USMLE WORLD NOTES

ENDOCRINOLOGY.......................................................................................................................................... 2 CARDIOLOGY ............................................................................................................................................... 11 PULMONOLOGY .......................................................................................................................................... 21 DERMATOLOGY ........................................................................................................................................... 27 INFECTIOUS DISEASE ................................................................................................................................... 33 PEDIATRICS.................................................................................................................................................. 40 SURGERY ..................................................................................................................................................... 63 HEMATOLOGY/ONCOLOGY......................................................................................................................... 78 OBSTETRICS/GYNECOLOGY ......................................................................................................................... 81

ENDOCRINOLOGY
DIABETES MELLITUS: Tight glycemic control DECREASES risk of developing NEW peripheral neuropathy. 1-DM diagnosis => fasting glucose in 2 separate times > 126 2-Pts with uncontrolled impaired fasting blood glucose [B/w 100 126] are at risk for => CADCORONARY ARTERY DISEASE [even with a normal lipid profile] and progression to evident DM 3-Fasting blood glucose < 100 is normal DM: HYPOGLYCEMIA => Glucose < 60 For the diagnosis of DM = use fasting blood glucose levels [> 126 /x2] Or= Random blood sugar > 200 Risk Of DM Type 1 In Offspring : Mother with DM type 1 = RISK is 3% Father with DM type 1 = RISK is 6% DM: Antihypertensive drugs that have been shown to reduce risk of development of type 2 DM: ACEIs [reduce insulin resistance] + lifestyle modifications Metformin Causes Of Hyperglycemia: Stress due to any illness can increase in insulin resistance causing a poor glycemic control and aggravating hyperglycemia Example are acute attack of gout, and noncompliance with diet and medication Polyglandular Autoimmune failure type II [Schmidts syndrome] => Addison disease, type I DM, Autoimmune thyroid disease and other autoimmune disorders like: pernicious anemia, premature ovarian failure, vitiligo, celiac disease. DM -Type I => do not have appreciable endogenous insulin production, ketoacidosis when deprived of insulin treatment. [High blood sugar, ketonuria, increased anion gap] Sulfonylurea Induced Hypoglycemia [is severe and prolonged], RX: -Admission -Bolus of D50% followed by dextrose infusion + Octeotride [Because bolus of dextrose lead to elevation in the blood glucose level increasing secretion of insulin>severe rebound hypoglycemia later] > Add OCTEOTRIDE [somatostatin analogue that inhibits insulin secretion] Causes Of Hypoglycemia With Increased Plasma Insulin Level: 1. Insulinoma {Elevated serum Insulin and C-Peptide 2. Sulfonylurea use {Elevated serum Insulin and C-Peptide} 3. Exogenous insulin [Elevated serum Insulin and LOW C-Peptide} Diabetes Mellitus/complicationsDiabetic Retinopathy needs some years to develop => poor glycemic control and blurry vision can be due to swelling in the optical lens secondary to osmotic changes. => Best next step is => Improve glycemic control In a patient with Diabetic Retinopathy => how to avoid further retinal damage? => Add insulin to the regimen to tighten glucose control.-. Autonomic Neuropathy/Delayed Gastric Emptying -> advice small frequent meals- Metoclopramide, Erythromycin -> Cisapride Rx for long term and severe refractory gastropathy Diabetic Gastroparesis Gastroparesis (D.M autonomic neuropathy, delayed gastric emptying -> food remaining in the stomach for a longer period of time than normal.) -symptoms: Postprandial bloating, postural dizziness, abnormal sweating, constipation => Delayed gastric emptying cause postprandial hypoglycemia DX: x rays, manometry, BEST TEST: Nuclear studies to study gastric emptying => Gastric emptying scan RX: Dietary changes (Low-fiber and low-residue diets, restrictions on fat and/or solids), oral medications [pro-kinetic] such as Metoclopramide (Reglan, Maxolon, Clopra). Erythromycin and Domperidone (Motilium); adjustments in insulin dosage for those with diabetes, For long term management: Cisapride (Propulsid), jejunostomy tube, parenteral nutrition, implanted gastric neurostimulators ("stomach pacemakers"), or botulinum toxin. Complications: Bacterial infection due to overgrowth in undigested food, also, the food can harden into

solid masses called bezoars if intestinal obstruction; malnutrition, WT loss, diff. controlling glucose. DM: Tight glucose control => decreases risk for development of microvascular complications [retinopathy, nephropathy, neuropathy]. No effect/control on macrovascular risks: MI, PVD, Stroke, etc Diabetic patient should maintain their LDL cholesterol < 100 mg/dL -> Statins are the DOC** Diabetic poly-neuropathy affects lower limbs in a stocking-glove pattern,decreased ankle reflexes, decreased sensitivity to pain or light touch, paresthesias progressing to motor weakness and pain. BEST screening and diagnostic test for Dx of Neuropathy is => NERVE conduction studies [axonal pattern of nerve damage] Diabetic peripheral neuropathy -> pain management: TCAs nortriptyline or amitriptyline [but are contraindicated in pts with HEART disease] Alternative: Gabapentin DM management during delivery and labor/surgery **Insulin administration should not be stopped [to prevent DKA] in a type 1 DM patient even if they are not eating.- Insulin requirement DECREASES following delivery of a pregnant diabetic. Take normal insulin dose on the night before surgery and start on insulin drip and infusion of D5% with KCL 40 mEq [to keep blood sugar < 160] DKA: Most common complication/mistake= incorrect fluid management. Understand that glucose infusion and potassium replacement are important components in DKA, aside from insulin and NSS. Initial fluid: NSS 0.9% until the blood sugar reaches 250 mg/dl + Insulin infusion Then: Decrease Insulin infusion to 1-2 U/hr and change to D5% NSS + KCL [Dextrose infusion is very important to decrease ketone levels]. Switch to SQ Insulin [Rapid acting] [when pt is stable, normal anion gap, HCO3 is > 10, able to tolerate food and precipitating factors are under control] then change to oral route feeding. DKA another common mistake: stopping IV Insulin w/o overlapping dose of SC Insulin Result= rapid recurrence of DKA. When change to SC insulin= this route takes time to be absorbed, so, it should be administered 30-60 minutes before insulin infusion is stopped => fails to do this = rapid recurrence of DKA. Diabetes Mellitus / HONKC **Diabetes type 2 patient presenting with a Hyperosmolar nonketotic coma => hyperglycemic crisis precipitated by infection and steroid use. Requires high doses of IV insulin due to insulin resistance induced by infection, steroid and hyperglycemia. Then insulin is reduced once blood sugar and infection are controlled. SC insulin is started once the patient starts to EAT consistently: - Regular insulin [rapidly acting] is required to cover meals. - And basal insulin (NPH or Glargine) insulin required to cover the period b/w meals. - AVOID oral hypoglycemic agents DM Meds: Metformin is especially useful in DM patient OBESE Metformin, Pioglitazone and Rosiglitazone => Decreases Triglycerides, improves NASH and increases HDL Insulin, thiazolidinediones, sulfonylureas [glyburide] -> cause WT gain Metformin can be continued in patients with PCOD UNTIL PREGNANCY IS DOCUMENTED. Then, advice her to STOP Metformin and prescribe INSULIN Metformin is contraindicated in: (USE Insulin for these cases) o CHF o Alcoholism o Renal failure Pt with uncontrolled DM and renal failure => Stop Metformin and other sulfonylureas [Stop Glyburide] and Start Insulin [Renal failure is an indication to treat DM with insulin]

 Glyburide is metabolized in the kidney, stop this drug; and Metformin. Since Rosiglitazone is metabolized by the liver =. No need to stop Rosiglitazone Metformin & lactic acidosis => in the elderly, pt with renal failure, hepatic or heart failure {Other causes of lactic acidosis: hypoperfusion and tissue hypoxia [sepsis, hypovolemic shock, and hypoxemia.=> Always look at the anion gap.- AG= Na - (CL + HCO3) Normal: 8-12} If there is a high Anion gap metabolic acidosis: Lactic acidosis [metformin], renal failure, DKA, intoxications, ASA, ethylene glycol or methanol. Patients with type 1 DM or any autoimmune disease are in risk or predisposed to get other autoimmune disorders such as: Addison disease, hypothyroidism, pernicious anemia, atrophic gastritis; etc [MEN or PAS]. If a patient with DM type 1 has symptoms of Addison disease; or adrenal failure [WT loss, asthenia, eosinophilia, hyperkalemia, borderline sodium levels, mild anion gap acidosis, pre renal azotemia, low blood glucose]. Effects Of Exercise On Glycemic Control [Principally DM Type 2] Hypoglycemic effect of exercise remains for hrs after completion of exercise=> Exercise decreases blood glucose by improving insulin sensitivity and increasing non-insulin mediated uptake of glucose by the muscles => serious problems in glycemic management [can lower blood glucose in the presence of high insulin or increase blood glucose when insulin is low] Pt needs to check blood glucose before exercise, advice to eat a snack if glucose is in low normal range Most reasonable option is: => Start patient on insulin pump [free to vary the timing of their exercise and food intake] The role of exercise control in DM type 1 [is not as clearly defined as for the DM type 2] **Type 1 DM achieve glycemic control with a lower dose of insulin when they exercise regularly or participate in sports Make an appropriate schedule in order to make appropriate insulin adjustments Pts Should decrease dose of insulin prior to their most active time of the day or when participating in sports **Exercise in early afternoon=> morning dose of NPH should be reduced **Patients on insulin pumps => have more flexibility for changing their insulin dose and may participate in unplanned activities. **AVOID exercise when blood sugar is > 250 => because risk of DKA Glucagonoma: Pancreatic tumor associated to mild Diabetes and a classic skin rash called Necrolytic migratory Erythema High Glucagon level in serum--Can have metastasis, mainly in liver at the time of diagnosis Can secrete other peptides: VIP, calcitonin, GLP1 RX: Surgery Somatosatinoma: Classic triad of Somatostinoma [tumor, Delta cells of pancreas; majority are cancerous] Gallstones [by inhibitory effect of somatostatin on gallbladder motility] Malabsorption [by inhibition of pancreatic secretion] Diabetes Mellitus [inhibition of insulin secretion by somatostatin] DX/ Next step: Fasting somatostatin levels [> 160] Incidentalomas: Incidentaloma=unilateral Adrenal mass => require further workup for hormone secretion or malignancy => evaluate hormone production is the first step Incidentaloma [Adrenal mass] work up: Serum electrolytes Dexamethasone suppression testing 24 hr urine catecholamine, metanephrine, VMA 17-ketosteroid measurement All masses should be managed conservatively with SERIAL ABDOMINAL IMAGING

The next step is: Check Cosyntropin stimulated cortisol levels

Remove if masses increase in size All functional mass with radiographic evidence of malignancy or masses > 4 cm in size should be removed PITUITARY INCIDENTALOMA: Patients with a small mass [5 mm] or lesion without any hormonal dysfunction can be safely followed by periodic assessment of the pituitary gland with MRI [Repeat MRI of pituitary in 6-12 months] PARATHYROID: Indications of parathyroidectomy [pts with 2ry or 3ry hyperparathyroidism] Calcium > 10.5 not responding to conservative management Moderate/severe hyperphosphatemia, not responding to medical management PTH of > 1000 pg/mL Intractable bone pain Intractable pruritus Episode of calciphylaxis -Soft tissue calcification It is very important to rule out low bone turnover or adynamic bone disease before a parathyroidectomy => if ALP is very high { indicates that bone turnover is increased, so the surgery is safe. Indications of Parathyroidectomy In Patients With Hyperparathyroidism: Bone mineral density T score < 2.5 SD Complications of 1ry hyperparathyroidism like= kidney stones, evidence of bone disease Serum calcium > 1 mg/dl above upper limit of normal History of life threatening hypercalcemia Urinary Calcium > 400 mg/day Creatinine clearance decreased 30% younger than 50 y/o Bone Loss After Delivery => exaggerated bone loss if predisposing factor like Heparin use combined with increased bone loss during postpartum state. => Discontinuation of breastfeeding during postpartum -> can preserve or improve bone mineral density because decrease calcium loss and decrease in the level of parathyroid hormone rP [PTHrP] which is important in calcium transfer into breast milk, and levels are increased during nursing. CELIAC DISEASE: or gluten induce enteropathy can present w/o signs of malabsorption; in a pt with iron and vitamin D deficiency despite consuming a nutritious diet ,celian dz can be suggested by family history of autoimmune diseases and vitiligo. Celiac disease screening= Anti-endomysial and Anti-tissue transglutaminase antibody level Gold standard => Small Intestinal biopsy FAMILIAL HYPOCALCIURIC HYPERCALCEMIA [FHH]: Can be managed with moderation of calcium intake, adequate hydration and regular physical activity Has LOW Urine Calcium [ 10 Osteopenic =T score 1.0-2.5 Oteoporosis = T score < 2.5 Optimal intake of calcium and vitamin D Excessive Bone Resorption After Prolonged Immobilization => leads to hypercalcemia. Seen in patient with a very high turnover [adolescent, older pt with Pagets] days to weeks following immobilization. Management: Biphosphonates are useful in decreasing bone resorption. MEN 1 with 3 Ps = hyperparathyroidism, pancreatic tumor [gastrinoma] and pituitary tumor => Next step in the management => require referal to a surgeon for parathyroidectomy SARCOIDOSIS: Hypercalcemia => Overproduction of 1,25-dihydroxyvitamin D => Increased Calcium uptake Sarcoid produce the enzyme 1-alpha-hydroxylase [convert 25 hydroxyvitamin D to 1,25 dihydroxyvitamin D leading to an increase in GI absorption of calcium. => Resulting hypercalcemia leads a suppressed PTH secretion and an increased urinary calcium excretion. Sarcoidosis / hypercalcemia => RX: Glucocorticoids + hydration

HYPERCALCEMIA: 1-Primary hyperparathyroidism 2-Malignancy induced hypercalcemia [calcium is very high] 3-Vitamin D induced hypercalcemia **In hypercalcemia due to malignancy [e.g. lung tumors, smokers] => SERUM Calcium levels is much higher than in primary HP. Hypercalcemia classification: Parathyroid dependent {primary, terciary HP, lithium induced hypercalcemia, familial hypocalciuric hypercalcemia} Parathyroid independent {Malignancies, vitamin D toxicity, granulomatous diseases [sarcoidosis], milk alkali syndrome Malignancy: due to secretion of PTHrP and other causes Next step in managment => Serum PTH measurement PSEUDO-HYPOPARATHYRODISM: Long standing hypocalcemia, hyperphosphatemia, bilateral cataracts and calcificationof basal ganglia Cause ( resistance of PTH on its target tissues) th Type 1A: Albright hereditary osteodystrophy AHO [short stature, round facies, short 4 and 5th metacarpals and a short neck] Type 1B: Does not have features of 1A AHO Pseudo-Pseudo hypoparathyroidism [PPHP]: does not have hypocalcemia and hyperphosphatemia because resistance to PTH is mild but has features of Albrights Following gastric bypass surgery => malabsorption => Dx: Measure 25-hydroxyvitamin D in serum Rx: need higher doses of vitamin D supplementation to prevent osteomalacia PAGETS DISEASE: Rx: Biphosphonates Treatment is indicated when: Bone pain Involvement of weightbearing bones Neurological compromise Hypercalcemia Hypercalciuria CHF When pt does not respond to treatment for osteoporosis [biphosphonates] despite being compliant and has rapid bone loss => suspect secondary causes [MM]* NEXT STEP: Serum Urine protein electrophoresis** Long Term Management of Chronic Hypoparathyroidism: Vitamin D + Calcium **Borderline serum calcium and high urinary calcium [due to low PTH levels, PTH increases renal calcium absorption]Add a Thiazide diuretic [increase serum calcium and decrease loss of calcium through urine] ADRENALS: CORTISOL DEFICIENCY = hypotension LONG TERM USE OF GLUCOCORTICOIDS Patients with chronic suppression of hypothalamicpituitary-adrenal axis 2ry or 3ry Adrenal insufficiencylow Cortisol, low ACTH Since ACTH does not control secretion of mineralocorticoids from the zona glomerulosa of adrenal gland, patients have normal plasma aldosterone and are normotensive, but can develop vascular collapse under a stressful situation [infection] [ACUTE ADRENAL INSUFFICIENCY] due to decrease of cortisol [hormone responsible for keep vascular tone] and since cortisol promotes synthesis of catecholamines in adrenal medulla, cortisol deficient patients are unable to grow a good pressor response to stress.Hypotension in these pts responds to administration of a stress dose of glucocorticoids and hydration. In secondary and tertiary adrenal failure, there are no significant abnormal mineralocorticoid levels [no need of fludrocortisone]. Goals Of Treatment In ACUTE ADRENAL INSUFFICIENCY Reverse hypotension -> Hydration IV NSS 0.9% Correct electrolyte abnormalities Replace cortisol => IV Dexamethasone followed by Cosyntropin Stimulation test

Dexamethasone is preferred because it does not interfere with the measurement of ACTH or Cosyntropin test or with urinary steroids. SPONTANEOUS HYPOKALEMIA, HYPERTENSION: Screen for hyperaldosteronism => Plasma/aldosterone to plasma/renin activity PHEOCHROMOCYTOMA: Biochemical confirmation is required before imaging is performed to localize tumor => Screening test: - Urinary metanephrine and catecholamine levels. Next step: Alpha blocker {Phenoxybenzamine} and liberal salt/fluid intake to control HTN and restore intravascular volume [for 10-14 days before surgery] Then: Imaging to localize tumor before surgery {CT or MRI Intraoperative hypotension -> IV bolus of NS followed by continuous NS infusion. Screen for Pheochromocytoma in pts with Medullary thyroid cancer => measure plasma free metanephrine {MEN 2A} USE OF GLUCOCORTICOIDS => HIGH DOSES, > 7.5 MG/D, FOR MORE OF 3 WEEKS => can cause suppression of the hypothalamic-pituitary-adrenal- axis -> Lead to tertiary ADRENAL insufficiency CUSHING SYNDROME: **Cushing with ADRENAL etiology is biochemically characterized by a non-suppressible or non-response high dose dexamethasone suppression test and low plasma ACTH levels.=> Next step => Do a CT scan of the adrenal glands. Young patient with diabetes and HTN, osteoporosis, hypokalemia and metabolic alkalosis => Screening for Cushing syndrome => Overnight Dexamethasone suppression test [or 24 hr urinary free cortisol] PITUITARY: Nelsons Syndrome: Bitemporal hemianopsia, hyperpigmentation following bilateral adrenalectomy x Cushings disease is suggestive of => Nelsons syndrome. [pituitary enlargement due to loss of feedback by adrenal glucocorticoids; hyperpigmentation and visual defect after adrenalectomy] Diagnosis: MRI of the brain = Mass lesion in the sellar and suprasellar region and high plasma ACTH RX: Surgery and pituitary radiation Untreated Acromegaly Increased RISK of C/V disease [leading cause of death in acromegaly] 50% acromegalic pt has HTN, LV dysfunction, others has asymmetrical septal atrophy, conduction defects, atherosclerosis, etc Increased risk for COLON cancer Hypogonadism, high prolactin and low gonadotropin LH/FSH levels; increased serum alpha subunits => Classic non-functioning pituitary adenoma [Arises from gonadotropin secreting cells or gonadotrophs in the pituitary] First line of therapy is Transphenoidal surgery THYROID GLAND: AMIODARONE Pt taking Amiodarone and with WT gain, swelling on feet, tiredness. Next step check TSH in serum [Amiodarone Thyroid dysfunction, corneal deposits, skin discoloration, pulmonary fibrosis [lipoid Pneumonitis] and liver toxicity] Amiodarone effects thyroid functions.Pt on amioradone due to Atrial fibrillation thyroid side effects Causes decrease in conversion of T4 to T3 in turn decrease T3 levels and elevated T4 THYROID NODULES: Thyroid nodules > 1 cm should be subjected to FNA and biopsy Thyroid nodules < 1 cm should be followed by thyroid U/S YEARLY Radionuclide scan is useful in Toxic adenoma [thyrotoxic state] A toxic thyroid nodule is charactherized by signs and symptoms of hyperthyroidism and the RIAU is increased focally [focal uptake] Papillary Thryroid Cancer = NTT Near total Thyroidectomy is the TOC. Then use RAI to destroy any residual thyroid -> then total body scan Symptomatic tachycardia in hyperthyroid patient => use B-blockers (propranolol) Subclinical Hypothyroidism =mild elevation of TSH [5- 10] with normal FT4

Subclinical hypothyroidism + depression and ovulatory dysfunction [irregular heavy painless menstrual cycles] with *only mild elevated TSH *Next step: => Low dose Levothyroxine [start 50 mcg of levothyroxine or L4] *Resolves depression and menstrual irregularities ASYMPTOMATIC Subclinical hypothyroidism => does not requires treatment Subclinical hypothyroidism = Treatment is required if: Antithyroid antibodies [Anti-TPO] Abnormal lipid profile Symptoms of hypothyroidism Ovulatory and menstrual dysfunction When TSH > 10----- RX: Levothyroxine Subclinical Hyperthyroidism or EVIDENT Hyperthyroidism Has increased risk for Chronic ATRIAL FIBRILLATION Primary goal of treatment: Rate/Rhythm control with B-blockers or CCC And to prevent systemic embolization with anticoagulation- Heparin HRT => increases the risk of DVT venous thromboembolism and for PE [can lead to increased risk of forming blood clots] It is not indicated for primary or secondary prevention of CAD. [indicated to prevent osteoporosis and vasomotor symptoms]. Subclinical Hyperthyroidism /Or/ Thyrotoxicosis: Suppressed TSH levels with normal thyroid hormones [Normal FT4] MCC: treatment with levothyroxine, nodular thyroid disease, Gravess disease and thyroiditis Subclinical thyrotoxicosis induced by levothyroxine Rx: reduce the dose Recheck TSH after 6-8 wks [etiology not determined, TSH becomes normal if repeated in a few weeks] No treatment is necessary: asymptomatic patients mildly decreased TSH normal bone density Calcium carbonate and iron preparations and OTC vitamins can impair absorption of Levothyroxine That could lead to unexplained increased in TSH. Pt should be instructed to take L4 on an empty stomach, in the morning, separately from other medications. Thyroglobulin (TG) => the only source in the body is the thyroid gland, thus the presence of EXOGENOUS Thyroid hormones would suppress the thyroid gland, inhibiting TG release into the circulation Exogenous Thyroid hormone => Undetectable levels of Thyroglobulin Some OTC weight loss pills contain thyroid hormones and can lead to pill induced thyrotoxicosis but decreased TG Thyroid LYMPHOMA [Rare thyroid malignancy in pts with Hashimotos] Suspected if a patient with longstanding Hashimotos thyroiditis presents with a rapidly enlarging and compressive symptoms [dysphagia] and a firm thyroid gland or goiter Dx: large fine needle aspiration/biopsy Rx: Radiation and chemotherapy, => the response is good Hashimotos thyroiditis diagnosis => High titers of anti TPO Other studies => U/S, Radionuclide thyroid scan, aspiration biopsy Thyroid lymphoma needs large needle aspiration biopsy Primary hypothyroidism => have hyperlipidemia [isolated elevation of LDL or combined elevation in LDL and triglycerides]. PREGNANCY AND THYROID: Thyroid hormones and contraception or HRT: Estrogen replacement therapy/contraception => increases requirements for L-thyroxine in hypothyroid patients taking this medication.- [due to induction of liver enzymes, increased level of TBG and increased volume of distribution of the thyroid hormones] Next step: Increase dose of levothyroxine T4 [Total T4] and total T3 are elevated due to increased levels of TBG => induced by estrogens

The total serum thyroxine (T4) and triiodothyronine (T3) levels are increased in pregnancy due to high levels of estrogen which, in turn, increase the thyroid hormone-binding protein concentrations Free T4, Free T3 and TSH are normal in pregnancy In the post-partum period T4 and T3 return to normal [unless postpartum thyroiditis] POST PARTUM THYROIDITIS [THYROTOXICOSIS FOLLOWED BY HYPOTHYROIDISM]: By autoimmunity, has triphasic course: 1st phase: Thyrotoxic phase= Low Radioactive iodine uptake [1-3 months after delivery] -anxiety, insomnia, palpitations (fast heart rate), fatigue, weight loss, and irritability 2nd phase: Hypothyroid phase = 4-8 months after delivery- fatigue, weight gain, constipation, dry skin, depression and poor exercise tolerance. 3rd phase: Recovery phase [within 12-18 months of the onset] **Permanent hypothyroidism develops only in 20% cases PREGNANT PT WITH THYROTOXICOSIS: Needs to be treated with PTU => if no response or intolerance => Surgery is indicated Treatment cannot wait until postpartum period [risk of thyroid storm is high] Pregnancy + Hyperthyrodism => Discontinue Methimazole [scalp defect or aplasia cutis in the fetus] Prescribe: Propylthiouracil PREGNANT WOMAN WITH HYPOTHYRODISM: *** Very important to be treated to avoid fetal mental retardation, low IQ **During the first trimester: INCREASE dose of levothyroxine! MOST APPROPRIATE COURSE OF ACTION IN GRAVES DISEASE IN USA: 1- Radioiodine ablation + concurrent prednisone administration [To avoid worsening of ophthalmopathy] Contraindications: * Large retrosternal goiter [due to post-procedure swelling of the gland may compromise airways] THYROID STORM: Diagnosis is made clinically -> Treatment can be started ASAP without waiting for Labs Glucocorticoids are used in thyroid storm because they inhibit the conversion of T4 to T3 Iodine can not be administered before antithyroid drugs because excess iodine can serve as a substrate for the formation of more thyroid hormones, worsening the problem **Other drugs that inhibit the conversion of T4 to T3=> B-blockers, amiodarone, PTU, iopanoic acid THYROID CANCER: **Post-operative patient [total thyroidectomy] of Medullary thyroid cancer=> persistently of calcitonin => Indicates Residual metastatic thyroid cancer => NEXT step => CT-scan of the neck and chest [with or w/o high resolution U/S] Thyroid Cancer In Remission => Suppressive doses of levothyroxine are needed Papillary Thyroid Cancer In Remission => dose of levothyroxine is adjusted to suppress the TSH below normal range (0.1 and 0.3 mU/mL) => Then, the dose can be increased to bring TSH to WNL goal range Patient with distant metastasis => even lower levels [complete suppression] is required. Remember: These Suppressive doses of levothyroxine puts the pt at risk of=> Bone loss and Atrial fibrillation

Important concept:
**Hypothyroidism, even it is severe; it not a contraindication to emergency surgical procedures! Example-cardiac catheterization MEN II: a) Medullary thyroid cancer b) Pheochromocytoma c) Hyperparathyroidism MEN II B: a) Pheochromocytoma b) Medullary carcinoma of thyroid c) Marfanoid habitus with mucocutaneous and GI neuromas Patient with medullary thyroid cancer and symptoms of pheochromocytoma like palpitations, headaches and sweating; surgery for thyroid cancer is scheduled => What is the NEXT STEP in management?

REMEMBER: MEN II => Alpha blocking agent for at least 10-14 days before ANY surgical procedure + liberal fluid/salt intake to restore intravascular balance REMEMBER: Suspecting pheochromocytoma and any surgery scheduled-> next step is=> Alpha blocking agent to avoid intraoperative complications with fluids/salt intake to restore intravascular volume Iodine Induce Thyrotoxicosis after Angiography; next step-> Thyroid function tests Secondary to iodine administration during coronary angiography extreme fatigue, shakiness, WT loss, palpitations, firm irregular thyroid [possible multinodular] and tachycardia despite B-Blockers after coronary angiography. Rx: Self limited disorder [can persist for months, is usually refractory to antithyroid medication] For mild symptoms: B-Blockers Moderate/severe symptoms: Antithyroid drugs => Refractory cases: Potassium perchlorate *****Ineffective Radioactive iodine ablation because RAIU is low**** Subacute thyroiditisVery low RAIU***Decreased uptake!! Classical symptoms of thyrotoxicosis, heat intolerance, palpitations, SOB; thyroid gland enlarged, painful and tender. Lymphocytic thyroiditiswith symptoms of thyrotoxicosis are treated with B-blockers [Propranolol] Hashimoto thyroiditis High titers of Anti-TPO => hypothyroid state => Rx: replacement with levothyroxine Central hypothyroidismEVALUATION OF THE ADRENAL STATUS [Cosyntropin stimulation test] is the best next step in patients with central hypothyroidism A patient with Central hypothyroidism has Borderline elevated TSH, low FT4 ***But this TSH is not biologically active NEED to rule out concomitant central adrenal insufficiency [Addison disease] that can increase TSH levels without hypothyroidism [due to loss of an inhibitory effect of glucocorticoids on TSH secretion]. Next step: Measurement of CORTISOL with Cosyntropin stimulation test (Treating pt with central hypothyroidism and concomitant adrenal insufficiency or Addison => could precipitate adrenal crisis) Combination of elevated T3, T4 and TSH can be seen in: 1- TSH secreting pituitary adenoma and in 2- Thyroid hormone resistant syndrome The difference: Hyperthyroidism central/pituitary adenoma has ELEVATED Alpha subunits TSH SECRETING PITUITARY ADENOMA Clinical features of thyrotoxicosis with: T3, T4 and TSH + serum alpha subunits Similar: Thyroid hormone resistant syndrome **Clinical features of thyrotoxicosis with: T3, T4 and TSH BUT: Normal serum alpha subunits EUTHYROID SICK SYNDROME [LOW T3 SYNDROME] -Commonly seen in hospitalized pts due to another condition -LABS: Decreased total T3 [Total T3] with Normal T4 and TSH -If patient is extremely sick can be reduced T4 and TSH too [bad prognosis] -TSH transiently increases above normal limits when pt recovers Rx or next step: Repeat thyroid function test in 8 weeks [because recovery phase], do not use thyroid hormone Elder people with mental status change Order Thyroid function tests MCC of mental status change in elderly: Medication, polypharmacy Infections UTI, pneumonia, etc Metabolic abnormalities=> hypothyroidism, thyrotoxicosis [with depression]

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CARDIOLOGY
CORONARY ARTERY DISEASE
Multiple risk factors increase the risk of acute CAD. The risk can be significantly reduced by decreasing LDL cholesterol and, to a lesser degree, by adequately controlling the blood pressure (in diabetic patients, as well as in patients with previous CAD, a blood pressure lower than 130/80 mmHg is recommended). The contribution of other interventions such as smoking cessation, diabetes control, exercise, and HDL increase is also beneficial, but not as critical as the first two measures. In patients with hypercholesterolemia and hypertriglyceridemia, a statin is the best initial drug of choice. The primary target of therapy is normalizing LDL-cholesterol; the secondary target is normalizing non-HDL cholesterol (total cholesterol - HDL cholesterol). If the statin fails to control hypertriglyceridemia, gemfibrozil or niacin can be added. In prospective studies of healthy patients, those with higher plasma fibrinogen concentrations developed coronary heart disease more frequently. Fibrinogen levels decrease only 20 years after smoking cessation; while certain drugs such as atorvastatin and lovastatin can produce hyperfibrinogenemia. Even though it is uncertain how dangerous hyperfibrinogenemia can be, it is currently recommended to maintain fibrinogen levels as low as possible and to discontinue any medication that can increase them, unless the benefits outweigh the risks. Exercise Electrocardiography should be the initial test of choice for evaluation of suspected CAD in patients with a normal resting EKG and the ability to exercise. Exercise stress testing is useful for the diagnosis and risk stratification of patients with stable angina. Exercise testing is useful to identify a high-risk group that will benefit from coronary angiography. Patients At High Risk Have One Of The Following Findings On Exercise Testing: 1. failure to increase their blood pressure with exercise 2. Inability to complete stage I of Bruce protocols 3. Appearance of horizontal or down sloping ST segment during exercise Pharmacological Stress Testing is an alternative to exercise stress testing, and is indicated in the setting of CAD, when the patient is unable to exercise due to some underlying medical disorder (amputation), when an exercise stress test is relatively contraindicated (MI, unstable angina), or in patients in whom interpretation of an EKG is difficult because of preexisting changes, such as left bundle branch block, baseline ST/T changes from left ventricular hypertrophy, etc. Both adenosine and dipyridamole scans are contraindicated in patients with COPD because they can induce bronchospasm. The American College of Cardiology/American Heart Association (ACC/AHA) defines A Positive Exercise Stress Test as 1 mm or more of down sloping or flat ST segment depression during exercise or during the recovery period. EXERCISE ECHOCARDIOGRAPHY is more sensitive than the resting echocardiogram or stress EKG, and is also commonly done in patients with stable angina. RESTING ECHOCARDIOGRAPHY OR EKG is useless in stable angina when the patient has no active chest pain. PRINCIPLES AND PRACTICE OF STRESS TESTING are based on the relative development of manifestations of myocardial ischemia as the stress to the myocardium is increased. Regional wall motion defects are the first to appear (detected by stress echocardiography). This is followed by significant perfusion defects (detected by perfusion scans), pulmonary capillary wedge elevation, ST segment changes on electrocardiogram, and finally, anginal pain. Stress imaging should therefore be pursued if there are no EKG changes during or after the stress test. It is also the modality of choice in patients with bundle branch block, WPW syndrome, paced ventricular rhythm, and baseline ST changes before exercise (ventricular hypertrophy, digitalis therapy, etc.). A positive stress test result in a patient with symptoms warrants further intervention, preferably with a coronary angiogram. Nuclear Scans should be performed in subsets of patients with baseline ST segment changes. It is important to recognize the advantages and limitations of different available testing modalities for the evaluation of myocardial ischemia.

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Adenosine, Along With Dipyridamole And Dobutamine, is one of the most frequently used pharmacologic agents to induce ischemia in patients with poor functional status. Sestamibi test is one of the three available technetium-99m labeled tracers used frequently for radionuclide imaging. In patients with angina and a prior history of revascularization (PTCA or CABG), technetium-99m (sestamibi) and thallium perfusion imaging are the two types of radionuclide perfusion imaging modalities used for characterizing the ischemia, establishing the functional effects of lesions, and determining the viability of myocardium. The two modalities are also used in patients with complete left bundle branch block (LBBB), electronicallypaced ventricular rhythm, preexcitation (WPW) syndromes, > 1 mm ST segment depression at rest, LVH with repolarization changes, and in patients who are unable to exercise. Coronary Angiography is indicated in the setting of stable angina pectoris when the angina is refractory to medical treatment, or when exercise testing identifies the patient as high-risk. Studies have shown that compared to angioplasty, Coronary artery bypass graft (CABG) improves longterm survival in diabetic patients with multivessel disease and recent Q-wave infarction. Good, perioperative control of the blood glucose levels is advocated during CABG. An insulin drip achieves better blood glucose control during CABG, and decreases the incidence of sternotomy wound infections. According to the ACC/AHA guidelines, patients who are unable or unfit to exercise should undergo adenosine or dipyridamole myocardial perfusion imaging for the diagnosis and risk stratification of CAD. Adenosine, along with dipyridamole and dobutamine, is one of the most frequently used pharmacologic agents to induce ischemia in patients with poor functional status. All patients with chronic stable angina should undergo an exercise stress test for prognostic and risk stratification. All patients with coronary artery disease and stable angina should be referred for an exercise stress test for further risk stratification. Patients with a low risk treadmill score (able to exercise more with a normal EKG) have less than 1% annual mortality rate. On the other hand, patients who have a high-risk treadmill score (presence of chest pain or EKG changes with minimal exercise) have greater than 3% annual mortality rate and require more aggressive management. Metformin use is contraindicated in patients with renal failure, sepsis, hepatic dysfunction, and severe heart failure. It should also be stopped in patients who are at risk to develop renal failure, such as those who will undergo angiography, a procedure that involves infusion of a high load of contrast agent In patients whose chest pain may be ischemic in origin, supplemental oxygen and ASA aspirin should be administered immediately, followed by Nitroglycerin, Morphine, and Beta-blockers (presuming no contraindications exist). Calcium channel blockers can be harmful in patients with acute MI. Beta blockers, ACE inhibitors, and statins have significant effects on the secondary prevention of coronary artery disease, and should be continued indefinitely unless absolutely contraindicated. The only indications of calcium channel blockers in the setting of acute myocardial infarction include: Intolerance to beta blockers, Post-infarction angina refractory to beta blockers and nitrates, and Rapid atrial fibrillation with contraindications to beta-blocker use (COPD, pulm. disease) Peripheral Edema is a well-known side effect of calcium antagonist therapy. It is more common with dihydropyridine agents (e.g. nifedipine, amlodipine), but also occurs in 2 to 15% of patients taking diltiazem [cardizem]. The exact mechanism of calcium antagonist-associated edema is not known; arteriolar dilatation seems to be responsible for increased interstitial fluid accumulation in these patients. ACUTE PERICARDITIS Acute pericarditis (infarct associated or infarction pericarditis) can occur within one to four days as a direct complication of a transmural myocardial infarction. The recurrence of chest pain three days after a myocardial infarction, which gets worse with position changes and deep inspiration, is suggestive of infarction pericarditis. It is usually a clinical diagnosis, and is supported by the presence of pericardial

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friction rub and EKG changes of pericarditis (sinus tachycardia, diffuse ST segment elevations with PR segment depression). A pericardial rub is usually heard over the left sternal border and can be present during any of the phases of the cardiac cycle. It is heard as a superficial scratchy or grating sound, which gets more pronounced when the patient leans forward. The EKG changes of pericarditis are not always seen, but usually resemble that of an acute myocardial infarction. INFARCTION PERICARDITIS Is seen less frequently in patients with early and complete reperfusion. It is usually a transient episode and does not affect the management of acute myocardial infarction, unless it is complicated by a large pericardial effusion or tamponade. It should be managed with close clinical observation and adequate pain control. Nonsteroidal anti-inflammatory medications (NSAIDs) are effective in alleviating the pain associated with acute pericardial inflammation, although there are some concerns that they may increase the risk of myocardial rupture after a transmural MI. D/Ds: 1. Chordae Tendineae Or Papillary Muscle Rupture is a life threatening mechanical complication of an acute myocardial infarction. It usually occurs two to seven days after the infarction and causes acute hemodynamic instability. Patients also develop acute pulmonary edema. 2. Dresslers Syndrome, or post-cardiac injury syndrome, occurs in patients with myocardial infarction and after cardiac surgery. It is an autoimmune mediated syndrome, which usually develops weeks to months after an acute MI. It usually presents with fever, leukocytosis, pleuritic chest pain, and a pericardial rub. 3. A Left Ventricular Aneurysm usually occurs as a late complication of a transmural myocardial infarction (usually a large anterior wall MI). It may result in heart failure, ventricular arrhythmias, or peripheral arterial embolization due to the formation of a left ventricular thrombus. It develops over a longer period of time, and is usually not associated with chest pain. Persistent ST elevation can be present in these patients. Sinus Bradycardia is commonly seen as a complication of an inferior wall myocardial infarction. It is usually present transiently, immediately after or within the first six hours, and resolves within 24 to 48 hours of acute myocardial infarction. Most of the episodes are asymptomatic, and resolve without any therapy or intervention. BUT: Active intervention is required in patients with sinus bradycardia after myocardial infarction, if the patient exhibits signs and symptoms of hemodynamic compromise. The definite treatment is by reperfusion of the infarcted myocardium, either with thrombolysis or percutaneous transluminal coronary angioplasty (PTCA). If bradycardia persists after reperfusion, the patients can still respond to the administration of intravenous Atropine. VERY HD UNSTABLE: Temporary transvenous cardiac pacing is usually required in patients with persistent bradycardia and hemodynamic instability after myocardial infarction, despite the above measures. Recent Myocardial Infarction And Atrial Fibrillation are two most common causes of arterial thromboembolism. The single most important step in the early management of the patients with acute arterial occlusion diagnosed by history and physical examination is immediate IV heparin therapy followed by continuous heparin infusion. Heparin therapy will prevent further propagation of thrombus, and inhibit thrombosis distally in the arterial and venous systems due to low flow and stasis. Sexual Activity After MI: An important issue for many patients after a myocardial infarction is when sexual activity can be safely resumed.Therefore. this should be addressed in all sexually active patients before hospital discharge. A consensus panel concluded that patients resuming sexual activity 6 weeks after an uncomplicated myocardial infarction are at low risk for future myocardial events.

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On the other hand, those resuming sexual activity within six weeks are at intermediate risk, and those resuming activity within two weeks are at high risk. Patients with complications such as post-infarction chest pain, evidence of arrhythmias, or heart failure are also at intermediate or high risk Patients at intermediate risk should receive further evaluation and subsequent reclassification into the low-risk or high-risk category, while patients at high risk should be stabilized with appropriate therapy before resuming sexual activity. Consultation with a cardiologist prior to resuming sexual activity is recommended in all high-risk patients RADIONUCLIDE VENTRICULOGRAPHY [RVG] The anthracyclines (doxorubicin, daunorubicin, idarubicin, epirubicin, and mitoxantrone) are the most common cause of cardiovascular complications in cancer patients. Patients who are about to receive such cardiotoxic chemotherapy are therefore recommended to undergo baseline testing and serial reevaluation of systolic function to identify early signs of cardiotoxicity. Noninvasive serial monitoring of cardiac function with radionuclide ventriculography (RVG) has been the most effective way to detect early toxicity and reduce the risk of anthracycline toxicity. Radionuclide ventriculography [also known as radionuclide angiography (RNA) or multiple-gated cardiac blood pool imaging (MUGA scan)] is performed by labeling a patients red cells with a radioactive tracer and measuring radioactivity over the anterior chest with a gamma camera. It is the ideal and most reproducible test for providing longitudinal quantitative assessment of LV systolic function in patients receiving doxorubicin or other anthracyclines. It should be used when detection of slight changes in the ejection fraction are of importance, such as during chemotherapy, before and after cardiac transplantation, and severe CHF.

HYPERTENSION

According to the new JNC VII guidelines, thiazide diuretics are the initial drugs of choice for the treatment of essential hypertension. Approximately 90% of patients with secondary HTN will have an unidentified cause. Of the remaining, around 3% will be due to renovascular HTN. Other less common causes account for less than 1% each, and are comprised of the following: primary hyperaldosteronism, drug-induced HTN, acute stress, and renal parenchymal disease. Abdominal or flank bruits are present in 50% of the patients with renovascular HTN. This makes this clinical finding the most common and expected clinical finding in a patient with suspected secondary HTN. Almost all guidelines recommend non-pharmacologic measures that can be preventive, adjunctive or sometimes definitive in the treatment of hypertension. Weight loss enhances the effect of anti-hypertensive drugs. It is the single most effective nonpharmacologic measure to decrease blood pressure in overweight individuals, and it is believed to reduce the overall cardiovascular risk in such patients. Note: Smoking cessation is an important component of lifestyle modification that reduces the risk of future cardiovascular events. Ischemic heart disease is the most common cause of congestive heart failure (CHF), especially dilated cardiomyopathy, in the United States. Approximately 50 to 75% of the patients with heart failure (HF) have coronary disease as the etiology. Other known etiologies are: hypertension (13%), valvular disease (10-12%), renovascular disease, and very rare causes, such as obstructive sleep apnea, myocarditis, alcohol or cocaine abuse, etc. In a new case of CHF with unknown etiology, efforts must first be made to rule out the presence of coronary lesions which may be corrected by an angioplasty. Congestive heart failure is a clinical syndrome that results from impaired or inadequate ventricular emptying (systolic dysfunction) or impaired ventricular relaxation (diastolic dysfunction). It is characterized by specific symptoms that are either due to reduced cardiac output (fatigue, weakness) or excessive fluid retention (peripheral or pedal edema, dyspnea).

CONGESTIVE HEART FAILURE

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 All symptoms are exacerbated by exertion, and the degree of these symptoms helps in assessing the severity of heart failure. Heart failure is primarily a clinical diagnosis and is based on a detailed history and physical examination. A detailed history and physical examination can also provide clues to the specific cause of heart failure. Major Criteria the presence of paroxysmal nocturnal dyspnea, orthopnea raised jugular venous pressure pulmonary rales presence of third heart sound increased cardiac silhouette pulmonary vascular congestion on chest x-ray.m Minor Criteria presence of bilateral lower extremity edema nocturnal cough, dyspnea on exertion tachycardia presence of pleural effusion,hepatomegaly

(The diagnosis of heart failure is based on the presence of two major criteria or

one major and two minor criteria, provided the minor criteria cannot be explained by the presence of any concurrent medical illness.)
Chest Radiograph Findings suggestive of congestive heart failure include cardiomegaly, pulmonary vascular congestion (especially in the upper lobes), Kerley B lines and bilateral pleural effusions. The presence or absence of such findings will help to differentiate heart failure from dyspnea secondary to a primary pulmonary pathology. Plasma B type natriuretic peptide levels are useful at times to differentiate between cardiogenic versus non-cardiogenic causes of dyspnea. Rupture Of Chordae Tendineae should be suspected in healthy individuals who develop flash pulmonary edema (heart failure) associated with an acute mitral regurgitation. The differential diagnosis of this condition includes infective endocarditis, papillary muscle rupture secondary to ischemia, and mitral valve rupture secondary to trauma. Ace inhibitors are the main therapy for CHF. They are indicated even in the asymptomatic phase. Although there is currently insufficient data to show its benefits to the mortality rate of African-Americans and women, their use in CHF is always recommended. The only reasons for not giving ACE inhibitors are: (1) Poor tolerance to the drugs (presence of severe adverse effects) and (2) The presence of contraindications, such as renal failure (Creatinine greater than or equal to 3 mg/dL) or hyperkalemia) Hydralazine and isosorbide combination is frequently used in the management of congestive heart failure in patients intolerant of ACE inhibitors. - Patients should be informed regarding the possible adverse reactions that may result from the use of these drugs, and instructed to stop the medication if they develop any of these reactions. The development of drug-induced lupus-like syndrome: -has been associated with the use of hydralazine. -Other drugs that have been associated with lupus include procainamide, penicillamine, isoniazid, minocycline, diltiazem, methyldopa, chlorpromazine, and interferon-alfa. -Patients with drug-induced lupus can develop a variety of flu-like symptoms such as fever, malaise, arthralgias, myalgias, and maculopapular facial rash. They can also develop lymphadenopathy, splenomegaly, pleurisy, and pericarditis. An important immunological marker of drug-induced lupus is the presence of antihistone antibodies.

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REMEMBER: All patients with flash pulmonary edema of unknown etiology should be evaluated with an Echocardiogram. Patients with acute pulmonary edema are initially managed with oxygen, morphine and loop diuretics (IV furosemide). The two most commonly used antihypertensive agents in the management of hypertensive crisis complicated by acute pulmonary edema are => IV nitroglycerine and IV nitroprusside. MARFANS Marfan or Ehlers-Danlos syndrome must be suspected in patients with connective tissue abnormalities and an acute mitral regurgitation secondary to chordae tendineae rupture, although a primary, preexisting mitral valve prolapse (MVP) is the most common cause. Some cases may be idiopathic (individuals who experience rupture of the chordae tendineae without previous MVP or connective tissue disease), but an etiology can be found in most occasions. CARDIAC RISK FACTORS Diabetes mellitus is the single most important predictor of adverse cardiovascular outcomes, especially in women. It is considered to be an equivalent of coronary heart disease (CHD). The role of glycemic control in the development of macrovascular disease in patients with type-2 diabetes is not firmly established. Hypertension is a well-established risk factor. The blood pressure should be kept below 130/85 mmHg in diabetics, unlike non-diabetic individuals whose target blood pressure is below 140/90 mmHg. Smoking is an important modifiable risk factor. The risk of cardiovascular events declines rapidly after smoking cessation, and approaches that of non-smokers in several years MULTI FOCAL ATRIAL TACHYCARDIA Multifocal or multiform atrial tachycardia (MAT) is characterized by the presence of: 3 or more P waves of different morphologies The QRS complexes are narrow While the PR segments and the R-R intervals are variable The heart rate can reach up to 200 beats per minute. MAT is usually secondary to the following conditions: 1) Hypoxia 2) Chronic obstructive pulmonary disease (COPD) 3) Hypokalemia 4) Hypomagnesemia 5) Coronary/ hypertensive/ valvular disease 6) Medications (i.e., theophylline, aminophylline, isoproterenol) Treatment M A T: 1. Correct cause: Do ABGs because Hypoxia and COPD are the most common etiologies that affect mainly elderly patients. -Therapy is aimed at correcting the underlying cause. 2. If the patient fails to improve >>electrolyte abnormalities (e.g., hypokalemia or hypomagnesemia) should be wanted. If therapy is not effective and there are no contraindications, beta-blockers can be used successfully. In patients with asthma or COPD, verapamil is the drug of choice. SVT and sinus tachycardia are the most frequent types of tachyarrhythmias. Narrow and regular QRS complexes, and absent P waves suggest supraventricular tachycardia. Narrow and regular QRS complexes, and presence of P waves Sinus tachycardia WPW SYNDROME can be identified in around 0.2% of the population. It is characterized by a short PR interval (less than 0.12sec), a delta wave at the beginning of the QRS complex, QRS duration of 0.12sec or wider, and non-specific ST segments or T wave abnormalities. Although WPW Syndrome is not common, its diagnosis is important because it can present as SVT. If verapamil or beta-blockers are given, AV nodal conduction will be slow, and the accessory pathway conduction will increase.These can lead to ventricular fibrillation (especially if the patients already have atrial fibrillation) and death.

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HEARTBLOCKS: -In comparison to Mobitz I, second-degree AV Block (Wenckebachs), the PR does not prolong progressively, {PR is fixed] but QRS complexes are suddenly lost periodically -Mobitz II AV Block can cause dizziness, episodes of syncope, or transient altered mental status, thus explaining the symptoms of the patient. Because Mobitz II can progress to third-degree AV Block, it needs to be managed with a permanent pacemaker. Even if the patient is asymptomatic, the AHA/ACC (American Heart Association/American College of Cardiology) consensus advises the use of a permanent pacemaker inserted through a venous access. NONSUSTAINED VENTRICULAR TACHYCARDIA Is defined as the presence of three or more consecutive ventricular beats with a heart rate greater than 120 beats/min, and with the episode lasting for less than 30 seconds. It is seen most commonly in patients with some form of structural heart disease, possibly because structural abnormalities lead to ventricular arrhythmia. Some structural abnormalities that can lead to nonsustained ventricular tachycardia include scarred myocardium from prior myocardial infarctions (coronary artery disease), ventricular hypertrophy (LVH or hypertrophic obstructive cardiomyopathy), dilated left ventricle (dilated cardiomyopathy), and valvular abnormalities such as mitral valve prolapse. Although nonsustained ventricular tachycardia can also be seen in patients without any evidence of structural heart disease, it is important to recognize that structural heart disease is the most common cause, and a 2D-echocardiogram and stress test should be obtained to rule out ischemia. Patients with multiple risk factors for developing cardiac arrhythmias need proper evaluation for possible implantable cardiac defibrillator placement to prevent sudden cardiac death. ATRIAL FIBRILLATION Treatment of atrial fibrillation in a hemodynamically stable patient is different from one who is unstable. 1. If the patient is hemodynamically unstable (low BP, patient not responding to commands), the treatment of choice is electrical cardioversion. 2. If the patient is hemodynamically stable, the atrial fibrillation has to be categorized first as either an acute or a chronic process. i. If it is an acute process, the patient may undergo either Cardioversion [electrical or pharmacological with anti arrhythmic drugs class III agents (amiodarone, sotalol, ibutilide, etc.). Or Rate control [B-blocker or CCB] to convert his arrhythmia to sinus rhythm. [If > 48 hrs, cardioversion need 1 month of anticoagulation in high risk pt] ii. If it is a chronic process, then the patient should be managed with Rate control and Anticoagulation via heparin/Warfarin. Cardioversion -can be either electrical or chemical. Electrical cardioversion is indicated in hemodynamically unstable patients. Synchronized cardioversion (electrical shock administered in synchrony with the P wave) is the procedure of choice. Electrical cardioversion should not be performed without 3-4 weeks of anticoagulation first in chronic atrial fibrillation (> 48 hours), as the risk of embolization is high. -The required joules are about 100200 joules. Atrial fibrillation is generally more resistant to convert to normal sinus rhythm than atrial flutter, and the energy required is much higher.If you choose to do chemical cardioversion, the drugs of choice are class III agents (amiodarone, sotalol, ibutilide, etc.). Lone Atrial Fibrillation in a patient younger than 60 years of age and without structural or functional cardiac abnormalities [CHF, valvular disease] does not increase the risk of stroke. However, small studies suggest that there can be some risk, especially if the patient has other risk factors, such as advanced age, diabetes, or hypertension. For this reason, ASA Aspirin is recommended as prophylactic therapy. The risk of anticoagulation with Coumadin outweighs the benefits in this setting.Amiodarone interacts with Warfarin, prolonging its effect and increasing the risk of bleeding. Its clinical response is predictable; it is known that the Warfarin dose needs to be decreased about 25% in order to avoid over coagulation.

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STROKES AND WARFARIN USE: The use of FFP or intravenous vitamin K is only necessary if the patient is bleeding or has an INR greater than 20. If the INR is supratherapeutic, but not higher than 5, it is enough to hold the Coumadin or decrease its dose. All other cases of excessive anticoagulation with Coumadin can be successfully managed with oral vitamin K TCA TOXICITY: TCA overdose is the leading cause of hospitalization and death. The signs of TCA overdose include hypotension, anticholinergic effects, CNS manifestations, and cardiac arrhythmias. Cardiotoxic effects are responsible for most of the mortality in patients with TCA overdose. TCAs inhibit fast sodium channels, which result in slowing of the phase 0 depolarization in The His Purkinje tissue and the myocardium. This may lead to QRS prolongation and reentrant arrhythmias, like ventricular tachycardia, ventricular fibrillation, and torsades de pointes. Sodium bicarbonate is the most effective agent for the management of TCA-induced cardiotoxic effects. Lidocaine is the antiarrhythmic drug of choice for TCA-induced ventricular dysrhythmias. VALVULAR DISORDERS: Mitral Stenosis is a narrowing of the outflow tract from the left atrium to the left ventricle, resulting in increased pressure in the left atrium, pulmonary vasculature, and right side of the heart. It is more common in women, and is most commonly linked to a remote episode of rheumatic fever, though congenital mitral stenosis may be found as well. On physical examination, mitral stenosis produces a diastolic thrill palpable over the apex and a lowpitched, rumbling diastolic murmur best heard over the apex when the patient is lying in a left lateral decubitus position. Mitral Regurgitation causes an apical holosystolic murmur, and is most often secondary to myocardial infarction, mitral valve prolapse, rheumatic heart disease, or coronary artery disease. Aortic Stenosis causes a crescendo-decrescendo systolic murmur with a normal S1, a diminished A2, and a paradoxical splitting of S2. It is most often secondary to senile degenerative calcification, or congenital malformation. An aortic valve area of less than 1.0 cm2 is considered severe stenosis. The onset of symptoms markedly affects the prognosis in patients with aortic stenosis; therefore, prompt intervention is recommended in patients who have cardinal symptoms of aortic stenosis (dyspnea of heart failure, anginal pain, and syncope). Aortic valve replacement is associated with marked reduction in symptoms and mortality in patients with symptomatic aortic stenosis, and is considered the treatment of choice. Critical aortic stenosis and angina at rest >> Highest risk factors for peri-operative cardiac risk Aortic Insufficiency causes a diastolic murmur best heard adjacent to the sternum in the second to fourth intercostal space. It is most often secondary to infective endocarditis, congenital malformation, connective tissue disorders, or rheumatic heart disease. Pulmonic Stenosis causes a systolic crescendo-decrescendo ejection murmur in the left upper sternal border. It is most often secondary to congenital malformation, rheumatic heart disease, or carcinoid. COARCTATION OF THE AORTA: This is usually associated with a congenital bicuspid aortic wall. In a previously undiagnosed patient, the classic presenting sign is hypertension. Most patients are asymptomatic unless severe hypertension is present, which can lead to headaches, epistaxis, heart failure, or dissecting aneurysm. The major clinical manifestation in children and adults with COA is a difference in the systolic blood pressure between the upper and lower extremities. In most cases, the diastolic blood pressures are similar. The classic findings are hypertension in the upper extremities, diminished or delayed femoral pulses, and lower unobtainable arterial blood pressures in the lower extremities.

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Magnetic resonance imaging (MRI) is the best noninvasive modality to diagnose COA because it can usually clearly define the location of severe coarctation of the aorta. MRI can also detect associated cardiac abnormalities and can be used for serial follow-up after surgical repair or balloon angioplasty. DELIRIUM: Acute infections are a common cause of delirium, especially in elderly patients being admitted to the hospital. An important goal of treatment in such patients is to avoid the use of medications that can potentially worsen the acute delirious state. -Diuretics, ACE inhibitors, spironolactone, beta-blockers, and digoxin are all a part of standard therapy for patients with heart failure or cardiomyopathy due to any cause. ACE inhibitors (lisinopril) have consistently been shown in multiple, large, randomized trials to have a significant beneficial effect on patients with heart failure. They have a very low incidence of central nervous system (CNS) side effects, and do not cause worsening of confusional states or delirium. Lisinopril can be safely started in this patient without the risk of exacerbating his confusion and agitation. Digoxin is a cardiac glycoside frequently used in patients with congestive heart failure due to systolic dysfunction and atrial dysrhythmias; however, its use has been associated with significant CNS side effects. These include blurred vision, dizziness, confusion, mental disturbances, anxiety, delirium, and hallucinations. Its use should be avoided in patients with ongoing acute mental confusion or delirium. Spironolactone is a useful adjunct in the management of patients with congestive heart failure, especially in patients with a low ejection fraction; however, its use can also cause CNS disturbances such as drowsiness, lethargy, and mental confusion. Digoxin toxicity is characterized by nausea, vomiting, anorexia, fatigue, confusion, visual disturbances, and cardiac abnormalities. Verapamil, quinidine, and amiodarone can potentially cause digoxin toxicity. SYNCOPE: Vasovagal Syncope is associated with prodromal symptoms of nausea, lightheadedness, pallor and diaphoresis. It usually occurs when the patient is erect, and recovery occurs in the supine position. Patients are usually young and otherwise healthy. Precipitating events include prolonged standing, exertion, venipuncture, or a painful stimulus. Cardiovascular Syncope is due to arrhythmia or obstructive lesions such as aortic stenosis or HOCM. Syncope may be associated with a prodrome of palpitations. Arrhythmias usually occur without warning, with the patient in a supine or resting position, and lasts for a few seconds. Patients will have risk factors such as left ventricular dysfunction, prior myocardial infarction or conduction system disease. Physical examination may show the murmur of aortic stenosis or HOCM. EKG/Holter monitoring may detect an arrhythmia. Neurological Syncope is due to atherosclerotic disease of the cerebral circulation, and is associated with a history of focal neurological deficits. DDs: A seizure may mimic syncope; however, patients usually have a history of tonic-clonic movements, urinary or fecal incontinence, and a postictal state. Jerky movements similar to tonic-clonic movements can occur in any patient with syncope, but the postictal confusion is very unlikely with other conditions except seizures. ORTHOSTATIC HYPOTENSION: Orthostatic hypotension is defined as a significant drop in blood pressure upon assuming a standing position, causing symptoms of cerebral hypoperfusion. Orthostatic hypotension is diagnosed if there is a fall of at least 20 mmHg of systolic blood pressure, or a fall of at least 10 mmHg of diastolic blood pressure, within two to five minutes of standing from a supine or sitting position. A fall in the blood pressure with/after standing or eating (postprandial hypotension) is a commonly encountered clinical situation, especially in the elderly population. It is usually caused by autonomic dysfunction or failure, or intravascular volume depletion from various causes. Almost all the patients suffering from orthostatic hypotension experience a sensation of dizziness or lightheadedness, especially after rapid changes in position (i.e. from supine or sitting to standing position). In some severe cases, it can lead to a fall (presyncope), angina, acute stroke, or loss of consciousness (syncope).

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-The symptoms of orthostatic hypotension are primarily caused by a rapid decrease in cerebral perfusion. There are multiple causes of orthostatic hypotension in elderly patientsThe two major mechanisms of orthostatic hypotension are autonomic dysfunction/failure and intravascular volume depletion. Autonomic dysfunction is caused by various neurological disorders, systemic disorders (diabetes mellitus, amyloid neuropathy) or medications. Common drugs causing orthostatic hypotension include antihypertensives, antianginal drugs, vasodilators (nitrates, calcium channel blockers), antidepressants (especially tricyclic antidepressants), and opiate analgesics. When a patient stands up from a supine position, there is pooling of 500 to 1000 cc of blood in the lower extremities and mesenteric circulation. This causes a decrease in the venous return to the heart, which decreases ventricular filling pressures. A drop in the cardiac output and blood pressure occurs, causing decreased cerebral perfusion. This is a normal response seen in all patients, and is counteracted by a reflex increase in sympathetic discharge, which causes vasoconstriction and an increase in cardiac output. Nitrates may cause excess vasodilation, which could reduce the venous return to and cardiac output of the heart. An excess drop in blood pressure and cerebral perfusion may occur, and lead to symptoms of orthostatic hypotension. Rx: The first step in reducing the frequency and symptoms of orthostatic hypotension is to recognize and remove the potential offending medications; therefore, isosorbide nitrate should be discontinued, and the patient should be observed for any recurrence of symptoms. Fludrocortisone is a synthetic mineralocorticoid. It is used as a first-line agent for most patients whose orthostatic hypotension is not controlled by nonpharmacologic measures. It causes an increase in salt and water retention, which increases the effective circulating blood volume. CARDIAC TEMPONADE: Pericardial effusion may occur in response to any cause of pericarditis or from malignancies. The pericardial effusion may develop slowly or rapidly. However, sudden filling of the pericardial space with fluid can have catastrophic consequences by limiting ventricular filling. Patients with pericardial tamponade often complain of shortness of breath. It is accompanied by typical physical signs and symptoms that arise from the limited filling of the ventricle. The classic Becks triad is hypotension, muffled or distant heart sounds, and elevated jugular venous pressure. Arterial systolic blood pressure normally drops 10 -12 mmHg with inspiration. Marked inspiratory drop in systolic blood pressure (> 20 mmHg) is an important physical finding in cardiac tamponade, but can also be seen in severe obstructive pulmonary disease and constrictive pericarditis. In pericardial tamponade, low limb voltage with alternating size of QRS complex due to swinging of the heart is seen. CXR in cardiac tamponade will show an enlarged cardiac silhouette. When a chest x-ray shows an enlarged heart with pulmonary edema, congestive heart failure should be suspected. In cardiac tamponade, usually, there is no pulmonary edema. Cardiac tamponade is a surgical emergency, and an ECHO should be obtained urgently. The ECHO will reveal the large pericardial effusion, with prominent collapse of the right atrium and ventricle during diastole. Cardiac catheterization can confirm the diagnosis by showing equalization of diastolic pressures in all chambers. However, if the patient is collapsing, one should not wait for an ECHO. Rapid pericardiocentesis is life saving. MECHANICAL VALVES: The following are the recommendations from the Sixth ACCP Consensus Conference for a mechanical valve: A goal INR of 2.5 (range 2 to 3) is recommended for patients with AVR with bileaflet mechanical valve, provided that the patient is in sinus rhythm, left atrium is of normal size, and the left ventricular ejection fraction is normal, as in this patient. A goal INR of 3 (range 2.5 to 3.5) is recommended for patients with MVR with bileaflet mechanical valve or for patients with a bileaflet mechanical aortic valve who have atrial fibrillation

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A goal INR of 3 (range 2.5 to 3.5) in combination with low dose aspirin is recommended for patients with mechanical prosthetic valves who suffer a systemic embolism despite adequate anticoagulant therapy. However, more data is coming in favor of a higher level of anticoagulation (target INR >3.0) for both aortic and mitral prosthetic mechanical valve

PULMONOLOGY

TUBERCULOSIS: Even though it is not common, a new pleural effusion in a patient already on anti-tuberculosis treatment may occur and must be studied, because this can progress despite the clinical improvement of the patient. There is no need to change therapy, unless there is proof of a new infection or drug resistance. Some authors advocate the use of steroids in this setting, but this is not a universally accepted practice. CHRONIC EOSINOPHILIC PNEUMONIA (CEP): Chronic Eosinophilic Pneumonia (CEP) is the most common eosinophilic pneumonia in the USA. Patients with chronic eosinophilic pneumonia present with systemic symptoms such as fever, malaise, anorexia, and weight loss for several weeks to months. Pulmonary symptoms include cough and breathlessness. Sometimes, patients may give a history of bronchial asthma or allergic rhinitis. Chest auscultation shows crackles or wheezing. Chest x-ray reveals peripheral infiltrates that are the "photographic negative" of pulmonary edema, and this radiographic finding is pathognomonic for the disease. Bronchoalveolar lavage (BAL) that reveals eosinophils greater than 40% is suggestive of the diagnosis. Glucocorticoid therapy results in rapid resolution of the symptoms and radiographic clearing. Acute bronchopulmonary aspergillosis ABPA: This hypersensitivity reaction to Aspergillus antigens is seen in patients with underlying asthma. When the airways of such patients become colonized with Aspergillus, the intense IgE and IgG mediated immune response leads to the characteristic recurrent episodes of fever, malaise, and cough with brownish mucoid expectoration, wheezing, and symptoms of bronchial obstruction. There is no single diagnostic test to confirm the diagnosis of ABPA. The diagnosis is usually made by clinical, radiographic, and immunologic criteria, which include the following: 1. A history of asthma. 2. Immediate skin test reactivity to Aspergillus antigen. 3. Precipitating serum antibodies to Aspergillus fumigatus. 4. Serum total IgE concentration of greater than 1000 ng/mL. 5. Peripheral blood eosinophilia greater than 500 per cubic millimeter. 6. Lung infiltrates, usually involving the upper lobes. 7. Central bronchiectasis. A skin prick test for Aspergillus should be performed initially in all asthmatic patients suspected of having ABPA. If the skin prick test is positive, serum total IgE levels and precipitating serum antibodies to Aspergillus fumigatus should be measured. If the skin prick test is negative, the diagnosis of ABPA is extremely unlikely. Recurrent episodes of airway inflammation and bronchial obstruction in patients with ABPA can lead to bronchiectasis and lung fibrosis; therefore, it is important to diagnose and treat such patients early to reduce the risk of progressive lung damage. Corticosteroids are the mainstay of therapy for patients with ABPA. Treatment with corticosteroids is effective in controlling the episodes of acute inflammation and preventing progressive lung fibrosis. The clinical response to treatment is measured by the reduction of serum total IgE concentration, clinical improvement and resolution of radiographic findings.

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Churg Strauss syndrome (CCS): is a multisystem vasculitic disorder of unknown etiology that affects the skin, kidney, nervous system, lungs, gastrointestinal tract, and heart. It is characterized by allergic rhinitis, asthma, and prominent peripheral blood eosinophilia. A CSS-like syndrome has been noted in patients who have been successfully treated for chronic steroiddependent asthma with leukotriene receptor antagonists. Up to 75% of the patients have evidence of peripheral neuropathy. The disease is severe, and requires treatment with glucocorticoids and sometimes with immunosuppressants. There have been significant reports which associate the use of leukotriene inhibitors with Churg-Strauss vasculitis. To date, there are more than 28 cases of Churg Strauss vasculitis associated with its use. ARDS: ARDS can occur secondary to sepsis, pneumonia, severe trauma, burns, drowning, or pancreatitis. The presentation is sudden. Oxygen requirements increase very rapidly. Criteria for ARDS diagnosis are: 1. A pulmonary capillary wedge pressure less than 18 mmHg 2. PaO2 to FiO2 ratio of 200 mmHg or less, regardless of the PEEP level 3. Diffuse bilateral infiltrates on chest x-ray In contrast to heart failure, patients with ARDS will typically have clear lungs on exam but will show diffuse, bilateral infiltrates on the chest x-ray results. The management of ARDS through mechanical ventilation involves the interplay of the following settings: 1. PEEP (positive pressure at the end of expiration) 2. Oxygen concentration 3. Tidal volume The PEEP attempts to expand the collapsed alveoli in ARDS in order to decrease the high oxygen requirement. It also prevents the development of atelectasis. Although the physiologic PEEP is around 5 cmH2O, the mechanical ventilator settings of ARDS patients are usually around 9 cmH2O. Oxygen is set at high concentrations, while the tidal volume is set to the lowest possible value. ARDS is associated with a mortality rate of 35-40%. Among the different strategies, mechanical ventilation that delivers lower tidal volumes (< 6 ml/kg) and limits plateau pressure (< 30 CmH2O) has been shown to be relatively more effective. Studies comparing the effects of low tidal volume and limited plateau pressure to that of high tidal volume and plateau pressure have shown a significant reduction in mortality in the first group (32% vs. 40%). Mechanical ventilation in the management of ARDS is a dynamic process. When the patient improves, FiO2 and PEEP should be decreased stepwise, as tolerated. The objective is to maintain the patient on the following settings: a PaO2 more than 60mmHg, oxygen saturation more than 90%, and a normal or slightly acidic pH (permissive hypercapnia). Once this is achieved, the patient should be weaned as soon as possible, in order to avoid complications such as barotrauma, ventilator-associated pneumonia, prolonged sedation, and hypotension. PULMONARY EMBOLISM: Pulmonary thromboembolism is difficult to diagnose, and usually requires the combination of several diagnostic modalities. It is therefore important to know the order in which to order these diagnostic tests. The first test that is usually employed is ventilation/perfusion scanning. If the results reveal the classic pattern of mismatched perfusion; it is advisable to proceed directly with treatment. If the scan is normal, significant pulmonary thromboembolism should be ruled out; however, ventilation/perfusion scanning results are inconclusive in a substantial number of patients. Since the usual source of emboli causing this condition is deep venous thrombosis (DVT) of the lower extremities, the next best step in this case is Venous ultrasonography to reveal DVT or CT angiogram of the chest. A diagnosis of DVT makes the probability of pulmonary thromboembolism very high, and warrants immediate treatment.

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Pulmonary angiogram is the gold standard test for the diagnosis of pulmonary embolism (PE); however, this procedure is rarely being performed since it is invasive and CT angiogram is readily available. Mild fever and leukocytosis can be seen in the setting of PE. Rx:Pulmonary embolism (PE) is generally treated by starting the patient on heparin first, and then adding warfarin (Coumadin) after 24-48 hours. The recommended duration of pharmacotherapy depends on the setting in which the PE occurred, as indicated below: 1. Occurrence of PE in the setting of reversible risk factors (e.g., use of oral contraceptive pills, immobilization, or surgery) should be treated with 3-6 months of warfarin therapy. 2. If the first episode of thromboembolism occurs in a setting that involves an underlying malignancy, anticardiolipin antibody, and antithrombin deficiency, the patient should be treated with at least 12 months of warfarin therapy. 3. Patients with a first episode of idiopathic thromboembolism should be treated for at least six months with warfarin; three months of therapy is inadequate in this patient group. 4. Patients with recurrent thromboembolism or a continuing risk factor should be treated indefinitely. The indications for an inferior vena caval (IVC) or Greenfield filter insertion include patients with: 1. A documented recurrent venous thromboembolism while on therapeutic anticoagulation 2. A recurrent venous thromboembolism and absolute contraindications to anticoagulation 3. A history of massive pulmonary embolism in whom a recurrent episode may be life-threatening 4. Chronic recurrent pulmonary embolism and a history of pulmonary hypertension 5.It is also considered prophylactically in patients with severe chronic obstructive pulmonary disease, cor pulmonale, or a previous history of venous thromboembolism who develop a predisposing risk factor for pulmonary embolism, such as an acute fracture or cancer. A Chest X-Ray should be obtained in all post-operative patients who complain of shortness of breath before performing more specific tests that will determine or exclude the diagnosis of PE. Chest x-ray findings may suggest the presence of PE and may help exclude other chest pathology. Septic Pulmonary Emboli may result from septic thrombophlebitis and/or tricuspid endocarditis. DEEP VEIN THROMBOSIS MANAGEMENT: If first episode of proximal DVT in leg, symptomatic pt => Need Anticoagulation / the primary goal of RX is to prevent clot extension and prevent acute PE! RX: UnFractioned Heparin IV /or LMWH x 5 days and add WARFARIN 24 hr after heparin starting. Heparin continued until INR is in 2.0-3.0 for at least 2 days. If pt is a woman taking HRT => urged to stop HRT and continue WARFARIN for at least 3 months After the 1st thromboembolic event in the presence of a reversible risk factor = should be treated with anticoagulation for at least 3 months After the 1st IDIOPATHIC thromboembolic event [no risk factor] or recurrent thromboembolic event => should be treated for a prolonged period of time. ASTHMA: the allergen most frequently associated with asthma is house dust mites. Cough induced by forced expiration is characteristic of airway hyperreactivity, and is usually suggestive of asthma; however, this presentation has also been described in some patients with COPD who can occasionally have an overlapping condition with asthma. It is important to recognize and initiate early interventions in a patient with acute exacerbation of asthma. Early recognition, rapid assessment and treatment are crucial in preventing significant morbidity and mortality. Measurement of the peak expiratory flow rate with a peak flow meter is an excellent method to assess the degree of severity of airflow limitation, and subsequent serial measurements of the peak flow rate are useful in assessing the response to therapy. The goal of treatment is to rapidly correct the airflow obstruction. This is most rapidly achieved by the administration of inhaled beta-2 adrenergic agonists, either by continuous nebulization or with the use of metered dose inhalers with a spacer. Systemic corticosteroids should also be administered early in the treatment of acute asthmatic exacerbation; however, their effect is usually not apparent in the first few hours. Their use should be preceded or accompanied by inhaled beta-2 agonist therapy.

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In a patient with an acute, severe, asthma exacerbation, it is important to periodically assess the response to initial therapy during the first few hours. Failure to recognize early signs of clinical deterioration and impending respiratory failure is responsible for majority of the morbidity and mortality seen in patients with status asthmaticus. Some of the clues to a patients clinical deterioration and poor outcome include a history of prior intubation, exhaustion or extreme fatigue, diaphoresis, change in consciousness (confusion and drowsiness), use of accessory muscles, presence of suprasternal retractions, depressed respiratory drive, marked tachycardia, pulsus paradoxus, PaCO2 greater than 40 mmHg, and a peak expiratory flow rate less than 25% of the normal predicted. Any patient with the above signs and symptoms of impending respiratory failure should be immediately intubated to secure and protect the airways. Patients with hypoxemia due to an acute asthma exacerbation should be immediately managed with oxygen inhalation, followed by administration of an inhaled beta-2 agonist, which is the mainstay of therapy. Hospital admission for asthma exacerbation is recommended if the peak flow reading is 40-50% lower than the patients baseline, if there are signs of respiratory distress, if oral steroid therapy fails, or if the patients clinical condition worsens. Ipratropium nebulization may be given in the emergency department, but this is not the mainstay of therapy. For any acute exacerbation, oral or parenteral steroid therapy with prednisone, prednisolone, methylprednisolone, or hydrocortisone is essential for therapeutic success. SOLITARY PULMONARY NODULE Solitary pulmonary nodules represent a common clinical problem in the primary care setting. They are usually detected in an asymptomatic patient and present a clinical dilemma for the primary care physician. The clinical and diagnostic workup of a solitary pulmonary nodule is aimed towards differentiating between a benign lesion and a malignant lesion (lung cancer). Some of the factors that suggest a malignant cause of a solitary pulmonary nodule include: Age greater than 50 years, History of smoking or asbestos exposure, presence of another primary cancer elsewhere in the body (malignant melanoma, colon, breast, kidney, testis), Size greater than 3 cm, irregular or speculated borders of the nodule, and certain patterns of calcification within the lesion (eccentric calcification). Another important clue is the growth of the pulmonary lesion over time. Malignant lesions usually have a doubling time of 20-400 days, whereas the doubling time of benign lesions is either less than 20 days (infectious cause) or greater than 450 days. As a general guideline, any solitary pulmonary nodule with the absence of any changes in size over the last two years is strongly suggestive of a benign lesion; therefore, a comparison of the pulmonary nodule on chest x-ray with the previous chest radiographs to document any changes in the size of the lesion is a critical initial part of the diagnostic workup of this patient. A chest CT scan should be obtained to characterize the pulmonary nodule before performing any invasive procedures. It demonstrates the pattern of calcification within the nodule, and identifies any mediastinal lymph node involvement and small pleural effusions. Particular CT scan findings that suggest malignant lesions include an irregular or speculated border and the presence of eccentric, reticular or punctate calcifications within the lesion. Such findings can help distinguish between a benign from a malignant cause of the solitary nodule. BENIGN: Certain patterns of calcification within the pulmonary nodule, as seen on chest x-ray or CT scan, are strongly suggestive of a benign cause of the lesion or nodule. These include popcorn calcifications, concentric or laminated calcifications, central calcifications and diffuse homogenous calcifications. Popcorn calcifications are characteristically seen on radiographic imaging in patients with pulmonary hamartoma. Any patient with a solitary peripheral lung nodule suspicious for malignancy should undergo videoassisted thoracoscopic surgery (VATS) and excisional biopsy of the lesion. This is the procedure of choice in most patients for the removal and definite diagnosis of a peripherally located pulmonary

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nodule. It is a relatively safe procedure and has a low risk of complications if performed by a skilled surgeon. SARCOIDOSIS: Sarcoidosis is a chronic granulomatous disease seen more frequently in young African-American patients. It is characterized by the formation of non-caseating granulomas in various involved tissues and organs. It usually involves the lungs, but can also involve other organ systems including the skin, lymph nodes, liver, spleen, eyes, exocrine glands (salivary and lacrimal glands), heart, kidneys, and central nervous system. It is usually asymptomatic and is frequently detected as an incidental finding on a routine chest x-ray. Patients with pulmonary sarcoidosis usually present with cough, chest pain, or dyspnea. Some other nonspecific features include generalized weakness, lethargy, fever, and weight loss. Sarcoidosis- Initial Test/Screening: The chest radiograph in patients with pulmonary sarcoidosis classically reveals Bilateral hilar adenopathy with or without right paratracheal lymph node enlargement Serum ACE levels are elevated [screening test] in more than half of the patients with sarcoidosis, but this is a nonspecific finding. Although serum ACE levels have little role in diagnosing the disease, these may prove to be useful in monitoring disease activity. The biopsy of accessible tissues [not erythema nudosum] for confirmation of the diagnosis is not required in an asymptomatic patient with the typical history and chest x-ray findings. Hypercalciuria occurs in 50% of cases of sarcoidosis. Macrophages in the sarcoid granulomas produce calcitriol, which is the active form of vitamin D, and as a result, calcium absorption from the gut increases. Nephrocalcinosis may result in chronic renal failure (CRF) and end stage renal disease. Hypercalcemia occurs in 10-20% of cases of sarcoidosis [high vitamin D]. Thrombocytopenia may occur in patients with sarcoidosis. Definitive diagnosis of sarcoidosis can be made from the biopsy of the easily accessible lesions, including: 1. Any palpable lymph node 2. Skin lesion [except erythema nodosum] 3. Enlarged parotid 4. Lacrimal glands NEXT STEP IF NOT ACCESSIBLE LESION LUNG BIOPSY with fiberoptic bronchoscopy and transbronchial lung biopsy is the procedure of choice. Nerve and liver biopsies are not recommended unless all other approaches fail. Hypercalcemia, non-caseating granulomas, depressed-cell mediated immunity, and activated humoral immunity are characteristic features of sarcoidosis.Asymptomatic pulmonary sarcoidosis generally does not need treatment. Hilar adenopathy associated with erythema nodosum represents a very favorable variant of sarcoidosis that is associated with a high rate of spontaneous remission and good prognosis. Rx: Symptomatic pulmonary disease is usually an indication for corticosteroid therapy in patients with sarcoidosis, especially if it is accompanied by systemic symptoms such as severe fatigue, fever and hypercalcemia. Severe extrapulmonary manifestations of sarcoidosis such as cardiac, ocular and neurologic involvement may require high-dose corticosteroid therapy. Alternative agents (e.g. methotrexate) may be indicated if corticosteroids are not effective or if intolerable side effects of corticosteroid therapy occur. OBSTRUCTIVE SLEEP APNEA: Although there are no specific physical findings consistent with obstructive sleep apnea (OSA), some general observations can contribute to the diagnosis. Truncal obesity and a large neck circumference (collar size > 17.5 inches) are common, and the oropharynx may be visibly "crowded." In some patients, the uvula is enlarged. Systemic hypertension is seen in approximately half of the patients with OSA. Hypothyroidism should be screened for, especially in older patients or those with symptoms suggestive of hypothyroidism (e.g., constipation and hair loss, as seen in this patient). Therefore, physical examination and thyroid function testing should be performed next.

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Sleep studies are typically performed to confirm the diagnosis of OSA.Polysomnography in particular is considered the gold standard for diagnosis.After completing the physical and laboratory evaluation of the patient, polysomnography is indicated. PRIMARY PULMONARY HYPERTENSION: The diagnosis of primary pulmonary hypertension is made when there is evidence of increased pulmonary arterial pressure in the absence of other identifiable causes. Pulmonary hypertension may be primary or secondary to interstitial lung disease, chronic venous thromboembolism, valvular or myocardial disease, connective tissue disease, or congenital heart disease. All patients with primary pulmonary hypertension should receive anticoagulation therapy because of an increased risk of pulmonary thromboembolism. This increased risk is due to slow pulmonary blood flow, a dilated right heart, and venous stasis. The anticoagulant of choice for this purpose is warfarin, and a target INR of 2 should be achieved. Oral vasodilators prolong survival and provide hemodynamic and clinical benefit in those patients of primary pulmonary hypertension who show vasoreactivity to nitric oxide and other vasodilators. Patients who do not show vasoreactivity may experience an acute cardiopulmonary decompensation if oral vasodilators are used. It is therefore recommended that all patients with primary pulmonary hypertension be tested for vasoreactivity before starting therapy with oral vasodilators. Untreated primary pulmonary hypertension can lead to cor pulmonale. COPD: It is important to recognize that some patients with COPD will be oxygen dependent at some point of their disease. Oxygen therapy in this setting will decrease mortality and delay the development of pulmonary hypertension or cor pulmonale as a consequence of chronic hypoxia. The current recommendations to use home oxygen therapy are: 1. PaO2 less than or equal to 55 mmHg or an arterial oxygen saturation (SaO2) less than or equal to 88 percent. 2. PaO2 between 56 to 59 mmHg (or) a SaO2 of 89 percent, if there is evidence of cor pulmonale, right heart failure, or erythrocytosis (hematocrit above 55 percent). HIGH YIELD: Recurrent pneumonia in an elderly smoker may be the first manifestation of bronchogenic carcinoma. Flexible bronchoscopy is a primary diagnostic tool to evaluate patients with persistent or nonresolving pneumonia or pulmonary infiltrates (HRCT scan is an alternative, but it does not provide confirmatory information). The best diagnostic test for endobronchial obstructive lesions is flexible bronchoscopy. If the question had asked for the next best step in management, then the answer would have been CT scan. Syndrome of inappropriate antidiuretic hormone (SIADH) is associated with normovolemic hyponatremia and can be caused by small cell carcinoma of the lung. Water restriction (with the possible inclusion of salt administration) is the preferred means of correcting mild to moderate hyponatremia associated with SIADH. POSTOPERATIVE COMPLICATIONS: Are a common cause of perioperative morbidity and mortality. Some of the factors that increase the risk of developing postoperative complications are upper abdominal and thoracic surgeries, underlying chronic lung disease, a history of smoking within the last eight weeks, baseline PaCO2 > 45 mmHg, duration of surgery of more than 3-4 hours, and the use of general anesthesia. The most common complications include atelectasis, bronchospasm, worsening of the underlying lung disease, postoperative pneumonia, and prolonged need for mechanical ventilation. All patients undergoing upper abdominal or thoracic surgery with one or more additional risk factors are at a high risk for postoperative complications. These patients should be the target of risk reduction strategies. Antibiotics should be given prior to surgery only in patients with clinically apparent respiratory infection. These include patients with purulent sputum or a recent change in the color of the sputum.They should not be used routinely in stable COPD patients.

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SILICOSIS: Is the type of neumoconiosis caused by exposure to silica crystals. -There are three patterns of disease: acute, accelerated, and chronic silicosis. High-risk professions include glass making, pottery working, underground mining, and working with abrasives. Pertinent radiographic findings of chronic silicosis are small nodules with predominance in the upper lung lobes. The presence of eggshell calcifications in hilar lymph nodes is a very characteristic finding. For all these reasons, a tentative diagnosis of silicosis in this patient can be made. There is a strong association between silicosis and tuberculosis; therefore, measures such as yearly PPD testing should be taken to prevent tuberculosis in all patients who have developed silicosis

DERMATOLOGY
MELANOMA: It is important to recognize the presence of a melanoma, because excision can be curative if the lesion is identified early. Melanoma lesions are usually asymmetric, with color variegation, and usually more than 5 mm in diameter. An excisional biopsy is the next best step in patients with a suspected malignant melanoma. A complete excision is the treatment of choice. Interferon alfa-2b is used as an adjutant therapy in patients with a high risk of developing metastatic disease. Malignant melanoma most often arises in fair-skinned people who are intermittently exposed to intense amounts of sunlight, especially during childhood or adolescence. Wearing protective clothing will reduce the risk of developing malignant melanoma. While sunscreen usage is of theoretical benefit, it has not been scientifically proven to prevent malignant melanoma. D/Ds: 1. Basal cell carcinoma is usually pink or red in color. It is more frequent in males, and it rarely appears before the age of 40 2. Keratoacanthoma is common on the cheek. It is a low-grade malignancy that pathologically resembles squamous cell carcinoma. It appears as a solitary, firm, round, skin-colored or reddish plaque that develops into a nodule with a central keratin plug. 3. Seborrheic keratosis is rare before the age of 30. It also has a "stuck on" appearance, with a "warty" form 4. Verruca vulgaris has the same warty appearance as seborrheic keratosis, and it is a well-demarcated lesion. ACTINIC KERATOSIS Actinic keratosis is a pre-malignant condition that develops from the sun-damaged (due to its UV component) clone of squamous cells in the skin. Further UV damage to "gene repair mechanisms" in these cells can lead to the development of squamous cell carcinoma (SCC). 1 out of 1,000 cases of AK progresses to SCC, while 60% of SCC arises from AK. Photoaging Photoaging is a phenomenon that arises from intrinsic aging and damage caused by ultraviolet light. While intrinsic aging tends to result in fine wrinkles on an otherwise smooth skin surface, photodamage tends to result in coarse, deep wrinkles on a rough skin surface. Photoaged skin is often marked with actinic keratoses, telangiectasias and brown "liver" spots) Cigarette smokers have been shown to have more and deeper wrinkles than do nonsmokers. Tretinoin is an emollient cream approved by the FDA for reduction of fine wrinkles, mottled hyperpigmentation, and roughness of the facial skin. Tretinoin is also successful in reducing actinic keratoses and in improving the appearance of brown spots, regardless of etiology. D/Ds; 1. Erythrasma is an infection of the skin that occurs most often in intertriginous spaces and is caused by Corynebacterium minutissimum. The appearance of erythrasma includes a confluence of pruritic, reddish

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brown, finely wrinkled papules. The use of a Wood lamp reveals a coral-red fluorescence caused by the Corynebacterium porphyrins. 2. Pityriasis rosea is a self-limited condition of unknown etiology that first manifests as a single primary plaque ("herald patch") with a fine collarette scale. A generalized eruption develops 1 to 2 weeks later, with fine, scaling papules and plaques in the "Christmas tree" distribution. 3. Rosacea is a chronic inflammatory disease that causes erythema of the central face. It first manifests as easy flushing and later results in persistent erythema and telangiectasia. Patients are sensitive to chemical or physical insults and should limit exposure to sunlight. Metronidazole is an antibiotic prescribed for treatment of rosacea 4. Seborrheic dermatitis is a chronic, superficial, inflammatory process that arises in areas rich in sebaceous glands. The condition worsens during infancy and puberty, when the sebaceous glands are more active. In adults with seborrheic dermatitis, erythema with fine scale is evident on the scalp ("dandruff"), eyebrows, eyelids, nasolabial creases, ears, sternal area, axillae, umbilicus, groin, and gluteal crease. Tar-based creams and shampoos are used in the treatment of seborrheic dermatitis. ALOPECIA AREATA: It is a relatively common disease and is characterized by discrete, smooth and circular areas of hair loss over the scalp. There is typically no associated scaling or inflammation present in the area of hair loss. The hair loss usually develops over a few weeks and has a recurring pattern. Most of the patients will have regrowth of the hair in the involved areas over time. The exact etiology of alopecia areata is unknown. An autoimmune process is thought to play at least a partial role in its pathogenesis. This is supported by the finding of T-cell infiltration around the hair follicles and the association of other autoimmune conditions (i.e., pernicious anemia, vitiligo, and thyroid diseases) with alopecia areata. The disease can recur in up to one-third of these patients. Some factors associated with the higher chance of relapse include a longer duration of the disease, a more extensive disease, involvement of peripheral areas, and onset prior to puberty. Rx:-Topical or intralesional corticosteroids are the treatment of choice for patients with alopecia areata. Patient education and information is also the key part of treatment. Patients should be made aware that: (1) The disease is usually benign, (2) They can have multiple relapses in spite of treatment, and (3) Most patients have normal hair growth within the next one to two years even without treatment. They should also be informed that treatment with steroids, either intralesional or topical, can restore normal hair growth but does not cure the disease. After a steroid injection, new hair growth is usually seen in the next four to six weeks. D/Ds: 1. Patients with tinea capitis have an associated scaling and inflammation of the scalp in the areas of hair loss. 2. Localized discoid lupus erythematosus of the scalp causes hair loss, scaling, inflammation, scarring, and hypopigmentation of the skin. There may be associated lesions present over the face or extremities. 3. Areas of hair loss in secondary syphilis are not smooth and discrete. The lesions usually have a "motheaten" appearance and are associated with significant scarring. 4. Hair loss in men with androgenetic alopecia starts in the frontal or temporal areas and progresses gradually (male pattern baldness). 5. Drug hair loss-Numerous drugs can produce hair loss. Lithium, thallium, and chemotherapeutic agents are between the most common ones; however, they characteristically do not affect the hair shaft, produce split-ends, or other lesions. 6.Traumatic alopecia, caused by traction, hair eating (trichotillomania), or chemical reactions, usually produces lesions on the hair strand or shaft itself, and is manifested as split-ends, trichoclasis, or fractured hair.

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SPOROTRICHOSIS: Sporotrichosis is a subacute infection caused by a dimorphic fungus, Sporothrix schenckii. The infection usually arises when the soil or other organic matter containing the fungus is inoculated in the skin or subcutaneous tissue. It is usually seen in persons involved in outdoor activities or occupations. The infection initially manifests as a papular lesion over the site of inoculation. The lesion usually ulcerates over time with non-purulent discharge from the lesion. Similar lesions are seen along the lymphatic channels proximal to the original lesion. Diagnosis is by clinical presentation and culture of the tissue or aspirated material from the lesion. Rx-Itraconazole for three to six months is the treatment of choice for lymphocutaneous sporotrichosis. PSORIASIS: Psoriasis is a common inflammatory skin disorder characterized by erythematous, well-defined plaques covered by thick, silvery scales. These lesions are typically seen over the scalp, knees, elbows, back, and nail plates. Patients are often asymptomatic, but some may complain of mild pruritus. Once diagnosed, most patients tend to have the disease for life. Spontaneous remissions and marked variations in the severity of symptoms are observed throughout the course of the disease. Psoriasis results from hyperproliferation and abnormal differentiation of the epidermal layer of the skin. Although the exact pathophysiology of these changes is not understood, immunologic and genetic factors are both thought to play significant roles. Physicians should be wary when prescribing medications to patients with psoriasis because several drugs may exacerbate psoriatic lesions. The most common of these drugs are beta-blockers, antimalarial drugs, nonsteroidal antiinflammatory drugs (NSAIDs), angiotensin-converting enzyme (ACE) inhibitors, and lithium. Bacterial and viral infections, especially HIV infection, have also been associated with worsening of psoriasis. As a general rule, all drug-induced skin rashes or eruptions should be managed by complete discontinuation of the offending drug. Beta-blockers are one of the most common classes of drugs known to exacerbate or unmask psoriatic lesions in patients predisposed to develop psoriasis; therefore, the use of such drugs should be completely stopped and substituted with another class of antihypertensive agents. A variety of different treatment options, both local and systemic, are available for the treatment of psoriasis Mild, asymptomatic psoriasis without any joint or nail involvement does not need aggressive treatment. Some patients may request treatment only for cosmetic reasons. Topical corticosteroid creams are the mainstay of therapy for localized skin lesions. High-potency agents (betamethasone 0.05%) should be initially used for thick plaques on extensor surfaces, and should be started as a twice-daily application for at least two to three weeks. The lesions should be covered with a plastic wrap or occlusion tape after steroid cream application to maximize its effects. Phototherapy with ultraviolet-B radiation is only used in patients with extensive disease (more than 30% of the body surface area). Severe lesions may be treated with a combination of cold tar application and exposure to ultraviolet-B light (Goeckerman regimen). Methotrexate is very effective in severe psoriasis, psoriatic arthritis, and psoriasis involving the nails. It is typically used as a weekly low-dose regimen. Note: Systemic corticosteroids should not be used because of the concerns of inducing pustular psoriasis. ACNE: Although there are no definitive evidence-based guidelines on the treatment of acne, some general principles are observed by most clinicians. Treatment regimens usually progress through several stages, based upon how severe the acne is at presentation and how effective the treatment options are in resolving the symptoms. Mild acne is initially treated with topical products (e.g., retinoid, benzoyl peroxide, antibiotics).

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Moderate acne (or refractory mild acne) is treated with topical retinoid and either benzoyl peroxide or a topical antibiotic. More severe acne (or refractory moderate acne) is treated with: 1) Topical retinoid, benzoyl peroxide, and topical antibiotic [erythromycin] or 2) Systemic antibiotic [tetracycline] plus topical retinoid or benzoyl peroxide.Note that systemic antibiotics are not typically used exclusively. 3) The most severe cases of acne should be treated with systemic antibiotic and topical retinoid or benzoyl peroxide; if there is no response after 3-6 months, then Oral isotretinoin is indicated. Microcomedones take eight weeks to mature, so any acne therapy regimen must be continued for at least this length of time before determining its efficacy. The more severe forms of acne vulgaris warrant treatment with an oral antibiotic in conjunction with topical retinoid or benzoyl peroxide. Oral antibiotics frequently used for this purpose include tetracycline, doxycycline, minocycline, erythromycin, trimethoprim-sulfamethoxazole, and clindamycin. Tetracycline is considered a first-line agent because it is inexpensive and highly effective. Doxycycline and minocycline are second-line agents prescribed in patients who have failed therapy with tetracycline. Doxycycline is a phototoxic agent in that it permits light-activated compounds to damage cell membranes and DNA. It can also cause esophageal ulcerations if insufficient liquid accompanies ingestion of the pill.. Phototoxic reactions can develop in users of doxycycline who are exposed to sufficient quantities of both sunlight and medication.Typically, the phototoxic reaction manifests as an exaggerated sunburn response. RX: In general, treatment for sunburns includes replenishment of lost fluids and relief for pain or pruritus. NSAIDs (e.g., oral or topical indomethacin, ibuprofen) have been shown to reduce pain and erythema and can minimize the damage to the epidermis if administered immediately after sun exposure. Diphenhydramine or hydroxyzine may be used for relief of itching. Isotretinoin is known to cause hypertriglyceridemia in up to 25% of individuals. This hypertriglyceridemia, if unrecognized and untreated, can cause acute pancreatitis. Topical retinoids have been shown to have teratogenic effects; therefore, all patients on topical retinoids should be advised to avoid pregnancy. TINEA VERSICOLOR: Tinea versicolor is a fungal infection of the skin that is caused by the dimorphic yeast Pityrosporum orbiculare (also known as Malassezia Furfur). The clinical picture is usually very characteristic: multiple small circular maculae are observed that may vary in color (white, pink or brown). The rash is typically more prominent in the summer time because the yeast inhibits pigment transfer to keratinocytes and makes the affected skin more demarcated from unaffected tanned skin. The lesions are usually asymptomatic, although mild pruritus may be present. The typical location of the lesions is the upper trunk, but the rash may also involve the upper arms, neck and abdomen. The treatment of choice for patients with tinea versicolor is topical anti-fungal therapy. Any anti-yeast topical agent can be used, including terbinafine, clotrimazole and ketoconazole. The success rate with topical anti-fungal agents exceeds 80%. With extensive disease or recalcitrant infection, Oral antifungals are preferred (ketoconazole, itraconazole or fluconazole). D/Ds: Pityriasis rosea is characterized by the presence of a herald patch, confinement of the lesions to the central trunk, orientation of the lesion along the lines of cleavage of the skin, and a typical pink color of the lesions. RX-Oral erythromycin is effective in patients with pityriasis rosea. ONYCHOMYCOSIS: Onychomycosis is a fungal infection of the toenails or fingernails. The most common form of onychomycosis is distal subungual onychomycosis, which is caused by the dermatophyte Trichophyton rubrum. Because nail dystrophies caused by other diseases (e.g., psoriasis, lichen planus, eczematous conditions) can mimic the appearance of onychomycosis, many insurance companies require diagnostic confirmation of the condition before reimbursing treatment costs.

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The diagnosis is typically established with KOH examination of nail bed scrapings. If KOH examination is negative, then evaluation by culture is appropriate. Oral terbinafine is one of the newest medications available for treating this condition, and is considered superior in terms of efficacy. Infection of the fingernails requires 6 weeks of therapy with terbinafine, while infection of the toenails requires 12 weeks of therapy. Ciclopirox is a topical antifungal nail lacquer recently approved for the treatment of mild to moderate onychomycosis. Although ciclopirox is considered safe, studies show its efficacy to be minimal. TINEA PEDIS: Tinea pedis is the most common dermatophyte infection and is usually accompanied by tinea manuum, onychomycosis, or tinea cruris (infection of the hand, nails, or groin). It presents as slowly progressive pruritic erythematous lesions usually between the toes and extends to the sole and side of the foot. There is typically a sharp border between the involved and uninvolved skin. It is a self-limiting, but recurrent infection and is usually associated with activities causing excessive sweating. Rx- Treatment of tenia pedis is with a topical antifungal cream for about two to four weeks (not a combination of antifungal and steroid cream). D/Ds: 1. Scabies is due to skin infestation by a mite, sarcoptes scabiei. It presents with intense pruritus, which is usually worse at night. Examination of the skin reveals multiple, small, erythematous papules and characteristic burrows. The diagnosis is typically made by the characteristic distribution of the lesions. They usually involve the sides and webs of fingers, flexor aspects of the wrists, extensor aspects of the elbow, axillary folds, periumbilical areas and waist, lower half of the buttocks, and adjacent thighs. Treatment of scabies is with topical 5% permethrin cream or topical lindane. 2. Dyshidrotic eczema or dermatitis (pompholyx) is an intensely pruritic, chronic, and recurrent dermatitis of unknown etiology. It typically involves the palms, soles, and lateral aspects of the fingers and toes. The patients present with multiple small and pruritic vesicles which desquamate over time, leaving erosions and fissures. Rx-Topical steroids can usually control the lesions in mild cases. A short course of oral corticosteroids may be required in severe cases. 3. Tinea versicolor is a superficial infection of the skin caused by Pityrosporum orbiculare, also known as Malassezia furfur. It is usually seen in adolescents and young adults. The lesions can be mildly pruritic, hypopigmented and light brown or salmon colored macules and are seen on the upper trunk, extremities, and face. Rx-Treatment of choice is topical antifungals for a limited disease. Oral agents, like ketoconazole, may be used for extensive lesions. TRICHOPHYTON TONSURANS VS MICROSPORUM CANIS Unlike Trichophyton tonsurans infection, Microsporum canis infection is characterized by a bright green fluorescence when the lesion is observed under Woods ultraviolet (UV) lamp. POISON IVY: Poison Ivy contact dermatitis presents as pruritic linear lesions, which are usually papular. When the reaction is severe, the papules may evolve into vesicles, which can exude a serous fluid. The lesions have a linear or curvilinear appearance, showing the points of contact with the leaves or stems of the plant. New lesions can appear two to three days later if the poison ivy resin was transported to other skin surfaces by the patient before washing the primary lesion. D/Ds 1) Dyshidrotic dermatitis, also known as pompholyx, is chronic and usually affects the palms and soles.See detail above 2) Detergent contact dermatitis is composed of papules found mainly on the hands, and sometimes, the face. PORPHYRIA CUTANEA TARDA Porphyria cutanea tarda is a condition that arises from the deficiency of uroporphyrinogen decarboxylase, an enzyme in the heme synthesis pathway.

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This condition is characterized by painless blisters, an increased fragility of the skin on the dorsal surfaces of the hands, and facial hypertrichosis and hyperpigmentation. It can be triggered by the ingestion of certain substances (e.g., ethanol, estrogens) that should be discontinued if suspect. Diagnosis is confirmed with an elevation of the urinary uroporphyrins. Phlebotomy or hydroxychloroquine may provide relief, as can interferon alpha in those patients simultaneously infected with Hepatitis C virus. D/Ds 1. Allergic contact dermatitis results from direct skin contact with chemicals or allergens. It is characterized by pruritus, erythema, and edema, often followed by the development of vesicles and bullae in the irritated region. 2. Herpes zoster is characterized by painful vesicular lesions clustered unilaterally along the course of a nerve. The lesions are typically found on the face or trunk, and will be Tzanck smear positive. 3. Dermatitis herpetiformis is characterized by pruritic papules and vesicles that appear mainly on the elbows, knees, buttocks, posterior neck, and scalp. The condition arises in the context of gluten-sensitive enteropathy, which may be subclinical. 4. Impetigo is characterized by pruritic and honey-colored macules, vesicles, and bullae on the face and other exposed parts. The condition is caused by Staphylococcus aureus or group A streptococcus. PRESSURE ULCERS: Pressure ulcers are typically categorized into four stages. Stage 1 ulcers are characterized by nonblanchable erythema of intact skin. Stage 2 ulcers are superficial ulcers causing a partial thickness loss of the epidermis, dermis, or both. Stage 3 ulcers are deeper ulcers causing a full thickness loss with damage to subcutaneous tissue that may extend to, but not through, any underlying fascia. Stage 4 ulcers are very deep ulcers causing a full thickness loss with extensive tissue destruction that may damage adjacent muscle, bone, or supporting structures. Stage 3 or 4 pressure ulcers should be loosely packed with saline-moistened gauze to preserve the moist wound environment. SEBORRHEIC DERMATITIS: It is characterized by erythematous, scaling plaques and patches with indistinct margins. The most common sites affected are the scalp, central face (eyebrows, nasal bridge, and nasolabial folds), ears, chest, upper back, axilla, and pubic area. Dandruff of the scalp is a form of seborrheic dermatitis with minimal inflammation. Diagnosis is usually made by physical examination alone. Seborrheic dermatitis is common in HIV infection and can be a presenting feature. The reported frequency of seborrheic dermatitis varies from 40-80% in AIDS patients. It usually presents with a greater severity in these patients.Physicians should consider the possibility of HIV infection in patients presenting with a new onset of severe seborrheic dermatitis. ********* TATTOOING: Tattooing is a relatively common practice and most of the tattoos are seen in adolescents and young adults (13 to 25 years of age). The tattooing process involves repeated skin punctures using solid bore needles to place the tattoo pigment into the dermis. The pigment is taken up by macrophages in the dermis, which allows it to remain in the skin permanently. People who have had these marks for a long time sometimes desire tattoo removal. It is an expensive and complicated procedure but is certainly possible. It has no relation with the age of the tattoo marks. Some of the common techniques used to remove tattoo marks include dermabrasion, cryosurgery, thermal cautery, surgical resection, and, more recently, laser removal. These techniques can be used to remove the marks on any part of the body. Dermabrasion involves removal of the superficial layer of the epidermis, allowing the pigment to leach out of the skin. Laser removal is a more recent advancement and it involves the use of lasers of different wave lengths. It is thought that the laser breaks up the pigments into smaller molecules, which are taken up

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and cleared by macrophages in the skin. Although it is a safe procedure, laser removal can leave scar marks and cause skin hypo- or hyper-pigmentation.

INFECTIOUS DISEASE

NON GONOCOCCAL URETHRITIS/ OR NON-GOCOCCOCAL CERVICITIS: Preferred RX=> Azythromycin 1 g single dose [to assure patient adherence] Alternative: Doxycycline 100mg twice/day PO x 7 days 10 days later no response Rule out re-exposure and non-adherence to treatment => next step is give: Metronidazole 2 g single dose followed by: Erythromycin 500 mg Q/6 hrs x 7 days OSTEOMYELITIS: Initial step: X-Rays [are positive 2-3 weeks after changes in bone] Test Of Choice: Un-complicated osteomyelitis: 3-phase technetium 99-m bone scan [+ 2-3 days after the onset of infection] or Indium-labeled white cell scan and gallium citrate scan Complicated /Early stages of osteomyelitis/ Vertebral osteomyelitis, diabetic foot ulcer/osteomyelitis: MRI or CT-scan [MRI contraindicated if metal implants, prosthesis or pacemakers] Bone biopsy=gold standard [used when index of suspicion s high, after less invasive tests] Osteomyelitis of diabetic foot lesion/ulcerMRIMost useful to obtain microbiologic diagnosis Culture of deep tissue obtained by curettage RABIESuniversally fatal once pt is symptomatic RABIES post-exposure prophylaxis: Rabies vaccine for active immunization and Rabies immunoglobulin [IG] for passive immunization In pts previously vaccinated who has been re-exposed to rabiesshould receive only ACTIVE immunization: rabies vaccine COMMUNITY ACQUIRED PNEUMONIA: ADMIT when: > 65 y/o, DM, chronic lung disease, others comorbities, tachypnea, hypoxia, multilobular involvement, hypotension. Rx: Cover s. pneumoniae and atypical agents => Ceftriaxone IV + Macrolide: Azithromycin MENINGITIS: CSF Bacterial Cryptococcal Viral Opening pressure [10-20 cm H20] [ > 180 mmH2O] [>200 mmH2O] Normal or mild [>100-300] WBC < 5 [>100 cells/L] Low [< 40 cells/L][25-500 cells/L] Predominance Polymorphonuclear leukocytosis Mononuclear /Lymphocytes [>90%] Lymphocytic pleocytosis Glucose [40-70] Low [< 40] Low [< 40] Normal Protein [15-45] [ > 45 ] [ > 45 ] Normal or mild PML=PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY [opportunistic infection in Immunocompromised pt x JC virus, multiple focal neuro deficits => MRI = non enhancing, demyelinating lesions with no mass effect Cryptococcal meningitis [elevated intracranial pressure, severe headaches, altered sensorium; blurred vision => increased opening pressure=Do repeated or serial LP to relief symptoms] RX- Cryptococcal meningitis=> Amphotericin B + Flucytosine x 10-14 days Then: Start FLUCONAZOLE life long [maintenance therapy] in HIV + patients Meningococcus prophylaxis to contacts => Rifampin [alternatives=fluoroquinolone, sulfonamide, ceftriaxone, minocycline] Meningococcal meningitis: Prophylaxis: **Oral Rifampin **Alternatives: SD oral Ciprofloxacin or SD IM Ceftriaxone

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CHLAMYDIA PSCITTACI PNEUMONIA => TRIAD: 1. Meningoencephalitis 2. Splenomegaly 3. Pneumonia In an Immunocompromised host => Suggest Chlamydia pscittaci pneumonia until proven otherwise Other- important clues: Community acquired pneumonia in veterinarian, poultry farmer, bird raiser CXR: Consolidation of one of the lower lobes Confirmation: Serology Rx: Doxycycline 100 mg 2/day x 21 days If Outpatient therapy: Give empiric Doxycycline waiting for serologic results and follow up If hospitalized: Give empiric Doxycycline waiting for serologic results, re-evaluate on an in-patient basis. Hospitalization Criteria In Community Acquired Pneumonia: 1. Age > 65 y/o 2. Comorbities: DM, immuno-compromise, sickle cell anemia, malignancy, steroid use, HIV 3. Presence of pleural effusion 4. Pulse > 120 or 30 6. BP < 100/systolic 7. P. Oximetry 3 episodes per year Who Have A High Probability Of Intercourse-Related UTI: 1. Post-coital prophylaxis [voiding] 2. Continuous antibiotic therapy and 3. then short course of antibiotics Patient with symptoms of intestinal parasitosis /diarrhea/malabsorption/eosinophilia and a history of family visit from Central America; or traveling => Give Albendazole GIARDIASIS= Metronidazole* [TOC] but its category B in pregnancy => FDA approved this drug in pregnancy if severe infection and dehydration. Giardiasis in pregnancy: Mild to moderate infection, especially occurring in the 2nd trimester => use Paramomycin, alternative drug category C, resolves 70% of the cases Pregnancy + Severe infection, malabsorption, dehydration => DOC: Metronidazole [category B] In the first and 3rd trimester LATENT TB AND HEALTHCARE WORKERS => should be counseled about the risk of developing active TB and offered preventive therapy with: Isoniazid + Vit B6 x 6-12 months or 9 months. -They should not be excluded from the workplace if they refuse to accept recommended therapy or further intervention [document on chart this advice or discussion with the patient, decision and make a written agreement to continue regular follow up appointments] Suspected Rocky mountain fever [petechial rash on ankles, wrists to palms and soles, central body-> to fulminant disease, complications] => clinical diagnosis -> immediately treated empirically with Doxycycline INFLUENZA: Rx: Immediately in vulnerable patients -> In the first 30-36 hrs => Zanamivir / Oseltamivir [neuraminidase inhibitors] -> In the first 48 hrs => Rimantadine / Amantadine -> After 48 hrs => symptomatic therapy or support, acetaminophen The four Centor Criteria for the diagnosis of Acute pharyngitis in adults: 1. Fever 2. Tonsillar exudates 3. Tender anterior cervical adenopathy 4. Absence of cough If 0 criteria => no further testing or treatment If 1-2 criteria => Rapid antistreptococcal antigen testing => if positive => Rx with antibiotic If 3-4 criteria => immediately empiric antibiotics

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HERPES ZOSTER: [reactivation of a latent varicella zoster virus in the sensory/dorsal nerve root ganglion Its a clinical diagnosis => RX immediately within 48 hrs of the onset and clinical suspicion => Acyclovir. Diagnostic workup is not necessary [Tzanck test, skin biopsy or serologies] Transmitted from person to person by droplets and close contact => All pt with disseminated infection should be isolated until lesions are crusted All healthcare workers w/o history of varicella zoster infection are encouraged to=AVOID close contact with VZV or herpes zoster virus patients If only local lesion => cover lesion with a scarf until lesions are crusted STAPH AND STREP: Erisipelas: MC site is lower extremities, and face is 5-20 % of the cases Facial Erisipelas: MCC: #1: B-hemolytic strep*, Group A, and less frequently Staph Aureus or Penicillin resistant strep [PRS] Facial erysipelas needs to be treated immediately due to this location = if not open blisters or exudates => No need skin cultures DOC or current management => Penicillin G IM/IV Pt predisposed to Staph Aureus or to PRS: healthcare workers, nursing home resident, IV drug abuser: Antistaphylococcal penicillin {Nafcillin, Oxacillin, Methicillin, Cloxacillin NECROTIZING FASCIITIS = GROUP A STREPTOCOCCI: -Fulminant infection of SQ tissue that spreads along fascial planes -> extensive tissue necrosis-> HD collapse and shock 1. Type I: [aerobic and anaerobic organisms] -> Group A Strepcococci, Staph Aureus, E. coli, bacteroides, prevotella ->Seen in pt with underlying DM and PVD 2. Type II: Rapidly spreading infection* => Group A Streptococci [pyogenes]*** No underlying condition; but has a history of laceration, blunt trauma, surgical procedure, IV drug abuse Erythema, blister and bullae, fever, malaise, systemic toxicity and shock Treatment: Urgent surgical exploration and debridement -> got tissue samples C & S, cytology Empiric antibiotics= Clindamycin is the DOC* CENTRAL VENOUS CATHETER RELATED SYSTEMIC INFECTION: STAPH AUREUS** 1. Local infection = at the insertion site, exit site or SQ tunnel with erythema, induration, tenderness, pus from the exit site 2. Systemic infection= systemic symptoms, fever, chills, altered mental status-immuno-compromised pt with a tunneled catheter 1-Remove catheter, put new line in another site, make culture of catheter tip and blood cultures 2-IV empiric antibiotics w/o delay: Vancomycin [gram +] and Gentamicin [gram negative bacilli] PSEUDOMONA AERUGINOSA BACTERIEMIA: = common in immuno-compromised pt, with indwelling urinary catheter or Central venous catheter, infection of traumatic or surgical wound; severe nosocomial infections =>P. Aeruginosa bacteriemia => Frequently develop Ecthyma gangrenosum infection of skin or mucous membranes worsening to nodular patches with hemorrhage, ulcer and necrosis [yellow-green exudates, purulent fluid. RX= IV Empiric Antibiotics = 2 drug regimen: 1- Aminoglycoside [Tobramycin or Amikacin] 2- Stended spectrum Anti-pseudomonal penicillin [Piperacillin] 3- Or/ a Antipseudomonal Cephalosporin [Cefepime or Ceftazidime] TSS [STAPH AUREUS]: =history of tampon [vaginal or nasal] =>fever, chills, myalgias-> progressing to systemic hypotension, shock, rash. Bacterial [Staphylococcal] exotoxin production; called: TSS toxin-1 -> widespread activation of T-cells by exotoxin acting as superantigens which leads to massive release of cytokines->SYSTEMIC TOXICITY Rx: IV fluids and antibiotic therapy => [Clindamycin/Vancomycin with/w/o Nafcillin [anti-staphylococcal penicillin] HIV CLUES: HIV suspicion = young pt, with unintentional WT loss, vague symptoms, rash dry and itchy over face/axilla [seborrheic dermatitis] => Screen for HIV, detailed sexual history and drug use [IV drug abuser]

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HIV [+] patient with Typical pneumonia => consider entire C/P => Typical pneumonia [acute onset, purulent rusty sputum, lobular infiltration, etc => Strep pneumoniae] HIV pt with Atypical pneumonia=> subacute onset, gradual, non-productive cough, exertional dyspnea, interstitial infiltrates on CXR=> PCP, Mycoplasma WIDESPREAD DISSEMINATED CANDIDIASIS: = Candida Endophthalmitis => Risk factors: central venous catheters, total parenteral nutrition, immuno-compromised, AIDS, neutropenia, chronic corticosteroid therapy, IV drug abuser, broad spectrum Atb therapy, prior abdominal surgery. CAUSE= esophageal / oropharyngeal candidiasis disseminated or hematogenous seeding [spreading to eye] Rx: When have chorioretinitis and vitreal involvement=> Vitrectomy and systemic antifungal therapy [Amphotericin B] PHAT= HIV patient with bleeding disorder=thrombocytopenia in all stages of the disease => Primary /HIV associated thrombocytopenia [PHAT] and only 20% has spontaneous remission **Mainstay of Rx is: Zidovudine [reduce occurrence of opportunistic infections and Kaposis sarcoma] Pt started with HAART => HIV viral load should be measured at 4 weeks and again at 8-12 weeks [Q/6-8 weeks until viral load is undetectable: 0-50 copies/L after 6 months of treatment] HIV TESTING, POST-EXPOSURE: # 1: HIV/ELISA [HIV antibody testing] at initial visit and repeated at 6, 12, 24 weeks (1 month, 3 months, 6 months) If HIV/ELISA is (+) => Order a Western blot HIV + patients not already on HAART => Should measure CD4 count every 3-4 months When to start HAART: Asymptomatic pt with CD4 < 300-350 and HIV viral load of > 55.000 or 60.000 Symptomatic or with AIDS defining illness HIV Postexposure Prophylaxis/Within The First 48 Hrs Is Successful Preventing HIV In: Healthcare workers Infants [perinatal transmission] Unprotected sex with an individual HIV (+) [within 72 hrs of sexual intercourse] Rx=> Zidovudine and Lamivudine x 4 weeks Post-Exposure to body fluid of HIV (+) => requires antiretroviral prophylaxis: Zidovudine and lamivudine /or/ zidovudine, lamivudine and Indinavir HIV POST-EXPOSURE PROPHYLAXIS AND HEALTHCARE WORKERS: -All cases of occupational transmission have been due to transmission via exposure to BLOOD and certain body fluids [semen, vagina and any other body fluid containing visible blood. -Standard precautions DO NOT apply to: urine, saliva, sweat, sputum, tears, vomitus, nasal secretion, or feces as long as there is no gross visible blood => The exposure to urine w/o visible blood is not considered a significant exposure => does not need further intervention HIV Pt, With Progressive Multifocal Leukoencephalopathy PML=> JC virus or human papilloma virus => no specific treatment but => regressions of well over two years treated with: HAART Without treatment => majority of pts with PML will die within 3-6 months of the onset HIV pt, homosexual with low CD4 count=>HBV vaccine Esophagitis /HIV pt, aphthous ulcers => Fluconazole -> no improvement => Prednisone LIFE THREATENING REACTIONS ASSOCIATED WITH HIV THERAPY: 1. Crystal induced nephropathy => side effect of INDINAVIR [protease inhibitor] 2. Pancreatitis =Didanosine 3. Hypersensitivity syndrome = Abacavir 4. NRTIs = lactic cidosis 5. NNRTIs = Stevens-Johnson syndrome 6. Liver failure = Nevirapine IRIS = IMMUNE RECONSTITUTION INFLAMMATORY SYNDROME: Paradoxical worsening of pre-existing and sub-clinical infections in HIV + individuals -DAYS TO WEEKS OF initiation of HAART, secondary to the rapid improvement of immune function

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-It is SELF Limited, best management: Provide Reassurance; continue HAART and antibiotic treatment of underlying pathogen HAART can lead to: => HIV Lipodystrophic syndrome [redistribution of fat and insulin resistance and significant hyperlipidemia => Rx: Gemfibrozil ACUTE RETROVIRAL SYNDROME: - Is another term for Primary HIV infection [2-3 weeks after exposure, precedes seroconversion by 10-21 days, illness similar to I. mononucleosis, low grade fever, fatigue, maculopapular rash, face-trunkextremities], G/I symptoms, LAD, myalgias and arthralgias, oral thrust, etc. - HIV/ELISA is often negative initially -> can be supplemented by testing for HIV RNA or p24 Antigen if high suspicion. PCP: in pts with defects in cell mediated immunity, HIV, CD4 < 200 **Fever, non productive cough, progressive dyspnea and tachypnea **CXR= diffuse bilateral ground lgass or alveolar infiltrates **DX: Fiberoptic Bronchoscopy and BAL Bronchoalveolar lavage and transbronchial biopsy **Rx: Admission / TMP/SMX [IV] /alternative: aerolized pentamidine Adjunctive treatment with corticosteroids->when Alveolar-to-Arterial gradient of >35 mmHg on room air. PCP and HIV pt, allergic to sulfas: IV pentamidine [may have several electrolytic disturbances] next step= finger stick glucose to detect hypoglycemia Do not test a patients HIV status => w/o obtaining a formal consent CD4 count => is an indicator or current level of immunosupression immunologic damage that has already occurred. HIV Patient With Syphilis Of Unknown Duration [Or Late Latent Syphilis] => Best management: should have a Lumbar Puncture and CSF examination before syphilis treatment [since results will determine the optimal RX] Rx: Benzathine penicillin G [IM] /week x 3 weeks Jarish-Herxheimer reaction or ACUTE Febrile reaction developing within 24 hrs after start RX for Syphilis. Fever-malaise-chills-headache-myalgias /immunological reaction to the rupture of spirochetes. => Rx: No effective prevention is available; pt should be advised of the possible signs and the need to contact the Dr if any symptoms appear. HIV Infected Pt With Late/Latent Syphilis And Normal CSF Analysis: Benzathine penicillin G, IM for 3 weeks IRIS = Immune Reconstitution Inflammatory Syndrome Paradoxical worsening of pre-existing and sub-clinical infections in HIV + individuals DAYS TO WEEKS OF initiation of HAART, secondary to the rapid improvement of immune function It is SELF Limited, best management: Provide Reassurance; continue HAART and antibiotic treatment of underlying pathogen PHARYNGEAL GONORRHEA => Ceftriaxone DOC, if allergic to cephalosporins [ceftriaxone] => alternative is: => Ofloxacin and Ciprofloxacin INFECTIOUS MONONUCLEOSIS: 1st test: Monospot test [heterophile antibodies] If negative or inconclusive => EBV-specific antibodies **RX of IM: bed rest and NSAIDs **If severe complication of IM; airway obstruction, aplastic anemia, thrombocytopenia =>Rx is Admit pt and IV steroids **Ampicillin associated maculo-papular rash => in pts with I.M, its a vasculitic rash immune mediated [Circulating immune complexes] [IgG and IgM antibodies vs. penicillin derivatives] **Rx: Discontinue antibiotic and observe, supportive treatment [acetaminophen/NSAIDs, nutrition, fluids, bed rest. Adult vaccination more common: Influenza, pneumococcal and TT INDICATIONS FOR INFLUENZA VACCINE: 1. 50 y/o and older 2. Chronic resp, cardiac or metabolic conditions 3. Immunosupressed state 4. Resident of long care term facilities

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5. Healthcare worker and people in prolonged contact with adults in this high risk category INDICATIONS PNEUMOCOCCAL VACCINE: 1. 65 y/o and older 2. Younger 65 who were vaccinated more than 5 years ago INDICATIONS TT: 1. Serious dirty wound, puncture wound, contaminated with saliva, soil, feces] and who received last dose > 5 years ago 2. Clean minor wound, last dose more than 10 years ago CHRONIC PROSTATITIS: => Antibiotics for 6 to 12 weeks For chronic infection: DOC => Quinolones Ciprofloxacin and Levofloxacin Alternative: TMP/SMX TRANSVERSE MYELITIS (Rapidly Developed Transverse Myelopathy) -Rapid progressive weakness of lower extremities following a URI -Sensory loss -Urinary retention -Dull back pain, muscle flaccidity / hyporeflexia and spasticity with hypereflexia thereafter -Diagnosis: MRI SALMONELLOSIS Salmonella enteritidis, symptomatic pt => its a self limited disease -RX: Supportive therapy, observe, fluids, electrolytes CLOSTRIDIUM DIFFICILE ASSOCIATED COLITIS: limited sigmoidoscopy is more useful than stool cytotoxin in severe cases [is more quickly] Medication provoking CD colitis: Clindamycin, Ampicillin, Amoxicillin, Cephalosporins Hepatic Encephalopathy May Be The Only Manifestation Of SBP In Chronic Hepatitis Pts / Cirrhosis Or Nephritic Syndrome => Tremors Is Suggestive Of Stage 2 Of HE -Spontaneous bacterial peritonitis SBP -> When > 250 neutrophils/mm3 in ascitic fluid -RX => 1st step- diagnostic testing, paracentesis and take blood cultures and ascitic fluid analysis *** Lactulose *** Antibiotics -Hospital admission for intravenous antibiotics (Cefotaxime or Ceftriaxone) *** Albumin ***Once patients have recovered from SBP, they require regular prophylactic antibiotics (e.g. Septra DS, Cipro, norfloxacin) as long as they still have ascites. Cirrhosis secondary to chronic hepatitis C => liver damage if -> PT remains prolonged, hepatic enzymes elevated AST and higher ALT, hyperbilirubinemia and hypoalbuminemia CPT SCORE- CHILD TURCOTTE PUGH SCORE OF LIVER DAMAGE [CANDIDATE FOR LIVER TRANSPLANT] Points 1 2 3 Bilirubin [mg/dL] < 2 2 - 3 > 3 Ascites Absent Slight responsive Moderate severe PT < 15 sec 15-17 sec > 17 sec Albumin > 3.5 2.8-3.5 < 2.8 Encephalopathy None Stage 1-2 Stage 3-5 For cholestatic disorders=> Bilirubin are: < 4, 4-10 and > 10 Class A = CTP = 6 Class B = CTP = 7-9 Class C = CPT > 10 Liver transplantation => CTP > 7 ASYMPTOMATIC BACTERIURIA => in elderly patient, does not requires oral antibiotic therapy if urine WBC is < 20 WBC/HPF => Reassurance pt and repeat urine culture in 2 months FUO: infectious disease** is the most common cause DIPHTHERIA is a serious condition, pharyngitis, cervical adenopathy, low grade fever. Throat culture (+) > Give D. Antitoxin Diphtheria antitoxin: High risk of anaphylaxis!

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>Its made with horse serum => HIGH RISK of hypersensitivity or serum sickness-> and risk of anaphylaxis => Rx: Epinephrine DKA PATIENT IS PREDISPOSED TO RHINOCEREBRAL MUCORMYCOSIS => Rx: Surgical debridement and IV Amphothericin B CRYPTOCOCCAL CUTANEOUS INFECTION;= early manifestation of CM / HIV patient with multiple discrete, redist colored papules with central umbilication; DX: histopathologic exam of the biopsy LYME DISEASE/ARTHRITIS can not be confirmed by Serologic tests Serology identify too previous exposures => Best test= ELISA antibody in Synovial fluid Lyme arthritis in children= 30 day of Amoxicillin or parenteral Ceftriaxone. In adults: Doxycycline -> Ceftriaxone. Allergic to penicillin => Erythromycin Prognosis for children= Good => more than 905 of the children are disease free 1 year after therapy. If not treatment => have recurrent episodes of arthritis even 8 years after the onset Lyme Disease And Prophylaxis In Pregnant Woman: Prophylaxis after tick bite can be done with Amoxicillin in pregnant woman Use Doxycycline single dose if: Immuno-depression and other debilitating conditions BACTERIEMIA: Systemic manifestations of bacteriemia [abrupt temperature elevation, chills] occur 30-90 min after bacteria enter blood stream. When best to drawn blood cultures? => one hour before the anticipated fever or spiking of a temperature and chill. Quantitative jejunal cultures or the demonstration of Excessive bacterial concentration in a jejunal aspirate =>is the Gold standard test for diagnosis of bacterial overgrowth [Quantitative jenunal cultures] TUBERCULOSIS: TB: Sputum microscopy [AFB smear] -> is the quick/easy test to confirm pulmonary TB. Sputum Culture is the gold standard or most useful for diagnosis. Sputum microscopy for AFB [is a marker of infectivity] => If 3 consecutive negative smears=> the pt can be considered: Non infectious PPD is a screening test- used to assess previous exposure; is the first step if suspicion of TB. If PPD is (+) => CXR is the next step; then => Sputum smear and culture Pt with a (+) PPD, but w/o any evidence of active TB => Considered to have latent TB and they are at increased risk of develop TB PPD > 10 cm is (+) if immigrant from high incidence TB country within the past 5 years Latent TB treatment=> Isoniazid daily x 6-12 months [for prevention] LTB latent TB infection => PPD > 15 mm and normal CXR => INH monotherapy x 9 months Tuberculin test [PPD] => initially performed in all persons exposed to patients with TB Isoniazid /INH => Side effect => Hepatotoxicity [RX: discontinue drug] Rifampin = Red-orange colored body fluids [urine, feces, sweat] INFECTIVE ENDOCARDITIS: Complication: Conduction system abnormalities if involved of => Aortic valve endocarditis Because of it is close proximity to proximal ventricular conduction system. BONE MARROW TRANSPLANT PATIENT have high risk of Aspergillosis, invasive fulgal infection affecting sinuses and lungs principally. Risk factors: Allogeneic transplantation vs. autologous transplantation, older age, acute graft versus host disease, corticosteroid therapy. HEPATITIS B: Anyone who has received 2 rounds of HBV vaccine and still has a titer < 10 mlU/mL is considered a Vaccine non-responder and should be given hepatitis B immune globulin when exposed to HBsAg positive blood. Pearly penile papules are a normal variant and not a STD. Common in uncircumcised male Due to high incidence of lung cancer in smokers, if they presents with recurrent pneumonianext step Admit to the hospital and workup= CXR CT-scan chest next

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PEDIATRICS
PRECOCIOUS PUBERTY: It is very important to distinguish between the two most common presentations and causes of precocious pubarche in order to facilitate the proper treatment. Precocious puberty is caused by premature activation of the hypothalamus-pituitary-gonad (HPG) axis. Precocious pseudo-puberty is caused by a gonadotropin-independent process, typically an excess of sex steroids (severe cystic acne, significant growth acceleration). It can be caused by late-onset congenital adrenal hyperplasia. Hypothalamic dysfunction leading to precocious puberty is usually less dramatic in presentation. Sequential development of the following is typically present: testicular enlargement, penis enlargement, pubic hair growth, and lastly, a growth spurt. BENIGN PREMATURE THELARCHE: Is characterized by bilateral breast enlargement not accompanied by other signs of isosexual precocious puberty. These other signs of precocious puberty include rapid increase in height, increase in bone maturity, appearance of axillary and pubic hair, and menstrual bleeding. The treatment for benign premature thelarche is expectant because majority of the patients remain stable or have reversal of the breast enlargement in a few months. Patients with benign premature thelarche have a normal hormone profile. Their final height is generally not compromised. DD: 1. Hypothalamic hamartomas secrete GnRH and cause central isosexual precocious puberty in both males and females. Central precocious puberty is characterized by rapid acceleration of height, increase in bone age, thelarche, adrenarche, pubarche, and menarche. Lab investigations in patients with hypothalamic hamartoma reveal gonadotropin levels in the pubertal range and elevated estrogen levels. Majority of these patients will require treatment with a GnRH analog. 2. Estrogen production from an ovarian tumor can lead to peripheral precocious puberty. This syndrome has similar clinical features as hypothalamic hamartoma, and is characterized by accelerated height and bone age, and menstrual bleeding. Hormonal profile reveals elevated estradiol in the presence suppressed LH and FSH. Treatment is usually surgical. 3. McCune-Albright syndrome consists of cafe au-lait" spots, fibrous dysplasia of the bone, and precocious puberty. This patient does not have any features to suggest McCune-Albright syndrome. The cause of precocious puberty in McCune-Albright syndrome is excessive production of estrogen from ovarian cysts. NOCTURNAL ENURESIS can be categorized as primary or secondary, with secondary enuresis accounting for roughly of all cases. If the child was continent for at least 6 months prior to the onset of bed-wetting, then the enuresis is considered secondary. While psychological problems are very rarely the cause of primary nocturnal enuresis, they are quite frequently the cause of secondary nocturnal enuresis. Nocturnal enuresis is more common in boys. Prevalence declines slowly throughout childhood; almost of 5-year-old children (such as the boy in this case) continue to have nocturnal enuresis. Typically, the condition resolves of its own accord between the ages of 5 and 7. By age 10, prevalence of nocturnal enuresis has dropped to under 5% of all children. To increase the likelihood of success, parents should maintain a caring, patient approach, and may wish to try behavioral modification with positive reinforcement. If the childs nocturnal enuresis persists for some time, alarm therapy or a prescription for Desmopressin may be worth trying. RX**First line management for primary nocturnal enuresis for children less than 7 seven years of age is to reassure the patients parents that the child usually outgrows this phase and spontaneously recovers. Other options for treatment, however, are the use of alarms, along with behavioral therapy, such as limiting the childs fluid intake before bedtime. In the alarm method, a sensor is placed in the childs

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underwear or in the bed padding. Once the child voids and moisture is detected, the alarm is activated, waking up the child so that he could go to the toilet before he continues to empty his bladder. Although alarms have been shown to be less immediately effective than desmopressin use, the former is still more effective in preventing relapses. Alarms are more effective than treatment with tricyclics during and after treatment. When giving an opinion about a patients diagnosis, the physician must be cautious and try to avoid giving false reassurance or a premature diagnosis that cannot be supported by adequate clinical evidence. In cases wherein the patients history or physical findings do not point to a specific diagnosis, the physician can correctly state that it is "probably a medical condition", and then begin the work up in order to arrive at a more specific diagnosis. CHRONIC ADRENAL INSUFFICIENCY: If HIV/ELISA is (-)/indeterminate and C/P suggestive of HIV => Order a viral load test: HIV RNA PCR assay [confirming a high viral load] It must be suspected in patients with the corresponding signs and symptoms: fatigue, weight loss, myalgias, increased pigmentation, and a decreased amount of axillary and pubic hair. Hyponatremia, hyperkalemia and hyperchloremic metabolic acidosis are characteristic laboratory findings. The most common etiology of this condition is primary adrenal insufficiency (Addisons disease). Diagnosis can be made through the ACTH stimulation test, or by the measurement of early morning serum cortisol level (A level less than 10 mg/dl indicates a high probability of the disease). DD/s: Hyperthyroidism shares some similar clinical manifestations with Addisons disease (weight loss, asthenia,); however, the presence of other findings, such as fatigue, androgen deficit signs, hyponatremia and hyperkalemia, cannot be explained by hyperthyroidism alone. Hypothyroidism, not hyperthyroidism, is usually related to fatigue and hyponatremia (although the other symptoms still cannot be explained by hypothyroidism). SICKLE CELL DISEASE: In children, the most common initial symptom of sickle cell disease is dactylitis, which develops in 40% of patients. Splenic sequestration is the second most common, and occurs in about 20% of patients. Other complications, such as ischemic events, are not as frequent, and are seen mainly in the adult population. Salmonella is an uncommon cause of hematogenous osteomyelitis in the general population; however, it is the most common cause of osteomyelitis in patients with sickle cell disease. Long bones are usually affected, and multiple foci are often present. Sickle cell anemia should be strongly suspected in child who has a history of anemia and an episode of Salmonella osteomyelitis. Interestingly, only about 30% of cases of sickle cell anemia are diagnosed at the age of 1 year. DX-Hemoglobin electrophoresis will confirm the diagnosis. ACUTE OTITIS MEDIA: The most common complication after an episode of acute otitis media is another episode of otitis media. Approximately 75% of early recurrences are due to different bacteria, while other recurrent episodes are caused by the same agents (usually Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis). Children who have had more than two episodes are especially at risk. Some authors recommend prophylactic antibiotic therapy in such cases. Contrary to popular belief, pneumonia is not a complication of acute otitis media. Both conditions can coexist, but one is not a risk factor for the other. While adults have wide, steeply angled Eustachian tubes, infants have shorter, almost horizontal Eustachian tubes. This fact makes fluid accumulation and infection quite common in young children; however, not all children develop acute otitis media (AOM). Recurrent episodes require further exploration by the clinician. Exposure to cigarette smoke has been shown to alter mucosa, cilia, and adenoid structures, in addition to increasing the risk of developing AOM and upper respiratory tract infections.

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An increase in the level of smoke exposure is paralleled by an increase in the number of AOM episodes. Exposure to cigarette smoke is one of the most important risk factors for developing acute otitis media. Parents should be urged to quit smoking. Initial clinical treatment failure (failure of acute otitis media to respond clinically to amoxicillin by day 3 of treatment) and who has not received antibiotics in the month prior to the initiation of treatment are: High doses of amoxicillin/clavulanate or certain second or third generation cephalosporins. The rationale is to enhance activity against penicillin-resistant S. pneumoniae (drug resistant S. pneumoniae or DRSP) found in an increasing percentage (30-60%) of cases of pneumococcal AOM in the US. If the patient has an initial clinical treatment failure and has received antibiotics in the month prior to beginning the current treatment. (Prior antibiotics in the month preceding AOM increase the likelihood that AOM is due to DRSP): Discontinue amoxicillin, begin IM ceftriaxone, and 2- refer the boy to an otolaryngologist for urgent tympanocentesis. Under these conditions, the patient would also have been initially treated with high dose amoxicillin, high dose amoxicillin/clavulanate, or certain second or third generation cephalosporins. These regimens are reported to be more effective against DRSP than the usual dose of amoxicillin. IM ceftriaxone is even more effective against DRSP. Moreover, immediate tympanocentesis allows culture and sensitivity testing which can provide invaluable guidance in selected difficult cases not responding to empiric treatment. Tympanostomy and tubing is generally reserved for chronic otitis media (COM) with effusion persisting for more than 3 months, or recurrent AOM (greater than six episodes in 6 months) which is not prevented by prophylactic antibiotics (half of normal dose amoxicillin or sulfisoxazole). -It might be considered in AOM if the TM bulging, earache, fever, vomiting, and/or diarrhea were unusually severe or persistent. **POST OM MANAGEMENT: A normal appearing tympanic membrane with decreased mobility on pneumatic otoscopy is suggestive of an effusion in the middle ear. An effusion commonly persists up to three months after an acute episode of otitis media (OM) has been treated. If no other symptoms are present in such cases, watchful waiting is all that is necessary. If other symptoms are present, the effusion is bilateral, or has persisted for more than three months, further therapy should be considered. Switching to a second-line antibiotic should be considered if there is inadequate improvement of symptoms or appearance of the tympanic membrane, or when there is persistence of a purulent nasal discharge. According to the CDC, three drugs can be used as alternatives. These are amoxicillin-clavulanate, cefuroxime axetil, and intramuscular ceftriaxone. Tympanocentesis or myringotomy with culture are indicated in children in whom the clinical response to a second-line treatment has been unsatisfactory. Hearing should be assessed if effusion has persisted for more than three months. Myringotomy and insertion of tympanostomy tubes should be considered for patients with otitis media and effusion after antibiotic therapy and an ample period of watchful waiting. GYNECOMASTIA: is very common (up to 70%) in pubertal males. Its occurrence during puberty is associated with the relative excess production of estrogens from the testes. In majority of subjects, gynecomastia regresses in about 18-24 months; however, this may persist in some patients, and although rare, it could be cosmetically disfiguring. Surgical resection is required in very large, cosmetically disfiguring gynecomastia which has not responded to medical therapy. Liver cirrhosis is associated with gynecomastia. This is mainly due to an increased aromatization of circulating androgens. METHAMPHETAMINE (MF): Therapy is associated with decreased weight and height. Sadness and irritability can be seen in up to 22% of children at therapeutic doses.

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MF overdose has similar effects as dextroamphetamine, that is: anorexia, nausea, vomiting, tachycardia, increased blood pressure, palpitations, dizziness, headache, nervousness, euphoria, agitation, and aggressive or violent behavior. It is very important to remember that MF cannot be stopped abruptly because of the high prevalence of psychological dependence to the drug. MF must therefore be slowly tapered. DD/s: MF use in childhood has been associated with an increased probability of drug abuse problems in adulthood. Illicit drug overdose, especially cocaine, may be difficult to differentiate from MF or amphetamine overdose. A urine toxicology test may be useful in most cases. EXERCISE-INDUCED BRONCHOCONSTRICTION: Is usually seen after strenuous activities or exercises Bronchodilation initially occurs during exercise, followed by bronchoconstriction, which begins after 3 to 5 minutes, and rapidly peaks within 10 to 15 minutes of cessation of exercise. This is extremely common in patients with a history of symptomatic asthma, and the patient"s response correlates with the degree of airway hyperresponsiveness. The first step in the management of patients with exercise-induced bronchoconstriction is to control the underlying asthma effectively. Patients with well-controlled asthma and a history of exercise-induced bronchoconstriction should have prophylactic treatment with inhaled beta-2 agonists (e.g., albuterol) approximately 5 to 10 minutes before the initiation of exercise. Patients with less severe or less frequent attacks, along with their close contacts, must be taught how to recognize and treat the acute attack with inhaled beta-2 agonists. It is important to realize that exercise is not the cause of asthma, but it induces bronchoconstriction in patients with underlying asthma. The patient should not be instructed to avoid exercise. In contrast, exercise should be encouraged to reduce the minute ventilation for any given level of exercise, and to prevent the recurrence of exercise-induced bronchoconstriction CAPILLARY (STRAWBERRY) HEMANGIOMA: Superficial, bright, red, strawberry-like round lesion is a benign vascular lesion. Most capillary hemangiomas are evident at birth. They may undergo subsequent growth for a period of several months (proliferation phase). Spontaneous regression usually follows (involution phase). It is estimated that 70% of superficial lesions will disappear by seven years of age, although residual skin changes may be left. For lesions that are small, do not affect normal functioning, and do not constitute a significant cosmetic problem, observation is the best approach. Laser treatment should be considered in patients with lesions on the face, and at sites of potential functional impairment (orbital area). Imaging studies are usually indicated in infants with multiple superficial lesions to exclude visceral involvement. Oral corticosteroids, and sometimes subcutaneous interferon, are indicated for the treatment of rapidly growing lesions. ANOREXIA NERVOSA: Anorexia nervosa is a complex medical condition, which is difficult to treat. There are some indications to admit a patient with anorexia nervosa to the hospital.

The Society for Adolescent Medicine (SAM) has developed some guidelines.

The indications for admission of Anorexia nervosa are: Dehydration, electrolyte abnormalities (hypokalemia, hyponatremia), bradycardia (less than 50 beats per minute), hypotension (BP < 80/50 mmHg) Hypothermia (under 96F), orthostatism, acute food refusal Severe malnutrition (weight < 75% of the average for her age, height and sex) Acute medical or psychiatric emergencies (pancreatitis, seizures, syncope, suicidal ideation, psychosis), and cardiac arrhythmias If the patient meets any of these criteria, she must be admitted immediately.

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All other medical and psychiatric evaluations may be done after the patient is admitted to the hospital. Hypocalcemia is common in patients with anorexia nervosa because of the presence of hypoalbuminemia. Refeeding syndrome can develop during the second or third week of nutritional therapy of patients with anorexia nervosa. It is characterized by edema and heart failure, and can lead to delirium and cardiac arrest. Phosphate must be replaced immediately, and the patient should be managed in the intensive care unit NEONATAL SEPSIS: The diagnosis of neonatal sepsis is suspected when an infant has poor appetite, decreased reactivity to external stimuli, diminished oral intake, and lassitude or depressed sensorium. Neonatal sepsis -The most common etiologic agents are Group B Streptococcus, Escherichia coli, Klebsiella and Enterobacter species. Although Listeria infections are rare in the United States, ampicillin is recommended as part of the antibiotic regimen. Cefotaxime, ceftriaxone or antipseudomonal penicillins are used in combination with the aforementioned drug. The type of bilirubinemia involved also affects the approach in management of septic infants. Indirect hyperbilirubinemia is usually physiologic in nature and persists, while direct hyperbilirubinemia is probably induced by sepsis-related cholestasis. Ceftriaxone should not be used if there is hyperbilirubinemia, because it will increase both types of bilirubin. Moxalactam and sulfonamides are not recommended due to their capability of increasing indirect bilirubin levels. Sydenhams chorea (SC; also known as Saint Vitus dance), one of the classic manifestations of rheumatic fever. SC is more common in girls, especially between 5 and 13 years of age. SC is usually preceded by a period of emotional lability, manifested by a tendency to cry or laugh, as well as deterioration of school performance. SC starts with distal hand movements, later progressing to facial jerking and grimacing, as well as abnormal feet movement. Chorea usually develops several (one to eight) months after the onset of acute rheumatic fever, whereas carditis and arthritis typically develop within 21 days. The presence of carditis is diagnostic. Approximately one third of the patients have carditis; mitral regurgitation is the most common cardiac finding. Patients may not remember a prior sore throat, and cultures are also usually negative. Patients usually have hypotonia, and the relaxation phase of the patellar reflex is usually delayed. When the patient is examined with the arms stretched out, the arms move from the prone to the supine position (positive pronator sign). DD/s: Gilles de la Tourette syndrome starts between 2 and 15 years of age, and is four times more frequent in boys. Pronator sign, carditis and hypotonia are not present. Attention deficit disorder is a chronic condition with no abnormal findings on physical examination. Rx-Sydenhams chorea (SC) should be treated immediately with oral penicillin for ten days. If patient adherence is an issue, an alternative is a single dose of intramuscular Benzathine penicillin: In patients who are allergic to penicillin, weight based erythromycin, divided in 2-4 doses, and should be given. SC usually resolves within 12 to 15 weeks; however, prophylaxis should be continued into adulthood. If the motor function is severely compromised valproic acid, phenobarbital or haloperidol can be started, and the patient must be referred to a neurologist. ATOPIC DERMATITIS: The characteristic (red, oozing) rash may involve the face and the scalp in children. Scaly, dry cheeks, especially in the winter, are also typical. Atopic dermatitis is believed to have a strong allergic/immunologic component because many patients demonstrate allergies to food and

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inhalant allergens. 80-85% of patients have elevated IgE levels, and there is a strong family predisposition to the disease. The condition promptly responds to topical steroids and calcineurin inhibitors such as topical tacrolimus and pimecrolimus. DIARRHEA DIET: In a child with diarrhea and no clinical signs of dehydration, preferred intake includes fluids low in sugar and the resumption of a normal, age-appropriate diet with plenty of complex carbohydrates with limited fats and sugars. Foods containing excessive sugar can increase the osmolarity of the stool in the intestinal lumen, and fatty foods are known to delay gastric emptying. Both can worsen diarrhea. The previously popular BRAT diet is no longer recommended for refeeding children with diarrhea because it is quite low in calories and protein. Moreover, the bananas and applesauce in the BRAT diet add excessive sugar. Of greater concern is loperamides linkage with paralytic ileus, toxic megacolon, CNS depression, coma, and death in children. RABIES PROPHYLAXIS: In a case of exposure to bats, immediate vaccination is recommended if the person was not aware of the presence of the animal. Postexposure prophylaxis consists of the administration of one dose of anti-rabies IG immunoglobulin and five doses of anti-rabies vaccine. If treatment is postponed for no more than five days (if the patient did not immediately report the exposure), effectiveness will be the same, although there have been reports of rabies in persons not vaccinated in the first 72 hours when the bite was in the head or the neck. ETHICS: Permission to treat a child can only be granted by the parent or legal guardian. As an exception to this rule, adolescents are typically allowed to give consent for their own care in regards to pregnancy, contraception, sexually transmitted diseases, substance use, and emotional illness. When providing medical care, clinicians must seek to balance the autonomy of the family with the welfare of the child. In true emergency situations requiring imminent treatment of a child, most medical teams choose to proceed with treatment despite the parental refusal of care. Very rarely do courts uphold charges against physicians in such cases. HOMOSEXUAL PARENTS: Homosexuality was classified as a sexual disorders in the DSM I and II, but was removed from the revised DSM III. Multiple studies of both biological and adopted children of homosexual parents have been performed, and the general consensus is that these children experience normal childhood development. Among children of homosexual parents, adolescent concerns about identity and peer approval are becoming less intense as variance in the American family unit grows more common and socially accepted. The majority of children adopted by homosexuals consider themselves to be heterosexual, though some do describe themselves as homosexual or bisexual. Homosexual parents have not been proven to be more passive than heterosexual parents, and there is no documentation of increased violence or antisocial behavior in their children. Studies of domestic violence suggest it is similarly prevalent in homosexual and heterosexual relationships. Although at least one study has suggested that certain learning disabilities (e.g., dyslexia, stuttering) are more common in homosexuals than in heterosexuals, there is no evidence that this tendency translates to increased learning disabilities in the children of homosexual parents. BACTERIAL CONJUNCTIVITIS: Characterized by redness and copious, purulent discharge - No fever or blurred vision. Examination shows conjunctival erythema and yellow exudates. It is usually a self-limited disease; however, it must be treated because there is a small, but real risk of keratitis, which can lead to visual impairment.

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DD: Constitutional pubertal delay is characterized by delayed puberty, retarded bone age, and a positive family history without any evidence of systemic disorder. These patients develop puberty without any intervention. The development of secondary sexual characteristics can be enhanced in patients with constitutional pubertal delay by using small doses of testosterone for a short time. The use of testosterone for a short period of time does not compromise the final adult height. Kallmans syndrome consists of anosmia with hypogonadotropic hypogonadism, and sometimes there are associated midline facial defects. This syndrome is due to a genetic defect which leads to the defective migration of GnRH-secreting and olfactory neurons to their final adult positions. NEUROFIBROMATOSIS: To meet the diagnostic criteria NF 1, two or more of the following are required: a first degree relative with NF 1, the development of more than six CALS of 5 mm in greatest diameter (if children) or 15 mm (if adult), or the presence of more than two neurofibromas, Lisch nodules, optic glioma, bone dysplasia, or axillary freckling. If the patient is a child, there is a 15% possibility of development of optic nerve gliomas. Current recommendations include having a detailed ophthalmologic evaluation for early detection of this problem and for search of Lisch nodules (iris hamartoma). As primary care physicians have a lack of expertise in such an evaluation, immediate ophthalmologic referral is advised.-If there are any ophthalmologic or neurologic abnormalities, other tests such as MRI, head CT scan, EMG, or neurosurgery evaluation may be needed. DD: Hypopigmented spots, in combination with a family history of bilateral deafness, strongly suggest neurofibromatosis type 2 (NF-2), an autosomal-dominant disorder. The spots described actually represent cafe-au-lait spots that are usually hypopigmented (unlike the hyperpigmented caf-au-lait spots found in NF-1). Deafness is caused by bilateral acoustic neuromas, a characteristic neurologic manifestation of the syndrome. HERPES ZOSTER OR VARICELLA: The diagnosis of herpes zoster or varicella is made clinically. -No further laboratory tests are needed In immunosuppressed patients (e.g., HIV), the rash can be atypical and can be confused with herpes simplex.

RX: Erythromycin ointment or sulfa drops are the first line of therapy for uncomplicated bacterial conjunctivitis, as they cover most organisms. Fluoroquinolone eye drops are preferred for contact lens wearers and corneal ulcers because of the activity against pseudomonas. -They should not be used in uncomplicated bacterial conjunctivitis as first line therapy because of the risk of the emergence of resistance. Primary care physicians should not prescribe corticosteroids, as they can cause sight-threatening complications in patients with bacterial conjunctivitis and herpes keratitis. Bacterial conjunctivitis is very contagious. The best thing to do is to keep the child at home until the discharge is cleared. However, in many patients who work outside, this may not be feasible. In those patients, at least 24hours of topical antibiotic therapy should be applied before returning to work. Delayed puberty: The earliest sign of puberty is nocturnal increase in the LH surge. This is followed by a daytime increase in the levels of gonadotrophins, and increase in testosterone levels. On physical examination, enlargement of testes is one of the earliest signs of onset of puberty. A patient is diagnosed with delayed puberty if he does not have testicular enlargement by 14 years of age, or if his testicles are 2.5 cm or less in diameter. -Another criterion is a delay in the development for 5 years or more from the onset of genitalia enlargement. The most common cause of delayed puberty is constitutional delay. The initial evaluation involves the use of an imaging test to determine bone age. Bone age that is older or equal to the chronological age warrants further testing to rule out chromosomal abnormality and endocrine causes

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If the patient is critical and antiviral therapy needs to be started, lesions can be scraped for PCR or immunofluorescence studies. VACCINATION: True contraindications for DTaP vaccination: Anaphylaxis within seven days of administration of a previous DTP or DTaP vaccine, and Encephalopathy within seven days of administration of a previous DTP or DTaP vaccine. If high fever (>104.8F), shock, inconsolable crying for three or more hours, or seizure occur within 24 hours of receiving a dose of DTaP vaccine, then subsequent doses should be given with caution. Temporary contraindications to receipt of the DTaP vaccine include: Moderate or severe illness, with the vaccine administered as soon as the illness resolves. Mild acute illness with or without fever is not a contraindication to vaccine administration. There are no significant contraindications to receipt of vaccinations against Hib, poliovirus, and pneumococcus; therefore, a four-month-old child with otitis media should be vaccinated against DTaP, Hib, IPV, and PCV. **Varicella vaccination of household contacts of transplant recipients is relatively safe and is currently recommended by the American Association of Pediatrics (AAP). It is advisable for all patients to receive pre-transplantation immunization, although this is not always possible and durable protection is reached in less than 50% of patients. Transmission of vaccine-associated VZV is not typical, except for some cases when post-vaccination rash appears; therefore, this child should be monitored for the appearance of a rash and isolated if a rash appears TUBERCULOSIS: All patients with sputum-positive pulmonary or laryngeal tuberculosis can transmit the infection to other household contacts or healthcare workers via infectious aerosols containing Mycobacterium tuberculosis bacilli. The acts of coughing, sneezing, singing, and even speaking can all produce microscopic aerosols containing the organism. All such patients should be placed in respiratory isolation until they are confirmed to be noninfectious. Patients are rendered non-infectious if they are receiving effective antituberculous therapy and have had three consecutive negative results on sputum acid-fast smears performed on different occasions. Non-infectivity should be documented by serial negative acid-fast smears, and not by the duration of therapy. A patient can still be infectious after prolonged drug therapy if he has a drug-resistant infection. Resolution of chest x-ray findings in patients with pulmonary tuberculosis typically lag behind the clinical response. Chest radiograph changes can persist for longer periods of time after the patient has been rendered non-infectious, and may even become permanent. **Multi-drug resistant TB: is an emerging problem in the USA. If the organisms are resistant to both rifampin and INH, we call it a multi-drug resistant TB (MDR-TB). In case of exposure to MDR-TB, chemoprophylaxis with pyrazinamide and ethambutol or quinolone with anti-mycobacterial activity, like ofloxacin or levofloxacin is recommended. But, if it is resistant to INH only, then the standard recommendations are to give the chemoprophylaxis with Rifampicin alone for four months or Rifampicin plus PZA for two months. The problem with the rifampin plus PZA combination in an immunocompetent host is liver toxicity. The patient needs careful monitoring. **TUBERCULOUS MENINGITIS: Is one of the forms of extrapulmonary tuberculosis. It is associated with high morbidity and mortality rates. Patients usually present with an insidious onset of symptoms such as malaise, headache, and low-grade fever. If left untreated, these symptoms can rapidly progress to persistent headaches, vomiting, cranial nerve involvement, confusion, seizures, coma, and eventually, death within six to eight weeks of the onset of illness. All patients with suspected tuberculous meningitis (based on initial history and CSF examination) should be immediately started on empiric antituberculous therapy, pending the results of confirmatory tests. The prognosis of the patient with tuberculous meningitis greatly depends on the stage in which the treatment is initiated. Early diagnosis and treatment of the patients is critical to prevent adverse clinical outcomes.

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All patients with tuberculous meningitis should be initially treated with a combination of isoniazid, rifampin, and pyrazinamide (bactericidal agents) for the first two months, followed by treatment with INH and rifampin for the succeeding months. These three agents have good CSF penetration, and can achieve adequate therapeutic levels in the cerebrospinal fluid. Based on the current guidelines, all infants and children with drug-sensitive tuberculous meningitis should be treated for at least 12 months. In a patient with drug-resistant infection, the therapy may be extended to 18-24 months, depending on the clinical response and severity of the illness. SUMMARY: 1. Specific antituberculous therapy should be initiated early in all patients with clinically suspected tuberculous meningitis. 2. Infants and children with tuberculous meningitis, miliary TB, and tuberculous osteomyelitis should receive 12 months of antituberculous therapy. KYPHOSIS: Flexible: Scenario: Physical examination shows a postural round back that is corrected by voluntary hyperextension. Forward bending reveals no lateral deformity and no angulation. Neurological examination of the lower extremities is normal. You order x-ray of the spine that shows a convex alignment of the thoracic spine at 35 degrees. It is typically noticed by parents or teachers who observe adolescents sitting or standing in a slouched position. On lateral radiographs, the angle of thoracic kyphosis is normal or slightly increased (normal 20-40 degree). Interestingly, contrary to common belief, there is no evidence that flexible kyphosis leads to adverse physical effects or permanent deformity. Scheuermann disease (structural kyphosis) Scenario: Physical examination reveals thoracic curving of the spine that is not corrected with voluntary hyperextension of the spine. On forward bending, sharp angularity is observed in the thoracic region, but no lateral deformity is present. Neurological examination of the lower extremities is normal. X-ray of the spine shows a convex alignment of the thoracic spine at 55 degrees. Unlike flexible kyphosis, structural kyFphosis is not corrected with voluntary efforts, and a sharp angulation is commonly seen on forward bending. The typical treatment for structural kyphosis that is not severe (less than 70-80 degrees) includes the use of a Milwaukee brace. In more severe cases (significant angulation, intractable pain, neurological abnormalities), surgical correction is used. TURNER SYNDROME (45,XO): Dorsal feet and hands edema, short webbed neck, and a cardiac murmur) is typical for Turner syndrome. It represents monosomy for the X chromosome (45, X), that is why no Barr body is revealed on the buccal smear. Less common chromosomal abnormalities that can be present in patients with Turner syndrome include X chromosome mosaicism and Xp deletion. Interestingly, the risk of having an infant with monosomy for the X chromosome does not increase with advance maternal age, unlike Downs syndrome and Klinefelter syndrome (47, XXY). Moreover, no increased recurrence risk is present after having an infant with Turner syndrome. All patients who are initially diagnosed must be screened for the presence of other associated somatic abnormalities. The most important of these are the cardiac defects, which include coarctation of the aorta, bicuspid aortic valve, mitral valve prolapse, and hypoplastic heart. Since some of these defects cannot be picked up by clinical examination, an echocardiogram is necessary. The other associated defects are: visual and hearing deficits, kidney malformation (including horseshoe shaped kidney), and an increased predisposition for autoimmune endocrinopathy (especially primary hypothyroidism); therefore, in addition to an echocardiogram, all patients initially diagnosed with Turner syndrome require visual and hearing assessment, renal ultrasound, and TSH level measurement. Patients with Turner syndrome develop moderate to severe insulin resistance and diabetes when they are older. Blood sugar screening is performed based on the patient"s clinical manifestations. Patients with Turner syndrome have hypogonadism, and eventually require estrogen replacement; however, if estrogen therapy is given at an early age, there may be premature fusion of the epiphysis,

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which will potentially decrease the patient"s final height. Most physicians begin prescribing hormone replacement therapy when the patient reaches 14 years of age. Growth hormone is approved for use in patients with Turners syndrome to improve their final height. IMAGING STUDIES IN UTI: Imaging studies are recommended in the following patients: 1. Children under the age of five years with a febrile UTI 2. Males of any age with a first UTI 3. Females under the age of three years with a first UTI 4. Children with UTI who do not promptly respond to antibiotic therapy 5. Children with recurrent UTI Voiding cystourethrogram is routinely recommended, and is considered by most authors as an important imaging study to demonstrate vesico-ureteral reflux (VUR). INFANTILE HYPERTROPHIC PYLORIC STENOSIS (IHPS): Usually presents in infants who are three to six weeks old. 83% of affected patients are boys. Postprandial, non-bilious vomiting is characteristic. Peristaltic waves can sometimes be detected just before vomiting. These occur as wavy movements traveling from left to right across the upper abdomen. A palpable "olive-like" mass in the right upper quadrant is pathognomonic of the disease, but is actually detected by only 49% of physicians, since most cases are diagnosed at an early stage (usually between the third and fourth week). Historically, laboratory evaluation will show hypokalemia and a hypochloremic, metabolic alkalosis secondary to the loss of gastric hydrochloric acid, although electrolyte imbalances are seen less often now that the diagnosis is made earlier. The imaging modality used most commonly to diagnose IHPS is ultrasound, though an upper gastrointestinal (UGI) contrast study is preferred in some medical centers. Electrolyte derangements and dehydration must be corrected before proceeding with surgical correction of infantile hypertrophic pyloric stenosis. Studies have shown that children who undergo surgery without first correcting the electrolyte imbalances are at increased risk for postoperative apnea. Rx: pyloromyotomy Endoscopically guided balloon dilation has been studied, but is not often used because of inconsistent success in opening the muscular ring of the pylorus. This approach is typically reserved for patients who are not otherwise good surgical candidates. Studies have documented an association between the development of infantile hypertrophic pyloric stenosis and the usage of oral erythromycin, which is typically given as postexposure prophylaxis for pertussis. In addition, there is some indication that the usage of macrolides in breastfeeding women is linked to the development of infantile hypertrophic pyloric stenosis, especially in infant girls. CONSTIPATION: The normal frequency of passage of stools in the infant is around six to eight times daily. This approximates to one stool passage per episode of breastfeeding. On the fourth week of life, the pattern changes. The stool frequency decreases to one or two episodes daily or even less, such as three episodes per week. This has to be differentiated from true constipation in order to avoid exaggerated concern. DD: Hirschsprungs disease usually presents earlier in life (failure to pass meconium in first 48 hours) as intestinal obstruction or enterocolitis. Notwithstanding, some patients will be diagnosed later, but will have a history of chronic constipation and failure to thrive. For this reason, observation is required to determine if the constipation persists. **While constipation can signify a serious disorder (e.g., Hirschsprungs disease, cystic fibrosis, hypothyroidism) in select circumstances, most children who are constipated are normal. Children with a history of resisting toilet training are at increased risk for developing constipation, as are those children whose dietary intake is high in dairy products and low in fiber. If dietary modification fails to relieve constipation, usage of a laxative is the next best step. Once the childs bowel begins to operate properly on its own, the laxatives should be discontinued gradually.

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Magnesium hydroxide, also known as milk of magnesia, is a mild saline laxative that causes the osmotic retention of fluid in the gut lumen. It can be titrated to produce soft, but non-liquid stool, and is safe for use in young children. In a child experiencing moderate constipation and no encopresis, magnesium hydroxide is an excellent treatment choice.

RX: Bisacodyl suppositories are powerful stimulant laxatives that cause increased peristalsis. Usage of these suppositories commonly results in abdominal cramping, diarrhea, and nausea, and is best reserved for short-term "rescue therapy" in children with severe constipation. Phosphate enemas are highly effective at relieving impaction, and act by distending the rectum and stimulating the muscles of the colon; however, frequent use of these enemas can cause electrolyte imbalances, and is therefore discouraged. This form of treatment is best reserved for relieving impaction or for bowel preparation prior to medical procedures. TICK BITE: The risk of acquiring Lyme disease after being bitten by a tick is less than 1.5%. The most common complication of tick bites is local inflammation or infection. In order to be infected with Lyme disease, the patient must have been exposed to the tick for more than 36 hours, because the transmission of the infectious agent - Borrelia burgdorferi - takes place only after the tick is firmly attached to the skin and has suctioned a certain amount of blood which gives it an engorged appearance. If a tick is found and it is not engorged with blood, there is no risk of Lyme disease, as ticks take at least 24 hours to firmly attach to their victims. The majority of patients have a transitory skin reaction in the first 24-72 hours on the site of contact with the tick; this lesion must not be confounded with erythema chronicus migrans, which develops later. The tick that transmits Lyme disease is brown, while the one that transmits RMSF is black EPIGLOTTITIS: With the introduction of the Haemophilus influenzae type b vaccine in 1985, epiglottitis has become much less common in recent years. When it does occur, it causes an inflammatory edema of the epiglottis that impinges upon the airway. Respiratory arrest is easily provoked at this stage, and treatment should be focused on relieving any airway obstruction and treating the infection. The threshold for performing intubation should be very low. Since the outpatient setting is inadequate for such procedures, it is imperative that an ambulance be called so the childs condition can be properly addressed by emergency personnel. Frequently, epiglottitis is diagnosed solely by the clinical presentation. However, if a lateral neck radiograph is deemed necessary, it will reveal a swollen epiglottis (the "thumbprint sign") in classic epiglottitis. Endotracheal intubation should be performed before the radiograph is obtained, because patient is at great risk for respiratory arrest. LEAD INTOXICATION: Lead intoxication remains a common preventable environmental hazard, although its prevalence is declining in developed countries. Early recognition of lead poisoning helps to prevent the development of long-term irreversible neurological sequelae. The two main factors contributing to lead poisoning in industrialized countries are exposure to old, lead-based paints which are usually found in old houses, and non-nutritive hand-to-mouth activities of young children. Children with a blood lead level greater than 10 g/dL should be comprehensively evaluated by obtaining a CBC, serum electrolyte levels, and urinalysis. Environmental/behavioral interventions are crucial in the management of patients with lead intoxication. Ideally, these include identifying the source of exposure, removing the family from the lead-containing dwelling, cleansing of the environment, and educating the family in an effort to reduce hand-to-mouth activitiesof the children. High-risk populations must be screened for lead intoxication. This includes children who live in or frequently visit old houses, and children whose sibling was diagnosed with lead poisoning.

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Measurement of the blood lead level is the gold standard in lead intoxication screening. A blood lead level greater than 10 g/dL is diagnostic. Venous sampling is always preferred to capillary sampling because the former is more accurate. **Mild lead poisoning (blood lead level < 45 g/dL) can be treated by DMSA or d-penicillamine, although this approach is not evidence-based. Moderate lead poisoning (blood lead level between 45 and 70 g/dL) requires the treatment with EDTA IV or oral DMSA. Continuous IV infusion of EDTA is preferred to IM injection Severe lead intoxication (blood lead level > 70 g/dL and/or acute encephalopathy) is a medical emergency and prompt chelation therapy with dimercaprol and EDTA is necessary. AFEBRILE PNEUMONIA SYNDROME (APS): Causative organisms of APS include Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma, CMV, RSV, Parainfluenza virus, Adenovirus, and Pneumocystis carinii. The fever may either be absent or low grade. Other symptoms include cough, tachypnea, irritability, and poor feeding. Because of the lack of specificity of symptoms and radiologic findings, the causative organism cannot be determined solely by the clinical presentation. However, some organisms have characteristic features which may aid in the differential diagnosis and direct the necessary work-up of the patient. The age of onset (between 2 and 19 weeks) and the presence of staccato cough are suggestive of Chlamydia pneumonia. This diagnosis can further be supported if there is a history of conjunctivitis in the neonatal period. Conjunctivitis is present in half of cases and may present either in the neonatal period or be concurrent with the pulmonary infection. Additional characteristics include auscultatory and radiologic findings that are out of proportion to the overall healthy appearance of the infant. Chest-x ray shows hyperinflation, peribronchial thickening, and bilateral, symmetrical, interstitial infiltrates. The WBC count is usually normal, but the eosinophil count is elevated. The diagnosis can be confirmed by tissue culture isolation of the organism from nasopharyngeal specimens, direct fluorescent antibody tests, enzyme-linked immunoassays, or polymerase chain reaction. DELAYED SPEECH DEVELOPMENT: May indicate an underlying hearing impairment and should prompt referral of the patient for audiologic assessment. Other candidates for hearing evaluation include children with a family history of hereditary childhood hearing loss, history of meningitis, history of recurrent or persistent otitis media with effusion for more than three months, documented intrauterine infections, craniofacial anomalies, and use of ototoxic medications such as aminoglycoside. Hearing loss early in life, even mild or unilateral, may affect speech and language development, social and emotional development, and academic achievements. Early identification is thus mandatory for a better prognosis; hence, screening programs have been widely and strongly advocated. Although the American Academy of Pediatrics endorses universal screening, at present, systematic screening is implemented in 32 states only. The etiology of hearing impairment depends on whether the hearing loss is conductive or sensorineural. The most common cause of conductive hearing loss in children is presence of fluid in the middle ear. Other causes include tympanic membrane perforation (trauma or infection), ossicular discontinuity (infection, cholesteatoma, and trauma), tympanosclerosis, and congenital anomalies of the external ear canal or middle ear components. As for sensorineural hearing loss (SNHL), it may be congenital or acquired. The most common infectious cause of congenital SNHL is CMV. Other less common congenital infectious causes include toxoplasmosis, syphilis, and rubella. Postnatal infectious causes include group B streptococcus and bacterial meningitis. Hearing loss can also be genetically determined; it may be autosomal dominant or recessive, isolated or in a syndromic association with other anomalies.

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DOWNS SYNDROME: Endocardial cushion defect is the most common congenital heart lesion in patients with Downs syndrome. Other malformations that are frequent in Downs syndrome include duodenal atresia, Hirschsprungs disease, atlanto-axial instability, and hypothyroidism. Echocardiography is the most useful test for diagnostic evaluation of this condition. Cardiac catheterization is evidently more accurate than echocardiography for diagnostic evaluation, but this modality is reserved for cases in which the size of the shunt is uncertain, laboratory data and clinical findings are equivocal, or when pulmonary vascular disease is suspected. Patients with Downs syndrome are at increased risk of developing acute leukemia later in life. Other conditions which occur with a higher frequency in Downs syndrome include Alzheimer-like dementia, autism, ADHD, depressive disorder, and seizure disorder. INFECTIOUS MONONUCLEOSIS: Suspect IM in any adolescent who presents with fever, pharyngitis, tonsillitis, lymphadenopathy, splenomegaly, and rash. The recognition of "atypical lymphocytes" in the peripheral smear can be a clue to its identification, but these can also be seen in toxoplasmosis, CMV infection, or lymphocytic leukemia. **It is infrequent to find posterior cervical adenopathy in a case of common bacterial pharyngitis. The development of rash after administration of amoxicillin is also one of the characteristics of the disease. Even though the spleen and liver are not always palpable, the former is constantly increased in size and friable. Since there is an increased risk of splenic rupture, especially if the patient is actively involved in sports, a patient who is highly suspicious for IM must be recommended to avoid practicing sports while waiting for the test results. Despite this fact, almost 50% of the cases of splenic rupture associated with IM can occur spontaneously, without evidence of previous trauma or excessive exercise. SMOKING CESSATION: Nicotine is a highly addictive drug. It is extremely difficult for even the highly motivated to stop smoking. Numerous factors may elicit the urge to smoke. Studies have shown that smokers who attempt to quit while working or living with people who continue to smoke are much more likely to relapse. Smoking cessation is difficult to accomplish if the smoker remains subject to environmental triggers, including friends and family who continue to smoke. Parents who want their children to stop smoking should quit themselves. Prescriptions for nicotine replacement (e.g., nicotine patch, nicotine gum) should be offered to those smokers interested in quitting. RASH: Due to the success of immunization campaigns, infection with the Rubella Virus is now very rarely seen in the United States; cases today typically arise in non-immunized foreign born populations. Infection with rubella is most often asymptomatic, but can cause German measles, a mild illness classically characterized by low-grade fever, lymphadenopathy involving the posterior cervical and occipital lymph nodes, and a maculopapular rash that begins on the face and spreads caudally. The rash is similar in appearance to that caused by measles, but patients are usually much less sick upon presentation with rubella. Supportive treatment is sufficient when the illness is selflimited. Of primary concern is the congenital rubella syndrome, which has devastating effects on the unborn child, especially when a non-immune pregnant woman is exposed to the virus in the first trimester. VARICELLA, commonly known as chickenpox, is an illness characterized by a low-grade fever, malaise, and a macular rash that appears in crops which progress through several stages, including papules, vesicles, pustules, and crusts. The rash is considered distinctive because it includes a variety of lesions at different stages. RUBEOLA, commonly known as measles, is an illness characterized by the three Cs: cough, conjunctivitis, and coryza. Fever and photophobia are also common. The blue-white Koplik spots found

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on the buccal mucosa precede the appearance of the maculopapular rash, which starts on the face and spreads caudally to the trunk and extremities. ROSEOLA is a mild illness characterized by a high fever that rapidly resolves. The fever is followed by the eruption of a characteristic rosy nonpruritic rash originating on the trunk and spreading to involve the extremities. ROCKY MOUNTAIN SPOTTED FEVER is a rickettsial disease transmitted by tick bite. It is characterized by fever, myalgias, headache, and a petechial rash. - Classically, the rash first involves the distal extremities (especially the palms and soles) and subsequently spreads to involve the trunk. HENOCH-SCHONLEIN PURPURA: Classical clinical manifestations of Henoch-SchOnlein purpura include abdominal pain, arthralgias, skin lesions, and renal involvement. An antecedent upper respiratory infection is present in 50% of patients. Abdominal pain is a presenting symptom in 10-15% of patients. The skin lesions are symmetric, involve dependent parts of the body, and classically progress from an erythematous, macular rash to papular purpura. The joints and kidneys are also commonly involved. THROMBOTIC THROMBOCYTOPENIC PURPURA (TTP) is a serious disorder characterized by the following classical pentad: 1. Severe thrombocytopenia 2. Microangiopathic hemolytic anemia (RBC fragments) 3. Fluctuating neurological signs 4. Renal failure 5. Fever Patients with TTP generally present with fever, pallor, petechiae, and confusion.The peripheral smear shows RBC fragments. PT and PTT are usually normal.The LDH is elevated due to hemolysis. Hemolytic uremic syndrome (HUS) and TTP comes under a spectrum of diseases. If a patient has more neurologic symptoms and less renal failure, the disease is considered TTP. On the other hand, if a patient has significant renal failure and less neurologic symptoms, the disease is considered HUS. Both TTP and HUS are very serious conditions, and require emergent plasmapheresis. IDIOPATHIC THROMBOCYTOPENIC PURPURA: Platelet-specific autoantibodies are the presumed pathogenesis of idiopathic thrombocytopenic purpura. In children, the condition is typically characterized by a sudden onset of bleeding, manifested as petechiae, purpura, epistaxis, and gingival bleeding. More severe bleeding is rare. Commonly, there is a history of infection in the several weeks prior to presentation. Symptomatic patients with moderate to severe thrombocytopenia DIAPER RASH (DIAPER DERMATITIS): is a type of irritant contact dermatitis that is caused by a combination of factors: overhydration, friction, maceration and prolonged contact with excretions. The appearance of the rash after an episode of diarrhea is very characteristic. Management includes keeping the diaper area of the skin as dry as possible. This involves: frequent changing of diapers, avoiding tight-fitting diapers, exposing the skin to air, using diapers with super absorbent surfaces, and applying barrier creams such as zinc oxide or petrolatum. An uncomplicated diaper rash resolves quickly if the abovementioned measures are performed. Otherwise, a low-potency corticosteroid ointment may be prescribed. DDs: Candidal Diaper Rash: Tomato-red plaques and satellite papules are characteristic of candidal intertrigo and perineal infection. This infection is common in infants who have recently received antibiotic therapy because the decrease in the normal bacterial flora favors yeast proliferation. The condition can be confounded with diaper dermatitis, which affects the same area but usually spares the crural folds. Treatment of candidal diaper rash involves the application of an antimycotic cream such as clotrimazole or nystatin, while zinc oxide is the preferred treatment for diaper dermatitis.

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Intestinal Parasitosis: Due to Helminths (hookworms, roundworms, pinworms, or whipworms) is the most frequent cause of chronic diarrhea, iron-deficiency anemia, and eosinophilia in patients coming from endemic countries. The prognosis is excellent with adequate therapy. Since the disease is easily transmitted, prophylactic treatment should be given to the rest of the household members. HEMOPHILIA: Is an X-linked recessive disorder that occurs almost exclusively in males. Females are usually the carriers of the disease. A female may acquire hemophilia, an extremely rare possibility, only when her father is a hemophiliac, and her mother is a carrier who transmits the abnormal allele to her. When a father is a hemophiliac, he will transmit his abnormal X gene to all his daughters, and consequently, they will all be carriers of the disease. When the mother is a carrier, her daughters have 50% chances of being carriers and her sons have 50% chances of getting the disease. CHILDHOOD ABSENCE EPILEPSY (CAE): Age of onset (4-8 years), no neurologic signs, typical EEG pattern, and no myoclonic activity. This condition is usually responsive to ethosuximide or valproate, although high doses may be required to control it effectively. Interestingly, many traditional anti-epileptic drugs are not effective in absence epilepsy, and can even exacerbate the condition (e.g. gabapentin). The prognosis in patients with CAE, especially if generalized tonic-clonic seizures are absent, is good. Staring spells will disappear in the teenage years. The risk of persistence of the condition is higher in patients who develop generalized tonic-clonic seizures. Unlike CAE, juvenile myoclonic epilepsy (JME) is characterized by a late onset of absence seizures with myoclonic activity, and is associated with life-long seizures. CANDIDIASIS: The first-line therapy for oral candidiasis is a topical antifungal - nystatin suspension or clotrimazole troches. Oral fluconazole can be used in resistant cases. CHILD ABUSE: Always maintain a high index of suspicion for physical/sexual abuse in children (especially females) with sudden behavioral problems, especially if the family has an unstable economic background or if the childs parents have a history of drug/alcohol abuse. **Whenever you suspect child abuse, it is strongly recommended that you inform the social services of your hospital or to call the child protection agency. Even if you are proved wrong later on, you do not owe any liability legally and, perhaps, it is the most important step in the management of suspected child abuse. ALLERGIC RHINITIS: Dog or cat dander is one of the most common identifiable allergen in patients with perennial allergic rhinitis. Allergen avoidance is traditionally considered the first step in the management. If the allergen is not identified or the symptoms persist after the avoidance measures, nasal corticosteroids should be the first-line therapy. Second-generation antihistamines and cromolyn are less effective than topical steroids. Nasal decongestive sprays are not recommended because tachyphylaxis usually develops and rebound phenomena may result. THALASSEMIA MAJOR: Patients with this disorder usually die early in life due to relentless anemia and catastrophic expansion of erythroid precursors. Hypertransfusion therapy has a great role in treated patients (i.e. the child may survive several years after the diagnosis). Hypertransfusion regimen can suppress the effects of chronic severe anemia and extramedullary hematopoiesis, but result in significant iron overload and resultant organ damage.

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FAILURE TO THRIVE (FTT): Is not a diagnosis in itself; rather, it is a term used to describe failure to gain weight in children younger than two years old. Children categorized as FTT weigh less than the 5th percentile for their age; more severe cases involve a slowing of linear growth and head circumference as well. The three causes of FTT are inadequate calorie intake, inadequate calorie absorption, and Increased calorie requirements. Newborn infants need 110 kcal/kg/day, while children up to twelve months need 100 kcal/kg/day to grow at a normal pace. Psychosocial factors are very commonly involved in cases of FTT; this is why the clinician must explore whether there are stressors in the home environment. Organic causes of FTT, while less common, may include feeding problems, milk-protein intolerance, and inborn errors of metabolism, infection, cystic fibrosis, gastroesophageal reflux, or renal tubular acidosis. Rx:Dietary modification is the first-line of treatment in an otherwise well-appearing child with FTT. The anxiety caused to the family by admitting the child to the hospital should not be underestimated. Although admitting a child with FTT for hyperalimentation was a common practice in the past, it is now considered unnecessary unless the child is severely malnourished, or if the child is at risk for neglect or abuse. Dietary modification is the first-line of treatment If oral feedings do not result in appropriate weight gain within four to six weeks, supplemental feeding by nasogastric tube is preferred to the intravenous route. If the history and physical examination are suggestive of an organic cause for the childs FTT, then laboratory evaluation is warranted. Appropriate tests include urinalysis and culture, hematocrit, blood urea nitrogen, calcium, electrolyte levels, HIV ELISA test, and Mantoux tuberculin skin testing. Note that unless there is clinical evidence suggestive of thyroid disturbance, thyroid hormone levels are not typically tested. CAT BITES: Get infected most of the time. Furthermore, the lesion is usually deeper than when produced by a dog, because the cats teeth are smaller and sharper. Pasteurella multocida, the major causative organism, is transmitted by the cats bite. However, this is often a polymicrobial infection. Adequate prophylaxis can be obtained by using amoxicillin and clavulanic acid. In adults, especially those allergic to penicillin, the second alternative is doxycycline. More ill patients can be treated with intravenous ampicillin-sulbactam combination. ** The incidence of infection complicating a cat bite is close to 50%; therefore, antibiotic prophylaxis is usually recommended, especially in high-risk situations (a hand bite is considered a high-risk situation) wherein the potential infection could extend to the bone and joint. The first dose of antibiotics (e.g. ampicillin/sulbactam) is usually given parenterally, and covers a broad spectrum of cat mouth flora, including Pasteurella multocida. An oral antibiotic (e.g. amoxicillin/clavulanate) is administered subsequently for 3-5 days. CAT-SCRATCH DISEASE: Is an infection that usually affects the young immunocompetent population. It is produced by Bartonella henselae. Around 10% of the patients with cat-scratch disease can develop suppuration of the lymph nodes. Other complications are: visual loss due to neuroretinitis, encephalopathy, fever of unknown origin, and hepatosplenomegaly. GASTROESOPHAGEAL REFLUX DISEASE (GERD) is a clinical diagnosis. Reassurance should be offered to the mother that the "spitting up" is a normal occurrence in infants up to 24 months old. It typically requires no intervention if the child is otherwise healthy and developing appropriately (the "happy spitter"). -Children with mild GER symptoms, should be initially addressed with reassurance and thickening of formula with cereal, which usually results in decreased emesis, decreased cry, and better weight gain.

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-Prone positioning is another conservative treatment that may alleviate symptoms; however, this treatment method is of some concern, because of the correlation between prone positioning and SIDS. -Formula thickening should be attempted first. -H2 receptor antagonists such as ranitidine are appropriate in those infants with a more severe GER presentation and who have failed conservative treatment. -Surgery is reserved for cases of GER that do not respond to medical management. PNEUMONIA: It can be difficult to distinguish between bacterial and viral pneumonia, and indeed viral pneumonia is very common in previously healthy children and adults.-Classically, bacterial pneumonias are sudden in onset, associated with high fevers, and cause the child to look very ill if not toxic. Auscultatory findings are typically focal and distinctive. -Chest radiographs may demonstrate a lobar consolidation. In contrast, viral pneumonias are gradual in onset and cause the child to look mildly ill. Auscultatory findings are more diffuse and bilateral. -Chest radiographs may also demonstrate a more diffuse, bilateral infiltrate. Both forms of pneumonia are frequently preceded by an upper respiratory tract infection. Community-acquired bacterial pneumonia in children is most commonly caused by S. pneumoniae. Amoxicillin is the drug of choice for the outpatient treatment of patients younger than five years of age Group B streptococcus pneumonia occurs most often in neonates. Mycoplasma causes respiratory infection most often in school-aged children and young adults. The clinical presentation is usually gradual (although it may be abrupt) and is characterized by malaise, headache, fever, rhinorrhea, and sore throat with progression to lower respiratory symptoms. Pneumocystis carinii pneumonia (PCP) is seen in patients with defects in cell-mediated immunity, especially in HIV-infected patients. It is usually seen in HIV patients when the CD4 cell count decreases to less than 200 cells/cubic mm. It has an insidious onset, and usually presents with lowgrade fever, cough, dyspnea, and tachypnea. Chest x-ray results of patients with PCP reveal diffuse, bilateral ground-glass opacity. Trimethoprim-sulfamethoxazole is the initial drug of choice for treatment in patients with suspected or proven Pneumocystis carinii pneumonia. RESPIRATORY SYNCYTIAL VIRUS: Are the most important respiratory pathogen of early childhood, and the major cause of bronchiolitis and pneumonia in children < 1 year. T he illness manifests in annual outbreaks, appearing in winter with peaks in January, February, or March. Although this disease affects all age groups, lower respiratory symptoms appear mainly in children. Apnea is an important clue for this condition, as up to 25% of infants presenting with RSV infection will have this. How it causes significant apnea is not clearly known. The illness tends to be more severe, with a higher frequency of complications in preterms and infants with chronic medical conditions such as congenital heart disease, chronic lung disease, and immune deficiencies. Diagnosis of RSV is quickly made by detection of RSV antigen in nasal or pulmonary secretions by ELISA. RX-** In healthy infants and young children, bronchiolitis is usually a self-limited disease; however, patients who are hypoxic or cannot feed because of distress should be hospitalized. These children should be kept in respiratory isolation. Therapy in most cases consists of supportive measures. Humidified oxygen and tube or intravenous feedings are indicated. Although there is no strong evidence that inhaled bronchodilators are effective in patients with bronchiolitis, it is a routine practice to administer these (nebulized albuterol or epinephrine) and observe the patient for any effect. If no prompt clinical response is seen, most clinicians discontinue these drugs. Although ribavirin is a nucleoside analogue with good in vitro activity against RSV, studies examining its effect in children have been conflicting, and the cost for a course of therapy is substantial. It is usually reserved for patients with severe disease.

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COMPLICATIONS, RISKS: A secondary bacterial infection of the middle ear and future risk of bronchial hyperreactivity are the most common complications of RSV bronchiolitis. CONGENITAL TOXOPLASMOSIS: The consumption of undercooked meat during pregnancy may be associated with congenital toxoplasmosis, which can manifest as microcephaly or other abnormalities, such as chorioretinitis, mental retardation, deafness, and seizures. Domestic cats are definite hosts for T. gondii. Humans can acquire the infection by: (1) The consumption of raw or undercooked meat of infected animals (including lamb, beef, or game), or (2) Contact with cat feces. Other congenital infections of the TORCH group can also result in microcephaly. RHEUMATIC DISEASE PROPHYLAXIS: The benefits of antibiotic therapy in a child with acute pharyngitis include: (1) Reduction of the severity and duration of the symptoms, (2) Prevention of rheumatic fever, and (3) Prevention of local suppurative complications. Interestingly, antibiotic therapy does not decrease the risk of acute glomerulonephritis because cutaneous (not pharyngeal) infection is typically implicated as its cause. DISEASE ASSOCIATIONS: Meconium Ileus - Is usually the earliest manifestation of cystic fibrosis (CF), and is almost pathognomonic for the disease. Uncomplicated meconium ileus is characterized by distal intestinal obstruction, wherein the terminal ileum is dilated and filled with thick, tar-like, inspissated meconium. - Plain abdominal x-ray findings (dilated, gas-filled loops of small bowel, absent air-fluid levels, and a meconium mass within the right side of the abdomen) are usually suggestive of the diagnosis. - Since CF is inherited in an autosomal recessive pattern, a family history of recurrent respiratory infections (or other manifestations of CF) is an important clue to the diagnosis of this patient. Duodenal Atresia is associated with Downs syndrome and polyhydramnios. A family history of severe constipation is sometimes present in patients with Hirschsprungs Disease. Patients with pyloric stenosis are typically firstborn males. Even though most cases of muscular dystrophy such as Duchennes, Beckers, or myotonic dystrophy present around 10-12 years of age, some cases can be diagnosed when the child is 2-3 years old. Limb-Girdle Or Facioscapulohumeral Muscular Dystrophies can be detected at this age; while congenital dystrophies and glycogen-storage diseases are evident soon after birth, and have early mortality. Muscular dystrophy can be a cause of inability to walk or limping in the infant or toddler, even though the more common cause of this problem is spasticity, a condition amenable to rehabilitation therapy. Hypothyroidism, MSUP and phenylketonuria must be screened for at birth, and are almost always accompanied by mental retardation and global delays in development. NEONATAL SCREENING FOR HYPOTHYROIDISM Is performed by obtaining a small sample (few drops) of blood from the heel pad and using a piece of filter paper to absorb the blood sample. This test may be done within two to five days following delivery. It is performed after the first 24 hours of life because there is a normal physiologic TSH surge following delivery. After 24 hours, the TSH levels gradually drop to normal levels or may remain slightly elevated for the next few days. It is very important to avoid any delays in the diagnosis and treatment to avoid permanent neurological deficits. Most centers in the United States use total T4 measurement as a primary tool for screening for neonatal hypothyroidism. If the total T4 levels are low, TSH levels of the same sample is measured, and if the TSH levels are over 20 U/L, repeat testing (measurement of both Free T4 and TSH levels) is performed from a regular blood draw to confirm the diagnosis. Some programs use TSH as a primary screening tool.

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Once the diagnosis of neonatal hypothyroidism is confirmed by measuring the Free T4 and TSH levels from a regular blood draw, other ancillary procedures such as thyroid ultrasonography, radioactive iodine scanning and urinary iodide levels are performed to investigate the etiology of the hypothyroid state. Radioactive iodine uptake and scanning are useful to determine the location, size and function of the thyroid gland. Levothyroxine is the treatment of choice for hypothyroidism, and the dose in the neonate is higher than the adult dose; however, levothyroxine therapy should be started once the diagnosis is confirmed with a regular blood draw. The clinical features of hypothyroidism in neonates can be subtle and unreliable. Levothyroxine therapy in neonates is therefore started once the biochemical confirmation is obtained, even if the clinical features of hypothyroidism are not present. FEBRILE SEIZURES: The generally accepted criteria for febrile seizures are: 1. Age less than six years 2. No past history of afebrile seizures 3. Temperature greater than 38 C 4. No evidence of CNS infection / inflammation 5. No metabolic disturbances present which may produce seizures **Febrile Seizures may be subdivided into 2 forms: Simple and Complex. Simple Febrile Seizure is characterized by the absence of focal features, duration of less than 15 minutes for an isolated event, and for seizures occurring in series, a cumulative duration of less than 30 minutes. This form of seizures is more common, and is associated with only a mild elevation of the risk for subsequent epilepsy (i.e. afebrile seizures) in latter life, compared to the general population, contrary to previous thinking. - It is important to note that the question specifically asks about prognosis, and not recurrence. If the question particularly asks about the recurrence of febrile seizures during childhood, then the answer would be significantly elevated risk, regardless if this case was a simple or complex febrile seizure for the first time. - Febrile seizures often occur on the first day of a mild illness as the childs temperature is rising, and may be the first manifestation of illness. - Generally, studies are not necessary for the evaluation of the simple febrile seizure, although it may be appropriate to explore the cause of the fever in children with other symptoms (e.g., severe diarrhea). - Parents should be reassured that it is not an indication of future neurologic dysfunction or disease. Complex Febrile Seizures, on the other hand, are characterized by focal features (i.e. postictal paresis), a duration of more than 15 minutes, and if occurring in series, a cumulative duration of greater than 30 minutes. CONGENITAL ADRENAL HYPERPLASIA (CAH): Is a group of disorders characterized by a deficiency in one of the enzymes involved in steroid synthesis. In 90% of cases, the deficiency concerns 21-hydroxylase, which is necessary in mineralocorticoid and glucocorticoid synthesis. - In addition to a low production of mineralocorticoids and glucocorticoids, the deficiency of 21hydroxylase results in an excess of its substrates. - These excess substrates are shunted towards androgen synthesis, resulting in ambiguous genitalia and virilization in females, and precocious puberty in males. - ACTH levels are also evidently elevated, and lead to hyperplasia of the adrenal glands, further contributing to the increased production of androgens. - Salt Wasting Syndrome occurs in severe deficiencies. It presents in the first 2-4 weeks of life with emesis, dehydration, and shock. Laboratory work-up reveals hyponatremia and hyperkalemia (from lack of aldosterone), and hypoglycemia (from lack of cortisol). - Diagnosis confirmation of 21-hydroxylase deficiency is carried out by documenting the elevation of 17 alpha-hydroxyprogesterone, a substrate of 21-hydroxylase.

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Other biologic disturbances occurring in 21-hydroxylase deficiency include elevated corticotropin and renin levels, and a serum aldosterone level that is inappropriately low for the renin level. - Rx :The treatment principle for 21-hydroxylase deficiency is based on supplementation of deficient hormones (mineralocorticoids and glucocorticoids). This supplementation will decrease corticotropin (ACTH) production, and consequently correct androgen levels. 11-Hydroxylase Deficiency is a far less frequent cause of CAH than 21-hydroxylase deficiency. It is characterized by: o Decreased aldosterone and cortisol, and o increased androgens and deoxycorticosterone. - A deficiency in 11-hydroxylase results in an excess in its substrate, 11-deoxycorticosterone. This substrate has mineralocorticoid activity. - Patients with this condition present with hypertension, hypernatremia, and hypokalemia. 3-Beta-Hydroxysteroid Dehydrogenase is a rare cause of CAH. It involves: o a decrease in testosterone, mineralocorticoids and glucocorticoids, and o an increase in DHEA-S. -Consequently, males fail to acquire normal external genitalia because of a lack of testosterone, and females are slightly masculinized because of DHEA-S excess. MARFAN SYNDROME (MFS): A disease characterized by arachnodactyly, increased arm span relative to height, and valvular (mitral or aortic) insufficiency. Associations: 1) Dural ectasia is the most common finding, although frequently overlooked (present in more than 90% of patients), and usually requires an MRI of the lumbar spine for the confirmation of the diagnosis 2) Other characteristics that can affect up to 80% of the patients with MFS are ectopia lentis, aortic dilatation (more frequent in adults), and mitral valve prolapse. 3) The risk of aortic dissection is high in patients with MFS. 4) For this reason, corrective surgery is recommended when the aortic root reaches 45 mm. 5) About 80% of the patients will have mitral insufficiency, which can lead to CHF. 6) These patients will benefit from mitral valve replacement. DIAPHRAGMATIC PARALYSIS IN A NEWBORN: usually results from phrenic nerve injury The two most common causes of phrenic nerve injury are birth injury and cardiothoracic injury It is typically accompanied by the signs of brachial plexus injury, like Erbs palsy. Other causes of diaphragmatic paralysis (diaphragmatic hypoplasia, neural and neuromuscular disorders) are very rare. MYELOMENINGOCELE: In 80% of myelomeningocele cases, the lumbar region is involved. Almost all these patients will have bladder dysfunction, which can ultimately lead to upper urinary tract involvement and renal dysfunction. Children with S2-S3 involvement can have external anal sphincter dysfunction that can lead to fecal incontinence.This is a much less common complication than bladder involvement, and is specifically associated with S2-S3 involvement. GIARDIASIS: Have several routes of transmission: person-to-person, food-borne and waterborne. Person-to-person transmission occurs in two settings: o In institutions where there is fecal incontinence and poor hygiene (e.g., some daycare centers), and o In male homosexuals. Symptomatic patients with giardiasis should receive appropriate treatment. Asymptomatic carriers of Giardia lamblia are not usually treated, except in specific instances such as in outbreak control and for prevention of household transmission by toddlers to pregnant women and patients with hypogammaglobulinemia or cystic fibrosis.

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SEVERE MALNUTRITION: Remains as one of the major health problems in developing countries The initial treatment of patients with severe malnutrition should address the following issues: temperature control (warming), possible infection, dehydration and malnutrition (feeding) Dehydration should be treated with oral rehydration whenever possible. POSTERIOR URETHRAL VALVES: Are predominantly found in males and is the most common cause of severe obstructive uropathy in children. The abnormal development of the valves in utero can obstruct urinary flow, leading to detrusor hypertrophy and, eventually, vesicoureteral reflux and hydronephrosis. Hallmarks of PUV include a distended bladder and a weak urine stream. Voiding cystourethrogram (VCUG) is a radiographic examination of the bladder and lower urinary tract. The bladder is filled with contrast material by catheter and multiple radiographic images of the bladder and urethra are obtained as the patient empties the bladder. VCUG is especially helpful in evaluating young children for vesicoureteral reflux and posterior urethral valves. FOREIGN BODY ASPIRATION: Never forget your ABCs of resuscitation no matter what the nature of emergency is. The Heimlich maneuver is recommended in kids older than one year.Below that age, give blows on the back with chest thrusts. If the child is unconscious, do it while the patient is lying down. After the abdominal thrusts, examine the airway for a foreign body. If visualized, it should be removed. TRANSIENT SYNOVITIS (ALSO KNOWN AS TOXIC SYNOVITIS): Is a common condition that causes pain in the hip, thigh, or knee in boys aged 3-10 years old. Up to 25% of children with transient synovitis will have bilateral effusions. The disorder may be preceded by a respiratory infection, although the erythrocyte sedimentation rate (ESR) and white blood count (WBC) are typically normal. If the clinical presentation suggests transient synovitis and plain radiographs are unremarkable, an ultrasound should be performed. Ultrasonography is the preferred technique for identifying small joint effusions, and may demonstrate widening of the joint space of the hip. This modality is also useful in guiding aspiration of the joint, a procedure that is warranted in a febrile child with hip effusion. BREASTFEEDING ISSUES: Every primary care physician should encourage breastfeeding. It is recommended that the infant be fed at least every 4 four hours. The mother should be able to identify early signs of hunger, like suckling of the hand or fingers or arm movements towards the mouth, as preterm or debilitated infants may not be able to cry vigorously or show agitation. Cry is a late sign of hunger! It is a good practice to feed the newborn using both breasts, as complete emptying of the breast will increase the milks nutritional qualities. Unfortunately, sometimes there may be a decreased production of milk, and the baby has to be fed using artificial formula. But Feeding the baby using both breasts will therefore not guarantee the infants satiety. NEONATAL JAUNDICE: If appearing in the first 24 hours of birth is always pathologic. Immune or non-immune hemolysis is frequently present in such patients. G-6-PD Deficiency is the most common red cell enzymopathy that can lead to hemolysis. It is an Xlinked disorder, and should be suspected in a male infant of African, Mediterranean, or Asian descent. No triggering agent is usually present, although those infants who develop severe jaundice with G6PD deficiency usually have Gilbert"s syndrome as well. Physiologic jaundice manifests 24 hours after birth. ENTEROVIRUS AND ARBOVIRUS INFECTIONS: Is the most common cause of viral meningitis or encephalitis in the pediatric population. These infections are more frequent during summer, late spring, and early fall. Most arbovirus infections are zoonosis (transmitted through animal vectors); for this reason, these infections are more common in the rural areas.

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Herpes simplex virus is the most common cause of viral meningitis in the adult population, not in children. SICKLE CELL DISEASE: Is an inherited disorder that results from the presence of hemoglobin S. The most severe and common form is sickle cell anemia, in which only hemoglobin S is present (HbSS). TRAIT: HbS, HbA Clinical manifestations rarely present prior to 6 months of age, when fetal hemoglobin levels decline and functional asplenia typically develops. Dactylitis (pain in the hands and feet) is common in the first 18 months of life. The best diagnostic test is hemoglobin electrophoresis because it precisely determines which form of sickle cell disease is present. ACUTE SEVERE ANEMIA: May be superimposed on chronic anemia in patients with sickle cell disease When this occurs, it is a life-threatening condition. Clinical manifestations include weakness, pallor and lethargy. The three typical causes of acute anemia are splenic sequestration crisis, aplastic crisis, and hyperhemolytic crisis. APLASTIC CRISIS: Represents a transient failure of erythropoiesis with an abrupt reduction in the blood hemoglobin and the number of erythroid precursors in the bone marrow. A very important finding during a crisis is the virtual absence of reticulocytes.T The typical cause is an infection; parvovirus B19 infection is the most common cause in children. INTUSSUSCEPTION: Occurs when a part of the small bowel is telescoped into itself The most frequent vicinity is the ileocecal region. Almost 60% of the cases occur in children younger than 1 year of age, while 80% present before 2 years of age. The classic presentation is a sudden onset of colicky abdominal pain followed by vomiting, and the vomitus rapidly changes from alimentary to bilious. The child usually draws up his legs towards the abdomen because of the pain. Hematochezia is present in 70% of the cases; 15% of the patients have the characteristic "currant jelly" stools. Initially, the child is irritable, but he may eventually become apathetic when he is no longer able to eat, and he gets dehydrated. Palpation of a sausage-shaped abdominal mass on the right side is characteristic. Abdominal x-ray reveals generalized distension of the bowel loops or another evidence of obstruction. An enhanced density that projects into the air level of the large bowel can be identified in 25% of the cases. This density represents the invaginated bowel loop, and is known as the "crescent sign." DD: Acute gastroenteritis (AGE) presents with fever that precedes abdominal pain and diarrhea. AGE will not explain the presence of the abdominal mass and the massive bowel distention seen in the abdominal x-ray of this patient. MECKELS DIVERTICULUM: Usually presents in toddlers and older children, generally between five and ten years of age, and in young adults. The most common location of pain is in the right lower quadrant. Hematochezia is also present, but the stool is non-mucoid, and there is no palpable abdominal mass. ERBS PALSY: The classical scenario of Erbs palsy is described. It is the most common form of obstetrical brachial plexus injury and involves the upper roots (C5, C6, and sometimes C7) of the plexus resulting in an adducted and internally rotated right arm with forearm pronation and flexed wrist. -A serious complication is diaphragmatic paralysis due to phrenic nerve involvement. Symmetric palmar grasp reflex indicates that lower roots of the brachial plexus are intact and is a good prognostic sign. The prognosis of Erbs palsy is typically good with an 80% chance of full or near-full recovery. Horners syndrome may be associated with the injury of lower roots of the brachial plexus.

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GASTROINTESTINAL FOREIGN BODIES: Occur typically in toddlers, because exploring objects by putting them into the mouth is a characteristic behavior pattern in that age group. Coins are the most common GI foreign bodies. Foreign bodies can become lodged in any of the areas of esophageal physiologic narrowing. They require attention and frequently removal in that case. Up to 90% of foreign bodies that have made it into the stomach will be passed without difficulty. Pyloric obstruction is rare and manifests as persistent vomiting. Up to 90% of foreign bodies that have made it into the stomach will be passed without difficulty; therefore, no intervention is usually necessary. CELLULITIS: Is characterized by its irregular and elevated borders, as well as increased local temperature, tenderness, and erythema. It is an infection located between the subcutaneous tissue and the fat, therefore local anesthesia will not be useful in this situation. Pain can be treated by oral analgesics. CLEFT LIP WITH OR WITHOUT CLEFT PALATE: Is typically a multifactorial disorder but can have autosomal dominant, autosomal recessive, and Xlinked inheritance, as well as be associated with teratogenic agents. Reconstruction of a cleft lip is generally performed at approximately three months of age according to the rule of 10:10 lbs of weight, 10 weeks of age, and 10 g of hemoglobin. The Reticulocyte Count Is An Index Of RBC Production By The Bone Marrow. Increased destruction of RBCs (hemolytic anemia) prompts the normal bone marrow to compensate for the loss by increasing the rate of erythropoiesis, which results in an increased reticulocyte count. On the other hand, nonhemolytic anemias, due to a decreased production of RBCs, will result in a low reticulocyte count. The reticulocyte count is therefore increased in hemolytic anemia, and decreased in nonhemolytic anemia. DIABETIC KETOACIDOSIS (DKA): Must be suspected in any child with dehydration, metabolic acidosis, nausea, vomiting, tachypnea without oxygenation problems, abdominal pain, and hyperglycemia. Patients must be immediately admitted to the Intensive Care Unit for correction of the metabolic acidosis and dehydration. Treatment involves intravenous fluids and insulin administration, as well as adequate potassium supplementation (to avoid hypokalemia). BOTULISM: Giving honey to the child is the main clue to the diagnosis. Constipation is typically the first manifestation of the disease, and is followed by lethargy, poor sucking and weak crying. Gag reflex is frequently impaired.This may result in aspiration if airways are not protected. NEONATAL CONJUNCTIVITIS: is classically due to one of three causes (though typical adult bacterial and viral etiologies are also possible during the neonatal period): 1. ChemicaI reaction. - Silver nitrate, erythromycin or tetracycline drops are given prophylactically to newborns to prevent gonorrheal conjunctivitis, The drops may cause a chemical conjunctivitis (with no purulent discharge). wllich develops within 6-12 hours of instilling the drops and resolves within 48 hours. - Chemical reaction is "always the answer if conjunctivitis in the first 24 hours of lives 2. Gonorrhea. - Look for symptoms of gonorrhea in the mother. The infant has an purulent discharge that start 2-5 days off a birth. - Treatment is topical (erythromycin ointment) plus IV or 1M third-generation cephalosporin (e.g .. ceftriaxone).lnfants who are given prophylactic drops should not develop gonorrheal conjunctivitis. 3. Chlamydial infection - The mother often reports no symptoms.The infant has mild-to-severe conjunctivitis. - Prophylactic eye drops do not effectively prevent Chlamydia conjunctivitis.

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SURGERY
CONSENT FOR SURGERY: Normally, the parents or legal guardian of a minor must provide voluntary, informed consent for treatment and most medical tests or procedures. However, if immediate medical care is necessary to prevent serious harm or death, consent is always assumed. PROSTATE CA: Patients with PSA levels greater than 4 ng/ml, should be referred to an urologist for biopsy. Radical prostatectomy is a treatment option for early prostate cancer. Pretreatment tests include biopsy of the tumor and a CT scan. Urinary incontinence and erectile dysfunction are two common complications of radical prostatectomy, which is used for the treatment of early prostate cancer. Retrograde ejaculation is the most frequent complication of transurethral resection of the prostate, and all patients should be made aware of this. Suprapubic resection of the prostate is the currently accepted therapy for patients whose prostate cancer was diagnosed through TURP, needle biopsy, or cytology. This procedure is accompanied by lymph node resection, which can be preceded by sentinel lymph node identification through technetium radio labeling for a higher yield. Radiotherapy, estrogens, and chemotherapy are measures reserved for more advanced stages of the disease. TESTICULAR CA: The differential diagnosis of testicular swelling includes entities such as epididymitis, hydrocele, testicular torsion, varicocele, hernia or hematoma. A painless testicular mass is considered as cancer unless proven otherwise. The first step in the evaluation of males with testicular swelling is a scrotal Ultrasound, which helps in differentiating intra- and extra- testicular lesions. Cystic or fluid-filled lesions are unlikely to be cancerous. If the lesion appears suspicious on ultrasound,it is followed with: CT scan of the abdomen and pelvis (to detect retroperitoneal lymph nodes metastasis) Measurement of serum tumor marker levels (alpha fetoprotein, beta hCG). If scrotal ultrasound and serological tests confirm the suspicion, Radical inguinal orchiectomy is done to provide a histological diagnosis. EPIDIDYMITIS: is an infection characterized by testicular pain and tenderness, hydrocele, and a tender, swollen epididymis. No irritative voiding symptoms are usually present, and urinalysis is normal. Dramatic presentation characteristics for acute bacterial epididymitis with severe scrotal pain, fever, and voiding symptoms are less common. The most common cause of epididymitis is Chlamydia trachomatis. Prehn"s sign (decrease in pain on testicular elevation) is usually present [but not universally present] and cremasteric reflex is intact. When there is an apparent increase in testicular size, transillumination of the testicle can be done to determine the presence of a hydrocele or malignancy. Treatment of epididymitis is done with ceftriaxone and doxycycline because Chlamydia trachomatis and Neisseria gonorrhoeae are the usual pathogens involved. In any case, antibiotic therapy must not be started until transillumination is done, and the possibility of a malignancy is ruled out. TESTICULAR TORSION: Is characterized by sudden development of moderate-to-severe pain High-riding testis can usually be palpated on the affected side. Cremasteric reflex is usually absent. In equivocal cases, color Doppler ultrasonography is helpful. VARICOCELE: presents as dull scrotal pain relieved by recumbency.

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 A soft scrotal mass can be palpated (bag of worms) that disappears in the recumbent position. Besides that, varicocele is left-sided or bilateral in a vast majority of cases. CRYPTORCHIDISM: Cryptorchidism (undescended testis) is a common problem. It affects 4% of newborn infants, but the majority of cases resolve spontaneously during the first several months of life. Spontaneous descent is rare after six months of age. The complications of undescended testis include decreased fertility, increased risk of testicular torsion, inguinal hernia, and malignant transformation. Rx: Early orchiopexy helps to prevent testicular torsion and infertility. Risk of malignancy: Although the risk of malignant transformation may decrease a little after the surgery, it remains higher than that of the general population. At the same time, the surgery makes it easier to examine the testis. Orchiopexy can be performed as early as six months of age, but definitely before two years of age ORAL LESION: The most common cause of oral lesions in elderly patients is trauma. People who wear dentures all the time are more prone to develop such lesions. The most appropriate next step is to advise the patient to remove her dentures for one to two weeks, after which reevaluation is necessary. If the lesion does not subside, the patient should have a biopsy to rule out malignancy. PARENTERAL NUTRITION: The most dangerous metabolic complication, hyperglycemia, is most commonly caused by too rapid initiation of the infusion. This complication is best prevented by initiation of the infusion at 40-60 ml per hour, and slowly increasing the rate at 20 cc/hour every 24 hours, while monitoring glucose. Patients with normal glucose tolerance may manifest glycosuria for the first 48 hours of parenteral nutrition. Before initiating insulin, one must verify that the glucose level is high, and that glycosuria is not secondary to a reduced renal threshold for glucose. The most common cause of sudden hyperglycemia is sepsis, and hyperglycemia may antedate other signs of sepsis within 24 hours. The sudden appearance of hyperglycemia should initiate a thorough search for the source of infection. The infection may be due to line sepsis, pneumonia, wound infection, or another process. Blood cultures and a thorough examination of the patient are required Hypophosphatemia: Is reported to occur in 30% of patients receiving intravenous nutrition. The mechanism is enhanced phosphate uptake into cells associated with enhanced glucose uptake. The consequences of hypophosphatemia include respiratory weakness, hemolysis, and impaired oxygen release from hemoglobin. These may be particularly prominent when serum phosphate falls below 1.0 mg/dL. Phosphate supplementation in the diet will prevent these complications. A fatty liver can be seen when glucose infusions exceed the daily caloric requirements. This is because of the production of fatty acids from excess glucose and the impaired ability to mobilize the fat for energy needs. Fat accumulation eventually leads to abnormal liver enzyme elevations in the serum, particularly alkaline phosphatase. Carbon dioxide retention can develop when excess glucose is given to patients with severe lung disease. Glucose metabolism produces a larger quantity of CO2 for each liter of O2 consumed than the other two nutrient substrates. When the ability to eliminate CO2 via alveolar ventilation is impaired, this enhanced CO2 production of carbon produces hypercapnia, and the impaired ability to wean from mechanical ventilation. ACUTE CHOLANGITIS: This condition is characterized by Charcots triad: right upper quadrant pain, fever and jaundice. Charcots triad is present in 50-75% of the cases of cholangitis. Hypotension and confusion may develop due to sepsis. When these two signs occur with Charcots triad, the patient is said to have Reynolds pentad, which has a 50% mortality rate. Elevated levels of direct bilirubin and alkaline phosphatase, without a rise in the aminotransferases, confirms the presence of an extrahepatic obstruction. Treatment of cholangitis is begun with adequate hydration, strict vital signs monitoring, and immediate antibiotic therapy.

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A blood culture should be taken before starting antibiotics. The preferred empiric antibiotics are ampicillin + gentamicin or monotherapy with imipenem or levofloxacin. In 80% of the cases, the cholangitis is controlled within 24 hours. An elective endoscopic retrograde cholangiopancreatography (ERCP) is then scheduled. If the patient does not improve, an urgent biliary decompression is necessary. Decompression is achieved through biliary drainage, and is usually done through ERCP due to its lower morbidity rate of 10% (compared with 50% morbidity rate via surgical drainage). RECTAL PROLAPSE: Rectal prolapse occurs when a mucosal or full-thickness layer of rectal tissue slides through the anal orifice. It is usually associated with conditions causing increased intraabdominal pressure such as chronic straining with constipation, benign prostatic hypertrophy, and COPD. It usually presents with difficulty with defecation, diarrhea/fecal incontinence, pain in the anal area, rectal bleeding, and a protruding rectal mass. Untreated complete rectal prolapse can lead to strangulation and gangrene of the rectal mucosa. Uncomplicated prolapsed rectal mucosa can be reduced by gentle digital pressure. Adequate local anesthesia and sedation help reduce the prolapsed mucosa. Topical application of granulated sucrose helps reduce the mucosal edema and makes manual reduction easier. Irreducible prolapsed mucosa and gangrene of the mucosa warrant a prompt surgical consultation. The prognosis is generally good with prompt and appropriate care. KNEE Medial collateral ligament injury is associated with tenderness and pain along the medial joint line. This common condition is most frequently caused by an injury involving valgus (abductor) stress to the partially flexed knee with the foot fixed. Such an injury can occur while skiing or during contact sports, when another person falls across the knee from the lateral to medial direction. ANTERIOR CRUCIATE LIGAMENT INJURY: Is associated with pain and laxity upon performance of the Anterior drawer or Lachman maneuver. This condition most frequently occurs after noncontact deceleration, a cutting movement, or hyperextension. It may be accompanied by a "popping" sound. POSTERIOR CRUCIATE LIGAMENT INJURY: Is associated with little pain or alteration in range of motion, but the posterior drawer test is positive. This uncommon condition occurs from a posteriorly directed force on a flexed knee (e.g., the dashboard being struck by the anterior of the flexed knee in a motor vehicle accident) or from hyperextension. LATERAL COLLATERAL LIGAMENT INJURY: Is associated with tenderness and pain along the lateral joint line. This uncommon condition is most frequently caused by an injury involving dramatic varus (adductor) stress. MENISCAL INJURIES: Principally occur after a twisting injury to the knee with one foot fixed to the ground (e.g. with sudden turning while running). The medial meniscus is more commonly injured, as compared to the lateral meniscus. A bucket handle tear is the most common type of medial meniscus tear. Patients generally complain of pain and swelling of the knee, and a popping sensation at the time of injury. In medial meniscus injuries, tenderness is generally felt along the medial side of the knee. Effusion with meniscus injuries takes about 24 hours to form, and is often not significantly bloody, unlike ACL or osteochondral injuries. Locking of the knee joint on extension is generally seen. McMurrays sign is snapping felt with tibial torsion and the knee flexed at 90 degrees. PREPATELLAR BURSITIS: Is an inflammation of the largest knee bursa. This condition is most frequently caused by trauma from a fall or secondary to prolonged friction and pressure from repetitive kneeling ("housemaids knee").

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DONOHUES UNHAPPY TRIAD: Typically occurs after a lateral knee injury, resulting in an Anterior cruciate ligament tear, a medial (Tibial) collateral ligament injury, and a Medial meniscal injury. Remember "MAT". ACUTE COMPARTMENT SYNDROME: Acute compartment syndrome refers to ischemic tissue damage secondary to elevated pressures in the enclosed compartments of the lower legs or forearm. When the tissue pressure in an enclosed compartment exceeds the perfusion pressure, the resulting diminished tissue perfusion and compromised blood flow to the muscles and nerves inevitably lead to ischemic tissue necrosis. Majority of the cases involving the lower extremities are due to a traumatic event, most commonly tibial fractures. Other causes include a crush injury or other long bone fractures in a motor vehicle accident, a tight cast or dressing after trauma, and drug overdose. Patients usually present with severe pain which is out of proportion to the extent of injury. The pain is typically worsened by passive movements of the involved muscles. Sensory nerves are usually affected earlier than the motor nerves, and the neurologic deficit presents as decreased vibration sense, decreased two-point discrimination, numbness or hypoesthesia. Late features include extremity paralysis and absent distal pulsation (pulseless paralysis). [Ominous sign] Complications: Rhabdomyolysis and subsequent development of acute renal failure is one of the most common and severe life-threatening complications of acute compartment syndrome. Laboratory studies Typically reveal markedly elevated CK creatinine kinase levels and the presence of myoglobin in the urine (positive dipstick for blood in the absence of RBCs in the urine). Direct measurement of the compartment or tissue pressure is the diagnostic procedure of choice for patients with suspected acute compartment syndrome. The exact value for the tissue pressure at which blood flows to the muscle and nerve tissue stops is controversial. The current general consensus for the threshold value is greater than 30 mmHg. It is therefore important to measure the tissue or compartment pressure early in the course of management, especially if the diagnosis is in question. RX: Acute compartment syndrome is a surgical emergency. Any delay in treatment leads to irreversible muscle and nerve damage. A compartment pressures of 30 mmHg or greater warrants an emergent fasciotomy (also known as compartment release). Surgical decompression aims to relieve the pressure within the enclosed compartment and to restore the blood flow to muscles and other tissues within 6-10 hours of the initial symptoms. -Some patients may develop a persistent sensory or motor deficit after an episode of acute compartment syndrome despite early fasciotomy. REPLANTATION: As a general rule, all amputated body parts should be retrieved and brought to the emergency room. Since the thumb or finger amputation can especially compromise the function of the hand, all attempts should be made to retrieve and replant the digit in the hope to preserve function. For transportation purposes, the amputated part should be wrapped in saline-moistened sterile gauze and sealed in a sterile plastic bag. After adequate steps have been taken to preserve the severed finger; it should be sealed in a plastic bag and placed on ice in a container. The severed part should never be placed directly on ice, as this could lead to injury to the vessels and other tissues. It should also not be immersed in water as this may make the replantation technically more difficult. BREAST MASS: Cysts that disappear completely, contain non-bloody fluid, and possess a characteristic diffuse nodularity, are most likely due to fibrocystic disease. Careful observation for recurrence of the mass is the standard follow-up therapy. A mammogram would be indicated if the mass didnt disappear completely, or if its content was bloody.

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An ultrasound is indicated if the mass cannot be visualized using a mammogram because of dense, normal breast tissue (seen especially in young women). Ultrasound is also useful for the evaluation of cystic lesions, but not in the case that the cyst has already been drained. Even though breast cancer is rare in women younger than 35 years, every breast lesion must be taken seriously. Patients can be reevaluated 3 to 10 days after the menstrual period to look for regression. If the lesion appears cystic, FNA should be done unless the patient declines. If the mass looks solid, is too small, or cannot be felt, ultrasound is the next step to determine if biopsy is needed. Breast Lumps Are A Very Common Patient Problem In The Outpatient Setting. -They cause significant anxiety in most patients. A vast majority of breast lumps in women under age 35 are usually due to benign causes, most commonly benign cystic disease or fibroadenoma of the breast; however, any complaint of a breast mass or lump in a female patient should be evaluated thoroughly. All patients should be followed closely until a definite diagnosis is made. A thorough history and physical examination is an important part of a complete evaluation. Benign cysts are most prominent just prior to the beginning of the menstrual cycle, and regress after the menstrual period is over. It is important to examine a young patient in the postmenstrual period to document any regression in the size of the breast lump. Fine-needle aspiration biopsy should be performed in an easily palpable cystic breast mass in an anxious patient to obtain fluid or tissue for a specific diagnosis. Any blood-tinged fluid should be sent for cytologic examination. If the fluid obtained is not bloody, the patient should be reexamined in four to six weeks to look for any regression or recurrence of the lump. Ultrasound of the breast is an alternative option for evaluation of breast masses in patients under age 35. It can differentiate a simple or complex cyst from a solid mass. It can also be used in patients who decline a fine-needle aspiration biopsy. Mammograms are usually not indicated in women less than 35 years of age, as the normal breast tissue is too dense to evaluate the lump. Moreover, mammograms can miss up to 20% of palpable breast cancers and should be substituted or followed up with another diagnostic modality. Silicone is a long-chain polymer derived from silicon. - A silicone implant consists of an outer shell made of silicone, and is inflated with a saline solution. They are most often used by women to "improve" their physical appearance (breast augmentation). -They are also used for breast reconstruction in women who have had a unilateral or bilateral mastectomy for various reasons, including breast cancer. - There have been a lot of questions and concerns about the safety of silicone breast implants. - Women who have received breast implants have had local postoperative complications in the form of capsular contracture, causing pain and distortion of the shape, implant deflation, and rupture, requiring surgical removal of the implant. These local complications are the most common cause of morbidity associated with implants. - Silicone breast implants do not cause any major rheumatologic, autoimmune, or neurological disorder. - Silicone breast implants do not cause any disease or defects in the developing fetus. - Breast milk is the best source of nutrition for the babies. All women, even those with breast implants, should be encouraged to breast feed their babies. There is no risk in breast-feeding with a silicone breast implant. - Regular mammograms starting at age 40 years, or earlier if there are risk factors, have consistently been shown to reduce morbidity and mortality from breast cancer. It plays an important role in detecting the lesions in early stages, thereby improving the chances of a complete cure. It is recommended that all women, including those with breast implants, obtain regular screening mammograms as per the guidelines. KLINEFELTERS SYNDROME: Is a chromosomal abnormality caused by an additional X chromosome (47, XXY). It is characterized by hypogonadism, low testosterone levels, gynecomastia due to an increased testosterone-to-estrogen ratio.

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 Klinefelters syndrome is the strongest known risk factor for male breast cancer. It carries a 50-fold increase in the risk of breast cancer compared to men with a normal genotype. PORCELAIN GALLBLADDER: Porcelain gallbladder is a condition characterized by calcium salt deposits in the wall of a chronically inflamed gallbladder. The calcifications can be thin or faintly visible, or may be amorphous, patchy, and thick. -The gallbladder is generally large, but its size can vary considerably. Most porcelain gallbladders are associated with gallstones. A plain radiograph generally detects these, but computed tomography (CT) has a higher specificity; therefore, a CT scan is performed to confirm the diagnosis. Due to their high risk of gallbladder carcinoma, all patients with porcelain gallbladder should have an Elective cholecystectomy. GALLSTONES: Multiple therapies are available for individuals with gallstones. Asymptomatic patients require no further intervention. Patients with mild symptoms and small cholesterol stones may respond to ursodeoxycholic acid. Extracorporeal lithotripsy may be used for those with bigger cholesterol stones. The most effective therapy for symptomatic gallstones is cholecystectomy; High-risk patients, especially those with non-cholesterol stones Endoscopic electrohydraulic lithotripsy. MORPHINE OVERDOSE: Morphine overdose is a common scenario in the hospitalized patients, postoperative patients receiving high doses of morphine for acute pain control. Opiate naive patients with renal insufficiency are at a much higher risk. The usual manifestations of overdose are lethargy, drowsiness, miosis, bradycardia, hypotension, respiratory depression, and apnea. The first and initial priority in the management of overdose is always to check for and maintain a patent airway. It is important to ensure adequate respiratory exchange at all times before instituting specific therapy. Specific therapy with naloxone should be given after ensuring adequate gas exchange. IN DIGITAL INJURIES: Tendons are more likely to be injured than arteries, veins, or nerves due to their relative, vulnerable, anatomic location. Even in cases where the risk is high, only the absence of benefits may prompt the physician to refuse a procedure; therefore, a physician must always look at the entire clinical picture and prognosis before suggesting or refusing a surgical intervention. The patients age, presence of comorbidities, functional status, quality of life, and personal values must all be considered to determine if the patient will benefit from hip surgery. If the patient is already bedridden, the benefit of surgery is minimal. If the patient has other serious medical problems, the risks may outweigh the benefits. Pain alone is not an indication for surgery, as conservative therapy can also effectively control this symptom. Management of retrosternal goiter with compressive symptoms is surgical. Tachycardia is the earliest sign of hypovolemia. Most shoulder / clavicle fractures are treated with: Sling or a figure-of-eight brace placement, along with rest and pain control; however, some lesions, such as Compound, distal comminuted, or severely displaced fractures, need surgical intervention. COMPLEX REGIONAL PAIN SYNDROME (CRPS) TYPE I, AKA REFLEX SYMPATHETIC DYSTROPHY (RSD): International Association for the Study of Pain Diagnostic Criteria 1. The presence of an initiating noxious event or a cause of immobilization. 2. Continuing pain, allodynia (pain elicited by a normally non-noxious stimulus, particularly if repetitive or prolonged) or hyperalgesia (pain disproportionate to the inciting event)

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3. Evidence at some time of edema, changes in skin blood flow, or abnormal sudomotor activity in the painful region 4. Absence of other conditions that could account for the degree of pain and dysfunction. At least one half of the patients meeting these diagnostic criteria have sympathetically maintained pain (SMP), which is defined as pain that is maintained by sympathetic efferent nerve activity or by circulating catecholamines. Normally, the sympathetic reflex after injury results in vasoconstriction to prevent excessive blood loss or swelling Ordinarily, this reflex shuts off after an appropriate period. In the patient who develops CRPS Type I with SMP, the normal sympathetic reflex does not shut off, but continues unabated in a pathologic positive feedback mechanism. The intense vasoconstriction causes localized ischemia, which in turn causes pain that further initiates the sympathetic "pain reflex," etc. Pharmacologic sympathetic blockade or sympathectomy may interrupt this vicious cycle and reduce long-term periarticular skin and muscle atrophy, flexion contractures, and osteoporosis. There is evidence that such treatment for CRPS- I with SMP is most or only effective during the first three months after onset. In CRPS-I of the knee, the most favorable prognostic indicators are early diagnosis, early interruption of the abnormal sympathetic activity (e.g., via alpha blockers, chemical or surgical sympathectomy), and early institution of aggressive physical therapy). D/D: acute pyogenic arthritis usually presents with a tense joint effusion, and the patient generally cannot tolerate weight-bearing or joint motion. PLICA SYNDROME OF THE KNEE: -Is pain, crepitus, snapping, popping, or effusion related to patellofemoral joint motion. -The clinical picture mimics a torn medial meniscus or a maltracking patella, and is due to a prominent medial plica (synovial fold) which impinges against the medial patellofemoral articular surface and may become inflamed. PULMONARY EMBOLISM: Pulmonary embolism may still occur in patients who are receiving DVT prophylaxis due to their high risk. V/Q scan. OSTEOPOROSIS: While less common in men than in women, osteoporosis is associated with significant morbidity. It is estimated that a 60-year-old male has a 25% chance of suffering an osteoporotic fracture. Bone mineral density depends on peak bone mass and the rate of bone mass loss. The peak bone mass is higher in men than in women; therefore, they present with osteoporotic fracture about 10 years later than women. The rate of bone mineral content loss after 30 years of age is approximately 0.5 1%/year. Age is considered to be the most important single risk factor for osteoporosis and osteoporotic bone fracture. Other contributing factors are important, for example, family history, smoking, and alcohol consumption Medications predisposing to osteoporosis include glucocorticoids, anti-androgens, and some anticonvulsants. Caucasian males are more susceptible to osteoporosis than African-Americans. Raloxifene is a selective estrogen receptor modulator (SERM) which selectively stimulates estrogen receptors on bone cells. It has been shown to improve bone mineral density at both the hip and lumbar spine. Studies have not shown that it reduces the risk for vertebral fractures. Side effects include hot flashes and an increased risk for deep venous thrombosis and pulmonary embolism. Raloxifene should therefore be discontinued at least 72 hours prior to an elective surgical procedure to prevent DVT deep venous thrombosis. It can be restarted after the patient is fully ambulated. MECKELS DIVERTICULUM: Acute abdominal pain with rectal bleeding in children between five and ten years of age can be due to Meckels diverticulum bleeding, inflammatory bowel disease or appendicitis. A technetium-99 nuclear scan is highly specific for Meckels diverticulum. DUMPING SYNDROME: Dumping syndrome is a common complication of gastrectomy. Treatment is aimed at decreasing the speed of the passage of fluids and food into the small gut.

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A high-protein and low-carbohydrate diet is advised, as well as smaller but more frequent meals throughout the day. DEEP VEIN THROMBOSIS: Patients undergoing surgery can be classified into four levels of risk for postoperative deep venous thrombosis (DVT), depending upon age, type of surgery, and presence of clinical risk factors for DVT. Low riskUncomplicated minor surgery in patients younger than 40 years with no clinical risk factors Moderate riskany surgery in patients aged 40-60 years with no additional risk factors; major surgery in patients younger than 40 years with no additional risk factors; minor surgery in patients with risk factors High riskMajor surgery in patients older than 60 years without additional risk factors or patients aged 40-60 years with additional risk factors; patients with MI; medical patients with risk factors Highest riskMajor surgery in patients older than 40 years with prior venous thromboembolism, malignant disease, or hypercoagulable state - patients with elective major lower extremity orthopedic surgery, hip fracture, stroke, multiple trauma, or spinal cord injury. Clinical risk factors for deep venous thrombosis include the following Age (>40 y) Prolonged immobility (>4 h) or paralysis Prior DVT or PE Obesity Hypercoagulable states (e.g. factor V Leiden mutation, protein S deficiency, protein C deficiency, antithrombin III deficiency, antiphospholipid antibodies or lupus anticoagulant, plasma hyperhomocystinemia) Major surgery or fractures (especially abdominal, pelvic, lower extremities) Malignancy Varicose veins Heart failure Myocardial infarction (MI) Rx: The modalities recommended preventing such DVT, assuming prophylaxis is only begun postoperatively, are, in approximate (decreasing) order of effectiveness 1. Full-dose therapeutic IV heparin 2. Either: * Adjusted-dose oral Warfarin (goal INR 2.5) (or) * Low dose heparin (unfractionated) 5000 U administered SC q8h to q12h (or) * Adjusted (low dose) heparin (unfractionated) - 3500 U administered SC q8h adjust 500 U to maintain 1.5-2 times the reference range aPTT (or) 3. Low molecular weight heparin SC [for example Enoxaparin (Lovenox) 3000 U (30 mg) SC q12h] Adjuvant: *Calf-length elastic stockings (ES) with early ambulation (or) *Intermittent pneumatic compression devices (IPC Highest/High-Risk Patients Without Contraindications require anticoagulation via modalities 1 or 2. 1 [Full dose therapeutic IV heparin] is generally reserved for patients with MI. Warfarin is recommended mainly as a possible alternative to low dose or low molecular weight heparin for highest risk orthopedic patients undergoing lower extremity procedures. Modality 3 is adequate for low risk patients and some moderate risk patients, although most moderate risk patients should receive low dose or low molecular weight heparin. ES and/or IPC may be used adjunctively in higher risk patients. LMWH is considered to be the prophylactic therapy of choice for preventing deep vein thrombosis in patients at high risk. Then coumadin and then aspirin. -Pressure stockings as adjuvant CARDIOPULMONARY RESUSCITATION Remember and follow the "ABC"s" of cardiopulmonary resuscitation. After the airway has been secured by endotracheal intubation, it is important to confirm its correct placement in the trachea by checking for lung expansion and auscultating for breath sounds on both sides. Emergent large-bore needle decompression should be performed in a patient with suspected tension pneumothorax causing hemodynamic instability and cardiovascular collapse.

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STRESS FRACTURES Stress fractures most commonly occur on the lower one-third of the tibia, fibula, lateral metatarsals, and sometimes the tarsal bones of the foot. These are usually seen in athletes and military recruits with a history of excessive running or training. Patients often complain of pain that occurs with exercise or running, and improves with rest. Physical examination reveals localized tenderness and swelling over the fracture site. It is important to distinguish a stress fracture from the other common tendon and ligament injuries in order to provide specific therapy. Dx: Plain radiographs are often unremarkable in the first two to four weeks after the injury or fracture. Magnetic resonance imaging or triple phase bone scans with technetium are highly sensitive and accurate imaging modalities used to confirm the diagnosis of stress fracture. Rx: Most of the stress fractures of the lower extremities can be managed with conservative treatment. This includes complete cessation of aggravating activities for at least four to six weeks, with a gradual return to activity. Other general measures include pain control with nonsteroidal antiinflammatory drugs and support with crutches or a brace while walking. FAT EMBOLISM: Always consider the risk of fat embolism in patients with multiple complicated fractures. Fat embolism is a clinical diagnosis that is usually characterized by a triad of respiratory insufficiency, neurological impairment, and a petechial rash. Early immobilization and operative fixation of fractures reduce the chances of fat embolism. Superficial suppurative thrombophlebitis requires drainage if the antibiotic therapy alone is ineffective. A multilocular pancreatic cyst in a patient without a history of pancreatitis should be considered malignant until proven otherwise. MESENTERIC ISCHEMIA: A sudden onset of severe periumbilical pain that is out of proportion to the physical examination findings, along with metabolic acidosis, and occurs in a setting with risk factors such as atrial fibrillation, congestive heart failure, and peripheral vascular disease, should always raise the suspicion for acute mesenteric ischemia. This condition is frequently overlooked initially. All radiological studies may be initially normal. Laboratory data may show a mild to moderate metabolic acidosis. Leukocytes and elevated Hb and Hct% in the CBC may occur secondary to hemoconcentration. The ischemia may be due to an occlusion secondary to thrombosis, embolism and/or vasospasm. The most common cause is superior mesenteric artery (SMA) occlusion secondary to an embolism. The SMA is the most common site involved because it runs off at a minimal angle from the aorta and has a wide diameter. The origin of the embolus is commonly from the left atrium, left ventricle or cardiac valves. Risk factors are cardiac arrhythmias, recent MI and abdominal malignancy.The patient may later develop abdominal distention and signs of acute peritonitis. If not treated promptly, consequences may be very serious. Untreated mesenteric ischemia may cause bowel infarction, sepsis and death. Mortality in this case may be as high as 60%. D/Ds: 1. Patients with acute colonic ischemia usually have a more lateralized abdominal pain with tenderness, along with a history of bloody diarrhea or hematochezia. This usually results from hypovolemic states or transient ischemia to the bowel. This is not because of the obstruction of flow to the colon. 2. Patients with intestinal obstruction usually have a history of absolute constipation. Plain abdominal radiographs will show air fluid levels. CREMASTERIC REFLEX: The cremasteric reflex is regulated at the L1-L2 level of the spinal cord.

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 This reflex can be diminished or lost secondary to diabetic autonomic neuropathy. OBESITY: The National Institute of Health (NIH) recommends that severe obesity (BMI of more than 40 Kg/m2) is an indication for surgery. Other indications are: (1) A significant decrease in the quality of life (2) Serious medical problems such as obstructive sleep apnea, movement limitations, or brittle diabetes. ABDOMINAL GUNSHOT WOUNDS: Most abdominal gunshot wounds will require laparotomy for further exploration and immediate management of intra abdominal injuries, unless the wounds are only superficial or tangential to the skin. The absolute indications for an urgent laparotomy are: presence of peritoneal signs, spinal cord damage intra abdominal vessels or bladder damage, and hollow viscus perforation If the patient is hemodynamically unstable or has lost a great amount of blood, the procedure must be done immediately. Early transportation can be life-saving for patients with penetrating abdominal trauma secondary to gunshots. Transfer to a regional trauma center is required if there is no surgeon or operating room available, if the patient has multiple injuries, or if he needs procedures that are not available (e.g., hemodialysis, organ transplantation, neurosurgery, etc.). Air transport (life flight) is recommended for patients who are potentially unstable, or who are in rural areas or places where ground transportation may take more than 20 minutes. EPIDURAL ABSCESS: An epidural abscess should be suspected in a susceptible patient who presents with fever and back pain. Patients who are susceptible are the elderly, immunocompromised individuals (i.e., patients with AIDS, IV DRUG ABUSER, cancer, diabetes mellitus, chronic renal failure, or alcoholism), and patients who were recently involved in trauma, spinal surgery, or administration of epidural anesthesia. The diagnosis must be made immediately because delays in treatment increase the risk of permanent neurologic damage or death. A gadolinium-enhanced MRI is the preferred imaging modality to confirm the diagnosis because it adequately demonstrates inflammatory changes in the soft tissue. When MRI is not available, CT with myelography is an alternative. Once the diagnosis is made, Antibiotic therapy should be guided by obtaining a culture specimen via CT-guided aspiration or open biopsy. The most common etiologic agent is Staphylococcus aureus. RX: Spinal epidural abscesses is a surgical emergency Early surgical decompression and drainage, preferably within the first 24 hours, is the most important part of management to improve the ultimate prognosis. SUBARACHNOID HEMORRHAGE: The constellation of a headache of sudden onset, nausea, and nuchal rigidity is characteristic. Cranial nerve III palsy (ptosis and anisocoria) is a typical finding in patients with a posterior communicating artery aneurysm. It is also characteristic for cavernous-carotid aneurysms, but they are uncommon. Posterior inferior cerebellar artery aneurysms frequently result in ataxia and bulbar dysfunction. Brainstem glioma presents with signs and symptoms of progressive brainstem involvement as ataxia, cranial nerve palsies, motor, and sensory abnormalities. Lacunar stroke manifests as relatively limited neurologic dysfunction (e.g., pure motor stroke), but headache and nuchal rigidity are not present. VARICOSE VEINS: Varicose veins refer to visible, palpable, and tortuous superficial veins of the legs, usually on the calf or medial thigh. Most of the patients with varicose veins are asymptomatic. Some patients may complain of leg cramping, heaviness, fatigue, and swelling. The symptoms are generally worse in the evening with prolonged standing, and improve with leg elevation.

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Treatment of varicose veins is aimed at alleviating symptoms, although some patients may seek a physician"s attention due to cosmetic reasons. Various treatment options for varicose veins include leg elevation, compression stockings, sclerotherapy, and surgical ligation. Most patients with symptomatic varicose veins should initially be treated with conservative measures such as leg elevation and compression stockings. Compression stockings along with leg elevation and weight reduction decrease the venous pressures in the lower extremities by direct compression and improves the patients symptomsCompression stockings should not be used in patients with an underlying arterial insufficiency Injection sclerotherapy with or without anesthetics is used in patients with symptomatic, small, varicose veins who have failed at least three to six months of conservative treatment. It involves the injection of a sclerosing agent into the affected vein. It causes endothelial damage and sclerosis of the involved vein, thus preventing further vein filling. Surgical ligation and stripping is used in patients with large symptomatic varicose veins with ulcers, bleeding, or recurrent thrombophlebitis of the veins BITES: An animal bite is an extremely common problem encountered in the emergency department. Most of the bites are due to the animal known to the victim and are unprovoked. Sometimes the bites can be from the stray and wild animals as well. It is important to obtain an accurate and complete history from the patient for appropriate management. The most important piece of information to get is to find out the exact location of the animal in the zoo. The bite in the zoo should not be presumed to be from the animals kept under observation. It can still happen from an animal in the surroundings. This is important, as these animals are not vaccinated and are not under observation. This can change the whole management strategy for a particular patient and will warrant a more aggressive approach to the management. Animal bites can lead to a wide spectrum of injuries, ranging from minor scratches or abrasions to deep puncture wounds or lacerations. The extremities, especially the upper extremities, are common sites of injury in older children or adult patients. All animal bites, regardless of the site, should be thoroughly cleaned and irrigated with normal saline, and all devitalized tissues should be dbrided. A plain radiograph should be obtained if a patient is suspected of having a foreign body or has a bite occurring close to a bone. Most open lacerations can be closed primarily within a few hours of injury. This is especially true for injuries of the face where infections are less common due to a good vascular supply Primary closure is not recommended in the hands [should not be sutured or closed primarily due to a high risk of subsequent wound infection]. These should be left open to drain and examined frequently for signs of infection. Primary closure is not recommended in puncture wounds, cat and human bites (high risk of infection), and patients presenting late after the bite. Cat and dog bites should be treated prophylactically with amoxicillin/clavulanate. Tetanus toxoid must be given to individuals with dirty wounds who have received a booster >5 years ago and to individuals with clean wounds who have received a booster >10 years ago. Tetanus immune globulin should be given to any individual with a dirty wound and an unclear or insufficient immunization history. A second dose of tetanus toxoid must be given in one month, and a third dose in twelve months. SUBPHRENIC ABSCESS: Typically develops 14-21 days after abdominal surgery. Clues to this diagnosis are a history of abdominal surgery, swinging fever, and leukocytosis. Cough and shoulder-tip pain may be the presenting symptoms. Abdominal ultrasound is the best diagnostic test for a suspected subphrenic or other abdominal abscess.

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THYROGLOSSAL DUCT CYST: About one-third of patients with a thyroglossal duct cyst present after the age of 20. They present with a midline neck mass that moves with protrusion of the tongue. The thyroid is formed as an outpouching from the base of the tongue, and then descends to the base of the anterior neck. The thyroglossal duct connects the tongue and the thyroid gland, and a cyst can develop from the epithelial remnants within the duct. Ectopic thyroid tissue is present in a large number of patients within the thyroglossal duct cysts, but sometimes this is the only functional tissue present. Therefore, imaging studies, like a thyroid nuclear scan, ultrasound, or CT is mandatory before subjecting the patient to surgery. A CT scan is thought to be more useful because it not only delineates the normal thyroid gland, but also clarifies the anatomy of the thyroglossal duct cyst in relation to the surrounding structures. Preoperative assessment of thyroid function is also required. A fine needle aspiration biopsy is not generally required unless there is high suspicion of malignancy. FLAIL CHEST: The patient has tachypnea, shallow breathing, tachycardia, anterior chest bruises and peripheral cyanosis. Flail chest is usually the result of double rib fractures in more than one site, and is present in 10-20% of trauma admissions. The main pathophysiologic feature of flail chest is the increased work of breathing due to muscular spasm and pain. Hypoxia develops frequently due to associated pulmonary contusions. ACUTE APPENDICITIS: McBurneys sign (tenderness at McBurneys point, the site two-thirds between the umbilicus and right anterior superior iliac spine) Rovsings sign (transmission of pain from the left to the right lower quadrant), and iliopsoas sign (RLQ pain on passive extension of the right hip). There is a left shift in the white blood cell count (true for 95% of diagnosed cases) In a third trimester pregnant woman, there is a minimal risk of premature delivery; however, if rupture of the appendix occurs, peritonitis can lead to fetal death, abscess formation and pylephlebitis (infectious thrombosis of the portal veins). These complications are rare but feasible, especially if therapy is not offered within the first 24 hours of the initiation of symptoms DESMOID TUMORS [SLOW-GROWING MUSCLE MASSES]: Desmoid tumors are locally aggressive neoplasms arising from fibroplastic elements within the muscle or fascial planes. Since these are locally invasive and slowly infiltrate the surrounding tissues and structures, these only cause local complications. These usually present as painless or minimally painful, slow-growing muscle masses over the extremities, shoulder girdle, and hip-buttock area, although these may occur at all body sites. The diagnosis is generally confirmed with a tissue biopsy. Surgical excision with a wide margin of resection is the treatment of choice for patients with an easily approachable and resectable mass. There is a high rate of local recurrence, even after adequate resection. D/Ds: 1. Abdominal aortic aneurysms usually present as a painless pulsatile mass. 2. Ventral or incisional hernia can develop at the site of previous surgical scars; however, this is generally reducible, and pain is an unusual symptom of ventral hernia, unless it is strangulated. AORTIC DISSECTION: Aortic dissection is an uncommon but potentially life threatening cause of severe and sudden chest pain. It has the same predisposing risk factors as an acute coronary syndrome (unstable angina and myocardial infarction), including age greater than 55 years, hypertension, hyperlipidemia, and chronic smoking. The diagnosis of aortic dissection is usually based on the history and the physical examination findings.

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Patients with acute aortic dissection typically present with a sudden onset of severe or "tearing" chest pain radiating to the back. The pain is usually not relieved by sublingual nitroglycerine. Other clinical clues favoring the diagnosis of an aortic dissection include the blood pressure difference in the two arms, an early diastolic murmur (reflecting aortic insufficiency And the presence of mediastinal widening on chest x-ray. BURNS: The majority of burn center deaths are due to inhalation injuries. COMPLICATION: Supraglottic damage [EDEMA] is one of the most alarming types of inhalation injuries and stems from inhaling hot air, steam, or smoke. The ensuing inflammatory response results in edema of surrounding soft tissues and significant narrowing of the airway. Fiberoptic laryngoscopy or bronchoscopy may be necessary to properly assess the extent of airway involvement. TETANUS: For those patients with a contaminated wound and unknown immunization status, both tetanus antitoxin and tetanus immune globulins are indicated. The situations in which only tetanus antitoxin is given are the following: 1. When the patient has a clean wound but unknown immunization status, or if he has received less than three doses of tetanus antitoxin. 2. When the patient has a clean wound and has received three or more doses of tetanus antitoxin with the last dose received more than ten years ago. 3. When the patient has a contaminated wound and has received three or more doses of tetanus antitoxin with the last dose received more then five years ago. AVASCULAR NECROSIS OR OSTEOCHONDRITIS DISSECANS: A variety of disorders and disease processes can cause osteonecrosis. Among all the causes, corticosteroid use and excessive alcohol intake are responsible for about 90% of the cases. Some other disorders associated with the development of osteonecrosis include systemic lupus erythematosus (SLE), sickle cell disease, antiphospholipid antibody syndrome, chronic renal insufficiency and hemodialysis, trauma, Gauchers disease, HIV infection, following renal transplantation, and Caissons disease. Patients with SLE on chronic high-dose corticosteroid therapy are at greatest risk (more than 15 to 20 mg/day). Osteonecrosis usually occurs in the anterolateral femoral head, though it can also affect the humeral head, femoral condyles, vertebrae, proximal tibia, and small bones of hand and foot. Early diagnosis of osteonecrosis is important to prevent bone collapse and the need for joint replacement. Physical findings are usually nonspecific, making it necessary to obtain sensitive imaging. MRI scanning is far more sensitive than plain films or bone scanning. Focal lesions are well demarcated and changes can be seen early in the course of the disease when other studies are negative. The goal of therapy of osteonecrosis is to preserve the native joint for as long as possible. The main modalities of treatment include conservative therapy, core decompression, osteotomy, and joint replacement. Total hip replacement is the therapy of choice for stage-4 disease of the femoral head (flattening of the femoral head with joint space narrowing). AORTIC INJURY: The most common cause of sudden death after a steering wheel injury from motor vehicle accident is aortic injury. Patients typically die at the scene before an ambulance service arrives. Rapid deceleration produces a shearing force along the aortic arch where the aorta is firmly attached. It is usually observed in the area of the ligamentum arteriosum, the aortic root, and the diaphragmatic hiatus.

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HERNIA: A hernia is a small area of weakness or defect in the overlying muscular or fibrous wall through which abdominal contents pass. Groin hernias are either inguinal or femoral hernias. The most common presentation is the dull sensation of heaviness or discomfort that is more pronounced with prolonged standing or straining (increased intraabdominal pressure). These are easily reducible in most cases, and symptoms are relieved with lying flat. A dreaded complication is incarceration or strangulation. It occurs when a tight constriction ring forms around the herniated contents and the hernia then becomes irreducible. Patients typically present with a constant pain that gets worse over time. If left untreated, it leads to necrosis and gangrene of the contents, and can be life-threatening. A femoral hernia is much more predisposed to strangulation than an inguinal hernia. The most effective treatment for all types of hernias is surgical repair. Risks of delaying the surgery are mainly those related to incarceration and strangulation. Inguinal hernias in the pediatric age group should be surgically repaired as early as possible [FIRST MONTHS OF LIFE] -These will not resolve with age. The risk of potential complications, including incarceration, is particularly high if it remains unrepaired during the first months of life. RUPTURE OF THE ACHILLES TENDON: Rupture of the Achilles tendon may occur after abrupt calf muscle contraction. This typically occurs in men over the age of 40 who do not perform a regular leg-conditioning program. The most common symptoms are severe pain in the calf and the inability to stand up on the toes. The patient may note an audible snap at the time of injury. A positive Thompson test is further evidence of rupture. This test is performed with the patient kneeling on a chair or lying prone on an examination table and the feet hanging over the edge. When the examiner squeezes the calf muscle on the normal side, the foot responds with plantar flexion. On the affected side there is no foot response after squeeze gastronemius Treatment consists of immediate immobilization of the lower leg and surgical repair of the tendon as soon as possible. NECK TRAUMA: Whenever there is an accident with possible neck trauma, the airway must be secured through the jaw lift maneuver to avoid further strain in the neck area. Cricothyrotomy may be necessary if there is complete obstruction of the airway. If the patient is unconscious, completely unresponsive, unable to protect the airway, not breathing or coughing, he or she will need to be intubated. INFECTIOUS MONONUCLEOSIS: Is a viral illness caused by the Epstein-Barr virus. It classically presents with marked fatigue, fever, tonsillar pharyngitis, and generalized lymphadenopathy. Acute symptoms usually resolve in one to two weeks. The infection is usually seen in adolescents and young adults, although most of them are asymptomatic. LYMPHADENOPATHY: Is typically symmetric, and usually involves posterior cervical nodes. It peaks in the first week of infection, and subsides over the next 2-3 weeks. Rx: Patients with localized lymphadenopathy can be observed for 3-4 weeks. A biopsy should be performed if the abnormal nodes fail to resolve after that time, or earlier, if there are other signs of malignancy. Abnormal and persistent lymphadenopathy is sometimes the first clinical manifestation of an underlying lymphoma. Persistent and localized abnormal lymph nodes should be biopsied. SCROTAL TRAUMA: The utility of ultrasound in scrotal trauma is controversial.

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Some studies report excellent sensitivity, while others do not recommend it because of its unreliability. In any case, a sonogram is a useful adjunct to physical examination, but normal results should not preclude surgical exploration when the testis is grossly abnormal. Several studies have demonstrated a significant increase in orchiectomy rates when surgical repair was delayed. Surgical exploration and repair should therefore be performed without delay if there is evidence of significant trauma on physical examination. NERVE INJURY: Femoral Nerve: On examination, patients with significant femoral neuropathies develop weakness involving the quadriceps muscle group with sparing of leg adduction (this is a function of the obturator nerve). This leads to the inability to extend the knee against resistance. In addition to muscle weakness, sensory loss over the anterior thigh and most of the medial thigh is typical. The sensory loss extends down the medial shin to the region of the arch of the foot due to saphenous nerve dysfunction (saphenous nerve is a branch of femoral nerve). The knee jerk also decreases in amplitude or becomes absent. Sciatic Nerve: Complain of weakness affecting most of the lower leg musculature, including the hamstrings. Hip flexion, extension, abduction and adduction, and knee extension are usually normal.There is sensory loss involving the lower leg. However, in contrast to the femoral nerve injury, the medial calf and arch of the foot may be spared secondary to innervation by the preserved saphenous nerve (a branch of the femoral nerve). Sensation is also spared above the knee both anteriorly and posteriorly. -The knee jerk is normal, but the ankle jerk is unobtainable. The most common cause for compression or injury to the sciatic nerve in this region is trauma, including hip dislocation, fracture, or replacement. Other etiologies include wayward buttock injections, compression by external sources, such as prolonged bed rest and any deep-seated mass in the pelvis (hematomas). Obuturator Nerve: An obturator nerve injury presents with: Pain, weakness in leg adduction, and sensory loss over a small area in the medial thigh. Obturator neuropathy is often secondary to pelvic trauma or surgery. The clinical presentation of common peroneal nerve injury is usually acute foot drop, with weakness in foot dorsiflexion and eversion. Patients may also complain of paresthesias and/or sensory loss over the dorsum of the foot and lateral shin (superficial peroneal nerve territory). It is usually injured at the knee at the lateral aspect of the fibular head. RENAL OR URETERAL STONES: Renal or ureteral stones are a common presenting problem in the emergency department. Most of the patients present with a sudden onset of pain and hematuria. The pain is usually colicky in nature (waxing and waning) and can vary from a mild ache to severe discomfort requiring narcotic analgesics. The location of the pain can sometimes give clues to the site of the stone. Upper ureteral or renal stones usually cause pain in the flank, whereas a lower or distal ureteral stone causes pain which radiates to the ipsilateral groin area. Initial management is usually conservative, and includes intravenous hydration and pain control. Stones that are less than 5 mm in size usually pass spontaneously. On the other hand, stones greater than 8 to 10 mm are unlikely to pass spontaneously and require removal. Stone removal is also indicated in patients with persistent pain, acute renal failure, or signs of urosepsis. There are three common techniques that have been employed to facilitate stone removal or passage from the ureters.

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These include extracorporeal shockwave lithotripsy (ESWL), flexible ureteroscopy, and percutaneous ureterolithotomy. The choice of procedure usually depends on the location of the ureteral stone. Shockwave lithotripsy is the treatment of choice for small symptomatic proximal ureteral calculi (less than 5-10 mm in size). For large (more than 10 mm) proximal ureteral stones, flexible ureteroscopy combined with laser lithotripsy is the preferred initial therapy. Any case of acute urinary obstruction in which there is no evidence of pelvic or urethral trauma, or no history of urethral strictures, must be managed immediately through urethral catheterization in order to decompress the bladder, alleviate the pain, and avoid further renal compromise. Suprapubic catheterization should never be done on an empty bladder, and should preferably be performed by the urologist when the aforementioned conditions are present, or if Foley catheter placement is difficult. INTRACRANIAL HYPERTENSION: Patients with intracranial hypertension have been classically described to have bradycardia, hypertension and respiratory depression (Cushing"s triad). In the early stages, patients complain of headaches, vomiting, blurred vision, and have papilledema on funduscopic examination. Further elevation in the intracranial pressure leads to transtentorial herniation of brain tissue, causing altered levels of consciousness (stupor progressing to coma), dilation of the ipsilateral pupil, third cranial nerve palsy, hemiparesis, decerebrate posturing, and eventually, respiratory arrest. The most important next step in the management is to rapidly intubate the patient to protect and maintain her airway, in case of a respiratory arrest

HEMATOLOGY/ONCOLOGY

Multiple Brain Metastasis whole brain radiation therapy [improves survival ESCC=Epidural Spinal Cord Compression: common complication of cancer pain [classic thoracic radicular pain] and neurological dysfunction metastatic tumor from any 1ry site can cause ESCC. Symptomatic epidural spinal cord compression Emergency High dose corticosteroids {dexamethasone} and radiation therapy. Order MRI of spine [to confirm the diagnosis. PRIMARY CNS LYMPHOMA [PCNSL]: is a common malignancy in pts with HIV, related to EBV, and the major determinant of the survival is the significant degree of immunosupression [CD4 < 50]. The best prognostic sign for PCNSL is a increase in CD4 count and a decrease in viral load management: HAART therapy improve prognosis Sickle Cell Crisis acute painful episode, vasooclusive type, with splenomegaly; triggers: infection, cold, menses, dehydration, alcohol, etc. First step in management [especially in children] is IV fluids to ensure optimal hydration. Then analgesia Ketorolac or Morphine. **Next step after management of acute abdominal pain crisis is undertaken CBC [remember spleen sequestration crisis in children and hypovolemic shock] Transfusion Order first test: ABO and RH then screen for antibodies [pretransfusion antibody screen] looking for RBC antibodies if positive further testing Major reason for incompatibility or difficulty finding cross-match blood is patients with a history of multiple transfusions is= ALLOANTIBODIES thah make finding compatible blood even more difficult [example in pts with sickle-cell anemia or myelodysplasia] **MC implicated RBC antigen E, L, K Anemia Of Chronic Disease can be difficult to differentiate from iron def. anemia in the setting of an acute bacterial infection [like pneumonia] The best test to CONFIRM diagnosis of Anemia of chronic disease and rule our iron def. is BONE MARROW BIOPSY

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ITP: Most likely cause of the drop in platelet count => autoimmune phenomena involving formation of antiplatelet antibodies [platelet destruction by spec. antibodies] ITP management: self limited in children, but may be chronic in adults. Rx: is only necessary in severe or symptomatic thrombocytopenia => Corticosteroid therapy => if no response -> IV- IGs refractory cases Splenectomy PANCOAST TUMOR /METASTATIC with Horner syndrome and hoarseness, local invasion of paravertebral symp. Chain and RLN [MC tumor is small cell lung cancer] Rx: Radiation therapy with surgical resection. If distant metastatic disease radiation therapy alone as palliative. NORMOCYTIC NORMOCHROMIC ANEMIA: 1) Diseases with decreased RBC production and 2) Hemolytic disorders. To determine the mechanism of this anemia Reticulocyte count [elevated if hemolysis] Elevated Reticulocyte count:Hemolysis sign = RC elevated, Indirect bilirubin elevated, LDH elevated, decreased haptoglobin; and splenomegaly Low Reticulocyte count: hypoproliferative state renal disease, aplastic anemia, hypothyroidism, and late stage anemia of chronic disease when chronic bleeding become in microcytic anemia due to iron deficiency] HEPARIN INDUCED THROMBOCYTOPENIA: Arterial thrombosis to left arm following administration of UFH => Heparin induced thrombocytopenia TYPE 1: within 2 days, lesser degree in fall of PC, after stop heparin, PC return to WNL TYPE 2: more serious, formation of antibodies vs. heparin platelet factor 4 complex, spontaneous bleeding is usual, with thrombosis, PE, venous limb gangrene, cerebral sinus thrombosis, strokes, MI, organ ischemia; etc Rx: Discontinue heparin, warfarin and initiate argatroban or lepidurin [direct thrombin inhibitor] Most useful strategy in preventing HIT=> Substitution of UFH with LMWH or heparinoids [Danaparoid], or use heparin less than 5 days in order to prevent any antibody response METASTATIC PROSTATE CANCER with spread to vertebral column [osteoblastic lesions in skeleton] Best test for new bony metastasis Radionuclide bone scan or Radioisotope bone scan Best treatment for metastatic prostate cancer palliative Leuprolide and flutamide [androgen depletion] Leuprolide is a LH releasing hormone agonist-> binds LHRH receptors in ant pituitary ->initial release of LH and FSH, rising testosterone transiently [symptoms can worsen] but after 1 week there is a down regulation of LHRH receptors causing decrease of LH and decrease of testosterone. LHRH agonist therapy is contraindicated in pts with painful vertebral metastasis and urethral obstruction because in the first week the symptoms can worsen; so give: Flutamide [antiandrogen] for 1 week before starting LHRH agonist [leuprolide, goserelin or zoladex, etc] to block effects of testosterone surge or initial symptom flare. If after hormone treatment the pt has a progressive cancer despite leuprolide/flutamide or chemotherapy => Next step: REFER pt for RADIATION therapy. If spinal cord compression emergency, neuro signs, pain to 2ry compression or visceral distention => Admit pt and IV Corticosteroids. SVC syndrome - in pt with high risk of malignancy [smoker] neck pain swelling, cervical and upper extremities venous dilation CT scan neck and chest with contrast Factor V Leiden mutation=MC heredity thrombophilia predisposes to venous thromboembolism Long term management life long Warfarin. Neutropenic fever is an emergency=please take pt to the local ER immediately [pt can have a serous life threatening infection even in the absence of typical signs and symptoms. Venogram indicating=Recurrent DVT [2nd] with a more proximal extension into IVC and internal iliac vein due to inadequate anticoagulation with warfarin [INR=1.4] => next step=>pt requires

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higher doses of warfarin to bring INR within therapeutic range =with serial monitoring of PT/INR. Maybe pt is in high diet of vit k [green leafy vegetables] or is taking any medicatin that is metabolized in the livers P450 cytochrome isoenzyme. IVC filter= indicated hen contraindicated anticoagulation or recurrent venous thromboembolism despite a correct and adequate anticoagulation. Posttransfusion platelet count should be measured 10-60 min after transfusion=> each unit of platelet should cause immediate post-transfusion rise in PC => platelet refractoriness due to alloimmunization should be considered if platelet transfusion fail to cause expected increment in PC. Alloantibodies can cause a rapid destruction of transfused platelets and cause refractoriness. Doxorubicin based chemo causing extrapiramidal symptoms, unstable gait => Due to metochlopramide [dopamine blocker] => for chemo induced emesis => next step=> > Change to Ondansetron [5HT3 serotonin rec. antagonist LOBULAR CARCINOMA IN SITU LCIS [incidental finding of mammography]: bilateral and multicentric => is not considered to be a direct precursor of invasive breast cancer , but the risk factor is important. The risk is increased in both the ipsilateral and contralateral regardless of the side where its present Management 1) regular close observation and mammogram, if any problem: tamoxifen and bilateral prophylactic mastectomy Methotrexate, trimethoprim and phenytoin=> interfere w folate metabolism->folic acid def. anemia Rx=folinic acid or Leucovorin rescue is the DOC [more potent than folic acid] when folic def. is due to MTX. Folinic acid is more potent rescuing RBC from the deficiency bypassing the block on DHFR enzyme Greatest RISK FACTOR for developing COLON CANCER=> 1] Alcohol intake 2] cigarette smoking PROTECTIVE factors for COLON Cancer=> NSAIDs, ASA, regular exercise, fibrous diet rich in fruits/vegetables, HRT. Anemia of chronic disease due to ESRD due to EPO def. => RX: EPO but you need to rule out other causes of anemia before stat treatment with EPO.If after 6 weeks of treatment the HCT fails to increase adequately =>next step-> measure transferring saturation and ferritin levels [to rule out iron deficiency] and iron def. should be treated by weekly IV iron RENAL failure, anemia tendency to bleed, due to platelet dysfunction [prolonged bleeding time in uremic coagulopathy] PT, PTT, PC are normal. Rx= correct anemia, Desmopressin dialysis, estrogen treatment, cryoprecipitate infusion. DOC=Desmopressin if prolonged bleeding time. Desmopressin simplest and least toxic acute treatment of a prolonged bleeding time, acts by releasing factor VIII, von willebrand factor multimers from endothelium [vWF is ligant for platelet adhesion in a damaged vessel and is a cofactor of factor VIII, too. Other coagulopathies using Desmopressin= Von Willebrands disease, Hemophilia A, Bernard Soulier, Renal failure coagulopathy CANCER OF THE HEAD / NECK OF THE PANCREAS [60%] are advanced at the time of diagnosis, and are INOPERABLE. most appropriate treatment option => Combined Radiotherapy and Chemotherapy MOST EFFECTIVE STRATEGY IN PT MANAGEMENT IN CML => { Philadelphia chromosome and LOW leukocyte ALP } => Refer pt to hematologist for bone marrow transplantation [allogeneic hematopoietic cell transplantation] *Requirements for success/good candidate: 1. 50 y/o, less than 1 yr diseased. 2. stable chronic phase. 3. have not taken busulfan (cumulative dose lead to pulmonary toxicity]. CML= other management: oral chemotherapy [busulfan, hydroxyurea]; parenteral Interferon alpha; newer oral thyrosine kinase inhibitors =Imanitib SECONDARY POLYCYTHEMIA = CBC => High EPO to compensate for hypoxemia [due to pulmonary disease, cardiac disease or chronic hypoxic stimulus, OSA, smoking [carboxyhemoglobin], COPD, RT to LT cardiac shunt, high altitude], high HB, high RBC, but PC and WBC are normal [unlike polycythemia vera] POLYCYTHEMIA VERA: Low EPO [Erythroid production is independent of EPO]; normal SaO2; increased erythrocyte mass, increased HCT, WBC, increased plasma volume. Mutations in JAK-2 gene. Thrmbotic events! Due to

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hyperviscosity=> daily ASA; increased histamine [prurutus] -> Diphenhydramine, SSRIs; increased PC or thrombocytosis -> Anagrelide; Phlebotomy to lower HCT, Hydroxyurea and for hyperuricemia-> Allopurinol Best next step= Diagnose secondary polycythemia due to chronic hypoxic stimulus or lung disease=> Pulse oximetry or oxygen saturation measurement [taken after minimal exertion], and ABGs => Then: Sleep studies => to determine presence of nocturnal oxygen desaturation MULTIPLE MYELOMA: Best next step => Serum protein electrophoresis, skeletal survey and bone marrow biopsy Best test to reveal any potential skeletal lesion =>A complete skeletal series [skull, long bones, spine] Whole body x rays [bone-scan are not useful] Hyperviscosity syndrome= due to high protein content [MM*] and in WM* ANEMIA OF CHRONIC DISEASEnext step is treat underlying disease [infection, organ failure, RA, SLE] and follow ups. When anemia of chronic disease is severe=>periodic Blood transfusions with PRBC are necessary. If Hb < 10 and EPO serum < 500 [N=500-3.600] =>Give EPO PANCOAST TUMOR/SUPERIOR SULCUS TUMOR Dangerous sign Chest movement asymmetry and asymmetric lower extremity DTRs [indicates phrenic nerve involvement and possible invasion of intervertebral foramina spinal cord compromise] MISC. POINTS: Anti IF antibody testing very sensitive/specific in detecting pernicious anemia Autoimmune metaplastic atrophic gastritis, pernicious anemia caused by autoimmune aggression vs. gastric mucosa. Most likely findings: Absent rugae in the fundus or glandular atrophy; intestinal metaplasia and inflammation. Mononulear antibodies to HER-2 neu oncogene can be added to the RX of pts with breast carcinoma who over express this oncogene good response and improve sensitivity to chemotherapy. [Over expression of HER-2/neu is a worse prognosis in breast carcinoma and resistance to alkilating agents in treatment] Lung cancer, initial step in the optimal management CT-scan of the chest as the initial staging workup accurate histological identification and staging of tumor along with pre-operative assessment of lung function. Rx: surgery is the 1st line of choice Systemic mastocytosis suspected if unexplained peptic ulcer disease, malabsorption, eosinophilia, unexplained flushing or anaphylaxis, sclerotic bone lesions, diarrhea Rx: H1 rec. antagonists, PPIs, Cromolyn sodium. Best next step in management of a MALE pt with microcytic anemia, anisocytosis [iron deficiency] The GI tract is the major source of blood loss leading to iron deficiency in males; in women GU tract with menorhagia Fecal occult blood. EATON LAMBERT SYNDROME: associated with small cell lung carcinoma= from antibodies vs. the voltage gated calcium channels in the presynaptic motor nerve terminal. Next step Chest X-rays; if negative do a CT scan. Rx: plasmapheresis and immunosuppressive drug therapy

OBSTETRICS/GYNECOLOGY
CHLAMYDIAL INFECTION : This newborn most likely has conjunctival and pulmonary chlamydial infection. Chlamydia may have been transmitted from the mother during the neonates passage through the birth canal. Cervical carriage in the mother has been associated with a higher incidence of preterm labor, PROM, and late post-term endometritis. Chlamydia is the most common causative agent of infectious neonatal conjunctivitis. Infected infants have a 25-50% risk of developing conjunctivitis and a 5-20% risk of developing pneumonia.

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Chlamydial conjunctivitis develops a few days to several weeks after birth and manifests with conjunctival congestion, edema, and mucoid or frank purulent discharge. Pneumonia usually appears 3-19 weeks after birth, and symptoms include cough, tachypnea, rales, and absence of fever. Wheezing is rare. The latter two features differentiate chlamydial pneumonia from RSV bronchiolitis. Neonatal disease is best prevented by early detection and treatment in pregnant women. Screening is recommended in high-risk individuals such as single mothers, adolescents, patients with low socioeconomic status, and promiscuous patients. And in < 25 y/o Erythromycin is the drug of choice in pregnancy and should be given to both the patient and her sexual partner. Another test should be performed later in pregnancy, and a positive result warrants a second course of antibiotics. Infants should also be treated with oral erythromycin for 14 days, as topical agents are ineffective. Colonization takes place during delivery, when the newborn comes in contact with the vaginal secretions of the mother.

RH INCOMPATIBILITY: Hemolytic disease of the newborn due to Rh-incompatibility is possible only when the mother is Rhnegative and the father is Rh-positive. Hemolytic disease is very unlikely in the first pregnancy, as the mother is not sensitized. The mother becomes sensitized as a result of fetomaternal hemorrhage at or near the end of pregnancy. This risk of sensitization can be reduced by a RhoGAM injection within 72 hours of the delivery. Anti-D immune globulin should be administered intramuscularly at 28 weeks gestation to all Rh (D) negative women if no anti-D isoimmunization is detected by antibody screening. Antenatal prophylaxis is not necessary only if the father of the child is known with certainty to be Rh (D) negative. Antenatal prophylaxis helps to reduce significantly the risk of Rh (D) isoimmunization during pregnancy. Peripartum anti-D immune globulin is also indicated to reduce the risk of isoimmunization due to fetomaternal transfusion during the delivery. Early antenatal anti-D immune globulin prophylaxis is indicated in case of the events and procedures that can increase the risk of isoimmunization (e.g., spontaneous abortion, ectopic pregnancy, and amniocentesis). Otherwise, the risk of isoimmunization before the 28th week of pregnancy is very low. Failure to adjust the dose of anti-D immune globulin after events that are associated with excessive feto-maternal hemorrhage (e.g., placental abruption) may result in maternal alloimmunization. Events that are associated with feto-maternal hemorrhage (such as placental abruption) may require adjustments in the dosage of anti-D immune globulin; therefore, the presence and the amount of feto-maternal transfusion should have been determined in this patient during her first pregnancy. The rosette test is a qualitative test that helps determine the presence of feto-maternal hemorrhage. If negative, the standard dose of anti-D immune globulin should be administered. If positive, the amount of hemorrhage can be evaluated using Kleihauer-Betke stain or fetal red cell stain using flow cytometry, and the dose of anti-D immune globulin should be corrected accordingly. PREGNANCY FACTS AND CONDITIONS: Screening for group B strep should be done 36-37 week gestation and positive cases should be tx with Penicilline G during labor, even in the absence of risks. Low back pain is very common in thrid trimester. Its caused by lumbar lordosis and relaxation of ligament to the joints. Both Graves dis and Migraine will improve in Pregnancy. Excessive use of oxytocin may cause water retention (acts like ADH), hyponatremia and seizures (water intoxication). ACE inhibitors and Oral hypoglycemic agents (Glibenclamide) are C/I in pregnancy. Stop them and give Insulin for DM, and Methyldopa (most commonly used), Hydralazine and Labetalol for HT control in pregnancy. Pregnancy has protective effect on both MS and PUD In pregnancy both BUN and Creatinine are decreased to half of prepregnancy levels. Amoxicilin has no effect on them.

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Pregnancy and UTI: Asymptomatic Bacteriuria of Pregnancy, increases risk of developing cystitis and pyelonephritis. E coli are the cause 70% of the times. Rx- UTI in pregnancy: 7-10 days Cephalexin [first gen Cephalos] or Ampicillin or Nitrofurantoin Pyelonephritis/pregnancy: Rx: Ceftriaxone or Cefazolin or Ampicillin or Gentamicin Neonates of pts with Graves disease treated with surgery are at risk for Thyrotoxoicosis because of the passage of thyroid stimulating immunoglobin across the placenta. Hypotension is a common se of epidural anesthesia. The cause of hypotension is blood redistribution to the lower extremities and venous pooling. Pregnancy and EXERCISE: It iss recommended to CONTINUE exercise as you were doing before, like an aerobic instructor. Aerobic is Ok, scuba diving are contraindicated Edema of lower extremities (Bilateral) in pregnancy is most commonly a benign problem. Preeclampsia should be suspected if the edema is associated with hypertension or proteinuria, no need to do ECG or DVT (presents unilateral and fever). Oxytocin is like ADH so it causes water retention and Water toxicity due to decrease in Na concentration (123 ). So it could cause seizure post partum. Screening cultures should be performed at week 36-37 and positive cases should be treated with IV penicillin therapy during labor to prevent the new born from getting infected. HYPERTENSION and Pregnancy: If hypertension sets in before 20 weeks, its either Mole or CHRONIC hypertension. If it sets in after 20 weeks, its either Preeclampsia (Proteinuria, >300mg) or TRANSIENT hypertension (not accompanied by proteinuria) Antibodies to ABO antigens belong to IgM antibody class so they dont cross placenta and hence mother and baby can have different blood type. But Anti-D antibodies that are responsible for Rh alloimmunization belong to IgG class and do cross placenta. Pregnancy and Driving: All pregnant drivers should wear seatbelts while driving. Seat belts have been shown to improve both fetal and maternal outcomes in automobile accidents. Pregnant drivers who do not wear seat belts while driving are more likely to have excessive internal bleeding and fetal death if they are involved in a car accident. The current recommendation is that both lap and shoulder straps should be used. The lap strap should be placed under the abdomen, and the shoulder strap should be placed diagonally across the chest and abdomen Pregnancy and Epilepsy: Although anti-epileptic drug use during pregnancy is associated with an increased risk of congenital abnormalities, over 90% of women with epilepsy have normal pregnancy. There is currently no agreement about which anti-epileptic drug is most or least teratogenic; therefore, the drug that works best for the patient should be used. Early detection of neural tube defects by serum alpha-fetoprotein screening, amniocentesis or ultrasonography is important. If major abnormalities are present, the pregnancy can be terminated or an optimal management strategy can be planned. Switching to another drug is not usually recommended for the patient taking anti-epileptic drugs during pregnancy. According to the American Academy of Pediatrics (AAP) and American Academy of Neurology (AAN), breastfeeding should be encouraged in women with epilepsy. This is due to the belief that the benefits of breastfeeding outweigh the risk of exposure of the infant to antiepileptic drugs. ETHICS: Expectant teenage mothers are legally entitled to give consent for procedures related to the management of their pregnancies, including the performing of cesarean sections. Adolescents do not need consent from their parents for contraceptive services. Barrier methods should be used by all sexually active adolescents even if an additional method of contraception is being used.

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Most states have implemented laws that allow for a physician to provide certain types of medical care to adolescents without parental consent.Elective abortions are typically protected under these laws.Therefore, a teenaged girl would have the authority to provide legal consent for an abortion. When deciding ethical issues such as this, it is important to focus on the principles of patient autonomy and beneficence. Patients have the right to seek, accept, or refuse care. With the mentally disabled, it may be impossible to obtain informed consent, but at the least simple assent should be strenuously pursued. If sterilization is not wanted, it should not be performed against the patients will. Involuntary sterilization violates a womans right to privacy, her reproductive rights, and her bodily integrity. Advice long time hormonal contraceptives Lesbian women often conceal their sexual orientation from their primary care physicians. Recent developments and legislations regarding same sex marriages have encouraged more homosexual couples to "come forward" or reveal their sexual orientation. It is important for primary care physicians to be sensitive and knowledgeable to their special needs and concerns. Advice taking her Pap smears yearly. EMERGENCY CONTRACEPTION: Levonorgestrel is the recommended method of emergency contraception if used soon enough after an unprotected sexual intercourse. It has maximal efficacy when used within the first 12 hours after intercourse, good efficacy within 48 hours, and appears to work up to 120 hours after intercourse. One controlled trial showed that levonorgestrel prevents 85% of expected pregnancies (compared to 57% prevented by estrogen/progesterone combination). The copper iud intrauterine device is an effective emergency contraception tool that can be used if a patient presents more than 120 hours after unprotected intercourse. PLANNED CONTRACEPTION: The most effective reversible contraceptive methods are injectable contraceptives (97 to 98% in 1 year) and Oral contraceptives (92%). Oral contraceptives (OC) are contraindicated in patients with a history of thrombosis, estrogendependant tumors, or liver disease, as well as those who are heavy smokers or older than 35 years. They are also not recommended for patients who are younger, on anticonvulsant medication, have a heavy smoking history, have migraines, or uncontrolled hypertension. The absolute contraindications to the use of Oral contraceptives are the following: 1. History of thromboembolic event or stroke 2. Active liver disease 3. History of estrogen dependent tumor 4. Pregnancy 5. Abnormal uterine bleeding 6. Heavy smokers who are older than 35 7. Hypertriglyceridemia Relative contraindications are the following: 1. Migraine headaches 2. Poorly controlled hypertension 3. Anticonvulsant drug therapy Depot medroxyprogesterone is ideal for women with heavy menstrual loss, fibroids, a history of PID, or heavy smoking > 35 y/o. Implantable and injectable contraceptives, including implantable levonorgestrel and depot medroxyprogesterone acetate, have the lowest rate of pregnancy (does not exceed 2-3%) among nonpermanent methods of contraception. Norplant consists of six capsules of levonorgestrel which are placed sub-dermally, generally in the upper arm. It offers contraceptive protection for about five years. The most common complication is menorrhagia (prolonged vaginal bleeding during each period), which occurs in about 28% of the cases. Numerous commonly used anti seizure medications (e.g., phenytoin, carbamazepine, ethosuximide, phenobarbital, topiramate) are known to decrease the efficacy of OCs oral contraceptives.Alternative

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anti seizure medications that do not decrease oral contraceptive efficacy include Gabapentin and Valproate. Affect Of OCPS On Thyroid Gland Combination oral contraceptive pills (OCPs) are the most reliable form of reversible contraception; however, the use of these hormonal drugs may affect a person"s TBG, total T4, and free T4 levels. The estrogen component of the combination pill increases Thyroxine Binding Globulin (TBG) levels, which may result in an increase in the total T4 levels and decrease in free T4 levels. Check with: total T4, Free T4, Total T3 and TSH A person with an intact and normal thyroid gland may compensate for these changes by increasing thyroid hormone production, which normalizes the free T4 levels. On the other hand, a hypothyroid patient cannot compensate for these possible physiologic changes since she is unable to produce sufficient amounts of thyroid hormone and is dependent on levothyroxine therapy. The dosage of levothyroxine may therefore be increased in hypothyroid patients who are taking OCPs to compensate for the mentioned physiologic responses. After starting combination OCPs in well-controlled patients with hypothyroidism, TSH levels should be checked in 12 weeks, and the dose of levothyroxine should be adjusted accordingly. Affect of OCPS on Weight Studies have shown that adolescents in a private practice setting are very concerned about the prospect of gaining weight secondary to oral contraceptive (OCP) use. However, available data has demonstrated that OCPs do not cause an increase in body weight or percent body fat. Occasionally adolescents voice other concerns about OCP use, including fears of developing blood clots, birth defects, and infertility, but these concerns are more common in the lower socioeconomic groups. Other Affects of OCPs Chronic OCP can cause hypertension, discontinue it and problem goes away. SLE pts with increased risk of thrombosis (antiphospholipid and nephritic synd) and pts with active renal involvement should avoid OCP. Pt with Migraine should avoid OCP due to increased risk for Stroke. Breast cancer has NO assoc with COP. Endometrial and Ovarian cancers risk is decreased with use if OCP. When you 1st start taking it could cause irregular bleeding and that is the mcc of incompliance. Tell the pt to keep taking it and it will be OK. The accidental usage of oral contraceptives during the first trimester of pregnancy is not associated with an increased risk of fetal malformation. HUMAN PAPILLOMA VIRUS (HPV) INFECTION: Is a sexually transmitted infection strongly linked with the development of cervical intraepithelial neoplasia (CIN) and cervical cancer. -Early initiation of sexual activity, multiple new sexual partners, and high-risk partners (partners with HPV infection), are the main risk factors for the acquisition of HPV infection and cervical cancer. Sexual intercourse, especially with multiple new partners, is the main risk factor for the acquisition of HPV infection. Screening for cervical cancer by cytologic examination/Pap smear is an effective way of detecting early pre-invasive and invasive carcinoma. The risk of acquiring HPV infection (and, hence, CIN/cervical cancer) is much lower in lesbian women if they do not engage in sexual intercourse with men. BUT: Lesbian women still need to undergo routine screening for cervical cancer The risk of acquiring HPV infection (and CIN/cervical cancer) is lower in lesbian women if they do not engage in sexual intercourse with men. The risk of cervical neoplasia is highest in lesbian women who have had sex with more than one male sexual partner, have an early age at first coitus with men, have been infected with HPV, and have been

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treated for an abnormal cervical cytology test in the past. The risk is also increased with cigarette smoking. ANNUAL SCREENING BY PAPANICOLAOU SMEAR: is recommended for all women approximately three years after the onset of vaginal intercourse, or at the age of 21, whichever is earlier. According to the guidelines, screening for cervical intraepithelial neoplasia (CIN) or cancer should be started three years after the onset of sexual intercourse, or at the age of 18 years (recently changed to 21 years) whichever is earlier. This is due to the fact that high-grade cervical cytologic abnormalities due to HPV usually do not occur until three to five years after HPV exposure. After a Pap abnormal Colposcopy, Endo cervical curettage and Ecto cervical curettage. RESULTS: A colposcopic examination is Satisfactory when an entire lesion and a transformation zone are visualized. If there is progression during the follow-up, or lesions are persistent after one year treatment is indicated. When the colposcopic exam is Unsatisfactorythe next step is always excision as this allows for histological examination. Even if colposcopic examination is satisfactory, treatment may be indicated if the patient is anxious about her disease, or if she seems to be non-compliant with follow-up. If the patient opts for treatment, available modalities are either ablation or excision. Ablation can be done with cryosurgery or laser. Excision can be done with knife conization, laser conization, or Loop Electrosurgical Excision Procedure (LEEP). 1. ASCUS. ATYPICAL SQUAMOUS CELLS OF UNKNOWN SIGNIFICANCE - HPV DNA testing from sample is the best test to evaluate atypical squamous cells of unknown significance. In this method, samples are collected both for cytology and HPV DNA. - If cytology results are negative, the sample for HPV DNA is discarded. - If cytology results are positive, HPV DNA testing is performed, and if this test is positive for highrisk HPV type, an immediate colposcopy is performed. - If the test is negative for high-risk HPV type, the Pap smear is repeated after one year. 2. HGSIL -HIGH-GRADE SQUAMOUS INTRAEPITHELIAL LESIONS INCLUDE: - CIN II, CIN III, moderate and severe dysplasia, and CIS carcinoma in situ - High-grade squamous intraepithelial lesions are more likely to be progressive than low-grade lesions, and these should always be treated with ablation or excision. - Ablation,Cryosurgery or laser - Excision knife conization, Laser conization or Loop Electrosurgical Excision Procedure (LEEP) - Loop Electrosurgical Excision Procedure (LEEP) is the treatment of choice for high-grade squamous intraepithelial lesion.***LEEP is preferred because of its low cost, accuracy, and easiness to perform. It is a very successful procedure and can be performed in an office setting. - A HGSIL revealed on Pap smear indicates a 1-2% probability of already having invasive cervical cancer and a 20% probability of acquiring invasive cervical cancer if left untreated. - Immediate referral to colposcopy and endocervical curettage is indicated. - If colposcopy suggests HGSIL, a Diagnostic excisional procedure should be performed. 3. LSIL- LOW-GRADE SQUAMOUS INTRAEPITHELIAL LESIONS OR LOW-GRADE CERVICAL INTRAEPITHELIAL NEOPLASIA (CIN I) - Regress spontaneously; therefore - Expectant management is preferred for biopsy proven CIN 1 with satisfactory colposcopic examination. - Expectant management includes repeat cytology at 6 and 12 months, or HPV DNA testing at 12 months.

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BLEEDING is the most common short-term complication after cervical conization (cone biopsy), both cold knife conization and LEEP. The causes of bleeding include inadequate intraoperative hemostasis and vasodilatation after the effect of the local vasoconstrictor wears off. Usually, the bleeding can be easily controlled by conservative measures. Surgical hemostasis is rarely required. All women at high risk of HPV infection and a normal Pap smear should have annual Pap smear tests. CERVICAL STENOSIS AND CERVICAL INCOMPETENCE FROM LEEP SURGERY: Surgical treatment of cervical intraepithelial neoplasia before conception increases the incidence of cervical incompetence and preterm birth 200-300%. It is thought that the risk is proportional to the amount of tissue removed during the procedure. Frequent cervical examinations in the second trimester will aid in determining if either cerclage is necessary in the short term or cesarean section is necessary in the long term. HIV/PREGNANCY: All HIV-positive adults are normally counseled to receive HAART (highly active antiretroviral therapy), which is a combination of two nucleoside analogue reverse transcriptase inhibitors and one protease inhibitor or one non-nucleoside reverse transcriptase inhibitor. An HIV-positive woman who is already receiving HAART should be counseled to continue her treatment regimen if her pregnancy is identified after the first trimester. (Zidovudine in particular is considered an essential component of the treatment regimen as it has been demonstrated to significantly decrease the vertical transmission of HIV.) For those HIV-positive women whose pregnancies are identified Early on in the first trimester, an acceptable.Alternative is to discontinue HAART for the remainder of the first trimester and then resume it thereafter. Ultimately, the preferred mode of delivery in all HIV-positive women is elective cesarean section. Efavirenz and Delavirdine are thought to have some teratogenic qualities and are best avoided during pregnancy if other options are available. Studies have shown that HIV can be transmitted through breast milk. Worldwide, it is estimated that one of every eight babies born to HIV-positive women will acquire the virus through breastfeeding. For this reason, HIV-positive women in the United States and other industrialized countries who have ready access to commercially prepared formula are advised to feed their infants with formula instead of breast milk. Most antiretroviral drugs are passed through breast milk in significant quantities, which is thought to decrease HIV transmission by indirectly providing the drugs to the infant. This understanding accompanied by the concern that formula is often too difficult or expensive to obtain in developing countries is the justification for suggesting that HIV-positive women in developing countries be given HAART while breastfeeding their children. However, the recommendation in the United States remains that HIV-positive women feed their infants with formula instead of breast milk, regardless of therapy given to the mother or infant. CONDYLOMA ACUMINATA: This is the dermatologic manifestation of an infection with the human papilloma virus, with over 90% of such condylomas arising from HPV subtypes 6 and 11 specifically. HPV is primarily transmitted through sexual contact, and the areas affected include the penis, vulva, vagina, cervix, perineum, and perianal region. Less frequently, HPV may be found in the oropharynx, larynx, or trachea secondary to oral-genital contact or secondary to vertical transmission from mother to infant during childbirth. One relatively common benign laryngeal tumor in children, recurrent respiratory papillomatosis, is caused by the acquisition of HPV during passage through the vaginal canal. However, since HPV is thought to be contracted by the infant in less than 1% of all childbirths to women who have condylomas, no intervention is usually undertaken. PELVIC INFLAMMATORY DISEASE (PID): The risk factors for PID include the following: 1. Oral contraception 2. No barrier contraception

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3. Multiple sexual partners 4. Age < 35 years 5. History of previous episodes 6. African-American ethnicity Studies have shown that among all the PID risk factors, having multiple sexual partners is the one associated with the highest increase in risk for occurrence of PID (4.6 to 20 fold increase in risk). The presence of fever, chills, bandemia, leukocytosis, as well as nausea and vomiting, indicates that the infection is severe. PID can be a serious condition that needs to be treated immediately. Treatment of severe PID is aimed at obtaining high blood concentrations of the antibiotics as soon as possible. For this reason, all therapy should be intravenous. Combinations that can be used are: cefoxitin + doxycycline or ceftriaxone + doxycycline. If a tubo-ovarian abscess is diagnosed, surgical evaluation is immediately needed. TUBO-VARIAN ABSCESS: Is seen in 10% of pt w PID. Admit the pt, Broad spectrum antibiotics should be started immediately AFTER taking cultures. Gentamycin+Clindamycin+Ampicillin. In absence of obvious response w/i 48 hours , drainage should be considered. If there is doubt regarding Dx do Laparoscopy. If rupture we need to do exploratory Laparotomy. VAGINITIS: Candida it is not an STD. It may appear in presence of risk factors like DM, OCP, pregnancy and immunosupresive therapy. It can also trigger by Alkaline pH of the vagina during menses that is favorable for growth of Candida. Symptoms are vaginal and vulvar pruritus, burning and dyspareunia. Discharge has cottage cheese appearance. Its NOT malodorous and pH is 4-4.5. Dx is by KOH wet mount preparation and visualization of pseudohypha and spores. Rx is Imidazole cream or 10 day oral Ketoconazole (especially if recurrent). Fluconazole is the new drug with fewer SE. Give 2 doses, a week apart. Most recurrences are due to non-compliance. If that is OK, then suspect another organism and culture on Saboraud. 50% of recurrence is due to other organism like like T. Glabrata and Candida tropicalis. In addition, 35% of pt with recurrent yeast infection and who have negative cultures, have HPV on biopsy. DD: Trichomonas (Metro) Gardenella Vaginitis (Metro). MITTELSCHMERZ: -Its a mid-cycle (LMP was 2 weeks ago) abdominal pain that typically presents in young females. If there is no fever it is not PID. VAGINISMUS: Involuntary spasm of the perineal musculature that interferes with sexual intercourse. Unlike Dysparunia, Vaginismus is not due to any medical cause. In ALL cases it is due to ignorance of women's anatomy, huge apprehension about penetration, and an uncontrollable fear of pain. Rx includes relaxation, Kegel excercise (to relax vaginal muscle), and graduation dilation (penetration). CHLAMYDIA TRACHOMATIS: Genitourinary infection caused by Chlamydia trachomatis is extremely common, and results in insidious and often chronic unrecognized disease. The large majority of women (up to 70 percent) are asymptomatic. It is a major cause of infertility, pelvic inflammatory disease (PID), and ectopic pregnancy in women. Some of the risk factors associated with the development of Chlamydia trachomatis infection include younger age with multiple sexual partners, inconsistent use of barrier contraceptives, and a history of prior sexually transmitted disease (STD). The Centers for Disease Control recommend that all pregnant women be screened for Chlamydia at the first prenatal visit. Women under age 25 and those at increased risk for chlamydial infection should have repeat testing in the third trimester.

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Chlamydia endometritis during pregnancy can lead to chorioamnionitis and premature delivery of the fetus. Untreated infection during pregnancy can also lead to conjunctivitis (ophthalmia neonatorum) and pneumonia in the newborn baby. Chlamydia infection is a sexually transmitted disease. Pregnant women under age 25 and those at increased risk for chlamydial infection should have repeat testing in the third trimester. Chlamydia infections are susceptible to tetracyclines, macrolides, and fluoroquinolones. Azithromycin (1 g PO as a single dose) and doxycycline (100 mg PO BID for 7 days) are the two most commonly used and recommended treatment regimens in the general population. Some of the other less frequently used alternative regimens include seven days of an erythromycin base (500 mg PO QID), erythromycin ethylsuccinate (800 mg PO), ofloxacin (300 mg PO BID), or levofloxacin (500 mg PO QD). Presumptive treatment of the partners is crucial in the management of these patients to prevent recurrence/reinfection. Doxycycline, the fluoroquinolones, and erythromycin estolate are contraindicated for use in pregnant women. The recommended regimens during pregnancy include erythromycin base (500 mg PO QID for 7 days) and amoxicillin (500 mg PO TID for 7 days). Azithromycin (1 gm as a single dose) is an alternative, though it has not been well tested in pregnancy. LYMPHOGANULOMA VENEREUM: It is a STD caused by C. Trachomatis. Serotype L1L2L3. Initially there is headache and fever, then a papule appears that turns in to an ulcer typicaly in vulvovaginal region. Ulcer is painless and disease may go unnoticed until inguinal adenitis develops a month after. If untreated at this stage LGV becomes chronic causing ulceration, PROCTATITIS, rectal stricture rectovaginal fistulas and elephantiasis. Tx is Doxycycline or Erythromycin . DD: Granuloma Inguinale is caused by Donovania granulomatis, Unlike LGV the ulcer and lymphadenopahty present simultaneously. Also the ulcer here has irregular borders and beefy red granular base. Recommended Rx include azithromycin, doxycycline, erythromycin. TRICHOMONIASIS: Trichomoniasis is a sexually transmitted infection caused by the protozoa Trichomonas vaginalis. The infection may be entirely asymptomatic or may be characterized by a copious frothy gray-green vaginal discharge, fishy odor, vulvar and vaginal pruritus, or dysuria. Treatment is indicated for all women diagnosed with trichomoniasis and their sexual partners, and metronidazole is considered the treatment of choice. Metronidazole is known to enter breast milk in significant concentrations, but few adverse effects have been reported in infants. Therefore most physicians recommend that lactating women be treated with Metronidazole 2g PO for 1 dose and that breastfeeding be discontinued for 12-24 hours only. VULVOVAGINITIS: is an extremely common condition in the sexually active age group. The etiology of symptoms includes infection of the vulva, vagina, and cervix, and the noninfectious causes are chemicals and irritants, hormonal disorders, and, rarely, some systemic disorders. Common infectious causes are vulvovaginal candidiasis, bacterial vaginosis, and trichomoniasis. Most of the symptoms of vaginitis are nonspecific, and self-diagnosis and treatment by the patient is unreliable. Even diagnosis by history and physical examination by a physician is not reliable and should always be confirmed in the office by microscopy. This is important to avoid frequent misdiagnosis and inappropriate treatment. Most common techniques used are saline and KOH preparation for microscopy. The vaginal secretions have characteristic pseudohyphae in candidiasis. Bacterial vaginosis is confirmed by the presence of clue cells in the smear. Motile trichomonads and an abundance of polymorphonuclear cells are found in patients with trichomoniasis.

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PELVIC CYSTIC MASS: A pregnant woman with a pelvic cystic mass needs to be observed carefully. If the mass is larger than 5 cm in size and persists beyond the first trimester or shows no regression in subsequent visits, surgical intervention is indicated. Removal of the cyst is recommended during the second trimester to avoid acute complications that lead to preterm delivery or abnormal labor. ASCITES: Abdominal paracentesis and ascitic fluid analysis is the most reliable way to differentiate between the different causes of ascites. The most common cause of ascites in the United States is hepatic cirrhosis. Some of the other causes are cancer, congestive heart failure, peritoneal tuberculosis, nephrotic syndrome, and pancreatic disease. The differential diagnosis of ascites can be narrowed down by calculating the serum to ascitic fluid albumin gradient (SAAG). This is done by subtracting the ascitic fluid albumin value from the serum albumin value. SAAG value is useful in identifying the presence or absence of portal hypertension. >SAAG value of > or = 1.1 g/dL indicates the presence of portal hypertension. Clinical conditions associated with high SAAG (> 1.1 g/dL), include cirrhosis, congestive heart failure and alcoholic hepatitis. Conditions associated with low (< 1.1 g/dL) albumin gradient; include peritoneal carcinomatosis, peritoneal tuberculosis, nephrotic syndrome, pancreatitis, and serositis PREMENSTRUAL SYNDROME (PMS): Abdominal bloating, headache, fatigue, weight gain, anxiety, and decreased libido 7 to 10-days before the start of each menstrual cycle. The presence of symptoms such as this patient is presenting, after menstrual cycle begins or after ovulation, points out to the diagnosis of premenstrual syndrome (PMS). Symptoms usually disappear near menses and the patient is symptom free until her next ovulation. Psychological symptoms may include anxiety, mood swings, difficulty concentrating, decreased libido and irritability. PMS has to be differentiated primarily from major depression because there is an association between puerperal depression, menopausal depression and PMS. A menstrual diary for at least 3 cycles is a useful aid for confirming the diagnosis in suspected cases; PMS is confirmed when one or several particular symptoms occur repeatedly at the same time of the several cycles. Once the diagnosis is confirmed, treatment depends on the patient's complaints. There is no universally accepted treatment. Reduction of caffeine intake may reduce breast symptoms. Exercise program may be effective in improving the general well being. Recently, selective serotonin reuptake inhibitors have been shown to be beneficial in double blind controlled trials and now the drug of choice for mood decline. AMENORRHEA: Amenorrhea is thought to occur in female athletes when there is a relative caloric deficiency secondary to inadequate nutritional intake as compared to the amount of energy expended. Women athletes with this condition have been shown to have decreased levels of luteinizing hormone (LH) and gonadotropin-releasing hormone (GnRH), resulting in an estrogen deficiency. These amenorrheic women are therefore at increased risk for all conditions associated with estrogen deficiency, including infertility, vaginal atrophy, breast atrophy, and osteopenia. Females who maintain a lower weight or body mass index (BMI) due to the sport or activity that they regularly engage in (e.g. ballet dancers, gymnasts, and runners) may become hypoestrogenic and present with exercise-induced amenorrhea. They are at special risk of developing osteopenia, and even osteoporosis. Spontaneous fractures have been reported in these types of patients, with osteoporosis or osteopenia confirmed through bone densitometry.

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Treatment consists of improving caloric intake; if this is not possible, patients are started on hormonal replacement with oral contraceptives and supplementation with calcium and vitamin D. The most common cause of secondary amenorrhea is pregnancy. Drugs that inhibit or induce the cytochrome P450 system can reduce oral contraceptive efficacy. INFERTILITY: The first step in WOMEN is to check Basal Body Temperature and mid luteal PROGESTERONE. The ovulatory factor involves defects in the hypo-thalamic pituitary ovarian axis, and related infertility maybe due to impairment of follicular maturation ovulation or endometrial development. BBT assess the DURATION of luteal function and MLP asseses LEVEL of lutal function. Endometrial biposy is done to confirm luteal phase defect. rather than the initial evaluation. Males Factor In Infertility: According to the recent studies, male factors account for 20-30% of the infertility causes. Semen analysis is therefore performed early in the evaluation of the infertile couple. It is usually the initial screening test, and it evaluates sperm concentration, motility, and morphology. Identification of azoospermia and severe oligospermia are likely causes of infertility. Although cutoff values for semen analysis exist, there is a broad overlap in the values of the semen measurements in fertile and infertile samples; therefore, borderline results should be interpreted with caution. If sperm analysis is normal then an endocrine hormonal evaluation is carried out. It includes: 1. TFT (since increased TSH inhibits GnRH and then decrease FSH. 2. Testosterone levels to indicate the presence or not of Gonadism 3. Gonadotropin to determine whether hypogonadism is central or testicular and 4. Prolactin levels Causes Of Infertility In Females : 1. Peritoneal factor 2. Ovulatory 3. Cervical 4. tubo-uterine 1. Peritoneal is the mc type and includes Endometriosis and peritoneal adhesions. Laparoscopy is the procedure of choice for Dx and Rx. Mild forms of endometriosis usually respond to meds like GnRH agonists, Danazol and Medroxyprogesterone. 2. Ovulatory Factor involves hypothalamus-pit-ovarian axis and infertility might be due to impairment of follicular maturation, ovulation,or endometrial development. ovulatory abnormality may initially be screened by Basal body temp and midluteal phase level of progesterone, the former assesses Duration and later LEVEL of luteal function. If luteal phase shows low progesterone, hence infertility, then tx is suppository progesterone deposition. 4. Cervical involves cervical structure abnormalities and abnormal mucus production. In 5-10% infertility remains unidentified. Intrauterine insemination is the Rx. 4. Tubo-uterine is seldom a cause. It involves Fibroids, endometrial polyps, tubal occlusion (2ary to IUD or endometriosis). Investigation is hysterosalpingography or laparoscopy. CLOMIPHENE CITRATE is an antiesterogen that acts by competitively inhibiting estrogen receptors at hypo-thalamus, thus inhibiting the negative feed back estrogen has on GnRH production and consequently increasing LH & FSH secretion and improving ovulation. Along with HCG and HMC it is indicated for chronic anovulation. Side effects include large ovaries, hot flashes, abdominal bloating, breast discomfort and abnormal uterine bleeding. RETROVERTED UTERUS: It is a common condition found in 11% of the female population If this condition is secondary to chronic PID or endometriosis, it can be associated with infertility. It is also related to dyspareunia, low back pain, and dysmenorrhea.

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If it is not spontaneously corrected during pregnancy before the second trimester, it can lead to uterus incarceration and be life-threatening. It is not an etiologic cause of abortion. Chances of infertility in a female with cystic fibrosis: are 20% percent.This increased risk is due to secondary amenorrhea caused by malnutrition, and is also due to thick, tenacious cervical mucus. Chances of infertility in a male with cystic fibrosis are 95%. Spermatogenesis is normal in a patient with cystic fibrosis, but sperm transport is impaired because of impaired development of the Wolffian duct. A DEFECT IN THE LUTEAL PHASE: A defect in the luteal phase refers to a relatively low progesterone secretion by the corpus luteum. Progesterone is important for embryo implantation and maintenance of pregnancy, so a defect in its secretion may cause infertility even if ovulation takes place. The defect may affect the level or duration of production of progesterone. Luteal phase defect is suggested by short cycles, history of spontaneous abortion, abnormal basal body temperature (BBT) or low levels of midluteal progesterone. The diagnosis is confirmed by endometrial biopsy, which demonstrates a lag in endometrial maturation of 2 days or more as compared with normal states. Rx: Luteal phase defect is treated with progesterone vaginal suppositories. Clomiphene citrate or human menopausal gonadotropin (hMG) may be used if progesterone suppositories give no results; they increase serum FSH level and thus correct follicular maturation and oocyte expulsion As mentioned above, luteal phase defect refers to a deficiency in progesterone production; therefore, combined oral contraceptive pills are not appropriate. Danazol is an androgen derivative that has a gonadotropin inhibitory effect. It is indicated in endometriosis, fibroids and fibrocystic breast disease. POLYCYSTIC OVARIAN SYNDROME (STEIN-LEVENTHAL SYNDROME): infertility, menstrual irregularity, obesity, hirsutism, and increased ovarian volume measured by ultrasonography. Anovulation is the principal cause of infertility in patients with polycystic ovarian syndrome. Interestingly, several studies have demonstrated that weight reduction in overweight or obese patients with this syndrome is associated with restoration of ovulation, decrease in androgen production, and pregnancy. Furthermore, the data from these studies indicate that even a moderate reduction in weight may restore fertility. Insulin-resistant hyperinsulinemia is a common finding in patients with PCOD. PCOD is an important risk factor for development of DM-2 in women. About 10% of diabetes in premenstural women is POS related. Thus a glucose tolerance test is needed in all POS pts.A two hour test with > 140 is Dx and needs further action.Rx: Life style modification and Metformin is then indicated. o Metformin helps in following ways: prevents DM, Causes anorexia and prevents obesity, corrects hirsutism mildly, menstural irregularity and infertility The treatment of PCOS is directed primarily at the problems of hirsutism, menstrual irregularity, and infertility. Treatment modalities for hirsutism include ovarian and adrenal suppression, antiandrogen therapy, and local depilatory measures. Oral contraceptives are a simple and relatively safe method of ovarian suppression and will often normalize the menstrual cycle. The estrogen component in oral contraceptives increases the sex hormone binding globulin with a resultant decrease in free testosterone. This reduces the symptoms of excessive hair growth and acne. Clomiphene citrate is the drug most commonly used to induce ovulation in patients with polycystic ovary syndrome (PCOS).

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This condition should be suspected in any pt who has menstrual irregularities, and evidence of Hyperandrogenism (facial hair). Presence f these establishes the dx.50% of pts are obese and are at risk of DM-II. The next step is to do Oral glulcose tolerance test Characterized by unbalanced Estrogen secretion resulting in Endometrial Hyperplasia. OVARIAN HYPERSTIMULATION SYNDROME: Major complications of ovulation induction are multiple gestation and OHSS. OHSS occurs in 1-3% of pts. It develops 5-7 days after administration of hMG or hcg and refers to acute increase in vascular permeability of enlarged ovaries. Symptoms include abdominal pain, distension, nausea, vomiting diarrhea, weight gain, hypotension and pleural effusion. Ovaries are large in US. OHSS maybe complicated with ovarian torsion, ovarian rupture, renal insufficiency. Symptoms resolve in 1-2 weeks, but may persist longer is pregnancy is successful. Rx is supportive. ANDROGEN INSENSITIVITY SYNDROME: The combination of primary amenorrhea, bilateral inguinal masses (one removed earlier and one palpable in this case), and breast development without pubic or axillary hair is strongly suggestive of androgen insensitivity syndrome. This condition is related to a mutation of the androgen receptor (AR) gene, making peripheral tissues unresponsive to androgens that are typically available in normal concentrations in these patients. Although the genotype is 46, XY, a female phenotype develops. Breast development is present, because testosterone is converted to estrogen; however, there is no pubic or axillary hair. No mullerian structure is present (uterus, fallopian tube), and the vagina ends with a blind pouch. Primary amenorrhea is usually due to chromosomal abnormalities and physiologic delay of puberty (45% and 20% of causes, respectively). In both cases, development of secondary sexual characteristics is delayed. Imperforate hymen presents as cyclic, pelvic or abdominal pain with primary amenorrhea. Sometimes, a small suprapubic mass (the uterus containing retained menstrual blood) can be palpated. Perineal exam will reveal a bulging, bluish membrane between the labia. This bluish or violaceous discoloration is due to blood sequestration behind the imperforate hymen, and is also known as hematocolpos. TESTICULAR FEMINIZATION: defect or absence of androgen receptor results in feminine phenotype with 46XY genotype. MIF is produced by gonads, so uterus and vagina are absent. Breasts develop because peripheral production of estrogen, whereas axillary hair and pubic hair do not. Rx is testicular resection at puberty and creation of a neo-vagina. Pt presents with amenorrhea, developed breasts, absent pubic and axillary hair, absent internal reproductive organs and a 46XY karyotype. TURNER SYNDROME: Ovarian function and morphology is highly variable in patients with Turner syndrome. Most patients do not undergo puberty, and present with primary amenorrhea. Some patients may develop normally and undergo spontaneous menarche, but secondary amenorrhea may occur after some time. Such patients may become pregnant without medical assistance before developing secondary amenorrhea; however, most women are infertile. In one retrospective study of 522 patients, three women became pregnant spontaneously. Summary: Pregnancy is almost impossible, but there still remains a very small chance, in patients with Turner syndrome. ENDOMETRIOSIS: is a progressive disease typically diagnosed in women aged 25 to 29 years, and is thought to affect 510% of all women. It is characterized by the presence of endometrial tissue in the ovaries, fallopian tubes, or other abnormal sites, and commonly causes significant pelvic pain and infertility.

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Typically pt presents with Dysmenorrhea, Dyspareunia (when endometriomas is in cul-de-sac), Dyschezia (Pain on defecation), hematochezia, hematuria, and pre post menstrual spotting. Endometriosis should be considered a strong likelihood in women who experience dysmenorrhea after years of painless menstruation. Diagnosis: Is difficult and is best done with direct visualization of the implants by laparoscopy or, less commonly, laparotomy. Laparoscopy is GOLD standard which shows powder burns. The hemorrhage of endometriomas into the ovaries results in formation of cystic cavity filled with blood with dark color, hence the name 'Chocolate cyst'. To complicate matters, there may be little correlation between the clinical manifestations and the actual extent of endometrial implants. The most frequent sites of involvement are the ovaries, cul-de-sac, broad ligaments, uterosacral ligaments, uterus, fallopian tubes, and sigmoid colon. Endometriosis may also involve the appendix, cecum, and colon, which may lead to intestinal obstruction. Endometriosis can be treated medically or surgically. Rx: The first line of tx is OCP. They cause a state of pseudo pregnancy and causing an "exhaustion atrophy" of the endometriomas. If OCP fails or not tolerated then we give Danazole, its an androgen derivative that causes Pseudomenopause state. S/E are acne, hirsutism, deep voice. GnRh agonists have an inhibitory action of LH & FSH when given continually which produces temporary castration. It is also a 2nd line of choice. Surgical treatment involves removal of lesions through bipolar coagulation or laser vaporization, while severe cases may require hysterectomy and bilateral salpingo-oophorectomy. In patients with severe or unresponsive symptoms (including infertility), the standard of care requires that confirmatory laparoscopy be performed to definitively establish the diagnosis of endometriosis before instituting treatment. D/D: Vaginismus, use vaginal dialators. -Pain disorder, pain in one or more anatomical site, pain management training. Somatization disorder, tx is follow up visits regularly scheduled. Endometriosis is the location of tissue outside uterine cavity so hysterosalpingogram cannot see it. DYSFUNCTIONAL UTERINE BLEEDING (DUB): Heavy unremitting endometrial hemorrhage through the menarche and peri-menopause requires: o (IV) high dose conjugated estrogens to suppress bleeding, and to ensure cardiovascular stability. Once cardiovascular stability is achieved D&C should be performed. The most common cause of dysfunctional uterine bleeding (DUB) in adolescent women is anovulation. So, endometrial biopsy is not required in these patients. Once the bleeding is stoppedUterine ablation: advice the patient to: take 25 mg of oral conjugated estrogen daily for 25 days; add 10 mg of medroxypreogesterone for the last 10 to 15 days of treatment; then allow 5-7 days for withdrawal bleeding. All this in order is to mimic the menstrual cycle. In which pts with DUB do you perform endometrail biopsy to rule out endometrial carcinoma? When a pt is >35, obese, DM or has chronic HT. MENOPAUSE: HIGH FSH* Most females rapidly lose considerable bone mass following menopause. Lifestyle modification, including weight bearing exercises and optimum calcium and vitamin D supplementation, prevents postmenopausal bone mass loss and possibly reduces the risk of fragility fractures. The National Academy of Science recommends daily supplementation of elemental calcium (1200 mg) and vitamin D (400 to 800 international units) in women after 50 years of age.

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This can be easily achieved by taking one multivitamin tablet (which contains 400 international units of vitamin D) with two tablets of calcium/vitamin D (containing 600 mg of elemental calcium and 200 international units of vitamin D) everyday. Short-term use of low-dose estrogen for menopausal symptoms does not appear to be harmful; however, hormone replacement therapy fell out of favor following a recently published study of the womens health initiative because of increased, undesirable cardiovascular and other side effects. Exercise with weight bearing leads to improvement in bone mass .However, exercise should be individualized in patients with significant osteoporosis, since they have a higher risk of fracture. In such patients, stressful exercises should be avoided as much as possible. Recently published womens health initiative studies show that older postmenopausal women on hormone replacement therapy are at an increased risk for myocardial infarction, deep venous thrombosis, strokes, and breast cancer. The findings of this study do not apply to younger patients with premature ovarian failure. Rx: Hormone replacement therapy in the form of conjugated equine estrogen and medroxyprogesterone with careful monitoring can be safely used in younger patients without any excessive cardiovascular risk. The use of bisphosphonates in older, postmenopausal women has been extensively studied, and has been shown to be very useful in the treatment of low bone density. On the other hand, bisphosphonates are not very well studied in younger patients with low bone density. The long-term effects of bisphosphonates such as alendronate or etidronate are unknown in younger patients. Furthermore, although risedronate (bisphosphonates) may improve bone mineral density in this patient, it will not improve her hypoestrogenic symptoms; therefore, it is not the preferred drug regimen. PREMATURE OVARIAN FAILURE: Premature ovarian failure refers to a failure of estrogen production by the ovaries that occur in women less than 35 years. It may be secondary to an increased atresia or a reduced number of primordial follicles. It is most commonly idiopathic but may also be due to mumps, oophoritis, irradiation or chemotherapy. It can be associated with disorders such as Hashimoto's thyroiditis, Addison's disease, type I diabetes mellitus and pernicious anemia, which supports the hypothesis of an autoimmune origin. Diagnosis is confirmed by increased FSH serum levels and in patients less than 30 years. A chromosomal analysis becomes necessary in order to rule out the presence of a Y chromosome. Since patients with premature ovarian failure lack viable oocytes, measures of ovulation induction, such as clomiphene citrate, hCG and hMG, will be useless, and the only option such patients have to restore fertility is egg or embryo donation. Ovarian failure, chemo induced chemotherapy causes failure of follicular cells of the ovary resulting in decreased production of estrogen and inhibin. This result in loss of feedback inhibition of estrogen on FSH and LH , causing their high levels. Inhibin causes feedback inhibition of FSH only, so in the absence of inhibin, FSH levels are higher than LH which is pathognomonic of ovarian failure. Clinically, pts have Amenorrhea, hot flashes. They might develop anxiety, depression and irritability. Loss of estrogen results in atrophy of breast, vagina, and myometrium. POSTMENOPAUSAL BLEEDING: The most common cause of postmenopausal bleeding is atrophic vaginitis (50-60%). However, one should always rule out the most serious conditions, such as endometrial carcinoma (less than 10%) by obtaining endometrial biopsy. ATROPHIC VAGINITIS is characterized by vaginal dryness, burning, dyspareunia, reduced vaginal secretions, and vulvar pruritus. Occasionally, urinary symptoms such as dysuria, hematuria, and discomfort are also seen. Pelvic examination typically reveals loss of labial fullness, pallor of the vaginal epithelium, and decreased vaginal secretions. The condition commonly occur secondary to declining estrogen levels in postmenopausal women.

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In nonmenopausal women, estrogen production can be countered by radiation therapy, chemotherapy, immunologic disorders, oophorectomy, and lactation. Rx: Atrophic vaginitis is treated with hormonal replacement therapy, transvaginal estrogen replacement (e.g., creams, hormone-releasing rings), or lubricants. D/D: Vulvar cancer most often occurs in women aged 65-75 and is characterized by a long history of pruritus. Vulvar bleeding, discharge, dysuria, and pain are reported less often. A raised vulvar lump or mass is apparent on pelvic examination, and may be fleshy, ulcerated, leukoplakia, or warty in appearance. -Cervical cancer most often occurs in women aged 40-60. Women at increased risk for developing cervical cancer include smokers and those with a history of sexually transmitted diseases, human papillomavirus infection, low socioeconomic status, two or more lifetime sexual partners, or immunosuppression (e.g., AIDS).-Cervical cancer is responsible for less than 1% cases of postmenopausal bleeding. BREAST MASS: Most of the palpable breast masses in young patients (less than 35 years of age) are due to benign etiology, most commonly benign fibrocystic disease or fibroadenoma of the breast. The symptoms of fibrocystic disease may get worse during pregnancy due to the hormonal changes in the body. Despite these facts, any complaints of a dominant mass in the breast should be thoroughly evaluated to exclude malignancy. A dominant breast mass characterized by a hard, single, and immobile mass with irregular borders should raise the suspicion for malignancy. A cystic breast mass should be evaluated with fine needle aspiration biopsy to obtain tissue or fluid for a more specific diagnosis. The goal of aspiration is complete drainage of the cyst and collapse of the cyst wall. Clear cyst fluid may be discarded, with a follow up exam in 4-6 weeks. If the mass persists at that time it may be re-aspirated and further workup may be warranted.Any blood-tinged fluid obtained should be sent for cytologic analysis. If the fluid is non-bloody, the patient should be reassured and reexamined in four to six weeks to check for any signs of recurrence. Excisional biopsy is invasive and does not need to be the first step in a breast cyst evaluation. If the mass persists, definitive evaluation with a biopsy would be an appropriate next step. FIBROADENOMA: 1x1 cm firm rubbery freely mobile round mass in a 35 yo women w/o axillary nodes palpable. Best initial step is Mammogram. BREAST CARCINOMA: Inflamatory beast cancer: Erythema and edema of non lactating breast could be due to locally advanced cancer. Biopsy should be done first to rule out the dx. Rx is 2-3 weeks of combination chemotherapy to shrink the tumor allowing sybsequent extended resection. Metastatic Breast Cancer: has a poor prognosis. With little chance of cure it is important to choose Local (Surgery) vs. Systemic (Systemic Chemotherapy) tx in pt with metastatic breast cancer. Tumor burden, based on TNM staging, is considered the single most important prognostic consideration in treating pts with breast cancer. ER+ and PR+ are good prognostic factors. Over expression of Her2/Neu oncogene is worst prognosis. Breast cancer is the leading cause of metastatic skin disease in women. These lesions are erythematous that present as erosions covered by necrotic skin. Rx: is palliative radiation therapy with aggressive wound care. Two prohibitions when having breast cancer in pregnant: No chemo in 1st trimester, and no Radiotherapy anytime in pregnancy. Also Lumpectomy is not a good choice for 1st trimester cause it needs Radiation afterwards. So the only Tx for 1st trimester is Modified Radical Mastectomy.

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NIPPLE DISCHARGE: Nipple discharge is a relatively common problem, and is due to a benign cause in most cases. A detailed history and physical examination can essentially determine the differential diagnoses and necessary diagnostic work-up. It is important to determine whether the discharge is spontaneous or provoked, and whether it is unilateral or bilateral. Patients with a malignant cause have a spontaneous, unilateral and guaiac positive or grossly bloody discharge. Patients with endocrine, medication-induced or other physiologic causes tend to have a bilateral nipple discharge. All patients with a unilateral spontaneous nipple discharge should be screened for breast cancer with a mammogram. Patients with evidence of a mass or suspicious finding on mammogram should have further evaluation such as fine needle aspiration biopsy or open breast biopsy. The discharge should also be examined for the presence of occult or gross blood; positive results are then sent for cytologic analysis. INTRADUCTAL PAPILOMA: A benign tumor of lactiferous ducts. Clinically manifest as serous bloody discharge. Mamogram wont show it, too small. Resection has to be done to relief pain guided by galactogram. LACTATION SUPPRESSION: Tight fitting bra and ice packs. Bromocriptine is no longer used. MASTITIS INFECTION OF BREAST WITH S. AUREUS: It must be ddx with Breast Engorgement (heavy,tender,firm and warm breasts bilaterally in women who are not nursing. Its managed with tight fitting bras, analgesics and ice pack, breast feeding should be resumed). Mastitis is tx with oral Dicloxacillin. Breast feeding should be suspended but milk has to be pumped until infection clears. If it involves abscess, incision and drainage is required. RALOXIFENE: Is A Selective Estrogen Receptor Modulator (SERM) used for prevention of osteoporosis. Unlike Estrogen, it doesnt increase risk of endometrial cancer. It decreases risk of Breast cancer. It has no effect on Ovarian cancer. The most important S/E is it increase the risk of Pulmonary Thromboembolism and it is C/I in pt with hx of DVT. It may also worsen hot flashes and vaginal dryness. TAMOXIFEN: An antiestrogen drug used for breast cancer. When used as adjuvant therapy for early stage disease it reduces the risk of recurrence of original cancer and new cancer in other breast. However it increases the risk of 2 types of cancer, 1-endometrial (lining of Uterus) and Uterine Sarcoma. It reduces the risk of breast cancer in those who are at increased risk for developing breast cancer, it is PROVEN. SEE RALOXIFEN. It increased the risk for endometrial cancer by 1% and ONLY in postmenopasusal women. It decreased risk of breast cancer, so overall it reduces mortality rate. It also decreases risk facto in the opposite breast. It protects against osteoporosis. However it does cause hot flashes and vaginal dryness due to its antiesterogenic effect. Remember its mixed agonist-antagonist on estrogen receptors.

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MATERNAL SUBSTANCE ABUSE: 1. Herion Abuse: Newborn will show tremors, increased weakness, frequent loose stool, high pich cry, fist sucking, poor feeding and tachypnea, Hyperirritability. Symptoms manifest w/I 24/48 after birth, Exclude hypocalcemia and hypoglycemia. 2. Methadone Withdrawal: presents at the 2nd to6th wek of life with seizure. 3. Cocaine: assoc w IUGR, intracranial hemorrhages, and premature labor or abrupta placenta. It is not common. 4. Alcohol Withdrawal: presents with tremors, agitation, lethargy and seizures .Its rare. URINARY INCONTINENCE: Urinary incontinence is a common problem in the elderly population which causes significant functional and psychological morbidity. It frequently leads to a decline in self-confidence and a diminished quality of life in the elderly population. It is important to distinguish between the three main types of urinary incontinence to devise a proper treatment plan. A detailed history and physical examination is the most important step to differentiate between the various types of urinary incontinence. A thorough history is also useful to identify various reversible causes of urinary continence, such as excessive fluid intake, urinary tract infection, atrophic vaginitis, stool impaction, and the use of various drugs causing or contributing to urinary incontinence. The three major types of urinary incontinence are stress incontinence, urge incontinence, and overflow urinary incontinence. Stress incontinence is the most common cause of urinary incontinence in younger females and occurs due to inadequate urethral support from the fascia and muscles. An increase in the intraabdominal pressure leads to urethral sphincter opening, which causes urinary leakage in the absence of bladder contraction. A detailed history, physical examination, and clinical stress test can provide the diagnosis of stress urinary incontinence in almost all the patients. In a clinical stress test, the patient is asked to relax and give a single vigorous cough. Leakage that occurs instantaneously with coughing is virtually diagnostic of stress urinary incontinence. Aggrevating factors are Obesity, pregnancy, COPD and Smoking. Postvoid cystometry is normal. Tx include Kegel excercise, esterogen in post menopausal women. Surgical tx is Burch and Sling procedures. It is important to differentiate stress urinary incontinence (urethral hypermobility) from urge incontinence (detrusor overactivity). Pelvic floor exercises should always be the first line of treatment in patients with stress urinary incontinence. URGE Incontinence: Detrusor instability, bladder irritation form neoplasm, and interstitial cystitis result in UI, which causes sudden and frequesnt loss of moderate to large amount of urine. Is often accompanied with Nocturia. OVERFLOW: Diabetic Nephropathy causes OI. Characterized by loss of small amount of urine from an over extended bladder and a markedly increased residual volume. There is hx of DM which is not controlled. CC are certain medications (Ibuprofen), Diabetic nephropathy, MS and spinal cord injury. NSAIDs have an inhibitory action on the detruser, so the first step is to stop NSAID. Then cholinergic drug (Bethanechol) should be added afterwards to improve detruser action. Intermittent self catheterization can be used. One Of Effects Of Epidural Anesthesia Is Urinary Retension Due To Denervation Of Bladder. When bladder presure is > sphingter pt urianates until balace is achieved again. This incontinence is transient. PE may show distended blader. Postvoidal vol is high. Rx is by Intermittant cathaterization until control is regained. Oxybutyrin is used for Urge incontinence. Urethroplexy is for stress incontinence.

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UTERINE PROLAPSE: Uterine prolapse is typically seen in multiparous, postmenopausal woman with a history of multiple vaginal deliveries. The injury to the pelvic ligaments and loss of estrogen weakens the endopelvic fascia. The uterus and cervix descend down the vaginal canal towards the vaginal orifice (introitus). Patients usually complain of a sensation of pressure or heaviness in the pelvic area, which is relieved by lying down and aggravated by prolonged standing or exertion. Some patients may complain of low back pain, dyspareunia, or a visible mass at the introitus. In chronic cases, patients may have bleeding or discharge from ulcerative, superficial epithelium. All symptomatic patients (constant sensation of heaviness, pain, or bleeding) should have surgical correction of the defect in the pelvic support. The aim of surgical treatment is to completely relieve the symptoms and prevent any future relapse. Conservative treatment with the insertion of a pessary to hold the pelvic organs in place should be only used in patients who are poor candidates for surgical intervention. It does not correct the underlying defect, and there is a higher chance of relapse in active patients. ALKALINE PHOSPHATASE: Pregnancy is characterized by increased alkaline phosphatase being secreted from the placenta. Alkaline phosphatase is usually secreted by biliary canalicular cells, placenta, bone, and intestinal mucosal cells. Hence, raised alkaline phosphatase is a normal value in growing children and pregnant women, provided there are no associated symptoms or signs. Hence, reassuring the patient and explaining this observation is adequate and no further investigation is necessary. CERVICAL CANCER: Risk factors: Young age at first coitus

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