CARDIOLOGY

Visit Etiology Presentation & PE Diagnosis Treatment & Complications

• Irregular rhythm from sinus node • EKG = beat to beat variation of P-P interval • Stable = no treatment
Sinus o ↑ with inspiration & ↓ with expiration • Unstable = atropine or transcutaneous pacing
Arrythmia
• MC = normal variant (due to high vagal tone)
• Rate = >100 bpm • EKG = rapid & regular; QRS after every P • Treatment = treat underlying cause & beta blockers

• Etiologies
o Fever or infection
Sinus o Hypovolemia or hemorrhage
Tachycardia o Anxiety or pain
o Thyrotoxicosis
o Hypoglycemia
o Shock
o Sympathomimetics = decongestants / cocaine
• Rate = <60 bpm • EKG = slow & regular; QRS after every P • Stable = no treatment
• Unstable = atropine or transcutaneous pacing
• Etiologies
Sinus o ↑ ICP
Bradycardia o Meds = BB, CCB or digoxin
o Hypothyroidism
o Carotid massage
o Infection = gram (–) sepsis
• Dysfunction of sinus node • Palpitations • EKG = alternating bradycardia & tachycardia • Stable = no treatment
o Sinus arrest with tachy & bradyarrhythmia’s • Dizziness o Tachyarrhythmia = Afib (MC), SVT, sinus • Unstable = atropine or transcutaneous pacing
• Angina tachycardia, or atrial flutter • Definitive = pacemaker
Sick Sinus • Etiologies • DOE
Syndrome o Sinus node fibrosis = MC • Presyncope or syncope
o Elderly
o Cardiac surgery
o Meds
• AV node dysfunction • Mostly asymptomatic! • EKG = prolonged PR interval • Stable = no treatment
o Conducted with delayed impulses • Unstable = atropine or transcutaneous pacing
• Fatigue • Other = BMP, Mg2+, CBC, TSH, Lyme titers, • Definitive = pacemaker
• MC = normal variant (due to high vagal tone) • Dizziness troponin, & echocardiogram
• SOB
• Location = AV node • CP
1st Degree
• Syncope
AV Block • Etiologies
o Intrinsic AV node disease • Severe = HOTN or AMS
o Acute MI
o Electrolyte disturbances = hyperkalemia
o AV node blocking meds = BB, CCB, digoxin
o Myocarditis → from Lyme disease
o Cardiac surgery
• AV node dysfunction • Mostly asymptomatic! • EKG = lengthening PR interval & dropped QRS • Stable = no treatment
o Occasional non-conducted impulses • Unstable = atropine or transcutaneous pacing
• Fatigue • Other = BMP, Mg2+, CBC, TSH, Lyme titers, • Definitive = pacemaker
• MC = normal variant (due to ↑ vagal tone) • Dizziness troponin, & echocardiogram
2ndDegree • SOB
• Location = bundle of His • CP
Type 1
• Syncope
AV Block • Etiologies
o Myocardial ischemia = inferior wall MI Severe = HOTN or AMS
Wenckebach o Cardiomyopathy = amyloidosis or sarcoidosis
o Myocarditis → from Lyme disease
o Endocarditis
o Electrolyte disturbances = hyperkalemia
o AV node blocking meds = BB, CCB, digoxin
o Cardiac surgery
 • AV node dysfunction
o Occasional non-conducted impulses
• Rarely seen in patients without structural HD
2nd Degree • Location = bundle of His
Type 2
AV Block • Etiologies
o Myocardial ischemia = inferior wall MI
o Cardiomyopathy = amyloidosis or sarcoidosis
o Myocarditis → from Lyme disease
o Endocarditis
o Electrolyte disturbances = hyperkalemia
o AV node blocking meds = BB, CCB, digoxin
• AV node dissociation
o Atrial & ventricular activity are independent
o NO conducted atrial impulses
o Escape rhythm below block
3rd Degree • Location = AV node, bundle of His, or branches
AV Block
• Etiologies
Complete o Myocardial ischemia = inferior wall MI
o Myocarditis → from Lyme disease
o Endocarditis
o Electrolyte disturbances = hyperkalemia
o AV node blocking meds = BB, CCB, digoxin
o Hypothyroidism
• 1 irritable atrial focus
• AV node doesn’t allow all flutter waves to conduct
Atrial Flutter to ventricles → 2:1, 3:1 or 4:1
• Atrial rate = 250–350
• Ventricular rate = 150 bpm (MC) → 2:1**
• Multiple irritable atrial foci
• Atrial rate = 350-450
• Ventricular rate = FAST
• Types
o Lone = <60 y/o & no h/o CHD, HTN or DM
o Paroxysmal = self-terminating & <7 days
o Persistent = non self-terminating & >7 days
o Longstanding persistent = >1 year
o Permanent = >1 year & refractory to tx
▪ Rate control & CVA prevention ONLY
Atrial • Etiologies = related to enlarged left atrium
o OSA = MC risk factor!
Fibrillation
▪ Hypoxia → pulmonary vasoconstriction
pulmonary HTN → ↑ LA
o CAD = complicated by MI or CHF
o Congenial heart disease
o Valvular heart disease = rheumatic
o Metabolic syndrome = HTN, HLD, & DM
o VTE = PE or DVT
o Hypertrophic cardiomyopathy
o Hyperthyroidism
o Meds = digoxin
o Drugs = stimulants
o EtOH
o Infection
o Inflammation
• Mostly asymptomatic! • EKG = constant PR interval & dropped QRS • Stable = place transcutaneous pads
o PR interval might be prolonged • Unstable = atropine or transcutaneous pacing
• Fatigue • Definitive = pacemaker*** (even if asymptomatic!)
• Dizziness • Other = BMP, Mg2+, CBC, TSH, Lyme titers, o Likely to progress to 3rd degree AV block
• SOB troponin, & echocardiogram
• CP • Complications = 3rd degree AV block
• Syncope
Severe = HOTN or AMS
• Mostly asymptomatic! • EKG = unrelated P-P & R-R intervals • Stable = place transcutaneous pads
o AV dissociation • Unstable = atropine or transcutaneous pacing
• Fatigue • Definitive = pacemaker***
• Dizziness • Other = BMP, Mg2+, CBC, TSH, Lyme titers,
• SOB troponin, & echocardiogram
• CP
• Syncope
Severe = HOTN or AMS
• Palpitations • EKG = saw tooth with no discernable P waves • Stable = meds or cardioversion
• Fatigue o Meds = BB, CCB or digoxin (ex: HFrEF)
• Dizziness o Cardioversion = at least 1 attempt to NSR
• SOB
• CP • Unstable = cardioversion
o Ischemia = symptomatic or EKG
o HOTN (severe)
• Unstable = HOTN, AMS or refractory CP o CHF +/– pulmonary edema
• Palpitations • EKG = irregularly irregular rhythm
• Fatigue o NO isoelectric baseline • Long-term = rate and rhythm control & anticoagulation
• Dizziness o +/– slow down HR → r/out A. flutter or MAT o Rate control = more important than rhythm control
• SOB ▪ >65 years old & mildly or asymptomatic
• CP • Cardiac monitoring = Holter monitor or telemetry ▪ Pharmacologic = BB, CCB or digoxin
o Afib suspected but not seen on EKG
• CCB = verapamil or diltiazem
• Unstable = HOTN, AMS or refractory CP
• Echo = clots, valvular disease, & atrium size • Digoxin = BB or CCB contraindicated (HrEF)
o Rhythm control
o Enlarged = old Afib
o Normal = new Afib ▪ <65 years old & symptomatic
▪ Pharmacologic = antiarrhythmics
• No structural heart disease
o Propafenone or flecainide
• Structural heart disease
o Heart failure = Amiodarone
o LVH = Amiodarone or Multaq
• S/E = arrythmias (ex: VT)
▪ Nonpharmacologic = ablation or cardioversion
o Anticoagulation =>2 CHA2DS2-VASc
▪ CHA2DS2 = CHF, HTN, Age (>75), DM, & Stroke
▪ VASc = Vascular Disease , Age (65-74), & Sex (F)
▪ HAS-BLED = bleeding risk score
• Complications = CVA (atrial thrombus formation)
 • Tachyarrhythmia originating above ventricles • Palpitations • EKG = regular, narrow, & no discernable P waves • Stable (narrow) = vagal maneuver, adenosine, BB or CCB
• Fatigue o Other = regular & wide (mimics Vtach) o Vagal = cough, bear down, straw breathing
Supra- • Types • Dizziness ▪ From BBB or WPW o Adenosine = 1st try 6 mg → then try 12 mg
ventricular o AVNRT = accessory pathway within AV node • SOB o NO fusion or capture beats • Stable (wide) = amiodarone or procainamide (WPW)
Tachycardia ▪ MC type of SVT • CP • Unstable = cardioversion
o AVRT = accessory pathway outside AV node • Definitive = catheter ablation
▪ Ex: WPW • Unstable = HOTN, AMS or refractory CP
• Accessory pathway (Bundle of Kent) pre-excites • Mostly asymptomatic! • EKG • Stable = procainamide & ibutilide
ventricles → AVRT o Delta wave o Avoid AV nodal blocking agents (ABCD) in antidomic
o Electrical conduction through extra pathway • Palpitations o Short PR interval = <.12s ▪ ABCD = adenosine, BB, CCB, & digoxin
Wolff o Widened QRS = >.12s
• Fatigue ▪ Cause MORE conduction down Bundle of Kent
Parkinson- • Types • Dizziness • Unstable = cardioversion
White o Orthodromic = antegrade direction impulse • SOB • Definitive treatment = catheter ablation
(WPW) ▪ Narrow-complex • CP
o Antidromic = retrograde direction impulse • Complications = ventricular arrhythmias or cardiac arrest
▪ Wide-complex WPW = Wave (delta); PR that’s short; Wide QRS
• Unstable = HOTN, AMS or refractory CP
• >3 PVCs in a row at a rate of >100 bpm • Palpitations • EKG = regular, wide; no discernable P waves • Stable = amiodarone, lidocaine & procainamide
o Monomorphic = same focus • Fatigue o +/– fusion or capture beats 1. Amiodarone
o Polymorphic = multiple foci • Dizziness o Fusion = QRS blending with PVC from partial 2. Lidocaine
• SOB normal conduction from atria to ventricles 3. Procainamide
• Unsustained = <30 seconds • CP
o Capture = atrial beat conducting to ventricles • Unstable = cardioversion
• Sustained = >30 seconds o Cardioversion = synchronized
Ventricular • EP study = locate source of VT • Pulseless VT = defibrillation + CPR
• Unstable = HOTN, AMS or refractory CP
Tachycardia • Etiologies o Defibrillation = unsynchronized cardioversion
o Ischemic heart disease (post MI) = MC • Torsades de pointes = IV magnesium sulfate
o Structural heart defect
o Cardiomyopathy • Ablation = cures 90% of VT
o Prolonged QT interval
o Electrolyte disturbances = ↓ K+, ↓ Mg2+, ↓ Ca2+ • Complications = Vib
o Digoxin toxicity
• Polymorphic ventricular tachycardia • Palpitations • EKG = polymorphic VT • Treatment = IV MgSO4 & stop all QT prolongation meds
• Fatigue
• Etiologies • Dizziness • CBC = rule out hypokalmiea or hypocalemia
o Prolonged QT interval • SOB
o Electrolyte disturbances = ↓ K+, ↓ Mg2+, ↓ Ca2+ • CP • Mg2+ = rule out hypomagnesmia
o Meds
Torsades De ▪ Digoxin
Pointes ▪ Class IA (Procainamide)
▪ Class III (Satolol)
▪ Antibiotics = macrolides
▪ Antipsychotics = 1st generation (Haldol)
▪ Antidepressants
▪ Antiemetics (Zofran)
• Ineffective ventricular contraction = cardiac death • Unresponsive • EKG = erratic pattern; no P waves • Treatment = defibrillation + CPR + epinephrine
• Pulseless
Ventricular • Risk factors • Syncope
o Ischemic heart disease (MI) = MC
Fibrillation
o Structural heart disease
o Cardiomyopathies
o Sustained VT
• PEA = electrical & mechanical activity NOT • Unresponsive • Treatment = defibrillation + CPR + epinephrine
coupled → organized rhythm w/ no palpable pulse • Pulseless
• Asystole = absent electrical & mechanical activity
Pulseless
Electrical • Etiologies
Activity o Hypovolemia (hemorrhage)
o Hyperkalemia
and o Hypoxia
o Metabolic acidosis
Asystole o Tension PTX
o Tamponade
o Toxin
o Thrombosis = pulmonary or cardiac
 • Systolic dysfunction = DILATED & weak • SOB • Echo = dilated left ventricle & ↓ EF Treatment = meds & ICD
• Fatigue o Gold standard o Meds = ACE inhibitors, BB, diuretics +/– digoxin
• MC type of cardiomyopathy o ICD (implanted cardioverter-defibrillator) = EF <35%
• Peripheral edema
• JVD • CXR = cardiomegaly, pulmonary edema, &
• Etiologies pleural effusion • Complications = arrythmias or valvular regurgitation
• Hepatomegaly
o Idiopathic = MC
o Ischemia = CAD or MI • S3 gallop • EKG = +/– tachycardia or arrythmias
o Valvular dysfunction
Dilated o Infection
Cardio- ▪ Enteroviruses (MC)
myopathy ▪ Myocarditis
▪ HIV
▪ Lyme disease
▪ Parvovirus
▪ Chagas disease = Trypanosoma cruzi
o Toxin = EtOH & cocaine
o Pregnancy
o Vitamin B1 deficiency Normal Dilated
o Thyroid disease
• Diastolic dysfunction = non-dilated & STIFF • SOB • Echo = non-dilated ventricles, diastolic • Treatment = treat underlying disorder
• Fatigue dysfunction & dilated atria
• Etiology • Peripheral edema o Gold standard • Diuretics if symptomatic
o Infiltrative disease • JVD
▪ Amyloidosis (MC) • Hepatomegaly • CXR = enlarged atria & pulmonary congestion
Restrictive ▪ Sarcoidosis • Ascites
Cardio- ▪ Hemochromatosis • EKG = low voltage QRS & arrythmias
• SOB
myopathy ▪ Scleroderma
▪ Metastatic disease • ↑ BNP
• Kussmaul’s sign = ↑ JVP with inspiration
▪ Endomyocardial fibrosis
o Chemotherapy or radiation • Endomyocardial biopsy = definitive diagnosis
• S3 gallop = sign of HF o Amyloidosis = apple-green birefringence &
• Pulmonary HTN = sign of HF congo-red staining Restrictive
• Diastolic dysfunction = from LVH or RVH • SOB • Echo = ↑ septal wall thickness, small LV • Treatment = meds, surgery and supportive
• Fatigue chamber, & LVOT obstruction o Meds = BB (1st line) or CCB
• Autosomal dominant • CP = angina ▪ Goal = ↓ HR → to ↑ diastole
o Mutations in sarcomeric proteins • Syncope • EKG = LVH, pseudo Q waves & enlarged atria o Surgery = myomectomy if young & refractory to meds
o AVOID dehydration, extreme exertion & exercise
• Dizziness o AVOID digoxin, nitrates & diuretics
• Worse with ↑ contractility & ↓ LV volume • Arrythmias
o ↑ contractility = exercise, B agonist, digoxin ▪ Digoxin = ↑ contractility
o ↓ LV volume = ↓ venous return, Valsalva, ▪ Nitrates & diuretics = ↓ LV volume
Hypertrophic • Harsh systolic murmur @ LSB
Cardio- dehydration
o ↑ w/ ↓ venous return = valsalva or standing • Complications = sudden cardiac death from Vfib
myopathy o ↓ w/ ↑ venous return = squatting or supine
• LV outlet obstruction when dehydrated
o Outlet opens with more blood in heart
• Displaced PMI
• S4 gallop
• Pulsus bisferiens = double pulse
o Backflow of blood during early diastole
• Jugular venous pulsations Hypertrophic

• Transient systolic dysfunction of left ventricle
• Mimics MI → no CAD or plaque rupture
• Catecholamine surge w/ stress, microvascular
Stress dysfunction & coronary artery spasm
(Takotsubo)
Cardio- • Risk factors
myopathy o Postmenopausal women (MC in women)
o Physical & emotional STRESS
• CP = substernal • EKG = ST elevation or ST depression
• SOB
• Syncope • Cardiac enzymes = (+) troponin
• Coronary angiogram = NO plaque or obstruction
• Echo = transient left ventricular dyfsunction
o Apical ballooning of ventricles (L > R)
• ↑ BNP
• Initial = meds & serial imaging
o Meds = ASA, nitro, BB, heparin (same as ACS)
▪ Recovery = 1-4 weeks
▪ Medication = 3-4 months
o Serial imaging = assess for improvement
• Short-term = BB, ACE inhibitors & anticoagulation
o Anticoagulation = severe LV dysfunction (EF <30%)
or thrombus
• Complications = HF, shock, CVA, & TIA
 • Inability of heart to pump sufficient blood
• Etiologies
o Left-sided = CAD (MC) & HTN
o Right-sided = pulmonary disease (COPD,
pulmonary HTN, etc.) & left-sided HF (MC)
• Systolic (HFrEF) = low ejection fraction
o MI
o Dilated cardiomyopathy
o Myocarditis
• Diastolic (HFpEF) = preserved ejection fraction
o HTN
o LVH
o Valvular heart disease
o Hypertrophic or restrictive cardiomyopathy
• High output = metabolic demands exceed cardiac
function (ex: hyperthyroidism or AV fistula)
• Low output = problem of myocardial contraction
• Remodeling = SNS & RAAS → remodeling
o SNS = norepinephrine
o RAAS = angiotensin II & aldosterone
Heart Failure
• Class 1 = no symptoms
o >7 metabolic equivalents
• Class 2 = no symptoms with ADLs; ok at rest
o >4 metabolic equivalents
• Class 3 = symptoms with ADLs; ok at rest
o >2 metabolic equivalents
Class 4 = symptomatic at
• rest → end-stage
• Left-sided • CMP = electrolytes (especially with diuretics) • HFrEF Treatment = meds & +/– surgery
o DOE o Diuretics (loops) = ↓ preload
o Orthopnea • ↑ BNP = >100 o ACEi & BB = ↓ afterload & prevent remodeling
o PND ▪ ACEi = block angiotensin II & aldosterone
o Fatigue • CBC = anemia or infection • Start ACE inhibitor first!! = most important
o Cough = nonproductive or pink frothy sputum ▪ BB = block SNS activation
o Pulmonary edema and congestion • Troponin = suspect MI o 2o agents = added as needed
o Cheyne-Stokes breathing
▪ Spironolactone = aldosterone ® antagonist
• TSH = rule out hyperthyroidism ▪ Entresto = neprilysin inhibitor with ARB
• Right-sided
o Peripheral edema • Replaces ACEi/ARB
o Jugular venous distension • EKG = arrythmia or infarction • Sacubitril / Valsartan
o HSM ▪ Hydralazine & long acting nitrates
• Echo = gold standard
o Ascites • Patients intolerant to ACE inhibitors or ARBs
o Hepatojugular reflex o Systolic = decreased EF, thin ventricular • Ex: isosorbide mononitrate or dinitrate
o N/V walls, & dilated LV chamber
▪ Digoxin = persistent HF sx despite other meds
o Diastolic = preserved EF, thick ventricular
walls & small LV chamber • No mortality benefit
• S3 gallop = systolic • May decrease hospitalizations
• S4 gallop = diastolic (atrial kick) • Systolic HF or Afib → “add on”
• CXR = Kerley B lines, butterfly/batwing pattern,
pulmonary edema, pleural effusions, cardiomegaly ▪ Ivabradine = slows HR at SA node
o Kerley B lines = fluid in interstitial spaces o ICD = severe (EF <35%) → & NOT class 4
o Pulmonary edema = fluid in alveoli interstitium ▪ VAD, pacemakers or ICDs
o Cephalization of blood vessels ▪ LVEF <35% after 90 days of medical therapy
▪ Before procedure, LifeVest prevents sudden death
• Cardiac MRI = allows you to look at myocardium
• HFpEF Treatment = meds → control HTN!
• Right heart catheterization = measure PCWP o Spironolactone = mineralocorticoid ® antagonist
o ↑ PCWP means mostly likely HF o ACEi & BB or CBB = HR & BP control
o Diuretics = prn for symptomatic relief
• Endomyocardial biopsy = risks vs. benefits
• Avoid NSAIDS! → ↑ RAAS → ↑ Na+ & H2O retention
• Supportive
o <2L fluid/day
o Na+ = <2 g/day
o Daily weight checks → call if >5 lb weight gain!
o Exercise
o Cardiac rehab
o BP control
o A1C control
o Lipid control

• Sudden worsening of s/s of HF • DOE • CBC = anemia or infection • Treatment = meds, position & +/– surgery
• Cough o Diuretics = Lasix
• Etiologies • Rales • CMP = electrolytes (especially with diuretics) o Nitrates = nitroglycerin → ↓ afterload & preload
o Mediation noncompliance • Peripheral edema o O2 = NC, NIPPV, or ventilation
o Hypertensive crisis • ↑ BNP = >100 o Position = sit up right
• ↑ JVP
o Acute MI o Inotropes = no improvement with other treatment
o Afib • HSM ▪ Dobutamine = beta 1 & 2 and alpha-1 adrenergic
Acute • EKG = evaluate for STEMI or arrythmia
o Valvular disease • Hepatojugular reflex ▪ Milrinone = does not target beta ®
Decompensated
Heart Failure o Papillary muscle rupture o Mechanical circulatory support
• Cardiac enzymes = evaluate troponin level
o Pregnancy ▪ Intra-aortic balloon counterpulsation
o Infection ▪ Impella = delivers blood from LV to aorta
o EtOH • CXR = Kerley B lines, pulmonary edema, pleural
effusions, or cardiomegaly
o Anemia • Can keep on BB if already it, but do not initiate or ↑ it
o Meds = BB, CCB, NSAIDs & antiarrhythmics
• Echo = gold standard
 • Stable coronary blood flow (stable plaque) • CP = substernal • EKG = normal vs. ST depression, T wave inversion, • Treatment = meds & manage risk factors
o Burning or pressure & poor R wave progression o Meds = ASA, BB, nitro & statin (no BB in Prinzmetal)
• Inadequate tissue perfusion / blood flow o Short duration = 3-5 minutes o Risk factors = HTN, DM, exercise, diet, & smoking
Stable o ↑ demand & ↓ coronary artery blood supply o Reproducible = exercise, stress, etc. • Cardiac enzymes = normal troponin
Angina
o Relieved with nitroglycerin & rest • Stress test = evaluate if pt needs cath (HR goal = 220-age)
• First manifestation of IHD • Coronary angiogram = definitive diagnosis o Types = EKG, echo & nuclear
• Radiation = arm, jaw, back, epigastrium, shoulders ▪ EKG = treadmill
Angina Pectoris ▪ Echo = treadmill or chemical (dobutamine)
• Atypical CP = dyspnea, palpitations, N/V, syncope, • Need to move quickly from treadmill to bed
shoulder or epigastric pain ▪ Nuclear = treadmill or chemical (lexiscan or DB)
o Women, elderly, DM & obese patients • Given with cardiolite
• ↓ coronary blood flow (unstable plaque) • CP at rest → NO relief of symptoms • EKG = ST depression & +/– T wave inversion • Meds = ASA, nitro, BB, statin, morphine, UFH & Plavix
o Rest angina >20 minutes
Unstable • Inadequate tissue perfusion / blood flow o New onset angina that limits physical activity • Cardiac enzymes = normal troponin • PCI = high risk or unstable
Angina o ↑ demand & ↓ coronary artery blood supply o More frequent, longer in duration, or occurs o Hemodynamic instability or cardiogenic shock
with less exertion than previous angina • Echo = wall motion abnormalities o Severe left ventricular dysfunction or heart failure
(ACS) • Plaque rupture → coronary artery thrombosis o Recurrent or persistent rest angina despite medication
• Lightheaded or dizzy • Risk stratification = GRACE & TIMI scores o New or worsening MR or new ventricular septal defect
• Risk factors • SOB o TIMI ≥3 = invasive strategy (PCI or CABG) o Sustained ventricular arrhythmias
o Metabolic triad = DM, HTN, HLD • N/V • EKG = ST depression & +/– T wave inversion
o Smoking • DC meds = ASA (Plavix if stent), BB, statin, & nitro
o Obesity • Radiation = arm, jaw, back, epigastrium, shoulders o ACE inhibitor if indicated otherwise (ex: DM)
• Cardiac enzymes = (+) troponin or CK-MB o No NSAIDs → GI bleeding risk b/c on ASA + Plavix
o Family history
o CK-MB = used to detect early reinfarction
o Men >45 years old & women >55 years old • Atypical CP = dyspnea, palpitations, N/V, syncope,
shoulder or epigastric pain • Echo = wall motion abnormalities
NSTEMI o Women, elderly, DM & obese patients
• Risk stratification = GRACE & TIMI scores
(ACS) • Symptoms at 70% blocked lumen o TIMI ≥3 = invasive strategy (PCI or CABG)

• ↓ coronary blood flow (unstable plaque)
• NO tissue perfusion / blood flow
o ↑ demand & ↓ coronary artery blood supply
• Plaque rupture → coronary artery thrombosis
• Risk factors
o Metabolic triad = DM, HTN, HLD
o Smoking
o Obesity
o Family history
o Men >45 years old & women >55 years old
• CP at rest → NO relief of symptoms
o Long duration = >30 minutes
o Non-pleuritic, non-positional, & non-tender
• SOB
• Presyncope
• N/V
• Radiation = arm, jaw, back, epigastrium, shoulders
• Atypical = SOB or shoulder or epigastric pain*
o Women, elderly, DM & obese patients
• EKG = ST elevation >1 mm (except V2 & V3)
o >1.5 mm in women
o >2 mm in men >40 years
o >2.5 mm in men <40 years old
• Cardiac enzymes = (+) troponin or CK-MB
o CK-MB = used to detect early reinfarction
• Meds = ASA, nitro, BB, statin, morphine, UFH & Plavix
o Right-sided MI = no nitrates! (preload dependent)
• Reperfusion = PCI, CABG or thrombolytics**
• PCI = percutaneous coronary intervention (<90 minutes)
o <3 vessel disease
o Treatment = angioplasty or stent
o Meds = ASA, Plavix, heparin, & BB
o DC meds = ASA + Plavix (need loading dose)
• PTCA = percutaneous transluminal coronary angioplasty
o 1 or 2 vessel disease, non-DM, or no left main disease

STEMI • Considered STEMI • CABG = coronary artery bypass graft

o New LBBB o Left main stenosis (>50%), 3 vessel disease, EF <40%
(ACS) o Isolated posterior MI
• Thrombolytics (tPA) = can’t cath lab for PCI (<60 minutes)

• DC meds = ASA (Plavix if stent), BB, statin, & nitro

o ACE inhibitor if indicated otherwise (ex: DM)
o No NSAIDs → GI bleeding risk b/c on ASA + Plavix

• Complications = arrhythmias, VFib, & cardiogenic shock

• Complications s/p MI = HF, Dressler’s syndrome, LV

aneurysm, LV rupture, papillary rupture, valve dysfunction
 • S/S due to coronary artery vasospasm
• Triggers
o Cold weather
o Exercise
o Alpha agonists
o Hyperventilation
Prinzmetal
Angina • Risk factors
o Female
o >50 years old
o Smoker
o Vasospastic disorders (Raynaud & migraines)
• MC = younger patients w/out typical risk factors
• Infection of endothelium / valves with vegetations
o Septic emboli = vegetations detach from
valve and float through blood stream
• MC = mitral (prolapse) or aortic (bicuspid)
o IVDA = tricuspid
o M>A>T>P
• Risk factors
o Elderly
o RHD
o IVDA
o Congenital HD
o Immunosuppression
o Prosthetic heart valve
• S. aureus = infection of damaged & healthy valves
o s/p wound, surgery or IVDA (skin)
o HIGH virulence
• S. viridans = infection of damaged valves
o Poor dentition or dental surgery (mouth)
o LOW virulence
• S. epidermis = prosthetic heart valve (surgery)
o Also with IV catheter
Endocarditis • Enterococcus = colon CA or UC
• Strep gallolyticus (aka S. bovis) = colon CA or UC
• Coxiella burnetiid = animal exposure & Q fever
• HACEK organisms = flora of mouth & throat
o Haemophilus, Actinobacillus,
Cardiobacterium, Eikenella, Kingella
• Cx (–) bacteria = Chlamydia, Legionella, & fungal
• Acute = infection of normal valves
o Staph & strep = toxic appearing
o No osler’s nodes or roth spots
• Subacute = infection of abnormal valves
o HACEK = non-toxic appearing
o Osler’s nodes & roth spots
• CP at rest → especially @ night or early AM
o Not exertional
o Short duration = 5-15 minutes
• Fever = persistent
• Fatigue & anorexia
• New murmur OR worsening of old murmur
• Janeway lesions = septic emboli
o PAINLESS lesions on palms
• Splinter hemorrhage = septic emboli
o Found on nailbed
• Osler nodes = immune complex deposition
o PAINFULE papules
• Roth spots = immune complex deposition
o Retinal hemorrhage – found on eye exam
• 5 minor
• Splenomegaly = immune complex deposition
• Glomerulonephritis = immune complex deposition
• EKG = transient ST elevation
• Coronary angiogram = coronary vasospasms
• Blood culture = 3 sets at least 1 hour apart
• EKG = assess for arrythmias
• Echo = TTE 1st then TEE → vegetation
• CBC = ↑ WBC & anemia
• ↑ ESR & CRP
• ↑ RF
• Duke Criteria = 2 major OR 1 major + 3 minor OR
o Major
▪ 2 (+) blood cultures
• Typical microorganism
• Persistently (+) BC
• Singe (+) BC for Coxiella burnetii
▪ (+) echo = veggie, abscess, or dehiscence
▪ New murmur / valvular regurgitation
o Minor
▪ Predisposition = IVDA, hx endocarditis,
prosthetic valve, & indwelling catheters
▪ Fever = >100.4 oF
▪ Vascular & embolic phenomena
• Janeway lesions
• Splinter hemorrhages
• Septic emboli = arterial or PE
o Systemic emboli = mitral
o Pulmonary emboli = tricuspid
• ICH
• Conjunctival hemorrhage
▪ Immunologic phenomena
• Osler’s nodes
• Roth spots
• (+) RF
• Glomerulonephritis
▪ (+) BC not meeting major criteria
• Treatment = meds
o CCB = 1st line
o Nitrates (nitroglycerin) = 2nd line
• AVOID beta blockers! → cause unopposed vasospasm
• Treatment = antibiotics & possibly surgery
o Acute = nafcillin OR oxacillin + ceftriaxone OR
gentamicin
o Subacute = PCN + ampicillin or gentamicin
o Prosthetic = vancomycin + gentamicin + rifampin
o Fungal = amphotericin B
• ABX = 4-6 weeks from (–) blood cultures
• IVDA = vancomycin + ceftriaxone
• Acquired = ampicillin + gentamicin
• Strep bovis = do colonoscopy (likely has colon CA)
• Surgery = severe CHF, >15 mm vegetation, >10 mm
vegetation & embolization (CVA, limb ischemia, etc.),
multiple septic emboli, abscess or fungus, & resistant
organisms
o High risk emboli or bacteria won’t be killed by ABX
• Complications = septic emboli (CVA, PE, spleen, etc.)
o Left septic emboli = CVA
o Right septic embolic = PE
• Prophylaxis = prior to dental procedures → amoxicillin
o Prosthetic heart valve
o Previous infectious endocarditis
o Congenital heart defect
o Cardiac transplant recipients with valve regurgitation
 • LV outflow obstruction
• MC valvular disease
• Etiologies
o Calcifications (>70 years old)
▪ Older patient with atherosclerosis
Aortic o Bicuspid valve (<70 years old)
Stenosis o Rheumatic heart disease
• Incomplete aortic valve closure
o LV volume overload → LV dilation
• Etiologies
o Acute = MI, aortic dissection, & endocarditis
▪ Cardiogenic shock & pulmonary edema
Aortic o Chronic = Marfan, rheumatic fever, syphilis,
Regurgitation HTN, & inflammatory disorders
▪ CHF symptoms = DOE, PND & crackles
• Aortic dissection, infection or infarction
• Outflow obstruction from LA to LV
• Etiologies
o Rheumatic heart disease = MC cause!!!
▪ Younger patients = 20-30 years old
▪ Inflammation of mitral valve
o Congenital left atrial myxoma
Mitral o Thrombus
Stenosis o Valvulitis = SLE, amyloid, carcinoid
• Retrograde blood flow
• Etiologies
o Leaflet abnormalities
▪ Mitral valve prolapse = MC cause
▪ Rheumatic fever
▪ Endocarditis or valvulitis
▪ LV dilation = annulus dilation
Mitral
Regurgitation ▪ Marfan syndrome
o Papillary muscle dysfunction
▪ Myocardial ischemia or MI
▪ Cardiomyopathy
o Ruptured chordae tendinea
▪ Collagen vascular disease
▪ Dilated cardiomyopathy
• Systolic crescendo-decrescendo murmur @ RUSB
o Radiation = carotid artery
• ↑ murmur = sitting, leaning forward, squatting,
supine, & leg raise
• ↓ murmur = valsalva, standing, inspiration, &
handgrip
• Triad = syncope, DOE & CP
o Exertional dizziness (presyncope) or syncope
o Exertional dyspnea
o Exertional chest pain
• Fixed S2 → no splitting of S2
• Pulsus parvus et tardus = weak & delayed carotid
o S2 & carotid upstroke should occur together
• Diastolic blowing decrescendo @ LUSB
• Austin-Flint murmur = diastolic rumble @ apex
• de Musset sign = head bob with every heartbeat
• ↑ murmur = sitting, leaning forward, squatting,
supine, leg raise, handgrip
o Handgrip = tightening fists (↑ afterload)
• ↓ murmur = valsalva, standing, inspiration
• Widened pulse pressure
• Bounding pulses
• Mid-diastolic rumbling @ apex
o Opening snap = forceful opening of valve
o Loud S1 = forceful closure of valve
• ↑ murmur = left lateral decubitus, squatting,
supine, & leg raise
• ↓ murmur = valsalva, standing, & inspiration
• Dyspnea
• Cough
• Hemoptysis
• Pulmonary HTN
• Mitral facies = flushed cheeks & facial pallor
• Dysphagia = from left atrial enlargement
• Blowing holosystolic murmur @ apex
o Radiation = axilla
• ↑ murmur = left lateral decubitus, squatting,
supine, leg raise, & handgrip
• ↓ murmur = valsalva, standing, inspiration
• Dyspnea
• Hypotension
• Acute = cardiogenic shock
• Chronic = CHF symptoms & Afib
• Echo = best test
o Severe = aortic valve area <1.0 cm, aortic
velocity >4.0 m/s, & gradient >40 mmHg
• EKG = LVH
• CXR = aortic valve calcification
• Cardiac cath = definitive diagnosis
• Echo = best test
• Cardiac cath = definitive diagnosis
• Echo = best test
• EKG = LA enlargement; Afib (atrial stretch)
• CXR = LA enlargement; pulmonary edema
• Cardiac cath = definitive diagnosis
• Echo = best test
• EKG = LA enlargement; LVH; Afib (atrial stretch)
• CXR = LA enlargement; LVH; pulmonary edema
Cardiac cath = definitive diagnosis
• Treatment = aortic valve replacement!
o NO medical treatment is effective!
• AVOID anything that ↓ preload
o Physical exertion, venodilators, & (–) inotropes
• Complications = LVH → HF
• Symptomatic = lifespan REDUCED
• Treatment = meds or surgery
o Meds = ACEi, ARBs, nifedipine, hydralazine
▪ ↓ afterload
o Surgery = replacement is definitive management
▪ Acute & symptomatic
▪ Asymptomatic w/ decompensated LV (EF <50%)
▪ Acute = emergent replacement
▪ Chronic = urgent replacement
• Monitoring = serial echocardiograms
• Complications = LVH → HF
• Treatment = surgery, meds, & diet
o Surgery = balloon valvuloplasty or replacement
▪ Repair = preferred for younger patients
▪ Replacement = valvuloplasty contraindicated
• Wait for replacement b/c need sternotomy
• Replaced valves will need replaced again
o Meds = diuretics & Na+ restriction
o Anticoagulation = Afib
• Complications = CHF, Afib, or Ortner’s syndrome
o CHF = atrial overload → pulmonary congestion →
pulmonary HTN → CHF
o Afib = secondary to atrial enlargement
o Ortner’s syndrome = compression on recurrent
laryngeal nerve by dilated LA causing hoarseness
• Treatment = meds & surgery
o Meds = ACEi, ARBs, nifedipine, hydralazine
▪ ↓ afterload
o Surgery = repair preferred over replacement
▪ EF <60% OR refractory to medical therapy
 • Leaflets of mitral valve prolapse into left atrium • Mid-late systolic click @ apex • Echo = best test → posterior bulging leaflets • Treatment = reassurance, meds & surgery
o >2 mm beyond annulus in LA during systole o Reassurance = good prognosis
• ↓ preload = earlier click & longer murmur o Meds = BB for autonomic dysfunction
• MVP = MC cause of MR o Valsalva & standing o Surgery = repair or replacement = severe MR
o Increased prolapse ▪ To prevent CHF
• Etiologies • ↑ preload = delayed click & shorter murmur
Mitral Valve o Myxomatous degeneration o Squatting, leg raise, supine, & handgrip • Complications = mitral regurgitation, CHF & CVA (rare)
Prolapse o Marfan or Ehlers-Danlos o Decreased prolapse
o Osteogenesis imperfecta • Avoid dehydration & decrease HR (BB) to ↑ diastole
• Ventricle fill w/ blood → leaflets closer → murmur ↓
• Congenital = MC → seen in young women
• Autonomic dysfunction = atypical CP, panic attacks,
palpitations, syncope, dizziness, fatigue

• Outflow obstruction • Harsh systolic murmur @ LUSB • Treatment = surgery

Pulmonary o Radiation = neck o Surgery = balloon valvuloplasty
Stenosis • Etiology
o Congenital (MC) = congenital rubella • ↑ murmur = inspiration
• Retrograde blood flow • Decrescendo early diastolic murmur @ LUSB • Treatment = usually none

• Etiologies • ↑ murmur = inspiration, squatting, supine

Pulmonary o Congenital = Tetralogy of Fallot → MC!! o Graham-Steell murmur = ↑ with inspiration
Regurgitation o Pulmonary HTN = MC acquired cause • ↓ murmur = valsalva, standing, expiration
o Endocarditis
o Rheumatic heart disease

• Outflow obstruction • Diastolic murmur @ LLSB • Treatment = meds, diet & surgery
Tricuspid o Meds = diuretics (↓ R atrial volume overload)
Stenosis • ↑ murmur = inspiration, squatting, supine o Diet = limit Na+ (↓ R atrial volume overload)
o Surgery = replacement if right HF or ↓ cardiac output
• Retrograde blood flow • Holosystolic blowing murmur @ LSB • Treatment = meds & surgery
o Radiation = epigastrium o Meds = diuretics (↓ R atrial volume overload)
Tricuspid • Associated with right HF symptoms o Surgery = repair or replacement
Regurgitation • ↑ murmur = inspiration
o Carvallo’s sign = ↑ murmur with inspiration

• HLD = high cholesterol & TG • Mostly asymptomatic! • LDL <100 = optimal (>190 = very high) • Treatment = weight control, diet & meds
o Weight = weight reduction & ↑ exercise
• Etiologies – hypercholesterolemia • Xanthomas = fatty growths underneath skin • Triglyceride <150 = optimal (>500 = very high) o Diet = restriction of cholesterol, carbs & trans fat
o Hypothyroidism o Achilles tendon MC o ↑ TG related to ↑ glucose o Meds = lipid-lowering agents → statins
o Pregnancy o ↑ glucose is used to make ↑ TG
o Kidney failure • Xanthelasma = lipid plaques on eyelids • Meds
o Family history • Cholesterol <200 = optimal (>240 = very high) o Ezetimide = non-statin, but cardioprotective

• Familial hypercholesterolemia = autosomal • HDL >60 = optimal (<40 = very low) • Guidelines for Initiation of Statin Therapy
dominant o Clinical ASCVD
o >21 years old with LDL >190
• Etiologies – hypertriglyceridemia o DM I or II & 40-75 years old & LDL 70-189
o DM = ↑↑ glucose Metabolic Syndrome Diagnosis = 3/5 components o 40-75 years old & >7.5% ASCVD risk
Hyper- o <19 years old w/ familial hypercholesterolemia
o EtOH
lipidemia
o Obesity
(HLD) o Steroids • Benefits of Lipid Lowering Meds
o Estrogen o ↓ LDL = statins & bile acid sequestrants
o Hypothyroidism o ↓ TG = fibrates & niacin
o ↑ HDL = niacin & fibrates
• Screening
o High risk = >1 risk factor (HTN, smoking, • Complications = pancreatitis (hypertriglyceridemia)
FHx) or 1 severe risk factor
▪ Males = 20-25 years old
▪ Females = 30-35 years old
o Low risk
▪ Males = 35 years old
▪ Females = 45 years old
 • Primary (essential) = idiopathic • Normal = <120/<80 • 2 different readings on 2 different visits • Treatment = lifestyle & meds
o ↑ salt sensitivity • Elevated BP = 120-129/<80 o Lifestyle = 1st line
o ↑ sympathetic & mineralocorticoid activity • Stage I HTN = 130-139/80-89 • EKG = possible LVH ▪ Weight loss = BMI 18.5-24.9
• Stage II HTN = >140/>90 ▪ Smoking cessation
• Secondary = underlying cause • Fundoscopy = retinopathy or AV nicking ▪ DASH diet = fruits, veggies and limit fats & Na+
o Renovascular (MC) = renal artery stenosis ▪ Mediterranean diet = BEST cardiac diet!
o Cushing syndrome • CMP = creatine (kidney function) & glucose ▪ Exercise = >30 minutes for most days / week
o Sleep apnea = VERY IMPORTANT! ▪ Limit EtOH → 2 drinks men & 1 drink women
Hypertension o Hyperaldosteronism o Meds = fail lifestyle modifications for BP control
• UA = urine albumin:creatine
(HTN) o Pheochromocytoma ▪ Thiazide diuretics = 1st line (chlorthalidone)
o Coarctation of aorta ▪ ACE/ARBs = 1st line in CKD or DM
• Lipid panel = TG, cholesterol, LDL, & HDL ▪ CCB = 1st line in African Americans
o Smoking & EtOH & obesity
o Obesity
o ↑ salt • ASCVD risk = >10% with stage I needs meds • BP <140/90 for patients <60 years old
o OCPs & COX-2 inhibitors • BP <150/90 for patients >60 years old

• Complications = CAD, MI, AAA, CHF, PVD, TIA, CVA,

RAS, ESRD, retinal hemorrhage, bindless, & retinopathy
• SBP >180 and/or DBP >120 • Headache • Treatment = gradual BP reduction (PO meds)
• SOB o Meds = sodium nitroprusside, labetalol,
• WITHOUT evidence of end organ damage • CP clonidine, captopril, nicardipine, furosemide
Hypertensive o MAP ↓ = 10-20% over 1st hour & 5-15% over 23 hours
Urgency • Focal neuro deficits
• AMS or seizure
• N/V

• SBP >180 and/or DBP >120 • Headache • CXR = evaluate for CHF or other diagnoses • Treatment = gradual BP reduction (IV meds)
• SOB o Meds = sodium nitroprusside, labetalol, etc.
• WITH evidence of end organ damage • CP • EKG & troponin = evaluate for MI or arrythmia o MAP ↓ = 10-20% over 1st hour & 5-15% over 23 hours
• Focal neuro deficits
• AMS or seizure • CMP = electrolytes & creatine • CVA
o BP lowered if >185/110 & needs tPA
Hypertensive • N/V o BP lowered if >220/120 & no tPA
• BNP = evaluate for CHF
Emergency • Acute aortic dissection
• Cardiac = ACS, aortic dissection, acute HF o Rapid reduction to 100-120 bpm in 20 minutes
• Neuro = CVA or encephalopathy • UA = evaluate kidneys
• Intracerebral HTN
• Renal = AKD → proteinuria and hematuria o Treatment depends on different factors
• Fundoscopy = papilledema
• Eyes = retinopathy or cotton wool spots
• Malignant HTN = papilledema + DP >140 • CT head = suspicious of CVA or neuro symptoms
• Inflammation of myocardium • Viral prodrome = fever, myalgia, & malaise • CXR = cardiomegaly • Treatment = supportive or meds (systolic HF treatment)
o Myocellular damage o Supportive = mainstay of treatment
• Chest discomfort • EKG = normal, sinus tachycardia or pericarditis o Meds = ACEi, BB, diuretics, & antiarrhythmics
• MC = young adults • SOB
• Palpitations or ↑ HR • Cardiac enzymes = +/– (+) troponin • Complications = cardiac cell necrosis, heart failure, or
• Etiologies arrythmias
o Infection • Systolic dysfunction → dilated cardiomyopathy • ↑ ESR
Myocarditis
▪ Viral (enterovirus) = MC o Dyspnea
▪ Bacterial o Fatigue • Echo = ventricular systolic dysfunction
o Autoimmune = SLE or RA o Exercise intolerance
o Uremia o S3 gallop • Cardiac MRI = MI vs. myocarditis
o Toxins = scorpion or diphtheria
o Meds = clozapine, methyldopa, isoniazid, • Other = megacolon or pericarditis • Endomyocardial biopsy = gold standard
indomethacin, phenytoin, sulfonamide o Usually for refractory cases
• Fluid in pericardial space • CP • Echo = fluid in pericardial space (best test) • Treatment = treat underling condition & pericardiocentesis
o Normal = 5-15 mL in pericardial space • Dyspnea o Large effusion = pericardiocentesis
• Fatigue • EKG = electrical alternans & low QRS voltage
• Etiologies o Due to fluid
Pericardial o Idiopathic = 1st MC • Muffled (decreased) heart sounds
Effusion o Viral (coxsackie & echovirus) = 2nd MC • CXR = large cardiac silhouette & clear lung fields
o Autoimmune = SLE, RA, & scleroderma
o Uremia
o Malignancy = lung (MC) or breast cancer
o Aortic dissection
o Trauma
 • Inflammation of pericardium → outer heart layer
• Etiologies
o Idiopathic = 1st MC
o Viral (coxsackie & echovirus) = 2nd MC
o Autoimmune = SLE, RA, & scleroderma
o Uremia
Pericarditis o Hypothyroidism
o Trauma
o Meds = procainamide, PCN, & hydralazine
o Chem or radiation
o Malignancy = lung (MC) or breast cancer
• Dressler syndrome = 2-3 days post MI
o Pericarditis, fever, & pleural effusion
• ↓ pericardial elasticity = thickening, fibrosis &
calcifications → restricted ventricle diastolic filing
Constrictive • Etiologies = any cause of pericarditis!
Pericarditis o Idiopathic = 1st MC
o Viral (coxsackie & echovirus) = 2nd MC
o Ionizing radiation
• Chest pain = pleuritic, sharp & persistent
o Worse = inspiration & supine
o Better = sitting forward
• Pericardial friction rub
o End of inspiration, upright, & leaning forward
• Maybe present with viral prodrome!
• Dyspnea
• Right HF = ↑ JVP, edema & ↑ hepatojugular reflex
o Kussmaul’s sign = ↑ JVP with inspiration
• Pericardial knock = high-pitched diastolic sound
o Sudden cessation of ventricular filling
• EKG = ST elevations & PR depression • Treatment = meds
o avR (knuckle) = ST depression & PR elevation o NSAIDs or aspirin= 1st line → 7-14 days
o 4 stages o Colchicine = 2nd line or recurrent pericarditis
▪ ST elevation & PR depression o Steroids = refractory, SLE, RA, or uremic pericarditis
▪ Normal ▪ Recurrence is higher if treated with steroids
▪ T wave inversion
▪ Normal
• Diagnostic criteria = 2 out of 4 of the following:
o CP = sharp, pleuritic, & better leaning forward
o Pericardial friction rub
o EKG w/ diffuse ST elevation & PR depression
o New or worsening pericardial effusion
• Echo = pericardial effusion or cardiac tamponade
• CXR = pericardial calcification • Treatment = meds & +/– surgery
o Diuretics = symptomatic relief
• Echo = pericardial thickening or calcification o Pericardiectomy = definitive management
o Square root sign = diastolic dip → plateau
• CT or MRI = pericardial thickening or calcification
o More sensitive than echo

• Pericardial effusion causing ↓ cardiac filling • Becks triad • Echo = pericardial effusion • Treatment = meds & pericardiocentesis
o Causing too much pressure on heart o Muffled heart sounds o Also diastolic collapse of cardiac chambers o Meds = IVF and vasopressors
o ↑ JVP o Pericardiocentesis = immediate to remove pressure
• Rate of fluid accumulation WORSE than amount o Hypotension • EKG = electrical alternans & low QRS voltage
o Rapid accumulation of 150 mL worse than o Due to fluid buildup & heart moving around • Complications = ↓ CO (↓ blood flow to ventricles) & shock
slow of 1L (if compliant pericardium) • Pulsus paradoxus = >10 mmHg change in SBP
o BP ↑ = expiration • EKG = enlarged cardiac silhouette
• Risk factors o BP ↓ = inspiration
o Acute pericarditis = complicated • R cardiac cath = equal pressures in diastole
Cardiac o Trauma • Dyspnea
Tamponade o Malignancy = MC for nontraumatic tamponade • Fatigue
• Peripheral edema
• Reflex tachycardia
• Cool extremities

• Fluid in pleural space • Dyspnea • CXR = blunting of costophrenic angles • Treatment = treat underling cause, thoracentesis, chest
• CP = pleuritic o Lateral decubitus = evaluate for loculations tube, pleurodesis, & surgery
• Types • Cough or smaller effusions o Thoracentesis = diagnostic & therapeutic
o Transudative o 75 mL = blunts posterior costophrenic angle ▪ DO NOT remove >1.5 L at one time
▪ CHF = ↑ hydrostatic pressure • Dullness to percussion o 175 mL = blunts lateral costophrenic angle o Chest tube = empyema
▪ Cirrhosis = ↓ oncotic pressure o Pleurodesis (talc) = malignant or recurrent effusions
• ↓ tactile fremitus
▪ Nephrotic syndrome = ↓ oncotic pressure • Thoracentesis = gold standard (light criteria) o Surgery = locuated effusion (empyema)
• ↓ breath sounds o Transudative = clear
o Exudative • +/– tracheal deviation
▪ Pulmonary embolism o Exudative = cloudy & high cholesterol level
o Lymphatic = milky
Pleural ▪ Pneumonia • Symptoms depend on size!
Effusion ▪ Malignancy
• Light’s Criteria = 1/3 indicates exudative
▪ Tuberculosis o Protein pleural fluid/serum = >0.5
▪ Collagen vascular disorder o LDH pleural fluid/serum = >0.6
▪ Pancreatitis o LDH >2/3 ULN serum LDH
▪ Hemothorax
▪ Empyema = pus (PNA or TB) • CT = if needed for more information
o Lymphatic
▪ Chylothorax = ↑ lymph (thoracic duct)
• Damaged thoracic duct during surgery
• Malignancy compressing thoracic duct
 • Atherosclerotic disease of LE arteries • Intermittent claudication = LE pain w/ walking • ABI = ankle:brachial systolic BP • Treatment = supportive, meds & surgery
• Ischemic rest pain = at night (advanced disease) o Claudication = <0.9 o Supportive = exercise, stop smoking, & risk factor tx
• Risk factors o Ischemia = <0.3 ▪ Risk factors = HTN, DM, & HLD
o Smoking • Atrophic skin = thin/ shiny, hair loss & thick nails o Calcification/Diabetes = >1.3 o PLT inhibitors = Cilostazol (best) ASA, & Plavix
o DM ▪ Cilostazol = 1st line
o HTN • Arterial ulcers = lateral malleolus • US = assess for stenosis or occlusion • Phosphodiesterase 5 inhibitor
Peripheral o HLD • Relaxes muscle, stops PLTs & vasodilates
o Male • Angiography = gold standard (prior to surgery)
Arterial • ↓ or absent pulses o Statins = atorvastatin & rosuvastatin
o Obesity o Revascularization
Disease • ↓ capillary refill
o History of atherosclerosis
• Bruits ▪ Percutaneous transluminal angioplasty = 1st line
• Pale on elevation & dependent rubor ▪ Bypass grafts
▪ Endarterectomy
• Erectile dysfunction
• Avoid elastic compression stockings = ↓ circulation

• Acute limb ischemia = rapid ↓ in limb perfusion • 6 P’s • Doppler US = initial assessment of pulses • Treatment = reperfusion & supportive
o Paresthesia’s = early o Reperfusion = mainstay of treatment!
• VASCULAR EMERGENCY o Pain • CT or catheter angiogram = definitive diagnosis ▪ Surgical bypass
o Pallor ▪ Thromboembolectomy
• Risk factor = preexisting PAD o Pulselessness • EKG = assess for Afib or MI ▪ Endarterectomy
Acute Arterial o Poikilothermia ▪ Thrombolytic therapy
Occlusion • Etiology o Paralysis = late (worse prognosis) • Echo = clot, MI or valvular vegetation ▪ Percutaneous angioplasty
o Thrombotic (MC) o Supportive = pain meds, IVF, & UFH
▪ Superficial femoral or popliteal a. • ↓ capillary refill • CBC
o Embolic • ↓ or absent pulses • Complications (reperfusion) = compartment syndrome
o Iatrogenic = ex: s/p femoral catheter • Cool extremities • PT/INR & PTT
o Traumatic

• Small & medium vessel vasculitis • Distal extremity ischemia • Allen test = ↓ perfusion in radial & ulnar arteries • Treatment = supportive, meds & surgery
Thromboangitis o Nonatherosclerotic inflammation o Claudication o Supportive = tobacco cessation & wound care
Obliterans o ↓ blood flow → vasocclusive phenomena o Ischemic ulcers • Angiography = corkscrew collaterals o Meds
▪ CCB = Raynaud’s phenomenon
(Buerger’s • Risk factors • Raynaud’s phenomenon • Biopsy = segmental vascular inflammation ▪ Iloprost = helps during initial smoking cessation
Disease) o Young (20-45 years old) • Superficial migratory thrombophlebitis • IV prostaglandin
o Smokers/tobacco users o Surgery = amputation → gangrene present
• Venous valvular incompetency • Leg pain = burning, achy, crampy “heavy” • Clinical diagnosis • Treatment = supportive, ablation & ulcer management
o Worse = standing & sitting o Supportive = compressions, leg elevation, pain meds
• Risk factors o Improved = elevation & ambulation o Ablation = unresponsive to conservative management
o Superficial thrombophlebitis ▪ Laser or radiofrequency
o DVT • Stasis dermatitis = eczematous rash, o Ulcers = wound care & debridement
o Trauma brown/purple discoloration (hemosiderin)
Chronic
• Atrophie blanche = hypopigmentation areas
Venous o s/p injury because blood supply is poor &
Insufficiency healing is delayed

• Venous stasis ulcers = medial malleolus

• Pitting edema
• ↑ leg circumference
• Varicosities
• Dilation of superficial vein • Mostly asymptomatic! • Clinical diagnosis • Treatment = supportive or ablation
o Failure of venous valves in saphenous veins o Supportive = compressions, leg elevation, pain meds
o Retrograde flow, venous stasis & pooling • Dull ache or pressure sensation o Ablation = unresponsive to conservative management
o Worse = standing & sitting ▪ Laser or radiofrequency
• Risk factors o Improved = elevation & ambulation
Varicose o FHx • Complications = venous stasis ulcers
Veins o Female • Dilated visible veins
o Older age • Telangiectasias
o Standing = long periods of time • Swelling
o Obesity
• Discoloration
o ↑ estrogen (OCPs or pregnancy)
o Chronic venous insufficiency • Mild ankle edema
 • Inflammation / thrombosis of superficial vein • Tenderness • Clinical diagnosis • Treatment = supportive or surgery
• Pain o Supportive = NSAIDs, elevation, & warm compress
• Risk factors • Induration • US = noncompressible vein with clot & thickening o Surgery = vein ligation/excision (phlebectomy)
Superficial o IV catheterization • Edema ▪ Extensive varicose veins
Thrombo-
o Pregnancy • Erythema • Hypercoagulability = Factor V Leiden (MC), ▪ Septic phlebitis → also needs IV ABX
o Varicose veins prothrombin gene mutation, protein C & S, ▪ Persistent symptoms despite supportive care
phlebitis o Venous stasis
• Palpable cord antiphospholipid antibodies, & lupus anticoagulant

• Trousseau sign = migratory thrombophlebitis • Migratory phlebitis = malignancy workup

associated with pancreatic cancer
• Blood clot in venous system • Unilateral swelling & edema = >3 cm (MC) • Venous US = 1st line • Treatment
• Calf pain & tenderness o Anticoagulation = mainstay of treatment
• Virchow’s triad • Warm • D-dimer = depends on Wells Score ▪ Body will reabsorb/breakdown the clot
o Endothelial damage • Erythema o Low (zero) = stop here & document ▪ Anticoagulate to stop clot from getting bigger
▪ Trauma o Moderate = get d-dimer or US ▪ Delay in starting will ↑ risk of embolization
▪ Surgery o High = get US ▪ Continue for at least 3 months
• Homan sing = calf pain with dorsiflexion while
▪ Venipuncture squeezing calf ▪ Indefinite = unprovoked or active cancer
▪ Effort thrombosis = Paget-Schroetter dz • Palpable cord • MODERATE & HIGH risk o IVC filter = anticoagulation contraindicated
• Arm movement → subclavian vein o (–) US does not rule out DVT o Thrombolytics = unstable or massive DVT (tPA)
rubs → endothelial damage → clot o DVTs can occur in areas inaccessible to US o Thrombectomy = unstable or massive DVT
o Stasis o Repeat in 1 week → 2 US week apart r/o DVT ▪ Thrombolytics contradicted or ineffective
▪ Immobilization • LOW risk
Deep Venous o (–) D-dimer plus a (–) US rules out DVT • Anticoagulation
▪ Travel = prolonged sitting (>4 hours)
Thrombosis ▪ Venous stasis o Heparin = UFH & LMWH
• Intravenous venography = gold standard ▪ Need to bridge to another medication
▪ Hospitalization o IV contrast with X-ray o Factor Xa Inhibitors
o Hypercoagulability
o NOT routinely done ▪ Indirect = Fondaparinux (Arixtra)
▪ Inheritable disorder
• Protein C or S deficiency ▪ Direct = Xarelto & Eliquis
• Factor V Leiden o Direct thrombin inhibitor = Pradaxa
• Antithrombin III deficiency ▪ Need heparin bridge
o Vitamin K Antagonist = Warfarin
• Antiphospholipid syndrome
▪ Need heparin bridge
▪ OCPs o DOAC’s = Direct Oral Anticoagulants
▪ Malignancy ▪ Factor Xa inhibitor = Xarelto & Eliquis
▪ Smoking
▪ Pregnancy • Complications = pulmonary embolism
• Large & medium vessel granulomatous vasculitis • Headache = new onset & unilateral • Clinical diagnosis • Treatment = high-dose steroids, ASA & non-steroids
• Jaw claudication with mastication o Steroids = prednisone & methylprednisolone
• Arteries • Visual changes • CBC = normocytic anemia ▪ Prednisone = no vision loss
o External carotid artery branches = MC o Monocular vision loss ▪ IV methylprednisolone = vision loss
▪ Temporal artery o Central retinal artery occlusion = curtain vision • ↑ ESR (>100) & ↑ CRP • URGENT → DON’T wait for biopsy results
▪ Occipital artery ▪ Amaurosis fugax = vision loss from ↓ o Aspirin = only if needed for atherosclerosis
▪ Ophthalmic artery blood flow • Temporal biopsy = definitive diagnosis o Non-steroids = methotrexate & azathioprine
▪ Posterior ciliary artery
o Other • Scalp tenderness • Temporal artery US = thickening (halo sign), • Complications = blindness (central retinal artery
▪ Aorta • Temporal artery tenderness stenosis or occlusion occlusion), aortic dissection, aortic arch syndrome, valvular
▪ Carotid arteries • Fever, fatigue, weight loss, night sweats & malaise insufficiency
▪ Vestibular arteries
Giant Cell
• Risk factors
Arteritis o Women
o >50 years old
o Northeastern Europeans

• Associated with polymyalgia rheumatic

 • Focal aortic dilation >1.5 (>3 is aneurysmal) • Mostly asymptomatic! • CT with IV contrast = hemodynamically stable • Treatment = surgery (>5.5 cm, rapid growth, symptomatic)
o Proteolytic degeneration of aortic wall
o Connective tissue inflammation • Unruptured • Bedside US (FAST) = hemodynamically unstable • Screening = US men 65-75 years old with smoking history
o Abdominal, flank or back pain
• Risk factors o Abdominal bruit • US = asymptomatic & monitor progression • >0.5 cm / 6 months or >1 cm / year = surgery
o Smoking = MC modifiable risk factor o Pulsatile mass = MC exam finding • >5.5 cm = surgery
Aortic o Atherosclerosis • >4.5 cm = vascular surgeon referral
Aneurysm o >60 years old • Ruptured
o HTN • 4-4.5 cm = US q 6 months
o Abdominal, flank or back pain
o HLD • 3-4 cm = US q year
o Abdominal bruit
o Marfan or Ehlers-Danlos o Pulsatile mass = MC exam finding
o Syphilis o Hypotension
o Caucasian o Syncope • Complications = aneurysm or dissection
o Males o FLANK ecchymosis
• Tear through innermost aorta layer (intima) • Tearing chest/back pain • CT or MR angiogram or TEE = 1st line • Treatment = meds or surgery
o Ascending = anterior CP o Hemodynamically stable = CTA or MRA o Meds = distal/descending
• MC = ascending (high mortality) o Aortic arch = neck/jaw pain o Hemodynamically unstable = TTE ▪ BB = 1st line (labetalol or esmolol)
o Descending = interscapular (back) pain ▪ Nitroprusside (prn) = 2nd line
• Risk factors • CXR = widened mediastinum o Surgery = acute proximal or distal w/ complications
o HTN = MC • Aortic regurgitation
o >50 years old • DeBakey I (Stanford A) = proximal • Complications = aortic regurgitation (ascending)
o Smoking • Unequal BP in both arms o Type I = originates in ascending and goes to
o Men • ↓ peripheral pulses aortic arch & sometimes distally
o FHx o A = involves ascending & maybe descending
Aortic o Bicuspid aortic valve
Dissection o Marfan or Ehlers-Danlos • DeBakey II (Stanford A) = proximal
o Turners syndrome o Type II = originates & confined in ascending
o Pregnancy o A = involves ascending & maybe descending
o Cocaine
o Iatrogenic = cardiac catheterization • DeBakey III (Stanford B) = distal
o Type III = originates in descending
o B = involves descending

• Autoimmune inflammatory systemic disease
• 1-3 weeks after GABHS throat infection
• 3-6 weeks after GABHS skin infection
• GABHS = Strep pyogenes
• MC = 5-15 years old
• Rheumatic heart disease = 10-20 years later
• Jaccoud arthropathy = loosened & lengthened
periarticular structures and tendons
Rheumatic
o Mostly on hands and feet
Fever
• Symptoms of strep throat
o Sore throat with erythema & exudates
o Low-grade fever
o Cervical LAD
• Polyarthritis = >2 joints or migratory
• Carditis = valvulitis (aortic and mitral),
myocarditis, or pericarditis
• Sydenham’s chorea = sudden, involuntary jerky
movements (1-8 months after initial infection)
• Erythema marginatum = annular rash, trunk
and extremities (NOT face)
• Subcutaneous nodules = joints, scalp & spine
• (+) throat culture, rapid antigen or strep Ab titers
o Evidence of recent GABHS infection
• Jones criteria
o 2 major or 1 major and 2 minor + GABHS
• Major = JONES
o Joints = migratory polyarthritis
o Oh my heart = carditis or valvulitis
o Nodules = subcutaneous
o Erythema margination
o Sydenham chorea
• Minor
o Fever = >101.3
o Arthralgia
o ↑ ESR (>60) & CRP (>3.0)
o Prolonged PR interval (>0.2 sec)
• Treatment = supportive & meds
o Supportive = symptomatic relief of symptoms
o Penicillin G (IM) = eradication of GABHS
▪ PPX against GABHS = monthly penicillin G
• No carditis = 5 years or until 21 years old
(whichever is longer)
• Carditis & NO heart damage = 10 years or
until 21 years old (whichever is longer)
• Carditis & heart damage = 10 years or until
40 years old (whichever is longer)
o Aspirin = anti-inflammatory (2-6 weeks with taper)
o Corticosteroids = severe cases & carditis
• Complications = rheumatic valvualr disease (mitral MC)

• Biopsy (myocardium) = aschoff body

 PULMONOLOGY
Visit Etiology Presentation & PE Diagnosis Treatment & Complications
• Inflammation of bronchi • Cough → at least 5 days • Clinical diagnosis • Treatment = supportive & meds
• Dyspnea o Supportive = fluids, antipyretics, & pain meds
• Etiologies • URI sx = rhinorrhea, sore throat, & low-grade fever • CXR = if PNA is suspected o Antitussive = codeine (narcotic cough suppressant)
o Viral (MC) • Hemoptysis o Expectorant = guaifenesin (↑ mucus secretion)
▪ Adenovirus o Bronchodilators = albuterol
▪ Coronavirus • Wheezing ▪ Wheezing & underlying pulmonary disease
▪ Rhinovirus • Rhonchi
Acute • Complications = 2o pneumonia
▪ Parainfluenza
Bronchitis
▪ Coxsackie
▪ RSV
o Bacterial
▪ S. pneumonia
▪ H. influenza
▪ M. catarrhalis
▪ Mycoplasma
• Reversible & obstructive disease • Wheezing • PFTs (spirometry) = reversible airway obstruction • SABA prn
o Involves small airways • Cough → mostly PM or early AM o Do at 5 years old → can follow commands • Low ICS + SABA
• Chest tightness o ↓ FEV1 >12% from baseline • SABA + Med ICS OR SABA + Low ICS + LABA
• 3 components • SOB • SABA + Med ICS + LABA
o Inflammation • ↑ RR • CXR = PNA suspected, complicated asthma or
o Hyperactivity = bronchospasm suspect something else (poor treatment response) • Inhalers = MDI, dry powder inhalers and neb solutions
o Bronchoconstriction = obstruction • Prolonged expiratory phase
• Nasal polyps → maybe
• Peak expiratory flow = acute episodes
• Atopic triad = eczema → rhinitis → asthma

• Triggers = intrinisc vs. extrinsic

o Inrtrinsic = stress, excersie, & cold / dry air
o Extrinsic = pollen, mold, dust, cockroaches,
& pets (dogs, cats, etc.)
Asthma

• Permanent & irreversible bronchial dilation • Cough = persistent & productive (thick sputum) • High resolution CT = preferred imaging • Treatment = supportive, ABX & surgery
o Impaired mucociliary action • Dyspnea o Thick bronchial walls & airway dilation o Supportive = mucolytics (acetylcysteine), chest
o Lungs = dilated & damaged • CP = pleuritic o Tram-track appearance physiotherapy, & bronchodilators (albuterol)
▪ Can’t clear mucus! • Hemoptysis ▪ Lack of tapering of airway o ABX = prn
o Mucus builds up & then frequent infections o Signet ring sign o Surgery = resect / transplant for severe OR refractory
• Crackles = MC ▪ ↑ airway diameter > vessel diameter
• Repeated infection, airway obstruction &
Bronchiectasis • Wheezing
peribronchial fibrosis • PFT = gold standard → obstructive pattern
• Rhonchi
o ↓ FEV1 & FEV1/FVC <70%
• Etiologies
o Cystic fibrosis = pseudomonas
o Recurrent lung infections = H. flu
o Airway FB
o Alpha-1 antitrypsin deficiency
o Collagen vascular disorder
 • Chronic inflammation with mucus • Dyspnea • Productive cough >3 months a year for 2 years • Treatment = supportive & meds
o Mucus gland hyperplasia • Chronic cough o Supportive = stop smoking, O2, vaccines, & ABX prn
Chronic o Goblet cell mucus production • Sputum production • PFT = gold standard o Category A = SABA or SAMA
Bronchitis o Dysfunctional cilia o ↓ FEV1 & ↓ FEV1/FVC <70% o Category B = LAMA or LABA
(COPD) o Infiltration of neutrophils & CD8+ cells • Crackles o Category C = LAMA or LAMA + LABA or LABA + ICS
• EKG = cor pulmonale (RVH, RAD, & RAE) o Category D = LAMA + LABA + ICS
• Rhonchi
Obstructive • Etiologies
o Smoking
• Wheezing • Avoid SAMA + LAMA together!
Lung Disease • CBC = ↑ Hg & HCT
o Air pollution
o Hazardous dust • Cyanosis & obesity = blue bloaters • Complications = cor pulmonale, HF, pulmonary HTN
• ABG = respiratory acidosis
(hypoxic vasoconstriction), & susceptible to infections
• Enlargement of terminal airspaces • Dyspnea • PFT = gold standard
o Chronic inflammation • Chronic cough o ↓ FEV1 & ↓ FEV1/FVC <70%
o ↓ protective enzymes = alpha-1 antitrypsin o ↓ DLCO • Vaccines = pneumovax & influenza
o ↑ damaging enzymes = elastase • Hyperinflation
o Alveolar capillary & wall destruction o ↓ breath sounds & ↑ AP diameter • CXR = hyperinflation, flat diaphragm, ↑ AP
o Loss of elastic recoil = ↑ air trapping diameter, & ↓ vascular markings
Emphysema o ↑ compliance = airway obstruction • Cachectic & non-cyanotic = pink puffers
(COPD)
• Etiologies • Pursed-lip expiration
o Smoking o Prevents airway collapse by ↑ airway pressure
Obstructive o Air pollution
Lung Disease • Semi-tripod position to improve breathing
o Hazardous dust
o Alpha-1 antitrypsin deficiency

• Types
o Centrilobar = related to smoking
o Panacinar = ↓ alpha-1 antitrypsin
o Paraseptal = others or spontaneous PTX
• Acute worsening of COPD • ↑ dyspnea • CXR = evaluate PNA, PTX or HF • Treatment = bronchodilators, steroids, & ABX
• ↑ sputum purulence o Bronchodilators = albuterol & ipratropium
• Etiologies • ↑ sputum volume • Echo = evaluate for HF o Steroids = prednisone
COPD
o PNA o ABX = depends on cause
Exacerbation
o PTX ▪ MC = macrolides, fluroquinolones or augmentin
o PE
o HF
• RVH / right heart failure from lung disease • Edema • Echo = ↑ pressure in RV & pulmonary arteries • Treatment = treat underling condition
o Lung disease → pulmonary HTN → RHF • JVD
• Hepatomegaly • Spirometry = evaluate for lung disease • Diuretics may be harmful!
• Etiologies
o COPD • Right heart cath (measure P) = gold standard
o Pulmonary embolism
Cor o Sleep apnea
o Asthma
Pulmonale
o ILD
o ARDS
o Vasculitis
o Myasthenia gravis

• ↑ pulmonary pressure >20 mmHg • Dyspnea • CXR = enlarged (pruning) pulmonary arteries • Treatment = depends on 1o or 2o
o BP in lungs usually VERY low • Fatigue o Primary = meds
• Chest pain • EKG = cor pulmonale (RHV, RAD, RAE, & RBBB) ▪ CBB = 1st line
• 1o = idiopathic → BMPR2 gene defect • Weakness ▪ Endothelial ® antagonist = Ambrisentan
o BMPR2 inhibits pulmonary vasoconstriction • Echo = RVH & ↑ RVSP ▪ PDE inhibitor = Tadalafil & Sildenafil
• Cyanosis
• Edema ▪ Prostacyclin analog = Epoprostenol & Iloprost
Pulmonary • 2o = pulmonary disease • Right heart cath = gold standard o Secondary = treat underlying cause
o COPD • Loud S2 → prominent P2
Hypertension
o Pulmonary embolism • CBC = polycythemia & ↑ HCT • Complications = right HF
o Sleep apnea • Right HF
o Congenital heart disease o JVD
o Valvular disease (MS) o Peripheral edema
o Scleroderma o Ascites
o SLE o HSM
o HIV
 • Inhalation of silicon dioxide • Chronic = DOE, nonproductive cough, & crackles • CXR = small round nodular opacities = upper lobe • Treatment = supportive
o Silica activates alveolar macrophage o Eggshell calcifications of enlarged hilar & o Supportive = remove exposure, steroids, O2, & rehab
▪ Causes fibrogenesis • Acute = dyspnea, cough, weight loss, & fatigue mediastinal nodes
Silicosis • Complications = ↑ risk of TB & non-TB mycobacterium
• Occupational pulmonary disease • Biopsy = if diagnosis not made clinically (rare) infection
(Pneumoconiosis)
• Etiologies
Interstitial o Coal mining
o Quarry work = granite, slate or quartz
Lung Disease
o Pottery makers
o Sandblasting
o Glass & cement manufacturer
o Hydraulic fracturing
Coal • Inhalation & deposition of coal dust particles • Dyspnea • CXR = small nodules in upper lung • Treatment = supportive
Worker’s • Cough o Hyperinflation of lower lobes
Lung • Occupational pulmonary disease • Fine crackles ▪ Obstructive pattern = like emphysema

(Pneumoconiosis) • AKA black lung disease • PFTs = obstructive pattern (↓ FEV1)

Interstitial • Caplan syndrome = coal worker’s lung + RA • Biopsy = dark “black” lungs
Lung Disease
• Granulomatous pulmonary disease • Dyspnea • CXR = hilar LAD & interstitial lung markings • Treatment = steroids, O2 & methotrexate
• Cough o Steroids & O2 = 1st line
• Allergic-type lung disease • Joint pain • PFTs = restrictive pattern (↑ FEV1/FVC) o Methotrexate = no response to steroids
Berylliosis • Fever o ↓ lung volumes (TLC, RV, etc.)
• Beryllium exposure = nickel, aluminum, or copper • Weight loss
(Pneumoconiosis) • Biopsy = noncaseating granulomas
• Risk factors
Interstitial o Aerospace
Lung Disease o Electronics
o Ceramic
o Jewelry making
o Fluorescent light bulbs
• Etiologies • Dyspnea
Byssinosis o Cotton exposure = textile industry • Cough
o Flax or hemp dust exposure • Chest tightness
(Pneumoconiosis) • Wheezing

Interstitial • “Monday fever”

Lung Disease o Worse = beginning of week
o Better = end of week/weekends
• Pulmonary fibrosis from inhaled asbestos fibers • DOE • CXR = pleural plaques, fibrosis & shaggy heart • Treatment = supportive or surgery
• Cough o Pleural plaques = thick/calcified pleural o Supportive = steroids, bronchodilators, & O2
Asbestos • Risk factors o Fibrosis = honeycomb & interstitial fibrosis o Surgery = lung transplant
o Destruction, repair or renovation • Bibasilar crackles o Shaggy heart = indistinct heart border
(Pneumoconiosis) o Insulation • Complications = bronchogenic carcinoma & mesothelioma
o Fire-resistant products
Interstitial
Lung Disease

• Progressive scarring of lung → unknown cause • Dyspnea • CXR = reticular opacities (honeycombing) • Treatment = supportive & surgery (NO meds)
• Cough = nonproductive o Supportive = stop smoking & O2 therapy
• Men >40 years old • High resolution CT = reticular, honeycombing o Meds = steroids & immunosuppressive agents
Idiopathic & focal ground-glass opacification o Surgery = transplant
Pulmonary • Etiologies
Fibrosis o Idiopathic • Lung biopsy = definitive diagnosis • NO effective medical management!
o Non-diopathic
Interstitial ▪ Smoking • PFTs = restrictive pattern
Lung Disease ▪ Viral infections o ↑ FEV1/FVC & ↓ lung volumes (TLC, RV, etc.)
▪ Environmental (silica)
▪ Meds = amiodarone, methotrexate, &
macrobid
 • Inflammatory granulomatous disease
o Exaggerated T cell response
▪ Causing ↑ ACE levels
o Central immune activation → granuloma →
peripheral immune depression
o Non-caseating = no necrosis in center
▪ T helper % inflammatory cells
o o Worse with intestinal lung disease & lupus pernio
o Macrophages produce vitamin D**
▪ Causing ↑ absorption of Ca2+
Sarcoidosis
• Idiopathic = unknown cause
Interstitial
Lung Disease • Lofgren syndrome = acute sarcoidosis
• Mostly asymptomatic!
• General = fever, weight loss, & fatigue
• LAD = hilar & paratracheal
• Lungs = dry cough, DOE, hemoptysis & rales
• Skin = erythema nodosum, lupus pernio,
maculopapular rash, enlarged parotid gland, &
calcinosis cutis
o Erythema nodosum = red, hard & painful lump
o Lupus pernio = raised indurated purple lesion
o Calcinosis cutis = deposition of calcium salts
• CXR = bilateral hilar LAD & ground-glass
opacification
• PFTs = restrictive pattern
• Tissue biopsy = noncaseating granulomas
o Lungs or rash
• ↑ ACE levels → due to ↑ T cell response
• Hypercalciuria, hypercalcemia & ↑ vitamin D
• Treatment = no treatment UNLESS symptomatic
o Steroids (prednisone) = 1st line
o Methotrexate = severe
o Hydroxychloroquine = severe skin lesions
• Prognosis = good (remission in 2 years)
o Resolves in weeks & complete remission in ~2 years
• Complications = CKD (due to ↑ Ca2+)

Polyarticular • Risk factors • Cardiac = arrythmia, restrictive CM, & HF

o Female
o African Americans • Neuro = CN VII palsy (facial droop, 2o to enlarged
o Northern European parotid gland) & diabetes insipidus

• Rheumatology = polyarthritis & HSM

• Eyes = uveitis & conjunctivitis

• Lofgren syndrome = erythema nodosum,

bilateral hilar LAD, & polyarthralgia’s with fever
• Typical • Typical = fever, productive cough, pleuritic CP • CXR (typical) = lobar infiltrates • Treatment
o S. pneumonia = CAP o S. pneumonia = chills, rigors, bloody sputum o Klebsiella = cavitary lesions o Outpatient = amoxicillin + azithromycin OR
o H. influenzae o Klebsiella = currant jelly (purple) sputum Levaquin (not cipro → doesn’t reach lung)
▪ Age extremes (<6 & older) • CXR (atypical or viral) = diffuse, PATCHY, ▪ S. pneumonia = amoxicillin
▪ Immunocompromised (DM & HIV) • Typical = ↑ RR & HR, bronchial breath sounds, interstitial or reticulonodular infiltrates ▪ Mycoplasma = macrolides (azithromycin)
▪ Lung disease (COPD, asthma, or CF) dullness to percussion, ↑ tactile fremitus, egophony, o Reticular = too many lines ▪ Legionella = macrolides or fluroquinolones
o S. aureus = s/p viral infection (flu) & HAP inspiratory crackles o Nodular = too many dots • Respiratory fluroquinolones = levofloxacin
o Klebsiella = EtOH o Rigors = S. pneumonia • Macrolide = azithromycin or clarithromycin
o Pseudomonas = lung disease (CF or COPD) • CBC = ↑ WBCs ▪ Chlamydia psittaci = tetracyclines (doxycycline)
o Moraxella catarrhalis • Atypical = low-grade fever, nonproductive cough, o Inpatient = ceftriaxone + azithromycin OR
extrapulmonary symptoms (URI prodrome) • Blood cultures = usually only diagnostic test done Levaquin (not cipro → doesn’t reach lung)
• Atypical o Myalgia, malaise, pharyngitis & N/V/D ▪ Without MRSA or PSA
o Mycoplasma = atypical (walking) o Mycoplasma = bullous myringitis • Sputum cultures = sputum or broncholavage
o Legionella = GI symptoms → N/V/D, HA, AMS • Ceftriaxone, cefotaxime, ceftaroline,
o Chlamydia pneumoniae = s/p pharyngitis ertapenem, OR unasyn
o Legionella = contaminated water / air filter • ET tube samples = intubated patients
Pneumonia PLUS
▪ Lung disease = COPD, OSA, etc. • Atypical = normal exam → maybe crackles
• Azithromycin OR clarithromycin
o Coxiella brunetti = livestock • CMP = ↑ LFTs (Chlamydia) & ↓ Na+ (Legionella)
o Chlamydia psittaci = birds ▪ MRSA = vancomycin
• Vancomycin OR linezolid
• UA = Legionella & S. pneumonia ▪ PSA = zosyn + ciprofloxacin
• Viral
o Influenza • Zosyn, imipenem, meropenem,
• Cold agglutin’s = Mycoplasma → PCR cefepime, OR ceftazidime
o Parainfluenza
o RSV PLUS
o Adenovirus • CURB 65 = 1 DC; 2 DC vs. admit; 3-5 admit • Ciprofloxacin OR levofloxacin
o C = confusion (1 point) o MDR gram (–) bacilli & MRSA
o U = urea (BUN) >7 (1 point)
• CAP = <48 hours ▪ Zosyn + gentamycin + vancomycin
o R = RR >30 (1 point)
• HAP = >48 hours → PSA & MRSA o B = SBP <90 or DBP <60 (1 point)
o 65 = >65 years old (1 point) • Complications
o Mycoplasma = SJS/TENS, erythema multiforme, cold
autoimmune hemolytic anemia

• Inhalation of oropharyngeal or gastric microbes • Reduced consciousness • CXR = right lower lobe (MC) • Treatment
• Protracted vomiting o Vertical angle of right bronchus o CAP = Unasyn (IV) or Augmentin (PO)
• Associated w/ pulmonary abscess & emphysema ▪ Unasyn = extended action from ampicillin
Aspiration • Foul-smelling sputum = rotten egg ▪ Augmentin = extended action from amoxicillin
Pneumonia • Etiology = anaerobes o HAP = Imipenem, Meropenem, or Zosyn
o Peptostreptcoccus ▪ PLUS vancomycin or linezolid if MRSA
o Bacteroide
o Fusobacterium
 • Single & small → <30 mm • Malignant = weight loss, fever, & hemoptysis • CXR = best initial imaging • Low probability = surveillance with monitoring

• Etiologies • CT chest = further evaluate for malignancy • Intermediate probability = bronchoscopy (central lesion)
o Infectious granuloma = MC or transthoracic needle aspiration (peripheral lesion)
▪ Mycobacteria (TB) • No change in 2 years = stable nodule
▪ Fungi (histoplasmosis) • New changes = unstable nodule • High probability = resection with biopsy
Solitary o Tumor = benign or malignant
Pulmonary ▪ Thymoma = MC mediastinal tumor
Nodule
• ↑ risk for malignancy = spiculated, large (>2 cm)
irregular, smoker, >40 years old & asymmetric
calcifications

• ↓ risk for malignancy = well circumscribed,

<30 years old, non-smoker & diffuse calcifications
• 2nd MC cancer • Screening = 55-80 years old → 30 pack year smoking hx
o Currently smoke OR quit within last 15 years
• Risk factors = smoking & asbestosis o Low-dose CT scan
o Other = radon, idiopathic pulmonary fibrosis,
TB, COPD, & genetics
Bronchogenic
Carcinoma • METS = liver, brain, bone, lymph & adrenals

• Type = non-small cell & small cell

o NSCLC (85%) = adenocarcinoma, squamous
cell, & carcinoid
o SCLC (15%) = more aggressive
Adeno- • MC primary lung cancer • Mostly asymptomatic! → early on • Histology = gland formation & mucin production • Treatment = surgery, chemo & radiation
o Stage cancer & get PFTs before treatment
carcinoma
• Peripheral = from bronchial mucosal glands • Cough • Transthoracic aspiration = peripheral lesion
of Lung o CT guided
• Dyspnea
• Smoking (MC risk factor) & asbestosis • Hemoptysis
(NSCLC)
• Weight loss
• 2nd MC primary lung cancer • Cough • CXR = cavitary lesions • Treatment = surgery, chemo & radiation
• Dyspnea o Stage cancer & get PFTs before treatment
Squamous • Central = widened mediastinum • Hemoptysis • CMP = hypercalcemia
Cell • Weight loss
Carcinoma • Smoking = MC risk factor • Biopsy = keratinization, intracellular desmosomes
• Pancoast tumor = Horner’s syndrome, hoarseness
(NSCLC) • Pancoast syndrome = located in lung apices (n. compression), & brachial plexus compression • Bronchoscopy aspiration = central lesion
o Mass effect = interfere with nerves & vessels (shoulder pain, numbness, atrophy, & paresthesia)
o Horner’s = miosis, ptosis, & anhidrosis
• Aggressive lung cancer → early metastasis • Cough • CXR = centrally located mass • Treatment = surgery (stage I or II) & chemo if metastatic
• Chest pain o Stage cancer & get PFTs before treatment
• Central = widened mediastinum • Dyspnea • Biopsy = CT guided or bronchoscopy if central
Small Cell
Carcinoma • Hemoptysis
• Smoking = MC risk factor • Wheezing • Histology = sheets of small blue cells in rosette • SVC syndrome = facial/arm edema & swollen chest veins
• Weight loss formation
(SCLC) • Paraneoplastic = SVC syndrome, Lambert- • Lambert-Eaton syndrome = muscle weakness (better
Eaton syndrome, SIADH (ADH), & Cushing • Bronchoscopy aspiration = central lesion with movement) , dry mouth & hyporeflexia
syndrome (ACTH)
• Neuroendocrine (enterochromaffin cell) tumors • Carcinoid syndrome • UA = 24 hour 5-HIAA (end product of serotonin) • Treatment = supportive, meds, & surgery
o Slow growth, low mets, well-differentiated o Flushing o Supportive = limit stress & EtOH consumption
o Serotonin, histamine & bradykinin o Diarrhea • ↓ tryptophan → ↓ niacin (B3) → pellagra ▪ These contribute to hormone release
Bronchial o Location = lung, liver, stomach, skin, etc. o SOB o Octreotide = reduce symptoms
o Itching • CT scan OR octreotide scintigraphy = locate tumor ▪ ↓ secretion of active hormones
Carcinoid
• GI = 1st MC o Bronchoconstriction → serotonin & histamine ▪ Somatostatin analogue = inhibit hormone release
Tumor o Hypotension → hemodynamic instability
• Lung = 2nd MC → bronchial carcinoid tumor • Biopsy = definitive diagnosis o Surgery = remove tumor (definitive)
• Liver = MC mets site
(NSCLC) • Pellagra = dermatitis, dementia & diarrhea • Bronchoscopy = pink/purple central tumor (lung)
• Symptoms from neuroendocrine cells build-up
o Secrete = serotonin, ACTH, ADK, & MSH • Wheezing or hemoptysis
• SIADH or Cushing’s syndrome
 • Inability to initiate or maintain sleep
• Nonrestorative sleep
• Acute/situational insomnia = last few days
Insomnia
• Difficulty falling asleep • Treatment = sleep hygiene, stimulus control therapy, meds
• Multiple awakenings during night o Sleep hygiene = no phones, blackout room, etc.
▪ Bed ONLY for sleeping & sex = stimulus control
• Fatigue ▪ Only go to bed if tired
• Concentration problems ▪ Take hot shower before bed
• Irritability ▪ Do not eat too close to bedtime
▪ If cannot sleep after 15 minutes → get up
Preoccupation with not • Do something relaxing & only return if tired
getting enough sleep worsens ▪ Relaxation training = medication, etc.
ability to sleep! ▪ Regular wake-up time regardless of how they slept
▪ Avoid naps
▪ Workout during the day (not right before bed)
o CBT = correct dysfunctional beliefs about sleep
o Meds = ramelteon (melatonin agonist), benzos
(Ativan & Triazolam), non-benzos (Sonata,
Ambien, & Lunesta)
▪ Melatonin and Benadryl = OTC
• Not recommended for routine use
▪ Benzos = NO more than 2 weeks
• Bependence & withdraw

• Ensure patient their health won’t be endangered if getting

<6 hours of sleep for a short time → helps anxiety (which
might help sleep!)

• RULE OUT = narcolepsy, sleep apnea, sleep terrors, sleep

• ↓ ability to regulate sleep-wake cycles • Excessive daytime sleepiness
• Difficulty falling asleep
• Onset = teens & early 20s • Frequent nighttime awakenings
• Nightmares
• Auto-immune??
• Cataplexy = weakness or loss of muscle tone
brought on by emotion
Narcolepsy o Begins in face (slack, ptosis, etc.)
• Polysomnography = rule out alternative diagnoses
o Narcolepsy = spontaneous awakenings,
mild ↓ sleep efficiency, ↑ non-REM sleep,
REM sleep within 15 minutes (usually 80-100
minutes after onset)
• Sleep latency test = measure sleep latency & REM
o Narcolepsy = asleep <8 minutes (usually 10-
15 minutes); REM during naps
• Epworth Sleepiness Score = quantify patients
perception of fatigue & sleep
walking, GERD, craving cigarette, circadian rhythm sleep
disorder, mania, psychosis, depression, or anxiety
o Circadian rhythm = ex: going from night to day shift
• Treatment = scheduled naps & mediation
o Wakefulness promoting drugs
▪ Modafinil (Provigil) = 1st line
▪ CNS stimulants = promote release of
monoamines
• Methylphenidate (Ritalin)
• Amphetamines (dextroamphetamine &
methamphetamine)
• Complications = other sleep disorders (obstructive sleep
apnea, RLS, sleepwalking, REM sleep behavior disorder)

• ↓ hypocretin = wake promoting neuropeptide

• Involuntary cessation of breathing during sleep • Snoring • Polysomnography = 1st line • Treatment = lifestyle, CPAP, & surgery
• Unrestful sleep o Lifestyle
• Types • Fatigue • CBC = polycythemia ▪ Weight loss
o Central sleep apnea = ↓ CNS respiratory • Nocturnal choking / transient apnea ▪ Limit EtOH
drive & ↓ respiratory effort • HA = morning • Epworth Sleepiness Score = quantify patients ▪ Change sleep position
o Obstructive sleep apnea = physical airway perception of fatigue & sleep o CPAP = best treatment option
• GERD
obstruction o Surgery = definitive treatment
▪ External airway compression • Nocturia
• STOP-BANG = low (0-2), med (3-4), & high (5-8) ▪ Tracheostomy
▪ ↓ pharyngeal muscle tone • Impotence o Snore ▪ Nasal septoplasty
▪ ↑ tonsil size • Enlarged tongue & tonsils o Tired ▪ Uvulopalatopharyngoplasty
Sleep Apnea
▪ Deviated septum • Large neck o Observed stopped breathing
• Micrognathia o Pressure (BP)
• Risk factors o BMI >35
o Obesity o Age >50
o Male o Neck circumference >40 cm
o FHx o Gender (male)

• EtOH and sedatives (benzos) worsen sleep apnea

 GASTROENTEROLOGY
Visit Etiology Presentation & PE Diagnosis Treatment & Complications
• Autodigestion of pancreas • Epigastric pain → radiates to back • Diagnostic Criteria (2/3 → 1st 2 (+), no imaging) • Treatment = diet, IVF, pain meds, NPO, NG tube
o From exocrine enzymes o Worse supine = stretching pancreas o Acute, severe epigastric pain radiating to back o Diet = low fat diet
▪ Protease (trypsin) = protein o Better leaning forward = relaxing pancreas o Lipase/amylase 3x upper limit of normal o IVF = LR preferred
▪ Amylase = carbohydrates o CT/MRI/US showing acute pancreatitis o Pain meds = hydromorphone & fentanyl
▪ Lipase = fat • Nausea & vomiting ▪ NO morphine = sphincter of Oddi spasm
o Intracellular activation of enzymes • Anorexia • ↑ lipase (more specific) & amylase o NG tube = if vomiting present
o Acinar cell damage • Fever o Amylase = ↑ with gallstones & vomiting o ERCP = gallstone pancreatitis to remove stone
• Tachycardia
• Etiologies = GET SMASHED • CBC = ↑ WBC • Recovery = usually in 3-7 days (within a week)
o G = gallstones → blocked pancreatic duct • Necrosis or hemorrhage
o E = EtOH → thick mucus in pancreatic duct o Cullen sign = periumbilical ecchymosis • CMP = ↓ Ca2+, ↑ glucose, ↑ bilirubin, & ↑ ALT • ABX = infected necrotizing pancreatitis
o T = trauma o Grey Turner sign = flank ecchymosis o Hypocalcemia → fat necrosis consumes Ca2+ o Necrotizing pancreatitis can cause sepsis & infection
o S = steroids o ALT 3x ↑ = gallstone pancreatitis o Meropenem >> ciprofloxacin → change prn for Cx
o M = mumps or malignancy
o A = autoimmune • Lipid panel = ↑ triglycerides • Complications = necrotizing pancreatitis, hemorrhagic
o S = scorpion bite pancreatitis (damaged blood vessels), pseudocyst, pleural
o H = hypertriglyceridemia or hypercalcemia • Abdominal x-ray = sentinel loop due to ileus effusion, ascites, abscess, infection, DIC, & shock
o E = ERCP (iatrogenic) o Early = ARDS, hypocalcemia, ascites, pleural effusions
o D = drugs (thiazide, tetracycline, HIV meds) ▪ DO NOT drain fluid in setting of pancreatitis
• CXR = left-sided pleural effusion; colon cutoff sign
o Colon cutoff sign = abrupt termination of o Mid = necrosis
gas in colon at level of flexure; abrupt collapse ▪ Biopsy necrotic tissue (FNA) → meropenem
Acute of colon near pancreas ▪ Necrosis = necrosectomy
Pancreatitis o Late = abscess or pseudocyst (NOT epithelial line)
• US = gallstones (etiology) ▪ CT to look for abscess & pseudocyst
▪ <6cm & <6 weeks pseudocyst = watch & wait
• MRCP = strictures or malignancy (etiology) ▪ >6cm & >6 weeks pseudocyst = drainage
• Pseudocyst could get infected!
• CT = good to show complications of pancreatitis ▪ Abscess = I & D
o DO NOT always need it to make diagnosis!
o Balthazar score = assess severity • Atlanta Criteria = mild, moderate or severe
▪ Grading of pancreatitis & necrosis
• Ranson’s Criteria = determines prognosis
o 1-3 = mild pancreatitis
o >3 = severe pancreatitis

• Progressive inflammatory changes • Steatorrhea • Normal amylase & lipase • Treatment = supportive & meds
o Loss of endocrine & exocrine function • Weight loss = difficulty absorbing food & fat o Supportive = quit EtOH, pain meds, low fat diet
• Epigastric or back pin • ↓ vitamin A, D, E, K (fat soluble vitamins) o Meds = vitamins & pancreatic enzyme replacement
• Risk factors
o EtOH • CT scan = calcification of pancreas • Pancreatectomy = retractable pain despite medical therapy
o Idiopathic o Chain of lakes = stenosis & dilation of ducts
Chronic o Cystic fibrosis • Complications = pancreatic cancer & DM
Pancreatitis o Trauma • Abdominal x-ray = calcification of pancreas
o Hypertriglyceridemia
o Islet cell tumor • Pancreatic function = fecal elastase & fecal fact
o Familial o Fecal elastase = made by pancreas
o Iatrogenic
▪ <200 is abnormal
o Fecal fat = 72 hour stool collection
▪ Gold standard
 • ACUTE • Mostly symptomatic! • Acute = IgM anti-HAV • Treatment = supportive
• Previous = IgG HAV Ab
• Transmission = fecal-oral • Fever • Preexposure PPX = HAV vaccination (international travel)
o Day care workers • Malaise • ↑ AST & ALT
o Homeless • Anorexia • ↑ bilirubin • Postexposure PPX = HAV vaccine or HAV immunoglobin
o Shellfish • N/V o Healthy = vaccine
Hepatitis A
• Abdominal pain o Immunocompromised = vaccine + Ig
o Liver disease >1 year = vaccine + Ig
• Jaundice
• Hepatomegaly • Prevention = hepatitis A vaccine

• Complications = fulminant hepatitis → RARE

• ACUTE & CHRONIC • Acute • HBsAg = acute or chronic hepatitis • Treatment = supportive or antiviral therapy
o Subclinical = URI symptoms, N/V, RUQ pain • Anti-Hbs = recovery or immunization o Antivirals = persistent, severe or marked jaundice
• Transmission = parental, sex, perinatal, & o Icteric = jaundice ▪ Entecavir or Tenofovir
percutaneous o Fulminant = encephalopathy & coagulopathy • Anti-HBc (IgM) = acute
• Anti-HBc (IgG) = chronic or recovery • Prevention = hepatitis B vaccine
• Chronic
o Chronic = persistent sx, ↑ LFTs & viral load • HbeAg = acute or chronic (replicative) • Complications = fulminant hepatitis (liver failure)
o Carrier = no sx, normal LFTs & viral load
• Anti-Hbe = chronic (nonreplicative)
Hepatitis B • LFTs = 1000’s (acute) & 100’s (chronic)

• ACUTE & CHRONIC • Most are symptomatic • Screening = anti-HCV (HCV antibodies) • Treatment = antivirals
• Fatigue o Antivirals = Interferon, Ribavirin, & Sofosbuvir
• Transmission = parental (blood-borne) • Myalgia • Confirmatory = HCV RNA
• Nausea o (+) in active infection (chronic or acute) • Complications = fulminant hepatitis (liver failure)
• Abdominal pain
• Jaundice • ↑ AST & ALT
• Dark urine & clay-colored stools
Hepatitis C

• ACUTE & CHRONIC • Most are symptomatic • Anti-HDV • Treatment = supportive, meds or surgery
• Fatigue o Interferon alpha = chronic HDV
• Transmission = parental • Myalgia • Hepatitis B serology o Liver transplant = definitive
Hepatitis D • Nausea
• Requires hepatitis B virus • Abdominal pain • Prevention = hepatitis B vaccine
o HDV uses HBsAg as its envelope protein • Jaundice
• Complications = fulminant hepatitis → RARE
• Dark urine & clay-colored stools
• ACUTE • Most are symptomatic • Acute = IgM anti-HEV • Treatment = supportive

• Transmission = fecal-oral, blood transfusions & • Fever • ↑ AST & ALT • Complications = fulminant hepatitis → PREGNANCY
mother-to-child • Malaise • ↑ bilirubin
Hepatitis E • Anorexia
• N/V
• Abdominal pain
• Jaundice
• Hepatomegaly
 • MC = adenocarcinoma • Rectal bleeding • Colonoscopy = initial test • Treatment = surgical excision, radiation or chemotherapy
Anorectal
• Tenesmus
Cancer
• Rectal mass
• MC = adenomatous polyps • Pallor, fatigue & weakness = IDA • Colonoscopy (with biopsy) = definitive diagnosis • Treatment = surgical resection and chemotherapy
• Rectal bleeding o Likely benign = <1 cm & distal o METS = palliative chemotherapy
• Risk factors • Abdominal pain o Likely malignant = >1 cm & proximal
o >50 years old • Large bowel obstruction • Complications = Streptococcus bovis endocarditis
o FHx • Fecal occult stool = screening
o African American • Right sided = occult bleeding, IDA & diarrhea • Screening = colonoscopy q 10 years from 50-75 years old
o Ulcerative colitis • Barium enema = apple core lesion o Polyp = screening q 3 years
o Low fiber o FHx = screening @ 4o or 10 years before diagnosis
o Red meat, processed meat & animal fat • Left sided = bowel obstruction & pencil thin stools
• Tumor marker = CEA
o Obesity
o Smoking & EtOH • CBC = anemia (iron deficiency anemia)
Colorectal
Cancer • Familial adenomatous polyposis = mutated APC
gene; autosomal dominant; MANY polyps

• Turcot syndrome = FAP-like & CNS tumors

• Lynch syndrome = endometrial, ovarian, SI, brain

& skin CA → autosomal dominant

• Peutz-Jehgers syndrome = hamartomatous

polyps, mucocutaneous hyperpigmentation; breast
& pancreatic CA → autosomal dominant
• Types • Most have advanced disease at time of diagnosis • Endoscopy (with biopsy) = definitive diagnosis • Treatment = stents, surgery, chemotherapy & radiation
o Adenocarcinoma MC in US o Stents = improve dysphagia for palliative care
▪ Distal esophagus • Dysphagia → solid foods to liquids • CT scan (neck, chest, abdomen) = staging o Surgery = resection
▪ Esophagogastric junction • Odynophagia
▪ Caucasians • Weight loss & anorexia • CBC = anemia (iron deficiency anemia)
o Squamous cell = MC in world • CP
▪ Proximal esophagus • Cough
▪ African Americans • Hematemesis
• Hoarseness = recurrent laryngeal n. irritation
• Types
Esophageal o Adenocarcinoma (GERD)
• Horner’s syndrome = ptosis, miosis, anhidrosis
Cancer ▪ Barret’s esophagus (GERD)
• Tracheal-esophageal fistula
▪ Smoking
▪ High BMI
o Squamous cell (smoking & EtOH)
▪ Smoking & EtOH
▪ Thermal injury = hot beverage
▪ Low intake of fruits
▪ HPV
▪ Atrophic gastritis

• Protective = ASA or NSAIDs (esp with Barret’s)

• MC = adenocarcinoma • Most have advanced disease at time of diagnosis • Endoscopy (with biopsy) = definitive diagnosis • Treatment = surgical resection, chemotherapy & radiation

• Risk factors • Weight loss • CBC = anemia (iron deficiency anemia)

o H. pylori • Abdominal pain
o Salted, cured, smoked or pickled food • Early satiety
o Nitrites & nitrates • Nausea & post-prandial vomiting
o Obesity
Gastric • Dysphagia
Carcinoma • Other = pernicious anemia, smoking, chronic • Melena or hematemesis
atrophic gastritis, achlorhydria, blood type A,
post antrectomy, Non-Hodgkin lymphoma • Virchow’s node = supraclavicular lymph nodes
• Sister Mary Joseph’s node = umbilical lymph node
• Krukenburg tumor = ovarian mets
• Blumer’s shelf = rectal node
• Irish sign = left axillary lymph node
 • Head of pancreas = MC • Painless jaundice • CT scan = initial test of choice • Treatment = surgery with chemotherpay & radiotherapy
• Weight loss o Surgery = whipple (head) or distal resection (tail)
• Types • Abdominal pain → radiating to back • Endoscopy w/ biopsy = if (–) CT scan o Chemo & radiation = post-surgery
o Adenocarcinoma (ductal) = MC • Pruritus
Pancreatic o Ampullary • ↑ CA 19-9 & CEA • Prognosis = 5 year suvivial is 5-15%
Cancer • Dark urine
o Duodenal
o Cystadenoma
• Trousseau sign = migratory thrombophlebitis
• Risk factors = smoking
• Courvoisier’s sign = palpable & nontender GB
• Primary neoplasm of liver • Weight loss • CT or MRI = best initial test • Treatment = surgical resection
• Malaise
• Risk factors • Jaundice • Liver biopsy = definitive • Screening = US q 6 months (+/– alpha fetoprotein)
Hepato-
o Chronic liver disease = HBV, HCV, & cirrhosis • Abdominal pain o High-risk patients = HBV, cirrhosis, FHx, AA, etc.
cellular ▪ Hep C → cirrhosis → HCC • HSM • ↑ alpha fetoprotein
Carcinoma ▪ Hep B → HCC (doesn’t need cirrhosis!)
▪ Cirrhosis → HCC
o Aflatoxin B (Aspergillus)
• Gallstones in gall bladder → no inflammation • Mostly asymptomatic! • US = best initial imaging • Treatment = observation, meds or surgery
o Ursodeoxycholic acid = dissolve gallstones
• Types • Biliary colic = episodic RUQ or epigastric pain • HIDA scan = not helpful o Cholecystectomy = definitive treatment
Cholelithiasis o Cholesterol = MC o Precipitated by fatty food
o Black = hemolysis • Nausea • Complications = choledocholithiasis, cholangitis, &
o Brown = bacterial or parasitic infection • +/– clay-colored stools cholecystitis
• Gallstones in bile duct • RUQ pain • US = best initial imaging • Treatment = ERCP
Choledocho- • Jaundice o ERCP = removal of stone
lithiasis • +/– clay-colored stools • ERCP = test of choice (diagnostic & therapeutic)
Complications = cholangitis, obstructive jaundice, acute
pancreatitis, primary biliary cirrhosis (cholangitis)
• Inflammation & infection of gallbladder • Abdominal pain = RUQ • CBC = ↑ WBCs • Treatment = supportive, ABX, & cholecystectomy
o Gallstones obstructing cystic duct • Fever o Supportive = NPO & IVF
o 2o bacterial infection • Enlarged palpable gallbladder • ↑ Alk Phos & GGT o ABX = Augmentin OR Keflex + Metronidazole
Calculous • Shoulder pain = referred o Cholecystostomy = percutaneous drainage
Cholecystitis • MC = E. coli, Klebsiella & other enteric bacteria • ↑ bilirubin > ↑ AST and ALT ▪ If patient is nonoperative
o Cholecystectomy = definitive treatment
• (+) Murphy’s sign = RUQ pain
• Risk factors = fat, female, fertile, & forty o Inspiratory arrest with palpation of gallbladder • US = best initial imaging ▪ Cholestyramine = helps control diarrhea s/p
lap chole due to no gallbladder / bile storage
• (+) Boas sign = referred pain to right shoulder
• Inflammation of gallbladder • Fever • CT = alternative imaging • Treatment = NPO, IVF, ABX, & cholecystectomy
o NOT due to gallstones • Abdominal pain o Supportive = NPO & IVF
• HIDA scan = most accurate o ABX = depends on community or hospital acquired
• Jaundice
• Gallbladder stasis & ischemia → inflammation • Sepsis o Cholecystostomy = percutaneous drainage
→ distension → 2o infection → perforation, etc. ▪ If patient is nonoperative
o Cholecystectomy = definitive treatment
Acalculous
Cholecystitis • Risk factors ▪ Cholestyramine = helps control diarrhea s/p lap
o ICU = NPO, dehydration, & sepsis chole due to no gallbladder / bile storage
o DM
o HF
o CAD
o CKD
o Post-op
• Biliary tract infection → 2o to obstruction • Charcot’s triad • CBC = ↑ WBCs • Treatment = IV ABX, CBD decompression & stone removal
o Choledocholithiasis → infection (E. coli) o RUQ pain o ABX = broad-spectrum
o Malignancy o Jaundice • ↑ Alk Phos & GGT ▪ Ex: Unasyn
o Fever/chills o CBD decompression & stone removal
• ↑ bilirubin > ↑ AST & ALT ▪ ERCP = once patient stable & afebrile for 48 hours
• Reynold’s pentad ▪ PTC = percutaneous transhepatic cholangiogram
Ascending o RUQ pain • US = initial test ▪ Open decompression + T tube (draining tube)
Cholangitis o Jaundice
o Fever/chills • MRCP = most accurate imaging • Need elective cholecystectomy!!
o Hypotension or shock
o AMS
• Cholangiography via ERCP = gold standard
 • Autoimmune disorder of intrahepatic bile ducts • Mostly asymptomatic! • ↑ Alk Phos & GGT • Treatment = meds & surgery
• ↑ cholesterol o Ursodeoxycholic acid = 1st line
• Etiology = idiopathic • Fatigue ▪ Reduces biliary cholesterol
Primary • Pruritis • ↑ IgM ▪ Prevents or delays liver damage
• Risk factors • RUQ pain o Cholestyramine & UV light = pruritis
Biliary o Middle aged women o Liver transplant = definitive treatment
• HSM • (+) antimitochondrial antibody
Cholangitis
• Jaundice
• US = best initial imaging • Complications = ↓ bile salt excretion, cirrhosis, & liver
failure
• Xanthelasma & osteoporosis
• Liver biopsy = definitive diagnosis
• Autoimmune cholestasis → diffuse fibrosis of • Fatigue • ↑ Alk Phos & GGT • Treatment = dilation, meds & surgery
intra & extra hepatic biliary ducts • Pruritis • ↑ bilirubin, ALT, & AST o Stricture dilation = symptomatic relief
• RUQ pain o Cholestyramine & UV light = pruritis
Primary • Risk factors • HSM • ↑ IgM o Liver transplant = definitive treatment
Sclerosing o IBD = Ulcerative Colitis (MC) • Jaundice
Cholangitis o Men 20-40 years old • (+) P-ANCA
• Complications = cirrhosis, liver failure, &
• MRCP & ERCP = most accurate test cholangiocarcinoma
o Beaded appearance of biliary ducts
• Irreversible liver disease = scarring & fibrosis • Fatigue & weight loss • PT/INR & PTT = ↑ → best liver function test • Treatment = stop EtOH, stop offending meds, weight loss,
o Nodular regeneration → ↑ portal pressure • Ascites vaccination for HAV and HBV, & liver transplant
• Hair loss = MC of upper extremities • CMP = ↓ albumin, ↑ Alk Phos, LFTs (↑ or normal) o Supportive = stop EtOH, stop offending meds,
• Risk factors • Gynecomastia weight loss, vaccination for HAV & HBV, & liver
o Hepatitis (B & C) • CBC = anemia, ↓ PLTs & ↓ WBCs transplant
• Spider hemangioma o Encephalopathy = lactulose or rifaximin
o EtOH o EtOH effects bone marrow
• Caput medusa ▪ Bind to toxic metabolites (ex: ammonia)
o NAFLD & NASH o Thrombocytopenia = splenic sequestration
o Hemochromatosis • Palmar erythema o PLTs 1st → then Hgb & WBCs o Ascites = limit Na+, diuretics, & paracentesis
Cirrhosis o Autoimmune hepatitis (anti-smooth muscle) • Jaundice & HSM o Anemia ▪ Paracentesis = diuretics not effective or to dx SBP
o Primary biliary cirrhosis • Dark urine ▪ Chronic disease ▪ TIPS = additional option
o Primary sclerosing cholangitis • Infertility, amenorrhea & impotence ▪ Hypersplenism o Pruritis = cholestyramine → bile acid sequestrant
o Drug toxicity • Pruritis ▪ Suppressed bone marrow
• Esophageal varices • Complications = hepatic encephalopathy, portal vein
• Cruveilhier-baumgarten murmur = due to Liver makes coags & anticoags → clots & bleeding! thrombosis, hepatocellular carcinoma, hepatorenal
distended umbilical veins syndrome, & spontaneous bacterial peritonitis (SBP)
• Hepatic encephalopathy = confusion & lethargy
o Asterixis (liver flap) • MELD & Child Pugh Score = mortality calculators
• Major complications developing from cirrhosis • Complications • Variceal bleeding = endoscopy • Treatment = treat complications
o Variceal bleeding = hematemesis • Ascites = paracentesis o SBP = cefotaxime (3rd generation cephalosporin)
o Ascites • SBP = neutrophils >250 o Encephalopathy = lactulose or rifaximin
Decompensated o Spontaneous bacterial peritonitis (SBP) • Hepatic encephalopathy = ↑ ammonia
Cirrhosis o Hepatic encephalopathy = AMS
o Hepatocellular carcinoma • Hepatocellular carcinoma = US, AFP & biopsy
o Hepatorenal syndrome = 2o artery vasodilation • Hepatorenal syndrome = CMP (BUN & Cr)
o Hepatopulmonary syndrome • Hepatopulmonary syndrome = CXR
• Longitudinal superficial mucosal lacerations • Upper GI bleed → preceded by retching or vomiting • Endoscopy = test of choice • Treatment
o Hematemesis o No bleeding = supportive & acid suppression (PPIs)
• @ gastroesophageal junction or gastric cardia o Melena o Bleeding = thermal coagulation, hemoclips, band
Mallory- o Hematochezia ligation, & balloon tamponade
Weiss Tear • Etiologies
o ↑ intraabdominal pressure • Abdominal or back pain • Most cases stop bleeding without intervention
▪ Vomiting (EtOH) = MC
o Gastric prolapse into esophagus
• Full thickness tear of esophageal wall • Mackler’s triad = CP, vomiting, & crepitus • CXR or CT = hydropneumothorax & • Treatment = small vs. large
o MC = left posteriolatreal pneumomediastinum (mediastinal air) o Small = IVF, NPO, BS-ABX & PPIs
• CP = retrosternal o Large = surgical repair
• Etiologies o Worse with deep breathing & swallowing • Esophagram = test of choice
Boerhaave
o Iatrogenic perforation 2o to endoscopy = MC • Vomiting → hematemesis o Gastrografin swallow = water soluble
o Forceful vomiting = bulimia or EtOH • Crepitus = subcutaneous emphysema
Syndrome
• Hamman’s sign = mediastinal “crackling” with
every heart beat in left lateral decubitus
 • Reflux of gastric contents • Heartburn (pyrosis) → postprandial • Clinical diagnosis • Treatment = lifestyle, meds or surgery
o Incompetent lower esophageal sphincter o Retrosternal CP & worse with lying supine o Lifestyle = weight loss, elevate HOB, upright 3 hrs
• Sour taste • 24 hour pH monitoring = gold standard after a meal, avoid large meals, avoid foods that delay
• Risk factors • Cough gastric emptying (spicy food, fatty food & chocolate,
o Obesity • Esophageal manometry = ↓ LES pressure orange juice), stop smoking & stop drinking EtOH
GERD o Meds = antacids, H2 blockers, & PPIs
o Pregnancy • Atypical = hoarseness, aspiration PNA, wheezing
o Hiatal hernia • Endoscopy = persistent or alarm symptoms o Surgery = Nissen fundoplication
o EtOH • Alarm symptoms = dysphagia, odynophagia, weight
o Smoking loss, & bleeding • Complications = esophagitis, strictures, Barrett’s
esophagus, & esophageal adenocarcinoma
• Functional idiopathic pain disorder • Abdominal pain → relieved with defecation • Diagnosis of exclusion → colonoscopy & CT scan • Treatment = lifestyle & diet
• Altered bowel habits → diarrhea vs. constipation o Low fat, high fiber, & unprocessed foods
• Risk factors • Rome IV Criteria = abdominal pain at least 1 o AOVID sorbitol or fructose foods (apples, blackberries)
o Abnormal motility & spasm = chemical • Alarm symptoms day/week in last 3 months with 2/3 symptoms or gas-producing foods (beans, raw fruits & vegetables)
imbalance → ACh & serotonin o GI bleeding = occult blood or rectal bleeding o Relieved with defecation o Exercise, diet, sleep, & smoking cessation
Irritable
o Visceral hypersensitivity = ↓ pain level o Weight loss o Change in stool frequency
Bowel o Psychosocial & altered CNS processing o Change in stool form • Constipation = fiber, psyllium, miralax
o Fever
Syndrome o Diarrhea with dehydration • Diarrhea = imodium, bismuth subsalicylate, lomotil
o Constipation with fecal impaction • Pain = SSRIs, TCAs or antispasmodics
o Antispasmodic = atropine, hyoscyamine, bentyl
o SSRIs = citalopram
o TCAs = desipramine
• Inflammatory bowel disease → autoimmune • Diarrhea (NOT bloody) → steatorrhea • CBC = anemia (iron & B12 deficiency) • Treatment = supportive& meds
o Transmural inflammation • Fever & weight loss o Supportive = STOP smoking
• Abdominal pain → crampy • ↑ ESR & CRP = severe o Mild to moderate
• Any part of GI tract → terminal ileum MC • Malabsorption → nutritional deficiencies ▪ 5-ASA (5-aminosicylic) = mesalamine (1st line)
• Electrolyte disorders • Upper GI series = string sign ▪ Metronidazole = refractory to 5-ASA
• Anal fissure = lateral ▪ Steroids = refractory to 5-ASA or ABX
Crohn’s • Skin tags • Endoscopy = skip lesions & cobblestoning o Severe or refractory
▪ Methotrexate = immunosuppressant
Disease
• Biopsy = transmural inflammation & noncaseating ▪ Infliximab (anti-TNF)= immunosuppressant
• Extraintestinal
granulomas
o Uveitis
o Erythema nodosum • TPN = alternative to chronic low dose steroids
o Pyoderma gangrenosum • (+) anti-saccharomyces antibodies (ASCA)
o Arthritis • Complications = fistulas, bowel strictures, perianal fissures,
abscesses, fibrosis, & bowel obstruction

• Inflammatory bowel disease → autoimmune
o Mucosal & submucosal inflammation
• Colon & rectum → starts in rectum MC
o Starts in rectum and extends proximally
• • Moderate = >4 BMs/day (anemic from bloody BMs)
Ulcerative
Colitis
• Diarrhea → bloody • CBC = ↑ WBCs & anemia (chronic disease) • Treatment = ASA (5-aminosicylic), steroids, & surgery
• Abdominal pain → especially LLQ o Mild to moderate = ASA & steroids → topical / PO
• Tenesmus • ↑ ESR & CRP ▪ Topical ASA = 1st line → add topical steroids prn
o Severe = PO steroids, PO ASA, & topical of both
• Mild = <4 BMs/day • Colonoscopy = uniform erythema & ulceration ▪ No response = IV steroids & IVF
o Flexible sigmoidoscopy ▪ 2nd line = immunosuppressant or TNFα antagonist
• Severe = 6 BMs/day & systemic toxicity (fever, • Immunosuppressant = cyclosporine
anemia, ↑ ESR & CRP) • Biopsy = mucosal & submucosal inflammation • TNF-α antagonists = infliximab
o Fulminant colitis = IV steroids, IVF, & IV ABX
• Barium enema = stovepipe or lead pipe sign ▪ 2nd line = immunosuppressant or TNFα antagonist
o Loss of haustral markings • Immunosuppressant = cyclosporine
• TNF-α antagonists = infliximab
• (+) P-ANCA o Surgery = surgical resection in some cases
▪ Colectomy eliminates cancer risk

• Complications = toxic megacolon and colon cancer

• Autoimmune inflammation of small bowel
o Damage to villi = malabsorption
• Reaction with alpha-gliadin in gluten food
Celiac o Wheat, rye & barley
Disease
• Abdominal pain • Clinical diagnosis = trial off gluten • Treatment = gluten-free diet & vitamin supplementation
• Diarrhea → steatorrhea (malabsorption) o Avoid = wheat, rye & barely
• Bloating • (+) transglutaminase IgA antibodies o Limit = oat consumption
• Growth delay o Safe = rice & corn
• (+) antiendomysial antibodies
• Dermatitis herpetiformis = papulovesicular
rash & pruritic • Small bowel biopsy = definitive diagnosis
o Villi atrophy
 • Outpouchings due to herniation of mucosa • Lower GI bleeding → painless hematochezia • Colonoscopy = test of choice • Treatment = supportive or meds
o MC cause of significant lower GI bleeding o Diagnostic & therapeutic o Supportive = maintain high fiber diet
• Sigmoid colon = MC ▪ Bleeding usually stops on its own
• Technetium-99 tagged RBC scan = next option o Meds = IVF, blood products or FFPs if needed
• Risk factors
Diverticulosis o Low fiber • Endoscopy = control bleeding (tamponade, inject epi)
o Constipation
o Obesity

• Inflammation & focal necrosis of diverticula • LLQ abdominal pain • CBC = ↑ WBCs • Treatment = supportive, ABX, & surgery
• Fever o Supportive = clear liquid diet
• Sigmoid colon = MC • N/V • CT scan = pericolonic fat & +/– abscess o ABX = Flagyl + Cipro or Levofloxacin
• Constipation or diarrhea o Surgery = perforation, frequent recurrence, strictures
Diverticulitis • Risk factors
o Low fiber • Urinary symptoms → due to fistula formation • Complications = perforation, obstruction, abscess, & fistula
o Constipation
o Obesity • Admit = complicated OR uncomplicated & high risk
o Complicated = perforation, obstructed, abscess, fistula
o High risk = fever >102.5, sepsis, immunosuppressed
• Noncircumferential • Dysphagia → especially solids • Barium swallow = test of choice • Treatment = meds & dilation
o Meds = PPIs
Esophageal • Thin membrane in upper esophagus o Dilation = endoscopic dilation
Web
• Plummer-Vinson syndrome = dysphagia,
esophageal webs & iron deficiency anemia

• Circumferential • Dysphagia → especially solids • Barium swallow = test of choice • Treatment = meds, dilation & +/– surgery
o Bolus of food may get stuck o Meds = PPIs
• Thin membrane in lower esophagus • Endoscopy = if biopsy needed o Dilation = endoscopic dilation
o Surgery = antireflux surgery → Nissen
Esophageal • Risk factors
(Schatzki) o Hiatal hernia
o Eosinophilic esophagitis
Ring
o Corrosive esophageal injury → GERD

• Dilation of gastroesophageal collateral veins • Upper GI bleed • Endoscopy = test of choice • Treatment = supportive, ligation, meds, or surgery
o Complication of portal vein hypertension o Hematemesis o Diagnostic & therapeutic o Acute
o Melena ▪ Supportive = IVF & +/– RBCs or FFPs
• Risk factors o Hematochezia ▪ Octreotide = causes vasoconstriction (1st line)
o Cirrhosis • Hypovolemia → if severe ▪ Vasopressin =↓ portal venous pressure (2nd line)
o Portal vein thrombosis ▪ ABX prophylaxis = ceftriazone
o Complication of portal vein hypertension ▪ Surgery = banding / ligation, sclerotherapy,
Esophageal
balloon tamponade, or decompression (TIPS)
Varices
o Chronic
▪ Beta blockers = prevention of rebleed
▪ Surgery = endoscopic variceal ligation

• Inflammation of esophagus • Odynophagia • Endoscopy = test of choice • Treatment = treat underlying cause
• Dysphagia o Candida = fluconazole
• Risk factors • Chest pain → retrosternal o HSV = acyclovir
o GERD = MC cause o CMV = ganciclovir
Esophagitis o Infectious = candida, CMV, HSV
o Eosinophilic = allergic reaction
o Pill = bisphosphates, BB, CCB, NSAIDs, KCl,
vitamin C, iron, & ABX
o Corrosive = acidic or basic substances
 • Inflammation or irritation of stomach mucosa • Mostly asymptomatic! • Endoscopy (with biopsy) = test of choice • Treatment = acid suppression & H. pylori eradication
o Acid suppression = H2 blockers or PPIs
• Imbalance of bad & protective mechanisms • Dyspepsia = burning, gnawing, & epigastric pain • H. pylori testing o H. pylori eradication = triple therapy
• N/V o Urea breath test = line1st ▪ Patients WITHOUT risk factors = triple therapy
• Etiologies o Stool antigen • PPI
o H. pylori = MC o Endoscopy (w/ biopsy) = gold standard • Amoxicillin (metronidazole PCN allergy)
o NSADs & aspirin = 2nd MC o Serology antibodies = confirms H. pylori • Clarithromycin
o EtOH infection, but NOT eradication
Gastritis ▪ Patients WITH risk factors = quadruple therapy
o Stress = critically ill patients ▪ Preferred test if patient on PPI
• PPI
o Meds
o Trauma • Bismuth → in Pepto-Bismol
o Corrosives • Metronidazole
o Pernicious anemia • Tetracycline
o Portal HTN
o Ischemia • Complications = bleeding, ulcers & strictures

• Gastric erosion → duodenal (MC) & gastric
• ↑ aggressive factors = duodenal ulcers
o HCl & H. pylori
• ↓ protective mechanisms = gastric ulcers
o Mucus, HCO3, & prostaglandins
• Risk factors
Peptic Ulcer o H. pylori
Disease o NSADs & aspirin = 2nd MC
o EtOH
o ZES = secrete gastrin
o Smoking = diminishes healing
o Stress = trauma, burns, & surgery
• Dyspepsia = burning, gnawing, & epigastric pain
• Duodenal ulcer = relieved with food
o Awakens patient at night
o Postprandial pain (1-to-2-hour delay)
• Gastric ulcer = worse with food
o Early satiety
o Pain immediately after meals
• Endoscopy (with biopsy) = test of choice
• H. pylori testing
o Urea breath test = 1st line
o Stool antigen
o Endoscopy (w/ biopsy) = gold standard
o Serology antibodies = confirms H. pylori
infection, but NOT eradication
▪ Preferred test if patient on PPI
• Treatment = acid suppression & H. pylori eradication
o Acid suppression = H2 blockers or PPIs
o H. pylori eradication = triple therapy
▪ Patients WITHOUT risk factors = triple therapy
• PPI
• Amoxicillin (metronidazole PCN allergy)
• Clarithromycin
▪ Patients WITH risk factors = quadruple therapy
• PPI
• Bismuth → in Pepto-Bismol
• Metronidazole
• Tetracycline
• Complications = toxic megacolon or perforation

• MC = viral • Nausea • Clinical diagnosis • Treatment = oral rehydration (IVF if needed)

• 6 months-2 years = rotavirus (5-7 days)
o ↓ in prevalence with vaccine
• >5 years old = norovirus (1-4 days) = MC
Gastro-
enteritis • Transmission = fecal-oral route
• Other = bacterial (shigella) or EHEC
• Enterohemorrhagic E. coli
o EHEC makes Shiga-like toxin (beef or milk)
• Vomiting → main symptom of norovirus
• Diarrhea → main symptom of rotavirus • Shigella = PO azithromycin or IV ceftriaxone
• Fever
• Headache • EHEC = AVOID antibiotics! → risk of HUS
• Shigella = dysentery (pus & blood) • Complications = dehydration
o Daycare + febrile seizure + bloody diarrhea
• Complications of EHEC = HUS
• Enterohemorrhagic E. coli = bloody diarrhea o Hemolytic anemia, thrombocytopenia, & AKI

• Engorgement of venous plexuses • Internal = PAINLESS bright red blood • Clinical diagnosis • Treatment = supportive, meds, procedure or surgery
o Seen on toilet paper o Lifestyle = fiber, fluids, less straining, less toilet time
• Types • DRE = digital rectal exam o Meds = steroids
o Internal = superior hemorrhoid vein • External = perianal PAIN without bleeding ▪ Topical (hydrocortisone) = external
▪ Above dentate line o Tender palpable mass & skin tags • Fecal occult blood = not always needed ▪ Suppositories (anusol-HC) = internal
o External = inferior hemorrhoid vein & o Procedure = recurrent, prolapsed, etc.
▪ Bellow dentate line • Itching! • Anoscopy = better to visualize internal ▪ Band ligation = MC
Hemorrhoids ▪ Sclerotherapy
• Risk factors • Stage I = NO prolapse ▪ Infrared coagulation
o Straining with defecation • Stage II = prolapse & retract on their own o Surgery = hemorrhoidectomy (external hemorrhoids)
o Pregnancy • Stage III = prolapse & retract manually
o Obesity • Stage IV = prolapse & NO retraction
o Prolonged sitting
o Cirrhosis with portal HTN
 • Abscess = infection of anal ducts or glands • Abscess = anorectal swelling, throbbing pain, & • Clinical diagnosis • Treatment = I&D & supportive
o MC = S. aureus induration or fluctuance o I&D = 1st line
Anal Abscess o Posterior rectal wall o Worse with sitting, defection & coughing o Supportive = analgesics, sitz bath & fiber
& Fistula o Deeper abscess = palpated on rectal exam
• Fistula = open tract of 2 epithelial lined areas
• Fistula = anal discharge & pain
• Linear tear or crack in distal anal canal • Rectal pain (tearing) = worse with BM • Clinical diagnosis • Treatment = supportive, vasodilators, Botox or surgery
• Bright red blood o Supportive = analgesics, sitz bath & fiber
• Types o Vasodilators = nitroglycerin
o Primary = POSTERIOR midline • Longitudinal tear → MC at posterior midline o Botox = reduce spasms of internal sphincter
▪ Trauma o Usually no more proximally than dentate line o Surgery = internal sphincterotomy (refractory cases)
▪ Constipation
▪ Diarrhea • Skin tags = sentinel pile
▪ Vaginal delivery
Anal Fissure ▪ Anal intercourse
o Secondary = LATERAL midline
▪ Crohn disease
▪ Malignancy

• Risk factors
o Low fiber
o Constipation (hard stools)
o Anal trauma
• Herniation of abdominal contents through • Epigastric or substernal chest pain • Barium enema = anatomy & size • Treatment = meds or surgery
esophageal hiatus of diaphragm • Postprandial fullness o Sliding = PPIs & weight loss
• Retching • Endoscopy = anatomy & size o Paraoesophageal = surgical repair if symptomatic
Hiatal • Types • Nausea
Hernia o Sliding = GE junction into mediastinum • GERD symptoms → reflux & heartburn
▪ MC type!
o Paraoesophageal = fundus of stomach
through diaphragm w/ GE junction in place
• Fascial opening in utero fails to close • Skin intact • Clinical diagnosis • Treatment = observation vs. surgery
o Observation = watch until 2 years old or surgery
Umbilical • CT scan = may suggest hernia ▪ Most close spontaneously by 2 years old
Hernia o Surgery = failed closure or incarcerated/strangulated

• Direct = medial to epigastric arteries • Extra full scrotal sac → after crying • Treatment = surgery
o MC in adults o Surgery = pain, incarcerated, or strangulated
• Transillumination = hernia vs. hydrocele
Inguinal • Indirect = lateral to epigastric arteries • Reduce = Trendelenburg & massage inguinal contents
Hernia o MC in premature males • Incarcerated = pain, enlarged & irreducible
• Strangulated = pain and ↓ blood supply
•
• Partial or complete mechanical blockage of • Abdominal pain • X-ray = air-fluid level & dilated bowel loops • Treatment = supportive vs. surgery
small intestine • Distension o Supportive = NPO, IVF, & NGT
• N/V • CT scan = transition zone o Surgery = strangulated bowel or no improvement
• Etiologies • Obstipation = no flatus o Loops w/ contrast to area w/out contrast with supportive measures
o Adhesions (postop) = MC • Tympany
o Hernias = incarcerated
o Malignancy = MC large bowel obstruction
o Chron’s disease = causes adhesions • High-pitched bowel sounds = early (partial)
o Intussusception • Hypoactive bowel sounds = late (complete)
Small Bowel
Obstruction • Types
o Closed loop vs. open loop = closed can
reduce blood
▪ Closed = lumen occluded at 2 points
• ↓ blood → strangulation (necrosis)
o Complete vs. partial
▪ Complete = severe obstipation
o Distal vs. proximal
▪ Distal = distension & ↓ vomiting
 • Obstruction of appendix • Periumbilical (visceral) → RLQ pain (parietal) • CBC = ↑ WBCs • Treatment = nonoperative vs. operative
• N/V/D & anorexia → vomiting after pain o Nonoperative = ABX & observation
• MC = fecalith & lymphoid hyperplasia • Low-grade fever • Alvarado score = high score → imaging ▪ Nonperforated (uncomplicated) appendicitis
• LC = infection, malignancy, collagen vascular • Variability in anatomy and pain! o Migratory RLQ pain (1 point) ▪ Might as well take it out b/c it might reoccur
disease & IBS o Anorexia (1 point) o Operative
• (+) McBurney’s point tenderness o Nausea or vomiting (1 point) ▪ Nonperforated
• MC = 9 to 12 years old o Tenderness in RLQ (2 points) • Timing = <12 hours
o Rebound tenderness in RLQ (1 point)
• (+) Rovsing sign = pain with LLQ palpation • PPX ABX
o Fever >99.5°F (1 point) o Cefoxitin OR cefotetan
o Leukocytosis >10 (2 points)
• (+) Psoas sign = pain with hip extension OR
o Cefazolin PLUS flagyl
Appendicitis • CT = preferred imaging ▪ Perforated
• (+) Obturator sign = pain with knee flexion and
internal rotation • Timing = immediate
• US = children & pregnant women
• PPX ABX = gram (–) rods & anerobic
• (+) Jar sign = pain with dropping heel o Carbapenem = meropenem
OR
o Zosyn
OR
o Cefepime PLUS flagyl

• Complications = perforation and peritonitis

o Perforation = 90% in kids <4 years old (can’t talk)
o Peritonitis = fever, abdominal pain & ↑ WBCs
• Bleeding proximal to ligament of Treitz • Hematemesis = proximal to ligament • CBC = check for anemia or ↓ PLTs • Treatment = supportive & treat underlying cause
• Melena = proximal to ligament o Normocytic = acute blood loss o Supportive = IVF, O2 & PPI
• Risk factors o Microcytic = chronic blood loss (IDA) o Anemia = blood transfusion (Hgb <8)
o PMHx = PMHx GI bleed or other risk factors • Hematochezia = distal to ligament o Thrombocytopenia = PLTs (PLTs <50,000)
o Meds = NSAIDs, anti-platelets or • CMP = electrolytes & LFTs ▪ If stent placement <1 year ago, consult cardiology
anticoagulants • Mild blood loss = ↑ HR before stopping ASA or Plavix
• PT/INR & PTT = evaluate for coagulopathy o Coagulopathy = FFP (INR >2.o)
• Mod blood loss = orthostatic HOTN & ↑ HR
Upper GI • Etiologies • Severe blood loss = supine HOTN & ↑ HR
Bleed o PUD = upper abdominal pain • EKG & troponin = patients @ risk for MI
o Esophageal ulcer = GERD & dysphagia o Older adults
o Esophagitis o CAD
o Mallory-Weiss = emesis or hematemesis o Chest pain or dyspnea
o Esophageal varices
o Portal HTN gastropathy = jaundice & • Upper endoscopy = best initial imaging
ascites
o Malignancy = dysphagia, weight loss, &
cachexia
• Bleeding distal to ligament of Treitz • Hematemesis = proximal to ligament • CBC = check for anemia or ↓ PLTs • Treatment = supportive & treat underlying cause
• Melena = proximal to ligament o Normocytic = acute blood loss o Supportive = IVF, O2 & PPI
• Risk factors o Microcytic = chronic blood loss (IDA) ▪ PPI = incase it’s an upper GI bleed
o PMHx = PMHx GI bleed or other risk factors • Hematochezia = distal to ligament o Anemia = blood transfusion (Hgb <8)
o Meds = NSAIDs, anti-platelets or • CMP = electrolytes & liver function tests o Thrombocytopenia = PLTs (PLTs <50,000)
anticoagulants • Mild blood loss = ↑ HR ▪ If stent placement <1 year ago, consult cardiology
• Mod blood loss = orthostatic HOTN & ↑ HR • PT/INR & PTT before stopping ASA or Plavix
• Etiologies • Severe blood loss = supine HOTN & ↑ HR
o Coagulopathy = FFP (INR >2.o)
o Diverticulosis = painless hematochezia • EKG = monitoring for arrythmias
o Inflammatory bowel disease = diarrhea
o Colon cancer = IDA • Stool guaiac test = heme occult + / –
o Hemorrhoids = itching
Lower GI
o Anal fissure
Bleed • Colonoscopy = diagnostic & therapeutic
o Colitis = noninfectious (IBD), infectious, or
ischemic
o Polyps • Radionuclide scanning = most sensitive
o Detects blood loss 0.1 to 0.5 mL/minute
▪ Requires active bleeding
o Two types of nuclear scans
▪ 99mTc sulfur colloid
▪ 99mTc pertechnetate-labeled RBCs

• CT angiography = widely available & fast

o Detects blood loss 0.3 to 0.5 mL/minute
▪ Requires active bleeding
 EYES, EARS, NOSE & THROAT
Etiology Presentation & PE Diagnosis Treatment & Complications
• Inflammation of nasal cavity & paranasal sinuses • Facial pain & pressure • Clinical diagnosis • Treatment = supportive or ABX
o Frontal, maxillary, sphenoid & ethmoid o Worse = bending down or leaning forward o Supportive = 1st line
o <4 weeks • CT scan = >4 weeks (with medical management) ▪ Analgesics & antipyretics = NSAIDs & Tylenol
• Headache & failed 2 courses of ABX OR recurrent sinusitis ▪ Decongestants = promote nasal drainage
• Etiologies • Malaise o Air-fluid levels ▪ Saline irrigation = Neti Pots & saline spray
o Viral = MC • Maxillary tooth discomfort o Air bubbles within sinuses ▪ Intranasal steroids = short term use (Flonase)
Acute ▪ Rhinovirus • Nasal discharge o Mucosal edema • Most beneficial in those with allergic rhinitis
Sinusitis ▪ Influenza • Nasal congestion o ABX = acute treat for 7 days; chronic treat for 21 days
▪ Parainfluenza • Fever ▪ Augmentin = 1st line
o Bacterial ▪ Doxycycline = 2nd line
▪ Streptococcus pneumonia • Viral = <10 days ▪ Clindamycin = MRSA or anaerobes
▪ H. influenzae o ENT follow-up = CHRONIC need to see a specialist
• Bacterial = >10 days (improves, then worsens)
▪ Moraxella catarrhalis
• Inflammation of nasal cavity & paranasal sinuses • Facial pain & pressure • Clinical diagnosis • Complications = meningitis, brain abscess, mastoiditis, &
o Frontal, maxillary, sphenoid & ethmoid o Worse = bending down or leaning forward periorbital cellulitis
o >12 weeks • CT scan = >4 weeks (with medical management)
• Headache & failed 2 courses of ABX OR recurrent sinusitis
• Etiologies • Malaise o Air-fluid levels
o Bacterial • Maxillary tooth discomfort o Air bubbles within sinuses
▪ Staph aureus • Nasal discharge o Mucosal edema
Chronic
▪ Pseudomonas • Nasal congestion
Sinusitis • Biopsy = definitive diagnosis
▪ Anaerobes • Fever
o Fungal
▪ Aspergillus = MC fungal cause • Mucormycosis = black eschar on palate
▪ Mucormycosis = associated with DM

• Recurrent sinusitis = >4 episodes/year with at least 8

weeks free of disease between episodes
• Inflammation of nasal membranes • Sneezing • Clinical diagnosis • Treatment = supportive & meds
o Eyes, ears, nose & throat can be involved • Nasal congestion o Supportive = AVOID TRIGGERS!!
o Type I IgE mediated • Clear & watery rhinorrhea o Meds
▪ Intranasal steroids (1st line) = ocular, pruritis,
• Types • Allergic shiners = blue color under eyes sneezing, & rhinorrhea → most beneficial
o Allergic = MC • Horizontal nasal crease • Fluticasone (Flonase)
▪ Due to allergens = pollen, mold, dust • Dennie Morgan lines = under eyes • Especially use if patient has nasal polyps!
▪ IgE-mediated mast cell histamine release ▪ Antihistamines = pruritis, sneezing, & rhinorrhea
o Infectious = rhinovirus (MC) • Allegra & Zyrtec
• Pale or boggy turbinates
o Vasomotor = dilated blood vessels ▪ Mast cell stabilizer = patient w/ asthma & allergies
Allergic • Nasal polyps
▪ Nonallergic & noninfectious • Singular (Montelukast)
Rhinitis • Cobblestone mucosa
• Strong smell ▪ Decongestants = congestion & +/– rhinorrhea
• Humidity • Nasal = oxymetazoline & phenylephrine
• Temperature changes • PO = pseudoephedrine
• Do not use >5 days → rebound decongestant
▪ Desensitization therapy = refractory to other meds
• Inject diluted concentration of antigen
o Effort to reduce inflammatory response
• Weekly or biweekly
• S/E = anaphylaxis
• Sac-like growths of inflamed tissue of nasal passages • Mostly asymptomatic! • Direct visualization = pale & boggy mass • Treatment = meds & surgery
o Intranasal steroids = 1st line
• Etiologies • Congestion ▪ Fluticasone (Flonase)
o Allergic rhinitis • Obstruction o Surgery = large & medical therapy unsuccessful
Nasal
o Cystic fibrosis • Anosmia = ↓ sense of smell
Polyps o Asthma
o Aspirin sensitivity

• Samter’s triad = asthma, aspirin sensitivity & polyps

 • Anterior epistaxis = kiesselbach venous plexus • Anterior epistaxis = BRIGHT red blood • CBC = H&H (anemia if significant blood loss) • Treatment = child vs. elderly
o Bleed slowly & often self-limiting o Direct pressure = bridge of nose for 10 minutes
o Unilateral • Posterior epistaxis = DARK red blood • PT/INR & PTT = if patient on anticoagulation o Cautery
o Easily manageable o Swallow blood = N/V & hematemesis ▪ Afrin spray = vasoconstriction
o Aspirate blood = hemoptysis ▪ Cotton balls = with LET solution
• Posterior epistaxis = sphenopalatine artery • Lidocaine 4%
o More severe & blood drains down throat • Epinephrine 0.1%
o Bilateral
• Tetracaine 0.4%
o Difficult to manage
▪ Cautery = silver nitrate sticks
o Nasal packing = 1st line in elderly!
• Etiologies = anterior epistaxis
o Nasal trauma
▪ Afrin spray = vasoconstriction
o Dry air = low humidity ▪ Cotton balls = with LET solution
o Dry heat = hot environment (dried mucosa) • Lidocaine 4%
Epistaxis • Epinephrine 0.1%
o Rhinitis
o EtOH • Tetracaine 0.4%
o Cocaine ▪ Nasal packing = Rapid Rhino
o Antiplatelet meds • Insert straight back! (NOT up)
o Foreign body • Methyl cellulose = coagulant
• Inflate with air, NOT water
• Etiologies = posterior epistaxis
o HTN
• Soak with STERILE water (not tap water)
o Older patients • Inflate until firm
o Anticoagulation • If swelling ↓, then inflate it more!
o Nasal neoplasms • DC with ENT follow up

• Complications = continued & severe bleeding, HOTN,

hypoxia & hypercapnia
• Etiologies • Sore throat • Clinical diagnosis • Treatment = supportive
o Viral • Cough o Supportive = fluids, warm saline gargles, topical
▪ Adenovirus • Hoarseness anesthetics, lozenges, & NSAIDs
▪ Rhinovirus • Coryza
Pharyngitis ▪ Enterovirus • Conjunctivitis
/ Tonsillitis ▪ EBV • Diarrhea
▪ RSV
▪ Influenza
▪ Herpes zoster virus
o Bacterial = strep pyogenes (GAS)
• Bacterial infection of tonsils • Dysphagia • Rapid step antigen = throat swab • Treatment = ABX
• Fever o Amoxicillin = 1st line
• Erythematous & exudative tonsils • Throat culture = GOLD standard ▪ Tastes better than penicillin
• Cervical LAD o PNC allergy = cephalosporin → 1st, 2nd or 3rd
• Etiology = strep pyogenes (GAS) • CENTOR criteria o Severe PCN allergy = azithromycin or clindamycin
Streptococcal • N/V/D
Pharyngitis o C – cough absent (can’t cough)
• Petechiae on palate o E – exudate • Complications = rheumatic fever, glomerulonephritis, &
o N – nodes → anterior cervical LAD peritonsillar abscess
• White strawberry tongue o T – temperature (fever) → >100.4 oF o Rheumatic fever is preventable with ABX
• Sand paper rash = scarlet fever o OR – young OR old modifier
▪ 1 point <15 and -1 for >45
• Inflammation of mucosa of larynx • Hoarseness • Clinical diagnosis • Treatment = supportive
• Aphonia o Supportive = resolves ~3 weeks
• Etiologies • Dry or scratchy throat • Laryngoscopy = symptoms >3 weeks ▪ Fluids
o Viral ▪ Vocal rest
▪ Adenovirus • URI symptoms = cough, rhinorrhea, sore throat ▪ Humidifier
▪ Rhinovirus ▪ Warm saline gargles
▪ RSV ▪ Lozenges
Laryngitis ▪ Influenza & Parainfluenza
o Bacterial
▪ Moraxella catarrhalis
▪ Mycoplasma pneumoniae
o Vocal strain = screaming or singing
o Irritants = acid (GERD)
o Polyps
o Laryngeal cancer
 • Pus between palatine tonsil & pharyngeal muscles • Dysphagia • Clinical diagnosis • Treatment = drainage, ABX, pain meds, & +/– surgery
o Occurs in a potential space • Unilateral pharyngitis o Drainage = needle aspiration (preferred) or I&D
• Fever • Rapid step antigen = could be from strep throat ▪ Performed by ENT → right near carotid artery!
• Etiology = complication of pharyngitis / tonsillitis • Cervical LAD o ABX = outpatient vs. inpatient
o Strep pyogenes (GABHS) • Dehydration = because cannot drink! • Monospot = could be from mono ▪ PO = outpatient
o Staph aureus • Augmentin
o Anaerobes • CT scan = imaging test of choice • Clindamycin = good for anaerobes
o EBV
• Halitosis
o Differentiates cellulitis vs. abscess ▪ IV = inpatient
• Tonsillar exudate & erythema
o Not always needed • Unasyn
Peritonsillar • Risk factor = smoking
Abscess • Ulnar deviation = contralateral side • Metronidazole + Penicillin
• Hot potato voice = muffled • Clindamycin = typical choice
• Drooling o Pain meds
• Trismus = lockjaw ▪ Ketorolac (IV) = helpful with pain & fever
▪ Narcotics (IV)
o Tonsillectomy = fail to respond to drainage, PTA
with complications, or recurrent severe pharyngitis

• Etiologies • Round or oval shallow ulcer • Clinical diagnosis • Treatment = steroids or pain meds
o Idiopathic o Central exudate = grayish-white o Topical steroids = 1st line
o HHV 6 o Erythematous halo ▪ Clobetasol = gel or ointment
o IBD o Location = buccal or labial mucosa ▪ Dexamethasone = swish & spit
o HIV ▪ Triamcinolone
Aphthous o Food allergies = celiac disease • Last ~1 week & then months before reoccurring o Analgesics = topical
Ulcers o SLE ▪ Lidocaine (2%) = viscous mouth wash
o Methotrexate
▪ Diphenhydramine (Benadryl)
o Neutropenia
(Canker Sore) o Trauma ▪ Aluminum hydroxide + magnesium
hydroxide + simethicone
o Ill-fitting dentures
o Vitamin deficiencies
o Hormonal fluctuations
o Stress

• Stones in salivary glands or ducts
o Stensen’s duct = parotid gland
o Wharton’s duct = submandibular gland
• Risk factors = ↓ salivation
o Dehydration
o Anticholinergics
Sialolithiasis o Diuretics
o Chronic illness = Sjogren’s
• Salivary gland pain & swelling
o Worse = meals or anticipation of food
• Clinical diagnosis • Treatment = supportive, invasive or surgery
o Supportive = sialagogues (↑ salivary flow)
▪ Tart or hard candies
▪ Lemon drops
▪ ↑ fluid intake
▪ Gland massage
o Invasive = sialoendoscopy or lithotripsy
o Surgery = recurrent stone or failure of other methods
• AVOID anticholinergics! = decrease salivation

• Complications = parotitis

• Bacterial infection of salivary glands • Salivary gland pain & swelling • Clinical diagnosis • Treatment = supportive & ABX
o Stensen’s duct = parotid gland o Worse = meals or anticipation of food o Supportive = sialagogues (↑ salivary flow)
o Wharton’s duct = submandibular gland • CT scan = assess for abscess or extent of tissue ▪ Tart or hard candies
• Purulent discharge involvement ▪ Lemon drops
• Etiologies • Dysphagia ▪ ↑ fluid intake
o Staph aureus • Trismus ▪ Gland massage
o Strep pneumonia • Fever & chills o ABX
Sialadenitis o Strep viridans ▪ Dicloxacillin = MSSA
o H. flu
▪ Clindamycin = MRSA
• Risk factors = ↓ salivation
o Sialolithiasis = salivary gland obstruction
o Dehydration
o Chronic illness = Sjogren’s
 • Eyelid & lashes turn OUTWARD = everted • Irritation • Clinical diagnosis • Treatment = supportive & surgery
Ectropion
o Relaxation of orbicularis oculi muscle • Ocular dryness o Supportive = lubricating eye drops & moisture shield
• Eyelid sagging o Surgery = failure of other methods
• Risk factors = elderly or CN 7 palsy
• Eyelid & lashes turn INWARD = inverted • Irritation • Clinical diagnosis
o Spasms of orbicularis oculi muscle • Erythema & tearing
Entropion
• Corneal abrasion or ulceration from eyelashes
• MC = elderly
• Infection of lacrimal sac • Tearing • Clinical diagnosis • Treatment = supportive, ABX, & surgery
o 2o to obstruction of nasolacrimal duct • Tenderness o Supportive = warm compress & massage
o Medial canthal (nasal) side of lower eyelid • Edema o ABX = if needed
• Erythema ▪ Mild = clindamycin
• Etiologies • Warmth ▪ Severe = vancomycin + ceftriaxone (3rd gen)
Dacryocystitis o Staph aureus = MC o Dacryocystorhinostomy = failure of other methods
Staph epidermis • +/– purulent discharge
o ▪ Create an artificial tear drain
o Strep pyogenes (GAS)
o Pseudomonas

• Inflammation of eyelid margin • Crusting • Clinical diagnosis • Treatment = supportive or ABX

• Scaling o Supportive = eyelid hygiene
• Risk factors • Burning • Slit lamp = more definitive diagnosis ▪ Warm compresses
o Atopic dermatitis • Erythema ▪ Eyelid scrubbing/ washing = baby shampoo
o Rosacea • Photophobia ▪ Artificial tears
o Seborrheic dermatitis o ABX (topical) = severe or refractory
Blepharitis • Foreign body sensation
▪ Azithromycin = solution or ointment
• Types = posterior is MC ▪ Erythromycin
o Posterior = meibomian gland dysfunction ▪ Bacitracin
o Anterior = infectious or seborrheic
▪ Infectious = staph aureus or staph epidermis • Complications = orbital cellulitis

• Infection / abscess of eyelid margin • Erythema • Clinical diagnosis • Treatment = supportive, I&D or ABX
• Tender – PAINFUL o Supportive = eyelid hygiene
• Types • Warmth ▪ Warm compresses
o External = infection of gland of Zeis & Moll • Nodule or pustule o I&D = if no spontaneous drainage after 48 hours
Hordeolum o Internal = infection of Meibomian gland o ABX = topical antibiotic ointment
(Stye) ▪ Erythromycin
• Risk factors ▪ Bacitracin
o Rosacea
o Seborrheic dermatitis

• Obstruction of Zeis or Meibomian gland • Non-tender • Clinical diagnosis • Treatment = supportive, I&D or ABX
o Painless indurated granuloma • Eyelid swelling o Supportive = resolve in days to weeks
Chalazion
o May develop from internal hordeolum ▪ Eyelid hygiene
▪ Warm compresses
o I&D = refractory
o Steroid injection = refractory
• Thickening of bulbar conjunctiva • Yellow • Clinical diagnosis • Treatment = none or resection
o Consists of protein, fat, & calcium • Nodule o Resection = chronically inflamed or cosmetic reasons

• Risk factors = eye irritation • DOES NOT go to cornea

Pinguecula
o Dry
o Wind
o UV light
o Ocular trauma
• Thickening of bulbar conjunctiva • Triangular-shaped fibrovascular mass • Clinical diagnosis • Treatment = supportive or resection
o Consists of protein, fat, & calcium o Medial to lateral o Supportive (observation) = artificial tears
• Irritation o Resection = chronically inflamed or cosmetic reasons
• Risk factors = eye irritation • Erythema
Pterygium o UV light • Foreign body sensation
o Sand
o Wind • DOES go to cornea
o Dust exposure
 • Outer membranes of eye disrupted by trauma • ↓ visual acuity • Seidel’s test = parting of fluorescein dye • Treatment = supportive & ophthalmology consult
• Diplopia o Supportive
• OPTHALMOLOGIC EMERGNECY • Enophthalmos or exophthalmos ▪ Rigid eye shield
• Conjunctival hemorrhage ▪ Leave impaled objects in place
• Prolapsed ocular tissue or iris ▪ IV ABX
Globe • Teardrop or irregular pupil ▪ Tetanus PPX
Rupture • Hyphema = blood in anterior chamber o Ophthalmology consult = immediately!!!

• AVOID topical eye solutions

• AVOID applying pressure to eyeball → do not check IOP!

• Permanent blindness & vision loss • Central vision loss (color & detailed vision) • Fundoscopy • Treatment = dry vs. wet
o Dry = drusen bodies (yellow deposits) o Dry
• Types • Metamorphopsia = straight lines appear bent ▪ Round yellow-white spots on outer retina ▪ Zinc & antioxidant vitamins (C & E)
o Dry (atrophic) = progressive (decades) → MC • Micropsia = objects smaller in affected eye o Wet = choroidal neovascularization ▪ Smoking cessation
Macular ▪ Atrophic ▪ New & abnormal blood vessels ▪ Amsler grid to monitor progression
Degeneration o Wet (exudative) = aggressive (months) ▪ Can cause retinal hemorrhages & scarring o Wet
▪ Neovascular or exudative ▪ Zinc & antioxidant vitamins (C & E)
PAINLESS • Amsler grid = metamorphopsia ▪ Smoking cessation
▪ VEGF inhibitors = Bevacizumab
(CENTRAL) • ↓ new abnormal vessel formation
▪ Laser therapy photocoagulation

• Permanent vision loss • Vision changes = red spots & floaters • Fundoscopy • Treatment = non-proliferative vs. proliferative
o Microaneurysms o Nonproliferative = glucose control & laser therapy
• Types o Hard exudates = yellow w/ sharp margins ▪ Glucose control
o Nonproliferative = exudates, cotton wool spots, ▪ Lipid or lipoprotein deposit ▪ Laser therapy photocoagulation
dot and flame hemorrhages & microaneurysms o Cotton wool spots (soft exudates) = fluffy o Proliferative
Diabetic o Proliferative = neovascularization ▪ Nerve layer microinfarctions ▪ Glucose control
Retinopathy o Maculopathy = edema or exudates o Flame-shaped hemorrhages = nerve fiber ▪ Laser therapy photocoagulation
▪ Nerve fiber hemorrhage ▪ VEGF inhibitors = Bevacizumab
o Dot hemorrhages • ↓ new abnormal vessel formation
▪ Bleeding into deep retinal layer
• Prevention = annual eye exams
• Damage to retinal blood vessels from HTN • HTN • Fundoscopy • Treatment = treat hypertension
o Mild = AV nicking (venous compression)
Hypertensive • Types o Moderate = hemorrhages, exudates &
Retinopathy o Mild = AV nicking microaneurysms
o Moderate = hemorrhages & exudates o Severe = papilledema (blurred optic disc)
o Severe = OPTHALMOLOGIC EMERGENCY ▪ OPTHALMOLOGIC EMERGENCY
• Separation of retina from retinal pigment epithelium • PAINLESS peripheral vision loss • Fundoscopy = retinal tear & (+) Shafer’s sign • Treatment = supportive & ophthalmology consult
o “Curtain coming down” o Retinal tear = detached tissue flapping o Supportive
• Risk factors = eye irritation o Peripheral → central vision loss o Shafer’s sign = clumping of brown pigment ▪ Supine with head toward side of detachment
o Myopia = near sightedness • Photopsia = flashing lights vitreous cells (tobacco dust) o Ophthalmology consult = immediately!!!
o Cataract surgery • Floaters = cobweb appearance ▪ Laser therapy photocoagulation
o Older age ▪ Cryotherapy
o Trauma ▪ Ocular surgery
Retinal • NO pain or erythema ▪ Retinopexy = air bubble
Detachment • Types
o Rhegmatogenous = MC
PAINLESS ▪ Full thickness retinal tear causes retinal inner
sensory layer detachment from choroid plexus
(PERIPHERAL) o Tractional = proliferative DM retinopathy, sickle
cell disease, & trauma
▪ Adhesions separate retina from its base
o Exudative (serous) = HTN, CRVO, papilledema
▪ Fluid accumulates beneath retina

• OPTHALMOLOGIC EMERGENCY
 • Retinal artery thrombus or embolus • PAINLESS monocular vision loss • Fundoscopy = pale retina, cherry-red macula, • Treatment = supportive & ophthalmology consult
Central o “Curtain coming down” & boxcaer apperance of retinal vessels o Supportive
Retinal • Etiologies ▪ O2 therapy = 100%
Artery o Carotid artery emboli = atherosclerosis (MC) • +/– ipsilateral carotid bruit • Catroid US = evaualte for atheroscloris ▪ Ocular massage = dilate vessels & dislodge clot
Occlusion o Cardiogenic emboli ▪ ↓ IOP = acetazolamide or timolol
(CRAO)
o Vasculitis (giant cell arteritis) • Echocardiogram = evaualte for clot o Ophthalmology consult = immediately!!!

• OPTHALMOLOGIC EMERGENCY • Prognosis = poor (even with treatment)

PAINLESS

(MONOCULAR)

• Retinal vein thrombus → causes fluid backup in retina • PAINLESS monocular vision loss • Fundoscopy = retinal hemorrhages (blood & • Treatment = meds & ophthalmology consult
o “Curtain coming down” thunder apperance) & Marcus-Gunn pupil o VEGF inhibitors = 1st line
Central • Risk factors o Marcus-Gunn pupil = pupil dialtes to light ▪ Bevacizumab
Retinal o HTN ▪ Pegaptanib
Vein o DM ▪ Ranibizumab
Occlusion o Smoking o Steroids = 2nd line
o Glaucoma ▪ Dexamethasone
(CRVO)
o Hypercoagulable states ▪ Triamcinolone
o Multiple myeloma o Ophthalmology consult = refer patient!
PAINLESS
▪ Laser therapy OR surgery if neovascularization
(MONOCULAR)

• Accumulation of blood in anterior chamber • Pain • Clinical diagnosis • Treatment = supportive & ophthalmology consult
o Bleeding ciliary muscles usually after trauma • Vision changes o Supportive
o Fluid level noted with patient in upright position • ↑ IOP ▪ Elevated HOB 45o
▪ Different grade levels • Photophobia ▪ Avoid heavy lifting
• Absent red light reflex ▪ Eye shield
• Risk factors = eye irritation ▪ Dilation drops
Hyphema o Trauma o Ophthalmology consult = EMERGENT referral!
o DM
o Blood disorder = ex: anticoagulation use • AVOID
o Neoplasm o Antiplatelets
o Eye surgery o Anticoagulants
o Carbonic anhydrase inhibitors = sickle cell patient
• Scratched cornea → MC from foreign bodies • Eye discharge = tearing • Visual acuity = best initial test • Treatment = ABX, removal, patch, ophthalmology consult
• Erythema o ABX = non-contact vs. contact
• Foreign body sensation • Fluorescein stain = ice rink / linear abrasions ▪ Non-contact = erythromycin ointment
• Photophobia ▪ Contact = ciprofloxacin or ofloxacin topically
• Cover pseudomonas
Corneal • Blepharospasms = hard to open eye o Foreign body removal = sterile irrigation,
moistened sterile cotton swab or needle via slit lamp
Abrasion ▪ Remove rust ring in 24 hours = corneal burr
• Usually done by ophthalmologist
OCULAR PAIN
o Patch = only for certain patients if >5 mm
▪ DO NOT patch >24 hours
▪ DO NOT patch for pseudomonas
o Ophthalmology consult = refer patient! (24 hours)

• AVOID topical anesthetic → prevent healing!!

• Loss of corneal tissue → MC from trauma • Eye discharge = tearing • Fluorescein stain = well circumscribed opacity • Treatment = ABX & ophthalmology consult
o Cellular infiltrate of cornea • Erythema o ABX = non-contact vs. contact
▪ With associated epithelial defect • Foreign body sensation ▪ Non-contact = erythromycin ointment
Corneal o Start with abrasion & it gets 2o infection • Photophobia ▪ Contact = ciprofloxacin or ofloxacin topically
Ulceration • Vision changes • Cover pseudomonas
• Trauma → infection o Ophthalmology consult = immediately!!
o Infection = bacterial >> fungal > protozoal
OCULAR PAIN
• Complications = cornea thinning & perforation if untreated
• OPTHALMOLOGIC EMERGENCY
 • Inflammation of conjunctiva • Discharge = purulent • Clinical diagnosis • Treatment = ABX
• Lid crusting = eye “stuck shut” in AM o Erythromycin (ointment) = 1st line
• Pathogens • Conjunctival injection • Gram stain & culture = definitive diagnosis o Polytrim (drop) = 2nd line
o Staph aureus = MC in adults o Tobrex (drop)
Bacterial o Streptococcus pneumonia • Fluorescein stain = rule out keratitis or corneal o Moxifloxacin
Conjunctivitis o H. influenzae abrasion o Ofloxacin (fluroquinolone)
o Moraxella catarrhalis o Ciprofloxacin = pseudomonas coverage
o N. gonorrhea o Ceftriaxone (IM) = gonorrhea
o Chlamydia trachomatis o Erythromycin (PO) = chlamydia

• Inflammation of conjunctiva
• Etiology = adenovirus (MC)
Viral
Conjunctivitis • Risk factor = swimming pool
• Discharge = watery • Clinical diagnosis • Treatment = supportive & meds
• Erythema o Supportive = warm to cool compress & artificial tears
• Pruritis • Slit lamp = punctate staining o Meds = antihistamines → itching & redness
• Unilateral → bilateral (1-2 days)
• Viral symptoms = cough, nasal drainage, & LAD
• Conjunctival injection

• Preauricular LAD
• Inflammation of conjunctiva • Discharge = watery or mucoid • Clinical diagnosis • Treatment = meds
o Mast cell degeneration & release of histamine • Erythema o Topical antihistamines = H1 blockers
o Type I IgE mediated • Pruritis = SEVERE! ▪ Olopatadine = antihistamine, mast cell stabilizer
• Unilateral → bilateral (1-2 days) ▪ Azelastin = antihistamine
Allergic • Etiology = allergen • Allergic symptoms = cough, congestion, sneezing ▪ Naphcon = antihistamine & decongestant
Conjunctivitis • Conjunctival injection o Topical NSAIDs = Ketorolac

• Cobblestone mucosa
• Chemosis = conjunctival edema

• Infection of orbit = fat & ocular muscles • OCULAR PAIN → painful EOM • Clinical diagnosis • Treatment = ABX
o POSTERIOR to orbital septum • Ophthalmoplegia = EOM weakness o ABX (IV) = vancomycin + ceftriaxone
• Proptosis • CT scan = definitive diagnosis
• Pathogens • Diplopia
o Staph aureus = MC • Visual changes
o Streptococcus pneumonia
Orbital o Strep pyogenes (GAS)
• Eyelid edema & erythema
Cellulitis o H. influenzae

OCULAR PAIN • Etiologies

o Sinusitis = MC
o Blepharitis
o Dacryocystitis
o Facial trauma
o Facial infections
o Dental infections
o Ophthalmic surgery
• Infection of eyelid & periocular tissues • OCULAR PAIN → NO painful EOM • Clinical diagnosis • Treatment = ABX
Periorbital o ANTERIOR to orbital septum • Eyelid edema & erythema o Clindamycin or Bactrim
Cellulitis • CT scan = definitive diagnosis PLUS
• Pathogens • NO visual changes! o Amoxicillin, Augmentin or Cefpodoxime
o Staph aureus = MC in adults
OCULAR PAIN
o Streptococcus pneumonia
o Anaerobes

• Anterior = inflammation of iris & ciliary body • OCULAR PAIN • Slit lamp = inflammatory “cells & flare” • Treatment = meds
• Posterior = inflammation of choroid • Photophobia o Cells = WBCs o Steroids (topical) = anterior
• Eye redness o Flare = protein in vitreous humor o Steroids (PO) = posterior
Uveitis • Etiologies • Vision changes o Cyclopentolate = relieve pain from spasms
(Iritis) o Inflammatory & autoimmune diseases • Miosis = constricted pupil
▪ Spondyloarthropathies (HLA-B27)
OCULAR PAIN ▪ Sarcoidosis • Ciliary injection
▪ IBD
o Infections = CMV, toxoplasmosis,, syphilis, TB
o Trauma
 • Corneal ulceration &/or inflammation • Ocular pain • Fluorescein stain = ↑ fluorescein uptake • Treatment = ABX
• Photophobia o ABX = fluoroquinolones (topical) → 1st line
• Pathogens • Eye redness ▪ Moxifloxacin or Gatifloxacin
o Staph aureus = MC in adults • Vision changes
o Streptococcus pneumonia • Hazy cornea • DO NOT PATCH
Bacterial o Pseudomonas (associated with contact lenses)
• Corneal OPACIFICATION & ULCERATION
Keratitis
• Risk factors
o Improper contact lens usage • Ciliary injection = limbal flush
o Dry eye (ex: not fully closing eye with Bell’s palsy)
o Topical steroid use
o Immunosuppression
• Corneal ulceration &/or inflammation • Ocular pain • Fluorescein stain = dendritic corneal ulceration • Treatment = antivirals & +/– corneal transplant
• Photophobia o Antivirals
• Pathogens • Eye redness ▪ Topical = trifluridine or ganciclovir
o HSV = reactivation of virus in trigeminal ganglion • Vision changes ▪ PO = acyclovir
• Hazy cornea o Corneal transplant = severe
Herpes
• Ciliary injection = limbal flush • Complications = blindness
Keratitis

• Lens opacification = thickening of lens • Painless & slow vision loss or blurred vision • Treatment = observation vs. surgery
o Observation = not impairing activities
• Risk factors • ABSENT red-light reflex o Surgery = impairing activities → definitive treatment
o Elderly = >60 years old • Opaque lens
o Smoking • Prevention = MC cause of preventable blindness!
Cataract o DM o Diet & exercise
o Steroids o Control DM & obesity
o UV light o Quit smoking & EtOH
o Malnutrition or obesity o Avoid UV light
o Trauma
o ToRCH infection = toxo, rubella, CMV, HSV
• ↓ aqueous drainage via trabeculum • OCULAR PAIN = severe & unilateral • Tonometry = ↑ IOP (>21 mmHg) • Treatment = meds & surgery
o Optic nerve damage from ↑ IOP • Halos = around light o Topical agents
• Peripheral vision loss → central vision loss • Fundoscopy = optic disc blurring & cupping ▪ Timolol = BB
• OPTHALAMIC EMERGENCY • N/V • ↓ aqueous humor production
• Headache • Gonioscopy = gold standard ▪ Apraclonidine = alpha agonist
Closed-
• Risk factors • ↓ aqueous humor production
Angle o Preexisting narrow angle or large lens
Glaucoma • Conjunctival erythema ▪ Pilocarpine = miotic/cholinergic = ↑ outflow
o Hyperopes = farsightedness • ↑ outflow of aqueous humor
• Cloudy, steamy, or hazy cornea
o Females o Systemic agents
OCULAR PAIN o Asian • Mid-dilated fixed pupil = 4-6 cm
▪ Acetazolamide = carbonic anhydrase inhibitor
(PERIPHERAL) • ↓ aqueous humor production
• Mydriasis = pupillary dilation closes angle (worsens)
o Dim light = dark room or movie theater ▪ Mannitol = osmotic diuretic
UNILATERAL o Sympathomimetic • ↓ intraocular pressure
o Anticholinergics o Iridotomy = definitive treatment (last resort)
▪ Laser (preferred) or surgical

• Complications = blindness (damaged optic nerve)

• ↓ aqueous drainage via trabeculum • Mostly asymptomatic! • Fundoscopy = cupping of optic disc, ↑ cup to disc • Treatment = meds & surgery
Open-Angle o Eventually damages optic nerve ratio & notching of disc rim o Meds
Glaucoma • PAINLESS bilateral peripheral vision loss ▪ Latanoprost = prostaglandin analog (1st line)
• Risk factors ▪ Timolol = BB
PAINLESS o African American ▪ Brimonidine = alpha agonist
o >40 years old ▪ Acetazolamide = carbonic anhydrase inhibitor
o FHx • ↓ aqueous production
(PERIPHERAL)
o DM o Laser therapy = trabeculoplasty
BILATERAL ▪ If medical treatment fails
o Surgery = definitive treatment (last resort)
 • Optic nerve (disc) swelling from ↑ ICP • Headache • Fundoscopy = swollen optic disc & blurred margin • Treatment = meds & treat underlying condition
• N/V o Acetazolamide = ↓ CSF production
• Etiologies • +/– vision changes • MRI or CT = rule out mass
o Idiopathic intracranial HTN
o Space occupying lesion = tumor or abscess • LP = evaluate for ↑ ICP
o ↑ CSF production
o Cerebral edema
Papilledema o Severe HTN

• Inflammatory demyelination of optic nerve • OCULAR PAIN → painful EOM • Fundoscopy = normal or blurred disc/cup • Treatment = steroids
• PAINFUL loss of vision o Steroids = IV methylprednisolone → PO steroids
• Etiologies
o Multiple sclerosis • ↓ color vision = red vision loss
o Autoimmune = SLE
Optic
o Infection = Lyme’s disease, HSV, syphilis • Visual field defects = central scotoma
Neuritis o B12 deficiency o Blind spot
o DM
OCULAR PAIN o Meds = ethambutol (TB tx), PDE5 inhibitors, & • Marcus-Gunn pupil = pupillary dilation with
chloramphenicol flashlight test in affected pupil
(MONOCULAR)

• Misalignment of one or both eyes • Asymmetric corneal light reflex • Cover-uncover test • Treatment = eye patch, eye exercise, eyeglasses or surgery
o Stable alignment not present until 2-3 months o Patch therapy = 1st line → causes you to use bad eye
▪ Maybe up to 4-6 months o Surgery (severe) = release or tighten EOM

• Binocular fixation is NOT present • Complication = amblyopia (lazy eye) if treated >2 y/o

• Infants have temporary eye deviations → cross eyed

Strabismus
• Esotropia = deviation nasally (inward)
• Exotropia = deviation temporally (outward)
• Hypertropia = deviation upward (vertical)
• Hypotropia = deviation downward

• Pseudo esotropia = epicanthal folds

• Near-light dissociation • Bilateral small pupils → do NOT react to light

Argyll- • Etiologies • Pupil constricts on accommodation, NOT light!!

Robertson o Neurosyphilis
Pupil o Midbrain lesions
o DM neuropathy

• Transient monocular vision loss → complete recovery • Vision loss = “curtain or shade” • Clinical diagnosis

• Etiologies • Resolution = within 1 hour • Carotid US = if due to TIA

o Retinal emboli o TIA = 1-15 minutes
Amaurosis o TIA o Migraine = 10-30 minutes • Ophthalmologic exam = due to eye problem
o Giant cell arteritis
Fugax
o Central retinal artery occlusion
o Migraine
o SLE
 • Inflammation of external ear canal • Otalgia = ear pain • Clinical diagnosis • Treatment = supportive & meds
• Pruritus o Mild = antiseptics (isopropyl alcohol & acetic acid)
• Risk factors • Discharge • Otoscopy = edema, erythema DC & debris ▪ Drying agent to prevent moisture
o Water = swimmers ear • Pressure or fullness o Moderate / severe = ABX (cover staph & PSA)
▪ Moisture ↑ pH = prone to infections ▪ Fluoroquinolones = oflaxacin & ciprofloxacin
o Trauma (mechanical) = Q-tip ▪ Polymyxin B & neomycin (Cortisporin)
• Pain on traction of tragus
o Ear wax ▪ Tobramycin & gentamicin = NOT if perforated
• Aminoglycosides are ototoxic
• Etiologies o Steroids (topical) = ↓ inflammation so ABX can work
Otitis
o Pseudomonas ▪ Hydrocortisone
Externa
o Staph aureus
o Staph epidermis • No improvement → maybe too much swelling
o GABHS o Insert wick w/ ABX drops into ear canal
o Proteus
o Anaerobes • NO water 3 days then ear plugs OR NO water 7 days
o Fungi
• Complications = necrotizing otitis externa
o Diabetes & immunocompromised → hospitalize them!
o Caused by aspergillus
• Infection of middle ear, temporal bone & mastoid • Fever • Clinical diagnosis • Treatment = supportive vs. ABX
o Preceded by viral URI → causing blocked ET • Otalgia = ear pain o Supportive = >2 years with mild sx (watch & wait)
• Bulging & erythema • Pneumatic otoscopy = ↓ TM mobility ▪ Tylenol or NSAIDs
• Risk factors • Middle ear effusion ▪ Decongestants
o 6-18 months old (ET short, narrow & horizontal) • Tympanocentesis = culture if recurrent cases o ABX = <6 months → likely 6 months to 2 years
• Conductive hearing loss ▪ Amoxicillin = 1st line
o Day care
o Pacifier or bottle use • Minor PCN allergy (rash) → cephalosporin
• Nasal congestion
o 2nd hand smoke • Severe PCN allergy (anaphylaxis) →
o Not breastfed • Conjunctivitis azithromycin or clindamycin
▪ Augmentin = 2nd line
• Etiologies o Tympanostomy tubes = severe or recurrent
o Strep pneumonia = MC o Myringotomy = severe or recurrent
o H. influenza
Acute Otitis
o Moraxella catarrhalis • Tympanostomy tubes = topical therapy (quinolones)
o GABHS
Media
• Indications of ABX
o Ill appearing
o Suspect another bacterial illness
o Recurrent AOM (within 2 to 4 weeks)
o Immunocompromised
o Uncertain access to care (ED)
o Craniofacial anomalies

• Treatment failure = no improvement in 48-72 hours

o Amoxicillin → Augmentin (>15 days)
o Augmentin → cephalosporins (<15 days)

• Complications = mastoiditis or cholesteatoma

• Middle ear fluid + no s/s of acute inflammation • NO fever, pain, erythema or bulging TM • Clinical diagnosis • Treatment = supportive or drainage
o Supportive = observation for spontaneous resolution
• Etiologies = s/p resolution of AOM or ET dysfunction • Otoscopy = effusion with refracted or flat TM o Tympanostomy tube = persistent or complicated
Serous
▪ Hearing impairment
Otitis Media
• Pneumatic otoscopy = hypomobility ▪ Developmental delays
▪ Specific conditions

• Persistent middle ear infection + TM perforation • Perforated TM & persistent/recurrent otorrhea • Clinical diagnosis • Treatment = supportive, meds, & surgery
• Conductive hearing loss o Supportive = avoid water, moisture & topical
• Complication of AOM, trauma or cholesteatoma • CT scan = suspecting extracranial manifestations aminoglycosides if TM rupture
o ABX (topical) = oflaxacin or ciprofloxacin
Chronic • Etiologies o Surgery = TM repair or reconstruction
Otitis Media o Pseudomonas
o Staph aureus
o Proteus
o Anaerobes
o Mycoplasma
 • Infection of mastoid air cells → temporal bone • Otalgia = ear pain • CT scan = 1st line imaging • Treatment = meds, ear drainage, & surgery
• Fever o ABX (IV) = Vancomycin + Zosyn
• Risk factor = AOM • Otitis media = budging & erythema o Myringotomy = middle ear or mastoid drainage
• Mastoid tenderness, edema & erythema o Mastoidectomy = refractory to meds or complicated
Mastoiditis • Etiologies
o Strep pneumonia = MC • Protrusion of auricle
o H. influenza
o Moraxella catarrhalis
o GABHS
• Eustachian tube (ET) swelling • Ear fullness or pressure • Clinical diagnosis • Treatment = autoinsufflation, steroids or decongestants
o Inhibits ET ability to autoinsufflate • Popping of ears o Autoinsufflation = yawning, swallowing, etc.
o (–) pressure • Underwater feeling • Otoscopy = +/– fluid behind TM o NSAIDs = pain
• Disequilibrium o Steroids (spray) = sinusoidal inflammation present
• Eustachian tube connects middle ear to nasopharynx o Decongestants = congestive symptoms
• Conductive hearing loss
Eustachian ▪ Pseudoephedrine
• Tinnitus
Tube • All children <7 have some degree of ET dysfunction ▪ Phenylephrine
Dysfunction ▪ Afrin
• Etiologies o Surgery = medical management fails
o Viral URI
o Allergic rhinitis • Complications = AOM
o Sinusitis
o Tumor
• External auditory canal wax impaction • Ear fullness • Otoscopy = impacted cerumen • Treatment = cerumen softening & aural toilet
• Conductive hearing loss o Cerumen softening = hydrogen peroxide
Cerumen
• Weber test = lateralization to AFFECTED ear o Aural toilet = irrigation, curette removal, or suction
Impaction ▪ Use body temperature water to avoid vertigo
• Rinne test = bone conduction > air conduction
• Rupture of tympanic membrane • Otalgia = ear pain • Otoscopy = perforated TM • Treatment = supportive or ABX
• Hearing loss o Supportive = avoid water, moisture & topical
Tympanic • Etiologies • Tinnitus • Weber test = lateralization to AFFECTED ear aminoglycosides
Membrane o Trauma = penetrating or noise • Vertigo o ABX (topical) = oflaxacin or ciprofloxacin
Perforation o AOM • Rinne test = bone conduction > air conduction
• Sudden pain relief with bloody otorrhea • Complications = cholesteatoma

• Abnormal keratinized collection of epithelium • PAINLESS otorrhea = yellow/brown & foul • Otoscopy = granulation tissue • Treatment = surgery
o Desquamated squamous epithelium smelling o Surgery = surgical excision of debris & cholesteatoma
o Located in middle ear • Weber test = lateralization to AFFECTED ear
Chole- • Conductive hearing loss
steatoma • Etiologies • Vertigo = peripheral • Rinne test = bone conduction > air conduction
o Chronic middle ear disease • Tinnitus
o ET dysfunction • Dizziness
• Cranial nerve palsies
• Peripheral vertigo 2o to displaced otolith particles • Peripheral vertigo = EPISODIC • Dix Hallpike test = (+) if vertigo and nystagmus • Treatment = canalith repositioning
o Otolith particles = calcium crystals o Lasting seconds to minutes = <60 seconds o With patient sitting, turn head 45o to one side o Epley maneuver = multiple head movements
Benign o Within semicircular canals of inner ear o Lie patient down with head overhanging edge
Paroxysmal • Head movements provoke & worsen of bed and look for nystagmus
Positional • MC cause of peripheral vertigo o Rolling over in bed o Repeat on contralateral side
Vertigo o Lying down
o Getting up from bed
o Looking up
• Distension of endolymphatic compartment • Peripheral vertigo = EPISODIC • Diagnosis of exclusion • Treatment = diet, meds, & surgery
o Idiopathic o Lasting minutes to hours = >20 minutes o Supportive = limit salt, caffeine, nicotine, chocolate,
o Due to excess fluid • Hearing loss = sensorineural (UNILATERAL) • Weber test = lateralization to NORMAL ear & EtOH → all ↑ endolymphatic pressure
• Tinnitus o Meds = suppress vestibular system
• Meniere SYNDROME = identifiable cause • Rinne test = air conduction > bone conduction ▪ Zofran & Reglan = antiemetic (1st line)
Meniere’s • Meniere DISEASE = idiopathic • Ear fullness ▪ Meclizine = antihistamine
Disease • Nystagmus = horizontal ▪ Diazepam = benzodiazepine
• N/V o Other
▪ Scopolamine = anticholinergics
▪ Betahistine = vasodilator
▪ HCTZ-triamterene = diuretic
o Surgery = surgical decompression or labyrinthectomy
 • Inflamed vestibular portion of CN VIII • Peripheral vertigo = CONTINUOUS • Clinical diagnosis • Treatment = steroids & meds
o Steroids = 1st line
Vestibular • Etiologies • Nystagmus = horizontal • MRI = rule out alternative causes o Meds = suppress vestibular system
Neuritis o Idiopathic • Gait instability ▪ Zofran & Reglan = antiemetic (1st line)
o Viral or post-viral inflammation • N/V ▪ Meclizine = antihistamine
▪ Diazepam = benzodiazepine
• Inflamed vestibular & cochlear portion of CN VIII • Peripheral vertigo = CONTINUOUS
• Hearing loss = sensorineural (UNILATERAL)
• Etiologies • Tinnitus
o Idiopathic
Labyrinthitis o Viral or post-viral inflammation • Vestibular neuritis + unilateral hearing loss

• Nystagmus = horizontal
• Gait instability
• N/V
• Benign tumor of Schwann cells • Peripheral vertigo = CONTINUOUS • MRI = imaging of choice • Treatment = surgery & radiation
o Schwann cells = produce myelin sheath • Hearing loss = sensorineural (UNILATERAL)
Acoustic o Arises in cerebellopontine angle • Tinnitus • Audiometry = unilateral sensorineural hearing
CN VII o Can compress structures = CN VIII, VII, & V loss; poor speech discrimination
Neuroma • Vertigo
• HA
Vestibular
Schwannoma • Ataxia = CN VIII involvement
• Facial numbness = CN V involvement
• Facial paresis = CN VII involvement
 OBSTETRICS & GYNECOLOGY
Etiology Presentation & PE Diagnosis Treatment & Complications
• MC cancer in women • Painless, hard, fixed, immobile lump • Triple test • Treatment = based on TMN staging
o Might be mobile or painful early on o Physical exam
• 2nd MC cause of cancer death in women • Unilateral DC = bloody o Mammography • Early = lumpectomy w/ sentinel node biopsy + radiation
o 1st = lung cancer o Needle biopsy
• MC = upper outer quadrant • ER & PR (+) = respond to endocrine therapy
• 1 out of 8 women will have breast cancer • Mammography = initial test
• Asymmetric erythema o Microcalcifications & spiculated • Anti-estrogen HT (SERM) = tamoxifen
• Risk factors • Discoloration o Estrogen ® positive tumors
o BRCA 1 & BRCA 2 = breast & ovarian cancer • Ulceration • US = initial test (<30 years old) o Premenopausal = most useful
▪ BRCA1 = breast CA > ovarian CA o Malignancy = irregular borders, heterogenous o S/E = hot flashes, VTE & endometrial CA
• Skin retraction = dimpling Cooper’s ligament
▪ BRCA2 = male breast cancer echogenicity (hypoechoic), thick echogenic • Aromatase inhibitor HT = letrozole & anastrozole
• Breast size & contour changes capsule, & calcifications
o 1st degree relative with breast cancer o Stop production of estrogen
• Nipple inversion o Postmenopausal = most useful
o Older age = >60 years old
o ↑ menstrual cycles • Skin thickening • MRI = cancer shows enhancement with contrast o S/E = osteoporosis → need DEXA scan
▪ Nulliparity o Gadolinium-contrast dye • Anti-HER2/neu HT = trastuzumab
▪ Late first term pregnant (>35 years old) • Axillary LAD = locally advanced o HER2 ® positive tumors
▪ Early onset menarche (<12 years old) • FNA biopsy = removes least amount of tissue; if o Monoclonal antibody
• Metastatic = bone, lungs, liver or brain (MC) (+) doesn’t allow for ® testing o S/E = cardiotoxicity
▪ Late menopause
▪ Never breastfed
o ↑ estrogen • Paget disease = eczematous itchy rash on areola • Core biopsy (large needle) = leaves deformity & • Adjuvant chemo = treat any residual disease
o Lump often present causes bruising & pain; if (+) allows for ® testing
▪ Postmenopausal HRT
▪ Obesity • Surgery = one day
• Inflammatory = red, swollen, warm, itchy breast • Open biopsy (surgical) = most accurate test; • Radiation = 5 weeks → usually daily
▪ EtOH o Nipple retraction causes bruising & pain; if (+) allows for ® testing
▪ Physical inactivity • Chemotherapy = 5 months
o Peau d’orange = skin changes like orange
▪ Endometrial cancer • Hormonal therapy = 5 years
▪ Lymphatic obstruction • Biopsy results = ER, PR, & Her2 (+/–)
o History of radiation therapy = lymphoma o Poor prognosis o ER = estrogen ®
o Lump often absent o HER2 = human epidermal GF ® 2 • Traditional
• Types o Surgery (one day) = 3-4 weeks for wound healing
o PR = progesterone ®
Breast o Infiltrative ductal carcinoma = MC **** o Triple negative is the worst! o Chemotherapy (5 months)
Cancer o Infiltrative lobular carcinoma ▪ Wait a few weeks after surgery to start chemo
o Paget disease = related to ductal carcinoma o Radiation (5 weeks daily) = 7-8 months total
• Breast imaging-reporting & data (BIRAD)
o Hormonal therapy = 5+ years
o 0 = incomplete
• Premalignant o 1 = negative
o Lobular carcinoma in situ (LCIS) o 2 = benign finding • Neoadjuvant chemotherapy = chemo before surgery (try to
o Ductal carcinoma in situ (DCIS) o 3 = probably benign shrink large tumors or lymph nodes)
o Atypical ductal hyperplasia o 4 = suspicious abnormality o Chemo → surgery → radiation → hormonal therapy
o 5 = highly suggestive of malignancy
• In situ = noninvasive cancer cells in duct or lobe o 6 = known biopsy proven malignancy • Screening = benefits vs. harm
o If unchecked, can become more invasive o Benefit = ↓ breast CA morbidity & mortality
• BIRADS 3 = aspirate or observe for 1-2 years o Harm = radiation exposure, pain from mammogram,
• Increased risk anxiety, false (–) or false (+)
o LCIS • BIRADS 4 & 5 = biopsy
o DCIS • Screening = CBE & mammogram
o Atypical ductal hyperplasia o CBE
o Papilloma ▪ 1-3 years = 21-39 years old
o Sclerosing adenosis ▪ Every year = >40 years old
▪ Every 6 months = high risk
• No increased risk o Mammogram = start at 40-50 years old
o Adenosis ▪ Annually or biannually = >40 years old
o Fibroadenoma ▪ 10 years prior to youngest onset of breast CA
o Duct ectasia • 1st degree relative
o Mild hyperplasia
▪ Every year starting @ 25-30 years = high risk
o MRI = >20% lifetime breast cancer risk
▪ Including BRAC1 & BRAC2

• BRAC1/2 testing = test patient

o If (+), offer testing to the family
 • Benign solid tumor • Non-tender • Clinical breast exam • Treatment = followed clinically or surgery
o Glandular & fibrous tissue • Rubbery o Follow clinically = young (<30), no proliferative
• Firm • US = best initial test <30 years old damage & no FHX
• 2nd MC breast mass • Round o Well-circumscribed ▪ Reassurance & follow-up
• Mobile o Flattened oval shape ▪ Can repeat US in 3-6 months
• MC = 15-35 years old • Well-circumscribed
o Hypoechoic (gray) → solid NOT liquid o Removal = large, growing, or changing in shape
▪ Homogeneous echogenicity ▪ Excision
• Unilateral o Thin echogenic pseudo-capsule
• Hormonal cause = estrogen ▪ Cryoablation = alternative to surgery
Fibroadenoma o ↑ in size w/ pregnancy & estrogen therapy o May have benign calcification • Extreme cold to destroy tissue
• Changes with menstruation, pregnancy & OCPs o Posterior acoustic enhancement
o Regress after menopause

• Risk of breast CA ↑ = fibroadenoma is complex, • Mammogram = best initial test >30 years old
adjacent proliferative disease or FHx of breast CA
• FNA = definitive diagnosis
o Fibrous tissues & “swirled” collagen

• Fluid-filled breast cysts • Painful or painless = usually tender or painful • Clinical breast exam • Treatment = supportive, meds, & FNA or excision
• Nodular / lumpy / rope-like o Supportive = hot/cold compress, supportive/tight
• 1st MC breast mass • Smooth • US = best initial test <30 years old bra, NSAIDs, ↓ caffeine, tea, smoking & chocolate
• Round o Well-circumscribed & well-defined margins o Meds = OCPs, Danazol, primrose, vitamin E & B6
• Exaggerated hormonal response • Mobile o Fibroglandular tissue with cyst ▪ Danazol = antiestrogen & androgenic
Fibrocystic o ↑ in size during premenstrual part of cycle o Anechoic (black) o Removal = large, growing or changing in shape
• Bilateral = usually bilateral but can be unilateral Acoustic enhancement = increased white
Disease o
• Dark brown or green discharge
• MC = 30-50 years old
• Mammogram = best initial test >30 years old
• Changes w/ menstruation = grows & ↑ pain
• Simple vs. complicated
o Complicated = low echoes w/ vascular flow • FNA = definitive diagnosis

• 3rd MC gynecologic cancer • Irregular or heavy bleeding • Colposcopy with biopsy = definitive diagnosis • Treatment = depends on stage
• Postcoital bleeding o Lesions turn white with acetic acid o Stage 0 (in situ) = excision (preferred) or ablation
• Types • Vaginal discharge ▪ Acetowhite change o Stage IA1 = total hysterectomy
o Squamous cell carcinoma = MC (70%) o Stage IA2, IB, IIA = radiation with brachytherapy &
▪ Squamocolumnar junction • Pelvic/low back pain = late/advanced disease • HPV has a role in triaging ASC-US → not others teletherapy
o Adenocarcinoma (25%) • Bowel or urinary sx = late/advanced disease ▪ OR hysterectomy with lymphadenectomy
o Other o Advanced = radiation + chemo
▪ Adenosquamous, neuroendocrine/small cell, • Cervical discharge or ulceration if invasive
rhabdomyosarcoma, lymphoma, sarcoma,
clear cell carcinoma

• Risk Factors
o HPV = MC risk factor (especially 16 & 18)
o Early onset of sexual activity
o Multiple & high-risk sexual partners
o Smoking
Cervical o History of STD
Carcinoma o History of VIN or VaIN
o Immunosuppression (HIV)
o Early age at first birth or multiparity
o Low socioeconomic status

• Direct extension = uterus, vagina, parametria,

peritoneal cavity, bladder or rectum

• Hematogenous = lungs, liver, bone, bowel, adrenal

glands, spleen and brain
 • Abnormal bleeding in nonpregnant women • Abnormal bleeding • hCG = rule out pregnancy • Treatment = meds or surgery
o Oligomenorrhea = cycle length >35 days • CBC = anemia (H&H) or low PLTs o OCPs = 1st line → estrogen-progestin
• Diagnosis of exclusion o Polymenorrhea = cycle length <21 days • FSH/LH = check with perimenopausal women ▪ Progesterone only if estrogen contradicted
o Hypomenorrhea = scanty menstruation • Estrogen & androgen levels o Hysterectomy = definitive treatment
• PALM-COEIN o Amenorrhea = absent menses >6 months o Endometrial ablation = doesn’t want hysterectomy
o Menorrhagia = excess flow/duration • TSH
Abnormal o Polyp • Prolactin
▪ Most likely eliminates ability to have a baby
(Dysfunctional) o Adenomyosis ▪ Regular cycles
o Leiomyoma o Menorrhagia = irregular cycles • PT/PTT & Von Willebrand factor = coag disorder
Uterine o Menometrorhagia = excess flow/duration
o Malignancy/Hyperplasia
Bleeding ▪ Irregular cycles • Speculum exam = cervix vs. uterine bleeding
o Coagulopathy
o Ovulatory Dysfunction (PCOS) • Pap smear & cultures
o Endometrial • Normal physical exam • Endometrial biopsy = >45 years old & younger
o Iatrogenic patients at providers discretion
o Not Yet Classified
• Transvaginal US = 1st line imaging
• Painful menstruation • Crampy lower abdominal or pelvic pain • hCG = rule out pregnancy • Treatment = supportive & meds
o 1-2 days before or at onset of menses o May radiate to lower back or thighs o Supportive = diet & exercise, heat, & vitamin B + E
• HA • Speculum exam = rule out infection! o NSAIDs = start prior to pain onset
• Primary = ↑ prostaglandins • Fatigue o OCPs = 1st line → estrogen-progestin
o Prostaglandins ↑ uterine contractions • N/V • Transvaginal US = 1st line imaging ▪ Progesterone only if estrogen contradicted
o Begins when menses begins
o May improve after childbirth • Laparoscopy = definitive diagnosis (rule out 2o)
o Risk factors
▪ <30 years old
▪ BMI <20
Dysmenorrhea ▪ Smoking
▪ Menarche <12 years old
▪ Longer menstrual cycles
▪ Heavy flow
▪ History of sexual assault

• Secondary = pelvis or uterine pathology

o Endometriosis
o Adenomyosis
o Leiomyoma = uterine fibroids
o PID
• Cessation of menses for >1 year
• Onset = 50-52 years old
o Premature if <40 years old
• Smoking = risk factor for early menopause
• Marked decline in oocyte number due to atresia
Menopause • Can still get hot flashes with hysterectomy!
• Perimenopause = begins ~47 years old
o Longer menstrual interval = 40-50 days
o Progress to missed cycles, amenorrhea and
anovulatory cycles → mostly cycle irregularity
▪ Lasts for 1-3 years
o Can’t check FSH because vary hour to hour!!!
• Descent of bladder
Cystocele
• Anterior compartment collapse
• Descent of rectum
Rectocele
• Posterior compartment collapse
• Hot flashes = vasomotor instability
o Sudden heat sensation in chest & face
o Lasts for 2-4 minutes
o Sometimes palpitations
• Sleep disturbances
• Mood changes
• Skin, hair & nail changes = dry & thin
• Vaginal atrophy
• Sexual dysfunction = low or no libido
• Poor concentration = low estrogen?
• Osteoporosis
o MC 1 year before & 2 years after
• Urethral hypermobility
• Urinary incontinence
• Constipation
• Difficulty evacuating stool
• ↑ FSH = most sensitive • Treatment = behavioral & meds
• ↑ LH o ↓ room temperature, fans, & dress in layers
• ↓ estrogen (estradiol) o Avoid triggers = spice, stress, caffeine, etc.
o HRT = 1st line → within 10 years of menopause or <60
• ↑ estrone ▪ Estrogen only = NO UTERUS (hysterectomy)
• Unchanged testosterone ▪ Estrogen & progestin = UTERUS
• Progestin prevents endometrial hyperplasia
• ↓ AMH (antimullerian hormone) ▪ LOWEST dose for SHORTEST time (5 years)
• NOT LIFELONG TREATMENT
• Bone Mineral Density Testing = osteoporosis test • Risk of breast cancer if used >5 years
▪ Contradictions = breast CA, CVD, VTE or CVA
▪ If hot flashes are absent, HRT is NOT indicated
o SSRIs (Lexapro) & SNRI (Cymbalta) = 2nd line
o Gabapentin = good for night sweats
o Clonidine = last resort
o OCPs = good for perimenopause & for birth control
• Complications = osteoporosis, HLD, ↑ CVD risk
o Due to ↓ estrogen
• Surgery = anterior colporrhaphy
• Surgery = posterior colporrhaphy
 • Types • Bulging mass • View vagina with cough, strain or valsalva • Treatment = conservative, pessaries & surgery
o Cystocele = anterior defects • Heaviness or pressure sensation o Conservative
o Rectocele = posterior defects • Urinary retention • Pelvic exam = single blade speculum exam ▪ Pelvic floor exercises = Kegel exercises
o Enterocoele = central defects • Urinary incontinence o Downward retraction = cystocele ▪ Estrogen cream = Premarin
o Vaginal prolapse = lateral & central defects o Stress urinary incontinence (SUI) o Upward retraction = recto or enterocele o Pelvic floor PT with biofeedback
o Uterine prolapse = central defects ▪ Used in conjunction with Kegel exercises
o Uterine procidentia
• Enuresis = nighttime bed wetting
• Constipation • Rectal exam = rule out rectocele exam o Pessaries = hammock to support pelvic structures
• Fecal urgency/incontinence
▪ Different pessaries for different types of defects
• Risk factors • Baden-Walker system = POP staging o Surgery = reconstructive, hysterectomy, etc.
o Parity = being pregnant increases risk • Sexual dysfunction or pain o 0 = normal position ▪ Symptomatic women
o Advancing age o Dyspareunia o 1 = descent halfway to hymen ▪ Decline/fail conservative therapy
o Obesity = more pressure on compartments o Incontinence with intercourse o 2 = descent to hymen ▪ Finished childbearing
o Hysterectomy = lose supports of attachment o 3 = descent halfway past hymen
Pelvic o Chronic constipation • Worse with prolonged standing ▪ Young age = ↑ risk of prolapse recurrence
o 4 = maximum possible descent
Organ o Chronic cough • Relieved by lying down ▪ Elderly
Prolapse o Menopause = ↓ estrogen & atrophy ▪ Obesity → treatment would be weight loss!
• Sacral nerve integrity/Bulbocavernosus reflex =
• DeLancey Levels of Vaginal Support tap & squeeze the clitoris for erection • Treatment is only indicated for symptomatic prolapse
o Level 1 = cardinal & uterosacral ligaments • Anocutaneous reflex (anal wink) = stroke skin on
▪ Suspends vaginal apex either side of anus to see contraction
▪ Apical prolapse (uterine prolapse)
o Level 2 = paravaginal attachments (endopelvic, • Test pelvic muscle strength by squeezing fingers
arcus tendinous & levator ani muscle fascia) o Normal = can voluntarily contract and relax
▪ Lateral attachments of mid-vagina o Overactive = can’t relax (can’t get in vagina)
▪ Cystocele & rectocele o Underactive = cannot voluntarily contract
o Level 3 = perineal body o Non-function = no pelvic floor muscle action
▪ Distal support
▪ Rectocele, perineocele urethrocele
• Trichomonas vaginalis • DISCHARGE = “frothy” green/yellow • Wet mount = mobile trichomonads • Treatment = ABX & partner DOES need treated
o Flagellated protozoan o Worse after/during menses & sex o Slightly larger than WBCs o Metronidazole = 2 g PO x 1 dose
Tricho-
▪ OR 500 mg PO BID x 7 days
moniasis • Purulent & malodorous vaginal discharge • Vaginal pH = >4.5 (5-6) o Tinidazole (Tindamax) = more expensive option
• Burning & pruritus
Cervicitis • Dysuria & urinary frequency • Culture = definitive diagnosis • Complications = PID
Vaginitis • Lower abdominal pain
• Dyspareunia • NAAT = option if microscopy not available
STD • Postcoital bleeding
• Strawberry cervix = cervical petechia
• Gardnerella vaginalis → gram variable • DISCHARGE = grayish-white • Criteria = ¾ Amsel Criteria • Treatment = ABX & partner DOES NOT need treated
o Worse after/during menses & sex o Thin, white, homogenous discharge o Metronidazole = 500mg PO BID x 7 days
• Decreased lactobacillus acidophilus o Wet prep = clue cells on microscopy ▪ OR 0.75% gel 5 grams once daily x 5 days
o Maintains vaginal pH • Malodorous vaginal discharge = fishy odor ▪ Epithelial cell borders “stippled” by o Clindamycin = 2% cream qhs x 7 days
o Worse with sex or menses bacterial coverage • OR 300mg PO BID x 7 days
Bacterial • Overgrowth of polymicrobial anaerobes • Pruritis & burning o pH vaginal fluid >4.5 o Tinidazole (Tindamax) = more expensive option
Vaginosis o Change in normal vaginal flora • Dyspareunia o Whiff amine test = fishy odor w/ KOH
o Microbial imbalance ▪ Add KOH to saline wet prep • PO flagyl or clindamycin = 1st line in pregnancy
Vaginitis
• Risk factors • Gram stain = gold standard • Complications = premature ROM, chorioamnionitis, PID &
o Douching or poor hygiene preterm labor
o Smoking = tobacco use
o Multiple sexual partners
o Women who have sex with women
• Candida albicans = part of GI & GU flora • DISCHARGE = thick, white, & “cottage cheese” • Clinical diagnosis • Treatment = topical or oral -azoles
o Worse before menses o Fluconazole = 150 mg PO x 1 dose → 1st line
• MC opportunistic pathogen • KOH = budding yeast & pseudohyphae ▪ Complicated = 2-3 doses (72 hours apart)
• Pruritis & burning ▪ DO NOT use in 3rd trimester pregnancy
Candidiasis • Risk factors • Dyspareunia • Vaginal pH = <4.5 o Miconazole = vaginal suppository
o DM • Vulvar erythema o Terconazole = vaginal suppository
o HIV • Gram stain = Swartz-Lamkins fungal stain o Clotrimazole = vaginal suppository
Vaginitis o Pregnant
o Recent ABX use • Culture = recurrent or refractory to tx • Vaginal suppositories are preferred in pregnancy
o Sabouraud agar or Nickerson medium

• Culture identifies non-albicans species

 • Infection of upper reproductive tract • Pelvic / lower abdominal pain • NAAT = C. trachomatis & N. gonorrhea • Treatment = antibiotics (outpatient vs. inpatient)
• Dysuria o Vaginal swabs = women
• MC = C. trachomatis & N. gonorrhea • Mucopurulent vaginal discharge o Urine testing = men • Outpatient
o Other = anaerobes, enteric gram (–) rods and • Abnormal bleeding o Ceftriaxone = 250 mg IM
cytomegalovirus • N/V • Gram stain = positive (N. gonorrhea) PLUS
o Doxycycline = 100 mg BID x 14 days
• Fever >101° F (>38.3°C) = LC
• PID = endometritis, salpingitis, TOA, pelvic peritonitis • Wet prep = ↑ WBC microscopy (>10,000) +/–
o Any combination of the above! • Cervical motion tenderness = chandelier sign o Metronidazole = 500 mg PO BID X 14 days
• Adnexal tenderness • US = rule out tubo-ovarian abscess (TOA) ▪ Coinfection of BV or trichomonas
• Risk factors ▪ For anaerobes if GYN instrument in 2-3 weeks
o Unprotected sex • ↑ ESR & CRP
o Multiple partners • Inpatient or TOA
o Prior PID • hCG = rule out pregnancy o 2nd generation IV cephalosporin = IV
o IUD = breaks endocervical barrier ▪ Cefoxitin = 2 g IV q 6 hours
o 15-19 years old • Laparoscopy = definitive diagnosis OR
o Nulliparous ▪ Cefotetan = 2 g IV q 12 hours
• RULE OUT = HIV & hepatitis PLUS
• OCPs ↓ risk from progestin thickening cervix & o Doxycycline = 1oo mg PO or IV q 12 hours
Pelvic thinning endometrium
Inflammatory • Cephalosporin allergy = IV clindamycin & gentamicin
Disease
• Complications = ectopic pregnancy, infertility, tubo-
(PID) ovarian abscess (TOA), chronic pelvic pain

• Admission = TOA, vomiting & can’t maintain PO ABX,

septic, pregnant, refractory to outpatient treatment

• GPA Classification
o Gravida = # of pregnancies
o T = term births (>37 weeks)
o P = preterm births
o A = abortions
o L = living children
• Estimated Date of Delivery = Naegele’s Rule
o Only applies if the woman has a 28-day cycle
o 1st day LMP – 3 months + 7 days + 1 year
Prenatal o Most patients get US for accurate dating
Diagnosis ▪ Testing is driven by due date!
• Nulligravida = not currently pregnant & never before
• Primigravida = currently pregnant & never before
• Multigravida = currently pregnant & been pregnant
• Uterine size • Serum β-hCG = detects 5 days after conception
o Small orange = 6 weeks
o Large orange = 8 weeks • Urine β-hCG = detects 14 days after conception
o Grapefruit = 12 weeks
• ↑ serum progesterone (>10)
• Cervical dilation, length, consistency
• Pelvic architecture • hCG needs to be ~1000-2000 to see fetus on US
• US = detects fetus on US ~5-6 weeks
o Gestational sac = 4 weeks
o Yolk sac = 5 weeks (disappears ~12 weeks)
o Fetal pole/embryo = 6 weeks
o Crown-rump = 7-10 weeks
▪ Most accurate way for date of delivery
• Fetal heart tones = 10-12 weeks
o Normal HR = 120-160 bpm
 • Ideally start by 10 weeks estimated gestational age
(EGA)
• Weight gain
o BMI <18.5 (underweight) = 28-40 lbs
o BMI 18.5-24.9 (normal weight) = 25-35 lbs
o BMI 25.0-29.9 (overweight) = 15-25 lbs
o BMI >30.0 (obese) = 10-20 lbs
• 4 to 28 weeks = visit every 4 weeks
• 28 to 36 weeks = visit every 2 weeks
• 36 weeks to delivery = visit every week
• A lot of complications are related to hormones!
• Spontaneous abortions ↓ after 12 weeks
Prenatal • hCG = stimulates corpus luteum to continue to secrete
Care estrogen and progesterone until placenta takes over
• Yolk sac = nutrients until placenta forms
• Viable fetus is >24 weeks
• Pregnancy loss <20 weeks gestation
• MC = malformed uterus or abnormal chromosome
o 50% of fertilized oocytes do not result in live birth
• Threatened = POC intact & cervical os closed
• Inevitable = POC intact & cervical os DILATED
• Incomplete = POC expelled & cervical os DILATED
Spontaneous • Complete = all POC expelled & cervical os closed
• Missed = POC intact, cervical os closed & no FHR
Abortion
o NO BLEEDING → rest have bleeding!
• Septic = POC expelled, cervical os closed, cervical
Miscarriage
motion tenderness, foul brown DC with fever & chills
• Risk factors
1 Trimester
st
o Chromosomal abnormalities = MC
Bleeding o STIs
o Antiphospholipid syndrome
o Trauma
o Rh isoimmunization
o Malnutrition & celiac disease
o Anatomic abnormalities
o Previous spontaneous abortion
o Tobacco, EtOH & cocaine
o NSAIDs
o Maternal BMI <18.5 or >25
• Morning sickness = N/V
o Tx = see below
• Hyperemesis gravidum = severe N/V
o Tx = see below
• Back pain
o Tx = squatting, back pillow, PT, massage,
heating, Tylenol
• Hemorrhoids
o ↑ pelvic pressure → pain & swelling
o Tx = topical pain meds, warm soaks, stool
softeners
• Varicosities & edema
o ↑ femoral venous pressure
o Tx = leg elevation & TED socks
• Heart burn = VERY common
o LES pushed upward
o Tx = antacids, H2 blockers & PPIs
• Sleep & fatigue
o Poor sleep with ↑ gestational age
o Tx = daytime naps & Benadryl prn
• Round ligament pain
o 2nd & 3rd trimester from it stretching
o Tx = warm compress & Tylenol
• Carpal tunnel syndrome
o Swelling
o Tx = splint, Tylenol, reduce activity
• Crampy abdominal pain
• Vaginal bleeding
• Check cervical os = open or closed
EVERY visit = red
• Weight & BP
• CBC = anemia (Fe, thalassemia & sickle cell)
• Blood type & Rh status
• Antibodies = indicates isoimmunization
o Lewis = lives (IgM → don’t cross placenta)
o Duffy = dies
o Kell = kills
• HBsAg, HIV, syphilis, chlamydia & gonorrhea
• TB & lead = consider if risk factors present
• CF & spinal muscular atrophy = all patients
• Fragile X, Tay-Sachs disease & phenylketonuria
• Rubella & (?VAR) = titers to determine immunity
• Pap smear = if due for pap smear & >21 years old
• UA = check glucose & protein & send for culture
o GBS (+) = treat at time of culture & in labor
o Asymptomatic bacteriuria = treat
▪ Can become pyelonephritis & then ARDS
• Fundal height = 20 weeks EGA corresponds 20 cm
o 12 weeks = pubic symphysis
o 16 weeks = b/w pubis & umbilicus
o 20 weeks = umbilicus
o 28 weeks = b/w umbilicus & xiphoid process
• Fetal heart tones = 10-14 weeks (NL = 120-160)
• Symptoms = leakage, bleeding, contractions, N/V?
• US = absent FHR or POC
• CBC = rule out anemia or infection
• Blood type & Rh status
• hCG = repeat in 48 hours
o Normally doubles q 48-72 hours
• Progesterone = <5 → likely not viable pregnancy
o >20 is likely a viable pregnancy
• At follow up visit:
o Karyotyping = >3 consecutive losses
o hCG = until negative
o US (+/–) = confirm absent gestational sac
• Treatment = patient education!
o Prenatal vitamins, iron & folate
▪ ALL women take prenatal vitamins
▪ Folate = preconceptually & 1st trimester
• Patients on seizure meds need to extra to
prevent neural tube defects
▪ Iron = H&H <10&30
▪ DHA = 200mg daily or fish 2-3 times/week
• NO shark, swordfish, king mackerel or tilefish
due to high levels of mercury
o Influenza vaccine = all pregnant women
o TdaP = 3rd trimester for fetal pertussis immunity
o Diet = additional 100-300 calories/day
o EtOH, tobacco & substance abuse = discuss risks
o Seat belts & airbags = seatbelt under abdomen
▪ Airbags DO NOT get turned off
o Caffeine = <200 mg/day (200 mg = 12 oz)
o Airplanes = can fly up to 36 weeks (risk of DVT)
▪ Ambulate hourly & wear TED socks
o Exercise = do not limit
o Sex = not harmful (unless reason to avoid)
o AVOID
▪ Hot tubs & saunas during 1st trimester
▪ Uncooked & unpasteurized meat, dairy, eggs
▪ Vitamin A & vitamin E excess
▪ Raw sprouts = alfalfa, clover, & radish
• HBsAg = check LFTs & hepatitis serology
o Baby needs HBIG & hep B vaccine
• HIV = western blot or PCR
o Mom needs antiviral meds & C-section
• UA culture = ABX & recheck urine culture for (–)
o GBS = penicillin @ diagnosis & during labor
• Rubella & VAR = nonimmune → vaccine postpartum
o Stay away from sick individuals
• Antibodies = get titers to determine severity
• Treatment = expectant, medical. & surgical
o Rh (–) = give RhoGAM
o Expectant = US to confirm absence POC
▪ Waiting for it to happen on its own
o Medical = misoprostol & +/– mifepristone
▪ Misoprostol = uterine contractions
• Prostaglandin E1 analog
▪ Mifepristone = dilates & softens cervix
• Progesterone ® antagonist
▪ Misoprostol + mifepristone = preferred
o Surgical = hemorrhage, unstable or infection
▪ D&C = 4-12 weeks (1st trimester)
▪ D&E = 14-24 weeks (2nd trimester)
▪ Used for incomplete abortion
• Nothing per vagina x 2 weeks
• Wait until normal menses before conceiving again
o Helps if hCG is (–) before new conception occurs
• Complications = hemorrhage, uterine perforation, retained
POC, endometritis, & septic abortion
 • Partial or complete separation of placenta from uterus • PAINFUL vaginal bleeding = 3rd trimester • Clinical diagnosis • Treatment = delivery
o Bleeding not always present o C-section = best method of delivery
• Blood = concealed or external • Severe abdominal or pelvic pain • Transabdominal US = retroplacental clot o Vaginal delivery = fetal death & coagulopathy
o Uterine contractions o Fresh blood looks same as placenta! ▪ If baby is dead, safest for mom to do vaginal
• Risk factors • Uterine tenderness & rigidity o NOT reliable → can miss clot o RhoGAM = Rh (–) mom & Rh (+) baby
o HTN → chronic HTN & preeclampsia
o Prior abruption • Type & screen = Rh status & incase of transfusion • Complications = postpartum hemorrhage & DIC
Placenta o Smoking, EtOH & cocaine
Abruption o Folate deficiency • Monitor for a minimum of 4-6 hours after trauma
o Advanced maternal age (AMA) o Uterine tenderness
o Abdominal trauma o Abdominal ecchymosis
o Multiple gestations o Vaginal bleeding
2nd /3rd
o PPROM o Frequent contractions
Trimester o Chorioamnionitis
Bleeding o Fibroids = especially if large
o Placenta insufficiency = IUGR & oligohydramnios
o African American

• Placenta over or close to internal cervical os • PAINLESS vaginal bleeding = 3rd trimester • Transabdominal US = initial test • Treatment = watchful waiting, C-section, RhoGAM
o Complete = completely covering cervical os • NO abdominal or pelvic pain o Watchful waiting = pelvic rest & no sex
o Partial/low lying = partially covering cervical os • NO uterine tenderness • Transvaginal US = confirmatory test ▪ No intercourse/exercise after 20 weeks
o Marginal = <2 cm from cervical os ▪ Modified bedrest in 3rd trimester
• DO NOT do a digital vaginal or speculum exam! • Type & screen = Rh status & incase of transfusion ▪ Go to ER if contractions/vaginal bleeding
• Placenta should be >2 cm from internal cervical os o May cause separation & hemorrhage! o C-section = deliver between 36 & 36 6/7 EGA
• US = also diagnose accrete, increta, or percreta ▪ Nonreassuring fetal tracing
• 90% resolve spontaneously → serial US ▪ Life threatening maternal hemorrhage
Placenta • MRI = rule out accreta/increta/percreta ▪ Significant vaginal bleeding after 34 EGA
• Risk factors o Accreta (PA) = not invasive (endometrium) o Vaginal = low lying placentas can attempt labor
Previa o Previous placenta previa o Increta (PI) = invades myometrium o RhoGAM = Rh (–) mom & Rh (+) baby
o C-section o Percreta (PP) = through uterine wall
o Multiple gestations & multiparity ▪ Could go into neighboring organs! • Management after an acute bleed
2nd / 3rd o Advanced maternal age (AMA) o Inpatient = severe bleeding & needs delivery
Trimester o Previous uterine surgery o Outpatient = stable, reliable, & maintain bedrest
Bleeding o Smoking & cocaine use
o Previous abortion • Complications = preterm labor, PROM, IUGR,
o Infertility treatment = IVF malpresentation, placenta accreta, increta, or
percreta, & vasa previa
• Risk factors for PA, PI, PP = previous placenta previa
& C-section

• Fetal vessels over cervical os • PAINLESS vaginal bleeding • US = initial test • Treatment = delivery!!
• Fetal distress o C-section = immediate C-section
• Vulnerable for fetal exsanguination upon ROM • ROM (rupture of fetal membranes) • Doppler US = more definitive diagnosis
• Complications = fetal exsanguination
• Risk factors • FHR = variable decelerations o Rapid fetal demise after ROM
Vasa Previa o Bilobed & low-lying placenta
o Multiple gestations
o Infertility treatment = IVF
2nd / 3rd
Trimester
Bleeding
 • Estrogen & progesterone = inhibits GnRH, LH, FSH &
LH surge
• Estrogen = suppress FSH & prevent folliculogenesis
• Progesterone = inhibits ovulation, prevents
implantation, thickens cervical mucosa & thins
endometrium
• Oral contraceptives = suppress LH surge
o Prevent ovulation
Oral o Monophasic & multiphasic
Contraception ▪ Monophasic = most popular
o Start any time in cycle
(Estrogen & o 1st few months period will be irregular
Progesterone) o If >2 pills are missed, need back up for 7 days!
o Efficacy ↓ if taking meds that ↑ liver enzymes
▪ For example anticonvulsant drugs
▪ Antibiotics DO NOT decrease efficacy
• Cycle regularity
• Treatment of menorrhagia
• Treatment of dysmenorrhea
• Inducing amenorrhea as a lifestyle choice
• Treatment of PMS
• Treatment of menstrual migraines
• ↓ risk of endometrial, ovarian & colon CA
o Neutral for breast cancer
• Treatment of acne & hirsutism
• Improved bone mineral density
• Treatment of bleeding due to leiomyomas
• Treatment of pelvic pain due to endometriosis
• >35 years old & smoking = ↑ risk of MI • Gallstone formation → cholestasis
o Causes vessel damage & hypercoagulability • Fluid retention
• CVD or multiple risk factors for CVD • Hypercoagulability = DVT & PE
• Hypertension = severe (unless well managed) • ↑ triglycerides
• DVT or thrombogenic mutation (Factor V Leiden) • DM
• SLE • Mastalgia
• Migraine with aura = ↑ risk of CVA • Melasma (“mask of pregnancy”)
•
Breast cancer • Chloasma medicamentosum
• Liver disease = cirrhosis, fatty liver disease, etc.
• DM = estrogens may inhibit release of insulin

• Ethinyl estradiol (EE) → pharmacologic active form

o Primary estrogen used in most COCs
• Mestranol (converted to EE by liver) → prodrug
• Estradiol valerate (metabolized to estradiol &
valeric acid)
• Progesterone = inhibits ovulation, prevents • Treatment of abnormal uterine bleeding • Breast cancer • Weight gain
implantation, thickens cervical mucosa & thins • DVT or PE • ↑ triglycerides
endometrium • Safe during lactation • DM • Irregular menses
o Progestins compete with insulin at insulin ® • Acne, PMDD or hirsutism
• If estrogen contraceptive is contraindicated or causes o Related to progestins with higher androgenicity
health issues

• Taken every day of cycle → no “hormone free” days

o Must be taken SAME TIME everyday

• AKA “mini pill”

• Less effective to prevent pregnancy

• Pills containing only norethindrone or desogestrel

• 1st & 2nd gen (testosterone derivatives → androgenic)

Mini Pill o Norethindrone
o Norethindrone acetate
(Progesterone o Levonorgestrel → Plan B is only Levonorgestrel
Only) • 3rd gen (testosterone derived → low androgenic)
o Norgestimate
o Desogestrel
• Antiandrogenic progestins (mild antiandrogenic)
o Dienogest
o Drospirenone (DRSP) → use this with acne
▪ Derived from spironolactone → treats acne
▪ Progestogenic, antiandrogenic, &
antimineralocorticoid activity

• New progestins & routes of administration developed

o To decrease undesired androgenic side effects
o Progestins w/ anti-androgenic (drospirenone)
 • Periodic Abstinence = abstinence shortly before & after estimated ovulation period
o Requires regular & predictable menstrual cycles
o Effectiveness = 55-80%
Natural • Coitus Interruptus = withdrawal of penis from vagina before ejaculation
o Failure rate = 27%
Methods
• Lactational Amenorrhea = prolactin-induced inhibition of pulsatile GnRH
o Return of ovulation returns before return of menstruation → so could become pregnant!
o Failure rate = 15-55% become pregnant
o Maximum of 6 months after deliver & experiencing amenorrhea
• Male Condoms = BEST protecting from STD’s → most effective barrier method!
o Effectiveness = 85-90%
o Failure rate = 16%
o Leave well at tip of condom to collect ejaculate & avoid leakage of semen
• Female Condoms = GOOOD protection from STD’s
o Effectiveness = 85-90%
o Failure rate = 20-25%
• Diaphragm, Cervical Cap & Cervical Shield = NO protection against STD’s
o Requires prescription = higher cost!
Barrier o Diaphragm & cervical cap = must be fitted
Method o Shield = does not need to be fitted
o Use with contraceptive jelly = spermicide
o Effectiveness = ~80%
o Failure rate = higher because lack of compliance & inappropriate use
• Sponge & Vaginal Inserts = NO protection against STD’s
o Failure rate = high if used alone
• Spermicide = INCREASE risk of certain STD’s
o Effectiveness = 70-75%
o Failure rate = high if used alone

• Norelgestromin (progestin) & ethinyl estradiol (estrogen)

• Same side effects as the pill = avoids 1st pass (directly into blood stream)
• Estrogen effects may be more severe with the Patch
The Patch
• Never place the Patch on the BREAST!!
• VTE risk ↑ compared to the Pill
• Patch may not be off for >24 hours or back up is needed
• No longer available in the US as of 2015
• Estrogen & etonogestrel (progestin)

• Failure rate = 0.3/100

NuvaRing
• Failure rate and S/E = same as the Pill and the Patch
• Convenient → worn for 21 days and removed for 7 days (to allow for withdraw bleeding)
• S/E = initial break through bleeding
• Medroxyprogesterone = progestin → NO estrogen

• One injection every 3 months

Depo-Provera • S/E = irregular bleeding, amenorrhea & reversible bone loss (osteoporosis)
• Delay in return of fertility after cessation → can take 18 months to ovulate after last shot
• Caution if history of uncomplicated VTE, smoker or HTN
• Progesterone only = progesterone causes fluid retention & stimulates appetite → average weight gain is 5 lbs in 1st year (most patients will gain weight)
• Etonogestrel = progestin → NO estrogen

Nexplanon • Implant in upper arm → good for 3 years

• Probably OK to use with a history of VTE
Implanon • Failure rate = 0.38/100
• Very similar side effect profile to DepoProvera
(LARC) o Not as much uncontrollable heavy bleeding → some initial cycle irregularity
• If a patient is postpartum and not breastfeeding can be inserted anytime
• If a patient is postpartum and breastfeeding can be inserted 4 weeks postpartum
 • Nonhormonal IUD → copper
Nonhormonal
IUD • Good for 10 years → cost effective
• Relatively few contraindications
Paraguard • Best form of emergency contraception → can be offered for up to 5 days (120 hours) after unprotected event → effectives decreases over time
• S/E = heavy bleeding & dysmenorrhea

• Levonorgestrel = progestin → NO estrogen

• Liletta = ok for all women → lasts for 3 years

Hormonal • Skyla = ok for all women → lasts for 3 years
IUD’s • Kyleena = ok for all women & women who have NEVER given birth → lasts for 5 years
• Mirena = ok for all women & women who have ALREADY given birth → lasts for 5 years
(LARC) • If failure does occur = ↑ risk for ectopic pregnancy
o If you get pregnant on an IUD you have an increased risk of ectopic pregnancy
o Overall low risk of ectopic pregnancy because it prevents overall pregnancy
• Noncontraceptive benefits = treat pelvic pain and irregular menses
• Tubal ligation
o Not 100%!!! → failure rate = 18.5/1000 women
o If a failure does occur → more likely to be ectopic
o Reversal is not guaranteed → inversely proportional to woman’s age at sterilization
o Surgical procedure = surgical risks and anesthesia risks
o Can be done immediately following delivery & is the most common in the US
Female o Can be done as an interval procedure at any other time
Sterilization
• Essure = hysteroscopic procedure
o Surgical procedure to place coil and later a hysterosalpingogram to ensure occlusion has occurred
o Good for patients who are not surgical candidates = can do with IV sedation & you stay out of abdomen
o S/E = painful periods or painful intercourse → can remove tubes and coils if this occurs
o Failure rate = 0.1%

• Vasectomy is safer, cheaper, has a quicker recovery time and a lower failure rate
Male
• Office procedure
Sterilization
• Requires semen analysis 3-4 months post-procedure = make sure it was effective
• Levonorgestrel = progestin → NO estrogen

• Most effective if taken within 72 hours of unprotected sex

• Some methods effective up to 5 days (120 hours) with diminishing efficacy
• Inhibit ovulation, decrease tubal mobility, and maybe interrupt implantation
Emergency
• Paraguard IUD is the most effective → can give after sex!
Contraception
• Available OTC for individuals ages >17 years old
o Plan B (One Step) = one pill & progestin only (levonorgestrel)
o Next Choice = two pills 12 hours apart & progestin only
• Will mess up menstrual cycle
• Clarify that this is “morning after” pill but it is NOT considered an abortifacient (NOT RU-486 abortion pill)
• Estrogen & progesterone = inhibits GnRH, LH, FSH & LH surge
• Estrogen = suppress FSH & prevents follicular development
MOA
o Folliculogenesis = follicular development
• Progesterone = inhibits ovulation, prevents implantation, thickens cervical mucosa & thins endometrium
• Breast pain = MC with estrogen
Side Effects • Nausea = MC with estrogen
• Fluid retention = MC with progestin
• Cessation of pills = 2 weeks
Fertility Delay • Cessation of injections = ~8-18 months
• Cessation of IUD = rapid return
Progestin/ • Spotting (bleeding) prior to finishing active pills = increase progestin
o To increase endometrial “support”
Estrogen
• Continued bleeding after menses = increase estrogen
Changes
 RHEUMATOLOGY
Etiology Presentation & PE Diagnosis Treatment & Complications
• Inflammation of costal cartilages or • CP = pleuritic • X-ray = normal • Treatment = meds
costochondral junctions o NSAIDs = pain control
Costo- • Reproducible chest wall tenderness • EKG = normal
chondritis • Etiologies
o Idiopathic • NO palpable edema • Labs = normal
o Viral
o Traumatic = physical strain, coughing, etc. • CP = pleuritic

Tietze • Reproducible chest wall tenderness

Syndrome
• PALPABLE EDEMA

• Abnormal pain perception = idiopathic • Musculoskeletal pain → NOT joint • Clinical diagnosis • Treatment = conservative or meds
• Fatigue → extreme o Conservative = education, sleep hygiene, low impact
• MC = women 20-55 years old • Sleep & cognitive disturbances = fibro fog • Diagnostic criteria aerobic exercise (swim, walk, bike, & water aerobics)
• Headache o Tenderness 11/18 trigger points o Meds = TCAs, cyclobenzaprine, SNRIs, pregabalin
Fibromyalgia ▪ Amitriptyline (TCA) = 1st line → sleepiness
• Numbness o Pain >3 months
▪ Cyclobenzaprine = muscle relaxer
• Sleep study = no REM sleep ▪ Duloxetine (SNRI)
▪ Pregabalin = helps with sleep problems
• Mucin-filled synovial cyst • Mostly asymptomatic! • Clinical diagnosis • Treatment = observation, aspiration, or excision
o MC = hands (dorsal aspect of wrist) o Observation = 1st line (usually resolve within 1 year)
o Median or ulnar nerve compression • Firm & well circumscribed • US = differentiates cyst vs. aneurysm o Aspiration = 2nd line
• Fixed to deep tissue ▪ Avoid on volar surface b/c near radial & ulnar a.
• Etiologies • Transilluminates • Allen test = evaluate radial & ulnar artery flow o Excision = severe or neurovascular complications
o Trauma
o Mucoid degeneration • Complications = hand ischemia from vascular occlusion
o Synovial herniation
Ganglion Cyst

• Uric acid deposition in tissues, joints & bones • Pain • Arthrocentesis = (–) birefringent & needle • Treatment = lifestyle & meds
• Erythema shaped crystals o Acute = NSAIDs, steroids & colchicine
• Etiologies • Warmth o ↑ WBC (<50,000) & mostly neutrophils ▪ NSAIDs = 1st line
o Renal uric acid underexcretion (MC) • Swelling ▪ Steroids = 2nd line
▪ Renal insufficiency, thiazides, & ASA • Tenderness • X-ray = punched out erosions (rate bite lesions) ▪ Colchicine = can’t tolerate NSAIDs or steroids
Gout o Uric acid overproduction o Chronic = lifestyle allopurinol, uricosuric drugs, etc.
▪ ↑ cell turnover → CA, chemo, hemolysis • MC = 1st MTP joint of great toe (podagra) • Tophi = deposit of crystalline ▪ Lifestyle = ↓ EtOH & purine (meats), weight loss
Monoarticular ▪ Allopurinol = 1st line (↓ uric acid production)
• Risk factors • Acute with precipitating event = stubbing toe • ↑ ESR • Monitor = creatinine!
o Purine diet = red meat, liver or seafood ▪ Probenecid = ↑ urinary uric acid secretion
o EtOH
• Triggers = trauma, surgery or fasting • CBC = ↑ WBC ▪ Pegloticase = dissolves uric acid
o Meds = diuretics, ASA, ACEi, niacin ▪ Colchicine = inhibits chemotactic response
o Men = MC • Hyperuricemia = not diagnostic / helpful acutely • Blocks neutrophils response
• Calcium pyrophosphate dihydrate deposition • Pain • Arthrocentesis = (+) birefringent & rhomboid • Treatment = meds
• Erythema shaped crystals o Acute = NSAIDs, steroids & colchicine
• Risk factors • Warmth o ↑ WBC (<50,000) & mostly neutrophils ▪ Steroids (intraarticular) = 1st line → 1-2 joints
Pseudogout o Hemochromatosis • Swelling ▪ NSAIDs = 1st line → >2 joints
o Hyperparathyroidism • Tenderness • X-ray = chondrocalcinosis (cartilage calcification) ▪ Colchicine = can’t tolerate NSAIDs or steroids
Monoarticular o Hypomagnesemia o Chronic
• MC = knee (MC), elbow, wrist & ankle ▪ NSAIDs
▪ Colchicine = inhibits chemotactic response
 • Autoimmune disease of exocrine glands
o Salivary & lacrimal glands
• Sicca = eyes & mouth only (not autoimmune)
o Dryness not caused by Sjogren Syndrome
Sjogren • 1o = occurs alone
Syndrome • 2o = occurs with other autoimmune diseases
o Hashimoto’s, RA, & SLE
• MC = women 40-60 years old
• HLDA-DR52
• Autoimmune connective tissue disease
o Collagen deposition
o Skin & organ fibrosis
Systemic • MC = women 30-50 years old
Sclerosis
(Scleroderma) • Types
o Localized = morphea & linear scleroderma
o Systemic = limited & diffuse
• Muscle & nerve ischemia = ↓ tissue perfusion
o Compartment pressure >> perfusion
pressure
Compartment • Etiologies
Syndrome
o Trauma = long bone fractures (TIBIA)
o Crush injuries
o Constriction
▪ Tight cast
▪ Splints
▪ Circumferential burns
• Acute infection of bone = weeks to months
• Children (MC) = femur & tibia
• Adults (MC) = vertebrae
• Risk factors
o Sickle cell disease
o DM
o Immunocompromised
o Preexisting joint infection
• Types
Acute o Hematogenous spread = MC in kids
o Direct inoculation = MC in adults
Osteomyelitis
▪ Infection = close to bone
▪ Trauma = open fx or puncture wound
▪ Surgery = prosthetic joint
o Contiguous spread
▪ Vascular insufficiency
▪ Ex: PVD or DM
• Etiologies
o Staph aureus = MC overall
o Staph epidermis = prosthetic joint
o Salmonella = sickle cell disease
o GBS = neonates
o PSA = puncture wounds in shoes or IVDA
• Dry mouth = xerostomia
• Dry eyes = keratoconjunctivitis sicca
• Vaginal dryness → presents as dyspareunia
• Parotid gland enlargement
• Dental caries → complication of xerostomia
• Polyarthritis → associated with RA
• Limited = tight, thick skin → distal to elbow & knee
o CREST syndrome
▪ Calcinosis cutis = Ca2+ nodules on skin
▪ Raynaud’s phenomenon
▪ Esophageal motility disorder
▪ Sclerodactyly (claw hand) → 2o to fibrosis
▪ Telangiectasias
• Diffuse = tight, thick skin → trunk & proximal
o Greater internal organ involvement
▪ Pulmonary fibrosis = restrictive lung dz
▪ Myocardial fibrosis = restrictive CM
• Pain out of proportion to injury
• Tense compartment = firm or “wood-like”
• 6 P’s
o Paresthesia’s = early
o Pain = out of proportion to injury
o Pallor
o Pulselessness
o Poikilothermia
o Paralysis = late (worse prognosis)
• Fever, chills & malaise
• Pain
• Warmth
• Swelling
• Tenderness
• ↓ ROM
• (+) anti-Ro/SSA
• (+) anti-La/SSA
• (+) Schirmer test = ↓ tear production
• Biopsy (lip or parotid gland) = definitive diagnosis
o Gland fibrosis & lymphocytic infiltration
• US or MRI = glandular abnormalities
• Rose Bengal stain = abnormal corneal epithelium
• (+) RF or (+) ANA
• CBC = anemia & ↓ WBCs
• (+) anti-centromere Ab = limited (CREST)
• (+) anti-SCL-70 Ab = diffuse
• (+) ANA
• Compartment pressure = >30 mmHg
• Delta pressure = <30 mmHg
o diastolic BP – compartment pressure
• ↑ CPK
• ↑ myoglobin
• ↑ ESR & CRP
• CBC = ↑ WBCs
• X-ray = may take 2 weeks to see on x-ray
• MRI = most sensitive
• Bone aspiration = definitive diagnosis
• Treatment = symptom management & meds
o Dry eyes = artificial tears
o Dry mouth = artificial salvia, special toothpaste with
peroxide, water, sugar free candy, paraffin
o Cholinergics = ↑ secretions
▪ Pilocarpine or cevimeline
o MSK = APAP, NSAIDs, steroids, hydroxychloroquine
o Intense inflammation = methotrexate,
azathioprine, & cyclosporin
• AVOID decongestants
• Complications = Non-Hodgkin lymphoma, pneumonitis,
AIN, & congenital heart block if mom w/ ↑ antibody titers
• Treatment = organ specific
o GI = PPIs & H2 blockers
o HTN w/ renal disease = ACE inhibitors
o Raynaud = vasodilators (CCB)
o Pulmonary fibrosis = cyclophosphamide
o Pulmonary HTN = bosentan, sildenafil, etc.
• Severe = DMARDs → methotrexate, etc.
• Complications = renal HTN crisis, pulmonary fibrosis, &
myocardial fibrosis
• Treatment = decompression & limb placement
o Decompression = emergency fasciotomy!!!!
o Limb placement = place limb at heart level
• Treatment = surgical debridement & ABX
o Surgical debridement = remove necrotic tissue,
culture wound, & +/– local antimicrobials
▪ ABX won’t work well with PAD or scar tissue!!!!
o ABX = 4-6 weeks → at least 2 weeks IV
▪ Staph aureus
• MSSA = nafcillin, oxacillin or cefazolin
• MRSA = vancomycin or linezolid
▪ Staph epidermis
• MSSA = nafcillin, oxacillin or cefazolin
• MRSA = vancomycin or linezolid
▪ Salmonella
• Ciprofloxacin
• Levofloxacin
• Ceftriaxone
• Cefepime
• Ertapenem
• Meropenem
▪ GBS
• Ceftriaxone + vancomycin
▪ Pseudomonas
• Ciprofloxacin or Levofloxacin
• Ceftazidime
• Cefepime
• Meropenem
 • Systemic vasculitis of medium-sized vessels
o MC = renal, CNS & GI vessels (NOT lungs)
o Type III hypersensitivity reaction
o Ischemia & microaneurysm of vessels
• Risk factors = hepatitis B & C
Polyarteritis
Nodosa
• MC = men 40-60 yeas old
• Constitutional = fever, arthralgia, & myalgia • Angiogram (renal / mesenteric) = microaneurysm • Treatment = medication
o Steroids = 1st line
• Renal = HTN (RAS or renal ischemia) • Biopsy (affected organ) = definitive diagnosis o Cyclophosphamide = severe
▪ Immunosuppressant / chemotherapy drug
• GI = ab pain ↑ after meals & N/V (intestinal angina) • ↑ ESR
• CNS = neuropathy (foot drop), mononeuritis • UA = proteinuria
multiplex (multiple peripheral neuropathy), & CVA
• (–) ANCA = antineutrophil cytoplasmic antibodies
• Derm = livedo reticularis & Raynaud’s,
palpable purpura, nodules & ulcers on tibia

• Inflammation of joints, bursae & tendons • Pain & stiffness = proximal (shoulder & hips) • Normal CPK & aldolase (muscle enzymes) • Treatment = = meds & supplements
o Idiopathic o AM stiffness >30 minutes o Steroids = LOW dose corticosteroids
o Difficulty combing hair & raising from chair • ↑ ESR & CRP o Methotrexate = if no response to steroids
• MC = women >50 years old o Vitamin D & Ca2+ = prevent osteoporosis
Polymyalgia • Fever, weight loss, & fatigue • CBC = anemia → normochromic normocytic
Rheumatica • Associated with giant cell arteritis
• Normal muscle strength → ↓ ROM

• Inflammation of muscle
o Idiopathic autoimmune disorder
Polymyositis o CD8+ lymphocytes infiltrate endomysium
o Inflammatory myopathy
▪ Proximal limbs, neck & pharynx
• Inflammation of muscle & dermatology
o Idiopathic autoimmune disorder
o CD4+ lymphocytes infiltrate perimysium
o Inflammatory myopathy
▪ Proximal limbs, neck & pharynx
Dermato-
myositis
• Muscle weakness = proximal (shoulder & hips)
o Difficulty combing hair & raising from chair
• Dysphagia
• Polyarthralgia
• Fever, weight loss, & fatigue
• ↓ muscle strength
• Dermatomyositis
o Gottron’s papule = scaly skin on dorsal hand
o Heliotrope rash = blue or purple eyelid
o Malar rash = erythematous macules
▪ Shawl sign = shoulder, chest & back V
sign = neck & upper chest erythema
• ↑ CPK & aldolase (muscle enzymes)
• (+) anti-Jo-1 (both)
• (+) anti-signal recognition protein (PM)
• (+) anti-Mi-2 (DM)
• ↑ ESR & CRP → might be normal!
• (+) RF & (+) ANA
• CBC = anemia → normochromic normocytic
• Biopsy (quadriceps) = definitive diagnosis
• Treatment = meds & supplements
o Steroids = HIGH dose corticosteroids
o Methotrexate = refractory to steroids
o Hydroxychloroquine = skin lesions (DM)
o Vitamin D & Ca2+ = prevent osteoporosis
• Complications = ILD & respiratory insufficiency from
muscle weakness

• Inflammatory arthropathy = axial skeleton • Back pain & stiffness • (+) HLA-B27 • Treatment = meds & supportive
o Spine & sacroiliac joints o Improves = exercise & activity o Supportive = exercise & physical therapy
o Progressive spine stiffness • ↑ ESR o NSAIDs = 1st line
• Uveitis o TNF antagonist = 2nd line
Ankylosing • MC = males 15-30 years old • (–) RF ▪ Etanercept, Infliximab, or Adalimumab
Spondylitis • Cardiac issues = AV blocks & aortic regurgitation • (–) ANA

Polyarticular • X-ray = sacroiliitis & bamboo spine

o Bamboo spine = fusion of vertebrae
Seronegative • EKG = AV blocks

• Echo = aortic regurgitation

Psoriatic • Inflammatory arthritis → due to psoriasis • Arthritis → involve DIP joint • X-ray = pencil in a cup • Treatment = meds
Arthritis
o Psoriasis preceding arthritis months to years • Dactylitis = sausage hands & feet o NSAIDs = 1st line
• Sacroiliitis o Methotrexate = 2nd line
• Uveitis o TNF antagonist = refractory to methotrexate
Oligoarticular ▪ Etanercept, Infliximab, or Adalimumab
o Interleukin antagonist = refractory to anti-TNFs
• Silvery white scales & pitting nails
Seronegative ▪ Ustekinumab or Secukinumab
 • Infection of joint cavity • Swollen • Arthrocentesis = WBCs >50,000 w/ neutrophils • Treatment = meds & supplements
o Knee = MC in adults • Warmth o Prosthetic joint = WBC >1,100 o Empiric = vancomycin + ceftriaxone
o Hip = MC in kids • Pain o Gram (+) = vancomycin
o Sternoclavicular = MC in IVDU • ↓ ROM • ↑ ESR & CRP → CRP is more useful o Gram (–) = ceftriaxone

• Risk factors • Fever & chills • Blood cultures = (+) 50% of the time
o Immunosuppression
o Prosthetics joint / surgery
• Diaphoresis
Septic • Myalgia • X-ray = soft tissue swelling
o Chronic arthropathies = RA, gout, OA, etc.
Arthritis
• Pathogens
o Staph aureus (MC) & Staph epidermis
o GAS, GBS & strep pneumonia
o Neisseria gonorrhea = sexually active
o Pseudomonas = immunocompromised
o Mycobacterium = immunocompromised
o Fungi = immunocompromised
• Inflammatory arthritis → GI or GU infection • Triad = arthritis, conjunctivitis & urethritis • Arthrocentesis = rule out septic arthritis • Treatment = treat arthritis & treat underlying cause
o Arthritis = knees & ankles (weight bearing) o ↑ WBC (<50,000) & mostly neutrophils o Arthritis
• Etiologies = GU or GI infection o Ocular = conjunctivitis & uveitis ▪ NSAIDs = 1st line
Reactive o GU = Chlamydia trachomatis o Genital = urethritis, cervicitis or balanitis • GI high probability = stool studies ▪ Steroids (PO or injection) = 2nd line
Arthritis o GI = Salmonella, Shigella, Campylobacter, ▪ Methotrexate or sulfasalazine = alternative
& Yersinia • Keratoderma blennorrhagicum = hyperkeratotic • GU high probability = UA or vaginal swab o Chlamydia trachomatis = ABX
(Reiter lesions on palms & soles o GI infection = usually no treatment needed
Syndrome) • HLA-B27 = ↑ incidence • (+) HLA-B27

Oligoarticular • ↑ ESR
• ↑ IgG
Seronegative
• CBC = anemia → normochromic normocytic

• Autoimmune connective tissue disease • Triad = arthritis + fever + malar rash • (+) ANA = higher seNsitivity • Treatment = lifestyle & meds
o Type III hypersensitivity reaction o Malar “butterfly” rash = spares nasolabial folds o Lifestyle = sunscreen & avoid sun
▪ Ag-Ab immune complexes o Arthritis = immune complexes • (+) anti-dsDNA & anti-Sm = higher sPecificity o Mild = hydroxychloroquine & NSAIDs
▪ Hydroxychloroquine (Plaquenil) = best agent
• Risk factors • Discoid lupus = annular red patches on face & scalp • Anti-phospholipid antibodies o Moderate = above + glucocorticoids
o Women (20-40 years old) o Anti-cardiolipin Ab & lupus anticoagulant o Severe = above + cyclophosphamide
Systemic o African American • Fever, fatigue & weight loss
Lupus o Sun = UV radiation damages cells • Photosensitivity • ↓ complement (C3 & C4) • Complication’s = CVA, DVT & PE (hypercoagulable), ILD
Erythematosus o Estrogen (OCPs) • CNS = seizures or psychosis
(SLE) o Genetic • UA = hematuria & proteinuria
• Glomerulonephritis = immune complexes
o Environmental
o Meds = procainamide, isoniazid, & • Retinitis
Polyarticular • Oral ulcers • PT/INR & PTT = ↑ PTT (coagulation)
quinidine
• Alopecia
• Serositis = pericarditis or pleuritis • CBC = pancytopenia
o Anemia of chronic disease >> hemolytic
• Other = discoid (skin only) or drug induced o Leukopenia & lymphocytopenia
o Thrombocytopenia → +/– coagulopathy

• Systemic autoimmune inflammatory disease • Symmetric joint pain = worse with REST • (+) RF • Treatment = NSAIDs & steroids, & DMARDS
o Swollen & inflamed synovial membrane o AM stiffness >1 hour → improves during day • (+) anti-CCP o NSAIDs = 1st line (immediate relief)
o MC = small joints (wrist, MCP, PIP → no DIP) • (+) ANA o Steroids = 2nd line
• Risk factors o Nonbiologic DMARDs = slow disease progression
o Women • Joints = warm, red & soft (boggy) • (+) HLA-DR4 ▪ Methotrexate = ↑ LFTs & ↓ WBCs
Rheumatoid o 30-50 years old o Ulnar deviation ▪ Leflunomide = teratogenic
Arthritis o Smoking o Swan neck & boutonniere deformity • ↑ ESR & CRP ▪ Hydroxychloroquine = safe in pregnancy
o Rheumatoid nodule = boney prominences o Biologic DMARDS = TNF antagonists
Polyarticular • Felty syndrome = RA, splenomegaly, o Pannus = hyperplastic synovial tissue
• X-ray = SYMMETRIC joint narrowing & ↓ joint ▪ Adalimumab (Humira)
neutropenia ▪ Erodes cartilage & bone space, osteopenia, cartilage loss, & bone erosions ▪ Infliximab
o Severe = joint subluxation ▪ Etanercept
• Caplan syndrome = coal worker’s lung + RA • Fever, fatigue & weight loss
• Scleritis
 ORTHOPEDICS
Etiology Presentation & PE Diagnosis Treatment & Complications
• Loss of articular cartilage & joint degeneration • Asymmetric joint pain = worse with ACTIVITY • Normal inflammatory markers • Treatment = lifestyle, meds, injections, & surgery
o AM stiffness <1 hour → worsens during day o ESR, CRP, RA, ANA o Lifestyle = weight loss, exercise, & assistive devices
• MC = weight-bearing joints (knees, hips, spine) o MC = small joints (wrist, MCP, PIP → no DIP) o NSAIDs (topical & PO) = 1st line
• X-ray = ASYMMETRIC joint narrowing, ▪ Oral = naproxen, ibuprofen, & diclofenac
• Risk factors • Joints = hard & bony (no inflammatory signs!) osteophytes, & subchondral bone sclerosis & cysts • Takes ~2 weeks to work
o Obesity o Heberden (DIP) & Bouchard (PIP) nodes • S/E = GI, renal & CV (naproxen if CV risk)
o Trauma ▪ Topical = diclofenac sodium gel 1% & patch
o Heavy labor • ↓ ROM • Topical = better safety profile
o Elderly • Crepitus • Takes ~2 weeks to work
o Female
o FHx • S/E = rash, itching, or burning
o Sports activities o Tramadol = mild narcotic with low abuse potential
o Tylenol = no longer considered 1st line
▪ Pitching = shoulders & elbow
o Duloxetine = multiple joints & can’t use NSAIDs
▪ Football = knees, ankles & feet o Capsaicin (topical) = not for acute pain
▪ Soccer = neck, hip, knees & talar joints ▪ Takes ~2 weeks to work
Osteoarthritis ▪ S/E = local burning at site
o Hyaluronic acid (injection) = symptomatic relief
o Steroid (injection) = temporary relief
▪ Moderate to severe pain
▪ Affecting one or a few joints
o Joint replacement = refractory to lifestyle & meds

• Loss of bone density → mineral & matrix • Pain = back, hip, knees, etc. • DEXA scan = best diagnostic test (hip & spine) • Treatment = lifestyle & meds
o Imbalance of bone resorption > formation o T-scores o Lifestyle
o Osteopenia = precursor • Bone fractures = vertebrae (MC), hip, & radius ▪ Normal = >-1.0 ▪ Vitamin D (800) & Ca2+ (1200) supplements
▪ Osteopenia = -1.0 to -2.5 ▪ Weight bearing exercise
• Types • Loss of vertebral height = spine compression ▪ Osteoporosis = <-2.5 ▪ Smoking cessation
o Primary ▪ Fall prevention
▪ Postmenopausal (↓ estrogen) • Ca2+, phosphate & PTH = normal o Bisphosponates = 1st line → inhibit osteoclasts
▪ Elderly ▪ IV = zoledronic acid & ibandronate
o Secondary • Alk phos = normal ▪ PO = alendronate, risedronate, &
▪ Hypogonadism ibandronate
▪ CKD, DM, or hyperthyroidism • TSH = screen for hyperthyroidism ▪ S/E = flu-like symptoms, MSK pain, esophagitis,
▪ Cushing’s disease = ↑ cortisol GI sx, osteonecrosis of the jaw
▪ ↓ Ca2+ & vitamin D ▪ Take with water & stay upright for 30 min
Osteoporosis ▪ Malignancy = skeletal cancer (myeloma) o Calcitonin = last line → weak effect on bone density
▪ Meds = heparin, phenytoin,
lithium, & levothyroxine • No treatment for osteopenia → supportive care!
o Vitamin D (800) & Ca2+ (1200) supplements
• Risk factors o Weight bearing exercise
o Female o Smoking cessation
o History of frailty fracture o Fall prevention
o Low BMI or BMD
o Steroid use
o Smoking & EtOH
 • Strained muscle or sprained ligament in back
o Something alters mechanics of lumbar area
• Etiologies
o Acute traumatic event
o Repetitive micro-trauma
• Risk factor = obesity
Mechanical
Low Back Pain
• Bulging disc into or though annulus fibrosus
o Firm fibrous ring = annulus fibrosus (AF)
▪ Tiny unmyelinated nerves in AF
• Can get tear in AF & cause pain
o Gelatinous core = nucleus pulposus (NP)
▪ No nerves identified within NP
Herniated • Most discs herniate posterolaterally
o PLL in the back which is strong
Disc
(Nucleus Pulpous)
o ALL in the front which is strong
o Bending forward = jelly in donut goes back
o Can’t go straight back because of PLL
▪ Goes off to the sides!
• Etiologies
o Cervical = MC at C5-C6 & C6-C7
o Lumbar = MC at L5-S1 (also L4-L5)
• Narrowing spinal canal with nerve impingement
• Types
o Degenerative disc disease (DDD)
▪ Disc gets smaller because losing water
▪ Losing height from DDD – so foramen is
more narrow (stenosed)
o Degenerative joint disease (DJD)
Lumbar ▪ Spondylosis = arthritis of back
Spinal ▪ Osteophytes & bone spurs
Stenosis ▪ Compressing & stenosing foramen
• Etiologies
o Degenerative arthritis (DDD)
o Spondylosis (DJD)
o Post-surgical
o Congenial
o Trauma
o Inflammation
• Pars interarticularis defect
o Stress fracture at pars interarticularis
• Mechanism = repetitive hyperextension
Spondylolysis o Football
o Gymnasts
o Weight lifters
• MC = L5-S1
• Worse with movement = spine ROM
• Improves with rest
o Pain without moving = not good! (CA??)
• Delayed soreness/stiffness after event
• Paraspinal muscle tenderness
• NORMAL neuro exam
• RADICULOPATHY
• Back pain = unilateral & radiates down leg
• (+) straight leg test
• (+) cross over test
• L4 = anterior thigh pain
o DTR = loss of knee jerk
o Weakness of ankle dorsiflexion
• L5 = lateral thigh/leg, hip & groin pain
o DTR = none
o Weakness of big toe extension
• S1 = posterior leg & calf pain
o DTR = loss of ankle jerk
o Weakness of plantar flexion
• RADICULOPATHY
• Back pain = bilateral or unilateral
• Numbness & paresthesia’s → radiates down leg
• Worsens = extension or walking DOWNHILL
• Improves = flexion or walking UPHILL
• Back pain = low back
• Sciatica
• +/– hamstring tightness
• X-ray = red flags!
o Trauma
o Malignancy
o Concern for new cancer
▪ Fever, chills, weight loss, night pain, etc.
o Immunosuppression
o Night pain
o TTP on spinous processes (midline)
o Age >50
o >4-6 weeks without improvement
• X-ray = loss of disc height & degenerative changes
• MRI = diagnostic test of choice
• MRI = test of choice
• X-ray (LATERAL) = scottie dog deformity
o Scottie dog with “broken neck”
o Defect in pars interarticularis
• Bone scan = more sensitive
• MRI = more sensitive
• Treatment = supportive & meds
o Supportive = resume activity & BRIEF bed rest
▪ Movement helps muscles repair!
▪ AVOID prolonged bed rest
▪ Patient education = proper lifting techniques
• Muscle tear → scar tissue → risk of reinjury
o Likely to injure again because scar tissue
is not as flexible as native muscle tissue
o NSAIDs = IV or IM if in severe pain before discharge
▪ Scheduled pain meds often better than prn
o Muscle relaxers
▪ Flexeril = can make you tired (do not drive)
▪ Baclofen = help control spasm
▪ Valium (benzo) = ultimate muscle relaxer
• Most resolve in ~6 weeks!
• Treatment = supportive, steroids, injections, or surgery
o Supportive = PT, NSAIDs and muscle relaxers
▪ PT (Mckenzie method) = extension exercises
▪ NSAIDs or Tylenol = main thing in ER
▪ Muscle relaxers = nerve causing 2o muscle spasm
• Flexeril = can make you tired (do not drive)
• Valium (benzo) = ultimate muscle relaxer
o Steroids (PO) = takes 48 hours so need pain meds 1st
▪ Help because of inflammation around nerve
o Steroids (injection) = refractory to other therapy
▪ Preferred over PO steroid b/c no systemic S/E
o Surgery = decompression or discectomy
▪ Decompression (laminectomy) = taking out
lamina (area around spinal nerve) to decompress
▪ Discectomy w/ fusion
▪ Discectomy w/ replacement = more popular
• Treatment = supportive & surgery
o Supportive = pain control & physical therapy
o Steroids (injection) = epidural or foraminal
▪ Delay need for surgery
o Surgery = decompression laminectomy
• Treatment = mild & asymptomatic vs. symptomatic
o Mild & asymptomatic = observation & no restriction
o Symptomatic = activity restriction & PT
o Bracing = acute or failed PT
• Complications = spondylolisthesis
 • Slippage of vertebrae at pars interarticularis • Back pain = low back • X-ray (LATERAL) = forward slipping of vertebrae • Treatment = mild vs. severe
o Forward slippage due to B/L spondylolysis o Mild = activity restriction & physical therapy
• Sciatica • Bone scan = more sensitive o Severe = surgery
• +/– bowel or bladder dysfunction = severe
• MRI = more sensitive
Spondylo-
listhesis

• Anterior & posterior height loss from axial load • Back pain • X-ray = comminuted vertebral body & loss of • Treatment = supportive or surgery
vertebral height o Supportive = observation, pain meds, & brace
Burst Fracture • Etiology = jumping & landing on feet • Heel pain = associated with calcaneal fracture o Surgery = pressure on spinal cord / neuro symptoms

• Fracture within vertebral body • Back pain • X-ray = loss of vertebral height • Treatment = supportive or surgery
o AKA wedge fracture o Supportive = observation, pain meds, & brace
• Midline tenderness = focal o Surgery = kyphoplasty or vertebroplasty
• Pathologic fracture = in elderly, can occur ▪ Kyphoplasty = balloon + cement
Vertebral with heavy lifting or even spontaneously! ▪ Vertebroplasty = cement
Compression
Fracture • Etiologies
o Elderly = osteoporosis
o Malignancy = multiple myeloma or
prostate cancer
o Systemic illness

• Pus-filled collection • Triad = fever + spinal pain + neuro deficits • CBC = ↑ WBCs • Treatment = I&D and ABX
o I&D = interventional radiology → CT & drainage
• Etiologies • Back pain = focal & severe • ↑ ESR & CRP o ABX = vancomycin + ceftriaxone
o Osteomyelitis • Radiculopathy
o Diskitis • Myelopathy = neuro deficits • MRI (with gadolinium) = ring-enhancing lesion

• Pathogens
o Staph aureus = MC
Spinal o E. coli
Epidural o Streptococcus
Abscess o Mycobacterium tuberculosis

• Risk factors
o >50 years old
o IVDA
o Immunosuppression = HIV, DM, chemo
drugs, & steroids
o Epidural catheter placement
o Recent spinal procedure
• Terminal spinal cord compression • Back pain • MRI = imaging of choice • Treatment = surgery & meds
o Surgery = EMERGENT decompression
• NEUROSURGICAL EMERGENCY • Bilateral radicular symptoms = leg pain/weakness • CT myelography = unable to perform MRI o Steroids = ↓ inflammation

• Etiologies • Saddle anesthesia = perineal sensory deficits

o Lumbar disc herniation = MC
Cauda Equina o Spinal stenosis • Urinary or bowel retention = MC
o Trauma • Urinary or bowel incontinence
Syndrome
o Tumors
o Epidural abscess
• ↓ rectal tone
o Epidural hematoma
o Vertebral fractures • ↓ DTRs

• MC = L4-L5 or L5-S1
 • Compression of brachial plexus, subclavian
vein or subclavian artery
Thoracic • Etiologies = congenital or trauma
Outlet
Syndrome • MC = women 20-50 years old
• Nerve compression • MRI = confirms diagnosis • Treatment = supportive vs. surgery
o Ulnar neuropathy o Supportive = PT & avoid strenuous activity
o Atrophy = intrinsic hand muscles • Special tests o Surgery = orthopedic consult
o Adson sign = loss of radial pulse with head
• Vascular compression rotation to ipsilateral or contralateral side
o Weak pulse
o Swelling
o Discoloration

• ACL = posterior femur to anterior tibia • “pop” & swelling • Special tests • Treatment = supportive vs. surgery
o INTRA-articular o Lachman = pulling tibia forward w/ 1 hand o Supportive = sedentary lifestyle
• Hemarthrosis = immediate effusion ▪ Sensitive & specific = gold standard ▪ NSAIDs
• Mechanism = NON-contact injury to ACL o ACL is very vasculature & it’s intra-articular o Anterior drawer = both thumbs on knee & ▪ RICE
o Deceleration push backwards ▪ Physical therapy
Anterior o Changing direction • Knee buckling = “giving way” → instability o Pivot shift = while in internal rotation, o Surgery = active lifestyle (prevents early DJD)
o Hyperextension valgus force while knee is slowly flexed ▪ Allograft or autograft
Cruciate
o Internal rotation ▪ Significant knee instability, young & active
Ligament • X-ray = rule out fracture
Injuries patients, or high demand jobs or sports
• MC knee ligamental injury o Segond fracture = avulsion of lateral tibial
condyle with varus stress to knee
▪ Pathognomonic for ACL tear

• MRI = best test to asses for ACL tears

o ACL appears less taut
• PCL = anterior femur to posterior tibia • Posterior knee pain • Special tests • Treatment = supportive vs. surgery
o INTRA-articular • Anterior bruising o Posterior drawer = both thumbs on knee & o Supportive = sedentary lifestyle
pull forward ▪ NSAIDs
• Mechanism • NO frank instability ▪ Sensitive & specific = gold standard ▪ RICE
Posterior o MVC = dashboard injury o Quadriceps active = posterior sag of tibia ▪ Knee immobilization
Cruciate o Hyperextension = ACL tearing through PCL while at 90o, and repositioning (anterior ▪ Physical therapy
Ligament movement) of tibia with activated quads o Surgery = instability or occurring w/ multiple injuries
Injuries • Isolated PCL injury is RARE!! o Sag sign = posterior sag of tibia
o Often occurs with LCL tear
• X-ray = rule out fracture

• MRI = best test to assess for PCL tears

• MCL = medial femur to medial tibia • Medial knee pain • Special tests • Treatment = supportive vs. surgery
o EXTRA-articular o Valgus stress test = medial knee pressure o Supportive = most common
Medial • Able to bear weight → painful ambulation ▪ 0o (combined) = complete extension ▪ Hinged knee brace = isolated MCL tear
Collateral • Mechanism = valgus force • Testing both MCL & some capsule • 6-8 weeks
Ligament • NO effusion (b/c it is extra-articular) ▪ 30o (isolated MCL) = a little flexion • Prevents secondary valgus bow
Injuries • Testing only MCL (more sensitive) • NOT knee immobilizer
o Then knee will get stiff & scarred
• MRI = not indicated UNLESS possible ACL tear ▪ Therapeutic exercise
Lateral • LCL = lateral femur to lateral tibia • Lateral knee pain • Special tests o Surgery = severe
Collateral o EXTRA-articular o Varus stress test = lateral knee pressure
Ligament
Injuries • Mechanism = varus force • MRI = not indicated UNLESS possible PCL tear
• Lateral meniscus = “O” shaped • Mechanical symptoms = clicking, locking, etc. • Special tests • Treatment = supportive vs. surgery
• Medial meniscus = “C” shaped o McMurray = patient is supine; pain with o Supportive = most common
• Effusion = synovial fluid → usually next day internal rotation (lateral meniscus) or pain ▪ NSAIDs
• Types o Meniscus doesn’t have good blood supply o Apley compression = patient is prone; pain ▪ RICE
o Acute tear = young kids playing sports with internal rotation (lateral meniscus) or ▪ Physical therapy
▪ Twisting or pivoting of foot • Joint line tenderness pain with external rotation (medial meniscus) ▪ Orthopedic follow-up
o with external rotation (medial meniscus)
▪ Single & discrete tear o Surgery = severe symptoms, poor function, persistent
o Bounce home = knee does not fall into full symptoms (“knee locking”), significant tear, etc.
Meniscus Tear o Degenerative tear = elderly patients
extension when legs extended & bounced
▪ Degenerative = 2o to DJD o Thessaly = stand on one leg (affected leg)
▪ Frayed & ratty = no specific tear and try to reproduce symptoms

• MRI = +/– for acute injuries

o NOT for DJD knees → all have meniscus tears
 • Types • Pain & swelling • X-ray = lateral view & sunrise view • Treatment = supportive vs. surgery
o Nondisplaced • Limited knee extension o Rule out bipatellar tendon → smooth margins o Supportive = non-displaced or avulsion
o Transverse = MC • Tenderness over patella ▪ Knee immobilizer
o Lower or upper pole • Hemarthrosis ▪ WBAT
Patellar o Comminuted displaced vs. nondisplaced ▪ Early active ROM after healing
• +/– palpable patellar defect
Fracture o Surgery = displaced (>3 mm), comminuted, loss of
• Mechanism = direct blow extensor function, or articular step-off
▪ Tension wire
▪ Circlage
▪ Screw fixation
• Lateral = MC • Pain • X-ray = rule out avulsion fracture • Treatment = reduction, RICE, & patient education
Patellar • Knee deformity o Reduction = extend knee & push patella medially
Dislocation • Mechanism = valgus stress • MRI = contusion pattern ▪ Often spontaneously reduce!
o RICE = no brace needed
o Patient education = likely to re-occur
• Apophysitis of tibial tuberosity • Pain & swelling • X-ray = elevation, heterotopic ossification, & • Treatment = supportive vs. surgery
o Inflammation of patellar tendon at tibial bone fragmentation o Supportive = non-displaced or avulsion
tubercle insertion • TTP to anterior tibial tubercle ▪ RICE
Osgood- ▪ NSAIDs
Schlatter • Mechanism = overuse injury ▪ Quadriceps stretching
Disease o Small avulsions from repetitive knee ▪ Knee immobilization
extension & quadriceps contraction o Surgery = refractory cases (after closed growth plate)

• MC = athletes & growth spurts

• Mechanism = forceful quadriceps contraction • Sharp & proximal knee pain • X-ray = high vs. low riding patella • Treatment = supportive vs. surgery
o Fall on flexed knee • Focal tenderness to palpation o Supportive = non-displaced or avulsion
o Walking up/downstairs • Focal defect to palpation • MRI = better look at tendons ▪ RICE
▪ NSAIDs
• Quadricep rupture = MC >40 years old • Quadricep rupture = defect ABOVE knee ▪ Knee immobilization = full extension
Patellar & • Patellar rupture = MC <40 years old o Low-riding patella (patella baja) o Surgery = ASAP → within 2 weeks!
Quadriceps
Tendon • Risk factors • Patellar rupture = defect BELOW knee
Ruptures o Gout o High-riding patella (patella alta)
o DM
o Obesity • UNABLE to extend knee
o Renal disease • UNABLE to do active straight leg raise
o EtOH
o Steroid abuse = anabolic steroids
• Anterior = MC • Pain • X-ray = initial imaging of choice • Treatment = surgery
Tibial- o Tibia (distal bone) is anterior to femur • Knee deformity o Surgery = emergent surgical intervention
Femoral
Dislocation • Mechanism = high velocity trauma • Complications = popliteal artery injury, peroneal nerve
injury, & tibial nerve injury
• Mechanism = axial load (fall from height) or • Pain & swelling • X-ray = initial imaging of choice • Treatment = surgery
Femoral direct blow to femur • Inability to bear weight o Surgery = emergent surgical intervention
Condyle
Fracture • Complications = popliteal artery injury or peroneal nerve
injury (foot drop)
• Lateral = MC • Pain & swelling • Schatzker classification = six different types • Treatment = supportive vs. surgery
• Hemarthrosis o Supportive = non-displaced or minimally displaced
• Mechanism = axial load, rotation, & trauma • Lipohemarthrosis = bone marrow & blood ▪ Long leg splint or knee immobilizer
o Axial load = fall from height o Seen on x-ray or CT ▪ NWB = crutches
o Trauma = MVA ▪ RICE
• X-ray = prior to checking ligaments! ▪ Analgesia
Tibial Plateau • Often with ligament & meniscus injury o AP, lateral, & 2 obliques ▪ Ortho follow-up = within 1-week
Fracture ▪ Warn patient of S/S of compartment syndrome!
• CT = if (+) x-ray → for surgical planning o Surgery = significant displacement
▪ External fixation = percutaneous pins
• MRI = suspect soft tissue injury • Allow for skin to heal before they fix it
▪ ORIF

Complications = compartment syndrome

 • Retropatellar articular cartilage softening • Knee pain • Clinical diagnosis • Treatment = supportive vs. surgery
o Usually bilateral o Worse = sitting, stairs, running (loaded flexion) o Supportive
• (+) apprehension sign ▪ Brace or sleeves
• Mechanism = overuse injury • (+) theater sign = knee pain after sitting at 90o ▪ Physical therapy
Patellofemoral • Stretch hamstrings
• Risk factors • (+) “C”sign = grasp knee with hand in shape of a C • Strengthen quadriceps & hip abductors
Syndrome o Overactivity = runner or cyclist instead of directly pointing ▪ Pain meds
o Muscle imbalance ▪ Weight loss
o Patella mal-alignment • Pseudo-locking o Surgery = severe cases
• Retro-patellar tenderness
• Patella grind test
• Inflammation of iliotibial band bursa • Sharp & burning knee / hip pain = lateral • Special tests • Treatment = supportive
o Worse = change in terrain (stairs or downhill) o Noble compression test = pain over distal o Supportive
Iliotibial Band • Risk factors o Improve = rest IT band at 30o flexion ▪ NSAIDs
Syndrome o Runners o Ober test = pain or resistance to adduction ▪ RICE
o Cyclist • (+) cross over test of leg while patient lying on their side ▪ Massage & therapeutic US if needed
▪ Aggressive ITB stretching = with crossfit roller
• Types • Pain & swelling • Ottawa Ankle Rules = tenderness to certain areas • Treatment = supportive
o Lateral (MC) = inversion • Inability to bear weight o Lateral malleolus o Supportive
▪ Anterior talofibular ligament = MC • Ecchymosis o Tip of media malleolus ▪ Immobilization = grade II & III
▪ Posterior talofibular ligament o Base of 5th metatarsal ▪ NSAIDs
▪ Calcaneofibular ligament • Syndesmosis = proximal ankle pain o Navicular ▪ RICE
o Medial = eversion • Rest = limited WB (crutches) → 1-3 days
▪ Deltoid ligament Amount of swelling/ecchymosis DOES NOT • X-ray = AP, oblique, lateral • Ice = 2-3 days until inflammatory phase over
o Syndesmosis (high-ankle) = externally correlate with degree of sprain or sign of a fracture o (+) Ottawa
o Cannot walk >4 steps immediately & in ED • Compression = ACE ↓ hydrostatic pressure
rotated foot
• Elevation = above heart
▪ Anterior tibiofibular ligament
• MRI = +/– if pain >6 weeks ▪ Therapeutic exercises
▪ Posterior tibiofibular ligament
• Stretching/ROM & strengthening
• Risk factors • Special tests • Helps prevent chronic instability
o Females > males o Lateral • Return to full WB as tolerated
o Children/teenagers > adults ▪ Inversion stress test = invert foot
o Indoor court sports > outdoor ▪ Anterior drawer = pull ankle forward
Ankle Sprain o Natural grass > artificial turf • Injured anterior talofibular ligament
o Defensive player > offensive player o Medial
▪ Eversion stress test = evert foot
o Syndesmosis
▪ Kleiger’s test = externally rotate foot

• Grading system
o Grade I = stretched ligament
o Grade II = partially torn ligament
o Grade III = fully torn (ruptured) ligament

• Other
o Usually just get x-ray in ED!
o Don’t use Ottawa on kids, intoxicated or
distracting injury!

• Mechanism of injury = high vs. low energy • Treatment = supportive vs. surgery
o High energy = MVCs and falls from height Ottawa Ankle Rules o Weber A = stable
o Low energy = twisting injuries ▪ Cast or walking boot & WBAT
▪ NO surgery needed
• Weber Classification = high vs. low energy o Weber B = stable & unstable
o A = transverse fx distal to plafond ▪ Stable = cast or walking boot & WBAT
Ankle o B = oblique fx at plafond & extend proximal ▪ Unstable = ORIF
Fracture o C = fracture proximal to plafond o Weber C = unstable
▪ ORIF
• Malleolus involvement o Bimalleolar or trimalleolar = unstable
o Bimalleolar = medial and lateral fracture ▪ ORIF
o Trimalleolar = involving back of tibia ▪ Anytime it involves tibia it needs surgery
 • Types
o Zone 1 = avulsion fracture (MC)
▪ Fibular brevis attaches at 5th metatarsal
▪ When you invert ankle, fibularis brevis
tries to bring back into eversion
o Zone 2 = Jones fracture
Jones ▪ Transverse fx through 5th metatarsal
(5th Metatarsal) ▪ Problematic due to poor bloody supply
Fracture ▪ Watershed area
o Zone 3 = stress fracture
• Pain = 5th metatarsal & lateral midfoot
• X-ray = transverse fracture • Treatment = supportive vs. surgery
o Involving metaphyseal-diaphyseal junction o Zone 1 = non-operative & can treat in PCP
o Zone 2 = non-operative or operative
▪ Refer to ortho b/c of high incidence of non-union
▪ Early WB ↑ risk of malunion
o Zone 3 = non-operative at first & can treat in PCP
▪ If not healing, refer to ortho for possible surgery
• Complications = non-union (Jones fracture)

• Mechanism = traumatic or overuse fractures

o Inversion ankle injuries
o Direct blow
o Twisting of the foot
• Tarsometatarsal (Lisfranc) joint complex • Pain & swelling • X-ray = AP, oblique, lateral → weight bearing! • Treatment = acute vs. long-term
o Disruption between medical cuneiform & • Inability to bear weight o Often misread as normal! o Acute
base of 2nd metatarsal • Ecchymosis o Fleck sign = fracture at base of 2nd ▪ Immobilize = splint or CAM walker
metatarsal pathognomonic for disruption of ▪ NWB = crutches
• Tenderness over tarsometatarsal joint
• Dorsal ligament = Lisfranc ligament • ↓ ROM
tarsometatarsal ligaments ▪ Referral to orthopedics
o Most often happens to this joint o Long-term = non-operative or operative
o But can happen anywhere along joint line • ↓ strength • CT or MRI = better imaging choice! ▪ Non-operative = immobilize 6-10 weeks, then PT
▪ Operative = ORIF
Lisfranc • Mechanism = rotational & severe axial load
Fracture o MVA
o Falls
o Axial load
▪ Plantar flexion & someone falls on foot

• Types = rotational & severe axial load

o Lisfranc fracture
o Lisfranc dislocation
o Lisfranc “injury” = tear Lisfranc ligament
• Rupture of achilles tendon • SUDDEN heal pain • Clinical diagnosis • Treatment = acute vs. long-term
• “pop” o Acute
• Mechanism • Inability to weight bear • (+) Thompson test = weak or absent plantar ▪ Immobilize (splint or CAM walker)
o Running flexion with gastrocnemius squeeze ▪ Heel lift = takes stress off Achilles
o Jumping • Some patients can plantarflex ▪ NWB = crutches
o Sudden acceleration or deceleration o Other muscles help with plantar flexion! • US = done at bedside ▪ Referral to orthopedics = 1-2 days
o Maybe fibularis longus or tibialis posterior o Long-term = non-operative or operative
• Risk factors • MRI = uncertain clinically and US (–) ▪ Non-operative = immobilize 6-8 weeks w/ heel lift
Achilles o Fluroquinolone = 1st 90 days ▪ Operative = repair vs. reconstruction
Tendon o Steroids = PO or injections
Rupture o 30-50 years old
o Male

• ↑ sport participation = ↑ rate of tendon ruptures

• Achilles tendon = “water shed” area

o Poor blood supply = 2-6 cm above insertion
o Most ruptures occur here
o Happens above calcaneus
• Inflammation & micro tears of plantar fascia • Inferior heel pain • Clinical diagnosis • Treatment = supportive, steroids, & surgery
o Worse = AM (1st few steps) & PM (end of day) o Supportive
• Mechanism = overuse injury o Improve = activity, walking, massage, • X-ray = might show heel spur (NOT helpful) ▪ RICE
stretching, & rest o Heel spur from walking different ▪ NSAIDs
• Risk factors o Heels spurs do NOT cause pain! ▪ Heel & arch support
Plantar o Flat feet • Local point tenderness ▪ PT = plantar stretching exercises
Fasciitis o High arches o Steroids (injections) = refractory to NSAIDs
o Heel spurs • Pain with dorsiflexion of toes = stretching fascia o Surgery = refractory to NSAIDs & steroids
o Female
o 40-60 years old
o Obese
o Faulty running shoes
 • Posterior tibial nerve compression • Pain & numbness = medial malleolus, heel & sole • Clinical diagnosis • Treatment = conservative, steroids, & surgery
o Worse = during day, at night, & dorsiflexion o Conservative
• Risk factors o NO improvement with rest • (+) tinel sign = tapping tarsal tunnel (posterior ▪ RICE
o Overuse medial malleolus) reproduces symptoms ▪ NSAIDs
Tarsal Tunnel o Restrictive footwear ▪ Heel & arch support
o Edema ▪ PT = plantar stretching exercises
Syndrome
o Steroids (injections) = refractory to NSAIDs
o Surgery = refractory to NSAIDs & steroids

• 1st metatarsophalangeal joint w/ lateral deviation • Great toe pain • Clinical diagnosis • Treatment = conservative vs. surgery
• Lateral deformity o Conservative = wide-toes shoes
Bunion • Risk factors o Surgery = refractory or severe pain
o Poorly-fitted, tight, or pointed shoes
(Hallux Valgus)
o Pes planus = flat feet
o Rheumatoid arthritis
o Women
• Flexion of PIP joint • PIP pain & deformity • Clinical diagnosis • Treatment = conservative vs. surgery
Hammer Toe • Hyperextension of MTP & DIP joint o Conservative = well-fitting shoes, braces, & stretches
o Surgery = refractory or severe pain
• Joint damage & destruction from neuropathy • Acute = swollen & warm • X-ray = obliteration of joint space, fragmentation • Treatment = conservative vs. surgery
o ↓ sensation, autonomic dysfunction & of bone, ↑ bone density, & disorganized joint o Conservative = accommodative footwear
repetitive microtrauma • Chronic = joint or foot deformity, altered shape of o Surgery = severe deformity
Neuropathic o Bone resorption & weakening foot, ulcer or skin changes
(Charcot)
Arthropathy • Risk factors
o DM
o PVD
o Tabes dorsalis = form of tertiary syphilis
• Entrapment/compression of interdigital nerve • Burning & stinging pain • Clinical diagnosis • Treatment = conservative, steroids, or surgery
o Perineural fibrosis of common digital nerve o Worse = WB (weight bearing) o Conservative
o MC = 2nd & 3rd web spaces • X-ray = not helpful ▪ Metatarsal support or pad
• “pebble” or “rock” in shoe ▪ Broad-toed shoes with firm soles
Interdigital • Risk factors • Numbness/tingling into toes • US or MRI = show most, but not all o Steroids (injections) = refractory to NSAIDs
(Morton’s) o Running o Surgery = refractory to NSAIDs & steroids
Neuroma o Ballet • (+) metatarsal compression test = try to
o High heels reproduce symptoms
o Narrow toe box shoes
o Flat feet • (+) mulder’s sign = clicking sensation when
palpating interspace white squeezing MT joint
• Synovial fluid displaced with cyst formation • Posterior knee pain • US = best initial test (rule out DVT) • Treatment = conservative, steroids, or surgery
• Stiffness o Conservative
• Risk factors • Mass behind knee • X-ray = joint abnormalities associated with cyst ▪ RICE
Baker’s Cyst o Degenerative joint disease • Knee effusion ▪ Assisted weight bearing
o Inflammatory joint disease ▪ NSAIDs
• Ruptured cyst = tenderness, warmth, & erythema o Steroids (injections) = refractory to conservative
o Mimics DVT! o Surgery = refractory to conservative & steroids
• Mechanism = high or low impact injury • Painful ambulation or inability to ambulate • X-ray = initial imaging of choice • Treatment = conservative vs. surgery
• Perineal ecchymosis o Conservative = stable fracture
• Pelvic bones • CT = obtain if (-) x-ray ▪ WBAT
o Ilium ▪ Pelvic binder
o Ischium o Surgery = unstable/severe fracture
o Pubis ▪ ORIF
Pelvic • Complications = DVT, sciatic nerve damage, & vascular
Fracture injury (bleeding)
 • Mechanism = trauma (MC)
o MVC
o Fall from height
• Types
o Posterior = MC
Hip ▪ Axial loading on adducted femur
o Anterior
Dislocation
▪ Axial loading on abducted femur
• Mechanism = depends on age
o Minor or indirect trauma = elderly
o High-impact = younger patients
Hip Fracture • Types = depends on age
o Femoral neck = intracapsular
▪ Higher incident of avascular necrosis
o Intertrochanteric = extracapsular
o Subtrochanteric = extracapsular
• Groin pain
• Posterior = internally rotated & adducted
o Shortened
• Anterior = externally rotated & abducted
• Shortened, externally rotated, abducted
• Hip, thigh, or groin pain
• X-ray = initial imaging of choice
o Posterior = femoral head small & adducted
o Anterior = femoral head large & abducted
• X-ray = initial imaging of choice
• Treatment = conservative vs. surgery
o Conservative
▪ Closed reduction with conscious sedation
o Surgery = severe or associated fracture
▪ ORIF
• Complications = avascular necrosis of femoral head, DVT,
femoral artery injury, sciatic nerve injury, & femoral nerve
injury (anterior)
o Sciatic nerve injury = loss of sensation to posterior
leg & foot, loss of dorsiflexion & plantar flexion, & loss
of DTR at foot
o Femoral nerve injury = loss of sensation over thigh,
weak quadriceps, & loss of DTR at knee
o Femoral artery injury = hematoma, no pulse, pale
• Treatment = conservative vs. surgery
o Conservative = high surgical risk, minimal pain,
non-ambulatory prior to fracture
o Surgery = ORIF or arthroplasty

• Avascular necrosis of femoral head = idiopathic • PAINLESS limp • X-ray = widened cartilage space; (+) crescent • Treatment = conservative vs. surgery
o Lack of blood flow = osteonecrosis sign (microfracture w/ collapsed bone) o Conservative = self-limiting with revascularization
• Hip, thigh, groin or knee pain within 2 years
Legg-Calve- • Risk factors ▪ Activity restriction = NBW
Perthes o 4-10 years old • ↓ ROM = loss of abduction & internal rotation ▪ Orthopedic follow-up
o Male ▪ PT or brace/cast
Disease o Obesity ▪ NSAIDs
o Coagulopathy = Factor V Leiden o Surgery = advanced disease
o Caucasian

• Displacement of femoral head from femoral neck • PAINFUL limp • X-ray = posterior displacement of femoral • Treatment = acute vs. long-term
epiphysis; “ice cream falling from cone” o Acute = NWB & rest
• Occurs during rapid growth • Hip, thigh, groin or knee pain o Early sign = widening & irregularity of physis o Long-term = surgery → internal fixation & pinning
o Blurring metaphyseal-growth plate junction
• Risk factors • ↓ ROM = loss of abduction & internal rotation o Frog-leg view • Complications = avascual necrosis of femoral head
Slipped o 8-16 years old
Capital o Male • Shortened & externally rotated • CT or MRI = additional imaging if needed
Femoral o Obesity • Inability to bear weight
Epiphysis o Growth spurt = weak growth plate & • Drehmann sign = while supine, hip externally
hormonal change at puberty • Evaluate both hips → 25-50% bilateral rotates and abducts with passive hip flexion
o African American
SCFE
• Before puberty = hormonal or systemic disorder
(hypothyroidism or hypopituitarism)

• Irritated or inflamed bursa • Hip pain = specific & well-localized lateral pain • Clinical diagnosis • Treatment = conservative vs. steroids
o Conservative
• Etiologies • Evaluation = put hand at hip & have them due IR & ▪ Analgesics & NSAIDs
o Trauma = MC ER femur (“put out a cigarette”) ▪ RICE
o Repetitive irritation = MC ▪ Therapeutic US
Trochanteric ▪ Ex: = runner ▪ IT band stretching = crossfit roller
Bursitis o Infectious = rare! • Fascia = NOT muscle or tendon
• Hard to stretch
o Steroids (injections) = refractory to conservative
▪ Inject at point of maximal tenderness
 • Anterior or lateral hip pain + audible click • Audible click • Clinical diagnosis • Treatment = conservative
o Snapping with flexion, extension, or abduction o Conservative
• Risk factors ▪ Analgesics & NSAIDs
o Young females • +/ – hip pain = often click WITHOUT pain ▪ Therapeutic exercise
o Athletes ▪ Stretching
Snapping Hip
• Types
Syndrome o External snapping syndrome (lateral)
▪ Tendon = IT band
▪ Grater trochanter
o Internal snapping syndrome (anterior)
▪ Tendon = iliopsoas tendon
▪ Iliopectineal eminence
• Degeneration (wear & tear) of articular cartilage • Crepitus • X-ray • Treatment = conservative, injections, & surgery
o Overgrowth of bone (osteophytes) • Pain o Solidify diagnosis o Conservative
o Narrowing of joint space • Clicking o Aid in tracking progression ▪ NSAIDs
o Joint surface hardening (sclerosis) • Mechanical symptoms o Patient education ▪ Therapeutic exercise
▪ Glucosamine supplement
• Results in joint deformity o Injections = steroids or hyaluronic acid
Glenohumeral
o Surgery = arthroplasty
DJD
• NOT usually associated with inflammation

• Risk factors
o History of surgery or instability
o >50 years old
o Trauma
• AC sprain = shoulder separation • Pain with active ROM → overhead activities • Grading sysyem = 1-6 • Treatment = depends on grade
• ↓ strength (2° pain) o Grade I = overstretching (sprain) o Grade I & II = conservative (non-operative)
• Mechanism = fall directly onto lateral shoulder • Step-off deformity o Grade II = tears (with weakness) ▪ Sling 1-2 weeks prn → use it as they please
o Grade III = complete ligament disruption ▪ ROM & strengthening after sling
• Tenderness @ AC joint
• Shoulder ligaments o Grade IV-VI = displacement ▪ Patient education = make sure to address this!
o Acromioclavicular = horizontal stability • Very painful!
o Coracoclavicular = vertical stability • X-ray = Zanca view (with & without weights) • May have lasting deformity (will not go away)
• Not completely better for 6-8 weeks
• Special tests o Grade III = conservative & surgery (persistent sx)
o Horizontal flexion (cross body) = pain
▪ Surgery has high failure rate
o “Piano key” sign = step-off deformity when
Acromio- o Grade IV-VI = surgery
you push down on clavicle (see if it moves)
clavicular
Sprain /
Dislocation

• Mechanism = blow to abducted & ER arm; • Abducted & ER arm (elbow pointing outward) • X-ray = axillary & scapular “Y” views • Treatment = reduction & immobilization
Anterior FOOSH; posterior humeral force o Hillsach lesion = groove fx of humerus
• Humeral head palpable inferiorly o Bankart lesion = glenoid rim fracture • Complications = axillary nerve injury, axillary artery injury,
Glenohumeral
brachial plexus injury, suprascapular nerve injury, & radial
Dislocation • CT or MRI = additional imaging if needed nerve injury

• Mechanism = forced adduction & IR • Adducted & IR arm • X-ray = axillary & scapular “Y” views
Posterior o Seizure o Light bulb sign = humeral head appears to
o Electric shock look like a light bulb
Glenohumeral
o Trauma
Dislocation
• CT or MRI = additional imaging if needed
 • Overuse/repetitive syndrome
o NOT an injury
• Often with impingement or RTC tear
Bicipital
Tendonitis • Risk factors
o Baseball, tennis, volleyball, or swimming
o Painters
o Carpenters
o Technicians
• Superior labrum anterior to posterior
o Tear of top of labrum from front to back
• SLAP tear = disruption of biceps tendon anchor
• Labrum = “bumper” anteriorly & posteriorly
o Superior labrum = biceps anchor
• Shoulder pain = anterior
o Worse = overhead motion or throwing
• TTP in bicipital groove
• Pain/weakness with arm & forearm flexion
• Shoulder pain = anterior
o Worse = overhead motion or throwing
• TTP in bicipital groove
• Pain/weakness with arm & forearm flexion
• Special tests
o (+) yergasons test = elbow flexion & push
against resistance & palpate bicipital groove
o (+) speeds test = supination & push against
resistance & palpate bicipital groove
• Special tests
o (+) yergasons test = elbow flexion & push
against resistance & palpate bicipital groove
o (+) speeds test = supination & push against
resistance & palpate bicipital groove
o (+) O’Brien’s test = pain with shoulder
flexion resistance with palm down, but not up
• Treatment = conservative vs. steroids
o Conservative
▪ RICE
▪ Tylenol vs. NSAIDS
▪ PT / therapeutic exercises= strengthen muscles
▪ Work restrictions
▪ Therapeutic US
o Steroids = refractory to conservative
▪ NO steroid injections into tendon = could tear it!
▪ Fluro guided & US guided into tendon sheath
• Treatment = depends on types
o Type 1 = debridement → fast (~2 weeks)
o Type 2 = repair (sutures/anchors) → slow (12 weeks)
o Type 3 = debridement → fast (~2 weeks)
o Type 4 = repair (sutures/anchors) → slow (12 weeks)

• Mechanism
o Traumatic = acute injury
o Degenerative = overuse

SLAP Tears • Types

o Type I = fraying labrum by bicep insertion
o Type II = avulsion/detachment of superior
labrum & biceps anchor
▪ Anchor disrupted
o Type III = bucket-handle tear of superior
labrum & biceps anchor intact
o Type IV = bucket-handle tear of superior
labrum that extends into biceps tendon
▪ Anchor disrupted

• Types • Traumatic = deformity & instability • X-ray = pre & post reduction • Treatment = reduction
o Traumatic = glenohumeral dislocation or
subluxation • Atraumatic = deformity & multi-instability • Special tests
▪ Bankart tear = anterior labrum o (+) sulcus sign = pulling inferiorly on arm
▪ Reverse Bankart tear = posterior labrum displaces it inferiorly
Shoulder o Atraumatic = hyperligamentous laxity o (+) anterior apprehension test = pain
▪ Swimmers with shoulder flexion while shoulder abducted
Instability
▪ Ehlers-Danlos & elbow flexed
▪ Marfan o (+) jobe relocation test = pressing on
anterior shoulder after apprehnesion test
relieves pain
o (+) posterior drawer = shoulder & elbow
flexed & pain with axial load posteriorly
• Shoulder stiffness 2o to inflammation • Shoulder pain & stiffness • Clinical diagnosis • Treatment = PT, steroids + ROM vs. lysis of adhesions
o Involves glenohumeral joint & capsule o Worse = at night o Conservative = PT with ROM exercises (1st line)
o Steroids & ROM = fluoro guided steroid injection
• Etiology = immobilization for a long time • ↓ active & passive ROM = worse with ER with aggressive ROM
▪ Glenohumeral intra-articular steroid injection
Adhesive • Risk factors ▪ Aggressive ROM to break up adhesions!
Capsulitis o Hypothyroidism ▪ Need steroid injection before b/c it will be painful
(Frozen o DM o Lysis of adhesions = manipulation under anesthesia
Shoulder) o Prolonged immobilization ▪ Fail injections x2 → they go to OR
o CVA ▪ Shave adhesions then surgeon moves your arm
o Autoimmune

• Gradual return of ROM = 18-24 months

 • Impingement of supraspinatus tendon
o RTC stabilizes humeral head
o Rotator cuff muscles are dynamic stabilizers
▪ During abduction, rotator cuff
depresses humeral head
▪ No stabilization = nerve impingement
• 2o impingement = pinching RTC (supraspinatus)
due to excessive humeral head movement
• 1o impingement = pinching RTC (supraspinatus)
due to anatomic abnormality
Rotator Cuff o Acromion shape & inflamed SA bursa
Impingement
• Mechanism = chronic overuse & trauma
• Shoulder pain = anterolateral
o Worse = combing hair or reaching for wallet
• ↓ ROM with overhead activities, ER & abduction
o passive ROM > active ROM
• Inability to sleep on affected side
• Shoulder pain = anterolateral
• Night pain = wakes from sleep (rotator cuff tear)
• Special tests • Treatment = conservative, steroids, vs. surgery
o (+) neer test = pain with flexion of shoulder o Conservative
with palm facing down ▪ NSAIDS
▪ Impingement ▪ PT / therapeutic exercises = strengthen muscles
o (+) hawkins-kennedy test = elbow & ▪ Rest = NO sling (minimal rest)
shoulder flex with pain with IR o Steroids = subacromial steroid injection
▪ Impingement o Surgery = failed conservative & steroids
o (+) empty can test = thumb down & pain
with shoulder flexion resistance • Full tear or >50% partial tear = surgery
▪ Tear (strength test) • <50% partial tear = conservative
o (+) ER test = pain with ER
▪ Tear (strength test)
o (+) drop arm test = pain with lowering arm
from 90o abduction
▪ Tear (strength test)

• Risk factors = athletes, labor, elderly, smoking • (+) strength / ↓ strength then a tear! → get MRI

• MC = >40 years old • MRI = arthrogram

o MRI dye (gadolinium) into shoulder
• Rotator cuff o Gadolinium = contrast & inflate joint for
o Supraspinatus = MC better visualization
o Infraspinatus
o Teres minor
o Subscapularis

• Mechanism = FOOSH

• Types
o Partial-thickness tear
▪ Bursal side = top tear by acromion
▪ Articular side = bottom tear by humerus
Rotator Cuff o Complete (full-thickness) tear
Tear o Massive = multiple tendons or retracting
▪ Full thickness tear of multiple tendons
▪ Tendon pulls toward body & retracts
▪ Causes a lot more pain
▪ Muscle is not being used → atrophy
▪ MRI = fat in muscle

• Mechanism • Pain & swelling • X-ray = initial imaging • Treatment = acute vs. long-term
o Fall with arm tucked • Ecchymosis o Acute = sling or coaptation splint
▪ Younger = AC separation • CT or MRI = further evaluation o Long-term = conservative & surgery
▪ Older = proximal humerus fracture • ↓ ROM ▪ Conservative = sling or coaptation splint
Proximal o MVC ▪ Surgery = ORIF or hemi-arthroplasty
o Direct blow • Arm held in adducted position
Humerus
Fracture • Classification
o Surgical neck
o Greater tuberosity
o Lesser tuberosity
o “Head splitting” = comminuted fracture
• Mechanism • Pain & swelling • X-ray = initial imaging • Treatment = non-operative vs. operative
o FOOSH • Ecchymosis o Non-operative = sling or sling & swathe
o Direct blow • CT or MRI = further evaluation o Operative = ORIF
• ↓ ROM
Humeral Shaft
• Arm held in adducted position • Complications = radial nerve injury
Fracture
 • Most commonly fractured bone in shoulder • Pain with ROM • X-ray = best initial imaging • Treatment = acute vs. long-term
• Deformity o Acute = sling
• Mechanism • Tenting of skin o Long-term = conservative & surgery
o Fall • Crepitus ▪ Conservative = sling
o Direct blow (anterior) ▪ Surgery = ORIF
• Open
• Classification • Severe skin tenting
Clavicle o Group 1 = midshaft (middle) 1/3 → MC • Severe shortening
Fracture o Group 2 = distal (lateral) 1/3
• 100% displacement
o Group 3 = proximal (medial) 1/3
• Severe comminution
• NOT for cosmetics

• Complications = PTX, hemothorax, coracoclavicular

ligament disruption, & brachial plexus injury

• Mechanism = FOOSH w/ extension & axial load • Flexed elbow • X-ray = initial imaging • Treatment = stable vs. unstable
• Olecranon prominence o Stable = EMERGENT reduction with posterior splint
• Posterior = MC o Unstable = ORIF
Elbow • ↓ ROM
Dislocation • Complications = brachial artery injury, median, ulnar, or
radial nerve injuries, ↓ terminal extension, joint stiffness or
contractures if splint >3 weeks, & compartment syndrome

• Inflammation of tendon insertion of extensor • Lateral elbow pain • Clinical diagnosis • Treatment = conservative, steroids, vs. surgery
carpi radialis brevis (MC) o Worse = pronation, active & resistive wrist o Conservative
extension, & passive wrist flexion ▪ RICE
• Mechanism = pronation & wrist extension ▪ NSAIDs
o Repetitive motions ▪ Diclofenac = topical gel
▪ Activity modification
• MC = >40 years old ▪ Occupational therapy = more helpful than PT
Lateral ▪ Wrist splint = resting wrist is resting elbow tendon
Epicondylitis ▪ Counterforce bracing = tennis elbow strap
• Pressure distally to change angle of pull on
(Tennis Elbow) tendon → putting counterforce on tendon
o Steroids = short-term benefit
▪ Any steroid into tendon weakens tendon
▪ Can put in UE tendon b/c they do not have as
much weight bearing or as much force as LE
o Surgery = refractory to conservative & steroids
▪ No improvement with 6-12 months

• Inflammation of tendon insertion of pronator • Medial elbow pain • Clinical diagnosis • Treatment = conservative, steroids, vs. surgery
Medial teres & flexor carpi radialis o Worse = active & resistive wrist flexion o Conservative
Epicondylitis ▪ RICE
• MC = 40-60 years old ▪ NSAIDS
(Golfer’s Elbow) ▪ Activity modification
o Steroids = short-term benefit → RARELY done
• Mechanism= valgus force • Medial elbow pain • MRI = imaging of choice • Treatment = surgery
• Special tests o Conservative = NONE → will not heal on own!
• Risk factor = overhead throwing (baseball) o (+) valgus stress test = pain with vagus o Surgery = Tommy John w/ ulnar nerve transposition
o Especially pitchers stress
Ulnar o Late cocking & early acceleration o (+) milking maneuver = flex albow &
(Medial) o Loss of velocity/accuracy supinate wrist then pull thumb laterall
Collateral ▪ Feel for gaping or laxity over UCL
Ligament
Injuries
 • Ruptured distal biceps tendon • Pain & swelling • Clinical diagnosis • Treatment = conservative vs. surgery
• Ecchymosis o Conservative = very old OR surgery risks outweigh
• MC = 40-60 years old • MRI/US = surgical planning benefits → will be left with popeye deformity
Biceps Tendon • TTP at radial tuberosity o Surgery = within 3 weeks
(Distal) • Special tests ▪ >3 weeks = muscle/tendon retracts & scars down
Rupture • Popeye deformity = muscle retracted up into arm o (+) hook sign = hooking of biceps tendon ▪ Endo-button with fibro-wire

• Weakness with supination

• Compression/entrapped ulnar nerve @ elbow • Burning & stinging = down into forearm • EMG/NCS = not necessary, but diagnostic • Treatment = conservative vs. surgery
o At cubital tunnel along medial elbow • Numbness & tingling = down into forearm & wrist o Conservative = OT referral
o ↓ sensation to 5th & ulnar side of 4th finger • Special tests o Surgery = surgical decompression or transposition
o (+) tinel sign = reproducible pain with
Cubital tapping ulnar nerve
o (+) wartenburg test = when patient
Tunnel
adducts with palm on table, pinky “lags”
Syndrome ▪ Unopposed action of extensor
o (+) froment’s sign = patient uses thumb to
grab paper
▪ If they flex their thumb, trying to use
flexor pollicis instead of adductor pollicis
• Inflamed or irritated bursa • Goose egg = boggy & swelling • Clinical diagnosis • Treatment = bursitis vs. septic bursitis
o Bursitis = NSAIDs, elbow padding, & ACE wrap
• Etiologies • Chronic = painless & full ROM • Aspiration = evaluate for septic or gout o Septic bursitis = I&D and ABX
o Trauma • Infectious or inflammatory = painful ROM, o +/ – bursa excision = rare
o Overuse = repetitive microtrauma warmth, & erythema
o Gout
o Infectious = staph aureus (MC)
Olecranon o Hemorrhage
Bursitis

• Mechanism = direct blow (fall on flexed elbow) • Pain & swelling • X-ray = best initial imaging • Treatment = non-displaced vs. displaced
Olecranon • Inability to fully extend elbow o Non-displaced = posterior long arm splint
o Displaced = surgical decompression or transposition
Fracture
• Complications = ulnar neuropathy
• Mechanism = direct blow • Pain & swelling • X-ray = best initial imaging • Treatment = non-displaced vs. displaced
o Non-displaced
Ulnar Shaft • Nightstick fracture = fracture of middle ▪ Distal 3rd = short arm cast
Fracture portion of ulnar shaft without any other fractures ▪ Mid-proximal 3rd = long arm cast
o Displaced = surgical decompression or transposition

• Radial head wedges into annular ligament • Arm flexed at elbow & pronated • Clinical diagnosis • Treatment = closed reduction
o Annular ligament slips over head of radius & • Child refuses to use arm o Closed reduction = supinate & flex or hyperpronate
into radiohumeral joint • Tenderness to radial head (lateral elbow)
• Observe child using arm after 15 minutes
• Mechanism = axial traction on pronated forearm
Radial Head w/ elbow in extension
Subluxation o Swinging
o Pulling
(Nursemaid’s o Lifting
Elbow)
• MC = 2-5 years old
 • Mechanism = FOOSH • Tenderness to lateral elbow • X-ray = best initial imaging • Treatment = acute vs. long-term
• Inability to fully extend elbow o Anterior fat pad DISPLACED = sail sign o Acute = sling & posterior splint
• +/– effusion o Posterior fat pad PRESENT o Long-term = conservative & surgery
▪ Abnormal & more specific for fracture ▪ Conservative = sling & posterior splint
Radial Head • Splint <10-14 days
Fracture ▪ Surgery = ORIF

• Proximal 1/3 ulnar shaft fracture + radial • Pain & swelling • X-ray = best initial imaging • Treatment = stable vs. unstable
head dislocation • Thumb paresthesia o Stable = splint
o Unstable = ORIF
Monteggia • Mechanism = direct blow
• Complications = wrist drop (radial nerve injury)
Fracture
• “A” = bones affected proximally

• Mid-distal radial shaft fracture + distal • Pain & swelling • X-ray = best initial imaging • Treatment = stable vs. unstable
radioulnar joint dislocation • Deformity o Stable = splint
• Ulnar head appears prominent at wrist o Unstable = ORIF
Galeazzi • Mechanism = FOOSH
• Complications = anterior interosseous nerve injury and
Fracture
• “Z” = bones affected distally compartment syndrome

• MC than Monteggia

• Incomplete fracture through part of cortex • Pain & swelling • X-ray = best initial imaging • Treatment = depends on location & involvement
Greenstick o Like fracturing young wood stick/ wood • Deformity o Immobilization followed by casting
▪ Does not get break through entire bone
Fracture o Pediatric bones are squishy & less calcified • Complications = high risk for repeat fracture

• Bowing or bending deformation • Pain & swelling • X-ray = best initial imaging • Treatment = depends on location & involvement
o Pediatric bones are spongey & compress • Deformity
Torus
• Mechanism = axial loading
(Buckle)
Fracture • Only seen in pediatric population

• Too high to be Salter Harris

• Where they lie in relation to growth plates
o ONLY applies to open growth plates
• Epiphysis vs. metaphysis
o Epiphysis = pink area
o Metaphysis = white area
o physis = growth plate = epiphyseal plate
• Salter-Harris classification
o Type 1 = growth plate only
Salter-Harris o Type 2 = fracture above epiphyseal plate
Fracture o Type 3 = below growth plate
o Type 4 = through growth plate
o Type 5 = crush
• Pain & swelling • X-ray = best initial imaging
• Deformity o Type 1 = can’t see anything on x-ray because
growth plates are black on x-ray
▪ Commonly missed injuries
▪ REPEAT = calcification (bone healing)
o Type 5 = crushed black growth plate
• Treatment = depends on type
• Prognosis
o Type 1 = good
o Type 2 = good** → MC type of SH fracture!!
o Type 3 = poor (often unstable)
o Type 4 = poor
▪ Prone to limb length discrepancies
o Type 5 = worst
▪ Prone to limb length discrepancies

• Mnemonic
o S = slipped
o A = above
o L = lower
o T = through
o (e)
o R = raised
 • Mechanism = FOOSH with wrist extension
• Location = anatomical snuff box
• MC fractured carpal bone
Scaphoid
Fracture
• Onset = sharp pain • X-rays (AP, lateral, & oblique) = initial imaging • Treatment = acute vs. long-term
• Later = dull & achy pain o Scaphoid views = zoom in on scaphoid o Acute = thumb spica
o May not show up on initial films ▪ Non-displaced or snuff box tenderness
• TPP in snuffbox ▪ Repeat films in 1 week o Long-term = conservative & surgery (ortho referral)
• Palpable crepitus ▪ Conservative = thumb spica & bone stimulator
• Bone scan, CT or MRI = more sensitive ▪ Surgery = screw or pin +/ – bone graft
• Pain with passive radial deviation
• Pain with axial loading of thumb • Complications = avascular necrosis of scaphoid
o Poor blood supply = “watershed area”
o Non-union = non-healing
o More distal = more likely to heal (better blood supply)

• Widened space between scaphoid & lunate • Pain & swelling • X-ray = widened scapholunate spaces >3 mm • Treatment = conservative vs. surgery
Scapholunate • Mechanism = FOOSH o Pain = dorsal radial wrist o Conservative = radial gutter splint
Dissociation o Surgery = severe

• Genetic defect of type 1 collagen • Osteoporosis = severe & premature • Clinical diagnosis • Treatment = meds, PT, or surgery
• Spontaneous fractures o Meds = bisphosphonates
Osteogenesis • Autosomal dominant • Limb deformities & shortening → increased laxity • X-ray = osteopenia o Physical therapy
• Blue sclera o Surgery = fractures
Imperfecta
• AKA “brittle bone” disease • Easily bruise • Genetic testing = definitive diagnosis
• Complications = fetal or perinatal death & IUGR
• Hearing loss = presenile

• Distal radial fracture w/ DORSAL displacement • Wrist pain • X-ray = best initial imaging → need lateral view • Treatment = acute vs. long-term
o Worse = passive motion o Acute = short arm cast (sugar-tong splint)
• Mechanism = FOOSH with wrist extension ▪ Control supination & pronation
• Dinner fork deformity o Long-term = conservative & surgery
▪ Conservative = short arm cast
Colles
▪ Surgery = ORIF
Fracture
• Complications = extensor pollicis longus tendon rupture,
malunion, nonunion, joint stiffness, median nerve
compression, residual radius shortening, & complex
regional pain syndrome
• Distal radial fracture w/ VOLAR displacement • Wrist pain • X-ray = best initial imaging • Treatment = acute vs. long-term
o Worse = passive motion o Acute = short arm cast (sugar-tong splint)
• Mechanism = FOOSH with wrist flexion ▪ Control supination & pronation
Smith • Garden spade deformity o Long-term = conservative & surgery
Fracture ▪ Conservative = short arm cast
▪ Surgery = ORIF

• Lunate not articulating with capitate & radius • Pain & swelling • X-ray = best initial imaging • Treatment = acute vs. long-term
• Median nerve symptoms o “piece of pie” = lunate appears triangular o Acute = closed reduction & splint
• ORTHOPEDIC EMERGENCY o Palmar aspect of first 3 + ½ of 4th digits o “spilled teacup” = volar displaced & tilt of o Long-term = ORIF
Lunate lunate
Dislocation

• Lunate occupies 2/3 of radial articular surface • Pain & swelling • X-ray = best initial imaging • Treatment = immobilization & ortho follow-up
Lunate
Fracture
• Complications = Kienbock’s disease
• Avascular necrosis of lunate • Swelling & stiffness • X-ray = increased denisty of lunate • Treatment = conservative vs. surgery
o Leads to progressive collapse o Ulna negative variance = shorter o Conservative = immobilization
• Crepitus o Surgery = late presentation or severe
Kienbock’s • Etiology = unknown • ↓ ROM • Bone scan & MRI = more sensitive ▪ Radial shortening osteotomy
Disease o Disruption of blood supply? • Weakness with grip ▪ Vascularized bone graft
o Undiagnosed fracture? • TTP over lunate ▪ Proximal row carpectomy
o Repetitive trauma ▪ Wrist arthrodesis = joint fusion
• Effusion
 • Injury to extensor tendon @ dorsal DIP joint • Pain & swelling = dorsal aspect • X-rays (AP, lateral, & oblique) = initial imaging • Treatment = soft tissue vs. bony (fracture)
o May be tendon rupture • Ecchymosis o Finger specific = not just hand x-rays o Soft tissue = 6-8 weeks of extension splinting
o May be avulsion fracture ▪ May initiate within 3 months of injury
Mallet
• Flexion deformity & extensor lag at DIP ▪ DO NOT immobilize PIP joint
(Baseball) • Mechanism = sudden flexion of DIP o Bony (fracture) = K-wire fixation
Finger o Volleyball ▪ Fracture fragment > 50% articular surface
• TTP at distal finger = DIP
o Basketball • Pain with motion ▪ Dislocation with fracture

• Injury to flexor tendon @ volar DIP joint • Pain & swelling = volar aspect • X-rays (AP, lateral, & oblique) = initial imaging • Treatment = conservative vs. surgery
o May be tendon rupture • Ecchymosis o Finger specific = not just hand x-rays o Conservative = not usually an option
o May be avulsion fracture o Surgery = ALL jersey fingers require surgery
• Flexion deformity at DIP → CANNOT flex DIP ▪ Primary tendon repair
• FDP = flexor digitorum profundus ▪ Fracture fragment repair
• TTP at distal finger = DIP
• Mechanism = sudden hyperextension of DIP • Pain with motion
Jersey Finger during active flexion
o Caught in shirt/jersey • Lump in palm = tendon balled up
o Football o Tendon retracts back into palm
o Lump is their tendon
• Ringer finger = MC o Retracts because tension pulling it back
o Flexor tendons = stronger & deeper
▪ Compared to extensor tendons

• Entrapment tendinitis of lateral wrist
• 1st dorsal extensor compartment
o Abductor pollicis longus
o Extensor pollicis brevis
De Quervain • Mechanism = repetitive lifting & thumb use
Tenosynovitis o Golfers
o Clerical workers
o Postpartum = lifting newborn
o Diabetes
• Pain & swelling @ radial side of wrist
o Worse = thumb extension
• TTP radial wrist & base of thumb
• “Snowball crepitus” = like snowball crunching
• Clinical diagnosis = no imaging needed
• Special tests
o (+) finkelstein test = pain with ulnar
deviation while thumb flexed in palm
• Treatment = conservative, steroids, or surgery
o Conservative = 6-8 weeks of extension splinting
▪ RICE
▪ NSAIDs
▪ Thumb spica splint
▪ PT/OT referral
o Steroids (injections) = refractory to conservative
o Surgery = refractory to nonoperative

• MC = women 30-50 years old & new moms

• Stenosing flexor tenosynovitis
o Thickened “pulley”/ thickened sheath
• MC = 2nd, 3rd, & 4th fingers
Trigger Finger • Etiologies = overuse or injury
• Pain = worse in AM & PM
• Palpable nodule = thickened “pulley”
• Finger gets “stuck”
• Clinical diagnosis = no imaging needed
• Treatment = conservative, steroids, vs. surgery
o Conservative
▪ NSAIDs
▪ Bracing = trigger finger brace
o Steroids = short-term benefit
▪ Persistent relief >1 year in 50% of patients
• Other 50% may need 2nd injection
o Surgery = surgical release
▪ 98% effective → EXCEPT in diabetics!
• Not as effective in diabetics

• Loss of joint continuity • Pain & loss of ROM • X-rays (AP, lateral, & oblique) = initial imaging • Treatment = reduction & splint
• Deformity o Finger specific = not just hand x-rays o Reduction = with or w/out anesthetic (digital block)
• DIP > PIP > MCP o Rule out fracture before reduction! ▪ Traction = no recreation → right into traction
▪ “Re-create injury” then traction
• Dorsal > volar o Splint
▪ Lateral/medial = buddy tape → follow-up prn
Finger • Mechanism ▪ Dorsal = splint → need ortho follow-up
Dislocation o Hyperflexion ▪ Volar = splint → need ortho follow-up
o Hyperextension
o Lateral force • Contraindications to reduction
o Medial force o Open dislocation
o Axial load o Associated fracture
o Digital N/V compromise
o Inability to reduce
 • Injury to thumb ulnar collateral ligament (UCL) • Pain & swelling = 1st MCP • X-ray = best initial imaging • Treatment = acute vs. long-term
o Base of proximal phalanx at 1st MCP o Do not stress MCP joint prior to X-rays! o Acute = thumb spica & ortho referral
o Forced abduction • “Jammed thumb” ▪ Must rule out fracture first o Long-term
• Ecchymosis @ thenar eminence ▪ Do not want to displace bony fragment ▪ Partial tear or non-displaced fracture = cast/splint
• Mechanism = valgus & hyperextension ▪ Complete tear or displaced fracture = surgery
o Skier • Valgus stress causes >35-degree laxity • Special tests
o Football o (+) valgus stress test = increased laxity
Gamekeeper’s o FOOSH
• Painful ROM
& Skier’s • Stress x-ray = PE equivocal & standard x-ray (–)
• Weak pincer grip
Thumb • Classifications
o Partial or complete tear • MRI = increased signal if tear present
o +/– fracture = proximal phalanx fracture
o Acute or chronic

• Types
o Skier’s thumb = acute
o Gamekeeper’s thumb = chronic / overuse
• Fracture at neck of 4th & 5th metacarpal • Pain & swelling • X-rays (AP, lateral, & oblique) = initial imaging • Treatment = conservative vs. surgery
Boxer’s • LOOK FOR BITE WOUNDS!! o Conservative = ulnar gutter splint
Fracture • Mechanism = punching wall or face o Might get bit while punching o Surgery = severe
o ABX = bite wound (augmentin)
• Thumb arthritis • Grinding & cracking at joint • X-rays = best initial imaging • Treatment = conservative, injections, vs. surgery
o Solidify diagnosis o Conservative
• Pain o Monitor disease progression ▪ Rest
Carpo- o Worse = repetitive activity, grip, or writing o Patient education ▪ Activity restriction
metacarpal o Improves = rest ▪ NSAIDs = analgesics
DJD ▪ Bracing
• Grip weakness ▪ Therapy = improves function
o Injections = steroids or hyaluronic
o Surgery = arthrodesis
• Median nerve entrapment & compression • Pain & paresthesia • No imaging needed • Treatment = conservative, steroids or surgery
o Palmar aspect of first 3 + ½ of 4th digits o Conservative
• Risk factors o Worse = night, driving, & repetitive activities • EMG/NCS = diagnosis is not clear / confirm ▪ Volar splint / brace = help if waiting for surgery
o Women o Cervical radiculopathy or thoracic outlet?? ▪ NSAIDs
o DM • Clumsiness with hand o Make sure it is just locally at wrist! ▪ Avoid repetitive movements / activity restriction
o Pregnancy ▪ PT & OT = improve function & strength
o Hypothyroidism • Thenar muscle wasting = advanced disease • Special tests • Nerve gliding
Carpal Tunnel o Rheumatoid arthritis o (+) carpal compression test = pressure on • Therapeutic ultrasound
o Overweight / obese median nerve reproduces symptoms
Syndrome o Steroids (injections) = refractory to conservative
• Short term = numbness & tingling in fingers o (+) tinel test = percussion of median nerve
▪ Methylprednisolone = 40 mg vs. 80 mg
• Long term = nerve damage & muscle weakness reproduces symptoms
o (+) phalen test = flexion of both wrists ▪ 80% get relief initially
reproduces symptoms ▪ +/– no more than 2x per year
o Surgery = refractory to nonoperative
▪ Open or endoscopic = cutting flexor retinaculum
▪ Earlier return to work & activity with endoscopic
▪ No difference in long-term outcomes
• Metacarpal fracture of base of thumb • Pain & swelling • X-ray = best initial imaging • Treatment = conservative vs. surgery
• Ecchymosis o Bennet = small fragment of thumb base o Conservative = thumb spica splint
Bennet & • Mechanism = axial force to flexed thumb • TTP of CMC joint = base of thumb o Rolando (Y-sign) = splitting of thumb base o Surgery = closed reduction with pinning & ORIF
Rolando
Fracture • Bennet = non-comminuted
• Rolando = comminuted

• Fibrosis of palmar fascia • Nodules over distal palmar crease • Clinical diagnosis • Treatment = conservative, injections, or surgery
o Leads to contracture from nodules or cords • Thickened skin o Conservative = physical therapy
• Bands in palmar fascia o Injections = intralesional collagenase or steroids
• Risk factors • Fixed flexion deformity at MCP o Surgery = advanced stages, impaired function, or
Dupuytren o Men refractory cases
Contracture o >40 years age • UNABLE to straighten finger!
o EtOH
o Cirrhosis
o Diabetes mellitus
o Smoking
 NEUROLOGY
Visit Etiology Presentation & PE Diagnosis Treatment & Complications
• Unilateral CN VII (facial) nerve palsy • Hemifacial weakness & paralysis → forehead • Diagnosis of exclusion → rule out CVA! • Treatment = supportive & meds
o From inflammation or compression o Can’t lift eyebrow or wrinkle forehead o Supportive = artificial tears & eye patches
o Meds = prednisone & acyclovir
• LOWER motor neuron disorder • Hyperacusis = ear pain (ipsilateral) ▪ Prednisone = within 72 hours to ↓ recovery time
• Dysgeusia = loss of taste ▪ Acyclovir = HSV suspected
Bell’s Palsy • Etiologies
o HSV = MC • ↓ lacrimation & ability to full close eye
o Idiopathic • Lip droop = unable to smile • Consider LYME DISEASE in certain areas!
o DM • Ipsilateral tongue numbness
o Pregnancy = especially 3rd trimester
o Post URI
o Dental nerve block • Ramsay Hunt = shingles causing Bell’s palsy
• Death of brain tissue with neurological symptoms • Anterior cerebral artery • CT head = best initial test (rule out hemorrhagic) • Treatment = short vs. long term
o Arm & leg weakness with sensory deficits o Might be normal in 1st 6-24 hours o Short-term = ↓ brain injury by reestablishing perfusion
• Ischemic = MC type of stroke ▪ Incontinence ▪ tPA = within 3-4 hours
▪ Impaired gait & stance • CTA & MRA = evaluate location of ischemic CVA • Within 3 hours after symptoms onset
• Types o Homonymous hemianopsia • S/E = bleeding (ICH)
o Thrombotic = thrombus inside artery (MC) • Fingerstick = rule out hypoglycemia • BP = ≤185/≤110 (tPA) & <220/<120 (no tPA)
o Embolic = piece of thrombus breaks off • Middle cerebral artery ▪ Thrombectomy = within 24 hours
▪ Intracerebral o Face & arm weakness with sensory deficits • CBC = anemia & PLTs • Large artery occlusion in anterior circulation
Ischemic ▪ Extracerebral = carotid artery dissection o Aphasia
Stroke • Can do outside of 3-4 hour window of tPA
▪ Cardioembolic = Afib, valvular disease, etc. ▪ Broca’s = expressive • PT/INR & PTT = hypercoagulable assessment o Long-term = prevent recurrent strokes
▪ Wernicke’s = receptive ▪ Antiplatelet = ASA , Plavix or dipyridamole
CVA • Risk factors • Troponin = rule out MI ▪ Statins = regardless of LDL level
o HTN = MC & modifiable risk factor • Posterior cerebral artery
o Visual changes
▪ Anticoagulation = nonvalvular Afib
o HLD • EKG & telemetry = evaluate for arrythmias or MI
o DM o Vertigo
o Afib o Vomiting • Do not treat HTN until BP is extreme or giving tPA
• Echo = detect cardiogenic and aortic sources o If needed, lower by 15% in 1st 24 hours
o Smoking
o Male • Typically no headache! → headache = bleed • Carotid US = rule out atherosclerotic disease
o Older age • Complications = MI, CHF, dysphagia, aspiration PNA, UTI,
o FHx DVT, PE, dehydration, malnutrition, & pressure ulcer
• Bleeding between skull & dura • LOC → lucid interval → neurological symptoms • CT head w/out contract = biconvex (lens) • Treatment = observation vs. surgery
o Potential space o Artery spasms to stop bleeding initially o Does NOT cross suture lines o Observation = small & stable
o Arterial bleed o Surgery = hematoma evacuation or craniotomy
• Minutes-hours later = rapid deterioration • GCS = initial assessment & serial monitoring ▪ Surgery should be done within 2-4 hours
• Middle meningeal artery & basilar skull fracture o Headache
Epidural o MMA is behind pterion (thin area of bone) o VOMITING • ↑ ICP = hyperventilation, head elevation, & mannitol
o Basilar skull fracture = through petrous part of o Aphasia
Hematoma
temporal bone o Hemiparesis
o Seizures & coma
ICH • Etiologies
o Trauma = MVA, falls, assault, athletics, blasts • Basilar skull fracture
o Periorbital ecchymosis = raccoon eyes
• CC = younger male with history of trauma o Hemotympanum
o Postauricular ecchymosis = battle sign
o CSF otorrhea & rhinorrhea = halo sign
• Bleeding between dura & arachnoid membrane • LOC → lucid interval → neurological symptoms • CT head w/out contract = crescent or semilunar • Treatment = observation vs. surgery
o Potential space o Veins have slower bleeding time o DOES cross suture lines o Observation = small & stable
o Venous bleed o Surgery = hematoma evacuation or craniotomy
• Minutes-hours later = rapid deterioration • GCS = initial assessment & serial monitoring ▪ Surgery should be done within 2-4 hours
Subdural • Etiologies o Headache
Hematoma o Trauma = MVA, falls, assault, athletics, blasts o VOMITING • ↑ ICP = hyperventilation, head elevation, & mannitol
o Spontaneous o Aphasia
ICH ▪ Deceleration o Hemiparesis
▪ Coagulopathy = anticoagulants o Seizures & coma
o Elderly & EtOH = veins stretch w/ brain atrophy

• CC = older person with or without fall

 • Bleeding between arachnoid membrane & pia • Headache = THUNDERCLAP • CT head w/out contract = subarachnoid bleeding • Treatment = supportive, surgery & meds
• Worst headache of my life o Supportive = neuro intensive care unit
• Etiologies = MC anterior communicating artery • Nausea & VOMITING • GCS = initial assessment & serial monitoring ▪ ICP = elevate HOB, hyperventilation, mannitol
o Ruptured berry aneurysm • Seizure = typically a late finding • Mannitol = hypertonic saline
o AVM @ Circle of Willis • AMS • LP = (–) CT & no papilledema or focal deficits ▪ Maintain adequate O2, breathing & circulation
• Meningismus o Xanthochromia = breakdown of RBCs o Meds
Subarachnoid
• Risk factors ▪ Yellow tinge → CSF should be clear ▪ HTN = labetalol or nicardipine
Hemorrhage o Smoking o ↑ protein • Lowering BP too much could cause infarction
o HTN o ↑ opening pressure (because of ↑ ICP) ▪ CCBs = nimodipine
CVA o Polycystic kidney disease
• Works longer than labetalol & nicardipine
o Atherosclerotic disease
o EtOH • ↓ cerebral vasospasms → spasms could cause
ICH ischemia & further neurological damage
o Ehlers-Danlos
o Marfan syndrome o Surgery = clipping or coil embolization
o FHx ▪ Within 72 hours to prevent rebleeding

• CC = rapid onset of HA with or without exertion

• Bleeding in brain parenchyma • Headache • CT head w/out contract = intracerebral bleeding • Treatment = supportive, surgery & meds
• Nausea & VOMITING o Supportive = neuro intensive care unit
• Risk factors • Syncope ▪ ICP = elevate HOB, hyperventilation, mannitol
o HTN = MC • Focal neuro deficits = hemiplegia & hemiparesis • Mannitol = hypertonic saline
o Cerebral amyloid angiopathy • Seizure = typically a late finding ▪ Maintain adequate O2, breathing & circulation
Intracerebral ▪ Angiopathy of small & medium vessels o Meds
Hemorrhage • AMS
▪ Beta amyloid accumulates in media ▪ HTN = labetalol or nicardipine
• Meningismus
o AMV = arteriovenous malformation • Lowering BP too much could cause infarction
CVA ▪ Abnormal connection of arteries & veins o Surgery = certain cases → ex: craniotomy
o Trauma
o Older age
o EtOH
o Coagulopathy = anticoagulants

• Transient brain, spinal cord or retinal ischemia • Neurological symptoms • CT head = best initial test (rule out hemorrhagic) • Treatment = depends on cause
o WITHOUT acute infarction o <24 hours (MC = <30 minutes) o Large artery disease = meds & revascularization
o Symptoms vary depending on location • CTA & MRA = evaluate location of ischemic CVA ▪ Antiplatelet, BP meds, & statins
• Types o NO permanent neuro symptoms o Internal carotid artery = carotid endarterectomy
o Embolic = Afib, ventricular thrombus, etc. • +/– carotid bruits • Carotid US = rule out atherosclerotic disease ▪ Stenosis = 50-99% & life expectancy of 5 years
o Lacunar = small vessel • Amaurosis fugax = monocular vision loss ▪ ASA 81 to 325 mg/day started before surgery
o Large artery = low-flow (carotid a. stenosis) o Transient vision loss! • EKG & telemetry = evaluate for arrythmias or MI o Small vessel disease = meds
o Temporary shade down on one eye ▪ Antiplatelet, BP meds, & statins
• Risk factors • Echo = detect cardiogenic & aortic sources o Unknown cause = BP reduction, antithrombotic
o HTN = MC & modifiable risk factor therapy, statins, & lifestyle modification
o HLD • Fingerstick = rule out hypoglycemia o Atrial fibrillation = anticoagulation
o DM ▪ Coumadin or direct oral anticoagulant (DOAC)
o Afib
o Smoking • CBC = anemia & PLTs
o Male • ASA = 2o CVA prevention
Transient o Older age • PT/INR & PTT = hypercoagulable assessment
Ischemic o FHx
Attack • ABCD2 = identify those at risk of ischemic stroke
o Age ≥60 years = 1 point
o BP ≥140/≥90 mmHg = 1 point
o Clinical features
▪ Unilateral weakness = 2 points
▪ Speech disturbance = 1 point
▪ Other = 0 points
o Duration of symptoms
▪ ≥60 minutes = 2 point
▪ 10 to 59 minutes = 1 point
▪ <10 minutes = 0 points
o Diabetes = 1 point
 • Abnormal state of unconsciousness • No appropriate response to verbal stimulation or • CBC, CMP, ABG, PT/PTT & drug screen • Treatment = treat underling cause & +/– intubation
o Being unconsciousness is not abnormal appropriate resistance to motor stimulation o Intubation = usually GCS <8
• Loss of oculocephalic response = dolls eyes • GCS = helps determine prognosis NOT diagnosis o HOTN = vasopressors
• Risk factors • Loss of caloric responses o Eyes = 4 points o Dextrose or thiamine = EtOH or malnourished
o Lesion of RAS = maintains alertness & breathing • Decerebrate responses o Verbal = 5 points o Herniation = mannitol
o Damaged cerebral hemispheres o Motor = 6 points o Hyperthermia = antipyretics &/or cooling blankets
o Drugs o Seizures = phenytoin or fosphenytoin
• Eyes closed & need respirator
o Toxins o PVS = eyes open, sleep cycles & respirations
o Metabolic • Complications = persistent vegetative state or brain death
Coma o Infection

• Types
o Deep coma = no reactions of any kind
o Lighter stages = reflexes may be elicited or
spontaneous movement may occur
o Still lighter stages = "semicomatose", person
may stir or moan to vigorous stimulation

• Mild traumatic brain injury • Headache • CT head = if meets Canadian Head CT criteria • Treatment = cognitive & physical rest
o Temporary disturbance in brain function • Dizziness o Slowly begin exercise & work after symptom-free
o Brain “rattled” inside skull by a blow to head • Confusion ▪ School ½ day & walk 20 minutes
o Bruise / sprain of your brain • Amnesia o AVOID falling → bikes, trampoline, etc.
• Visual disturbances
• Risk factors • Complications = Second Impact Syndrome or Chronic
• Delayed responses
o Blunt force Traumatic Encephalopathy
o Acceleration/deceleration head injury
• Labile emotions o Post-concussive Syndrome
• Sleeping difficulties ▪ Symptoms persist >10 days after initial injury
• Software problem = concussion o Second Impact Syndrome
Concussion • Hardware problem = skull fx, bleeding, herniation • ↑ ICP = HA, vomiting & papilledema ▪ Swelling & herniation
o Need to rule out hardware problem! o Chronic Traumatic Encephalopathy (CTE)
• Physical exam • Stages ▪ Long term & permanent cognitive impairment
o Cognitive = memory & concentration o Initial injury = + /– LOC
▪ Emotional/personality changes
o Coordination = finger-to-nose & Romberg o Migraine = light/sound sensitivity & N/V
o Hangover = tired, poor concentration, & ▪ Chronic brain damage from multiple head injuries
o Eyes (fundoscopy) = assess for papilledema
o Ears/nose = look for CSF dull HA
o Observe for broken nose, lacerated lip, etc. o Resolution of symptoms = but not risk!
o Palpate head & neck
o Assess neck ROM
o Assess cranial nerves → EOM (nystagmus)
• Autonomic dysfunction s/p bone or soft tissue injury • Sensory = pain & hyperalgesia • Clinical diagnosis • Treatment = pain management
o Ex: fracture or surgery • Motor/tropic changes o NSAIDs = 1st line
o ↓ ROM • X-ray = patchy osteoporosis & osteopenia o PT & OT
• MC = upper extremities, women & >30 years old o ↑ hair & nail growth → ↓ growth o Steroids (PO and injections)
• Edema • Bone scintigraphy = ↑ uptake (“hot spot”) o TCAs = amitriptyline
o Gabapentin
• Erythema
• Diagnostic criteria o Transcutaneous electric nerve stimulation
• Sweating
• Vasomotor = temperature & color changes o Continuing pain
Complex
o >1 symptom in 3/4 categories:
Regional ▪ Sensory = hyperesthesia or allodynia
Pain ▪ Vasomotor = temp asymmetry &/or
Syndrome skin color changes &/or asymmetry
(CRPS) ▪ Sudomotor (sweating) or edema
▪ Motor/trophic = ↓ ROM &/or motor
Reflex dysfunction &/or trophic changes
Sympathetic o >1 sign in 2/ 4 categories:
Dystrophy ▪ Sensory = hyperalgesia (to pinprick)
(RSD) and/or allodynia (to light touch,
temperature sensation, deep somatic
pressure, and/or joint movement)
▪ Vasomotor = temp asymmetry &/or
skin color changes &/or asymmetry
▪ Sudomotor (sweating) or edema
▪ Motor/trophic = ↓ ROM &/or motor
dysfunction &/or trophic changes
o No other diagnosis better explains S/S
 • Acute, abrupt & transient confused state • Rapid onset! → transient confused state • CBC = infection • Treatment = treat underlying disease, meds & supportive
o Disturbances in attention or awareness o Usually resolves within 1 week
o 80% have pre-existing dementia • AMS • CMP = electrolyte or metabolic disturbances o Haldol & risperidone = 1st line
• Short-term memory deficit o Comfort measures = reorientation strategies,
• Etiologies = 2o to identifiable cause • Disorganized thinking • Drug screen reducing stimulation, frequent reassurance, & limit
Delirium o Medications visitations of family and friends in hospital
• Hallucinations
o Infections → UTI, PNA, etc. • EtOH level
o Electrolyte abnormalities
• Disturbed sleep/wake cycle
o CNS injury
o Organ failure • Worse in evening
o Drug intoxication or withdraw • Rapid shifts in mood states
• Progressive & nonreversible dementia • Short-term to long-term memory loss • Diagnosis of exclusion → rule out other causes • Treatment = medication to treat symptoms (NO CURE)
• Loss of IADLs → loss of ADLs o Depression o Cholinesterase Inhibitors = mild to moderate
• MC type of dementia • Disorientation o Electrolytes & hypothyroidism ▪ Donepezil (Aricept)
• Behavioral & personality changes o Meds (esp with anticholinergic activity) ▪ Rivastigmine (Exelon)
• Risk factors o Eyes/ears (declining vision/hearing) ▪ Galantamine (Razadyne)
o Disinhibition = lack social graces
o Older age o Normal pressure hydrocephalus o NMDA Receptor Antagonist = moderate to severe
o Apathy
o FHx o Tumors / Trauma / Toxic ▪ Memantine (Namenda) = neuroprotective
o Social withdraw
Alzheimer’s o Genetics o Self-centered o Infection (HIV & syphilis) / Ischemia / ICH
Dementia o Anemia (B12 or folate deficiency) or Alcohol
o Wandering • Medication for behavioral side effects
• Causes o Other = SLE, sarcoidosis, COPD, & OSA
• Langue difficulties o SSRIs = treatment of agitation & paranoia
o Amyloid deposition (senile plaques) • Loss of motor skills o Benzodiazepines = not proven to be of benefit
o Tau proteins (tangles) • MMSE = monitor progression & severity o Atypical antipsychotics = behavioral benefits, but
o ACh deficiency increased mortality
• In beginning, declarative (semantic) memory • MRI = cortex atrophy
(WHAT) worse than procedural (HOW) ▪ Olanzapine, risperidone, quetiapine
• Autopsy = definitive diagnosis
• Brain disease from ischemia & infarctions • ABRUPT & step-wise progression • Diagnosis of exclusion → rule out other causes • Treatment = manage risk factors!
o Lacunar infarctions o HTN, HLD, & DM
Vascular • Executive dysfunction • MRI = cortical & subcortical infarcts o Smoking
Dementia • Risk factor = HTN (MC) • Apathy o Afib
o EtOH abuse
• Focal motor deficits
• 2nd MC type of dementia • Ataxia
• Rapid dementia → frontotemporal pick bodies • Memory impairment = early on • Histology = pick bodies in cortex • Treatment = N/A
o Brain degeneration in frontotemporal lobes
Frontotemporal • Personality & social behavior changes
Dementia • Younger age of onset • Disinhibition = lack social graces
• Executive dysfunction
Pick’s Disease • Apathy
• Neglect of personal habits
• Loss of ability to communicate
• Progressive dementia → diffuse Lewy bodies • Memory impairment = later on • Histology = Lewy bodies in cortex • Treatment = N/A
o Lewy body dementia = diffuse Lewy bodies
o Parkinson disease = localized Lewy bodies • Visual hallucinations
Lewy Body • Delirium
Dementia • Parkinsonism
• Autonomic dysfunction
• Motor symptoms linked to memory problems

• From cells of CNS or METS from systemic cancers
o Systemic cancers = lung, melanoma, & breast
• Astrocytoma = derived from astrocytes
o Various grades → grade I = MC in kids
Intracranial • Glioblastoma multiforme = MC & aggressive
Tumors o Males, >50 years old, HHV-B, CMV, radiation
o Grade IV astrocytoma
• Meningioma = MC from dura mater
o Females & radiation
• Headache → wakes you up at night • MRI w/ contrast = contrast enhancing masses • Treatment = surgery, chemotherapy & radiation
o New onset >40 years old o Surgery = astrocytoma, glioblastoma & meningioma
• Fever, night sweats & weight loss • Histology ▪ Chemo & radiation = adjunct therapy or surgery
• CN deficits o Glioblastoma = pseudo palisading not possible
• AMS o Meningioma = psammoma bodies & o Chemo & radiation= CNS lymphoma
• Neurological deficits spindle cells ▪ Methotrexate = most effective chemo
• Seizures
• Vision changes
• ↑ ICP = HA, vomiting & papilledema
• Weakness

• CNS lymphoma = rare form of NHL

 • Infection of brain parenchyma • Headache • Head CT = rule out lesions • Treatment = supportive
• Stiff neck = nuchal rigidity o Supportive = antipyretics, IVF, & analgesics
• Etiologies • Photosensitivity • LP = best initial test
o HSV = MC • Fever & chills o High = lymphocytes
Encephalitis o Varicella zoster • N/V o Normal = protein & glucose
o Epstein-Barr
• Seizures
o Measles
o Mumps • AMS
o Rubella • Personality, speech & movement changes
o HIV o Distinguishes from aseptic meningitis
• Bacterial infection of meninges • Headache • BC, gram stain, & LP (CSF examination) • Treatment
• Stiff neck = nuchal rigidity o S. pneumoniae
• Etiologies • Photosensitivity • LP = best initial test ▪ Dexamethasone = ↓ neuro complications
o Listeria = <1 month old & >50 years old • Fever & chills o High = WBCs (>1000), protein & pressure • Might ↓ entry of vancomycin into CSF
o E. coli = <1 month old • N/V o Low = glucose • Add rifampin if giving dexamethasone
o S. agalactiae (GBS) = <1 month-3months ▪ Ceftriaxone or cefotaxime
• Lethargy
o S. pneumoniae = >3 months old & adults • LP first, UNLESS… ▪ Vancomycin
o Haemophilus influenzae = 3 months-18 years • AMS o Immunocompromised (ex: chemo or HIV)
• Petechial rash = N. meningitidis o Neisseria meningitidis
o Neisseria meningitidis = 10-19 years old o History of CNS disease (ex: lesion or CVA)
• Prostration = lying stretched out
▪ Ceftriaxone or cefotaxime OR ampicillin
o New onset seizure
▪ Add rifampin OR ciprofloxacin to eradicate
• Might have parameningeal infection • Papilledema o Papilledema
nasopharyngeal colonization
o Abscess, OM, or sinusitis • Kernig & Brudzinski signs o Abnormal LOC
o Haemophilus influenzae
o Focal neurologic deficit
Bacterial ▪ Ceftriaxone or cefotaxime OR ampicillin
• … then CT before LP o Listeria monocyotgenes
Meningitis
▪ Ampicillin OR penicillin
▪ Gentamicin = added for synergy
o Gram negative bacteria = E. coli and Klebsiella
▪ Ceftriaxone or cefotaxime
o Pseudomonas
▪ Ceftazidime OR cefepime OR meropenem

• DO NOT DELAY START OF ABX FOR LP OR CT

• Empiric <50 years old

o Ceftriaxone + vancomycin
• Empiric >50 years old
o Ceftriaxone + vancomycin+ ampicillin
• Viral infection of meninges • Headache • BC, gram stain, & LP (CSF examination) • Treatment = supportive & antivirals
• Stiff neck = nuchal rigidity o Headache & fever = Tylenol
• Etiologies • Photosensitivity • Rule out bacterial meningitis o Acyclovir = if you suspect HSV
o Viral • Fever & chills
▪ Enterovirus = coxsackie or echovirus • N/V • LP = best initial test (PCR) • Empiric ABX until you rule out bacterial meningitis
▪ HSV • Lethargy o High = lymphocytes
Viral ▪ Measles, mumps or rubella o Normal = protein, glucose, & pressure
• AMS
(Aseptic) ▪ Arbovirus → mosquito & ticks • Prostration = lying stretched out
o Mycobacteria • LP first, UNLESS…
Meningitis • Papilledema
o Spirochetes o Immunocompromised (ex: chemo or HIV)
o Malignancy • Kernig & Brudzinski signs o History of CNS disease (ex: lesion or CVA)
o Meds o New onset seizure
o Papilledema
o Abnormal LOC
o Focal neurologic deficit
• … then CT before LP
• Fungal or TB infection of meninges • Headache • BC, acid-fast stain, & LP (CSF examination) • Treatment = antifungals or antituberculous therapy
• Stiff neck = nuchal rigidity o Fungal = amphotericin B + flucytosine
• Fungal meningitis = candida albicans or • Photosensitivity • Rule out bacterial meningitis o TB = 4 drug antituberculous therapy & steroids
cryptococcus neoformans • Fever & chills ▪ TB therapy = isoniazid, rifampin,
o Candida = premature babies & s/p neuro surgery • LP = best initial test ethambutol, & pyrazinamide
Fungal / TB • N/V
Meningitis
o cryptococcus neoformans = HIV and CD4 <100 o High = lymphocytes & protein ▪ Steroids = dexamethasone
• Lethargy
o Low = glucose
• TB meningitis = Mycobacterium tuberculosis • AMS o Normal = pressure
• Prostration = lying stretched out
• Papilledema • Indiana ink stain (CSF) = Cryptococcus
• Kernig & Brudzinski signs
 • Dilation of cerebral ventricles • Triad = wet, wobbly & weird • MRI or CT = enlarged ventricles • Treatment = VP shunt & CSF drainage for gait problems
o Impaired CSF absorption = after CNS injury o Dementia/cognitive dysfunction
o Gait disturbances = wide & shuffling gait • LP = normal opening pressure
• Etiologies ▪ Magnetic gait
Normal o SAH o Urinary incontinence
Pressure o Chronic meningitis • ↑ DTRs = hyperreflexia
Hydrocephalus o Tumor • Rigidity
o Trauma = head injury • Spasticity
• Weakness
• Lethargy

• Primary headache • Headache = lateralized & pulsatile/throbbing • Clinical diagnosis • Treatment = acute vs. preventative
o Worse with physical activity o Acute
• MC = women • N/V ▪ Mild to moderate = NSAIDs or Excedrin
• Photophobia • Excedrin = acetaminophen/ASA/caffeine
• Risk factors • Phonophobia ▪ Moderate to severe (outpatient) = triptans
o Stress • Auras = focal neurological symptoms • Sumatriptan
o Sleep deprivation & fatigue o Occurring prior to OR during an attack • Sumatriptan/naproxen combination
o EtOH o Visual = MC ▪ Moderate to severe (inpatient) = triptans,
o Foods = chocolate o Auditory ergots, antiemetics, NSAIDS, or steroids
o Hormonal = OCPs or menstruation o Somatosensory
Migraine o Dehydration • Triptans = sumatriptan
o Loss of function = aphasia or hearing
Headaches • Antiemetic = Reglan or Compazine
o With Benadryl to prevent dystonic rxns
• Duration = 4-72 hours • Severe = dihydroergotamine plus Reglan
o Give ergots with antiemetics
• Ketorolac (Toradol) → IV NSAID
• Dexamethasone = adjunct
o Preventative
▪ Antihypertensives = BB or CCB (Verapamil)
▪ Antidepressants = TCAs or SNRIs (Effexor)
▪ Anticonvulsants = valproate or topiramate

• Primary headache • Headache = unilateral & periorbital/temporal
o Worse at night, EtOH, stress or foods
• PNS activation = vasoactive neuropeptide release • Horner’s syndrome = ptosis, miosis, anhidrosis
Cluster • Nasal congestion & rhinorrhea
• MC = young & middle-aged males • Conjunctivitis & lacrimation
Headaches
• Duration = <2 hours (several times a day)
o Attacks occur daily → followed by remission
• Clinical diagnosis • Treatment = acute vs. preventative
o Acute = O2 vs. triptans
▪ High flow O2 = 1st line
▪ Triptans = 2nd line → only if O2 ineffective
o Preventative = CCB (Verapamil)

• Primary headache = MC type
• Caused by sensitization to pericranial nociception
o Muscle tenderness from hypersensitivity to pain
o Frontoparietal and parietal-occipital areas
Tension-Type
Headaches • Onset = 30 years old
• Headache = bilateral & tightening
o Tightening = head band tightness
o Non-throbbing/non-pulsatile
o Worse with stress, fatigue, noise or glare
• Duration = starts in morning & lasts during day
• Clinical diagnosis = diagnosis of exclusion • Treatment = acute vs. preventative
o Acute = NSAIDs, ASA, or acetaminophen
o Preventative = TCAs (amitriptyline)
• Complications = chronic TTH may form migraines

• Risk factors
o Stress
o Sleep deprivation / fatigue
o Eye strain

• Compression of trigeminal nerve (CN V) • Headache = paroxysmal, brief, & stabbing • Clinical diagnosis • Treatment = meds or surgery
Trigeminal o Superior cerebellar artery or vein OR idiopathic o Shock-like pain o Meds
Neuralgia
o Worse = touch, chewing, brushing teeth, wind ▪ Carbamazepine = 1st line
• MC = middle-aged women or movement ▪ Oxcarbazepine = 2nd line
▪ Gabapentin, baclofen, or lamictal
Tic Douloureux • Trigeminal nerve = V1, V2, & V3 o Surgery = surgical decompression or gamma knife
 • Autoimmune demyelinating disease of PNS • Symmetric ascending weakness & paresthesia • Electrophysical studies = ↓ motor n. conduction • Treatment = plasmapheresis or IVIG
o Demyelinating polyradiculopathy of PNS • Weakness of respiratory & bulbar muscles o Nerve conduction o Plasmapheresis or IVIG = 1st line
o Autoantibodies attack myelin sheath o Bulbar = swallowing, chewing & speech o Needle electromyography ▪ Choice is dependent on local availability
• ↓ DTRs o Intubation = respiratory failure
• MC = 2o to infection (GI or respiratory) • Sensory deficits = CN palsies • LP = seen 1-3 weeks after symptom onset o DVT prophylaxis
Guillain- • Autonomic dysfunction = ↑ HR, arrythmias, o High = protein
Barre • Risk factors = GI or respiratory infections HOTN or HTN, breathing difficulties o Normal = WBCs • Prognosis = 60% fully recover
Syndrome o Campylobacter jejuni = MC o Poor prognosis
o CMV • PFTs = ↓ FVC ▪ Older age
PNS o Epstein-Barr virus ▪ Rapid onset = <7 days prior to presentation
o HIV ▪ Severe muscle weakness on admission
o Mycoplasma ▪ Need for ventilatory support
o Immunizations ▪ Distal motor response reduced to <20% of normal
o Post-surgical
▪ Preceding diarrheal illness

• Autoimmune demyelinating disease of CNS
o Degenerated white matter (brain & spinal cord)
• MC = women 20-40 years old & colder countries
o Colder country = less vitamin D
Multiple
Sclerosis • Types
o Relapsing remitting = episodic exacerbations
CNS o Progressive = decline without exacerbations
o Secondary progressive = relapsing remitting
that becomes progressive
• Relapsing remitting = MC
• Sensory disturbances
• Weakness
• Visual disturbances = diplopia & optic neuritis
o Optic neuritis = inflammation of optic nerve
• Nystagmus
• Trigeminal neuralgia
• UMN lesion = spasticity, (+) Babinski, & ↑ DTRs
• Bladder, bowel & sexual dysfunction
• Lhermitte’s sign = neck flexion causes lightning-
shock from spine down to legs
• MRI = hyperintense white matter plaques
o Periventricular area
• LP = ↑ IgG & oligoclonal bands
• Treatment = meds
o IV steroids (high dose) = 1st line
o Plasmapheresis = no response to steroids
• Prevention of relapses = meds
o Beta-interferon or glatiramer = 1st line
o Natalizumab = relapsing remitting
o Methotrexate = 1o or 2o progressive
o Amantadine = antiviral that helps with fatigue
o Baclofen = helps with spasticity

• Autoimmune peripheral nerve disorder
o Autoantibodies against ACh ® on muscles
• MC = women <40 years old & men >50 years old
• Associated with abnormal thymus gland
o Hyperplasia or thymoma
Myasthenia
Gravis
• Ocular & general muscle weakness
o Ocular = diplopia & ptosis
o General = respiratory & bulbar muscles
• Weakness WORSE with repeated muscle use
• (+) anti-Ach ® antibodies
• Electrophysical studies = repetitive stimulation
of affected muscles leads to worsening deficit
o Nerve conduction
o Needle electromyography
• Edrophonium (Tensilon) test = improvement of
symptoms after administration (b/c ↑ ACh)
• Ice pack test = apply ice for 10 minutes
o Improves ocular symptoms
o Cold ↓ AChE breakdown of ACh at NMJ
• CXR, CT or MRI = to evaluate thymus gland
• Treatment = meds & surgery
o AChE inhibitors = 1st line
▪ Pyridostigmine or neostigmine
o Thymectomy = even if thymus gland is normal
o Immunosuppression
• AVOID fluroquinolones, aminoglycosides & BB
o Exacerbate myasthenia gravis
• Complications = myasthenic crisis or pemphigus vulgaris
• Myasthenic crisis
o Bulbar or respiratory weakness requiring intubation
o Causes = infection, metabolic, meds, overdose of AChE
inhibitors, & idiopathic
o Tx = plasmapheresis or IVIG

• Antibodies against presynaptic Ca2+ channels • Proximal muscle weakness • (+) Ca2+ channel antibodies • Treatment = treat underling malignancy & meds
• Dry mouth o Pyridostigmine = 1st line
• Associated w/ small cell lung CA or other malignancy • Postural HOTN • Electrophysical studies = repetitive stimulation o Plasmapheresis, IVIG or immunosuppression
Lambert- • ↓ DTRs of affective muscle leads to improvement ▪ Considered 2nd line
Eaton o Nerve conduction
Syndrome • Weakness IMPROVES with repeated muscle use o Needle electromyography

• CT scan = asses for malignancy

Amyotrophic • Necrosis of UPPER & LOWER motor neurons • Asymmetric limb weakness • Electromyography = loss of neural innervation • Treatment = no cure (no medication stops the disease)
Lateral
o Neurodegenerative disorder • Bulbar symptoms = swallowing, chewing & speech o Riluzole = ↓ glutamate in neurons
o Progressive motor degeneration • Cognitive impairment • ↑ CPK o CPAP, BiPAP, and ventilator = might be needed
Sclerosis
(ALS) • Prognosis = fatal within 3-5 years → respiratory failure MC
• UMN = spasticity, stiffness, ↑ DTRs
• LMN = atrophy, ↓ DTRs, fasciculations
Lou Gehrig’s
 • Slow, progressive neurodegenerative disease
• Movement disorder = loss of dopaminergic
neurons in substanita nigra
o Decreased dopamine from Lewy bodies
o Lewy Bodies = substantia nigra
Parkinson’s
Disease
• Loss of dopamine = failure of ACh inhibition
o ACh = excitatory neurotransmitter
o Dopamine = inhibitory neurotransmitter
• Onset = 45-65 years old
• Autosomal dominant
Essential • Onset = incidence increases with age
Tremor
• Autosomal dominant
• Progressive neurodegenerative disorder
Huntington
• Trinucleotide repeats (CAG) on Huntington gene
Disease
o Chromosome 4
• Onset = 20-50 years old
• Disease with spontaneously recurring seizures
o Recurrent & unprovoked seizure
o Provoked seizures = NOT epilepsy
▪ Structural = bleed, CVA or tumor
▪ Metabolic = CKD, ↓ Na, or ↓ glucose
▪ Infection = meningitis or encephalitis
▪ Medications or toxins
▪ EtOH withdrawal
▪ Hypoxia
Epilepsy
• ↑ excitatory neurotransmitter (glutamate)
• ↓ inhibitory neurotransmitter (GABA)
• Some AEDs inactivate voltage gated Na+ channels
• Some AEDs inactivate voltage gated Ca2+ channels
• Single & continuous epileptic seizure
o >5 minutes OR
o >2 seizures w/out full recovery of consciousness
• Refractory status epilepticus (RES) = seizure not
responding to 1st or 2nd line antiepileptic meds
Status • Etiologies
Epilepticus o Structural = bleed, CVA or tumor
o Metabolic = CKD, ↓ Na, or ↓ glucose
o Infection = meningitis or encephalitis
o Medications or toxins
o EtOH withdrawal
o Hypoxia
• NEUROLOGICAL EMERGENCY
• Triad = tremor, bradykinesia & rigidity
o Tremor = resting tremor (pill rolling)
o Bradykinesia = slow movement
o Rigidity (muscle) = cogwheel rigidity
• Akinesia = trouble starting movement
• Postural instability = more prone to falls
• Propulsive gait (stooped and bent)
• Poor speech quality & drooling
• Masklike face → no facial expression
• Dementia = late finding
• Autonomic nervous system abnormalities
• Excess sweating and salivation
• Intentional tremor → bilateral & symmetric
o Postural tremor
o Worse = movement, writing, stress or anxiety
o Improves = EtOH & rest
• No other neurological findings
• Triad = mood, movement & memory
o Behavioral & mood changes
o Chorea → worse w/ stress & voluntary moving
o Dementia → onset before 50 years old
• Gait abnormalities
• Ataxia
• Incontinence
• Facial grimacing
• Seizures = <5 minutes
o Focal
o Generalized
o Unknown
• Post-ictal state = brief confusion after seizure
• Continued seizure
• Clinical diagnosis
• Diagnosis of exclusion
• History, FHx & rule out other causes
• Clinical symptoms + FHx + genetic testing
• CT or MRI = cerebral & striatal atrophy
• Diagnostic criteria = any of the following
o >2 unprovoked seizures
▪ >24 hours apart
o 1 unprovoked seizure & probability of
future seizures similar to recurrence risk
after 2 unprovoked seizures, occurring over
the next 10 years
o Diagnosis of an epilepsy syndrome
• Neurological exam = generally normal!
• EEG = determines type of seizure
o May be normal between seizures
o Way to evoke seizure = prolong monitoring,
sleep deprivation, & hyperventilation
• CT or MRI = rule out stroke or tumor
• CBC & CMP = rule out reversible causes
• Fingerstick = rule out hypoglycemia
• CT or MRI = rule out stroke or tumor
• EEG = determines if seizure is occurring
o Helpful if patient sedated & need to know if
there is still seizure activity
• Treatment = medication to treat symptoms (NO CURE)
o Levodopa/carbidopa → delay starting this
▪ S/E = dyskinesia (chorea & dystonia) & on-off sx
o Bromocriptine (1st line) = dopamine antagonist
o Selegiline & Rasagiline (Azilect) = MOA-B inhibitor
o Benztropine (helps with tremors) = anticholinergic
▪ Used in younger patients b/c tremor predominates
o Amantadine = antiviral & dopamine agonist
o Catechol-O-methyltransferase (COMT) inhibitors
• Complications = mood disorders, psychosis, ANS
dysfunction, fatigue, sleep disturbance, etc.
• Treatment = none, meds or surgery
o Usually no treatment needed
o Propranolol = 1st line → if severe or situational
o Primidone (barbiturate) = 2nd line
o Alprazolam (benzodiazepine) = 3rd line
o Thaolamotomy = refractory cases
• Treatment = no cure (no medication stops the disease)
o Antidopaminergics = Tetrabenazine
▪ Dyskinesia or chorea
▪ Chorea caused by ↑ dopamine
o Antipsychotics
o Benzodiazepines = helps chorea & sleep
• Treatment = antiepileptics (after >2 unprovoked seizures)
o Sodium channel blockers
▪ Phenytoin = focal or status epilepticus
▪ Carbamazepine = focal
▪ Oxcarbazepine = focal
▪ Lamictal = focal & generalized (S/E = SJS)
▪ Zonisamide = add-on → focal & generalized
▪ Lacosamide = focal
o Enhanced GABA activity
▪ Phenobarbital = focal
▪ Tigabine = focal
▪ Benzodiazepines = status epilepticus
o Calcium Channel Blockers
▪ Ethosuximide = absence
o Multiple Mechanisms of Action
▪ Valproic Acid = broad spectrum
▪ Topiramate = focal & generalized
▪ Gabapentin = focal
▪ Pregabalin = add-on → focal
▪ Keppra = broad spectrum
• Treatment = supportive & meds (benzos & AEDs)
o Supportive = O2, lay on side & seizure pads
o Benzodiazepines (long-acting) = 1st line
▪ Diazepam, lorazepam, midazolam
• Lorazepam = considered 1st line by doctors
o AEDs = 2nd line & continued suppression of seizures
▪ Phenytoin, fosphenytoin, valproate or
phenobarbital
• Fosphenytoin = drug of choice
o Thiamine = EtOH abuse
• RSE (refractory status ep) = no response to benzos or AED
o IV midazolam, propofol, or phenobarbital
o Will require intubation**
• Complications = brain damage or refractory SE
 • Neuronal discharge from 1 section of 1 hemisphere • Focal sensory, motor or autonomic symptoms
o Depends on lobe effected
• Retained awareness (simple) = LOC maintained • Motor = jerky rhythmic movements
• Impaired awareness (complex) = LOC impaired o Tonic = muscular rigidity
o Clonic = rhythmic jerking
• Sensory = paresthesia’s, numbness, pain, flashing
lights, head & cold, olfactory
• Autonomic = abdomen (pain & N/V), BP changes,
Focal
cardiac (↑ HR), & bronchoconstriction
(Partial)
Seizures • Auras = precede or accompany seizure
• Automatisms = repetitive behaviors (chewing,
lip smacking, facial grimacing, or eye twitching)
• Todd’s paralysis = neuro deficit for <24 hours
• Jacksonian march = jerky rhythmic
movements starting in one area & spreading
• Neuronal discharge from both hemispheres • Tonic-clonic (grand mal) = LOC with tonic &
clonic activity and postictal state
• Generalized tonic-clonic (grand mal) = MC o Cyanosis
Generalized o Urinary incontinence
(Grand Mal)
Seizure • Tonic = muscular rigidity
• Clonic = rhythmic jerking
LOC • Myoclonic = sudden & brief sporadic twitching
o One muscle or a group of muscles
• Atonic = complete loss of tone = drop attacks
• Absence = pause/staring
• Generalized seizure involving both hemispheres • Pause/staring = lasting 5-10 seconds
Absence o Impaired LOC without loss of body tone
(Petit Mal) • MC = childhood
Seizure • NO post-ictal phase
• CBC & CMP = rule out reversible causes
• Fingerstick = rule out hypoglycemia
• CT or MRI = rule out stroke or tumor
• EEG = determines type of seizure
o Simple = focal discharge
o Complex = interictal spike & slow waves
• CBC & CMP = rule out reversible causes
• Fingerstick = rule out hypoglycemia
• CT or MRI = rule out stroke or tumor
• EEG = high-amplitude rapid spiking
• EEG = bilateral 3 Hz spike & wave activity
• Treatment = supportive, follow-up, +/– meds
o Treat underlying cause!
o Supportive = O2, lay on side & seizure pads
o Discharge = most patients recover & can be DC’d
o Referral = neurologist (unless provoked seizure)
o Admission = complicated patient
▪ Prolonged postictal state
▪ Incomplete recovery
▪ Serious seizure-related injury
o Seizure precautions = be aware of seizure triggers
▪ Avoid activities that pose danger with sudden LOC
• Bathing
• Swimming alone
• Working at heights
• Operating heavy machinery
o Driving restriction = ~6-12 months of no driving
o Medication = meets criteria for epilepsy
• Treatment = meds
o Ethosuximide = 1st line

LOC • Automatisms = repetitive behaviors (chewing,

lip smacking, facial grimacing, or eye twitching)
• Types • Vasovagal = pale, nauseous, dizzy, & myoclonic • Orthostatic = systolic >20 mmHg drop, diastolic • Orthostatic hypotension = fluids & meds
o Reflex syncope jerks before syncope >10 mmHg drop BP, or HR >20 bpm rise o Supportive = fluids (PO or IV)
▪ Vasovagal, situational, carotid sinus syncope o Meds
• Vasovagal = blood, pain, fear, stress • Orthostatic HOTN = dizzy during vital signs • Brugada syndrome = RBBB with ST elevation ▪ Fludrocortisone
• Situational = coughing, urination, BM in V1-V3 ▪ Pyridostigmine (Mestinon) = AChE inhibitor
• Carotid = turn head, shave, tight clothes • Brugada syndrome = hereditary & sudden death • Improves ganglionic neurotransmission in
o Postural hypotension • Long Q syndrome = prolonged QT interval sympathetic baroreflex pathway
▪ Impaired autonomic function • Long QT syndrome = hereditary & sudden death o Could lead to R on T → Torsades (v tach)
• Postganglionic sympathetic neurons do • Brugada syndrome = pacemaker
not release norepinephrine correctly
▪ Hypovolemia = hemorrhage or N/V/D • Long Q syndrome = pacemaker & avoid certain meds
▪ Meds = alpha blockers, BB, SSRIs, diuretics
▪ DM neuropathy
Syncope ▪ EOTH
▪ Parkinson disease or Lewy body dementia
▪ Adrenal insufficiency
o Cardiac
▪ HCM, Brugada, Long QT syndrome, SVT, &
valvular disease (ex: aortic stenosis)

• Children = breath holding or toxin ingestion

• Mimic syncope
o Hypoglycemia
o Seizure
o Hyperventilation
 DERMATOLOGY
Etiology Presentation & PE Diagnosis Treatment & Complications
• Inflammatory skin disorder of pilosebaceous unit • Open comedos = blackhead • Clinical diagnosis • Treatment = topical vs. PO → ~6-8 weeks for results
o Papules & pustules • Closed comedos = whitehead o Topical = mild to moderate
• Severe = pustules, pustules & nodules • Severity ▪ Salicylic acid = prevents hyperkeratinization
• Risk factors o Mild = small # of papules & pustules ▪ Azelaic acid = limits C. acnes
1. Excess sebum • Face, chest, back, neck & shoulders o Moderate = large # of papules & pustules ▪ Benzoyl peroxide = OTC panoxyl wash or cream
2. Keratinization o Severe = nodular (>5 cm) or cystic acne • Antibacterial & comedolytic
3. Bacterial growth → Cutibacterium acnes • Use with ABX but NEVER with retinoids
▪ aka Propionibacterium
4. Inflammation
▪ ABX (topical) = erythromycin & clindamycin
▪ Retinoid (topical) = 1st line for mild (entire face)
• Androgens = ↑ sebaceous glands • Tretinoin (Retin-A)
• Adapalene (Differin)
Acne • Tazarotene (Tazorac)
Vulgaris o Oral = moderate or severe
▪ ABX (PO) = doxycycline & minocycline
▪ Hormonal = OCPs & spironolactone
• ↓ androgens
▪ Isotretinoin (PO) = refractory nodular acne
• ↓ sebaceous glands & sebum production
• S/E = dry skin, teratogenic, ↑ TGs & chol,
photosensitivity, HA, & worsens DM

• Chronic acneiform skin condition • MC = face • Clinical diagnosis • Treatment = lifestyle & meds
o Lifestyle = sunscreen & avoid irritants
• Etiology = unknown • Centrofacial erythema • Biopsy = definitive diagnosis o Mild to moderate
o Vasomotor instability • Flushing ▪ ABX (topical) = Metronidazole (1st line)
o Capillary vasodilation • Telangiectasias = cheeks & nose (MC) ▪ Azelaic acid = Finacea
o Abnormal pilosebaceous activity • Skin coarsening = burning & stinging ▪ Ivermectin (topical) = Soolantra
• Red eyes o Moderate to severe
• Risk factors ▪ ABX (PO) = doxycycline
• Rhinophyma = enlarged & red nose
o Caucasian = light skin ▪ Laser therapy
o Women o Telangiectasias = Mirvaso and Rhofade
Rosacea o 30-50 years old ▪ Vasoconstrictors only!
▪ Can get rebound redness after Rhofade wears off
• Triggers • Rhofade is like Afrin
o EtOH
o Hot or cold weather
o Hot drinks
o Hot baths
o Spicy foods
o Sun exposure
o Medication

• Superficial hair follicle infection & inflammation • Papules & pustules with surrounding erythema • Clinical diagnosis • Treatment = mild or severe
• Pruritis o Mild
• Etiologies ▪ ABX (topical) = erythromycin & clindamycin
o Staph aureus = MC overall ▪ Benzoyl peroxide = OTC panoxyl wash or cream
o Other gram (+) & gram (–) • Antibacterial & comedolytic
o Fungi o Severe
Folliculitis o Pseudomonas = hot tub folliculitis ▪ ABX (PO) = cephalexin & dicloxacillin
• Risk factors
o Men
o ABX use
o Steroids = topical
 • Follicular keratinization • Follicular papules & perifollicular erythema • Clinical diagnosis • Treatment
o Lifestyle = avoid skin dryness & hot showers
• MC = proximal arms & legs o Emollients
Keratosis o Keratolytics (topical)
o Retinoids (topical)
Pilaris o Steroids (topical) = prominent inflammation

• Autoimmune hair loss • Hair loss (patches) = smooth, discrete & circular • Clinical diagnosis • Treatment = steroids
o Targets anagen hair follicles o Local = intralesional steroids
▪ Anagen = growth phase • Exclamation point hairs • Biopsy (punch) = definitive diagnosis o Extensive = topical steroids
o Associated with other autoimmune disorders o Short hair broken off a few mm from scalp
▪ SLE o Tapering near proximal hair shaft
▪ Hashimoto’s
Alopecia ▪ Addison’s disease • Nails = pitting, fissuring, & trachyonychia (rough)
Areata
• Scalp = MC

• Genetic progressive loss of terminal hairs
o DHT = androgen causing androgenic alopecia
o Activation of DHT ® ↓ growth phase
o ↓ anagen to telogen ratio
Androgenetic ▪ Anagen = growth phase
Alopecia ▪ Telogen = resting phase
• Onset = after puberty
• Hair loss = thinning & nonscarring • Clinical diagnosis • Treatment = meds or surgery
o Minoxidil (topical) = vasodilator → aka Rogaine
• Men = bitemporal & vertex • Dermoscopy = mini hairs & brown perihilar casts ▪ MOA = vasodilates to ↑ delivery of O2 & nutrients
• Women = frontal & vertex • Promotes anagen phase
▪ S/E = pruritis & local irritation with flaking
o Finasteride (PO) = 5 alpha reductase inhibitor
▪ MOA = inhibits testosterone to DHT
▪ S/E = ↓ libido & sexual dysfunction; ↑ risk of
prostate cancer

• Fungal nail infection (MC = great toe) • Triad = thickened, discolored & cracked • Clinical diagnosis • Treatment = antifungal (PO or topical)
o PO = most effective treatment (S/E = hepatotoxicity)
• Etiologies • Subungual hyperkeratinization • Culture (fungal) = weeks to get results ▪ Terbinafine = 1st line
o Dermatophytes ▪ Itraconazole = 2nd line
▪ Trichophyton & epidermophyton • KOH wet mount = rapid results (yeast) o Topical = PO agents contraindicated or not desired
o Candida albicans ▪ Efinaconazole
o Nondermatophyte molds • Acid-schiff test = rapid results (fungus) ▪ Tavaborole
Onychomycosis
• Risk factors
o Elderly
o Tinea pedis
o Psoriasis
o Occlusive shoes
o Immunodeficiency

• Infection of lateral & proximal nail folds • Pain & swelling • Clinical diagnosis • Treatment = with or without abscess
• Erythema o Without abscess
• Etiologies ▪ Mild
o Staph aureus = MC • Warm water soaks or antiseptic soaks
o Strep pyogenes (GAS) • ABX (topical) = mupirocin
o Candida albicans ▪ Moderate
o Oral flora = nail biting
• ABX (PO) = cephalexin or dicloxacillin
Paronychia o With abscess
• Risk factors = penetrating nail trauma ▪ I&D
o Nail biting o Nail biting = augmentin or clindamycin
o Cuticle damage
o Splinters
 • Infection of fingertip pulp space • Pain & swelling • Clinical diagnosis • Treatment = with or without abscess
o Paronychia → felon • Erythema o No fluctuance
• Throbbing ▪ Warm water soaks or antiseptic soaks
• Etiologies ▪ ABX (PO) = cephalexin or dicloxacillin
o Staph aureus = MC o Fluctuance
o Strep pyogenes (GAS) ▪ I&D
Felon
• Risk factors = penetrating nail trauma
o Nail biting
o Cuticle damage
o Splinters

• Infection of deep dermis & subcutaneous fat • Erythema • Clinical diagnosis • Treatment = ABX
o Bacterial entry after break in skin • NOT sharply demarcated o MSSA
▪ Skin problem = impetigo or tinea • Blanchable ▪ PO = cephalexin or dicloxacillin
▪ Trauma = bites, wounds or pressure ulcers • Swelling ▪ IV = cefazolin, nafcillin or oxacillin
▪ Surgical wounds • Warmth o MRSA
• Tenderness ▪ PO = clindamycin, doxycycline or bactrim
• Etiologies ▪ IV = vancomycin
o Strep pyogenes (GAS) = MC o Dog or cat bite = Augmentin
• Uncommon = fever, chills, & LAD
o Staph aureus
Cellulitis • Complications = gangrene, sepsis, & glomerulonephritis

• Infection of upper dermis & cutaneous lymphatics • Erythema • Clinical diagnosis • Treatment = ABX
• SHARPLY demarcated o MSSA
• Etiologies • Blanchable ▪ PO = cephalexin or dicloxacillin
o Strep pyogenes (GAS) = MC • Swelling ▪ IV = cefazolin or ceftriaxone
o Staph aureus • Warmth o MRSA
• Tenderness ▪ PO = clindamycin, doxycycline or bactrim
▪ IV = vancomycin
• Common = fever, chills, & LAD
• Complications = gangrene, sepsis, & glomerulonephritis
• Millian = ear involvement

Erysipelas
 • HIGHLY contagious superficial bacterial infection
• Types
o Primary = direct invasion of normal skin
o Secondary = cut or bite and it got infected
• Non-bullous = MC
o S. aureus (MC) & strep pyogenes (GABHS)
o Papules, vesicles, & pustules + weeping
o “Honey” crusted yellow lesions (1 week)
o Face & extremities
• Clinical diagnosis • Treatment = supportive & ABX
o Supportive = soap + water & good skin hygiene
• Gram stain = if needed o Topical = mupirocin (1st line)
o PO = cephalexin or dicloxacillin
• Wound culture = definitive diagnosis

• MC in children = 2-5 years old • Bullous impetigo = young kids → severe & rate
o S. aureus (MC) & strep pyogenes (GABHS)
• Risk factors ▪ S. aureus = produce exfoliative toxin
o Poor hygiene o Vesicles to flaccid bullae + clear yellow fluid
Impetigo o Poverty ▪ Ruptures → brown crust (varnish-like)
o Crowding o Fever & diarrhea
o Warm & humid o Severe form = Staph Scalded Skin
o Skin trauma Syndrome

• Ecthyma = ulcerative pyoderma → uncommon

o Strep pyogenes (GAS)
o Punched-out ulcers = epidermis & dermis
o Yellow crust surrounded by raised margins

• Candida albicans = part of GI & GU flora • Esophageal = odynophagia, GERD, epigastric • Clinical diagnosis • Treatment = depends on type
o Encapsulated budding round yeast pain, & N/V → AIDs defining disease (CD4 <200) o Esophageal = fluconazole (PO)
• KOH = budding yeast & pseudohyphae o Thrush = nystatin (wash) or fluconazole (PO)
• MC opportunistic pathogen • Oropharyngeal (thrush) = friable white plaques o Vulvovaginal = fluconazole (PO), miconazole or
o Bleeds if scraped! • Gram stain = Swartz-Lamkins fungal stain clotrimazole (vaginal suppository)
• Risk factors o MC opportunistic infection in HIV patients ▪ Vaginal suppositories are preferred in pregnancy
o DM • Culture = Sabouraud agar or Nickerson’s medium o Intertrigo = clotrimazole (topical) & keep dry
o HIV • Vulvovaginal = pruritis, burning, & white DC o Recurrent infections or lack of response to tx o Endocarditis (fungemia) = Amphotericin B (IV)
Candidiasis o Pregnant o Culture identifies non-albicans species
o ABX • Intertrigo = pruritic beefy red rash & satellite
AIDS Defining lesions in moist & macerated area • Endoscopy = esophagitis
o MC under folds (breasts and pannus)
Illness
(Esophageal) • BC & echo = endocarditis (fungemia)
• Endocarditis (fungemia) = immunocompromised

• Inflammation of lymphatic channels • Erythema • Clinical diagnosis • Treatment = ABX if associated with cellulitis
o Infectious or noninfectious • Tenderness o MSSA
• Streaks = extending proximally ▪ PO = cephalexin or dicloxacillin
Lymphangitis • +/– associated with cellulitis ▪ IV = cefazolin or ceftriaxone
• Lymph nodes (local) = lymphadenitis o MRSA
• System = fever & chills ▪ PO = clindamycin, doxycycline or bactrim
▪ IV = vancomycin
• Furuncle = deep infection of hair follicle • Erythema • Clinical diagnosis • Treatment = supportive, I&D, and ABX
o AKA folliculitis + boil • Tenderness o Supportive = warm compress & dry covering
Furuncle & • Carbuncle = multiple furuncles o I&D = mainstay of treatment
• Nodule = indurated & fluctuant o ABX = recurrent, severe, or cellulitis
Carbuncle
• Etiologies o +/– central plug
o Staph aureus = MC
o Strep pyogenes (GAS)
• HIGHLY contagious poxvirus infection • Papules = dome-shaped & fleshed colored • Clinical diagnosis • Treatment = observation vs. intervention
• Pearly-white o Observation = usually resolve within 2 years
Molluscum • Risk factors • Central umbilication • Histology = Henderson-Paterson bodies o Salicylic acid = good for thin skin
Contagiosum o Children o Curettage = keep area clean & use Vaseline
o Sexually active o Cryotherapy (liquid nitrogen) = risk of scar
• Curd-like material = expressed from center
o HIV o Imiquimod (Aldara) = causes local skin reaction
 • HPV infection • Common & plantar = hyperkeratotic papules • Clinical diagnosis • Treatment = observation vs. intervention
Common, o HPV infects keratinized skin o Red-brown dots = thrombosed capillaries o Observation = usually resolve within 2 years
Flat, & • Histology = koilocytotic squamous cells with o Salicylic acid = good for thin skin
Plantar • Types • Flat = flesh-colored papules hyperplastic hyperkeratosis o Cryotherapy (liquid nitrogen) = OTC for thin skin
Warts o Common = vulgaris o Hands, face, & shins o Imiquimod = local skin reaction (genital warts)
(Verrucae) o Plantar = plantaris o Podophyllin = blistering agent (genital warts)
o Flat = plana
• HPV infection = anogenital warts • Papules = painless, fleshy, & soft • Clinical diagnosis • Treatment = observation vs. intervention
o Cauliflower-like lesions o Observation = may resolve on their own
• Types • Acetic acid = whitening of lesion with acetic acid o Trichloroacetic acid = chemoablation
o 6 & 11 = anogenital warts o Cryotherapy (liquid nitrogen)
o 16 & 18 = cervical cancer • Histology = koilocytotic squamous cells with o Imiquimod (Aldara) = causes local skin reaction
Condyloma hyperplastic hyperkeratosis Podophyllotoxin = blistering agent (genital warts)
Acuminatum o Surgical removal

• Complications = squamous cell carcinoma

• Vaccination = Gardasil → 6, 11, 16, & 18

o Contraindicated if pregnant or lactating
• Inflammation of dermis & epidermis • Itching, burning, & stinging • Clinical diagnosis • Treatment = avoid irritant, supportive, & meds
o Avoid agent = identify & avoid irritant!!!
• Types • Acute = vesicles, erosions, & crusts • Patch test = identify potential allergens o Supportive = wet dressing, cool bath & emollients
o Irritant = not immune mediated o Well-demarcated ▪ Wet dressing = Burrow’s solution
▪ Chemicals = solvents, cleaners, detergents • Gram stain & culture = 2o infection present ▪ Pruritis = antihistamines or calamine lotion
▪ Alcohol • Chronic = plaques, scaling, licenification o Meds
▪ Creams o Satellite papules & excoriations ▪ Hydrocortisone = 1st line
▪ Diaper = from urine or feces ▪ Triamcinolone = prescription steroid
Contact
o Allergic = type IV hypersensitivity ▪ Atarax = helps with itching
Dermatitis
▪ Nickel • Less sedating than Benadryl
▪ Poison ivy ▪ Tacrolimus = topical calcineurin inhibitor
▪ Oak • ↓ skin atrophy → intertriginous areas & face
▪ Sumac ▪ Prednisone (systemic steroids) = severe cases!

• Irritant contact dermatitis
o ↑ moisture (urine & feces), friction & pH
o May affect ANY individual wearing a diaper
• MC = 9-12 months
• Recurrent Candida = DM or immune deficiency
• Erythematous papules or superficial erosions
o Buttocks, thighs, abdomen & genitalia
o Within borders of diaper (skin folds spared)
▪ Unless Candida!
• Candida = lasting > 3 days
o Beefy red, satellite lesions, & skin folds
• “Cowboy holster” = allergy to adhesive side bands
o Allergic contact dermatitis
• Topical steroids
o High potency if poor penetration = elbows & knees
o Low potency if high penetration = face, axilla, & groin
• Clinical diagnosis • Treatment = supportive, barriers, & steroids
o Supportive
• KOH prep = suspecting Candida ▪ Keep area clean
▪ Frequent diaper changes
▪ Diaper rest
o Topical barriers = protectants (every diaper change)
▪ Petroleum (Vaseline) & zinc oxide = MC
• Desitin, A&D, Triple Paste, & Balme
o Topical steroids = severe inflammation
▪ Hydrocortisone (low potency) = only for 1 week

• Candida = topical antifungals

o Nystatin = 1st line (clotrimazole or ketoconazole)
Diaper o Apply beneath barrier ointment 2-3 times a day
Dermatitis o DO NOT combine topical steroids & antifungals

• Therapy fails = consider 2o bacterial infection

o Staph & strep = MC pathogens
o Localized & mild = topical mupirocin → gram (+)
o Severe = PO ABX
o AVOID Neosporin ointment (Bacitracin)
▪ Contains neomycin → common allergen
 • Chronic, pruritic, inflammatory skin condition • Pruritus = needed for diagnosis • Clinical diagnosis • Treatment = avoid irritant, supportive, & meds
o Disrupted skin barrier = ↑ risk of drying • Papules & plaques = erythematous o Avoid irritants = identify & avoid irritant!!!
o Disordered immune response • CBC = ↑ IgE ▪ Excessive bathing
o Filaggrin gene mutation • Later = dry, crust over, & scale ▪ Low humidity
▪ Detergents
• Type I IgE hypersensitivity • Flexor region = older children & adults ▪ Solvents
• Extensor region = infants (crawling & rubbing) ▪ Allergens/foods
• Triggers o Supportive = maintain skin hydration
o Heat ▪ Skin emollients = thick creams
o Perspiration • NO scents → made with alcohol & dry skin
o Allergens • Nummular = discoid or coin-shaped lesions ▪ Bath = pat dry & thick creams immediately after!
Atopic o Irritants = wool, nickel, food, etc. o Dorsum of hands, feet, & extensor region ▪ Wet dressing = Burrow’s solution
Dermatitis o Meds & other
(Eczema) • Atopic triad = eczema + allergic rhinitis + asthma
▪ Hydrocortisone = 1st line
▪ Triamcinolone = prescription steroid
▪ Antihistamines = Atarax & Benadryl
▪ Tacrolimus = topical calcineurin inhibitor
• ↓ skin atrophy → intertriginous areas & face
▪ Crisaborole = phosphodiesterase-4 inhibitor
▪ Cyclosporine = severe cases (not for young kids)
▪ Phototherapy = severe cases (not for young kids)

• Pruritic vesicular rash on palms & soles • Tapioca-like small tense vesicles • Clinical diagnosis • Treatment = avoid irritant, supportive, steroids, & other
o Soles, palms, & fingers o Avoid agent = identify & avoid irritant!!!
• MC = <40 years old o Supportive = resolve over a few weeks
• Pruritic!!! ▪ Cold compresses
Acute • Types ▪ Wet compresses = Burrow’s solution
Palmoplantar o Sweating • Later = desquamation, papules, scaling, ▪ Witch hazel = weeping wet skin
o Stress = emotional licenification, erosions, & bullae ▪ Lukewarm water & soap-free cleansers
Eczema o Warm & humid
(Dyshidrosis) • Dry hands & use emollients immediately
o Metals = nickel ▪ Cotton gloves > latex gloves for washing dishes
o Steroid (topical) = medium-high potency
o Steroid (PO) = severe cases
o Topical psoralen + UVA light = frequent episodes
not controlled with steroids
• Causes • Plaques • Clinical diagnosis • Treatment = observation, emollients, & meds
o ↑ sebaceous gland activity • Erythematous o Observation = resolves by 1 years old
▪ Circulating maternal hormones after birth • Yellow or white greasy scales o Emollients = mineral oil, baby oil, or petroleum
Infantile o Hypersensitivity to Malassezia furfur ▪ Overnight
Seborrheic ▪ 15 minutes prior to shampooing
Dermatitis • Remove scales with soft brush
o Steroid (topical & low potency) = severe cases
(Cradle Cap) o Ketoconazole (cream or shampoo) = severe cases

• Causes • Plaques • Clinical diagnosis • Treatment = meds

o ↑ sebaceous gland activity • Erythematous o Topical = 1st line
o Hypersensitivity to Malassezia furfur • Yellow or white greasy scales ▪ Selenium sulfide = Selsun blue
▪ Sodium sulfacetamide = Ovace
• Worse = cold & dry weather (fall / winter) & stress • Locations ▪ Zinc pyrithione = head & shoulders
o Scalp ▪ Ketoconazole = shampoo or cream
Seborrheic • ↑ severity = neuro conditions (Parkinson’s) or HIV o Eyelids ▪ Steroids = low potency
Dermatitis o Beards ▪ Tacrolimus = topical calcineurin inhibitor
• MC = men o Mustache • ↓ skin atrophy → intertriginous areas & face
o Nasolabial folds o PO (antifungal) = severe
o Chest ▪ Ketoconazole
o Groin
▪ Itraconazole
 • Inflammatory dermatitis • 6 P’s • Clinical diagnosis • Treatment = supportive, antihistamines, steroids, & other
o Type IV hypersensitivity o Purple o Supportive = resolve in 8-12 months
o Polygonal • Biopsy & immunofluorescence = definitive ▪ Occlusive dressing → use with steroids!
• MC = adults o Planar diagnosis (saw-tooth lymphocyte infiltrate) o Steroid (topical) = 1st line
o Pruritic o Steroid (PO or intralesional) = severe cases
• Risk factors o Papules o Antihistamines = pruritus
o Hepatitis C o Plaques o Topical psoralen + UVA light = refractory cases
o Drug reactions
o Transplant = graft vs. host • Extremities = volar surfaces of wrists & ankles
Lichen o Other = mouth, scalp, genital, nails & MM
o Lymphoma
Planus
• Nail dystrophy
• +/– scarring alopecia

• Wickham striae = fine white lines

• Koebner’s phenomenon = new lesions at site

of trauma or scratching

• Skin thickening = patients with atopic dermatitis • Plaques = scaly, well-demarcated, hyperkeratotic • Clinical diagnosis • Treatment = avoidance, supportive, steroids, & meds
o Repetitive rubbing & scratching o Supportive = avoid scratching & occlusive dressings
o Antihistamines = pruritus
Lichen o Steroid (topical) = high potency
Simplex
Chronicus
(Neurodermatitis)

• Precancerous lesion from hyperkeratosis • Mostly asymptomatic! • Clinical diagnosis • Treatment

o Due to chronic irritation o Cessation of irritants
• PAINLESS white patchy lesion • Biopsy = rule out SCC ▪ Tobacco
• Risk factors • CANNOT be scrapped off ▪ Smoking
o Tobacco ▪ EtOH
Oral o Smoking o Cryotherapy = risk of malignancy
Leukoplakia o EtOH o Laser ablation = risk of malignancy
o Dentures o Surgical excision = risk of malignancy
o HPV
• Complications = SCC

• Immune-mediated multisystemic disease
o Genetic predisposition
o Keratin hyperplasia & proliferating cells
▪ Stratum basale & stratum spinosum
o T cell activation & cytokine release
• Variants
o Guttate = tear drop papules with fine scales
▪ s/p strep pyogenes (GAS) pharyngitis
o Inverse = erythema on body fold
o Pustular = yellow pustules & large pus areas
o Erythroderma = general erythematous rash
Psoriasis
• Plaque = raised, well-demarcated, & pink-red
o Thick silvery white scales
o Extensor surfaces
• Pitting nails
• Oil spot = yellow/brown color under nails
• Onycholysis = separation of nail from nail bed
• Auspitz sign = punctate bleeding with plaque or
scale removal
o Also seen with actinic keratosis
• Koebner’s phenomenon = new lesions at sites
of trauma
o Also seen with eczema & ligo
• Clinical diagnosis • Treatment = mild, moderate, or severe
o Mild
▪ Steroids (topical) = high potency (1st line)
▪ Vitamin D analog = Calcipotriene & Calcitriol
• MOA = inhibit keratinocyte proliferation
▪ Coal tar (topical)
• MOA = ketolytic
▪ Retinoid & vitamin A (topical) = Tazarotene
• MOA = ↓ keratin & anti-inflammatory
▪ Calcineurin inhibitor (topical) = Tacrolimus &
Pimecrolimus
• ↓ skin atrophy → intertriginous areas & face
• MOA = calcineurin usually activates T cells
o Moderate
▪ Phototherapy = UVB & PUVA
• PVUA = Psoralen (PO) followed by UVA
o Severe
▪ Cyclosporine = systemic calcineurin inhibitor
• MOA = calcineurin usually activates T cells
▪ Retinoid = Acitretin
▪ TNF inhibitors = Etanercept, Infliximab, &
Adalimumab
▪ Methotrexate = last resort b/c of S/E
 • Autoimmune disorder → skin depigmentation
o Autoimmune destruction of melanocytes
o Associated with other autoimmune disorders
Vitiligo
• White macules & patches
o Irregular & discrete
o Location = dorsum of hands, axilla, face,
fingers, body fold, & genitalia
• Clinical diagnosis
• Woods lamp = bright blue-white fluorescence
• Biopsy (rarely) = loss of epidermal melanocytes
• Treatment = localized vs. disseminated & surgery
o Localized
▪ Sunscreen
▪ Steroids (topical) = high potency (1st line)
▪ Calcineurin inhibitor (topical) = Tacrolimus &
Pimecrolimus
• ↓ skin atrophy → intertriginous areas & face
• MOA = calcineurin usually activates T cells
▪ Vitamin D analog = Calcipotriene & Calcitriol
o Disseminated
▪ Phototherapy = UVB
▪ Steroids = topical or PO
o Surgery = laser therapy or grafts

• Hyperpigmentation of sun exposed areas • Brown (hypermelanotic) symmetrical macules • Clinical diagnosis • Treatment = localized vs. disseminated & surgery
o Hypermelanosis = too many melanocytes o Mask-like o Sun protection = avoidance, sunscreen, hats, etc.
o Location = face & neck • Woods lamp = epidermal seen better than dermal o Triple therapy
• Risk factors ▪ Fluocinolone acetonide
o Estrogen = OCPs or pregnancy • Dermal melasma = bluish-grey appearance • Dermoscopy = levels of pigment deposition ▪ Hydroquinone = bleaching agent
o Sun exposure ▪ Tretinoin
Melasma o FHx o Bleaches (topical) = hydroquinone or azelaic acid
o Darker complexion o Retinoids (topical)
o Chemical peels
o Laser therapy = dermal melasma

• Velvety hyperpigmented plaques • Plaques = hyperpigmented, thick, & velvety • Clinical diagnosis • Treatment = treat underlying disease, lifestyle, & meds
o Location = skin folds o No specific treatment = treat underlying cause
• Etiologies ▪ Neck, forehead, groin, axilla, & navel o Lifestyle = diet & exercise (control glucose levels)
o Obesity o Meds = keratolytics
o DM ▪ Retinoid = Tretinoin (topical)
Acanthosis o Cushing syndrome ▪ Vitamin D analog = Calcipotriene
Nigricans o Hypothyroidism
o Acromegaly
o PCOS
o Meds = nicotinic acid
o Cancer = GI, uterus, breast, & ovarian

• Chronic inflammation of apocrine sweat glands • Inflammatory nodules • Clinical diagnosis • Treatment = lifestyle, meds, & office procedures
o Hair follicle obstruction → follicular rupture • Abscesses o Lifestyle
o Excess TNF-⍺ • Draining tracts ▪ Diet = avoid high glycemic foods
• Fibrotic hypertrophic scars ▪ Smoking cessation
• Risk factors ▪ Skin care
o Obesity ▪ Eliminate irritants
o Female • Tight-fitting clothes
o Smoking
• Harsh cleaning products
o Acne = history
Hidradenitis o FHx ▪ Reduce skin friction = avoid tight fitting clothes
Suppurativa o Friction o ABX
o Meds ▪ Topical = Clindamycin (1st line)
▪ PO = Tetracycline or Clindamycin
o Steroid (injections) = triamcinolone (intralesional)
o TNF inhibitor = Humira
o Procedures
▪ Punch debridement = SMALL, recurrent & deep
▪ Unroofing = LARGE, recurrent & deep
▪ I&D = abscess
 • Autoimmune skin disorder → celiac disease
o IgA immune complex in dermal papillae
Dermatitis
Herpetiformis
• Panniculitis = fat layer inflammation under skin
o Type IV delayed hypersensitivity reaction
• o Pink, red, or purple
• Etiologies
o Infection = strep, TB, or fungal
o Inflammatory = sarcoidosis, IBD, leukemia
Erythema o Estrogen = OCPs or pregnancy
Nodosum o Meds = sulfonamides, PCN, phenytoin
• Cyst/abscess/sinus tract in upper natal cleft
o Hairs puncturing skin
▪ Hair found inside abscess
▪ NOT a hair follicle
▪ Hair into abscess and it becomes infected
Pilonidal
Disease
• Subcutaneous tumor of mature adipocytes
o Enclosed by thin fibrous capsule
o Benign soft-tissue neoplasm
Lipoma
• Papulovesicular rash = pruritic
o Location = extensor surfaces
• Nodules = painful & erythematous
o Location = anterior shins
• Abscess above butt crack
• Subcutaneous nodule = soft & painless
o Location = trunk, neck, face, & extremities
• Freely mobile
• Clinical diagnosis
• (+) transglutaminase IgA antibodies
• (+) antiendomysial antibodies
• Immunofluorescence = IgA in papillary dermis
• Clinical diagnosis
• Clinical diagnosis
• Clinical diagnosis
• Biopsy = enlarging, fixed, firm, or painful
• X-ray (prior to excision) = enlarging, fixed,
painful, or deep
• Treatment = diet & meds
o Diet = gluten free diet
o Sulfonamides
▪ Dapsone = 1st line
• MOA = ↓ inflammation
• S/E = hemolysis, agranulocytosis, etc.
▪ Sulfapyridine or sulfasalazine = less S/E
o Steroid (topical) = pruritus
• Treatment = treat underlying condition, NSAIDs & steroids
o Treat underlying condition
▪ Lesions are self-limiting
▪ Resolve in ~8 weeks
o NSAIDs = pain control
o Steroids = only if underlying cause is NOT infectious
• Treatment = acute vs. long-term
o Acute = I&D
o Long-term = surgery to take it out
• Treatment = none or surgery
o None = no treatment needed
o Surgery = cosmetic, painful, or rapidly enlarging
 • Encapsulated subepidermal nodules • Cyst or nodules • Clinical diagnosis • Treatment = none, steroids, surgery, or I&D
o Filled w/ fibrous tissue & keratinous material • Freely mobile o None = no treatment needed (resolve spontaneously)
o Secrete KERATIN → NOT sebum • Central punctum = dark comedone • Biopsy = cyst wall composed of stratified o Steroid (injection) = Kenalog → quicken resolution
▪ Do not originate from sebaceous glands squamous epithelium o Surgery = cosmetic or recurrent
▪ Keratinous = cottage cheese-like • Ruptured or infected = cottage cheese discharge o I&D = infection or abscess
o Plugging of follicular orifices
Epidermal
Inclusion • MC = male & 30-40 years old
Cyst

• Skin breakdown & injury from prolonged pressure • Depends on stage • Clinical diagnosis • Treatment = wound care & debridement
o Stage 1 = epidermis (non-blanchable) o Wound care
• MC = sacrum & hip o Stage 2 = epidermis & dermis o Surgical debridement
o Stage 3 = epidermis, dermis & subQ
• Risk factors o Stage 4 = epidermis, dermis, subQ & muscle • Complications = osteomyelitis & sepsis
o Immobility
o Poor nutrition • Prevention = change position q 2 hours
o PVD

Pressure
Ulcer

• Lesions & ulcers 2o to immune dysregulation • Papules or pustules • Clinical diagnosis • Treatment = localized vs. deep or refractory
o Erythematous, blue-red, & inflamed o Localized
• Associated with inflammatory diseases • Biopsy = neutrophilic infiltration ▪ Wound care = basic wound care
o IBD • Necrotic ulcer • MINIMAL debridement → worsens
o RA o Painful, purple/violet, raised ▪ Steroids (topical) = high potency (1st line)
o Spondyloarthropathies ▪ Calcineurin inhibitor (topical) = Tacrolimus
o Deep or refractory
Pyoderma
▪ Steroids (PO)
Gangrenosum
▪ Cyclosporine
o 3rd line
▪ IVIG
▪ Cyclophosphamide
▪ Chlorambucil

• Hypertrophic benign raised scarring • Exaggerated scar • Clinical diagnosis • Treatment = meds, laser therapy or surgery
o Excess production of type I & III collagen • Pedunculated o Steroids (injection) = Triamcinolone
o Laser therapy
• MC = dark skinned people o Cryotherapy (liquid nitrogen)
Keloid o Pressure therapy
o Radiotherapy
o Surgical excision
 • Idiopathic skin infection • Herald patch = salmon-colored macule • Clinical diagnosis • Treatment = none, control pruritis, lotions, UVB, or meds
o Human Herpesvirus 7 (HHV7) = most likely o Precedes rash by 1-2 weeks o None = education & reassurance
▪ But unsure → cause unknown ▪ Resolves in 6-12 weeks
• Salmon-colored pruritic papules o Pruritis = education & reassurance
• MC = children & adolescents o 1-2 weeks later ▪ Antihistamines (PO)
Pityriasis o Christmas tree pattern ▪ Steroids (topical)
Rosea • MC = spring & fall ▪ Oatmeal baths
• TRUNK & proximal extremities o Lotions or emollients = scaling
o UVB phototherapy = severe or within 1st week
• +/– prodrome = mild URI o Acyclovir = +/ – speed up healing
o Erythromycin = +/ – speed up healing
• NOT CONTAGIOUS
• Fungal skin infection from Malassezia furfur • Hypo or hyperpigmented macules • Clinical diagnosis • Treatment = topical vs. oral
o Overgrowth of Malassezia (yeast on skin) o Well-demarcated o Topical
o Malassezia is part of normal skin flora o Round or oval • KOH prep = spaghetti & meatballs ▪ Selenium sulfide shampoo = 1st line
o Fine scaling o Hyphae & spores • Neck to waist
Pityriasis • Risk factors • Leave on for 15 minutes
o Hot & humid • Involved skin fails to tan with sun exposure • Woods lamp = yellow-green fluorescence ▪ Sodium sulfacetamide
(Tinea) o Sweating
Versicolor o Oral
o Oily skin • TRUNK & proximal extremities ▪ Fluconazole = 1st line
• Do no shower
• MC = children & adolescents • NOT CONTAGIOUS • Delivered to skin surface through sweat
▪ Itraconazole
• Fungal infection scalp • Alopecia & black dots (broken hair shafts) • Clinical diagnosis • Treatment = antifungals (PO)
o Trichophyton & Microsporum • Scaly patches = pruritis & erythema o Griseofulvin (PO) = 1st line → for 6-12 weeks
o Fungi infect keratinized tissue • KOH prep = initial test of choice (fungal spores) ▪ S/E = hepatoxicity (CBC & LFTs before tx), GI,
HA, & disulfiram reaction
• Risk factors • Woods lamp = fluorescence with Microsporum ▪ Better absorbed w/ fatty food → peanut butter
o Poor hygiene o Terbinafine (PO or topical) = 2nd line
o Direct contact • Culture = definitive diagnosis
Tinea Capitis o Preadolescents • Antifungal treatment for ALL house members
o African Americans • Kerion = indurated, boggy, inflammatory plaque • Dermoscopy = broken, corkscrew, & comma hairs
with pustules and thick crusting → MC in capitis
o 2nd picture

• Fungal infection feet • Interdigital = pruritic & erythematous erosions • Clinical diagnosis • Treatment = supportive & antifungals (PO or topical)
o Trichophyton or scales; MC 3rd & 4th digital interspaces o Supportive
• KOH prep = initial test of choice (fungal spores) ▪ Antifungal spray for shoes
• Risk factors • Hyperkeratotic = hyperkeratotic rash in a ▪ Keep cool/dry
o Locker rooms moccasin pattern • Woods lamp = fluorescence with Microsporum o Meds = PO if fail topical
Tinea Pedis o Swimming pools ▪ Terbinafine (PO or topical) = 1st line
• Vesiculobullous = pruritic vesicular or bullous • Culture = definitive diagnosis ▪ Clotrimazole (topical)
eruption with erythema ▪ Ketoconazole (PO)
▪ Fluconazole (PO)
▪ Griseofulvin (PO)

• Fungal infection groin • Annular patches or plaques • Clinical diagnosis • Treatment = supportive & antifungals (PO or topical)
o Trichophyton & Epidermophyton • Diffuse erythema o Supportive
• Pruritic • KOH prep = initial test of choice (fungal spores) ▪ Desiccant Powders
• Risk factors • Sharply demarcated raised order ▪ Avoid tight fitting clothing
o Males • Woods lamp = fluorescence with Microsporum ▪ Put on socks before underwear
o Sweating • Keep cool/dry
Tinea Cruris o Immunocompromised • Culture = definitive diagnosis o Meds = PO if fail topical
o Tine pedis = after putting on underwear ▪ Terbinafine (PO or topical) = 1st line
▪ Clotrimazole (topical) = 1st line
▪ Butenafine (topical) = 1st line
▪ Ketoconazole (PO)
▪ Fluconazole (PO)
▪ Griseofulvin (PO)
 • Fungal infection body • Pruritic, circular or oval, erythematous, scaly • Clinical diagnosis • Treatment = antifungals (PO or topical)
o Trichophyton & Microsporum patch or plaque with central clearing o Meds = PO if fail topical
o Well defined raised borders • KOH prep = initial test of choice (fungal spores) ▪ Terbinafine (PO or topical) = 1st line
• Transmission ▪ Clotrimazole (topical) = 1st line
Tinea o Animal = puppy/kitten • Itching, stinging & burning • Woods lamp = fluorescence with Microsporum ▪ Butenafine (topical) = 1st line
Corporis o Direct contact = body part ▪ Ketoconazole (PO)
• Culture = definitive diagnosis ▪ Fluconazole (PO)
• Risk factors ▪ Griseofulvin (PO)
Ring Worm o Moisture (sweating)
o PVD
o Obesity
o DM
o Immunodeficiency
• Fungal infection nail • Thickened & discolored • Clinical diagnosis • Treatment = antifungals (PO)
o Trichophyton & Microsporu • Onycholysis of nail bed & plate o Terbinafine (PO) = 1st line
• KOH prep = initial test of choice (fungal spores) o Griseofulvin (PO) = 2nd line
Tinea
Unguium
• Woods lamp = fluorescence with Microsporum

• Culture = definitive diagnosis

• Coxsackievirus (type A = MC) • Prodrome = 3-5 days after exposure • Clinical diagnosis • Treatment = supportive & meds
o HIGHLY contagious o Low-grade fever o Supportive = lasts 3-6 days
o URI symptoms • Viral culture (Coxsackievirus IgA) = definitive ▪ Fluids = oral hydration
• MC = <5 years old o ↓ appetite ▪ Good hygiene / cleaning surfaces
o Meds = antipyretics, analgesics, & numbing meds
• Incubation = 4-6 days • Oral Enanthem ▪ Tylenol
Hand-foot-
o Vesicles with erythematous halos ▪ Advil
and-mouth ▪ Lidocaine = numbing mouth sprays
• Transmission = respiratory droplets, blister o POSTERIOR PHARYNX
disease
fluid & feces
• Enanthem • Complications = dehydration, aseptic meningitis &
• Peak incidence = summer & fall o Macular, maculopapular, or vesicular Gullian Barre
o MC = distal extremities & buttocks o Meningitis & Gullian Barre = rare
o Palms & soles
o RARELY ITCHY OR PAINFUL
• HSV-1 • Red & swollen ORAL MUCOSA • Clinical diagnosis • Treatment = supportive & meds
• Vesicles = oral mucosa, tongue, & lips o Supportive = lasts 12 days
• MC = 6 months-5 years old • Regional LAD • PCR = test of choice ▪ Fluids = oral hydration
Herpetic o Meds = antipyretics, analgesics, & numbing meds
• Gingivitis
Gingivo- • Viral cultures = definitive diagnosis ▪ Tylenol
• Fever ▪ Advil
stomatitis
• ↓ appetite
• Complications = dehydration, herpetic whitlow, herpetic
keratitis, eczema herpeticum, & bacteremia
• Coxsackievirus (type A = MC) • Stomatitis = white-yellow papulovesicular • Clinical diagnosis • Treatment = supportive & meds
lesions on POSTERIOR PHARYNX o Supportive
• MC = 3-5 years old • Viral culture (Coxsackievirus IgA) = definitive ▪ Fluids = oral hydration
• Pharyngitis o Meds = antipyretics, analgesics, & numbing meds
Herpangina • Peak incidence = summer & fall • Odynophagia ▪ Tylenol
▪ Advil
• Older kids = fever, malaise, HA, vomiting, neck
stiffness, or back stiffness • Complications = dehydration, aseptic meningitis &
Gullian Barre
• Varicella zoster → HHV-3 • URI prodrome • Clinical diagnosis • Treatment = supportive & meds
o Fever o Supportive = lasts 7-10 days
• Incubation = 10-21 days o ↓ appetite • PCR = highest yield ▪ Cool compresses
o Cough ▪ Warm soaks & Oatmeal bath
• Infectious = 2 days before & until rash is crusted o Sore throat • Tzanck smear = multi-nucleated giant cells ▪ Discourage scratching & clip nails
• Rash within 24 hours o Meds = antipyretics, analgesics, & numbing meds
Varicella ▪ Tylenol = 1st line
Zoster • Transmission = respiratory droplets & vesicle • Serology = anti-VZV IgM or IgG
fluid • Rash = dew drop on a rose ▪ Advil
o Macules → papules → vesicles → crust ▪ Calamine (topical)
o Starts on head & trunk ▪ Antihistamines (PO)
• Peak incidence = late winter & spring ▪ Acyclovir = immunocompromised
o MM may be involved
o Clustered rash in various stages • Complications = encephalitis, secondary bacterial skin
o Pruritic infection, PNA and scarring
 • Paramyxovirus • URI prodrome = 3 days • Clinical diagnosis • Treatment = supportive, meds, & immune globulin
o 3 C’s = cough, coryza, & conjunctivitis o Supportive
• Incubation period = 7-21 days o Fever >104 = lasts for 4-7 days • Serology = PCR or antibodies ▪ Fluids = oral hydration
o Malaise, ↓ appetite, & myalgias o Vitamin A = reduces morbidity & mortality
• Infectious period = 4 days before & 4 days after rash o Meds = antipyretics & analgesics
Measles
• Koplick spots = buccal musoca lesions ▪ Tylenol
• Transmission = respiratory droplets or direct o White or blue papules on erythematous base ▪ Advil
(Rubeola) o Immune globin = high risk
contact
o Live up to 2 hours in airspace • Maculopapular rash = starts on FACE
o Lasts for 4-7 days • Complications = PNA, encephalitis & OM

• Paramyxovirus • Fever • Clinical diagnosis • Treatment = supportive & meds

• Myalgia o Supportive = lasts 7-10 days
• Incubation = 12-14 days • HA • Serology = definitive diagnosis ▪ Fluids = oral hydration
o Meds = antipyretics & analgesics
• Fatigue
• Infectious = 2 days before & 9 days after parotitis • ↑ amylase ▪ Tylenol
Mumps • ↓ appetite ▪ Advil
• Parotitis → parotid gland pain & swelling
• Transmission = respiratory droplets, saliva &
fomites • Complications = orchitis, encephalitis, meningitis,
pancreatitis, & hearing loss

• Rubella virus = part of Togavirus family • URI prodrome = 3 days • Clinical diagnosis • Treatment = supportive & meds
o AKA 3-day measles o Low grade fever, cough, & posterior LAD o Supportive = lasts 7-10 days
o Myalgia & arthralgia • Serology & viral culture = definitive diagnosis ▪ Fluids = oral hydration
• Incubation = 14-21 days o Headache o Meds = antipyretics & analgesics
Rubella ▪ Tylenol
• Transmission = respiratory droplets • Forchheimer spots = soft palate petechiae ▪ Advil
(German
Measles) • Maculopapular rash = starts on FACE • Complications = arthritis & encephalitis
o Spreads more rapidly than measles
• Pregnancy = teratogenic in 1st trimester
• +/– photosensitivity & arthralgia o Jaundice, cataracts, HSM, & heart disease

• Parvovirus B19 • Fever, HA, & nausea → facial rash • Clinical diagnosis • Treatment = supportive & meds
o Infects & destroys reticulocytes o Supportive
o Transient bone marrow suppression • Slapped cheek = malar rash (1st) • Serology = parvovirus IgM ▪ Fluids = oral hydration
o ↓ erythropoiesis → aplastic crisis (anemia) o Circumoral pallor o Meds = antipyretics, analgesics, & antihistamines
▪ ↓ Hgb ≥3 with reticulocytopenia & without ▪ Tylenol
hemolysis • Maculopapular, lacy & reticulated rash (2nd) ▪ Advil
▪ Patients with sickle cell need a lot of RBCs o Trunk & extremities days later ▪ Benadryl = pruritis

Erythema • Incubation = 4-14 days • Arthralgia = older children & adults • Complications = aplastic crisis & fetal issues
Infectiosum o Aplastic crisis = severely anemic (↓ Hb)
• Transmission = respiratory droplets & blood ▪ Child with hematologic issues
• Sickle cell, hereditary spherocytosis, G6PD
o Pregnancy = fetal death & hydrops fetalis

• Human Herpesvirus 6 (HHV6) • HIGH FEVER (104o F) 3-5 days → abrupt end • Clinical diagnosis • Treatment = supportive & meds
o Supportive
• Incubation = 10 days • Maculopapular rash = starts on TRUNK ▪ Fluids = oral hydration
o Meds = antipyretics & analgesics
Roseola
• Transmission = respiratory droplets or direct • Nagayama spots = red papules on palate & uvula ▪ Tylenol
Infantum ▪ Advil
contact
• Other symptoms = red TMs, seizures, & ↓ appetite
Erythema • Complications = seizure, meningitis, encephalitis
• MC = <2 years old o Seizures from sudden high fevers
Subitum
• “Look Well” for high fever
 • Infestation by Sarcoptes scabiei
o Mites burrow into epidermis
o Lay eggs, feed, & defecate
• Scybala (fecal parts) cause skin reaction
o Females lay 2-3 eggs per day
o Females die in 4-6 weeks
o Can’t survive >4 days off the human body
Scabies • Transmission = direct skin (MC) or fomites (LC)
• Onset = 4-6 weeks after infestation
• Pediculus humanus capitus = scalp
• Pediculus humanus corporis = body
• Phthirus pubis = pubic area (crabs)
• Life cycle
o Louse lives 1 month
o Lays 7-10 eggs per day
Lice o Eggs hatch in 1 week
o Baby louse require 1 week to mature
• MC = 3-12 years old
• Loxoseles reclusa
o Violin pattern on anterior cephalothorax
o Cytotoxic & hemolytic = necrosis
Brown
Recluse
Spider Bite
• Latrodectus hesperus
o Red hourglass shape on underside of belly
o Neurotoxic = muscle pain
Black Widow
Spider Bite
• Erythematous papules
• Linear burrows = intertriginous & web spaces
o Location = wrists, axillae, areolae, genitals,
belt line, & sock edge
• Papules = pruritic & erythematous
• Pruritis is worse at night
• Pruritis = MC complaint!!
• Excoriations = may be secondarily infected
• Lice = can be hard to find
• Nits = easier to see on hair shafts
• Erythema & burning
• Blanching = vasoconstriction
• Red halo = erythema around ischemic center
• Hemorrhagic bulla undergoes eschar formation
• Muscle pain, spasms, & rigidity
• Clinical diagnosis • Treatment = supportive & anti-parasitic
o Supportive
• Skin scrapings = wet mount & adhesive tape test ▪ Treat all household members!
▪ Clothing, bedding, etc. in plastic bag 48-72 hours
• Wash & dry with heat
o Permethrin (topical) = 1st line
▪ Massage cream into skin from neck to feet (adults)
• Children = include scalp and face
▪ Leave on 8-14 hours then wash
▪ 2 dose 1-2 weeks later
nd
▪ Safe in pregnancy & lactation
o Lindane (topical) = cheaper
▪ NOT after bath → ↑ absorption = seizure
o Ivermectin (PO) = extensive → only for >15 kg
▪ 1st dose, then 2nd dose repeated 1-2 weeks later
▪ Treat orally if they failed topical
• Clinical diagnosis • Treatment = supportive & anti-parasitic
o Supportive
▪ Wet combs to remove nits
▪ Petroleum jelly to suffocate lice
▪ Bedding/clothing washed in hot water & hot dryer
▪ If cannot be washed → air-tight bag x 14 days
o Permethrin (topical) = 1st line
▪ Leave on 8-14 hours then wash
▪ 2nd application 1-2 weeks later
▪ Safe in pregnancy & lactation
o Pyrethrine (topical) = 1st line
▪ From chrysanthemum extract
o Lindane (topical) = 2nd line
▪ NOT after bath → ↑ absorption = seizure
o Ivermectin (PO) = 2nd line
• Clinical diagnosis • Treatment = wound care, pain meds, +/ – ABX
o Wound care = most heal in days to weeks
▪ Soap & water
▪ Cold packs to bite
▪ Elevate or neural position
▪ Debridement = wait until lesion is stable
o Pain control
▪ NSAIDs
▪ Opioids = severe
o ABX = 2o infection (ex: cellulitis)
• Usually heals in days to weeks
• Clinical diagnosis • Treatment = wound care, pain meds, +/ – ABX
o Wound care = most heal in days to weeks
▪ Soap & water
o Pain control
▪ NSAIDs
▪ Opioids = severe
o Muscle relaxer
▪ Benzodiazepine
▪ Methocarbamol
▪ Baclofen
▪ Cyclobenzaprine
o Antivenom = not responsive to other meds
• Usually resolves in 1-3 days
 • Autoimmune disorder → subepidermal blisters • 1st = pruritic & eczematous or urticarial plaque • Skin biopsy = liner C3, IgG, & eosinophilia • Treatment = meds
o Type II hypersensitivity reaction • 2nd = TENSE large bullae o With direct immunofluorescence o Steroids
o IgG autoantibodies to hemidesmosomes & ▪ Topical (high potency) = 1st line
Bullous basement membrane • DO NOT rupture easily • ELISA = autoantibodies to BP antigen 230 & 180 ▪ Systemic = severe or refractory to topical
Pemphigoid o Antihistamines = pruritis
• Risk factors • (–) Nikolsky sign o Immunosuppressant
o Elderly ▪ Azathioprine = severe
Autoimmune o Meds = loop diuretics & metformin

• Autoimmune disorder → blistering of MM & skin
o Type II hypersensitivity reaction
o IgG autoantibodies to desmosomes
▪ Desmosomes connect keratinocyte in skin
Pemphigus
Vulgaris • Risk factors
o Myasthenia gravis & thymoma
Autoimmune o 30-40 years old
o Meds = penicillamine, captopril,
cephalosporins, & phenobarbital
• 1st = MM with pain erosions & ulceration • Skin biopsy = IgG throughout epidermis • Treatment = wounds care & meds
• 2nd = FLACCID painful bullae o With direct immunofluorescence o Wound care = treat like burns
o Steroids
• DO rupture easily • ELISA = anti-desmoglein or anti-epithelial ▪ Systemic (high dose) = 1st line
o Immunosuppressant
• (+) Nikolsky sign ▪ Methotrexate
▪ Azathioprine
▪ Cyclophosphamide
▪ Mycophenolate

• Edema of superficial layers of skin • Hives or wheals = blanchable, raised red areas • Clinical diagnosis • Treatment = antihistamines (H1 blockers), H2
o Histamine related ↑ vascular permeability • Pruritic → might sting or burn o H1 blockers (antihistamines) = 1st line
o Type I (IgE) immediate hypersensitivity • Involve skin OR mucous membranes • Assess for anaphylaxis = respiratory & cardio ▪ 2nd generation = less anticholinergic effects
o Release of vasodilators • Cetirizine (Zyrtec)
▪ Histamine • Acute = <6 weeks (IgE) • Loratadine (Claritin)
▪ Bradykinin o Infection or allergy • Fexofenadine (Aller-ease)
▪ Kallikrein o Viral syndromes ▪ 1st generation
▪ Prostaglandins o Insect bites or stings • Benadryl
o Food induced reactions
• Hydroxyzine (Atarax)
• Triggers o Medication related
• Chlorpheniramine
o Food ▪ ABX o H2 blockers = 2nd line
Urticaria o Meds ▪ NSAIDs
o Heat or cold ▪ Ranitidine (Zantac)
▪ Narcotics
o Stress ▪ Famotidine (Pepcid)
▪ Angioedema due to ACEi o Steroids = 3rd line
o Insect bites
o Environmental ▪ Prednisone = adults
• Chronic = >6 weeks
o Infection ▪ Prednisolone = children
o Idiopathic urticaria
o Epinephrine = severe or airway obstruction
o Stress
• Urticaria = involving superficial dermis o Physical urticarias ▪ 1:1000 in a dose of 0.2 to 0.5 mL subQ or IM
• Anaphylaxis = systemic reaction ▪ Dermographism, cholinergic, or cold
o Autoimmune = SLE, RA, or thyroid

• Maculopapular drug eruption after drugs • Erythematous macules & papules • Clinical diagnosis • Treatment = supportive & meds
o Type IV hypersensitivity o Pruritus & mild fever may be present o Supportive = drug withdraw & avoidance
o Lesions >3 days after drug started o Location = skin (NOT systemic or MM) o H1 blockers (antihistamines) = 1st or 2nd generation
▪ Mainly day 8-11 ▪ 2nd generation = less anticholinergic effects
▪ Persist 2-3 days after drug stopped • Trunk → extremities (spreads centrifugally) • Cetirizine (Zyrtec)
• Loratadine (Claritin)
• Eliciting drugs • Fexofenadine (Aller-ease)
Exanthematous
o PCN ▪ 1st generation
Drug o Sulfa
Eruption • Benadryl
o NSAIDs
o Allopurinol • Hydroxyzine (Atarax)
• Chlorpheniramine
o Steroids (topical) = localized reaction
o Steroids (PO) = severe skin reactions
▪ NOT recommended to give oral steroids
 • Allergic reaction to a drug reoccurring in same site • Solitary erythematous patch or plaque • Clinical diagnosis • Treatment = supportive
o Recurs at same site with each re-exposure o Sharply demarcated o Supportive
o Lesions 30 minutes to 8 hours after drug o Plaque may evolve to bulla with erosion ▪ Drug withdraw & avoidance
o Location = mouth, genitalia, & face ▪ Benadryl
• Eliciting drugs
o Bactrim
Fixed Drug o Tetracycline
o Penicillin
Eruption
o Quinolinones
o Dapsone
o NSAIDs
o ASA
o Tylenol
o Barbiturates
o Antimalarials
• Type IV hypersensitivity s/p infection or drug • Target lesions • Clinical diagnosis • Treatment = supportive or meds
o Dusky central area or blister o Supportive
• Causes o Surrounded by pale ring of edema • Biopsy = definitive diagnosis ▪ Drug withdraw & avoidance
o Infection o Erythematous halo on periphery ▪ Steroid + Lidocaine + Benadryl mouthwash
▪ HSV, mycoplasma, or strep pneumoniae o Antihistamines
o Meds • (–) Nikolsky sign o Analgesics
Erythema ▪ Sulfa, PCN, Allopurinol, or Phenytoin o Steroids (PO) = severe skin reactions
Multiforme o Idiopathic • Minor = no MM involvement o Acyclovir = herpes
o Malignancy o Confined to extremities & face o ABX = mycoplasma or strep pneumoniae
o Autoimmune
• Major = MM involvement
o Fever, weakness, & malaise
o Lungs & eyes effected

• Detachment of epidermis & extensive necrosis • Prodrome of fever & URI → flaccid bullae • Clinical diagnosis • Treatment = supportive or meds
o Thought to be immune-mediated o Supportive
• Macule → papule → vesicle/bullae → erosion • CBC = anemia & lymphopenia ▪ Drug withdraw & avoidance
• Etiologies ▪ Burn unit admission / transfer
o Meds = MC • Pruritic targetoid lesions • CMP = acute tubular necrosis (ATN) ▪ Pain control
▪ Sulfa drugs o Erythematous macules with purpuric centers ▪ IVF & electrolytes
Steven- ▪ Anticonvulsants • Biopsy = diagnostic ▪ Wound care
Johnson ▪ PCN • >1 MM involved & epidermal detachment
Syndrome ▪ Allopurinol • SJS = <10% surface • Complications = 2o infection, dehydration, electrolyte
▪ NSAIDs • Trunk & face 1st • SJS/TEN = 10-30% imbalance, & loss of vision
& ▪ Antipsychotics • TEN = >30% surface
o Infections • Photophobia = corneal ulceration or uveitis
Toxic ▪ Mycoplasma pneumoniae • Sore throat or sore mouth
Epidermal ▪ HIV • Bronchitis or pneumonitis
Necrolysis ▪ HSV • Erosion of lungs & gut
o Malignancy
o Idiopathic = MC • TENs = high fever & severe epidermal separation
• SJS = severe variant of erythema multiforme • (+) Nikolsky sign = traction causes peeling
• TENS= severe variant of SJS
o Toxic epidermal necrolysis

• Vascular cancer associated with HHV8 • Macules, plaques, & nodules • Biopsy = angiogenesis, inflammation & • Treatment = HAART, chemo, & radiation
o Painless & nonpruritic proliferation & immunohistologic staining o HAART
• Risk factors = immunosuppressed (HIV) o Purple, red-blue, & dark brown o Chemotherapy
o Radiation therapy = local disease

Kaposi
Sarcoma
 • Benign epidermal skin tumor • Velvety warty lesions • Clinical diagnosis • Treatment = none or cosmetic procedure
o Benign proliferation immature keratinocytes o Well-demarcated o None = benign & no premalignant potential
o Round or oval • Biopsy = well-demarcated proliferation of o Cryotherapy = MC treatment
• Risk factors keratinocytes o Curettage
Seborrheic o Sun exposure • Greasy or “stuck on” appearance o Electrodesiccation
Keratosis o Light skin o Laser therapy
o Elderly • Colors = flesh-colored, grey, brown, & black

• Premalignant skin condition • Macules or papules = dry & rough • Clinical diagnosis • Treatment = lifestyle, cryotherapy, & meds
o Atypical epidermal keratinocytes • Sandpaper rough o Lifestyle = avoid sun exposure & use sunscreen
• Transparent or yellow scaling • Biopsy = punch or shave o Cryotherapy = MC treatment
Actinic • Risk factors o Atypical epidermal keratinocytes o Imiquimod (Aldara) = causes local skin reaction
Keratosis o Sun exposure o 5-flurouracil (Efudex) = topical chemo
o Light skin
o Elderly • Complications = squamous cell carcinoma
o Males
• Locally invasive & slow growing • Papules = pearly, translucent, & raised • Biopsy = punch or shave • Treatment = lifestyle, cryotherapy, surgery, & meds
o Rolled borders o Mohs = facial involvement, high-risk, or recurrent
• MC type of skin cancer o Central ulceration o Electrodesiccation & curettage = MC non-facial
o Surgical excision = low or high risk of recurrence
Basal Cell
• Risk factors • Telangiectatic vessels = bleeds easily o Cryosurgery
Carcinoma o Imiquimod (Aldara) = causes local skin reaction
o Sun exposure
o Light skin o 5-flurouracil (Efudex) = topical chemo
o Elderly
• Complications = squamous cell carcinoma
• Malignancy of keratinocytes = dermis & beyond • Erythematous & elevated thick nodule • Biopsy = atypical keratinocytes & malignant cells • Treatment = excision, cryotherapy, or radiation
o Hyperkeratosis & ulceration o White scaly or crusted bloody margins o Pleomorphic & hyperchromatic nuclei o Surgical excision = clear margins
o Bowen’s disease = SCC I situ o Location = lips, hands, neck, & head o Mohs surgery = cosmetically sensitive areas
o Slow growing → rapid if invasive o Cryotherapy = small, well-denied & low risk
• Nonhealing ulceration or erosion o Radiation = nonsurgical choice or adjuvant therapy
Squamous • 2nd MC skin cancer
Cell
Carcinoma • Risk factors
o Sun exposure
o Actinic keratosis
o HPV
o Light skin
o Xeroderma pigmentation
• Cancer arises from melanocytes • ABCDE • Biopsy = definitive diagnosis (with lymph nodes) • Treatment = excision, biopsy, chemo & radiation
o HIGH malignant potential o Asymmetry o FULL thickness wide excision o Wide margin excision = removing normal skin
o MC cause of skin cancer-related death o Borders = irregular o DO NOT do shave biopsy around melanoma
o Irregular ▪ Remove normal skin to decrease risk of recurrence
• Risk factors o Color o Sentinel lymph node biopsy = >1 mm deep
o UV radiation o Diameter = >6 cm o Chemo & radiation = high-risk
o FHx o Evolution = rapid or recent change
o >3 burns before 20 years • Prognosis = based on depth (>1 mm deep is bad!)
o Large # of nevi
o Tanning booth

• Types
Melanoma o Superficial spreading = MC type
▪ Trunk = men
▪ Legs = women
o Nodular = 2nd MC type
o Lentigo malignant = MC on face
▪ Arising from a lentigo (sun spot)
▪ Hard to diagnose!
o Acral lentiginous = MC on dark-skinned
▪ Palms, soles, & nail beds
o Desmoplastic = most aggressive
o Amelanotic = no melanocytes (just skin)
 • Types = scalding, thermal & flame • 1st degree (superficial burn) = PAINFUL
o Epidermis
• <2 years = ↑ risk of complication o (+) cap refill
• 2nd degree (partial thickness) = PAINFUL
o Dermis
o Superficial = (+) cap refill & moist
o Deep = (–) cap refill & dry
• 3rd degree (full thickness) = PAINLESS
o Entire skin
o (–) cap refill
o Waxy & white
Burns
• 4th degree (full thickness) = PAINLESS
o subQ, muscle & bone
o (–) cap refill
o Thick & dry
• Acids = coagulation necrosis
o Creates eschar
o Usually self-limiting
• Bases (alkali) = liquefaction necrosis
o Continued penetration
• Lund-Browder = most accurate method
o Children = 18% head & 14% each leg
▪ Otherwise same as adult
• Palm method = palm account for 1% TBSA
• Burn center referral
• Complications = <2 years = ↑ risk of complication
• Treatment = supportive, IVF, irrigation & topical ABX
o Supportive = dressings & IVF
o ABX = topical
o Irrigation = chemical
o Fluids = parkland formula → LR or NS
▪ 2-4ml x kg x % TBSA = total volume fluid
▪ ½ over first 8 hours and ½ over next 16 hours
▪ Fluid therapy for:
• >10% BSA 3rd degree burns
• >15% BSA 2nd degree burns
• >30-50% BSA mixed PT burns
o Partial thickness >10% TBSA
o Face, hands, feet, genitalia, perineum, major joints
o 3rd degree burn in any age group
o Electrical burns = lightning injury
o Chemical burn
o Inhalation injury
o Burn in patient with preexisting medical condition
o Burn + concomitant trauma (ex: fracture)
o Burned child in hospital without qualified personnel
o Burn injury in patient requiring social, emotional or
rehabilitation intervention
 ENDOCRINOLOGY
Visit Etiology Presentation & PE Diagnosis Treatment & Complications
• GH secreting pituitary adenoma = ↑ GH • Enlargement of soft tissue, bones & cartilage • IGF-1 = best initial test • Treatment = surgery, medication or radiation
o Somatotroph adenoma o Hands, feet, skull, tongue, jaw (macrognathia) o GH = pulsatile & single test NOT diagnostic o Surgery = transsphenoidal surgical removal
• Carpal tunnel syndrome o Octreotide = somatostatin inhibits GH release
• Acromegaly (adults) or gigantism (children) • Obstructive sleep apnea • Oral glucose suppression test = ↑ GH ▪ Or lanreotide
o Gigantism = before epiphyseal plates close • ↑ space between teeth o ↑ glucose should ↓ GH o Bromocriptine = dopamine inhibits GH release
• Coarse facial features o Acromegaly causes glucose intolerance ▪ Or cabergoline
• Rare = non-pituitary tumor secreting GH • Headache
o Pegvisomant = GH ® antagonist → inhibits ILG-F
• MRI = stellar or pituitary tumor o Radiation = if not responsive to surgery or meds
• Bitemporal hemianopsia
• GH = ↑ glucose & ↑ IGF-1
• Deep voice
o GH stimulates ↑ hepatic production of ILG-F
• Thick & moist skin (doughy)
Acromegaly • HTN & hypertrophy
• Cardiomyopathy
• Kidney stones
• Colonic polyps

• Adrenal gland does not produce enough hormones • Weakness, myalgia & fatigue • AM cortisol = low • Treatment = steroid and mineralocorticoid replacement
o ↓↓ cortisol (+/– aldosterone & sex hormones) • N/V/ D o Hydrocortisone (1st line) or dexamethasone
• Weight loss or poor appetite • AM ACTH = ↑ with 1o & ↓ with 2o o Fludrocortisone = aldosterone replacement
• 1o = adrenal gland dysfunction (aldosterone low) • Headache ▪ Used for 1o adrenal insufficiency
o Autoimmune = MC • Hypotension • AM renin = ↑ with 1o
Adrenal o Infection = TB or HIV • PPX = IV steroids & IVF before & after surgery
Insufficiency • Abnormal menstruation
o Vascular = thrombosis or hemorrhage • CMP = ↓ Na+ & ↑ K+ (1o) & hypoglycemia (1o & 2o) o Adjust PO steroid dose if illness, surgery, or high fever
o Trauma
Addison’s o METS • Hyperpigmentation = ↑ ACTH (1o only)
• ABG = non-anion gap acidosis (1o)
Disease o Meds = ketoconazole, rifampin,
phenytoin, & barbiturates • Orthostatic hypotension
o 1o from loss of aldosterone • ACTH stimulation test (cosyntropin) = 1o if
insufficient rise in cortisol after ACTH
• 2o
= pituitary ↓ ACTH secretion (aldosterone ok) • Poor libido, ↓ axillary hair, & amenorrhea (women)
o Exogenous steroids = MC o 1o from of sex hormones
o Hypopituitarism
• Acute adrenocortical insufficiency • Shock = hypotension & hypovolemia • ↓ cortisol & ↓ aldosterone • Treatment = IVF, steroids, & correct electrolytes
o Unable to ↑ cortisol during stress • N/V/D o Hydrocortisone = know Addison’s
o Sudden worsening of symptoms • Abdominal pain • CMP = ↓ glucose, ↓ Na+ & ↑ K+ o Dexamethasone = undiagnosed Addison’s
▪ Doesn’t interfere w/ cortisol assay
• Etiologies = precipitating “stressful” event • CBC = WBCs (infection) o Fludrocortisone = NOT for crisis → days to work
o Steroid withdraw = no tapering (MC)
o Infection
o Surgery
o Trauma
o Volume loss
o Fever
Adrenal o MI
(Addisonian) o Hypothermia
Crisis o Sepsis
o Hypoglycemia
o Bilateral adrenal infarction

• Etiologies
o Undiagnosed Addison’s & undergo stress
o Diagnosed Addison’s & don’t stress dose
o Chronic steroid use & don’t stress dose
 • ↑↑ cortisol from pituitary adenoma & ↑ ACTH
• Exogenous
o Long-term high-dose steroids → MC CAUSE
• Endogenous
o Pituitary adenoma
• MC = Cushing’s Disease
o Pituitary hyperplasia
o Ectopic ACTH-producing tumor
• SCC & medullary thyroid cancer
o Adrenal tumor (adenoma)
• Cushing’s syndrome = anything causing ↑ cortisol
• Weight gain → truncal obesity
• Moon facies = round face with puffiness & redness
• Buffalo hump
• Supraclavicular fat pads
• Thin extremities
• Atrophic & thin skin with purple striae
• Easy bruising & poor wound healing
• Hyperpigmentation → ↑ ACTH
• Acanthosis nigricans = hyperplasic & thick skin
• Androgen excess = hirsutism, oily skin, & acne
o Excess ACTH can activate androgens
• HTN
• 24-hour free cortisol = high (most specific) • Treatment = steroid taper or surgery
o Cushing’s Disease = transsphenoidal resection
• PM cortisol = high o Adrenal tumor = tumor excision
o Ectopic tumor = resection if possible
• Dexamethasone suppression test = low / high dose
o Should ↓ ACTH, which then should ↓ cortisol
o No suppression = abnormal cortisol secretion
• Cushing’s syndrome = NO cortisol suppression on
low-dose dexamethasone
• Cushing’s disease = cortisol suppression on
high-dose dexamethasone

• Ectopic ACTH-producing tumor = ↑ ACTH & NO

Cushing’s cortisol suppression on high-dose dexamethasone
Disease
• Adrenal tumor & steroids = ↓ ACTH & NO cortisol
suppression on high-dose dexamethasone

• MRI = Cushing’s Disease

• CT Abdomen = adrenal tumor

• CXR = ectopic ACTH-producing tumor

• CMP = hyperglycemia & ↓ K+

• ABG = metabolic acidosis

• Cholesterol = HLD

• Inability of kidney to concentrate urine
• Central = no ADH production (MC)
o Idiopathic
o Destruction of posterior pituitary
o Trauma
o CNS tumor sarcoid granuloma
Diabetes
Insipidus • Nephrogenic = renal insensitivity to ADH
o Medications = lithium, amphotericin B, etc.
o Hypokalemia
o Hypercalcemia
▪ Disrupts kidneys concentration ability
o Acute tubular necrosis (ATN)
o Hyperparathyroidism
• Polyuria • ↑ serum osmolarity • Treatment = central vs. nephrogenic
• Polydipsia • ↓ urine osmolarity o Central = desmopressin
o Nephrogenic = correct underlying cause
• High-volume nocturia • CBC = ↑ Na+ ▪ Na+ & protein restriction
▪ HCTZ, indomethacin or amiloride
• Symptoms of hypernatremia = confusion, lethargy, • Fluid deprivation test = dilute urine
disorientation, seizures or coma o Normal = urine concentrated
o DI = continued dilute urine
• Desmopressin (ADH) stimulation test
o Central = ↓ U/O & ↑ urine osmolarity
o Nephrogenic = continued dilute urine

• Autoimmune → pancreatic β cell destruction • Polyuria & glucosuria • Fasting glucose = >126 (pre = 110-125) • Treatment = insulin
o Patients T cells attacking pancreas • Polydipsia o Gold standard → repeat 2 times o ↑ ↑ insulin → hypoglycemia = LOC & seizures
o NO insulin secretion • Polyphagia
• A1C = >6.5% (pre = 5.7-6.4%) • Complications = DKA
• Early onset → 4-6 years old & 10-14 years old • Weight loss → fat & muscle breakdown for energy
• Lethargy • 2 hour glucose test = >200 (pre = >140-199) • ↑ glucose → arterial wall damage → atherosclerosis (CAD)
Diabetes o Best for pregnancy • ↑ glucose → nerve damage (neuropathy)
Mellitus • ↑ glucose → kidney damage (nephropathy)
Type I • Random glucose = >200 (with other symptoms) o Urinary albumin = >30 mg/24hour
o Not used for pre-diabetes • ↑ glucose → retina damage (retinopathy)
• ↑ glucose → gastroparesis
• C-peptide test (product of insulin) = low
o Not enough insulin because not making it

• Glutamic acid decarboxylase = high

 • Insulin resistance & impaired insulin secretion • Polyuria • Fasting glucose = >126 (pre = 110-125) • Treatment = weight loss, diet and medications
• Polydipsia o Gold standard → repeat 2 times o Metformin = euglycemic
• Risk factors = genetic & environmental factors • Polyphagia ▪ Check LFTs & monitor for LA
o Obesity • A1C = >6.5% (pre = 5.7-6.4%) ▪ Contraindication = CKD, liver disease, CHF, &
o FHx • Fatigue metabolic acidosis
o Ethnicity = Hispanic, AA, & Pacific islander • Poor wound healing • 2 hour glucose test = >200 (pre = >140-199) o Sulfonylureas = hypoglycemia risk; weight gain
o HTN o Best for pregnancy o Meglitinides
HLD
• ↑ infections → especially fungal
o o TZDs = weight gain & worsening CHF
o Ex: chronic vaginal discharge
• Random glucose = >200 (with other symptoms) o DPP-4 inhibitors = weight neutral
• Neuropathy o GLP-1 agonists = weight loss
o Not used for pre-diabetes
• Dry & itchy skin → damaged nerves!! o SGLT-2 inhibitors = weight loss
• Blurred vision • C-peptide test (product of insulin) = high o Insulin = hypoglycemia risk → if PO meds fail
Diabetes • Acanthosis nigricans o Too much insulin because body not using it
Mellitus • Complications = hyperosmolar hyperglycemic state
Type II o Dehydration → ↑ glucose → brings H2O out of cells
• UA = proteinuria
o Screen for proteinuria annually** o Leads to AMS due to cell shrinking

• CMP = evaluate kidney function
• Fundoscopy = evaluate retina
• ↑ glucose → arterial wall damage → atherosclerosis (CAD)
• ↑ glucose → nerve damage (neuropathy)
• ↑ glucose → kidney damage (nephropathy)
• ↑ glucose → retina damage (retinopathy)
• ↑ glucose → gastroparesis

• Screening
o BMI >25 & 1 other risk factor
o 45 years old & normal BMI
• Risk factors • Stones = kidney stones • Work-up • Treatment = IVF, meds, surgery, & +/– dialysis
o Primary hyperparathyroidism = MC • Bones = bone pain & fractures o Repeat Ca2+ & correct for albumin o Acute = IVF (NS) & loop diuretics (furosemide)
o Malignancy = PTH-related protein production • Abdominal groans = ileus & constipation ▪ Check ionized Ca2+ ▪ Diuretics after adequate hydration from IVF
o Vitamin D intoxication o Check PTH = rule out hyperparathyroidism o Chronic = steroids, calcitonin, pamidronate
• Psychiatric moans = depression, anxiety,
▪ ↑ intake cognitive dysfunction, & psychosis ▪ High = hyperparathyroid (bisphosphonate), & plicamycin
▪ ↑ renal production • Vascular tones = HTN ▪ Normal = hyperparathyroid or familial ▪ Calcitonin = ↓ bone reabsorption of Ca2+
▪ ↑ extrarenal production • ↓ DTRs ▪ Low = malignancy or vit D intoxication • Works faster than bisphosphonates
• Granulomatous disease or lymphoma • Weakness o PTH-rp = order if normal or low PTH ▪ Steroids = granulomatous disease
o Immobilization o Vitamin D = check if ↓ PTH & no malignancy ▪ Bisphosphonate = ↓ Ca2+ release
Hyper- o Granulomas = sarcoidosis ▪ ↑ 1,25(OH) = granuloma or lymphoma ▪ Denosumab = option after bisphosphonates
calcemia o Thiazide diuretics ▪ ↑ 25(OH) = intoxication o Parathyroidectomy = hyperparathyroidism
o Vitamin A intoxication o Consider TSH & vitamin A o Dialysis = severe hypercalcemia
o Hyperthyroidism
o Calcium supplementation • CXR = if ↑ vitamin D to check for granuloma
o Milk-alkali syndrome
o Addison’s disease • EKG = shortened QT interval
o Acromegaly
o ZES
• Hyperparathyroidism = SLOW ↑ Ca2+
• Malignancy = RAPID ↑↑ Ca2+
• Risk factors • Muscle cramps • Work-up • Treatment = Ca2+ & maybe vitamin D, K+ or Mg2+
o CKD • Bronchospasm o Repeat Ca2+ & correct for albumin o Mild = oral Ca2+ & vitamin D
o Hypoparathyroidism • Tetany = intermittent muscular spasms ▪ Check ionized Ca2+ o Severe = calcium gluconate & calcium chloride
o Vitamin D deficiency o Chvostek’s sign = facial spasm w/ CN 7 tapping o Check PTH ▪ Calcium gluconate (IV) = symptomatic patients
o Calcium sequestration o Trousseau’s sign = BP cuff causes carpal spasm ▪ High = CKD, vitamin D deficiency, & • Need ~200mg Ca2+ to stop attack of tetany
o Hypomagnesemia • ↑ DTRs pseudohypoparathyroidism • Less toxic than Ca2+ chloride if infiltrated
o Acute pancreatitis ▪ Normal = ↓ Mg2+
• Seizures ▪ Calcium chloride (IV) = 3x more Ca2+
o Rhabdomyolysis ▪ Low = hypoparathyroidism
o Blood transfusion = citrate binds to Ca2+ • Avoid peripheral infusion
Hypo- o Phosphate • Infiltrated IV site can cause tissue necrosis
▪ Citrate = preservative in blood products ▪ High w/out CKD = hypoparathyroidism
calcemia
▪ High w/ low 1,25 vit D = CKD
▪ Low w/ low 25 vit D = vit D deficiency
o Magnesium = if malabsorption or alcoholic
o Vitamin D = low 1,25 (CKD) or 25 (vit D def)
o Creatine = high in CKD

• EKG = prolonged QT interval

 • Excess PTH • Stones = kidney stones • Triad = ↑ Ca2+, ↑ PTH, ↓ phosphate • Treatment = surgery, meds & treat hypercalcemia
• Bones = bone pain & fractures o Parathyroidectomy = definitive treatment
• Etiologies • Abdominal groans = ileus & constipation • EKG = shortened QT interval ▪ Oral Ca2+ & vitamin D = post parathyroidectomy
Hyper- o Parathyroid adenoma = MC • Psychiatric moans = depression, anxiety, o Cinacalcet = inhibits release of PTH
parathyroidism o Lithium cognitive dysfunction, psychosis ▪ If not surgical candidate
o MEN I and IIa malignancy = rare • Vascular tones = HTN o Severe ↑ Ca2+ = IVF & furosemide
o Vitamin D deficiency (ex: CKD)
• ↓ DTRs
• Weakness
• Etiologies • Muscle cramps • Triad = ↓ Ca2+, ↓ PTH, ↑ phosphate • Treatment treat hypocalcemia
o Post-surgery = thyroidectomy or • Bronchospasm o Mild = oral Ca2+ & vitamin D
parathyroidectomy (MC) • Tetany = intermittent muscular spasms • EKG = prolonged QT interval o Severe ↓ Ca2+= calcium gluconate or chloride
Hypo- o Autoimmune = destruction of thyroid (MC) o Chvostek’s sign = facial spasm w/ CN 7 tapping
parathyroidism o Radiation therapy o Trousseau’s sign = BP cuff causes carpal spasm
o Hypomagnesaemia • ↑ DTRs
o Congenital pseudohypoparathyroidism
o DiGeorge syndrome = parathyroid hypoplasia • Seizures
• Etiologies • ↓ DTRs • ↑ Mg2+ • Treatment = Ca2+, IVF, diuretics, insulin, & +/– dialysis
o Renal failure • Weakness o Stabilize myocardium = Ca2+ gluconate or chloride
o ↑↑ Mg2+ = antacids, vitamins, TPN, treatment • N/V • EKG = prolonged QT or PR interval & wide QRS o IVF & diuretics (furosemide) = ↑ Mg2+ excretion
Hyper- ▪ Iatrogenic = excess Mg2+ for tx of asthma, • Lightheadedness & AMS o Dialysis = severe or refractory
preeclampsia, & torsades de pointes
magnesemia • Ileus
o Diabetic ketoacidosis
o Lithium • Respiratory depression
o Milk-alkali syndrome
o Adrenal insufficiency • ↓ HR & HOTN = ↑ Mg2+ has CCB effects
• Etiologies • ↑ DTRs • ↓ Mg2+ • Treatment = Mg2+
o GI loss = malabsorption • Seizures o Acute = magnesium sulfate (MgSO4) (IV)
▪ EtOHism, celiac, N/V/D, & laxatives • Tetany = intermittent muscular spasms • ↓ K+ o Chronic = magnesium oxide (MgO) (PO)
o Renal loss = diuretics, DM, & RTA o Chvostek’s sign = facial spasm w/ CN 7 tapping • ↓ Ca2+
Hypo- ▪ Diuretics = thiazide & loop diuretics o Trousseau’s sign = BP cuff causes carpal spasm • ↓ PTH ALWAYS FIX HYPOKALEMIA WITH HYPOMAGNESEMIA
magnesemia ▪ RTA (renal tubular acidosis) = renal failure • Palpitations & arrythmias
o Endocrine = hyperaldosteronism • EKG = prolonged QT or PR interval, wide QRS, • Complications = hypokalemia, hypocalcemia,
o Iatrogenic = TPN & NGT suctioning peaked T waves, Vtach (torsades), Afib or Vifb hypoparathyroidism, & torsades de pointes
o Meds = PPIs, aminoglycosides, cisplatin
amphotericin B, cyclosporine & diuretics
• K+ = MAJOR intracellular cation • Weakness • ↑ K+ → critical value = >6.5 • Treatment = stabilize, temporize & eliminate
• Fatigue o Stabilize myocardium = Ca2+ gluconate or chloride
• Hemolysis = pseudohyperkalemia • Paralysis • Glucose = hyperglycemia o Temporize = insulin & D50
• Paresthesia’s • Bicarbonate = acidosis ▪ Insulin moves K+ into cells
• Risk factors • o Eliminate = lasix or kayexalate
• Palpitations CBC = hemolysis
o Renal failure • CPK = rhabdomyolysis ▪ Lasix = through urine
• Cardiac arrythmias
Hyper- o Hypoaldosteronism = Addison’s, ACEi, ARB ▪ Kayexalate = through stool
o Meds = excess K+, NSAIDS, sulfa, digoxin, BB, • Ileus o Dialysis = severe or refractory
kalemia • Abdominal distension • EKG = peaked tall T waves, wide QRS,
cyclosporine, heparin, & spironolactone prolonged PR interval, & sine waves
o Tissue destruction = rhabdomyolysis, burns, o EKG needed for all patients with K+ >6.0 • Complications = VT or Vfib
& tumor lysis syndrome
o Overcorrection = iatrogenic overdose
o Metabolic acidosis = DKA
o Insulin deficiency
o Blood transfusion
• K+ = MAJOR intracellular cation • Weakness • ↓ K+ • Treatment = K+
• N/V o Mild = potassium chloride (KCl) (PO)
• Risk factors • Tetany • ↓ Mg2+ → can be the cause of hypokalemia! o Severe = potassium chloride (KCl) (IV)
o N/V/D, laxatives, or diuretics • Paresthesia’s ▪ Maximum via peripheral IV = 10 mEq/hour
o Hyperaldosteronism • Ileus = MC cause of electrolyte induced ileus • EKG = T wave flattening & U waves ▪ Maximum via central line = 20 mEq/hour
o Metabolic alkalosis
Hypo- Hypomagnesemia = inhibits K+ reabsorption
o • K+ >3 = 10 mEq ↑ K+ 0.1
kalemia o RTA = renal tubular acidosis • K+ <3 = need more mEq to get same ↑ in K+
o Insulin excess o Lower K+ = be more aggressive to get same level
o Steroids = ↑ renal excretion of K+ o Ex: if K+ = 2.5-3, it takes 15 mEq to get up 0.1
o Intestinal fistulas
o NGT • Complications = VT (Torsades)
 • Free water loss • Confusion & disorientation • ↓ Na+ • Treatment = IVF (hypotonic or isotonic fluids)
• Lethargy & fatigue o Hypotonic IVF = water (PO), D5W, or ¼ or ½ NS
• Always associated with hyperosmolality • Headache • Urine sodium ▪ PO = preferred
o Skip straight to volume status • N/V o ↑ = renal loss ▪ Typically D5W or ½ NS if using IVF
o Don’t measure serum osmolality (always high!) • Tremors o ↓ = extrarenal loss ▪ Replace ½ over 1st 24 hours, then rest over 2-3 days
o Isotonic IVF = NS or LR if hypovolemic
• Risk factors • Seizures • Urine osmolality ▪ Then switch to hypotonic once volume repleted
o Diarrhea & vomiting o ↑ (concentrated) = extrarenal loss
Diuretics • Coma
o o ↓ (dilute) = diabetes insipidus • Rapid correction = cerebral edema & seizures
o Sweating • Respiratory arrest
o Seizures from cerebral edema
o Burns
o Fever • Dry MM
• Complications = coma, seizures, & respiratory arrest
o Impaired thirst mechanisms • ↓ skin turgor
Hyper-
natremia ▪ Elderly, infants, or debilitated patients • ↑ HR & HOTN
o Insensible loss
o Inadequate hydration
o Diabetes insipidus
o Iatrogenic = TPN & Zosyn
o Induced = TBI & neurosurgical patients
▪ Induce to ↓ cerebral edema
▪ Mannitol lowers ICP

• Free water gain • Confusion & disorientation • ↑ Na+ • Treatment =

• Type = determined by osmolality & volume status
• Clinically significant = hypotonic hyponatremia
• Hypertonic = hyperglycemia or mannitol
o Hyperglycemia causes osmotic diuresis
• Isotonic = hyperproteinemia or HLD
o Both cause water to shift from cells into blood
• Lethargy & fatigue o Hypovolemic = IVF (NS) & correct underlying cause
• Headache • Serum osmolality = 2Na + glucose/18 + Bun/2.8 o Euvolemic = H2O restriction & treat underlying cause
• N/V o High (>290) = hypertonic ▪ Diuretics (furosemide) & IVF (NS) acutely
o Normal (280-290) = isotonic o Hypervolemic = H2O restriction & diuretics
• Muscle cramps
o Low (<280) = hypotonic
• Rapid correction = central pontine myelinolysis
• Seizures
• Volume status = hypotonic / ↓ osmolality o Causes permanent neurological / brain damage
• Coma o Hypervolemia = edema, ↑ JVP, ↓ HCT, HTN
• Respiratory arrest o Euvolemic = no change • Complications = coma, seizures, & respiratory arrest
o Hypovolemic = dry MM, ↓ skin turgor, HOTN

• Hypotonic hyponatremia
o Hypovolemic
▪ Diuretics
▪ Hypoaldosteronism = adrenal insufficiency
▪ Vomiting
▪ NGT
Hypo- ▪ Diaphoresis
natremia ▪ GI loss
▪ Burns
▪ Rhabdomyolysis
▪ 3rd spacing = peritonitis or pancreatitis
▪ TBI
o Euvolemic
▪ SIADH = sodium is always down here
▪ Hypothyroidism
▪ Adrenal insufficiency
▪ Water intoxication
▪ Drugs = ecstasy
▪ Tea & toast syndrome
▪ Beer potomania
o Hypervolemic
▪ Renal failure
▪ CHF
▪ Liver failure (cirrhosis)
▪ Fluid overload (dilutional) = iatrogenic
 • Risk factors
o Grave’s disease = MC cause
▪ Autoimmune = TSH ® autoantibodies
▪ Targets & stimulates TSH ® on thyroid
▪ Thyroid-stimulating immunoglobulins
o Meds = levothyroxine or amiodarone
o Pituitary adenoma = secreting TSH
o Stopping OCPs = frees previously bound T4
• Hypermetabolic state
• MC = 20-40 years old
Hyper-
thyroidism
• T3 = ↑ metabolic rate, CO, SNS, bone resorption
• Clammy skin
• Palpitations → A. fib. & PVCs
• Heat intolerance
• WEIGHT LOSS
• Diarrhea
• Hyperreflexia & tremors
• Amenorrhea & gynecomastia
• Hair loss
• Exophthalmos
• Goiter
• Hoarseness = goiter on recurrent laryngeal nerve
• Muscle weakness → thyrotoxic myopathy
• Anterior neck bruit = ↑ blood flow to goiter
• Myxedema (pretibial) = swollen red or brown
patches with non-pitting edema
• Thyroid = enlarged & non-tender
• ↓ TSH • Treatment = meds, radioactive iodine, surgery
• ↑ T4 & T3 o Propylthiouracil (PTU) & methimazole (MMI)
▪ Stop synthesis of new thyroid hormones (T4 & T3)
• TSH ® antibodies ▪ PTU only = ↓ peripheral conversion of T4 to T3
▪ Monitor with T4 & T3 at 6 week intervals
• Radioactive uptake scan = diffuse ↑ iodine uptake ▪ Once stable, monitor with TSH
▪ S/E = agranulocytosis (check CBC)
o BB (propranolol) = ↓ HR & ↓ adrenergic symptoms
o Radioiodine therapy = multinodular goiter
▪ ↓ cost & complications
o Steroids = exophthalmos
▪ ↓ peripheral conversion of T4 to T3
o Thyroidectomy = severe, obstructing & large goiter
▪ Patients unable or not willing to do radioiodine
• Complications = thyroid storm, osteoporosis, & CHF
• Thyroid storm = severe hyperthyroidism
o Cause = stopping medicine, surgery or infection
o Symptoms
▪ Heat intolerance → high fever
▪ ↑ HR → arrythmias
▪ Agitation & delirium
o Treatment = BB, PTU, steroids, & iodine

• Risk factors
o Hashimoto’s thyroiditis = MC cause
▪ Autoimmune = anti-thyroid peroxidase
& anti-thyroglobulin antibodies
▪ TSH ® blocking antibodies
▪ Antibodies damage thyroid
▪ Enlargement of thyroid because trying to
compensate for other damaged parts
o Iodine deficiency = MC worldwide in low SES
o Meds = MMI, PTU, lithium, or amiodarone
Hypo- o Thyroidectomy
thyroidism o Radiation
o Postpartum thyroiditis
• Hypometabolic state
• MC = 20-40 years old
• Dry skin & loss of 1/3 outer eyebrow • ↑ TSH • Treatment = meds & monitoring
• Bradycardia • ↓ T4 & T3 o Meds
• Cold intolerance ▪ Levothyroxine (synthroid) = T4
• WEIGHT GAIN • anti-thyroid peroxidase & anti-thyroglobulin Ab ▪ Liothyronine (cytomel) = T3
• Constipation o Monitor = TSH at 6 week intervals
• Hyporeflexia • Radioactive uptake scan = ↓ iodine uptake
• Complications = myxedema coma
• Menorrhagia
• Memory loss & forgetfulness
• Myxedema coma = severe hypothyroidism
• Low libido o Cause = stopping medicine, surgery or infection
• Peripheral neuropathy o Symptoms
▪ Hypothermia
• Myxedema (pretibial & periorbital) = swollen red ▪ Hypoglycemia
or brown patches with non-pitting edema ▪ Coma or obtunded
o Periorbital = puffy face ▪ ↓ HR & HOTN
o Skin, tongue, & soft tissue swelling
o Treatment = levothyroxine, IVF & steroids
• Thyroid = atrophic, normal or enlarged

• Classification • Bitemporal hemianopsia • MRI = detect adenoma on pituitary • Treatment = surgery & hormone replacement
o Functional = secretes hormones • Headache o Transsphenoidal surgery = definitive treatment
o Nonfunctional • Hormone levels ▪ Surgery if macroadenoma (>1 cm)
o Compressive = local symptoms • Symptoms depend on hormone levels o LH/FSH o Hormone replacement = as needed
o ↑ LH/FSH = rarely cause symptoms o TSH ▪ Replace CORTISOL 1st!!!!!!
• Types o ↑ TSH = hyperthyroidism o Cortisol = 24-hour urinary free cortisol
o Gonadotroph = LH/FSH o ↑ cortisol = Cushing’s disease o Prolactin • Complications = pituitary apoplexy (hemorrhage or
Pituitary o Thyrotroph = TSH o ↑ prolactin = lactation & hypogonadism o IGF-1 outgrows blood supply)
Adenoma o Corticotroph = cortisol o ↑ IGF-1 = acromegaly
o Lactotroph = prolactin
o Somatotroph = IGF-1
 • Types of thyroid carcinoma
o Papillary = MC & least aggressive
▪ Radiation exposure
▪ Family history
▪ Local METS > distant METS
o Follicular = 2nd MC & more aggressive
▪ Iodine deficiency
▪ Distant METS > local METs
• Follicular goes FAR
o Medullary = calcitonin-synthesizing C cells
▪ 10% associated with MEN IIa or IIb
▪ Local METS = early on
▪ Distal METS = later on
o Anaplastic = aggressive & poor prognosis
Thyroid
Cancer
• Abnormal & accelerated bone remodeling
o ↑ osteoclast bone resorption
o ↑ osteoblastic bone formation
o Hypervascular bone
• Disorganized osteoid formation
o Osteoid = unmineralized part of bone matrix
Paget that forms prior to maturation of bone tissue
Disease
(of bone) • Risk factors
o Western European
o FHx= autosomal dominant (40%)
o >40 years old
• Catecholamine-secreting adrenal medulla tumor
o Arise from chromaffin cells
o Norepinephrine, epinephrine & dopamine
• Triggers = surgery, exercise, pregnancy, meds
o Meds = TCAs, opiates, glucagon, Reglan, BB,
steroids, & anesthesia
Pheochromo
-cytoma
• High risk = FHx, previous pheochromocytoma, or
genetic syndrome (MEN2)
• 90% benign
• Rule of 10s = 10% malignant, 10% bilateral, 10% in
children, 10% extra-adrenal (paraganglion)
• Papillary = painless thyroid nodule • TSH = initial testing
o Normal or elevated = FNA
• Follicular = painless thyroid nodule o Subnormal or low = radioiodine uptake scan
• Medullary = flushing & diarrhea • US = initial testing
o Hypoechoic
• Anaplastic = rapidly enlarging hard thyroid mass o Incomplete halo
o Compressive symptoms = dyspnea & dysphagia o Irregular margins
o Microcalcifications
o Central vascularity
• Radiodine uptake = cold & low uptake
o Nonfunctional nodule is suspicious for CA
• FNA = definitive diagnosis
o Normal TSH
o ↑ TSH
o Nonfunctional nodule
• CT or MRI = US suspicious for cancer OR (+) FNA
o Also done to look for METS!
• Medullary = ↑ calcitonin & CEA
• Thyroglobulin = monitoring for reocurrence
• Mostly asymptomatic! • ↑ alk phos
• Bone pain = MC symptom • Normal Ca2+ & phosphate
• Bowing deformities = bowed tibia
• Skull enlargement • X-ray
o Deafness = compressed CN VII o Lytic phase = blade of grass / flame sign
o Headache o Sclerotic phase = ↑ trabecular markings
• Skull x-ray = cotton wool appearance
o From thickened & disorganized trabeculae
• Triad = palpitations, headache, & diaphoresis • Low risk = 24-hour urine fractionated
o HTN = MC finding metanephrines & catecholamines
• Chest or abdominal pain • High risk = plasma fractionated metanephrine
• Weakness
• Fatigue • CT or MRI = visualize adrenal tumor after testing
• Weight loss
• Pallor
• Vision changes
• Treatment = surgery & meds
o Thyroidectomy = definitive treatment
o Levothyroxine = post-surgical treatment
o Radioiodine = post-surgical for some patients
• Treatment = meds
o Asymptomatic = no treatment
o Symptomatic (pain, fx, high output HF, etc.) = meds
▪ Bisphosphates = inhibit osteoclasts (1st line)
• IV = zoledronic acid & ibandronate
• PO = alendronate, risedronate, &
ibandronate
• S/E = flu-like symptoms, MSK pain,
esophagitis, GI sx, osteonecrosis of the jaw
• Take with water & stay upright for 30 min
▪ Calcitonin = inhibit osteoclasts
• Less potent than newer bisphosphonate
▪ Vitamin D & Ca2+ supplementation
▪ NSAIDs = pain
• Complications = fractures
• Treatment = surgery
o Complete adrenalectomy = definitive treatment
o Preoperative management
▪ Alpha blockade = initial therapy
• Phenoxybenzamine or phentolamine
• Prior to BB to prevent unopposed α-agonism
▪ Beta blockade = 2nd therapy
• Propranolol
• Avoid these meds = BB, reglan, glucagon, histamine
• Hypertensive crisis = phentolamine, nitroprusside or
nicardipine
 PSYCHOLOGY
Visit Etiology Presentation & PE Diagnosis Treatment & Complications
• Anxiety occurring beyond stimulus duration • S = sleep • Criteria = anxiety >6 months w/ >3 symptoms • Treatment = pharmacological & nonpharmacologic
o Excessive anxiety that impairs functioning • I = irritable o Fatigue
o No real focus of anxiety • M = muscle tension o Restlessness • Pharmacologic
• E = energy o Difficulty concentrating o SSRI = 1st line (Zoloft, Celexa, Paxil, or Lexapro)
• Female > male • C = concentration
o Muscle tension ▪ Continue for ~12 months
o Sleep disturbances o SNRI = 2nd line (Cymbalta or Effexor)
• H = headache o Irritability
Generalized • Causes o Benzodiazepines = PRN or until SSRI works (Xanax)
o Neurotransmitters disturbance = GABA, • A = agitated/restless/shaky o Shakiness
Anxiety • P = panic attack o Headaches
serotonin & noradrenergic • Nonpharmacologic therapy
Disorder o Autonomic nervous system dysfunction • S = SI or HI o Psychotherapy = CBT
o Structural / functional brain abnormalities • Anxiety out of proportion to stimulus o Education = stress management
o HPA axis = ↑ cortisol • Worry → “worry wart” • Impaired ability to function o Exercise
• Diarrhea & diaphoresis o Avoid caffeine, decongestants, diet pills & ETOH

• Feel anxious most of the time

• Anxiety and worry that is generalized
• Abrupt episode of intense fear • Sense of impending doom or dread = hallmark • Criteria = >4 symptoms; episodes of intense fear • Treatment = medication & r/o life threatening conditions
o Dizziness o Benzodiazepines = 1st line (Xanax)
• Peaks within 10 minutes (rarely >1 hour) o Trembling o Life threatening conditions = MI, thyrotoxicosis, etc.
o Choking feeling
Panic o Paresthesia’s
Attack o Sweating, chills or hot flashes
o CP, palpitations, tachycardia, & SOB
o Fear of losing control or dying (impending doom)
o Nausea or abdominal distress
o Depersonalization or derealization
• Recurrent panic attacks • Fear of having another attack → not fear of a • Criteria = recurrent unprovoked panic attacks & both of • Treatment = medication and therapy (CBT)
specific situation the following for >1 month after panic attack o SSRI = 1st line (Zoloft, Celexa or Prozac)
• Causes o Persistent concern about future attacks o CBT = helps reduce or eliminate core fears
o Neurotransmitters disturbance = GABA, o Maladaptive behaviors related to attacks o Benzodiazepines = PRN for acute attacks (Xanax)
serotonin & noradrenergic ▪ Avoidance of exercise or unfamiliar situations ▪ Use as small a dose for as short a period of time
Panic o FHx → especially 1st degree relatives ▪ Discontinue once SSRI reaches full effect
Disorder o Smoking • Worry about implications of attacks (losing control) • Need in beginning since SSRIs can take weeks
to show effect
• Comorbidities = anxiety disorders & depression

• Female > male

• Prevalence = 3-5%
• Fear or anxiety of specific object or situation • Criteria = >6 months of fear or anxiety of a specific • Treatment = therapy & medication
situation, object, or place o CBT (exposure & desensitization therapy) = 1st line
• May be abnormality of anterior insular cortex o Situation = heights or flying o Benzodiazepines = PRN for acute attacks (Xanax)
o Between temporal and frontal lobe o Object = pigeons, snakes or blood o Beta-blockers = PRN (Propranolol)
o Place = hospitals o SSRIs = maybe, but usually very little benefit
• Usually, but not always, follows trauma
• Exposure triggers immediate response
• Vicarious learning OR “false alarm” experience
• Actively avoids specific object or situation
Specific • Subtypes
Phobias o Animals (50%) = spiders, dogs, mice • Everyday activity impaired to avoid situation or objects
o Situation = airplanes, elevators
o Natural = heights, thunder, water
o Blood-injection = injury, needles, blood
o Other = choking, vomiting, costume
characters, & 13 (triskaidekaphobia)

• Prevalence = 12%

• Median age = 7 (may persist during life)

 • Etiology unknown
o Biological, genetic, & psychosocial factors
▪ Biological factors = neurotransmitters
(norepinephrine, serotonin, &
dopamine, among others), hormonal
dysregulation (including cortisol), &
anatomical issues
o Life stressors and personality factors
Bipolar I
Disorder • Sleep dysfunction and circadian rhythm
abnormalities are also hypothesized
• Risk factor = positive FHx
• Male = female
• Age of onset = 20s-30s
• Prevalence = 1%
• 2o causes = infection, CNS disorder, thyroid
disorder, sleep deprivation, meds (cocaine, etc.)
Bipolar II • Mixed = meets criteria for major depression &
manic episode at the same time
Disorder
• Bipolar I = more severe than II and easier to dx
• Monoamine neurotransmitter deficiency
o Serotonin, dopamine, epinephrine,
norepinephrine, acetylcholine & histamine
• Neuroendocrine dysregulation
o Adrenal, thyroid & GH dysregulation
• Risk factors = FHx, female, age in the 20s
• ↑ risk = adverse childhood & stressors
• Female > male
• Often co-morbid with anxiety disorders
Major
Depressive • Children = lasts 8-13 months
o Relapse rate 30-70%
Disorder
• Adolescents = lasts 4-9 months
o Relapse rate 20-70%
• Depression = risk factor for CAD
• D = distractibility
• I = impulsivity (reckless driving, spending)
• G = grandiosity
• F = flight of ideas
• A = agitation and activity increase
• S = sleep decrease
• T = talkativeness → pressured speech
• Depression lasts longer than mania
• S = sleep
• I = interest
• G = guilt & worthlessness
• E = energy
• C = concentration & indecisiveness
• A = appetite & weight changes
• P = psychomotor → agitation or retardation
• S = SI or HI
• Functional impairment = school, parental
relationships, engaging in high risk behaviors
• Kids & adolescents may present w/ irritability
o Angry & mad rather than sad or depressed
• Somatic complaints (HA or abdominal pain)
o Common in children and elderly
• At least 1 manic episode (+/ – MDD episode)
• Mania = irritable mood >1 week; >3 symptoms
o Grandiosity
o ↓ need for sleep
o Pressured speech
o Flight of ideas & racing thoughts
o Distractibility
o ↑ goal-directed activity
o Engage in pleasurable activities with high risk
o Irritability
o Hypersexuality
• MDD = >2 weeks with >5 symptoms & 2 episodes
• Psychosis & marked impairment of function
• May need hospitalization
• At least 1 hypomanic episode & 1 MDD episode
• Hypomania = irritable mood >4 days; >3 symptoms
o Grandiosity
o ↓ need for sleep
o Pressured speech
o Flight of ideas & racing thoughts
o Distractibility
o ↑ goal-directed activity
o Engage in pleasurable activities with high risk
o Irritability
o Hypersexuality
• NO psychosis or marked impairment of function
• DO NOT need hospitalization
• Criteria = >2 weeks with >5 symptoms & 2
episodes
o Depressive mood → must be present
o Anhedonia → must be present
o Fatigue
o Insomnia or hypersomnia
o Guilt or worthlessness
o Recurring thoughts of death or suicide
o Psychomotor agitation or retardation
▪ Restlessness or slowness
o Weight changes → gain OR loss
o Decreased or increased appetite
o Decreased concertation or indecisiveness
o NOT associated with mania or hypomania
• Symptoms must cause significant distress or
impairment
• NEVER been a manic or hypomanic episode
• Screening = PHQ-2 → if positive, use PHQ-9
o Little or no interest in doing things?
o Down depressed or hopeless?
• Treatment = medication & therapy (CBT) & sleep hygiene
o Mood stabilizer (lithium, lamictal, valproic acid)
▪ Lithium = 1st line
• Avoid in renal insufficiency & pregnancy
• S/E = LITH & hypernatremia
o L = leukocytosis
o I = insipidus (DI)
o T = toxicity/teratogenic
o H = hypothyroidism
▪ Lamictal = SJS side effect
▪ Valproic acid = maybe safer for <12 years old
o 2nd gen. antipsychotics (risperidone, quetiapine,
olanzapine, ziprasidone) = mono or adjunct
▪ Antipsychotics better for pregnant women
• Less teratogenic side effects!
• Acute mania = antipsychotics, mood stabilizer or benzos
• Add antidepressant if also showing s/s of MDD
o DO NOT use antidepressant monotherapy! → may
precipitate mania or hypomania***
• NOT Haldol
• Pregnant or breast feeding = lamictal or antipsychotic
• Complications = suicide (↑ 15x) & distress/disability
• Patients usually seek help when depressed, NOT manic
• Treatment = medication & therapy (CBT) & exercise
o SSRI = 1st line (Zoloft & Lexapro)
o SNRI = 2nd line (Cymbalta or Effexor)
o NDRIs = Wellbutrin
o Atypical antidepressant = Remeron (Mirtazapine)
o TCAs = Amitriptyline or Imipramine
▪ Lower seizure threshold & prolong QT interval
▪ S/E = anticholinergic effects & orthostatic HOTN
o MAO inhibitors = Selegiline & Phenelzine
▪ Low tyramine diet to avoid hypertensive crisis
o Antipsychotics = if bipolar disorder suspected
• 2-6 weeks of therapy before improvement in symptoms
• 6-12 weeks for full effects to be seen (several months)
• Stay on meds for 6-12 months after asymptomatic
o 1 year recurrence rate is 40%
• Pregnant or breast feeding = Zoloft, Celexa, & Lexapro
• Geriatric = SSRIs & avoid TCAs
o TCAs = anticholinergic, CV & sedative
• Pediatric = Prozac (SSRI) → Black Box Warning!
o Assess for suicide risk → ↑ risk of suicide with AD
• ECT = electroconvulsive therapy
o Unresponsive to medical treatment, unable to tolerate
meds (pregnancy) OR rapid reduction of sx
o S/E = cognitive problems, HA, fatigue
o May be 1st line treatment for certain populations
▪ Medically ill, very suicidal, catatonic, pregnancy
• TMS = transcranial magnetic stimulation
o Offered in an outpatient setting as alternative
 • 3rd leading cause of death of kids
• Attempts > females
• Completion > males
Suicide • Risk factors
o Low birth weight
o Psychiatric disorders
o Previous suicide attempt or current plan
o FHx of mood disorder or suicide
o History of physical or sexual abuse
• Failure to maintain normal body weight
o Mild = BMI ≥17
o Moderate = BMI 16–16.99
o Severe = BMI 15–15.99
o Extreme = BMI <15
• Behaviors are accepted by them
• Females > Males
• MC = 14-18 years old (adolescence)
• Classic features = white, smart, early to middle
Anorexia
adolescent girl, high SES, conflict-avoidant, risk-
Disorder aversive, perfectionist with anxiety or mood
disturbances
• Two types → behavior over last 3 months
o Restrictive = diet, fast, & exercise
o Binging/purging = vomiting, laxatives, &
diuretics
• Being eating and compensatory behaviors
o Mild = 1–3 episodes per week
o Moderate = 4–7 episodes per week
o Severe = 8–13 episodes per week
o Extreme = >14 episodes per week
• Distressed about their behaviors
• Females > males
• MC = 18 years old (early adulthood)
Bulimia
Disorder • Often later onset than anorexia!
• S = sex: male
• A = age: middle (45-64)
• D = depression
• P = previous attempt
• E = ethanol use
• R = rational thinking loss
• S = single → being alone is big risk factor
• O = organized plan
• N = no social support
• S = sickness
• Thin to cachectic (might wear bulky clothes)
• Fatigue
• Tired & lack energy
• Dizziness & fainting
• Hair loss & dry skin = lanugo
• Early satiety & constipation
• Cold & blue hands & feet
• Depression & anxiety
• Hypothermia (less than 95.9 F)
• Amenorrhea = absent 3 consecutive cycles
• Slow psychomotor response
• o
Orange or yellow hands
o ↓ hepatic conversion of β-carotene to vit A
• Bradycardia & HOTN → orthostatic HOTN
• Edema of feet
• Loss of muscle, subcutaneous, and fat tissue
• Normal weight → or might be overweight
• GI = esophagitis, Mallory Weiss tear, impaired
colonic function
• Calluses over knuckles (Russell’s sign)
• Subconjunctival hemorrhage s/p emesis
• Eroded dental enamel and tooth decay
• Parotid gland enlargement → round face
o Enlarged salivary glands 2o to vomiting
• Absent gag reflex
• Access to means • Treatment = ensure safety, admit, psychotherapy
• Alcohol and drug use
• Exposure to suicide • SSRIs and other antidepressants may ↑ risk
• Social stress and isolation
• Emotional and cognitive factors • Treat any underlying mental disorder
o Hopeless, helpless, impaired problem solving
• Ask if they have an organized plan!
• Ask: Why are you still here? What is keeping you alive?
• Ideal body weight <85% OR BMI <17 • Treatment = therapy, nutrition, & +/– meds
o CBT, family therapy & group therapy = 1st line
• Criteria ▪ Family therapy = 1st line therapy
o Restricting calorie intake ▪ Appetite focused therapy
o Fear weight gain or behavior preventing weight gain o Nutritional rehabilitation = monitor weight &
o Distorted body image, undue influence of weight on supervised meals
self-worth, or denial of seriousness of low body o SSRIs = if depressed (helps with weight gain)
weight o Antipsychotics = if 1st line treatment with nutritional
therapy & psychotherapy does not work
• Labs ▪ Olanzapine = can help with weight gain
o Hypokalemia (vomiting)
o ↑ BUN (dehydration) • If no comorbidities, then medications are not indicated
o Hypochloremia metabolic alkalosis (vomiting)
↑ total cholesterol → body producing ↑ HDL
• Hospitalization = <70% expected body weight (BMI <15)
o Metabolic acidosis (diarrhea) o Correct dehydration, starvation, electrolyte imbalance
o Calcium
o Magnesium • Accountability = major factor! → food diaries, weights, etc.
o Phosphate
o LFTs, albumin & prealbumin
o INR • Complications
o Refeeding syndrome = hypophosphatemia,
o CBC → anemia, leukopenia & thrombocytopenia
hypokalemia, & hypomagnesemia
▪ Bone marrow is affected o Vitamin deficiencies (thiamine), CHF, peripheral
o TSH → hypothyroidism edema, rhabdo, seizures, hemolysis, & arrythmias
o Low estrogen o Cerebral atrophy = gray matter loss
o Vitamin D
o Pregnancy test
o ECG
• Criteria • Treatment = therapy, nutrition and meds (Prozac)
o Recurrent episodes of binge eating o CBT, family therapy and group therapy = 1st line
▪ Eating in 2 hours more than normal ▪ Family therapy = 1st line therapy
▪ Lack of control over eating ▪ Appetite focused therapy
o Recurrent behaviors to prevent weight gain o Nutritional rehabilitation= monitor weight &
o Eating & behaviors >1/week for 3 months supervised meals
o Self-evaluation influenced by shape and weight o SSRIs = Prozac (Fluoxetine) = FDA approved drug
o Does not occur only during episodes of anorexia
• Bupropion is contraindicated = could cause seizures
• Compensatory behaviors
o Purging = vomit, diuretics, laxatives
o Non-purging = reduce calories, diet, fast, exercise
• Labs
o Hypokalemia (vomiting)
o Hypomagnesemia
o ↑ amylase → enlarged salivary glands
o Hypochloremic metabolic alkalosis → 2o vomiting
 • Biological factors = dysfunction in noradrenergic
or opioid system, or HPA axis
• Risk factors = prior psychiatric history, lower
socioeconomic status, low education levels,
exposure to previous trauma, & female
• ↑ rates among veterans and high-risk vocations
o e.g., police, firefighters, EMT
• Highest risk = survivors of rape, combat vets and
those in captivity
• Can occur at any age after first year of life
o <6 year old → children express re-
experiencing symptoms through play
Post- • MC in females across the lifespan
Traumatic
• PTSD = exposure to a traumatic event,
Stress
reexperiencing, avoidance of reminders, negative
Disorder alterations in thoughts and mood, and symptoms
of increased arousal
• Traumatic event = anytime in the past
• Opioids = heroin, oxycodone, hydrocodone,
codeine, morphine, dextromethorphan,
meperidine & methadone
o Heroin (short half-life) = rapid & severe
withdrawal
o Methadone (long half-life) = less severe &
more gradual / prolonged withdrawal
• MOA = mu ® agonist
Opioid
Related
Disorders
• Dreams or flashbacks • Criteria = trauma anytime in past & symptoms >1 • Treatment = medication and therapy
• Dysphoric mood states or amnesia month o SSRI = 1st line (Zoloft, Celexa or Prozac)
• Irritability o CBT = counseling & relaxation techniques
• ↑ startle response • Criteria A = exposure to actual or threatened death, o Trazodone = treats insomnia & depression
• Difficulty concentrating serious injury, or sexual violence by >1 of the following: ▪ Hypnotic
o Directly experiencing the trauma o Prazosin = treats nightmares and hypervigilance
o Witnessing, in person, events occurring to others ▪ Alpha-1 adrenergic antagonist
• Avoids reminders of the trauma o Learning event occurred to family or friend
o Exposure to details of traumatic event (EMS • Need to establish safety!
• Children & under 6 years old collecting human remains, officers responding to
o A. Excludes repeated exposure (e.g., 1st child abuse)
responders) • AVOID benzodiazepines → substance use high in PTSD
o B. As adult/adolescent criteria • Criteria B = >1 of these symptoms after exposure to • Complications = suicidal ideation or attempt
o C & D. Require only one symptom
trauma
o E. No self-destructive behavior
o Recurrent & intrusive distressing memories
o Recurrent & distressing dreams related to trauma
o Dissociative reactions (flashbacks)
• E = event o Psychological distress at exposure to cues of trauma
• R = recurrent
• A = avoid • Criteria C = avoidance of stimuli associated with trauma
• N = negative o Avoiding distressing memories, thoughts, or
• S = startle response feelings
o Avoiding external reminders (people, place, objects)
• Criteria D = negative alteration in cognitions and mood
associated with traumatic event; >2 of the following:
o Inability to recall important aspect of traumatic
event
o Negative beliefs about oneself, others or the world
o Negative emotional state (fear, anger, guilt, shame)
o Disinterest in activities = anhedonia
o Feeling detached
• Criteria E = alteration in arousal and reactivity
associated with trauma by >2 of the following:
o Irritable behavior and angry outbursts
o Reckless or self-destructiveness
o Hypervigilance
o Exaggerated startle response
o Problems with concentration & sleep disturbances
• Intoxication • Clinical diagnosis • Treatment = medication, support airway & O2
o Euphoria & sedation
o Pupillary constriction (miosis) • Criteria = >2 of the following o Intoxication = naloxone (opioid antagonist)
o AMS & sedation o Taken in large amounts over a long time ▪ Support airway & O2 before administering
o Respiratory depression o Persistent desire or unsuccessful efforts quit ▪ Can get severe withdraw symptoms after giving this
o ↓ HR and HOTN o A lot of time spent trying to obtain & use
o Constipation o Craving or strong desire to use o Withdraw = methadone; clonidine (α2 agonist ↓ BP);
o Failure to fulfill obligations at work, etc. zofran, & buprenorphine → meds if severe withdraw
• Withdraw o Use despite social or interpersonal problems ▪ Methadone = long-acting opioid agonist → taper
o Restlessness o Important activities given up or reduced ▪ Buprenorphine = long-acting opioid agonist &
o Pupillary dilation (mydriasis) o Recurrent use in hazardous situations antagonist
o Flu-like symptoms o Continued despite known problem
o Lacrimation & rhinorrhea o Tolerance o Long-term = methadone, suboxone or naltrexone
o Pruritus o Withdrawal ▪ Methadone = full opioid agonist; for maintenance
o ↑ HR & HTN ▪ Suboxone = partial opioid agonist; used for detox
o Yawning
• Suboxone = buprenorphine + naloxone
▪ Naltrexone = opiate antagonists
 • Dependence = withdraw symptoms & tolerance • Intoxication
o Euphoria & sedation
• 4 types o Slurred speech
o Unhealth alcohol use o Incoordination & unsteady gait
o Risky use = 3-4 drinks/day or 7-14 o Nystagmus
drinks/wk o Impairment in attention or memory
▪ Women = 1st # & men = 2nd # o Stupor or coma
o Binge drinking o Sexual or aggressive behavior
o Alcohol use disorder = dependence o Mood lability
o Impaired judgement
• Drink standards
o Beer = 12 oz • Withdraw
o Malt liquor = 8 oz o Sweating
o Hard liquor = 1.3 oz o ↑ HR
o Wine = 5 oz o Hand tremor = 6-12 hours
o Insomnia
• BAC = % ETOH in blood o Nausea or vomiting
o Hallucinations or illusions
o 0.08% or over is considered legally impaired
▪ Visual, tactile, or auditory
o Psychomotor agitation
• Legal and medical intoxication is different
o Anxiety
o Seizures = 1-2 days
• Comorbid conditions = depression o Delirium tremens = 2-4 days
▪ Delirium & AMS
▪ Can be fatal!
LIFE THREATENING WITHDRAW!
Alcohol
Related
Disorders
• Clinical diagnosis
• Criteria = >2 of the following
o Lack of control
o Unsuccessful attempts to quit
o Significant time investment
o Cravings
o Impact on daily obligations
o Use continues despite conflicts
o Abandonment of activities
o Physical harm
o Use despite understanding of consequences
o Tolerance
o Withdrawal
• CAGE = >2 is a positive screen
o Cutdown
o Annoyed
o Guilt
o Eye opener
• CIWA = decides withdraw management
o Agitation (0 – 7)
o Anxiety (0 – 7)
o Auditory Disturbances (0 – 7)
o Clouding of Sensorium (0 – 4)
o Headache (0 – 7)
o Nausea/Vomiting (0 – 7)
o Paroxysmal Sweats (0 – 7)
• CIWA score & medication
o Tactile Disturbances (0 – 7)
o Tremor (0 – 7)
o Visual Disturbances (0 – 7)
• Complications = cirrhosis, pancreatitis, macrocytic anemia,
• Treatment = medication & monitoring
o Intoxication = aspiration prevention, VS, & BACs, check
for hypoglycemia or hypovolemia; thiamine
▪ Agitated → use antipsychotics (Haldol)
• NO benzodiazepines (respiratory depression)
o Withdraw = CIWA, benzodiazepines, IVF, thiamine,
folate, multivitamins, electrolyte repletion
▪ Ativan = good choice b/c not metabolized by liver
▪ Phenobarbital or propofol = seizures & delirium
despite benzodiazepines
• ICU & ventilation → admitted & intubated
▪ AVOID antipsychotics → lower seizure threshold
o Long-term = therapy & medication
▪ Psychotherapy = individual, group (AA), inpatient
▪ Naltrexone = opioid antagonist (1st line)
• ↓ EtOH cravings
• IM injection once/month → better compliance
▪ Acamprosate = glutamate antagonist & GABA
agonist
• Patient with liver disease not responding to
naltrexone
▪ Disulfiram = ↑ levels of acetaldehyde
• N/V, palpitations, ↑ HR, ↓ BP, HA
• Do NOT use if history of CVD or CVA
o CIWA >0 but <8 and VS stable = no medication
o CIWA >8 but <15 = Lorazepam (Ativan) 2 mg PO/IM
and repeat VS q 2 hours and CIWA q 4 hours
o CIWA >15 or DBP >110 mmHg = Lorazepam (Ativan)
2 mg PO/IM q hour & repeat VS q hour and CIWA q
hour until patient has a CIWA of <15 or DBP <110
mmHg
HTN, encephalopathy (Wernicke-Korsakoff & hepatic),
cardiomyopathy, peripheral neuropathy, FAS, withdraw
seizures, delirium tremens, alcoholic ketoacidosis
o Wernicke encephalopathy = acute, reversible,
from thiamine deficiency & triad of delirium, ataxia,
& ophthalmoplegia (CN 6 palsy)
o Korsakoff syndrome = chronic, irreversible, from
thiamine deficiency, anterograde amnesia,
confabulation
o Alcoholic ketoacidosis = from starvation; ketonuria, ↑
anion gap, & normal glucose level
▪ Treatment = IVF, thiamine and glucose!
▪ Must give thiamine PRIOR to glucose & IVF
• If not, could worsen cell death & patient
outcome
 • Anxiolytics = benzodiazepines • Intoxication • UA = drug screen • Treatment = GABA antagonist & monitoring
o Respiratory depression
• MOA = GABA agonist o Hypotension • APAP levels o Intoxication = monitor ABC’s & flumazenil (benzo
o Amnesia antagonist)
• Withdraw worse for short-acting meds & with o Ataxia • Glucose = check for hypoglycemia ▪ Flumazenil = can precipitate severe
combined EtOH use o Stupor/somnolence withdraw
Sedative, o Coma & death
Hypotonic • EKG = conduction abnormalities
o Withdraw = long-acting benzo (diazepam) with
or • Withdraw tapering
Anxiolytic o Anxiety
Related o Seizures
Disorders o Tremor & twitching • RULE OUT = hypoglycemia or DKA
o Nausea or vomiting
o Hallucinations
o ↑ HR & HTN
o Psychomotor agitation

LIFE THREATENING WITHDRAW!

• Inhibits reuptake of dopamine, norepinephrine • Intoxication • EKG = conduction abnormalities, MI, etc. • Treatment = medication & supportive
& epinephrine o Euphoric mood
o Psychomotor agitation o Intoxication = benzodiazepines or antipsychotics
• Cocaine = coke, blow, nose candy, snow o Pressured speech ▪ DO NOT place in restraints → might cause rhabdo
o N/V ▪ Antipsychotics = s/s of psychosis
• ADHD meds = Addys, Uppers, Vit R o Seizures
o Tremor o Withdraw = monitor & symptom management
• Meth = crank, crystal, chalk o Flushing ▪ Monitor for depression & suicide in cocaine
o Cold sweats withdraw
o Pupillary dilation ▪ Cocaine usually cleared from body in 3 days
o HTN or HOTN
▪ May need antidepressants after withdraw is over
o ↑ HR or ↓ HR
o Psychotic symptoms • Only for a few weeks or so

Stimulant ▪ Hallucinations
Related ▪ Paranoia
• NO beta-blockers with cocaine → unopposed alpha
Disorders stimulation
• Withdraw o Would cause constriction of coronary arteries
o Depression
o Anhedonia
o Hypersomnia • Complications = respiratory depression, arrythmias, MI,
CVA, ICH, seizures, cardiomyopathies, TIA
o ↑ HR
o Pupillary constriction
o Nightmares
o Suicidal ideation
o HA
o Irritable

• Risk factor for cardiopulmonary & cancer • Intoxication • Clinical diagnosis • Treatment = therapy & medication
diseases o Restless
o ↑ HR • Criteria = >2 of the following o Counseling, support groups and CBT
• Discuss smoking cessation at EVERY visit o Insomnia o Lack of control
o HTN o Unsuccessful attempts to quit o Nicotine tapering therapy = gum, nasal sprays,
o ↓ appetite o Significant time investment transdermal patches, inhaler & lozenges
o Cravings
Tobacco • Withdraw o Impact on daily obligations o Varenicline = blocks nicotine ®; BUT ↑ suicide risk
Related o Restlessness o Use continues despite conflicts ▪ Most effective
o Irritable o Abandonment of activities o Bupropion = reduce nicotine cravings; BUT ↑ seizures
Disorders o Anxious o Physical harm
o HA o Use despite understanding of consequences • Start medication 1 week prior to quit date
o Difficulty concentrating o Tolerance
o Depressed mood o Withdrawal • Complications = CAD, CVA, PVD, COPD, lung CA, bladder
o Sleep disturbances → insomnia CA, AAA
o ↑ appetite & weight gain
o Chest tightness
o Nicotine craving
 • MOA = binds to CB 1 & 2 cannabinoid • Intoxication • Clinical diagnosis • Treatment = symptomatic management
receptors o Euphoria
o Anxiety • UA = drug screen → lasts ~1 month in urine • Complications = hyperemesis syndrome → managed
• 2 phases = euphoria & sedation o Paranoid delusions o 4-6 days in occasional users with cessation of marijuana & antiemetics (zofran &
o Conjunctival injection o 50 days in chronic users reglan)
• Moderate dose = euphoria, anxiety, o Impaired judgment
disinhibition, conjunctival injection, impaired o ↑ appetite • Criteria = >2 of the following • Chronic abuse
judgment, social withdrawal, increased appetite, o Dry mouth o Lack of control o Cognitive performance issues
dry mouth o Hallucinations o Unsuccessful attempts to quit o Restlessness
o Respiratory depression o Significant time investment o Laryngitis & rhinitis
Cannabis • High doses = psychotic states (hallucinations, o Arrythmias o Cravings o Low testosterone & sperm count
Related paranoia, delusions) o HTN o Impact on daily obligations o COPD
o Seizures o Use continues despite conflicts
Disorders
• Tetrahydrocannabinol (THC) = high feeling o Abandonment of activities
• Withdraw o Physical harm
o Irritability o Use despite understanding of consequences
• CBD oil = treatment of seizure disorder & o Depression o Tolerance
anxiety o Insomnia o Withdrawal
o Nausea
o Anorexia
• K2 or Spice = herbs, spices or shredded plant
material that is sprayed with synthetic
compounds known as cannabinoids
(chemically like THC)
• NMDA glutamate ® antagonist • Impulsiveness & rage • Criteria = >2 of the following • Treatment = supportive & meds
• Homicidality o Lack of control o Supportive = ABC monitoring
• LSD = acid, blotter hits • Psychosis & delirium o Unsuccessful attempts to quit o Meds = benzodiazepines (1st line) or antipsychotic
• Psychomotor agitation o Significant time investment (Haldol)
• PCP = angel dust, ozone, embalming fluid • Muscle rigidity
o Cravings ▪ Antipsychotics may worsen symptoms via
o Usually in laced marijuana o Impact on daily obligations anticholinergic S/E, but might be necessary to
Hallucinogen • Hallucinations o Use continues despite conflicts control violent behavior
Related • Nystagmus o Abandonment of activities o May require physical restraints
Disorders • Mushroom = shrooms
• Ataxia o Physical harm
• Ketamine = K, special K, vitamin K • Dysarthria o Use despite understanding of consequences • Complications = long-lasting anxiety & paranoid effects
• ↑ HR & HTN o Tolerance o May need to use anti-psychotics or non-addictive
• Severe = hyperthermia & seizures o Withdrawal anxiety meds
• DXM = robo, triple C’s, orange crush
o Found in cough & cold OTC products
• PCP = super strength **
• Solvents = liquids that are gas at room temp) • Slurred or distorted speech • Criteria = >2 of the following • Treatment = supportive
• Aerosol sprays • Lack of coordination o Lack of control o Staying away from at risk products
• Gases • Euphoria = feeling "high" o Unsuccessful attempts to quit o Behavioral changes
• Nitrites (prescription medicines for chest pain) • Dizziness o Significant time investment o May require inpatient treatment
Inhalant o Cravings
• Vomiting o Impact on daily obligations
Related • Contain substances that have psychoactive • Coughing o Use continues despite conflicts
Disorders (mind-altering) properties when inhaled • Loss of appetite o Abandonment of activities
o Physical harm
• Products bought and found in home or • Contact dermatitis o Use despite understanding of consequences
workplace o May turn into 2o bacterial infection o Tolerance
o Spray paints, markers, glue, cleaning fluids o Withdrawal
 NEPHROLOGY
Visit Etiology Presentation & PE Diagnosis Treatment & Complications
• Retaining CO2 → hypoventilation • Somnolence • ↓ pH • Treatment = treat underlying cause
• Drowsiness
• Risk factors = CHAMPP • Confusion • ↑ CO2
Respiratory o CNS depression • Myoclonus with asterixis
o Hemo/pneumothorax •
Acidosis Stupor and coma from CO2 narcosis
o Airway obstruction
o Myopathy • Hypercapnia = ↑ cerebral blood flow → ↑ ICP
o Pneumonia
o Pulmonary edema
• Blowing off CO2 → hyperventilation • Hyperventilation • ↑ pH • Treatment = treat underlying cause
• Light-headedness
• Risk factors = CHAMPS • Anxiety • ↓ CO2
o CNS disease = stroke • Paresthesia's
o Hypoxia • Tetany
o Anxiety (MC) or asthma
Respiratory • Tingling in hand and feet, mouth numbness
▪ Asthma = respiratory acidosis & alkalosis
Alkalosis
• Initial attack causes hyperventilation
• As obstruction worsens, muscles wear out =
respiratory acidosis
o Mechanical ventilation = over ventilating
o Progesterone, pregnancy & pain
o Salicylates
• Gaining H+ ions OR Cl- ions • ↑ respirations = compensatory • ↑ pH • Treatment = treat underlying cause
• Ventricular arrhythmias
• Risk factors (high anion gap) = MUD PILES • Lethargy • ↓ HCO3
o Methanol = antifreeze • Coma
o Uremia • Anion gap = Na+ – (Cl− + CO2)
o Diabetic ketoacidosis /EtOH ketoacidosis o Normal = 8-12 (hyperchloremic acidosis)
o Propylene glycol (packaged food) or paraldehyde
o Infection, isoniazid or iron
o Lactic acidosis
o Ethylene glycol = antifreeze
o Salicylates
Metabolic
Acidosis • Risk factors (normal anion gap) = HAARD UPS
o Hyperalimentation
o Acetazolamide
o Amphotericin B
o Renal tubular acidosis (RTA)
▪ Type I RTA (distal) = inability to excrete H+
▪ Type II RTA (proximal) = inability to absorb HCO3-
o Diarrhea
o Ureterosigmoidostomy
o Post-hypocapnic state
o Spironolactone
• Losing H+ ions • Lightheadedness • ↓ pH • Treatment = treat underlying cause
• Paresthesia
• Risk factors = CLEVER PD • Carpopedal spasms • ↑ HCO3
o Contraction alkalosis • Confusion stupor
▪ Over diuresis or volume depletion • Symptoms of volume depletion
▪ HCO3 elevates from loss of H+ in kidneys
Metabolic o Licorice
o Endo = hyperaldosteronism
Alkalosis
▪ Reabsorbs Na+ & excretes K+ and H+
▪ Alkalosis due to loss of H+ ions
o Vomiting/NG suction = lose H+ ions
o Excess alkali / milk alkali syndrome
o Refeeding alkalosis
o Post hypercapnia
o Diuretics
 • Abrupt ↓ in kidney function = ↑ Cr & ↑ BUN • Edema = pulmonary & peripheral & ascites • ↑ Cr, ↑ BUN & ↓ GFR • Treatment = treat underlying cause & +/ – dialysis
o Ascites = N/V, abdominal pain, anorexia o Dialysis = AEIOU
• Azotemia = ↑ BUN • HTN • BUN:Cr ▪ Acidosis = pH< 7.1
• Nitrogenous wastes = urea • ↓ U/O = 1st symptom o Prerenal = >20:1 ▪ Electrolyte disturbances = hyperkalemia
o Intrarenal = normal to <10:1 ▪ Intoxication = dialyzable drug/toxin
• RIFLE criteria = Risk, Injury, Failure, Loss of Kidney • Azotemia = buildup of nitrogenous wastes o Postrenal = 10-20:1 ▪ Overload = volume overload, respiratory
Function & End Stage Renal Disease WITHOUT symptoms compromise, or hypoxia → despite diuresis
• CMP = Cr, BUN, & K+ (hyperkalemia) ▪ Uremia = AMS, pericarditis, encephalopathy
Acute Renal • 3 phases • Uremia = buildup of nitrogenous wastes
Injury/Failure o Oliguric phase = ↓ U/O (<400 mL), azotemia, ↑ K+ WITH symptoms • Urine Na, urine osmolality, & FENa
o Diuretic phase = ↑ U/O, HOTN, hypokalemia o Bruising = thrombocytopenia
o Recovery phase = normalization of Cr & BUN o Peripheral edema • UA = usually benign in pre-renal & post renal
o Confusion, lethargy or coma o ATN = muddy brown casts
• 3 types o HTN o Glomerulonephritis = RBC casts
o Prerenal = low blood flow o Leg cramps o AIN = eosinophils & WBC casts
o Intrarenal = damaged nephron (ATN, GN, AIN, RAS) o Insomnia
o Postrenal = obstruction o Pericarditis • Oliguria = <400 mL urine output/24 hours
• Anuria = <100 mL urine output/24 hours
• Decreased renal perfusion → nephrons intact • Hypotension • ↑ Cr, ↑ BUN & ↓ GFR • Treatment = volume repletion → restore renal perfusion
• Tachycardia o Dehydration = IVF
• MC type of AKI • Nausea & vomiting • BUN:Cr = >20:1 o Hemorrhage = blood
o CHF = Lasix
• Risk factors • UA = normal
o Hypovolemia = renal loss, GI loss, blood loss • Complications = could lead to acute tubular necrosis
▪ Renal loss = diuretics & glycosuria • FENa = <1% → dry & trying to conserve Na+
Prerenal ▪ GI loss = vomiting, diarrhea & dehydration
Failure ▪ Blood loss = hemorrhage, trauma & surgery • Urine Na = <20
o Afferent arteriole vasoconstriction = NSAIDs or contrast
o Efferent arteriole vasodilation = ACEi or ARBs • Urine osmolality = >500
o Hypotension = sepsis & antihypertensives
o ↓ cardiac output or poor circulation
▪ CHF, tamponade, cardiac arrest, or cirrhosis
o Renal artery atherosclerosis
▪ Bilateral OR unilateral in solitary kidney

• Destruction & necrosis of renal tubules of nephron • ↑ Cr, ↑ BUN & ↓ GFR • Treatment = remove offending agent, IVF, & monitor

• Types • UA = epithelial cell & muddy brown casts

o Ischemic = prolonged prerenal azotemia (low volume)
Acute ▪ Associated with HOTN & hypovolemia • BUN:Cr = <20:1
Tubular o Nephrotoxic = exogenous or endogenous toxins
Necrosis ▪ Exogenous = contrast dye, aminoglycosides, NSAIDs, • FENa = >1% → Na+ not being conserved
cyclosporine, metformin & vancomycin
▪ Endogenous = uric acid, myoglobinuria, lymphoma, • Urine Na = >40
Intrinsic leukemia, & multiple myeloma
o Sepsis • Urine osmolality = <350
• MC type of AKI in hospitalized patients & MC type of intrinsic

• Immunologic inflammation of glomeruli = protein & RBC loss
• Types
o IgA nephropathy (Berger’s Disease) = MC
▪ 1-2 days following viral infection
Glomerulo- o Post-infectious = strep pyogenes (GAS)
nephritis ▪ 1-3 weeks following strep pharyngitis
▪ 3-6 weeks following skin infection
Intrinsic o Membranoproliferative = SLE or viral hepatitis
o Goodpasture’s disease = anti-GBM antibodies
o Rapidly progressive GN (RPGN) = poor prognosis
o Vasculitis = lack of immune deposit & ANCA antibodies
• Hematuria = color or tea-colored
• Edema = peripheral or periorbital
• HTN
• Fever, abdominal pain, & flank pain
• ↑ Cr, ↑ BUN & ↓ GFR • Treatment = self-limited → meds if needed
o Steroids, immunosuppressives & plasmapheresis
• UA = hematuria, RBC casts, & proteinuria o Furosemide = volume overload
o Proteinuria = <3.5 g/day o ABX = strep pyogenes (GAS)
o BB or CCB = HTN
• ↑ ASO, antiDNase B, antiNAD & AHase titers
• Strep culture → to determine active infection
• Renal biopsy = gold standard
o IgA nephropathy = IgA deposits
o Post-strep = hypercellularity, monocytes
& lymphocytes, IgG, IgM & C3
o Goodpasture’s = linear IgG deposits
o RPGN = crescent-shaped glomerulus
 • Inflammatory or allergic response in interstitium • Fever • ↑ Cr, ↑ BUN & ↓ GFR • Treatment = remove offending agent & supportive care
• Maculopapular rash
• Risk factors • Arthralgia • Eosinophilia & ↑ IgE
Acute o Drug hypersensitivity = MC
Interstitial ▪ NSAIDs • UA = WBC casts & eosinophiluria
Nephritis ▪ Penicillin
▪ Sulfa drugs → bactrim
Intrinsic ▪ Cephalosporins
o Infection = strep, legionella, CMV, EBV, & HIV
o Idiopathic
o Autoimmune = SLE, sarcoidosis, & cryoglobulinemia
• Problem with blood flow • Symptoms depend on cause! • ↑ Cr, ↑ BUN & ↓ GFR • Treatment = treat underlying cause

• Risk factors
o Microvascular = TTP, HELLP, & DIC
Vascular o Macrovascular
Disease ▪ Aortic aneurysm
▪ Renal artery dissection
Intrinsic ▪ Renal artery or vein thrombosis (occlusion)
▪ Malignant HTN
▪ RAS
▪ Renal infarct
▪ Atheroembolic disease = emboli from angiography
• Obstruction causing back flow & ↓ GFR/renal function • Symptoms depend on cause! • ↑ Cr, ↑ BUN & ↓ GFR • Treatment = removal of obstruction
o Ureteral stent
Postrenal • Sites of obstruction • Change in urine output (usually ↓ U/O) • UA = normal o Foley catheter
Failure o Ureter = kidney stones, cancer (tumor), or blood clots • Distended bladder o Nephrostomy tube
o Bladder = BPH, prostate CA, neurogenic bladder, or • Enlarged prostate • US = look for obstruction/hydronephrosis o Lithotripsy
Obstructive urinary retention (anti-Ch, pain meds, antihistamines) o Surgery
• HTN
Uropathy o Urethra = strictures or phimosis • Bladder scan = evaluate for urinary retention
• Pain = rare

• CT w/out contrast = gold standard for stones

• Progressive loss of kidney function = irreversible • Gen = fatigue, weakness, poor concentration, • Need = BP, creatinine & spot protein:creatinine • Treatment = treat reversible risk factors & related issues
irritable, pruritus, muscle wasting, & cachexia o HTN = goal <130/80 → ACE inhibitors & ARBs
• Albuminuria/proteinuria or GFR <60 for >3 months o All due to uremia • ↑ Cr, ↑ BUN & ↓ GFR ▪ Limit Na+ & fluid intake
▪ ACE inhibitors & ARBs = early on
• Nephrons destroyed due to etiology of kidney disease • Pulm = SOB, pleural effusions, pulmonary • CBC = anemia & ↓ PLTs o HLD = goal LDL <100, HDL >50, & TG <150
o Hypertrophy of remaining nephrons edema, Kussmauls respirations (met acidosis) o Anemia (↓ EPO) → normocytic o DM = goal A1C 6.5-7.5
o Failure from ↑ workload → fibrosis, scarring, & dilation o ↓ PLT = uremia causes PLT dysfunction o Proteinuria = ACE inhibitors & ARBS
• Cardiac = pericarditis, MI, CAD, edema, ▪ Slows progression of renal dysfunction
• Stages HTN, CHF, LVH, arrhythmias, orthopnea • CMP = hyperkalemia & hypocalcemia o Diet = protein, K+, PO43 –, & Na+ restriction
o Stage 1 = GFR >90 → asymptomatic & normal labs ▪ Protein restriction can help slow progression
o Stage 2 = GFR 60-90 → asymptomatic & normal labs • GI = anorexia & N/V (uremia), hiccups, • Hyperphosphatemia o Immunization = flu shot & pneumovax
o Stage 3 = GFR 30-59 → asymptomatic & abnormal labs metallic taste, uremic fetor (odor from ▪ High risk for infection → DM & exposure of
o Stage 4 = GFR 15-29 → symptomatic & abnormal labs uremia), & GI bleeding • ABG = metabolic acidosis pathogens during dialysis
Chronic o Stage 5 = GFR <15 → symptomatic & abnormal labs o Anemia = iron supplements or EPO if refractory
Renal Failure • GU = nocturia, ↓ urine output o Osteodystrophy = keep PO43 – & Ca2+ normal
• EKG = arrythmias (uremia & electrolyte Δ’s)
• Risk Factors o Hyperphosphatemia = PO43 – & Ca2+ binders
Chronic Kidney o Hypertension = 1st MC • Derm = darkening/yellowing of skin, pallor, o Hypocalcemia = Ca2+ supplement & vitamin D
• ↑ PTH (2o hyperparathyroidism) = ↓ vitamin D
Disease o Diabetes Mellitus = 2nd MC dry/scaly skin, pruritus, petechiae o ↓ vitamin D conversion = ↓ Ca2+ uptake
o Renal transplant = best treatment option
o Polycystic kidney disease o Conservative treatment = palliative approach
o Glomerulonephritis • Neuro = CVA, RLS, numbness & cramps in
o Chronic NSAID use • Uremia = can’t filter out wastes • Adjust all meds for renal function/creatinine clearance
hands, encephalopathy (from uremia),
o African American muscle twitching, asterixis, sensory deficits
o Male sex • UA = proteinuria & broad waxy casts • NO ACE inhibitors or ARBs in hyperkalemia or AKI***
o Age >60 o protein:creatine = best to asses CKD
• Endo = 2o hyperparathyroidism, mild glucose ▪ 24-hour OR spot urine (preferred)
o FHx intolerance, ↓ insulin requirements • Dialysis = GFR <5 OR <15 & symptomatic OR Cr >8
o SLE o Women = amenorrhea & infertility o Hemodialysis = usually at a center & fistula
o Kidney transplant o Men = impotence & oligospermia • US = small kidneys (<9 cm) with ↑ erogenicity ▪ AV fistula or AV graft
o Obesity o Peritoneal dialysis = mostly at home
o HLD
• Metabolic = metabolic acidosis • Renal Osteodystrophy = ↑ PO43 – & ↓ Ca2+
o Smoking o 2o hyperparathyroidism from ↓ Ca2+ (from
↓ vit D causes) ↑ PTH = ↑ bone breakdown
 • Glomerular damage = protein loss • Edema = ascites & periorbital (esp. children) • ↑ Cr, ↑ BUN & ↓ GFR • Treatment = meds
o Malnutrition 2o edema o Minimal change disease or FSGS = steroids
• Primary etiologies • Frothy urine = due to proteinuria • Hypoalbuminemia ▪ Prednisone = 1st line
o Minimal change disease = MC in kids • HLD • Until UA protein (–) for 5 days
▪ s/p viral syndrome, allergies or Hodgkin disease • DVT → loss of protein C & S & antithrombin o Edema = diuretics & ↓ Na+
▪ Loss of (–) charge of BM → promotes proteinuria o Hypercoagulable state • UA = fatty casts, oval bodies & proteinuria o Proteinuria = ACE inhibitors or ARBs
o Membranous nephropathy = MC in males >40 y/o • Infection → loss of immunoglobulins o Proteinuria = >3.5 g/day o HLD = stains & diet
▪ SLE, viral hepatitis, malaria meds (penicillamine) o Frothy urine o DVT = anticoagulation
o Focal segmental glomerulosclerosis = MC in AA
Nephrotic ▪ HTN, heroin, & HIV • Renal biopsy = definitive diagnosis • Complications = protein malnutrition, infection,
o Minimal change = podocyte damage thromboembolism, anemia
Syndrome
• Secondary etiologies o Membranous nephropathy = thick BM
o DM = MC 2o cause
o SLE
o Amyloidosis
o Hepatitis
o Sjogren syndrome
o Sarcoidosis
o HSP
o Infections
o Malignancy
• Autosomal dominant = mutations of PKD1 or PKD2 • Abdominal or flank pain • UA = hematuria, proteinuria & ↓ concentration • Treatment = simple vs. complex → BP control
• Flank mass o Simple = observation & ACEi or ARBs
• Formation of kidney cysts & cysts in other organs • HTN = MC early symptom • US = best initial test o Complex = ↑ fluids & HTN control
o Liver = MC • Hematuria
Polycystic • Complications = ESRD, ruptured cyst, portal HTN,
o Spleen • Kidney stones • CT or MRI = most sensitive
Kidney o Pancreas berry aneurysm (SAH), mitral valve prolapse, &
Disease • UTI
• Diagnostic criteria nodular hepatomegaly or diverticulosis → cysts can be
• Vasopressin stimulates cytogenesis o 15-39 years old = >3 cysts in other organs!
o 40-59 years old = >2 cysts
• Onset = 30-40 years old o >6o years old = >4 cysts

Renal • HTN secondary to renal artery stenosis • Headache • CTA or MRA = initial testing • Treatment = surgical vs. meds
Vascular o MC cause of secondary HTN • HTN → especially resistant HTN o Surgery = revascularization vs. angioplasty & stent
Disease / • Abdominal bruit • US (duplex) = unilateral small kidney ▪ Revascularization = definitive treatment
• ↓ renal blood flow = activation of RAAS ▪ Angioplasty = Cr >4 or >80% stenosis
HTN
• AKI after initiation of ACE inhibitors • Renal catheter arteriography = gold standard o Meds = ACE inhibitors or ARBs
• Risk factors o Threads catheter into artery ▪ Contraindication = B/L stenosis or one kidney
(Renal Artery o Atherosclerosis = elderly • Can cause AKI in these patients
Stenosis) o Fibromuscular dysplasia = women <50 years old ▪ Also consider thiazide diuretics or CCBs
• Tumor of proximal convoluted tubule • Triad = hematuria, flank pain & abd mass • US = best initial test to evaluate kidney mass • Treatment = nephrectomy (surgery)
o Very metabolically active = prone to dysplasia • Weight loss, fevers & night sweats o Radical = preferred treatment
• CT with & w/out contrast = best test o Partial = bilateral or multiple lesions
• Clear cell = MC • HTN
• Left varicocele = blocking L testicular vein • IVP = additional testing option • Frequent imaging in follow up for metastatic lesions
Renal Cell • Risk Factors o Can resect METS in RCC (unlike other cancers)
Carcinoma o Smoking • METS = lung (MC) & bone
o HTN
o Obesity
o Male
o Dialysis
o Cadmium or industrial exposure
• Types • Renal colic = sudden & constant flank pain • CBC = ↑ WBCs • Treatment = depends on size
o Calcium = calcium oxalate (MC) • Radiating to groin o <5 mm = spontaneous passage
o Uric acid = high protein, gout, chemo (tumor lysis) • N/V • UA = hematuria & +/– UTI ▪ Pain meds = opioids, NSAIDs & APAP
o Struvite = magnesium ammonium phosphate • Urinary frequency & urgency o pH <5.0 = uric acid & cystine • Opioid = morphine, dilaudid, fentanyl
▪ Staghorn calculi → from urea-splitting organisms • Hematuria o pH >7.2 = struvite • NSAIDs = toradol
Nephrolithiasis • MC = Proteus & PSA o Check creatine before giving NSAIDs!
• CVA tenderness
• LC = Klebsiella, PSA, Enterobacter, & Serratia • CT ab/pelvis non-contrast = gold standard ▪ Zofran = helps with nausea
Renal Calculi • +/– fever
o Cystine = congenital defect ▪ Flomax = helps pass stone (relaxes ureter)
• US = stones or hydronephrosis ▪ Strain urine & drink plenty of fluids
• Locations o 5-10 mm = lithotripsy or ureteroscopy +/– stent
o UPJ (ureteropelvic junction) • KUB = calcium & struvite are radiopaque o >10 mm = percutaneous nephrolithotomy
o Pelvic brim → mid ureter & iliac vessels
o UVJ (ureterovesical junction) = MC
 UROLOGY
Visit Etiology Presentation & PE Diagnosis Treatment & Complications
• Inflammation of urethra • Urethral discharge • NAAT = gonorrhea, chlamydia, M. genitalium • Treatment = empiric ABX for gonorrhea & chlamydia
o Gonococcal = yellow, white or clear o Vaginal swabs = women o Ceftriaxone = 250 mg IM (IV for disseminated)
• MC = sexually transmitted disease o Chlamydia = purulent or mucopurulent o Urine testing = men PLUS
o Chlamydia = MC nongonococcal urethritis o Doxycycline = 100 mg BID x 7 days
Urethritis o Gonorrhea • Penile or vaginal pruritus • Gram stain = gonorrhea OR
o Ureaplasma urealyticum • Dysuria o Urethral swabs o Azithromycin = 1 g PO
Lower UTI o Trichomonas • Abdominal pain
o M. genitalium • Abnormal vaginal bleeding • UA = leukocyte esterase or pyuria
o Virus
• Dyspareunia = Chlamydia
• Hematuria = Chlamydia

• Ascending infection from urethra • Dysuria = burning • UA = pyuria, hematuria, leukocyte esterase, • Treatment = medication & supportive
• Urgency nitrites, cloudy urine, bacteriuria o Meds = 3-7 days
• Risk factors • Frequency o Proteus = ↑ pH ▪ Macrobid, Bactrim & Fosfomycin = 1st line
o Women = sex or spermicide use • Hematuria ▪ Cipro, Doxy, Keflex, Ceftin, Amoxicillin,
o Pregnancy = E & P cause ureter dilation • Suprapubic pain • Urine Cx = definitive diagnosis Augmentin, Levaquin = other options
o Elderly & postmenopausal = atrophic vaginitis o >100,000 CFU = (+) • Enterococci = amoxicillin
o DM o Little growth (10,000) & dysuria = (+) o Supportive = fluids, void after sex & hot sitz
o Indwelling catheter • Elderly = confusion, incontinence, & leg pain
baths, cranberry juice, & probiotics
o Infants = rule out congenital abnormalities o Pyridium = bladder analgesic
▪ Turns urine orange
Cystitis • Causes ▪ Limit use to 3 days
o E. coli = MC
o Staph saprophyticus • Recurrent PPX = Macrobid, Levofloxacin, Bactrim
Lower UTI o Klebsiella, Proteus, Enterobacter, Pseudomonas
o Enterococci = indwelling catheter
• Healthy woman with uncomplicated UTI can clear
infection in 3 days without ABX
• Complicated
o Male
• Urology referral = male <65 years old with UTI or
o Fever / symptoms indicating involvement beyond bladder
female >40 years old & >2 UTIs in 1 year
o Neurogenic bladder, stones, retention, abscess, catheter
o Also hx of stones, reflux or recurrent pyelonephritis
o Immunosuppressed, DM II or pregnant
o Antibiotics for 7-14 days

• UA or Cx (+) for bacteria in absence of any urinary symptoms • No symptoms • UA = pyuria, hematuria, leukocyte esterase, • Treatment = depends on patient
nitrites, cloudy urine, bacteriuria o General population = none
Asymptomatic • 100% occurrence in long-term catheter use o Pregnancy = needs treatment
Bacteriuria • Urine Cx = >100,000 CFU = (+) ▪ Macrobid or Fosfomycin = 1st line

• Infectious process of kidney parenchyma & renal pelvis • Unilateral flank pain • UA = pyuria, hematuria, leukocyte esterase, • Treatment = 14 days
• Fever & chills nitrites, cloudy urine, bacteriuria, WBC casts o Outpatient = ertapenem & fluroquinolones
• Ascending infection from bladder (can be hematogenous) • N/V ▪ Ertapenem x 1 then daily ertapenem
• CVA tenderness • Urine Cx = definitive diagnosis OR
• Risk factors • Dysuria o >100,000 CFU = (+) ▪ Ertapenem then fluoroquinolones
o DM • Frequency • Fluoroquinolones = 1st line
o Pregnancy • CBC = ↑ WBCs with left shift o Ciprofloxacin
Pyelonephritis Recurrent UTIs or kidney stones • Urgency
o o Levofloxacin
o Congenital urinary tract malformations • CT or US = hydronephrosis or stones suspected o Inpatient (w/out MDR) = ceftriaxone or zosyn
Upper UTI o Inpatient (w/ MDR) = carbapenem (anti-PSA)
• Causes ▪ Imipenem, meropenem, or doripenem
o E. coli = MC
o Staph saprophyticus • Admission = septic, vomiting, pregnant or elderly/frail
o Klebsiella, Proteus, Enterobacter, Pseudomonas
o Enterococci = indwelling catheter • No culture of cure required
 • Prostate inflammation from ascending infection • Fever & chills • UA = pyuria & bacteriuria • Treatment = ABX (4-6 weeks) & supportive
• Perineal pain o AVOID prostate massage (bacteriuria!) o <35 years old = Doxycycline & Ceftriaxone
Acute • Risk factors • Tender, BOGGY & warm o >35 years old = fluroquinolones or Bactrim
Bacterial o Children = virus (mumps) • Burning at tip of penis • DRE = boggy, warm, & tender ▪ Fluoroquinolones = Cipro & Levofloxacin
Prostatitis o <35 years old = gonorrhea & chlamydia o Supportive = NSAIDs, hydration & warm baths
• Frequency, urgency & dysuria = irritative sx
o >35 years old = E. coli
• Hesitancy, poor stream, incomplete emptying • Urine Cx & CBC = febrile & appear ill
• Complications = bacteriuria or prostatic abscess
• Prostate inflammation from ascending infection • Pelvic discomfort • UA = usually negative • Treatment = ABX (6-12 weeks)
• Nontender & BOGGY o Prostate massage = ↑ UA bacterial yield o Fluroquinolones = 1st line
Chronic • Risk factors • Frequency, urgency & dysuria = irritative sx ▪ Fluoroquinolones = Cipro & Levofloxacin
Bacterial o Enteric organism = E. coli (MC), Proteus, Enterococci • DRE = boggy & nontender o Bactrim = 2nd line
Prostatitis o Structural or functional abnormality
o Recurrent UTIs
o Acute prostatitis → chronic prostatitis
• Inflammation & infection of epididymis • Testicular pain & swelling = gradual onset • US = enlarged epididymis & ↑ blood flow • Treatment = supportive & ABX (2 weeks)
• Fever & chills o Rule out testicular torsion o NSAIDs, scrotal elevation, & cool compresses
• Risk factors • Dysuria, frequency, & urgency = irritative sx o <14 years old = cephalexin or amoxicillin
o <14 years old (prepubertal) = virus or bacteria (E. coli) • Groin, flank or abdominal pain • UA = pyuria or bacteriuria o 14-35 years old = Doxycycline & Ceftriaxone
o 14-35 years old = chlamydia (MC) & gonorrhea o >35 years old = fluroquinolones or Bactrim
Epididymitis o >35 years old = enteric organism (E. coli) • NAAT = gonorrhea & chlamydia ▪ Fluoroquinolones = Cipro & Levofloxacin
• Indurated & tender epididymis
o Normal testes o Urine testing = men

• (+) Phren sign = pain relief with elevation

• Inflammation & infection of testes
• Etiology = virus (MC)
Orchitis o Mumps
o Echovirus
o Coxsackie (HFM)
o Rubella
• Proliferation of benign tissue of prostate = transition zone
o Prostate hyperplasia causes bladder outlet obstruction
o Compresses prostatic urethra & causes obstruction
• Onset = 60-65 years old
o 40 years old = prostate “growth spurt” that continues
• Testosterone → dihydrotestosterone (glandular tissue growth)
o 5 alpha reductase = enzyme required
▪ Promotes testosterone to dihydrotestosterone
o Dihydrotestosterone (DHT) = promotes tissue growth
• Types of prostate tissue
o Glandular (epithelial) = prostatic secretions & PSA
▪ Stimulated by dihydrotestosterone
Benign o Stromal (smooth muscle) = contract when stimulated
Prostatic ▪ Stimulated by alpha 1A receptors
Hyperplasia
▪ Stroma contracts around prostatic urethra
• Issue if too much contraction = can’t pee
• (+) cremaster reflex
• Scrotal pain, swelling & tenderness • US = enlarged testes
• Scrotal erythema o Rule out testicular torsion or cancer
• Dysuria • Lower urinary tract symptoms (LUTS)
• Frequency
• Urgency • DRE = uniformly enlarged, symmetrical,
• Hesitancy & straining firm, nontender & rubbery prostate
• Poor stream
• Incomplete emptying • UA = monitor for infection or hematuria
• Post-void dribbling
• Creatinine = rule out kidney disease
• Nocturia
• PSA = ↑.with large prostates
• IPPS symptom score = quantify symptoms
o Follow treatment status
▪ Patient perception most important
• Post-void residual volume
• Urine cytology = rule out cancer
• Treatment = supportive
o Supportive = NSAIDs, scrotal elevation, & cool
compresses
• Elderly/DM II = may require admission for IV ABX
• Treatment = supportive, meds or surgery
o Supportive = treat if significant impact on QOL
▪ “Watchful waiting” → evaluate q 3-6 months
• IPSS symptom score to quantify symptoms
▪ Avoid fluids prior to bedtime or going out
▪ ↓ consumption of diuretics (caffeine & EtOH)
▪ Avoid meds which exacerbate symptoms
• Sympathomimetics or anticholinergics
o Alpha blockers = initial therapy (1st line)
▪ Rapid onset of action
▪ 2nd generation = Terazosin & Doxazosin
▪ Uroselective = Tamsulosin (Flomax)
▪ MOA = smooth muscle relaxation
▪ S/E = HOTN → less with uroselective
o 5-α reductase inhibitors = reduce prostate size
▪ Slow onset of action
▪ Finasteride (Proscar) & Dutasteride
▪ MOA = block conversion of testosterone to
dihydrotestosterone (DHT) → shrink prostate
▪ S/E = ED, helps with male pattern baldness,
↓ libido, & breast enlargement
o PDE-5 inhibitors = ED & mild-to-moderate BPH
▪ Tadalafil (Cialis)
o Anticholinergics = irritative bladder symptoms
▪ Tolterodine (Detrol) & Oxybutynin
o Surgery = refractory or severe (UTIs or hematuria)
▪ TURP = removes excess prostate tissue

• Complications = urinary retention, renal failure (post),

UTIs, urinary incontinence (overflow), bladder stones,
bladder diverticula
 • Inability to achieve or maintain erection sufficient for sex • Erection issues • Testosterone = evaluate for hypogonadism • Treatment = lifestyle, vacuums, prothesis, injections,
meds, & surgery
• PNS = erection & SNS = ejaculation • Low T = ↓ libido, weight gain & ↓ energy • Nocturnal penile tumescence = evaluate sleep o Lifestyle = weight loss, exercise, smoking
erection cessation, & stop EtOH
• Flaccid state = arteries constricted & veins non-compressed • Check BP, pulses & sensation o Meds = 1st line
• Sexual stimulation = ↑ in PNS activity → ↑ blood flow via • US doppler = evaluate blood flow ▪ Phosphodiesterase-5 Inhibitors = 1st line
smooth muscle relaxation and vasodilation • Sildenafil (Viagra), Vardenafil,
o Venous outflow drops from compression of venous plexus Tadalafil (Cialis), & Avanafil (Stendra)
by engorged corpora cavernosa • MOA = inhibits enzyme that breaks down
cGMP → maintains erection
• PNS = nitric oxide • S/E = HA, congestion, myalgia, cyanopsia
o cGMP gets broken down in 5 GMP by PDE-5 • Contraindicated with nitrates! → HOTN
▪ Stop this so higher levels of cGMP ▪ Injection/Intraurethral Suppository = 2nd line
Erectile o Higher cGMP allows erection to continue • Alprostadil = prostaglandin E1
Dysfunction • Stimulates adenyl cyclase → smooth
• Onset = increases in frequency as men age muscle relaxation → erection
• Enhances blood flow to corpora of penis
• Etiologies • Useful for patients on nitro or with HOTN
o Vascular (MC) = HTN, HLD, DM, smoking, CAD, OSA,
▪ Testosterone
depression, & EtOH
o Neurologic = spinal cord injury • Only effective in hypogonadism (low T)
o Psychogenic • Dosage forms = PO, IM, topical patches/
o Prolactinoma gel, implantable pellet, buccal adhesive
o Trauma or surgery • AVOID oral T → poor oral bioavailability
o Medications = BB, HCTZ, spironolactone, CCB, o Vacuums = 2nd line
SSRIs, TCAs, Proscar, Zantac, & Pepcid ▪ ↓ venous outflow
▪ Caution = anticoagulants or bleeding disorder
• Abrupt onset = psychological o Prothesis = 3rd line → surgically placed
• Gradual onset = systemic ▪ Semirigid, malleable, or inflatable rods
• Urothelial (transitional) carcinoma • Painless hematuria • UA & Cx = rule out benign causes • Treatment
o Gross or microscopic o Localized = transurethral resection of tumor
• Types • CT urography = preferred imaging o Invasive = radical cystectomy
o Transitional cell carcinoma = MC • +/– dysuria, urgency & frequency o Recurrent = intravesicular BCG (TB) vaccine
o Squamous cell carcinoma (SCC) • Cystoscopy with biopsy = gold standard ▪ Immune rxn causes rxn with tumor antigens
o Adenocarcinoma • METS = lymph nodes, lung & bone
o Sarcoma • IV pyelogram = additional imaging
o Small cell carcinoma o More sensitive for small lesions
Bladder
Cancer • Risk factors • MRI urography = additional imaging
o Smoking
o Occupational exposure = dyes, leather & rubber • US = not very helpful for diagnosis or staging
o Age >40 years old
o Caucasian
o Male
o Meds = cyclophosphamide & pioglitazone
o Long-term indwelling catheters
o Infected bladder stones = SCC
o Cytoxan chemotherapy
• Malignant neoplasm of adenomatous cells of prostate • Mostly asymptomatic! • DRE = hard, indurated, nodular, enlarged, & • Treatment = depends on age & metastatic disease
asymmetrical prostate o Active surveillance = local disease & <10 years of
• Adenocarcinoma = MC • Frequency, urgency, retention or poor stream life expectancy
• PSA = ↑ or dramatic change o Prostatectomy, brachytherapy or external
• 2nd MC cancer in men & 2nd MC cause of cancer death in men • Back or bone pain = METS to bone o More sensitive than DRE beam radiation = definitive diagnosis
o Lacks specificity for diagnosing cancer o Anti-androgen therapy = advanced disease
• Risk factors • METS = lymph nodes & bone o Secreted by normal & cancerous cells o Chemotherapy = hormonal therapy unsuccessful
Age >40 years old o GnRH agonist = leuprolide
Prostate o
o Genetics • Transrectal US needle biopsy = definitive
Cancer • Complications = METS (bone = MC)
o African American diagnosis
o Diet = high animal fat & low vegetables
• Gleason score (2-10) = aggressiveness or
malignant potential (higher = more aggressive)
 • Types • Painless testicular mass • Scrotal US = best initial test • Treatment = depends on stage
o Germinal cell tumor o Hard & fixed o Low grade nonseminoma = radical orchiectomy
▪ Nonseminomas = more aggressive • Dull pain or testicular heaviness • Radical inguinal orchiectomy = definitive dx with lymph node dissection
▪ Seminomas = simple, slow growing, sensitive to • Hydrocele o Biopsy not usually done → may result in o Low grade seminoma = radical orchiectomy
radiation & stepwise spread tumor seeding into scrotal sac or o High grade seminoma = debulking chemo, then
o Nongerminal cell tumors metastatic spread into inguinal nodes orchiectomy & radiation
▪ Leydig cell tumor = often benign & secrete hormones
Testicular ▪ Sertoli cell tumor = often benign & secrete hormones • Nonseminomas = ↑ alpha-fetoprotein & hCG • Nonseminomas = radiation resistant
Cancer • Seminomas = radiation sensitive
• Onset = 15-35 years old o Radiation works for seminoma

• Risk factors • Prognosis = 5 year survival >95% → excellent!

o Cryptorchidism
o Caucasians
o Klinefelter’s syndrome (47 XXY = male with extra X)
o Hypospadias
• Squamous cell carcinoma = MC (MC on glans) • Lesion, ulcer or mass on penis • Biopsy = definitive diagnosis • Treatment = early vs. late disease
o Early = limited excision
• Rare in US • Inguinal LAD o Late = penile amputation & lymph node dissection

• Onset = 60 years old

Penile
Cancer • Risk factors
o HPV 16, 18 & 6
o Smoking
o Uncircumcised
o HIV
o Bowen’s disease = leukoplakia on shaft of penis
• Serous fluid collection in tunica vaginalis of scrotum • Painless & nontender scrotal swelling • US = best initial test • Treatment = observation vs. surgery
• Dull ache or heavy sensation o Rule out torsion or other diagnoses o Observation = often resolves by 1 years old
• MC cause of scrotal swelling in children ▪ Could be causing swelling or hydrocele o Hydrocelectomy = >1 years old OR older patient
• Transilluminates with communicating or any complications
• Causes = developmental connection vs. imbalance of fluid ▪ DO NOT percutaneously drain hydroceles!
buildup vs. absorption • Swelling worse w/ valsalva = communicating • They will always come back
Hydrocele
• Types
o Communicating = peritoneal fluid enters scrotum via
patent processus vaginalis (PPV)
o Noncommunicating = no connection to peritoneum

• Reactive hydrocele = occurs with inflammatory conditions

o Orchitis, epididymitis, & testicular tumor
• Varicose veins from incompetent valves & ↑ venous pressure • Painless testicular mass • Clinical diagnosis • Treatment = observation vs. surgery
o Pampiniform venous plexus • Dull ache or heavy sensation o Observation = wear compression underwear
o Internal spermatic vein • US = best initial test o Surgery = infertility, pain, or delayed growth
• Bag of worms → superior to testicles
• Left-sided = MC → ↑ left renal vein pressure • Complications = infertility
• Worse = valsalva or upright (standing all day) o ↑ venous blood flow = ↑ temp = ↓ spermatogenesis
• Types • Improves = supine or testicular elevation
Varicocele
o Primary = idiopathic
o Secondary = abdominal mass compressing renal veins
(MC w/ right-sided) OR renal cell carcinoma compressing
superior mesenteric artery (MC w/ left-sided)

• Right-sided = retroperitoneal or abdominal malignancy

• Left-sided (sudden onset) = renal cell carcinomas
• Epididymal cyst = fluid filled cyst • Painless mass at head of epididymis • US = best initial test • Treatment = none or surgery
o Fluid may contain sperm o Surgery = chronic pain (rarely needed)
Spermatocele • Transilluminates
& • Spermatocele = epididymal cyst >2 cm
Epididymal
Cyst
 • Prolonged erection without sexual stimulation for >4 hours
• Types = distal scarring of foreskin
o Ischemic (low-flow) = ↓ venous outflow (MC type)
o Nonischemic (high-flow) = ↑ arterial inflow
• Risk factors = distal scarring of foreskin
o Idiopathic = MC
o Sickle cell disease
Priapism
o Drugs = cocaine & marijuana
o EtOH
o Penile trauma = high-flow
o Meds = PDE-5 inhibitors, trazadone, antipsychotics,
anticonvulsants, & alpha blockers
o Neuro = head trauma, meningitis, SAH, & postop
o Metabolic = HLD, DM, gout, hemodialysis
• Inability to retract foreskin over glans
• Etiology = distal scarring of foreskin
o Trauma, inflammation, or infection
Phimosis
• Unretractable foreskin is normal in newborns
o Normal up to 5 years old → should retract by school age
• Inability to return retracted foreskin to normal position
o Foreskin trapped behind corona of glans
o Forms tight band & constricts penile tissue
• UROLOGICAL EMERGENCY
Paraphimosis
• Etiologies = distal scarring of foreskin
o Infants & young boys = physiologic or iatrogenic
o Adults = penile inflammation (DM) or sexual activity
• Twisting of tests on spermatic cord cutting off blood supply
o Ischemic injury of testis
• UROLOGICAL EMERGENCY
Testicular
• Etiology = insufficient fixation of lower pole of testes to
Torsion tunica vaginalis → bell-clapper deformity (testes hang free)
o ↑ mobility of testes
• MC = 12-18 years old
• Torsion of appendix testis or appendix epididymis
o Embryologic vestigial tissue that is pedunculated
• MC = 7-14 years old
Torsed
Testicular
Appendages
• Ischemic = painful & rigid erection
• Nonischemic = less painful & not fully rigid
• Un-retracted foreskin
• Completely retracted foreskin
• Pain & swelling
• Sudden onset of severe unilateral pain
• N/V
• Swollen & tender testis
• +/– erythema of scrotum
• Abnormal lie of testis = high & transverse
• (–) Phren sign = no pain relief w/ elevation
• (–) cremaster reflex = no elevation of
testes after stroking inner thigh
• Sudden onset of unilateral pain
• Swollen & tender testis
• +/– erythema of scrotum
• Blue dot sign = blue discoloration over torsed
appendage → infarction & necrosis
• CBC = anemia, low PLTs, hemoglobinopathy
• Drug screen = cocaine & marijuana
• EtOH level
• Cavernosal blood gas = O2, CO2, & pH
o Ischemic = ↓ O2, ↑ CO2, & ↓ pH
o Nonischemic = normal
• US = ischemic vs. nonischemic
o Ischemic = minimal or absent flow
o Nonischemic = normal flow
• Clinical diagnosis
• Clinical diagnosis
• US = lack of blood flow
• Surgical exploration = definitive diagnosis
• US = might be inconclusive
o Rule out testicular torsion
• Treatment = ischemic vs. nonischemic
o Ischemic = meds or surgery
▪ Phenylephrine = 1st line (<4 hours)
• Intracavernosal injection
• MOA = alpha agonist to contract cavernous
smooth muscle to ↑ venous outflow
▪ Aspiration + phenylephrine (>4 hours)
• Remove blood from needle aspiration
• Combo works best!
▪ Terbutaline = not as effective (<4 hours)
• MOA = constricts cavernosal artery to ↓
arterial inflow
▪ Surgery = shunt placement
• No response to meds or aspiration
o Nonischemic = observation or surgery
▪ Observation = resolve in hours to days
▪ Refractory = artery embolization or ligation
• Treatment = supportive, meds & surgery
o Hygiene & traction = gentle traction & cleaning
to avoid scarring & adhesions
o ABX = suspect infection
o Steroids = topical for 4-8 weeks to ↑ retractability
▪ Lotrisone = MC
o Circumcision = definitive treatment
• Complications = voiding difficulty, infection, & SSC
• Treatment = reduce foreskin
o Manual reduction = ↓ edema with cool compress
or pressure dressing then return to normal position
o Meds = granulated sugar or hyaluronidase
o Surgery = dorsal slit (incision) or circumcision
• Complications = gangrene
• Treatment = manual detorsion & surgery
o Manual = “open book” (+/– before surgery)
o Orchiopexy = pex both sides to prevent torsion
o Orchiectomy = testes not salvageable
• 6 hours before complete ischemia and loss of testicle
o Almost 0% chance salvageable if >48 hours
• Treatment = supportive & surgery
o Supportive = cool compresses (ice) & NSAIDs
o Surgical excision = persistent pain
 • Testicle that hasn’t descended into scrotum by 4 months old • Empty, small & poorly rugated scrotum • Clinical diagnosis • Treatment = observation vs. surgery
o Most descend spontaneously → 80% by 1 years old o Orchiopexy = >4 months old & <2 years old
o Rarely spontaneously descend after 4-6 months • Nonretractable ▪ For congenitally undescended testes
o MC congenital abnormality (birth defect) of GU tract o MUST BE RETRACTABLE!! ▪ NEEDS to be done before 2 years old
o Observation = <6 months old
Crypt- • Location = outside external ring, inguinal canal or abdomen • Examine in frogleg position ▪ Most descend by 4 moths old
orchidism o MC = right side o Orchiectomy = detected at puberty to ↓ CA risk

• Risk factors • Refer to urology at 6 months old

o Prematurity
o Low birth weight • Complications = testicular cancer, testicular torsion,
o Maternal obesity or DM infertility & inguinal hernia
• Narrowing of urethral lumen • Obstructive symptoms = weak stream & • Imaging • Treatment = urethral dilation or reconstruction
incomplete bladder emptying o Cystourethroscopy o Endoscopic dilation or urethrotomy
• Etiologies • Dysuria o Retrograde urethrogram (RUG) o Catheter dilation
o Idiopathic = MC • Spraying or splitting stream o Voiding cystourethrogram (VCUG) o Surgical reconstruction
o Iatrogenic = bladder/prostate surgery, radiation, catheter • Recurrent UTIs o US urethrograph ▪ Urinary diversion = suprapubic tube
Urethral
o Infection = STI or UTI ▪ Urethral reconstruction
Strictures o Trauma = pelvic fracture
o Skin condition = lichen sclerosis/meatal stenosis • Prophylactic ABX for all urethral procedures

• Complications = urinary fistula, large post-void

residual, bladder stones, hydronephrosis & UTIs
• Etiologies • Hematuria • UA = hematuria • Treatment = supportive vs. surgery
o Blunt trauma • Blood at urethral meatus o Supportive = catheterization & monitor
Urethral ▪ Anterior urethral injury = straddle falls or direct blow • Retrograde urethrogram = test of choice o Surgery = severe injuries
• Swelling
Injuries ▪ Posterior urethral injury = pelvic fracture or MVA o Prior to catheterization! ▪ Temporary suprapubic catheter prior to repair
• Ecchymosis
o Physical or sexual assault • High-riding prostate
• Dorsally placed urethral meatus = congenital anomaly • Dorsal placement of urethra • Prenatal US = detects bladder exstrophy • Treatment = surgery
o Failure of midline penile fusion o Surgery
• Absent dorsal foreskin ▪ Cosmetic/psychological reason in adolescence
• Associated with bladder exstrophy • Upward (dorsal) curvature of penis ▪ Permit normal voiding & erection
o Bladder wall protrusion through defect in abdominal wall ▪ Prevent UTIs
o In utero rupture of overdeveloped cloacal membrane
Epispadias

• Ventrally placed urethral meatus = congenital anomaly • Ventral placement of urethra • Clinical diagnosis • Treatment = none or surgery
o Urethral folds fail to close o No treatment = mild
o Foreskin doesn’t fuse onto ventral aspect of penis • Abnormal foreskin o Surgery = elective
• Curved penis ▪ MC = 6 months to 1 years old
• MC = Caucasians • Appearance of “two urethral openings” • Delay repair until 6-12 months old
▪ Decision for surgery later in life:
• Maybe related with syndrome → Denys-Drash or WAGR • Can’t pee standing & stream deflection
• ED due to curvature
• Infertility from sperm deposition difficulty
• Family choice based on severity
Hypospadias
• Avoid neonatal circumcision → foreskin to repair defect
 • Obstruction of urine flow with dilation of collecting system • Mostly asymptomatic! • UA = +/– hematuria • Treatment = remove obstruction

• Risk factors • Change in urinary output • CMP = ↑ creatinine • Complications = UTI or ESRD
o Intrinsic obstruction • Hematuria
▪ Stone • HTN • US = best initial imaging
▪ Scar tissue or stricture
▪ Vesicoureteral reflux
Hydro-
▪ Sloughed off renal papillae
nephrosis
▪ Blood clot
o Extrinsic obstruction
▪ BPH
▪ Tumor
▪ Lymph nodes or fibroid
▪ Pregnancy
•
• Risk factors • Blood in urine • CBC = check for anemia or infection • Treatment = depends on cause
o Upper GU tract = stones, kidney disease (GN), RCC, • BMP = check creatinine o Blood clot = continuous bladder irrigation (CBI)
trauma, DM & sickle cell ▪ Women can pass large blood clots
o Lower GU tract = BPH, bladder CA, sexual or physical • UA = initial test of choice ▪ Men may get obstructed by them
assault, blood clot, trauma, UTI, DM & sickle cell o Rule out UTI, pyelo, GN, etc. ▪ Foley catheter = preferably 18-20 Fr
o Pseudohematuria = rhabdo, myoglobinuria, beets, o Recheck UA in 4-6 weeks for resolution ▪ Irrigate with sterile water or normal saline
hemoglobinuria, & runner’s hematuria
o Meds = ibuprofen, pyridium, rifampin, • CT urogram = best initial imaging (1st line)
cyclophosphamide
Hematuria o With & without IV contrast
• Timing • US = pregnancy or can’t receive dye
o Initial = urethra
o Throughout = bladder, ureters, or kidney
o Terminal = bladder irritation (stone / infection) or BPH • IV pyelogram = additional imaging option

• Cystoscopy = unknown cause or cancer risk

• Cytology = rule out bladder cancer

 HEMATOLOGY
Visit Etiology Presentation & PE Diagnosis Treatment & Complications
• Immature lymphoid stem cells in bone marrow • Anemia = pallor, fatigue & dyspnea • CBC = ↑ WBCs, anemia & thrombocytopenia • Treatment = chemo (induction, consolidation and
o Immature WBCs overtake normal hematopoiesis • Leukopenia = fever & infections o Pancytopenia = blasts interfere with their maintenance) or bone marrow transplant
o Chromosome abnormality → cells don’t mature • Thrombocytopenia = petechia & easy bleeding development
• Survival = 80%
• MC = B cell • Hepatosplenomegaly • Blood smear = lymphoblasts
• LC = T cell • Lymphadenopathy • Tumor lysis syndrome = rapid tumor lysis after chemo
• Bone marrow biopsy = gold standard o Tumor cells release their contents into bloodstream
• MC cancer in children • Headache, stiff neck and vision changes o >20 % blasts o ↓ Ca2+, ↑ K+, ↑ phosphate, & ↑ creatine (AKI)
o METS MC to CNS & testes o Treatment = IVF and electrolytes
• Onset = 2-5 years old • PT/INR & PTT = DIC
Acute
Lymphocytic • Boys > Girls
Leukemia
(ALL) • Genetic syndromes ↑ risk → Down syndrome

• MC cancer in children

• Accumulation of leukemic blasts • Anemia = pallor, fatigue & dyspnea • CBC = ↑ WBCs, anemia & thrombocytopenia • Treatment = chemo or bone marrow transplant
o Bone marrow, peripheral blood or other tissues • Leukopenia = fever & infections
o From malignant hematopoietic precursor cells • Thrombocytopenia = petechia & easy bleeding • Blood smear = myeloblasts • Survival = 65-70%
o Chromosome abnormality → cells don’t mature
Acute
Myelogenous • HSM & LAD = uncommon • Bone marrow biopsy = gold standard • Complications = leukostasis reaction (medical emergency)
Leukemia • MC leukemia in adults o Auer rods o WBCs plug microvasculature → ↓ tissue perfusion
(AML) o ↑ myeloblasts = >20 % blasts o S/S = SOB, HA, dizziness, vision changes
• Onset = 60 years old o Treatment = cytoreduction (leukapheresis)

• Malignancy of B cell lymphocytes • Mostly asymptomatic! • CBC = ↑ WBCs with lymphocytosis >5000 • Treatment
o Chromosome abnormality → cells mature partially o Stage I & II = observe
• Anemia = pallor, fatigue & dyspnea • Blood smear = smudge cells & immature B cells o Stage III & IV = chemo
Chronic • MC leukemia in adults (USA) • Leukopenia = fever & infections
Lymphocytic • Thrombocytopenia = petechia & easy bleeding • Complications = infections, autoimmune hemolytic
Leukemia • Onset = 65 years old anemia, & idiopathic thrombocytopenia purpura
(CLL) • Lymphadenopathy = MC finding
• Hepatosplenomegaly • Prophylaxis = vaccinations

• Myeloproliferative disorder of uncontrolled production • Asymptomatic until blast crisis • CBC = ↑ WBCs • Treatment = chemo, tyrosine kinase inhibitors,
of granulocytes (mostly neutrophils) immunotherapy & stem cell / bone marrow transplant
o Chromosome abnormality → cells mature partially • Fatigue • Genetic testing
• Night sweats • Complications = leukostasis reaction (medical emergency)
Chronic • Onset = 55 years old • Fever • Philadelphia chromosome → BRC-ABL o WBCs plug microvasculature → ↓ tissue perfusion
Myelogenous • Weight loss o S/S = SOB, HA, dizziness, vision changes
Leukemia • 3 phases • Sweating • Blood smear = granulocytes & monocytes o Treatment = cytoreduction (leukapheresis)
(CML) o Chronic
o Accelerated
o Acute = blast crisis → acute leukemia • Pruritus after hot bath → histamine from basophil

• Splenomegaly = MC finding
• Hepatomegaly
 • B cell malignancy in lymphatic system • Spread contiguously • Nodal biopsy = Reed-Sternberg cells • Treatment = chemo
• Painless supradiaphragmatic/cervical LAD o Stage I & II = chemo & radiation
• Onset = 15-19 years old (again @ 50 years old) o Posterior LAD = most concerning • CT scan = staging o Stage III & IV = chemo
o Painful lymph nodes with EtOH ingestion!
• Females > males • Mediastinal mass • Prognosis = good (better prognosis than Non-Hodgkin)
• Hepatosplenomegaly
• Associated with Epstein-Barr virus
Hodgkin • B symptoms = common
Lymphoma • Types o Fever
o Nodular sclerosis = developed countries (US) o Night sweats
o Mixed cellularity o Weight loss
o Lymphocyte rich (best prognosis)
o Lymphocyte deplete

• B & T cell lymphomas → uncontrolled division • Spread non-contiguously • Nodal biopsy = starry sky (Burkitt lymphoma) • Treatment = chemo
• Painless disseminated LAD o Low grade (asymptomatic) = no treatment
• Type • Hepatosplenomegaly • CT scan = staging o Low grade (symptomatic) = radiation
o Large B cell = rapid growth & aggressive o Intermediate and high grade = chemo
o Follicular • Extranodal involvement = GI, skin, bone • ↑ LDH & uric acid = Burkitt lymphoma
o Burkitt lymphoma = type of NHL o GI = bowel obstruction • Tumor lysis syndrome = rapid tumor lysis after chemo
▪ Associated w/ Epstein-Barr virus in Africa o Bone = pancytopenia o Tumor cells release their contents into bloodstream
▪ MC in pediatric → average = 10 years old o Burkitt lymphoma = GI nodes o ↓ Ca2+, ↑ K+, ↑ phosphate, ↑ Cr, ↑ uric acid & ↑ LDH
Non- ▪ Aggressive! o Treatment = IVF & electrolytes
Hodgkin • B symptoms = less common
Lymphoma • T cell lymphomas → uncontrolled division Prognosis = poor (worse prognosis than Hodgkin)

• Proliferation of a single clone of plasma cells • BREAK • CBC = ↓ WBCs & anemia • Treatment = medication
o Malignant proliferation of plasma cells o Bone pain = MC in vertebrae or ribs o Autologous stem cell transplant = most effective
o ↑ production of ineffective monoclonal antibodies ▪ Osteolytic lesions, fractures, radiculopathy • Blood smear = rouleaux formation o Chemotherapy = controls symptoms temporarily
o Plasma cells accumulate in bone marrow o Recurrent infections = leukopenia, o Radiation therapy
▪ Interrupting normal production ineffective IgG & hyperviscosity (with IgM) • CMP = ↑ BUN & ↑ creatinine o Bisphosphates = inhibit osteoclasts
o Elevated calcium = osteoclast activity
• Risk factors o Anemia = fatigue, weakness, HSM • ↑ ESR • Complications = hyperviscosity syndrome
o >65 years old o Kidney injury = antibodies deposit in kidney o Too much IgM
o African American • Serum electrophoresis = monoclonal protein spike o S/S = HA, fatigue, blurry vision, CVA
Multiple o Male o Treatment = phlebotomy or plasmapheresis
Myeloma o Benzene exposure • Urine electrophoresis = Bence-Jones protein
o Kappa or lambda light chains

• Skull x-ray = “punched out” lytic lesions

• Bone marrow aspiration = definitive diagnosis

o Plasma cells >10%

• Abnormal cell differentiation of myeloid cell line • Anemia = pallor, fatigue & dyspnea • CBC = ↓ number of >1 myeloid line • Treatment = supportive, meds & transplant
o Heterogenous preleukemic disorder • Leukopenia = fever & infections o PLTs, neutrophils or RBCs o Supportive = intermittent blood or PLT transfusions
• Thrombocytopenia = petechia & easy bleeding o Meds = pyrimidine analogs or lenalidomide
Myelo- • Bone marrow biopsy = dysplastic bone marrow o Allogenic stem cell transplant = only effective tx
dysplastic o ↑ myeloblasts = <20 % blasts
Syndrome o Ringed sideroblasts • Complications = acute leukemia (AML)
o Pseudo-Pelger-Huet cells
 • Blood loss, ↓ intake, OR ↓ absorption • Pallor, fatigue, & dyspnea • CBC = anemia • Treatment = iron vs. blood transfusion
• Poor concentration → poor school performance o +/– ↑ PLTs (reactive thrombocytosis) o Iron = iron formula or ferrous sulfate (6-12 months)
• Etiologies • Restless leg syndrome ▪ 5-10 days for reticulocytosis
o Blood loss = CHRONIC • ↑ HR • Iron studies ▪ 6-8 weeks to correct anemia
▪ Excessive menstruation o ↓ Fe & ferritin ▪ 6 months to correct ferritin
▪ Occult GI blood loss = colon cancer • Pica = craving for non-food substances o ↑ TIBC ▪ Take with vitamin C
▪ Parasitic hookworm o ↓ transferrin saturation ▪ S/E = constipation
• Pagophagia = craving for ice
o ↓ absorption o ↑ RDW o Blood transfusion = severe life-threatening anemia
• Koilonychia = spooning of nails o ↓ reticulocyte count = severe
Iron ▪ Celiac disease • Angular cheilitis = inflamed mouth corners
Deficiency ▪ Bariatric surgery • Glossitis (atrophic) = swollen tongue
▪ H. pylori • Blood smear = hypochromic & poikilocytosis
Anemia
o ↓ intake
▪ Vegan • Bone marrow biopsy = definitive diagnosis
Microcytic o Absent iron stores
▪ Limited access to food
Anemia
• Risk factors • Assessments
o 1st risk assessment = 4 months
o ↑ metabolic demands
o 2nd risk assessment = 12 months
▪ Children o Routine = 15, 18, 24, 30 & 36 months
▪ Pregnant & lactating women
o Cow’s milk
▪ Low iron
▪ Prevents body from absorbing Fe
o Lead exposure
• ↓ α-globin chain • Pallor, fatigue, & dyspnea • CBC = anemia • Treatment = transfusion, vitamin C & folate, surgery
• Neonatal jaundice o Transfusion = severe anemia
• MC = Asian • HSM • Iron studies ▪ Iron overload from transfusions*
• Frontal bossing → severe forms o Normal or ↑ Fe & ferritin o Iron chelating agents = deferoxamine
• Autosomal recessive • Pigmented gallstones o Normal TIBC ▪ Prevent iron overload
o Inherited = ask about family history! o Normal RDW o Vitamin C & folate = help with RBC production
• Premature fusion of epiphyses
o Intrauterine transfusion = hydrops fetalis
Alpha • Osteopenia & osteoporosis
• Consider at 3-6 months old • Blood smear = target cells, Heinz bodies, & ▪ Bone marrow transplant later in life
Thalassemia • Cardiac dysfunction = CHF or arrythmias schistocytes → hemolytic anemia o Splenectomy = some cases (splenomegaly)
• ¼ = silent carrier → normal Hb ratio o Bone marrow transplant = definitive in some cases
Microcytic • Minor = mild anemia • Electrophoresis = gold standard
Anemia • 2/4 = minor (trait) → normal Hb ratio
• HbH = severe anemia • Complications = iron overload (hemochromatosis)
• ¾ = intermedia → HbH
• HB Bart’s = hydrops fetalis o When alpha chains are broken down
o Oxygen is not released easily from heme
Hemolytic o Intramedullary & extravascular hemolysis o Hypogonadism, DM, growth failure, hypothyroidism
Anemia • 4/4 = hydrops fetalis → Hb Bart’s
o Oxygen is not released from heme
o Not compatible with life

• ↓ β-globin chain • Pallor, fatigue, & dyspnea • CBC = anemia • Treatment = transfusion, vitamin C & folate, surgery
• Neonatal jaundice o Transfusion = severe anemia
• MC = Mediterranean • HSM • Iron studies ▪ Iron overload from transfusions*
• Frontal bossing → severe forms o Normal or ↑ Fe & ferritin o Iron chelating agents = deferoxamine
• Autosomal recessive • Mental delays o Normal TIBC ▪ Prevent iron overload
Beta o Inherited = ask about family history! o Normal RDW o Vitamin C & folate = help with RBC production
• Premature fusion of epiphyses
Thalassemia o Splenectomy = some cases (splenomegaly)
• Osteopenia & osteoporosis • Blood smear = target cells
• Consider at 3-6 months old
• Cardiac dysfunction = CHF or arrythmias • Beta thalassemia minor = no treatment needed
Microcytic
• ½ (trait) = minor (asymptomatic) • Growth impairment • Electrophoresis = gold standard
Anemia
o Only one gene is defective • Enlarged kidney = hematopoiesis in kidney • Complications = iron overload (hemochromatosis)
• 2/2 (reduced production) = intermedia o When alpha chains are broken down
Hemolytic
o Mild homozygous form o Hypogonadism, DM, growth failure, hypothyroidism
Anemia
• 2/2 (absent production) = major → Cooleys
o Both genes are mutated
 • Sickle point mutation in the beta globin gene
o Less soluble than fetal or adult hemoglobin
o Thymine for adenine = mutated β-globin gene
• Autosomal recessive
• FA = normal ( “A” is good)
o FAS or FAC = sickle trait (carrier)
o FS or FSC = sick cell disease
• MC = African Americans
Sickle Cell
• Hemolysis and vaso-occlusive crises
Anemia
• Presents at 3-6 months → HbF is gone
Hemolytic
Anemia
• Aplastic crisis → parvovirus destroys erythrocytes
o SEVERE anemia → aplastic anemia
o Pallor, fatigue, dyspnea, & weakness
• Vaso-occlusive crises → ischemia & PAIN
o Dactlytitis
o Priapism
o Avascular necrosis of femoral head
o CVA
o Renal dysfunction → hematuria
o Acute chest syndrome → SOB, CP, & cough
o Splenic infarct
• Jaundice = hemolysis
• Infections = functional asplenia
• Hepatomegaly = ↑ RBC production
• Chronic issues
o Growth & developmental delay
o Learning & behavior issues
o Auto-splenectomy = scars & fibrosis
▪ Functional asplenia = infections
▪ ↑ risk of encapsulated organisms
• CBC = anemia
• ↑ LDH = released from destroyed Hgb
• ↓ haptoglobin = binds to free Hgb
• Blood smear = sickle cells & Howell-Jolly bodies
o Howell-Jolly bodies = unfunctional spleen
▪ Remnants usually removed by spleen
• Electrophoresis = gold standard
• X-ray = H-shaped vertebrae from micro infarcts
• Complications = functional asplenia, aplastic crisis,
• Prenatal screening
o Chorionic villous sampling = 10-14 weeks
o Amniocentesis = 15 weeks
• Newborn screening = electrophoresis
• Treatment = fluids, O2, meds, ABX, vaccination, surgery
o Home = avoid stress, ↑ fluids, & NSAIDs for pain
o ER = O2, IVF, pain meds, warming or cooling blankets
o Hydroxyurea = 1st line → ↑ production of HbF
▪ L-glutamine = 2nd line / newer option
o Splenectomy = once vaccines done
▪ Mostly from splenic sequestration causing anemia
o PCN = <5 y/o OR lifelong if nonfunctional spleen
▪ 125 mg at 2 months
▪ 250 mg at 3 years
o Transfusions = severe anemia
▪ S/E = iron overload from transfusions*
infections (encapsulated organisms), vaso-occlusice
crises, acute chest syndrome, & CVA
o “SHITAE” = stress, hypoxia, infection, temperature,
infection, acidosis, exercise → O2 REMOVED
o Encapsulated organisms = S. pneumonia, H. flu,
GBS, Klebsiella, N. meningitides, & Salmonellosis

• WORSENS = dehydration, hypoxia, physical stress,

high altitude, & extreme temperature

• Enzymatic disorder causing hemolytic anemia
o G6PD catalyzes NADP to NADPH
▪ NADPH protects RBCs from oxidative injury
o G6PD deficiency = ↓ NADPH in oxidative stress
▪ Results in oxidative Hgb = methemoglobin
▪ Denatured Hgb precipitates as Heinz bodies
▪ RBC membrane damage & fragility
• Extravascular hemolysis
G6PD o Spleen, bone, & liver
Deficiency • Intravascular hemolysis
Hemolytic • X-linked recessive = MC males
anemia
• Risk factors
o Infection
o Fava beans
o Meds = sulfa drugs (bactrim), dapsone,
methylene blue, macrobid, pyridium, &
antimalarial drugs (primaquine)
• Mostly asymptomatic! → until oxidative stress • CBC = anemia & ↑ reticulocytes • Treatment = supportive, supplements or phototherapy
o Supportive = avoid offending foods & drugs
• Back pain • ↑ bilirubin (indirect) o Iron & folic acid supplementation = severe
• Abdominal pain • ↓ haptoglobin = binds to free Hgb o Transfusion = severe
• Anemia o Phototherapy = neonatal jaundice (1st line)
• Blood smear = Heinz bodies & schistocytes o Exchange transfusion = neonatal jaundice (2nd line)
• Jaundice
• Splenomegaly o Heinz bodies = denatured Hgb
• Neonatal jaundice o Performed during attack (normal afterwards)
o Schistocytes = “bite cells”
• Symptom onset = 2-4 days after exposure
• Enzyme assay = fluorescent spot test
o Performed after attack (normal during)
o G6PD deficient cells removed hemolysis

• ↓ RBC production in the setting of chronic disease • Pallor, fatigue, & dyspnea • CBC = anemia & ↓ reticulocytes • Treatment = treat underlying disease & +/– EPO
o Erythropoietin = renal disease or ↓ EPO levels
• 3 factors • Iron studies
o ↑ hepcidin = blocks release of iron from o ↓ Fe
Anemia of macrophages & ↓ GI absorption of iron o ↑ ferritin
Chronic o ↑ ferritin = sequesters iron into storage o ↓ TIBC
Disease o EPO inhibitor = via cytokines o Normal or ↑ RDW
o Normal or ↓ transferrin saturation
Normocytic • Etiologies = chronic inflammatory conditions
Anemia o Infection = chronic
o Inflammation
o Autoimmune disorders
o Malignancy
o CKD
 • Folate = found in leafy greens • Pallor, fatigue, & dyspnea • CBC = anemia • Treatment = folate supplement
• Glossitis
• Folate required for DNA synthesis • Cheilitis • ↓ folate
• N/V/D • Normal methylmalonic acid
• Folate deficiency = abnormal synthesis of DNA, • ↑ homocysteine
nucleic acids & metabolism of erythroid precursors • NO neuro symptoms
o Converts homocysteine • ↑ LDH
• Etiologies • Blood smear = hypersegmented neutrophils
o ↓ intake = MC cause!!!*
▪ EtOH
▪ Diet
o ↑ requirements
Folate
▪ Pregnancy
Deficiency
▪ Infancy
▪ Hemolytic anemia
Macrocytic ▪ Malignancy
Anemia ▪ Psoriasis = ↑ skin turnover
o ↓ absorption
▪ Celiac disease
▪ IBD
▪ Chronic diarrhea
▪ Anticonvulsants (ex: phenytoin)
o ↓ metabolism
▪ Methotrexate
▪ Trimethoprim
▪ Anticonvulsants (ex: phenytoin)
o Loss
▪ Dialysis

• B12 = found in animal products (meats, dairy, eggs) • Pallor, fatigue, & dyspnea • CBC = anemia • Treatment = B12 supplement
• Glossitis o Neuro symptoms = IM B12
• B12 required for DNA synthesis • Cheilitis • ↓ B12 ▪ Switch to PO if deficiency corrected & no more sx
o Converts homocysteine & methionine • Diarrhea = malabsorption • ↑ methylmalonic acid o Pernicious anemia = lifelong IM B12
• ↑ homocysteine o Dietary deficiency = PO B12
• B12 deficiency = abnormal synthesis of DNA, nucleic • NEURO symptoms
acids & metabolism of erythroid precursors o Paresthesia’s • ↑ LDH
o Loss of position & vibration
• B12 is released from ingested proteins by stomach acid o Dementia • Blood smear = hypersegmented neutrophils
(HCl) & combines with intrinsic factor → absorbed o Balance problems or ataxia
in distal ileum o (+) Romberg • (+) anti-intrinsic factor antibodies
o (+) Babinski
• Etiologies o Hyporeflexia = ↓ DTRs
o ↓ absorption o Seizures
B12 ▪ Pernicious anemia = MC o Psychosis
Deficiency • No intrinsic factor b/c parietal cell Ab
▪ H2 blockers & PPIs = ↓ stomach acid
Macrocytic ▪ Pancreatic insufficiency
Anemia ▪ Crohn disease = affects terminal ileum
▪ Celiac disease = affects terminal ileum
▪ Gastric bypass
▪ Gastrectomy = ↓ stomach acid
▪ Gastritis = ↓ stomach acid
▪ Achlorhydria = ↓ stomach acid
▪ ZES
▪ EtOH
▪ Metformin = ↓ nucleic acid synthesis
o ↓ intake
▪ Vegans
▪ Vegetarians
 • Immune-mediated isolated thrombocytopenia • Petechia rash → non-blanching • CBC = ↓ PLT (↑ bleeding time) • Treatment = observation vs. meds
• Mucocutaneous bleeding = epistaxis & gums o No bleeding & PLTS >30,000
• Autoantibodies to PLTs → splenic destruction of PLTs • Menorrhagia • PT/INR & PTT = normal ▪ Watchful waiting → observe (no anti-PLT meds)
• Bruising • Observation is preferred in children
• Types • Bone marrow biopsy = megakaryocytes ▪ Activity restriction if PLTs <30,000
o Primary ITP = post viral infection o Mild bleeding & PLTS <30,000
o Secondary ITP = immune-mediated ▪ Glucocorticoids = 1st line → ↑ PLTs in 2-5 days
▪ SLE, HIV, HCV, antiphospholipid syndrome ▪ IVIG = 2nd line → ↑ PLTs in 1-2 days
Idiopathic ▪ RhoGAM = alternative to IVIG in Rh+ patients
• 3 categories ▪ Rituximab = last option (monoclonal antibody)
(Immune) o Newly diagnosed = <3 months
Thrombo- ▪ Splenectomy = refractory to meds
o Persistent = 3-12 months o Severe bleeding & PLTS <30,000
cytopenic o Chronic = >12 months ▪ PLT transfusion = 1st line
Purpura ▪ Glucocorticoids = 1st line (high-dose)
• Onset = 2-5 years old & adolescence ▪ IVIG = 1st line
▪ Rituximab = 2nd line (monoclonal antibody)
▪ Splenectomy = refractory to transfusion or meds

• Complications = GI bleeding, ICH, or chronic ITP

o Severe bleeding (GI, ICH, hematuria) = uncommon

• Most respond to 1st line meds & 1/3 of patients relapse

• Thrombotic microangiography from ↓ ADAMTS13 • Thrombocytopenia = mucocutaneous bleeding • CBC = anemia & ↓ PLT (↑ bleeding time) • Treatment = plasmapheresis, steroids or surgery
• Hemolytic anemia = jaundice & splenomegaly o Plasmapheresis = 1st line
• ADAMTS13 = von Willebrand factor-cleaving protease • Neurologic sx = HA, seizure, CVA, AMS, vision △ • CMP = ↑ BUN & Cr ▪ Removes ADAMTS13 antibodies
• Fever ▪ Adds ADAMTS13
• ADAMTS13 deficiency = large vWF multimer • Kidney failure or uremia • PT/INR & PTT = normal o Glucocorticoids = 2nd line
o Leads to small vessel thrombosis o Splenectomy = refractory to plasmapheresis or meds
• ↓ ADAMTS13 levels
• vWF not cleaved & PLTs stick to it = multiple clots • (+) ADAMTS13 antibodies • NO PLTs = might potentiate thrombi formation

Thrombotic • Etiology • Coombs’s test = negative • Complications = organ damage

Thrombo- o Primary = idiopathic (autoimmune)
cytopenic ▪ Antibodies against ADAMTS13 • ↑ LDH
Purpura o Secondary • ↑ bilirubin
▪ Malignancy • ↓ haptoglobin
▪ Bone marrow transplant
▪ Estrogen • Blood smear = schistocytes or helmet cells
▪ SLE
▪ Scleroderma
▪ Sjogren’s
▪ Pregnancy
▪ HIV
▪ Meds = plavix, quinidine, ticlopidine, etc.
• Thrombotic microangiography from PLT activation • Abdominal pain • CBC = anemia & ↓ PLT (↑ bleeding time) • Treatment = supportive or plasmapheresis
by exotoxins • Bloody diarrhea o Supportive = IVF, electrolytes & stop offending meds
o Exotoxins damage endothelium & activate PLTs • CMP = ↑ BUN & ↑ Cr (uremia) → AKI o Transfusion = severe anemia
▪ PLTs used & less available when clots needed • Hematuria o Plasmapheresis = severe or neuro complications
▪ Hemolysis because clots break RBCs • Proteinuria Hemolytic anemia, thrombocytopenia, AKI ▪ Must have NO renal complications
o Exotoxins damage kidney epithelial • Oliguria → decreased urine output
▪ Leading to uremia • PT/INR & PTT = normal • AVOID antimotility meds & antibiotics
Hemolytic • Pallor
Uremic • Risk factors • Jaundice • Coombs’s test = negative
o Children = infectious
Syndrome • Fatigue & lethargy
▪ Recent gastroenteritis • Blood smear = schistocytes or helmet cells
(HUS) o Adults = immune
• Petechia & purpura = uncommon
▪ HIV, SLE, antiphospholipid syndrome, chemo • Stool studies = if needed
• TRIAD
• Enterohemorrhagic E. coli = Shiga-like toxin
o Macroangiopathic hemolytic anemia
o EHEC from beef or milk
o Thrombocytopenia (low platelets)
• Shigella = Shiga enterotoxin o Renal insufficiency
 • Pathological activation of coagulation system • Bleeding = from IV, catheters, drains, etc. • CBC = ↓ PLT (↑ bleeding time) • Treatment = treat underlying cause & supportive
• Thrombosis = arterial or venous o PLT transfusion = replaces PLTs (only if <20,000)
• ↑ fibrin production from tissue factor activation • PT/INR & PTT = increased o FFP = replaces coagulation factors
o Microthrombi → consumes coag proteins & PLTs o Cryoprecipitate = replaces fibrinogen
o Consumption → ↓ PLTs & diffuse bleeding • ↓ fibrinogen o Heparin = evidence of thrombosis

• Risk factors • D-dimer = increased • Complications = gangrene or multi-organ failure

o Infections = gram negative s
▪ Gram negative sepsis = MC • Blood smear = schistocytes
Disseminated ▪ Rock Mountain spotted fever
Intra- ▪ Virus
vascular o Malignancy
Coagulation ▪ AML
▪ Lung, GI or prostate cancer
(DIC) o Obstetric
▪ Pre-eclampsia
▪ Abruptio placentae
▪ Amniotic fluid embolism
▪ Septic abortion
o Trauma & tissue injury
▪ Burns
▪ Liver disease
▪ Aortic aneurysm
▪ ARDS
• Factor 8 deficiency → failure of hematoma formation • Hemarthrosis • CBC = normal H&H • Treatment = factor 8 infusion & desmopressin
• Epistaxis o Factor VIII infusion = 1st line
Hemophilia • X-linked recessive • Bruising • ↓ factor 8 ▪ Acute bleeding or PPX
A o Males > Females • Bleeding after tooth extraction o Desmopressin = prior to procedures to ↓ bleeding
• Melena or hematemesis = GI bleeding • PT/INR & PTT = ↑ PTT & normal PT ▪ ↑ factor 8 & vWF
• MC type of hemophilia • Hematuria o PTT corrects with mixing studies
• Factor 9 deficiency → failure of hematoma formation • ICH = severe! • CBC = normal H&H • Treatment = factor 9 infusion
o Factor IX infusion = 1st line
• Bleeding into soft tissues and gingiva
Hemophilia • X-linked recessive • ↓ factor 9 ▪ Acute bleeding or PPX
B o Males > Females
• Hemorrhage s/p trauma or surgery
• PT/INR & PTT = ↑ PTT & normal PT • NO Desmopressin = only helpful in vWD & hemophilia A
• Incisional bleeding
• AKA Christmas disease o PTT corrects with mixing studies
• Ineffective PLT adhesion → ↓ von Willebrand factor • Mucocutaneous bleeding • CBC = normal PLT (↑ bleeding time) • Treatment = Desmopressin or vWF-containing product
o vWF = stabilizes factor 8 & causes PLT adhesion o Epistaxis, gums, GI & menorrhagia o Worse with aspirin o Desmopressin = mild to moderate bleeding
o Petechia & purpura ▪ PPX before minor procedures
• Autosomal dominant • Easy bruising • PT/INR & PTT = ↑ PTT & normal PT ▪ ↑ factor 8 & vWF
Von o PTT corrects with mixing studies o vWF-containing product = severe bleeding
Willebrand • MC hereditary bleeding disorder (could be acquired) • Incisional bleeding = less common o ↑ PTT because ↓ factor 8 ▪ PPX before major procedures
Disease
• ↓ vWF

• ↓ or normal factor 8

• Factor V resistant to breakdown by protein C • DVT or PE • PT/INR & PTT = normal • Treatment = anticoagulation
o Factor V = convert prothrombin to thrombin (clot) • Hepatic vein or cerebral vein thrombus o High-risk = lifelong anticoagulation
Factor V • Miscarriages • (+) activated protein C assay o Moderate-risk = PPX anticoagulation
Leiden • Autosomal dominant
• DNA testing = mutation analysis
Mutation
• MC inherited cause of hypercoagulability

• Vitamin K dependent anticoagulant proteins • DVT or PE • (+) protein C & S assay • Treatment = depends on complication
o Inactivate factor V & VIII o Thrombosis = protein C & S and anticoagulation
Protein • Warfarin-induced skin necrosis o Warfarin-induced skin necrosis = discontinue
• Etiologies meds, give vitamin K, heparin, protein C or S, or FFP
C&S
Deficiency
o Inherited = autosomal dominant • Purpura fulminans = coagulation in small vessels
o Acquired = liver disease & early coumadin o Leads to necrosis & DIC
administration
 • Antibodies → complement-mediated thrombosis • DVT or PE • PT/INR & PTT = ↑ PTT • Treatment = asymptomatic vs. symptomatic vs. pregnant
o Venous or arterial thromboses • Miscarriages (fetal loss) o PTT DOES NOT correct w/ mixing studies o Asymptomatic = no treatment
• Livedo reticularis o Symptomatic = anticoagulation
• Etiology • Valvular heart disease • Autoantibodies o Pregnant = LMWH to prevent miscarriages
o Primary disease • CVA or TIA o (+) anticardiolipin antibodies
o Secondary disease = with other diseases (SLE) o (+) lupus anticoagulation (↑ PTT)
Anti- o (+) beta-2 glycoprotein I antibodies
phospho- • Triggers
lipid o Smoking • Russel viper venom test = prolonged
o Immobilization
Antibody
o Estrogen = OCPs, pregnancy, HRT
Syndrome o Malignancy
o HLD
o HTN

• Autoantibody to hapten of heparin & PLT factor 4 • Thrombosis = venous thrombosis, gangrene, • CBC = ↑ or ↓ PLT • Treatment = stop & switch meds!
o PLT activation & consumption organ infarction, or skin necrosis o STOP heparin & start non-heparin anticoagulation
Heparin o Thrombosis & thrombocytopenia • Heparin antibody testing o Initiate non-heparin anticoagulation
Induced • Thrombocytopenia = bleeding o ELISA = immunoassay ▪ Direct Factor Xa inhibitors = Xarelto or Eliquis
Thrombo- • Acquired thrombocytopenia after heparin initiation o 14-C serotonin assay = functional assay ▪ Direct thrombin inhibitors = Pradaxa
cytopenia o Within first 5-10 days ▪ +/– gold standard
o UFH > LMWH

• Acquired myeloproliferative disorder • Thrombosis • Diagnostic Criteria = 3 major or 2 major + 1 minor • Treatment
o Bone marrow overproduction of all 2 myeloid o Erythromelalgia = burning of hands/feet o Major o Low risk = <60 years old & no thrombosis
stem cells → primarily RBCs o Cyanosis ▪ CBC = Hgb (>16) & ↑ HCT (>48) ▪ Phlebotomy = until HCT <45%
o JAK2 mutation = primary erythrocytosis o Pallor ▪ Bone marrow biopsy = hypercellularity ▪ ASA = prevent thrombosis
o TIA / CVA / MI / DVT ▪ JAK2 mutation o High risk = <60 years old &/or thrombosis
• MC = men 50-60 years old o Minor ▪ Phlebotomy = until HCT <45%
• Hyperviscosity ▪ ↓ EPO ▪ ASA = prevent thrombosis
o Headache ▪ Hydroxyurea = ↓ cell count
Poly-
o Dizziness & tinnitus • ↑ uric acid & histamine
cythemia ▪ Interferon-alfa = 2nd line
o Blurred vision = engorged retinal vessel
Vera o Weakness & fatigue
▪ Ruxolitinib (JAK inhibitor) = 2nd line
o Pruritus = antihistamines
o Pruritus → after hot bath or shower
o Hyperuricemia = allopurinol
▪ Histamine release from basophils
o Epistaxis
• Avoid iron & alkylating agents
• Hepatosplenomegaly
• Facial plethora = flushed face

• Bone marrow hypocellularity • Anemia = pallor, fatigue & dyspnea • CBC = >2 cytopenia’s (PLTs, WBCs or RBCs) • Treatment
o T cells attack OR direct damage to hemopoietic • Leukopenia = fever & infections o Supportive
stem cells → leads to bone marrow failure • Thrombocytopenia = petechia & easy bleeding • Bone marrow biopsy = most accurate test ▪ BS-ABX = BS-ABX for infection
o Hypocellular & fatty bone marrow ▪ PLTs = PLTs <10,000
• Etiologies ▪ PRBCs = Hgb <7
o Idiopathic o Allogenic stem cell transplant = tx of choice!
o B12 & folate deficiency ▪ Reserved for severe aplastic anemia
o Radiation o Immunosuppressives = patients >50 years old or
o Infection patients without matched donor
Aplastic ▪ Seronegative viral hepatitis
Anemia ▪ Parvovirus B19 (with sickle cell or G6PD)
o Meds
▪ ABX (sulfa)
▪ Chemo
▪ Benzene
▪ Anti-epileptics
▪ Quinine
▪ NSAIDs
▪ Anti-thyroid meds = MMI & PTU