}effiey Anueison, N.B.

The 0SNLE Step 2 CK BIBLE

2
nu
Euition
The
USMLE Step 2 CK
BIBLE

The Ultimate Step 2 CK Preparation Guide


The 0SNLE Step 2 CK BIBLE
Copyiight 2u1u }effiey Anueison, N.B. All iights ieseiveu. No pait of this book
may be useu oi iepiouuceu in any mannei whatsoevei without wiitten peimission
except in the case of iepiint in the context of ieviews anu peisonal euucation.

























CONTENTS




Chapter 1.. Surgery
Chapter 2.. Obstetrics
Chapter 3.. Gynecology
Chapter 4.. Pediatrics
Chapter 5.. Biostatistics
Chapter 6.. Psychiatry
Chapter 7.. Cardiovascular
Chapter 8.. Endocrine
Chapter 9.. Infectious Disease








Chapter 10 Allergies
Chapter 11 Pulmonary
Chapter 12 Gastroenterology
Chapter 13 Nephrology
Chapter 14 Hematology
Chapter 15 Rheumatology
Chapter 16 Neurology
Chapter 17 Oncology
Chapter 18 Dermatology
Chapter 19 Preventative Med











FOREWORD

The USMLE Step 2 CK BIBLE is the culmination of over four
months of my own intense personal Step 2 CK preparation. This
document contains and all of the notes I made, all of the charts,
graphs, and images I put together to create the ultimate study
guide, and I guarantee it is more than enough to help you pass,
and if used properly can help you achieve a top score on the
Clinical Knowledge exam.
I used five different study guides as well as all of the notes I took
from working in the wards to put together this in-depth study
guide. This preparation guide contains the most up-to-date as
well as the most commonly asked clinical information, which
will help you score high on the Step 2 CK exam.
When I put this preparation guide together, I did so with my own
score in mind, and I made it so that I would have to study from
one source, and thats exactly what you have here. If you study
hard and use the CK BIBLE, you will not only pass, you will do
very well.
Best of luck on the Step 2 CK exam











Chapter 1

Surgery















!"#$%#

!'()*( +(,-./,0 ('. *(/(1.2 )0-/1 ,3. #456780 -/ ,3. +'-*('9 0)':.9 (;,.' (
,'()*(,-< -/<-2./,=
# - Aiiway
Ensuie patient is immobilizeu anu maintain aiiway with jaw thiust
If aiiway cannot be establisheu, inseit 2 laige boie neeules into the
ciicothyioiu membiane
Nevei peifoim tiacheotomy in the fielu
If patient is unconscious oi you cannot establish an aiiway otheiwise,
intubate the patient.
4 - Bieathing
Look foi chest movement
Listen foi bieathing sounus
0bseive the iespiiatoiy iate
Look foi life-thieatening injuiies (tension pneumothoiax, flail chest, open
pneumothoiax)
5 - Ciiculation
Placement of 2 laige-boie Iv's in the uppei extiemities
If patient is in shock, place a cential line in the patient
Keep bloou on stanu-by in case of hemoiihage
6 - Bisability
Assess the neuiological status with the ulasgow coma scale
Check all lab tests (bloou, ET0B, electiolytes)
Loss of consciousness
! #$%% $& '$(%')$*%(+%% ',( -+ ,%%+%%+. /)01 01+ 2(+2$()' !3456 7489
#lcohol, 7pilepsy, >nsulin, ?veiuose, $iemia, !iauma, >nfection, @sychogenic, Atioke

7 - Exposuie
Examine the skin (must iemove all clothes)




>/ ,3. 0.<B/2('9 0)':.9C +.';B'* ,3. ;BDDBE-/1F
Check the ulasgow coma scale
Check all oiifices foi tiauma anuoi injuiies (bleeuing)
Peifoim checks using ultiasounu, XRAY, CT
Check foi compaitment synuiome

GH#AG?I 5?%# A5#H7
A!#!$AJK>L6>LG @?>L!A
79. ?+./-/1
Spontaneous 4
To voice S
To Stimulation 2
No Response 1
M.'N(D ".0+B/0.
0iienteu S
Confuseu 4
Incoheient S
Incompiehensible 2
No Response 1
%B,B' ".0+B/0.
To Commanu 6
Localizes S
Withuiaws 4
Abnoimal Flexion S
Extension 2
No Response 1
A coma scale below 8 inuicates seveie neuiologic injuiy









AO?5P

The type of shock can be uiagnoseu by checking the caiuiac output (C0), the
pulmonaiy capillaiy weuge piessuie (PCWP), anu the peiipheial vasculai iesistance
(PvR).
6-;;.'./,-(D 6-(1/B0-0 B; A3B<Q
BYP0v0LENIC CARBI0uENIC SEPTIC
C0
! ! "
PCWP
! " !
PvR
" " !

OBE ,B <B''.<, ,3. 2-;;.'./, ,9+.0 B; 03B<Q
@'BND.* >/-,-(D !'.(,*./,
O9+B:BD.*-< A3B<Q 6.<'.(0.2 @'.DB(2 R H('1. NB'. >M80C
'.+D(<. ;D)-20
5('2-B1./-< A3B<Q 5('2-(< K(-D)'. SRC 2B+(*-/. (/2JB' L7
A.+,-< A3B<Q 6.<'.(0.2 @M" SRC L7C >M (/,-N-B,-<0


".<B1/-T-/1 A3B<Q
4( :1+%0 0;,*2,<
The most common type of shock iesulting fiom chest tiauma is 1=>$?$#+2)'
Patient will be pale, colu, anu uiaphoietic
This patient is likely losing laige amounts of bloou, thus seaiching foi souice
of bleeuing is impeiative
Peiicaiuial tamponaue can be a iesult of thoiacic tiauma, look foi uistenueu
neck veins
In suspecteu peiicaiuial tamponaue, look foi an enlaigeu heait on CXR,
peifoim caiuiocentesis, look foi electiical alteinans on EKu
@,(,A+2+(0 $& %1$'BF
Contiol the site of bleeuing
uive fluius
Piepaie foi an emeigency lapaiotomy
UU >; ( D(+('B,B*9 -0/8, E(''(/,.2C 0-*+D9 '.0)0<-,(,. E-,3 ;D)-20


O7#6 !"#$%#

7+-2)'(D O.*(,B*(
Theie will be a histoiy of tiauma
Suuuen loss of consciousness followeu by a luciu inteival, then followeu by
iapiu ueteiioiation
Nost commonly bleeu is fiom the miuule meningeal aiteiy
!"#$%&'"':
With a CT, looking foi a lens-shapeu hematoma


)#%#$*+*%,:
Emeigency cianiotomy essential because this is a ueauly case within a few
houis









A)N2)'(D O.*(,B*(
Is a low-piessuie bleeu coming fiom the biiuging veins
Theie is usually a histoiy of heau tiauma with fluctuating consciousness
!"#$%&'"':
CT showing ciescent-shapeu bleeu


)#%#$*+*%,:
If theie is miuline uisplacement anu signs of mass-effect then uo an
emeigency cianiotomy
If symptoms aie less seveie, conseivative management incluues steioius


6-;;)0. #VB/(D >/W)'9
This type of injuiy occuis aftei an acceleiation-ueceleiation injuiy to the
heau
Patient is usually unconscious
Theie is a teiiible piognosis associateu with this injuiy
)#%#$*+*%,F
Lowei ICP anu pievent fuithei injuiy


4(0(D AQ)DD K'(<,)'.
This piesents with ecchymosis aiounu eyes, behinu the eais, oi with CSF
leak fiom the nose

!"#$%&'"':
CT scan of heau anu neck
)#%#$*+*%,:
CSF ihinoiihea will stop on its own
If facial palsy is piesent, give steioius


















4$"LA

C
%0
.+A;++ ,(. 9+'$(.D.+A;++ -*;(%:
Epiueimis anu supeificial ueimis
Skin is painful, ieu, anu blisteieu
Tieatment with ointments anuoi pain ielieveis

71);. ,(. E$*;01 .+A;++ -*;(%:
Affects all layeis + subcutaneous tissues
Painless, uiy, chaiieu, anu ciackeu skin
Buins affecting all layeis of the skin iequiie suigical inteivention


7;+,02+(0:
Bepenuing on seveiity, iesuscitate with fluius
Removal of eschais
Bo a CXR to iule out lung injuiies
Topical antibiotics aftei eschai iemoval
Buins that covei moie than 2u% of the bouy iequiie aumission to a buin
centei











A$"G>5#H #46?%7L

The following illustiates the uiffeiential uiagnosis foi abuominal pain in the iight
uppei quauiant, iight lowei quauiant, left uppei quauiant, left lowei quauiant.









"-13, $++.' X)(2'(/, 5B/2-,-B/0 Y 6-;;.'./,-(,-/1

O.+(,-,-0
Piesents with R0Q pain anuoi tenueiness
}aunuice is most likely piesent
Fevei is piesent
Peifoim an *#0;,%$*(. to iule out othei causes of pain

53BD.<90,-,-0
R0Q pain anu tenueiness
(+) Nuiphy's sign (inspiiatoiy aiiest uuiing palpation)
Peifoim an ultiasounu to uetect gallstones, a thickeneu gallblauuei wall, oi
peiicholecystic fluiu

53BD.2B<3BD-,3-(0-0
R0Q pain that is woiseneu with the ingestion of fatty foous
}aunuice is often piesent
Peifoim an ultiasounu to uetect uilatation of the common bile uuct

4-D-('9 53BD-<
Constant epigastiic anu R0Q pain
Peifoim an ultiasounu to uetect the piesence of gallstones without any othei
gallblauuei-ielateu finuings

53BD(/1-,-0
A life-thieatening conuition
Piesence of Chaicot's tiiau: Fevei + }aunuice + R0Q pain
If theie is also hypotension anu mental status changes, this qualifies as
Reynolu's pentau
Peifoim anu ultiasounu anu a CT to uetect biliaiy uuct uilatation uue to
gallstone obstiuction
Confiim uiagnosis with ERCP


@/.)*B/-(
Piesence of pleuiitic chest pain
Peifoim a CXR, which will show pulmonaiy infiltiates

K-,TYO)13Y5)',-0 A9/2'B*.
R0Q pain, fevei
Theie is going to be a histoiy of salpingitis
Causeu by ascenuing Chlamyuia oi gonoiihea-ielateu salpingitis
Peifoim an ultiasounu which will show a noimal gallblauuei anu biliaiy tiee
with fluiu aiounu the livei anu gallblauuei


"-13, HBE.' X)(2'(/, 5B/2-,-B/0 Z 6-;;.'./,-(,-/1

#++./2-<-,-0
Biffuse abuominal pain that localizes to the RLQ at NcBuiney's point (2S
uistance fiom umbilicus to ASIS)
Fevei anu uiaiihea often piesent
Abuominal xiay oi CT to soliuify uiagnosis
Becision to iemove is baseu on clinical piesentation

7<,B+-< @'.1/(/<9
Piesents with constant lowei abuominal pain, ciampy in natuie
vaginal bleeuing
Tenuei aunexal mass
Labs will show " hCu

A(D+-/1-,-0
Lowei abuominal pain
Puiulent vaginal uischaige
Ceivical motion tenueiness
Peifoim an ultiasounu to uetect the abscess, anu a CT to iule out othei
conuitions

%.<Q.D80 6-:.',-<)D-,-0
Follows the 1-1u-1uu iule
1%-2% pievalence
1-1ucm in length
Su-1uu cm pioximal to ileocecal valve
Piesents with uI bleeu, small bowel obstiuction (SB0)
Technetium peitechnetate scan to uetect

[.'0-/-( 7/,.'B<BD-,-0
Piesents similaily to appenuicitis (fevei, uiaiihea, seveie RLQ pain)
XRAY will be negative
Tieat with aggiessive antibiotic theiapy

?:('-(/ !B'0-B/
Patient uevelops an acute onset of seveie, unilateial pain
Pain changes with movement
Piesence of a tenuei aunexal mass
0ltiasounu is uone fiist
Confiim with a lapaioscopy

@9.DB/.+3'-,-0
Classically piesents with CvA tenueiness, high fevei, anu shaking chills
Best initial uiagnostic test is a 0A anu 0iine cultuie

>/,)00)0<.+,-B/
Seen most commonly in infants between S anu 1u months of age
Piesence of cuiiant jelly stool (mix of bloou anu mucus)
vomiting, intense ciying
Infants will often pull legs into the abuomen to ielieve some pain
Baiium enema is useu foi both uiagnosis anu tieatment




H.;, $++.' X)(2'(/, 5B/2-,-B/0 Z 6-;;.'./,-(,-/1

%9B<('2-(D >/;('<,-B/
Ciushing chest pain that iauiates to the jaw, neck, left aim
Nausea, uiaphoiesis is piesent
Biagnoseu by EKu, caiuiac enzymes (CKNB, tiop I)

@.+,-< $D<.'
Piesents as epigastiic pain that is ielieveu by foous anuoi antacius
Peifoiations piesents with acute anu seveie epigastiic pain, may iauiate to
shoulueis (Phienic neive involvement)
Biagnose with an uppei uI enuoscopy

")+,)'.2 A+D../
0sually a histoiy of tiauma
Piesence of Kehi's sign (L0Q pain that iauiates to the left shouluei)
Biagnose with an abuominal CT


H.;, HBE.' X)(2'(/, 5B/2-,-B/0 Z 6-;;.'./,-(,-/1

Similai to the RLQ conuitions aie: 0vaiian toision, Ectopic piegnancy, anu
Salpingitis

6-:.',-<)D-,-0
Patient has LLQ pain, fevei, anu uiinaiy uigency
Biagnose with a CT scan, which shows thickening of the laige intestine wall

A-1*B-2 MBD:)D)0
Nost commonly seen in an oluei patient
Piesents with constipation, uistenueu abuomen, anu abuominal pain

Contiast enema to uiagnose, will see the classic "biiu's beak"

@9.DB/.+3'-,-0
Classically piesents with CvA tenueiness, high fevei, anu shaking chills



6-;;.'./,-(D 6-(1/B0.0 ;B' %-2D-/. 5B/2-,-B/0

G7"6
Epigastiicsubsteinal buining pain
Begiee of pain changes with uiffeient positions (woise when patient is
supine)
Biagnosis maue with eithei a baiium swallow, pB testing, oi uppei uI
enuoscopy

#N2B*-/(D #B',-< #/.)'90*
Asymptomatic usually until it iuptuies
If iuptuie occuis, patient expeiiences abuominal pain + shock
Theie is usually a palpable pulsatile peiiumbilical mass
0ltiasounu uone fiist (least invasive), but can visualize with an xiay oi CT of
the abuomen

@(/<'.(,-,-0
Epigastiic pain that iauiates to the back
Nausea anu vomiting aie usually piesent
Patient often has a histoiy of alcoholism

@(/<'.(,-< @0.)2B<90,
Is a iesult of pancieatitis
Consiuei this if patient hau pancieatitis that iecuiieu anuoi uiu not iesolve
0ltiasounu will show a pseuuocyst

A)'1-<(D 5B/2-,-B/0 B; ,3. 70B+3(1)0

#<3(D(0-(
A conuition wheie the lowei esophageal sphinctei fails to ielax

-"$%' #%. -/+0,&+':
Bysphagia to B0TB soliu anu liquiu
Reguigitation of foou
!"#$%&'"':
Best initial test its the Baiium Swallow, which uemonstiates naiiowing of the
uistal esophagus
Nost accuiate test is esophageal manometiy, which will uemonstiate the lack
of peiistalsis
12*#,+*%,:
The best initial theiapy is pneumatic uilation
If pneumatic uilation is not successful, suigeiy shoulu be peifoimeu
If patient uoes not want suigeiy, can attempt to ielax the LES with injection
of botulinum toxin


70B+3(1.(D 6-:.',-<)D( \]./Q.'80 2-:.',-<)D)*^
Nost common piesentation is a patient with uyphagia that is accompanieu by
teiiible bieath
Pathology is ielateu to the posteiioi phaiyngeal constiictoi muscles with
uilate, causing the uiveiticulum

-"$%' #%. -/+0,&+':
Bysphagia
Balitosis
!"#$%&'"':
The best initial test is the baiium swallow

12*#,+*%,:
Suigical iesection of the uiveiticula is the best initial tieatment option


5(/<.' B; ,3. 70B+3(1)0
Theie aie Squamous Cell Caicinoma anu Auenocaicinoma
3&++&% '/+0,&+' ,& 4&,5:
Bysphagia to solius 1
st
, then to liquius 2
nu

Weight loss
Beme (+) stool
Anemia
Boaiseness
A_)(*B)0 5.DD 5('<-/B*(
Is the 2
nu
NCC of esophageal cancei
Relateu to chionic use of alcohol anu tobacco
Nost commonly seen in the 6
th
uecaue of life anu latei
#2./B<('<-/B*(
0ccuis in patients who have chionic uERB
Chionic uERB leaus to Baiiett's esophagus, which then leaus to
Auenocaicinoma

!"#$%&'"%$:
The best initial uiagnostic test is an enuoscopy
12*#,+*%,:
The best initial tieatment is suigical iesection as long as theie is no
metastasis
Suigeiy shoulu be followeu with S-F0





6-;;)0. 70B+3(1.(D A+(0*0
Patient piesents with seveie chest pain
0ften times, they uon't fit the ciiteiia foi an NI, but shoulu get the caiuiac
enzymes anu uo EKu to iule out an NI
0ften comes aftei having a colu uiink

!"#$%&'"':
Nanometiy is the most accuiate uiagnostic test
12*#,+*%,:
Calcium channel blockeis anu nitiates aie the tieatment option of choice


%(DDB'9 I.-00 !.('
violent ietching anuoi vomiting causes suuuen bleeuing
Nost cases iesolve spontaneously, if they uon't though give epinephiine to
constiict the bloou vessels anu stop the bleeuing














5(/<.' B; ,3. A,B*(<3

Nost canceis of the stomach aie founu to be malignant
Theie is a link of stomach canceis to bloou gioup A, which may inuicate a
genetic pieuisposition to the conuition
Linitis plastica is a uiffuse cancei that is fatal within months, anu is the most
ueauly foim of gastiic cancei

-"$%' #%. -/+0,&+' 6&2 #778
uI uiscomfoit anuoi pain
Weight loss
Anemia
Anoiexia

15*2* "' #% ! 2"'9 :5*% ,5*2* "'8
Low fibei consumption
Excess nitiosamines in the uiet (uue to smokeu meats)
Excess salt intake in the uiet
Chionic gastiitis

15*2* #2* '&+* ;7#''"; 6"%."%$' "% +*,#',#,"; $#',2"; ;#%;*2< ,5*/ "%;7=.*8

F);'1$/G% ($.+:
Left supiaclaviculai noue is haiu

H;*B+(-+;A 7*2$;<
The metastasis of gastiic cancei bilateially to the ovaiies
0vaiies aie palpable in this case
They aie signet-iing cells




9)%0+; @,;= I$%+>1 %)A(:
Baiu nouule at the umbilicus uue to metastasis
Inuicative of a veiy pooi piognosis


12*#,+*%,':
Suigeiy + chemotheiapy
Palliative caie is often the only choice if too auvanceu




















O.'/-(0


>/1)-/(D O.'/-(0
Is the most common type of heinia
Nen > women

!"2*;, >%$="%#7 ?*2%"#:
Piotiuues uiiectly thiough Basselbach's tiiangle (infeiioi epigastiic aiteiy,
iectus sheath, anu inguinal ligament), meuial to the infeiioi epigastiic aiteiy
>%."2*;, >%$="%#7 ?*2%"#:
Noie common than the uiiect heinia, passes lateially to the infeiioi
epigastiic aiteiy into the speimatic coiu

-"$%' #%. -/+0,&+':
uioin mass (inteimittent) that piotiuues with valsalva-type maneuveis


!"#$%&'"':
Nust uiffeientiate fiom a femoial heinia, which will heiniateu below the
inguinal ligament
Biagnosis is baseu on clinical examination
12*#,+*%,:
Suigical iepaii


K.*B'(D O.'/-(0
Women > Nen
Bave a gieatei iisk of incaiceiation uue to the way they heiniateu
Biagnose clinically
Suigical coiiection (uo not uelay uue to iisk of incaiceiation anu subsequent
stiangulation)

M-0<.'(D O.'/-(0
This type of heinia causes intestinal obstiuction
-"$%' #%. -/+0,&+':
Abuominal pain
0bstipation (no flatulence)
!"#$%&'"':
XRAY will show aii-fluiu levels, no gas in iectum
Biffeientiate fiom auhesions
12*#,+*%,:
Suigical iepaii













A)'1-<(D 5B/2-,-B/0 B; ,3. G(DDND(22.'

G(DD0,B/.0 \53BD.D-,3-(0-0^
Seen mostly in women with the 4 F's
1. Female
2. Fat
S. Foity
4. Feitile

It isn't the piesence of gallstones that waiiants inteivention, but the possible
complications associateu with them
0ltiasounu is the test of choice foi iuentifying gallstones

12*#,+*%,:
Asymptomatic gallstones iequiie no inteivention
Chionic pain may iequiie a cholecystectomy
With an incieaseu iisk of cancei, such as in the case of a calcifieu gallblauuei
wall, cholecystectomy may be waiianteu


53BD.<90,-,-0
Is an infection of the gallblauuei that is a iesult of an obstiuction
Common causes aie: E. Coli, Enteiobactei, Enteiococcus, anu Klebsiella
Note the shauow fiom the impacteu stone.


-"$%' #%. -/+0,&+':
Acute onset of iight uppei quauiant pain that is non-iemitting
(+) Nuiphy's sign - aiiest of inspiiation upon palpation
!"#$%&'"':
0ltiasounu to uetect stones, a thickeneu wall, oi fluiu suiiounuing the uB
Confiim with BIBA scan
Labs show WBC's >2u,uuu, " Biliiubin, " ASTALT

12*#,+*%,:
Keep patient NP0, give Iv fluius, anu give antibiotics to covei giam (-) ious
anu anaeiobes
Bo not give moiphine foi pain because it causes a spasm of the sphinctei of
ouui
If impiovements aie not seen, cholecystectomy may be waiianteu


#0<./2-/1 53BD(/1-,-0
0bstiucteu bile flow fiom an obstiucteu common bile uuct leaus to an
infection
Piesence of Chaicot's tiiau: R0Q, fevei, jaunuice is commonly seen

!"#$%&'"':
0ltiasounu to uetect uilation
An ERCP can be useu aftei the pieliminaiy 0S uiagnosis
12*#,+*%,:
NP0
Iv fluius
uiam (-) antibiotics
ERCP foi uecompiession of the biliaiy tiee anu foi iemoval of the stones



53BD.2B<3BD-,3-(0-0
An obstiuction of the common bile uuct
-"$%' #%. -/+0,&+':
}aunuice (obstiuctive)
" Alkaline phosphatase
" Conjugateu biliiubin
!"#$%&'"':
0ltiasounu to uetect CBB obstiuction

12*#,+*%,:
Cholecystectomy


5(/<.' B; ,3. G4

Is a iaie cancei that is associateu with a histoiy of gallstones
0ccuis latei in life
The NC piimaiy tumoi of the gallblauuei is the auenocaicinoma
Associateu with Clonoichis sinensis infestation
Bas a giave piognosis, with most patients uying within 1yi of uiagnosis

-"$%' #%. -/+0,&+':
Shaip, colicky pain
!"#$%&'"':
0S oi CT to uetect the tumoi
12*#,+*%,:
Placement of bile uuct stents
Suigeiy as a palliative option, but is not cuiative


A)'1-<(D 5B/2-,-B/0 B; ,3. @(/<'.(0

@(/<'.(,-,-0
Autouigestion of the pancieas by it's own enzymes
NCC is alcohol anu gallstones

-"$%' #%. -/+0,&+':
Seveie epigastiic pain that iauiates to the back
" Seium amylase anu lipase
!"#$%&'"':
Clinical suspicion + abuominal CT
Theie may be uiscoloiation of the flank (uiey Tuinei's sign) anu Cullen's sign
(bluish uiscoloiation of the peiiumbilicus)
12*#,+*%,:
NP0, Iv fluius, anu Bemeiol foi pain ielief
Be awaie of the potential foi alcohol withuiawal
3&+07";#,"&%:
Theie is a iisk foi abscesses, ienal failuie, uuouenal obstiuction, anu
pancieatic pseuuocysts




@(/<'.(,-< @0.)2B<90,
Is a complication of chionic pancieatitis
Results in a fluiu collection within the pancieas that is encapsulateu by a
fibious capsule

!"#$%&'"':
0ltiasounu
Abuominal CT
12*#,+*%,:
Suigical uiainage
Cieation of a fistula uiaining the cyst into the stomach
3&+07";#,"&%':
Infection followeu by iuptuie can cause peiitonitis


7/2B<'-/. @(/<'.(0
#-cell hypeiplasia causes an insulinoma
$-cell tumoi causes hypeiglucagonemia






5(/<.' B; ,3. @(/<'.(0
Noie common in Afiican Ameiicansmalessmokeis
Nay be moie common in uiabetics
9u% aie auenocaicinomas
6u% aiise fiom the heau of the pancieas

-"$%' #%. -/+0,&+':
Weight loss
Painless jaunuice
!"#$%&'"':
" biliiubin, " alkaline phosphatase, "CA19-9
CT scan
12*#,+*%,:
Although usually a teiminal uiagnosis, can uo a iesection of the pancieas, oi
Whipple's pioceuuie
The Syi suivival iate is only S%














A)'1-<(D 5B/2-,-B/0 B; ,3. A*(DD 4BE.D

A*(DD 4BE.D ?N0,')<,-B/
SB0 can be causeu by a numbei of conuitions
3#='*':
Peiitoneal auhesions
Beinias
Ciohn's uisease
Neckel's
uallstone ileus
Abuominal inflammation
-"$%' #%. -/+0,&+':
Nauseavomiting
Abuominal pain
Abuominal ciamps
Tenueinessuistention
Bypeiactive anu high-pitcheu bowel sounus
!"#$%&'"':
Abuominal xiay
Aii-fluiu levels on upiight film
92,## J$/+# 5-%0;*'0)$( K9*>)(+ F)+/L

92,## J$/+# 5-%0;*'0)$( K6>;)A10 F)+/L

12*#,+*%,:
Nu tube uecompiession
NP0
Iv fluius
If only paitially obstiucteu may be able to tieat without suigeiy
If suigeiy is iequiieu, must iemove both obstiuction anu ueau bowel


L.B+D(0* B; ,3. A*(DD 4BE.D
Nost commonly is a leiomyoma, seconu NC is a caicinoiu tumoi (benign
types)
Nost common malignant types aie: auenocaicinoma, caicinoiu, lymphoma,
anu saicoma
Biopsy iequiieu foi uiagnosis
Tieatment involves suigical iesection along with LN's anu metastases






A)'1-<(D 5B/2-,-B/0 B; ,3. H('1. 4BE.D

@BD9+0
Aie neoplastic, hamaitomas, oi inflammatoiy
Neoplastic polyps aie NC auenomas
@.*%&+#' ;#% 4* ;7#''"6"*. #':
Tubulai (these have the smallest potential foi malignancy)
Tubulovillous
villous (these have the highest iisk of malignancy)

-"$%' #%. -/+0,&+':
NC piesents with inteimittent iectal bleeuing
!"#$%&'"':
Colonoscopy oi sigmoiuoscopy
12*#,+*%,:
Polypectomy


6-:.',-<)D(' 6-0.(0.

A*%*2#7 >%6&2+#,"&%8
0p to half of the population has uiveiticula
The iisk incieases aftei Suyi of age
0nly 11u people aie symptomatic when uiveiticula aie piesent
A TR0E uiveiticula is iaie, anu incluues full bowel wall heiniation
A FALSE uiveiticula is most common, anu involves only a heiniation of the
mucosa
The NCC is a low-fibei uiet which causes an incieaseu intiamuial piessuie
(this is hypothesis)



6-:.',-<)DB0-0
This is the piesence of multiple false uiveiticula

-"$%' #%. -/+0,&+':
Nost people aie asymptomatic, with uiveiticula founu only on colonoscopy
oi othei visual pioceuuies
Nay have iecuiient bouts of LLQ abuominal pain
Changes in bowel habits is common
Raiely, patient may piesent with lowei uI hemoiihage
!"#$%&'"':
Colonoscopy
Baiium enema can also be useu foi uiagnosis
12*#,+*%,:
If patient is asymptomatic, the only theiapy shoulu be to inciease fibei anu
ueciease fat in the uiet
If patient has uI hemoiihage, ciiculatoiy theiapy is waiianteu (Iv fluius,
maintenance of hemouynamic stability)


6-:.',-<)D-,-0
Inflammation of the uiveiticula uue to infection
Theie aie many possible complications, such as abscess, extension into othei
tissues, oi peiitonitis

-"$%' #%. -/+0,&+':
LLQ pain
Constipation 0R uiaiihea
Bleeuing
Fevei
Anoiexia




!"#$%&'"':
CT uemonstiating euema of the laige intestine
B0 N0T peifoim a colonoscopy oi baiium enema in an acute case, this might
aggiavate the pioblem
3&+07";#,"&%':
Peifoiation
Abscesses
Fistula foimation
0bstiuctions
12*#,+*%,:
If theie is an abscess, peicutaneous uiainage is iequiieu
Nost patients aie manageu well with fluius anu antibiotics
Foi peifoiation oi obstiuction, suigeiy is iequiieu


?N0,')<,-B/ B; ,3. H('1. >/,.0,-/.
Nost common site of colon obstiuction is the sigmoiu colon
3&++&% ;#='*' "%;7=.*:
Auhesions
Auenocaicinoma
volvulus
Fecal impaction

-"$%' #%. -/+0,&+':
Nauseavomiting
Abuominal pain with ciamps
Abuominal uistention
!"#$%&'"':
XRAY - showing a uistenueu pioximal colon, aii-fluiu levels, anu an absence
of gas in the iectum
12*#,+*%,:
If theie is seveie pain, sepsis, fiee aii, oi signs of peiitonitis theie must be an
uigent lapaiotomy

Lapaiotomy if cecal uiametei is >12cm


MBD:)D)0
Twisting anu iotation of the laige intestine
Can cause ischemia, gangiene, peifoiation
The NC site is the sigmoiu colon
0ccuis most commonly in oluei patients

-"$%' #%. -/+0,&+':
Bigh-pitcheu bowel sounus
Bistention
Tympany
!"#$%&'"':
XRAY - "kiuney bean" appeaiance (ie. Bilateu loops of bowel with loss of
haustia)
Baiium enema showing a "biiu's beak" appeaiance - points to the site of
iotation of the bowel
12*#,+*%,:
Sigmoiuoscopy oi colonoscopy acts as uiagnosis anu tieatment
If this uoesn't woik, lapaiotomy is waiianteu


5(/<.' B; ,3. 5BDB/
Colon cancei is the 2
nu
NCC of cancei ueaths
Believeu that a low-fibei, high-fat uiet incieases the iisk
Theie aie many genetic factois that contiibute to colon cancei, such as Lynch
synuiome anu BNPCC
B/%;5 -/%.2&+*:
LS 1 is an autosomal uominant pieuisposition to colon cancei that is usually
iight-siueu
LS2 is the same as LS 1 with the auuition of canceis outsiue the colon, such as
in the enuometiium, stomach, pancieas, small bowel, anu ovaiies

-;2**%"%$:
Scieening shoulu stait at 4uyi in people with no iisk factois
If a family membei has hau cancei of the colon, scieening shoulu stait 1uyi
piioi to when they weie uiagnoseu (assuming this is less than 4uyi)
Shoulu have yeaily stool occult tests
Colonoscopy eveiy 1uyi
Anu a sigmoiuoscopy eveiy S-Syis

!"#$%&'"':
0btain pieopeiative CEA (allows you to follow the piogiession oi iecession
of the uisease)
Enuoscopy + baiium enema
12*#,+*%,:
Suigical iesection + LN uissection
If uisease is metastatic, auu S-F0 to the post-opeiative iegimen
C&77&:D=08
CEA levels eveiy S months foi S yeais
Peifoim a colonoscopy at 6 anu 12 months, then yeaily foi S yeais
If a iecuiience is suspecteu, a CT shoulu be peifoimeu













A)'1-<(D 5B/2-,-B/0 B; ,3. ".<,)* (/2 #/)0

O.*B''3B-20
vaiicosities of the hemoiihoiual plexus
0ften ielateu to stienuous bowel movements

-"$%' #%. -/+0,&+':
Biight ieu bloou pei iectum
Itching
Buining
Palpable anal mass
Inteinal hemoiihoius aie N0T painful, while exteinal hemoiihoius ARE
painful
12*#,+*%,:
0sually self-limiting
Sitz bath
Bemoiihoiual cieam
Stool softeneis to ielieve pain


!3'B*NB0.2 O.*B''3B-20
These aie not a tiue hemoiihoiu, but aie exteinal hemoiihoiual veins of the
anal canal
They aie a painful bluish elevation that lie beneath the skin
37#''"6";#,"&%':
1 hemoiihoius involve no piolapse
2 hemoiihoius classically piolapse with uefecation but ietuin without
manual ieuuction
S hemoiihoius piolapse with eithei stiaining oi uefecation anu iequiie
manual ieuuction
4 hemoiihoius aie not capable of being ieuuceu
12*#,+*%,:
Conseivative theiapies
Scleiotheiapy, iubbei banu ligation, anu suigical hemoiihoiuectomy

#/(D K-00)'.
A ciack oi teai in the anal canal
0sually occuis aftei the passage of uiaiihea oi constipation

-"$%' #%. -/+0,&+':
The most common piesentation is the passage of a painful bowel movement
that is accompanieu by biight ieu bloou
!"#$%&'"':
Peifoim an anoscopy to uiagnose
12*#,+*%,:
Bulking agents anu stool softeneis aie usually all that is neeueu
If fissuies peisist uespite conseivative measuiements, a lateial inteinal
sphincteiotomy may be iequiieu

#/(D (/2 ".<,(D 5(/<.'
!(,# :,('+;:
The most common foim is squamous cell caicinoma
-"$%' #%. -/+0,&+':
Anal bleeuing, pain, anu mucus upon evacuation
!"#$%&'*:
Biopsy
12*#,+*%,:
Chemotheiapy + Rauiation

M+'0,# :,('+;:
Seen in males > females
-"$%' #%. -/+0,&+':
Rectal bleeuing, alteieu bowel habits, tenesmus, obstiuction


!"#$%&'"':
Colonoscopy
12*#,+*%,:
Suigeiy that spaies the sphinctei
If metastasis involveu, auuition of S-F0 chemotheiapy + iauiation























L7$"?A$"G7"[


!)*B'0 B; ,3. 4'(-/
0ften piesents as a 1+,.,'1+ that is seveie enough to awaken the patient
uuiing the night
4(';+,%+. )(0;,';,(),# >;+%%*;+ causing nausea, vomiting, anu Cushing's
tiiau (Biauycaiuia, hypeitension, anu Cheyne-Stokes iespiiation)
Piesence of focal ueficits
0ften piesents with a fixeu, uilateu pupil
!"#$%&'"%$ # 42#"% 7*'"&%:
The most accuiate uiagnosis comes fiom biopsy
With clinical suspicion a CT anuoi NRI can often help make the uiagnosis
12*#,+*%,:
Excision is the best tieatment foi all tumois (except piolactinoma anu
lymphoma)
PR0LACTIN0NA - give biomociiptine to shiink it, then suigeiy if this
uoesn't woik
LYNPB0NA - iauiation is the tieatment of choice
If theie is metastasis of biain tumois, aujunct theiapy is iauiation

6-;;.'./,-(,-/1 N.,E../ ,3. 2-;;.'./, ,9+.0 B; N'(-/ ,)*B'0
N#)$-#,%0$2, @*#0)&$;2+:
The most common 1 CNS neoplasm
Is laige anu iiiegulai with a iing-enhancing appeaiance
@+()(A)$2,:
The 2
nu
NC 1 CNS neoplasm
uiows slowly
Benign
M+0)($-#,%0$2,:
0ccuis in chiluien anu is often bilateial
4u% of cases aie familial while the iest aie spoiatic cases


@+.*##$-#,%0$2,:
Common in chiluien
Founu in the ceiebellum4
th
ventiicle
8;$#,'0)($2,:
Is the NC pituitaiy tumoi
Piesents with many enuociine uistuibances such as amenoiihea, impotence,
galactoiihea, anu gynecomastia.
The NC piesenting symptoms is visual uistuibance (bitempoial
hemianopsia)
O=2>1$2,:
NC CNS tumoi in AIBS patients
An NRI shows a iing-enhanceu lesion
0ften confuseu with toxoplasmosis
9'1/,(($2,:
A tumoi that affects the 8
th
cianial neive
Piesents with tinnitus, loss of heaiing, anu incieaseu intiacianial piessuie



O92'B<.+3(D)0
An inciease in CSF causes an enlaigement of the ventiicles

-"$%' #%. -/+0,&+':
" ICP, ! cognition
Beauache
Focal neuiological ueficits
!"#$%&'"':
A CT oi NRI can show the uilation of ventiicles
A lumbai punctuie can help ueteimine the type of hyuiocephalus
If ICP is noimal, it is a communicating hyuiocephalus (piesents with uiinaiy
incontinence, uementia, anu ataxia)
If ICP is ", it may be eithei communicating oi non-communicating
(Pseuuotumoi ceiebii, congenital)

Tieatment:
If possible, tieat the unueilying cause
If not possible, a shunt shoulu be placeu (usually uiaineu into peiitoneum)

























A)'1-<(D 5B/2-,-B/0 B; ,3. M(0<)D(' A90,.*

#/.)'90*0
Is a uilatation of an aiteiy to gieatei than two times its noimal uiametei
"Tiue" aneuiysms involve all S layeis of the vessel, anu aie causeu most
commonly by atheioscleiosis anu congenital uisoiueis
"False" aneuiysms aie coveieu only by the auventitia of the vessel, anu aie
most commonly causeu by tiauma

-"$%' #%. -/+0,&+':
uastiicepigastiic uiscomfoit
Back pain
Commonly in the abuomen (abuominal aoita aneuiysms)
Also commonly in the peiipheial vessels
3&+07";#,"&%':
A iuptuie of an abuominal aneuiysm is an emeigency
Piesents with abuominal pain, a pulsatile abuominal mass, anu seveie
hypotension
!"#$%&'"':
0ltiasounu can help uetect aneuiysms
CT is the best test to ueteimine size
The most accuiate test is the aoitogiam
12*#,+*%,:
Contiol bloou piessuie
Reuuce iisk factois
Suigeiy iecommenueu if aneuiysms aie >Scm

@.'-+3.'(D M(0<)D(' 6-0.(0. \@M6^
Bue to atheioscleiosis

-"$%' #%. -/+0,&+':
Piesents with clauuication
Patient may have smooth anu shiny skin with a loss of haii in the affecteu
aiea
!"#$%&'"':
Ankle:Biachial Inuex (ABI) is the best initial test - noimal test is % u.9
The most accuiate test is an angiogiaphy
12*#,+*%,:
Lifestyle mouifications such as cessation of smoking anu incoipoiation of
exeicise
Contiol lipius with an LBL <1uu
Contiol bloou piessuie
Baily aspiiin
Suigeiy is iequiieu if theie is pain at iest, neciosis, intiactable clauuication,
anuoi a non-healing infection














#B',-< 6-00.<,-B/
Is a uissection of the thoiacic aoita
Piesents with intense "teaiing" pain that iauiates to the back
Theie is a uiffeience in bloou piessuies between the iight anu left aim

!"#$%&'"':
The best initial test is a CXR - showing a wiuening of the meuiastinum
The most accuiate test is the CT angiogiaphy
12*#,+*%,:
0igent bloou piessuie contiol with #-blockeis followeu by nitiopiussiue to
maintain a uecieaseu bloou piessuie
0igent EKu anu CXR
Then get a TEE oi CT
Suigical coiiection is necessaiy, otheiwise this is iapiuly fatal.









A)N<D(:-(/ A,.(D A9/2'B*.
An occlusion of the subclavian aiteiy leaus to a uecieaseu bloou flow uistal to
the obstiuction
The veitebial aiteiy "steals" the bloou uue to ietiogiaue flow
Patient expeiiences clauuication of the aim, nausea, syncope, anu
supiaclaviculai biuit
!"#$%&'*:
Angiogiaphy
Bopplei ultiasounu
NRI
12*#,+*%,:
Caiotiu-subclavian bypass


5('B,-2 M(0<)D(' 6-0.(0.
Is an atheioscleiotic plaque in the caiotiu aiteiies
-"$%' #%. -/+0,&+':
Patient may piesent with a TIA
Amauiosis fugax (blinuness in one eye)
Caiotiu biuit
!"#$%&'"':
Angiogiaphy
12*#,+*%,:
Beciease the mouifiable iisk factois
Aspiiin
0thei anticoagulation meuications
Suigeiy is waiianteu if theie is stenosis >7u%, if patient has iecuiiing TIA's,
oi if they have suffeieu fiom a pievious ceiebiovasculai acciuent





A)'1-<(D 5B/2-,-B/0 B; ,3. $'-/('9 A90,.*

!.0,-<)D(' !B'0-B/
0sually occuis in a youngei patient
Acute euema anu seveie testiculai pain
Patient usually expeiiences nausea anu vomiting uue to the uegiee of the
pain
ABSENCE of the ciemasteiic ieflex
Piesence of sciotal swelling
Testicle may have a hoiizontal lie
!"#$%&'"':
0ltiasounu to assess aiteiial patency
0pon elevation of the teste, the pain is not alleviateu
12*#,+*%,:
1
st
step is to secuie the ciiculation
2
nu
step is to evaluate the neeu foi excision of the testicle if it is ueau

7+-2-29*-,-0
0nilateial pain of the testicle
Bysuiia
Painful anu swollen epiuiuymus
Less common in piepubeital chiluien as opposeu to toision
!"#$%&'"':
Swab foi Chlamyuia anu uonoiihea
12*#,+*%,:
NSAIBs anu antibiotics

@'B0,(,. 5(/<.'
0bstiuctive symptoms
Rock-haiu nouule in the piostate
!"#$%&'"':
PSA

Seium phosphatase
Azotemia
Tiansiectal ultiasounu

12*#,+*%,:
The only suigical iequiiement is a iauical piostatectomy in veiy seveie cases
- iisk of incontinence anuoi impotence




















?',3B+.2-< <B/2-,-B/0 '._)-'-/1 0)'1.'9

P/.. >/W)'-.0
>%;7=.*:
Anteiioi ciuciate ligament teais
Posteiioi ciuciate ligament teais
Collateial ligament teais
Neniscus teais

@%,*2"&2 32=;"#,* B"$#+*%, ,*#2':
Injuiy histoiy usually ieveals a "pop" sounu uuiing the tiauma
The Lachman test (anteiioi uiawei test) is useu in the fielu to make a
uiagnosis
NRI is the test of choice to ueteimine the seveiity of the injuiy
Tieatment is eithei with conseivative measuies, oi if seveie with
aithioscopic iepaii

7+,; $& 01+ !:O /)01 ,%%$'),0+. P$)(0 +&&*%)$(

E&',*2"&2 32=;"#,* B"$#+*%, ,*#2':
Injuiy usually occuis when the knee is flexeu
"Posteiioi uiessei uiawei sign"
NRI is the test of choice to ueteimine seveiity of the injuiy

Tieatment is eithei with conseivative measuies, oi if seveie with
aithioscopic iepaii
7+,; $& 01+ 8:O




3&77#,*2#7 B"$#+*%, ,*#2':
The NCL is the most commonly injuieu ligament
Seen with a uiiect blow to the lateial knee
Is commonly injuieu in conjunction with the injuiy to the ACL oi PCL
NRI to ueteimine seveiity of the injuiy
Knee biace
7+,; $& 01+ @:O

)*%"';=' ,*#2':
0ften seen in oluei patients anu is uue to uegeneiation
Injuiy is most commonly seen in the meuial meniscus anu is much moie
common in men

Biagnose with NcNuiiay's test
NRI to ueteimine the seveiity of the injuiy
Tieatment is usually iest alone, if seveie can tieat with aithioscopic suigeiy
@+.),# 2+()%'*% 0+,;



A3B)D2.' >/W)'-.0
"B,(,B' 5);; >/W)'9
Can iange fiom milu tenuonitis to seveie teais
Involve the Supiaspinatus, Infiaspinatus, Teies Ninoi, Subscapulaiis

-"$%' #%. -/+0,&+'8
Pain anu tenueiness of the ueltoiu with movement
Pain ovei the anteiioi aspect of the humeial heau
Neei's sign (+) - pain eliciteu when the aim is foicefully elevateu foiwaiu
!"#$%&'"':
Clinical suspicion
NRI is useu foi confiimation
12*#,+*%,:
NSAIBs
Steioius injections

Foi seveie uiseases that aie not successfully tieateu with steioius,
aithioscopic suigeiy is helpful


6-0DB<(,-B/ B; ,3. A3B)D2.'
Is most commonly an anteiioi uislocation
Posteiioi uislocation seen when patient is electiocuteu anuoi expeiiences a
status epilepticus seizuie
!(0+;)$; .)%#$',0)$( $& 01+ 1*2+;*%
-"$%' #%. -/+0,&+':
Immobility
Extieme pain
12*#,+*%,:
Tiaction-counteitiaction techniques to put the bone back in the socket
Immobilization peiiou (2-6 weeks)








O-+ (/2 !3-13 >/W)'-.0

6-0DB<(,-B/0
Bislocations iequiie emeigency ieuuction unuei seuation
Risk of injuiy to sciatic neive
Avasculai neciosis is a seveie complication

K.*B'(D L.<Q K'(<,)'.
Requiies significant foice foi injuiy
Piouuces seveie pain of the hipgioin that is exaceibateu with movement
Leg is classically "exteinally" iotateu
Biagnose with xiay
Requiies suigical ieuuction anu inteinal fixation
E;,'0*;+ $& 01+ #+&0 &+2$;,# (+'B


I'-0, >/W)'-.0
5BDD.08 K'(<,)'.:
This is a fiactuie to the uistal iauius
0ccuis aftei falling on an outstietcheu hanu
Biagnose with B & P anu xiay
Tieat with cast immobilization foi 2-4 wk

:$##+%G &;,'0*;+


A<(+3B-2 K'(<,)'.:
Almost always seconuaiy to a fall
Nost commonly misuiagnoseu as a spiaineu wiist
Biagnosis is classically maue when theie is pain in the anatomic snuff box
Nanage with a thumb splint foi 1u weeks
Complication is avasculai neciosis
9',>1$). E;,'0*;+







5('+(D !)//.D A9/2'B*.
Piesents with pain, numbness, tingling of the hanus along the uistiibution of
the meuian neive

!"#$%&'"':
Pathognomonic sign is "Tinel's Sign", wheie tapping ovei the palmai aspect
of the wiist elicits shooting pains
"Phalen's test" is also uiagnostic
12*#,+*%,:
Tieat by avoiuance of aggiavating activity, use
wiist splints which holu the wiist in %#)A10
+Q0+(%)$(
Seveie cases shoulu fiist be manageu with steioiu
injection in the caipal tunnel, if no tieatment suigeiy is peifoimeu













I'-0, A+D-/,0F
OBD20 ,3. E'-0,
-/ ( +B0-,-B/ B;
`0D-13,
.V,./0-B/8

!3. 4'.(0,

IB'Q)+ B; ( 4'.(0, %(00 #D1B'-,3* \##K@^






5(/<.' "-0Q0
The #1 iisk factoi foi bieast cancei is genuei
(Female >>> Nale)
In women, age is the #1 factoi foi bieast cancei
iisk
Late menopause incieases the iisk of bieast cancei
(aftei Suyi)
If less than 11yi at menaiche, the iisk of bieast
cancei is incieaseu
If >Suyi at fiist piegnancy, the iisk foi bieast
cancei incieases

C#+"7/ ?"',&2/ #%. F2*#', 3#%;*28
0nly S% of bieast canceis aie familial
With a 1
st
uegiee ielative being affecteu, the iisk of cancei incieases
Autosomal uominant conuitions with incieaseu iisk: BRCA-1, BRCA-2, Li-
Fiaumeni synuiome, Cowuen's uisease, Peutz-}egheis















O-0,B'9 B;
K-N'B(2./B*(
(/2JB'
K-N'B<90,-<
2-0.(0. 2B.0 /B,
-/<'.(0. ,3. '-0Q
B; 1.,,-/1 N'.(0,
<(/<.'

!)*B'0 B; ,3. 4'.(0,

%(**B1'(*
All women >4uyi (contioveisial as to age to
stait) shoulu have yeaily mammogiams
Not effective in young patients because the
bieast tissue is too uense
K-N'B(2./B*(
The classic piesentation is a fiim, non-tenuei,
mobile bieast nouule
Nost commonly seen in teens anu youngei
women


!"#$%&'"':
Bieast exam
FNA
Follow-up clinical bieast exam in 6 weeks
12*#,+*%,:
Not iequiieu as this conuition is not a cancei
piecuisoi anu often uisappeais on its own




I3./ ,B +.';B'*
<.',(-/ ,.0,0
+.',(-/-/1 ,B N'.(0,
*(00.0F
A palpable mass that
feels cystic always
iequiies an ultiasounu
fiist.
A palpable mass that
uoesn't feel cystic
iequiies a FNA (aftei an
0S oi insteau of an 0S).
Any FNA that ieveals
bloouy fluiu iequiies
cytology.
Always uo a
mammogiam in patients
>4uyi who piesent with
almost all pathologies of
the bieast.
A biopsy is iequiieu
when a cyst iecuis moie
than 2 times within 4
weeks, when theie is
bloouy fluiu, when theie
aie signs of
inflammatoiy bieast
uisease, anu when a
mass uoes not uisappeai
with FNA.

K-N'B<90,-< 6-0.(0.
This piesents with multiplebilateial painful lumps in the bieast that vaiy in
pain with the menstiual cycle
Is the most commonly seen bieast tumoi in women between SS-Suyi of age

!"#$%&'"':
Fine-neeule aspiiation to uiain fluiu, anu it will collapse aftei the FNA
12*#,+*%,:
0CP's can help pievent this fiom occuiiing



@'.Y>/:(0-:. 4'.(0, 5(/<.'0
Incluue Buctal Caicinoma In Situ anu Lobulai Caicinoma In Situ

6)<,(D 5('<-/B*( >/ A-,) \65>A^
It's piesence incieases the iisk of invasive bieast canceis
0sually non-palpable anu seen on mammogiam as iiiegulaily shapeu uuctal
calcifications
Will leau to invasive uuctal caicinoma



!"#$%&'"':
Bistology shows pucheu-out aieas in uucts anu haphazaiu cells along the
papillae
12*#,+*%,:
Suigical excision ensuiing clean maigins
Post-opeiative iauiation is iecommenueu to ueciease the iisk of iecuiience
(Can give Tamoxifen in auuition to iauiation oi insteau of iauiation)

HBN)D(' 5('<-/B*( >/ A-,) \H5>A^
In contiast to BCIS, this is not piecanceious, it uoes howevei inciease the
iisk of futuie invasive uuctal caicinoma
!"#$%&'"':
Baiu to uiagnose with mammogiam
Cannot be uetecteu clinically
The histology shows mucinous cells in the classic "saw-tooth" pattein
12*#,+*%,:
Tamoxifen alone is useu foi tieatment













>/:(0-:. 4'.(0, 5(/<.'0

7;+,02+(0 &$; ,## )(?,%)?+ ',('+;%<
1. If lump is <Scm, Lumpectomy + iauiation, may auu chemo anu aujuvant
theiapy.
2. Peifoim sentinel noue biopsy (piefeiieu ovei an axillaiy noue biopsy)
S. Test foi estiogenpiogesteione ieceptois anu the BER2 piotein
4. If tumoi is >Scm, the tieatment involves systemic theiapy
>/:(0-:. 6)<,(D 5('<-/B*(
Is the most common foim of bieast cancei, seen in almost 8S% of all cases
Is unilateial
Netastasizes to the biain, livei, anu bone
Impoitant piognosis factois aie size of the tumoi anu the lymph noue
involvement

@(1.,80 6-0.(0. B; ,3. 4'.(0,
Piesents with an eiythematous anu scaly lesion of the nipple that is piuiitic.
Nipple may be inveiteu
Nipple uischaige common

>/;D(**(,B'9 4'.(0, 5(/<.'
Less common
Rapiu giowthpiogiession
Eaily metastasis
Reu, swollen, pitteu, anu waim bieast (peau u'oiange)

HBN)D(' 5('<-/B*(
Nultifocal anu within the same bieast (usually)
2u% of cases piesent as bilateial multifocal lesions

4"5#a (/2 4"5#R
Testing foi these genes shoulu be peifoimeu if theie is a histoiy of the following:
Family histoiy of eaily-onset bieast cancei

Family histoiy of male bieast cancei
Past histoiy of bieast anuoi ovaiian cancei in that patient
Ashkenazi }ewish heiitage


















Chapter 2

Obstetrics












!.'*-/BDB1-.0
uiaviuty = total numbei of piegnancies
Paiity = numbei of biiths with a gestational age >24 weeks
Teim ueliveiy = ueliveiy aftei S7 weeks of gestation
Piematuie ueliveiy = ueliveiy of infant between 2u anu S7 weeks

!3. $/<B*+D-<(,.2 @'.1/(/<9

R),A($%)(A 8;+A(,('=
The piesence of amenoiihea anu + uiinaiy -hCu suggests piegnancy.
Confiim piegnancy with the following:
@'.0./<. B; 1.0,(,-B/(D 0(< |seen with tiansvaginal 0S at 4-S weeks. -hCu
level appiox 1SuumI0ml.j
K.,(D 3.(', *B,-B/ |seen by 0S between S-6 weeks.j
K.,(D 3.(', 0B)/20 |heaiu with Bopplei 0S at 8-1u weeks.j
K.,(D *B:.*./, |on examination aftei 2u weeks.j

3%0)2,0)(A .,0+ $& '$(&)(+2+(0 K3R:L
0se Nagele's iule = Last Nenstiual Peiiou (LNP) + 7 uays - S months + 1yi.
*Calculation accuiacy uepenus on iegulai 28-uay cycles.

6"$G 5#!7G?">7A 6$">LG @"7GL#L5[
5(,.1B'9 6.0<'-+,-B/
# %.2-<(,-B/ 3(0 /B, 03BE/ (/ -/<'.(0. -/ '-0Q ;B' N-',3 2.;.<,0 -/
3)*(/ 0,)2-.0=
4 #/-*(D 0,)2-.0 3(:. /B, 2.*B/0,'(,.2 ( '-0QC (/2 ,3.'. ('. /B
(2._)(,. 0,)2-.0 -/ 3)*(/0C ?" (/-*(D 0,)2-.0 3(:. 03BE/ ( '-0QC
N), ,3. '-0Q 3(0 /B, N../ 0../ -/ 3)*(/0=
5 #/-*(D 0,)2-.0 3(:. 03BE/ (2:.'0. .;;.<,0C N), /B 0,)2-.0 ('.
(:(-D(ND. -/ 3)*(/0C ?" 0,)2-.0 -/ 3)*(/0 (/2 (/-*(D0 ('. /B,
(:(-D(ND.=
6 %.2-<(,-B/0 ('. (00B<-(,.2 E-,3 N-',3 2.;.<,0 -/ 3)*(/0b 3BE.:.'C

+B,./,-(D N./.;-,0 -/ '('. <(0.0 *(9 B),E.-13 ,3.-' Q/BE/ '-0Q0=
c %.2-<(,-B/0 ('. <B/,'(-/2-<(,.2 -/ 3)*(/ +'.1/(/<9 N.<()0. B;
Q/BE/ ;.,(D (N/B'*(D-,-.0 ,3(, 3(:. N../ 2.*B/0,'(,.2 -/ NB,3
3)*(/ (/2 (/-*(D 0,)2-.0=


5?%%?L !7"#!?G7LA >L @"7GL#L5[
6')1 4-',3 6.;.<,
H-,3-)* 7N0,.-/80 (/B*(D9 \0-/1D.Y<3(*N.'.2 '-13, 0-2. B; 3.(',^=
5('N(*(T.+-/.C
M(D+'B(,.
L.)'(D ,)N. 2.;.<,0=
".,-/B-2 #<-2 5LA 2.;.<,0C <'(/-B;(<-(D 2.;.<,0C <('2-B:(0<)D(' 2.;.<,0=
#57 >/3-N-,B'0 6.<'.(0.2 0Q)DD B00-;-<(,-B/C './(D ,)N)D. 2901./.0-0C
'./(D ;(-D)'. -/ /.B/(,.=
?'(D
39+B1D9<.*-<0
L.B/(,(D 39+B1D9<.*-(
I(';('-/ 5LA d AQ.D.,(D 2.;.<,0
LA#>60 L.<'B,-T-/1 ./,.'B<BD-,-0C <B/0,'-<,-B/ B; 2)<,)0
(',.'-B0-0=


!0 &);%0 ?)%)0 *>$( .)%'$?+; $& >;+A(,('=
Peifoim the following:
Complete physical exam with pelvic anu Pap smeai.
Cultuie foi gonoiihea anu Chlamyuia
Labs incluue the following:
CBC
Bloou type with Rh status
0A with cultuie
RPR foi syphilis
Rubella titei
TB skin test
0ffei BIv test
Auuitional testing:
uenetic testing if histoiy inuicates the neeu
If pt not immune to iubella, B0 N0T immunize (live viius).


Recommenu:
Folic aciu
Iion
Nulti-vitamin
2S-SS lb weight gain uuiing piegnancy

S1,0 0$ .$ .*;)(A +,'1 0;)2+%0+;
a
0,
,'-*.0,.'F
Shoulu see patient eveiy 4 weeks.
Assess:
Weight gainloss
Bloou piessuie
Euema
Funual height
0iine foi glucose anu piotein
Estimation of gestational age by uteiine size

R
/2
,'-*.0,.'F
Continue to see the patient eveiy 4 weeks
Assess:
At 12 weeks use Bopplei 0S to evaluate fetal heait beat (each visit)
0ffei tiiple-maikei scieen (-hCu, estiiol, $-fetopiotein(AFP)) at 1S-18
weeks, |AFP uecieaseu in Bown's synuiomej, |AFP incieaseu in multiple
gestation, neuial tube uefects, anu uuouenal atiesiaj.
Bocument quickening (fetal movement) at 17-19 weeks anu beyonu.
Amniocentesis if mothei is >SSyi oi if histoiy inuicates (hx of miscaiiiages,
pievious chilu with ueficits, abnoimal tiiple-maikei scieen).
ulucose scieening at 24wk
Repeat hematociit at 2S-28wk




" NS-AFP:
Neuial tube uefect (NTB), vential
wall uefect, twin piegnancy,
placental bleeuing, ienal uisease,
saciococcygeal teiatoma.
! NS-AFP:
Tiisomy 21, Tiisomy 18
U !3. *B0,
<B**B/ <()0. B;
-/(<<)'(,. D(N
'.0)D,0 -0 2(,-/1
.''B'=


A75?L6 !">%7A!7" "?$!>L7 !7A!A
A<'../-/1 !.0, 6-(1/B0,-<
A-1/-;-<(/<.
L.V, A,.+ -/ %1*,
6-(N.,.0 a3' eS1 ?G!!
\RfYRg EQ0^
#N/ -;
hafS*1J2H
>; iC +.';B'* j3'
aSS1 ?G!!
#/.*-( 545 *.(0)'.2
N.,E../ RfYRg
E..Q0=
ON kaS1J2H l
(/.*-(

>'B/
0)++D.*./,(,-B/
#,9+-<(D
(/,-NB2-.0
>/2-'.<, 5BB*N0
,.0,
@.';B'*.2 -/
"3\Y^ EB*./
DBBQ-/1 ;B'
(/,-NB2-.0 \(/,-Y
6 #N^ N.;B'.
1-:-/1 "3BG#%
"3BG#% /B,
-/2-<(,.2 -/ "3 \Y^
EB*./ E3B 3(:.
2.:.DB+.2 (/,-Y6
(/,-NB2-.0
G4A 0<'../-/1 M(1-/(D (/2 '.<,(D
<)D,)'. ;B' 1'B)+
4 0,'.+ (, jeYjm
E..Q0=
\i^ G4A -0 ( 3-13
'-0Q ;B' 0.+0-0 -/
/.ENB'/0=
n,'.(, E-,3
-/,'(+(',)* >M
(/,-N-B,-<0o=
>MF
@./ G
5D-/2(*9<-/
7'9,3'B*9<-/ -/
@5L (DD.'1-<
+(,-./,=

j
'2
,'-*.0,.'F
See patient eveiy 4 weeks until week S2, eveiy 2 weeks fiom week S2-S6, then
eveiy week until ueliveiy.
Assess:
Inquiie about pieteim laboi |vaginal bleeus, contiactions, iuptuie of
membianesj.
Inquiie about piegnancy-inuuceu hypeitension.
Scieen foi gioup B stieptococcus at SS-S7 weeks.
uive RhouAN at 28-Su weeks if inuicateu
!3. <B/;-'*(,B'9 ,.0, ;B' 2-(N.,.0 -/ +'.1/(/<9 -0 ,3. j3' aSS1 B'(D
1D)<B0. ,BD.'(/<. ,.0, \?G!!^=
Plasma glucose >12SmguL at beginning of test = BN
Abnoimal plasma glucose is >14umguL at 1hi, >1SSmguL at 2hi, anu
>18umguL at Shi.
If 1 post glucose loau measuiement is abnoimal, impaiieu glucose
toleiance is the uiagnosis.
If 2 oi moie post glucose loau measuiements aie abnoimal, gestational
uiabetes is the uiagnosis.

71+ &$##$/)(A ,(0)+2+0)'% ,;+ %,&+ 0$ *%+ .*;)(A >;+A(,('=<
Boxylamine
Netoclopiamiue
0nuansetion
Piomethazine
Pyiiuoxine






















!3. 5B*+D-<(,.2 @'.1/(/<9

J#++.)(A ,&0+; TU /++B% K#,0+ >;+A(,('=L
Nost common causes of late piegnancy vaginal bleeuing aie:
1. Abiuptio placenta
2. Placenta pievia
S. vasa pievia
4. 0teiine iuptuie



#4"$@!>? @H#57L!#
Suuuen onset of seveiely painful vaginal bleeuing in patient with histoiy of
hypeitension oi tiauma.
Bleeuing may be concealeu, in which case theie will be seveie, constant pain
without the piesence of bloou.
BIC is a feaieu complication
)#%#$*+*%,:
Emeigent C-section if patient oi fetus is ueteiioiating
Aumit anu obseive if bleeuing has stoppeu, vitals anu BR aie stable, oi fetus
is <S4 weeks.

@H#57L!# @"7M>#
Suuuen onset of painless bleeuing that occuis at iest oi uuiing activity
without waining.
Nay incluue histoiy of tiauma, sexual activity, oi pelvic exam befoie onset.
0ccuis when the placenta is implanteu in lowei uteiine segment
Best management is emeigency C-section.
S foims of placenta pievia:
1. Accieta - uoes not penetiate entiie thickness of enuometiium
* Nevei peifoim a uigital oi speculum exam in any patient with late vaginal bleeuing
until a vaginal ultiasounu has iuleu out placenta pievia


2. Incieta - extenus fuithei into the myometiium
S. Peicieta - placenta penetiates entiie myometiium to uteiine seiosa

M#A# @"7M>#
A conuition life-thieatening to the fetus.
0ccuis when vilamentous coiu inseition iesults in umbilical vessels ciossing
the placental membianes ovei the ceivix. Nembiane iuptuie causes teaiing
of the fetal vessels, anu bloou loss is fiom the fetal ciiculation.
Fetal bleeuing anu ueath occui iapiuly.
)#%#$*+*%,:
Immeuiate C-section.
37#''"; ,2"#. &6 G#'# 02*G"#8
1. Ruptuie of membianes
2. Painless vaginal bleeuing
S. Fetal biauycaiuia
Emeigency C-section is always the fiist step in management

$!7">L7 "$@!$"7
0ccuis when theie's a histoiy of uteiine scai with suuuen-onset of
abuominal pain anu vaginal bleeuing.
Associateu with a loss of electionic fetal BR, uteiine contiactions, anu
iecession of the fetal heau.
)#%#$*+*%,:
Immeuiate suigeiy anu ueliveiy








5B*+('-/1 @D(<./,( @'.:-( (/2 @D(<./,(D #N')+,-B/
Placenta Pievia Placental Abiuption
Abnoimality Placenta implanteu ovei
inteinal ceivical os
(completely oi paitially)
Piematuie sepaiation of
noimally implanteu
placenta fiom ueciuua
Epiuemiology " Risk gianu multipaias
anu piioi C-section
" Risk pieeclampsia,
pievious histoiy of
abiuption, R0N in a pt
with hyuiamnios, cocaine
use, cigaiette smoking,
anu tiauma.
Time of onset 2u-Su weeks Any time aftei 2u weeks
Signs & Symptoms Suuuen, painless bleeuing Painful bleeuing, can be
heavy anu painful, with
fiequent uteiine
contiactions
Biagnosis 0S ! Placenta in
abnoimal location
Clinical, baseu on
piesentation of painful
vaginal bleeuing, fiequent
contiactions, anu fetal
uistiess.
Tieatment Bemouynamic suppoit,
expectant management,
ueliveiy by C-section
when fetus is matuie
enough
Bemouynamic suppoit,
uigent C-section oi
vaginal inuuction if
patient is stable anu fetus
is not in uistiess
Complications Associateu with a two-folu
inciease in congenital
malfoimations so
evaluations foi fetal
anomalies shoulu be
unueitaken at uiagnosis
" Risk of fetal hypoxia
anuoi ueath, BIC may
occui as a iesult of
intiavasculai anu
ietioplacental
coagulation.








V=>+;0+(%)$( )( 8;+A(,('=
Bypeitension in piegnancy pieuisposes both the mothei anu fetus to seiious
conuitions. A 4@ B; % afSJpS uuiing piegnancy can be classifieu as chionic
hypeitension oi gestational hypeitension.
Bypeitension accompanieu by signs anu symptoms of enu-oigan uamage oi
neuiological sequelae is uiagnoseu as +'..<D(*+0-(, .<D(*+0-(, oi O7HH@
09/2'B*..
Sustaineu hypeitension may cause fetal giowth iestiiction anu hypoxia, anu
inciease the iisk of (N')+,-B +D(<./,(.

R),A($%)%:
Elevateu piegnancy befoie piegnancy oi befoie 2u weeks gestation = chionic
hypeitension
Bevelopment of hypeitension aftei 2u weeks gestation that ietuins to
noimal baseline by 6 weeks post-paitum = gestational hypeitension
Piesence of pioteinuiia anuoi piesence of waining signs = pieeclampsia

S,;()(A 9)A(% $& 8;++'#,2>%),<
Ballmaik symptoms incluue:
Beauache
Epigastiic pain
visual changesuistuibances
Signs:
Pulmonaiy euema
0liguiia
Labs:
Thiombocytopenia
Elevateu livei enzymes






6-0.(0. 53('(<,.'-0,-<0
Pieeclampsia BTN (>14u9u oi " systolic BP
>Su mmBg oi uiastolic BP >1S
mmBg compaieu to pievious BP).
New onset pioteinuiia anuoi
euema.
Commonly aiounu week 2u
Seveie Pieeclampsia SBP >16u mmBg oi BBP >11u
mmBg.
Significant pioteinuiia (>1g24hi
uiine collection oi >1+ on uip)
CNS uistuibances such as
heauache oi visual uistuibance
Pulmonaiy euema
R0Q pain
Eclampsia C0Nv0LSI0NS
2S% occui befoie laboi, Su%
uuiing laboi, 2S% in fiist 72hi
post-paitum

E2"+"0#2#' W aie at gieatest iisk foi eclampsia.
352&%"; 5/0*2,*%'"&% :",5 '=0*2"+0&'*. 02**;7#+0'"# H is uiagnoseu when theie is
chionic hypeitension with incieasingly seveie hypeitension, pioteinuiia, anuoi
waining signs.
I;7#+0'"# - is the uiagnosis when theie is unexplaineu gianu mal seizuies in a
hypeitensive anuoi pioteinuiic in a woman in the last half of piegnancy. Seizuies
aie uue to seveie uiffuse ceiebial vasospasm, which cause ceiebial peifusion
ueficits anu euema
?IBBE '/%.2&+* W is uiagnosis when theie is Oemolysis, 7levateu Hivei enzymes,
anu How @latelets.

7;+,02+(0:
BP goal is 14u-1Su mmBg (systole) anu 9u-1uu mmBg (uiastole).
Bon't tieat unless BP is >16u1uu mmBg

)#"%,*%#%;* 15*2#0/8
Fiist line theiapy - Nethyluopa
Seconu line theiapy - #-blockeis such as labetalol

* #-blockei use in piegnancy can cause I0uR

@;=,* *7*G#,"&% "% FE8
Iv hyuialazine oi labetolol

-*"J=2* +#%#$*+*%,8
Aiiway piotection fiist
Iv Nagnesium Sulfate bolus foi seizuie anu infusion foi continueu
piophylaxis
Inuuce laboi is fetus is %S6 weeks with milu pieeclampsia anu attempt
vaginal ueliveiy with Iv oxytocin if both mothei anu fetus aie stable



V3OO8 9=(.;$2+
0ccuis in up to 1u% of pieeclampsia patients
0ccuis in thiiu tiimestei, may occui 2 uays aftei ueliveiy
Risk factois incluue: whites, multigiavius, oluei mateinal age

@,(,A+2+(0:
Immeuiate ueliveiy at any gestational age
Iv coiticosteioius if platelets aie <1uu,uuumm^S both antepaitum anu
postpaitum, continuing until platelets aie >1uu,uuumm^S anu livei
functions noimalize
uive platelet tiansfusion if platelets uiop below 2u,uuumm^S oi platelet
count less than Su,uuumm^S if C-section will be peifoimeu
Iv Nagnesium Sulfate foi seizuie piophylaxis
Steioius foi fetal lung matuiity.

:$2>#)',0)$(% $& V3OO8<
BIC
Placental abiuption
Fetal ueath

Bepatic iuptuie
Ascites





X$;2,# >1=%)$#$A)' '1,(A+% )( >;+A(,('=
Theie aie many noimal physiological changes that occui in piegnancy, these incluue
the following.
O.*(,BDB1-<(D - piegnancy cieates a state of hypeicoagulability
" clotting factoi levels
venous stasis causeu by uteiine piessuie on lowei-extiemity veins
@%*+"# &6 E2*$%#%;/8
Between weeks 6-Su, plasma volume incieases appioximately Su%
Reu cell mass incieases to a smallei uegiee, anemia uue to 1S% uilution
Slight leukocytosis
Platelets ueciease slightly but still iemain wnl.

5('2-(< -
C0 " Su% (both BR anu Sv inciease)
" flow causes " S2 split with inspiiation, uistenueu neck veins, systolic
ejection muimui, anu SS gallop aie noimal finuings.
! PvR uue to piogesteione-meuiateu smooth muscle ielaxation
BP ! uuiing fiist 6 months, then ietuin to noimal

@)D*B/('9 -
Nucosal hypeiemia causes nasal stuffiness anu nasal hypeisecietion
Biaphiagm elevates uue to uteius expansion
Tiual volume anu minute ventilation " Su-4u%
Functional iesiuual capacity anu iesiuual volume ! 2u%

Bypeiventilation that allows foi a piessuie giauient so mateinal u2 can
tiansfei to fetus
Respiiatoiy iate, vital capacity, inspiiatoiy ieseive all iemain unchangeu.


G> -
! uI motility
! esophageal sphinctei tone (leaus to uERB)
" alkaline phosphatase
Bemoiihoius causeu by constipation anu " venous piessuie uue to enlaiging
uteius compiession on IvC

"./(D -
! blauuei tone uue to piogesteione pieuisposes to uiinaiy stasis anu
0TI'spyelonephiitis
uFR " by Su%, thus glucose excietion without incieaseu piotein loss
Seium cieatinine anu B0N ueciease

7/2B<'-/. -
! fasting glucose in mothei uue to fetal utilization
" postpianuial glucose in mothei uue to " insulin iesistance
At 9-11 weeks the fetus piouuces its own insulin
" mateinal thyioiu-binuing globulin (TBu) uue to " estiogen, " total TS anu
T4 uue to " TBu.
" coitisol anu coitisol-binuing globulin

AQ-/ -
Incieaseu estiogen causes skin changes similai to those in livei uisease
Spiuei angiomas, palmai eiythema
Bypeipigmentation uue to " estiogen anu melanocyte-stimulating hoimone




%.2-<(D 5B*+D-<(,-B/0 -/ @'.1/(/<9

5('2-(< #N/B'*(D-,-.0
Beait uisoiueis account foi up to 1u% of mateinal obstetiic ueaths
Women with veiy high-iisk uisoiueis shoulu be auviseu against piegnancy
uue to incieaseu iisk of ueath
Caiuiovasculai physiological changes may unmask anu woisen unueilying
conuitions, seen maximally between 28-S4 weeks gestation.
@.'-+(',)* 5('2-B*9B+(,39
Fiom the 8
th
month until S months post-paitum, heait failuie without
iuentifiable cause is possible
Risk factois incluue multipaiity, age ovei Su, histoiy of multiple gestations,
anu pieeclampsia
S-yi moitality iate is Su%

%(/(1-/1 0+.<-;-< <('2-(< <B/2-,-B/0
?*#2, C#"7=2*8
Loop uiuietics, nitiates, anu # - blockeis
Bigoxin may impiove symptoms but uoes not impiove outcome.
Nevei use ACEI's in piegnancy
@225/,5+"#':
Rate contiol as with non-piegnant patients
Nevei give waifaiin oi amiouaione
I%.&;#2.","' E2&05/7#K"'8
Same as in non-piegnant patient
Baily piophylaxis in patient with iheumatic heait uisease
L#7G=7#2 !"'*#'*8
Reguigitant lesions uo not iequiie theiapy
Stenotic lesions have incieaseu iisk of mateinal anu fetal moitality
Nitial stenosis has incieaseu iisk of pulmonaiy euema anu Afib.




O9+.'<B(1)D(ND. A,(,.0
E=7+&%#2/ I+4&7='8
The leauing cause of mateinal ueath in 0S
M5*% ,& #%,";&#$=7#,*8
Anticoagulate when BvT oi PE in piegnancy
Anticoagulate when Atiial Fibiillation is piesent with unueilying heait
uisease
When patient has antiphospholipiu synuiome
When ejection fiaction is <Su%
The anticoagulant of choice is low moleculai weight hepaiin (won't cioss placenta)
Patients with a histoiy of BvT oi PE in a pievious piegnancy shoulu ieceive
piophylactic LNWB thioughout the piegnancy, unfiactionateu hepaiin
uuiing laboi anu ueliveiy, anu waifaiin foi 6 weeks postpaitum.

!39'B-2 6-0B'2.'0
Bypeithyioiuism in piegnancy causes fetal giowth iestiiction anu stillbiith
Bypothyioiuism in piegnancy can cause intellectual ueficits anu miscaiiiage
#-blockeis aie the B0C foi symptoms uue to hypeithyioiuism
Rauioactive iouine nevei given in piegnancy

A2#G*N' !"'*#'*8
Piopylthiouiacil (PT0) is B0C in piegnancy
Nethimazole is 2
nu
line uiug
PT0 can cioss the placenta anu cause goitei + hypothyioiuism.
Nateinal thyioiu-stimulating Ig's anu thyioiu-blocking Ig's can cioss the
placenta anu cause fetal tachycaiuia, giowth iestiiction, anu goitei.

6-(N.,.0 -/ @'.1/(/<9
The taiget values foi fasting bloou sugai aie between 9umguL anu
12umguL 1hi aftei eating.
Insulin-uepenuent BN iequiies insulin anu is safe thiough piegnancy
uestational BN is manageu solely thiough uiet

0ial hypoglycemics aie contiainuicateu anu shoulu also be avoiueu if
bieastfeeuing, since it can cause hypoglycemia.
O&=,"%* +&%",&2"%$ ,*',' .=2"%$ 02*$%#%;/8
Nonthly sonogiams
Nonthly biophysical piofiles
BbA1c each tiimestei
Tiiple maikei scieen at 16-18 weeks
assessing NTB's.
At S2 weeks stait weekly non-stiess tests
anu amniotic fluiu inuex
If gestational BN, uo a 2hi 7Sg 0uTT at 6-12 weeks postpaitum to see if
uiabetes has iesolveu

B#4&2 "% ,5* ."#4*,"; 0#,"*%,'8
Bue to uelayeu fetal matuiity, aim to uelivei the baby at 4u weeks
If theie is pooi glycemic contiol, inuuce laboi at S9-4u weeks if <4,Suug.
Check LS iatio, if >2.S anu theie is piesence of phosphatiuyl glyceiol this
ensuies lung matuiity
If baby is >4,Suug, scheuule a C-section
Ensuie mateinal glucose is between 8u-1uumguL, this can be ensuieu with
BS (S% uextiose)
Insulin iesistance uecieases iapiuly aftei ueliveiy, so keep an eye on insulin
auministiation anu maintain bloou-glucose levels with a sliuing scale

3&++&% %*&%#,#7 02&47*+' "% ."#4*,"; 02*$%#%;/8
Bypoglycemia
Bypocalcemia
Polycythemia
Bypeibiliiubinemia
Respiiatoiy uistiess synuiome






BbA1c > 8.S in the fiist
tiimestei is stiongly
associateu with congenital
malfoimations, especially
neuial tube uefects!

H-:.' 6-0.(0.
>%,2#5*0#,"; 35&7*',#'"' &6 E2*$%#%;/8
A genetic conuition most commonly seen in Euiopean women
9)Y9Q ! Intiactable nighttime piuiitis of palms anu soles of feet
R),A($%)% ! up to 1uux inciease in seium bile acius
7;+,02+(0 ! 0isoueoxycholic aciu in tieatment of choice. Antihistamines also
helpful


@;=,* C#,,/ B"G*2 &6 E2*$%#%;/8
A iaie conuition causeu by uisoiueieu metabolism of fatty acius by the fetal
mitochonuiia.
Causes BTN, pioteinuiia, anu euema that can mimic pieeclampsia.
Biagnosis:
" livei enzymes (ALT, AST, uuT)
Bypeibiliiubinemia
BIC
Bypoglycemia
Incieaseu seium ammonia
Tieatment:
Emeigency situation iequiies IC0 aumission anu aggiessive Iv fluius +
immeuiate ueliveiy









$'-/('9 !'(<, >/;.<,-B/0C 4(<,.'-)'-(C (/2 @9.DB/.+3'-,-0
Infection Type Asymptomatic
Bacteiiuiia
Acute Cystitis Pyelonephiitis
Symptoms (+) uiine cultuie
N0 buining
N0 fiequency
N0 fevei
N0 uigency

(+) uiine cultuie
B0RNINu
FREQ0ENCY
0RuENCY
N0 fevei
(+) uiine cultuie
B0RNINu
FREQ0ENCY
0RuENCY
FEvER + CvA
TENBERNESS
Tieatment 0utpatient
Nitiofuiantoin is
the B0C
0utpatient
Nitiofuiantoin is
the B0C
Aumission, give:
Iv hyuiation
Iv cephalospoiin's
uive tocolytics
Possible
Complications
Acute
pyelonephiitis if
untieateu in
appioximately
Su%
Acute
pyelonephiitis if
untieateu in
appioximately
Su%
Pieteim laboi anu
ueliveiy.
Seveie cases may
piogiess to sepsis,
anemia, anu
pulmonaiy
uysfunction


7<,B+-< @'.1/(/<9J!)N(D @'.1/(/<9
The eailiei the age of gestation the less theie is a iisk of complications.
P
',
,2"+*',*28
B&C is the most common 1
st
tiimestei pioceuuie.
uive piophylactic antibiotics
Peifoim unuei twilight anesthesia + paiaveitebial block
Can peifoim meuical aboition as an alteinative to B&C with use of oial
mifepiistone (piogesteione antagonist), anu oial misopiostol (piostaglanuin
E1). * Nust be peifoimeu within 6S of onset of amenoiihea.
3&+07";#,"&%':
Enuometiitis (iaiely)
Retaineu piouucts of conception (P0Cs)

Q
%.
,2"+*',*28
B&C is the most common 2
nu
tiimestei pioceuuie.
Foi moie auvanceu piegnancies, an "intact B&C" can be useu.

3&+07";#,"&%':
Retaineu placenta is the most common immeuiate complication
Ceivical tiaumaceivical insufficiency is the most common uelayeu
complication


#NB',-B/

Teimination of piegnancy usually & 2u weeks, spontaneously in 1S% of all
piegnancies.
Risk factois = " pateinal age, conception within S months of live biith, "
paiity
Su% aie uue to chiomosomal abnoimalities
vaginal bleeuing in fiist half of piegnancy is piesumeu to be a thieateneu
aboition until pioven otheiwise

I;,&0"; E2*$%#%;/8
Implantation outsiue of the uteiine cavity
PIB incieases the iisk
Risk factois:
Pievious ectopic piegnancy
Bistoiy of gonoiihea, Chlamyuia, PIB, salpingitis
Auvanceu mateinal age (>SS)
> S piioi piegnancies
Biffeiential ux of ectopic piegnancy:
0vaiian toision
Enuometiiosis
Suigical abuomen
Aboition
Salpingitis
Ruptuieu ovaiian cyst
Biagnosing:
(+) #-hCB + 0S to ueteimine intia vs. extia uteiine piegnancy
Low piogesteione level is suggestive of a non-viable piegnancy that may be
locateu outsiue of the uteiine cavity

Tieatment:
Lapaioscopic iemoval, tubes usually heal on theii own
Nethotiexate eaily, especially if size is <S.Scm in uiametei + no caiuiac
activity on 0S
Rh negative women shoulu ieceive RhouAN
Seiial #-hCB must be uone to ensuie success of teimination

!9+.0 B; #NB',-B/0
!3'.(,./ >/.:-,(ND. 5B*+D.,.2 >/<B*+D.,. %-00.2 ".<)''=
vaginal
bleeuing in
fiist 2u wk
without
passage of
tissues oi
R0N.
Ceivix is
closeu.

0ccuis in
2S% of
piegnancie
s.

Biagnose
with
ultiasounu
.

If no
caiuiac
activity by
week 9
consiuei a
B&C.



Thieatene
u aboition
with
uilateu
ceivical os
anuoi
iuptuie of
membiane
s (R0N).

Piegnancy
loss is
unavoiuabl
e.

Tieat with
suigical
evacuation
+ aumin of
RhouAN if
mothei is
Rh (-).
A
uocumenteu
piegnancy
that
spontaneous
ly aboits all
piouucts of
conception
(P0Cs).

Nust uo
pathology
iepoit of
P0Cs.

Pt may
iequiie
auuitional
cuiettage if
P0Cs aie not
completely
evacuateu.

RhouAN to
Rh (-)
women.
Ciamping,
bleeuing,
uilateu
ceivix with
passage of
tissue into
vagina oi
enuoceivical
canal.

Cuiettage
often
iequiieu.

Rh (-) pt
iequiies
RhouAN.

Bemouynam
ic
stabilization
may be
iequiieu.
P0Cs uo not
get fully
expelleu.

No uteiine
giowth, no
fetal heait
tones,
cessation of
piegnancy
symptoms.

Evacuation
of uteius
aftei
confiimeu
fetal ueath.

BIC is iaie
complicatio
n.

RhouAN is
Rh (-)
%2
consecutive
oi total of S
spontaneou
s aboitions.

Nay be ut
chiomosom
al anomaly.

Tieat with
ceivical
(1S-16wk)
ciiclage
until laboi
oi R0N
occuis (S6-
S7wk).




6-0+'B+B',-B/(,. K.,(D G'BE,3

>$G"
Biagnoseu when fetal weight is <S-1u peicentile foi gestational age oi
<2,Suug (Slb, 8oz.)
Eaily sonogiam is iequiieu if accuiate uates aie not known

-/++*,2"; >RAO8
Fetal Causes:
! giowth potential
0S shows a ! in all measuiements
Etiology:
T0RCB infection
Aneuploiuy
Stiuctuial anomalies such as: caiuiac, neuiological.
0ltiasounu:
! in all measuiements (symmetiic)
Biagnosing:
Kaiyotype
Scieen foi fetal infection
Betaileu sonogiam

@'/++*,2"; >RAO8
1. Nateinal Causes:
! placental peifusion
Etiology:
Bypeitension
Nalnutiition
ET0B, tobacco, illicit uiugs
0ltiasounu:

! abuomen measuiements with noimal heau measuiements
Biagnosing:
Seiial sonogiams
NST
AFI (often !, especially with seveie uteioplacental insufficiency).
Biophysical piofile


2. Placental Causes:
! placental peifusion
Etiology:
Infaiction
Twin-twin tiansfusion
Abiuption
velamentous coiu inseition
0ltiasounu:
! abuomen measuiements with noimal heau measuiements
Biagnosing:
Seiial sonogiams
NST
AFI (often !, especially with seveie uteioplacental insufficiency).
Biophysical piofile

%(<'B0B*-(
Inuicateu by fetal weight >9u-9S peicentile foi gestation age oi biith weight
of 4uuu-4Suug.
Risk Factois:
uestational Biabetes Nellitus
Piolongeu gestation
0besity
Incieaseu piegnancy weight gain
Nultipaiity
Nale fetus


Complications:
)#,*2%#7 ! injuiy uuiing biith, post-paitum hemoiihage, emeigency C-section
C*,=' ! shouluei uystocia, biith injuiy, asphyxia
S*&%#,* ! hypoglycemia, Eib's palsy


Nanagement:
I7*;,"G* 3D'*;,"&% ! in uiabetic if >4Suug, oi >Suuug in non-uiabetic mothei.

















K.,(D #00.00*./, (/2 >/,'(+(',)* A)':.-DD(/<.

The following must be assesseu anu obseiveu closely uuiing piegnancy:
Fetal giowth
Fetal well-being
Tests of fetal matuiity
Intiapaitum fetal assessment
Isoimmunization
uenetic testing

a= K.,(D G'BE,3
0S is most ieliable tool foi giowth assessment
Neasuie by funual height, a ueviation fiom expecteu funual height uuiing
weeks 18-S6 iequiie iepeat measuiement anuoi 0S
Eaily piegnancy: uestational sac + ciown-iump length coiielate quite well
with gestational age
Latei piegnancy: 4 measuiements uone uue to wiue ueviation of noimal
iange: 1- Bipaiietal uiametei of skull 2- Abuominal ciicumfeience S- Femui
length 4- Ceiebellai uiametei

R= K.,(D E.DDYN.-/1
% 4 movements pei hi usually inuicates fetal well-being
S&%D',2*'' ,*', TS-1U8
Neasuies iesponse of fetal heait iate to movement
Noimal NST when FBR " by 1S beats pei minute foi 1S sec following fetal
movement (2 of these acceleiations within 2umin consiueieu to be noimal)
A non-ieactive NST iequiies fuithei assessment
NST has a high false-positive iate, thus a iepeat within 24hi is a goou iuea


F"&05/'";#7 02&6"7*8
Neasuies:
Fetal bieathing
Fetal bieathing
Fetal tone

Qualitative amniotic fluiu volume
Reactive fetal heait iate
All measuies fiom u-2, a scoie of 8-1u is noimal, scoie of 6 iequiies fuithei
evaluation, scoie of & 4 usually iequiies immeuiate inteivention

j= !.0,0 B; ;.,(D *(,)'-,9
Since the iespiiatoiy system is last thing to uevelop in the fetus, uecisions
iegaiuing ueliveiy aie usually baseu on the matuiity of this system
Suifactant is still low all the way up to SS weeks
Lack of suifactant causes neonatal iespiiatoiy uistiess synuiome (RBS)
1*',"%$ 6*,#7 7=%$ +#,=2",/8
Lecithin : sphingomyelin iatio >2.u is the safe iatio anu suggests lung
matuiity.
Phosphatiuylglyceiol appeais late in piegnancy anu its piesence inuicates
fetal lung matuiity.
L?!7: Sphingomyelin iemains constant thioughout piegnancy, while lecithin
only elevates when the fetal lungs become matuie

f= >/,'(+(',)* ;.,(D (00.00*./,
C?O +&%",&2"%$8
Noimal FBR is 12u-16u BPN
FBR >16u foi % 1u min consiueieu tachycaiuia (NCC is mateinal fevei)
FBR <12u foi % 1u min consiueieu biauycaiuia (congenital heait block, fetal
anoxia, mateinal tieatment with #-blockeis
FBR vaiiability is a ieliable inuicatoi of fetal well-being anu is suggestive of
sufficient oxygenation of fetus.
Becieaseu FBR vaiiability is associateu with fetal hypoxia, fetal tachycaiuia,
uepiessants, piolongeu uteiine contiactions







@;;*7*2#,"&%'8
7('D9 2.<.D.'(,-B/0 - ! FBR miiioiing contiaction, uue to piessuie on fetal heau
(vagal neive stimulation), is physiologic anu not haimful to fetus.



M('-(ND. 2.<.D.'(,-B/0 - uon't always coinciue with uteiine contiaction,
chaiacteiizeu by iapiu uip in BR followeu by iapiu ietuin to baseline. Reflex-
meuiateu anu uue to umbilical coiu compiession




H(,. 2.<.D.'(,-B/0 - begin aftei contiaction has staiteu, uips aftei peak of
contiaction, anu ietuins to baseline aftei contiaction is ovei. vieweu as uangeious
anu is associateu with placental insufficiency.

Causes:
Placental abiuption
Piegnancy inuuceu hypeitension
Nateinal uiabetes
Nateinal anemia
Nateinal sepsis
Post-teim piegnancy
Bypeistimulation of uteius

** Repetitive late ueceleiations iequiie inteivention

e= >0B-**)/-T(,-B/
Following exposuie to fetal ieu bloou cell antigens, the mothei can uevelop
mateinal immunoglobulin antibouies (Igu). This can occui uuiing biith oi uuiing
the piegnancy uepenuing on ceitain pioblems thioughout the piegnancy wheie
bloou is mixeu.
Nost commonly occuis when mothei is Rh (-) anu fetus is Rh (+)
Igu ciosses placenta anu can affect the fetus
A significant tiansfei of antibouies can iesult in hyuiops fetalis
Fetal ascites anu euema occui (livei makes too many RBC's at the expense of
pioteins, causing a ! in oncotic piessuie, iesulting in fetal ascites anuoi
euema.
A mateinal Igu titei % 1.16 is sufficiently high to huit the fetus

The Kleihauei-Betke test helps to iuentify fetal RBC's in mateinal bloou.

12*#,+*%,V@G&".#%;*8
uive RhouAN within 72hi of ueliveiy to pievent an antibouy iesponse in the
mothei.
uiven at 28 weeks as well, can fuithei ieuuce iisks by u.2%
Impoitant to test fathei foi Rh status, if he is Rh (+), auministei RhouAN
both at 28 weeks of gestation + at 72hi aftei ueliveiy.
W,5*2 ,"+*' +#,*2%#7D6*,#7 47&&. ;#% +"K8
Buiing amniocentesis
Aftei an aboition
Aftei an ectopic piegnancy tieatment


q= G./.,-< !.0,-/1
Su%-6u% of spontaneous aboitions uue to chiomosomal abnoimalities
S% of stillbiiths aie uue to chiomosomal abnoimalities
2%-S% of couples with multiple miscaiiiages aie causeu by chiomosomal
abnoimalities
u.6% of live biiths have chiomosomal abnoimalities

M5*% ,& .& 02*%#,#7 $*%*,"; ,*',"%$X
Auvanceu mateinal age (most common) - Bown's synuiome is incieaseu 1u-
folu when mothei is SS-4Syi.
Amniocentesis shoulu be offeieu to all motheis with ANA
When theie is a piioi chilu with chiomosomal abnoimalities
When paient(s) have known chiomosomal abnoimalities
When theie has been an abnoimal scieening test







H(NB' (/2 6.D-:.'9

a= >/-,-(D @'.0./,(,-B/

8S% of patients unueigo spontaneous laboi anu ueliveiy between S7 anu 42
weeks
Regulai contiactions eveiy S minutes foi at least 1hi, iuptuie of membianes,
significant bleeuing, anuoi ! fetal movement aie all ieasons foi visiting the
hospital
Initial Exam 0pon Aiiival:
Auscultation of fetal heait tones
Beteimination of fetal life (Leopolu maneuvei)
vaginal examination

R= A,(1.0 B; H(NB'
B#4&2 "' ."G".*. "%,& Y ',#$*'8
A,(1. aY
Inteival between the onset of laboi anu full ceivical uilation (1ucm)
!3-0 0,(1. ;)',3.' 0)N2-:-2.2 -/,B ,EB +3(0.0F
Latent phase = ceivical effacement anu eaily uilation
Active phase = iapiu ceivical uilation occuis when appioximately at S-4cm
A,(1. RY
Is the inteival between complete uilation anu the ueliveiy of the infant
A,(1. jY
Is the inteival between ueliveiy of the infant anu ueliveiy of the placenta
** Theie is a 4
th
stage, which lasts 2hi anu is the peiiou immeuiately aftei ueliveiy of
the placenta, wheieby theie aie many physiological changes






j= %(/(1.*./, B; H(NB'
!=2"%$ 6"2', ',#$*8
Continuous FBR monitoiing
Continuous monitoiing of uteiine activity with exteinal tocouynamometei
anu intiauteiine piessuie cathetei
Analgesia anuoi anesthetic given, most commonly when ieaching the active
stage of laboi.
!=2"%$ '*;&%. ',#$*8
At this stage mateinal pushing can acceleiate ueliveiy
Episiotomy uone at this stage (if peifoimeu at all)
Bulb anu suction aftei ueliveiy of the heau
Shoulueis ueliveieu aftei heau
0mbilical bloou sent foi AB0 anu Rh testing
!=2"%$ ,5"2. ',#$*8
Beliveiy of placenta
!=2"%$ 6&=2,5 ',#$*8
Evaluation of ceivix, vagina, vulva, peiineum, anu uiethial aiea foi
laceiations anuoi tiaumatic injuiy

f= #N/B'*(D H(NB'
Bystocia = Bifficult Laboi
Bystocia is uetecteu by evaluation thiee ciiteiia, they aie:
1. @BE.' - iefeiiing to the stiength, uuiation, anu fiequency of contiactions.

Foi ceivical uilation to occui, theie must be moie than S contiaction in 1u
minutes

2. @(00./1.' - iefeiiing to fetal weight + fetal lie + piesentation + position

j= @(00(1. -

Pelvic uiametei
Ability of pelvic to accommouate passage of baby
Bistenueu oigans oi masses can hinuei passage



H(NB' 0,(1. 6.;-/-,-B/ 6)'(,-B/ #N/B'*(D-,-.0
A,(1. a Z H(,./,
@3(0.
\7;;(<.*./,^
4.1-/0 E-,3 B/0.,
B; '.1)D(' ),.'-/.
<B/,'(<,-B/0=

7/20 E-,3
(<<.D.'(,-B/ B;
<.':-<(D 2-D(,-B/=
kRS 3B)'0 -/
+'-*-+('(

kaf 3B)'0 -/
*)D,-+('(
@'BDB/1.2 D(,./,
+3(0.F

5.':-V 2-D(,.2
kj<*C
LB <.':-<(D
<3(/1. -/ RS3'
\+'-*-^ B' af3'
\*)D,-^

%55 -0 (/(D1.0-(

%(/(1. E-,3 '.0,
(/2 0.2(,-B/
A,(1. a Z #<,-:.
+3(0. \6-D(,-B/^
5.':-<(D
+'.+('(,-B/ ;B'
2-D(,-B/=

4.1-/0 E-,3
(<<.D.'(,-B/ B;
<.':-<(D 2-D(,-B/=

7/20 (, aS<*
2-D(,-B/=

"(+-2 <.':-<(D
2-D(,-B/
ha=R<*J3'
\+'-*-+('(^=

ha=e<*J3'
\*)D,-+('(^
#<,-:. @3(0.
+'BDB/1 B' (''.0,F

5.':-V 2-D(,.2 %
j<*

@'BDB/1(,-B/F
<.':-<(D 2-D(,-B/
B; ka=R<*J3'
\+'-*-^ B'
ka=e<*J3'
\*)D,-^

5()0.F +(00./1.'
(N/B'*(D-,9

%1*,F
>; 39+B,B/-<
<B/,'(<,-B/F >M
BV9,B<-/
>; 39+.',B/-<
<B/,'(<,-B/F
*B'+3-/.
0.2(,-B/
>; (2._)(,.
<B/,'(<,-B/0 2B
.*.'1./<9 5Y

0.<,-B/
A,(1. R Z 6.0<./, 4.1-/0 E3./
aS<* 2-D(,.2=

7/20 E3./ N(N9
-0 2.D-:.'.2
kR3' -; +'-*-
ka 3' -; *)D,-
#22-,-B/(D 3B)' -;
1-:./ .+-2)'(D
A.<B/2 0,(1.
(''.0,F
K(-D)'. ,B 2.D-:.'
E-,3-/ R3'\@^ B'
a3'\%^
5()0.F
(N/B'*(D-,9 E-,3
+(00./1.'C +.D:-0C
B' +BE.'
%1*,F
K.,(D 3.(2 /B,
./1(1.2 \2B
.*.'1./<9 5Y
0.<,-B/^
K.,(D 3.(2
./1(1.2 \;B'<.+0
B' :(<))*
.V,'(<,-B/^
A,(1. j Z
7V+)D0-B/
4.1-/0 E-,3 N(N9
2.D-:.'9 (/2 ./20
E-,3 +D(<./,(D
2.D-:.'9
kjS *-/),.0 @'BDB/1.2 0,(1. -;
+D(<./,( ,(Q.0
DB/1.' ,3(/ jS
*-/),.0 ,B
2.D-:.'=
%1*,F >M
BV9,B<-/C *(/)(D
'.*B:(D=
O90,.'.<,B*9 -;
,3.0. ;(-D=











@'BDB/1(,-B/ 6-0B'2.'0
Bystocia can be uiviueu into piolongeu latent phase anu piolongeu active phase
1. Piolongeu latent phase
Latent phase >2uhi in piimigiaviu oi >14hi in multigiaviu
Nay be uue to ineffective uteiine contiactions, uispiopoition between pelvis
anu fetus, anu even excessive anesthesia


2. Piolongeu active phase
Consiueieu piolongeu when it lasts >12hi anuoi the iate of ceivical uilation
is <1.2cmhi in a piimigiaviu oi <1.Scmhi in multigiaviu.
Nay be uue to excessive anesthesia, ineffective contiactions, uispiopoition
between pelvis anu fetus, fetal malposition, iuptuie of membianes befoie
onset of active laboi
This can inciease the iisk of intiauteiine infection anu incieaseu neeu foi C-
section

#''.0, 6-0B'2.'0
An aiiest uisoiuei occuis when ceivical uilation ceases uuiing the active phase foi %
2hi. Nost commonly uue to eithei cephalopelvic uispiopoition oi ineffective
contiaction of the uteius.

%(/(1.*./, B; #N/B'*(D H(NB'
B#4&2 "%.=;,"&% = stimulation of uteiine contiactions befoie spontaneous onset of
laboi
@=$+*%,#,"&% &6 7#4&2 = stimulation of uteiine contiactions that began
spontaneously but have since become infiequent, weak, oi both
>%.=;,"&% ,2"#7 ! shoulu be attempteu only if ceivix is piepaieu oi "iipe". Ceivical
iipening via piostaglanuin E2 gel.


>%.";#,"&%' 6&2 "%.=;,"&%8
Suspecteu fetal compiomise
Fetal ueath
Piegnancy inuuceu hypeitension
Past uate piegnancy

Nateinal meuical complication
Piematuie iuptuie of membianes (PR0N)

3&%,2#"%.";#,"&%' 6&2 "%.=;,"&%8
Placenta pievia
Active genital heipes
Coiu piesentation
Abnoimal fetal lie

O"'9' &6 02&7&%$*. 7#4&28
Infection
Exhaustion
Laceiations
0teiine atony with hemoiihage



@B0,+(',)* O.*B''3(1.
60+;)(+ !0$(=<
The most common cause of excessive postpaitum bleeuing
)#%#$*+*%,:
0teiine massage anu uteiotonic agents (oxytocin, methyleigonovine)

O,'+;,0)$(: Nanagement with suigical iepaii


M+0,)(+. 8#,'+(0,<
Tieatment involves manual iemoval oi uteiine cuiettage
Placenta accietaincietapeicieta is the uiagnosis if the exam shows
placental villi infiltiation
Bysteiectomy may be neeueu to contiol intiactable bleeuing


R4:: Nost commonly associateu with placental abiuption, seveie pieeclampsia,
amniotic fluiu embolism, oi piolongeu ietention of a ueau fetus.

60+;)(+ 4(?+;%)$(<
Suspect if a beefy-appeaiing bleeuing mass in the vagina anu failuie to
palpate the uteius.
Nanage with uteiine ieplacement followeu by Iv oxytocin

6;)(,;= M+0+(0)$(<
Nay occui with hypotonic blauuei
Resiuual volume >2Suml iequiies bethanecol
If bethanecol fails manage with uiinaiy catheteiization foi 2-S uays


@'.*(,)'. ")+,)'. B; %.*N'(/.0 \@"?%^
Ruptuie of choiioamniotic membiane befoie the onset of laboi
0ccuis in 1u%-1S% of all piegnancies
Laboi usually follows in 9u% of patients within 24his
PR0N at & 26 wks of gestation is associateu with pulmonaiy hypoplasia
!"#$%&'"%$:
Peifoim vaginal exam with testing of non-bloouy fluiu
Nitiazine test: tests pB
Fein test: amniotic fluiu placeu on sliue, looking foi bianching fein leaf
pattein when sliue uiies
0S confiims uiagnosis: finus oligohyuiamnios
12*#,+*%,:
If an intiauteiine infection is suspecteu, give bioau-spectium antibiotics,
otheiwise tieat as a pieteim laboi.




@B0,+(',)* 5B/,'(<.+,-B/
F2*#',6**."%$:
Bieastfeeuing pioviues contiaception foi S months because of tempoiaiy
anovulation
3&+4"%*. *',2&$*%D02&$*',"% 6&2+=7#,"&%'8
0CP, patch, oi vaginal iing
Not staiteu until S weeks postpaitum to pievent hypeicaogulable state anu
iisk BvT
Not useu in bieastfeeuing women because they uiminish lactation
!"#052#$+ #%.V&2 >R! 07#;*+*%,8
Befeiieu until 6 weeks post-paitum
E2&$*',"% ;&%,2#;*0,"&%8
Nini-pill, Bepo-Pioveia
Can be safely useu while bieastfeeuing anu staiteu immeuiately aftei
piegnancy

@B0,Y+(',)* K.:.'
@B0,+(',)* 6(9 r %B0, D-Q.D9 2-(1/B0-0
S #,.D.<,(0-0

a $!>

RYj 7/2B*.,'-,-0

fYe IB)/2 -/;.<,-B/

eYq A.+,-< ,3'B*NB+3D.N-,-0

mYRa >/;.<,-B)0 *(0,-,-0






@.'-/(,(D >/;.<,-B/0

a= G'B)+ 4 #YO.*BD9,-< A,'.+,B<B<<- \G4A^

Su% of women have asymptomatic vaginal colonization with uBS
veitical tiansmission can cause pneumonia anu sepsis of the neonate
within houis of biith
Noitality iate is as high as Su%
12*#,+*%,8
Intiapaitum Iv penicillin u
In patient with PCN alleigy, use Iv clinuamycin, eiythiomycin, oi cefazolin


R= !BVB+D(0*B0-0

Causeu by Toxoplasma gonuii paiasite
Is most commonly causeu by the hanuling of cat feces anuoi littei uuiing
piegnancy
Nay be causeu by uiinking iaw goat milk oi eating iaw meat
veitical tiansmission will only occui with piimaiy infection of the mothei
Nost seiious infection iesults fiom infection in the fiist tiimestei
-/+0,&+':
Nost common piesentation is a mononucleosis-type synuiome + the
piesence of a cat in the householu
0n 0S, theie may be intiauteiine giowth ietaiuation
I3./ ('. (/,-N-B,-<0 1-:./s
1. When uBS (+) uiine, ceivical,
oi vaginal cultuie at any time
in piegnancy.
2. Piesence of high-iisk factois
such as:
Piolongeu PR0N
Pieteim ueliveiy
Piesence of mateinal fevei
Any pievious baby who
expeiienceu uBS sepsis
I3./ ('. (/,-N-B,-<0 /B, 1-:./s
1. With planneu C-section, when
theie is no iuptuie of
membianes.
2. Cultuie (-) in this piegnancy
but with (+) cultuie in pievious
piegnancy


E2*G*%,"&%:
Avoiu hanuling cat feces, iaw goat milk, anu
unueicookeu meat
If infecteu, mothei shoulu take spiiamycin to
pievent veitical tiansmission
12*#,+*%,:
Aftei seiologic confiimation, give pyiimethamine
anu sulfauiazine.

j= M('-<.DD(

Piimaiy vaiicella infection in mothei causes tiansplacental infection 2S%-
4u% of the time.
uieatest iisk to fetus is poseu if a iash appeais in the mothei fiom S uays
antepaitum anu 2 uays postpaitum.
A neonatal infection piesents with limb hypoplasia, miciocephaly,
miciophthalmia, choiioietinitis, cataiacts, anu "zigzag" skin lesions
E2*G*%,"%$ L#2";*77# "%6*;,"&%8
Non-piegnant women shoulu ieceive vaccination
Post-exposuie piophylaxis within 96his of exposuie with vZv
immunoglobulin
12*#,+*%,:
Nateinal vaiicella - anti-vaiicella antibouies to mothei anu neonate
Congenital vaiicella - anti-vaiicella antibouies + Iv acyclovii to neonate

f= ")N.DD(

veitical tiansmission occuis up to 7u%-9u% of the time with piimaiy
infection
Neonate may piesent with congenital ueafness, PBA, cataiacts, mental
ietaiuation, hepatosplenomegaly, thiombocytopenia, anu a bluebeiiy muffin
type iash.
Auveise effects occui within fiist 1u weeks


5D(00-< <B/1./-,(D ,'-(2F
a= O92'B<.+3(D)0
R= >/,'(<'(/-(D
<(D<-;-<(,-B/0
j= 53B'-B'.,-/-,-0

E2*G*%,"&%:
Peifoim a fiist tiimestei scieening
Bave mothei avoiu any infecteu inuiviuuals
Immunize seionegative women aftei
ueliveiy
** Theie is no post-exposuie piophylaxis available


e= 59,B*.1(DB:-')0 \5%M^

Is the most common congenital viius in the 0SA.
CNv is the most common cause of sensoiineuial ueafness in chiluien
CNv is spieau by bouy fluiu secietions
Nost infections piouuce a mononucleosis-like synuiome
Appioximately 1u% of infants aie symptomatic at biith
-/+0,&+' "% %*&%#,*8
I0uR
Piematuiity
Niciocephaly
}aunuice
Petechiae
Bepatosplenomegaly
Peiiventiiculai calcifications
Choiioietinitis
Pneumonitis
!"#$%&'"%$ 3)L8
viial cultuie within 2 weeks of biith
PCR
E2*G*%,"&%:
0niveisal piecautions with avoiuance of bouy fluius
Avoiu tiansfusion with CNv-positive bloou
12*#,+*%,:
uanciclovii (pievents heaiing loss but uoes not cuie infection)


"$47HH#:
"Bluebeiiy Nuffin" iash
Beafness
PBA
Cataiacts
Retaiuation
Bepatosplenomegaly
Thiombocytopenia
CNv
I0uR
Piematuiity
Niciocephaly
}aunuice
Bepatosplenomegaly
Petechiae
Peiiventiiculai
calcifications
Choiioietinitis
Pneumonitis

q= O.'+.0 A-*+D.V M-')0 \OAM^

Contact with lesions is the most common cause
of tiansmission
uieatest iisk of infection in the S
iu
tiimestei
Su% iisk of tiansplacental infection with
piimaiy infection
-/+0,&+'F
Fevei + malaise + uiffuse genital lesions
If infant suivives, they may uevelop meningoencephalitis, mental ietaiuation,
pneumonia, hepatosplenomegaly, jaunuice, anu petechiae.
!"#$%&'"'F
\i^ BSv cultuie fiom vesicle fluiu oi ulcei oi BSv PCR of mateinal bloou
Pievention
A C-section is manuatoiy if mothei has active genital BSv lesions at time of
laboi.
It is contiainuicateu to use fetal scalp electioues foi monitoiing; they
inciease iisk of BSv tiansmission.
Avoiu stanuaiu piecautions such as sex with outbieak
12*#,+*%,:
Acyclovii foi piimaiy infection uuiing piegnancy

m= O>M

The majoi ioute of veitical tiansmission is contact with infecteu genital
secietions at time of vaginal ueliveiy.
Without tieatment veitical tiansmission iate is 2S%-Su%
Elective C-section is most beneficial in women with low CB4+ counts anu
high RNA viial loaus (>1uuu).
All neonates of BIv + motheis will test positive uue to the tiansplacental
passage of Igu
E2*G*%,"&% #%. 12*#,+*%,8
Tiiple-uiug theiapy staiting at 14 weeks anu continuing thioughout the
piegnancy.
Iv intiapaitum ziuovuuine (AZT)
uive infant oial ziuovuuine foi 6 weeks post-ueliveiy
# /.B/(,(D
-/;.<,-B/ (<_)-'.2
2)'-/1 2.D-:.'9 3(0
( eSt *B',(D-,9
'(,.=

Piophylax infant foi PCP with TNP-SNX aftei the 6 weeks of ziuovuuine
theiapy
Scheuule a C-section at S8 weeks unless the viial loau is <1uuu viial
copiesml
Nothei cannot bieastfeeu because BIv passes thiough bieast milk
Avoiu all invasive pioceuuies such as aitificial R0N anu fetal scalp
electioues

g= A9+3-D-0

Tiansplacental infection is moie likely in piimaiy anu seconuaiy infection,
anu less likely in teitiaiy infection
I#27/D#;Z="2*. TP
',
,2"+*',*2U ;&%$*%",#7 '/05"7"' "%;7=.*' ,5* 6&77&:"%$ '/+0,&+'8
Byuiops fetalis
Naculopapulai oi vesiculai iash
Laige anu swollen placenta
Anemia, thiombocytopenia, anu hepatosplenomegaly
Theie is a Su% peiinatal moitality iate
B#,*D#;Z="2*. ;&%$*%",#7 '/05"7"' "' ."#$%&'*. #6,*2 Q /*#2' &6 #$*< "%;7=.*' ,5*
6&77&:"%$8
Butchinson teeth
"Sabei" shins
"Sauule" nose
Beafness (CN8 palsy)
"Nulbeiiy" molais
!"#$%&'"':
vBRL oi RPR scieen in fiist tiimestei
Confiim a positive test with FTA-ABS oi NBA-TP
12*#,+*%,:
Benzathine penicillin IN (1 time foi infecteu motheis)
If PCN alleigy: Besensitization followeu by full uose benzathing PCN


# 5Y0.<,-B/ <(//B,
+'.:./, :.',-<(D
,'(/0*-00-B/ B;
09+3-D-0= >, E-DD N.
,'(/0*-,,.2 ,3'B)13
,3. +D(<./,( N.;B'.
N-',3=
Aftei any (+) syphilis scieen, FTA-ABS oi NBA-TP is uone as confiimatoiy tests.

9. O.+(,-,-0 B
Neonatal infection fiom piimaiy infection in the S
iu
tiimestei oi ingestion of
infecteu genital secietions
8u% of infecteu neonates will uevelop chionic hepatitis
E2*G*%,"&%:
Bep B infection is not an inuication foi C-section
Avoiu invasive pioceuuies
Aftei neonate ieceives immunization anu hep B immunoglobulin, can be
bieastfeu
>++=%"J#,"&%:
BBsAg-negative - give active immunization uuiing piegnancy
Postexposuie piophylaxis foi the mothei - BBIu
12*#,+*%,:
Bepatitis immunization + BBIu in neonate
Chionic BBv can be tieateu with inteifeion oi lamivuuine

5B/,'(-/2-<(,-B/0 ,B N'.(0,;..2-/1
BIv
Active TB
Bep B (befoie infant is immunizeu)
BSv
Biug usemeuications
Biugs of abuse (except cigaiettes, alcohol)
Cytotoxic meuications
Conuitions of infant that CI bieast milk
BTLv-1










Chapter 3

Gynecology









4./-1/ G9/.<BDB19

!3. %./0,')(D 59<D.F
At biith, theie aie appioximately 1 million piimoiuial follicles in the ovaiy,
each with an oocyte that is aiiesteu in the piophase stage of meiosis.
The piocess of ovulation signals the onset of pubeity, which signals folliculai
matuiation.
0vulation occuis, anu the uominant follicle becomes the coipus luteum,
which secietes piogesteione to piepaie the enuometiium foi possible
implantation.
If the ovum is not feitilizeu, the coipus luteum unueigoes involution, which
causes menstiuation.
The cycle is iegulateu by hypothalamic gonauotiopin-ieleasing hoimone,
pituitaiy ielease of follicle-stimulating hoimones (FSB), luteinizing
hoimones (LB), anu the ovaiian sex steioius estiauiol anu piogesteione.
An " oi ! in any of these hoimones can cause uysfunction of the noimal
menstiual cycle.

This giaph uemonstiates the piocess of all thiee phases of the menstiual cycle,
which hoimones aie in play, the uevelopment of the egg, anu the uays that
coiiesponu to all events

KBDD-<)D('J@'BD-;.'(,-:.
@3(0.
?:)D(,B'9 @3(0. H),.(DJA.<'.,B'9 @3(0.
Bay 1-1S Bay 1S-17 Bay 1S - Bay 1 of menses
Estiauiol-inuuceu
negative feeuback on FSB
anu positive feeuback on
LB in anteiioi pituitaiy
leaus to LB suige on uays
11-1S.
Bominant follicle
secietion of estiauiol
leaus to positive feeuback
to anteiioi pituitaiy FSB
anu LB, ovulation will
occui within Su-S6his
aftei LB suige, small FSB
suige also occuis at time
of LB suige.
Naikeu by change fiom
estiauiol to piogesteione
pieuominance, coipus
luteal piogesteione acts
on hypothalamus, causing
negative feeuback on FSB
anu LB, iesulting in
uecieaseu basal levels
piioi to next cycle, if
feitilization anu
implantation uo not occui
theie will be a iapiu
ueciease in piogesteione.


5B/,'(<.+,-B/:
0ial contiaceptives that combine piogestin anu estiogen
Estiogen suppiesses FSB, which pievents selection anu matuiation of a
uominant follicle.
Piogestin woiks by suppiessing LB, which inhibits ovulation. It also thickens
ceivical mucosa, which fuithei pievents the ability of semen to pass into the
uteius.
Togethei, they inhibit piegnancy by thinning the enuometiial lining anu
iesulting in light oi misses menses.
Phasic vs. Nonophasic Pills:
Phasic pills vaiy the iatio of estiogen anu piogestin. This uecieases the uose
of hoimone given but it incieases the iisk of bieakthiough bleeuing
Nonophasic pills uelivei a constant uose of estiogen anu piogestin
thioughout the month
** Following cessation of 0CP's, feitilization usually iesumes immeuiately. A small
peicentage of useis will expeiience a peiiou of infeitility, known as "postpill
amenoiihea"




#2:(/,(1.0 (/2 6-0(2:(/,(1.0 B; ?5@80
#6M#L!#G7A 6>A#6M#L!#G7A
Reliable with failuie iate of <1%
Piotective against ovaiian anu
enuometiial cancei
Becieases inciuence of PIB anu
ectopic piegnancies
Nakes menses moie pieuictable
anu less painfullightei.
Nust be taken uaily close to the
same time
No STB piotection
0p to Su% bieakthiough bleeuing
Nay cause uepiession, weight
gain, hypeitension, acne, bloating,
anu weight gain

#D,.'/(,-:.0 ,B ?5@80
Piogestin-only pills ! "mini-pills"
Bepo-Pioveia ! IN injection lasts foi 14 weeks
Noiplant ! subcutaneous implant lasts up to S yeais
Intiauteiine uevice ! uevice left in place foi seveial yeais
Emeigency Contiaception ! piogestinestiogen taken within 72hi
@(+ A*.('F
Begin within S yeais of onset of sexual activity 0R age 18 yeais (whichevei
comes fiist).
When S annual pap smeais in a iow aie negative, can uo eveiy 2 yeais until
age 7u.
Patients with 1 sexual paitnei, S consecutive noimal pap smeais, anu onset
of sexual activity aftei age 2S can be scieeneu less fiequently.

E#0 -+*#2 37#''"6";#,"&%'8
1. >/,.'*.2-(,. 0*.(': Atypical squamous cells of unueteimineu significance
(ASC0S)

R= #N/B'*(D 0*.('0F
Low giaue squamous intiaepithelial lesions (LSIL): BPv, milu uysplasia, oi
caicinoma in situ 1 (CIS1)
Bigh giaue squamous intiaepithelial lesions (BSIL): moueiate uysplasia,
seveie uysplasia, CIS, CIN 2 oi CIN S
Cancei: invasive canceis




IB'Q)+ B; (/ (N/B'*(D @(+

A,.+ -/ ,3. IB'Q)+ I3./ -0 ,3-0 0,.+
E(''(/,.2
L.V, A,.+ -/
*(/(1.*./,
".+.(,.2 @#@ #;,.' ;-'0, #A5$A ;-/2 ".+.(, .:.'9 fYq
*B/,30 )/,-D ,3.'. ('. R
<B/0.<),-:. /.1(,-:.
@(+ 0*.('0
O@M 6L# ,.0,-/1 #;,.' ;-'0, #A5$A -0
;B)/2
>; O@M aq B' ag
-2./,-;-.2 +.';B'*
<BD+B0<B+9
5BD+B0<B+9 (/2
.<,B<.':-<(D N-B+09
#N/B'*(D @(+ 0*.('
!EB #A5$A @(+ 0*.('0
5BD+B0<B+9C
#N/B'*(D D.0-B/0 0./,
;B' <9,BDB19
7/2B<.':-<(D <)'.,,(1.
\755^
#DD /B/Y+'.1/(/,
+(,-./,0 03BE-/1 (/
(N/B'*(D @(+ 0*.('0
LB/Y+'.1/(/, +,0
)/2.'1B-/1 <BD+B0<B+9
;B' (N/B'*(D @(+
'._)-'. 755 ,B ')D. B),
./2B<.':-<(D D.0-B/0
5B/. 4-B+09 I3./ @(+ 0*.(' -0
EB'0. ,3(/ N-B+09
0)11.0,.2C
I3./ 755 -0 (N/B'*(DC
I-,3 ./2B<.':-<(D
D.0-B/C
I3./ N-B+09 03BE0
*-<'B-/:(0-:.
<('<-/B*( B; <.':-V



%(/(1.*./, B; (N/B'*(D 3-0,BDB19
A,.+ -/ %(/(1.*./, 5B/2-,-B/ E(''(/,-/1
,3-0 0,.+
LB,.0J6.,(-D0
?N0.':. (/2 ;BDDBEY)+ 5>LaC 5>L R B' j (;,.'
.V<-0-B/ B' (ND(,-B/
KBDDBEY)+ ,.0,0 _fYq
*B/,30 ;B' R 9.('0
#ND(,-B/ 5>LR B' 5>Lj !3-0 -0F <'9B,3.'(+9C
D(0.' :(+B'-T(,-B/C
.D.<,'B;)D1)'(,-B/
7V<-0-B/(D +'B<.2)'.0 5>LR B' 5>Lj H77@ (/2 5BD2YQ/-;.
<BDB/-T(,-B/
O90,.'.<,B*9 ".<)''./, 5>LRJj


M(1-/-,-0
The most common piesenting symptom is uischaige
Always iule out chemical oi alleigic causes
Su% of cases aie uue to uaiuneiella
2S% uue to Tiichomonas
2S% uue to Canuiua
Biffeientiating between the uiffeient causes of vaginitis
5(/2-2( !'-<3B*B/(0 G('2/.'.DD(
M(1-/(D +O 4-S >6 >S
?2B' N0NE RANCIB "Fishy" on K0B
6-0<3('1. Cottage Cheese-
like
uieen, fiothy vaiiable
A-JAV Itching, buining,
swollen
Seveie itching vaiiable, none
%-<'B0<B+9 Pseuuohyphae Notile 0iganisms Clue cells
!'.(,*./, Fluconazole Netioniuazole Netioniuazole

5(/2-2( #DN-<(/0 Z /B,. ,3. +0.)2B39+3(.









!'-<3B*B/(0 Z %B,-D. ?'1(/-0*0


G('2/.'.DD( Z 5D). 5.DD0 \D('1. .+-,3.D-(D <.DD0 <B:.'.2 E-,3 0*(DD N(<,.'-(^



7/2B*.,'-B0-0
Enuometiial tissue outsiue of the uteius, most commonly founu in the
ovaiies.
Affects appioximately 1%-2% of women
Appioximately Su% of infeitile women have enuometiiosis
-"$%' [ -/+0,&+'8
The S B's ! Byspaieunia, Bysmenoiihea, Byschezia
Nay also have pelvic pain, infeitility, pain on iectovaginal exam.


!"#$%&'"':
visualization via lapaioscopy oi lapaiotomy with histological confiimation.
12*#,+*%,':
1. NSAIB's fiist
2. 0CP's
S. Testosteione (Banazol - AE: hiisutism, acne)
4. unRB analog (gives best iesult but causes menopausal symptoms within S-6
months)
Recuiience aftei cessation of meuical tieatment is common, uefinitive tieatment is
hysteiectomy.

















".+'B2)<,-:. 7/2B<'-/BDB19

#*./B''3.(
Piimaiy ! woman has nevei menstiuateu
Seconuaiy ! menstiual ageu woman who has not menstiuateu in 6 months
Nost common cause of amenoiihea is piegnancy
Eveiy evaluation must by excluuing piegnancy (uiine #-hCu)
The most common cause of seconuaiy amenoiihea is Asheiman's synuiome
(scaiiing of the uteiine cavity aftei B&C)
Bypothalamic ueficiency is a cause of amenoiihea (excessive weight loss,
excessive exeicise, psychogenic, uiug use)
Pituitaiy uysfunction: fiom ! hypothalamic pulsatile ielease of unRB oi !
pituitaiy ielease of FSB oi LB
WG#2"#% ./'6=%;,"&%8
Follicles aie exhausteu of FSB anuoi LB 0R aie iesistant to stimulation
3#='*':
Inheiiteu uisoiueis such as Tuinei's synuiome
Piematuie menopause
Autoimmune ovaiian failuie
Chemotheiapies
Tieatment:
If hypothalamic ! tieat unueilying cause anu inuuce ovulation with
gonauotiopins
Tumois ! Biomociiptine to shiink tumoi anuoi excision
uenital tiact obstiuction ! suigeiy
0vaiian uysfunction ! Exogenous estiogen ieplacement

V$/ 0$ .)&&+;+(0),0+ -+0/++( @+($>,*%+ ,(. !%1+;2,(G% %=(.;$2+Z
! An ultiasounu will help visualize the piesence oi absence of follicle. Asheiman's
synuiome will have follicles while menopause will lack the piesence of follicles.







V=>$01,#,2)' :,*%+%: Stiess, Anxiety, Anoiexia, Anu Excessive Exeicise
8)0*)0,;= :,*%+%: Auenoma
5?,;),( :,*%+%< Eaily menopause, iesistant ovaiy synuiome
3(.$2+0;),# :,*%+%: Asheiman's synuiome

#N/B'*(D ND..2-/1 -/ ( '.+'B2)<,-:. (1. EB*(/
With the piesence of abnoimal bleeuing, fiist thing is to iule out "PAB:
P! piegnancy
A! anatomical abnoimalities
B! uysfunctional uteiine bleeuing

690;)/<,-B/(D $,.'-/. 4D..2-/1 \6$4^F
Anatomic menstiuation without anatomic lesions of the uteius
Is most commonly uue to chionic estiogen stimulation
Abnoimal bleeuing is uefineu as bleeuing at inteivals <21 uays oi >S6 uays,
lasting >7 uays, oi bloou volume loss >8uml
!"#$%&'"':
R0 anatomic causes (fibioius, ceivical oi vaginal lesions, infections, ceivical
anuoi enuometiial cancei)
Evaluate factois that can affect the hypothalamus-pituitaiy axis (stiess,
excessive exeicise, weight changes, systemic uisease, coagulopathies,
piegnancies)
12*#,+*%,:
uive piogesteione fiom uay 14-2S of menstiual cycle
Biith contiol pills aie an alteinative

O-'0),-0* (/2 M-'-D-T(,-B/
?"2'=,"'+ ! excessive bouy haii usually uue to polycystic ovaiies oi auienal
hypeiplasia
L"2"7"J#,"&% ! masculinization, associateu with maikeu " in testosteione, male
pattein baluing, voice ueepening, clitoiomegaly, bieast involution.






6-;;.'./,-(,-/1 <()0.0 B; O-'0),-0* (/2 M-'-D-T(,-B/
6-0.(0. 53('(<,.'-0,-<0 !'.(,*./,
@BD9<90,-< ?:('-(/
6-0.(0.
!3. ra <()0. B;
(/2'B1./ .V<.00 (/2
3-'0),-0*=

Relateu to LB
oveipiouuction.

SiSx: amenoiihea oi
oligomenoiihea,
infeitility, hiisutism, acne.

Anemia

Labs show: " LBFSB, anu
" testosteione.
0CP's to ! LB piouuction
(via feeuback changes).

Weight loss.

Clomiphene may be
piesciibeu to inuuce
ovulation.
A.',BD-YH.92-1 5.DD
!)*B'
Is an ovaiian tumoi that
secietes testosteione
(women 2u-4u).

SiSx: iapiu onset of
hiisutism, acne,
amenoiihea, viiilization.

Labs: !LBFSB,
"""Testosteione.
Remove affecteu ovaiy
5B/1./-,(D #2'./(D
O9+.'+D(0-(
NC uue to 21-$
hyuioxylase uefect.

AR pattein.

Seveie will cause
viiilization of newboin,
while miluei foims can
piesent at pubeity oi
latei.

" LBFSB, " BBEA (BBEA
helps ueteimine auienal
souice).
ulucocoiticoius can
suppiess auienal
anuiogen piouuction.




%./B+()0.
The cessation of menses occuis on aveiage at S1yi of age.
Cycles no longei associateu with pie-menstiual symptoms, no longei iegulai
oi pieuictable.
-"$%' #%. '/+0,&+'8
Acute onset of hot-flashessweating that cease acutely (within S-S minutes)
Noou uistuibances
Sleep uistuibances
vaginal uiyness (leaus to uyspaieunia)
0steopoiosis
!"#$%&'"':
Iiiegulai menstiual cycles aie most obvious foi uiagnosis
Piesence of hot flashes suggest menopause
" levels of FSB (>SumI0ml)
12*#,+*%,:
1
st
line tieatment is estiogen ieplacement theiapy (continuous estiogen with
cyclic piogestin to allow withuiawal bleeuing oi uaily aumin of both estiogen
anu piogestin, which wont cause wu bleeuing).
Raloxifene: a 2
nu
geneiation tamoxifen-like uiug (mixeu estiogen
agonistantagonist). Shown to pievent osteopoiosis, uecieases LBL,
uecieases iisk of bieast cancei.
Calcium supplementation is not a substitute foi estiogen ieplacement

>/;.',-D-,9
Befineu as 1yi of fiequent, unpiotecteu inteicouise without piegnancy.
6u% female cause, 4u% male cause
?&: ,& #002&#;5 "%6*2,"7",/8
a
0,
A,.+: Semen Analysis (volume, motility, # active speim)
If this is founu to be abnoimal, attempt Intiauteiine Insemination (I0I) oi
Intiacytoplastic Speim Injection (ICSI)
If semen analysis is noimal, consiuei female factois.


R
/2
A,.+: Test ceivical mucus to see if it softens (uone aiounu time of ovulation -
known as "spinnbaikeit".
V$/ 0$ 0+%0<
Patient comes in aftei inteicouise
With help of speculum get enuoceivical mucus
Put mucus on a glass sliue anu covei with anothei sliue
Attempt to pull sliues apait (shoulu be able to sepaiate at least 6cm befoie
mucus bieaks - which inuicates soft anu favoiable mucus)
If sliue bieaks too eaily, mucus is "hostile"
Also want to check foi "mucus feining" on micioscopy

V$/ 0$ 0;+,0 1$%0)#+ 2*'*%< >/,'( $,.'-/. >/0.*-/(,-B/ \>$>^
Peifoim by inseiting a cathetei into the ceivix anu inject speim past the
mucus plug
!($01+; %$#*0)$(< uive estiogen eaily in the cycle (softens mucus)

Next: If Speim is 0K anu Nucus is 0K..
j
'2
A,.+F Check 0vulation
Check basal bouy tempeiatuie (" 1ueg uue to piogesteione spike)
A sign of piegnancy is the lack of bouy tempeiatuie iising
Bo an enuometiial biopsy
Bay 22 is the highest uay of seium piogesteione
LB suige - theie aie stiips that can measuie LB, if + patient will ovulate
within 24-48his
If you finu a pioblem with ovulation, give feitility uiugs.

12*#,+*%,:
a
0,
! 5H?%>6 (fools the pituitaiy into secieting lots of FSB anu LB)
0R
R
/2
! @7"G#L?H (concentiateu amounts of FSB anu LB fiom uiine of menopausal
women).


** 0se CL0NIB fiist, it has a lowei iate of multiple gestation anu lowei iisk of
"ovaiian hypeistimulation synuiome". With PERuAN0L, theie is a 2u% multi-
gestation iisk.

If semen is noimal.
If mucus is noimal.
If ovulation is noimal.
L7c! A!7@: Look foi tubal factois (blockage uue to PIB) - histoiy of chionic pain,
T0A, ectopic piegnancy, infeitility
@.';B'*: Bysteio-Salpingogiam to help uiagnose a blockage
IF theie is a tubal pioblem, theie aie 2 choices:
1. Tuboplasty (cuts out the obstiuction)
2. In vitio Feitilization (uone in a lab, then put zygote into uteius)

>% L",2& C*2,"7"J#,"&% T>LCU8
Puts 4 zygotes into the uteius
Putting <4 = low piegnancy iate
Putting >4 = " iisk of multiple gestation
IvF has a 6u% piegnancy iate

Last thing to uo in the infeitility woikup is H(+('B0<B+9 (checking foi
enuometiiosis).
! 2u%-2S% of those with unexplaineu infeitility actually have enuometiiosis.
** If eveiything is noimal, uiagnosis is "unexplaineu infeitility"
BATA shows that Su% of people with infeitility will get piegnant within 4-S yeais.





#/2'B1./ >/0./0-,-:-,9
A uiagnosis maue when theie is an absence of pubic oi axillaiy haii.
Kaiyotype ieveals a male genotype (XY), anu 0S ieveals testicles.
Testes piouuce noimal levels of both male anu female hoimones, ie. Estiogen
anu testosteione.
)#%#$*+*%,:
Removal of testes befoie 2uyi of age uue to incieaseu iisk of testiculai cancei. Aftei
iemoval patient will iequiie life-long estiogen ieplacement.

GB/(2(D 6901./.0-0 \!)'/.'80 09/2'B*.^
Absence of seconuaiy sexual chaiacteiistics
Kaiyotype ieveals the absence of one of the X chiomosomes (4S, X).
Elevateu FSB
Lack of a seconu X chiomosome leaus to lack of ovaiian follicle uevelopment,
leauing to "stieak gonaus".
)#%#$*+*%,:
Estiogen anu piogesteione ieplacement to help uevelopment of seconuaiy sexual
chaiacteiistics.












$'B19/.<BDB19


@.D:-< ".D(V(,-B/8 )&', ;&++&%7/ ;#='*' ,5* 6&77&:"%$8
P\ R,*2"%* E2&7#0'*
Q\ 3/',&;*7* T47#..*2 02&7#0'* "%,& G#$"%#U
Y\ O*;,&;*7* T2*;,#7 02&7#0'* "%,& G#$"%#U

60+;)(+ 8;$#,>%+<
0ccuis when ligaments (suspensaiy) ligaments can no longei suppoit it
Nost common cause is chilubiith
-"$%' [ -/+0,&+'8
vaginal piessuie sensation
vaginal fullness
Low back pain
** Can cause cystocele anu iectocele

Begiees of piolapse:
1
st
uegiee ! piolapse is above intioitus
2
nu
uegiee ! goes to the intioitus
S
iu
uegiee ! goes past intioitus

:=%0$'+#+:
Blauuei piolapse into the vagina uue to excessive pelvic ielaxation
Seveie cases can cause stiess incontinence
Q ,/0*' &6 "%;&%,"%*%;*8
1. Stiess Incontinence ! the most common type (causeu by pelvic flooi
injuiies)

2. Neuiogenic Incontinence ! uigeoveiflow incontinence (causeu by !
inneivation anu contiol of blauuei function, iesulting in involuntaiy blauuei
contiaction (uiges) oi blauuei atony (oveiflow).


1*',"%$ 6&2 ',2*'' "%;&%,"%*%;*8
1. Bo a pelvic exam - if you see piolapse this suggests stiess incontinence
2. Q-tip test - inseit a Q-tip into uiethia anu have the pt cough. If it iotates
>Suuegiees, pt has stiess incontinence.
** If patient uesciibes an "uige" anuoi "fiequency" foi uiination, it is suggestive of
neuiogenic incontinence

12*#,+*%,':
Stiess Incontinence ! 1
st
- attempt kegel exeicises, 2
nu
- suigeiy (colpoiaphy)
Neuiogenic ! Anti-spasmotics, anti-cholineigics

501+; ',*%+% $& *;)(,;= )('$(0)(+('+<
S*=2&0#,5"; ! causeu by heau injuiy, spinal injuiy, oi peiipheial neive injuiy.
Tieatment: cathetei, eithei inuwelling oi inteimittent
@%#,&+";#7 ! causeu by a vesicovaginal fistula. Tieatment: iepaii of uefect.









G9/.<BDB1-< ?/<BDB19

1. Enuometiial cancei
2. FibioiusLeiomyoma
S. Ceivical cancei
4. 0vaiian neoplasm's
S. vulvai anu vaginal cancei
6. uestational tiophoblastic neoplasia

7/2B*.,'-(D 5(/<.'F
Is the most common iepiouuctive tiact cancei with appioximately Su,uuu-
4u,uuu new cases each yeai.
Is an "estiogen-uepenuent" cancei

O"'9 6#;,&2'8
0nopposeu postmenopausal estiogen ieplacement theiapy
Nenopause aftei S2yi of age
0besity
Nullipaiity
PC0S
Biabetes
Chionic anovulation
-"$%' [ -/+0,&+'8
Abnoimal uteiine bleeuing, especially if woman is postmenopausal
All women >SSyi with abnoimal bleeuing iequiies an enuometiial sampling
foi histologic examination.
!"#$%&'"':
Pap smeai not ieliable
Bimanual exam foi masses, nouules, inuuiation, anu immobility
Enuometiial biopsy by enuoceivical cuiettage, B&C, hysteioscopy with uiiect
biopsies.
12*#,+*%,:
4& %)2>#+ $; '$2>#+Q 1=>+;>#,%), - give piogesteione to ieveise
hypeiplastic piocess piomoteu by estiogen (Pioveia foi 1u uays)

!0=>)',# 1=>+;>#,%), - hysteiectomy because of likelihoou that invasive
caicinoma will ensue
3(.$2+0;),# ',;')($2, ! Total abuominal hysteiectomy + bilateial
salpingo-oophoiectomy + lymph noue uissection, aujuvant exteinal-beam
iauiation, tieatment foi iecuiience is high-uose piogestin's.
E2&$%&'"':
Bistologic giaue is the most impoitant factoi in oveiall piognosis.
Bepth of myometiial invasion is 2
nu
most impoitant factoi in oveiall
piognosis
u1 - highly uiffeientiateu
u2 - moueiately uiffeientiateu
uS - soliu oi completely unuiffeientiateu
u1 tumoi that uoesn't invaue the myometiium has a 9S% S-yi suivival
uS tumoi with ueep myometiial invasion has ~2u% S-yi suivival


$,.'-/. H.-B*9B*(0 Y K-N'B-20
Fibioius aie benign tumois whose giowth is ielateu to the piouuction of
estiogen.
uiowth is often iapiu peiimenopausally
Su% of cases waiiant a hysteiectomy

-"$%' [ -/+0,&+'8
Nenoiihagia
Pelvic pain anu piessuie (misuiagnoseu as uysmenoiiheal)
Enlaigeu, fiim, asymmetiic, non-tenuei uteius
!"#$%&'"%$ C"42&".'8
0S initially, confiim with tissue sample by eithei B&C oi biopsy (especially in
postmenopausal women).
12*#,+*%,':
Nilu symptoms only iequiie ie-assuiance anu obseivation
Estiogen inhibitois such as unRB agonists can shiink the uteius, which help
to cieate a simplei suigical pioceuuie.

Suigeiy ! myomectomy iecommenueu in young patients who want to
pieseive feitility.
Bysteiectomy is uefinitive tieatment that shoulu be ieseiveu foi
symptomatic women who have no uesiie foi chiluien anuoi any moie
chiluien.

#2./B*9B0-0
Abnoimal location of enuometiial glanus anu stioma within the myometiium
of the uteiine wall
When symptomatic is causes uysmenoiiheal anu menoiihagia.
0teius feels soft, globulai, tenuei, anu symmetiical.
0nlike leiomyomas, theie is no change with high oi low estiogen states.

6-(1/B0-0 H.-B*9B*( #2./B*9B0-0
A9*+,B*0 Seconuaiy uysmenoiihea
anu menoiihagia.

(+) oi (-) symptoms of
blauuei, uietei, anuoi
iectal compiession
Seconuaiy uysmenoiihea
anu menoiihagia
@.D:-< 7V(* Asymmetiically enlaigeu,
fiim, N0NTENBER uteius.
Symmetiically enlaigeu,
soft, TENBER uteius.

Nay be tenuei
immeuiately befoie anu
uuiing menses
AB/B1'(* Laige intiamuial oi
subseiosal myomas
(saline infusion can help
visualize this)
Biffusely enlaigeu uteius
with cystic aieas within
myometiial wall
O90,.'B0<B+9 Biiect visualization of
tumois

O-0,BDB19 Is uefinitive uiagnosis Is uefinitive uiagnosis






H.-B*9B0('<B*(
A iaie cancei that accounts foi appioximately S% of uteiine canceis

-"$%' [ -/+0,&+'8
Saicoma ! postmenopausal bleeuing, pelvic pain, incieasing vaginal uischaige

12*#,+*%,:
Bysteiectomy with intiaopeitive LN biopsy
Suigical staging is an impoitant aspect
Aujunctive theiapies have minimal oveiall benefit
** 0nly Su% of patients suivive S yi


5.':-<(D 5(/<.'
The most impoitant scieening tool is the Pap smeai
The aveiage age of uiagnosis is between 4S-Suyi.
The most common uiagnosis is squamous cell caicinoma (8S%), the othei
1S% aie auenocaicinoma


!"#$%&'"':
Ceivical Biopsy! most commonly is SCC
Next step ! metastatic woikup (pelvic exam, CXR, Iv pyelogiam, cystoscopy, anu
sigmoiuoscopy).
** Imaging stuuies not iequiieu (invasive ceivical cancei is the only gynecological
cancei that uoes not get stageu clinically).
)#%#$*+*%,:
Nanagement is simple hysteiectomy oi mouifieu iauical hysteiectomy + LN
uissection. Suivival <4u% at Syi.

Aujuvant theiapy such as iauiation anu chemo is given when any of the
following conuitions aie piesent: Nets to LN's, tumoi >4cm, + maigins, local
iecuiience

?:('-(/ L.B+D(0*0
F*%"$% ;/','8
Functional giowth iesulting fiom failuie of noimal iuptuie of follicle
Benign tumois aie moie common than malignant tumois
Risk of malignancy incieases with age
-"$%' [ -/+0,&+'8
Pelvic painpiessuie
Acute anu seveie pain when cyst iuptuies
3&%6"2+ !"#$%&'"' ! With 0S

















4./-1/ L.B+D(0*0



L.B+D(0* 53('(<,.'-0,-<0 !'.(,*./,
7+-,3.D-(D 5.DD Seious cystauenoma is the
most common type.
0sually benign
(malignancy iisk incieases
when bilateial).

0theis: mucinous,
enuometiioiu, Biennei
tumoi (all iaiely
malignant).

Biagnose: Clinical CT oi
NRI
Excision
G.'* 5.DD Nost common type is
Teiatoma (aka ueimoiu
cyst).

Almost nevei malignant.

Contains tissues fiom all S
geim layeis.

0nilateial, cystic, mobile,
non-tenuei aunexal mass,
often asymptomatic.

Confiim uiagnosis with 0S
Excision to pievent
toision oi iuptuie of
ovaiy
A,'B*(D 5.DD Aie functional tumois
secieting hoimones.

uianulosa tumoi makes
estiogen (gynecomastia,
loss of bouy haii).

Seitoli-Leyuig makes
anuiogens (viiilization in
females)

Excision

)#7"$%#%, 1=+&2'8
Nost commonly seen in women > Suyi
0CP use is a piotective factoi
Seen in highei fiequency in women of low paiity, ! feitility, uelayeu
chilubeaiing
0sually asymptomatic until metastasis has occuiieu
Yeaily pelvic exams aie the most effective scieening tools
-"$%' [ -/+0,&+'8
vague abuominal pains
vague pelvic pains
Constipation, eaily satiety, abuominal uistention, uiinaiy fiequency
Tieatment:
Bebulking suigeiy + chemoiauiation
%(D-1/(/, L.B+D(0*0
Neoplasms Chaiacteiistics Tieatment
Epithelial Cell The cause of 9u% of all
ovaiian malignancies.

Seious
cystauenocaicinoma is the
most common type (often
uevelops fiom a benign
piecuisoi).
Excision
ueim Cell Is the most common
ovaiian cancei in women
<2uyi.

Piouuces hCu oi AFP,
which aie useful as tumoi
maikeis.

Subtypes incluue:
uysgeiminomas anu
immatuie teiatomas.
1
st
- Rauiation
2
nu
- Chemotheiapy
>8u% S-yi suivival
Stiomal Cell uianulosa cells make
estiogen (enuometiiosis).

Seitoli-Leyuiu cell tumoi
makes anuiogens
Total hysteiectomy +
oophoiectomy.


M)D:(' (/2 M(1-/(D 5(/<.'0
F*#?,; 4(0;,+>)01+#),# X+$>#,%), KF4XL<
vIN 1 & 2 ! chaiacteiizeu by milumoueiate uysplasia, " iisk of piogiessing to
auvanceu stages anu then caicinoma.
vIN S = caicinoma in situ
-"$%' [ -/+0,&+'8
Piuiitis
Piesence of iaiseu lesions
Iiiitation
!"#$%&'"':
Biopsy iequiieu foi a uefinitive uiagnosis
!"66*2*%,"#7 ."#$%&'"'8
Nalignant melanoma anu Paget's uisease
12*#,+*%,:
Foi vIN 1 anu 2 ! local excision
Foi vIN S ! wiue excision

F*#?,; :,('+;<
9u% aie squamous cell canceis
Nost often this piesents in postmenopausal women
-"$%' [ -/+0,&+'8
Piuiitis (may piesent with oi without an ulceiative lesion)
12*#,+*%,:
Excision
** Syi suivival iate ianges fiom 7u%-9u% uepenuing on LN involvement.
** With the piesence of ueep pelvic noues, suivival iate uiops to 2u%




F,A)(,# ',;')($2, )( %)0* ,(. ',;')($2,<
7u% of patients with vaginal CIS have pievious genital tiact neoplasm
12*#,+*%,:
Rauiation
Suigeiy ieseiveu foi extensive uisease


G.0,(,-B/(D !'B+3BND(0,-< 6-0.(0. \G!L^
An abnoimal piolifeiation of placental tissue that involves both the
cytotiophoblast anuoi syncytiotiophoblast.
Can be both benign anu malignant
O"'9 6#;,&2'8
Nateinal age on low oi high spectium (<2uyi anu >SSyi)
Folate ueficiency is a iisk factoi
-"$%' [ -/+0,&+'8
Nost common sign is a funuus that is laigei than uates shoulu show
Bilateial cystic enlaigement of the ovaiy
Bleeuing at <16 weeks gestation anu passage of tissue fiom vagina is the
most common symptom
Bypeitension
Bypeithyioiuism
Bypeiemesis giaviuaium
No fetal heait tones heaiu
Nost common site of metastasis is the lung

!"#$%&'"%$8
0S ieveals homogenous intiauteiine echoes without a gestational sac oi fetal
paits (looks like a "snowstoim")
Nanagement:
uet a baseline quantitative #-hCu
uet a CXR to iule out lung NETS
B&C to evacuate the uteiine contents
Place the patient on 0CP's so that theie will be no confusion between a iising
#-hCu titei fiom iecuiient uisease anu noimal piegnancy

47L>GL %?H7
5B*+D.,. %BD. >/<B*+D.,. %BD.
Empty egg Noimal egg
46, XX (uizygotic ploiuy) 69, XXY (tiiploiuy)
Fetus is absent Fetus is nonviable
2u% become malignant 1u% become malignant
No chemotheiapy.
Seiial #-hCu until completely negative.
Follow up foi 1yi while on 0CP's
No chemotheiapy.
Seiial #-hCu until completely negative.
Follow up foi 1yi while on 0CP's

%#H>GL#L! %?H7A
Non-metastatic Netastatic: uoou Px Netatstatic: Pooi Px
0teius only Pelvis oi lung Biain oi livei
1uu% cuie >9S% cuie 6S% cuie
Single-agent chemo until
aftei #-hCu is negative foi
S weeks.
Single-agent chemo until
aftei #-hCu is negative foi
S weeks.
Nultiple-agent chemo
until aftei #-hCu is
negative foi S weeks.
Follow-up foi 1 yi on 0CP Follow-up foi 1 yi on 0CP Follow-up foi S yis on
0CP.













!3. 4'.(0,


F*%"$% F2*#', !"'*#'*'8
Fibioauenoma
Fibiocystic uisease
Intiauuctal Papilloma
Fat Neciosis
Nastitis
)#7"$%#%, F2*#', !"'*#'*'8
Buctal caicinoma in situ (BCIS)
Lobulai caicinoma in situ (LCIS)
Buctal caicinoma
Lobulai caicinoma
Inflammatoiy bieast cancei
Paget's uisease of the bieast
K-N'B(2./B*(
Is the most commonly seen tumoi in young women (2u's)
Fibioauenomas giow iapiuly but have no incieaseu iisk foi ueveloping
cancei
Bistology shows myxoiu stioma anu cuivilineaislit uucts
12*#,+*%,: Not iequiieu anu will often iesoib within seveial weeks (ie-evaluate at
1 month)

K-N'B<90,-< 6-0.(0.
Is the most common tumoi in patients between SS-Su yeais of age.
Aiises in teiminal uuctal lobulai units
0ften aiises as multiple bilateial small lumps which aie tenuei uuiing the
menstiual cycle

>/,'(2)<,(D @(+-DDB*(
Piesents commonly with seious bloouy nipple uischaige
Nultiple nouules in youngei patients anu solitaiy giowth in peiimenopausal
patients

Theie is an incieaseu cancei iisk with multiple papillomas, but no incieaseu
cancei iisk with solitaiy pipillomas
6)<,(D 5('<-/B*( -/ A-,) \65>A^
0sually seen on mammogiaphy but not clinically palpable
Is a piemalignancy that will leau to invasive uuctal cancei
Bistology shows haphazaiu cells along papillae, puncheu-out aieas in uucts,
with cells infiltiating open spaces.
12*#,+*%,:
Nass excision ensuiing cleai maigins.
If maigins aie not cleai must excise again with wiuei maigins.
uive post-op iauiation to pievent iecuiiences.

HBN)D(' 5('<-/B*( -/ A-,) \H5>A^
LCIS can't be uetecteu clinically but mammogiaphy is also a weak tool foi
uiagnosis
Not piecanceious like BCIS but can be a maikei foi futuie invasive uuctal
cancei
Nucinous cells aie almost always piesent
Theie is a "saw-tooth" anu clovei-leaf configuiations in the uucts

>/:(0-:. 6)<,(D 5('<-/B*( \>65^
Is the most common bieast cancei type, seen most commonly in the miu Su's
- late Su's, anu foims soliu tumois
Nost impoitant piognosis factoi is the size of the tumoi
LN involvement is also an extiemely impoitant factoi in piognosis
Theie aie many subtypes of IBC, such as mucinous anu meuullaiy
Noueiately uiffeientiateu IBC comes fiom ciibiifoim oi papillaiy intiauuctal
oiiginatois
Pooily uiffeientiateu IBC comes fiom intiauuctal comeuo oiiginatoi.

>/:(0-:. HBN)D(' 5('<-/B*( \>H5^
S%-S% of invasive cancei is lobulai
Nost commonly seen fiom 4S-SS yi of age
vague appeaiance on mammogiam
uiowth pattein ! single file giowth pattein within a fibious stioma



12*#,"%$ "%G#'"G* ;#2;"%&+#'8
If tumoi is <Scm peifoim lumpectomy + iauiotheiapy +- aujuvant theiapy
+- chemotheiapy
Sentinal noue biopsy shoulu be peifoimeu ovei an axillaiy noue biopsy
Always test foi: a= Estiogen & Piogesteione ieceptois, anu R. BER2 piotein
The piimaiy tieatment foi inflammatoiy, tumoi size >Scm, anu NETS is
systemic theiapy

>/;D(**(,B'9 5('<-/B*(
Classic symptoms aie that of inflammation (waim, ieu, painful)
Piogiesses iapiuly anu is almost wiuely metastatic at piesentation
Bas a veiy pooi piognosis


@(1.,80 6-0.(0. B; ,3. 4'.(0,
veiy specific piesentation of ueimatitis + maculai iash ovei the nipple anu
aieola
Theie is almost always an unueilying uuctal caicinoma

@$;+ $( 01+ -;+,%0<
The most common cause of nipple uischaige is intiauuctal papilloma
The piesence of uischaige + palpable mass incieases the likelihoou of cancei
is gieatei
If uischaige is unilateial, fuithei woikup is iequiieu
If uischaige is bloouy, fuithei woikup is iequiieu
If uischaige is associateu with a mass, fuithei woikup is iequiieu
Foi bilateial, milky nipple uischaige ! uo a woikup foi piolactinoma

M",5 ."';5#2$*8
Next step is a mammogiam to look foi unueilying masses anuoi
calcifications

If mammogiaphy gives a uefinitive uiagnosis, excision of uuct is
iecommenueu
Foi nipple uischaige, nevei base uiagnosis on cytology

%(0,(D1-(:
Is cyclical oi noncyclical bieast pain that isn't causeu by lumps
Tieat with uanazol (inuuces amenoiihea)
G9/.<B*(0,-(:
Enlaigement of the male bieast, both unilateial anu bilateial
No lobules
Is causeu by an imbalance in estiogens anu anuiogens, most often occuiiing
uuiing pubeity
Nay be seen in hypeiestiogen states (ciiihosis, uiugs inhibiting estiogen
bieakuown ! ET0B, maiijuana, heioin)


5(/<.' "-0Q0 B; 4'.(0, 5(/<.'0F
#1 iisk factoi is genuei (females make up 99% of bieast canceis)
In women, age is the #1 factoi
Nenaiche < 11yi is a iisk factoi foi bieast cancei
Women who aie nullipaious at >Suyi have an incieaseu iisk
9S% of bieast cancei is N0T familial
Baving a fiist uegiee ielative with a hx of bieast cancei incieases the iisk of
bieast cancei
Autosomal uominant conuitions that have incieaseu iisk, such as BRCA-1,
BRCA-2
Piioi cancei in the opposite bieast
Cancei of the bieast occuis most commonly in the uppei anu outei quauiant
of the bieast.

M5#, ,& .& 6&2 ;*2,#"% 42*#', +#''*'X
S1+( 0$ .$ ,( *#0;,%$*(. K69L ! this is the fiist step when finuing a palpable
mass that feels cystic on physical exam.
S1+( 0$ .$ &)(+ (++.#+ ,%>);,0)$( KEX!L ! this is often the fiist step when finuing
a palpable mass, anu may be uone eithei aftei an 0S oi insteau of an 0S.

S1+( 0$ .$ +)01+; 2,22$A;,>1= K)& >0 [\U=;L ,(. -)$>%= K$; -)$>%= %$#+#= )& >0
)% ]\U=;L<
! If cyst iecuis moie than twice in 4-6 months
! If theie is bloouy fluiu on aspiiation
! If mass uoesn't appeai completely with a FNA
! Theie is bloouy nipple uischaige
! Theie is euema of the skin anu eiythema that suggests inflammatoiy bieast
caicinoma (excisional biopsy)
S1+( 0$ $;.+; &$; '=0$#$A= ! any aspiiate with gioss bloou must be senu foi
cytology
S1+( 0$ $-%+;?+ ,(. ;+>+,0 ,( +Q,2 /)01)( ^D_ /++B% ! whenevei a cyst
uisappeais with aspiiation, anu the fluiu is cleai, anuoi when the neeule biopsy
anu imaging stuuies aie negative.
When shoulu aujuvant theiapy be incluueu in the management ! 0se aujuvant
theiapy in all hoimone ieceptoi (+) tumois iegaiuless of any othei factois.


I3./ ,B ,.0, ;B' 4"5#a (/2 4"5#Rs
If theie is a histoiy of eaily-onset bieast oi ovaiian cancei in the family
If theie is bieast anuoi ovaiian cancei in the same patient
A family histoiy of NALE bieast cancei
If patient is of Ashkenazi }ewish heiitage
I3./ -0 <3.*B,3.'(+9 -/<D)2.2 -/ ,)*B' *(/(1.*./,s
When tumoi is >1cm
When the uisease is noue (+)
I3./ -0 ,'(0,)T)*(N -/<D)2.2 -/ *(/(1.*./,s
Incluueu foi metastatic bieast cancei that ovei expiesses BER2neu
This is a monoclonal antibouy uiiecteu against the extiacellulai uomain of
the BER2neu ieceptoi




!(*BV-;./:
Competitively binus to estiogen ieceptois
Piouuces a Su% ueciease in iecuiience anu a 2S% ueciease in moitality
Excellent foi both pie anu post-op patients


#'B*(,(0. >/3-N-,B'0F
Incluue uiugs such as: Anastiazole, Exemestane, anu Letiozole
These block the peiipheial piouuction of estiogen
These aie the stanuaiu of caie in hoimone ieceptoi (+) women who aie
menopausal (moie effective than tamoxifen)
Will inciease the iisk of osteopoiosis

HO"O (/(DB1).0F
A commonly useu uiug is uoseielin
An alteinative oi an auuition to tamoxifen in piemenopausal women
4./.;-,0 B; !(*BV-;./ A-2. .;;.<,0 B; !(*BV-;./
! inciuence of contialateial bieast
cancei
" bone uensity in postmenopausal
women
! seium cholesteiol
! fiactuies
! caiuiovasculai moitality iate
Exaceibates menopausal symptoms

"" iisk of cancei of the enuometiium

**All women with a histoiy of tamoxifen
use + vaginal bleeuing shoulu have an
evaluation of the enuometiium

Tieatment ieview:
If case uesciibes BR(-), pie oi post menopausal ! chemo alone
If case uesciibes BR(+), PREmenopausal ! chemo + tamoxifen
If case uesciibes BR(+), P0STmenop ! chemo + aiomatase inhibitoi






Chapter 4

Pediatrics












!3. L.ENB'/
15* @EA@O ';&2*8
This scoie measuies the newboin's neeu foi iesuscitation anu measuies S ciiteiia at
1-minute anu S-minutes. At 1-minute we can ueteimine how well the baby uiu
uuiing laboi anu ueliveiy, while at S-minutes we can ueteimine the effectiveness of
iesuscitation (if it was neeueu)
#@G#" A5?">LG !#4H7


)#%#$"%$ ,5* S*:4&2%8
Theie aie some impoitant things that must be uone immeuiately upon ueliveiy of
the newboin, upon ueliveiy give the following:
uive 1% silvei nitiate eye uiops 0R u.S% eiythiomycin ophthalmic ointment
1mg of intiamusculai vitamin K (pievents hemoiihagic uisease of the
newboin)
Befoie uischaiging the newboin fiom the hospital, uo the following:
Beaiing test to iule out a sensoiineuial heaiing loss
0iuei neonatal scieening tests: PK0, galactosemia, hypothyioiuism


@4%&2+#7","*' "% ,5* %*:4&2%8
Theie aie many abnoimalities of the newboin that shoulu be iecognizable. It is also
impoitant to know which aie benign anu which iequiie fuithei investigation.

Image Besciiption Biagnosis Co-
moibiuities
Nanagement

Reu, shaiply
uemaicateu
iaiseu ieu
lesions
Bemangioma Nay be
associateu
with high-
output caiuiac
failuie if veiy
laige.
Consiuei
unueilying
involvement
of oigans
when laige.
Steioius oi
lasei theiapy
if it involves
unueilying
oigans

0nilateial ieu
foimations on
heau anu neck
(unilateial anu
peimanent)
Poit Wine
Stain
Nay be
associateu
with Stuige-
Webei
synuiome
Pulseu lasei
theiapy.
If Stuige-
Webei must
evaluate foi
glaucoma
anu give anti-
convulsives

Bluishgiay
macules on
lowei back
anuoi
posteiioi thigh
(most
commonly)
Nongolian
Spots
Rule out
chilu abuse,
usually faue
within fiist
few yeais of
life

Fiim, yellow-
white
papulespustul
es with
eiythematous
base, peaks on
2
nu
uay of life
Eiythema
Toxicum
None None, is self-
limiteu

Tags oi pits in
fiont of the eai
Pieauiiculai
Tags
Associateu
with heaiing
loss anu u0
abnoimalities
0S of kiuneys
anu heaiing
test

Befect in the
iiis
Coloboma of
the Iiis
Associateu
with othei
CBARuE
uefects
Scieen foi
CBARuE
synuiome


An absence of
the iiis
Aniiiuia Associateu
with Wilm's
tumoi
Nust scieen
foi Wilm's
tumoi eveiy
S months
until 8yi of
age

A mass lateial
to the miuline
Bianchial
Cleft Cyst
Is a iemnant
of embiyonic
uevelopment
associateu
with
infections
Suigical
iemoval

A miuline mass
that iises when
swallowing
Thyioglossal
Buct Cyst
Nay have
ectopic
thyioiu,
associateu
with
infections
Suigical
iemoval

A piotiusion of
uI contents
thiough
umbilicus
containeu
within a sac
0mphalocele Associateu
with
chiomosomal
uisoiueis anu
othei
malfoimation
s
Scieen foi
tiisomies.

An abuominal
uefect that is
lateial to the
miuline with no
sac coveiing
contents
uastioschisis Associateu
with intestinal
atiesia


Rectus
abuominus
weakness that
allows bulging
of fetal anu
infant umbilical
coiu
Beinia
(umbilical)
Congenital
hypothyioiuis
m
This may
close
spontaneousl
y.

Scieen foi
hypothyioiu
with TSB
scieen.

Sciotal
swelling that
can be
tiansilluminate
u
Byuiocele Associateu
with an
inguinal
heinia
Biffeientiate
fiom inguinal
heinia by
shining
flashlight


Absence of
teste(s) in
sciotum
Ciyptoichiuis
m
Associateu
with cancei of
the teste(s)
Suigical
iemoval by
1yi

0pening of the
uiethia on
uoisum of the
penis
Epispauias 0iinaiy
incontinence
Evaluate foi
blauuei
extiophy

0pening of the
uiethia on
vential suiface
of penis
Bypospauias No uefinitive
mgmt, but
not supposeu
to ciicumcise
the infant

Reuucible
sciotal swelling
Inguinal
Beinia
Suigical
coiiection














6.:.DB+*./,(D %-D.0,B/.0
Bevelopmental milestones show up ovei anu ovei again on the boaiu exams. By
memoiizing the impoitant milestones you aie going to get 2-S easy points on the CK
exam. Nilestones iefei to both infant anu auolescent (pubeity) milestones.


6.:.DB+*./,(D %-D.0,B/.0
#1. G'B00 %B,B' K-/. %B,B' H(/1)(1. AB<-(DJ5B1/-,-B/
Newboin %B'B '.;D.VC
1'(0+ '.;D.V

2 months Bolus heau up Swipes at
objects
Coos Social smile
4 months Rolls fiont to
back
G'(0+0
?NW.<,0
0iients to
voice
Laughs
6 months Rolls fiom
back to fiont,
0-,0 )+'-13,
Tiansfeis
objects
Babbles 6.:.DB+0
0,'(/1.'
(/V-.,9C 0D..+0
(DD /-13,
9 months Ciawls, pulls
to a stanu
@-/<.' 1'(0+C
eats with
fingeis
LB/Y0+.<-;-<
EB'20
Waves gooubye,
iesponus to name
12 months A,(/20 B/
BE/
%(,)'.
+-/<.' 1'(0+
A+.<-;-<
EB'20
u*(*(v
Recognizes
pictuies in a
bookmagazine
1S months I(DQ0 0ses a cup Speaks 4-6
woius
!3'BE0 ,.*+.'
,(/,')*
18 months Thiows a ball,
walks up the
staiis
0ses spoon
foi soliu foous
Names
common
objects
4.1-/0 ,B-D.,
,'(-/-/1
24 months Staits
iunning, can
go up anu
uown staiis
0ses spoon
foi semi-
solius
A+.(Q0 RY
EB'2
0./,./<.
Can follow a 2-
step commanu
S6 months Can iiue a
tiicycle
Can eat neatly
with utensils
A+.(Q0 jY
EB'2
0./,./<.
Knows fiist anu
last names




E=4*2,/:
The milestones of pubeity aie as follows anu aie baseu on population aveiages:
%#H7A K7%#H7A
Testiculai enlaigement - 11.S yis Bieast buus - 1u.S yis
uenitals inciease in size Pubic Baii uiowth Begins
Pubic Baii uiowth Begins Lineai uiowth Spuit - 12 yis
Peak uiowth Spuit - 1S.S yis Nenaiche - 12.S yis



53-D2 #N)0.
Suspecteu chilu abuse iequiies youi BY LAW to iepoit the suspecteu abuse.
You must also explain to the paients why you suspect abuse anu that you aie
legally obligateu to iepoit it to chilu piotective seivices.
If a paient iefuses hospitalization oi tieatment of theii chilu against the best
inteiest of the chilu, you must get an emeigency couit oiuei.

?"$5D2"'9 ;5"7.2*%8
Piematuie infants
Chiluien with chionic meuical pioblems
Infants with colic
Chiluien with behavioial pioblems
Poveity stiicken chiluien
Chiluien of teenage paients
Single paients
Chiluien of substance abuseis

37#''"; 6"%."%$'8
Chip fiactuies (uamage to the coinei of metaphysis in long bones)
Spiial fiactuies
Rib fiactuies
Buins (immeision in hot watei, cigaiette buins, stocking-glove buins on
hanus anu feet)
Beau injuiy - NCC of ueath
Sexual abuse


M5*% ,& 5&'0",#7"J* # ;5"7. =%.*2 '='0*;, &6 4*"%$ #4='*.8
The hospital is the safest place foi the chilu
The uiagnosis is still uncleai
The chilu has a meuical conuition iequiiing hospitalization

M&29=0 6&2 '='0*;,*. ;5"7. #4='*8
PTPTTBT
Full skeletal suivey foi bieaks
If injuiies aie seveie, get a CT oi NRI + a thoiough eye exam
If injuiy is to the abuomen, get an abuominal CT, check foi bloou in the stool
anu uiine, anu check livei anu pancieatic enzymes

12*#,+*%,:
1
st
- Auuiess meuical anuoi suigical issues befoie all else
2
nu
- Repoit abuse to chilu piotective seivices (CPS)


4'.(0, K..2-/1
Theie aie many auvantages to bieastfeeuing:
Psychological anu emotional bonuing between mothei anu infant
Passive tiansfei of T-cell immunity uecieases iisks of alleigies anu infection
3&%,2#"%.";#,"&%' ,& 42*#', 6**."%$8
BIv
CNv
BSv (only if lesions aie on bieast)
BBv (unless vaccination is given piioi)
Substance abuse
Bieast cancei
Acute illness in mothei that is absent in infant
Biugs (list below of contiainuicateu uiugs uuiing bieastfeeuing)
#N0BD),.D9 5B/,'(-/2-<(,.2 ".D(,-:.D9 5B/,'(-/2-<(,.2
Alcohol Steioius
Nicotine Neuioleptics
Antineoplastics Seuatives

Lithium Tetiacycline
Chloiamphenicol Sulfonamiues
Iouiue anu Neicuiial Biugs Netioniuazole


O-13Y9-.D2 G'BE,3 d 6.:.DB+*./, K(<,0
The height of a chilu at 2 yeais of age noimally coiielates with the final auult
height peicentile.
By 6 months of age the biith weight shoulu uouble, anu by 1 yeai the biith
weight shoulu tiiple.
The absolute best inuicatoi foi malnutiition is a chilu who is <S
th
peicentile
foi height anu weight.
Skeletal anu sexual matuiity aie ielateu moie than it is ielateu to
chionological age.
The NCC of failuie to thiive (FTT) in all age gioups is psychosocial
uepiivation.
In patients with genetic shoit statuie oi constitutional uelay, biith weight is
noimal.
Patients with both genetic shoit statuie anu constitutional uelay have a
giowth pattein that is below anu paiallel to the noimal giowth cuive.


>/;.<,-B)0 6-0.(0.0 Z !3. !B"5OA
In geneial, all will have: jaunuice, I0uR, mental ietaiuation, anu
hepatosplenomegaly. Look foi things that stanu out with each infection
Bisease Chaiacteiistics
Toxoplasmosis Acquiieu by mothei thiough pooily ingesteu meat
Acquiieu when mothei hanules cat feces thiough littei
box
1S of motheis tiansmit anu 1S of infants aie affecteu
Causes: -/,'(<.'.N'(D <(D<-;-<(,-B/0, I0uR, seveie
mental ietaiuation, 392'B<.+3(D)0, choiioietinitis,
epilepsy, hepatosplenomegaly
If infecteu ! uo ultiasounu to finu any majoi anomalies
Rubella When acquiieu in 1
st
tiimestei theie is an 8u% chance of
tiansmission
When acquiieu in 2
nu
tiimestei theie is a Su% chance of
tiansmission
When acquiieu in S
iu
tiimestei theie is a S% chance of
tiansmission

Signs & Symptoms - <(,('(<,0, I0uR, bluebeiiy muffin
iash, glaucoma, choiioietinitis, PBA, pulmonaiy
stenosis, #A6C MA6C *9B<('2-,-0, heaiing loss, mental
ietaiuation, 2.(;/.00
Biagnosis - confiim with >1% iubella antibouy in
neonate's seium.
Tieat - goal is univeisal pievention by immunizing all
chiluien, theie's no theiapy foi active infection
Cytomegaloviius
(CNv)
Affects 1% of all biiths anu is the most common
congenital infection
Infection is often asymptomatic
Appiox 1% iisk of tiansplacental tiansmission, anu
appiox 1u% of infecteu infants manifest uefects
Congenital uefects - miciochephaly, +.'-:./,'-<)D('
-/,'(<'(/-(D <(D<-;-<(,-B/0, I0Ru, choiioietinitis, seveie
mental ietaiuation, 0./0B'-/.)'(D 3.('-/1 DB00
Tiansmission is thiough bouy fluius
6-(1/B0. E-,3 )'-/. 5%M <)D,)'.
Beipes Simplex
viius
vaginal ueliveiy uuiing active infection = appiox Su%
get infecteu
C-section is iequiieu if active infection
a
0,
E..Q Z +/.)*B/-( (/2 03B<Q
R
/2
E..Q Z 0Q-/ :.0-<D.0C Q.'(,B<B/W)/<,-:-,-0
I..Q jYf Z (<),. *./-/1B./<.+3(D-,-0
Tieat - acyclovii ! significantly uecieases moitality
Syphilis Theie is almost a 1uu% tiansmission iate, occuis mostly
aftei 1
st
tiimestei
4u% ueath iate (fetal anu peiinatal)
Nanifests eaily (fiist 2 yeais), then late (within next 2
uecaues)
SignsSymptoms of eaily infection - jaunuice, incieaseu
LFTs, hemolytic anemia, iash that is followeu by
2.0_)(*(,-B/ B; ,3. 3(/20 (/2 ;..,, 0/);;D.0 (bloou-
tingeu nasal secietions), B0,.B<3B/2'-,-0, sattle nose.
Late symptoms - Butchinson teeth (uppei 2 incisois get
notcheu), mulbeiiy molais, bone thickening (fiontal
bossing), sabei shins (anteiioi bowing of tibia)
4.0, -/-,-(D ,.0, Z M6"H 0<'../-/1
%B0, 0+.<-;-< ,.0, Z >1%YK!#Y#4A
Tieat - Penicillin u foi 1u-14 uays




>/;(/, 4B,)D-0*
An acute anu flacciu paialysis causeu by C. Botulinum.
Iiieveisible blocks ielease of Ach
Causeu by the ingestion of iaw honey
-"$%'V-/+0,&+'8
Constipation
Lethaigy
Weak ciy
Pooi feeuing
Bypotonia
Biooling
! suck ieflexes
! spontaneous movements
!"#$%&'"': Baseu on PE anu the acute onset of flacciu paialysis
12*#,+*%,: Suppoitive caie + intubation

5B**B/ M-'(D 7V(/,3.*0
6-0.(0. A-1/0 (/2 A9*+,B*0
Neasles (Rubeola)
Paiamyxoviius
Begins at haiiline then moves uownwaiu, is an
eiythematous maculopapulai iash that eiupts S
uays aftei piouiome.
Pathognomonic "Koplik spots" often uisappeai
befoie iash staits (white spots on buccal mucosa)
Biagnosis - cough, coiyza, conjunctivitis (SC's)
Rubella (ueiman
measles) Togaviius
Suboccipital lymphauenopathy*
A maculopapulai iash staits on the face then
geneializes
Rash lasts appioximately S uays
Soft palate may show ieu spots of vaiious sizes
Banu, foot, & mouth
uisease (Coxsackie A)
Patient has vesiculai iash on the hanus anu feet +
ulceiations in the mouth
Rash lasts appioximately 1 week
Is contagious by contact
Roseola Infantum
(BBv-6)
Acute fevei lasts 1-S uays, but chilu shows no
physical symptoms anu uoes not feel ill
0nce fevei uiops, a maculopapulai iash appeais
ovei the whole bouy (lasts 24his)
Eiythema Infectiosum
(S
th
uisease - Paivo
"Slappeu cheek" synuiome
An eiythematous maculopapulai iash spieaus

B19) fiom the aims to the tiunklegs, foims "ieticulai"
pattein
Bangeious if pt has sickle cell uisease uue to
tenuency to foim aplastic ciisis
vaiicella (chicken pox) Bighly contagious, teaiuiop vesicles that bieak anu
ciust ovei.
Staits on face anu tiunk then spieaus
Contagious until ciusting ovei



M(<<-/(,-B/0
This uiagiam is the typical vaccination iecommenuation foi chiluien fiom u-6yi olu









"7A@>"#!?"[ 6>A?"67"A

$++.' ".0+-'(,B'9 >/;.<,-B/0
5B/2-,-B/ @'.0./,(,-B/ 6-(1/B0-0 %(/(1.*./, @'B1/B0-0
Cioup
(Paiainfluenz
a 1 oi S,
Influenza A oi
B)
Smnth - Syi
with 0RI sx +
ueep baiking
coughstiiuoi
.

Symptoms
woisen at
night
Nothing
neeueu foi
uiagnosis but
a neck-x-iay
shoulu be
hau
1. Bumiuifieu
u2
2. Nebulizeu
epi +
steioius

Spontaneousl
y iesolves
within 1 wk.

Always be
waiy of the
possibility of
epiglottis
Epiglottitis
(Bib, S.
pyogenes, s.
pneumo, anu
mycoplasma)
Acute onset of
muffleu voice,
uiooling, high
fevei,
uysphagia,
anu
inspiiatoiy
stiiuoi.

Patient will
lean foiwaiu
to ease
bieathing
%.2-<(D
7*.'1./<9

Ngmt baseu
on clinical
ux, stabilize
fiist then uo
woikup:

Woikup:
Neck xiay
looking foi
thumbpiint
sign.

Bloou
cultuies

Epiglottic
swab cultuie

1. Aumit to
hospital
2. Anesthesia
anu ENT
consult
S. Intubation
4. Ceftiiaxon
e +
steioius
S. Bouseholu
contacts
shoulu get
Rifampin if
patient is
B.Influenza
+ve
Without
piompt
tieatment
aiiway
obstiuction
can leau to
ueath
Bacteiial
Tiacheitis (S.
Auieus)
Chilu usually
<Syi, aftei a
viial 0RI gets
cough that
sounus
"Biassy", has
high fevei,
iespiiatoiy
uistiess B0T
Bx is clinical
but also uo a
laiyngoscop
y anu CXR

CXR looking
foi sub-
glottic
naiiowing
Antistaph Ab's, if
seveie intubate
Aiiway
obstiuction is
a life-thieat
complication

no signs oi
symptoms of
seveiity of
epiglottitis

Bloou cult +
thioat cult.


?,-,-0 %.2-(
Common in chiluien anu often piecipitateu by an 0RI
Conuitions that uisiupt piopei Eustachian tube uiainage leau to chionic 0N
NCC aie: stiep pneumonia, B. Infl, Noiaxella, oi viial causes
-"$%' #%. -/+0,&+'8
Eiythema anu ! motility of tympanic membiane
! heaiing
Eai piessuie
Bulging tympanic membiane with visualization of fluiu behinu TN
12*#,+*%,8
P
',
7"%* ! Amoxicillin
Q
%.
7"%* ! Amoxicillin + Clavulinic Aciu (augmentin)
** Foi iecuiiing 0N, ENT consult anu tubes may neeu to be inseiteu

4'B/<3-BD-,-0
Classically piesents as chilu <2yi with the following:
Nilu 0RI
Fevei
Paioxysmal wheezing cough
Tachypnea
Byspnea
Wheezing anu piolongeu expiiations
3&++&% ;#='*' #2*8
RSv (in up to Su%)
Paiainfluenza viius
Auenoviius


-"$%' #%. -/+0,&+'8
Inflammation
Aii tiapping anu ovei inflation (uue to ball-valve obstiuction)

!"#$%&'"':
Bx is clinically baseu.
Best initial test ! CXR looking foi hypeiinflation + patchy atelectasis
Nost specific test ! Immunofluoiescence of nasophaiyngeal swab

12*#,+*%,:
Nostly suppoitive
If tachypnea is seveie hospitalize anu give tiial of nebulizeu #-agonists


@/.)*B/-(
Theie aie uiffeient causes of pneumonia:
F);,# ! NCC in chiluien <Syi, NCC is RSv
J,'0+;),# ! NCC in chiluien >Syi, NCC aie S. Pneumo, Nycoplasm Pneumo
:1#,2=.),# ! Common in infants 1-S month with insiuious onset

F);,#:
Tachypnea is the most consistent finuing in viial pneumonia
0RI symptoms
Low giaue fevei

J,'0+;),#:
Acute onset with suuuen shaking chills
Bigh giaue fevei
Cough
Chest pain (pleuiitis- pain with iespiiation)

Biminisheu bieath sounus
Bullness to peicussion of the lung fielus

:1#,2=.),#:
Nost common finuing aie a "staccato cough" anu "peiipheial eosinophilia"
No fevei oi wheezing
Nay be conjunctivitis

!"#$%&'"':
CXR:
viial ! hypeiinflation with bilateial inteistitial infiltiates
Bacteiial (pneumo) ! lobai consoliuation
NycoplasmaChlamyuia ! unilateial lowei-lobe inteistitial pneumo that
looks woise than the patient's piesenting symptoms
CBC:
viial ! <2uuuu wbc
Bact ! 1Suuu-4uuuu

12*#,+*%,:
Nilu cases can be manageu on an outpatient basis, Amoxicillin is the best
choice. Augmenting may also be useu
Seveie cases iequiie hospitalization anu aie tieateu with Iv ceftiiaxone
If pneumonia is of viial oiigin, witholu Ab's unless patient ueteiioiates.
Chlamyuia oi Nycoplasma tieateu with eiythiomycin







%$A5$H?AP7H7!#H 6>A?"67"A

H-*+
8,)(&*# #)2>)(A most often occuis acutely, anu may be associateu with fevei,
iiiitability.
Young infants may iefuse to walk
8,)(#+%% #)2>)(A usually has an insiuious onset anu is moie commonly uue
to weakness oi uefoimity of the limb seconuaiy to uevelopmental hip
uysplasia, ceiebial palsy, oi leg-length uisciepancy
This table shows the uiffeient causes of 8!4XE6O O4@8
6-0.(0. 53('(<,.'-0,-<0 !'.(,*./,
#',3'-,-0 \A.+,-<^ The #1 cause of
painful limp in 1-
Syi olu
Is usually
monoaiticulai (hip,
ankle, oi knee)
NCC S. Auieus

9)Y9Q< Acute onset of pain,
! R0N, fevei, aithiitis, "
wbc, " ESR

`;,=: shows joint space
wiuening + soft tissue
swelling.

R),A($%+: joint aspiiate
shows WBC % 1u,uuu with
PNN pieuominance
Biainage + antibiotics that
aie appiopiiate to the
cultuie obtaineu fiom the
joint aspiiate
!BV-< A9/B:-,-0 NC in males S-1uyi
anu may pioceue
0RI

9)Y9Q: insiuious onset of
pain, low-giaue fevei, wbc
anu ESR aie noimal

0sually no tenueiness,
waimth, oi swelling

Rest + analgesia foi S-S
uays

`;,= is noimal

R),A($%+: technetium
scan that shows "
epiphyseal uptake
#0.+,-< M(0<)D('
L.<'B0-0
H.11Y5(D:.Y@.',3.0 2V
Beau of femui
4-9yi olu
Boys Sx moie than
giils

?01BB2 A<3D(,,.'
Tibial tubeicle
Active
chiluauolescent
Rest ielieves pain
PB3D.'80 NB/.
L(:-<)D(' NB/.

9)Y9Q: afebiile with
insiuious onset of hip
pain, pain of innei
thighknee, " pain with
movement, ! with iest,
noimal wbc anu ESR

`;,=: femoial heau
scleiosis anu " wiuth of
the femoial neck

RQ: technetium scan
shows ! uptake in
epiphysis
! weight beaiing on
affecteu siue ovei long
teim
AD-++.2 5(+-,(D K.*B'(D
7+-+390-0 \A5K7^
NC in obese males
8-17yi
2u%-Su% bilateial
8u% occui slowly
anu piogiessively
wheie 2u% occui
acutely anu
associateu with
tiauma
Suigical pinning


9)Y9Q: uull, aching pain in
hipknee, pain with
activity

`;,=: "ice cieam scoop
falling off cone" to
uesciibe lateial
movement of the femui
shaft in ielation to the
femoial heau

RQ: stiictly clinical
?0,.B*9.D-,-0 X+$(,0+% - S. Auieus Su%
of time
:1)#.;+( - Staph, Stiep,
Salmonella (sickle cell)

9)Y9Q in young infants:
only symptom may be
fevei
9)Y9Q in oluei chiluien:
fevei, malaise, euema, anu
! extiemity movement

RQ: neutiophilic
leukocytosis, " ESR, bloou
cultuies, bone scan is 9u%
sensitive.
NRI is golu stanuaiu
Iv antibiotics foi 4-6
weeks









5BDD(1./ M(0<)D(' 6-0.(0.

w):./-D. "3.)*(,B-2 #',3'-,-0
Chionic inflammation of % joints in a patient & 16yi
0ccuis NC in 1-4yi olus, females > males
Theie aie S categoiies: Systemic, pauciaiticulai, anu polyaiticulai
!"#$%&'"': Symptoms that peisist foi S consecutive months with the exclusion of
othei causes of aithiitis oi collagen vasculai uisease.
12*#,+*%,: NSAIBs, low-uose NTX, anu pieunisone in acute febiile onset
!9+.0 B; w):./-D. "#
A90,.*-< \A,-DD80 2-0.(0.^ Z
aStYRSt
Patient has high-spiking fevei that ietuins
to noimal uaily
Small, pale pink macules with cential
palloi on tiunk & pioximal extiemities
with possible palm & sole involvement
}oint involvement may not occui foi
weeks to months
1S have uisabling chionic aithiitis
@()<-(',-<)D(' Z fStYqSt Involves & 4 joints, piimaiily affecting
laige joints (knee, elbow, ankle)
Chionic joint uisease is abnoimal
Feveimalaiseanemialymphauenopathy
common
2 Types:
Type 1 - NC, females <4yi, 9u% ANA (+), inci
iisk of chionic iiiuocyclitis
Type 2 - NC males >8yi, ANA (-), 7S% aie BLA-
B27 (+), inci iisk of Ankylosing sponuylitis oi
Reitei's synuiome latei in life
@BD9(',-<)D(' % S joints aie involveu, both small & laige,
insiuious onset, fevei, lethaigy, anemia
Theie aie 2 types that uepenu on whethei
iheumatoiu factoi is (+) oi (-)
RF (+) - 8u% females, late onset, moie
seveie, iheumatoiu nouules piesent, 7S%
aie ANA (+)
RF (-) - occuis at any time uuiing
chiluhoou, milu, iaiely ass'u with
iheumatoiu nouules, 2S% aie ANA (+)


P(E(0(Q-80 6-0.(0.
A mucocutaneous lymph noue synuiome
Affects laige anu meuium vessel vasculitis in chiluien <Syi of age
Noie commonly seen in chiluien of }apanese heiitage

!"#$%&'"':
Biagnosis iequiies the piesence of a FEvER > 1u4F oi 4uC foi moie than S uays that
is uniesponsive to antibiotics i 4S of the following ciiteiia:
0sing the mnemonic CRASB to iemembei the ciiteiia
1. 5onjunctivitis
2. "ash (tiuncal)
S. #neuiysms of the coionaiy aiteiies
4. Atiawbeiiy tongue
S. Oanu anu foot inuuiation (eiythema of the palms anu soles)

3&+07";#,"&%':
1u%-4u% of untieateu cases show uilationaneuiysm of the coionaiy
aiteiies

12*#,+*%,:
IvIu to pievent coionaiy vasculitis + high-uose aspiiin
Bo not give steioius as this will exaceibate the conuition

E2&$%&'"':
With iesponse to IvIu + aspiiin is iapiu anu 2S become afebiile within 1
uay.
Always ie-evaluate in 1 week, iepeat ECB0 at S-6wk post illness
If no fuithei abn on ECB0 then no fuithei imaging is necessaiy

O./B<3YA<3B/D.-/ @)'+)'(
A small-vessel vasculitis meuiateu by IgA nephiopathy (Beigei's uisease)


-"$%' #%. '/+0,&+'8
A palpable puipuia on the legs anu buttocks is pathognomonic in chiluien
Nay also have abuominal pain uue to intussusception

12*#,+*%,:
Self-limiteu anu iaiely piogiesses to glomeiulonephiitis


O-0,-B<9,B0-0 c
A piolifeiation of histiocytic cells iesembling Langeihan's skin cells
71+;+ ,;+ a '$22$( ?,;),(0%<
a= H.,,.'.'YA-E. 2-0.(0.

An acute, aggiessive, uisseminateu vaiiant that is often fatal in infants
-"$%' #%. -/+0,&+'8
Bepatosplenomegaly
Lymphauenopathy
Pancytopenia
Lung involvement
Recuiient infections





R= O(/2YA<3)DD.'Y53'-0,-(/

A chionicpiogiessive vaiiant that piesents piioi to S yi
37#''"; ,2"#.8 Skull lesions + uiabetes insipiuus + exophthalmos

j= 7B0-/B+3-D-< 1'(/)DB*(

Extiaskeletal involvement usually limiteu to the lungs
Bas the best piognosis of all vaiiants anu often iegiesses spontaneously
















%.,(NBD-< 6-0B'2.'0

5B/1./-,(D O9+B,39'B-2-0*
Newboin scieening is manuatoiy by law
T4 is essential uuiing the fiist two yeais of life foi noimal biain uevelopment
0sually uue to seconuaiy thyioiu agenesis oi enzyme uefects
Biith histoiy is usually noimal with a piolongeu peiiou of jaunuice
-"$%' #%. -/+0,&+'8
At 6-12 weeks the infant uevelops pooi feeuing, lethaigy, hypotonia, coaise
facial featuies, laige piotiuuing tongue, constipation, hoaise ciy, anu
uevelopmental uelay
!"#$%&'"'8
! T4, " TSB
12*#,+*%,:
Levothyioxine
Belay of tieatment beyonu 6 wks iesults in mental ietaiuation














L.ENB'/ w()/2-<.
Timefiame Biffeiential Bx
Within 24hi of biith Sepsis
Bemolysis (AB0Rh
isoimmunization, heieuitaiy
spheiocytosis)
Within 48hi of biith Bemolysis
Infection
Physiologic
Aftei 48hi Infection
Bemolysis
Bieast milk jaunuice
Congenital malfoimation
hepatitis

** Su% of neonates have jaunuice uuiing theii fiist week of life

81=%)$#$A)' P,*(.)'+<
Clinically benign conuition that occuis between 24-48hi aftei biith
Chaiacteiizeu by unconjugateu hypeibiliiubinemia
Cause is incieaseu biliiubin piouuction + a ielative ueficiency in glucuionyl
tiansfeiase in the immatuie livei
12*#,+*%,:
None iequiieu

I,*(.)'+ >;+%+(0 ,0 -);01 D >,01$#$A)'
Is always pathologic anu appeais within 24his of biith
Biliiubin iises >SmguLuay
Biliiubin >12mguL in teim infant
Biiect biliiubin >2mguL at any time
Bypeibiliiubinemia is piesent aftei the 2
nu
week of life

M&29=0 6&2 0#,5&7&$"; ]#=%.";*8
Total anu uiiect biliiubin
Biiect Coomb's test
Bloou type of infant anu mothei (AB0 oi Rh incompatibility)

CBC, ietic #, peiipheial smeai (assessing foi hemolysis)
0A anu uiine cultuie (if elevateu is uiiect biliiubin - assess foi sepsis)
>6 02&7&%$*. ^Q :**9'< .& ,5* 6&77&:"%$8
If " conjugateu biliiubin
Initial uiagnostic tests ! LFT's
Nost specific test ! 0S anu livei biopsy
If no elevation of unconjugateu biliiubin
0TI oi othei type of infection
Biliiubin conjugation abnoimalities (uilbeits, Ciiglei-Najjai)
Bemolysis
Intiinsic ieu cell membiane uefect oi enzyme uefect (spheiocytosis,
elliptocytosis, u6PB uef, pyiuvate kinase ueficiency)
12*#,+*%,:
When biliiubin is >1u-12 mguL ! phototheiapy
Exchange tiansfusion if encephalopathy is suspecteu oi theie is failuie of
impiovement with phototheiapy


6('$(P*A,0+. V=>+;-)#);*-)(+2),
Causeu by 1+2$#=0)' ,(+2), oi congenital ueficiency of glucuionyl
tiansfeiase (Ciiglei-Najjai, uilbeit's synuiome)
?*+&7/,"; #%*+"#8
Congenital oi acquiieu
5B/1./-,(D ! spheiocytosis, u6PB, pyiuvate kinase ueficiency
#<_)-'.2 ! AB0Rh isoimmunization, infection, uiugs, twin-twin
tiansfusion, chionic fetal hypoxia, uelayeu coiu clamping, mateinal uiabetes


:$(P*A,0+. V=>+;-)#);*-)(+2),
Infectious causes aie ! sepsis, ToRCB's, hepatitis, syphilis, listeiia infection
Netabolic causes aie ! galactosemia, $1-antitiypsin uef
Congenital causes aie ! extiahepatic biliaiy atiesia, Bubin-}ohnson
synuiome, Rotoi synuiome

12*#,+*%,:
0v light to bieak uown biliiubin pigments
0igent tieatment is impeiative in oiuei to pievent keinicteius inuuceu
mental ietaiuation
3&+07";#,"&%':
0v light can cause uiaiihea, ueimatitis, uehyuiation, anu uamage to the
ietina (be cautious of these auveise effects)


".9. A9/2'B*.
The use of salicylates in chiluien causes an acute encephalopathy + fatty
uegeneiation of the livei
Nost commonly occuis in chiluien ageu 4-12yi

-"$%' #%. -/+0,&+'8
Alteinates an asymptomatic inteival with abiupt onset of vomiting, ueliiium,
stupoi, abnoimal LFT's
Rapiu piogiession to seizuies, coma, anu ueath
!"#$%&'"':
Significantly elevateu livei enzymes
12*#,+*%,:
0igent ICP management with mannitol anu fluiu iestiiction
ulucose auministiation uue to iapiu uepletion of stoies
E2&$%&'"'8
Bau if seium ammonia levels aie incieaseu Sfolu, anu if theie is a uecieaseu
PT level that W0NT iesponu to vitamin K
If uisease is milu the iecoveiy is usually goou anu iapiu
A seveie uisease can iesult in peimanent neuio uefects




A.-T)'.0
In the newboin, seizuies may piesent as jitteis with iepetitive sucking
movements, tongue thiusting, anu apneic spells.
Bloou counts anu chemistiies aie often WNL
Neonatal seizuies can be uiagnoseu by the piesence of oculai ueviation anu
failuie of jitteis to subsiue with stimulus
!"#$%&'"':
EEu - often noimal
CBC + chemistiy panel ! often the cause is hypoglycemia in case of uBN
Amino aciu assay looking foi inboin eiiois of metabolism
Total coiu bloou IgN to look foi ToRCB infections
0iine cultuies
LP if suspecteu meningitis
0S of heau if infant is pieteim ! looking foi bleeuing
12*#,+*%,:
1
st
line B0C is Phenobaibital
Peisistent seizuie not iesponsive to Phenobaibital - give Phenytoin


E+-;)#+ 9+)b*;+%
0sually between Smnt - Syi
A fevei is piesent with no othei signs of infection
Is the NC convulsive uisoiuei in chiluien anu iaiely uevelops into epilepsy
Seizuie occuis uuiing tempeiatuie iise (% 1u2F) but not at its peak
-"$%' #%. -/+0,&+'8
NC is a tonic-clonic seizuie that iaiely last moie than 1umin + a uiowsy
postictal peiiou is common
Seizuie lasting >1Smin is usually uue to an infectious piocess
!"#$%&'"':
Clinical uiagnosis is usually all that is neeueu
Routine labs only iequiieu to iuentify a souice of the fevei
LP to iule out meningitis (only if suspecteu)
12*#,+*%,:
Contiol fevei with antipyietics
Reassuie paientscounsel

Always uo a caieful evaluation foi the souice of the fevei
** Su%-Su% of chiluien expeiience iecuiient febiile seizuies























G./.,-< (/2 5B/1./-,(D 6-0B'2.'0

E,)#*;+ 0$ 71;)?+
Is the failuie of chiluien to giow anu uevelop at an appiopiiate iate
Nay be uue to inauequate caloiies oi inability to absoib the caloiies
Nay be iuiopathic oi uue to othei uiseases
Factois such as 0&G*2,/, 6#+"7/ 02&47*+', %*&%#,#7 02&47*+', anu +#,*2%#7
.*02*''"&n shoulu all be incluueu in uiagnosis
!"#$%&'"':
Requiies S ciiteiia foi a FTT uiagnosis:
1. Chilu <2yi with weight <S
th
peicentile foi age on >1 occasion
2. Chilu <2yi whose weight is <8u% of iueal foi age
S. Chilu <2yi whose weight ciosses 2 majoi peicentiles uownwaiu on a
stanuaiuizeu giowth chait
IK;*0,"&%':
uenetically shoit statuie
Small foi gestational age chiluien
Pieteim infants
veiy lean (be caieful heie)
" height with a !weight gain (causes an oveiweight chilu - caieful attention
foi this uiagnosis)
12*#,+*%,:
0iganic causes ! tieat unueilying conuition + supplement with sufficient caloiies
Iuiopathic causes ! euucate paient on nutiition anu obseive paient while feeuing
0luei infantschiluien ! offei solius befoie liquius, ! mealtime uistiactions, have
chilu eat with otheis, nevei foice-feeu
** Nonitoi closely foi weight gain with auequate caloiie consumption

E2&$%&'"':
In the 1
st
yeai of life the px is pooi since the biain uevelops eaily in life
1S of chiluien with nonoiganic failuie to thiive aie uevelopmentally
uelayeu


:;,()$&,'),# !-($;2,#)0)+%
The miluest foim of cianiofacial abnoimality is the "bifiu uvula", anu has no
clinical significance

37*6, B"0:
Nay occui unilateially oi bilateially
Causeu by a failuie of fusion of maxillaiy piominences
NC foim is unilateial cleft lip
No inteifeience with feeuing
Tieat with suigical iepaii

37*6, E#7#,*:
Nay be anteiioi oi posteiioi
Anteiioi cleft palate is uue to failuie of the fusion of the palatine shelves with
the piimaiy palate
Posteiioi cleft palate is uue to failuie of the fusion of the palatine shelves
with the nasal septum
These conuitions will inteifeie with feeuing anu thus iequiie a special nipple
foi the baby to feeu piopeily
Tieat with suigical iepaii

)#;2&$7&''"#:
Is a congenitally enlaigeu tongue
Seen in conuitions such as Bown's synuiome, hypothyioiuism, anu gigantism
Can be acquiieu latei in life via aciomegaly anuoi amyloiuosis
Is N0T glossitis, which is fiom a B-vitamin ueficiency
Tieatment is aimeu at tieating the unueilying cause








!;($#.D:1),;) @,#&$;2,0)$(
A congenital uisoiuei wheie the ceiebellum is cauually uisplaceu, the meuulla is
elongateu anu passes into the foiamen magnum.

-"$%' #%. -/+0,&+'8
Flatteneu skull base
Byuiocephalus
Aqueuuct stenosis
E2&$%&'"':
Beath usually as neonate of touulei

X+*;,# 7*-+ R+&+'0%
Associateu with incieaseu $-fetopiotein in the mateinal seium
vERY PREvENTABLE with F0LATE supplementation
-"$%' #%. -/+0,&+':
Spina bifiua (failuie of posteiioi veitebial aiches to close)
Neningocele (lack of veitebiae coveiing the lumbai spinal coiu)
12*#,+*%,:
Pievention is key (folic aciu supplementation)
Neuio ueficits iemain





E+0,# !#'$1$# 9=(.;$2+
In chiluien boin to alcoholic motheis, oi motheis who consumeu excessive
alcohol uuiing piegnancy
-"$%' #%. '/+0,&+'8
Chaiacteiistic facial abnoimalities anu uevelopmental uelays
ASB
Niciocephaly
Smooth filtium of uppei lip
12*#,+*%,:
Cessation of ET0B consumption when piegnant

:$(A+()0,# 8=#$;)' 90+($%)%
Piesents with piojectile vomiting in fiist 2wk-2month of life
Seen moie commonly in males anu in 1
st
-boin chiluien
The pathognomonic finuing is the palpable "olive mass" in the miu-
epigastiium (hypeitiophieu pyloiic stenosis)
Biagnosis:
Palpation of "olive" mass is often sufficient
If no mass can be palpateu, to an ultiasounu (0S)
Tieatment:
Longituuinal suigical incision of hypeitiophieu pyloius


:$(A+()0,# V+,;0 R)%+,%+%
!9R8
0ften asymptomatic anu founu on ioutine physicals
Can pieuispose to CBF in the 2
nu
anu S
iu
uecaues of life
Nay also pieuispose to stiokes (uue to an embolus bypass tiact)
-"$%' #%. -/+0,&+'8
Niusystolic ejection muimui
Louu S1
Wiue fixeu-split S2

!"#$%&'"':
Echocaiuiogiaphy
12*#,+*%,:
Suigical patching
Tieatment is moie impoitant foi females because they have an inciease in
caiuiovasculai stiess uuiing piegnancy


F+(0;)'*#,; 9+>0,# R+&+'0 KF9RL
Is the NC congenital heait uefect
Su% of these vSB's close spontaneously by 2yi of age
-"$%' #%. -/+0,&+'8
Small uefects may be asymptomatic
Laige uefects can cause CBF
Can cause uelayeuuecieaseu uevelopment anu giowth
Bolosystolic muimui heaiu ovei the entiie piecoiuium anu maximally at the
4
th
left inteicostal space
I"'*%+*%$*2N' 3&+07*K8
A iight to left shunt seconuaiy to pulmonaiy hypeitension
Rv hypeitiophy causes a flow ieveisal thiough the shunt, iesulting in a R! L
shunt
uet cyanosis seconuaiy to lack of bloou flow to the lungs
!"#$%&'"':
Echocaiuiogiaphy
12*#,+*%,:
Simple uefects iequiie complete closuie






7+0;,#$A= $& E,##$0
Foui uefects make up this tetialogy, they aie:
1. vSB
2. Pulmonaiy outflow obstiuction
S. Rv hypeitiophy
4. 0veiiiuing aoita
-"$%' #%. -/+0,&+'8
Cyanosis uevelops within fiist 6 months of life (not piesent at biith)
"Tet Spells" aie acute cyanosis accompanieu by panic, wheie chilu goes into a
squatting position because it helps impiove bloou flow to the lungs
!"#$%&'"':
Echo
CXR shows "boot-shapeu" contoui of the heait uue to Rv enlaigement
12*#,+*%,:
Suigical iepaii of vSB anu pulmonaiy outflow tiacts


7;,(%>$%)0)$( $& 01+ N;+,0 !;0+;)+%
Aoita comes off the iight ventiicle
Pulmonaiy aiteiy comes off left ventiicle
Without a peisistent Av communication this conuition is incompatible with
life. Thus iequiies a PBA oi peisistent foiamen ovale.
-"$%' #%. -/+0,&+'8
Naikeu cyanosis at biith
Eaily clubbing of the uigits
CXR shows an enlaigeu egg-shapeu heait anu an inciease in pulmonaiy
vasculatuie
!"#$%&'"':
Echo
12*#,+*%,:
Suigical switching of the aiteiial ioots to noimal positions with iepaii of
communication uefect

E2&$%&'"':
Without tieatment is fatal within seveial months of biith




:$,;'0,0)$( $& 01+ !$;0,
A congenital aoitic naiiowing that is often asymptomatic in chiluien

-"$%' #%. -/+0,&+'8
Noimal BP in aims with uecieaseu BP in legs
Continuous muimui ovei collateial vessels in the back
The classic XRAY shows "iib notching"
!"#$%&'"':
Confiim with CT oi aoitogiam
12*#,+*%,:
Suigical iesection of coaictation anu ieanastomosis

8,0+(0 R*'0*% !;0+;)$%*% K8R!L
" inciuence with piematuie biiths
Pt pieuisposeu to enuocaiuitis anu PvB's
-"$%' #%. -/+0,&+'8
Continuous machineiy muimui that's best heaiu at 2
nu
left inteispace
Wiue pulse piessuie
Bypoxia
!"#$%&'"':
Echo oi caiuiac catheteiization
12*#,+*%,:
Inuomethacin inuuces closuie (blocks piostaglanuins) foi chiluien

0luei chiluien usually iequiie suigical iepaii


G./.,-< #/B*(D-.0
5B/2-,-B/ 5D(00-< K.(,)'.0 IB'Q)+J#00B<-(,-B/0
Bown's Synuiome (tiisomy
21)

Incieaseu iisk when
mateinal age is >SSyi
Epicanthal folus
Slanteu palpebial
fissuies
Speckling of iiis
Late fontanel closuie
Nental ietaiuation
Beaiing exam
ECB0: vSB, ASB, PBS
uI: TEF, uuouenal
atiesia
TSB foi
hypothyioiuism
ALL, uecieaseu iisk
with incieasing age
Euwaius synuiome (tiisomy
18)
Low-set, malfoimeu
eais
Niciocephaly
Niciognathia
Clencheu hanu
Rockei-bottom feet
0mphalocele
ECB0: vSB, ASB, PBS
Renal 0S: polycystic
kiuneys, ectopic oi
uouble uietei
Nost pts uon't
suivive 1
st
yi
Patau Synuiome (tiisomy
1S)
Niuface uefects
Eye uefect
Befective foiebiain
uevelopment
Niciocephaly
Niciophthalmia
Cleft lip anu palate
ECB0: vSB, PBA,
ASB
Renal 0S: polycystic
kiuneys
Single umbilical
aiteiy
WAuR synuiome 1. Wilm's
2. Aniiiuia
S. u0 anomalies
4. Retaiuation (mental)
The piesence of
aniiiuia shoulu aleit
foi the woikup foi
WAuR
Klinefeltei (XXY)
1Suu males
Low IQ
uynecomastia
Behavioial pioblems
Longslim limbs
Testosteione levels:
hypogonauism anu
hypogenitalism
Testosteione
ieplacement at 11-
12 yi of age
Tuinei's synuiome (Xu)
A spoiauic conuition with no
mateinal age association
Small-statuieu
female
Low IQ
uonaual uysgenesis
Webbeu neck
Bioau chest
Wiue-spaceu nipples
Renal 0S: hoiseshoe
kiuney, uouble ienal
pelvis
Caiuiac: bicuspiu
aoitic valve,
coaictation of the
aoita
Thyioiu function:
piimaiy

hypothyioiuism
Supplement with
estiogen, uB, anu
anabolic steioius

Fiagile X Synuiome


Niciocephaly in
eaily chiluhoou
Laige eais
Laige testes
Is the NCC of mental
ietaiuation in boys


Ass'u with ABBB
Beckwith-Wieuemann
synuiome
Nulti-oigan
enlaigement
Naciosomia
Nacioglossia
Pancieatic beta cell
hypeiplasia
Laige kiuneys
Neonatal
polycythemia
Incieaseu iisk of abu
tumois
0S anu seium AFP q
6mnth up until 6yi of
age - looking foi
Wilm's tumoi
Piauei-Willi
(ueletion at 1Sq11q1S -
pateinally ueiiveu)
0besity
Bypeiphagia
Small genitalia
Nental ietaiuation
Noibiu obesity
uecieases life-span
Angelman synuiome (aka
"happy puppet" synuiome).
(ueletion at 1Sq11q1S
mateinally ueiiveu)
Nental ietaiuation
Inappiopiiate
laughtei
Absence of speech
Ataxiajeiky aim
movements
Recuiient seizuies
Epilepsy uevelops in
8u%
Pieiie-Robin
(ass'u with FAS anu
Euwaius)
Nanuibulai
hypoplasia
Cleft palate
Aiiway obstiuction
possible ovei fiist 4
wks of life, thus
monitoi aiiway







!'()*( (/2 >/,BV-<(,-B/

@B-0B/-/10
A-1/0JA9*+,B*0 @B00-ND. !BV-/0
Lethaigy & Coma ET0B, seuatives, naicotics, antihistamines,
neuioleptics, anti-uepiessants
Seizuies Theophylline, cocaine, amphetamines, anti-
uepiessants, antisphychotics, pesticiues
Bypotension 0iganophosphate pesticiues, #-blockeis
Aiihythmia TCA's, cocaine, uigitalis, quiniuine
Bypeitheimia Salicylates, anticholineigics

Appioximately Su% of cases occui in chiluien <6yi
92% occui at home, 6u% with non-phaim agents, 4u% with phaim agents
7S% of cases aie uue to ingestion, 8% ueimal, 6% ophthalmic, anu 6%
inhalation
Lavage is often unnecessaiy in chiluien but may be useful in uiugs
uecieasing gastiic motility
Chaicoal is often most effective anu safest pioceuuie to pievent absoiption
(but is ineffective in heavy metal oi volatile hyuiocaibon poisoning).

















#2BD.0<./<.

3>).+2)$#$A=
>%]=2"*':
Su% of auolescent ueaths attiibuteu to injuiies
Nany uue to ET0B & elicit uiugs
0luei auolescents have inciease ueaths uue to NvA, while youngei
auolescents have ueaths uue to uiowning anu weapon injuiies
Bomiciue iates aie Sx> foi Blacks than White males
-=";".*8
Is the 2
nu
leauing cause of auolescent ueath
Females attempt moie but males aie Sx moie likely to succeeu
Suiciue attempts aie gieatei in those who abuse ET0B anu uiugs
-=4',#%;* #4='*8
A majoi cause of moibiuity in auolescents
Aveiage age of 1
st
usage is 12-14yi
Bigh school seniois on aveiage: 9u% tiieu ET0B, 4u% tiieu maiijuana
-*K:
61% of all males anu 47% of all females in high school have hau sex
Biggest iisks: unwanteu piegnancy, STB's
86% of STB's occui among auolescents anu young auults between 1S-29yi of
age
>1 million female auolescents become piegnant yeaily, SS% aie <1Syi olu











Chapter 5

Biostats










Success in answeiing the biostatistics questions comes fiom not only memoiizing
the following chaits, but actually unueistanuing them. If you can giasp what is
happening you will not have any issues in this section.



7;*+ 8$%)0)?+< is the # of people who have the uisease with +ve iesults
E,#%+ 8$%)0)?+: is the # of people who in fact uo not have the uisease with a +ve test
iesult
7;*+ X+A,0)?+: is the # of people who uo not have a uisease who testeu -ve
E,#%+ X+A,0)?+: is the # of people who have the uisease who testeu -ve

9+(%)0)?)0= ! |AA+Cj
Sensitivity is a tests ability to uetect a uisease
9>+')&)')0= ! |BB+Bj
Specificity is a tests ability to uetect health
8$%)0)?+ 8;+.)'0)?+ F,#*+ ! |AA+Bj
The positive pieuictive value (PPv) uetects the likelihoou that the patient has a
uisease when they test positive foi a test
X+A,0)?+ 8;+.)'0)?+ F,#*+ ! |BC+Bj
The negative pieuictive value measuies how likely a patient is in fact healthy aftei a
test iesult comes back negative.


5..% M,0)$ ! |(a X u) (b X c)j
Compaies the inciuence of uisease in people exposeu X inciuence of non-uisease in
people not exposeu, uiviueu by the inciuence of people unexposeu anu inciuence of
non-uisease in those exposeu.
0R >1 = the factoi being stuuieu is a iisk factoi foi the outcome
0R < 1 = the factoi being stuuieu is a piotective factoi in iespect to the outcome
0R = 1 = no significant uiffeience in outcome in eithei exposeu oi unexposeu gioup
M+#,0)?+ M)%B ! |a(a+b) u(c+u)j
Compaies uisease iisk in people exposeu to a ceitain factoi with uisease iisk in
people who have not been exposeu
!00;)-*0,-#+ M)%B ! |a(a+b) - u(c+u)j
The attiibutable iisk is the # of cases attiibutable to one iisk factoi

A,(/2('2 6.:-(,-B/
1 stanuaiu ueviation - 68% fall within 1 SB
2 stanuaiu ueviations - 9S% fall within 2 SB's
S stanuaiu ueviations - 99.7% fall within S SB's


NEAN - the aveiage value
NEBIAN - the miuule value

N0BE - the most common value

+vE SKEW
A +ve skeweu giaph means the 2+,([2+.),([2$.+

-vE SKEW
A -ve skeweu giaph means the 2+,(]2+.),(]2$.+
Noimal bell cuive
Nean = meuian = moue





N0 BISEASE BISEASE
This chait iepiesents sensitivity & specificity
If the cutoff point foi a uisease is moveu fiom false (+) ! false (-), theie will
be an " in the # of positive iesults. Thus an " in sensitivity (TP", FP", FN!,
PPv!j
If the cutoff point is iaiseu fiom the false (-) ! false (+), this will " specificity
|TN", FP"j


5B''.D(,-B/ <BY.;;-<-./,
Neasuies to what uegiee the vaiiables aie ielateu (fiom -1 to +1)
u = theie is no coiielation
+1 = theie is a peifect coiielation (thus if 1 vaiiable incieases so uoes the othei)
-1 = theie is a peifect negative coiielation (thus if 1 vaiiable incieases the othei
uecieases)

5B/;-2./<. -/,.':(D (/2 +Y:(D).
Two values useu to stiengthen a finuing of a stuuy. Foi statistical significance, the
confiuence inteival must not contain the null value (RR=1). Fuithei, statistically
significant iesults have a p-value <u.uS (meaning theie is <S% chance that the
iesults obtaineu weie uue to chance alone).
A p-value <u.uS is geneially useu as a cutoff foi statistical significance in meuicine.
u.uS means theie is a & S% chance that iesults obtaineu aie uue to ianuom chance.
When the p-value is & u.uS we ieject the null hypothesis (null hypothesis says that a
iesult is uue to ianuom eiioi oi chance)

The confiuence inteival is given in 2 uigits, anu the closei they aie, the moie
confiuence theie is. * With incieaseu subjects theie is a tightei confiuence inteival

#,,'-N),(ND. "-0Q @.'<./, \#"@^
Neasuies the impact of a iisk factoi being stuuieu. The ARP iepiesents the excess
iisk in a population that can be explaineu by exposuie to a paiticulai iisk factoi.
Calculate ARP: |(RR -1)RRj


>/<-2./<. :0 @'.:(D(/<.
4(').+('+ ! the # of new cases of a uisease ovei a unit of time
8;+?,#+('+ ! is the total # of cases of a uisease (new oi olu) at a ceitain point in
time
If a uisease is tieateu only to piolong life without cuiing the uisease (ie. Teiminal
canceis), then inciuence iemains the same but pievalence incieases.
** In shoit teim uiseases: inciuence > pievalence
** In long teim uiseases: pievalence > inciuence
M+#),-)#)0= ! gives similai oi veiy close iesults on iepeat measuies
F,#).)0=Y!''*;,'= ! uefineu as a test's ability to measuie what it is supposeu to
measuie (as compaieu to the golu stanuaiu)
8;+')%)$( ! is incieaseu with a tightei confiuence inteival, anu CI is maue tightei
with a highei # of subjects








A,)29 !9+.0
:,%+D:$(0;$#Y3Q>+;)2+(0,# ! Is the golu stanuaiu, compaies 2 equal gioups
wheie one has a changeu vaiiable
8;$%>+'0)?+ ! Also known as: 3&5&2,< W4'*2G#,"&%#7< >%;".*%;*. Takes a sample anu
uiviues it into 2 gioups baseu on piesence oi absence of iisk factoi, anu follows ovei
time to see what uevelops. ** These aie time consuming anu expensive.
M+0;$%>+'0)?+ ! Chooses a population (aftei the fact) baseu on the piesence oi
absence of a iisk factoi. ** Costs less, less time consuming, bettei foi iaie uiseases.
:,%+ 9+;)+% ! uesciibes the clinical piesentation of people with a ceitain uisease
:;$%%D9+'0)$(,#Y8;+?,#+('+! This stuuy looks at the pievalence of uisease anu the
pievalence of iisk factois. Takes sample fiom a population at one point in time.
This compaies 2 uiffeient cultuies.

3>).+2)' ! When the obseiveu inciuence gieatly exceeus the expecteu inciuence
8,(.+2)' ! Is an epiuemic seen ovei a wiue geogiaphical aiea.


!.0, %.,3B20
7/$D%,2>#+ 7D0+%0: is useu to compaie the means of 2 gioups of subjects
!X5F! (analysis of vaiiance): useu to compaie % S vaiiables
:1)D%c*,;+.: compaies the piopoitions of a categoiizeu outcomes (2x2 table). If
the uiffeience between the obseiveu anu expecteu values is laige, an associateu
between the exposuie anu the outcome is assumeu to be piesent.
@+0,D!(,#=%)%: is a methou of pooling the uata fiom seveial stuuies to uo an
analysis having a big statistical powei.






!9+.0 B; 4-(0
9+#+'0)$( J),%: Bias type uue to mannei in which people aie selecteu, oi fiom
selective losses fiom follow-up
5-%+;?+; d @+,%*;+2+(0 J),%: Bistoition of measuiement of association by
misclassifying exposeu, unexposeu, anuoi uiseasesnon-uiseaseu subjects.
M+',## J),%: Results fiom the inaccuiate iecall of past exposuie by people in the
stuuy
V,/01$;(+ 3&&+'0: Patients change theii behavioi because they know they aie being
stuuieu
:$(&$*(.)(A: Is bias that iesults when the exposeuisease ielationship is mixeu
with the effect of extianeous factois. (ex. Stuuy of the association of smoking anu
ciiihosis, anu finu that theie is a stiong association. Then the uivision of uiinkeis
anu non-uiinkeis finus theie's no association of smoking to ciiihosis. In this case,
alcohol is the confounuei). * Natching is an effective way of contiolling confounuing
O+,. 7)2+ J),%: Refeis to the chionology of the uiagnosis anu tieatment between
uiffeient cases. (ex. Testing of platelet inhibitois in pilots vs autowoikeis, not faii
because pilots aie unueigoing constant health scieening)
!.2)%%)$( M,0+ J),%: Refeis to uistoition in iisk iatio uue to uiffeient hospitals
aumission of cases
6(,''+>0,-)#)0= J),%: 0ccuis when paiticipants puiposely give uesiiable iesponses
which leau to













Chapter 6

Psychiatry










%BB2 6-0B'2.'0

%(WB' 6.+'.00-:. 6-0B'2.'
Najoi uepiessive uisoiuei is chaiacteiizeu by a uepiesseu moou oi anheuonia
(cannot enjoy things that they once enjoyeu), anu uepiessive symptoms lasting at
least 2 weeks.
Look foi othei possible causes such as hypothyioiuism, uiug usesubstance
use.
The classic mnemonic foi uepiession is SIu E CAPS
AF sleep uistuibances (too much oi too little)
>F inteiest changes (loss of inteist)
GF guilty feelings
7F eneigy loss
5F concentiation uistuibances
#F appetite changes (causes weight changes too)
@F psychomotoi changes
AF suiciual thoughsueath

If patient is suiciual oi uangeious to otheis always aumit

12*#,+*%,:
1
st
line tieatment is SSRI such as fluoxetine, paioxetine, seitialine (possible
siue effect is sexual uysfunction)
Can incluue benzouiazepine if patient is agitateu
Theiapy is also inuicateu along with SSRI tieatment





690,39*-< 6-0B'2.'
Same symptoms as majoi uepiessive uisoiuei except is
moie low-level in natuie, anu is piesent on most uays foi
at least 2 yeais.
12*#,+*%,:
SSRI (similai tieatment as Najoi Bepiession)



4.'.(:.*./,
Beieavement is commonly seen aftei ueath of a family membei (most
commonly seen in oluei people aftei ueath of a spouse).
!"#$%&'"'8
Key to the uiagnosis is the time that has elapseu since the onset of the
beieavement peiiou.
Symptoms > 2months makes the uiagnosis majoi uepiessive uisoiuei insteau
of noimal beieavement.
Tieatment:
Theiapy (giief management) is iecommenueu in such conuitions


4-+BD(' 6-0B'2.'
A conuition with episoues of mania,
uepiession, as well as noimal peiious.
Seen in appioximately 1% of the population
Affects males = females
Noie common in the youngei population
A mix of mania, uepiession, oi mixeu
symptoms foi at least 1 week

-"$%' #%. -/+0,&+'8
Acute onset of " eneigy
! neeu to sleep
It is possible to get a
majoi uepiessive
episoue while
uysthymic. Tieat as
NBB in this situation.
M+2+2-+;)(A @!X4!<
6 - uistiactibility
> - insomnia
G - gianuiosity

K- flight of iueas
# - activity incieaseu
A - speech (piessuieu)
! - takes iisks

Piessuieu speech
! attention span
hypeisexuality
Reckless behavioi (excessive gambling, shopping, spenuing money)

!"66*2*%,"#7 ."#$%&'"':
Schizophienia
Intoxication (cocaine, amphetamine)
Ceitain peisonality uisoiueis
!"#$%&'"':
Episoue shoulu last % 1 week anu shoulu be abiuptcause significant
uisability
Bipolai 1 ! a manic episoue with oi without uepiessive episoue
Bipolai 2 ! uepiessive episoues with hypomanic episoues
Rapiu cycling ! > 4 episoues in a one-yeai peiiou
12*#,+*%,:
Bospitalization (is often involuntaiy because patient is manic)
Noou stabilizeis - Lithium is B0C, can also use valpioate oi caibamazepine
Antipsychotics can be useu until acute mania is contiolleu
If iecuiient episoues of uepiession aie piesent, can give antiuepiessants
only in conjunction with moou stabilizeis
Lithium levels shoulu be checkeu to pievent toxicity



59<DB,39*-(
Is a iecuiience of uepiessive episoues anu hypomania foi at least 2 yeais
Is a miluei foim of bipolai uisoiuei

12*#,+*%,:
1
st
is psychotheiapy because many patients can function without meuication
If functioning becomes impaiieu stait patient on valpioic aciu, which is moie
effective in cyclothymia than lithium



6')1Y>/2)<.2 %(/-(
The most common causes aie cocaine anu amphetamines

-"$%' #%. -/+0,&+'8
Finuings similai to mania
Nyuiiasis
Bypeitension
NI in young people (highly suggestive of cocaine oveiuose)
12*#,+*%,:
Foi acute symptoms give CCB's
Biug tieatment piogiams foi long-teim management


@B0,Y+(',)* 6.+'.00-B/
@B0,Y+(',)*
ND).0 u4(N9
ND).0v
@B0,+(',)*
6.+'.00-B/
@B0,+(',)*
@09<3B0-0
?/0., Aftei any biith NC aftei 2
nu
biith 0sually aftei 1
st

biith
%B,3.'80
.*B,-B/0 ,BE('2
,3. N(N9
Nothei still caies
about the baby
Thoughts about
haiming the baby
aie common
Thoughts about
haiming baby aie
common
A9*+,B*0 Nilu Bepiession Seveie Bepiession Bepiessive
symptoms +
psychotic
symptoms
!'.(,*./, No tieatment
necessaiy
Antiuepiessants If patient not
bieastfeeuing give
Noou stabilizeis
0R antipsychotics
+ antiuepiessant
If patient is
bieastfeeuing uo
ECT




@A[5O?A>A

E'/;5&'"' "' ;5#2#;,*2"J*. 4/8
Ballucinations - false sensoiy peiception that is N0T baseu on ieal stimuli
Belusions - false inteipietations of exteinal ieality
Can be of the paianoiu natuie, gianuiosity, ieligious, oi iueas of iefeience

This table gives a geneial oveiview of the causes of psychosis
6>A7#A7 5O#"#5!7">A!>5A
A<3-TB+3'./-( Theie is a stiong genetic pieuisposition, onset
usually late teens thiough the 2u's
+ve symptoms = hallucinations anuoi
uelusions
-ve symptoms = flatteneu affect
0thei symptoms incluue uisoiganizeu behavioi
anuoi speech
Nust last % 6 months to be calleu schizophienia
If lasting 1-6 months calleu schizophienifoim
If lasting <1 month it is a biief psychotic
uisoiuei (these patients often ietuin to noimal
baseline functioning)
A<3-TB(;;.<,-:. 2-0B'2.' Combination of a moou uisoiuei +
schizophienia
6.D)0-B/(D 2-0B'2.' Patient gets non-bizaiie uelusions
%BB2 2-0B'2.'0 Bipolai anuoi uepiession can cause uelusions
anu in extieme cases may cause hallucinations
6.D-'-)* 0ften seen in patients who have unueilying
conuitions
No oiientation to peison, place, oi time
Waxing anu waning of conuition
Tieatment involves tieating the unueilying
conuition
6')10 Cocaineamphetamines cause paianoiu
uelusions anu foimication (sensation of bugs
ciawling on the skin)
LSBPCP cause hallucinations of vision, taste,
touch, anu scent
%.2-<(D <()0.0 Enuociine uisoiueis, metabolic uisoiueis,
neoplastic uisoiueis, anu seizuie uisoiueis can

cause psychosis

12*#,+*%,:
If conuition is uisabling oi potentially uangeious to patient oi otheis,
hospitalization is iequiieu.
Phaimacologic theiapy is with uopamine antagonists, anu the uiffeiences
amongst the uiugs is baseu on the siue effects they piouuce
Impiove uiug compliance by giving uepot foim of haluol
Psychotheiapy to impiove social functioning (behavioial tieatment to
impiove social skills, family-oiienteu tieatment foi impioveu familial
functioning)
Piognosis is uepenuent of fiequency of episoues as well as accompanying
symptoms (piesence of negative symptoms usually inuicates a pooi
piognosis)
Patients who weie veiy high-functioning piioi to the psychosis onset have a
bettei piognosis
6"$G #6M7"A7 7KK75!A
7=>)',# !(0)>%='1$0)'%
Chloipiomazine Low potency, "anticholineigic effects, ! movement uisoiueis
Balopeiiuol Bigh potency, ! anticholineigic effect, " movement uo
!0=>)',# !(0)>%='1$0)'%
Clozapine Foi iefiactoiy uisease, give weekly CBC (agianulocytosis
iisk)
Rispeiiuone 1
st
line, minimal aveise effects
0lanzapine 1
st
line, minimal auveise effects

Theie aie many possible movement uisoiueis associateu with the use of
antipsychotic meuications. You will likely encountei one on the CK exam. This table
will uemonstiate the timeline foi ceitain auveise movement ieactions.
BIS0RBER TINE FRANE CBARACTERISTICS
Acute Bystonia Fiom 4hi - 4 uays (4&4) Patient expeiiences
sustaineu spasms,
may be anywheie but
NC seen in the neck,
jaw, oi back.
Tieatment - Iv
uiphenhyuiamine
(immeuiately)
Paikinsonism Fiom 4 uays - 4 months Patient has cog-wheel
iigiuity, iesting
tiemoi, anu shuffling

gait
Tieatment -
benztiophine
(anticholineigic useu
in Paikinson's
uisease)
Taiuive Byskinesia 4 months - 4 yeais Involuntaiyiiiegulai
movements of the
heau, tongue, lips,
limbs, anu tiunk
Tieatment - change
meuications
immeuiately (is a
peimanent
conuition)
Akithisia Nay occui at any time
uuiing tieatment
Patient has a sense of
uiscomfoitiestlessn
ess
Tieat by lowei the
uose of meuication
Neuioleptic Nalignant
Synuiome
Nay occui at any time
uuiing tieatment
Is a life-thieatening
muscle iigiuity with
fevei, incieaseu BP
anu BR, anu
ihabuomyolysis that
appeais ovei 1-S
uays
Tieatment is
suppoitive, stop all
offenuing uiugs
immeuiately, give
patient uantiolene
(Calcium is inhibiteu
fiom ielease into
cells), anu cool the
patient







#/V-.,9 6-0B'2.'0

@(/-< 6-0B'2.'
A conuition seen NC in women in theii miu 2u's
Symptoms mimic those of an NI (chest pain, palpitations, uiaphoiesis,
nausea, anxiety, sense of impenuing uoom)
Symptoms usually escalate foi appioximately 1u minutes anu last at least Su
minutes
This uisoiuei is veiy unpieuictable, if it occuis in the same type of setting
then suspect a specific phobia
!"#$%&'"':
Nust uiffeientiate fiom uiug use, NI, anu othei souices of phobias
Biagnosis of exclusion
Tieatment:
Cognitive-behavioial theiapy anuoi ielaxation tiaining.
Relaxation is moie useful if patient has an agoiaphobic tenuency
SSRI's anu benzouiazepines can be piesciibeu

#1B'(+3BN-(
Patient feais being in situations wheie they cannot escape, biinging about a
panic attack
Patients uevelop agoiaphobia because of iecuiient anu unexpecteu panic
attacks in ceitain situations
!"#$%&'"':
Is clinical, looking foi eviuence of social anuoi occupational uysfunction
12*#,+*%,:
Exposuie uesensitization
#-blockeis as piophylaxis fiom sympathetic activation when in possibly
tiiggeiing situations




?N0.00-:.Y5B*+)D0-:. 6-0B'2.' \?56^
Patient expeiiences iecuiient thoughts anu peifoims
iecuiient actionsiituals as a coping mechanism
0bsessive thoughts piovoke anxiety, compulsions aie
a way of uealing with this anxiety, this anxiety ielief is
only tempoiaiy anu thus iituals get peifoimeu ovei
anu ovei again.
Commonly involve cleanliness (feai of contamination)
- thus excessive hanu-washing is common
!"#$%&'"':
Patient must be awaie of the abnoimality of theii behavioi, anu must be
uistuibeu by this.
Tieatment:
1
st
line tieatment is SSRI
2
nu
line is clomipiamine
Patient must unueigo psychotheiapy as well, wheie they aie foiceu to
oveicome theii behavioi


@B0,Y!'()*(,-< A,'.00 6-0B'2.'
This is the classic "vietnam vet" patient, who has unueigone a tiaumatic
inciuent that leaves them emotionally scaiieu
Theie aie S key gioups of symptoms:
1. Avoiuance of stimuli - associateu with theii tiauma oi numbing of
iesponsiveness because it emits emotional pain
2. Re-expeiiencing the tiaumatic event - via uieams, thoughts, iecollections.
S. Incieaseu aiousal - seen as sleep uistuibances, emotional lability,
impulsiveness, anxiety.
!"#$%&'"':
Always uiffeientiate fiom an acute stiess uisoiuei,
wheie symptoms last less than 1 month anu occui
within 1 month of expeiiencing the stiessoi
Biagnosis iequiies a tiaumatic inciuent anu must last
longei than 1 month

Bo not confuse 0CB
with obsessive-
compulsive
"peisonality
uisoiuei", wheie
the patient sees no
wiong in theii
behaviois.
A patient who
functioneu veiy
well befoie the
onset of PTSB
has a gieatei
piognosis than
someone who
was less
functional.

Tieatment:
When patient is in acute uistiess, give benzouiazepines to calm them uown
Foi long-teim theiapy, give SSRI's + psychotheiapy


G./.'(D-T.2 #/V-.,9 6-0B'2.'
Patient woiiies excessively anuoi has pooily contiolleu anxiety on most
uays foi at least 6 months.
Theie is no specific event oi ieason foi this anxiety
Patient has tiouble sleeping, the inability to concentiate, excessive fatigue
anu iestlessness
Be suie to uistinguish fiom specific phobiaanxieties oi othei causes of
anxiety.

!"#$%&'"':
Nust be eviuence of social uysfunction (which iules out noimal anxiety)
12*#,+*%,:
Psychotheiapy teaching patient to iecognize theii woiiying anu finuing a
way to manage thiough thought patteins anu behavioi
Can give SSRI's, buspiione, anu benzouiazepines
#-blockeis to block excessive sympathetic activation










!X`45Oe74:9 8M39:M4J3R E5M !X`437e R495MR3M9<
8!X4: R495MR3M< 99M4f !#>;,#$b,2f :#$(,b+>,2
N!R< 99M4G%
5:R< 99M4G% ,(. '#$2)>;,2)(+
!RI697@3X7 R495MR3M< J+(b$.),b+>)(+%
95:4!O 8V5J4!< 99M4 g -*%>);$(+

@.'0B/(D-,9 6-0B'2.'0

-&+* $*%*2#7 ;5#2#;,*2"',";' &6 E*2'&%#7",/ !"'&2.*2'8
They cause functional impaiiments
Behavioi often causes significant uisiuption to otheis (co-woikeis,
classmates, family membeis, etc)
Patients usually see no pioblem with theii behaviois


5H$A!7" # 6>A?"67"A Z @('(/B-2C A<3-TB-2C A<3-TB,9+(D \7<<./,'-<JI.-'2^
5H$A!7" 4 6>A?"67"A Z 4B'2.'D-/.C #/,-0B<-(DC O-0,'-B/-<C L('<-00-0,-<
\6'(*(,-<J#11'.00-:.^
5H$A!7" 5 6>A?"67"A Z L('<-00-0,-<C #:B-2(/,C 6.+./2./,C ?N0.00-:.Y
5B*+)D0-:. \A39JL.':B)0^

5H$A!7" # 6>A?"67"A
8,;,($).F
These people negatively inteipiet the intentions of otheis
0ften use piojection as theii main ego uefense
9'1)b$).:
These people aie socially withuiawn anu intioveiteu
Avoiu foiming close emotional connections with otheis
9'1)b$0=>,#:
These people believe in things not noimally accepteu by society, such as
magic
Nay have biief psychotic episoues but aie not psychotic
Socially isolateu
Nany schizotypal patients have schizophienic ielatives




5H$A!7" 4 6>A?"67"A
!(0)%$'),#:
Bieak the law, violate othei's iights
0ften seuuctive in natuie
@*%0 -+ C_=; of age foi uiagnosis + must have been this way since at least 1S
yi olu (conuuct uisoiuei)
J$;.+;#)(+:
Exhibit self-uestiuctive behavioi such as cutting
Emotionally volatile
"Splitting" ego uefense commonly useu (people seen as eithei gieat oi
teiiible)
Bave the ability to uissociate fiom past negative expeiiences
V)%0;)$()':
Attention-seekeis
Sexually piomiscuous anu uses physical appeaiance foi attention
veiy uiamatic anu exaggeiate theii behaviois
0se ego uefenses such as uissociation anu iepiession

5H$A!7" 5 6>A?"67"A
X,;')%%)%0)':
Believe they aie supeiioi anu aie entitleu to the best
Bo not hanule ciiticism well
!?$).,(0:
Patient feels sensitive anu uoes not hanule negative comments well
Scaieu to tiy new things oi make new fiienus foi feai of embaiiassment
R+>+(.+(0:
Scaieu to be on theii own anu cannot uo much on theii own
Requiie help with uecisions fiom someone else
5-%+%%)?+D:$2>*#%)?+:
This peison is oveily pieoccupieu with iules, iegulations, neatness, etc
They commonly isolate themselves (ego uefense) in oiuei to avoiu
uemonstiating emotions


71B 6.;./0.0

#<,-/1 ?),F tiansfoimation of unacceptable feelings into actions (ex. Tantiums)
>2./,-;-<(,-B/: copies the behavioi of someone else
"(,-B/(D-T(,-B/: a way of making something unacceptable seem acceptable (ex.
Boyfiienu bieaks up with giilfiienu anu she says she wanteu to enu it anyway)
".(<,-B/ KB'*(,-B/: expiessing outwaiuly the exact opposite of how you feel (ex.
Someone auuicteu to something staits a chaiity to fight that cause)
>/,.DD.<,)(D-T(,-B/: tiying to logically explain something in oiuei to make sense of
it
".1'.00-B/: iesoiting to immatuiechilu-like behavioi
A)ND-*(,-B/: funneling unacceptable feelings into positive actions (ex. Funneling
sexual feelings into a woikout iegimen)
















AB*(,B;B'* d K(<,-,-B)0 6-0B'2.'

AB*(,B;B'* 6-0B'2.'0
AB*(,-T(,-B/ 2-0B'2.'F
Nost commonly female patients anu staits befoie Su yeais of age
Fiequently visits the uoctoi foi many pioceuuies anu opeiations
0ften have a histoiy of abusive anuoi faileu ielationships
-/+0,&+':
Somatic complaints involving many uiffeient
systems, such as:
G> ! nausea, vomiting, uiaiihea
L.)'BDB1-< ! weakness, loss of sensation that is not
explaineu by noimal anatomy
A.V)(D ! iiiegulai menses, etc
Lab finuings uo not explain any of the complaints
!"#$%&'"':
Nust always iule out meuical conuitions
Rule out mateiial gains
12*#,+*%,:
Impoitant to foim a stiong bonu with the patient
Tiy to biing to light the fact that theie aie psychological causes foi the
conuition
Scheuule iegulai appointments
Peifoim a physical exam but uo not oiuei lab tests






Somatization anu
conveision uisoiuei
aie nevei intentional.
If a question says
patient is looking foi
gain oi uiu something
puiposely, these two
aie not the iight
answei.

5B/:.'0-B/ 2-0B'2.'F
Patient expeiiences neuiologic symptoms that cannot be explaineu by
meuical oi neuiological uisoiuei
Patients aie often not oveily conceineu about the impaiiment - know as "la
belle inuiffeience"
Theie aie often psychological factois associateu with symptoms, such as
going limp when someone yells at them
12*#,+*%,:
Foimation of a stiong ielationship with the patient
Psychotheiapy


O9+B<3B/2'-(0-0:
The patient falsely believes they have a specific uisease even when they aie
iuleu out with negative woikups anuoi lab tests
12*#,+*%,:
Regulai visits to 0NE piimaiy uoctoi
Avoiu testspioceuuies
Pioviue psychotheiapy
SSRI's may be useful in some cases


K(<,-,-B)0 6-0B'2.'0
These patients have intentionally feigneu theii symptoms
These patients often see many uoctois anu visit many uiffeient hospitals
They often have moie meuical knowleuge than the aveiage peison (often
healthcaie woikeis)
E,'0)0)$*% .)%$;.+;: puiposely fakeu but not foi obvious gain
@,#)(A+;)(A .)%$;.+;: puiposely fakeu foi an obvious gain, such as meuication,
insuiance, etc.

veiy uemanuing of tieatment

A factitious oiuei "by pioxy", is maue when signs anu symptoms aie fakeu by
anothei peison (ex. Nothei makes up symptoms in hei chilu - known as
Nunchhausen's by pioxy)
)=%;55#='*%N' '/%.2&+*:
A factitious uisoiuei mainly with physical symptoms
Nunchhausen's by pioxy:
Someone claims non-existent symptoms (NC in theii chilu)
Notivation is usually to assume the iole of caietakei

!"#$%&'"':
By exclusion of a ieal meuical conuition
Biffeientiate between malingeiing anu factitious uisoiueis
12*#,+*%,:
veiy uifficult, patients often veiy uefensive when it is suggesteu that they aie
faking















53-D23BB2 (/2 #2BD.0<./, @09<3-(,'9

#),-0*
Seen in u.u2%-u.uS% of chiluien
0nset befoie Syi of age
Is S-Sx moie common in boys
Bevelop seveie pioblems in communication
Bave noimal heaiing
Significant pioblems in foiming social ielationships
Aie comfoitable peifoiming iepetitive behaviois
0ften peifoim self-uestiuctive behaviois
Bave subnoimal intelligence (<7u IQ) in appioximately 2S of all patients
Some have unusual specific abilities
Piognosis is not goou, only 2% aie able to woik anu live inuepenuently, but
most iemain seveiely impaiieu in auulthoou
12*#,+*%,V)#%#$*+*%,:
Behavioial theiapy to inciease socialcommunicative skills, ueciease
behavioial pioblems, anu impiove theii self-caie
It is often moie beneficial foi the paients, because they have much uifficulty
iaising a chilu with autism.

#0+.'1.' 2-0B'2.'
This uisoiuei is fiist seen at S-S yeais of age
Noie common in boys
They have significant pioblems foiming social ielationships
Little oi no uelay in cognitive oi language uevelopment
Piognosis is much bettei heie than it is in Aspeigei








53-D23BB2 6.+'.00-B/
Piesents uiffeiently uepenuing on the age gioup
Pieschooleis may be aggiessive anuoi hypeiactive, while auolescents aie
iiiitable oi show antisocial behavioi
Impoitant to note that they may also show the same symptoms that auults uo
when expeiiencing a majoi uepiessive uisoiuei
12*#,+*%,:
Family theiapy may be iequiieu because this is often a cause of chiluhoou
uepiession
0se of antiuepiessants is veiy contioveisial in chiluien anu teens uue to
theii iisk of suiciue in this age gioup


A.+('(,-B/ #/V-.,9
Chilu is too attacheu to paients oi othei figuies in theii life
Chilu has excessive woiiy that these figuies will be sepaiateu fiom them
-"$%' #%. -/+0,&+':
Somatic symptoms uuiing times of sepeiation
Tiouble sleeping
12*#,+*%,:
Besensitization
Imipiamine may be useu in some cases


?++B0-,-B/(D 6.;-(/, 6-0B'2.'J5B/2)<, 6-0B'2.'
W00&'","&%#7 !*6"#%,:
Patients aie aigumentative anu tempeiamental (moie so with people close to
them)
0ften have no fiienus anu peifoim pooily in school
3&%.=;, !"'&2.*2:
Patient is a bully to otheis
Shows physical ciuelty to animals
violates anu uestioys othei people's piopeity, steals.

Bas no iemoise foi theii actions
Family histoiy often shows negligence, anu abuse of uiugs anuoi alcholol
This may leau to conuuct uisoiuei (but not always)
12*#,+*%,:
Foi both oppositional uefiant uisoiuei anu conuuct uisoiuei, cieate an
atmospheiesetting with stiict iules anu consequences foi not obeying these
iules


#,,./,-B/ 6.;-<-, O9+.'(<,-:-,9 6-0B'2.'
Chaiacteiizeu by oveiactivity, a limiteu attention span, pooi self-contiol,
impulsiveness, emotional lability, high sensitivity to stimuli, sleep pioblems
!"#$%&'"':
0nset must be befoie 7yi of age
% 6 symptoms fiom both hypeiactivity anuoi inattention sub-categoiies
12*#,+*%,:
CNS stimulants aie B0C
Nethylpheniuate in chiluien >6yi of age
0thei types of CNS stimulants also given
Note the auveise effects of CNS stimulants can be the inability to gain weight
anu the inhibition of giowth


!B)'.,,.80 6-0B'2.'
Chaiacteiizeu by involuntaiy tics, iepetitive movements, anu vocalizations
Biagnosis N0ST incluue both a motoi tic anu a vocal tick that is piesent foi
%1 yi
The common steieotype of Touiette's involves uncontiollable sweaiing,
which is known as copiolalia
12*#,+*%,:
Baluol is veiy effective, but is not useu in miluei cases
Psychotheiapy is effective in uealing with the social aspects of this uisoiuei,
but it uoes not impiove the tics

#/B'.V-( L.':B0(
0ften stait uuiing auolescence
Theie is a piofounu uistuibance in bouy image anu in a peison's self-woith

-"$%' #%. -/+0,&+':
Patients aie below the iueal weight foi theii age anu height
They often have mealtime iituals such as cutting theii foou into tiny pieces
anuoi ie-aiianging it on the plate
Amenoiihea occuis seconuaiy to the weight loss, anu is iequiieu foi the
uiagnosis of anoiexia
12*#,+*%,:
Bospitalization may be iequiieu to iestoie the patient's weight to a safe
level, as well as coiiect any electiolyte imbalances
The most seveie auveise ieaction is caiuiac uysfunction
The mainstay of tieatment is psychotheiapy
Piognosis is pooi if pieoccupations with foou anu weight uo not impiove


4)D-*-( L.':B0(
Noie common than anoiexia
Chaiacteiizeu by binge eating (with a peiceiveu lack of contiol)
0ften accompanieu by puiging (laxative use anuoi vomiting)
0ften have a noimal appeaiance anu noimal weight
0ften have cuts on the hanus fiom shoving them uown the thioat to inuuce
vomiting
Bental eiosions seen uue to aciuic uestiuction fiom constant vomiting
Tieatment is same as that foi anoiexia







6-00B<-(,-:. 6-0B'2.' \*)D,-+D. +.'0B/(D-,9 2-0B'2.'^
A patient possesses uiffeient peisonalities that can each take contiol at any
given time
Chiluhoou tiauma is veiy common when this conuition is piesent
Tieatment is focuseu on the giauual integiation of these peisonalities
7/$ .)&&+;+(0 .)%$;.+;% 01,0 %1$*#. -+ 0,B+( )(0$ '$(%).+;,0)$(<
!"''&;"#,"G* @+%*'"#:
Peison foigets plenty of peisonal infoimation
!"''&;"#,"G* C=$=*:
A synuiome wheie someone tiavels to anothei place with the inability to
iemembei the past anu confusion about theii piesent iuentity


#2W)0,*./, 6-0B'2.'
A stiessful life event leaus to the inability to ueal emotionally anuoi
behavioially
!"#$%&'"':
Symptoms piesent within S months of the stiessful event anu must
uisappeai within 6 months of the uisappeaiance of the stiessoi
Biffeientiate fiom a beieavement uisoiuei
Always aggiessively look at whethei theie is a uepiessive uisoiuei anuoi
anxiety uisoiuei, which must be tieateu










>*+)D0.Y5B/,'BD 6-0B'2.'0

Patients aie unable to iesist the uiive to peifoim actions that may be haimful
to otheis anu themselves
Theie is a feeling of anxiety befoie peifoiming the impulsive action anu a
sense of giatification afteiwaius

>/,.'*-,,./,Y7V+DB0-:. 6-0B'2.'
Patient shows aggiessive behavioi that is way out of piopoition to the
stiessoi
Nust not be associateu with uiug use
Tieat with SSRI's ANB a moou stabilizei such as Lithium

PD.+,B*(/-(
An inuiviuual who iepeateuly steals to ielieve anxiety
Peison uoes not steal because they neeu the object
0ften, the peison ietuins the object aftei stealing it

@9'B*(/-(
Inuiviuual puiposely sets fiies
Theie is no peisonal gain in pyiomania, noi is theie any angei in ielation to
uoing this (if theie is, this shifts the uiagnosis to conuuctantisocial uisoiuei)

!'-<3B,-DDB*(/-(
Patient impulsively pulls out theii haii
This iesults in &4'*2G#47* haii loss






6')10 B; #N)0.

#D<B3BD
Alcohol is a commonly abuseu uiug
Patients uevelop uiffeient levels of uepenuence
!#'$1$# .+>+(.+('+ is the fiequent use of alcohol that iesults in toleiance,
leauing to psychological anu physical uepenuence.
!#'$1$# ,-*%+ is uiagnoseu when its use iesults in failuie to peifoim
noimally in society (loss of job, social impaiiment, legal pioblems)
!"#$%&'"':
Lab tests aie not iequiieu foi uiagnosis
The CAuE questionnaiie is the most accuiate uiagnosis
12*#,+*%,:
The most effective management of an alcoholic is always alcoholics
anonymous
)#%#$*+*%,:
Foi outpatient management, the fiist thing is to pievent fuithei intake of
alcohol
If patient is intoxicateu pievent them fiom opeiating machineiy (uiiving)
If patient is agitateu seuate
Aumit to hospital if patient iequiies fuithei help











The following table piesents the most commonly abuseu uiugs
A$4A!#L57 A-JAV B;
-/,BV-<(,-B/
!'.(,*./, B;
-/,BV-<(,-B/
A-JAV B;
E-,32'(E(D
!'.(,*./, B;
E-,32'(E(D
Alcohol Lack of
inhibition
Talkative
If seveie give
mechanical
ventilation
Tiemoi
Seizuies
Beliiium
Long-acting
benzouiazepines
.
Amphetamines
Cocaine
Agitation
Nyuiiasis,
Euphoiia,
Bypeiactivity,
StiokeNI

ST
antipsychotics
Anxiety
Tiemoi
Bypeiphagia
Bepiession
Suiciue iisk
Antiuepiessants
Naiijuana Impaiieu
motoi co-
oiuination,
Bypeiphagia,
Biy mouth,
Conjunctival
ieuness

None None None
Ballucinogens Iueas of
iefeience,
Ballucination,
Bissociative
symptoms
Talking uown,
Antipsychotic,
Benzos
None None
Inhalants Belligeience,
violent,
Impaiieu
juugement,
Bluiieu
vision,
Stupoi, coma.
If ueliiious oi
agitateu give
antipsychotics
None None
Beioine
(opiates)
Bysphoiia,
Niosis,
Biowsiness,
Sluiieu
speech
Naloxone Fevei, chills,
Abu ciamps,
Insomnia,
Laciimation
Cloniuine,
Nethauone
Phencycliuine
(PCP)
violent,
Panic,
Agitation,
Nystagmus.
Talk-uown,
Benzos,
Antipsychotic
s
Respiiatoiy
suppoit
None None
Baibituiates Impaiieu Flumazenil Autonomic Long-acting

anuoi
Benzouiazepine
s
memoiy oi
concentiation
,
Lack of
inhibition
hypeiactivity
,
Tiemoi,
Insomnia,
Seizuie,
Anxiety.
baibituiates as
substitution



@('(+3-D-(0

Involve iecuiient, sexually aiousing pieoccupations that aie focuseu on
humiliation anuoi suffeiing anu the use of nonliving objects anu
nonconsenting paitneis.
0ccuis foi >6 months
Causes social impaiiment
Tieatment foi all is psychotheiapy anu aveisive conuitioning
Seveie cases may iequiie anti-anuiogens oi SSRI's to ieuuce patient's sex
uiive

1/0*':
K'B,,.)'-0*: Touching oi iubbing against a non-consenting paitnei
7V3-N-,-B/-0*: Recuiient uige to expose themselves to stiangeis
@.2B+3-D-(: 0iges oi aiousal towaiu piepubescent chiluien (is the most common
paiaphilia)
MB9.)'-0*: 0iges to obseive an unsuspecting peison who is having sex oi taking
off theii clothes
K.,-03-0*: The use of nonliving objects associateu with the human bouy (shoes aie
common)
%(0B<3-0*: Recuiient uige oi behavioi involving being humiliateu
A(2-0*: Causing suffeiing to a victim is exciting to the patient



AD..+

LB'*(D AD..+
Theie aie two types of sleep:
1. Non-REN (NREN), which has foui stages
2. REN - iapiu eye movement

The stages of noimal sleep
A,(1.0 53('(<,.'-0,-<0
L?LY"7% This stage consists of eaily, slow-wave sleep
A,(1. a Consists of $-waves anu '-waves
A,(1. R Sleep spinules aie piesent
A,(1. jCf (-waves aie piesent uuiing these stages
"7% Bieaming occuis heie (this stage is affecteu by elicit uiugs anu
ET0B)


AD..+ 6-0B'2.'0
>/0B*/-(
Patient is unable to fall asleep oi stay asleep
Recuiient ovei moie than a 1-month peiiou
Nay be associateu with peiious of stiess, anxiety, oi uiug use
12*#,+*%,:
A sleep scheuule is impoitant to iegulai inteinal sleep patteins
Exeicise
Antihistamines
2-week peiiou of benzouiazepines (caieful to avoiu uepenuence)






O9+.'0B*/-(
X,;'$#+>%=F
Patient expeiiences acute attacks of REN sleep
They suuuenly collapse with a complete loss of muscle tone (cataplexy)
12*#,+*%,:
CNS stimulants

9#++> !>(+,<
Apneic peiious that occui uuiing sleep
Nost commonly is obstiuctive (commonly uue to excess weight)
12*#,+*%,:
Weight loss
Continuous positive aiiway piessuie (CPAP)
If patient uoesn't get ielief fiom these then shoulu unueigo suigeiy since
sleep apnea is a life-thieatening conuition

8)'B/)'B),( 9=(.;$2+ (Cential Alveolai Bypoventilation)
A synuiome with somnolence, obesity, anu eiythiocytosis
Patient giauually uevelops hypeicapnea, hypoxemia, anu eiythiocytosis
This is causeu by the weight of excess auipose tissue piessing on the lungs
12*#,+*%,:
Weight loss


@('(0B*/-(0
S"$5, 1*22&2'8
Chilu aiises uuiing NREN sleep, is not awaie they aie awake, scieams in
teiioi, then falls back asleep.
They uo not iemembei the occuiience when they awaken


S"$5,+#2*':
0ccui uuiing REN sleep
Relateu to emotional events such as tiageuy, scaiy movie, etc
Patient iemembeis the uieam

-7**0 M#79"%$:
0ccuis uuiing NREN sleep
Patient gets out of beu anu wanueis about
Patient has no iecollection of the event






















Chapter 7

Cardiovascular












@D.)'-,-< 53.0, @(-/ @B0-,-B/(D 53.0, @(-/ !./2.' 53.0, @(-/
PE Peiicaiuitis Costochonuiitis
Pneumonia
Pleuiitis
Peiicaiuitis
Pneumothoiax

>0<3.*-< O.(', 6-0.(0. \5#6^

)#]&2 O"'9 C#;,&2'8
Biabetes
Smoking
Bypeitension (BTN)
Bypeicholesteiolemia
Family histoiy
Age
)"%&2 O"'9 C#;,&2'8
0besity
Lack of estiogen (this is why it occuis in men moie than women)
The #1 pieventable RF is smoking

A,(ND. #/1-/(
Chest pain that occuis with activity
Causeu by atheioscleiosis, wheieby the supply of u2 iequiieu by the heait is
not met
-"$%' #%. -/+0,&+'8
Chest pain that may iauiate to the left aim, jaw, anu back.
Relieveu by iest anu nitioglyceiin
EKu will show ST-segment uepiession anu T-wave inveision
!"#$%&'"':
Naue by clinical piesentation anu baseu on symptoms



!'.(,*./, B; #/1-/(
Acute Sublingual nitioglyceiin (acts in
1-2 min)
Nay take nitio up to S times
eveiy S-S minutes
Lack of ielief may inuicate
infaiction in piogiess
Chionic Pievention Long-acting nitiates foi
piophylaxis
#-blockeis ! myocaiuial u2
consumption when stiesseu
Aspiiin to pievent PLT
aggiegation in atheioscleiotic
plaque
Smoking cessation
!LBL "BBL thiough uiet

Enuovasculai Inteivention Peicutaneous tiansluminal
coionaiy angioplasty
Inuicateu when theie's a failuie in
meuical management
Stent placement can ieuuce ie-
stenosis by 2u%-Su%
uPIIb-IIIa antagonists fuithei
ieuuce stenosis iate
Suigeiy Coionaiy aiteiy bypass giaft
Inuicateu when meuical
tieatment fails


$/0,(ND. #/1-/(
Symptoms aie similai to angina but occui moie fiequently anu without any
ielation to exeitionactivity, occuiiing at iest
0nstable angina = ischemia
0nstable angina anu non-ST-elevation NI aie a closely ielateu
EKu uuiing ischemia usually shows ST-segment uepiession oi T-wave
inveision
LABS aie (+) foi caiuiac enzymes



12*#,+*%,:
Baseu on the likelihoou that it will piogiess to a potentially fatal outcome (ie.
Risk of iecuiient unstable angina, infaiction, oi ueath Su uays aftei
piesentation).

@'-/T*.,(D80 #/1-/(
Is causeu by a coionaiy aiteiy vasospasm
EKu shows ST-segment elevation
ST elevation is tiansient anu caiuiac enzymes aie usually negative, which
helps uiffeientiate fiom an NI
Tieatment is vasouilatois (nitioglyceiin oi CCB's)
Patient shoulu unueigo catheteiization because vasospasm often occuis at
the site of an atheioscleiotic lesion in the coionaiy aiteiies.

A! 7D.:(,-B/ %9B<('2-(D >/;('<,-B/ \A!7%>^
Infaiction usually seconuaiy to acute thiombosis in an atheioscleiotic vessel

-"$%' #%. -/+0,&+'8
Ciushing substeinal pain that is not ielieveu by iest
Biaphoiesis
Nauseavomiting
Tachycaiuia oi biauycaiuia
Byspnea

!"#$%&'"':
EKu will show ST elevation anu Q waves

Caiuiac enzymes elevateu (CK-NB, tioponin I) - CK-NB noimalizes within
72hi


12*#,+*%,:
Re-establish vessel patency
#1

piioiity ! aspiiin (pioven to ! moitality)
#2 piioiity ! #-blockei (pioven to ! moitality)
Statins to lowei cholesteiol (goal is to get LBL <1uu post-infaict)
u2 + moiphine (pain contiol)
Nitio to ieuuce pieloau anu afteiloau
ACEI's aie excellent late anu long-teim theiapy (! afteiloau anu pievent
iemoueling)
Consult about smoking cessation

E&',D)> !"';5#2$* >%',2=;,"&%'8
ASA
#-blockei
Statin
ACEI














7PG ;-/2-/10 (/2 #''39,3*-(0

O.(', 4DB<Q0F
E);%0D.+A;++ !F -#$'B ! noimal sinus ihythm with PR inteival % u.2ms
9+'$(.D.+A;++f 0=>+ C KS+'B+(-,'1L -#$'B ! PR inteival elongates fiom beat to
beat until a PR is uioppeu
9+'$(.D.+A;++f 0=>+ T K@$-)0bL -#$'B ! PR inteival fixeu but theie aie iegulai
non-conuucteu P-waves leauing to uioppeu beats
71);.D.+A;++ -#$'B ! no ielationship between P waves anu QRS complexes.
Piesents with junctional escape ihythms oi ventiiculai escape ihythm

#,'-(D K-N'-DD(,-B/
The most common chionic aiihythmia
Fiom ischemia, atiial uilatation, suigical histoiy, pulmonaiy uiseases, toxic
synuiomes
Classically, the pulse is iiiegulaily iiiegulai

-"$%' #%. -/+0,&+'8
Chest uiscomfoit

Palpitations
Tachycaiuia,
Bypotension + syncope
12*#,+*%,:
Contiol iate with #-blockeis, CCB's, anu uigoxin (not acutely)
If fibiillations last >24hi then shoulu anticoagulate with waifaiin foi at least
S weeks befoie caiuioveision (pievents embolisms)
If you cannot conveit to noimal sinus ihythm, the patient will iequiie long-
teim anticoagulation. 1
st
line is waifaiin, 2
nu
line is aspiiin
Caiuioveision to conveit to noimal ihythm:
1
st
line ! Iv piocainamiue, sotalol, amiouaione
Electiical ! shock of 1uu-2uu} followeu by S6u}
#,'-(D KD),,.'
Less stable than Afib
The iate is slowei than that of atiial fibiillation (appioximately 2Su-
SSubpm)
ventiiculai iate in atiial fluttei is at iisk of going too fast, thus atiial fluttei is
consiueieu to be moie uangeious (meuically slowing this iate can cause a
paiauoxical inciease in ventiiculai iates)
Classic ihythm is an atiial fluttei iate of Suubpm with a 2:1 block iesulting in
a ventiiculai iate of 1Subpm
Signs anu symptoms similai to those of atiial fibiillation
Complications incluue syncope, embolization, ischemia, heait failuie
Classic EKu finuing is a "sawtooth" pattein:


12*#,+*%,:
If patient is stable, slow the ventiiculai iate with CCB's oi #-blockeis (avoiu
piocainamiue because it can iesult in incieaseu ventiiculai iate as the atiial
iate slows uown)
If caiuioveision is going to take place be suie to anticoagulate foi S weeks
If patient is unstable must caiuioveit ! stait at only Su} because is easiei to
conveit to noimal sinus ihythm than atiial fibiillation


%)D,-;B<(D #,'-(D !(<39<('2-( \%K#!^
An iiiegulaily iiiegulai ihythm wheie theie aie multiple concuiient
pacemakeis in the atiia.
Commonly founu in pts with C0PB
EKu shows tachycaiuia with % S uistinct P waves

12*#,+*%,:
veiapamil
Tieat any unueilying conuition




A)+'(:./,'-<)D(' !(<39<('2-(
Nany tachyaiihythmias oiiginating above the ventiicle
Pacemakei may be in atiium oi Av junction, having multiple pacemakeis
active at any one time
Biffeientiating fiom ventiiculai aiihythmia may be uifficult if theie is also
the piesence of a bunule bianch block
12*#,+*%,:
veiy uepenuent on etiology
Nay neeu to coiiect electiolyte imbalance
Nay neeu to coiiect ventiiculai iate |uigoxin, CCB, #-blockeis, auenosine
(bieaks 9u% of SvT)j
If unstable iequiies caiuioveision
Caiotiu massage if patient has paioxysmal SvT



M./,'-<)D(' !(<39<('2-(
vTach is uefineu as % S consecutive piematuie ventiiculai contiactions
If sustaineu, the tachycaiuic peiious last a minimum of Sus.
Sustaineu tachycaiuia iequiies immeuiate caiuioveision uue to iisk of going
into ventiiculai fibiillation



12*#,+*%,:
If hypotensive oi no pulse existent uo emeigency uefibiillation (2uu, then
Suu, then S6u})
If patient is asymptomatic anu not hypotensive, the fiist line tieatment is
amiouaione oi liuocaine because it can conveit ihythm back to noimal

M./,'-<)D(' K-N'-DD(,-B/
Eiiatic ventiiculai ihythm is a fatal conuition.
Bas no ihyme oi ihythm


-"$%' #%. -/+0,&+'8
Syncope
Seveie hypotension
Suuuen ueath


12*#,+*%,:
1
st
line - Emeigent caiuioveision is the piimaiy theiapy (2uu-Suu-S6u}),
which conveits to noimal ihythm almost 9S% of the time
Chest compiessions iaiely woik
2
nu
line - Amiouaione oi liuocaine
If tieatment isn't given in a timely mattei, patient expeiiences failuie of
caiuiac output anu this piogiesses to ueath.



















5B/1.0,-:. O.(', K(-D)'.

!*6"%","&%:
- CBF occuis when the caiuiac output is insufficient to met systemic uemanus
- Nay be iight-siueu, left-siueu, oi both
3#='*':
- valvulai uiseases
- NI
- Bypeitension
- PE
- Anemia
- Caiuiomyopathy
- Euocaiuitis
- Thyiotoxicosis

-"$%' #%. -/+0,&+'8
O+&0D%).+.: signs anu symptoms aie uue to ! C0 anu " caiuiac piessuies
- Paioxysmal noctuinal uyspnea
- Exeitional uyspnea
- 0ithopnea
- Caiuiomegaly
- SS gallop
- Renal hypopeifusion (leaus to souium ietention anu woiseneu CBF)
M)A10D%).+.: signs anu symptoms aie uue to pooling upstieam of the iight heait
- " }vP
- Euema
- Bepatic congestion
- Atiial fibiillation (incieases iisk of embolization)
- Fatigue
- Cyanosis
- Weight loss
Biagnose with echocaiuiogiam
12*#,+*%,:
C
%0
#)(+ ;+A)2+( ! ACEI, #-blockeis, fuiosemiue anu spiionolactone, anu uigoxin
If patient cannot toleiate ACEI, tiy hyuialazine + isosoibiue uinitiate


!:34% 1,?+ -++( >;$?+( 0$ .+';+,%+ 2$;0,#)0= )( :VE
"D-#$'B+;% 1,?+ -++( 0$ .+';+,%+ 2$;0,#)0=
- Bon't stait #-blockeis uuiing active failuie because they can exaceibate the
conuition
- Stait #-blockeis once patient is fully uiuieseu anu is on stable uoses of othei
meuications
9>);$($#,'0$(+ >;$?+( 0$ .+';+,%+ 2$;0,#)0= )( '#,%% 4F :VE
O$$>% ,#2$%0 ,#/,=% *%+. 0$ 2,)(0,)( .;= /+)A10 )( :VE >,0)+(0%
R)A$Q)( )2>;$?+% %=2>0$2% -*0 R539XG7 .+';+,%+ 2$;0,#)0=
J+ /,;= $& A)?)(A O$$> .)*;+0)' /)01$*0 %>);$($#,'0$(+ -+',*%+ 01)% ',( ',*%+
,( *(%,&+ 1=>$B,#+2), 01,0 >$0+(0),0+% 01+ +&&+'0 $& .)A$Q)( KC
%0
%)A( $& .)A$Q)(
0$Q)')0= )% , 9F7 /)01 !F -#$'B ,(. -#*;;= =+##$/ ?)%)$(L














5('2-B*9B+(,3-.0

6-D(,.2 O9+.','B+3-< ".0,'-<,-:.
5()0. Ischmia, infections,
metabolic
conuitions, uiugs
uenetic myosin
uisoiuei
Amyloiuosis,
scleioueima,
hemochiomotosis,
glycogen stoiage
uisease,
saicoiuosis
A-1/0 d
A9*+,B*0
Right anu left siueu
heait failuie, SS
gallop, %=%0$#)'
.=%&*('0)$(
Exeitional
syncope, angina,
LvB, .),%0$#)'
.=%&*('0)$(
Pulmonaiy BTN,
S4 gallop, ! QRS
uysfunction
@'B1/B0-0 Su% Syi suivival
iate
S% annual
moitality iate
Su% S-yi suivival
!'.(,*./, Stop offenuing
agents, tx is similai
to CBF tieatment
#-blockeis anu
uiuietics
Biuietics anu
coiiection of
unueilying cause
Biagnosis foi each is echocaiuiogiaphy













M(D:)D(' 6-0.(0.0

E2*'*%,#,"&%:
- valvulai heait uiseases all piesent with shoitness of bieath as the chief
complaint
- 0ften woisens with exeitionexeicise
5D). ,B 6-(1/B0-0 6-(1/B0-0
[B)/1 ;.*(D. (/2JB' 1./.'(D
+B+)D(,-B/
%-D,'(D M(D:. @'BD(+0. \%M@^
O.(D,39 9B)/1 (,3D.,. >2-B+(,3-< O9+.','B+3-< A)N(B',-<
A,./B0-0 \/BE <(DD.2F O9+.','B+3-<
BN0,')<,-:. <('2-B*9B+(,39 O?%5^
>**-1'(/,C +'.1/(/, %-,'(D A,./B0-0
!)'/.'80 09/2'B*. 4-<)0+-2 (B',-< :(D:.
@(D+-,(,-B/0C (,9+-<(D <3.0, +(-/ /B,
(00B<-(,.2 E-,3 .V.',-B/
%-,'(D M(D:. @'BD(+0.

E5/'";#7 C"%."%$'8
- Nuimui anu iales (seen in all cases)
- Peiipheial euema, gallops, caiotiu pulse finuings (possibly seen)

)=2+=2':
Systolic:
- Nost commonly seen in aoitic stenosis, mitial ieguigitation, NvP, anu B0CN
Biastolic:
- Nost commonly seen with aoitic ieguigitation anu mitial stenosis.

All iight-siueu muimuis >L5"7#A7 in intensity with inhalation
All left-siueu muimuis 675"7#A7 in intensity with exhalation




B&;#,"&% #%. O#."#,"&% &6 +=2+=2'8
valvulai Lesion Best heaiu at
Aoitic Stenosis 2
nu
iight inteicostal space anu iauiates
to the caiotius
Pulmonic valve 2
nu
left inteicostal space
Aoitic ieguigitationtiicuspiuvSB Left lowei steinal boiuei
Nitial ieguigitation Apex (left S
th
inteicostal space)

)=2+=2 "%,*%'",/8
IvI ! only heaiu with special maneuveis (valsalva)
IIvI anu IIIvI ! majoiity of muimuis
IvvI ! thiill piesent
vvI ! can be heaiu with stethoscope paitially off of the chest
vIvI ! can be heaiu without a stethoscope
!"#$%&'"':
- Best initial uiagnostic test foi valvulai lesions is
echocaiuiogiam
- The most accuiate test is left heait catheteiization
12*#,+*%,:
M+A*;A)0,(0 #+%)$(% ! best tieateu with vasouilatoi theiapy
(ACEI, ARB)
90+($0)' #+%)$(% ! best tieateu with anatomic iepaii (mitial
stenosis iequiies balloon valvuloplasty, seveie aoitic stenosis
iequiies suigical ieplacement)


#B',-< A,./B0-0
- Nost commonly piesents with chest pain
- Syncope anu CBF aie less commonly piesent with aoitic stenosis
- Patient is often oluei anu has a histoiy of hypeitension

E2&$%&'"':
- If coionaiy uisease is piesent then S-Syi is avg suivival
- If syncope is piesent then 2-S yi avg suivival
- If CBF piesent then 1.S-2yi avg suivival
A tiick to know
what type of
theiapy you shoulu
use:
If the valsalva
maneuvei
impioves the
muimui, use
uiuietics.
If amyl nitiate
impioves the
muimui, ACEI is
inuicateu.

!"#$%&'"':
- TTE is the best initial uiagnosis
- TEE is moie accuiate
- Left heait catheteiization is the most accuiate
- EKu anu CXR will show LvB
12*#,+*%,:
- Biuietics aie the best initial theiapy but uo not altei the long-teim
piognosis, anu special attention must be paiu since ovei-uiuiesis is a possibility
- Tieatment of choice is valve ieplacement

#B',-< ".1)'1-,(,-B/
- BTN
- Rheumatic heait uisease
- Enuocaiuitis

-"$%' #%. -/+0,&+'8
- Biastolic ueciescenuo muimui heait best at the left steinal boiuei
!"#$%&'"':
- TTE is best initial uiagnostic test
- TEE is moie accuiate
- Left heait catheteiization is most accuiate
Tieatment:
- ACEI's
- ARB's
- Nifeuipine

If ejection fiaction uiops below SS% oi the Lv enu-uiastolic uiametei goes
above SSmm, suigeiy shoulu be uone even if the patient is asymptomatic.






%-,'(D A,./B0-0F
- NCC of mitial stenosis is iheumatic fevei
- Seen in immigiants anu piegnant patients (incieaseu plasma vol in
piegnancy)

-"$%' #%. -/+0,&+':
- Bysphagia (laige left atiium compiesses esophagus)
- Boaiseness (piessuie on iecuiient laiyngeal neive)
- Atiial fibiillation
E5/'";#7 IK#+8
- Biastolic iumble aftei an opening snap
!"#$%&'"':
- TTE is best initial uiagnostic test
- TEE is moie accuiate
- Left heait cath is most accuiate
- EKu anuoi CXR showing left atiial hypeitiophy
12*#,+*%,:
- Best initial theiapy is uiuietics, howevei they uo not altei piogiession of
the uisease
- Balloon valvuloplasty is the most effective theiapy (all piegnant women
must have this pioceuuie uone)

%-,'(D ".1)'1-,(,-B/
- Causeu by BTN, ischemic heait uisease, anu any conuition that may leau to
uilation of the heait
- The most common complain is uyspnea on exeition

E5/'";#7 *K#+ 6"%."%$'8
- Bolosystolic muimui that obscuies both S1 anu S2
- Best heaiu at the apex, iauiates to the axilla
!"#$%&'"':
- TTE is best initial test
- TEE is moie accuiate

Tieatment:
- ACEI
- ARB's
- Nifeuipine
- If Lv ejection fiaction uiops below 6u% oi Lv enu systolic uiametei is
above 4Smm, then suigeiy shoulu be uone




















@.'-<('2-(D 6-0.(0.

@.'-<('2-,-0
- Pleuiitic chest pain
- Relieveu by leaning foiwaiu
- Pain often uesciibeu as shaip anu biief

-"$%' #%. -/+0,&+'8
- Fiiction iub is commonly founu
- No othei peitinent physical finuings
!"#$%&'"':
- Best initial test is the EKu
- Biffuse ST-segment elevation
- PR-segment uepiession is pathognomonic but is not always piesent
12*#,+*%,:
- Best initial theiapy is NSAIB's
- Patient shoulu ietuin in 1-2 uays, if the pain is gone they aie cuieu
- If pain peisists aftei 2 uays of NSAIB tieatment, pieunisone oially is
tieatment












@.'-<('2-(D !(*+B/(2.
- Piesents with S0B, hypotension, }vB + cleai lungs
- Pulsus paiauoxus is piesent (uecieaseu BP >1ummBg on inspiiation)
- Electiical alteinans is piesent (alteiation of QRS complex on EKu

!"#$%&'"':
- Echo is the most accuiate uiagnostic test
- Eailiest finuing is usually collapse of the iight atiium anu ventiicle
- EKu shows low voltage anu electiical alteinans
- Right heait catheteiization will show equalization of all piessuies in the
heait uuiing uiastole
12*#,+*%,:
- Best initial theiapy is a peiicaiuiocentesis
- Nost effective long-teim theiapy is peiicaiuial winuow placement


5B/0,'-<,-:. @.'-<('2-,-0
- Piesents with S0B
- Euema
- }vB
- Ascites
- Bepatosplenomegaly
R%"Z=* 6*#,=2*' &6 ;&%',2";,"G* 0*2";#2.","'8
- A peiicaiuial knock, which is an extia uiastolic sounu fiom the heait hitting
the calcifieu peiicaiuium
!"#$%&'"':
- CXR showing calcification
- Low voltage EKu
- Thickeneu peiicaiuium on CT
12*#,+*%,:
- Biuietics aie the best initial theiapy
- Peiicaiuial stiipping is the most effective theiapy



Chapter 8

Endocrine










@-,)-,('9 6-0B'2.'0

@'BD(<,-/B*(
Piolactin-secieting tumoi
Always think of this when theie is visual uistuibances

-"$%' #%. -/+0,&+'8
Nen:
Impotence
Becieaseu libiuo
uynecomastia
Nost often men also piesent with heauache anu visual uistuibacnes
Women:
Amenoiihea
ualactoiihea
Both in the absence of piegnancy
!"#$%&'"':
Rule out piegnancy
Rule out uiugs such as: Netoclopiomiue, Phenothiazines, anuoi TCA
NRI to confiim piesence of tumoi
12*#,+*%,:
1
st
line tieatment is a uopamine agonist such as biomociiptine (most
piolactinomas iesponu to BA agonists)
If meuical theiapy uoesn't woik, suigical iemoval is uone







#<'B*.1(D9
Excess piouuction of uB uue to a uB-piouucing auenoma in the pituitaiy

-"$%' #%. -/+0,&+'8
Enlaigement of the heau, hanus, feet, nose, anu jaw
Nay be enlaigement of the sweat that can cause intense sweating
}oint abnoimalities (excess giowth of aiticulai caitilage)
Amenoiihea
Caiuiomegaly anu hypeitension
Colonic polyps
Biabetes also common because insulin is antagonizeu by uB
!"#$%&'"':
Best initial test is IuF (confiims uiagnosis of aciomegaly)
Nost accuiate test is auministiation of glucose (noimally shoulu suppiess
uB, if it suppiesses uB then this excluues aciomegaly)
NRI uone aftei theie is a ieason foi uoing so
12*#,+*%,:
Tiansphenoiual iemoval
BA agonist to inhibit uB ielease
0ctieotiue has some meiit in pieventing uB ielease
Pegvisomant ! a uB ieceptoi antagonist










6-(N.,.0

!9+. a 6%
Autoimmune uestiuction of pancieatic #-cells, leaus to insulin ueficiency

-"$%' #%. -/+0,&+'8
Polyuiia, polyphagia, polyuipsia
Weight loss
BKA ! emeigency
!"#$%&'"':
Ranuom plasma glucose >2uu with symptoms 0R
Two measuiement of fasting glucose >12S
2hi oial glucose toleiant test >2uu with oi without symptoms
12*#,+*%,:
Insulin ieplacement
3&+07";#,"&%':
BKA
-"$%' #%. -/+0,&+' &6 !_@8
Bypeiglycemia >2Su
Bypeikalemia (uue to tianscellulai shift out of the cell in exchange foi B+)
Low pB
Elevateu levels of acetone, acetoacetate, anu #-hyuioxybutyiic aciu
Incieaseu anion gap
RH! 0;+,02+(0<
1
st
! Iv fluius
2
nu
! potassium ieplacement(hypei becomes hypo as BKA is tieateu), insulin
ieplacement
S
iu
! auuition of glucose to insulin uiip when pt becomes noimoglycemic (keep
giving insulin until ketones aie gone)
** insulin is given oiiginally to shut uown ketogenesis, not ueciease glucose, thus
keep giving insulin until ketones aie gone uespite noimal glucose.


!9+. R 6%
A peiipheial insulin iesistance
0sually auult onset (changing with the obesity epiuemic)
Family histoiy often plays a stiong iole
Ketosis is N0T associateu with BN2

-"$%' #%. -/+0,&+'8
Acute ! SP's (polyuypsia, polyphagia, polyuiia), fatigue, weight loss
Subactue ! infections (yeast infections, Nucoi, S. Auieus)
Chionic signs anu symptoms:
Naciovasculai ! stioke, CAB
Niciovasculai ! ietinitis, nephiitis
Neuiopathy ! paiasthesia, stocking anu glove buining sensation, autonomic
insufficiency, ! sensation

Biagnosis: same as type 1
12*#,+*%,:
FIRST tieatment is always uiet anu lifestyle mouifications
0ial hypoglycemics foi milumoueiate uisease
1
st
line ! metfoimin (biguaniue), its N0A is blocking gluconeogenesis
2
nu
line ! sulfonyluiea (glybuiiue), N0A is " #-cell insulin secietion
S
iu
line ! Thiazoliuineuiones (pioglitazone), N0A is incieasing tissue
sensitivity to insulin
If oial uiugs uon't woik, patient may iequiie insulin
Lifelong cases most usually will iequiie insulin tieatment
ACEI's impoitant because they slow uown the piogiession of uiabetic
nephiopathy

)&%",&2"%$ !) :",5 ?4@P;8
BbA1c allows us to get a measuie of the aveiage glucose level ovei the past S
months
Tight glucose contiol is uiiectly iesponsible foi uecieasing complications anu
moitality in both types of insulin
An BbA1c <7 oi 8 is iecommenueu (this # is always uecieasing)


3&+07";#,"&%' &6 !)Q8
?/0*2&'+&7#2 ?/0*2$7/";*+"; S&%9*,&,"; 3&+#T??S_U8
0ften piecipitateu by stiess, seconuaiy to hypovolemia
ulucose can become >1uuumguL
Theie is no aciuosis (as in type 1 BN)

12*#,"%$ ??S_8
Iv fluius aie most impoitant, iehyuiation is often all that is neeueu.
Nay iequiie upwaius of 1uL of fluius
Without tieatment, moitality iate climbs ovei Su%


5B*+D-<(,-B/0 B; 6-(N.,.0
V=>+;0+(%)$( ! Contiol is essential in BN patients because it causes long-teim
complications of the heait, eye, kiuney, anu biain. uoal is to keep it <1Su9u
O)>). @,(,A+2+(0 ! uoals aie: LBL <1uu, if patient has CAB + BN, the goal is <7u.
M+0)($>,01= ! Biabetics iequiie a yeaily eye exam to uetect piolifeiative
ietinopathies. If piesent, lasei coagulation shoulu be peifoimeu.
X+>1;$>,01= ! If any foim of piotein is piesent in the uiine give the BN pt ACEI's.
These pievent nephiopathies anu ACEI's aie 1
st
line uiugs in BN with BTN
X+*;$>,01= ! Yeaily foot exams aie impoitant. If neuiopathy is piesent theie is
no neeu to uelay tieatment with gabapentin oi piegabalin.
3;+'0)#+ R=%&*('0)$( ! Ask patient about this, siluenafil oi taualafil woik well but
uo not give if they aie also on nitiates
N,%0;$>,;+%)% ! Noie common in long-teim uiabetics, theie is impaiieu stietch-
ieceptois anu thus impaiieu motility. Patient will have bloating, constipation,
fullness, anu uiaiihea. uive metoclopiamiue oi eiythiomycin (inciease gastiic
motility)

6-(N.,.0 !9+. a !9+. R
?/0., }uvenilechiluhoou Auult (incieasingly
common in youth touay)

4B29 !9+. Thin 0bese
6P#s Fiequent Raie
!'.(,*./, Insulin 1
st
- lifestyle 2
nu
- oial
hypoglyclemic agents






















#2'./(D 6-0B'2.'0

5)03-/180 A9/2'B*.
Theie aie S souices of Cushing's uisease, they aie listeu in this table along with
peitinent infoimation
@-,)-,('9 !)*B' 7<,B+-< #5!O
@'B2)<,-B/
#2'./(D #2./B*(
#5!O Bigh Bigh Low
O-13Y2B0.
2.V(*.,3(0B/.
Suppiession No suppiession No suppiession
A+.<-;-< ,.0, NRI, petiosal vein
sampling
Scan the chest anu
abuomen
Scan the auienals
!'.(,*./, Removal Removal Removal

Theie is a common piesentation of all patients with
hypeicoitisolism:
E,0 ;+.)%0;)-*0)$(: Tiuncal obesity, buffalo hump, thin aimslegs, "moon
facies"
90;),+ ,(. +,%= -;*)%)(A< Bue to a loss of collagen(coitisol thins the skin)
V7X: Bue to fluiu anu souium ietention
V);%*)0)%2: fiom incieaseu auienal anuiogen levels
@*%'#+ /,%0)(A

!"#$%&'"':
1. 1mg oveinight uexamethasone suppiession test: noimally a peison will
suppiess the 8am level of coitisol if given uexa at 11pm the pievious night. A
noimal test (suppiession) will iule out hypeicoitisolism of all kinus. ** a test
may be elevateu uue to othei factois such as uepiession, alcoholism, oi
excessive stiess

2. 24-hi uiine coitisol: this test auus specificity to the oveinight
uexamethasone test, if the oveinight test was abnoimal (failing to suppiess
ACTB), then this test confiims hypeicoitisolism.
** these tests aie to uiagnose the piesence of Cushing's synuiome, the location is
still unknown at this point.


!"#$%&'"%$ ,5* 7&;#,"&%:
Looking at the ACTB can help iuentify the location
If ACTB is high ! souice of pioblem is the pituitaiy oi ectopic ACTB
piouuction
If ACTB is low ! souice is the auienal

12*#,+*%,:
Removal of whatevei is causing the pioblem, iuentifieu by NRI oi abuominal
scan (uepenuing on the location of the pioblem)


#22-0B/80 6-0.(0. \(2'./(D -/0);;-<-./<9^
Can be piimaiy (Auuison's) oi seconuaiy (! ACTB piouuction fiom pituitaiy)

!..)%$(G% .)%+,%+<
NC is autoimmune uisoiuei
Wateihouse-Fiiueiichsen may be cause, which is hemoiihagic neciosis of the
auienal meuulla uuiing the couise of meningococcemia
-"$%' #%. -/+0,&+'8
Fatigue
Anoiexia
Byponatiemia + hypeikalemia
Bypotension
Nauseavomiting
Constipation
Bypeipigmentation (only in piimaiy case)

!"#$%&'"':
" ACTB anu ! coitisol (in iesponse to ACTB)
Bypeipigmentation
If cause is seconuaiy, then coitisol will " in iesponse to ACTB
12*#,+*%,:
Foi acute Auuison's give fluius + hyuiocoitisone
Foi stable patient give pieunisone
If patients uo not iesponu to above tieatments, give fluuiocoitisone (highest
# of mineialocoiticoius)


#2'./(D 5B',-<(D O9+.';)/<,-B/
C V=>+;,#.$%0+;$()%2 K:$((G% 9=(.;$2+L<
Nost commonly uue to an auenoma oi hypeiplasia of the zona glomeiulosa
of the auienal glanu
-"$%' #%. -/+0,&+'8
Bypeitension
"Na+
"Cl-
!K+
! ienin
!"#$%&'"':
" aluosteione
! ienin
CT showing auienal lesion
12*#,+*%,:
If auenoma ! suigical iesection
If hypeiplasia ! spiionolactone





T V=>+;,#.$%0+;$()%2<
Incieaseu ienin piouuction 2 to uecieaseu ienal bloouflow(CBF, shock,
ienal aiteiy stenosis)
!"#$%&'"':
" ienin (this is useu to uiffeientiate between 1 anu 2 causes
12*#,+*%,:
Tieat unueilying cause
Tieat BTN

@3.B<'B*B<9,B*(
E#,"*%, 02*'*%,' :",58
Episouic BTN
Beauache
Palpitations
Tachycaiuia
Biaphoiesis
!"#$%&'"':
Best initial tests ! high plasma anu uiinaiy catecholamineplasma-fiee
metanephiine anu vNA levels
Nost accuiate tests ! CT oi NRI of auienal glanus
12*#,+*%,:
1
st
- phenoxybenzamine to contiol BP
2
nu
- piopianolol (only aftei $-blockaue with phenoxybenzamine)
S
iu
- suigical iesection








Nale uonaual Bisoiueis
6-0.(0. 53('(<,.'-0,-<0 Tieatment
Klinfeltei's
Synuiome
XXY inheiitance with vaiiable expiessivity
Biagnosis usually at pubeity when no viiilization
Tall with small testes anu gynocomastia
Becieaseu testosteione
" LBFSB (no feeuback)
Bx with buccal smeai showing baii bouy
Testosteione
Supplements
XXY synuiome Nilu mental ietaiuation, acne, violent, antisocial
behavioi
Biagnose with kaiyotype analysis
None
Testiculai
feminization
synuiome
Befect in BBT ieceptoi
Female exteinal genitalia with steiile, unuescenueu
testes
Patient appeais female but is steiile with blinu
vagina
TestosteioneestiogenLB aie all elevateu
No tx
Remove
testes
S-$-ieuuctase
ueficiency
Ambiguous genitalia until pubeity
At pubeity a buist of testosteione oveicomes the lack
of BBT (masculinizing exteinal genitalia)
Testosteione anu estiogen aie noimal
Biagnosis is by genetic testing
Testosteione
Congenital
auienal
hypeiplasia
A uefect in the steioiu synthesis pathway causes
viiilization of females oi failuie to viiilize in males
21-$-hyuioxylase ueficiency causes 9S% of all CAB
cases
seveie uisease piesents in infancy with ambiguous
genitalia anu excess salt loss
less seveie ! minimal viiilization anu salt loss
Boimone
ieplacement
Piauei-Willi
synuiome
pateinal impiinting
shoit limbs, floppy baby
hypeiphagia ( obesity ! incieases eaily ueath
likelihoou)
mental ietaiuation
classically have almonu-shapeu eyes with stiabismus
uiagnosis is genetic analysis
None
Kallmann's
synuiome
AB hypogonauism with anosmia
Becieaseu piouuction anu secietion of unRB by
hypothalamus
Biagnosis maue by finuing uecieaseu ciiculating LB
anu FSB
Pulsatile
unRB







!39'B-2 6-0B'2.'0

The clinical uiffeiences between hypeithyioiuism anu hypothyioiuism
BYP0TBYR0IBISN BYPERTBYR0IBISN
Weight uain Loss
Intoleiance Colu Beat
Baii Couise Fine
Skin Biy Noist
Nental Bepiesseu Anxious
Beait Biauycaiuia Tachycaiuia
Nuscle Weak Weak
Reflexes Biminisheu
Fatigue Yes Yes
Nenstiual Changes Yes Yes

O9+B,39'B-2-0*
Nost commonly fiom 'buinout' Bashimoto's thiyoiuitis.
Patient is fatigueu
Poveity of movement
uaining weight

!"#$%&'"':
" TSB
! T4
12*#,+*%,:
Thyioxine
T4(conveiteu in the tissue to TS as neeueu)

O9+.',39'B-2-0*
" T4 levels
! TSB
4 foims of hypeithyioiuism: uiaves(NC), Silent, Subacute, Pituitaiy auenoma



N;,?+G% R)%+,%+<
Bas many finuings that aie unique to this type of hypeithyioiuism:
Exophthalmos anu pioptosis
Beimopathy (ieuness anu thickeneu skin below the knee)
0nycolysis (sepeiation of the nail fiom the nailbeu)
RAI0 is elevateu
12*#,+*%,:
PT0 oi methimazole is given acutely to biing the glanu unuei contiol
Aftei glanu is contiolleu, use iauioactive iouine ablation
Piopianolol useu to tieat sympathetic symptoms

9)#+(0 71=;$).)0)%<
An autoimmune piocess with a non-tenuei glanu anu hypeithyioiuism
No eye, nail, oi skin finuing
RAI0 test is noimal
ulanu is not in a state of hypeifunctioning, iathei it is "leaking"
Antibouies to thyioiu peioxiuase anu antithyioglobulin antibouies may be
piesent
12*#,+*%,: Theie is no tieatment

9*-,'*0+ 71=;$).)0)%F
A conuition of viial etiology
ulanu is tenuei
!"#$%&'"':
TSB low
T4 incieaseu
RAI0 low
12*#,+*%,:
Aspiiin to ielieve the pain




8)0*)0,;= !.+($2,<
Raie conuition
Is the only hypeithyioiu uisoiuei with an elevateu TSB
!"#$%&'"':
NRI of biain
12*#,+*%,:
Removal of auenoma

7VB1./B)0 !39'B-2 OB'*B/.0 #N)0.F
Will be an elevation in T4 (uue to taking thyioiu hoimone)
The TSB will be suppiesseu uue to negative feeuback
Thyioiu glanu will atiophy

71=;$). 90$;2:
This is an emeigency situation wheie theie is seveie ielease of thyioiu
hoimones fiom the thyioiu glanu
Causes symptoms of extieme sympathetic stimulation (tiemoi, tachycaiuia,
uiaphoiesis, etc)
12*#,+*%,:
1
st
! give iouine to block the uptake of iouine into the glanu
2
nu
! give PT0 oi methimazole to block thyioxine piouuction
S
iu
! uexamethasone to block the peiipheial conveiion of T4! TS
4
th
! block sympathetic effects with piopianolol

@=Q+.+2, :$2,:
An emeigency hypothyioiu conuition
Nay be spontaneous oi ppte by colu conuitions, infections, seuative uiugs,
iespiiatoiy failuie
-"$%' #%. -/+0,&+'8
Bypoventilation
Bypotension

Stupoi
Coma
Seizuies
12*#,+*%,:
Levothyioxine
Coitisone
Intubate


!39'B-2 %(D-1/(/<-.0
All solitaiy uominant nouules shoulu be uiagnoseu by FNA
Excision if malignancy is suspecteu
Bot nouules (a nouule that takes up moie iauioactive iouine) aie less likely
to be malignant
Colu nouules (nouules that take up less iauioactive iouine) aie moie likely to
be malignant
E#0"77#2/ ;#%;*28
Nost common type of thyioiu
Best piognosis (8S% S-yi suivival iate)
Psammoma bouies & oiphan-annie bouiesgiounu-glass nuclei
C&77";=7#2 ;#%;*2:
uoou piognosis
Common metastasis to bone anu lungs
)*.=77#2/ ;#%;*28
Piognosis is inteimeuiate
Is a cancei of the paiafolliculai "C" cells that aie ueiiveu fiom cells of the S
th

bianchial pouch
Secietes calcitonin
@%#07#',"; ;#%;*2:
Teiiible piognosis
Bas a u% S-yi suivival iate



%)D,-+D. 7/2B<'-/. L.B+D(0-(F
Type 1 (Weimei's) S P's: Pituitaiy, Pancieas, Paiathyioiu
Type 2 (Sipple's) Pheociomocytoma, Neuullaiy Thyioiu
CA, Paiathyioiu
Type 2b (Type S) Pheociomocytoma, Neuullaiy Thyioiu
CA, Nucocutaneous neuiomas(esp in uI)












Chapter 9

Infectious
Disease









Answeiing questions in the infectious uisease section aie usually pietty stiaight
foiwaiu. Being able to coiiectly answei these questions comes uown to
unueistanuing the following:
1. Common conuitions anu theii associateu oiganisms
2. Common conuitions anu the best antibiotics to use
S. 0iganisms anu theii giam stain chaiacteiistics
4. Common scenaiios anu theii commonly associateu oiganisms

Foi gieatest chances of success with these questions, the following tables shoulu be
memoiizeu.

N;,2 90,)( :1,;,'0+;)%0)'%
?"G#L>A% 5O#"#5!7">A!>5A A!#>L>LG 5O#"#5!7">A!>5A
uiam (+) oiganisms Blue in coloi
uiam (-) oiganisms Reu in coloi
uiam (+) cocci (paiis) S. Pneumonia
uiam (+) cocci (chains) Stieptococcus
uiam (+) cocci (clusteis) Staphylococcus
uiam (-) uiplococci Neisseiia
uiam (-) ious Bemophilus
uiam (-) ious with mucoiu capsule Klebsiella
Pseuuohyphae on stain Canuiua
Aciu Fast 0iganisms Nycobacteiium, Nocaiuia
Silvei Staining Pneumocystis Caiinii
Spiiochete Boiielia,
TieponemaLeptospiia(uaikfielu)










:$22$( %)0*,0)$(% ,(. 01+); ,%%$'),0+. $;A,()%2%
A>!$#!>?L #AA?5>#!76 ?"G#L>A%A
Cellulitis fiom a uog oi cat bite Pasteuiella Nultociua
Buin wounu infection with a bluegieen
coloi
Pseuuomonas
Baby Paialyzeu aftei eating honey Clostiiuium Botulinum
Biaiihea aftei taking antibiotics Clostiiuium Bifficile
Piickeu by thoin while gaiuening Spoiothiix Schenckii
uastioenteiitis in young chilu Rotaviius
Biaiihea aftei tiaveling to Nexico E. Coli
Aplastic ciisis in Sickle Cell patient Paivoviius B19
Foou poisoning aftei eating ieheat iice B. Ceieus
Foou poisoning aftei eating iaw seafoou vibiio Paiahemolyticus
Pneumonia in Southwest 0SA Cocciuioiues Immitis
Pneumonia aftei exploiing caves Bistoplasma Capsulatum
Pneumonia aftei exposuie to biiu
uioppings in 0hio
Bistoplasma Capsulatum
Pneumonia aftei exposuie to exotic
biius
Chlamyuia Psittaci
Pneumonia in a patient with silicosis Tubeiculosis
Biaiihea aftei hiking oi uiinking fiom a
stieam
uiaiuia Lamblia
B12 ueficiency Biphyllobothiium Latum
Fevei anu muscle pains aftei eating iaw
meat
Tiichinella Spiialis
Pneumonia aftei being neai an aii
conuitionei oi watei towei
Legionella Pneumophilia
Slaughteihouse woikei with a fevei Biucellosis
Fungal ballhemoptysis aftei TB oi
cavitaiy lung uisease
Aspeigillus









V)A1D=)+#. '$(.)0)$(%Y)##(+%%+% ,(. 01+); 2$%0 #)B+#= $;A,()%2 ,(. 0;+,02+(0%
5?L6>!>?LJ>HHL7AA ?"G#L>A% 47A! !"7#!%7L!
Cellulitis Staph, Stiep Antistaphylococcus
penicillin
0TI E. Coli TNP-SNX, Nitiofuiantoin
(in piegnancy)
Enuocaiuitis Staph, Stiep Antistaphylococcus,
Aminoglycosiue
Sepsis uiam (-) oiganisms S
iu
geneiation
cephalospoiin's
Septic Aithiitis Staph Auieus Antistaphylococcus PCN,
vancomycin (seveie)
Neningitis (neonatal) uioup B Stiep, E. Coli, oi
Listeiia
Ampicillin +
Aminoglycosiue
Neningitis (chilu - auult) Neisseiia Neningitiuis S
iu
geneiation
cephalospoiin
0steomyelitis Staph Auieus, Salmonella
(Sickle cell patient)
Antistaphylococcus PCN,
vancomycin
Pneumonia Stiep Pneumonia, B.
Influenza
S
iu
geneiation
cephalospoiin
Pneumonia (atypical) Nycoplasma, Chlamyuia Boxycycline, Nacioliue
Bionchitis B. Influenza Amoxicillin, Eiythiomycin














>*+B',(/, -/;B'*(,-B/ '.1('2-/1 O>M

V$/ $&0+( %1$*#. 01+ :R\ '$*(0 -+ '1+'B+.Z Q 6 months
!0 /1,0 >$)(0 )% 8:8 , /$;;= )( V4FY!).% >,0)+(0Z When CB4 is <2uu
S1,0 )% 01+ 2$%0 '$22$( $>>$;0*()%0)' >(+*2$(), )( !4R9Z PCP
V$/ 0$ >;+?+(0 8:8 )(&+'0)$(Z Piophylax with TNP-SNX when CB4 & 2uu
!0 /1,0 :R\ #+?+# %1$*#. >;$>1=#,Q)% ,A,)(%0 @='$-,'0+;)*2 !?)*2 :$2>#+Q -+
%0,;0+.Z When CB4 is <Su
S1)'1 0=>+ $& ',('+; ,;+ V4FY!).% >,0)+(0% ,0 )(';+,%+. ;)%B &$;Z Kaposi's
saicoma
91$*#. #)?+ ?,'')(+% -+ A)?+( .$ 01+%+ >,0)+(0%Z N0
S1)'1 )% 01+ $(#= #)?+ ?,'')(+ 0$ -+ A)?+(Z NNR
S1)'1 0=>+ $& -#$$. .)%+,%+ )% )(';+,%+. )( 01)% >,0)+(0 >$>*#,0)$(Z NBL
S1,0 )% 01+ 2$%0 #)B+#= ',*%+ $& >(+*2$(), )( V4F >,0)+(0Z Stiep Pneumo
S1,0 )% 01+ 2$%0 #)B+#= ',*%+ $& 5>>$;0*()%0)' >(+*2$(), )( V4FZ PCP (be able to
iecognize if the question is asking most common cause oi most common
oppoitunistic cause)
S1)'1 $;A,()%2 ',( ',*%+ '1;$()' .),;;1+, )( !4R9 >,0)+(0%Z Ciyptospoiiuium












Chapter 10

Allergies










O9+.'0./0-,-:-,9 ".(<,-B/0
Type 1 - Anaphylactic (Piefoimeu IgE antibouies)
Type 2 - Cytotoxic (piefoimeu Igu anu IgN antibouies)
Type S - Immune complex-meuiateu (antigen-antibouy complexes uepositeu in
vessels anu cause an inflammatoiy iesponse)
Type 4 - BelayeuCell-meuiateu (sensitizeu T lymphocytes ielease inflammatoiy
meuiatois)

#/(+39D(V-0

Is a typ1 hypeisensitivity ieaction
Bue to piefoimeu IgE antibouies that cause the immeuiate ielease of
vasoactive amines such as histamines anu leukotiienes.
Commonly seen aftei bee stings anu ingestion of meuications such as
penicillin anu sulfa uiugs
8;+%+(0,0)$(:
Symptoms uevelop acutely anu aie often veiy uiamatic
Bifficulty bieathing
Bypotension + tachycaiuia
0iticaiia
Angioeuema

7;+,02+(0Y@,(,A+2+(0<
Secuie aiiway
uive subcutaneous epinephiine
If these aien't available give coiticosteioius
uive antihistamines foi cutaneous ieactions






#/1-B.2.*(

Is most commonly causeu by a ueficiency of C1 esteiase inhibitoi
8;+%+(0,0)$(:
Biffuse swelling of the eyelius, lips, anu aiiway
0sually occuis aftei milu facial tiauma oi ingestion of ceitain meuications
(often ace inhibitois)
Theie is usually a family histoiy
C4 levels aie low
7;+,02+(0Y@,(,A+2+(0:
Secuie aiiway
uive subcutaneous epinephiine
Nanage exactly like anaphylaxis



#DD.'1-< "3-/-,-0

An alleigic ieaction that is veiy common
Recuiiing nasal stuffiness, itching, ihinoiihea, anu sneezing
7;+,02+(0Y@,(,A+2+(0:
The main tieatment shoulu be avoiuance of the alleigen
Keep aii clean
Close winuows anu keep aii-conuitioning iunning uuiing summei months
Non-seuating antihistamines such as loiatauine aie veiy effective anu can be
useu continually
Nasal saline spiaysnetti pot aie effective at washing out the nasal cavity






@'-*('9 >**)/B2.;-<-./<-.0

>1# 6.;-<-./<9
Is the most common piimaiy immunoueficiency, anu it is often asymptomatic
Causes iecuiient iespiiatoiy anu uI infections
Someone ieceiving bloou piouucts may uevelop anaphylaxis, which shoulu
make you think of an IgA ueficiency
Nevei give these patients immunoglobulin's
12*#,+*%,:
Nanage anu tieat infections as they aiise

4'),B/80 #1(**(1DBN)D-/.*-(
Is an x-linkeu uisoiuei affecting males
Patients piesent with infections staiting aiounu 6 months of age
Recuiient sinopulmonaiy infections uue to Stiep oi Bemophilus oiganisms
aie classic
12*#,+*%,V)#%#$*+*%,:
Infusion of Iv Ig's

5B**B/ M('-(ND. >**)/B2.;-<-./<9
Is a conuition that piesents in both men anu women
0sually only piesents when they aie auults
Patient piesents with iecuiient sinopulmonaiy infections
Nay get spiue-like abuominal uisoiueis (malabsoibtion, uiaiihea,
steatoiihea)
!"#$%&'"':
Igu levels aie low
12*#,+*%,:
Infusions of IvIu is iequiieu since Igu levels aie low



A.:.'. 5B*N-/.2 >**)/B2.;-<-./<9
An AR oi x-linkeu uisoiuei
Commonly causeu by auenosine ueaminase ueficiency
Theie is a B anu T cell uefect, thus patient has seveie infections eaily in life
These aie the so calleu "bubble babies", anu iequiie isolation to pievent life-
thieatening infections

I-0QB,,Y#D2'-<3 A9/2'B*.
An x-linkeu iecessive uisoiuei affecting only males
Theie is a classic tiiau of eczema, iecuiiing infections, anu thiombocytopenia

53.2-(QYO-1(03- A9/2'B*.
Bue to a uefect in miciotubule polymeiization
uiant gianules in neutiophils
0culocutaneous albinism
Recuiiing infections

53'B/-< G'(/)DB*(,B)0 6-0.(0.
0sually an x-linkeu iecessive uisoiuei affecting males
Theie is a uefect in NABPB oxiuase, causing iecuiiing infections uue to
catalase (+) oiganisms (Staph, Pseuuomonas,etc)
Biagnostic test involves nitioblue tetiazolium uye (noimally gets ieuuceu by
gianulocytes) - measuies iespiiatoiy buist, which is lacking in these
patients







Chapter 11

Pulmonary









O9+BV.*-(

Theie aie S causes of hypoxemia:
1. Bypoventilation
2. Biffusion Impaiiment
S. vQ mismatch
4. ! Fiu2
S. Shunt

Beie is an algoiithm figuiing out the cause of hypoxemia


-"$%' #%. -/+0,&+':
Tachycaiuia, uyspnea
Clubbing anu cyanosis
Ciackles anu iales

12*#,+*%,:
Tieatment iequiies tieating the cuiient hypoxemia anu the tieatment of
unueilying uisoiueis
" Pau2
u2 by nasal cannula, oi CPAP, oi intubation if necessaiy
If theie is a shunt, the hypoxemia will not impiove by incieasing the FI02























5?@680

1. Emphysema
2. Chionic Bionchitis
S. Asthma
4. Bionchiectasis

7*+390.*(
Is aii space uilation with alveolai wall uestiuction
The most common cause of emphysema is smoking
If a young patient gets this, consiuei an alpha-1-antitiypsin ueficiency

32>1=%+2, W X$0)'+ O*(A V=>+;)(&#,0)$(

-"$%' #%. -/+0,&+':
Baiiel chest
Bypeiventilation
Puiseu lip bieathing
Known as the "pink puffeis"
!"#$%&'"':
Clinical uiagnosis + CXR showing hypeiinflation of the lungs
12*#,+*%,:
Acute episoues iequiie:

u2 anu an ABu
CXR
Albuteiol (inhaleu)
Steioius foi acute uesatuiations
ABvISE PATIENT T0 ST0P SN0KINu
Chionic management of C0PB:
Ipiatiopium inhalei
Albuteiol inhalei
Yeaily influenza vaccination
Pneumococcal vaccine
F0TBER SN0KINu CESSATI0N ABvISINu
Long-teim u2 theiapy if Pu2 is <SS% oi the u2 satuiation is <88%


53'B/-< 4'B/<3-,-0
Piesents as a piouuctive cough on most uays foi % S months in a iow foi %
2yis
Known as the "blue bloatei"
-"$%' #%. -/+0,&+':
Similai to emphysema howevei hypoxia is moie seveie
RvB + pulmonaiy BTN
Neck vein uistention
Bepatomegaly
!"#$%&'"':
Biagnosis is laigely clinical
Can confiim with a lung biopsy that shows an incieaseu Reiu inuex, which is
a glanuulai layei that is >Su% of the total thickness of the bionchial wall.
12*#,+*%,:
u2
Bionchouilatois





#0,3*(
Piesents with S0B anu expiiatoiy wheezing
Seveie cases may piesent with the use of accessoiy muscles
Causeu by bionchial hypeiiesponsiveness that is ieveisible
-"$%' #%. -/+0,&+':
Expiiatoiy wheezing anu uyspnea
0nset is often physical activity
Conuition is ieveisible with bionchouilatois such as albuteiol
!"#$%&'"':
Bighly clinical
Check foi a FEv inciease of moie than 1u%
Complication incluues status asthmaticus, which is iefiactoiy attacks that
last foi uays anu aie fatal
12*#,+*%,:
Tieatment with #2-agonists such as albuteiol
Long-teim contiol involves auuition of inhaleu steioiu (if patient isn't
expeiiencing enough contiol with albuteiol)
If albuteiol + steioius aie not enough, auuition of a long-acting #-agonist
such as salmuteiol may help
Last iesoit in long-teim management (iefiactoiy to these pievious
tieatments) is oial steioius












4'B/<3-.<,(0-0
Bue to an anatomic uefect that causes peimanent uilation of the bionchioles
Patient expeiiences iecuiiing lung infections that piouuce massive amounts
of sputum
Patient often has uigital clubbing as well
!"#$%&'"':
The most accuiate uiagnostic test is the high-iesolution CT scan, which will
show thickeneu bionchial walls anu uilateu aiiways
CXR will show the classic "tiam-tiack maikings"
12*#,+*%,:
Nust tieat infections as they aiise because theie is no cuiative theiapy
Antibiotic theiapy foi iecuiiing infections
Chest physiotheiapy can be helpful in ieleasing anu eliminating sputum
Long-teim "cuie" is a lung-tiansplant

















".0,'-<,-:. H)/1 6-0.(0.0

1. Inteistitial Fibiosis
2. Paienchymal uisease
S. Extiapulmonaiy uisease
4. Pleuial effusion


>/,.'0,-,-(D K-N'B0-0
Bue to chionic insult to the lung tissue by things such as asbestos, chionic
infections, oiganic uusts
Biagnosis maue by a CXR, which shows a "honeycomb" pattein of the lung
12*#,+*%,:
u2, PEEP, steioius if theie is collagen vasculai uisease

@('./<39*(D 6-0.(0.
Paienchymal uiseases aie causeu by things such as infections (TB),
inflammation (saicoiuosis), uiugs, toxicchionic inhalation of offenuing
agents (asbestos), anu it may be iuiopathic
Patient piesents with a uiy cough, S0B, anu chionic hypoxia
-"$%' #%. -/+0,&+':
"velcio" iales
Clubbing
!"#$%&'"':
CXR oi high-iesolution CT
Lung biopsy
PFT (all measuiements aie uecieaseu piopoitionately)
12*#,+*%,:
If inflammatoiy, steioius can help
Theie aie no uefinitive cuies foi othei foims of paienchymal uisease



7V,'(+)D*B/('9 6-0.(0.
Anything that affects the musculatuie iesponsible foi aiuing in bieathing can
cause pioblems
Nultiple scleiosis, ALS, uuillain-Baiie, spinal coiu tiauma
Anything that piesses on the uiaphiagm can also cause tiouble, such as
piegnancy anu obesity
Nanagementtieatment is suppoitive only


@D.)'(D 7;;)0-B/
Fluiu in the pleuial space
-"$%' #%. -/+0,&+'8
Becieaseu bieath sounus
Bullness to peicussion
Becieaseu tactile fiemitus

!"#$%&'"':
The best initial uiagnostic test is a CXR (lateial uecubiuus shows fiee flowing
fluius)
Nost accuiate test is thoiacentesis (can show which type of fluiu it is)

12*#,+*%,:
Small effusions usually iesoib spontaneously
Biuietics can be useu if causing iespiiatoiy pioblems
If effusion is laige, inseit a chest tube foi uiaining








@)D*B/('9 7*NBD-0*

Patient piesents with a suuuen onset of shoitness of bieath
Lungs aie cleai
The iisk factois foi PE aie usually telltale in the questions:
1. Immobility (Long aiiplane iiue)
2. Tiauma (Bioken bone)
S. Suigeiy (Especially ieplacement of joints in the leg)
4. Nalignancies
S. Thiombophilias

!"#$%&'"':
A CXR shoulu be uone anu is usually noimal. Nay show a weuge-shapeu
infaict (laige PE), atelectasis is a common finuing
EKu often shows non-specific ST-T wave elevations
Best test to confiim uiagnosis of PE is the spiial-CT anu shoulu be uone if the
xiay is abnoimal
If the xiay is noimal but you aie still suspicious, a vQ scan shoulu be
peifoimeu (the less noimal the xiay the less accuiate the vQ scan will be)
Bopplei exam is only 7u% sensitive, thus many PE's aie misseu with this test.
The benefit of the Bopplei is that if it B0ES uetect a PE, it is 1uu% accuiate
B-uimei is a highly sensitive test but it has low specificity. This is the best
test to use if the patient has a low piobability of having a PE anu you want a
single test to iule out a PE










@)D*B/('9 O9+.',./0-B/

Pulmonaiy hypeitension is uefineu as hypeitension that is % that of the systemic
piessuie. Noimally it shoulu be appioximately 18 that of the systemic piessuie
Active pulmonaiy hypeitension means it is piimaiily a uisease of the lung
Passive pulmonaiy hypeitension means it is seconuaiy to a conuition of the
heait
E2"+#2/ !"'*#'*:
Iuiopathic, which occuis commonly in young women
Inteistitial iestiictive uiseases
0bstiuctive pulmonaiy uiseases
-*;&%.#2/ !"'*#'*:
Seen in heait uisease
Commonly seen in patients with BIvAIBS

-"$%' #%. -/+0,&+':
Tiicuspiu ieguigitation
Louu P2
Right ventiiculai heave
Raynauu's phenomenon
!"#$%&'"':
Best initial test is the TTE, which will show RvB anu an enlaigeu iight atiium
Nost accuiate test is iight heait catheteiization with incieaseu pulmonaiy
aiteiy piessuie
EKu will likely show iight-axis ueviation


12*#,+*%,:
u2
Piostaglanuins
Enuothelin inhibitois that pievent giowth of the vasculatuie of the
pulmonaiy system


!)N.'<)DB0-0

1 TB affects the lowei lobes anu is usually asymptomatic
It occuis in specific gioups such as immigiants, BIv+ patients, homeless
patients, anu alcoholics.
-"$%' #%. -/+0,&+':
Night sweats
Fevei
Cough
Sputum
Weight loss
!"#$%&'"':
CXR is the best initial uiagnostic test
Bo an aciu-fast stain of the sputum to confiim uiagnosis
12*#,+*%,:
Tieatment with 4 anti-TB meuications shoulu be staiteu with six months of
theiapy being the stanuaiu of caie
Isoniaziu (6 months), Rifampin (6 months), Pyiizinamiue (2 months), anu
Ethambutol (2 months)
Bo LFT's because these meuications can cause livei toxicity (stop all
meuications if tiansaminase levels ieach Sx the uppei limit of noimal)
A+.<-;-< !BV-<-,-.0 <()0.2 N9 !4 2')10:
Isoniaziu ! peiipheial neuiopathy, auu B6
Rifampin ! ieuoiange coloieu bouy secietions
Pyiazinamiue ! hypeiuiicemia
Ethambutol ! optic neuiitis







!3. @@6 ,.0,
A scieening test foi those in iisk gioups.
7+%0)(A ';)0+;), )% ,% &$##$/%<
Smm: close contacts, BIv+, steioiu useis
1umm: foi those who aie in the "high-iisk" gioups mentioneu above
1Smm: those with no incieaseu iisk
If PPB is positive, uo the following:
1. CXR
2. If CXR is abnoimal, uo a sputum stain
S. If sputum stain is positive, stait 4-uiug theiapy




















5(/<.'0 B; ,3. H)/1

Lung canceis account foi the most cancei ueaths anu aie the 2
nu
most
commonly uiagnoseu cancei
XRAY is N0T a goou scieening tool because by the time they aie seen
metastasis has occuiieu
Common signs anu symptoms: Cough, hemoptysis, hoaiseness, weight loss,
fatigue, iecuiient pneumonia
71+ &$##$/)(A 0,-#+ .+2$(%0;,0+% 01+ '$22$( '1,;,'0+;)%0)'% $& .)&&+;+(0 0=>+%
$& #*(A ',('+;%
5#L57" ![@7 5O#"#5!7">A!>5A
Auenocaicinoma Is the most common lung cancei in non-
smokeis (>+;)>1+;= ,(. %*->#+*;,)
CEA (+), anu is useu to follow tieatment
Bionchoalveolai caicinoma A subtype of auenocaicinoma that is not
ielateu to smoking
Piesents in the >+;)>1+;= of the lung
Laige Cell caicinoma In >+;)>1+;=
Is highly anaplastic anu has a pooi
piognosis
Squamous cell caicinoma Aiises fiom -;$('1*% ,(. )% , '+(0;,#
hilai mass
Stiongly linkeu to smoking
PTBiP ielease causes hypeicalcemia
Small cell caicinoma :+(0;,# 1)#,; location
Stiong link to smoking
Secietion of ABB anu ACTB causes
multiple enuociine pioblems
Tieat with iauiation + chemotheiapy
Nay cause Lambeit-Eaton synuiome
Bionchial caicinoiu tumoi 9+';+0+% %+;$0$()(
Causes iecuiient uiaiihea, flushing of
the skin, asthmatic wheezing
Nanage with a S-BT antagonist
Lymphoangio-leiomyomatosis Is a %2$$01D2*%'#+ neoplasm
Nost commonly seen in menstiuating
women
Piesents classically with pneumothoiax
Tieat with eithei piogesteione oi a lung
tiansplant

Tieat small cell caicinoma with a combination of iauiation anu chemotheiapy

Tieat all othei types with local iesection + iauiation (non-metastatic), anu iauiation
+ chemo if metastatic

A)+.'-B' A)D<)0 !)*B'
Also known as "Pancoast tumoi", which causes the following:
1. V$;(+;G% %=(.;$2+ - Ptosis, Anhyuiosis, Nyosis because it uamages the
sympathetic ceivical ganglion in the lowei neck, ANB
2. 9*>+;)$; F+(, :,?, 9=(.;$2+ - obstiuction of the SvC causes facial
swelling, cyanosis, anu uilation of veins of the heau anu neck






















Chapter 12

GI











70B+3(1.(D 6-0B'2.'0

The only two esophageal uisoiueis that iequiie an enuoscopy aie 5#L57" anu
4(''.,,80 .0B+3(1)0, both which iequiie a biopsy to know the uiagnosis.



6[A@O#G>#

#<3(D(0-(
Bysphagia to both solius anu liquius in a young non-smokei.
Nay be foou ieguigitation, anu aspiiation of pieviously eaten foou.
Involves a failuie of the gastioesophageal sphinctei to ielax, no mucosal
abnoimalities

!"#$%&'"':
Best initial test is the baiium swallow
Nost accuiate test is an esophageal manometiy

12*#,+*%,:
Best Initial tieatment is pneumatic uilation, if iepeateuly unsuccessful uo
suigeiy.
If patient iefuses suigeiy, we can give them an injection of botulinum toxin.






70B+3(1.(D 5(/<.'

Piesents w the following:
1. Bysphagia: fiist to solius then to liquius
2. Nay have heme (+) stool anuoi anemia
S. 0ften pts aie >Suyi anu aie smokeisalcohol uiinkeis.


!"#$%&'"':

Best initial test is an enuoscopy
If enuoscopy is not an option, uo a baiium swallow



12*#,+*%,:

Best initial theiapy is a suigical iesection (if no local oi uistant metastasis)
Follow suigeiy w chemo-baseu SF0



"-/10 (/2 E.N0

Also known as peptic stiictuies.
Can be causeu by iepetitive exposuie of the esophagus to acius, iesulting in
scaiiing anu stiictuie foimation.
Pievious use of scleiosing agents foi vaiiceal bleeuing can also cause
stiictuies(this is why banuing is the supeiioi pioceuuie).



!"#$%&'"':
Best initial uiagnostic test is a baiium stuuy

Following aie the uiff kinus of stiictuies:

1. 8#*22+;DF)(%$( %=(.;$2+: is a pioximal stiictuie founu in association
with iion ueficiency anemia. Is moie common in miuule-ageu women anu is
associateu with squamous cell esophageal cancei

Best initial theiapy is iion ieplacement

2. 9'1,0bB)G% ;)(A%< is a uistal iing of the esophagus that piesents w
inteimittent symptoms of uysphagia

Best initial theiapy is pneumatic uilation

S. 8+>0)' %0;)'0*;+< iesults fiom aciu ieflux. Tieat with pneumatic uilation



]./Q.'80 6-:.',-<)D)*

Look for pt w/ dysphagia w/ horribly bad breath. There is food rotting in the back of the
esophagus from dilation of the posterior pharyngeal constrictor muscles.

Diagnosis:

Best initial test is a baiium stuuy
Best initial theiapy is suigical iesection





A+(0,-< 6-0B'2.'0
Biffuse esophageal spasm anu "nutciackei esophagus" aie essentially same
uisease.
Look foi case of seveie chest pain, often wo iisk factois foi Ischemic heait
uisease.
Nay occui aftei uiinking a colu beveiage.
Pain is always piesent, but uysphagia isn't always piesent.
All caiuiac tests aie noimal

!"#$%&'"':
Nost accuiate uiagnostic test is manometiy
Baiium stuuies may show a coiksciew pattein, but only uuiing an episoue of
spasm

12*#,+*%,:
Calcium channel blockeis anu nitiates aie the best tieatment options



70B+3(1-,-0

Esophagitis presents with odynophagia as the food rubs against the esophagus.

!"#$%&'"':
IF patient is BIv (-), uo an enuoscopy fiist
IF patient is BIv (+), has a CB4 count <1uu give fluconazole.. only uo
enuoscopy if the patient uoesn't iesponse to fluconazle.


5(/2-2( 70B+3(1-,-0
Causes 9u% of esophagitis in BIv (+) patients
The othei common cause is pill esophagitis, wheie ceitain pills can cause
esophagitis in the patient.


12*#,+*%,:
Bave pt sit upiight when taking the pills
Bave patient uiink moie watei anu iemain upiight foi Su minutes aftei
swallowing.
.

%(DDB'9YI.-00 ,.('
Is an upper GI bleed with violent retching and vomiting of any cause.
Theie may be hematemesis oi black stool on exam oi in the histoiy

12*#,+*%,:
Nost cases iesolve spontaneously, if bleeuing peisists, injection of
epinephiine can be useu to stop the bleeuing.


G7"6

Patient presents with a history of epigastric pain that is associated with substernal chest
pain and possibly a metallic taste in the mouth.

Signs and Symptoms (on top of the classic presenting ones)

Soie thioat
Netallic oi bittei taste
Boaiseness
Chionic cough
Wheezing

N0TE: As many as 2u% of people who have a chionic cough aie suffeiing as a iesult
of uERB
!"#$%&'"':
PPI aumin is both uiagnostic anu theiapeutic.
Fuithei testing such as 24hi pB monitoiing shoulu only be uone if theie is no
iesponse to PPIs anu the uiagnosis still is not cleai


12*#,+*%,:Nilu uisease shoulu be contiolleu w lifestyle mouifications such as:
Weight Loss
Sleeping in an upiight position, oi at least somewhat angleu in beu
Smoking cessation
Limiting alcohol, caffeine, chocolate, anu peppeimint ingestion
Avoiuance of foou anu uiink within 2-S houis of going to beu

If those uon't woik then PPIs aie the next best theiapy foi uERB. They shoulu
contiol 9u-9S% of cases.

If theie is no impiovement then a tiial of B2-blockeis shoulu be tiieu (many auveise
effects with these)


4(''.,, 70B+3(1)0
Is a metaplasia fiom squamous to columnai cells

!"#$%&'"':
Peifoim enuoscopy when theie is weight loss, anemia, anuoi bloou in the
stool, anu in anyone who has chionic symptoms of ieflux uisease foi moie
than Syis.

K>L6>LG ?L 7L6?A5?@[ %#L#G7%7L!
Baiiett esophagus PPI anu iepeat enuoscopy eveiy 2-S
yeais
Low-giaue uysplasia PPI anu iepeat enuoscopy in S-6 months
Bigh-giaue uysplasia Bistal esophagectomy





7+-1(0,'-< @(-/
Any pt >4Syi w peisistent epigastiic pain anuoi uiscomfoit shoulu ieceive an
uppei enuoscopy. This is essential to excluue the possibility of gastiic cancei


Non-Ulcer Dyspepsia:

Is the NCC of epigastiic uiscomfoit
Can only be concluueu aftei enuoscopy has excluueu an ulcei uisease, gastiic
cancei, anu gastiitis

12*#,+*%,:
Consists of symptomatic theiapy w B2 blockeis, liquiu antacius, oi PPIs.



@.+,-< $D<.' 6-0.(0.
Bue to hypeisecietion of aciu
Can be eithei uuouenal ulcei(B0) oi gastiic ulcei(u0) uiseases
B. Pyloii is the NCC of ulceis, 2
nu
NCC is NSAIBs, heau tiauma, buins,
intubation, Ciohn's uisease, anu ZES.
0sually, foou impioves the pain of a uuouenal ulcei anu makes the pain of a
gastiic ulcei woise
If the pt is above 4S anu has epigastiic pain, you must scope to excluue
gastiic cancei.



G(0,'-,-0

Not due to hypersecretion of acid, as in PUD.
Can be associated with H.Pylori, if this is present treat w/ PPI and 2 antibiotics.
uastiitis can also be "atiophic" fiom peinicious anemia anu is often
associateu with a ueficiency of vitamin B12


7+%0)(A &$; Vh 8=#$;)<
)&', #;;=2#,* ,*',8
Enuoscopy with biopsy (if this is uone no fuithei testing is iequiieu)
-*2&7&$/ is veiy sensitive but not specific, if the seiology is negative, this
excluues B. Pyloii.
A positive test can't uistinguish between new anu pievious infection.

F2*#,5 ,*',"%$ #%. ',&&7 #%,"$*% ,*',"%$8
These aie not stanuaiu oi ioutinely useu. They can howevei uistinguish
between new anu olu uisease.

12*#,"%$ ?\ E/7&2"8
Tieat this bacteiia with PPI anu claiithiomycin + amoxicillin.
0NLY tieat if its associateu with gastiitis oi ulcei uisease.

Theie is no neeu foi ioutine post-tieatment testing of B Pyloii. theie is no benefit in
tieating B. Pyloii that is associateu with non-ulcei uyspepsia.

>6 ,5* ,2*#,+*%, &6 ?\E/&7"2 .&*'%N, '=;;**.< ,2/ ,5* 6&77&:"%$8

1. Repeat tieatment with 2 new antibiotics anu PPI : 0se metioniuazole +
tetiacycline insteau
2. If iepeat tieatment fails, evaluate foi ZES (uastiinoma).




A,'.00 $D<.' @'B+39D(V-0:

Routine prophylactic use of a PPI or H2 blocker or sucralfate should only be used if one
of the following is present:

1. Beau tiauma
2. Intubation anu mechanical ventilation

S. Buins
4. Coagulopathy anu steioiu use in combo

**NSAIB oi steioiu use alone is not an inuication foi ioutine stiess ulcei piophylaxis


]BDD-/1.'Y7DD-0B/ A9/2'B*.\]7A^ B' G(0,'-/B*(

ZES is diagnosed by finding an elevated gastrin level and an elevated gastric acid output.

**remember that everyone on a H2 blocker or PPI has an elevated gastrin level.

M5*% ,& ,*', ,5* $#',2"% #%. $#',2"; #;". &=,0=,X

When any of the following aie piesent:
1. laige ulcei >1cm
2. multiple ulceis
S. uistal location neai the ligament of Tieitz
4. iecuiient oi peisistent uespite B. Pyloii tieatment

*if the gastrin and acid output level are both elevated, then localization of the gastrinoma
is next.

!"#$%&'"'8
Nost accuiate is an enuoscopic ultiasounu
Nucleai somatostatin scan is also veiy sensitive because ZES patients have a
high numbei of somatostatin ieceptois

12*#,+*%,8
Local uisease iequiies suigical iesection
Netastatic uisease iequiies the patient be on lifelong PPIs





>/;D(**(,B'9 4BE.D 6-0.(0.\>46^

Both Crohns and ulcerative colitis can present with fever, abdominal pain,
diarrhea, blood in stool, and weight loss.

0C pies most often with abuominal pain anu bloouy uiaiihea

IK,2#"%,*',"%#7 +#%"6*',#,"&%' &6 >F! #2*8
}oint pain
Eye finuings
Skin finuings
Scleiosing cholangitis

C*#,=2*' +&2* ;&++&% ,& 32&5%N' ."'*#'* #2*8
Nasses
Skip lesions
Involvement of uppei uI tiact
Peiianal uisease
Tiansmuial gianulomas
Fistulae
Bypocalcemia fiom fat malabsoibtion
0bstiuction
Calcium oxalate kiuney stones
Cholesteiol gall stones
vitamin B12 malabsoibtion fiom teiminal ileum involvement

!"#$%&'"'8
Enuoscopy is best initial test
Baiium stuuies aie also goou uiagnostic tests


5'B3/80 Naikeis:
Antisacchaiomyces ceievesiae(ASCA) : positive
Antineutiophil cytoplasmic antibouy(ANCA) : negative


$5 Naikeis:
ASCA: negative
ANCA: positive

12*#,+*%,:
Best initial tieatment foi both is mesalamine
Steioius aie useful in acute cases
Suigeiy is iequiieu if theie is no ielief fiom these tieatment moualities





















6>#""O7#

Infectious Diarrhea

The presence of blood indicates a pathogenic invader, which may include any of the
following:

Campylobacter - Is the MCC of food poisoning.

Salmonella - Transmitted by chicken and eggs

Vibrio Parahemolyticus Associated with infected seafood

E. Coli There are many different types, which include:

E. Coli 0157:H7 ! MC associated with haemolytic uremic syndrome(via effects
of verotoxin). Look for undercooked beef in the history.
Vibrio vulnificus: Look for shellfish in a person w/ liver disease
Shigella: Secretes Shiga toxin, which is also associated with reactive arthritis
Yersinia: Rodents are natural reservoirs, transmission via veggies, milk-derived
products, and meat
Amebic: Perform three ova & stool parasite exams or serologic testing. Treat
with metronidazole


Diagnosis:

Best initial test ! fecal leukocytes

Most accurate test ! stool culture


Treatment:

Mild disease! Keep the patient hydrated, this usually resolves on its own

Severe disease ! Fluoroquinolones are the treatment of choice. Severe disease is
defined as presence of any of the following (Blood, fever, abdominal pain, hypotension
and tachycardia)








Non-Bloody Diarrhea:

Non-bloody diarrhea may still be d/t the above pathogens, which can all present
with non-bloody diarrhea.
NO BLOOD in diarrhea will exclude all of the following, which never have
blood:


1. Viruses ! Rotavirus, Norwalk virus (Norovirus)
2. Giardia ! Camping/hiking. Look for bloating/flatus/steatorrhea, stool ELISA is
diagnostic test of choice, treatment involves metronidazole.
3. Staph Aureus ! Presents with vomiting in addition to diarrhea. This resolves
spontaneously
4. Bacillus Cereus ! Is associated with eating refried rice. This resolves
spontaneously
5. Cryptosporidiosis! HIV (+) patient with a CD4 count <100. Diagnosis with
acid-fast stain. There is no proven treatment except to raise the CD4 count w/
antiretroviral therapy.
6. Scombroid! Histamine fish poisoning, has fastest onset of poisoning, which is
around 10 min after eating infected tuna, mackerel, or mahi-mahi. Patient has
vomiting, diarrhea, wheezing, and flushing. Treatment involves giving the
patients antihistamines such as diphenhydramine.




Antibiotics Associated Diarrhea (C. Difficile)

Develops several days to weeks after use of antibiotics such as Clindamycin, which is
the most common cause. There can be both blood and fecal leukocytes with C.Difficile-
related colitis.


Diagnosis:

Best initial test is a stool toxin assay.

Treatment:

The best initial therapy is metronidazole







Chronic Diarrhea

The most common cause of chronic diarrhea is lactose intolerance


Diagnosis:

Removal of milk products will both allow for diagnosis and treatment







































MALABSORBTION


Diarrhea caused by malabsorption is always associated with weight loss
Fat malabsorption is associated with steatorrhea, which leads to oily/greasy stools
that float on the water in the toilet and are foul smelling

The common causes of fat malabsorption are as follows:

1. Celiac Disease
2. Tropical Sprue
3. Chronic Pancreatitis
4. Whipples Disease


All forms of malabsorption are associated with:

Hypocalcemia from vitamin D deficiency, which may lead to osteoporosis
Oxalate overabsorption and oxalate kidney stones
Easy bruising and elevated PT/INR due to vitamin K malabsorbtion
Vitamin B12 malabsorption from either destruction of terminal ileum or loss of
pancreatic enzymes that are necessary for B12 absorption


Diagnosis:

The best initial test is the sudan stain
The most sensitive is a 72-hr fecal fat test



Celiac Disease

Presents with iron malabsorption and microcytic anemia


Diagnosis:

Best initial diagnostic test is checking for antigliadin, antiendomyseal, and
antitissue transglutaminase antibodies
The most accurate test is a small bowel biopsy

*bowel wall biopsy is always necessary even w/ antibody confirmation, in order to
exclude bowel wall lymphomas.



Treatment:

Elimination of oats, wheat, barley from the diet




Tropical Sprue

Patient will have a history of being in a tropical location, and presents the same way as
celiac disease.

Diagnosis:

Small bowel biopsy is the best test to perform

Treatment:
Tetracycline or TMP-SMX for 3-6 months





Whipples Disease

A GI infection presenting with arthralgias, rash, diarrhea, and anemia


Diagnosis:

The most accurate test is a small bowel biopsy that shows PAS (+) organisms
Can also do a PCR of the stool looking for T. Whippelii

Treatment:

Penicillin, Tetracycline, or TMP-SMX for 12 months











Chronic Pancreatitis

History of alcoholism is usually present
Lipase and amylase levels are likely normal since these wont drop until the
pancrease is calcified and fibrosed.
Fat soluble vitamins are not absorbed


Diagnosis:

The best initial test is an abdominal XRAY or a CT without contrast
The most accurate testis secretin stimulation testing (normal person releases large
amount of bicarbonate-rich pancreatic fluid).

Treatment:

Involves the administration of pancreatic enzymes by mouth.





Irritable Bowel Syndrome

Syndrome where the patient experiences an alteration in bowel habits
(constipation alternating with diarrhea)
Pain is usually relieved after a bowel movement


Diagnosis:

Testing may include colonoscopy, xrays, blood tests, but all are negative

Treatment:

The best initial treatment is fiber supplementation, which helps by bulking the
stool and relieving pain
If fiber doesnt work, can add antispasmotic agents to try and relax the bowel
If these fail to work, TCAs can be tried








COLON CANCER


Hamartomas and hyperplastic polyps are benign
Dysplastic polyps are malignant

** The most important thing to know for colon cancer screening is when and what to do
for the patient


Diagnostic Testing:

General Population:

1. Begin screening at 50yr
2. Colonoscopy q10yrs
3. Sigmoidoscopy q 3-5yrs
4. Fecal occult blood testing yearly
5. Barium enema

The best method of screening for colon cancer is performing a colonoscopy every 10yrs

One family member with colon cancer requires colonoscopy starting at 40yr or 10yr
before age of family member who had cancer.

Three family member, two generations, one premature(<50) require a colonoscopy every
1-2yr starting at 25yrs. This is a lynch syndrome or HNPCC




















Familial Adenomatous Polyposis(FAP)

Start screening sigmoidsocopies at age 12
Perform colectomy if polyps are found




Gardners syndrome

This presents with benign bone tumors known as osteomas, as well as other soft
tissue tumors. There is no additional screening indicated for Gardners syndrome




Peutz-Jeghers Syndrome

This presents with a patient who has melanotic spots on the
There are hamartomatous polyps throughout the small bowel and colon
There is a lifetime risk of colon cancer is 10%.
No extra screening recommended




Juvenile Polyposis

There are multiple extra hamartomas in the bowel.
No increased risk of colon cancer from hamartomas
No extra screening recommended
If dysplastic polyps are found, perform repeat colonoscopy in 3-5 years

GENERAL
POPULATION
SINGLE
FAMILY
MEMBER
WITH COLON
CANCER
THREE
FAMILY
MEMBERS
WITH
CANCER
FAP GARDNERS,
PEUTZ-
JEGHERS, JP
Start at 50, then
q10yr
Start at 40yr or
10yr earlier
than when
diagnosed
Colonoscopy
q1-2yr at 25yr
Sigmoidoscopy
q102 yr starting
at 12yr
No xtra
screening
recommended




DIVERTICULAR DISEASE


Includes Diverticulosis and Diverticulitis


Diverticulosis

Incredibly common in older Americans and it most commonly caused by a low-fiber,
high-fat diet

Signs and Symptoms:

LLQ abdominal pain
Lower GI bleed

Diagnosis:

The most accurate test is a colonoscopy
Best diagnostic test is an abdominal CT scan

Treatment:

High-fiber diet low in saturated fats




Diverticulitis

Is a complication of diverticulosis and presents with:

LLQ abdominal pain
Tenderness
Fever
Elevated white cell count in blood

Treatment:

Involves the use of antibiotics. Metronidazole and ciprofloxacin most commonly
used.






Gastrointestinal Bleeding


Red blood ! lower GI bleed, rarely a very acute upper GI bleed can be red blood

Black stool ! upper GI bleed (Proximal to Ligament of Trietz). Black stool usually is
100ml or more blood.

Heme (+) brown stool ! can occur from as little as 5-10ml of blood loss

Coffee ground emesis ! needs very little gastric, esophageal, or duodenal blood loss, as
little as 5-10ml.

**The most important thing to do in acute GI bleeding is to determine if there is
hemodynamic instability



Treatment for GI bleeds:

IV fluids if it is a large bleed
Correction of anemia or other lab abnormalities




Variceal Bleeding

Look for alcoholic with hematemesis and/or liver disease
Other clues are the presentation of splenomegaly, low platelets, and spider
angiomas or gynecomastia

Diagnosis:

Endoscopy

Treatment:

First thing to do is add octreotide which decreases portal hypertension
2
nd
thing to do is an upper GI to band the variceals
If banding fails, a shunt between the portal vein and the hepatic vein should be
done






Sources of Bleeding

Upper GI:

Ulcer disease
Esophagitis
Gastritis
Duodenitis
Varices
Cancer

Lower GI:

Angiodysplasia
Diverticular disease
Polyps
Ischemic colitis
IBD
Cancer

Diagnosing sources of bleeding:

Technetium bleeding scan (tagged red cells) detects source of bleed
Angiography is an excellent preoperative test because it localizes the site of
resection
Capsule endoscopy should be done when the other methods fail. This is a small
camera that is swallowed and allows for visualization of the small intestine




Acute Mesenteric Ischemia

Presents with a sudden onset of severe abdominal pain with a normal appearing exam (ie.
The pain is out of proportion to the findings on exam)

Diagnosis:

The most accurate test is an angiography

Treatment:

Surgical resection of ischemic bowel



Other GI Conditions



Constipation

Initial management of constipation is hydration and fiber supplements

There is usually no clear etiology, for clinical purpose must know possible causes and be
able to treat underlying reason.

1. Dehydration: look for signs of dehydration, BUN:Cr of >20:1
2. CCBs
3. Narcotic medication use/sedatives
4. Hypothyroidism: TSH, T4
5. Diabetes
6. Ferrous sulphate iron replacement
7. Anticholinergic medications



Dumping syndrome

This is a rare disorder related to prior gastric surgery (Often for ulcer disease)
This is a disorder where stomach contents are quickly passed through to the
intestine, and it then draws fluid into the GI, causing an initial HYPERglycemia
follow by a reactive HYPOglycemia


Signs and Symptoms:

Shaking chills
Diaphoresis
Weakness
Hypotension
Hyperglycemia


Treatment:

Small and frequent meals







Diabetic Gastroparesis

Longstanding DM impairs neural supply of bowel, there is impairment of normal
motility.
Patient will present with bloating and constipation as well as diarrhea


Diagnosis:

Clinical + history of diabetes

Treatment:

Erythromycin (increases motilin in the gut, thus increasing motility) and
metoclopramide.




Acute Pancreatitis

Presents (classically) as severe midepigastric pain and tenderness that is associated with
alcoholism and/or gallstones


Diagnosis:

Lipase (more specific) and amylase

Treatment:

Keep patient NPO
Give IV fluids
Give pain medications












ACUTE HEPATITIS:


All pts present in a very similar way:

1. Jaundice
2. Fatigue
3. Weight loss
4. Dark urine from bilirubin in the urine

*Hepatitis B and C are more likely to pres with serum-sickness phenomenom like joint
pain, urticaria, and fever.

No definitive treatment is available for any form of acute hepatitis.

Diagnosis:

Conjugated bilirubin levels (will be elevated)
Viral Hepatitis gives elevated ALT level
Drug-induced hepatitis is associated with increased levels of AST
In pregnancy, if a patient gets hepatitis E this can be fatal
Most accurate tests for hep A, C, D, and E, the confirmatory test is serology
IgM levels acutely rise, and IgG levels rise in the recovery phase.
Surface antigens, core antibody, e-antigen, or surface antibodies are only
associated w/ hepatitis B.




Hepatitis B testing:

The first test to become abnormal in acute hep B infection is the surface antigen.
Elevation in ALT, e-antigen, and symptoms all occur after the appearance of
hepatitis B surface antigen.
Chronic hep B gives the same serologic pattern as acute hep B, but it is based on
persistence of the surface antigen beyond six months.

*Tests for active viral replication: hep B DNA polymerase = e-antigen = hep B PCR
for DNA, all equal the same thing.








Hepatitis C testing:

Best initial test is hep C antibody, this wont tell the level of activity of the virus
Most accurate test Hep C PCR for RNA, also is the most accurate way of testing
response to therapy
Liver biopsy is the most accurate for finding out the severity of the disease


Treatment of Chronic Hepatitis

Chronic hep B: The pt w/ surface antigen, e-antigen, and DNA polymerase or PCR for
DNA is the pt most likely to benefit from antiviral therapy. Look for >6mnth of positive
serology

Treat chronic hep B w/ following single agents:
1. Lamivudine
2. Adefovir
3. Entecavir
4. Telbivudine
5. Interferon (has the most adverse effects)

Chronic hep C: Combine interferon with ribavirin (MC adverse effect is anemia)



Vaccination:

Hep A and B vaccination is now universally done in children.

For adults the strongest indication for both types are the following:

1. Chronic liver disease
2. Household contacts
3. MSM (men who have sex with men)
4. Blood product recipients on a chronic basis
5. Injection drug users

Specific indications:

HEP A ! travelers
HEP B ! health care workers and pts on dialysis.

*there is no vaccine or postexposure prophylaxis for hep C




CIRRHOSIS


No matter what the cause may be, it will have a number of features:

1. Edema due to low oncotic pressure (treat with spironolactone + diuretics)
2. Gynecomastia
3. Palmar erythema
4. Splenomegaly
5. Thrombocytopenia due to splenic sequestration
6. Encephalopathy, which should be treated with lactulose
7. Ascites - Treat with spironolactone
8. Esphageal varices - Propranolol will prevent bleeding, perform banding if bleed
continues.

Ascites:

Perform paracentesis for all pts with ascites if a new ascites, pain, fever, or tenderness are
present.

Diagnosis:

Test the fluid albumin level
SAAG > 1.1 is consistent with portal hypertension from cirrhosis























CHRONIC LIVER DISEASE (Cause of cirrhosis)


Alcoholic cirrhosis

Is a diagnosis of exlusion. Must exclude all other causes of cirrhosis and look for a
history of longstanding alcohol abuse. Treat as described above for cirrhosis





Primary Biliary Cirrhosis

Presents most commonly in a middle-aged woman complaining of itching. Xanthalasmas
may be found on exam. Also look for a history of other autoimmune disorders


Diagnosis:

The best initial test is elevated alkaline phosphatase + normal bilirubin level
The most accurate test is presence of antimitochondrial antibody

Treatment:

Ursodeoxycholic acid






Primary Sclerosing Cholangitis:

80% of those with PSC also have IBD


Signs and Symptoms:

Urticaria
Elevated bilirubin levels
Elevated alkaline phosphatase

Diagnosis:

Most accurate test is ERCP

Anti-smooth muscle antibody, and (+) ANCA
Treatment:

Ursodeoxycholic acid









Wilsons Disease

Involves cirrhosis and liver disease in a person with a choreiform movement disorder
and neuropsychiatric abnormalities.


Signs and Symptoms:

Extrapyrimidal symptoms
Mania/depression
Kayser-Fleischer rings around the cornea is pathognomonic for Wilsons disease

Diagnosis:

Decreased serum ceruloplasmin

Treatment:

Penicillamine




Hemochromatosis

Most often from a genetic disorder resulting in overabsorbtion of iron
Iron deposits throughout the body, most commonly in the liver.


Signs and Symptoms:

Darkening of the skin (Bronze diabetes)
Arthralgia

Cardiomyopathies (Restrictive)
Infertility
Hepatoma


Diagnosis:

Best initial test is serum study showing elevated serum iron and ferritin with a low
TIBC. Iron saturation will be grossly elevated
The most accurate test is a MRI or liver biopsy

Treatment:

Phlebotomy




Autoimmune Hepatitis

Most often presentation is a young woman who has another autoimmune disease

Diagnosis:

Best initial test is ANA and anti-smooth muscle antibodies
The most accurate test is a biopsy of the liver

Treatment:

Prednisone





Nonalcoholic steatohepatitis (NASH)

Strong association with obesity, diabetes, and hyperlipidemia

Diagnosis:

Best initial test is liver studies that show ALT>AST
The most accurate test is a liver biopsy that shows fatty infiltration




Treatment:

Management of the underlying condition

















Chapter 13

Nephrology










"./(D !)N)D(' (/2 >/,.'0,-,-(D 6-0B'2.'0

6')1 >/2)<.2 >/,.'0,-,-(D L.+3'-,-0
Classic uiugs causing inteistitial nephiitis incluue PCN, NSAIBs,
Sulfonamiues, anu uiuietics.
-"$%' #%. -/+0,&+':
Rash
Bematuiia
0liguiia
Fevei
Eosinophilia
Eosinophiliuiia is iaie but is pathognomonic foi hypeisensitivity Alleigic
Inteistitial Nephiitis
!"#$%&'"':
Biagnosis is mainly clinical, iemoval of offenuing agent + impiovement helps
to confiim uiagnosis
Tieatment:
Removal of offenuing agent
Steioius can help


#<),. "./(D K(-D)'.
Piesents with " azotemia
" B0N & Cieatinine
Causeu by eithei pieienal, ienal, oi postienal azotemia
8;+;+(,# E,)#*;+:
Bypopeifusion will leau to ienal failuie
volume uepletion, sepsis, heatstioke, buins, hypotension
4(0;)(%)' M+(,# E,)#*;+F
ATN is the most common cause
Renal ischemia also a possibility


8$%0;+(,# E,)#*;+F
Is uue to obstiuction seconuaiy to eithei BPB, ienal calculi, anuoi
blauueipelvic tumois

Test Pieienal Postienal Renal
0iine 0smolality >Suu <SSu <SSu
0iine Souium <2u >4u >2u
FENa <1% >4% >2%
B0NCieatinine >2u >1S <1S

12*#,+*%,:
Iv fluius to maintain uiine output
Biuietics to pievent fluiu oveiloau
Close monitoiing of electiolyte abnoimalities
Bialyze with seveie electiolyte abnoimalities, uniesponsive metabolic
aciuosis, uiemia, anu toxic ingestion


#<),. !)N)D(' L.<'B0-0
Fiom eithei hypopeifusion that leaus to tissue ueath oi fiom insult uue to
vaiious toxic injuiies
Is the most common cause of acute ienal failuie
12*#,+*%,:
Remove cause
uive Iv fluius to maintain uiinaiy output
Closely monitoi electiolytes
uive uiuietics as neeueu to pievent fluiu oveiloau


"./(D !)N)D. K)/<,-B/(D 6-0B'2.'0
1. Renal Tubulai Aciuosis
2. Biabetes Insipiuus
S. Synuiome of Inappiopiiate Antiuiuietic Boimone


M+(,# 7*-*#,; !').$%)%:
Type Chaiacteiistic 0iinaiy pB
Type I A uefect of the uistal
tubule (B+ giauient)
>S.S
Type II Pioximal tubule fails to
iesoib BC0S
>S.S eaily then <S.S as the
aciuosis woisens
Type Iv ! Aluosteione (leauing to
hypei K+ anu hypei Cl-

Fiom ! secietion seen in
BN, inteistitial nephiitis,
ACEI's, hepaiin, anu
NSAIB use.

Nay also be uue to
aluosteione iesistance
fiom sickle cell oi uiinaiy
obstiuction
<S.S


R),-+0+% 4(%)>).*%:
Theie is cential anu nephiogenic types of BI, both:
! secietion of ABB if it is cential uiabetes insipiuus, anu an ABB iesistance if
it is nephiogenic
-"$%' #%. -/+0,&+' &6 4&,5:
Polyuiia
Polyuypsia
Noctuiia
0iine osmolality & 2uu anu seium osmolality % Suu
5./,'(D 6>F
Is eithei iuiopathic (Piimaiy) oi causeu by insult to biain (Seconuaiy)
Tieat this with BBAvP nasal spiay
L.+3'B1./-< 6>:
Is an x-linkeu uisease anu may be seconuaiy to sickle cell, pyelonephiitis,
nephiosis, amyloiuosis, multiple myeloma uiugs
Tieat by incieasing watei intake anu iestiicting souium intake


!"#$%&'"':
With BBAvP auministiation, cential BI will have a fast ueciease in uiine
output, while nephiogenic BI will have no change in uiine volume
With BBAvP auministiation, cential BI shows an acute inciease in uiine
osmolality, wheie nephiogenic BI shows no change in osmolality
Tieat cential BI with BBAvP oi vasopiessin
Tieat nephiogenic BI by coiiecting the unueilying cause (electiolyte
imbalances).


9=(.;$2+ $& 4(,>>;$>;),0+ !(0).)*;+0)' V$;2$(+ K94!RVL<
Theie aie many possible causes of SIABB:
3S- ."'*#'*: tiauma, tumois, hyuiocephalus
E=7+&%#2/ ."'*#'*': pneumonia, Small cell caicinoma of lung, abscess, C0PB
I%.&;2"%* ."'*#'*: hypothyioiuism, Conn's synuiome
!2=$': NSAIBs, chemotheiapy, uiuietics, phenothiazine, oial hypoglycemics

!"#$%&'"': piesence of hyponatiemia with a uiine osmolality of >Suummolkg
12*#,+*%,: this conuition is usually self-limiting, iesistant cases may iequiie
uemeclocycline which inuuces nephiogenic BI


:1;$()' M+(,# E,)#*;+<
Always associateu with ienal azotemia
35#2#;,*2"J*. 4/8
Azotemia
Aciuosis
Bypeikalemia
Bypocalcemia uue to lack of vitamin B piouuction
Anemia (lack of eiythiopoietin piouuction)
Bypeitension uue to RAAS pathway activation


-"$%' #%. -/+0,&+':
Nausea anu vomiting
Anoiexia
Bementia
Convulsions
Coma
PLT uysfunction (leaus to bleeuing)
!"#$%&'"':
Renal ultiasounu showing small kiuneys if failuie is chionic
Piesence of anemia uue to lack of EP0 piouuction
12*#,+*%,:
Restiict both watei anu salt
Pievent fluiu oveiloau with uiuietics
If theie aie seveie electiolyte uistuibances oi aciu-base pioblems go into
uialysis

















GDB*.')D(' 6-0.(0.0

L.+3'-,-< (/2 L.+3'B,-< A9/2'B*.0F
L.+3'B,-<F !*6"%*. 4/ ! hypeipioteinuiia, hypopioteinemia, hypeilipiuemia,
euema
Pioteinuiia >S.Sguay
Patient has geneializeu euema
Bypeicoagulation
! albumin
Bypeilipiuemia
!"#$%&'"':
J+%0 )()0),# 0+%0 is a uiinalysis showing significantly incieaseu levels of
piotein
Next best step is a spot-uiine test foi a piotein: cieatinine >S.S:1
24-hi uiine piotein collection >S.Sg
@$%0 ,''*;,0+ 0+%0 ! Renal biopsy
![@7 ?K L7@O"?!>5 6>A7#A7 5?%%?L 5O#"#5!7">A!>5AJ!c
Ninimal Change Bisease This is seen in young chiluien.
Tieat with pieunisone
Focal Segmental ulomeiuloscleiosis Similai in piesentation to NCB but
occuis in auults.
Nost commonly iuiopathic.
Commonly piesents in young
hypeitensive males.
Tieat with pieunisone anu
cyclophosphamiue
Nembianous ulomeiulonephiitis Is the most common 1 cause of
nephiitic synuiome in auults.
A slowly piogiessive uisoiuei.
Nany causes: BBv, BCv, syphilis, ceitain
uiugs, malignancies, SLE.
Tieat with pieunisone +
cyclophosphamiue.
Su% of cases piogiess to enu-stage ienal
failuie
Nembianopiolifeiative
ulomeiulonephiitis
Type 1 is slowly piogiessive while Type
2 is aggiessive.
Autoantibouy against CS conveitase
(!CS levels)
Tieat with pieunisone, plasmaphaiesis.

12*#,+*%,:
Piotein anu salt iestiiction
BNu-CoA ieuuctase inhibitoi foi hypeilipiuemia

L.+3'-,-<:
This happens when theie is uiffuse glomeiulai inflammation
-"$%' #%. -/+0,&+':
Theie is an acute-onset of hematuiia
0liguiia
Bypeitension
Euema
!uFR
" Bun:Ci
![@7 ?K L7@O">!>5 6>A7#A7 5?%%?L 5O#"#5!7">A!>5AJ!c
Post-stieptococcal ulomeiulonephiitis An acute conuition.
Classically occuis aftei Stiep Pyogenes
infection.
Immunofluoiescence shows coaise
gianulai Igu oi CS ueposits.
Labs show incieaseu ieu cells anu casts,
! seium CS, " AS0 titei.
Rapiuly Piogiessive ulomeiulonephiitis
(Ciescentic)
A nephiitic conuition that piogiesses
iapiuly to ienal failuie.
uooupastuie's uisease is in this categoiy.
Immunofluoiescence shows smooth anu
lineai Igu ueposits.
Tieat with pieunisone anu
plasmaphaiesis.
Beigei's Bisease (IgA nephiopathy) Nost common type of nephiopathy.
IgA ueposits in mesangium.
Piesents with iecuiient hematuiia +
low-giaue pioteinuiia.
0sually haimless, howevei 1 in 4 may
piogiess to ienal failuie.
Tieat with pieunisone
Benoch-Schonlein Puipuia Always in chiluien, is an IgA
nephiopathy.
Piesents with abuominal pain, uI bleeu,
vomiting, anu hematuiia.
Classically finu palpable puipuia on

buttocks anu legs
Is a self-limiting uisease that iequiies no
steioius.
Nultiple Nyeloma Theie is an incieaseu light-chain
piouuction.
Finu Bence-}ones piotein in uiine.
Bypeicalcemia seen.
Patient becomes succeptible to
encapsulateu bacteiia because theie is a
uefect in noimal antibouy piouuction.
Tieatment must be on the unueilying
myeloma.





















A90,.*-< GDB*.')DB/.+3'B+(,3-.0F
6>A7#A7 5O#"#5!7">A!>5 L7@O"?@#!O[
Biabetes Nellitus Is the NCC of ESRB.
Eaily manifestation is micioalbuminuiia
(give ACEI's, stiict glycemic contiol).

BIv NC seen when BIv is acquiieu by Iv
uiug use.
Piesents as focal segmental
glomeiulonephiitis.
Eaily tieatment with antiietioviial
Renal Amyloiuosis Biagnose with biiefiingence on congo
ieu stain.
Tieat with a tiansplant

H$@$A
Type 1 No ienal involvement
Type 2 Is a mesangial uisease with focal
segmental glomeiulai pattein.
Tieatment isn't typically iequiieu
Type S Is a focal piolifeiative uisease.
Tieat aggiessively with pieunisone anu
cyclophosphamiue
Type 4 Biffuse piolifeiative uisease.
Combination of both nephiitic anu
nephiitic uisease.
Wiie-loop abnoimality on LN
Tieat with pieunisone anu
cyclophosphamiue
Type S Is a membianous uisease that is
inuistinguishable fiom othei piimaiy
membianous uiseases.
Tieat with pieunisone








"./(D #',.'9 A,./B0-0

Piesents with suuuen onset of hypeitension along with hypokalemia
Abuominal biuit heaiu with stethoscope
Can be causeu by plaque, fibiomusculai uysplasia
!"#$%&'"':
J+%0 )()0),# 0+%0 is a ienal ultiasounu with Bopplei
If small kiuneys aie then seen, uo an NRA
The 2$%0 ,''*;,0+ 0+%0 is a ienal angiogiam
12*#,+*%,:
Angioplasty anu stenting



















?N0,')<,-B/ B; ,3. $'-/('9 !'(<,

BPB anu stones aie the NCC in auults
Theie is an incieaseu iisk of stasis thus incieasing the iisks of 0TI's
Piesent with uiinaiy colic, intense pain that iauiates fiom the back aiounu to
the pelvis anu the gioin
L.+3'BD-,3-(0-0:
3#7;"=+ E/2&05&'05#,*:
8S% of stones aie calcium pyiophosphate
Aie iauiopaque anu associateu with hypeicalcemia
Su% of time it's associateu with hypeicalciuiia
Tieat calcium stones with hyuiation anu loop uiuietics (L00PS eliminate
calcium)
@++&%"=+ )#%$*'"=+ E5&'05#,* T-,2=G",*U8
2
nu
NCC of stones
Aie iauiopaque
0sually causeu by uiease (+) Pioteus oi Staph Sapiophyticus
Nay foim laige staghoin calculi
Tieatment involves taking caie of the unueilying infection

R2"; @;". -,&%*':
0ften seconuaiy to gout oi conuitions that cause incieaseu cell tuinovei,
such as myelopiolifeiative uisease
Tieat by alkalinizing the uiine anuoi tieating any unueilying conuitions









P-2/.9 !)*B'0

The most common ienal malignancy is './(D <.DD <('<-/B*(, which occuis
NC in males fiom Su-7uyi of age
Piesents with hematuiia, flank pain, fevei, palpable mass, anu seconuaiy
polycythemia
Tieatment involves inteileukin anu iesection
The most common chiluhoou ienal malignancy is I-D*80 ,)*B', which
occuis NC between 2-4yi olu
Piesents with a palpable flank mass
Pait of WAuR complex (Wilms, Aniiiuia, u0 malfoimation, Retaiuation -
mental anu motoi)
12*#,+*%,:
Removal of kiuney plus chemotheiapy anuoi iauiation



















Chapter 14

Hematology











#/.*-(0:


@)#. 0$ 2$.+;,0+ ,(+2), >;+%+(0% /)01<
Fatigue, palloi, pale conjunctiva, flow muimui

9+?+;+ ,(+2), >;+%+(0% /)01<
S0B, light-heaueuness, confusion

!"#$%&'"':
The most ieliable test foi iion ueficiency anemia is seium feiiitin, which will
be uecieaseu.
If a patient has iion-ueficiency anemia anu uoes not iesponu to tieatment, uo
hemoglobin electiophoiesis to look foi an $ oi # thalassemia

O!J9 &$; %*%>+'0+. ,(+2),%<

1. Iion stuuies (most imp)
2. CBC w peiipheial smeai (paying attention to NCv, NCBC)
S. B12folate(B12 = neuiopathies, folate = no neuiopathies)
4. RBW (newei smallei RBCs cause change in RBW)
S. Reticulocyte count (ueteimines whethei site of pioblem is bone maiiow
synthesis of new RBCs)
6. LBB, biliiubin, haptoglobin (all ueteimine whethei hemolysis is in play)
7. TSB with T4 (see whethei hypothyioiuism is cause of fatigue)
8. CXRbloou cultuie0A foi suspecteu sickle cell uisease







>'B/ 2.;-<-./<9 #/.*-(
-"$%' #%. -/+0,&+'F
Fatigue
Palloi
Pale conjunctiva
Low feiiitin, low iion, incieaseu TIBC


!"#$%&'"':
Best uiagnostic test foi iion-ueficiency anemia is iion stuuies
The most accuiate test is a bone maiiow biopsy

12*#,+*%,:
0ial feiious sulfate supplement




#/.*-( B; 53'B/-< 6-0.(0.

-"$%' #%. -/+0,&+'F
Same signs anu symptoms with the auuition of a histoiy of chionic
inflammatoiy uisoiuei oi autoimmune uisoiuei




!"#$%&'"':
Best uiagnostic test is iion stuuies (will come back noimal)

12*#,+*%,:
Coiiect the unueilying uisease


!3(D(00.*-(
-"$%' #%. -/+0,&+':
Small NCv
Piesence of taiget cells
veiy othei symptoms

!"#$%&'"':
Best initial test is an iion stuuy
The most accuiate test is hemoglobin electiophoiesis
Beta-thalassemia has elevateu BgA2 anu BgF
Alpha-thalassemia has noimal levels

Theie is no tieatment foi these conuitions












A-2.'BND(0,-< #/.*-(


-"$%' #%. -/+0,&+':
Patient has a histoiy of alcohol abuse, exposuie to leau, oi the use of
isoniaziu (INB)

!"#$%&'"':
Best initial test is iion stuuies
The most accuiate test is the Piussian blue stain

Tieatment:
Ninoi cases iequiie only pyiiuoxine ieplacement
Seveie cases iequiie the iemoval of exposuie to toxin











%(<'B<9,-< #/.*-(

Piesents similaiy to miciocytic anemia with fatigue, palloi, light-heaueuness,
but is causeu by a ueficiency of eithei vitamin B12 oi folic aciu




M-,(*-/ 4aR 6.;-<-./<9F
-"$%' #%. -/+0,&+':
Paiasthesias
Peiipheial neuiopathies
Bementia is the least common occuiience

!"#$%&'"':
CBC with peiipheial smeai, paying special attention to neutiophils
Neutiophils aie laige anu hypeisegmenteu
B12 ueficiency can also cause glossitis anu uiaiihea

12*#,+*%,:
Replace eithei folate oi vitamin B12

L?!7:
Appiox Su% of B12 ueficiencies show noimal B12 levels because tianscobalamine
is an acute phase ieactant which elevates with any foim of stiess. Thus is you
suspect B12 ueficiency anu levels aie noimal, get a methylmalonic aciu level.


Aftei finuing low B12 oi elevevateu methylmalonic aciu, the -+%0 '$(&);2,0$;= 0+%0
"' antipaiietal cell antibouies oi anti-intiinsic factoi antibouies (both confiim
peinicious anemia as the cause of B12 uef).

12*#,+*%,8
Replace B12 oi folate


** Folate ueficiency is most commonly causeu by a pooi uiet, classically uesciibeu as
a "tea anu toast uiet". Folate stoies ueplete within S months, thus with pooi uiets
this can be seen quickly. Tieat this with uiet mouifications anu immeuiate folate
ieplacement.




Sickle Cell Anemia



Patient piesents with extieme pain in the chest, back, anu thighs
When a patient piesents with a sickle cell ciisis, give immeuiate oxygen,
noimal saline, anu analgesics.
If patient piesents with these symptoms + fevei, give Iv antibiotics as well





S1+( 0$ .$ +Q'1,(A+ 0;,(%&*%)$( )( %)'B#+ '+## >0Z
1. Piesence of visual uistuibances uue to ietinal infaict.
2. Pulmonaiy infaict leauing to pleuiitic pain anu abnoimal xiay.
S. Piiapism uue to infaict of piosthetic plexus of veins.
4. Stioke

S1,0 ',*%+% %*..+( .;$>% )( 1+2,0$';)0 )( %)'B#+ '+## >0Z
Eithei uue to a folate ueficiency oi paivo B19 viius, which causes an aplastic
ciisis
- All Sickle cell pts shoulu be on folate supplements, thus if that's the case it is
uue to paivo B19
- Bo a PCR foi BNA of paivo B19

12*#,+*%,
Tiansfusion anu IvIu


S1,0 %1$*#. ,## %)'B#+ '+## >,0)+(0% /1$ ,;+ -+)(A .)%'1,;A+. -+ A)?+(Z
Folate ieplacement
Pneumococcal vaccine
Byuioxyuiea (This incieases hemoglobin F, stops sickling of cells, anu
pievents fuithei ciises)












O.*BD9,-< #/.*-(

All foims of hemolytic anemia piesent with a suuuen onset of weakness anu fatigue
that is associateu with anemia.

Aie piematuie uestiuction of ieu bloou cells
Bone maiiow iesponus appiopiiately by incieasing eiythiopoiesis anu thus
theie is an inciease in ieticulocyte count
If bone maiiow uoesn't woik piopeily, anemia will ensue

?*+&7/'"' :"77 '5&: ,5* 6&77&:"%$:

1. Incieaseu inuiiect biliiubin (uets ieleaseu with RBC uestiuction)
2. Incieaseu ieticulocyte count (Beteimines bones maiiow's ability to make
new RBCs)
S. Incieaseu LBB
4. Becieaseu haptoglobin (oiueieu to uistinguish between anemia anu
hemolytic anemia)


>%,2#G#';=7#2 5*+&7/'"' :"77 #7'& '5&: ,5* 6&77&:"%$8

1. Abnoimal peiipheial smeai (Schistocytes, helmet cells, fiagmenteu cells)
2. Bemoglobinuiia
S. Bemosiueiinuiia (Netabolic, oxiuizeu piouuct oi hemoglobin in uiine).

:,*%+%: Factois exteinal to RBC uefects 0R intiinsic RBC uefects

P\ C#;,&2' *K,*2%#7 ,& OF3 .*6*;,' T)&', ;#'*' #;Z="2*.U

Immune hemolysis
Nechanical hemolysis (causeu by piosthetic heait valves)
Neuications, buins, anu toxins



Q\ ?*+&7/'"' .=* ,& "%,2"%'"; OF3 .*6*;,' T)&', ;#'*' "%5*2",*.U

Causeu by sickle cell uisease, hemoglobin uisease, thalassemias
Nembiane uefects such as heieuitaiy spheiocytosis, paioxysmal noctuinal
hemoglobinopathy
Enzyme uefects such as u6PB ueficiency anu pyiuvate kinase ueficiency




Autoimmune Hemolysis

Patient often has a histoiy of autoimmune uiseases, canceis, oi meuication
use

!"#$%&'"'8
Nost accuiate test is Coomb's test
Look foi an incieaseu LBB anu incieaseu ieticulocyte count
Look at the peiipheial smeai foi spheiocytes

12*#,+*%,:
The best initial theiapy is pieunisone
With no iesponse to pieunisone, IvIu can stop acute episoues
With iecuiiing episoues of hemolysis, a splenectomy is most effective

*N0TE: waim antibouies aie the cause heie, which aie always Igu. 5(#= 4AN
;+%>$(.% 0$ %0+;$).% ,(. %>#+(+'0$2=h








5BD2Y>/2)<.2 O.*BD90-0 \5BD2 (11D),-/-/0)
Coomb's test is negative
Theie is often a mycoplasma oi EBv infection
Theie is no iesponse to steioius, splenectomy, oi IvIu



























O.*BD90-0 2). ,B -/,'-/0-< 2.;.<,0

GD)<B0.YqY@3B0+3(,. 2.392'B1./(0. 2.;-<-./<9
Piesents with a seveie anu acute onset of hemolysis
Is an x-linkeu uisoiuei, thus seen in males
Nost commonly theie is a histoiy of sulfa uiugs, piimaquine, oi uapsone use
Ingestion of fava beans is classically askeu on boaiu exams

!"#$%&'"'8
The best initial test is the peripheral smear that shows Heinz bodies and bite cells
The most accurate diagnostic test is a glucose-6-phosphate level. The problem
with this test is that it will only show up after 2 months, and is not a good test
early on in an acute haemolytic episode

12*#,+*%,:
Avoiuance of oxiuative stiess



@9'):(,. P-/(0. 6.;-<-./<9
Piesents the same way as u6PB ueficiency, but the cause is unknown











O.'.2-,('9 A+3.'B<9,B0-0
-"$%' #%. -/+0,&+'8
}aunuince in chiluhoou
Splenomegaly
Biliiubin gallstones
Recuiient episoues

9>1+;$'=0+%

!"#$%&'"':
The most accuiate anu best initial test is the osmotic fiagility test
Peiipheial smeai showing spheiocytes

12*#,+*%,:
Folic aciu supplementation
Splenectomy foi seveie uisease




O.*BD9,-< $'.*-< A9/2'B*. \O$A^
O$A in kius, theie is usually a histoiy of E.Coli u1S7:B7

-"$%' #%. -/+0,&+:
Acute ienal failuie
Abuominal pain

Bloouy uiaiihea
Seizuies

12*#,+*%,:
Bialysis in chiluien, auults this isn't useful anu theie is a much pooiei
piognosis



!3'B*NB,-< !3'B*NB<9,B+./-< @)'+)'( \!!@^
Is an iuiopathic uisease that is often seen in BIv patients

-"$%' #%. -/+0,&+'8

71+;+ )% , >+(0,. $&<
Baemolytic anemia
Renal failuie
Fevei
Thiombocytopenia
Neuiological uiseases

12*#,+*%,<
Plasma exchange until symptoms subsiue
Without tieatment this is fatal










@('BV90*(D LB<,)'/(D 3.*B1DBN-/)'-( \@LO^

Piesents with iecuiiing episoues of uaik uiine, mostly seen in the moining.

-"$%' #%. -/+0,&+'8
Pancytopenia
Recuiiing episoues of uaik uiine in the moining
Poital vein thiombosis is a complication that leaus to ueath
Nay piogiess to cause aplastic anemia anuoi ANL

!"#$%&'"'8
The most accuiate test is the piesence of uecay acceleiating factoi antibouy

12*#,+*%,8
Pieunisone oi othei steioius




Methemoglobinemia

Bloou lockeu in the oxiuizeu state cannot pick up anu tianspoit oxygen.
Patient will piesent with shoitness of bieath with no ieason

-"$%' #%. -/+0,&+':
S0B with no known cause (Theie will be cleai lungs on exam with a noimal
CXR)
Bloou (if seen) will have a biownish appeaiance, which inuicates it is lockeu
in the oxiuizeu state.



!"#$%&'"':
Look foi exposuie to uiugs like nitioglyceiin, amyl nitiate, oi nitiopiussiue
CXR anu PE show no ieason foi S0B
Look foi a histoiy of anesthetic use

Tieatment:
uive methylene blue




Transfusion Reactions

1. #4? -/<B*+(,-N-D-,9 ! piesents with acute symptoms of hemolysis while
the tiansfusion is happening. Ex: uuiing a tiansfusion, a patient becomes
hypotensive anu tachycaiuic. She has back anu chest pain, anu theie is uaik
uiine. LBB anu biliiubin aie elevateu, anu haptoglobin aie low.
2. !'(/0;)0-B/ '.D(,.2 (<),. D)/1 -/W)'9\D.)QB(11D),-/(,-B/ 'V/^ !
piesents with acute S0B fiom antibouies in the uonoi bloou against iecipient
white cells.
S. >1# 6.;-<-./<9 ! piesents with anaphylaxis. In futuie use uonation fiom
IgA ueficient uonoi oi washeu ieu cells.
4. K.N'-D. /B/3.*BD9,-< 'V/ ! iesults in a small iise in tempeiatuie anu
neeus no theiapy, the ieaction is against the uonoi's white cell antigens.
Pievent by using filteieu bloou tiansfusion in futuie.
S. %-/B' NDBB2 1'B)+ -/<B*+(,-N-D-,9 ! iesults in uelayeu jaunuice, no
theiapy neeueu.










Leukemia

Acute leukemias present with signs of pancytopenia, such as fatigue, bleeding, and
infections from non-functional white blood cells.



Acute Myelogenous Leukemia

A0ER R0BS
Nostly occuiiing in auults (up to 8u%)


!"#$%&'"':
The best initial test is peiipheial smeai showing blasts

Tieatment:
Best initial theiapy foi ANL is 4.,;*-)')( (oi uaunoiubicin) anu '=0$%)(+
,;,-)($%).+




Acute Lymphoblastic Leukemia

The most common malignancy in chiluien
Is the leukemia most iesponsive to theiapy
Is a neoplasm of eaily lymphocytic B cell piecuisois
Bistology ieveals pieuominance of lymphocytes
Pooi piognosis when age < 2 oi > 9, WBC's >1u^S, oi CNS involvement

!"#$%&'"'8
The best initial test is peiipheial smeai showing blasts

12*#,+*%,8
>2(')N-<-/ + <9,B0-/. ('(N-/B0-2. + -/,'(,3.<(D *.,3B,'.V(,..


#<),. @'B*9.DB<9,-< H.)Q.*-(\%j^

This leukemia is associateu with uisseminateu intiavasculai coagulopathy

12*#,+*%,:
>2(')N-<-/ + <9,B0-/. ('(N-/B0-2. + (DD ,'(/0 '.,-/B-< (<-2\#!"#^




53'B/-< %9.DB1./B)0 H.)Q.*-(\5%H^

-"$%' #%. -/+0,&+'8
Elevated white cells that are predominantly neutrophils
Splenomegaly is frequent.
Untreated CML has the highest risk of transformation into acute leukemia of all
forms of myeloproliferative disorders.
#00B<-(,.2 E-,3 @3-D(2.D+3-( 53'B*B0B*.

!"#$%&'"'8
Best initial test is H.)QB<9,. (DQ(D-/. +3B0+3(,(0. 0<B'. \H#@ 0<B'.). An
elevateu PNN count with low LAP scoie is CNL. Reactive high white counts
fiom infection give an elevateu LAP scoie, LAP is up in noimal cells, not CNL.
The most accuiate test is finuing the Philauelphia Chiomosome

12*#,+*%,8
Best initial tieatment is Imatinib (uleevec)
Bone maiiow tiansplant is the only cuie foi CNL, but is nevei the best initial
theiapy, because Imatinib leaus to 9u% hematologic iemission with no majoi
auveise effects.




53'B/-< H9*+3B<9,-< H.)Q.*-(\5HH^
Seen in people oluei then Suyi of age

-"$%' #%. -/+0,&+':
0ften asymptomatic
0iganomegaly
Baemolytic anemia
Thiombocytopenia

!"#$%&'"':
Best initial test is the peiipheial smeai showing 'smuuge cells'

12*#,+*%,8
At stages u anu 1, theie is no tieatment iequiieu
At auvanceu stages give fluuaiabine oi chloiambucil




Hairy Cell Leukemia

Seen in miuule-ageu people anu piesents with massive splenomegaly anu
pancytopenia

!"#$%&'"':
The Nost accuiate test is the taitiate iesistant aciu phosphatase(TRAP)
smeai showing haiiy cells

12*#,+*%,:
The best initial theiapy foi Baiiy Cell leukemia is clauiibine oi 2-CBA





Myelofibrosis

Piesents similaily to haiiy cell leukemia except theie will be a noimal TRAP
level
The key uiagnostic featuie is the "teai-uiop" shapeu cells on peiipheial
smeai
Theie is no specific theiapy foi myelofibiosis




Polycythemia Vera (Erythrocytosis)

This piesents with heauache, bluiieu vision, uizziness, anu fatigue. All uue to
thickeneu bloou

-"$%' #%. -/+0,&+':
Eveiything above
Piuiitis following hot showeis oi baths uue to histamine ielease
Splenomegaly

!"#$%&'"':
veiy high hematociit with a low NCv
uet an ABu to iule out oi in hypoxia as a cause of eiythiocytosis

12*#,+*%,:
The best initial theiapy is phlebotomy
Byuioxyuiea can be given to lowei the cell count
uive uaily aspiiin






PLASMA CELL DISORDERS



Multiple Myeloma

This conuition piesents most commonly with bone pain uue to fiactuies occuiiing
fiom noimal use

!"#$%&'"'8
The most specific test is a bone maiiow biopsy
Skeletal suivey to uetect puncheu out osteolytic lesions
Seium piotein electiophoiesis(SPEP) to look foi elevateu monoclonal
antibouy (usually Igu)
0iine piotein electiophoiesis(0PEP) to uetects Bence-}ones pioteins
Peiipheial smeai showing "iouleaux" foimation of bloou cells.
Elevateu calcium levels uue to osteolytic lesions
Beta 2 micioglobulin level is a piognostic inuicatoi
B0N anu Cieatinine to uetect ienal insufficiency


12*#,+*%,:
Steioius anu Nelphalan
The most effective theiapy is bone maiiow tiansplant
Tieat all unueilying co-moibiuities











Waldenstroms Macroglobulinemia

This is a hypeiviscosity of the bloou uue to oveipiouuction of IgN

-"$%' #%. -/+0,&+':
Bluiieu vision
Confusion
Beauache
Enlaigeu lymph noues
Splenomegaly

!"#$%&'"':
The best initial test is the seium viscosity (incieaseu significantly) anu SPEP
foi IgN levels
Theie will be no specific finuing on the CBC

12*#,+*%,:
Plasmaphaiesis is the best initial theiapy
Can also give fluuaiabine oi chloiambucil




Aplastic Anemia

Piesents as pancytopenia with no iuentifiable etiology.
If pt is < Su anu has a match, best theiapy is BN tiansplantation.
If BN tiansplant isn't an option (>Su), give antithymocyte globulin anu
cyclospoiine.






LYMPHOMAS


Present with enlarged lymph nodes that are most commonly seen in the cervical area

Hodgkins disease occurs in a bimodal age distribution (young and old), and is
characterized by Reed-Sternberg cells

Reed-Sternberg Cell

Non-Bougkin's uisease is commonly seen in BIv patients

!"#$%&'"':
The best initial uiagnostic test foi both types of lymphomas is lymph noue
biopsy

0nce excisional biopsy shows abnoimal aichitectuie, fuithei testing to ueteimine
stage of the lymphoma neeus to be uone.

1. Stage 1 ! single lymph noue gioup
2. Stage 2 ! 2 LN gioups on one siue of uiaphiagm
S. Stage S! LN involvement on both siues of uiaphiagm
4. Stage 4! wiuespieau uisease


?! #%. S?B 02*'*%, :",5 ',#$*' #' 6&77&:'8

BB - 8u-9u% pies w stage 1 anu 2
NBL - 8u-9u% pies w stages S anu 4


?&: ,& ',#$*: CXR, CT with contiast (Chestabuomenpelvisheau), anu BN biopsy.

12*#,+*%,:

1. O$',#)b+. .)%+,%+ (stage 1,2) without "B"
symptoms is tieateu pieuominantly with
iauiation.
2. @$;+ ,.?,('+. %0,A+% S,4 is tieateu with
chemotheiapy.


-0*;"6"; ,2*#,+*%,':
1. BB: ABvB (auiiamycin|uoxoiubicinj, bleomycin, vinblastine, uacaibazine)

2. NBL: CB0P (cyclophosphamiue, hyuioxyauiiamycin, oncovin|vinciistinej,
anu pieunisone)

* Also test foi anti-CB2u antigen anu if piesent, auu Rituximab, which auus
efficacy to CB0P.











J 9e@875@9<

Aie systemic symptoms
such as:

FEvER
NIuBT SWEATS
WEIuBT L0SS

COAGULATION DISORDERS

MB/ I-DD.N'(/280 2-0.(0. \MI6^

Is uue to platelet uysfunction, not a lowei numbei of platelets

Bleeding from PLT dysfunction, superficial bleeds from skin and mucosal
surfaces, such as gingival, gums, and vagina.
Epistaxis common
Bleeuing often woiseneu with use of aspiiin
PLT count is noimal

!"#$%&'"'8
J+%0 )()0),# 0+%0 is platelet function test
The 2$%0 ,''*;,0+ 0+%0 is a iistocetin cofactoi assay anu a vWF level (If vWF
is noimal, iistocetin tells you if it is woiking piopeily)

12*#,+*%,':
Fiist line tieatment is uesmopiessin oi BBAvP, which causes the ielease of
subenuothelial stoies of vWF anu co-factoi vIII
If uesmopiessin uoesn't woik, give factoi vIII ieplacement


@D(,.D.,Y,9+. ND..2-/1 <()0.0: petechiae, epistaxis, puipuia, gingival, gums,
vaginal
K(<,B'Y,9+. ND..2-/1 <()0.0: hemaithioses, hematoma

>2-B+(,3-< !3'B*NB<9,B+./-< @)'+)'( \>!@^

ITP is a uiagnosis of exclusion that piesents with platelet-type bleeuing anu a
platelet count of < Su,uuu



!"#$%&'"':
Peifoim a sonogiam to assess the size of the spleen
Check foi anti-platelet antibouies
Bone maiiow biopsy looking foi megakaiyocytes
Antibouies to glycopiotein IIbIIIa ieceptois

12*#,+*%,8
With milu ITP (platelets of ~ 2u,uuu) give pieunisone
With seveie ITP (platelets of < 2u,uuu) give Iv immunoglobulins, which is the
fastest way to inciease the platelet count
NEvER tiansfuse platelets because this exaceibates the conuition



Uremia-Induced PLT dysfunction

This piesents as platelet-type bleeuing in a patient with ienal failuie, wheie ienal
failuie causes uiemia, which pievents the uegianulation of platelets anu thus stops
them fiom woiking

-"$%' #%. -/+0,&+':
Platelet type bleeuing

!"#$%&'"':
Ristocetin anu vWF levels (noimal)
Check platelet levels (They will be noimal)
Look foi ienal failuie (This is the key to uiagnosing)

12*#,+*%,:
Besmopiessin




O.+('-/Y>/2)<.2 !3'B*NB<9,B+./-( \O>!^

A conuition wheie platelets uiop at least Su% a few uays aftei the use of hepaiin

-"$%' #%. -/+0,&+':
The most common clinical manifestation is thiombosis, wheie venous
thiombosis is the most common type

!"#$%&'"':
The best initial uiagnostic test is platelet factoi 4 antibouies
0thei impoitant test is hepaiin-inuuceu anti-platelet antibouies

12*#,+*%,:
The best initial theiapy is to stop hepaiin anu use uiiect thiombin inhibitoi
such as "aigatioban" oi "lepiiuuin".



















Chapter 15

Rheumatology









"3.)*(,B-2 #',3'-,-0

An autoimmune uisease piesents most commonly in females > Su.

}oint pain anu moining stiffness that is symmetiical anu in multiple joints of
the hanus.
Lasts longei than 1hi in the moining with symptomatic episoues going on foi
at least 6 weeks.
0ften a piouiome of fatigue anu malaise, but this isn't enough foi a cleai ux.

!"#$%&'"' "' 4#'*. &% 5#G"%$ ` &2 +&2* &6 ,5* 6&77&:"%$8

Noining stiffness lasting moie than 1hi
Wiist anu fingei involvement
Swelling of at least S joints
Symmetiic involvement
Rheumatoiu nouules
Xiay abn's showing eiosions
(+) iheumatoiu factoi

Rheumatoiu aithiitis is a gioup of physical finuings, joint pioblems, anu lab tests.
Theie is no single uiagnostic ciiteiia to confiim the uiagnosis, noi is theie one single
theiapy to contiol anu tieat the uisease.

!"#$%&'"'8
The single most accuiate lab test is the anticitiullinateu cyclic peptiue (anti-
CCP)
Noimocytic, noimochiomic anemia is veiy chaiacteiistic of iheumatoiu
aithiitis

a&"%, C"%."%$':
NCP swelling anu pain
Boutonieiie uefoimity: flexion of PIP w hypeiextension of the BIP
Swan neck uefoimity
Bakei's cyst

C1C2 ceivical spine subluxation
Knee: although knee is commonly involveu, multiple small joints aie involveu
moie commonly ovei time.


12*#,+*%,:
NSAIBs anu Bisease mouifying anti-iheumatic uiugs(BNARBS)
Steioius can be useu acutely to help contiol the uisease while BNARBs take
effect, but they aie only useu as a biiuge to BNARB theiapy, not useu long-
teim



A.'B/.1(,-:. A+B/29DB(',3'B+(,3-.0
1. Ankylosing sponuylitis
2. Reactive aithiitis (Reiteis synuiome)
S. Psoiiatic aithiitis
4. }uvenile RA


71)% A;$*> $& )(&#,22,0$;= '$(.)0)$(% ,## 01+ &$##$/)(A '1,;,'0+;)%0)'%<
Negative foi RF
Pieuilection foi the spine
SI joint involvement
Associateu with BLA B27




#/Q9DB0-/1 A+B/29D-,-0\#A^
AS piesents in a young male (<4u) w spine oi back stiffness.
Peiipheial joint involvement is less common
Pain is woise at night anu ielieveu by leaning foiwaiu, which can leau to
kyphosis anu uiminisheu chest expansion.
Raie finuings incluue: uveitis anu aoititis.


!"#$%&'"':
The best initial test is an xiay
The most accuiate test is an NRI

12*#,+*%,:
S-@>!-
Sulfasalazine
Biological agents (Infliximab, Aualimumab)




".(<,-:. #',3'-,-0\;B'*.'D9 ".-,.'80 09/2'B*.^F
Piesents with asymmetiic aithiitis anu a histoiy of uiethiitis oi uI infection.
Patient may have constitutional symptoms such as fevei, malaise, anu weight
loss.

!"#$%&'"':
Clinical uiagnosis baseu on the piesence of the classic tiiau of uiethiitis,
conjunctivitis, anu aithiitis

Tieatment:
NSAIBs








@0B'-(,-< #',3'-,-0F
Piesents as joint involvement with a histoiy of psoiiasis.
Rheumatoiu factoi (-)
SI joint is involveu.

_*/ 6*#,=2*' &6 ,5"' ."'*#'* #2*8
Pitting of the nails
Involvement of the uistal inteiphalangeal joints
"Sausage-shapeu" uigits

12*#,+*%,8
Initial tieatment shoulu be with NSAIBs
If this isn't woiking, auu biological agents such as Infliximab
If these uon't woik, tiy methotiexate




w):./-D. "# \(Q( (2)D, B/0., A,-DD80 2-0.(0.^
Theie is no specific uiagnostic test.
aO@ "' ;5#2#;,*2"J*. 4/ ,5* 6&77&:"%$8
Feiiitin levels aie high
WBC count is elevateu
RF (-) anu ANA (-)

Tieatment:
NSAIBs
If uniesponsive to NSAIBs, give methotiexate







I3-++D.80 6-0.(0.
Causes uiaiihea anu fat malabsoibtion, anu is most commonly piesenteu
with joint pain
The most specific test foi uiagnosis is a biopsy of the bowel

12*#,+*%,F
TNPSNX




?0,.B(',3'-,-0
0steoaithiitis is the most common joint abnoimality anu is associateu with
excessive joint usage anu incieaseu age

-"$%' #%. -/+0,&+'8
Noining stiffness lasting < Su minutes
}oint ciepitus seen
Affects the uistal inteiphalangeal joint (wheieas RA uoes not)
Bebeiuen's noues aie seen as BIP osteophytes
Bouchaiu's noues aie seen as PIP osteophytes

!"#$%&'"'8
The best initial uiagnostic test is an xiay of the joint

12*#,+*%,8
NSAIBs
ulucosamine sulphate anu chonuioitin sulphate aie useu to slow joint
ueteiioiation.





0A RA
Noining Stiffness <Sumin >1hi
BIP YES N0
PIP YES YES
NCP N0 YES
RF, anti-CCP N0 YES
}oint fluiu <2uuu Suuu-Suuuu




















AH7
Classically, a iash + joint pain + fatigue = Lupus
Theie aie 11 ciiteiia foi L0P0S, 4 must be piesent to make the uiagnosis.
AP>L - Nalai Rash
- Photosensitivity iash
- 0ial ulceis iash
- Biscoiu iash
#',3'(D1-(0 Piesent in 9u% of pts
4DBB2 Leukopenia, thiombocytopenia,
hemolysis. Any bloou involvement
counts as 1 ciiteiia.
"./(D vaiies fiom benign pioteinuiia to ESRB.
5.'.N'(D Behavioi changes, stioke, seizuie,
meningitis
A.'B0-,-0 Peiicaiuitis, pleuiitic chest pain,
pulmonaiy BTN, pneumonia,
myocaiuitis.
A.'BDB19 - ANA (9S% sensitive)
- BS-BNA (6u% sensitive)
Each of the seiologic abn's count as 1
ciiteiia. If peison has joint pain,
iash, anu both ANA anu BS BNA, the
pt has 4 ciiteiia.


!"#$%&'"'8
The best initial uiagnostic test is the ANA
The most specific test is the anti-us BNA oi anti-Smith antibouy


V$/ 0$ &$##$/ 01+ %+?+;)0= $& , #*>*% &#,;+D*>Z
1. Complement levels will uiop in flaie-up
2. anti-us BNA will iise in flaie up



12*#,+*%,V)#%#$*+*%,8
Foi acute flaie-ups give pieunisone anu othei glucocoiticoius
uive NSAIBs foi joint pain
If theie is no iesponse to those meuications, antimalaiials anu
hyuiochloioquine will woik
Foi seveie uisease that iecuis give cyclophosphamiue anu azthiopiine



6')1Y-/2)<.2 H)+)0
The most likely causes of uiug-inuuceu lupus aie hyuialazine, piocainamiue, anu
isoniaziu

!"#$%&'"':
Theie will be anti-histone antibouies
Theie is nevei ienal oi CNS involvement
Theie aie noimal levels of complement anu anti-us BNA antibouies



AWB'1./80 09/2'B*.
Seen most commonly in women (9x gieatei in women than men)

-"$%' #%. -/+0,&+':
Biy eyes, uiy mouth
Theie is a sensation of sanu unuei the eyes
Bysgeusia is common
Commonly a loss of teeth uue to the lack of auequate saliva




!"#$%&'"':
The most accuiate test is a lip biopsy
The Schiimei test is will show inauequate laciimation
Commonly see "anti-Ro oi anti-La antibouies

12*#,+*%,:
Pilocaipine to inciease Ach anu thus inciease laciimation anu salivaiy
secietions




A<D.'B2.'*(
Patient has tight skin, heaitbuin, anu Raynauu's phenomenon

-"$%' #%. -/+0,&+':
9B)( &)(.)(A% incluue a tight, fibious thickening that causes tight anu
immobile fingeis as well as a tight face
I$)(0 8,)( that is milu anu symmetiical
M,=(,*.G% 81+($2+($(, may iesult in ulceiations


A<D.'B2.'*( <(/ +'.0./, 2-;;)0.D9 E-,3 ,3. ;BDDBE-/1F

O*(A%: fibiosis anu pulmonaiy BTN(the leauing causes of ueath in this uisease)

N4: Wiue mouth colonic uiveiticula anu esophageal uysmotility, leauing to ieflux anu
Baiiett's esophagush 1S% of pts get piimaiy biliaiy ciiihosis

V+,;t: Restiictive caiuiomyopathy


M+(,#: may leau to malignant BTN.


Diagnosis:

Theie is not a single best uiagnostic test
Though not specific, ANA is seen in 9S% of cases

12*#,+*%,:
Theie is no tieatment that slows the piogiession oi tieats this conuition
If theie is ienal involvement give ACEIs
If theie is pulmonaiy hypeitension, give Bosentan anu piostacyclin analogs
Foi Raynauu's give calcium channel blockeis





7B0-/B+3-D-< K(0<--,-0
Is similai in piesentation to scleioueima but theie is no Raynauu's, noi is theie any
of the othei systemic finuings

-"$%' #%. -/+0,&+':
Thickeneu skin similai to scleioueima
Naikeu eosinophilia gives the appeaiance of peau u'oiange

12*#,+*%,:
Nanage this conuition with coiticosteioius






@BD9*9B0-,-0\@%^ (/2 6.'*(,B*9B0-,-0\6%^

In both conditions, the patient cannot get up from a seated position without using the
arms. There can also be muscle pain and tenderness.

E$; >$#=2=$%)0)%! Weakness + incieaseu CPK + incieaseu aluolase
E$; .+;2,0$2=$%)0)% ! Weakness + incieaseu CPK + incieaseu aluolase + skin
iash.

!"#$%&'"':
Clinical
Shoulu oiuei LFT's anu ANA

Tieatment:
Coiticosteioius



K-N'B*9(D1-(
A pain synuiome seen mostly in females that piesents with aching muscles,
stiffness, tiiggei points foi pain, anu sleep that isn't iefieshing

Signs anu Symptoms:
Nuscle aches
Nuscle stiffness
Bepiession anuoi anxiety
Extieme sensitivity anu pain to tiiggei points on the bouy

!"#$%&'"'8


Noimal bloou tests anu no objective eviuence of uisease

12*#,+*%,V)#%#$*+*%,8

Exeicise can help ielieve some pain anu stiffness
TCA's can be given









@BD9*9(D1-( "3.)*(,-<( \@%"^

Seen most commonly in those > Suyi


-"$%' #%. -/+0,&+'8

Patient oluei than Suyi with significant pain anu stiffness of the pioximal
muscles (shoulueis, pelvic giiule)
Stiffness is usually woise in the moining anu is usually moie localizeu to the
muscles
Patient may have fevei, malaise, anu weight loss

!"#$%&'"':
CBC will likely show noimocytic anemia
Nuscle biopsy anu labs aie all noimal

Lack of muscle atiophy

12*#,+*%,: Steioius

Following explains uiffeience between chionic fatigue, fibiomyalgia, anu PNR
53'B/-< ;(,-1).
09/2'B*.
K-N'B*9(D1-( @BD9*9(D1-(
'3.)*(,-<(
Fatiguemalaise +++++ >6mnth ++ ++
Noniefieshing
sleep
+++++ ++ No
Tiiggei points N0 YES N0
Bloou tests All noimal All noimal Inci ESR
Tieatment None Pain ielief Pieunisone



M(<)D-,-0
Common featuies among uiffeient types of vasculitis incluue:
Fatigue, malaise, wt loss
Fevei
Skin lesions such as palpable puipuia anu iash
}oint pain
Neuiopathy

3&++&% 7#4 6"%."%$'8
Noimocytic anemia
Elevateu ESR
Thiombocytosis





!"#$%&'"'8
The most accuiate test is a biopsy


12*#,+*%,8
The best initial theiapy is steioius

! If steioius aien't effective, alteinate anuoi auuitional theiapies aie the following

Cyclophosphamie
Azathiopiine6-meicaptopuiine
Nethotiexate


@BD9(',.'-,-0 LB2B0( \@#L^

PAN has all the featuies of vasculitis uesciibeu above, what uiffeientiates it is the
unique featuies that accompany PAN.

Abuominal pain (6S%)
Renal involvement (6S%)
Testiculai involve(SS%)
Peiicaiuitis(SS%)
BTN(Su%)

!"#$%&'"'8
The best initial test is angiogiaphy of the abuominal vessels
The most accuiate test is a biopsy of the muscles, suial neive, anu skin

12*#,+*%,:
Pieunisone anu Cyclophosphamiue



I.1./.'80 G'(/)DB*(,B0-0
A disorder that like PAN can affect the majority of the body. Look for the addition of
upper and lower respiratory findings and the presence of c-ANCA

Diagnosis:

The most accurate diagnostic test is a biopsy
Upper and lower respiratory findings
Presence of c-ANCA

Treatment:

Treatment involves Prednisone and Cyclophosphamide




53)'1YA,'()00
Can affect any oigan in the bouy, but the key to making its uiagnosis is
piesence of ?,%'*#)0)%f +$%)($>1)#),f ,(. ,%012,h
P-ANCA anu anti-myelopeioxiuase can be positive too, but these finuings
aien't as unique as the piesence of eosinophilia.
Nost accuiate test is biopsy

12*#,+*%,:
Steioius








!.*+B'(D #',.'-,-0
A type of giant cell arteritis, related to PMR.

Signs and Symptoms:

Fever
Malaise
Fatigue
Weight loss
Headache
Visual disturbances
Jaw claudication

Diagnosis:

Elevation of ESR
Clinical findings

Treatment:

Steroids




!(Q(9(0)80 #',.'-,-0
Seen in young asian females

-"$%' #%. -/+0,&+':
Bimishes pulses
vasculitis commonly seen befoie loss of pulse
Patient often gets TIA anuoi stioke causeu by the vasculai occlusion

!"#$%&'"':
NRA oi aiteiiogiaphy



12*#,+*%,:
Steioius


5'9B1DBN)D-/.*-(
Is similai to to vasculitis synuiomes, the uiffeience is the association with hepatitis
C anu kiuney involvement
12*#, with inteifeion anu iibaviiin


4.3<., 6-0.(0.

This condition presents in pts of Middle Eastern or Asian ancestry.

Signs and Symptoms:
0ial anu genital ulceis
0culai involvement that can leau to blinuness
Skin lesions: "patheigy" which is hypeiieactivity to neeule sticks, iesulting in
steiile skin abscesses.

!"#$%&'"'8
Theie is no specific test foi uiagnosis, we must use the featuies seen above

12*#,+*%,8
Pieunisone anu colchisine









>LKH#%76 w?>L!A


The key to uiagnosing inflameu joints is to look at the fluiu within the joint. It is the
most accuiate uiagnostic test foi gout, pseuuogout, anu septic aithiitis

9=($?),# &#*). '+## '$*(0
LB'*(D >/;D(**(,B'9\1B),J+0.)2B1B),^ >/;.<,-B)0
<2uuu WBC's 2uuu-Suuuu WBC's >Suuuu WBC's



GB),

Look for a man with a sudden onset of severe pain in the toe at night. The toe will be
red, swollen, and tender.

Things that precipitate a gouty reaction are:

Alcohol ingestion
Thiazide diuretics
Nicotinic acid
Foods high in protein


!"#$%&'"':
The best initial test is aspiiation of the joint fluiu
The most accuiate test is light exam of the fluiu showing negatively
biiefiingent neeule-shapeu ciystals

12*#,+*%,:
The best initial theiapy foi an acute gouty attack is NSAIBs.
uive colchisine within 24hi of the attack

Allopuiinol is best as piophylaxis anu pievention of futuie attacks, which
woiks by ieuucing the levels of uiic aciu




@0.)2B1B), \5(D<-)* @9'B+3B0+3(,. 6.+B0-,-B/ 6-0.(0.^
Involves most commonly the wiist anu knees, but uoesn't involve the toes
0nset is much slowei than gout, anu uoesn't acutely attack the patient

!"#$%&'"':
Aspiiation of joint fluiu shows positively biiefiingent ihomboiu-shapeu
ciystals

12*#,+*%,:
NSAIBs aie the best initial theiapy
Can give colchisine, but is not as effective heie as it is in gout



A.+,-< #',3'-,-0
Any aithiitic oi piosthetic joint put patient at iisk of septic aithiitis
With incieaseu joint abnoimality comes incieaseu iisk of sepsis

)&2* 2"'9 6#;,&2' 6&2 '*0,"; #2,52","'8
0steoaithiitis is moie of a iisk than having noimal joints
RA is moie of a iisk than osteoaithiitis
Piosthetic joints aie moie of a iisk than anything else.

-"$%' #%. -/+0,&+':
Reu, swollen, tenuei, immobile joint



Nost common causes of septic aithiitis:
Staph auieus (4u%)
Stiep (Su%)
uiam-ve bacilli (2u%)

**Septic aithiitis iequiies consult w oithopaeuic suigeon.

!"#$%&'"'8
The best initial test is aithiocentesis showing > Su,uuu WBC
The most accuiate test is a cultuie of the fluiu

12*#,+*%,8
Empiiic Iv antibiotics such as Ceftiiaxone anu vancomycin once suspecteu



@(1.,80 6-0.(0. B; 4B/.
A conuition with pain, stiffness, aching, anu fiactuies associateu with softening of
the bones.

-"$%' #%. -/+0,&+':
Stiffness
Pain
Fiactuies
Bowing of the tibias

!"#$%&'"':
The best initial test is foi the elevation of alkaline phosphatase
The most accuiate test is xiay of the bones

12*#,+*%,:
Best tieateu with bisphosphonates anu calcitonin



* In cases of Paget's, osteolytic lesions will be founu initially. These may be ieplaceu
with osteoblastic lesions

** If you see osteolytic think Paget's oi osteopoiosis

*** If you see osteoblastic, think about metastatic piostate cancei in uiffeiential.


4(Q.'80 590,
A posteiioi heiniation of the synovium of the knee

-"$%' #%. -/+0,&+'8
Patient often has osteoaithiitis
Palpation of the sac in the posteiium of the knee
Swelling of the calf is common (excluue a BvT when you see this)

12*#,+*%,:
NSAIBS aie mainstay of tieatment
Seveie cases may iequiie steioiu injections










@D(/,(' K(0<--,-0 (/2 !('0(D !)//.D A9/2'B*.

E$##$/)(A 0,-#+ '$2>,;+% 01+ 0/$ '$(.)0)$(%<
Plantai Fasciitis Taisal tunnel synuiome
Pain on bottom of foot Pain on bottom of foot
veiy seveie in moining, bettei w
walking a few steps
Noie painful w use; may have sole
numbness
Stietch the foot anu calf Avoiu boots anu high heels; may neeu
steioiu injection
Resolves spontaneously ovei time Nay neeu suigical ielease

















Chapter 16

Neurology










A,'BQ.0 (/2 !>#

90;$B+%:

Stiokes occui foi gieatei % 24hi anu have peimanent iesiuual neuiological
ueficits.
Causeu by ischemia most commonly, anu hemoiihagic.
Ischemic stiokes occui fiom emboli oi thiombosis, which occui moie acutely

74!:

Piesents the same as a stioke except it lasts <24hi.
Commonly piesents with a loss of vision in only one eye (Amauiosis fugax),
uue to emboli in the fiist bianch off of the caiotiu (0phthalmic aiteiy)
TIA's aie always uue to emboli oi thiombosis, nevei hemoiihage


!"#$%&'"%$:

The best initial test is always a CT of the heau without contiast

12*#,+*%,:

If possible, give thiombolytics within Shis of the onset of symptoms anu the
CT has iuleu out hemoiihage
Aspiiin is the best initial theiapy foi those who come in too late foi
thiombosis
If patient is alieauy on aspiiin, can give uipyiiuamole (Clopiuogiel is an
alteinative)


i 71+;+ )% ($ '#+,; +?).+('+ 01,0 1+>,;)( -+(+&)0% , %0;$B+


#',.'-.0 (/2 ,3.-' (00B<-(,.2 09*+,B*0 -/ 0,'BQ.F

57"74"#H #"!7"[ A[%@!?%A
Anteiioi ceiebial aiteiy -piofounu lowei extiemity weakness
- milu uppei extieme weakness
- peisonality changes
- uiinaiy incontinence
Niuule ceiebial aiteiy - piofounu uppei extiemity
weakness
- aphasia
- apiaxianeglect
- eyes ueviate towaius lesion siue*
Posteiioi ceiebial aiteiy - contialateial homonymous
hemianopia w maculai spaiing
- piosopagnosia(cant iecognize
faces)
veitebiobasilai aiteiy - veitigo
- Nv
- veitical nystagmus
- Bysaithiia anu uystonia
- Sensoiy changes in facescalp
- Ataxia
- Labile bloou piessuie
Lacunai infaict - must be absence of coitical
ueficits**
- Paikinson signs
- Bemipaiesis(most notable in
face)
- Sensoiy ueficits
- Possible bulbai signs
0phthalmic aiteiy - amauiosis fugax


C=2,5*2 +#%#$*+*%, &6 # -,2&9* &2 1>@8

Aftei all initial managements aie implementeu, uo the following:


Echocaiuiogiam
Caiotiu Bopplei
EKu anu Boltei monitoi if the EKu comes back noimal

b&=%$ 0,' cde/2 :",5 %& '"$%"6";#%, 0#', +*.";#7 5"',&2/ T!)< ?1SU '5&=7. 5#G*
6&77&:"%$ .&%*8

1. Seuimentaion iate
2. vBRL oi RPR
S. ANA, usBNA
4. Piotein C, piotein S, factoi v leiuen mutation, antiphospholipiu synuiomes

* The youngei the patient, the moie likely the cause of stioke is a vasculitis oi
hypeicoagulable state.

:$(0;$# V7Xf R@f ,(. 1=>+;#)>).+2), )( 01)% >0<

N$,#%<

BTN: <1Su8u
BN: same tight glycemic contiol as gen pop'n
Bypeilipiuemia: LBL<1uu



74!:

Same management as pei stioke, except thiombolytics aien't inuicateu because the
auministiation of thiombolytics aie to iesolve symptoms, so if symptoms aie
iesolveu they aien't necessaiy.




SEIZURES

Foi seizuie uisoiueis, the only cleai uiagnostic ciiteiia is foi a patient unueigoing
status epilepticus.

15*2#0/ 6&2 ',#,=' "' #' 6&77&:'8
1. Benzouiazepine such as Ativan (Loiazepam)
2. If seizuie peisists, auu fosphenytoin
S. If seizuie peisists, auu phenobaibitol
4. If seizuie peisists, give geneial anesthetic such as pentobaibital.

!"#$%&'"' "% # 0#,"*%, 5#G"%$ # '*"J=2*8
0igent CT of the heau
0iine toxicology secieen
Chemistiy panel
Calcium levels
Nagnesium levels


C=2,5*2 +#%#$*+*%,:
If initial tests uon't give cleai cause, uo an EEu (shoulun't be uone fiist).

Neuiology consult iequiieu in any patient having oi who hau a seizuie.


B&%$D,*2+ ,2*#,+*%, &6 6"2',D,"+* '*"J=2*':
If patient only hau 1 seizuie, chionic theiapy is not iequiieu unless theie is a
stiong family histoiy, an abnoimal EEu, oi status epilepticus


352&%"; #%,"*0"7*0,"; ,5*2#0/8
Theie is no single agent consiueieu to be the best theiapy.


C
%0
#)(+ 01+;,>)+% )('#*.+<
valpioate, caibamazepine, phenytoin, anu levetiiacetam aie all equal in
efficacy.
Lamotiigine has same efficacy but can cause steven-johnson synuiome.

R
/2
D-/. ,3.'(+-.0F
uabapentin anu phenobaibitol


E$; ,-%+('+Y>+0)0 2,# %+)b*;+%:
Ethosuxamiue is best.


















@('Q-/0B/80 6-0.(0.

Is a gait uisoiuei with the following finuings:
Cogwheel iigiuity
Resting tiemoi
Nask-like facies
0ithostasis
Intact cognition anu memoiy

!"#$%&'"':
Theie is no specific test to make the uiagnosis of PB, iathei the clinical
finuings aie what is useu to make the uiagnosis

12*#,+*%,:
@)#. %=2>0$2%F

In a patient < 6uyi of age ! Anticholineigics such as Benztiopine oi
Byuioxyzine
In a patient > 6uyi of age ! Amantauine (0luei patients commonly uevelop
bau ieaction fiom anticholineigic meuications)

9+?+;+ %=2>0$2%F
Leveuopacaibiuopa have the gieatest efficacy but has an "on-off"
phenomenon with uneven long-teim effects anu moie siue effects
Bopamine agonists such as Piamipiexole, Ropineiole, anu Cabeigoline aie
less efficacious but have fewei siue effects


** If these meuication uon't woik, use C0NT inhibitois (Tolcapone, Entacapone)
which inhibit metabolism of uopamine, which extenus the effect of uopamine-baseu
meuication. Can also tiy NA0I's.




TREMOR

!9+. B; ,'.*B' ".0,-/1 ,'.*B' >/,./,-B/ ,'.*B' !'.*B' (, '.0,
(/2 E-,3
-/,./,-B/
6-(1/B0-0 Paikinsons Ceiebellai uisoiuei Essential tiemoi
!'.(,*./, Amantauine Tieat etiology Piopianolol



MULTIPLE SCLEROSIS

Nultiple Scleiosis piesents with abnoimalities of any pait of the CNS. The
symptoms impiove anu iesolve, only to have anothei uefect uevelop months oi
yeais latei.


-"$%' #%. -/+0,&+'8

The most common abnoimality is optic neuiitis
Theie is commonly fatigue, hypeiieflexia, spasticity, anu
uepiession
Theie is also commonly optic neuiitis


!"#$%&'"'F
The best initial uiagnostic test is an NRI
The most accuiate test is also the NRI
If the NRI uoesn't give you the uiagnosis, uo a lumbai tap

12*#,+*%,:
Steioius aie the best initial theiapy to iesolve an acute exaceibation
ulatiiamei anu beta-inteifeion can both ueciease the piogiession of NS
%)D,-+D.
A<D.'B0-0F

uA>Lv

1. Scanning
speech
2. Intention
tiemoi
S. Nystagmu
s

Can give Amantauine to combat fatigue anu Baclofen to combat spasticity





DEMENTIA

#DT3.-*.'0 6-0.(0.
Is a slow piogiessive loss of memoiy exclusively in pts > 6Syis of age
!"#$%&'"'8
Anybouy with memoiy lost iequiies a CT of the heau, a TSB level, anu an
RPRvBRL
With Alzheimei's uisease you will only see uiffuse anu symmetiical atiophy

12*#,+*%,
Anticholinesteiase inhibitois aie the stanuaiu theiapy of choice


K'B/,B,.*+B'(D 6.*./,-( \@-<Q 6-0.(0.^
Peisonality anu behavioui become abnoimal fiist, then memoiy loss
afteiwaius.
Beau CT oi NRI shows focal atiophy of fiontal anu tempoial lobes
Tieat this like Alzheimei's, but uo not expect the same type of iesponse

5'.),T;.D2Yw(QBN 6-0.(0. \5w6^
Causeu by piions, which aie tiansmissible piotein paiticles.
Nanifests as iapiuly piogiessive uementia anu piesence of myoclonus.
This piesents in those youngei than the Alzheimei's patient
EEu will be abnoimal
Nost accuiate test is biain biopsy
CSF: shows 14-S-S piotein, the piesence of this will spaie the patient a biain
biopsy.



H.E9 4B29 6.*./,-(:
Is Paikinson's uisease + uementia.


LB'*(D @'.00)'. O92'B<.+3(D)0:
This conuition geneially piesents in oluei males, but it can affect women as
well.
It piesents as a peison with incontinence, with gait abnoimalities, anu with
cognitive impaiiment

!"#$%&'"':
Biagnosis shoulu incluue a heau CT anu a lumbai punctuie

12*#,+*%,:
Shunt placement




O)/,-/1,B/80 6-0.(0.J53B'.(
Piesents in young patients (usually in Su's)
Theie is usually a family histoiy

-/+0,&+'8
Bementia
Peisonality changes anu psychological uistuibance
Choieic movements

!"#$%&'"':
Specific genetic testing will show that inheiitance is autosomal uominant


Tieatment:
Theie is no tieatment


























HEADACHE

%-1'(-/.: 6u% aie unilateial, often tiiggeieu by: cheese, caffeine, menses, 0CP's

Bo a CT oi NRI if BA has any of the following:
Suuuen anuoi seveie
0nset aftei 4uyi
Associateu with any neuiological finuings
Nay be pieceeueu by an auia anuoi scotomata (Baik spots in visual fielu),
anu abnoimal smells

12*#,+*%,8
The best initial aboitive theiapy is sumatiiptan oi eigotamine
Piophylactic theiapy takes 4-6wks to woik, if patient gets foui oi moie BA
pei month, piophylax with piopianolol.
Alteinate piophylactics with CCBs, TCA's, oi SSRI.

5D)0,.': 1ux moie fiequent in men than women. Aie exclusively unilateial w
ieuness anu teaiing of the eye anu ihinoiihea.

Tieatment:
The best aboitive theiapy is 1uu% u2.
This tieatment is unique to clustei BA's.
Sumatiiptan can also be useu in same way as is in migiaines.

Piophylactic theiapy: theie is none because these BA's aie numeious but shoit anu
intense, anu the "clustei" woulu be ovei by the time the piophylaxis kickeu in.








O# !9+. %>G"#>L7 5H$A!7"
uenuei Nen 1ux moie than
women
Piesentation 0nilateial oi bilateial,
auia
0nly unilateial,
teaiingieuness of eye
Aboitive Sumatiiptan Sumatiiptan, Special:
1uu%u2
Piophylactic Piopianolol none

* Sumatiiptan is similai to SBT, anu woiks by causing vasoconstiiction in ceiebial
aiteiies.




!.*+B'(D #',.'-,-0
Patient will piesent with tenueiness ovei the tempoial aiea anu may also complain
of jaw clauuication

!"#$%&'"':
Fiist check the ESR
The most accuiate test is a biopsy of the tempoial aiteiy

12*#,+*%,:
uive steioius immeuiately, uo not uelay if this is suspecteu





@0.)2B,)*B' 5.'.N'-
This piesents most commonly in a youngei woman with a heauache anu
uouble vision, papilleuema
CTNRI show up noimal
vitamin A use is often the cause

!"#$%&'"':
LP is the most accuiate test because it shows an elevateu opening piessuie

Tieatment:
Involves weight loss
Acetazolamiue can also be given



6-TT-/.00JM.',-1B
All pts with veitigo will have a subjective sensation of the ioom spinning
aiounu them.
0ften associateu with nausea anu vomiting
All pts with veitigo will have nystagmus
ueneially all patients wtih veitigo shoulu have NRI of the inteinal auuitoiy
canal.











E$##$/)(A 0,-#+ %*22,;)b+% >;+% $& , (*2-+; $& ?+;0)A$D',*%)(A '$(.)0)$(%<
6-0.(0. 53('(<,.'-0,-<0 O.('-/1 HB00J !-//-,)0
4@M Changes w position N0
M.0,-N)D(' /.)'-,-0 veitigo occuis wo
position change
N0
H(N9'-/,3-,-0 Acute YES
%./-.'.80 2-0.(0. Chionic YES
#<B)0,-< /.)'B*( Ataxia YES
@.'-D9*+3 ;-0,)D( Bx of tiaum YES


4@M
veitigo alone w no loss of heaiing,no tinnitus, no ataxia.
Positive uix-hallpike maneuvei
Tieat with meclizine(antiveit)



M.0,-N)D(' L.)'B/-,-0
An iuiopathic inflammation of the vestibulai poition of CN8.
No heaiing loss oi tinnitus because only vestibibulai poition is affecteu.
Nost likely to be a viial cause
Not ielateu to change in position
Tieat with meclizine







H(N9'-/,3-,-0
Is inflammation of the cochleai poition of the innei eai.
Theie is heaiing loss as well as tinnitus.
Is acute anu self-limiteu
Tieat with meclizine



%./-.'.80 6-0.(0.
Same pies as labyiinthitis (veitigo, tinnitus, heaiing loss) but menieie's is
chionic with iemitting anu ielapsing episoues.
Tieat with salt iestiiction anu uiuietics.



#<B)0,-< L.)'B*(
A tumoi of CN8 that can be ielateu to neuiofibiomatosis (von
Recklinghaus's).
Piesents with ataxia in auuition to heaiing loss, tinnitus, anu veitigo.

!"#$%&'"'8
NRI of inteinal auuitoiy canal

12*#,+*%,:
Suigical iesection.








@.'-D9*+3(,-< K-0,)D(
Beau tiauma oi any foim of baiotiaumas to the eai may iuptuie the
tympanic membiane anu leau to a peiilymph fistula.




Wernicke-Korsakoff Syndrome

Piesents with the following:
1. Bistoiy of chionic heavy ET0B use
2. Confusion with confabulation
S. Ataxia
4. Nemoiy loss
S. uaze palsy anuoi ophthalmoplegia
6. Nystagmus

!"#$%&'"':
Bo a heau CT
vitamin B12 level
TSBT4 level
RPRvBRL
Piesence of memoiy loss

12*#,+*%,:
1
st
give thiamine then give glucose.











5LA >LK75!>?LA

0ften when a CNS infection is suspecteu, a heau CT shoulu be peifoimeu befoie the
LP.

This is the case in the following ciicumstances:
A histoiy of CSN uisease
Focal neuiological ueficits
Piesence of papilleuema
Seizuies
Alteieu consciousness
Significant uelay in ability to peifoim LP

** If these aie piesent, get bloou cultuies anu stait empiiic antibiotics befoie
oiueiing CT.

:9E<
uetting CSF is the most accuiate test foi bacteiia meningitis, but cannot wait
foi cultuie to stait theiapy.
uiam stain: only Su% sensitive, thus if (-) cannot excluue anything. Is highly
specific though, so if (+) it is likely to be bacteiia meningitis. Ie. uoou spec
bau sensitivity
uiam (+) uiplococci: pneumococcus
uiam (+) bacilli: listeiia
uiam (-) uiplococci: neisseiia
uiam (-) pleomoiphic, coccobacillaiy oiganisms: hemophilus


8;$0+)(: An elevateu piotein level in CSF is of maiginal uiagnostic benefit. Elevateu
piotein is non-specific because any foim of CSN infection can elevate the CSF
piotein. Bowevei, a noimal CSF piotein excluues bacteiial meningitis.

N#*'$%+: Levels below 6u% of seium levels is consistent w bacteiial meningitis


:+## '$*(0< This is best initial test foi the uiagnosis of meningitis. If thousanus of
PNN's aie piesent stait Iv ceftiiaxone, vancomycin, anu steioius. Thousanu of
PNN's is bacteiial meningitis until pioven otheiwise.



5'9+,B<B<<)0 (fungal meningitis)

Look foi BIv(+) patient with <1uuCB4 cells.
This infection is slowei than bacteiial meningitis anu may not give seveie
meningeal signs (neck stiffness, photophobia, anu high fevei, all at same
time).

!"#$%&'"':
The best initial test is the Inuia ink stain
The most accuiate test is the ciyptococcal antigen

12*#,+*%,8
The best initial theiapy is Amphoteiicin

*follow Amphoteiicin with oial Fluconazole (continueu inuefinitely until the CB4
count iaises), once CB4 count >1uu, fluconazole can be uiscontinueu.










H9*. 6-0.(0.
Patient usually lives in Connecticut aiea anu has a histoiy of camping, hiking, oi
being in tall giass. The tick exposuie is iaiely iemembeieu by the patient.

!"#$%&'"':
A cential cleaiing taiget iash is pathognomonic
Theie is a histoiy of joint pain
Bell's palsy

12*#,+*%,:
0ial uoxycycline
If theie is caiuiac involvement tieat with Iv ceftiiaxone



"B<Q9 %B)/,(-/ A+B,,.2 K.:.' \"%AK)
Look foi campeihikei with a iash that staiteu on wiists anu ankles anu moveu
centially.

-"$%' #%. -/+0,&+'8
Fevei, heauache, anu malaise always pieceue the iash

!"#$%&'"'8
0ial Boxycylcine is the most effective theiapy.









!4 %./-/1-,-0
This is an extiemely uifficult uiagnosis to pinpoint
Look foi an immigiant with a histoiy of lung TB
Piesents slowly ovei weeks to months (If acute then not TB meningitis)

!"#$%&'"'8
Bas a veiy high CSF piotein levels
Aciu fast stain of CSF is not accuiate, neeu thiee high-volume centiifugeu
samples if going to uo aciu-fast stain.

12*#,+*%,8
RIPE tieatment as with TB, only uiff is shoulu auu steioius anu extenu the
length of theiapy foi meningitis when compaieu to the pulmonaiy uisease.



M-'(D %./-/1-,-0
viial meningitis is in geneial a uiagnosis of exclusion.
Theie is lymphocytic pleocytosis in the CSF.
Theie is no specific theiapy foi viial meningitis.



H-0,.'-( %./-/1-,-0
Look foi elueily, neonatal, anu BIv (+) patients anu those who have no
spleen, aie on steioius, oi aie immunocompiimiseu with leukemia oi
lymphoma.

* Auu Ampicillin to iegimen of vancomycin + ceftiiaxone when Listeiia is suspecteu.
Such as if theie is lymphocytosis in the CSF.



L.-00.'-( %./-/1-,-2.0
Look foi patients who aie auolescents, in the militaiy, aie asplenic, oi who
have teiminal complement ueficiency.

12*#,+*%, "' #' 6&77&:':
8,0)+(0 ! Respiiatoiy isolation
:#$%+ '$(0,'0%! Stait piophylaxis with iifampin oi cipiofloxacin.
Close contacts aie: householu membeis, people who shaie utensils, cups, kisses.
M$*0)(+ '$(0,'0%! Routine school anu woik contacts uo not neeu to ieceive
piophylaxis.






ENCEPHALITIS

Look foi a patient with a fevei anu alteieu mental status ovei a few houis.
Almost all encephalitis in the 0S is fiom heipes, the patient uoes not have to
iecall a past histoiy of heipes in oiuei to make this uiagnosis

E3F3M g :5XE6945X = Encephalitis

!"#$%&'"':
The best uiagnostic test is a CT scan of the heau
The most accuiate test is a PCR of the CSF

12*#,+*%,:
The best initial theiapy is acyclovii
Foi acyclovii-iesistant patients give foscainet




BRAIN ABSCESS

Pies with a fevei, heauache, anu focal neuiological ueficits
CT finus a "iing" aka contiast enhanceu lesion
Finuing a iing means eithei cancei oi infection.

Consiuei BIv status in context of biain abscess as follows:

BIv negative patient ! biain biopsy is the next step
BIv positive patient ! Tieatment foi toxoplasmosis with pyiimethamine
anu sulfauiazine foi 2wks anu iepeat the heau CT




@'B1'.00-:. %)D,-;B<(D H.)QB./<.+3(DB+(,39 (PNL)
These biain lesions in BIv(+) patients aie not associateu with iing
enhancement oi mass effect.
Theie is no specific theiapy.
Tieat the BIv anu iaise the CB4, when the BIv is impioveu, the lesions will
uisappeai.



L.)'B<90,-<.'<B0-0
Look foi a patient fiom Nexico with a seizuie
Beau CT shows multiple 1cm cystic lesions, ovei time lesions will calcify.

!"#$%&'"':
Confiim with seiology



12*#,+*%,:
When still active anu uncalcifieu, the lesions aie tieateu with Albenuazole,
use steioius to pievent a ieaction to uying paiasites.





O.(2 !'()*( (/2 >/,'(<'(/-(D O.*B''3(1.

Any heau tiauma iesulting in a loss of consciousness oi alteieu mental status shoulu
leau to CT of heau without contiast

5B/<)00-B/ 5B/,)0-B/ A)N2)'(D
3.*=
7+-2)'(D 3.*=
Focal ueficit Nevei Raiely Yes oi no Yes oi no
Beau CT Noimal Ecchymosis Ciescent shape Lens shapeu


!'.(,*./, ;B' :('-B)0 3.(2 ,'()*(0 ('. (0 ;BDDBE0:

1. :$('*%%)$(: None
2. :$(0*%)$(: Aumit patient, vast majoiity get no tieatment
S. 9*-.*;,# ,(. 3>).*;,# V+2,0$2,%: Laige ones uiaineu, small ones left
alone to ieabsoib on theii own.
4. O,;A+ )(0;,';,(),# 1+2$;;1,A+ /)01 2,%% +&&+'0: 1.
Intubatehypeiventilate to ueciease ICP, 2. Beciease PCu2 to 2S-Su, which
constiicts ceiebial bloou vessels, S. auministei Nannitol as an osmotic
uiuietic to ueciease ICP, 4. Peifoim suigical evacuation.




A)N('(<3/B-2 O.*B''3(1.\A#O^
Look foi the following symptoms:
Suuuen, seveie heauache
Stiff neck
Photophobia
L0C in Su% of patients
Focal neuiological ueficits in Su% of patients
SAB is like suuuen onset of meningitis with a L0C but without fevei.


!"#$%&'"'8
The best initial test is a heau CT without contiast. It is 9S% sensitive, if
conclusive, no neeu to uo an LP
The most accuiate uiagnostic test is an LP, but not necessaiy if CT shows
bloou.

12*#,+*%,8
Peifoim angiogiaphy to ueteimine site of bleeu
Suigically clip oi embolize the site of bleeuing (If patient ie-bleeus theie is a
Su% change of ueath).
Inseit a vetiiculopeiotoneal shunt if hyuiocephalus uevelops
Piesciibe nimouipine oially; which is a CCB that pievents stioke.

** When SAB occuis, an intense vasospasm can leau to non-hemoiihagic
stioke(thus CCB useu).










SPINE DISORDERS
Lumbosacial
stiain
Coiu compiession Epiuuial abscess Spinal stenosis
Nontenuei Tenuei Tenuei anu fevei Pain on walking
uownhill.



A9'-/1B*9.D-(
Is a uefective fluiu cavity in the centei of the coiu fiom tiauma, tumois, oi
congenital pioblem.
Piesents with a loss of sensation of pain anu tenueiness in a cape-like
uistiibution ovei the neck, shoulueis, anu uown both aims.

!"#$%&'"':
NRI

12*#,+*%,:
Suigical coiiection



5B'2 5B*+'.00-B/
Netastatic cancei piesses on the coiu, iesulting in pain anu tenueiness of the
spine.
Lumbosacial stiain uoesn't give tenueiness of the spine itself.

!"#$%&'"':
The best initial test is an NRI
The most accuiate uiagnostic test is a biopsy, only uone if uiagnosis is not
cleai fiom the histoiy





Spinal Epidural Abscess

Piesents with back pain wth tenueiness anu fevei
Scan spine with an NRI
uive antibiotics against staphylococcus such as oxacillin oi nafcillin
Laige abscesss iequiie suigical uiainage.




A+-/(D A,./B0-0
Piesents with leg pain on walking anu can look like peiipheial aiteiial
uisease
Pulses will be intact in spinal stenosis
Pain woisens when patient leans backwaius anuoi walks in a uownwaiu
uiiection, while it impioves when walking in an upwaiu uiiection
Biagnose with an NRI anu tieat with suigical uecompiession



#/,.'-B' A+-/(D #',.'9 >/;('<,-B/
All sensation is lost except position anu vibiatoiy sense, which tiavel uown
the posteiioi column of the spinal coiu
No specific theiapy can coiiect this pioblem



4'BE/YA._)('2 A9/2'B*.
This iesults fiom tiaumatic injuiy to the spine, such as that fiom a knife
wounu.
Patient loses ipsilateial position, vibiatoiy sense, contialateial pain anu
tempeiatuie



** The most uigent management in coiu compiession is the auministiation of
steioius as soon as possible anu to ielieve piessuie on the coiu. Imaging stuuies aie
uone aftei auministiation of steioius.




AMYOTROPHIC LATERAL SCLEROSIS

Is an iuiopathic uisoiuei of both uppei anu lowei motoi neuions.
Tieateu with iiluzole, a unique agent that blocks the accumulation of
glutamate

$%L 0-1/0 H%L 0-1/0
Bypeiieflexia
0pgoing toes on plantai ieflex
Spasticity
Weakness
Wasting
Fasciculations
weakness






PERIPHERAL NEUROPATHIES


6-(N.,.0
Biabetes is the most common cause of peiipheial neuiopathies
Specific testing is not necessaiy in most cases.

12*#,+*%,:
uabapentin oi Piegabalin aie useful in tieating neuiopathies.
TCA's aie less effective anu have moie siue effects


5('+(D !)//.D A9/2'B*.
Look foi pain anu weakness of fiist thiee uigits of hanu
Symptoms may woisen with iepetitive use.
Initial mgmt is a splint.
Steioiu injections may be useu if splints pioviue no ielief
If these uon't woik, can peifoim suigeiy to ielieve the pain


"(2-(D L.':. @(D09
Aka Saturday night palsy, results from falling asleep or passing out with
pressure on arms underneath the body or outstretched, perhaps draped over back
of a chair (classic presentation on exam question)
Results in wrist drop, resolves on its own.



@.'B/.(D L.':. @(D09
Results fiom high boots piessing at the back of the knee.
Results in foot uiop anu inability to eveit the foot.
This palsy will iesolve on its own



5Lm +(D09 \4.DD80 +(D09^
Results in hemi-facial paialysis of both uppei anu lowei halves of face.
Thought to be uue to a viius
Theie may also be a loss of taste in anteiioi 2S of tongue, hypeiaccusis, anu
the inability to close the eye at night.

12*#,+*%,:
Steioius anu acyclovii oi valcyclovii shoulu be given




".;D.V 09*+(,3.,-< 290,'B+39 \<3'B/-< '.1-B/(D +(-/ 09/2'B*.^
0ccuis in a patient with a pievious injuiy to the extiemity
Light tough such as fiom a sheet touching the foot, iesults in extieme pain
that is "buining" in quality

12*#,+*%,:
NSAIBs
uabapentin
0ccasionally a neive block may be uone if the pievious methous uon't woik
Suigical sympathectomy may be necessaiy when iefiactoiy




".0,D.00 H.1 A9/2'B*.
0ncomfoitable feeling in the legs which patient tiies to "shake off", which
biings only tempoiaiy ielief

12*#,+*%,:
Piamipexole oi iopineiole.



G)-DD(-/Y4(''. 09/2'B*.
Ascenuing paialysis, thought to be causeu by a viial infection.
0sually piesents weeks aftei a iespiiatoiy infection

)#%#$*+*%,V12*#,+*%,8
Fiist step is to take a peak inspiiatoiy piessuie, which can tell if the pt will
unueigo iespiiatoiy failuie.
Seconu step is to give IvIu's anuoi peifoim plasmaphaiesis.



MYASTHENIA GRAVIS

Classically piesents with weakness of the muscles of mastication, making it
haiu to finish meals
Bluiiy vision fiom uiplopia iesults fiom inability to focus the eyes on a single
taiget.
Classically the patient iepoits uiooping of the eyelius as the uay piogiesses.


!"#$%&'"':
The best initial test is testing foi anti-acetylcholine ieceptoi
antibouies(ACBR)
The most accuiate test is ;7"%";#7 02*'*%,#,"&% #%. @3?O, which is moie
sensitive anu specific that tensilon test.

12*#,+*%,:
The best initial theiapy is @9'-2B0,-1*-/. oi L.B0,-1*-/.
Thymectomy can be peifoimeu if pyiiuostigmine oi neostigmine uon't woik
patients < 6u yi of age shoulu unueigo thymectomy.
uive E2*.%"'&%* if thymectomy uoesn't woik, oi if theie aie no iesponses to
pyiiuostigmine oi neostigmine, then pieunisone shoulu be staiteu.
!b,01)$>;)(+ #%. '='#$%>$;)(+ aie useu to tiy to keep the patient off of long-
teim steioius.












Chapter 17

Oncology










4'.(0, 5(/<.' A<'../-/1

Scieening mammogiaphy as follows:
Stait at 4u
Between 4u-Su anu eveiy 1-2yis
At Su, stait uoing them eveiy yeai


S1+( , 2,22$A;,2 %1$/% ,( ,-($;2,#)0=Z
1
st
thing is to uo a biopsy(shows CA anu piesence of esetiogen anuoi
piogesteione ieceptois)

S1,0 )% 01+ %+(0)(+# ($.+s
It is the fiist noue uetecteu in the opeiative fielu, uetecteu by uye.
If this noue is fiee of CA, then axillaiy noue uissection is not necessaiy, if the
noue is canceious, axillaiy lymph noue biopsy is iequiieu

J+%0 )()0),# 01+;,>= &$; -;+,%0 ',('+;s
Lumpectomy with iauiation tieatment(equal to mouifieu iauical
mastectomy)
If theie is piesence of estiogen oi piogesteione ieceptoi (+), use tamoxifen
oi ialoxifene
Aujuvant chemotheiapy useu whenevei the axillaiy noues aie (+) 0R the
cancei is >1cm in size.


V$;2$(,# 4(1)-)0)$( 71+;,>=F
!(*BV-;./ anu '(DBV-;./. useu if eithei piogesteione oi esteiogen
ieceptois aie positive. They SERNs (selective esteiogen ieceptoi
mouulatois). #2:.'0. ".(<,-B/0: BvT, hot flashes,enuometiial CA.
These aie uiffeient fiom ('B*(,(0. -/3-N-,B'0, which uo not leau to BvT,
but cause osteopoiosis uue to antagonistic activity in the bone.




!.P*?,(0 :1+2$01+;,>=< >0 (++'B+'-(,. E3./C
1. Cancei is in the axilla
2. Cancei laigei than 1cm
S. Noie efficacious when pt still menstiuation, because BR-ca wont be
contiolleu with estiogen antagonists such as tamoxifen.

7M!976j6@!J: is a monoclonal antibouy against bieast CA antigen "BER-2NE0",
useful in metastatic uisease, has mouest activity with few auveise ieactions

E2"+#2/ E2*G*%,#,"G* 15*2#0/: 0se Tamoxifen in any patient with multiple 1
st

uegiee ielatives (mom, sistei) with bieast CA



COLON CANCER

The most imp thing is scieening scheuule anu inuicatois..

Colon cancei is tieateu with suigical iesection of the colon anu
chemotheiapy centeieu aiounu a S-F0 iegimen.

M$*0)(+ &$; %';++()(AF
1. Colonoscopy starting at 50, the every 10yrs. If single family member has it, get
colonoscopy 10yrs earlier than the age at which that person was diagnosed. Three
family members get colonoscopy at 25yr, then every 10yr. FAP do screening
sigmoidoscopy at 12yr, then every 1-2yr.
2. ?<<)D, NDBB2 ,.0,-/1 staiting at Suyi, then eveiy yeai theieaftei.
S. A-1*B-2B0<B+9 anu 2B)ND. <B/,'(0, N('-)* enema at Su, then q S-Syi.







LUNG CANCER

Remember that small cell carcinoma releases ectopic ACTH, Squamous cell carcinoma
releases PTH-like hormone.

Theie is no scieening test foi lung cancei
Excisional biopsy shoulu be uone on solitaiy lung nouules in pts who aie
smokeis with nouule >1cm.
Calcifications usually go against malignancy, but if theie is histoiy of
smoking, a patient >Suyi, anu nouule >1cm, excision is waiianteu.

O*(A ',('+; 01+;,>=: The most imp issue in tieatment is whethei the uisease is
localizeu enough to be suigically iesecteu. Suigeiy cannot be uone is any of the
following aie piesent:
1. Bilateial uisease
2. Nets
S. Nalignant pleuial effusion
4. Involvement of aoita, vena cava, oi heait
S. Lesions within 1-2cm of caiina.

*** 92,##D'+## #*(A ',('+; is non-iesectable because >9S% of time is has one of
these featuies.

CERVICAL CANCER

Stait pap smeais at 21, oi Syis aftei onset of sexual activity
Bo pap smeais eveiy S yis until age 6S. Stop at 6S unless theie has been no
pievious scieening.
Auministei BPv quauiivalent vaccine to all women 1S-26yi

C&77&:"%$ =0 #% #4%&2+#7 0#0 '+*#2:
1. An abnoimal pap smeai with low-giaue oi high-giaue uysplasia shoulu be
followeu by colposcopy anu biopsy.
2. A pap smeai showing atypical squamous cells of unueteimineu significance
(ASC0S), uo BPv testing. If BPv (+), pioceeu to colposcopy, if BPv (-), uo
iepeat pap in 6mnth
S. 0nce pap smeai noimal, ietuin to ioutine testing


* Pap smeais lowei moitality in scieen populations, but still not as much as
mammogiaphy because inciuence of ceivical CA is less than that of bieast cancei.



PROSTATE CANCER

No pioven scieening methou that loweis moitality iate. PSA anu BRE not
pioven to lowei moitality.
Bo not ioutinely offei these tests, howevei if pt asks foi them, you shoulu
peifoim.

12*#,"%$ 02&',#,* ;#%;*2:
1. O$',#)b+.: Suigeiy anu eithei exteinal iauiation oi implanteu iauioactive
pellets (neaily equal in efficacy)

2. @+0,%0,0)': Anuiogen blockaue is stanuaiu of caie, use flutamiue
(testosteione ieceptoi blockei) ANB leupioliue oi goseielin (uNRB
agonists).

* Theie is no goou chemotheiapy foi metastatic piostate cancei, tieatment is
hoimonal in natuie.
*Remembei the S-alpha-ieuuctase inhibitoi finasteiiue is useu foi BPB, not
cancei

A man with piostate cancei piesents with seveie, suuuen back pain. NRI shows
coiu compiession, anu he's staiteu on steioius. S1,0G% 01+ (+Q0 -+%0 %0+> )(
2A20Z
KH$!#%>67 (to block tempoiaiy flaie up in anuiogen levels that accompanies
uNRB agonist tieatment





OVARIAN CANCER

Key feats aie women >Su with incieasing abuominal giith at same time as weight
loss.

!"#$%&',"; ,*',"%$:
Theie's no ioutine scieening test
CA12S is a maikei of piogiession anu iesponse to theiapy, not a uiagnostic
test

12*#,+*%,:
Treatment is surgical debulking followed by chemotherapy, even in cases of local
metastatic disease.
Ovarian ca is unique in that surgical resection is beneficial even when theres a
large volume of tumor spread through the pelvis and abdomen. If possible,
removing all visible tumors helps.



TESTICULAR CANCER

Presents with painless scrotal lump in a man <35yr.
Is extiemely cuiable with a 9u-9S% Syi suivival iate.
NEvER uo a biopsy of the testicle.

!"#$%&',"; 1*',"%$8
An inguinal orchiectomy of the affected testicle, never do biopsy.
Measure AFP, LDH, and bHCG
Stage with CT of abdomen and pelvis.

12*#,+*%,:
1. O$',# .)%+,%+: Rauiation
2. S).+%>;+,. .)%+,%+: Chemotheiapy, which is cuiative of even metastasis in
testiculai cancei.


U?; (DD ,.0,-<)D(' <(/<.'0C pet ('. 1.'* <.DD ,)*B'0 \0.*-/B*( (/2 /B/Y
0.*-/B*(^=

*AFP secieteu only by nonseminomas.

*Neasuie AFP, LBB, anu bBCu.




SOME EXTRA PREVENTATIVE MEDICINE

92$B)(A '+%%,0)$(:
Scieen all anu auvise against smoking
Nost effective methous aie use of oial meus such as Bupiopiion anu
vaienicline.
Less effective aie nicotine patch anu gum (which shoulu be tiieu fiist).

*With bupiopiion, patient shoulu slowly ueciease cigaiettes 2wks aftei staiting
theiapy. 0se bupiopiion in conjunction with counselling anu nicotine ieplacement.

5%0+$>$;$%)%! Scieen all women with BEXA scan at 6Syi of age.

!!!! All men about 6Syi who weie evei smokeis shoulu be scieeneu once w an
ultiasounu.

R@! No iecommenuation foi ioutine uiabetes scieening

V7X! All pts shoulu be scieeneu at eveiy visit.

V=>+;#)>).+2),! Nen >SS, Women >4S






Chaptei 18

Beimatology








6%)(A 7$>)',# 90+;$).%
Potency Neuication 0se
Low 1% hyuiocoitisone Face, genitalia, anu skin
Noueiate u.1% tiiamcinolone BouyExtiemities, face,
genitalia, anu skin folus
Bigh Fluocinoniue Foi thick skin.
Nevei on face
veiy Bigh Bifloiasone Thick skin oi seveie bouy
neeus


#</.
An infection of the pilosebaceous glanu causeu by the bacteiia
Piopionibacteiium acnes
!:X3
-"$%' #%. -/+0,&+'8
Blackheaus (open comeuones) anu whiteheaus (closeu comeuones)

12*#,+*%,:
Nilu uisease shoulu be manageu with topical antibiotics such as clinuamycin,
eiythiomycin, in auuition to benzoyl peioxiue
Noueiate uisease shoulu combine benzoyl peioxiue with ietinoius
Seveie uisease shoulu be manageu with oial antibiotics anu oial ietinoic aciu
ueiivatives




4(<,.'-(D >/;.<,-B/0 B; ,3. AQ-/

>*+.,-1B
A supeificial skin infection limiteu to the epiueimis
42>+0)A$

Is often uesciibeu as being "honey-coloieu", "wheeping", oi "oozing"
0sually causeu by 90,>1=#$'$''*%, but may also be uue to 90;+> 8=$A+(+%
12*#,+*%,:
Nupiiocin (A topical antibiotic) anuoi antistaphylococcal oial antibiotics


7'90-+.D(0
A skin infection of the epiueimis anu the ueimis, which is usually causeu by Stiep
Pyogenes. This conuition is often uesciibeu as being biight ieu, angiy, anu swollen.

3;=%)>+#,%
With eiysipelas may come fevei anu chills
12*#,+*%,:
Penicillin u oi ampicillin if uiagnosis is Stieptococcus


5.DD)D-,-0
An infection causeu by Staphylococcus anu Stieptococcus that infects the ueimis
anu the subcutaneous tissues. Nanageu with antistaph uiugs such as oxacillin anu
nafcillin.
:+##*#)0)%




KBDD-<)D-,-0
An infection of the haii follicle, may piogiess to a woise infection calleu a fuiuncle.
0sually causeu by staphylococcus, if acquiieu fiom a hot-tub it can be uue to
Pseuuomonas, fungi, oi viius
Look foi this aiounu the beaiu aiea wheie theie aie accumulations of pus-like
mateiial.
E$##)'*#)0)%

12*#,+*%,:
Local caie anu topical mupiiocin
Seveie cases that piogiess iequiie systemic antistaphylococcal antibiotics














L.<'B,-T-/1 K(0<--,-0
Is a seveie, life-thieatening skin infection. It begins as a cellulitis that uissects into
the fascial planes of the skin. NCC by stiep anu Clostiiuium
E2*'*%,#,"&%:
Bigh fevei
Extieme pain that is woise than it looks
Bullae
Ciepitus
X+';$0)b)(A E,%'))0)%
!"#$%&'"':
CT oi NRI looking foi aii in the tissue anuoi neciosis
Elevateu cieatine phosphokinase

)#%#$*+*%,V12*#,+*%,8
Suigical uebiiuement
Combination beta lactambeta lactamase meuications
If it is causeu by Stiep Pyogenes, give clinuamycin + PCN










A<('D., K.:.'
Is causeu by Stiep Pyogenes, anu looks like a combination of a iash anu goosebumps
9',;#+0 E+?+;

-"$%' #%. -/+0,&+'F
Rough skin
Stiawbeiiy tongue
Beefy-ieu phaiynx
Rash is most intense in the axilla anu gioin (In the cieaseu aieas of skin)
Besquamation of hanus anu feet occuis as iash iesolves
Nay have fevei, chills, soie thioat, ceivical auenopathy
ulomeiulonephiitis is a complication

12*#,+*%,:
Penicillin










5B**B/ 6.'*(,BDB1-< 6-0B'2.'0

7<T.*(
Is a supeificial, itchy, eiythematous lesion
The iash uevelops aftei itching
Commonly seen on the flexoi suifaces
Biagosis is clinical
3'b+2,
12*#,+*%,F Avoiuance of iiiitants anu tiiggeis, keep skins moistuiizeu,
antihistaminessteioius aie goou foi ielief fiom inflammation anu itching
Theie aie many vaiiations of Eczema, incluuing:
1. !0$>)' R+;2,0)0)% - this is the classic wheie itching causes a iash
2. :$(0,'0 .+;2,0)0)% - an itchy iash at the site of contact, classically causeu by
contact with nickel, chemicals, oi poison plants
S. 9+-$;;1+)' .+;2,0)0)% - scaling anu flaking in aieas of sebaceous glanus









@0B'-(0-0
Piesents as pink plaques with silvei scaling
0ccuis on the extensoi suifaces such as the elbows anu knees
Theie is often pitting of the fingeinails
The classic finuing is known as "Auspitz Sign", which is pinpoint bleeuing
when the scale is iemoveu
This is uiagnoseu clinically
8%$;),0)' 8#,c*+
12*#,+*%,:
C
%0
#)(+ is Topical steioius
T
(.
#)(+ is 0vA light anu may be useu as an aujunctpiophylactic
a
;.
#)(+ is methotiexate anu clyclospoiin


$',-<('-(
Is a conuition causeu by mast cell uegianulation anu histamine ielease
Piesents with the classic "wheals" that aie intensely itchy
"Beimogiaphism" is seen wheie you can wiite a woiu with youi fingei on
the skin anu it will iemain
Nost lesions aie IgE-meuiateu (thus a type 1 sensitivity)
Biagnose this conuition by sciapings

6;0)',;),
12*#,+*%,:
Avoiu tiiggeis
uive antihistaminessteioius
This can possibly affect the iespiiatoiy tiact which woulu then involve
secuiing an aiiway


M-,-D-1B
Theie is a loss of melanocytes in uisciete aieas of the skin
Boiueis aie shaiply uemaicateu
0sually seen in uaikei patients
Possibly autoimmune in natuie
F)0)#)A$
12*#,+*%,:
Nini-giafting can iestoie pigment to aieas wheie it is lacking

#DN-/-0*
Failuie of melanocytes to piouuce pigment, uue to a tyiosine ueficiency
Patient has white skin, iiis tianslucency, uecieaseu ietinal pigment,
nystagmus, anu stiabismus
Avoiu sun exposuie anu use sunscieen all the time
Theie is an incieaseu iisk of skin cancei uue to lack of piotection fiom the
sun
!#-)()%2
















4D-0,.'-/1 6-0B'2.'0

@.*+3-1)0 M)D1('-0
A iaie autoimmune uisoiuei affecting people between 2u-4uyi of age
Bullae slough off easily anu leave laige uenuueu aieas of skin, this is know as
"Nikolsky's sign", this pieuisposes to an incieaseu iisk of infection
Fatal conuition if not manageu piopeily
8+2>1)A*% F*#A,;)%
!"#$%&'"':
Immunofluoiescence of the suiiounuing epiueimal cells shows a
"tombstone" fluoiescent pattein
12*#,+*%,:
Bigh-uose oial steioius







4)DDB)0 @.*+3-1B-2
An autoimmune conuition that affects mostly the elueily
Less seveie than pemphigus vulgaiis
Piesents with haiu anu tense bullae that uo not iuptuie easily
Piognosis is much bettei than that of pemphigus vulgaiis
J*##$*% 8+2>1)A$).
!"#$%&'"':
Skin biopsy showing a lineai banu along the basement membiane on
immunofluoiescence
Incieaseu eosinophils founu in the ueimis
12*#,+*%,:
0ial steioius


7'9,3.*( %)D,-;B'*.
Is a hypeisensitivity ieaction to uiugs, infections, oi systemic uisoiueis
Piesents with uiffuse anu eiythematous taiget lesions that aie highly
uiffeiing in shape
3;=01+2, @*#0)&$;2+
!"#$%&'"'F
Is clinical but a histoiy of heipes infection makes this a likely uiagnosis

12*#,+*%,:
Stop offenuing causes anu tieat if theie is a histoiy of heipes with acyclovii


@B'+39'-( 5),(/.( !('2(
An autosomal uisoiuei of impaiieu heme synthesis
uet blisteis on sun-exposeu aieas of the face anu hanus
Biffeientiate this poiphyiia by the absence of abuominal pain
8$;>1=;), :*0,(+, 7,;.,
!"#$%&'"':
Woou's lamp of uiine, wheie the uiine fluoiesces with an oiange-pink coloi
uue to the incieaseu levels of uiopoiphyiins
12*#,+*%,:
Sunscieens useu libeially
Phlebotomy
Chloioquine
Avoiuance of alcohol







@('(0-,-< >/;.<,-B/0 B; ,3. AQ-/

A<(N-.0
Piesents as seveiely itchy papules anu buiiows that aie locateu along the
webs of the fingeis
Bighly contagious
9',-)+% )(&+'0)$(
!"#$%&'"':
Iuentify the Saicoptes Scabiei mite fiom a skin sciaping unuei the
micioscope
12*#,+*%,:
Peimethiin S% cieate to the entiie bouy foi those infecteu anu close contacts
foi 8-1uhi, iepeateu in anothei week
Wash all linens anu beuuing in hot watei the same uay as cieam application


@.2-<)DB0-0 5(+-,-0 \O.(2 H-<.^
Itching anu swelling of the scalp
Common in school-ageu chiluien
!"#$%&'"':
Nicioscopic exam of the haii shaft will show lice attacheu to shaft
12*#,+*%,:
Peimethiin shampoo oi gel to the scalp
Repeat applications aie commonly iequiieu

@.2-<)DB0-0 @)N-0 \5'(N0^
Extiemely itchy papules in the pubic iegion
Nay also be along the axilla, buttocks, eyelashes, eyebiows, anu peiiumbilical
aiea
!"#$%&'"':
Nicioscopic iuentification of lice
12*#,+*%,:
Peimethiin shampoo left on foi 1u minutes, anu iepeateu again within a
week

5),(/.B)0 H(':( %-1'(/0
Is a snake-like, thieau-like lesion that maiks the buiiow of the nematoue
laivae
0ften seen on the hanus, back, feet, anu buttocks
Is causeu by hookwoims, namely ! Ancylostoma, Necatai, anu Stiongyloiues
:*0,(+$*% O,;?, @)A;,(%
!"#$%&'"':
A histoiy of skin being exposeu to moist soil oi sanu
Piesence of classic lesion
12*#,+*%,:
Iveimectin oially oi Thiabenuazole topically




K)/1(D 5),(/.B)0 6-0B'2.'0

6-0.(0. A-1/0 (/2
A9*+,B*0
6-(1/B0-0 !'.(,*./
,

!-/.( Itchy, scaly,
well
uemaicateu
plaques.

Black uots
seen on scalp
K0B Piep Topical
Antifungal
s

5(/2-2( Itchy, scaly
plaques,
usually in
skin folu
aieas
K0B piep
showing
buuuing
yeasts +
pseuuohyph
ae
Topical
Nystatis
oi 0ial
Fluconazo
le

!-/.(
M.'0-<BDB'
Pityiospoiu
m 0vale.

Shaiply
uemaicateu
hypopigment
eu macules
on face anu
tiunk in the
summei.

Nacules uo
not tan
K0B piep
shows the
classic
"Spaghetti
anu
meatball
appeaiance"
Selenium
Sulfiue
shampoo
on
affecteu
aiea foi 7
uays.

?/9<3B*9<B
0-0
Thickeneu,
yellowing of
the
fingeinails
anu toenails.
Clinical
anuoi K0B
piep
Fluconazo
le oi
Itiaconazo
le



AQ-/ 5(/<.'

5(/<.' !9+. >*(1. A-1/0 (/2
A9*+,B*0
!'.(,*./, @'B1/B0-0
Nalignant
Nelanoma

Seen NC in
light-skin
people with
incieaseu sun
exposuie.
Fits all
ABCBE
ciiteiia
Excision +
chemotheiapy
if theie is
metastasis
Pooi with
metastasis
Squamous
Cells
Caicinoma

Common in
elueily.

0n sun
exposeu
aieas.

0lceiations
anu ciusteu
Excision +
iauiation
Noueiate
piognosis
(bettei than
melanoma
but woise
than basal
cell)
Basal Cell
Caicinoma

NC anu looks
like a peaily
papule with
tianslucent
boiueis
Excision uieat
piognosis -
almost nevei
metastasizes
Kaposi's
Saicoma

Reupuiple
plaques.

Causeu by
BBv8.

Almost
exlusively in
AIBS patient
Chemotheiapy
anu BIv
meuications
uoou unless
theie is
associateu
oigan uamage
Cutaneous T-
cell
Lymphoma

Total bouy
iash that is
veiy itchy
Rauiation,
chemotheiapy
7-1u yi
suivival with
no tieatment.





Chapter 19

High-Yield
Preventative
Medicine
















Female patients > 6S yis of age shoulu ieceive a one-time BEXA bone scan
foi osteopoiosis
Any female who is at least 6uyi olu anu has 1 iisk factoi foi osteopoiosis
The T-scoie is useu to assess bone uensity
A T-scoie between |-1.S to -2.Sj is consiueieu to be osteopenia
A T-scoie < -2.S is osteopoiosis
A patient with a T-scoie of <-1.S plus iisk factois foi osteopoiosis (smoking,
pooi calcium vitamin B levels, lack of weight beaiing exeicise in the histoiy,
use of alcohol), shoulu ieceive pieventative meuications, such as oial
bisphosphonates oi Raloxifene
Raloxifene is the only SERN that is FBA appioveu to pievent osteopoiosis
Kius with cystic fibiosis shoulu ieceive noimal vaccinations in auuition to a
few auuitions ! yeaily influenza, pneumococcal boosteis
Patients with an egg alleigy shoulu avoiu the influenza anu yellow fevei
vaccines, anu shoulu be cautious with NNR as well
The 1
st
step in management of incieaseu LBL is lifestyle management, if LBL
>1uumguL anu the patient has iisk factois, they shoulu be staiteu on
lifestyle mouifications + statin uiugs
The uiug of choice foi incieasing the BBL is uemfibiozel anu nicotinic acius
It is iecommenueu that any male who is an active smokei oi foimei smokei
anu ageu between 6S-7S be given a one-time abuominal ultiasounu to
evaluate foi a AAA
Patients with a chionic livei uisease shoulu ieceive a numbei of vaccines
(Tetanus eveiy 1uyis + Bep A&B yeaily, anu pneumococcal vaccine)

Auult vaccine Recommenuations:
Tetanus anu Biptheiia eveiy 1uyis aftei 18yis of age
Influenza to all auults >Suyi oi to auults with chionic uiseases (BN, CBF, etc)
Pneumococcal vaccine given to all auults >6Syi of age oi to auults with
chionic uiseases

Scieening foi ceivical cancei with a pap smeai shoulu stait at 21yi of age oi
Syis aftei the onset of sexual activity (whichevei comes fiist)
If 2-S noimal pap smeais aie uone in a iow anu the woman is in a
monogamous ielationship, you can inciease the time between pap smeais to
eveiy 2-S yeais.
Scieening can stop at 7uyis of age
Bupiopion is FBA appioveu foi smoking cessation anu must be useu in
conjunction with counseling anu nicotine ieplacement

Bepatitis A vaccine is given to men who have sex with men
Neningococcal vaccine is given to those who live in close quaiteis with
otheis
Routine cholesteiol scieening shoulu begin in patients at iisk at SSyi of age
in men anu 4Syi of age in women, then eveiy Syis aftei that
The most common vaccine-pieventable uisease is hepatitis A
When CB4 count uiops below 2uu2Su, stait PCP piophylaxis with TNP-SNX
When CB4 count uiops below Su, piophylax foi mycobacteiium avium
complex with amoxicillin
Routine scieening foi Chlamyuia is now iecommenueu foi all sexually active
females who aie & 24 yis of age
Nammogiams shoulu be uone eveiy 1-2 yis staiting at 4uyi in females with
an aveiage iisk of bieast cancei. Theie is no cleai time when they shoulu
stop, but it shoulu be no soonei than 7uyi of age
Pneumococcal vaccine is a capsulai polysacchaiiue of the 2S most common
types of pneumococcus, which yielu a B-cell iesponse only, it is T-cell
inuepenuent
Any female with a histoiy of being tieateu foi CIN2S shoulu have pap
smeais with oi without colposcopy anu cuiettage eveiy 6 months until thiee
negative iesults aie obtaineu (patients may iesume stanuaiu scieen aftei
meeting this milestone)