounced altered mentation, gradula
Endocrine, Diabetes & onset of hyperglycemic symps, hyperventilation &
2185 Medicine
Metabolism abd pain less common
-Glucose >600 mg/dL, Bicarb >18, Normal anion
gap, Negative or small serum ketones, Serum
osmolality >320
Hyperosmolar hyperglycemic state is
characterized by severe hyperglycemia w mental
status changes. Severe hyperglycemia induces an
2186 Medicine osmotic diuresis, which can lead to a deficit of
Metabolism
8-10 liters in total body water. Fluid replacement
w normal saline is the most important initial step in
mgmt of hyperosmolar hyperglycemic state.
Hypoglycemia is assoc w multipl ddx. Helpful tests
used are c-peptide, proinsulin and sulfonylurea
2188 Medicine levels, Hypoglycemia secondary to insulinoma is
Metabolism
assoc w elevated insulin, c-peptide and proinsulin
levels.
The best markers indicating resolution of DKA are
the serum anion gap and beta-hydroxybutyrate
Endocrine, Diabetes & levels. The serum anion gap estimates the
2189 Medicine
Metabolism unmeasured anion concentration in the blood and
returns to normal w disappearance of ketoacid
anions.
Most important causes of thryotoxicosis w low
radioactive iodine uptake include:
1. Subacute painless thyroiditis - painless
2. Subacute granulomatous thyroiditis (De
Quervain's) - intense pain in thyroid region
Endocrine, Diabetes & 3. Iodine-induced thyroid toxicosis
2191 Medicine
Metabolism 4. Levothyroxine OD
5. Struma ovarii (very rare ovarian teratoma)
Toxic multinoduler goiter is common in older ppl.
Pts have hetergeneous uptake of radioactive
iodine. Toxic nodules cause "hot nodules" w no
uptake in rest of gland.
Current guidelines recommend initial metformin in
DM2 w/o contraindications (eg, renal
insufficiency). Pts w suboptimal control on
metformin require a 2nd drug, w the choice
Endocrine, Diabetes & depending on factors such as patient preference,
2192 Medicine
Metabolism efficacy, risk of hypoglycemia, cost, weight gain or
desired weight loss, presence of comorbidities,
and side effects. GLP-1 agonists (eg, exenatide,
liraglutide) induce weight loss have and have lower
hypoglycemia risk.
Carcinoid tumors are rare neuroendocrine tumors
that cause episodic flushing, secretory diarrhea,
bronchospasm, and cardiac valvular abnormalities.
2220 Medicine Carcinoid cells cause increased production of
Metabolism
serotoning from tryptophan (required for niacin
synthesis), resulting in niacin deficiency (pellagra -
dermatitis, diarrhea, and dementia)
Ectopic ACTH causes more sever htn and
hypokalemia. Cortisol has high affinity for the
mineralocorticoid receptors but is normally
converted to inactive cortisone by the enzyme 11
beta hyroxyl dehydrogenase (11-beta HSD) in the
2592 Medicine renal tubular cells. However, high levels of cortisol
Metabolism
from ectopic ACTH production can saturate
11-beta HSD and instead bind to the
mineralocorticoid receptors to cause htn and
hypokalemia. Some tumors produce CRH instead
of ACTH.
Type 1 multiple endocrine neoplasia is
characterized by primary hyperparathyroidism,
Endocrine, Diabetes & pituitary tumors, and pancreatic endocrine tumors.
2630 Medicine
Metabolism In addition to hypercalcemia, patients often
develop recurrent peptic ulcers due to an assoc
gastrin-producing tumor.
Glucagonoma often presents w nonspecific
symptoms and requires a high index of suspicion
to make the dx. Glucagonoma should be
2645 Medicine suspected in pts presenting w mild DM or
Metabolism
hyperglycemia w necrotic migratory erythema,
diarrhea, anemia, and weight loss. Glucagon
>500pg/mL usually confirms the dx.
VIPoma is a rare tumor affecting the pancreatic
cells that produce Vasoactive Intestinal Peptide.
Most pts develop VIPoma syndrome (Pancreatic
Endocrine, Diabetes & cholera) - watery diarrhea, muscles
2649 Medicine
Metabolism weakness/cramps (hypokalemia), and hypo- or
achlorhydria (d/t dec gastric acid secretion). Stool
studies rare consistent w secretory diarrhea; a
VIP level >75pg/mL confirmes VIPoma dx.
The clinical manifestations of vit D toxicity are
3083 Medicine mainly d/t hypercalcemia and include constipation,
Metabolism
abdominal pain, polyuria, and polydipsia.
Plasma Ca exists in 3 forms: ionized (45%),
albumin-bound (40%), and bound to inorganic and
organic anions (15%). Homeostasis is significantly
influenced by extracellular pH level. Increased
3099 Medicine extracellular pH causes H+ to dissociate from
Metabolism
albumin, thereby freeing up albumin to bind w
calcium. This leads to decreased levels of ionized
calcium. Low ionized calcium leads to crampy
pain, paresthesias, carpopedal spasm.
Serum calcium concentration decreases by 0.8 for
Endocrine, Diabetes & every 1g/dL decrease in serum albumin.
3100 Medicine
Metabolism Corrected calcium = measured total calcium +
0.8(4 - serum albumin in g/dL)
Breast cancer causes osteolytic lesions.
Metastatic tumor cells do not directly cause bone
Endocrine, Diabetes & resorption but instead secrete factors that activate
3101 Medicine
Metabolism osteoclasts to indirectly cause bone resorption.
Metastatic breast cancer MCC hypercalcemia by
prodcung PTHrP (not produced by primary tumor).
Hypothyroidism can cause add'l metabolic
abnormalities such as hyperlipidemia,
hyponatremia, and asymptomatic elevations of
Endocrine, Diabetes & creatinine kinase and serum transaminases (AST
3483 Medicine
Metabolism and ALT). Most pts have hypercholesterolemia
alone (d/t decr LDL surface receptors and/or decr
LDL receptor activity) or combined w
hypertriglyceridemia (d/t lipoprotein lipase activity).
Although thyroid nodules in adults have a high
prevalence, most are benign. TSH measurement
and USG are 1st steps in eval. Radionuclide scan
Endocrine, Diabetes & is indicated for pts w low TSH. Hot nodules r
3484 Medicine
Metabolism almost always benign and tx for hyperthyroidism.
FNA is indicated in pts w normal or high TSH, cold
nodules, family hx of thyroid CA, or suspicious
USG findings.
Patients w generalized resistance to thyroid
hormones have high serum T4 and T3 levels w
3486 Medicine normal to mildly elevated TSH. Pts typically have
Metabolism
feats of hypothyroidism despite having elevated
free thyroid hormones.
Tx Graves
Antithyroid drugs (MC adverse affect - allergy) -

AGRANULOCYTOSIS, MMI - 1st trimester
teratogen, cholestasis. PTU - Hepatic failure,
ANCA-associated vasculitis
3487 Medicine
Metabolism
Radioiodine ablation - Permanent hypothyroidism,
worsening ophthalmopathy, radiation s/e
Surgery - Permanent hypothyroidism, risk of

recurrent laryngeal nerve damage, risk of
hypoparathyroidism
A large number of pts who undergo radioiodine
ablation develop permanent hypothyroidism, but
the chances of developing this complication are
3488 Medicine greatest in pts w Graves' disease. Since the
Metabolism
whole thyroid is hyperfxnal in Graves', radioiodine
is taken up by the entire thyroid gland, thereby
resulting in complete thyroid ablation.
Patients w osteomalacia d/t vit D deficiency have
low or low-normal serum calcium, low serum
phosphate, increased serum PTH, low plasma
Endocrine, Diabetes & 25-OH vit D levels, and elevated ALP. Unlike in
3489 Medicine
Metabolism osteoporosis most pts complain of bone pain and
muscle weakness. X-ray findings included
decreased bone density w thinning of cortex and
pseudofractures (Looser zones).
Pituitary tumor <10mm is microadenoma.
Microprolactinoma - amenorrhea, galactorrhea in
females; hypogonadism in males. Usually doesn't
cause problems w other hormones or a mass
Endocrine, Diabetes & effect. Primary tx for all prolactinomas (micro and
3492 Medicine
Metabolism macro) is medical w dopaminergic agents
(bromocriptine and cabergoline). Medical tx
normalizes prl levels and leads to significant
reduction in tumor size. Cabergoline is found to be
more effective than bromocriptine.
Prolactinomas account for 50% of primary
pituitary tumors. Usually detected early (<10mm
microadenomas) in premenopausal women d/t
assoc endocrine symps (oligo/amenorrhea,
infertility, galactorrhea). In men and
3493 Medicine post-menopausual women it produces only
Metabolism
minimal or nonspecific symps so it isn't dx till it's
much larger and produces compressive symps -
headaches, visual field defects. Men may dvlp
hypogonadotropic hypogonadism - suppresion of
GnRH by Prolactin.
Euthyroid sick syndrome ("low T3 syndrome") is
characterized by a fall in total and free T3 levels w
normal T4 and TSH levels. Thought to be a result
Endocrine, Diabetes & of decreased peripheral 5'-deiodination of T4 d/t
3495 Medicine
Metabolism caloric deprivation, elevated glucocorticoid and
inflammatory cytokine levels, and inhibitors of
5'monodeiodinase (eg, Free Fatty Acids, certain
meds).
Anti-thyroid peroxidase and anti-thyroglobulin
antibodies are present in more than 90% of pts w
Hashimoto's thyroiditis. Prevalence of positive
anti-TPO antibodies is ~30% in older females. The
3496 Medicine appearance of anti-TPO perhaps heralds the
Metabolism
occurrence of clinically significant thyroid disease
in later life. Titers of anti-TPO are higher early in
the course of Hashimoto's; these titers decrease
w time and thyroid hormone treatment.
The risk of thyroid lymphoma is 60x higher in pts w
Hashimoto's thyroiditis compared to pts w/o
thyroiditis. Typical presentation is rapid
enlargement of the thyroid gland in pts w
preexisting Hashimoto's thyroiditis. Compressive
3497 Medicine symps are common (dysphagia, voice change).
Metabolism
CT of neck shows enlargement of the thyroid
around trachea; this is known as "doughnut sign."
Thyroid USG shows pseudocystic patter. RAIU is
reduced. FNA biopsy may miss dx. Core biopsy is
often required.
Follicular thyroid CA have early hematogenous
spread to lung, brain, and bone. On histo -
invasion of capsule and blood vessels is required
Endocrine, Diabetes & for differentiating follicular CA from follicular
3499 Medicine
Metabolism adenomas. FNAB - large numbers of
normal-appearing follicular cells - commonly called
"follicular neoplasm" impossible to differentiate
from adenoma using FNAB.
MEN 2A - medullary CA of thyroid, primary
hyperparathyroidism, and pheochromocytoma.
Genetic testing (RET proto-oncogene germline
3520 Medicine mutation) is more sensitive than biochemical
Metabolism
measurement (serum calcitonin) and is the
recommended screening test for suspected MEN
2 syndromes.
Leydig cell tumor is the MC type of testicular sex
cord stromal tumors. Leydig cells are the principal
source of testosterone and are capable of
estrogen production, d/t markedly incr aromatase
3594 Medicine expression. Estrogen production is markedly incr
Metabolism
in tumorous growth of Leydig cells, w secondary
inhibition of LH and FSH. Endocrine manifestations
only in 20-30% of adults, MC being gynecomastia.
In prepubertal cases - precocious puberty
Women produce androgens, such as
androstenedione (AS), dehydroepiandrosterone
(DHEA), testosterone (T), and
dehydroepiandrosterone sulfate (DHEA-S). AS,
DHEA and T are produced byt the ovaries and
3598 Medicine adrenals, whereas DHEA-S is produced in the
Metabolism
adrenal glands only. AS, DHEA and DHEA-S re
not true androgens bc they don't interact w the
androgen receptor. They can be converted to T,
and overproduction of them causes clinical feats of
androgen excess.
Acromegaly is a clinical syndrome that is
characterized by GH excess from somatotroph
(pituitary) adeonmas. Inc GH -> excessive
insulin-like growth factor 1 (IGF-1). Excess IGF-1
Endocrine, Diabetes & leads to excessive growth of bone and soft
3634 Medicine
Metabolism tissues. Direct and indirect effects of IGF-1 also
contribute to CV manifestations. Inc incidence of
coronary heart disease, cardiomyopathy,
arrhythmias, LVH, diastolic dysfxn. Overall leading
cause of death is CV (38-62% of death)
Endocrine, Diabetes & Demopression (intranasal form preferred) is the
3729 Medicine
Metabolism 1st line tx for central DI.
Diabetic neuropathy is the MCC of diabetic foot
ulcers. Neuropathy dec pain sensation and
pressure percetpion. They occur MC in the feet
under bony prominences such as the metatarsal
Endocrine, Diabetes & heads. Punched out or undermined border.
3781 Medicine
Metabolism Peripheral sensory neuropathy can be
documented by testing for pressure sensation w a
10-g monofilament. Pts w neuropathy have loss of
monofilament sensation assoc w higher risk of foot
ulcerations.
Symmetric distal sensorimotor polyneuropathy is
the MC type of diabetic neuropathy, and is
characterized by the classic "stocking glove"
3795 Medicine pattern of sensory loss. Aside from symmetric
Metabolism
distal sensorimotor polyneuropathy, diabetes can
also cause mononeuropathies of cranial and
peripheral nerves.
Diabetic gastroparesis (delayed gastric emptying)
presents w symptoms of anorexia, nausea,
Endocrine, Diabetes & vomiting, early satiety, postprandial fullness, and
3797 Medicine
Metabolism impaired glycemic control. Prokinetic agents
(metclopromide, erythromycin, cisapride) are
useful in the mgmt of symptoms.
Diabetic neuropathy is often difficult to treat.
Current tx options include TCAs (amitriptyline,
desipramine, nortriptyline), gabapentin or NSAIDs.
Mexiletine, phenytoin, topiramate, carbamazepine
3800 Medicine and topical capsaicin cream have also been used.
Metabolism
Referral to pain mgmt may be needed. TCAs
worsen urinary symps, and orthostatic
hypotension. Gabapentin is an alternative for
these pts.
Grade 0: high-risk foot w/o ulcer
Grade 1: Superficial ulcer w full skin thickness
involvement, but no involvement of underlying tissue
Grade 2: Deep ulcer penetrating to ligament or
muscle, but no bone involvement or abscess
3803 Medicine formation
Metabolism
Grade 3: Deep ulcer w cellulitis, abscess
formation or osteomyelitis
Grade 4: Localized gangrene
Grade 5: Extensive gangrene involving the whole
foot
Screening for diabetes is recommended in
patients w sustained blood pressure >135/80 and
Endocrine, Diabetes & may be considered in all pts over 45, as well as
3807 Medicine
Metabolism those w addl RF for DM. Screening options
include fasting plasma glucose, 2-hour oral GTT
and hemoglobin A1c.
The ratio of plasma aldosterone concentration to
plasma renin activity is the preferred initial
screening test for primary hyperaldosteronism.
Adrenal suppression testing can confirm the dx,
3832 Medicine and positive tests require further adrenal imaging.
Metabolism
Adrenal venous sampling is the most sensitive test
for differentiating adrenal adenoma and bilateral
adrenal hyperplasia in patients without discrete
unilarteral adrenal mass on imaging.
Hypothyroidism should always be considered in
pts w unexplained elevation in serum creatine
3878 Medicine kinase and myopathy. ANA may be + in pts w
Metabolism
Hashimotos. Serum TSH is the most sensitive test
to Dx hypothyroidism
Oligomenorrhea, hirsutism, elevated testosterone
Endocrine, Diabetes & - PCOS. Many pts are overweight or obese.
3996 Medicine
Metabolism First-line tx is weight loss and oral
estrogen/progestin contraceptives.
Pts w hypothyroidism have inc need for
levothyroxine after started oral estrogen. Oral
estrogen decrease clearance of Thyroxine-binding
4154 Medicine globulin (TBG), leading to elevated TBG. TBG is
Metabolism
synthesized and sialylated in the liver.
Transdermal estrogen bypasses liver doesn't
affect TBG.
Failure to achieve a spontaneous erection during
the night and/or early morning is pathognomic of
organic erectile dysfunction. ED is very common
Endocrine, Diabetes & complication in pts w/ pelvic fracture and urethral
4161 Medicine
Metabolism injury. A pelvic fracture w urethral injury is
commonly accompanied by ED. The causes of ED
in this case are nerve injury and altered arterial
supply.
Metabolic syndrome - hyt, impaired fasting
glucose, dyslipidemia. 3 of 5 following criteria:
1. abdominal obesity (men: waist >40 inches;
women: waist > 35 inches)
2. Fasting glucose > 100-110mg/dL
3. Blood pressure > 130/80
4164 Medicine 4. TGs > 150
Metabolism
5. HDL (Men: <40; Women: <50)
Insulin resistance typical for pts w central-type
obesity is the key pathogenic factor in the
development of type-2 diabetes mellitus and
associated abnormalities (hypertension,
dyslipidemia)
The main substrates of gluconeogenesis are
glucogenic amino acids from muscle breakdown
(alanine, glutamine), lactate (anaerobic glycolysis),
4275 Medicine and glycerol 3-phosphate (from triacyglycerol in
Metabolism
fat). Alanine, the major gluconeogenic amino acid
in the liver, is converted to pyruvate during the
process of gluconeogenesis.
Primary hyperparathyroidism is the MCC of
hypercalcemia in ambulatory patients.
Endocrine, Diabetes & Hypercalcemia due to primary
4304 Medicine
Metabolism hyperparathyroidism is associated w elevated or
inappropriately normal serum PTH levels. Serum
phosphours may be low or normal in pts w PHPT.
Adrenoleukodystrophy is a common cause of
congenital problems that lead to adrenal
insufficiency. Typically seen in young males, its
pathophys involves accumulation of very long chain
Endocrine, Diabetes & fatty acids w/in the adrenal glands. Females are
4305 Medicine
Metabolism carriers and don't show clinical signs. Adrenal
insufficiency soon after birth also seen in CAH d/t
21-hydroxylase deficiency. Autoimmune adrenalitis
remains the MCC of primary adrenal insufficiency
in developed countries
TB is a prominent cause of primary adrenal
insufficiency in developing countries. In developed
countries, the MCC is autoimmune adrenalitis
Endocrine, Diabetes & (currently responsible for >80% of pts w primary
4306 Medicine
Metabolism adrenal cortical insuffiency). Tx of TB usually does
NOT result in normalization of adrenal fxns. Most
pts require lifelong replacement of glucocorticoids
andmineralocorticoids.
Excess thyroid hormone -> Inc Osteoclast activity
(inc bone resorption - dec bone density inc
fracture risk) -> hypercalcemia -> dec PTH
4307 Medicine -> dec vit D hydroxylation, inc vit D catabolism ->
Metabolism
dec GI Ca absorption, dec renal Ca reabsorption
-> dec renal calcium reabsorption ->
hypercalciuria, net Ca wasting
Hypercalcemia of malignancy may be due to
osteolytic metastasis, increased tumor production
of PTHrp, increased production of 1, 25-Vit D, or
Endocrine, Diabetes & increased IL-6. PTH levels are suppressed in
4308 Medicine
Metabolism patients w/ hypercal of malign. Serum Ca2+ levels
are generally much higher (>13mg/dL) in pts w
hypercalcemia of malign than those w primary
hyperparathyroidism.
Hypercalcemia due to immobilization likely is due
to inc osteoclastic bone resporption. Risk is incr in
immobilized pts w pre-existing high bone turnover
(younger individuals, older pts w Paget's disease).
Endocrine, Diabetes & Onset of hyperCa2+ depends on balance b/t
4309 Medicine
Metabolism magnitude of bone turnover and renal calcium
excretion, but the median onset is around 4 weeks
after immoblization. Pts w chornic renal failure
may dvlop hyperCa2+ early as 3 days after
immoblizaiton.
Proximal muscle weakness w or w/o muscle
atrophy can occur in 60-80% of pts w untx
hyperthyroidism and correlates to the duration of
4382 Medicine the hyperthyroid state. Hip flexors and quadriceps
Metabolism
are predominantly affected, and the weakness can
gradually progress to involve proximal muscles of
the upper extremities.
The 3 main treatment options for Graves' disease
include radioactive iodine (RAI), antithyroid drugs
(PTU, MMI), and thyroidectomy. All 3 modalities
4415 Medicine are equally effective, but surgery and RAI can
Metabolism
permanently tx hyperthyroidism. However, RAI is
associated w potential development or worsening
of Graves' ophthalmopathy.
Cushing syndrome MC iatrogenic from systemic
steroid use. Fatigue, weight gain, easy bruising,
central adiposity, proximal muscle weakness,
hyperglycemia, osteopenia and osteoporosis,
4419 Medicine hypertension, acne, cataracts, and susceptibility to
Metabolism
infxns. Most corticosteroids also have
mineralocorticoid activity and will cause renal K+
wasting. Hypokalemia of Cushing's can be tx w an
aldosterone antagonist
Addison's dz - anorexia, fatigue, GI symps -
nausea, vomiting, abd pain, diarrhea or
constipation - weight loss, hyperpigmentation, dec
BP, and vitilligo. Hyponatremia is MC electrolyte
Endocrine, Diabetes & abnormality in adrenal insufficiency, affecting up to
4420 Medicine
Metabolism 90% of pts. Result of volume contraction (lack of
mineralocorticoid) and inc vasopressin (lack of
cortisol suppression). HyperK+ is also common d/t
dec activation of aldosterone receptors. HyperK+
usu accompanied by mild hyperCl- acidosis.
In hyperthyroidism, increased radioactive Iodine
uptake (RAIU) suggests de novo thyroid hormone
synthesis, whereas decreased RAIU suggests
4588 Medicine release of preformed hormone or exogenous
Metabolism
hormone intage. Thyrotoxicosis d/t exogenous
thyroid hormone is characterized by low serum
thyroglobulin levels w a small thyroid gland.
Graves' ophthalmopathy - increased volume of
retro-orbital tissues (connective, muscular, and
adipose tissue expansion; lymphocytic infiltration) -
Endocrine, Diabetes & direct result of the anti-thyrotropin recepter
4726 Medicine
Metabolism autoantibodies stimulating the orbital fibroblasts -
Risk factors for Graves - female sex, advancing
age, smoking - Tx of Graves w RAID tends to
exacerbateophthalmopathy
Hypocalcemia.
Low Mg level? Drug? blood transfusion?
Yes -> correct underlying cause.
No -> Measure PTH

8876 Medicine
Metabolism
PTH high - Vit D deficiency, CKD, Pancreatitis,
Sepsis, Tumor lysis
PTH normal or low - Parathyroidectomy,

thyroidectomy, Radical neck surgery, metastatic
cancer, wilsons, hemochromatosis, polyglandular
autoimmune syndrome.
Foul-smelling diarrhea, weight loss, fatigue -
steatorrhea & malabsorption. Steatorrhea
prevents fat emulsification and disrupts absorption
of vit D in the intestine. Vit D mediates intestinal
Endocrine, Diabetes & Ca(2+) & PO4(3-) absorption. Lack of vit D results
8901 Medicine
Metabolism in hypocalcemia and dec phosphorus levels.
Hypocalcemia -> secondary hyperparathyroidism
w elevated PTH. Pts can be asymptomatic or
complain of bone pain or tenderness, muscle
weakness or cramps, and gait abnormalities.
Thyroid storm
Thyroid or non-thyroid surgery
Acute illness (trauma, infxn), childbirth
Acute iodine load (iodine contrast)
Fever as high as 40-41.1 (104-106), Tachycardia,
10958 Medicine htn, CHF, arrhythmias, Afib, Agitation, delirium,
Metabolism
seizure, coma, goiter, lid lag, tremor, warm &
moist skin, nausea, vomiting, diarrhea, jaundice
Tx - Beta blocker (propanalol), PTU followed by
iodine solution (SSKI), Glucocorticoids, Identify
triger & treat, supportive care
Tight blood glucose control in pts w diabetes
decreases the risk of microvasc complications
Endocrine, Diabetes & (eg, retinopathy, nephropathy), increases the risk
11367 Medicine
Metabolism of hypoglycemia, and has an uncertain effect on
macrovascular complications (eg, MI, stroke) and
all-cause mortality.
Diabetes screening should be performed in all
pregnant women. During 2nd and 3rd trimesters or
pregnancy, placenta secretes hormones that
Obstetrics cause insulin resistance. Women w inadequate
2404 & pancreatic fxn are at risk of gestational diabetes.
Metabolism
Gynecology RF - obesity, excessive weight gain during preg,
Fam hx of DM, Hispanic, African American, Native
American. All pts should undergo OGTT at end of
2nd trimester 24-28 weeks.
Neonatal thyrotoxicosis - maternal hx of Graves,
low birth weight, tachycardia, warm skin,
irritability. Transplacental passage of anti-TSH
receptor antibodies during the 3rd trimester.
Obstetrics
Endocrine, Diabetes & Antibody can be present despite maternal tx for
2423 &
Metabolism Graves. Most infants w thyrotoxicosis are born to
Gynecology
mothers w known Graves. Symptomatic pts
require methimazole and a B blocker. Condition
self-resolves as materenal antibody disappears
from circulation (weeks to months)
~90% of CAH cases are d/t 21-hydroxylase
deficiency (21hd). Low plasma cortisol stimulates
the pituitary to incrase ACTH -> adrenal
Obstetrics hyperplasia. Increase in 17-hydroxyprogesterone
2425 & is diverted toward adrenal androgen synthesis and
Metabolism
Gynecology leads to hyperadrogenism. Severe (classic) 21hd
in infancy - virilization, salt losing crisis. nonclassic
- mild, acne, irregular menses, hirsutism, no
virilzation. Boys -precocious puberty.
In pregnancy there is an increased produciton of
thyroid hormone. Significantly increased total
thyroxine (T4) and T3 concentrations. Thyroid
Obstetrics hormone production is stimulated by B-hCG which
4124 & shares a common alpha subunit w TSH. Estrogen
Metabolism
Gynecology leads to increased amount of TBG. Slight increase
in free T4 and T3. Pituitary gland responds by
decreasing TSH secretion, resulting in relatively
decr TSH levels compared to non-preg values.
Major source of estrogen in menopausal women is
from the peripheral conversion of adrenal
Obstetrics
Endocrine, Diabetes & androgens by the aromatase enzyme present in
4149 &
Metabolism adipose tissue. This process is increased in obese
Gynecology
women and may result in milder menopausal
symptoms.
Secondary amenorrhea - absence of menses
>3cycles or >6months in women who menstruated
previously. When etiology is unknown, first step is
a pregnancy test. Menstrual patterns, amount of
Obstetrics
Endocrine, Diabetes & stress and exercise, medical problems,
4220 &
Metabolism medications (OCPs, DA antags), and FHx of early
Gynecology
menopause should be explored. Exam should
assess for signs of hyperandrogenism. MCCs
secondary amenorrhea - hyperprolactinemia,
thryoid dysfxn, premature ovarian failure
Sheehan syndrome (postpartum ischemic necrosis
of the anterior pituitary) classically presents w
Obstetrics failure of postpartum lactation d/t prolactin
4678 & deficiency. Pts w Sheehan syndrome often have
Metabolism
Gynecology deficiencies of other anterior pituitary hormones in
addition to prolactin, but deficiency of posterior
pituitary hormones is uncommon.
First step in tx gestational diabetes is dietary
modification and exercise. If nutritional therapy
fails to produce euglycemia, insulin or oral
Obstetrics antidiabetic meds are indicated. Sulfonylureas are
4793 & not recommended during pregnancy - cross the
Metabolism
Gynecology placenta and cause fetal hyperinsulinemia and
neonatal hypoglycemia. Pioglitazone is not
recommended d/t adverse effects in animal repro
studies.
Uncontrolled maternal hyperglycemia is
teratogenic in early pregnancy and continues to
have numerous adverse effects on the developing
Obstetrics
Endocrine, Diabetes & fetus. There are numerous complications.
4794 &
Metabolism Persistent maternal hyperglycemia -> fetal
Gynecology
hyperglycemia -> fetal hyperinsulinemia ->
constant anabolism -> incraesed O2 demand ->
increased EPO -> polycythemia
Enzymedeficiency
21-hydroxylase - decr aldosterone & cortisol, incr
Endocrine, Diabetes & testosterone, incr 17-OH-progesterone
3600 Pediatrics
Metabolism 11B-hydroxylase - decr aldosterone & cortisol,
incr testosterone, incr 11-deoxycorticosterone &
11-deoxycortisol
Infants w congenital hypothyroidism initially appear
normal at birth, but gradually develop apathy,
weakness, hypotonia, large tongue, sluggish
3662 Pediatrics mvmnt, abd bloating, and an umbilical hernia. For
Metabolism
this reason, screening newborns for
hypothyroidism, along w PKU and galactosemia, is
standarly performed in all states.
Congenitalhypothyroidism
Thyroid dysgenesis (MCC)
Majority of infants are asymptomatic. Symptoms
Endocrine, Diabetes & include lethargy, hoarse cry, poor feeding,
3721 Pediatrics
Metabolism constipation, jaundice, dry skin, large fontanelles
Dx - Incr TSH, Decr free T4. Most infants
identified by newborn screening
Tx - Levothyroxine
Gynecomastia can occur in up to 2/3 pubertal
boys and presents as a unilateral or bilateral firm
subareolar nodule (sometimes tender to touch).
Pubertal gynecomastia resolves in most pts w/in a
few months to 2 years w/o intervention.
Pathologic causes
Endocrine, Diabetes & Tumors
3783 Pediatrics
Metabolism Cirrhosis or malnutrition
Thyrotoxicosis
Congenital excessive aromatase activity
Androgen use
Drugs (spirinolactone, cimetidine) herbal procuts
(tea tree oil, lavender oil)
Androgen deficiency - Renal failure, hyperPRL
Gonadotropin-dependent (central) precocious
puberty (GDPP) results from premature activation
of the HPG axis. Clinical - premature adrenearche
(axillary & pubic hair), thelarche (breast
dvelopment), & menarche, or advanced bone age.
3875 Pediatrics LH levls r high at baseline or after GnRH
Metabolism
stimulation. CDPP is MC idiopathic, all pts w it
should get brain MRI w contrast. Primary tx for
GDPP is GnRH agonist therapy to prevent
premature epiphyseal plate closure. Girls age <6
w tx can grow 10cm
In GnRH-independent (peripheral) precocious
puberty, LH levels are low at baseline & dont incr
Endocrine, Diabetes & after stimulation w a GnRH agonist. Advanced
4239 Pediatrics
Metabolism bone age, coarse axillary and pubic hair, & severe
cystic acne are seen in late-onset (nonclassic)
CAH caused by 21-hydroxylase deficiency.
Dry mucous membranes, polyuria, decr LOC,
diffuse abd pain, metabolic acidosis, following an
URTI - DKA. Infxn can precipitate DKA d/t
systemic release of insulin counterregulatoy
hormones ie catecholamines & cortisol. Resultant
4514 Pediatrics excess glucagon causes hyperglycemia,
Metabolism
ketonemia, & an osmotic diuresis. Diuresis
accompanied by a net renal loss of K+ w depletion
of total body stores. Despite this reduction in K+,
serum [K+] may be elevated d/t acidemia & decr
insulinactivity.
Refeeding syndrome
When an anorexic or someone who hasn't eaten in
a long time suddenly eats. Carbohydrate ingestion
causes insulin secretion and cellular uptake of
phosphorus, potassium, and magnesium.
8871 Pediatrics Phosphorus is the primary deficient electrolyte as
Metabolism
it is required for ATP. Deficiencys in K+ & Mg2+
cause cardiac arrhythmias in a heart already
atrophic from malnutrition. Aggressive nutrition w/o
adequate electrolytes -> Cardiopulmonary failure
(inc HR, RR, JVD, lung crackle
Acute adrenal insufficiency is a potentially lethal
postop complication. Characteristic feats include
nausea, vomiting, abd pain, hypoglycemia, and
hypotension. Pts taking chronic glucocorticoids
Endocrine, Diabetes & may have glucocorticoid-induced suppression of
4077 Surgery
Metabolism the H-P-A axis and require stress-dose
perioperative glucocorticoids. Etomidate can inhibit
steroid synthesis and cause acute adrenal crisis; it
should be avoided in pts w suspected HPA
suppression.
Hypoparathyroidism (PTH deficiency) is
characterized by hypocalcemia and
hyperphosphatemia in the presence of normal
4254 Surgery renal fxn. Causes include post-surgical,
Metabolism
autoimmunteand non-autoimmuneparathyroid
destruction, and defected calcium-sensing
receptor.
Post-surg hypoparathyroidism can occur after
thyroidectomy or removal of 3 1/2 parathyroid
glands due to parathyroid hyperplasia.
Hypocalcemia is the resultant condition of
8882 Surgery hypoparathyroidism and MC complication of
Metabolism
thyroidectomy. Hypocalcemia - fatigue, anxiety,
depression, involuntary contractions of lips, face,
extremities, and seizures in severe hypocalcemia.
ECG - QT prolongation.
Tumor burden is the single most important
prognostic consideration i the tx of pts w breast
cancer. It is based on TNM staging. Pts w stage
IV dz have the worst prognosis. ER+ and PR+ are
FemaleReproductive good prognositc features. Overexpression of
2605 Medicine
System & Breast Her-2/neu oncogene is related to a worse
prognosis. Histologic grade also reflects outcome.
Poorly differentiated being worse. Mammogram
findings are inconclusive for prognostic
significance.
Diffusely nodular (cordlike thickening) breasts and
bilateral nonfocal premenstrual tenderness are
consistent with fibrocystic changes of the breast.
Fibrocystic breast changes - benign & common in
FemaleReproductive
11970 Medicine women of reproductive age. Develop from
System & Breast
fluctuations in estrogen & progesterone during the
menstrual cycle. NSAIDs or OCPs for
symptomatic relief. Fat necrosis-firm, irregular
mass - ecchymosis or skin/nipple retraction.
A pregnancy test should be administered to any
Obstetrics
FemaleReproductive woman of childbearing age before performing any
2330 &
System & Breast diagnostic tests such as x-rays or CT scans that
Gynecology
involveionizingradiation.
Lactational mastitis - skin flora (S aureus) enter
ducts thru nipple & multiplies in stagnant milk -
Past hx of mastitis, engorgement & inadequate
milk drainage(inc in sleep, replaced nursing w
Obstetrics
FemaleReproductive pumped breast milk, weaning, pressure on duct,
2344 &
System & Breast cracked or clogged nipple pore, poor latch) -
Gynecology
Fever, firm, red, tender, swollen quadrant of
unilateral breast, +/- myalgia, chills, malaise -
Analgesia, frequent breastfeeding (every 2-3 hrs)
or pumping, Abx.
Palpable breast abnormalities in patient under 30
are evaluated w USG whereas those in pts over
30 are evaluated w mammogram and USG.
Obstetrics
FemaleReproductive Palpable breast masses should generally have an
2345 &
System & Breast imaging eval even if the findings are relatively
Gynecology
benign on physical exam. Imaging evaluation is
helpful both in characterizing the lesion as benign
or malignant, and for guiding biopsy if needed.
Inflammatory breast carcinoma - brawny
edematous plaque w a "peau d'orange"
appearance - aggressive tumor most pts also
present w axillary lymphadenopathy and 1/4 of
Obstetrics
FemaleReproductive patients are found to have metastatic disease.
2346 &
System & Breast Nipple discharge in a non-lactating woman should
Gynecology
always raise suspicion for breast CA, esp if
spontaneous, unilateral, localized to single duct,
occurs in someone over 40, and assoc w a mass.
Dx biopsy for histology.
Fat necrosis shows clinical and radiographic
findings similar to those seen in breast cancer,
including skin or nipple retraction and calcifications
Obstetrics
FemaleReproductive on mammography. Biopsy of the mass will reveal
2362 &
System & Breast fat globules and foamy histiocytes in fat necrosis.
Gynecology
No tx is indicated fro tihs self-ltd condition. Calcs
in malignancy tend to be microcalc, benign tend to
be coarse.
Abnormal Uterine Bleeding (AUB) - abnormal
duration, quantity, or schedule. Structural
Obstetrics
FemaleReproductive (endometrial polyps, adenomyosis, fibroids,
2391 &
System & Breast malignancy) or nonstructural (coagulopathy,
Gynecology
thyroid d/o, endometrial infxn). First priority in AUB
is to exclude pregnancy.
Combinations estrogen/progestin OCPs offer risks
and benefits. Majority of OCPs contain a low dose
estrogen. Ptntal S/E is increase in BP. Women w
Obstetrics
FemaleReproductive uncontrollled htn, end-organ damage, who smoke,
2392 &
System & Breast and are >35 should consider another method of
Gynecology
contraception w/o estrrogen. Controlled htn can
take combination OCPs w monitoring of BP to
ensure ongoing control
Primary dysmenorrhea - painful menses w
Obstetrics cramping of the lower abdomen and back in
FemaleReproductive
2394 & women w a normal examination in the absence of
System & Breast
Gynecology dyspareunia or GI symptoms. First line tx -
NSAIDs and/pr hormonal contraception.
Urge incontinence, overactivity of the bladder, is tx
w oxybutynin. Stress incontinence, inneffective
Obstetrics closure of urethral sphincter, is treated by pelvic
FemaleReproductive
2398 & muscle exercises (Kegels) and urethropexy.
System & Breast
Gynecology Kegel's should be attempted before pursuing
surgery. Pregnancy, childbirth, menopause, and
obesity are all risk factors for stress incontinence.
Raloxifene is a SERM that increases bone mineral
density and is used to prevent osteoporosis. One
of the first-line agents for this purpose, although it
Obstetrics
FemaleReproductive is somewhat less effective than bisphosphonates
2408 &
System & Breast or estrogen. Most imporant side effect of
Gynecology
raloxifene is an increased risk of VTE. Raloxifene
is contraindicated in those w a hx of DVT. Also
causes hot flashes and leg cramps.
Hyperandrogenic women w PCOS usually have
adequate amount of active estrogens. Androgens
will be converted into estrogens in the peripheral
tissues, even in absence of normal ovarian fxn.
Obstetrics Women w PCOS are oligo-, or anovulatory and
FemaleReproductive
2413 & are deficient in progesterone secretion; thus they
System & Breast
Gynecology usually have a constant and unbalanced mitogenic
stimulation of the endometrium by estrogens
leading to endometrial hyperplasia, intermittent
breathrough bleeding, and DUB. Inc risk
endometrial CA
Women with abnormal uterine bleeding should
undergo endometrial biopsy. If it shows
Obstetrics
FemaleReproductive hyperplasia without atypia they should get
2418 &
System & Breast progestin therapy. If there is atypia it depends if
Gynecology
they want to get pregnant again. If so, progestin
therapy. If not, hysterectomy.
PMS - anxiety, mood swings, difficulty
concentrating, decreased libido, irritability. Symps
begin 1-2 weeks prior to menses and regress
around the time of menstrual flow. Symps are
Obstetrics
FemaleReproductive absent until after next ovulation. Premenstrual
2419 &
System & Breast dysphoric disorder (PMDD) is a severe variant of
Gynecology
PMS w prominent irritability and anger. When
symps are irregular or vary in severity, the pt
should keep a MENSTRUAL DIARY for 2-3
months and note any assoc symptoms. Tx - SSRIs
Vaginismus is caused by involuntary contraction of
the perineal musculature. Underlying cause is
psychological. Pts often had strict religious
upbringings in which sex was not discussed or
Obstetrics
FemaleReproductive was discussed negatively, or had traumatic
2420 &
System & Breast childhood experiences which left them fearful of
Gynecology
vaginal penetration. Tx for vaginismus is 80% or
greater successful. Tx includes relaxation, kegel
exercises, insertion of dilators, fingers, etc. to
desensitize.
Endometriosis
Risk factors - Nulliparity, early menarche, shorter
menstrual cycles, menstrual outflow obstruction
Pathogenesis - Ectopic endometrial tissue forms
on or beneath pelvic mucosal/serosal surfaces,
Obstetrics
FemaleReproductive cyclic hyperplasia & degeneration occur in
2546 &
System & Breast response to female sex hormones, chronic
Gynecology
hemorrhaging leads to formation of fibrotic pelvic
adhesions
Presentation - Dyspareunia, dysmenorrhea, pelvic
pain, infertility
Dx - direct visualization on laparoscopy +/- biopsy
Daughters of women who received diethylbestrol
during pregnancy are at increased risk of
Obstetrics
FemaleReproductive developing clear cell adenocarcinoma of the
2575 &
System & Breast vagina and cervix. In addition, daughters and sons
Gynecology
w in-utero exposure are at risk for genital tract
anomalies
Tamoxifen increases the risk of (1) endometrial
Obstetrics
FemaleReproductive cancer, which arises in the lining of the uterus, and
2606 &
System & Breast (2) uterine sarcoma which arises in the muscular
Gynecology
wall of the uterus.
Breast cancer should be considred whenever a pt
w/o a prior hx of skin disease develops a breast
rash that is nonresponsive to standard tx. Severe,
ductal carcinoma can infiltrate into the dermal
Obstetrics
FemaleReproductive lymphatics w resulting edema, erythema, and
2607 &
System & Breast warmth of the entire breast - inflammatory CA.
Gynecology
When rash is localized to the nipple and has
ulcerating eczematous appears - Paget's disease
of the breast. 85% of those w this have underlying
breast CA usu adenoCA.
Trastuzumab, AKA Herceptin, a monoclonal
antibody, is commonly used to tx breast cancer
that is HER2 positive. It has benefit both in
Obstetrics
FemaleReproductive adjuvant situations as well as in the case of
2608 &
System & Breast metastatic disease. An echocardiogram is
Gynecology
recommended before beginning tx as there is a
risk of developing cardiotoxicity, particularly in pts
w baseline low ejection fractions.
Fibrocystic disease - Rubbery, firm, mobile and
painful mass in a young patient who experiences
more tenderness during her menses. Aspiration of
such a cyst yields clear fluid and results in
Obstetrics disappearance of the mass. Afterwards, pts are
FemaleReproductive
2611 & typically observed for 4-6 weeks. Cytology is
System & Breast
Gynecology warranted if the aspirated fluid is bloody or foul
smelling. Biopsy if the mass recurs or doesn't
disapp. Mammograms in women <35 are useless
bc the breast is too dense for accurate
visualization.
Overexpression of the oncogene HER2 can be
Obstetrics
FemaleReproductive detected either by immunohistochemical staining
2612 &
System & Breast or FISH. Positivity predicts a positive response to
Gynecology
trastuzumab and anthracycline chemotherapy.
Ovarian cancer is the gynecologic malignancy w
the highest mortality rate in the US. Pelvic USG
and testing for CA125 both can be used to make a
Obstetrics dx of ovarian cancer. To date, no evidence
FemaleReproductive
2613 & suggests screening for ovarian cancer w these
System & Breast
Gynecology methods reduces mortality, and therefore they are
not recommended screening measures. In women
w a strong fam hx, testing for BRCA genes could
be considered.
In most states, adolescents seeking pregnancy
prevention options may receive confidential
medical care w/o parental consent. Levonorgestrel
Obstetrics
FemaleReproductive and ulipristal are widely available oral emergency
3241 &
System & Breast contraceptive options. The copper IUD is the most
Gynecology
effective emergency and long-term contraception
option and requires a provider who's trained to
insert the device.
First trimester US w Crown-Rump Length
measurement is the most accureate method of
determining gestational age. It becomes less
Obstetrics accurate as the pregnancy progresses as there is
FemaleReproductive
3278 & minimal variabilyt in size among fetuses during the
System & Breast
Gynecology first trimester. Accuracy is +/- 3-5 days between
7-14 weeks gestation. EGA from first trimester
shouldn't be changed. Discrepencies found in later
on USG can indicated grwth abnormalities.
Milk production is activated by 2 mechanisms: 1.
sudden decrease in estrogen and progesterone -in
pregnancy they interfere w action of prolactin. 2.
Release of prolactin and oxytoxin through nipple
Obstetrics
FemaleReproductive suckling. Prl is responsible for milk synthesis and
3338 &
System & Breast oxytocin mediates contraction of the lactiferous
Gynecology
glands and ducts -> excretion of milk. Lactation
suppression is indicated when there is no need to
breastfeed (infant death). Ice packs + analgesics
and tight bra.
Lactation alone causes anovulation and therefore
some degree of contraception bc the high
prolactin levels inhibit the release of GnRH from
the hypothalamus. This is not considered to be a
Obstetrics
FemaleReproductive reliable form of birth control as ovulation can
3339 &
System & Breast resume while a mother is still breastfeeding.
Gynecology
Progestin-only OCPs preferred in lactating
women. Do not affect volume or composition of
milk produced by bother. No effects on the infant,
do not carry the risk of DVT.
Most OCPs contain estrogen and progesterone.
S/E include nausea, bloating, and breast
tenderness, which usually improve w continued
use. Breakthrough bleeding is MC s/e. Other
Obstetrics
FemaleReproductive adverse effects include htn, inc risk of cervical CA,
3359 &
System & Breast VTE, amenorrhea. Combination OCs have shown
Gynecology
to cause no significant weight gain in several
studies. Older high-dose OCs did cause weight
gain possibly related to insulin resistance, but
newer lower-dose ones don't.
Hysterosalpingogram - infusing radiocontrast
material into the uterus under fluoroscopy.
Abnormalities in the uterine cavity or fallopian
Obstetrics
FemaleReproductive tubes can be identified by this method. PID,
3365 &
System & Breast endometriosis, in utero DES exposure, congenital
Gynecology
malformations, and other acquiredd abnormalities
cause anatomic defects in the uterus or fallopian
tubes.
PCOS - anovulation, signs of androgen excess,
ovarian cysts. Pts are often infertile or subfertile.
Imbalances in LH, FSH, and insulin resistance.
Obstetrics Ovaries are fxnal so ovulation can be induced by
FemaleReproductive
3367 & tx w clomiphene citrate (CC). CC is an estrogen
System & Breast
Gynecology analog that improves GnRH release and FSH
release thereby improving the chances of
ovulation. Pts w PCOS are also tx w metformin,
which has been shown to impove ovulation.
Premature ovarian failure - amenorrhea,
hypoestrogenism, and elevated gonadotropin
levels in women <40 y.o. Amenorrhea only needs
to be of 3 months duration w FSH in menopausal
Obstetrics
FemaleReproductive range to meet diagnostic criteria. Early dx is
3368 &
System & Breast important to prevent osteoporosis. May be d/t
Gynecology
accelerated follicle atresia or a low initial number
of primordial follicles. Idiopathic or 2ndary to
Hashimotos, addisons, DM1, pernicious anemia.
IVF for pregnancy.
Ovulatory phase - profuse cervical mucus, clear
and thin in contrast to mucus of the post- and
Obstetrics
FemaleReproductive pre-ovulatory phases, which is scant, opaque and
3370 &
System & Breast thick. Eval of the cervical mucus is part of the
Gynecology
infertility workup as "hostile" cervical mucus can
block sperm from entering the uterus.
Midcycle pain (mittelschmerz) is common in
women w regular menstrual periods who are not
taking birth control pills. The pain is the result of
Obstetrics
FemaleReproductive ovulations itself, occurring 2 weeks after the start
3480 &
System & Breast of the last menstrual period. Ovarian torsion is a
Gynecology
medical emergency w pain that radiates to the
groin or back and accompanied by nausea and
vomiting.
Pseudohyphae from vaginal wet mount indicates
Candida vulvovaginitis. Vulvar pruritis is usually the
primary symptom. Dysuria and dyspareunia are
Obstetrics also common. Vaginal discharge is thick and white
FemaleReproductive
3656 & (cottage cheese) and adheres to the vaginal walls
System & Breast
Gynecology but may be scant in some pts. Systemic
corticosteroids allows for candida overgrowth and
subseqent infxn. Other risk factors include
pregnancy, DM, and recent abx use.
Atrophic vaginitis is a Clx based on H&P. Vaginal
dryness, pruritis, dyspareunia, dysuria, urinary
frequency. Pelvic exam - pale, dry and smooth
vaginal epithelium, scarce pubic hair, and loss of
Obstetrics
FemaleReproductive labial fat pad. Occurs in post-menopausal women
3744 &
System & Breast d/t dec estrogen levels. Sxs of atrophic vaginitis
Gynecology
can be seen in UTI. Dipstick r/o UTI. Moisturizers
+ lubricants - mild atrophic vaginitis. Local
low-dose vaginal estrogen therapy - moderate to
severe cases.
Vaginal lesion (MC in upper 1/3 of posterior
vagina), malodorous discharge, history of smoking
- vaginal cancer. Metastatic dz to the vagina is MC
Obstetrics
FemaleReproductive than primary dz, w the MC mode of spread being
3745 &
System & Breast direct extension from the cervix, vulva, or
Gynecology
endometrium. Women w primary vaginal cancer
MC have SCC. Risk factors are very similar to
those for cervical cancer - smoking and HPV.
HPV - condyloma acuminata - teardrop shaped
Obstetrics
FemaleReproductive growths at the vestibule of the vulva - application
3757 &
System & Breast of tricholoacetic acid results in resolution of the
Gynecology
lesions.
Premature ovarian failure - primary hypogonadism
in a woman under age 40. Causes include CTx,
RTx, autoimmune ovarian failure, Turner's
Obstetrics
FemaleReproductive syndrome, and fragile X syndrome. Developing
3814 &
System & Breast follicles are the main source of estrogen. Symps
Gynecology
of POF are amenorrhea, hot flashes, vaginal and
breast atrophy. Psychologic symps - anxiety,
depression, irritability.
Genito-pelvic pain disorder. One of the following:
Vaginal penetration during intercouse
Vaginal or pelvic pain during intercourse or
attempted pentration (or fear or anxiety of this)
Obstetrics
FemaleReproductive Tenseness of pelvic floor muscles during
3861 &
System & Breast attempted vaginal penetration
Gynecology
At least for 6 months
Significant distress
Not accounted for by any other reasons
Endometriosis - chornic pelvic pain (s/t worse
during menses) - dyspareunia, infertility, s/t
bowel/bladder problems. Pts w pelvic pain and no
Obstetrics complications can be tx empirically w NSAIDs,
FemaleReproductive
3862 & combined OCPs, progestins, or GnRH analogs.
System & Breast
Gynecology Laparoscopy is useful for dx and tx of complicated
endometriosis (bowel/bladder obstruction, rupture
of endometrioma) and for pts refractory to
medical therapy.
hCG is secreted by the syncytiotrophoblast and is
responsible for presevering the corpus luteum
during early pregnancy in order to maintain
Obstetrics progesterone secretion until the placenta is able to
FemaleReproductive
4135 & produce progesterone on its own. Production of
System & Breast
Gynecology hCG begins 8 days after fertilization and levels
double every 48 hours until they peak at 6-8
weeks. alpha subunit is common to TSH, LH, FSH.
Beta is specific to hCG sensed in pregnancy tests.
Prolactin production is inhibited by dopamine and
stimulated by serotonin and TRH. An increase in
TSH and TRH production and, consequently, in
prolactin release may be the result of
Obstetrics
FemaleReproductive hypothyroidism. Hyperprolactinemia may also
4221 &
System & Breast affect GnRH and gonadotropin secretion and,
Gynecology
thus, result in amenorrhea and galactorrhea. Other
causes of high prolactin levels include dopamine
antagonists (antipsychotics, TCAs, and MAOIs),
hypothalamic and pituitary tumors.
Stress incontinence is common in older women w
high parity being a major risk factor. More vaginal
deliveries leads to wearker pelvic floor muscles
over time. Proximal urethra prolapses outside the
Obstetrics
FemaleReproductive pelvis d/t pelvic relaxation so increases in intraabd
4224 &
System & Breast pressure cause urine loss. Morbid obesity,
Gynecology
pregnancy, COPD, and smoking aggravate stress
incontinence. Tx is kegel exercises, pessaries, and
estrogen replacemtn. Surgical tx - Burch
procedure and sling procedures; these r best
Aromatase deficiency - can't convert androgens to
estrogens - in utero the mother will get
masculinization that resolves after delivery. The
Obstetrics internal genitalia will be normal but external will be
FemaleReproductive
4496 & ambiguous at birth. Clitoromegaly is often seen.
System & Breast
Gynecology Later in life pts will have delayed puberty,
osteoporosis, undetectable circulating estrogens,
high concentration of gonadotropins and polycystic
ovaries, high FSH&LH
Intermittent bloody discharge from one nipple is
the classic presentation of intraductal papilloma, a
Obstetrics benign breast disease. Most common in
FemaleReproductive
4542 & perimenopausal women. Masses are generally not
System & Breast
Gynecology appreciated in this condition, as the abnormality is
small(2mm, xray is best at 1cm), soft, and located
directly beneath the nipple .
Physiologic galactorrhea is usually bilateral and
milky (MC), yellow, brown, gray, or green.
Hyperprolactinemia is the MCC of physiologic
Obstetrics
FemaleReproductive galactorrhea. Galactorrhea should be evaluated w
4543 &
System & Breast serum prolactin, TSH, and possible brain MRI. Pts
Gynecology
w unilateral or bloody (gross or occult) nipple
discharge, palpable abnormalities, or skin changes
should be evaluated for possible malignant causes.
MCC of decreased fertility in women in their 4th
decade who are still experiencing menstrual cycles
is age-related decreased ovarian reserve.
Obstetrics Infertility - attempting to conceive >1year. Women
FemaleReproductive
4756 & over 35, >6months inability to conceive is infertility.
System & Breast
Gynecology 1 in 5 women age 35-39 is no longer fertile.
Infertility d/t aging can be assessed using early
follicular phase FSH level, clomiphene challenge
test, or inhibin-B level.
Positive pregancy test, no evidence of intrauterine
or extrauterine pregnancy - Ddx - early viable
intrauterine pregnancy, ectopic pregnancy,
nonviable intrauterine pregnancy (completed
Obstetrics
FemaleReproductive abortion). Seriel BHCG levels reqd when inital
4759 &
System & Breast USG is indeterminate. BHCG should double every
Gynecology
48 hrs normally. Intrauterine preg shuold be seen
w TV USG at BHCG levels 1500-2000. If level is
<1000, both BHCG and TVUSG should be
repeated in 2-3 days.
PCOS - anovulation, androgen excess, and
ovarian cysts. PCOS results from abnormal GnRH
secretion that stimulates pituitary to secrete
excessive LH and insufficient FSH. Excess LH
Obstetrics stimulates excess androgen production by ovarian
FemaleReproductive
4768 & theca cells resulting in hirsutism, male escucheon,
System & Breast
Gynecology acne & adrogenic allopecia. Anovulation is caused
in part by imbalances in LH & FSH & in part by
insulin resistance. Anovulation can be assoc w
both amenorrhea & irregular menses &
menometorrhagia
Menorrhagia - prolonged or heavy menstruation
Obstetrics (>7 days or >80mL). Anovulatory cycles occur in
FemaleReproductive
4769 & the first 2 years after menarche. Immature HPO
System & Breast
Gynecology axis may fail to produce gonadotropins in the
proper quantities and ratios to induce ovulation.
Laparoscopy w visualization and biopsy of
Obstetrics implants (ectopic endometrial tissue) is the only
FemaleReproductive
4773 & definitive way to dx endometriosis. It is indicated
System & Breast
Gynecology when NSAIDs and hormonal contraceptive therapy
have failed.
Endometriosis is dx in 25-50% of women being
evaluated for infertility, and almost half of women
w endometriosis have impaired fertility or infertility.
Obstetrics Chronic inflammation and adhesions may damage
FemaleReproductive
4774 & sperm and interfere w the normal transfer of
System & Breast
Gynecology oocytes from the ovarian surface to the fallopian
tubes. Pts w endometriosis may also have a
suboptimal uterine endometrium for implantation or
hormonal issues that may affect ovarian fxn.
Copious vaginal discharge that is white or yellow
Obstetrics
FemaleReproductive in appearance, nonmalodorous, and occurs in
4787 &
System & Breast absence of other symptoms or findings on vaginal
Gynecology
exam is referred to as physiologic leukorrhea.
2-3 weeks after infxn w T pallidum, pts develop a
painless papule at the site of inoculation. The
papule ulcerates, forming a chancre w
punched-out base and raised, indurated margins.
Obstetrics Most lesions occur on the genitalia and are
FemaleReproductive
4791 & accompanied by painless inguinal adenopathy. If
System & Breast
Gynecology left untx, the chancre heals spontaneously w/in 1-3
months. Like syphilis, Granuloma inguinale
(donovanosis) presents w painless genital ulcers.
They have a red, beefy base but there's no
adenopathy.
Nontreponemal serologic tests (VDRL, RPR) are
used as screening for syphilis and treponemal
serologic tests (FTA-ABS) are used for
Obstetrics confirmation. Darkfield microscopy is also an
FemaleReproductive
4792 & effective method for dx syphilis but requires
System & Breast
Gynecology proper equipment and clinical expertise. In primary
syphilis, there is a high rate of false-negative
results to serologic testing, and therefore darkfield
is necessary.
HELLP syndrome is thought to result from
abnormal placentation, triggering systemic
inflammation and activation of the coagulation
system and complement cascade. Circulating
Obstetrics platelets are rapidly consumed, and
FemaleReproductive
4795 & microangiopathic hemolytic anemia damages the
System & Breast
Gynecology liver. Resulting in hepatocellular necrosis and
thrombi in the portal system cause elevated liver
enzymes, liver swelling, and distension of the
hepatic capsule. 50% of women w HELLP
progress to DIC.
Lichen sclerosus is a chronic inflammatory
condition of the anogenital region that MC affects
postmenopausal women. Anogenital discomfort -
Obstetrics pruritis, dyspareunia, dysuria, and painful
FemaleReproductive
4810 & defectation. Physical exam reveals porcelain-white
System & Breast
Gynecology polygonal macules and patches w atrophic
"cigarette paper" qualtiy. Vulvar SCC occurs
commonly in LS. Punch biopsy of any suspicious
lesion should be performed.
Lichen sclerosus et atrophicus (LS&A) is one of
the few conditions for which use of high-potency
Obstetrics topical steroids on the genitals is encouraged.
FemaleReproductive
4811 & Class I topial steroid in ointment form should be
System & Breast
Gynecology applied twice daily for 4 weeks, then transition to
a less potent steroid or a topical calcineurin
inhibitor for maintenance therapy.
Atypical Squamous Cells of Undetermined
Significance (ASC-US) - MC cervical cytological
abnormality. Risk of invasive cancer is low
(40-60% not associated w HPV). High-grade
Obstetrics
FemaleReproductive squamous intraepithelial lesions is assoc w
8877 &
System & Breast premalignant lesions. Finding ASC reqs further
Gynecology
investigation. 21-24 y.o w ASCUS get repeat Pap
smear in 1 year. >25 need HPV testing. + HPV
requires colposcopy. - HPV f/u papsmear and
HPV test in 3 years.
Anovulation secondary to anovulation - FSH and
LH are normal, ovaries are still prodcuing
Obstetrics
FemaleReproductive estrogen, but progesterone is not being produced
8892 &
System & Breast at the normal post ovulation levels. Therefore,
Gynecology
progesterone withdrawal menses at the end of the
cycle does not occur.
Initial workup of an adnexal mass should include
transvaginal ultrasonography and a serum cancer
antigen CA-125. Elevated CA-125 is highly
suspicious for malignancy in a postmenopausal
Obstetrics woman. Sensitivity is 61-90% and specificity is
FemaleReproductive
8903 & 71-93%. If it has benign feats on USG and
System & Breast
Gynecology CA-125 is low, then observe w periodic USG.
Suspicious feats on USG - Size >10cm, nodular or
fixed pelvic mass, ascites, evidence of metastasis,
elevated CA-125. Pts should be evaluated by
gyneonco
Rupture ovarian cyst presents w acute onset of
unilateral pelvic pain immediately after strenuous
activity or sexual intercourse. Pelvic ultrasound
Obstetrics
FemaleReproductive can confirm the dx by showing free fluid in the
8941 &
System & Breast pelvis. Supportive care (eg, analgesics) is
Gynecology
recommended for uncomplicated cyst rupture;
complicated cyst rupture may require surgical
interventionl
Uterine leiomyoma (myoma/fibroid) - MC pelvic
tumor in repoductive-age women. Uterine fibroids
are benign smooth muscle tumors of the
Obstetrics myometrium. Small ones r asymptomatic. Large
FemaleReproductive
8948 & ones can cause local compressive symptoms i.e.
System & Breast
Gynecology constipation, frequency/retention, back/pelvic pain.
Also abnormal menstrual bleeding and
reproductive dysfxn occur. USG is preferred initial
dx imaging modality for most pts. High sensitivity.
Leiomyoma (myoma/fibroid) - benign smooth
muscle tumor arising from myometrium. MC pelvic
tumor in women (esp African American). Can
Obstetrics
FemaleReproductive cause extrinsic compression of the bladder or
8953 &
System & Breast sigmoid colon (frequency, constipation). Can
Gynecology
compress the ureters and cause hydronephrosis.
Can distort and enlarge the uterus. Heavy and
prolonged menstrual bleeding.
Unilateral bloody nipple discharge is the hallmark
Obstetrics presenting symptom of an intraductal papilloma, a
FemaleReproductive
11972 & benign breast condition, Lack of breast mass or
System & Breast
Gynecology ladpy differentiates this condition from other
benign and malignant breast pathology.
BRCA mutations & ovarian CA
Genetics
BRCA1(ovarian) & 2 mutations. AD inheritance.
Ashkenazi Jews.
Obstetrics Cancer risks
FemaleReproductive
11985 & Premenopausal epithelial ovarian CA. Fallopian
System & Breast
Gynecology tube. Primary peritoneal. Breast at age <50.
Breast cancer in male.
Risk modification
Bilateral salpingo-oophorectomy. OCP use. Age
<30 at first live birth. Breastfeeding. Tubal ligation.
Submucosal fibroids arise from the myometrium
immediately under the endometrial lining and
Obstetrics protrude into the uterine cavity. They commonly
FemaleReproductive
12004 & cause heavy and prolonged menstrual bleeding.
System & Breast
Gynecology Submucous fibroids can also prolapse through the
cervical os and cause labor-like pain d/t cervical
distension by the solid mass.
Obstetrics
FemaleReproductive Alcohol is a dose dependent risk factor for breast
12021 &
System & Breast cancer.
Gynecology
Abnl Uterine Bleeding
Endometriosis - dysmenorrhea, pelvic pain,
dyspareunia. infertility.
Fibroids - Heavy menses +/- clots. Constipation,
urinary frequency, pelvic pain/heaviness.
Obstetrics
FemaleReproductive Irregularly enlarged uterus
12027 &
System & Breast Adenomyosis - Dysmenorrhea, pelvic pain. Heavy
Gynecology
menses. Bulky, globular, & tender uterus.
Endometrial CA/hyperplasia - Hx of obesity,
nulliparity, or chronic anovulation. Irregular,
intermenstrual, or postmenopausal bleeding.
Small, nontender uterus.
In a pt w primary amenorrhea:
-FSH measurement should be ordered if there's no
FemaleReproductive
2388 Pediatrics breast development
System & Breast
-Pituitary MRI is the next step if FSH is decreased
-Karyotyping is the next step if FSH is increased
Tx for acute abnl uterine bleeding
High-dose IV or oral estrogen
FemaleReproductive
2390 Pediatrics High-dose combined OCPs
System & Breast
High-dose progestin pills
Tranexamic acid
Female infants <3 mo of age sometimes develop
vaginal spotting or bleeding. Maternal estrogens
can cross the placenta and enter the fetal blood
FemaleReproductive
3773 Pediatrics stream before birth, thereby causing a pubertal
System & Breast
effect in the newborn which disappears as soon
as the hormone is cleared from the infants
circulation.
Normal ovaries, abnl vagina, & absent uterus
precluding menstruation is consistent w Mullerian
agenesis (MRKH syndrome). Mullerian agenesis
affects 46 XX females and is characterized by
FemaleReproductive failure of the mullerian ductal system to
3911 Pediatrics
System & Breast differentiate into a uterus, cervix, and upper
vagina. However, the gonads (ovaries) and
external genitalia (labia, clitoris) develop normally.
Breast development and body hair growth are also
normal.
Aortic coarctation is a common finding in Turner
FemaleReproductive syndrome. Pts w Turner syndrome have ovarian
4142 Pediatrics
System & Breast dysgenesis and poor ovarian fxn; FSH should be
high d/t lack of negative feedback.
Cryptorchid gonads have a 1-5% risk of
developing dysgerminoma or gonadoblastoma
after puberty. Benefits of undergoing
gonad-stimulated puberty (eg, attainment of adult
FemaleReproductive heigt) outweigh the low risk of malignancy. Thus, a
4217 Pediatrics
System & Breast gonadectomy can be deferred until completion of
puberty. Most XY individuals w complete AIS
identify w the female gender identity. Pts should
receive age-appropriate disclosure and familys
offered psychosocial support.
A young woman who presents w a breast lump
can be asked to return after her menstrual period
FemaleReproductive
4242 Pediatrics for reexmination (which may reveal regression of
System & Breast
the mass) if no obvious signs of malignancy are
present.
Initial menstrual cycles in pubertal females are
usually irregular and often anovulatory. D/T the
immaturity of the developing HPG axis that does
FemaleReproductive not produce adequate quantities & proportions of
4767 Pediatrics
System & Breast hormones LH & FSH to induce ovulation. The
endometrium builds up under the influence of
estrogen, but w/o progesterone the lining doesn't
slough and menstruation doesn't occur.
Vulvovaginitis in prepubertal children MCC by
foreign bodies. Toilet paper is the MC vaginal
foreign body, small toys and other objects can be
seen. Presnting symps - foul-smelling discharge,
FemaleReproductive intermittent VB, spotting, occasionally urinary
4870 Pediatrics
System & Breast complaints. External exam of genitalia should be
performed w child in knee-to-chest or frog leg
position. Calcium alginate swab or irrigation w
warm fluids after topical anesthetic is good for
small foreign bodies like TP.
Primary amenorrhea - absence of menarche by 15
- fxnal or anatomic problems at level of
hypothalamus, pituitary, ovaries, uterus, or vagina.
1st step is to evaluate whether sex organs are
present. USG is the preferred imaging modality to
FemaleReproductive
9566 Pediatrics evaluate the anatomy of the repro tract. TS is one
System & Breast
of the MCC of primary amenorrhea. Causes
primary ovarian failure from gonadal dysgenesis,
though some have normal puberty w early
menopause & infertility. Pelvic USG - streak
ovaries
Worsening postprandial pain that leads to
avoidance of food is characteristic of chronic
2149 Medicine Gastrointestinal & Nutrition occlusion of visceral arteries (abdominal angina).
Routine imaging studies are usually not
informative. Dx - angiography or doppler usg.
Abdominal succussion splash - place the
stethoscope over the upper abdomen and rock the
patient back and forth at the hips. Retained gastric
material >3 hours after a meal will generate a
2166 Medicine Gastrointestinal & Nutrition splash sound, indicating the presence of a hollow
visucs filled with fluid and gas. Initial management
of GOO includes nasogastric suctioning to
decompress the stomach, IV hydration, and
endoscopy for definitive Dx.
D-xylose is a monosaccharide that is absorbed in
the proximal small intestine without degradation by
pancreatic or brush border enzymes. Pts w small
2198 Medicine Gastrointestinal & Nutrition intestinal mucosal dz will have impaired absorption
of D-xylose. Pts w malabsorption due to enzyme
deficiencies will have a normal absorption of
D-xylose.
Achalasia typically presents w dysphagia for
solids and liquids, heartburn, regurg of food, and
weight loss. Barium swallow usually shows a
dilated esophagus w distal narrowing, and
2199 Medicine Gastrointestinal & Nutrition
manometry shows LES abnormalities. Esophageal
malignancy at the esophageal-gastric jxn can
mimic achalasia and should be excluded w
endoscopy before starting tx for achalasia.
Patients w typical GERD symptoms require an
upper GI endoscopy if they have alarm symptoms
(dysphagia, odynophagia, weight loss, anemia, GI
bleeding, or recurrent vomiting) or are men >50 w
chronic (>5 years) symptoms and cancer risk
factors (eg, tobacco use). ALl other pts can
receive an empiric trial of PPI therapy and further
evaluation if refractory to therapy.
Increased intragastric pressure during vomiting
can cause tears in the mucosa of the distal
esophagus and proximal stomach. These are
called Mallory-Weiss tears, and account for 10%
2203 Medicine Gastrointestinal & Nutrition of upper GI bleeds. These tears cause bleeding
from submucosal arteries. Bleeding stops
spontaneously in 90% of patients; however,
vasopressin, endoscopic injection, or
electrocautery may be required in a few cases.
Lower abd pain, bloody diarrhea, tenesmus - IBD
(UC). Acutely worsened fever, elevated WBC,
hypotension, tachycardia (indicative of sepsis not
simple UC) - concerning for toxic megacolon -
lethal complication of IBD and sometimes the first
presentation of IBD. Dx - radiographic evidence +
3 of the following: Fever >38, HR >120 bpm,
leukocytosis >10,500, anemia. + 1 of: Volume
depletion, altered sensorium, electrolyte
disturbance, hypotension.
Crohn's disease can involve the GI tract
anywhere, from the esophagus to the anus. It is
frequently associated w intestinal fistula, strictures
and anal disease. Lab findings of every chronic
inflammatory disease can include anemia and
reactive thrombocytosis.
Nagging epigastric pain, worse at night, food
intolerance, weight loss, enlarged nontender
gallbladder, icterus suggestive of biliary
obstruction, has findings consistent w pancreatic
cancer. 60-70% originate in head of panc. They
compress the panc duct (steatorrhea) and CBD
(jaundice/icterus) manifesting radiologically as
double duct sign. Subsequent backup of bile leads
to intra and extrahepatic biliary duct dilation and
nontender, distended gallbladder.
MCC of IDA in elderly is GI blood loss. Next step
in evaluation is colonoscopy and endoscopy. A
single negative FOBT does not exclude the
possibility of GI bleeding.
Diffuse esophageal spasm - nitrates and CCBs
relax myocytes in coronary vessels as well as
those in the esophagus thereby alleviating pain.
Esophagography may or may not show other
anomalies (eg. corkscrew shape). Esophageal
manometry should show repetitive, non-peristaltic,
high amplitude contractions, either spontaneously
or after ergonovine stimulations.
Zenker's diverticulum is MC in elderly men and
presents with dysphagia, regurgitation,
foul-smelling breath, aspiration, and occasionally a
palpable mass. Contrast esophagram is the test
of choice for confirming the dx. Treatment is
generally surgical.
Spontaneous bacterial peritonitis superimposed on
cirrhosis has a subtle presentation, requiring a low
threshold of suspicion. Fever and subtle changes
in mental status are the MC symps, while abd pain
2217 Medicine Gastrointestinal & Nutrition often less prominent than in peritonitis d/t other
causes. Dx by paracentesis is test of choice. Dx
criteria - ascites fluid culture +, neutrophil ct
250/mm^3. Enteric orgs are MC - E coli &
Klebsiella. Empiric tx - 3rd gen cephalosporin
Stepwise approach for ascites:
1. Na+ and H2O restriction
2. Spirinolactone
2218 Medicine Gastrointestinal & Nutrition 3. Loop diuretic (not more than 1L/day of diuresis
- risk of hepatorenal syndrome)
4. Frequent abdominal paracentesis (2-4L/day, as
long as the renal fxn is okay)
Instrumentation of the esophagus is the MCC of
Boerhaave's sydnrome. CXR shows a pleural
effusion,pneumomediastinum,and/or
pneumothorax. A water-soluble
Technetium-99 labeled RBC scintigraphy should
be used in cases of lower GI bleeding where the
source cannot be identified by colonoscopy. This
study localizes the source of blood loss so that
region can be further evaluated and treated by
colonoscopy or angiography.
Diverticulosis is the MCC of gross LGIB in adults.
Bleeding is typically painless but may be
associated w lightheadedness and hemodynamic
instability. Diverticular hemorrhage usually
resolves spontaneously but occasionally requires
endoscopic or surgical intervention.
Esophageal rupture MC occurs following
instrumentation of the esophagus. Less commonly
it may occur in patients w protracted vomiting who
have been resisting the urge to vomit. Rupture in
these cases typically occurs into the mediastinum
resultinginpneumomediastinum.
IBD usually presents around the age of 20, there
is a bimodal age distribuation w a 2nd peak
around age 60. Elevated inflammatory markers &
2581 Medicine Gastrointestinal & Nutrition a subacute presentation of abd pain w bloody
stool suggest the dx. CD and UC can be difficult to
distinguish both clinically and pathologically, w
neutrophilic cryptitis being a feat of both.
Pts w UC are at increased risk of CRC. Screening
colonoscopy w mucosal sampling should be
2582 Medicine Gastrointestinal & Nutrition offered to pts w ulcerative colitis beginning 8
years after the initial dx, and repeated every 1-2
years thereafter.
Lynch syndrome (HNPCC)
1. At least 3 relatives w CRC, one must be first
degree relative
2. Involvement of 2 or more generations
3. At least 1 case dx before 50
4. FAP is excluded
2585 Medicine Gastrointestinal & Nutrition 2 subgroupes
1. Hereditary site specific colon cancer (Lynch I)

2. Cancer family syndrome (Lynch II)
II is assoc a high risk of extracolonic tumors, MC

is endometrial CA, which dvlops in 43% of females
in affected families
Familial colonic polyposis (FAP) - AD - caused by
mutations in the adenomatous polyposis coli
(APC) gene. FAP occurs in approx 1/10000 -
1/30000 live births. Affects both sexes equally,
2586 Medicine Gastrointestinal & Nutrition and has a worldwide distribution. Accounts for
less than 1% of the total colon cancer risk in the
US. A pt w FAP and hundreds of adenomas in the
colon as a 100% risk of cancer, if he/she is not
treated appropriately with a proctocolectomy
CTX plays a role in mgmt of pts w MALT
lymphoma if eradication of H. Pylori fails to
produce regression of the lymphoma. Such
therapeutic regimens include CHOP
(cyclophosphamide, adriamycin, vincristine, and
prednisone) or CHOP + Bleomycin.
Esophageal cancer should be suspected in a pt w
burning chest pain, probable dysphagia (careful
chewing of food), significant weight loss.
Adenocarcinoma - Barrett esophagus near the
gastroesophageal jxn; risk is inc w smoking and
GERD. SCC occurs anywhere in esophagus; risk
is inc w smoking and heavy alcohol consumption.
Dx - endoscopy w biopsy. Young pts w/t alarm
symps can undergo barium esophagram, those
>55 + alarm symps should get endoscopy
Episodic flushing is the hallmark of carcinoid
syndrome and occurs in almost 85% of patients.
Severe flushing may be assoc w hypotension and
tachycardia. Secretory diarrhea may be
accompanied by abdominal cramping. Other
2625 Medicine Gastrointestinal & Nutrition common feats include cutaneous telangiectasias,
bronchospasm, and tricuspid regurg.
Pathognomonic plaque-like deposits of fibrous
tissue occur MC on the endocardium of the right
heart, leading to tricuspid regurg and RHF. Dx -
Elevated 24-hr urinary 5-HIAA
Carcinoid syndrome
Clinical
Skin: flushing, telangiectasias, cyanosis
GI: diarrhea, cramping
Cardiac: valvular defects (right>left side)
Pulmonary:bronchospasm
Misc: Niacin deficiency
Dx
Elevated 24-hour urinary excretion of 5-HIAA
CT/MRI of abdomen & pelvis to localize tumor
Octreoscan to detect metastases
Echo (if symps of carcinoid heart dz are present)
Tx
Octreotide for symptomatic pts & prior to
surgery/anesthesia
Surgery for liver metastases
PBC: prurits, jaundice, steatorrhea, HSM, inc Alk
Phos, serum bilirubin, and the presence of
anti-mitochondrial antibodies. Destruction of the
intrahepatic bile ducts leading bile stasis and
cirrhosis. Xanthomas and xanthelasmas. Fat
soluble vitamins may be depleted, increasing risk
for osteoporosis. Xanthelasma - soft yellow
plaques that appear on the medial aspects of the
eyelids bilaterally. Benign lesions characterized
histologically by lipid-filled macrophages in the der
Cirrhosis, neuropsych symps, and kayser-fleisher
rings (brownish, gray-green rings of Cu in the
cornea) in a young adult - Wilson's dz AKA
hepatolenticular degeneration. AR. Low
Ceruloplasmin, decreased secretion of copper into
biliary system. Cu is pro-oxidant - accumulation in
liver generates inc free radicals. Cu eventually
leaks from injured hepatocytes into blood, spreads
to various tissues (basal ganglia). Tx penicillamine.
Assoc w fanconi syndrome. Dx liver biopsy
Pancreatic pseudocysts are not true cysts (lack
epithelial lining, walled by a thick fibrous capsule).
Pseudocyst is full of inflammatory fluid (amylase,
lipase, enterokinase), tissue and debris that
accumulate w/in the panc or by extension along
anatomic planes. US to dx. Often resolves
spontaneously in 5 weeks. Drain if >6 weeks,
>5cm, or becomes infected. Significant
complication is when it erodes into a blood vessel
- severe hemorrhaging
Primary biliary cholangitis is a chronic liver disease
characterized by intrahepatic cholestasis d/t
autoimmune destruction of small bile ducts. It
prsents in middle-aged women w fatigue, pruritis,
hepatomegaly, and elevated ALP. Dx - serum
anti-mitochondrial antibody titers.
Liver fxn: Synthetic (synthesis of clotting factors,
cholesterol, and protein); metabolic (metabolic of
drugs and steroids, including detoxification); and
excretory (bile excretion). In the cirrhotic pt,
gynecomastia arises from hyperestrogenism
secondary to the damaged liver's inability to
metabolize circulating estrogens. Other
manifestations of hyperestrogenism in the cirrhotic
patient include palmar erythema, spider angiomas,
& testicular atrophy and dec body hair in men
Acute liver failure is defeined as acute onset of
severe liver injury w encephalopathy and impaired
synthetic fxn (INR >1.5) in a pt w/o cirrhosis or
underlying liver disease. Acute liver failure is MC
d/t drugs (acetaminophen) and viral hepatitis
(HAV, HBV). Patients w rapidly progressing liver
failure have decreasing transaminases w
worsening PT/INR and bilirubin
SBP - d/t intestinal bacterial translocation directly
into ascitic fluid or hematogenous spread to liver
and ascitic fluid (d/t other bacterial infxns). Abd
pain/tenderness, mental status changes,
2901 Medicine Gastrointestinal & Nutrition hypotension, hypothermia, or paralytic ileus.
Ascitic PMN or neutrophil ct >250 and + peritoneal
fluid culture confirm dx. SAAG>1.1 indicates portal
htn as the cause of ascites and makes SBP more
likely.
Hepatitis: prodromal stage, icteric phase (jaundice
and worsening symps), convalescent phase. Infxn
w HAV - recent travel to endemic country & family
member w similar complaint. HAV - picorna virus.
2905 Medicine Gastrointestinal & Nutrition Fecal-oral route. Common in overcrowded poor
sanitation areas. Contaminated food or water.
HAV is self-limiting. Tx is supportive, complete
recovery in 3-6 weeks. Hep A vacc for prophylaxis
for ppl at high risk of contracting it.
Chronic alcohol abuse and viral hepatitis are the
MC underlying causes of cirrhosis in the US. Viral
hepatitis can be silent w/o symptoms or elevations
of AST/ALT and can presnt in late stages w
cirrhosis. Cirrhotic pts are at inc risk of developing
HCC. HCC by itself does not inc risk of cirrhosis.
NAFLD - steatosis in absence of other causes of
hepatic fat accumulation. Incidence as risen along
w increase in obesity. NAFLD - hepatomegaly,
mild elevations in AST and ALT, and AST/ALT <2.
2910 Medicine Gastrointestinal & Nutrition Hepatic fibrosis develops in 40% of individuals w
NAFLD, and cirrhosis in 10-15%. The foundation
of management includes weight loss and control of
metabolic risk factors. Generally safe to continue
statins in ppl w NAFLD.
Alcoholic hepatitis - jaundice, anorexia, tender
2911 Medicine Gastrointestinal & Nutrition hepatomegaly. Modest elevations in AST and
ALT, usually <300
First serologic marker in acute HBV infxn is HBsAg
which appears 4-8 weeks after infxn. IgM anti-HBc
appears shortly thereafter, which is around the
time clinical symps occur and pts develop
elevations in LFTs. There can be a time lag
between disappearance of HBsAg and
appearance of anti-HBs (window period). IgM
anti-HBc may be the only marker for HBV infxn at
this time. HBsAg and anti-HBc are most
appropriate dx tests for acute HBV.
Acute Liver Failure - medication-induced liver
injury. Markedly elevated aminotransferases (in
the thousands), impaired hepatic synthetic fxn
2914 Medicine Gastrointestinal & Nutrition (prolonged coag markers), and encephalopathy.
Caused by medications (tylenol), acute viral
hepatitis (HBV), ischemia ("shock liver"), and
autoimmune hepatitis.
INH hepatotoxicity has a similar histological picture
to viral hepatitis. Rash, arthralgias, fever,
leukocytosis, and eosinophilia are common in pts
w drug-induced liver injury - characteristically
2917 Medicine Gastrointestinal & Nutrition absent in cases of INH induced hepatotoxicity.
Drug induced liver dz: cholestasis-erythromycin,
fatty liver-tetracycline, hepatitis-INH,
toxic/fulminantliverfailure-acetaminophen,
granulomatous-allopurinol
PSC
Clinical feats
Fatigue & pruritis
Majority of pts asymptomatic at time of dx
About 90% of pts have underlying IBD, mainly UC
Labs/Imaging
Cholestatic liver fxn test pattern (serum
aminotransferases <300)
2920 Medicine Gastrointestinal & Nutrition Multifocal stricturing/dilation of intrahepatic &/or
extrahepatic bile ducts on cholangiography
Biopsy
Fibrous obliteration of small bile ducts w
concentric replacement by connective tissue in an
"onion-skin" pattern
Complications
Cholangitis,cholelithiasis
CholangioCA
In patients w small nonbleeding varcies, ppx tx w
nonselective beta blockers (propanolol, nadolol) is
recommended to reduce the likelihood of
progression to large varices and the risk of
variceal hemorrhage. Endoscopic variceal ligation
can be used as an alternate primary preventive
therapy in pts w contraindications to beta blocker
therapy.
Hepatic metabolism of bilirubin - uptake from
bloodstream; storage w/in hepatocyte; conjugation
w glucuronic acid; biliary excretion. Gilbert's
syndrome is a familial d/o of bilirubin
2923 Medicine Gastrointestinal & Nutrition glucuronidation in which production of UDP
glucuronyl transferases is reduced. Defect is d/t
mutation in promotor region. Mild, unconjugated
hyperbilirubinemia.Nonspecificcomplaints
malaise, fatigue, abd discomfort.
Dubin-Johnson - conjugated chronic
hyperbilirubinemia due to defective liver excretion.
Mostly asymptomatic. Very mild icterus, may
become apparent after a trigger (illness,
pregnancy, OCP usage). Urinary coproporphyrin I
2924 Medicine Gastrointestinal & Nutrition higer in DJ, III higher in normal ppl. Dense pigment
composed of epinephrine metabolites within
lysosomes can be seen. Livers look very dark. DJ
is benign and prognosis is great. Dx is made by
inc direct bilirub w direct bilirubin fraction of > or =
50%.
Solid liver masses
Focal Nodular Hyperplasia - Assoc w anomalous
arteries, arterial flow & central scar on imaging
Hepatic adenoma - Benign epithelial tumor, well
demarcated, hyperechoic lesion - Women on long
term OCPs, possible hemorrhage or malignant
2932 Medicine Gastrointestinal & Nutrition transformation
Regenerative nodules - Acute or chronic liver injury
(cirrhosis)
HCC - Systemic symps, chronic hep or cirrhosis,
elevated AFP
Liver metastasis - Single/multiple lesions, known
extrahepatic malignancy
ERCP may decrease M&M for biliary pancreatitis.
2934 Medicine Gastrointestinal & Nutrition Also effective for evaluating pts w recurrent
pancreatitis or draining pancreatic pseudocysts.
Abdominal CT scan is very sensitive an specific for
dx panc CA - detects bile and pancreatic duct
2935 Medicine Gastrointestinal & Nutrition dilation, mass lesions, and indications of
extrahepatic spread. Ultrasound when there is
jaundice.
Patients with cirrhosis should undergo screening
endoscopy to exclude varices, indicate the risk of
variceal hemorrhage, and determine strategies
(eg, nonselective beta blockers) for primary
prevention of variceal hemorrhage. All pts w
cirrhosis, regardless of etiology, should also
undergo surveillance for HCC w USG every 6
months.
In an asymptomatic pt w elevated transaminases
first step is to screen all hepatitis risk factors,
drug/alcohol intake, travel outside US, blood
transfusions, high-risk sexual practices. Can
provide insight to whether the transaminase
elevation could be caused by alcohol, medications
(NSAIDs, Abx, Statins, antiepileptic drugs, anti-TB
durgs, herbal preparations), or viral agents.
Repeat LFTs in 6 months after asking pt to stop
etoh tobacco.
Urosdeoxycholic acid decreases the cholesterol
2939 Medicine Gastrointestinal & Nutrition content of bile by reducing the hepatic secretion
and intestinal reabsorption of cholesterol.
Postcholescystectomy syndrome is persistent abd
pain or dyspepsia either post-op (early) or months
to years (late) after cholecystectomy. Etiologies
include biliary (eg, retained CBD, cystic duct
stone) or extra-biliary (eg, pancreatitis, PUD)
causes. Abd imaging (eg, USG) followed by direct
visualization (eg, ERCP, MRCP) can establish the
dx and guide therapy toward the caustive factor.
Acalculous cholecystitis - acute inflammation of the
gallbladder in the absence of gallstones. Most
often seen in hospitalized patients who are
critically ill. Recent surgery, severe truama,
extensive burns, sepsis or shock, prolonged
2946 Medicine Gastrointestinal & Nutrition fasting or TPN, or critical illness requiring
mechanical intubation. Unexplained fever, diffuse
upper abd pain. RUQ mass, leukocytosis, or abn
LFTs. Complications: gangrene, perforation,
emphysematous cholecystits. Unclear USG -> CT
or HIDA scan
Hepatic encephalopathy is a CNS complication of
liver failure likely d/t inability to break down
ammonia into urea. The condition can present
clinically as stage 1 (diurnal sleep pattern
disturbances and impaired cognition) and progress
to stage 4 (stupor and coma). Serum ammonia
can help support the dx in pts w high suspicioun of
hepatic encephalopathy, though it is relatively
nonspecific and can be elevated in asymptomatic
pts.
Ursodeoxycholic acid - drug of choice in PBC.
UDCA is a hydrophilic bile acid that decreases
biliary injury by the more hydrophobic endogenous
bile acids. Also increases biliary secretion and
may have anti-inflammatory and
immunomodulatory effects. UDCA delays
histologic progression in PBC and may improve
symps and possibly survivial. Tx should be started
as dx is made, in asymptomatic pts too. Advanced
disease - liver transplant
Management of hepatic encephalopathy involves
supportive care, tx the precipitating cause (volume
depletion, electrolyte abnormalities), and lowering
serum ammonia. Disaccharides (lactulose, lactitol)
are initally preferred for lowering serum ammonia.
Rifaximin can be added to lactulose in pts w/o
improvement after 48 hours or used as
monotherapy in those unable to take lactulose.
Hepatic hydrothorax is a cause of transudative
pleural effusions (from abd ascitic fluid) in pts w
cirrhosis who hae no underlying cardiac or
pulmonary dz to account for development of such
an effusion. Hepatic hydrothorax usually results in
a right-sided pleural effusion. Initial tx is usually w
salt restriction and diuretics. TIPS placement is
considered in pts w refractory hepatic
hydrothorax. Best tx option is liver transplant, but
ltd by other factors.
Fever, jaundice, RUQ pain, confusion, hypotension
- Reynold's pentad.
Infxn of CBD, cholangitis MCly arises 2ndary to
CBD obstruction by stone or stricture. USG is first
imaging used to confirm dx. Immediate supportive
2978 Medicine Gastrointestinal & Nutrition care and broad-spec abx reqd. 80% of pts this is
sufficient. Those w continuing problems need
urgent biliary decompression - done by ERCOP.
TxSphincterotomy w stone removal or stent
insertion. Early drainage of biliary tree in acute
cholangitis can sig dec M&M.
Acute pancreatitis from uncorrectable causes
2982 Medicine Gastrointestinal & Nutrition (ischemia, atheroembolism) can be conservatively
managed w analgesics and IV fluids.
Tea and toast type of diet is assoc w folic acid
deficiency. Folic acid is heat sensitive so cooked
3086 Medicine Gastrointestinal & Nutrition foods are lacking. Folic acid stores can become
depleted in 4-5 months. Folic acid deficiency
causes macrocytic anemia.
Pellagra - niacin deficiency
Dermatitis - sun-exposed areas of the body -
rough, hyperpigmented, scaly skin
Diarrhea - abdominal pain, nausea, loss of appetite
Dementia - neuronal degeneration in the brain and
spinal cord and can lead to memory loss, affective
symps, and psychosis
Niacin - synthesized endogenously from
tryptophan. Pellagra RF - carcinoid syndrome (trp
depletion) Hartnup dz (congential d/o of tryptophan
absorption). Prolonged INH therapy (interferes w
trp)
Chemical peritonitis d/t perforated peptic ulcer
should be suspected in pts presenting w sudden
onset of severe epigastric pain that spreads over
the entire abdomen. Upright chest and/or
abdominal radiographs typically reveal free air
under the diaphragm.
Suspect tropical sprue in pts w malabsorption,
along w a hx of living in endemic areas for
>1month. Tropical sprue involves the small
3581 Medicine Gastrointestinal & Nutrition intestine; the typical biopsy is characterized by
blunting of villi w infiltration of chronic inflammatory
cells, including lymphocytes, plasma cells and
eosinophils.
Whipple's disease is a rare multi-systemic illness.
Infectious disease caused by the bacillus
Tropheryma whippelii. MC - white men in 40s-60s
w weight loss. GI symps - abd pain, diarrhea,
malabsorption, flatulence, and steatorrhea.
Extraintestinal manifestations include migratory
polyarthropathy, chronic cough, and myocardial or
valular involvement - CHF or regurg. Dementia
CNS findings. PAS + material in lamina propria of
small intestine.
Pancreatic CA should be suspected in pts w a hx
of chronic pancreatitis who develop abd pain and
weight loss. USG of the abd is useful to exclude
biliary obstruction in pts w jaundice.
Conrast-enhanced CT of the abdomen is preferred
for pts w/o jaundice.
Patients with dyspepsia who have risk factors for
gastric or esophageal CA - age>55, weight loss,
gross or occult bleeding, anemia, dysphagia, or
early satiety - should be evaluated with upper GI
endoscopy. Pts w NSAID induced dyspepsia
should receive a PPI. Pts from high-prevalence
areas or w possible exposure to H pylori may
have testing for active infxn and tx as an initial step.
Gastrinoma (Zollinger-Ellison) should be
suspected in pts w multiple stomach ulcers and
thickened gastric folds on endoscopy. Dx is
3591 Medicine Gastrointestinal & Nutrition strongly suggested by a fasting serum gastrin
level >1000pg/mL. Patient w non-diagnostic serum
gastrin levels should be evaluated w a secretin
stim test.
Factitious diarrhea - laxative abuse - watery w
increase in frequency and volume of stool. Bowel
movement is generally profuse w 10-20
movements daily. Dx is confirmed a characteristic
biopsy finding of dark brown discoloration of the
colon w lymph follicles shining through as pale
patches (melanosis coli); typically seen in those
usinganthraquinone-containinglaxatives
(bisacodyl). Dvlops in 4 months of onset and
disappears in same amt of time if DC'd.
Celiac dz should be suspected in any pt w
malabsorption and iron def anemia. IgA
anti-endomysial and anti-tissue transglutaminase
3602 Medicine Gastrointestinal & Nutrition antibodies are highly predictive of celiac dz but
may be absent if there is concurrent IgA
deficiency (common in celiac dz). Small bowel
biopsy will show villous atrophy.
Small-intestine bacterial overgrowth (SIBO) - incr
# of native and non-native intestinal bacteria that
alter the normal flora and cause excessive
fermentation, inflammation, or malabsorption.
3603 Medicine Gastrointestinal & Nutrition Small intestine normally contains minimal bacterial
colonizatino d/t bacterial degradation by
proteolytic digestive enzymes. Abd bloating,
flatulence diarrhea. Endoscopy w jejunal aspirate
showing >10^5 orgs/mL is gold standard for dx.
Lactase is a brush border enzyme that hydrolyses
lactose. Its concentration declines steadily as one
ages esp in ppl of non-european ancestry.
Lactose intolerance is MC seen in
Asian-Americans (90%). Pts typically manifest w
3605 Medicine Gastrointestinal & Nutrition osmotic diarrhea, abd cramps, bloating and
flatulence. Lactose tolerance test used to be used
for dx. Measurement of blood glucose level after
oral lactose admin. Lactose hydrogen breath test
has replaced this. Positive hydrogen breath test -
look up
Abd pain in acute appendicitis. Visceral pain
followed by somatic pain. First only viscera are
inflamed so pain is poorly localized (peri-umbilical)
3703 Medicine Gastrointestinal & Nutrition and constant. As disease proceeds subsequent
inflammation of parietal peritoneum and skeletal
muscles causes somatic pain, which is well
localized (RLQ) and more severe.
Porcelain gallbladder results from the intramural
deposition of calcium salts, is usually dx on ab
imaging, is assoc w an inc risk of gallbladder
carcinoma, reqs surgical resection.
Zinc - digested in the jejunum - deficiency - ppl w
small bowel resections - ppl receiving TPN (lacks
zinc) - ppl w IBD - alopecia, abnormal taste,
3790 Medicine Gastrointestinal & Nutrition bullous, pustulous lesions surrounding body
orifices and/or the extremities, and impaired
wound healing. In children it may cause growth
retardation.
Acute pancreatitis is MC d/t EtOH use, gallstones
or medications. Commonly implicated drugs
include diuretics, anti-seizure drugs (eg, valproic
acid), and Abx (metronidazole). Abd CT scan can
reveal diffuse or focal parenchymal changes,
edema, necrosis, or liquefaction. Drug-induced
pancreatitis is usually mild and resolves w
supportive care.
Toxic megacolon typically presents w total or
segmental nonobstructive colonic dilation, severe
bloody diarrhea, and systemic findings (eg, fever,
tachycardia). Patients w IBD are at higher risk of
developing toxic megacolon. Dx is confirmed by
plain abd X-rays and > or =3 of the following:
fever (>38C), pulse >120, WBC >10,500, and
anemia. Toxic megacolon is a medical emergency
that requires prompt IV steroids, NG
decompression, ABx, and fluid management.
Minimal rectal bleeding is usually d/t hemorrhoids
or other benign conditions. Evaluation depends on
the patient's presentation and risk factors. Pts age
3857 Medicine Gastrointestinal & Nutrition >50 or w clnical feats suggesting malignancy
should undergo colonoscopy. Younger patients
<40 and no other risk factors, office-based
anoscopy may be performed first.
Hyperplastic polyps - MC non-neoplastic polyps -
hyperplastic mucosal proliferation - no further
workup needed.
Hamartomatous polyps - juvenile polyp (removed
for bleeding risk) and peutz jeghers polyp - non
malignant
Adenoma - MC type of polyp found in colon.
Potentiall premalignant. <1% become malignant.
Sessile (MCly cancerous) or pedunculated.
Tubular, tubulovillous, and villous. <1.5cm low risk
(<2%), 1.5-2.5 intermediate risk (2-10%), >2.5
high risk (10%)
NSAIDs are a common cause of Fe-deficiency
anemia, often through chronic blood loss from the
GI tract. Fe-deficiency anemia should prompt a
thorough evaluation for the cause as early
low-grade bleeding can herald later catastrophic
hemorrhage. Elderly pts often have a low-grade
chronic anemia at baseline and may not tolerate
additional blood loss.
CD - transmural involvement of colon, skip lesions,
cobblestone appearance of colon, creeping fatty
appearance of mesentery, fistulas, fissures, and
perianal disease, non-caseating granulomas
Angiodysplasia is characterized by dilated
submucosal veins and AVMs. Inc incidence after
age 60. MC in advanced renal disease and von
Willebrand disease. May be more common in ppl
4085 Medicine Gastrointestinal & Nutrition w Aortic Stenosis. It's a common cause of
recurrent, painless GI bleeding. Dx by
colonoscopy, although it's frequently missed.
Asymptomatic pts do not require tx. Those w
anemia or bleding can be tx w cautery.
Zollinger-Ellison - suspected when multiple ulcers
in stomach, duodenum, and/or jejunum. Gastric
acid in small intestine can inactivate pancreatic
enzymes causing diarrhea and steatorrhea.
Inflammatory diarrhea - typical cause is IBD -
Infectious causes are less likely w chronic
diarrhea (>4weeks) than w acute diarrhea - assoc
4150 Medicine Gastrointestinal & Nutrition w inflammatory changes in the blood (anemia,
elevated ESR, acute phase reactants, reactive
thrombocytosis). FOBT + is another important
finding.
90% of gastric CA are dx at advanced stages
(III-IV), at which point radical resection is very
complicated or impossible. Evaluation of the extent
of the cancer is most important following histologic
dx. CT of the abd and pelvis is employed for
disease staging and is sensitive for revealing
metastases (esp in liver). Depending on CT
findings, addl staging procedures ie. laparoscopy,
endoscopic usg, chest CT, or PET may be
necessary. Limited stage dz - resection
Zenker(pharyngoesophageal)diverticulum
develops immediately above the upper esophageal
sphincter. It occurs due to posterior herniation
between the fibers of the cricopharyngeal muscle.
4188 Medicine Gastrointestinal & Nutrition Symptoms include dysphagia, tracheal
compression, halitosis, aspiration, and
regurgitation. Diagnosis is confirmed with a barium
esophagram and tx is surgical. Pts usually over
60. Oropharyngeal dysphagia w a neck mass.
3 stages of alcoholic liver disease: 1) Fatty liver
(steatosis) 2) Alcoholic hepatitis 3) Alcoholic
fibrosis/cirrhosis. Fatty liver is the result of short
term alcoholic ingestion, whereas hepatitis and
cirrhosis require long term EtOH use. Alcoholic
hepatitis is characteried by Mallory bodies,
infiltration by neutrophils, liver cell necrosis, and
perivenular distribution of inflammation. Fatty liver,
alc hep and early fibrosis are reversible.
Regenerative nodules - irreversi
Patients w upper GI bleeding often have elevated
BUN and elevated BUN/Cr ratio, possibly d/t
4303 Medicine Gastrointestinal & Nutrition increased urea production (from intestinal
breakdown of Hgb) and increased urea
reabsorption (d/t hypovolemia).
Nonalcoholic fatty liver disease (NAFLD) -
resembles EtOH-induced liver injury on histo but
occurs in pts w/o EtOH hx. Pts are middle-aged,
obese, have metabolic syndrome (central obesity,
DM, HLD, HTN). NAFLD is futher classified by
histo into fatty liver dz and nonalcoholic
steatohepatitis, which can progress faster to
fibrosis and cirrhosis. Most likely d/t insulin
resistance -> inc lipolysis, TG synthesis, hepatic
uptake of fatty acids
Spontaneous rupture of the esophagus
(Boerhaave syndrome) typically occurs after
severe retching and vomiting. CXR can reveal
unilateral pleural effusion w or w/o pneumothorax,
subq or mediastinal emphysema, and widened
mediastinum. Pleural fluid analysis is typically
exudative w low pH and a very high amylase
(>2500) and may contain food particles. CT or
contrast esophagography w gastrograffin confirms
dx.
Chronicpancreatitis
Etiology - Alcohol use, cystic fibrosis (in children),
ductal obstruction (malignancy, stones),
autoimmune
Clinical Presentation - Chronic epigastric pain w
intermittent pain-free intervals, malabsorption -
steatorrhea, weight loss, DM
Lab results/imaging - Amylase/lipase can be
normal and nondiagnostic, CT or MRCP can show
calcifications, dilated ducts & enlarged pancreas
Tx - Pain management, EtOH and smoking
cessation, frequent small meals, enzyme supp
Melena + nocturnal pain that is relieved by eating -
duodenal ulcer disease. Worse on an empty
stomach bc of unopposed acidic fluid that empties
into the duodenum and relieves pain. Pain
associated w gastric ulcers tends to worsen with
eating. Very high (over 90%) prevalence of H.
pylori infxn in ppl w duodenal ulcer disease.
Mainstay of therapy for pts w PUD is acid
suppression and ABx tx. Amoxicillin +
clarithromycin + PPI
Alcoholic liver disease w upper GI hemorrhage -
esophageal varices. Initial tx of suspected variceal
bleeding includes volume resuscitaiton (2
large-bore IV lines). PPx Abx (ceftriaxone).
Somatostatin analogues (octreotide) inhibit
4386 Medicine Gastrointestinal & Nutrition release of vasodilator hormones which leads
indirectly to splanchnic vasoconstriction and
decreased portal flow. Urgent endoscopy w/in 12
hrs can dx and tx. Uncontrollable bleeding reqs
balloon tamponade. TIPS surgery for refractory
ascites.
MC site of colon CA metastasis is the liver. Liver
metastasis manifest as RUQ pain, mildly elevated
transaminases, elevated ALP, and firm
hepatomegaly. Dx is confirmed by CT of the
abdomen. NASH is asymptomatic and manifests
as hepatomegaly w elevated transaminates.
Imaging shows fatty infiltration of the liver. Leading
causes of NASH are obesity, DM, HyperTG.
Autoimmune hepatitis has transaminases above
1000.
Burning, localized pain and regional
hyperesthesia/allodynia, in the context of recent
cancer tx, has common feats of VZV. Pain from
shingles may precede the onset of the classic
vesicular rash by several dyas. Possibility of
shingles should be considered in pts w regional
pain who have no conclusive evidence of disease
in the local internal organs.
Amiodarone can increase the serum levels of
digoxin and cause toxicity in a patient on a stable
digoxin regiment. Acute digoxin toxicity typically
presents w GI symptoms (anorexia, nausea,
vomiting, abd pain). Chornic digoxin toxicity
presents w less pronounced GI symps but more
significant neurologic and visual symps (changes in
color vision, scotomas, blindness).
Pts at avg risk of developing CRC should begin
screening at age 50 w high-sensitivity FOBT
annually, flexible sigmoidoscopy every 5 years
4504 Medicine Gastrointestinal & Nutrition combined w FOBT every 3 years, or colonoscopy
every 10 years. Pts w an affected 1st-degree
relative should begin screening at age 40 or 10
years before the age of the relative's dx.
RF pancreatic cancer:
Family history, elderly age, chronic pancreatitis,
abdominal radiation, obesity, and tobacco use.
Unfortunately, no serologic or radiographic test
has proven effective in screening for pancreatic
cancer in asymptomatic adults.
Rome dx criteria - Recurrent abd pain/discomfort
>or=3days/month for the past 3 months & >or=2
of the following:
-Symptom improvement w bowel movement
-change in frequency of stool
4595 Medicine Gastrointestinal & Nutrition -Change in form of stool
R/O IBS if there's rectal bleeding, nocturnal or
worsening abd pain, weight loss, abnormal lab
findings.
IBS - fxnal d/o of GI tract. ROME III criteria + no
alarm feats - no workup for dx
Ascites is MCC by cirrhosis d/t alcoholic liver
disease or chronic viral hepatitis. All pts w
new-onset ascites require paracentesis to
determine the cause.
Severe pancreatitis progresses to multisystem
organ dysfxn (shock, renal failure, early resp
failure). Most pts w actue panc have mild disease
and recover w conservative management. 15-20%
can dvlp severe acute panc (def - pancreatitis w
4603 Medicine Gastrointestinal & Nutrition failure of at least 1 organ). Inc risk for severe
panc: >75ya, alcoholism, obsesity, CRP >150, inc
BUN/Cr. Severe panc - release of activated
enzymes - inc vasc perm of local structures -
massive fluid migration out of vasc - hypotension
-IVF
Weight loss and fatigue in the setting of multiple
liver masses on CT - metastatic malignancy to the
liver. Primary tumors of GI tract, lung, and breast
metastasize commonly to the liver.
PUD may present w epigastric pain, nausea,
and/or early satiety in assoc w food. Symps of
duodenal ulcer classically occur in the absence of
4623 Medicine Gastrointestinal & Nutrition a food buffer (eg, 2-5 hours after meals, on an
empty stomach, or at night). Melena is a
manifestation of upper GI bleeding, w PUD being
one of the MCC.
Vanishing bile duct syndrome - rare disease
involving progressive destrucxn of the intrahepatic
bile ducts. Histologic hallmark is ductopenia. Exact
pathophys is unknown. PBC is the MCC of
ductopenia in adults. Other causes include failing
liver transplant, Hodgkin's disease,
graft-versus-host disease, sarcoid, CMV infxn,
HIV, and medication toxicity.
Hepatic encephalopathy is an alteration in CNS fxn
due to poor hepatic clearance of toxins. There is
4625 Medicine Gastrointestinal & Nutrition typically a clear precipitant, and symps may range
from mild confusion to coma. Tx include lactulose,
rifamixin, and laxatives
All patients with chronic liver disease should be
immunized against HAV and HBV unless they are
4626 Medicine Gastrointestinal & Nutrition already immune, as they are at high risk for acute
hepatic failure or cirrhosis upon infection w viral
hepatitis.
Septic shock followed by AST and ALT elevations
a day later is consistent with ischemic hepatic
injury - schock liver. The hallmark of ischemic
hepatopathy is a rapid and massive increase in the
transaminases w modest accompanying elevations
in total bilirubin and ALP. In patients who survive
the underlying cause of hypotension, liver enzymes
typically return to normal w/in one or two weeks.
Essential mixed cryoglobulinemia - circulating
immune complexes deposit in small-medium
vessels and is assoc w low serum complement
levels. Pts develop palpable purpura, arthralgias
and renal complicaions (MPGN). Nearly 90% of
pts also have HCV, and nearly 50% of pts w HCV
have cryoglobulinemia. Porphyria Cutanea Tarda,
cryoglobulinemia, lichen planus, and
leuckocytoclastic vasculitis are all associated with
HCV.
HCV - intermittent elevations of transaminases,
skin findings consistent w porphyria cutanea tarda
(fragile skin, photosensitivity, vesicles and
erosions on dorsum of hand). High assoc w PCT.
Also high assoc. w essential mixed
cryoglobulinemia - circulating immune complexes
deposit in small to medium vessels and may be
assoc w low serum complement levels. Purpura,
arthralgias and renal effects
(membranoproliferative glomerulonephritis)
Chronic GERD w new dysphagia and symmetric
esophageal narrowing - suggests esophageal
(peptic) stricture. Chronic GERD predisposes to
Barrett's esophagus and esophageml strictures.
Both are consequences of the body's reparative
4694 Medicine Gastrointestinal & Nutrition repsonse to chronic gastric acid exposure.
Systemic sclerosis, radiation, caustic ingestions
also cause strictures. Strictures tend to appear as
symmetric, circumferential narrowing on barium
swallow. Biopsy is necessary to r/o
adenocarcinoma.
Anticoagulation,weakness/dizziness,anemia,
tachycardia - internal hemorrhage. Risk of
4697 Medicine Gastrointestinal & Nutrition bleeding while on warfarin is greatest in pts w risk
factors such as diabetes, age >60, htn,
alcoholism, supratherapeutic INR.
In evaluating ascites, a serum-to-ascites albumin
gradient (SAAG) >or= 1.1g/dL indicateds portal
hypertensiv etiologies (eg, cardiac ascites,
cirrhosis) while a SAAG <1.1 suggests non-portal
hypertensive etiologies (eg, malignancy,
pancreatitis, nephrotic syndrome, tuberculosis).
HepatoRenal Syndrome - complication of ESLD -
decr GFR in absence of shock, proteinuria or
other clear cause of renal dysfxn, and failure to
respont to 1.5L normal saline bolus - thought to
result from renal vasoconstriction in response to
dec total RBF and vasodilatory subs synth. 2
types of HRS - type 1 is rapidly progressive pts
die in 10 weeks. Type 2 is much slower survival of
3-6 months. MCC of death is infxn and
hemorrhage. Liver transplantation is only tx.
Steatorrhea is diarrhea d/t fat malabsorption and
generally presents w pale, volumnious, greasy,
and foul-smelling stools that are difficult to flush.
4919 Medicine Gastrointestinal & Nutrition Causes of steatorrhea include pancreatic
insufficiency, bile salt-related dysfxn, impaired
intestinal epithelium, and other rare causes. MCC
is chronic pancreatitis d/t alcohol abuse.
Pts w upper GI bleeding who have a depressed
level of consciousness and ongoing hematemesis
should be intubated to protect the airway as a part
of initial stabilization and resuscitation. Prompt
endoscopic tx w band ligation or sclerotherapy
should then be performed to stop the bleeding.
Pill esophagitis is d/t a direct effect of certain
meds on esophageal mucosa. Tetracyclines,
potassium chloride, bisphosphonates, and NSAIDs
are common causes. Pts experience sudden-onset
odynophagia and retrosternal pain that can
sometimes cause difficulty swallowing.
Low-grade fever, acute watery diarrhea, abd pain,
and FOBT + stool in the setting of prolonged
omeprazole use are consistent w likely C dif. RF -
advanced age, recent Abx, hospitalization, and
comorbid illness (ESRD). Prolonged gastric acid
suppression w PPIs or H2 antags is also assoc w
inc risk. Dx confirmed w stool assay for C dif
(PCR for toxin A B)
Pruritic urticarial papules and plaques of
pregnancy (PUPPP) is a skin condition that
develops in the 3rd trimester. Classic finding on
Obstetrics
abd exam is red papules within striae w sparing
2925 & Gastrointestinal & Nutrition
around the umbilicus, sometimes extending to the
Gynecology
extremities. The palms, soles, and face are rarely
involved, helping to distinguish it from ICP. No lab
or liver abnormalities assoc w PUPPP.
Most appropriate step in a pat w suspected acute
appendicitis during pregnancy is to obtain USG w
Obstetrics
graded compression technique. Noncompression
8910 & Gastrointestinal & Nutrition
and dilation of the appendix are dx of appendicitis.
Gynecology
USG is useful in excluding other potentional dx and
doesn't expose the fetus to ionizing radiation.
Cyclic vomiting syndrome
> or = 3 episodes in a 6 month period
Easily recognizable to family
2453 Pediatrics Gastrointestinal & Nutrition Lasts 1-10 days
Vomiting > or = 4x/hr at peak
No symps in between vomiting episodes
No underlying condition can be identified
~75% of intussusception cases occur before age
2 following a viral illness. Antecedent illness is
thought to cause hypertrophy of the Peyer
patches in the lymphoid-rich terminal ileum.
Intussusception in older children should raise
2463 Pediatrics Gastrointestinal & Nutrition
concern for a pathologic lead pt, esp in the setting
of recurrence. Meckel's diverticulum is the MC
congenital GI anomaly and should be suspected in
all kids w recurrent intussusception. Dx - ex lap,
technetium-99m pertechnetate scan. Tx - surgery
Milk- or soy-protein-induced colitis
Risk Factors
Family hx of allergies, eczema, or asthma
Clinical feats
Presents at 2-8 weeks, Regurgitation or vomiting,
+/-Painless bloody stools, +/-Eczema
2464 Pediatrics Gastrointestinal & Nutrition Treatment
Elimination of milk & soy from maternal diet of
exclusively breastfed infants
Initiation of hydrolyzed formula in formula-fed
infants
Prognosis
Spontaneous resolution be age 1 year
Bilious emesis in neonate -> stop feeds, NG tube
decompression,
IVF -> Abd xray:
Free air, hematemesis, unstable vitals -> surgery
Dilated loops of bowel -> contrast enema -> if
microcolon then meconium ileus; if rectosigmoid
2465 Pediatrics Gastrointestinal & Nutrition transition zone then Hirschsprung disease
NG tube in misplaced duodenum -> UPPER GI
SERIES -> Ligament of treitz on right side of abd
-> Malrotation
Double bubble sign -> duodenal atresia
Malrotation w midgut volvulus - bilious vomiting
abd distension
Hirschsprung disease
Associated w Down syndrome (though congenital
aganglionic megacolon is usually an isolated birth
defect)
Rectosigmoid level of obstruction
Normal meconium consistency
2467 Pediatrics Gastrointestinal & Nutrition "squirt sign" positive (poop shoots out)
Meconium ileus
Associated w CF
Ileum level of obstruction
Inspissated meconicum
"squirt sign" negative
Necrotizingenterocolitis
RF - Prematurity, very low birth weight, reduced
mesenteric perfusion, enteral feeding (formula
more than breast milk)
Clinical feat - systemic: vital sign instability,
lethargy. GI: vomiting, bloody stools, abd
distension/tenderness
X-ray findings: Pneumatosis instestinalis, portal
venous fas, pneumoperitoneum
Tx: Supportive care (bowel rest, parenteral
hydration/nutrition), Broad-spec IV abx, +/- Surgery
Comp: Shock, strictures, Death, short bowel
Breastfed infants have a decreased risk of
developing otitis media; respiratory, GI, UTI; &
necrotizing enterocolitis. Breastfed infants also
lower rates of type 1 DM and childhood cancer.
The only absolute infant contraindication to
breastfeeding is galactosemia.
Full-term infants are born w adequate iron stores
to prevent anemia for the first 4-6 months of life
regardless of dietary intake. Preterm infants are
at significantly incr risk for iron deficiency anemia.
2479 Pediatrics Gastrointestinal & Nutrition Iron supplementation should be started at birth in
exclusively breastfed preterm infants and
continued until age 1 year. All exclusively
breastfed infants should also be started on vit D
supplementation.
Batteries lodged in the esophagus on x-ray should
be removed immediately under endoscopic
guidance to prevent mucosal damage and
2656 Pediatrics Gastrointestinal & Nutrition esophageal ulceration. Batteries located distal to
the esophagus pass uneventfully in most cases
and need only to be observed w stool exam
and/or follow up x-rays to confirm excretion.
Celiac disease - immune mediated HSR to gluten
-> impaired nutrient absoption in proximal small
intestin. GI symps (abd pain, nausea, vomiting,
diarrhea, and/or weight loss). Fatigue, dermatitis
herpetiformis, and iron deficiency anemia (poor
iron absorption from duodenal villous atrophy).
Biliary cyst.. congenital dilation of the biliary tree.
single or multiple. intra or extrahepatic. MC is type
1 (single, extrahepatic cyst). Congenital or
acquired. Classic signs: abd pain, jaundice (d/t
obstructive cholestasis), and a palpable mass.
Clinical presentation varies w age. Most pts <10.
Infants.. jaundice w acholic stools (biliary atresia
picture). Older kids can have pancreatitis. Adults
vague epigastric or RUQ abd pain or cholangitis.
Dx USG or ERCP. Tx Surgery
Reye syndrome - seen in children <15 years old
who were tx w salicylates for a viral infxn.
Vomiting, agitation, & irrational behavior
progressing to lethargy, stupor, and restlessness.
Convulsions may occur. Characteristic labs show
hyperammoniemia, nl or elevated bilirubin and alk
phos, prolonged PT, hypoglycemia, and moderate
to severe elevations in AST, ALT, and LDH.
Biopsy of liver, kidneys, and brain shows
microvesicular steatosis. Tx is supportive.
Choanal atresia - malformation - posterior nasal
passage doesn't canalize completely, leaving a
bondy or membranous obstruction. CHARGE
syndrome:
Coloboma
Heart defects
Atresia choanae
3872 Pediatrics Gastrointestinal & Nutrition Retardation of growth/development
Genito-urinary anomalies
Ear abnlties/deafness
CT scan shows a narrowing @ level of the
pterygoid plate in the posterior nasal cavity.
Catheter won't passy through nasopharynx.
Cynosis & distress worsened by feeding &
relieved by crying
Cystic Fibrosis
Resp:
Obstructive lung disease -> bronchiectasis
Recurrent pneumonia
Chronicrhinosinusitis
GI:
Obstruction (10-20%) - Meconium ileus, Distal
intestinal obstruction syndrome
Pancreatic disease - Exocrine pancreatic
insufficiency, CF-related DM (~25%)
Biliary cirrhosis
Repro:
Infertility (>95% men, ~20% women)
Musculoskeletal:
Osteopenia -> fractures, kyphoscoliosis, digital
clubbing
Biliary atresia
Clinical: Initially well-appearing, followed by
development of the following: Jaundice, acholic
(pale) stools or dark urine, hepatomegaly,
conjugated hyperbilirubinemia, mild elevation in
transaminases
Dx:
3970 Pediatrics Gastrointestinal & Nutrition USG: absent or abnl gallbladder
Hepatobiliary scintigraphy: failure of tracer
excretion
Liver Bpx: expanded portal tracts w bile duct
obstrxn & proliferation
Intraop cholangiogram (gold standard): biliary
obstrxn
Tx: Liver transplant, Hepatoportoenterostomy
Nearly all CF pts will develop Sinopulmonary
disease. Opacification of all sinuses can be seen
early as 8 months, and pts often require surgical
debridement of their sinuses during childhood and
4183 Pediatrics Gastrointestinal & Nutrition adulthood. Chronic lung inflammation and recurrent
pneumonias can progress to bronchiectasis. Bc of
frquent tx w aminoglycosides for Gram-neg infxns
(psuedomonas), 10-50% of pts may develop
sensorineural hearing loss.
Gastroschisis is an isolated defect >90% of the
time. After delivery, wrap the bowel in sterile
saline dressings and plastic wrap to minimize
insensible heat & fluid losses. Infant should have
an NG tube for decompression and should be
started on ABx. Prompt surgical repair is
necessary. Single-stage closure. Complications -
necrotizing enterocolitis, short bowel syndrome.
Dysmotility in >50% of cases -> prolonged TPN.
2nd Semester USG is >95% sensitive.
Vit Defic
B1 - Beriberi (peripheral neuropathy, heart failure),
Wernicke-Korsakoff
B2 - Angular cheilosis, stomatits, glossitis.
Normocytic anemia. Seborrheic dermatitis
B3 - Pellagra
B6 - Cheilosis, stomatitis, glossitis. Irritability,
confusion, depression
B9 - Megaloblastic anemia. Neural tube defects
B12 - Megaloblastic anemia. Neurologic deficits
(confusion, paresthesias, ataxia)
C - Scurvy
Breastfeeding failure jaundice - first week of life -
lactaction failure resulting in : decreased bilirubin
elimination, increased enterohepatic circulation -
suboptimal breastfeeding, signs of dehydration
4817 Pediatrics Gastrointestinal & Nutrition Breast milk jaundice - starts at age 3-5 days;
peaks at 2 weeks - High levels of B-glucuronidase
in breast milk deconjugate intestinal bilirubin &
incrased enterohepatic circulation - adequate
breastfeeding, normal examination
Tx of breastfeeding failure jaundice consists of
optimizing lactation & inc breastfeeding frequency.
If the mother's milk supply is inadequate,
supplementation w cow's milk-based formular can
be considered, but breastfeeding should not be
DC.
Meckel'sdiverticulum
Rule of 2s
2% prevalence, 2:1 male-to-female ratio, 2% are
symptomatic at age 2, located w/in 2 feet of
ileocecal valve
Asymptomatic incidental finding, painless
hematochezia,intussusception,intestinal
obstruction, volvulus
Dx - Technetium-99 pertechnetate scan
Tx - Surgery for symptomatic pts
Intussusception is MCC of intestinal obstruction in
children age 6-36 months. Ileocolic jxn is most
frequently involved, w invagination of the ileum into
the colon. Most children (~75%) have no
indentifiable lead pt. Preceding viral illness inflame
intestinal lympatic tissue which can serve as lead
pts. Meckel's diverticulum, follwed by polyps and
hematomas (HSP) MCC in remaining 25%.
Telescoping is intermittent, periodic pain. Emesis
may follow pain. Currant jelly stools.
The composition of human milk varies based on
the mother's diet, the duration of lactation, and the
needs of the infant. Protein in human milk is 70%
whey and 30% casein, and the protein content is
highest @ birth and decreases over the first month
of life. Whey is more easily digested than casein &
improves gastric emptying. It contains lactoferrin,
lysozyme & IgA - immunity for baby. Minerals are
better absorbed from human milk (formula does
have higher conc of minerals but
Jejunal atresia on xray has a triple bubble sign.
Gas trapping in stomach, duodenum, and jejunum.
Pt has bilious emesis and abd distension. Thought
to be caused by vascular accident in utero that
causes necrosis & resorption of the fetal intestine
leaving behind blind proximal and distal ends of the
gut tube. It can occur anywhere in the GI tract.
Jujenal & ileal atresia are assoc w maternal use of
cocaine or vasoconstrictive meds. Duodenal
atresia is assoc w Down syndrome.
Moderate to severe dehydration in children should
be tx w IV bolus of isotonic fluid
Ddx regurgitation & vomiting in infants
GER
Physiologic - asymptomatic, "happy spitter"
Mgmt: Provide reassurance, positioning therapy
Pathologic (GERD)- Failure to thrive, significant
irritability, sandifer syndrome
Mgmt: Thickened feeds, antacid therapy
4926 Pediatrics Gastrointestinal & Nutrition If severe, esophageal pH probe monitoring &
upper endoscopy
Milk protein allergy - Regurgitation/vomiting,

eczema, bloody stools
mgmt - eliminate dairy & soy protein from diet
Pyloric stenosis - projectile nonbilious vomit

Constipation in children
RF - Initiation of solid food & cow's milk, toilet
training, school entry
Clinical - Straining w passage of hard stools,
8955 Pediatrics Gastrointestinal & Nutrition crampy abd pain, <2 defecations/wk
Comps - Anal fissures, hemorrhoids, encopresis,
enuresis/UTIs, vomiting
Tx - Incr dietary fiber, Limit cows milk intake to
<24 oz, laxative, +/- suppositories, enema
Acute mesenteric ischemia classically presents w
severe acute-onset midabdominal pain out of
2143 Surgery Gastrointestinal & Nutrition proportion to phys exam findings. MCC is embolus
from heart. Progression to bowel infarcxn causes
peritoneal signs and passage of bloody stool.
Acalculous cholecystitis occurs in critically ill
patients. The clinical presentation may be similar
to calculous cholecystitis, though assessment may
be difficult due to the underlying illness. Imaging
2245 Surgery Gastrointestinal & Nutrition studies show gallbladder wall thickening and
distension and pericholecystic fluid. The
emergency tx of choice is Abx and percutaneous
cholecystostomy, followed by cholecystectomy
when the medical condition stabilizes.
SMO - colicky abd pain, vomiting, no bowel
movement or passing gas (obstipation), abd dist,
and diffuse tenderness. Nausea and vomiting more
w sbo than lbo (ileocecal valve is competent). Inc
2322 Surgery Gastrointestinal & Nutrition
pain w hyperactive bowel sounds during peristaltic
rush. Fever, tachycard, leukocytosis, and metab
acidosis indicate inc risk of impending
strangulation.
The dx of bowel ischemia depends on a high index
of clinical suspicion in pts w known risk factors for
thromboembolic dz (afib, pvd). Typical feats
include acute abd pain out of proportion to exam
findings, and associated metabolic acidosis. Lab
studies show leukocytosis, elevated amylase, and
metabolic acidosis from inc serum lactate.
Mesenteric angiography is gold standard. CTA
may be used. Tx is supportive (IVF, ABx, NG
tube).
Variceal bleeding is life threatening - fluid loss is
sudden and dramatic - prompt and aggressive
fluid resuscitation should be the first step - pts
should have vascular access established
immediately - two large bore IV needs or a central
line should be placed and fluid resuscitaiton
undertaken. Airway should be protected and
gastric decompression initiated w NG aspiration.
2nd step control bleeding. 50% self resolves.
Terlipressin, octreotide, somatostatin.
Acute mid-epigastric pain radiating to her back,
leukocytosis, and markedly elevated amylase
lipase - Acute pancreatitis. Alcohol, medications,
and gallstones. Cholecystectomy is indicated for
all patients w symptomatic gallstones who are
medically stable enough for surgery.
Emphysematous cholecystitis
RF: DM, vascular compromise,
immunosuppression
Clinical: Fever, RUQ pain, nausea/vomiting.
Crepitus in abd wall adjacent to gallbladder.
2940 Surgery Gastrointestinal & Nutrition Dx: Air-fluid levels in gallbladder, gas in
gallbladder wall. Cx w gas-forming clostridium, E
coli. Unconjugated hyperbilirubinemia, mildly
elevatedaminotransferases
Tx: Emergent cholecystectomy. BSAbx w
Clostridiumcoverage(ampicillin-sulbactam)
Postop cholestasis - benign condition develops
after a majory surgery - hypotension, ext blood
loss into tissues, massive blood replacement -
2983 Surgery Gastrointestinal & Nutrition jaundice due to inc pigment load (transfusion), dec
liver fxn (hypotension), dec renal bilirubin excretion
(tubular necrosis). Mildly elevated transams,
elevated alk phos, hyperbilirubinemia.
Absent bowel sounds w gaseous distention of
both the small and large bowels indicates a
paralytic (adynamic) ileus. This clasically follows
abdominal surgery but can also occur in cases of
retroperitoneal hemorrhage assoc w vertebral
fracture.
Blunt abdominal trauma often causes splenic injury
which can present w delayed onset hypotension,
LUQ ab pain, and left shoulder pain. Pts should
have abdominal CT scan w IV contrast for dx.
Those w persistent hemodynamic instability
require urgent laparotomy.
Isolated duodenal hematoma MC occurs in
children following blunt abd trauma. It is tx
conservatively w nasogastric suction and
3851 Surgery Gastrointestinal & Nutrition parenteral nutrition. Pts normally present w
epigastric pain and vomiting bc gastric secretions
can't pass the obstruction. Most hematomas
resolve spontaneously w/in 1-2 weeks.
Bowel ischemia may complicate up to 7% of
procedures on the aortoiliac vessels and MC
affects the distal left colon. Pts report dull pain
over the ischemic bowel as well as hematochezia.
3877 Surgery Gastrointestinal & Nutrition Colonoscopy shows a discrete segment of
cyanotic and ulcerated bowel with a sharp
transition from affected to unaffected mucosa w
only a segment of bowel affected by ischemia. CT
scan will show thickening of the bowel wall.
Ischemic colitis - initial presentation acute onset of
lower abdominal pain, bloody diarrhea w/in 12-24
hrs. Fever, nausea, vomiting and extreme
leukocytosis. MC involved segment of the colon is
4098 Surgery Gastrointestinal & Nutrition the splenic flexxure bc it is supplied by end
arteries. 2 watershed zones in the colon: 1.
splenic flexure, narrow terminal branches of SMA,
and 2. the recto-sigmoid jxn, narrow terminal
branches of IMA.
Pts who have a delayed appendicitis presentation
w longer duration (>5 days) often have
appendiceal rupture w a contained abscess.
Significant fever, leukocytosis. Anterior abd
palpation may be unrevealing. Manuevers that
4251 Surgery Gastrointestinal & Nutrition assess the deep abdominal spaces are more
informative (psoas sign, obturator sign, rectal
exam). Psoas sign suggests abscess post to
appendix adjacent to psoas muscle. CT confirms
dx. IV abx, bowel rest, perc drainage of abscess.
elective appy in 6-8 weeks
Proximal SBO early vomiting, abdominal
discomfort, abnormal contrast filling on xray. Mid
or distal SBO colicky abd pain, delayed vomiting,
prominent abdo distension,
4364 Surgery Gastrointestinal & Nutrition constipation-obstipation, hyperactive bowel
sounds, dilated loops of bowel on ab x-ray. Pts w
strangulated obstructions may have peritoneal
signs (rigidity, rebound) and signs of shock; fever,
tachycard, leukocytosis are late findings.
Gastric outlet obstruction caused by mechanical
obstructino leading to postprandial pain and
vomiting w early satiety. Common causes -
malignancy, PUD, CD, strictures (w pyloric
stenosis) secondary to ingestion of caustic agents,
and gastric bezoars. Abdominal succussion splash
- stethoscope over abdomen and rockin pt back
and forth at hips. Retained gastric material >3hrs
post meal will generate splash sound indicating
presence of hollow viscus w gas and fluid.
Fever, chills, and deep abdominal pain may
indicate a retroperitoneal abscess. Blunt
abdominal trauma can cause a pancreatic
contusion, crush injury, laceration, or transection.
Abd CT scans done immedately after trauma may
fail to detect panc injury. Serial CT scans are
often req to detect evolution of the injury. Tx of
pancreatic abscess - percutaneous drainage
catheter, culture of drained fluid, surgical
debridement.
Acute GI perforation requires emergent
laparotomy. If an affected patient is on warfarin,
then reversal of anticoag must be rapidly achieved
pre-op by infusion of FFP.
Acute pain and swelling of the midline
sacrococcygeal skin a subcutaneous tissues is
MC due to infxn of a pilonidal cyst. Most prevalent
in young males, esp those w larger amts of body
hair. Precise etiology is not described but thot to
arise from chronic activity involving sweating and
friction of the skin overlying the coccyx w/in the
sup gluteal cleft. Infxn of hair follicles in this region
may spread subq forming an abscess that then
ruptures forming a pilonidalsinustract
Blunt Abdominal Trauma (BAT) - hypotension,
tachycard, facial lacerations, abdominal wall
ecchymoses, abdominal pain, tenderness, and
peritoneal signs. 1. fluid resusciation 2. determine
if pt needs ex lap. All pts w BAT should 1st be
assessed for intraperitoneal free fluid or
hemorrhage. Bedside USG to see fluid in the
hepatorenal space, splenorenal recess, and inf
portion of intraperitoneal cavity. FAST combines
this w eval of the pericardium.
Mammograms should be performed every 2 years
starting at age 50 in women at avg risk for brast
3863 Medicine General Principles
cancer. Routine mammography is not necessary
beyond age 75.
Women should be screened for cervical cancer w
Pap smear every 3 years at age 21-65 (or w Pap
smear & HPV testing every 5 years at age 30-65).
4477 Medicine General Principles A single dose of Tdap (tetanus toxoid, reduced
diphtheria toxoid, and acellular pertussis) is
recommended beginning at age 11, w Td (tetanus
& diphtheria toxoids) every 10 years thereafter.
Bedwetting is normal before the age of 5. Mastery
of nighttime continence can take months to years,
2433 Pediatrics General Principles
and boys generally achieve this milestone later
than girls.
Patau - cleft lip, flexed fingers w polydactyly,
ocular hypotelorism, bulbous nose, low-set
malformed ears, small abnl skull, cerebral
malformation, microphthalmia, cardiac
malformations, scalp defects, hypoplastic or
absent ribs, visceral & genital anomalies.
Edwards - microcephaly, prominent occiput,
micrognathia, closed fists w index finger
overlapping 3rd digit and 5th over 4th, and rocker
bottom feet.
In a child who needs fluid resuscitaiton but IV
access cannot obtained the next step shoul dbe to
get Intraosseous (IO) access. IO requires less
skill and practice and clinical trials have shown it's
safer and faster than central lines. IO lines provide
a cannula large enough to deliver fluids and meds
rapidly and obtain blood for labs. MC site is
proximal tibia d/t its wide, flat surface. Any large
bone can be used. Contraindications - cellulitis
over access site. OI
Normal growth involves periods of rapid incr in
weight & length esp during the first 6 months of
life. By age 12 months, a child's weight should
triple and height should increase by 50%. By 12
months a baby should also be able to follow a
one-step command accompanied by a gesture,
imitating an action, & cooperating w dressing of
clothes.
@ 12 months - "mama" "dada" & one other word.
They should also be able to follow simple
commands w gestures
@ 15 months - can say "mama" "dada" & 3-5
other words. They can also understand simple
commands even w/o gesture
@ 18 months - vocab should be 5-20 words
@ 2 yo - vocab 150-300 words and combine
words into 2 word sentences "me do it"
@ 3 yo - vocab 1000 words and 75% of child's
speech can be understood by a stranger. speak in
3-4 word sentences & use pronouns correctly
A 2-year old should speak in 2-word phrases,
follow 2-step commands, walk up stairs, build a
7741 Pediatrics General Principles tower of 6 cubes, & help to remove his clothing. A
24 month old male should have a vocab of ~200
works.
All trauma patients should be triaged using GCS,
which can predict the severity and prognosis of
3213 Surgery General Principles coma, during the primary survey. GCS assesses
the pts ability to open his/her eyes, motor
response, and verbal response.
Gunshot Wound (GSW) involving the abdomen can
cause significant injury, MC to the small bowel,
colon, and liver. Pts hemodynamically unstable,
have evidence of peritonitis, or have evisceration
3221 Surgery General Principles of any organ need immediate Ex Lap. Focused
Assessment w Sonography for Trauma (FAST)
can be done in few mins. High sens and spec for
hemoperitoneum, pericard effusion, and
intraperitoneal fluid.
Pts w a cervical spine injury require initial
stabilization of the cervical spine. Orotracheal
3227 Surgery General Principles intubation w rapid-sequence intubation is preferred
for establishing an airway in an apneic patient w a
cervical spine injury.
Coag negative staph are the MCC of nosocomial
bloodstream infxn in pts w intravascular devices.
Factors favoring infxn over contamination include
3464 Surgery General Principles
fever, leukocytosis, hypotension, blood culture
growth in >2 bottles (aerobic and anaerobic) w the
same organism and drug susceptibility.
Chest radiography is the most importnt dx study in
all ABC stabilized chest trauma patients.
Tension pneumothorax is dx clinically and should
be suspected in trauma pts w resp distress,
tracheal deviation, hemodynamic collapse, and
3505 Surgery General Principles absent breath sounds w tympanitic percussion
note. Immediate needle thoracostomy should be
performed in the 2nd intercostal space (btween
2nd and 3rd ribs) at the midclavicular line.
In case of amputation injury, amputated parts
should be wrapped in saline-moistened gauze,
sealed in a plastic bag, placed on ice and brought
to the ED w the patient.
Pulse is the first sign of hypovolemia. Hemorrhagic
shock is divided into 4 classes based on the amt
4207 Surgery General Principles of blood loss. Class 1 - <15% of their intravasc
volume or less than 750 ccs. BP is nrmal and
organs are adequately perfused.
Ruptured AAA releases blood into peritoneal
cavity or retroperitoneum. Sig ab pain and
4212 Surgery General Principles hypotension. Requires urgent surgery. CT
scanning only in stable pts. If not stable use USG.
Very high M&M w surgical repair.
The immediate managemnt of splenic trauma
caused by blunt injury depends on the pts
hemodynamic status and response to IV fluids. If
the pt is unstable but improves w fluid
administration, the next best step is to obtain an
abdominal CT scan. If the patient is unstable and
doesn't respond ot fluid administration, then
emergent ex lap is reqd.
when you suspect a perforated ulcer, no further dx
studies are required for this surgical emergency,
surgery consult must be made immediately.
pneumaperitoneum visible on imaging.
Intraabdominal pathology causing pain in one or
both shoulders suggests subdiaphragmatic
peritonitis. Amond the possible blunt traumatic
bladder injuries, only an intraperitoneal rupture of
the bladder dome could, by itself, cause a
chemical peritonitis and irritation of the diaphragm
that refers pain to the ipsilateral shoulder because
of the phrenic nerve.
Unprovoked DVT in a pt w no hx of surgery, hx of
smoking, and systemic symptoms (back pain,
weight loss) is concerning for occult malignancy
and rquires further investigation. In pts w first
2208 Medicine Hematology & Oncology unprovoked VTE, evaluation w age-appropriate
screening (colonoscopy, mammogram) and CXR
can yield early identification of occult malignancy.
More detailed testing (CT scan) is indicated for
high-risk pts.
AIHA and HS can cause extravascular hemolytic
anemia. A negative FHx and + Coombs test
suggest AIHA; a + FHx and negative Coombs test
2248 Medicine Hematology & Oncology
suggest HS. The peripheral blood smear in both
conditions may show spherocytes w/o central
pallor.
Elevated serum protein w normal albumin (gamma
gap) suggests d/o ie MM, amyloidosis,
Waldenstroms, and MGUS. MGUS is
asymptomatic elevation of monoclonal M protein
on serum protein electrophoresis. M proteins are
monoclonal immunoglobulins secreted by excess
plasma cell clones. MGUS is common - found
incidentally on lab tests. Dx confirmed by excluding
MM.
MGUS <3g/dL M proteins on SPEP <10% plasma
cells in bone marrow
MM >3g/dL M protein and >10% plasma cells
HIT type 2
Suspected w heparin exposure >5 days AND any
of the following:
Platelet ct reduction >50%
Arterial or venous thrombosis
Necrotic skin lesions at heparin injection sites
Acute systemic (anaphylactoid) rxns after heparin
Dx
Serotonin release assay: gold standard
confirmatory test
Start tx in suspected cases prior to confirmatory
tests
Tx
Cessation of ALL heparin products
Start a direct thrombin inhibitor (argatroban) or
fondaparinux(syntheticpentasaccharide)
Paroxysmal nocturnal hemoglobinuria - intra and
extravascular hemolysis and hemoglobinuria. This
disease is d/t an acquired genetic defect that
results in lack of the GPI anchor which connects
CD55 and CD59 to the cell surface. These
proteins
Waldenstrom's Macroglobulinemia - plasma cell
neoplasm. Abnormal plasma cells which multiply
uncontrollably and invade the bone marrow, lymph
nodes, and spleen. Excess IgM -> hyperviscosity
of blood. Sxs 1. Inc size of spleen, liver, and
lymph nodes
2. Tiredness <- anemia (too few RBCs)
3. Bleed and bruise easily
4. Night sweats
5. Headache and dizziness
6. Various visual problems
7. Pain and numbness in the extremities d/t
predominantlydemyelinatingsensorimotor
neuropathy
Mild hypercalcemia in the setting of metastatic
breast cancer to bone. Asymptomatic or mild
hypercalcemia (Ca<12) does not require urgent
therapy, but hypercalcemia of malignancy may
2599 Medicine Hematology & Oncology worsen over time. Bisphosphantes (eg, zoledronic
acid) inhibit the osteoclastic activity of bone,
stabilizing destructive bony tumors and reducing
the risk of skeletal-related events ie pathologic
fracture and malignant hypercalcemia.
Squamous cell carcinoma of the mucose of the
head and neck is common in people w a significant
hx of alcohol and tobacco use. First manifestation
may be a palpable cervial lymph node. BIT -
Panendoscopy (triple endoscopy =
2614 Medicine Hematology & Oncology esophagoscopy, bronchoscopy, laryngoscopy) to
detect the primary tumor. Followed by biopsy
after tumor is detected. Histologic dx is needed for
mgmt and prognosis. Tx depends on stage, grade.
Tumor resection, platinum based ctx, radiotherap
and palliative
Giant cell tumor of bone is a benign and locally
aggressive skeletal neoplasm that usu presents w
pain, swelling, and decr ROM at the involved jt.
Typically presnts as osteolytic lesions
("soap-bubble" appearance on radiographs) in the
epiphyseal regions of the long bones and MC the
distal femur and proximal tibia around the knee jt.
Osteoid osteoma - sclerotic, cortical lesion on
imaging w central nidus of lucency. Causes pain
that's worse @ night & unrelated to activity.
Pain medication in terminal cancer. 1. Try
non-narcotic measures first, unless you are sure
(using clinical judgement) that the patient is in
severe pain. 2. Do not be afraid to give narcotic
analgesics. 3. Prescribe adequate amts of
medication.
Trousseau's syndrome is a hypercoagulability d/o
presenting w recurrent and migratory superficial
thrombophlebitis at unusual sites (eg, arm, chest
area). It is usually associated w an occult visceral
malignancy ie pancreatic (MC), stomach, lung, or
prostate, colon, and acute leukemias.
Tumor lysis syndrome - mostly lymphomas
(Burkitts) and leukemias (ALL) -
Hyperphosphatemia, hypoCa2+, hyperK+, and
hyperuricemia - K+ and PO43- are intracellular
ions and breakdown of cells releases these in high
2641 Medicine Hematology & Oncology quantities. Released phosphate binds Ca2+ and
causes hypocal. Degradation of cellular proteins
causes elevation of [uric acid]. TLS can lead to
fatal arrhythmias, acute renal failure, and even
sudden death. Allopurinol reduces acute urate
nephropathy
Progesterone analogues (megestrol and
medroxyprogesterone) and steroids have been
shown to increase appetite and weight gain in pts
w caner-related anorexia/cachexia syndrome.
Progesterone analogues are preferred over
corticosteroids d/t their decreased incidence of s/e
Warfarin inhibits production of vit K-dependent
clotting factors. Also inhibits production of natural
anticoagulants proteins C and S. This decreases
protein C anticoagulant activity to 50% w/in the
2658 Medicine Hematology & Oncology first day while levels of procoagulant factors
decline more slowly, leading to a transient
hypercoagulable state. This incr risk for VTE and
skin necrosis, esp in pts w underlying hereditary
protein C deficiency.
CLL - MC type of leukemia in western countries.
In the US it comprises ~30% of leukemias. Almost
always seen in elderly. Pts r often asymptomatic
and dx incidentally. Lymphocytosis is the classical
2865 Medicine Hematology & Oncology signature mark of the disease. Most cells have
over-matured look bc of the hypercondensed
nuclear chromatin material. Smudge cells are
highly characteristic. Lapy and splenomegaly also
present. As it advances anemia nd tcpa are seen.
Hairy cell leukemia so called because it has fine,
hair-like irregular projections in the lymphocytes.
Bone marrow becomes fibrotic; therefore bone
marrow aspirates are unsuccessful (dry tap).
Tartrate-resistant acid phosphatase (TRAP) stain,
and CD11c marker, specific for Hairy cell.
Pancytopenia and splenomegaly 10-20% of pts
haveleukopenia.
Clinical manifestations of IM include extreme
fatigue, malaise, sore throat, fever, and a
generalized maculopapular rash. Posterior cervical
lymphadenopathy and palatal petechiae can be
present. Splenomegaly is also common.
Heterophile antibodies are very sensitive and
specific, but may be negative early in the illness.
Repeating the test may be helpful.
Macrocytic anemia can be d/t megaloblastic
(impaired DNA synthesis d/t B12 or folate
deficiency) or non-megaloblastic (alcoholism,
2872 Medicine Hematology & Oncology hypothyroidism, drugs, liver disease) etiologies.
Peripheral smear, reticulocyte count, and B12 and
folate levels can aid dx and distinguish between
B12 and folate deficiency.
Polycythemia Vera - cloncal myeloproliferative
disease of the pluripotent hematopoietic stem cell.
Etiology is unknown. Incr RBC mass, mild
granulocytosis, elevated platelet count, and low
EPO. Reversible moderate htn bc of expanded
2883 Medicine Hematology & Oncology blood volume. Incr incidence of peptic ulceration
(histamine release from basophils) and gouty
arthritis (inc cell turnover). Phys exam shows
plethoric face and splenomegaly. RBC indices
normal. Bone marrow - hypercellular. Phlebotomy
is tx.
Polycythemia vera is a myeloproliferative d/o d/t
EPO-independent overproduction of RBCs. Symps
of hyperviscosity (dizziness, headache), pruritis
esp after a shower, and splenomegaly are
common. Dx is confirmed by JAK2 V617F
mutation (present in >95% of pts) and low EPO
levels. CML - BCR-ABL fusino protein - causes
leuko- and thrombocytosis but no elevated Hgb.
WHO classification of CML
Chronic phase
-<9% blasts
Accelerated phase
-10-19% myeloblasts in the peripheral blood or
bone marrow
-Persistent increase in WBCs
-Persistent splenomegaly unresponsive to therapy
-Thrombocytosis unresponsive to therapy
-Thrombocytopenia (unrlated to therapy)
->20% basophils in peripheral blood
Blast phase
->20% blasts in bone marrow or peripheral blood
-Extramedullary blast proliferation
CML and leukemoid rxn are indistinguishable on
peripheral blood film. Sudden elevation in total
leukocyte ct and marked increase in granulocyte
precursors (left shift) suggest a serious infxn w or
2886 Medicine Hematology & Oncology w/o and underlying leukemic state. LAP is
decreased in CML; however it may be incr in
presence of subsequent secondary infxns.
Presence of Philadelphia chromosome should be
determined in suspicious cases bc it's dx for CML.
CLL - B-cell disease - smudge cells - break down
d/t incr fragility. Pts usu asymptomatic.
Splenomegaly, anemia, and tcpa.
Stage - clinical feature - prognosis
0 - Lymphocytosis only - Good
2888 Medicine Hematology & Oncology I - Lymphocytosis + adenopathy - Fair
II - Splenomegaly - Fair
III - Anemia - Intermediate
IV - Tcpa - Poor
Thrombocytopenia indicates a poor prognosis.
Infxn is the principle cause of death of pts w CLL.
In a pt w suspected MM the first step in
2889 Medicine Hematology & Oncology management is to order a serum
immunoelectrophoresis.
Hairy cell leukemia (leukemic reticuloendotheliosis)
- a type of B-lymphocyte derived chronic leukemia.
Lymphocytes have fine, hair-like, irregular
projections. Bone marrow may become fibrotic -
bone marrow aspirates are unsuccessful (dry tap).
Cytochemical feature includes Tartrate Resistant
Acid Phosphatase (TRAP) postitive stain. DOC is
purine analog, cladribine. Cladribine is toxic to
bone marrow, and its adverse effects include
neurological and kidney damage.
Philadelphia chromosome - reciprocal
translocation os chromosomes 9 & 22.
Translocation forms an abnormal BCR-ABL fusion
gene that causes abnl tyrosine kinase activity.
Characteristic finding in CML. Imatinib binds to the
ATP binding site of the BCR-ABL protein,
prohibiting the conformation change to its active
form.
Pts w liver failure often develop bleeding
disorders. Liver synthesizes all the clotting factors
except VIII. Chief among these are the vit K
dependent factors II, VII, IX, X. Acute bleeding in
pts w liver failure is best tx w FFP, which has all
the clotting factors.
Hereditary spherocytosis
-AD, Northern European descent
-Hemolytic anemia, Jaundice, Splenomegaly
-Incr mean corpuscular [hgb], Spherocytes on
peripheral smear, Negative Coombs test, Incr
3062 Medicine Hematology & Oncology osmotic fragility on acidified glycerol lysis test,
abnl eosin-5-maleimide binding test
-Folic acid supplementation, blood transfusion,
splenectomy
-Pigment gallstones, Aplastic crises from
parvovirus B19 infxn
Pernicious anemia is the MCC of Vit B12
deficiency in whites of northern European
ancestry. It should be suspected in pateints with
megaloblastic anemia, atrophic glossitis (shiny
tongue), vitiligo, thyroid disease, and neurologic
abnormalities.
Superior Vena Cava syndrome - obstruction of the
SVC causes swelling of the arms, neck, and head.
Sxs include dyspnea, venous congestion.
Malignancy is MCC of obstruction (SCLC, NHL)
>60% of cases. CXR can identify the cause of
SVC syndrome >80% of cases. Abnormal chest
x-ray warrants f/u w/ chest CT and histology to
determine tumor type and therapy.
DVT presents w pain, swelling, and discoloration.
Ddx include venous insufficiency, ruptured Baker
cyst, post-thrombotic syndrome, cellulitis.
Anticoag has risks but failure to anti coag pts w
DVT increases their risk for PE. Pts w clinical
evidence of PE should be started in anticoag while
undergoing dx eval. Dx of DVT = medical hx +
phys exam + lab results + imaging. Compression
USG is the preferred initial test in pts w high
pretest probability of DVT.
The deep veins of the lower extremities are the
MC source of emboluses. Lower extremity DVT:
proximal vein thrombosis (above the knee) and
3597 Medicine Hematology & Oncology calf vein thrombosis. The proximal deep veins
(iliac, femoral, iliofemoral, and popliteal veins) are
the source of >90% of acute PEs, probably bc of
their large caliber and proximity to the lungs.
G6PD deficiency should be suspected in patients
who develop acute hemolysis after ingesting
primaquine or sulfa drugs. G6PD activity is often
3609 Medicine Hematology & Oncology normal during the hemolytic episode as the
G6PD-deficient RBCs are hemolyzed early, and
reticulocytes (which have normal G6PD enzyme
levels) are abnormally high.
Rapid recognition of Epidural Spinal Cord
Compression is crucial to avoid permanent
neurologic sequelae (bowel and bladder). MRI of
the spine is recommended for inital eval. Tx w IV
3680 Medicine Hematology & Oncology glucocorticoids (dexamethasone) must be initiated
while awaiting imaging studies. Glucocorticoids
decr vasogenic edema (caused by obstructed
epidural venous plexus) and help alleviate pain and
restore neurologic fxn.
Radiation therapy is the most appropriate for the
mgmt of progressive pain in a pt w prostate CA
and bony metastases after androgen ablation
(orchiectomy). Focal external beam therapy is an
excellent choice in pts where the metastasis is
localized to a few sites.
Hereditary Hemochromatosis (HH) - Autosomal
recessive - mutated HFE gene that increases
intestinal iron absorption - increased total body
iron deposits in various organs to cause eventual
3890 Medicine Hematology & Oncology end organ damage. HH is assoc w a 20-200 fold
increased risk for HCC. HCC accounts for 30% of
deaths in HH pts. Elevated iron labs (inc
transferrin sat, serum ferritin) testing should be
done for HFE, C282Y, or H63D mutations.
Alcohol abuse is the MCC of nutritional folate
deficiency in the US and would cause
megaloblastic anemia. Impairs folate's
enterohepatic cycle and inhibiting it's absorption.
Any elderly patient w bone pain, renal failure, and
hypercalcemia has MM until proven otherwise.
Approximately 50% of MM pts develop some
degree of renal insufficiency; this is most likely due
to obstruction of the distal and collecting tubules
by large laminated casts containing paraproteins
(mainly Bence Jones. Hyperuricemia, amyloid
deposition, and pyelonephritis may occur w MM
and contribute to renal insufficiency. ARF may also
be precipitated after infxn and use of dye
Common s/e of EPO therapy:
-Worsening of htn: seen in ~30% of pts. 20-50%
of pts receiving IV EPO will have more than >10
mmHg rise in diastolic BP. Rise in BP is less
3978 Medicine Hematology & Oncology common after the SC route of EPO, as compared
to IV route.
-Headaches: seen in 15% of pts
-Flu-like syndrome: seen in 5% of pts
-Red cell aplasia: rare but potential side effect
Factor V Leiden is the result of a pt mutation in a
gene coding for the coag factor V. Factor V
3999 Medicine Hematology & Oncology becomes resistant to inactivation by protein C.
Prevalence may be as high as 5-6% of human
population.
Back pain, anemia, renal dysfunction, and
elevated ESR = multiple myeloma. Hypercalcemia
is seen in 28% of pts, along with symptoms of
hypercalcemia (polyuria, constipation). Polyuria in
hypercalcemia is due to defect in concentrating
ability of renal tubules.
Sideroblastic anemia manifests as
microcytic/hypochromic anemia simulating
iron-deficiency anemia, but iron studies reveal
elevated serum iron level and decreased TIBC. In
pts w an identifiable cause of vit B6 deficiency
(alcoholism, drugs), the administration of
pyridoxine can correct the problem. B6 is a
cofactor used in protoporphyrin synthesis.
Microcytic/hypochromic anemia:
-Iron deficiency-dec intake or inc loss
-Defective utilization of storage iron-anemia of
4069 Medicine Hematology & Oncology chronic dz
-Reducedglobinproduction-thalassemia
-Reduced heme synthesis - lead poisoning,
sideroblastic anemia.
Vitamin K deficiency - fat solume vitamin - plays a
role in hemostasis - cofactor for carboxylation of
glutamic acid residues on prothrombin complex
proteins - exogenous from intestinal absorption of
4112 Medicine Hematology & Oncology dietary vit K - endogenous from bacterial
production in the intestine - deficiency MC d/t
inadequate dietary intake, malabsorption,
hepatocellular dz causing loss of storage. Liver
stores 30 day supply.
Anti-epileptic drugs including phenytoin, primidone
and phenobarbital can cause a mild megaloblastic
anemia. The pathophys inovlves impaired
absorption of folic acid in the small intestine. Folic
acid supplementation can effectively prevent this
complication.
Irradiated - Bone marrow transplant recipients,
Acquired or congenital cellular immunodeficiency,
Blood components donated by 1st or 2nd degree
relatives
Leukoreduced - Chronically transfused pts, CMV
4160 Medicine Hematology & Oncology seronegative at-risk (AIDS, transplant pts),
Potential transplant recipients, Previous febrile
nonhemolytic transfusion rxn
Washed - IgA deficiency, Complement-dependent
autoimmune hemolytic anemia, Continued allergic
rxns (hives) w red cell despite antihistamine tx.
Studies have shown that the risk for sepsis is
present up to 30 years and probs longer after
splenectomy. Current recommendations state that
patients should receive anti-pneumococcal,
Haemophilus, and meningococcal vaccines several
4281 Medicine Hematology & Oncology weeks before the operation, and daily oral
penicillin ppx for 3-5 years following splenectomy
or until adulthood (for pediatric pts). A case can
be made for lifetime PCN ppx. Abx can also be
made available at home for immediate tx of any
sig fever.
Anemia of lymphoproliferative disorders, such as
leukemia and lymphoma, is d/t the replacement of
RBC progenitor cells w cancer cells in the bone
marrow. Tx of the malignancy may improve the
pt's anemia, though many CTX agents are
myelosuppressive. The spleen and
reticuloendothelial system are considered
extravascular. Therefore, AIHA in pts w CLL is
extravascular. Intravascular hemolysis - DIC, TTP,
ITP, HUS, PNH - Schistocytes
Vit B12 deficiency results in megaloblastic,
macrocytic anemia. D/T decreased IF and
subsequent malabsorption of vit B12. In advanced
stages, cobalamin deficiency can result in
4330 Medicine Hematology & Oncology peripheral neuropathy or posterior column defects
d/t defective myelin synth. Folate and Cobalamin
are cofactors in conv of homocysteine to
methionine. Thus folate supplementation can
improve anemia of B12 def.
Unexplained hemolytic anemia and tcpa in a pt w
renal failure and neurologic symps should raise
strong suspicion for TTP-HUS. Presence of
fragmented cells in peripheral smear suggests
MAHA, a characteristic finding in TTP-HUS.
4339 Medicine Hematology & Oncology TTP-HUS is thought to be d/t a deficiency of or
autoantibody against a specific vWF-cleaving
protease (ADAMTS-13). Causes accumulation of
vWF multimers and platelet agg. Tx -
plasmapheresis (plasma exchange) started ASAP
removes offending antibods
Pts w CKD and ESRD develop normocytic,
normochromic, hypoproliferative anemia d/t dec
EPO by failing kidneys. Mainstay tx is
supplemental EPO. EPO stimulates progenitor
4349 Medicine Hematology & Oncology cells in bone marrow to differentiate. Production of
RBCs assoc w a surge of iron usage. Iron def
manifests as microcytic, hypochromic anemia. Tx
for iron deficiency in dialysis pts is IV iron, such as
iron dextran.
Asymptomatic localized lymphadenopathy -
commonly develops in the setting of an upper
respiratory infxn. Small, rubbery lymph nodes are
rarely pathologic and are often found in healthy
children and young adults. Nodes assoc w cancer
4351 Medicine Hematology & Oncology tend to be firm and immobile. A nodal diameter
>2.0 cm is assoc w a greater likelihood of
malignancy or granulomatous disease. Hard
cervical nodes in a n older pt or smoker would
prompt an investigation for metastatic CA or
oropharyngeal neoplasia
Hard, unilateral, non-tender lymph nodes are
always suspicious for cancer and must be
evaluated immediately. In older pt w a hx of
smoking, such lymph nodes in the submandibular
4352 Medicine Hematology & Oncology or cervical region are highly concerning for head
and neck cancer. The vast majority of head and
neck cancer is squamous cell carcinoma. Biopsy
should be done promptly to further evaluate
masses.
Pernicious anemia - B12 deficiency in 2 ways
1. Anti-intrinsic factor antibodies decrease the amt
of fxnal intrinsic factor available to facilitate B12
absorption
2. Pts develop a chronic atrophic gastritis w
decreased producion of intrinsic factor by gastric
parietal cells.
Atrophic gastritis increases the risk of
intestinal-type gastric cancer & gastric carcinoid
tumors by 2-3x over the general pop. Pts w
pernicious anemia need to be monitored for the
dvlpment of gastric CA
Both folate and cobalamin are involved in the
conversion of homocysteine to methionine. Thus,
deficiency in either will result in elevated
homocysteine levels. Folate and cobalamin
deficiencies can be distinguished by measuring
MMA concentrations. Cobalamin, unlike folic acid,
is also involved in the conversion of
methlmanoyl-CoA to succinyl-CoA.
Anemia of chronic disease is a d/o of iron
utilization that MC occurs in the setting of chronic
inflammation. It is characterized by a normocytic,
anemia w decr serum iron, decr TIBC, decr iron
4358 Medicine Hematology & Oncology sat., and normal/elevated serum ferritin. Tx the
underlying inflammatory d/o will often improve the
anemia (methotrexate, hydroxychloroquine, and
TNF inhibitors). EPO can help if these measures
fail. PRBCs last resort.
Androgen abuse
Types:
Exogenous (testosterone HRT)
Synthetic (stanozolol, nandrolone)
Androgen precursors (DHEA)
Side effects/clinical presentation

Reproductive
Men: Decr testicular fxn & sperm production,
gynecomastia
Women: Acne, hirsutism, voice deepening,
menstrualirregularities
CV: LVH, possible decr HDL, incr LDL
Psych: Aggressive behavior, mood disturbances
Hematologic: Polycythemia, possible
hypercoagulability
ITP - autoimmune d/o - incr platelet destruction
and inhibition of megakaryocyte platelet production
d/t IgG autoantibodies against the platelet
membrane glycoproteins. Dx of exclusion. Tx
involves glucocorticoids for pts w severe tcpa
(platelets <30,000/uL) or sig bleeding.
Homocysteine is a highly reactive amino acid. Incr
levels predispose to VTE & atherosclerosis,
presumably by damaging vascular endothelium,
activating clotting mechanisms, and inhibiting
4384 Medicine Hematology & Oncology antithrombotic pathways. Homocysteine can be
metabolized to cysteine (by cystathionine
B-synthase using vit B6 cofactor) or methylated to
methionine (by MTHFR and methionine synthase w
folate and B12 cofactors).
Whole blood (for transfusions) is generally mixed
w solutions containing citrate anticoagulant.
PRBCs derived from these whole blood collections
4402 Medicine Hematology & Oncology contain citrate. Infused citrate can chelate serum
Ca, causing hypocalcemia. (most likely after
massive transfusion of the equivalent of more than
one blood volume over 24 hours.)
Thrombosis & a hx of miscarriages in a pt w
suspected SLE suggest antiphospholipid
syndrome (APS). APS occurs at higher frquency in
those w an underlying dz ie SLE, but can occur
independently. APS is characterized by:
VTE or recurrent early miscarriages
Presence of antiphospholipid antibody ie lupus
anticoagulant (LA), anticardiolipin antibody, or
anti-b2GP1. LA prolongs the PTT in vitro and is an
indirect indicator for presnce of LA.
Pancytopenia is a common in pts w SLE. It usually
4416 Medicine Hematology & Oncology indicates concurrent peripheral immune-mediated
destruction of all 3 cell lines.
Hyposthenuria - found in pts w SCD, but is also
common, though less severe, in pts w sickle cell
trait. African Americans w a FHx of fatal blood d/o
are likely to be carriers of sickle cell trait.
Hyposthenuria - results from RBC sickling in teh
vassa rectae of the inner medulla, which impairs
countercurrent exchange and free water
reabsorption.
AIHA - normocytic anemia, splenomegaly,
reticulocytosis, jaundice w elevated indirect
4437 Medicine Hematology & Oncology bilirubin, inc LDH, and decr serum haptoglobin
levels. Symptomatic pts are tx w high-dose
glucocorticoids.
Pts w Beta-thalassemia trait usually are
asymptomatic w mild anemia, disproportionately
high RBC, low MCV, and Hgb >10. B-thalassemia
minor is commonly confused w iron deficiency
anemia. However, iron deficiency anemia has low
RBCs and rarely becomes microcytic until Hgb
<10. No specific therapy is required for
B-thalassemia minor.
Hereditary telangiectasia (Osler-Weber-Rendu
syndrome) - AD d/o characterized by diffuse
telangiectasias, recurrent epistaxis, and
widespread AVMs. In hereditary telangiectasia,
4447 Medicine Hematology & Oncology AVMs tend to occur in the mucous membranes,
skin, and GI tract, but may also be present in the
liver, brain, and lung. AVMs in the lungs can shunt
blood from the right to left side of heart -> chronic
hypoxemia and reactive polycythemia.
CRAB:
Calcium(hypercalcemia)
Renalimpairment
Anemia
Bones (bone pain, lytic lesions, fractures)
IgG antibodies, or paraproteins, produced by the
4466 Medicine Hematology & Oncology myeloma cells can collect in the glomeruli, causing
renal failure, or "myeloma kidney"
Incr risk for infxn d/t total decr in fxnal antibodies
and lkpna secondary to bone marrow crowding w
malignant plasma cells.
Paraprotein gap caused by myeloma plasma cells
making proteins but not albumin.
Chronic hemolysis contributes to the anemia seen
in SCD. Folate deficiency often ensues (often in
the form of macrocytic anemia) as the bone
4468 Medicine Hematology & Oncology marrow tries to make more RBCs to compensate.
Daily folic acid supplementation is recommended
to in all SCD pts to correct the underlying folate
deficiency.
Type 1 HIT - nonimmune effect of heparin on
platelet activation presents in first 2 days of hep
exposure. No consequences, plt ct normalizes w
continued therapy.
Type 2 HIT - immune mediated Antibodies to
4616 Medicine Hematology & Oncology platelet factor 4 (PF4) complexed w heparin.
Platelet aggregation, thrombocytopenia, and
thrombosis (arterial and venous). plt ct drops
>50% from baseline, w nadir of 30-60k. Presents
5-10 days after start hep. Can lead to serious
consequences.
Antigens enter the spleen via the splenic artery
and are phagocytosed by dendritic cells in the
white pulp. Dendritic cells present antigens in
assoc w MHC II to the T-helper cells, activating
them. Activated, they migrate to the marginal zone
of the spleen where they conact the B-cells in
primary follicles. B-cell activation causes
secondary follicles and plasma cell-rich germinal
centers to form. Abs produced by germinal center
plasma cells enter the sytemic circ & opsonize
Rivaroxaban is an oral anticoagulant (direct factor
Xa inhibitor) that has similar efficacy compared to
LMWH and warfarin in tx of acute DVT or PE.
Does not require freqent lab monitoring or daily
injxns; however, there is no antidote in the event of
major hemorrhage.
Acute hemolytic transfusion rxn is a life-threatening
txn from transfusion of mismatched blood (ABO
mismatch). Pts rapidly develop fever, flank pain,
hemolysis, oliguric renal failure, and DIC w/in an
hour of transfuion. Febrile nonhemolytic
transfusion rxns are the MC adverse rxn to
transfusion and present w fever and chills w/in 1-6
hours of transfusion.
Anaphylaxis occurs seconds to minutes after
transfusion. IgA-deficient individuals are at risk d/t
presence of anti-IgA IgG antibodies. Pts present
w difficulty breathing (wheezing or
bronchospasm), angioedema, and hypotension.
4672 Medicine Hematology & Oncology Transfusion must be stopped immediately and IM
epinepherin administered. Hemodynamic and resp
support w vasopressors and mechanical vent
required. Antihistamine + glucocorticoids should be
given. Washed red cell products for future
transfusions.
HIT 2 - d/t heparin binding to platelet factor 4
(PF4), a heparin-neutralizing protein released w
platelet activation. Heparin-PF4 complex triggers
IgG antibodies to bind to the complex. This
antibody complex then activates platelets by
4859 Medicine Hematology & Oncology binding to the platelet Fc receptor. Tcpa is d/t the
splenic macrophages prematurely removing the
activatedplatelet-antibody-heparin-PF4
complexes. The complexes also release
procoagulant cytokines and induce aggregation,
and thrombosis.
ITP is usually Dx after excluding other possible
causes of thrombocytopenia. THese patients
should be tested for Hep C and HIV as
thrombocytopenia may be the initial presentation
of HIV infection (5-10%). Tx of the underlying
infection can affect the platelet count.
Hemophilia A & B - XLR - Delayed/prolonged
bleeding w mild trauma or procedure -
hemarthrosis, hemophilic arthropathy -
Intramuscular hematomas - GI or GU bleeding -
Prolonged aPTT - normal platelet ct, bleeding
time, PT - Dec or absent factor VIII (A) or factor
IX (B) activity - Tx. admin factor VIII or IX,
desmopressin for mild hemophilia A.
Pb poisoning in adults
RF - Occupational exposure (eg, lead paint,
batteries, ammunition, construction)
Clinical feats - GI (abd pain, constipation,
anorexia), Neuro (cognitive deficits, peripheral
neuropathy), Heme (anemia)
Lab findings - Anemia, Elevated venous [Pb],
elevated serum [zinc protoporphyrin], Basophilic
stippling on peripheral smear
Dx - blood lead levels, CBC w blood smear, x-ray
fluorescence to measure bone [lead]
Tx - chelation therapy
Salvage therapy - form of tx for a disease when a
standard tx fails. For men w PSA recurrence after
radical prostatectomy, salvage radiation thearpy
4940 Medicine Hematology & Oncology can provide long-term dz ctrl for localized
recurrent dz. Neoadjuvant therapy is tx given
before the standard therapy for a particular dz -
radiation given before a radical prostatectomy.
Preconception counseling and testing can help
identify couples who are at risk for
hemoglobinopathies that might affect their
offspring during pregnancy or after birth. The most
8894 Medicine Hematology & Oncology important initial screening test in a female is a
complete blood count. Based on the results, other
appropriate screening tests should be obtained. In
a pt w african descent hemoglobin electrophoresis
along with CBC done together
ABO incompatibility generally occurs in a group O
mother w a group A or B baby, but ABO
incompatibility causes less severe hemolytic
Obstetrics
disease of the newborn than does Rh(D)
4162 & Hematology & Oncology
incompatibility. Affected infants are usually
Gynecology
asymptomatic at birth w absent or mild anemia
and develop neonatal jaundice, which is usually
successfully tx w phototherapy.
An anti-D antibody titer of 1:32 reflects
alloimmunization.Placentalabruptionincreases
risk of alloimmunization. To prevent this anti-D
immune globulin is first administered at 28 weeks
Obstetrics
gestation and repeated w/in 72 hrs of delivery. A
4193 & Hematology & Oncology
standard dose is 300 micrograms at 28 weeks,
Gynecology
however ~50% of women need a higher dose esp
after abruption or procedures. Kleihauer-Betke
test is used to determine the dose. Dose of anti-D
immune globulin is calculated from % of fetal RBCs
Stroke is a common complication of SCD
secondary to sludging and occlusion in the
cerebral vasculature. Exchange transfusion is the
2253 Pediatrics Hematology & Oncology
recommended tx since it helps to decrease the %
of sickle cells and prevent a 2nd infact from
occurring.
ALL is predominantly a disease of children.
Lymphoblasts lack peroxidase positive granules
(myeloblasts contain peroxidase positive material)
but often contain cytoplasmic aggregates of
2867 Pediatrics Hematology & Oncology periodic acid Schiff (PAS) positive material.
Immunostaining for terminal
deoxynucleotidyltransferse (TdT) is positive in
>95% of pts. TdT is expressed only by pre B and
pre T lymphoblasts.
Acquired aplastic anemia from injury to bone
marrow by RTX, drugs, insecticides, toxins, or
infxns. Signs & symps include pallor, fatigue,
weakness, loss of appetite, easy bruising,
petechiae, muscosal hemorrhage, & fever. Labs
show normocytic or macrocytic anemia, lkpa,
reticulopenia, & tcpa. Bone marrow biopsy - dx -
profound hypocellularity, decr in all cell lines &
fatty infiltration. Diamond-Blackfan = congenital
red cell aplasia
HS
ADinheritance
Northern European descent
Clinical presentation - Hemolytic anemia, jaundice,

splenomegaly
Lab findings - Incr MCHC, Spherocytes on

peripheral smear, Negative coombs test,
Increased osmotic fragility on acidified glycerol
lysis test, abnl eosin-5-maleimide binding test
Tx - folic acid, blood transfusions, splenectomy
Complications - Pigment gallstones, aplastic crises

from parvovirus B19 infxn
Immune TCPA
Clinical: Antecedent viral infxn, asymptomatic
petechiae & ecchymosis MC, mucocutaneous
bleeding (epistaxis, hematuria, GI bleeding)
Labs: Isolated tcpa <100,000. Peripheral smear w
megakaryocytes & no other abnls
Tx:
Kids (normally recover in 6 months) - Skin
manifestation only: Observe
Bleeding IVIG or Glucocorticoids
Adults - Plts >/= 30,000 w/o bleeding: Observe
Plts < 30,000 OR bleeding: IVIG or glucocorticoids
CNS tumors are the MC solid tumors and 2nd MC
malignancies (after leukemias). ~60% of these
tumors are infratentorial, 25% are supratentorial,
15% arise in the midline. Astrocytomas are the
3658 Pediatrics Hematology & Oncology MC histologic type for both groups. Pinaloma
develops in the dorsal aspect of the midbrain.
Symps consist of endocrine syndrome, intracranial
htn, Parinaud's (paralysis of vertical gaze) sign
and Collier's (retraction of the eyelid) sign.
Pinealoma
-Parinaud syndrome (dorsal midbrain syndrome)
Ltd upward gaze
Ptosis
Upper eyelid retraction
Pupillaryabnormalities
-Obstructive hydrocephalus
3665 Pediatrics Hematology & Oncology Papilledema
Headache, vomiting
Ataxia
-Central precocious puberty
Workup
Brain MRI
Serum & CSF AFP and B-hCG
Anemia of prematurity (AOP) affects most
preterm infants - onset and severity of anemia are
proportional to the degree of prematurity. After
delivery, circulating EPO normally decreases d/t
incr O2 in tissue. Decr EPO -> decr reticulocyte
production in bone marrow. Physiologic RBC nadir
occurs at age 2-3 months in term infants. In
preterm, low EPO is exacerbated by short RBC
life span and frequent phlebotomy in NICU. Most
infants w APO r asymptomatic.
Hand-foot syndrome or dactylitis is the earliest
manifestation of vaso-occlusion in sickle cell
anemia, thereby warranting a complete workup for
previously asymptomatic sick cell pts. Patients
usually present @ 6mnths - 2yrs w an acute onset
of pain & symmetric swelling of hands & feet. Only
soft tissue swelling is initially seen, fever is
sometimes present. Pathophys of dactylitis
involves vascular necrosis of the metacarpals and
tarsals, on xray looks like osteolytic lesion
Sickle cell disease - AR inheritance.
Ppl w sickle cell trait are generally asymptomatic
and can lead a healthy life. Pts are at increased
risk for renal issues, the MC of these is painless
microscopic or gross hematuria that results from
3787 Pediatrics Hematology & Oncology sickling in renal medulla. Isothenuria (problem in
concentrating ability is also common & presents as
nocturia & polyuria.
SCD 0% HbA, 85-95% HbS, 5-15% HbF
SCT 50-60% HbA, 35-45% HbS, <2% HbF
Normal ~99% HbA, 0% HbS, <1% HbF
Diamond-Blackfan Syndrome (AKA Congenital
hypoplastic anemia) - Suspect it in a child w
anemia, low reticulocyte count, & congenital
anomalies. Majority of cases are sporadic, though
dominant and recessive inheritance is found in
3818 Pediatrics Hematology & Oncology 15% of cases. Path - intrinsic defect in erythroid
progenitor cells -> increased apoptosis. Pallor in
the neonatal period. >90% dx in first year of life.
Congenital anomalies in >50% of cases.
Macrocytic anemia w/o hypersegmented
neutrophils. Inf HbF
SCD is chronic and well-compensated hemolytic
anemia w appropriate reticulocytosis. Acute drop
in Hgb is a known complication of CD that can
occur secondary to hyperhemolytic crisis, splenic
sequestration, or an aplastic crisis. Aplastic crisis
3838 Pediatrics Hematology & Oncology is characterized by transient arrest of
erythropoiesis that results in a sever drop in hgb
and virtual absence of reticulocytes. Infxns
(parvovirus b19) can cause it. Tx- blood
transfusion. Aplastic crisis diff from aplastic
anemia
HUS is a disease of young children. Preceded by
an acute diarrheal illness d/t E coli 0157:H7,
Shigella, Salmonella, Yersinia, & Campylobacter.
Less commonly preceded by URTI. GI bleeding is
a less common symp. Phys exm - purpura & htn.
Hallmark is microangiopathic hemolytic anemia.
Other typical feats - acute renal failure, fever,
oliguira & tcpa. Peripheral smear - schistocytes &
giant platelets. Intravascu hemolysis -> elevated
LDH, indirect bilirubin, reticulocytes, BUNCr
Hemophilia A & B
XLR
Clinical - Delayed/prolonged bleeding after mild
trauma or procedure
Hemarthrosis, hemophilic arthropathy
IM hematomas
GI or GU bleeding
Labs - Prolonged aPTT
normal Plt, bleeding time, PT
Decr or absent factor VIII, or IX activity
Tx - Administration of missing factors
Desmopressin for mild hemophilia A
Osteonecrosis is a common complicatoin of sickle
cell anemia d/t vasoocclusion of the bone. It
causes significant jt pain and fxnal limitation. The
humerus and femur are the most frequently
4341 Pediatrics Hematology & Oncology affected bones. Up to 50% of pts homozygous for
sickle cell gene will develop osteonecrosis by
adulthood. Tx is pain mgmt & limitation of weight
bearing, w surgical intervention if conservative
mgmt is unsuccessful (jt reconstruction)
Howell-Jolly bodies - nuclear remnants w/in blood
cells that are typically removed by the spleen.
Evident on peripheral smear as single, round, blue
inclusions on Wright stain. Presence of
Howell-Jolly bodies indicates absence of spleen or
fxnal hyposplenism d/t splenic autoinfarction,
infiltrative disorders of the spleen, or splenic
congestion.
Fanconi anemia is an autosomal recessive or
X-linked d/o that causes congenital marrow failure,
poor growth and macrocytic anemia.
Bone marrow - aplastic anemia & progressive
marrow failure
Appearance - short stature, microcephaly,
4438 Pediatrics Hematology & Oncology abnormal thumbs, hypogonadism
Skin - hypopigmented/hyperpigmented areas, cafe
au lait spots, large freckles
Eyes/ears - strabismus, low-set ears, middle ear
problems (hemorrhage, chronic infxns, deafness,
malformation)
Dx - chromosomal breaks + ^^^
Stroke in children is rare but when it does happen
it's usually caused by a congenital abnormality,
infection, or systemic illness. Many childhood
strokes are caused by sickle cell anemia. The
exact mechanism underlying strokes in children w
sickle cell anemia is not fully understood, but RBC
adherence to the endothelium, activation of vWF,
and hyperviscosity are all thought to contribute.
Neonatalpolycythemia
Hematocrit >65% in term infants
Incr erythropoiesis from intrauterine hypoxia
Maternal DM, htn, smoking
IUGR
Erythrocyte transfusion
Delayed cord clamping
twin-twin transfusion
Ruddy skin
hypoglycemia
Resp distress
Cyanosis
Apnea, irritability, jitteriness
Abd distension
Tx - Partial exchange transfusion (remove blood,
infuse normal saline)
Hydroxyurea has been shown to decrease pain
crises, the need for transfusions, & episodes of
acute chest syndrome. S/E occur bc hydroxyurea
4825 Pediatrics Hematology & Oncology suppresses the bone marrow. Leukopenia,
anemia, and tcpa may occur. These effect are
generally temporary and reversible but may
predispose to the pt to infxn.
Wiskott-Aldrich syndrome
Etiology: XLR defect in WAS protein gene,
Impaired cytoskeleton changes in leukocytes,
platelets
Clinical feats:
Eczema - itchy, red, scaly skin
Microthrombocytopenia - small & low #of plts -
purpura & petechiae
Recurrent infxns - otitis, pneumonia
Tx - Stem cell transplant
Both types of thalassemia minor are characterized
by abnormally small RBCs (reflected by low
MCV). RDW is normal, & total RBC count is
normal or elevated. This results in a Mentzer index
(MCV/RBC) < 13. The hematocrit is usually >30%
4875 Pediatrics Hematology & Oncology in pts w thalassemia minor. In addition to
hypochromic microcytic cells, a peripheral smear
of thalassemia shows target cells & teardrop cells.
Important to exclude Fe-deficiency. Inc RBC
turnover in thalassemia may inc serum iron, ferritin
& ret
MCC of microcytic anemia in kids is Iron
deficiency and thalassemia. Iron deficiency is the
MC nutritional deficiency in children - often caused
by excessive consumption of cow's milk (>24
ounces [700mL] per day). Low iron content of
milk, poor bioavailability of iron from milk, and
increased intestinal blood loss from cow's milk
protein-induced colitis. RDW values >20% are
suggestive of iron deficiency anemia. Normal
values are seen in thalassemia
Osteosarcoma - MC primary bone tumor affecting
children & young adults. Boys 13-16 @ highest
risk. MC on metaphyses of long bones.
Constitutional symps are absent. Tender soft
8772 Pediatrics Hematology & Oncology tissue mass. Xray - spiculated "sunburst" pattern
& periosteal elevation known as Codman triangle.
ALP & LDH are elevated from damaged
osteocytes; high levels may correlated w adverse
prognosis. Tx Tumor excision & CTX.
Ddx for anterior mediastinal mass include the 4
Ts: Thymoma, Teratoma, Thyroid neoplasm, and
Terrible Lymphoma. W/in the category of
teratoma one must include other germ cell tumors.
Teratomas have fat, hair, and teeth. Seminomas
2590 Surgery Hematology & Oncology
have B-HCG but AFP is normal.
Nonseminomatous germ cell tumors include yolk
sac, choriocarcinoma, and embryonal carcinoma.
Mixture of cell types = mixed germ cell tumor (has
elevated AFP and B-HCG).
DVT requires therapeutic dosing of unfractionated
or LMW Heparine. Superficial thromboses do not
need anticoag, DVTs require several months of tx.
4493 Surgery Hematology & Oncology 1st time DVT w a clearly reversible inciting
incident (surgery), a heparin should be started as
the pt transitions to >3 months of warfarin therapy
w a goal INR of 2-3.
Cellulitis in the majority of pts is caused by
2161 Medicine Infectious Diseases
beta-hemolytic strep.
Dysuria, pyuria (WBC>10), urinary frequency, and
urethral discharge - concerning for urethritis. No
growth on gram stain and urine culture -
chlamydial urethritis. Chlamydia trachomatis
2236 Medicine Infectious Diseases cannot be visualised in Gram-stained material or
recovered in conventional culture. Dx can be made
w nucleic acid amplification testing of a first-catch
urine sample w/o pre-cleaning the genital area. Tx
azithromycin or doxycycline.
Acute epididymitis - fever, painful enlargement of
testes, and irritative voiding symps. Can be
sexually and non-sexually transmitted. Sexually
(chlamydia, gonorrhea) MC in adults and assoc w
urethritis, pain at tip of penis and urethral
discharge. Non-sexually (gram neg rods e.coli)
transmitted occurs in older persons and assoc w a
UTI.
Suspect bacterial pneumonia in an HIV-infected
patient who presents with acute onset, high-grade
fever and plerual effusion. Pneumococcus is the
MCC of pneumonia in HIV patients. Due to their
impaired humoral immunity, HIV patients are
2267 Medicine Infectious Diseases susceptible to infection by encapsulated
organisms in general, so other encapsulated
bacteria should also be considered in the
differential. P. jiroveci pneumonia-dry cough +
dyspnea-bilateral diffuse infiltrates - pleural
effusion not common
Disseminated MAC infexn - Nonspecific symps
(fever, cough, abd pain, diarrhea, night sweats,
weight loss) in the presence of splenomegaly and
elevated ALP (reflecting MAC hepatosplenic
involvement) in HIV pts w CD4<50. Dx is made
thru blood cultures and first-line tx includes clarithr-
or azithromycin. Pts w HIV and CD4 <50 should
receive azithro as MAC ppx.
AIDS-related infectious diarreha -
Cryptosporidium, MAC (if CD4 <50),
microsporidia, Giardia, or Isospora belli. Absence
of colitis (eg, bloody diarrhea) makes infxn of
2269 Medicine Infectious Diseases non-opportunisticpathogens(salmonella,
campylobacter, entamoeba, shigella) less likely.
1st step in dx would be to perform a stool exam
for culture, ova/parasites, C dif antigen, and
acid-fast stain for cryptosporidium
Fatigue, fever, muscle aches, arthralgias -
mononucleosis like. Lack or pharyngitis and
cervical lymphadenopathy on exam, atypical
lymphocytes, and negative heterophile (monospot)
test most likely has CMV mononucleosis. Atypical
lymphocytes are largely basophilic cells w
vacuolated appearance. In contrast to
EBV-associated infection, CMV mononucleosis
usually presents w.o pharyingitis(sore throat) and
cervicallymphadenopathy.
Pneumocystis pneumonia is one of the MC
opportunistic infxns in AIDS ppl w CD4 <200.
TMP-SMX is first line tx due to its efficacy and
tolerability. Many pts will experience initial
worsening in Pul fxning w possible resp failure
when abx therapy is started, likely d/t
inflammatory effects of dead organisms in lung
tissue. Corticosteroid therapy has been shown to
minimize the initial abx-induced worsening of resp
fxn.
Esophagitis
Candida albicans - white plaques, oral thrush
HSV - herpetic vesicles & round/ovoid ulcers,
2274 Medicine Infectious Diseases concurrent perioral/oral HSV
CMV - Deep, linear ulcers, distal esophagus
Idiopathic/aphthous - Concurrent oral aphthous
ulcers
Progressive multifocal leukoencephalopathy -
multiple, hypodense, non-enhancing lesions w no
mass effect in cerebral white matter - JC virus
(polyomavirus) - Transmission unkwn - PML
predominantly involves cortical white matter, but
brainstem and cerebellum may be involved - onset
gradual - cranial nerve deficits develop -
hemiparesis, disturbances in speech, vision, and
gait - Mean duration of survival time of dx is 6
months.
Brochoalveolar lavage has greatest diagnostic
utility in evaluation of suspected malignancy and
opportunistic infxn. Want to establish definitive dx
of PCP before started tx. Sputum induction w
2304 Medicine Infectious Diseases hypertonic saline is first-line method bc it's
minimally invasive. Though highly specific, it's only
50% sensitive. When sputum induction doesn't
confirm dx, BAL is performed. For PCP dx, BAL
has >90% sensitivity & specificity.
HBV vaccination consists of recombinant hepatitis
B surface antigen. Immunity occurs as patients
develop anti-hepatitis B surface antibodies
(HBsAb). Reassurance is all that is needed for a
pt who is exposed to HBV and has a documented
response to previous HBV vaccination.
Neutropenia - ANC<1500/microliter (severe
neutropenia is ANC <500/microliter). Pts w
ANC<1000 are at higher risk for overwelhming
bacterial infxn. Febrile neutropenia is a medical
emergency and starting early empiric abx can
2616 Medicine Infectious Diseases avoid severe sepsis and life-threatening
complications. Monotherapy w an
anti-pseudomonal beta-lactam agent (cefepime,
meropenem,piperacillin-tazobactam)provides
both gram-neg and pos coverage and is
recommended initially.
Nec Fasc presents w erythema and swelling,
severe pain out of proportion to the physical exam,
and signs of tissue necrosis such as crepitus,
purulent drainage, or radiographic evidence of gas
2749 Medicine Infectious Diseases in the deep tissues. When skin or soft-tissue infxn
is suspected, rapid progression of physical exam
findings or severe systemic signs such as
hypotension should raise suspicion for necrotizing
fasciitis.
MC organism responsible for development of
epiglottits, esp in the adult population, are H.
influenzae and S. pyogenes. Epiglottits is a
medical emergency, and rapid treatment must be
initiated in order to prevent obstruction of the
airway.
Individuals w a hx of high-risk sexual intercourse
(unprotected or MSM) should be screened for HIV
and HBV. Individuals who use injections drugs,
have a high-risk needlestick exposure, or received
blood transfusions before 1992 should be
screened for HCV.
Active HBV infxn presets w + HB surface antigen,
positive Be antigen, and absent surface antibody.
Health care workers exposed to blood from HB
2927 Medicine Infectious Diseases pts (ocular, mucous membranes, or skin) should
receive post-exposure ppx. Unvaccinated
individuals should receive both the HB vaccine and
HB IG asap.
Most guidelines recommend treating chronic HBV
pts w acute liver failure or cirrhosis and high
serum HBV DNA. Tx is also recommended for pts
w/o cirrhosis but w positive HBeAg, HBV DNA
>20,000 IU/mL, and serum ALT >2x upper limit of
normal. Entecavir and tenofovir have become
preferred therapies d/t lower drug resistance and
ability to be used in decompensated cirrhosis.
Entamoeba histolytic - amebiasis - primary infxn in
colon, presents w bloody diarrhea. Ameba may be
transported to the liver by portal circulation thus
leading to amebic liver abscess. Generally single
2968 Medicine Infectious Diseases and located in the right lobe. Abscess on the
superior surface of the liver can cause a
pleuritic-like type of pain and radiation to shoulder.
Dx by stool exam for trophozoites, serology, and
liver imaging. Tx - metronidazole.
Hydatid cyst d/t Echinococccus granulosus.
Humans contract infxn from close and intimate
contact w dogs (definitive host). E granulosus
causes unilocular cystic lesions that can occur in
any organ (liver, lung, muscle, bone); smaller
daughter cysts may be present. Most hydatid
cysts are dx incidentally. Cysts can cause symps
d/t compression on surrounding tissues. Eggshell
calcification of a hepatic cyst on CT scan is
indicative. Tx - albendazole.
~10-20% of pts on INH develop mild
aminotransferase elevation w/in first few weeks of
tx. This hepatic injury is typically self-limited and
will resolve w/o intervention.
More than 90% of adults with HBV will recover
completely. Some will get chronic HBV, and 0.1 -
0.5% will develop Fulminant Hepatic Failure. FHF -
hepatic encephalopathy that develops within 8
weks of onset of acute liver failure. Heavy users of
tylenol, alcohol, or amphetamines more prone.
FHF has >80% mortality rate - patients are
considered high priority candidates for liver
transplant. Orthotopic liver transplant should be
considered in all such pts.
Pulmonary cavitation in an HIV-infected patient can
be caused by a number of different orgnisms,
including MTB, atypical mycobacteria, Nocardia,
gram-neg rods, and anaerobes. Nocardia is a
2989 Medicine Infectious Diseases gram-pos, weakly acid-fast, filamentous,
branching rod. Tx is TMP-SMX. Lung is MC
infected organ, and infection manifests as nodules,
a reticulonodular pattern, diffuse pulmonary
infiltrate, abscess, or cavity formation.
Low-grade fever, bloody nasal discharge, nasal
congestion, involvement of the eye w chemosis,
proptosis, and diplopia - in a pt w uncontrolled DM
- mucormycosis caused by Rhizopus. Involved
turbinates often become necrotic. Invasion of local
tissues can lead to blindness, cavernous sinus
thrombosis, and coma. If left untx, mucormycosis
can lead to death in days to weeks.
Mucormycosis, most often caused by Rhizopus,
can lead to serious complications or death if left
2994 Medicine Infectious Diseases untx. It requires aggressive surgical debridement +
early systemic tx w amphotericin B, the only
effective drug against this fungus.
Histoplasmosis closely mimics the presentation of
sarcoidosis and should be considered when a pt w
suspected sarcoidosis deteriorates after
2995 Medicine Infectious Diseases immunosuppressive therapy. In endemic regions,
dimorphic fungi (eg, histoplasma, blastomyces,
coccidiodes) should be excluded before
immunosuppression is initiated.
Invasive aspergillosis occurs in
immunocompromised pts (those w neutropenia,
taking cytotoxic drugs i.e cyclosporine, or high
doses corticosteroids). Invasive pulmonary dz w
fever, cough, dyspnea, hemoptysis. CXR shows
rapidly progressing, dense consolidation. CT can
show pulmonary nodules w halo sign or lesions w
an air crescent. Aspergillusdoes not have specific
geography.Histoplasmosis-southeastern,mid
atlantic, central US.
Coccidioidomycosis is endemic in the SW US, as
well as Central and S America. Primary pulmonary
infxn has non-specific feats, such as fever, fatigue,
2998 Medicine Infectious Diseases dry cough, weight loss, and pleuritic chest pain.
Cutaneous findings, such as erythema multiforme
and erythema nodosum, as well as arthralgias are
common.
Blastomycosis
South/central states, Mississippi & Ohio River
valleys, Upper Midwest states, Great Lakes
states & Canadian provinces
Disseminated dz may occur in immunocompetent
pts
Lung: acute & chronic pneumonia
2999 Medicine Infectious Diseases Skin: wartlike lesions, violaceous nodules, skin
ulcers
Bone: Osteomyelitis
GU: Prostatits, epididymo-orchitis
CNS: meningitis, brain abscess
Dx - Culture, microscopy, antigen (urine, blood)
Tx - Mild no tx, moderate - oral itraconazole,
Severe - IV amphotericin B
Recommended rabies PEP for animal bites
depends on the region and the species of
exposure. For pts exposed to healthy-appearing
domesticated animals (dogs, cats, ferrets), the
animal can be observed for 10 days w/o PEP.
Unvaccinated individuals who are bitten by animals
that couuld have rabies should receive PEP w
active and passive immunization.
Herpesencephalitis
Symps - Fever, AMS, seizures & coma
Exam - Hemiparesis, cranial nerve palsies (signs
of focal neurologic deficits), hyperreflexia
Labs/Imaging -
CSF: incr WBCs (lymphocyte predominant), nl
glucose, incr protein
Brain MRI: Temporal lobe abnormalities
Dx: CSF analysis shows presence of viral DNA on
PRR
Tx: IV acyclovir: strat immediately after obtaining
CSF fluid
IM - all athletes should refrain from playing sports
>3 weeks until all symps resolve. Spleen may not
be palpable till it's 2-3x the normal size, phys
exam is not a reliable indication of resolution. USG
measurement of the spleen can be considered for
return to play in athletes participating in strenuous
sports or activities that increase intraabdominal
pressure (weightlifting).
Amoxicillin-clavulanate is the antibiotic of choice
for ppx and tx of infections caused by human
bites. These infxns are usually polymicrobial, and
3011 Medicine Infectious Diseases thus coverage for gram +, Gram -, and anaerobes
should be provided. Clinda effective against gram
+ and anaerobes. Typically used for lung
abscesses and infxns of the female genital tract.
Duke Criteria
Major - Blood cult + for typical organisms, echo
showing valvular vegetation
Minor - Predisposing cardiac lesion, IVDA,
Temp>38, Embolic phenomena, Immunologic
phenomena (glomeruloneph), + blood cult not
meeting above crit
Definite IE - 2 major OR 1 major + 3 minor
Possible IE - 1 major + 1 minor OR 3 minor
Sxs - fever, murmur, petechiae, subungal splinter
hemorrhages, osler nodes, janeway lesions, roth
spots (<5%), neurologic phenomena, splenomegaly
Right-sided endocarditis should be considered in
pts w presumed hx of IVDA. Empiric abx tx of
3013 Medicine Infectious Diseases native-valve endocarditis should be geared toward
MRSA, strep, and enterococci. Vancomycin is the
most appropriate empiric abx for these pts.
Blastomycosis - fungal infxn occurring MC in the
vicinity of the Great lakes, Mississippi river and
Ohio River basins (Wisconsin has highest infxn
rate). The pulmonary symps and CXR findings
resemble TB and histoplasmosis. However,
systemic Blastomycosis may cause characteristic
ulcerated skin lesions and lytic bone lesions.
Broad-based budding yeast grown from sputum
confirm dx. Itraconazole or amphotericin B may be
used to tx symptomatic dz.
Bilateral lung infiltrates, confusion, diarrhea,
hyponatremia - Legionnaire's disease. D/T
contaminated water supplies linked to ships and
hotels. Legionella (gram neg rod) pneumonia vs
other CAP.. Legionella has: high grade fever
(>39), GI symptoms, neurologic symptoms
(confusion, ataxia). Exam shows rales, and chest
radiograph shows interstitial infiltrates.
Hyponatremia and hepatic dysfxn are common. Tx
- Macrolides or fluoroquinolones.
Low-grade fever, generalized weakness,
holosystolic murmur, tender erythematous lesions
affecting fingertips + hx of rheumatic fever - IE.
Staph infnx is MCC of healthcare-assoc IE; strep
infxn is a common cause of community-acquired
IE. Enterococci species are another common
(30%) cause of nosocomial-acquired endocarditis
esp assoc w UTIs.
MCC of dysphagia/odynophagia in HIV pts is
Candida. Pain is usu mild and pts often have oral
thrush. Many clinicians tx HIV pts w esophagitis
symps empirically w oral fluconazole. But if symps
are severe or persist, then endoscopy w biopsy
should be performed, esp in absence of thrush.
CMV - focal substernal burning pain w
odynophagia, large linear ulcerations and
presence of intranuclear and intracytoplasmis
inclusions. IV ganciclovir
Babesia - transmitted by Ixodes tick. Parasite
enters pts RBCs and causes hemolysis. Clinically -
asymptomatic to hemolytic anemia assoc w
jaundice, hemoglobinuria, renal failure, and death.
Unlike other tick-borne ilnesses, rash is not a feat
of babesiosis, except in severe infxn where tcpa
may cause a secondary petechial or purpuric rash.
Significant illness occurs in ppl >40, pts w/o a
speen, or immunocomp ppl. Dx - Giemsa-stained
thick & thin blood smear. Tx quinine-clind
TMP-SMX is Pneumocystis pneumonia prophylaxis
in in transplant patients. Also prevents
toxoplasmosis, nocardiosis, and other UTIs and
3105 Medicine Infectious Diseases pneumonias. All posttransplant pts should receive
ppx w TMP-SMX. Ganciclovir or valganciclovir can
be used to prevent CMV infxns. Azithromycin is
ppx to MAC in HIV pts w CD4 <50.
Bright red, firm. friable, exophytic nodules in an
HIV pt are most likely bacillary angiomatosis. The
classic lesion is shown in the above picture.
Bacillary angiomatosis is caused by Bartonella, a
Gram-neg bacillus. Oral erythromycin is the
antibiotic of choice. Pneumocystis may cause
nodular and papular cutaneous lesions of the
external auditory meatus in immunocompromised
patients. W use of TMPSMX pneumocystic
infection is highly unlikely.
Dx of IM - atypical lymphocytosis and
anti-heterophile antibodies (monospot), which
indicate EBV assoc disease. AIHA and
thrombocytopenia are complications of IM d/t
cross reactivity of the EBV induced antibodies
3131 Medicine Infectious Diseases against RBCs and platelets. These are IgM
cold-agglutinin antibodies known as anti-i
antibodies, which lead to complement-mediated
destruction of RBCs (coombs positive). Onset of
AIHA can be 2-3 weeks after symps, even though
initial labs may not show anemia or tcpa.
Viral arthritis secondary to parvovirus B19 - acute
symmetric arthralgias. HBV, HCV, HIV, and rubella
can also cause acute viral arthritis. Parvovirus
infxn MCly affectts adults who have frequent
3172 Medicine Infectious Diseases contact w children. Dx by detecting anti-B19 IgM
antibodies in serum, which develop w/in 10-15
days of infection and remain + for 1-6 months.
Symps resolve spontaneously in 2-3 weeks w/o
need for specific tx.
Lyme dz
Erythema migrans
Fatigue, malaise, lethargy
Mild headaches & neck stiffness
Myalgias & arthralgias
Carditis (AV block, cardiomyopathy)

Neurologic (uni or bilat CN VII, meningits,
3243 Medicine Infectious Diseases encephalitis)
Muscular (migratory arthralgias)
Conjunctivits
Skin multiple erythema migrans
Regional or gen LAD
Muscular - Arthiritis
Neurologic - Encephalomyelitis, peripheral
neuropathy
Empiric abx must not be delayed while awaiting
results of CT scan or performing LP to dx
bacterial meningitis. Vanco + ampicillin + cefepime
is the drug regimen of choice for
3245 Medicine Infectious Diseases immunocompromised patients w suspected
bacterial meningitis. Corticosteroids must be
started at the same time as abx and should be
discontinued if cultures show an organism other
than Strep pneumo.
HIV patients are at high risk for TB. A positive
3246 Medicine Infectious Diseases PPD test, but negative CXR, requires prophylaxis
w INH (and B6) for 9 months
Ehrlichiosis
Epidemiology - transmitted by lone star tick, seen
in southeastern & south central US
Clinical manifest - Flu-like illness (high fever,
headache, myalgias, chills), neurologic symps
(confusion), Rash is uncommon (<30% in
3247 Medicine Infectious Diseases adults)("Spotless RMSF")
Lab findings - Leukopenia, thrombocytopenia,
elevated liver enzymes & LDH
Dx - Intracytoplasmic morulae in monocytes, PCR
testing for E chaffeensis/E ewingii
Tx - Empiric doxycycline while awaiting
confirmatory testing
EHEC is a food-borne pathogen that causes acute
water to bloody diarrhea. Dx can be confirmed w
3248 Medicine Infectious Diseases a stool assay for Shiga toxin. If EHEC is
suspected, empiric antibiotic therapy should be
avoided as it may increase the risk of HUS.
Cryptosporidium is an emerging and important
cause of travelers diarrhea and should be
considered in pts w persistent, nonbloody, watery
diarrhea for >2 weeks.
Postexposure HIV ppx w 3-drug antiretroviral
(tenofovir-emtricitabine with raltegravir is preferred
d/t a low side effect progile and few drug-to-drug
interactions) therapy for 4 weeks is recommended
following high-risk occupational exposure to blood
or body fluids from an HIV-infected individual.
Therapy should be started ASAP, preferably in the
first few hours.
HIV patients with CD4 counts <200 cells/microliter
require antimicrobial prophylaxis to prevent
opportunistic infections. M avium complex
prophylaxis should be initiated when CD4 count is
<50cells/microliter. Preferred agents include
azithromycin or clarithromycin.
Kaposi Sarcoma (KS) is a vascular tumor due to
HHV-8 that typically occurs in advanced HIV.
3253 Medicine Infectious Diseases Typical lesions appear as violet papules, nodules,
or plaques. KS will often regress if the underlying
HIV disease is treated w HAART
Cryptococcal meningoencephalitis develops in pts
w advanced HIV disease (CD4 <100). Induction
therapy includes amphotericin B plus flucytosine
followed by fluconazole for consolidation and
maintenance therapy. Serial LPs may be required
to reduce increased ICP. Antiretroviral therapy
should be deferred for at least 2 weeks after
antifungal therapy is started.
Single dose of IM benzathing penicillin G is the tx
of choice for primary syphilis. In nonpregnant pts
w penicillin allergy a 2-week course of doxycycline
can be used. Pregnant pts w pencillin allergy
should undergo desensitization before penicillin
therapy.
Amoxicillin is tx of choice for lyme disease in
pregnant and lactating women as well as children
age <8 years. Rash and constitutional symps
3257 Medicine Infectious Diseases should resolve w/in 3 weeks of tx. Pregnant pts
should be reassured that Lyme disease is not
known to cause congenital anomalies or fetal
demise.
India - P falciparum is endemic. Chemoppx is
indicated for travel there. Optimal regimen should
be based on travel itinerary, presence of
chloroquine-resistant P falciparum in the region,
and the S/E assoc w each option. Southern and
3259 Medicine Infectious Diseases SE Asia, along w Sub-Saharan Africa and the
Amazon basin lots of chloroquine-resistant P
falciparum. PPx regimens for these areas -
mefloquine,atovaquone-proguanil,and
doxycycline. Low resitance areas - chloroquine &
hydroxychloroquine
Lyme dz - non preg pts and children >8 should be
tx w doxycycline. In severe cases of facial palsy,
cornea may be at risk of dryness and abrasions
due to poor eyelid closure and reduced tearing.
Artificial tears should be used durin the day in
addition to ophthalmic ointments and eye patching
at night. HSV VZV - MCC idiopathic cranial nerve
VII palsy. Ramsay Hunt synd manifestation of VZV
reactivation - ipsilateral facial paralysis, ear pain,
vesicles in auditory canal.
P mirabilis - secretes urease (hydrolyzes urea to
NH3 and CO2). Then NH3 + H+ -> NH4,
decreases the free H+ concentration. This leads
to urinary alkalinization and promotes formation of
struvite stones (mixture of bacteria, proteinaceous
matrix, and leukocytes,NH4MgPO4). The stone
bcomes a permanent source of bacteria to
perpetuate the cycle. Klebsiella, morganella,
pseudomonas, ureaplasma also make urease.
Look for urine pH >7
Erysipelas is a specific type of cellulitis. It is
characterized by inflammation of the superficial
dermis, thereby producing prominent swelling. The
classic finding is a sharply demarcated,
erythematous, edematous, tender skin lesion w
3263 Medicine Infectious Diseases raised borders. The onset of illness is abrupt, and
there are usually systemic signs, including fever
and chills. The legs are the most
frequently-involved site. The most likely causative
organism is group A beta-hemolytic strep. (S
pyogenes).
B cereus causes nausea and vomiting after eating
rice. Symptom onset is 1-6 hours.
Rubella - German measles
Congenital dz
Sensorineural hearing loss, intellectual disability,
cardiac anomalies, cataracts, glaucoma
Children
Low-grade fever, conjunctivitis, coryza, cervial
3266 Medicine Infectious Diseases LAD, Forschheimer spots, cephalocaudal spread
of blanching erythematous maculopapular rash
Adolescents/Adults
same as children + arthraglia/arthritis
Dx - PCR, anti-rubella IgM & IgG
Prevention - live attenuated vaccine
Tx - supportive care
Trichinellosis
Ingestion of undercooked meat (pork)
More endemic in Mexico, China, Thailand, parts of
central Europe & Argentina
Gastric acid releases larvae (w/in 1st week of
ingestion) that invade small intestine & dvlop into
3267 Medicine Infectious Diseases worms
Female worms rlease larvae (up to 4 wks later)
migrate & encyst in striated muscle
Intestinal stage - asymptomatic or abd pain,
nausea, vomiting & diarrhea
Msucle stage - mysositis, fever, subungal splinter
hemorrhages, periorbital edema, Eosinop
Disseminated gonococcal infxn causes high fever,
chills, tenosynovitis (wrist, ankles, fingers &
knees), migratory polyarthralgia, and dermatitis
(pustular lesions on the trunk and extremities,
macules, papules & bullae). Disseminated
3320 Medicine Infectious Diseases gonococcal infxn should be considered when risk
factors for gonococcal infxn are present. Routine
blood and pustule cults can be negative d/t the
fastidious nature of N gonorrhoeae. Tx IV
ceftriaxone 7-14 days then PO cefixime + azithro
or doxy
Valacyclovir is the drug of choice in thte tx of
herpes zoster; acyclovir is an alternative.
3422 Medicine Infectious Diseases Postherpetic neuralgia can be prevented and/or tx
w TCAs ie amitriptyline or nortriptyline along w
acute antiviral therapy.
Leprosy is a chronic granulomatous disesase that
affects peripheral nerves and skin. Caused by M
leprae. May present as an insensate,
hypopigmented plaque. Progressive nerve
3425 Medicine Infectious Diseases damage results in muscle atrophy, followed by
crippling deformities of the hands. MC affected
areas are face, ears, wrists, buttocks, knees, and
eyebrows. Dx is made by demonstration of
acid-fast bacilli on skin biospy.
Acute pyelonephritis can result in gram-negative
sepsis. Urine (and blood) cultures should be
obtained routinely before administration of empiric
abx. Urological imaging is typically reserved for
pts w persistent clinical symptoms despite 48-72
hours of therapy, hx of nephrolithiasis, complicated
pyelonephrigits, or unusual urinary findings (eg,
gross hematuria, suspicion for urinary obstruction).
Ludwig angina - rapidly progressive bilateral
cellulitis of the submandibular and sublingual
spaces. Arises from infected 2nd or 3rd
mandibular molar; usu by Strep and anaerobes.
Pts present w fever, dysphagia, odynophagia and
3530 Medicine Infectious Diseases drooling. Swelling of the submadibular space
causes psteror displacement of the tongue.
Anaerobes may cause crepitus d/t gas formaiton.
MCC of death - asphyxiation. Pts should be
monitored for resp status. Tx - Abx & removal of
infected tooth
Cervicofacial actinomycosis MC presents in the
mandibular region as a slowly growing, nontender
mass w characterisitc yellow granular puss. The
3561 Medicine Infectious Diseases infxn can extend thru tissue planes and form
abscesses, fistulas, and draining sinus tracts. Dx
is confirmed by gram stain and culture. Penicillin is
the preferred therapy.
Acute HIV
Presents 2-4 weeks after exposure
Mononucleosis-like syndrome (fever, LAD, sore
throat, arthralgias), generalized macular rash, GI
symps
Dx - Viral loan is markedly elevated (>100,000
copies/mL), HIV antibody testing may be negative
(not yet seroconverted), CD4 count may be normal
Mgmt - Combination antiretroviral therapy, Partner
notification, consider secondary ppx
Modified acid-fast stain showing oocysts in the
stool is very suggestive of Cryptosporidium
parvum infxn. Causes severe diarrheal disease in
immunocompetentandimmunocompromised
individuals. HIV-infected pts w a more preserved
3590 Medicine Infectious Diseases CD4 count tend to have a self-limiting illness,
whereas AIDS pts w CD4 counts <180 tend to
have a more persistent clinical course. Isospora
belli also has acid-fast oocysts, just not as
common in US. Microsporidia also diarrhea in HIV
pts - spores not
Cutaneous larva migrans - creeping eruption -
helminthic disease - Ancylostoma baziliense - dog
and cat hookwork - contact w soil contaminated w
feces containing larvae - tropical and subtropical
regions - southeastern US - sandy beaches &
sandboxes are high risk areas - multiple pruritic
elevated serpiginous reddish brown lesions on skin
which elongate several mm/day as larvae move
up. MC seen in lower extremities but upper
involved too
Malaria - protozoal dz caused by Plasmodium
(RBC parasite spread by Anopheles). Hallmark is
cyclical feer, coinciding w Plasmodium-induced
RBC lysis. Typical cycle consists of cold phase
(chills, shivering), then a hot phase (high-grade
fevers), then a sweating stage (diaphoresis, fever
resolution). Anemia & thrombocytopenia are
classic. Blood smears are dx gold standard.
Toxic Shock Syndrome
Fever >38.9 (102)
Hypotension w SBP <90
Diffuse Macular erythroderma
Skin desquamation, including palms & soles, 1-2
weeks after illness onset
Multisystem involvement (3 or more systems)
3743 Medicine Infectious Diseases -GI (vomiting &/or diarrhea)
-Muscular (severe myalgias or inc CK)
-Mucous membrane hyperemia
-Renal (BUN or Cr >1-2x upper limit)
-Hematologic (platelets <100,000)
-Liver (ALT,AST & total bilirubin >2x upper limit)
-CNS (altered mentation w/o focal neurological
signs)
Echinococcosis - E granulosus (cystic dz) and E
multilocularis (alveolar dz). Most human infxns are
d/t sheep strain E. granulosus, dogs and other
canids are definitive hosts and sheep are
intermediate hosts. Humans are dead- end
3789 Medicine Infectious Diseases accidental intermediate host. MC seen in areas
where sheep are raised. Infectious eggs excreted
by dogs in feces are passed on to other animals
and humans. Ingestion of eggs by humans,
oncospheres are hatched and penetrate bowel
wall - heme spread.
Neurocysticercosis (NCC) is MC parasitic infxn of
the brain. Caused by ingestion of eggs found in
human feces. Pig is an intermediate host.
Consuming infected, undercooked pork will give a
human the intestinal infxn w the adult tapeworm
but not NCC. NCC is only contracted from eating
the eggs in feces. Ppl who don't eat pork can still
get NCC. 80% of NCC infxns are asymptomatic.
Adb pain, fever, leukocytosis + liver abscess on
imaging.. hx of dysentery -> amebic abscess
caused by Entamoeba histolytica. Ddx includes
pyogenic abscess and hydatid cyst caused by
Echinococcus. Echinococcus cysts are not assoc
3819 Medicine Infectious Diseases w fever, frequently asymptomatic and require
contact w animals. Tx of amebic abscess -
Metronidazole. Serologic testing for E histolytica
antibodies confirms the dx. Paromomycin for
intestinal colonization. Hydatid cysts - aspiration w
albendazole.
Infective endocarditis w Strep gallolyticus (S Bovis
biotype 1) is 1 of 4 species that belong to group D
strep (AKA S bovis/S equinus complex). Increased
3825 Medicine Infectious Diseases risk of CRC and endocarditis in pts w infxn due to
S gallolyticus compared to pts w S bovis biotype II
infxn. Pts w S gallolyticus (biotype 1) infxn should
have colonoscopy to look for occult malignancy.
Patients w HIV should receive vaccination for
MMR if their CD4 cell count >200/microliter, they
have no Hx of AIDS-defining illness, and they have
no evidence of immunity (birth before 1957,
documented evidence of prior vaccination, or +
titers)
The most recent immunization guidelines for
HIV-pos individuals recommend a Tdap in
adulthood, followed by tetanus-diphtheria (Td)
boosters every 10 years (sooner if required d/t a
contaminated wound). Tdap is also indicated w
every pregnancy to protect the infant.
PCV13 is recommended for all adults age > 65
followed by the PPSV23 at least 6-12 mo later.
PPSV23 alone is recommended for adults age
<65 who are current smokers or have chronic
medical conditions including heart or lung disease,
diabetes, or chronic liver disease. Influenza
vaccination should be provided annually to all
adults.
Any HIV + pt w bloody diarrhea and normal stool
exam should have a colonoscopy w biopsy to look
for CMV colitis. CMV colitis is chrctzd by bloody
3917 Medicine Infectious Diseases diarrhea w abdominal pain. Colonoscopy shows
multiple ulcers w mucosal erosions. Biopsy
demonstrates cytomegalic cells w intracytoplasmic
inclusion bodies. Tx is ganciclovir or foscarnet.
Strep viridans - mitis, sanguis, mutans, salivarius.
3928 Medicine Infectious Diseases Mutans also causes dental caries. All cause IE on
a heart valve w previous damage.
Tx PCP. Preferred is Corticosteroids + TMP-SMX
(IV for acutely ill, oral for non-acutely ill pts) S/E
Rash, neutropenia, hyperkalemia, elevated LFTs
Pentamidine (IV). S/E nephrotox, hypotension,
hypoglycemia, cardiac arrhythmias, pancreatitis,
elevated transams
Atovaquone (oral). S/E GI distress, rash
TMP + Dapsone (both oral). S/E Hemolytic
anemia (check for G6PD deficiency)
Clinda (IV or oral) + Primaquine (Oral).
Methemoglobinemia, hemolytic anemia (G6PD
deficiency)
Pulm nocardiosis - pneumonia developing over
days to weeks. Pulmonary nodules are MC
manifestation and tissue necrosis or empyema is
present in 1/3 of pts. Up to 50% of pts have
extrapulmonary dissemination, w brain and skin
being MC extrapulmonary sites. Gram stain +
culture - crooked, branching, beaded, gram +,
partially acid-fast filaments. Tx TMP-SMX. In
severe dz - meropenem or linezolid is added.
Drainage of abscesses.
Most pts w cat-scratch disease have a gradual
resolution of symps, even w/o specific abx
therapy; however, tender regional
lymphadenopathy and systemic symps may be
debilitating. Therefore, a short course of abx
therapy (5 days of azithro) is recommended for
pts w CSD. 5 days of azithro has been found to
be effective.
VAP - nosocomial pneumonia usually develops
>48 hrs after endotracheal intubation. MCC by
aerobic gram-neg bacilli (P aeuroginosa, E coli, K
pneumoniae) and gram-pos cocci (MRSA, strep).
Pts have fever, purulent secretions, difficulty w
ventilation (eg, inc resp rate, dec tidal volume),
and leukocytosis. 1st step - CXR. Normal CXR
unlikely to have VAP. Abnl CXR - lower RT
sampling (tracheobronchial aspiration) for
gram-stain & culture.
Risk factors for C dif: recent hospitalization,
advanced age, or ABx. C dif colitis can range from
mild colitis (watery diarrhea, low-grade fever, abd
pain, leukocytosis) to fulminant colitis w toxic
megacolon. Dx is confirmed w stool studies for C
dif toxin ( PCR or enzyme immunoassay).
Necrotizing surgical site needs to be tx w broad
spectrum abx, adequtae hydration, tight glycemic
4102 Medicine Infectious Diseases control, and surgical exploration. Surgical
exploration is necessary to assess the extent of
the process and debride necrotic tissues.
Vertebral osteomyelitis usually presents w fever,
back pain, and focal spinal tenderness. Evaluation
4120 Medicine Infectious Diseases includes blood cultures and inflammatory markers
(ESR and CRP). MRI - Dx, followed by CT-guided
bone biopsy.
IE - fever, chills, generalized malaise
Underlying heart condition (eg, murmur), indwelling
structures (eg, intravascular catheters), or hx of
IVDA should prompt further investigation for
bacteremia assoc w endocarditis. About 75% of
pts w IE have previously damaged heart valves, w
mitral valvular disease being the most common.
Pts w MVP and assoc regurgitation have a 5-8x
higher risk of IE than those w a normal valve.
Initial tx - Vancomycin
S. Pneumo is the MCC of pneumonia in nursing
home pts.
Intermittent catheterization is assoc w significantly
lower risk of UTI compared to use of indwelling
catheters in pts w spinal cord injuries. Indwelling
catheters carry a high risk of infxn bc of the ability
of bacteria to form a biofilm along the catheter
wall that can reach the bladder w/in 24 hrs of
insertion. Longer the catheterization the greater
the risk of bacteruria.
Diabetic pts are prone to developing foot ulcers
d/t combination of arterial insufficiency and
peripheral neuropathy. Bc of poor tissue perfusion,
immune system has difficulty combating infxn in
4168 Medicine Infectious Diseases the region surrounding the ulcer. Open ulcer is an
ideal site for entry of bacteria and infxn.
Contiguous spread is the most likely pathogenic
mechanism of osteomyelitis in pts w arterial
insufficiency.
Diabetic pts w acute pyelonephritis are generally
tx w parenteral abx for 48-72 hrs. Once the pts
has a clear response, tx can be switched to oral
abx for a total course of 10-14 days.
Fluoroquinolones and TMP-SMX are good options
for oral therapy, w the choice of abx usually
individualized based on culture and sensitivity
results.
Legionnaires' disease - pulmonary manifestations
accompanied by other organ dysfxn from CNS to
GI involvement. Relative bradycardia (despite high
fever) is a classic associaiton; hyponatremia &
mild hepatitis are frequently seen. Legionella is
intracellular gram-neg rod, so sputum gram stain
can show neutrophils but no organisms. Dx made
by culture, gen from bronchscopy. Urine antigen
testing is rapidly available MC dx method. Tx
macrolide or fluoroquinolone
P aeruginosa - frquent cause of osteomyelitis in
adults w a hx of a nail puncture wound (esp when
the puncture occurs through a rubber-soled
footwear). The pt presents w local pain, swelling,
4257 Medicine Infectious Diseases fever, and increased WBC. Blood cultures reveal
infecting microorganism; otherwise, a bone biopsy
is required. Plain x-rays take 2 weeks+ to show
evidence of disease. Tx is oral or parenteral
quinolones and aggressive surgical debridement.
Fever, stiff neck, headache, nausea and myalgias
- meningitis. Hypotension, tachycardia, myalgias,
& purpuric skin lesions suggest meningococcal
meningitis w meningococcemia which can develop
w/in several hours of initial meningitis. Myalgias
MCly occur in meningococal meningitis than other
bacterial causes and can be more intense &
painful than myalgias caused by viral influenza.
Neuraminidaseinhibitors(oseltamivir,zanamivir)
can dec severity and duration of influenza. Current
guidelines recommend tx all confirmed or
suspected influenze w/in 48 hours of symptom
onset. Otherwise healthy pts presenting later are
usually managed w symptomatic tx.
Crystal-induced nephropathy is a well-known side
effect of indinavir therapy (indinavir - protease
inhibitor). Caused by precipitation of the drug in
the urine and obstruction of urine flow. Monitor UA
and Cr levels every 3-4 months in ppl taking
4327 Medicine Infectious Diseases indinavir.
Didanosine-induced pancreatitis
abcavir-related hypersensitivity syndrome
Lactic acidosis secondary to any NRTIs
SJS secondary to use of any NNRTIs
Nevirapine-associated liver failure
Fever, malaise, pharyngitis, and posterior cervical
lymphadenopathy - IM d/t EBV. Mild moderate
fever, pharyngitis, and lymphadenopathy. Post
more than Ant lmpadnpathy. Splenomegaly w
splenic rupture is a rare complication. Heterophile
antibodies typically arise w/in 1 week of symps
and persist for up to 1 year. Can also test for
anti-EBV antibodies.
Bartonella henselae and quintana cause bacillary
angiomatosis in immunocompromised ppl. Pts
present w cutaneous and viseral angioma-like
blood vessel growths. Large, pedunculated
exophytic papule w a collarette of scale
-resembles pyogenic granuloma or cherry
angioma. Abx tx causes lesion regression. Dx is
made via tissue biopsy and ID of orgs and
characteristic angiomatous histology. Lesions are
very prone to hemorrhage.
IE in IVDA
-HIV infxn increases IE in IVDA
-S aureus is MC organism
-Tricuspid valve (TV) involvement (right-sided) MC
than aortic valve
Often lacks audible heart murmur
Fewer peripheral IE manifestations
Heart failure more common in aortic valve
involvement, but rare w TV disease
Septic pulmonary emboli common - look like
infiltrates, abscesses, infarction, gangrene, or
cavities
Nocardia - immunocompromised pt systemic
symptoms, lung nodules, n brain abscess (causing
seizures) - gram+ partially acid-fast, filamentous,
branching rods. CXR findings include alveolar
infiltrates and nodules, often w cavitation. DOC for
pulmonary nocardiosis TMP-SMX. When brain is
involved, carbapenems should be added.
Abscesses should be surgically drained as well.
PCV13 recommended for all adults > or = to 65
followed by PPSV23 6-12 months later. Sequential
PCV13 and PPSV23 are also recommended for
adults <65 w high-risk underlying conditions (CSF
leaks, SCD, cochlear implants, congenital or
acquired asplenia, immunocompromised status,
chronic renal failure. PPSV23 alone is
recommended for adults <65 who are current
smokers or have chronic heart or lung dz, dibetes,
chronic liver disease.
Recommended vaccines for chronic liver disease
Tdap/Td - Tdap once as substitute for Td booster,
then Td every 10 years
Influenza - Annually
Pneumococcal vaccines - PPSV23 once, then
revacc w sequential PCV12 & PPSV23 @65
HAV - 2 doses 6 months apart w initial negative
serologies
HBV - 3 doses @ 0 months, 1 month & at least 4
months w initial negative serologies
Patients w PID should be tx w appropriate abx,
counseled on safe-sex practices, and encouraged
to informa ny sexual partners from the past 60
4488 Medicine Infectious Diseases days of heir condition so that they can be tx as
well. Pts w PID should also be screened for HIV,
syphilis, HBV, cervical cancer (pap smear), and
HCV if they have a hx of IV drug use.
Of the bacterial pathogens known to cause
secondary pneumonia complicating a viral URI,
only S aureus is associated w necrotizing
bronchopneumonia resulting in pneumatocoeles. S
4517 Medicine Infectious Diseases pneumo, S aureus, and H influ all cause secondary
bacterial pneumonia. Only S aureus is known to
cause post viral URI necortizing pulmonary
bronchopneumonia w multiple nodular infiltrates
that cavitate to cause small abscesses.
TMP/SMX is ppx for PCP and Toxoplasma.
Ganciclovir is ppx for CMV in HIV pts w CD4 cts
<50. Fluconazole is ppx for Cryptococcus
4611 Medicine Infectious Diseases neoformans and coccidioides immits. Azithro is
ppx for MAC. INH is ppx for TB against HIV-pos
pts w positive TB skin tests (>5mm) or those who
have had contact w an individual w active TB.
Recommended vaccines for asplenic adult pts
Pneumococcus - Sequential PCV13 and PPSV23,
Revacc w PPSV23 5 years later and at age 65
H influenzae - 1 dose Hib
4634 Medicine Infectious Diseases Meningococcus - Meningococcal quadrivalent
vaccine, Revacc every 5 years
Influenza - Inactivated influenza vaccine annually
Other - HAV, HBV, Tdap once as substitute for
Td, then Td every 10 years
Secondary syphilis typically causes a diffuse
maculopapular rash involving the trunk and
extremities, including the palms and soles, w
generalized lymphadenopathy and systemic
symps. Suspected cases should be confirmed w
lab testing (eg, RPR or VDRL, followed by a
treponemal test [eg, FTA-ABS]). Tx of primary or
secondary syphilis is a dose of IM penicillin.
4662 Medicine Infectious Diseases Remove ticks w tweezers
Allergic bronchopulmonary aspergillosis (ABPA) is
HSR to Aspergillus colonization of bronchi. MC in
pts w asthma or CF - presents w fever, malaise,
productive cough, eosinophilia, and hemoptysis.
Bronchiectasis - progressive bronchial dilation,
cyst formation, poor mucus clearance, and
secretion pooling results from sever, repeated
airway inflammation. CT shows bronchial
thickening. Reactivation TB shows upper lobe
cavitations.
Splenic abscess usually presents w the classic
triad of fever, leukocytosis, and LUQ pain. Pts can
also develop left-sided pleuritic chest pain, left
4714 Medicine Infectious Diseases pleural effusion, and splenomegaly. RF include
hematogenous spread, immunosuppression, IVDA,
trauma, hemoglobinopathies. IE is MC associated
w splenic abscess.
Post-influenza S aureus pneumonia. Pts first
rpesent a w syndrome consistent w influenza
which improves. Then they develop a pneumonia
>2 weeks after his initial presentation. S aureus is
4867 Medicine Infectious Diseases a relatively uncommon cause of community
acquired pneumonia. Mostly affects hospitalized
pts, nursing home residents, IVDA, pts w CF, or
ppl w recent influenza infxn. Gram + cocci in
clusters
Histoplasma usu causes asymptomatic or minor
resp illness in healthy patients, but
immunocompromised pts can develop severe
4938 Medicine Infectious Diseases pulmonary or disseminated disease. The most
rapid and sensitive test to dx disseminated
histoplasmosis in immunocompromised pts is urine
or serum assay or Histoplasma antigen.
Tx of disseminated pulmonary Histo in HIV pts
depends on severity of disease. Pts w mild to
moderate dz may be tx w itraconazole. More
4939 Medicine Infectious Diseases severe dz (>39.5 C, lab abnormalities, or
fungemia) should be tx initially w IV liposomal
amphotericin B for 2 weeks followed by
itraconazole for 1 year.
Culture negative IE - HACEK group. Haemophilus
aphrophilus,Aggregatibacter
actinomycetemcomitans,Cardiobacteriumhominis,
Eikinella corrodens, Kingella kingae. Responsible
for ~3% of IE. E corrodens is gram-neg anaerobe
and a common constituent of normal human oral
flora. IE d/t eikenella is seen in the setting of poor
oral dentition and/or periodontal infxn, along w
dental procedures that involve manipulation of
gingival or oral mucosa.
Infectious esophagitis common in pts w advanced
HIV (CD4 <50-100). MCC of esophagitis is
Candida; however, in pts whose predominant
symptom is SEVERE ODYNOPHAGIA (painful
swallowing) w/o dysphagia (difficulty swallowing)
8959 Medicine Infectious Diseases or thrush - viral esophagitis is more likely. MC
implicated viruses include HSV and CMV. Dx of
vrial esophagitis is made on endoscopy w biopsy.
HSV causes circular or ovoid vesicular and
ulcerated lesions. HIV causes large, linear distal
esophageal ulcers.
USPSTF recommends routine one-time HIV
testing in individuals between 16-65. Annual or
more frequent testing is suggested for individuals
in higher-risk groups (men who have sex with men,
IVDA, sex workers, sexual partners of HIV + ppl,
those w hx of STD, ppl who have unsafe sex).
Preferred HIV screening test is a 4th gen assay
that detects HIV p24 antigen and antibodies. If
pos, then pt needs confirmational testing
HIV1/HIV2 antibody differentiation immunoassay.
Meningococcal vaccination is recommended for all
adolescents at age 11-12 and also for those age
13-18 who did not receive initial vaccination. In
addition, all pts who were vaccinated prior to age
10904 Medicine Infectious Diseases 16 should receive a booster dose at age 16-21.
Increased risk of meningococcal meningitis among
young adults in large groups living in close
proximity, military recruits and 1st-yr college
students.
Chikungunya
Central & S America, tropical regions of Africa, S
Asia
Vector: Aedes mosquito (same as Dengue fever)
Incubation: 3-7days
High fevers, severe polyarthralgias (virtuall always
present)
Headache, myalgias,conjunctivitis, maculopapular
rash
Lymphopenia, Thrombocytopenia, elevated liver
enzymes
Mgmt: Supportive care (resolves w/in 7-10 days)

PID - fever >38, leukocytosis, elevated ESR,
purulent cervical discharge, adnexal tenderness,
cervical motion tenderness, and lower abdominal
tenderness. PID is MCC of infertility of women
Obstetrics
age <30 w normal menstruation. If left untx can
2416 & Infectious Diseases
lead to tubo-ovarian abscess, abscess rupture,
Gynecology
pelvic peritonitis, and sepsis. Should be managed
promptly. MCC N gonorrhoeae, C trachomatis,
and genital mycoplasmas. Tx cefoxitin or
cefotetan/doxycycline, clindmycin/gentamicin
Toxoplasmosis - chorioretinitis, hydrocephauls,
and intracranial calcifications. HSM, microcephaly,
microphthalmia, jaundice, diffuse LAD. Systemic
infxn. Maternal infxn by exposure to feces from
Obstetrics infected cats or ingestion of raw meat or
3676 & Infectious Diseases unpasteurized goat's milk. Risk of transmission inc
Gynecology as the pregnancy progresses, but the severity of
neonatal dz decr. ~75% of infants are
asymptomatic at birth, and 25-50% present w
complications. Labs show high bilirubin and
platelets.
Most important intervention to prevent HIV
transmission from mother to child is starting
HAART therapy ASAP, regardless of maternal
Obstetrics
CD4 count. 3-drug regiment should include 2
NRTIs + NNRTI or protease inhibitor. NRTI w
Gynecology
good placental transfer (zidovudine, tenofovir)
should be given. Zidovudine should be given to the
neonate for > or = 6 weeks.
Trichomonas vaginitis usually presents w vaginal
discharge (pH>4.5) that is malodorous, thin,
frothy, and yellow-green in color. Bacterial
vaginosis typically prsents w minimal to absent
Obstetrics
vaginal inflammation and a discharge (pH >4.5)
that is thin, off-white in color, and has a "fishy"
Gynecology
odor. Candida vulvovaginitis usually presents w
significant vulvar inflammation and thick vaginal
discharge (normal pH) that is odorless and
appears like "cottage cheese"
Obstetrics
Tx vaginosis - flagyl 500mg PO BID x 7days.
Metronidazole is not teratogenic.
Gynecology
Penicillin remains drug of choice for syphillis in
pregnancy even if the patient has a penicillin
Obstetrics
allergy. Need to distinguish between allergy and
adverse response to penicillin. If truly allergy, then
Gynecology
penicillin desensitization is recommended (slowly
increasing doses of oral penicillin V).
Up to 80% of pts w HCV devlop chronic hepatitis
making HCV the MCC. HCV infxn is acquired mC
by exposure to infected blood. Preg women w
Obstetrics chronic hep C are generally asymptomatic though
4272 & Infectious Diseases incr risk for gestational dibetes, cholestasis, and
Gynecology preterm delivery. Also at risk for cirrhosis. All pts
should be immunized against hep A and B if they
aren't immune. Acute viral hep on top of chronic
hep is life threatening.
Pregnant women w asymptomatic bacteruria
should be tx w ABx to decrease risk of
Obstetrics
pyelonephritis, preterm birth, low birth weight, and
perinatal mortality. Amoxicillin, nitrofurantoin, and
Gynecology
cephalexin are first-line abx options during
pregnancy.
Asymptomatic pts w chlamydia detected by
screening should be tx w a single dose of
Obstetrics
azithromycin or a 7-day course of doxycycline.
Concurrent tx for gonorrhea is not needed if
Gynecology
screening for gonorrhea is negative using the
nucleic acid amplification technique.
HSV eruptions manifests as painful vesicles on an
erythematous base that evolve to shallow,
"punched-out" ulcerations or erosions. Risk of
neonatal HSV infxn is drastically increased if the
Obstetrics
infant passes through the vaginal canal. C-section
is recommended to all women in laber w active
Gynecology
HSV lesions or prodromal symps (burning, pain).
Preg women w HSV should receive ppx acyclovir
or valacyclovir at 36 weeks of pregnancy.
Reduces risk for needing a C-section.
Genital ulcers
Painful
HSV - Multiple small, grouped w erythematous
base, shallow, tender lymph nodes, MC in US,
recurrent
Haemophilus ducreyi - Single or mult deep ulcers,
Obstetrics w irregular border, base may be friable and have
10068 & Infectious Diseases gray/yellow exudate, matted lymph nodes
Gynecology Painless
Syphilis - single, indurated, well-circumscribed,
clean base, nontender lymphnodes
Chlamydia - Small, shallow ulcers (absent),
matted lymph nodes, large painful buboes, sinus
tracts
Klebsiellagranulomatis
Group A Strep is MCC of bacterial pharyngitis in
children and adolescents. GAS is MC at 5-15 and
presents w abrupt onset of sore throat, fever,
poor oral intake, and malaise. Tonsillar erythema
and exudates, tender anterior cervical nodes, and
2193 Pediatrics Infectious Diseases palatal petechiae. Dx of bacterial pharyngitis
should be confirmed prior to tx to avoid
unnecessary abx. Rapid strep antigen testing or
throat culture. Negative RSAT results must be
followed up by culture bc of low sensitivity. PCN
AMX
HiB should be suspected cause of epiglottitis in
unimmunized children. The presentation of
epiglottitis includes abrupt onset of fever, sore
2196 Pediatrics Infectious Diseases throat, dysphagia, and drooling. Airway
obstruction is the most worrisome complication.
Keeping the neck hyperextended often provides
some relief as it maximizes the airway diameter.
Atypical pneumonia - Mycoplasma, chlamydia,
legionella, coxiella, influenza. M. pneumoniae MCC
in the ambulatory setting. Low grade fever and
2296 Pediatrics Infectious Diseases week's worth of symptoms are the typical indolent
course. Extrapulmonary symptoms also found -
headache, sore throat, skin rash (erythema
multiforme). Mycoplasma does not gram stain.
Always give a trial of epinephrine in cases of
croup before intubation. Controlled trials have
shown that a trial of racemic epinephrine should
precede any invasive procedure in cases of croup,
as this decr the need for intubation. Epinephrine
2424 Pediatrics Infectious Diseases
acts by its alpha & beta adrenergic effects. In
asthma, the alpha-adrenergic effect is beneficial
by reducing bronchial secretions & mucosal
edema. This similar process is thought to help pts
w croup. Beta-adrenergic effect also helps w
Neonatal sepsis - Poor feeding and decreased
level of alertness are among the earliest signs of
infxn in a neonate. It can present w fever or
hypothermia. Phys exam doesn't distinguish
between meningitis & sepsis in neonates.
Neonates w meningitis do not present w headache
or neck stiffness. Neonates w sepsis or meningitis
are irritable, lethargic, or hypotonic. Tests - CBC,
Blood Cx, LP, UA, UCx. Empirix abx - Ampicillin &
Gentamicin, or Ampicillin & Cefotaxime
High fever, knee pain & swelling, refusal to bear
weight in the setting of leukocytosis and elevated
CRP and ESR = Septic arthritis. Septic arthritis is
often preceded by a skin or URTI. Arthrocentesis
is diagnostic and therapeutic and should be done
ASAP d/t risk of permanent jt destruction. Blood
and synovial fluid Cx should be obtained prior to
giving abx so they don't mess w results.
Non-bullous impetigo - erythematous papules that
evolve quickly into painful pustules. Pustules later
rupture and leave honey-colored crusted
exudates. Rash is not pruritic and systemic symps
2781 Pediatrics Infectious Diseases (eg, fever) are typically absent. Pts w underlying
skin problems (eg, eczema, abrasion, insect bite)
are at inc risk of developing superinfxn.
Non-bullous impetigo is caused by S aureus and/or
S pyogenes. Topical abx are tx of choice.
Measles (rubeola)
Prodrome: fever, malaise, anorexia
Conjunctivits, coryza, cough, koplik spots
Exanthem:
Blanching, reddish-brown maculopapular rash
Cephalocaudal & centrifugal spread
Usually spares palmssoles
Dx. PCR, Acute & convalescent serology for
2782 Pediatrics Infectious Diseases anti-measles IgM & IgG
Ppx. Live attenuated measles vaccine
Tx. Supportive care, Vit A for hospitalized kids
Complications
Otitis media
Pneumonia
Neurlogic: Encephalitis (w/in days), SSPE (w/in
years),
Gastroenteritis
Rubella (German measles) - RNA togavirus.
Children remain asymptomtic or develop mild
disease 2-3 wks after inhalation of infected
respiratory droplets. Erythematous "pink"
maculopapular exanthem begins on the face and
spreads in a cephalocaudal and centrifugal pattern
to the rest of the body and lasts <3 days. Some
pts have a nonexudative conjunctivitis and patchy
erythema (Forschheimer spots) on the soft palate.
Tx - symptomatic relief.
Vertical transmission of HBV occurs during
delivery but transplacental infxn can also occur
(esp in women who developed an acute HBV infxn
2906 Pediatrics Infectious Diseases in 3rd trimester). Newsborns of all mothers w
active HBV should be passively immunized at birth
w HBV immune globulin, followed by active
immunization w recombinant HBV vaccine.
Orchitis is one of the most frequent complications
of mumps, developing in 20% of cases. It is MC in
postpubertal young men, 15-29. Bc <15% of
orchitis cases are bilateral, infertility is a rare
complication. Tx is supportive w application of cold
compresses to the parotid area or testes. Other
common complications are aseptic meningitis and
encephalitis.
Leukopenia (T-cell cytopenia) and tcpa can be
seen w measles infxn. Vit A has been shown to
3077 Pediatrics Infectious Diseases reduce the morbidity and mortality rates of pts w
measles through immune enhancement. It also
helps the GI and resp epithelium to regenerate.
S pneumo, and nontypeable H influ are the MCC
of acute bacterial rhinosinusitis. D/t increasing
beta-lactamase resistance, the tx of choice is
amoxicillin-clavulanic acid.
Croup - Parainfluenza virus - AKA laryngotracheitis
or larygotracheobronchitis - children younger than
3 w hoarsenss, barking cough, varying degress of
resp distress. Croup is a clinical dx. Lateral neck
x-rays show subglottic narrowing. Epiglottitis -
older children - cough not croupy - stridor &
excessive drooling - Xrays show swollen epiglottis
(thumb sign), thickened aryepiglottic folds,
obliteration of the vallecula. Bactrial
laryngotracheobronchopneumonitis - lower resp
Malaria
P falciparum, vivax, ovale, or malariae by infected
Anopheles mosquito
Periodic febrile paroxysms (cyclic fever), malaise,
headache, nausea, vomiting, abd pain, diarrhea,
myalgia, pallor, jaundice, petechiae, HSM
Kids: seizure, coma, metabolic acidosis,
3423 Pediatrics Infectious Diseases hypoglycemia
Adults: jaundice, acute renal failure, acute pulm
edema
Dx: thick & thin peripheral smears
Ppx: hemoglobinopathies, partial immunity from
prior infxn
Ppx. Drugs (atovaquone, doxy, meflo, chloro,
hydroxy)
HUS - E coli - verotoxin invades & destroys colonic
epithelial lining - bloody diarrhea. Subsequent
activation of coag system and RBC hemolysis
results in jaundice. HUS is MC in chilren in age
1-4. Initial presentation includes abd pain &
diarrhea. Classic triad is uremia, tcpa, & hemolytic
anemia. Investigations: CBC, plt ct, blood smear,
urinalysis, BUN, Cr. Tx is supportive -
plasmapheresis, dialysis if necessary, & steroids.
ABx not indicated.
Meningococcal meningitis is the MCC of bacterial
meningitis in children and young adults. It typically
presents w fever, headache, neck stiffness, AMS,
and a petechial or purpuric rash. Prompt dx and tx
are critical given that it has a high morbidity and
mortality rate even with appropriate tx.
Meningitis + rash = most of the time neisseria
meningitidis - meningococcemia. Watch for
Waterhour-Friderichsen - sudden vasomotor
collapse & skin rash (large purpuric lesions on the
flanks) d/t adrenal hemorrhage. Fulminant
meningococcemia can occur after a
meningococcus infxn, and approxiately 10-20% of
infants present w vasomotor collapse, large
petechiae and purpuric lesions. Alomst 100%
mortality.
Aphthous stomatitis (canker sores) - Recurrent
ulcers on anterior oral mucosa (lips, cheeks,
mouth floor, ventrum of tongue), No fever or
systemic symps
Herpangina - Vesicles & ulcers on posterior
oropharynx, fever
Herpes gingivostomatitis - Vesicles & ulcers on
anterior oral mucosa & around mouth, fever
Group A strep pharyngitis - Tonsillar exudates,
fever, anter cervial lad
Infectious mononucleosis - Tonsillar exudates,
fever, diffuse cervical lad, +/- HSM
Septic arthritis should be suspected when a pt has
acute fever, jt pain, turbid synovial fluid, &
neutrophil-predominantleukocytosis.Emergency
surgical drainage and IV Abx are needed to
prevent permanent jt destruction. Septic arthritis is
often preceded by a seemingly mild infxn (cellulitis)
in which there may be intermittent bacteremic
showers, allowing for hematogenous spread of
bacteria into synovial fluid. S aureus and strep.
Empiric vanco start immed. Surg drainage.
Infectiousmononucleosis
Etiology - EBV
Clinical feats - Fever, tonsillitis/pharyngitis +/-
exudates, Posterior or diffuse cervical
lymphadenopathy, significant fatigue, +/- HSM
Dx - Positive heterophile antibody (Monospot) test
(25% false neg rate during 1st week of illness),
atypical lymphocytosis, transient hepatitis
Mgmt - Avoid contact sports for > or = 3 weeks
d/t the risk of splenic rupture
Enterobiasis is the MC helminthic infxn in the US.
E vermicularis MC infects school-aged children
aged 5-10. Adult pinworm thrives primarily in the
human cecum & appendix. @ night the female
3612 Pediatrics Infectious Diseases migrates out through the rectum and deposits
eggs in the perianal region -> nocturnal perianal
pruritis. Dx - cellophane tape test. Albendazole &
pyrantel pamoate - first line tx. Pyrantel in
pregnant women. Infxn is highly contagious.
Bacterial meningitis in children >1 month
Fever, vomiting/poor feeding, Seizures, AMS,
Nuchal rigidity, Kernig & Brudzinski signs, Bulging
anterior fontanelle
WOrkup - CBC & electrolytes, Blood Cx, LP &
3633 Pediatrics Infectious Diseases CSF studies
Indications for imaging prior to LP: Hx of
hydrocephalus or neurosurgical procedure, Hx of
head trauma, Coma or focal findings
Tx. IV vanco & ceftriaxon OR cefotaxime
Dexamethasone for HiB meningitis
Oral doxycycline, amoxicillin, and cefuroxime have
equivalent efficacy for treating early localized
Lyme disease. Doxy is often used bc it's effective
in tx potential Anaplasma phagocytophilum infxn
3636 Pediatrics Infectious Diseases which is also transmitted by Ixodes tick. It can
slow bone growth and cause enamel hypoplasia &
permanent teeth stains during tooth development
in young kids. Oral amoxicillin or cefuroxime is tx
of choice in children <8 or pregant women.
Incidence of bacteremia in SCD pts has
decreased as a result of impoved vaccination
(pneumococcal conjugate & polysaccharide
vaccines, meningococcal conjugate vaccine).
Despite this, S pneumo is the MCC of sepsis in
pts w SCD, usually from non-vaccine serotypes.
Pts w SCD should receive prophylactic penicillin
until at least age 5.
Impetigo
Non-bullous - S aureus, GAS, Painful non-pruritic
pustules, honey-crusted lesions
Bullous - S aureus, Rapidly enlarging flaccid bullae
3642 Pediatrics Infectious Diseases w yellow fluid, collarette of scale at periphery of
ruptured lesions
Tx - Ltd skin involvement: Topical abx (muciprocin)
Extensive skin involvement: Oral abx (cephalexin,
dicloxacillin, clindamycin)
Universal maternal prenatal testing and tx for
chlamydia are recommended to prevent neonatal
infxn. Oral erythromycin is the tx of choice for
neonatal chlamydia. Erythromycin ophthalmic
ointment can prevent neonatal gonococcal but not
chlamydialconjunctivitis.
HIV infxn should be suspected when an infant has
failure to thrive, lymphadenopathy, and thrush in
the setting of maternal IVDA. Preg pts w risky
3670 Pediatrics Infectious Diseases behavior should undergo HIV antibody testing in
the 1st & 3rd trimesters as it can take up to 3
months to develop detectable antibody. Dx in
infants consists of PCR testing.
GBS & E coli are the MCC of neonatal sepsis.
Prevention of GBS infxn include maternal testing &
tx w intrapartum IV Abx (eg, PCN). Evaluating
neonatal sepsis involves obtaining CBC & blood &
CSF Cx prior to administering systmic abx
(ampicillin + gentamicin). Neutrophilia w significant
left shift (>700/microL bands) indicates neonatal
sepsis from bacterial infxn.
Conjunctivitis
Chemical - <24 hrs - Mild conjunctival

irritation/injection & tearing after AgNO3
ophthalmic ppx - eye lubricant
Gonococcal - 2-5 days - Marked eyelid swelling;

profuse purulent discharge; corneal
3758 Pediatrics Infectious Diseases edema/ulceration - IV or IM ceftriaxone or
cefotaxime
Chlamydial - 5-14 days - Eyelid swelling;

chemosis; watery, bloody, or mucopurulent eye
discharge - oral erythromycin
avoid ceftriaxone displaces bilirubin from albumin -

avoid in kids w jaundice
Tetanus is an infxn of the nervous system
characterized by spasms & hypertonicity.
Tetanospasmin. 4 clinical types of tetanus are
recognized: generalized, localized, cephalic, &
3788 Pediatrics Infectious Diseases neonatal. Neonatal is often generalized and
invariably fatal if left untx. Significant problem in
developing countries. Commonly seen in infants
born to unimmunized mothers, frequently following
umbilical stump infxn. Onset w/in 2 weeks of birth.
Vulvovaginitis in a prepubertal child can be caused
by infxns, congenital abnlties, trauma, or
dermatologicconditions.Nonspecificvulvovaginitis
is responsible for 25-75% of cases d/t lack of
labial development, unestrogenized thin mucosa,
poor hygiene, bubble bthats, shampoos, obesity,
and choices of clothing. Pinworm infxn is common
in school going children. Nocturnal anal pruritis and
prepubertal vulvovaginitis. Scotch tape test.
Mebendazole.
Pertussis
Catarrhal (1-2 wks) - mild cough, rhinitis
Paroxysmal (2-6 wks) - Coughing paroxysms w
inspiratory "whoop", posttussive emesis, apnea,
cyanosis (infants)
Convalescent (wks - mnths) - Symptoms resolve
gradually
Dx - Pertussis culture or PCR,
Lymphocyte-predominant leukocytosis
Tx - Macrolides
Ppx - Acellular pertussis vaccine
Comps - Pneumonia, weight loss, pneumothorax,
resp failure, death (infants), subconjunctival
hemorrhages
Pertussis tx & post-exposure ppx
Age <1 month - Azithromycin x 5 days
Age >/= 1 month - Azithro x 5 days, OR
Clarithromycin x 7 days, OR Erythromycin x 14
days
Scarlet fever - caused by Group A strep that
produces erythrogenic exotoxins. Same mode of
transmission & age of distribution as strep
pharyngitis. Incubation period 1-7 days. Starts as
fever, chills, toxicity, abd pain, pharyngitis. Rash
appears on neck, axillae, & groin w/in 12-48 hrs
then generalizes. Sandpaper-like. Pharynx -
swollen, erythematous, covered w gray-white
exudates. Mouth pale in comparison to red cheeks
"circumoral pallor" Tx Penicillin V. Erythro clinda
Pts w CF suffer from life-threatening, recurrent
sinopulmonary infxns d/t accumulation of viscous
airway secretions. S aureus is MCC of bacterial
pneumonia in young children w CF, esp w
coexisting influenza infxn. IV vanco is the drug of
choice for severe pneumonia in this setting. P
aeruginosa is the MCC of pneumonia in adults w
CF, can tx w amikacin, ceftazidime, & cipro
Chickenpox incubation period is up to 3 weeks.
Most pts develop symps w/in 2 weeks of
exposure. After a prodrome of fever & malaise,
pruritic vesicles appear in different stages across
the face & body and are usually fully crusted w/in
4186 Pediatrics Infectious Diseases a week. Complications include bacterial superinfxn
in children and pneumonia in adults.
Immunocompromised adults are at risk for
potentially disseminated disease. pts are
contagious from 2 days prior to onset until all
vesicles are crusted/
Cat bites are of significant concern bc these often
result in deep puncture wounds. Infxn of such
wounds w Pasteurella multocida develops quickly
4317 Pediatrics Infectious Diseases and causes pain, erythema, & swelling. In some
cases - systemic effects (fever, LAD). PPx is
recommended. Tx of minor cat bite wounds -
amoxicillin/clavulanate for 5 days is recommended.
Acute cervical adenitis in children
Unilateral
S aureus, S pyogenes - pronounced erythema,
tenderness - Empiric tx - Clindamycin (active
against MRSA & strep)
Anaerobic bacteria (prevotella buccae) - dental
caries, periodontal disease
Bartonella henselae - papular nodular @ site of
cat scratch or bite
M Avium - Gradual onset, nontender
Bilateral
Adenovirus-pharyngoconjunctivitis
EBV/CMV - Mononucleosis
Cervical ladpy is common in children.
Lymphadenitis is dx when the lymph node is
tender & erythematous in addition to being
enlarged (3-6cm). Ddx narrowed by determining if
the ladpy is acute, subacute/chronic, and if bilat or
unilat. Acute, unilat is usu caused by #1-S aureus,
#2-GAS. Pts w bacterial lymphadenitis are usually
<5yo and nontoxic appearing.
Preseptal (periorbital) - mild infxn of eyelid anterior
to the orbital septum
Orbital (postseptal) cellulitis - serious infxn

posterior to the orbital septum
4845 Pediatrics Infectious Diseases Both have eyelid edema, erythema, tenderness,
fever, and leukocytosis. Orbital (postseptal) is
more serious so it also has ophthalmoplegia, pain
w extraocular mvmnts, +/- proptosis, +/- vision
impairment. When dx is unclear - CT of orbits
helps. Abx - tx for both. Preseptal, PO abx.
Orbital, IV abx + monitoring.
Congenital syphilis is contracted through
transplacental transmission. Most infants born w/
it are asymptomatic. Those w early symps
present w cutaneous lesions on the palms & soles,
HSM, jaundice, anemia, & rhinorrhea. xrays show
metaphyseal dystrophy & periostitis. Late
manifestations (frontal bossing, high arched
palate, hutchinson teeth, interstitial keratitis,
saddle nose) can be prevented w early tx w
parenteral penicillin G
Fever, odynophagia/dysphagia, drooling, neck
stiffness, muffled voice, & trismus - concerning for
infxn of the larynx, pharynx, or deep neck space.
D/t proximity of the airway, spine, & major
vascular structures, infxns in this area are
life-threatening. Inability to extend neck and
widened prevertebral space suggest a dx of
retropharyngeal abscess (RPA). CT w contrast
should be done to confirm presence & size. Early
dx & mgmt are essential.
Herpangina is caused by coxsackie viral infxn and
presents w posterior oropharyngeal
vesicles/ulcerations, fever, and pharyngitis. Tx is
9849 Pediatrics Infectious Diseases supportive w hydration & pain control. In contrast,
herpetic gingivostomatitis presents as clusters of
call vesicles on ANTERIOR oropharynx (tx
acyclovir).
Infection in the retropharyngeal space carries the
highest risk of spread to the medistinum,
particularly the ant and post portions of the sup
mediastinum as well as the entire length of the
posterior mediastinum. Pts w an infection in the
2846 Surgery Infectious Diseases
retropharyngeal space, abscess can form in the
"danger space" which lies between the alar and
prevertebral fascia and drain into the post
mediastinum - acute necrotizing mediastinitis.
Early dx and debridement necessary to tx.
Neck pain, fever, limited neck mobility secondary
to pain should raise concern for a retropharyngeal
abscess. Trisums (inability to open the mouth) and
ltd cervical ext also common. Usual source of infxn
is local penetrating trauma, after instrumentation
or chicken bone injury. CT of the neck and/or
lateral radiographs of the neck can be prfomd -
may demonstrate lordosis of cervical spine w gas
and swelling in retropharyngeal space. Tx is IV
broad-spec Abx and urgent drainage
The timing of fever (immediate, acute, subacute,
delayed0 after surg usually indicates dx. Febrile
nonhemolytic transfusion rxn can occur w/in 1-6
hours of transfusion and can cause immediate
4526 Surgery Infectious Diseases postop fever in pts receiving blood during or after
surgery. Other causes of immediate (within a few
hours) postop fever include prior infxn or trauma,
inflammation due to surg, malignant hyperthermia,
and medications
Fever, leukocytosis, parotid inflammation suggest
acute bacterial parotitis. Dehydrated post-op pts
and elderly are most prone to this infxn. Presents
w painful swelling of the parotid gland aggravated
by chewing. Phs Exam - tender, swollen,
erythematous gland - purulent saliva. MCC - S
aureus. Fluid hydration and oral hygiene pre- and
post-op can prevent this complication.
Infxn of prosthetic jt w/in 3 mo of primary
arthroplasty w wound drainage, erythema,
swelling, and fever - MCC S aureus, gram neg
rods, anaerobes - Tx implant removal/exchange,
9111 Surgery Infectious Diseases debridement & implant retention. Infxn of
prosthetic jt >3 mo after arthroplasty w persistent
jt pain, implant loosening or sinus tract formation -
MCC Coag-neg staph, propionibacterium,
enterococci - Tx Implant removal/exchange.
Pts w non-inflammatory chronic prostatitis are
afebrile and have irritative voiding symps. Physical
exam is unremarkable and urinalysis is normal.
2238 Medicine Male Reproductive System Expressed prostatic secretions show a normal #
of WBCs and cultures is neg for bacteria. Usually
no Hx of past UTI but voiding abnormalities may
be present in the past.
When acute bacterial prostatitis is suspected, the
most appropriate next step is to obatain a
mid-stream urine sample. Prostate massage to
increase Cx yield has been recommended but it's
2246 Medicine Male Reproductive System
painful and may induce bacteremia. Empiric abx w
TMP-SMX or fluoroquinolone should be started
while awaiting culture results, and tx should be
continued for 4-6 wks in most cases.
Common causes of priapism:
1. Sickle cell dz and leukemia - usually in children
or adolescents
2. Perineal or genital trauma - results in laceration
3916 Medicine Male Reproductive System
of the cavernous artery
3. Neurogenic lesions - i.e. spinal cord injury,
cauda equina compression, etc.
4. Medications - trazodone & prazosin
Achilles tendon reflex can decrease or even be
4232 Medicine Male Reproductive System absent with age, can be a normal finding in elderly
patients.
Most cases of hydrocele will disappear
spontaneously by the age of 12 months and can
2373 Pediatrics Male Reproductive System be safely observed during that period. Hydroceles
that do not resolve spontaneously sould be
removed surgically d/t the risk of inguinal hernia.
The normal scrotum is thick and rugated and
contains palpable testes. Testicles that have not
descended by age 6 months are unlikely to
descend spontaneously and require surgery.
Orchoipexy is optimally peformed before age 1
8956 Pediatrics Male Reproductive System
year. Testicular torsion risk is removed as teh
testis is surgically affixed to the scrotal wall but
sperm count and quality remain substandard.
Prepubertal surgery also decr but doesn't
eliminate testicular cancer risk.
HUS - hemolytic anemia, tcpa, acute renal failure.
MC seen in toddlers. >90% of HUS occurs d/t
shiga-toxin producing diarrheogenic pathogens ie
E coli O157:H7 or Shigella. ~10% of HUS d/t S
Miscellaneous pneumo, these pts have pneumonia or meningitis
3438 Pediatrics
(Multisystem) instead of diarrhea. Both cases the toxins enter
the systemic circ and injure endothelial cells in the
kidney. Children have fatigue/lethargy and pallor.
Progressive renal involvement leads to decr UOP
& gross microscopic hematuria.
Duchenne muscular dystrophy should be
suspected in a boy age <5 w proximal muscle
weakness, Gower sign, and bilat calf
pseudohypertrophy. Serum creatine
Miscellaneous
3544 Pediatrics phosphokinase and aldolase levels are elevated
(Multisystem)
even before the manifestation of weakness.
Absent dystrophin gene on genetic testing and
undetectable dystrophin protein on muscle bpsy
confirm dx.
HSP - immune-mediated vasculitis of childhood
that often occurs after mild illnesses ie. upper
RTIs. boys > girls. fall and winter months. Abd
pain, palpable purpura on lower extremities,
Miscellaneous
3554 Pediatrics arthralgias, & renal dz. Pts can have scrotal pain &
(Multisystem)
swelling as initial presenting symps. Presnce of
abd pain should prompt further workup of GI
hemorrhage or intussusception (known
complications of HSP). "Currant jelly stools".
Duchenne muscular dystrophy (DMD) - MC
muscular dystrophy in children. Myopathy presents
@ age 2-5 w bilateral calf pseudohypertrophy and
Miscellaneous
3669 Pediatrics Gower sign. X-linked Recessive transmission.
(Multisystem)
Gold stanadard for dx is genetic testing, which
would show deletion of the dystrophin gene on
Xp21.
Marfan syndrome - AD - mutation in fibrillin-1.
Affected pts have a tall stature; long, thin
extremities; arachnodactyly; joint hypermobility;
upward lens dislocation; & aortic root dilation.
Miscellaneous Congenital contractural arachnodactyly - AD -
3686 Pediatrics
(Multisystem) fibrillin-2 - tall stature, arachnodactyly, multpile
contractures of large jts - Ocular & CV symps not
present in this dz. Ehlers-Danlos - Collagen d/o -
scoliosis, jt laxity, aortic dilation but no tall stature,
lens dislocation or pectus
Prader-Willi
Clinical: hypotonia, weak suck/feeding problems in
infancy, hyper-phagia/obesity, short stature,
hypogonadism, intellectual disability, dysmorphic
Miscellaneous
3821 Pediatrics facies (narrow forehead, almond shaped eyes,
(Multisystem)
downturned mouth)
Dx: Deletions on paternal 15q11-q13
Complications: Sleep apnea (70%), DM2 (25%),
Gastric distension/rupture, Death by choking
McCune-Albright - Precocious puberty, cafe au lait
spots, & multiple bone defects (polyostotic fibrous
dysplasia). 5% of cases of female precocious
puberty. Also assoc w hyperthyroidism, prl or GH
Miscellaneous secreting pituitary adenomas, and adrenal
3871 Pediatrics
(Multisystem) hypercortisolism. McCune-Albright is a sporadic
syndrome attributed to defect in G-protein
cAMP-kinase fxn resulting in autonomous activity
in affected tissue. 3 Ps: Precocious puberty,
Pigmentation, Polyostotic fibrous dysplasia
Kallman syndrome - XLR - d/o of migration of fetal
GnRH and olfactory neurons resulting in
hypogonadotropic hypogonadism and
rhinencephalon hypoplasia. Affted ppl have normal
Miscellaneous
3912 Pediatrics genotype. Congenital absence of GnRH results in
(Multisystem)
short stature and delayed or absent puberty.
Anosmia is a distinguishing feature. Early dx is
important as hormonal tx can help facilitate
development.
Kartagener's syndrome - situs inversus, recurrent
sinusitis, & bronchiectasis. Typical xray shows
Miscellaneous
3974 Pediatrics dextrocardia. Autosomal recessive. Dysmotile cilia
(Multisystem)
from aberrant production or attachment of dynein
arms.
Friedreich Ataxia - MC type of spinocerebellar
ataxia. AR inheritance. Symps begin before age
22. Gait ataxia, frequent falling, dysarthria from
degeneration of spinal tracts (spinocerebellar,
Miscellaneous
3985 Pediatrics posterior columns, pyramidal tract). Concentric
(Multisystem)
HCM, DM, & skeletal deformities (scoliosis,
hammer toes). Median survival after dz onset
rarely >20 yrs. MCC death - Cardiomyopathy &
resp complications. Cardio in 90% of pts.
All sexually active women age </= 24 should be
screened for C trachomatis and N gonorrhoeae by
nucleic acid amplification testing. Athletes w risk
Miscellaneous factors for sudden death should undergo cardiac
4140 Pediatrics
(Multisystem) evaluation, but routine screening is not
recommended otherwise. Random urine tox is
generally not recommended, but the risks of short-
and long-term drug use should be discussed
Webbed neck, carpal and pedal edema, nail
dysplasia, horseshoe kidney, cystic hygroma -
Turner syndrome. These pts can present w
congenital lymphedema because there is abnl
Miscellaneous development of the lymphatic network. The
4764 Pediatrics
(Multisystem) dysfunctional lymphatic system causes
accumulation of protein-rich interstitial fluid in the
hands, feet, and neck. Severe obstruction of
lymphatic vessels can result in cystic hygroma of
the neck and fetal hydrops.
Pts w Turner syndrome are prone to the
development of osteoporosis. In part d/t low
estrogen levels from gonadal dysgenesis. There is
also thought to be increased risk from having only
Miscellaneous
4765 Pediatrics 1 copy of X chromosome genes that may be
(Multisystem)
involved in bone metabolism. Estrogen
replacement therapy is given to nearly all pts to
promote normal maturation, but it also has the
effect of reducing the risk of osteoporosis.
Suspect primary CNS lymphoma in an
HIV-infected pt w an altered mental status, EBV
2276 Medicine Nervous System
DNA in the CSF, and a solitary, weakly
ring-enhancing periventricular mass on MRI.
Tick-borne paralysis is characterized by rapidly
progressive ascending paralysis (which may be
asymmetrical), abscence of fever and sensory
2289 Medicine Nervous System abnormalities, and normal CSF exam. ticks must
feed for 4-7 days and are typically found on the
pts after meticulous searching. Removal of the tick
results in spontaneous improvement in most pts.
Guillain-Barre
Antecedent respiratory or GI infxn
Probable association w certain vaccines
Clinical
Symmetric ascending muscle weakness w absent
or depressed DTRs
Bulbar symptoms (dysarthria & dysphasia)
CN VII palsy
Resp compromise
Mild sensory symps
Autonomic dysfxn (arrhythmias, orthostatic
hypotension, urinary retention, ileus & lack of
sweating)
back & extremity pain
Dx - LP w elevated CSF protein & normal WBC
count (<10mm^3). Electrodx findings consistent w
GBS
Tx IVIG
Lumbar spinal stenosis is MCC by DJD.
"Neuropathic claudications" often used to
described lumbar stenosis. Exacerbation of leg
symps w walking (similar to PVD). However,
unlike PVD, symptoms are positional and remain
while standing still. Pain is relieved by flexion of
the spine. Dx is made based on clinical hx and
classic findings on spinal MRI.
The MC primary sites of origin of brain
metastasis, in order of frequency: Lung, breast,
unknown primary, melanoma, and colon cancer.
Some studies indicate that lung cancer is the
2620 Medicine Nervous System primary tumor in almost 80% of brain metastases.
Brain metastases from breast, colon, and RCC
usually have solitary brain metastases. Lung
cancer and malignant melanoma can present with
multiple brain metastases.
CT of the chest should be done to look for a
2634 Medicine Nervous System thymoma in all newly-diagnosed myasthenia gravis
patients.
CT of brain w/o contrast is initial imaging study of
choice in pts w unprovoked first seizure to exclude
acute neurologic problems (intracranial or
subarachnoid bleed) that might require urgent
intervention. MRI is more sensitive than CT in
identifying most structural causes of epilepsy and
is the neuroimaging modality of choice in elective
situations.
Deep intracranial hemorrhage (eg, basal ganglia,
cerebellum, thalamus, pons) is typically due to
hypertensive vasculopathy; lobar hemorrhage is
more often associated w amyloid angiopathy (esp
in elderly). Eyes may deviate toward the side of
hemiparesis in pts w thalamic hemorrhage, helping
to differentiate it from other sites of intracranial
hemorrhage.
Bell's palsy - sudden onset unilateral facial
paralysis. Inability to raise the eyebrow or close
the eye, drooping of the mouth corner (w the
mouth drawn to the unaffected side), and
disappearance of the nasolabial fold. Pts may also
have decreased tearing, hyperacusis, and/or loss
of taste sensation over the anterior 2/3 of the
tongue. Lesions in the CNS occuring above the
facial nucleus will typically cause a contralat lower
facial weakness that spares the forehead.
Spasticity, bulbar symptoms, and exaggerated
DTRs are signs of UMN lesions. Fasciculations
indicate LMN damage. Weakness and wasting are
common to both UMN and LMN lesions.
Lesion in upper thoracic spinal cord - paraplegia,
bladder and fecal incontinence, absent sensation
from nipple downwards. Lesion in cerebellum -
posterior fossa symps (nausea, vomiting, ataxia).
Lesion in posterior columns - ataxia. Lesion in
lower thoracic cord - absent sensation from
umbilicus downwards. Lesion supratentorially -
partial or complete hemiparesis.
Vasospasm is the major cause of delayed (3-10
days) M&M in SAH and can result in cerebral
infarction. Vasospasm can best be prevented w
initiation of nimodipine. CT angio to detect
vasospasm. Rebleeding is major cause of death in
first 24 hours esp in first 6 hours.
Use MRI to evaluate the spinal cord. Look for cord
2679 Medicine Nervous System compression. Diabetics are prone to epidural
abscesses.
Aminoglycoside - ototoxicity - damage to cochlear
cells - hearing loss - damage hair cells in inner ear
- selective vestibular injury (vestibulopathy - esp
gentamicin) w or w.o ototoxicity. Pts can
experience oscillopsia - sensation of objects
moving around in the visual field when looking in
any direction. Abnormal head thrust test can
detect vestibular dysfxn d/t gentamicin. Pts w
aminoglycoside tox have severe bilat
vestibulopathy, which can lead to chronic symps
Wilson's disease - AR - abnormal copper
deposition in tissues such as liver, basal ganglia,
and cornea. Children and adolescents present w
liver disease (anywhere from asymptomatic
aminotransferase elevations to fulminant hepatic
failure), while young adults have neuropsychiatric
disease (tremor, rigidity, depression, paranoia,
and catatonia). Confirmed by low ceruloplasmin
(<20mg/dL) in conjunction w inc urinary copper
excretion or kayser-fleischer rings.
Creutzfeldt-Jakob dz should be suspected in an
older adult pt (between 50-70) w rapidly
progressive dementia, myoclonus, sharp wave
2990 Medicine Nervous System complexes on EEG, and/or elevated 14-3-3
proteins in CSF. Rapidly progressive course and
prominent myoclonus differentiate CJD from other
causes of dementia.
MMSE score of <24 is suggestive of dementia
(total max is 30). AD presents initially w memory
problems, w symptoms that progress over a
period of years. Socail disinhibition and personality
changes are the early feats in frontotemporal
demential. Neuroimaging may demonstrate
atrophy which is more prominent in the temporal
and parietal lobes in pts w Alzheimer's disease,
although imaging should primarily be used to
exclude alternative causes for dementia.
Hypertensive intracerebral hemorrhage generally
evolves over a course of minutes to hours. 1st -
focal neurologic symps (hemiplegia, hemiparesis,
hemisensory disturbances). Followed by findings
3060 Medicine Nervous System of inc ICP (vomiting, headache, bradycardia, dec
alertness). Ischemic thrombotic - atherosclerotic
RF (TIA, HTN, PVD, DM). Ischemic embolic - Hx
heart dz (Afib, endocarditis), carotid
atherosclerosis, onset is abrupt & maximal at start
Central cord syndrome - hyperextension injuries in
elderly pts w pre-existing degenerative changes in
the cervical spine. This type of traumatic injury
causes selective damage to the central portion of
the anterior spinal cord, spec the central portions
of the corticospinal tracts and the decussating
fibers of the lat spinothalamic tract. CCS -
weakness more pronounced in upper extremities
than lower. Motor fibers serving arms are close to
center of corticospinal tract.
Idiopathic intracranial hypertension (IIH) presents
w headache, vision changes (blurry or double
vision), papilledema, and/or cranial nerve palsies.
CSF shows incrased opening pressure and normal
3081 Medicine Nervous System studies. IIH is MC in young obese women. GH,
tetracyclines (minocycline, doxycycline), and
excessive vit A and it's derivatives (isotretinoin,
all-trans-retinoic acid) can cause IIH. Withdrawal
of these meds leads to symp resolution.
Thiamine deficiency can cause Wernicke's
encephalopathy (WE), the triad of
encephalopathy, oculomotor dysfxn, and gait
ataxia. This condition may be induced
iatrogenically in susceptible pts by administration
of glucose w/o vit B1. Chronic thiamine deficiency
can also cause Korsakoff's syndrome - irreversible
amnesia, confabulation, and apathy.
Idiopathic intracrania htn typically presents in
young, obese women w headache, vision changes
(blurry vision and diplopia), and pulsatile tinnitus.
Dx involves ocular exam, neuroimagine (eg, MRI,
MRVenography), and Lumbar Puncture (LP).
Papilledema is not a contraindication to LP in the
absenceofobstructive/noncommunicating
hydrocephalus or mass lesion. CSF fluid analysis
is normal in IIH w the exception of elevated
opening pressure (>250 mm H2O).
Diffuse axonal injury is the most significant cause
of morbidity in pts w traumatic brain injuries.
Frequently d/t traumatic deceleration injury and
results in vegetative state. Sudden
acceleration-deceleration impact produces
rotational forces that affect the brain areas were
the density difference is max, thus most of the DAI
occur at the gray white matter jxn. CT - blurring of
grey-white interface & numerous punctate
hemorrhages.
Anterior cord syndrome - burst fracture of the
vertebra - total loss of motor fxn below the level of
the lesion w loss of pain and temp on both sides
below the lesion - do MRI to see the extent of
damage
Central cord - burning pain and paralysis in upper
extremities w sparing of lower.
Brown Sequard - ipsilateral motor and
proprioception loss and contralat pain loss below
level of lesion
Cavernous Sinus Thrombosis - facial/ophthalmic
venous system is valveless so infxn can spread
throughout the cavernous signus. This leads to
inflammation which leads to CST and intracranial
3327 Medicine Nervous System htn. MC symp - headache. Vomiting and
papilledema also occur. CN III, IV, V, & VI pass
thru the cavernous sinus. MRI is dx test of choice.
Tx - IV abx, prevention or reversal of cerebral
herniation.
First-line tx for cognitive symps of Alzheimer's
dementia are cholinesterase inhibitors. Donepezil,
galantamine,and rivastimine have been shown to
be effective in pts w mild-to-moderate dementia.
They may improve quality of life and cognitive
fxns. Donepezil is approved for all stages of AD.
Memeantine - NMDA antagonist is approved for
moderate-to-severe dementia.
CJD is characterized by rapidly progressive
dementia, myoclonus and sharp, triphasic,
3374 Medicine Nervous System synchronous discharges on EEG. This spongiform
encephalopathy is caused by a prion. Most
patients die w/in 1 year of symptom onset.
Relapsing-remitting neurologic deficits
(disseminated in space and time) suggests MS.
Autoimmune inflammatory demyelinated disease
of CNS that affects women of childbearing age.
Optic neuritis, diplopia, sensory deficits, motor
weakness, bowel and bladder dysfxn, neuropsych
disturbances. T2-weighted MRI shows multifocal
ovoid subcortical white matter lesions
periventricular, juxtacortical, infratentorial, or
spinal. MRI is test of choice.
Carbamazepine is drug of choice for treating
trigeminal neuralgia
MS presents in the 3rd or 4th decade w recurrent
focal neurologic dysfxn. Attacks are
non-predictable and erratic in presentation. Symps
may last a few weeks w variable recovery. MS is
one of the few conditions that may present w
bilateral trigeminal neuralgia.
Primidone is an anticonvulsant agent, used to tx
benign essential tremors. Its administration can
precipitate acute intermittent porphyria, which can
be diagnosed by checking for urine
porphobilinogen. Primidone is converted into
phenylethylmalonamide and phenobarbital. AIP
manifests as abdominal pain, neurologic and
psychiatric abnormalities.
Amaurosis fugax is the painless loss of vision from
emboli, and is a warning sign for an impending
3528 Medicine Nervous System stroke. Most emboli occur from the carotid
bifurcation; hence, a duplex USG of the neck
should be performed.
Spinal cord compression
-Descending corticospinal tracts (lower-extremity
weakness and loss of rectal tone)
-Ascending sensory spinothalamic tracts (the
sensory level is 2 spinal cord segments below the
level of the lesion)
-Descending autonomics in the reticulospinal tract
(urinary retention/bladder flaccidity/bladder shock)
Mgmt include emergency surgical consult,
neuroimaging, and possibly IV glucocorticoids
IV antiemetics (chlorpromazine, prochlorperazine
or metoclopromide) can be used as monotherapy
or as adjuvant therapy in combination w NSAIDs
3619 Medicine Nervous System or triptans for the tx of actue migraine headaches.
Migraine should be suspected in pts w a unilateral
headache w a pulsatile quality, esp if
accompanied by vomiting and photophobia.
Subarachnoid hemorrhage looks like hyperdense
(bright) areas on CT scan. Nontraumatic SAH is
MC d/t ruptured saccular or berry aneurysms
(>2/3 cases). They occur in 3-4% of the pop but
rarely rupture. Likely to rupture when >7mm &
3622 Medicine Nervous System occur MC in ant circulation of COW. CT scan w/o
contrast is preferred to r/o SAH. Pts w neg CT
scan & suspected SAH should get LP. Elevated
opening pressure and xanthochromia indicate
SAH. Craniotomy w aneurysm clippin, or coiling
and stenting
IIH (pseudotumor cerebri)
-Feats of inc ICP in an alert pt
-Absence of focal neuro signs except for CN VI
palsy
-No evidence for other causes (tumors) or
increased IH on neuroimaging
3637 Medicine Nervous System -Normal CSF exam except inc CSF opening
pressure
Acetazolamide +/- furosemide is 1st-line tx. Optic
nerve sheath decomp or lumboperitoneal shunting
is for pts refractory to meds. Steroids and serial
LPs are not recommened as long-term primary tx
but can be used as briding therapies.
Acute exacerbations of MS are treated w
corticosteroids. Beta-interferon or glatiramer
3643 Medicine Nervous System acetate is used to dec the frequency of
exacerbations in pts w relapsing-remitting or
secondary progressive form of MS.
Total protein concentraion in pts w MS is normal
but immunoglobulin levels are high relative to other
proteins. Mainly IgG but IgM and IgA are
increased too. Oligoclonal bands are present in
85-90% of cases of MS. CSF pressure, protein
and cell ct are grossly normal.
Exertional heat stroke (EHS) - strenuous activity in
hot and humid weather. Body temp >40 w CNS
dysfxn. Humidity >75% overcomes sweat
evaporation - body cant cool. Hypotension,
3691 Medicine Nervous System tachycardia, hypervent, diarrhea, cramps, ataxia.
Hyperthermia can cause rhabdomyolysis, acute
renal failure, and DIC. Mortality of EHS is 20%.
Management involves rapid cooling, preferably ice
water immersion
Aspirin is the only antiplatelet agent that is
effective in reducing the risk of early recurrence of
ischemic stroke. It should eb given w/in 24 hrs to
3712 Medicine Nervous System all patients presenting w ischemic stroke. Aspiring
+ dipyridamole OR clopidogrel is recommended
for patients who have recurrent stroke on aspirin
therapy.
Most effective symptomatic therapy for
parkinsonism is levodopa/carbidopa. The MC early
3715 Medicine Nervous System S/E are hallucinations, dizziness, headache, and
agitation. After several years of therapy,
involuntary movements are more likely to occur.
In a younger patient where tremor is the first
3718 Medicine Nervous System symptom of PD - use an anticholinergic med to
treat the tremor.
Glioblastoma Multiforme - symps of increased ICP
due to the space-occupying lesion. Presnce of
personality changes would localize the lesion to
the frontal lobe. CT/MTI findings of a butterfly
appearance w central necrosis is classic for GBM,
and hetergeneous, serpiginous contrast
enchancement is typical of high-grade
astrocytoma.
Hypertension most important risk factor for
intraparenchymal brain hemorrhage. Focal
neurologic signs develop suddenly and gradually
worsen over minutes or horus. Onset of symps os
not maximal at onset, as in SAH or embolic stroke.
3728 Medicine Nervous System Most htnive hemorrhages (except cerebellar)
occur in the same blood vessels responsible for
lacunar strokes. Basal ganglia (esp putamen),
followed by thalamus, pons, cerebellum, and
cortex. Internal capsule involvement - contralat
hemiparesis
The basal ganglia (putamen) is a common site of
hypertensive intraparenchymal brain hemorrhage.
The internal capsule that lies adjacent to the
3728 Medicine Nervous System putamen is almost always involved, leading to
contralateral hemiparesis, contralateral sensory
loss, and conjugate gaze deviation toward the side
of the lesion.
Dominant frontal lobe lesions can cause
expressive (Broca's) aphasia, contralateral
hemiparesis d/t involvement of the primary motor
cortex, and contralateral apraxia (inability to carry
out learned purposeful movements) d/t
involvement of the supplementary motor cortex.
Patients w acute, severe pain should receieve the
same standard of pain management regardless of
drug history. IV morphine is appropriate tx for
acute, severe pain. Physicians should never
undertreat pain, even if there is a risk of abuse. In
the case of concern for abuse, frequent
reassessment, outpatient follow-up, and referral to
a pain specialist is appropriate.
Lambert-Eaton syndrome is associated w small
cell carcinoma of the lung, and results from
autoantibodies directed against the voltage-gated
calcium channels in the presynaptic motor nerve
3837 Medicine Nervous System terminal. Electrophysiological studies confirm the
dx (the muscle response to motor nerve
stimulation should increase w reptitive stimulation).
Tx - plasmapheresis and immunosuppressive drug
therapy.
15% of pts w myasthenia gravis also have a
thymoma. Thus, whenever a dx of myasthenia
3891 Medicine Nervous System gravis is made, a CT scan of the chest is required
to exclude thymoma, a small percentage of which
may be invasive.
Cluster headache - unilateral, sharp, stabbing pain
in the eye, which wakes him from sleep. Pain
behind the right eye, and spreads to his face and
temple region. Assoc w watering of the eyes and
nose, with red eye. Best treatment is 100%
Oxygen.
Always suspect lacunar stroke if a pt presents w a
ltd neurologic deficit. The typical lacunar stroke
scenarios are pure motor stroke, pure sensory
stroke (thalamus), ataxic-hemiparesis, and
dysarthria-clumsy hand syndrome. The principle
cauase of lacunar stroke is hypertension.
Acoustic neuroma is best diagnosed with MRI w
gadolinium enhancement. Acousti neuromas are
4049 Medicine Nervous System frequently bilateral in patients w neurofibromatosis
type II. Sporadic unilateral acoustic neuroma
usually presents after 40 years of age.
Severe depression esp in older adults may
present w feats similar to dementia and is known
as psudodementia or reversible cognitive
impairment. Pts w this condition will exhibit
4060 Medicine Nervous System difficulties in attention, concentraion, memory, and
executive fxn. Reversible w tx of depression using
meds such as SSRIs. AD the pt doesn't realize
that they have memory loss, they are unconcerned
and confabulate
Surgical resection is recommended for solitary
brain metastasis in pts w good performance
4072 Medicine Nervous System status and stable extracranial dz. In patients w
multiple brain metastases, whole brain radiation
therapy is typically used.
Approx 30% of epileptics will have status
epilepticus (a single seizure lasting >5 minutes).
Brain that has seized for >5 minutes is at
increased risk of developing permanent injury d/t
excitatory cytotoxicity. Cortical laminar necrosis is
the hallmark of prolonged seizures & can lead to
persistent neurologic deficits & recurrent seizures.
MRI - cortical hyperintensity.
HSV encephalitis mainly affects the temporal lobe
of the brain and may present acutely (<1 week
duration) w focal neurological findings-altered
mentation, ataxia, hyperreflexia, focal seizures.
The characteristic CSF findings are lyphocytic
pleocytosis, inc erythrocytes, and inc protein.
Brain imaging shows temporal lobe lesions. MRI
better than CT. Focal EEG occur in >70-80%.
HSV PCR analysis of HSV DNA in CSF is gold
standard for dx. IV acyclovir is tx of choice.
Acute subdural hematoma (SDH), collection of
blood in the subdural space secondary to severe
trauma. Can also occur after minor trauma is the
pt is on anticoags esp aspirin + warfarin. Bleeding
4153 Medicine Nervous System occurs d/t tearing of the bridging veins between
cortex and venous sinuses. Characteristic CT
finding is a semi-lenticular hematoma. MC in
elderly and alcoholics. Pts have brain atrophy, and
superficial bridging veins are stretched.
Criteria for brain death include: 1 evaluating
cortical and brain stem fxns and 2 proving the
irreversibilty of brain activity loss. Brain death is a
clinical dx. Characteristc findings are absent
cortical and brain stem fxns. Spinal core may still
be fxning therefore DTRs may be present.
MC site of ulnar nerve entrapment is the elbow
where the ulnar nerve lies at the medial
epicondylar groove. Prolonged, inadvertent
4170 Medicine Nervous System compression of the nerve by leaning on the elbows
while working at a desk or table is the typical
scenario. Ulnar nerve compression can occur at
the wrist, but is less common.
Dejerine-Roussy syndrome - Thalamic stroke -
Stroke involving VPL of thalamus which transmits
sensory information from the contralateral side of
the body. Classic presentation - contralateral
hemianesthesia accompanied w transient
4203 Medicine Nervous System hemiparesis, athetosis, or ballistic movements.
Dysesthesia of the area affected by sensory loss
is characterisitc, and is called thalamic pain
phenomenon. Stroke internal capusle motor
symptoms. Stroke Midbrain medulla CN
involvement
Cluster headache is characterized by intense
unilateral retroorbital pain which starts suddenly
(usu at night), peaks rapidly, and lasts for ~2 hrs.
MC in men. May be accompanied by redness of
4253 Medicine Nervous System the ipsilateral eye, tearing, stuffed or runny nose,
and ipsilateral Horner's syndrome. The attacks
occur in clusters, daily, for 6-8 weeks followed by
remission for 1 year. PPx - verapamil, lithium,
ergotamine. Tx - 100% O2, subq sumatriptan
Sellar masses:
Benign tumors - pituitary adenoma,
craniopharyngioma,meningioma,pituicytomas
(low-grade glioma)
Malignant tumors - Primary (germ cell tumors,
chordoma, lymphoma), metastatic (breast, lung)
Clinical presentation - diplopia, bitemporal
hemianopsia, vision loss, headache, hormonal
deficiencies, can be found incidentally on brain
imaging
Posterior limb of internal capsule lesion - Unilateral
motor impairment, no sensory or cortical deficits,
no visual field abnormalities
Lesions of MCA - Contralateral sensory and motor
deficits (face, arm & leg), conjugate eye deviation
toward side of infarct, visual field problems,
aphasia (dominant hemisphere), hemineglect
(nondominante hemisphere)
ACA - Sensory and motor deficit lower extremity,
abulia, emotional probs, incontinence
Wallenberg syndrome
Vetibulocerebellar - vertigo, falling to side of
lesion, difficulty sitting upright, diplopia &
nystagmus (h & v), ipsilateral limb ataxia
Sensory symps - Abn facial sensation or pain, loss
of pain & temp in ipsilateral face & contralateral
trunk & limbs
Ispilateral bulbar muscle weakness- dysphagia &
aspiration, dysarthria, dysphonia, hoarseness
(ipsilateral vocal cord paralysis)
Autonomic dsyfxn - Ipsilateral Horner's, intractable
hiccups, lack of respir
Brown-Sequard syndrome - damage to lateral
spinothalamic tracts - contralateral loss of pain
and temp sensation beginning 2 levels below the
level of the lesions (the spinothalamic tracts cross
early on in the spinal cord near where they enter).
Lesion of right-side lateral spinothalamic tract at
T10 -> left-side loss of pain and temp beginning at
T12.
Cerebellar tumor - ipsilateral ataxia. Pt falls
towards the lesion. Pt also tends to sway to the
affected side and may exhibit titubation (forward
and backward movement of the trunk).
4311 Medicine Nervous System Nystagmus, intention tremor, ipsilateral muscular
hypotonia, marked difficulty in coordination and
performing rapid, alternating movements.
Obstruction of the CSF flow results in inc ICP -
headaches, nausea, vomiting, papilledema
Parkinsonism is caused by overactivity of
cholinergic neurons and underactivity of
dopaminergic neurons in the substantia nigra. A
shuffling gait (the patient appears as if he was
chasing his center of gravity) is characteristic of
the disease.
Metclopromide is a DA receptor antagonist used
to tx nausea, vomiting, and gastroparesis. It has
prokinetic properties which include promoting incr
peristalsis, inc strength of gastric contractions and
4366 Medicine Nervous System relaxation of the pyloric sphincter. Common S/E -
agitation, loose stools, EPS (tardive dyskinesia,
dystonic rxns, parkinsonism). NMS may occur. Tx
- DC reglan, admin benztropine or
diphenhydramine.
Acute angle-closure glaucoma commonly occurs
as a response to pupillary dilation from meds
(anticholinergices, sympathomimetics) or another
stimulus (dim light). Pts typically develop unilateral
4367 Medicine Nervous System orbitofrontal headache assoc w nausea/vomiting,
unilateral eye pain w conjunctival injection, and a
dilated pupil w poor light response. Untx pts can
develop permanent vision loss w/in 2-5 hours of
symptom onset.
Epidural abscess presents w fever, focal spinal
tenderness/back pain, and neurologic dysfxn.
Evaluation includes urgent MIR, blood cultures,
4372 Medicine Nervous System inflammatory markers (ESR, CRP) and CT guided
aspiration and culture. Abx along w emergency
surgical decompression and drainage of the
abscess are recommended for most pts.
Both seizures and syncope can cause sudden loss
of consciousness, and it can sometimes be difficult
to distinguish between them. Seizures typically
have a preceding aura, delayed return to
neurologic baseline, head deviation or unusual
body posturing, and tongue laceration. Syncope is
associated w loss of postural tone and
spontaneous return to baseline neurologic fxn.
Pronator drift - close eyes and stretch out arms
with palms facing up.. one of the palms will turn
inward and downward. Relatively sensitive and
specific for UMN lesion. Considered sensitive for
4381 Medicine Nervous System subtle deficits a pt may not notice. UMN causes
weakness in supination resulting in pronator
muscles becoming dominant. In a pt who smokes,
has a sedentary lifestyle, poor diet, and obese a
pronator drift is concerning for a stroke.
Cauda equina syndrome presents w severe lower
back pain w unilateral radiculopathy, saddle
anesthesia, hyporeflexia, profound asymmetric
motor weakness, and late-onset bowel and
bladder dysfxn. Conus medullaris syndrome
4392 Medicine Nervous System presents w severe backpain w a lesser degree of
radiculopathy, perianal anesthesia, hyperreflexia,
mild bilat motor weakness, and early-onset bowel
and bladder disturbances. Mgmt of both d/o
includes emergent MRI, IV gluocorticoids, and
neurosurg eval.
Subdural hematomas are serious intracranial
hemorrhages that occur d/t tearing of briding
4394 Medicine Nervous System veins. Blunt trauma is the MCC, and surgical
evacuation is usually required. MC symps of SDH
are headache and gradual loss of consciousness.
Neurocardiogenic or vasovagal syncope occurs d/t
excessive vagal tone. Episodes are preceded by
nausea, diaphoresis, bradycardia, and pallor.
Pain, stress, and situations that include medical
needles and urination can precipitate vasovagal
syncope.
Parkinson's Disease commonly presents initially w
the tetrad of resting tremor, rigidity, postural
instability, & bradykinesia. Parkinsonian tremors
are more pronounced w distractibility (eg,
performing mental tasks) & re-emergence (tremor
goes away w movement & then re-emerges when
the movement is stopped). PD is d/t progressive
loss of dopaminergic neurons in the basal ganglia
that interrupts neurologic connecxns from the
basal ganglia to the thalamus & motor cortex.
Red as a beet, dry as a bone, hot as a hare, blind
as a bat, mad as a hatter, and full as a flask =
4401 Medicine Nervous System flushing, anhidrosis/dry mouth, hyperthermia,
mydriasis/visionchanges,delirium/confusion,and
urinaryretention/constipation.
In DM, CN III neuropathy is ischemic. Somatic and
PSNS fibers of CNIII have separate blood
supplies. CN III neuropathy affects only somatic
fibers, leaving PSNS fibers intact. Down and out
gaze. Accommodation and pupil's response to light
remain intact.
High-stepping or "steppage" gait due to foot drop.
Foot drop is due to weakness in foot dorsiflexion.
Pts must flex the hip and knee to raise the foot to
avoid dragging the toe w each step. MCC by L5
radiculopathy or neuropathy of the common
peroneal nerve. L5 radiculopathy - back pain
radiating to the foot, w weakness of foot inversion
and plantar flexion. Peroneal neuropathy is due to
compression of th enerve at the lateral aspect of
the fibule. Dx - electromyography n NCS.
Glucocorticoid-induced myopathy is a complication
of chronic corticosteroid use. It is characterized by
painless proximal muscle weakness, which is more
prominent in the lower extremities. There is no
muscle inflammation or tenderness, and creatine
kinase level and ESR are normal.
Glucocorticoid-induced myopathy slowly improves
once the offending medication is discontinued.
BPPV is the MCC of vertigo. It is triggered by
changes in head position, and the dx is confirmed
by the Dix-Hallpike maneuver (vertigo and
nystagmus on quickly lying back into a supine
position w the head rotated 45 degrees).
Dizziness related to CV causes (arrhythmia, aortic
stenosis, hypovolemia) is usually d/t global
cerebral hypoperfusion and presents as
lightheadedness or near-syncope rather than true
vertigo.
Common causes of corneal abrasion include
trauma, foreign body lodging under the lid, and
contact lens use leading to a corneal epithelial
defect. Abrasions can also occur w/o obvious
4461 Medicine Nervous System cornal trauma. Pts typically develop severe eye
pain, photophobia w reluctance to open the eye,
and a sensation of a foreign body in the eye.
Ophthalmic branch of the trigeminal nerve controls
sensation of the cornea.
Muscle weakness can be due to CNS or PNS dz
involving the motor cortex, spinal cord, peripheral
nerve, or muscle itself depnding on the distr of
findings. Myasthenia gravis can cause extra-ocular
muscle weakness (diplopia and ptosis) w
symmetric proximal weakness of the extremities
(upper > lower), neck (flexors and/or extensors),
and bulbar muscles (dysarthria or dysphagia).
Ascending polyradiculoneuropathy - preceded by
URI or diarrheal illness. Typically presents as B/L
leg weakness that ascends to the arms, resp
muscles, and face to generalized flaccid paralysis.
Distal paresthesias are common, but other
4465 Medicine Nervous System sensory symps are uncommon or mild. CSF
shows albuminocytologic dissociation (elev
protein). Gold standard tx - IVIG or
plasmapheresis. Pts should be monitored closely
for risk of resp failure. Most pts take several
months to recover.
Deep lacunar stroke - occlusion of a single deep
penetrating artery in the brain - combination of
microatheroma and lipohyalinosis - usually
thrombotic origin - lacunes are not seen on
noncontrast CT scans obtained during or after the
event bc they too small - MC iste is posterior limb
of internal capsule - where a pure motor stroke
occurs by affecting coritcospinal and corticobulbar
motor fibers - pts have contralateral symps
affecting face, arm and leg equally.
Headaches, focal neurologic deficit, solitary
ring-enhancing lesion on brain CT scna, and a fluid
collection in the ethmoid sinus - development of a
4513 Medicine Nervous System brain abscess secondary to ethmoid sinusitis.
Classic triad of fever, headache, focal neuro sign
present in <20% of cases and only 50% of pts w
a brain abscess will have fever.
The 3 cardinal signs of Parkinson disease are rest
tremor, rigidity, and bradykinesia. The presence of
at least 2 on physical exam is grounds for a
clinical dx.
Tremor: resting 4-6Hz pill rolling, first in 1 hand
then in other
Rigidity: baseline inc resistance to passive
movement about a jt which may be uniform (lead
pipe) or oscillating (cogwheel)
Bradykinesia: difficult initiating movements
Postural instability: flexed axial posture, loss of
balance, frequent falls
Alcoholic cerebellar dysfunction - gait instability,
truncal ataxia, difficulty w rapid alternating
4618 Medicine Nervous System movements, hypotonia, intention tremor. This
cerebellar degeneration is not associated with
hearing loss.
Lewy body dementia - alterations in
consciousness, disorganized speech, visual
hallucinations, EPS, early compromise of
executive fxns. Autopsy - Lewy Bodies -
4619 Medicine Nervous System eosinophilic intracystoplasmic inclusions -
alpha-synuclein - seen in substantia nigra, locus
ceruleus, dorsal raphe, and substantia innominata.
Tx - acetylcholinesterase inhibitors - rivastigmine.
It's like Parkinsons with early dementia.
Alzheimer's dz is MC type of dementia in the US -
memory and visuospatial impairments. Ddx
includes vascular dementia and Lewy body
4620 Medicine Nervous System dementia. Gait impairment is most prominent early
clinical feat of NPH but is a later finding in
Alzheimer's dementia. NPH doesn't have cortical
feats like aphasia or agnosia but AD does.
Toxic-metabolic and infectious etiologies are MCC
of delirium in a hospitalized patient. Pts w
dementia have an inc risk of developing agitated
4622 Medicine Nervous System delirium in the hospital. Typical and atypical
antipsychotics are useful for tx acute agitation in
elderly pts w dementia. Benzos are not
recommended.
The prevailing theory for the pathogenesis of NPH
is that patients have a transient increase in ICP
that causes ventricular enlargement. After the
4651 Medicine Nervous System ventricles enlarge, the presure returns to normal.
The initial increase in ventricular size may be d/t
either diminished CSF absorption at the arachnoid
villi or obstructive hydrocephalus.
Epidural Spinal Cord Compression (ESCC) -
malignancies which affect the spine (lung, renal,
breast, prostate, and MM) - thoracic spine MC
affected level (60%), followed by lumbar spine
4691 Medicine Nervous System (30%) - Progressively worsening back pain - usu
worse in recumbent position (distention of the
epidural venous plexus when lying down). B/L
lower extremity weakness is present in 60% of
pts.
WE - encephalopathy, ocular dysfxn, gait ataxia.
Giving thiamine promptly may prevent further
complications. Thiamine should be given before
glucose.
New-onset neurologcial deficits, occipital
headache, and PMH of vascular disease, htn, afib
raise suspicion for stroke. Whenever stroke is
4702 Medicine Nervous System suspected clinically, non-contrast head CT must
be performed. Ischemic stroke - thrombolytic
therapy, pts w ICH - neurosurg eval, no
thrombolytics,antihypertensives.
Acute confusion, extreme hyperthermia >40.5
degrees celsius, tachycardia, and coagulopathic
bleeding after heavy work under direct sunlight are
4703 Medicine Nervous System most likely d/t exertional heat stroke. Malignant
hyperthermia affects genetically susceptible
individuals during anesthesia involving agents like
halothaneandsuccinylcholine.
Intracranial HTN - headache (worse at night),
nausea/vomiting, mental status changes.
Papilledema and focal neurologic deficits may be
4708 Medicine Nervous System seen on exam. Cushing reflex (hypertension,
bradycardia, respiratory depression) is a
worrisome finding suggestive of brainstem
compression.
Increased ICP -> optic nerve sheath -> swelling of
the optic nerve head -> papilledema on
ophthalmologic exam - optic disc swelling.
Papilledema presents with transient vision loss
lasting a few seconds and changes in head
position. It requires urgent diagnositc evaluation
(ophthalmologic exam, neuroimaging, and/or LP)
as persistent papilledema can lead to vision loss.
Essential tremor is characterized by a fine tremor
that is typically suppressed at rest and
exacerbated at the end of goal-directed
4913 Medicine Nervous System movements. MC in the upper extremities but is
highly variable and may affect any part of the
body. It is usually not asociated w ohter neurologic
symps.
Tx of essential tremor typically begins w a
beta-blocker propanalol, which is esp helpful if the
pt also has coexistent htn. Other tx possibilies
4914 Medicine Nervous System include anticonvulsants, i.e. primidone and
topiramate. Although benzos can reduce the
symps of essential tremor, their use should be
restricted d/t the potential for dependence.
Vascular Dementia (VaD) - sudden change in fxnal
status starting after an unprovoked fall. Stepwise
decline - some improvement followed by another
fall and subsequent mood problems and urinary
10348 Medicine Nervous System incontinence. Early mild forgetfulness. Risk factors
for stroke (HTN, HLD, DM) and focal neurologic
findings. Neuroimaging shows cerebral infarction
and/or deep white matter changes from chronic
ischemia.
Dementia
AD - early short term memory loss, language
deficits, spatial disorientation, personality changes
Vasc - Stepwise decline, early executive dysfxn,
cerebral infarction &/or deep white matter changes
Frontotemporal - early personality changes,
10448 Medicine Nervous System apathy, disinhibition, comuplsivity, frontotemporal
atrophy
Lewy body - visual hallucinations, parkinsonism,
fluctuating cognition
NPH - wobbly (early), wet, wacky
Prion - Behavioral changes, rapidly progressive,
myoclonus
CTX-induced peripheral neuropathy (CIPN) -
commonly caused by platinum-based meds
(cisplatin) and taxanes (paclitaxel). Neuropathy
starts after weeks of tx and presents as
10477 Medicine Nervous System symmetrical paresthesias in fingers and toes
spreading proximally in a stocking-glove pattern.
Loss of ankle jerk reflexes, loss of pain and temp
sensation. Sometimes - motor neuropathy
resulting in weakness and bilat foot drop.
Tx of septic embolism stroke should be aimed at
tx the infection. IV Abx significantly reduce the risk
of septic cardioembolism w/in weeks of initiating
therapy; therefore, the most appropriate next step
10972 Medicine Nervous System in mgmt is to contine care with observation. Aortic
valve surgery can be considered if there is
significant valvular dysfxn resulting in heart failure,
if the infxn is persistent or difficult to tx medically,
or if septic embolization is recurrent.
Traumatic Brain Injury of any severity can lead to
(few hours-days later) postconcussive syndrome -
headache, confusion, amnesia, difficulty
concentrating or w multitasking, vertigo, mood
11557 Medicine Nervous System alteration, sleep disturbance, and anxiety. These
symps resolve w symptomatic tx w/in a few
weeks to months following TBI; however some pts
may have persistent symps lasting > or = 6
months.
The initial diagnostic workup of a first-time seizure
in an adult should include basic blood tests (eg,
serum electrolytes, glucose, calcium, magnesium,
11982 Medicine Nervous System CBC, renal and liver fxn tests) and a toxicology
screen to evaluate for metabolic and toxic causes.
Unprovoked seizures generally require further eval
w neuroimaging and EEG.
Presbycusis (age-related hearing loss) -
progressive bilateral symmetric and predominantly
high-frequency sensorineural hearing loss that
occurs over many years. Condition affects >50%
of all adults by age 75 and is d/t degenerative
changes of inner ear or cochlear portion of CN
VIII. Pts w presbycusis often hear well in
one-on-one conversations in a quiet room but
difficulty hearing even if a small amt of competing
noise is present.
Myasthenia gravis
Women: 2-3rd decade
Men: 6-8th decade
S/S: Fluctuating & fatigable proximal muscle
weakness; worse later in the day
Ocular (diplopia, ptosis)
Bulbar (dysphagia, dysarthria)
Respiratory muscles (myasthenic crisis)
12028 Medicine Nervous System Dx.
Bedside: edrophonium ("Tensilon") test, ice pack
test
AchR antibodies (highly specific)
CT scan of chest to evaluate for thymoma
Tx.
AchE inhibitors (pyridostigmine)
+/- Immunotherapy (corticosteroids, azathioprine)
Thymectomy
Duringpregnancy:
Phenytoin or carbamazepine use - fetal hydantoin
syndrome - midfacial hypoplasia, microcephaly,
cleft lip and palate, digital hypoplasia, hirsutism
and developmental delay
Obstetrics
Syphillis - rhinitis, HSM, skin lesions, interstitial
2572 & Nervous System
keratitis, hutinson teeth, saddle nose, saber shins,
Gynecology
deafness, CNS involvement
Alcohol - midfacial hypoplasia, microcephaly,
stunted grwoth, hyperactivity, mental retardation,
learningdisability
Cocaine - placental abruption
Absence (petit mal) seizures - daydreaming
episodes, brief staring spells, declining school
performance. Absent warning and postictal
phases, unresponsiveness during the seizure, and
no memory of what just occured after the seizure.
2279 Pediatrics Nervous System
Classic EEG - Generalized, symmetrical 3-Hz
spike-and-wave activity on a normal background
(finding is provoked by hyperventilation of the pt
during EEG). Occur in children 4-8. Tx is
ethosuximide or valproic acid.
Seizures are focal or generalized w and w/o LOC.
Focal can be motor, sensory-paresthesias, or
autonomic-sweating. Focal w LOC can't respond
to stimuli, w/o LOC remain alert, awake,
responsive. Automatisms, repetitive
semi-purposeful mvmnts, involve both hemispheres
and seen only in focal seizures w LOC. EEG
shows abnl activity that's sustained w distinct start
n stop diff from background EEG. Focal seizures
not provoked by hyperventilation.
Focal Seizure
Originates from 1 cerebral hemisphere
+/- LOC
Types
2280 Pediatrics Nervous System Motor: Jacksonian march, turning of
eyes/head/trunk
Sensory: Paresthesias, vertigo, visual phenomena
Autonomic: Sweating, epigastric "rising" sensation
Psychic: Deja vu, affective changes (eg, fear)
Friedrich Ataxia. AR inheritance. Trinucleotide
repeat sequences, abnl tocopherol transfer
protein. D/O is progressive w poor prognosis.
Most pts are wheelchair bound by age 25, w
death occurring by 30-35 years. FA is assoc w
necrosis & degeneration of cardiac muscle fibers
leading to myocarditis, myocardial fibrosis, and
cardiomyopathy. Ddx T-wave inversion: MI,
myocarditis, old pericarditis, myocardial contusion,
digoxin toxicity.
Fragile X syndrome - large head, long face,
prominent forehead & chin, protruding ears, joint
laxity, large testes. Behavioral abnlties, short
attention span, and autism, are common. The
syndrome results from a full mutation in the FMR1
gene caused by incr $ of CGG trinucleotide
repeats accompanied by aberrant methylation of
FMR1 gene.
Long-term neurologic sequelae assoc w bacterial
meningitis are:
1. Hearing loss
2. Loss of cognitive fxns (due to neuronal loss in
the dentate gyrus of the hippocampus)
3. Seizures
4. Mental retardation
5. Spasticity or paresis
Cerebral Palsy
Prematurity
IUGR
IUinfxn
Antepartum hemorrhage
Placental pathology
2443 Pediatrics Nervous System Multiple gestation
Maternal alcohol consumption
Maternal tobacco use
MGMT - Physical, occupational & speech
therapies. Baclofen & botox for spasticity.
Comorbidities - Intellectual disability, epilepsy,
strabismus, scoliosis
Cerebral Palsy
RF: Prematurity, IUGR, IU infxn, Antepartum
hemorrhage, Placental pathology, Multiple
gestation, Maternal alcohol consumption and/or
2443 Pediatrics Nervous System tobacco use
Mgmt: Physical, occupational & speech therapies.
Baclofen & botulinum toxin for spasticity
Comorbidities: Intellectual disability, epilepsy,
strabismus, scoliosis
Fetal Alcohol Sydrome - Smooth philtrum, thin
vermillion border, small palpebral fissures,
microcephaly
Down syndrome - Flat facial profile, slanted

palpebral fissures, small low-set ears.
2444 Pediatrics Nervous System Body - Excessive skin at nape of the neck, single
transverse palmar crease, clinodactyly, large
space bt first 2 toes
Fragile X syndrome - Long narrow face, prominent

forehead & chin, large ears, macrocephaly.
Body - Macroorchidism
Niemann-Pick - Sphingomyelinase deficiency - AR
inheritance, Ashkenazi Jewish heritage - Age 2-6
months - Loss of motor milestones, hypotonia,
feeding difficulties, "cherry-red macula", HSM,
AREFLEXIA
Tay-Sachs - B-hexosaminidase A deficiency - AR
inheritance, Ashkenazi Jews - Age 2-6 months -
Loss of motor milestones, hypotonia, feeding
difficulties, "cherry-red macula", HYPERREFLEXIA
Highest incidence of botulism is in Cali, Penn, &
Utah which have the greatest concentration of soil
botulism spores. Ingestion of inhaled botulism
spores from environmental dust (construction
sites) -> colonic colonization. Botox blocks
acetylcholine release at presynaptic NMJs. Dx
should be suspected in infants w bilateral bulbar
palsies followed by descending flaccid paralysis.
Constipation & drooling occur d/t autonomic
dysfxn. Tx - Resp support, NG tube feeding & IVIG
Cephalohematoma - Subperiosteal hemorrhage;
hence it is always limited to the surface of one
cranial bone. There is no discoloration of the
overlying scalp and swelling usually not visible until
several hours after birth bc subperiosteal bleeding
is slow. Most cases require no tx and resorb w/in
2wks to 3mnths. Rarely phototherapy may be
necessary to improve hyperbilirubinemia.
Craniopharyngioma
Low-grade malignancy derived from remnants of
Rathke pouch
Optic chiasm compression -> bitemporal
hemianopsia
Pituitary stalk compression -> endocrinopathies
(eg, GH deficiency, DI)
Suprasellar, calcified mass on imaging
The characteristic feats of neurofibromatosis 1
include cafe-au-lait spots, macrocephaly, feeding
2669 Pediatrics Nervous System problems, short stature, and learning disabilities.
Pts may later develop fibromas, neurofibromas or
different tumors.
LOC is seen w complex partial seizures & partial
seizures w secondary generalization but not
simple partial seizures. Pts w complex partial
seizures typically have automatisms during their
LOC; these activities include chewing, picking
movements of the hands, and lip smacking.
Sturge-Weber - focal or generalized seizures,
mental retardation, port wine stain (nevus
flammeus) along the territory of the trigeminal
nerve, which represents a congenital unilateral
cavernous hemangioma. Seizures are the usual
2763 Pediatrics Nervous System neurologic presentation and may start @ any age.
Hemianopia,hemiparesis,hemisensory
disturbance & ipsilateral glaucoma. Skull x-rays,
taken after age 2 show gyriform intracranial calcs
that resemble a tramline. Tx - antiepileptic & IOP
control.
Phenylketonuria
AR inheritance - mutation in phenylalanine
hydroxylase. Failure to convert phenylalanine into
tyroine results in hyperphenylalaninemia &
neurologic injury
3123 Pediatrics Nervous System Clinical - Severe intellectual disability, seizures,
musty body odor, hypopigmentation of skin, hair,
eyes & brain nuclei
Dx - newborn screening (tandem mass spec),
quantitative amino acid analysis (inc phenylalanine)
Tx - Strict diet
G-6-phosphatase deficiency (Von-Gierkes') - 3-4
month old pt w hypoglycemia, lactic acidosis,
hyperuricemia, & HLD. Hypoglycemic seizures
3192 Pediatrics Nervous System occr. Doll like face (fat cheeks), thin extremities,
short stature, and a protuberant abdoment (d/t
enlarged liver & kidneys). Spleen & heart are
normal.
Mild TBI (eg, concussion) - head injury that is
assoc w a GCS of 13-15, LOC <5 mins,
headache, loss of memory before/after injury <24
hrs, AMS at time of injury, and/or vomiting.
Head CT w/o contrast is the 1st-line imaging
3218 Pediatrics Nervous System modality in the ED. Neuroimaging results are often
normal but should be considered bc of overlapping
clinical feats w serious TBI (headache, vomiting,
LOC). Observation 4-6 hrs in ED is alternative
option. Pt can be DCd if nothing happens w return
precauti
Non-accidental trauma
Hx - Vague or changing details, injury inconsistent
w child's dvlopmntl stage, sibling described as
responsible
Exam - Injury inconsistent w hx, mltple fractures or
3396 Pediatrics Nervous System bruises in different healing stages, likely inflicted
injuries (cig burn), poorly kempt child, bruises on
neck, abd, or unusual sites
Caregiver behavior - Argumentative or violent, lack
of emotional intaxn, inapp response to child, delay
in seeking med care, partial confession
NF1 (von Recklinghausen dz) - NF1 tumor
suppressor gene; codes the protein neurofibromin
- chromosome 17 - Cafe-au-lait spots (earliest
manifestation), multiple neurofibromas (benign
peripheral nerve sheath tumors), lisch nodules (iris
3550 Pediatrics Nervous System hamartomas). Optic pathway glioma is MC type of
intracranial lesion. MRI of brain and orbits.
NF2 (central neurofibromatosis) - NF2 tumor

suppressor gene; codes the protein merlin -
chromosome 22 - Bilateral acousic neuromas
IVH is MC seen in premature and LBW infants.
Pts may present w pallor, cyanosis, hypotension,
seizures, focal neurologic signs, bulging or tense
3657 Pediatrics Nervous System fontanel, apnea and bradycardia; however, many
cases remain asymptomatic, thus mandating
transfontanel USG for all newborns w
predisposing risk factors.
Myotonic muscular dystrophy
AD - expansion of CTG repeat in DMPK gene on
chromosome 19q 13.3
Clinical
Onset: age 12-30
Facial weakness, hand grip, myotonia, dysphagia.
Comorbidities
Arrhythimias, cataracts, balding, testicular
atrophy/infertility
Prognosis
Death from respiratory or heart failure depending
on age of onset
Guillain-Barre syndrome - acute ascending
polyneuropathy after a recent upper RTI or GI
infxn. Pathophys - demyelination of peripheral
motor nerves (sensory and autonomic may also be
affected). Pt usually has ascending weakness
3664 Pediatrics Nervous System accompanied by feet tingling (pins n needles) &
neuropathic pain. Weakness begins in lower
extremities & spreads to trunk, upper extremities,
& bulbar & resp muscles. The final stage is flaccid
paralysis w absent DTRs & nerve conduction
studies
Complications of prematurity
Respiratory distress sydnrome
PDA
Bronchopulmonary dysplasia
Necrotizingenterocolitis
Retinopathy of prematurity
Interventricular hemorrage -lethargy, hypotonia,
high pitched cry, bulging fontanels, rapidly incr HC
- common in neonates <30 wks or <1500 g.
Capillary fragility of the subependymal germinal
matrix & immature autoregulation of cerebral blood
flow. Need seriel head USG.
Medulloblastoma, the 2nd MC (cerebellar
astrocytomy #1) infratentorial tumor in children,
arises from the vermis. It represents 7% of
primary brain tumors. Highly radiosensitive & can
metastasize through the CSF tract. >90% of
medulloblastomas develop in the vermis. Posterior
vermis syndrome - truncal ataxia, unbalanced gait,
horizontal nystagmus
Migraine headaches are the MCC of acute &
recurrent headaches in pediatric population. They
present w unilateral or bifrontal pain; photophobia;
3672 Pediatrics Nervous System phonophobia; nausea; vomiting; & a visual,
auditory, or linguistic aura. 1st line tx in children
includes acetaminophen, NSAIDs, & supportive
mgmt. Triptans may be tried if these don't work.
Homocystinuria - AR inheritance - cystathione
synthase deficiency. Marfanoid body habitus -
intellectual disability, downward lens dislocation &
hypercoagulability. Tx vitamin supplementation
(B6, folate, B12) & antiplatelet or anticoagulation
to prevent thromboembolic events.
Self-mutilation + dystonia - Lesch-Nyhan. XLR (all
victims are male). Deficiency of HGPRT.
Deficiency results in incr Uric acid and consequent
accumulation in tissue. Presents around age 6
months w hypotonia & persistent vomiting. Clinical
picture worsens thereafter, w progressive mental
retardation, choreoathetosis, spasticity, dysarthric
speech, dystonia and compulsive self-injury. Gouty
arthritis, tophus formation, obstructive
nephropathy. Tx. Allopurinol + fluids.
Neuroblasoma is the 3rd MC cancer in kids (after
leukemia, and CNS tumors). The tumor arises
from the neural crest cells, which are also the
precursor cells of the sympathetic chains and
3824 Pediatrics Nervous System adrenal medulla. The MC site is the abdomen.
Calcifications and hemorrhages are seen on plain
X-ray and CT scan. The levels of serum and urine
catecholamines and their metabolites (HVA &
VMA) are usually elevated.
Children who have trauma to the soft palate w a
sharp object can either compress the ICA (causing
a thrombosis that embolizes to the brain & causes
stroke) or dissect the ICA (leading to ischemic
4117 Pediatrics Nervous System stroke). Onset of symps can be delayed up to 24
hrs. Dx - clinical and confirmed w imaging, ie
MRI/MRA of the brain. Tx - controversial & ranges
from close observation w supportive care to
aggressive tx w anticoagulation.
CT is significantly faster and more readily
available on an emergency basis. CT is better at
depicting bone. MRI is superior for soft-tisse
4248 Pediatrics Nervous System details and does not use ionizing radiation. MRI is
more sensitive for early cerebritis and is better at
delineating the extent of ring enhancement and
differentiating between edema & necrosis.
After the dx of GBS is suspected, the most
important next step in mgmt is assessing PFT w
serial spirometry. Measurement of FVC is the gold
standard for assessing ventilation; a decline in
4271 Pediatrics Nervous System FVC )esp </= 20ml/Kg) indicates impending
respiratory arrest requiring endotracheal
intubation. W early dx & cardiopulmonary support
most young pts have a good prognosis
experiencing spontaneous recovery w/in a year
Febrile seizure
Fever from mild viral (influenza, adenovirus, HHV6)
or bacterial infxn
Immunizations (DTaP, MMR)
Family hx
Dx. Age 6mo-6yrs, Temp >/= 30, No hx of afebrile
seizures, No CNS infxn, No acute systemic
metabolic cause
Subtypes
Simple: Nonfocal (tonic-clonic or atonic), 1
episode <15 mins or multiple episodes <30 mins
Complex: Focal, 1 episode >15 mins or multiple
>30 mins
Mgmt: Abortive therapy if seizure >/= 5 mins,
Reassurance/education
Prognosis: Normal
RF for brain abscess
Otitis media, mastoiditis - direct spread - temporal
lobe, cerebellum
Frontal or ethmoid sinusitis - direct spread - frontal
lobe
Dental infxn - direct spread - frontal lobe
4865 Pediatrics Nervous System Bacteremia from other sites of infxn, cyanotic
heart disease - hematogenous spread - multiple
abscesses along distribution of middle cerebral
artery (gray-white matter jxn)
Brain abscess - fever, severe headaches
(nocturnal or morning) & focal neurologic changes.
Seizures in 25%.
Infants w hydrocephalus
Symps
Poor feeding
Irritability
Decreased Activity
Vomiting
Phys exam
Tense and bulging fontanelle
Prominent scalp veins
Widely spaced cranial sutures
Rapidly increasing head circumference
Best dx approach is imaging. CT of brain is best

choice in an infant who's acutely symptomatic.
Tx - shunt placed from the ventricle to the
peritoneum, pleura, or right atrium; allows excess
CSF to drain rather than collect in ventricles.
Breath-holding spells
Benign and occur in children aged 6mo - 2yrs.
Clinical:
Cyanotic - crying followed by breath-holding in
forced expiration, apnea, cyanosis, limpness &
LOC
Pallid - Minor trauma followed by LOC,
breath-holding, pallor & diaphoresis
Evaluation:
CBC, Serum Ferritin
Epidural hematoma (football shaped) - CT of the
head is dx test of choice. GCS < 8, signs of
4923 Pediatrics Nervous System increased ICP, pupillary abnormalities,
hemiparesis, or cerebellar signs - indications for
emergent craniotomy
Sleep patterns tend to change in older individuals.
As people age, they typically sleep less at night
and nap during the day. The period of deep sleep
(stage 4 sleep) becomes shorter and eventually
2350 Psychiatry Nervous System
disappears. Older people also awaken more
during all stages of sleep. These changes are
normal and usually do not indicate a sleep
disorder.
Neuroimaging studies have frequently reported
loss of cortical tissue volume w ventricular
enlargement in a subset of patients w
schizophrenia, w lateral ventricular enlargement
being the most widely replicated finding.
Decreased volume of amygdala and left temporal
lobe has - panic disorder. Decreased volume of
hippocampus - PTSD. Increased total brain
volume - Autism. Structural abnormalities in the
orbitofrontal cortex and basal ganglia - OCD.
Benzodiazepines should be used sparingly in the
elderly d/t increased risk of adverse effects. As
ppl age, they metabolize benzos more slowly and
are more likely to experience confusion &
increased risk of falls. There is also paradoxical
agitation - increased agitation, confusion,
aggression, and disinhibition typically w/in an hour
of administration
Bupropion lowers the seizure threshold. A hx of
seizure d/o is an absolute contraindication to the
use of bupropion. Individuals with anorexia or
3702 Psychiatry Nervous System buliumia nervosa frequently develop electrolyte
abnormalities that can precipitate seizures.
Therefore, a h/o anorexia nervosa/bulimia is also a
contraindication to bupropion usage.
Mesolimbic pathway - Positive symptoms.
Dopamine antagonism here accounts for the
therapeutic effects of antipsychotics. Mesocortical
pathway - Negative symptoms. 5-HT antagonism
here increases dopamine and relieves the negative
symptoms.
Diagnostic test of choice after someone has blunt
trauma to the head is CT scan, which can show a
biconvex hematoma (FOOTBALL SHAPE!) that
3297 Surgery Nervous System does not cross the suture lines. Emergent
craniotomy should be performed in pts w focal
neurologic symps or signs to prevent brain
herniation or injury.
The femoral nerve innervates the muscles of the
anterior compartment of the thigh, thus is
responsible for knee extension and hip flexion. The
femoral nerve provides sensation to the anterior
thigh and medial leg via the saphenous branch.
4293 Surgery Nervous System
Tibial nerve - muscles of the post compartment of
the thigh, leg, and plantar muscles of the foot -
knee flexion and plantar flexion - sensation to the
leg (except medial side) and plantar foot. Fibular
nerve = common peroneal nerve.
Epidural hematoma can rapidly expand and
compress the temporal lobe. The uncus is the
innermost part of the temporal lobe and herniates
through the tentorium to cause pressure on the
ipsilateral oculomotor nerve, ipsilateral posterior
cerebral artery, and contralateral cerebral
peduncle against the edge of the tentorium.
Presence of HTN, bradycard, and respiratory
depression (Cushing's reflex) indicates elevated
ICP.
3-4% of pts w spinal cord injuries will develop
post-traumatic syringomyelia. Whiplash is often
the inciting injury. Sxs develop months to years
later. The condition involves enlargement of the
central canal of the spinal cord due to CSF
retention, resulting in impaired strength and
pain/temp sensation in the upper extremities. MRI
is used for definitive dx.
The presence of extra-axial well-circumscribed or
round homogenously enhancing dural-based mass
on MRI is strongly suffestive of a meningioma.
These tumors undergo calcification and can
appear hyperdense on non-contrast head CT.
11997 Surgery Nervous System Benign primary brain tumors that arise from
meningoepithelial cells, MC found in middle-age to
elderly women. Cause headache, seizure, focal
weakness/numbness. Dx is confirmed
intraoperatively. Tx complete resection leads to
cure in most individuals.
External hordeolum or stye is a common staph
abscess of the eyelid. It is tx w warm
compresses. Incision and drainage is performed if
resolution doesn't begin in 48 hrs. Incision and
2374 Medicine Ophthalmology
curettage is the tx of choice for chalazion, which is
granulomatous inflammation of meibomian gland.
Abx may be indicated such as bacitracin or
erythromycin.
Angle closure glaucoma - closure of a pre-existing
narrow anterior chamber angle. Ppl 55-70. Severe
eye pain and blurred vision, assoc. nausea and
vomiting. Occurs following pupillary dilation
-occuring in darkened movie theaters, times of
stress, or drug intake. Red eye w steamy cornea
and moderatly dilated pupil - non reactive to light.
Ant chamber is shallow w inflam changes.
Tonometry revels inc IOP. IV acetazolamide
lowers IOP. Cure - laser peripheral iridotomy.
Herpes zoster ophthalmicus - infxn caused by
VZV. Occurs in old ppl and immunocompromised.
VZV latent in trigeminal ganglion. Virus can travel
via the ophthalmic branch to the forehead and eye.
Symps become manifest thereafter w fever,
malaise and a burning, itching sensation in the
periorbital region. Exam reveals vesicular rash in
the dermatomal branch of CN V1. Conjunctivitis
and dendriform corneal ulcers characterize eye
involvement. Tx w/in 72hrs w high-dose acyclovir
Hypertensive pt w temporary vision loss -
amaurosis fugax (Greek: amaursosis [darkening])
(Latin: fugax [fleeting]). MC d/t retinal emboli from
the ipsilateral carotid artery, generally d/t
atherosclerosis. Once the clot is displaced or
breaks up, blood flow is restored and vision
returns. Funduscopic findings depend on
underlying cause, and exam may be normal or
show zones of whitened retina (from edema)
following distribution of retinal arterioles.
The 3 main causes of diabetic retinopathy are
background or simple (microaneurysms,
hemorrhages, exudates, retinal edema),
pre-proliferative (cotton wool spots), and
proliferative or malignant (neovascularization).
Visual impairment occurs w the dvlopment of
macular edema. Argon laser photocoagulation is
performed for the prevention of complications.
Acute angle-closure glaucoma is characterized by
sudden-onset eye pain, headache, and nausea.
Signs may include conjunctival erythema, corneal
opacification, and a mid-dilated pupil. Gonoiscopy
is the gold standard for dx. Ocular tonometry can
be helpful if urgent ophthalmological consultation is
unavailable. Fluorescein staining of the eye is used
to detect corneal abrasions or herpes keratitis.
In AIDs pts opportunistic infxns cause retinits. VZV
and HSV can cause sever intraocular
inflammation. HSV retinitis - rapidly progressing
bilateral necrotizing retinitis (acute retinal necrosis
syndrome). Keratitis and conjunctivitis w eye pain,
followed by rapidly progressive visual loss. HSV
infxn is MCC of corneal blindness in the US. CMV
retinitis is MC serious ocular comp in HIV + pts.
Painless, funduscopy - fluffy or granular retinal
lesions near retinal vessel
Conjunctivitis tx
Bacterial - Erythromycin ointment,
polymyxin-trimethoprim drops, Azithromycin drops,
Preferred agent in contact lens wearers:
fluoroquinolone drops
8925 Medicine Ophthalmology Viral - Warm or cold compresses, +/-
Antihistamine/decongestant drops
Allergic - OTC antihistamin/decongestant drops for
intermittent symps, mast cell
stabilizer(olopatadine,azelastine)/antihistamine
drops for frequent episodes
Painful, red eye and opacification and ulceration of
the cornea has typical feats of contact lens-assoc
keratitis. Most cases d/t Gram neg organisms
such as Pseudomonas and Serratia. Can be gram
8926 Medicine Ophthalmology + like fungi and amoebas. Contact lens-assoc
keratitis is a medical emergency and can lead to
corneal perf, scarring,and permanent vision loss.
Tx removal of contact + topical broad-spectrum
Abx.
Trachoma - Chlamydia trachomatic A-C. Major
cause of blindness worldwide. Active phase of the
disease is characterized by follicular conjunctivitis
and pannus (neovascularization) formation in the
cornea. Concurrent infxn in the nasopharynx leads
2857 Pediatrics Ophthalmology
to nasal discharge. The dx can be made by
Giemsa stain exam of conjunctival scrapings.
Topical tetracycline or oral azithromycin should be
started immedately. Repeated infxns can lead to
scarring of the cornea.
Copious purulent drainage & eyelid swelling in a 2-
to 5-day-old newborn are most consistent w
gonococcalconjunctivitis.Gonococcalconjunctivitis
3329 Pediatrics Ophthalmology can be prevented w application of topical
erythromycin ointment within 1 hour of birth.
Conjunctivitis caused by Chlamydia is usually
milder and presents 5-14 days after birth.
Every case of leukocoria is considered a
retinoblastoma - promptly refer to an
ophthalmologist. Retinoblastoma is the MC
intraocular tumor of childhood. Inactivation of the
Rb suppressor gene, which may be familial or
3681 Pediatrics Ophthalmology sporadic. Retinoblastoma is highly malignant and
failure to dx & tx may lead to death from liver &
brain metastases. Strabismus, decr vision, ocular
inflammation, eye pain, glaucoma, orbital cellulitis.
Dx highly suspected if USG or CT mass w
calcifications
Strabismus
Abnlfindings:
Constant strabismus at any age
Eye deviation after 4 mo
Asymmetric corneal light reflexes
Asymmetric intensity of red reflexes
Deviation on cover test
Torticollis or head tilt
3711 Pediatrics Ophthalmology Tx options:
Penalization therapy: cycloplegic drops to blur
normal eye
Occlusion therapy: Patch normal eye
Prescription eyeglasses
Surgery
Complications:
Amblyopia - vision loss from disuse of deviated eye
Diplopia
Vision development is critical during the first few
years of life, and screening should occur at every
well-child exam. Infants should be evaluated by
observing fixation and tracking. The cover-uncover
test should be performed in older infants and
children to assess for strabismus. Visual acuity
testing should begin at age 3 w the tumbling E or
Snellen chart.
Orbital cellulitis - infxn of orbital soft tissue post to
orbital septum. Pain w eye mvmnts, proptosis,
ophthalmoplegia & diplopia. Bacterial sinusitis is
MC predisposing factor for orbital cellulitis d/t
prevalence of disease as well as proximity of
sinuses to the orbital space & valveless orbital
venous system. Dangerous complications include
blindness, subperiosteal abscesses, cavernous
sinus thrombosis, intracranial infxn, & death.
Contrast enhanced CT can identify absces
Organophosphatepoisoninginhibits
acetylcholinesterase, leading to symptoms of
cholinergic excess: bradycardia, miosis, rhonchi,
muscle fasciculations, salivation, lacrimation,
Poisoning&Environmental
3134 Medicine urination, and defecation. Atropine administration
Exposure
can reverse these effects. Of equal importance is
removal of any clothes (which may be
contaminated w pesticides) & washing of the skin
to prevent further transcutaneous absorption.
Fever, confusion, muscle rigitidy and diaphoresis -
Neuroleptic Malignant Sydnrome - a drug induced
idiosyncratic reaction. Typical neuroleptic agents
(haloperidol) are implicated in NMS but other
3135 Medicine dopaminergic agents including the "atypicals" are
Exposure
also implicated. Think about when someone who
had hallucinations was stablized. Symps begin
w/in 2 weeks of initiation of precipitating drug and
mortality rates range from 10-20%.
TCAs are cardiotoxic bc they inhibit fast Na+
channels in the His-Purkinkje system &
myocardium. This decr conduction velocity, incr
duration of repolarization, & incr absolute
refractory periods. The result is hypotension, QRS
3138 Medicine prolongation, & V arrhythmias (eg, V tach, V fib).
Exposure
QRS>100 in the setting of TCA OD is an indication
for tx w NAHCO3. Incr'd extracellular [Na+]
incrses electrochemical gradient across cardiac
cells and affects abilty of TCAs to bind fast Na+
channels
Heat stroke is categorized as exertional or
nonexertional. Nonexertional heat stroke occurs in
patients w chronic medical conditions, often bc
they can't remove themselvesf rom the inciting
Poisoning&Environmental stimulus and/or have impaired thermoreg d/t
3690 Medicine
Exposure medications and underlying illness. Exertional heat
stroke occurs in healthy ppl underoing conditioning
in extreme heat and humidity. Body loses its ability
to dissipate heat when humidity is over 75% and
temp is up.
TCA overdose - CNS depression, hypotension,
anticholinergic effects (dilated pupils,
hyperthermia, intestinal ileus). QRS prolongation,
Poisoning&Environmental leaving the pt susceptible to ventricular
4487 Medicine
Exposure arrhythmias. Pts suspected of TCA OD should
first undergo the ABCs and NAHCO3 should be
administered to improve BP, shorten the QRS,
and prevent arrhythmia.
Symptoms of opioid withdrawal include nausea,
vomiting, cramps, diarrhea, dysphoria,
restlessness, rhinorrhea, lacrimation, myaglias,
Poisoning&Environmental and arthralgias. Physical exam signs include
4509 Medicine
Exposure mydriasis, piloerection, and hyperactive bowel
sounds. Oral or IM methadone is the tx of choice
to relieve the symptoms of opioid withdrawal in
dependent pts.
NMS - fever, muscles rigidity, autonomic instability
and mental status change. Serum CK is often
elevated. Based on clinical evidence, dantrolene, a
4522 Medicine muscle relaxant, is the MC drug used to reverse
Exposure
the condition, followed (a dopamine agonist) and
amantadine (an antiviral drug w dopaminergic
properties).
Tx for suspected CN- poisoning
Decontamination:
Dermal exposure: Removal of clothing, skin
decontamination
Ingestion: Activated charcoal
All exposures: Antidote (hydroxycobalamin
10146 Medicine preferred, Sodium thiosulphate as alternate
Exposure
therapy)
Antidote not available: Nitrites to induce
methemoglobinemia
Resp support: No mouth-to-mouth, Supplemental
O2, Airway protection (intubation)
CV support: IV fluids for hypotension
Causticingestion
Clinical - Chemical burn or liquefaction necrosis
resulting in:
laryngeal damage: hoarseness, stridor
esophageal damage: dysphagia, odynophagia
gastric damage: epigastric pain, bleeding
Mgmt - Secure ABCs
Decontamination: remove contaminated clothing &
2378 Pediatrics visible chemicals; irrigate exposed skin
Exposure
CXR if resp symps
Endoscopy w/in 24 hrs
Complications:
Upper airway compromise
Peforation
Strictures/stenosis (2-3 weeks)
Ulcers
Cancer
Iron poisoning dirupts basic cell processes,
causing systemic manifestations including abd
pain, hematemesis, shock and metabolic acidosis.
Poisoning&Environmental It commonly occurs in children of pregnant women
2655 Pediatrics
Exposure taking PNV bc children often confuse brightly
colored pills for candy. Tx of iron poisoning
involves deferoxamine, which binds ferric iron,
allowing urinary excretion.
Iron poisoning
Clinical feats
Within 30 mins to 4 days:
Abd pain, vomiting (hematemesis), Diarrhea
(melena), Hypotensive shock (iron is a potent
vasodilator & toxic to cellular processes),
Poisoning&Environmental Metabolic acidosis (poor perfusion and
3827 Pediatrics
Exposure accumulation of lactic acid)
Within 2 das: hepatic necrosis
Within 2-8 weeks: pyloric stenosis (scarring)
Dx - Anion gap metabolic acidosis, Radiopaque
pills
Tx - Whole bowel irrigation, deferoxamine,
supportive care for ciruclation, airway & breathing
Pb poisoning
Home built before 1978, under renovation or w
peeling paint
Pica
Sibling w Pb poisoning
4837 Pediatrics Low socioeconomic status (medicaid)
Exposure
Immigrant or international adoptee
Capillary (fingerstick) blood speciments are widely
used for inital screening but have false-positive
results. Abnormal values must be confirmed by
venous blood draw.
Compartment syndrome resulting from
circumferential compression by eschar can be
3395 Surgery relieved by performing an escharotomy. A muscle
Exposure
compartment pressure that exceeds 30mmHg is
also an indication for escharotomy.
Escharotomy is indicated for circumferential
full-thickness burns of an extremity with an eschar
causing significant edema and constriction of the
3398 Surgery vascular supply and dec peripheral pulses. Pts
Exposure
should be evaluated for clinical signs of adequate
perfusion after escharotomy, and fasciotomy
should be performed if there is no sign of relief.
Choriocarcinoma is a highly metastatic form of
gestational trophoblastic dz. It may occur after
molar pregnancy or normal gestation, and the
Pregnancy, Childbirth & lungs are the most frequent site of metastatic
2299 Medicine
Puerperium spread. Suspect choriocarcinoma in any
postpartum woman w pulmonary symptoms and
multiple nodules on CXR. Elevated beta hCG
helps to confirm dx.
Posterior dislocation of the glenohumeral jt -
commonly caused by violent muscle contractions
during a tonic-clonic seizure. Exam will show
flattening of anterior shoulder, prominent coracoid
Obstetrics
Pregnancy, Childbirth & process, and the pt holding the arm adducted and
2372 &
Puerperium internally rotated w an inability of external rotation.
Gynecology
Radiographs show internal rotation of humeral
head w circular appearance, widened jt space
>6mm, or 2 parallel cortical bone lines on the
medial aspect of humeral head
Benign edema of pregnancy - leg cramps and mild
leg edema are very common and occur in 1/3 of
normal pregnancies. Symptomatic DVT presents
Obstetrics
Pregnancy, Childbirth & w combination of fever, unilateral leg pain,
2406 &
Puerperium swelling, redness and calf tenderness.
Gynecology
Preeclampsia may also present w bilateral leg
edema but also prsents w hypertension and
proteinuria.
Use of lithium in 1st trimester is assoc w incr risk
of congenital heart disease - Ebstein's anomaly In
pts who have stable bipolar dz, slow tapering of
lithium should be considered. Abrupt
Obstetrics
Pregnancy, Childbirth & discontinuation is not recommended as this may
2409 &
Puerperium inc risk of relapse. Isotretinoin - many congenital
Gynecology
abnormalities - craniofacial dysmorphism, heart
defects, deafness. Contraception must start 1
month before tx, be continued during tx, and for 1
month after isotretinoin is dc.
Unruptured ectopic pregnancy - need to do
TVUSG if B-hCG is under 6500 - after 6500 a
TAUSG should be fine - If intrauterine sac is
revealed, then ectopic is ruled out - if adnexal sac
Obstetrics
Pregnancy, Childbirth & is revealed then ectopic pregnancy is confirmed -
2411 &
Puerperium if TVUSG fails to find either sac, then serial
Gynecology
B-hCG measurements are necessary to r/o
ectopic. Doubling of B-hCH every 48 hrs suggests
normal pregnancy, slower rise suggests abnormal
pregnancy.
Palpation of the vertex at the fundus indicates a
Obstetrics fetus is in the breech position. Majority of breech
Pregnancy, Childbirth &
2412 & presentations will self-correct by the 37th week of
Puerperium
Gynecology gestation. Any attmempt to convert breech into
vertex is not indicated before the 37th week.
Pregnancy luteomas and theca luteum cysts are
the MCC of hyperandrogenism in pregnancy.
Luteomas appear as solid masses on USG and
Obstetrics
Pregnancy, Childbirth & can induce virilization in female fetuses; no
2415 &
Puerperium maternal tx is warranted. Theca luteum cysts are
Gynecology
unlikely to cause virilization in female offspring;
suction curretage is indicated if the underlying
cause is molar pregnancy.
Placenta Previa - Prior placenta previa, prior
cesarean or other uterine surgery, multiparity,
Obstetrics
Pregnancy, Childbirth & advanced age - Painless 3rd-trimester bleeding
2523 &
Puerperium (~80%), Bleeding w uterine contractions (~20%) -
Gynecology
TAUSG followed by TVUSG, NO digital vaginal
exam before USG
Placenta previa presents w painless vaginal
hemorrhage. USG dx. Pelvic exam is
contraindicated in any pt w antepartum
hemorrhage. Mgmt depends on gestational age
Obstetrics and severity of bleeding. If mother is stable and
2524 & fetus is at term, scheduled C-section is tx. If preg
Puerperium
Gynecology is not at term and mother is stable, expectant
management w close monitoring is tx. At 36
weeks, amniocentesis should be done to assess
lung maturity. If mature - elective c-section can be
performed.
Mgmt of placenta previa depends on gestational
age and severity of bleeding. C-section must be
performed if the bleeding doesn't stop even if the
pregnancy isn't term. Placent accreta - abnormal
Obstetrics
Pregnancy, Childbirth & insertion of the placent through the uterine wall - a
2525 &
Puerperium cause of extended bleeding. Pts w prior c-sxn
Gynecology
have 25% risk of developing this, 2/3 cases of
placenta accreta require a hysterectomy. Other
causes of uncontrollable bleeding - placenta
previa, uterine atony, DIC, abruption.
Abruptio placentae is one of the most common
causes of antepartum hemorrhage. Dx is clinical.
MC findings - CONSTANT ABDOMINAL PAIN,
Obstetrics
Pregnancy, Childbirth & 3RD TRIMESTER VAGINAL BLEEDING (80%),
2527 &
Puerperium AND A HYPERTONIC/TENDER UTERUS,
Gynecology
RETROPLACENTAL HEMORRHAGE ON USG
(ONLY 25% OF ABRUPTIONS ARE VISIBLE ON
USG).
Vaginal bleeding and hyperactive and tender
uterus are concerning for placental abruption, is
MC dx by clinical presentation. Abruption occurs
when theres bleeding between the decidua and
Obstetrics
Pregnancy, Childbirth & placenta interface. The bleeding causes placental
2528 &
Puerperium detachment so exchange of gas and nutrients
Gynecology
can't occur which leads to compromoise of the
fetus. USG should be performed to rule out
placenta previa. If USG shoes fundal placenta and
mother is stable - proceed to vaginal delivery.
Tx of Abruptio placenta.
Unstable maternal vital signs or nonreassuring
fetal heart tracing at any gestation age:
EMERGENCY C-SECTION
Obstetrics
Pregnancy, Childbirth & Stable maternal signs, reassuring fetal heart
2530 &
Puerperium tracing, no placenta previa & >34 weeks
Gynecology
gestation: TRIAL OF VAGINAL DELIVERY
Reassuring fetal heart tracing: HR 110-160/min,
long-term variability >2cycles/min, beat-to-beat
variability 6-25/min
Uterine surgery (c-sxn) leaves an area of inelastic
scar which may not be able to hand the pressure
from subsequent labor contractions. If it cannot, it
will break and lead to uterine rupture. Uterine
Obstetrics
Pregnancy, Childbirth & rupture is life-threatening for mother and baby.
2531 &
Puerperium Presents w abdominal pain, vaginal bleeding. Fetal
Gynecology
heart decelerations, loss of fetal station, palpation
of fetal parts on abd exam are concerning feats.
Excessive intraabd bleedin can result in abd
distension, hypotension, inc HR
Fetal station 0 is midway between ischial spines.
Intense abdominal pain and vaginal bleeding are
classic for uterine rupture (UR). Hyperventilation,
agitation, tachycard - indicate imminent rupture.
Obstetrics
Pregnancy, Childbirth & After rupture occurs, pt may feel relieved but pain
2532 &
Puerperium returns more diffusely. Loss of fetal station - red
Gynecology
flag for rupture (fetus goes back upwards).
Emergency C-section is indicated (mother can
bleed out). PLTCS - <1% risk of rupture, classic
c-sxn - ~9% risk.
Vasa previa - fetal blood vessels traverse the fetal
membranes across the lower segment of the
uterus between the fetus and the internal cervical
os. Here the fetal vessels are vulnerable to tearing
Obstetrics
Pregnancy, Childbirth & during spontaneous or artificial rupture of
2533 &
Puerperium membranes. There is 75% risk of death by
Gynecology
exsanguination for the fetus. FHM demonstrates
tachy followed by bradycardia and eventually
sinusoidal pattern. TV Doppler is gold standard for
dx. C-section should be done. Apt test Kliehauer
10-20% incidence of spontaneous abortions in the
general population and approximately half result
from chromosomal abnormalities (trisome 13, 18)
Obstetrics that are incompatible w life. Advanced maternal
2536 & age is assoc w incrased risk of chromosomal
Puerperium
Gynecology abnormalities and also assoc w higher incidence
of spontaneous abortion (up to 80% at age 45).
Infxn, DM, smoking, EtOh consumption are other
RF.
Spontaneous abortion (miscarriage) - excessive
bleeding, dilated cervix, and IUFD. Spontaneous
abortion occurs in 15% of pregnancies and is MC
Obstetrics
Pregnancy, Childbirth & in 1st trimester. Surgical management is
2541 &
Puerperium appropriate in pts w excessive bleeding or low
Gynecology
hemoglobin. Also indicated for pts w unstable vital
signs. Dilation and suction curretage involve
opening the cervix and aspirating the uterus.
Complete abortion is a form of spontaneous
abortion where the whole conceptus passes
throught the cervix before 20 weeks gestation.
Usually a solid white mass covered w blood.
Obstetrics
Pregnancy, Childbirth & Cervix then closes and assoc pain and uterine
2542 &
Puerperium contractions subside. USG shows empty uterus.
Gynecology
Urine B-hCG will still be positive but serum B-hCG
becomes undetectable by 4-6 weeks after
miscarriage. Maternal smoking, maternal age,
previous spontaneous abortion.
Anti-D immune globulin (RhoGAM) is indicated in
Obstetrics unsensitized, Rh-negative women at 28 weeks
2543 & gestation or within 72 horus of any procedure or
Puerperium
Gynecology incident in which there is any possibilty of
feto-maternal blood mixing.
Inevitable abortion - vaginal bleeding, fluid
dischage, lower abdominal cramps and a dilated
cervix through which the products of conception
Obstetrics
Pregnancy, Childbirth & can occasionally be visualized. Fluid lost is
2544 &
Puerperium amniotic fluid draining from ruptured amniotic
Gynecology
membrane. USG demonstrates a ruptured or
collapsed gestational sac and absence of fetal
cardiac motion.
Septic abortion is a medical emergency that
should be treated promptly w broad-spectrum abx
and surgical evacuation of the uterus (suction
Obstetrics
Pregnancy, Childbirth & curretage). After the initial tx, the patient should be
2545 &
Puerperium monitored closely for signs of systemic sepsis. If
Gynecology
they don't improve rapidly after the initial phase of
tx - laparotomy and possible hysterectomy may be
indicated.
Labor should be induced w/o delay in pts w IUFD
Obstetrics
Pregnancy, Childbirth & who develop coagulation abnormalities. A
2549 &
Puerperium fibrinogen and platelet levels in the low-normal
Gynecology
range can indicate developing DIC.
Magnesium sulfate toxicity - acts as a CNX
depressant by blocking neuromuscular
Obstetrics
Pregnancy, Childbirth & transmission. Decreased reflexes and respiratory
2561 &
Puerperium depression are seen. Tx of MgSO4 toxicity is
Gynecology
immediate discontinuation of the infusion and
administration of calcium gluconate.
Obstetrics
Pregnancy, Childbirth & Htn, proteinuria, RBC casts, edema, high titer
2563 &
Puerperium ANA, malar rash - SLE glomerulonephritis.
Gynecology
Maternal Serum AFP (MSAFP) is measured at
15-20 weeks gestation (optimally at 16-18) to
screen for fetal anomalies. MSAFP primarily
screens for open neural tube defects. Incr levels
Obstetrics are also assoc w fetal abdominal wall defects
2567 & (gastroschisis, omphalocele) and multiple
Puerperium
Gynecology gestation. Elevated MSAFP warrants careful
ultrasound eval of fetal anatomy. Down syndrome:
low MSAFP, low estriol, elevated BHCG and
inhibin A. Edwards: low MSAFP, very low estriol
and BHCG, normal inhibin A.
Quadruple test is performed in the 2nd trimester
(15-20 weeks) MSAFP, BhCG, estriol, and inhibin
A. Women > 35 are at increased risk of fetal
aneuploidy. Quadruple screen detects ~80% of
Obstetrics
Pregnancy, Childbirth & fetuses w Down syndrome but has a false-positive
2569 &
Puerperium rate of ~5%. Pts w abnormal Quad screen results
Gynecology
can be offered a cell-free fetal DNA test, which
measures circulating, free maternal and fetal DNA
in maternal plasma and has sensi and speci of
99%. USG - fetal abnormalities
Women should generally be advised to avoid live
vaccines immediately before and during
pregnancy. Wild-type rubella has been assoc w
significant adverse fetal effects, but the vaccine
Obstetrics strain was not. Women who are inadvertently
3106 & given rubella vaccination before or during
Puerperium
Gynecology pregnancy do no require additional intervention
and may proceed w routine prenatal care.
Advisory Committee on Immunization Practices
says to avoid conception for 28 days after
receivingrubellaimmunization.
Healthy pregnant women w no contraindications
should do moderate-intensity exercise for >30
minutes, 5-7 days/week. Pregnant women should
Obstetrics
Pregnancy, Childbirth & be warned about ligamental laxity and changes in
3109 &
Puerperium center-of-balance can increase propensity for jt
Gynecology
injuries and falls. Contact sports, High fall risk
sports, scuba diving, Hot yoga - should not be
performed while pregnant
Maternal comorbidities such as chronic
hypertension require antepartum fetal surveillance
Obstetrics to dx fetal compromise and prevent death. NST
3111 & should be performed at least weekly in the 3rd
Puerperium
Gynecology trimester until delivery. A normal result consists of
2 heart rate accelerations for 15bpm for at least
15 seconds.
Late-term pregnancies are at risk for
uteroplacental insufficiency. Antenatal fetal
Obstetrics
Pregnancy, Childbirth & surveillance should begin at 41 weeks gestation to
3112 &
Puerperium detect fetal compromise suggested by abnormal
Gynecology
heart rate patterns, decreased fetal activity, and
oligohydramnios.
Arrest of labor in the first stage is dx when dilation
is >6cm w ruptured membranes in the setting of
Obstetrics no cervical change >4 hours despite adequate
3116 & contractions OR when there is no cervical change
Puerperium
Gynecology for >6 hours w inadequate contractions. Pts who
do not meet criteria should be observed if there is
no fetal distress.
External cephalic version can be attempted in
women w breech pregnancies at >37 weeks
Obstetrics
Pregnancy, Childbirth & gestation age if there are no contraindications to
3118 &
Puerperium vaginal delivery, and fetal well-being has been
Gynecology
established. These maneuvars can reduce the rate
of c-section.
Hx of preterm birth is a RF for preterm birth in a
subsequent pregnancy. Preterm labor at 23
weeks to 34 weeks gestation should be delayed
to improve fetal outcome when there is no
Obstetrics evidence of a threat to maternal or fetal health
3269 & (preeclampsia,abruption,chorioamnionitis).
Puerperium
Gynecology Tocolytics (B-agonists, CCBs, or NSAIDs). Can
delay labor for ~2 days. Corticosteroids are given
to mature fetal lungs, and MgSO4 for
neuroprotection. Risk of cerebral palsy inc w dec
GA esp <32 weeks.
In false labor, progressive cervical changes are
Obstetrics
Pregnancy, Childbirth & absent, contractions are irregular and discomfort
3271 &
Puerperium is readily relieved by sedation. All such pts need
Gynecology
reassurance.
Fetus' with bilateral renal agenesis have a
congenital anomaly that is incompatible with life.
Obstetrics
Pregnancy, Childbirth & They will have severe pulmonary hypoplasia. They
3273 &
Puerperium can survive in utero but attempts to prolong
Gynecology
pregnancy in efforts to improve fetal mortality are
futile.
Premature rupture of membranes (PROM) -
occurs before labor starts. It is preterm if it occurs
before term (PPROM). Pt usu complains of a gush
Obstetrics or continual leakage of clear fluid from the vagina.
3274 & If PPROM is dx - amniotic fluid analysis to detect
Puerperium
Gynecology fetal lung indices is mandatory. USG exam should
be performed to detect anomalies, gestational
age, and AFI. Steroid tx is effective between
24-34 weeks in accelerating lung maturity.
Obstetrics
Pregnancy, Childbirth & Fetal distress (repetitive late decelerations) is an
3275 &
Puerperium indication for emergent cesarean section.
Gynecology
Screening by vaginal and rectal culture for GBS
colonization and PCN ppx have drastically reduced
the incidence of neonatal GBS infxn. Universal
Obstetrics screening occurs at 35-37 weeks gestation as the
3277 & result is most accureate w/in 5 weeks of the
Puerperium
Gynecology anticipated delivery date. Exceptions include a hx
of GBS bacteruria, UTI, or an infant early-onset
GBS disease; these pts should receive ABx PPx
w/o testing.
Causes of fetal growth restriction (weight <10th
percentile)
Asymmetric (maternal factors): vascular dz (htn,
preeclampsia, DM)
Antiphospholipid antibody syndrome
Autoimmune dz (SLE)
Obstetrics Cyanotic cardiac dz
3280 & Substance abuse (tobacco, EtOH, cocaine)
Puerperium
Gynecology Symmetric (fetal factors):
Genetic disorders (aneuploidy)
Congenital heart disease
Intrauterine infxn (malaria, CMV, rubella,
toxoplasmosis, varicella)
CMV is the MC infectious etiology in developed
countries, and most women have no Sx
Late-term and postterm pregnancy complications
Fetal
Oligohydramnios (single deepest vertical pocket of
amniotic fluid <2cm or an AFI of <5 on TAUSG)
aging placenta has decr fetal perfusion -> decr
fetal renal perfusion -> decr urinary output
Obstetrics Meconiumaspiration
3281 & Stillbirth
Puerperium
Gynecology Macrosomia
Convulsions
Maternal
Cesarean delivery
Infection
Postpartum hemorrhage
Perineal trauma
Low grade fever and leukocytosis are common in
the first 24hrs of postpartum period. Intrapartum
and postpartum chills are also common. Lochia
Obstetrics rubra is normal and characteristic of the first few
3337 & days following delivery. After 3-4 days the color
Puerperium
Gynecology becomes pale and the discharge is then called
lochia serosa. Subsequently turns white or yellow
then called lochia alboa. If lochia is foul smelling -
endometritis should be suspected.
Variable decelerations result from umbilical cord
compression. Intermittent variable decelerations
(variable decelerations occurring independently of
Obstetrics
Pregnancy, Childbirth & the majority of contractiosn) do not require
3869 &
Puerperium intervention. However, recurrent variable
Gynecology
decelerations (accompanying >50% of
contractions) require evaluation and maternal
intrauterine resuscitative measures.
Antiphospholipidantibodies(lupusanticoagulant,
Obstetrics anticardiolipin antibodies) are present in some pts
3893 & w SLE. In pregnant women these can cause
Puerperium
Gynecology recurrent fetal loss via thrombus development
within the placenta.
Common findings in anorexic pts:
Osteoporosis
Elevated cholesterol and carotene levels
Cardiac arrhythmias (prolonged QT interval)
Obstetrics Euthyroid sick syndrome
3953 & Hypothalamic-pituitary axis dysfxn - anovulation,
Puerperium
Gynecology amenorrhea, and estrogen deficiency
Hyponatremia secondary to excess water drinking
- often the only electrolyte abnormality - presence
of other electrolyte abnormalities indicates purging
behavior.
Hypotension as a S/E of epidural anesthesia
occurs in up to 10% of txs. Continuous epidural
analgesia involves infusion of a low concentration
of a local anesthetic in to the epidural space at the
Obstetrics
Pregnancy, Childbirth & L2-L5 level. Highly effective modality for pain relief
4146 &
Puerperium in labor. Hypotension occurs when sympathetic
Gynecology
fibers responsible for vascular tone are blocked,
resulting in vasodilation (venous pooling), decr
venous return to the right side of the heart, and
decr CO.
Shoulder dystocia can cause excessive traction of
the C8 and T1 nerves during delivery and can
Obstetrics
Pregnancy, Childbirth & result in the rare complication of left hand
4198 &
Puerperium paralysis. Associated damage to the sympathetic
Gynecology
fibers that run along C8 and T1 manifests as
ipsilateral miosis and ptosis.
Blood typing and antibody screening should be
performed at the 1st prenatal visit. An Rh
Obstetrics (D)-negative woman w a negative antibody screen
4528 & is unsensitized (not alloimmunized) and should
Puerperium
Gynecology receive anti-D immune globulin. Anti-D immune
globulin should be given at 28-32 weeks gestation
and again after delivery if the baby is Rh positive.
CDC recommends all pregnant women w/o
contraindications receive the influenza vaccination.
Obstetrics
Pregnancy, Childbirth & Maternal morbidity and mortality from influenza in
4529 &
Puerperium pregnant women are prevalent and preventable.
Gynecology
Vaccine is recommened during flu season and can
be given in any trimester.
Breast engorgement - common in first 24-72 horus
after childbirth secondary to milk accumulation. It
can occur at any time during breast feeding but is
Obstetrics most common in early postpartum period when
4666 & milk production is robust. Symps include breast
Puerperium
Gynecology fullness, tenderness, and warmth. It peaks 3 - 5
days postpartum and improves spontaneously in
most pts. Cool compresses, acetaminophen, and
NSAIDs may be used for symptom control.
Osteogenesis imperfecta - AD - mutation in type 1
collagen. Pts w/ type II form of this disease
Obstetrics
Pregnancy, Childbirth & typically expire in utero d/t multiple intrauterine
4735 &
Puerperium and/or perinatal fractures. Clinical findings limb
Gynecology
deformities, growth retardation, multiple fractures
and blue sclerae.
Stillbirth delivery options
2nd trimester:
D&C (up to 24 weeks)
Induction of labor
Obstetrics
Pregnancy, Childbirth & Spontaneous vaginal delivery
4745 &
Puerperium 3rd trimester:
Gynecology
Induction of labor +/- cervical ripening agents
Spontaneous vaginal delivery
Repeat cesarean upon maternal request if pt has
a prior hx of cesarean delivery
Patients w preterm premature rupture of the
membranes (PPROM) whose group B strep
status is unknown should receive abx ppx. If a
Obstetrics woman is admitted to the hospital after 34 weeks
4757 & gestation w PPROM, delivery is usually
Puerperium
Gynecology recommended. Risks assoc w prematurity are
diminished after this gestational age and
complications are higher w continued expectant
management.
IntraUterine Fetal Demise (IUFD) - death of a
fetus in utero that occurs after 20 weeks gestation
and before onset of labor. Suspected when the pt
reports the disappearance of fetal movements, a
Obstetrics
Pregnancy, Childbirth & decr or stagnation in uterin size or when fetal
4775 &
Puerperium heart sounds are no longer heard. B-hCG levels
Gynecology
may continue to be elevated d/t ongoing placental
production. Real-time USG is more reliable tool for
confirming the dx; it demonstrates an absence of
fetal movement fetal cardiac activity.
IUFD can be caused by many conditions - htn,
DM, placental and cord complications,
antiphospholipidsyndrome, congenitalanomalies
and fetal infxns (TORCH or listeriosis). The cause
Obstetrics
Pregnancy, Childbirth & remains unknown in 50% of cases. It is very
4776 &
Puerperium important to dx the cause of fetal demise after the
Gynecology
first episode in order to prevent the recurrence of
the same issue in subsequent pregnancies.
Autopsy of the fetus and placenta should be
performed.
Gestational htn and preeclampsia begin >20weeks
gestation. Trace urine protein can occur in normal
pregnancies as urinary protein excretion increases
Obstetrics significantly d/t incr GFR and permeability of the
4777 & GBM. Mild peripheral edema is also normal due to
Puerperium
Gynecology inc plasma volume. Proteinuria in preeclampsia is
>300 mg/24hr, 3+ on dipstick. Elevated BP before
20 weeks is preexisting chronic htn (primary htn).
Tx - labetalol, nifedipine, methyldopa.
Placental abruption refers to premature separation
of the placent from the site of uterine implantation
and causes maternal hemorrhage and disruption
Obstetrics
Pregnancy, Childbirth & of placental perfusion. Htn of any types is the
4778 &
Puerperium most significant risk factor as poor placental
Gynecology
perfusion can disrupt the vascular integrity at the
decidual-placental interface. Other risk factors
include DM, prior abrution, cocaine, and smoking.
BP is monitored regularly in pregnancy as htn is
assoc w incr maternal and fetal morbidity and
mortality. Preeclampsia - htn (SBP>140 and/or
Obstetrics diastolic >90) at >20 weeks gestation +
4779 & proteinuria (>300mg/24hr, protein/creatinine >0.3,
Puerperium
Gynecology or dipstick >1+) or signs of end-organ damage.
RF for preeclampsia - multiple gestation,
nulliparity, preexisting DM, obesity, advanced age,
CKD, prior hx. Severe fts -
Preeclampsia - endothelial dysfxn or vasospasm
originating from abnormal placental vasculature
development in early pregnancy. Preeclampsia pts
Obstetrics w severe feats should receive a fast-acting
4780 & antihypertensive agent immediately d/t risk of
Puerperium
Gynecology stroke, cerebral hemorrhage, and death. IV
MgSO4 should also be administered to decr risk
of seizures, esp in the setting of a new headache
and severely elevated BP.
HELLP
Hemolysis (microangiopathic hemolytic anemia):
Schistocytes on peripheral smear, elevated
bilirubin, low serum haptoglobin
Elevated Liver enzymes: AST or ALT twice the
Obstetrics upper limit
4781 & Low Platelets: platelets <100,000
Puerperium
Gynecology RUQ or epigastric pain & nausea or vomiting
(30-90% of patients).
Liver problems including centrilobular necrosis,
hematoma formaion, and thrombi in the portal
capillary system. These can cause liver swelling
and distension of the hepatic (Glisson's) capsule.
Acute pulmonary edema - rare and life-threatening
complication of severe preeclampsia.
Preeclamptic pts have generalized arterial
vasospasm leading to incr SVR and high cardiac
Obstetrics
Pregnancy, Childbirth & afterload. Heart becomes hyperdynamic to
4782 &
Puerperium overcome the systemic htn. Decr renal fxn, decr
Gynecology
serum albumin, and endothelial damage leading to
incr capillary permeability also contribute to
pulmonary edema. Tx - O2, fluid restriciton,
diuresis.
In ecclampsia cesarean delivery is indicated for
typical obstetrical reasons - breech presenation,
non-reassuring fetal heart tracing despite
resuscitation efforts, hx of multiple prior cesarean
Obstetrics
Pregnancy, Childbirth & deliveries. Tx for preeclampsia-eclampsia
4784 &
Puerperium syndromeis to stabilize the pt, initiate tx for seizure
Gynecology
and stroke prevention as indicated and proceed w
delivery. In stable pts w pregnancies close to
term, induction of labor is appropriate if there are
no standard obstetric contraindication
Hyperemesis gravidarum - severe form of
pregnancy induced nausea (1% of pts). Severe,
persistent vomiting, lab derangements
(Hypokalemia, ketonuria) and >5% loss of
Obstetrics
Pregnancy, Childbirth & pre-pregnancy weight. Preg pts w increased
4789 &
Puerperium placental mass (eg, multifetal gestation, molar
Gynecology
pregnancy) have inc risk for HG. Discrepancies
between exam and expected uterine size can be
d/t several reasons. Pelvic USG should be done
for evaluation.
Molar pregnancy - abnormal fertilization of
trophoblastic tissue - complete mole - 2 sperm in
ovum w/o genetic material - no fetal tissue - partial
mole - 2 sperm in haploid ovum - abnormal
Obstetrics
Pregnancy, Childbirth & placenta and fetal tissue w triploid karyotype.
4790 &
Puerperium Complete mole - symptomatic - markedly elevated
Gynecology
serum B-hCG levels - hyperemesis gravidarum,
enlarged uterus, theca lutein ovarian cysts. Partial
moles less symptomatic lower B-hCG. Tx - suction
currettage. Molar preg -> neoplasia
Postpartum (puerperal) endometritis - should be
suspected if women experiences a fever >38
degrees outside the first 24 hrs postpartum. RF
Obstetrics
Pregnancy, Childbirth & include prolonged rupture of membranes,
4799 &
Puerperium prolonged labor, c-section, and use of IU pressure
Gynecology
catheters or fetal scalp electrodes. Characterized
by fever, uterine tenderness, foul smelling lochia
and leukocytosis.
Endometritis is a polymicrobial infxn caused by a
Obstetrics combination of gram + and gram - organisms,
4800 & aerobic and anaerobic organisms, and
Puerperium
Gynecology occasionally other organisms such as Mycoplasma
and Chlamydia.
Obstetrics Tx of choice for postpartum endometritis, which is
4801 & a polymicrobial infxn, is IV clindamycin and and
Puerperium
Gynecology gentamicin.
A missed abortion is a form of spontaneous
abortion defined as intrauterine fetal death before
Obstetrics
Pregnancy, Childbirth & 20 weeks gestational age w complete retained
4802 &
Puerperium products of conception and a closed cervix. Pts
Gynecology
often develop loss of pregnancy symps and scant
to light vaginal dc. Pelvic USG is necessary for dx.
Inevitable, missed, and incomplete abortions can
be managed surgically(dilation&curretage),
medically(prostaglandins), or expectantly.
Obstetrics Although all 3 methods can be effective, surgery
4803 & achieves more complete evacuation than medical
Puerperium
Gynecology or expectant management. In the case of medical
and expectant management, USG is generally
performed to confirm that there are no retained
products of conception.
Threatened abortion is a term used to describe
any hemorrhage occurring before the 20th week
of gestation w a live fetus. Cervix is closed and
Obstetrics
Pregnancy, Childbirth & there is no passage of fetal tissue. Mild lower abd
4804 &
Puerperium pain may be noted and the fetal heart is active on
Gynecology
USG. 25% of pregnancies have some extent of
vaginal bleeding in the first trimester. In 1/2 of
these cases, a spontaneous abortion will occur.
First step in a threatened abortion is to ascertain
that the fetus is present and alive. Once confirmed
w USG, management is reassurance and
Obstetrics performance of an USG one week later. Bed rest
4805 & and abstaining from sex are usually recommended
Puerperium
Gynecology bc this will prevent any feelings of on the part of
the parents in case the pregnancy is actually lost;
however, there is no evidence of the benefit of
these interventions on the outcome.
Uterine atony is the MCC of postpartum
hemorrhage w/in 24 hours of delivery. Important to
dx quickly by checking firmness and location of
Obstetrics uterine fundus. Soft, boggy, poorly contracted
4808 & uterus is characteristic. Compression of the uterus
Puerperium
Gynecology usually results in expulsion of blood clots and
blood from the vagine. RF - overdistension
(multiple gestation, polyhydramnios, macrosomia)
and uterine fatigue (prolonged labor).
Mgmt of postpartum hemorrhage:
Fundal or bimanual massage (stimulates uterus to
contract and resolves hemorrhage)
IV access
Crystalloid infusion to keep SBP > 90
Obstetrics
Pregnancy, Childbirth & Notification of blood bank for RBCs.
4809 &
Puerperium Uterotonic agent such as oxytocin should be
Gynecology
administered immediately. Oxytocin causes
contraction of myometrial fibers and retraction of
myometrial blood vessels and will control bleeding
in most cases. Bleeding usually stops 10-40
minutes after admin of uterotonic agent.
Active, untreated TB, HIV, and active illicit drug
and alcohol abuse are contraindications to
breastfeeding. HBV and HCV are not considered
Obstetrics
Pregnancy, Childbirth & contraindications, and mothers w these conditions
4892 &
Puerperium should be encouraged to breastfeed.
Gynecology
Galactosemia is the only condition in the infant
which is an absolute contraindication to
breastfeeding.
Risk factors for cervical insufficiency (cervical
incompetence) include prior gynecological surgery
Obstetrics esp a LEEP procedure or cone biopsy of the
4915 & cervix. Other risk factors include prior obstetrical
Puerperium
Gynecology trauma, multiple gestation, Mullerian anomalies
and a hx of a preterm birth or a second-trimester
pregnancy loss.
TVUSG is considered the "gold standard" for
evaluating the cervix for possible cervical
incompetence. TVUSG is used to look for the
Obstetrics
Pregnancy, Childbirth & presence of funneling of the cervix or shortening of
4916 &
Puerperium the cervical length. Cervical length should be more
Gynecology
than 25mm at 24 week. A cervical length below
the 10th percenile for the gestational age is
considered a short cervix.
Missed menstrual period(s), acute abdominal pain,
intermittent vaginal bleeding - ectopic pregnancy.
Intraabdominal bleeding from a ruptured ectopic
Obstetrics pregnancy should be suspected w a hx of
8945 & syncope, hypotension, and tachycardia. Pooling of
Puerperium
Gynecology blood with irritation of nearby structures can result
in adnexal tenderness, cervical motion tenderness,
diffuse abdominal pain, shoulder pain, urge to
defecate.
Intrapartum FHR monitoring is used to assess
fetal oxygenation. Well-oxygenated fetal brain
provides autonomic control t the heart, resulting in
Obstetrics
Pregnancy, Childbirth & fetal heart rate of 110-160 w moderate variability
8962 &
Puerperium (6-25bpm). In conjuncxn w a tocometer, which
Gynecology
measures the force of uterine contractions, a
clinician can interevene if there is concern for fetal
hypoxia.
A normal NST has a high NPV, whereas an
abnormal result has a high false positive rate and
low PPV, necessitation a BPP or CST. BPP and
Obstetrics CST are equivalent in assessing fetal status and
9984 & are selected based on available resources. A CST
Puerperium
Gynecology can be performed if there is no contraindication to
labor. If a pt doesn't have spontaneous
contraction, it can be induced by nipple stimulation
or IV oxytocin.
Woman age>35 are at inc risk of fetal aneuploidy
and should be offered cell-free fetal DNA testing
(cffDNA) of maternal plasma. ~99% sens and
spec for detecting down syndrome, >92% sens
Obstetrics
Pregnancy, Childbirth & for Edward syndrome, and >80% sens for Patau
10441 &
Puerperium syndrome. Also identifies fetal sex and sex
Gynecology
chromosome d/o. Abnormal results can be
confirmed via karyotyping via chorionic villus
sampling (in 1st sem) or amniocentesis (in 2nd
sem).
Labor and vaginal delivery are contraindicated
Obstetrics after a classic cesarean delivery or extensive
11966 & myomectomy d/t significan risk of uterine rupture.
Puerperium
Gynecology Laboring pts a high risk of uterine rupture requires
laparotomy and delivery.
Neonatal displaced clavicular fracture
RF
Fetal Macrosomia (maternal DM, post-term
pregnancy)
Instrumental delivery (vacuum or forcepts)
Shoulder dystocia
Pregnancy, Childbirth & Clinical feats

2485 Pediatrics
Puerperium Crying/pain w passive motion of affected extremity
Crepitus over clavicle
Asymmetric Moro reflex
Dx - X-ray
Tx - Reassurance, gentle handling, analgesics,

place arm in a long-sleeved garment & pin sleep
to chest w elbox flexed at 90 degrees.
Thermoregulatory center is underdeveloped in
newborns, and they can lose heat easily; that is
why quick drying and keeping warm is important in
early neonatal care. Neonatal gonoccola
4174 Pediatrics ophthalmia prevention and parenteral
Puerperium
administration of vit K are alsp important in early
neonatal care and should be applied soon after
the initial assessment and measures to prevent
body heat loss.
Infants who are small for gestational age are at
risk for several complications d/t their size,
including hypoxia, perinatal asphyxia, meconium
4889 Pediatrics aspiration, hypothermia, hypoglycemia,
Puerperium
hypocalcemia, & polycythemia. The polycythemia
results from increaed EPO secretion in response
to fetal hypoxia
Delayed sleep phase syndrome is a circadian
rhythm d/o characterized by inability to fall asleep
at "normal" bedtimes (10PM-midnight); sleep is
Psychiatric/Behavioral &
8823 Medicine normal if allowed to continue until late morning. Pts
Substance Abuse
have insomnia and excessive daytime sleepiness.
An accurate hx and/or a sleep diary are essection
in making the dx.
Amnesia, sleep disturbance, hypervigilance,
irritability, emotional detachment - PTSD. Frequen
nightmares and flashbacks are other common
Psychiatric/Behavioral & symps. Some PTSD symps may appear
11811 Medicine
Substance Abuse immediately but usually there is delay of months or
even years before full criteria for dx are met.
Dissociate amnesia is also common in PTSD. Tx
SSRI, SNRI, trauma-focused psychotherapy
"Bath salts" have amphetamine properties that can
cause severe agitation, combativeness, delirium,
and psychosis. Tachycardia is often present. In
11815 Medicine contrast to other stimulants and hallucinogens,
Substance Abuse
which have a much shorter duration of effect, the
effects of bath salt intoxication may take several
days or weeks to subside.
Pseudocyesis is a rare psychiatric condition in
Obstetrics
Psychiatric/Behavioral & which a woman presents w nearly all Sxs of
2552 &
Substance Abuse pregnancy; however, USG reveals a normal
Gynecology
endometrial shape and negative pregnancy test.
Anorexia nervosa - high achieving type A
personalities, participation in activities in which
there is pressure to be slender. Nutritonal rehab &
psychotherapy are cornerstones of tx for anorexia
2353 Pediatrics nervosa w primary goal of weight gain.
Substance Abuse
Hospitalization & acute stabilization are highly
recommended for dehydration, electrolyte
disturbances, bradycardia, severe weight loss.
Refeeding syndrome.
> or = to 6 inattentive &/or > or = 6
hyperactive/impulsive symps for > or = 6 mnths.
Several symps present before age 12. Symps
2470 Pediatrics occur in at least 2 settings. Fxnal impairment.
Substance Abuse
Subtypes: predominantly inattentive,
predominantlyhyperactive/impulsive,combined
type
Tourette disorder
Both multiple motor & one or more vocal tics (not
necessarily concurrent, >1 year)
Motor: Facial grimacing, blinking, head/neck
jerking, shoulder shrugging, tongue protrusion,
Psychiatric/Behavioral & sniffing
3375 Pediatrics
Substance Abuse Vocal: Grunts, snorts, throat cleaning, barking,
yelling, coprlalia (obscenities)
Onset before age 18
Tx - Antipsychotics (second gen - risperidone),
alpha agonists (clonidine, guanfacine), behavioral
therapy (habit reversal training)
Autism spectrum disorder - repetitive stereotypied
behavior and abnl reactivity to sensory input.
Intellectual impairment.
Multiple, persistent deficits in social
communication & interactions currently or by
Psychiatric/Behavioral & history
3379 Pediatrics
Substance Abuse Restricted, repetitive patterns of behavior
currently or by history
Symptoms occur in the early developmental period
& cause impairment
Not better explained exclusively by intellectual
disability or another condition
Children who suffer from selective mutism are
verbal and talkative at home but refuse to speack
in specific settings, generally school. DSM-5
criteria: Consistent failure to speak in specific
situations but not others in which a person is
3380 Pediatrics expected to speak, duration of >1month,
Substance Abuse
interference w educational or other expected
achievement or w social communications, not
attributable to lack of knowledge or comfort w
spoken languate, other communication d/o
(autism) not responsible
Trichotillomania (hair pulling disorder):
Recurrent hair pulling resulting in hair loss
Repeated attempts to decrease/stop hair pulling
3384 Pediatrics Significant distress or impairment
Substance Abuse
Not d/t a medical/dermatologic condition
Not d/t another mental disorder
Tx - CBT (habit reversal training)
Psychiatric/Behavioral & Patients w Tourette syndrome have a significantly
3760 Pediatrics
Substance Abuse increased risk of developing ADHD or OCD.
Neonatal abstinence syndrome - infant withdrawal
to opiates and usually presents in the first few
Psychiatric/Behavioral & days of life. Characterized by irritability, a
4893 Pediatrics
Substance Abuse high-pitched cry, poor sleeping, tremors, seizures,
sweating, sneezing, tachypnea, poor feeding,
vomiting, and diarrhea.
Toddlers are normally curious about the human
body. It is normal for toddlers to touch their own
or other young children's genitals, to undress
themselves or others, and make masturbatory
Psychiatric/Behavioral & movements. These behaviors are typically brief,
4924 Pediatrics
Substance Abuse intermittent, and distractable. Abnormal things
include: repeated object insertion into vagina or
anus, sex play involving genital-genital,
oral-genital, or anal-genital contact, use of force,
threats or bribes in sex play, age-inapp sexual kno
OCD lookup PANDAS
Obsessions: recurrent, intrusive, anxiety-provoking
thoughts, urges, or images with attempts to
suppress or neutralize w other thoughts. No
relation to another mental or substance use d/o
8923 Pediatrics Compulsions: Response to obsessive thoughts w
Substance Abuse
repeated behaviors or mental acts
Tx - CBT (exposure & response prevention) &/or
high-dose SSRI. Clomipramine or antipsychotic
augmentation for tx nonresponse. Deep-brain
stimulation for severe or refractory cases.
OCD involves repetitive mental and physical rituals
Psychiatric/Behavioral & that interfere w social and occupational fxning. Tx
8923 Pediatrics
Substance Abuse involves high-dose SSRIs and psychotherapy.
Onset may be assoc w recent strep infxn.
Alcohol withdrawal:
Mild - anxiety, tremulous, sweating, palpitations -
6 hrs
seizures - Single seizure or multiple in small period
of time - 12-48 hrs
2349 Psychiatry Alcoholic hallucinosis - Auditory, visual, tactile
Substance Abuse
hallucinations w normal vital signs and intact
sensorium - 12-24 hours
Delirium tremens - Fever, HTN, Tachycardia,
Diaphoresis, hallucinations, disorientation - 48-96
hrs
Loss of a loved one can trigger the onset of a
MDD. Bereaved patients who epxerience
2351 Psychiatry depressive symptoms for at least 2 weeks after a
Substance Abuse
major loss should be considered for tx w/ both
psychotherapy and a trial of antidepressants.
First-line treatments for acute mania include
antipsychotics, lithium, valproate, and
carbamazepine. Patients experiencing severe
2355 Psychiatry mania with acute agitation commonly receieve and
Substance Abuse
antipsychotic alone or in combination with initiation
of a mood stabilizer to manage symptoms
effectively.
Long-term S/E of lithium include nephrogenic DI,
hyperparathyroidism with hypercalcemia, and
2356 Psychiatry thyroid dysfunction. Calcium, renal function, and
Substance Abuse
thyroid function should be monitored prior to
starting lithium and periodically during therapy.
First line pharmacologic tx for Bipolar d/o is:
1. Atypical antipsychotics
2. Lithium
2357 Psychiatry 3. Valproic acid
Substance Abuse
Lithium should not be administered in patients w/
renal dysfxn or a FH or renal dysfunction.
Following acute stabilization, patients w bipolar
d/o should receive the following maintenance
therapy:
1. Atypical antipsychotics are preferred for mild to
moderately ill patients.
2495 Psychiatry 2. Monotherapy with lithium or valproic acid can be
Substance Abuse
used as alternate therapy.
3. For more severe episodes, combination therapy
with lithium or valproate plus atypical
antipsychotics is usually preferred over
monotherapy
Benzodiazepines are used for the acute treatment
Psychiatric/Behavioral & of panic attacks. In panic disorder, a SSRI or
2496 Psychiatry
Substance Abuse SNRI or CBT should be used for long-term
symptom relief.
Antipsychotic medications can cause
Psychiatric/Behavioral & hyperprolactinemia secondary to their dopamine
2497 Psychiatry
Substance Abuse blockade effect. Prolactinomas tend to produce
very high levels of prolactin (>200 ng/ml)
ECT - indications - severe depression, depression
in pregnancy, refractory mania, NMS, and
Psychiatric/Behavioral & catatonic schizophrenia. S/E - Anterograde and
2498 Psychiatry
Substance Abuse Retrograde amnesia. Anterograde resolves
quickly but retrograde and persist for a longer
period.
Psychiatric/Behavioral & Busipirone is used to treat generalized anxiety
2502 Psychiatry
Substance Abuse disorder but not social anxiety disorder.
Acute dystonic reactions are treated with
Psychiatric/Behavioral & anticholinergic medication (benztropine) and
2505 Psychiatry
Substance Abuse antihistamines (diphenhydramine) that have
significant anticholinergic activity.
Agranulocytosis is a serious S/E associated w
clozapine usage. Patients should have their WBC
monitored frequently for this complication. It is
2507 Psychiatry also important to note that clozapine lowers the
Substance Abuse
seizure threshold. Clozapine is never first line,
used after pt has EPS. Cataracts are associated
with quetiapine.
Disruptive mood dysregulation d/o is a childhood
d/o characterized by chronic irritability, manifested
Psychiatric/Behavioral & as temperamental outbursts and persistent
2510 Psychiatry
Substance Abuse angry/irritable mood. Bipolar d/o is an episodic
illness in which irritability only occurs during
discrete mood episodes.
Typical and atypical antipsychotics cause adverse
effects including EPS (dystonia, parkinsonism,
tardive dyskinesia, and akathisia) and NMS. TD -
Psychiatric/Behavioral & periodical biting, chewing, grimacing, and tongue
2518 Psychiatry
Substance Abuse protrusions. Atypical antipsychotic med most likely
to cause EPS is risperidone, and best
management to replace it with an alternative
antipsychotic.
Borderline personality disorder is characterized by
"splitting," unstable relationships, and impulsivity.
Psychiatric/Behavioral & Angry outbursts and suicidal gestures are common.
2520 Psychiatry
Substance Abuse Cluster A - Odd, eccentric
Cluster B - Dramatic, emotional
Cluster C - Anxious, fearful
Somatic symptom disorder is distinct from illness
anxiety disorder (formerly hypochondriasis), which
2521 Psychiatry involves a prolonged fear and concern about
Substance Abuse
getting or having a disease but with minimal or no
actual physical symptoms.
Patients with anorexia nervosa and bulimia
nervosa have distorted body image and can
Psychiatric/Behavioral & engage in purging behaviors. The main difference
3140 Psychiatry
Substance Abuse between diagnoses is patients with anorexia
nervosa maintain a body weight below a minimal
level for age, sex, and developmental trajectory.
Individuals w schizoid personality disorder are
socially detached and aloof but do not have
bizarre cognition. Those w schizotypal are also
Psychiatric/Behavioral & socially detached but demonstrate "magical
3146 Psychiatry
Substance Abuse thinking" and a more eccentric thought process.
Schizophreniform disorder have full-blown
schizophrenic symptoms (eg hallucinations,
delusions) that have been present 1-6 months
Lorazepam, an intermediate-duration
benzodiazepine available in IV form, is preferred in
3187 Psychiatry the inpatient setting, particularly in patients with
Substance Abuse
comorbid liver disease. Phenytoin doesn't work in
alcohol withdrawal seizures.
PCP and LSD intoxication present similarly, but
Psychiatric/Behavioral & agitation and aggression occur more often in
3191 Psychiatry
Substance Abuse patients using PCP. VH and intensified perceptions
are hallmarks of LSD use.
Inability to recall important autobiographical
information is suggestive of dissociative amnesia.
Can consist of localized or selective amnesia for a
specific period or event or generalized amnesia for
Psychiatric/Behavioral & a personal identity and life history. Onset is
3372 Psychiatry
Substance Abuse sudden and preceded by overwhelming or
intolerable events. Dissociate fugue - when
amnesia is assoc w seemingly purposeful travel or
bewildered wandering. Ddx alcohol blackouts,
drugs, medications or neurologic condition.
Dx schizoaffective d/o requires assessing the
longitudinal course of illness and determining if
there is a period of at least 2 weeks of psychotic
3376 Psychiatry symptoms in the absence of mood symptoms.
Substance Abuse
Schizoaffective d/o is distinguished from
schizophrenia by the presence of mood symptoms
for the majority of the illness.
Treatment of choice for adjustment disorder is
psychodynamic psychotherapy or brief
Psychiatric/Behavioral & psychotherapy. These 2 methods focus on
3382 Psychiatry
Substance Abuse developing coping mechanisms and on improving
the individual's response to and attitude about
stressful situations.
Kleptomania - type of impulse control d/o -
overwhelming feelings of tension or anxiety
precede impulses and are relieved with the act of
theft. Feelings of guilt or shame typically follow
these acts. Mainstay tx is psychotherapy. Limited
3385 Psychiatry evidence for medication. Psychotherapy involves
Substance Abuse
CBT orientation, focusing on techniques to resist
and mangage urges and anxiety. Family
psychoeducation is key in helping these pts to
seek mental health tx, fear of moral/legal can
hinder this
Introjection - when a battered woman who
believes her husband is right when he says she is
worthless (accepting another person's attitude into
Psychiatric/Behavioral & one's own perspective)
3535 Psychiatry
Substance Abuse Dissociation - patient rescued from a burning
building now denies any memory of the event.
Distortion - IVDA contracts Hep C and blames
inadquate Hep C control within the community.
Conversion disorder is characterized by sudden
onset of neurological symptoms and clinical
findings that are incompatible with recognized
neurological conditions. Conversion disorder is
often precipitated by stress, and patients can
3719 Psychiatry present as hysterical or strangely indifferent (la
Substance Abuse
belle indifference) to their symptoms. Somatic
symptom disorder involves one or more persistent
physical symptoms w disproportionate and
excessive anxiety, concern and energy devoted to
these symp
Somatic symptom d/o
One or more somatic symps that cause distress
or significantly disrupt daily life
Excessive thoughts or behaviors related to the
somatic symps, as demonstrated by the following:
3750 Psychiatry -Unwarranted & persistent thoughts about the
Substance Abuse
seriousness of the condition
-Persistent anxiety about health or symps
-Too much time & energy dedicated to symps
Symps persist >6mo (not all present
simultaneously)
Body dysmorphic disorder is define as an
excessive preoccupation with a slight or imagined
Psychiatric/Behavioral & bodily defect. It is best treated with medication or
3751 Psychiatry
Substance Abuse psychotherapy (not surgery) and requires a
measured, sensitive, and empathic approach that
takes into account the patient's level of insight.
Abrupt cessation of alprazolam, short acting
Psychiatric/Behavioral & benzo, is associated w significant withdrawal
3762 Psychiatry
Substance Abuse symptoms such as generalized seizures and
confusion.
Acutely psychotic patients should be assessed for
suicidal/homocidal ideation, command
Psychiatric/Behavioral & hallucinations to hurt self or others, and ability to
3794 Psychiatry
Substance Abuse care for self. Indications for involuntary psychiatric
hospitalization include being a danger to self or
others and/or grave disability.
Patients using the neurotic defense mechanism
REACTION FORMATION address their anxiety by
subsituting behavior or feelings that are the exact
opposite of their own unacceptable feelings.
3798 Psychiatry Patients usually not aware that they're doing it.
Substance Abuse
Woman angry with immigrants who compete with
her for employment. Substitutes anger with the
opposite action of offering job search advice to the
same group of people.
GAD is characterized by anxiety and fear of
scrutiny in social situations, resulting in avoidance,
distress, and social-occupational dysfunction. The
Psychiatric/Behavioral & preferred pharmacological treatment is a SSRI or
3839 Psychiatry
Substance Abuse SNRI. Cognitive behavioral therapy can also be
used as first-line treatment. Supportive
psychotherapy is helpful in treating social anxiety
disorder, althought it is not as effective as CBT.
When treating a single episode of major
depression, the antidepressant should be
Psychiatric/Behavioral & continued for a period of 6 months following the
3843 Psychiatry
Substance Abuse patient's response. If multiple episodes of
depression have occurred, maintenance therapy
will likely need to be continued for a longer period.
Minimizing conflict and stress in the home
decreases the risk of relapse in patients with
Psychiatric/Behavioral & schizophrenia. Family psycosocial interventions
3844 Psychiatry
Substance Abuse are indicated for patients with a recent psychotic
episode who have significant ongoing contact with
family members.
Because symptoms of hypochondriasis usually
develop during periods of stress, patients suffering
3845 Psychiatry from the condition should be asked about their
Substance Abuse
current emotional stressors and then referred for
brief psychotherapy.
Although primarily a 5HT-DA antagonist,
olanzapine also has affinity for Histamine, a1 and
Muscarinic receptors. Most common S/E of are
4046 Psychiatry sedation and weight gain due to antagonism of H1
Substance Abuse
and 5-HT2c receptors. Olanzapine and clozapine
cause the greatest weight gain. Hyperglycemia,
dyslipidemia, and DM are less common
Persistent depressive disorder (dysthymia) refers
to a depressed mood lasting most days for at
4051 Psychiatry least 2 years. Symptoms of a major depressive
Substance Abuse
episode may occur concurrently or intermittently in
persisent depressive disorder.
Schizoaffective disorder
Major depressive or manic episode concurrent w
symps of schizophrenia
Lifetime hx of delusions or hallucinations for >/= 2
weeks in the absence of major depressive or
manic episode
4055 Psychiatry Mood symps are present for majority of illness
Substance Abuse
Not d/t substances or another medical condition
Ddx: Major depressive or bipolar d/o w psychotic
feats: Psychotic symps occur exclusively during
mood episodes
Schizophrenia: Mood symps present for relatively
brief periods
OCD - characterized by presence of persistent,
intrusive thoughts and/or compulsive acts to allay
inherent anxieties. Patients with this condition
often perform multiple time-wasting rituals and
4063 Psychiatry recognize the irrational nature of their behavior but
Substance Abuse
feel unable to stop and are likely to suffer
significant fxnal impairment. First-line tx is SSRIs.
Clomipramine(TCA),Fluvoxamine,Fluoxetine,
Paroxetine, Setraline approved to tx OCD.
Noncompliance with antipsychotic medication is a
common cause of relapse and rehospitalization in
Psychiatric/Behavioral & patients with schizophrenia. Long-acting injectable
4067 Psychiatry
Substance Abuse antipsychotics are useful in patients who are
chronically noncompliant but have responded to
oral antipsychotics.
Circumstantiality - thought processes provide
unnecessarily detailed answers that deviate from
the topic of conversation but remain vaguely
related. Eventually, there is a return to the original
Psychiatric/Behavioral & subject. Tangentiality - abrupt permanent deviation
4137 Psychiatry
Substance Abuse from the current subject. Thought process is
minimally relevant at best and never returns to
original subject. Loose associations - lack of
logical connection between sentences. More
severe form of tangentiality.
SSRIs and SNRIs are first-line meds for tx GAD
that can also potentially treat comorbid major
Psychiatric/Behavioral & depression. Benzos should be reserved fro
4141 Psychiatry
Substance Abuse nondepressed patients w/o a hx of substance
abuse who fail to respond to or cannot tolerate
antidepressants.
Panic d/o - recurrent and unexpected panic
attacks. A panic attack involves a rush of intense
fear or discomfort that peaks w/in minutes + 4
cognitive or physical symps. Comorbidities assoc
Psychiatric/Behavioral & w panic d/o include MDD, Bipolar, agoraphobia
4285 Psychiatry
Substance Abuse (fear of public places), and substance abuse. 60%
of pts w panic d/o have had >1 lifetime episode of
MDD. ~40% of pts meet the criteria of
agoraphobia. Pts are also at a high risk of SI and
attempts.
Obsessive-compulsive personality disorder - need
for order and perfection carrying out activities in
an extremely methodical way beginning before
Psychiatric/Behavioral & adulthood. Frequently do not complete tasks in a
4815 Psychiatry
Substance Abuse timely manner due to being rigid, meticulous, and
focused on perfection. Anxiety, indecisiveness,
and perseveration on assignments. Believing their
work is superior suggests ego-syntonic beliefs.
Grief - loss and emptiness, decreasing sadness in
weeks, intermittent increases or "waves" following
reminders of the deceased, memories and
Psychiatric/Behavioral & thoughts of the deceased
4881 Psychiatry
Substance Abuse Depression - anhedonia and persistent depressed
mood, persistent and less specific sadness, more
negative and self-critical ruminations, feelings of
worthlessness and self-loathing
The extrapyrimidal side effects of antipsychotics
Psychiatric/Behavioral & can be treated with anticholinergic medications like
4886 Psychiatry
Substance Abuse benztropine. EPS - rigidity, bradykinesia, tremor,
and akathisia.
Neuroleptic Malignant Syndrome is a potentially
life-threatening condition that can occur after
administration of antipsychotic medications.
Psychiatric/Behavioral & Symptoms include fever, rigidity, altered mental
4887 Psychiatry
Substance Abuse status, and autonomic instability. Tx includes DC
all antipsychotics, aggressive monitoring in ICU,
control of hyperthermia, maintenance of
electrolyte balance.
Specific phobia is the fear of a specific object or
Psychiatric/Behavioral & situation. Like the guy who was afraid of flying.
4905 Psychiatry
Substance Abuse BEHAVIOR THERAPY using exposure techniques
is the preferred treatment.
Antipsychotics are mainstay tx for schizophrenia.
No evidence that one is better than another.
Clozapine is unique in that it has shown superiority
intx-resistant-schizophrenia,andschizophrenia
7957 Psychiatry assoc w persistent suicidality. Risk of
Substance Abuse
agranulocytosis is high so clozapine is reserved
for the more difficult cases. Use requires
monitoring of the pt's CBC. Other A/E - Seizures,
myocarditis, metabolic syndrome.
Classification of psychiatric illnesses by phase is
necessary to determine the appropriate
pharmacotherapy. Treatment response occurs
when a patient demonstrates significant
Psychiatric/Behavioral & improvement (with or without a remission),
8841 Psychiatry
Substance Abuse generally defined as a 50% reduction in the
baseline level of severity. Illness has 3 phases
Acute(remission or response),
Continuation(sustained remission or relapse), and
Maintenance(recovery, or later, recurrence).
Hoarding d/o is responsive to tx with SSRIs and
CBT. Likely hereditary basis. Stress may intensify
symptoms, onset occurs during adolescence or
8875 Psychiatry young adulthood, significant lag time between
Substance Abuse
onset of symptoms. Deep-brain stimulation is used
in pts who have been refractory to medications w
OCDs (including hoarding syndrome).
Psychiatric/Behavioral & Survivors of sexual assault are at high risk for
8915 Psychiatry
Substance Abuse developing PTSD, depression, and suicidality.
Cognitive-behavioral therapy focuses on reducing
automatic negative thoughts and avoidance
8938 Psychiatry behaviors that cause distress. It is effective as
Substance Abuse
monotherapy or in combination with medical for a
wide range of psychiatric disorders.
Access to firearms is the greatest risk in
Psychiatric/Behavioral & completing homocide. Other important risk factors
9841 Psychiatry
Substance Abuse include a history ov violence, substance abuse,
and high levels of impulsivity.
Psychiatric/Behavioral & Teenagers with serious SI must be hospitalized
10754 Psychiatry
Substance Abuse and their parents informed of the situation.
Meds that block D2 receptor cause EPS. MCC
include typical antipsychotics, some atypical
Psychiatric/Behavioral & antipsychotics (risperidone) and antiemetics
10780 Psychiatry
Substance Abuse (metclopromide). Acute dystonia is sudden onset
of sustained muscle contractions resulting in
twisting and abnormal postures (torticollis).
Medication-induced psychosis is characterized by
delusions and/or hallucinations that are temporally
assoc w the use of new medication and rapid
Psychiatric/Behavioral & onset of symps while the med is being used.
11790 Psychiatry
Substance Abuse Glucocorticoids, particularly at high doses, are
often implicated in new-onset psychotic symps in
pts who may have no current underlying
psychiatric illness.
Postpartum psychosis - MC occurs w/in first
weeks after birth & can present w delusions,
hallucinations,thoughtdisorganization,and/or
bizarre behavior. Symps of a mood d/o are
Psychiatric/Behavioral & common. Although rare, it is a medical
11876 Psychiatry
Substance Abuse emergency. Women can develop delusions and
hallucinations that could result in infanticide (eg,
mother believes baby's evil, hears commands to
kill baby). Mgmt - hospitalization, antipsychotic
medication, & tx of underlying d/o.
Panic d/o
Recurrent & unexpected panic attacks w >/= 4 of
the following:
Chest pain, palpitations, SOB
Trembling, sweating, nausea
Psychiatric/Behavioral & Dizziness,paresthesias
11894 Psychiatry
Substance Abuse Derealization,depersonalization
Fear of losing control, dying
Worry about additional attacks, avoidance behavior
Tx
Immediate: Benzos
Long-term: SSRI/SNRI &/or CBT
Akathisia should be considered if a psychotic
patient worsens clinically as the dose of
11898 Psychiatry antipsychotic is increased. Tx includes decreasing
Substance Abuse
the antipsychotic dose and tx w propanalol or
lorazepam
SLE can affect the CNS and manifest w both
acute and chronic psychiatric symptoms, including
Psychiatric/Behavioral & psychosis, depression, mania & anxiety. Seizures,
11967 Psychiatry
Substance Abuse headaches, peripheral neuropathy, strokes,
chorea are other neuropsychiatric manifestations
seen in SLE.
Massive PE is PE complicated by hypotension
and/or acute right heart strain. JVD on phys exam
and RBBB on EKG are signs of acute right heart
strain. Survival following massive PE is poor w
death often occurring w/in 1 hour of symps.
2145 Medicine Pulmonary & Critical Care Massive PE can be confirmed w CT pulmonary
angiography. Although echo has poor sensitivity,
massive PE often has visible echo abnlties that
allow for rapid bedside dx. Fibrinolysis is in the tx.
Recent surgery (w/in 10 days) is a
contraindication.
Hypertrophic osteoarthropathy (HOA) is a
condition where digital clubbing is accompanied by
sudden-onset arthropathy, commonly affecting the
wrist and hand joints. HPulmonaryOA (HPOA) is a
2298 Medicine Pulmonary & Critical Care
subset of HOA where the clubbing and arthropathy
are attributable to underlying lung dz like lung ca,
TB, bronchiectasis, or emphysema. CXR is
indicated to identify cause of HPOA.
S/S of PE are nonspecific and highly variable. Dx
should be suspected in any pt who presents w
some combinations of sudden-onset SOB, pleuritic
2300 Medicine Pulmonary & Critical Care chest pain, low-grade fever, and hemoptysis.
Tachypnea, tachycardia, and hypoxemia are
common exam findings. Calf swelling & virchow's
triad aren't always present in PE
Pancoast tumor
Shoulder pain (MC)
Horner's syndrome - ipsilateral ptosis, miosis,
enophthalmos, & anhidrosis) from involvement of
paravertebral sympathetic chain & inferior cervical
ganglion
C8-T2neurologicalinvolvement
Weakness and/or atrophy of intrinsic hand muscles
Pain & paresthesias of 4th & 5th digits, medial
arm, and forearm
Supraclavicular lymph node enlargement
Weight loss
SIADH is common w small cell lung cancer. Tx is
fluid restriction. Severe symptomatic or resistant
2636 Medicine Pulmonary & Critical Care hyponatremia from SIADH requires administration
of hypertonic saline. Demeclocycline is rarely
necessary.
Criteria for ARDS
New or worsening resp symptoms during past
week or w/in 1 week of known clinical insult
Bilateral lung opacities on imaging consistent w
pulmonary edema
No signs of cardiac failure or fluid overload
Objective assessment (eg, echo) to definitively
exclude hydrostatic pulmonary edema in pts w/o
ARDS risk factors
Severity of hypoxemia as defined by PaO2/FiO2
ratio (PF) </=300 mmHg w PEEP >/= 5 cmH2O
Mild PF 200-300 mmHG
Moderate PF 100-200
Severe PF </= 100
A1AT is a serum protein that inhibits several
proteolytic enzymes (pancreatic trypsin,
chymotrypsin, neutrophil elastase). Also is an
acute-phase reactant that plays a significant role
2919 Medicine Pulmonary & Critical Care in inflammatory states. A1AT deficiency is due to
a mutated gene on chromosome 14. It can be mild
to very severe. It results in liver cirrhosis and
panacinar emphysema (by age 40 in smokers, and
53 in nonsmokers).
Bird fancier's lung (a type of hypersensitivity
pneumonitis). HP - repeated inhalation of inciting
antigen -> alveolar inflamm. Aerosolaized bird
droppings & molds. Hx of antigen exposure in
setting of compatible symps is highly suggestive.
Acute episodes present w cough, breathlessness,
fever & malaise. Chronically pts may develop
pulmonary fibrosis and restrictive pattern on
spirometry. Ground glass opacity, "haziness" of
lower lung fields. Best tx is avoiding antigen expos
ARDS is associated with hypoxemia (PaO2/FiO2
< or = 300mmHg) and bilateral alveolar infiltrates.
ARDS is due to impaired gas exchange,
decreased lung compliance (stiff lungs) and
increased pulmonary arterial pressure (pulmonary
hypertension).
Smoking + asbestos = bronchogenic carcinoma.
Asbestosis seen in plumbers, carpenters,
electricians, construction, shipbuilders, plastic or
rubber manufacturing, pipefitters, and insulation
workers. Asbestosis and bronchogenic CA can
present similarly except the former can remain
asymptomatic for up to 20-30 years. Cough,
sputum, wheezing not typically present.
Asbestosis - prolonged asbestos exposure
(shipyard, mining & construction workers, pipe
fitters), symptoms dvlp >20 years after initial
exposure, progressive dyspnea over months,
bibasilar end-inspiratory fine crackles & clubbing,
3022 Medicine Pulmonary & Critical Care inc risk for malignancies (lung ca, malignant
mesothelioma)
Hx & clinical findings of exposure (pleural plaques
on chest imaging is pathognomonic), interstitial
fibrosis on imaging or histo, PFTs showing
restrictive pattern, exclusion of other dzs
Beta-2 agonists like albuteral reduce serum
potassium levels by driving potassium into cells. In
some pts, clinically significant hypokalemia can
3026 Medicine Pulmonary & Critical Care result, causing muscle weakness, arrhythmias,
and EKG changes. Other common s/e of beta-2
agonists include tremor, headache, and
palpitations.
Mild intermittent asthma, least severe form,
symptoms </= 2x/wk, </= 2 nighttime
awakenings/month, w normal FEV1 and no
limitations on activity. For this form of asthma, only
3027 Medicine Pulmonary & Critical Care a PRN albuterol inhaler is required. Daily
controlloer corticosteroids are reserved for
persistent asthma (mild persistent >2days/wk but
<daily, nigghttime awakenings 3-4x/mnth, minor
activity limitations, normal PFTs).
Recurrent pneumonias in the same anatomic
region of the lung suggest bronchial obstruction d/t
underlying abnormality. Bronchogenic carcinoma is
the msot concerning possiblity. Other possible
causes are: carcinoid tumor, foreign body,
bronchial stenosis. Chest CT is indicated to
visualizeunderlyingparenchymalabnormalities.
Bronchoscopy is invasive and reserved for pts w
masses documented by CT. It would the next step
in pts w neg CT w high suspicion for obstruction.
SOB, productive cough, & evidence of destruction
of the lower lung lobes -> AAT deficiency. AAT
deficiency-related lung dz presents similarly to
other forms of COPD but results in panacinar
(panlobular)emphysema.Smoking-induced
3031 Medicine Pulmonary & Critical Care centriacinar emphysema affects the upper lobes.
Panacinar emphysema of AAT deficiency
classically affects lower lobes. 1) COPD at young
age (</= 45 yrs) 2) COPD w minimal or no
smoking hx 3) basilar-predominant COPD 4) Hx -
unexplained liver disease
Uvulopalatopharyngoplasty (surgery for OSA) is
indicated when CPAP, oral applicances, and
weight loss have proven ineffective in treating
OSA.
Bronchiectasis
S/S: cough w sputum production most of the
week. Rhinosinusitis. Dyspnea, hemoptysis,
pleurisy. Wheezing, crackles, digital clubbing.
Etiology: Airway obstruction, congenital,
immunodeficiency, post-infectious, Rheumatic &
systemic dz, toxic inhalation/aspiration
Evaluation:CBD-D,Immunoglobulinquantification.
Sputum culture/smear for bacteria, fungi, TB. High
res CT. PFTs.
Long-term supplemental oxygen therapy has been
proven to prolong survival in pts w COPD and
3042 Medicine Pulmonary & Critical Care hypoxemia. Criteria for therapy include
PaO2</=55, SaO2</=88%, erythrocytosis
(hct>55%), or evidence of cor pulmonale
Idiopathic pulmonary fibrosis is d/t excessive
collagen deposition in peri-alveolar tissues. This
leads to decreased lung volumes (low TLC, FRC,
3045 Medicine Pulmonary & Critical Care and RV) w preserved or increased FEV1:FVC
ratio. Patients have impaired gas exchange
resulting in reduced diffusion capacity of carbon
monoxide and increased A-a gradient.
ILD can be d/t known causes (infxns, connective
tissue dz) or idiopathic (IPF, cryptogenic
organizing pneumonia). Dx is based on clinical
feats, PFT, and radiographic imaging. However,
lung bpx may be required in pts who have an
unclear dx after initial assessments. Those w/o an
identifiable environmental, infectious, or AI etiology
likely have IPF.
Sarcoidosis - systemic granulomatous disease of
unknown etiology that affects multiple organ
systems - lungs, skin, eyes, liver, kidney and/or
heart. Young- to middle-aged African American
women MC affected. Presentation - insidious w
progressive dyspnea & chronic nonproductive
cough. Pulm sarcoidosis: interstitial inflammation
-> fibrosis. Dry rales heard. CXR: bilateral hilar
ladpy & diffuse interstitial infiltrates. 1/4 of pts w
sarcoidosis - ant uveitis.
Ventilation = RR * TV. Resp alk - hyperventilation.
3048 Medicine Pulmonary & Critical Care Mech vent w resp alk -> RR or TV should be
lowered.
Granulomatosis w polyangiitis triad:
Systemic vasculitis
Upper & lower airway granulomatous inflammation
Glomerulonephritis
Nasal cartilage destruction (leading to saddle
nose) and vasculitic cutaneous lesions (tender
nodules, palpable purpura, ulcerations) are
common external manifestations.
Short-acting beta-adrenergic agonists
administered 10-20 mins before exercise are the
first-line tx for exercise-induced
3050 Medicine Pulmonary & Critical Care bronchoconstriction if req only few times a week
(less than daily). Inhaled corticosteroids or
antileukotriene agents can be used in pts who
exercise daily.
ARDS develops in the setting of sepsis, severe
bleeding, severe infxn, toxic ingestions, or burns.
ARDS develops when inflammatory mediators
damage the alveoli. Resultant incr alveolar
capillary permeability allows fluid to leak into the
alveoli causing pulmonary edema.
Goodpasture's dz - MC in young males. Renal
findings - nephritic range proteinure (<1.5g/day),
ARF, & urinary sediment w dysmorphic red cells
and red cell casts. Pulmonary findings include
3579 Medicine Pulmonary & Critical Care SOB, cough, & hemoptysis. Underlying cause is
antibodies to the alpha-3 chain of type IV collagen,
a protein expressed most strongly in the
glomerular & alveolar BMs. Renal Bpx - Linera
IgG deposition along glomerular BM on DIF.
Granulomatosis w Polyangiitis (GPA) - systemic
vasculitis of small- and medium-sized arteries w
high incidence among caucasians 30-50
Upper airway: Bloody/purulent nasal discharge,
oral ulcers, and sinusitis
Lower airway: Dyspnea, cough, hemoptysis
Renal: Renal insufficiency, microscopic hematuria,
RBC casts (RPGN)
Systemic: Fever, weight loss, fatigue
CXR: nodular densities & alveolar/pleural opacities
c-ANCA is + in >90% of affected ppl
Bpx from affected area makes Dx
Warfarin dosing should be adjusted to maintain a
goal INR appropriate for the condition being
treated. For pts w idiopathic VTE or Afib, a target
INR of 2-3 provides adequate anticoagulation w/o
excessive risk of bleeding. Warfaring inhibits vit-K
dependent coag factors of the extrinsic clotting
pathway, reflected in PT. INR is the ratio of pts
PT to a standard international reference PT.
In all COPD pts, home O2 therapy and smoking
3716 Medicine Pulmonary & Critical Care cessation are the two modalities shown to dec
mortality.
Acute PE is associated w a mortality rate of
approx 30%, w recurrent PE the MCC of death.
Early and effective anticoagulation decreases the
3717 Medicine Pulmonary & Critical Care mortality risk w acute PE to about 2-8%. Early
empiric anticoag should be initiated prior to
pursuing dx testing in pts w high clinical suspicion
of acute PE.
Germ cell tumors typically affect young patients
and display aggressive biologic behavior.
Nonseminomatous germ cell tumors produce both
AFP and hCG tumor markers.
Aspergilloma - hemoptysis, fever, weight loss and
a chronic cough. The mass is usually mobile and
moves w position. The dx is made by finding
hyphae in the specimen.
MC adverse effect assoc w the use of any inhaled
corticosteroid is oropharyngeal candidiasis (oral
thrush). High doses can lead to inc systemic
absorption and can produce adrenal suppression,
3846 Medicine Pulmonary & Critical Care cataract formation, dec growth in children,
interference w bone metabolism and purpura.
These systemic effects are dose-dependent and
occur in pts who are on high-dose inhaled steroids
for prolonged period of time.
Massive PE - PE + Syncope, Shock,
Hemodynamic Instability
Mitral Stenosis - Gradual & progessively
worsening dyspnea on exertion, orthopnea, &
hemoptysis (d/t pulmonary edema). Symps are
precipitated by conditions that cause tachycardia
(fever, anemia, pregnancy). Auscultation show a
loud first heart sound, opening snap after S2 and
low-pitched diastolic rumble best heard at apex.
Left atrium hypertrophy can compress the
recurrent laryngeal nerve to cause persistent
cough or hoarse voice.
Common causes of CAP - S pneumo,
Haemophilus, & atypical organisms. Empiric outpt
tx of healthy pts include doxy or macrolides.
4024 Medicine Pulmonary & Critical Care Hospitalized pts require an extended-specture
fluroquinolone (levo, moxi) or a beta-lactam +
macrolide. CURB-65 can determin the need for
admission & inpt therapy.
Glucocorticoids cause neutrophilia by increasing
the bone marrow release and mobilizing the
marginated neutrophil pool. Eosinophils and
lymphocytes are decreased.
Acute COPD exacerbation - Supplemental O2,
Bronchodilators, and systemic glucocorticoids.
Antibiotics are indicated for pts with the following:
2/3 cardinal symptoms of ACOPDE (incr dyspnea,
cough, and sputum production).
Moderate-to-severe COPD exacerbation, or
Those requiring mechanical ventilation.
Commonly used Abx include macrolides,
fluoroquinolones,orpenicillins/beta-lacatamase
inhibitors. Typical duration of abx tx is 3-7 days.
Initial AECOPD mgmt - inhaled SABA,
glucocorticoids, and abx. Pts w continued symps
despite medical mgmt should be considered for
noninvasive ventilatory support. NPPV decreases
work of breathing, improves alveolar ventilation,
and is the preferred method of respiratory support
in pts w AECOPD. Invasive mechanical ventilation
may be required in hypercapnic pts w poor mental
status, hemodynamic instability, or profound
acidemia. Or if 2hr trial of NPPV don't work.
Theophylline has a narrow therapeutic index,
toxicity can occur easily d/t saturation of metabolic
pathways. It's metabolized by cytochrome oxidase
in the liver. Inhibition of enzymes by concurrent
4048 Medicine Pulmonary & Critical Care illness (cirrhosis, cholestasis, resp infxns w fever)
or drugs (cimetidine, cipro, erythro, clarithro,
verpamil) can raise serum conc. Tox: CNS
stimulation (headache, insomnia, seizures), GI
(nausea, vomiting) & Cardiac (arrhythmia)
CHF causes transudative effusions however 25%
of these can meet exudative criteria if the pt has
received aggressive diuretics prior to
thoracentesis. Effusions are usually bilateral
4053 Medicine Pulmonary & Critical Care (61%) but can be unilateral, on the right (27) or
left (12%). Normal pleural fluid pH is 7.6.
Transudative fluid usually has a pleural fluid pH of
7.4-7.44. Acidic pH is assoc w malignancy,
infection (pneumonia, empyema).
Aspirin-exacerbated respiratory disease (AERD)
is a non-IgE-mediated rxn that results from
aspirin-inducedprostaglandin/leukotriene
misbalance. It is most often seen in pts w a hx of
4065 Medicine Pulmonary & Critical Care asthma or chronic rhinosinusitis w nasal polyposis.
AERD - bronchospasm and nasal congestion
following aspirin ingestion. Tx - avoid NSAIDs,
desensitization if NSAIDs are required, and use of
leukotriene receptor antagonists (eg, montelukast).
Diagnostic thoracentesis is the preliminary
investigation of choice in the management of
pleural effusion, except in patients with classic
signs and symptoms of CHF, where a trial of a
diuretic is warranted. Lung carcinoma, breast
carcinoma, and lymphoma are the three tumors
that cause approximately 75% of all malignant
pleural effusions.
All patient w suspected pneumonia should be
assessed w a CXR. Sputum testing for microbial
4097 Medicine Pulmonary & Critical Care dx is optional in the outpatient setting d/t low yield
of culture results and high success rate of tx w
empiric abx.
Normal PCO2 is one indicator of a sever asthma
attack. During asthma exacerbation, hypervent is
usu present, and work of breathing is inc. PO2 is
usu depressed bc of V/Q mismatch, and
tachypnea is usu present. PCO2 is dec due to
hyper vent. Normal to inc PCO2 values indicate
CO2 retention bc of severe airway obstruction
and/or resp muscle fatige. Other indicators -
speech difficulty, diaphoresis, altered sensorium,
cyanosis, "silent" lungs.
H cap is a common and usually asymptomatic
infection in endemic areas like Mississippi and
Ohio River valleys and Central America. It is
usually found in soil with a high concentration of
bird or bat guano droppings. Less than 5% of
4114 Medicine Pulmonary & Critical Care infected ppl develop the symptomatic disease.
Extent of disease is determined by the amount of
exposure and immunity of the host. Characterized
by self-limiting fever, chills, and a non-productive
cough. CXR may show patchy lobar or
multinodular i
P. jiroveci - Bilateral diffuse interstitial infiltrates
4115 Medicine Pulmonary & Critical Care beginning in the perihilar region is a characterisitc
finding on CXR.
FEV1/FVC is decreased in COPD, as opposed to
normal in restrictive lung dz. Diffusing capacity of
4116 Medicine Pulmonary & Critical Care the lung (DLCO) is decreased in emphysema and
normal in chronic bronchitis. DLCO is also
decreased in interstitial lung diseases.
Risk factors for aspiration pneumonia include
altered consciousness d/t excessive EtOH intake,
neurologic dysphagia, or mechanical disruption of
glottic closure. Recurrent pneumonia involving the
same anatomic region of the lung is usu d/t local
obstruction or recurrent aspiration. Pts need abx
(clindamycin, ampicillin-sulbactam) or they run a
high risk of developing an abscess.
Advanced dementia -> impaired swallowing and
4119 Medicine Pulmonary & Critical Care epiglottic reflex -> Community-acquired
pneumonia.
All COPD patients w PaO2 <55 mmHG or SaO2 <
88% are candidates for long-term home O2 tx.
4131 Medicine Pulmonary & Critical Care Pts w signs of pulmonary htn or hct >55% should
be started on home oxygen when the PaO2 <60
mmHg.
Pulmonary HTN:
1. Pulm htn assoc w d/o of resp systen,
hypoxemia, or both
2. Pulm htn d/t pulm venous htn (left ventricular dz,
mitral valve dz, or pulmonary veno-occlusive dz)
3. Pulm htn following chronic thromboembolic dz
4. Pulm arterial htn (primary pulm htn, pulm htn
assoc w vasculopathy)
5. Pulm htn d/t d/o directly affecting pulm
vasculature (pulm capillary hemangiomatosis)
Sarcoidosis: Pulmonary - bilateral hilar
adenopathy, interstitial infiltrates. Ophthalmic-
Ant&post uveitis. Reticuloendothelial - Peripheral
lymphadenopathy, hepato and/or spleno megaly.
4200 Medicine Pulmonary & Critical Care Musculoskeletal - Acute polyarthritis (ankles),
chronic arthritis w periosteal bone resorption.
CNS/Endocrine - Central DI, hypercalcemia.
Lofgren's Syndrome - Erythema nodosum, hilar
adenopathy, fever, migratory polyarthralgias
Nonallergic rhinitis usually presents w one of the
chronic rhinitis symps (nasal congestion,
rhinorrhea, sneezing, and postnasal drainage) w/o
a specific etiology. Routine allergy testing is not
4201 Medicine Pulmonary & Critical Care necessasry prior to initiating empiric tx. Depending
on severity of the symps, pts should be tx w
intranasal antihistamine(only first generation, those
w anticholinergic props, work), intranasal
glucocorticoids, or combination therapy.
PAO2 = (FiO2 x [Patm - PH2O]) - (PaCO2/R). An
elevated A-a gradient is caused by any process
4208 Medicine Pulmonary & Critical Care that results in impaired gas exchange. Interstitial
disease, and processes that result in V/Q
mismatching, such as pulmonary embolism.
Pulmonary aspergillosis - immunocompromised,
asthma, copd, cavitary lung disease (TB),
sarcoidosis, malignancy - pleuritic chest pain,
dyspnea, cough, hemoptysis - Positive Aspergillus
4210 Medicine Pulmonary & Critical Care IgG PLUS radiographic evidence: single/multiple
nodules, cavities (+/- fungal ball), consolidation,
peribronchial infiltrates - Aspergilloma: surgical
resection, Invasive aspergillosis: voriconazole or
caspofungin
Solitary pulmonary nodule defined by: Rounded
opacity, <3cm, Completely surroundd by
pulmonary parenchyma, no assoc lymph node
enlargement. 1st step is to determine the risk of
malignancy. Nodule size, patient age, smoking
4252 Medicine Pulmonary & Critical Care status, years since smoking cessation, nodule
margins. Risk categorized as low, inter, or high.
Surgical excision is for high risk nodules, growing
nodules on serial imaging, and +
18-fluorodeoxyglucose PET scans, and suspected
malignancy on tissue path.
CorPulmonale
COPD is MCC
Gradual onset but can present acutely d/t sudden
incr in pulmonary artery pressure
Exertional symps (dyspnea, angina, syncope)
Loud P2, TR murmur (holosystolic @ left lower
sternal border), incr JVP, peripheral edema,
hepatomegaly, ascites
CXR: enlarged pulm arteries, loss of retrosternal
air space. EKG: right axis deviation, RBBB, RVH,
right atrial enlargement. Right heart cath is gold
standard for dx & shows elevated CVP, RVEDP
Recurrent bacterial infxns suggests
immunodeficiency w involvement of humoral
immunity.Selectiveimmunoglobulindeficiency
include IgA and/or IgG is a possible dx. Selective
def of IgG3 is common in adult females and is
assoc w recurrent sinopulmonary and GI infxns.
Quantitative measurement of serum
immunoglobulin levels helps to establish dx.
Wells criteria for pretest probability of PE. <2 low
risk, 2-6 mod risk, >7 high risk. PE typically
presents w dyspnea, tachypnea and tachycardia.
Occlusion of a peripheral pulmonary artery by
thrombus may cause pulmonary infarction with
pleuritic pain and hemoptysis.
Exam of resp system - inspection, palpation,
percussion, ausculatation. In consolidated lungs -
there is dullness to percussion. Sound conduction
through the consolidated region will result in
bronchial breath sounds, which are louder with
more prominent expiratory component (than the
normal vesicular sounds). This is true only if
airway is patent. If airways are blocked the breath
sounds over consolidated tissue would be
decreased.
Light's criteria states that pleural fluid is exudative
if the fluid protein/serum protein ratio is >0.5, the
fluid LDH/serum LDH is >0.6, or the pleural fluid
4467 Medicine Pulmonary & Critical Care LDH is greater than 2/3 the upper limits of normal
serum LDH. Exudates are caused by incr capillary
permeability while transudates are caused by incr
hydrostatic or decreased oncotic pressure.
Obesity hypoventilation syndrome (OHS) is
defined by obesity (BMI>30), daytime hypercapnia
(PaCO2 >45), and alveolar hypoventilation. ABG
shows hypercapnia, hypoxemia, and respiratory
acidosis as a result of altered lung mechanics d/e
obesity and nocturnal hypoventilation. Weight loss
and noninvasive positive pressure ventilation are
first-line therapies for OHS.
3 most common causes of chronic cough are
upper-airway cough syndrome (postnasal drip),
asthma, and GERD. Dx of upper-airway cough
syndrome is confirmed by the elimination of nasal
discharge and cough with the use of H1 recepter
antagonists.
Spontaneous PTX commonly caused by COPD.
Cigarette smoking markedly increases the risk of
PTX, and is thought that smoking leads to chronic
airway inflammation and a form of respiratory
4520 Medicine Pulmonary & Critical Care bronchiolitis. Chronic destruction of alveolar sacs
leads to formation of large alveolar blebs (gen in
upper lobes), which can eventually rupture and
leak air into pleural space. Pts w PTX - acute
onset chest pain & SOB.
Conditions assoc w digital clubbing
Intrathoracic neoplasms - Bronchogenic
carcinoma, Metastatic cancers, Malignant
mesothelioma, Lymphoma
Intrathoracic suppurative dzs - Lung abscess,
empyema, bronchiectasis, CF, Chronic cavitary
infxns (fungal, mycobacterial)
Lung disease - Idiopathic pulm fibrosis,
asbestosis, Pulmonary AVMs
CV disease - Cyanotic congenital heart disease
Acute pancreatitis can cause ARDS in up to 15%
of patients. The first step in the initial ventilator
management of ARDS is usually to decrease the
FiO2 to relatively non-toxic values (i.e. <60%).
PEEP may be increased as needed to maintain
adequate oxygenation after the FiO2 is lowered.
ARDS - diffuse injury to pulmonary capillary
endothelium and alveolar epithelium resulting in
leakage of protein-rich fluid into the alveolar and
interstitial spaces. This fluid forms hyaline
membranes that predispose to alveolar collapse
and impaired pulmonary gas exchange.
Oxygenation can be improved by increasing FiO2
or adding PEEP. Want to keep FiO2 below 40%.
Acute bronchitis is a common cause of
blood-tinged sputum and is mostly viral in etiology.
Observation and close clinical follow-up is the best
4566 Medicine Pulmonary & Critical Care tx strategy for new-onset blood-tinged sputum in
an afebrile pt w acute bronchitis but no significant
signs of more serious dz (eg, pneumonia,
malignancy).
Empyema - intrapleural collection of pus - MC d/t
bacterial seeding of parapneumonic effusion in the
setting of bacterial pneumonia. Also direct
inoculation of bacteria during surgical procedures.
Causes of empyema mirror those of pneumonia (S
4568 Medicine Pulmonary & Critical Care pneumo, S aureus, & k pneumo). Mixed aerobic &
anaerobic bacteria take over as pleural effusion
becomes empyema; one reason empyema is
unresponsive to abx nlly used to tx CAP. Tx:
drainage & abx
CXR: early free flowing late loculated w
COPD exacerbation is characterized by an acute
worsening of symps in a pt w chronic lung
disease. It is commonly triggered by an URTI.
4569 Medicine Pulmonary & Critical Care Exam often shows wheezes, prolonged expiration,
crackles at lung bases, and use of accessory
muscles. ABG may show compensated (chronic)
resp acidosis & hypoxemia.
Pt's w worsening CHF commonly have bibasilar
crackles. Decreased breath sounds at the bases
could be due to pleural effusions. Wheezing can
4570 Medicine Pulmonary & Critical Care occasionally be present (cardiac asthma). ABGs
show hypoxia, hypocapnia, and respiratory
alkalosis. Signs of fluid overload, S3 n S4 gallops,
cardiomegaly.
S/S - Ankylosing Spondylitis
Low back pain (age <40, insidious onset,
improves w exercise but not w rest, pain at night)
Hip & buttock pain
Ltd chest expansion & spinal mobility
4575 Medicine Pulmonary & Critical Care Enthesitis (inflammation at the site of insertion of a
tendon to the bone)
Systemic symptoms (fever, chills, fatigue, weight
loss)
Acute anterior uveitis (unilateral pain, photophobia,
blurry vision)
Evaluation of a solitary pulmonary nodule detected
in CXR includes comparison w old imaging, if
available, followed by chest CT. Decision to
observe, biopsy, or surgically resect the nodule is
based on its size and characteristics as well as
the pts age and smoking hx.
Light's criteria:
-Pleural fluid protein/serum protein ratio >0.5
-Pleural fluid lactate dehydrogenase (LDH)/serum
4613 Medicine Pulmonary & Critical Care LDH ratio >0.6
-Pleural fluid LDH > 2/3 of the upper limit of
normal for serum LDH
An exudate has at least 1 of the above criteria.
Fixed upper-airway obstruction - limits airflow
4630 Medicine Pulmonary & Critical Care during inspiration and expiration, causing flattening
of the top and bottom of the flow-volume curve.
Right mainstem bronchus intubation is a relatively
common complication of endotracheal intubation. It
causes asymmetric chest expansion during
inspiration and markedly decreased or absent
breath sounds on the left side on auscultation.
Repositioning the endotracheal tube by pulling
back slightly will move the tip b/t the carina &
vocal cords & solve the problem.
FEV1:FVC < 0.7 in COPD. As airflow limitation
increases, more air is trapped during expiration
4645 Medicine Pulmonary & Critical Care and residual and total lung volumes increase. Air
trapping and airflow obstruction also decrease
vital capacity.
Obesity hypoventilation syndrome is a long-term
consequence of severe obesity and untreated
4663 Medicine Pulmonary & Critical Care OSA. It causes chronic hypercapnic/hypoxic resp
failure, secondary erythrocytosis, pulmonary htn,
and cor pulmonale.
Large lung volumes + diaphragmatic flattening
make it more difficult to decrease intrathoracic
pressure during inhalation, thus increasing the
work of breathing. Lung volume reduction surgery
involves excising the emphysematous tissue. This
increases diaphragm length and returns it's
curvature. It's also thought to decrease FRC;
improve the interplay between diaphragm, chest,
and abd walls; incr exercise capacity; & reduce
work of breathing
Seizure w ABG showing acidosis. First determine
respiratory or metabolic. Elevated pCO2 is resp
due to hypoventilation. Low bicarb is metabolic.
Resp acidosis can be assoc w prolonged seizures
resulting in apnea or hypopnea or an aspiration
event.
Hodgkin lymphoma is curable lymphoma that tends
to affect young pts. Unfortunately, pts, esp those
tx before age 30 can develop secondary
malignancies from CTX and/or RTX. There's
18.5-fold incr risk of developing a 2nd cancer in
HL pts compared to gen pop. Incidence is 10%
w/in 20 yrs and 30% by 30 yrs. MC secondary
solid tumor malignancies are lung (esp smokers),
breast, thyroid, bone and GI. In addition, incr risk
of subsequent acute leukemia or non-HL.
Acute-onset pleuritic chest pain, hemoptysis, &
tachycardia - PE. Hemoptysis is a result of
Pulmonary Infarction. Low-grade fever and mild
leukocytosis are also common w PE. HIV &
hemoconcentration d/t dehydration in the settting
of a recent GI illness are RF for PE. Chest CT
shows wedge-shaped, pleural based opacification.
On contrast-enhanced CT, PE will appear as pulm
artery filling defect. PE causes transudative &
exudative effusions.
Patients with severe asthma exacerbation should
receive inhaled short-acting B2 agonists, inhaled
ipratropium, and systemic corticosteroids.
Elevated or even normal partial pressure of
carbon dioxide suggests failure of medical therapy
and impending respiratory collapse. These
patients require endotracheal intubaion and
mechanicalventilation.
Peak airway pressure is the sum or airway
resistance and plateau pressure. The plateau
pressure is the sum of the elastic pressure and
4713 Medicine Pulmonary & Critical Care positive end-expiratory pressure (PEEP) and is
calculated by peforming the end-inspiratory hold
maneuver. PEEP is calculated w the
end-expiratory hold maneuver.
Malignancy (prothrombotic state) & acute
presentation of dyspnea, chest pain, tachycardia,
hypoxia, and clear lungs -> Pulmonary Embolism
(PE). Pts w acute massive PE can present w
syncope and hemodynamic collapse. Acute
4716 Medicine Pulmonary & Critical Care massive PE -> Incr PVR -> Incr RVP -> Incr RV
wall tension, cardiac muscle stretching, & dilation
-> Incr RV O2 demand -> Decr coronary artery
perfusion -> Supply/demand mismatch -> RV
ischemia -> RV dysfxn -> decr venous return to
left atrium, decr CO
Supplemental O2 in pts w advanced COPD can
worsen hypercapnia d/t a combination of
increased dead space perfusion causing
4718 Medicine Pulmonary & Critical Care ventilation-perfusion mismatch, decreased affinitiy
of oxyhemoglobin for CO2, and reduced alveolar
ventilation. The goal of oxyhemoglobin saturation
in these pts is 90-93%
Early phases of acute pneumonia w consolidation
can have persistent blood flow to areas w
impaired ventilation. This leads to a physiologic
4770 Medicine Pulmonary & Critical Care intrapulmonary (right-to-left) shunt and arterial
hypoxemia. Positionin of the patient w the affected
lung in the dependent position can worsen the
shunt.
Pulmonary Embolism will cause pulmonary
hypertension. The PE can occlue part of the
pulmonary artery causing increased Right Atrial,
Right Ventricular, and Pulmonary Artery
pressures. This results in hyperdynamic left
ventricular fxn w increased cardiac index
(CO:BSA). PCWP and SVR are generally not
affected. Massive PE causes right atrial pressure
>10mm Hg and pulmonary artery pressure >40mm
Hg.
A normal or increased FEV1/FEV ratio w a low
VC is seen in restrictive lung disease. The DLCO
4863 Medicine Pulmonary & Critical Care is decreased w interstitial lung disease.
Neuromuscular disorders are not associated w a
decreased DLCO.
Pulmonary airway disease (eg, chronic bronchitis,
bronchogenic carcinoma, bronchiectasis) is the
MCC of hemoptysis in adults w/ a hx of smoking.
Chronic bronchitis is defined as a chronic
productive cough for 3 months in 2 successive
years, w cigarette smoking as the leading cause.
Postnasal drip, GERD, & asthma account for
>90% of chronic cough in nonsmokers who dont
have pulmonary disease. For pts w suspected
8815 Medicine Pulmonary & Critical Care postnasal drip initial empiric tx includes oral
first-gen antihistamine (eg, chlorpheniramine) or
combinedantihistamine-decongestant(eg,
brompheniramine&pseudoephedrine)
Breast cancer recurrence w metastases to the
lungs can cause a malignant effusion. Pleural
8818 Medicine Pulmonary & Critical Care effusion shows decreased tactile fremitus,
dullness to percussion, and decreased breath
sounds over the effusion.
Although asthma is usually dx in childhood or early
adulthood, in some cases it presents for the first
time in late adulthood. The dx is confirmed on
8905 Medicine Pulmonary & Critical Care PFTs. Reversible airway obstruction (>12%
increase in FEV1) w normal diffusion capacity for
Carbon Monoxide suggests asthma regardless of
age.
Chronic cough (>8 weeks) that worsens overnight
and does not improve w antihistamines - suspect
asthma. Evaluate w spirometry to assess
bronchodilator response. Methacholine challenge
test can be performed if no bronchodilator
response is seen. Nocturnal or early morning peak
flow rate can be used to dx pts w only nocturnal
symps. Alternate approach is to tx empirically w
2-4 weeks of inhaled glucocorticoids. If cough
improves, can dx asthma.
Aspiration pneumonitis - acute lung injury due to
aspiration of acidic stomach contents. Usually
occurs as a witnessed aspiration event (vomiting
during intubation that requires suctioning).
11669 Medicine Pulmonary & Critical Care Profound hypoxemia w bilateral infiltrates on CXR.
Gastric acid induces chemical burn and
inflammatory response. Presents w/in hours.
Aspiration pneumonia usually unwitnessed and
takes days to present.
Amniotic fluid embolism syndrome typically
presents w rapid onset of respiratory failure,
Obstetrics severe hypotension, and DIC during labor or the
2405 & Pulmonary & Critical Care immediate postpartum period. Dx is made
Gynecology clinically, and management is supportive. Amniotic
fluid embolism is rare, unpredictable, and assoc w
poor maternal and fetal outcomes.
Foreign body aspiration
S/S:
Hx of choking (80-90% of cases)
Coughing
Sudden-onset respiratory distress
Cyanosis
AMS
Physical exam:
2451 Pediatrics Pulmonary & Critical Care Focal monophonic wheezing on affected side
Diminished aeration on affected side
Generalized wheezing
Inspiratory stridor
Hoarseness
Respiratory distress
Imaging studies:
Hyperinflation or atelectasis of affected side
Visualization of foreign body
Epiglottitis
H influenzae type b, Nontypable H influenza, Strep,
Staph
Clinical feat - distress ("tripod" positioning,
3289 Pediatrics Pulmonary & Critical Care inspiratory stridor), dysphagia, drooling
X-Ray - "Thumbprint" sign (enlarged epiglottis),
Loss of vallecular space
Mgmt - Keep child calm & comfortable,
Emergency endotracheal intubation in the OR
Racemic epinephrine should be tried before
endotracheal intubation in pts w croup but it has
no role in mgmt of asthma. ~10% of children w the
disease ceom to the ED w unremitting asthma. Of
3459 Pediatrics Pulmonary & Critical Care these, fewer than 10% require intubation &
mechanical ventilation. AMS, "silent chest" +
hypoxemia and CO2 retention are signs of
impending respiratory fialure and indications for
intubation and mechanical ventilation
Clinical feats of CF
Resp: Obstructive lung disease -> bronchiectasis,
Recurrentpneumonia,Chronicrhinosinusitis
GI: Obstruction (10-20%) Meconium ileus, distal
intestinal obstruction syndrome
3531 Pediatrics Pulmonary & Critical Care Pancreatic disease - exocrine pancreatic
insufficiency, CF-related DM (~25%), Biliary
cirrhosis
Reproductive: infertility (>95% men, ~20% women)
Musck: Osteopenia -> fractures, kyphoscoliosis,
digital clubbing
CF
Chronic sinopulmonary dz (eg, bronchiectasis)
GI & nutritional abnlties (eg, pancreatic
insufficieny, meconium ileus, failure to thrive)
Salt loss syndromes (eg, acute salt depletion,
chronic metabolic alkalosis)
3538 Pediatrics Pulmonary & Critical Care
Male urogential abnlties (obstructive azoospermia)
Dx One or more clinical feats OR hx of CF in a
sibling OR + newborn screening tes PLUS inc
sweat [Cl-] >60mmol/L on 2 or more occasions
OR identificatin of 2 CF mutations OR abnl nasal
epithelial ion transport
Bronchiolitis is a common winter resp tract infxn
caused primarily by RSV. RSV infxn is generally
self-limiting, mild, URTI (nasal congestion,
rhinorrhea). Children <2 years tend to have lower
resp tract involvement. Wheezing and/or crackles
and resp distress can have a waxing/waning
course that peaks on 5-7 days of illness. Dx is
clinical and tx is supportive. Palivizumab is a
monoclonal antibody against RSV that is used for
ppx in kids <2 who're at high risk of complicatios
Epinephrine is the only med proven to prevent and
reverse progression of anaphylaxis to anaphylactic
shock & death. Its B2 agonist effect causes
bronchodilation and decreases the systemic
realease of inflammatory mediators. Its a1 agonist
effect causes vasoconstriction, which raises BP
and decreases upper-airway edema. IM epi
should be given in acute anaphylaxis
RDS main risk factors are prematurity and
maternal diabetes. Also male sex, perinatal
asphyxia, and c-section w/o labor. Maternal DM
increases incidence of RDS by delaying
maturation of pulmonary surfactact production.
Maternal hyperglycemia causes fetal
hyperglycemia which in turn triggers fetal
hyperinsulinism. High levels of insulin antagonize
cortisol and block the maturation of sphingomyelin
necessary for surfactant production.
CFTR gene mutation results in accumulation of
tenacious secretions in ducts throughout the body.
Severity of CF can vary among pts, but most will
have pulm and panc insufficiency. >95% of men
are infertile d/t congenital bilateral absence of the
vas deferens. Accumulation of inspissated mucus
in the fetal genital tract obstructs the developing
vas deferens. Spermatogenesis should be nl but
can be ejaculated. Early panc insuffient pts rarely
get pancreatitis
A-a gradient (PAO2 - PaO2). Measure of O2
transfer from the alveoli to the blood. Alveolar
tension can be calculated using: PAO2 = (FiO2 x
2788 Surgery Pulmonary & Critical Care
[Patm - PH2O]) - (PaCO2/R) =
(0.21x[760-47])-(59/0.8) = 76. Pts PaO2 was 62.
so A-a = 76-62= 14.
Subclavian central venous catheter placement
accounts for 1/4 of iatrogenic pneumothorax.
Tension pneumothorax is life threatening and
3216 Surgery Pulmonary & Critical Care requires immediate needle thoracotomy to
decompress the pleural cavity. This should be
followed by an emergency tube thoracostomy w
underwater seal.
Pulmonary contusion - parenchymal bruising of the
lung may by assoc w rib fractures - tachypnea,
tachycardia, and hypoxia. Chest wall bruising and
dec breath sounds on the affected side. cxr shows
4145 Surgery Pulmonary & Critical Care patchy irregular alveolar infiltrate and a CT scan
may be employed to make an early dx. ABG
shows hypoxemia n may indicates pulmonary
contusion. ARDS develops 24-48 hours after
trauma, besides that it's the same.
Diaphragmatic rupture is MC on the left side
because the right side tends to be protected by
the liver. Patients usu have resp distress and can
have deviation of the mediastinal contents to the
opposite side. Elevation of the hemidiaphragm on
the CXR might be the only abnormal finding. CXR
showing a nasogastric tube in the pulmonary
cavity is dignostic.
Presence of tachypnea, tachycardia, distended
neck veins, and tracheal deviation suggest tension
pneumothorax (TP) in pt w blunt or penetrating
chest trauma. Pts w hemodynamic instability and
suspected TP should have immediate needle
thoracostomy prior to intubation, as positive
ventilation following intubation usually exacerbates
an existing pneumothorax.
Hypotension, tachcardia, tachypnea after receiving
fluids - hemorrhagic shock. SBP < 90, HR > 120,
and resp rate >30 - consistent w Class II-III
hemorrhagic shock, from loss of around 30% of
blood. Each hemi thorax is capable of holding up
to 50% of circulating blood volume.
Postop pulmonary complications are common,
particulartly in pts w known risk factors. RF:
smoking hx, preexisting pulmonary dz, age>50,
thoracic or abdominal surgery, surgery lasting
4545 Surgery Pulmonary & Critical Care >3hrs, and poor gen health. Postop measures
such as incentive spirometry and deep breathing
exercises are used to prevent such complications
and improve outcomes by promoting lung
expansion
Poss pressure mechanical ventilation inc
intrathroacic pressure, incing right atrial pressure
and decreasing systemic venous return. Sudden
loss of venous return may cause acute circulatory
failure and death. Sedative meds used prior to
intubation relax venous capacitance vessels and
may themselves cause circ failure by acutely dec
venous return in the hypovolemic pt.
Moving from supine to sitting can increase the
FRC by 20-35%. In normal adults, this can amount
4600 Surgery Pulmonary & Critical Care to several hundred cubic centimeteres of lung
volume. Increasing the FRC can help prevent
postop atelectasis.
Resp Quotient is Ratio of CO2 produced to O2
consumed per unit time. Used to make
assessment of metabolism taking place in organs
or body as a whole. RQ close to 1 indicates carbs
as main nutrient being oxidized. Metbolism of
proteins alone has RQ ~0.8. Fatty acids ~0.7.
Atelectasis is one of the MC postop pulmonary
complications and is usu d/t airway obstruction
from retained airway secretions, dec lung
compliance, postop pain, and medications that
interfere w deep breathing. ABG typically shows
hypoxemia, hypocapnia, and resp alkalosis.
Postop pt education and a program of inspiratory
muscle training (breathing exercises, forced
expiration techniques, incentive spirometry) should
4932 Surgery Pulmonary & Critical Care be conducted to prevent postop atelectasis.
Postop breathing exercises and incentive
spirometry are also effective in reducing the risk of
pulmonarycomplications.
Hemoptysis: Pulm (bronchitis, PE, bronchiectasis,
lung cancer) Cardiac (MS/acute pulm edema),
4936 Surgery Pulmonary & Critical Care Infectious (TB, lung abscess), Hematologic
(coagulopathy), Vascular (AVM), Systemic dzs
(Wegener, Goodpasture, SLE, vasculitis).
massive hemoptysis > 600mL of expectorated
blood over a 24 hr period. Greatest danger is
asphyxiation due to airway flooding w blood. 1.
Establish adequate patent airway, adequate
ventilation, ensuring hemodynamic stability.
Bleeding lung in the dependent position to avoid
blood collecting in the opposite lung.
Bronchoscopy is initial procedure of choice as it
localizes the bleeding site, provide suctioning, and
include other therapeutic interventions.
Familial hypocalciuric hypercalcemia. FHH - AD -
abnl Ca-sensing receptors on the parathyroid cells
& renal tubules. This hinders the normal
calcium-induced PTH suppression in the setting of
Renal, Urinary Systems &
2165 Medicine hypercalcemia. Pts typically have a mild
Electrolytes
asymptomatic hypercalcemia and inappropriately
high-normal to borderline-elevated PTH levels.
Urinary calcium creatinine clearance ratio is
usually <0.01 in FHH compared to >0.02 in PHP.
Mgmt of Hypercalcemia
Severe (Ca2+ > 14mg/dL) or symptomatic
Short-term (immediate) tx
Normal saline hydration + calcitonin
Avoid loop diuretics unless volume overload (heart
failure) exists
Renal, Urinary Systems & Long-term tx
2169 Medicine
Electrolytes Bisphosphonate (zoledronic acid)
Moderate (Ca2+ 12-14)
Usually no tx unless symptomatic
Tx is similar to that for severe
Asymptomatic or mild (Ca2+ < 12)
No immediate tx required. Avoid thiazide diuretics,
lithium, volume depletion & prolonged bed rest.
The normal response to hypotonicity (low plasma
osmolality) is the production of maximally dilute
urine (low urine osmolality, or values
<100mOsm/Kg). Low plasma osmolality
2180 Medicine (<280mOsm/Kg) w high urine osmolality
Electrolytes
(>100-150mOsm/Kg) in suspected pts is thus
diagnositc of SIADH. Serum uric acid is low d/t
increased urinary excretion of uric acid and
hemodilution.
Asymptomatic patients or those with mild
symptoms from SIADH usually respond to fluid
2181 Medicine restriciton (<800mL/day) and/or salt tablets. Sever
Electrolytes
symptomatic hyponatremia tx w hypertonic (3%)
saline.
Hepatorenal syndrome
RF - Advanced cirrhosis w portal htn & edema
Precipitating factors:
Reduced renal perfusion - GI bleed, vomiting,
sepsis, excessive diuresis, SBP
Reduced glomerular pressure & GFR - NSAID use
(constricts afferent arterioles)
Dx.
2219 Medicine Renal hypoperfusion - FeNa <1% (or urine Na<10
Electrolytes
mEq/L)
Absence of tubular injury - no RBC, protein, or
granular cases in urine
No improvement in renal fxn w fluids
Tx.
Tx precipitating factors
Splanchnicvasoconstrictors
Liver tran
RCC
Flank pain, hematuria & a palpable abdominal
renal mass
Scrotal varicoceles (left-sided)
Paraneoplastic symptoms: Anemia or
erythrocytosis, Thrombocytosis, Fever,
Renal, Urinary Systems & Hypercalcemia
2221 Medicine
Electrolytes Classic triad: flank pain, hematuria, palpable
abdominal renal mass
^ found in only 10% of patients
Hematuria seen in about 40%
Scrotal varicoceles that fail to empty when pt is
recumbent seen in ~10% of pts
20% of pts also have constitutional symptoms
Nephrotic syndrome is def (>3.5g/24hr) w
hypoalbuminemia and edema. FSGS and
membranous nephropathy are the most common
2223 Medicine causes of nephrotic syndrome in adults in the
Electrolytes
absence of a systemic dz. FSGGS is MC in
African American pts and in those w obesity,
heroin use, and HIV.
Nephrolithiasis
1. Imaging study - CT scan w/o contrast. High
sensitivity & specificity. KUB can't detect
radiolucent stones
2. Narcotics & NSAIDs - equally effective in
relieving pain of acute renal colic (narcotics can
2227 Medicine exacerbate nausea)
Electrolytes
3. Size of stone - <5mm pass spontaneously.
Conservative mgmt. Fluid intake >2L/day. Incr
hydration -> incr urinary flow rate -> lower urinary
soluteconcentration
4. Urology referral - Urologic eval in pts w anuria,
urosepsis, or ARF
Renal, Urinary Systems & 75-90% of renal stones are calcium oxalate.
2228 Medicine
Electrolytes Envelope shaped.
IgA nephropathy is the MCC of glomerulonephritis
in adults. Pts have recurrent episodes of gross
hematuria, w/in 5 days after an URTI
(synpharyngitic presenation). IgA nephropathy is
Renal, Urinary Systems & differentiated from postinfectious
2230 Medicine
Electrolytes glmoerulonephritis (21 post infection and MC in
children) based on earlier onset of URTI-related
glomerulonephritis and normal serum complement
levels. Kidney biopsy can also help differentiate
these 2 processes.
Suspect mixed cryoglobulinemia in a pt who
presents w palpable purpura, proteinuria and
hematuria. Other suggestive clinical manifestations
include nonspecific systemic symptoms,
2232 Medicine arthralgias, HSM and hypocomplementemia. The
Electrolytes
demonstration of circulating cryoglobulins is
confirmatory. Majority of patients have an
underlying HCV infxn. For this reason, all such
patient should be tested for HCV antibodies.
Uncomplicated cystitis commonly occurs in
otherwise healthy patients and has a low risk of tx
failure. UA confirms the dx. Pts can be tx w/o a
2235 Medicine urine culturs, which may be done later in those
Electrolytes
who fail initial therapy. Oral TMPSMX,
nitrofurantoin, and fosfomycin are effective
first-line tx options.
70% of cases w interstitial nephritis are caused by
drugs such as cephalosporins, penicillins,
sulfonamides, sulfonamide containing diuretics,
2242 Medicine NSAIDs, rifampin, phenytoin, and allopurinol.
Electrolytes
DCing the offending agent is the tx of drug-induced
interstitial nephritis. Clinical feats include fever,
rash, and arthralgias.
Renal vein thrombosis and other thromboembolism
are significant complications of nephrotic
syndrome. Loss of ATIII in the urine increases the
risk of venous and arterial thrombosis. Thrombosis
Renal, Urinary Systems & of the renal vein can be acute and present w abd
2243 Medicine
Electrolytes pain, fever, & hematuria. RVT is more commonly
progressive, causing worsening of renal fxn and
proteinuria in an asymptomatic pt. RVT can occur
in any etiology of nephrotic syndrome, but is MC
seen w membranous glomerulopahy.
Nephrotic syndrome can result in alterations in lipid
metabolism. This dyslipidemia puts affected
patients at increased risk for accelerated
2244 Medicine atherosclerosis. This atherosclerotic tendency,
Electrolytes
along w intrinsic hypercoagulability, places
patients with nephrotic syndrome at risk for
complications such as stroke and MI.
Ureteral colic caused by stone can cause a vagal
reaction that causes ileus. Needle-shaped crystals
on urinalysis indicated uric acid stones. Uric acid
stones are radiolucent, have to be evaluated by
CT of the abdomen or IV pyelogrpahy. Abd USG
2324 Medicine may also detect radiolucent stones. CT is also
Electrolytes
useful for dx other pathology, such as
appendicular abscess or bowel obstruction, esp in
a pt w ileus. Ileus will resolve when the
ureterolithiasis is tx. Stones <1cm can pass; or
surgery
In any pt, the pH and PaCO2 are the two lab
values that provide the best picture of acid-base
Renal, Urinary Systems & status; the HCO3- can be calculated from these
2787 Medicine
Electrolytes values usingtheHendersong-Hasselbach
equation. pH = pKa + log ([HCO3-]/(0.03 x
PaCO2))
Mixed acid-base d/o refer to > or = 2 primary
acid-base disturbances in a pt. After IDing a
primary acid-base d/o, the calculated expected
pCO2 or HCO3- should be compared to measure
2790 Medicine values to distinguish between appropriate
Electrolytes
compensation and a mixed d/o. Winter's formula:
arterial pCO2 = 1.5[HCO3-] + 8 + or - 2. PCO2 >
expected = mixed resp acidosis. PCO2 <
expected = mixed metabolic acid and resp alk
Winter's formula (calculates expected change in
2796 Medicine PaCO2 based on [HCO3-]).
Electrolytes
PaCO2 = 1.5*(HCO3-) + 8 (+/- 2).
Ethylene glycol, methanol, and ethanol intoxication
cause metabolic acidosis with both an anion gap
and osmolal gap. Calcium oxalate crystals
(rectangular, envelope-shaped) are seen in pts w
2799 Medicine ethylene glycol (antifreeze) poisoning. Ethylene
Electrolytes
glycol intoxication can result in renal failure;
methanol intoxication can cause blindness.
Calculated serum osmolality = (2*Na+) +
(glucose/18) + (BUN/2.8)
Metabolic acidosis in CKD is rarely seen until
there is advanced renal dysfxn (GFR <20ml/min).
Non-anion gap metabolic acidosis and
hyperkalemia that occur out of proportion to the
renal dysfxn indicate a renal tubular d/o. RTA -
2810 Medicine characterized by non-anion gap metabolic acidosis
Electrolytes
in the presence of preserved renal fxn.
Hyperkalemic RTA is commonly seen in elderly pts
who have poorly controlled DM w damage to the
JGA which causes hyporeninemic
hypoaldosteronism.
Primary adrenal insufficiency
Etiology: Autoimmune, infxns (TB, HIV, fungal),
Hemorrhagic infarct (meningococccemia),
metastatic cancer
Clinical:
Acute: Shock, abd tenderness w deep palpation,
2817 Medicine unexplained fever, nausea, vomiting, weight loss &
Electrolytes
anorexia, low Na+, hi K+, hi Ca2+, eosinophilia
Chronic: fatigue, weakness, anorexia, GI, weight
loss, hyperpigmentation, low BP, low Na+, hi K+,
hi Ca2+, anemia & eosinophilia
Dx: Measure ACTH & cortisol w hi dose ACTH
stim test
Based on urinary chloride levels and ECF volume
status, metabolic alkalosis can be classified as
saline-responsiveandsaline-unresponsive.
Renal, Urinary Systems & Saline-responsive metabolic alkalosis is assoc w
2819 Medicine
Electrolytes low urinary chloride excretion and volume
contraction, and corrects w saline infusion alone.
Saline-unresponsive metabolic alkalosis typically
presents w urinary chloride >20mEq/L
Aspirin intoxication causes a mixed respiratory
alkalosis and metabolic acidosis. Respiratory
Renal, Urinary Systems & alkalosis is d/t incr respiratory drive. Metabolic
2820 Medicine
Electrolytes acidosis is d/t incr production and decr renal
elimination of organic acids (eg, lactic acid,
ketoacids).
Seizures result in accelerated production of lactic
acid in the muscle and reduced hepatic lactate
uptake. Post-ictal lactic acidosis is transient and
2821 Medicine typically resolves w/in 60-90 minutes. Most
Electrolytes
appropriate tx is observation and repeated the
chem panel after 2 hrs to see the if the acidosis
has resolved. If not, look for other causes.
Loop diuretics are frequently administered to
Renal, Urinary Systems & cirrhotic pts w volume overload and ascites.
2826 Medicine
Electrolytes Potential S/E include hypokalemia, metabolic
alkalosis, and prerenal kidney injury.
Cryoglobulinemia is an immune complex disorder
(IgM against HCV IgG) MC due to chronic hep C.
Pts may develop vasculitis involving the skin,
2958 Medicine kidney, nerves, or joints. Low complement levels,
Electrolytes
inc rheumatoid factor, inc liver transaminases,
serum cryoglobulins and kidney/skin biopsy can
confrim the dx.
Drug-induced interstitial nephritis is usually caused
by abx (PCNs, cephalosporins, TMP, rifapin),
3061 Medicine NSAIDs, and diuretics. Pts present w a fever,
Electrolytes
maculopapular rash, and renal failure. UA may
reveal WBC casts, and less frequently, eosinophils.
Hypokalemia, alkalosis, and normotension:
3228 Medicine surreptitious vomiting, diuretic abuse, bartter
Electrolytes
syndrome, gitelman's syndrome
Oxalate absorption is increased in CD and all
other intestinal diseases causing fat
malabsorption. Increased absorption is the MCC
Renal, Urinary Systems & of symptomatic hyperoxaluria & oxalate stone
3435 Medicine
Electrolytes formation. Excess fat in the gut lumen binds with
calcium which otherwise would normally bind to
oxalate. Since more oxalate is unbound to calcium,
more can be absorbed by the colon.
Current guidelines recommend evaluating all pts w
probable BPH based on hx and rectal exam w a
Renal, Urinary Systems & urinalysis to assess for urinary infxn and
3481 Medicine
Electrolytes hematuria. Pts w life expectancy >10 years should
also have a PSA measured to screen for prostate
cancer.
Clinicalhyperkalemia
EKG changes: Tall peaked T waves w shortened
QT interval -> PR prolongation and QRS widening
-> Disappearance of P wave -> Conduction
Renal, Urinary Systems & blocks, ectopy, or sine wave pattern
3648 Medicine
Electrolytes Cardiac membrane stabilization: Calcium infusion
Rapidly acting tx options: Insulin w glucose,
Beta-2 agonists, NaHCO3
Removal of K+ (slow-acting): Diuretics, Cation
exchange resins, hemodialysis
Mgmt of hyperkalemia is determined by its
severity and acuity, presence of assoc EKG
changes, and underlying renal fxn. Options include:
Stabilizing myocardial excitability w Ca2+ (when
abnl EKG present)
Renal, Urinary Systems & Driving extracellular K+ w Beta-2 agonists(inhaled
3654 Medicine
Electrolytes albuterol), insulin w glucose(when abnl EKG
present), or NaHCO3
Removing K+ from the body w loop diuretics,
cation exchange resins (eliminates in feces by
Na+/K+ exchange in gut), or hemodialysis (when
pt is in ESRD)
Pts w RAS and renovascular htn should be
managed w aggressive risk factor reduction
(antiplatelet therapy w aspirin, optimal ctrl of DM
and HLD, smoking cessation) for prevention of
3894 Medicine cardiovascular disease. Pts w htn should be
Electrolytes
managed initially w ACEI or ARBs w close
monitoring of renal fxn. Addl antihypertensive
therapy should be instituted as needed for optimal
BP control.
Renal calculi - colicky abd pain - MC stones are
Ca2+. CT of abd w/o contrast is dx test of choice
- can detect radioopaque and lucent stones. KUB
3895 Medicine xray is not the best test. Dietary
Electrolytes
recommendations: Decr dietary protein and
oxalate, decr Na+, Inc fluid intake, Inc dietary
Calcium
SLE
Gradual symptom onset
Malar or discoid rash
Joint, renal, serosal &/or neurologic involvement
Anemia, leukopenia, thrombocytopenia
Positive ANA, anti-dsDNA, anti-Sm
Renal, Urinary Systems & Low complement levels, increased immune
3898 Medicine
Electrolytes complexes
Immune complexes (dsDNA & anti-dsDNA) deposit
in mesangium and/or subendothelial space. ICs
trigger intense inflammatory rxn w activation of
complement system, lowering C3 & C4 levels. ICs
may also deposit in subepithelial space & cause
membranous GN w/o hypoco
ADPKD is a potential cause of HTN. Hepatic cysts
are the MC extrarenal manifestations. Also
valvular heart disease (MVP and Aortic regurg),
colonic diverticula & abd wall & inguinal hernia.
3939 Medicine Intracranial berry aneurysms are seen in 5-10% of
Electrolytes
the cases. Although such aneurysms are common
and dangerous when coupled w htn, routine
screening for intracranial aneurysms is not
recommended.
HTN is the 2nd leading cause of ESRD in the US.
Inter-related w kidney disease; htn causes
nephropathy, and vice versa. Renal vasculature is
exquisitely sensitive to damage from htn.
Renal, Urinary Systems & Arteriosclerotic lesions of afferent & efferent renal
3942 Medicine
Electrolytes arterioles and glomerular capillary tufts are the
MC renal vasc lesions seen. As HTN gets worse
so does RBF & GFR. Nephrosclerosis -
hypertrophy & intimal medial fibrosis of renal
arterioles. Kidneys decr in size
Nephrotic range proteinuria & hematuria most
likely has membranoproliferative
glomerulonephritis.Denseintramembranoud
deposits that stain for C3 is characteristic finding
Renal, Urinary Systems & for MPGN type 2. It is unique because it is caused
3946 Medicine
Electrolytes by IgG antibodies (C3 nephritic factor) directed
against C3 converstase of the alternative
complement pathway. This Abs reacting w C3
convertase lead to persistat complement
activation & kidney damage.
Cystinuria - inherited disease - defective transport
of dibasic amino acids (cystine, lysine, arginine,
ornithine) by the brush borders of renal and
intestinal epithelial cells - causing recurrent renal
Renal, Urinary Systems & stone formation. Personal hx of recurrent kidney
3949 Medicine
Electrolytes stones from childhood and a positive family hx.
The characteristic stones are hard and
radioopaque. UA shows typical hexagonal
crystals. The urinary cyanide nitroprusside test is
widely used as a qualitative screening procedure.
Platelet dysfxn is the MCC of abnl hemostasis in
pts w CRF. PT, PTT, and plt ct are normal. BT is
prolonged. DDAVP is usually the tx of choice.
DDVAP increases release of factor VIII & vWF.
Renal, Urinary Systems & Platelet transfusion is not indicated bc the
3951 Medicine
Electrolytes transfused plts quickly become inactive.
Pathogenesis is multifactorial involving
platelet-vessel wall & platelet-platelet intraction.
Several uremic toxins have been implicated, the
chief one being guanidinosuccinic acid.
Muddy brown granular cast - Acute tubular
necrosis
RBC casts - Glomerulonephritis
WBC casts - Interstitial nephritis and pyelonephritis
Renal, Urinary Systems & Fatty casts - Nephrotic syndrome
3955 Medicine
Electrolytes Broad and waxy casts - Chronic renal failure
ATN: BUN:Cr < 20:1
Other findings: Urine osmolality 300-350mOsm/L
but never <300. Urine Na of >20mEq/L.
FE----Na-->2%
Nephrotic syndromed
FSGS - African American & Hispanic ethnicity;
obesity; HIV & heroine use
Membranous nephropathy - Adenocarcinoma (eg,
3966 Medicine breast, lung); NSAIDS; HBV; SLE
Electrolytes
Membrnaoproliferative glomerulonephritis - HBV,
HCV; lipodystrophy
Minimal Change Disease - NSAIDs; lymphoma
IgA nephropathy - URTI
Effectiveness of ACE inhibitors in diabetic
nephropathy is related to their ability to REDUCE
INTRAGLOMERULARHYPERTENSIONand,
thereby, decrease glomerular damage.
Renal, Urinary Systems & Glomerular hyperfiltration is the earliest renal
3986 Medicine
Electrolytes abnlty seen in diabetic nephropathy. It's also the
major pathophysiologic mechanism of glomerular
injury. It creates intraglomerular hypertension.
Thickening of the glomerular BM is the first change
that can be quantitated.
Rheumatoid arthritis predisposes to amyloidosis.
Renal involvement is characterized by nephrotic
syndrome. The classic pathologic finding is
Renal, Urinary Systems & amyloid deposits that stain w Congo red and
3997 Medicine
Electrolytes demonstrate apple-green birefringence under
polarized light. Multiply myeloma is the MCC of AL
amyloidosis, and RA is the MCC of AA
amyloidosis.
Clinical feats of analgesic nephropathy
Clinical:
Assoc w long-term use of 1 or multiple analgesics
(aspirin, ibuprofen) for chronic headaches or other
somatic complaints
Usually asymptomatic but can have chronic
Renal, Urinary Systems & tubulointerstitial nephritis or hematuira d/t papillary
4004 Medicine
Electrolytes necrosis
Dx:
Elevated creatinine w UA showing hematuria or
sterile pyuria
Can have mild proteinuria (<1.5g/day)
CT can show small kidneys w bilateral renal
papillarycalcifications
Analgesic nephropathy is the MC form of
drug-induced chronic renal failure. Papillary
necrosis and chronic tubulointerstitial nephritis are
4007 Medicine the MC pathologies seen. Pts w chronic analegsic
Electrolytes
abuse are also more likely to develop premature
aging, atherosclerotic vascular disease, and
urinary tract cancer.
Polyuria and sterile pyuria (WBC casts may also
be seen) are early manifestations of papillary
necrosis and chronic tubulointerstitial nephritis.
Renal, Urinary Systems & Microscopic hematuria and renal colic may occur
4007 Medicine
Electrolytes following sloughing of renal papilla. Htn, mild
proteinuria, and impaired urinary concentration
commonly occur as the disease advances.
Nephrotic range proteinuria can be seen.
CV disease - MCC of death in the gen pop, but
rates are declining. This trend is not observed in
dialysis pop. CV disease remains at the MCC of
death in dialysis pts. Approx 50% of deaths in this
4026 Medicine group. Of these, 20% are MI, and 60% are SCD.
Electrolytes
Non dialysis RF: HTN, DM, low HDL, LVH by
EKG, CAD, Advanced age. Dialysis RF:, Anemia,
Incr homocysteine, accelerated artherogenesis in
dialysis pts, Incr Ca2+, Inhibition of NO.
Uric acid stones are radiolucent but seen on USG
or CT. Highly soluble in alkaline urine; alkalinization
Renal, Urinary Systems & of the urine to pH 6-6.5 w oral potassium citrate is
4027 Medicine
Electrolytes tx of choice. Purine restricted diet is indicated in
pts w uric acid stones. Calcium restricted diet is
not beneficial w uric acid stones.
Classic signs of dehydration: altered mental
status, dry oral mucosa, marginally high values of
serum electrolytes and hematocrit, and BUN:Cr
>20. Elderly pts very prone to dehydration.
Renal, Urinary Systems & Decreased thirst response to dehyd, impaired Na+
4034 Medicine
Electrolytes conservation, impaired renal concentration ability.
Mainstay tx is IV Na-containing crystalloid
solutions. Rehydration therapy in elderly pts
should be undertaken w caution bc Na+ loading
can unmask subclinical heart failure.
Prevention of recurrent nephrolithiasis
Increase fluids (produce >2L urine/day)
Reduce Na+ (<100 mEq/dL)
Reduce protein
Normal Ca2+ intake (1200 mg/day)
4058 Medicine Increase citrate (fruits & veggies)
Electrolytes
Reduced-oxalate diet for oxalate stones (dark
roughage, vit C)
Drugs: Thiazide diuretics, Urine alkalinization
(Potassium citrate/bicarbonate salt), Allopurinol
(for hyperuricosuria-related stones)
Renal transplant dysfxn in the early post-op period
can be explained by a variety of causes, including
ureteral obstruction, acute rejection, cyclosporine
4152 Medicine toxicity, vascular obstruction, and acute tubular
Electrolytes
necrosis. Radioisotope scanning, renal USG, MRI,
and renal biopsy can be employed in conducting a
Ddx. Acute rejection is best tx w IV steroids.
Thiazide diuretics - hyperglycemia, increased LDL
4171 Medicine and TGs. Electrolyte abnormalities -
Electrolytes
hyponatremia, hypokalemia, and hypercalcemia.
Simple renal cyst: Thin, smooth, regular wall.
Unilocular. No septae. Homogenous content.
Absence of contrast enhancement on CT/MRI.
Usually asymptomatic. No follow-up needed.
Renal, Urinary Systems & Malignant cystic mass: Thick, irregular wall.
4181 Medicine
Electrolytes Multilocular. Multiple septae, occasionally thick &
calcified. Hetergenous content (solid & cystic).
Presence of contrast enhancement on CT/MRI.
May cause pain, hematuria, or htn. Requires
follow-up imaging & urological evaluation for
malignancy.
ESRD - 2 tx options - dialysis or renal transplant.
Choice depends on pt and co-morbid conditions; if
both are available, transplant is preferred.
Transplant is assoc w better survival and quality of
4211 Medicine life. Anemia, bone disease, htn are better
Electrolytes
controlled. Have return of normal endocrine,
sexual & repro fxns, enhanced energy. Autonomic
neuropathy stabilizes or improves. 88% survival at
5 years. Hemodialysis - 30-40%, 20% in diabetics
Diabetic autonomic neuropathy (DAN) can affect
the genitournary tract to cause a neurogenic
bladder w urinary retention and distended bladder.
Renal, Urinary Systems & Risk factors include poor glucose ctrl and other
4228 Medicine
Electrolytes vascular risk factors (htn, elevated TGs, smoking,
obesity). Pts can then dvlp overflow incontinence
(dribbling, poor urinary stream) w a high post-void
residual volume (>50mL).
Nephrotic syndrome is a hypercoagulable
condition which manifests as venous or arterial
thrombosis, and even PE. RVT is the most
4266 Medicine frequent manifestation. Complications include:
Electrolytes
protein malnutrition, iron-resistant microcytic
hypochromic anemia, increase susceptibility to
infxn, and vit D deficiency.
Metformin should not be given to acutely ill
4337 Medicine patients w ARF, liver failure, or sepsis as these
Electrolytes
conditions increase the risk of lactic acidosis.
Ureteral calculi may cause flank or abd pain
radiating to the perineum, often w nausea &
4361 Medicine vomiting. USG or noncontrast spiral CT scan of
Electrolytes
the abd and pelvis are the imaging modalities of
choice to confirm the dx.
Aminoglycosides are commonly used to treat
pyelonephritis (or just infxn) w a
Renal, Urinary Systems & multidrug-resistant organism (eg gram-neg rod).
4379 Medicine
Electrolytes Aminoglycosides may be used in pts w renal
dysfxn, but their serum levels and the pts renal fxn
must be followed closely.
Acyclovir nephrotoxicity - in 5-10% of pts who
recieve IV acyclovir - excreted primarily in urine via
glomerular filtration - When [acyclovir] in collecting
Renal, Urinary Systems & duct exceeds its solubility.. crystallization,
4414 Medicine
Electrolytes crystalluira, and renal tubular damage result. This
toxic complication is transient and can be
prevented and tx with adequate hydration and
dosage adjustment (slowing rate of IV infusion).
Insulin/glucose administration is the quickest way
to decrease serum [K+]. B2 agonists transiently
4422 Medicine move K+ into cells. B2 agonists & furosemide take
Electrolytes
longer to exert their K+ lowering effects than
insulin/glucose
MCC of hypernatremia is hypovolemia. Severe
Renal, Urinary Systems & cases should be initially tx w 0.9% NS. Mild cases
4424 Medicine
Electrolytes can be tx w D5 1/2 NS. Goal rate of plasma Na+
correction is no more than 1 mEq/L/h.
Succinylcholine-depolarizingneuromuscular
blocker often used during rapid-sequence
intubation bc it has a rapid onset and offset.
However, it can cause significant K+ release and
life-threatening arrhythmias, and so it should not
4428 Medicine be used in pts w or at high risk for hyperkalemia.
Electrolytes
This includes pts w crush or burn injuries >/= 8
hours old (high risk of rhabdo), pts w
demyelinating syndromes like GBS, and pts w
tumor lysis syndrome. Vecuronium or rocuronium
are a better choi
Correcting severe hyponatremia should be done
Renal, Urinary Systems & with 3% saline but the correction of serum sodium
4430 Medicine
Electrolytes should not exceed 0.5 mEq/L/hr to avoid causing
CPM.
Amitriptyline - TCA antidepressant w
anticholinergic properties - bladder empties under
muscarinic control w both detruses muscle
Renal, Urinary Systems & contraction and internal urethral sphincter
4432 Medicine
Electrolytes relaxation. anticholinergic agents can cause
urinary retention by reducing detrusor contraction
and preventing urethral sphincter relaxation. Tx
urinary cath and dc amitriptyline
Horseshoe kidney doesn't cause pain. P/W
ureteropelvic jxn obstruction, renal stones,
vesicoureteric reflux, chronic UTIs. ADPKD - one
4474 Medicine of the MC hereditary dz in US accounts for 10% of
Electrolytes
dialysis pts. HTN & palpable kidneys on exam.
Enlarged right kidney is easier to palpate bc it lies
lower than left kidney.
Contrast induced nephropathy - renal
vasoconstriction and tubular injury. Pts w DM,
chronic renal insufficiency, are at incr risk of
contrast nephropathy. MC presentation is a spike
Renal, Urinary Systems & in creatinine w/in 24 hrs of contrast administartion,
4491 Medicine
Electrolytes followed by a return to normal renal fxn in 5 days.
Adequate pre-CT IV hydration is the single most
imporant intervention for ppx. IV isotonic bicarb or
nl saline is typically used. Acetylcysteine also been
shown to prevent nephropathy.
DN
Starts w hyperfiltration
Glomerular hypertrophy, Increased GFR
Then incipient DN
Mesangial expansion, glomerular basement
Renal, Urinary Systems & membrane thickening, arterioloar hyalinosis.
4515 Medicine
Electrolytes Microalbuminuria and hypertension. GFR returns
to normal.
Finally there is overt DN
Mesangial nodules (Kimmelstiel-Wilsons lesions),
tubulointerstitial fibrosis. Overt proteinuria.
Nephoric syndrome. Decreased GFR
CO2 narcosis - lethargy/stupor seen at PaCO2 >
60 mmHg. Acute hypercarbia can be differentiated
4535 Medicine from chronic CO2 retention in COPD by the assoc
Electrolytes
acidosis and low bicarb level (chronic CO2
retainers have normal pH and high serum bicarb).
Decr RBF activates RAA axis. Angiotensin
constricts efferent arterioles - maintains
intraglomerular pressure and GFR despite
reduced RBF. Low RBF also causes release of
prostaglandins that dilate the afferent arteriole. As
4567 Medicine intravascular volume continues to fall the volume
Electrolytes
depletion overwhelms the RAA axis -
intraglomerular pressure and GFR fall despit
MAXIMAL EFFERENT ARTERIOLAR
VASOCONSTRICTION. Dec fluid intake, ACEi,
and aspirin worsen this condition.
Acute nephritic syndrome can cause anasarca,
pulmonary, and facial edema, htn, abnl UA w
proteinuria & microscopic hematuria. Primary
Renal, Urinary Systems & glomerular damage leads to decr GFR w eventual
4591 Medicine
Electrolytes development of significant volume overload. Abnl
urinary sediment is seen on UA. Serum Cr can be
elevated. Decreased GFR is also the cause of
edema in pts w ESRD.
Herniated intervertebral disk -> spinal nerve
impingement. Classic symps: unilateral radicular
pain in a dermatomal distribution. Back tenderness
d/t spasm of the paraspinous muscles is common,
Renal, Urinary Systems & and symps r worsened w straight leg raise test.
4615 Medicine
Electrolytes Cauda equina can be ruled out if no saddle
anesthesia and sphincter tone is intact. Severe
pain can limit a pts ability to generate enough
intraabdominal pressure to urinate, esp if there's
BPH.
Dx criteria for SIADH
1. Serum osm <270
2. U osm > S osm
3. U Na+ > 20
4. Absence of hypovolemia
Renal, Urinary Systems & 5. Normal renal, adrenal and thyroid fxn
4643 Medicine
Electrolytes 6. No obvious surgical, traumatic or painful
stimulus known to activate the neuroendocrine
stress response, including ADH release
7. Absence of other known causes of
hyponatremia
Sosm = 2xNa + BUN/2.8 + Glucose/18
Prolonged immobilization causes direct muscle
damage and the release of CPK. Cocaine, a
potent vasoconstrictor, causes diffuse ischemia,
seizures, agitation, incidental trauma, hyperpyrexia
Renal, Urinary Systems & and a direct toxic effect on myocytes. Elevated K+
4683 Medicine
Electrolytes and CPK are strongly suggestive of rhabdo. Renal
failure in rhabdo is caused by ATN from excessive
myoglobin. Urine dipstick is + for blood but no
RBCs are seen. Hydration, mannitol, and urine
alkalinization can be beneficial/renoprotectiv
First gen H1 antihistamines (diphenhydramine,
chlorpheniramine, doxepin, & hydroxyzine) have
significant anticholinergic effects. Anticholinergic
effects inhibit the action of ACh on muscarinic
4733 Medicine receptors throughout the PSNS. S/E include:
Electrolytes
dryness of the eyes, oral mucosa and resp
passages, urinary retention (failure of destrusor
contraction- parasympathetic input from pelvic
splanchnic nerves) and dysuria.
Resp alkalosis has renal compensation. The
kidneys retain increased amts of H+ and excrete
4739 Medicine increased amounts of bicarbonate in attempt to
Electrolytes
normalize the serum pH. The increased amount of
bicarb in the urine increases it's pH.
Obstructive uropathy - flank pain (renal capsule
distension), poor UOP (mechanical obstruction to
Renal, Urinary Systems & urine outflow), intermittent episodes of
4749 Medicine
Electrolytes high-volume urination when obstruction is
overcome by a large volume of retained urine
(post-obstructive diuresis).
The MC histologic lesion in diabetic nephropathy is
diffuse glomerulosclerosis. Nodular
Renal, Urinary Systems & glomerulosclerosis (w Kimmelstiel-Wilson nodules)
4750 Medicine
Electrolytes is pathognomonic. Dz progression can be slowed
with strict glycemic control, tx of htn, and
angiotensin axis blockade.
Initial hematuria suggests urethral damage.
Terminal hematuria indicates bladder or prostatic
4751 Medicine damage, and total hematuria reflects damage in
Electrolytes
the kidney or ureters. Clots are not usually seen w
renal causes of hematuria.
Hyperkalemia - EKG shows QRS prolongation w
peaked T waves - Usually asymptomatic but can
cause muscle weakness - Flaccid paralysis can
Renal, Urinary Systems & dvlop - Severe can cause life-threatening
4760 Medicine
Electrolytes arrhythmias, requires urgent tx. IV calcium
gluconate to stabilize cardiac membrane. Then
lower serum K+ by giving insulin, glucose, sodium
bicarb, and beta-2 agonists.
Interstitial cystitis (painful bladder syndrome)
Epidemiology: MC in women. Assoc w psychiatric
d/o (anxiety) & pain syndromes (fibromyalgia).
Clinical presentation: Bladder pain w filling, relief w
Renal, Urinary Systems & voiding. Incr frequency, urgency. Dyspareunia
4807 Medicine
Electrolytes Dx: Bladder pain w no other attributable cause for
>/= 6 weeks duration. Normal urinalysis
Tx: Not curative; focus is on quality of life.
Behavioral modification & trigger avoidance.
Amitriptyline. Analgesics for exacerbations.
Saline-responsive MA - Vomiting, gastric
suctioning, diuretics, laxative abuse, decr oral fluid
intake (volume depletion)
Saline-resistant MA - Primary hyperaldosteronism,
Cushing's syndrome, Severe hypokalemia (<2
mEq/L
Renal, Urinary Systems & P/W: Volume depletion: easy fatigability, postural
4866 Medicine
Electrolytes dizziness, muscle cramps
Low K+: Muscle weakness, arrhythmias
Urine Cl-: <20 (saline-responsive), >20(saline
resistant)
Tx: Tx underlying cause to reverse generation
phase
Saline-responsive: Also give NS
Hyponatremia is usu due to excess water intake
greater than the kidney's ability to excrete free
water. Water load dec serum osmolality,
7722 Medicine supresses ADH. Hyponatremia - d/o w excessively
Electrolytes
inc water intake, inability to supress ADH, or
impaired renal ability to excrete free water. Hypo-,
eu-, hypervolemic.
TMP can cause hyperkalemia by blocking
epithelial Na+ channel in the collecting tubule,
similar to the action of K+ sparing diuretic
amiloride. Occurs MC in HIV-infected pts who are
8331 Medicine tx w high doses of TMP, but even normal doses
Electrolytes
can produce a modest elevation in plasma [K+].
Pts tx w high-dose TMP require seriel monitoring.
TMP also competitively inhibits tubular creatinine
secretion.
Cystoscopy is recommended for pts w gross
hematuria or w microscopic hematuria and other
8929 Medicine risk factors for bladder cancer (cigs,
Electrolytes
occupation-painters, metal workers, chronic
cystitis, cyclophosphamide, radiation).
Glomerular hematuria
Type: Microscopic > gross hematuria
Etiologies: Glomerulonephritis. Basement
membrane disorders (Alport syndrome)
Clinical: Nonspecific or no symps. Nephritic
syndrome (htn, oliguira, elevated Cr)
UA: Blood and protein. RBC casts, dysmorphic
10287 Medicine RBCs
Electrolytes
Non-glomerular hematuria
Type: Gross > Microscopic
Etiology: Nephrolithiasis, Cancer, PKD, Infxns,
Papillary necrosis, renal infarct
Clinical: Dysuria or symps of urinary obstruction
UA: Blood but no protein.
Dx of uremia is based on symps/signs and not on
absolute BUN level. Typically symps appear at
BUN >100. Uremic encephalopathy is an indication
for urgent hemodialysis. Asterixis is seen in
hepatic encephalopathy, uremic encephalopathy,
and CO2 retention.
10776 Medicine Acidosis (pH <7.1)
Electrolytes
Electrolyte abnormalities (EKG changes,
ventricular arrhythmias, K+>6.5)
Ingestion (toxic alcohols, ethylene glycol,
salicylate, lithium, Valproate, carbamazepine)
Overload
Uremia (symptomatic: bleeding,
Alpha receptors are found on the distal ureter,
base of detrusor, bladder neck, and urethra. In
11109 Medicine someone w stones, antagonizing the alpha
Electrolytes
receptor in these locations would help the stone
pass.
Cyanide accumulation & toxicity
Skin: Flushing (cherry-red color), cyanosis (ocurs
later)
CNS: Headache, AMS, seizures, coma
Renal, Urinary Systems & CV: Arrhythmias
11566 Medicine
Electrolytes Resp: Tachypnea followed by resp depression,
pulmonary edema
GI: Abd pain, nausea, vomiting
Renal: Metabolic acidosis (from lactic acidosis)
renal failure
Suspect CN- toxicity when someone's been tx with
sodium nitroprusside. Combustion of carbon and
nitrogen containing compounds (wool, silk) and
industrial exposure (metal extraction in mining) are
Renal, Urinary Systems & other potential sources. CN- binds to cytochrome
11566 Medicine
Electrolytes oxidase and inhibits mitochondrial oxidative
phosphorylation. Cells shift to anaerobic
metabolism and causes lactic acidosis.
Nitroprusside arterio- and venodilator used in
htnsive emergencies. Tx. Sodium Thiosulfate
Asymptomatic bacteruria during preg increases
the risk of cystitis, pyelonephritis, preterm birth,
low birth weight, and perinatal mortality. E. coli
Obstetrics accounts for >70% of cases. Accepted regimens
2399 & include nitrofurantoin for 5-7 days, amocicillin +/-
Electrolytes
Gynecology clavulanate for 3-7 days, or fosfomycin as a single
dose. Fluoroquinolones should be avoided during
pregnancy, and TMPSMX should be avoided in the
1st and 3rd trimesters.
Half of all adult women have a UTI at some pt in
their life. High incidence is due to their short
Obstetrics urethra. After the periurethral area bcomes
3884 & colonized by rectal flora, the bacteria ascent to
Electrolytes
Gynecology the bladder and cause infxn. RF - recent abx use,
sexual intercourse, diaphragm or spermacide use,
family hx of multiple UTIs
RPF and GFR are increased in pregnancy, which
causes a decrease in BUN and Cr from baseline.
Obstetrics
Renal, Urinary Systems & Increase in renal fxn begins early in the 1st
4148 &
Electrolytes trimester, progresses gradually until reaching
Gynecology
40-50% above the non-pregnant state by
mid-pregnancy, and remains unchanged until term.
Epidural anesthesia in labor impairs bladder fxn,
Obstetrics and an overdistended bladder may lose its ability
4225 & to contract and result in urinary retention and
Electrolytes
Gynecology overflow incontinence. Urinary retention is tx w
short-term indwelling catheterization.
Asymptomatic bacteruria - positive urine culture
(>100,000 colony forming units per ml of a single
organism in a midstream, clean catch urine
sample). Pregnancy is a risk factor for developing
Obstetrics
Renal, Urinary Systems & UTIs d/t stasis of urine, owing to compression by
4256 &
Electrolytes the enlarging uterus, and smooth muscle relaxation
Gynecology
caused by progesteron. If left untx it may progress
to pyelonephritis in 30-40% of cases. Amoxicilin,
ampicilin, nitrofurantoin, and cephalexin are used
to tx the pts.
USG of the kidneys and pelvis is recommended to
evaluate renal colic in pregnant pts. Renal stones,
hydronephrosis, hydroureter can be evaluated w
Obstetrics
Renal, Urinary Systems & USG. Physiologic hydronephrosis in pregnancy
4294 &
Electrolytes must be distinguesed from pathological
Gynecology
hydronephrosis secondary to obstrxn. Low-dose
CT urography may be considered only in the 2nd
and 3rd trimesters.
Recurrent cystitis in toddlers is often caused by
constipation. Fecal retention can cause rectal
distension, which in turn compresses the bladder
and prevents complete voiding. The residual
Renal, Urinary Systems & volume is a breeding ground for bacteria that
2226 Pediatrics
Electrolytes ascend to the urethra from the perineum.
Transitioning to cow's milk & solid food from
breast milk can cause constipation. Straining &
pain w defecation, fissures, hemorrhoids,
pellet-like stools.
A urine dipstick can be + in up to 10% of
school-aged children. Transient proteinuria
(caused by fever, exercise, seizures, stress,
volume depletion) is the MCC of isolated
2234 Pediatrics proteinuria in children and should be reevaluated w
Electrolytes
a repeat urine dipstick testing on 2 separate
occasions to r/o persistent proteinuria, which
requires further evaluation for underlying renal
disease.
Isolated enuresis
Urinary incontinence in children age >/=5
Workup
UA, Urologic imaging for children w significant
daytime symps & hx of recurrent UTI
MGMT
Renal, Urinary Systems & Behavior mods (avoid sugary/caffeinated
2513 Pediatrics
Electrolytes beverages, void regularly during the day &
immediately before bed, drink ample fluid in
morning & early afternoon; minimize fluid intake
before bedtime, Reward system w gold star chart)
Enuresis alarm: 1st-line intervention when behavior
mods fail; best long-term outcome
Desmopressin
Polyuria and polydipsia are red flags for type 1
3548 Pediatrics DM. Type 1 DM has bimodal onset, w pts
Electrolytes
presenting at 4-6 years or at early puberty.
Indications for renal & bladder ultrasound
-Infants and children < 24months w a first febrile
UTI
-Recurrent febrile UTIs in children of any age
-UTI in a child of any age w a family history of
Renal, Urinary Systems & renal or urologic disease, htn, or poor growth
3692 Pediatrics
Electrolytes -Children who do not respond to appropriate abx tx
Voiding cystourethrogram considered if
hydronephrosis or scarring seen in renal USG.
Also indicted in newborns <1 month and children
<2 years w recurrent UTIs or first UTI not from E
coli
Vesicoureteral Reflux
Grade I - Into a nondilated ureter
II - Into the pelvis & calyces w/o dilation
III - Mild to moderate dilation of the ureter, renal
pelvis & calyces, w minimal blunting of the fornices
Renal, Urinary Systems & IV - Moderate ureteral tortuosity & dilaiton of the
3694 Pediatrics
Electrolytes pelvis & calyces
V - Gross dilation of the ureter, pelvis & calyces;
loss of papillary impressions; ureteral tortuosity
Severe VUR can cause recurrent or chronic
pyelonephritis. Parenchymal scarring, htn, & renal
insuffic
Edema, hypoalbuminemia, markedly elevated
urine protein - nephrotic syndrome (NS). Common
causes of NS - minimal change disease in young
Renal, Urinary Systems & children, FSGS, and membranous nephropathy in
3940 Pediatrics
Electrolytes adolescents and adults. Membranous nephropathy
is assoc w HBV. Vaccination has dramatically
reduced rates of HBV-associated membranous
nephropathy (HBVMN).
Sickle cell trait
Renalcomplications
Hematuria, renal medullary carcinoma, UTIs.
Painless Hematuria d/t renal papillary ischemia or
necrosis. Low partial pressure of O2 in the vasa
Renal, Urinary Systems & rectae predisposes affected RBCs to sickling.
3967 Pediatrics
Electrolytes Papillary necrosis can occur w massive hematuria,
but episodes are mild and resolve spontaneously.
Urinalysis shows normal appearing RBCs.
Isothenuria and distal RTA (tubular damage w
impaired H+ secretion) are other renal
complications.
Tests in UTIs
Serum BUN & Cr - Estimate renal fxn
Urine dipstick - Qualitative measurement of urine
4005 Pediatrics properties
Electrolytes
UA - Quantitative measurement of urine properties
Urine Cx - Identification, quantification &
susceptibility testing of bacterial colonies
Minimal change disease
Epi - MCC of nephrotic syndrome in children,
Median age 2-3; 85% of cases occur before 10
years of age
Path- T-cell mediated injury to podocytes causes
4018 Pediatrics incr molecular permeability to albumin, majority of
Electrolytes
cases are idiopathic
Clinical feat - Edema, fatigue, no hematuria
Dx - Proteinuria, hypoalbuminemia, renal biopsy
w/o microscopic changes
Tx - corticosteroids
HSP - IgA-mediated vasculitis of small vessels.
Palpable purpura on lower extremities,
arthralgias/arthritis of knees & ankles, colicky abd
pain, & renal disease - proteinuria + hematuria.
Renal, Urinary Systems & Immunofluorescence microscopy shows IgA
4279 Pediatrics
Electrolytes deposition in the kidney. Renal involvement occurs
in 20-50% and occurs up to 4-6 weeks after onset
of illness. Dx - clinical. Renal biopsy may be
helpful to confirm dx and will show deposition of
IgA in the mesangium.
Posterior urethral valves (abnl folds in the distal
prostatic urethra obstruct urinary flow) are the
MCC of urinary tract obstruction in newborn boys.
Classic findings on USG include bladder
Renal, Urinary Systems & distension, bilateral hydroureters and bilateral
4548 Pediatrics
Electrolytes hydronephrosis. Oligohydramnios from low urine
production in utero can cause pulmonary
hypoplasia and postnatal resp distress. Dx:
voiding CUG & cystoscopy. Tx PUV ablation or
urinarydiversion.
RTA - 1 (Distal) - Poor hydrogen secretion into
urine, urine pH >5.5 - serum K+ low-normal -
Genetic d/o, medication toxicity, Autoimmune d/o
(sjogren, RA)
RTA - 2 (Proximal) - Poor bicarb resorption, urine
4828 Pediatrics pH <5.5 - serum K+ low-normal - Fanconi
Electrolytes
syndrome (glucosuria, phosphaturia,
aminoaciduria)
RTA - 4 - Aldosterone resistance - urine pH <5.5 -
serum K+ high - Obstructive uropathy, congential
adrenal hyperplasia
S/S hypernatremia - Mainly neurologic: Lethargy,
AMS, irritability, & seizures. Also muscle cramps,
muscle weakness, and decreased DTRs.
Hypovolemic hypernatremia is secondary to renal
losses (diuretics, glycosuria) or extra renal losses
4853 Pediatrics (GI upset, excessive sweating). Hypervolemic
Electrolytes
hypernatremia occurs d/t exogenous Na+ intake or
mineralocorticoid excess. When tx, Na+ must be
returned to normal slowly. Initial goal is
stabilization. Done w boluses of isotonic solutions
or LR
Injury to ant urethra (portion of urethra distal to
urogenital diaphragm) MC results from blunt
trauma to the perineum (straddle injuries) or
instrumentation of urethra. Perineal tenderness or
Renal, Urinary Systems & hematoma, normal prostate, urethral bleeding.
3348 Surgery
Electrolytes Post urethra (prostatic and membranous) injuries
are common w pelvic fractures. Pts complain of
suprapubic pain, inability to void. Blood at urethral
meatus, high riding prostate (pelvic hmatma dspl,
scrotal hematoma. Sxs of pelvic fracture.
A retrograde urethrogram should be the first step
in mgmt of a suspted urethral injury. Foley cath in
3349 Surgery the presence of urethral injury will predispose the
Electrolytes
pt to abscess formation and worsening of the
urethral damage.
All trauma pts should be eval for cardiorespiratory
stability and have the spine immobilized until spinal
injury is ruled out. In pts w traumatic spinal cord
injuries (and no obvious pelvic injury w blood at
3784 Surgery urethral meatus), urinary catheter placement can
Electrolytes
assess for urinary retention and prevent acute
bladder distension and damage. Surg intervention
for acute cord compress w neurologic defects or
unstable vertebral fracture/dislocation
Oliguria, azotemia and elevated BUN/Cr ratio of
>20:1 in the post-op state most likely indicates
acute pre-renal failure from hypovolemia, though
4607 Surgery urinary catheter obstruction should be first ruled
Electrolytes
out. The next step in the dx/management of acute
renal failure manifesting as oliguira or anuria is an
IV fluid challenge.
Dx of OA should be considered in pts >40
presenting w knee pain. Morning stiffness >/= 30
mins suggests inflammatory arthritis; 10 mins is
Rheumatology/Orthopedics consistent w OA, non-inflammatory. Crepitus in
2305 Medicine
& Sports OA is a result of cartilage erosion and incongruous
jt surfaces. Initial drug of choice in
mild-to-moderate OA is acetaminophen. Proven
efficacy w a favorable S/E profile.
Erythema Nodosum (EN) is a condition of painful,
subq, pretibial nodules. Common in women age
15-40. Tends to be a benign condition, however it
can be a symptom of more serious dz processes
Rheumatology/Orthopedics including sarcoidosis (MC in AA women - need
2317 Medicine
& Sports CXR), TB, histoplasmosis, recent strep infxn
(MCC), & IBD. The assoc of EN w sarcoidosis is
particularly strong in young, AA women. Cough,
arthritis, uveitis, and hilar adenopathy on CXR are
also assoc w sarcoidosis.
Female athlete triad - Oligo/amenorrhea, decr
Rheumatology/Orthopedics caloric intake, osteoporosis. More likely to
2329 Medicine
& Sports develop stress fractures (occurs MC in athletes
and non-athletes who suddenly inc their activity).
Antiphospholipid Syndrome presents w a
thrombotic event (DVT or arterial thrombus) or
pregnancy morbidity (fetal loss, severe
preeclampsia, placental insufficiency) + a positive
Rheumatology/Orthopedics
2450 Medicine for 1 of 3 antiphospholipid antibodies:
& Sports
anticardiolipin antibody, anti-beta2-glycoprotein-I
antibody, or lupus anticoagulant. The biggest risk
factor for APS is SLE; APS occurs in 40% of
these pts.
Hemochromatosis is commonly assoc w Ca
pyrophosphate dihydrate deposition in joints,
leading to chondrocalcinosis and assoc symps
(episodic synovitis, chronic arthropathy). Other
2880 Medicine manifests: diabetes, hyperpigmentation, dilated
& Sports
cardiomyopathy, liver dz w hepatomegaly and
fibrosis. Dx is suggested by iron overload on
serum iron studies and confirmed by genetic tests
(HFE) or liver biopsy. Tx is phlebotomy.
Polymyositis
Clinical: Symmetrical proximal muscle weakness.
No/mild pain or muscle tenderness
Dx: Elevated muscle enzymes (eg, CK, aldolase).
Autoantibodies (eg, ANA, anti-Jo-1). Bpx:
3059 Medicine Endomysial mononuclear infiltrate, patchy necrosis
& Sports
Assoc conditions: Interstitial lung disease,
myocarditis, malignancy
Tx: Systemic glucocorticoids,
Glucocorticoid-sparing agents (eg, MTX,
Azathioprine)
OA is a noninflammatory arthritis MC affects the
hands and weight-bearing jts. Inc age is leading
risk factor. Mild morning stiffness exacerbated by
exercise. Effusions may occur but jnt remains cool
Rheumatology/Orthopedics to touch. Bony crepitus, enlargement, and painful
3148 Medicine
& Sports or dec ROM are common on exam. Synovial fluid
will show a WBC 200-2000 (normal: 0-200; inflam
condition: 2000-50000; Septic >50000). Plain film
narrowed jnt space w osteophyte and subchondral
sclerosis/cysts
Greater than 60% of patients with a first episode
of gouty arthritis suffer from a recurrence within 1
Rheumatology/Orthopedics year. Septic arthritis and pseudogout may present
3149 Medicine
& Sports similarly to gout and these conditions may coexist
in the same joint. Synovial fluid analysis is critical
for diagnosis.
Risk factors for gout
Medications (diuretics, low-dose aspirin)
Surgery, trauama, recent hospitalization
Volumedepletion
Diet: High-protein (meat, seafood), high-fat,
3150 Medicine fructose or sweetened beverages
& Sports
Heavyalcoholconsumption
Underlying medical conditions (htn, obestiy, CKD,
organ transplant)
Decreased risk: Dairy product intake, Vit C (>/=
1500 mg/day), Coffee intake (>/=6 cups/day)
Neisseria gonorrhoeae is the MCC of septic
arthritis in young, sexually active pts. Gonococcal
septic arthritis may present w asymmetric
polyarthralgias (often assoc w tenosynovitis & skin
rash) or as an isolated purulent mono- or
3153 Medicine polyarthritis. Dx may be confirmed by gram stain
& Sports
of the synovial fluid, blood cultures, and
genital/pharyngeal mucosal nucleic acid
amplification tests. Purulent arthritis in a sexually
active individual is gonococcal arthritis until proven
otherwis
Lower extremity pain relieved w spinal flexion -
lumbar spinal stenosis. Spinal stenosis is d/t
narrowing of the spinal canal w resulting
compression of the lumbar nerve roots. Common
Rheumatology/Orthopedics contributing factors include degenerative arthritis
3157 Medicine
& Sports (spondylosis), degenerative disk dz, and
thickening of the ligamentum flavum. Pain is often
assoc w activity, as lumbr extension during
walking worsens narrowing of the canal. AKA
neurogeniccluadication.
Giant cell arteritis (temporal arteritis) should be
suspected in patients w temporal headaches, jaw
claudication, and vision loss. Patients w suspected
3164 Medicine giant cell arteritis who have visual symptoms
& Sports
should be started immediately on high-dose
systemic glucocorticoids to reduce the
progression of visual complications.
Anterior uveitis is the MC extraskeletal
complication of ankylosing spondylitis. It causes
3165 Medicine inflammation in the iris, ciliary body and choroid,
& Sports
and presents w unilateral ocular pain and
photophobia.
>90% of pts w AS have HLA-B27, only 5% of pts
w HLA-B27 have AS. Therefore, HLA-B27 is not
Rheumatology/Orthopedics specific for AS and testing for it is not necessary
3167 Medicine
& Sports for dx. To dx AS do XRay of pelvis (shows
sacroiliitis). Xrays can be negative in early stages;
MRI can confirm in such cases.
Cyclophosphamide is an alkylating agent frequenly
used as an immunosuppressant in SLE, vasculitis
and certain cancers. Serious S/E include acute
hemorrhagic cystitis, bladder CA, sterility &
3169 Medicine myelosuppression. Hemorrhagic cystitis & bladder
& Sports
CA are caused by acrolein, bladder-toxic
metabolite of CYC. High fluid intake, frequent
voiding, & taking MESNA help prevent these
complications.
Rotator cuff tendinopathy & tear
Rotator cuff impingement or tendinopathy:
Pain w abduction, external rotation
Subacromial tenderness
Rheumatology/Orthopedics Normal ROM w positive impingement tests (eg,
3170 Medicine
& Sports Neer, Hawkins)
Rotator cuff tear:
Similar to rotator cuff tendinopathy
Weakness w abduction & external rotation
Age >40
Viral arthritis - Parvovirus B19. Acute onset,
polyarticular, and symmetric - resolves in 2
months. One of MCC of viral arthritis, likely in
Rheumatology/Orthopedics adults who have frequent contact w children.
3171 Medicine
& Sports Parvovirus infxn in adults presents w
arthritis/arthralgias involving MCP, PIP, and wrist
jts. "Slapped cheek" appearance is unusual in
adults.
MTX (purine antimetabolite) - Hepatotoxicity,
stomatitis, cytopenias
Leflunomide (pyrimidine synthesis inhibitor) -
Hepatotoxicity, cytopenias
Rheumatology/Orthopedics Hydroxychloroquine (TNF & IL-1 suppressor) -
3173 Medicine
& Sports Retinopathy
Sulfasalazine (TNF & IL-1 suppressor) -
Hepatotoxicity, stomatitis, hemolytic anemia
TNF inhibitors - Infxn, demyelination, CHF,
Malignancy
Fibromyalgia presents MC in young to
middle-aged women w widespread pain, fatigue,
and cognitive/mood disturbances. Normal phys
exam except for pooint muscle tenderness in
Rheumatology/Orthopedics areas ie mid trapezius, lateral epicondyle,
3202 Medicine
& Sports costochondral jxn in chest, & greater trochanter.
MGMT - Pt eduction (FM is a benign condition w a
favorable prognosis), regular aerobic exercise
(improves long-term pain), & good sleep hygiene.
Meds (TCAs) reserved as secondary measure.
Carpal Tunnel Syndrome - compression of the
median nerve. Obesity, DM, hypothyroidism, and
pregnancy.
Things that cause swelling of the flexor tendons,
3203 Medicine fibrosis, or edema of the surrounding soft tissues
& Sports
can reduce available space for the median nerve
and lead to compressive neuropathy. Symps of
CTS - pain & numbness in a median nerve
distribution. Pain radiates to the palm and wrist
Dermatomyositis is characterized by classic
cutaneous findings accompanied by proximal
extensor muscle inflammatory myopathy.
Gottron's violaceous scaly papules over joints.
3208 Medicine anti-Jo-1(antisynthetase), anti-Mi-2(antihelicase).
& Sports
Elevated CPK 10x the upper limit of normal. >15%
of adult pts will have or dvelop an internal
malignancy, MC ovarian, lung, pancreatic,
stomach, or CRC, or NHL.
Lower back pain
Metastatic cancer - Hx of malignancy, Age >50,
Worse @ night, unintentional weight loss, Cauda
Rheumatology/Orthopedics equina syndrome (weakness, urine
3211 Medicine
& Sports retention/incontinence, saddle anesthesia)
Infectious - Osteomyelitis, discitis, abscess -
Recent infxn, IVDA, DM, Fever, exquisite jt
tenderness
Anserine bursa - anteromedial over the tibial
plateau just below the jt line of the knee - inflamm
from abnormal gait, overuse or trauma - localized
pain over anteromedial tibia; pain present
Rheumatology/Orthopedics overnight as pressure from knees making contact
3303 Medicine
& Sports w one another while pt lies on side. Exam shows
well-defined area of tenderness over medial tibial
plateau. Valgus test does not aggravate the pain
indicating healthy MCL. X-ray is normal. Tx Ice,
rest, reducing pressure on bursa. Kenalog.
Single MCC of asymptomatic isolated elevation of
ALP in an elderly patient is Paget's disease of
bone (osteitis deformans). Bone lesions in this
condition are result of defective osteoid formation
3304 Medicine at sites of high bone turnover resulting in
& Sports
hypertrophy of bone. MC affected areas are skull,
clavicles, pelvis, n long bones. Pathologic
fractures, pain, osteosarcoma and neurological
symps are possible complications of this condition.
Whipple dz is a multisystem d/o w a varied
presentation caused by infxn w the gram+ bacillus
Rheumatology/Orthopedics Tropheryma whippelii. Chronic malabsorptive
3311 Medicine
& Sports diarrhea, weight loss, migratory non-deforming
arthritis, lymphadenopathy and a low-grade fever
are the MC presenting symptoms.
IBD may occur in association w inflammatory
arthritis. Ankylosing spondylitis and IBD are both
Rheumatology/Orthopedics assoc w HLA-B27 and may occur in assoc w one
3312 Medicine
& Sports another. Both conditions may also be assoc w a
positive p-ANCA despite the absence of vasculitis
in both conditions.
RA -> MTX -> Persistent symptoms for >6 months
-> Parallel therapy: Add another nonbiologic agent
Rheumatology/Orthopedics (eg,sulfasalazine,hydroxychloroquine)
3318 Medicine
& Sports -> Step-up therapy: Add biologic agent (TNF
inhibitor) -> Inadequate response -> Switch to
alternate TNF inhibitor & continue MTX
Sjogrens commonly affects women in their 5th or
6th decade of life. Keratoconjunctivitis sicca
(xerophthalmia) and xerostomia. Increased
incidence of dental caries and difficulty
Rheumatology/Orthopedics swallowing. Lymphocytic infiltration of salivary
3321 Medicine
& Sports glands will cause enlargement and firmness to
palpation of these glands. Dx is made w subjective
and objective evidence of dry mouth and eyes w
histologic evidence of lymphocytic infiltration of
salivary glands and anti-ssa (Ro) or anti-ssb (La)
Systemic sclerosis can affect every organ system
in the body. Thickening of the skin begins in acral
sites (hands and feet) w edema that transitions to
Rheumatology/Orthopedics dermal sclerosis w obliteration of skin appendages
3322 Medicine
& Sports (hair follicles and sweat glands) and flexion
contractures. Raynaud & calcinosis cutis
commonly seen. Connective tissue thickening.
PAH -> RHF. ANA and Anti-topoisomerase-I
Paget dz of bone (osteitis deformans) is assoc w
normal serum Ca2+ and PO43- levels and
increased Alk Phos and urinary hydroxyproline,
3516 Medicine deoxypyridinoline, N-telopeptide and
& Sports
C-telopeptide. Accelerated and disordered bone
resporption and formaltion of lamellar or woven
bone in affected sites.
Asymptomatic pts w mild Paget's dz involving
non-weight-bearing bones doesn't require tx.
Symptomatic pts best tx w oral or IV
aminobisphosphonates. Measurement of alk phos
is effective and inexpensive test for determing
3518 Medicine Paget's dz activity in most pts. Bisphosphonates
& Sports
inhibit osteoclasts to suppress bone turnover & r
the preferred therapy. Full-body bone scintigraphy
followed by plain radiographic confirmation in
areas of inc tracer uptake assess the full extent of
dz.
Subacromial bursa lies between the acromion and
tendon of the supraspinatus muscle. Inflam of the
subacromial bursa typically occurs in the setting of
chronic microtrauma to the supraspinatus tendon
caused by overhead work n repeated overhead
3574 Medicine movements of the arm during work or sporting
& Sports
activities. Tendon is traumatized by compression
between the acromion and the humeral head and
its vasc supply may be temp compromised during
such eps of compression. Pain w ROM of
shoulder.
De Quervain tenosynovitis classically affects new
mothers who hold their infants w the thumb
outstretched (abducted/extended). Inflammation of
the abductor pollicis longus and extensor pollicis
3576 Medicine brevis tendons as they pass through a fibrous
& Sports
sheath at the radial styloid process. Tenderness
can be elicited by direct palpation of the radial
side of the wrist at the base of the hand.
Finkelstein test positive.
Urate crystals can deposit in soft tissues, forming
tumors known as tophi. They can ulcerate and
drain a chalky material. Uric acid tophi are
pathognomonic for gout even in the absence of
Rheumatology/Orthopedics microscopic confirmation of crystals, the dx can be
3778 Medicine
& Sports made provisionally in pts w visible tophi and a hx
of episodic monoarthritis. Elevated serum uric acid
is nonspecific but can also contribute to the dx.
Calcinosis cutis is deposition of ca and po4 in the
skin. scattered whitish papules
Behcet disease
Young adults. Turkish, Middle Eastern, or Asian
descent.
Clinical: Recurrent, painful oral aphthous ulcers.
Genital ulcers. Eye lesions (eg, uveitis). Skin
3815 Medicine lesions (eg, erythema nodosum, acneiform
& Sports
lesions). Thrombosis.
Evaluation: Pathergy - Exaggerated ulceration w
minor trauma (eg, needlestick)
BPx - Nonspecific vasculitis of different-sized
vessels
Acute back pain + positive straight-leg raise test
suggest disk herniation. Management is
conservative. In trials - patients did better w/o bed
rest than with it; bedrest is no longer advised for
Rheumatology/Orthopedics this type of low back pain. Pts should be advised
4000 Medicine
& Sports to return to daily activities. Pain and stiffness is
better managed w NSAIDs and muscle relaxants.
Exercise program has also not been shown to be
beneficial. If pain persists >6 weeks. Get MRI and
CT w or w/o contrast myelography.
Felty syndrome occurs in people w longstanding
4047 Medicine RA (>/= 10 years) and is characterized by
& Sports
splenomegaly and neutropenia.
Vertebral Compression Fracture
Causes: Trauma, Osteoporosis, Osteomalacia,
Infxn (osteomyelitis), bone metastases, Metabolic
(hyperPTH), Paget Dz
Clinical:
Chronic/gradual VCF
Rheumatology/Orthopedics Painless. Progressive kyphosis. Loss of stature.
4083 Medicine
& Sports Acute VCF
Low back pain & decr spinal mobility. Pain
increasing w standing, walking, lying on back.
Tenderness at affected level.
Complications: Increased risk of future fractures.
Hyperkyphosis -> protuberant abd, early satiety,
weight loss, decr resp
Dematoymyositis is an idiopathic inflammatory
myopathy w immune-mediated muscle injury that
can be d/t paraneoplastic syndrome in malignancy.
4123 Medicine Pts typically have symmetrical proximal muscle
& Sports
weakness and erythematous rash over the dorsum
of fingers (gottron's papules) and/or eyelids
(heliotrope eruption)
Numbness and occasional pain in the right palm
and thenar eminence atrophy - Median nerve
involvement. Carpal tunnel syndrome. Carpal
tunnel is a fibro-osseous structure formed by the
4173 Medicine carpal bones and covered by the transverse
& Sports
carpal ligaments. Median nerve passes through w
the flexor tendons. Median nerve prone to
compression w/in this channel. Develops in 7% of
hypothyroidism pts.
Cervial spondylosis - affects >10% of ppl over 50.
The hx of chronic neck pain is typical. Limited neck
rotation and lateral bending is d/t OA and
secondary muscle spasm. Sensory deficit is d/t
Rheumatology/Orthopedics osteophyte-induced radiculopathy and isolated
4205 Medicine
& Sports sensory abnlties are assoc w good prognosis.
Typical radio findings - bony spurs & sclerotic
facet joints. Such changes are common finding in
asymptomatic pts >50; therefore specificity is low.
Narrowing of disk spaces & hypertrophic verteb
Prevent gout
Weight loss to acheieve BMI <25
Low-fat diet
Decr seafood & red meat intake
Protein intake preferably from vegetable & low-fat
dairy prodcuts
Rheumatology/Orthopedics Avoidance of organ-rich foods (liver &
4259 Medicine
& Sports sweetbreads)
Avoidance of beer & distilled spirits
Avoidance of diuretics when possible
Meds for lowering serum urate are indicated for

pts w repeated attacks of gouty arthritis or
complicated dz (tophi, uric acid kidney stones)
Methotrexate is a DMARD. It works by inhibiting
dihydrofolate reductase. Macrocytic anemia is a
common side effect. Other side effects include:
Rheumatology/Orthopedics nausea, stomatitis, rash, hepatotoxicity, interstitial
4295 Medicine
& Sports lung disease, alopecia and fever. Methotrexate
acts by interfering w the cellular utilization of folic
acid, and folate depletion is considered to be the
cause of most of these complaints.
Systemic Sclerosis
Systemic: Fatigue, jt stiffness & pain
Skin: Telangiectasia, Sclerodactyly, Digital ulcers,
Calcinosis cutis
Vascular:Raynaudphenomenon
GI: Dysphagia, dyspepsia. Angiodysplasia of
4328 Medicine stomach (watermelon stomach) w GI bleeding.
& Sports
Malabsorption d/t bacterial overgrowth.
Pulm: Fibrosis, PAH
Renal: Scleroderma renal crisis (Acute onset
oligurin renal failure w malignant htn, tcpa, MAHA)
Cardiac: Myocarditis, pericarditis, pericardial
effusion
Back pain red flags:
Age >50
Hx of previous cancer
Constitutional symps
Nighttime pain causing sleep difficulty
Rheumatology/Orthopedics Pain duration >1month
4368 Medicine
& Sports No response to previous therapy
Neurologic symps
These things warrant additonal testing with X-rays
and ESR. If neg -> conervative therapy. If pos get
MRI. If no red flags -> conservative therapy. If
signs of cord compression -> MRI immediately.
Chronic low back pain
Mechanical (muscle strain, disc degeneration) -
Normal neuro exam. Paraspinal tenderness
Radiculopathy (herniated disk) - Radiation below
the knee. Positive straight-leg raise. Neurologic
deficits
4370 Medicine Spinal stenosis - Pseudoclaudication. Relieved by
& Sports
leaning forward.
Inflammatory (spondyloarthropathy) - Worse w
rest, better w activity. Sacroiliitis.
Metastatic cancer - Age >50, worse @ night, not
relieved w rest
Infectious - Recent infxn or IVDU
Tenderness to gentle percussion over the spinous
process of the involved vertebra is the most
reliable sign for spinal osteomyelitis. Pain is not
relieved w rest. Fever & leukocytosis are
4371 Medicine unreliable findings. The ESR is grossly elevated.
& Sports
MRI is the most sensitive dx study. A very high
index of suspicion for vertebral osteomyelitis
should be present for pateients w a hx of injection
drug use or recent distant site infxn (UTI).
Gout
Increased urate production: Primary gout
Rheumatology/Orthopedics (idiopathic).Myeloproliferative/lymphoproliferative
4449 Medicine
& Sports d/o. Tumor lysis syndrome. HGPRT deficiency.
Decreased urate clearance: CKD, Thiazide/loop
diuretics
Headache, jaw claudication, muscle fatigue, visual
disturbance in association w Polymyalgia
Rheumatica = Giant cell arteritis. On exam, pts
have scalp tenderness and a decreased temporal
Rheumatology/Orthopedics artery pulse. ESR is generally more than
4460 Medicine
& Sports 50mm/hr. Giant cell arteritis can involve branches
of the aorta, and aortic aneurysm is a well-known
complication. Pts should be followed with serial
CXRs. CLL is MC leukemia in adults. MCC of
hypothyroidism is Hashimotos. UC seen in jews.
DJD presents in adults >40ya w indolent
progressive anterior hip pain worsened by activity
and relieved by rest. The hip is not tender and
systemic symps are absent. Short-lived morning
4564 Medicine stiffness may occur. Trochanteric bursa
& Sports
inflammation has tenderness to palpation. It's
caused by frikxn between gluteus medius and
tensor fascia lata over greater trochanter. Pain
disrupts sleep.
Pts w RA are at increased risk of developing
osteopenia, osteoporosis, and bone fractures, esp
if additional risk factors for osteoporosis are
4572 Medicine present. Mgmt includes adequate physical activity,
& Sports
optimization of Ca2+ and vit D intake, minimization
of corticosteroid therapy, and consideration for
bisphosphonate tx.
MTX toxicity - Oral ulcers & acute rise in serum
transaminases. MTX is a nonbiologic DMARD that
targets inflammatory pathways. (Biologic agents
target cytokines & cell-surface proteins). MTX can
Rheumatology/Orthopedics be used alone or w other meds in pts w
4573 Medicine
& Sports moderate-to-severe RA. Folic acid
supplementation is recommeneded on a chronic
basis. S/E are reversible if med is DCd but pts
should be observed closely bc withdrawal can
cause acute RA flare-up.
RA
Symps:
Insidious onset, multiple jt pain, stiffness & swelling
Morning stiffness lasting hours, improves w activity
Small jts (PIP, MCP, MTP)
Monoarthritis (knees, elbows)
SPARES THE DIP, unlike OA
Exam:
4574 Medicine Affected jts are tender, swollen, w ltd ROM
& Sports
Tenosynovitis of palms -> trigger finger
Rheumatoid nodules (esp on elbows)
Cervical jt involvement leading to spine subluxation
-> spinal cord compression
Labs
Positive anti-CCP (dx)
High IgM RF
High CRP & ESR to level of severi
Enthesitis - inflammation and pain where tendons
and ligaments attach to bone. MC seen in faces of
recurrent tendon or ligament stress and HLA-B27
assoc arthropathies such as ankylosing spondylitis
Rheumatology/Orthopedics (AS), psoriaritic arthiritis and reactive arthritis. Esp
4576 Medicine
& Sports prominent in AS and manifests w heel pain @
insertion of achilles tendon. Tibial tuberosities and
iliac crests are also common sites. Shoulder and
hip pain, stiffness, low back pain, and limited
spinal mobility r common in AS
Reactive arthritis is a seronegative
spondyloarthropathy resulting from enteric or
genitourinary infection. Findings in reactive arthritis
may include urethritis, conjunctivitis,
4577 Medicine mucocutaneous lesions, enthesitis (achilles tendon
& Sports
pain) and asymmetric oligoarthritis. Not all
extra-articular manifestations need be present to
suspect the diagnosis. NSAIDs are first line
therapy.
Ankylosing Spondylitis
Inflammatory back pain: Insidious onset at age
<40. Symps >3 months. Relieved w exercise but
not rest. Nocturnal pain
Exam findings: Arthritis (sacroiliitis), Reduced
Rheumatology/Orthopedics chest expansion & spinal mobility, Enthesitis,
4578 Medicine
& Sports Dactylitis (swelling of fingers & toes), Uveitis
Complication: Osteoporosis/vertebral fractures,
aortic regurg, Cauda equina
Labs: Elevated ESR & CRP, HLA-B27
Imaging: X-ray of sacroiliac jts. MRI of sacroiliac
jts
Psoriatic arthritis
Arthritis: DIP joints, asymmetric oligoarthritis,
symmetric polyarthritis similar to RA, Arthritis
mutilans (deforming & destructive arthritis),
Spondylarthritides (sacroiliitis & spondylitis)
Rheumatology/Orthopedics Soft tissue & nail involvement: Enthesitis, Dactylitis
4581 Medicine
& Sports ("sausage digits) of toe or finger, nail pitting &
onycholysis, swelling of the hands or feet w pitting
edema
Skin lesions:
Arthritis precedes skin dz in 15% of pts
Skin lesions are present but not yet dx in 15%
Pseudogout (acute calcium pyrophosphate crystal
arthritis)
Symps: Acute mono- or oligoarticular arthritis
Peripheral jts (knee most common)
Dx:
Inflammatory effusion (15K-30K cells/mm^3)
4582 Medicine CPPD crystals (rhomboid shape, positive
& Sports
birefringence)
Chondrocalcinosis on imaging
Tx:
Intra-articular glucocorticoids
NSAIDs
Colchicine
Baker cysts occur as a result of excessive fluid
production by inflamed synovium. This occurs in
cases of RA, OA, and cartilage tears. As synovial
volume expands, excess fluid accumulates in the
Rheumatology/Orthopedics popliteal bursa. Popliteal bursa bulges beyond its
4583 Medicine
& Sports usual size and fills the popliteal fossa producing
the tender synovial fluid-filled mass known as a
Baker cyst. Baker cysts occasionally burst and
release their contents into the calf, resulting in an
appearance similar to DVT.
Secondary amyloidosis is a complication of a
chronic inflammatory condition (eg, chronic infxns,
IBD, RA) resulting in extracellular tissue deposition
4585 Medicine of fibrils into tissues & organs. Pts can develop
& Sports
multi-organ dysfxn (kidneys, liver, GI tract). Tx
underlying inflammatory dz. Colchicine is approved
for both tx and ppx of AA.
Disseminated gonococcal infxn - Polyarthralgia
(eg, wrist, elbow, ankle pain), tenosynovitis (eg,
pain elicited along the tendon sheaths), & painless
vesiculopustular skin lesions (tend to number from
Rheumatology/Orthopedics 2-10 and may be dismissed as furuncles or
4590 Medicine
& Sports pimples). Fevers & chills may be present. Hx of
recent unprotected sex w a new partner is
frequently assoc w disseminated gonococcal infxn,
while symps of symptomatic veneral dz are most
often absent.
Paget's disease
Mostly asymptomatic
Skull: enlargement, hearing loss, dizziness
Spine & pelvis: bone pain, spinal stenosis, nerve
compression
Long bones: bowing deformities w inc fracture risk
Rheumatology/Orthopedics Bone tumors: osteosarcoma, giant cell tumors
4627 Medicine
& Sports Elevated serum ALP
Ca & PO4 usually normal; elevated w fracture
Plain radiographs show osteolytic or mixed
lytic/sclerotic lesions
Dx combination of radiograph findings & ALP
Bone scan more sensi than XRAY
Txbisphosphonates
Paresthesias or pain in the distribution of the
median nerve during pregnancy is likely to be due
to carpal tunnel syndrome (CTS). Initial tx for CTS
involve neutral position wrist splinting and NSAIDs.
4636 Medicine Local corticosteroid injection is indicated in cases
& Sports
where wrist splinting is insufficient to relieve
symptoms. Surgical decompression of the carpal
tunnel is reserved for cases when conservative
management fails.
Neurogenic arthropathy (Charcot joint) due to DM
Pathogenesis: Decr propioception, pain, and temp
perception. Pts unknowingly traumatize their
weight-bearing jts. Secondary DJD, jt deformation,
and fxnal limitation
Rheumatology/Orthopedics Causes: DM, peripheral nerve damage,
4743 Medicine
& Sports syringomyelia, spinal cord injury, B12 deficiency,
tabes dorsalis
Radio: X-ray loss of cartilage, osteophyte
development, and loose bodies
Mgmt: Tx underlying dz and provide devices to
assist in weight bearing & decr trauma
Morton neuroma - numbness or pain between 3rd
& 4th toes, clicking sensation when palpating b/t
3rd & 4th toes while squeezing the metatarsal jts.
Tarsal tunnel syndrome - Compression of the tibial
Rheumatology/Orthopedics nerve at the ankle, Burning, numbness & aching of
4933 Medicine
& Sports the distal plantar surface of the foot/toes
Achilles tendinopathy - burning pain or stiffness
2-6cm above post calcaneus
Plantar fasciitis - plantar surface of heel pain,
worse when running or first steps of the day
ACL injuries are common, esp in young athletes in
sports requiring rapid direction changes or twisting
movements of the lower extremity. ACL injuries
8895 Medicine usually present w rapid onset of pain and swelling
& Sports
w hemarthrosis. Exam findings include laxity of
anterior motion of the tibia relative to the femur.
Dx - MRI. Tx - RICE +/- surgery.
Primary Raynauds
No underlying cause
Usually women age <30. No tissue injury. Negative
ANA & ESR
Avoid aggravating factors
CCB for persistent symptoms
9906 Medicine Secondary Raynauds
& Sports
Connective tissue diseases, occlusive vascular
conditions, sympathomimetic drugs, vibrating
tools, hyperviscosity syndrome, nicotine
Men >40, Symps of underlying dz, tissue injury or
digital ulcers, abnl nail fold capillary exam
Evaluate & tx underlying d/o. CCB for persistent
symps, ASA for pts @ risk for
Pyoderma gangrenosum - neutrophilic ulcerateive
skin disease. PG starts as an inflammatory
papule, pustule, vesicle, or nodule and progresses
to form an expanding ulcer w a purulent base and
Rheumatology/Orthopedics ragged violaceous borders. Can present as single
10434 Medicine
& Sports or multiple lesions, on trunk or lower extremities.
Nearly 30% of cases triggered by local trauama.
>50% w PG have an associated underlying
systemic d/o (IBD, RA, AML). PG dx w skin bpx.
Tx local or systemic corticosteroids.
Adhesive Capsulitis (AC - frozen shoulder
syndrome) - Markedly decreased ROM. The
glenohumeral jt loses its normal distensibility d/t
chronic inflammation, fibrosis, and contracture of
Rheumatology/Orthopedics the jt capsule. AC can be idiopatic or secondary to
11254 Medicine
& Sports underlying conditions (ie rotator cuff tendinopathy
[MC], subacromial bursitis, paralytic stroke, DM,
or humeral head fracture). Pts w AC - gradual
onset of shoulder stiffness, w or w/o pain, that
limits their ROM. Dx - >50% reduced motion
Involvement of salivary and other exocrine glands
(eg, lacrimal glands) can produce generalized
11915 Medicine dryness of mucous membranes, leading to dry
& Sports
mouth, irritated/itchy eyes, cough, and
dyspareunia.
Fatigue & weight loss, inflammatory arthritis,
serositis (pericardial friction rub), pancytopenia,
and protein-losing nephropathy (edema,
proteinuria, microscopic hematuria) in a young
woman is highly concerning for SLE, even in
11988 Medicine absence of characteristic rash. Initial labs should
& Sports
be CBC, UA, and ANA titer. ANA is highly sensitive
for SLE but is not specific. If ANA is elevated then
more specific autoantibodies can be obtained to
confirm dx. Complement, ESR, & CRP should be
as
RF for osteoporosis include advanced age, thin
Obstetrics body habitus, cigarette smoking, excessive EtOH
4122 & consumption, corticosteroid use, menopause,
& Sports
Gynecology malnutrition, FHx of osteoporosis, and Asian or
Caucuasian ethnicity.
Rickets
RF
Incr skin pigment (blck ppl)
Exclusivebreastfeeding
Inadequate sun exposure
Maternal vit D deficiency
Clinical
Craniotabes ("ping-pong ball" skull)
Delayed fontanel closure
Enlarged skull (frontal bossing), costochondral jts
("rachitic rosary"), long-bone jts (wrist widening)
2486 Pediatrics Genu varum
& Sports
XRAY
Osteopenia
Metaphysial cupping & fraying
Epiphyseal widening
Serum labs
Calcium: normal/low
Phosphorus: normal/low
Alk phos: very high
PTH: high
25-OH vit D: low
Ewings sarcoma is highly malignant, most often
found in the lower extremity. MC sites are
metaphysis and diaphysis of the femur, tibia, &
humerus in desc order. Metastasizes early to
Rheumatology/Orthopedics lungs & lymph nodes. White males 0-20. Pain &
2629 Pediatrics
& Sports swelling for weeks or mnths. Erythema and
warmth of local area. Intermittent fever, inc WBC,
anemia, inc ESR. Xray - onion skinning, lytic,
central, moth-eaten appearance in later xrays. Tx
- surgery, (rtx, multidrug ctx - preop).
Developmental dysplasia of the hip - dislocation of
the femoral head from the acetabulum. Early dx is
critical. Tx initiation before age 6 mo portends a
favorable prognosis. Delayed dx - limp, scoliosis,
Rheumatology/Orthopedics arthritis, avascular necrosis - 1 of the MC reasons
3402 Pediatrics
& Sports for lawsuits against peds. Barlow and Ortolani
maneuvars should assess jt stability. Hip laxity
resolves around 2 weeks. USG should be done 2
wks - 6 mos. DDH is bilat in ~20% of pts. X-ray
not helpful till >4-6 mos. Pavlik
All neonates and infants should be screened for
DDH w Barlow and Ortolani maneuvers. A
palpable clunk should prompt referral to an
Rheumatology/Orthopedics orthopedic surgeon. A soft click, leg-length
3402 Pediatrics
& Sports discrepancy, or asymmetric inguinal skin folds
require dx imaging w USG (age </= 6 months) or
x-rays (age >/= 4-6 months). The tx of choice for
age <6 mo is the Pavlik hip harness.
SCFE - displacement of the femoral head on the
femoral neck d/t disruption of the proximal femoral
growth plate. Commonly seen in obese adolescent
boys. The physis weakens during early
Rheumatology/Orthopedics adolescence bc it is rapidly expanding a primarily
3403 Pediatrics
& Sports made of cartilage. When exposed to shear stress
the physis fractures and femoral head slips
posteriorly & medially relative to femoral neck. Dx
- knee pain is prsenting complaint, xrays. Tx -
Surgical pinning
Legg-Calve-Perthes - idiopathic osteonecrosis of
the femoral head - boys <4-10 w peak incidence
@ 7. Etiology is unclear but some pts have an
underlying thrombophilia as a predisposing factor.
Rheumatology/Orthopedics Mild chornic hip or knee pain of insidious onset
3404 Pediatrics
& Sports with an antalgic gait (shorter time weight bearing
on the affected side d/t pain). Dx - high index of
suspicion. Initial xrays can be negative pointing to
transient synovitis (though should resolve in 1-4
weeks).
Growing pains
Occur primarily at night & resolve by morning
Affects lower extremities (eg, thighs, calves)
3555 Pediatrics usuallybilateral
& Sports
Normal phys exam & activity
Tx - Parental education & reassurance. Massage,
stretching exercises, heat & analgesics
Radial head subluxation-nursemaid's elbow
Mechanism: Axial traction on forearm w elbow
extended (child pulled, lifted or swung by arm)
annular
Phys exam: Arm held extended & pronated. No
Rheumatology/Orthopedics swelling, deformity, or focal tenderness
3668 Pediatrics
& Sports Treatment: Supination of forearm & flexion of
elbow OR HYPERPRONATION of forearm
Panner disease - osteochondrosis of the
capitellum. Adolescent who is actively engaged in
sports that involve throwing. Chronic dull pain,
crepitation, loss of pronation.
Metatarsus adductus - congenital foot deformity
most frequent in first-born infants. ~10% of pts
have associated acetabular dysplasia so careful
hip exam is required.
3 types
Type I - feet that overcorrect both passively &
3684 Pediatrics actively into abdution (spontaneously correct over
& Sports
time)
Type II - feet that correct to netural position w
passive & active movements (orthosis, cast,
shoes)
Type III - rigid feet that don't correct (serial
casting necessary)
Clubfoot (talipes equinovarus) - varus of the
calcaneum and talus, varus of the midfoot, and
adduction of the forefoot. Congential cases are
usually idiopathic. Teratologic assoc w
neuromuscular d/o or a complex syndrome.
3685 Pediatrics Positional cases occur d/t abnl positioning of the
& Sports
foot in utero (oligohydramnios). Tx involves
nonsurgical methods (stretching manipulations
followed byt serial plaster casts, malleable splints,
or taping) bc conservative tx corrects the majority
of cases.
Osteogenesis imperfecta - Inherited connective
tissue disorder - mutation in genes coding for type
Rheumatology/Orthopedics 1 collagen. Type 1 collagen is in skin, sclera,
3770 Pediatrics
& Sports bone, tendon and ligament - multiple recurrent
fractures, blue sclera, hearing loss, joint laxity,
short stature, & scoliosis.
Spondylolisthesis is a developmental d/o
characterized by a forward slip of vertebrae
(L5-S1) that usually manifests in preadolescent
4064 Pediatrics children. In the typical clinical scenario, back pain,
& Sports
neurologic dysfxn (eg, urinary incontience), and a
palpable "step-off" at the lumbosacral area are
present if the disease is severe.
Drooping of the contralateral hemipelvis below its
normal horizontal level during monopedal stance
constitutes a positive Trendelenburg sign. It is
caused by weakness or paralysis of the gluteus
4534 Pediatrics medius & minimus muscles (fxn to abduct the thigh
& Sports
at the hip when standing on one foot or during
normal ambulation whent he body's weight rests
on only one foot), which are innervated by the
superior gluteal nerve
Serum sickness-like rxn
Etiology: Abx (B-lactams, sulfa) MC. Type III HSR
Clinical: Fever, urticaria & polyarthralgia 1-2 wks
after first exposure. Gradual onset. Headache,
4584 Pediatrics edema, ladpy & splenomegaly less common
& Sports
Labs: nonspecific hypocomplementemia &
elevated inflammatory markers (ESR, CRP)
Tx: Remove/avoid offending agent. Steroids for
severe cases
Ddx Lytic bone lesion in a child
Infxn (Brodie abscess from osteomyelitis)
Endocrine (hyperparathyroid osteitis fibrosa
cystica)
Neoplastic (Ewing sarcoma, Langerhans cell
Rheumatology/Orthopedics histiocytosis (LCH), metastases)
4642 Pediatrics
& Sports Idiopathic (benign bone cyst, aneurysmal bone
cyst).
LCH aka LCGranulomatosis aka histiocytosis X
causes solitary, lytic, long bone lesions.
Eosinophilic granuloma - least severe form of
histiocytosis x.
Acquired torticollis (AKA wryneck) - twisting
usually d/t asymmetric muscle activity. MCC are
URTI, minor trauma, cervial lymphadenitis. Serious
4761 Pediatrics causes include RPA & atlantoaxial subluxation.
& Sports
Cervical spine radiographs should be obtaiend in
children presenting w torticollis to ensure there is
no cervical spine fracture or dislocation
OI - connective tissue d/o MC inherited AD
mutation of COL1A1. D/O has a varying spectrum
of severity, mild (type I), moderate (types III-IX)
to fatal perinatal (type II) disease. All pts have
Rheumatology/Orthopedics osteopenia, dx suspected w blue sclera.
4832 Pediatrics
& Sports Recurrent fractures, easy bruising, hypotonia,
HEARING LOSS. Also dentinogenesis imperfecta,
opalescent blue-gray to yellow-brown
discoloration caused by discolored dentin shining
through translucent weak enamel.
Kawasaki Disease - peak age 18-24mnths.
Children <5 yrs. Persistene release of
inflammatory cytokines - prolonged fever,
irritability, systemic inflammation. Children of east
asian ethnicity.
Fever for >5 consecutive days + 4/5 following:
Conjunctivitis (bilateral, nonexudative, spares
4834 Pediatrics limbus)
& Sports
Oral mucosal changes (erythema, fissured lips,
strawberry tongue)
Rash
Extremity changes (erythema, edema,
desquamation)
Cervical LAD (>1.5cm, unilateral, least consistent
finding)
Atlantoaxial instability should be suspected in any
pt w Down syndrome who presents w UMN
findings. This malformation is seen in 10-15% of
pts w Down Syndrome, MC occurs d/t excessive
Rheumatology/Orthopedics laxity in the posterior transverse ligament - incr
4840 Pediatrics
& Sports mobility bt the atlas and axis. Only 1-2% w it are
symptomatic. Behavioral changes, torticollis,
urinary incontinence, vertebrobasilar symps -
dizziness, vertigo, diplopia. Dx - lateral
radiographs of spine in different positions
Osgood-Schlatter common cause of knee pain,
esp in adolescent male athletes. During early
adolescence (ages 13-14 for males, 10-11
4849 Pediatrics females), there are period of rapid growth in which
& Sports
the quadriceps tendon puts traction on the
apophysis of the tibial tubercle where the patellar
tendon inserts.
Transient synovitis is MCC of hip pain in children
and is tx w rest and ibuprofen. There are usually
no lab abnlties or fever. Bilateral hip xrays should
be obtained to assess for Legg-Calve-Perthes
disease.
4857 Pediatrics Septic arthritis of the hip
& Sports
Fever >38.5
Inability to bear weight
WBC >12000
ESR >40
CRP >2 mg/dL (20mg/L)
Elbow fractures >50% of all fractures in children.
MC type is supracondylar humerus fracture. MC in
2-12 yo. Fall onto an outstretched arm w elbow
extended. Xrays show a large or triangular
anterior fat pad & presence of a posterior fat pad.
4873 Pediatrics Injury may be complicated by neurovascular injury
& Sports
or compartment syndrome (pain, pallor,
pulselessness, paralysis, paresthesia,
poikilothermia). Tx - removal bandages,
measurement of compartment pressures,
emergent orthopedic evaluation.
Osteoid osteoma - Dull, aching pain over the
affected area occurring mostly at night and is
improved w ibuprofen.. May present without focal
findings on exam. Pain is unrelated to physical
activity. Xray shows a hypodense lesion. Osteoid
11441 Pediatrics osteoma is a benign bone forming tumor that
& Sports
occurs most often in adolescence and early
adulthood and is MC in males. Osteoid osteoma
MC affects proximal femur but can also involve
other long bones & spine. Pts should follow w
serial exam & xr
Rotator cuff impingement or tendinopathy: Pain w
abduction, external rotation. Subacromial
tenderness. Nl ROM w pos impingement tests
Adhesive Capsulitis: Decreased passive & active
ROM. More stiffness than pain
Rheumatology/Orthopedics Biceps tendinopathy/rupture: Ant shoulder pain.
3168 Surgery
& Sports Pain w lifting, carrying, or overhead reaching.
Weakness less common
Glenohumeral OA: Uncommon & caused by
trauma. Gradual onset of ant or deep shoulder
pain. Decr active & passive abduction & external
rotation
Fat embolism is MC in pts w polytrauma, esp w
fractures of long bones. Severe resp distress,
petechial rash, subconjunctival hemorrhage,
tachycard, tachypnea, and fever. Dx fat droplets in
Rheumatology/Orthopedics urine or intra-arterial fat globules on funduscopy.
3302 Surgery
& Sports Occurs 12-72 hours after the injury. CNS dsyfxn -
confusion, agitation progressing to stupor,
seizures, or coma. Serial xrays show inc diffuse
bilat pulmonary infiltrates w/in 24-48 hrs of onset
of clinical findings. Tx - resp support.
Radiolucent line through scaphoid bone - scaphoid
fracture. MC seen in young adults after a fall on
outstretched hand. Pts complain of pain at the
Rheumatology/Orthopedics wrist. Tenderness in the snuffbox. Fracture MCO
3415 Surgery
& Sports across the waist of the scaphoid. Wrist
immobilization is tx for all nondisplaced scaphoid
fractures (fracs w <2mm of displacement and no
angulation)
DVT pain and swelling is more insidious and less
severe than compartment syndrome. There is also
an absence of neurologic symptoms.
3463 Surgery Compartment syndrome has neurologic
& Sports
symptoms. Pain w passive ROM and paresthesia.
Pallor and loss of limb pulses are uncommon
findings.
Supracondylar fractures are assoc w high risk of
neurovasc injury. The radial and brachial pulses
Rheumatology/Orthopedics must be assessed before and after reduction as
3556 Surgery
& Sports the brachial artery can be impinged. Motor and
sensory fxn should also be assessed d/t risk of
median nerve injury.
A careful neurovascular exam should accompany
all fractures to the clavicle due to its proximity to
the subclavian artery and brachial plexus.
3557 Surgery Clavicular fracture MCO in the middle 1/3.
& Sports
Contralateral hand classically is used to support
the weight of the effected arm. Shoulder on the
affected side is displaced posteriorly and inferiorly.
Femoral neck fracture - intra (femoral neck and
head) or extracapsular (intertrochanteric,
subtrochanteric). Intra have a higher chance of
avascular necrosis. Extra have a greater need for
Rheumatology/Orthopedics implant devices (nails, rods). The specific surgical
3564 Surgery
& Sports intervention varies case to case. Surgery ASAP to
relieve pain, minimize complications, and reduce
length of stay. Surgery may be delayed up to 72
hrs to evaluate surgical risk and ensure medical
stability.
Stress fracture - MCly occurs in athletes (15%
incidence in runners) or nonathletes who suddenly
inc their activity. Causes are categorized as
activity related, biomechanical, or metabolic.
Rheumatology/Orthopedics Increase in repeated tension of compression w/o
3566 Surgery
& Sports adequate rest that eventually breaks the bone.
Medial tibial stress syndrome (shin splints w no
tenderness on palpation). X-rays frequently are
normal. Injury is best defined using MRI or bone
scan.
Injury to medial collateral ligament is MC injured
ligament of the knee. Forcefull abduction of the
knee, often w a torsional component causes most
injuries to this ligament. MCL normally resists
Rheumatology/Orthopedics valgus angulations (abduction) at the knee, injury
3569 Surgery
& Sports to this ligament leads to inc angulation of the
affected knee on valgus stress. MRI is
investigation of choice to assess soft tissue
injuries of the knee. MRI can detect complete and
partial tears.
Meniscal injuries often result from twisting injuries
w the foot fixed. medial mcly injured than lateral.
Popping sound w severe pain. Meniscus is not
3572 Surgery directly perfused, effusion following injury is not
& Sports
apparent for many hours. A bucket handle tear of
the medial meniscus leads to locking of the knee jt
during terminal extension.
Nondisplaced hairline (stress) fracture of
metatarsal - common in athletes and military
recruits, sudden and drastic increase in activity.
Pts present compaining of slow onset foot pain
that initially only occurs w activity but later is
4485 Surgery present during rest as well. Pt tenderness over the
& Sports
affected metatarsal is present on exam. Fracs of
2nd 3rd 4th metatarsals are managed
conservatively bc surrounding bones act as splints
and nonunion is uncommon. Tx-Rest and pain
control
Ddx for unilateral hip pain in a middle-aged adult
includes infxn, trauma, arthritis, bursitis, and
radiculopathy. Trochanteric bursitis is inflammation
of the bursa surrounding the insertion of the
Rheumatology/Orthopedics gluteus medius onto the femur's greater
4546 Surgery
& Sports trochanter. Excessive frictional forces 2ndary to
overuse trauma, jt crystals, or infxn are
responsible. Pts complain of hip pain when
pressure is applied (as when sleeping) w external
rotation or resisted abduction.
Most meniscal tears in the knee joint occur during
a distinctly recalled acute knee injury, often assoc
w a popping sensation. Subsequent joint swelling
Rheumatology/Orthopedics develops gradually, and is often not noticed until
4554 Surgery
& Sports the following day. This is in contrast to
ligamentous tears, which may also be assoc w a
popping sensation, but which cause rapid jt
swelling due to hemarthrosis.
Prepatellar bursitis - anterior knee pain,
tenderness, erythema, localized swelling, common
in occupations requiring repetitive kneeling. Often
d/t S aureus, which can infect the bursa via
11976 Surgery penetrating trauma, repetitive friction, or extension
& Sports
from local cellulitis. Dx confirmed w aspiration of
bursal fluid for cell ct & gram stain. If negative, tx
is just NSAIDs. If positive, tx is drainage and
systemic abx.
In an emergency always tx the patient if there's no
Social Sciences
3616 Medicine documentation saying not to. If ever uncertain, err
(Ethics/Legal/Professional)
on the side of caution and tx the patient.
Brain death is defined as irreversible loss of fxn of
the whole brain, including the brainstem. There are
several criteria for declaring brain death. Brain
dead is a legally acceptable definition of death,
Social Sciences
4653 Medicine and artificial life support does not need to be
continued. Some states (NY and NJ) have
regulations in place in case the declaration of legal
death based on brain death is in violation of an
individual's religious beliefs.
Social Sciences Do not take the flash drive as only small gifts that
11911 Medicine
(Ethics/Legal/Professional) directly benefit patients are acceptable
Patient confidentiality should not be maintained if it
endangers the health and welfare of others (TB,
Obstetrics
Social Sciences HIV). In cases of HIV, public health laws require
3233 &
(Ethics/Legal/Professional) reportsing of the pt's positive test results to the
Gynecology
local health dept. The health dept. usually contacts
the patient's contacts.
PARENTS ARE NOT ALLOWED TO REFUSE
LIFE-SAVING TX FOR A CHILD INCLUDING
Social Sciences FOR RELIGIOUS REASONS. If parents refuse to
3235 Pediatrics
(Ethics/Legal/Professional) consent for tx for their child for a non-emergency
but fatal medical condition, the physician should
seek a court order mandating tx.
Circumstances in which minors do not require
consent
Medical circumstances: Emergency care, STIs,
substance abuse (most states), prenatal care
(most states)
Social Sciences Emancipated minor: Homeless, parent, married,
3624 Pediatrics
(Ethics/Legal/Professional) military, financially independent, high school
graduate
In cases w divorced parents w joint custody only
one parent's consent is necessary to proceed w
tx, esp if the decision is clearly in the child's best
interests.
Under HIPAA, patients have the legal right to
Social Sciences
3742 Psychiatry obtain copies of their medical records within a
specified timeframe.

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Question Main

Sub Division Notes

Supportive (hydration & NSAIDs) for most pts

Antithyroid drugs (MC adverse affect - allergy) -

Surgery - Permanent hypothyroidism, risk of

Low Mg level? Drug? blood transfusion?

Yes -> correct underlying cause.

No -> Measure PTH

PTH normal or low - Parathyroidectomy,

2585 Medicine Gastrointestinal & Nutrition 2 subgroupes

1. Hereditary site specific colon cancer (Lynch I)

II is assoc a high risk of extracolonic tumors, MC

Milk protein allergy - Regurgitation/vomiting,

Pyloric stenosis - projectile nonbilious vomit

Side effects/clinical presentation

Clinical presentation - Hemolytic anemia, jaundice,

Lab findings - Incr MCHC, Spherocytes on

Tx - folic acid, blood transfusions, splenectomy

Complications - Pigment gallstones, aplastic crises

Carditis (AV block, cardiomyopathy)

Mgmt: Supportive care (resolves w/in 7-10 days)

Chemical - <24 hrs - Mild conjunctival

Gonococcal - 2-5 days - Marked eyelid swelling;

Chlamydial - 5-14 days - Eyelid swelling;

avoid ceftriaxone displaces bilirubin from albumin -

Orbital (postseptal) cellulitis - serious infxn

Down syndrome - Flat facial profile, slanted

Fragile X syndrome - Long narrow face, prominent

NF2 (central neurofibromatosis) - NF2 tumor

Best dx approach is imaging. CT of brain is best

Pregnancy, Childbirth & Clinical feats

Tx - Reassurance, gentle handling, analgesics,

Meds for lowering serum urate are indicated for

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