1

PROM
Premature Rupture Of Membranes
 2
Defn: Rupture of the choriaoamniotic membrane before the onset of labor.
10-15% of all pregos. 1/3 of preterm pregos.
Risk Factors: Smoking during prego  2x risk of PROM; short vagina, Hx of PROM,
preterm delivery, hyramnios, multiple gestation, bleeding early in prego.
Sequalae: Neuro probs eg cerebral palsy, leukomalacia, pulmonary hypoplasia
Dgx: Leaking vagina pH>7.0, +fern test, U/S shows lots of amnio fluid around fetus
DDx: ↑ vag secretions, exogenous fluids discharge from infx, vesicovaginal fistula.
Tx: R/O infx and determine viability, nothing if full term, delivery & Abx if preterm and
infx
 3
Ectopic Pregnancies
 4
Leading cause of maternal mortality in US.
SSx: Abdominal pain, vaginal bleeding
 5
Vulvar Cancer
 6
Epidemiology: Uncommon. Post menopausal fem 65-70 5% of gyn cancer. Pts usually
embarrassed to visit Dr.  delay in t(x).
SSx: Vulvar pruitus, red or white ulcerative exophytic lesion usu from post 2/3 of lab. mjr.
Bleeding, pain.
Dgx: Bpx
Etiology: Unk ?smoking, ?HPV. 90% of cases are Sq cell carcinoma. Extramammary,
Bartholins, basal cell, melanoma, sarcoma or mets also found. Spread via lymph of
superficial inguinal, deep femoral or external iliac nodes. Extension to upper vag can 
deep pelvic spread.
Tx: Vulvectomy and Lymphectomy
 7
Induction of Labor
 8
Defn: Stimulation of uterine contrx bf spontaneous onset of labor with the goal of achieving
delivery. Usu w/ Oxytocin and when the cervix is ‘ripe’
Indications: benefits of delivery >> risks of inertia-less pregnancy/labor. Mother and fetus
must be taken into account.
Methods: To ‘ripen’ the cervix use PGE2 or Dinoprostone. PGE2 can  uterine
hyperstimulation  placental insuffx or uterine rupture. PGE2 C/I if asthma
Laminaria is seaweed stems that are inserted into cervix, then expand, via moisture, to
dilate cervix. Complx=cervical lax, membr ruptx, infx.
Prolonged latent phase managed w/ rest or augmentation of labor
 9
Surgical Alternatives to Hysterectomy for Myomas
 10
1. R/o endometrial hyperplasia or CA esp in perimenopausal fems.
2. If fibroids don’t cause any probs (anemia, social hinderence) then monitor and reassure
3. Myomectomy if pt wishes to stay potentially fertile, or if myomas are getting in the way
of fertility.
4. Pharm inhibition of E2, GnRH agonists to inhibit HoTH-Pit-Ovar axis from releasing E2.
Watch x rebound upon withdrawal. Danazol to ↓ ovarian E2.
5. Uterine AA Embolization (UAE) with polyvinyl alcohol particles. Complx=PE
 11
Intrauterine Growth Restriction
IUGR
 12
Defn: a fetus or infant whose wt is in the lowest 10% of the nl population for it’s gestational
age. Dgx via U/S using biparietal diameter, head C, abd C & femur length, amniocentesis x
karyotype, & PCR. Prevalence is 10%-by defn. NOT ‘low birth weight’.
↑%x fetal death, neonatal death, asphyxia, fetal intolerance of labor; or meconium aspirax,
hypoglycemia, hypothermia, resp distress s/p labor.
Causes: ↓ fetal : placenta surface area. 1)Maternal causes-HTN bc of ↓ placental perfux,
SLE, smoking, EtOH, cocaine, anticonvulsants, steroids, immunosuppressants,
malnutrition, young/teen antiphospholipid Antibodies, thrombophilias 2)Fetal-infx from
Ruella or CMV esp if in 1st trimester, bact infx, tri 13, tri 18. Usu Early onset (↓ cell
division) or Delayed onset (↓ cell size) can be reversed w/ nutrition-Usu due to
uteroplacental insuffx. Hx if prev IUGR
Asymmetric vs Symmetric: Asymm-Abd C>head C. Seen in nutritional defx. Sym-Abd
C≈head C. Usu anomaly
Tx: Deliver the healthiest possible fetus at the healthiest possible time (maturity vs fetal
compromise). Correct cause if poss (eg. nutrition). U/S q4wks to monitor progress. Bed
rest.
 13
Prevention Of Venous Thromboembolism
 14
Prego is considered a hypercoagulable state (like CA)  ↑%x VTE up to 42days post-
partum. Fibrinogen (factor I) increases to 500mg/dL. Factors VII, VIII, IX, and X are also
increased. PT/PTT and clotting time do not change.
 15
Uterine Cancer
 16
Epidemiology: Menopausal fem
SSx: Abnl Vag bleeding, discharge. Hematometra in older pts.
Risk Factors: too much E2 (menopause, unopposed E2 tx, nulliparity, obesity, Tamoxifen,
DM)
?: Mostly adenocarninoma +/- sq epith CA (if sq epith present then adenoacanthoma; or
adenosquamous carcinoma if sq epith more malignant). 1) E2 Independent usu in
menopausal pts. vs 2) E2 Dependent usu in perimenopausal pts. due to excessive E2 from
wherever (testosterone, ovaries, OCPs)  endometrial growth. and is more common vs the
former. R/o prego
Dgx: Bpx after abnl uterine bleed esp if >35yo. Staging is Surgical taking into acct lymph
nodes and lots of sampling. the higher the grade the less % of long term survival
Spread: endometriummyometriumcervixlymphaticsadnexa.
Tx: Surgery: radical TAH, BSO +/- periaortic nodes. Post surgery radiation.
Estrogen/progestin if recurrence. Progesterone to reverse the E2 dependent growth.
 17
Oxytocin
 18
Uses: induce contractions of labor (esp latent phase) via IV after mechanical probs are ruled
out. Postlabortal Syndrome (+Abx), Oxytocin challenge test to test for uteral contractions.
Milk let down.
 19
Benign Ovarian Cancer
 20
Types: 1) Epithelial-Glandular type. ?derived from embryo GU tract (mullerian). Mostly
Serous Cystadenoma which are multilocular, large. Tx is sgx bc of ↑%x malignancy.
Unilateral if pt is young/fertile, or BL oophorectomy w/ hysterectomy if pt is past
reproductive age.
2) Germ Cell arise in the ovary & may contain bones, hair w/ appendages etc. Most
common type is Benign Cystic Teratoma (aka Dermoid cyst). Most occur ≈ 30yo found
during routine pelvic exam. Mobile, NT, ↑ fat content, →↑%x ovarian torsion. Tx is
surgical to prevent torsion
3)Stromal Cell-Derived from sex cord stroma and may → granulose theca cell tumor (E2),
or sertoli-leydic cell tumor (Testosterone). Can lead to precocious puberty, thelarche,
vaginal bleeding
Epidemiology: More common vs malignant ovary stuff. ↑%x malignancy w/ ↑age. Tx is
surgery to avoid malignancy or torsion. Dgx via pelvic exam, U/S.
 21
MALIGNANT Ovarian Cancer
 22
Epidemiology: 5th most common fem CA. 2nd most common Gyn CA. MOST DEADLY Gyn CA.
Poor prognosis (40% 5yr survival rate). 50-60 yo White F. BRCA-1 →5%↑%. BRCA-1 AND
BRCA-2 →45%↑%. Long term suppression of ovulation is protective eg OCPs
Ssx: Abd fullness, distension, abd pain, LBP, ↑urinary Hz.
Dgx: Psammoma bodies
Spread via direct extension in pelvis/perineum due to ovarian sloughing/seeding. CA-125 not Dgx
but used to follow suppression s/p Tx
Types: 1) Epithelial Cell (most common), have Serous Cystadenocarcinoma, Mucinous
(psudomyxomatous peritonei), Endometrial Tumors in the ovary.
2) Germ Cell – Produce βhCG, or αFetoProtein. Dysgerminoma (unilateral; Tx is chemo/radio
sensitive) and Immature Teratoma (painful, hemorrhage, necrosis; Tx is oophorectomy) types.
Spread via lymphatics.
3)Stromal Cell
Mets TO Ovary: Krukenberg Tumor is a tumor that is met from another site eg GI, breast,
endometrium. Infiltrative, mucinoius of signet-ring type. Tx is BSO + hysterectomy.
Poor Prognosis. 5% 5yr survival rate.
 23
Cervical Cancer
24
 25
External Cephalic Version
 26
Defn: version performed entirely by external manipulation
Indications: Breech deliveries.
Stats: Only works in about ½ of all cases. Eligible cases should benl fetus, good heart
tracing, adequate amniotic fluid, presenting part not in the pelvis?, no uterine op scars, no
labor?. ECV works best in parous fem.
 27
SERMs
Selective Estrogen Receptor Modulators
 28
Example: Raloxifene, Tamoxifene, Evista
MOA: estrogen agonists w/in some organs (bone, liver, CV) >> antagonists w/in other
organs (uterine, breast)  ↓ bone resorption [designed to have less potential of drug-
induced uterine or breast cancer]
Indication: Osteoporosis, women lacking estrogen (postmenopause, post-hysterectomy) -
[prophylaxis & treatment], Breast CA?,
Adverse: hot flashes, venous thromboembolism, ovarian, breast & endometrium cancer,
fetal death, teratogen
CI: pregnancy, immobilization, thrombosis
 29
Operative Vaginal Delivery
30
 31
Cervical Cytology
32
 33
β hCG
 34
Source: Placental Sycntiotrophoblasts. 1st detectable @ 10 daysPEAK @ 9 weeks 
falls to plateau @ 20 weeks
Sx: α sub-u looks like FSH. β sub-u needed x pregnancy
If levels are too high: multigestation, hydatidform mole, choriocarcinoma, embryonal
carcinoma
If levels are too low: ectopic prego, threatened prego, missed Ab
Function: stimulate corpus luteum to produce Progesterone, until the placenta can take
over; Regulate steroid biosyths in the placenta and fetal adrenal growth; Stimulate
Testosterone in male fetal testes
 35
Human Placental Lactogen
 36
Function: similar to somatotropin
Effects: Antagonizes insulin cellular RE  ↓ gluc and insulin utilization  ↑ % x
gestational DM
 37
Progesterone
 38
Structure
Source: Corpus luteum luteal cells early on but declines after 9 weeks making way
for placental progesterone
Function: Early Prego-induces secretory uterine changes to favor blastocyst
implantation. LATER Prego-Induces immune tolerance for prego and prevent
myometrial contrx.
 39
Estrogens
 40
E2: Major estrogen in fertile NON-prego fems; made in the follicular granulose
cells by aromatase from androgens. (the androgens are made in the follicular theca
cells)

E3: Main estrogen during prego. Made in the placenta by sulfatase from
DeHydroEpiAndroSterone (DHEAS is secreted from the fetal adrenals)

Eone: Main estro during menopause. Made in fat cells by from adrenal
androstenedione.
 41
Pregnancy
 42
Signs: Fetal heart sounds, +β hCG, amenorrhea, softening of corpus and cervix
1st Trimester: <13 weeks. +NV, fatigue, breast tenderness, Spotting, 8lb wt gain.
Complication is spont ab.
2nd Trimester: 13-26 wks; Round ligament pain; Braxton Hicks Contrx (contrx w/o
pain); +1lb/wk; awareness of fetal mvmts; complications are cervical
incompetency, PROM, and premature membrane
3rd Trimester: 26-40wks; ↓ libido; LBP, urinary Hz, fetal head descent into pelvis,
bloody show from cervical dilation; complications PROM, premature labor,
preeclampsia, UTI, gestational DM, anemia
Nl Complaints: bleeding gums, bigger breasts, carpal tunnel, LBP, chloasma, linea
nigra, dizziness, fatigue, fluid retention, hair and nail shedding (telogen effluviam),
HA, leg cramps, vomiting, nosebleeds, stretch marks, stress incontinence, varicose
veins
Nl menstruation=21-38days
 43
Pregnancy Complaints
 44
Vaginal Bleeding Early on – Spont Ab; Late-Placenta Previa
Vaginal Fluid leak-ROM or urinary incontinence
Epigastric Pain-SEVERE preeclampsia
Uterine Cramping-Preterm labor, Preterm Contractions
↓ Fetal Movements-Fetal Compromise
Persistent Vomiting-Hyperemesis, hepatitis, pyelonephritis
HA+Visual changes-SEVERE Preeclampsia
Pain w/ Urination-Cystitis, Pyelonephritis
Chills and Fever-Pyelonephritis, Chorioamnionitis
 45
Safe Immunizations
 46
Flu-in all women during flu season
HepA-pre/post exposure
HepB-pre/post exposure
Pneumococcus-ONLY HIGH RISK fems
Meningococcus-in outbreak areas
Typhoid-
 47
Unsafe Immunizations
 48
MMR
Polio
Yellow Fever
Varicella
 49
Projects I can’t do cuz someone else is doing it
 50
Ovarian Dermoids: Hari
Cerv CA: Vanessa
HIV and Prego: Katie
Fitz-Hugh Kurtis SSx: Jessica
Trauma in Prego: Chris
Dysgerminoma: Adham
Maternal Congenital Heart Disease: Linda
Fistulas: Marianne
Nl Prego/Isoimmunization/Infertility: ME
 51
Infertility
 52
Defn: inability to conceive x 1 year of unprotected sex.
Causes: 1) Anovulation 2) anatomic defects 2) abnl spermatogenesis
DDx: Endometriosis, low body wt, marijane, PID & its risk factors, salpingitis, Asherman’s
SSx/intrauterine synechiae, leiomyoma, uterine septum,
Diagnosis: 1) check basal body temp, endometriosis, luteal phase progesterone lvls; Urine
LH to predict ovulation, androgen lvsl, PL, GnRH 2) do a hysterosalpingogram 7-11days of
cycle to ↓%x retrograde menses (hysteroscopy x uterine health); endometrial bpx after
ovulation 3) check semen
Tx: 1) Antiestrogens (clomiphen), Progesterone, FSH/Pergonal if clomiphene fails 2)
Surgery via Lysis of adhesions, Deobstruction,
Path:
Random Info: Repro ages 15-44; % of fertility is 1/2ed bw 37 & 45. Body temp falls at time
of menses and PEAKS 2 days after the LH surge/somatic progesterone >4ml. Ovulation
occurs about 1 day bf the 1st temp elevation. If hx of irreg Menses then no need x basal
body temp check. Check FSH, LH, PL, TSH, DHESA. Implantation happens 3-5 days sp
fertilization. redupulication of genital tract is associated w loss/recurrent preg NOT so much
infertility
 53
Danazol
 54
Tx: Endometriosis, Fibrocystic Breast Changes, Hereditary Angioedema
MOA: Suppresses LH and FSH surges from ant. pit.  no E2 from the ovary  no
proliferation of endometrium
SDFX: Amenorrhea, pseudomenopause, acne, spotting, hot flashes, oily skin, facial
hair, deepening of voice, decrease libido, atrophic vaginitis, decrease in HDL and
LDL cholesterol,
C/I: PREGO, breast feeding, porphyria, liver, kidney heart dysfx,
Misc: ↓ LH and FSH (menopause  increase LH and FSH)
 55
2 Cell Theory Of E2 Production
 56
Oocyte surrounded by Granulosa cells (lack 17-α so can’t make testosterone).
Granulosa cells surrounded by Theca interna cells.

FSH from anterior pituitary acts on Granulosa cell to secrete E2. More E2 causes
proliferation of Granulosa cells. The follicle with the most granulosa cells wins.

LH from Ant Pit work on Theca cells to change cholesterol into Androstendione.

FSH stimulates the Granulosa cells to change Androstendione via Aromatase into
E2 or E3. As E2 lvls increase, E2 + FSH  granulosa cells to make LH receptors.

The LH receptor’d Granulosa cells start secreting progesterone. LH surge causes

ovulation. After ovulation Granulosa and Theca cells secrete E2 and progesterone in
response to LH.
 57
Lupron
 58
MOA: Suppresses GnRH down regulate ant pit  decreased LH/FSH 
decrease E2 and testosterone
Treats: Endometriosis, Fibroids
SDFX: effects of decreased estrogen (menopause)
C/I: prego, breast feeding,
 59
Placenta Previa
 60
Defn: abnormal location of placenta near/over the internal cervical os. ≈ 1/250
pregos
Path: Bleeding is caused by separation of part of the placenta from uterus possibly
from contrx. Bleeding usu stops on it’s own.
Types: 1) Total-the placenta covers the os 2) Partial-the placenta covers part of the
os 3) Marginal-the placenta is w/in a few cm of the os
SSx: Painless vag bleeding esp in 3rd trimester.
Dgx: US
Tx: Hemostabalization, rest, cs, induced delivery if amnio shows developed lungs
Risk Factors: Multiparity, AMA, h/o cs
Complx: associated with CNS probs and deformities so do an anatomic US of the
fetus if placenta previa is suspected or dgx
 61
Placenta Abrupto
 62
Path: Hemorrhage into the dedidua basalis  Premature separation of the nl
implanted placenta from the uterine wall
SSx: Painful VB, abdominal discomort,
Tx:
Risk Factors: HTN, cocaine use, abdominal trauma, baring down,
Complx:
 63
Mood Disorders
≥≤
 64
Common 3-5% of pop. Major Mood Disorders: Bipolar I, II, MDD. Other Specific
Mood D/O: Minor Depression, Dysthymic D/O, Cyclothymic D/O. Mood Disorder
Due to a Medical Condition, Mood Disorder Due to Substance-Induced Mood
Disorder. Adjustment Disorder w/ Depressed Mood.

Bipolar is further described as Manic, Depressed or Mixed, # episode, ?recurrent, ?

post-partum,. Major Depression should be characterized as Minor Mood D/o-
cyclothymia, dysthymia, adjustment d/o w/ depressed mood. Usu due to childhood
loss and manifesting in late 20’s
 65
Bipolar I
 66
Epidemiology: young poor fem. 1% of pop usu >30yo
SSx: periods of depression w/ >1 episode of mania that compromised functioning.
Mania = >3 of Distractability, Indiscretion, Grandiosity, Flight of ideas, Activity ↑,
Sleep Deficit, Talk is pressured (DIGFAST). Manic episode develops over days
may → psychotic/uncontrolled characteristic. 20% have hallucinations or delusions
or both; or can be confused w/ organic delirium. Can Mania can take up to 4 mos to
resolve if untreated. Mania  legal/social probs. Depression  ↑%x suicide in BPI
pts.
Tx: Manic Episode-Li to maintain, Maintain x1yr and then taper off. If no more ssx
then no need to continue meds. If ssx come back start and continue x 2more years; ?
Carbamazepine to stabilize or other anticonvulsant, or a BZD
Depressed- Lamotrigine (MOA is to inhibit Na channels  decreasing Glutamate)
Mixed- Zoprazidone, Risperidone, Olanzapine
Rapid Cyclers – Li
 67
Major Depression Disorder
MDD
≥≤♀♂
 68
Epidemiology: usu starts in late 20yo F; but evenly distributed in all age groups
and becoming more prevalent in teens
SSx: Vary-Agitation or irritability vs c/o unusual bodily feelings or inexplicable
mind disturbances. Usu worse in the am getting better throughout the day. Most
attacks begin gradually over a 3wk span and last to ≈8mos to indefinitely if
untreated. There must be absence of: Mania, Hypomania or due to something else
(eg schizoaffective)
“Psychotic” if w/ hallucinations or delusions. Elderly may present w/ retardation,
memory impairment or disorientation (pseudodementia).

Atypical fts-mood reactivity+>2 of increased appetite, wt gain, hypersomnia, leaden

paralysis, or rejection sensitivity. Tx here is MAOIs
Melancholic fts-anhedonia, or decreased rxn to pleasurable stimuli

Misc: these pts ↑%x suicide

 69
Post-Partum Depression
 70
“Post Partum” is a specifier for any Mood Disorder (BP, MDD etc). Severe
depression <4 wks post partum esp after 2nd or 3rd baby. ↑%x recurrent episodes
with following babies.
 71
Dysthymia
 72
SSx: Depressed mood for most of the day, more days vs not x >2yrs. Depression + 2
or more of: change in appetite, change in sleep, ↓ in E, ↓ self-esteem, ↓
concentration, hopelessness. Ssx have not been absent x >2mos in this 2 yr (1 yr for
kids/teens) period; no MDD, mania or cannot be due to another cause (eg schizophr
or subst abuse or hypothyroidism). The ssx cause social dysfx

Specify: Early – <21 yo vs Late – > 21yo; if Atypical-wt gain, +mood w +events
 73
Cyclothymia
 74
SSx: ≥2yrs (1yr in kids/teens) w hypomanic and depressive ssx but NOT w/o ssx
≥2mos. Rule Out: MDD, other dss (schizo bipolar delusional), drugs, medical
condition
If manic during this 2/1 yr period than u can add BPI to the dgx. If MDD during this
2/1 period u can add BPII to the dgx
 75
Seasonal Affective Disorder
 76
A specifier which can be applied to BP, MDD.
SSx: Regular temporal relationship bw onset of MDD, BP and a particular time of
year (eg. MDD during winter) and full remissions during other times of the year.
MDD episode in the last 2 years that correlate with seasonal change and no other
time. Seasonal MDD episodes >> Non-seasonal MDD over pts lifetime
Rule Out: Stressors eg. seasonal occupation
 77
Bipolar II
 78
SSx: Hx of ≥1 MDD episode + Hx of ≥1 hypomanic episode. Ssx cause marked
distress or impair social/legal/job fux
Rule out: Schizoaff, schizophr, delusional d/o,
Specify: Hypomanic vs depressed; Mild vs Moderate vs Severe w/(o) Psychotic Ft;
Chronic; w Catatonic, Melancholic, Atypical Fts or Post Partum; Partial vs Full
Remission; w/(o) Rapic Cycling
 79
Hypomania
 80
SSx: ≥4 days of elevated, expansive or irritable mood clearly different from the
usual nondepressed mood. ≥3 of DIGFAST Distractability, Indiscretion,
Grandiosity (↑self-esteem), Flight of ideas, Activity ↑, Sleep Deficit, Talk is
pressured. This episode is noticeable by others but does NOT cause social/job
impairment and does NOT have psychotic fts.
Rule Out: Drugs, or general med condition (hyperthyroidism, tumor etc), somatic
RE to antidepressant tx.
 81
Mania
 82
SSx: ≥1 week of elevated, expansive or irritable mood clearly different from the
usual nondepressed mood. ≥3 of DIGFAST Distractability, Indiscretion,
Grandiosity (↑self-esteem), Flight of ideas, Activity ↑, Sleep Deficit, Talk is
pressured. This episode is noticeable by others AND causes social/job/legal
impairment, may have psychotic fts or may need hosbitalization.
Rule Out: Drugs, or general med condition (hyperthyroidism, tumor etc), somatic
RE to antidepressant tx.
 83
Mood Disorder 2ry to General Medical Conditon
 84
Depression is due to physiological response to illness (eg hypothyroidism, )
SSx: 1 or both of – Depressed mood or marked ↓interest or anhedonia;
elevated/expansive/irritable mood.
Rule out: Adjustment w/ depressed mood in RE to the stress of having a general
medical condition
 85
Substance Induced Mood Disorder
 86
SSx: 1 or both of – Depressed mood or marked ↓interest or anhedonia;
elevated/expansive/irritable mood. The ssx developed w/in 1mo of subst use or
withdrawal and/or is etiologically related to disturbance.
Rule out if: SSx occurred before the subst use; ssx last >1mo after use and
withdrawal; MDD
 87
Mood Stabalizers
 88
Li x BP-mania; Valproic Acid DOC x BP-Depression; Carbamazepine BP-
depresion; Lamotrigine BP-maintenance
Gabapentin, Topiramate and Pregabalin are used if DOC’s are not tolerated
 89
Lithium
 90
Use: DOC x BP Mania. Monitor CBC, CMP Cr, BUN, UA, T3/4, EKG
MOA: ? but causes ↑ in presynaptic 5HT transmission. ?↓ DA transmission. ↑Plasma NE
lvls. NSAIDS inhibit renal clearance causing increased blood levels
PhKinetics: absorbed From GI. Maintenace plasma lvls 1.0-1.5 meq/L. t ½ ≈ 18-36hrs
SDFX: Renal: Polyuria, polydipsia 2ry to Vasopressin-resistant DI in 50% of new pts,
reversible. Focal Interstital Cortical Fibrosis w Tubular atrophy/sclerotic Glomer,
IRReversible. ↑Cr; Neuro: ↑ EEG amp, ↓Hz, HA, slurred speech, confusion,
↓concentration/consciousness, delirium, coma, death, dysarthriea, ataxia, nystagmus,
discoordination, Parkinson ssx, choreiform movements; NeuroMusc: Tremor, hyperactive
reflex, fasciculations, paralysis; Blood: Leukocytosis reversible, ↑ESR; GI: NV, switch to
Li-Tartate; Heart: flat/inverted T-waves, MI, Sudden Death; Hypothyroidism tx w low
dose thyroxin; Wt Gain via hypoglycemia; Prego-Ebsteins Anomaly (tricuspid displaced
down and to the R), crosses milk barrier, decrease the dose prior to birth cuz clearance falls
during prego and mother can become toxic after birth
 91
Carbamazepine
(Tegretol)
 92
Use: Rapid Cycling Bipolar; 2ry choice x BP – mania and depression.
Anticonvulsant.
SDFX: Agranulocytosis, aplastic anemia, liver damage, allergic rash, sedation,
dizziness, Tox can present with gum/mucous bleeding. Monitor CBC w every
blood check.
 93
Valproic Acid
 94
Use: 2ry choice x BP – mania and depression; Rapid Cyclers; Less SDFX vs
Carbamazepine
SDFX: sedation, wt gain, GI upset
 95
Lamotrigine
(Lamictal)
 96
Use: 3rd line tx x BP episode and BP maintenance
SDFX: Steven-Johnsons Syndrome
 97
Oxcarbazepine
(Triliptal)
 98
Use:
MOA: blocks voltage sensitive Na channels, stabilizes neural membranes, inhibits
repetitive firing and ↓synaptic impulse propagation.
PhKinetics: Met in liver p450 to active metabolite, excreted in urine. t1/2 ≈ 9 hrs
 99
Psychotic Disorders
 100
Schizophrenia (disorganized, catatonic, paranoid, undifferentiated, residual);
Schizophreniphorm; Brief Psychotic Disorder; Schizoaffective Disorder; Shared
Psychotic Disorder; Delusional/Paranoid Disorder; Psychotic Disorder due to a
Medical Condition; Substance induced psychotic Disorder; Psychotic Disorder NOS
 101
Schizophrenia
 102
Epidemiology: 1% of world pop ≈ 2million in US esp in urban and lower SES via
downward drift. More pronounced in “poor environments”. 10% chance of
developing if 1° relative has it.
SSx: Rambling (loose associations, neologisms, overinclusivesness, blocking,
clanging, echolalia, concreteness, lack of speech or speech content); Delusions
(reference, bizarre, persecutory, grandiose insertion); Disturbance of perception
(auditory hallucinations BL from outside head, illusions, derealizations);
Disturbance of emotions (blunt, labile, inappropriate affect); Disturbance of
Beahavior; Positive Symptoms-Things that SHOULD NOT be there but are eg
hallucinations, delusions, paranoia, loose associations; Negative Symptoms-Things
that SHOULD be there but are not (normal affect SHOULD be there but may be
manifest as flat affect)
 103
Residual Phase of Schizophrenia
 104
Pt is withdrawn, isolated, peculiar. Being disinterested, odd → loss of jobs friends.
May think mystically or that they have special powers. IQ=wnl, but w/ cognitive
deficits in memory attention, frontal lobe function. Previously dgx as borderline,
antisocial or schizotypal. The first “breakdown” happens around 20yo.
 105
Dissociative Disorders
 106
Amnesia, Fugue, Dissociative Identity Disorder, Depersonalization Disorder
 107
Dissociative Amnesia
 108
Predominate feature is/are episode(s) where the pt can’t recall personal info usu of a
traumatic or stressful nature that is too extensive to be explained by ordinary
forgetfulness. Ssx cause marked distress/impairment socially/job/home
Rule Out: Dissociative Fugue, DID, PTSD, Acute Stress, Nero insults, Drugs
 109
Dissociative Fugue
 110
Main thing is that the pt suddenly/unexpectdedly travels away from home/work w
inability to recall his/her past; confusion about personal ID or assumption of a new
ID. SSx must cause marked social/job impairment
Rule out: DID, drugs or Gen.Med condition
 111
Dissociative Identity Disorder
 112
The presence of 2+ distinct ID’s/personalities which each have their own way of
behaving (ego, superego, id). These personalities recurrently take control of the
persons behavior. The pt cannot recall important personal info that is too extensieve
to be explained by ordinary forgetfulness.
Rule out: Drugs, Szrs, GenMedCond, Imaginary friends
 113
Depersonalization Disorder
 114
Pt feels recurrent feelins of detachment from his/her body/mental process (feeling
like one is in a dream). Reality testing remains intact. The episode causes clinically
marked social/job dysfx
Rule out: Schizophr, Panic D/o, Acute Stress, other Dissoc D/o, Drugs, GenMed
Cond(eg. temporal lobe szr)
 115
Somatoform Disorders
 116
Somatization, Hypochondriasis, Conversion, Pain, Body Dysmorphic, Somatoform
NOS
 117
Somatization
 118
Dgx: All of the following: 1) Pain in ≥4 sites, 2) ≥1 Neuro ssx eg conversion or
dissociation, 3) GU complaint, 4) ≥2 GI ssx. SSx must be present ≥30yo
Hallmarks: ssx wax/wane; negative lab/clinical tests; comorbid w/ other psych
probs;
Epidemiology: F>>M; anxiety, irritability, impulse, depression and suicide are Hz;
lower IQ and SES; relationship probs w/ chaotic lifestyle; hx of antisocial
personality d/o or others; or w/ EtOHism, esp in M pts;
R/O: variably presenting med cond’s – SLE, lymphoma, sarcoidosis etc;
Tx: Management, many visits, gradually focusing on stressors; if meds=SSRI; tx
other psych probs separately
 119
Pain Disorder
 120
Hallmarks: Pain from unk source; comorbid w/ anxiety d/o or depressive d/o;
Appears suddenly usu after stress and disappear in a few days-years
Epidemiology: 10% of pop
Tx: encourage the pt to participate in life or antidepressants
 121
Hypochondriasis
 122
Dgx: convinced he has a serious med prob despite evidence to the contrary; insists
on tests, txs; doctor shopping, is only happy when illness is confirmed; temporarily
feels better but sx return in days-weeks
Epidemiology: <5% of pop, M=F, begins in adolescents or middle age esp in
elderly; frequent in schizophr, MDD, dysthymia or organic brain ssx
Hallmarks: Sees lots of kinds of doctors but never psychiatrists; hyperalert to ssx
and present them compulsively (that is they repeat the ssx, not dramatize them); this
preoccupation w/ illness can  social disfx; can display anxiety or depression;
Tx: None help but try tx underlying depression or psychosis, reassurance that the
condition is not fatal, schedule frequent regular appts; try placebos or vitamins
 123
Body Dysmorphic Disorder
 124
Dgx:
Epidemiology: usu young ppl w/ preoccupation w/ imagined physical defect usu on
face  seeking surg intervention;
Hallmarks: usu comorbid w/ MDD or OCD; may become a delusional or psychotic
severity; DON’T DO SRGY cuz it won’t help, make things worse and possibly get
u sued
Tx: ?SSRI or clomipramine;
 125
Conversion Disorder
 126
Dgx: 1) Loss of neurological fx eg szr, blindness, paralysis, anosmia, vomiting 2) the dysfx
 a 1º (relief of some kind of stress) or 2º gain (something that pt wants eg $$)
Hallmarks: La Belle Indifference; ¼ of pts have organic probs eg szr; ssx are acute usu
after stress; usu a hx of conversion; usu first seen as teen/20’s usu in ppl w/ antisocial or
passive-aggressive personality d/o; associated w/ anxiety and depression, pts usu w/
narcissistic tendenciesusu in Fem
Specific Conversions: Szr – The pt usu cries or LOLs during the szr, is aware and has
muscle tone during ‘szr’ tx=sit the pt up; Unconsciousness – pt does not completely lose
consciousness and stays aware of surroundings – VS, pain stimuli & DTRs are wnl – and
makes purposefule movements; Paralysis – usu a hemiparesis inconsistent with
neuroanatomy, DTR variable but pathological reflxs (babinski) are not present, paralyzed
part resists force of gravity and has little Ω to passive movement, mvmnt can occur if pt is
startled or hurt; Astasia-Abasia – pts dramatically fall but usu rarely are ever hurt by this;
Sensory Changes; Blindnes – usu c/o blurry, 2x vision, tunnel loss or complete, behavior is
usu inconsistent w/ reprted loss of vision
Tx=Amobarbital to temporarily relieve the conversion. If no change in ssx: Then: not
conversion; psychotherapy, supportive tx,
R/O: Depression, Schiozophre; Amytal inj relieves ssx
 127
Benzodiazepine
 128
Uses: Hypnotic, anxiolytic, antidepressant, acute stress d/o, alcohol intoxication and
withdrawal, amphetamine abuse, delirium, hallucinogen abuse, insomnia from narcolepsy,
mania, panic d/o, PTSD, Schizophrenia, belligerent pts, anticonvulsant, muscle relaxant
MOA: helps GABA bind to GABAA (Cl channel)↑ Cl/ion flux ↓ neuronal activity
PhKinetics: lipid soluble if non-ionic and vv, GI absorption, prot bound, metb by p450 or
conjugation, [CSF]=[blood]
SDFX: HA, NVD, blurry vision, drowsiness, ↓ motor, nightmare, abuse, hyperactivity, ↓
resp rate?resp acidosis, vasodilation
C/I: COPD, obstr sleep apnea, ↓ stomach acid secretion, ?ppl w/ szrs?
Examples: Alprazolam, Clonazepam, Diazepam, Lorazepam,
 129
Alprazolam
(Xanax; Niravam)
 130
MOA: helps GABA bind to GABAA (Cl channel)↑ Cl/ion flux ↓ neuronal activity;
short t1/2
DOC: Acute anxiety attacks
USES: Anxiety, agoraphobia, abuse & dependence,
SDFX: somnolence, fatigue, confusion, coma, ↓ reflxs
Withdrawal: Paranoia, Seizures, anxiety, agitation, psychosis, hallucinations,
Misc: MUST TAPER
 131
Diazepam
Valium
 132
MOA: helps GABA bind to GABAA (Cl channel)↑ Cl/ion flux ↓ neuronal activity;
long t1/2
DOC: Amphetamine abuse/withdrawal, LSD abuse/withdrawal, bad weed trip, PCP
abuse/withdrawal
USES: Amphetamine abuse/withdrawal, LSD abuse/withdrawal, bad weed trip, PCP
abuse/withdrawal, status epileptcus
SDFX:
PhKintcs: OH-ylated
 133
Lorazepam
Ativan
 134
MOA: helps GABA bind to GABAA (Cl channel)↑ Cl/ion flux ↓ neuronal activity;
long t1/2, short onset
DOC: Status Epilepticus; Acutely Violent patient
USES: Anterograde Amnesia; 3rd line x akathisia (pacing, fidgety); BZD w/d; 3rd line x
GAD
SDFX: withdrawal; sedation, decreased concentration,
PhKintcs:
 135
Clonazepam
Klonopin
 136
Use: acute exacerbation of Panic Disorder +/- Agoraphobia; Flashbacks of PTSD
MOA: increase GABA effects  more inhibition
DOC: BZD w/d; 3rd line x Panic d/o; Trichotillomania
 137
Generalized Anxiety Disorder
General Anxiety Disorder
GAD
 138
Etiology: W>M esp in higher SES
SSx: palpitations, perspiration, mydriasis, dizziness, trembling, diarrhea
Misc: increased NE, Decreased GABA, Decreased 5HT
Tx: BZD’s; Zolpidem, Bispirone; Venlafaxine Propanolol
 139
Anorexia Nervosa
 140
Dx: 1) Body wt >15W%below nl wt 2) Refusal to maintain body wt at nl levels 3)
Amenorrhea x 3mos 4) Body image distortion where pt sees him/herself as obese
despite being thin 5) Fear of gaining wt or becoming fat despite being underweight
Ssx: BMI well below nl; Binge and Purge type; or Fast and Exercise type
Tx: CBT, Amitriptyline
Mortality rate is 20%
 141
Citalopram
Celexa
SSRI
 142
MOA: SSRI
SDFX: Impotence, delayed ejaculation, decreased libido
 143
GCS
Eye Opening
1=none
2=to pain
3=to speech/command
4=spontaneous

Verbal Response
1=None
2=incomprehensible
3=inappropriate words
4=confused
5=oriented

Motor Response-best indication of prognosis

1=none
 144
2=Decerebrate/extended
3=Decorticate/flexion
4=withdraw from pain
5=localizes pain
6=obeys commands
Mild Head Injury 13-15
Moderate Head Inj 9-12
Severe Head Injury 8>
Coma 8>
Any change in GCS >2 requires a CT.
Unequal pupil size is indicative of ↑ ICP.
Monroe-Kelley Doctrine-For ICP to be maintained the volume of blood, CSF and
brain in the head must be constant. If one changes then the others must compensate.

Epidural Hematoma-outside dura but w/in skull. Lens shape (biconvex) on CT.
Lucid interval.
 145
Slow pupil rxn to light is indication of temporal herniation usu on same side of lxn.
CO has 240x more affinity for Hg vs O2 → left shift of O2 curve (carboxyHg). t1/2 of
COHg on 100% O2 is ≈ 40mins.
Fluid (LR or Crystalloids) Requirements x burn pts >10kg = TBSA burned(%) x Wt
(kg) x 4mL (Give 1/2 of total requirements in 1st 8 hours, then give 2nd half over
next 16 hours of burn event). DO NOT USE colloids or NS.
Urine OutPut should increase upon resuscitation.
-Burn Rules of 9’s= Chest, Abdomen, 1 Arm, 1 Anterior Leg, 1 Posterior Leg,
Upper back, Lower Back; ea is ≈ 9% of body surface area.
Trauma
-Shock Ssx=low BP, Tachycardia, Tachypnea
-All trauma cases need Airway (do they have access for air to get to lungs)
Breathing (can they breath on their own) and Cicrulation (stop bleeding, and resume
normal BP c 2L NS; if doesn’t work then 1L blood; use 14G needles in the arms).
ABC’s
 146
-It’s OK to do ABC’s even tho u don’t know the status of other vital organs (eg
spine)
- Penetrating wounds to the chest can cause tension pneumo, cardiac tamponade,
hemothrx c massive bleeding
-DPL is used to find abd bleeds or perfs in hemodynamically UNSTABLE pts.
-Spine trauma should be to log roll the patient with Cspine precautions until the pt is
stable/sober so they can get spine films.
-CT, U/S, DPL are other ways to examine abdomen. FAST can also be used but will
miss retroperitoneal bleeds
-Seat belt sign should prompt concern for ruptured bowel

Classes of Hemorrhage
I Loss of Tachycardia, 3sec capillary refill time ≈ 10% loss, nml BP
15%>
II 15-30% cool clammy skin, ↓ catecholamine lvls → ↑ peripheral vascΩ → ↑
Loss Diast, ↓ pulse pressure, Tachycardia, Tachypnea,
 147
III 30-40% Hypotension, more severe Tachycardia/Tachypnea, oliguria,
Loss confusion/agitation
IV >40% ↓ in 147etaphy BP, cold pale skin, ↓/no urine output, ↓
Loss conciousness or LOC, tachyca tachypn hypotension
-In trauma, hemorrhage is the assumed cause of shock
-Tx for adults in trauma shock is 1-2L bolus of NS
-“shed blood”=blood at the scene
-Blood at the external urethral meatus mandates a retrograde urethrogram from tip
of urethra
-Blood loss can go into the: thorax, abdomen, pelvis, thigh and head
-Indications for Laparotomy: >500WBC cells/mm3; 10cc blood from syringe;
>120K RBC/mm3; +bact (≈ bowel perf).
-pts w LOC or altered GCS should receive head CT
-IV bolus of ped’s=20cc/kg crystalloid
Nml Urine Lvls
<1 yo 2ml/min
 148
1-18 1ml/min
yo
Adult 0.5ml/min
-Old ppl, athletes, pts on β blockers (HTN meds), pregos usu experience class III
hemorrhage bf getting hypotensive
-Clots, Ca2+, ↑ Cells (tumors), and Contrast, show up as dense on CT
-Compartment syndrome=Poikilothermia, Pallor, Pain, Paraesthesia, Pulselesness;
Tx=remove whatever is causing problem (cast, burns/eschars etc)
-Methylprednisone is used in spine trauma cases, also C-spine and serial vitals
-Hypothermia is tx w/ heted blankets, (active external warming and warm lavage if
going to ER)
-Scrotal hematoma is indicative of pelvic fx
-Amaurosis fugax (loss of vision in 1 eye) can be caused by dissecting carotid.
-Internal pelvic fixation is the definitive tx x pelvic fxrs but if that isn’t available
just wrap a sheet around it til you can get to a hospital.
 149
-When ordering tests/imaging be sure to order the safer faster ones first (e.g. u/s bf
endoscopy)
-Tx x Coccidioides immitus is Amphotericin B
-#1 Hospital infx=UTI via E. coli; #1 Ventilator infx → pneumonia
-Pay attn to age and sex of pt bf deciding dgx (eg CHF is proly not likely in a young
pt)
-MI is a common problem s/p surgery. Β blockers are cardioprotective s/p surgery x
2wks
-Crystalloids → ↓ pee
-DffDgx x young ♀ RLQ pain radiating to shoulder are: acute appy; tubo-ovarian
abscess; ruptured ovarian cyst; perf ulcer;
-Consumptive coagulopathy can → Thrombocytopenia → bleeding esp if much
blood loss or transfusion cuz whole blood is not allowed thus lack platelets.
-Perf bowel disseminates E. coli
-Hematuria w/o blood at meatus requires CT of Abd/pelvis c/ triple contrast
-Hypercalcemia DDx-CHIMPANZEES
 150
Calcium xcess; Hyperparathyroidism; Immobility; Mets; Pagets; Addisons;
Neoplasms; Excess vit A; Excess Vit D; Sarcoidosis
-After injury to chest, EKG should follow chest tube if possible tamponade
-Sigmoid Volvulous-LLQ pain, constipation, ?fever, abd distension, tender LLQ,
distended bowel on KUB. Imaging should be Rigid Sigmoidoscopy.
-Charcot’s Triad-Jaundice Fever ↑ T-Bili. Indicative of Cholangitis
-DVT prophylaxis s/p surgery is 40mg LMWHeparin (Lovenox/Enoxaparin)
-Crohns-Creeping fat on laparoscopy, inflamed ileus. If you start and
appendectomy but you find other pathology, you STILL TAKE OUT the appendix
and proly fix whatever else you can.
-Elective Surgery should be postponed 6mos after MI
-Meckel’s Diverticulum
-Pain>exam=acute bowel ischemia/necrosis. [Base deficit is usu (-#)]
Mesenteric Ischemia
-“Food Fear” ≈ chronic mesenteric ischemia. [food fear + wt loss + post prandial
pain].
 151
-Screen w U/S
-Tx = bypass graft or operative revascularization eg from Iliac aa.
-Risk Factors x CMI: athersclerosis, old age

-Acute Mesenteric Ischemia caused by aa occlusion of Celiac or SMA. Usu no hx of

chronic ssx.
-This Is An Emergency!
-Screen via Arteriography but I delay in tx.
-Laparotomy=dusky to necrotic bowel, non-mobile
Abdomen
-CV disease can cause thrombosis and emboli anywhere in the body (e.g. cystic aa
→ GB necrosis)
-NON-life threatening conditions encountered during srgy should be consulted after
the elected operation is completed. DON’T take anything out, and don’t just give
up.
 152
-1st test to run are Labs (CBC, BMP, LFT’s etc); UNLESS there is overwhelming
evidence of a defintive dx (e.g. ?CA in a pt w FamHx and +Ssx.
-Hernia’s are usu NOT pulsatile.
-Most common cause of SBO in pts w/ + PSH=adhesions
-Esophageal varices can be due to splenic vv thrombosis. SSx hematemesis and
esophageal varices on EGD. Fixed with splenic excision.
-Steroid OD can be tx w VitA and…
-Hepatic Adenoma-SSx Abd pain, L shoulder pain, syncope, PMH of OCP/BCP.
Images=free fluid. ?↓ HnH
-ITP is tx w splenectomy
-Pancreatic Pseudocyst-Tx is to do a cystogastrostomy AFTER the cyst has grown
>1cm
-Most common cause of SBO in pts – PSH- =hernia
-Distended loops of Small Intestine can be Adhesions or strictures. Tx is
conservative (NPO, IV hydration, AB’s, and NG tube) if known cause. Or Ex Lap
if unk cause
 153
-Perforated Duodenal Ulcer-SSx Epigastric pain, +N, +EtOH, +Coffee/stimulants.
Abd is tender, rigid. Tx=
-Colovesicular Fistula-SSx Fever, Bacturemia, Dysuria. Imaging = sigmoid
Diverticula via contrast CT, pneumobladder. Tx=IV ABs, cystogram
-Colonic Ischemia-SSx +N/V, ↓ BP. Dgx via sigmoidoscopy → purple areas in
sigmoid. Tx=IV ABs, Hydration, repeat sigmoidoscopy in 24hrs. (NOT enema)
-Tx x Crohns flare up=IV fluids, BMP, CBC, CT. NOT invasive imaging (eg –
oscopy’s)
-Toxic Megacolon-SSx Bloody diarrhea, -AB’s use, crampy abd pain.
Imaging=Dilated Colon. Tx=
-Suspected liver condition should be tested with labs: CBC, LFT’s, CMP
-Post Op complications of Lap Chole=biliary leak from cystic duct. SSx= RUQ
pain, tender, ≈ tachy ↑ bili, nl Alk Phos and nl AST/ALT
-Ischemic Bowel Tx=IV hydration, serum lactate, angiogram of suspected vessel
(SMV, SMA eg).
 154
-Definitive Tx x UC=Total colectomy and anal mucosectomy and ileoanal
anastamosis.
-Abdominal pain w/ nl blood labs should be followed with CT and/or HIDA biliary
scan. DDx=Gastric malignancy or Gastric ulcer.
- Dieulafoy ulcer=SSx ulcerative gastroenteritis due to ↑ steroid hormones. Dx via
endoscopy. Tx=vagotomy and actrectomy
-Antrum Ulcer is associated w/ H. pylori, CA, NSAIDs, & atrophic gastritis (NOT ↑
H+)
-Duodenal Ulcers are associated w/ H. pylori, ↑ [H+], NSAIDs, M>F (NOT CA)
-Gastrin should be checked if; pt has recurrent ulcers after srgy, has many ulcers or
in weird areas, has ssx of endocrine adenomatosis syndrome.
-Duodenum aa supply=Common hepatic
-Duodenal ulcers are harder to tx and require 4 quadrant bx vs Gastric ulcers. (both
usu require total gastrectomy, are equally malignant and occur in older pts M>F)
 155
-Acute pancreatitis is most commonly due to Alcoholism and Biliary tract dss.
Rarely but pimpy via scorpion bites of pacific tropic ares. SSx=nl serum amylase,
+N/V, ARDS, ↓ Ca2+, Abd TTP. Tx=broad spec ABs
-↑ Amylase due to: perf’d PUD, Bowel Obstrx, Acute Chole’it is. (Pancreatic
trauma will have ↑ amylase in ≈ 24 hrs)
-Pancreatic CA SSx=painless jaundice; abdominal pain only, ie w/o jaundice; pain
w/ jaundice. Dx=ERCP or Percutaneous Transhepatic Cholangiography.
Tx=resection w or w/o histo evidence; <20% or pancreas or 5% or tumors are
resectable; biliary stent to relieve jaundice/itching due to biliary salts; excision of
head requires excision of duodenum.

PreOp/PostOp Considerations
-ADH postop → ↓ serum Na
-Trauma fluids=0.9%NS @ 125cc/hr
-SSx of blood transfusion rxn due to WBCs=nl BP, clear urine, fever/chills.
-MI is a common risk PostOp.
 156
-Narcotic analgesics can cause ↓ mental status eg demerol, morphine.
-Patchy infiltrates sp trauma can indicate pulmonary contusion. SSx ↓ breath
sounds, tachypnea.
-Fever
Wind POD1
Water POD3
Wound POD5
Walking POD1-7
Wonder Drugs POD1-7
-Superficial hematuria w/o blood via cystoscopy is proly urethral injury
-Fistulas can occur bw vessels and biliary tract. SSx=icterus, hematemesis, ↓ BP, ↑
pulse
-↑ gluc can → DKA → ↑ RR
-Diffuse abd pain +fever, ↑ pulse, ↑ RR, -wound contmx, can be acute mesenteric
ischemia
-Metabolic Acidosis pH, PCO2, PO2, HCO3, BE,
 157
-Respiratory Alkalosis pH, PCO2, PO2, HCO3, BE
-Metabolic Alkalosis pH, PCO2, PO2, HCO3, BE
-Respiratory Acidosis pH, PCO2, PO2, HCO3, BE
-Thyroidectomy can → ↓Ca2+ → paraesthesias, Chvostek or Trosseau sign
-Necrotizing Fasciitis causes by Strep is foul smelling and hot to the touch. Soft
tissue infx via Clostr perf shows air in soft tissues, under skin and wound crepitance.
-Srgy of GI tract should receive a PNC + AG. Pts who can’t take PO should take
Vancomycin and Gentamycin cuz they are IV.
-Homans sign pain in calf when ankle is slowly dorsiflexed while knee is bent,
indicative of DVT. Image DVT via duplex U/S
-Clindamycin covers G- bact
-SOB sp trauma of chest (eg broken ribs) is proly due to pneumothorax
-Long bone fx can → SOB via fat embolism syndrome ≈ 8hrs sp trauma.
-SOB days sp MVC/trauma w/ tachy is pulmonary embolism
-Septic Shock=Fever, ↑ WBC, tachycardia, met acidosis, neg BE, ↓ BP, ?patchy
lung infiltrates
 158
Thoracic/Vascular
-A/V fistula SSx=?Hx of vasc srgy, ↓ exercise toler, edema, palp thrill. Dx=. Tx=.
-Lung CA SSx=blood tinged sputum, wt loss, usu Hx of smoking, Dgx=X-ray,
Chest CT, Bronchoscopy if nodes<1cm. Tx=. Rule out TB and other pathogens.
-Spinal Ischemia SSx=↓ limb movement, Hx of aorta repair
-Arterial Steal Phenomenon SSx=extremity pain/numbness, thrill, ↓ pulse on
affected side, ?Hx of fistula or injury. Dx=. Tx=.
-Amarugis Fugax should be investigated via Carotid duplex U/S c/ color flow
doppler.
-Renal aa stenosis should be investigated by labs, followed by U/S of kidneys.
-Claudication SSx=pain while ambulation. Due to vascular spasm causing ischemia.
Dgx clinical, ABIndex>.5, Usu obese, Hx +smoking. Tx=stop smoking, ↑ exercise,
↓ wt, pentoxifylline, noninvasive vasc tests.
-Boerhave Syndrome SSx=CP, vomiting, ?↓ lung sounds, ↓VS, Hx +EtOH. Dx=.incr
amylase of pleural effusion, widened mediastinum Tx=.
 159
-PeriOp MI risk is best tested w/ Myoview stress test
-Symptomatic AAA should be managed via blood type/cross and srgy.
-Suspicion of vascular insuffx should be managed via Duplex US, of aa and vv.
-Pneumothorax –Hx trauma is usu due to pulmonary blebs.
-Packed Red Blood Cells (PRBC)-Administer when pt is anemic, c active bleeding
-Fresh Frozen Plasma-contains clotting factors and plasma proteins. Used to reverse
coagulopathy eg to lower INR in a pt taking warfarin
-Cryoprecipitate-Clotting factor rich product used in coagulopathy pts that are sensitive to
volume
-Platelet Transfusion-
-Plasmapherisis-Process of removing pts plasma and replacing it c IV fluid. Done when a
destructive subs (eg Ig) is in pts body. Used eg in
 160
Pancreatic Pseudocyst
 161
Path: Encapsulated fluid w ↑ pancreatic enzx usu near/in pancr or somewhere in
abd. Walls=inflx fibrosis of connective tiss. Does not have epith lining. Hx of acute
pancreatitis.
SSx: Epigastric mass and pain, fever, wt loss,↑WBC, ?jaunice, Failure to recover
>1wk tx of acute pancrx. Palpable tender mass including surrounding tissues
(phlegmon)
Dx: CT or US x f/u, ↑ amylase, ↑bili,
Tx: Excision, or anastamosis to duo or stomach after it has ‘matured’.
 162
Acute Pancreatitis
 163
Etiology: Usu caused by alcohol abuse, gall stones, or scorpion bites (or trauma)
SSx: Acute upper abd pain sp large meal, N/V, dehydration, ↑pulse, , lack of
fever, ?↓BP. ↓BS, blue/gray discoloration if bleeding
Dgx: ↑amylase esp if EtOH and ↑lipase esp if biliary, usu nl CMP, ↑urine amylase,
↓Ca2+. KUB shows sentinel loop (isolated dilation) of large or small bowel near
pancr, glandular calcification, CXR might show L pleural effusion
Tx: ABs if severe (Imipenem/Cilastatin), ↓secretions and correct serum lvls (Ca2+,
Mg2+, CBC), gastric suxn, CT if not resolved >2 days, O2 x insidious hypoxemia
Prognosis: Ransons criteria; high C-Reactive Prot=high % of death
DDx: acute chole, perf’d PUD, upper SBO, acute appy, mesenteric infarx.
Can cause ARDS secondary to acute pancreatitis.
 164
Ransons Criteria For Pancreatitis Severity
Criteria Present Initially
Age>55yo
WBC>16K/µL
gluc>200mg/dL
LDH>350IU/L
AST.250IU/dL
Critereia Developing w/in 24hrs
Hct ↓ >10%
BUN ↑ >8mg/dL
Serum Ca2+ <8mg/dL
aaPO2 <60mmHg
BE >4meg/L ???
est free fluid >6L
0-2 criteria=2% mortx; 3-4 criteria=15% mortalx; 5-6 criteria=40% mortalx; 7+
criteria=100% mortalx
 165
Classes of Hemorrhage
I Loss of Tachycardia, 3sec capillary refill time ≈ 10% loss, nml BP
15%>
II 15-30% cool clammy skin, ↓ catecholamine lvls → ↑ peripheral vascΩ → ↑
Loss Diast, ↓ pulse pressure, Tachycardia, Tachypnea,
III 30-40% Hypotension, more severe Tachycardia/Tachypnea, oliguria,
Loss confusion/agitation
IV >40% ↓ in 165etaphy BP, cold pale skin, ↓/no urine output, ↓
Loss conciousness or LOC, tachyca tachypn hypotension
 166
TPN bypasses the GI Tract which bypasses stimulation of the GI hormones b/c there
are no nutrients in the GI tract. Without this stimulation bile stays in the gall bladder
causing pain and predisposes to gall stones.
 167
Appendicitis
 168
SSx: Achy epigastric pain evolving to RLQ sharp pain TTP and ambulation. NV,
anorexia, indigestion, +rebound tenderness.
Dx: ↑WBC w/ neutrophilia, +/- hematuria. CT/Imaging shows weird stuff on RLQ
eg free air/fluid, ↑tiss density, calculus (R psoas shadow), fat stranding.
Tx: appendectomy
Complications: Perf from late dx → ↑ % infertility in fems, peritonitis if
gangrenous →toxicity distension and adynamic ileus.
DDx: PID, tubo-ovarian torsion
 169
Crohn’s
“Regional Enteritis”
 170
Chronic progressive granulomatous inflmx dss aaprox 90/100K ppl suffer, esp
40yo’s.
Path: Usu involves distal ileum and colon but can involve entire GI tract
(mouthanus). Can also have skin lesions.
SSx: Diarrhea, neg hematochezia, postprandial colicky pains relieved by pooping,
wt loss, malaise, chronic anal fissures, cobblestone-ing ulcers, malnutruition
Dx: ?↑sed rate, ↓ albumin, anemia, steatorrhea. Barium test  string sign,
thickened bowel wall, ulcers; Non-caseating granulomas, skip lesions, cobblestone
appearance, fistulas, fissures and anal disease.
Tx: rest, ↓ stress, eliminate dairy, ↑ prot. Steroids, sulfasalazine, aminosalicylates,
mercaptopurine. Surgery if obstrx, perf, internal or external fistula, abscess, perianal
dss or developmental failure.
Complxs: fistulas, abscess, pain, hepatobiliary dss, uveitis, arthritis, ankylosing
spondylitis, aphtous ulcers, thromboembolism, GU complxs.
 171
Gastric Cancer
 172
incidence≈ 20K/yr. (10/100K). Main cause ?H. pylorichronic atrophic gastritisgastric
adenoCA. ↑[Ab’s]H. pylori α ↑risk gastricCA. Also ↑starches/↓fruits n veggies in diet ≈ ↑%x
gastricCA. Parts involved=body or antrum.
SSx: Postprandial heaviness becoming more Hz and longer. Anorexia, wt loss, coffee-
ground emesis, dysphagia. Epigastric mass on PE, +guaiac, Virchow node (palpable
supraclavicular lymph node), anemia, +CEA. Bx of >6 brush samples during gastroscopy to
be useful. Gastrectomy shows rolled up margins.
Tx: Surgical resection. ≈ ½ are curable.
Complxs: Krukenberg (ovary) tumor, Blumer (anal) shelf, mets to lung, liver, brain or
bone.
Types: 1) Ulcerative CA-Deep penetrating ulcer possibly involving adjacent organs. Kinda
looks like benign ulcers. 2) Polypoid CA-Large bulky intraluminal growths which mets
later. 3) Superficial Spreading CA/Early Gastric CA is confined to mucosa and submucosa;
1/3 mets; good prognx if gastrectomy. 4) Spreading tumor involving all layers w/ marked
desmoplastic rxn  ↓pliability and leather like consistency. Bad prognx. 5) Advanced CA-
Advanced stages of the previous mentioned classes.
 173
Ulcerative Colitis
“Idiopathic Mucosal Ulcerative Colitis”
 174
Onset age has bimodal distribution. Jews esp.
SSx: Rectal bleeding, Diarrhea, watery purulent bloody stool usu w/ tenesmus (spasm) or
anal incontinence. ?Fever, cramping, abd pain, vomiting or wt loss? Aggravated by dairy.
Onset is variable and progressive. ?LLQ tenderness, anal fissures and tenderness, blood on
rectal exam. UC is Confined to the Colon esp rectum c no cobblestone appearance.
Dx: Sigmoidoscopy shows granular dull hyperemic and friable mucosa. Oozing blood on
contact. Mucosa is purple/red/velvety, NO skip lesions. Anemia, leukocytosis, ↑ sed rate,
hypoalbuminemia, dehydration, ↓BMP and vits, steatorrhea. Must rule out bact/parasites.
KUB can show megacolon, lead pipe appearance (lack of haustra). DON’T DO
Colonoscopy or Barium Enema.
DDx: CA/lymphoma, diverticulosis, salmonellosis, dysentery, shigellosis, campylobacter
jejuni, E coli, amebiasis, TB. Complxs: skin/mucous lesions, erythema nodosum, erythema
multiforme, pyederma gangrenosum, dermatitis, uveitits, spondylitis, OA, hep/bili/pancr
lesions, cirrhosis, anemia, malnutrition, pericarditis, colon perf, toxic megacolon, massive
hemorrhage, strictures, Colon/rectal CA@ ≈ 10yrs
Tx: qs Mesalamine x maintenance. Total colectomy w ileal anastamosis if chronic, or
megacolon does not resolve in 24hrs, or ≈10yrs to avoid colon CA.
 175
Urinary Tract Fistulas
Vesicovaginal, Ureterovaginal, Urethrovaginal
 176
Due to injury to urinary tract (eg during labor) or ischemic necrosis following
radiation tx x CA
SSx: Constant urinary leakage can be seen in vagina. Ureto/vesico-vag fistulas are
usu at the ‘vault’ closure; urethra-vag fistulas are usu @ anterior wall.
DDx: Cytoscopy or xray can see the os. Sometimes complicated os’s exist.
Tx: Srgy, self limiting, skin excoriation x UTIs; Ureterovaginal fists are fixed
vaiureteroureterostomy or ureteroneocystostomy. Must maintain bladder pressure
postop; Radiation fists usu require new blood supply eg from gracilis.
 177
Recto/Sigmoido-Vaginal Fistulas
 178
Usu due to Ob/Gyn injury, srgy probs, cervical CA, radiation, IBD or diverticulitis.
SSx: Flatus incontinence, feces thru vagina, fould vaginal discharge w/(o) blood. Os
can be seen on vag exam, or DRE
Dx: Colonoscopy or retrograde dye studies.
Tx: Fix edema/inflmx, low residue diet, Abxthen: diverting colostomy if proximal.
NO SRGY if: Crohns, no response to mx management, CA
 179
Zollinger-Ellisoin Syndrome
 180
SSx: PUD, diarrhea, steatorrhea, relief from high dose PPI or H2 blockers,
hemorrhage, perf, obstrx.
Dx: ↑gastrinserum (>500pg/mL), antacid mx can cause rebound ↑gastrin  worse ssx.
If mildly elevated: Then: secretin provocative test ↑gastrin>150pg/mL in 15mins.
Upper GI seriesulcers in duodenal bulb to prox jejunum, dilated duodenum w
hyperactive perstalsis; somatostatin receptor scintography locates the gastrinoma
and mets. Ulcers in ectopic locations is pathognemnonic x ZES.
Tx: H2 blockers x acid prodx. Gastrinomaectomy w streptozocin 5-FU, and
Doxorubicin x CA.
Complications: Metsdeath
 181
Gastric Ulcer Classes
 182
Type I: Most common. Usu older vs duod ulcer pts. Nl acid prodx. Usu 2cm distal
in the pyloric area in the lesser curvature near incisura angularis.
Type II: Prepyloric ulcers, usu associated w/ duodenal ulcers. Low%xCA. Acid
secretion≈ duodenal ulcer
Type III: In the Antrum due to NSAID use.
Must differentiate bw benign vs malignant ulcer
 183
Gastric Ulcers
 184
SSx: Epigastric pain exacerbated by eating.
Dx: Gastroscopy shows flat edges. 6 marginal bx sections. Upper GI XRulcer usu
on lesser curvature near pylorus. Malignant if: shallow ulcer, +meniscus sign
(radiolucency around ulcer), ulcer>2cm. Rule out H. pylori.
Complications: Bleeding, obstrx, perf
Tx: Stop NSAIDs, endoscopy to track healing, H2 blockers, Omeprazole
Amoxicillin or Clarithromycin Metronidazole if H. pylori
 185
Mallory Weiss Syndrome
 186
10% of UGI bleeds. 1-4cm longitudinal tear thru submucosa (not sm muscle). Usu
associated w hiatal hernia. Appears after severe retching or CPR. Sequence: Vomit
foodretchingbloody vomit
Tx: Ice water lavage, e-cauterage. Srgy if bleeding doesn’t stop (high/proximal
gastrotomy.
Good prognosis
 187
Small Bowel Obstruction (SBO)
Simple vs. Strangulation
 188
1. Mechanical/physical obstrx. 2. Parlytic Ileus-neurogenic failure. Etiology-a. Adhesions is
most common cause. B. Neoplasms of the lumenintussusceptionchronic anemia;
masses @ ileocecal jx can also present as SBO. C. Hernia eg into obturator foramen, or
surgical defects. D. Volvulus e. Intussusception f. Foreign bodies eg swallowing toys g.
Gallstone ileus gallstones can pass via GB/SB fistula. H. IBDobstrx inflmx i. Stricture
due to ischemia j. Cystic Fibrosis k. Hematoma eg from anticoagulants
SSx: I. Simple Emesis, upper abd discomfort, crescendo-decrescendo diffuse pain. The
more distal the obstrx the ↑%x feculent emesis, ?obstipation, dehydration, ↑pitched ‘tinkles’
on auscultation. Nl DRE. II. Strangulation Shock, fever, severe abd cramping, emesis w
gross/occult blood.
Dx: I. Simple Concentrated BMP, ↑amylase, Dilated loops in a ladder like pattern w air-
fluid lvls. Gas is absent in colon. II. Free fluid bw loops of dilated bowel indicate perf
Tx: Decompression via NG tube. Correct any e-lyte imbalances prior to srgy. Srgy if >3days
obstrx or complete obstrx.
Complx: death following seemingly successful srgy
 189
Thoracic Empyema
 190
Pus in the pleural cavity usu thick and malodorous; usu due to srgy or suppurative
lung dss or trauma. Starts as Acute Exudative is sterile fluid, low LDH, and
glucFibrinopurulent is thicker, whiter, ↓gluc and pH and ↑LDH causing fibrin
deposition causing trapping of the empyema and also the lung. Usu caused by
Staphylcoccus, Bacteroides or Peptococcus, Fusobacterium, E coli, Pseudomonas…
SSx: Random-Fever CP, chest discomfort, anemia, tachycardia/pnea, ↓breath
sounds dull to percussion, pulmonary osteoarthropathy.
Dx: CXR’D’ shaped density, shifted mediastinum away from affected side.
Bronchoscopy to r/o bronchial obstrx. CT or US to r/o abscess.
Thoracocentesispus
Tx: 1o Abx x infx, removal of purulent material and sterilization, fix underlying dss.
2o Open drainage, re-thoracocentesis. Add fibrinolytic enzx. *Pts w/ cont sepsis, are
inadequately drained, or need long-term tube drainage should have open drainage
≈14 days sp closed tube drainage to ↓lung collapse and max pleurae fusion.
 191
Pleural Effusions
 192
Can be caused by Hydrothorax, CV Dss, Empyema, Hemothorax or Chylothorax
Dx: CXR usu shows mediastinum shift to affected side; decreased breath sounds,
decreased tactile fremitus, decreased transmitted airway sounds
Tx: Thoracocentisis.
 193
Abscess
 194
A circumscribed collection of purulent exudate frequently associated with swelling
and other signs of inflammation. A cavity formed by liquefactive necrosis within
solid tissue.
Acute<6mos
Chronic>6mos
 195
Superior Vena Cava Syndrome
 196
M>F usu caused by lung CA tumors, thymoma, or breast
SSx: Nasal congestion, edema in the upper half of body, cyanosis or purple skin.
NV, dizziness, change in vision, drowsiness, stupor, & convulsions, cough,
hoarseness, dyspnea due to bronchio/tracheal edema, usu exacerbated by lying down
or bends over. Long standing dss canesophageal varices.
Dgx: Upper extremity pressure ≈ 200-500mmH2O; venography. CXR shows
impinging mass.
Tx: Diuretics, avoid hydration and lines, head elevation, radiation tx x tumor,
fibrinolytics. Improvement w/in 10 days,
Complx: fatal cerebral edema w/in mins, anticoagulants can cause brain re-
hemorrhage.
Good progx
 197
Esophageal Perforations
 198
THIS IS AN EMERGENCY Hx of recent instrumentation in the esophagus or sp
emesis. Cricopharyngeal perfs due to instruments are most common or near tracheal
impingement.
Caused by: instruments, Boerhaaves.
SSx: Pain in: Chest, epigastric, or neck; signs of mediastinal or thoracic sepsis
<24hrs.
Dx: Esophageal leak via, Hammans sign (mediastinal crunch), CXRair in soft
tissues, widening of mediastinum, ant displacement of trachea, pleural effusion w/
(o) pneumothx, esophagram w/ contrast then barium (if contrast=0)
Tx: Abx, srgy <24hrs,
Complx: Esophageal infx if not fixed fast, communication w pleural cavity.
Prognosis is 90% if srgy <24hrs or 50% if >24 hrs.
 199
Lung Abscess
 200
1o abscesses due to aspiration of S aureus or K pneumo or fungi. 2o due to CA,
bronch obstrx, mediastinal LAD, or infx spread.
SSx: Cough, fever, SOB, pleuritic CP; malaise & wt loss if chronic; insidious; lobar
consolidation
Dx: CMP x diff, sputum cx, CXR, bronchoscopy if idiopathic, FNA Cx
Tx: Abx (PNC+Clinda; Bactirim, AmphoB, or Erythromycin if immunocmprsd) x
5mos, good hygiene; percutaneous drainage if complex (eg >4cm). Prognx is good
as long as pts don’t end up in ICU.
 201
Duodenal Ulcer
 202
M>W. Due to H. pylori infx 90%; NSAIDs 10%; sometimes ZES
SSx: Epigastric pain relieved by eating, TTP, nl-↑acid secretion; back pain when
pancreas is involved; +/- NV
Dx: upper KUBduodenal deformities; Endoscopy x UGI bleeds or obstrx; basal
acid output, serum gastrin.
Tx: H2 blockers, Abx x H. pylori; Vagotomy, (gastrojujenostomy) Distal
gastrectomy anastomosed to the duod (Bilroth I) or proximal jejunum (bilroth II);
Subtotal gastrectomy (3/4 of distal stomach)
Complx: Dumping syndrome-combo of palpitationssweating, wkness, dyspnea,
flushing, nausea, abd cramp, belching, V/D; alkaline gastritis, anemia; post
vagotomy diarrhea, chronic gastroparesis
 203
Paraesophageal Hiatal Hernia
 204
Part of stomach herniates thru diaphragmair bubble displacement and pressure
phenomenon.
SSx: burping, snese of pressure in lower chest after eating
Tx: Srgical fix w suture to esophagus.
 205
Sliding Esophageal Hernia
 206
GE jx herniates up diaphragmGERDadenocarcinoma; Aspiration
canpneumonia.
SSx: Acid reflux while laying down, burping
Dx: Upper GI series shows sliding hiatal hernia. Bxevidence of esophagitis; ↓
LES resting pressure; ↑acid prodx.
Tx: None if assx; No late meals, no lying down after meals, elevate bed head,
frequent sm meals; H2 blockers; Srgy x pts who are resistant to Rx via Nissen
fundiplication
 207
Umbilical Hernia
208
 209
Primary Amenorrhea
 210
FSHE2 (stimulates endometrial hypertrophy) at first then Prog by dominant
follicle after ovulation

Primary: No period >16yo

Causes: E2 defx (pale vaginal mucosa, lack rugal folds), Turner Syndrome (short,
webbed neck, gonadal dysgenesis), PCOS (hirsutism, obesity, acanthosis,
irregular), Kallman Syndrome (agenesis of olfactory bulbsno GnRH neurons),
hormonal, congenital, chromosomal (no breasts, no uterus). Anatomic (usu have 2º
sex characteristics). “Testicular Feminiziation” (have 2º sex characteristics).
Gonadal Dysfx or HoTH(have uterus, no breasts),
 211
Secondary Amenorrhea
 212
FSHE2 (stimulates endometrial hypertrophy) at first then Prog by dominant
follicle after ovulation

Secondary: No period >6months after previously having 6 regular cycles or 12

irregular cycles
Causes: Pregnancy. Tumor (hyperprolactinemia, androgenic dysfx). Stress, chronic
infx, systemic illness, anorexia, weight loss and too much exercise can inhibit
HoTH. Thyroid dysfx (palpitations, fatigue). PCOS (irregular, hirsutism, ↑LH or
LH:FSH=2.5)
(-)β PL, TSH. If PL, TSH nlProg challenge test. If bleeding <1week after
progesterone=HoTH, pit, ovarian, uterus are fxing=no ovulation or PCOS. No
bleeding=↓E2 or anatomic abnlcheck FSH lvls. ↑FSH=ovarian dysfx. ↓/nl
FSHhead CT. Outlet obstrx tx=Prog/E2
If Testosterone>200mg/dL or DHEA>7mg/dLCT to r/o adrenal/androgen stuff
 213
Aortic Dissection
 214
SSx: Tearing chest pain in the “back of the chest” or the back
Dgx: CXR=widened mediastinum, discreprancy bw pulse:BP and BP of arms. CT
shows double lumen aorta. EKG can be nl. Diastolic murmur of aortic regurg; HTN;
hypotension can occur if tear extends into coronary aa or pericardium  impaired
cardiac fx; If Trauma &/or coumadin/warfarin then suspect mediastinal hemorrhage
Tx: IV β blockers to reduce BP& pulse, or vasodilators (NO), Ca channel blockers,
or ACE-I’s. Radial aa cath to monitor BP
F/U: CT <7days to r.o. re-expansion
Management: Hx, physical, TEE,CT, ECG, Cardiac Enzx
 215
Unstable Angina
 216
SSx: Chest pain or pressure type discomfort, radiating to hand or jaw, pain
alleviated by rest or decreasing O2 demand.
Dgx: EKG (ST seg elevation/depression and/or T-wave inversion; MI have this
PLUS elevated CK-MB Troponins), CXR, CBC, CK-MB, Troponin-T & I,
electrolytes, Renal fx, PT, PTT, INR, glucose
Tx: Immediate tx=EKG, CXR, MONA and antithrombotic. Morphine, O2, NO,
Aspirin, β-Blocker, Glycoprotein Iib/IIIa inhibitors (MONA β Gentle). ACE-I’s
reduce immediate mortality, and stop ventricular remodeling.
Causes: Atherosclerosis, coronary spasm, cocaine, endocarditisembolus,
Monitor: O2 sats. After dgx/tx do LFT’s, Mg, homocystein, UA & tox screen,
myoglobin. Then tx CAD if applicapble
Risk Factors: Hx or Fam hx of CAD, HTN, tobacco, obesity
 217
Congestive Heart Failure
CHF
 218
Systolic: Dilated ventricle failure, increased TPR, decreased CO, increased LVEDV
SSx: Dyspnea on exertion, paroxysmal nocturnal dyspnea, night cough, S3 gallop,
pulmonary edema, pleural effusion, JVD, tachycardia, cardiomegaly, cyanosis,
oliguria, nocturia, peripheral edema, wt loss, Cheyne-Stokes Respiration, pink
frothy sputum, weakness, lightheadedness, wheezing. Hx of HTN, CAD, smoking.
Dgx: Echo (decreased EF, valvular stenosis, regurgitation), CXR (cephalization,
pulmonary edema/perihilar infiltrates, cardiomegaly, chamber enlargement), EKG,
increased BNP (Brain/B-type Natriuretic Peptide). Check CBC, LFT, renal fx,
cardiac enzx. Can be precipitated by infx or anemia. HypoNa=(-) prognosis
Tx: Furosemide/loop diuretics (reduces fluid overload and causes bronchial
vasculature vasodilation), ACE-I’s (ARB’s if cough, prego, hypotension,
hyperkalemia, renal probs), β Blockers (only outpatient), O2, IV access
Diastolic: can’t contract, relax or fill
Risk Factors: >50yo, Hx of HTN, CAD, heavy alcohol abuse, smoking, Ca++
channel blockers, Amyloidosis
 219
Palpitations
 220
Work-Up: EKG, CBC, TSH, CMP,
DDx: A-fib. A flutter-Saw tooth pattern on EKG due to re-entry, variable AV node
conduction and 2:1 condu hyper/hypothyroidism, DM, MI, hyperadrenalism,
substance abuse (caffeine, cocaine, fen-phen), anemia, hyperK+ familial long QT
syndrome, mitral valve prolapse, wolf Parkinson white (δ waves), sick sinus
syndrome.
Tx: SVT-IV adenosine, β blockers, Ca++ channel blockers, digoxin, carotid massage.
A Fib-warfarin, β blockers. V Tach-Defribillation, Pacemaker. PSVT-Cold water to
suppress AV Node
Deadly: Long Q-T ssx (syncope, QTc>470ms). Hypertrophic Cardiomyopathy
(kids, chest pain, syncope, palps, murmur on valsalva) dgx w ECG.
 221
Mitral Valve Stenosis
 222
→ an increased risk of stroke bc calcific nodules provide a
Most Common Cause: Rheumatic Heart Disease (migratory polyarthiritis, carditis,
subQ nodules, erythema marginatum, Sydenham chorea) decades earlier from Gp A
Strep.
SSx: Dilated Left atrium, mural thrombi, Right ventricular hypertrophy, a fib,
pancarditis. Opening snap. Capillary pulse (alternating reddening/blanching of
capillary area due to arteriolar dilation). Loud S1. Mid diastolic rumbling/murmur at
at apex. Decreased atrial kick; L main stem bronchus is pushed upward/elevated
Dgx: Aschoff bodies (swollen eosinophilic collagen, T cells, swollen
MΦ[Anitschkow cells/caterpillar], enlarged multinucleated MΦs aka Aschoff giant
cells
Tx: Surgery
 223
Aortic Stenosis
 224
Most common of valv abnl. Usu due to old age/wear n tear. Rheumatic Aortic
Stenosis is ~10%.
SSx: BP >200, Angina. CHF. Syncope. Systolic Murmur at the right sternal border ?
radiating to carotids. Aortic Stenosis in a young person is usually due to a Bicuspid
Valve which → ↑ myocardial O2 demand.
Path: Hypertrophied ventr myocard becomes ischemic due to decreased blood flow.
Causes CHF
Tx: Sgx
 225
Mitral Valve Prolapse
 226
most often young women. Valves are big and thin, the tendinous cords can be long
and thin too. Concurrent tricuspid prolapse is common. Increased risk for infective
endocarditis
Path: Annular dilation, no fusion of leaflets, thin cords, ?congential/systemic defect,
so common in Marfan’s.
SSx: incidental find MID SYSTOLIC CLICK, usu seen on ECG, ?Systemic
connective tissue probs, possibly: angina, dyspnea, psych probs, holosystolic
murmur.
Dgx: ECG, left sided ventr enlargement, holosystolic murmur. Murmur disappears
with squatting/increased preload.
Complxs: mitral insuffx requiring surgery, increased risk of infective endocarditis,
stroke from emboli, fatal ventr and atrial arrhythmias
 227
Infective Endocarditis
 228
Acute IE starts and causes death w/in a few days by high virulence organisms
Subacute IE affects abnl heart on previously deformed valves and are
Path: mostly bacterial, hx of mitral valve prolapse
SSx: FEVER, murmur on the L, fatigue, wt loss, flu like ssx, ?:petechiae, red streaks
of the nail bed (hemorrhages)
Acute-necrotizing, ulcerative invasive valve infx.
Subacute- Strep viridans,
Dgx: hx of RHD, mitral valve prolapse,
Tx: Abx for tx and for prevention bf dental, surgical, invasive procedures
Risk Factors: IV drug abuse predisposing to staph aureus, hx of RHD, prosthetic
valves, oral bacteria (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella,
Kingella [HACEK]), Prosthetic Valve (staph epidermidis), Dental srgx,
 229
Tetralogy of Fallot
 230
VSD
Pulmonis Stenosis
Overriding aorta
RVH
SSx: Cyanosis
 231
Hypertension
HTN
 232
Parathyroid Gland Disease-kidney STONES, BONES ache with hypercalcemia,
GROANS of GI ssx, and PYSCHiatric Overtones
 233
Myocardial Infarction
MI
 234
SSx: ST segment elevations, inverted T waves, S4, ?NV,?Sweating
Reasons: Coronary aa occlusion, CAD from DM hyperlipidemia, Cocaine
Tx: Restore Coronary Blood Flow!, MONA β G. Cocaine-BZDs, ASA, NO, α
blockers (phentolamine).
Post MI: ACE-I’s if low EF. Β-blockers if nl EF
Death is caused by cmplx ventricular arrhythmia, reentry. Ventricular free wall
rupture can occur during remodeling (ssx=pulseless electrical activity/PEA,
pericardial tamponade, hypotension, sinus tachycardia; Tx-percardiocentesis)
 235
Double Aortic Arch
 236
SSx: child wheezing not responding to steroids or bronchodilators. Ssx worse while
supine, alleviated by neck extension.
Dgx: Vascular ring occluding neck airway
Tx: Surgery
 237
Premature ventricular Complexes
PVC
 238
SSx: QRS >120ms, bizarre morphology, compensatory pause (dropped beat?)
Tx: Observation if assx. Β-blockers if +ssx
 239
Pericardial Effusion
 240
SSx: Distant heart sounds, non palpable PMI
Dgx: CXR may appear as an enlarged globular appearing cardiac shadow “water
bottle” shape.
 241
Pericardial Effusion
 242
SSx: Alternating QRS amplitude (
Hx: viral URI
Dgx: Electrical Alternans on EKG-varying QRS amp’s from beat to beat
 243
Amiodarone SDFX
 244
Pulmonary toxicity eg lipoid pneumonia
Thyroid dysfx-Hypothyroidism in 85% and HypeRthyroidism in 15% so check TSH
q3-4mos
Hepatotoxicity-AST/ALT elevations, assx, benign if <2x increase
Corneal Deposits-caused by secretion by the lacrimal gland. Benign
Skin changes-blue-gray skind discoloration esp in the face
 245
Stable Angina
Exertional Angina
Angina of Exertion
 246
Tx: β blocker x HTN if isolated. NO to control ssx
 247
Grave Disease
 248
SSx: fatigue, wt loss, LID LAG, tremor
Path: Toxic Goiter hyperthyroidism caused by increased β receptor sensitivity to
sympathetic stimuli
Tx: Propanolol to control A fib and other hyperthyroid ssx.
 249
I (β) Blockers
 250
DOC:
SDFX: vasoconstriction
 251
Atroventricular Fistula
AV Fistula
 252
Path: high output cardiac failure by shunting blood from aa to vv side increasing
cardiac preload
SSx:
 253
Prinzmetal Angina
Variant Angina
 254
SSx: young F, smoking nighttime chest pain not associated with exertion, ST
elevations on ECG
Tx: eliminate risk factors, Ca Ch blockers, NO
Path: coronary vasospasm
 255
Ascites
 256
Most common cause is hepatic cirrhosis. HepatoSplenomegaly is strongly
suggestive of Hep.
Risk Factors: Hep, risk factors for hep
 257
Wolf Parkinson White
 258
Path: Accessory electrical pathway conducts depolarization directly from atria to
ventricles faster vs thru AV node
Incidence: Kids or adolescents
SSx: Asymptomatic; Tachyarryhthmia, CP, aplpitations, syncope cardiac arrest
Dgx: EKG short PR interval, slurred initial portion of ARS (delta wave), wide QRS
complex
Tx: Cardioversion, Procainamide
 259
1st I Heart Block
First I AV Block
 260
Tx: Observation if no other ssx, stop offending drugs eg digitalis,
 261
Hydorchlorothiazide
 262
SDFX: Hyperglycemia, Hpyokalemia
 263
Vasovagal Syncope
Neurocardiogenic Syncope
 264
Common in women.
SSx: Nausea. Sweating, Tachycardia. Pallor. Warm feeling. Usu in response to pain,
stress, strong emotions, peeing, pooping
Dgx: Upright Tilt table testing
 265
Statins
HMG CoA Reductase Inhibitors
 266
MOA: HMG CoA Reductase inhibitors → ↓ mevalonate → ↓ dolichol and CoQ10
→ myopathy.
SDFX: Myonecrosis
 267
Pericarditis
 268
SSx: chest pain worse with inspiration, alleviated on leaning forward;
Dressler syndrome: recurrent pericarditis s/p acute MI; EKG shows diffuse ST
elevation everywhere except in aVR
Tx: NSAIDS
 269
Digoxin
 270
SDFX: NVD, blurry yellow vision, arrhythmias. Scooped ST segments, prolonged
PR intervals, short QT intervals, T wave inversion. Renal failure, hypokalemia
exacerbate dig toxicity.
Monitor dig lvls closely
 271
Hypertrophic Cardiomyopathy
 272
SSx: heart murmur at the left lower sternal border that decreases with an increase in
preload/squatting
Autosomal Dom
 273
Acute Respiratory Distress Disorder
Adult Respiratory Distress Disorder
ARDS
Non-Cardiogenic Pulmonary Edema
 274
Path: Release of inflammatory mediators due to local tissue injuryalveolar
damageincreased alveolar capillary permeabilityleakage protein-aceous fluid
into alveoli from capillaries
SSx: Acute onsetPaO2/Fio2<200, CXR=bilateral infiltrates. Absent JVD. Absent
Cardiomegaly, Sepsis; Diffuse injury to the pulmonary capillary endothelium and
alveolar epithelium leakage of protein rich fluid into alveolar and interstitial
spacehyaline membr  alveolar collapse and decreased pulmonary gas exchange
Dgx: ABG-Hypoxia, hypercapnia, Respiratory acidosis; nl PaCO2; Pulmonary
Capillary Wedge Pressure<18mmHg
Tx: PEEP and increased FiO2; NOT Responsive to O2; Maintain PaO2>60
Tidal volume and RespRate affecte pulmonary minute ventilation which affect
PaCO2.
 275
Benign Essential Tremor
 276
SSx: Postural Tremor alleviated by alcohol. May affect head, hands, arms, eyelids,
voice, disappear during sleep.
Tx: Propanolol
 277
Chest Pain
 278
If it’s not angina, and only precipitated by emotional stressors. The chest pain is
likely psychosocial and just needs reassurance.
 279
Pulsus Paradoxus
 280
An abnl drop in systolic pressure with inspiration. The result of increased vv return
to heart during inspiration impeding L ventricular filling.
Dgx: Tamponade.
Pericardial effusion.
Tension pneumo.
Asthma (caused by very elevated intrathoracic pressures during inhalation
exacerbating the L ventr 280etaphysic280)
Tx: tx underlying condition
 281
Asbestosis
 282
Etiology: Non smokers with progressive dyspnea who work in shipyards or
something like that
SSx: Dyspnea w/o cought or sputum.
Dgx: CXR=Lower Lung Field abnl’s like pulmonary fibrosis or pleural plaques.
Consequences: Bronchogenic Carcinoma; Mesothelioma
 283
Atypical Pneumonia
 284
SSx: Dry cough, HA, sore throat, skin rash
Bugs: Mycoplasma pneumoniae, Chlamydia pneumoniae, legionella, Coxiella,
Influenza, Pnemocystis jirovici
Etiology: Old; Immunocompromised
 285
Blastomycosis
 286
SSx: Low fever, night sweats, Productive Cough, wt loss, lytic bone lesions skin
involvement;
Where: Mississippi, Ohio, Wisconsin, Great lakes.
Dgx CXR looks like TB
 287
Flail Chest
 288
What: Broken ribs that are still attached to the pleural connective tissue
SSx: Positive Pressure Mechanical Ventilation correct paradoxical thoracic wall
movement, tachypnea. Shallow breathing due to pain, hyperventilation; Inward
motion of affected side
 289
Deep Vein Thrombosis
DVT
 290
Tx: Acute Anticoagulation and Clot Stabilization-Heparin so that INR is 2.0-3.0;
Long Term Anticoagulation-Warfarin Takes 4-5 days to become therapeutic so use
Heparin until Warfarin starts to work; DVT Tx-Compression stockings to decrease
the risk of developing post phlebitic syndrome
CONTRAINDICATIONS: Recent surgery; Hemorrhagic stroke; Bleeding
diathesis; Active bleeding
 291
Hodgkins Disease
Hodgkins Lymphoma
 292
Path:
SSx: Painless rubbery nodules; airway obstruction; nonspecific symptoms esp after
URI or other illness
Dgx: CBC shows ABSENT Lymphoblasts
Complx: Post radiation 2ry malignancy esp if tx <30yo with chemo AND Radx
DDx: ALL presents the same as HD; the only difference is that there are no
lymphoblasts on CBC
 293
Pulmonary Embolism
PE
 294
SSx: Dyspnea, CP, cough, tachypnea, pain on inspiration; tachycardia
Dgx: +D-Dimer; V/P Scanvv US to look for DVTSpiral CT angiogram of the
chestPulmonary Angiography
Tx: Hemodynamic instability or R ventr strain are indications for thrombolytic
therapy, Heparin; INR should be 2-3
Risk Factors: hypotension, tachycardia, SOB, hx/predisposition of DVT
Complx: R ventricular dilation and failure (secondary to obstructed outflow)
Massive Pulmonary Embolism: Hypotension &/or acute R heart strain, syncope
 295
Respiratory Acidosis
 296
Caused by inadequate pulmonary ventilation or HYPOventilation  low blood pH
from CO2 retention
Dgx: Elevated pCO2, low pH
 297
Chronic Obstructive Pulmonary Disorder
COPD
 298
SSx: Cough, Wheezing on 298etaphysic298298, hypoxia,; Prominent use of
Accessory Respiratory muscles; Acute exacerbations can be precipitated by URI;
Tx: inhaled bronchodilators like ipratropium, β agonists c anti-muscinic, inhaled
steroids and long acting β agonists, corticosteroids; if PaO2<55, SaO2>88%,
Hct>55%, or cor pulmonale then Supplementary O2 for best long term survival
rates; smoking cessation and O2 decrease mortality rates;
Theophyline/bronchdilators are useless for COPD; Try NonInvasive Positive
Pressure Ventilation before intubation
COPD + Finger Cluibbing=Cancer
Dgx: CXR shows flattening of diaphragm due to increased work of breathing
 299
Factor V Leiden Deficiency
 300
Point mutation for factor V leaving it inactivatable by Protein C. This causes
hypercoagulability, predisposition to DVTs, thrombosis, etc.
 301
Asthma
 302
SSx: V/Q mismatch, tachypnea, decreased PCO2 due to hyperventilation or
tachypnea
PCO2 is the best indicator of asthma severity. The higher the PCO2, the worse the
asthma; normal is also bad.
Tx: Depends on severity: Intermittent-PRN albuterol; Mild Persistent-
Rescue+inhaled steroids; Moderate Persistent-Rescue+Low Dose Inhaled
Steroids+Long acting β agonist: Severe Persistent- PRN Albuterol+Long acting β
agonist+High Dose Inhaled Steroids
SDFX of treatmenthypokalemiamuscle weakness, arrhythmias, EKG changes;
tremor, HA, palpitations
 303
Acute Bronchitis
 304
SSx: No fever, ; maybe blood-tinged sputum due to hard coughing
Causes: usu viruses
 305
Wegeners Granulomatosis
 306
SSx: Systemic vasculitis, upper and lower airway granulomatous inflammation,
glomerulonephritis; Nasal cartilage destruction; tender nodules, palpable 306etaphy,
ulerations
 307
Community Acquired Pneumonia
CAP
 308
SSx: Fever, chills, cought, purulent sputum, CP; alveolar consolidation-decreased
breath sounds, dullness to percussion, increased tactile fremitus, egophony,
bronchophony;
Tx: Levofloxacin; Ciprofloxacin; β lactam abx;
Causes: H. flu, Strep pneumo, Moraxella respond to Abx;
Legionella-Azithromycin, macrolides; fluoroquinolones; does NOT respond to β
lactams; ssx-High Fever, GI ssx, neuro ssx, rales, CXR=focal lobar consolidation;
Sputum cx=lots of neutrophils, no organisms; Dgx via growth on charcoal agar or
UA
 309
Emypema
 310
Defn: Infx in the pleural space usu from parapneumonic effusions, contamination of
pleural space by abscess rupture, bronchopleural fistula, infective trauma, nonsterile
thoracotomy, s/p hemothorax
SSx: Fever, dyspnea s/p trauma err wvr
Dgx: CT scan shows loculation; can have a thick peel around it
Tx: Surgery
 311
Hypoxemia
 312
Defn: PaO2<80
Caused by:
1) Hypoventiliation- elevated PaCO2 nl A-a Gradient; usu follows srgx
2) Low inspired O2-nl PaCO2 no A-a gradient
3) Shunting-nl PaCO2 elevated A-a gradient that does not correct with 100% O2
4) V/Q mismatch-nl PaCO2 elevated A-a gradient IS CORRECTED with
100% O2
A-a gradient =[PAO2] – [PaO2]
=[FiO2(760-47)-PaCO2/0.8] – [usu given]
 313
Histoplasmosis
 314
Where: Mississippi
 315
Aspiration Pneumonia
 316
Dgx: Foul smelling sputum and lower lobe pneumonia
Risk Factors: Decreased conciousness; Dysphagia eg GERD, DBO; Neurologic
DO eg dementia, myasthenia; Sedation x procedures
 317
Idiopathic Pulmonary Fibrosis
 318
Chronic Inflx of alveolar wallsfibrosis and destruction of lung architecture
SSx: Progressive dyspnea, nonproductive cough, Digital Clubbing; Dry End
inspiratory crackles; Fever/Chest pain are Absent
Dgx: PFT show decreased TLC, FEV1 and FVC; nl FEV1/FVC; Increased A-a
gradient; CXR decreased lung volumes, airway fibrosis/Honeycomb pattern, and
pulmonary vascular congestion in the hilum
 319
Cardiac Tamponade
 320
SSx: Becks Triad-JV Distension, HYPOtension, Decreased heart sounds, Pulusus
Paradoxus
 321
Cor Pulmonale
 322
Right Sided Heart Failure due to: Acute-dilation and failure of R side of heart by PE
or lung probs; Chronic-Hypertrophy of R ventricle from lung disease
SSx: Wheezing, fatigue; SOB, ; Elevated JVP, hepatomegaly, ascites, edema; NO
evidnence of pulmonary congestion (eg CXR); Severe-S3 R ventricular heave
Dgx: CXR may show big R ventricle and pulmonary aa, and maybe lung disease
Causes: Pulmonary disease
 323
Sarcoidosis
 324
Immune dss usu seen in black F.
SSx: Fever night sweats, wt loss, dyspnea; erythema nodosa, skin probs, eye, liver,
kidney, CNS involvement; Elevated Ca and ACE;
Dgx: CXR shows mediastinal adenopathybronchoscopy and biopsy
Tx: Steroids if ssx
 325
Aspirin Sensitivity Syndrome
 326
Pseudoallergic rxn from aspirin induced prostaglandin/leukotriene bisbalance in
susceptible pts
 327
Goodpasteurs Syndrome
 328
SSx: Proteinuria <1.5g/day, acute renal failure, urine dseiment c dysmorphic RBC
and red cell hemorrhage;
Dgx: Renal Bpx shows linear IgG deposits on glomerular basement membr

Affects young white male. Ig’s vs α 3 chain of type IV collagen

 329
Bronchiectasia
Bronchiectasis
 330
Abnl dilated segments of bronchial treeimpaired clearance of secretionsairflow
obstrx
SSx: Cough, mucopurulent foul-smelling sputum, hemoptysis
Dgx: HRCT is standard dilated bronchioles, thickened bronchiole walls; CXR
shows dilated bronchioles, peripheral opacities, linear atelectasis
Inheritied usu caused by CF. Acquired usu caused by TB
 331
Obstructive Sleep Apnea
OSA
 332
Sleep ApneaHYPOventilationacidosisRenal retention of bicarbdecreased
serum Cl (it’s shifted back into the cells)
 333
Friedlander Pneumonia
 334
Pneumonia caused by Klebsiella pneumo, an encapsulated G- bacilli
SSx: Currant jelly sputum, tissure necrosis; alcoholic or baby
Dgx: Cx=mucoid colony;
 335
Indications for Chest Tube Placement
 336
Glucose<60mg/dL, low pH, empyema
 337
Theophyline
 338
MOA: Sm muscle relaxant, bronchodilator, diuretic, cardiac stimulant, vasodilator
SDFX: Phosphodiesterase Inhibition adenosine antagonism and stimulation of
epinephrine release  CNS ssx: HA, palpitations, insomnia, GI ssx
 339
Choriocarcinoma
 340
Metastatic form of gestational trophoblastic dss. Can occur after molar prego or nl
gestation. Lungs are most frequent site of mets.
Dgx: CXR=pulmonary ssx and multiple nodules esp in postpartum F
 341
Meniere Disease
342
 343
Diverticulitis
 344
SSx: LLQ or RLQ pain, maybe bleeding, aggravated by eatingfever, chills, NV,
decreased appetite, constipation; massive GI bleed
Dgx: CT Scan
Tx: clear water, f/u; NPO IV fluids; clear liquids Abx, colonoscopy in 6weeks;
hospitalization; surgery if abscess, stricture,
DDf: Colon CA in the elderly; Ovarian cyst, endometriosis, ectopic prego, torsion;
IBC infectious colitis; appendicitis
 345
Iron Deficient Anemia
Microcytic Hypochromic Anemia
 346
SSx:
Dgx: Microscopy shows small, pale RBC’s; Low Hg, MCV<80mcL; Decreased Fe,
Decreased Ferritin, High TIBC (Total Iron Binding Capacity); Colonoscopy if GI
blood loss suspected then Endoscopy; Capsule endoscopy if AV malformations are
suspscted
Tx:
Path: Can be caused by GI bleeding, meatless diets; In old ppl it’s due to GI blood
loss until proven otherwise; Peptic Ulcer Disease eg from NSAID use
 347
Clostridium Difficile Diarrhea
 348
SSx: Nausea, Vomiting, abdominal pain, Diarrhea after antibiotic use, increased
WBC
Dgx: Stool testing for cytotoxin
Tx: Metronidazole
Path: Abx kill most GI flora letting C. diff grow and wreak havoc
 349
Dysphagia
 350
Common Causes: Crico pharyngeal dysfunction (oropharyngeal dysphagia)
achalasia, stricture, tumor.
Dysphagia for solids AND liquids = motility problem
Solid food dysphagialiquid food dysphagia= organic? Cause
SSx:
Dgx: Barium Swallow to check for anatomical abnlEndoscopy or Video
Fluoroscopy if cricopharyngeal dysfx is suspected
Tx:
Path:
 351
Esophageal Cancer
Esophageal Adenocarinoma or
Esophageal Squamous Cell Carinoma SCC
 352
SSx: Heartburn worse when supine; Antacids do not relieve pain
Dgx:
Tx:
Path: Untreated GERD causes metaplasia  Barrett’s esophagus
adenocarcinoma or SCC;
Risk Factors x Adenocarcinoma Barretts, obesity, high dietary calorie and fat intake,
smoking and GERD.
SCC risk factors = smoking EtOH, dietary defx of β carotene, vitamin B1, zinc,
selenium, environmental viral infx, toxin producing fungi, hot foods/beverages,
Nitrate preserved foods
 353
Whipple Disease
 354
SSx: Diarrhea, abdominal pain, wt loss; bulky foul smelling stools, abdominal
distenstion, flatulence, mal-absorption; arthralgia. Generalized LAD, skin
hyperpigmentation; valve dysfx, heart problems, CHF
Dgx: Sm bowel bpx = villous atrophy c numerous PAS + materials in the lamina
propria
Tx:
Path: caused by Tropheryma whippelii infx esp in white 40-60yos
 355
Peptic Stricture
 356
SSx: Difficulty swallowing solids at first then solids and foods; NO wt loss, NO
anorexia;
Dgx: Endoscopy=symmetric circumferential narrowins
Tx: Bpx to r/o adenoCA or SCC
Path: caused by body’s attempt to repair chronic GERD or Barrett’s  peptic
esophageal strictures which causes progressive dysphagia; as the strictures progress
they can actually improve GERD ssx.
 357
Achalasia
 358
SSx:
Dgx: Barium Swallow= “bird beak” 358etaphysi
Tx:
Path: Inability to relax the sphincter
 359
Zenkers Diverticulum
Pharyngoesophageal Diverticulum
 360
SSx: Difficulty Swallowing
Dgx: Barium swallow=
Tx:
Path: Upper Esophageal Motor dysfx and dysmotility herniation between the
fibers of cricopharyneal muscle
 361
Deficiency
 362
SSx:
Dgx:
Tx:
Path:
 363
B Vitamins
 364
B1 Thiamine
B2 Riboflavin
B3 Niacin-Pellagra-Diarrhea, Dermatitis, Dementia
B5 Pantothenic Acid
B6 Pyridoxine/amine
B7 Biotin, Vitamin H
B9 Folate, Folic acid, Vitamin M
B12 Cyanocobalamin
 365
Zinc Deficiency
Zn
 366
SSx: Derm lesions bullous pustulous on body or extremities, hair loss, change in
taste sensation; hx of IBD, being NPO or Short Bowel Syndrome
Dgx:
Tx:
Path: Zn is found in animal protein, whole grains, beans and nuts and absorbed in
the jejunum
 367
Chronic Pancreatitis
 368
Path: Chronic inflmx of the pancreas due to EtOH; can lead to Pancreatic Cancer
SSx: Chronic abd pain not relived by antacids; diarrhea due to fat mal-absorption;
Hx of chronic EtOH abuse; DM due to β cell destrx
Dgx: Stool Elastase levels are low; nl to high amylase and lipase;
Tx: Abx, NPO, fluids
 369
Endoscopy
Esophagogastroduodenoscopy
EGD
 370
Used to dgx luminal defects of upper GI esp Peptic Ulcer Disease, gastritis,
dysphagia or upper GI bleeds; chronic abd pains not due to pancreatitis
 371
Carcinoid Tumor
 372
Path: Small slow growing neoplasm made of rounded oxyphilic or spindle shaped
cells c moderately small vesicular nuclei. Covered by mucosa c yellow cut surface.
Very invasive. Found anywhere in GI or lungs esp appendix/ileum
SSx: Abdominal pain, diarrhea, Flushing, Pruritus, wt loss (Carcinoid Syndrome)
Dgx: +Urine 5-HIAA
Tx: Surgical Resection
 373
Tropical Sprue
 374
SSx: Diarrhea; Malabsorption, glossitis, cheilosis, protuberant abdomen, pallor,
pedal edema; Hx of living in endemic areas eg Puerto Rico, Latin America etc
Dgx: Decreased B12, Folatemegaloblastic anemia; Small intestinal bpx=villi
blunting and lots of WBC’s;
 375
Pertonitis
 376
Dgx: Paracentisis, culture
Tx: Cephalosporins
 377
Toxic Megacolon from Ulcerative Colitis
 378
Path: As UC progresses it causes the Rectum to lose elasticity lumen
collapsetenesmus (spasm)
SSx: Abdominal pain, diarrhea wt loss, fever; 40 BM per day
Dgx: diffuse tenderness and distension; Abd Xray=colonic dilatation
Tx: IV fluids, Abx and NPO, IV steroids; Surgery=subtotal colectomy c end
ileostomy if does not resolve
This is a medical emergency b/c it can  colonic perforation. Other causes of
Toxic Megacolon are ischemic colitis,k volvulus, diverticulitis infx
 379
MEN 1
Multiple Endocrine Neoplasia 1
Wermer Syndrome
 380
Path: Tumors on the pituitary gland, pancreatic islet cells and parathyroid; 3P’s are
affected, Pancreas, Parathyroid and Pituitary.
SSx: -Pancreas: Aggressive. Secrete pancreatic polypeptide. Usu seen c Zollinger-
Ellison syndrome and insulinomas causing hypoglycemia and neurologic probs
-Parathyroid: Primary hyperparathyroidism c hyperplasia and adenomas.
Nephrolithiasis, hypercalcemia
-Pituitary: most likely Prolactinomaacromegaly from somatotropin. Can also
cause gastrinomas eg in the duodenum
 381
MEN 2
Multiple Endocrine Neoplasia 2
Sipple Syndrome
 382
Path: Pheochromocytoma, Medullary Carcinoma, Parathyroid Hyperplasia; thyroid
medullary c-cell hyperplasia carcinoma; Amino acid mutation affects RET gene
which tyrosine kinase catalytic domain.
SSx: -Pheochromocytoma: usu BL or found in extraadrenal sites
-Parathyroid Hyperplasia: Hypercalcemia or renal stones
 383
MEN 3
MEN 2B
Multiple Endocrine Neoplasia 3 (2B)
 384
Medullary Thyroid Carcinoma, Pheochromocytoma, Neuromas or Ganglioneuroma
of the skin/mucus membranes c marfinoid habitus
 385
Ileus
 386
Path: functional defect in bowel motility w/o physical obstruction. Usu due to
surgery
SSx: NV, abdominal distension, failure to fart or poo, decreased bowel sounds;
Other causes include post-op increased sympathetic tone and post-op analgesics
from disordered peristalsis
 387
Heat Stroke
 388
1) Exertional
Occurs in healthy individuals doing hard physical work in extreme temp’s and
humidityinability of thermoregulatory center to dissipate heat
SSx: T>105 °, altered mental status, dehydration (concentrated Htc, dry
skin/membranes), hypotension; tachycardia, tachypnea; high body temp can also
cause rhabdomyolysis (UA=large blood c no RBC) and organ system damage
2) Non-Exertional
 389
HELLP Syndrome
Hemolysis, Elevated Liver enzymes, Low Platelets
 390
Path: A type of SEVERE Preeclampsia;
SSx:
Dgx: Hemolysis, Elevated Liver enzymes, Low Platelets
Tx: <34weeks=Termination if severe, ; >34weeks=Delivery via MgSO4 and labor
induction
 391
Hematuria
 392
3 Types: 1) Glomerula-Proeinuria, RBC casts, dysmorphic RBC; Renal
Parenchymal dss esp if >80% dysmorphic RBC
2) Renal – 2° to tubulointerstitial, renovascular and metabolic disorders. Has
proteinuria sans RBC dysmorphia
3) Urologic – Caused by tumors, calculi, infx, trauma, BPH
DDx: Cancer; STD; Chemical exposure; strenuous exercise; Drugs, Herbs; The
chances of painless microscopic hematuria being cancer is very very very low.
Workup/Dgx: Repeat UA; Urine Culture; Lower GU images via cytoscopy,
cytology; Upper GU images via CT or IV pyelogram
Risk Factors: Smoking, chemical exposure eg dyes, hx of gross hematuria, >40yo,
hx of GU probs, chronic analgesic ab/use
Gross Hematuria Should Always Be Worked Up
 393
Chronic Renal Failure
CRF
 394
Chronic renal failure 
 395
Jaundice
396
 397
Metoprolol
 398
SDFX: Worsening of PVD via β2 mediated vasoconstriction; AV node conduction
blocker
 399
Pneumothorax
 400
SSx: Tachypnea, tracheal deviation away from affected side, neck vv distension;
decreased breath sounds, hyperresonance
Tx: Needle thoracostomy
 401
Indications for Hemodialysis
Reasons for Hemodialysis
 402
1. Refractroy hyperkalemia
2. Volume overload orpulmonary edema not responding to diuretics
3. Refractory metabolic acidosis
4. Uremic pericarditis
5. Uremic encephalopathy
6. Coagulopathy due to renal failure
 403
Tension Pneumothorax
404
 405
Olanzapine
 406
MOA: Atypical Antipsychotic. Blocks D2 receptors
DOC:
SDFX: Wt gain, hyperglycemia, dyslipidemia, HTN
Montior: Fasting blood sugar, wt, BP regularly; CBC yearly for agranuloytosis or if
ssx
 407
Tourrette’s
Tourrette
 408
Tx: Traditional antipsychotics eg Haloperidol or Pimozide; Risperidone
Misc: Do baseline EKG bc Pimozide causes long QTc
 409
Haloperidol
 410
MOA: D2 antagonist; Traditional Typical Antipsychotic;
DOC: Tourrette; Acute and Chronic Schizophrenia; Alcohol Idiosyncratic
Intoxication (pathological intoxication); MDD c Psychosis; Agitated PCP
intoxication; Delirium or Agitated Amphetamine intoxication
SDFX: Extrapyramidal (via Nigrostriatal pathway); Increased Prolactin (via
Tuberoinfundibular pathway); Antipsychotic (via Mesolimbic); Anticholinergic;
Sedation
Misc: Prot bound;
Other Uses: Acute Mania; Symptoms of Psychotic Dementia; Delirium esp if
psychotic; Violent Psychosis; EtOHic w/d +chlordiazepoxide
 411
Extrapyramidal Side Effects
 412
Caused by: Typical (traditional) Antipsychotics (Haloperidol; Chlorpromazine)
SSx: Dystonia-Sustained muscle contraction usu the jaw or neck muscels (lock jaw,
torticollis, carpo-pedal spasms, oculogyric crisis)
Parkinsonism-Tremor (at rest and movement; esp upper extremities); Rigidity
starting in the upper limbs then spreading to rest of body; Akinesia a zombie like
affect c slowness, fatigue, little facial expression (can be mistaken x depression)
Akathisia-Fidgety constanly moving, rocking from the waist, pacing, dysphoria
(mistaken for anxiety or agitation)
Rabbit syndrome-involuntary chewing movements
Tardive Dyskinesia- involuntary movements of the facial muscles and tongue;
tongue protrusion, lip smacking, puckering and pursing of the lips, and rapid eye
blinking
Tx: Benztropine; Benadryl/Diphenhydramine
C/I: TCA, SSRI,
 413
Atypical Anytpsychotics
 414
e.g. Riseperidone; clozapine; olanzapine; quetiapine; ziprasidone aripraprazole
MOA: D4, D2 5HT2a receptor antagonists
SDFX: Clozapine-seizure exacerbation, agranulocytosis wt gain, DM; Risperidone-
the same as clozapine + elevated Prolactin
DOC: Schizophrenia? 2nd line after Typicals have been tried
 415
Clozapine
Clozaril
 416
MOA: D4 antagonist 5HT2a receptor antagonist; Atypical Antipsychotic
DOC: none; Use in Schizophrenia pts who can’t tolerate other mx; esp if ssx of
apathy, anhedonia and flat affect
SDFX: Szrs; AGRANULOCYTOSIS WBC<3000; mouth watering;
416etaphysic416; wt gain, DM
 417
Risperidone
Risperdal
 418
MOA: D4 antagonist 5HT2a receptor antagonist; Atypical Antipsychotic; use depot
inj for noncompliant pts
DOC: none; chronic Schizophrenia
SDFX: increased Prolactin; EPS; Orthostatic 418etaphysic418; Tardive Dyskinesia
 419
Thioridazine
Mellaril
Traditional Antipsychotic
 420
MOA: D2 receptor antagonist
DOC: Psychosis in Borderline Personality
SDFX: impotence; Retinitis Pigmentosa
 421
Paroxetine
Paxil
SSRI
 422
MOA: SSRI
DOC: Depression; OCD, GAD, social anxiety d/o; Premature ejaculation
SDFX: Delayed orgasm, anorgasmia; Birth defects;
MISC: Hard to discontinue because pts get HA, nausea dizziness, insomnia and
nervousness when u try to taper
 423
Fluoxetine
Prozac
SSRI
 424
MOA: SSRI
DOC: Mild-Moderate Depression Panic d/o, OCD, bulimia
SDFX: GI upset, rashes, sexual inhibition, insomnia, restlessness
Misc:
 425
Adjustment Disorder
 426
SSx: Marked distress or functional impairment to known stressor w/in 3mos of
stressor; Not Bereavement; ssx alleviated within 6mos of disappearance of stressor;
SSx do not last >6mos after insult
Specifiers: c Depressed Mood-main ssx are depressed mood, tearfulness or feelings
of hopelessness; c Disturbance of Conduct-main ssx are conduct which violates
rights of others or age inappropriate norms (fighting, legal)
Tx: supportive psychotherapy; group therapy
 427
Schizophrenia Types
 428
Disorganized-Disinhibited, poor grooming and organization, inappropriate
emotional RE; Onset <25yo
Catatonic-Bizarre posturing or extreme excitability
Paranoid-Delusions of persecution; usu older age of onset, better fxing
Undifferentiated-characteristics of more than one type
Residual-dgx of schizophre but no psychotic ssx

Negative (lack of) SSx-flat affect, thought blocking, poor grooming, amotivational,
social withdrawal, poor speech. Atypical Antipsychotics work well on these ssx

Positive (Too much of) SSx-Hallucinations, delusions, agitation; Both classes of

antipsychotics work well here
 429
Oppositional Defiant Disorder
 430
SSx: A) pattern of negative, hostile and defiant behavior >6mos where >4 of the
following are present: 1) loses temper 2) argues with adults 3) refuses to cooperate c
adults or defies requests 4) deliberately annoys ppl 5) blames others for his/her
misbehavior 6) easily annoyed by others 7) often angry or resentful 8) spiteful or
vindictive; B) Causes social/academic/etc dysfx C) doesn’t occur during a psychotic
or manic episode D) Is not conduct disorder or antisocial personality disorder
Tx:
 431
Amitriptyline
(Elavil)
 432
MOA: TCA
DOC: Anorexia
SDFX:
 433
Panic Disorder
 434
SSx: Sudden onset of intense apprehension fear c CP palpitations, HA dizziness,
faintness, paresthesias, trembling
DSM: >3 attachis in a 3 week period; No obvious reason; peak w/in 10 mins and
over in 30mins.
Tx: SSRI for long term maintenance; BZD for acute episodes
Misc: High association c depression, agoraphobia, GAD and substance abuse
 435
Neuroleptic Malignant Syndrome
NMS
 436
SSx: Severe (lead pipe) rigidity, change in mental status, autonomic instability,
elevated CPK (rhabdomyolysis), elevated WBC
Dgx: Usu caused by antipsychotic
Tx: Dantrolene
 437
Phenelzine
MAOI
 438
MOA: MAOI; inhibits the enzyme that breaks down amines
 439
Hypertensive Crisis
 440
SSx: Hypertension, hyperpyrexia
Caused By: Ingesting tyramine with MAOIs (eg cheese, pickled foods, yoguret,
nondistilled EtOH, broad beans); Uppers
Tx: phentolamine
Dgx:
MAO in the gut wall usually prevents tyramine from being absorbed. MAOIs inhibit
this enzx  absorption of tyramine  HTN, fever
 441
Mental Retardation
MR
 442
nl IQ >70
Mild MR 55-69 These pts can hold down simple jobs and be independent eg
assembly workers. 6th grade academic skills
Moderate MR 35-55
Severe MR 20-35 Will need to be cared for as they cannot protect themselves
Proufound MR <20
Cuases: Fragile X; Downs Syndrome, Trisomy 21;
 443
Mirtazipine
SSNRI
 444
MOA: α2 antagonist  increased synaptic 5HT lvls and NE release
SDFX: wt gain sedation; NO SEX SDFX
DOC: none
Uses: Anxiety
 445
Ziprasidone
Atypical Antipsycotic
 446
DOC: Since it doesn't cause wt gain like the other atypical antipsychotics it's good
in
MOA: 5HT and DA2 blocker; Atypical Antipsychotic; moderate inhibitor of NE and
5HT
SDFX: rash; NMS, somnolence, ohrthostatic hypotension, rhinitis, wt gain; Torsads
de Pointes; prolonged QT
 447
Sertraline
Zoloft
SSRI
 448
MOA: SSRI
DOC: Panic disorder, GAD, depression, PMDD
SDFX: nausea, diarrhea, tremor, insomnia, somnolence dry mouth, ejaculatory
delay, SIADH
 449
Perphenazine
Typical Antipsychotic
 450
MOA:
DOC:
SDFX:
 451
Wernicke Encephalopathy
 452
SSx: ACE (Ataxia, Confusion and Eye movement nystagmus) Delirium, ataxia,
vertical and horizontal nystagmus, external rectus eye muscle weakness; due to
thiamine defx
Dgx: decreased B1
Tx: Thiamine! to prevent…
 453
Korsakoff Syndrome
 454
SSx: confusion, severe impairment of memory, anterograde amnesia, confabulation;
delirium tremens may precede the syndrome; due to malnutrition moreso vs EtOH
Etiology: chronic alcoholics
Dgx: Mammilary bodies are atrophied/dysfunctional; amnesia suggests temporal
lobe involvement
Tx: Thiamine!
 455
Delusional Disorder
 456
SSx:
Dgx: Non-Bizarre delusions; Usually specific delusions. Affect, and cognition are
intact; no loose associations
Tx: individual psychotherapy
Etiology: M, 40's,
 457
Antipsychotics
Neuroleptics
 458
Typical/Traditional: Haloperidol, Chlorpromazine, Thioridazine, Fluphenazine,
Perphanazine,
Atypical: Risperidone, Ziprasidone, Quetiapine, Olanzipine, Clozapine
 459
Anticholinergic Syndrome
 460
SSx: Dry mouth, constipation, blurred vision, urinary hesitancy, glaucoma
exacerbation;
Tx: water gum or neostigmine, stool softeners, physostigmine, urecholine, /
Cuased By: Traditional Antipsychotics (Chlorpromazine, pluphenazine,
Haloperidol, Perphenazine)
 461
Malignant Hyperthermia
 462
SSx: Rapid onset of fever with muscle rigidity usually due to halothane or
succinylcholine or some inhaled anesthetic.
Tx: Dantrolene
 463
Flumazenil
Romazicon
 464
MOA: BZD Receptor Antagonist
DOC: BZD overdose; BZD sedation reversal
SDFX: szrs, withdrawal, arrhtythmia, resdation
 465
Narcolepsy
 466
SSx: Persistant daytime somnolence relieved by naps, hypnagogic hallucinations,
cataplexy, sleep paralysis just before falling asleep or waking up.
 467
TCAs
 468
MOA: Seritonin and NE reuptake inhibitors
Tertiary: Amitriptyline, Clomipramine, Dexepin, Imipramine, Trimipramine
Secondary Amines: Sesipramine, Nortriptyline Protriptyline
 469
Dialectical Behavioral Therapy
 470
The patient wants to improve
The patient is doing the best he can
The patient is encouraged to take responsibility for his actions.
The patient is encouraged to solve his problems despite whether or not he is
responsible for them.
The patient must believe that he cannot fail therapy
 471
Zolpidem
Ambien
Sedative Hypnotic
Benzodiazepine Like Drug
 472
MOA: Potentiates GABA receptors making the inhibitory pathway easier
 473
Serotonin Syndrome
 474
SSx: Abdoninal pain, diarrhea, diaphoresis, hyperpyrexia, tachycardia,
hypertension, myoclonus, irritability, agitation, seizures and delirium
Causes: SSRI + other SSRI potentiating meds eg MAOI, Li or carbamazepine
Tx: stop drugs, supportive care
 475
Nefazadone
Serotonin Norepenipherine Reuptake inhibitor
SNERI
 476
MOA: Selective Serotonin Norepeneprine Reuptake Inhibitor
DOC: n/a; 3rd line antidepressant
SDFX: Hepatitis, liver failure
 477
Venlafaxine
SNERI
 478
MOA: SNERI
DOC: Maintenance tx for Panic and General Anxiety Disorder
SDFX: HTN at higher doses
 479
Trazadone
 480
MOA: SSRI
DOC: use to tx insomnia in pts with liver damage or history of alcohol abuse
 481
Fetal Alcohol Syndrome
FAS
 482
SSx: Microcephaly, short palpebral fissures, flat midface, thin upper lip and MR
 483
Complex Partial Epilepsy
 484
SSx: Hyperreligious thinking, preoccupation, with moral ehavior, altered sexual
behavior, altered sexual behaviors, hyperphagia, overelaborative communication
styles/viscosity and heightened experience of emotions
Misc: Psychotic ssx occur in 20% of pts
 485
Clonidine
 486
MOA: α2 autoreceptor agonist
DOC: Opioid withdrawal
 487
Idiopathic Avascular Necrosis of the Femoral Capital Epiphysis
Legg-Clave-Perthes Disease
 488
Epidemiolgy: M 4-10yo
Path: Epiphyseal osteonecrosis of proximal femur
SSx: hip, groin or knee pain, antalgic gait; decreased ROM
Dgx: X-ray=collapse of bone structures
Tx: 1° conservative tx c braces and observation; 2ry=surgery if femoral head not
well w/in acetabulum
 489
Breast Cancer
 490
Epidemiolgy: Strongest risk factor is Age esp after 45yo;
SSx: Piel-d'-orange; bloody discharge; irregular immobile lump;
Dgx: Mammogram= ; FNA=blood, send bloody aspirates for cytology;
Tx:
 491
Fibrocystic Changes of Breast
 492
Epidemiology: F <50yo
SSx: Breast pain worse around menstrual period that occur and resolve rapidly;
Cysts are tender and mobile
Dgx: FNA=serous, non-bloody aspirate; cysts disappear after aspiration
Tx: Reassurance and f/u w/in 2months; Bpx if recurrence
 493
Osteosarcoma
 494
Epidemiology: M <20yo; occurs most commonly at site of bone growth eg
epiphysis or 494etaphysic
SSx: persisting bone pain
Dgx: high alk phos; X-ray=destructive lesion and periosteal new bone formation c
periosteal elevation (Codman triangle), or a 'sunburst' profile of the tumor
Tx: chemotherapy and surgery
Prognosis: Limb saving tx is likely if not too advanced?
 495
Normal Arterial Blood Gas Values
ABG
 496
pH 7.35-7.45

pO2 80-100 mmHg

pCO2 35-45 mmHg

HCO3-22-28 mEq/L

02Sat=>95%
 497
Meniscial Tear
 498
Epidemiology: M:F 1:1 30s-40s
SSx: joint pain after exertion; 'popping' sensation of joints;
Dgx: MRI; hemarthrosis is indicative of ligament tear
Tx: conservative, NSAIDS,
 499
Squamous Cell Carcinoma
 500
Epidemiology: M>>F
Path:
Risk Factors: sun exposure; chronic wounds; radiation; venous ulcers
SSx: non-healing wounds
Dgx:
Tx:
Misc: Marjolin Ulcer is that arises from a burn
 501
Abdominal Aortic Aneurysm
AAA
 502
Epidemiology:
SSx: Sudden onset back pain, large abdominal pulsatile mass, +/- syncope,
hypotension, ?tachycardia
Dgx:
Tx:
 503
Adrenal Insufficiency
 504
Path: insufficient cortisol produced by the adrenal cortex zona fasciculate. Most
common cause is iatrogenic but can occur after severe stress eg surgery, trauma.
Exogenous steroids depress pituitary adrenal axis causing decreased cortisol release.
SSx: Nausea vomiting abdominal pain, hypoglycemia, hypotension; especially if
already taking exogenous steroids
Dgx:
Tx:
 505
Varicocele
 506
Path: Tortuous dilation of the pampiniform plexus due to vv valve incompetence of
testicular vv; usu on the L.
SSx: scrotal swelling, dull aching, fullness, "bad of worms" feeling
Dgx: Negative transillumination test, increase swelling with Valsalva maneuver
 507
Slipped Capital Femoral Epiphysis
SCFE
 508
Epidemiology: Fat boys
SSx: insidious knee or hip pain; loss of abduction and internal rotation of the hip,
pts hold the thigh in external rotation while the hip is being flexed
Dgx: frog leg lateral x ray of hip shows posteriorly and inferiorly displaced femoral
head (or ? just a collapsed epiphysis)
Tx: surgery, pin the epiphysis where it lays to lessen risk of avascular necrosis
Path: Displacement of the femoral head on the femoral neck due to disruption of the
proximal femoral growth plate.
 509
Benign Prostatic Hypertrophy
BPH
 510
Dgx: hematuria usu due to ruptured dilated vv in the prostatic urethra
 511
Hypotension
 512
Dgx: manual BP, urine output, CVP, echocardiogram if severe; PT (extrinsic and
common coagulation pathway) is prolonged. aPTT (intrinsic and common) is
prolonged. INR platelets
 513
Intraductal Papilloma
 514
SSx: spontaneous bloody discharge; sometimes serous discharge
Dgx: ductogram, US; if ductogram is abnormal it should be followed by surgical
biopsy; Mammography to rule out carcinoma and Duct Ectasia
Prognosis: Most papillomas are benign and do not increase chance of breast cancer;
carcinoma MUST be ruled out
Differential Dgx: Paget (ductal carcinoma), Bowen (Squamous carcinoma) should
be biopsied if suspected. Dominant mass, inverted nipple, skin changes or abnl
mammogram MANDATE surgical bpx.
 515
Boerhave Syndrome
Boorhave
516
 517
Mallory Weiss Tear
Mallory-Weiss
518
 519
Acute Lymphoblastic Lymphoma
Acute Lymphoblastic Leukemia
ALL
 520
Path: Precursor B cells (sometimes T cells; lymphoblasts); hyperploidy (>50
chromosomes), t(12;21) w CBF α and ETV6, t(9;22), t(4;11)
Etiology: 2500 new cases dgx/yr. <15yo, peak at 4yo (teens if T cell).
Whites>>Nonwhites. M>F
SSx: Abrupt onset (eg <weeks), fatigue, fever due to low mature leukocytes,
bleeding, petechiae, ecchymoses, epistaxis, gum bleeding, bone pain,
lymphadenopathy, hepato/splenomegaly, HA, vomiting, nerve palsies due to
meningeal spread; Pancytopenia ssx
Dgx: Bone marrow aspirate for definitive dgx, anemia, neutropenia,
thrombocytopenia; Microscopy=condensed chromatin, inconspicuous nuclei, scant
agranular cytoplasm; normal tissue infiltrated w lypmhoblasts;
Prognosis: With aggressive tx 90% reach remission, 2/3rds can be considered
"cured". Favorable if low WBC count, 2-10yo, B phenotype, hyperploidy, t(12;21);
No tx; Poor prognosis if <2yo cuz of choromosome 11 involvement, teen/adult
presentation, t(9;22)
 521
Persistent Pulmonary Hypertension of the Newborn
PPHN
Persistent Fetal Circulation
 522
Path: Failure of pulmonary vasculature to fall w postnatal lung expansion and
oxygenation. Deoxygentaged blood is shunted from the R atrium thru foramen ovale
&/or ductus arteriosis, bypassing the lungs. This causes hypoxemia and acidosis,
which further worsen the pulmonary aa HTN causing a bad cycle
SSx: Rapidly progressive cyanosis, hypoxia, mild-severe respiratory distress;
Dgx: Clinical manifestations are less severe vs CXR; CXR findings depend on
cause; Echo to r/o structural probs
Tx: Maximaize O2, decrease pulm aa HTN
Risk Factors:
 523
Premature Adrenarche
 524
SSx: Axillary before 6yo
Path: Premature androgen secretion of the adrenal glands
 525
Gastroschisis
 526
Path:
SSx: Bowel protrudes thru defect on R side of umbilical cord; bowel not covered by
protective membrane; bowel looks “angry” and matted; not asasociated with other
abnormalities; polyhydraminos in utero; premature birth
Dgx: Maternal AFP
Tx: Surgery-Sterile wrapping (silastic silo) over exposed bowel to allow reduction
into abdomen over several days
Complx: 15% associated w jejunoileal stenosis or atresias
 527
Macrocytic Anemia
 528
Defn: MCV <???
Things that present with Macrocytic Anemia:
 529
Meconium Aspiration
 530
Path: Baby (usu post-term or SGA) poops meconium in utero and aspirates it;
Meconium plugs airwayhyperinflationbarrel shaped chest.
Hypoxiaacidosisrespiratory aggravation
SSx: Meconium stained amniotic fluid at birth, respiratory distress, cyanosis, rales,
rhonchi, sasal flaring, grunting retractions. Barrel shaped chest. Hypoxia, acidosis
causing increased pulmonary vascular resistance leading to aggravating respiratory
compromise
Dgx: CXR=flat diaphragm, hyperinflation, coarse streaing, BL patchy opacities
Comlx: pneumothorax, infx, pulmonary HTN, residual lung problems, permanent
neurological impairment 2ry to asphyxia
 531
Sickle Cell Disease
 532
Path:
SSx: Painless hematuria; Hand-Foot syndrome or Dactylitis-vaso-
occlusionsymmetric painful swelling, vascular necrosis of the metacarpals and
metatarsals. Dgx via Xray showing osteolytic lesions.
Dgx: Plasmapherisis of HB S >40%; Parents w ≥ Sickle cell trait
Complx: chronic hemolytic anemia, gallstones, splenomegaly +/- infarct, higher %x
infx; folate defx due to high turnover of RBC and RBC building blocks; meningitis
from strep pneumo; osteomyelitis from salmonella,
 533
Riboflavin
 534
Importance: Energy production
Sources: Green vegetables,
Defx: Stomatitis, cheilitis, glossitis, normocytic normochromic anemia, seborrhic
dermatitis, photophobia
 535
Henoch-Schonlein Prupura
HSP
 536
Path: Systemic vasculitis; IgA immune complexes in vessel walls; higher rate in
winter months
SSx: Abdominal pain, vomiting, GI bleeding, nonthrombocytopenic palpable
Purpura esp in lower extremities and buttocks, scrotal edema, swelling; painful
arthritis; can present as glomerulonephritis type syndrome; nl C3 lvls, often
preceded by respiratory infx like Group A β hemoylitic Strep pyogenes
Dgx: Bpx=IgA deposits in vessels, proteinuria, hematuria
Tx: Supportive, NSAIDs for pain, glucocorticoids x severe GI and renal
manifestations
DDx: IgA nephropathy,
Complx: Long term renal impairment; nephritic and/or nephrotic sydromes
 537
Down Syndrome
Down’s Syndrome
Trisomy 21
 538
Path: Trisomy 21 or extra 21 on another chromosome
SSx: Brachycephaly (flat occiput), flat facial profile, upslanted palpebral fissures,
small ears, flat nasal bridge, epicanthal folds, small mouth, big or protruding tongue;
Hand-simian crease, short broad hands (brachydactyly, incurved finger
(clinodactyly) small middle finger, sandal sign on foot; short stature, hypotonia,
endocardial cushion or septal defects, duodenal atresia, Hirschsprung disease
Dgx: Karyotype
Tx: supportive
Complx: ALL, Alzheimers, hypothyroidism
Prognosis: With supervision these patients can live into adulthood
 539
Epiglottitis
 540
Path: Haemophilus Influenza Type B (HiB)
SSx: Usu 3-5yo with fever sore throat, hoarseness, drooling, leans forward to extend
neck, swollen epiglottis, +/- stridor; Kid appears toxic,
Dgx: Neck X Ray shows “thumbprinting”; aid in dgx but delay tx
Tx: Intubation, IV Ampicillin-Sulbactam; 3 ° cephalosporin
 541
Niemann-Pick Disease
Niemann-Pick’s Disease
 542
Path: sphingolipidosis due to defx in sphingomyelinase (ceramide
phosphorylcholine)  accumulation of sphingomyelin of reticuloendothlieal cells
of liver, spleen bone marrow and brain
Incidence: Ashkenazi jews
SSx: hypotonia, hepatosplenomegaly, cervical LAD, cherry red macula;
degeneration of developmental milestones;
Dgx: sphingomyelinase assay in liver or bone marrow bpx; DNA analysis x
defective gene
Tx:
 543
Tricyclic Depressant Poisoning
TCA Poisoning
Tricyclic Antidepressant Overdose
Tricyclic Antidepressant Overdose
 544
SSx: Seizure, hypotension, long QRS complex
Tx: ABC’s; Sodium Carbonate to correct acidosis, narrow QRS complex and
control HTN (this is tx if severe intoxication); physostigmine if mild intoxication
 545
Vitamin A
 546
Defx: SSx – impaired night time adaptation, photophobia, dry scaly skin, xerosis
conjunctiva, xerosis cornea, wrinkled cloudy cornea (keartomalacia); less common-
Bitoto spots-dry silver-gray plaques on bulbar conjunctiva and follicular
hyperkeratosis of shoulders butt and extensor surfaces
Excess: SSx – anorexia, pruritius, poor wt gain, increased irritability, limitation of
motion, bone tenderness, alopecia, seborrheic cutanious lesions, fissuring of mouth,
increased ICP, hepatomegaly
 547
Von Gierkes
Type I Glycogen Storage Disease
Glucose 6 Phosphatase Deficiency
 548
SSx: Failure to thrive, hepatomegaly, hypoglycemia, stunted growth, renomegaly,
convulsions, hyperlipidemia, hyperuricemia, gout, skin xanthomas, platelet
dysfxbleeding episodes
 549
Severe Combined Immune Deficiency
SCID
 550
SSx: recurrent sinopulmonary infx, oral thrush, persistent diarrhea, opportunistic
infx and viral infx
Dgx: Absent lymph nodes and tonsils, lymphopenia, absent thymic shadow on
CXR, low T, B or NK cell numbers on flow cytology
 551
Cyclical Vomiting
 552
SSx: Recurrent self-limiting episodes of vomiting and nausea in kids in the absence
of any apparent cause
Risk Factors: Parents with migraines
Complx: anemia, dehydration, hypochloremic hyperkalemic? Alkalosis
 553
Galactosemia
Galactose-1-Phosphate Uridyl Transferase Deficiency
 554
Path: Galactose 1P Uridyl Transferase enzyme defx  increased blood galactose
SSx: Failure to thrive, BL cataracts, jaundice, vomiting, jaundice, hepatomegaly,
convulsions; aminoaciduria, hepatic cirrhosis, hypoglycemia, MR, hypoglycemia
Complx: Increased %x E. coli neonatal sepsis
 555
Transposition of the Great Vessels
 556
Path: Aorta attached to R ventricle. Pulmonary aa attached to L ventricle. When the
foramen ovale and ductus arteriosis close around 24hrs of life, the blood is no
longer mixed and the kid becomes cyanotic
SSx: cyanosis in the first 24hrs of life
Risk Factors: Mom w diabetes
Tx: PGE1, surgery is definitive
 557
Chlamydia pneumonia
Newborn Chlamydia
 558
SSx: usu manifest at 2-3mos
Dgx:
Tx: Erythromycin, clarithromycin or azithromycin
DDx: Strep pneumo
 559
Gaucher Disease
Gaucher’s Disease
 560
Path: Lysosomal storage dss caused by defx of β glucosidaseaccumulation of
glucerebrosidase
SSx: Hepatosplenomegaly, anemia from bone marrow suppression, leucopenia,
thrombocytopenia, recurrent bone pain
Dgx: WBC exam shows low enzx activity; X-Ray shows “Erlennyer flask”
deformity of the distal femur; Bone marrow examination
Tx: Recombinant enzx thereapy x ssx
 561
Osgood-Schlatter Disease
 562
Path: Traction apophysitis of the tibial tubercle
Incidence: Adolescent male athletes
SSx: knee pain especially after exercise, relived by rest; edema, tenderness over
tubercle, firm mass can sometimes be felt; pain reproduced against resistance
Dgx: X-ray soft tissue swelling, lifting tubercle from shaft, iffegularity or
fragmentation of the tubercle
Tx: NSAIDs
 563
Otitis Media
 564
Path/Etiology: RSV, different flu viruses, Strep pneumo, non-typeable H.
influenzae, Moxarella catarrhalis
SSx: Immobile tympanic membrane; fever, pain, decreased hearing, fnflamed
tympanic membrane
Dgx: Otoscopy, diminished movement of the membrane with insuffflation
Tx: Amoxicillin; Augmentin if refractory; Nothing if over 1yo and fever resolving
 565
Parinaud’s Syndrome
Pinealoma
566
 567
Minimal Change Disease
MCD
Lipoid Nephrosis
 568
Path: Nephrotic syndrome (massive proteinuria, hypoalbuminemia, edema/ascites,
hyperlipidemia/lipiduria)diffuse effacement of foot processes of epithelial cells in
glomeruli caused by Ig complexes?
Incidence: usu 3-5yo
SSx: Proteinuria (usu albumin), generalized edema; fatigue; often preceded by viral
infx or vaccination or something
Dgx: ; Renal bpx is normal, hyperlipidemia
Tx: Steroids (Prednisone)
 569
Meconium Ileus
 570
Path: Failure to pass meconium within wth first 24hrs of life.
SSx:
Dgx: KUB shows SBO (around ileus)
Usually due to Cystic Fibrosis (deletion of a phenylalanine) an AR inherited dss
Damn near pathognomic for CF.
 571
Beckwith-Wiederman Syndrome
 572
Path: chromosome 11p supplication which has gene for IGF-2
SSx: Macrosomia, macroglossia, visceromegaly, omphalocele, hypoglycemia,
hyperinulinemia; big eyes, prominent occiput, ear creases, pancreas hyperplasia
Tx: Pancreatectomy?
Complx: Wilms tumor, hepatoblastoma, gonadoblastoma
 573
Bronchiolitis
 574
Defn: Fist episode of wheezing associated w an URI
Etiology: RSV mainly (also influenzae, parainfluenzae, adenovirus); usu b/w Nov
and April; 2-5month olds
Path: Acute viral lower respiratory tract infection  lymphocytic infiltration into
peribronchial and peribronchiolar epithelium that promotes submucosal edema.
Mucous and cellular debris accumulate because of impaired mucocilliary prodx
SSx: pt presents with fever, cough, rhinorrhea followed by respiratory distress;
tachypnea; wheeing, rhonchi, crackles, ?retractions; restless or lethargic, sick
contract; Acute 5-10 day illness; recovery is about 2 weeks
Dgx: RSV or influenzae assay (NPO wash); CXR nl-air trapping or atelectasis,
hyperinflation, peribronchial thickening (cuffing), increased interstitial markings
Tx: Humidified Oxygen; Ribavirin if high risk kids; Ig, palivizumab
Risk Factors: kids w chronic lung disease, congenital heart disease, immune defx,
2-5months old
 575
Phenylketonuria
PKU
 576
Dgx: Urine Tetrahydrobiopterin lvls for confirmation (nl), UA increased lls of
phenylpyruvic and o-OHphenylacetic acids (phenylalanine metablites), plasma
phenylalanine > 20mg/dL; nl plasma tyrosine lvls, nl THF lvls
 577
Omphalocele
 578
Path: arrested folding of embryonic discabdominal viscera herniate thru imbilical
supraumnilical portions of abdomen into a peritoneum and amniotic membrane sac
SSx: protruding intestines inside a sac
Dgx: Prenatal US shows omphalocele
Tx: C-section to prevent sac rupture; primary closure if small defect; large defects
via staged repairs; emergent surgery if sac rupture
 579
Clostridium botulinum
580
 581
Laryngomalacia
Congenital Flaccid Larynx
 582
Path: large floppy arytenoid cartilages or ipiglottis
SSx: chronic inspiratory noise usu after first 2 months of life; nl VS, happy baby
Dgx: Laryngoscopy shows epiglottis rolling from side to side
Tx: hold the child in an upright position for half an hour after feeding and NEVER
feed the child in the supine position
 583
Klumpke Paralysis
 584
Path: Injury to C7-T1 (brachial palsy) caused by excessive traction on arm during
delivery
SSx: Horners syndrome-like presentation esp within 1wk of life; hemi-paralysis,
miosis, ptosis
Dgx: MRI=nerve rood abulsion/rupture
Tx:
DDx: Erb-Duchenne palsy, cerebral injury, Fx, epiphyseal separation of humerus,
clavicle fx
 585
Hereditary Spherocytosis
 586
Path: Spectrin (and ankyrin) dysfx causing RBC vulnerability to osmotic
variationsloss of membrane fragmentsformation of microspheres. These
microspheres get stuck in the spleen and get recycled
SSx: asymptomatic to severe anemia, growth failure, splenomegaly, chronic
transfusion requirements in infancy, severe unconjusgated hyperbilirubinemia;
aplastic crisis after parvovirus infx; gallstones in teens; pallor scleral icterus,
splenomegaly
Dgx: + osmotic fragility test; CBC=normocytic anemia, reticuloctyosis, increase in
indirect bili; reticulocytopenia if severe
Tx: Folate supplementation; RBC transfusion during aplastic crisis; splenectomy
after 6yo x anemia, reticulocytosis and scleral icterus
 587
Congenital Diaphragmatic Hernia
588
 589
Prader-Willli Syndrome
 590
Path: Deletion of PATERNAL Chromosome 15
SSx: Hypotonia, hyperphagia, obesity, short stature, MR, delayed milestions;
narrow bifrontal diameter, diamond-shaped eyes & down turned microagnathia;
Hypothalamic dysfx-GH defx, hypogonadism;
Tx: Short stature, hypotonia and obesity respond to GH
 591
Measles
Rubeola
 592
Path: Due to measles virus, paramyxoviridae, infx
SSx: Prodrome-fever, cough, coryza (rhinitis), non-purulent conjunctivitis; Koplik
spots-blue-whie lesions look like salt crystals on erythematous buccal mucous
membranes &/or conjunctivae and vaginal mucosa
Dgx: SSx, 592eucopenia, lymphopenia, +/-proteinuria, +hemagglutination inhibition
titer
Tx: Vaccination
 593
Staphylcoccus aureus
 594
Path:
Diseases:
Tx:
 595
Intussusception
 596
Path: Telescoping bowel; most commonly at ileocolic jx; mesentery of telescoping
bowel becomes compressed  impaired vv return, bowel wall aedema, ischemia
and necrosis
Incidence: M>F, esp bw 3mos-3yrs old, peak ≈ 8 mos
SSx: Colicky abdominal pain, vomiring, red currant jelly stools, kid is perfect
between episodes; abdomen may have sausage shaped mass;
Dgx: Air/Contrast Enema; KUB-targetoid lesion
Tx: Enema
 597
Anemia of Prematurity
 598
Path: Various 1) Transitions in erythropoiesic sites 2) shorter life span of neonate
RBC 3) holding the baby above the placenta for a long time (decreased fetoplacental
perfusion)
SSx: Premature, hospitalized, low birthweight infants; poor wt gain, poor feding,
lethargy, tachypnea, tachycardia, pallor
Dgx: Normochromic Normocytic Anemia 7-10g/dL; low reticulocyte count, low
RBC precursors in bone marrow
Tx:
 599
Bedwetting
 600
Normal until age 5-7 years old
 601
Apgar Scores
 602
Total of 10 points scored typically at 1 min and 5mins after birth
Color 2-body and extremities pink; 1-body is pink extremities blue/pale; 0-body
and extremities blue/pale
Heart Rate: 2 – >100 bpm; 1 – <100bpm; 0 – no pulse
Reaction to Nasal Stimuli: 2 – active cough; 1 – grimace; 0 – no response
Tone/Activity: 2 – active flexion of extremities; 1 – some flexion of extremities; 0 –
limp
Respirations: 2 – good respiratory effort; 1 – slow and irregular; 0 – apneic
 603
DtaP Vaccine
Diphtheria Tetanus and acellular Pertussis Vaccine
 604
Doses: 5 total – ;
 605
Acute Rheumatic Fever
ARF
 606
Path: Caused by Ig’s vs Group A Streptococcus pyogenes
SSx: Hx of URI or sore throat in recent weeks; Jones Critera –
2 Major – Carditis, Migratory Polyarthritis, Sydenham chorea, Subcutaneous
nodules, Erythema marginatum; or 1 Major and 2 Minor – Fever, increased CRP or
ESR, long PR interval on EKG
Dgx: + streptoccal antige test; increased ASO titer
Tx: Prevention via treating the pharyngitis w PNC
 607
Turner Syndrome
Turner’s Syndrome
XO Syndrome
 608
Path: Patient is born w 45 chromosomes, missing an X sex chromosome
SSx: Webbed neck, wide spaced nipples, broad chest, lack of 2ry sexual
characteristics, amenorrhea; coarctation of the aorta-rib knotching, HTN in the
arms, hypoperfusion of lower extremities, HA
Dgx: Karyotype shows 45 XO
Tx: Estrogen to promote nl maturation and reduce % of osteoporosis
Complx: Osteoporosis
 609
Enterobius vermicularis
Pinworm
 610
Live in lumen transmitted via feco-oral transmission or human to human contact
SSx: rectal or perineal pruritus
Dgx: Scotch tape test
Tx: Piperazine; Albendazole
 611
Duchenne Muscular Dystrophy
DMD
Childhood Muscular Atrophy
 612
Path: X-linked Recessive dysfx of Dystrophin gene causing dysfx Dystrophin
protein which is necessary for muscle fx.
SSx: Gower sign-using hands to walk up legs to assume an upright position,
hypertrophied calves, depressed reflexes, lethargy, difficulty walking and getting up
Dgx: EMG=myopathic pattern; Serum CK is SUPER high like 4000; definitive dgx
via muscle bpx and family pedigree; genetic studies
Tx: Supportive
Prognosis: Wheel chair bound by age 12
 613
Congenital Hypothyroidism
 614
Path: Various: thyroid dysgenisis, thyroxin dysfx, transplacental maternal
thyrtropin-receptor blocking antibodies
SSx: hypotonia, large tongue, abdominal bloating, GI hernias
Dgx: neonatal screening
Tx: Levothyroxine
 615
Breast Feeding Jaundice
Breastfeeding Jaundice
 616
Path: Exclusively breastfed infants are not getting enough milkpoor enteral
intake  dehydration  increased enterohepato circulation of total bilirubin
(>13mg/dL unconj; >15mg/dL of conj)
SSx: Jaundice baby usually 2-4 days of life
Dgx:
Tx: Increase breast feedings
 617
Necrotizing Enterocolitis
Nec
 618
Path: perinatal asphyxia  bowel wall injury
SSx: hx of perinatal asphyxia or preterm delivery, usu 3-10 days after birth,
increased gastric resiues in preterms, feeding intolerance, bilious aspirates,
abdominal distention
Dgx: metabolic acidosis, T° instability, KUB
Tx: NPO, NG tube x suction, blood cx and IV antibiotics, serial KUB to check for
pneumotaosis intestinalis and free air, IV fluids to prevent shock; surgery if air in
abdomen
Prognosis: poor
 619
Rubella
German Measles
3 Three Day Measles
Third Disease
 620
Path: Caused by rubella virus (Togaviridae family)
SSx: constitutional symptoms, +/- fever, cervical LAD, pink maculopapular rash
that starts on face/neck and spreads to limbs/trunk
Dgx: Clinical
Tx: Supportive?; vaccination
DDx: Measles (Rubeola?)
Complx: Gestational infx can cause congenital heart disease, MR, cataracts,
deafness
 621
Polycythemia
 622
Defn: central venous Hematocrit >65%
Path: in infants it’s usu due to delayed clamping of the umbilical cord resulting in
excess transfer of placental blood. Hyperviscosity of blood causes problems
SSx: any organ system but usu CNS eg lethargy, irritability, jitteriness szrs;
respiratory distress syndrome, tachypnea, cyanosis; poor feeding, hypoglycemia
hypocalcemia
Dgx: CBC
Tx: Hydration, partial exchange transfusion
Complx: Nec can be caused by the partial exchange transfusion
 623
Immune Thrombocytopenia
 624
Path: Antibodies bind to platelets  destruction in spleen
SSx: usu 2-6yo; usu preceded by viral infx; Purpura, petechiae, hematuria, +/- GI
bleeding; no LAD
Dgx: thrombocytopenia
Tx: if Platelets >30K, then no treatment unless severe ssx; if platelets <30K then
steroids
 625
Tricuspid Atresia
 626
Path: Narrow/absent tricuspid valve  absent avenue for blood to get from R
atrium to R ventricle
SSx: Cyanosis, holosystolic murmur at L lower sternal border, single S2
Dgx: CXR=decreased pulmonary markings, no sized heart, EKG=L axis deviation;
Echo=small R ventricle, VSD, large L ventricle
Tx: PGE1, balloon arterial septostomy
Complx: VSD, transposition of great arteries (30%)
 627
Neonatal Conjunctivitis
 628
Path: in USA usu due to chlamydial gonoccal and chemical
SSx: Chemical-usu due to silver nitrate prophylaxiz so presentation usu within 24
hrs of life; Gonococcal-presents on 2-5th days of life as hyperacute, highly purulent.
Can cause corneal perforation; Chlamydia trachomatis-presents on 5-14days of life,
congestion, discharge can be scant, mucoid or purulent and can happen despite
silver nitrate
Dgx: Clinically
Tx: Chemical-reassurance/observation; Gonococcal-ceftriaxone; Chlamydial-oral
erythromycin
 629
Pertussis
Whooping cough
 630
Path: Bordetella pertussis
SSx: Flue like ssx (catarrhal phase) followed by successive rapid coughps followed
by long deep loud inspiratory wheezing/whoop
Dgx: Leukocytosis w nl looking but small lymphocytes
Tx: Erythromycin; Admission if <3mos, or >3mos with severe symptoms ssx
 631
Physiologic Jaundice
 632
Path: increased bilirubin prodx, decreased bilirubin clearance (due to defx of
UGT1A1) and increased enterohepatic ciculation
SSx: Jaundice esp bw 2-3 or 4 day of life; serum bilirubin increases >5mg/dL/24hrs;
serum bili (< >)12mg/dL if full term, or 10-14 mg/dL in preterm
Tx:
 633
Congenital Syphilis
 634
SSx: Hepatosplenomegaly, muco/cutaneous lesions, jaundice, anemia,
hyperbilirubinemia, LAD, snuffles (bloody mucopurulent nasal discharge)
Dgx: Lesional scrapings on microscopy show spirochetes, blood test for VDRL or
RPR
Tx PNC-G
Complx: Death, MR, deafness
 635
NF-1
Neurofibromatosis Type 1
von Recklinghausen disease
 636
Path: Chromosome 17 AD due to dysfx of NF1 neurofibromin gene
SSx/Dgx: 2 of the Following: 1) ≥6 café au lait spots >5mm in size 2) axillary or
inguinal freckling 3) ≥2 lisch nodules on the iris 4) ≥2 neurofibromas or 1 plexiform
neurofibroma 5) distinct osseous lesion eg sphenoid dysplasia 6) optic glioma or 7)
affected 1st ° relative diagnosed based on the preceding criteria
Complx: depends on where the neurofibromas are, but generally seizures and vision
impairment, learning disorders, renovascular hypertension, scoliosis
Tx: treat the szrs, remove the fibromas
 637
Lymphocytic Hypothyroidism
638
 639
Hashimoto Thyroiditis
 640
Path: Chronic lymphocytic thyroiditisautoimmune destruction of the thyroid
glandhypothyroidism
SSx: hypothyroidism
Tx: levothyroxine
 641
Myotonic Musculure Dystrophy
Myotonic Dystrophy
Steinert Disease
 642
Path: Autosomal Dominant affecting all muscle types
SSx: Nl at birth slowly developing muscle weakness and muscle wasting esp in
distal (arm/hand) muscles; temporal (head) wasting, thin cheeks, upper lip in the
shape of an inverted V; looks emaciated w atrophy of thenar and hypothenar
eminences, proximal muscle weakness, +gowers sign, winged scapula, myotonia
(delayed relaxation after contraction); Endocrine manifesttions-DM, testicular
atrophy, frontal baldness, hypothyroidism
Dgx: percussion of thenar eminence produces myotonia
Tx:
 643
Septic Arthritis
 644
Path: Group B Streptococcus agalactiae, E coli, Streptococcus pneumoniae, Staph
aureus, Psuedomonas aureginosa due to foot puncture thru sneakers; pathogens
enter joint during bout of bacteremia; hip or knee most commonly involved
SSx: painful joint, refusal to bear weight, fever, irritability; decreased ROM, joint is
tender, +/- edema
Dgx: WBC >12K, T>39° C/102F, ESR>40mm/h
Tx: Emergency Ortho joint aspiration and IV ceftriaxone/cefotaxime or directed
towards cultured organism
DDx: Neisseria if multiple joints involved
 645
Friedreich Ataxia
FA
 646
Path: Chromosome 9 Autosomal recessive condition caused by lots of GCC repeat
sequences  defx of tocopherol transfer protein
SSx: Neuro-gait ataxia, frequent falling, dysarthia from degeneration of
spinocerebellar tracts, posterior columns or pyramidal tracts; Non-Neuro-
hypertrophic cardiomyopathy, DM scoliosis, hammer toes
Tx:
Complx: Necrosis and degeneration of cardiac muscle fibers  myocarditis,
myocardial fibrosis and cardiomyopathy. Arrhythmia and CHF lots of deaths.
Prognosis: Progressive. Poor. Wheel chair bound by 25yo. Death by 35-40
 647
Craniopharyngioma
 648
Path: Remnants of Rathke’s pouch  nests of sq cells in a loose stroma that looks
like embryonic tooth bud enamel. Located suprasellar and inferior to optic chiasm
Incidence: usu 7-12yo; 70-90% 5yyear survival rate
SSx: ssx of increased ICP (HA, N/V), bitemporal hemianopsia, calcified lesion
above sella; associated ssx-DI, growth failure from hypothyroidism or growth
hormone defx; decreased ACTH
Dgx: CT=cystic calcified parasellar lesionCalcified lesion above sella
Tx: Surgery
 649
Cystic Fibrosis
 650
Complx: Infx-Pseudomonas tx is PO ciprofloxacin if mild. IV ceftazidime and
gentamycin (PNC and aminoglycoside) if moderate or severe; Imipenem/.cilastatin
is 2nd line tx;
 651
Metatarsus adductus
 652
SSx: Type I-adduction of the anterior aspect of the foot with convex lateral boder
and cancave medial border, nl ankle movements, passive and active movement of
the foot overcorrects the deformity into abduction; Type II-
Tx: Type I-Reassurance; Type II-IMMEDIATE casting
 653
Langerhans Cell Granulomatosis
Langerhans Cell Histiocytosis
Histiocytosis X
LCH
 654
Path: Type of cancer characterized by proliferation of immature dendritic cells of
Langerhans. 3 Types
SSx: papules and nodules, erythematous scaling plaques that look like seborrheic
dermatitis. 1) Letterer-Siwe disease – usu affects 2yo, seborrheic eruptions caused
by langerhan cell infiltration on trunk and scalp, hepatosplenomegaly, LAD,
pulmonary lesions, eventually destructive bone lesions anemia,
thrombocytopenia, recurrent infx eg OM or mastoiditis 2) Eosinophilic granulomas
– expanding erosive accumulations of langerhans cells usu w/in the medullary
cavities of bones esp ribs femur, bpx is usu mixed with other WBCs 3) Hand
Schuller Christian – multiple erosive bony masses that may expand to soft tissue
 655
Vaccine Schedule
 656
DtaP – 5 doses. 5th at 4-5yrs.
Hib – 4 doses before 15yo
Inactivated Polio – 4 doses. 3 doses before 18mos. 4th at 4-5yrs.
Pneumococcal Conjugate – 4 doses before 15yo
MMR – 2 doses. 1st dose at 12-15mos. 2nd dose at 4-5yrs
Varicella – 2 doses.
Hep A – 2 doses.
Hep B – 3 doses. All due before 18mos.
Rotavirus – 3 doses.
 657
Vaccine Schedule
 658
4-5yrs old – DTaP#5, IPV#4, MMR#2, Varicella #2
 659
Tracheo Esophageal Fistula
TEF
 660
Path: Abnormal anastomosis of superior and inferior portions of the esophagus
esophageal atresia
SSx: Excessive oral secretions, inability to feed, gagging, respiratory distress;
polyhydraminos on fetal US; chronic cough or recurrent pneumonia
Dgx: AP/LA CXR shows blind pouch with air in the GI tract::Esophageal atresia
without TEF
Tx: surgery-division and closure and dilatation of pertinent parts
 661
Guillain Barre Syndrome
Guillain-Barre
 662
Path: Autoimmune-mediated demyelination of peripheral nerves
SSx: hx of URI or GI illness 7-21 days before onset of weakness followed by
progressive ascending weakness, decreased DTR, sensory or autonomic defx are usu
present but not prominent; may involve CN’s
Dgx: increased CSF prot; nerve conduction studies; CT or MRI if ssx warrant
Tx: IV-Ig shortens duration of ssx
Prognosis: ssx last up to 4 weeks  resolution 4 weeks after (so 2mos total?);
Recovery usu complete in kids
DDx: Tick paralysis from ticks of Appalachian or Rocky Mts bc of neurotoxin vs
acetylcholine receptors; myasthenia gravis; Duchenne muscular dystrophy; spinal
muscle atrophy;
 663
Epiglottitis
 664
Path: Most common cause is Strep pneumothickened qryepiglottic folds and
effacement of the valleculae
Incidence: 3-5 yo, cold months
SSx: Fever, sore throat, hoarsness, progressive stridor; kid looks toxic, drools, leans
forward with chin extended
Dgx: Neck Xray shows “thumbprint” sign
Tx: Airway access via endotracheal intubation with setup for tracheostomy.
Cricothyroidectomy if tracheostomy cannot be performed. Ceftriaxone (or
Ampicillin-Sulbactam) to cover for Streptococcus pneumonia and agalactiae;
Vaccination vs Haemophilus influenzae type B
 665
Laryngotracheobronchitis
Croup
 666
Path: virus induced inflammation of the laryngotracheal tissues resulting in a
syndrome of upper airway obstruction. Usu caused by parainfluenza (less
commonly by influenza or RSV)
SSx: Sudden onset of hoarse voice, barky seal-like cough and stridor; often a
prodromew low grade fever and rhinorrhea 12-24 days before stridor; respiratory
distress tachypnea, hypoxia, nasal flaring, retractions, impending airway obstrx
Dgx: Clinical; AP/LA Xray shows tapered, narrow subglottic airway (steeple sign)
Tx: Cool night air, humidity; cool nebulized racemic epinephrine w oralor IM
steroids if respiratory distress
 667
Talipes Equinovarus
Clubfoot
 668
SSx: Medial rotation of the tibia, fixed plantar flexion at the ankle, inversion of the
heel, forefoot adduction, restricted dorsifledion
Tx: Serial casting; surgical repair
 669
Breast Milk Jaundice
Breastmilk Jaundice
 670
SSx: Jaundice b/w 2-7 days, persists for weeks
 671
Kawasaki Disease
 672
Dgx: Fever plus 4/5 of the following: 1)Extremity changes eg erythema, edema or
desquamation 2) Conjunctivitis 3) truncal rash 4) Cervical LAD 5)Oral changes
which include erythema, fissured lips or strawberry tongue
Tx: IV-Ig and ASA
Labs: Sterile Pyuria, CRP>3, ESR>40, albumin<3, increased ALT, thrombocytosis,
leukocytosis >12K
Complx: Coronary artery aneurysmMI; orchitis, myocarditis, hepatitis also but
less common
 673
Sturge-Weber Syndrome
 674
SSx: szrs, MR, port wind stain, nevus flammeus along the trigeminal nerve
distribution which represents a unilateral cavernous hemangioma
Dgx: Skull xrays=gyriform intracranial calcifications that look like a tramline
Tx: Szr control, decrease intraocular pressure, argon laser therapy to remove skin
lesions
 675
Hyaline Membrane Disease
Respiratory Distress Syndrome Type-I (1)
 676
SSx: Tachypnea, retractions, respiratory distress which worsens over the next
couple of days, nasal flaring, cyanosis
Dgx: CXR=diffuse reticulogranular pattern and air bronchograms
Tx: Antenatal prevention w corticosteroids and postnatal tx w surfactant and
respiratory support
Risk Factors: Prematurity esp <28 weeks; Maternal gestational DM, C-section,
males>fem,
Maternal HTN, PROM and IUGR reduce the risk of HMD
 677
Ig A deficiency
 678
SSx: Recurrent mucous related infx eg sinus, GI, pulmonary. Usu strep or
hemophilus or Giardia.
Defx Ig A also predispose to anaphylactic rxns esp to anaesthesias
 679
Hemolytic Uremic Syndrome
HUS
 680
Path: Toxins released by E. colidestruction of colonic epithelial lining
SSx: acute bloody diarrhea, abdominal pain; jaundice from red cell destruction and
coagulation system activation
Dgx: HUS Triad – Uremia, thrombocytopenia, hemolytic anemia; CBC, platelets,
blood smears, UA, BUN/creatinine
Tx: Supportive, plasmapheresis; dialysis and steroids if severe
 681
Hydrocephalus
682
 683
Wiskott-Aldrich Syndrome
WAS
 684
Path: X-linked recessive disorder affecting B and T cells
SSx: Atopic dermatitis, thrombocytopenia (<50K), bleeding, recurrent infiections
usu from strep pneumo, n. meningitidis or H. influ, eczema
Complx: Cancers
 685
Systemic Lupus Erythematosus
Lupus
SLE
 686
Epidemiology:
Path:
SSx:
Dgx:
Tx:
Complx:
687