Documente Academic
Documente Profesional
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Surgery
Psychiatry
Obstetrics/gynecology
Medicine
Pediatrics
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27 51
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SURGERY
CV ISSUES
Goldmans index: cardiac risk factors in surgery
JVD (#1), recent MI (#2), PVCs and arrhythmias, age
>70, emergency surgery, aortic stenosis
JVD: indicates CHF, #1 CV risk factor overall, give
-blockers, Ca2+-channel blockers, digitalis, and
diuretics if possible before surgery
MI: previous MI increases risk of post-op MI, so
consult cards and order a stress test
RESPIRATORY ISSUES
Premature ventricular contractions: at risk of
arrhythmia due to ventricular dysfunction,
indicated for stress test and echo
Ejection fraction: SV/EDV; normal EF >67%, an
EF<35% increases risk of operative MI
Diabetes: should be NPO 8 hours before surgery,
administer IVF with D5, check glucose morning of
surgery; if glucose >250 2/3 of insulin, if glucose
<250 1/2 of insulin
Hyperglycemia: ideal glucose is 100-250,
delay surgery until glucose is under control
Diabetic coma: absolute contraindication to
surgery; give IVF, correct acidosis and glucose
hct: important to determine underlying cause of
anemia, consider possible colorectal cancer
HEPATOBILIARY ISSUES
hct: either hypovolemia or polycythemia; if
hypovolemic delay until hydrated, if polycythemic
important to determine underlying cause
VALVULAR ISSUES
POST-OP FLUIDS
Post-op fluid management: replace blood lost
during surgery + provide maintenance IVF + make up
for fluid loss in drains/NG tubes/fistulas
Surgical blood loss: replace in a 3:1 ratio with IVF
(e.g. replace 500mL blood loss with 1.5L NS or LR)
Maintenance IVF: administer D5NS+KCl,
using the 100/50/20 rule for daily fluid
requirements, or 4/2/1 rule for hourly fluids
Drains/NG tubes/fistulas: fluid loss should be
replaced milliliter for milliliter with regard to
specific electrolyte content
Third space: fluid sequestered into ISF due to
inflammation or injury, mobilized 3-5 days after
recovery requires decrease in IVF rate
OPERATIVE COMPLICATIONS
Malignant hyperthermia: T>104 following
anesthesia w/ high risk of myoglobinuria; Tx
dantrolene, 100% O2, and cooling blankets
Bacteremia: T>104 and chills within 1 hour of an
invasive procedure; get blood Cx 3 and start
empiric abx
Aspiration: complication of awake intubations;
leads to sudden death, chemical pneumonitis, or
secondary pneumonia
POST-OP COMPLICATIONS
Normal urine output: at least 0.5-1 mL/kg/hr
Post-op urine retention: presents as a need to
void, but inability to do so; Tx straight cath at 6
shours post-op and Foley after 2nd straight cath
WOUND HEALING
Primary intention: close approximation of wound
edges via sutures or staples
Primary intention timing: epithelialized by POD
#2, max collagen in 5-7 days, avoid weight-lifting
for 4-6 weeks, complete healing by 6 months
(only 60-80% of original strength)
Secondary intention: contamined wounds left open
to prevent abscess formation; granulation tissue
forms first, then contraction via myofibroblasts,
then finally a delayed epithelialization
Third intention: wound initially left open, then
delayed primary closure afterwards
Secondary/tertiary intention timing: much more
delayed than healing by primary intention
Healing growth factors: PDGF, TGF-, FGF, EGF
Suture knot: hard, knot-like structure below wound
site; absorbable sutures will resolve with time, nonabsorbable sutures can be taken out under lido/epi
Stitch abscess: infected suture that intermittently
drains pus, should be taken out under lido/epi
Incisional hernia: presents as bulging at wound site
with increased abd pressure (e.g. coughing), needs
to be repaired surgically
Red/sensitive scar: assuming no wound infection, it
could be completely normal; observe for 6 months
before considering surgical revision
Hypertrophic scar: raised scar within site of incision;
observe until scar is stable, then steroids + excision
Keloid: raised scar that extends beyond site of
incision; will grow back if excised
WOUND INFECTION
Wound infection: red and tender area on incision
site; Tx drainage and BID wet-to-dry dressing
changes, no antibiotics unless cellulitis is spreading
Post-infection management: observation is slow
and can result in contractions; other options
include skin grafting (must have <105 bacteria per
gram of tissue) or healing by third intention
Wound types: clean, clean-contaminated,
contaminated, infected
Clean wounds: no entry into GI, GU, or
respiratory tracts; <1% infection rate, Tx primary
closure
Clean-contamined wounds: enters GI, GU, or
respiratory tract in a controlled manner;
<10% infection rate, Tx primary closure
Contaminated wounds: major wound
contamination (e.g. bowel spillage or stab
wounds); Tx secondary closure
LUNG CANCERS
LUNG DISEASES
MEDIASTINAL DISEASES
Anterior mediastinal mass: thymomas, lymphomas,
teratomas, other metastatic germ cell neoplasms
Thymoma: often presents with progressive
muscle weakness secondary to myasthenia gravis,
Tx surgical removal via median sternotomy
Lymphoma: Tx radiation and chemotherapy
CAROTID DISEASES
Atherosclerosis: systemic disease that has multiple
manifestations (stroke, TIA, CAD, MI, mesenteric
ischemia, AAA, PVD); presence of any one of these
should raise suspicion for the others
Stroke: a neurologic deficit that doesnt resolve
within 24 hours, Tx t-PA only within 3 hours
Stroke management: carotid duplex study,
observation for improvement; CEA is not
indicated until pt has stabilized
Transient ischemic attack: brief neurologic deficit
that fully resolves within 24 hours; due to thromboembolus from internal carotid arteries
ESOPHAGEAL CANCERS
Dysphagia: management includes barium swallow
and esophagoscopy w/ biopsy; DDx achalasia,
Zenker diverticulum, esophageal cancers, strictures
Esophageal cancer: SCC in upper 2/3 due to cigs and
EtOH, adenocarcinoma in lower 1/3 due to Barretts,
Sx progressive dysphagia and weight loss
EC management: esophagoscopy and biopsy,
then staging via endoscopic ultrasound and CT
scan, then specific Tx
EC staging: stage I invades submucosa only, stage
II invades muscularis +/- LN, stage III invades
adventitia + adjacent structures, stage IV is
metastatic
EC prevalence: adeno MC in US, SCC elsewhere
EC Tx: upper 1/3 chemo and radiation only;
middle 1/3 chemo and radiation to shrink the
tumor, then esophagectomy; lower 1/3
esophagectomy and proximal gastrectomy; never
operate on stage IV cancer
Advanced esophageal cancer: Sx severe dysphagia
and chronic cough (due to aspiration from TE fistula),
management is palliative care b/c surgery wont help
ESOPHAGEAL DISEASES
Zenker diverticulum: pulsion diverticulum that
develops at upper esophagus due to abnormal
coordination of cricopharyngeal constriction;
Sx dysphagia, regurgitation, and bad breath
Zenker management: Dx barium swallow, Tx
cricopharyngeus myotomy
Traction diverticulum: diverticulum at middle
esophagus due to LN traction, indicates cancer
Esophageal motility disorders: achalasia (only one
treated surgically), nutcracker esophagus, spasms,
hypertensive LES
Achalasia: hypertonic and non-relaxing LES w/
poorly relaxing esophagus, Sx dysphagia of
liquids > solids
Achalasia management: Dx birds beak on barium
swallow and LES pressure on manometry, Tx
Heller myotomy
Nutcracker esophagus: painful swallowing due to
high amplitude action potentials, Tx nifedipine
Diffuse esophageal spasms: uncoordinated 3
peristalsis, Tx medically
Hypertensive LES: high LES pressure at baseline
but relaxes with swallow, Tx medically
Acute epigastric pain: DDx acute pancreatitis, GERD,
PUD (gastric ulcers or duodenal ulcers), cholelithiasis,
gastroenteritis
GB/BILIARY DISEASES
JAUNDICE
LIVER DISEASES
Hemolytic jaundice: bilirubin (direct <20%),
search for whats killing the RBCs
Hepatocellular jaundice: bilirubin (direct 20-50%)
and AST/ALT, consider HBV/HCV and alcoholism
Obstructive jaundice: bilirubin (direct >50%) and
alk phos, caused by CBD stones and cancers
Painless jaundice: caused by biliary obstructive
tumors (ampullary cancer, duodenal cancer,
cholangiocarcinoma, pancreatic adenocarcinoma)
Painless jaundice management: Dx CT scan then
ERCP, Tx Whipple if no mets or local invasion
Painless jaundice occult bleed: indicates
ampullary cancer, get CT scan then Whipple
PANCREATIC DISEASES
GI BLEEDING
Hematemesis: bloody vomiting, always UGIB
Melena: coffee ground blood in stool, usually UGIB
but can also be from ascending colon
Hematochezia: BRBPR, can be either UGIB or LGIB;
NG tube aspirate/lavage LGIB if blood/+bile,
UGIB if +blood, indeterminate if blood/bile
UGIB: GI bleeding proximal to Ligament of Treitz,
management is EGD
UGIB in ICU pt: most likely a stress ulcer
LGIB: GI bleeding distal to Ligament of Treitz, 85%
stop spontaneously; MCC are AVM, diverticulosis,
and colon cancer
LGIB management: must localize site of bleeding
w/ tagged RBCs (<1 cc/min) or angiography (>1
cc/min); if not currently bleeding, get upper and
lower endoscopy since localization wont help
LGIB surgery indications: hemodynamic
instability despite transfusion, loss of 4-6 units in
24 hrs or 8-10 units in 48 hrs
LGIB scenario: GI bleed stops spontaneously
get colonoscopy to determine cause and rule out
possibility of colon cancer coagulate if AVM,
leave alone if diverticulosis
LGIB scenario: unstable patient, massive BRBPR,
no imaging to localize site of bleeding total
colectomy since 85% of bleeding is from the colon
LGIB in kids: indicates Meckels diverticulum, Dx
technetium uptake into ectopic gastric mucosa
Dx tagged RBCs: sensitive for LGIB at 0.1 cc/min, but
not specific for localizing site of LGIB; bladder always
lights up first so ignore that part
Dx angiogram: less sensitive for LGIB at 1.0 cc/min,
but more specific for localizing site of LGIB; allows
for smaller LGI resection in surgery if necessary
OTHER GI DISEASES
Sigmoid volvulus: twisting of sigmoid colon around
mesentery results in closed-loop obstruction; Tx
detorse the colon via rigid scope and rectal tube,
then elective sigmoid colectomy
Cecal volvulus: twisting of cecum; Tx right
colectomy since detorsion usually wont work
Ogilvies syndrome: pseudoobstruction and massive
colon dilation w/o mechanical obstruction; Tx
endoscopic decompression or neostigmine if >11 cm
due to possibility of cecal perforation
Constipation: do a rectal exam to make sure stool
isnt impacted, then give enemas from below
THYROID DISEASES
Thyroid embryology: derivative of foramen cecum
from the base of the tongue
Thyroglossal duct cyst: remnant of thyroglossal
duct as a mobile midline neck mass, Dx at 1-2 yo
due to neck fat, Tx Sistrunk operation (take out
cyst, trunk, and medial portion of hyoid bone)
Thyroid nodule management: first get TSH levels
if euthyroid, get FNA for cancer Dx; otherwise, work
up for hypo- or hyperthyroidism
Risk of malignancy: solid nodules, cold nodules
(lack of radioiodine uptake), size > 1.5 cm
Colloid nodule: benign nodule, manage medically
Hyperthyroidism: Graves disease (most common),
toxic adenoma (#2), toxic multinodular goiter (#3)
Graves disease (diffuse toxic goiter): autoimmune disease due to IgG against TSH-R causing
exophthalmos, pretibial myxedema, and
hyperthyroidism; more common in women
PARATHYROID DISEASES
SKIN CANCERS
Skin cancers: basal cell carcinoma (50%), squamous
cell carcinoma (25%), malignant melanoma (15%);
management is full-thickness incisional biopsy at
border of the lesion
Basal cell carcinoma: raised waxy lesion or nonhealing ulcer in upper face, doesnt spread; Tx local
excision w/ 1 mm margins
Squamous cell carcinoma: non-healing ulcer in lower
face, spreads to LN; Tx local excision w/ 1 cm margins
and LN excision
SCC risk factors: draining fistulas, arsenic
exposure
Keratoacanthoma: variant of SCC that grows
rapidly and then dies off spontaneously
Dysplastic nevus: atypical mole, precursor of
malignant melanomas, requires close observation
Melanoma: ABCDE Asymmetric, irregular Borders,
different Colors, Diameter >5mm, Evolving; Px
related to depth, highly metastatic and will be found
in weird places
Ulcerated melanoma: 1/3 reduction in survival
Depth <0.75 mm: Tx excision w/ 1 cm margin,
good prognosis
Depth 0.76-3.99 mm: Tx excision w/ 2 cm margin,
palpable LN removal, no palpable LN
sentinel LN biopsy w/ elective removal
Depth >4 mm: Tx excision w/ 2 cm margin,
remove palpable LN, pt will likely die from mets
Melanoma LN involvement: remove regional LN,
then complete staging for mets (CXR, CT scan, LFTs,
brain MRI)
Melanoma metastases: Tx radiation and
chemotherapy (interferons)
SARCOMAS
Sarcomas: present as firm, painless masses; Px
depends on size, grade, and distant metastases (no
LN since sarcomas spread hematogenously)
Sarcoma management: Dx incisional biopsy
parallel to resection margins, chest CT for mets,
Tx resection w/ 1 cm negative margins
High-grade sarcomas: Tx radical amputation w/
post-op radiation therapy
HERNIAS
BREAST MANAGEMENT
MC breast masses: <25 fibroadenoma, 25-50 fibrocystic change, >50 infiltrating ductal carcinoma
TRAUMA EVALUATION
Evaluation of trauma pt: primary survey, get an
ample Hx, secondary survey
Primary survey: initial evaluation of trauma pt;
ABCDE airway, breathing, circulation, disability
(neurological), environment/exposure
HEAD TRAUMA
Ample Hx: things to ask a trauma pt allergies,
meds, previous illnesses, last meal, events
surrounding injury
Secondary survey: full inspection of trauma pt
following clearance of life-threatening issues,
continual reassessment is necessary for changes
Airway: determine if airway is clear, quickest way to
evaluate is to see if pt can talk; use intubation,
cricothyroidotomy, or tracheostomy if obstructed
Blunt trauma to neck: consider possibility of
laryngeal edema developing into airway
obstruction
Breathing: evaluate via lung auscultation, CXR, and
pulse oximetry
Circulation: stop external hemorrhage, 2 large-bore
IV lines (14 or 16-gauge) w/ 2L crystalloid, followed
by packed RBC (type O) if necessary
Cardiac tamponade: presents with Becks triad
JVD, muffled heart sounds, hypotension;
Tx subxiphoid pericardiocentesis and go to OR
Hypovolemic shock: class I <15% and lactic acid;
class II 15-30% and HR; class III 30-40% and BP;
class IV >40% with lethargy and anuria
Hypovolemic shock Tx: 2 large-bore IV lines and
2L crystalloid infusion, resuscitation measured by
urine output, HR, BP, and mental status
Hypovolemic shock Tx unresponsive: search for
underlying cause, ex lap or thoracotomy may be
indicated for continuous internal bleeding
Closed head injury: brain edema and ischemia
causes Cushing reflex peripheral vasoconstriction (BP), bradycardia (HR), and
respiratory depression (RR)
Circulation pregnancy: HR is normal and may
not indicate shock, hct of 31-35% is normal, best
evaluated laying on her left side
Disability: evaluate with GCS; 15 max, 8 coma, 3
nearly dead
Disability awake: stabilize C-spine, palpate
posterior neck for tenderness, assess extremities
for motor/sensory function, and get lateral Cspine imaging
Disability comatose: C-spine cannot be cleared,
so precautions must continue
RETROPERITONEAL TRAUMA
Dx DPL/FAST: diagnostic peritoneal lavage (DPL)
or ultrasound (FAST) useful for quick Dx of
internal free fluid positive DPL/FAST is
indicated for ex lap; may be false negative in
retroperitoneal injuries
LIMB TRAUMA
BURNS
Burn assessment: determine depth of burn, type of
burn, and body surface area (%BSA) burned
First-degree burns: epidermis only, painful
Second-degree burns: extends into dermis,
causes pain and blistering, may develop into
third-degree burns w/o proper management
Third-degree burns: full thickness, painless
Burn management: tetanus PPx, IV pain meds,
topical agents (silver sulfadiazine is default, mafenide
acetate for deep penetration, triple abx ointment for
the eyes)
Rule of 9s: estimates %BSA burned; head and upper
extremities are 9% each; anterior trunk, posterior
trunk, and lower extremities are 18% each; and
perineum is the last 1%
Parkland formula: estimates fluid replacement in
burn victims, LR volume = %BSA kg 4mL/kg;
give 50%LR in first 8 hours, 50%LR in next 16 hours
Fluid for infants: 20 mL/kg if BSA>20%
Chemical burns: alkaline burns are worse than acids
Chemical burn management: massive tap water
irrigation, dont try acid-base neutralization,
except in ingestion orange juice for alkali, milk
for acids
Electrical burns: may appear benign on surface, but
masks large amounts of interior damage to muscles,
nerves, and vessels; at risk of cardiac injury
(arrhythmias) and muscle injury (myoglobinuria)
Electrical burn management: IV fluids + mannitol
+ acetazolamide to maintain a high urine output
Inhalation burns: suspected with carbonaceous
sputum, facial burns, singed facial/nasal hairs,
hoarseness, etc. due to smoke inhalation
Inhalation burn management: confirm w/
fiberoptic bronchoscopy and order serial ABGs;
high COHb levels Tx 100% O2
Circumferential burns: rapidly become thick and
contracted, causing restricted ventilation in the
chest and ischemia in extremities; Tx escharotomy
PEDIATRIC SURGERY
VACTERL syndrome: vertebral, anal atresia, cardiac,
TE fistula, esophageal atresia, renal, limbs (radius);
presence of any of these requires checking for the
others
Esophageal atresia: presents as excess salivation,
choking spells, coiling NG tube, and often a TE
fistula; Tx surgical repair (if delay is necessary,
gastrostomy)
Anal atresia: high rectal pouch colostomy then
delayed repair, low rectal pouch repair, if anofistula present delay repair since further
growth may correct condition
Congenital diaphragmatic hernia: presents as RDS
due to hypoplastic left lung; Dx CXR shows bowel in
left chest, Tx intubation w/ low-pressure ventilation
Gastroschisis: midline hernia to left of umbilical cord
tearing through peritoneum; Tx closure if small, silo
if large, and TPN for a month since GI doesnt work
Omphalocele: midline hernia through the cord with
peritoneal covering; Tx closure if small, silo if large
OPHTHALMOLOGY
then resect (give mannitol, hyperventilate, and highdose steroids while waiting)
Frontal lobe tumors: present as disinhibition,
anosmia (CN I), ipsilateral blindness (CN II), and
contralateral papilledema
Craniopharyngioma: presents as GH deficit and
bitemporal hemianopsia in a kid, Dx calcified
lesion in sella turcica
Prolactinoma: presents as amenorrhea and
galactorrhea in a young woman, consider
possibility of MEN1 syndrome, Tx bromocriptine
Acromegaly: presents as huge hands, feet,
tongue, and jaws in a tall man due to GH; Dx get
somatomedin C levels and MRI, then resection
Nelson syndrome: presents as bitemporal
hemianopsia and hyperpigmentation in an
adult due to pituitary microadenomas that grew
to full size; Dx MRI then Tx surgical resection
Pituitary apoplexy: presents with typical pituitary
adenoma sx, then sudden onset headache and
CNS sx due to bleeding into tumor; Dx MRI then
emergent steroid replacement
Pinealoma: presents as loss of upper gaze and
sunset eyes due to compression of vertical
gaze center in superior colliculi
NEUROSURGERY
CNS diseases: vascular (sudden onset), metabolic
(hours), infectious (days-weeks), tumors (months),
degenerative disease (years)
PEDIATRIC DISEASES
Congenital hip dysplasia: presents as uneven gluteal
folds, posterior dislocating hips (with snapping) in
a newborn; Dx U/S since hip isnt calcified for X-ray,
Tx splinting
Avascular necrosis of femoral head: presents in a kid
w/ limping, hip pain, and limited hip ROM; Dx X-ray,
Tx cast + crutches
PSYCHIATRY
Psychotic Disorders
PSYCHOSIS
Psychosis: distorted perception of reality presenting
as delusions, hallucinations, or severely disorganized
thought/behavior
SCHIZOPHRENIA
Schizophrenia: >6 months with 2/5 for at least 1
month delusions, hallucinations, disorganized
speech, disorganized/catatonic behavior, negative
symptoms
Brief psychotic vs. BPD: BPD can have brief, stressrelated psychoses that are part of the personality
d/o and not brief psychotic d/o
Schizophreniform disorder: SCZ-like for 1-6 months;
Tx antipsychotics + supportive psychotherapy
Mood Disorders
MOOD
Mood: inner emotional state
MOOD DISORDERS
Mood disorder 2/2 GMC: must have direct causal,
physiologic relationship to mood sx
Substance-induced mood disorder: -blockers
(depression), steroids, levodopa, cocaine (mania),
OCP (depression)
Major depressive disorder: 1 major depressive
episode, no manic or hypomanic episodes
MDD prevalence: 16.2% (25-50% in elderly)
MDD risk factors: stroke (30-50%, lasts 2 years),
pancreatic cancer, loss of parent before age 11,
genetics (70% in twins)
MDD sleep: difficulty falling asleep, multiple
awakenings, and early morning awakenings;
hypersomnia characteristic of atypical depression
MDD etiology: monoamine hypothesis is most
popular (5-HT/DA/NE), other causes include
cortisol, thyroid, psychosocial and genetics
MDD brain: reduced frontal lobe blood flow and
metabolism
MDD Px: 15% suicide, 30-40% alcoholism, only 50%
receive Tx, 50-85% have another episode
MDD Dx: Beck depression inventory
MDD Tx: antidepressants psychotherapy; acute
risk hospitalization, elderly use lower dose,
unresponsive to drugs add lithium or try ECT
ANXIETY
Anxiety: subjective experience of fear and its
sympathetic response (e.g. HR, BP, SOB, etc.)
Pathological anxiety: inappropriate to situation
and interferes w/ daily functioning
Specific phobia Tx: CBT + desensitization is firstline, BDZs and -blockers help w/ autonomic sx
Social phobia: aka social anxiety disorder, same as
specific phobia but related to social settings
Social phobia Tx: SSRI (paroxetine) + CBT is firstline, BDZs and -blockers help w/ performance
anxiety
ADJUSTMENT DISORDERS
Obsession: intrusive, repetitive thought
Compulsion: ritualistic behavior
ANXIETY DISORDERS
Anxiety disorders: panic disorder, agoraphobia,
specific and social phobias, OCD, PTSD, ASD, GAD,
anxiety 2/2 GMC or substance use
Anxiety d/o prevalence: 30% women > 19% men,
more frequent in higher socioeconomic groups
Personality Disorders
PERSONALITY DISORDERS
CLUSTER B
CLUSTER A
CLUSTER C
Substance-Related Disorders
SEDATIVES
Sedatives: alcohol, sedative-hypnotics (e.g. BDZs
and barbiturates), inhalants
Substance-Related Disorders
OPIOIDS
Cognitive Disorders
Definition
Onset
Duration
Px
Amnesia
Alert
Oriented
Dx
Delirium
waxing-andwaning change in
pts level of
consciousness
acute
3 days 2 wks
reversible
immediate and
recent memory
no
no
abnormal EEG
Dementia
impairment in
memory and
other cognitive
functions
chronic
months yrs
irreversible
recent and
remote memory
yes
sometimes
abnormal MRI
DELIRIUM
Cognitive Disorders
Geriatric Psychiatry
GEROPSYCHIATRY
Normal aging: brain volume w/ enlarged ventricles,
muscle, fat, vision/hearing, minor forgetfulness
Elderly MDD: MC psychiatric disorder in elderly,
incidence s/p MI, stroke, and new admits to nursing
homes
Elderly suicide: white elderly males have highest
rate of successful suicides
Definition
Onset
Features
Tx
Pseudodementia
MDD + cognitive
defects due to
underlying
depression
acute
often answers I
dont know,
aware of
problems
cognitive defects
respond to antidepressants
Dementia
impairment in
memory and
other cognitive
functions
chronic
confabulates
answers,
unaware of
problems
cognitive
defects persist
despite antidepressants
Child Psychiatry
MENTAL RETARDATION
Mental retardation: IQ 70 and deficits in adaptive
skills, with onset before 18 y/o
MR/DD types: profound <25, severe 25-40,
moderate 40-55, mild 55-70 (intervals of 15)
MR/DD causes: 50% idiopathic, Down syndrome (MC
genetic), Fragile X (MC inherited), fetal alcohol
syndrome (overall MCC); prenatal, perinatal, or
postnatal pathology
TORCHES complex: perinatal infections than can
lead to MR/DD, includes Toxoplasmosis, Rubella,
CMV, Herpes simplex, Syphilis
Prader-Willi syndrome: partial deletion of 15q
MR/DD, obesity, hypogonadism, almond eyes
Fragile X syndrome: MC inherited form of MR/DD;
X-linked CGG trinucleotide expansion in FMR1
gene causes DSM-IV Discontinued chromosomal
staining, Shows anticipation, Males, Mental
retardation, Macrognathia, Macroorchidism
Learning disorders: achievement in reading, writing,
or math that is significantly lower than expected;
must r/o sensory deficits first
Learning disorder types: reading disorder (MC),
mathematics disorder, writing disorder
Learning disorder Tx: remedial education
DISRUPTIVE BEHAVIOR DISORDERS
Disruptive behavior disorders: includes oppositional
defiant disorder and conduct disorder
Oppositional defiant disorder: >6 months of hostile
and defiant behavior towards parents/teachers, but
perfectly fine w/ peers
ODD Tx: individual psychotherapy + family
involvement
Conduct disorder: hostile and defiant behavior
towards everyone
CD in boys: cruelty to animals, fighting, stealing,
fire-setting, vandalism
CD in girls: lying, running away, promiscuity
CD Px: 40% of conduct d/o ASPD
CD Tx: multimodal approach w/ family and
teacher involvement
CD vs. ASPD: conduct disorder <18 y/o, ASPD 18 y/o
CD vs. ODD: unlike conduct disorder, ODD doesnt
involve physical aggression or violation of basic
rights of others
CD vs. pyromania: pyromaniacs light things on fire
due to inner tension, not out of anger issues
Attention deficit disorder: >6 months of hyperactivity, inattentiveness, or both; onset before 7 y/o
ADHD types: inattentive type, hyperactiveimpulsive type, combined type
ADHD prevalence: boys > girls, >50% have
comorbid psychiatric diagnosis
Dissociative Disorders
DISSOCIATIVE DISORDERS
Dissociation: loss of memory, identity, or sense of
self; often following trauma, may involve NE + glu
Abreaction: strong reaction pts get when retrieving
traumatic memories
Dissociative disorders: dissociative amnesia,
dissociative fugue, dissociative identity disorder,
depersonalization disorder, dissociative disorder
NOS
Dissociative amnesia: 1+ episode of inability to recall
personal information; not due to TBI, medical
condition, substance abuse, or ordinary amnesia
DA epidemiology: MC dissociative disorder,
incidence of MDD and anxiety disorders
DA Tx: psychotherapy; most acute cases return to
normal after min-days, lorazepam or amobarbital
often used to help pt talk freely during interview
DA vs. dementia: DA cant recall common personal
info but can remember obscure details, dementia
can remember personal info but not obscure details
Dissociative fugue: sudden, unexpected travel away
from home + inability to recall ones past
DF epidemiology: rare, usually follows stressful
life event or personal conflict
DF Tx: same as DA
DF vs. DA: DA pts are aware of what they cant seem
to remember, DF dont acknowledge the amnesia
DF vs. transient global amnesia: DA pts show loss of
identity, global amnesia have difficulty with more
recent events but identity remains intact
Dissociative identity disorder: 2+ distinct identities +
inability to recall information about non-dominant
personalities; not due to substance abuse or medical
condition, existence is controversial
DID epidemiology: usually women w/ prior
trauma (e.g. childhood sexual abuse); incidence
of MDD, anxiety, BPD, substance abuse, suicide
DID Tx: psychotherapy; worst Px of all
dissociative disorders
DID DDx: DID-like sx may be seen in BPD, psychosis,
or malingering (factitious disorder)
Depersonalization: feeling that one is falling apart,
fragmenting, detached, not oneself, etc.
Derealization: feeling that the world is not real
Depersonalization disorder: persistent or recurrent
episodes of being detached from ones body or
mental processes; not due to substance use or
medical condition
GAIN
Primary gain: internal motives (e.g. stress, anxiety)
as the cause of symptoms
Secondary gain: external motives (e.g. attention,
money, avoiding law) as the cause of symptoms
Mnchhausen syndrome: aka factitious disorder,
consciously feigning symptoms to play the sick role
(primary gain)
Mnchhausen Sx: triad of 3 Ps Peregrination,
Pseudologia phantastica, Polysurgery
Mnchhausen Tx: establish therapeutic alliance,
avoid confrontation and unnecessary procedures
Mnchhausen by proxy: intentionally producing
symptoms in someone else, usually ones children
must report child abuse
Malingering: consciously feigning symptoms for
external motives (secondary gain), presents w/
multiple vague complaints and a long medical hx
SOMATOFORM DISORDERS
Somatoform disorders: not consciously feigning
symptoms, though no direct link to medical cause;
50% have comorbid anxiety d/o or MDD
Somatoform disorders gender: women > men,
except hypochondriasis where women = men
Somatization disorder: onset before 30 y/o with
multiple sx (4 pain + 2 GI + 1 sexual/GU + 1 neuro)
that are not intentionally produced
Somatization Px: chronic and debilitating, worse
under stress
Somatization Tx: r/o potential medical causes,
regularly scheduled visits w/ a single PCP who
limits extensive medical work-ups
Somatization vs. conversion: somatization pts are
concerned over condition, conversion dont care
Conversion disorder: conversion of a psych issue
into a neurological one, not limited to pain or sexual
dysfunction, preceeded by conflict or stressors
Conversion Sx: commonly paralysis, blindness,
mutism, parasthesias, seizures, globus hystericus
La belle indifference: apathy despite severity of
condition
Conversion Tx: most spontaneously recover;
if it persists insight-oriented psychotherapy,
hypnosis, or relaxation therapy
Conversion in elderly: high chance of real neuro
deficit, get a neuro consult
Conversion seizures: use EEG to differentiate
between epileptic vs. nonepileptic seizures
Eating Disorders
EATING DISORDERS
Eating disorders: anorexia nervosa, bulimia nervosa,
binge-eating disorder (eating disorder NOS)
Anorexia nervosa: fear of being fat <85% ideal
body weight, amenorrhea in postmenarchal females
Sleep Disorders
SLEEP
Normal sleep cycle: non-rapid eye movement sleep
(stages 1-4) alternating w/ REM sleep every 90 min
NREM: deeper sleep progression through stages;
stage 2 is tooth grinding, stage (delta sleep) is
sleepwalking, bedwetting, and sleep terrors
REM: dreaming, loss of motor tone, erections,
sympathetic activity (HR, RR, BP)
Sleep EEG waveforms: BATS Drink Blood Beta
(awake), Alpha (resting), Theta (1), Sleep spindles
and K complexes (2), Delta (), Beta (REM)
Sleep disorders: dyssomnias and parasomnias
DYSSOMNIAS
Dyssomnias: / or altered timing of sleep
Primary insomnia: sleep duration and/or quality;
acute insomnia 1-4 wks, chronic insomnia >1 month
PI subtypes: sleep-onset insomnia (cant go to sleep),
sleep-maintenance insomnia (cant stay asleep),
sleep-offset insomnia (early morning awakenings),
nonrestorative sleep (wake up still tired)
PI etiology: usually poor sleep hygiene
PI Tx: fix sleep hygiene, Chronic insomnia CBT,
acute insomnia long-term BDZs or non-BDZ
hypnotics, insomnia + depression trazodone
Obstructive sleep apnea: difficulty breathing during
sleep snoring and apneic episodes sleep
fragmentation excessive daytime sleepiness
OSA etiology: repetitive upper airway collapse
due to obesity and/or airway narrowing
OSA Tx: first-line is weight loss and exercise,
second-line is CPAP or BiPAP, third-line is surgery
Narcolepsy: excess daytime sleepiness, cataplexy
(suddenly fainting w/ intense emotion), hypnogogic
and hypnopompic hallucinations
Narcolepsy etiology: loss of hypothalamic
neurons that contain hypocretin, may have autoimmune component
Sexual Disorders
NORMAL SEXUALITY
Sexual response cycle: desire to EXPLORE desire,
EXcitement, PLateau, Orgasm, REsolution
Refractory period: post-resolution period in
which men cant reexperience orgasm
Sex male aging: desire unchanged but requires
stimulation and time to orgasm, intensity of
ejaculation, refractory period
Sex female aging: desire unchanged but estrogen
levels vaginal dryness and thinning
Sex drugs: libido cocaine, amphetamines,
marijuana, and acute alcohol use; libido narcotics
and chronic alcohol use
Sex NTs: DA libido, 5-HT inhibits sexual function
Sex hormones: testosterone libido, progesterone
libido, postmenopausal estrogen levels vaginal
dryness and thinning
Substance-induced sexual dysfunction: anti-HTN,
anticholinergics, antipsychotics, antidepressants
(esp. SSRIs), or substance abuse
Sexual dysfunction 2/2 GMC: atherosclerosis (ED),
diabetes (ED + neuropathy), pelvic adhesions
(dyspareunia), depression or anxiety
SEXUAL DISORDERS
Sexual disorders: problems involving any stage of
sexual response cycle or pain during intercourse, not
due to substance use or GMC
MC sexual disorders: premature ejaculation and 2
ED in men, HSDD and orgasmic disorder in women
Hypoactive sexual desire disorder: deficient or
absent libido
HSDD Tx: hormone replacement therapy
Sexual aversion disorder: avoidance of genital
contact w/ sexual partner
Erectile dysfunction: aka impotence, cant get it up,
either 1 (never had one) or 2 (had it but lost it)
ED Tx: PDE5-inhibitors (sildenafil) or alprostadil
injection are first-line; vacuum pumps, surgical
tube insertion, or constrictive rings
ED vs. psychological condition: men w/ psych
condition can get it up at other times (e.g. other
partners, masturbating, morning wood)
Sexual arousal disorder: cant get it wet
Premature ejaculation: ejaculation earlier than
expected
Premature ejaculation Tx: SSRIs or TCAs can
prolong time to ejaculation
Psychotherapy
FREUDS THEORIES
Topographic theory: mind is composed of three
types of thoughts conscious, preconscious, and
unconscious
Conscious thoughts: current thoughts and 2
process thinking (logical, mature, organized, etc.)
Preconscious thoughts: memories that are not
immediately aware but easy to recall
Unconscious thoughts: repressed thoughts that
are out of ones awareness, involves 1 process
thinking (primitive and pleasure-seeking)
Structural theory: mind is composed of three
identities id, ego, and super-ego
PSYCHOANALYSIS
Suppression: consciously avoiding unacceptable
impulse or emotion (vs. repression)
Humor: using comedy to express thoughts or
feelings w/o discomfort to self or others
Neurotic defenses: RIDICulous Rationalization,
Reaction formation, Repression, Intellectualization,
Displacement, Isolation of affect, Controlling
Rationalization: making reassuring but incorrect
explanations for outcome or behavior
Reaction formation: doing the exact opposite of
an unacceptable impulse
Repression: unconsciously avoiding unacceptable
impulse or emotion (vs. suppression)
Intellectualization: using excessive abstract
thinking to avoid experiencing disturbing feelings
Psychotherapy
Psychopharmacology
NEUROTRANSMITTERS
Anti-H2: sedation, weight gain
Anti-A1: orthostatic hypotension, sexual dysfunction
Anti-M: dry mouth, blurry vision, constipation,
urinary retention, exacerbates Alzheimer disease
ANTIDEPRESSANTS
Imipramine (Tofranil): Tx enuresis
Psychopharmacology
ANTICONVULSANTS
Anticonvulsants: includes carbamazepine,
oxcarbazepine, valproic acid, lamotrigine,
gabapentin, pregabalin, tiagabine, topiramate
ANXIOLYTICS
Psychopharmacology
Forensic Psychiatry
LEGAL ISSUES
Additional Notes
MOOD DISORDERS
Circumlocution: substitution of a word or
description for a word that cant be recalled (e.g.
that thing you write with)
Tangentiality vs. circumstantiality: tangentiality
never comes back to original topic, circumstantiality
eventually does
Abuse vs. dependence: inability to quit despite
knowledge of harm best indicates dependence over
abuse
COGNITIVE DISORDERS
PSYCHOPHARMACOLOGY
Placebos: 33% efficacy for depression
ETHICS
Depressed pt: ask about suicidal ideation
OBSTETRICS/GYNECOLOGY
OB 1 Pregnancy
Terminology
Embryo: 0-8 wk
Fetus: 8 wk delivery
Infant: delivery 1 yr
GXPTPAL
Pregnancy signs
Fetal dating
Physiologic changes
Nutrition
: kcal, folate (neural tube defects), iron (RBC), vitamin C, 3 fatty acids
: vitamin A (teratogenic), calcium (need more but chelates iron)
Common pregnancy
complaints
Complaint
Lower back pain
Constipation
Braxton-Hicks contractions
Dehydration
Edema
GERD
Hemorrhoids
PICA
Round ligament pain
Urinary frequency
Varicose veins
Hyperemesis gravidarum
Prenatal labs
Management
d/t hyperlordosis; Tx mild exercise + stretching, Tylenol
Tx fluids, exercise, fiber supplement
irregular contractions w/o cervical dilatation, normal
Tx PO fluids
Tx leg elevation + r/o preeclampsia
Tx antacids, PPIs or H2-blockers if severe
Tx topical steroids, fiber, stool softeners, sitz baths
eating inedible items; Tx encourage immediate cessation + toxicology
consult
shooting pelvic pain due to ligament stretching; Tx Tylenol + warm
compresses
normal, but get UA/UCx to r/o UTI
Tx leg elevation + pressure stockings
Tx NPO 3 days, IV fluids + antiemetics; if severe doxylamine + vitamin B6
Prenatal visits: first visit in first trimester, then q4wks until 28th, q2wks until 36th, and qwk until delivery
Lab test
CBC
Blood type
Rh status
HBsAg
HIV ELISA
RPR-VDRL
UA/UCx
Rubella Ab
GC/chlamydia
Management
check for anemia or hemoglobinopathies
for future transfusion
if Rh, give RhoGAM at week 28 and postpartum (if fetus is Rh+)
if HBsAg+, get LFTs and hepatitis panel to determine acute vs. chronic infx;
Tx infant HBIG and HBV vaccine
if ELISA+, confirm w/ Western blot; if WB+ then give anti-HIV meds, elective
C/S, or IV ZDV during labor
if RPR+, confirm with FTA-ABS; if FTA-ABS+ then determine syphilis stage and
Tx benzathine PCN G
if positive, Tx nitrofurantoin + recheck UCx; if organism is GBS then give PCN
during labor
if rubella ab, stay away from sick ppl and vaccinate postpartum
if GC/CT+, Tx ceftriaxone + azithromycin
Antenatal assessment NST (non-stress test): continuous fetal monitoring (toco + HR), look for reactivity (21515)
BPP (biophysical profile): U/S evaluation on a 10 pt scale
BPP >8: normal
BPP =6: get CST
BPP <4: deliver
CST/OCT (ctx stress test/oxytocin challenge test): give oxytocin, look for 3 ctx/10 min w/o late decels
Ectopic pregnancy
r/o ectopic
ruptured
not ruptured
stabilize w/ IVF
ex lap
if no definitive dx,
f/u serial -HCG Q 48hrs
Tx MTX
incomplete abortion
inevitable abortion
missed abortion
Tx D+C, prostaglandins,
or allow to finish on its own
threatened abortion
Incompetent cervix
Incompetent cervix: painless dilation and cervical effacement before term, usually 2nd trimester
Causes: surgery or trauma (MCC), uterine abnormalities, DES exposure
Management:
Incompetent cervix?
Dx dilated cervix on PE,
or hourglass membranes on U/S
viable (>24 wks)
Tx betamethasone +
strict bed rest
if cerclage fails,
transabdominal cerclage
Hx of incompetent cervix: offer elective prophylactic cerclage at 12-14 wks
Cerclage: surgical closure of cervix at external os (McDonald) or internal os (Shirokar)
Complications: rupture of membranes, PTL, infx
Dx
karyotype of both parents
screen w/ HSG (hysterosalpingogram),
confirm w/ hysteroscopic or ex lap
RPR-VDRL, lupus anticoagulant, ANA,
coag panel, anticardiolipin antibody
progesterone levels
cx cervix, vagina, endometrium
TSH, T4
Tx
IVF or preimplantation dx
surgery (may not be correctable)
low-dose aspirin
progesterone
abx
Synthroid
OB 3 Prenatal Diseases
Epidemiology
Dx+
Dx
Disease+
TP
FN (type II)
Disease
FP (type I)
TN
Sensitivity: TP / (TP+FN)
Specificity: TN / (TN+FP)
PPV: TP / (TP+FP)
NPV: TN / (TN+FN)
Cystic fibrosis
Sickle-cell disease
Sickle-cell disease: AR HbE6V (hemoglobin -chain) hemolytic anemia, vasoocclusive crises, autosplenic infarction
Dx: screen mom w/ Hb electrophoresis, then dad if positive, then confirm w/ fetal dx
Epidemiology: heterozygote advantage allows for resistance to P. vivax malaria in Africans
Tay-Sachs disease
-thalassemia
-thalassemia
Chromosomal defects
chronic bronchitis
recurrent Pseudomonas pneumonia
bronchiectasis
pancreatic insufficiency
male infertility
ADEK deficiency
meconium ileus
Dx: screen mom and dad for F508/G542X, confirm w/ fetal dx
Tx: N-acetylcysteine loosens mucus plugs, pancreatic enzyme replacement
Disease
Down syndrome
trisomy 21
Sx
flat facies, epicanthal folds, simian crease,
Alzheimer by 40 y/o, MR
Edwards syndrome
trisomy 18
Patau syndrome
trisomy 13
Turner syndrome
45/X
Klinefelter syndrome
47/XXY
Cri-du-chat syndrome
5p-
Williams syndrome
7q-
22q11
Dx
quad screen at 15-20 wk (-HCG, inhibin,
FP, estriol) + nuchal translucency on
U/S ; MCC abnormal value is error in dating
triple screen (-HCG, FP, estriol)
found on routine U/S
---
---------
OB 3 Prenatal Diseases
Embryogenesis
Week 0
Week 1
Week 2
Week 3
Week 3-8
Week 4
Week 8
Cardiac defects
Echogenic intracardiac focus (EIF): calcification of papillary muscle on U/S, usually insignificant
LR shunts: all present with murmurs + late-onset cyanosis due to Eisenmenger syndrome (pulmonary HTN reversing direction of shunt)
ASD: presents as low-grade systolic murmur, fixed S2, and frequent colds
VSD: presents as pansystolic harsh-sounding murmur with failure to thrive
PDA: presents with machinery-like murmur, often seen with Congenital Rubella Syndrome
RL shunts: all present with murmurs + early-onset cyanosis
Tetralogy of Fallot: presents as cyanosis and clubbing in a 5 y/o child who squats for relief; Px determined by degree of pulmonary stenosis
Transposition of great vessels: presents as life-threatening cyanosis in a newborn
Dx: fetal echocardiogram
Tx: surgery, indomethacin for PDA
Potter syndrome
Potter syndrome: failure of mesonephros and metanephros to meet at ureteropelvic junction bilateral renal agenesis anhydramnios (no amniotic fluid)
pulmonary hypoplasia + limb contractures
Dx: U/S shows anhydramnios or oligohydramnios (AFI <5)
Tx: none available
Prenatal diagnosis
Prenatal sampling: amniocentesis, chorionic blood sampling (CVS), percutaneous umbilical blood sampling (PUBS)
Method
Amniocentesis
CVS
PUBS
Technique
insert needle transabdominally into uterus
and withdraw amniotic fluid
insert catheter into intrauterine cavity and
aspirate chorionic villi from placenta
insert needle transabdominally into uterus
and withdraw umbilical cord blood
Advantages/disadvantages
+ 1:200 risk of PTL, PROM, injury
2nd trimester
+ 1st trimester
>1:200 risk of PTL, PROM, injury
+ rapid karyotype analysis
may take maternal blood
OB 4 L&D
Labor
3 Ps of labor
pelvis types
Induction of labor
Bishop score
0-4
5-9
10+
Management
cytotec
pitocin
expectant management
OB 4 L&D
Stages of labor
Cardinal movements
Cardinal movements:
1. Engagement (0 station)
2. Flexion
3. Descent
4. Internal rotation
5. Extension
6. External rotation
7. Expulsion
Operative vaginal
delivery
Perineal lacerations
Caesarian section
Anesthesia
Pudendal block: indicated for operative vaginal delivery, direct needle towards jxn of ischial spine and sacrospinous ligament
Local anesthesia: indicated for episiotomy and laceration repairs
Epidural anesthesia: more commonly used during labor, can lengthen stage 2
Spinal anesthesia: more commonly used during C/S
OB 4 L&D
Fetal HR
Periodic changes
category 2
routine mgmt
evaluation and
surveillance
category 3
resuscitative measures,
prepare for delivery
if no accels or variability,
resuscitative measures
if not improved, prompt delivery
Resuscitative measures: give O2 + change maternal position
OB 5 Antepartum Hemorrhage
Terminology
Antepartum
hemorrhage
Obstetric causes: placenta previa (20%), abruptio placentae (30%), fetal vessel rupture, uterine rupture
Non-obstetric causes: cervical/vaginal lacerations, hemorrhoids, infx, neoplasms
DDx: present as spotting (not frank bleeding), no contractions or abdominal pain
Px: simple management, good outcomes (vs. obstetric causes)
Placenta previa
stable
stabilize w/ IVF
emergent C/S
expectant management
tocolytics + betamethasone (<34 wk)
Placenta accreta
Abruptio placentae
Uterine rupture
Uterine rupture: rupture of uterus associated w/ prior uterine scar (C/S or other surgery)
Sx: sudden onset severe abd pain vaginal bleeding, subjective pop sensation
Tx: emergent ex lap and delivery
OB 6 L&D Complications
Preterm labor
Tocolysis
Premature rupture
of membranes
Tocolysis: delaying premature labor for 48 hrs, to allow for fetal lung maturity w/ betamethasone
Tocolytic
Nifedipine
MgSO4
MOA
Ca-channel blocker (1st line)
competes w/ Ca2+ for Ca-channels
Terbutaline
Ritodrine
Indomethacin
2-agonist
2-agonist
NSAID (blocks PGF2 production)
Side-effects
headache, flushing, dizziness
headache, flushing, dizziness, pulmonary edema,
cardiac arrest (high dose)
headache, tachycardia, anxiety
headache, tachycardia, anxiety
fetal PDA closure, pulmonary hypertension, renal
failure oligohydramnios
Cephalopelvic
disproportion
CPD: fetal head is too big to pass through maternal pelvis; MCC active phase prolongation
CPD management: suspected CPD trial of labor anyways, if CPD confirmed by CT or U/S C/S
Breech presentation
Malpresentation of
vertex
Fetal bradycardia
Bradycardia: <110 bpm for >10 min (2-10 min is prolonged decel)
Preuterine causes: maternal hypotension or hypoxia (seizure, PE, AFE, MI, etc.)
Uteroplacental causes: placental abruption, infx, hemorrhage
Postplacental causes: cord prolapse, cord compression, fetal vx rupture
Bradycardia management: place in LLD/RLD start 2L O2 NC look for cause Tx appropriately
OB 6 L&D Complications
Shoulder dystocia
Hypotension
Hypotension: maternal BP <80/40; causes include regional anesthesia, hemorrhage, vasovagal events, AFE, anaphylaxis
Hypotension management: start IV fluids + ephedrine, then Tx cause (e.g. Benadryl for anaphylaxis)
AFE: high mortality rate, Dx fetal cells in pulmonary vasculature at autopsy
Seizure
Seizure vs. syncope: check for postictal disorientation (found in sz but not syncope)
Seizure management: Tx IV or IM MgSO4, get PEII panel, consult neuro if negative for eclampsia
OB 7 Pregnancy Complications
Fetal growth
Amniotic fluid
Oligohydramnios
term/postterm
ROM
congenital anomaly
expectant
management
deliver
induce labor
compatible
w/ life
incompatible
w/ life
genetic counseling
meconium in
amniotic fluid
amnioinfusion
deliver
Polyhydramnios
Erythroblastosis
fetalis
Erythroblastosis fetalis: Rh woman w/ Rh+ fetus anti-Rh IgG crosses placenta hemolytic anemia hydrops fetalis (edema, ascites, heart failure)
Rh prevalence: 15% in caucasians, lower in other races
Rh management:
Rh woman
Intrauterine fetal
demise
unsensitized
sensitized
OB 7 Pregnancy Complications
Postterm pregnancy
Cleavage
Multiple gestations
TTTS
TTTS: unequal blood flow in shared placenta of Mo-Di twins small/anemic twin + large/polycythemic twin
TTTS management: serial U/S Q 2 wks in all Mo-Di twins Tx serial amnioreduction in larger twin
OB 8 Pregnancy HTN
Gestational HTN
Preeclampsia
HELLP syndrome
HELLP syndrome: Hemolysis (schistocytes, LDH, bilirubin), Elevated LFTs, Low Platelets in preeclamptic pts
Eclampsia
Chronic HTN
Chronic HTN: HTN occuring before conception, before 20 wks GA, or lasting >6 wks postpartum
Chronic HTN management: control HTN (labetalol, nifedipine) + baseline EKG + 24hr urine protein
Superimposed preeclampsia: 24hr urine protein >300 mg in previously HTN pt
OB 9 Pregnancy DM
Pregestational DM
GDM
White classification
of diabetes
Class
A1
A2
B
C
D
F
R
RF
H
T
Definition
GDM, diet controlled
GDM, insulin controlled
onset >20 y/o, duration <10 yrs
onset 10-19 y/o, duration 10-19 yrs
onset <10 y/o, duration >20 yrs
neFropathy
Retinopathy
Retinopathy + neFropathy
ischemic Heart disease
prior renal Txp
OB 10 Pregnancy Infx
UTIs
Chorioamnionitis
Other infections
HBV
Presentation
thin homogenous vaginal discharge + fishy
odor; complications include preterm
delivery, PPROM, and puerperal infx
subclinical illness or mono-like syndrome
Cytomegalic Inclusion Disease (CID):
blueberry muffin rash, hepatosplenomegaly, jaundice, thrombocytopenia, periventricular calcifications
UTIs, chorioamnionitis, endomyometritis,
neonatal sepsis (MCC)
Neonatal GC/chlamydia: conjunctivitis,
ophthalmia, otitis externa, pneumonia
---
HIV
(usually asx)
HSV
CMV
GBS
GC/chlamydia
Parvovirus B19
Rubella
Syphilis
Toxoplasmosis
VZV
Management
Dx clue cells on wet prep Tx
PO metronidazole
postpartum GCV
no tx exists
OB 11 Pregnancy Complications
Hyperemesis
gravidarum
Seizure d/o
Seizure d/o: both seizures and AEDs can cause fetal malformations, pregnancy is a seizure state
Etiology: either AED metabolism, pt compliance, seizure threshold, or hormonal changes
AED teratogenicity: folate antagonism NTDs, epoxide generation (fetal hydantoin syndrome)
Sz d/o management:
Heart disease
High-risk heart dz: primary PH, Eisenmenger syndrome, severe MS or AS, Marfan syndrome
Marfan syndrome: AD fibrillin elastic tissue dysfxn MVP, aortic aneurysms (cystic medial necrosis), or aortic dissection
Heart dz management: terminate pregnancy (first line)
baseline EKG + medical stabilization
d/c teratogenic drugs (ACEI/ARBs, diuretics, coumadin)
if severe MS/AS surgical or valvuloplasty repair (1 yr prior)
if delivering early epidural, careful fluid monitoring, assisted vaginal delivery, abx ppx for SBE
Peripartum cardiomyopathy: dilated cardiomyopathy 2/2 pregnancy, presents w/ sx of CHF (dyspnea/orthopnea/PND)
PPCM management: Dx echo shows dilated heart w/ EF <40% deliver if 34 wk, medical mgmt if <34 wk
Renal disease
Coagulation d/o
Coagulation d/o: pregnancy is a hypercoagulable state; increased risk for SVT, DVT, PE
Virchows triad: risk of blood clots w/ stasis, hypercoagulability (pregnancy), endothelial damage
Coagulation d/o
SVT
DVT
PE
Presentation
painful, palpable, venous cord w/ local erythema
and edema
acute onset dull leg pain, unilateral swelling, and
Homans sign (calf pain w/ dorsiflexion)
acute onset chest pain, dyspnea, and
hyperventilation (PCO2); right-sided heart failure
MCC maternal death
Management
Tx warm compresses + analgesics
Dx duplex U/S Tx heparin or
Lovenox (enoxaparin); warfarin is
contraindicated in pregnancy
Dx D-dimer to r/in, V/Q scan to r/o
Tx heparin or Lovenox; t-PA if <3
hrs and no contraindications
Hyperthyroidism
Hyperthyroidism: Graves disease (MCC), toxic adenoma (#2), toxic multinodular goiter (#3)
Graves disease (diffuse toxic goiter): autoimmune disease due to IgG against TSH-R causing exophthalmos, pretibial myxedema, and
hyperthyroidism; more common in women
Thyroid storm Tx: -blockers
Hyperthyroidism management: screen for TSIs if elevated, Tx PTU + monitor fetus for goiter and IUGR
Infantile hyperthyroidism: maternal TSI (IgG) crosses placenta and attacks fetal thyroid gland
Hypothyroidism
OB 11 Pregnancy Complications
SLE
Neonatal lupus
Substance abuse
Neonatal lupus syndrome: maternal ag-ab complexes cross placenta and cause lupus in neonate
Congenital heart block: anti-Ro (SSA) can cross placenta and attack fetal heart 3 heart block
Substance
Alcohol
Caffeine
Cocaine
Nicotine
Opiates (heroin,
methadone)
Presentation
Fetal Alcohol Syndrome: abnormal facies,
IUGR, MR, cardiac teratogenic effects
risk of SAB w/ >150 mg/day
placental abruption, MR
IUGR, placental abruption, preterm
delivery, fetal death
no teratogenic effects w/ opiate abuse; but
withdrawal can cause miscarriage, preterm
delivery, fetal death
Management
stop use
reduce to <150 mg/day
stop use
stop use
enroll in methadone program
(opiate withdrawal is worse for
fetus than chronic abuse)
OB 12 Postpartum
Postpartum care
Postpartum
contraception
Postpartum
hemorrhage
Postpartum fever
Postpartum fever: consider endometriitis, acute mastitis, and the 5 Ws Wind (atelectasis POD #1)
Water (UTI POD #3)
Walking (DVT POD #5)
Wound infx (POD #7+)
Wonder drug (drug-induced fever)
Disease
Endometritis
Acute mastitis
Atelectasis
UTI
Urosepsis
DVT
Wound cellulitis
Wound abscess
Wound
dehiscence
Postpartum mood
changes
Presentation
polymicrobial infx fever, uterine tenderness,
foul-smelling lochia
breastfeeding women get Staph/Strep infection
through cracks in nipple w/ yellowish discharge
partial lung collapse
Management
Tx clindamycin + gentamicin
Tx dicloxacillin, do not stop breastfeeding
Dx bilateral inspiratory crackles;
prevent with pulmonary toilet and
incentive spirometry
Dx UA/UCx, Tx Cipro or Bactrim
Dx UA/UCx, Tx empiric abx + IVF
Dx duplex U/S Tx IV heparin or
Lovenox
Tx Bactrim or Keflex
Tx I+D and BID dressing change
Tx stabilize wound site, surgical
closure at a later date
Postpartum mood d/o: three types blues (30-70%), depression (10-20%), psychosis (0.1%)
Postpartum blues: self-resolves by day 10
Postpartum depression: Tx SSRIs (sertraline)
Postpartum psychosis: admit and consult psych
GYN 1 Lower GU
Vulva/vagina
congenital anomalies
Labial fusion: due to excess androgen exposure (MC overall) or to 21-hydroxylase deficiency (MC endogenous)
Excess androgens: Tx d/c androgens + reconstructive surgery
21-OH deficiency: Dx 17-OHP Tx cortisol + reconstructive surgery
Imperforate hymen: presents as primary amenorrhea + cyclic abdominal pain; Dx mucocolpos/hematocolpos Tx surgery
Transverse vaginal septum: presents as primary amenorrhea + cyclic abdominal pain; Dx short vagina that ends in blind pouch Tx surgery
Imperforate hymen vs. septum: presence of hymenal ring indicates transverse vaginal septum
Vaginal atresia: failure of lower vagina to develop, presents as primary amenorrhea + cyclic abdominal pain; Dx U/S or MRI Tx surgery (pull-through)
Vaginal agenesis: aka MRKH syndrome, absence of vagina w/ partial uterus and tubes; Tx surgery (create neovagina w/ McIndoe procedure)
Vulvar/vaginal
epithelial disorders
Presentation
vaginal thinning and atrophy in postmenopausal
women, 10% associated w/ cancer
chronic irritation pruritis w/ hyperkeratotic
changes
chronic irritation pruritis w/ reactive changes
shiny purple papules vaginal adesions
silvery scaling plaques, Auspitz sign (bleeding when
plaques are removed)
red spots/patches in upper 1/3 vagina due to DES
exposure in utero; precursor for clear cell adeno
vaginal dryness bleeding in postmenopausal
women
Tx
topical steroids
topical steroids
topical steroids
steroid suppository +
surgery for adhesions
topical steroids or UV
light
close f/u
topical estrogen
Vulvar/vaginal cysts
Epidermal inclusion cysts: MC vulvar cyst, due to blocked hair follicle; Tx I+D or excision if infected
Sebaceous cysts: due to blocked sebaceous gland, often multiple and asx; Tx I+D if infected
Apocrine cysts: due to blocked apocrine sweat glands; found only on groin and axillary region
Hidradenitis suppurativa: superinfx of apocrine cysts abscess formation; Tx I+D or excision
Fox-Fordyce disease: multiple pruritic apocrine cysts
Skene cysts: appear at 12-oclock
Bartholin cysts/abscess: appear at 4- and 8-oclock
Bartholin management: usually self-resolves; if >40 y/o bx to r/o cancer; if large/symptomatic I+D w/ Word catheter or marsupialization
Gartner duct cysts: remnant of mesonephric (Wolffian) ducts; Tx excision
Cervical lesions
DES-associated anomalies: vaginal adenosis, clear cell adenocarcinoma, other cervical or uterine anomalies
Nabothian cysts: benign; occurs when ectocervix (strat squamous) overgrows endocervix (simple columnar)
Cervical endometriosis: reddish-purple, presents w/ sx of endometriosis (dyspareunia/dyschezia/dysmenorrhea)
Cervical polyps: benign; Tx removal if symptomatic, and to avoid masking bleeding from other sources
Cervical fibroids: benign; Tx removal if symptomatic, and to avoid masking bleeding from other sources
Cervical stenosis: Tx cervical dilataion
GYN 2 Upper GU
Uterine anatomic
anomalies
Uterine anomalies: septate uterus (#1), bicornuate uterus, uterus didelphys; associated w/ urinary tract anomalies and inguinal hernias
Etiology: problems in fusion of paramesonephric (Mullerian) ducts
Sx: amenorrhea, dysmenorrhea, infertility, recurrent pregnancy loss (2nd trimester), PTL
Management: Dx imaging (pelvic U/S, CT, MRI, HSG, etc.) leave alone if asx
Tx surgery for septate uterus and bicornuate uterus
Leiomyoma
(uterine fibroids)
Endometrial polyps
Endometrial
hyperplasia
Ovarian cysts
high-risk
(premenarchal, postmenopausal,
size >8 cm, or persists >60 days)
Dx pelvic U/S
Endometriosis
Adenomyosis
UTI
Bug
Candida albicans
Presentation
thick, white curd-like discharge,
itching, satellite lesions, no odor
Syphilis
Treponema pallidum
HSV
HSV-1/2
Chancroid
Haemophilus ducreyi
LGV
Chlamydia trachomatis,
L1-L3 serotypes
Condyloma acuminata
Molluscum contagiosum
HPV-6/11
MCV
Trichomoniasis
Trichomonas vaginalis
Gonorrhea
Neisseria gonorrhoeae
Chlamydia
Chlamydia trachomatis
Management
Dx budding yeast + pseudohyphae on KOH prep Tx
fluconazole (Diflucan)
Dx screen w/ RPR-VDRL
confirm w/ FTA-ABS Tx
benzathine penicillin G
Tx IV penicillin G
Dx Tzanck smear or viral cx
Tx ACV/VACV + palliative care
Dx school of fish on Gram
stain Tx azithromycin or
ceftriaxone
Dx PE or complement fixation
Tx doxycycline
Dx PE Tx removal
Dx PE Tx removal
Dx PE Tx permethrin cream
Dx clue cells on wet prep
Tx metronidazole
Dx mobile trichomonads on
wet prep Tx metronidazole
Tx ceftriazone ( azithromycin)
Tx azithromycin ( ceftriaxone)
Jarisch-Herxheimer rxn: acute febrile rxn s/p syphilis tx (MC w/ 2 syphilis), due to dead spirochetes endotoxin release
Endometritis
PID
Tubo-ovarian
abscess
Toxic shock
syndrome
HIV
HIV: retroviral virus infects CD4+ TH cells cellular immunity AIDS-related opportunistic infx death
Primary HIV infx: presents as mono-like syndrome maculopapular rash
Latent stage: CD4+ >500, asymptomatic
Symptomatic stage: CD4+ 200-500, mild HIV sx
AIDS: CD4 + <200 or presence of AIDS OI
Transmission: sexual, parenteral, vertical or via breast milk
Management: Dx ELISA screen confirm w/ WB Tx HAART (2 NRTIs + 1 NNRTI or PI) + OI tx/ppx
HIV+ during pregnancy: give anti-HIV meds, elective C/S, or IV ZDV during labor
HIV+ postpartum: avoid breastfeeding
GYN 6 Prolapse
GYN 7 Incontinence
Continence
Incontinence
Definition
urine leakage w/ exertion or
straining
Urge incontinence
Mixed incontinence
Overflow incontinence
Bypass incontinence
Functional incontinence
Etiology
chronic abdominal
pressure, pelvic relaxation,
old age (estrogen loss of
mucosal coaptation)
idiopathic (MCC), UTIs,
bladder stones or cancer,
urethral diverticula, foreign
bodies
--medications, neurologic
disease
vesicovaginal, urethrovaginal,
or ureterovaginal fistulas
physical impairment,
dementia or delirium,
medications
Management
surgery to stabilize
hypermobile urethra (best),
Kegel exercises, pessaries
anticholinergics (oxybutinin),
TCAs (imipramine)
--intermittent self-cath,
cholinergics (bladder
contactility) + 1-blockers
(urethral resistance)
Dx methylene blue or indigo
carmine dye Tx surgery to
repair fistula
Tx underlying cause
Puberty
Tanner stages
Stage 1
Stage 2
Stage 3
Stage 4
Stage 5
HPO axis
Always
go
(to)
adrenarche gonadarche
the
thelarche
at 7 y/o
at 10 y/o
at 8 y/o
---
pub,
men.
pubarche/ menarche
peak growth
at 11 y/o
at 12 y/o
kid
breast buds
breast elevation
areolar mound (look 4 big nipples)
adult
GnRH
DA
TRH
FSH/LH
PRL
TSH
E2/P4
stimulates
inhibits
T3/T4
Ovarian follicle:
Endometrium:
Hormones:
Theca/granulosa cells
Menopause
Menopause: cessation of menses and estrogen-deficient state for >12 months; avg age is 51 y/o
Sx: HAVOC hot flashes, atrophy of vagina, osteoporosis, coronary artery dz
Management: Dx FSH, Tx lowest dose HRT (estrogen + progesterone) for only 6-12 months
HRT benefits: prevention of osteoporosis, relief of menopausal sx
HRT risks: risk of endometrial hyperplasia/cancer
HRT contraindications: h/o clotting dz, liver dz, pregnancy, estrogen-dependent neoplasm, undiagnosed vaginal bleeding
GYN 9 Amenorrhea
Amenorrhea
1 amenorrhea
1 amenorrhea labs:
1 amenorrhea?
uterus
(lacks MIF)
vagina
no uterus
(MIF present)
no vagina
Dx karyotype ...
(46/XY females)
outflow tract
breasts no breasts obstruction
(E present) (lacks E)
P challenge
2 amenorrhea
P challenge negative
prolactin normal
TSH normal
TSH
Tx Synthroid
head CT or MRI
P challenge test
negative
r/o Asherman syndrome
and cervical stenosis
FSH >40
positive
FSH <40
hirsute
Tx surgery
nonhirsute
mild hypothalamic
dysfunction
Dysmenorrhea: pain and cramping during menstruation that interferes w/ normal activity
1 dysmenorrhea: PGF2 uterine ctx dysmenorrhea w/o organic cause; Tx NSAIDs and/or COCs
2 dysmenorrhea: dysmenorrhea 2/2 endometriosis, adenomyosis, fibroids, cervical stenosis, pelvic adhesions
Cervical stenosis: surgical or obstetric trauma scarring of cervical os; Tx surgical dilation or laminaria
Pelvic adhesions: infx (PID), inflammation, or prior surgery scarring of endometrium; Dx/Tx laparoscopy
PMS/PMDD
AUB
PMS/PMDD: luteal phase sx (HA, bloating, weight gain, dysphoric mood) for 2+ consecutive cycles
Etiology: interaction between 5-HT and E/P
Management: Dx menstrual diary Tx SSRI/SNRI, Xanax (alprazolam), Yaz OCP (E + drospirenone), diet and exercise
AUB
Normal menses
Menorrhagia
Hypomenorrhea
Metrorrhagia
Menometrorrhagia
Oligomenorrhea
Polymenorrhea
DUB
Pattern
3-5 days Q 4 wks, 30-50 mL/cycle
heavy flow
light flow
irregular timing
heavy flow + irregular timing
slow cycles (>5 wks, <6 months)
fast cycles (<3 wks)
heavy or irregular bleeding w/o
identifiable cause, dx of exclusion
MCC
--cervical or endometrial lesions
hypogonadotropic hypogonadism in athletes/anorexics
cervical or endometrial lesions
cervical or endometrial lesions
anovulation, PCOS, pregnancy, thyroid dz
anovulation
anovulation
AUB management: Dx labs (-HCG, TSH, prolactin, FSH) + endometrial bx (>35 or obese) + pelvic U/S; Tx the underlying cause
Fibroids: Tx myomectomy vs. hysterectomy
Adenomyosis: Tx NSAID/OCP vs. hysterectomy
Cervical polyps: Tx polypectomy
Endometrial polyps: Tx hysteroscopy vs. polypectomy D+C
Endometrial hyperplasia: Tx progestins vs. hysterectomy
Endometrial cancer: Tx hysterectomy + BSO + radiation
Pregnancy: Tx expectant management vs. delivery
Miscarriage: Tx expectant management vs. D+C
Ectopic pregnancy: Tx MTX vs. surgery
Hypothyroidism: Tx Synthroid
Hyperprolactinemia: Tx bromocriptine or cabergoline
Anovulation: Tx cyclic OCP or progestins
DUB
chronic DUB
Tx 25mg IV estrogen
Tx NSAIDs + COC
(POP if estrogen c/i)
GYN 11 Hirsutism/Virilization
Hirsutism vs.
virilization
Hirsutism labs
Hirsutism diseases
Theca-lutein cysts
Stromal
hyperthecosis
Sertoli-Leydig cell
tumors
Exogenous
hirsutism
Idiopathic hirsutism
Mechanism/presentation
excess production of cortisol from pituitary adenomas,
adrenal tumors, or paraneoplastic syndromes
congenital deficiency of 21-hydroxylase (MC), 11hydroxylase, or 3-HSD
Rotterdam criteria: 2/3 of the following polycystic
ovaries on U/S, anovulation, signs of hyperandrogenism
LH or HCG (pregnancy, moles) bilateral ovarian
cysts possible androgen production
ovarian hyperplasia in postmenopausal women
possible androgen production
androblastoma, secretes testosterone
due to drug use
absence of adrenal or ovarian causes, not drug-induced
Management
Dx cortisol dexamethasone
suppression test to confirm Tx surgery
Dx DHEAS + 17-OHP Tx cortisol
replacement, consult endocrinology
Dx LH:FSH ratio >3:1 + estrone Tx
OCPs, clomiphene, metformin, weightloss; and screen for fasting blood sugars
Dx ovarian bx should resolve
postpartum or s/p mole removal
Dx ovarian bx
Dx pelvic U/S Tx unilateral salpingooophrectomy
Tx d/c meds
Dx normal T and DHEAS look for
increased peripheral 5-R activity Tx
finasteride (5R blocker) if elevated
GYN 12 Contraception
Contraception
and sterilization
Method
COC
Mechanism
blocks LH surge, thickens
cervical mucus, slows tubal
peristalsis, creates hostile
environment
Failure rate
~1%
Benefits
normalizes cycles
cervical and
ovarian cancer
benign breast dz
dysmenorrhea
PID
acne
Risks
$30/month
hypercoagulability
hepatic adenoma
Contraindications
smokers >35, clotting
dz (PE, DVT, stroke,
CAD), uncontrolled
HTN, migraines w/
aura, CHF, estrogendependent cancers,
pregnancy, liver dz
Ortho Evra
---
0.3%
indicated for
lactating women
indicated for
women >40 y/o
---
Depo-Provera
0.3%
effective
Implanon
---
Condoms
~5%
---
-----
Cervical caps
~10% nullip
~25% multip
low cost
Nonoxynol-9,
octoxynol-9
Mirena IUD
(levonorgestrel)
spermicide
20-30%
<1%
used in combo w/
other methods
indicated for
monogamous pts
good for 5 yrs
low maintenance
menstrual flow
toxic shock
syndrome
UTIs
must leave inside
6-8 hrs after sex
needs to be fitted
by MD
failure rate
needs to be fitted
by MD
must have nl Pap
STI susceptibility
pregnancy, uterine
anomalies, infx,
unresolved vaginal
bleeding, breast
cancer
ParaGard IUD
(copper-T)
<1%
indicated for
monogamous pts
good for 10 yrs
low mainenance
Natural family
planning
~20%
free
self-managed
---
free
---
90% effective
not abortifacient
~1%
99% effective
~1%
99% effective
more reversible
than tubal ligation
safer and more
effective than tubals
ratio of ectopics
cramping
needs to be placed
by MD
risk of PID, uterine
perforation, SAB
menstrual flow
ratio of ectopics
cramping
needs to be placed
by MD
risk of PID, uterine
perforation, SAB
failure rate
variability
between cycles
failure rate
only use for max
of 6 months
nausea/vomiting
headache
breast tenderness
permanent
surgical risks
risk of regret (1015%)
no STD protection
permanent
surgical risks
no STD protection
must wait 3
months before sex
NuvaRing
POP
Diaphragms
Lactational
amenorrhea
Emergency
contraception
Tubal ligation
Vasectomy
~5%
---
---
---
---
pregnancy, uterine
anomalies, infx,
unresolved vaginal
bleeding, copper
allergy or Wilson dz
---
>5 days
GYN 13 Abortion
1st trimester abortion: suction D+C (MC), manual vacuum extraction, medical abortion (7 wk)
MCC death during abortion: general anesthesia
Suction D+C: 90% of all abortions, safest method, most effective 7-13 wk
Medical abortion: indicated 7 wk only, requires f/u in 2 wks for -HCG levels
Mifepristone (RU-486): blocks progesterone stimulation embryo detachment
Methotrexate: blocks DHF reductase cell division blocks placental proliferation
Misoprostol: ripens cervix; use w/ MTX or RU-486 to efficacy rates
Side-effects: abd pain/cramps, uterine bleeding, nausea/vomiting
2nd trimester abortion 2nd trimester abortion: D+E or induction of labor (IOL is better, since intact fetus can be used for autopsy)
D+E: like D+C, but requires wider cervical dilation + use of special forceps to extract fetal parts
Complications: trauma, infx, retained tissue, uterine perforation
Induction: cervical ripening w/ misoprostol (Cytotec) amniotomy induction w/ high-dose oxytocin (Pitocin)
Complications: trauma, infx, retained tissue
3rd trimester abortion
3nd trimester abortion: illegal 24 wk, unless necessary for preservation of maternal life
GYN 14 Infertility
Infertility
Female factor
infertility
Category
Ovarian factors
Disease
PCOS
Tubal factors
Uterine factors
Cervical factors
Tubal ligation
Asherman syndrome
Polyps
Submucosal fibroids
Congenital malformations
Endometritis
Cervical stenosis
Chronic cervicitis
DES exposure
Congenital malformations
Tx
OCPs, clomiphene, metformin, weight-loss, and screen for
fasting blood sugars
ART
ART
cabergoline or bromocriptine
Synthroid
surgical ablation (if fertility desired)
hysterectomy + LOA + removal of implants (definitive)
surgery (lysis of adhesions)
IV clindamycin + gentamicin (pregnant)
IV ceftriaxone + doxycycline (not pregnant)
IVF/ICSI
hysteroscopic lysis of adhesions + estrogen
hysteroscopic polypectomy
hysteroscopic myomectomy
surgery, may not be treatable
IV clindamycin + gentamicin
cervical dilation or IUI
IVF/ICSI
none
surgery, may not be treatable
Male factor
infertility
Male factor infertility: 3 categories sexual problems, endocrine d/o, sperm abnormalities
Management: stay away from risk factors (drugs, radiation, heat) + Tx underlying cause
Unexplained
infertility
Assisted reproductive ART: any therapy where sperm/egg are handled for increasing rate of conception
technologies
Clomiphene: blocks E-receptors in hypothalamus FSH/LH promotes ovulation
Indications: chronic anovulation, hypothalamic insufficiency
Letrozole: aromatase inhibitor E FSH/LH promotes ovulation
HMGs: FSH/LH analogs promotes ovulation
Indications: second line to Clomid
Complications: antiestrogen effects, ovarian hyperstimulation syndrome (OHSS), multiple gestation
OHSS: overstimulation of ovaries risk of torsion or rupture
IVF: insert fertilized gamete into uterus
ICSI: inject sperm into oocyte before IVF
Squamous neoplasia
Squamous neoplasia: defined by depth of epithelial involvement (xIN if not invasive, SCC if invasive)
Risk factors: multiple sexual partners (#1), sex at young age, high-risk HPV strains, smoking, immunosuppression, other xINs
VIN
Vulvar SCC
TNM criteria
<2 cm, <1 mm depth
<2 cm, >1 mm depth
>2 cm
LN+ or local spread (lower urethra, distal vagina, anus)
IVa
IVb
Tx
wide local excision + ipsi LN-ectomy
"
radical vulvectomy + bilat LN-ectomy
radical vulvectomy + bilat LN-ectomy +
pelvic exenteration
"
"
Vaginal SCC
Vaginal SCC: malignant dz of vaginal epithelium, usually in upper 1/3 and posterior wall
Sx: usually asx but can have vaginal discharge, itching, or bleeding
Management: Dx colpo-directed bx + check for spread (CXR/cystoscopy/proctosigmoidoscopy/IVP) Tx (see below)
Stage
0
I
II
III
IVa
IVb
TNM criteria
carcinoma in situ
within vaginal wall
spread into subvaginal tissue
spread into pelvic wall
local met+ (bladder or rectum)
distal met+
Tx
surgical resection
"
radiation tx
"
"
"
Extramammary
Paget disease
Paget disease: red, velvety lesions + scarred white plaques; 20% associated w/ underlying adenocarcinoma
Paget vs. melanoma: Paget halo cells are PAS+, mucicarmine+, Alcian blue+; melanoma cells are PASSx: classic presentation is vulvar itching and pain in women >60 y/o
Management: Dx vulvar bx Tx wide local excision + r/o underlying adeno
Px: high local recurrence rate, fatal if LN+
Sarcoma botryoides
Sarcoma botryoides: embryonal rhabdomyosarcoma, resembles grape-like mass protruding from vagina in girls <5 y/o
Management: Dx bx shows desmin+ spindle-shaped rhabdomyoblasts, Tx excision
HPV
Pap smears
Pap smear: scrape transformation zone w/ spatula, then sample endocervical canal w/ brush
Screening protocol: start age 21, Q2 yrs 21-29 y/o, Q3 yrs >30 y/o after 3 negative Paps
Exceptions: annual if HIV, immunosuppressed, DES, previous CIN II+; dont need s/p total hysterectomy
Bethesda system
Pap result
ASC-US
Definition
atypical squamous cells, undetermined significance
ASC-H
LSIL
HSIL
SCC
AGC
Management
HPV DNA testing repeat Pap in 1 yr if
HPV, colpo + cervical bx if HPV+
colpo + cervical bx
"
"
"
"
Diagnostic cone bx
Cone indications:
Microinvasion <3mm
ECC positive
Discrepancy of 2 steps (high-grade Pap, not confirmed on bx)
Inadequate colpo (cant see all borders of TZ or lesion)
Adenocarcinoma in situ
Cone complications: bleeding or infx (common), cervical stenosis, incompetent cervix, PROM/PTL
CIN
CIN: premalignant dz of cervical epithelium due to high-risk HPV strains, three grades (CIN I-III)
MC timing: during menarche and after pregnancy
MC location: anterior lip of transformation zone, multifocal
Stage
CIN I
Definition
dysplasia in basal 1/3 of epithelium, mild
Management
repeat Pap Q 6 mo 2 or HPV testing in
12 mo (65% regression rate) LEEP if
persistent for 2 yrs
LEEP
LEEP
diagnostic cone bx
CIN II
dysplasia in basal 2/3 of epithelium, moderate
CIN III
dysplasia >2/3 to full epithelium, severe
2-step discrepancy (e.g. HGSIL on pap but normal bx)
Cervical SCC
TNM criteria
carcinoma in situ
cervix only,<7 mm
cervix only, >7 mm or visible lesion
involves upper 2/3 vagina, no parametrium
involves upper 2/3 vagina, parametrium
IIIa
IIIb
IVa
IVb
Tx
simple hysterectomy or cold knife cone
"
radical hysterectomy or radiation tx
"
chemoradiation (external and internal
radiation + cisplatin chemotherapy)
"
"
Px (5 yr)
-->80%
"
60%
"
"
"
20%
"
40%
"
Endometrial
hyperplasia
Endometrial cancer
Etiology
E-dependent neoplasm preceded by hyperplasia
E-independent neoplasm, not preceded by
hyperplasia (papillary serous or clear-cell)
%
80%
20%
Race
white
black,
asian
Age
perimenopausal
postmenopausal
Px
good
bad
TNM criteria
uterus, endometrium only
Ib
uterus, <50% myometrial invasion
Ic
uterus, >50% myometrial invasion
IIa
endocervix, glands only
IIb
endocervix, stroma
IIIa
in serosa
IIIb
in vagina
IIIc
pelvic/paraaortic LN+
IVa
spread beyond true pelvis, or in bladder or rectum
IVb
distal met+
Pelvic recurrence
Vaginal recurrence
Tx
TAHBSO pelvic/paraaortic LN-ectomy
and radiation (if high-risk)
"
"
"
"
"
"
"
"
"
High-dose progestins chemotherapy
Vaginal radiation
Px: grade is #1 factor; three grades G1 shows <5% solid growth pattern, G2 6-50%, G3 >50%
High-risk endo cancers: >50% myometrial invasion
type 2 (papillary serous or clear-cell)
grade 3 (>50% solid growth)
stage 3+
size >2 cm
LN+
Ovarian cancer
Ovarian cancer: four types epithelial (90%), germ cell, sex-cord stromal, metastatic
Sx: asx in early stages; present w/ vague abd pain, bloating, distention, early satiety in later stages
Etiology: chronic uninterrupted ovulation cellular repair opportunities for gene deletion/mutation
CA-125: ovarian tumor marker useful for testing tx response and recurrence, but not screening or dx
Risk factors: family hx (#1), familial ovarian cancer syndrome, uninterruped ovulation, old age
Familial ovarian cancer syndrome: BRCA1/2, HNPCC (Lynch II)
Uninterrupted ovulation: nulliparity, infertility, early menarche, late menopause
Protective factors: OCPs, multiparity, breastfeeding, chronic anovulation (all ovulation)
Management: Dx pelvic U/S stage Tx (see below)
Stage
Ia
Ib
Ic
IIa
IIb
IIc
IIIa
IIIb
IIIc
IV
TNM criteria
one ovary
two ovaries
Ia/Ib + ovarian surface tumor, ruptured capsule, malignant ascites, or peritoneal cytology+
invades FT or uterus
invades other pelvic tissue
IIa/IIb + ovarian surface tumor, ruptured capsule, malignant ascites, or peritoneal cytology+
abd peritoneal met+, <2 cm
abd peritoneal met+, >2 cm
pelvic/paraaortic/inguinal LN+
distal met+
Class
Epithelial
Germ cell
Sex-cord stromal
Tx
surgery (TAHBSO, omentectomy, pelvic/paraaortic LN-ectomy) + carboplatin/paclitaxel
USO + BEP (bleomycin/etoposide/cisplatin)
USO only
Ovarian cancer
complications
Carcinomatous ileus: intraperitoneal tumor spread ascites and bowel encasement intermittent bowel obstruction
Sister-Mary-Joseph nodule: ovarian cancer metastasis to umbilicus
Pseudomyxoma peritonei: jelly belly associated w/ appendiceal carcinoma and mucinous cystadenocarcinoma
Meigs syndrome: fibroma + ascites + right-sided hydrothorax
Latzko triad: pain, profuse watery d/c, pelvic mass; associated w/ FT adenocarcinoma
Precocious puberty: granulosa cell tumor
Epithelial tumors
Epithelial tumors: slow growing and usually asx, thus found at stage III+
MC type: serous cystadenocarcinoma
Serous cystadenoma: bilateral, lined w/ FT-like epithelium
Serous (papillary) cystadenocarcinoma: bilateral, Dx Psamomma bodies
Mucinous cystadenoma: multilocular cyst lined w/ mucus-secreting epithelium
Mucinous cystadenocarcinoma: pseudomyxoma peritonei
Endometrioid carcinoma: resembles endometrial cancer, good px
Clear cell carcinoma: masses of glycogen-filled clear cells, poor px
Brenner tumor: benign, resembles bladder (transitional epithelium)
Psammoma body
Germ cell tumors: rapidly growing in women <20 y/o, thus found at early stages
MC type: mature teratoma aka dermoid cyst (MC overall), dysgerminomas (MC malignant)
Teratoma: tumor of totipotent fetal tissue
Mature teratoma: benign, contains hair/teeth/calcifications
Immature teratoma: aggressively malignant, contains neural tissue
Struma ovarii: monodermal, contains thyroid tissue
Dysgerminoma: LDH, associated w/ Turner syndrome (45/XO), good px due to radiosensitivity
Endodermal sinus (yolk sac) tumor: AFP, Dx Schiller-Duval bodies resembling primitive glomeruli
Choriocarcinoma: -hCG, also a malignant type of GTD
Schiller-Duval body
Sex-cord stromal
tumors
Metastatic tumors
FT cancer
FT adenocarcinoma: very rare (0.5%), mets to FT are more common than primary FT cancer
Sx: 15% present as Latzkos triad Pain, Profuse watery discharge (hydrops tubae profluens), Pelvic mass
Management: Dx pelvic U/S Tx same as epithelial ovarian cancers
Call-Exner body
GTD
Benign GTD
Malignant potential
Management
Malignant GTD
Choriocarcinoma
malignant, necrotizing tumor
Presentation
Management
presents w/ sx of metastasis
(lungs, vagina, liver, brain,
kidneys)
Dx -hCG and pelvic U/S
check for mets Tx singleagent chemo (non-met or
low-risk), multi-agent chemo
(high-risk) f/u serial -hCG
and reliable contraception for
6 months
Etiology
PSTTs
rare tumors that arise
from placental invasion
site, have no villi
presents as abnormal
vaginal bleeding
Dx -hCG (persistently
<100) and pelvic U/S
Tx hysterectomy + multiagent chemo
Breast anatomy
and physiology
Blood supply: internal mammary (off subclavian) + lateral thoracic (off axillary) arteries
Lymph drainage: axillary LN (97%) + internal mammary LN (3%)
Estrogen: promotes ductal development + fat deposition
Progesterone: promotes lobular-alveolar (stromal) development
Prolactin: promotes milk production
Oxytocin: promotes milk letdown, uterine ctx
Breast pain
h/o trauma
reassurance, NSAIDs,
sports bra, compresses
high-risk
U/S
mammogram
Nipple discharge
Breast cancer
Incidence: 1 in 8 women
Screening: annual mammogram (>50, >40 if strong family hx); monthly self-exam + annual physician exam (>20)
Risk factors: family hx (#1), previous breast cancer, old age, BRCA1 and BRCA2 genes (only 5-10% are genetic)
MC location: upper outer quadrant (has most breast tissue)
Mets sx:
bone pathologic fx, back pain, coma (hypercalcemia)
liver jaundice, elevated LFTs
lung dyspnea, cough, hemoptysis
brain severe HA, seizures
pleura pleuritic chest pain
Breast masses
MC breast masses:
<25 y/o
fibroadenoma
25-50 y/o fibrocystic change
>50 y/o
infiltrating ductal carcinoma
Benign masses: soft/rubbery, smooth surface, mobile, painful, <50 y/o
Malignant masses: firm/hard, irregular surface, fixed, painless, >50 y/o
Breast mass management:
Breast mass?
<30 y/o
30 y/o
Nonpalpable abnormal
mammogram finding?
U/S
cystic
solid
wire-guided excision
needle drainage
resolves
f/u in 4 wks
BI-RADS
Cat
0
1
2
3
4
5
6
Definition
incomplete
negative
benign
probably benign
suspicious of malignancy
probably malignant
malignant
FNA
bloody/recurrent
core needle bx
mammogram +
core needle bx
excisional bx if
nondiagnostic
Management
additional imaging needed
routine f/u
routine f/u
short-term f/u (6 mo)
core needle bx
core needle bx
tx
Risk of malignancy
--0%
0%
2%
2-95%
95%
100%
Benign tumors
Fibroadenoma: firm, mobile, rubbery mass <5 cm in young women; Tx elective removal
Giant juvenile fibroadenoma: 5 cm, seen in teens with rapid breast growth; Tx excision to avoid breast deformity
Intraductal papilloma: presents as bloody nipple discharge; Tx galactogram/ductogram-guided excision (due to small risk of carcinoma)
Phyllodes tumor: huge, benign tumors that distort the breast; Dx core or incisional biopsy since FNA is insufficient, Tx excision w/ negative margins
Malignant tumors
Breast cancer Tx
Stage
I
TNM criteria
T1 (<2 cm)
II
III
IV
Tx
lumpectomy + ALND/SLN + post-op radiation;
or modified radical mastectomy
"
chemotherapy
"
Fibrocystic change: painful, multiple/bilateral lumps that vary with menstrual cycle; Tx reduction in tea/caffeine/chocolate
Dominant lump: Tx aspiration excision if mass recurs or persists
Atypical ductal hyperplasia: Tx excision; not precancerous, but high risk of becoming a cancer
Acute mastitis: breastfeeding women get Staph/Strep infection through cracks in nipple w/ yellowish discharge, Tx dicloxacillin + continue breastfeeding
Periductal mastitis: subareolar infection in smokers, both males and females affected
Breast abscess: pus pocket in lactating women; Tx I&D + biopsy to r/o possible cancer
Mammary duct ectasia: bilateral breast pain and green/sticky discharge in perimenopausal women; Tx excision + biopsy to r/o possible cancer
Dystrophic calcification: presents as breast lump following trauma, but work up as a cancer until proven otherwise (trick question!)
INTERNAL MEDICINE
MEDICINE CV
ISCHEMIC HEART DZ
Presentation
substernal gripping chest
pain or pressure on exertion,
relieved w/ rest or NTG
unstable angina
+biomarkers
NSTEMI
+EKG change
STEMI
Unstable angina: ruptured
atherosclerotic plaque
increasing pain or pain at rest
NSTEMI/STEMI: ruptured
atherosclerotic plaque
typical MI-pattern chest pain;
can be asx in elderly, diabetics,
women, s/p heart txp
CARDIAC DRUGS
Management
EKG
normal
abnl ST or T-wave
positive
negative
catheterization
close f/u
Other
Positive stress test: chest pain,
ST depression, hypotension, or
significant arrhythmias
Pharmacological stress test: IV
adenosine, dipyridamole, or
dobutamine can stress the heart
in place of exercise
Coronary steal: dipyridamole
causes blood flow redistribution
to nondiseased vx in stress test
MEDICINE CV
ARRHYTHMIAS
Arrhythmia
PAC
PVC
EKG tracing
early P wave that looks differently than other P waves
wide QRS without preceding P wave
AFib
AFlutter
MAT
Management/Other
reassurance
no risk factors reassurance
recurrrent PVCs w/ underlying
heart dz implantable defib
Couplet: 2 PVCs
Bigeminy: sinus beat + PVC
Trigeminy: sinus beat + 2 PVCs
acute, stable anticoagulate +
rate control w/ Ca-blockers
then cardioversion
acute, unstable immediate
cardioversion
chronic anticoagulate +
rate control w/ Ca-blockers
(same as AFib)
Tx improve oxygenation
Etiology: end-stage COPD (MCC)
Tx IV adenosine if stable,
cardioversion if unstable
PSVT
HR > 200
Tx ablation
WPW syndrome
VTach
VFib
Sinus bradycardia
3 AV block (complete)
MEDICINE CV
MYOCARDIAL DZ
Dz
DCM
Presentation
contractility CHF sx
HCM
RCM
PERICARDIAL DZ
Other
Etiology: MI (MCC), infx, alcohol,
doxorubicin (Adriamycin), etc.
Etiology: most are autosomal
dominant, few are sporadic
Myocarditis
Dz
Acute pericarditis
Presentation
pleuritic positional chest pain
(relieved by leaning forward),
pericardial friction rub; can lead
to pericardial effusion and
cardiac tamponade
fibrous pericardial scarring
systemic venous pressure
edema, ascites, hepatic
congestion, JVD, pericardial
knock, Kussmaul sign
muffled heart sounds, soft PMI,
pericardial friction rub
Management
Dx EKG (diffuse ST elevation + PR dePRession)
Tx NSAIDs
Constrictive pericarditis
Pericardial effusion
Cardiac tamponade
VALVULAR DZ
Management
Dx echo + CXR
Tx for CHF + heart txp (MC indication)
Dx echo + family hx
asx avoid exercise
sx -blockers vs. myomectomy vs.
pacemaker implantation
Other
Etiology: coxsackie B virus (MCC)
Dressler syndrome: post-MI
pericarditis, feels like a second
heart attack; Tx NSAIDs
Constrictive pericarditis vs.
tamponade: pericarditis fills
rapidly then stops suddenly,
tamponade fills slowly throughout diastole
Etiology: acute pericarditis
(MCC)
Presentation
loud S1, opening snap w/ late
diastolic rumble
Management
asx nothing
sx Tx balloon valvuloplasty
Other
Etiology: rheumatic heart
disease (MCC)
Mitral regurgitation
Aortic stenosis
systolic crescendo-decrescendo
murmur following opening
snap, parvus et tardus; triad
of angina, syncope, dyspnea
asx nothing
sx Tx valve replacement
Aortic regurgitation
Tricuspid regurgitation
reassurance
MEDICINE CV
ENDOCARDITIS
Marantic (thrombotic)
endocarditis
Libman-Sacks endocarditis
CONGENITAL HEART DZ
Presentation
strep throat (GAS) anti-M ab
type 2 hypersensitivity
FEVERSS fever, erythema
marginatum, valvular damage,
ESR, red-hot joints (migratory
polyarthritis), subcutaneous
nodules, Sydenham chorea
repeated episodes of rheumatic
fever scarring of mitral valve
Acute: S. aureus on normal
valves rapid onset
Subacute: dental procedures
S. viridans (or GU/GI procedures
enterococcus) on damaged
valves insidious onset
Management
Dx ASO titers
strep throat Tx PCN or erythromycin
rheumatic fever Tx steroids
Other
MC murmur: mitral regurgitation
Tx valve repair
Tx heparin (controversial)
Dx ANA
Tx underlying SLE + anticoagulate
CHD endocarditis: all CHD require amoxicillin (SBE ppx) before dental procedures
Eisenmenger syndrome: L-to-R shunts pulmonary HTN reversal of shunting late-onset cyanosis
Dz
ASD
Presentation
low-grade diastolic rumble
murmur w/ fixed split S2
VSD
PDA
continuous, machinery-like
murmur
Aortic coarctation
Management
Dx echo
asx reassurance
sx Tx surgical repair
Dx echo
asx reassurance
sx Tx surgical repair
Dx echo
infants Tx indomethacin
adults w/o Eisenmenger surgical ligation
adults w/ Eisenmenger surgery is
contraindicated
Dx CXR (rib notching + figure 3 aorta)
Tx surgical decompression
Other
Paradoxical emboli: venous clots
can travel through ASD and
cause stroke instead of PE
MEDICINE CV
ARTERIAL DZ
Aortic dissection
AAA
Management
lower BP gradually over 24 hrs w/ PO meds
lower BP by 25% in 1-2 hrs w/ IV nitroprusside
severe HA get head CT to r/o intracranial
bleeding lumbar puncture if CT is negative
Dx screen w/ CXR (widened mediastinum),
confirm w/ TEE or CT scan
type A Tx -blockers + surgery
type B Tx -blockers
Dx abdominal U/S
<5 cm close f/u vs. elective repair
>5 cm or sx Tx synthetic graft
Ruptured AAA
Peripheral vascular dz
peripheral atherosclerosis
intermittent claducation (mild),
rest pain and ischemic ulcers
(severe)
Cholesterol embolization
syndrome
Mycotic aneurysm
Luetic heart
VENOUS DZ
Presentation
BP >220/120
BP >220/120 + end-organ
damage (e.g. headache, renal
failure, pulmonary edema)
acute-onset tearing chest pain
(type A) or interscapular back
pain (type B), asymmetric BP, pt
usually in severe distress
Dx arteriogram
Tx IV heparin + surgical embolectomy (<6 hrs)
vs. amputation (>6 hrs)
Tx fasciotomy for compartment syndrome ppx
Tx supportive care
severe amputation
Other
Presentation
painful, palpable venous cord
w/ local erythema and edema
DVT
PE
Post-thrombotic syndrome
(chronic venous insufficiency)
Management
mild Tx aspirin
severe Tx aspirin + warm compresses
septic remove IV cath + give IV abx
Dx duplex U/S
Tx heparin + warfarin
PPx compression boots + early ambulation
heparin/LMWH
Dx D-dimer to r/o, spiral CT or V/Q to confirm
Tx heparin + warfarin
Tx tPA to speed up clot resolution (massive
PE, unstable, right heart failure, no c/i)
recurrent PE Tx IVC filter
Dx duplex U/S or pelvic CT scan
Tx heparin + venous thrombectomy
Tx compression stockings + leg elevation;
wet-to-dry TID for ulcers
Other
Migratory SVT: consider
pancreatic cancer (Trousseau
phenomenon)
MEDICINE CV
SHOCK
Presentation
typical shock sx (MS, BP/HR,
pale cool skin) + JVD
Hypovolemic shock
Septic shock
Neurogenic shock
CARDIAC NEOPLASMS
Dz
Cardiac metastases
Presentation
---
Atrial myxoma
Cardiac rhabdomyoma
EKG READING
Management
(initial shock management) but use dopamine
or IABP instead of IV fluids
Dx EKG + echo to find underlying cause
Tx underlying cause
(initial shock management)
hemorrhagic find and stop source of bleed
nonhemorrhagic stabilize w/ IVF + close
monitoring for improvement
(initial shock management)
Tx IV abx + IV fluids, dopamine (2nd line)
Other
Etiology: acute MI (MCC),
cardiac tamponade, tension PTX,
massive PE, etc.
Management
Dx CT scan
Tx surgical excision
Other
more common than primary
tumors (75%)
Etiology: most are sporadic, few
are autosomal dominant
Etiology: associated w/ tuberous
sclerosis
MEDICINE PULMONARY
OBSTRUCTIVE LUNG DZ
Lung volumes:
Presentation
destruction of alveolar walls
permanent alveolar dilation
pink puffers, thin w/ barrel
chest, expiration w/ pursed lips
Management
Dx spirometry shows FEV1/FVC <70%
Dx CXR shows hyperinflated lungs and
increased AP diameter (emphysema only)
<50 y/o Dx A1AT levels
Chronic bronchitis
Asthma
Bronchiectasis
Other
Etiology: smoking causes centriacinar emphysema in upper
lungs; A1AT deficiency causes
panacinar emphysema in lower
lungs in pts <50 y/o
Etiology: smoking (MCC)
MEDICINE PULMONARY
LUNG NEOPLASMS
Dz
Lung cancer
Presentation
cough, hemoptysis, dyspnea,
wheezing, recurrent PNA in
same lobe
Management
Dx CXR if suspicious, sputum cytology and
CT scan if still suspicious, bronchoscopy and
mediastinoscopy w/ biopsy (tissue is the
issue)
Other
Complications: SPHERE SVC
syndrome, Pancoast tumor
Horner syndrome, Endocrine
(paraneoplastic), Recurrent
laryngeal nerve (hoarseness),
Effusions (pleural or pericardial)
Lambert-Eaton myasthenic
syndrome (LEMS): SCLC antiVGCC antibodies myasthenia
gravis-like presentation
Paraneoplastic syndromes:
squamous cell makes PTH-rP,
SCLC makes ADH and ACTH
PLEURAL DZ
Dz
Pleural effusion
Presentation
fluid build-up in pleural space;
two types transudative (thin)
and exudative (thick)
Management
Dx CXR shows blunting of costophrenic angle
Dx thoracentesis + 4 Cs chemistry (glucose,
protein), cytology, CBC+diff, culture
transudative Tx diuretics + Na+ restriction
exudative Tx underlying disease
parapneumonic abx chest tube drainage
Empyema
PTX
Tension PTX
Mesothelioma
Dx CXR or CT scan
Tx abx + insert chest tube, evacuate pus
collection, then re-expand the lung
Dx CXR shows visceral pleura line or deep
sulcus sign
small/asx observation
large or sx Tx chest tube drainage
recurrent Tx pleurodesis (scraping vs. talc)
always get CXR after transthoracic needle
aspiration, chest tube, or central line to r/o
Dx H+P, do not get a CXR
Tx immediate needle decompression (2nd
intercostal space) + chest tube
Dx CT scan shows thick pleural walls
Tx extrapleural pneumonectomy (high rate of
morbidity/mortality)
Other
Lights criteria: pleural fluid is
exudative if any of the following
p/s protein <0.5, p/s LDH <0.6,
p LDH at upper 2/3 of normal
Pleural fluid analysis:
amylase = esophageal rupture,
pancreatitis, malignancy
milky fluid = chylothorax
purulent fluid = empyema
bloody fluid = cancer
lymphocytic fluid = TB
pH <7.2 = empyema or
parapneumonic effusion
glucose <60 = r/o RA
Etiology: Staph aureus is MCC
MEDICINE PULMONARY
INTERSTITIAL LUNG DZ
Presentation
(classic ILD sx) s/p amiodarone,
busulfan, bleomycin, MTX, or
nitrofurantoin
young black female w/
respiratory complaints,
erythema nodosum, and blurry
vision (anterior uveitis)
Histiocytosis X
Wegener granulomatosis
Churg-Strauss syndrome
Coal worker pneumoconiosis
Asbestosis
Silicosis
Berylliosis
inhalation of beryllium
sarcoidosis-like presentation
Acute form: inhalation of
antigenic agent (e.g. bird
droppings) type III and IV
hypersensitivity flu-like sx
Chronic form: (classic ILD sx)
(classic ILD sx) + fever +
eosinophilia
Hypersensitivity pneumonitis
(extrinsic allergic alveolitis)
Eosinophilic pneumonia
Goodpasture syndrome
Cryptogenic organizing
pneumonitis (COP)
infectious pneumonia-like
presentation (cough, dyspnea,
flu-like sx) but unresponsive to
abx
s/p thoracic radiation for lung or
breast cancer alveolar
thickening and pulmonary
fibrosis (classic ILD sx)
Radiation pneumonitis
Management
Tx d/c meds
Other
Dx p-ANCA
Tx steroids
---
MEDICINE PULMONARY
RESPIRATORY
FAILURE
Dz
Acute respiratory failure
Presentation
dyspnea (first sx), cough,
respiratory distress, etc.
Types: hypoxia (PaO2 <60),
hypercapnia (PCO2 >50)
Management
Dx ABG analysis
A-a
A-a nl
ARDS
VENTILATION
CO2
CO2 nl
V/Q mismatch vs. shunting
(DDx w/ supplemental O2)
hypoventilation
inspired PaO2
Other
V/Q mismatch: imbalance
between lung perfusion and
ventilation, presents as O2 but
nl CO2
Shunting: lack of ventilation in
well-perfused areas (e.g. PNA,
atelectasis); not responsive to
supplemental O2
Hypoventilation: not breathing
inspired PaO2: high altitudes
Etiology: septic shock (MCC),
aspiration pneumonia, trauma
Tracheomalacia: softening of tracheal cartilage w/ prolonged ventilation; PPx tracheostomy if ventilator-dependent for 2+ wks
PULMONARY VX DZ
Dz
Pulmonary HTN
Presentation
PA pressure >25 mmHg (rest) or
>30 mmHg (exercise)
presents as exertional dyspnea,
fatigue, chest pain, syncope
pulmonary HTN w/o identifiable
cause (a dx of exclusion)
Management
Dx loud P2 + subtle sternal lift on auscultation
Dx find the underlying cause via CXR, PFTs,
ABG, EKG, echo, catheterization
Tx underlying cause + bosentan
Dx (see above)
Tx pulmonary vasodilators (CCB) + lung txp
Cor pulmonale
Dx (see above)
Tx underlying cause + bosentan
PE
Dz
Pulmonary aspiration
Presentation
either acute onset respiratory
distress, or delayed onset of
respiratory sx (cough, SOB,
fever, tachypnea, dypsnea, etc.)
Management
Dx CXR + H+P
Tx ABCs, O2 mask, supportive care
aspiration pneumonia Tx abx
obstruction Tx bronchoscopy
Other
Other
Etiology: gastric aspirates (can
lead to ARDS), oral flora (can
lead to abscess), foreign bodies
Risk factors: MS, alcoholics,
instrumentation, esophageal d/o
MEDICINE GI
ABDOMINAL PAIN
RUQ pain:
RLQ pain:
COLON DZ
liver (hepatitis)
common bile duct (cholecystitis, cholangitis)
lungs (PE, pneumonia)
duodenum (ulcer)
bowels (appendicitis, perforated ulcer, IBD,
inguinal hernia)
male GU (testicular torsion)
female GU (ectopic, PID, ovarian cyst)
ureters (ureterolithiasis)
Dz
Colorectal cancer
Presentation
Proximal colon: bleeding
melena, iron-deficiency anemia,
fatigue, dull pain
LUQ pain:
pancreas (pancreatitis)
spleen (splenic dz)
lungs (PE, pneumonia, subphrenic abscess)
LLQ pain:
Management
>50 y/o colonoscopy screen q 10 yrs
Dx barium enema (apple core) + CEA marker
Polyps
asx
Dx colonoscopy
Tx polypectomy
Diverticulosis
Dx barium enema
Tx stool softeners (high-fiber diet, psyllium)
Diverticulitis
Angiodysplasia (vascular
ectasia, AVM)
Acute mesenteric ischemia
Ogilvie syndrome
Pseudomembranous colitis
Volvulus
Other
Risk factors: old age (>50),
villous adenomas, IBD, family hx,
low-fiber diet, major polyposis
syndromes
FAP: AD APC thousands of
polyps 100% progression to
CRC; Tx ppx colectomy
Gardner syndrome: FAP +
osteomas, soft tissue tumors
Turcot syndrome: FAP + CNS
tumors
Peutz-Jeghers syndrome:
multiple nonmalignant
hamartomas throughout GI tract
w/ pigmented spots around
mucus surfaces
HNPCC/Lynch syndrome: AD
DNA repair genes hundreds
of polyps 80% progression to
CRC
Hyperplastic polyps: MC type,
leave alone, no malig potential
Juvenile polyps: polyps in kids,
remove due to vascularity
Inflammatory (pseudo) polyps:
associated w/ UC
Adenomatous polyps: high risk
of malig potential, worst types
are large villous polyps
Complications: hypovolemic
shock, diverticulitis
Dx CT scan
first episode Tx IVF, NPO, IV abx
recurrent episodes Tx surgery
Dx colonoscopy
Tx observation (90% stop spontaneously),
colonoscopy w/ coagulation (2nd line)
Dx screen w/ LDH, confirm w/ mesenteric
angiography
Tx IVF, NPO, IV abx; intra-arterial papaverine if
arterial, heparin if venous
dead bowel Tx surgery
Dx mesenteric angiography
Tx surgical revascularization
(equivalent to MI or unstable
angina of the bowels)
MEDICINE GI
APPENDICEAL DZ
Dz
Acute appendicitis
Carcinoid tumor
STOMACH DZ
Dz
Peptic ulcer disease (PUD)
Acute gastritis
Chronic gastritis
Gastric adenocarcinoma
Presentation
lymphoid hyperplasia or fecalith
in appendix ischemia infx
and necrosis perforation
peritonitis
Nonruptured sx: umbilical abd
pain that migrates to RLQ,
anorexia, n/v
Ruptured sx: severe abd pain w/
guarding in all 4 quadrants
neuroendocrine tumor that
secretes 5-HT, most commonly
found in appendix (no systemic
effects b/c liver metabolism)
Carcinoid syndrome: metastasis
of carcinoid tumor to liver
systemic 5-HT effects flush +
diarrhea + wheezing + TIPS
(tricuspid insufficiency,
pulmonary stenosis)
Management
Dx CT scan + CBC (WBC) + -HCG (r/o ectopic
in females)
Tx appendectomy
Other
Rovsing sign: LLQ pressure
causes referred RLQ pain
Psoas sign: right psoas flexion
causes RLQ pain
Obturator sign: right obturator
flexion causes RLQ pain
McBurney point: 2/3 distance
from umbilicus to right ASIS
Dx CT scan
Tx appendectomy (<2 cm), right
hemicolectomy (>2 cm)
Dx urinary 5-HIAA
Tx resection
Presentation
aching or gnawing epigastric
pain, either relieved (DU) or
exacerbated (GU) by eating
Management
Dx EGD
H. pylori Dx stool ag > urease breath test,
Tx triple or quad therapy
Other
Etiology: NSAIDs and H. pylori
(MCC); EtOH, uremia, burns
(Curling), smoking, stress, head
injury (Cushing)
Zollinger-Ellison syndrome:
gastrinoma gastrin
parietal cell stimulation HCl
ulcer formation
Dx CXR (pneumoperitoneum)
Tx emergent surgical repair
Dx barium swallow
Tx NPO/IVF/NG tube
Dx EGD
Tx PPIs (slow) or surgical repair (rapid)
Dx EGD w/ bx
Tx d/c NSAIDs, triple therapy for H. pylori
Dx EGD w/ bx
Tx d/c NSAIDs, triple therapy for H. pylori
Dx EGD w/ bx
Tx radiation (partial thickness) or surgical
resection (full thickness)
MEDICINE GI
GI BLEEDING
Dz
UGIB
LGIB
ESOPHAGEAL DZ
Dz
Esophageal cancer
Achalasia
Hiatal hernia
Mallory-Weiss syndrome
Boerhaave syndrome
Plummer-Vinson syndrome
Schatzki ring
Esophageal divertula
Presentation
GI bleed proximal to Ligament
of Treitz hematemesis,
melena, hematochezia (if rapid)
Presentation
dysphagia of solids > liquids +
weight loss odynophagia (if
severe)
SCC: found in upper 2/3, due to
smoking and EtOH abuse
Adenocarcinoma: found in
lower 1/3, due to GERD/Barretts
hypertonic and nonrelaxing LES
w/ poorly relaxing esophagus
dysphagia of liquids > solids
uncoordinated esophageal
peristalsis dysphagia +
angina-like chest pain
Type 1 HH: sliding hernia, can
present as GERD or reflux
esophagitis
Type 2 HH: paraesophageal
hernia, high risk of incarceration
and strangulation
Type 3 HH: both type 1+2
retching laceration of lower
esophagus UGIB
retching perforation of lower
esophagus epigastric pain,
fever, pneumomediastinum
iron deficiency anemia,
upper esophageal webs
(dysphagia), koilonychia
ingestion of acids, alkali, bleach,
or detergents lower
esophageal webs usually asx,
dysphagia if severe
Zenker diverticulum: lack of
cricopharyngeal relaxation
diverticulum at upper
esophagus food gets stuck
halitosis + dysphagia
Traction diverticulum: TB or
cancer LN-opathy traction
diverticulum at middle
esophagus
Epiphrenic diverticulum:
esophageal motility d/o
diverticulum at lower
esophagus
Management
Dx NG tube aspirate/lavage
+blood/bile is UGIB
blood/+bile is LGIB
blood/bile is indeterminate
UGIB Dx/Tx EGD
LGIB Dx colonoscopy
bleeding wont stop Dx tagged RBCs or
angiography to localize site of bleeding
hemodynamic instability despite
transfusion, loss of 4-6 units in 24 hrs, or 8-10
units in 48 hrs Tx ex lap
unstable pt w/ massive BRBPR, no imaging to
help localize site Tx total colectomy
Management
Dx esophagoscopy w/ bx, then staging via
endoscopic U/S + CT scan
Other
Etiology: PUD (#1), NSAID use
(#2), esophageal varices (#3)
UGIB in ICU pt: stress ulcer
UGIB in alcoholics: esophageal
varices, Mallory-Weiss tear,
Boerhaave syndrome
UGIB s/p aortic graft: aortoenteric fistula (small herald bleed
followed by massive UGIB)
Etiology: diverticulosis (#1), AVM
(#1), colon cancer (#3)
LGIB in kids: Meckel diverticulum
Other
Tx surgical repair
Tx surgical repair
Dx upper GI endoscopy
Tx observation (bleeding stops on its own)
Dx barium swallow
Tx emergent surgical repair
Dx barium swallow
Tx cricopharyngeal myotomy
Dx barium swallow
Tx observation
Dx barium swallow
Tx esophagomyotomy
Complications: esophageal
stricture or cancer
MEDICINE GI
SI DZ
IBD
Dz
SBO
Presentation
colicky abd pain, n/v,
obstipation or constipation
Paralytic ileus
lack of peristalsis
Celiac sprue
Management
Dx KUB (dilated loops w/ air-fluid levels)
Tx NPO/IVF/NG tube, observation
adhesions Tx LOA + resect dead gut
hernias Tx herniorrhaphy + resect dead gut
Dx KUB (uniform gas in SI, colon, rectum)
Tx NPO/IVF/NG tube, observation
Dx anti-gliadin or anti-endomysial ab
Tx avoid wheat/gluten in diet
Other
Etiology: adhesions from prior
abd surgery (MCC), hernias (#2)
Complications: septic shock,
gangrene, peritonitis, bowel
perforation
Etiology: s/p abd surgery, meds
(e.g. narcotics, anticholinergics),
spinal cord injury, shock, hypokalemia, peritonitis
Dermatitis herpetiformis: skin
lesions found in celiac sprue
Ulcerative colitis
Presentation
flare-and-remission pattern of
crampy abd pain, bloody
diarrhea, recent weight loss
flare-and-remission pattern of
crampy abd pain, bloody
diarrhea, recent weight loss
Management
Dx KUB (terminal ileum string sign), flex sig,
tissue bx (transmural, noncaseating
granulomas, creeping fat)
Tx steroids + 5-ASA (sulfsalazine)
perianal Crohn Tx metronidazole
rectal Crohn Tx subtotal colectomy
Dx KUB (lead pipe sign), flex sig, tissue bx
(mucosa only, crypt abscesses, pseudopolyps)
Tx steroids + 5-ASA (sulfsalazine)
severe dysplasia Tx total proctocolectomy
Tx metronidazole
Other
Location: mouth to anus w/
skip lesions, terminal ileum is MC
site
Complications: erythema
nodosum, SBO, fissures/fistulae
MEDICINE HEPATOBILIARY/PANCREATIC
LIVER DZ
Dz
Cirrhosis
Wilson disease
(hepatolenticular degeneration)
Hemochromatosis (bronze
diabetes)
Hepatic adenoma
Cavernous hemangioma
Focal nodular hyperplasia (FNH)
Presentation
fibrosis disruption of liver
architecture portal HTN +
impaired biosynthetic function
multiple complications
Varices: portal HTN dilated
veins in butt (hemorrhoids), gut
(esophageal varices), and caput
(caput medusae)
Nonalcoholic steatohepatitis
(NASH)
Gilbert syndrome
Hemobilia
Liver cysts
Liver abscess
Budd-Chiari syndrome
Management
Dx liver bx
PPx -blockers
bleeding esophageal varices Tx band the
varices, correct coagulopathy, IV octreotide to
lower portal pressure if bleeding continues,
repeat banding if bleeding continues, TIPS
or gastric balloon tamponade
Dx PE (shifting dullness, fluid wave) +
paracentesis (to determine cause)
Tx salt restriction + loop diuretic
Tx lactulose (prevents NH4 absorption) +
neomycin (kills GI flora that make NH4) + low
protein diet
Other
Etiology: alcohol (MCC), HBV and
HCV (2nd), other causes
Childs classification: stratifies
risk of surgery in pts w/ liver
failure; measure 3 labs (albumin,
bilirubin, PT) and 3 clinical
findings (encephalopathy,
ascites, nutrition)
Tx liver txp
Dx paracentesis (WBC)
Tx IV abx + repeat paracentesis in 2-3 days
---
Dx PT/PTT
Tx FFP transfusion (vit K wont work)
Dx ceruloplasmin, AST/ALT, liver bx
Tx D-penicillamine (copper chelating agent) +
zinc (copper uptake competition)
Dx CT scan or U/S
Tx d/c OCP, if it persists Tx resection due to
possibility of rupture
Dx CT scan or U/S
Tx reassurance
Dx CT scan (central stellate scar or sunburst
pattern)
Tx reassurance
Dx CT scan, FP
Tx resection w/ negative margins (as long as
theres no mets)
1 hemochromatosis: AR dz that
GI iron absorption
2 hemochromatosis: iron 2/2
multiple transfusions or chronic
hemolytic anemia
Etiology: associated with OCP
and anabolic steroid use
Etiology: VAT vinyl chloride,
aflatoxin, thorotrast
Dx mild ALT/AST
Tx controversial
Tx reassurance
Tx reassurance
Tx inject hypertonic saline inside cyst and
carefully excise it + post-op mebendazole
MEDICINE HEPATOBILIARY/PANCREATIC
LFTS
albumin
AST
bilirubin
ALT
BILIARY DZ
Dz
Gallstone dz
Presentation
cholelithiasis
fatty meal
passes
biliary colic
into CBD
lodge/infx
acute cholecystitis
Management
Dx RUQ U/S (HIDA scan if inconclusive) + get
ERCP for choledocholithiasis/acute cholangitis
choledocholithiasis
lodge/infx
acute cholangitis
lodge
gallstone pancreatitis
Acalculous cholecystitis
GB adenocarcinoma
Cholangiocarcinoma
Choledochal cysts
Biliary stricture
Biliary dyskinesia
Cholelithiasis: presence of
stones in GB, usually asx
Biliary colic: cholelithiasis
RUQ pain after fatty meals n/v
Acute cholecystitis: impacted
stone in cystic duct infx
RUQ pain, n/v, Murphys sign
Choledocholithiasis: presence
of stones in CBD
Gallstone pancreatitis:
impacted stone in pancreatic
duct reflux of pancreatic
enzymes midepigastric pain
Acute cholangitis: impacted
stone in CBD infx Charcot
triad Reynold pentad
acute cholecystitis (RUQ pain,
n/v, Murphys sign) w/o stones
in the cystic duct, usually found
in ICU pts
presents as a mass in GB fossa
Other
Boas sign: referred right scapular
pain of biliary colic
Charcot triad: RUQ pain, fever,
jaundice
Reynold pentad: Charcot triad +
MS, hypotension
Gallstone ileus: gallstone enters
bowel through cholecystenteric
fistula gets stuck in terminal
ileum SBO
Tx reassurance
Tx elective lap chole
Tx NPO, IVF, abx lap chole within 24 hrs
Dx ERCP
Tx Whipple if resectable
Dx ERCP
Tx resection
Dx ERCP
Tx endoscopic stent (1st line), surgical bypass
Dx HIDA scan (fill up GB w/ contrast and give
CCK to determine ejection fraction)
Tx lap chole
MEDICINE HEPATOBILIARY/PANCREATIC
PANCREATIC DZ
Dz
Acute pancreatitis
Chronic pancreatitis
Pancreatic cancer
Presentation
stabbing epigastric pain boring
through to the back
Management
Dx screen w/ lipase, confirm w/ CT scan
Tx NPO/IVF/pain meds
Hemorrhagic pancreatitis:
presents as MSOF, ARDS, hemodynamic instability, signs of
ecchymoses (Grey-Turner, Fox,
Cullen signs)
Pancreatic abscess: presents as
abd pain and early satiety 2 wks
s/p acute pancreatitis
Pseudocyst: presents as abd
pain and early satiety 5 wks s/p
acute pancreatitis
chronic epigastric pain,
steatorrhea, diabetes mellitus
Dx CT scan
Tx admit to ICU for close monitoring
Dx CT scan
Tx perc drain + IV abx
Dx CT scan
Tx observation (<5 cm), perc drain (>5 cm)
Dx stool elastase test
Tx insulin + pancreatic enzyme replacement,
IVF/NPO/pain meds for acute attacks
Dx CT scan
cancer in head Tx Whipple
cancer in body or tail Tx distal
pancreatectomy
mets or local invasion palliative care
f/u tumor markers CA 19-9, CEA
Other
Etiology: I GET SMASHED
idiopathic, gallstones (#1), EtOH
(#2), trauma, steroids, mumps,
autoimmune, scorpion sting,
hypertriglyceridemia (#3),
hypercalcemia, ERCP, drugs
Grey-Turner sign: flank
ecchymoses
Cullen sign: periumbilical
ecchymoses
Fox sign: ecchymoses of inguinal
ligament
Etiology: alcoholism (MCC
adults), cystic fibrosis (MCC kids)
Trousseau phenomenon:
migratory SVT in 10% of
pancreatic cancer pts
Courvoisier sign: palpable GB
w/o pain in 30% of cancer pts
MEDICINE ENDOCRINE
THYROID DZ
Dz
Thyroglossal duct cyst
Hyperthyroidism
Thyroid storm
Hypothyroidism
Myxedema coma
Thyroid nodules
Presentation
remnant of thyroglossal duct
mobile midline neck mass
Graves disease (diffuse toxic
goiter): autoimmune dz due to
TSI (anti-TSH) hyperthyroid
sx, exophthalmos, thyroid
bruits, pretibial myxedema
Plummer disease (toxic
multinodular goiter): multiple
hyperfunctioning areas in
thyroid hyperthyroid sx
Toxic adenoma: single hyperfunctioning nodule hyperthyroid sx
precipitating factor (stress,
infx) hyperthyroidism
exacerbation marked fever,
tachycardia, agitation, GI sx
Hashimoto thyroiditis:
autoimmune dz w/ lymphocytic
infiltration hypothyroid sx
De Quervain thyroiditis: painful
granulomatous inflammation
following viral URI hypothyroid sx
Acute thyroiditis: painful,
swollen, tender thyroid mass
due to Staph/Strep infx hypothyroid sx
Riedel thyroiditis: firm, painless
thyroid hypothyroid sx
precipitating factor (stress,
infx) hypothyroidism
exacerbation marked
hypothermia, MS, respiratory
depression
thyroid nodule found on
physical exam
Management
Tx Sistrunk operation (take out cyst, trunk, and
medial portion of hyoid bone)
Dx TSH, free T4
Tx PTU (pregnant), methimazole (not
pregnant), oral radioiodine (can become
hypothyroid), subtotal thyroidectomy
(permanent)
Dx TSH, free T4 + patchy uptake on T3 scan
Tx oral radioiodine (<2 cm), subtotal
thyroidectomy (>2 cm)
Other
Hyperthyroidism in elderly:
presents as weakness, weight
loss, atrial fibrillation
Dx TSH (normal)
Dx FNA
benign
indeterminate
malignant
Dx thyroid scan
hot
Thyroid cancer
cold
observation
Tx surgery
Dx FNA (for all types except follicular, must
see capsular invasion for adenoma/carcinoma)
MEDICINE ENDOCRINE
PARATHYROID DZ
Presentation
head/neck surgery accidental
PTH-ectomy hypocalcemia sx
Management
Dx PTH, Ca, P
Tx vit D + calcium replacement
Pseudohypoparathyroidism
Dx PTH, Ca, P
Tx vit D + calcium replacement
1 HPTH
2 HPTH
3 HPTH
Hypercalcemic crisis
PITUITARY DZ
Other
Chvostek sign: tapping on Cheek
causes muscle contractions
Trousseau sign: inflating BP cuff
causes carpal muscle spasms
DiGeorge syndrome: thyroid +
parathyroid hypoplasia
Knuckle-knuckle-dimple-dimple
sign: hand morphology seen w/
pseudohypoparathyroidism
Dx PTH, Ca, P
Tx observation for 1 year, then 3 gland
excision if still problematic
Tx flush and drain (NS then Lasix), then
surgery for parathyroid carcinoma
Craniopharyngioma
SIADH
Presentation
tumor of anterior pituitary
gland bitemporal hemianopsia () + hyperpituitary
or hypopituitary sx
Prolactinoma: PRL
galactorrhea, amenorrhea,
infertility, libido
Acromegaly: GH
overgrowth of brow, jaw,
hands, and feet; MCC death is
CV disease
Pituitary Cushing: ACTH
truncal obesity, abd striae,
buffalo hump, hyperglycemia,
osteoporosis, HTN, immunosuppression
Hypopituitarism: FSH/LH,
ACTH, TSH, PRL, GH
embryological remnant of
Rathke pouch bitemporal
hemianopsia (), headache,
papilledema, MS
polyuria, polydipsia
Management
Dx MRI
Other
Dx hormone levels
Tx hormone replacement
Dx MRI (supracellar calcified cysts)
Tx transsphenoid hypophysectomy
MEDICINE ENDOCRINE
ADRENAL DZ
Dz
Cushing syndrome
Presentation
cortisol truncal obesity, abd
striae, buffalo hump,
hyperglycemia, osteoporosis,
HTN, immunosuppression
Management
Other
Cushing syndrome
Dx ACTH, cortisol,
dexamethasone suppression test
ACTH, cortisol
ACTH, cortisol
adrenal Cushing
(Dx abd CT)
>50% suppression
Pheochromocytoma
1 hyperaldosteronism (Conn
syndrome)
Adrenal insufficiency
Incidentaloma
PANCREATIC DZ
Dz
Insulinoma
Glucagonoma
Somatostatinoma
VIPoma
MEN SYNDROME
Dz
MEN 1 (Wermer syndrome)
MEN 2B
Presentation
insulin Whipples triad
(hypoglycemia, worse w/
fasting, better w/ glucose)
gastrin gastric acid
secretion ulcers
glucagon new-onset
diabetes + necrolytic migratory
erythema
SST triad of gallstones,
diabetes, steatorrhea
VIP rice water diarrhea
Presentation
pituitary adenoma, pancreatic
endocrinoma (MC gastrinoma),
parathyroid hyperplasia
parathyroid hyperplasia,
pheochromocytoma, thyroid
medullary cancer
pheochromocytoma, thyroid
medullary cancer, mucosal
neuromas, Marfanoid habitus
<50% suppression
pituitary Cushing
ectopic Cushing
(Dx head MRI)
(Dx chest/abd CT)
Tx transsphenoid hypophysectomy
Tx adrenalectomy
Tx underlying cause
Dx abd CT scan
Tx adrenalectomy (adenoma), spironolactone
(hyperplasia)
Dx cortisol + ACTH levels (ACTH if primary,
ACTH if secondary)
Tx glucocorticoid (prednisone) +
mineralocorticoid (fludrocortisone)
Dx 17-OHP
Tx glucocorticoid (prednisone) +
mineralocorticoid (fludrocortisone)
<5 cm leave alone
>5 cm Tx resection + check other organs
since adrenals are common site of metastasis
Management
Dx C-peptide levels or monitored fasting (to
see if theyre faking it)
Tx resection
Dx gastrin levels (<200 absent, >500 present);
if 200-500, get secretin stimulation test
(paradoxical gastrin w/ secretin)
Tx resection
Dx glucose challenge test
Tx resection
Other
Tx resection
Tx resection
Management
Tx excise parathyroid first (since hyper
calcemia can cause gastrin), then gastrinoma,
then pituitary adenoma (w/ cabergoline)
Tx excise pheo first (life-threatening)
Other
MEDICINE ENDOCRINE
DIABETES MELLITUS
Dz
Impaired glucose tolerance
T1DM
T2DM
Presentation
asx
autoimmune destruction of cells lack of insulin pt
usually presents in acute DKA
obesity FFA release
insulin resistance glucose
classic sx (polyuria, polydipsia, polyphagia) + blurry
vision, weight loss, recurrent
vaginal yeast infx
Management
Dx fasting glc 110-126
Tx insulin, 0.5-1 u/kg (2/3 morning, 1/3 evening)
inpatient Tx SSI
Other
T2DM
fasting glc <240
lifestyle changes
(still high)
Tx metformin or
sulfonylurea
(still high)
add another PO drug
DM complications
DKA
HHNS
Hypoglycemia
Macrovascular complications:
nonenzymatic glycosylation
(NEG) atherosclerosis
CAD, MI, PVD, stroke/TIA, etc.
Diabetic nephropathy: NEG of
basement membrane loss of
negative charge microalbuminuria proteinuria
CKD ESRD
Diabetic retinopathy: NEG of
retinal vx either background
or proliferative retinopathy
Diabetic neuropathy: NEG of
peripheral nerves damage
stocking/glove burning pain,
numbness, tingling
Diabetic foot: peripheral
neuropathy + PVD (ischemia)
repetitive injuries ulcers and
nonhealing
T1DM exacerbation insulin
hyperglycemia + ketosis
osmotic diuresis, dehydration,
fruity breath, Kussmaul
respiration, etc.
T2DM exacerbation insulin
hyperglycemia hyperosmolarity, osmotic diuresis,
severe dehydration
glc epinephrine
(sympathetic sx), CNS
dysfunction at 40-50 (HA,
weakness, drowsiness, coma)
Tx insulin
(still high)
Microalbuminuria: 20-200
g/min or 30-300 mg/day
Dx glc
Dx C-peptide, insulin levels, anti-insulin ab, and
sulfonylurea levels (look for underlying cause)
Tx underlying cause + sugary foods or IV D50W
MEDICINE NEURO
STROKE
Ischemic stroke
Hemorrhagic stroke
HEAD TRAUMA
Presentation
asx at rest, but arm claudication
and CNS sx with exercise due to
stenotic subclavian artery (can
present like a TIA)
focal neuro sx <24 hrs (usually
<1 hr)
Carotid TIA: abrupt
contralateral sx
Vertebrobasilar TIA: ipsilateral
CN palsy, contralateral
hemiplegia
Drop attacks: brief paralytic
spells resulting in pt dropping
to knees w/o LOC
Transient global amnesia: TIA in
temporal lobes or thalamus
rapid retrograde memory loss +
confusion but preservation of
self-identity
Amaurosis fugax: TIA in retinal
artery temporary unilateral
loss of vision
focal neuro sx >24 hours
ACA syndrome: contralateral
leg hemiparesis, incontinence
MCA syndrome: contralateral
face/arm hemiparesis
PCA syndrome: homonymous
hemianopia
Vertebrobasilar syndrome:
ipsilateral CN palsy,
contralateral hemiplegia
Cerebellar infarction:
headache, nausea, vomiting,
vertigo, nystagmus
Lacunar syndromes: pure
motor or sensory stroke, clumsy
hand-dysarthria syndrome
ICH: bleeding into brain
parenchyma focal neuro sx +
sudden headache + vomiting
SAH: rupture of berry aneurysm
bleeding into subarachnoid
space worst headache of my
life
Management
Dx arteriogram
Tx bypass surgery
Other
Basal skull fx: raccoon eyes, hemotympanum, otorrhea, rhinorrhea, ecchymosis behind the ear (Battle sign)
Coup-contrecoup injury: injury at site of impact + opposite point of impact
Diffuse axonal injury: global damage to entire brain during impact severe neuro dysfxn, coma
Dz
EDH
SDH
Concussion
Presentation
temporal bone fx tear in
middle meningeal artery
bleeding into epidural space
LOC w/ lucid interval
tear in bridging veins venous
bleed into subdural space
MS, headache, cortical dysfxn,
possible herniation if acute
brief LOC following blunt head
trauma w/ confusion, dizziness,
impaired concentration, etc.
Management
Dx head CT (convex lens hematoma)
Tx emergent craniotomy
Other
no tx available
MEDICINE NEURO
MOVEMENT D/O
Presentation
loss of dopaminergic neurons
early PD presents as TRAP
pill-rolling Tremor, cogwheel
Rigidity, Akinesia, Postural
instability; late PD presents as
Alzheimer-like dementia
Management
early PD Tx Sinemet (carbidopa + levodopa)
late PD Tx subthalamic nucleus deep brain
stimulation
Huntington chorea
Other
PD brain: neuronal death in
substantia nigra, senile plaques,
Lewy bodies
Shy-Drager syndrome: PD +
autonomic insufficiency
Progressive supranuclear palsy
(PSP): PD w/o ophthalmoplegia
or tremors
Ataxia
Tourette syndrome
AD tremor w/ intentional
activity but not at rest,
improved w/ EtOH use
gait instability, loss of balance,
impaired limb coordination
Acquired ataxia: ataxia 2/2
EtOH, B12/thiamine deficiency,
cerebellar dz, demyelinating dz,
or 3 syphilis
Friedreich ataxia: ataxia w/
staggering gait, nystagmus, pes
cavus and hammer toes
Ataxia-telangiectasia:
Friedreich ataxia +
telangiectasias
most severe tic disorder w/
multiple daily motor/vocal tics,
onset before 18 y/o; associated
w/ OCD and ADHD
Tx -blockers
Tx underlying cause
MEDICINE NEURO
DEMENTIA
Onset
Duration
Px
Amnesia
Alert
Oriented
Dx
waxing-andwaning change in
pts level of
consciousness
acute
3 days 2 wks
reversible
immediate and
recent memory
no
no
abnormal EEG
impairment in
memory and
other cognitive
functions
chronic
months yrs
irreversible
recent and
remote memory
yes
sometimes
abnormal MRI
Dementia: progressive and irreversible impairment in memory and other cognitive functions w/o change in level of consciousness
Causes of dementia: Alzheimer (#1), vascular (#2), Lewy body (#3), others
Dz
Pseudodementia
Secondary dementia
Vascular dementia
HIV-associated dementia
Creutzfeldt-Jakob disease
Presentation
severe depression that can
present like dementia in elderly
dementia 2/2 hypothyroidism,
B12/folate deficiency, thiamine
deficiency, neurosyphilis, or
medication use
ACh gradual progressive
decline in memory and other
cognitive functions
Management
Tx SSRIs
Other
Tx underlying cause
Tx HAART
MEDICINE NEURO
ALTERED MS
ICP: normally 5-15; ICP >20 bilateral fixed/dilated pupils herniation death
Cushing triad: triad of vital signs in ICP BP, HR, irregular RR
Glasgow coma scale: GCS score = E+M+V / 15
Abnl pupillary light reflex: mass lesions, pupil drugs, hypoxia, eye drops
Bilateral fixed/dilated pupils: severe anoxia
Unilateral fixed/dilated pupil: herniation w/ CN III compression
Pinpoint pupils: narcotics, ICH (in pons)
Dz
Delirium
Coma
Locked in syndrome
Brain herniation
Presentation
waxing-and-waning change in
level of consciousness; can also
have visual hallucinations, short
attention span, and impaired
recent memory
Sundowning: worsening of
delirium at night
damage to RAS or bilateral
hemispheres depressed LOC,
unresponsive to any stimuli
damage to ventral pons
coma-like state but pt is fully
conscious and can control
blinking, vertical eye movement
edema or mass lesion ICP
brain tissue moves past
anatomic barriers
Management
Dx MMSE (<25)
r/o life-threatening causes, then ID and Tx
underlying cause
Other
Etiology: AEIOU TIPSS Alcohol
and drug toxicity or withdrawal,
Electrolyte imbalance,
Iatrogenic, Oxygen hypoxia,
Uremia/hepatic encephalopathy,
Trauma, Infection, Poison,
Seizures, Stroke
Dx GCS (8)
r/o life-threatening causes, then ID and Tx
underlying cause
---
Dx head CT
Tx intubate, lower ICP, consult neurosurg
DEMYELINATING DZ
CNS NEOPLASMS
Brain death
Dz
Multiple sclerosis
Presentation
selective CNS demyelination
optic neuritis, intranuclear
ophthalmoplegia (crazy eyes),
transient sensory deficits, etc.
Management
Dx MRI (multiple white plaques), LP w/ CSF
analysis (oligoclonal bands)
Tx IFN- (prevent relapses), high-dose steroids
(for acute attacks)
Guillain-Barr syndrome
Other
Astrocytoma
Oligodendroglioma
Meningioma
Acoustic schwannoma
CNS metastases
Primary CNS lymphoma
Meningeal carcinomatosis
Buzzwords
can cross corpus callosum
(butterfly glioma), pseudopalisading necrosis, GFAP+
Rosenthal fibers, GFAP+
fried egg cells, chicken-wire
capillary pattern
Psamomma bodies, attached to
dura
S-100+, CN VIII
multiple ring-enhancing lesions
AIDS/immunosuppression
cancer that metastasizes to
meninges via bloodstream
focal neuro sx, meningitis,
hydrocephalus
Management
Dx MRI
Tx resection (if resectable), radiation
(astrocytomas, oligodendrogliomas,
lymphoma, metastases)
Other
MEDICINE NEURO
NEUROMUSCULAR DZ
Dz
Myasthenia gravis
Presentation
anti-nAChR gradually
progressive muscle weakness
(initial sx is ptosis, diplopia,
blurry vision) that get worse w/
repetitive muscle use
Lambert-Eaton myasthenic
syndrome (LEMS)
NEUROCUTANEOUS
SYNDROMES
Dz
Neurofibromatosis type I
(von Recklinghausen disease)
Neurofibromatosis type II
Tuberous sclerosis
Sturge-Weber syndrome
Von Hippel-Lindau disease
SPINAL CORD DZ
Presentation
AD NF1 caf-au-lait spots,
Lisch nodules (iris hamartomas),
CNS tumors, pheo
AD NF2 bilateral acoustic
neuromas, juvenile cataracts
AD TSC1/2 CNS/retinal
hamartomas, sebaceous
adenomas, hypopigmented
ash leaf spots, Shagreen
patches, renal angiomyolipoma, cardiac rhabdomyoma
facial port-wine stain w/
ipsilateral brain AVM
AD VHL hemangioblastomas, bilateral RCC,
pheochromocytomas
Management
Dx anti-nAChR (best), edrophonium test,
EMG (decreased response w/ repetitive
stimulation), chest CT to look for thymoma
Tx pyridostigmine, plasmapheresis (if severe),
thymectomy (if thymoma)
Other
Management
NF pt w/ HTN Dx urinary metanephrines
Other
-----
-----
Presentation
central cavitation of cervical
cord bilateral cape-like
loss of ALS, ipsilateral CS
Management
Dx MRI
Tx syringosubarachnoid shunt
Brown-Sequard syndrome
---
Transverse myelitis
Dx MRI
Tx high-dose steroids
Poliomyelitis
PPx vaccination
Other
MEDICINE NEURO
OTHER CNS DZ
Presentation
spinning of the room, five
types (BLAME) BPPV,
Labyrinthitis, Acoustic
neuroma, Meniere disease,
EtOH/drug-induced
Cardiac syncope: sudden LOC
w/o prodromal sx; d/t massive
MI, arrhythmias, or obstruction
(e.g. aortic stenosis)
Vasovagal syncope: paradoxical
PSNS activity during intense
emotion LOC w/ premonitory
sx (pallor, sweating, nausea)
Orthostatic hypotension: delay
in peripheral venoconstriction
LOC w/ sudden or prolonged
standing
Simple partial sz: transient
unilateral movements w/o LOC
Complex partial sz: transient
automatisms w/ LOC
postictal confusion
Grand-mal sz: sudden LOC
rigidity (tonic phase)
musculature jerking (clonic
phase) postictal confusion
Absence sz: staring into
space for a few seconds
Management
Tx underlying cause + meclizine for nausea
Aphasia
Syncope
Seizures
Bell palsy
Other
Tx CBZ
Etiology: 4 Is + 4 Ms Infx,
Ischemia (stroke/TIA), ICP,
Intoxication, Metabolic and
electrolytes, Mass lesions,
Missing drugs (anticonvulsants,
sedatives/EtOH), Misc
Pseudoseizure: looks like sz but
no EEG changes
Secondary generalization:
partial sz generalized sz
Status epilepticus: brain is stuck
in a state of persistent seizure
MEDICINE MSK
BUZZWORDS
CONNECTIVE TISSUE DZ
Dz
SLE
Drug-induced lupus
Neonatal lupus
APA syndrome
Raynaud disease
Scleroderma (diffuse)
Scleroderma (CREST syndrome)
Sjgren syndrome
Mixed CT disease
Presentation
type 3 HS flare-and-remission
pattern of IM DAMN SHARP
IgG
Malar rash
Discoid rash
ANA
Mucositis (throat ulcers)
Neurologic d/o
Serositis (pleuritis, pericarditis)
Hematologic d/o
Arthritis
Renal d/o (wire loops)
Photosensitivity
drugs type 3 HS SLE-like
presentation but no kidney or
CNS involvement
maternal ag-ab cross placenta
lupus sx; anti-SSA attacks
fetal heart 3 AV block
hypercoagulability in SLE or
other collagen-vascular dz
high-risk for venous (DVT, PE)
and arterial clots (stroke, MI),
recurrent abortions
digital vasospasm fingertips
go from blue-to-white-to-red
severe, widespread fibrosis of
skin (sclerodactyly) and viscera
Calcinosis of fingers, Raynaud
phenomenon, Esophageal
dysmotility, Sclerodactyly (only
face and fingers), and
Telangiectasias (over fingers)
autoimmune attack of salivary
and lacrimal glands dry eyes,
dry mouth, arthritis
overlap syndrome of SLE,
RA, scleroderma, polymyositis
Management
Dx screen w/ ANA, confirm w/ anti-dsDNA,
anti-Sm, or C3-C5
Tx low-dose aspirin, corticosteroids for flares,
cyclophosphamide for lupus nephritis
Other
MC pts: Af-American women
Dx anti-histone
Tx d/c meds
Dx anti-SSA/SSB (anti-Ro/La)
Tx pilocarpine, artifical tears, oral hygiene
Dx anti-U1-RNP
Tx predominant dz
MEDICINE MSK
ARTHRITIS
Dz
Osteoarthritis
Rheumatoid arthritis
Gout
Pseudogout (CPPD)
MYOSITIS
Dermatomyositis
Fibromyalgia
SPONDYLOARTHROPATHY
Management
Dx X-ray (joint space narrowing, osteophytes
aka bone spurs, sclerosis, subchondral cysts)
Tx weight loss + physical therapy (1st line),
acetaminophen/NSAIDs (2nd line), steroid
injections (3rd line), joint replacement (4th line)
Other
Risk factors: old age, obesity,
joint overuse, trauma
Felty syndrome: RA +
neutropenia + splenomegaly
Juvenile RA: RA before 18 y/o
calcium pyrophosphate
deposits in joints suddenonset monoarthritis
Presentation
hip and shoulder muscle
weakness pain
hip and shoulder muscle
weakness pain, skin rashes
(heliotrope rash, Gottron
papules, V sign, shawl sign)
symmetrical proximal and distal
muscle weakness
hip and shoulder muscle pain
w/o weakness, profound
morning stiffness
widespread muscle pain and
stiffness associated w/ trigger
points
Management
Dx CK, anti-Jo-1, muscle bx
Tx steroids
Dx CK, anti-Jo-1, muscle bx
Tx steroids
Lesch-Nyhan syndrome: AR
HGPRT gout, self-mutilation,
yellow sand in diapers
SERONEGATIVE
Presentation
wear-and-tear of joints
degeneration of cartilage
deep, dull joint pain, worse w/
activity and improved w/ rest
Other
Complications: depression,
anxiety, axis II diagnoses
Seronegative spondyloarthropathies: PAIR Psoriatic arthritis, Ankylosing spondylitis, IBD, Reiter syndrome
Common features: inflammatory oligoarthritis, negative RF, HLA-B27 association
Dz
Ankylosing spondylitis
Psoriatic arthritis
Presentation
bilateral sacroiliitis + gradualonset upward fusion of spine +
enthesitis (pain at tendon
attachment sites)
triad of anterior uveitis,
urethritis, arthritis (cant see,
cant pee, cant climb a tree)
following a bacterial GI infx
(Salmonella, Shigella, Campy,
Chlamydia, Yersinia)
asymmetric polyarthritis in 10%
of psoriasis pts, usually fingers
Management
Dx X-ray (bamboo spine)
Tx NSAIDs + physical therapy
Other
Complications: restrictive lung
dz, cauda equina syndrome,
spine fx w/ spinal cord damage,
osteoporosis, spondylodiscitis
Complications: dactylitis
(sausage fingers)
MEDICINE MSK
VASCULITIS
Buerger disease
(thromboangiitis obliterans)
Behet syndrome
Churg-Strauss syndrome
Wegener granulomatosis
Hypersensitivity vasculitis
Presentation
elderly pt w/ unilateral
headache, jaw claudication,
visual changes
young Asian woman w/ absent
pulses and asymmetrical BP
vasculitis of renal and visceral
vx abd pain (bowel angina),
fatigue, joint pain, renal failure;
associated w/ HBV infx
smokers w/ gangrene and
autoamputation of fingers/toes
recurrent oral and genital
ulcers, arthritis, uveitis, CNS sx
triad of asthma + eosinophilia +
granulomatous vasculitis
triad of necrotizing vasculitis,
necrotizing granulomas in lungs
and upper respiratory tract, and
necrotizing glomerulonephritis
hematuria + hemoptysis
drug-induced type 3 HS
palpable purpura
Management
Dx ESR
Tx emergent high-dose steroids (can become
blind if you wait too long)
Dx arteriogram
Tx steroids, angioplasty for stenosed vx
Dx tissue bx, P-ANCA
Tx steroids
Tx smoking cessation
Dx tissue bx
Tx steroids
Dx tissue bx, P-ANCA
Tx steroids
Dx tissue bx (necrotizing granulomas),
C-ANCA
Tx cyclophosphamide
Dx tissue bx
Tx steroids, d/c meds
Other
Complications: polymyalgia
rheumatica, blindness, aortic
aneurysms
MEDICINE RENAL
URINALYSIS
RENAL FAILURE
Etiology
Urine osm
Urine Na+
FENa
BUN/Cr
Prerenal ARF
renal blood flow
GFR (hypotension,
CHF, etc.)
>500
<10
<1%
>20:1
Intrinsic ARF
damage to renal
parenchyma (ATN,
toxins, glomerulonephritis, etc.)
<350
>20
>2%
<15:1
Postrenal ARF
bilateral urinary tract
obstruction (stones,
BPH, cancer, etc.)
<350
>40
>4%
>15:1
Ischemic ATN: renal blood flow proximal/distal tubules dont enough O2 for Na/K pump cell death ARF
Nephrotoxic ATN: toxin-mediated damage to proximal tubules cell death ARF (e.g. IV dye, gentamycin, Hb/Mb)
Chronic renal failure: irreversible, progressive reduction in GFR
Etiology: DM (#1), HTN (#2), chronic glomerulonephritis (#3)
Stages: stage 1 GFR 90-100
stage 2 GFR 60-89
stage 3 GFR 30-59
stage 4 GFR 15-29
stage 5 GFR <15 or dialysis (aka ESRD)
ARF/CRF complications: GFR electrolyte retention Na, K, H HTN, CHF
uremia n/v, pericarditis, asterixis, encephalopathy, platelet dysfxn
EPO normocytic anemia
vit D renal osteodystrophy, 2 HPTH, calciphylaxis
DIALYSIS
Method
Frequency
Advantages
Disadvantages
Hemodialysis
blood from AV fistula pumped
through dialyzer, filtrated, then
sent back into pt body
MWF or TuThSa
faster/more efficienct
can be initiated quickly
risk of removing too much
fluid or electrolytes
requires vascular access
first-use syndrome
chest and back pain, rare
anaphylaxis w/ new machine
Peritoneal dialysis
high-glucose dialysate infused into
peritoneal cavity, then drained from
abdomen
q 4-8 hrs
mimics normal kidney fxn
self-dialysis
risk of hyperglycemia
risk of peritonitis
increased abdominal girth
MEDICINE RENAL
PROTEINURIA AND
HEMATURIA
Dz
Proteinuria
Hematuria
Presentation
>150 mg protein/24 hr
Microscopic hematuria:
>3 RBC/HPF
Gross hematuria: visible to
naked eye
Glomeruli
Casts
GLOMERULAR DZ
Management
Dx screen w/ dipstick and UA, then get 24 hr
urine collection
asx/transient reassurance
asx/persistent Dx check BP and examine
urine sediment; Tx underlying cause
sx Tx underlying cause + ACE inhibitors
Dx screen w/ dipstick and UA, then get
imaging of upper/lower urinary tracts
Tx underlying cause
Nephritic syndrome
glomerular
inflammation
- hematuria
- oliguria
- HTN
- azotemia
- proteinuria (<3.5 g)
hypercellular
RBC casts
Other
Etiology: glomerular dz
Etiology: postrenal causes
(trauma, stones, cancer)
NephrOtic syndrome
loss of GBM negative
charge
- proteinuria (>3.5 g)
- edema
- hypoalbuminemia
- hyperlipidemia
- hypercoagulability
normo-/hypocellular
fatty casts
Alport syndrome
Diabetic nephropathy
Presentation
nephrOtic syndrome in kids
following a viral infx
nephrOtic syndrome in adults
and HIV+ pts, steroid-resistant
nephrOtic syndrome in adults;
associated w/ drugs, infx, SLE,
and solid tumors
nephritic syndrome following
URI or gastroenteritis;
associated w/ Henoch-Schonlein
(palpable) purpura in kids
XR type 4 collagen split
GBM (nephritic and nephrOtic
syndromes), deafness, ocular
and nerve disorders
nephrOtic syndrome in DM pts
HTN nephropathy
Lupus nephropathy
Membranoproliferative
glomerulonephritis (MPGN)
Poststreptococcal GN
Goodpasture syndrome
Management
Dx EM (foot process effacement)
Tx steroids
Dx LM (segmental sclerosis)
Dx LM (diffuse GBM thickening), EM (spike
and dome appearance)
Dx LM (mesangial deposits), IF (IgA stain)
Dx family hx
Dx microalbuminuria, LM (mesangial
expansion, Kimmelsteil-Wilson nodules)
Tx ACE inhibitors
Tx underlying HTN
Dx LM (wire loops), EM (subendothelial
deposits), IF (full house)
Tx underlying SLE
Dx EM (tram tracks or dense deposits)
Dx ASO, LM (lumpy-bumpy appearance)
Tx reassurance
Dx LM (crescent shaped), IF (linear staining)
Other
MEDICINE RENAL
TUBULOINTERSTITIAL DZ
Dz
Acute interstitial nephritis (AIN)
Chronic interstitial nephritis
Hartnup syndrome
Fanconi syndrome
RENAL CYSTIC DZ
Dz
Adult polycystic kidney dz
(ADPKD)
RENAL VASCULAR DZ
Dz
RA stenosis (renovascular HTN)
RV thrombosis
Hypertensive nephrosclerosis
Presentation
drug allergy acute renal
railure, rash, fever, eosinophilia
slowly progressive nephritis
asx, but can lead to progressive
scarring, renal failure, and ESRD
damage to renal papillae
necrosis slough off and
cause ureteral obstruction
Management
Dx UA (eosinophuria)
Tx d/c meds
---
Other
Etiology: gentamycin, IV dye,
Hb/Mb
Dx excretory urogram
Tx underlying cause
Tx IV HCO3-
Presentation
AD APKD1/2 multiple, large
bilateral cysts that can destroy
renal parenchyma renal
failure, HTN, berry aneurysms,
liver cysts
cystic dilation of collecting
ducts resembles sponge in
medulla hematuria,
recurrent UTIs, kidney stones
benign incidental finding
Management
Dx renal U/S (multiple large cysts)
no tx available
Presentation
RA stenosis renal blood
flow kidney thinks youre
hypotensive RAA system
HTN, abdominal bruits, renal
function
intrinsic clot or extrinsic
compression renal blood
outflow flank pain, HTN,
hematuria, proteinuria
Benign nephrosclerosis: hyaline
arteriolosclerosis in chronic
HTN
Malignant nephrosclerosis:
hyperplastic (onion skin)
arteriolosclerosis in rapidly
progressive HTN
recurrent sickling papillary
infarction eventual papillary
necrosis, renal failure, UTIs
Management
Dx renal arteriogram (if pt is in renal failure,
use MRA instead since dye is nephrotoxic)
Tx angioplasty
Tx underlying cause
-- Tx fludrocortisone
Tx niacin replacement
Tx electrolyte replacement
Other
leave it alone
Dx renal venography
Tx underlying cause
Other
Etiology: fibromuscular dysplasia
(young women), atherosclerosis
(old men)
MEDICINE RENAL
STONES/OBSTRUCTIONS
Dz
Nephrolithiasis (kidney stones)
GU NEOPLASMS
OTHER GU DZ
Presentation
colicky flank pain radiation to
groin, hematuria, n/v
Calcium stones: most common
type, 2/2 hypercalciuria or
hyperoxaluria
Uric acid stones: radiolUcent
(rest are all radioopaque), 2/2
gout or tumor lysis syndrome
Struvite stones: 2/2 urease+
bugs (P. mirabilis), can form
large staghorn caliculi
Cystine stones: 2/2 cystinuria
colicky flank pain radiation to
groin (if acute), asx (if chronic)
Dz
Prostate cancer
Presentation
usually asx, elderly man w/ low
back pain if invasive
Bladder cancer
Testicular cancer
Penile cancer
Dz
Testicular torsion
Presentation
twisting of spermatic cord
severe testicular pain + high
riding testicle w/ horizontal lie
presents like testicular torsion,
but w/ fever, pyuria, and cord is
also tender
Epididymitis
Management
Dx KUB
Tx analgesics + fluids (<0.5 cm), shockwave
lithotripsy (0.5 2 cm), percutaneous
nephrolithotomy (2 cm)
recurrent calcium stones PPx HCTZ
uric acid stones PPx allopurinol, Tx
potassium citrate
cystine stones Dx urinary sodium nitro prusside test, Tx acetazolamide
Other
Hematuria + pyuria: stone w/
concomitant UTI
Kidney stone diet: high fluids
(#1), low sodium, low protein,
high calcium (counterintuitive),
low oxalate
Management
Dx screen w/ PSA (10) or DRE (firm nodule);
confirm w/ U/S-guided needle bx
Tx radical prostatectomy (local), radiation +
flutamide + leuprolide (invasive)
Dx abdominal CT
Tx radical nephrectomy
Other
Cancers that rarely metastasize:
prostate, esophageal, skin
(nonmelanoma), oropharyngeal
Dx IV pyelo + cystoscopy w/ bx
Tx resection + close f/u for high recurrence
Management
Tx emergent surgical detorsion, then
orchipexy (dont waste time on dx tests)
Dx U/S to r/o torsion
Tx abx
Other
Cremasteric reflex: stroking of
inner thigh causes elevation of
testicle; absent w/ torsion
Etiology: GC or CT in young men,
E. coli in kids and elderly
Cystine crystals
Struvite crystal
Oval calcium
oxalate crystals
RBCs
Budding yeast
Normal RBC
Ghost RBC
Crenated RBC Normal RBC
RBC casts
(think acute pyelonephritis)
WBC casts
PMNs
Subepi Humps
Granular CapillaryIgG/C3
EM
IF
Light
Nephritic Dz
PostInfx
MSG Deposits
IgA Neprho
MSG
HyperCellular
-ity
Subepi
Full House:
Class
III/IV
SLE Class II
Subendo
Wire Loops
Crescents + Fibrin
Normal
Anti-GBM
EM
IF
Light
Normal
Normal
Minimal Change
Nephrotic Dz
Foot process
effacement
Normal
Segmental Sclerosis
FSGS
Granular
Capillary
IgG
Pseudolinear
Capillary IgG
Art. Hyalinosis
Diabetic Neph
Nodular MSG
Expansion
Spikes&Holes
in BM
Subepi Deposits
Thick Cap
walls
MembranousNeph
Thick GBM
Nodulesl
MEDICINE FEN
FLUIDS
60-40-20 rule: 60% of body weight is water, 40% is ICF, 20% is ECF (5% plasma, 15% ISF)
Starling forces: hydrostatic pressure drives fluid into ISF, oncotic pressure sucks it back out
Blood osmolarity: 2Na + BUN/2.8 + gluc/18; normally 285-300 mOsm/L
Urine osmolarity: 70-1200 mOsm/L, controlled by ADH
Urine output: normally 0.5-1.0 mL/kg/hr
IV fluids: NS, LR, D5NS, D5W
NS: good for dehydrated pts
LR: good for trauma pts
D5NS: standard maintenance fluid
D5W: good for hypernatremic pts
100-50-20 rule: maintenance fluids for 24 hrs (100 mL/kg for first 10 kg, then 50 for next 10 kg, then 20 for each kg over)
4-2-1 rule: maintenance fluids for 1 hr (4 mL/kg for first 10 kg, then 2 for next 10 kg, then 1 for each kg over)
ELECTROLYTES
Etiology
water loss due to 6 Ds Diuresis,
Dehydration, Diabetes insipidus,
Docs (iatrogenic), Diarrhea,
Diseases
SIADH (MCC)
Presentation
thirst and signs of volume depletion
(slow) or MS (rapid)
Management
Tx PO fluids > IV fluids (correct gradually due
to risk of cerebral edema)
Hyperkalemia
Hypokalemia
Hypercalcemia
hyperparathyroidism (MCC
outpt), cancer (MCC inpt)
Hypocalcemia
hypoparathyroidism (MCC)
Hyponatremia
Hypermagnesemia
Hypomagnesemia
Hyperphosphatemia
Hypophosphatemia
ACID-BASE
Acid-base algorithm:
CO2 <40
CO2 >40
pH <7.4
met acidosis*
resp acidosis
pH >7.4
resp alkalosis
met alkalosis
*if met acidosis, calculate anion gap (Na+ (Cl- + HCO3-)), nl 8-12
Respiratory acidosis
Respiratory alkalosis
Anion-gap metabolic acidosis
Causes
hypoventilation
hyperventilation 2/2 pain, fever,
sepsis, or early ARDS
MUDPILES Methanol, Uremia,
DKA, Paraldehyde, Iron, INH,
Lactic acidosis, Ethylene glycol,
Salicylates
diarrhea, glue sniffing, RTA,
hyperchloremia
vomiting, diuretics, antacids,
hyperaldosteronism
Management
Tx mechanical ventilation
Tx underlying cause
Tx underlying cause
Tx underlying cause
Tx chloride or potassium replacement
MEDICINE HEM/ONC
TRANSFUSION
RBC PANEL
ANEMIA
Anemia?
microcytic
(MCV <80)
normocytic
(MCV 80-100)
macrocytic
(MCV >100)
IDA (TIBC)
ACD (TIBC)
thalassemias (RDW)
sideroblastic anemia
folate deficiency
B12 deficiency
reticulocytosis
normal erythropoiesis
(RI >2%)
intrinsic RBC defects
AIHA
prosthetic valves
MAHA
chronic hemorrhage
Presentation
(typical anemia sx)
Management
Dx RBC panel (MCV <80, Fe, TIBC, RDW)
Tx underlying cause + PO iron supplements
-thalassemia
Sideroblastic anemia
Aplastic anemia
Folate deficiency
Other
Etiology: Meckel diverticulum
(MCC kids), menorrhagia (MCC
women), peptic ulcers (MCC
men), colon cancer (MCC elderly)
Etiology: cancer, chronic infx,
systemic inflammation, trauma
MEDICINE HEM/ONC
HEMOLYTIC ANEMIA
Intravascular hemolysis: ABO-mismatched blood hemolysis within blood stream immediate fever/chills, nausea, vomiting, chest and flank pain,
dyspnea risk of hypovolemic shock, DIC, renal failure
Extravascular hemolysis: minor antigen-mismatched blood (e.g. Kell) delayed hemolysis within spleen mild fever, jaundice, anemia
Dz
Sickle cell disease
Hereditary spherocytosis
G6PD deficiency
Paroxysmal nocturnal
hemoglobinuria (PNH)
PLATELET D/O
Presentation
AR HbE6V (-chain) sickling
of RBCs w/ O2 conditions
small vessel occlusion extravascular hemolysis, painful
vasoocclusive crises,
autosplenic infarction
AR spectrin spherical RBCs
get stuck in spleen
extravascular hemolysis
XR G6PD glutathione for
handling oxidant stressors
intravascular hemolysis, back
pain, hemoglobinuria in men
Warm AIHA: IgG against RBC
chronic, extravascular
hemolysis
Cold AIHA: IgM against RBC
acute, intravascular hemolysis
triggered by cold
acquired DAF lack of
complement inactivation on
RBCs hemolytic anemia +
hepatic vein thromboses
Management
Dx blood smear (sickled RBCs), confirm w/ Hb
electrophoresis
Tx avoid crises + hydroxyurea (HbF) + early
SHiN vaccination
Other
Sickle cell trait: painless
hematuria in young black male
Splenic sequestration crisis:
sudden, rapid pooling of blood
into spleen splenomegaly,
hypovolemic shock, death
Aplastic crisis: spherocytosis +
parvovirus B19 infx, prevent w/
folic acid supplements
Etiology: sulfa drugs, antimalarials, infx, fava beans
Dx urine hemosiderin
Tx steroids, bone marrow txp
risk of clots
thrombocytosis by definition
normal
thrombocytopenia by definition
risk of bleeding during surgery/trauma
petechiae
major spontaneous bleeding
Idiopathic thrombocytopenic
purpura (ITP)
Thrombotic thrombocytopenic
purpura (TTP)
Bernard-Soulier syndrome
Glanzmann thrombasthenia
Presentation
plt <150,000; most common sx
is petechiae
HIT type 1: heparin directly
causes platelet aggregation,
within 0-2 days
HIT type 2: heparin induces
auto-antibodies against platelet
factor 4, after 3-12 days
auto-antibodies against
gpIIb/IIIa platelet clearance
petechiae, ecchymoses, etc.
HUS: tons of clots form in small
vx (e.g. renal vx) microangiopathic hemolytic anemia +
thrombocytopenia + renal
failure
TTP: HUS + fever + MS
AR gpIb platelets cant
adhere to subendothelium
AR gpIIb/IIIa platelets cant
aggregate
Management
Tx underlying cause, plt transfusion (severe)
Other
Asx thrombocytopenia: consider
HIV testing
Tx reassurance
Tx d/c heparin
-----
MEDICINE HEM/ONC
COAGULATION
ANTICOAGULATION
COAGULATION D/O
Dz
von Willebrand disease (vWD)
Management
Dx //no vWF, bleeding time
Tx DDAVP (types 1-2), factor 8 concentrate
(refractory type 2, type 3)
Other
Hemophilia A (classic
hemophilia)
Presentation
vWD type 1: AD vWF
bleeding diathesis
vWD type 2: AD vWF
bleeding diathesis
vWD type 3: AD lack of vWF
severe bleeding diathesis
XR factor 8 hemarthroses,
hematomas, and ICH in men
Dx PTT, factor 8
Tx factor 8 concentrate; analgesia + RICE (for
acute hemarthroses)
Hemophilia B (Christmas
disease)
XR factor 9 hemarthroses,
hematomas, and ICH in men
Disseminated intravascular
coagulation (DIC)
Dx PTT, factor 9
Tx factor 9 concentrate; analgesia + RICE (for
acute hemarthroses)
Dx PT/PTT, D-dimer, fibrinogen, plt,
blood smear (schistocytes)
Tx underlying cause, supportive measures
Vit K deficiency
Factor V leiden
---
MEDICINE HEM/ONC
PLASMA CELL D/O
Dz
Multiple myeloma
Monocolonal gammopathy of
undetermined significance
(MGUS)
Waldenstrom
macroglobulinemia
Presentation
monoclonal plasma cell
proliferation makes lots of
monoclonal IgG and eats up
bone marrow space CRAB
hyperCalcemia, Renal failure,
Anemia, Bone lesions/fx
(asx, precursor of myeloma)
Management
Dx SPEP (monoclonal spike), urinalysis (Bence
Jones protein), X-ray (punched out lytic bone
lesions), blood smear (rouleaux formation)
Tx chemo/radiation only if symptomatic
Other
MCCOD: recurrent lung or
urinary tract infx (normal IgG)
- painful
- small (<2 cm)
- rapid onset
- mobile
- normal site
Hodgkins lymphoma
Non-Hodgkins lymphoma
- painless
- large (>2 cm)
- insidious onset
- fixed (fibrotic)
- unusual site
LYMPHOMA
rare
RS > lymphocytes
6%
RS << lymphocytes
25%
RS = lymphocytes
65-75%
RS << lymphocytes
high grade
high grade
low grade
low grade
middle grade
high grade
high grade
Lymphocyte-depleted HL
- popcorn cells
- infrequent classic RS cells
- excellent prognosis
Lymphocyte-predominant HL
V
- male-dominant
- numerous RS cells, EBV association
Mixed cellularity HL
V = viral association
- female-dominant
- supraclavicular nodes + anterior mediastinal nodes
Nodular sclerosing HL
Mycosis fungoides
V
- adults with aggressive cutaneous lesions
- HTLV-1 association
MALT/extranodal lymphoma
- t(14;18)
- overexpression of BCL-2 anti-apoptosis gene
Follicular lymphoma
- t(11;14)
- poor prognosis, CD5+
V
- t(8;14)
- EBV association, common childhood NHL
- starry sky appearanceW
- jaw lesion in endemic form in Africa
- pelvis/abdomen in sporadic form
Burkitts lymphoma
ALL
AML/CML
CLL
Pre-leukemia
Leukemia
0-14
15-60
60+
(extremely important)
AGE BRACKETS
- <5% blasts
- accumulation of mature cells
Chronic leukemias
- >20% blasts
- accumulation of immature cells
Acute leukemias
myeloid lineage
myeloid lineage
B-cells
B-cells
MKC lineage
w/ fibroblasts
MKC lineage
RBC lineage
myeloid
lineage
Myeloproliferative neoplasms
LEUKEMIA
subtypes
- gum infiltration
Myelodysplastic syndrome
CLL
Primary myelofibrosis
Essential thrombocythemia
Polycythemia vera
CML
ALL
AML
MEDICINE ID
RESPIRATORY INFX
Dz
Pneumonia
Lung abscess
Tuberculosis
Influenza
Bug(s)
Typical CAP: Strep pneumo
(#1), H. influenzae (#2),
aerobic GNR
Atypical CAP: Mycoplasma
(#1), Chlamydia, Legionella
Nosocomial PNA: Staph
aureus (#1), Pseudomonas,
aerobic GNR
PNA alcoholics: Klebsiella
PNA immigrants: TB
PNA nursing home:
nosocomial pathogens
PNA AIDS: Pneumocystis
carinii (PCP), TB
oral anaerobes (Prevotella,
Peptostreptococcus, Fusobacterium, Bacteroides)
M. tuberculosis
influenza virus
Presentation
Typical CAP: sudden-onset fever/chills,
productive cough, pleuritic chest pain
Atypical CAP: insidious-onset sore throat,
headache, nonproductive cough, dyspnea
Complications: pleural effusions,
empyema, acute respiratory failure
Management
Dx CXR (consolidations)
suspect TB acid-fast stain
suspect Legionella urinary ag
HIV+ silver stain (fungi, PCP)
admit if 2/5 of CURB-65 Confusion, Uremia,
RR 30, BP <90/60, age 65
outpatient Tx azithromycin (<60 y/o),
ceftriaxone (60 y/o)
inpatient Tx azithromycin + either
ceftriaxone or fluoroquinolone
PPx annual flu vaccine, Pneumovax if 65 y/o
CNS INFX
Dz
Meningitis
Encephalitis
Brain abscess
Bug(s)
Meningitis neonates: GBS >
E. coli > Listeria
Meningitis kids: MC > Strep
pneumo > H. influenzae
Meningitis adults: Strep
pneumo > MC > H. influenzae
Meningitis elderly: Strep
pneumo > MC > Listeria
Presentation
triad of fever, nuchal rigidity, MS
Kerning sign: inability to fully extend knees
when lying supine w/ hips flexed
Brudzinski sign: flexion of head causes
flexion of hips/knees when lying supine
Disseminated meningococcal infx:
meningitis, purpura fulminans, bilateral
adrenal hemorrhage (W-F syndrome)
MS, focal neuro sx, s/sx of meningitis
Management
Dx head CT to check for ICP, then lumbar
puncture + CSF analysis
Tx IV abx
GU INFX
Dz
Asymptomatic
bacteruria
Lower UTI (cystitis)
Bug(s)
E. coli (#1), Staph saprophyticus (#2), Enterococcus
(#3), other GNB
"
Upper UTI
(pyelonephritis)
"
Prostatitis
Presentation
(asx)
Management
Dx UA/UCx (105 CFU w/o squamous cells)
Tx only if pregnant (nitrofurantoin) or before
urologic surgery, otherwise reassurance
Dx UA/UCx (105 CFU w/o squamous cells)
Tx Bactrim or Cipro, nitrofurantoin if pregnant,
low-dose Bactrim ppx if recurrent
MEDICINE ID
GI INFX
Dz
Viral hepatitis
Bug(s)
HAV (fecal-oral)
Presentation
jaundice, dark-colored urine, RUQ pain, n/v
Botulism
Intra-abdominal abscess
Diarrhea
Dz
Cellulitis
Erysipelas
Necrotizing fasciitis
(gas gangrene)
Lymphadenitis
HCV (parenteral)
HEV (fecal-oral)
Clostridium botulinum
preformed exotoxin (from
canned food or wound infx)
polymicrobial
Management
Dx HAV IgM = acute infx
Dx HAV IgG = previous infx or immunity
Tx supportive care
Dx HBsAg = acute/chronic infx
Dx HBsAb = previous infx or immunity
Dx HBeAg = infectivity
Dx HBcAb IgM = window period
Tx IFN-
Dx HCV RNA
Tx IFN- + ribavarin, liver txp if severe
Dx HDV Ab
Tx IFN-
Dx HEV Ab
Tx supportive care
Dx toxin assay
Tx admit + antitoxin
Dx CT scan (cavitation w/ air-fluid levels)
Tx I&D + IV abx
acute diarrhea
---
Bug(s)
skin flora (Strep pyogenes,
Staph aureus)
Presentation
infx of skin and subcutaneous tissue
erythema, warmth, pain, swelling
Management
Tx Keflex or Bactrim, consult ophtho if orbital
involvement
Tx PCN or erythromycin
Tetanus
H+P
not complicated
complicated
(blood, fever, n/v)
Tx symptomatic relief
(rehydrate, loperamide) Dx fecal leukocytes
WBC
+WBC
stool cx,
C. diff toxin
MEDICINE ID
STDS
BONE/JOINT INFX
Dz
Chlamydia
Bug(s)
Chlamydia trachomatis
Gonorrhea
Neisseria gonorrhoeae
Vaginal candidiasis
Candida albicans
Syphilis
Treponema pallidum
Chancroid
Haemophilus ducreyi
HSV
HSV-1/2
Presentation
Women: cervicitis, PID, TOA, usually asx
Men: urethritis
Women: cervicitis, PID, TOA, usually asx
Men: urethritis
Disseminated gonoccocal infx: migratory
polyarthritis, endocarditis, skin rash
Fitz-Hugh-Curtis syndrome: perihepatitis
causing RUQ pain, LFTs, violin string
adhesions
thick, white curd-like discharge, itching,
satellite lesions, no odor
1 syphilis: painless chancre + inguinal LNopathy
2 syphilis: palmar/plantar rash, fever,
condyloma lata, generalized LN-opathy
3 syphilis: neurosyphilis (tabes dorsalis),
CV syphilis (luetic heart), gummas
Jarisch-Herxheimer rxn: acute febrile rxn
s/p syphilis tx (MC w/ 2 syphilis), due to
dead spirochetes endotoxin release
painful chancre + inguinal LN-opathy
recurrent, painful oral (HSV-1) or genital
(HSV-2) vesicles that can rupture
LGV
Condyloma acuminata
HPV-6/11
Bacterial vaginosis
Gardnerella vaginalis
Trichomoniasis
Trichomonas vaginalis
HIV/AIDS
Pediculosis pubis
(crabs)
Phthirus pubis
Dz
Osteomyelitis
Bug(s)
Staph aureus (#1), coag-neg
Staph epidermidis (#2), others
Presentation
hematogenous or direct spread infx of
bone bone pain w/ local inflammation
Infx arthritis
OM IV catheter: Staph
aureus
OM prosthetic joint: coagneg Staph epidermidis
OM diabetic foot:
polymicrobial
OM nosocomial:
Pseudomonas
OM IVDA: Pseudomonas
OM sickle cell: Salmonella
OM vertebra: TB (Pott dz)
OM cat/dog bite: Pasturella
multocida
Staph aureus (#1), others
Arthritis sexually-active
young adults: N. gonorrhoeae
Arthritis IVDA:
Pseudomonas
Arthritis sickle cell:
Salmonella
Management
Dx Chlamydia NAAT
Tx azithromycin ceftriaxone
Dx discharge Gram stain (G diplococci)
Tx ceftriaxone azithromycin
Dx complement fixation
Tx doxycycline
Dx PE
Tx removal
Dx wet prep (clue cells)
Tx metronidazole
Dx wet prep (mobile trichomonads)
Tx metronidazole
Dx screen w/ HIV ELISA, confirm w/ WB
Tx HAART (2 NRTIs + 1 NNRTI or PI)
Management
Dx needle aspiration + cx (best), MRI
Tx admit + IV abx + debride dead bone
f/u serial ESR/CRP to monitor response to tx
MEDICINE ID
ZOONOSES AND
ARTHROPOD-BORNE INFX
FUNGAL INFX
Dz
Lyme disease
Bug(s)
Borrelia burgdorferi via Ixodes
tick vector
Rocky Mountain
spotted fever
Malaria
Rabies
Dz
Candidiasis
Bug(s)
Candida albicans
Management
Dx screen w/ ELISA, confirm w/ WB
Tx doxycycline
Presentation
Vaginal candidiasis: thick, white curd-like
discharge, itching, satellite lesions, no odor
Thrush: thick, white plaques in oral mucosa
Cutaneous candidiasis: erythematous,
eroded patches w/ satellite lesions
Management
Dx KOH prep (budding yeast + pseudohyphae)
Tx fluconazole or miconazole cream (vaginal),
nystatin powder (cutaneous), nystatin swish
and-swallow (thrush)
Tx doxycycline
Dx blood smear w/ Giemsa stain
Tx chloroquine (mefloquine if resistant)
primaquine for P. vivax/ovale hypnozoites
Aspergillosis
Aspergillus fumigatus
Cryptococcosis
Blastomycosis
Coccidioidomycosis
Coccidioides immitis
Sporotrichosis (rose
gardener disease)
Dz
Giardiasis
Bug(s)
Giardia lamblii
Amebiasis
Entamoeba histolytica
Cryptosporidiosis
Cryptosporidium parvum
Presentation
bloating, flatulence, foul-smelling fatty
diarrhea
flask-shaped ulcers in ascending colon
bloody diarrhea; anchovy paste abscess
in liver RUQ pain
mild diarrhea, severe diarrhea in HIV+ pts
Ascariasis
Ascaris lumbricoides
Hookworm
Tapeworm
Schistosomiasis
S. haematobium
Dx stool/urine sample
Tx praziquantel
Presentation
erythema around an IV cath left in for too
long (>3 days)
fever/chills, sore throat, malaise, myalgias,
severe cervical LN-opathy after making out
w/ someone
Management
Dx remove and send tip for cx
Tx IV abx
Dx Monospot (heterophile agglutination) test
Tx supportive care + avoid contact sports to
prevent splenic rupture
Histoplasmosis
PARASITIC INFX
Presentation
Stage 1: erythema chronicum migrans
(target-shaped lesion)
Stage 2: bilateral Bell palsy + AV block
Stage 3: chronic arthritis
triad of HA + fever + rash (vasculitis that
starts on extremities and comes inward)
cyclic fever/chills, headache, anemia,
splenomegaly
Pinworm
S. mansoni
Management
Dx stool sample
Tx metronidazole
Dx stool sample
Tx metronidazole (for diarrhea and abscess)
Dx acid-fast stain
(no tx exists)
Dx stool sample
Tx mebendazole
Dx stool sample
Tx mebendazole
Dx Scotch tape test
Tx mebendazole
Dx stool sample
Tx praziquantel
S. japonicum
OTHER INFX
Dz
Catheter-related sepsis
Mononucleosis
Bug(s)
Staph aureus (#1), coag-neg
Staph epidermidis (#2)
EBV (#1), CMV (#2)
MEDICINE SKIN
COMMON SKIN DZ
Dz
Acne vulgaris
Rosacea
Seborrheic dermatitis
Contact dermatitis
Pityriasis rosea
Erythema nodosum
Lichen planus
Bullous pemphigoid
Pemphigus vulgaris
INFX SKIN DZ
Dz
Warts
Molluscum contagiosum
Shingles (zoster)
Dermatophytes
Scabies
Presentation
obstruction of sebaceous
follicles proliferation of P.
acnes noninflammatory
comedones (pimples)
inflammatory acne
red forehead, nose, cheeks w/o
underlying comedones
usually asx; can present as scaly
patches on scalp (dandruff),
hairline, behind ears, eyebrows,
armpits, groin area
skin rash w/ vesicles and oozing
(acute) or crusted, thickened
skin (chronic)
Irritant contact dermatitis:
physical or chemical insult to
skin rash shortly after
exposure
Allergic contact dermatitis:
reexposure to allergen rash
hours-to-days after exposure
herald patches (ringworm-like),
then generalized Christmas
tree rash
painful, red, subcutaneous
nodules over shins
Presentation
HPV infx epithelial growth
fleshy asx mass, plantar warts
can be painful on walking
Common wart: verruca vulgaris
found on elbows, knees, palms,
and fingers
Flat wart: verruca plana found
on chin/face, dorsum of hands,
and legs
Plantar wart: verruca plantaris
found on sole of foot
Anogenital wart: condyloma
acuminatum found on genital
areas
poxvirus infx highly
contagious domed papules w/
umbilicated center
reactivation of latent VZV
(chicken pox) infx pain and
rash in dermatomal distribution
Management
Tx clean skin (1st line), topical benzoyl
peroxide, retinoids, or abx (2nd line), systemic
abx (3rd line), isotretinoin (last line/teratogen)
Other
Risk factors: male sex, puberty,
Cushing syndrome, oily skin,
androgens, meds
Steroid acne: not associated w/
underlying comedones
Rhinophyma: large, bulbous,
greasy nose in men
Tx reassurance
Tx systemic steroids
Tx systemic steroids
Management
Tx removal (cryotherapy, salicylic acid,
podophyllin, surgical or laser excision)
Other
MEDICINE SKIN
SKIN CANCERS
Dz
Actinic (solar) keratosis
Presentation
small, rough, scaly lesions on
face of fair-skinned people;
precursor to SCC
raised waxy lesion or nonhealing ulcer in upper face,
doesnt spread
non-healing ulcer in lower
face, spreads to LN
Management
Tx removal (cryotherapy, surgical scraping,
or topical 5-FU)
Melanoma
Dz
Decubitis ulcers (pressure
sores)
Presentation
prolonged pressure tissue
ischemia and necrosis ulcers
Management
Tx local wound care, surgical debridement,
BID wet-to-dry for deeper ulcers
PPx turn and reposition q 2 hrs
Psoriasis
BCC
SCC
OTHER SKIN DZ
Seborrheic keratosis
Vitiligo
ALLERGIC REACTIONS
Other
Tx excisional bx w/ 1 mm margins
Other
MC sites: sacrum, greater
tuberosity, ischial tuberosity
Risk factors: immobilization,
dementia, peripheral vascular dz
Complications: secondary
bacterial infx (cellulitis, osteomyelitis, nec fasc, gangrene)
Type 1 HS: allergen exposure IgE-mediated mast cell degranulation HA release, atopic/anaphylactic
Type 2 HS: IgG or IgM against cell surface, cytotoxic
Type 3 HS: ab-ag complex deposition complement activation cell damage
Type 4 HS: T-cell mediated activation of macrophages, delayed-type
Dz
Urticaria (hives)
Presentation
type 1 HS edematous wheals
(hives) that cause intense
pain/pruritus
severe urticaria + target lesions
(bulls-eye lesions)
severe erythema multiforme +
mucus membrane involvement
severe Stevens-Johnson
syndrome
fluid extravasation into
subcutaneous tissue painful
swelling of eyelids, lips, tongue,
genitalia, hands, or feet
types 1-4 HS skin eruptions
(MC), lung, kidney, hematologic
complications, anaphylaxis
Management
Tx remove offending agent, symptomatic
relief (anthistamines)
Other
Food allergy
Erythema multiforme
Stevens-Johnson syndrome
Toxic epidermal necrolysis
Angioedema
Drug allergy
Anaphylaxis
MEDICINE OUTPATIENT
CARDIOVASCULAR DZ
Dz/CC
HTN
Presentation
asx, but can present w/ end-organ
complications...
Management
Dx BP cuff
H+P
lifestyle modifications
not at goal BP
stage 1
Tx HCTZ
stage 2
compelling
indications
HLD
initial evaluation +
lifestyle modifications
TG >500
Tx niacin
Hyperlipidemia drugs:
Statins
LDL
HDL
TG
Niacin
Side-effects
hepatotoxicity, rhabdomyolysis (check
CK, LFTs)
flushing, hyperglycemia,
hyperuricemia (check CK, LFTs)
GI distress, poorly tolerated
hepatotoxicity, rhabdomyolysis,
cholesterol gallstones (check CK, LFTs)
Other
Pre-HTN: 120-139/80-89
Stage 1 HTN: 140/90
Stage 2 HTN: 160/100
HTN urgency: 220/120
HTN emergency: 220/120 + endorgan damage
1 (essential) HTN: 95%, no
underlying cause
2 HTN: 5%, due to renovascular
dz (MCC), OCPs (MCC young
women) or other meds,
stimulants, endocrine dz, etc.
MEDICINE OUTPATIENT
HEADACHE
Cluster HA
Migraine HA
Rebound analgesic HA
UPPER RESPIRATORY DZ
Presentation
tight band-like pain encircling
entire head + tightness in
posterior neck muscles
unilateral, episodic burning,
searing, or stabbing pain
behind eye + ipsi tearing, flush,
or nasal discharge in men
unilateral, throbbing HA n/v,
phono-/photophobia in women
migraine after discontinuing
long-term analgesic use
Management
Tx NSAIDs or Tylenol if mild/moderate,
sumatriptan (Imitrex) if severe
Other
Etiology: unknown
Etiology: unknown
Acute bronchitis
Common cold (viral
rhinosinusitis)
Presentation
---
Sinusitis
Laryngitis
Sore throat
Management
suspect pulmonary dz Dx CXR
suspect infx Dx CBC
suspect asthma Dx PFT
Tx underlying cause (if known) + symptomatic
relief (codeine syrup, hydration, expectorants)
smoker Tx cessation
postnasal drip Tx antihistamine +
decongestant
suspect PNA Dx CXR
Tx symptomatic relief (codeine syrup)
Tx symptomatic relief (codeine syrup,
hydration, expectorants, analgesics)
PPx hand washing
Dx (think viral if <7-10 days, bacterial if
>7-10 days)
viral Tx decongestant (pseudoephedrine)
bacterial Tx decongestant + amoxicillin; if
not improved after 2 wks, Tx penicillinase
resistant abx ENT consult
Tx voice rest
Dx rapid strep test, throat cx
suspect mono Dx Monospot test
Tx symptomatic relief (salt water gargling,
throat lozenges, analgesics)
strep throat Tx PCN x10 days
Other
Acute cough: <3 wks, MCC
viruses
Chronic cough: >3 wks, due to
smoking, postnasal drip, GERD,
or asthma
MEDICINE OUTPATIENT
GASTROINTESTINAL DZ
Dz/CC
Dyspepsia
GERD
Diarrhea
Presentation
spectrum of epigastric sx
(pain/discomfort, heartburn,
bloating, indigestion)
heartburn, regurgitation,
waterbrash (sour taste), cough,
dysphagia
---
Management
suspect severe GI dz Dx endoscopy +
urease breath test
suspect MI Dx EKG + cardiac enzymes
Tx underlying cause, make lifestyle changes,
antacids for acid reflux
H. pylori Tx triple or quadruple therapy
Tx PPIs if it persists >6 wks, Dx EGD w/ bx
to see whats going on
Esophagitis: multiple nonulcerating erosions;
mild Tx PPIs, severe lap Nissen
Barrett esophagus: intestinal metaplasia of
esophageal epithelium; no dysplasia Tx
PPIs, low-grade dysplasia Tx lap Nissen +
annual surveillance, high-grade dysplasia
Tx esophagectomy
acute diarrhea
H+P
not complicated
complicated
(blood, fever, n/v)
Tx symptomatic relief
(rehydrate, loperamide) Dx fecal leukocytes
WBC
+WBC
stool cx,
C. diff toxin
Constipation
IBS
Nausea/vomiting
Hemorrhoids
---
Other
Etiology: 90% due to GI causes
(PUD, GERD, gastritis, nonulcer
dyspepsia); must r/o acute MI
MEDICINE OUTPATIENT
MUSCULOSKELETAL DZ
Dz/CC
Low back pain
Ankle sprain
Tendinitis
Bursitis
Osteoarthritis (OA)
Osteoporosis
Presentation
Lumbar strain: dull LBP after
physical activity
Herniated disc: sciatic-type LBP
radiating to butt/thigh, worse w/
sitting or leaning forward
Degenerative disc dz: chronic
LBP, worse w/ activity
Cauda equina syndrome: bilat
sciatica + bowel/bladder sx,
neuro sx
Vertebral osteomyelitis: LBP +
fever, tender to palpation
Malignancy: LBP + night pain,
h/o cancer, weight loss, failure
to improve
Spinal stenosis: LBP worse w/
activity, better w/ sitting or
leaning forward
Compression fx: well-localized
LBP, worse w/ activity
Spondylolisthesis: LBP worse w/
hyperextension
tenderness directly over injured
ligament (ATFL or CFL)
wear-and-tear of joints
degeneration of cartilage
deep, dull joint pain, worse w/
activity and improved w/ rest
Management
Other
LBP
H+P
no red flags
Tx rest + NSAIDs
red flags
(night pain, pain at rest,
fever, neuro sx, trauma,
bowel/bladder sx, IVDA)
focused work-up
MEDICINE OUTPATIENT
EYE DZ
Dz/CC
Age-related macular
degeneration (ARMD)
Presentation
degeneration of macula loss
of central vision, scotoma
Glaucoma
Cataracts
Red eye
Conjunctivitis
Amaurosis fugax
SLEEP D/O
Dz/CC
Sleep apnea
Narcolepsy
Insomnia
Presentation
neck obesity or structural
abnormalities intermittent
airflow obstruction episodic
apenic/hypoxic periods
snoring + fragmented sleep
daytime sleepiness, brain
damage, HTN/pulmonary HTN
REM sleep disregulation
excessive daytime sleepiness,
cataplexy, sleep paralysis,
hypnogogic/hypnopompic
hallucinations
---
Management
Dx ophthalmoscope shows drusen (yellow white deposits under pigmented epithelium)
no effective tx exists, but ranibizumab
rate of vision loss due to wet ARMD
Other
red eye
H+P
no red flags
red flags
(severe eye pain, flashes,
Tx cause
floaters, trauma, recent
eye surgery, orbital cellulitis,
corneal ulcer/opacification)
consult ophtho
Management
Dx polysomnography
mild-moderate Tx weight loss
severe Tx CPAP, surgery (last resort)
Other
MEDICINE OUTPATIENT
OTHER PROBLEMS
Dz/CC
Hearing loss
Presentation
Conductive hearing loss: lesion
in external or middle ear
decreased perception of lowvolume sounds
Sensorineural hearing loss:
lesion in CN VIII or CNS
decreased perception of lowand high-volume sounds w/
tinnitus
Stress incontinence: urine
leakage w/ exertion or straining
Management
Dx whisper test, audiogram, Weber/Rinne test
suspect CNS lesion Dx MRI
Fatigue
Alcoholism
---
Urinary incontinence
Tx intermittent self-cath
Tx underlying cause
Smoking
---
Dz
HTN
HLD
Population
adults 18
adults 18
Colorectal cancer
adults 50
Prostate cancer
Breast cancer
--women 20
Cervical cancer
women 21-65
STDs
Screening test
measure BP
fasting lipid panel q 5 yrs (more frequently if
increased risk of CAD)
annual FOBT + either colonoscopy q 10 yrs or
flex sigmoidoscopy q 5 yrs
not recommended
monthly self-exam + physician exam q 3 yrs until
40, then q yr + mammogram q 1-2 yrs 40
Pap smear q 2 yrs 21-29, q 3 yrs >30 after 3
negative Paps (dont need s/p hysterectomy)
cervical sampling + RPR-VDRL HIV ELISA
Osteoporosis
Smoking
Alcohol
Depression
Diabetic retinopathy
Hearing loss
Atherosclerosis complications
(PVD, stroke, CAD)
diabetic pts
adults 65
adults 65
Tx AA referral
Tx disulfiram (Antabuse) blocks aldehyde
dehydrogenase aversive reaction;
naltrexone blocks opioid-R cravings;
acamprosate GABA/glu cravings
HEALTH MAINTENANCE
Other
Etiology: cerumen impaction
(MCC conductive), presbycusis
(MCC sensorineural), lots of
other causes
PEDIATRICS
GENERAL PEDS
Developmental milestones
Fine motor
---
Speech
cooing
Social
recognizes parents, social smile
6 mo
1 yr
Gross motor
holds head up, rolls
front-to-back
sits up
walks
raking grasp
throws object, 3 blocks
babbling
10 words
2 yr
climbs stairs
3 yr
rides tricycle
4 yr
draws cross
stranger anxiety
comes when called, imitates
actions, object permanence
parallel play
3 mo
Adverse response to DTaP: give DT instead, since rxn is due to pertussis component
Foot drop s/p injection: needle injection in lower/inner gluteal quadrant iatrogenic damage to sciatic nerve
Orthopedic issues
Clavicle fx: presents w/ clavicular crepitus or callus, risk w/ LGA infants and breech deliveries; Tx reassurance > figure-of-8 splint
Supracondylar fx: MC fx in kids, due to trauma to humerus; Tx ortho c/s + check radial pulse since brachial artery can be injured
Nursemaid elbow: pulling on hand subluxation of radial head from annular ligament kid holds arm in a pronated position; Tx manual
reduction via supinating motion
Radial epiphyseal separation: falling out outstretched arm separation of radius at epiphyseal plate
Genu varum (bowlegs): observe in kids <2 y/o, called Blount disease in kids >2 y/o and requires ortho c/s
group play
Clubfoot: congenital foot deformity, inward and downward-pointing feet, risk of associated spina bifida; Tx stretching + manipulation +
serial casts (<3 mo), surgery (>3 mo)
Legg-Calve-Perthes disease: avascular necrosis of femoral head, presents as painless limp in a boy <10 y/o, requires ortho c/s
Slipped capital femoral epiphysis: painful limp in a fat boy; Dx X-ray, requires ortho c/s
Osgood-Schlatter disease: overuse injury of quads and patellar tendon traction apophysitis of tibial tuberosity localized
pain/swelling; Tx RICE + NSAIDs
Congenital hip dysplasia: presents as uneven gluteal folds and snapping hips during physical exam in a newborn; Dx U/S (not calcified
enough for X-ray), Tx splinting
Osteomyelitis: fever + localized bone pain, due to hematogenous spread or direct inoculation; Dx bone scan (X-ray can be false-neg for 3
days), Tx admit + IV abx
Septic arthritis: fever + localized joint pain + limited ROM; Dx joint aspiration, Tx drainage + IV nafcillin
Osteogenesis imperfecta: AD type 1 collagen abnormal bone matrix (multiple fractures) + blue sclera + abnormal dentition + hearing loss;
often mistaken as child abuse
Osteosarcoma: presents w/ localized bone pain and swelling; Dx X-ray shows Codmans triangle and sunburst appearance, Tx ortho c/s for
surgery
Ewing sarcoma: presents w/ localized bone pain and swelling; Dx X-ray shows onion skin appearance, Tx ortho c/s for surgery
Growing pains: deep aching pain in leg muscles w/o any red flags (fever, swelling, systemic sx); Tx reassurance
Patellofemoral syndrome: chronic anterior knee pain, worse w/ exercise or prolonged sitting; Tx strengthening exercises
Skin rashes
Presentation
Management
Eczema (atopic dermatitis)
chronic pruritic rash on cheeks, behind ears,
Tx moisturizers (calamine or eucerin
extensor surfaces, flexural areas
lotion) + topical steroids
Urticaria
allergic reaction pruritic wheal and flare
Tx antihistamines + PO steroids + avoid
rash
allergen
Chickenpox (varicella)
VZV infx dew drops on a rose petal
Tx antihistamines, ACV if onset <24 hrs
vesicular rash in an ill child
Staphylococcal scalded skin syndrome
Staph aureus exfoliatoxins A/B fever +
Tx abx + local skin care
(SSSS)
severe, painful rash that develop into bullae,
rupture, and eventually desquamate
Pityriasis rosea
single oval herald patch (resembles
Tx reassurance
ringworm), followed by diffuse Christmas
tree pattern rash on back 5-10 days later
Lichen planus
Purple Polygonal Pruritic Papules (rare in
Tx PO steroids
children)
Contact dermatitis
skin rash w/ vesicles and oozing (acute) or
Tx antihistamines + topical steroids +
Psoriasis
Henoch-Schonlein (anaphylactoid)
purpura
Scabies
Impetigo
Porphyria cutanea tarda
avoid exposure
Behavioral issues
Enuresis: involuntary urination >5 y/o; Dx UA to r/o UTI, Tx bed-wetting alarm > desmopressin > imipramine
Encopresis: involuntary defecation >4 y/o, majority due to chronic constipation and overflow incontinence; Dx KUB shows dilated/stoolfilled colon, Tx bowel catharsis + miralax
Breath-holding spells: child holds breath and passes out, due to pain or being upset; Tx avoid reinforcing behavior
Night terrors: child wakes up screaming/agitated, but falls back asleep and remembers nothing in the morning
Learned behavior: child wakes up scared and crying, in order to gain sympathy and sleep in mommys bed; Tx avoid reinforcing behavior
Conduct disorder: Capriciousness, Oppressive, Nonconfrontational, Deceitful, Unlawful, Carefree, Temper issues; <18 y/o
ADHD: short attention span, impulsivity, hyperactivity for >6 months in 2+ settings (e.g. home and school); risk of aggression; Dx
Vanderbilt scale, Tx dextroamphetamine or methylphenidate
Mental retardation (MR/DD): IQ <70; MCC overall is fetal alcohol syndrome, MC genetic cause is Down syndrome, MC inherited cause is
Fragile X syndrome
Abnormal physical exam findings
Head lice: due to Pediculosis capitis; Tx permethrin shampoo (lindane causes seizures in kids/elderly)
Traction alopecia: linear hair-loss in kids who tie their hair too tightly
Alopecia areata: hair stops growing suddenly small patches of complete hair loss w/ exclamation point stubs
Asymmetric red reflex: retinoblastoma (AD Rb on chromosome 13), juvenile cataracts (galactosemia, congenital rubella syndrome,
neurofibromatosis II, myotonic muscular dystrophy)
Cherry-red macula: Tay-Sachs disease (AR hexosaminidase A) w/o HSM, Niemann-Pick disease (AR sphingomyelinase) w/ HSM
Strabismus: cross-eyes; Tx ophtho c/s to patch the good eye (uncorrected strabismus can lead to ambylopia)
Cholesteatoma: small whitish debris-containing sac on TM, risk w/ recurrent otitis media; Tx ENT c/s for surgical removal
Primary teeth eruption: central incisors (at ~6 mo), lateral incisors, first molars, canines
Permanent teeth eruption: central incisors (at ~6 yr), lateral incisors, canines, first molars, second molars, third molars
Tooth decay: prolonged use of bottles high sugar concentration extensive tooth decay of all but mandibular front teeth
Tooth avulsion: facial trauma knocked out teeth; Tx transport teeth in mouth or milk/saline, then replant permanent teeth within 30 min
(earlier is better)
Erythema nodosum: painful red nodules on shins; MCC in kids is Strep pyogenes (not sarcoidosis like adults)
Micropenis: GH deficiency
Child abuse: suspect w/ retinal hemorrhages, subdural hematoma, multiple healed fx, posterior rib fx, metaphyseal corner (bucket
handle) fx, long-bone spiral fx (except distal tibia), cigarette burns, stocking-and-glove scalding water injury, or genital trauma/STDs; first
r/o medical causes, then do a complete physical exam, then get whole-body X-rays, then call CPS if necessary
Neonatal HIV: suspect w/ thrush, generalized LAD, hepatomegaly, and FTT; Dx HIV PCR (not ELISA since moms ab can cause false-positive),
requires Bactrim ppx for PCP pneumonia
Environmental exposure
Dog/cat bite: Tx copious irrigation, make sure tetanus is up-to-date, allow healing by 2 intention, PPx Augmentin for Pasturella cellulitis
Human bite + cellulitis: due to Eikenella or other oral anaerobes; Tx admit + debridement + IV abx, leave open to heal by secondary intention
Black widow bite: neurotoxin severe abdominal cramps, acute abdomen, n/v; Tx IV calcium gluconate + muscle relaxants
Brown recluse bite: necrotoxin local skin ulceration; Tx excise ulcer + skin graft
Heat stroke: T>105 after playing in the sun, #1 risk factor is dehydration, risk of rhabdomyolysis renal ATN; Tx emergent cold water bath +
IV fluids
Frostnip: cold exposure small/firm/cold/white blisters on exposed skin; Tx rewarming
Frostbite: cold exposure dead tissue numb/white extremities followed by erythema and pain on reexposure to heat
Chilblain: cold exposure small, ulcerated lesion on ears and fingertips; Tx reassurance
Cold panniculitis: cold exposure destruction of fat cells; popsicle panniculitis found on lips/cheeks of kids during summertime
Hypothermia: cold exposure T<95, lethargic, tired, uncoordinated, bradycardia; Tx gradual rewarming
Trench foot: prolonged cold/moisture exposure foot becomes cold, clammy, numb, pale, swollen
NEWBORN
APGAR score: score of 0-10 taken at 1 and 5 minutes; score of 0-3 requires resuscitation
0
1
Appearance
all blue/pale
mixed blue/pale and pink
Pulse
0
<100
Grimace
no response to stimulation
grimace
Activity
limp
some flexion of limbs
Respirations
0
slow/irregular
2
all pink
>100
active cough
active flexion of limbs
regular
Primitive reflexes: originate from brainstem and vestibular (CN VIII) nuclei
Tonic neck reflex: turning neck causes arm extension (ipsi) and flexion (contra)
Salmon patch (nevus flammeus): benign, splotchy red rash on forehead, eyelids, or back of neck; more prominent with exercise or emotion
Pustular melanosis: benign, little pustules that leave a hyperpigmented spot when ruptured
Erythema toxicum: benign, yellow-white papules w/ surrounding erythema, fluid exam shows eosinophils
Seborrheic dermatitis: greasy scaly rash, usually on scalp in newborns (cradle cap), can result in dandruff; Tx sunlight + mild shampoo
Sebaceous nevus: raised, yellow-orange hairless lesion on scalp; Tx resection before adolescence (can undergo malignant degeneration)
Neonatal acne: pimples on healthy newborn due to maternal hormones; Tx reassurance (mild), topical benzoyl peroxide or tretinoin (severe)
Incontinentia pigmenti: XR, inflammatory bullae that evolve into hyperpigmented lesions, lethal in males
SIDS: sudden-death in infants w/o underlying cause; prevent by putting infant on back to sleep, dont smoke around your kid
Breastfeeding contraindications: HIV, HSV on breast, active TB, chemotherapy, galactosemia, PKU, lithium, EtOH, iodine
LP contraindications: elevated ICP w/o open fontanelle, severe cardiorespiratory distress, puncture site cellulitis, severe coagulopathy
Circumcision contraindications: hypospadias (foreskin used to repair defect)
Oligohydramnios: renal problems amniotic fluid pulmonary hypoplasia (respiratory distress) + constraint deformities (club feet)
Polyhydramnios: GI obstruction or maternal diabetes amniotic fluid
Twin-twin transfusion syndrome (TTTS): abnormal vascular flow between mono-di twins donor twin oligohydramnios/anemia, recipient twin
polyhydramnios/polycythemia; Dx hct difference >15
Coombs test: indicated for neonatal jaundice in type-O or Rh- moms
ABO hemolytic disease: type-O mom w/ type-A/B baby develops anti-A/B IgG crosses placenta and attacks fetal RBCs causes fetal
hydrops; risk of late-onset high output CHF; Dx Coombs test, PPx RhoGAM, Tx intrauterine blood transfusions
Rh hemolytic disease (erythroblastosis fetalis): Rh- mom w/ 2nd Rh+ baby develops anti-D IgG crosses placenta and attacks fetal RBCs
causes fetal hydrops; Dx Coombs test, PPx RhoGAM, Tx intrauterine blood transfusions
Neonatal care
Choanal atresia: non-canalized nasal passages difficulty breathing while feeding but normal when crying; Dx nasal catheter or checking
for fog under nares, Tx nasal tubes
Meconium aspiration: suspect w/ meconium staining, low Apgar scores, respiratory distress, can result in systemic hypoxia and
pulmonary hypertension; Tx intubation + tracheal suction + O2 mask
Transient tachypnea of the newborn (TTN): tachypnea, grunting, possible cyanosis in a c/s infant due to retained fetal lung fluid; Dx CXR
shows pulmonary vascular markings, Tx 100% O2 (will resolve in 3 days)
Neonatal bloody stool: first get Apt test to differentiate maternal from fetal bleed, then further tests only if blood is fetal
SGA: Small for Gestational Age, <10th percentile; risk of congenital malformations, hypoglycemia (low glycogen/fat stores), future growth
retardation
LGA: Large for Gestational Age, >90th percentile; risk of shoulder dystocia, type 2 DM, future obesity
Hyperviscosity syndrome: fetal hypoxia reactive polycythemia (hct >65%) sludging/clotting of blood in lungs (respiratory distress),
brain (seizures, tremors), kidney (renal vein thrombosis), GI (necrotizing enterocolitis); Tx partial exchange transfusion
Narcosis: lethargic/limp neonate in mom that got intrapartum opioids for pain control; Tx NICU admit + naloxone
Diaphragmatic hernia: bowels herniate into chest cavity respiratory distress in a newborn; first put in a orogastric tube, then Dx CXR
shows bowels in chest cavity, Tx surgical repair (high morbidity/mortality)
Esophageal atresia/TE fistula: presents as drooling and choking on first feed; Dx CXR shows coiled NG tube, Tx surgical correction
Duodenal atresia: presents as bilious vomiting and polyhydramnios, risk w/ Down syndrome; Dx KUB shows double bubble
appearance, Tx surgical repair
Intestinal atresia: aka apple peel atresia; presents like duodenal atresia, due to vascular accidents in utero; Dx KUB shows triple bubble
appearance, Tx surgical repair
Cleft lip/cleft palate: complications include recurrent OM, hearing loss speech defects; Tx surgical repair (CL in 2-3 months, CP in 6 mo)
Pierre-Robin sequence: micrognathia posteriorly displaced tongue (glossoptosis) cleft palate + airway obstruction
Neonatal hypothyroidism : thyroid dysgenesis lack of T4/T3 synthesis subtle, nonspecific sx (constipation distended abdomen
umbilical hernia, bradycardia, hypothermia, large fontanelles, etc.); Dx TSH, Tx Synthroid
Neonatal thyrotoxicosis: maternal TSI crosses placenta hyperthyroidism tachycardia, tachypnea, irritability, diarrhea, vomiting, CHF,
etc.; Dx TSH, Tx propylthiouracil (PTU) for 2-4 months until moms ab disappear
Neural tube defects: anencephaly, spina bifida occulta (tuft of hair), meningocele, myelomeningocele; Dx AFP, PPx folate
supplements before 4th week of gestation
Pinky polydactyly: Tx surgical removal, also get echo for white (but not black) kids since white kids have cardiac issues as well
Neonatal tetanus: tetanus toxin (found in dirt) infects umbilical stump rigidity, trismus, opisthotonus, risus sardonicus
Neonatal thrush: acquired from moms vag, does not indicate immunodeficiency; Tx nystatin swish-n-spit
Necrotizing enterocolitis: presents as abdominal distention, vomiting, GI bleed, decreased bowel sounds; Dx KUB shows pneumatosis
intestinalis, Tx NPO/IVF/abx if unperforated, surgery if perforated
Neonatal RDS: prematurity or infant of diabetic mother lack of surfactant respiratory distress in a newborn; Dx L:SM ratio <2, PPx 48
hrs of maternal steroids, Tx surfactant + O2 therapy + CPAP
Retinopathy of prematurity: disorganized growth of retinal blood vx in premies scarring and retinal detachment; risk w/ both hypoxia
and oxygen toxicity
Harlequin syndrome: transient erythema on dependent half of body, more common in premies
Cerebral palsy: cerebral anoxia in utero brain damage non-progressive impairment of motor function (hypotonia, hyperactive DTRs, learning
disabilities, low APGAR at birth)
TORCHES
Presentation
Management
Congenital toxoplasmosis
chorioretinitis + hydrocephalus + intracranial
Tx pyrimethamine + sulfadiazine
calcifications
Congenital rubella syndrome
cataracts + deafness + PDA
Tx supportive care
Congenital CMV
usually asx, MC sequelae is sensorineural
--hearing loss
CMV inclusion disease
blueberry muffin rash, HSM/jaundice,
Tx IV GCV + supportive care
thrombocytopenia, periventricular calcifications
Neonatal HSV
vesicular rash, HSV pneumonitis, temporal lobe
Tx IV ACV + vidarabine if disseminated/systemic
encephalitis (focal seizures)
Neonatal HIV
suspect w/ thrush, generalized LAD,
Dx HIV PCR (not ELISA since moms ab can cause
hepatomegaly, and FTT
false-positive), requires Bactrim ppx for PCP
pneumonia, give IV ZDV to all neonates of
infected mothers
Early congenital syphilis
maculopapular peeling rash, snuffles (rhinitis w/
Dx screen w/ RPR/VDRL, confirm w/ TPPA or FTAserous, purulent, or bloody discharge), HSM,
ABS, Tx PCN + supportive care
jaundice, generalized LAD
Late congenital syphilis
deafness, saber shins, mulberry molars,
Dx screen w/ RPR/VDRL, confirm w/ TPPA or FTAHutchinson teeth, saddle nose
ABS, Tx PCN + supportive care
Congenital varicella syndrome
limb hypoplasia, clear vesicles cutaneous
Tx VZIG if mom has chickenpox from 5 days prior
scars, chorioretinitis, cortical atrophy
to 2 days after delivery, otherwise reassurance
Neonatal head trauma
Caput succedaneum: soft-tissue swelling of scalp where baby was delivered, crosses midline
Cephalohematoma: bleeding between periosteum and skull squishy feel to scalp that doesnt cross midline
Subgaleal hemorrhage: bleeding under galeal aponeurosis squishy feel to rapidly expanding scalp that crosses midline; Tx NICU admit
for possible hemorrhagic shock
Intraventricular hemorrhage: progressive hemorrhagic hydrocephalus in premature infant; Dx head CT, Tx VP shunt
Epidural hematoma: head trauma to temporal bone torn middle meningeal artery LOC w/ lucid interval uncal herniation death;
Dx head CT shows convex lens, Tx emergent craniotomy
FEN
Adiposity rebound: period of growth where BMI increases faster than height, average 5 yrs
Vision: 20/200 at birth 20/40 at 6 mo 20/20 at 4 yr
Failure to thrive: growth <5th percentile in 2+ of the following height, weight, head circumference; most commonly due to nonorganic causes; Dx
bone age (left wrist X-ray), Tx underlying cause
Constitutional growth delay: bone age < real age, tracks along low percentile on growth chart, good prognosis
Familial short stature: bone age = real age, usually have short parents, poor prognosis
Pathologic short stature: craniopharyngioma, hypothyroidism, GH deficiency, Turner syndrome, renal tubular acidosis
Vitamins
Deficiency
Toxicity
Vitamin A: used to treat cystic acne,
night blindness, dry skin
increased CSF pressure (headache, blurry
measles, and AML (M3 type)
vision), dry skin, teratogenic; found in
animal liver consumption
Vitamin B1 (thiamine): given to kids
dry beriberi (peripheral neuropathy), wet
--before IV D5 to prevent iatrogenic
beriberi (CHF), Wernicke-Korsakoff (ataxia,
Wernicke-Korsakoff
amnesia, confabulations, etc.)
Vitamin B2 (riboflavin)
cheilosis (dried cracks along corners of lips),
--corneal vascularization
Vitamin B3 (niacin)
pellagra (diarrhea, dermatitis, dementia)
flushing, pruritus (Tx NSAIDs)
Vitamin B6 (pyridoxine)
peripheral neuropathy, seizures,
--sideroblastic anemia; found in INH usage
Vitamin B7 (biotin)
seborrheic dermatitis, enteritis, alopecia;
--found in kids who eat raw eggs (avidin binds
biotin) and biotinidase deficiency
Vitamin B9 (folate): given to sickle cell
megaloblastic anemia w/o neuro sx, neural
--kids to help hematopoiesis
tube defects; found in babies fed goats milk
Vitamin B12 (cobalamin)
megaloblastic anemia w/ neuro sx; found in
--strict vegan diets and pernicious anemia
Vitamin C
scurvy (bleeding gums)
uric acid stones
Vitamin D: given to breast-fed kids who
rickets (bowed legs, rachitic rosary)
metastatic calcifications, kidney stones
dont get enough sunlight
Vitamin E
hemolytic anemia
hemorrhagic diathesis
Vitamin K: all infants get vitamin K shot
hemorrhagic diathesis
--at birth
ADEK deficiency: malabsorption syndromes (cystic fibrosis, celiac sprue, tropical sprue, Whipple disease, abetalipoproteinemia, pancreatic
insufficiency, lactose intolerance, etc.)
Goat milk: folate megaloblastic anemia
Cow milk: iron microcytic anemia pica, fatigue, pallor; Tx PO iron supplements
Breast milk: vitamin D nutritional rickets
Zinc deficiency: acrodermatitis enteropathica (erythematous desquamating rash on hands/feet, scalp, buttocks, mouth)
Selenium deficiency: CHF
Kwashiorkor: protein malnutrition FTT, anemia, edema, apathy, fatty liver
Marasmus: overall lack of calories FTT, subcutaneous fat loss, muscle atrophy, premature aged look
Fluids/electrolytes
Maintenance fluids: D5NS+20KCl using 100/50/20 rule for daily fluids, 4/2/1 rule for hourly fluids
Dehydration: diarrhea or vomiting lethargy, HR, BP, delayed capillary refill; Tx PO fluids (mild), 20 mL/kg bolus of NS/LR (severe)
Parkland formula: fluid resuscitation for burn victims; give LR at 4 mL/kg %BSA, over first 8 hrs then over the next 16 hrs
DRUGS/POISONS
Poisons
Presentation
Management
Acetaminophen
n/v, malaise, liver damage (LFTs)
wait 4 hrs then get acet levels, determine
need for N-acetylcysteine at that time (no
harm in waiting up to 8 hrs before giving
antidote)
Aspirin, oil of wintergreen
triad of fever, tinnitus, tachypnea causes
Tx sodium bicarb vs. hemodialysis
mixed respiratory alkalosis + AGMA
Caustic agents, drain cleaner, lye
esophageal erosion, possible perforation
Dx endoscopy to determine extent of
damage, Tx controversial (call poison
control)
Cyanide
headache agitation/confusion seizures
Tx nitrites + hydroxocobalamin +
and metabolic acidosis
thiosulfate
Hydrocarbons
usually asx, may have transient gagging and
Dx CXR to r/o aspiration pneumonitis,
Iron
Lead
Opioids
Organophosphates
Phenothiazine, metoclopramide
Shellfish
TCAs
Warfarin
Tx naloxone
Tx atropine + pralidoxime (2-PAM)
Tx diphenhydramine
Tx supportive care, may need mechanical
ventilation
Tx sodium bicarb or Fab antibody
fragments
Dx PT/PTT, Tx vitamin K + FFP if severe
coughing
upper GI bleed, abd pain, metabolic acidosis,
shock
LEAD Lead lines (basophilic stippling),
Encephalopathy, Anemia and Abdominal pain,
wrist Drop, foot Drop; MC source is paint in
old homes (before 1950)
AMS and AGMA after drinking homemade
alcohol, methanol has optic disc hyperemia,
EG has renal failure (oxalic acid crystals)
miosis, bradypnea, bradycardia, hypotension
kid playing in garden shed found
salivating/unconscious, blocks ACh-esterase
muscarinic sx (LUSHPADS BBB)
extrapyramidal sx (e.g. torticollis,
opisthotonus, dysphagia)
perioral parasthesias/numbness, generalized
weakness, paralysis
AMS, hypotension, anticholinergic effects
(dilated pupils, etc), widened QRS complex
hemorrhagic diathesis
goiter, hypothyroidism
Ebstein anomaly
fetal macrosomia (risk of shoulder dystocia), caudal regression syndrome (anal atresia to sirenomelia), CV
defects
CNS defects, hydrocephalus, microtia/anotia, micrognathia, athymia
preterm labor, IUGR, ADHD
tooth discoloration
phocomelia (hands attached to shoulders)
blocks folate absorption NTDs; best management for anticonvulsants is monotherapy at lowest effective
dose w/ careful monitoring
bone deformities, fetal bleeding, abortion
multiple anomalies
Common side-effects
Corticosteroids
Cyclophosphamide
Diphenhydramine
Doxorubicin (Adriamycin)
Erythromycin
HCTZ
Inhaled corticosteroids
Local epinephrine
Nitrates
NSAIDs
Pseudoephedrine
Sodium nitroprusside
Topical benzocaine (Orajel)
Vincristine
Side-effects
infection, HTN, hyperglycemia, cataracts, osteoporosis, truncal obesity w/ abdominal striae, etc.
hemorrhagic cystitis (Tx mesna)
drowsiness
dilated cardiomyopathy
risk of pyloric stenosis in <1 mo
hyperGLUC hyperGlycemia, hyperLipidemia, hyperUricemia, hyperCalcemia
thrush
vasoconstriction (contraindicated in end-organ supply)
methemoglobinemia (Tx IV methylene blue)
platelet dysfxn, renal impairment, peptic ulcers
sympathetic stimulation (tachycardia, hypertension, etc.)
cyanide poisoning
methemoglobinemia (Tx IV methylene blue)
peripheral neuropathy
GENETICS
Fragile X syndrome
XR FMR1 (CGG
trinucleotide repeats)
Williams syndrome
7q (includes elastin)
Cri-du-chat syndrome
5p
DiGeorge/velocardiofacial
syndromes
22q11
Klinefelter syndrome
47, XXY
47, XYY
45, XO
Noonan syndrome
---
VACTERL syndrome
---
AngelMan syndrome
Maternal 15q11
Prader-Willi syndrome
Paternal 15q11
Ehlers-Danlos syndrome
AD type 3 collagen
Beckwith-Wiedemann syndrome
---
Holt-Oram syndrome
AD TBX5
---
Neurofibromatosis II
Tuberous sclerosis
AD NF2
AD TSC
Sturge-Weber syndrome
---
PHACES syndrome
---
AD VHL
XR type 4 collagen
AD or associated w/
advanced paternal age
AD FGFR3 or
associated w/ advanced
paternal age
---
--AD NF1
Achondroplasia
---
Kartagener syndrome
dynein immotile
cilia
AR frataxin (GAA
triplet repeats)
Friedreich ataxia
Inborn errors of metabolism: suspect w/ neonatal vomiting + metabolic acidosis, unusual odor of urine/sweat, HSM, MR, hyperammonemia, FHx of
Mutation
AR phenylalanine
hydroxylase
Presentation
MR, mousy body odor, blue eyes,
blond hair
AR branched-chain
amino acid
Management
Dx Guthrie test, Tx dietary
phe/tyr, can relax dietary
restrictions over time but must
reinstate during pregnancy to
prevent maternal PKU
Tx dietary ile/leu/val
Galactosemia
Hereditary fructose
intolerance
AR aldolase B
Biotinidase deficiency
AR biotinidase
Tyrosinemia
AR fumarylacetoacetate hydrolase
AR glucose-6phosphatase
decarboxylase
AR gal-1P
uridyltransferase
Pompe disease
AR acid maltase
A1AT deficiency
AR 1-antitrypsin
Mitochondrial diseases
---
---
Hurler syndrome
AR -L-iduronidase
OTC deficiency
XR ornithine
transcarmbamylase
Alkaptonuria
AR homogentisate
oxidase
Homocystinuria
AR cystathionine synthase
Lesch-Nyhan syndrome
XR HGPRT
Medium-chain acyl-CoA
deficiency (MCADD)
Collagen defects
Osteogenesis imperfecta: AD type 1 collagen abnormal bone matrix (multiple fractures) + blue sclera + abnormal dentition + hearing loss;
often mistaken as child abuse
Ehlers-Danlos syndrome: AD type 3 collagen thin stretchy skin, joint hypermotility/dislocations, MVP, aortic aneurysms, aortic dissection
Alport syndrome: XR type 4 collagen nephritic syndrome (hematuria), deafness, ocular defects
CARDIOVASCULAR
Antibiotic ppx for dental procedures: give amoxicillin only if prior endocarditis, prosthetic valve, heart txp, or severe or repaired congenital heart
defects (do not give for innocent childhood murmurs)
Cyanosis: normal if peripheral (doesnt involve mucus membranes), diagnostic for R-to-L shunt if central (involves mucus membranes)
Benign murmurs: asymptomatic, <grade II, normal S2, no clicks, normal pulses
Pathologic murmurs: symptomatic, >grade III, diastolic or continuous
Congenital heart defects: 1% incidence, 2-6% w/ one sibling, 20-30% w/ two siblings
L-to-R shunts: late-onset cyanosis due to Eisenmenger syndrome; includes VSD, ASD, PDA
VSD: MC CHD overall, presents w/ holosystolic blowing murmur at LLSB, louder is better, most resolve spontaneously
PDA: presents w/ continuous machinery-like murmur + bounding pulses; Tx keep Patent w/ PGE1 and closed w/ indomethacin,
surgical closure if >1 mo (wont close spontaneously)
Eisenmenger syndrome: pulmonary hypertension reverses L-to-R shunts into R-to-L shunts
R-to-L shunts: early-onset cyanosis; includes ToF, TGV, TAPVR, Tricuspid atresia
Tetralogy of Fallot: PROVe Pulmonic stenosis (determines Prognosis), RVH, Overriding aorta, VSD; presents as cyanotic tet
spells and clubbing in a kid who squats for relief; Dx CXR shows boot-shaped heart, Tx shunt placement
Transposition of the great vessels: presents w/ life-threatening cyanosis in a newborn + single loud S2 without murmur; Dx CXR
shows egg on a string w/ RVH, Tx emergent PGE1 then cath lab for atrial septostomy
TAPVR: presents w/ cyanosis + dyspnea; Dx CXR shows diffuse reticular pattern from pulmonary edema
Tricuspid atresia: lack of tricuspid valve + hypoplastic RV cyanosis + LVH; Tx emergent PGE1 to keep PDA open and consult
surgery
Aortic coarctation: suspect w/ weak femoral pulse or treatment-resistant HTN at young age, consider Turner syndrome in short women; Dx
CXR shows rib-notching and figure 3 aorta, Tx balloon angioplasty
Ebstein anomaly: RA hypertrophy + atrialized RV + tricuspid valve dilatation; associated w/ antenatal lithium use
Mitral valve prolapse: AD; presents w/ mid-systolic click and late-systolic rumble, does not require abx ppx for dental procedures
Carotid artery dissection: trauma to head/neck/soft palate dissection of internal carotid artery stroke-like presentation, may have delayed onset
relative to traumatic incident; Dx MRI, Tx observation vs. anticoagulation vs. surgical repair
Cardiac diseases
Myocarditis: coxsackie B virus infx inflammation of myocardium results in systolic dysfxn fever + lethargy + CHF sx
Dilated cardiomyopathy (DCM): ventricular dilatation systolic dysfunction CHF sx (dyspnea, orthopnea, PND); Tx diuretics + inotropes,
heart txp if severe
Hypertrophic cardiomyopathy (HCM): AD -myosin heavy chain exertional dyspnea, angina, syncope, sudden death in a young athlete,
systolic murmur enhanced by preload; Dx echo + family hx, Tx -blockers vs. myomectomy vs. pacemaker
Rheumatic fever: strep throat anti-M ab type 2 hypersensitivity carditis, arthritis (MC), erythema marginatum, chorea,
subcutaneous nodules; Dx ASO titer, Tx amoxicillin + PO steroids
Kawasaki disease: CRASH and BURN Conjunctivitis, Rash, Adenopathy, Strawberry tongue, Hand/feet swelling, fever >5 days; Tx IVIG +
high-dose aspirin (watch out for Reye syndrome)
Postpericardiotomy syndrome: pericardial effusion w/ possible tamponade s/p cardiac surgery; presents w/ Beck triad (hypOtension, JVD,
muffled heart sounds)
Arrhythmias
Supraventricular tachycardia (SVT): MC symptomatic arrhythmia in kids; re-entrant mechanism HR >200 sx of low cardiac output
(dyspnea, pallor, syncope); Tx vagal maneuvers (carotid massage) or IV adenosine
WPW syndrome: presence of atrioventricular accessory tract SVT + delta wave on EKG; Tx radiofrequency ablation
Congenital heart block: maternal SLE anti-Ro/SSA attacks fetal heart conduction complete (3) heart block
Prolonged QT syndrome: prolonged QT interval uncoordinated repolarization torsades de pointes (Tx IV mag) death
RESPIRATORY
Acute respiratory failure: hypoxemia (PO2 <50) or hypercapnea (PCO2 >60) cyanosis, tachypnea, grunting, nasal flaring, chest retractions; Tx ABCs,
then adequate oxygenation (may require intubation), then address underlying cause
Wheezing: asthma (MCC), bronchiolitis, cystic fibrosis, foreign body aspiration, tracheomalacia
Asthma: reversible airway obstruction wheezing, cough, chest tightness, dyspnea; normal PCO2 is a bad sign (retaining CO2 despite
hyperventilation); Dx reversible FEV1/FVC <70%
Asthma + thrush: due to inhaled corticosteroids; Tx rinse mouth after inhaler use
Respiratory infx
Croup: parainfluenza infx barking cough, low-grade fever, respiratory distress; Dx AP neck X-ray shows steeple sign, Tx PO steroids +
O2 therapy > racemic epinephrine > intubation
Bacterial tracheitis: rare complication of croup (superinfection), presents w/ biphasic stridor, spiking fever, respiratory distress;
Tx emergency intubation + IV abx
Epiglottitis: H. flu infx of epiglottis sore throat, fever, inspiratory stridor, drooling, sitting on a table leaning forward; Dx lateral neck
X-ray shows thumbprint sign, Tx emergency intubation + IV abx
Bronchiolitis: RSV infx during wintertime bronchiolar inflammation wheezing, URI sx, respiratory distress, risk of developing
asthma; Tx supportive care w/ monitoring of O2 and hydration status (ribavarin if severe, pavilizumab ppx for high-risk infants)
Typical PNA: Strep pneumo (MCC) infx acute-onset fever, chest pain, productive cough; Dx CXR shows lobar consolidation, Tx ceftriaxone
or respiratory fluoroquinolones
Atypical PNA: Mycoplasma (MCC), Legionella, or Chlamydia infx inflammation of lung interstitium presents w/ fever, malaise,
nonproductive cough; Dx CXR shows interstitial infiltrates, Tx azithromycin
Empyema: Strep/Staph infx of pleural space respiratory distress; Dx CXR shows unilateral white out of lung, Tx vancomycin + chest tube
drainage
Tuberculosis: Mycobaterium tuberculosis infx cough/hemoptysis, fever, weight loss; Dx Tb skin test (>15 mm w/o risk factors, >10 mm w/
risk factors, >5 mm w/ immunosppression or known contacts) if positive, get CXR
Active TB: positive CXR, Tx RIPE (Pyrazinamide + INH + Rifampin + Ethambutol) x 6 months
Retropharyngeal abscess: Staph/Strep or oral anaerobe infx of posterior pharyngeal wall fever, sore throat, muffled voice, drooling;
Dx lateral neck X-ray shows bulging mass, Tx emergent I+D
Peritonsillar abscess: Staph/Strep or oral anaerobe infx fever, sore throat, hot potato voice, deviated uvula; Tx emergent I+D
Pertussis: Bordetella pertussis via respiratory droplets whooping cough (short bursts of cough followed by loud inspiratory sound);
Dx CBC (lymphocytosis), confirm w/ nasopharyngeal swab if necessary, Tx azithromycin for pt + all close contacts (regardless of
immunization status)
Bronchopulmonary dysplasia: inadequate repair of acute lung injury in premies arrested lung development chronic respiratory sx,
need for O2 beyond 1 month; Dx abnormal CXR (nonspecific), Tx long-term supplemental O2
Congenital cystic adenomatoid malformation (CCAM): improper development of bronchioles cystic mass in lungs asx if small,
respiratory distress w/ mediastinal shift if large; Dx chest U/S, Tx surgical excision
Laryngomalacia: soft, small, underdeveloped larynx inspiratory stridor in neonates; Dx fiberoptic bronchoscopy, Tx reassurance (will
resolve w/ growth), feed child only while upright and keep him upright for 30 min afterwards
Vascular rings: congenital abnormalities of aortic arch or branches rings around airway can compromise ventilation inspiratory
stridor relieved w/ opisthotonic position (crowing respiration); Tx surgery
Esophageal atresia/TE fistula: presents as drooling and choking on first feed; Dx CXR shows coiled NG tube, Tx surgical correction
Neonatal apnea: breath-holding spells >20 seconds (<20 seconds is normal) w/ possible cyanosis or bradycardia, due to immature respiratory center
(central) or airway obstruction
Apparent life-threatening event (ALTE): apnea + color change (cyanosis, pallor), change in muscle tone (limpness), choking/gagging
Obstructive sleep apnea: Dx polysomnography, Tx underlying cause (tonsillectomy/adenoidectomy, weight loss, CPAP)
Idiopathic pulmonary hemosiderosis: unknown etiology bleeding into lungs recurrent PNA w/ hemoptysis, rapid clearing of CXR findings, irondeficiency anemia; Dx BAL shows hemosiderin-laden macrophages, Tx steroids
Tension PTX: PTX + building pressure mediastinal shift, hypOtension, JVD, absent unilateral breath sounds, hyperresonant to percussion; Tx emergent
needle thoracostomy + chest tube
ABG analysis
Dx
Causes
Management
Respiratory acidosis
pH <7.4, CO2 >40
hypoventilation
increase ventilation
Respiratory alkalosis
pH >7.4, CO2 <40
hyperventilation 2/2 pain, fever,
Tx underlying cause
ARDS, sepsis
NAGMA
pH <7.4, CO2 <40, AG 8diarrhea, glue sniffing, RTA,
Tx underlying cause
12
hyperchloremia
AGMA
pH <7.4, CO2 <40, AG >12
MUDPILES
Tx underlying cause
Metabolic alkalosis
pH >7.4, CO2 >40
vomiting, antacids,
Tx underlying cause
hyperaldosteronism
GI/HEPATOBILIARY
Cyclical vomiting: idiopathic, recurrent self-limited episodes of n/v in children, no abdominal pain or constipation/diarrhea; Tx antiemetics
Upper GI: proximal to Ligament of Treitz
Infant GERD: common complaint, presents w/ regurgitation of recently ingested food; Dx esophageal pH probe (gold standard but rarely
necessary), Tx thickened feeds + reassurance (will resolve by 1-2 y/o)
Eosinophilic esophagitis: allergic response to food in esophagus GERD-like sx unresponsive to PPIs; Dx EGD + bx shows eosinophils in
esophagus, Tx PO steroids
Esophageal atresia/TE fistula: presents as drooling and choking on first feed; Dx CXR shows coiled NG tube, Tx surgical correction
Mallory-Weiss syndrome: forceful emesis small mucosal tears in esophagus streaks of blood in vomitus; Tx reassurance
Boerhaave syndrome: forceful emesis esophageal rupture severe retrosternal pain + acute distress; Tx surgical repair
Caustic ingestion: alkali are worse than acids; Dx endoscopy to determine extent of damage, Tx controversial (call poison control)
Foreign body ingestion: Tx emergent removal of disc batteries stuck in esophagus, other materials can be watched
Pyloric stenosis: presents w/ non-bilious projectile vomiting in first-born boys; Dx palpable epigastric olive + abdominal U/S, Tx
pyloromyotomy
PUD: presents w/ gnawing epigastric pain (can persist at night) + occult GI bleed; Dx EGD, Tx PPIs
Lower GI: distal to Ligament of Treitz
Volvulus (malrotation): incomplete rotation of GI tract during development bilious vomiting, abdominal pain/distention; Dx barium
enema shows malposition of the cecum, Tx emergent surgical correction (risk of short gut)
Meconium ileus: pathognomonic for CF, presents in newborn w/ bilious vomiting, abdominal pain/distention; Dx KUB shows dilated
megacolon but barium enema shows microcolon from disuse, Tx gastrograffin enema
Acute appendicitis: lymphoid hyperplasia or fecalith impaction obstructed appendix w/ bacterial overgrowth presents w/ fever,
anorexia, n/v, diffuse abdominal pain that localizes to RLQ; Dx WBC + CT scan or U/S, Tx appendectomy
Mesenteric adenitis: Yersinia enterocolitica infx appendicitis-like presentation, associated w/ chitterlings and daycare centers
Intussusception: presents w/ colicky abdominal pain that lasts 1 min then resolves + currant jelly stools, RUQ sausage-like mass on
abdominal exam; Dx/Tx air contrast enema
Hirschsprung disease: neural crest cells fail to migrate lack of nerves in distal colon chronic constipation since birth; Dx screen w/
barium enema, confirm w/ rectal bx, Tx surgical pull-through
Necrotizing enterocolitis: presents as abdominal distention, vomiting, GI bleed, decreased bowel sounds; Dx KUB shows pneumatosis
intestinalis, Tx NPO/IVF/abx if unperforated, surgery if perforated
Anal atresia: Tx surgical repair (low pouch), colostomy then delayed repair (high pouch)
Congenital inguinal hernia: patent processus vaginalis indirect inguinal hernia incarcerated bowel is common; Tx elective
herniorrhaphy prior to d/c
Meckel diverticulum: MCC painless LGIB in a child; Dx technetium uptake for ectopic gastric mucosa, Tx surgery if symptomatic
Neonatal GI bleed: first get Apt test to differentiate maternal from fetal bleed, then further tests only if blood is fetal
Functional constipation: infrequent large/hard stools + normal physical exam; Dx KUB shows stool-filled megacolon, Tx reassurance +
dietary counseling
Encopresis: involuntary defecation >4 y/o, majority due to chronic constipation and overflow incontinence; Dx KUB shows stool-filled
megacolon, Tx bowel catharsis + miralax
Toddler diarrhea: chronic explosive diarrhea in an infant w/ normal physical exam; Tx reassurance
Malabsorption syndromes: present w/ steatorrhea + vitamin ADEK deficiency
Cystic fibrosis: AR CFTR (F508) thick mucus recurrent Pseudomonas pneumonia, bronchiectasis, infertility, chronic pancreatitis
malabsorption/steatorrhea + type 1 diabetes, meconium ileus (uncommon but pathognomonic), focal biliary cirrhosis, nasal polyps; Dx sweat
chloride test x2 (>60), Tx pancreatic enzymes + vitamins ADEK + chest physiotherapy + mucolytics (N-acetylcysteine)
Lactose intolerance: lactase (disaccharidase) deficiency at brush border lactose provides osmotic gradient for water + acts as GI flora
nutrient bloating, flatulence, diarrhea; Dx hydrogen breath test, Tx dietary lactose
Celiac disease: AR MTTP (microsomal TG transfer protein) gluten hypersensitivity chronic non-bloody diarrhea dermatitis
herpetiformis; Dx anti-gliadin or anti-endomysial ab, Tx dietary wheat/gluten
Abetalipoproteinemia: celiac disease-like presentation but normal GI bx; Tx ADEK supplements + low-fat diet
Inflammatory bowel disease (IBD): presents w/ flare-and-remission pattern of crampy abdominal pain, bloody diarrhea, and weight loss
Crohn disease
Ulcerative colitis
Location
mouth to anus w/ skip lesions, rectal sparing
colorectal, continuous lesion
Morphology
transmural inflammation, cobblestoning,
mucosal inflammation, crypt abscesses and
noncaseating granulomas
pseudopolyps
Complications
strictures, fistulas, SBO
toxic megacolon, colorectal cancer
Dx
+calprotectin, +ASCA, KUB shows terminal ileal
+calprotectin, +p-ANCA, KUB shows lead pipe sign
string sign
Tx
steroids + 5-ASA
steroids + 5-ASA + annual colonoscopy
Neonatal hyperbilirubinemia
Physiologic hyperbilirubinemia: appears after day 2, direct bilirubin <1, total bilirubin <12
Pathologic hyperbilirubinemia: suspect w/ jaundice on day 1, direct bilirubin >2, total bilirubin >20 (risk of kernicterus), rate of rise >5/day;
MCC neonatal hepatitis and biliary atresia
Biliary atresia: lack of CBD progressive direct hyperbilirubinemia; Dx abdominal U/S, confirm w/ HIDA scan, Tx hepatoportoenterostomy
(Kasai procedure)
Choledochal cyst: cyst in CBD biliary tree obstruction progressive direct hyperbilirubinemia; Dx abdominal U/S, confirm w/ HIDA scan,
Tx surgery
Breast-feeding jaundice: feeding dehydration retained meconium enterohepatic circulation of bilirubin; Tx feeding frequency
Acute cholecystitis: inflammation of gallbladder Charcot triad (RUQ pain, n/v, fever); Dx RUQ U/S, Tx NPO/IVF/abx then lap chole within
24 hrs
Acute pancreatitis: I GET SMASHHED (recall acronym) inflammation of pancreas stabbing epigastric pain boring through to the back,
exacerbated w/ eating; Dx screen w/ amylase/lipase, confirm w/ abdominal U/S, Tx NPO/IVF/pain meds
Viral hepatitis: presents w/ jaundice, RUQ pain, n/v, dark-colored urine
Buzzwords
Management
HAV (fecal-oral)
asymptomatic, daycare, travel
Dx HAV IgM (acute), HAV IgG (immune or previous
infx); Tx supportive care
HBV (parenteral, sexual)
polyarteritis nodosa, MGN
Dx HBsAg (acute), HBsAb (immune or previous
infx), HBcAb IgM (window), HBeAg (infectious); Tx
IFN-
HCV (parenteral, sexual)
cryoglobulinemia, chronic infx, carriers,
Dx HCV RNA (acute or chronic); Tx IFN- + ribavarin
cirrhosis, carcinoma, IVDA, MPGN
HDV (parenteral, sexual)
deadly, defective, HBV co-infection
Dx HDV Ab; Tx IFN-
HEV (fecal-oral)
cruise ships, fatal in pregnancy
Dx HEV Ab; Tx supportive care
A1AT deficiency: AR 1-antitrypsin inability to export enzyme builds up in liver (cirrhosis) and cant break down proteolytic enzymes in
lungs (early-onset panacinar emphysema)
Wilson disease (hepatolenticular degeneration): AR ATP7B (copper-transporting ATP-ase) copper overload cirrhosis + movement
disorder + hemolytic anemia + Kayser-Fleischer corneal rings; Dx LFTs/ceruloplasmin/total copper/free copper, Tx D-penicillamine
Reye syndrome: viral infx + ASA = fatty liver/liver failure, vomiting, AMS, 40% mortality rate (due to cerebral edema herniation)
Gilbert syndrome: AD UGT-glucuronyltransferase mild jaundice following stress or starvation; benign
RENAL/GU
Renal
Nephrotic syndrome: loss of negative charge on GBM proteinuria edema, hypoalbuminemia, hyperlipidemia; Dx UA shows fatty casts
Asymptomatic proteinuria: repeat dipstick, then quantify w/ 24 hr urine, then refer to nephro if still positive
Nephritic syndrome: inflammation of glomeruli hematuria, oliguria, HTN, azotemia; Dx UA shows RBC casts
Asymptomatic hematuria: repeat UA, then get renal imaging if still positive
Minimal change disease: nephrotic syndrome in kids following a viral URI, MCCOD is spontaneous bacterial peritonitis; Tx steroids, saltrestriction + diuretics during flares
WAGR syndrome: WT1 on chromosome 11 Wilms tumor (kidney), Aniridia, GU anomalies, mental Retardation, hemihypertrophy
Neuroblastoma: N-myc amplification proliferation of neural crest cells in adrenal gland abdominal mass/pain + opsoclonus-myoclonus
syndrome (muscle jerks + eyelid jerks) bone mets (pancytopenia); Dx urinary HVA/VMA
Goodpasture syndrome: anti-GBM antibodies attack pulmonary and renal basement membranes hemoptysis + hematuria; Dx renal bx +
linear-staining immunofluorescence
Fanconi syndrome: proximal tubule dysfunction defective resorption of amino acids, bicarb, glucose, phosphate polydipsia, polyuria,
glucosuria, aminoaciduria, type 2 RTA, hypophosphatemic rickets, etc.
Type 1 RTA: distal RTA, collecting duct cant excrete H+ metabolic acidosis + urinary alkalosis, hypo-K
Type 2 RTA: proximal RTA, proximal tubule cant resorb bicarb metabolic acidosis + urinary alkalosis, hypo-K
Type 4 RTA: hyperkalemic RTA, aldosterone or aldosterone-R metabolic acidosis + urinary acidosis, hyper-K
Low implantation of ureter: asx in boys, wet w/ urine all the time in girls b/c ureter drips into vagina instead of bladder; Dx IV pyelo, Tx
surgical correction
Posterior urethral valve: presents w/ oliguria + lower abdominal mass (distended bladder) in a neonate; first catheterize to empty bladder,
then Dx VCUG, Tx resection
Myoglobinuria: rhabdomyolysis (heat, niacin, etc.) myoglobin in urine risk of renal failure; Dx CPK, UA shows heme but no RBC
Alport syndrome: XR type 4 collagen nephritic syndrome (hematuria), deafness, ocular defects
Enuresis: involuntary urination >5 y/o; Tx bed-wetting alarm > desmopressin > imipramine
Idiopathic hypercalciuria: persistent excretion of calcium irritates urinary tract dysuria, risk of kidney stones, microscopic hematuria w/
recurrent episodes of gross hematuria
Kidney stones: presents w/ flank pain radiating to groin + hematuria; Dx U/S or CT scan, Tx hydration (< cm), shockwave lithotripsy (2
cm), surgery (>2 cm)
Dialysis indications: AEIOU Acidosis (severe metabolic acidosis), Electrolytes (severe hyperkalemia), Intoxication, Overload (severe hypervolemia),
Uremia (BUN >150, pericarditis)
Kidney infx
Lower UTI (acute cystitis): presents w/ dysuria, frequency/urgency; risk in uncircumcised males; Dx UA/UCx, Tx Bactrim > Cipro
Upper UTI (acute pyelonephritis): presents w/ dysuria, frequency/urgency, flank pain, fever/chills; Dx UA/UCx, Tx ceftriaxone
VCUG: indicated to r/o VUR in all males w/ UTIs, girls <5 y/o, or girls >5 w/ 2+ UTIs
Vesicoureteral reflux (VUR): ureters implanted into wrong site on bladder no mechanism for preventing retrograde urine reflux
recurrent UTIs at young age; Dx VCUG, Tx long-term abx until kid grows out of it (low grade), surgical reimplantation of ureter (high grade)
Chronic pyelonephritis: VUR recurrent upper UTI kidney scarring w/ blunted calyces on IV pyelo
Nephronia: halfway between pyelonephritis (dysuria, frequency/urgency, flank pain, fever/chills) and renal abscess; Dx CT scan shows
distinct tissue in kidney, Tx long-term IV abx
Poststreptococcal GN: GAS infx (strep throat, impetigo, cellulitis) ag-ab complexes deposit in GBM nephritic syndrome sx
(hematuria, HTN, oliguria, azotemia, edema); Dx ASO titers, Tx supportive care
Male GU
Inconspicuous penis: normal in fat boys, retract foreskin and measure refer to urology if <2.5 std dev
Micropenis: GH deficiency
Phimosis: inability to retract foreskin, Tx reassurance (normal for <3 y/o), urology consult (>3 y/o)
Hydrocele vs. scrotal edema: scrotal edema feels like a big scrotum, hydrocele feels like a big nut
Cryptorchidism: undescended testis high risk for testicular torsion and seminoma; Dx U/S of inguinal canal, Tx orchipexy if undescended
by 1 y/o (to avoid sterility and cancer)
Potter sequence: bilateral renal agenesis (or other renal abnormalities) inability to secrete amniotic fluid in utero oligohydramnios
w/ amnion nodosum (granules on amnion) pulmonary hypoplasia (respiratory distress) + constraint deformities (club feet)
Prune belly syndrome: congenital malformation in males that consists of lax abdominal wall marked distention, dilated urinary tract
Potter sequence, bilateral cryptorchidism
Female GU
Infant menstruation: maternal estrogen withdrawal endometrial sloughing sticky gray discharge (may be blood-tinged) in a 2-week
girl; Tx reassurance (normal phenomenon)
Bubble-bath vaginitis: vaginal irritation in little girls due to chemicals from bubble baths; Tx d/c bubble baths, wear cotton underwear,
wipe front-to-back after potty
Polycystic ovarian syndrome (PCOS): LH, FSH, E/T anovulation, hirsutism, obesity, polycystic ovaries; Tx OCP + weight loss
metformin
Pelvic inflammatory disease (PID): polymicrobial infx of upper female genital tract (endometritis, salpingitis, peritonitis) nonspecific
lower abdominal pain risk for infertility, ectopic pregnancy, pelvic adhesions, abscesses; Dx STD tests + cervical motion tenderness, Tx
ceftriaxone + doxycycline
Umbilical granuloma: red nodule on separated umbilical cord; Tx topical silver nitrate
Omphalocele: intestines protrude into umbilical cord w/ peritoneal covering, risk of associated cardiac defects; first sterile wrapping,
then Dx echo to r/o cardiac defects, then Tx closure if small, silo if large
Gastroschisis: intestines tear through abdominal wall w/o peritoneal covering; first sterile wrapping, then Tx closure if small, silo if large
Umbilical hernia: associated w/ neonatal hypothyroidism, Beckwith-Wiedemann syndrome; Tx reassurance (<2 cm), surgical repair (>2 cm
or persistent into kindergarten)
Vitelline fistula: failure of vitelline duct to obliterate meconium from umbilical cord
NEURO/MSK
Muscular dystrophy
Duchenne muscular dystrophy (DMD): XR dystrophin muscle cells die off ascending weakness w/ Gowers maneuver, calf
pseudohypertrophy, death by 15 y/o; Dx CPK + muscle bx, no tx available
Myotonic muscular dystrophy: AD; delayed muscle relaxation (cant release handshake) + distal muscle wasting (older kids), neonatal
respiratory distress (newborn), cataracts, ptosis, baldness, hypogonadism; Dx CPK + muscle bx, no tx available
Charcot-Marie-Tooth disease: intrinsic foot muscle atrophy (pes cavus), then intrinsic hand muscle atrophy
Muscle weakness/paralysis
Myasthenia gravis: anti-nAChR gradually progressive muscle weakness (initial sx is ptosis, diplopia, blurry vision) that get worse w/
repetitive use; Dx edrophonium test + get chest CT to r/o thymoma, Tx pyridostigmine
Acute disseminated encephalomyelitis (ADEM): autoimmune demyelination after viral infx multiple sclerosis-like sx but in kids <10 y/o; Dx
MRI shows white matter demyelination, Tx high-dose corticosteroids
Acute infantile hemiplegia: trauma, infx, hypercoagulable state, arteritis, or metabolic d/o MCA stroke in infant abrupt onset
hemiplegia
Guillain-Barre syndrome: rapidly ascending paralysis after viral infx (or other infx), risk of respiratory arrest (Tx mechanical ventilation);
Dx CSF shows protein, Tx IVIG or plasmapheresis
Bell palsy: facial nerve palsy 2 weeks after viral infx; Tx eyedrops (to prevent keratitis), will resolve on its own
Phrenic nerve palsy: presents w/ respiratory distress and unilateral decreased breath sounds in neonate (phrenic nerve innervates
hemidiaphragm); Dx chest U/S or fluoroscopy shows seesaw diaphragm
Erb-Duchenne palsy: C5/C6 palsy after difficult delivery waiters tip posture
Klumpke palsy: C7-T1 palsy after difficult delivery total hand paralysis + ipsilateral Horner syndrome
Werdnig-Hoffman disease (SMA type 1): SMN gene (protects neuroblasts from atrophy) progressive degeneration of CNS motor
neurons respiratory distress + tongue fasciculations in newborn; Tx supportive care
Seizures
Todd paralysis: focal weakness for 1-2 days following grand-mal seizure
Malignant hyperthermia: AD ryanodine receptor T>104 + muscle rigidity + rhabdomyolysis following anesthesia; Dx caffeine contracture test, Tx
dantrolene sodium, 100% O2, cooling blankets
Craniosynostosis: premature fusion of skull sutures abnormal head shape + impaired brain development, 80% sporadic, 20% genetic (e.g. Crouzon
syndrome); Tx surgical correction
Migraine headache: bifrontal headache w/o aura, or diffuse throbbing headache, atypical presentation in kids (no nausea/vomiting,
photophobia, phonophobia)
Tension headache: bilateral, tight squeezing pain + posterior neck muscle stiffness
Cluster headache: unilateral, episodic burning, stabbing pain behind eye + ipsilateral tearing, flush, rhinorrhea
Pseudotumor cerebri: fat girl w/ pulsatile headache/tinnitus, high risk of blindness; first get imaging to r/o mass lesion (can have empty
sella), then get LP w/ opening pressure to r/o infx causes, Tx acetazolamide vs. serial LPs
Brain abscess: headache + focal neuro sx + fever, risk w/ congenital heart defects; Dx head CT/MRI, Tx surgery + IV abx (unifocal), IV abx (multifocal)
Brain tumor: headache + focal neuro sx + subacute onset; infratentorial more common <10 y/o, supratentorial more common >10 y/o
Craniopharyngioma: embryological remnant of Rathke pouch in sella turcica headache, bitemporal hemianopsia, papilledema; Dx MRI
shows suprasellar calcified cysts, Tx transsphenoid hypophysectomy
Pinealoma: brain tumor at rostral midbrain vertical gaze paralysis (Parinaud syndrome) + eyelid retraction (Collier sign) + ICP sx
Retinoblastoma: AD Rb on chromosome 13 retinoblastoma (MCC leukocoria in kids) + risk of osteosarcoma later in life
Cushing triad: brain mass lesion ICP HR, BP, irregular RR
Epidural hematoma: head trauma to temporal bone torn middle meningeal artery LOC w/ lucid interval uncal herniation death; Dx head CT
shows convex lens, Tx emergent craniotomy
Infantile botulism: ingestion of C. botulinum bacteria (not toxin) in raw honey bacteria releases toxin in GI tract constipation (initial sx) then
gradual flaccid paralysis; Tx BabyBIG (botulinum immunoglobulin) + ventilator support
Dandy-Walker syndrome: enlargement of 4th ventricle (hydrocephalus) + agenesis of cerebellar vermis
Acute cerebellar ataxia: autoimmune attack on cerebellum after a viral infx cerebellar sx (ataxia, nystagmus, dysarthria); Dx of exclusion
Rasmussen encephalitis: autoimmune attack on brain rapid degeneration, initially presents w/ frequent and worsening seizures; Dx MRI, Tx
hemispherectomy
Pervasive developmental disorders
Autism: characterized by problems w/ social interaction, communication skills, and repetitive/stereotyped patterns of behavior and
activity before 3 y/o; must get hearing test to r/o deafness
Asperger syndrome: mild autism w/ normal language skills and cognitive development
Rett syndrome: MECP in girls normal development for 5 months, then rate of head growth + loss of purposeful hand movements, then
ataxia, language skills, hand wringing
Childhood disintegrative disorder: normal development for >2 years, then loss of previously acquired skills
Learning disability: significant discrepancy between IQ and ability in one of the following math, reading, or writing
Neurocardiogenic syncope: presents as 6 Ps syncope w/ upright Posture, Precipitating event causing intense emotion, Prodrome of dizziness or
light-headedness, Pallor, no Palpitations, no Postictal sx; Dx tilt table testing, Tx adequate hydration
Transient tic disorder of childhood: nonrhythmic, spasmodic, involuntary behaviors (e.g. blinking, throat clearing) that last <1 yr; Tx reassurance
Tourette syndrome: severe tic disorder w/ multiple daily motor/vocal tics, may have echolalia or coprolalia (rare), association w/ OCD and ADHD; Tx
haloperidol > 2-agonists (clonidine, guanfacine)
INFECTIOUS DISEASES
Ophthalmia neonatorum
Chemical conjunctivitis
Timing
day 0-1
Management
Tx reassurance
Gonococcal conjunctivitis
Chlamydia conjunctivitis
day 2-5
day 5-14
Features
not seen anymore since silver nitrate
drops are rarely used
can cause corneal ulceration
can cause chlamydial pneumonia
(staccato cough + eosinophilia)
STDs
Chlamydia
Bugs
Chlamydia trachomatis
Presentation
urethritis in men; cervicitis, PID, TOA, often
asx in women
Management
Dx Chlamydia NAAT, Tx
azithromycin (+ ceftriaxone)
Gonorrhea
Neisseria gonorrhoeae
Vaginal candidiasis
Candida albicans
Syphilis
Treponema pallidum
Chancroid
Haemophilus ducreyi
Herpes simplex
HSV-1/2
Lymphogranuloma
venereum
Chlamydia trachomatis,
L1-L3 serotypes
Condyloma acuminata
Bacterial vaginosis
HPV-6/11
Gardnerella vaginalis
Trichomoniasis
Trichomonas vaginalis
HIV/AIDS
HIV-1/2
Phthirus pubis
Tx removal
Dx wet prep (clue cells), Tx
metronidazole
Dx wet prep (motile
trichomonads), Tx
metronidazole
Dx screen w/ ELISA, confirm w/
WB, HIV PCR in infants; Tx
HAART (2 NRTIs + 1 NNRTI or
PI)
Rule-out sepsis: T >100.4 in any neonate (<28 days) gets admitted and the full work-up (UA/UCx, CSF, blood cx, CXR, etc.), MCC viral infx; Tx amp+gent
until cx negative
Bacteria
Neonatal PNA: MCC GBS; presents as respiratory distress, fever/hypothermia, leukocytosis/leukopenia w/ left-shift; Dx CXR, Tx ampicillin +
gentamicin
Neonatal meningitis: MCC GBS; presents as fever, irritability, AMS, bulging fontanelle, and may not have meningeal signs; Tx ABCs then LP
then ceftriaxone + vancomycin (different from adults, where youd get CT then LP)
Listeria meningitis: due to maternal ingestion of lunch meats or unpasteurized dairy products
Acute bacterial sinusitis: Strep pneumo > H. flu > Moraxella catarrhalis superinfx of viral URI sinus tenderness, nasal congestion/discharge,
headache, low-grade fever; Tx amoxicillin
Otitis media: Strep pneumo > H. flu > Moraxella catarrhalis; Tx amoxicillin
Diphtheria: due to Corynebacterium diphtheriae; presents as mild sore throat that leads to pseudomembranous pharyngitis, LAD with bull
neck appearance, possible respiratory compromise
Shigellosis: watery/bloody diarrhea, fever, tonic-clonic seizures can precede GI sx (Ekiri syndrome); Dx stool cx, Tx IV fluids + ceftriaxone
Strep throat: GAS infx of pharynx sore throat, fever, tonsillar exudates, palatal petechiae; Dx rapid strep test, Tx amoxicillin
Scarlet fever: due to GAS exotoxin; presents w/ sore throat, fever, strawberry tongue, sandpaper rash w/ possible
desquamation of palms/soles; Dx ASO titers or rapid strep test, Tx amoxicillin
Arcanobacterium haemolyticum: strep throat/scarlet fever-like presentation but throat cx grows out Arcanobacterium instead
Toxic shock syndrome: due to S. aureus TSST, often found in tampons; presents w/ septic shock, diffuse maculopapular rash
(desquamation of palms/soles is late finding), strawberry tongue; Tx admit + stabilize + IV nafcillin (prevents recurrence)
Staph food poisoning: ingestion of preformed S. aureus enterotoxin diarrhea, vomiting, abdominal cramps within 6 hrs
Meningococcemia: meningitis, purpura fulminans (petechiae becoming purpura in front of your eyes), death by bilateral adrenal
hemorrhage (W-F syndrome); Dx blood cx x3, Tx IV abx, PPx Rifampin for Roommates
Leptospirosis: due to Leptospira interrogans; presents as fever/chills, sore throat, myalgias, headache, cervical LAD, scleral injection,
photophobia, and can lead to meningitis (but most infx are subclinical)
Infx endocarditis: usually due to Strep/Staph; presents as FROM JANE Fever, Roth spots, Osler nodes, Murmurs, Janeway lesions, Anemia,
Nailbed hemorrhage, Embolic phenomena; Dx blood cx x3, Tx IV abx
Osteomyelitis: fever + localized bone pain, due to hematogenous spread or direct inoculation; Dx bone scan (X-ray can be false-neg), Tx
admit + IV abx
Septic arthritis: fever + localized joint pain + limited ROM; Dx joint aspiration, Tx admit + drainage + IV abx
Fungi
Viruses
Orbital vs. preseptal cellulitis: consider preseptal w/ eyelid discoloration; consider orbital w/ proptosis, limited eye movement,
pain w/ movement, or loss of vision
RMSF: due to Rickettsia rickettsii from Dermacentor ticks; causes fever/chills and rash that starts on hands/feet and moves inward, can result
in pancytopenia + hyponatremia; Tx doxycycline (regardless of age)
Lyme disease: due to Borrelia burgdorferi from Ixodes ticks; 1 Lyme = erythema chronicum migrans, 2 Lyme = bilateral Bell palsy + AV block,
3 Lyme = chronic arthritis; Tx amoxicillin (<9 y/o), doxycycline (>9 y/o)
Lyme disease + hemolytic anemia: due to Babesia microtii also from Ixodes ticks; Dx RBC smear, Tx clindamycin + quinine
Tularemia: rabbit fever due to Francisella tularensis; MC presentation is ulceroglandular syndrome (nonhealing ulcer + ascending LAD); Tx
streptomycin
Pseudomonas: G oxidase+ rod; commonly found in burns, tennis shoe puncture wounds, swimming pools, hot tubs, cystic fibrosis
Peptic ulcer disease: presents as dyspepsia and upper GI bleed; Dx EGD+bx or H. pylori breath test, Tx triple therapy (2 abx + 1 PPI)
HUS: due to EHEC O157:H7; presents w/ bloody diarrhea and possible renal failure (MCCOD) after eating undercooked hamburgers; Dx
stool cx on MacConkey (sorbitol) agar, Tx TPN + peritoneal dialysis (do not use abx)
Lymphadenitis: Staph aureus infx swollen, tender, erythematous LN; Tx dicloxacillin
Cat scratch disease: Bartonella henselae infx from cats (flea vector) Parinaud oculoglandular syndrome (nonpainful conjunctivitis +
preauricular LAD); Tx azithromycin
Typhoid fever: Salmonella typhi infx fever, diarrhea, HSM, abdominal pain w/ rose spot rash; Dx fecal leukocytes + stool cx
Campylobacter gastroenteritis: presents w/ fever, bloody diarrhea, abdominal pain; risk of Guillain-Barre syndrome
Yersinia gastroenteritis: presents w/ fever, bloody diarrhea, abdominal pain; risk of mesenteric adenitis (appendicitis-like presentation);
associated w/ chitterlings and daycare centers
Pseudomembranous colitis: broad-spectrum abx use C. difficile proliferates in colon profuse watery diarrhea; Dx stool toxins, Tx
metronidazole > PO vancomycin
Parasites
Sporotrichosis: rose gardner disease due to Sporothrix schenckii; presents as nonhealing ulcer + ascending LAD; Tx potassium iodide
Tinea capitis: due to Trichophyton tonsurans; presents as boggy scalp lesion w/ hair loss; Dx KOH prep, Tx PO griseofulvin
Cryptosporidiosis: chronic diarrhea in HIV+ pts
PCP pneumonia: opportunistic infx that indicates T-cell deficiency (AIDS, SCID, DiGeorge, etc.); Dx BAL, PPx azithromycin, Tx Bactrim
Viral meningitis: due to enterovirus infx (echo, coxsackie); Dx CSF shows lymphocytes + normal glucose, Tx supportive care
Bronchiolitis: due to RSV; presents w/ wheezing, URI sx, respiratory distress; Tx supportive care (ribavarin if severe, pavilizumab ppx for
high-risk infants)
Erythema infectiosum (fifth disease): due to Parvovirus B19; presents w/ fever, URI sx, slapped cheek and lacy rash on extremities, can
cause aplastic anemia in SCD or spherocytosis, hydrops fetalis in pregnant women (rare)
Hand-foot-mouth disease: due to Coxsackie A16; presents w/ sores/blisters on hand, feet, mouth, genitalia; Tx supportive care
Mononucleosis: due to EBV; presents w/ fever/chills, sore throat, myalgia, cervical LAD, HSM after making out w/ someone; Dx Monospot
(heterophile agglutination) test, Tx avoid contact sports
Amoxicillin rash: rash s/p amoxicillin in a misdiagnosed strep throat is pathognomonic for EBV infx
Mumps: parotitis, orchitis, meningitis, pancreatitis
Rabies: commonly found in bats, skunks, raccoons, foxes, coyotes; give reassurance if pet is sterile, kill animal for bx if unknown, give postexposure ppx for any bat exposure
Rubeola (measles): cough, coryza (head cold), conjunctivitis, Koplik spots, then diffuse maculopapular rash; Tx vitamin A
Rubella: diffuse maculopapular rash (starts on face and migrates down) w/ low-grade fever, marked LAD, sore throat, arthralgias
Roseola: due to HHV-6; high-grade fever for 3 days, then diffuse maculopapular rash
Varicella (chickenpox): due to VZV; dew drops on a rose petal vesicular rash in an ill child
Viral gastroenteritis: rotavirus infx fever, vomiting, severe watery diarrhea during the wintertime; Tx supportive care
Herpes keratoconjunctivitis: HSV infx vesicular lesions on skin + dendritic corneal ulcers, risk of blindness
Cutaneous larva migrans: due to Toxocara canis/cati; presents as itchy lesion on bottom of foot after playing around barefoot; Tx ivermectin
Visceral larva migrans: due to Toxocara canis/cati; presents w/ fever + HSM + eosinophilia; Tx ivermectin
Malaria: due to Plasmodium spp; presents w/ cyclic fever/chills and hemolytic anemia; Dx Giemsa stain of blood smear, Tx mefloquine (+
primaquine for hypnozoites)
Pinworm: due to Enterobius vermicularis; causes perianal pruritus worse at night; Dx scotch tape test, Tx mebendazole
Ascariasis: due to Ascaris lumbricoides; presents w/ eosinophilia + intestinal obstruction
Trichinellosis: found in undercooked pork; triad of periorbital edema, myositis, eosinophilia; may have nonspecific splinter hemorrhages
Giardiasis: due to Giardia lamblii; presents w/ fever, foul-smelling fatty stools, abdominal pain; Tx metronidazole
ALLERGY/IMMUNOLOGY
Allergy
Urticaria (hives): pruritic wheal and flare rash; Tx PO benadryl + avoid exposure
Erythema multiforme: urticaria + target lesions, <10% BSA (body surface area)
DRESS syndrome (drug rash, eosinophilia, systemic sx): EM w/ eosinophilia + systemic sx, usually due to anticonvulsants
Maternal ab: IgG via placenta (lasts 3-6 months), IgA via breast milk
Immunology
Chronic granulmatous disease: XR NADPH oxidase phagocytic defect recurrent abscesses; Dx nitroblue tetrazolium (NBT) test
Wiskott-Aldrich syndrome: XR, TIE thrombocytopenia (petechiae), recurrent infx, eczema; Dx CBC (plt), IgM, IgA, IgE
Bruton agammaglobulinemia: XR B-cell defect lack of all Ig types recurrent bacterial infx (OM, PNA, etc.) after 6 months since moms
Ig confers passive immunity; Dx serum Ig levels, Tx repeated IVIG
T-cell defect: likely DiGeorge syndrome (CATCH-22); Dx intradermal Candida test
Combined variable immunodeficiency: acquired B-cell defect (>10 y/o) lack of all Ig types but normal B-cell levels; risk of lymphomas
SCID (bubble boy disease): XR or AR adenosine deaminase lymphocytes cant make DNA to proliferate (both B- and T-cells) severe
infx death at young age; Tx bone marrow txp
Job syndrome: FATED coarse Facies, Abscesses, retained primary Teeth, IgE, Derm issues (eczema)
Asplenia: recurrent encapsulated bacterial infx (SHiN Strep pneumo, H. influenza, Neisseria), common in SCD kids; Dx CBC w/ smear (HowellJolly bodies)
Hereditary angioedema: AD C1 esterase inhibitor random activation of complement pathway recurrent episodes of edema w/ positive
family hx
IgA deficiency: recurrent respiratory infx + diarrhea + anaphylatic transfusion rxns (reacts to donor serum IgA); Dx IgA
Complement deficiency: C5-C9 deficiency predisposes to recurrent Neisseria infx; Dx CH50 test
HEM-ONC
Juvenile rheumatoid arthritis (Still disease): RF (anti-IgG Fc domain) type 3 HS; Tx NSAIDs > MTX > PO steroids
Pauciarticular JRA: 0-4 joints, can present w/ anterior uveitis (iridocyclitis); Dx slit-lamp eye exam, Tx PO/OU steroids
Systemic JRA: systemic sx prior to arthritis, rheumatoid rash, high spiking fevers
Juvenile dermatomyositis: presents w/ progressive muscle weakness, skin rash, fatigue; Dx CPK
Neonatal lupus: skin lesions (maternal ab-ag complexes cross placenta) + 3 heart block (anti-SSA attacks fetal heart conduction)
Systemic lupus erythematosus (SLE): type 3 HS flare-and-remission pattern of IM DAMN SHARP IgG, Malar rash, Discoid rash, ANA, Mucositis
(throat ulcers), Neuro sx, Serositis (pleuritis/pericarditis), Hematologic d/o, Arthritis, Renal d/o (wire loops), Photosensitivity; Dx screen w/ ANA, confirm
w/ anti-dsDNA or anti-Smith, Tx low-dose aspirin
ITP: autoantibodies against gpIIb/IIIa platelet sequestration in spleen petechiae, purpura; Dx plt/MKC, Tx RhoGAM (if Rh+), IVIG (if Rh-), steroids
(2nd line), splenectomy (if severe)
Anemia
Fanconi anemia: AR DNA repair genes aplastic anemia + short stature, hypopigmented areas, eye/ear deformities; Tx androgens +
hematopoietic drugs (EPO, neupogen, etc.)
Anemia of prematurity: MCC anemia in premature and SGA infants; Dx CBC shows profound anemia w/ reticulocytes, Tx iron supplements
Transient erythroblastopenia of childhood: RBC aplasia in children following a viral infx; Dx CBC shows profound anemia w/ no reticulocytes,
Tx supportive care (lasts 1-2 months, may need pRBCs)
Blackfan-Diamond anemia: macrocytic RBC aplasia + short stature, webbed neck, cleft lip, shield chest, triphalangeal thumbs
Sickle cell anemia: Dx Hb electrophoresis shows HbF, Tx folate supplements (for effective hematopoiesis) + hydroxyurea (HbF)
Dactylitis: sickle cell anemia vaso-occlusion vascular necrosis of metacarpals/metatarsals acute onset painful swelling of
hands and feet
Acute chest syndrome: PNA-like presentation; Dx CXR shows infiltrate, Tx azithromycin + ceftriaxone
Sickle cell trait: MC sx is painless gross hematuria; Dx Hb electrophoresis shows HbS of 35-40%
Thalassemias
Mechanism/presentation
Management
-thalassemia minor
heterozygous -chain mild anemia sx
Dx screen w/ CBC (microcytic anemia + RDW),
confirm w/ HbA2; Tx reassurance
-thalassemia major
homozygous -chain severe anemia sx
Dx screen w/ CBC (microcytic anemia + RDW),
confirm w/ HbF; Tx frequent transfusions
Silent carrier
1-2 -chain deletion asx
--HbH disease
3 -chain deletion severe anemia sx
Dx screen w/ CBC (microcytic anemia + RDW),
confirm w/ HbH; Tx frequent transfusions
Barts disease
4 -chain deletion fetal hydrops
Dx post-mortem autopsy
Kasabach-Merritt phenomenon: large vascular anomalies (kaposiform hemangioendothelioma, tufted angioma) sequester RBCs, platelets, and clotting
factors anemia, thrombocytopenia, coagulopathy; Tx steroids + IFN-
G6PD deficiency: XR G6PD in African-American boys RBCs cant make enough NADPH to deal w/ oxidative stress (fava beans, sulfa drugs,
antimalarials, infx) hemolytic anemia following exposure to oxidative stress
ALL: MC cancer in kids <15 y/o; pre-B-cell proliferation (CALLA+/TdT+) infiltration of reticuloendothelial system (LAD, splenomegaly) and bone
marrow (pancytopenia); Dx bone marrow bx shows >25% lymphoblasts, Tx chemotherapy
ALL prognosis: good px w/ age 1-10, hyperdiploidy, WBC <50, and TEL/AML1 on t(12;21); poor px w/ Philadelphia chromosome on t(9;22)
Hodgkin lymphoma: B-cell proliferation into Reed-Sternberg cells B-type sx (fever, weight loss, night sweats); Dx CXR to look for mediastinal mass
then LN bx, Tx chemotherapy
Langerhans cell histiocytosis: Langerhans cell proliferation eosinophilic granuloma painful, solitary lytic bone lesion (MC site is skull)
Hereditary spherocytosis: AR spectrin hemolytic anemia + jaundice in newborn; Dx CBC shows spherocytes + abnormal osmotic fragility test, Tx
splenectomy
Disseminated intravascular coagulation (DIC): systemic insult (MCC septic shock) widespread microcoagulation run out of clotting factors
bleeding out; Dx PT/INR + PTT + D-dimer + platelets, Tx underlying cause
Von Willebrand disease: AD vWF MCC hemorrhagic diathesis; Dx vWF levels + activity (ristocetin cofactor activity), Tx DDAVP
Tumor lysis syndrome: lysis of cancer cells hyperkalemia + hyperuricemia + renal failure; Dx renal panel + uric acid, Tx allopurinol
ENDOCRINE
Sick euthyroid syndrome: bodily stress (trauma, starvation, etc.) cortisol blocks TSH T4/T3, normal TSH, rT3 (deiodinase 3 activated by stress)
Adrenal
Pheochromocytoma: episodic catecholamine 5 Ps Pressure (BP), Pain (HA), Perspiration, Palpitations, Pallor; Dx 24 hr urinary
metanephrines, Tx -blockers (phenoxybenzamine) then -blockers then adrenalectomy
Cushing syndrome: cortisol truncal obesity, abd striae, buffalo hump, hyperglycemia, osteoporosis, HTN, immunosuppression; Dx
ACTH/cortisol levels + dexamethasone suppression test (pituitary Cushing can be suppressed), Tx underlying cause
Addison syndrome: cortisol/aldosterone fatigue, hypoglycemia, HTN, hyperpigmentation, weight loss; Tx prednisone + fludrocortisone
replacement
Congenital adrenal hyperplasia: 21-hydroxylase aldosterone/sex hormones Na, K, H (metabolic acidosis), hirsutism,
virilization; Dx 17-OHP, Tx hydrocortisone + fludrocortisone replacement
Central DI: ADH cant resorb water polyuria, polydipsia, hemoconcentration (Na, K); Tx DDAVP
Nephrogenic DI: end-organ resistance to ADH polyuria, polydipsia, hemoconcentration (Na, K); Tx HCTZ
DM type 2: presents as polyuria (bedwetting), polydipsia, polyphagia, acanthosis nigricans; Dx fasting glucose >126 x2, random >200 w/ sx,
or HbA1C >6.5%
Factitious hypoglycemia: moms giving baby insulin hypoglycemia + hyperinsulinemia + low C-peptide levels (high C-peptide reflects
insulinoma); Munchhausen by proxy is a form of child abuse
Parathyroid
Hypercalcemia sx: stones (kidney, GB), bones (pain, osteitis fibrosa cystica), groans (PUD, pancreatitis), psychic overtones
Hypercalcemia s/p fracture: due to extensive bone resorption; Dx urine calcium:creatinine ratio >0.2, Tx hydration, calcitonin if severe
Nutritional rickets: dietary vitamin D normal Ca, P decreased bone mineralization; increased risk in exclusively breast-fed babies, lack
of vitamin D supplements, African-Americans, limited sun exposure
X-linked hypophosphatemic rickets: XD PHEX (renal phosphate resorption gene) urinary P, serum P decreased bone mineralization
resistant to vitamin D supplements
Pseudohypoparathyroidism: renal tubules unresponsive to PTH Ca, P, PTH hypOcalcemia sx + 4th/5th finger bradydactyly (knuckleknuckle-dimple-dimple sign)
ADOLESCENT
Anorexia nervosa: fear of being fat <85% ideal body weight, secondary amenorrhea, lanugo, hypothermia, osteoporosis, arrhythmias; Tx
TID sandwiches
Bulimia nervosa: binge-eating + behaviors intended to counteract weight gain (purging, diuretics, exercise, fasting), sialadenosis, dental
caries, Russells sign (dorsal knuckle callouses); Tx SSRIs + CBT
Anorexia vs. bulimia: both can have purging behavior, but anorexia has <85% ideal body weight
Refeeding syndrome: increased nutrition in starving pt synthesis of glycogen, fat, proteins uses up electrolytes (especially K and
phosphate)
Sports contraindications: bleeding d/o (hemophilia), single eye, single kidney, unexplained syncope, infectious mononucleosis (to prevent splenic
rupture)
Sports concussions
Sx
Management
Grade 1 (mild)
no LOC, confusion <15 min
can return to play
Grade 2 (moderate)
no LOC, confusion >15 min
must sit out for a week, go to hospital if >1 hr
Grade 3 (severe)
LOC
go to hospital
Tanner (SMR) staging
Tanner 1
Tanner 2
Tanner 3
Tanner 4
Tanner 5
Males
kid
scrotal darkening, thin long pubic hair
dark curly pubic hair
adult pubic hair but w/o full coverage, peak growth velocity
adult
Females
kid
breast buds
breast elevation, peak growth velocity
areolar mound (look 4 big nipples)
adult
Late-onset congenital adrenal hyperplasia: 21-hydroxylase deficiency excess of sex steroids precocious puberty in boys
McCune-Albright syndrome: precocious puberty in girls + caf-au-lait spots + polyostotic fibrous dysplasia (bone zits that cause multiple fx)
Teenage pregnancy: complications include poor maternal weight gain, premature delivery, low birth weight, risk of pre-eclampsia
Substance abuse: suspect w/ declining school performance, poor hygiene, exaggerated mood swings, hanging w/ the wrong crowd, frequent hostile
reactions
Anabolic steroids: muscles, hirsutism, acne, gynecomastia, testicular atrophy, roid rage; consider in football players
MDMA (Ecstasy): euphoria, stimulant, sense of closeness with others, death by hyperthermia or dehydration; consider in clubs/raves